Are Nutritional Composed Scoring Systems and Protein-Energy Wasting Score Associated With Mortality in Maintenance Hemodialysis Patients?

OBJECTIVE: The diagnostic of protein-energy wasting should be done using a tool that can predict clinically important outcomes, besides identifying malnutrition. This study investigated which nutritional composed scoring systems best predicts all-cause mortality in maintenance hemodialysis patients. DESIGN AND METHODS: Cohort study that included prevalent patients undergoing hemodialysis for at least 1 month. To assess nutritional status, Subjective Global Assessment (SGA), Malnutrition-Inflammation Score (MIS), and diagnostic criteria for protein-energy wasting proposed by the International Society of Renal Nutrition and Metabolism (ISRNM) were used. Patients were assessed in the moment of inclusion in the study (between July 2012 and December 2012) and followed prospectively to verify the occurrence of deaths. RESULTS: A total of 163 patients were included, 54.6% were male, and mean age was 58.4 ± 15.5 years. During the follow-up period (15.5 ± 5.4 months), 29 patients died and 16 underwent kidney transplant. Kaplan-Meier survival curves and Cox proportional hazard analysis adjusted for age, gender, dialysis vintage, diabetes, and serum urea showed that SGA and MIS were predictors of all-cause mortality. CONCLUSION: Of the 3 investigated scoring systems, SGA and MIS predict mortality in a period of 15.5 ± 5.4 months of follow-up.

Aerobic Exercise Training and Nontraditional Cardiovascular Risk Factors in Hemodialysis Patients: Results from a Prospective Randomized Trial.

INTRODUCTION: Chronic kidney disease (CKD) patients have a high incidence of cardiovascular diseases (CVD) which increases their morbidity and mortality. A sedentary lifestyle in CKD is directly linked to the onset of CVD. Physical activity can bring beneficial effects to CKD patients. AIMS: The aim of this study was assess the impact of aerobic training on nontraditional cardiovascular risk factors in CKD patients on hemodialysis. MATERIALS AND METHODS: This is a prospective, controlled, and randomized clinical trial with analysis of intention to treat. Thirty patients underwent an exercise treadmill test, an arterial stiffness evaluation, echocardiography and analysis of endothelial reactivity, and carotid ultrasound and laboratorial tests, including analysis of serum aldosterone. The intervention group (IG) (n =15) underwent aerobic exercise during hemodialysis 3 times a week for 4 months. The control group (CG) (n =15) had no intervention. All of the patients were reassessed after 4 months. RESULTS: In the IG, there was a statistically significant improvement in flow-mediated vasodilation (FMV; p = 0.002) and a reduction in left ventricular hypertrophy (p = 0.006) and serum aldosterone (p = 0.016). There was an increase in C-reactive protein in the CG (p = 0.002). CONCLUSION: This aerobic training protocol was able to improve endothelial function with enhanced FMV and reduce left ventricular hypertrophy and serum aldosterone, which could have a positive impact on the reduction of nontraditional cardiovascular risk factors in CKD patients on hemodialysis.

Incorporating evidence-based principles in medical training. Sharing experience with McMaster.

This article was migrated. The article was marked as recommended. Background: This workshop was the second activity of the collaboration between the McMaster University, Botucatu Medical School- São Paulo State University (UNESP) and Pontifical Catholic University of Minas Gerais - PUC Minas that took place in Botucatu, Brazil between March 27th to 28th 2017. Aims: Its prime purpose was to share with the Brazilian professors and students how to include evidence-based concepts in their daily teaching activities. Methods: The participants were involved and guided in discussions on how to explore evidence-based techniques to improve their understanding and their willingness to include new teaching strategies in the future. Results: A final evaluation survey completed by the participants indicated that they were highly satisfied with the workshop experience and that they gained an enhancement of knowledge about evidence-based medicine. Conclusion: Participants had an increase in their self-confidence to implementevidence-based concepts in their future lecture programs.

Influence of Intradialytic Aerobic Training in Cerebral Blood Flow and Cognitive Function in Patients with Chronic Kidney Disease: A Pilot Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Changes in cerebral blood flow may play an important role in cognitive impairment among hemodialysis (HD) patients. Physical activity has a promising role in delaying cognitive impairment in general population, but there are only a few studies in HD to confirm this finding. We aimed to evaluate the effects of intradialytic aerobic training on cerebral blood flow and cognitive impairment in HD. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: This is a pilot, controlled, randomized trial. Fifteen patients underwent intradialytic aerobic training 3 times a week for 4 months. The control group was comprised of another 15 patients. RESULTS: Trained patients had a statistically significant improvement of cognitive impairment and basilar maximum blood flow velocity. The proportion of arteries with increased flow velocity was statistically significant between groups. CONCLUSIONS: Intradialytic aerobic training improves cognitive impairment and cerebral blood flow of patients in HD, suggesting a possible mechanism improving cognitive impairment by physical training in HD. These data still need to be confirmed by major trials.

Total body water and failure to control blood pressure by medication in hemodialysis patients.

BACKGROUND: Volume overload is the main factor responsible for the pathogenesis of hypertension in dialysis patients. Few studies have evaluated the interpretation of the parameters obtained by bioelectrical impedance (BIA) to manage these patients. The aim of this study was to assess the best cutoff level of volume overload obtained by BIA able to predict the absence of hypertension control in hemodialysis patients. METHODS: Volume overload was calculated as the difference between total body water (TBW) measured by bioimpedance and TBW estimated by the Watson formula in chronic stable hemodialysis patients. Inadequate control of blood pressure (BP) was defined as the mean of measurements obtained before five hemodialysis sessions ≥140 × 90 mm Hg. The best cutoff level of volume overload assessed by BIA able to predict the absence of BP control in patients on chronic hemodialysis was determined by the receiver operating characteristic (ROC) curve using the Youden method. RESULTS: We included 205 patients, 53% male, aged 56 ± 14.5 years. The largest area under the ROC curve was found for predialysis volume overload (0.660, 95% CI 0.556-0.765, p = 0.004). The ROC curve of postdialysis volume overload also reaches statistical significance. The best cutoff point was found for predialysis volume overload ≥1.4 liters with a sensitivity of 69% and a specificity of 67%. CONCLUSION: The association of TBW and inadequate BP control highlights the importance of volume management in hemodialysis patients. Predialysis volume overload of 1.4 liters was the parameter that best discriminated the presence of inadequate BP control.