Jocemir Ronaldo Lugon

Thalidomide for the Treatment of Uremic Pruritus: A Crossover Randomized Double-Blind Trial

Our observation that thalidomide administration to a dialysis patient with leprosy alleviated his pruritus led us to conduct this short-term study to assess the efficacy of the drug in this regard. From 210 hemodialysis patients, 29 cases of refractory uremic pruritus were entered into the study. Patients were instructed to score their symptoms from 0 to 3, three times a day and assigned to receive thalidomide or placebo at bed time for 7 days. After a washout period of 7 days, drugs were crossed over. Response was defined as a reduction of at least 50% in the pruritus scoring. Eighteen patients finished the study. In the first phase, 55% of patients responded showing a mean reduction in their pruritus scoring of 78% (p < 0.05 vs. placebo); no response to placebo was observed. A similar proportion of patients responded to thalidomide in the second phase with a mean reduction in their pruritus scoring of 81%. In conclusion, thalidomide can be a precious tool in the handling of uremic pruritus unresponsive to available therapy.

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.

Uremic pruritus: A review

Pruritus is a major disorder among the skin derangements in advanced renal failure. Its prevalence seems to be diminishing perhaps because of improvements in dialysis treatment. Recent information suggests that interactions between dermal mast cells and distal ends of nonmyelinated C fibers may be important in the precipitation and regulation of the sensory stimuli. The knowledge as to the control of pruritus transmission to cortex areas is still incomplete but endogenous opioid and opioid receptors may have a role in this regard. A recent classification was proposed for pruritus based on the level of its origin. Uremic pruritus, however, seems to be too complex to fit perfectly in any of the suggested modalities. Inflammation and malnutrition are recognized risk factors for cardiovascular death in end‐stage renal disease patients, which may be related to the genesis of pruritus. Consistent with this concept, lower serum levels of albumin and higher serum levels of ferritin were found in pruritic patients when compared to nonpruritic ones. Newer treatments for this difficult clinical problem are being developed and tested.

Effects of renal denervation with a standard irrigated cardiac ablation catheter on blood pressure and renal function in patients with chronic kidney disease and resistant hypertension

AIMS Evaluation of the safety and efficacy of renal denervation with a standard irrigated cardiac ablation catheter (SICAC) in chronic kidney disease (CKD) patients with refractory hypertension. METHODS AND RESULTS Twenty-four patients were included and treated with a SICAC. Denervation was performed by a single operator following the standard technique. Patients included with CKD were on stages 2 (n = 16), 3 (n = 4), and 4 (n = 4). Data were obtained at baseline and monthly until 180th day of follow-up. Baseline values of blood pressure (mean ± SD) were 186 ± 19 mmHg/108 ± 13 mmHg in the office, and 151 ± 18 mmHg/92 ± 11 mmHg by 24 h ambulatory blood pressure monitoring (ABPM). Office blood pressure values at 180th day after the procedure were 135 ± 13 mmHg/88 ± 7 mmHg (P < 0.0001, for both comparisons). The mean ABPM decreased to 132 ± 15 mmHg/85 ± 11 mmHg at the 180th day after the procedure (P < 0.0001 for systolic and P = 0.0015 for diastolic). Estimated glomerular filtration (mean ± SD) increased from baseline (64.4 ± 23.9 mL/min/1.73 m(2)) to the 180th day (85.4 ± 34.9 mL/min/1.73 m(2), P < 0.0001) of follow-up. The median urine albumin:creatinine ratio decreased from baseline (48.5, IQR: 35.8-157.2 mg/g) to the 180th day after ablation (ACR = 15.7, IQR: 10.3-34.2 mg/g, P = 0.0017). No major complications were seen. CONCLUSION The procedure using SICAC seemed to be feasible, effective, and safe resulting in a better control of BP, a short-term increase in estimated glomerular filtration rate, and reduced albuminuria. Although encouraging, our data are preliminary and need to be validated in the long term.

Prospective evaluation of an in-center daily hemodialysis program: results of two years of treatment.

Short duration daily hemodialysis (DHD) emerges as a well-tolerated alternative to standard hemodialysis (SHD). In this prospective study 5 patients in SHD were recruited to participate in an in-center DHD program. The SHD consisted of 3 sessions of 4 h each per week. Nonproportional mixture machines without an ultrafiltration control device and low flow dialyzers were used. For DHD, dialysis equipment and procedures were kept the same. Dialysis sessions, however, began at 6 p.m. (from Monday to Saturday) and lasted 2 h. Data from the last 6 months on SHD of the same patients were compared with the ones from each semester on DHD. Bone biopsy was performed at start and at the end of the 2-year study period. Hypotensive episodes, hypertensive crisis, cramps and headaches became 7–10 times less frequent in daily dialysis. A significant fractional increase (∼12%) was seen in mean values for hematocrit. Predialysis urea levels as well as predialysis creatinine levels declined significantly. Also lower during the daily dialysis period were the mean values for both phosphorus and Ca×P product. Significant increases were found in serum bicarbonate, albumin and in dry weight. The frequency of mean blood pressure ≧110 mm Hg on arrival for dialysis was significantly lower in every semester on daily hemodialysis. A significant twofold improvement in quality of life scoring was observed. Finally, daily hemodialysis also seemed to be beneficial to low turnover bone disease and bone aluminum deposition. These beneficial effects occurred despite of an increase in the frequency of missing days. Results from the present study which prospectively addressed the role of in-center short daily hemodialysis in the management of ESRD are encouraging.

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.

Latin American Dialysis and Transplant Registry: 2008 prevalence and incidence of end-stage renal disease and correlation with socioeconomic indexes.

In 2008, 563,294,000 people were living in Latin America (LA), of which 6.6% were older than 65. The region is going through a fast demographic and epidemiologic transition process, in the context of an improvement in socio-economic indices. The Latin American Dialysis and Renal Transplant Registry has collected data since 1991, through an annual survey completed by 20 affiliated National Societies. Renal replacement treatment (RRT) prevalence and incidence showed an increase year by year. The prevalence rate (in all modalities) correlated with the World Bank country classification by income and the epidemiologic transition stage the countries were experiencing. RRT prevalence and kidney transplantation rates correlated significantly with gross national income (GNI), health expenditure in constant dollars (HeExp), % older than 65, life expectancy at birth, and % of the population living in urban settings. Kidney transplantation increased also, year by year, with more than 50% of transplants performed using kidneys from deceased donors. Double transplants were performed in six countries. RRT prevalence and incidence increased in LA, and are associated with indexes reflecting higher and more evenly distributed national wealth (GNI and HeExp), and the stage of demographic and epidemiological transition.

Renal replacement therapy in Latin American end-stage renal disease

The Latin American Dialysis and Renal Transplant Registry (RLADTR) was founded in 1991; it collects data from 20 countries which are members of Sociedad Latinoamericana de Nefrología e Hipertension. This paper presents the results corresponding to the year 2010. This study is an annual survey requesting data on incident and prevalent patients undergoing renal replacement treatment (RRT) in all modalities: hemodialysis (HD), peritoneal dialysis (PD) and living with a functioning graft (LFG), etc. Prevalence and incidence were compared with previous years. The type of renal replacement therapy was analyzed, with special emphasis on PD and transplant (Tx). These variables were correlated with the gross national income (GNI) and the life expectancy at birth. Twenty countries participed in the surveys, covering 99% of the Latin American. The prevalence of end stage renal disease (ESRD) under RRT in Latin America (LA) increased from 119 patients per million population (pmp) in 1991 to 660 pmp in 2010 (HD 413 pmp, PD 135 pmp and LFG 111 pmp). HD proportionally increased more than PD, and Tx HD continues to be the treatment of choice in the region (75%). The kidney Tx rate increased from 3.7 pmp in 1987 to 6.9 pmp in 1991 and to 19.1 in 2010. The total number of Txs in 2010 was 10 397, with 58% deceased donors. The total RRT prevalence correlated positively with GNI (r2 0.86; P < 0.05) and life expectancy at birth (r2 0.58; P < 0.05). The HD prevalence and the kidney Tx rate correlated significantly with the same indexes, whereas the PD rate showed no correlation with these variables. A tendency to rate stabilization/little growth was reported in the most regional countries. As in previous reports, the global incidence rate correlated significantly only with GNI (r2 0.63; P < 0.05). Diabetes remained the leading cause of ESRD. The most frequent causes of death were cardiovascular (45%) and infections (22%). Neoplasms accounted for 10% of the causes of death. The prevalence of RRT continues to increase, particularly in countries with 100% public health or insurance coverage for RRT, where it approaches rates comparable to those displayed by developed countries with a better GNI. The incidence also continues to increase in both countries that have not yet extended its coverage to 100% of the population as well as in those that have an adequate program for timely detection and treatment of chronic kidney disease (CKD) and its associated risk factors. PD is still an underutilized strategy for RRT in the region. Even though renal Tx is feasible, its growth rate is still not as fast as it should be in order to compensate for the increased prevalence of patients on waiting lists. Diagnostic and prevention programs for hypertension and diabetes, appropriate policies promoting the expansion of PD and organ procurement as well as transplantation as cost-effective forms of RRT are needed in the region. Regional cooperation among Latin American countries, allowing the more developed to guide and train others in starting registries and CKD programs, may be one of the key initiatives to address this deficit.

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.