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Medicine (Baltimore) ; 96(6): e5799, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28178126


The uremic syndrome is attributed to progressive retention of compounds that, under normal conditions, are excreted by the healthy kidneys. p-cresol sulfate (PCS), a prototype protein-bound uremic retention solute, has been shown to exert toxic effects in vitro. Recent studies have identified relations between increased levels of PCS and indoxyl sulfate (IS) and adverse clinical outcomes in hemodialysis patients. We explored the relationship between free and total PCS and IS with infection-related hospitalizations (IH) and septicemia in 2 cohorts, Choices for Healthy Outcomes in Caring for end-stage renal disease (ESRD) Study (CHOICE) and Hemodialysis Study (HEMO).We measured free and total levels of PCS and IS in stored specimens in CHOICE, a cohort of 464 incident hemodialysis patients enrolled in 1995 to 1998 and followed for an average of 3.4 years and in a prevalent dialysis cohort of 495 patients enrolled in HEMO from 1995 to 2000 and followed for an average of 4.4 years. We measured free PCS and IS using mass spectroscopy. The 2 cohorts were linked to United States Renal Data System (USRDS) Medicare billing records to ascertain IH over follow-up. We examined the association of free and total levels of PCS and IS with IH and septicemia using multilevel Poisson regression models adjusted for demographics, comorbidities, clinical factors, and laboratory tests including residual kidney function. We stratified patients a priori based on gastrointestinal (GI) disease as PCS and IS are produced in colon.In CHOICE, highest tertile of free PCS in multivariable model was associated with 50% higher risk of IH [95% CI = 1.01-2.23] compared with lowest tertile in patients with no-GI disease. A significant trend was noted between greater levels of free PCS and septicemia in no-GI disease group in both cohorts, while no association was noted in GI disease group. Total PCS concentrations were not associated with either IH or septicemia in either cohort. No significant risk of IH or septicemia was noted with higher levels of free or total IS in either GI or no-GI disease group.These results suggest an association between higher concentrations of free PCS and infection-related and sepsis-related hospitalizations in hemodialysis patients. Better methods of dialysis should be developed to evaluate the utility of removing PCS and its effect on the outcome and also therapies to decrease gastrointestinal tract production of uremic solutes.

Cresóis/sangue , Gastroenteropatias/complicações , Indicã/sangue , Falência Renal Crônica/sangue , Sepse/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Falência Renal Crônica/complicações , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Sepse/etiologia , Adulto Jovem
Clin J Am Soc Nephrol ; 11(9): 1566-73, 2016 09 07.
Artigo em Inglês | MEDLINE | ID: mdl-27340288


BACKGROUND AND OBJECTIVES: Awareness of CKD is necessary for patient engagement and adherence to medical regimens. Having an accurate tool to assess awareness is important. Use of the National Health and Nutrition Examination Survey (NHANES) CKD awareness question "Have you ever been told by a doctor or other health professional that you had weak or failing kidneys (excluding kidney stones, bladder infections, or incontinence)?" produces surprisingly low measures of CKD awareness. We sought to compare the sensitivity and specificity of different questions ascertaining awareness of CKD and other health conditions. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Between August of 2011 and August of 2014, an in-person questionnaire was administered to 220 adults with CKD, diabetes, hypertension, or hyperlipidemia who received primary care in a public health care delivery system to ascertain awareness of each condition. CKD awareness was measured using the NHANES question, and other questions, asking if patients knew about their "kidney disease", "protein in the urine", "kidney problem", or "kidney damage." Demographic data were self-reported; health literacy was measured. The sensitivity and specificity of each question was calculated using the medical record as the gold standard. RESULTS: In this diverse population (9.6% white, 40.6% black, 36.5% Hispanic, 12.3% Asian), the mean age was 58 years, 30% had a non-English language preference, and 45% had low health literacy. Eighty percent of participants had CKD, with a mean eGFR of 47.2 ml/min per 1.73 m(2). The sensitivities of each CKD awareness question were: 26.4% for "kidney damage", 27.7% for "kidney disease", 33.2% for "weak or failing kidneys", 39.8% for "protein in the urine", and 40.1% for "kidney problem." Specificities ranged from 82.2% to 97.6%. The best two-question combination yielded a sensitivity of 53.1% and a specificity of 83.3%. This was lower than awareness of hypertension (90.1%) or diabetes (91.8%). CONCLUSIONS: CKD awareness is low compared with other chronic diseases regardless of how it is ascertained. Nevertheless, more sensitive questions to ascertain CKD awareness suggest current under-ascertainment.

Conhecimentos, Atitudes e Prática em Saúde , Insuficiência Renal Crônica , Inquéritos e Questionários , Adulto , Idoso , Estudos Transversais , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/psicologia , Feminino , Letramento em Saúde/estatística & dados numéricos , Humanos , Hiperlipidemias/diagnóstico , Hiperlipidemias/psicologia , Hipertensão/diagnóstico , Hipertensão/psicologia , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/psicologia , Sensibilidade e Especificidade
J Am Soc Nephrol ; 27(11): 3469-3478, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27026365


The Hemodialysis (HEMO) Study showed that high-dose hemodialysis providing a single-pool Kt/Vurea of 1.71 provided no benefit over a standard treatment providing a single-pool Kt/Vurea of 1.32. Here, we assessed whether the high-dose treatment used lowered plasma levels of small uremic solutes other than urea. Measurements made ≥3 months after randomization in 1281 patients in the HEMO Study showed a range in the effect of high-dose treatment compared with that of standard treatment: from no reduction in the level of p-cresol sulfate or asymmetric dimethylarginine to significant reductions in the levels of trimethylamine oxide (-9%; 95% confidence interval [95% CI], -2% to -15%), indoxyl sulfate (-11%; 95% CI, -6% to -15%), and methylguanidine (-22%; 95% CI, -18% to -27%). Levels of three other small solutes also decreased slightly; the level of urea decreased 9%. All-cause mortality did not significantly relate to the level of any of the solutes measured. Modeling indicated that the intermittency of treatment along with the presence of nondialytic clearance and/or increased solute production accounted for the limited reduction in solute levels with the higher Kt/Vurea In conclusion, failure to achieve greater reductions in solute levels may explain the failure of high Kt/Vurea treatment to improve outcomes in the HEMO Study. Furthermore, levels of the nonurea solutes varied widely among patients in the HEMO Study, and achieved Kt/Vurea accounted for very little of this variation. These results further suggest that an index only on the basis of urea does not provide a sufficient measure of dialysis adequacy.

Diálise Renal , Ureia/metabolismo , Feminino , Soluções para Hemodiálise/química , Humanos , Masculino , Pessoa de Meia-Idade , Ureia/análise
BMC Nephrol ; 16: 166, 2015 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-26494562


BACKGROUND: Chronic kidney disease (CKD) is common and is associated with excess mortality and morbidity. Better management could slow progression of disease, prevent metabolic complications, and reduce cardiovascular outcomes. Low patient awareness of CKD and ineffective patient-provider communication can impede such efforts. We developed provider and patient-directed interventions that harness health information technology to enhance provider recognition of CKD and delivery of guideline concordant care and augment patient understanding and engagement in CKD care. METHODS/DESIGN: We report the design and protocol of the Kidney Awareness Registry and Education (KARE) Study, a 2x2 factorial randomized controlled trial that examines the impact of a multi-level intervention on health outcomes among low-income English, Spanish and Cantonese-speaking patients with CKD in a safety net system. The intervention includes: (1) implementation of a primary care electronic CKD registry that notifies practice teams of patients' CKD status and employs a patient profile and quarterly feedback to encourage provision of guideline-concordant care at point-of-care and via outreach; and (2) a language-concordant, culturally-sensitive self-management support program that consists of automated telephone modules, provision of low-literacy written patient-educational materials and telephone health coaching. The primary outcomes of the trial are changes in systolic blood pressure (BP) and the proportion of patients with BP control (≤ 140/90 mmHg) after one year. Secondary outcomes include patient understanding of CKD, participation in healthy behaviors, and practice team delivery of guideline-concordant CKD care. DISCUSSION: Results from the KARE study will provide data on the feasibility, effectiveness, and acceptability of technology-based interventions that support primary care efforts at improving health outcomes among vulnerable patients with CKD. TRIAL REGISTRATION:, number: NCT01530958.

Comunicação , Fidelidade a Diretrizes , Conhecimentos, Atitudes e Prática em Saúde , Educação de Pacientes como Assunto , Insuficiência Renal Crônica/terapia , Americanos Asiáticos , Pressão Sanguínea , Competência Cultural , Comportamentos Relacionados com a Saúde , Letramento em Saúde , Hispano-Americanos , Humanos , Idioma , Informática Médica , Equipe de Assistência ao Paciente/normas , Relações Médico-Paciente , Guias de Prática Clínica como Assunto , Atenção Primária à Saúde , Sistema de Registros , Insuficiência Renal Crônica/fisiopatologia , Projetos de Pesquisa , São Francisco , Autocuidado , Populações Vulneráveis