Bioimpedanciometry in nutritional and hydration assessments in a single dialysis center / Bioimpedanciometria em avaliações nutricionais e de hidratação em um único centro de diálise

ABSTRACT Background: Bioimpedance analysis (BIA) has been demonstrated to add accuracy to nutritional and volume status assessments in dialysis (HD) patients. Aim: to describe a sample of dialysis patients from a single center on their demographics and BIA of volume distribution and nutritional status, and mortality during 12-month follow-up. Methods: prospective observational cohort study to evaluate vintage HD patients with single-frequency BIA. Results: we evaluated 82 patients, 29% over 65 years old. Elderly patients had higher ECW/TBW (0.51 vs. 0.44, p < 0.0001), and narrower phase angle (PhA) (4.9 vs. 6.4º, p < 0.0001). Fifteen patients (18.2%) died during follow-up, eight (53%) were elderly. Death was associated with age (62.6 vs. 50.2 years, p = 0.012), post-HD PhA (4.8 vs. 6.2º, p = 0.0001), and post-HD ECW/TBW (0.50 vs. 0.45, p = 0.015). The ROC curve analysis to predict mortality found ECW/TBW ≥ 0.47 and PhA ≤ 5.5º to have the best sensitivity and specificity. One-year patient survival was lower with post-HD ECW/TBW ≥ 0.47 (69.5% vs. 90.6%, p = 0.019), age ≥ 65 years (64.2%, vs. 86.2%, p = 0.029), and PhA ≤ 5.5º (68.2 vs. 91.0%, p = 0.002). Cox regression analysis demonstrated that PhA [HR 5.04 (95%CI 1.60-15.86), p = 0.006] remained associated with death after adjusting for age and ECW/TBW. Conclusion: BIA is useful in assessing volume distribution and nutrition in HD patients, and combined with clinical judgement, may help determine dry weight, especially in elderly patients. Narrower PhA and higher ECW/TBW after HD were associated with poorer one-year survival.

RESUMO Antecedentes: Análise de bioimpedância (BIA) demonstrou adicionar acurácia às avaliações de estado nutricional e de volume em pacientes em diálise (HD). Objetivo: descrever amostra de pacientes em diálise de um único centro quanto aos aspectos demográficos e BIA na distribuição de volume e no estado nutricional, e a mortalidade em 12 meses de acompanhamento. Métodos: estudo de coorte observacional prospectivo para avaliar pacientes prevalentes em HD com BIA de frequência única. Resultados: avaliamos 82 pacientes, 29% acima de 65 anos. Pacientes idosos apresentaram maior AEC/ACT (0,51 vs. 0,44; p < 0,0001), e ângulo de fase mais estreito (PhA) (4,9 vs. 6,4º; p < 0,0001). Quinze pacientes (18,2%) foram a óbito durante acompanhamento, oito (53%) eram idosos. Óbito foi associado à idade (62,6 vs. 50,2 anos, p = 0,012), PhA pós-HD (4,8 vs. 6,2º; p = 0,0001), e AEC/ACT pós-HD (0,50 vs. 0,45, p = 0,015). A análise da curva ROC para prever mortalidade constatou que AEC/ACT ≥ 0,47 e PhA ≤ 5,5º apresentam melhor sensibilidade e especificidade. Sobrevida do paciente em um ano foi menor com AEC/ACT pós-HD ≥ 0,47 (69,5% vs. 90,6%; p = 0,019), idade ≥ 65 anos (64,2% vs. 86,2%; p = 0,029), e PhA ≤ 5,5º (68,2 vs. 91,0%; p = 0,002). A análise de regressão de Cox demonstrou que PhA [HR 5,04 (IC 95% 1,60-15,86); p = 0,006] permaneceu associado ao óbito após ajuste para idade e AEC/ACT. Conclusão: BIA é útil ao avaliar distribuição de volume e nutrição em pacientes em HD, e juntamente com julgamento clínico, pode ajudar a determinar o peso seco, principalmente em pacientes idosos. PhA mais estreito e maior AEC/ACT pós-HD foram associados a pior sobrevida em um ano.

Bioimpedanciometry in nutritional and hydration assessments in a single dialysis center.

BACKGROUND: Bioimpedance analysis (BIA) has been demonstrated to add accuracy to nutritional and volume status assessments in dialysis (HD) patients. AIM: to describe a sample of dialysis patients from a single center on their demographics and BIA of volume distribution and nutritional status, and mortality during 12-month follow-up. METHODS: prospective observational cohort study to evaluate vintage HD patients with single-frequency BIA. RESULTS: we evaluated 82 patients, 29% over 65 years old. Elderly patients had higher ECW/TBW (0.51 vs. 0.44, p < 0.0001), and narrower phase angle (PhA) (4.9 vs. 6.4º, p < 0.0001). Fifteen patients (18.2%) died during follow-up, eight (53%) were elderly. Death was associated with age (62.6 vs. 50.2 years, p = 0.012), post-HD PhA (4.8 vs. 6.2º, p = 0.0001), and post-HD ECW/TBW (0.50 vs. 0.45, p = 0.015). The ROC curve analysis to predict mortality found ECW/TBW ≥ 0.47 and PhA ≤ 5.5º to have the best sensitivity and specificity. One-year patient survival was lower with post-HD ECW/TBW ≥ 0.47 (69.5% vs. 90.6%, p = 0.019), age ≥ 65 years (64.2%, vs. 86.2%, p = 0.029), and PhA ≤ 5.5º (68.2 vs. 91.0%, p = 0.002). Cox regression analysis demonstrated that PhA [HR 5.04 (95%CI 1.60-15.86), p = 0.006] remained associated with death after adjusting for age and ECW/TBW. CONCLUSION: BIA is useful in assessing volume distribution and nutrition in HD patients, and combined with clinical judgement, may help determine dry weight, especially in elderly patients. Narrower PhA and higher ECW/TBW after HD were associated with poorer one-year survival.

Urine microscopy as a biomarker of Acute Kidney Injury following cardiac surgery with cardiopulmonary bypass / Microscopia urinária como biomarcador de lesão renal aguda após cirurgia cardíaca com circulação extracorpórea

Abstract Introduction: Acute kidney injury (AKI) occurs in about 22% of the patients undergoing cardiac surgery and 2.3% requires renal replacement therapy (RRT). The current diagnostic criteria for AKI by increased serum creatinine levels have limitations and new biomarkers are being tested. Urine sediment may be considered a biomarker and it can help to differentiate pre-renal (functional) from renal (intrinsic) AKI. Aims: To investigate the microscopic urinalysis in the AKI diagnosis in patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: One hundred and fourteen patients, mean age 62.3 years, 67.5 % male, with creatinine 0.91 mg/dL (SD 0.22) had a urine sample examined in the first 24 h after the surgery. We looked for renal tubular epithelial cells (RTEC) and granular casts (GC) and associated the results with AKI development as defined by KDIGO criteria. Results: Twenty three patients (20.17 %) developed AKI according to the serum creatinine criterion and 76 (66.67 %) by the urine output criterion. Four patients required RRT. Mortality was 3.51 %. The use of urine creatinine criterion to predict AKI showed a sensitivity of 34.78 % and specificity of 86.81 %, positive likelihood ratio of 2.64 and negative likelihood ratio of 0.75, AUC-ROC of 0.584 (95%CI: 0.445-0.723). For the urine output criterion sensitivity was 23.68 % and specificity 92.11 %, AUC-ROC was 0.573 (95%CI: 0.465-0.680). Conclusion: RTEC and GC in urine sample detected by microscopy is a highly specific biomarker for early AKI diagnosis after cardiac surgery.

Resumo Introdução: Lesão renal aguda (LRA) ocorre em cerca de 22% dos pacientes submetidos a cirurgia cardíaca e 2,3% necessitam de terapia renal substitutiva (TRS). Os atuais critérios diagnósticos para LRA fundamentados no aumento dos níveis de creatinina sérica apresentam limitações e novos biomarcadores estão sendo testados. O sedimento urinário é um biomarcador que pode ajudar a diferenciar a LRA pré-renal (funcional) da LRA renal (intrínseca). Objetivos: Investigar a urinálise microscópica no diagnóstico de LRA em pacientes submetidos a cirurgia cardíaca com circulação extracorpórea. Métodos: Um total de 114 pacientes com idade média de 62,3 anos, 67,5% do sexo masculino e níveis médios de creatinina de 0,91 mg/dL (DP 0,22) tiveram amostras de urina examinadas nas primeiras 24 horas após a cirurgia. A identificação de células epiteliais tubulares renais (CETR) e cilindros granulares (CG) foi associada a desfechos de desenvolvimento de LRA conforme os critérios do KDIGO. Resultados: Vinte e três pacientes (20,17%) desenvolveram LRA pelo critério de creatinina sérica e 76 (66,67%) pelo critério de diurese. Quatro pacientes necessitaram de TRS. A mortalidade foi de 3,51%. O uso da creatinina urinária como critério preditivo para LRA mostrou sensibilidade de 34,78% e especificidade de 86,81%; razão de verossimilhança positiva de 2,64 e razão de verossimilhança negativa de 0,75; e ASC-COR de 0,584 (IC 95%: 0,445-0,723). Para o critério de diurese, a sensibilidade foi de 23,68% e a especificidade 92,11%; a ASC-COR foi 0,573 (IC 95%: 0,465-0,680). Conclusão: A identificação de CETR e CG em amostras de urina por microscopia representa um biomarcador altamente específico para o diagnóstico precoce de LRA após cirurgia cardíaca.

BK Polyomavirus-associated nephropathy managed by screening policy in a real-life setting.

BACKGROUND: BK polyomavirus-associated nephropathy (PyVAN) is an important complication after kidney transplantation. Prevalence ranges from 1% to 10%, and graft loss occurs in approximately 50% of the cases. There is no effective treatment, so early viral detection with immunosuppression tapering is the current strategy to prevent PyVAN. AIMS: To verify the frequency of PyVAN in a single center and evaluate the response to immunosuppressive adjustments through graft survival analysis. METHODS: Retrospective evaluation of a cohort of kidney transplant recipients with biopsy-proven PyVAN, compared with no-PyVAN patients regarding clinical aspects, immunosuppression, and graft survival over at least 2 years. RESULTS: There were 1404 kidney transplants analyzed in the study period, 58 with biopsy-proven PyVAN. Cumulative incidence was 4.1%. Median time from transplantation to PyVAN diagnosis was 6 (1-41) months. PyVAN was associated with recipient male gender (P = .041) and deceased donation (P = .005). Graft survival was inferior for PyVAN compared to no-PyVAN patients, 81.8% vs 75.2%, P = .019. Thirteen (22.4%) PyVAN patients lost their grafts, nine (15.5%) losses attributed to BKPyV infection. Three patients with BKPyV-associated graft losses were submitted to a successful second kidney transplant, with no evidence of viral replication during follow-up. CONCLUSION: PyVAN still is an important cause of kidney graft failure. Even though implementing active vigilance and immunosuppressive adjustment, this real-life single-center study demonstrated inferior graft survival in PyVAN patients compared to non-PyVAN.

Urine microscopy as a biomarker of Acute Kidney Injury following cardiac surgery with cardiopulmonary bypass.

INTRODUCTION: Acute kidney injury (AKI) occurs in about 22% of the patients undergoing cardiac surgery and 2.3% requires renal replacement therapy (RRT). The current diagnostic criteria for AKI by increased serum creatinine levels have limitations and new biomarkers are being tested. Urine sediment may be considered a biomarker and it can help to differentiate pre-renal (functional) from renal (intrinsic) AKI. AIMS: To investigate the microscopic urinalysis in the AKI diagnosis in patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS: One hundred and fourteen patients, mean age 62.3 years, 67.5 % male, with creatinine 0.91 mg/dL (SD 0.22) had a urine sample examined in the first 24 h after the surgery. We looked for renal tubular epithelial cells (RTEC) and granular casts (GC) and associated the results with AKI development as defined by KDIGO criteria. RESULTS: Twenty three patients (20.17 %) developed AKI according to the serum creatinine criterion and 76 (66.67 %) by the urine output criterion. Four patients required RRT. Mortality was 3.51 %. The use of urine creatinine criterion to predict AKI showed a sensitivity of 34.78 % and specificity of 86.81 %, positive likelihood ratio of 2.64 and negative likelihood ratio of 0.75, AUC-ROC of 0.584 (95%CI: 0.445-0.723). For the urine output criterion sensitivity was 23.68 % and specificity 92.11 %, AUC-ROC was 0.573 (95%CI: 0.465-0.680). CONCLUSION: RTEC and GC in urine sample detected by microscopy is a highly specific biomarker for early AKI diagnosis after cardiac surgery.

Frequency of onychomycoses in chronic renal failure patients undergoing hemodialysis in Porto Alegre, Brazil.

Onychomycosis is one of the most frequent infections affecting the fingernails or the toenails and it is caused mainly by dermatophytes. The aim of the study was to assess the frequency of onychomycoses in hemodialysis patients and to relate sex, age, duration of hemodialysis and causes of renal failure to the development of nail disorders. The study included 100 patients with chronic renal failure undergoing hemodialysis. The patients underwent detailed clinical examination of the toenails and those with any kind of clinical finding had nail scraping for mycological testing. In the study population, the frequency of onychomycosis was 39%. The most commonly isolated fungi were dermatophytes (69.23%), Candida spp. (15.38%) and nondermatophyte molds (15.38%). T. interdigitale was the most prevalent fungus followed by Candida ssp. and T. rubrum. The risk of onychomycosis increases by 1.9% for each additional year in age and diabetic patients are 88% more likely to develop onychomycosis than nondiabetic ones. The duration of hemodialysis treatment and sex were not associated with the development of onychomycosis. In conclusion, in hemodialysis patients, the frequency of onychomycosis was higher in those at advanced age and with diabetes.

Doença arterial renovascular: desafio terapêutico e seguimento a longo prazo / Arterial renovascular disease: therapeutic challenge and long term follow-up

Objetivo: Demonstrar dois casos de pacientes portadores de doença renovascular complicada tratados com sucesso através de cirurgia convencional. Método: Relato de dois casos de hipertensão renovascular tratados cirurgicamente. Resultados: Controle da hipertensão e melhora da função renal em ambos os casos tratados. Conclusão: Os dois casos apresentados são exemplos de como intervenções cirúrgicas com técnica adequada podem atenuar a hipertensão renovascular, remover o risco do edema agudo de pulmão, evitar o óbito iminente e postergar a entrada do paciente em programa de hemodiálise (AU)

Objective: Report two cases of complicated renovascular hypertension successfully treated with open surgery. Methods: Two case of renovascular hypertension surgically treated are herein reported. Results: There was improvement on hypertension control and renal function in both cases. Conclusions: Both cases reported are examples of how a correct surgery can attenuate renovascular hypertension, remove the risk of acute pulmonary edema, prevent death and delay hemodialysis (AU)

Renal transplants using expanded cadaver donor criteria.

AIMS: to analyze the frequency of transplants using expanded donor criteria (EDC) and the incidence of delayed graft function, acute rejection and the patient and graft survival compared to ideal donors (ID). PATIENTS: retrospective analysis of the 582 cadaver renal transplants performed from Jun 1988 to Mar 2003 in adult recipients. The expanded donor criteria were considered as history of hypertension or evidence of atherosclerosis, diabetes, age less than 5 or more than 55 years old, serum creatinine higher than 2.0 mg/dL, shock and retrieval in cardiac arrest. The statistical analysis used was Student t test, Chi-square test, and Kaplan-Meier method as indicated. RESULTS: 25.4% of our transplants used expanded criteria donor. Comparing, respectively, the EDC and ID we found: the incidence of delayed graft function of 63.9% vs 50.4% (P: 0.007); incidence of acute rejection of 66.1% vs 72.3% (P: 0.203). The patient survival at 1 and 5 years was 87% vs 92% and 81% vs 79%, respectively (P: 0.6809). The graft survival at 1 and 5 year was 74% vs 82% and 57% vs 59% (P: 0.2072), respectively for EDC and ID. CONCLUSIONS: One fourth of our cadaver transplants fulfilled the extended donor criteria. The incidence of delayed graft function was higher in these transplants, but the prevalence of rejection episodes was similar to ideal donors. The patient and graft survival were not statistically different at 1 and 5 year.

Twenty-five year experience with renal transplantation at Santa Casa Hospital, Porto Alegre.

From 1977 to July 2002, 1,376 renal transplants were performed at Santa Casa of Porto Alegre. The number of transplants and the patient and graft survival rates have been rising each year since 1987. The overall one-year graft survival rates were 90% for living donor recipients and 80% for cadaver donor recipients, respectively; however, the patient and graft survival rates increased significantly between the early (1977-1995) and more recent (1996-2002) periods. Pediatric patients (less than 18 years old) accounted for 15.8% of the transplants that were performed, most of them from living related donors. The patient and graft survival rates did not differ statistically when we compared recipients of transplants from "ideal" and marginal cadaver donors, even when we considered only those risk factors that affected graft function in assigning a marginal donor. During the 25-year observation period, 537 grafts have been lost (39%), including those patients who died with functioning graft. We are currently following 834 patients with a functioning graft, with an average follow-up of 67+54 months.

Incidência dos marcadores virais para a hepatite B e resposta a vacinaçäo em uma unidade de hemodiálise / Prevalence of viral markers for hepatitis B and response to vaccination in a hemodialysis init

O presente estudo avalia, em uma unidade de hemodiálise, a prevalência dos marcadores virais da hepatite pelo virus B e a taxa de seroconversäo após vacinaçäo. Para tanto, foram avaliados 397 pacientes. Em todos foi determinado o HBsAg e em 201 também foi realizado o anti-HBs, o anti-HBc IgG e o anti-HBc IgM.Sessenta e quatro pacientes sem marcadores virais, foram imunizados com vacina recombinante. A presença de algum marcador viral foi obsevada em 68,5 por cento dos casos, sendo que em 14,1 por cento o HBsAg foi positivo. Por outro lado, a taxa global de seroconversäo, após vacina, foi de 58 por cento. Conclui-se ser elevada a prevalência de marcadores do virus da hepatite B em pacientes hemodialisados, bem como ser baixa, nesta populaçäo de pacientes, a taxa de seroconvbersäo após vacinaçäo

Transplante simultâneo de rim e pâncreas: experiência com nove casos na Irmandade Santa Casa de Misericórdia de Porto Alegre / Simultaneous kidney and pancreas transplantation: experience with 9 cases in Irmandade Santa Casa de Misericórdia de Porto Alegre

É apresentada a experiência do Serviço de Nefrologia da Santa Casa de Porto Alegre com o Transplante Simultâneo de Rim e Pâncreas (TxSRP) em diabéticos insulino-dependentes urêmicos. Entre agosto de 1987 e fevereiro de 1996 foram realizados nove TxSRP. A sobrevida do paciente do rim e do pâncreas foi de 88,9 por cento, 77,8 por cento e 76,2 por cento no primeiro ano e de 63,4 por cento, 51,8 por cento e 50,7 por cento no terceiro ano. Ocorreram quatro óbitos. Foram perdidos um enxerto renal e um pancreático. Ao final da observaçäo, cinco pacientes estavam vivos com enxerto renal funcionante e quatro com funçäo pancreática normal. O TxSRP pode, em determinadas situaçöes, ser uma alternativa para o tratamento de diabéticos insulino-dependentes urêmicos necessitando de transplante renal.

Transplante renal na Santa Casa de Porto Alegre: uma análise de 520 casos em 17 anos / Kidney transplants at the Santa Casa of Porto Alegre: a review of 520 transplants done in the last 17 years

Apresentamos os dados disponíveis relativos aos primeiros 520 transplantes renais na Santa Casa de Porto Alegre. A partir de 1989 foram realizados em média 75 transplantes por ano, sendo que em 1993 este número foi de 108, com 51,9 por cento provenientes de doadores cadavéricos. A sobrevida do enxerto no primeiro ano nos transplantes realizados após 1988 passou a ser de 89,8 por cento para doadores vivos e de 75 por cento para doadores cadavéricos. Durante o período de observaçäo (máximo de 17 anos e mínimo de 6 meses), 187 enxertos foram perdidos (36 por cento). Permanecem com enxerto funcionante 333 pacientes, com seguimento médio de 43.9 +/-31,7 meses. Em conclusäo, dois terços de nossos pacientes foram reabilitados e retornaram à uma vida produtiva, mostrando que o transplante renal näo pode ser encarado como uma terapêutica de elite, mas como uma forma de tratamento capaz de beneficiar a maioria dos pacientes com insuficiência renal crônica

Coordenadoria de transplantes do Rio Grande do Sul (RS): análise de seis anos de atividades / Office of transplant coodinator in Rio Grande do Sul (RS): analysis of six-year activities

Realizada uma avaliaçao dos seis anos de atividade da Coordenadoria de transplantes do RS (1988 a 1993). Sao apresentados suas normas de funcionamento e seus objetivos, os quais foram parcialmente obtidos neste período. Há uma equipe de procura de órgaos e uma equipe de remoçao de rins funcionando ininterruptamente. Há um registro dos doadores e dos transplantes renais realizados no Estado.A taxa de potenciais doadores é conhecida (40,8pmp/ano), o número de transplantes renais com doador cadáver está aumentando, tendo sido realizados, em 1993, 15,5 transplantes pmp, representando 62 por cento dos transplantes naquele ano e foram removidos múltiplos órgaos em 22 por cento dos doadores. Foram estabelecidos novos objetivos para os próximos quatro anos.

Tuberculose em urêmicos / Tuberculosis in patients with chronic renal failure

A tuberculose ocorre com maior freqüência nos pacientes com insuficiência renal crônica em diálise. O diagnóstico é dificil, pois os sintomas säo inespecíficos e podem ser atribuídos à uremia. O teste tuberculínico é negativo na maioria dos pacientes (63,5%), e säo comuns as formas extra-pulmonares da doença *56%). Recomendamos a realizaçäo da reaçäo de Mantoux em todos os pacientes urêmicos; os que foram reatores ao teste, sem evidências de doença ativa, poderiam beneficiar-se da quimioprofilaxia com isoniazida pelo período de um ano. Considerando a eficácia, a facilidade de administraçäo e menores paraefeitos, propomos, como esquema terapêutico para tuberculose em pacientes em diálise, a associaçäo da pirazimida por 2 meses, isoniazida e rifampicina por 6 meses

Transplante renal: selecao do receptor e do doador / Renal transplantation: recipient and donor selection

O transplante renal por oferecer melhor qualidade de vida e maior sobrevida com menor custo social e o tratamento de escolha para a maioria dos pacientes uremicos cronicos. Os autores abordam os criterios usados na selecao do receptor de transplante renal, assim como aspectos medicos, eticos e legais na selecao do potencial doador vivo e cadaver