Neurocognitive Function with Conventional Hemodialysis versus Post-Dilution Hemofiltration as Initial Treatment in ESKD Patients: A Randomized Controlled Trial - The DA-VINCI Study.

INTRODUCTION: The ideal modality choice and dialysis prescription during the first renal replacement therapy (RRT) session remain unclear. We conducted a pilot study to determine the safety risk for hemodialysis (HD) versus hemofiltration (HF) and its relationship with neurocognitive assessment on incident RRT patients. METHODS: Twenty-four incident RRT patients were included. Patients were randomized to the conventional HD group or post-dilution HF group. Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA) tests were applied in all patients before and after session, and brain magnetic resonance image (MRI) was performed in 7 patients from the conventional HD group and 8 patients from the post-dilution HF group before and after the intervention. RESULTS: Baseline characteristics were similar between groups. Compared to conventional HD, post-dilution HF had longer treatment time. There were no significant changes in blood pressure after RRT in both groups. The MMSE test showed no significant differences between groups or within groups. The MOCA test showed an increase in the total score for the post-dilution HF group with no significant changes between groups. The MRI evaluation showed no differences between or within groups. CONCLUSION: Post-dilution HF is a safe alternative for the first HD session in incident RRT; it allows longer treatment time if ultrafiltration is required and has a similar neurological risk than conventional HD. This is a pilot study and that larger studies are needed to confirm the findings.

Baroreflex Sensitivity Assessment Using the Sequence Method with Delayed Signals in End-Stage Renal Disease Patients.

Impaired baroreflex sensitivity (BRS) is partially responsible for erratic blood pressure fluctuations in End-Stage Renal Disease (ESRD) patients on chronic hemodialysis (HD), which is related to autonomic nervous dysfunction. The sequence method with delayed signals allows for the measurement of BRS in a non-invasive fashion and the investigation of alterations in this physiological feedback system that maintains BP within healthy limits. Our objective was to evaluate the modified delayed signals in the sequence method for BRS assessment in ESRD patients without pharmacological antihypertensive treatment and compare them with those of healthy subjects. We recruited 22 healthy volunteers and 18 patients with ESRD. We recorded continuous BP to obtain a 15-min time series of systolic blood pressure and interbeat intervals during the supine position (SP) and active standing (AS) position. The time series with delays from 0 to 5 heartbeats were used to calculate the BRS, number of data points, number of sequences, and estimation error. The BRS from the ESRD patients was smaller than in healthy subjects (p < 0.05). The BRS estimation with the delayed sequences also increased the number of data points and sequences and decreased the estimation error compared to the original time series. The modified sequence method with delayed signals may be useful for the measurement of baroreflex sensitivity in ESRD patients with a shorter recording time and maintaining an estimation error below 0.01 in both the supine and active standing positions. With this framework, it was corroborated that baroreflex sensitivity in ESRD is decreased when compared with healthy subjects.

Low-Intensity Intradialytic Exercise Attenuates the Relative Blood Volume Drop Due to Intravascular Volume Loss during Hemodiafiltration.

INTRODUCTION: Patients in hemodiafiltration (HDF) eliminate volume overload by ultrafiltration. Vascular volume loss is among the main mechanisms contributing to adverse events such as intradialytic hypotension. Here, we hypothesize that the intradialytic exercise (IDEX) is an intervention that could improve the acute response of physiological mechanisms involved during vascular volume loss. To test this hypothesis, we evaluated the hemodynamic response to mild aerobic exercise during HDF. METHODS: Nineteen end-stage renal disease (ESRD) patients (11 women: 40 ± 10.8 years old, and 8 men: 42 ± 21 years old) receiving HDF thrice a week, with 6 months of previous physical conditioning, participated in this study. Three HDF sessions were scheduled for each patient: 1 resting in supine position, 1 resting in sitting position, and 1 doing aerobic exercise. The first 2 sessions were taken as control. The ultrafiltration rate was set to 800 mL/h in each session. The hemodynamic response was monitored through the relative blood volume (RBV), and cardiovascular variables measured noninvasively by photoplethysmography. Adequacy variables such as Kt/V and percentage reduction of urate, urea, creatinine (Cr), and phosphate were also monitored. FINDINGS: The decrease rate of the RBV was smaller in the session with IDEX compared to the sessions with no exercise. No differences were found neither in the cardiovascular variables nor in the adequacy variables among the 3 sessions. There were no hypotension events during the session with exercise, and 8 events during the sessions without exercise (p = 0.002). DISCUSSION: Mild exercise during HDF decreased the RBV drop and was associated with less hypotension events. The lack of differences in the hemodynamic variables suggests an adequate acute response of cardiovascular compensation variables to intradialytic hypovolemia.

Association between Mean Heart Rate and Recurrence Quantification Analysis of Heart Rate Variability in End-Stage Renal Disease.

Linear heart rate variability (HRV) indices are dependent on the mean heart rate, which has been demonstrated in different models (from sinoatrial cells to humans). The association between nonlinear HRV indices, including those provided by recurrence plot quantitative analysis (RQA), and the mean heart rate (or the mean cardiac period, also called meanNN) has been scarcely studied. For this purpose, we analyzed RQA indices of five minute-long HRV time series obtained in the supine position and during active standing from 30 healthy subjects and 29 end-stage renal disease (ESRD) patients (before and after hemodialysis). In the supine position, ESRD patients showed shorter meanNN (i.e., faster heart rate) and decreased variability compared to healthy subjects. The healthy subjects responded to active standing by shortening the meanNN and decreasing HRV indices to reach similar values of ESRD patients. Bivariate correlations between all RQA indices and meanNN were significant in healthy subjects and ESRD after hemodialysis and for most RQA indices in ESRD patients before hemodialysis. Multiple linear regression analyses showed that RQA indices were also dependent on the position and the ESRD condition. Then, future studies should consider the association among RQA indices, meanNN, and these other factors for a correct interpretation of HRV.

Sustained exercise programs for hemodialysis patients: The characteristics of successful approaches in Portugal, Canada, Mexico, and Germany.

Despite having good intentions, hemodialysis (HD) clinics often fail to sustain exercise programs that they initiate. There are many reasons for this, including a lack of funding, inadequate training of the clinic staff, a lack of exercise professionals to manage the program or train the staff, and the many challenges inherent to exercising a patient population with multiple comorbid diseases. Despite these barriers, there are several outstanding examples of successful exercise programs in HD clinics throughout the world. The aim of this manuscript is to review the characteristics of four successfully sustained HD exercise programs in Portugal, Canada, Mexico, and Germany. We describe the unique approaches they have used to fund and manage their programs, the varied exercise prescriptions they incorporate, the unique challenges they face, and discuss the benefits they have seen. While the programs differ in many regards, a consistent theme is that they each have substantial and committed support from the entire clinic staff, including the nephrologists, administration, nurses, dietitians, and technicians. This suggests that exercise programs in HD clinics can be successfully implemented and sustained provided significant effort is made to foster a culture of physical activity throughout the clinic.

Effects of Orthostatism and Hemodialysis on Mean Heart Period and Fractal Heart Rate Properties of Chronic Renal Failure Patients.

The aim of this work was to evaluate the short-term fractal index (α1 ) of heart rate variability (HRV) in chronic renal failure (CRF) patients by identifying the effects of orthostatism and hemodialysis (HD), and by evaluating the correlation between α1 and the mean RR interval from sinus beats (meanNN). HRV time series were derived from ECG data of 19 CRF patients and 20 age-matched healthy subjects obtained at supine and orthostatic positions (lasting 5 min each). Data from CRF patients were collected before and after HD. α1 was calculated from each time series and compared by analysis of variance. Pearson's correlations between meanNN and α1 were calculated using the data from both positions by considering three groups: healthy subjects, CRF before HD and CRF after HD. At supine position, α1 of CRF patients after HD (1.17 ± 0.30) was larger (P < 0.05) than in healthy subjects (0.89 ± 0.28) but not before HD (1.10 ± 0.34). α1 increased (P < 0.05) in response to orthostatism in healthy subjects (1.29 ± 0.26) and CRF patients after HD (1.34 ± 0.31), but not before HD (1.25 ± 0.37). Whereas α1 was correlated (P < 0.05) with the meanNN of healthy subjects (r = -0.562) and CRF patients after HD (r = -0.388), no significance in CRF patients before HD was identified (r = 0.003). Multiple regression analysis confirmed that α1 was mainly predicted by the orthostatic position (in all groups) and meanNN (healthy subjects and patients after HD), showing no association with the renal disease condition in itself. In conclusion, as in healthy subjects, α1 of CRF patients correlates with meanNN after HD (indicating a more irregular-like HRV behavior at slower heart rates). This suggests that CRF patients with stable blood pressure preserve a regulatory adaptability despite a shifted setting point of the heart period (i.e., higher heart rate) in comparison with healthy subjects.

Sign and magnitude scaling properties of heart rate variability in patients with end-stage renal failure: Are these properties useful to identify pathophysiological adaptations?

The scaling properties of heart rate variability data are reliable dynamical features to predict mortality and for the assessment of cardiovascular risk. The aim of this manuscript was to determine if the scaling properties, as provided by the sign and magnitude analysis, can be used to differentiate between pathological changes and those adaptations basically introduced by modifications of the mean heart rate in distinct manoeuvres (active standing or hemodialysis treatment, HD), as well as clinical conditions (end stage renal disease, ESRD). We found that in response to active standing, the short-term scaling index (α1) increased in healthy subjects and in ESRD patients only after HD. The sign short-term scaling exponent (α1sign) increased in healthy subjects and ESRD patients, showing a less anticorrelated behavior in active standing. Both α1 and α1sign did show covariance with the mean heart rate in healthy subjects, while in ESRD patients, this covariance was observed only after HD. A reliable estimation of the magnitude short-term scaling exponent (α1magn) required the analysis of time series with a large number of samples (>3000 data points). This exponent was similar for both groups and conditions and did not show covariance with the mean heart rate. A surrogate analysis confirmed the presence of multifractal properties (α1magn > 0.5) in the time series of healthy subjects and ESDR patients. In conclusion, α1 and α1sign provided insights into the physiological adaptations during active standing, which revealed a transitory impairment before HD in ESRD patients. The presence of multifractal properties indicated that a reduced short-term variability does not necessarily imply a declined regulatory complexity in these patients.

Hemodynamic Response to Hemodialysis With Ultrafiltration Rate Profiles Either Gradually Decreasing or Gradually Increasing.

Hemodialysis (HD) is usually performed with the gradually decreasing ultrafiltration rate (UFR) profile (dUFR). The aim of the present study was to compare the hemodynamic response to HD with the dUFR to that of HD with the gradually increasing UFR profile (iUFR). The study population included 10 patients (three women, mean age: 28 ± 8 years) undergoing maintenance HD who had reached dry weight without taking antihypertensive medications. Each patient received (in random order) one HD session with the dUFR and another with the iUFR (both with 3 h total UFR = 2200 mL). Hemodynamic response was evaluated with a brachial blood pressure (BP) monitor, echocardiogram and Portapres to measure digital BP, heart rate, cardiac output, stroke volume, and peripheral resistance. Mean values were compared at each HD hour during the first 3 h of a 4-h HD session. The HD characteristics, including Kt/V, were similar for both UFR profiles. Relative blood volume decreased more gradually and linearly with the iUFR. Hemodynamic variables were not significantly different between the two profiles, but brachial BP was more stable with the iUFR. Digital diastolic BP increased with both profiles. Peripheral resistance increased with both profiles, and tended to increase more with the iUFR. Echocardiographic variables changed similarly during the HD session with both profiles. In conclusion, these two UFR profiles are similar in most hemodynamic variables. The statistical equivalence of both profiles suggests that either could be prescribed based on the clinical characteristics of the patient.

Preserved autonomic heart rate modulation in chronic renal failure patients in response to hemodialysis and orthostatism.

BACKGROUND: The aim of this work was to measure the impact of active orthostatism and hemodialysis (HD) upon heart rate variability (HRV) in chronic renal failure (CRF) patients before and after HD. METHODS: Nineteen healthy subjects (age 27 ± 8 years old, 13 were female) and 19 unmedicated CRF patients with HD thrice per week (average HD vintage = 12 months, age 32 ± 9 years old, 11 were female) were included. Five-minute length HRV time series were obtained during supine position and orthostatism. Recordings from CRF patients were obtained before and after HD. Time domain and frequency domain HRV indexes were compared by analysis of variance. The correlation between each HRV index and change in sympathetic weighting induced by different maneuvers was tested by Kendall's Tau correlation. A p value <0.05 was considered statistically significant. RESULTS: HRV indexes which are associated with sympathetic activity increased in response to orthostatism in the healthy group, e.g., low-frequency to high-frequency (LF/HF) ratio, Ln (LF/HF) = -0.3 ± 0.9 versus 0.9 ± 0.9. CRF patients before HD had higher sympathetic weighting than healthy participants, even in supine position, Ln (LF/HF) = 0.6 ± 1.0, but such a difference was accentuated during orthostatism, Ln (LF/HF) = 1.5 ± 1.0, and after HD: Ln (LF/HF) = 0.8 ± 1.3 (supine position) and 2.5 ± 2.1 (orthostatism). All HRV indexes were associated with increments in sympathetic weighting between maneuvers (Kendall's correlations absolute values ≥ 0.24). CONCLUSION: Unmedicated young CRF patients treated with hemodynamically stable maintenance HD showed preserved capacity of autonomic response (with gradual sympathetic increases) induced by cardiovascular challenges such as orthostatism and HD.

Identification of impeding factors for dry weight achievement in end-stage renal disease after appropriate kidney graft function.

The aim of this study was to evaluate the factors that prevent dry weight achievement in patients with end-stage renal disease (ESRD) in renal replacement therapy through the change in their body weight after kidney transplant (KT) compared with 1 week before KT. The study included 188 ESRD patients of diverse etiology who received living kidney transplantation with normal immediate graft function, 62.2% were male, age 29 ± 11 years old. All patients were on renal replacement therapy for at least 1 month before KT with either hemodiafiltration (N = 106), hemodialysis (N = 25), or peritoneal dialysis (N = 57). Based on body weight difference (after transplant-before transplant), patients with body weight difference ≤2 kg were considered as being close to their dry weight (Group 1, N = 112), whereas patients with body weight difference >2 kg were considered as being overhydrated (Group 2, N = 76). Clinical and biochemical characteristics were obtained from the medical records at three periods of time: time of ESRD initiation (baseline), 1 week before undergoing KT, and 1 week after KT. The mean time (± standard deviation) from renal replacement therapy initiation to the week before KT was 9.2 ± 5 months. Group 2 had a higher proportion of men, antihypertensive use, peritoneal dialysis, and higher urine output during all periods. Before KT, Group 2 had higher systolic and diastolic blood pressures than Group 1. After KT, both systolic and diastolic blood pressures decreased in Group 2, whereas no change occurred in Group 1. Before KT, Group 2 had higher levels of blood urea nitrogen, creatinine, uric acid, and phosphorous compared with Group 1. Compared with baseline, Group 1 had more optimal blood urea nitrogen, creatinine, and uric acid parameters before KT than Group 2. After KT, all parameters improved with respect to baseline in both groups. Hemoglobin, albumin, and sodium were similar between groups, except for higher hemoglobin in Group 2 than Group 1 after KT. Multivariate regression analysis showed that male sex, peritoneal dialysis, and systolic blood pressure before KT were independent risk factors for overhydration. In conclusion, high systolic blood pressure and peritoneal dialysis were two independent modifiable variables associated with overhydration before KT. Assessment of the body weight change after KT is a useful tool to evaluate dry weight, in addition to identifying variables associated with poor volume control. This could allow adjustment of clinical and dialysis parameters in future patients.

Visual three-dimensional representation of beat-to-beat electrocardiogram traces during hemodiafiltration.

This study evaluated the usefulness of the three-dimensional representation of electrocardiogram traces (3DECG) to reveal acute and gradual changes during a full session of hemodiafiltration (HDF) in end-stage renal disease (ESRD) patients. Fifteen ESRD patients were included (six men, nine women, age 46 ± 19 years old). Serum electrolytes, blood pressure, heart rate, and blood urea nitrogen (BUN) were measured before and after HDF. Continuous electrocardiograms (ECGs) obtained by Holter monitoring during HDF were used to produce the 3DECG. Several major disturbances were identified by 3DECG images: increase in QRS amplitude (47%), decrease in T-wave amplitude (33%), increase in heart rate (33%), and occurrence of arrhythmia (53%). Different arrhythmia types were often concurrent and included isolated supraventricular premature beats (N = 5), atrial fibrillation or atrial bigeminy (N = 2), and isolated premature ventricular beats (N = 6). Patients with decrease in T-wave amplitude had higher potassium and BUN (both before HDF and total removal) than those without decrease in T-wave amplitude (P < 0.05). Concurrent acute and gradual ECG changes during HDF are identified by the 3DECG, which could be useful as a preventive and prognostic method.

Association of intradialytic hypotension and convective volume in hemodiafiltration: results from a retrospective cohort study.

BACKGROUND: Hemodiafiltration (HDF), as a convective blood purification technique, has been associated with favorable outcomes improved phosphate control, removal of middle-molecules such as Beta2-microglobulin and the occurrence of intradialytic hypotension (IDH) as compared to diffusive techniques. The aim of this retrospective cohort study in dialysis patients receiving HDF in one urban dialysis facility in Mexico City was to investigate the occurrence of IDH during HDF treatments with varying convective volume prescriptions. METHODS: Subjects were stratified into equal groups of percentiles of convective volume prescription: Group 1 of 0 to 7.53 liters, group 2 of 7.54 to 14.8 liters, group 3 of 14.9 to 16.96 liters, group 4 of 16.97 to 18.9 liters, group 5 of 21 to 19.9 liters and group 6 of 21.1 to 30 liters. Logistic Regression with and without adjustment for confounding factors was used to evaluate factors associated with the occurrence of IDH. RESULTS: 2276 treatments of 154 patients were analyzed. IDH occurred during 239 HDF treatments (10.5% of all treatments). Group 1 showed 31 treatments (8.2%) with IDH whereas group 6 showed IDH in only 15 sessions (4% of all treatments). Odds Ratio of IDH for Group 6 was 0.47 (95% CI 0.25 to 0.88) as compared to Group 1 after adjustment. CONCLUSIONS: In summary the data of this retrospective cohort study shows an inverse correlation between the occurrence of IDH and convective volume prescription. Further research in prospective settings is needed to confirm these findings.

Recurrence Quantitative Analysis of Wavelet-Based Surrogate Data for Nonlinearity Testing in Heart Rate Variability.

Exploring the presence of nonlinearity through surrogate data testing provides insights into the nature of physical and biological systems like those obtained from heart rate variability (HRV). Short-term HRV time series are of great clinical interest to study autonomic impairments manifested in chronic diseases such as the end stage renal disease (ESRD) and the response of patients to treatment with hemodialysis (HD). In contrast to Iterative Amplitude Adjusted Fourier Transform (IAAFT), the Pinned Wavelet Iterative Amplitude Adjusted Fourier Transform (PWIAAFT) surrogates preserve nonstationary behavior in time series, a common characteristic of HRV. We aimed to test synthetic data and HRV time series for the existence of nonlinearity. Recurrence Quantitative Analysis (RQA) indices were used as discriminative statistics in IAAFT and PWIAAFT surrogates of linear stationary and nonstationary processes. HRV time series of healthy subjects and 29 ESRD patients before and after HD were tested in this setting during an active standing test. Contrary to PWIAAFT, linear nonstationary time series may be erroneously regarded as nonlinear according to the IAAFT surrogates. Here, a lower proportion of HRV time series was classified as nonlinear with PWIAAFT, compared to IAAFT, confirming that the nonstationarity condition influences the testing of nonlinear behavior in HRV. A contribution of nonlinearity was found in the HRV data of healthy individuals. A lower proportion of nonlinear time series was also found in ESRD patients, but statistical significance was not found. Although this proportion tends to be lower in ESRD patients, as much as 60% of time series proved to be nonlinear in healthy subjects. Given the important contribution of nonlinearity in HRV data, a nonlinear point of view is required to achieve a broader understanding of cardiovascular physiology.

Correlation between Angiotensin Serum Levels and Very-Low-Frequency Spectral Power of Heart Rate Variability during Hemodialysis.

Cardiovascular regulatory mechanisms that fail to compensate for ultrafiltration and cause hypovolemia during hemodialysis (HD) are not completely understood. This includes the interaction between the autonomic nervous system and the biochemistry that regulates blood pressure and modulates cardiac activity and vascular tone in response to hypovolemia in patients treated with HD. The objective was to evaluate the association of spectral indices of heart rate variability (HRV) with serum levels of angiotensin II, angiotensin 1-7, nitric oxide and total antioxidant capacity during HD. Electrocardiographic records were obtained from 20 patients during HD (3 h), from which HRV data and spectral power data in the very-low-frequency (VLF), low-frequency (LF) and high-frequency (HF) bands were generated. Three blood samples per patient were collected during HD (0.0, 1.5, 3.0 h) to determine the levels of biomarkers involved in the pressor response during HD. Angiotensin II had a positive correlation with VLF (r = 0.390) and with LF/HF (r = 0.359) and a negative correlation with LF (r = -0.262) and HF (r = -0.383). There were no significant correlations between HRV and the other biomarkers. These results suggest that during HD, VLF could reflect the serum levels of angiotensin II, which may be associated with the autonomic response to HD.

[Prevalence, risk factors and consecuences of late nephrology referral]. / Prevalencia, factores de riesgo y consecuencias de la referencia tardía al nefrólogo.

BACKGROUND: Late referral of patients with chronic kidney disease (CKD) to specialized care by the nephrologist is associated with worse patient outcomes while on dialysis. OBJECTIVES: To determine the prevalence, risk factors, and consequences of late nephrology referral at a Mexican tertiary care hospital. MATERIAL AND METHODS: Retrospective chart review of all adult patients who began chronic hemodialysis between 2002 and 2006 at the National Institute of Cardiology "Ignacio Chavez" (NICICh), Mexico City. Timing of referral to Nephrology Department was classified as early, late or very late if the time elapsed between referral and initiation of dialysis was < 1 month, between 1-6 months or > or = 6 months, respectively. Socio-demographic, clinical, laboratory and echocardiographic characteristics were compared according to timing of referral. RESULTS: Eighty four out of 150 patients were included in the analysis. Of these, 56% were referred < 1 month, and an additional 15% between 1-6 months prior to the initiation of chronic hemodialysis. In univariate analysis, being referred by a relative or friend was associated with a higher risk (p = 0.04), and being employed with a lower risk of late referral (p = 0.05). Late referred patients were more likely to require emergency dialysis and hospitalization, and of not having a permanent vascular access for their first dialysis. They also had a higher prevalence of severe anemia (hematocrit < 28%) and of residual kidney function (estimated glomerular filtration rate < 5 mL/min/1.73 m2), as well as increased left ventricular mass. CONCLUSIONS: Late nephrology referral is highly prevalent in our population and is associated with markers of suboptimal predialysis care at the onset of chronic dialysis.

Intraocular Pressure Changes during Hemodiafiltration with Two different Concentrations of Sodium in the Dialysate.

Ocular complications are common among end-stage renal disease patients and some complications had been linked to increments of intraocular pressure (IOP) during hemodialysis. The changes of IOP during hemodiafiltration (HDF) have been scarcely investigated and the potential influence of the sodium dialysate concentration is unknown. The aim of this study was to compare the IOP changes during HDF with sodium dialysate concentration, either fixed or individualized. Thirteen end-stage renal disease patients participated in the study; they were treated with HDF using a dialysate sodium profile fixed at 138 mmol and another session with an individualized sodium profile. The intraocular pressure was measured before and after each session and every 30 min during HDF. Both groups had a similar HDF prescription, blood pressure, and biochemical parameters. At the end of hemodiafiltration, sodium concentration decreased only in the fixed sodium profile group. The number of patients with at least an episode of intraocular hypertension during HDF ranged from 5 (19%) to 8 (31%) without significant differences between right and left eye nor between dialysate sodium concentration. During HDF, there is a large variability of IOP; transient events of intraocular hypertension are highly prevalent in this sample, and they are not related to the sodium dialysate concentration.

Gender-Specific Differences in Self-Care, Treatment-Related Symptoms, and Quality of Life in Hemodialysis Patients.

Gender and sex differences affect women with kidney failure (KF) negatively at all stages of the disease. This study assessed gender differences in self-care, hemodialysis symptoms, and quality of life in a sample of 102 adult KF patients treated with hemodialysis, from two clinical centers in Mexico. Self-care agency, quality of life, and the symptoms related to hemodialysis were evaluated through questionnaires, and sociodemographic and laboratory variables were obtained from the clinical records. Compared to male patients, female patients reported similar self-care, lower quality of life subscales (symptoms, physical functioning, pain, and overall health), and higher prevalence and intensity of hemodialysis symptoms. There were gender differences regarding the correlation between self-care and quality of life, symptoms intensity, and symptoms prevalence. In conclusion, women with KF treated with hemodialysis perceived a higher impact of hemodialysis and reported a lower quality of life than men. Despite having a similar self-care agency, the self-care correlations with quality of life and hemodialysis symptoms appeared different between men and women treated with chronic hemodialysis. Such differences may be important in future nursing interventions to improve self-care and quality of life among KF patients.

Resilience: A Protective Factor from Depression and Anxiety in Mexican Dialysis Patients.

Depression and anxiety are highly prevalent psychological disorders in end-stage renal disease (ESRD) that have a negative clinical impact. The purpose of our study was to identify factors associated with the presence of depression and anxiety, in a sample of ESRD patients treated with hemodialysis. We included 187 patients from two dialysis facilities, age 18-65 years. Beck's depression and anxiety inventories, KDQOL36 questionnaire, the cognitive distortion scale and the Mexican scale of resilience were used. Socio-demographic and clinical information was obtained from medical records. Depression was present in 143 (76.4%) patients. Patient with depression were older (33 (26-52) years vs. 30 (24.43) years, p = 0.025), had a lower education level (36% vs. 9%, p = 0.001), used more medications (67% vs. 36%, p = 0.001), had a comorbidity (75% vs. 41%, p = 0.001), and a higher proportion were waiting for a kidney transplant. Anxiety was present in 112 (59.8%) cases. By multivariate analysis, depression was independently associated with lower education, absence of previous kidney transplant, anxiety, higher cognitive distortion, lower psychological resilience, and lower quality of life scores. In conclusion, lower psychological resilience, lower education level, and higher cognitive distortions are factors associated with depression and anxiety in ESRD patients.

Assessment of Factors Related to Diminished Appetite in Hemodialysis Patients with a New Adapted and Validated Questionnaire.

Appetite loss is a common phenomenon in end-stage renal disease (ESRD) patients undergoing maintenance hemodialysis (HD). We aimed to (i) adapt and validate a Spanish language version of the Council on Nutrition Appetite Questionnaire (CNAQ) and (ii) to identify psychological and biological factors associated with diminished appetite. We recruited 242 patients undergoing HD from four hemodialysis centers to validate the Spanish-translated version of the CNAQ. In another set of 182 patients from three HD centers, the Appetite and Diet Assessment Tool (ADAT) was used as the gold standard to identify a cut-off value for diminished appetite in our adapted questionnaire. The Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Distorted Thoughts Scale (DTS), Dialysis Malnutrition Score (DMS), anthropometric, values and laboratory values were also measured. Seven items were preserved in the adapted appetite questionnaire, with two factors associated with flavor and gastric fullness (Cronbach's alpha = 0.758). Diminished appetite was identified with a cut-off value ≤25 points (sensitivity 73%, specificity 77%). Patients with diminished appetite had a higher proportion of females and DMS punctuation, lower plasmatic level of creatinine, blood urea nitrogen, and phosphorus. Appetite score correlated with BDI score, BAI score and DTS. Conclusions: This simple but robust appetite score adequately discriminates against patients with diminished appetite. Screening and treatment of psychological conditions may be useful to increase appetite and the nutritional status of these patients.

[Short-term cardiovascular impact and change in the natural history of the disease after high-quality dialysis therapy]. / Impacto cardiovascular a corto plazo y cambio de la historia natural de la enfermedad tras terapia dialítica de alta calidad.

Se trata de hombre de 28 años de edad conocido previamente sano. Inició su cuadro con presencia de náuseas, vómitos y ataque al estado general. Durante la valoración se documentó nitrógeno ureico en sangre (BUN) 142 mg/dl y creatinina 12.8 mg/dl. Por recursos económicos limitados no fue posible inicio inmediato de terapia dialítica y solo se inició manejo médico. Tras progresión de la sintomatología, se inició terapia dialítica 10 meses después, recibiendo solamente dos sesiones por semana.