Alfonso M. Cueto-Manzano

Peritoneal Transport Kinetics Correlate With Serum Albumin But Not With the Overall Nutritional Status in CAPD Patients

The present study evaluates the influence of the peritoneal transport rate (PTR) on the nutritional status of continuous ambulatory peritoneal dialysis (CAPD) patients. Additionally, protein intake, dialysis adequacy, and other clinical variables were analyzed. Forty-two CAPD patients were concurrently subjected to the peritoneal equilibration test, a nutritional evaluation that included 24-hour dietary recall, and nutritional scoring system that included anthropometric, biochemical, and subjective parameters. Eight patients were high, 14 were high-average, 16 were low-average, and four were low transporters. Nine patients had normal nutritional status; six had mild, nine had moderate, and 18 had severe malnutrition. Malnutrition was inversely correlated (P < 0.05) with body surface, hemoglobin, and residual renal function, but not with PTR (r = 0.14; P = 0.38). In the multivariate analysis, the nutritional status was not predicted by the PTR, protein intake, or dialysis adequacy variables. When serum albumin (SA) level was evaluated as an isolated nutritional indicator, the most significant predictors were dialysate to plasma creatinine ratio at 4 hours (D/P4), body surface area, age, and diabetes mellitus. High transporters receiving a high dose of dialysis displayed a trend of having lower SA levels, whereas low-average transporters receiving a high dose of dialysis showed a trend of have higher SA levels. In conclusion, there was no correlation between PTR and nutritional status. In the multivariate analysis, no association was found between nutritional status and PTR, dialysis adequacy, and protein intake. The best predictors for SA are PTR, body surface area, age, and diabetes mellitus.

Pentoxifylline decreases serum levels of tumor necrosis factor alpha, interleukin 6 and C-reactive protein in hemodialysis patients: results of a randomized double-blind, controlled clinical trial

AIMnThe aim of this study was to compare the effect of pentoxifylline versus placebo on serum concentrations of tumor necrosis factor-alpha (TNF-α), interleukin 6 (IL-6) and C-reactive protein (CRP) of hemodialysis (HD) patients.nnnMETHODSnThis is a randomized double-blind, controlled clinical trial. HD patients without infection or drugs with anti-inflammatory effect were randomly allocated to a study (n = 18, pentoxifylline 400 mg/day) or control (n = 18, placebo) group; all patients had arteriovenous fistula. Besides clinical and laboratory monthly assessments, serum TNF-α and IL-6 (ELISA) and CRP (nephelometry) were measured at 0, 2 and 4 months.nnnRESULTSnAll the inflammation markers significantly (P < 0.05) decreased in the pentoxifylline group: TNF-α [baseline 0.4 (0-2) versus final 0 (0-0) pg/mL], IL-6 [baseline 9.4 (5-14) versus final 2.9 (2-5) pg/mL] and CRP [baseline 7.1 (3-20) versus final 2.6 (1-8) mg/L], whereas no significant changes were observed in the placebo group: TNF-α [baseline 0 (0-0) versus final 1.2 (0-4) pg/mL], IL-6 [baseline 8.0 (5-11) versus final 8.7 (4-11) pg/mL] and CRP [baseline 4.5 (2-9) versus final 3.8 (3-23) mg/L].nnnCONCLUSIONSnPentoxifylline significantly decreased serum concentrations of TNF-α, IL-6 and CRP compared to placebo. Pentoxifylline could be a promising and useful strategy to reduce the systemic inflammation frequently observed in patients on HD.

Peritoneal protein loss in patients with high peritoneal permeability: comparison between continuous ambulatory peritoneal dialysis and daytime intermittent peritoneal dialysis.

BACKGROUNDnDialysate protein loss is involved in the etiology of hypoalbuminemia and malnutrition on continuous ambulatory peritoneal dialysis (CAPD). Patients with high peritoneal membrane permeability had the lowest serum albumin (Alb) and highest dialysate protein concentrations and achieved higher small solute dialysis/plasma equilibration in a shorter time than patients with low peritoneal transport. The aim of this prospective crossover study was to evaluate whether protein loss might be decreased in patients with high peritoneal permeability on short dwell-time (DT) peritoneal dialysis.nnnMETHODSnFive high and nine high-average peritoneal transport patients were subjected to the following sequential dialysis schemes (four exchanges/day, glucose 1.5%): scheme A, three daytime exchanges (4-6 h DT) and one nightly (8-12 h DT) for 2-3 days, scheme B, 3-h DT each and dry peritoneum at night during 5 days, a wash-out period similar to scheme A, and scheme C, 2-h DT each and dry peritoneum the remainder of day and night during 5 days. Dialysate Alb, IgG, IgA, and IgM losses and adequacy of dialysis were evaluated at the end of each scheme.nnnRESULTSnDialysate IgM was not detected. All protein losses were reduced with the short DT dialysis schemes; however, dialysis CCl and KT/V(urea) were also decreased. In patients with high peritoneal transport type, the 3-h DT dialysis scheme achieved a reduction in Alb loss without significant reduction of adequacy of dialysis.nnnCONCLUSIONSnPeritoneal Alb, IgG, and IgA losses are significantly reduced in patients with high peritoneal permeability on short dwell-time dialysis and extended dry periods. However, a reduction of dialysis contribution to small solute clearances was also observed, Three-hour dwell-time dialysis may be particularly useful in patients with high peritoneal transport type, as it tends to reduce peritoneal protein loss without notably reducing adequacy of dialysis.

Prevalence of chronic kidney disease in an adult population.

BACKGROUND AND AIMSnOne strategy to prevent and manage chronic kidney disease (CKD) is to offer screening programs. The aim of this study was to determine the percentage prevalence and risk factors of CKD in a screening program performed in an adult general population.nnnMETHODSnThis is a cross-sectional study. Six-hundred ten adults (73% women, age 51xa0± 14 years) without previously known CKD were evaluated. Participants were subjected to a questionnaire, blood pressure measurement and anthropometry. Glomerular filtration rate estimated by CKD-EPI formula and urine tested with albuminuria dipstick.nnnRESULTSnMore than 50% of subjects reported family antecedents of diabetes mellitus (DM), hypertension and obesity, and 30% of CKD. DM was self-reported in 19% and hypertension in 29%. During screening, overweight/obesity was found in 75%; women had a higher frequency of obesity (41 vs. 34%) and high-risk abdominal waist circumference (87 vs. 75%) than men. Hypertension (both self-reported and diagnosed in screening) was more frequent in men (49%) than in women (38%). CKD was found in 14.7%: G1, 5.9%; G2, 4.5%; G3a, 2.6%; G3b, 1.1%, G4, 0.3%; and G5, 0.3%. Glomerular filtration rate was mildly/moderately reduced in 2.6%, moderately/severely reduced in 1.1%, and severely reduced in <1%. Abnormal albuminuria was found in 13%. CKD was predicted by DM, hypertension and male gender.nnnCONCLUSIONSnA percentage CKD prevalence of 14.7% was found in this sample of an adult population, with most patients at early stages. Screening programs constitute excellent opportunities in the fight against kidney disease, particularly in populations at high risk.

Multidisciplinary Strategies in the Management of Early Chronic Kidney Disease

Chronic kidney disease (CKD) is a worldwide epidemic especially in developing countries, with clear deficiencies in identification and treatment. Better care of CKD requires more than only economic resources, utilization of health research in policy-making and health systems changes that produce better outcomes. A multidisciplinary approach may facilitate and improve management of patients from early CKD in the primary health-care setting. This approach is a strategy for improving comprehensive care, initiating and maintaining healthy behaviors, promoting teamwork, eliminating barriers to achieve goals and improving the processes of care. A multidisciplinary intervention may include educational processes guided by health professional, use of self-help groups and the development of a CKD management plan. The complex and fragmented care management of patients with CKD, associated with poor outcome, enhances the importance of implementing a multidisciplinary approach in the management of this disease from the early stages. Multidisciplinary strategies should focus on the needs of patients (to increase their empowerment) and should be adapted to the resources and health systems prevailing in each country; its systematic implementation can help to improve patient care and slow the progression of CKD.

Retiro temprano de esteroides en una cohorte de trasplante renal tratada con tacrolimus, mofetil micofenolato y basiliximab

BACKGROUNDnAcute rejection and graft function have not been completely clarified in early-steroid-withdrawal (ESW) patients. The objective of this study was to compare the effect of early steroid withdrawal on GFR, graft survival/rejection in recipients in a cohort treated with tacrolimus/mycophenolate mofetil compared to a control cohort.nnnMATERIAL AND METHODnRetrospective cohort, in 60 low immunological risk recipients between December 2005 and July 2010. Study cohort (ESW-C N=32), steroid withdrawal was carried out after 5 days, while they were receiving tacrolimus/mycophenolate mofetil. The control cohort (C-C, N=28) received prednisone/tacrolimus/mycophenolate mofetil. Clinical, biochemical and histological variables were assessed at baseline and after 3, 6, and 12 months of follow-up. Kaplan-Meier and the Cox proportional hazards model were used to assess survival. Comparisons between cohorts were carried out by the Students t and c2 tests.nnnRESULTSnAt follow-up, C-C displayed significantly higher systolic (125 ± 10 vs. 114 ± 8) and diastolic (81 ± 8 vs. 72 ± 7) blood pressure, serum glucose (96 ± 13 vs. 86 ± 10), triglycerides (177 ± 61 vs. 129 ± 34), total (183 ± 43 vs. 148 ± 34) and LDL-cholesterol (100 ± 22 vs. 87 ± 25). C-C had a higher proportion of antihypertensive (57 vs. 13%), and statins (27 vs. 9%) use. eGFR was better in ESW-C than in C-C (85.4 ± 20.6 vs. 70.6 ± 17.0, p=.004). AR frequency was lower in ESW-C.nnnCONCLUSIONSnGraft survival, GFR, AR rate and metabolic profile were better in the ESW-C than in C-C.

Vascular Calcification in Mexican Hemodialysis Patients

BACKGROUND AND AIMSnVascular calcification (VC) is a predictor of poor survival and cardiovascular outcome in end-stage renal disease (ESRD) patients; however, there is scarce information of VC in Latin America, and virtually no data in our setting. We undertook this study to evaluate the prevalence and characteristics of VC in a hemodialysis (HD) population from western Mexico and to determine possible associated factors.nnnMETHODSnThis was a cross-sectional study performed in 52 patients. VC was evaluated using plain X-ray films (Adragaos score) of hands and pelvis; clinical and biochemical variables were also collected. Statistical analysis was carried out with Student t and χ(2) tests performed as appropriate and logistic regression to determine predictors of VC.nnnRESULTSnMean age was 43 years, 48% were female, 23% had diabetes mellitus (DM), and median time on dialysis was 46 months. Percentage prevalence was 52% with a mean calcification score of 2.0 ± 2.6; 23% of patients had severe calcification. VC was present in about 23-37% among the different vascular territories evaluated (radial, digital, femoral and iliac). Patients with calcification were significantly older, had a higher frequency of DM, higher alkaline phosphatase and lower HDL lipoproteins than those without VC. In the multivariate analysis, VC in these patients was significantly predicted only by an older age (OR [95% CI]: 1.15 [1.01-1.31], p = 0.04); lower HDL-cholesterol and higher alkaline phosphatase were marginal predictors.nnnCONCLUSIONSnHalf of our HD patients had VC. Territories of radial, iliac, femoral and digital arteries were roughly equally affected, and 25% of patients had a calcification considered as severe. Older age was the only significant predicting variable for VC, with low HDL-cholesterol and high alkaline phosphatase as marginal predictors.

Prevalence of Pica in Patients on Dialysis and its Association With Nutritional Status

OBJECTIVEnPica could be strongly implicated in nutritional status of patients on dialysis; however, very scarce data are currently available. The objective of this study was to evaluate the prevalence of pica and its association with nutritional status in dialysis patients.nnnDESIGN AND METHODSnThis is a cross-sectional study in a tertiary care teaching hospital. Four-hundred patients on dialysis, without previous pica diagnosis or transplant, pregnancy, mental illness, or infection, were included in the study. Pica, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, was classified as no pica, ice pica, or hard pica. Dialysis Malnutrition Score, 24-hour dietary recall, and biochemical measurements were obtained from patients. As part of statistical analysis, point prevalence and 95% confidence interval of pica were calculated. Comparisons between groups were performed by means of analysis of variance, Kruskal-Wallis test, χ2, or Fisher exact tests, as appropriate. A multivariate analysis was performed by multinomial logistic regression.nnnRESULTSnPrevalence of pica was 42% (ice pica, 46%; soil, 29%; two substances, 14%; red brick, 5%; paper, 3%; soap, 2%; and cattle pasture, 1%). Comparing patients with pica (hard pica and ice pica) versus no pica, subjects with pica were of younger age (25 ± 7, 27 ± 9, 30 ± 11 years, respectively), were more frequently educated <9 years (57%, 46%, 30%, respectively), and had longer dialysis duration (36 ± 19, 32 ± 18, 27 ± 16 months, respectively). Patients with pica achieved the recommended calorie and macronutrients intake target less frequently than those without pica (40-64% vs. 66-77%, P <.05). Malnutrition was present in 74% of the whole sample: (1) 67% in no pica group, (2) 80% in ice pica group, and (3) 89% in hard pica group (P = .001). In the multivariate analysis (R2, 0.27; Pxa0<xa0.0001), malnutrition, C-reactive protein, and lower educational level significantly predicted both ice and hard pica.nnnCONCLUSIONSnA worse nutritional status was observed in patients with pica, who additionally were younger, had lower educational level, longer dialysis duration, and worse macronutrient intake routine than patients without pica. Malnutrition, C-reactive protein, and lower educational level significantly predicted both ice and hard pica.

La disminución de triyodotironina se asocia con la elevación del péptido natriurético cerebral N-terminal y con la mortalidad en pacientes en diálisis

BACKGROUNDnLow thyroid hormone (TH) levels and myocardial damage are common in dialysis patients and are associated with mortality. However, little is known about the role of THs on myocardial damage as has been described in primary thyroid diseases. The aim of this study was to explore the potential relationship between low total triiodothyronine (total T3) and biomarkers of myocardial damage and the effect of their interaction on mortality, to ascertain if cardiovascular damage is the link between low THs and the risk of death in dialysis patients with CKD.nnnMATERIAL AND METHODSnTH plasma levels, nutritional markers, inflammation and myocardial damage were studied in 296 patients undergoing peritoneal dialysis or haemodialysis, who were followed up for 16 months to ascertain the association between biochemical variables and mortality.nnnRESULTSnLow total T3 levels were found in 45% of patients, which was inversely correlated with C-reactive protein (CRP) and NT-proBNP, and directly correlated with albumin and transferrin. Diabetes, CRP and total T3 were risk factors for all-cause mortality, and CRP, NT-proBNP and total T3 for cardiovascular mortality.nnnCONCLUSIONSnLow total T3 levels are common in dialysis patients and are associated with inflammation, malnutrition and myocardial damage. The latter may be the link between low THs and all-cause and cardiovascular mortality.

The Role of Primary Health Care Professionals

Chronic kidney disease (CKD) is a worldwide epidemic, especially in disadvantaged populations. Lack of economic resources is a clear constraint for improving kidney health in low-income countries and disadvantaged populations; therefore the employment of systematic strategies for prevention, screening, and treatment of CKD in the primary health-care setting would always be an opportunity to improve kidney health and to optimize resources in such limited environments. Under these circumstances, efforts should be focused on primary prevention and timely detection and management at the earliest CKD stages. This chapter describes the role of primary health-care professionals and the multidisciplinary approach in the prevention and management of kidney disease, focusing on patient education to increase empowerment and for the health-care team to improve clinical competence and employ a systematized attention model as the basis for prevention, and early diagnosis and treatment of CKD.