Toma de decisiones en hemodiálisis crónica: estudio cualitativo en adultos mayores / Decision making among older adults in hemodialysis. A qualitative assessment

Background: In Chile there are 22,310 people in Chronic Hemodialysis (CHD), 53% of them older adults (OA). Shared decision-making and advance directives (AD) are especially important in OA with end-stage chronic renal failure, since they have greater levels of disability, morbidity and mortality, raising doubts about the benefit of therapy. Aims: To understand the experience in decision making and explore ways to express AD, in OA in CHD. Material and Methods: A qualitative phenomenological study, performing 12 in-depth interviews to OA who had been at CHD for at least one year. Results: The analysis revealed four broad comprehensive categories, two related to participation in the decision to enter CHD, namely the experience of subjects as spectators and their lack of interest for decision support and two referred to the expression of AD, namely the difficulty in facing their own finitude and resistance to express AD. Conclusions: There is little participation of older adults in the decision about their admission to dialysis therapy, and once they enter the CHD program they are not prepared to discuss AD in general, nor an eventual suspension of dialysis in particular.

Recomendaciones del Comité de Ética de la Sociedad Chilena de Nefrología para el manejo de los problemas ético-clínicos de pacientes adultos con enfermedad renal crónica terminal / Recommendations of the Ethics Committee of the Chilean Society of Nephrology for the management of ethical problems in adult end stage renal disease patients

There are different approaches to treat patients with End Stage Renal Disease (ESRD): hemodialysis, peritoneal dialysis, renal transplantation and conservative medical management. The choice of the best therapy for each patient, needs both clinical and ethical skills. The Ethics Committee of the Chilean Society of Nephrology has elaborated recommendations to help health workers to deal with the ethical and clinical problems related to patients suffering ESRD. Its goal is to guide, at a national level, the effective use of minimal standards in the treatment and care of patients with ESRD, including appropriate care and information for patients, therapy selection, management of difficult cases and potential conflicts.

Renal vascular and excretory resistance to atrial natriuretic peptide in pre-cirrhotic, bile-duct ligated rats

Renal response to atrial natriuretic peptide in chronic cholestasis was studied in anaesthetized rats and in their isolated perfused kidneys. Cholestasis was induced by bile duct section after ligature, while controls were sham operated. Three weeks after surgery, cholestatic rats showed moderate arterial hypotension, elevated diuresis and no differences in urinary sodium, glomerular filtration rate (GFR) and fractional sodium excretion (FENa), when compared to controls. Isolated kidneys of cholestatic rats had equal basal diuresis and less natriuresis than the controls. Cholestatic rats presented blunted natriuretic and diuretic responses to iv injections of atrial natriuretic peptide (ANP 0.5 microgram), associated with reduced increments in GFR and FENa, when compared with controls. Similarly, the diuretic-natriuretic response of isolated kidneys to ANP (3.5 x 10(-9) M) was greatly attenuated in this group. ANP did not increase perfusion pressure in cholestatic rats, as it did in controls. These results indicate that animals with chronic cholestasis present refractoriness to ANP, which might be mediated by a direct impairment at the renal vascular and tubular sites for ANP action