Phosphorus Counting Table for the control of serum phosphorus levels without phosphate binders in hemodialysis patients.

BACKGROUND AND AIMS: Hyperphosphatemia constitutes one of the major problems faced by patients with chronic kidney disease, and nourishment plays a significant role in its control. The present study aimed to evaluate the maintenance of phosphorus serum levels by observing measurements before and after an intervention using the Phosphorus Counting Table (PCT), in hemodialysis patients lacking phosphate binder use. METHODS: The assessment included fifty individuals on hemodialysis who underwent phosphate binder suspension 30 days prior to the intervention. The participants received food and nutrition education on the PCT tool, which assists in the control of dietary phosphorus intake, and followed its instructions for two months. Fasting blood samples were collected at three moments for phosphorus, total calcium, and parathyroid hormone (PTH) analysis. The study sample was initially analyzed as a whole, then sub-classified into two groups: adherence and non-adherence. RESULTS: At the end of the study, no significant difference in serum phosphorus was observed in the total and the adherence groups (p > 0.05). The non-adherence group showed a substantial increase of 0.74 mg/dL in serum phosphorus levels and 6.16 mg2/dL2 in the calcium-phosphorus product after the intervention. Meanwhile, the calcium-phosphorus product improved from 56.42 ± 11.49 mg2/dL2 to 51.05 ± 10.67 mg2/dL2 in the adherence group. Serum calcium levels did not change throughout the study in the three groups. A significant increment in PTH serum levels was observed at the end of the study in all groups. CONCLUSION: The PCT showed to be efficient in the maintenance of serum phosphorus in the individuals who adhered well to the tool, without the administration of phosphate binders. Such a method can assist in patient adherence to treatment and enables better diet flexibility. The present trial was registered under the Brazilian Clinical Trials Registry (Rebec). Registration number: RBR-2vzd48.

Hemodialysis Water Parameters as Predisposing Factors for Anemia in Patients in Dialytic Treatment: Application of Mixed Regression Models.

Contamination by metals and microbiological agents in hemodialysis water can cause clinical intercurrences in hemodialysis patients. Evaluating and assuring minimum levels of contamination from metals and microorganisms in hemodialysis water can improve patient safety. The objective of this study was to assess hemodialysis water quality in a major tertiary hospital in Brazil and investigate the relationship between hemodialysis water quality and clinical intercurrences in hemodialysis patients. A prospective-observational cohort study for evaluation of water quality parameters and clinical intercurrences present by patients (n = 52) were performed from May 2014 to April 2015. Mixed linear regression models and binary regression models were fitted for water quality parameters and patients' clinical parameters. The increase in the levels of copper and nitrate in hemodialysis water was significant (p < 0.05) to explain anemia. Bone pain was related to age, sex (female), and hemodialysis treatment duration (years). Hypotensive episodes were related to serum sodium decrease. Aluminum in hemodialysis water was present in an average concentration higher than the permitted threshold (15.35 ± 14.53 µg/L). Cadmium, total coliforms, Escherichia coli, and endotoxins in hemodialysis water were not detected and the heterotrophic bacteria count was below the reference limit. These parameters' concentrations varied during the study, evidencing the need for continuous monitoring.

Omega-3 Fatty Acid Supplementation is Associated With Oxidative Stress and Dyslipidemia, but Does not Contribute to Better Lipid and Oxidative Status on Hemodialysis Patients.

OBJECTIVE: The aim of the study was to explore the effects of n-3 polyunsaturated fatty acids (PUFA) supplementation in physiological doses on oxidative stress (OS) and dyslipidemia in patients on hemodialysis (HD). DESIGN AND METHODS: Randomized, double-blind, controlled, experimental trial. A total of 88 HD patients ≥18 years old and on HD for at least 6 months. A total of 43 patients received 1.28 g/day of n-3 PUFA, and 45 other patients received soybean oil for 12 weeks. Both oil supplements were vitamin E standardized. Routine tests, lipid profile, advanced oxidation protein products, isoprostanes, vitamins C and E, total antioxidant capacity, serum fatty acids, and adverse effects were evaluated. RESULTS: Supplementation was not able to alter lipid or OS profiles. There was an increase in the serum n-3 PUFA levels (eicosapentaenoic acid: +116%; docosahexaenoic acid: +100%) and an improvement in the n-6/n-3 ratio (-49%) in the supplemented group. Associations between n-3 PUFA and improvement in isoprostane and advanced oxidation protein product and HDL were observed. Treatment was well tolerated. CONCLUSION: Although the n-3 PUFA supplementation was associated with lower concentrations of isoprostane and advanced oxidation protein product and higher HDL levels, it was not sufficient for the improvement of highly prevalent risk factors, such as OS and dyslipidemia in HD patients.

Effects of Acetylsalicylic Acid Usage on Inflammatory and Oxidative Stress Markers in Hemodialysis Patients.

The aims of this study were to determine the effects of acetylsalicylic acid (ASA) on inflammation and oxidative stress markers in hemodialysis (HD) patients and to examine the associations between these markers and the sociodemographic and clinical characteristics of participants. The study included 36 subjects who used 300 mg of ASA for 60 days. Inflammation and oxidative stress were assessed based on levels of biochemical markers. ASA usage promoted a decrease in high-sensitivity C-reactive protein (p = 0.01). The level of hydrogen peroxide increased after 30 days of use of ASA and subsequently decreased (p = 0.01). Reduced glutathione reduced at the end of the study (p < 0.01); the malondialdehyde level did not change and the levels of vitamins A and E were inverse to drug use (p = 0.01). ASA usage promoted reduced levels of inflammation, increased production of markers of oxidative stress, and reduced antioxidant defense.

Association of body fat with inflammation in peritoneal dialysis.

Peritoneal dialysis (PD) frequently leads to body weight gain, which appears to be a potential cause of the chronic inflammation frequently present in these patients. The consequences of this inflammation are impaired nutritional status, accelerated atherosclerosis, and increased mortality. To assess the association between inflammation and body fat in female patients treated with PD. Nineteen female patients on PD for at least 6 months with no infectious complications or malignant or acute inflammatory diseases. Nutritional status was determined by measuring weight, height, body mass index (BMI), waist (WC), and mid-arm circumferences (MAC), mid-arm muscle area, and tricipital fold (TCF). Bioelectrical impedance (BIA) was used to determine body composition. Biochemical evaluation included the determination of serum albumin, urea, creatinine, and C-reactive protein (CRP). The glucose absorbed from the dialysis solution was quantitated. According to BMI, two patients were classified as malnourished and ten as overweight/obese. Sixteen individuals had high WC measurements and 12 had excess body fat (BF) as measured by BIA. High CRP levels were observed in 12 patients, who had higher WC, MAC, BMI, TCF, and BF measurements compared to non-inflamed patients. Positive associations were detected between CRP and BMI, MAC, WC, and TCF. Associations between BF and CRP suggest that adiposity may be a potent exacerbating factor of inflammation in this population, especially visceral fat. Thus, obesity may be considered to be one more factor responsible for the early atherosclerosis and high cardiovascular mortality observed in these patients.

Increase in BMI over time is associated with fluid overload and signs of wasting in incident peritoneal dialysis patients.

OBJECTIVES: Peritoneal dialysis (PD) patients may suffer changes in nutritional status after starting PD. Several markers can be used to evaluate these modifications, such as body mass index (BMI), serum albumin, and serum creatinine. Fluid overload should be considered because it can overestimate or underestimate nutritional status. The objective of this study was to evaluate the BMI changes over time in incident PD patients and identify interactions among BMI, signs of fluid overload, serum albumin, and serum creatinine. DESIGN: The study included a cohort of 1,997 incident PD patients of the BRAZPD recruited from 2004 to 2007. Sociodemographic data and BMI classification were obtained at baseline. The evolutions of BMI and body weight were assessed over a period of 29 months. Changes in the evolution were analyzed when a patient presented with albumin < 3.8 g/dL, creatinine < 7.0 mg/dL, or the presence of edema. Data analysis was performed using linear mixed-effects regression models as the main statistical procedure. RESULTS: BMI increased over time (29 months) by an average of 0.05 kg/m(2) per month, and body weight increased by 0.11 kg/month for a total increase of 3.08 kg. BMI decreased by 0.12 kg/m(2) in the presence of albumin < 3.8 g/dL and by 0.38 kg/m(2) in the presence of creatinine < 7.0 mg/dL. BMI increased by 0.61 kg/m(2) in the presence of edema. BMI increased in the presence of edema and albumin < 3.8 mg/dL or edema and creatinine < 7.0 mg/dL. CONCLUSIONS: There is a mean increase in the BMI of incident PD patients over time, and these changes may be, at least partly, due to fluid overload, leading to distortions of body weight. When the patients presented with lower serum albumin or creatinine levels, the BMI values were reduced, suggesting that a reduction in lean mass and an increase in fat mass may be occurring in these patients.

Inflammation and insulin resistance as novel mechanisms of wasting in chronic dialysis patients.

Over the last decade, there have been no proven therapies to lower the mortality and morbidity risk for chronic dialysis patients. One of the most important determinants of this poor clinical outcome is protein energy wasting (PEW), a unique and highly prevalent nutritional and metabolic abnormality primarily characterized by increased protein breakdown in the skeletal muscle compartment. Although the etiology and mechanisms leading to increased protein breakdown in chronic dialysis patients are complex and mostly ill-defined, two well-recognized and presumably interrelated metabolic abnormalities, insulin resistance and chronic inflammation, are likely to play a critical role in the pathogenesis of this condition. Multiple studies demonstrate the anabolic effects of insulin that extend beyond simple carbohydrate metabolism. Insulin is a mediator of accelerated protein breakdown in the catabolic condition such as advanced kidney disease. Chronic inflammation, a condition known to cause muscle catabolism in experimental conditions, has a strong association with advanced kidney disease in epidemiologic studies. Chronic inflammation is also known to induce insulin resistance, primarily by the induction of proinflammatory cytokines. The protein catabolic effects of inflammation and insulin resistance involve common cellular pathways. Thus, it is reasonable to speculate that chronic inflammation of advanced kidney disease mediates its protein catabolic effects by inducing insulin resistance of protein metabolism at both the physiologic and cellular levels. Modulating inflammatory response or insulin signaling by pharmacologic interventions could allow us to clarify the mechanisms contributing to the development of PEW in the setting of these particular metabolic derangements.

Dynamics of parathyroid hormone secretion after total parathyroidectomy and autotransplantation.

BACKGROUND: Secondary hyperparathyroidism is a common complication in uremic patients. Total parathyroidectomy combined with partial autotransplantation into brachioradialis muscle has been the preference among the options for surgical treatment. This study was designed to evaluate the reserve and ability of suppression of autotransplanted parathyroid tissue using dynamics tests. METHODS: We studied, prospectively, 12 patients in recent (RP) and late (LP) postoperative of total parathyroidectomy with autotransplantation. For analysis of the secretory reserve capacity, we induced hypocalcemia by ethylenediaminetetraacetic acid (EDTA) infusion. Furthermore, for analysis of the ability for parathyroid hormone (PTH) suppression, the hypercalcemia test was used, by intravenous administration of calcium in LP. RESULTS: In RP, there was a decrease in the average serum levels of PTH, phosphorus, and alkaline phosphatase, which ranged from 13 to 231 (87 +/- 65) pg/ml, 2.3 to 6.2 (3.3 +/- 1.1) mg/dl, and 77 to 504 (250 +/- 135) U/L, respectively, similar to that observed in LP. The analysis of the average curve of variations in PTH during testing of the stimulus with EDTA showed lack of secretion in RP and partial response in LP. Impaired suppression ability of the graft in LP was observed in the test with intravenous calcium. CONCLUSIONS: Total parathyroidectomy followed by partial autotransplantation was effective in reducing PTH serum levels in patients with terminal kidney disease. The elevation of serum calcium during the suppression test was not able to inhibit the autograft gland secretion of PTH. The assessment of parathyroid graft function demonstrated an inability to respond to the stimulus of hypocalcemia induced by EDTA, although there was a partial recovery, in late postoperative period.

Arteriovenous fistula puncture: an essential factor for hemodialysis efficiency.

OBJECTIVE: To determine the blood recirculation ratio in the vascular access of patients on hemodialysis, and to calculate the Kt/Vs obtained with the different techniques of arteriovenous fistula punctures. MATERIALS AND METHODS: A total of 174 patients were divided according to the technique used for arteriovenous fistula puncture: group 1, needles in opposite directions and with a distance of 5 cm or more between them; group 2, needles in opposite directions but with a distance of less than 5 cm; group 3, unidirectional needles with both directed to the heart and with a distance of 5 cm or more; group 4, unidirectional needles but separated by a distance of less than 5 cm between needles; and group 5, patients carrying a temporary venous catheter. Blood samples were collected for urea analysis, pre and post-dialysis for Kt/V rate, and other samples for calculation of the access recirculation. RESULTS: Group 1 presented the lowest rate of access recirculation (8.51 +/- 4.90%) and the best Kt/V (1.71 +/- 0.36), while group 4 presented the worst access recirculation (20.68 +/- 4.92%) and Kt/V (1.16 +/- 0.26). All groups differed significantly from group 4 (p < 0.05), except group 5 with regard for Kt/V parameter. DISCUSSION: The technique of arteriovenous fistula puncture is an essential factor to decrease the access recirculation and assure better results of measurement of hemodialysis adequacy. On the basis of the results obtained, insertion of the needles in the same direction and with a distance of less than 5 cm between them should be avoided.

The evaluation of renal osteodystrophy with cortical quantitative ultrasound at various bone sites.

BACKGROUND: In this study we evaluated bone abnormalities of patients with chronic renal failure (CRF) by cortical quantitative bone ultrasound (QUS) measurements at different bone sites because these abnormalities may be of variable etiology and may start before symptoms or radiological changes are manifested. METHODS: Of fifteen patients with chronic renal failure, seven had moderate-severe disease and eight had been on chronic hemodialysis from 5 to 17 years, with renal osteodystrophy (ROD) confirmed by bone biopsies. Twelve normal subjects of similar age and gender volunteered for the control group. RESULTS: Patients and controls differed in creatinine clearance, in serum phosphate levels and in serum total alkaline phosphatase. Mean intact-PTH levels differed significantly amongst the three groups of subjects. All patients with ROD had intact-PTH higher than 200 pg/mL. The cortical ultrasound parameter, speed of sound (SOS), was slower in patients with more severe renal failure at all bone sites measured. The group with ROD had significantly lower cortical ultrasound values than the other patients and the control group at all sites. SOS values at the proximal phalanx, distal radius and midtibial sites were positively and significantly correlated. Cortical ultrasound measurements at the radial site correlated with midtibial and phalangeal sites but the correlation between midtibial and phalangeal sites did not reach significance. IPTH levels correlated negatively and significantly with cortical QUS values at all sites being the correlations higher at phalangeal and radial sites than at the midtibial region. CONCLUSIONS: The differences in cortical ultrasound observed indicate the potential clinical application of this methodology to evaluate bone abnormalities in chronic renal failure, especially in patients on chronic hemodialysis.

Molecular investigation of GB virus C RNA in hemodialysis and thalassemics patients from Brazil.

The GB virus C (GBV-C)/hepatitis G virus (HGV) is a member of the Flaviviridae family. Based on the clinical and epidemiological profiles, this virus could be acquired mainly by parenteral transmission through contaminated blood. We therefore investigated the presence of GBV-C/HGV and its relation with the other blood borne viruses as hepatitis B and C viruses (HBV, HCV) in hemodialysis and thalassemic individuals and blood donors from Ribeirão Preto-Brazil. Detection of blood borne virus markers including HBV surface antigen (HbsAg), HBV core antibody (anti-Hbc) and HCV antibody was carried out. HIV-1, HIV-2, HTLV-1 and HTLV-2 were also investigated. GBV-C/HGV RNA was detected by reverse transcriptase and polymerase chain reaction (RT-PCR). Ninety-four serum samples from patients with chronic renal failure were analyzed. GBV-C/HGV RNA was identified in 12 (12.8%) patients, anti-HCV antibodies in 28 (29.8%), anti-Hbc in 9 (9.6%), anti-HIV in 1 (1%), HBsAg in 33 (35.1%), and HBsAg/ anti-HBc was observed in 2 (2.1%) patients. Thirty-six (38.3%) samples were non-reactive. Seven of the 12 GBV-C/HGV RNA infected samples were co-infected with other viruses: 3 (25%) with HBsAg, 2 (16.7%) with anti-HCV and 2 (16.7%) with anti-HBc/anti-HCV/HBsAg. Among the 42 thalassemic patients GBV-C/HGV RNA was detected in 6/42 patients (14.2 %). Three patients presented GBV-C/HGV, with other blood borne markers. We also detected GBV-C/ HGV in 6/50 (12%) blood donors. In these GBV-C/HGV positive thalassemics patients, 50% (3/6) were young individuals (lesser 15 years old) and 67% (4/6) were female patients. The presence of GBV-C RNA in the absence of hepatitis B and C infection in the young patients and healthy donors could be indicate that this virus is capable of independent transmission and does not contribute to liver disease.

Intoxication by star fruit (Averrhoa carambola) in 32 uraemic patients: treatment and outcome.

BACKGROUND: Clinical symptoms and outcomes of uraemic patients ingesting star fruit are quite variable and may progress to death. The purpose of the present report was to discuss the neurotoxic effects of star fruit intoxication in uraemic patients and to present the efficacy of different therapeutic approaches. METHODS: We studied a total of 32 uraemic patients who had ingested star fruit. Before the intoxication episodes, 20 patients were on regular haemodialysis, eight were on peritoneal dialysis and four were not yet undergoing dialysis. Two patients were analysed retrospectively from their charts, 17 were directly monitored by our clinic and 13 were referred by physicians from many areas throughout the country, allowing us to follow their outcome from a distance. Intoxicated patients were given different therapeutic approaches (haemodialysis, peritoneal dialysis and supportive treatment), and their outcomes were analysed. RESULTS: The most common symptoms were persistent and intractable hiccups in 30 patients (93.75%), vomiting in 22 (68.7%), variable degrees of disturbed consciousness (mental confusion, psychomotor agitation) in 21 (65.6%), decreased muscle power, limb numbness, paresis, insomnia and paresthesias in 13 (40.6%) and seizures in seven (21.8%). Patients who were promptly treated with haemodialysis, including those with severe intoxication, recovered without sequelae. Patients with severe intoxication who were not treated or treated with peritoneal dialysis did not survive. CONCLUSIONS: Haemodialysis, especially on a daily basis, is the ideal treatment for star fruit intoxication. In severe cases, continuous methods of replacement therapy may provide a superior initial procedure, since rebound effects are a common event. Peritoneal dialysis is of no use as a treatment, especially when consciousness disorders ensue.