Neimar da Silva Fernandes

The Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD): Characterization of the cohort

The Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) was launched in December 2004 aiming to collect data monthly and continuously from a representative cohort, allowing for a continuous snapshot of the peritoneal dialysis (PD) reality in the country. This is an observational study of PD patients comprising follow-up from December 2004 to February 2007 (mean follow-up of 13.6 months-ranging from 1 to 26 months) in 114 Brazilian centers. All centers report data through a central web-based database. After an initial baseline retrospective data collection, all patients are followed prospectively every month until they drop out from the PD program. Total number of patients recruited until February 2007 was 3226 (2094 incident patients). Mean age was 54+/-19 years (37% above 65 years old), with 55% females and 64% Caucasians. The more frequent causes of renal failure were diabetic nephropathy (34%), renal vascular disease associated with hypertension (26%), and glomerulopathies (13%). The most common comorbidities were hypertension (76%), diabetes (36%), and ischemic heart disease (23%). Automated PD (APD) was the modality utilized in 53%. The estimated overall peritonitis rate was 1 episode per 30 patient-months (most frequently due to Staphylococcus aureus). The total dropout rate was 33%, mainly due to deaths, whereas 20% of dropouts were due to renal transplant. The gross mortality was 17.6% and the main causes of mortality were cardiovascular diseases (40%) and infections (15%). The initial results of this first Brazilian PD registry provide a unique opportunity to develop future clinical studies addressing specific PD questions in the Brazilian reality and context.

Transcultural adaptation and initial validation of Brazilian-Portuguese version of the Basel assessment of adherence to immunosuppressive medications scale (BAASIS) in kidney transplants

BackgroundTransplant recipients are expected to adhere to a lifelong immunosuppressant therapeutic regimen. However, nonadherence to treatment is an underestimated problem for which no properly validated measurement tool is available for Portuguese-speaking patients. We aimed to initially validate the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS®) to accurately estimate immunosuppressant nonadherence in Brazilian transplant patients.MethodsThe BAASIS® (English version) was transculturally adapted and its psychometric properties were assessed. The transcultural adaptation was performed using the Guillemin protocol. Psychometric testing included reliability (intraobserver and interobserver reproducibility, agreement, Kappa coefficient, and the Cronbach’s alpha) and validity (content, criterion, and construct validities).ResultsThe final version of the transculturally adapted BAASIS® was pretested, and no difficulties in understanding its content were found. The intraobserver and interobserver reproducibility variances (0.007 and 0.003, respectively), the Cronbach’s alpha (0.7), Kappa coefficient (0.88) and the agreement (95.2%) suggest accuracy, preciseness and reliability. For construct validity, exploratory factorial analysis demonstrated unidimensionality of the first three questions (r = 0.76, r = 0.80, and r = 0.68). For criterion validity, the adapted BAASIS® was correlated with another self-report instrument, the Measure of Adherence to Treatment, and showed good congruence (r = 0.65).ConclusionsThe BAASIS® has adequate psychometric properties and may be employed in advance to measure adherence to posttransplant immunosuppressant treatments. This instrument will be the first one validated to use in this specific transplant population and in the Portuguese language.

Multilevel Correlates of Non-Adherence in Kidney Transplant Patients Benefitting from Full Cost Coverage for Immunosuppressives: A Cross-Sectional Study.

Background Adherence is the result of the interaction of the macro, meso, micro, and patient level factors. The macro level includes full coverage of immunosuppressive medications as is the case in Brazil. We studied the correlates of immunosuppressive non-adherence in post kidney transplant patients in the Brazilian health care system. Methods Using a cross-sectional design, adherence to immunosuppressives was assessed in a sample of 100 kidney transplant patients using a composite non-adherence score consisting of three methods (self-report [i.e., The Basel Adherence Scale for Assessment of Immunossupressives–BAASIS], collateral report, and immunosuppressive blood levels). Multilevel correlations of non-adherence were assessed (macro, meso, micro and patient level). Univariate and multivariate logistic regression was applied to assess the correlates of non-adherence. Results Our sample consisted primarily of male (65%), Caucasians (72%) with a mean age of 45.0 ± 13.5 years old, who received grafts from a living donor (89%), with a mean time after transplantation of 72.3 ± 44.4 months. Prevalence of non-adherence was 51%. Family income higher than five reference wages (21.6 vs. 4%; OR 6.46 [1.35–30.89], p = 0.009; patient level), and having access to private health insurance (35.3% vs. 18.4%; OR 2.42 [0.96–6.10], p = 0.04; meso level) were associated with non-adherence in univariate analysis. Only the higher family income variable was retained in the multiple logistic regression model (OR 5.0; IC: 1.01–25.14; p = 0.04). Conclusions Higher family income was the only factor that was associated with immunosuppressive non-adherence. In Brazil, lower income recipients benefit from better access to care and coverage of health care costs after transplantation. This is supposed to result in a better immunosuppressive adherence compared to high-income patients who have experienced these benefits continuously.

Longitudinal Changes in Health-Related Quality of Life Scores in Brazilian Incident Peritoneal Dialysis Patients (BRAZPD): Socio-economic Status Not a Barrier

♦ Background and Objectives: A large proportion of the patients on peritoneal dialysis (PD) in Brazil have low levels of education and family income. The present study assessed whether education level and family income are associated with baseline and longitudinal changes in health-related quality of life (HRQOL) scores during the first year of PD therapy. ♦ Methods: We evaluated 1624 incident patients from the Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) at baseline, and 486 of them after 12 months. The SF-36 was used to determine HRQOL and the Karnofsky index (KI), physical performance. ♦ Results: At baseline, patients received high KI scores compared with scores on the SF-36. The means of the mental and physical components at baseline and after 12 months were 39.9 ± 10.5 compared with 38.7 ± 11.7 and 41.8 ± 9.6 compared with 40.7 ± 9.8 respectively, which were not statistically different. A multivariate regression analysis showed that age, sex, diabetes, and cardiovascular disease were predictors of the mental component (respectively, β = 0.12, p < 0.001; β = 0.11, p < 0.001; β = -0.08, β = 0.007; and β = -0.07, p = 0.007) and that age, sex, diabetes, cardiovascular disease, hemoglobin, glucose, and creatinine were predictors of the physical component (respectively, β = -0.28, p < 0.001; β = 0.06, p = 0.009; β = -0.09, p = 0.002; β = -0.09, p = 0.001; β = 0.07, p = 0.004; β = -0.05, p = 0.040; and β = 0.05, p = 0.040). Education level and family income were not significantly associated with HRQOL (mental and physical components) in the multivariate regression. ♦ Conclusions: The results indicate that, as predictors, family income and education level have no impact on HRQOL, supporting the idea that socio-economic status should not be a barrier to the selection of PD as a treatment modality in Brazil.

Modelagem do crescimento da aprendizagem nos anos iniciais com dados longitudinais da pesquisa GERES

Este artigo compara duas abordagens de valor agregado para dados oriundos do survey educacional de recorte longitudinal, chamado GERES - Estudo Longitudinal da Geracao Escolar 2005, que acompanhou uma coorte de alunos de mais de 300 escolas publicas e privadas ao longo dos primeiros quatro anos do Ensino Fundamental. Ambas as abordagens utilizam modelos lineares hierarquicos, permitindo o agrupamento natural dos dados educacionais provenientes dos tres niveis: aluno, turma e escola. Na primeira abordagem de valor agregado, constroem-se modelos cuja variavel dependente e a proficiencia do aluno em cada ano avaliado. Com um modelo distinto para cada ano e possivel detectar fatores do aluno, da turma e da escola associados ao desempenho dos alunos. A segunda abordagem cria modelos para mostrar o efeito das covariaveis de aluno, turma e escola nas curvas de evolucao da proficiencia ao longo do periodo do estudo. Quando comparados os dois tipos de modelos de valor agregado, o primeiro foi o mais eficiente em diagnosticar os efeitos do ambiente e da pratica pedagogica do professor, mas somente em determinados anos. Ja o segundo tipo de modelo foi capaz de identificar curvas de evolucao de proficiencia de formatos distintos de acordo com determinadas caracteristicas das escolas e dos alunos, mas foi menos sensivel na identificacao de variaveis associadas ao processo de formacao de grupos e a pratica pedagogica do professor. Os dois tipos de modelos de valor agregado oferecem indicacoes de processos de aprendizagem diferenciados para as disciplinas Lingua Portuguesa e Matematica que mereceriam estudos adicionais.

Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD): From Conception to Execution of a National Peritoneal Dialysis Reality Check

Systematic data collection of patients undergoing renal replacement therapy is critical to the epidemiological and clinical understanding of the treatment. These data may allow more rational use of economic resources and identify interventions to improve treatment and decrease the morbidity and mortality of these patients. The Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD), an observational cohort study of peritoneal dialysis (PD) patients in Brazil, aimed to collect monthly demographics, clinical, laboratory and outcome data of PD patients treated in 114 dialysis clinics around the country, was started in December 2004 and ended in September 2011. BRAZPD has been generating solid and important information, which is very useful as a reality check of the PD therapy for all Brazilian PD centers.

Evaluation of prevalence, biochemical profile, and drugs associatedwith chronic kidney disease-mineral and bone disorder in 11 dialysiscenters

ABSTRACT Introduction: The diagnosis and treatment of mineral and bone disorder of chronic kidney disease (CKD-MBD) is a challenge for nephrologists and health managers. The aim of this study was to evaluate the prevalence, biochemical profile, and drugs associated with CKD-MBD. Methods: Cross-sectional study between July and November 2013, with 1134 patients on dialysis. Sociodemographic, clinical, and laboratory data were compared between groups based on levels of intact parathyroid hormone (iPTH) (< 150, 150-300, 301-600, 601-1000, and > 1001 pg/mL). Results: The mean age was 57.3 ± 14.4 years. The prevalence of iPTH < 150 pg/mL was 23.4% and iPTH > 601 pg/mL was 27.1%. The comparison between the groups showed that the level of iPTH decreased with increasing age. Diabetic patients had a higher prevalence of iPTH < 150 pg/mL (27.6%). Hyperphosphatemia (> 5.5 mg/dL) was observed in 35.8%. Calcium carbonate was used by 50.5%, sevelamer by 14.7%, 40% of patients had used some form of vitamin D and 3.5% used cinacalcet. Linear regression analysis showed a significant negative association between iPTH, age, and diabetes mellitus and a significant positive association between iPTH and dialysis time. Conclusion: The prevalence of patients outside the target for iPTH was 50.5%. There was a high prevalence of hyperphosphatemia (35.8%), and the minority of patients were using active vitamin D, vitamin D analogs, selective vitamin D receptor activators, and cinacalcet. These data indicate the need for better compliance with clinical guidelines and public policies on the supply of drugs associated with CKD-MBD.

Fatores associados ao abandono escolar no ensino médio público de Minas Gerais

Este artigo tem como objetivo apontar quais sao os principais fatores que influenciam o abandono escolar no ensino medio. Os dados utilizados baseiam-se em uma serie historica construida a partir do levantamento das Pesquisas Nacionais por Amostra de Domicilios (PNAD) e numa ampla pesquisa realizada no estado de Minas Gerais (MG), a qual culminou na coleta de diversas informacoes de um total de 3.418 entrevistados (entre alunos cursantes e nao-cursantes). Com base nesses dados, estimaram-se modelos de regressao de risco proporcional de Cox, que permitiram identificar a correlacao entre fatores intra e extraescolares com o abandono precoce. Outro modelo desenvolvido utilizou as bases de dados da PNAD, em que um modelo logito foi estimado, permitindo verificar a taxa do nao abandono na trajetoria do ensino medio tambem para o estado de Minas Gerais. Entre os resultados encontrados, destacam-se alguns fatores expressivos na explicacao do abandono, tais como: a dificuldade nas disciplinas, ânsia por uma escola diferente, percepcao de melhores oportunidades de trabalho com a continuidade dos estudos e a importância atribuida na escolha a escola.