Peritoneal dialysis modality transition and impact on phosphate and potassium serum levels.

Peritoneal dialysis (PD) modalities affect solute removal differently. However, the impacts of switching PD modalities on serum levels of biomarkers of different sizes are not known. Our objective was to analyze whether a change in the PD modality associates with the levels of two routine biochemical laboratories. In this multicentric prospective cohort study. we selected all patients who remained on a PD modality for at least 6 months and switched PD modality. Patients were also required to be treated with the same PD modality for at least 3 months before and after the modality change. The primary outcome was change in potassium and phosphate serum levels. We identified 737 eligible patients who switched their PD modality during the study. We found mean serum phosphate levels increased during the 3 months after switching from CAPD to APD and conversely decreased after switching to from APD to CAPD. In contrast, for potassium the difference in the mean serum levels was comparable between groups switching from CAPD to APD, and vice versa. In conclusion, CAPD seems to be as efficient as APD for the control of potassium serum levels, but more effective for the control of phosphate serum levels. The effect of a higher removal of middle size molecules as result of PD modalities in terms of clinical and patient-reported outcomes should be further explored.

Impact of Renin-Angiotensin Aldosterone System Inhibition on Serum Potassium Levels among Peritoneal Dialysis Patients.

BACKGROUND: The chronic use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blocker has been associated with hyperkalemia in patients with reduced renal function even after the initiation of hemodialysis. Whether such medications may cause a similar effect in peritoneal dialysis patients is not well established. So, the aim of our study was to analyze the impact of renin-angiotensin-aldosterone inhibitors on the serum levels of potassium in a national cohort of peritoneal dialysis patients. METHOD: A prospective, observational, nationwide cohort study was conducted. We identified all incident patients on peritoneal dialysis that had angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) prescribed for at least 3 months and a similar period of time without these medications. Patients were divided into 4 groups: Groups I and III correspond to patients using, respectively, an ACEi or ARB and then got the drug suspended; Groups II and IV started peritoneal dialysis without the use of any renin-angiotensin aldosterone system inhibitor and then got, respectively, an ACEi or ARB introduced. Changes in potassium serum levels were compared using 2 statistical approaches: (1) the non-parametric Wilcoxon test for repeated measures and (2) a crossover analysis. RESULTS: Mean potassium serum levels at the first phase of the study for Groups I, II, III, and IV were, respectively, 4.46 ± 0.79, 4.33 ± 0.78, 4.41 ± 0.63, and 4.44 ± 0.56. Changes in mean potassium serum levels for Groups I, II, III, and IV were -0.10 ± 0.60, 0.02 ± 0.56, -0.06 ± 0.46, and 0.03 ± 0.50, respectively. CONCLUSION: The use of ACEi and ARB was not associated with a greater risk for hyperkalemia in stable peritoneal dialysis patients independently of residual renal function.

Racial and social disparities in the access to automated peritoneal dialysis - results of a national PD cohort.

The prevalence of patients on automated peritoneal dialysis (APD) is increasing worldwide and may be guided by clinical characteristics, financial issues and patient option. Whether socioeconomic factors at the patient level may influence the decision for the initial peritoneal dialysis (PD) modality is unknown. This is a prospective cohort study. The primary outcome of interest was the probability to start PD on APD. The inclusion criteria were adult patients incident in PD. Exclusion criteria were missing data for either race or initial PD modality. We used a mixed-model analysis clustering patients according to their PD center and region of the country. We included 3,901 patients of which 1,819 (46.6%) had APD as their first modality. We found a significant disparity for race and educational level with African American patients less likely to start on APD (Odds ratio 0.74 CI95% 0.58-0.94) compared to Whites whilst those with greater educational levels were more likely to start on APD (Odds ratio 3.70, CI95% 2.25-6.09) compared to illiterate patients. Limiting the use of APD in disadvantaged population may be unethical. Demographics and socioeconomic status should not be necessarily part of the decision-making process of PD modality choice.

Modalidades de terapia renal substitutiva

Este recurso educacional integra o conjunto de objetos autoinstrucionais ofertados pela UNA-SUS/UFMA na área temática de Nefrologia. Trata-se de um e-book que apresenta as modalidades de terapia renal substitutiva, abordando as indicações e contraindicações para cada uma delas. Desta forma, espera-se que o leitor possa conhecer as principais complicações destes métodos. Além deste, há mais 31 e-books tratando sobre diversas questões relacionadas à Nefrologia. Todos eles fornecem conteúdos interessantes para a formação dos profissionais da saúde que atuam no SUS e dos acadêmicos da área.

Terapia renal substitutiva

Este recurso educacional integra o conjunto de objetos na área temática de Nefrologia, ofertados pela UNA-SUS/UFMA. Trata-se de um recurso autoinstrucional, com carga horária sugerida de 30 horas. O curso é composto por 3 unidades educacionais com o objetivo de capacitar os profissionais da saúde que atuam ou que pretendem atuar na Atenção Básica. São abordados temas como as modalidades de terapia renal substitutiva e suas principais complicações; o transplante renal como modalidade de terapia renal substitutiva; a legislação para transplantes de órgãos; a importância da família no cuidado ao paciente com doença renal crônica.

Manejo clínico das doenças renais

Busca-se descrever estratégias para o manejo das doenças renais considerando as suas formas de controle, tratamento e complicações associadas. Este recurso educacional integra o conjunto de objetos na área temática de Nefrologia, ofertados pela UNA-SUS/UFMA. Trata-se de um recurso autoinstrucional, com carga horária sugerida de 45 horas, composto por 3 unidades, com o objetivo de capacitar os profissionais da saúde que atuam ou que pretendem atuar na Atenção Básica

Low Serum Potassium Levels Increase the Infectious-Caused Mortality in Peritoneal Dialysis Patients: A Propensity-Matched Score Study.

BACKGROUND AND OBJECTIVES: Hypokalemia has been consistently associated with high mortality rate in peritoneal dialysis. However, studies investigating if hypokalemia is acting as a surrogate marker of comorbidities or has a direct effect in the risk for mortality have not been studied. Thus, the aim of this study was to analyze the effect of hypokalemia on overall and cause-specific mortality. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: This is an analysis of BRAZPD II, a nationwide prospective cohort study. All patients on PD for longer than 90 days with measured serum potassium levels were used to verify the association of hypokalemia with overall and cause-specific mortality using a propensity match score to reduce selection bias. In addition, competing risks were also taken into account for the analysis of cause-specific mortality. RESULTS: There was a U-shaped relationship between time-averaged serum potassium and all-cause mortality of PD patients. Cardiovascular disease was the main cause of death in the normokalemic group with 133 events (41.8%) followed by PD-non related infections, n=105 (33.0%). Hypokalemia was associated with a 49% increased risk for CV mortality after adjustments for covariates and the presence of competing risks (SHR 1.49; CI95% 1.01-2.21). In contrast, in the group of patients with K <3.5 mEq/L, PD-non related infections were the main cause of death with 43 events (44.3%) followed by cardiovascular disease (n=36; 37.1%). For PD-non related infections the SHR was 2.19 (CI95% 1.52-3.14) while for peritonitis was SHR 1.09 (CI95% 0.47-2.49). CONCLUSIONS: Hypokalemia had a significant impact on overall, cardiovascular and infectious mortality even after adjustments for competing risks. The causative nature of this association suggested by our study raises the need for intervention studies looking at the effect of potassium supplementation on clinical outcomes of PD patients.

Modalidades de terapia renal substitutiva: hemodiálise e diálise peritoneal

Texto que compõe a unidade 3 do módulo "Manejo clínico das doenças renais" do Curso de Especialização em Nefrologia Multidisciplinar, produzido pela UNA-SUS/UFMA. Aborda as duas modalidades de terapia de substituição renal: a hemodiálise e a diálise peritoneal. Apresenta também as vantagens e desvantagens de cada terapia e a importância de orientar de maneira clara sobre as opções de escolha para que o paciente e sua família se sintam confortáveis.

Implantação da solução de diálise

Este material compõe o Curso de Especialização em Nefrologia Multidisciplinar (Unidade 3, Módulo 6), produzido pela UNA-SUS/UFMA. Trata-se de um recurso educacional interativo que apresenta como é feito o procedimento para que a solução de diálise seja colocada dentro do abdome.

Diálise peritoneal ambulatorial contínua

Este material compõe o Curso de Especialização em Nefrologia Multidisciplinar (Unidade 3, Módulo 6), produzido pela UNA-SUS/UFMA. Trata-se de um recurso educacional interativo que apresenta o processo de troca da solução de diálise, durante a DPAC (Diálise peritoneal ambulatorial contínua), também chamada de troca manual.

Diálise peritoneal: saída do líquido acumulado

Este material compõe o Curso de Especialização em Nefrologia Multidisciplinar (Unidade 3, Módulo 6), produzido pela UNA-SUS/UFMA. Trata-se de um recurso educacional interativo que apresenta o processo de osmose, ultrafiltração, difusão, convecção e permanência do líquido acumulado no organismo do paciente durante a diálise peritoneal.

Comparative analysis of lipid and glucose metabolism biomarkers in non-diabetic hemodialysis and peritoneal dialysis patients.

OBJECTIVE: To investigate and compare glucose and lipid metabolism biomarkers in non-diabetic peritoneal dialysis and hemodialysis patients. METHODS: The study followed a prospective and cross-sectional design. PARTICIPANTS: Participants included all prevalent end-stage renal disease patients under renal replacement therapy treated in a university-based clinic. INTERVENTIONS: There were no interventions. MAIN OUTCOMES MEASURES: Blood samples were taken after 8 hours of fasting. Insulin serum levels were determined by chemiluminescence. Insulin resistance were assessed by the insulin sensitivity check index (QUICKI) determined as follow: 1/[log(Io) + log(Go)], where Io is the fasting insulin, and Go is the fasting glucose. HOMA index was also measured: (FPG × FPI)/22.5; FPG = fasting plasma glucose (mmol/L); FPI = fasting plasma insulin (mU/mL). The others biochemical exams were measured utilizing the routine tests. RESULTS: We screened 154 patients (80 on hemodialysis and 74 on peritoneal dialysis). Seventy-four diabetic patients were excluded. Of the remaining 80 patients (55% males, mean age 52 ± 15 years), 35 were on peritoneal dialysis and 45 on hemodialysis. Fasting glucose of peritoneal dialysis patients compared to hemodialysis patients were 5.0 ± 0.14 versus 4,58 ± 0.14 mmol/L, p<0.05; glycated hemoglobin 5.9 ± 0.1 versus 5.5 ± 0.1%, p < 0.05; total cholesterol 5.06 ± 0.19 versus 3.39 ± 0.20 mmol/L, p < 0.01; LDL-c 2.93 ± 0.17 versus 1.60 ± 0.17 mmol/L, p < 0.01; and index HOMA 3.27 versus 1,68, p < 0,05. Importantly, all variables were adjusted for age, gender, dialysis vintage, calcium-phosphorus product, albumin and C-reactive protein levels. CONCLUSION: We observed a worst profile of lipid and glucose metabolism biomarkers in peritoneal dialysis patients (lower insulin sensitivity and higher fasting glucose, HbA1c, total cholesterol and LDL-c) when compared to hemodialysis, potentially due to the glucose-based dialysis solutions utilized in the peritoneal dialysis population.

Comparative analysis of lipid and glucose metabolism biomarkers in non-diabetic hemodialysis and peritoneal dialysis patients / Análise comparativa de biomarcadores do metabolismo de glicose e lipídeos em pacientes não diabéticos em hemodiálise e diálise peritoneal

OBJECTIVE: To investigate and compare glucose and lipid metabolism biomarkers in non-diabetic peritoneal dialysis and hemodialysis patients. METHODS: The study followed a prospective and cross-sectional design Participants: participants included all prevalent end-stage renal disease patients under renal replacement therapy treated in a university-based clinic. Interventions: there were no interventions. Main outcomes measures: blood samples were taken after 8 hours of fasting. Insulin serum levels were determined by chemiluminescence. Insulin resistance were assessed by the insulin sensitivity check index (QUICKI) determined as follow: 1/[log(Io) + log(Go)], where Io is the fasting insulin, and Go is the fasting glucose. HOMA index was also measured: (FPG × FPI)/22.5; FPG = fasting plasma glucose (mmol/L); FPI = fasting plasma insulin (mU/mL). The others biochemical exams were measured utilizing the routine tests. RESULTS: We screened 154 patients (80 on hemodialysis and 74 on peritoneal dialysis). Seventy-four diabetic patients were excluded. Of the remaining 80 patients (55 percent males, mean age 52 ± 15 years), 35 were on peritoneal dialysis and 45 on hemodialysis. Fasting glucose of peritoneal dialysis patients compared to hemodialysis patients were 5.0 ± 0.14 versus 4,58 ± 0.14 mmol/L, p<0.05; glycated hemoglobin 5.9 ± 0.1 versus 5.5 ± 0.1 percent, p < 0.05; total cholesterol 5.06 ± 0.19 versus 3.39 ± 0.20 mmol/L, p < 0.01; LDL-c 2.93 ± 0.17 versus 1.60 ± 0.17 mmol/L, p < 0.01; and index HOMA 3.27 versus 1,68, p < 0,05. Importantly, all variables were adjusted for age, gender, dialysis vintage, calcium-phosphorus product, albumin and C-reactive protein levels. CONCLUSION: We observed a worst profile of lipid and glucose metabolism biomarkers in peritoneal dialysis patients (lower insulin...

OBJETIVO: O presente estudo foi desenhado pra investigar e comparar biomarcadores do metabolismo de glicose e lipídeos em pacientes não diabéticos em diálise peri>toneal e hemodiálise. MÉTODOS: O estudo possui um desenho prospectivo e transversal. Participantes: foram incluídos todos os pacientes prevalentes em terapia de substituição renal tratados em uma clínica universitária. Intervenções: não houve intervenções. Medida das variáveis principais: as amostras de sangue foram coletadas com jejum oral de 8 horas. Os níveis séricos de insulina foram determinados por quimioluminescência. Resistência insulínica foi avaliada pelo index QUICKI como se segue: 1/[log(Io) + log(Go)], onde Io é a insulina de jejum, e Go a glicemia de jejum. Índice HOMA também foi medido: (FPG × FPI)/22,5; FPG = glicemia de jejum (mmol/L); FPI = insulina de jejum (mU/mL). Os demais exames bioquímicos foram analisados utilizando métodos de rotina. RESULTADOS: Foram avaliados 154 pacientes (80 em hemodiálise e 74 em diálise peritoneal). Setenta e quatro pacientes diabéticos foram excluídos. Dos 80 pacientes restantes (55 por cento homens, idade média de 52 ± 15 anos), 35 estavam em diálise peritoneal e 45 em hemodiálise. A glicemia em jejum dos pacientes em diálise peritoneal em relação à hemodiálise foi 5,0 ± 0,14 versus 4,58 ± 0,14 mmol/L, p < 0,05; para hemoglobina glicada (HbA1c) de 5,9 ± 0,1 versus 5,5 ± 0,1 por cento, p<0,05; colesterol total de 5,06 ± 0,19 versus 3,39 ± 0,20 mmol/L, p < 0,01; LDL-c de 2,93 ± 0,17 versus 1,60 ± 0,17 mmol/L, p < 0,01; e índice HOMA de 3,27 versus 1,68, p < 0,05. Todas as variáveis foram ajustadas para idade, sexo, tempo em diálise, produto cálcio-fósforo, albumina e proteína C-reativa. CONCLUSÃO: Nós observamos um pior perfil no metabolismo de glicose e lipídeos em pacientes em diálise peritoneal (menor sensibilidade insulínica e valores mais elevados de glicemia em jejum, HbA1c, colesterol total e LDL-c) quando comparados a pacientes...

Low-calcium peritoneal dialysis solution is effective in bringing PTH levels to the range recommended by current guidelines in patients with PTH levels < 150 pg/dL.

INTRODUCTION/OBJECTIVE: Adinamic bone disease (ABD) is a common finding in peritoneal dialysis (PD) and is associated with higher risk of developing cardiovascular and bone disease. Data from BRAZPD indicates that 3.5 mEq/L calcium PD solutions represents the majority of PD prescriptions in the country. A positive calcium balance can contribute to ABD development. Currently guidelines suggest that PTH-i levels in end stage renal disease should be kept from 150-300 pg/mL. The purpose of this study is to evaluate 6 month PTH-i response after conversion to 2.5 mEq/L calcium PD solution in patients with baseline PTH-i levels < 150 pg/mL. METHODS: Prospective, observational study of all prevalent patients (at least 90 days on therapy) on PD of a single Brazilian center from January 2008 to May 2009. Inclusion criteria (1) be in use of a PD solution with 3.5 mEq/L of calcium; (2) baseline PTH levels < 150 pg/ mL. According to clinical practice patients could be switched to PD solutions with 2.5 mEq/L of calcium. RESULTS: 35 patients (age 62 ± 17 years) were included. Of these 22 were converted to 2.5 mEq/L calcium solutions. Diabetic nephropathy (36%) was the main cause of renal disease followed by nephrosclerosis (25%) and glomerulonephritis (14%). Converted group presented a greater increase in PTH levels when compared with the control group (Δ194 pg/dL versus Δ 92/dL; p < 0,05). Among patients switched to low calcium solution, 41% reached the target values (PTH 150-300 pg/mL) compared to 14% whose remain with normal calcium solutions (p < 0.05). There were no differences between groups regarding calcium, phosphorus and alkaline phosphatase. CONCLUSION: In patients with PTH < 150 pg/mL conversion to low calcium solutions (2.5 mEq/L) appears to be a simple and effective strategy to bring PTH levels to the range determined by current guidelines when compared with 3.5 mEq/L calcium PD solutions.

Low-calcium peritoneal dialysis solution is effective in bringing PTH levels to the range recommended by current guidelines in patients with PTH levels < 150 pg/dL / Alteração do teor de cálcio no banho de DP para 2, 5 mEq/L é eficaz no reestabelecimento dos valores preconizados por diretrizes atuais em pacientes com PTH < 150 pg/dL

INTRODUÇÃO/OBJETIVO: A doença óssea adinâmica (DOA) é um achado comum em diálise peritoneal (PD) e é considerada fator de risco para desenvolvimento de fraturas e doença cardiovascular. Dados do BRAZPD apontam as soluções de cálcio a 3,5 mEq/L presentes na maioria das prescrições no país, que possui quase 9.000 pacientes em PD. É comum o balanço positivo de cálcio com concentrações a 3,5 mEq/L contribuindo para o desenvolvimento de DOA. Diretrizes atuais recomendam um PTHi na DRC V em diálise entre 2 e 9 vezes (150-500 pg/mL) o valor máximo da normalidade. O objetivo deste estudo foi avaliar a resposta em 6 meses do PTH-i após a conversão para solução de cálcio a 2,5 mEq/L de pacientes que usavam soluções com cálcio a 3,5 mEq/L e com PTH-i basal < 150 pg/mL. MÉTODOS: Coorte prospectiva, observacional, na qual todos pacientes prevalentes em PD entre janeiro de 2008 e janeiro de 2009 de um único centro foram incluídos. Critérios de inclusão foram:(1) estar em uso de solução de DP com cálcio a 3,5 mEq/L; (2)PTH sérico < 150 pg/mL. A critério médico, os pacientes poderiam ser convertidos ou não para soluções cálcio a 2,5 mEq/L. RESULTADOS: 35 pacientes (idade média 62 ± 17 anos) foram incluídos. Desses, 22 foram convertidos para solução de cálcio 2,5 mEq/L. Nefropatia diabética foi a principal doença de base (36 por cento) seguido por HAS (25 por cento) e GNC (14 por cento). Os grupos apresentavam valores basais semelhantes de PTH, cálcio, fósforo e fosfatase alcalina. No grupo-intervenção, houve aumento significativamente maior de PTH em 6 meses comparado com o grupo-controle (Δ194 pg/dL versus Δ 92/dL; p < 0,05).

INTRODUCTION/OBJECTIVE: Adinamic bone disease (ABD) is a common finding in peritoneal dialysis (PD) and is associated with higher risk of developing cardiovascular and bone disease. Data from BRAZPD indicates that 3.5 mEq/L calcium PD solutions represents the majority of PD prescriptions in the country. A positive calcium balance can contribute to ABD development. Currently guidelines suggest that PTH-i levels in end stage renal disease should be kept from 150-300 pg/mL. The purpose of this study is to evaluate 6 month PTH-i response after conversion to 2.5 mEq/L calcium PD solution in patients with baseline PTH-i levels < 150 pg/mL. METHODS: Prospective, observational study of all prevalent patients (at least 90 days on therapy) on PD of a single Brazilian center from January 2008 to May 2009. Inclusion criteria (1) be in use of a PD solution with 3.5mEq/L of calcium; (2) baseline PTH leves < 150 pg/ mL. According to clinical practice patients could be switched to PD solutions with 2.5 mEq/L of calcium. RESULTS: 35 patients (age 62 ± 17 years) were included. Of these 22 were converted to 2.5 mEq/L calcium solutions. Diabetic nephropathy (36 percent) was the main cause of renal disease followed by nephrosclerosis (25 percent) and glomerulonephritis (14 percent). Converted group presented a greater increase in PTH levels when compared with the control group (Δ194 pg/dL versus Δ 92/dL; p < 0,05). Among patients switched to low calcium solution, 41 percent reached the target values (PTH 150300 pg/mL) compared to 14 percent whose remain with normal calcium solutions (p < 0.05). There were no differences between groups regarding calcium, phosphorus and alkaline phosphatase. CONCLUSION: In patients with PTH < 150 pg/mL conversion to low calcium solutions (2.5 mEq/L) appears to be a simple and effective strategy to bring PTH levels to the range determined by current guidelines when compared with 3.5mEq/L calcium PD solutions.

Insulin resistance and glucose homeostasis in peritoneal dialysis.

Cardiovascular disease (CVD) is the main cause of death in peritoneal dialysis (PD) patients, a situation that can be explained by a combination of traditional and nontraditional risk factors for CVD in these patients. Glucose and insulin homeostasis are altered in chronic kidney disease (CKD) patients even in the early stages of CKD, leading to insulin resistance by various pathways. Several factors have been implicated in the pathogenesis of insulin resistance, including anemia, dyslipidemia, uremia, malnutrition, excess of parathyroid hormone, vitamin D deficiency, metabolic acidosis, and increase in plasma free fatty acids and proinflammatory cytokines. Insulin resistance and dyslipidemia are observed and increase with the progression of CKD, playing an important role in the pathogenesis of hypertension and atherosclerosis. Particularly in PD patients, exposure to glucose from dialysis fluid accentuates the foregoing metabolic abnormalities. In conclusion, insulin resistance and altered glucose metabolism are frequently observed in CKD, and although dialysis partly corrects those disturbances, the use of glucose PD solutions intensifies a series of harmful metabolic consequences. New therapeutic measures aimed at reducing metabolic disorders are urgently needed and perhaps will improve PD patient survival.

Alterações morfológicas causadas pela reaplicação de ondas de choque eletro-hidráulicas, no rim de ratos / Morphologic alterations caused by electro-hydraulic shock waves reapplication in rat kidney

A recidiva de cálculos urinários é freqüente, necessitando múltiplas aplicações de ondas de choque para seu tratamento. O objetivo deste trabalho é pesquisar alterações morfológicas agudas ocorridas nos rins de ratos submetidos a reaplicação de ondas de choque. Foram utilizados 48 ratos, distribuídos em 4 grupos de 12 animais. O grupo I recebeu duas aplicações de 2000 ondas de choque, com 14 KV de intensidade em intervalo de 14 dias entre as aplicações. O grupo II serviu de controle. O grupo III recebeu apenas uma aplicação. O grupo IV serviu de controle. Os rins foram examinados após 72 horas da aplicação das ondas de choque, observando: hemorragias subcapsular, intersticial e glomerular; perda da junção corticomedular; infiltrado crônico; necrose cortical e edema perivascular. Os resultados mostraram que a reaplicação de ondas de choque eletro-hidráulicas sobre rins de ratos não causou maiores danos que os produzidos pela primeira aplicação