Gildete Barreto Lopes

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.

Comparative study of the in-hospital case-fatality rate of leptospirosis between pediatric and adult patients of different age groups

The main objective was to compare the in-hospital case-fatality rate of leptospirosis between pediatric (< 19 years) and adult (>19 years) patients, taking into account gender, renal function, duration of symptoms and jaundice. Medical records of 1016 patients were reviewed. Comparative analysis was restricted to 840 patients (100 pediatric, 740 adults) with recorded information on the variables included in the analysis. Among these patients 81.7% were male and 91.5% were icteric. The case-fatality rate of leptospirosis was 14.4%. The odds of death adjusted for gender, jaundice, duration of symptoms, serum urea and serum creatinine were almost four times higher for the adult than for the pediatric group (odds ratio (OR) = 3.94; 95% confidence interval = 1.19-13.03, p = 0.029). Among adults, increased age was also significantly and independently associated with increased risk of death (p < 0.01). Older patients were also more often treated by dialysis. In conclusion, the data suggest that the in-hospital case fatality rate of leptospirosis is higher for adults than for children and adolescents, even after taking into account the effects of several potential risk factors of death. Among adults, older age was also strongly and independently associated with higher risk of death.

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.

Complicações da hipertensão arterial em homens e mulheres atendidos em um ambulatório de referência

OBJECTIVE To assess the association between sex and left ventricular hypertrophy, stroke, and renal failure in hypertensive patients in a referral outpatient care unit. METHODS This study assessed 622 hypertensive patients diagnosed with left ventricular hypertrophy based on electrocardiography, renal failure based on serum creatinine level > or = 1.4 mg/dL, and stroke based on a previous history and physical examination. Logistic regression was used to estimate the odds ratio of the association between sex and target-organ lesions in hypertension adjusted for race, age, and duration of the disease. RESULTS The mean age of the patients was 48.4 +/- 13.8 years; 74.1% were women, and 84.9% were mulattos or blacks. Almost half of the men and more than 40% of the women had had at least 1 definite event involving a target-organ lesion. The incidence of renal failure was greater among men [adjusted OR (ORa) = 2.73, P= 0.002]. In white patients, the incidence of stroke was significantly (P= 0.017) greater among men (4/33) than among women (0/56), and, in the age group > or = 49 years, the prevalence of left ventricular hypertrophy was significantly greater among men (ORa = 1.99, P= 0.024). CONCLUSION The data obtained suggest a greater prevalence of renal failure in men than in women, of stroke in white men than in white women, and of left ventricular hypertrophy in men than in women aged 49 years and above.

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.

Número de anos em tratamento dialítico crônico e risco de morte em pacientes com e sem diabetes melito

OBJECTIVE: To assess whether, in Brazil, the number of years on dialysis treatment in end-stage renal disease (ESRD) patients, with and without diabetes mellitus, relates to mortality risk. METHODS: Analysis of data from the Ministry of Health of Brazil of 25.952 patients older than 18 years who were on dialytic treatment in April 1997. Death cases that occurred from April 1997 to July 2000 were recorded. Cox models were used to estimate the relative risk (RR) of the association between years on dialysis and mortality risk. RESULTS: The mortality risk was significantly lower in patients on dialysis between 3 and <10 years as compared with 1 to <2 years (RR between 0.78 and 0.88). With adjustments for age and diabetes the effect of years on dialysis was reduced. In diabetics (n=2.952) the adjusted mortality risk showed a trend to decrease with more years on dialysis. CONCLUSIONS: In Brazil, the mortality risk for ESRD patients decreases with the increasing number of years on dialysis up to approximately 10 years. This finding can be partially explained by the lower mean age and prevalence of diabetes mellitus in patients with more years on dialysis treatment. The effect of years on dialysis on the mortality risk seems to be stronger in patients with diabetes.

Coping with fluid restriction and the quality of life in hemodialysis patients with very low or no daily urine output

Purpose Fluid restriction is crucial to prevent circulatory overload in maintenance hemodialysis (MHD) patients with very low urine volume, but fluid restriction may result in psychological distress. We studied MHD patients with urine volume ≤200 ml/day to investigate if their acceptance of fluid restriction was associated with their health-related quality of life (HRQOL). Methods Cross-sectional study of 271 Brazilian adult MHD patients enrolled in the Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO). To assess the acceptance of fluid restriction, patients were asked about the extent of feeling bothered by living on this restriction. The KDQOL was used to determine HRQOL scores. Higher scores indicate better HRQOL with differences of >3.0 points considered clinically significant. Results 52.4% reported being “moderately to extremely” bothered by fluid restriction and had lower scores for all HRQOL scales than patients less bothered by fluid restriction. The largest covariate-adjusted differences in HRQOL were 19.5 for emotional role (p<0.001), 15.1 for emotional well-being (p<0.001), and 14.1 for vitality (p<0.001). Adjusted differences were larger for mental component (7.53 points, p<0.001) than for physical component (2.07, p = 0.075) summaries. Conclusions These results indicate that MHD patients with a lower level of acceptance of fluid restriction have poorer HRQOL, particularly in mental domains of HRQOL. The high prevalence of poor acceptance of fluid restriction in the present study underscores the need for interventions to improve acceptance of fluid restriction and determine if such interventions improve HRQOL of MHD patients with very low urine volume.

Reducing serum phosphorus concentration in patients with end-stage renal disease.

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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.