Reutilização do dialisador e uso único: episódios de pirogenia e bacteremia / Reutilización del dializador y uso único: episodios de reacciones pirógenas y bacteriemias / Dialyzer reuse and single use: pyrogenesis and bacteremia episodes

Resumo Objetivos Comparar a reutilização do dialisador com o uso único deste material para marcadores bioquímicos, hematológicos, episódios de pirogenias e bacteremias. Métodos Estudo longitudinal com coleta de dados retrospectiva em prontuários de pacientes em hemodiálise, em hospital público universitário. A investigação foi conduzida seis meses com a reutilização do dialisador e seis meses com uso único. Os dados foram analisados no SPSS Versão 18.0. Para comparação das médias dos exames utilizou-se teste t pareado e Wilcoxon, episódios de pirogenia e bacteremia foram analisados pelo teste de Wilcoxon e Razão de Chances (RC) como medida de força de associação. Variáveis categóricas foram analisadas pelos testes de McNemar e Exato de Fisher. O estudo foi aprovado pelo Comitê de Ética e Pesquisa. Resultados Foram analisadas 5.508 sessões de hemodiálise de pacientes predominantemente masculinos 21(62%), média de idade 58(± 14) anos, hipertensos 14(41%), tempo médio de tratamento 6±3 anos. Durante uso único identificou-se redução da ureia pós diálise, creatinina, fósforo, ferritina, hematócrito e hemoglogina em relação ao reutilizado (p < 0,05) e 91% menos risco de pirogenia comparado a reutilização do dialisador (Razão de Chance= 0,091; IC 95%: 0,002-0,625). Não houve diferença significativa na ocorrência de bacteremias. Conclusão Os resultados sugerem maior remoção de biomarcadores bioquímicos e menos episódios de pirogenias quando o dialisador é uso único.ater removal of biochemical biomarkers and fewer pyrogenics episodes when the dialyzer is a single use.

Resumen Objetivos Comparar la reutilización del dializador con el uso único de este material en marcadores bioquímicos, hematológicos, episodios de reacciones pirógenas y bacteriemias. Métodos Estudio longitudinal con recolección de datos retrospectiva en historias clínicas de pacientes en hemodiálisis, en un hospital público universitario. La investigación fue conducida seis meses con la reutilización del dializador y seis meses con un único uso. Los datos fueron analizados en SPSS Versión 18.0. Para comparar los promedios de los análisis, se utilizó el Test-T pareado y prueba de Wilcoxon, los episodios de reacciones pirógenas y bacteriemia fueron analizados mediante la prueba de Wilcoxon y Razón de Momios (RM) como medida de fuerza de asociación. Las variables categóricas se analizaron con la prueba de McNemar y la prueba exacta de Fisher. El estudio fue aprobado por el Comité de Ética e Investigación. Resultados Se analizaron 5.508 sesiones de hemodiálisis de pacientes predominantemente masculinos 21 (62 %), promedio de edad 58 (±14) años, hipertensos 14 (41 %), tiempo promedio de tratamiento 6±3 años. Durante el uso único del dializador, se identificó una reducción de la urea posdiálisis, creatinina, fósforo, ferritina, hematocrito y hemoglobina respecto al dializador reutilizado (p < 0,05) y un 91 % menos de riesgo de reacción pirógena comparado con la reutilización del dializador (Razón de Momios = 0,091; IC 95 %: 0,002-0,625). No hubo diferencia significativa en episodios de bacteriemias. Conclusión Los resultados sugieren mayor eliminación de biomarcadores bioquímicos y menos episodios de reacciones pirógenas cuando el dializador se utiliza una única vez.

Abstract Objectives To compare dialyzer reuse with its single use for biochemical, hematological markers, pyrogenesis and bacteremia episodes. Methods A longitudinal study with retrospective data collection from medical records of patients on dialysis in a public university hospital. The investigation was conducted six months with dialyzer reuse and six months with single use. Data were analyzed using SPSS Version 18.0. To compare the tests means, paired t-test and Wilcoxon were used. Pyrogenesis and bacteremia episodes were analyzed using the Wilcoxon test and Odds Ratio (OR) as association strength measures. Categorical variables were analyzed using McNemar and Fisher's Exact tests. The study was approved by the hospital's Research Ethics Committee. Results Five thousand five hundred eight dialysis sessions of predominantly male patients were analyzed, 21 (62%), with mean age of 58 (± 14) years, hypertensive 14 (41%), with mean treatment time 6 ± 3 years. During single use, a reduction in urea after dialysis, creatinine, phosphorus, ferritin, hematocrit and hemoglogin was identified in relation to reuse (p<0.05) and 91% less risk of pyrogenesis compared to dialyzer reuse (Odds Ratio=0.091; 95% CI: 0.002-0.625). There was no significant difference in the occurrence of bacteremia. Conclusion The results suggest greater removal of biochemical biomarkers and fewer pyrogenics episodes when the dialyzer is a single use.

Risco de insuficiência renal aguda pós-contraste em tomografia computadorizada: estamos atentos à função renal? / Risk of post-contrast acute kidney injury in computed tomography: are we aware of renal function?

Introdução: Exames diagnósticos contrastados oferecem riscos para o desenvolvimento de Insuficiência Renal Aguda pós-contraste (IRA-PC), principalmente em pacientes com doença renal prévia. O objetivo deste estudo foi verificar se a função renal foi avaliada antes e após a realização de exame contrastado. Métodos: Coorte retrospectiva com 2778 pacientes que realizaram tomografia computadorizada (TC) contrastada em que foi verificada a creatinina sérica (CrS) pré e pós-exame, presença de fatores de risco, incidência de IRA-PC e óbito até 10 meses pós-TC. Resultados: Somente 263 (9,5%) apresentaram avaliação da função renal pré e pós-exame dentro dos prazos estabelecidos (7 dias para pacientes internados e 180 dias para ambulatoriais pré-exame, e 48 a 72 horas pós-exame), sendo que 91,6% eram de pacientes internados. IRA-PC foi observada em 38 (14,4%) pacientes e foi associada ao uso de medicamentos nefrotóxicos (Odds Ratio 1,645; IC95%: 1,138­2,390) e maior risco de óbito pós-exame (Razão de Incidência 1,84; IC95%:1,17-2,83). Conclusão: A grande maioria dos pacientes não apresentava adequada avaliação da função renal pré e pós-TC, principalmente em nível ambulatorial. Sugere-se o estabelecimento de medidas educativas para promover a aderência do corpo clínico à avaliação da função renal para pacientes de risco para IRA-PC. (AU)

Introduction: Contrast-enhanced diagnostic tests involve risks for the development of post-contrast acute kidney injury (PC-AKI), especially in patients with previous renal disease. The aim of this study was to investigate whether renal function was evaluated before and after the contrast-enhanced test. Methods: In this retrospective cohort of 2778 patients who underwent contrast-enhanced computed tomography (CT), pre- and post-CT serum creatinine (SCr), presence of risk factors, incidence of PC-AKI, and death within 10 months post-CT were investigated. Results: Only 263 (9.5%) patients had pre- and post-CT renal function evaluation performed within the established time frames (7 days for inpatients and 180 days for outpatients pre-CT and 48 to 72 hours post-CT), with 91.6% being inpatients. PC-AKI was observed in 38 (14.4%) patients and was associated with use of nephrotoxic drugs (odds ratio: 1.645, 95% CI: 1.138-2.390) and higher risk of death post-CT (incidence ratio: 1.84; 95% CI: 1.17-2.83). Conclusion: The vast majority of patients did not undergo an adequate pre- and post-CT renal function evaluation, especially at the outpatient level. Educational measures should be developed to promote adherence of clinical staff to renal function evaluation for patients at risk for PC-AKI. (AU)

Riscos ocupacionais para profissionais de enfermagem relacionados ao reúso e uso único do dialisador / Occupational hazards for nursing professionals related to the reuse and single use of the dialyzer / Riesgos ocupacionales para profesionales enfermeros relacionados con el reúso y el uso único del dializador

RESUMO Objetivo: Comparar as ocorrências ocupacionais registradas pelos profissionais de Enfermagem durante a utilização do dialisador reutilizado e de uso único. Método: Estudo longitudinal, retrospectivo, realizado com prontuários de técnicos de Enfermagem de um serviço de hemodiálise. Os dados foram analisados descritivamente e calculados pela Razão de Densidade de Incidência. Resultados: Durante a reutilização do dialisador, foram registradas sete notificações de cinco profissionais relacionadas a distúrbios osteomusculares, a alergias oculares e à dermatose. Durante o uso único, dois profissionais registraram dor lombar. A taxa de exposição ao uso de medicamentos foi de 6,7 dias para cada 1.000 profissionais no período de reutilização do dialisador e de 1,52 dias no período de uso único (RDI=4,4; IC 95%: 2.182-9.805). Os anti-inflamatórios foram os mais prescritos, e os afastamentos do trabalho foram semelhantes nos dois períodos. Conclusão: O reúso do dialisador esteve associado a distúrbios osteomusculares, irritação ocular, dermatoses e maior uso de medicamentos pelos profissionais. Os afastamentos do trabalho foram semelhantes durante o uso do dialisador reutilizado e de uso único.

ABSTRACT Objective: To compare the reports of occupational events recorded by nursing professionals during the periods of reuse and single use of the dialyzer. Method: Retrospective longitudinal study with electronic medical records from nursing technicians of a hemodialysis service. Data were analyzed descriptively and Rate ratio. Results: During the reuse of the dialyzer, there were seven events from five professionals reporting musculoskeletal disorders, ocular allergies and dermatosis. During single use, two professionals reported low back pain. The rate ratio of medication use was 6.7 days for every 1000 professionals during the reuse period and 1.52 days in the single use period (RR=4.4; 95% CI 2.182-9.805). Anti-inflammatory drugs were the most prescribed, and sick leaves were similar in both periods. Conclusion: Dialyzer reuse was associated with musculoskeletal disorders, ocular irritation, dermatosis and increased use of medications by professionals. Sick leaves were similar on the periods of dialyzer reuse and single use.

RESUMEN Objetivo: Comparar las ocurrencias ocupacionales registradas por los profesionales enfermeros durante la utilización del dializador reutilizado y de uso único. Método: Estudio longitudinal, retrospectivo, realizado con fichas de técnicos de Enfermería de un servicio de hemodiálisis. Los datos fueron analizados descriptivamente y calculados por la Razón de Densidades de Incidencia. Resultados: Durante la reutilización del dializador, fueron registradas siete notificaciones de cinco profesionales relacionadas con disturbios osteomusculares, alergias oculares y dermatosis. Durante el uso único, dos profesionales registraron dolor lumbar. La tasa de exposición al uso de fármacos fue de 6,7 días para cada 1.000 profesionales en el período de reutilización del dializador y de 1,52 días en el período de uso único (RDI=4,4; IC 95%: 2.182-9.805). Los antiinflamatorios fueron los más prescritos, y las bajas laborales fueron semejantes en ambos períodos. Conclusión: El reúso del dializador estuvo asociado con disturbios osteomusculares, irritación ocular, dermatosis y mayor uso de fármacos por los profesionales. Las bajas laborales fueron semejantes durante el uso del dializador reutilizado y de uso único.

Budd-Chiari syndrome secondary to catheter-associated inferior vena cava thrombosis.

INTRODUCTION: Patients with chronic kidney disease (CKD) are at increased risk for thrombotic complications. The use of central venous catheters as dialysis vascular access additionally increases this risk. We describe the first case of Budd-Chiari syndrome (BCS) secondary to central venous catheter misplacement in a patient with CKD. CASE REPORT: A 30-year-old female patient with HIV/AIDS and CKD on hemodialysis was admitted to the emergency room for complaints of fever, prostration, and headache in the last six days. She had a tunneled dialysis catheter placed at the left jugular vein. The diagnosis of BCS was established by abdominal computed tomography that showed a partial thrombus within the inferior vena cava which extended from the right atrium to medium hepatic vein, and continuing along the left hepatic vein. Patient was treated with anticoagulants and discharged asymptomatic. DISCUSSION: Budd-Chiari syndrome is a rare medical condition caused by hepatic veins thrombosis. It can involve one, two, or all three of the major hepatic veins. It is usually related to myeloproliferative disorders, malignancy and hypercoagulable states. This case calls attention for inadvertent catheter tip placement into hepatic vein leading to this rare complication. CONCLUSION: Assessment of catheter dialysis tip location with radiological image seems to be a prudent measure after each procedure even if the tunneled dialysis catheter has been introduced with fluoroscopy image.

Budd-Chiari syndrome secondary to catheter-associated inferior vena cava thrombosis / Síndrome de Budd-Chiari secundária a trombose de veia cava inferior associada a cateter

Abstract Introduction: Patients with chronic kidney disease (CKD) are at increased risk for thrombotic complications. The use of central venous catheters as dialysis vascular access additionally increases this risk. We describe the first case of Budd-Chiari syndrome (BCS) secondary to central venous catheter misplacement in a patient with CKD. Case report: A 30-year-old female patient with HIV/AIDS and CKD on hemodialysis was admitted to the emergency room for complaints of fever, prostration, and headache in the last six days. She had a tunneled dialysis catheter placed at the left jugular vein. The diagnosis of BCS was established by abdominal computed tomography that showed a partial thrombus within the inferior vena cava which extended from the right atrium to medium hepatic vein, and continuing along the left hepatic vein. Patient was treated with anticoagulants and discharged asymptomatic. Discussion: Budd-Chiari syndrome is a rare medical condition caused by hepatic veins thrombosis. It can involve one, two, or all three of the major hepatic veins. It is usually related to myeloproliferative disorders, malignancy and hypercoagulable states. This case calls attention for inadvertent catheter tip placement into hepatic vein leading to this rare complication. Conclusion: Assessment of catheter dialysis tip location with radiological image seems to be a prudent measure after each procedure even if the tunneled dialysis catheter has been introduced with fluoroscopy image.

Resumo Introdução: Pacientes com doença renal crônica (DRC) apresentam risco aumentado de complicações trombóticas e o uso de cateter venoso central para realização de hemodiálise aumenta este risco. Nós descrevemos um caso de síndrome de Budd-Chiari (SBC) causado pelo mal posicionamento de um cateter de diálise em um paciente com DRC e, para nosso conhecimento, este é o primeiro caso relatado na literatura. Caso clínico: Paciente feminina, 30 anos, com diagnóstico de HIV/SIDA e DRC em hemodiálise foi admitida na emergência com queixas de febre, prostração e cefaleia há 6 dias. Ela apresentava um cateter de diálise tunelizado implantado 7 dias antes na veia jugular esquerda. O diagnóstico de SBC foi realizado por tomografia computadorizada abdominal que mostrava um trombo no interior da veia cava inferior o qual estendia-se desde o átrio direito até a veia hepática esquerda. O cateter foi removido e a paciente foi anticoagulada. A paciente estava assintomática no momento da alta hospitalar. Discussão: SBC é uma condição clínica rara causada por trombose das veias hepáticas, podendo envolver desde uma até todas as três principais veias. Esta síndrome é em geral associada a desordens mieloproliferativas, a malignidades e a situações de hipercoagulabilidade. Este caso demonstra que o mal posicionamento da ponta do cateter no interior da veia hepática causou esta rara complicação. Conclusão: Realização de exame radiológico para avaliar localização da ponta do cateter de diálise é uma medida prudente após cada procedimento, mesmo nos casos de implante de cateter de diálise tunelizados com fluoroscopia.

The pitfall of treating low bone turnover: Effects on cortical porosity.

Although it is recognized that cortical bone contributes significantly to the mechanical strength of the skeleton, little is known about this compartment from bone biopsy studies, particularly in CKD patients. In addition, there is no prospective data on the effects of CKD-MBD therapy on cortical porosity (Ct.Po). This is a post hoc analysis on data from a randomized controlled trial on the effects of different phosphate binders on bone remodelling. Therapy was adjusted according to the first biopsy, and included sevelamer or calcium acetate, calcitriol and changes in calcium dialysate concentration. We measured Ct.Po at baseline and one year after. Fifty-two patients (46±13years old, 67% women and 60% white) were enrolled. Ct.Po was already high at baseline in 85% of patients [30% (17, 46)] and correlated with PTH (p=0.001). Low bone turnover was seen in 28 patients (54.9%). After one-year treatment, PTH increased in patients with low turnover, as intended. However, increased Ct.Po was seen in 49 patients (94%). This increase correlated with the delta of phosphate (p=0.015) and the delta of PTH (p=0.03); it was also higher among non-white patients than in white patients (p=0.039). The risk of increase in Ct.Po was 4.5 higher among non-white patients. Adjusted multiple regression analysis showed that the delta of Ct.Po was dependent on delta PTH and race (r(2)=0.193). We concluded that in an attempt to increase bone turnover, the increase in PTH levels might be associated with higher cortical porosity, particularly in non-white patients. Whether this finding leads to a high risk of fracture deserves further investigation.

Efeito da suplementação de colecalciferol nos RNA mensageiros urinários associados ao podócito em pacientes com doença renal crônica / Effect of cholecalciferol supplementation on urine podocyte-associated messenger RNAs in patients with chronic kidney disease

RESUMO Introdução: A vitamina D reduz a albuminúria em pacientes com doença renal crônica (DRC), mas o seu efeito sobre os podócitos glomerulares ainda não é claro. Objetivos: Avaliar se a suplementação de colecalciferol reduz os RNAm urinários associados ao podócito em pacientes com DRC. Métodos: Vinte e sete pacientes com DRC estágios 2 a 4 e níveis sub-ótimos de 25-hidroxi-vitamina D [25(OH)D] sérica foram tratados com colecalciferol por seis meses. Foram medidos antes e após a intervenção a 25(OH)D sérica e o RNAm urinário da nefrina, podocina, podocalixina, receptor transitório potencial do canal de cátions, subfamília C, membro 6 (TRPC6), fator A de crescimento do endotélio vascular (VEGF-A) e fator de crescimento transformador beta (TGF-β1). Resultados: A TFGe reduziu em média 4,71 mL/min/1,73 m2 (p = 0,010 vs. basal), sendo 28 ± 16 mL/min/1,73 m2 aos seis meses. Os RNAm dos produtos do podócito na urina não tiveram alteração significativa após o tratamento. Entretanto, pacientes que atingiram níveis de 25(OH)D ≥ 20 ng/mL aos 6 meses tiveram tendência de redução do RNAm da nefrina e da podocina na urina; nos pacientes em que a 25(OH)D permaneceu < 20 ng/mL houve aumento significativo da podocalixina, e tendência de maior expressão do RNAm da nefrina e da podocina. Conclusão: A reposição de colecalciferol por seis meses não teve efeito sobre os RNAm associados ao podócito nestes pacientes com DRC avançada. O efeito protetor da vitamina D ou seus análogos sobre o podócito glomerular deve ser investigado em estágios mais precoces da DRC e com maior tempo de tratamento.

ABSTRACT Introduction: Vitamin D reduces albuminuria in patients with chronic kidney disease (CKD) but its effects on glomerular podocytes are not entirely understood. Objective: To evaluate if cholecalciferol supplementation reduces the levels of podocyte-associated urine mRNAs in patients with CKD. Methods: A total of 27 patients with stages 2 to 4 CKD and suboptimal serum vitamin D [25(OH)D] levels were treated with cholecalciferol for 6 months. Serum 25(OH)D level, estimated glomerular filtration rate (eGFR), proteinuria, and urine mRNA of nephrin, podocin, podocalyxin, transient receptor potential cation channel 6, vascular endothelial growth factor A, and transforming growth factor beta were assessed before and after intervention. Results: eGFR declined at an average rate of -4.71 mL/min/1.73 m2 (p = 0.010 vs. baseline), being 28 ± 16 mL/min/1.73 m2 at six months. No changes in proteinuria or mineral and bone metabolism parameters were observed after cholecalciferol supplementation. Urinary podocyte-associated mRNAs did not change significantly after treatment. However, patients who achieved 25(OH)D level > 20 ng/mL at six months showed a trend of reduction of urinary nephrin and podocin mRNA levels; in patients with 25(OH)D that remained < 20 ng/mL there was a significant increase in urinary podocalyxin, and a trend of higher expression of urinary nephrin and podocin mRNA. Conclusion: Six months of cholecalciferol supplementation had no effect on urine podocyte-associated mRNA profile of patients with advanced CKD. The protective effect of vitamin D or its analogues on the glomerular podocyte should be investigated in early stages of CKD with a longer treatment period.

Brazilian Registry of Bone Biopsy (REBRABO): design, data elements and methodology.

INTRODUCTION: Mineral bone disorder (MBD) is a common condition in chronic kidney disease (CKD) patients and causes significant morbidity and mortality. Data involving prevalence of alterations in bone histological patterns, impact of different treatments and its repercussion in outcomes, such as bone fractures, hospitalization, cardiovascular disease and mortality, are scarce. Data bank registry can be a valuable tool to understand epidemiological aspects of MBD CKD. The Brazilian Registry of Bone Biopsy (REBRABO) will be a national registry, coordinating by the Brazilian Society of Nephrology - Committee of MBD-CKD. OBJECTIVE: To describe REBRABO's design, elements of data and methodology. METHODS: Will be an online national observational and multicentric data registry divided in two phases (retrospective, 1st phase) and prospective (2nd phase), including information from bone tissue histomorphometric analysis and demographics, clinical and laboratorial data from CKD-MBD patients. RESULTS: The REBRABO's first phase will explore data on demographics, clinical, laboratorial and bone histomorphometric analysis data from January/1986 to December/2013. The first RESULTS are expected in early 2015. CONCLUSION: Studies in the field of CKD-MBD are needed, particularly those analyzing its prevalence, associations between demographic, clinical, histological parameters, and major outcomes. The REBRABO will be a unique retrospective and prospective research platform including bone biopsy data in CKD-MBD patients.

Registro Brasileiro de Biópsias Ósseas (REBRABO): desenho, banco de dados e metodologia / Brazilian Registry of Bone Biopsy (REBRABO): design, data elements and methodology

Introdução: Os distúrbios mineral e ósseo (DMO) são encontrados com frequência em pacientes com doença renal crônica (DRC) e são causa importante de morbidade e mortalidade nessa população. São escassos na literatura estudos que avaliam a prevalência dos tipos de alterações histológicas no tecido ósseo e suas associações com desfechos clínicos, como fraturas, hospitalização, doença cardiovascular e mortalidade. Os estudos epidemiológicos dos DMO-DRC podem ser facilitados pela criação de registros. O Registro Brasileiro de Biópsias Ósseas (REBRABO) será uma base de dados coordenada pelo Comitê DMO-DRC da Sociedade Brasileira de Nefrologia. Objetivo: Descrever o desenho, banco de dados e metodologia do REBRABO. Métodos: Será uma base de dados eletrônica online, envolvendo informações nacionais, observacionais, multicêntricas retrospectivas (1ª fase), e prospectivas (2ª fase), contendo dados demográficos, clínicos, laboratoriais e de histologia óssea, obtidos por meio da técnica de histomorfometria em pacientes com DMO-DRC; serão empregadas análises estatísticas de relação e comparação para identificar possíveis associações entre os DMODRC e desfechos clínicos, incluindo fraturas, hospitalizações e mortalidade. Resultados: A primeira fase do REBRABO revelará análise de informações demográficas, clínicas, laboratoriais e de histologia do tecido ósseo de janeiro/1986 até dezembro/2013, cujos Resultados são esperados no primeiro semestre de 2015. Conclusão: Existe a necessidade de estudos que avaliem a prevalência, associações entre variáveis sociodemográficas, clínicas, laboratoriais ...

Introduction: Mineral bone disorder (MBD) is a common condition in chronic kidney disease (CKD) patients and causes significant morbidity and mortality. Data involving prevalence of alterations in bone histological patterns, impact of different treatments and its repercussion in outcomes, such as bone fractures, hospitalization, cardiovascular disease and mortality, are scarce. Data bank registry can be a valuable tool to understand epidemiological aspects of MBD CKD. The Brazilian Registry of Bone Biopsy (REBRABO) will be a national registry, coordinating by the Brazilian Society of Nephrology - Committee of MBD-CKD. Objective: To describe REBRABO's design, elements of data and methodology. Methods: Will be an online national observational and multicentric data registry divided in two phases (retrospective, 1st phase) and prospective (2nd phase), including information from bone tissue histomorphometric analysis and demographics, clinical and laboratorial data from CKD-MBD patients. Results: The REBRABO's first phase will explore data on demographics, clinical, laboratorial and bone histomorphometric analysis data from January/1986 to December/2013. The first Results are expected in early 2015. Conclusion: Studies in the field of CKD-MBD are needed, particularly those analyzing its prevalence, associations between demographic, clinical, histological parameters, and major outcomes. The REBRABO will be a unique retrospective and prospective research platform including bone biopsy data in CKD-MBD patients. .

Hybrid myocardial imaging for risk stratification prior to kidney transplantation: added value of coronary calcium and epicardial adipose tissue.

BACKGROUND: Patient selection and optimal approach to risk stratification prior to kidney transplantation remain uncertain. We sought new predictors of an abnormal myocardial perfusion (MYP) stress test result. METHODS: Retrospective study of 411 consecutive chronic kidney disease stages 4-5D patients awaiting kidney transplantation referred for risk stratification. PET-CT or SPECT-CT was used to assess MYP and quantify coronary artery calcium (CAC) and epicardial adipose tissue (EAT). Abnormal MYP was defined as a perfusion defect involving ≥5% of the left ventricular myocardium. RESULTS: Fixed or reversible MYP defects were present in 41 patients (10%). Male sex, smoking, and history of cardiovascular disease were more prevalent; age was higher and CAC and EAT were greater in patients with MYP defects than in those with normal MYP. On multivariate logistic regression, EAT and CAC were independent predictors of abnormal MYP while diabetes mellitus showed a borderline association (P = .08). EAT added incremental diagnostic value to a model including age, CAC and diabetes mellitus [AUC 0.73 (95% CI 0.64-0.81) to 0.76 (95% CI 0.68-0.84; P = .02)]. Furthermore, the model containing EAT showed improved diagnostic discrimination. CONCLUSIONS: Abnormal MYP on screening stress testing appears to be rare in patients awaiting kidney transplantation suggesting an excess of testing. EAT and CAC may help predict what patients are at higher risk of developing abnormalities of MYP under stress.

Vitamin D status and coronary flow reserve measured by positron emission tomography: a co-twin control study.

CONTEXT: Vitamin D insufficiency is associated with increased cardiovascular events in the general population. Additionally, low serum 25-hydroxyvitamin D [25(OH)D] is associated with endothelial dysfunction and arterial stiffness. However, little is known about the association between serum 25(OH)D level and myocardial blood flow. OBJECTIVE: Our objective was to examine the association between serum 25(OH)D levels and coronary flow reserve (CFR) measured by (13)N-positron emission tomography in asymptomatic middle-aged male twins. DESIGN: The Emory Twin Study is a cross-sectional study of soldiers from the Vietnam Era Registry. SETTING: The study was conducted at the General Clinical Research Center, Emory University, Atlanta, GA. PARTICIPANTS: A total of 368 middle-aged male twins were enrolled for the study. Serum 25(OH)D levels were measured in all subjects and classified as vitamin D insufficiency [25(OH)D <30 ng/ml] or sufficiency [25(OH)D ≥30 ng/ml]. Positron emission tomography with [(13)N]ammonia was used to evaluate myocardial blood flow at rest and after adenosine stress. CFR was measured as the ratio of maximum to rest myocardial blood flow. MAIN OUTCOME MEASURE: Primary outcome was CFR measurement. RESULTS: Mean overall serum 25(OH)D concentration was 37.0 ± 21.4 ng/ml; 167 twins (45%) were vitamin D insufficient. CFR was significantly lower in subjects with vitamin D insufficiency compared with subjects with vitamin D sufficiency (2.41 vs. 2.64; P = 0.007), even after adjustment for traditional cardiovascular risk factors, serum PTH, calcium, and phosphorus levels, and season. An abnormal CFR (CFR <2) was more prevalent in subjects with vitamin D insufficiency than with vitamin D sufficiency (31 vs. 20%; P = 0.03). In addition, in vitamin D status-discordant twin pairs, CFR was significantly lower in the vitamin D-insufficient twin than in the vitamin D-sufficient co-twin (2.35 vs. 2.58; P = 0.037). CONCLUSION: Vitamin D insufficiency is associated with lower CFR in men. This association may help explain some of the increased cardiovascular risk reported in individuals with vitamin D insufficiency.

Approach to cardiovascular disease prevention in patients with chronic kidney disease.

OPINION STATEMENT: Chronic kidney disease (CKD) is associated with a large burden of cardiovascular risk factors ultimately leading to increased cardiovascular events and mortality. Prevention of cardiovascular disease (CVD) in CKD involves early identification of individuals at high-risk of renal disease. In fact, substantial evidence points to a complex bidirectional relationship between CKD and CVD. Therefore, most interventions directed at CKD prevention should include multiple risk factor interventions with the goal of preventing CVD events while slowing progression of CKD. Clearly, prevention of CVD in CKD is a complex task and requires a multidisciplinary team approach, with a well-defined program, rational targets for each risk factor, and implementation of the most effective intervention strategies. Although several interventions to prevent CVD have proven effective in the general population and in individuals at high risk for CVD, a true benefit in patients with CKD remains to be demonstrated for several of them. A few rational targets of intervention should be optimal blood pressure control, reduction of proteinuria, treatment of dyslipidemia, good control of diabetes, smoking cessation, dietary salt restriction, achievement of normal body mass index, partial correction of anemia, and management of mineral metabolism abnormalities. Lifestyle modification and pharmacological therapy with renin-angiotensin blockers, ß-blockers, diuretics, statins, and aspirin should be encouraged in the early stages of CKD.

Secondary hyperparathyroidism status in Brazil: Brazilian census of parathyroidectomy.

INTRODUCTION: Secondary hyperparathyroidism (SHP) is a common and serious complication of chronic kidney disease (CKD), with a negative impact on morbidity and mortality. Despite advances in the clinical management of SHP, treatment failure still occurs in a significant number of patients. In such cases, parathyroidectomy (PTx) is indicated. OBJECTIVE: To have an overview of the prevalence of severe SHP and of its surgical treatment in hemodialysis (HD) patients in Brazil. METHODS: This was an observational and descriptive study. Data were obtained from questionnaires posted to 660 dialysis units (DU). RESULTS: Results are expressed in absolute values and percentages, or means and standard deviation, as appropriate. 226 (34%) DU answered the questionnaire, providing data about 32,264 HD patients. The prevalence rate of severe SHP (PTH > 1,000 pg/mL) was 10.7 % (n = 3,463). 68 hospitals countrywide perform PTX. Around 40% of them are university centers. 49 (21.7%) DU reported not to have a specialized medical center to refer their patients with severe SHP. 74 (33%) DU reported that the time interval between surgery indication and its performance was over 6 months. The main recognized obstacles to surgery performance were: difficulty to perform the preoperative exams, lack of head and neck surgeons and the long waiting time. CONCLUSIONS: Although severe SHP is highly prevalent in Brazil, a significant number of patients do not have access to PTx. Better public health policies and liaison between nephrologists and head and neck surgeons are urgently required to change this reality.

Situação do hiperparatireoidismo secundário autônomo no Brasil: dados do censo brasileiro de paratireoidectomia / Secondary hyperparathyroidism status in Brazil: Brazilian census of parathyroidectomy

INTRODUÇÃO: O hiperparatireoidismo secundário (HPS) é uma complicação comum e grave no curso da doença renal crônica (DRC), com impacto direto sobre a morbidade e mortalidade desses pacientes. Apesar dos avanços no tratamento clínico do HPS a falência terapêutica ocorre em parcela significativa dos pacientes. Nesses casos, a paratireoidectomia (PTx) é indicada. OBJETIVO: Este trabalho visa abordar a situação atual no Brasil de pacientes com HPS em hemodiálise com indicação de PTx. MÉTODOS: Estudo observacional, descritivo, com dados obtidos de questionário enviado a 660 centros de diálise (CD). RESULTADOS: Os resultados estão expressos em valores absolutos, médias e desvio padrão; 226 (34 por cento) CD responderam ao questionário, representando 32.264 pacientes em hemodiálise (HD). A prevalência de pacientes com paratormônio (PTH) > 1.000pg/mL foi de 3.463 (10,7 por cento). Em 49 (21,7 por cento) CD não é possível encaminhar os pacientes para PTx. Cerca de 40 por cento dos serviços que realizam PTx são ligados a centros universitários. Em 74 (33 por cento) CD o tempo de espera para que um paciente seja operado é superior a 6 meses. Foram contabilizados 68 serviços que realizam PTx. Os principais problemas relacionados para a realização de PTx foram: dificuldades com a realização dos exames pré-operatórios, escassez de cirurgiões de cabeça e pescoço, e longa fila de espera. CONCLUSÕES: a prevalência de HPS grave é elevada em nosso meio. Uma parcela significativa de pacientes não tem acesso ao tratamento cirúrgico. Uma melhor organização das políticas de saúde pública, além de um maior entrosamento entre nefrologistas e cirurgiões de cabeça e pescoço, em torno dessa questão, são necessários para a mudança dessa realidade.

INTRODUCTION: Secondary hyperparathyroidism (SHP) is a common and serious complication of chronic kidney disease (CKD), with a negative impact on morbidity and mortality. Despite advances in the clinical management of SHP, treatment failure still occurs in a significant number of patients. In such cases, parathyroidectomy (PTx) is indicated. OBJECTIVE: To have an overview of the prevalence of severe SHP and of its surgical treatment in hemodialysis (HD) patients in Brazil. METHODS: This was an observational and descriptive study. Data were obtained from questionnaires posted to 660 dialysis units (DU). RESULTS: Results are expressed in absolute values and percentages, or means and standard deviation, as appropriate. 226 (34 percent) DU answered the questionnaire, providing data about 32,264 HD patients. The prevalence rate of severe SHP (PTH > 1,000 pg/mL) was 10.7 percent (n = 3,463). 68 hospitals countrywide perform PTX. Around 40 percent of them are university centers. 49 (21.7 percent) DU reported not to have a specialized medical center to refer their patients with severe SHP. 74 (33 percent) DU reported that the time interval between surgery indication and its performance was over 6 months. The main recognized obstacles to surgery performance were: difficulty to perform the preoperative exams, lack of head and neck surgeons and the long waiting time. CONCLUSIONS: Although severe SHP is highly prevalent in Brazil, a significant number of patients do not have access to PTx. Better public health policies and liaison between nephrologists and head and neck surgeons are urgently required to change this reality.