Hospitalization and mortality during the pandemic in chronic hemodialysis patients and the general population in Peru / Hospitalização e mortalidade durante a pandemia em pacientes em hemodiálise crônica e na população em geral no Peru

ABSTRACT Background: Patients with chronic kidney disease have a higher risk of severe disease and mortality from COVID-19 than the general population. Objective: To compare hospitalization and mortality rates during the pandemic among chronic hemodialysis (HD) patients and the general population in Lima (Peru). Methods: This retrospective cohort included an assessment of the database of chronic HD patients of the health service providers of the social health insurance benefit networks of Lima and Callao between 2019 and 2021. Hospitalization and mortality rates were obtained for every 1,000 individuals, and variations in the percentages of COVID-19 cases and deaths were calculated. These rates were compared with those of the general population data and standardized by age and sex. Results: An average of 3,937 chronic HD patients were evaluated each month. Of these, 4.8% had COVID-19 and 64.97% were mild cases. The hospitalization rates per 1,000 patients were 19.5, 29.28, and 36.7 in 2019, 2020, and 2021, respectively. The mortality rates per 1,000 patients were 5.9, 9.74, and 11.49 in 2019, 2020, and 2021, respectively. When compared to the standardized general population, the peaks of both rates coincided with the plateaus of the waves during the pandemic. The hospitalization rate for COVID-19 was 12 times higher in HD patients than in the general population, and the mortality rate for COVID-19 was twice as high. Conclusion: HD patients had higher hospitalization and standardized mortality rates than the general population. Peaks in hospitalizations and mortality coincided with the plateaus of the first and second waves of the pandemic.

Resumo Histórico: Pacientes com DRC apresentam maior risco de doença grave e mortalidade por COVID-19 do que a população geral. Objetivo: Comparar taxas de hospitalização e mortalidade durante a pandemia entre pacientes em hemodiálise crônica (HD) e a população geral em Lima (Peru). Métodos: Esta coorte retrospectiva incluiu avaliação do banco de dados de pacientes em HD crônica dos prestadores de serviços de saúde das redes de benefícios do seguro social de saúde de Lima e Callao, entre 2019-2021. Obteve-se taxas de hospitalização e mortalidade para cada 1.000 indivíduos, e foram calculadas variações nas porcentagens de casos de COVID-19 e óbitos. Estas taxas foram comparadas com os dados da população geral e padronizadas por idade e sexo. Resultados: Uma média de 3.937 pacientes em HD crônica foram avaliados mensalmente. Destes, 4,8% tinham COVID-19, 64,97% eram casos leves. As taxas de hospitalização por 1.000 pacientes foram 19,5; 29,28; e 36,7 em 2019, 2020, e 2021, respectivamente. As taxas de mortalidade por 1.000 pacientes foram 5,9; 9,74 e 11,49 em 2019, 2020, e 2021, respectivamente. Quando comparados à população geral padronizada, os picos das taxas coincidiram com os platôs das ondas da pandemia. A taxa de hospitalização para COVID-19 foi 12 vezes maior em pacientes em HD do que na população geral e a taxa de mortalidade por COVID-19 foi duas vezes maior. Conclusão: Pacientes em HD apresentaram taxas de hospitalização e mortalidade padronizada mais elevadas do que a população geral. Os picos das hospitalizações e mortalidade coincidiram com os platôs da primeira e segunda ondas da pandemia.

Performance of the CKD-EPI and MDRD equations for estimating glomerular filtration rate: a systematic review of Latin American studies

ABSTRACT BACKGROUND: The most-used equations for estimating the glomerular filtration rate (GFR) are the CKD Epidemiology Collaboration (CKD-EPI) and Modification of Diet in Renal Disease (MDRD) equations. However, it is unclear which of these shows better performance in Latin America. OBJECTIVE: To assess the performance of two equations for estimated GFR (eGFR) in Latin American countries. DESIGN AND SETTING: Systematic review and meta-analysis in Latin American countries. METHODS: We searched in three databases to identify studies that reported eGFR using both equations and compared them with measured GFR (mGFR) using exogenous filtration markers, among adults in Latin American countries. We performed meta-analyses on P30, bias (using mean difference [MD] and 95% confidence intervals [95% CI]), sensitivity and specificity; and evaluated the certainty of evidence using the GRADE methodology. RESULTS: We included 12 papers, and meta-analyzed six (five from Brazil and one from Mexico). Meta-analyses that compared CKD-EPI using creatinine measured with calibration traceable to isotope dilution mass spectrometry (CKD-EPI-Cr IDMS) and using MDRD-4 IDMS did not show differences in bias (MD: 0.55 ml/min/1.73m2; 95% CI: -3.34 to 4.43), P30 (MD: 4%; 95% CI: -2% to 11%), sensitivity (76% and 75%) and specificity (91% and 89%), with very low certainty of evidence for bias and P30, and low certainty of evidence for sensitivity and specificity. CONCLUSION: We found that the performances of CKD-EPI-Cr IDMS and MDRD-4 IDMS did not differ significantly. However, since most of the meta-analyzed studies were from Brazil, the results cannot be extrapolated to other Latin American countries. REGISTRATION: PROSPERO (CRD42019123434) - https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019123434.

Possible association between dysnatremias and mortality during hospitalization in patients undergoing acute hemodialysis: analysis from a Peruvian retrospective cohort / Possível associação entre distúrbios do sódio e mortalidade hospitalar em pacientes submetidos a hemodiálise aguda: análise de uma coorte retrospectiva peruana

Abstract Objective: To evaluate the association between dysnatremias or dyschloremias and mortality during hospitalization in patients with acute kidney injury (AKI) or chronic kidney disease (CKD) undergoing acute hemodialysis. Methods: We carried out a retrospective cohort study on adult patients undergoing acute hemodialysis with AKI or CKD diagnosis at a public hospital in Lima, Peru. Dysnatremias were categorized as hyponatremia (Na < 135mmol/L) or hypernatremia (Na > 145mmol/L), and dyschloremias were defined as hypochloremia (Cl < 98 mmol/L) or hyperchloremia (Cl > 109mmol/L). The outcome of interest was mortality during hospitalization. We performed generalized lineal Poisson family models with bias-corrected and accelerated non-parametric bootstrap to estimate the risk ratios at crude (RR) and adjusted analysis (aRR) by gender, age, HCO3 (for all patients) and Liaño score (only for AKI) with CI95%. Results: We included 263 patients (mean age: 54.3 years, females: 43%): 191 with CKD and 72 with AKI. Mortality was higher in patients with AKI (59.7%) than in patients with CKD (14.1%). In overall, patients with hypernatremia had a higher mortality during hospitalization compared to those who had normal sodium values (aRR: 1.82, 95% CI: 1.17-2.83); patients with hyponatremia did not have different mortality (aRR: 0.19, 95% CI: 0.69-2.04). We also found that hyperchloremia (aRR: 1.35, 95% CI: 0.83-2.18) or hypochloremia (aRR: 0.66, 95% CI: 0.30-14.78) did not increase mortality in comparison to normal chloride values. No association between dysnatremias or dyschloremias and mortality during hospitalization was found in CKD and AKI subgroups. Conclusions: In our exploratory analysis, only hypernatremia was associated with mortality during hospitalization among patients with AKI or CKD undergoing acute hemodialysis.

Resumo Objetivo: Avaliar a associação entre distúrbios do sódio ou do cloro e mortalidade hospitalar de pacientes com insuficiência renal aguda (IRA) ou doença renal crônica (DRC) submetidos a hemodiálise aguda. Métodos: O presente estudo de coorte retrospectiva incluiu pacientes adultos submetidos a hemodiálise aguda com diagnóstico de IRA ou DRC em um hospital público de Lima, Peru. Os distúrbios do sódio foram classificados como hiponatremia (Na < 135mmol/L) ou hipernatremia (Na > 145mmol/L), enquanto os distúrbios do cloro foram classificados como hipocloremia (Cl < 98 mmol/L) ou hipercloremia (Cl > 109mmol/L). O desfecho de interesse foi mortalidade hospitalar. Utilizamos modelos de Poisson da família de modelos lineares generalizados com bootstrap não-paramétrico e correção de viés acelerado para estimar os riscos relativos na análise bruta (RR) e ajustada (RRa) para sexo, idade, HCO3 (para todos os pacientes) e escore de Liaño (apenas para IRA) com IC 95%. Resultados: Foram incluídos 263 pacientes (idade média 54,3 anos; 43% do sexo feminino), 191 com DRC e 72 com IRA. A mortalidade foi mais elevada nos pacientes com IRA (59,7%) do que nos indivíduos com DRC (14,1%). No geral, os pacientes com hipernatremia tiveram mortalidade hospitalar mais elevada do que os indivíduos com valores normais de sódio (RRa: 1,82; IC 95%: 1,17-2,83). Os pacientes com hiponatremia não apresentaram mortalidade diferente (RRa: 0,19; IC 95%: 0,69-2,04). Também identificamos que hipercloremia (RRa: 1,35; IC 95%: 0,83-2,18) e hipocloremia (RRa: 0,66; IC 95%: 0,30-14,78) não elevaram a mortalidade em comparação a indivíduos com níveis normais de cloro. Não foi encontrada associação entre distúrbios do sódio ou do cloro e mortalidade hospitalar nos subgrupos com DRC e IRA. Conclusões: Em nossa análise exploratória, apenas hipernatremia apresentou associação com mortalidade hospitalar em pacientes com IRA ou DRC submetidos a hemodiálise aguda.

Número de nefrólogos, servicios de hemodiálisis y tendencia de la prevalencia de enfermedad renal crónica en el Ministerio de Salud de Perú / Number of nephrologists, hemodialysis services, and prevalence trend of chronic kidney disease in the ministry of health of Peru

RESUMEN Realizamos un estudio descriptivo y ecológico que evaluó la relación entre la tendencia de la prevalencia de pacientes con enfermedad renal crónica (ERC), con el número de nefrólogos y con el número de servicios de hemodiálisis del Ministerio de salud (MINSA). El estudio se basó en un análisis secundario de las atenciones del MINSA, del Observatorio de Recursos Humanos en Salud y de los servicios de hemodiálisis registrados como Instituciones Prestadoras de Servicio de Salud del Fondo Intangible Solidario de Salud (FISSAL). Se encontró que la prevalencia ajustada de la ERC se incrementó de 0,5 a 1,5 por cada 1000 pacientes entre el 2010 y 2017, respectivamente. Las regiones con mayor incremento fueron Tumbes, Ucayali y Piura. La cantidad de nefrólogos por cada 1000 pacientes con ERC disminuyó de 4,4 en el 2010 a 1,9 en el 2016 y los servicios de hemodiálisis contratados por el FISSAL se incrementaron de 16 en el 2012 a 74 en el 2019.

ABTSRACT We conducted a descriptive and ecological study that evaluated the relationship between the prevalence trend of patients with chronic kidney disease (CKD), the number of nephrologists, and the number of hemodialysis services of the Ministry of Health (MINSA). The study was based on a secondary analysis of the care provided by MINSA, the Observatory of Human Resources in Health, and the hemodialysis services registered as Health Service Providers of the Intangible Health Solidarity Fund (FISSAL, in Spanish). The adjusted prevalence of CKD was found to have increased from 0.5 to 1.5 per 1,000 patients between 2010 and 2017. The regions with the greatest increase were Tumbes, Ucayali, and Piura. The number of nephrologists per 1,000 CKD patients decreased from 4.4 in 2010 to 1.9 in 2016; and the hemodialysis services contracted by FISSAL increased from 16 in 2012 to 74 in 2019.

Recaída de enfermedad entre pacientes hispanos lúpicos con enfermedad renal crónica en hemodiálisis. Presentación de casos / Relapse of disease among lupus Hispanic patients with chronic kidney disease treated with hemodialysis. Case Presentations

Introducción: Los pacientes con lupus eritematoso sistémico (LES) presentan una disminución de la actividad de la enfermedad cuando evoluciona a una enfermedad renal crónica (ERC). Se han publicado recaídas de LES en esta etapa en diferentes grupos étnicos, aunque no pacientes hispanos, tradicionalmente asociados a peor pronóstico. Objetivo: Describir los casos de pacientes con ERC en hemodiálisis con diagnóstico de recaída de la enfermedad. Presentación de casos: Se presentan 4 casos, 2 varones y 2 mujeres con una edad promedio de 28 años. Tuvieron un promedio de score de SLEDAI sin criterios renales de 20.25, quienes presentaron exacerbaciones de diferentes características. Todos recibieron tratamiento inmunosupresor y fallecieron 2 pacientes. Conclusiones: Nuestro sistema de salud debería establecer estrategia de seguimiento adecuado a estos pacientes con evaluaciones frecuentes de la actividad de su enfermedad de tal forma que permita hacer un diagnóstico y tratamiento temprano. Nuestro sistema de salud debe instaurar medidas de seguimiento de los pacientes con LES en hemodiálisis para el diagnóstico y tratamiento temprano de las recaídas por LES(AU)

Introduction: Patients with systemic lupus erythematosus (SLE) have a decrease in the activity of the disease when it evolves to chronic kidney disease (CKD). Relapses of SLE have been published in this stage in different ethnic groups, but not in Hispanic patients who are traditionally associated with a worse prognosis. Objective: To describe the cases of patients with CKD undergoing hemodialysis with a diagnosis of disease relapse. Case presentations: We present 4 cases (2 men and 2 women) with an average age of 28 years. They had an average SLEDAI score without renal criteria of 20.25, and presented exacerbations of different characteristics. All these patients received immunosuppressive treatment and 2 of them died. Conclusions: Our health system should establish adequate follow-up measures for patients with frequent evaluations of the activity and the disease so that it allows to make an early diagnosis and treatment. Our health system should implement new measures for the follow-up of patients with SLE receiving hemodialysis for the early diagnosis and treatment of relapses due to SLE(AU)

Mortalidad y factores asociados en pacientes con enfermedad renal crónica en hemodiálisis en un hospital peruano / Mortality and associated factors in chronic kidney disease patients under hemodialysis in a Peruvian hospital

Introducción: La enfermedad renal crónica es un problema de salud en Perú. Objetivo: Determinar la mortalidad y los factores asociados en pacientes con enfermedad renal crónica en hemodiálisis de una población incidente en un hospital peruano. Material y Métodos: Estudio de cohorte retrospectiva, de los pacientes que ingresaron al programa de hemodiálisis crónica del hospital Antonio Lorena (Cusco-Perú), entre 2010-2016. Para el análisis de supervivencia se utilizó el método de Kaplan-Meier, para determinar los factores asociados a mortalidad se realizó la Regresión de Cox, se obtuvo el Hazard Ratio (HR) y sus intervalos de confianza al 95 por ciento (IC 95). Resultados: Se estudiaron 187 pacientes, con una mediana de edad de 57 años (rango intercuartílico: 43-66. El 47 por ciento (89) de los pacientes fallecieron durante el seguimiento. La tasa de mortalidad fue de 24 muertes/100 personas-por año (IC 95 por ciento: 19,6-29,6). La mediana de supervivencia fue de 2,8 años (IC 95 por ciento: 1,9-4,0). La dilatación de la aurícula izquierda en la ecocardiografía (HR: 2,63; IC 95 por ciento: 1,03-6,69; p=0,041), el recuento de leucocitos ≥ 12x103u/mm3 (HR: 6,86; IC 95 por ciento: 2,08-22,66; p=0,002), y la hemoglobina < 7 g/dL (HR: 3,62; IC 95 por ciento: 1,05-12,48; p=0,041) se asociaron a mortalidad. Conclusiones: Se encontró una baja frecuencia de supervivencia la misma que estuvo asociada a factores potencialmente modificable(AU)

Introduction: Chronic kidney disease is a health problem in Perú. Objective: To determine the mortality and the associated factors in chronic kidney disease patients under hemodialysis in an incident population in a Peruvian hospital. Material and Methods: A retrospective cohort study was conducted in patients admitted to the chronic hemodialysis program at Hospital Antonio Lorena (Cusco-Peru), from 2010 to 2016. Kaplan-Meier method was used for the survival analysis to determine the factors associated with mortality, Cox´s Regression was carried out, obtaining Hazard Ratio (HR) and 95 percent confidence intervals (95 percent CI). Results: A total of 187 patients were studied, with a mean age of 57 years (interquartile range: 43-66). The 47 percent (89) of patients died during follow-up. Mortality rate was 24 deaths / 100 people-per year (95 percent CI: 19.6-29.6). The mean survival rate was 2.8 years (95 percent CI: 1.9-4.0). Dilatation of the left atrium in the echocardiography (HR: 2.63; 95 percent CI: 1.03-6.69; p=0.041), a white blood cell count ≥ 12x103u/mm3 (HR: 6.86; 95 percent CI: 2.08-22.66; p=0.002), and hemoglobin <7 g/dL (HR: 3.62; 95 percent CI: 1.05-12.48; p=0.041) were associated with mortality. Conclusions: A low frequency of survival was found, which was associated with potentially modifiable factors(AU)

Embarazos exitosos en pacientes en hemodiálisis crónica. Experiencia en hospitales públicos peruanos / Successful pregnancies in patients on chronic hemodialysis. Experience in peruvian public hospitals

Los reportes de pacientes gestantes con enfermedad renal crónica en hemodiálisis (ERCHD) con partos exitosos son cada vez más frecuentes. En el Ministerio de Salud no hay registros oficiales publicados de pacientes en diálisis y, por lo tanto, se desconocen datos de gestantes en diálisis. Se realizó un estudio retrospectivo y multicéntrico de los casos de pacientes con ERCHD que tuvieron partos éxitos en los Hospitales Públicos de Lima. Se encontraron solo 4 con datos suficientes para el reporte. Las pacientes tuvieron una edad promedio de 29 años (DE: 4,8), con un tiempo de gestación promedio al finalizar la gestación de 30,5 semanas (DE: 3,69). La preeclampsia fue la complicación más frecuente en 2 de 4 pacientes y todas las pacientes tuvieron menos de 20 hs. semanales de tratamiento. El Ministerio de Salud debe planear medidas de contingencia para el manejo de estas pacientes que serán cada vez más frecuentes

Reports of pregnant patients with chronic kidney disease on hemodialysis (CKDHD) with successful births are becoming more frequent. In the Ministry of Health there are no publications of official records of patients on dialysis and, therefore, data about pregnant women on dialysis are unknown. A retrospective and multicenter study was conducted on patients with CKDHD who had successful births in the public hospitals of Lima. Only 4 were found to have enough data for the report. The patients had an average age of 29 years (SD: 4.8), with an average gestation time at the end of pregnancy of 30.5 weeks (SD: 3.69). Preeclampsia was the most common complication in 2 out of 4 patients and all patients had less than 20 hours of treatment per week. The Ministry of Health should propose contingency measures for the management of these cases, which will be more and more frequent

Doença renal crônica no Peru: um desafio para um país com uma economia emergente / Chronic kidney disease in Peru: a challenge for a country with an emerging economy

Resumo A cobertura das terapias de substituição renal (TSR) no Ministério da Saúde do Peru é pobre, com distribuição desigual de TSR em nível nacional, e é possível que até 50% da população não tenha acesso a algum tipo de TSR. É preciso uma abordagem multissetorial para resolver este problema que não é consistente com a melhoria econômica do país.

Abstract Coverage of renal replacement therapies (RRT) in Peruvian Ministry of Health is poor. There is an unequal distribution of TRR in the country, and is possible that up to 50% of the population does not have access to any kind of TRR. A multi-institutional approach to address this problem is necessary as it has been in consistent with the economic improvement of the country.

Mortalidade dos pacientes com doença renal crônica em hemodiálise de manutenção em um hospital público do Peru / Mortality in patients with chronic kidney disease undergoing hemodialysis in a public hospital of Peru

Resumo Introdução: O Ministério da Saúde do Peru não tem um programa nacional de hemodiálise e os hospitais que oferecem este tipo de tratamento apresentam problemas de cobertura que podem resultar em aumento da mortalidade. Objetivo: Avaliar a mortalidade da população incidente em hemodiálise em um hospital de Lima. Métodos: Análise da população acima de 18 anos que iniciou o tratamento entre 1 de janeiro de 2012 e 31 de dezembro de 2013, com data de corte final do acompanhamento em 31 de março de 2014. Foi realizada regressão logística bivariada e multivariada dos fatores associados com a mortalidade e usadas as curvas de Kaplan-Meier para determinar a probabilidade de sobrevivência durante o acompanhamento. Resultados: Foram incluídos 235 pacientes para estudo, com idade média de 56,4 ± 15,8 anos. A mediana de acompanhamento foi 0,6 anos (IQR 0,3 a 1,5). A pesquisa mostra que 50% dos pacientes abandonaram o tratamento durante o estudo por falta de vagas ou recursos econômicos. No final do terceiro mês, a mortalidade foi 37,7% (IC 95% 29,3 a 48,5) e 49,5% (IC 95% 38,8 a 61,4) ao sétimo mês. A mortalidade foi menor quando o paciente tinha mais de seis meses com diagnóstico de doença insuficiência renal crônica (OR = 0,39 [IC 95% 0,12-1,27]) e quando o paciente ingressava à diálise programada (OR = 0,28 [IC 95% 0,01 a 2,28]). Conclusão: Metade dos pacientes foi a óbito no sétimo mês de seguimento. Ter ingressado com diálise programada e ter mais tempo de diagnóstico foi associado à menor mortalidade. .

Abstract Introduction: The Peruvian Ministry of Health does not have a national program of hemodialysis and hospitals that offer it have coverage problems, which may result in increased mortality. Objective: We evaluated mortality of a population with incident hemodialysis in a Peruvian public hospital as well as its associated factors. Methods: Retrospective and descriptive study of a population over 18 years-old who started treatment between January 1, 2012 and December 31, 2013 with the final follow-up day on31 March 2014. We used bivariate and multivariate logistic regression models to evaluate factors associated with mortality and Kaplan Meier curves were used to determine the probability of survival. Results: We included 235 patients with a mean age of 56.4 ± 15.8 years. Median follow-up was 0.6 years (IQR 0.3 to 1.5). 50% of years withdrew from therapy during the study for lack of financial resources or space available. The third month mortality was 37.7% (95% CI 4.7 to 48.5) and 49.5% (95% CI 5.8 to 61.4) at 7 months. There was a trend towards lower mortality when patients had more than 6 months with a diagnosis of chronic kidney disease (CKD) (OR = 0.39 [95% CI 0.12 to 1.27]) and when the patient was admitted with scheduled dialysis (OR = 0.28 [95% CI 0.01 to 2.28]). Conclusion: Half of patients died within seven months of follow-up. Scheduled dialysis and having longer time with CKD diagnosis tend to be associated with lower mortality .

Baja adherencia al régimen de hemodiálisis en pacientes con enfermedad crónica renal en un hospital de referencia del Ministerio de Salud en Perú / Low adherence to hemodialysis regime in patients with chronic renal disease in a Peruvian Ministry of Health reference hospital

Introducción: La ausencia a una sesión mensual en un esquema de diálisis convencional puede incrementar la mortalidad en 30 por ciento. Objetivos: Describir la frecuencia y la percepción de las causas de falta de adherencia a diálisis en una población prevalente de un hospital público de referencia nacional en Perú. Diseño: Estudio descriptivo. Institución: Servicio de Nefrología, Hospital Nacional 2 de Mayo, Lima, Perú. Participantes: Pacientes con más de un año en diálisis Intervenciones: Se determinó el número de faltas y se aplicó un cuestionario para describir su percepción respecto a las causas de las faltas, validado por juicio de expertos. Principales medidas de resultados: Baja adherencia a diálisis definida como: pacientes con más de una falta al mes o más de 12 faltas, entre julio de 2012 y julio de 2013. Resultados: Se incluyó 54 pacientes, 27 eran varones, con una edad y tiempo de diálisis promedio de 57 ± 16,4 años y 40,6 ± 11,5 meses, respectivamente; 7/54 pacientes tenían educación superior. Hubo 504 faltas (5,45 por ciento). El segundo día de la programación semanal fue el día con mayor frecuencia de faltas (292), seguido del tercer día (145); 13/54 tuvieron baja adherencia. Las principales causas reportadas fueron: una residencia alejada (6/13), la sensación de bienestar (6/13), el contar con escasos recursos económicos para solventar el traslado (5/13). Conclusiones: Uno de cada cuatro pacientes tuvo baja adherencia. El residir lejos o que se sintiera bien fueron las principales causas de la baja adherencia...

Background: Failing to attend a monthly session within a scheme of conventional dialysis may increase mortality by 30 per cent. Objectives: To describe the frequency and perceived causes of non-adherence to dialysis in a Peruvian national reference public hospital. Design: Descriptive study. Setting: Nephrology department, Hospital Nacional 2 de Mayo, Lima, Peru. Participants: Patients with more than one year on dialysis. Interventions: The number of absences to appointed sessions was determined and a validated questionnaire was used to describe perceptions regarding the causes of absences. Main outcomes measures: Low adherence to dialysis defined as patients with more than one absence per month or more than 12 absences between July 2012 and July 2013. Results: The study included 54 patients, of which 27 were male. Average age was 57 ± 16.4 years and average time on dialysis was 40.6 ± 11.5 months. Only 7 patients had higher education. There were 504 absences (5.45 per cent). The second day of the weekly schedule was the day with more absences (292), followed by the third day (145). Overall 13 patients showed low adherence. Main causes of absence reported included a remote residence (6/13), feeling good (6/13), and insufficient financial resources to cover transportation costs (5/13). Conclusions: A quarter of patients had low adherence, and main factors were distance to health facility and wellbeing self-perception...

Características clínicas de los pacientes diabéticos que acuden por primera vez a una consulta nefrológica en hospitales públicos de Lima / Clinical characteristics of diabetic patients attending for the first time a nephrologic consultation in Lima public hospitals

Introducción: La diabetes mellitus es la principal causa de enfermedad renal crónica y se recomienda una referencia temprana al nefrólogo, ya que se ha reportado peores resultados en pacientes con referencia tardía. Objetivos: Determinar las características de los pacientes diabéticos en su primera consulta nefrológica. Diseño: Estudio multicéntrico, observacional y analítico. Lugar: Hospital Nacional 2 de Mayo, Hospital Nacional Arzobispo Loayza, Hospital Daniel Alcides Carrión y Hospital María Auxiliadora. Participantes: Pacientes diabéticos. Intervenciones: Se estudió a los pacientes en su primera consulta nefrológica entre septiembre 2011 y febrero 2012. Para la descripción se utilizó porcentajes, frecuencias y desviaciones estándar. Principales medidas de resultados: Características clínicas de los pacientes diabéticos. Resultados: Se estudió 200 pacientes diabéticos, con tiempo de diagnóstico promedio de 12,9 años. El 73 por ciento recibió educación para autocuidados. El 40 por ciento refería que no tomaba sus medicamentos y 57 por ciento no seguía su dieta regularmente. El 70 por ciento era hipertenso con tiempo de diagnóstico promedio de 4,2 años; 36,5 por ciento era obeso, 52,8 por ciento sufría de dislipidemia, 10,5 por ciento tenía antecedente de enfermedad cardiovascular. El 81,5 por ciento refería no haber tenido una evaluación previa de la función renal. El 39,5 por ciento tenía hemoglobina glicosilada (HbA1c) >7 por ciento, 48,5 por ciento colesterol >200 mg/dL, 54,5 por ciento cLDL>100 mg/dL y 46,5 por ciento triglicéridos >150 mg/dL; 57 por ciento un tiempo de filtración glomerular<60 mL/min y 37 por ciento presentó albuminuria de 300 mg/d o más. Conclusiones: Casi la mitad de los pacientes no seguía las recomendaciones de autocuidados. Debido a los factores de riesgo cardiovascular involucrados en este grupo, se debería reforzar su educación.

Introduction: Diabetes mellitus is the leading cause of chronic renal disease; early referral to the nephrologist is recommended as the outcome is worse in patients with late referral. Objectives: To determine clinical characteristics of diabetic patients upon their first nephrologic consultation. Design: Multicenter, observational and analytical study. Setting: Hospital Nacional 2 de Mayo, Hospital Nacional Arzobispo Loayza, Hospital Daniel Alcides Carrion and Hospital Maria Auxiliadora. Participants: Diabetic patients. Interventions: Diabetic patients were studied between September 2011 and February 2012. Percentages were used to describe frequencies and standard deviations. Main outcome measures: Clinical characteristics of diabetes patients. Results: From 200 diabetic patients with 12.9 years mean time to diagnosis 73 per cent had received education for self-care, 40 per cent reported not taking their medications and 57 per cent did not follow a regular diet; 70 per cent were hypertensive with 4.2 years average from time of diagnosis, 36.5 per cent were obese, 52.8 per cent had dyslipidemia; 10.5 per cent had a history of cardiovascular disease, and 81.5 per cent reported no prior assessment of renal function; 39.5 per cent had glycated hemoglobin (HbA1c) >7 per cent, 48.5 per cent cholesterol >200 mg/dL, 54.5 per cent LDLc >100 mg/dL, and 46.5 per cent triglycerides >150 mg/dL. Fifty seven per cent had a glomerular filtration rate <60 mL/min, and 37 per cent albuminuria 300 mg/d or more. Conclusions: Almost half of all patients did not follow self-care recommendations. Due to substantial cardiovascular risk factors involved, education of this group should be strengthened.

Compromiso ocular en pacientes en hemodiálisis / Ocular involvement in hemodialysis patients

Objetivo. Describir los hallazgos oculares en una población en diálisis crónica convencional. Material y Métodos. Se realizó un estudio observacional, descriptivo y transversal en los pacientes en hemodiálisis crónica en el Servicio de Nefrología del Hospital Nacional Dos de Mayo de Lima. Resultados. Se estudió a 31 pacientes con edad promedio de 62,67 ± 12,46 años y 45,16% fueron varones. Como antecedente, 87,1% tenían hipertensión arterial y 45,16%, diabetes mellitus. Los síntomas oculares más frecuentes fueron: visión borrosa (67,74%), lagrimeo (38,71%), prurito (25,81%), ardor ocular (16,13%) y astenopia (6,41%). La presión intraocular promedio fue 14,5 ± 5,28 mmHg en el ojo derecho y 14,23 ± 4,78 mmHg en el ojo izquierdo. Agudeza visual, ceguera en 6,07% de los pacientes y baja visión en 39,39%. Los hallazgos externos más frecuentes fueron: Depósitos córneo-conjuntivales (41,94%), alteración en la película lagrimal (35,48%) e hiperpigmentación (35,48%). La alteración de refracción más frecuente fue hipermetropía con astigmatismo (67,77%). Las enfermedades oftalmológicas con diagnóstico definido más frecuentes fueron: retinopatía diabética no proliferativa (37,93%) y degeneración macular relacionada con la edad (24,14%). Conclusión. Los hallazgos oftalmológicos anormales son frecuentes en los pacientes en diálisis crónica, y los pacientes con agudeza visual normal son pocos. La evaluación ocular debería ser rutinaria en esta población.

Objective. To describe the visual findings in a population on conventional chronic dialysis. Material and Methods. A descriptive, prospective and cross sectional study was carried out in patients on chronic hemodialysis in the Nephrology Service of the National Hospital Dos de Mayo, Lima Results. We studied 31 patients whose average age was 62,67 ± 12,46 years and male 45, 16%. And with hypertension 87,1% and diabetes mellitus 45,16%. The most common ocular symptoms were blurred vision (67,74%), tearing (38,71%), pruritus (25,81%), ocular burning (16,13%) and asthenopia (6,41%). The average intraocular pressurewas 14,5 ± 5,28 mmHg in the right eye and 14,23 ± 4,78 mmHg in the left eye. Acuity blindness was found in 6,07% of patients and low vision in 39,9%. The most common external findings were corneal conjunctival deposits (41,94%), altered tear film (35,48%) and hyperpigmentation (35,48%). The most frequent refractive disorder was hypermetropia with astigmatism (67,77%). The most common ophthalmic diagnosis were non-proliferative diabetic retinopathy (37,93%) and age-related macular degeneration (24,14%). Conclusions. Abnormal ophthalmologic findings were frequently found in patients on chronic hemodialysis. So, the eye examination should be routine in this population.

Hipertensión arterial e hipertensión paradójica en los pacientes en hemodiálisis / Arterial hypertension and paradoxical hypertension in hemodialysis patients

Objetivos. Describir las características de la hipertensión arterial (HTA) y la hipertensión arterial paradójica (HTAP), y sus factores asociados en pacientes en hemodiálisis. Material y Métodos. Se estudió a 203 pacientes. Se definió HTA como antecedente clínico y/o toma de medicamentos para la HTA; presión arterial promedio (PAP): presión arterial medida antes y después de hemodiálisis; HTA no controlada, si PAP >140/90 mmHg. Se definió HTAP como presión diastólica posdiálisis mayor de 10 mmHg que en prediálisis. Se evaluó edad, tiempo en diálisis, etiología de la enfermedad, peso interdialítico, antecedente cardiovascular, analítica individual, tipo y número de antihipertensivos. Se realizó un análisis univariante y multivariante de estas variables. Resultados. La prevalencia de HTA fue 79,8 por ciento y la de HTA no controlada, 54,9 por ciento. La edad promedio fue 56,25 ± 15,29 años. Las causas de enfermedad renal crónica (ERC) fueron HTA, 37,7 por ciento, y diabetes mellitus (DM), 29 por ciento. El tiempo en diálisis promedio 41,8 ± 32,92 meses; variación de peso interdialítico 2 376,60 ± 1 019,31 g. Con antecedente cardiovascular, 19,75 por ciento: insuficiencia cardiaca (IC), 9,85 por ciento, enfermedad cardiovascular (ECV), 5,56 por ciento. Tomaban antihipertensivos el 88,3 por ciento y el 42,59 por ciento tomaba más de un antihipertensivo. Hemoglobina 9,6 ± 2.55 g/dL. No se encontró ningún factor asociado a HTA y la HTA no controlada se asoció a un mayor número de antihipertensivos (OR: 2,053; IC 95 por ciento: 1,248-3,378). La prevalencia de HTAP fue 12 por ciento. El tiempo en diálisis fue 43,8 ± 27,8 meses, la variación del peso interdialítico 2 384,0 ± 912,3 g. La causa de ERC fue HTA 33,3 por ciento, DM 29,6 por ciento. Con antecedente cardiovascular 9,5 por ciento: IC, 4,8 por ciento; ECV, 4,8 por ciento, El 66,7 por ciento tomaba más de un antihipertensivo. Hemoglobina 9,27 ± 2,77 g/dL. La...

Objectives. To describe arterial hypertension (AH) and paradoxical arterial hypertension (PAH) characteristics and their associated factors in hemodialysis patients. Material and methods. We studied 203 patients. AH was defined as a clinic antecedent for these patients or if they were taking medication for AH. Average arterial pressure (AAP) was calculated with arterial pressure measured before and after hemodialysis session. No-controlled AH was a AAP > 140/90 mmHg. PAH was defined as a postdialysis arterial pressure greater than 10 mmHg than the predialysis pressure. We evaluated age, time in dialysis, etiology of end stage renal disease (ESRD), interdialytic weight variation, cardiovascular antecedents, individual laboratory tests, and antihypertensive drugs (classand number). Univariate and multivariate analysis were performed on these variables. Results. Prevalence of AH was 79,8 percent and no-controlled AH was 54,9. Average age was 56,25 ± 15,29 years. Etiology of ESRD was AH 37,7 percent and diabetes mellitus 29 percent. Average time in dialysis was 41,8±32,92 months; interdialytic weight variation 2 376,60 ± 1 019,31 g. There were cardiovascular antecedents in 19,75 percent of the patients (cardiac failure in 9,85 percent and cardiovascular disease in 5,56 percent). Patients were taking antihypertensive drugs in 88,3 percent (angiotensinconverting enzyme inhibitors 58,09 percent, calcium antagonists 54,94 percent and more than one antihypertensive drug 42,59 percent).Hemoglobin was 9,6 ± 2,55 g/dL. We can not find any factor associated to AH in multivariate analysis; but no-controlled AH was associated with a greater intake of antihypertensive drugs(OR 2,053; IC 95 percent 1,248-3,378). Prevalence of PAH was 12 percent. Time in dialysis was 43,8 ± 27,8 months, interdialytic weight variation was 2384,0 ± 912,3 g. Etiology of ESRD was AH 33,3 percent and diabetes mellitus 29,6 percent...

Prurito en pacientes en hemodiálisis / Pruritus in hemodialysis patients

Objetivo: Determinar la prevalencia, características de la clínica y factores relacionados a prurito en pacientes de hemodiálisis. Material y métodos: Estudiamos a 188 pacientes de hemodiálisis crónica. Se encuestó a los pacientes para determinar la prevalencia y la clínica de prurito (alteración del sueño, frecuencia, localización, calendario, relación con diálisis y tratamiento). Se evaluó la relación entre los antecedentes de prurito y clínica y de laboratorio (calcio, fósforo, albúmina, ferritina, Kt/V, RCP, hemoglobina y hepatitis). Se realizó un análisis univariante y multivariante de estas variables. Resultados: La prevalencia de prurito fue 37,2 por ciento. El sueño fue perturbado en 37,14 por ciento, con una intensidad moderada de acuerdo a una escala visual analógica (6,2 puntos). El prurito tuvo una presentación diaria en el 98,8 por ciento de los pacientes; fue localizado en la parte posterior en 47,5 por ciento, principalmente en la mañanas 41,3 por ciento, posdiálisis en 45,7 por ciento, con tratamiento en 23 por ciento (principalmente antihistamínicos 24,7 por ciento). Los factores relacionados al prurito fueron hepatitis B (OR de 3,6; IC 95 por ciento 1,22 10,64) e hiperfosfatemia (O 1,21; IC 95 por ciento 1,03 1,42). Conclusiones: La prevalencia de prurito fue alta en los pacientes de hemodiálisis, su presencia fue diaria y alteró la calidad del sueño. Encontramos que el prurito se relacionó con hepatitis b y hiperfosfatemia.

Objective. To determine the prevalence, clinic characteristics and related factors to pruritus in hemodialysis patients. Material and methods. We studied 188 chronic hemodialysis patients. Prevalence and clinic characteristics of pruritus (sleep disturbance, frequency, localization, timing, relation to dialysis and treatment) were searched. The relationship between pruritus and clinic antecedents and laboratory analytic (calcium, phosphorus, albumin, ferritin, Kt/V, RCP, hemoglobin and hepatitis) was evaluated. A univariate and multivariate analysis were performed on these variables. Results. Prevalence of pruritus was 37,2 percent. Sleep was disturbed in 37,14 percent, with a moderate intensity according to an analogue visual scale (6,2 points). Pruritus was present daily in 57,7 percent of the patients; it was localized on the back in 47,5 percent, predominantly in the morning in 41,3 percent, postdialysis in 45,7 percent, with treatment in 23 percent (mainly antihistaminic drugs were administered in 24,7 percent). The related factors to pruritus were hepatitis B (OR of 3,6; IC 95 percent 1,22-10,64) and hyperphosphatemia (OR 1,21; IC 95 percent 1,03-1,42). Conclusions. Prevalence of pruritus was high in hemodialysis patients, its presence was a daily and disturbing sleep quality complaint, and under treated. We found that pruritus was related to hepatitis B and hyperphosphatemia.