A predictive model of progression of CKD to ESRD in a predialysis pediatric interdisciplinary program.

BACKGROUND AND OBJECTIVES: The incidence of ESRD in children has increased over the last two decades. Nevertheless, there are still limited data on risk factors related to the emergence of ESRD among patients with CKD. The aim of this study was to develop a model of prediction of ESRD in children and adolescents with CKD (stages 2-4) enrolled in a predialysis interdisciplinary management program. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective cohort study, 147 patients with CKD admitted from 1990 to 2008 were systematically followed up at a tertiary pediatric nephrology unit for a median of about 4.5 years. The primary outcome was the progression to CKD stage 5. A predictive model was developed using Cox proportional hazards model and evaluated by c statistics. RESULTS: The median renal survival was estimated at 98.7 months (95% confidence interval [95% CI], 68.7 to 129.6 months). The probability of reaching CKD stage 5 was estimated as 52% in 10 years. The most accurate model included eGFR, proteinuria at admission, and primary renal disease. Risk score ranged from 0 to 13 points (median, 4 points). The accuracy of the score applied to the sample was high, with c statistics of 0.865 (95% CI, 0.80 to 0.93) and 0.837 (95% CI, 0.76 to 0.91) at follow-up of 2 and 5 years, respectively. By survival analysis, it was estimated that at 10 years after admission, the probability of renal survival was about 63% for patients in the low-risk group and 43% for the medium-risk group; all patients assigned to the high-risk group had CKD stage 5 (P<0.001). CONCLUSION: The predictive model of progression of CKD might contribute to early identification of a subgroup of patients at high risk for accelerated renal failure.

Behavioral disorders and low quality of life in children and adolescents with chronic kidney disease.

Recent years has seen an increasing interest in the quality of life (QOL) of children with chronic kidney disease (CKD). The objective of this cross-sectional study was to investigate the prevalence of behavioral disorders and to assess the health-related QOL (HRQOL) in 136 patients with CKD. To estimate the prevalence of behavior disorders and analyze HRQOL, we used the Strengths and Difficulties Questionnaire (SDQ) and Pediatric Inventory of Quality of Life (PedsQL) Core Scales as assessment tools for both the patients and caregivers. When compared to healthy controls, the CKD group had significantly lower scores in almost all PedsQL domains. After adjustment, only absence of religion/other religions remained significantly associated with a lower global HRQOL score [odds ratio (OR) 6.2, P=0.009]. Among the parents, two factors remained significantly associated with a lower global HRQOL score: patients' age >10 years (OR 5.4, P=0.033) and absence of religion/other religions (OR 3.2, P=0.038). The CKD group demonstrated a higher proportion of behavioral and emotional disorders in all SDQ domains. There was a negative correlation between the presence of behavior and emotional disorders and HRQOL score (r= -0.552, P<0.001). Our findings suggest the importance of evaluating behavioral and social repercussions of CKD in order to improve the life quality of this pediatric population.

Conhecimento de pacientes e familiares sobre a doença renal crênica e seu tratamento conservador / Patients and their family’s knowledge about chronic kidney disease and its treatment / Conocimientos de los pacientes y familiares acerca de la enfermedad renal cronica y su tratamiento conservador

Com este estudo realizado no Ambulatório de Nefrologia Pediátrica do Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG), teve-se como objetivo avaliar o conhecimento de pacientes portadores de doença renal crônica(DRC) e de seus familiares sobre a doença e seu tratamento conservador. A população do estudo foi composta de 75pacientes e seus familiares. A coleta de dados constou de uma entrevista feita ao paciente, quando maior de 12 anos em condições de responder, ou ao cuidador principal sobre a doença, tratamento e dieta. Os resultados mostraram que 54,7% dos informantes possuíam conhecimento insuficiente e que o informante ter entre 12 e 30 anos (OR= 3,44)e o paciente estar a 5 anos ou menos no programa (OR= 2,77) foram estatisticamente associados ao conhecimento insuficiente. O estudo mostrou a necessidade de reavaliação das estratégias que vêm sendo utilizadas nas atividades educativas, tornando-as mais adequadas a cada paciente, levando em consideração sua capacidade de compreensão e experiências acumuladas.

This study was developed in the Pediatric Nephrology Ambulatory at the University Hospital of the Federal University of Minas Gerais. Its objective was to evaluate the patients and their family’s knowledge about chronic kidney disease(CKD) and its treatment. The study population comprised 75 patients and their families. Data was collected though interview with a patient (or his/her caretaker) older than 12 years of age and capable of answering the questions that dealt with the disease, its symptoms, treatment and diet. The data showed that 54.7% of the informants had poor knowledge about their disease and its treatment. Two conditions were statistically related to this poor knowledge: the age of the people interviewed being that between 12 and 30 years old (OR= 3, 44) and their participation in the Program being less than 5 years (OR= 2, 77). This study showed the necessity of reevaluating the strategies that are being used in educational activities that need to be more adequate to each patient and that should take into consideration their ability to understand the condition and their own experiences with the whole process.

Este estudio fue realizado en la Unidad de Nefrología Pediátrica del Hospital das Clínicas de la Universidad Federal de Minas Gerais (UFMG) con el objeto de evaluar el conocimiento de los pacientes con enfermedad renal crónica (ERC) y de sus familiares cuidadores sobre la enfermedad, su tratamiento conservador y dieta. La población del estudio estaba compuesta por 75 pacientes y sus familiares. La recogida de datos consistió en una entrevista al paciente (si tenía más de 12 años y estaba en condiciones de responder) o al cuidador principal acerca de la enfermedad, el tratamiento y la dieta. Los resultados mostraron que 54,7% de los informantes tenían conocimiento insuficiente; los informantes entre12 y 30 años de edad (OR=3,44) y los pacientes con menos de 5 años en el programa (OR= 2,77) estadísticamente fueron asociados al conocimiento insuficiente. El estudio demostró la necesidad de efectuar una reevaluación de las estrategias utilizadas en las actividades educativas con miras a tornarlas más adecuadas a cada paciente, teniendo encuenta su capacidad de entender y las experiencias acumuladas.

Development and validation of a matrix solid-phase dispersion method to determine acrylamide in coffee and coffee substitutes.

The present study describes the development and validation of a new method based on a matrix solid-phase dispersion (MSPD) sample preparation procedure followed by GC-MS for determination of acrylamide levels in coffee (ground coffee and brewed coffee) and coffee substitute samples. Samples were dispersed in C(18) sorbent and the mixture was further packed into a preconditioned custom-made ISOLUTE bilayered SPE column (C(18)/Multimode; 1 g + 1 g). Acrylamide was subsequently eluted with water, and then derivatized with bromine and quantified by GC-MS in SIM mode. The MSPD/GC-MS method presented a LOD of 5 microg/kg and a LOQ of 10 microg/kg. Intra and interday precisions ranged from 2% to 4% and 4% to 10%, respectively. To evaluate the performance of the method, 11 samples of ground and brewed coffee and coffee substitutes were simultaneously analyzed by the developed method and also by a previously validated method based in a liquid-extraction (LE) procedure, and the results were compared showing a high correlation between them.

Predictive factors of progression to chronic kidney disease stage 5 in a predialysis interdisciplinary programme.

BACKGROUND: The clinical course of chronic kidney disease (CKD) in children is heterogeneous and has not been fully established. The aim of this retrospective cohort study was to identify predictive factors associated with the progression of CKD among the children and adolescents admitted to a Predialysis Interdisciplinary Management Programme (PDIMP). METHODS: We analysed the following variables at admission: age, gender, race, blood pressure, primary renal disease, Z-scores for weight and height, CKD stage and degree of proteinuria. Two time-dependent covariates were considered: hypertension and proteinuria. CKD stage 5 was assigned as a dependent variable. Time-fixed and time-dependent Cox regression analyses were applied to evaluate renal survival. RESULTS: One hundred and seven patients with CKD stage 2-4 were followed up for a median time of 94 months. Fifty-seven patients (53.3%) progressed to CKD stage 5. After adjustment for time-fixed model, three baseline variables were found to be independent predictors of CKD stage 5: glomerular disease (hazard ratio, HR = 3.0, P = 0.015), CKD stage 4 (HR = 2.6, P = 0.001) and severe proteinuria (HR = 4.1, P = 0.006). After adjustment for the time-dependent model, three variables were found to be independent predictors of CKD stage 5: proteinuria as time-dependent covariate (HR = 1.9, P = 0.041), CKD stage 4 (HR = 2, P = 0.0086) and baseline serum albumin <3.5 g/dl (HR = 2.6, P = 0.0015). CONCLUSIONS: Taking into account manageable factors, further prospective controlled studies are necessary to assess intervention measures in order to possibly modify the clinical course of CKD in children.

Clinical outcome of children with chronic kidney disease in a pre-dialysis interdisciplinary program.

The purpose of this retrospective cohort study was to describe the outcome of 107 patients with chronic kidney disease (CKD) admitted to a pre-dialysis interdisciplinary management program from 1990 to 2006. The events of interest were progression to CKD stage 5 (renal survival), patient survival, hypertension, and somatic growth. Survival was studied by the Kaplan-Meier method. Patients were classified into four groups according to their primary renal disease: congenital nephro-uropathies; glomerular diseases; cystic disease, and miscellaneous. Median follow-up time was 94 months [Interquartile (IQ) range 38-145]. The probability of reaching CKD stage 5 was estimated to be 36% by 5 years after admission. As a whole, the mean estimated glomerular filtration rate (GFR) decrease per year was 5.8 ml/min per 1.73 m(2) body surface area [standard deviation (SD) 12.4]. The glomerular diseases group showed a median rate of GFR deterioration of 10 ml/min per 1.73 m(2) per year (IQ range -24 to -5.7), whereas the median rate of GFR deterioration for the groups with cystic diseases, congenital nephro-uropathies, and miscellanea were 2.5 ml/min (IQ range -10 to +0.34), 2.2 ml/min (IQ range -5.0 to -0.52), and 0.36 ml/min (IQ range -2.5 to +2.6), respectively (P < 0.001). The results of this study support the view that children and adolescents with glomerular diseases present a faster deterioration of renal function. Therefore, patients with glomerular diseases need to be referred early to a pediatric nephrology center so that suboptimal pre-dialysis care might possibly be avoided.

A visita domiciliar como estratégia assistencial no cuidado de doentes crônicos / Home visits as an assistance strategy in chronic disease care / La visita domiciliar como estrategia asistencial en el cuidado de enfermos crónicos

O estudo trata da importância da utilização da visita domiciliar na identificação de características e informações relacionadas às conseqüências da doença renal crônica na vida de pacientes e familiares atendidos pelos profissionais do Programa Interdisciplinar de Prevenção e Assistência na IRC em Crianças e Adolescentes do Hospital das Clínicas da UFMG. Foram visitados 21 doentes, sendo entrevistado um familiar. Entre as modificações ocorridas com a família, foram citadas as dificuldades de o familiar responsável pelos cuidados ter atividades fora do lar e as mudanças dos padrões alimentares de toda a família. A visita domiciliar se mostrou uma estratégia assistencial eficiente, contribuindo para a relação entre pacientes, familiares e profissionais.

This study emphasizes the importance of home visits in identifying the characteristics and information on the consequences of chronic renal disease in the life of patients and their families cared for by health workers in the Interdisciplinary Program for Prevention and Care in the Chronic Renal Failure for Children and Adolescents at the University Hospital of the Federal University of Minas Gerais. Twenty-one patients were visited and a family memeber of each one was interviewed. Modifications in the family included difficulties when the person caring for the patient had outdoor activities and the changes in eating patterns for the whole family. Home visits showed themselves to be an efficient strategy for care, contributing to the relation between patients, family members and health workers.

El estudio trata sobre la importancia de utilizar la visita domiciliaria para identificar características e informaciones relacionadas con las consecuencias de la enfermedad renal crónica en la vida de pacientes y familiares atendidos por los profesionales del Programa Interdisciplinario de Prevención y Asistencia a la IRC (insuficiencia renal crónica) en Niños y Adolescentes del Hospital de Clínicas de la UFMG (Universidad Federal de Minas Gerais). Se efectuaron visitas a 21 enfermos y entrevista a un familiar. Entre las modificaciones ocurridas en la familia se citaron las dificultades del familiar responsable de los cuidados para conciliar sus tareas fuera del hogar y los cambios en la alimentación de toda la familia. La visita domiciliaria demostró ser una estrategia asistencial eficiente que contribuye a la relación entre pacientes, familiares y profesionales.

Curso clínico da insuficiência renal crônica em crianças e adolescentes admitidos no programa interdisciplinar do HC-UFMG / Clinical course of chronic renal insufficiency in children and adolescents adnitted to the HC-UFMG interdisciplinary program

Objetivo :Avaliar o curso clínico da insuficiência renal crônica (IRC) em crianças e adolescentes admitidos no Programa lnterdisciplinar de Prevenção e Assistência da IRC do HC-UFMG. Métodos :A população estudada consistiu de 62 crianças e adolescentes portadores de IRC em tratamento conservador, admitidos no programa entre 1990 a 1999. Esses pacientes foram submetidos a avaliações clínico-laboratoriais com periodicidade média de dois meses. Foram avaliadas as seguintes variáveis: idade de admissão, idade de diagnóstico da IRC, causa básica da doença, sexo, data da última consulta ou data da indicação de diálise, dados iniciais e finais de pressão arterial, e dados laboratoriais incluindo uréia e creatinina. Para a realização do estudo foi construído um banco de dados no programa Epi lnfo. Foram estudados como parâmetros nutricionais o peso e a estatura, calculados o escore Z e o percentil. A sobrevida foi analisada pelo método de Kaplan-Meier. Resultados :As causas básicas mais freqüentes da IRC foram as uropatias (56 por cento) e as glomerulopatias (19 por cento). O tempo médio de acompanhamento foi de 43 meses. Na admissão, a taxa de filtração glomerular estimada variou de 7,0 ml/min a 69 ml/min, sendo a mediana de 33,2 ml/min. Um total de 21 (34 por cento) pacientes evoluiu para insuficiência renal crônica terminal (IRCT). O grupo de glomerulopatas apresentou maior risco de necessitar de terapêutica de substituição da função renal (RR=2,08). À admissão, as medianas dos escores Z de peso e estatura foram de - 1,95 e -2,60, respectivamente, e ao final do seguimento, de - 1,8 e -2,7. Conclusão :A instituição de cuidados por equipe interdisciplinar para pacientes portadores de insuficiência renal crônica antes do início da terapia da substituição da função renal oferece benefícios a estas crianças e adolescentes, possibilitando uma abordagem clínica mais abrangente e eficaz.

Predictive factors of progression of chronic renal insufficiency: a multivariate analysis.

The purpose of this study was to identify clinical, nutritional, and laboratory factors associated with the rate of progression of chronic renal insufficiency among children and adolescents admitted to a pre-end-stage renal failure (ESRF) interdisciplinary program. Sixty-two children and adolescents aged 2 months to 19 years with chronic renal failure on conservative management were prospectively followed from 1990 to 1999. The following variables were analyzed: age at admission, sex, race, blood pressure, primary renal disease, Z scores for weight and height, glomerular filtration rate (GFR), urea, and presence and degree of proteinuria. Progression to ESRF was assigned as a dependent variable. The analysis was conducted in two steps. In a univariate analysis, variables associated with ESRF outcome were identified by the log-rank test. Then, the variables that were significantly associated with adverse outcome were included in a multivariate analysis. This analysis, using the Cox proportional hazards model, was performed to identify variables that were independently associated with a worse prognosis. Only variables that remained independently associated with adverse outcome were included in the final model. Twenty-one (34%) patients evolved to ESRF during a median follow-up of 43 months. Two variables were identified as independent predictors of progression to ESRF: GFR under 30 ml/min (RR=3, 95% CI=1.7-5.3, P=0.0001) and severe proteinuria (RR=3.1, 95% CI=1.2-7.6, P=0.01). The combination of two factors-GFR lower than 30 ml/min and presence of severe proteinuria on admission-was an independent indicator of adverse outcome in children and adolescents with chronic renal insufficiency who were conservatively managed.