Panorama da qualidade biológica da água destinada ao tratamento dialítico em pacientes sob cuidados críticos em Unidades de Terapia Intensiva / Overview of the biological quality of water intended for dialysis treatment in patients under critical care in Intensive Care Units

A incidência da lesão renal aguda caracteriza-se como evento frequente em pacientes críticos internados em Unidades de Terapia Intensiva e está associada ao aumento de mortalidade, causando grande impacto à Saúde Pública. As intercorrências clínicas são minimizadas com intervenções dialíticas, acarretando a exposição do paciente a volumes expressivos de água tratada durante a terapia renal em leito. As análises microbiológicas e de determinação de endotoxinas bacterianas em amostras de água tratada e em soluções de dialisato foram executadas em dois hospitais públicos do município de São Paulo, seguindo metodologias analíticas preconizadas em compêndios oficiais. A avaliação demonstrou que a porcentagem de resultados satisfatórios no período de 2010 a 2022 variou entre 35,2 a 100% e de 40 a 100% para as unidades hospitalares I e II para a água tratada, respectivamente; e, 100% para as soluções de dialisato para a unidade hospitalar I. A eficácia de ações delineadas pelas equipes técnicas das unidades hospitalares, na adequação da água destinada à terapia dialítica, aponta para a importância em estimular outras instituições hospitalares na padronização e implantação de melhoria contínua de seus sistemas de tratamento de água para uso em procedimento dialítico, prevenindo riscos adicionais aos pacientes expostos à terapia renal.

The incidence of acute kidney is high among critically ill patients admitted to Intensive Care Units and is associated with increased mortality, having a major impact on public health. Clinical complications are minimized with dialysis interventions, which expose patients to significant volumes of treated water during in-bed renal therapy. Microbiological analyzes and determination of bacterial endotoxins were performed on treated water samples and dialysate solutions in two public hospitals in São Paulo city, using analytical methodologies recommended in official compendia. The evaluation showed that the percentage of satisfactory results for treated water ranged from 35.2% to 100% in Hospital Unit I and from 40% to 100% in Hospital Unit II between 2010 and 2022. For dialysate solutions in Hospital Unit I, the percentage of satisfactory results was 100% during the same period. The effectiveness of actions implemented by the technical hospital teams, in adapting water for dialysis therapy, points to the importance of encouraging other hospital institutions to standardize and implement a program of continuous improvement for their water treatment systems used in dialysis procedures. This will help to prevent additional risks to patients exposed to renal therapy.

Nota Técnica N. 2/2022 - SES/GERTRAN/CCM - 19813 - ações relacionadas ao transplante renal em Goiás / Technical Note N. 2/2022 - SES/GERTRAN/CCM-19813 - actions related to kidney transplantation in Goiás

A Portaria MS n.º 78, de 9 de março de 1.999, credenciou a Central Estadual de Transplantes de Goiás - CET/GO e desde então, os transplantes no Estado tem desenvolvido de forma íntegra e abrangente, inclusive no que tange outras instituições, as quais possam participar de forma direta ou indiretamente das ações relacionadas aos transplantes, no Estado. Diante disso, a presente Nota Técnica n.º 2/2022 visa orientar, organizar e publicizar o fluxo das ações relacionadas aos transplantes de rins em Goiás, de modo a atender as legislações vigentes, bem como a necessidade social e médica, em consonância com os princípios do SUS, que são norteadores desse processo

Ordinance MS n.º 78, of March 9, 1999, accredited the Goiás State Transplant Center - CET/GO and since then, transplants in the State have developed in an integral and comprehensive way, including with regard to other institutions, which can participate directly or indirectly in actions related to transplants in the State. Therefore, this Technical Note No. 2/2022 - aims to guide, organize and publicize the flow of actions related to kidney transplants in Goiás, in order to comply with current legislation, as well as the social need and medical, in line with the principles of the SUS, which guide this process

Good practices for dialysis education, treatment, and eHealth: A scoping review.

BACKGROUND: Recommendations regarding dialysis education and treatment are provided in various (inter)national guidelines, which should ensure that these are applied uniformly in nephrology and dialysis centers. However, there is much practice variation which could be explained by good practices: practices developed by local health care professionals, which are not evidence-based. Because an overview of good practices is lacking, we performed a scoping review to identify and summarize the available good practices for dialysis education, treatment, and eHealth. METHODS: Embase, Pubmed, the Cochrane Library, CINAHL databases and Web of Science were searched for relevant articles using all synonyms for the words 'kidney failure', 'dialysis', and 'good practice'. Relevant articles were structured according to the categories dialysis education, dialysis treatment or eHealth, and assessed for content and results. RESULTS: Nineteen articles (12 for dialysis education, 3 for dialysis treatment, 4 for eHealth) are identified. The good practices for education endorse the importance of providing complete and objective predialysis education, assisting peritoneal dialysis (PD) patients in adequately performing PD, educating hemodialysis (HD) patients on self-management, and talking with dialysis patients about their prognosis. The good practices for dialysis treatment focus mainly on dialysis access devices and general quality improvement of dialysis care. Finally, eHealth is useful for HD and PD and affects both quality of care and health-related quality of life. CONCLUSION: Our scoping review identifies 19 articles describing good practices and their results for dialysis education, dialysis treatment, and eHealth. These good practices could be valuable in addition to guidelines for increasing shared-decision making in predialysis education, using patients' contribution in the implementation of their dialysis treatment, and advanced care planning.

Trends in Cardiovascular Mortality Among a Cohort of Children and Young Adults Starting Dialysis in 1995 to 2015.

Importance: Survival of patients receiving dialysis has improved during the last 2 decades. However, few studies have examined temporal trends in the attributed causes of death (especially cardiovascular-related) in young populations. Objective: To determine temporal trends and risk of cause-specific mortality (ie, cardiovascular and infectious) for children and young adults receiving dialysis. Design, Setting, and Participants: This retrospective cohort study examined the records of children and young adults (aged <30 years) starting dialysis between 1995 and 2015 according to the United States Renal Data System database. Analyses were performed between June 2019 and June 2020. Fine-Gray models were used to examine trends in risk of different cardiovascular-related deaths. Models were adjusted for age, sex, race, neighborhood income, cause of end-stage kidney disease, insurance type, and comorbidities. Analyses were performed separately for children (ie, age <18 years) and young adults (between ages 18 and 30 years). Follow-up was censored at death or administratively, and transplantation was treated as a competing event. Exposures: Calendar year. Main Outcomes and Measures: Cardiovascular cause-specific mortality. Results: A total of 80 189 individuals (median [interquartile range] age, 24 [19-28] years; 36 259 [45.2%] female, 29 508 [36.8%] Black, and 15 516 [19.3%] Hispanic white) started dialysis and 16 179 experienced death during a median (interquartile range) of 14.3 (14.0-14.7) years of follow-up. Overall, 40.2% of deaths were from cardiovascular-related causes (6505 of 16 179 patients). In adjusted analysis, risk of cardiovascular-related death was stable initially but became statistically significantly lower after 2006 (vs 1995) in those starting dialysis as either children (subhazard ratio [SHR], 0.74; 95% CI, 0.55-1.00) or adults (SHR, 0.90; 95% CI, 0.83-0.98). Risk of sudden cardiac death improved steadily for all age groups, but to a greater degree in children (SHR, 0.31; 95% CI, 0.20-0.47) vs young adults (SHR, 0.64; 95% CI, 0.56-0.73) comparing 2015 vs 1995. Risk of stroke became statistically significantly lower around 2010 (vs 1995) for children (SHR, 0.40; 95% CI, 0.18-0.88) and young adults (SHR, 0.76; 95% CI, 0.59-0.99). Conclusions and Relevance: In this study, the risk of cardiovascular-related death declined for children and young adults starting dialysis during the last 2 decades, but trends differed depending on age at dialysis initiation and the specific cause of death. Additional studies are needed to improve risk of cardiovascular disease in young populations.

Managing care for people with diabetes undergoing dialysis.

BACKGROUND: Caring for patients with diabetes undergoing dialysis often proves challenging for staff working in haemodialysis units as they are not experts in diabetes and unfamiliar with insulin dosing regimens and the impact dialysis can have on blood sugar levels and lifestyle adjustment. There is a need to improve the knowledge base of renal healthcare professionals to better understand the physiology of diabetes, its relationship with end stage kidney disease, and potential changes that can take place when commencing dialysis. OBJECTIVES: The aim of this paper is to improve the understanding of the epidemiology of diabetes, associated risk factors, and complications associated with combined kidney disease & diabetes. In addition, readers will learn about the impact of dialysis on this complex patient group; adjustments which need to be made to accommodate haemodialysis schedules e.g. timing of meals and insulin requirements; treatment time including travel; the monitoring of blood glucose levels: increased risk of hypoglycaemia; review of oral glycaemic medication and the need to maintain regular health checks and contact with diabetes teams. RECOMMENDATIONS FOR PRACTICE: Specialist evidence based guidelines for the management of patients with diabetes receiving haemodialysis are readily available and can be used to support clinical practice. One of the key components to improving the patient experience is to maintain collaborative working relationship between renal and diabetes teams. LEARNING OUTCOMES: After reading this paper the reader will be able to Understand the risk factors and complications of diabetes and relate to patients in their care Critically review the management of patients undergoing dialysis with diabetes Gain knowledge and understanding of changes in the dosing of insulin needed for patients receiving dialysis Understand how clinical guidelines can be applied in practice.

Multicenter Validation of the Emotional State Instrument for Dialysis Patients.

BACKGROUND: The Emotional State Instrument for Dialysis Patients (ES-D) is a brief semistructured questionnaire to assess emotional distress in patients undergoing dialysis. It was designed to be administered by a healthcare provider. A previous study showed preliminary indicators of its content and face validity. OBJECTIVE: The aim of the current multicenter study was to explore the ES-D's psychometric properties. METHODS: A total of 605 patients with kidney disease undergoing dialysis (524 hemodialysis and 81 peritoneal dialysis) in 19 Spanish dialysis centers completed the ES-D, along with anxiety, depression (Hospital Anxiety and Depression Scale), and resilience (Brief Resilience Scale) questionnaires. The 75 healthcare providers who performed the assessments completed a satisfaction survey. RESULTS: The ES-D showed adequate internal consistency (α = .73). Correlations between the ES-D scores and the scores for anxiety, depression, and resilience showed evidence of its convergent and concurrent validity. The receiver operating characteristic curve analyses showed that a cutoff of nine detected patients with moderate-to-severe emotional distress. According to these criteria, 35.4% of patients showed emotional distress. No significant differences were found between patients undergoing hemodialysis and peritoneal dialysis. The healthcare providers perceived the ES-D as useful for knowing the patients' emotional state, understanding patients' concerns, and establishing therapeutic relationships. CONCLUSIONS: The ES-D is a useful tool for healthcare providers to explore the emotional dimension of their patients. Thus, its development represents a step forward in the improvement of comprehensive assistance and the quality of life of patients with kidney disease undergoing dialysis.

Informal caregivers' experiences of caring for people receiving dialysis: A mixed-methods systematic review.

BACKGROUND: Living with end stage kidney disease and having dialysis is burdensome, and there is a need for support from informal caregivers (i.e. family members and friends). Renal health professionals readily acknowledge and value the support provided by caregivers although the activities and experiences of caring for a loved-one who is receiving dialysis is less well understood. OBJECTIVES: To review studies about the perspectives and experiences of family members and friends who provide support for adults receiving either haemodialysis or peritoneal dialysis. METHODS: A mixed-methods systematic review was conducted. Eight databases (Medline, CINAHL, EMBASE, PsycINFO, Proquest, Web of Science, Cochrane Library and JBI library) were comprehensively searched using relevant key words for studies regardless of design published in English from January 2006 to July 2017. RESULTS: Twenty studies were included in this review. Informal caregivers undertake many everyday activities as well as a range of dialysis-specific activities, report an elevated level of burden, feel overwhelmed, experience social isolation, and also need to consider their own health. A unique finding was that caregivers also experienced personal growth that may defuse the impact of caregiving burden and to help them develop a sense of resilience to sustain the support through the tough times and for many years. CONCLUSION: This review substantiates that caregiver burden is due to the unrelenting nature of complex dialysis-specific activities although resilience often develops. Additional research is necessary to understand social support in this context and how health teams can assist caregivers further.

Bionalytical validation study for the determination of unbound ambrisentan in human plasma using rapid equilibrium dialysis followed by ultra performance liquid chromatography coupled to mass spectrometry.

Ambrisentan is a highly selective endothelin-1 type A receptor antagonist indicated for use in the treatment of pulmonary hypertension. In this study an assay was developed and validated for the quantification of total and unbound (free) concentrations of ambrisentan in human plasma. Plasma samples were dialysed against phosphate buffered saline in a rapid equilibrium dialysis device to obtain dialysate and plasma for unbound and total ambrisentan, respectively. Subsequently, ambrisentan and deuterated ambrisentan (internal standard) were extracted from plasma or plasma dialysate by solid-phase extraction and separated by ultra performance liquid chromatography using on a reversed-phase C18 column. Detection was conducted with a tandem mass spectrometer with an electrospray ionization source and analysed in positive ion mode with multiple reaction monitoring. Calibration curves were generated over a linear concentration range of 0.1-200 ng/mL in plasma and 0.1-10 ng/mL in plasma ultrafiltrate; with a recovery for ambrisentan of 69.4% and 77.5%, respectively. This assay has been shown to be reproducible and sensitive. The lower limit of quantification in both cases was 0.1 ng/mL; reaching a sensitivity not previously described in the literature. The inter- and intra-batch precision and accuracy were in both cases ≤±15%. The procedure was applied to assess total and free plasma concentrations of ambrisentan in healthy volunteers. Plasma protein binding of ambrisentan was approximately 99%.

Intra-dialytic hypotension: Identifying patients most at risk.

BACKGROUND: Intra-dialytic hypotension (IDH) remains a frequent but serious complication of haemodialysis. METHODS: We performed a retrospective observational analysis of our prevalent dialysis population extracting data from an online database. RESULTS: Four hundred and thirty-two patients underwent 21 consecutive outpatient dialysis sessions during the study period: Of the 9,072 dialysis sessions studied, 438 were complicated by episodes of IDH (4.8%). 266/432 patients were asymptomatic whilst 166/432 experienced at least one episode of IDH. Symptomatic patients had significantly lower pre-dialysis systolic blood pressures (137 mmHg compared with 146 mmHg p < 0.0001) and demonstrated a greater per cent drop in their systolic blood pressure (delta systolic) before and after dialysis (9.7% vs. 4.1% p < 0.0001). Patients taking either a single or no anti-hypertensive agents had a significantly higher delta systolic than those on two or more anti-hypertensive agents (7.6% vs. 2.2% p < 0.01) and were almost 50% more likely to suffer from IDH (RR = 1.48, p = 0.017). Using logistical regression we identified pre-dialysis systolic blood pressure and delta systolic blood pressure as strong predictor variables for IDH (p < 0.0001). We constructed a model able to calculate the risk of an individual patient suffering with IDH using delta systolic and pre-dialysis systolic blood pressure. A ROC analysis suggests this to be an accurate model (AUC = 0.79). CONCLUSION: Delta systolic blood pressure is clinically useful in identifying patients most at risk of IDH. Anti-hypertensive medication use is associated with a lower delta systolic and a lower risk of IDH.

Clinical value of natriuretic peptides in chronic kidney disease / Utilidad clínica de los péptidos natriuréticos en la enfermedad renal crónica

According to several lines of evidence, natriuretic peptides (NP) are the main components of a cardiac-renal axis that operate in clinical conditions of decreased cardiac hemodynamic tolerance to regulate sodium homeostasis, blood pressure and vascular function. Even though it is reasonable to assume that NP may exert a relevant role in the adaptive response to renal mass ablation, evidence gathered so far suggest that this contribution is probably complex and dependent on the type and degree of the functional mass loss. In the last years NP have been increasingly used to diagnose, monitor treatment and define the prognosis of several cardiovascular (CV) diseases. However, in many clinical settings, like chronic kidney disease (CKD), the predictive value of these biomarkers has been questioned. In fact, it is now well established that renal function significantly affects the plasmatic levels of NP and that renal failure is the clinical condition associated with the highest plasmatic levels of these peptides. The complexity of the relation between NP plasmatic levels and CV and renal functions has obvious consequences, as it may limit the predictive value of NP in CV assessment of CKD patients and be a demanding exercise for clinicians involved in the daily management of these patients. This review describes the role of NP in the regulatory response to renal function loss and addresses the main factors involved in the clinical valorization of the peptides in the context of significant renal failure (AU)

Existen varias líneas de evidencia que indican que los péptidos natriuréticos (PN) son los componentes principales de un eje cardio-renal que actúa en situaciones clínicas de reducción de la tolerancia hemodinámica cardiaca mediante la regulación de la homeostasis del sodio, la presión arterial y la función vascular. A pesar de que parece razonable asumir que los PN puedan desempeñar un papel importante en la respuesta adaptativa a la ablación de masa renal, la evidencia acumulada hasta ahora sugiere que esta contribución es probablemente compleja y depende del tipo y el grado de pérdida de masa funcional. En los últimos años los PN se han venido utilizando de manera creciente para diagnosticar, realizar un seguimiento del tratamiento y definir el pronóstico de varias enfermedades cardiovasculares (CV). Sin embargo, en varios contextos clínicos, como el de la enfermedad renal crónica (ERC), se ha puesto en duda el valor predictivo de esos biomarcadores. De hecho, actualmente está bien establecido que la función renal influye significativamente en los niveles plasmáticos de PN y que la insuficiencia renal es el estado clínico que se asocia a unos niveles plasmáticos más elevados de estos péptidos. La complejidad de la relación existente entre los niveles plasmáticos de PN y la función CV y renal tiene consecuencias obvias, puesto que puede limitar el valor predictivo de los PN en la evaluación CV de los pacientes con ERC y su uso puede requerir un esfuerzo adicional por parte de los clínicos encargados del manejo cotidiano de esos pacientes. En esta revisión se describe el papel que desempeñan los PN en la respuesta reguladora ante la pérdida de función renal, y se abordan los principales factores involucrados en el valor clínico que se asigna a los péptidos en el contexto de una insuficiencia renal significativa (AU)

Free testosterone by direct and calculated measurement versus equilibrium dialysis in a clinical population.

INTRODUCTION: The value of clinically available free testosterone (FT) assays remains controversial. Here, we evaluate the agreement between the radioimmunoassay (RIA) and calculated FT (cFT) versus equilibrium dialysis (EqD), considered the gold standard. METHODS: Fifty-six consecutive men (aged 26-77) had blood samples assessed for FT, including men with treated and untreated testosterone deficiency (TD) and men without TD. Samples were split and tested by the two methodologies at a Quest Diagnostics national reference laboratory. cFT was calculated by the Vermeulen method. RESULTS: A robust correlation was noted for RIA and EqD (r = 0.966) and for cFT and EqD (r = 0.986). Strong correlations were observed for men receiving testosterone therapy and for men in the lowest and highest quartiles for total and FT. The correlation of total testosterone with FT was similar for cFT (r = 0.843), RIA (r = 0.806), and EqD (r = 0.809). Sex-hormone binding globulin (SHBG) was not correlated with any measure of FT. Bland-Altman analysis demonstrated similar bias for both cFT and RIA, although cFT consistently overestimated FT. Numerical values for RIA were approximately one seventh of EqD values. CONCLUSIONS: These results support the clinical use of both RIA and cFT as measures of FT. Due to numerical differences, each test requires its own set of reference values.

[The need to revise the hemoglobin threshold value in the German Quality Assurance Directive for Dialysis]. / Die Notwendigkeit zur Revision des Hämoglobingrenzwerts in der deutschen Qualitätssicherungs-Richtlinie Dialyse.

The German Quality Assurance Directive for Dialysis (QSD-RL) stipulates that no more than 15 % of all patients treated in a dialysis unit in any quarter may have a hemoglobin (Hb) value lower than 10 g/dl. For approximately 90 % of dialysis patients, this Hb threshold value can be simply achieved by administering erythropoiesis-stimulating agents (ESA). However, the question is raised as to wether this Hb threshold accords with the current state of knowledge. It is now evident from four randomized controlled trials (above all the TREAT study) and three meta-analyses that an ESA-induced increase in Hb does not produce any significant survival benefit in cases of chronic kidney disease (CKD), but may actually be detrimental. Critical attention must be focused in this regard on the higher risk of cardiovascular and cerebrovascular events, as well as malignoma-associated risks. In 2011, in response to these findings, the American Food and Drug Administration (FDA), the Drug Directive (AM-RL) of the German Federal Joint Committee and KDIGO (Kidney Disease: Improving Global Outcomes) amended guidelines for the treatment of renal anemia. Very restrictive recommendations were made regarding the use of ESA in CKD, according to which the Hb threshold value of 10 g/dl stipulated in the Quality Assurance Directive is now obsolete, thus necessitating prompt revision of the Directive. Two alternatives are available in this regard: either the 10 g/dl Hb threshold value applicable hitherto is withdrawn without replacement, and individualized treatment of renal anemia is practised ("individualization") instead, or a threshold value of 9 g/dl (modified "standardization") is applied in future.

Plan de cuidados a una paciente con una fractura pertrocantérea / No disponible

No disponible