The impact of body mass index (BMI) variation on mortality of incident elderly patients on peritoneal dialysis: a joint model analysis.

INTRODUCTION: Data on impact of high body mass index (BMI) on mortality of patients on peritoneal dialysis (PD), especially among elderly, are inconsistent. Objective: To evaluate impact of BMI on cohort of incident elderly PD patients over time. METHODS: Prospective multicenter cohort study (December / 2004-October/2007) with 674 patients. Socio-demographic and clinical data evaluated with patients followed until death, transfer to hemodialysis (HD), recovery of renal function, loss of follow-up or transplant. Patients were divided into incident on renal replacement therapy (RRT) for PD (PD first: 230) and transferred from hemodialysis (HD first: 444). Analysis was performed comparing these two groups using chi-square or Kruskal Wallis. Similar analysis was used to compare patients on automated peritoneal dialysis (APD) vs. continuous ambulatory peritoneal dialysis (CAPD). Data were compared between patients according to BMI by ANOVA, Kruskal Wallis or chi-square. For analysis of survival, Kaplan Meier method was used and to adjust confounding variables, Cox regression proportional hazard. Joint model for longitudinal and time-dependent data was conducted, assessing impact that a longitudinal variable displays on time of survival. RESULTS: Malnourished patients (76.79 ± 7.53 years) were older (p < 0.0001) with higher percentage of death (44.6%, p = 0.001); diabetes mellitus showed high prevalence in obese patients (68%, p < 0.0001); higher blood pressure levels (p = 0.002) were present in obese and overweight patients. CONCLUSIONS: Increased BMI variation over time proved to be a protective factor, with a decrease of about 1% in risk of death for every BMI unit earned.

The impact of body mass index (BMI) variation on mortality of incident elderly patients on peritoneal dialysis: a joint model analysis / O impacto da variação do índice de massa corporal (IMC) na mortalidade de pacientes idosos incidentes em diálise peritoneal

Abstract Introduction: Data on impact of high body mass index (BMI) on mortality of patients on peritoneal dialysis (PD), especially among elderly, are inconsistent. Objective: To evaluate impact of BMI on cohort of incident elderly PD patients over time. Methods: Prospective multicenter cohort study (December / 2004-October/2007) with 674 patients. Socio-demographic and clinical data evaluated with patients followed until death, transfer to hemodialysis (HD), recovery of renal function, loss of follow-up or transplant. Patients were divided into incident on renal replacement therapy (RRT) for PD (PD first: 230) and transferred from hemodialysis (HD first: 444). Analysis was performed comparing these two groups using chi-square or Kruskal Wallis. Similar analysis was used to compare patients on automated peritoneal dialysis (APD) vs. continuous ambulatory peritoneal dialysis (CAPD). Data were compared between patients according to BMI by ANOVA, Kruskal Wallis or chi-square. For analysis of survival, Kaplan Meier method was used and to adjust confounding variables, Cox regression proportional hazard. Joint model for longitudinal and time-dependent data was conducted, assessing impact that a longitudinal variable displays on time of survival. Results: Malnourished patients (76.79 ± 7.53 years) were older (p < 0.0001) with higher percentage of death (44.6%, p = 0.001); diabetes mellitus showed high prevalence in obese patients (68%, p < 0.0001); higher blood pressure levels (p = 0.002) were present in obese and overweight patients. Conclusions: Increased BMI variation over time proved to be a protective factor, with a decrease of about 1% in risk of death for every BMI unit earned.

Resumo Introdução: Dados sobre o impacto do índice de massa corporal (IMC) sobre mortalidade de pacientes em diálise peritoneal (DP), especialmente entre os idosos, são inconsistentes. Objetivo: Avaliar o impacto do IMC sobre a mortalidade de coorte de pacientes incidentes idosos em DP ao longo do tempo. Métodos: Estudo de coorte prospectivo multicêntrico (dezembro de 2004 a outubro de 2007), com 674 pacientes. Avaliados dados sociodemográficos, clínicos e pacientes acompanhados até morte, transferência para hemodiálise (HD), recuperação da função renal, perda de seguimento ou transplante. Pacientes foram divididos em incidentes em terapia renal substitutiva por PD (230) e transferidos da hemodiálise (444). A análise foi feita comparando estes dois grupos usando Qui-Quadrado ou Kruskal Wallis. Análise semelhante foi utilizada para comparar os pacientes em diálise peritoneal automatizada vs. diálise peritoneal ambulatorial contínua. Os dados foram comparados entre pacientes de acordo com o IMC por ANOVA, Kruskal Wallis ou Qui-Quadrado. Para análise de sobrevivência, método de Kaplan Meier foi utilizado e, para ajustar variáveis confundidoras, usada regressão de Cox. Um modelo conjunto para dados longitudinais tempo-dependente foi utilizado, avaliando o impacto de variações longitudinais sobre a sobrevida. Resultados: Pacientes desnutridos (76,79 ± 7,53 anos), eram mais velhos (p < 0,0001) e apresentaram maior mortalidade (44,6%, p = 0,001). Diabetes mellitus foi mais prevalente em obesos (68%, p < 0,0001); níveis mais elevados de pressão arterial (p = 0,002) também foram mais frequentes em obesos e com sobrepeso. Conclusão: A variação positiva do IMC ao longo do tempo provou ser um fator de proteção, com uma diminuição de cerca de 1% no risco de morte por unidade de elevação do IMC.

Dialysis in the elderly patient: a challenge of the XXI century--narrative review.

With the increase in life expectancy, the improvement of therapeutic arsenal, knowledge and control of chronic degenerative diseases, the world population has reached older age groups. As advanced age is a risk factor for chronic kidney disease (CKD), along with the bonus of increased survival, today we are experiencing the greatest burden of progressive incidence of elderly patients on renal replacement therapy (RRT). Dialysis in elderly patients, which for three decades was considered out of question, today is a routine for nephrologists, who face the challenge of providing care to elderly patients with CKD stage 5 with dialysis indication. In fact, what we see nowadays are dialysis incidents elderly patients as the fastest growing group on RRT. Although without reaching a consensus, it seems indisputable that for elderly patients with CKD, the most important is the quality of life. In this paper we discuss the dialysis in the elderly patient.

Diálise no paciente idoso: um desafio do século XXI - revisão narrativa / Dialysis in the elderly patient: a challenge of the XXI century - narrative review

Com o aumento da expectativa de vida, com a melhora do arsenal terapêutico, conhecimento e controle das doenças crônicas degenerativas, a população mundial tem atingido faixas etárias elevadas. Por ser a idade avançada fator de risco para a doença renal crônica (DRC), juntamente com o bônus da maior sobrevida, vive-se hoje o ônus da maior e progressiva incidência de pacientes idosos em terapia renal substitutiva (TRS). A diálise nos pacientes idosos, que há três décadas era considerada fora de questão, hoje em dia é rotina para o nefrologista, que enfrenta o desafio de prestar atendimento a pacientes idosos com DRC em estágio 5 com indicação dialítica. Atualmente, o grupo de pacientes idosos incidentes em diálise é o que mais cresce. Apesar de não se haver chegado a um consenso, parece ser indiscutível que o importante é viver com qualidade de vida. Neste artigo, buscamos discutir a diálise no paciente idoso.

With the increase in life expectancy, the improvement of therapeutic arsenal, knowledge and control of chronic degenerative diseases, the world population has reached older age groups. As advanced age is a risk factor for chronic kidney disease (CKD), along with the bonus of increased survival, today we are experiencing the greatest burden of progressive incidence of elderly patients on renal replacement therapy (RRT). Dialysis in elderly patients, which for three decades was considered out of question, today is a routine for nephrologists, who face the challenge of providing care to elderly patients with CKD stage 5 with dialysis indication. In fact, what we see nowadays are dialysis incidents elderly patients as the fastest growing group on RRT. Although without reaching a consensus, it seems indisputable that for elderly patients with CKD, the most important is the quality of life. In this paper we discuss the dialysis in the elderly patient.

A Brazilian experience in assisted automated peritoneal dialysis: a reliable and effective home care approach.

INTRODUCTION: Automated assisted peritoneal dialysis (AAPD) has been shown to be successful as renal replacement therapy for elderly and physically incapable end-stage renal disease (ESRD) patients. In early 2003, a pioneer AAPD program was initiated at GAMEN Renal Clinic in Rio de Janeiro, Brazil. ♢ OBJECTIVE: We evaluated the results of an AAPD program offered as an option to elderly ESRD patients with physical or cognitive debilities or as last resort to patients with vascular access failure or hemodynamic instability during hemodialysis. ♢ METHODS: A cohort of 30 consecutive patients started AAPD from January 2003 to March 2008 and was followed to July 2009. Demographics, clinical and laboratory parameters, causes of death, and patient and technique survival were analyzed. ♢ RESULTS: Median age of the patients was 72 years (range: 47 - 93 years), with 60% being older than 65. The Davies score was greater than 2 in 73% of patients, and the Karnofsky index was less than 70 in 40%. The overall peritonitis rate was 1 episode in 37 patient-months. The total duration of AAPD ranged from 3 to 72 months. Patient survival was 80% at 12 months, 60% at 24 months, and 23.3% at 48 months. The most common cause of death was cardiovascular problems (70%). ♢ CONCLUSIONS: In this clinical observational study, AAPD fulfilled its expected role, offering an opportune, reliable, and effective homecare alternative for ESRD patients with no other renal replacement therapy options.

Body size and longitudinal body weight changes do not increase mortality in incident peritoneal dialysis patients of the Brazilian peritoneal dialysis multicenter study.

OBJECTIVES: To determine the roles of body size and longitudinal body weight changes in the survival of incident peritoneal dialysis patients. PATIENTS AND METHODS: Patients (n = 1911) older than 18 years of age recruited from 114 dialysis centers (Dec/ 2004-Oct/2007) and participating in the Brazilian Peritoneal Dialysis Multicenter Cohort Study were included. Clinical and laboratory data were collected monthly (except if the patient received a transplant, recovered renal function, was transferred to hemodialysis, or died). RESULTS: Survival analyses were performed using Kaplan-Meier survival curves and Cox proportional hazards. Total follow-up was 34 months. The mean age was 59 years (54% female). The weight category percentages were as follows: underweight: 8%; normal: 51%; overweight: 29%; and obese 12%. The multivariate model showed a higher risk of death for a body mass index <18.5 kg/m², a neutral risk between 25 and 29.9 kg/m² and a protective effect for an index >30 kg/m². Patients were divided into five categories according to quintiles of body weight changes during the first year of dialysis: <-3.1%, -3.1 to+0.12%, +0.12 to <+3.1% (reference category), +3.1 to +7.1% and >+7.1%. Patients in the lowest quintile had significantly higher mortality, whereas no negative impact was observed in the other quintiles. CONCLUSION: These findings suggest that overweight/obesity and a positive body weight variation during the first year of peritoneal dialysis therapy do not increase mortality in incident dialysis patients in Brazil.

Body size and longitudinal body weight changes do not increase mortality in incident peritoneal dialysis patients of the Brazilian peritoneal dialysis multicenter study

OBJECTIVES: To determine the roles of body size and longitudinal body weight changes in the survival of incident peritoneal dialysis patients. PATIENTS AND METHODS: Patients (n = 1911) older than 18 years of age recruited from 114 dialysis centers (Dec/ 2004-Oct/2007) and participating in the Brazilian Peritoneal Dialysis Multicenter Cohort Study were included. Clinical and laboratory data were collected monthly (except if the patient received a transplant, recovered renal function, was transferred to hemodialysis, or died). RESULTS: Survival analyses were performed using Kaplan-Meier survival curves and Cox proportional hazards. Total follow-up was 34 months. The mean age was 59 years (54% female). The weight category percentages were as follows: underweight: 8%; normal: 51%; overweight: 29%; and obese 12%. The multivariate model showed a higher risk of death for a body mass index <18.5 kg/m², a neutral risk between 25 and 29.9 kg/m² and a protective effect for an index >30 kg/m². Patients were divided into five categories according to quintiles of body weight changes during the first year of dialysis: <-3.1%, -3.1 to+0.12%, +0.12 to <+3.1% (reference category), +3.1 to +7.1% and >+7.1%. Patients in the lowest quintile had significantly higher mortality, whereas no negative impact was observed in the other quintiles. CONCLUSION: These findings suggest that overweight/obesity and a positive body weight variation during the first year of peritoneal dialysis therapy do not increase mortality in incident dialysis patients in Brazil.

Diagnóstico precoce e tratamento da insuficiência renal crônica em idosos / Early diagnosis and treatment of chronic renal failure in elderly

A insuficiência renal crônica é um problema de saúde pública mundial, afetando todas as idades. Atualmente apresenta prevalência acentuada entre os pacientes idosos. Seu diagnóstico envolve a necessidade de classificação quanto ao estágio em que o paciente se encontra. A avaliação da função renal mais prática inclui as fórmulas de cálculo do ritmo de filtração glomerular (RFG), que são apresentadas no texto. As manifestações da uremia nos idosos são semelhantes àquelas observadas nos segmentos mais jovens. O tratamento conservador visa à correção das mesmas e à manutenção da função renal, com o objetivo de dispensar o tratamento dialítico ou retardar o seu início.

The chronic renal failure constitutes a world wide health problem, affecting all ages, but nowadays with an accentuation of its prevalence among old people. Its diagnosis deserves the needing of a classification of the level of the renal function of the patient. The most practical renal function evaluation includes the equations for the estimation of the glomerular filtration rate which are presented in the text. The uremic manifestations of the aged are the same observed in younger groups and their conservative treatment is in order to promote the corrections of those manifestations and the renal function preservation for preventing the dialysis treatment or its beginning.