Fernando Saldanha Thomé

Diálise Crônica no Brasil - Relatório do Censo Brasileiro de Diálise, 2011

INTRODUCAO: Dados nacionais sobre dialise cronica sao fundamentais para o planejamento do tratamento. OBJETIVO: Descrever resultados do censo de dialise da Sociedade Brasileira de Nefrologia referentes a 2011 e tendencias observadas de 2000 a 2011. METODOS: Levantamento utilizando questionario preenchido “on-line” pelas unidades de dialise do Brasil usando julho de 2011 como referencia para estimativas. Do total de 643 unidades com programa dialitico cronico, 353 (54,9%) responderam. RESULTADOS: O numero estimado de pacientes em dialise no Brasil em 2011 foi [...]INTRODUCTION National data on maintenance dialysis are important for treatment planning. AIM To describe the results of the dialysis census of the Brazilian Society of Nephrology for 2011 and observed trends from 2000 to 2011. METHODS A survey was conducted using questionnaire filled online by the dialysis units, with July as reference month for estimates. From a total of 645 units, 353 (54.9%) responded to the survey. RESULTS The estimated number of patients on dialysis in Brazil was 91,314 in 2011 (42,629 in 2010; 92,091 in 2011). For approximately 85% of the patients the treatment was provided by the Brazilian Unified Health Care System. The estimated prevalence and incidence rates in 2011 were 475 and 149 maintenance dialysis patients per million population, respectively. For prevalent patients, 90.6% were on hemodialysis, 31.5% 65 years of age or older, 28% diabetic and 35.5% (n=32,454) on waiting list for transplantation in 2011. The estimated number of patients starting dialysis in 2011 was 28,680 (18,972 in 2010) and annual mortality rate 19.9% (17.9% in 2010). CONCLUSIONS The data indicate pronounced increase in the dialysis population across the years in Brazil with a trend for stabilization in the last two years. The reason for the increase in incidence and mortality in 2011 deserves investigation. A large number of patients were on waiting list for renal transplantation. By providing a picture of the situation and trends on maintenance dialysis treatment in Brazil the census is useful to guide resources allocation and interventions to improve treatment quality.

Relatorio do Censo Brasileiro de Dialise Cronica 2012

INTRODUCTION National chronic dialysis data are fundamental for treatment planning. OBJECTIVE To report data of the annual survey of the Brazilian Society of Nephrology about chronic kidney disease patients on dialysis in July 2012. METHODS A survey based on data of dialysis units from the whole country. The data collection was performed by using a questionnaire filled out on-line by the dialysis units in Brazil. RESULTS 255 (31.9%) of the dialysis units in the country answered the questionnaire. In July 2012, the total estimated number of patients on dialysis in the country was 97,586. The estimated prevalence and incidence rates of chronic kidney disease on maintenance dialysis were 503 and 177 patients per million population, respectively. The estimated number of new patients starting dialysis in 2012 was 34,366. The annual gross mortality rate was 18.8%. For prevalent patients, 31.9% were aged 65 years or older, 91.6% were on hemodialysis and 8.4% on peritoneal dialysis, 30,447 (31.2%) were on a waiting list of renal transplant, 28.5% were diabetics, 36.6% had serum phosphorus > 5.5 mg/dl and 34.4% hemoglobin < 11 g/dl. A venous catheter was the vascular access for 14.5% of the hemodialysis patients. CONCLUSION The prevalence and incidence rates of chronic kidney disease patients on dialysis increased, while the mortality rate tended to decrease compared with 2011. The indicators of the quality of maintenance dialysis remained stable with a trend towards decrease in levels of anemia. The data highlight the importance of the census to guide chronic dialysis therapy.

Risk factors for postoperative acute renal failure at a new orthotopic liver transplantation program.

ACUTE RENAL failure (ARF) is a frequently observed complication during the postoperative period of orthotopic liver transplantation (OLT) when the rate of reported renal failure varies according to the postoperative period and serum creatinine levels considered. Although some patients require dialysis, most recover normal renal function. ARF is one of the most frequent causes of morbidity and mortality after OLT, and Nuno et al indicate a 7.8 higher probability of mortality in patients who have undergone ARF, and 15 times higher than that for those patients who required dialysis. Various factors are outstanding in the preoperative and postoperative periods, as well as during surgery, which could explain the occurrence of ARF. Preoperative factors include: diabetes mellitus, a history of ascites and encephalopathy, and previous kidney lesion. Crawford et al described the occurrence of glomerular lesions as universal to all patients with end-stage liver disease. During surgery, hypovolemia, the number of packed red blood cell (PRBC) units required and the time of total ischemia are described as associated factors. Several series correlate the use of nephrotoxic drugs, such as cyclosporine A (CyA), as a factor which could contribute to renal lesions. However, this may also be the result of complications such as sepsis and multiorgan failure. The purpose of this study is to assess the factors associated with the development of renal failure during the immediate postoperative period of an initial OLT program.

Inquérito Brasileiro de Diálise Crônica 2014

INTRODUCTION National chronic dialysis data have had impact in the treatment planning. OBJECTIVE To report data of the annual survey of the Brazilian Society of Nephrology about chronic kidney disease patients on dialysis in July 2014. METHODS A survey based on data of dialysis units from the whole country. The data collection was performed by using a questionnaire filled out on-line by the dialysis units. RESULTS Three hundred twelve (44%) of the dialysis units in the country answered the questionnaire. In July 2014, the total estimated number of patients on dialysis was 112,004. The estimated prevalence and incidence rates of chronic maintenance dialysis were 552 (range: 364 in the North region and 672 in the Southeast) and 180 patients per million population (pmp), respectively. The annual incidence rate of patients with diabetic nephropathy was 77 pmp. The annual gross mortality rate was 19%. For prevalent patients, 91% were on hemodialysis and 9% on peritoneal dialysis, 32,499 (29%) were on a waiting list of renal transplant, 37% were overweight/obese, 29% were diabetics, 16% had PTH levels > 600 pg/ml and 26% hemoglobin < 10 g/dl. A venous catheter was the vascular access for 17% of the hemodialysis patients. CONCLUSION During 2011-2014 the prevalence and incidence rates of patients on dialysis tended to increase, while the gross mortality rate remained stable. In 2014, diabetes was the primary renal disease in 42% of the new dialysis patients.

Inquérito Brasileiro de Diálise Crônica 2013 - Análise das tendências entre 2011 e 2013

INTRODUCTION National chronic dialysis data have had impact in the treatment planning. OBJECTIVE To report data of the annual survey of the Brazilian Society of Nephrology about chronic kidney disease patients on dialysis in July 2013 and compare with 2011-12. METHODS A survey based on data of dialysis units from the whole country. The data collection was performed by using a questionnaire filled out on-line by the dialysis units. RESULTS Three hundred thirty four (51%) of the dialysis units in the country answered the questionnaire. In July 2013, the total estimated number of patients on dialysis was 100,397. The estimated prevalence and incidence rates of chronic maintenance dialysis were 449 (range: 284 in the North region and 622 in the South) and 170 patients per million population, respectively. The estimated number of new patients starting dialysis in 2013 was 34,161. The annual gross mortality rate was 17.9%. For prevalent patients, 31.4% were aged 65 years or older, 90.8% were on hemodialysis and 9.2% on peritoneal dialysis, 31,351 (31.2%) were on a waiting list of renal transplant, 30% were diabetics, 17% had PTH levels > 600 pg/ml and 23% hemoglobin < 10 g/ dl. A venous catheter was the vascular access for 15.4% of the hemodialysis patients. CONCLUSION The absolute number of patients on dialysis has increased 3% per year. The prevalence and incidence rates of patients on dialysis leveled off, while the mortality rate tended to decrease compared with 2012. There was a trend towards a better control of the anemia and PTH levels.

Effect of Peripheral and Respiratory Muscle Training on the Functional Capacity of Hemodialysis Patients

Patients on hemodialysis (HD) show changes in muscle structure and function reducing their functional capacity. This study was conduted to assess the effects of respiratory muscle training (RMT) and peripheral muscle training (PMT) during dialysis on functional parameters, inflammatory state, and quality of life (QoL) in patients on HD. Randomized controlled trial included 39 patients on HD, and they were divided into three groups: RMT (n = 11), PMT (n = 14), and controls (C, n = 14). Training was performed during the HD session for 10 weeks. Maximal inspiratory pressure (PImax), maximal expiratory pressure (PEmax), forced vital capacity (FVC), six-minute walk test (6MWT), Kt/Vsp, biochemical parameters, and inflammatory state (i.e., level of high sensitivity C-reactive protein) were evaluated. Variation from baseline was calculated by Analysis of Covariance (ANCOVA). The ΔPImax was 22.5 ± 3.2, 9.1 ± 2.9, and −4.9 ± 2.8 cmH2O in the RMT, PMT and C, respectively (p < 0.001); ΔPEmax was 10.8 ± 6.6, 3.7 ± 5.9, and −15.6 ± 5.9 cmH2O respectively (p = 0.014). The Δ6MWT was significantly greater in RMT and PMT (65.5 ± 9; 30.8 ± 8 m) than in C (−0.5 ± 8.1 m), p < 0.001. Although biochemical parameters decreased after training, Kt/V remained unchanged. CRP decreased only in the RMT and PMT groups. There was a significant increase in QoL scores in the training groups (vs. C) in energy/fatigue (p = 0.002), sleep (p < 0.001), pain (p < 0.001), and list of symptoms/problems (p = 0.014). A short period of RMT or PMT during HD significantly improved functional capacity, with RMT showing greater effect than PMT. Muscle training improved biochemical and inflammatory markers, but a direct cause and effect relationship could not be established by this study.

Doença renal crônica, inflamação e aterosclerose: novos conceitos de um velho problema

Chronic kidney disease (CKD) has reached epidemic proportions in the last few years, generating an emergent public health problem. Common risk factors for CKD and cardiovascular disease (CVD) are now well known resulting in a high prevalence rate of cardiovascular events which are the main cause of death in CKD patients. Development of accelerated atherosclerosis is related to traditional risk factors such as diabetes mellitus, arterial hypertension, dislipidemia and smoking, but recently other non traditional factors were found to be significantly associated with cardiovascular mortality, including inflammation, oxidative stress, endothelial dysfunction and uremia, even at early stages of CKD. Inflammatory markers such as C-reactive protein, interleukin 6 and fibrinogen are all correlated with cardiovascular death. The MIA syndrome is characterized by the association between inflammation, malnutrition and accelerated atherosclerosis, a condition commonly found in uremic patients, which is related to the genesis of CVD. Other important factors are the high level of oxidative stress, expressed by oxidized lipids, proteins and carbohydrates (AGES) (Advanced Glycation End Products), which cause tissue damage and endothelial dysfunction, that is aggraveted by the uremic environment and other factors. These alterations are the basis for the pathogenic process of atherosclerosis and CVD in CKD patients, contributing to their high morbidity/ mortality. This article is an updated review of the mechanisms of inflammation and oxidative stress and their relation to atherosclerosis in CKD.

Health-Related Quality of Life and Dialysis Dependence in Critically Ill Patient Survivors of Acute Kidney Injury

Background: Acute kidney injury is a common disorder in critical ill patients and it is associated with high mortality. Few studies focus on long-term perspectives such as health-related quality of life (HRQOL) and dialysis dependence. Methods: Prospective cohort study at the intensive care unit (ICU) of a Brazilian tertiary hospital. All patients requiring dialysis over a 2-year enrollment period were included. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) assessed the HRQOL along with patient status and dialysis dependence. Results: 408 patients (11%) required dialysis. ICU, hospital, and after-hospital cumulative fatality rates were 70%, 74%, and 80%, respectively. A total of 68 of 82 eligible patients were interviewed in an average of 256 days after hospital discharge, while 8 patients (11.8%) were in regular dialysis. There was no association between Acute Physiology and Chronic Health Evaluation II score, use of vasopressors, mechanical ventilation, creatinine, number of dialysis, and SF-36 scores. Better HRQOL was associated with previous conditions, as younger age and no chronic kidney disease; condition related to severity of acute illness, as have not had sepsis, short period at ICU, and hospital; and conditions after discharge, considered working currently. Conclusions: Previous chronic kidney disease was strongly associated with permanence in dialysis and lower further HRQOL. Younger survivors who have not had sepsis or long stays at hospitals, able to return to their jobs, had better HRQOL.

Monitoramento da doença renal crônica terminal pelo subsistema de Autorização de Procedimentos de Alta Complexidade - Apac - Brasil, 2000 a 2006

Summary This study describes data available at the High Complexity Procedures Authorization Subsystem on Renal Replacement Therapy (Apac/TRS) from 2000 to 2006 and evaluates its potential use for monitoring end stage chronic renal disease patients in Brazil. After gathering 2,192 Apac files and excluding repeated records, we have analyzed the epidemiological profile of patients initiating Renal Replacement Therapy according to age, sex, region, treatment and cause of renal disease. We have identified 148,284 patients in dialysis during the period of the study. The incidence rate was estimated as 119,8/1,000,000 inhabitants/year, varying from 143,6/1,000,000/year in the South of Brazil to 66,3/1,000,000/year in the North of the country. Hypertension was the listed cause of renal disease in 32,571 cases (22%), followed by dia-betes mellitus in 20,414 cases (13.8%) and glomerulonephritis in 10,654 cases (7.2%). Undetermined cause accounted for 66,439 of all cases (44.8%). Incidence was stable, except for those patients over 65, among whom incidence has increased. The data available at

Performance of CKD-EPI equation to estimate glomerular filtration rate as compared to MDRD equation in South Brazilian individuals in each stage of renal function

Abstract Background: The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation seems to correct the overdiagnosis of chronic kidney disease (CKD) provided by Modification of Diet in Renal Disease (MDRD) equation. However, this point has not been tested in some ethnic groups. This study investigated the performance of MDRD and CKD-EPI equations in South Brazilian individuals. Methods: This cross-sectional study included 354 individuals including healthy volunteers, diabetic and non-diabetic individuals with or without CKD. Glomerular filtration rate (GFR) was measured by the 51Cr-EDTA single-injection method (51Cr-GFR). Accuracy (P30), bias, and Bland-Altman agreement plots were evaluated. Results: In the group as a whole, 51Cr-GFR was 87±37 (6-187), CKD-EPI eGFR, 82±30 (6-152), and MDRD eGFR, 77±28 (6-156) mL/min/1.73 m2 (p<0.001 for all comparisons). Analyzing the subset of individuals with 51Cr-GFR <60 mL/min/1.73 m2, P30 values were, respectively, 76% and 84% for MDRD and for CKD-EPI (p<0.001) while for 51Cr-GFR ≥60 mL/min/1.73 m2, P30 values were 57.5% for both equations (p=1.000). For MDRD and CKD-EPI, mean bias were negative for GFRs <60 (–11 vs. –12, p=0.221) and positive for values >60 (16 vs. 9, p<0.001). In multivariate analysis, absolute bias was unfavorably influenced by measured GFR >60 (for MDRD) and being diabetic or younger (for CKD-EPI). Conclusions: CKD-EPI reduces GFR underestimation in individuals with GFRs >60, but still presents a quite low accuracy at this GFR range. Moreover, it tends to overestimate GFR in subjects with GFRs <60 mL/min/1.73 m2. CKD stages 1 and 2, diabetes and young age had a negative influence on the performance of the equations.