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1.
Medicine (Baltimore) ; 100(5): e24275, 2021 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-33592871

RESUMO

ABSTRACT: To investigate serum level of high mobility group box protein-1 (HMGB1) and prognosis of patients with end-stage renal disease (ESRD) on hemodialysis (HD) and peritoneal dialysis (PD).This prospective cohort observational study included a total of 253 ESRD patients who came to our hospital for HD or PD from February 2013 to February 2015. Enzyme linked immunosorbent assay (ELISA) method was used to detect the serum level of HMGB1, interleukin (IL-6), IL-8, and tumor necrosis factor-alpha (TNF-α). The kidney disease quality of life short form (KDQOL-SF) and kidney disease targeted area (KDTA) was applied for evaluating the quality of life. Kaplan-Meier (K-M) curve was performed for survival time.Serum level of HMGB1 in patients on HD was higher than PD. HMGB1 levels were gradually decreased with the treatment of HD or PD. Furthermore, HMGB1 was positively correlated with IL-6 and TNF-α. Moreover, patients with higher HMGB1 had more complications than patients with lower HMGB1, but there was no difference for the survival rate. In addition, the quality of life was associated with different dialysis methods.The serum level of HMGB1 and prognosis of ESRD patients was associated with different dialysis methods.


Assuntos
Proteína HMGB1/sangue , Falência Renal Crônica , Diálise Peritoneal , Qualidade de Vida , Diálise Renal , China/epidemiologia , Correlação de Dados , Feminino , Humanos , Interleucina-6/sangue , Estimativa de Kaplan-Meier , Falência Renal Crônica/sangue , Falência Renal Crônica/mortalidade , Falência Renal Crônica/psicologia , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Diálise Peritoneal/métodos , Diálise Peritoneal/estatística & dados numéricos , Prognóstico , Estudos Prospectivos , Diálise Renal/métodos , Diálise Renal/estatística & dados numéricos , Fator de Necrose Tumoral alfa/sangue
2.
Medicine (Baltimore) ; 100(7): e24474, 2021 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-33607778

RESUMO

ABSTRACT: Sepsis is a life-threatening condition, and serum lactate levels have been used to predict patient prognosis. Studies on serum lactate levels in patients undergoing regular hemodialysis who have sepsis are limited. This study aimed to determine the predictive value of serum lactate levels for sepsis-related mortality among patients who underwent last hemodialysis at three different times before admission to the emergency department (ED).This retrospective cohort study was conducted from January 2007 to December 2013 in southern Taiwan. All hemodialysis patients with sepsis, receiving antibiotics within 24 hours of sepsis confirmation, admitted for at least 3 days, and whose serum lactate levels were known were examined to determine the difference in the serum lactate levels of patients who underwent last hemodialysis within 4 hours (Groups A), in 4-12 hours (Group B), and beyond 12 hours (Group C) before visited to the ED. All the continuous variables, categorical variables and mortality were compared by using Kruskal-Wallis test or Mann-Whitney test, the χ2 or Fisher exact tests, and multiple logistic regression model, respectively.A total of 490 patients were enrolled in the study, and 8.0% (39), 21.5% (84), and 74.9% (367) of the patients were in Group A, Group B and Group C, respectively; the serum lactate levels (2.91 vs 2.13 vs 2.79 mmol/L, respectively; P = .175) and 28-day in-hospital mortality (17.9% vs 14.6% vs 22.9%) showed no statistically significant difference between 3 groups. The association between serum lactate levels and 28-day in-hospital mortality was reliable in Group B (P = .002) and Group C (P < .001), but it was unreliable in Group A (P = .629).Serum lactate level has acceptable sensitivity in predicting 28-day in-hospital mortality among patients with sepsis who undergo last hemodialysis after 4 hours, but is not reliable when the last hemodialysis takes place within 4 hours.


Assuntos
Falência Renal Crônica/sangue , Falência Renal Crônica/mortalidade , Ácido Láctico/sangue , Diálise Renal/estatística & dados numéricos , Sepse/sangue , Sepse/mortalidade , Idoso , Serviço Hospitalar de Emergência , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Curva ROC , Estudos Retrospectivos , Fatores de Tempo
5.
BMC Nephrol ; 22(1): 33, 2021 01 19.
Artigo em Inglês | MEDLINE | ID: mdl-33468081

RESUMO

BACKGROUND: The extent to which patients with End-stage renal disease (ESRD) are at a higher risk of COVID-19-related death is still unclear. Therefore, the aim of this study was to identify the ESRD patients at increased risk of COVID-19 -related death and its associated factors. METHODS: This retrospective cohort study was conducted on 74 patients with ESRD and 446 patients without ESRD hospitalized for COVID-19 in Alborz province, Iran, from Feb 20 2020 to Apr 26 2020. Data on demographic factors, medical history, Covid-19- related symptoms, and blood tests were obtained from the medical records of patients with confirmed COVID-19. We fitted univariable and multivariable Cox regression models to assess the association of underlying condition ESRD with the COVID-19 in-hospital mortality. Results were presented as crude and adjusted Hazard Ratios (HRs) and 95% confidence intervals (CIs). In the ESRD subgroup, demographic factors, medical history, symptoms, and blood parameters on the admission of survivors were compared with non-survivors to identify factors that might predict a high risk of mortality. RESULTS: COVID-19 patients with ESRD had in-hospital mortality of 37.8% compared to 11.9% for those without ESRD (P value < 0.001). After adjusting for confounding factors, age, sex, and comorbidities, ESRD patients were more likely to experience in-hospital mortality compared to non-ESRD patients (Adjusted HR (95% CI): 2.59 (1.55-4.32)). The Log-rank test revealed that there was a significant difference between the ESRD and non-ESRD groups in terms of the survival distribution (χ2 (1) = 21.18, P-value < 0.001). In the ESRD subgroup, compared to survivors, non-survivors were older, and more likely to present with lack of consciousness or O2 saturation less than 93%; they also had lower lymphocyte but higher neutrophil counts and AST concentration at the presentation (all p -values < 0.05). CONCLUSIONS: Our findings suggested that the presence of ESRD would be regarded as an important risk factor for mortality in COVID-19 patients, especially in those who are older than age 65 years and presented with a lack of consciousness or O2 saturation less than 93%.


Assuntos
/mortalidade , Mortalidade Hospitalar , Falência Renal Crônica/mortalidade , Fatores Etários , Idoso , /complicações , Comorbidade , Intervalos de Confiança , Feminino , Humanos , Irã (Geográfico)/epidemiologia , Falência Renal Crônica/sangue , Luteólise , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais
6.
JAMA Netw Open ; 4(1): e2034004, 2021 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-33443583

RESUMO

Importance: Kidney transplant is associated with improved survival and quality of life among patients with kidney failure; however, significant racial disparities have been noted in transplant access. Common equations that estimate glomerular filtration rate (eGFR) include adjustment for Black race; however, how inclusion of the race coefficient in common eGFR equations corresponds with measured GFR and whether it is associated with delayed eligibility for kidney transplant listing are unknown. Objective: To compare eGFR with measured GFR and evaluate the association between eGFR calculated with vs without a coefficient for race and time to eligibility for kidney transplant. Design, Setting, and Participants: This prospective cohort study used data from the Chronic Renal Insufficiency Cohort, a multicenter cohort study of participants with chronic kidney disease (CKD). Self-identified Black participants from that study were enrolled between April 2003 and September 2008, with follow-up through December 2018. Statistical analyses were completed on November 11, 2020. Exposure: Estimated GFR, measured annually and estimated using the creatinine-based Chronic Kidney Disease-Epidemiology (CKD-EPI) equation with and without a race coefficient. Main Outcomes and Measures: Iothalamate GFR (iGFR) measured in a subset of participants (n = 311) and time to achievement of an eGFR less than 20 mL/min/1.73 m2, an established threshold for kidney transplant referral and listing. Results: Among 1658 self-identified Black participants, mean (SD) age was 58 (11) years, 848 (51%) were female, and mean (SD) eGFR was 44 (15) mL/min/1.73 m2. The CKD-EPI eGFR with the race coefficient overestimated iGFR by a mean of 3.1 mL/min/1.73 m2 (95% CI, 2.2-3.9 mL/min/1.73 m2; P < .001). The mean difference between CKD-EPI eGFR without the race coefficient and iGFR was of smaller magnitude (-1.7 mL/min/1.73 m2; 95% CI, -2.5 to -0.9 mL/min/1.73 m2). For participants with an iGFR of 20 to 25 mL/min/1.73 m2, the mean difference in eGFR with vs without the race coefficient and iGFR was 5.1 mL/min/1.73 m2 (95% CI, 3.3-6.9 mL/min/1.73 m2) vs 1.3 mL/min/1.73 m2 (95% CI, -0.3 to 2.9 mL/min/1.73 m2). Over a median follow-up time of 4 years (interquartile range, 1-10 years), use of eGFR calculated without vs with the race coefficient was associated with a 35% (95% CI, 29%-41%) higher risk of achieving an eGFR less than 20 mL/min/1.73 m2 and a shorter median time to this end point of 1.9 years. Conclusions and Relevance: In this cohort study, inclusion of the race coefficient in the estimation of GFR was associated with greater bias in GFR estimation and with delayed achievement of a clinical threshold for kidney transplant referral and eligibility. These findings suggest that nephrologists and transplant programs should be cautious when using current estimating equations to determine kidney transplant eligibility.


Assuntos
Afro-Americanos , Definição da Elegibilidade , Taxa de Filtração Glomerular , Falência Renal Crônica/etnologia , Falência Renal Crônica/cirurgia , Transplante de Rim , Feminino , Humanos , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taxa de Sobrevida , Washington
7.
Support Care Cancer ; 29(1): 323-330, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32361829

RESUMO

INTRODUCTION: Patients with hematological malignancies (HM) require intensive chemotherapy with curative intent, especially in case of AML that results in more frequent admissions to Intensive Care Units (ICU). Due to our knowledge, this study is the first multicenter retrospective analysis in Polish population. METHODS: A total of 200 patients with HM hospitalized in 4 Polish hematological centers. Data concerning clinical indices and outcomes during admission and ICU stay were collected retrospectively. RESULTS: The most common hematological malignancy was acute leukemia (55%). The main cause of ICU admission was respiratory failure (88.5%), often accompanied by sepsis (58.5%) and acute renal failure (51.5%). In patients with hematological malignancies, the following factors were associated with ICU mortality: prolonged ICU stay (odd ratio [OR] = 6.98, 95% confidence interval [CI]: 1.38-35.33, χ2 = 5.61, p = 0.02), the presence of acute respiratory failure (odd ratio [OR] = 5.35, 95% confidence interval [CI]: 1.01-28.46, χ2 = 3.93, p = 0.04), and the need for renal replacement therapy (odd ratio [OR] = 8.75, 95% confidence interval [CI]: 1.23-62.11, χ2 = 4.78, p = 0.03). There were following associations with in-hospital mortality in patients with hematological malignancies: prolonged ICU stay (odd ratio [OR] = 10.12, 95% confidence interval [CI]: 1.85-55.37, χ2 = 7.21, p = 0.008), the presence of acute respiratory failure (odd ratio [OR] =5.24, 95% confidence interval [CI]: 1.36-20.16, χ2 = 5.87, p = 0.02), the need for catecholamine support (odd ratio [OR] =3.43, 95% confidence interval [CI]: 1.06-11.05, χ2 = 4.32, p = 0.04), and renal replacement therapy (odd ratio [OR] =5.55, 95% confidence interval [CI]: 1.14-26.92, χ2 = 4.59, p = 0.03). CONCLUSIONS: We have demonstrated that ICU and in-hospital mortalities among patients with hematological malignancies are still poor, but easier access to the intensive care unit and close cooperation between hematologists and intensivists may improve outcomes. We have found that acute failure of key organs (acute respiratory failure, end-stage renal failure requires renal replacement therapy) and length of ICU stay (but probably no comorbidities and illness severity) may have impact on mortality (both ICU and in-hospital).


Assuntos
Neoplasias Hematológicas/tratamento farmacológico , Neoplasias Hematológicas/mortalidade , Mortalidade Hospitalar , Leucemia Mieloide Aguda/tratamento farmacológico , Leucemia Mieloide Aguda/mortalidade , Lesão Renal Aguda/complicações , Lesão Renal Aguda/mortalidade , Adulto , Idoso , Antineoplásicos/uso terapêutico , Catecolaminas/uso terapêutico , Feminino , Hospitalização , Humanos , Unidades de Terapia Intensiva , Falência Renal Crônica/complicações , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Polônia , Terapia de Substituição Renal/estatística & dados numéricos , Insuficiência Respiratória/complicações , Estudos Retrospectivos , Sepse/complicações , Resultado do Tratamento
8.
Ren Fail ; 43(1): 49-57, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33307933

RESUMO

BACKGROUND: There is limited information about the clinical characteristics, treatment and outcome of maintenance hemodialysis patients with COVID-19. Moreover, regional differences are also conceivable since the extend and severity of outbreaks varied among countries. METHODS: In this retrospective, observational, single-center study, we analyzed the clinical course and outcomes of 37 maintenance hemodialysis patients (median age 64 years, 51% men) hospitalized with COVID-19 from 24 March to 22 May 2020 as confirmed by real-time PCR. RESULTS: The most common symptoms at admission were fatigue (51%), fever (43%), dyspnea (38%) and cough (35%). There were 59% mild/moderate patients and 41% severe/critical patients. Patients in the severe/critical group had a significantly higher atherosclerotic burden since diabetic kidney disease and vascular nephropathies were the most common primary kidney diseases and eighty percent of them had coronary heart disease. Also, Charlson comorbidity score was higher in this group. At admission chest X-ray, 46% had ground-glass abnormalities. Overall, 60% patients received hydroxychloroquine, 22% lopinavir-ritonavir, 11% tocilizumab, 24% systemic glucocorticoids, and 54% received prophylactic anticoagulation. Seven (19%) patients died during hospitalization and 30 were discharged. The main causes of death were cardiovascular (5 patients) and respiratory distress syndrome (2 patients). In Cox regression analysis, lower oxygen saturation, anemia and hypoalbuminemia at admission were associated with increased mortality. CONCLUSIONS: In conclusion, we observed a high mortality rate among maintenance hemodialysis patients hospitalized for COVID-19. Anemia, lower serum albumin and lower basal oxygen saturation at admission were factors associated with poor prognosis.


Assuntos
/mortalidade , Falência Renal Crônica/terapia , Diálise Renal , Idoso , /terapia , Causas de Morte , Comorbidade , Feminino , Mortalidade Hospitalar , Humanos , Falência Renal Crônica/sangue , Falência Renal Crônica/etiologia , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Admissão do Paciente , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Romênia/epidemiologia , Albumina Sérica Humana/análise , Índice de Gravidade de Doença
9.
Am J Physiol Renal Physiol ; 320(3): F249-F261, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33356957

RESUMO

Patients treated with hemodialysis (HD) repeatedly undergo intradialytic low arterial oxygen saturation and low central venous oxygen saturation, reflecting an imbalance between upper body systemic oxygen supply and demand, which are associated with increased mortality. Abnormalities along the entire oxygen cascade, with impaired diffusive and convective oxygen transport, contribute to the reduced tissue oxygen supply. HD treatment impairs pulmonary gas exchange and reduces ventilatory drive, whereas ultrafiltration can reduce tissue perfusion due to a decline in cardiac output. In addition to these factors, capillary rarefaction and reduced mitochondrial efficacy can further affect the balance between cellular oxygen supply and demand. Whereas it has been convincingly demonstrated that a reduced perfusion of heart and brain during HD contributes to organ damage, the significance of systemic hypoxia remains uncertain, although it may contribute to oxidative stress, systemic inflammation, and accelerated senescence. These abnormalities along the oxygen cascade of patients treated with HD appear to be diametrically opposite to the situation in Tibetan highlanders and Sherpa, whose physiology adapted to the inescapable hypobaric hypoxia of their living environment over many generations. Their adaptation includes pulmonary, vascular, and metabolic alterations with enhanced capillary density, nitric oxide production, and mitochondrial efficacy without oxidative stress. Improving the tissue oxygen supply in patients treated with HD depends primarily on preventing hemodynamic instability by increasing dialysis time/frequency or prescribing cool dialysis. Whether dietary or pharmacological interventions, such as the administration of L-arginine, fermented food, nitrate, nuclear factor erythroid 2-related factor 2 agonists, or prolyl hydroxylase 2 inhibitors, improve clinical outcome in patients treated with HD warrants future research.


Assuntos
Aclimatação , Altitude , Hipóxia/sangue , Falência Renal Crônica/terapia , Rim/fisiopatologia , Consumo de Oxigênio , Oxigênio/sangue , Diálise Renal , Animais , Biomarcadores/sangue , Hemodinâmica , Humanos , Hipóxia/mortalidade , Hipóxia/fisiopatologia , Hipóxia/prevenção & controle , Rim/metabolismo , Falência Renal Crônica/sangue , Falência Renal Crônica/mortalidade , Falência Renal Crônica/fisiopatologia , Diálise Renal/efeitos adversos , Diálise Renal/mortalidade , Fatores de Risco , Resultado do Tratamento
10.
Cochrane Database Syst Rev ; 12: CD004349, 2020 12 17.
Artigo em Inglês | MEDLINE | ID: mdl-33332584

RESUMO

BACKGROUND: This is the first update of this review first published in 2009. When treating elevated blood pressure, doctors usually try to achieve a blood pressure target. That target is the blood pressure value below which the optimal clinical benefit is supposedly obtained. "The lower the better" approach that guided the treatment of elevated blood pressure for many years was challenged during the last decade due to lack of evidence from randomised trials supporting that strategy. For that reason, the standard blood pressure target in clinical practice during the last years has been less than 140/90 mm Hg for the general population of patients with elevated blood pressure. However, new trials published in recent years have reintroduced the idea of trying to achieve lower blood pressure targets. Therefore, it is important to know whether the benefits outweigh harms when attempting to achieve targets lower than the standard target. OBJECTIVES: The primary objective was to determine if lower blood pressure targets (any target less than or equal to 135/85 mm Hg) are associated with reduction in mortality and morbidity as compared with standard blood pressure targets (less than or equal to 140/ 90 mm Hg) for the treatment of patients with chronic arterial hypertension. The secondary objectives were: to determine if there is a change in mean achieved systolic blood pressure (SBP) and diastolic blood pressure (DBP associated with "lower targets" as compared with "standard targets" in patients with chronic arterial hypertension; and to determine if there is a change in withdrawals due to adverse events with "lower targets" as compared with "standard targets", in patients with elevated blood pressure. SEARCH METHODS: The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to May 2019: the Cochrane Hypertension Specialised Register, CENTRAL (2019, Issue 4), Ovid MEDLINE, Ovid Embase, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing patients allocated to lower or to standard blood pressure targets (see above). DATA COLLECTION AND ANALYSIS: Two review authors (JAA, VL) independently assessed the included trials and extracted data. Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure, end stage renal disease, and other serious adverse events. Secondary outcomes were achieved mean SBP and DBP, withdrawals due to adverse effects, and mean number of antihypertensive drugs used. We assessed the risk of bias of each trial using the Cochrane risk of bias tool and the certainty of the evidence using the GRADE approach.  MAIN RESULTS: This update includes 11 RCTs involving 38,688 participants with a mean follow-up of 3.7 years. This represents 7 new RCTs compared with the original version. At baseline the mean weighted age was 63.1 years and the mean weighted blood pressure was 155/91 mm Hg. Lower targets do not reduce total mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.86 to 1.05; 11 trials, 38,688 participants; high-certainty evidence) and do not reduce total serious adverse events (RR 1.04, 95% CI 0.99 to 1.08; 6 trials, 18,165 participants; moderate-certainty evidence). This means that the benefits of lower targets do not outweigh the harms as compared to standard blood pressure targets. Lower targets may reduce myocardial infarction (RR 0.84, 95% CI 0.73 to 0.96; 6 trials, 18,938 participants, absolute risk reduction (ARR) 0.4%, number needed to treat to benefit (NNTB) 250 over 3.7 years) and congestive heart failure (RR 0.75, 95% CI 0.60 to 0.92; 5 trials, 15,859 participants, ARR 0.6%, NNTB  167 over 3.7 years) (low-certainty for both outcomes). Reduction in myocardial infarction and congestive heart failure was not reflected in total serious adverse events. This may be due to an increase in other serious adverse events (RR 1.44, 95% CI 1.32 to 1.59; 6 trials. 18,938 participants, absolute risk increase (ARI) 3%,  number needed to treat to harm (NNTH) 33 over four years) (low-certainty evidence). Participants assigned to a "lower" target received one additional antihypertensive medication and achieved a significantly lower mean SBP (122.8 mm Hg versus 135.0 mm Hg, and a lower mean DBP (82.0 mm Hg versus 85.2 mm Hg, than those assigned to "standard target". AUTHORS' CONCLUSIONS: For the general population of persons with elevated blood pressure, the benefits of trying to achieve a lower blood pressure target rather than a standard target (≤ 140/90 mm Hg) do not outweigh the harms associated with that intervention. Further research is needed to see if some groups of patients would benefit or be harmed by lower targets. The results of this review are primarily applicable to older people with moderate to high cardiovascular risk. They may not be applicable to other populations.


Assuntos
Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/fisiologia , Hipertensão/tratamento farmacológico , Viés , Doenças Cardiovasculares/mortalidade , Causas de Morte , Intervalos de Confiança , Diástole/fisiologia , Guias como Assunto , Insuficiência Cardíaca/prevenção & controle , Humanos , Hipertensão/mortalidade , Falência Renal Crônica/mortalidade , Pessoa de Meia-Idade , Infarto do Miocárdio/prevenção & controle , Números Necessários para Tratar , Ensaios Clínicos Controlados Aleatórios como Assunto , Valores de Referência , Acidente Vascular Cerebral/epidemiologia
11.
Cochrane Database Syst Rev ; 10: CD001892, 2020 10 29.
Artigo em Inglês | MEDLINE | ID: mdl-33118160

RESUMO

BACKGROUND: Chronic kidney disease (CKD) is defined as reduced function of the kidneys present for 3 months or longer with adverse implications for health and survival. For several decades low protein diets have been proposed for participants with CKD with the aim of slowing the progression to end-stage kidney disease (ESKD) and delaying the onset of renal replacement therapy. However the relative benefits and harms of dietary protein restriction for preventing progression of CKD have not been resolved. This is an update of a systematic review first published in 2000 and updated in 2006, 2009 and 2018. OBJECTIVES: To determine the efficacy of low protein diets in preventing the natural progression of CKD towards ESKD and in delaying the need for commencing dialysis treatment in non-diabetic adults. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 7 September 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi RCTs in which adults with non-diabetic CKD (stages 3 to 5) not on dialysis were randomised to receive a very low protein intake (0.3 to 0.4 g/kg/day) compared with a low protein intake (0.5 to 0.6 g/kg/day) or a low protein intake compared with a normal protein intake (≥ 0.8 g/kg/day) for 12 months or more. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies and extracted data. For dichotomous outcomes (death, all causes), requirement for dialysis, adverse effects) the risk ratios (RR) with 95% confidence intervals (CI) were calculated and summary statistics estimated using the random effects model. Where continuous scales of measurement were used (glomerular filtration rate (GFR), weight), these data were analysed as the mean difference (MD) or standardised mean difference (SMD) if different scales had been used. The certainty of the evidence was assessed using GRADE. MAIN RESULTS: We identified 17 studies with 2996 analysed participants (range 19 to 840). Four larger multicentre studies were subdivided according to interventions so that the review included 21 separate data sets. Mean duration of participant follow-up ranged from 12 to 50 months. Random sequence generation and allocation concealment were considered at low risk of bias in eleven and nine studies respectively. All studies were considered at high risk for performance bias as they were open-label studies. We assessed detection bias for outcome assessment for GFR and ESKD separately. As GFR measurement was a laboratory outcome all studies were assessed at low risk of detection bias. For ESKD, nine studies were at low risk of detection bias as the need to commence dialysis was determined by personnel independent of the study investigators. Five studies were assessed at high risk of attrition bias with eleven studies at low risk. Ten studies were at high risk for reporting bias as they did not include data which could be included in a meta-analysis. Eight studies reported funding from government bodies while the remainder did not report on funding. Ten studies compared a low protein diet with a normal protein diet in participants with CKD categories 3a and b (9 studies) or 4 (one study). There was probably little or no difference in the numbers of participants who died (5 studies 1680 participants: RR 0.77, 95% CI 0.51 to 1.18; 13 fewer deaths per 1000; moderate certainty evidence). A low protein diet may make little or no difference in the number of participants who reached ESKD compared with a normal protein diet (6 studies, 1814 participants: RR 1.05, 95% CI 0.73 to 1.53; 7 more per 1000 reached ESKD; low certainty evidence). It remains uncertain whether a low protein diet compared with a normal protein intake impacts on the outcome of final or change in GFR (8 studies, 1680 participants: SMD -0.18, 95% CI -0.75 to 0.38; very low certainty evidence). Eight studies compared a very low protein diet with a low protein diet and two studies compared a very low protein diet with a normal protein diet. A very low protein intake compared with a low protein intake probably made little or no difference to death (6 studies, 681 participants: RR 1.26, 95% CI 0.62 to 2.54; 10 more deaths per 1000; moderate certainty evidence). However it probably reduces the number who reach ESKD (10 studies, 1010 participants: RR 0.65, 95% CI 0.49 to 0.85; 165 per 1000 fewer reached ESKD; moderate certainty evidence). It remains uncertain whether a very low protein diet compared with a low or normal protein intake influences the final or change in GFR (6 studies, 456 participants: SMD 0.12, 95% CI -0.27 to 0.52; very low certainty evidence). Final body weight was reported in only three studies. It is uncertain whether the intervention alters final body weight (3 studies, 89 participants: MD -0.40 kg, 95% CI -6.33 to 5.52; very low certainty evidence).Twelve studies reported no evidence of protein energy wasting (malnutrition) in their study participants while three studies reported small numbers of participants in each group with protein energy wasting. Most studies reported that adherence to diet was satisfactory. Quality of life was not formally assessed in any studies. AUTHORS' CONCLUSIONS: This review found that very low protein diets probably reduce the number of people with CKD 4 or 5, who progress to ESKD. In contrast low protein diets may make little difference to the number of people who progress to ESKD. Low or very low protein diets probably do not influence death. However there are limited data on adverse effects such as weight differences and protein energy wasting. There are no data on whether quality of life is impacted by difficulties in adhering to protein restriction. Studies evaluating the adverse effects and the impact on quality of life of dietary protein restriction are required before these dietary approaches can be recommended for widespread use.


Assuntos
Dieta com Restrição de Proteínas , Progressão da Doença , Falência Renal Crônica/dietoterapia , Falência Renal Crônica/prevenção & controle , Adulto , Viés , Causas de Morte , Doença Crônica , Taxa de Filtração Glomerular , Humanos , Falência Renal Crônica/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto
12.
N Engl J Med ; 383(15): 1436-1446, 2020 10 08.
Artigo em Inglês | MEDLINE | ID: mdl-32970396

RESUMO

BACKGROUND: Patients with chronic kidney disease have a high risk of adverse kidney and cardiovascular outcomes. The effect of dapagliflozin in patients with chronic kidney disease, with or without type 2 diabetes, is not known. METHODS: We randomly assigned 4304 participants with an estimated glomerular filtration rate (GFR) of 25 to 75 ml per minute per 1.73 m2 of body-surface area and a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of 200 to 5000 to receive dapagliflozin (10 mg once daily) or placebo. The primary outcome was a composite of a sustained decline in the estimated GFR of at least 50%, end-stage kidney disease, or death from renal or cardiovascular causes. RESULTS: The independent data monitoring committee recommended stopping the trial because of efficacy. Over a median of 2.4 years, a primary outcome event occurred in 197 of 2152 participants (9.2%) in the dapagliflozin group and 312 of 2152 participants (14.5%) in the placebo group (hazard ratio, 0.61; 95% confidence interval [CI], 0.51 to 0.72; P<0.001; number needed to treat to prevent one primary outcome event, 19 [95% CI, 15 to 27]). The hazard ratio for the composite of a sustained decline in the estimated GFR of at least 50%, end-stage kidney disease, or death from renal causes was 0.56 (95% CI, 0.45 to 0.68; P<0.001), and the hazard ratio for the composite of death from cardiovascular causes or hospitalization for heart failure was 0.71 (95% CI, 0.55 to 0.92; P = 0.009). Death occurred in 101 participants (4.7%) in the dapagliflozin group and 146 participants (6.8%) in the placebo group (hazard ratio, 0.69; 95% CI, 0.53 to 0.88; P = 0.004). The effects of dapagliflozin were similar in participants with type 2 diabetes and in those without type 2 diabetes. The known safety profile of dapagliflozin was confirmed. CONCLUSIONS: Among patients with chronic kidney disease, regardless of the presence or absence of diabetes, the risk of a composite of a sustained decline in the estimated GFR of at least 50%, end-stage kidney disease, or death from renal or cardiovascular causes was significantly lower with dapagliflozin than with placebo. (Funded by AstraZeneca; DAPA-CKD ClinicalTrials.gov number, NCT03036150.).


Assuntos
Compostos Benzidrílicos/uso terapêutico , Taxa de Filtração Glomerular/efeitos dos fármacos , Glucosídeos/uso terapêutico , Insuficiência Renal Crônica/tratamento farmacológico , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Idoso , Compostos Benzidrílicos/efeitos adversos , Compostos Benzidrílicos/farmacologia , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/prevenção & controle , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/tratamento farmacológico , Nefropatias Diabéticas/tratamento farmacológico , Feminino , Glucosídeos/efeitos adversos , Glucosídeos/farmacologia , Humanos , Estimativa de Kaplan-Meier , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Insuficiência Renal Crônica/complicações , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos , Inibidores do Transportador 2 de Sódio-Glicose/farmacologia
13.
Nephrol Dial Transplant ; 35(7): 1244-1249, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-32777080

RESUMO

BACKGROUND: No prospective study has evaluated the long-term effect on mortality of the new acid concentrates added to bicarbonate dialysate. The aim of this pharmacoepidemiological study was to evaluate the association between hydrochloric or citric acid-based dialysate and mortality on haemodialysis (HD). METHODS: This study included 117 796 patients with 3 723 887 months on HD recorded in the national French Renal Epidemiology and Information Network registry. Dialysate acid components were retrospectively reconstructed for each facility. All patients on HD were associated each month with an exposure based on that at their facility of treatment. We took each patient's time-varying exposure into account to calculate the monthly mortality rates for each exposure. Incidence rate ratios (IRRs) for mortality were calculated with a Poisson regression, with acetic acid as the reference. Regressions were adjusted for initial clinical characteristics (age, gender, previous cardiovascular events, active malignancy, diabetes, pulmonary disease, mobility), dialysis technique and location (in-centre, outpatient centre, self-care unit) and ESRD vintage, updated monthly. RESULTS: The crude mortality rate per 1000 patient-months with citric acid {11.5 [95% confidence interval (CI) 11.1-12.0]} was lower than with either acetic acid [12.9 (95% CI 12.8-13.1)] or hydrochloric acid [12.8 (95% CI 12.2-13.5)]. For the 2014-17 period, the IRR for mortality with citric acid [adjusted IRR 0.94 (95% CI 0.90-0.99)] and with hydrochloric acid [adjusted IRR 0.86 (95% CI 0.79-0.94)] were significantly lower than with acetic acid. CONCLUSION: This post-marketing study of long-term exposure to dialysate acidifiers at the patient level found the use of citric and hydrochloric acid-based dialysates, compared with acetic acid, was associated with lower mortality.


Assuntos
Ácido Acético/farmacologia , Bicarbonatos/farmacologia , Ácido Cítrico/farmacologia , Ácido Clorídrico/farmacologia , Falência Renal Crônica/mortalidade , Diálise Renal/mortalidade , Terapia de Substituição Renal/mortalidade , Idoso , Antibacterianos/farmacologia , Tampões (Química) , Quelantes de Cálcio/farmacologia , Soluções para Diálise/farmacologia , Feminino , França/epidemiologia , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/terapia , Masculino , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
15.
Transplantation ; 104(8): e236-e242, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732842

RESUMO

BACKGROUND: Proper care of young children in need of kidney transplant (KT) requires many skilled professionals and an expensive hospital structure. Small children have lesser access to KT. METHODS: We describe a strategy performed in Brazil to enable and accelerate KT in children ≤15 kg based on the establishment of one specialized transplant center, focused on small children, and cooperating with distant centers throughout the country. Actions on 3 fronts were implemented: (a) providing excellent medical assistance, (b) coordinating educational activities to disseminate expertise and establish a professional network, and (c) fostering research to promote scientific knowledge. We presented the number and outcomes of small children KT as a result of this strategy. RESULTS: Three hundred forty-six pediatric KTs were performed in the specialized center from 2009 to 2017, being 130 in children ≤15 kg (38%, being 41 children ≤10 kg) and 216 in >15 kg (62%). Patient survival after 1 and 5 years of the transplant was 97% and 95% in the "small children" group, whereas, in the "heavier children" group, it was 99% and 96% (P = 0.923). Regarding graft survival, we observed in the "small children" group, 91% and 87%, whereas in the "heavier children" group, 94% and 87% (P = 0.873). These results are comparable to the literature data. Groups were similar in the incidence of reoperation, vascular thrombosis, posttransplant lymphoproliferative disease, and estimated glomerular filtration rate. CONCLUSIONS: The strategy allowed an improvement in the number of KT in small children with excellent results. We believe this experience may be useful in other locations.


Assuntos
Rejeição de Enxerto/epidemiologia , Hospitais Pediátricos/organização & administração , Falência Renal Crônica/cirurgia , Transplante de Rim/estatística & dados numéricos , Tempo para o Tratamento/organização & administração , Adolescente , Peso Corporal/fisiologia , Brasil/epidemiologia , Criança , Pré-Escolar , Feminino , Seguimentos , Taxa de Filtração Glomerular/fisiologia , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/fisiopatologia , Sobrevivência de Enxerto/fisiologia , Implementação de Plano de Saúde , Acesso aos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Incidência , Falência Renal Crônica/mortalidade , Falência Renal Crônica/fisiopatologia , Transplante de Rim/efeitos adversos , Masculino , Avaliação de Programas e Projetos de Saúde , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento
16.
Transplantation ; 104(8): 1654-1661, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732844

RESUMO

BACKGROUND: In the United Kingdom, 1 in 3 patients on the National Kidney Transplant Waiting List (NKTWL) is suspended from the list at least once during their wait. The mortality of this large cohort of patients remains underreported and poorly described. METHODS: We linked patient records from the UK transplant registry to mortality data from the Office of National Statistics and evaluated the impact of a clinically induced suspension event by estimating hazard ratios (HRs) that compared mortality and graft survival between those who had experienced a suspension event and those who had not. RESULTS: Between January 1, 2000, and December 31, 2010, 16.7% (2221/13 322) of all patients registered on the NKTWL were suspended. Forty-eight percent (588/1225) of those who were suspended and who were never transplanted died, most often from cardiothoracic causes. A suspension event was associated with increased mortality from the time of listing (adjusted HR [aHR], 1.79; 1.64-1.95) and from the time of transplantation (aHR, 1.20; 1.06-1.37; P = 0.005). Graft survival was also poorer in those who had been suspended (aHR, 1.13; 1.01-1.28; P = 0.04). CONCLUSIONS: Patients suspended on the NKTWL have a significantly higher rate of mortality both on the waiting list and following transplantation. Earlier prioritization of patients at risk of experiencing a suspension event may improve their outcomes.


Assuntos
Rejeição de Enxerto/epidemiologia , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Seleção de Pacientes , Listas de Espera/mortalidade , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Rejeição de Enxerto/etiologia , Humanos , Estimativa de Kaplan-Meier , Falência Renal Crônica/mortalidade , Transplante de Rim/normas , Transplante de Rim/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Sistema de Registros/estatística & dados numéricos , Alocação de Recursos/normas , Alocação de Recursos/estatística & dados numéricos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Resultado do Tratamento , Reino Unido/epidemiologia , Adulto Jovem
17.
Transplantation ; 104(8): 1703-1711, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732850

RESUMO

BACKGROUND: There are limited data on the outcome of transplant recipients with familial Mediterranean fever (FMF)-associated AA amyloidosis. The aim of the present study is to evaluate demographic, clinical, laboratory, and prognostic characteristics and outcome measures of these patients. METHODS: Eighty-one renal transplant recipients with FMF-associated AA amyloidosis (group 1) and propensity score-matched transplant recipients (group 2, n = 81) with nonamyloidosis etiologies were evaluated in this retrospective, multicenter study. Recurrence of AA amyloidosis was diagnosed in 21 patients (group 1a), and their features were compared with 21 propensity score-matched recipients with FMF amyloidosis with no laboratory signs of recurrence (group 1b). RESULTS: The risk of overall allograft loss was higher in group 1 compared with group 2 (25 [30.9%] versus 12 [14.8%]; P = 0.015 [hazard ratio, 2.083; 95% confidence interval, 1.126-3.856]). Patients in group 1 were characterized by an increased risk of mortality compared with group 2 (11 [13.6%] versus 0%; P = 0.001 [hazard ratio, 1.136; 95% confidence interval, 1.058-1.207]). Kaplan-Meier analysis revealed that 5- and 10-year patient survival rates in group 1 (92.5% and 70.4%) were significantly lower than in group 2 (100% and 100%; P = 0.026 and P = 0.023, respectively). Although not reaching significance, overall, 5- and 10-year graft survival rates (57.1%, 94.7%, and 53.8%, respectively) in group 1a were worse than in group 1b (76.2%, 95%, and 77.8%, respectively; P = 0.19, P = 0.95, and P = 0.27, respectively). CONCLUSIONS: AA amyloidosis is associated with higher risk of mortality after kidney transplantation. Inflammatory indicators should be monitored closely, and persistent high levels of acute-phase reactants should raise concerns about amyloid recurrence in allograft.


Assuntos
Amiloidose/cirurgia , Febre Familiar do Mediterrâneo/complicações , Rejeição de Enxerto/mortalidade , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Adulto , Aloenxertos/imunologia , Aloenxertos/patologia , Amiloidose/imunologia , Amiloidose/mortalidade , Amiloidose/patologia , Biópsia , Febre Familiar do Mediterrâneo/imunologia , Febre Familiar do Mediterrâneo/mortalidade , Febre Familiar do Mediterrâneo/cirurgia , Feminino , Seguimentos , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/patologia , Sobrevivência de Enxerto/imunologia , Humanos , Estimativa de Kaplan-Meier , Rim/imunologia , Rim/patologia , Falência Renal Crônica/imunologia , Falência Renal Crônica/mortalidade , Falência Renal Crônica/patologia , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Proteína Amiloide A Sérica/imunologia , Proteína Amiloide A Sérica/metabolismo , Taxa de Sobrevida , Resultado do Tratamento , Adulto Jovem
18.
Transplantation ; 104(8): 1738-1745, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732854

RESUMO

BACKGROUND: Falls occur in 28% of hemodialysis patients and increase the risk of physical impairment, morbidity, and mortality. Therefore, it is likely that kidney transplantation (KT) candidates with recurrent falls are less likely to access KT and more likely to experience adverse post-KT outcomes. METHODS: We used a 2-center cohort study of KT candidates (n = 3666) and recipients (n = 770) (January 2009 to January 2018). Among candidates, we estimated time to listing, waitlist mortality, and transplant rate by recurrent falls (≥2 falls) before evaluation using adjusted regression. Among KT recipients, we estimated risk of mortality, graft loss, and length of stay by recurrent falls before KT using adjusted regression. RESULTS: Candidates with recurrent falls (6.5%) had a lower chance of listing (adjusted hazard ratio [aHR] = 0.68, 95% confidence interval [CI], 0.56-0.83) but not transplant rate; waitlist mortality was 31-fold (95% CI, 11.33-85.93) higher in the first year and gradually decreased over time. Recipients with recurrent falls (5.1%) were at increased risk of mortality (aHR = 51.43, 95% CI, 16.00-165.43) and graft loss (aHR = 33.57, 95% CI, 11.25-100.21) in the first year, which declined over time, and a longer length of stay (adjusted relative ratio [aRR] = 1.13, 95% CI, 1.03-1.25). In summary, 6.5% of KT candidates and 5.1% of recipients experienced recurrent falls which were associated with adverse pre- and post-KT outcomes. CONCLUSIONS: While recurrent falls were relatively rare in KT candidates and recipients, they were associated with adverse outcomes. Transplant centers should consider employing fall prevention strategies for high-risk candidates as part of comprehensive prehabilitation.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Rejeição de Enxerto/epidemiologia , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Acidentes por Quedas/prevenção & controle , Adulto , Idoso , Feminino , Seguimentos , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/mortalidade , Transplante de Rim/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Recidiva , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Transplantados/estatística & dados numéricos , Resultado do Tratamento , Listas de Espera/mortalidade
19.
Transplantation ; 104(8): 1746-1751, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732855

RESUMO

BACKGROUND: The impact of renal transplantation (RT) in the elderly with many comorbid conditions is a matter of concern. The aim of our study was to assess the impact of RT on the survival of patients older than 60 years compared with those remaining on the waiting list (WL) according to their comorbidities. METHODS: In this multicentric observational retrospective cohort study, we included all patients older than 60 years old admitted on the WL from 01 January 2006 to 31 December 2016. The Charlson comorbidity index (CCI) score was calculated for each patient at inclusion on the WL. Kidney donor risk index was used to assess donor characteristics. RESULTS: One thousand and thirty-six patients were included on the WL of which 371 (36%) received an RT during a median follow-up period of 2.5 (1.4-4.1) years. Patient survival was higher after RT compared to patients remaining on the WL, 87%, 80%, and 72% versus 87%, 55%, and 30% at 1, 3, and 5 years, respectively. After RT survival at 5 years was 37% higher for patients with CCI ≥ 3, and 46% higher in those with CCI < 3, compared with patients remaining on the WL. On univariate and multivariate analysis, patient survival was independently associated with a CCI of ≥3 (hazard ratio 1.62; confidence interval 1.09-2.41; P < 0.02) and the use of calcineurin-based therapy maintenance therapy (hazard ratio 0.53; confidence interval 0.34-0.82; P < 0.004). CONCLUSIONS: Our study showed that RT improved survival in patients older than 60 years even those with high comorbidities. The survival after transplantation was also affected by comorbidities.


Assuntos
Falência Renal Crônica/terapia , Transplante de Rim/estatística & dados numéricos , Diálise Renal/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Argentina/epidemiologia , Causas de Morte , Comorbidade , Feminino , Seguimentos , Humanos , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento , Listas de Espera/mortalidade
20.
PLoS One ; 15(8): e0238029, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32857782

RESUMO

BACKGROUND: This study analyzed the survival and protective predictors of in-hospital cardiopulmonary cerebral resuscitation (CPCR) to potentially help physicians create effective treatment plans for End-stage kidney disease (ESKD) patients. METHODS: We extracted the data of 7,116 ESKD patients who received their first in-hospital CPCR after initial dialysis between 2004 and 2012 from the National Health Insurance Research Database. The primary outcome was the survival rate during the first in-hospital CPCR. The secondary outcome was the median post-discharge survival. RESULTS: From 2004 through 2012, the incidence of in-hospital CPCR decreases from 3.97 to 3.67 events per 1,000 admission days (P for linear trend <0.001). The survival rate for the first in-hospital CPCR did not change significantly across the 9 years (P for trend = 0.244), whereas the median survival of post-discharge survival increased significantly from 3.0 months in 2004 to 6.8 months in 2011 (P for linear trend <0.001). In addition, multivariable analysis identified older age as a risk factor and prior intracardiac defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) implantation as a protective factor for in-hospital death during the first in-hospital CPCR. CONCLUSION: The incidence of in-hospital CPCR and the duration post-discharge among ESKD patients improved despite there being no significant difference in the survival rate of ESKD patients after CPCP. Either ICD or CRT-D implantation may be advisable for ESKD patients with a high risk of sudden cardiac death.


Assuntos
Reanimação Cardiopulmonar/estatística & dados numéricos , Falência Renal Crônica/patologia , Fatores Etários , Idoso , Comorbidade , Bases de Dados Factuais , Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Feminino , Hospitais , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Razão de Chances , Diálise Renal , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
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