Reliability and validity of a clinical competence test for dietitians caring patients with early chronic kidney disease.

The aim of the present study was to develop and validate a test to evaluate dietitian's clinical competence (CC) about nutritional care in patients with early chronic kidney disease (CKD). The study was conducted through five steps: (1) CC and its dimensions were defined; (2) test items were elaborated, and choice of response format and scoring system was selected; (3) content and face validity were established; (4) test was subjected to a pilot test and those items with inadequate performance were removed; (5) criterion validity and internal consistency for final validation were established. A 120-items test was developed and applied to 207 dietitians for validation. Dietitians with previous CKD training obtained higher scores than those with no training, confirming the test validity criterion. According to item analysis, Cronbach's α was 0⋅85, difficulty index 0⋅61 ± 0⋅22, discrimination index 0⋅26 ± 0⋅15 and inter-item correlation 0⋅19 ± 0⋅11, displaying adequate internal consistency.

Can the implementation of clinical practice guidelines improve clinical competence of physicians and kidney function of patients with type 2 diabetes mellitus?

Background: There are many clinical practice guidelines (CPGs) in Nephrology; however, there is no evidence that their availability has improved the clinical competence of physicians or the outcome of patients with chronic kidney disease (CKD). This study was aimed to evaluate the effect of implementation of CPGs for early CKD on family physicians (FP) clinical competence and subsequently on kidney function preservation of type 2 diabetes mellitus (DM2) patients at a primary healthcare setting. Methods: A prospective educative intervention (40-h) based on CPGs for Prevention, Diagnosis and Treatment of Early CKD was applied to FP; a questionnaire to evaluate clinical competence was applied at the beginning and end of the educative intervention (0 and 2 months), and 12 months afterwards. DM2 patients with CKD were evaluated during 1-year of follow-up with estimated glomerular filtration rate (eGFR) and albuminuria. Results: After educative intervention, there was a significant increase in FP clinical competence compared to baseline; although it was reduced after 1 year, it remained higher compared to baseline. One-hundred thirteen patients with early nephropathy (58 stage 1, 55 stage 2) and 28 with overt nephropathy (23 stage 3, 5 stage 4) were studied. At final evaluation, both groups maintained eGFR [(mean change) early 0.20 ± 19 pNS; overt 0.51 ± 13 mL/min pNS], whereas albuminuria/creatinuria (early -67 ± 155 p < 0.0001; overt -301 ± 596 mg/g p < 0.0001), systolic blood pressure (early -10 ± 18 p < 0.05; overt -8 ± 20 mmHg p < 0.05), and total cholesterol (early -11 ± 31 p < 0.05; overt -17 ± 38 mg/dL p < 0.05) decreased. Diastolic blood pressure, waist circumference and LDL-cholesterol were also controlled in early nephropathy patients. Conclusions: CPGs for Prevention, Diagnosis and Treatment of CKD, by means of an educative intervention increases FP clinical competence and improves renal function in DM2 patients with CKD.

Frequency and Risk Factors of Kidney Alterations in Children and Adolescents who Are Overweight and Obese in a Primary Health-care Setting.

OBJECTIVE: Obesity is clearly associated to kidney disease in adult population; however, there is scarce evidence in children and adolescents. The aim was to compare frequency of renal damage according to the presence of overweight-obesity in children and adolescents, as well as to compare nutritional and biochemical risk factors, according to the presence of kidney alterations. METHODS: Cross-sectional study; 172 children and adolescents, 6-16 years old, without malnutrition, diabetes mellitus, hypertension and independent comorbid conditions associated to obesity or kidney disease, as well as transitory causes of microalbuminuria (MA) from a Primary Health-Care Unit were included. Clinical, biochemical, anthropometric and dietetic evaluations were measured in all subjects; subsequently they were classified as normal weight, overweight and obesity groups according to sex- and age-adjusted body mass index (BMI). Glomerular filtration rate (GFR, estimated by Schwartz equation) and albuminuria (albumin/creatinine ratio) were determined. Presence of kidney alterations was measured as decreased GFR (<90 mL/min/1.73m2), hyperfiltration (>170 mL/min/1.73m2) and MA (30-300 mg/g). RESULTS: Compared with controls, subjects with overweight-obesity had significantly (P<.05) abdominal obesity (0 vs 69%), hypertension (19 vs 26%), hypertriglyceridemia (11 vs 47%), high low-density lipoprotein cholesterol (2 vs 8%) and low high-density lipoprotein cholesterol (HDL-cholesterol; 2 vs 28%), hyperuricemia (11 vs 28%) and hyperinsulinemia (8 vs 70%). Hyperfiltration and MA were present in 5 and 4 subjects with overweight/obesity, respectively, whereas decreased GFR was present in only 1 subject with obesity. Normal weight subjects had no kidney alterations. In multivariate analysis, kidney alterations were significantly predicted by higher BMI and lower HDL-cholesterol. CONCLUSIONS: Kidney alterations were observed only in subjects with overweight (3.6%) and obesity (9.9%), who additionally, displayed cardiometabolic and kidney disease risk factors more frequently than normal weight subjects.

Prevalence of Pica in Patients on Dialysis and its Association With Nutritional Status.

OBJECTIVE: Pica could be strongly implicated in nutritional status of patients on dialysis; however, very scarce data are currently available. The objective of this study was to evaluate the prevalence of pica and its association with nutritional status in dialysis patients. DESIGN AND METHODS: This is a cross-sectional study in a tertiary care teaching hospital. Four-hundred patients on dialysis, without previous pica diagnosis or transplant, pregnancy, mental illness, or infection, were included in the study. Pica, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, was classified as no pica, ice pica, or hard pica. Dialysis Malnutrition Score, 24-hour dietary recall, and biochemical measurements were obtained from patients. As part of statistical analysis, point prevalence and 95% confidence interval of pica were calculated. Comparisons between groups were performed by means of analysis of variance, Kruskal-Wallis test, χ2, or Fisher exact tests, as appropriate. A multivariate analysis was performed by multinomial logistic regression. RESULTS: Prevalence of pica was 42% (ice pica, 46%; soil, 29%; two substances, 14%; red brick, 5%; paper, 3%; soap, 2%; and cattle pasture, 1%). Comparing patients with pica (hard pica and ice pica) versus no pica, subjects with pica were of younger age (25 ± 7, 27 ± 9, 30 ± 11 years, respectively), were more frequently educated <9 years (57%, 46%, 30%, respectively), and had longer dialysis duration (36 ± 19, 32 ± 18, 27 ± 16 months, respectively). Patients with pica achieved the recommended calorie and macronutrients intake target less frequently than those without pica (40-64% vs. 66-77%, P <.05). Malnutrition was present in 74% of the whole sample: (1) 67% in no pica group, (2) 80% in ice pica group, and (3) 89% in hard pica group (P = .001). In the multivariate analysis (R2, 0.27; P < .0001), malnutrition, C-reactive protein, and lower educational level significantly predicted both ice and hard pica. CONCLUSIONS: A worse nutritional status was observed in patients with pica, who additionally were younger, had lower educational level, longer dialysis duration, and worse macronutrient intake routine than patients without pica. Malnutrition, C-reactive protein, and lower educational level significantly predicted both ice and hard pica.

Prevalence of pre-diabetes in young Mexican adults in primary health care.

BACKGROUND: Pre-diabetes in young people is frequently unrecognized or not treated on time, with the consequent loss of opportunity for diabetes prevention. In Mexico, there is scarce information about the prevalence of pre-diabetes in young adults. OBJECTIVE: To determine the prevalence and risk factors for pre-diabetes in young Mexican adults in primary health care. METHODS: In a cross-sectional study, 288 subjects, aged 18-30 years, from a primary care unit were included. Pre-diabetes was diagnosed (according to the criteria of the American Diabetes Association) as impaired fasting glucose (8-12 hours fasting plasma glucose level: 100-125 mg/dl) or impaired glucose tolerance (140-199 mg/dl after a 2-hour oral glucose tolerance test). RESULTS: Prevalence of pre-diabetes was 14.6% [95% confidence interval (CI): 10.7-19.2], whereas that of diabetes was 2.4% (95% CI: 1.0-4.9). A high proportion of patients had history of obesity, diabetes, hypertension and consumption of tobacco and alcohol. Pre-diabetic patients were older than normoglycaemics (pre-diabetic patients: 26±4 years versus normoglycaemic subjects: 24±3 years, P = 0.003) and had higher body mass index (BMI; pre-diabetic patients: 29.4±6.8 kg/m(2) versus normoglycaemic subjects: 26.8±5.8 kg/m(2); P = 0.009), particularly in the case of men (pre-diabetic men: 29.3±7.0 kg/m(2) versus normoglycaemic men: 26.4±5.1 kg/m(2); P = 0.03). Although waist circumference showed a trend to be higher among pre-diabetics, no significant differences were found according to gender (among males: pre-diabetics: 99.5±18.8 cm versus normoglycaemics: 93.3±14.4 cm, P = 0.09; among females: pre-diabetics: 91.5±13.8 cm versus normoglycaemics: 85.8±15.9 cm, P = 0.16). Only age and BMI were significantly associated with the presence of pre-diabetes. CONCLUSIONS: Almost 15% of these young adults had pre-diabetes. Many modifiable and non-modifiable risk factors were present in these patients, but only age and a higher BMI were independent variables significantly associated with pre-diabetes. Timely interventions in primary health care are needed to prevent or delay the progression to diabetes.

Prevalence of chronic kidney disease in an adult population.

BACKGROUND AND AIMS: One strategy to prevent and manage chronic kidney disease (CKD) is to offer screening programs. The aim of this study was to determine the percentage prevalence and risk factors of CKD in a screening program performed in an adult general population. METHODS: This is a cross-sectional study. Six-hundred ten adults (73% women, age 51 ± 14 years) without previously known CKD were evaluated. Participants were subjected to a questionnaire, blood pressure measurement and anthropometry. Glomerular filtration rate estimated by CKD-EPI formula and urine tested with albuminuria dipstick. RESULTS: More than 50% of subjects reported family antecedents of diabetes mellitus (DM), hypertension and obesity, and 30% of CKD. DM was self-reported in 19% and hypertension in 29%. During screening, overweight/obesity was found in 75%; women had a higher frequency of obesity (41 vs. 34%) and high-risk abdominal waist circumference (87 vs. 75%) than men. Hypertension (both self-reported and diagnosed in screening) was more frequent in men (49%) than in women (38%). CKD was found in 14.7%: G1, 5.9%; G2, 4.5%; G3a, 2.6%; G3b, 1.1%, G4, 0.3%; and G5, 0.3%. Glomerular filtration rate was mildly/moderately reduced in 2.6%, moderately/severely reduced in 1.1%, and severely reduced in <1%. Abnormal albuminuria was found in 13%. CKD was predicted by DM, hypertension and male gender. CONCLUSIONS: A percentage CKD prevalence of 14.7% was found in this sample of an adult population, with most patients at early stages. Screening programs constitute excellent opportunities in the fight against kidney disease, particularly in populations at high risk.

Whole-body retention of α-linolenic acid and its apparent conversion to other n-3 PUFA in growing pigs are reduced with the duration of feeding α-linolenic acid.

In the present study, fifteen growing pigs were used to determine the whole-body oxidation, retention efficiency (RE) and apparent conversion (AC) of α-linolenic acid (18 : 3n-3) to n-3 highly unsaturated fatty acids (HUFA), including EPA (20 : 5n-3) and DHA (22 : 6n-3). The pigs were fed a diet containing 10% flaxseed for 30 d. Whole-body fatty acid composition was determined at initial (27.7 (SE 1.9) kg), intermediate (day 15; 39.2 (SE 1.4) kg) and final (45.7 (SE 2.2) kg) body weight. On day 12, four pigs were fed 10 mg/kg of uniformly labelled (13)C-18 : 3n-3 (single-bolus dose) to determine the oxidation of 18 : 3n-3. Expired CO2 samples were collected for 24 h thereafter. The whole-body content of n-3 PUFA increased linearly (P< 0.0001) with time; however, the content of 22 : 6n-3 exhibited a quadratic response (P< 0.01) with a peak occurring at 15 h. As a proportion of intake, the RE of 18 : 3n-3 tended to reduce with time (P = 0.098). The AC of ingested 18 : 3n-3 to the sum of n-3 HUFA was reduced with time (P< 0.05; 12.2 v. 7.53 % for days 0-15 and days 15-30, respectively). The AC of 18 : 3n-3 to 20 : 5n-3 or 22 : 6n-3 was lower than that to 20 : 3n-3, both for days 0-15 (P < 0.05; 1.14 or 1.07 v. 7.06 %) and for days 15-30 (P< 0.05; 1.51 or 0.33 v. 4.29 %). The direct oxidation of 18 : 3n-3 was 7.91 (SE 0.98) % and was similar to the calculated disappearance of 18 : 3n-3 between days 0 and 30 (8.81 (SE 5.24) %). The oxidation of 18 : 3n-3 was much lower than that reported in other species. The AC of 18 : 3n-3 to n-3 HUFA was reduced over time and that to 20 : 3n-3 in the present study was much higher than that reported in other species and should be explored further.

Multidisciplinary strategies in the management of early chronic kidney disease.

Chronic kidney disease (CKD) is a worldwide epidemic especially in developing countries, with clear deficiencies in identification and treatment. Better care of CKD requires more than only economic resources, utilization of health research in policy-making and health systems changes that produce better outcomes. A multidisciplinary approach may facilitate and improve management of patients from early CKD in the primary health-care setting. This approach is a strategy for improving comprehensive care, initiating and maintaining healthy behaviors, promoting teamwork, eliminating barriers to achieve goals and improving the processes of care. A multidisciplinary intervention may include educational processes guided by health professional, use of self-help groups and the development of a CKD management plan. The complex and fragmented care management of patients with CKD, associated with poor outcome, enhances the importance of implementing a multidisciplinary approach in the management of this disease from the early stages. Multidisciplinary strategies should focus on the needs of patients (to increase their empowerment) and should be adapted to the resources and health systems prevailing in each country; its systematic implementation can help to improve patient care and slow the progression of CKD.

Comparison of cost-utility between automated peritoneal dialysis and continuous ambulatory peritoneal dialysis.

BACKGROUND AND AIMS: The use of automated peritoneal dialysis (APD) is increasing compared to continuous ambulatory peritoneal dialysis (CAPD). Surprisingly, little data about health benefits and cost of APD exist, and virtually no information comparing the cost-utility between CAPD and APD is available. We undertook this study to evaluate and compare the health-related quality of life (HRQOL) and cost-utility indexes in patients on CAPD vs. APD METHODS: This was a prospective cohort of patients initiating dialysis (2008-2009). Two questionnaires were self-administered: European Research Questionnaire Quality of Life (EQ-5D) and Kidney Disease Quality of Life (short form, KDQOL-SF, Rand, Santa Monica, CA). Direct medical costs (DMC) were determined from the health provider perspective including the following medical resource utilization: outpatient clinic/emergency care, dialysis procedures, medications, laboratory tests, hospitalization, and surgery. Cost-utility indexes were calculated dividing total mean cost by indicators of the HRQOL. RESULTS: One hundred twenty-three patients were evaluated: 77 on CAPD and 46 on APD. Results of the EQ-5D and KDQOL-SF questionnaires were significantly better in APD compared to the CAPD group. Main costs in both APD and CAPD were attributed to hospitalization and dialysis procedures followed by medication and surgery. Outpatient clinic visits and laboratory tests were significantly more costly in CAPD than in APD, whereas dialysis procedures were more expensive in the latter. Cost-utility indexes were significantly better in APD compared to CAPD. CONCLUSIONS: A significant cost-utility advantage of APD vs. CAPD was observed. The annual DMC per-patient were not different between groups but the HRQOL was better in the APD compared to the CAPD group.

Anti-inflammatory interventions in end-stage kidney disease: a randomized, double-blinded, controlled and crossover clinical trial on the use of pravastatin in continuous ambulatory peritoneal dialysis.

BACKGROUND AND AIMS: Inflammation is highly prevalent in patients on dialysis. Statins have anti-inflammatory actions but their use has been scarcely studied in continuous ambulatory peritoneal dialysis (CAPD). We undertook this study to compare the effect of pravastatin vs. placebo on the serum concentrations of C-reactive protein (CRP) in patients on CAPD. METHODS: In a double-blind, controlled and crossover clinical trial, 76 CAPD patients were randomized to either pravastatin or placebo for 2 months. After this first period of treatment, patients had a 1-month wash-out period and, finally, they were crossed-over to receive the other drug (or placebo) for 2 more months. Measurement of clinical and biochemical variables and CRP was performed at the beginning and at the end of each treatment period. RESULTS: Median CRP was only significantly decreased in the pravastatin group in both periods of treatment: first period (baseline vs. final, mg/L): pravastatin 7.4 (2-21) vs. 2.6 (1-6), p <0.05; placebo 3.9 (2-10) vs. 6.8 (3-12), pNS; second period: pravastatin 4.3 (2-15) vs. 1.9 (1-7), p <0.05; placebo 4.9 (2-17) vs. 6.8 (2-19), p <0.05. Results were significantly different (p <0.05) between groups only at the end of each treatment period. Additionally, total and LDL-cholesterol significantly decreased in the pravastatin group. CONCLUSIONS: Pravastatin significantly reduced serum levels of CRP and total and LDL-cholesterol compared to placebo. This treatment may be of great help to decrease the inflammatory status and probably the cardiovascular disease of CAPD patients.

Comparison of direct medical costs between automated and continuous ambulatory peritoneal dialysis.

OBJECTIVE: We set out to estimate the direct medical costs (DMCs) of peritoneal dialysis (PD) and to compare the DMCs for continuous ambulatory PD (CAPD) and automated PD (APD). In addition, DMCs according to age, sex, and the presence of peritonitis were evaluated. METHODS: Our retrospective cohort analysis considered patients initiating PD, calculating 2008 costs and, for comparison, updating the results for 2010. The analysis took the perspective of the Mexican Institute of Social Security, including outpatient clinic and emergency room visits, dialysis procedures, medications, laboratory tests, hospitalizations, and surgeries. RESULTS: No baseline differences were observed for the 41 patients evaluated (22 on CAPD, 19 on APD). Median annual DMCs per patient on PD were US$15 072 in 2008 and US$16 452 in 2010. When analyzing percentage distribution, no differences were found in the DMCs for the modality groups. In both APD and CAPD, the main costs pertained to the dialysis procedure (CAPD 41%, APD 47%) and hospitalizations (CAPD 37%, APD 32%). Dialysis procedures cost significantly more (p = 0.001) in APD (US$7 084) than in CAPD (US$6 071), but total costs (APD US$15 389 vs CAPD US$14 798) and other resources were not different. The presence of peritonitis increased the total costs (US$16 075 vs US$14 705 for patients without peritonitis, p = 0.05), but in the generalized linear model analysis, DMCs were not predicted by age, sex, dialysis modality, or peritonitis. A similar picture was observed for costs extrapolated to 2010, with a 10% - 20% increase for each component--except for laboratory tests, which increased 52%, and dialysis procedures, which decreased 3%, from 2008. CONCLUSIONS: The annual DMCs per patient on PD in this study were US$15 072 in 2008 and US$16 452 in 2010. Total DMCs for dialysis procedures were higher in APD than in CAPD, but the difference was not statistically significant. In both APD and CAPD, 90% of costs were attributable to the dialysis procedure, hospitalizations, and medications. In a multivariate analysis, no independent variable significantly predicted a higher DMC.

Comparison of primary health-care models in the management of chronic kidney disease.

Negative lifestyle habits (potential risks for chronic kidney disease, CKD) are rarely modified by physicians in a conventional health-care model (CHCM). Multidisciplinary strategies may have better results; however, there is no information on their application in the early stages of CKD. Thus, the aim of this study was to compare a multiple intervention model versus CHCM on lifestyle and renal function in patients with type 2 diabetes mellitus and CKD stage 1-2. In a prospective cohort study, a family medicine unit (FMU) was assigned a multiple intervention model (MIM) and another continued with conventional health-care model (CHCM). MIM patients received an educational intervention guided by a multidisciplinary team (family physician (FP), social worker, dietitian, physical trainer); self-help groups functioned with free activities throughout the study. CHCM patients were managed only by the FP, who decided if patients needed referral to other professionals. Thirty-nine patients were studied in each cohort. According to a lifestyle questionnaire, no baseline differences were found between cohorts, but results reflected an unhealthy lifestyle. After 6 months of follow-up, both cohorts showed significant improvement in their dietary habits. Compared to CHCM diet, exercise, emotional management, knowledge of disease, and adherence to treatment showed greater improvement in the MIM. Blood pressure decreased in both cohorts, but body mass index, waist circumference, and HbA1C significantly decreased only in MIM. Glomerular filtration rate (GFR) was maintained equally in both cohorts, but albuminuria significantly decreased only in MIM. In conclusion, MIM achieves better control of lifestyle-related variables and CKD risk factors in type 2 diabetes mellitus (DM2) patients with CKD stage 1-2. Broadly, implementation of a MIM in primary health care may produce superior results that might assist in preventing the progression of CKD.

Role of the primary care physician in diagnosis and treatment of early renal damage.

In spite of all the technical advances and resources dedicated to the treatment of endstage renal disease (ESRD), it is still a growing problem all over the world. To address this issue adequately, it is crucial to detect chronic kidney disease patients early and optimize their care. However, a lack of awareness and appropriate management of potential underlying kidney disease, even in high-risk patients, seems to be common in many parts of the world, even though many of the measures recognized to decrease the risk and slow the progression of kidney disease are most effective when initiated early. Type 2 diabetes mellitus patients (a high-risk population) with early nephropathy treated by nephrologists have better preservation of their renal function than do patients treated only by family physicians. However, referral of patients to the nephrologist at earlier stages of disease than is recommended is not always feasible. A more plausible alternative may be that general practitioners learn to diagnose and treat these patients. We have demonstrated that an educational intervention increased family practitioners' clinical competence, which resulted in preserved renal function in diabetic patients with early renal disease. Variables not well controlled either by the nephrologist or the primary care physicians are those related to lifestyle and diet. These unhealthy habits are common in Westernized societies, and primary care physicians may be the most suitably positioned to promote health. Even so, counseling by physicians is not always effective in reducing risky habits, particularly when the health team is overworked; strategies such as community resources (including support groups) may also play a role. Preliminary results of an ongoing study based on a self-help and support group strategy that is coordinated by a multidisciplinary team (family practitioner, social worker, dietician, and physical trainer) show improvements in the lifestyle and dietary habits of patients with overweight or obesity, diabetes, or hypertension. All these findings support the need to implement health promotion programs with the participation of multidisciplinary teams.

Anthropometric and dietary evaluations in a sample of "healthy" Mexican older adults.

The purpose of this study was to describe anthropometric, metabolic, and nutritional characteristics in healthy elderly adults in a primary health care setting. It was conducted through a cross-sectional study of 80 subjects 60 years of age and older. After confirming healthy status, clinical, biochemical, dietetic, and anthropometric evaluations were performed. The findings indicated 22% had anemia, 22% had impaired glucose tolerance, 46% had hypertriglyceridemia, and 51% had hypercholesterolemia. More than 50% had obesity, and almost 80% had a high risk waist circumference measure. Mean energy intake was normal; however, more than 50% of participants did not have adequate intakes of potassium, calcium, magnesium, zinc, folic acid, and vitamins B(12) and A. Inadequate food intakes were common. Specific examples are that 16% of the subjects ate no meat/egg, 31% ate no dairy products, 56% ate no legumes, 22% ate no fruits, and 41% ate no vegetables. Additionally, 31% consumed soft drinks. Therefore, we can conclude that elderly people otherwise considered as "healthy" nonetheless had a high proportion of obesity and cardiovascular risk factors. Inadequate dietary patterns were also observed and corresponded with poor micronutrient intake.

How frequently the clinical practice recommendations for nephropathy are achieved in patients with type 2 diabetes mellitus in a primary health-care setting?

OBJECTIVE: To determine the proportion of DM2 patients in primary health-care setting who meet clinical practice recommendations for nephropathy. MATERIAL AND METHODS: 735 patients were included in this cross-sectional study. Nephropathy was defined as glomerular filtration rate < 60 mL/min/1.73 m2 or albuminuria > or = 30 mg/day. To estimate the proportion of patients meeting clinical practice recommendations, the achieved level was classified according to NKF -K/DOQI, ADA, IDF, JNC 7 report, and NCEP-ATPIII. RESULTS: A high frequency of kidney disease and cardiovascular risk factors (smoking, alcoholism, obesity) was observed. Adequate levels were attained in 13% for fasting glucose, 45% for blood pressure, 71% for albuminuria, and 30% for lipids. Nephropathy was diagnosed in 41%. Adequate systolic blood pressure was observed in 40% of patients with nephropathy vs. 49% without nephropathy (p = 0.03). In both groups, body mass index was acceptable in one fifth of patients, and waist circumference in two thirds of men and one third of women (p = NS). Patients with nephropathy used more antihypertensives, particularly angiotensin converting enzyme inhibitors (nephropathy 49% vs. no nephropathy 38%, p = 0.004). Subjects with nephropathy received more frequently (p = 0.05) insulin (11%) than those without nephropathy (7%). In both groups, there was low use of statins (nephropathy 14% vs. no nephropathy 17%, p = 0.23), and aspirin (nephropathy 7% vs. no nephropathy 5%, p = 0.39). CONCLUSIONS: Recommended goals for adequate control of DM2 patients attending primary health-care units are rarely achieved, and this was independent of the presence of nephropathy. These findings are disturbing, as poor clinical and metabolic control may eventually cause that patients without nephropathy develop renal damage, and those subjects already with renal disease progress to renal insufficiency.

Improving care of patients with diabetes and CKD: a pilot study for a cluster-randomized trial.

BACKGROUND: Family physicians may have the main role in managing patients with type 2 diabetes mellitus with early nephropathy. It is therefore important to determine the clinical competence of family physicians in preserving renal function of patients. The aim of this study is to evaluate the effect of an educational intervention on family physicians' clinical competence and subsequently determine the impact on kidney function of their patients with type 2 diabetes mellitus. STUDY DESIGN: Pilot study for a cluster-randomized trial. SETTING & PARTICIPANTS: Primary health care units of the Mexican Institute of Social Security, Guadalajara, Mexico. The study group was composed of 21 family physicians from 1 unit and a control group of 19 family physicians from another unit. 46 patients treated by study physicians and 48 treated by control physicians also were evaluated. INTERVENTION: An educative strategy based on a participative model used during 6 months in the study group. Allocation of units to receive or not receive the educative intervention was randomly established. OUTCOMES: Clinical competence of family physicians and kidney function of patients. MEASUREMENTS: To evaluate clinical competence, a validated questionnaire measuring family physicians' capability to identify risk factors, integrate diagnosis, and correctly use laboratory tests and therapeutic resources was applied to all physicians at the beginning and end of educative intervention (0 and 6 months). In patients, serum creatinine level, estimated glomerular filtration rate, and albuminuria were evaluated at 0, 6, and 12 months. RESULTS: At the end of the intervention, more family physicians from the study group improved clinical competence (91%) compared with controls (37%; P = 0.001). Family physicians in the study group who increased their competence improved renal function significantly better than physicians in the same group who did not increase competence and physicians in the control group (with or without increase in competence): change in estimated glomerular filtration rate, 0.9 versus -33, -21, and -16 mL/min/1.73 m(2) (P < 0.05); and change in urinary albumin excretion of -18 versus 226, 142, and 288 mg/d, respectively (P < 0.05). Compared with other groups, study family physicians with clinical competence also controlled systolic blood pressure significantly better and were more likely to increase the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and statins and to discontinue nonsteroidal anti-inflammatory drugs. LIMITATIONS: Our analysis did not adjust for clustering. Physicians in only 2 units were randomly assigned; thus, it is not possible to distinguish the effect of the intervention from the effect of the unit. CONCLUSIONS: Educative intervention to primary physicians is feasible. Our data may be the basis for additional prospective studies with a cluster-randomized trial design and larger numbers of centers, physicians, and patients.

Patient and technique survival in continuous ambulatory peritoneal dialysis in a single center of the west of Mexico.

INTRODUCTION: In Mexico, CAPD survival has been analyzed in few studies from the center of the country. However, there are concerns that such results may not represent what occurs in other province centers of our country, particularly in our geographical area. AIM: To evaluate the patient and technique survival on CAPD of a single center of the west of Mexico, and compare them with other reported series. DESIGN: Retrospective cohort study. SETTING: Tertiary care, teaching hospital located in Guadalajara, Jalisco. PATIENTS: Patients from our CAPD program (1999-2002) were retrospectively studied. Interventions. Clinical and biochemical variables at the start of dialysis and at the end of the follow-up were recorded and considered in the analysis of risk factors. MAIN OUTCOME MEASURES: Endpoints were patient (alive, dead or lost to follow-up) and technique status at the end of the study (June 2002). RESULTS: 49 patients were included. Mean patient survival (+/- SE) was 3.32 +/- 0.22 years (CI 95%: 2.9-3.8 years). Patients in the present study were younger (39 +/- 17yrs), had larger body surface area (1.72 +/- 0.22 m2), lower hematocrit (25.4 +/- 5.2%), albumin (2.6 +/- 0.6g/dL), and cholesterol (173 +/- 44 mg/dL), and higher urea (300 +/- 93 mg/dL) and creatinine (14.9 +/- 5.6 mg/ dL) than those in other Mexican series. In univariate analysis, the following variables were associated (p < 0.05) to mortality: pre-dialysis age and creatinine clearance, and serum albumin and cholesterol at the end of follow-up. In multivariate analysis, only pre-dialysis creatinine clearance (RR 0.66, p = 0.03) and age (RR 1.08, p = 0.005) significantly predicted mortality. Mean technique survival was 2.83 +/- 0.24 years (CI 95%: 2.4-3.3). Pre-dialysis age (p < 0.05), peritonitis rate (p < 0.05), and serum phosphorus at the end of follow-up (p < 0.05) were associated with technique failure in univariate analysis, while in multivariate analysis, only pre-dialysis age (RR 1.07, p = 0.001) and peritonitis rate (RR 481, p < 0.0001) were technique failure predictors. CONCLUSIONS: Patients from this single center of the west of Mexico were younger, had higher body surface area and initiated peritoneal dialysis with a more deteriorated general status than patients reported in other Mexican series; in spite of the latter, patient and technique survival were not different. In our setting, pre-dialysis older age and lower CrCl significantly predicted mortality, while older predialysis age and higher peritonitis rate predicted technique failure.

Utility of the Dipstick Micraltest II in the screening of microalbuminuria of diabetes mellitus type 2 and essential hypertension.

BACKGROUND: In Mexico, diabetes mellitus type 2 and hypertension are leading causes of end-stage renal disease. Diagnosis of early renal damage with detection of microalbuminuria (microAlbU) is fundamental for treatment and prevention, and so avoiding the catastrophes of renal failure. For screening purposes, several simplified tests, including dipstick methods, fulfill the accuracy requirements for microAlbU detection compared with gold standards; however, no study has established the reliability of such tests in our setting. AIM: To evaluate the utility of micraltest II as a screening test for microAlbU compared with nephelometry in patients with diabetes mellitus type 2 and non-diabetic patients with essential hypertension. PATIENTS AND METHODS: Patients with diabetes mellitus type 2 as well as patients with essential hypertension of any age, sex and time of evolution, attending to three primary health-care units (UMF No. 3, 92 and 93, Guadalajara, Jalisco) were included. Patients with transitory albuminuria, secondary hypertension and serum creatinine > or = 2 mg/dL were excluded. Micraltest II was performed in the first morning urine sample, and nephelometry was performed in a 24-h urine collection. Diagnostic accuracy of the dipstick test was then determined. RESULTS: 245 patients were studied: 71 (29%) were diabetics without hypertension, 95 (39%) were diabetics with hypertension, and 79 (32%) had only essential hypertension. In diabetic patients, micraltest II sensitivity was 83%, specificity 96%, and positive and negative predictive values were 95% and 88%, respectively. Correlation between nephelometry and micraltest II results was 0.81 (p < 0.001). The best cut-off point for microAlbU was 30.5 mg/L, and area under the curve (+/- SEM) was 0.91 +/- 0.03 (confidence interval 95%: 0.85-0.96). In non-diabetic patients with essential hypertension, micraltest II sensitivity was 75%, specificity 95%, and positive and negative predictive values were 43% and 99%, respectively. Correlation between nephelometry and micraltest II results was 0.43 (p < 0.001). The best cut-off point for microAlbU was 28.2 mg/L, and area under the curve was 0.85 +/- 0.13 (0.60-1.10). CONCLUSION: Micraltest II dispstick is a rapid, valid and reliable method for albuminuria screening in patients with diabetes mellitus type 2 and in those non-diabetic patients with essential hypertension in our setting.

Utility of the Dipstick Micraltest II TM in the screening of microalbuminuria of diabetes mellitus type 2 and essential hypertension / Utilidad de la tira reactiva Micraltest II TMen el escrutinio de microalbuminuria en diabetes mellitus tipo 2 e hipertensión esencial

Background. In Mexico, diabetes mellitus type 2 and hypertension are leading causes of end-stage renal disease. Diagnosis of early renal damage with detection of microalbuminuria (microAlbU) is fundamental for treatment and prevention, and so avoiding the catastrophes of renal failure. For screening purposes, several simplified tests, including dipstick methods, fulfill the accuracy requirements for microAlbU detection compared with gold standards; however, no study has established the reliability of such tests in our setting. Aim. To evaluate the utility of micraltest II TM as a screening test for microAlbU compared with nephelometry in patients with diabetes mellitus type 2 and non-diabetic patients with essential hypertension. Patients and methods. Patients with diabetes mellitus type 2 as well as patients with essential hypertension of any age, sex and time of evolution, attending to three primary health-care units (UMF No. 3, 92 and 93, Guadalajara, Jalisco) were included. Patients with transitory albuminuria, secondary hypertension and serum creatinine > 2 mg/dL were excluded. Micraltest II TM was performed in the first morning urine sample, and nephelometry was performed in a 24-h urine collection. Diagnostic accuracy of the dipstick test was then determined. Results. 245 patients were studied: 71 (29%) were diabetics without hypertension, 95 (39%) were diabetics with hypertension, and 79 (32%) had only essential hypertension. In diabetic patients, micraltest II TM sensitivity was 83%, specificity 96%, and positive and negative predictive values were 95% and 88%, respectively. Correlation between nephelometry and micraltest II TM results was 0.81 (p < 0.001). The best cut-off point for microAlbU was 30.5 mg/L, and area under the curve (± SEM) was 0.91 ± 0.03 (confidence interval 95%: 0.85-0.96). In non-diabetic patients with essential hypertension, micraltest II TM sensitivity was 75%, specificity 95%, and positive and negative predictive values were 43% and 99%, respectively. Correlation between nephelometry and micraltest II TM results was 0.43 (p < 0.001). The best cut-off point for microAlbU was 28.2 mg/L, and area under the curve was 0.85 ± 0.13 (0.60-1.10). Conclusion. Micraltest II TM dispstick is a rapid, valid and reliable method for albuminuria screening in patients with diabetes mellitus type 2 and in those non-diabetic patients with essential hypertension in our setting.

Antecedentes. En México, la diabetes mellitus tipo 2 y la hipertensión son las principales causas de insuficiencia renal crónica terminal. El diagnóstico temprano con detección de microalbuminuria (microAlbU) es fundamental para el tratamiento y prevención, y así evitar las catástrofes de la falla renal. Con el fin de tamizaje, varias pruebas simples, incluyendo las tiras reactivas, cumplen con los requerimientos de exactitud para detección de microAlbU comparados con esténdares de oro; sin embargo, ningún estudio ha establecido la confiabilidad de dichos métodos en nuestro medio. Objetivo. Evaluar la utilidad del micraltest II TM como prueba de tamizaje para microAlbU comparada con nefelometría en pacientes con diabetes mellitus tipo 2 y pacientes no diabáticos con hipertensión arterial esencial. Pacientes y métodos. Se incluyeron pacientes con diabetes mellitus tipo 2, así como pacientes con hipertensión arterial esencial de cualquiera de los dos sexos, sexo y tiempo de evolución que atendían a tres unidades de Medicina Familiar (UMF No. 3, 92 y 93, Guadalajara, Jalisco). Se excluyeron pacientes con albuminuria transitoria, hipertensión secundaria y creatinina sárica > 2 mg/dL. El micraltest II TM se realizó en la primera muestra matutina de orina, y la nefelometría en recolecciones de orina de 24 horas. La exactitud diagnóstica de la tira reactiva fue luego determinada. Resultados. Doscientos cuarenta y cinco pacientes fueron estudiados: 71 (29%) eran diabáticos sin hipertensión, 95 (39%) eran diabáticos con hipertensión, y 79 (32%) tenían sólo hipertensión arterial esencial. En los pacientes diabáticos, el micraltest II TM tuvo una sensibilidad de 83%, especificidad de 96%, y valores predictivos positivo y negativo de 95% y 88%, respectivamente. La correlación entre la nefelometría y el micraltest II TM fue 0.81 (p < 0.001). El mejor punto de corte para la detección de microAlbU fue 30.5 mg/L, y el área bajo la curva (± EE) fue 0.91 ± 0.03 (intervalo de confianza 95%: 0.85-0.96). En los pacientes no diabáticos con hipertensión esencial, el micraltest II TM tuvo una sensibilidad de 75%, especificidad de 95%, y valores predictivos positivo y negativo de 43 y 99%, respectivamente. La correlación entre los resultados de nefelometría y micraltest II TM fue 0.43 (p < 0.001). El mejor punto de corte para microAlbU fue 28.2 mg/L, y el área bajo la curva fue 0.85 ± 0.13 (intervalo de confianza 95%:0.60-1.10). Conclusión. La tira reactiva micraltest II TM es un método rápido, válido y confiable para el tamizaje de albuminuria en pacientes con diabetes mellitus tipo 2 y pacientes no diabáticos con hipertensión arterial esencial en nuestro medio.