Waiting for a kidney transplant: association with anxiety and stress.

BACKGROUND: The pretransplantation period is characterized by many stressful events that can result in symptoms of anxiety and stress and ultimately can have a negative impact on graft outcome. Our objective was to evaluate the association between symptoms of anxiety and stress in patients awaiting kidney transplantation. METHODS: This was a transversal study describing 50 randomly selected patients undergoing hemodialysis and waitlisted for kidney transplantation. We collected social and demographic data, and adopted the Beck Anxiety Inventory and the Lipp Stress Symptoms for Adults Inventory to respectively evaluate anxiety and stress. RESULTS: The mean age was 50.2 ± 11.7 years, 54% of patients were female, time on dialysis was 6.5 ± 4.5 years, and transplant waitlist time was 5.9 ± 4.4 years. Forty-six percent of patients were married or had a stable relationship, 50% were illiterate or had only finished primary school, and 64% were pensioners. Stress was documented in 60% of patients, of which 30% had severe stress, whereas 56% of patients showed symptoms of anxiety. The presence of stress was associated with longer waitlist time (P = .006) and longer time on dialysis (P = .052). Less severe stress was associated with higher education level (P = .031), whereas patients in more advanced phases of stress showed higher levels of anxiety. After a multivariate analysis, stress was 3.6 times (CI 1.34 to 9.89) more frequent among individuals with anxiety. CONCLUSIONS: Stress and anxiety were prevalent in patients on a waitlist and were associated with social and chronic kidney disease-related patterns. This observation can stimulate the adoption of strategies for the prevention of stress and anxiety, avoiding posttransplantation complications, such as nonadherence to treatment.

Body mass index in the first year after kidney transplantation.

INTRODUCTION: Kidney transplant recipients (KTR) experience better appetite, partly due to the use of steroids, and are subjected to less severe dietetic restrictions, hence they tend to increase the uptake of calories, which favors weight gain posttransplantation. In this study, we evaluate the profile of body mass index (BMI) in the first year posttransplantation. METHODS: This was a retrospective study including 131 patients who received transplants between 1991 and 2011. We collected demographic and clinical data such as body weight and height, and calculated BMI pretransplantation and at 6 and 12 months posttransplantation. RESULTS: Mean age was 47.1 ± 13.1 years, 64.9% were male, and 29% of patients were diabetic. Pretransplantation mean BMI was 23.04 ± 4.08 kg/m(2), and at 6 and 12 months posttransplantation it increased to 24.55 ± 4.2 kg/m(2) and 24.65 ± 4.16 kg/m(2), respectively (P < .001). At 6 months, this significant weight gain occurred in all patients, even those malnourished, eutrophic, overweight, and obese at pretransplantation. Looking at pretransplantation malnourished patients, 30.8% remained malnourished 1 year after transplantation. Otherwise, 28.6% of pretransplantation overweight patients and 100% of pretransplantation obese patients could be classified as obese at 1 year posttransplantation. CONCLUSIONS: Increase in BMI is common in obese and nonobese KTR. This study highlights the importance of identifying subjects at risk for excessive weight gain posttransplantation, thus allowing an early nutritional intervention to prevent its complications.

Programa de Rastreamento e Detecção Precoce do Câncer de Colo de Útero da CRS Norte SMS-SP

O trabalho descreve o instrumento implantado em 2013 em 86 Unidades Básicas de Saúde da CRS Norte, município de São Paulo, para seguimento das mulheres com lesões precursoras de Câncer de Colo de Útero detectadas no rastreamento através do exame Papanicolaou. Todas as ações, exames, consultas médicas ou de enfermagem, VD, contato (por telefone outros), faltas, são registradas no instrumento até que o tratamento seja concluído .

Programa de Rastreamento e Detecção Precoce do Câncer de Colo de Útero da CRS Norte SMS-SP: um instrumento para o seguimento das mulheres com lesão precursora no papanicolau nas Unidades Básicas de Saúde (UBS)

Apesar dos avanços alcançados, a UBS deve investir na busca ativa das mulheres resistentes ao exame e com lesões precursoras, priorizando as que apresentam lesões de maior risco e maior vulnerabilidade social

Programa de Rastreamento e Detecção Precoce do Câncer de Colo de Útero da CRS Norte SMS-SP / Program Tracking and Early Detection of Cancer of the Cervix North CRS SP-SMS

O trabalho descreve o instrumento implantado em 2013 em 86 Unidades Básicas de Saúde da CRS Norte, município de São Paulo, para seguimento das mulheres com lesões precursoras de Câncer de Colo de Útero detectadas no rastreamento através do exame Papanicolaou. Todas as ações, exames, consultas médicas ou de enfermagem, VD, contato (por telefone outros), faltas, são registradas no instrumento até que o tratamento seja concluído (AU).

Programa de Rastreamento e Detecção Precoce do Câncer de Colo de Útero da CRS Norte SMS-SP: um instrumento para o seguimento das mulheres com lesão precursora no papanicolau nas Unidades Básicas de Saúde (UBS) / Program Tracking and Early Detection of Cancer of the Cervix North CRS SP-SMS

Apesar dos avanços alcançados, a UBS deve investir na busca ativa das mulheres resistentes ao exame e com lesões precursoras, priorizando as que apresentam lesões de maior risco e maior vulnerabilidade social (AU)

Social diagnosis of chronic kidney disease patients in preparation for living donor renal transplantation.

BACKGROUND: The relationship between socioeconomic status and clinical outcome in health and disease is complex and multifactorial. An association between low socioeconomic status and shorter patient survival in renal replacement therapy, dialysis, and transplantation, has been reported, implicating individual and environmental factors. We sought to analyze the socioeconomic and demographic characteristics of chronic kidney disease (CKD) patients in preparation for living kidney transplantation. METHODS: We evaluated 60 patients with CKD-V, on hemodialysis or peritoneal dialysis and who were being prepared in our public service between July 2008 and January 2010. Socioeconomic data were collected from the records. RESULTS: The mean age was 44.8 ± 13.3 years and 51% were male. Sixty-three percent were married, most of them with children, with a family size of 3.5 ± 1.45 members. They were taken a mean of 5.8 ± 2.8 drugs; only half of them were dispensed by public health insurance. Almost all--93%--did not work regularly, and the majority reported some limitation in daily activities. The mean monthly income was US $1,535.70 and 76.2% reported a monthly income ≤ US $1,810.60. The mean of school years was 7.91 ± 4.19. CONCLUSION: Low-income patients are gaining access to preparing for renal transplantation; we believe that is inherent to the universal structure of Brazil's public health system. Besides the low income, this population showed a considerable educational level, suggesting this characteristic made the patient more active to search the living transplant as an alternative for their CKD treatment. Knowledge about social status is essential for design strategies in minimizing its potential undesirable effects after transplantation.

Excessive immunosuppression in kidney transplant patients: prevalence and outcomes.

BACKGROUND: Death with a functioning graft is currently one of the main causes of kidney graft loss. A large proportion of cases is attributed to infectious complications that can be related to overimmunosuppression. We retrospectively studied 80 kidney transplant patients, grafted from January 2005 to December 2009, to assess the prevalence of excessive immunosuppression, and its possible correlation with infections and infection-related death. METHODS: Excessive immunosuppression was defined by a prescribed dosage above the expected to the time point or an elevated drug blood level according to the Kidney Disease: Improving Global Outcomes (2009) recommendations at 1, 3, 6, and 12 months, and then annually. RESULTS: Death with a functioning graft accounted for 76.5% of losses. Overall, 53.8% of deaths were from infections, and 38.5% from cardiovascular causes. Acute rejection episodes were noted in 8.8% of patients. Only 10% of patients had adequate immunosuppression throughout the follow-up. Seventy-two percent of patients showed adequate immunosuppression at least half of the 18 evaluated points, although 50% showed between 1 and 3 drugs administered above recommended dosages during the whole period. Infections were recorded in 78.8% patients, with a median of 3 episodes per patient. Any level of excessive immunosuppression was associated with infections (odds ratio, 11.2; P < .001), but not with death caused thereby. CONCLUSION: Excessive immunosuppression among this cohort was associated with a greater incidence of infections, but not with death from this cause.

Adherence to drug therapy in kidney disease

Non-adherence to drug therapy has not been extensively studied in patients with chronic kidney disease (CKD). The objective of the present study was to identify determinants of non-adherence to drug therapy in patients with CKD, not on dialysis. A prospective cohort study involving 149 patients was conducted over a period of 12 months. Adherence to drug therapy was evaluated by the self-report method at baseline and at 12 months. Patients who knew the type of drug(s) and the respective number of prescribed pills in use at the visit preceding the interview were considered to be adherent. Patients with cognitive decline were assessed by interviewing their caregivers. Mean patient age was 51 ± 16.7 years. Male patients predominated (60.4 percent). Univariate analysis performed at baseline showed that non-adherence was associated with older age, more pills taken per day, worse renal function, presence of coronary artery disease, and reliance on caregivers for the administration of their medications. In multivariate analysis, the factors that were significantly associated with non-adherence were daily use of more than 5 pills and drug administration by a caregiver. Longitudinal evaluation showed an increase in non-adherence over time. Medication non-adherence was lower (17.4 percent) at the baseline period of the study than after 1 year of the study (26.8 percent). Compared to the baseline period, the percentage of adherent patients who became non-adherent (22 percent) was lower than the percentage of non-adherent patients who became adherent (50 percent). In CKD patients not on dialysis, non-adherence was significantly associated with the number of pills taken per day and drug administration by third parties. Adherence is more frequent than non-adherence over time.

Adherence to drug therapy in kidney disease.

Non-adherence to drug therapy has not been extensively studied in patients with chronic kidney disease (CKD). The objective of the present study was to identify determinants of non-adherence to drug therapy in patients with CKD, not on dialysis. A prospective cohort study involving 149 patients was conducted over a period of 12 months. Adherence to drug therapy was evaluated by the self-report method at baseline and at 12 months. Patients who knew the type of drug(s) and the respective number of prescribed pills in use at the visit preceding the interview were considered to be adherent. Patients with cognitive decline were assessed by interviewing their caregivers. Mean patient age was 51 ± 16.7 years. Male patients predominated (60.4%). Univariate analysis performed at baseline showed that non-adherence was associated with older age, more pills taken per day, worse renal function, presence of coronary artery disease, and reliance on caregivers for the administration of their medications. In multivariate analysis, the factors that were significantly associated with non-adherence were daily use of more than 5 pills and drug administration by a caregiver. Longitudinal evaluation showed an increase in non-adherence over time. Medication non-adherence was lower (17.4%) at the baseline period of the study than after 1 year of the study (26.8%). Compared to the baseline period, the percentage of adherent patients who became non-adherent (22%) was lower than the percentage of non-adherent patients who became adherent (50%). In CKD patients not on dialysis, non-adherence was significantly associated with the number of pills taken per day and drug administration by third parties. Adherence is more frequent than non-adherence over time.

Monitoring renal function: measured and estimated glomerular filtration rates: a review

Chronic kidney disease (CKD) is a wrld-wide public health problem, with adverse outcomes of kidney failure, cardiovascular disease, and premature death. This finding has led to the hypothesis that earlier recognition of kidney disease and successful intervention may improve outcome. The National Kidney Foundation, through its Kidney Disease Outcomes Quality Initiative (K/DOQI), and other National institutions recommend glomerular filtration rate (GFR) for the definition, classification, screening, and monitoring of CKD. Blood creatinine clearance, the most widely used clinical marker of kidney function, is now recognized as an unreliable measure of GFR because serum creatinine is affected by age, weight, muscle mass, race, various medications, and extra-glomerular elimination. Cystatin C concentration is a new and promising marker for kidney dysfunction in both native and transplanted kidneys. Because of its low molecular weight, cystatin C is freely filtered at the glomerulus and is almost completely reabsorbed and catabolized, but not secreted, by tubular cells. Given these characteristics, cystatin C concentration may be superior to creatinine concentration in detecting chronic kidney disease. This review aims to evaluate from recent literature the clinical efficiency and relevance of these GFR markers in terms of screening CKD.

Monitoring renal function: measured and estimated glomerular filtration rates - a review.

Chronic kidney disease (CKD) is a world-wide public health problem, with adverse outcomes of kidney failure, cardiovascular disease, and premature death. This finding has led to the hypothesis that earlier recognition of kidney disease and successful intervention may improve outcome. The National Kidney Foundation, through its Kidney Disease Outcomes Quality Initiative (K/DOQI), and other National institutions recommend glomerular filtration rate (GFR) for the definition, classification, screening, and monitoring of CKD. Blood creatinine clearance, the most widely used clinical marker of kidney function, is now recognized as an unreliable measure of GFR because serum creatinine is affected by age, weight, muscle mass, race, various medications, and extra-glomerular elimination. Cystatin C concentration is a new and promising marker for kidney dysfunction in both native and transplanted kidneys. Because of its low molecular weight, cystatin C is freely filtered at the glomerulus and is almost completely reabsorbed and catabolized, but not secreted, by tubular cells. Given these characteristics, cystatin C concentration may be superior to creatinine concentration in detecting chronic kidney disease. This review aims to evaluate from recent literature the clinical efficiency and relevance of these GFR markers in terms of screening CKD.

Urinary tract infection caused by extended-spectrum beta-lactamase-producing bacteria in kidney transplant patients.

Urinary tract infection (UTI) is a common complication among kidney transplant patients. UTI caused by multi-resistant extended-spectrum beta-lactamase producing bacteria (ESBL) have largely increased among the hospitalized patient population and especially kidney transplant recipients. We retrospectively studied 83 kidney transplant patients to evaluate the incidence and possible causative conditions of ESBL-related UTI over the last 6 years. ESBL production was determined by the antibiotic susceptibility profile of urine cultures. We compared the incidence in two 3-year periods, 2003-2005 (period 1) and 2006-2008 (period 2). An high incidence of ESBL-related UTI (16.8%) was observed in the posttransplant period performing 31% of the overall UTI incidence, with an increase over the last 3 years from 23.8% to 37.5%. ESBL-related UTI was related to previous episodes of UTI (78.6% vs 29.0%; P < .01) and reoperations (50.0% vs 12.9%; P < .05). We observed a progressively increasing incidence of 13%, 38%, and 45% of ESBL-related UTI among first, second, and third episodes, respectively. Age, gender, HLA mismatches, etiology of chronic kidney disease, diabetes mellitus, acute rejection, induction treatment, and type/level of immunosuppressants were similiar between the groups with or without ESBL-related UTI. We observed a high increased incidence of ESBL-related UTI among kidney transplant recipients, and particularly patients with recurrent UTI.

Roxithromycin reduces cyclosporine-induced gingival hyperplasia in renal transplant patients.

Gingival overgrowth (GO) is a common side effect of chronic cyclosporine use. The average prevalence of GO is about 30%, ranging from 10% to 85% in various series, due to diverse aggravating risk factors: drug interactions with calcium channel blockers, age, cyclosporine dose, bacterial plaque, and genetic predisposition. Recent studies have demonstrated elevated levels of specific cytokines particularly transforming growth factor-beta (TGF-beta) in hyperplastic gingival tissue, suggesting that this growth factor plays a role in the accumulation of the extracellular matrix. Until recently treatment for this complication was only surgical. Nowadays, several studies have been performed to evaluate the effects of antibiotic treatment on the regression of GO. In the present study, we used roxithromycin, a macrolide antibiotic that has inhibitory effect on TGF-beta production by inflammatory cells. The results suggested that roxithromycin may be an important therapeutic tool to reduce cyclosporine-induced GO.

The Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) : characterization of the cohort.

The Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) was launched in December 2004 aiming to collect data monthly and continuously from a representative cohort, allowing for a continuous snapshot of the peritoneal dialysis (PD) reality in the country. This is an observational study of PD patients comprising follow-up from December 2004 to February 2007 (mean follow-up of 13.6 months-ranging from 1 to 26 months) in 114 Brazilian centers. All centers report data through a central web-based database. After an initial baseline retrospective data collection, all patients are followed prospectively every month until they drop out from the PD program. Total number of patients recruited until February 2007 was 3226 (2094 incident patients). Mean age was 54+/-19 years (37% above 65 years old), with 55% females and 64% Caucasians. The more frequent causes of renal failure were diabetic nephropathy (34%), renal vascular disease associated with hypertension (26%), and glomerulopathies (13%). The most common comorbidities were hypertension (76%), diabetes (36%), and ischemic heart disease (23%). Automated PD (APD) was the modality utilized in 53%. The estimated overall peritonitis rate was 1 episode per 30 patient-months (most frequently due to Staphylococcus aureus). The total dropout rate was 33%, mainly due to deaths, whereas 20% of dropouts were due to renal transplant. The gross mortality was 17.6% and the main causes of mortality were cardiovascular diseases (40%) and infections (15%). The initial results of this first Brazilian PD registry provide a unique opportunity to develop future clinical studies addressing specific PD questions in the Brazilian reality and context.

Post-rapamycin proteinuria: incidence, evolution, and therapeutic handling at a single center.

We performed a retrospective study to evaluate the safety, incidence, and management of proteinuria in 31 renal transplant recipients converted to Rapamycin (RAPA). All patients received RAPA immediately after the cessation of the calcineurin inhibitor or the antiproliferative drug. No acute rejection episodes were seen after this regimen. Chronic allograft nephropathy (58.1%) and calcineurin inhibitor toxicity (51.6%), both biopsy-proven, were the major reasons to introduce RAPA. Post-RAPA proteinuria was defined as the appearance of urine protein excretion >300 mg/d or any further increase in protein among those who showed previously elevated levels. We observed an elevated incidence of proteinuria of 48.4%. It started at 5.3 +/- 2.5 months after the conversion and 60% occurred within 6 months. The proteinuria increased from a median of 200 mg/d to 1466 mg/d (P < .001). Age, gender, race, HLA mismatches, time to onset of RAPA, level of previous proteinuria, glomerular filtration rate, use of renin-angiotensin blockers, and etiology of chronic kidney disease were similar between the groups with or without proteinuria. Once it appeared, we suspended the drug in only 4 patients (26.7%), initiated or augmented the dosage of renin-angiotensin blockers in 26.7%, adjusted the RAPA dose in 20.1%, and did not perform a specific measure in 40% (6 of 15). At 15.6 +/- 12.7 months, 91% showed no further increase or reduction in proteinuria. We observed a high prevalence of proteinuria among renal transplant recipients converted to RAPA (48.4%). In addition, RAPA was suspended in only 4 patients and the proteinuria showed a tendency to stabilize or reduce over time.

[Training of local health managers: process of identification of strategic actions]. / Formação de gestores locais de saúde: processos para identificar estratégias de atuação.

In Brazil, in recent years, as a result of the increasing participation of county authorities in health care, a need for tools which would contribute to the better preparation of local administrators, complementary to the activities of a more academic nature, has been recognized. One of the possible alternatives is the exploitation of experiences, regarded as successful, in local health care planning and administration, by using them as material for "case studies" in activities with selected groups of health care administrators thus, stimulating the identification of those elements which contributed to the favorable results attained, and their interactions, in the quest for analogies which would facilitate the identification of new perspectives for their own situations. In this article an experience of a "case studies" development, in response to a demand from UNICEF, based on 8 counties in from the North and Northeast, which were successful in using a "focus approach" in their organization of data and their utilisation in a seminar with 21 local managers from both regions, is presented. During the seminar the local health managers attained greater knowledge of the strategies implemented and identified feasible intervention alternatives. The methodological proposition of teaching on the basis of case studies, using a conceptual strategy of grouping experiences according to specific dimensions enabled local health managers to learn from their practical experiences.

Estudo preliminar para detecçäo de cérvico-vaginites e lesöes precursoras do câncer de colo uterino, em índias da tribo Parakanä / Preliminary study on low-trait genital infection and cervical epithelial dysplasia in indian of the Parakanä tribe

OBJETIVO. Avaliaçao preliminar da freqüência de inflamaçoes genitais e lesoes precursoras do câncer cérvico-uterino em um grupo indígena isolado da Amazônia oriental brasileira. MATERIAL E MÉTODO. Estudo transversal, dirigido às mulheres maiores de dez anos das aldeias Maroxewara e Paranatinga, da tribo Parakana. Foram obtidas informaçoes demográficas, etno-culturais, tocoginecológicas; procedeu-se a um exame físico e ginecológico, com coleta de material para bacterioscopia e colpocitologia oncótica.RESULTADOS. Foram examinadas 80 mulheres (89,9 por cento), das quais 69 foram avaliadas laboratorialmente; 14(20,3 por cento) estavam grávidas. Na aldeia Paranatinga, a bacterioscopia revelou um maior número de mulheres com ausência de flora Döderlein (60,0 por cento vs.29,l por cento). Na colpocitologia, o padrao mais encontrado foi o inflamatório (91,5 por cento); das colpites de etiologia específica (63,1 por cento), em 63,4 por cento suspeitou-se de infecçao por Gardenerella vaginalis, em 7,3 por cento por Trichomonas vaginalis, e em 4,9 por cento por microrganismos semelhantes à Candida sp. Em 23,2 por cento dos esfregaços havia alteraçoes citopatológicas relacionadas à infecçao por papilomavírus humano (PVH). As alteraçoes celulares sugeriram NIC I em um caso, NIC II em outro e carcinoma epidermóide em uma índia de 48 anos; nos três casos, foi proposta a posterior realizaçao de biópsia dirigida e avaliaçao clínica em ambientes hospitalar. Conclusoes. A maioria das mulheres Parakanas apresenta alguma patologia cervical, a maior parte das quais de menor gravidade. Apresentam, ainda, início precoce da vida sexual, multiplicidade de parceiros, curto intervalo interparto e alteraçoes citopatológicas sugestivas de infecçao pelo PVH, condiçoes de risco para transmissao sexual de doenças e desenvolvimento de câncer cérvico-uterino.

[Preliminary study on low-trait genital infection and cervical epithelial dysplasia in women from the Parakanä tribe of South America]. / Estudo preliminar para detecção de cérvico-vaginites e lesões precursoras do câncer de colo uterino, em índias da tribo Parakanã.

BACKGROUND: We evaluated the occurrence of low-trait genital infection and cervical epithelial dysplasia in women from a South-american indian tribe in the Brazilian Amazonia. METHODS: Cross-sectional study of women older than 10 years from two indian settlements of the Parakanã tribe: Paranatinga and Maroxewara. Demographic data and information about sexual behavior as well as obstetric/gynaecological history were recorded. Two gynecologists examined 80 patients (89.9%), and collected vaginal and cervical specimens of 69 indians for further laboratory analysis, by Gram stain and Papanicolaou method. Fourteen (20.3%) women resulted to be pregnant. RESULTS: Parakanã women begin sexual activity early, after menarche; they have multiple sexual partners; are multiparous. Some of his partners already had intercourse with women of our society. In Paranatinga, vaginal discharges were a very frequent sign and not age-related, and women presented high frequency of disturbances on lactobacilli flora, greater than among inhabitants of Maroxewara. Pap smears in 91.5% of all patients showed inflammatory pattern. When found an possible etiologic agent (61.3%), in 63.4% it was Gardnerella vaginalis, in 7.3% Trichomonas vaginalis and in 4.9% Candida sp. In 23.2% of smears cythophatic signs related to infection by human papillomavirus were identified. One case had morphological changes compatible with cervical intraepithelial neoplasia grade I, another with CIN II and, in a 48 year old indian, cervical cancer. CONCLUSIONS: Near all women had some grade of cervical disease. Measure HPV-infection prevalence among Parakanã indians with adequate methods may improve our understanding about worldwide occurrence of HPV infections. Established risk factors for cancer of the cervix and sexually transmitted diseases were common in this tribe.