Hipertrofia ventricular esquerda e hipertensão arterial como mediadores da associação entre baixa escolaridade e mortalidade cadiovascular de pacientes em hemodiálise

Pós-graduação em Bases Gerais da Cirurgia - FMB

Impacto do acompanhamento com bioimpedância na predição de eventos cardiovasculares em pacientes em diálise crônica

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Importância da virulência nas linhagens de Staphylococcus spp. em portadores e no risco de peritonites em diálise peritoneal ambulatorial

Pós-graduação em Fisiopatologia em Clínica Médica - FMB

Influência do ganho de peso interdialítico na sobrevida e risco de óbito em pacientes tratados por hemodiálise crônica

Pós-graduação em Fisiopatologia em Clínica Médica - FMB

Modelagem em análise de sobrevivencia com eventos recorrentes aplicada a dados da área médica

Pós-graduação em Biometria - IBB

Efeito do treinamento físico na qualidade de vida, capacidade funcional e fatores de risco cardiovascular nos portadores de doença renal crônica em tratamento conservador

Pós-graduação em Fisiopatologia em Clínica Médica - FMB

Fatores associados com a regressão da hipertrofia esquerda em diálise e impacto com mortalidade cardiovascular

Pós-graduação em Fisiopatologia em Clínica Médica - FMB

Efeitos da redução da concentração de sódio na solução de hemodiálise e no conteúdo de sódio da dieta sobre a resposta inflamatória de pacientes com doença renal crônica

Pós-graduação em Fisiopatologia em Clínica Médica - FMB

Piperacillin/tazobactam-induced neurotoxicity in a hemodialysis patient: a case report

Antibiotics are potentially a cause of neurotoxicity in dialysis patients, the most common are thebeta-lactams as ceftazidime and cefepime, and few cases have been reported after piperacillin/tazobactam use. This report presents a case of a hypertensive and diabetic 67-year-old woman inregular hemodialysis, which previously had a stroke. She was hospitalized presenting pneumonia,which was initially treated with cefepime. Two days after treatment, she presented dysarthria, lefthemiparesis, ataxia, and IX and X cranial nerves paresis. Computed tomography showed no acutelesions and cefepime neurotoxicity was hypothesized, and the antibiotic was replaced bypiperacillin/tazobactam. The neurologic signs disappeared; however, 4 days after with piperacillin/tazobactam treatment, the neurological manifestations returned. A new computed tomographyshowed no new lesions, and the second antibiotic regimen withdrawn. After two hemodialysissessions, the patient completely recovered from neurological manifestations. The patient presentedsequentially neurotoxicity caused by two beta-lactams antibiotics. This report meant to alertclinicians that these antibiotics have dangerous neurological effects in chronic kidney diseasepatients.

Parathyroid hormone and phosphorus overload in uremia: impact on cardiovascular system

Background. Cardiac remodeling in uremia is characterized by left ventricular hypertrophy, interstitial fibrosis and microvascular disease. Cardiovascular disease is the leading cause of death in uremic patients, but coronary events alone are not the prevalent cause, sudden death and heart failure are. We studied the cardiac remodeling in experimental uremia, evaluating the isolated effect of parathyroid hormone (PTH) and phosphorus. Methods. Wistar rats were submitted to parathyroidectomy (PTx) and 5/6 nephrectomy (Nx); they also received vehicle (V) and PTH at normal (nPTH) or high (hPTH) doses. They were fed with a poor-phosphorus (pP) or rich-phosphorus (rP) diet and were divided into the following groups: 'Sham': G1 (V + normal-phosphorus diet (np)) and 'Nx + PTx': G2 (nPTH + pP), G3 (nPTH + rP), G4 (hPTH + pP) and G5 (hPTH + rP). After 8 weeks, biochemical analysis, myocardium morphometry and arteriolar morphological analysis were performed. In addition, using immunohistochemical analysis, we evaluated angiotensin II, alpha-actin, transforming growth factor-beta (TGF-beta) and nitrotyrosine, as well as fibroblast growth factor-23 (FGF-23), fibroblast growth factor receptor-1 (FGFR-1) and runt-related transcription factor-2 (Runx-2) expression. Results. Nx animals presented higher serum creatinine levels as well as arterial hypertension. Higher PTH levels were associated with myocardial hypertrophy and fibrosis as well as a higher coronary lesion score. High PTH animals also presented a higher myocardial expression of TGF-beta, angiotensin II, FGF-23 and nitrotyrosine and a lower expression of alpha-actin. Phosphorus overload was associated with higher serum FGF-23 levels and Runx-2, as well as myocardial hypertrophy. FGFR-1 was positive in the cardiomyocytes of all groups as well as in calcified coronaries of G4 and G5 whereas Runx-2 was positive in G3, G4 and G5. Conclusion. In uremia, PTH and phosphorus overload are both independently associated with major changes related to the cardiac remodeling process, emphasizing the need for a better control of these factors in chronic kidney disease.

La Restless Legs Syndrome aumenta il rischio cardiovascolare e la mortalità a breve termine nei pazienti emodializzati

Abstract Restless legs syndrome (RLS) is a sensori-motor neurological disorder characterzed by paraesthesia, dysaesthesia and irresistibile urge to move the legs especially at night. Its prevalence is much higher among dialysis patients at 12 to 62% compared to 3 to 9% in the general population. In our study we investigated the association between RLS and cardiovascular events risk and laboratory parameters in End-stage kidney disease (ESKD) patients on dialysis. We studied 100 ESKD patients undergoing hemodialysis that were enrolled in an 18-months prospective observational study. The main outcomes were the association of RLS with new cardiovascular events and cardiovascular mortality. RLS affected 31% of the study population. It was associated with female gender, gradual reduction in residual dieresis, lower albumin (P=0.039) and inflammation, but not the dialysis parameters spKt/V and URR. During observation, 47% of patients experienced new cardiovascular events (64.5% with and 39.1% without RLS; P=0.019). Mortality was 20.0% in all patients, 32.3% in those with and 14.5% in patients without RLS (P=0.04). This study confirmed the high prevalence of RLS among dialysis patients and the associations between the severity of RLS and the risk of new cardiovascular events and higher short-term mortality. Abstract Restless legs syndrome (RLS) is a sensori-motor neurological disorder characterzed by paraesthesia, dysaesthesia and irresistibile urge to move the legs especially at night. Its prevalence is much higher among dialysis patients at 12 to 62% compared to 3 to 9% in the general population. In our study we investigated the association between RLS and cardiovascular events risk and laboratory parameters in End-stage kidney disease (ESKD) patients on dialysis. We studied 100 ESKD patients undergoing hemodialysis that were enrolled in an 18-months prospective observational study. The main outcomes were the association of RLS with new cardiovascular events and cardiovascular mortality. RLS affected 31% of the study population. It was associated with female gender, gradual reduction in residual dieresis, lower albumin (P=0.039) and inflammation, but not the dialysis parameters spKt/V and URR. During observation, 47% of patients experienced new cardiovascular events (64.5% with and 39.1% without RLS; P=0.019). Mortality was 20.0% in all patients, 32.3% in those with and 14.5% in patients without RLS (P=0.04). This study confirmed the high prevalence of RLS among dialysis patients and the associations between the severity of RLS and the risk of new cardiovascular events and higher short-term mortality.

Studio multicentrico sulla prevalenza e sulle principali caratteristiche cliniche e biochimiche nei pazienti in dialisi paratiroidectomizzati in italia

Lo studio CAVE PTX ha lo scopo di valutare la reale prevalenza della paratiroidectomia nei pazienti dializzati in Italia, verificare l’aderenza ai targets ematochimici proposti dalle linee guida internazionali K/DOQI e ricercare la presenza di fratture vertebrali e calcificazioni vascolari. Al momento attuale riportiamo i dati preliminari sulla prevalenza e le caratteristiche cliniche generali dei pazienti finora arruolati. Il nostro studio ha ricevuto contributi da 149 centri dialisi italiani, su un totale di 670, pari al 22%. La popolazione dialitica dalla quale sono stati ottenuti i casi di paratiroidectomia è risultata pari a 12515 pazienti;l’87,7% dei pazienti effettuava l’emodialisi mentre il 12,3% la dialisi peritoneale. Cinquecentoventotto, pari al 4,22%, avevano effettuato un intervento di paratiroidectomia (4,5%emodializzati, 1,9% in dialisi peritoneale;p<0.001). Abbiamo considerato tre gruppi differenti di PTH: basso (<150 pg/ml), ottimale (150 -300 pg/ml) ed elevato (>300 pg/ml). I valori medi di PTH e calcemia sono risultati significativamente diversi (più alti) tra casi e controlli nei due gruppi con PTH basso (PTX = 40±39 vs controllo = 92±42 pg/ml; p<.0001) e PTH alto (PTX= 630 ± 417 vs controllo 577 ±331; p<.05). La percentuale di pazienti con PTH troppo basso è risultata più elevata nei pazienti chirurgici rispetto al resto della popolazione (64vs23%; p<0.0001), mentre la percentuale dei casi con PTH troppo alto è risultata significativamente più alta nel gruppo di controllo (38%vs19%; p<0.003). Il 61% dei casi assumeva vitamina D rispetto al 64 % dei controlli; l’88% vs 75% un chelante del fosforo ed il 13%vs 35% il calciomimentico. In conclusione, la paratiroidectomia ha una bassa prevalenza in Italia, i pazienti sono più spesso di sesso femminile, in emodialisi e con età relativamente giovane ma da più tempo in dialisi.

Compliance- und Lebensqualitätsmessung bei Patienten vor einer Nieren- oder Lebertransplantation

Die Arzneimittelcompliance hat eine hohe Vorhersagekraft für den Ausgang einer Organtransplantation. Allerdings wurden soweit keine Studien zur Arzneimittelcompliance mittels eletronischen Compliancemessung bei Dialyse- und Leberzirrhosepatienten durchgeführt. Das primäre Ziel dieser Studie war die Arzneimittelcompliance dieser beiden Patientenkollektive zu evaluieren und als sekundäres Ziel wurden die Einflussfaktoren von Non-Compliance untersucht. rnLeberzirrhosepatinten, die Propranolol und Dialysepatienten, die Phosphatbinder, jeweils 3 x tgl. einnahmen, konnten in der Studie teilnehmen. Die Arzneimittelcompliance wurde mittels MEMSTM über einen Zeitraum von jeweils 6 Monaten bestimmt. Des Weiteren wurde nach Einflussfaktoren wie die demopraphischen Daten, Depression, Lebensqualität und der Gesundheitszustand, bei den Dialysepatienten zusätzlich die Formulierung der Phosphatbinder und die Anzahl evaluiert. Zwischen den organinsuffizienten Patientenkollektiven war ein signifikanter Unterschied in der Dosing Compliancerate auszumachen (p<0,023). Die mittlere DC Rate war bei 61%±6% für Leberzirrhosepatienten im Vergleich zu 43%±5% in Dialysepatienten. Nur 10 Leberzirrhosepatienten (30%) and 6 Dialysepatienten (17%) konnten als compliant eingestuft werden. Je höher die Phosphatbinderdosen waren, umso niedrigere Dosing Complianceraten wurden erzielt. Bei 1,5-3 Tabletten pro Tag betrug die Compliancerate 55%±8% (n=16), bei 4-6 Tabletten pro Tag nur noch 37%±7% (n=15) und bei mehr als 7 Tabletten lediglich 21%±10% (n=5) (p<0,036). Bei den Dialysepatienten war jedoch auffällig, dass die Dosing Compliancerate in Abhängigkeit von der Anzahl der dokumentierten Erkrankungen inkl. Grunderkrankung stieg (Dosing Compliancerate 34%±9% für ≤1 Grunderkrankung, 42%±6% für 1-4 Komorbiditäten, 83%±3% für ≥5 Komorbiditäten; p<0,036).Das geringe Patientenwissen über die Arzneimittel und die Erkrankung und die niedrige Compliancerate bedürfen weitere Untersuchungen um die Aspekte zu verbessern. Diese Studie zeigte das eine pharmazeutische Betreuung schon vor einer Transplantation benötigt wird. Aber eine pharmazeutische Betreuung ist sehr kosten- und zeitintensiv. Vielleicht müssen neue Modelle der pharmazeutische Betreuung untersucht werden oder non-compliante Patienten müssen noch besser identifiziert werden für eine selektive pharmazeutische Betreuung.

Demographics of blood pressure and hypertension in children on renal replacement therapy in Europe

Hypertension is a well-known complication in children on renal replacement therapy and an important risk factor for cardiovascular disease in later life. In order to define the prevalence of and risk factors for hypertension among children, we enrolled 3337 pediatric patients from 15 countries in the ESPN/ERA-EDTA Registry of whom 464 were on hemodialysis, 851 on peritoneal dialysis, and 2023 had received a renal allograft. Hypertension was defined as either systolic or diastolic blood pressures in the 95th percentile or greater for age, height, and gender or use of antihypertensive medication. Analyses were adjusted for age, gender, duration, and modality of renal replacement therapy. In 10 countries in which information on the use of antihypertensive medication was available, hypertension was present in over two-thirds of hemodialysis, peritoneal dialysis, or transplant patients. Blood pressure values above the 95th percentile were significantly more prevalent in very young patients (under 3 years) compared to 13- to 17-year olds (odds ratio 2.47), during the first year compared to over 5 years of renal replacement therapy (odds ratio 1.80), and in patients on hemodialysis compared to transplant recipients or those on peritoneal dialysis (odds ratios of 2.48 and 1.59, respectively). Over time, mean blood pressures decreased in both hemodialysis and transplant patients, but not in peritoneal dialysis patients. Hence, our findings highlight the extent of the problem of hypertension in children with end-stage renal disease in Europe.

Effect of transcutaneous electrical muscle stimulation and passive cycling movements on blood pressure and removal of urea and phosphate during hemodialysis

BACKGROUND: Intradialytic exercise has been described to improve blood pressure stability and dialysis efficacy. However, comorbid conditions in the dialysis population often preclude the widespread use of active intradialytic exercise. Therefore, we investigated the effect of intradialytic transcutaneous muscle stimulation (TEMS) and passive cycling movements (PCMs) on blood pressure and dialysis efficacy in patients. STUDY DESIGN: Prospective, controlled, randomized, crossover investigation. SETTING ; PARTICIPANTS: Ten patients were randomly allocated to TEMS, PCMs, or no intervention (NI) for 9 consecutive dialysis sessions. INTERVENTION: Participants were studied with NI, PCMs using a motor-driven ergometer, and bilateral TEMS of the leg musculature. Individual dialysis prescriptions were unchanged during the investigation. OUTCOMES ; MEASUREMENTS: The effect of TEMS and PCMs on blood pressure and dialysis efficacy in patients was assessed. RESULTS: Mean blood pressure increased from 121/64 +/- 21/15 mm Hg with NI to 132/69 +/- 21/15 mm Hg (P < 0.001) during sessions with PCMs and 125/66 +/- 22/16 mm Hg (P < 0.05) during sessions with TEMS. Urea and phosphate removal during dialysis were significantly (P < 0.001) greater with TEMS (19.4 +/- 3.7 g/dialysis and 1,197 +/- 265 mg/dialysis) or PCMs (20.1 +/- 3.4 g/dialysis and 1,172 +/- 315 mg/dialysis) than with NI (15.1 +/- 3.9 g/dialysis and 895 +/- 202 mg/dialysis). Body weight, ultrafiltration, Kt/V, and increases in hemoglobin and albumin levels during dialysis did not differ among the NI, PCMs, and TEMS groups. LIMITATIONS: The study design does not allow extension of the findings to prolonged treatment. CONCLUSION: Future studies during longer observation periods will have to prove the persistence of these acute findings. Both TEMS and PCMs deserve future investigations in dialysis patients because they increase intradialytic blood pressure and facilitate urea and phosphate removal when applied short term.