Domingos O. d'Avila

Quality of life and sexuality in chronic dialysis female patients.

Patients in end-stage renal disease (ESRD) present reduced quality of life (QOL) and impaired sexual function. Previous studies have mostly addressed male sexual dysfunction. This was a cross-sectional controlled study that applied a general and the World Health Organization Quality of Life-bref© questionnaires to assess demographic, marital, and sexual conditions, and QOL in 86 healthy women aged 18 or more years (Group 1), and 38 female ESRD patients on dialysis for at least 2 months (Group 2). The effect of several explanatory variables upon QOL components was estimated. Quality of life was lower in Group 2 – overall, and on physical and environment domains. To undergo dialysis and to be poorly educated negatively affected the QOL. Yet age, a stable marital relationship or being sexually active had no effect. Female patients undergoing chronic dialysis had lower QOL and were significantly more sexually dysfunctional than comparable healthy women. Decline in sexual function had no effect on the QOL.

Acute renal failure needing dialysis in the intensive care unit and prognostic scores.

Background: Generic prognostic scores used in acute renal failure (ARF) give imprecise results; disease‐specific indices applied to distinct populations or intensive care practices becomes inaccurate. The current study evaluates the adequacy of prognostic scores, in patients with severe ARF needing dialysis. Methods: Known generic (APACHE II) and disease‐specific (ATN‐ISS) indices were applied to a cohort (n = 280) with ARF needing dialysis, under intensive care. Possible risk factors as causal factors, organ dysfunctions and clinical variables were examined, and a local index assembled by multivariate logistic regression analysis. Area under the receiver operating characteristics (ROC) curves evaluated the indices discriminating capacity. Goodness‐of‐fit testing and linear regression analysis appraised calibration. Validation was accomplished by the bootstrapping technique. The end‐point was hospital mortality. Results: Overall mortality was 85%. Female gender < 44 years (OR: 0.29; 95% CI: 0.10–0.84), liver/obstructive biliary disease (OR: 6.03; 95%CI: 1.65–22.08), being conscious (OR: 0.49; 95%CI: 0.21–1.14), use of vasoactive drug (OR: 3.13; 95%CI: 1.25–7.83), respiratory dysfunction (OR: 5.20; 95%CI: 1.25–7.83) or sepsis (OR: 2.62; 95%CI: 1.14–6.02) were associated with outcome. Areas under the ROC curve of 0.815, 0.652 and 0.814; Goodness‐of‐fit test P = 0.593, P < 0.001 and P = 0.002; and linear regression R2 = 0.973, R2 = 0.526 and R2 = 0.919 for the local index, APACHE II and ATN‐ISS, respectively, indicate better performance by the local index. The local index median area under the ROC curve, by bootstrapping, was 0.820 (95% CI: 0.741–0.907). Conclusions: APACHE II score was inaccurate, and ATN‐ISS poorly calibrated. When mortality or intensive care practices significantly deviate, local scores may better evaluate prognosis in severe ARF.

Low response to intradermal hepatitis B vaccination in incident hemodialysis patients

INTRODUCTION Hepatitis B (HB) may progress to cirrhosis and liver carcinoma. Its prevalence is estimated at 3.2 % in hemodialysis (HD) patients. HB vaccine when applied intramuscularly (IM) in end-stage renal disease patients often does not induce appropriate antibody titers. However, there has been suggestion for intradermal (ID) to be a more effective inoculation method. OBJECTIVE To compare the immune response to IM or ID vaccine administration on HD patients. PATIENTS AND METHODS Thirty one incident HD patients were randomly assigned alternately to IM or ID vaccine inoculation. Vaccine doses were applied at three monthly intervals, with patients being followed-up for six months. Sixteen patients were assigned to IM (40 mg/dose) and 15 to ID (4 mg/dose) vaccine administration. HB-virus surface antibody titer, hematimetric parameters, serum urea level and Kt/V were monthly evaluated. C-reactive protein, parathormone, ferritin, aminotransferases and albumin serum levels were evaluated before and at the sixth month of the initial inoculation. RESULTS Urea levels were significantly higher in the ID group (P(1) = 0.031); ferritin levels were higher in the IM (P(2) = 0.037) and C-reactive protein levels tended to be higher in the ID group. An interim evaluation by the Safety Monitoring Committee recommended discontinuing the study as IM vaccination had converted 62.5% of the exposed subjects, while ID inoculation converted only 13.3%. CONCLUSION As performed, ID applied vaccine was inferior to the IM inoculation. Such result may depend on the inoculated doses or some other factor, such as inflammation.

Two Variable Sodium Profiles and Adverse Effects During Hemodialysis: A Randomized Crossover Study

Intradialytic symptomatic hypotension and muscle cramps are frequent and disturbing adverse effects involving hemodialysis patients. The use of sodium profiling has been a proposed approach to preclude such events. The aim of the study was to compare the frequency of intradialytic adverse effects and changes in anthropometric and physiological variables without profiling and with two distinct sodium profiles. A prospective study randomized 22 stable hemodialysis patients to receive either a step (11 patients) or a linear (11 patients) dialysate sodium profile for 12 consecutive sessions, following a 12‐session steady sodium control period. After a wash‐out period of 12 sessions, the groups were crossed over for another 12‐session period. Frequency of adverse effects, interdialytic weight gain, pre‐ and post‐dialysis blood pressure were computed. The frequency of intradialytic adverse effects was significantly different between the control and either the step or linear periods (48.5%, 33.7%, and 36.0%, respectively; P < 0.001). No significant differences in interdialytic weight gain or pre‐dialysis blood pressure were detected between treatment periods. The mean post‐dialysis systolic blood pressure was lower in the linear period (128 ± 21; 127 ± 20; 123 ± 22 mm Hg, for the control, step and linear periods, respectively; P = 0.014). Seven patients benefited from sodium profiling, yet two became more symptomatic. Overall, both sodium profiles were associated with fewer intradialytic adverse effects. Intradialytic symptomatic hypotension occurred less often with the step profile, while a tendency to fewer cramps was associated with the linear profile. However, sodium profiling may not benefit every dialysis patient and should be individually evaluated.

Comparação entre duas técnicas de higienização das mãos em pacientes de diálise peritoneal

INTRODUCTION Hand hygiene is an important procedure in preventing peritoneal dialysis-related infections. OBJECTIVE To compare the effectiveness of two distinct techniques for hand hygiene in reducing the number of colony-forming units in patients on peritoneal dialysis. MATERIALS AND METHOD Controlled clinical trial. Thirty patients underwent three collections of microbiological flora from the hands in three different instances: before and after hand washing with glycerin soap and water, and after rubbing 70% glycerin gel-alcohol. Cultures were obtained by applying the fingers surface directly on agar-blood plates. RESULTS Cultures mean growth were 31, 30 e 12 colony-forming units prior to washing, after washing with glycerin soap and water, and following gel-alcohol, respectively (p < 0.001). Staphylococcus epidermidis was the predominant germ in culture, occurring in 93.7% of seeded plates. CONCLUSION Hand rubbing with gel-alcohol was more effective in reducing the number of colonies recovered than the other methods.INTRODUCTION: Hand hygiene is an important procedure in preventing peritoneal dialysis-related infections. OBJECTIVE: To compare the effectiveness of two distinct techniques for hand hygiene in reducing the number of colony-forming units in patients on peritoneal dialysis. MATERIALS AND METHOD: Controlled clinical trial. Thirty patients underwent three collections of microbiological flora from the hands in three different instances: before and after hand washing with glycerin soap and water, and after rubbing 70% glycerin gel-alcohol. Cultures were obtained by applying the fingers surface directly on agar-blood plates. RESULTS: Cultures mean growth were 31, 30 e 12 colony-forming units prior to washing, after washing with glycerin soap and water, and following gel-alcohol, respectively (p < 0.001). Staphylococcus epidermidis was the predominant germ in culture, occurring in 93.7% of seeded plates. CONCLUSION: Hand rubbing with gel-alcohol was more effective in reducing the number of colonies recovered than the other methods.

Avaliação de programa de ensino-aprendizagem sobre metabolismo de cálcio e fósforo para pacientes em hemodiálise

This cohort study evaluated the effects of an educational program about metabolism and control of serum levels of calcium (Ca), phosphorus (PO4), parathormone (PTH), Ca x PO4 product on 33 stable patients on hemodialysis. Patients were randomized into two groups: control (n = 17) and intervention (n = 16). The control group received information on vascular access. The intervention group was informed about Ca, PO4 and PTH metabolism.The changes in knowledge were evaluated using tests. Treatment compliance was assessed by serial laboratory tests. No significant change was observed in their knowledge [intervention: 8/17 vs. 14/17 competent patients before and after class, respectively (P < 0.001); control: 11/16 vs. 13/16 competent patients, respectively (P < 0.001)]. A reduction was observed in PO4 and Ca x PO4 product between time 0 and 1 in both groups and between time 1 and 2 in the control group. The program did not induce changes in knowledge or behavior. In conclusion, chronic renal patients should be offered continuous educational programs.Estudio de cohorte evaluando efectos de programa de ensenanza-aprendizaje sobre el metabolismo y control de niveles sericos de calcio (Ca), fosforo (PO4), parathormona (PTH), producto Ca x PO4 en 33 pacientes estables en HD, randomizados para dos grupos: Control (n=17) e Intervencion (n=16). El grupo Control recibio informacion sobre acceso vascular; el grupo Intervencion, sobre metabolismo de Ca, PO4 y PTH. Cambios de conocimiento evaluadas por pruebas pre y post clases, adhesion a la terapia por dosajes laboratoriales seriados. No existio cambio significativo de conocimiento en cualquier grupo [Intervencion: 8/17 vs 14/17 pacientes competentes en las etapas pre y post prueba, respectivamente (P<0,001); Control: 11/16 vs. 13/16 pacientes competentes, respectivamente (P<0,001)]. Existio reduccion de PO4 y producto Ca x PO4 entre momentos 0 y 1 en ambos grupos y entre momentos 1 y 2 en el grupo Control. El programa no indujo cambios de conocimiento o comportamiento. Los programas de ensenanza-aprendizaje para enfermos renales cronicos deben ser continuos.

Intramuscular or intradermal hepatitis B vaccine administration in hemodialysis patients

3.3% in the ID group. The study was interrupted by the afety Monitoring Committee. Antibody titers to hepatitis B urface antigen during the observation period per group are hown in Fig 1. Contrary to previous studies assessing stable patients for a onger treatment period, our cohort comprised patients who ere starting on HD therapy. Moreover, it is possible that arly interruption of the study prevented detection of signifiant differences that eventually may have arisen later. It also s possible that the lower response to ID inoculation ocurred because of multiple factors; for example, there was ome evidence of inflammation in this group, an observation ith significance that cannot be discarded. Thus, to explain the different responses obtained in our tudy versus that of Barraclough et al, several possibilities ight be considered: revaccination versus initial immunizaion, prevalent versus incident individuals, patient clinical onditions, characteristics of the populations at risk, or erhaps the different interval between vaccine and doses.

Depression, quality of life, and body composition in patients with end-stage renal disease: a cohort study

Objective: To prospectively evaluate depressive symptoms, nutritional status, and quality of life (QoL) and search for possible associations in patients with end-stage renal disease undergoing hemodialysis. Methods: A cohort study of 104 adult patients with end-stage renal disease undergoing hemodialysis was conducted. Anthropometric, clinical, and biochemical variables were evaluated after a midweek hemodialysis session. The participants’ body composition was assessed by direct segmental multi-frequency bioimpedance analysis. The WHOQOL-Bref questionnaire was used to evaluate QoL. Participants were separated into two groups - depressive symptoms and no depressive symptoms - at inclusion and evaluated annually for 2 years thereafter using the Beck Depression Inventory. Survival analysis used the Kaplan-Meier method and Cox regression analysis for the goodness of fit of associated factors. All-cause mortality was the outcome of interest. Results: Participants’ mean age was 55.3±15.6 years, 60% were male, and the median time on hemodialysis was 17.5 (8.0-36.8) months. Thirty-two patients had depressive symptoms and a significantly lower QoL compared with the 72 patients in the no depressive symptoms group. The fitted outcome model showed that lean body mass had a protective effect against all-cause mortality (hazard ratio [HR] = 0.89; 95%CI 0.80-0.99; p = 0.038). Conclusion: Depressive symptoms were highly prevalent in the cohort, and correlated with the physical and psychological components of the QoL life questionnaire, as well as with C-reactive protein and phosphorus levels. Lean body mass was protective for the assessed outcome.

Effect of standard and neutral-pH peritoneal dialysis solutions upon fibroblasts proliferation

INTRODUCTION Continuous exposition of the peritoneal membrane to conventional dialysis solutions is an important risk factor for inducing structural and functional alterations. OBJECTIVE To compare in vitro mouse fibroblast NIH-3T3 cell viability after exposition to a neutral pH dialysis solution in comparison to cells exposed to a standard solution. METHODS Experimental study to compare the effects of a conventional standard or a neutral-pH, low-glucose degradation products peritoneal dialysis solution on the viability of exposed fibroblasts in cell culture. Both solutions were tested in all the commercially available glucose concentrations. Cell viability was evaluated with tetrazolium salt colorimetric assay. RESULTS Fibroblast viability was significantly superior in the neutral pH solution in comparison to control, in all three glucose concentrations (Optical density in nm-means ± SD: 1.5% 0.295 ± 0.047 vs. 0.372 ± 0.042, p < 0.001; 2.3% 0.270 ± 0.036 vs. 0.337 ± 0.051, p < 0.001; 4.25% 0.284 ± 0.037 vs. 0.332 ± 0.032, p < 0.001; control vs. neutral pH respectively, Student t Test). There was no significant difference in cell viability between the three concentrations of glucose when standard solution was used (ANOVA p = 0.218), although cell viability was higher after exposition to neutral pH peritoneal dialysis fluid at 1.5% in comparison to 2.3 and 4.25% glucose concentrations (ANOVA p = 0.008: Bonferroni 1.5% vs. 2.3% p = 0.033, 1.5% vs. 4.25% p = 0.014, 2.3% vs. 4.25% p = 1.00). CONCLUSION Cell viability was better in neutral pH dialysis solution, especially in the lower glucose concentration. A more physiological pH and lower glucose degradation products may be responsible for such results.

Solutes transport characteristics in peritoneal dialysis: variations in glucose and insulin serum levels.

Background. Differences in small solutes transport rate (SSTR) during peritoneal dialysis (PD) may affect water and solutes removal. Patients with high SSTR must rely on shorter dwell times and increased dialysate glucose concentrations to keep fluid balance. Glucose absorption during peritoneal dialysis (PD), besides affecting glucose and insulin metabolism, may induce weight gain. The study aimed at examining acute glucose and insulin serum level changes and other potential relationships in PD patients with diverse SSTR. Methods. This cross-sectional study used a modified peritoneal equilibration test (PET) that enrolled 34 prevalent PD patients. Zero, 15, 30, 60, 120, 180, and 240-minute glucose and insulin serum levels were measured. Insulin resistance index was assessed by the homeostasis model assessment (HOMA-IR) formula. SSTR categories were classified by quartiles of the four-hour dialysate/serum creatinine ratio (D4/PCr). Demographic and clinical variables were evaluated, and the body mass index (BMI) was estimated. Correlations among variables of interest and categories of SSTR were explored. Results. Glucose serum levels were significantly different at 15, 30, and 60 minutes between high and low SSTR categories (p = 0.014, 0.009, and 0.022). Increased BMI (25.5 ± 5.1) and insulin resistance [HOMA-IR = 2.60 (1.40–4.23)] were evidenced overall. Very strong to moderate correlations between insulin levels along the PET and HOMA-IR (r = 0.973, 0.834, 0.766, 0.728, 0.843, 0.857, 0.882) and BMI (r = 0.562, 0.459, 0.417, 0.370, 0.508, 0.514, 0.483) were disclosed. Conclusions. Early glucose serum levels were associated with SSTR during a PET. Overweight or obesity and insulin resistance were prevalent. An association between insulin serum levels and BMI was demonstrated.