Cácia Mendes Matos

Depression as a Potential Explanation for Gender Differences in Health-Related Quality of Life among Patients on Maintenance Hemodialysis

Background/Aims: The reasons for lower health-related quality of life (HRQOL) scores in women compared to men on maintenance hemodialysis (MHD) are unknown. We investigated whether depression accounts for gender differences in HRQOL. Methods: Cross-sectional study of 868 (40.9% women) Brazilian MHD patients (PROHEMO Study). We used the Kidney Disease Quality of Life Short Form to assess HRQOL and the Center for Epidemiological Studies Depression (CES-D) scale (scores from 0–60) to assess depression with scores ≧18 indicating high depression probability. Results: Higher depression scores were associated with lower HRQOL in both sexes. Women had higher depression scores; 51.8% of women versus 38.2% of men (p < 0.001) had CES-D scores ≧18. Women scored lower on all 9 assessed HRQOL scales. The female-to-male differences in HRQOL were slightly reduced with inclusion of Kt/V and comorbidities in regression models. Substantial additional reductions in female-to-male differences in all HRQOL scales were observed after including depression scores in the models, by 50.9% for symptoms/problems related to renal failure, by 71.6% for mental health and by 87.1% for energy/vitality. Conclusions: Lower HRQOL among women was largely explained by depression symptoms. Results support greater emphasis on treating depression to improve HRQOL in MHD patients, particularly women.

Handgrip Strength as a Simple Indicator of Possible Malnutrition and Inflammation in Men and Women on Maintenance Hemodialysis

OBJECTIVE To assess the validity of handgrip strength (HGS) as a simple screening instrument for malnutrition and inflammation in patients on maintenance hemodialysis (MHD) by correlating it with malnutrition-inflammation score (MIS). DESIGN Cross-sectional analysis of the Prospective Study of the Prognosis in Chronic Hemodialysis Patients (PROHEMO). SETTING Satellite dialysis units in the city of Salvador, Brazil. PATIENTS The sample included 274 men and 162 women on MHD. MAIN PREDICTOR VARIABLE: HGS was chosen as the main predictor variable in this study. MAIN OUTCOME MEASURE An MIS ≥6. RESULTS As compared with men, women were found to have lower HGS values (19.38 ± 6.48 kg vs. 29.07 ± 8.67 kg; P < .001) and higher MIS (6.38 ± 3.84 vs. 5.57 ± 3.39; P = .032). HGS was found to be inversely correlated with MIS among women (Spearmans ρ = -.360; P < .001) as well as men (Spearmans ρ = -0.384; P < .001); this inverse correlation was observed in patients with and without diabetes, different racial groups, younger and older subjects, incident (<3 months) and prevalent patients, in the case of both genders. Among both men and women, every one standard deviation lower of HGS was associated with more than two-fold higher odds for MIS ≥6, after adjusting for age, race, duration of dialysis, and Kt/V. These associations remained statistically significant after more extensive adjustments. The optimized cutoff point of HGS for MIS ≥6 was 28.3 kg for men (sensitivity = 70.0%; specificity = 66.0%) and 23.4 kg for women (sensitivity = 87.0%; specificity = 43.0%). CONCLUSIONS Lower HGS values were independently associated with higher MIS among patients on MHD across several subgroups. These results suggest that HGS is a valid screening instrument for malnutrition and inflammation in patients on MHD.

Comparações de medidas de qualidade de vida entre mulheres e homens em hemodiálise

OBJECTIVE: To compare men and women on chronic hemodialysis in relation to their scores in health-related quality of life (HRQOL) and evaluate the potential influence of age and comorbidities on the comparison. METHODS: Cross-section of the baseline data of 254 women and 349 men, participants of the PROHEMO Study that has been developed in dialysis units of Salvador. By using the version of the Kidney Disease Quality of Life Short Form KDQOL-SF, validated for the Brazilian population, the following scores were determined: physical component summary (PCS), mental component summary [MCS] and the scale for symptoms/problems related to renal disease. The PCS and MCS scores were derived from the eight generic KDQOL-SF scales. Multiple linear regression was used to estimate differences in the scores of men and women (DS), adjusted for age, years on hemodialysis, heart failure, cerebrovascular disease, peripheral vasculopathy, diabetes, serum hemoglobin and serum albumin. RESULTS: Mean ages were 48.1±14.1 and 49.4±14.0 years for women and men, respectively. Women had lower scores for all generic HRQOL scales. They also had significantly (P<0.001) lower scores for PCS (DS = 2.4 points), MCS (DS = 3 points) and symptoms/problems (DS = 6.6 points). Differences were independent of comorbidties and greater in the group over 49 years of age. CONCLUSION: Data indicate that for several scales of HRQOL, women treated chronically by hemodialysis had lower scores than men. Lower scores in women were observed for different age groups, independently of comorbidities.

Prescription of phosphorus binders and calcitriol for chronic hemodialysis patients

OBJECTIVE To describe the frequency of prescription of phosphate binders (PB) and calcitriol for patients on chronic hemodialysis in Salvador, Brazil, and to assess whether treatment is in agreement with recommendations of the Kidney Disease Outcomes Quality Initiative (K/DOQI). METHODS Cross section of baseline data of the PROHEMO study. The frequency of prescription of PB and calcitriol according to laboratory indicators of mineral metabolism was compared with K/DOQI recommendations. RESULTS Sevelamer alone (i.e., not combined with other PB) was prescribed for 45.4% of patients, calcium carbonate (CaCO3) alone for 26.5%, sevelamer combined with CaCO3 for 2.1% and calcium acetate for 5.2%. Prescription of PB was noted in 53% of the patients with phosphorus <3.5 mg/dL and 40% with phosphorus <3.0 mg/dL. In disagreement with K/DOQI, prescription of calcitriol was found in 19% of patients with PTH<150 pg/mL and prescription was absent for approximately 35.4% with PTH>300 pg/dL combined with phosphorus equal or less than 5.5 mg/dL, calcium equal or less than 9.5 mg/dL and calcium x phosphorus product (CaxP)<55 mg2/dL2. For this latter group 38% had a prescription of sevelamer without other phosphate binders. CONCLUSION Results show a large percentage of prescriptions of sevelamer among patients on maintenance hemodialysis in a Brazilian city, despite the high cost of the medication and absence of contraindications for PB with calcium salts. Results in patients with PTH<150 pg/mL and with PTH>300 pg/mL combined with certain concentrations of calcium, phosphate and CaxP also indicate the need to evaluate practices for use of phosphate binders and calcitriol.

Prevalence and management of anemia in hemodialysis patients in a Brazilian population of predominantly African descent.

Background/Objective Findings from the international DOPPS indicated a rise in hemoglobin levels for patients on maintenance hemodialysis (MHD) for more than 180 days across many countries with more than 60% with hemoglobin ≥11 g/dl. However, the situation of anemia control for a large contingent of the hemodialysis population remains unknown. Studies in the United States indicate that hemoglobin level is lower for African Americans on MHD, but studies in other populations of African descent are lacking. We investigated the prevalence of, and associated factors for, hemoglobin ≤11 g/dl in MHD patients from the Brazilian city with the largest proportion of African descendants outside Africa. Methods Cross-sectional study of 1,263 MHD patients enrolled in the Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO) in Salvador, Brazil 2005-2009. Results 88.0% black or mixed race; age 49.0 ∓ 14.7 years; 96.6% receiving erythropoietin, median = 6,000 units/week. In patients on MHD for more than 180 days, 67.4% had hemoglobin ≤11 g/dl. Factors associated with hemoglobin≤11 g/dl were MHD by catheter (odds ratio (OR) = 3.03, 95% confidence interval (CI) = 1.43-6.42), hospitalization in prior 3 months (OR = 2.14, 95% CI = 1.20-3.83), transferrin saturation ≤20% (OR = 1.49, 95% CI = 1.05-2.12) and higher malnutrition-inflammation score (OR = 1.58 per each log-transformed unit, 95% CI = 1.14-2.19). Conclusions The results suggest that iron deficiency, insufficient erythropoietin dose, catheter use, malnutrition-inflammation, and problems associated with hospitalization are explanations for the high prevalence of hemoglobin below the guideline target in MHD patients from a large African descent Brazilian population. These results have implications for understanding the lower hemoglobin concentration in MHD populations of African descent.

Sex-age-specific handgrip strength and mortality in an incident hemodialysis cohort: The risk explained by nutrition and comorbidities

Objective: To investigate associations of sex-age-specific handgrip strength by a dynamometer with all-cause mortality and the percent excess risk explained (%ERE) by comorbidities and nutritional indicators in incident maintenance hemodialysis patients. Methods: Prospective cohort of 413 adult patients (165 women, 248 men, 299 <60 years and 114 ⩾60 years) with <6 months (82% <3 months) on dialysis enrolled in PROHEMO in Salvador, Brazil. Low and high handgrip strength groups were based on sex-age-specific cutoffs (17.8 kg for women <60 years, 13.8 kg for women ⩾60 years, 29.5 kg for men <60 years, and 21.9 kg for men ⩾60 years). We used Cox regression to estimate the mortality hazard ratio. The %ERE was determined by the equation (HR1 – HR2)/(HR1 – 1) × 100, in which HR1 represented the hazard ratio in a model with a smaller number of covariates and HR2 represented the hazard ratio in a subsequent model with the inclusion of new covariates plus the variables included in the previous model. Results: The mortality hazard ratio comparing low and high handgrip strength was 2.58 (95% confidence interval: 1.73, 3.85) in the model with sociodemographic factors and vintage and 2.25 (95% confidence interval: 1.49, 3.43) with addition of comorbidities, corresponding to a %ERE of 21%. The hazard ratio was 1.98 (95% confidence interval: 1.29, 3.06) after addition of nutritional indicators corresponding to %ERE of 38%. Results stratified by age and gender followed similar patterns. Conclusion: These results provide support for the assessment of handgrip strength in all maintenance hemodialysis patients for early identification of those who may require special care to improve nutritional status and survival.

A 3-day diary of dietary protein and calorie intake by serum phosphate concentration and binder use in hemodialysis patients

Introduction: The use of phosphate binders to control hyperphosphatemia may allow diets less restricted in protein and calories for maintenance hemodialysis (MHD) patients. The study compared intakes of protein, calorie and phosphate among MHD patients with different serum phosphate concentrations, taking into account binder use. The hypothesis was that low serum phosphate would be associated with low intakes of protein and calories only in patients not on binders. Methods: A cross-sectional study of 443 patients enrolled in the Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO) in Salvador, Brazil, with stratified sampling on serum phosphate: ≤3.0 (n = 41), 3.5-5.5 (n = 328) and ≥7.0 mg/dL (n = 74). A 3-day diet diary was used to determine dietary intakes. Results: Approximately 49.0% confirmed binder use. Covariate-adjusted linear regression showed that associations between dietary intakes and serum phosphate were modified by the binder use. In patients not on binders, protein intake was >20% lower for serum phosphate ≤3.0 mg/dL compared to higher concentrations. Also in those not on binders, calorie intake was >30% lower for serum phosphate ≤3.0 mg/dL compared to ≥7.0 mg/dL. Differences in dietary intakes by serum phosphate were virtually absent in patients on binders. Conclusions: The results are consistent with the hypothesis that low serum phosphate is associated with low protein and calorie intake only among MHD patients not on binders. This study supports recommendations to prevent hyperphosphatemia in MHD patients by adequate combination of binder use and selection of foods restricted in phosphors but not severely restricted in protein and calories.

Associations of physical activity energy expenditure with nutritional-inflammatory markers in hemodialysis patients

Background Sedentariness, high inflammation status and malnutrition are highly prevalent in end-stage kidney disease patients on maintenance hemodialysis (MHD). This study investigated associations of weekly physical activity energy expenditure (PAEE) with clinical and anthropometric markers of nutrition and inflammation. Methods The analysis was performed using baseline cross-sectional data of 640 patients enrolled in the prospective cohort “The Prospective Study of the Prognosis of Patients Treated Chronically by Hemodialysis” (PROHEMO) developed in Salvador, BA, Brazil. The long version of the International Physical Activity Questionnaire was used to determine a summary measure of PAEE, the metabolic equivalent of task (MET), taking into account physical activities related to occupation, recreation, travel, sports, and housework. PAEE was the predictor variable. To assess associations of PAEE with outcomes, the sex-age-specific median MET was used. The malnutrition-inflammation score (MIS) with range of 0 to 30 (higher is worse), conicity index as indicator of abdominal adiposity and C-reactive protein (CRP) were the nutritional-inflammatory outcomes. Results The mean age of the patients was 48.9 ± 13.8 y, 60.3% were males, 16.7% diabetic, 88.1% nonwhite. In multivariable logistic regression models with adjustments for sociodemographic variables and comorbidities, PAEE ≤median was associated with MIS ≥6 (odds ratio [OR] = 1.57; 95% confidence interval [CI] = 1.08, 2.29), conicity index ≥1.3 (OR = 1.52, 95% CI = 1.03, 2.23) and CRP >1.30 mg/dL (OR = 1.69, 95% CI = 1.08, 2.84). Conclusions Greater physical activity assessed by PAEE was associated with indicators of better nutritional and inflammation status. These results indicate opportunities for improving outcomes in MHD patients by counseling and treatment intervention.