Validity of malnutrition scores for predicting mortality in chronic hemodialysis patients

Purpose: Malnutrition is a strong predictor of mortality in hemodialysis patients. Several scoring systems for evaluating nutritional status have been proposed. However, they rely on different sets of anthropometric and laboratory markers to make a diagnosis of malnutrition and assess its impact on prognosis. To validate them, nutritional scores should be compared with clinical outcomes. Thus, the purpose of this study was to assess malnutrition by three different nutrition scoring systems and determine which best predicts mortality in hemodialysis patients. Methods: This prospective study included 106 adult chronic hemodialysis patients. Their mean age was 56.3 ± 14.9 years and mean body mass index 24.8 (21.8-28.9); 52 % were men and they had been on dialysis for 24 (5-55) months. Nutritional status was classified according to the diagnostic systems proposed by Wolfson et al. (Am J Clin Nutr 39(4):547-555, 1984), International Society of Renal Nutrition and Metabolism (ISRNM) (Fouque et al. in Kidney Int 73(4):391-398, 2008), and Beberashvili et al. (Nephrol Dial Transplant 25(8):2662-2671, 2010). During about 2 years of follow-up, mortality was assessed by Kaplan-Meier curves, log-rank, and Cox's models adjusted for diabetes, sex, C-reactive protein, time on dialysis, age, and fractional urea clearance. Results: Twenty-three deaths (21.5 %) occurred during the study period. According to the systems of Wolfson, Beberashvili, and the ISRNM, 54, 32, and 20 % of patients, respectively, had malnutrition. Both univariate and multivariate analyses showed that the ISRNM system was the only one that predicted poorer survival (fourfold higher death risk) in malnourished patients. Conclusions: The scoring system proposed by the ISRNM most accurately identifies patients at higher risk of death. © 2013 Springer Science+Business Media Dordrecht.

Time-course morphological and functional disorders of the kidney induced by long-term high-fat diet intake in female rats

BackgroundEvidence is emerging that highlights the far-reaching consequences of a high-fat diet (HFD) on kidney morphology and function disorders.MethodsThe present study was performed on 3-, 5-, 7- and 9-week-old HFD female rats compared with the appropriate gender and age-matched animals. We evaluated the kidney expression of angiotensin type II receptor and fibrotic and epithelial-to-mesenchymal transition (EMT) markers, by immunoblotting and immunohistochemical and histological techniques, in parallel with kidney function.ResultsIn the current study, the time-course HFD-treated group showed, by immunoblotting and immunohistochemical analysis, an early time-course increase in the expression of transforming growth factor β-1 (TGFβ-1) in the entire kidney of HFD-treated rats, compared with that observed in the control group. Simultaneously, the study shows a transient increase in the expression of ZEB2 in the HFD whole kidney accompanied by a fall in the E-cadherin expression and increased collagen and fibronectin deposition. A pronounced decrease in fractional urinary sodium excretion was also demonstrated in the long-term HFD-treated rats. The decreased FENa + was accompanied by a fall in FEPNa + and FEPP Na +, which occurred in association with significantly decreased CCr and, certainly on the sodium-filtered load. The reduction in the glomerular filtration rate (GFR) occurred in parallel to proteinuria and glomerular desmin overexpression.ConclusionsThe results of the current study suggest that podocyte injury in parallel with observed proteinuria and evidence of EMT transformation are associated with long-term loss of kidney function and renal sodium and water retention. © 2013 The Author. All rights reserved.

Cardiovascular risk and mortality in end-stage renal disease patients undergoing dialysis: sleep study, pulmonary function, respiratory mechanics, upper airway collapsibility, autonomic nervous activity, depression, anxiety, stress and quality of life: a prospective, double blind, randomized controlled clinical trial

Background: Chronic kidney disease (CKD) is one of the most serious public health problems. The increasing prevalence of CKD in developed and developing countries has led to a global epidemic. The hypothesis proposed is that patients undergoing dialysis would experience a marked negative influence on physiological variables of sleep and autonomic nervous system activity, compromising quality of life.Methods/Design: A prospective, consecutive, double blind, randomized controlled clinical trial is proposed to address the effect of dialysis on sleep, pulmonary function, respiratory mechanics, upper airway collapsibility, autonomic nervous activity, depression, anxiety, stress and quality of life in patients with CKD. The measurement protocol will include body weight (kg); height (cm); body mass index calculated as weight/height(2); circumferences (cm) of the neck, waist, and hip; heart and respiratory rates; blood pressures; Mallampati index; tonsil index; heart rate variability; maximum ventilatory pressures; negative expiratory pressure test, and polysomnography (sleep study), as well as the administration of specific questionnaires addressing sleep apnea, excessive daytime sleepiness, depression, anxiety, stress, and quality of life.Discussion: CKD is a major public health problem worldwide, and its incidence has increased in part by the increased life expectancy and increasing number of cases of diabetes mellitus and hypertension. Sleep disorders are common in patients with renal insufficiency. Our hypothesis is that the weather weight gain due to volume overload observed during interdialytic period will influence the degree of collapsibility of the upper airway due to narrowing and predispose to upper airway occlusion during sleep, and to investigate the negative influences of haemodialysis in the physiological variables of sleep, and autonomic nervous system, and respiratory mechanics and thereby compromise the quality of life of patients.

Different outcomes of peritoneal catheter percutaneous placement by nephrologists using a trocar versus the Seldinger technique: the experience of two Brazilian centers

A good catheter implantation technique is important to allow effective peritoneal access function and long-term technique survival. Studies regarding results obtained by nephrologists in comparison with different techniques have been limited. The aim of this study was to investigate the rate of early catheter-related complications and catheter survival in two Brazilian centers, according to two different percutaneous methods of catheter implantation performed by nephrologist team. Adult incident patients recruited from January 2006 to July 2013 having undergone first peritoneal dialysis (PD) catheter implantation were included in the analysis. Mechanical and infectious early complication rates were defined as time to the first event occurring up to 3 months. Four hundred and forty-five consecutive Tenckhoff catheters were implanted by nephrologist team percutaneously after antibiotic prophylaxis in an operating room: trocar was used in 349 (78.4 %) and Seldinger technique (ST) in 99 (21.6 %). The ST was significantly associated with a lower rate of leak (16.3 vs 3 %, p = 0.03) and outflow failure due to tip catheter migration (22.6 vs 10.1 %, p = 0.04), while early infectious complication rates were similar between the two groups (p = 0.59). Long-term catheter survival was higher in Seldinger group (log-rank, p = 0.031). By Cox multivariate analysis, adjusted for age, sex, and diabetes, the ST remained independently associated with better catheter survival [HR 0.681 (0.462-0.910), p = 0.04]. As conclusion, our experience showed better PD outcomes with the ST than trocar method of catheter implantation by nephrologist.

Quantified power Doppler as a predictor of delayed graft function after renal transplantation

No safe ultrasound (US) parameters have been established to differentiate the causes of graft dysfunction.To define US parameters and identify the predictors of normal graft evolution, delayed graft function (DGF), and rejection at the early period after kidney transplantation.Between June 2012 and August 2013, 79 renal transplant recipients underwent US examination 1-3 days posttransplantation. Resistive index (RI), power Doppler (PD), and RI + PD (quantified PD) were assessed. Patients were allocated into three groups: normal graft evolution, DGF, and rejection.Resistive index of upper and middle segments and PD were higher in the DGF group than in the normal group. ROC curve analysis revealed that RI + PD was the index that best correlated with DGF (cutoff = 0.84). In the high RI + PD group, time to renal function recovery (6.33 +/- A 6.5 days) and number of dialysis sessions (2.81 +/- A 2.8) were greater than in the low RI + PD group (2.11 +/- A 5.3 days and 0.69 +/- A 1.5 sessions, respectively), p = 0.0001. Multivariate analysis showed that high donor final creatinine with a relative risk (RR) of 19.7 (2.01-184.7, p = 0.009) and older donor age (RR = 1.17 (1.04-1.32), p = 0.007) correlated with risk DGF.Quantified PD (RI + PD) was the best DGF predictor. PD quantification has not been previously reported .

Bladder augmentation in rabbits with anionic collagen membrane, with or without urotelial preservation. Cistometric and hystologic evaluation

The use of bowel segments to perform bladder augmentation is associated with several metabolic and surgical complications. A great variety of synthetic materials, biodegradable or not, have been tested. Collagen-based biomaterials have shown effectiveness for the regeneration and obtainment of a functional bladder. Assess the functional and histological response of the rabbit bladder to anionic collagen membrane (ACM), either when it is anastomosed to the bladder or it is placed onto bladder after vesicomyectomy. In 15 male rabbit a partial cystectomy was performed. After 4 weeks they were divided in 3 groups. Group 1 (G1) - bladder augmentation with ACM. Group 2 (G2) ACM is placed onto bladder after vesicomyectomy. Group 3 (G3) control group. Maximal bladder capacity (MBC) and weight were assessed with 4 (M1), 8 (M2) and 12 (M3) weeks after partial cystectomy. In M3 was performed the sacrifice and extraction of the bladder and kidneys for anatomopathologic study. There were neither bladder stones, nor implant extrusion in M3. There was a significant increase in MBC in G1 and G2 (p<0.05), but no statistical differences in G3 (p=0.35). There is no significant difference comparing G1 and G2. In M3, both groups have shown a bigger MBC than G3 (p<0.05). The microscopic assessment showed an inflammatory reaction in the bladder augmented, with urothelium preserved. The ACM was effective for the increase of MBC. The bladders with preservation of the urothelium have shown an extensive inflammatory process.

Sedoanalgesia with midazolam and fentanyl citrate controls probe pain during prostate biopsy by transrectal ultrasound

To assess the pain intensity of patients administered midazolam and fentanyl citrate before undergoing transrectal ultrasound-guided prostate biopsy. This was a study in patients with different indications for prostate biopsy in whom 5 mg of midazolam and 50 µg of fentanyl citrate was administered intravenously 3 minutes before the procedure. After biopsy, pain was assessed by use of a visual analogue scale (VAS) in three stages: VAS 1, during probe introduction; VAS 2, during needle penetration into prostate tissue; and VAS 3, in the weeks following the exam. Pain intensity at these different times was tested with stratification by age, race, education, prostate volume, rebiopsy, and anxiety before biopsy. Pain was ranked according to the following scores: 0 (no pain), 1-3 (mild pain), 4-7 (moderate pain), and 8-10 (severe pain). Statistical analysis was performed by using Kruskal-Wallis and Wilcoxon two-tailed tests with a significance of 5%. Pain intensity was not influenced by any risk factors. The mean VAS 1 score was 1.95±1.98, the mean VAS 2 score was 2.73±2.55, and the mean VAS 3 score was 0.3±0.9, showing greater pain at the time of needle penetration than in other situations (VAS 2>VAS 1>VAS 3, p=0.0013, p=0.0001, respectively). Seventy-five percent of patients reported a VAS pain scale of less than 3.1 or mild pain. Intravenous sedation and analgesia with midazolam and fentanyl citrate is a good method for reducing pain caused by prostate biopsy, even during probe insertion.

Acute kidney injury in septic patients admitted to emergency clinical room: risk factors and outcome

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Surgical Performance During Laparoscopic Radical Nephrectomy Is Improved With Training in a Porcine Model

Background and Purpose: Becoming proficient in laparoscopic surgery is dependent on the acquisition of specialized skills that can only be obtained from specific training. This training could be achieved in various ways using inanimate models, animal models, or live patient surgery-each with its own pros and cons. Currently, there are substantial data that support the benefits of animal model training in the initial learning of laparoscopy. Nevertheless, whether these benefits extent themselves to moderately experienced surgeons is uncertain. The purpose of this study was to determine if training using a porcine model results in a quantifiable gain in laparoscopic skills for moderately experienced laparoscopic surgeons. Materials and Methods: Six urologists with some laparoscopic experience were asked to perform a radical nephrectomy weekly for 10 weeks in a porcine model. The procedures were recorded, and surgical performance was assessed by two experienced laparoscopic surgeons using a previously published surgical performance assessment tool. The obtained data were then submitted to statistical analysis. Results: With training, blood loss was reduced approximately 45% when comparing the averages of the first and last surgical procedures (P = 0.006). Depth perception showed an improvement close to 35% (P = 0.041), and dexterity showed an improvement close to 25% (P = 0.011). Total operative time showed trends of improvement, although it was not significant (P = 0.158). Autonomy, efficiency, and tissue handling were the only aspects that did not show any noteworthy change (P = 0.202, P = 0.677, and P = 0.456, respectively). Conclusions: These findings suggest that there are quantifiable gains in laparoscopic skills obtained from training in an animal model. Our results suggest that these benefits also extend to more advanced stages of the learning curve, but it is unclear how far along the learning curve training with animal models provides a clear benefit for the performance of laparoscopic procedures. Future studies are necessary to confirm these findings and better understand the impact of this learning tool on surgical practice.

Prevention of Intradialytic Hypotension in Patients with Acute Kidney Injury Submitted to Sustained Low-Efficiency Dialysis

Objectives: This study evaluated the effects of a protocol aiming to reduce hypotension in acute kidney injury (AKI) patients submitted to sustained low-efficiency dialysis (SLED). Methods: Patients were randomly assigned to two SLED prescriptions-control group, dialysate temperature was 37.0 degrees C with a fixed sodium concentration [138 mEq/L] and ultrafiltration (UF) rate; and profiling group, dialysate temperature was 35.5 degrees C with a variable sodium concentration [150-138 mEq/L] and UF rate. Results: Sixty-two SLED sessions were evaluated (34 in profiling and 28 in control). Patients (n = 31) were similar in terms of gender, age, and Sequential Organ Failure Assessment (SOFA) score. Dialysis time, dialysis dose, and post-dialysis serum sodium were similar in both groups. The profiling group had significantly less hypotension episodes (23% vs. 57% in control, p = 0.009) and achieved higher UF volume (2.23 +/- 1.25 L vs. 1.59 +/- 1.03 L in control, p = 0.04) when compared with control group. Conclusions: SLED protocol with modulation of dialysate temperature, sodium, and UF profiling showed similar efficacy but less intradialytic hypotension when compared with a standard SLED prescription.

When Is the Best Moment to Assess the Ankle Brachial Index: Pre- or Post-Hemodialysis?

Background: Cardiovascular disease is an important cause of death in patients on dialysis. Peripheral arterial disease (PAD) is a prognostic factor for cardiovascular disease. The ankle brachial index (ABI) is a noninvasive method used for the diagnosis of PAD. The difference between ABI pre- and post-dialysis had not yet been formally tested, and it was the main objective of this study. Methods:The ABI was assessed using an automated oscillometric device in incident patients on hemodialysis. All blood pressure readings were taken in triplicate pre- and post-dialysis in three consecutive dialysis sessions (times 1, 2, and 3). Results: One hundred and twenty-three patients (85 men) aged 53 +/- 19 years were enrolled. We found no difference in ABI pre- and post-dialysis on the right or left side, and there was no difference in times 1, 2, and 3. In patients with a history of PAD, the ABI pre- versus post-dialysis were of borderline significance on the right side (p = 0.088). Conclusion: ABI measured pre- and post-dialysis presented low variability. The ABI in patients with a history of PAD should be evaluated with caution. The applicability of the current method in predicting mortality among patients on hemodialysis therefore needs further investigation. Copyright (C) 2012 S. Karger AG, Basel

Silent Ureteral Stones: Impact on Kidney Function-Can Treatment of Silent Ureteral Stones Preserve Kidney Function?

OBJECTIVE To report our experience with silent ureteral stones and expose their true influence on renal function. METHODS We analyzed 506 patients who had undergone ureterolithotripsy from January 2005 to May 2010. Silent ureteral stones were calculi found in the absence of any specific or subjective ureteral stone-related symptoms. Of the 506 patients, 27 (5.3%) met these criteria (global cohort). All patients were assessed postoperatively with dimercaptosuccinic acid scintigraphy (DMSA). A difference in relative kidney function of >10% was considered abnormal. Pre- and postoperative comparative DMSA analyses were electively obtained for 9 patients (kidney function cohort). A t test was used to assess the numeric variables, and the chi-square test or Fisher's exact test was used for categorical variables. Two-tailed P < .05 was considered statistically significant. RESULTS Stones were diagnosed by radiologic abdominal evaluation for nonurologic diseases in 40% and after previous nephrolithiasis treatment in 33%. The primary therapy was ureterolithotripsy in 88%. The mean follow-up time was 23 months. The overall ureteral stone-free rate after 1 and 2 procedures was 96% and 100%, respectively. In the global cohort, the mean pre- and postoperative serum creatinine levels were similar (P = .39), and the mean postoperative function on DMSA was 31%. In the kidney function cohort, no difference was found between the pre-and postoperative DMSA findings (22% +/- 12.1% vs 20% +/- 11.8%; P = .83) and serum creatinine (0.8 +/- 0.13 mg/dL vs 1.0 +/- 0.21 mg/dL; P = .45). CONCLUSION Silent ureteral stones are associated with decreased kidney function present at the diagnosis. Hydronephrosis tends to diminish after stone removal, and kidney function remains unaltered. UROLOGY 79: 304-309, 2012. (C) 2012 Elsevier Inc.

The accuracy of pathological data for the prediction of insignificant prostate cancer

Introduction: The widespread screening programs prompted a decrease in prostate cancer stage at diagnosis, and active surveillance is an option for patients who may harbor clinically insignificant prostate cancer (IPC). Pathologists include the possibility of an IPC in their reports based on the Gleason score and tumor volume. This study determined the accuracy of pathological data in the identification of IPC in radical prostatectomy (RP) specimens. Materials and Methods: Of 592 radical prostatectomy specimens examined in our laboratory from 2001 to 2010, 20 patients harbored IPC and exhibited biopsy findings suggestive of IPC. These biopsy features served as the criteria to define patients with potentially insignificant tumor in this population. The results of the prostate biopsies and surgical specimens of the 592 patients were compared. Results: The twenty patients who had IPC in both biopsy and RP were considered real positive cases. All patients were divided into groups based on their diagnoses following RP: true positives (n = 20), false positives (n = 149), true negatives (n = 421), false negatives (n = 2). The accuracy of the pathological data alone for the prediction of IPC was 91.4%, the sensitivity was 91% and the specificity was 74%. Conclusion: The identification of IPC using pathological data exclusively is accurate, and pathologists should suggest this in their reports to aid surgeons, urologists and radiotherapists to decide the best treatment for their patients.

Prostate biopsy in patients with long-term use of indwelling bladder catheter: What is the rationale?

Objective: Acute urinary retention (AUR) is expected to occur in 2% to 39% men with benign prostatic hyperplasia. To date, no study has elucidated the effect of long-term use of indwelling bladder catheter on serum prostate specific antigen (PSA) levels and on the incidence of prostate cancer (CaP). The aim of the present study is to analyze the incidence of CaP in patients with long-term use of indwelling bladder catheter and determine some practice patterns on this issue. Materials and methods: The study comprised a retrospective analysis of data from 1,651 patients who had undergone transrectal ultrasound (TRUS)-guided prostate biopsy from July 2004 to June 2009. Among these patients, 198 (12%) were using an indwelling bladder catheter during the biopsy for at least 1 month. The incidence of CaP was recorded according to total PSA levels. Other variables such patient age, free/total PSA rate, PSA density, prostate volume, and duration of catheter use was also analyzed. Men with a digital rectal examination suspicious for cancer were not considered for analysis. Results: Median patient age was 71 years (37 to 89 years). Overall, 25% of patients presented a CaP diagnosis. CaP incidence according to the PSA levels was 0%, 18.9%, 24.5%, and 40.6% for patients with PSA <= 4.0, 4.1-10.0, 10.1-20.0, and >20.0 ng/ml, respectively. When prostate volume was analyzed together, we demonstrated that only 1 (2.4%) patient with PSA below 10.0 ng/ml and prostate volume >60 g had CaP. Median total PSA, PSA density, and prostate volume were statistically different between patients with and without CaP. Conclusions: Prostate biopsy should not be indicated for all patients with diagnosis of BPH and AUR who present an elevated PSA level. Patients with PSA below 10.0 ng/ml, and prostate volume >60 g should only undergo biopsy in selected cases. Patients with PSA >20.0 ng/ml and a prostate volume <= 60 g are at higher risk of CaP diagnosis. (C) 2012 Elsevier Inc. All rights reserved.