José Edevanilson de Barros Gueiros

Situação do hiperparatireoidismo secundário autônomo no Brasil: dados do Censo Brasileiro de Paratireoidectomia

INTRODUCTION Secondary hyperparathyroidism (SHP) is a common and serious complication of chronic kidney disease (CKD), with a negative impact on morbidity and mortality. Despite advances in the clinical management of SHP, treatment failure still occurs in a significant number of patients. In such cases, parathyroidectomy (PTx) is indicated. OBJECTIVE To have an overview of the prevalence of severe SHP and of its surgical treatment in hemodialysis (HD) patients in Brazil. METHODS This was an observational and descriptive study. Data were obtained from questionnaires posted to 660 dialysis units (DU). RESULTS Results are expressed in absolute values and percentages, or means and standard deviation, as appropriate. 226 (34%) DU answered the questionnaire, providing data about 32,264 HD patients. The prevalence rate of severe SHP (PTH > 1,000 pg/mL) was 10.7 % (n = 3,463). 68 hospitals countrywide perform PTX. Around 40% of them are university centers. 49 (21.7%) DU reported not to have a specialized medical center to refer their patients with severe SHP. 74 (33%) DU reported that the time interval between surgery indication and its performance was over 6 months. The main recognized obstacles to surgery performance were: difficulty to perform the preoperative exams, lack of head and neck surgeons and the long waiting time. CONCLUSIONS Although severe SHP is highly prevalent in Brazil, a significant number of patients do not have access to PTx. Better public health policies and liaison between nephrologists and head and neck surgeons are urgently required to change this reality.INTRODUCTION: Secondary hyperparathyroidism (SHP) is a common and serious complication of chronic kidney disease (CKD), with a negative impact on morbidity and mortality. Despite advances in the clinical management of SHP, treatment failure still occurs in a significant number of patients. In such cases, parathyroidectomy (PTx) is indicated. OBJECTIVE: To have an overview of the prevalence of severe SHP and of its surgical treatment in hemodialysis (HD) patients in Brazil. METHODS: This was an observational and descriptive study. Data were obtained from questionnaires posted to 660 dialysis units (DU). RESULTS: Results are expressed in absolute values and percentages, or means and standard deviation, as appropriate. 226 (34%) DU answered the questionnaire, providing data about 32,264 HD patients. The prevalence rate of severe SHP (PTH > 1,000 pg/mL) was 10.7 % (n = 3,463). 68 hospitals countrywide perform PTX. Around 40% of them are university centers. 49 (21.7%) DU reported not to have a specialized medical center to refer their patients with severe SHP. 74 (33%) DU reported that the time interval between surgery indication and its performance was over 6 months. The main recognized obstacles to surgery performance were: difficulty to perform the preoperative exams, lack of head and neck surgeons and the long waiting time. CONCLUSIONS: Although severe SHP is highly prevalent in Brazil, a significant number of patients do not have access to PTx. Better public health policies and liaison between nephrologists and head and neck surgeons are urgently required to change this reality.

Protocolo clínico e diretrizes terapêuticas para o tratamento do hiperparatireoidismo secundário em pacientes com doença renal crônica

INTRODUCAO A doenca renal cronica (DRC) afeta 5-10% da populacao mundial e sua incidencia no Brasil tem aumentado, devido ao numero crescente de pacientes diagnosticados, principalmente os portadores de diabetes mellitus, hipertensao arterial, bem como pelo aumento da longevidade da populacao. […] Protocolo clinico e diretrizes terapeuticas para o tratamento do hiperparatireoidismo secundario em pacientes com doenca renal cronica1 Serviço de Nefrologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil. 2 Serviço de Nefrologia da Universidade Federal de São Paulo, São Paulo, Brasil. 3 Escola de Medicina, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brasil. 4 Departamento de Medicina Interna da Universidade Federal da Bahia, Brasil. 5 Serviço de Nefrologia da Universidade Federal do Rio Grande do Sul, Brasil. 6 Serviço de Nefrologia da Universidade Federal Fluminense, Niterói, RJ, Brasil. 7 Serviço de Nefrologia da Universidade Federal de Pernambuco, Brasil.

Guidelines on Bone Mineral Disorder in Chronic Kidney Disease - Addendum Chapter 2

1 – AVALIACAO DOS NIVEIS DE PARATORMONIO (PTH) E FOSFATASE ALCALINA (FA) NA DRC 1.1 – Os niveis sericos de PTH devem ser analisados em todos os pacientes com DRC, cuja taxa de filtracao glomerular (TFG) for inferior a 60 mL/min/1,73 m2 (Evidencia). Deve-se modificar a frequencia de avaliacao dos niveis sericos de PTH se os resultados das analises mostrarem uma tendencia de elevacao ou de descenso ou apos a instituicao do tratamento, seja ele para reduzir ou elevar os [...]

Efeito benéfico da correção da acidose metabólica no estado nutricional de pacientes em hemodiálise

OBJECTIVE: To assess the nutritional effect of correcting metabolic acidosis in hemodialysis patients. METHODS: Twenty patients with metabolic acidosis, defined as mean serum bicarbonate < 22 mEq/L before dialysis, were studied for six months. They had been on dialysis for at least six months, with 35 mEq/L of bicarbonate in the dialysate. Metabolic acidosis was corrected through elevation in dialysate bicarbonate to values not exceeding 40 mEq/L, aiming at bicarbonate serum levels between 22 and 26 mEq/L. Biochemical, anthropometric, and dietary assessments were performed at the beginning and end of the study, as was Global Subjective Assessment (GSA). RESULTS: The nutritional assessment in the initial phase of the study showed normal body mass index (24.23 ± 3.83 kg/m2). However, according to arm muscle circumference, triceps skinfold, and GSA, men and women were classified as undernourished. Calorie and protein intakes were 29.7 ± 10.1 kcal/kg/day and 1.31 ± 0.35 g/kg/day, respectively. The biochemical evaluation showed normal serum albumin and low cholesterol. After correction, serum bicarbonate and pH increased from 18.2 ± 1.64 to 22 ± 1.70 (p < 0.001) and from 7.32 ± 0.45 to 7.37 ± 0.41 (p < 0.001), respectively. GSA improved (21.7 ± 6.4 versus 16.8 ± 6.6, p < 0.001) and calorie intake increased (1892 ± 454.30 versus 2110.30 ± 869.24, p < 0.05). CONCLUSIONS: Bicarbonate supplementation in hemodialysis solution was effective for correcting metabolic acidosis, determining an increase in calorie intake and improvement in GSA scores.

Prevenção e tratamento do hiperparatireoidismo secundário na DRC

2.1 Nos pacientes com DRC estagios III a V, os niveis ideais de PTH nao sao conhecidos. No entanto, sugerimos que os pacientes com niveis de PTH acima do limite su-perior de referencia para o meto-do sejam avaliados quanto a pre-senca de hipocalcemia, hiperfos-fatemia ou fracao de excrecao de P elevada, e deficiencia de 25-hi-droxivitamina D (25-vit D). Se fo -rem detectadas alteracoes nesses parâmetros, estes devem ser corri -gidos; sais de Ca para correcao da hipocalcemia, orientacao dietetica e/ou uso de quelantes de P para correcao da hiperfosfatemia e uso de ergocalciferol (vitamina D2) ou colecalciferol (vitamina D3) para correcao da hipovitaminose D (Evidencia).