Hemodialysis Water Parameters as Predisposing Factors for Anemia in Patients in Dialytic Treatment: Application of Mixed Regression Models.

Contamination by metals and microbiological agents in hemodialysis water can cause clinical intercurrences in hemodialysis patients. Evaluating and assuring minimum levels of contamination from metals and microorganisms in hemodialysis water can improve patient safety. The objective of this study was to assess hemodialysis water quality in a major tertiary hospital in Brazil and investigate the relationship between hemodialysis water quality and clinical intercurrences in hemodialysis patients. A prospective-observational cohort study for evaluation of water quality parameters and clinical intercurrences present by patients (n = 52) were performed from May 2014 to April 2015. Mixed linear regression models and binary regression models were fitted for water quality parameters and patients' clinical parameters. The increase in the levels of copper and nitrate in hemodialysis water was significant (p < 0.05) to explain anemia. Bone pain was related to age, sex (female), and hemodialysis treatment duration (years). Hypotensive episodes were related to serum sodium decrease. Aluminum in hemodialysis water was present in an average concentration higher than the permitted threshold (15.35 ± 14.53 µg/L). Cadmium, total coliforms, Escherichia coli, and endotoxins in hemodialysis water were not detected and the heterotrophic bacteria count was below the reference limit. These parameters' concentrations varied during the study, evidencing the need for continuous monitoring.

Qualidade da água tratada para hemodiálise e intercorrências clínicas apresentadas pelos pacientes em tratamento: enfoque para metais e agentes microbiológicos / Quality of treated water for hemodialysis and clinical intercurrences presented by patients in treatment: a focus on metals and microbiological agents

A contaminação por metais e agentes microbiológicos na água de hemodiálise pode ocasionar manifestações clínicas nos pacientes em tratamento, como anemia, dor óssea, picos hipertensivos, distúrbios neurológicos, episódios de hipotensão, náuseas e vômitos. Avaliar e garantir níveis mínimos de contaminação por metais e micro-organismos na água de hemodiálise pode, assim, aumentar a segurança do paciente. O objetivo deste estudo foi avaliar a relação entre a qualidade da água tratada para hemodiálise e as intercorrências clínicas apresentadas pelos pacientes. Foi utilizado um questionário para a coleta de informações referentes aos aspectos demográficos e hábitos de consumo, e um instrumento de registro mensal de intercorrências clínicas e parâmetros clínico-laboratoriais; tais informações foram obtidas por meio de entrevista e no prontuário do paciente, respectivamente. As dosagens de metais em sangue foram realizadas por EAA (Chama/ Forno de Grafite) no Setor de Metais do HCFMRP/USP, e em água por ICP/MS no Laboratório de Toxicologia e Saúde Ambiental da Universidade Rovira i Virgili, Espanha. A quantificação de bactérias heterotróficas foi realizada pelo Método "Pour Plate", a de Coliformes totais e E. coli por Tubos Múltiplos e a detecção de fungos filamentosos por Membrana Filtrante no Laboratório de Ecotoxicologia e Parasitologia Ambiental da EERP/USP. A quantificação de endotoxina foi realizada pela técnica cromogênica do lisado de Limulus Amebocyte, no Laboratório de Vacinas Gênicas da FMRP/USP. Para a análise dos dados foi aplicado o teste Wilcoxon- Mann Whitney bilateral ou Teste t bilateral no software R®, o teste de Kruskal-Wallis no software GraphPad Prism 6®, e ajustados modelos de regressão no software SAS/STAT®. Verificou-se que a concentração de Pb sérico entre os pacientes que exercem/exerciam atividades relacionadas à maior exposição a metais foi significativamente maior (p-valor = 0,0208) que aqueles que nunca realizaram tais atividades. A concentração média de Cu, Pb e Zn na água após filtração por osmose reversa (AFOR) foi inferior ao preconizado na RDC nº 154/2004 e RDC nº 11/2014 da ANVISA, somente o Al (15,35 ± 14,53 µg/L) apresentou concentração média superior a tais normativas. Não foi detectado presença, durante todo o período do estudo, de Cd, coliformes totais, E. coli e endotoxina na água AFOR. A contagem de bactérias heterotróficas foi significativamente maior (p-valor <0,0001) na água após a pré- filtração (APF) do que na água potável (AP) e na água AFOR. As concentrações de cloro total e nitrato foram significativamente maiores (p-valor <0,0001) na AP em relação à água APF e na água AFOR. A contagem de bactérias heterotróficas e a concentração de nitrato na água AFOR foi inferior ao preconizado nas normativas, o cloro total apresentou concentração média superior ao estabelecido na RDC nº 11/2014, mas dentro do limite preconizado pela RDC nº 154/2004. Foi verificado presença de fungos filamentosos em todos os pontos de coleta. Constatou-se que a diminuição da concentração de Cu e nitrato em água de hemodiálise foram significativos (p-valor = 0,001 e 0,0354, respectivamente) para explicar o aumento da concentração de hemoglobina em sangue. Embora a água utilizada no preparo do dialisato tenha apresentado excelente qualidade microbiológica e físico-química é importante o monitoramento contínuo para garantia dos parâmetros de qualidade e prevenção de intercorrências clínicas

The contamination by metals and microbiological agents in hemodialysis water can cause clinical manifestations in hemodialysis patients, such as anemia, bone pain, hypertensive peaks, neurological disturbances, hypotension episodes, nausea and vomiting. Evaluating and assuring minimum levels of contamination by metals and microorganisms in hemodialysis water can improve patient safety. The aim of the study was assess the relationship between the quality of treated water for hemodialysis and the clinical intercurrences presented by patients. A questionnaire was used to collect information about demographic characteristics and consumer habits, and an instrument was applied for monthly recording of clinical intercurrences and clinical laboratorial parameters. The data were obtained by interviews and from clinical records, respectively. Concentrations of metals in blood were determined by AAS (flame/graphite furnace) in the Metals Sector of HCFMRP/USP, and in water by ICP/MS in the Laboratory of Toxicology and Environmental Health of University Rovira i Virgili, Spain. The quantification of heterotrophic bacteria was performed by the pour plate method, the total coliforms and E. coli by multiple tubes, and filamentous fungi by the membrane filter at the Laboratory of Ecotoxicology and Environmental Parasitology of the EERP/USP. The quantification of endotoxin was performed by the chromogenic technique of Limulus Amebocyte lysate, at the Gene Vaccine Laboratory of the FMRP/USP. For data analysis, the bilateral Wilcoxon-Mann-Whitney or bilateral t-test was applied using the R® software, the Kruskal-Wallis test using GraphPad Prism 6®, and adjusted regression models with SAS/STAT®. The results showed that patients who reported having or having had job activities with high exposure to metals showed serum concentrations of Pb significantly higher (p-value = 0.0208) than patients without job exposure to metals. The mean concentrations of Cu, Pb and Zn in the water after reverse osmosis (ARO) were below the threshold limits set by RDC nº 154/2004 and RDC nº 11/2014 from the ANVISA; only Al (15.35 ± 14.53 µg/L) was present in average concentration higher than resolutions. The presence of Cd, total coliforms, E. coli and endotoxins in the water ARO during the study was not detected. The counting of heterotrophic bacteria was significantly higher (p-value <0.0001) in the water after the pre-filtration (APF) than the potable water (PW) and the wate ARO. The concentrations of total chlorine and nitrate were significantly higher (p-value <0.0001) in the PW than the water APF and the water ARO. The counting of heterotrophic bacteria and concentration of nitrate in the water ARO were below the reference limits, while the total chlorine was present in higher concentration than the established in RDC nº 11/2014 but lower than that in RDC nº 154/2004. Filamentous fungi were detected at all sampling points. The decrease in the levels of Cu and nitrate in hemodialysis water were significant (p value = 0.001 and 0.0354, respectively) to explaining the increase of hemoglobin concentration in the blood samples. Although the water used for dialysis showed excellen microbiological and physicochemical quality, it is important to monitor it regularly to assure the quality parameters and prevent clinical intercurrences

Emergent and re-emergent parasites in HIV-infected children: immunological and socio-environmental conditions that are involved in the transmission of Giardia spp. and Cryptosporidium spp.

INTRODUCTION: Emergent and re-emergent waterborne protozoans have become a worldwide public health problem, especially among vulnerable groups. METHODS: This cross-sectional study evaluated 17 HIV-infected children and their families. RESULTS: A high (76.5%) percentage of parasite-infected children was observed, even among children with CD4+ T-cell counts of >200 cells/mm3. Giardia spp., Cryptosporidium spp. and Cyclospora spp. were observed in 41.2% of these children Low income, poor hygiene practices, and co-infection in domestic, peridomestic and scholastic environments were significant sources of these intestinal infections. CONCLUSIONS: Early diagnosis, timely treatment, and socio-educational interventions may improve the health conditions of this vulnerable population.