Reflection about the hemodialysis water microbiological quality in Brazil

Abstract Dialysis has been widely used in the treatment of patients with chronic kidney diseases and is considered a global public health issue. This treatment, which has changed the prognosis and quality of life in patients with chronic renal failure, can lead to complications that are often fatal. For this reason, there is a need for validation of alternative tests that favor the monitoring of treated water for dialysis in real-time to promote and prevent injuries to patients submitted to this procedure.

Proteomic analysis of plasma proteins of high-flux haemodialysis and on-line haemodiafiltration patients reveals differences in transthyretin levels related with anaemia.

A large proportion of end-stage renal disease (ESRD) patients under long-term haemodialysis, have persistent anaemia and require high doses of recombinant human erythropoietin (rhEPO). However, the underlying mechanisms of renal anaemia have not been fully elucidated in these patients. In this study, we will be focusing on anaemia and plasma proteins in ESRD patients on high-flux haemodialysis (HF) and on-line haemodiafiltration (HDF), to investigate using two proteomic approaches if patients undergoing these treatments develop differences in their plasma protein composition and how this could be related to their anaemia. The demographic and biochemical data revealed that HDF patients had lower anaemia and much lower rhEPO requirements than HF patients. Regarding their plasma proteomes, HDF patients had increased levels of a protein highly similar to serotransferrin, trypsin-1 and immunoglobulin heavy constant chain alpha-1, and lower levels of alpha-1 antitrypsin, transthyretin, apolipoproteins E and C-III, and haptoglobin-related protein. Lower transthyretin levels in HDF patients were further confirmed by transthyretin-peptide quantification and western blot detection. Since ESRD patients have increased transthyretin, a protein that can aggregate and inhibit transferrin endocytosis and erythropoiesis, our finding that HDF patients have lower transthyretin and lower anaemia suggests that the decrease in transthyretin plasma levels would allow an increase in transferrin endocytosis, contributing to erythropoiesis. Thus, transthyretin could be a critical actor for anaemia in ESRD patients and a novel player for haemodialysis adequacy.

Is dialysis water a safe component for hemodialysis treatment in São Paulo State, Brazil?

Failure on the water treatment poses hemodialysis patients at risk of injury and death. Identifying if the patients are exposed to water quality related microbiological risks is an important objective to reduce the mortality for chronic renal patients and is the main issue of this study. We evaluated the microbiological water quality used by 205 dialysis services in São Paulo State, Brazil between 2010 to 2016. The study included heterotrophic bacteria count, total coliforms research, and bacterial endotoxin determination in 1366 dialysis water samples. The number of unsatisfactory clinics for at least one microbiological parameter decreased 16.0% between 2010 to 2015 but increased 57.2% in 2016. In 2010, the most frequent unsatisfactory parameter was related to heterotrophic bacteria count (54.8%) followed by endotoxin determination (45.2%). However, in 2013 an opposite situation was observed: endotoxin determination as the parameter of the higher incidence of nonconformities. Total coliform was verified at a lower frequency. We highlighted the importance of regular monitoring of dialysis water quality to prevent infections caused by dialytic procedures and to ensure that the water is a safe component of the treatment.

Conhecimento sobre a hemodiálise em pacientes renais crônicos: um estudo descritivo / Conocimiento sobre hemodiálisis en pacientes renales crónicos: un estudio descriptivo / Knowledge on hemodialysis in chronic renal patients: a descriptive study

OBJETIVO: Analisar o conhecimento dos pacientes renais crônicos submetidos à hemodiálise referente ao tratamento hemodialítico, de acordo com os indicadores do resultado de enfermagem Conhecimento: procedimentos de tratamento. MÉTODO: Estudo descritivo realizado em um hospital público em Pernambuco através da aplicação do resultado de enfermagem Conhecimento: procedimentos de tratamento em 51 pacientes submetidos à hemodiálise. RESULTADOS: Os pacientes pesquisados apresentaram nenhum conhecimento, conhecimento limitado e moderado e não apresentaram o conhecimento amplo e/ou substancial sobre a hemodiálise. DISCUSSÃO: A hemodiálise é um procedimento complexo e que exige do paciente uma adaptação no estilo de vida. Para tanto, conhecer a doença e seu tratamento pode contribuir para o sucesso da terapia. CONCLUSÃO: Através da aplicação dos indicadores do resultado de enfermagem na prática clínica, verificou-se que indivíduos renais crônicos têm um conhecimento moderado, limitado ou não têm conhecimento sobre a hemodiálise.

OBJETIVO: Analizar el conocimiento de pacientes renales crónicos sometidos a hemodiálisis con respecto al tratamiento de hemodiálisis, de acuerdo con los indicadores de resultados de enfermería Conocimiento: procedimientos de tratamiento. MÉTODO: Estudio descriptivo realizado en un hospital público de Pernambuco mediante la aplicación del resultado de enfermería Conocimiento: procedimientos de tratamiento en 51 pacientes sometidos a hemodiálisis. RESULTADOS: Los pacientes encuestados presentaron ningún conocimiento, conocimiento limitado y moderado y no presentaban conocimiento amplio y/o sustancial sobre hemodiálisis. DISCUSIÓN: La hemodiálisis es un procedimiento complejo y requiere del paciente una adaptación de su estilo de vida. Por lo tanto, conocer la enfermedad y su tratamiento puede contribuir al éxito de la terapia. CONCLUSIÓN: Mediante la aplicación de indicadores de resultados de enfermería en la práctica clínica, se descubrió que los pacientes renales crónicos tienen un conocimiento moderado, limitado o no tienen conocimientos sobre la hemodiálisis.

OBJECTIVES: To analyze the knowledge of the chronic renal patients undergoing hemodialysis regarding this treatment, according to the indicators of the "Knowledge:Treatment procedures" nursing outcome. METHOD: A descriptive study carried out in a public hospital of Pernambuco through the application of the "Knowledge: Treatment procedures" nursing outcome in 51 patients undergoing hemodialysis. RESULTS: The surveyed patients had no knowledge, or limited and moderate knowledge, and did not have broad and/or substantial knowledge on hemodialysis. DISCUSSION: Hemodialysis is a complex procedure and requires an adaptation of the patient's lifestyle. Therefore, knowing the disease and its treatment may contribute to a successful therapy. CONCLUSION: Through the application of the nursing outcome indicators in the clinical practice, it was verified that chronic renal patients have moderate, limited or no knowledge of hemodialysis.

Direct and indirect costs of end-stage renal disease patients in the first and second years after initiation of nocturnal home haemodialysis, hospital haemodialysis and peritoneal dialysis.

PURPOSE: To estimate the direct and indirect costs of end-stage renal disease (ESRD) patients in the first and second years of initiating peritoneal dialysis (PD), hospital-based haemodialysis (HD) and nocturnal home HD. METHODS: A cost analysis was performed to estimate the annual costs of PD, hospital-based HD and nocturnal home HD for ESRD patients from both the health service provider's and societal perspectives. Empirical data on healthcare resource use, patients' out-of-pocket costs, time spent on transportation and dialysis by ESRD patients and time spent by caregivers were analysed. All costs were expressed in Hong Kong year 2017 dollars. RESULTS: Analysis was based on 402 ESRD patients on maintenance dialysis (PD: 189; hospital-based HD: 170; and nocturnal home HD: 43). From the perspective of the healthcare provider, hospital-based HD had the highest total annual direct medical costs in the initial year (mean ± SD) (hospital-based HD = $400 057 ± 62 822; PD = $118 467 ± 15 559; nocturnal home HD = $223 358 ± 18 055; P < 0.001) and second year (hospital-based HD = $360 924 ± 63 014; PD = $80 796 ± 15 820; nocturnal home HD = $87 028 ± 9059; P < 0.001). From the societal perspective, hospital-based HD had the highest total annual costs in the initial year (hospital-based HD = $452 151 ± 73 327; PD = $189 191 ± 61 735; nocturnal home HD = $242 038 ± 28 281; P < 0.001) and second year (hospital-based HD = $413 017 ± 73 501; PD = $151 520 ± 60 353; nocturnal home HD = $105 708 ± 23 853; P < 0.001). CONCLUSIONS: This study quantified the economic burden of ESRD patients, and assessed the annual healthcare and societal costs in the initial and second years of PD, hospital-based HD and nocturnal home HD in Hong Kong. From both perspectives, PD is cost-saving relative to hospital-based HD and nocturnal home HD, except that nocturnal home HD has the lowest cost in the second year of treatment from the societal perspective. Results from this cost analysis facilitate economic evaluation in Hong Kong for health services and management targeted at ESRD patients.

Beta-2 microglobulin clearance in high-flux dialysis and convective dialysis modalities: a meta-analysis of published studies.

Background: Recent meta-analyses suggest that higher removal of beta-2 microglobulin (ß2M) with either high-flux (HFD) dialysis or hemodiafiltration (HDF) may be associated with decreased total and cardiovascular mortality in dialysis patients. However, there are limited data about the performance of high flux dialyzers and/or convective therapies in removing ß2M. Methods: This is a random effects meta-analysis and meta-regression of data extracted from randomized controlled trials and observational studies in hemodialysis, hemofiltration and HDF regarding the efficiency of high flux dialyzers to remove ß2M. Studies were searched using ProQuest in SCOPUS, EMBASE and MEDLINE. Results: We included 69 studies from 1 January 2001 to 12 June 2017 on 1879 patients with 6771 available measurements. Average ß2M clearance was 48.75 mL/min [95% confidence interval (CI) 42.50-55.21] for conventional HF dialysis, and 87.06 mL/min (95% CI 75.08-99.03) for convective therapies (hemofiltration and HDF) with substantial heterogeneity among studies [P (Q) ≤ 0.001]. In multivariable meta-regression analyses, we found significantly higher ß2M clearance for polyarylethersulfone dialyzers when used for HFD and polysulfone membranes in convective therapies. However, the mass of ß2M removed into the dialysate did not depend on membrane material. Adjusted dialysate-side (-22.279, 95% CI -9.8 to -34.757, P < 0.001) ß2M clearances were significantly lower than whole blood clearances, suggesting that adsorption contributes substantially to ß2M removal. Higher Kuf, blood flow and substitution fluid rates but not dialysate flow rates were associated with statistically significant and clinically meaningful elevation in ß2M clearance from the body independent of the dialysis modality. Conclusions: Membrane composition and characteristics, modality (convective versus diffusive), blood flow rates and substitution fluid rates in HDF play a significant role in the efficient removal of ß2M from the body in both diffusive and convective dialysis.

Association between conversion to in-center nocturnal hemodialysis and right ventricular remodeling.

Background: In-center nocturnal hemodialysis (INHD) is associated with favorable left ventricular (LV) remodeling. Although right ventricular (RV) structure and function carry prognostic significance, the impact of dialysis intensification on RV is unknown. Our objectives were to evaluate changes in RV mass index (MI), end-diastolic volume index (EDVI), end-systolic volume index (ESVI) and ejection fraction (EF) after conversion to INHD and their relationship with LV remodeling. Methods: Of 67 conventional hemodialysis (CHD, 4 h/session, three times/week) patients, 30 continued on CHD and 37 converted to INHD (7-8 h/session, three times/week). Cardiac magnetic resonance imaging was performed at baseline and 1 year using a standardized protocol; an experienced and blinded reader performed RV measurements. Results: At 1 year there were significant reductions in RVMI {-2.1 g/m2 [95% confidence interval (CI) -3.8 to - 0.4], P = 0.017}, RVEDVI [-9.5 mL/m2 (95% CI - 16.3 to - 2.6), P = 0.008] and RVESVI [-6.2 mL/m2 (95% CI - 10.9 to - 1.6), P = 0.011] in the INHD group; no significant changes were observed in the CHD group. Between-group comparisons showed significantly greater reduction of RVESVI [-7.9 mL/m2 (95% CI - 14.9 to - 0.9), P = 0.03] in the INHD group, a nonsignificant trend toward greater reduction in RVEDVI and no significant difference in RVMI and RVEF changes. There was significant correlation between LV and RV in terms of changes in mass index (MI) (r = 0.46), EDVI (r = 0.73), ESVI (r = 0.7) and EF (r = 0.38) over 1 year (all P < 0.01). Conclusions: Conversion to INHD was associated with a significant reduction of RVESVI. Temporal changes in RV mass, volume and function paralleled those of LV. Our findings support the need for larger, longer-term studies to confirm favorable RV remodeling and determine its impact on clinical outcomes.

Utilidad del mapeo ecográfico preoperatorio para los accesos vasculares de hemodiálisis / Use of pre-operative ultrasound mapping for haemodialysis vascular access

OBJETIVOS: Valorar la utilidad clínica de la introducción rutinaria del mapeo ecográfico de extremidades superiores en el estudio preoperatorio de los pacientes candidatos a un acceso vascular (AV) para hemodiálisis. MATERIAL Y MÉTODOS: Estudio unicéntrico retrospectivo de 4 años de duración. Incluimos pacientes con enfermedad renal crónica terminal (ERCT) candidatos a un AV para hemodiálisis, excluyendo a aquellos con fístulas arteriovenosas (FAV) previas en la misma extremidad superior. Dos grupos de estudio: exploración física (EF: junio de 2011-febrero de 2014) y mapeo ecográfico (ECO: marzo de 2014-junio de 2015). Analizamos: variables demográficas, comorbilidad y tipo de AV. En el subgrupo FAV radiocefálicas, analizamos la tasa de permeabilidad inmediata (48 h), precoz (4 semanas), tardía (6 meses) y los procedimientos realizados. RESULTADOS: Estudiamos a 81 pacientes (EF: 42; ECO: 39), de los que el 63% eran hombres, con una edad media de 66,5±13,1 años. El 81% fueron izquierdos. No se evidenciaron diferencias significativas entre los grupos respecto a demografía, comorbilidad ni etiología de la ERCT. Tipo de AV (EF vs. ECO): FAVRC* (47,6 vs. 69,2%; *p < 0,05); húmero-cefálicas* (38,1 vs. 10,3%); húmero-basílicas (11,9 vs. 17.9%) y prótesis húmero-axilares (2,4 vs. 2,6%). Tasa de permeabilidad FAV radiocefálicas: inmediata (90 vs. 85,2%); precoz (75 vs. 100%*) y tardía (55 vs. 88,9%*), respectivamente. Solo observamos un mayor número de AV realizados en otros territorios (25 vs. 3,7%*) en el grupo EF de las FAV radiocefálicas. CONCLUSIONES: En nuestro centro, la introducción rutinaria del mapeo ecográfico de las extremidades superiores en el estudio preoperatorio de los pacientes candidatos a un AV permitió optimizar el territorio vascular distal y mejorar la permeabilidad precoz y tardía de las fístulas radiocefálica

OBJECTIVES: To assess the clinical usefulness of routine doppler ultrasound vascular mapping of upper extremities before creating a vascular access (VA) for haemodialysis. MATERIAL AND METHODS: A retrospective single-centre study conducted over a four-year period including end-stage renal disease (ESRD) patients referred to for VA creation for haemodialysis. Patients with previous VA in the same upper extremities were excluded. Two study groups were formed: Physical examination (PE: June 2011-February 2014) and ultrasound mapping (US: March 2014-June 2015). An analysis was performed on the demographic variables, comorbidities and AV location. The results of the patency rates of the radio-cephalic fistulae (RCF) subgroup were recorded, immediately (48 h), early (4 weeks), and late (6 months). RESULTS: The study included a total 81 patients (42 PE, 39 US), with 63% males. The mean age was 66.5±13.1 years, and 81% were affected on the left side. There were no significant differences between the groups as regards, demographics, comorbidities, or ESRD aetiology. The VA type (PE vs. US): 47.6 vs. 69.2% radio-cephalic fistula* (*P<.05), 38.1 vs. 10.3% brachial-cephalic fistula*, 11.9 vs. 17.9% brachiobasilic fistula, and 2.4 vs. 2.6% humeral-axillary grafts. RCF patency rates: Immediate 90 vs. 85.2%, early 75 vs. 100%*, and late 88.9 vs. 55%*; respectively. However, an increase in AV performed in other territories was observed in PE group (25 vs. 3.7%*) in RCF. CONCLUSIONS: Routine doppler ultrasound mapping of upper extremities before VA creation in our centre allowed the distal vascular territory to be optimised, and improved the primary patency rates of both early and late radio-cephalic fistulas

Left ventricle ejection fraction may predict mortality in renal transplant patients.

PURPOSE: Mortality is a major problem in renal transplant patients, and appropriate preoperative evaluation is very important. We retrospectively reviewed the left ventricle ejection fraction (LVEF) of renal transplant patients. MATERIAL AND METHODS: The clinical records of 1763 patients who had preoperative LVEF results and who underwent renal transplantation at Akdeniz University Faculty of Medicine during the years 2004-2014 were studied. The LVEF limit was set at 55%. LVEF, age, gender, diabetes mellitus, hypertension, type of dialysis were assessed by linear multiple regression analysis on survival. RESULTS: There were a total of 1763 renal transplant patients. Those with LVEF of <55% were identified as having left ventricular dysfunction. The mean LVEF was 59.4 ± 9.1 in the 43 patients who died after renal transplantation, while it was 62.6 ± 7.4 in the survivors (p = 0.02). The mortality rate in the LVEF < 55% group was 6.8% (11/162 patients), while mortality in the LVEF ≥ 55% group was 2% (32/1601 patients, p < 0.001). LVEF was found to be the most powerful variable on survival by the linear multiple regression analysis, R2 = 0.05, p < 0.001. CONCLUSION: LVEF may predict mortality in renal transplant patients. LVEF is known to be lower in patients with high cardiac mortality, who may require greater modifications of the postoperative risks.

Nomenclature for renal replacement therapy in acute kidney injury: basic principles.

This article reports the conclusions of a consensus expert conference on the basic principles and nomenclature of renal replacement therapy (RRT) currently utilized to manage acute kidney injury (AKI). This multidisciplinary consensus conference discusses common definitions, components, techniques, and operations of the machines and platforms used to deliver extracorporeal therapies, utilizing a "machine-centric" rather than a "patient-centric" approach. We provide a detailed description of the performance characteristics of membranes, filters, transmembrane transport of solutes and fluid, flows, and methods of measurement of delivered treatment, focusing on continuous renal replacement therapies (CRRT) which are utilized in the management of critically ill patients with AKI. This is a consensus report on nomenclature harmonization for principles of extracorporeal renal replacement therapies. Devices and operations are classified and defined in detail to serve as guidelines for future use of terminology in papers and research.

Cuantificación del deterioro funcional durante seis meses en pacientes renales en estadio terminal / Quantificación of functional impairment for six months in hemodialysis patients

Introducción: Los pacientes en tratamiento de diálisis presentan una disminución de la función física, sin embargo, no hay estudios que demuestren el ritmo al que se produce este deterioro funcional. El objetivo principal es cuantificar el deterioro funcional de los pacientes en tratamiento de diálisis durante seis meses. Métodos: 43 pacientes en tratamiento de diálisis de dos centros de Valencia (España) (edad 61.3 (14.7) años) fueron analizados después de 6 meses. Los participantes completaron el Short Physical Performance Battery, equilibrio monopodal, el Timed Up and Go Test, Sit to stand to Sit Test 10 y 60, dinamometría de mano; elevación de talón y 6 minutos marcha. Además se recogieron datos de las historias clínicas y de las analíticas. Resultados: Tres de las pruebas mejoraron significativamente tras el periodo de 6 meses de observación: el Sit To Stand 10, la dinamometría de la mano derecha y la dinamometría de la mano izquierda, pero sin alcanzar un cambio clínico relevante. Por otro lado, otras medidas no obtuvieron un deterioro significativo como fueron el Short Physical Performance Battery, el Sit to Stand 60, la elevación del talón izquierdo y el 6 minutos marcha. Conclusiones: Después de 6 meses, en ninguna de las pruebas de capacidad funcional se observa un deterioro significativo. Se recomienda a los centros de hemodiálisis realizar un seguimiento de capacidad funcional anualmente, ya que con un periodo de 6 meses no se encuentran cambios significativos (AU)

Introduction: Patients in dialysis treatment present a decrease in physical function. However, we cannot find in the literature the rhythm of the functional deterioration. The main aim is quantify the functional deterioration in patients undergoing haemodialysis during six months period. Methods: 43 patients in dialysis treatment from two centres from Valencia (Spain) (age 61.3 (14.7) years old) were recruited and monitored after the 6 months period. Study participants performed the Short Physical Performance Battery, one leg stand, TUG, Sit to Stand 10 and 60, handgrip dynamometry, the one leg heel rise and the 6 minutes walking time. Outcomes: Three tests improve significantly: the Sit to Stand 10, the right and the left Handgrip Dynamometry. Nevertheless, we cannot observe a significant deterioration as the Short Physical Performance Battery, the Sit to Stand 60, the one leg heel rise in the left leg and the 6 minutes walking time. Conclusions: After 6 months, we have not observed a significant deterioration in the tests. We recommended the different units to follow the functional capacity of the patients yearly, because with a period of 6 months we have not find significantly changes (AU)

The effect of two different high-flux dialysis membranes on insulin resistance in non-diabetic end-stage renal disease patients.

OBJECTIVE: The aim of this study was to investigate the effect of two different types of high-flux dialysis membranes on insulin resistance among patients who are receiving hemodialysis (HD) due to end-stage renal failure (ESRF). MATERIALS AND METHODS: Forty-six (21 female, 25 male) patients were included in the study, who were on HD treatment due to stage-5 chronic renal failure. Prior to the study, fasting insulin resistance via Homeostasis Model Assessment-Insulin Resistance (HOMA-IR) and fractioned urea clearance (Kt/V) values were calculated using the urokinetic model. The polysulfone (PS) dialysis membrane of all patients included in the study was replaced with "polyarylethersulfone, polyvinylpyrrolidone, polyamide (PPP)" high-flux membrane that has the same surface area over 12 weeks. At the end of the 12-week period, HOMA and Kt/V values were recalculated. RESULTS: At the end of the 12-week period, Kt/V values rose statistically significant from 1.575 to 1.752 (p = 0.002). HOMA-IR values declined, though not statistically significant, from 3.268 to 2.926 (p = 0.085). PPP high-flux membrane increased the Kt/V values significantly compared to the PS membrane, while it decreased the insulin resistance and increased insulin sensitivity. CONCLUSION: The two different types of high-flux dialysis membranes used for HD have different effects on insulin sensitivity. Compared to the PS membrane, PPP high-flux membrane decreased insulin resistance by increasing insulin sensitivity among non-diabetic ESRF patients.

Predictors of treatment with dialysis modalities in observational studies for comparative effectiveness research.

BACKGROUND: The Institute of Medicine has identified the comparative effectiveness of renal replacement therapies as a kidney-related topic among the top 100 national priorities. Given the importance of ensuring internal and external validity, the goal of this study was to identify potential sources of bias in observational studies that compare outcomes with different dialysis modalities. METHODS: This observational cohort study used data from the electronic medical records of all patients that started maintenance dialysis in the calendar years 2007-2011 and underwent treatment for at least 60 days in any of the 2217 facilities operated by DaVita Inc. Each patient was assigned one of six dialysis modalities for each 91-day period from the date of first dialysis (thrice weekly in-center hemodialysis (HD), peritoneal dialysis (PD), less-frequent HD, home HD, frequent HD and nocturnal in-center HD). RESULTS: Of the 162 644 patients, 18% underwent treatment with a modality other than HD for at least one 91-day period. Except for PD, patients started treatment with alternative modalities after variable lengths of treatment with HD; the time until a change in modality was shortest for less-frequent HD (median time = 6 months) and longest for frequent HD (median time = 15 months). Between 30 and 78% of patients transferred to another dialysis facility prior to change in modality. Finally, there were significant differences in baseline and time-varying clinical characteristics associated with dialysis modality. CONCLUSIONS: This analysis identified numerous potential sources of bias in studies of the comparative effectiveness of dialysis modalities.

Educação nutricional para pacientes renais crônicos em programa de hemodiálise / Nutritional education for chronic renal failure patients inhemodialysis program

Introduction: Nutritional education is an important matter for hemodialysis patients because it can change patient behavior and, therefore, improve nutritional status, decreasing risks of inadequate diets. Objectives: To evaluate the effects of a specific nutritional education program developed for patients undergoing hemodialysis and the changes that may be induced by the program. Methodology: The effects of the nutritional education program were studied in 27 hemodialysis patients (13 men) with mean age of 50.2±13 years. Before and after the nutritional program, patients answered feed surveys and had their basic nutritional knowledge, laboratory test results, and interdialytic weight gain evaluated. The educational nutrition program itself was evaluated by questioning patients on their impressions and perceptions on the course. Results: A low level of knowledge of nutritional basic aspects was observed before the course, while a significant improvement of understanding was verified after the course (24% and 60% of correct answers before and after the course, respectively; p<0.0001). It was possible to observe a significant reduction of the blood potassium level after the course (5.2±0.9 vs 4.7±0.7mEq/L; p=0.029, before and after the course, respectively), but other laboratory variables were not modified. The feed questionnaire and the interdialytic weight gain were similar in both moments: pre and post course. The evaluation of the course by the patients was extremely positive. Conclusions: The educational nutrition program promoted a gain of knowledge in nutritional aspects for dialysis patients, but it did not foster significant changes in the quality or amount of food intake, interdialytic weight gain, and laboratorial levels. A positive assessment of the program was observed. It is possible that changes in the nutritional aspects andlaboratorial levels demand more monitoring time.

Introdução: A educação nutricional é importante para pacientes em hemodiálise, uma vez que pode provocar mudanças comportamentais, melhorar o estado nutricional e diminuir os riscos de dietas inadequadas. Objetivos: Avaliar os efeitos de um programa de educação nutricional para pacientes em hemodiálise e avaliar as mudanças induzidas por ele. Metodologia: Os efeitos do curso educacional foram estudados em 27 pacientes em hemodiálise (13 homens e 14 mulheres), com idade média de 50,2 ± 13 anos. Antes e após o curso, os pacientes foram submetidos a avaliações de conhecimentos relacionados à nutrição, inquéritos limentares, análise dos exames laboratoriais e do ganho de peso interdialítico. O programa educacional foi avaliado através de questionamento aos pacientes sobre suas impressões, percepções e a importância atribuída às aulas. Resultados: Observou-se baixo nível de conhecimento sobre aspectos básicos de nutrição antes do curso (24% de acerto) e importante acréscimo de conhecimento após o mesmo (60% de acerto p < 0,0001). Em relação aos exames laboratoriais, houve diminuição dos valores médios de potássio (5,2 ± 0,9 para 4,7 ± 0,7mEq/L; p = 0,029 antes e após o curso). Outras variáveis laboratoriais, como os inquéritos alimentares e o ganho de peso interdialítico, mostraram-se similares nos dois momentos. Houve elevada satisfação dos pacientes com o curso. Conclusões: O curso melhorou o nível de compreensão dos pacientes sobre os aspectos nutricionais, foi bem avaliado por eles, mas não induziu a mudanças significativas no comportamento alimentar e nos exames laboratoriais. É possível que essas alterações demandem maior tempo de observação.

Adesão ao tratamento dietoterápico sob a ótica dos pacientes com doença renal crônica em hemodiálise / Adherence to dietary treatment from the perspective of patients with chronic renal failure on hemodialysis

changes in their everyday lives, making it an aggravating factor along the dialysis treatment because of poor adherence. The object of this study was to identify the determinants of chronic renal disease patients? adherence to dietary therapy treatment. These patients were receiving treatment at the specialized hemodialysis service of a hospital in the metropolitan area of Goiania, Goias state. Methods: This is across-sectional study of qualitative approach. Data collection for patient identification began with the analysis of medical records, followed by semi-structured interviews with five adult patients and one elderly patient. Thematic content analysis was used to analyze the data. Results: The results were grouped into the following categories: a) dietary therapy in hemodialysis ? all the interviewees reported difficulties in following quantitative and qualitative food restrictions, particularly to liquids; b) length of hemodialysis ? over time, the majority of the interviewees resumed foodconsumption without restrictions; c) psychosocial factors ? the emotional and social responses were representations of threats to health due to the dietary therapy and dialysis treatment. Conclusions: In conclusion, dietary therapy and dialysis treatment imply behavioral changes and involve a variety of prescriptions and recommendations resulting in different levels of adherence. Adherence is a continuous and dynamic process which comprises not only overall behavior, but also a number of individual behaviors.

Objetivo: O tratamento dietoterápico do paciente que realiza hemodiálise exige profundas mudanças no cotidiano, tornando-se um agravante ao longo do tratamento dialítico, em virtude da baixa adesão. O objetivo deste estudo foi identificar os determinantes da adesão ao tratamento dietoterápico dos pacientes com Doença Renal Crônica, atendidos no Serviço Especializado em Hemodiálise de um hospital da região metropolitana de Goiânia, Goiás. Métodos: Estudo transversal de abordagem qualitativa. A coleta de dados de identificação dos pacientes iniciou-se nos prontuários, seguida da fase de entrevistas semiestruturadas com cinco pacientes adultos e um idoso. Os dados foram analisados por meio de análise de conteúdo temática. Resultados: Os resultados foram agrupados em categorias: a) dietoterapia em hemodiálise ? Todos os entrevistados referiram dificuldades de seguir a restriçãoquantitativa e qualitativa da alimentação, principalmente de líquidos; b) tempo de hemodiálise ? Ao longo dos anos, a maioria dos entrevistados voltou a consumir alimentos sem restrições; c) fatores psicossociais ? As respostas emocionais e sociais foram representações de ameaças à saúde em virtude do tratamento dietoterápico e dialítico. Conclusões: Conclui-se que os tratamentos dietoterápico e dialítico implicamalterações comportamentais, e envolvem uma diversidade de prescrições e recomendações, possibilitando níveis diferentes de adesão. A adesão é um processo contínuo e dinâmico que compreende não apenas um comportamento global, mas vários comportamentos individuais.

Histological and clinical findings in patients with post-transplantation and classical encapsulating peritoneal sclerosis: a European multicenter study.

BACKGROUND: Encapsulating peritoneal sclerosis (EPS) commonly presents after peritoneal dialysis has been stopped, either post-transplantation (PT-EPS) or after switching to hemodialysis (classical EPS, cEPS). The aim of the present study was to investigate whether PT-EPS and cEPS differ in morphology and clinical course. METHODS: In this European multicenter study we included fifty-six EPS patients, retrospectively paired-matched for peritoneal dialysis (PD) duration. Twenty-eight patients developed EPS after renal transplantation, whereas the other twenty-eight patients were classical EPS patients. Demographic data, PD details, and course of disease were documented. Peritoneal biopsies of all patients were investigated using histological criteria. RESULTS: Eighteen patients from the Netherlands and thirty-eight patients from Germany were included. Time on PD was 78(64-95) in the PT-EPS and 72(50-89) months in the cEPS group (p>0.05). There were no significant differences between the morphological findings of cEPS and PT-EPS. Podoplanin positive cells were a prominent feature in both groups, but with a similar distribution of the podoplanin patterns. Time between cessation of PD to the clinical diagnosis of EPS was significantly shorter in the PT-EPS group as compared to cEPS (4(2-9) months versus 23(7-24) months, p<0.001). Peritonitis rate was significantly higher in cEPS. CONCLUSIONS: In peritoneal biopsies PT-EPS and cEPS are not distinguishable by histomorphology and immunohistochemistry, which argues against different entities. The critical phase for PT-EPS is during the first year after transplantation and therefore earlier after PD cessation then in cEPS.