Localizing Dewey's Notions of Democracy and Education: A Journey across Configurations in Latin America.

This paper explores the reception of Dewey's ideas on democracy and education in Latin America from the beginning of the twentieth century through the "long 1960s" (1958-1974). The analysis is framed by a dynamic interplay between the local, regional, and supranational. To bring empirical specificity to Dewey's "translations," the author discusses Dewey's uptake in two political settings, in 1920s Chile and post-revolutionary Mexico, and two cases of Christian adaptation of Dewey's theories. The long 1960s signaled an epistemic shift in conceptions of education and social transformation. Dewey was not embraced while Paulo Freire and Ivan Illich became the referents.

Outcome and prognostic factors in HIV-1-infected patients on dialysis in the cART era: a GESIDA/SEN cohort study.

BACKGROUND: Prognosis of HIV-infected patients on dialysis has improved. Few studies have compared survival between HIV-infected and HIV-negative patients on dialysis in the combined antiretroviral therapy (cART) era. We compared the outcome of HIV-infected patients on dialysis with a matched HIV-negative cohort. METHODS: National, multicenter, retrospective cohort study of HIV-infected patients starting dialysis in Spain (1999-2006). Matching criteria for HIV-negative patients were dialysis center, year of starting dialysis, age, sex, and race. RESULTS: The study population comprised 122 patients, 66 HIV-infected, and 66 HIV-negative patients. Median age was 41 years, and all but 4 HIV-infected patients were white. HIV-associated nephropathy was only present in 4 cases. HIV-infected patients were less frequently included on the kidney transplantation waiting list (17% vs 62%, P < 0.001). They also had more hepatitis C virus coinfection (76% vs 11%, P < 0.001), fewer cardiovascular events (62% vs 88%, P = 0.001), fewer kidney transplants (4.5% vs 38%, P < 0.001), and higher mortality (32% vs 1.5%, P < 0.001). Survival rates [95% confidence interval (CI)] at 1, 3, and 5 years for HIV-infected patients were 95.2% (89.9%-100%), 71.7% (59.7%-83.7%), and 62.7% (46.6%-78.8%). Five-year survival for HIV-negative patients was 94.4% (83.8%-100%) (P < 0.001). Multivariate analysis revealed the following variables to be associated with death in HIV-infected patients: peritoneal dialysis vs hemodialysis [hazard ratio; (95% CI): 2.88 (1.16-7.17)] and being on effective cART [hazard ratio (95% CI): 0.39 (0.16-0.97)]. CONCLUSIONS: Medium-term survival of HIV-infected patients on dialysis was lower than that of matched HIV-negative patients. Fewer HIV-infected patients had access to kidney transplantation. Being on effective cART improves survival. Further studies are needed to determine whether peritoneal dialysis increases mortality.

Factors related to the absence of anemia in hemodialysis patients.

BACKGROUND: A small number of hemodialysis (HD) patients have normal hemoglobin (Hb) levels without the need for erythropoiesis-stimulating agents (ESAs). The factors associated with this condition have been little studied. The objective of this prospective study was to determine these factors in a prevalent population of HD patients. MATERIALS AND METHODS: All patients who had normal Hb levels and who had not received ESAs in the last 6 months (non-ESA group) were included. Epidemiological and laboratory data were collected and we performed an abdominal ultrasound to assess hepatic and renal cysts. This group was compared to a control group of 205 prevalent HD patients on ESA therapy (control group). RESULTS: We included 45 patients (16% from the whole group) in the non-ESA group. In this group, there was a higher proportion of men (76.5 vs. 61%), patients were younger (61.1 ± 14.7 vs. 67.5 ± 15.2 years), had a longer duration of renal replacement therapy (RRT) (9.4 ± 8.3 vs. 5.3 ± 5.8 years) and had a higher prevalence of adult polycystic kidney disease (APKD) and hepatitis C virus (HCV) liver disease (42.2 vs. 10.2%), p < 0.01. In the non-ESA group, HCV+ patients had a lower prevalence of APKD (2.2 vs. 38.4%) and hepatic cysts (2.2 vs. 19.2%), but significantly higher endogenous erythropoietin levels (55.8 ± 37.1 vs. 30.9 ± 38.4 mU/ml). No significant differences in anemia, iron metabolism, insulin, IGF-1 and renin were found between non-ESA and control groups. Non-ESA patients had a significantly higher number of renal (90.6 vs. 36.5%) and hepatic cysts (12.5 vs. 3.4%), and these were also larger in size (3.3 ± 2.4 vs. 1.5 ± 0.8 cm). In the multivariate Cox analysis, independent predictor factors for absence of anemia in HD patients were number of renal cysts >10 cysts (95% CI 1.058-1.405; p = 0.00), HCV+ liver disease (95% CI 1.147-1.511; p = 0.05) and time on RRT (95% CI 1.002-1.121; p = 0.05). CONCLUSIONS: The absence of anemia in HD patients is not infrequent. Its frequency is higher in men and younger patients with long-term RRT, in patients with HCV+ liver disease and in APKD. It is associated with increased endogenous erythropoietin production and the presence of renal and hepatic cysts.

Inflammatory syndrome in patients on hemodialysis.

Mortality is markedly elevated in hemodialysis (HD) patients. Between 30 and 50% of prevalent patients have elevated serum levels of inflammatory markers such as C-reactive protein and IL-6. The presence of inflammation, chronic or episodic, has been found to be associated with increased mortality risk. The causes of inflammation are multifactorial and include patient-related factors, such as underlying disease, comorbidity, oxidative stress, infections, obesity, and genetic or immunologic factors, or on the other side, HD-related factors, mainly depending on the membrane biocompatibility and dialysate quality. The adequate knowledge of these causes and their prevention or treatment if possible may contribute to improving the inflammatory state of patients who are on HD and possibly their mortality.

[Prevalence of HIV-1-infection in dialysis units in Spain and potential candidates for renal transplantation: results of a Spanish survey]. / Prevalencia de la infección por el VIH en centros de diálisis en España y potenciales candidatos para trasplante renal: resultados de una encuesta española.

INTRODUCTION: Patients with HIV infection and end-stage renal disease (ESRD) have improved their survival in the last few years. HIV infection is not considered a contradiction for renal transplantation, but little experience exists in renal transplantation in HIV infected individuals. There is no information about the prevalence of HIV infection in Spanish patients under renal replacement therapies (RRT). METHODS: A survey was performed in Spanish dialysis units during 2004. The objective was to study the prevalence and characteristics of HIV infection in patients under RRT in Spain. We also aimed to know how many of them met the Spanish criteria to be included on the renal transplantation waiting list. RESULTS: HIV prevalence was 1.15% (95%CI 0.85-1.45) of 4,962 patients who were under RRT, mostly under hemodialysis and, less commonly, peritoneal dialysis. The most frequent risk factor for HIV infection was parenteral drug use (58%). The most common causes of ESRD were glomerulonephritis (44%). The median time under RRT was 46 months. Coinfections with hepatitis C (60%) and B (7%) were found. Thirty-four percent of patients had a history of aids-defining events. Eighty-six percent were under HAART. The median CD4 cell count was 333 cells/.l and the viral load was undetectable in 68%. Of 40 patients with a completed clinical questionnaire, 9 (22.5%) met the Spanish criteria for renal transplantation. CONCLUSION: HIV prevalence in patients under RRT in Spain is 1.15% (0.85%-1.45%) and 22.5% percent of these patients met the Spanish criteria to be included on a renal transplantation waiting list.

Progression of secondary hyperparathyroidism involves deregulation of genes related to DNA and RNA stability.

BACKGROUND: Renal secondary hyperparathyroidism in its late stages becomes autonomous, so excessive parathyroid hormone (PTH) secretion no longer responds to physiologic stimuli or to aggressive medical treatment. METHODS: To gain molecular understanding of progression of renal secondary hyperparathyroidism, normal and hyperplastic parathyroid tissue with diffuse and nodular growth were analyzed. The results were also compared to parathyroid adenomas. The analysis was performed by high-density oligonucleotide microarray and bidirectional subtraction library. RESULTS: Analysis of the DNA arrays found 16 overexpressed and 132 repressed genes in the nodules while the subtraction library produced 34 overexpressed and 40 repressed genes. The differentially expressed genes between diffuse and nodular samples included some related to DNA stability and repair (TALDO1, PRDX2, DDB1, XRCC1, and POLB), RNA stability and degradation (OASL and AUF1), protein synthesis and processing (PFDN5, HSPD1, and NACA), cell growth (CDC25C and GRPR), and tumorigenesis and cell cycle (VIL2 and TPD52). CONCLUSION: According to the function described for the deregulated genes, when secondary hyperparathyroidism becomes autonomous and refractory to treatment, RNA degradation may be increased while DNA integrity may be compromised. These two mechanisms, combined with deregulation of genes related to growth and differentiation show the complex pathway of parathyroid glands' evolution in renal hyperparathyroidism and may explain the large amount of molecular cytogenetic aberrations found in refractory hyperparathyroidism. Considering that some of the genes with altered expression in nodular hyperplasia lead to irreversible consequences in the genomic integrity of the cells, an adequate and early management of the secondary hyperparathyroidism of chronic kidney disease becomes mandatory.

Psychosocial factors and health-related quality of life in hemodialysis patients.

Several sociodemographic and clinical variables are known to influence the health-related quality of life (HRQOL) of patients with kidney disease, yet the relationship between psychological factors and the HRQOL measured by the Kidney Disease Quality of Life Short-Form (KDQOL-SF) is incompletely understood. The objective of this study was to examine the relationship between psychosocial status (depressive symptoms, trait anxiety, and social support) and KDQOL-SF scales in hemodialysis (HD) patients by controlling the effects of sociodemographic and clinical variables. The HRQOL of 194 patients from 43 dialysis centers in Spain was assessed by completing the KDQOL-SF, and evaluating depressive Symptoms (Cognitive Depression Index), trait anxiety (Trait Anxiety Inventory) and degree of social support (Scale of Perceived Social Support). We also recorded several sociodemographic and clinical variables. Two regression models were estimated for each of the 19 scales in the KDQOL-SF. In the first model, we only included sociodemographic and clinical-factors, while the second model also took into consideration psychosocial variables. These last factors (trait anxiety and depressive symptoms, not social support) were found to increase the proportion of explained variability, with highest standardized regression coefficients observed for most KDQOL-SF scales. Depressive symptoms were related to a poor HRQOL when there was a strong physical component, while trait anxiety was mainly related to emotional upset and social relationships. We were able to conclude that trait anxiety and depressive symptoms are strongly associated with the HRQOL assessed by the KDQOL-SF in HD patients. The effects of these factors should therefore be considered when evaluating the quality of life of this type of patient.

Interdialytic weight gain as a marker of blood pressure, nutrition, and survival in hemodialysis patients.

BACKGROUND: Excessive interdialytic weight gain (IDWG) is usually related to an overload of sodium and water, and is the most important factor for arterial hypertension in dialysis. On the other hand, food intake also contributes to IDWG, and is the basic factor for nutrition. The objective of this study is to assess the long-term prognostic effect of IDWG and its relationship with the nutritional status and blood pressure in patients in hemodialysis (HD). METHODS: We describe the results of a 5-year prospective observation study in which 134 HD patients were included (70 males and 64 females), with ages between 18 and 81. Initially, the average data were collected during 4 weeks, including total IDWG and percentages according to dry weight (IDWG%), nutritional parameters, and blood pressure. Patients were divided into 3 cohorts according to IDWG% (<2.9, 2.9-3.9, and >3.9%, respectively). Student t test, ANOVA, linear regression analysis, and Kaplan-Meier survival curves compared with log-rank test were used as statistical tools. RESULTS: The mean IDWG% for the whole studied population was 3.5 +/- 1.1% (1.5-8.0%). It was not related to gender, but had an inverse correlation with age (P < 0.000) and serum bicarbonate level (P= 0.009). It was directly correlated with predialysis systolic and diastolic blood pressure, nPCR, urea and creatinine levels (P < 0.01 for all of them), and the body mass index (P < 0.000). Serum levels of albumin (44.7 +/- 4.0 g/dL) and prealbumin (31.9 +/- 7.4 mg/dL) had a direct correlation with total IDWG (P < 0.01). We found no significant relationship between or IDWG% and ferritin and transferrin levels. Five-year actuarial survival was 0.38, 0.52, and 0.63, respectively, in the 3 cohorts for IDWG% (P < 0.01). CONCLUSION: Our results show that a greater IDWG is directly associated with a better nutritional status, although it is also associated with higher predialysis blood pressure. The greater the IDWG%, the better the long-term prognosis of the patients. The beneficial effects of IDWG on the nutritional status and prognosis are greater than the negative aspects that depend on its effects on blood pressure. One must distinguish clearly between some isolated instances of not complying with a diet from those situations where a higher IDWG is merely a reflection of a good nutritional status, and one must be careful so that dietary recommendations will not have a negative influence on nutritional aspects. One must watch and correct the trend towards higher acidosis in patients with a greater IDWG.

Presence of a failed kidney transplant in patients who are on hemodialysis is associated with chronic inflammatory state and erythropoietin resistance.

Patients returning to hemodialysis (HD) after failure of their kidney transplant suffer from high morbidity and mortality rates. It is common practice to keep failed kidney transplants in place. It is not known if these failed kidney transplants induce an inflammatory state that contributes to morbidity and mortality. In a single facility, patients starting on HD with failed kidney transplant were identified (Group A) and screened for the presence of chronic inflammatory state. Those with clinical symptoms attributed to the failed allograft (Group A1) were not offered transplant nephrectomy unless deemed necessary during follow-up. Their clinical and laboratory data were followed up for 6 months. Similar data were obtained from a group of incident HD patients (Group B). Forty-three patients had a failed Kidney transplant (Group A). Of these, 29 comprised Group A1 and 14 Group A2. Group B comprised 121 patients. In comparison with Group B, Group A exhibited worse anemia and erythropoietin resistance index (ERI), had lower serum albumin and prealbumin, and higher CRP. Group A1 had lower Hb and higher ferritin, CRP, and ESR in comparison with Group A2. Following transplant nephrectomy, Group A1 had improvement in ERI, serum albumin, prealbumin, ferritin, fibrinogen, CRP, and ESR. At 6 months, Group A1 had higher Hb and serum albumin levels, and lower CRP and ERI in comparison with Group A2. Group B parameters showed no change during follow-up. Patients returning to HD following failure of their kidney transplant suffer from a chronic inflammatory state. Resection of failed transplants in symptomatic patients is associated with amelioration of markers of chronic inflammation. Transplant nephrectomy should be considered a treatment option for patients with failed kidney transplants, especially if they exhibit signs and symptoms of chronic inflammatory state.

Comparative study of the expression of proteins involved in the cell cycle in renal secondary hyperparathyroidism.

BACKGROUND: In renal hyperparathyroidism, parathyroid cell proliferation seems to play a key role in the progression of the disease. Therefore, G1/S transition, a main cell cycle regulatory step, could be deregulated in these patients. METHODS: One hundred and one parathyroid glands, taken from parathyroidectomies performed on 41 patients on hemodialysis (HD), and 15 glands, taken from 7 patients with post-transplantation persistent hyperparathyroidism (HPT), were studied. Twelve normal parathyroid (PT) glands were used as the control. Biochemical data, immunohistochemical (IHC) profiles of G1/S transition regulators belonging to the two main pathways (cyclin D1/p16INK4A/pRb and p14ARF/p53/MDM2), and proliferation rate (Ki67) were correlated. RESULTS: All of the other proteins differed from normal IHC profiles in both groups that showed significant higher proliferating rates, decreases in p27KIP1, pRb, and cyclin D1, as well as increases in p16INK4A, p53, MDM2, and p21WAF1 levels, in comparison with normal PT glands, with the exception of cyclin D3. Contrary to patients with HPT who were on hemodialysis, in post-transplantation HPT, consistent correlations between biochemical data and IHC profiles were obtained. CONCLUSION: In both groups IHC profiles of proteins involved in G1/S transition regulation significantly differed from normal PT glands. The results support partial reversion to normal IHC profile in post-transplantation HPT.

Chromosomal aberrations, the consequence of refractory hyperparathyroidism: its relationship with biochemical parameters.

BACKGROUND: It has been shown that refractory hyperparathyroidism (HPT) correlates biologically with a monoclonal true neoplasm, but the chromosomal changes and their relationship with biochemical variables such as high levels of phosphate, low levels of calcium (Ca), and calcitriol deficiency are still in need of a deeper analysis. METHODS: Comparative genomic hybridization was used to scan for DNA copy number changes in two groups of samples: 57 glands from refractory secondary HPT and 28 glands from refractory HPT after kidney transplantation. Biochemical HPT-related parameters from these patients were collected and analyzed. RESULTS: Sixty-one percent of the glands from dialysis patients and 53.6% of the glands from transplanted patients suffering severe secondary hyperparathyroidism had clonal chromosomal imbalances. Losses were far more common than gains. The most recurrent changes were losses of 1p (71%), monosomies of chromosomes 19 and 22 (45%), and losses of 20q (44%) and 16p (42%). The most frequent gains were 5q, 6q, and 13q. Biochemical parameters suggested that Ca excess is related to the development of these chromosomal aberrations, although it is not known if it is by playing a role in producing the alterations or merely as a reflection of HPT severity. Phosphate levels, despite their known effect in increasing the proliferation of the parathyroid glands, were not related to the chromosomal aberrations found in severe secondary HPT. CONCLUSION: Clonal recurrent chromosomal changes are present in more than half of the glands from patients with refractory HPT, which undergo extreme biochemical levels in hyperparathyroidism effectors. These changes support the idea of the monoclonal neoplastic nature of this disorder.

Parathyroidectomy: whom and when?

Hyperparathyroidism (HPT) is common in patients on dialysis, and parathyroidectomy (PTx) is often required. We present a retrospective, descriptive analysis of data corresponding to 148 patients on dialysis undergoing PTx due to severe refractory HPT (PTH 1401 +/- 497 pg/mL, Ca 10.6 +/- 0.8 mg/dL, P 6.9 +/- 1.7 mg/dL). Demographic data were compared with those recorded in 309 patients on dialysis not subjected to PTx who were managed at the same hospital. In the PTx group, the factors age (49.3 +/- 14 years), male gender (48.6%), and diabetes (0.7%) were significantly lower than in the non-PTx group (61.5 +/- 14.9 years, male gender 59%, diabetes 19.4%), while time on dialysis was longer (8.6 +/- 5.8 vs. 5.5 +/- 5.4 years). In 129 of the study patients (87.4%), four or more glands were identified, and total PTx plus autotransplantation (AT) in the forearm was performed. In the remaining 19 patients, two to three glands were identified, and AT was not undertaken. Four of the 19 patients were successfully operated on again for persistent HPT, seven showed PTH levels <250 pg/mL, and eight maintained severe HPT. Perioperative complications included one death due to cardiac insufficiency, two repeat operations due to bleeding, and one patient with chronic hoarseness. Hospital stay was prolonged in 20% of patients due to a hungry bone syndrome. Among those patients with PTx and AT, HPT recurred in 21 patients (16.2%) at 3.1 +/- 2.3 years. In 13 of these patients, autograft was removed at 7.5 +/- 2.9 years. Serum calcium and phosphate levels improved after PTx, and these results were maintained for 5 years (9.6 +/- 0.8 and 4.2 +/- 1.2 mg/dL, respectively). In conclusion, PTx with AT is a safe option for the treatment of severe HPT that is accompanied by low morbidity and mortality and a good outcome. Medical treatment should not be prolonged at the expense of long repeated bouts of hypercalcemia and/or hyperphosphatemia with their irreversible consequences.

Psychosocial factors and quality of life in young hemodialysis patients with low comorbidity.

BACKGROUND: The current predominance of older patients, diabetic patients and high-comorbidity patients among the hemodialysis (HD) population has probably influenced the definition of the effects of renal disease on health-related quality of life (HRQOL), and these effects can be different in the patient subgroup without these characteristics. This multicenter study aimed to assess HRQOL in non-diabetic HD patients, aged < 65 yrs and with low comorbidity, and to study the effects of the demographic, clinical and psychosocial characteristics on their HRQOL. METHODS: 117 patients from 43 Spanish HD centers participated in the study. Patients completed the Kidney Disease Quality of Life Short-Form questionnaire (KDQOL-SF) and screening for depressive symptoms, anxiety symptoms and social support. Various sociodemographic and clinical variables were also recorded. RESULTS: HD patients' HRQOL showed a profile similar to that of the general HD population, with low physical health scores, but normal mental health scores. Multivariate analysis demonstrated that gender, older age, non-working status, low social support and low levels of hemoglobin (Hb), Kt/V or protein catabolic rate (PCR), had a negative effects, but these effects were of relatively small magnitude and appeared only in some scales. The most important independent predictors of HRQOL were anxiety state and depressive symptoms. CONCLUSIONS: In non-diabetic HD patients, aged < or = 65 yrs and with low comorbidity, psychological factors (anxiety state and depressive symptoms) are crucial HRQOL determinants. These variables should be considered when assessing HRQOL in HD patients with these demographic and clinical characteristics.

Increasing the hematocrit has a beneficial effect on quality of life and is safe in selected hemodialysis patients. Spanish Cooperative Renal Patients Quality of Life Study Group of the Spanish Society of Nephrology.

Target hematocrit/hemoglobin values in dialysis patients are still controversial. The Spanish Cooperative Renal Patients Quality of Life Study Group (including 34 hemodialysis units) conducted a prospective, 6-mo study of the effect on patient functional status and quality of life of using epoetin to achieve normal hematocrit in hemodialysis patients with anemia. The possible adverse effects of increased hematocrit, patient hospitalization, and epoetin requirements were also studied. The study included 156 patients (age range, 18 to 65 yr). Given the minimal experience in the safety of increasing hematocrit in dialysis patients to normal levels with epoetin, stable patients on hemodialysis who had received epoetin treatment for at least 3 mo and had a stable hemoglobin level of > or = 9 g/dl were included in the study. Patients with antecedents of congestive cardiac failure, ischemic cardiopathy, diabetes mellitus, uncontrolled hypertension, cerebrovascular accident or seizures, malfunction of the vascular access or severe comorbidity (defined by a comorbidity index), and those over 65 yr of age were excluded from the study. Quality of life was measured with the Sickness Impact Profile (SIP) and Karnofsky scale. Patients completed questionnaires at home at onset and conclusion of the 6-mo study. Mean hematocrit increased from 30.9 to 38.4% and hemoglobin from 10.2 to 12.5 g/dl during the study. Health indicator scores improved significantly: mean Physical Dimension (SIP) from 5.38 to 4.1 (P < 0.005); mean Psychosocial Dimension from 9.2 to 7 (P < 0.001); mean global SIP from 8.9 to 7.25 (P < 0.001); mean Karnofsky scale score from 75.6 to 78.4 (P < 0.01). (SIP is scaled so that lower scores represent better functional status, and vice versa for the Karnofsky scale). Therefore, functional status and quality of life improved with increased hematocrit. No deaths occurred. Three patients (2%) were censored for hypertension and nine (5.7%) for thrombosis of the vascular access. The cumulative probability of thrombosis of the vascular access was 0.067. The average epoetin dose rose from 93 +/- 62 U/kg per wk at onset to 141 +/- 80 U/kg per wk at conclusion, a 51% increase. The number of patients hospitalized decreased and hospital lengths of stay were shorter during the study period than in the same patients in the 6-mo period preceding the study (P < 0.05). Nine patients (5.7%) had thrombosis of the vascular access. There were no changes in the prevalence of arterial hypertension, but three patients (2%) showed hypertension that was difficult to control. It is concluded that normalization of hematocrit in selected hemodialysis patients, i.e., nondiabetic patients without severe cardiovascular or cerebrovascular comorbidities, improves quality of life and decreases morbidity without significant adverse effects.