RESUMEN
PURPOSE: Parathyroid hormone (PTH) is merit as a risk factor for mortality in patients with chronic kidney disease in prevalent hemodialysis patients in a U shape. Most studies, however, do not focus on incident patients and those who died within the first 90 days of therapy. We evaluated PTH as a risk factor for mortality in a large cohort population in Brazil. METHODS: This is an observational cohort study that included 4317 adult patients who initiated hemodialysis between July 1st, 2012 and June 30, 2017. The main outcome was all-cause mortality. Fine-gray sub-distribution hazard models were used to evaluate survival in the presence of a competing event (kidney transplant). RESULTS: Median PTH levels of 252 (118, 479) pg/mL. There were 331 deaths during the first 90 days of therapy (6.7%), 430 in a 1-year follow-up (10.7%) and 1282 (32%) during the 5-year study period. Deaths according to PTH < 150, 150-600 and > 600 pg/mL corresponded to 38.1%, 33.0% and 28.5%, respectively (p < 0.001). In an adjusted model, patients who started dialysis with PTH < 150 pg/mL had a higher mortality risk within the first 90 days, but not in 1 year and 5 years after starting dialysis. Analyses in a subset of patients with a repeated PTH in 1 year (N = 1954) showed that although persistent PTH low levels (< 150 pg/mL) at 1 year were significantly associated with all-cause mortality, this result was not sustained after multiple adjustments. CONCLUSION: PTH < 150 pg/mL confers a high mortality risk in the first 90 days of dialysis. If this result reflects poor nutritional conditions, it deserves further investigations.
RESUMEN
BACKGROUND: Iron (Fe) supplementation is a critical component of anemia therapy for patients with chronic kidney disease (CKD). However, serum Fe, ferritin, and transferrin saturation, used to guide Fe replacement, are far from optimal, as they can be influenced by malnutrition and inflammation. Currently, there is a trend of increasing Fe supplementation to target high ferritin levels, although the long-term risk has been overlooked. METHODS: We prospectively enrolled 28 patients with CKD on hemodialysis with high serum ferritin (> 1000 ng/ml) and tested the effects of 1-year deferoxamine treatment, accompanied by withdrawal of Fe administration, on laboratory parameters (Fe status, inflammatory and CKD-MBD markers), heart, liver, and iliac crest Fe deposition (quantitative magnetic resonance imaging [MRI]), and bone biopsy (histomorphometry and counting of the number of Fe positive cells in the bone marrow). RESULTS: MRI parameters showed that none of the patients had heart iron overload, but they all presented iron overload in the liver and bone marrow, which was confirmed by bone histology. After therapy, ferritin levels decreased, although neither hemoglobin levels nor erythropoietin dose was changed. A significant decrease in hepcidin and FGF-23 levels was observed. Fe accumulation was improved in the liver and bone marrow, reaching normal values only in the bone marrow. No significant changes in turnover, mineralization or volume were observed. CONCLUSIONS: Our data suggest that treatment with deferoxamine was safe and could improve Fe accumulation, as measured by MRI and histomorphometry. Whether MRI is considered a standard tool for investigating bone marrow Fe accumulation requires further investigation. Registry and the registration number of clinical trial: ReBEC (Registro Brasileiro de Ensaios Clinicos) under the identification RBR-3rnskcj available at: https://ensaiosclinicos.gov.br/pesquisador.
Asunto(s)
Médula Ósea , Deferoxamina , Ferritinas , Sobrecarga de Hierro , Hierro , Hígado , Diálisis Renal , Humanos , Masculino , Femenino , Sobrecarga de Hierro/tratamiento farmacológico , Sobrecarga de Hierro/etiología , Sobrecarga de Hierro/metabolismo , Médula Ósea/metabolismo , Médula Ósea/efectos de los fármacos , Médula Ósea/patología , Ferritinas/sangre , Ferritinas/metabolismo , Hígado/metabolismo , Hígado/efectos de los fármacos , Hígado/patología , Hígado/diagnóstico por imagen , Persona de Mediana Edad , Deferoxamina/uso terapéutico , Deferoxamina/administración & dosificación , Hierro/metabolismo , Anciano , Imagen por Resonancia Magnética , Estudios Prospectivos , Insuficiencia Renal Crónica/terapia , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/tratamiento farmacológico , Insuficiencia Renal Crónica/metabolismo , Insuficiencia Renal Crónica/sangre , Factor-23 de Crecimiento de Fibroblastos , Hepcidinas/metabolismoRESUMEN
Muscle weakness is a common symptom in CKD patients, and the pathway by which secondary hyperparathyroidism (SHPT) affects muscle function is unknown. Osteopontin (OPN), a bone matrix protein stimulated by PTH and phosphate, has been associated with inflammatory muscle diseases. In this observational and prospective cohort study, we evaluated 30 patients with severe SHPT (39 ± 12 yr; 18 women), before and 6 mo after parathyroidectomy (PTx). We examined the relationships among CKD-mineral and bone disorder parameters; myokine and inflammatory cytokine levels; and changes in resting energy expenditure (REE), muscle function, BMD, and muscle-related proteins. At baseline, the patients showed low gene expression of muscle turnover markers and irisin, as well as high protein expression of OPN, transforming growth factor beta (TGF-ß), and fibroblast growth factor 21. Six months after PTx, REE and muscle mass had not changed, but physical performance, muscle strength, and bone mass improved, more so in patients undergoing total PTx. Also, there were reductions in the protein expression of OPN (11 vs 3%, p=.01) and TGF-ß (21 vs 7%, p=.002) in muscle, together with a significant increase in irisin muscular levels (30 vs 35 pg/mg, p=.02). The gain in bone mass and the increase in irisin levels correlated with a reduction in PTH. The levels of interleukin (IL)-1ß, tumor necrosis factor alpha, and IL-17 (markers of myositis) were also lower after PTx. Our data suggest that SHPT plays a role in CKD-induced muscle dysfunction, indirectly, via release of bone-specific proteins, which is partially reverted with PTx.
RESUMEN
PURPOSE: Frailty is common in older patients with chronic kidney disease (CKD) and has been considered an independent risk factor for adverse clinical outcomes in this population. CKD-associated mineral and bone metabolism (CKD-MBD) increases energy expenditure and causes malnutrition and inflammation leading to frailty. We investigated whether CKD-MBD markers and energy metabolism are associated with frailty in patients with advanced CKD on conservative management. METHODS: In this cross-sectional study, we investigated factors associated with frailty in a sample of 75 patients ≥ 65 years, with stage 4 or 5 CKD. Collected data included age, sex, body mass index, physical activity status, educational level, Charlson Comorbidity Index, and laboratory markers. Frailty was evaluated according to Fried's classification. RESULTS: Frailty was observed in 51.3% and pre-frailty in 47.3%. The frail population was significantly older, with a high proportion of females, more inactive, had lower educational levels, spent a long time sitting throughout the day, and had higher phosphate and fibroblast growth factor 21 (FGF-21). In the multivariate logistic analysis age (odds ratio 1.13, p = 0.026) and phosphate (odds ratio 3.38, p = 0.021) remained independently associated with frailty. CONCLUSION: Serum phosphate seems to be a toxin associated with the frailty phenotype in older patients with CKD. Whether strategies to decrease serum phosphate would reduce the risk of frailty in this population deserves further evaluation.
Asunto(s)
Fragilidad , Fosfatos , Insuficiencia Renal Crónica , Humanos , Femenino , Masculino , Anciano , Estudios Transversales , Insuficiencia Renal Crónica/terapia , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/sangre , Fragilidad/complicaciones , Fragilidad/sangre , Fosfatos/sangre , Anciano de 80 o más Años , Factores de Crecimiento de Fibroblastos/sangre , Factores de Edad , Conducta Sedentaria , Escolaridad , Metabolismo Energético , Biomarcadores/sangre , Factores Sexuales , Anciano Frágil , Tratamiento ConservadorRESUMEN
BACKGROUND & AIMS: Malnutrition is common in older individuals with end-stage renal disease on maintenance dialysis. Whether nutritional supplementation may improve skeletal muscle mass (SMM) and survival rate in this population is uncertain. We aimed to analyze the effect of a year of nutritional supplementation on muscle mass and survival rate in older patients on hemodiafiltration. METHODS: In this observational study, older patients (≥65 years old) on maintenance hemodiafiltration were selected to receive nutritional counselling + nutritional supplementation (N = 85, Supp+) or nutritional counselling alone (N = 47, Supp-) and followed for 1 year. The outcomes were a change in SMM and sarcopenia diagnosis. The secondary outcome was 1-year mortality rate. Nutritional parameters included calf circumference, body mass index, anthropometric measurements, subjective global assessment, and handgrip strength (HGS). Data were evaluated using GLM for repeated measures with adjustment for covariates (age and diabetes). RESULTS: Malnutrition was found in 50.8% of patients. At baseline, patients from the Supp+ group were older and had worse nutritional parameters including hand grip strength, calf circumference, anthropometric findings and sarcopenia (all p values < 0.05). During the follow-up, there was no significant change in sarcopenia (from 50.8% to 58.3%, p = 0.108), and there was a more pronounced decrease in the SMM index in the Supp-group (p = 0.049), with a significant intervention interaction (p = 0.030). Twenty deaths occurred, 7 (35%) in the Supp- and 13 (65%) in the Supp+ group (p = 0.540). SMM index (relative risk 0.90, p = 0.030) and age (relative risk 1.07, p = 0.046) were independently associated with higher mortality rates. CONCLUSION: Nutritional supplementation in older and malnourished individuals undergoing hemodiafiltration mitigates the loss of the SMM index and benefits survival rate.
Asunto(s)
Hemodiafiltración , Desnutrición , Sarcopenia , Humanos , Anciano , Sarcopenia/epidemiología , Fuerza de la Mano , Desnutrición/diagnóstico , Suplementos Dietéticos , MúsculosRESUMEN
PURPOSE: Despite CKD is common among older patients, and although factors associated with CKD progression have been explored over decades, little is known about the decline of renal function specifically in older individuals. METHODS: We included adult patients with CKD on conservative management in a propensity-score matched study 1:1 older (> 65 year) and young (≤ 65 yr). Factors associated with the slope of the decline of eGFR such as proteinuria, initial eGFR, diabetes, sex, and use of angiotensin-converting enzyme inhibitor/angiotensin receptor block (ACEI/ARB) were analyzed. Inclusion criteria were at least two consultations in the service and an initial eGFR lower than 45 ml/min/m2, in the period between January 2012 and December 2017. RESULTS: Crude analysis of eGFR decline shows a slower progression of older patients when compared to younger patients in both absolute change [- 2.0 (- 4.5, - 1.0) vs. -3.0 (- 7.0, - 1.0) ml/min/1.73m2, p < 0.001] and slope of eGFR reduction [- 2.2 (- 4.4, - 1.0) vs. 3.1 (- 6.7, - 1.2)) ml/min/1.73m2, p < 0.001]. Patients considered fast progressors (> 5 ml/min/1.73 m2/year decline in eGFR) were less likely to be older (35.2% young vs. 22.0% older, p < 0.001). Adjusted logistic multivariate regression confirmed that older patients had less odds ratio of eGFR decline, independently of the presence of proteinuria, diabetes, ACEI/ARB use, sex, baseline eGFR, baseline phosphate and baseline 25(OH) vitamin D. CONCLUSION: Older patients present slower CKD progression even after multiple adjustments. This information should be taken into consideration while treating these patients on conservative management and should be kept in mind while planning dialysis start.
Asunto(s)
Diabetes Mellitus , Fallo Renal Crónico , Insuficiencia Renal Crónica , Humanos , Anciano , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/terapia , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antagonistas de Receptores de Angiotensina/uso terapéutico , Progresión de la Enfermedad , Tasa de Filtración Glomerular , Proteinuria/etiología , Riñón/fisiologíaRESUMEN
Abstract Introduction: There is disagreement between data on sleep duration obtained from questionnaires and objective measurements. Whether this is also true for individuals with CKD is unknown. Here we compared self-reported sleep duration with sleep duration obtained by actigraphy. Methods: This prospective study included adult individuals with stage 3 CKD recruited between September/2016 and February/2019. We evaluated subjective sleep duration by asking the following question: "How many hours of actual sleep did you get at night?" Results: Patients (N=34) were relatively young (51 ± 13 years). Self-reported and measured sleep duration were 7.1 ± 1.7 and 6.9 ± 1.6 hours, respectively, with no correlation between them (p=0.165). Although the mean difference between measurements was 0.21 h, the limits of agreement ranged from -3.7 to 4.1 h. Conclusion: Patients with CKD who are not on dialysis have an erroneous sleep perception. Data on sleep duration should be preferentially obtained from objective measurements in patients with CKD.
Resumo Introdução: Há discordância entre os dados sobre duração do sono obtidos a partir de questionários e medições objetivas. Não se sabe se isto também é verdade para indivíduos com DRC. Aqui comparamos a duração do sono autorrelatada com a duração do sono obtida por meio de actigrafia. Métodos: Este estudo prospectivo incluiu indivíduos adultos com DRC estadio 3 recrutados entre Setembro/2016 e Fevereiro/2019. Avaliamos a duração subjetiva do sono, fazendo a seguinte questão: "Quantas horas de sono real você teve à noite?" Resultados: Os pacientes (N=34) eram relativamente jovens (51 ± 13 anos). A duração do sono autorrelatada e mensurada foi de 7,1 ± 1,7 e 6,9 ± 1,6 horas, respectivamente, sem correlação entre elas (p=0,165). Embora a diferença média entre as medições tenha sido de 0,21 h, os limites de concordância variaram de -3,7 a 4,1 h. Conclusão: Pacientes com DRC que não estão em diálise apresentam uma percepção equivocada do sono. Dados sobre a duração do sono devem ser obtidos preferencialmente a partir de medições objetivas em pacientes com DRC.
RESUMEN
INTRODUCTION: There is disagreement between data on sleep duration obtained from questionnaires and objective measurements. Whether this is also true for individuals with CKD is unknown. Here we compared self-reported sleep duration with sleep duration obtained by actigraphy. METHODS: This prospective study included adult individuals with stage 3 CKD recruited between September/2016 and February/2019. We evaluated subjective sleep duration by asking the following question: "How many hours of actual sleep did you get at night?" RESULTS: Patients (N=34) were relatively young (51 ± 13 years). Self-reported and measured sleep duration were 7.1 ± 1.7 and 6.9 ± 1.6 hours, respectively, with no correlation between them (p=0.165). Although the mean difference between measurements was 0.21 h, the limits of agreement ranged from -3.7 to 4.1 h. CONCLUSION: Patients with CKD who are not on dialysis have an erroneous sleep perception. Data on sleep duration should be preferentially obtained from objective measurements in patients with CKD.
Asunto(s)
Insuficiencia Renal Crónica , Duración del Sueño , Humanos , Autoinforme , Estudios Prospectivos , Factores de Tiempo , Diálisis Renal , Insuficiencia Renal Crónica/complicacionesRESUMEN
OBJECTIVE: Older patients with chronic kidney disease (CKD) undergoing maintenance hemodialysis are at a higher risk of falling. However, there is no standard method to screen patients at higher risk. We have evaluated whether calf circumference (CC) measurement would be able to predict falls in this population. METHODS: This is a prospective study that enrolled patients aged ≥65 years on conventional hemodialysis, followed for 6 months. The presence of falls was associated with demographical, clinical, and biochemical data. Reduced CC was set at <34 cm for men and <33 cm for women. We evaluated physical status using Duke activity status index (DASI) and hand grip strength (HGS). RESULTS: Ninety-one patients were included (age 73.7 ± 5.4 years, 69.2% men, 56% with diabetes). Mean CC was 32.6 ± 3.7 cm, with a high prevalence of reduced CC (61.5%). During the follow-up, 13 falls were identified (1 had a fracture and died). These patients were older and heavier (P = .017 and P = .025, respectively). Most falls occurred in patients with sarcopenic obesity (BMI >27 kg/m2 plus reduced HGS or reduced CC). In a logistic regression model, reduced CC (hazard ratio (HR) 7.81, confidence interval (CI): 1.13-53.86, P = .037), higher age (HR 1.19, CI: 1.04-1.36, P = .011), and higher body weight (relative risk (RR) 1.13, CI: 1.04-1.22, P = .003) were independently associated with falls in a fully adjusted model. CONCLUSION: CC measurement, an easy and nonexpensive tool, was able to predict falls in older patients on HD. Further studies should test the inclusion of CC in a fall risk assessment in older patients on hemodialysis.
Asunto(s)
Fuerza de la Mano , Sarcopenia , Masculino , Humanos , Femenino , Anciano , Estudios Prospectivos , Sarcopenia/epidemiología , Diálisis Renal/efectos adversos , Obesidad/complicacionesAsunto(s)
Hiperparatiroidismo Secundario , Fallo Renal Crónico , Nefrología , Humanos , Hiperparatiroidismo Secundario/diagnóstico , Hiperparatiroidismo Secundario/tratamiento farmacológico , Hiperparatiroidismo Secundario/etiología , Paratiroidectomía , Fallo Renal Crónico/terapia , Hormona ParatiroideaRESUMEN
Left ventricular hypertrophy is a risk factor for cardiovascular mortality in patients on peritoneal dialysis (PD). Because icodextrin has a greater ultrafiltration power compared with glucose-based solutions for long dwell, it could improve left ventricular mass by reducing fluid overload. This was a randomized clinical trial that included patients on PD recruited from 2 teaching hospitals, in Sao Paulo-Brazil. Patients were allocated to the control glucose group (GLU) or the intervention icodextrin (ICO) group. Clinical and cardiac magnetic resonance image (MRI) parameters were evaluated at baseline and 6 months after randomization. The primary outcome was the change in left ventricular mass adjusted by surface area (ΔLVMI), measured by cardiac MRI. A total of 22 patients completed the study (GLU, N = 12 and ICO, N = 10). Baseline characteristics such as age, sex, underlying disease, and time on dialysis were similar in both groups. At baseline, 17 patients (77.3%) presented with left ventricular hypertrophy with no difference between groups (p = 0.748). According to the total body water (TBW)/extracellular water (ECW) ratio, 36.8% and 80% of patients from GLU and ICO groups, respectively, were considered hypervolemic (p = 0.044). During follow-up, ΔLVMI was 3.9 g/m (- 10.7, 2.2) in GLU and 5.2 (- 26.8, 16.8) in ICO group (p = 0.651). ΔLVMI correlated with change in brain natriuretic peptide (r = 0.566, p = 0.044), which remained significant in a multiple regression analysis. The use of the icodextrin-based solution in prevalent patients on PD compared with a glucose-based solution was not able to improve LMV. A larger randomized trial with a longer follow-up period may be needed to show changes in LVM in this patient population.Trial registration: this study has been registered at ReBEC (Registro Brasileiro de Ensaios Clinicos) under the identification #RBR-2mzhmj2, available at: https://ensaiosclinicos.gov.br/pesquisador .
Asunto(s)
Soluciones para Diálisis , Icodextrina , Diálisis Peritoneal , Brasil , Glucanos/uso terapéutico , Glucosa/efectos adversos , Glucosa/uso terapéutico , Humanos , Hipertrofia Ventricular Izquierda/etiología , Icodextrina/uso terapéutico , Péptido Natriurético Encefálico , Diálisis Peritoneal/métodos , Estudios Prospectivos , Diálisis RenalRESUMEN
PURPOSE: Hyperuricemia is common among patients with chronic kidney disease (CKD). In the general population, hyperuricemia is associated with secondary hyperparathyroidism (SHPT), in a mechanism that involves vitamin D metabolism. Data for patients with CKD, however, are scarce. We aimed to evaluate the relationship between hyperuricemia and mineral and bone metabolism, particularly hyperparathyroidism. METHODS: This is a retrospective study that included 922 adult patients with stages 3, 4, or 5 CKD, not on dialysis. Clinical, demographic, and biochemical data were collected from charts and included uric acid, parathyroid hormone (PTH), 25(OH)-vitamin D, calcium, phosphate, renal function (estimated glomerular filtration rate-eGFR), and medications such as allopurinol, furosemide, and cholecalciferol. SHPT was defined as PTH > 65 pg/ml. RESULTS: Our patients were mostly Caucasian women, with a mean age of 64 ± 16 years. SHPT and hyperuricemia were observed in 70% and 62.4% of patients, respectively. Patients with SHPT presented higher levels of uric acid (7.2 ± 1.8 vs. 6.6 ± 1.7 mg/dL, p = 0.0001) and a higher frequency of hyperuricemia (66% vs. 33%, p = 0.0001). Patients with hyperuricemia were mostly female, with lower eGFR, higher phosphate, and higher PTH. The risk of hypovitaminosis D was higher among patients with SHPT (69.7% vs. 53.1%, p = 0.0001). Hyperuricemia remained independently associated with hyperparathyroidism, (p = 0.033) even after adjustments for eGFR, calcium, phosphate, hypovitaminosis D, and use of allopurinol, calcitriol, furosemide, and cholecalciferol. CONCLUSION: Hyperuricemia seems to be a contributing factor for SHPT in patients with CKD. The mechanisms behind this finding have yet to be elucidated.
Asunto(s)
Hiperparatiroidismo Secundario , Hiperuricemia , Insuficiencia Renal Crónica , Deficiencia de Vitamina D , Adulto , Anciano , Anciano de 80 o más Años , Alopurinol/uso terapéutico , Calcio/uso terapéutico , Colecalciferol/uso terapéutico , Femenino , Furosemida/uso terapéutico , Humanos , Hiperparatiroidismo Secundario/complicaciones , Hiperparatiroidismo Secundario/epidemiología , Hiperuricemia/complicaciones , Hiperuricemia/epidemiología , Masculino , Persona de Mediana Edad , Hormona Paratiroidea , Fosfatos , Insuficiencia Renal Crónica/complicaciones , Estudios Retrospectivos , Ácido Úrico , Vitamina D/uso terapéutico , Deficiencia de Vitamina D/complicacionesRESUMEN
PURPOSE: There is a paucity of data on the prognosis for patients returning to peritoneal dialysis (PD) after a failed transplant. PD has an advantage over hemodialysis in preserving residual renal function, which is associated with better outcomes. METHODS: We have reviewed the electronic charts of patients on PD in a tertiary academic hospital for the last 8 years. We have compared technique survival, peritonitis-free survival, and residual diuresis in two groups: patients with graft failure which returned to PD (PD-KTx, N = 18) and patients starting PD for other causes (PD-not KTx, N = 163). RESULTS: The median follow-up was similar between groups [42(16,71) in PD-not KTx vs. 48(22,90) months in PD-KTx, p = 0.293]. Kaplan-Meier survival comparing PD-KTx and PD-not KTx showed no difference in technique survival (p = 0.196), and peritonitis-free survival (log-rank 0.238), which were confirmed in a fully adjusted Cox regression. Diuresis at baseline and at the end of the first year was similar between groups (p = 0.799 and p = 0.354, respectively). Six out of 18 patients from the PD-KTx group had the immunosuppression maintained and none of those had peritonitis. The reduction of diuresis across the first year of PD was significant for all patients, except for those on continued immunosuppressive therapy. CONCLUSION: PD is a worthy dialysis alternative after a failed kidney transplant, providing similar outcomes when compared to patients who started PD for other reasons.
Asunto(s)
Fallo Renal Crónico , Trasplante de Riñón , Diálisis Peritoneal , Peritonitis , Humanos , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/cirugía , Trasplante de Riñón/efectos adversos , Diálisis Peritoneal/efectos adversos , Peritonitis/etiología , Diálisis Renal/efectos adversos , Estudios RetrospectivosRESUMEN
Abstract Patients on hemodialysis are exposed to calcium via the dialysate at least three times a week. Changes in serum calcium vary according to calcium mass transfer during dialysis, which is dependent on the gradient between serum and dialysate calcium concentration (d[Ca]) and the skeleton turnover status that alters the ability of bone to incorporate calcium. Although underappreciated, the d[Ca] can potentially cause positive calcium balance that leads to systemic organ damage, including associations with mortality, myocardial dysfunction, hemodynamic tolerability, vascular calcification, and arrhythmias. The pathophysiology of these adverse effects includes serum calcium changes, parathyroid hormone suppression, and vascular calcification through indirect and direct effects. Some organs are more susceptible to alterations in calcium homeostasis. In this review, we discuss the existing data and potential mechanisms linking the d[Ca] to calcium balance with consequent dysfunction of the skeleton, myocardium, and arteries.
Resumo Pacientes em hemodiálise são expostos ao cálcio, por meio do dialisato, pelo menos três vezes por semana. As alterações no cálcio sérico variam de acordo com a transferência de massa de cálcio durante a diálise, que é dependente do gradiente entre a concentração de cálcio no plasma e no dialisato (d [Ca]) e o estado de renovação do esqueleto que altera a capacidade do osso de incorporar cálcio. Embora subestimado, o d [Ca] pode potencialmente causar balanço positivo de cálcio que leva a danos em órgãos sistêmicos, incluindo associações com mortalidade, disfunção miocárdica, tolerabilidade hemodinâmica, calcificação vascular e arritmias. A fisiopatologia desses efeitos adversos inclui alterações do cálcio sérico, supressão do hormônio da paratireóide e calcificação vascular por meio de efeitos diretos e indiretos. Alguns órgãos são mais suscetíveis a alterações na homeostase do cálcio. Nesta revisão, discutimos os dados existentes e os mecanismos potenciais que ligam o d [Ca] ao equilíbrio do cálcio com a consequente disfunção no esqueleto, miocárdio e artérias.
Asunto(s)
Humanos , Sistema Cardiovascular , Calcio , Hormona Paratiroidea , Huesos , Diálisis RenalRESUMEN
Although diuretics are often prescribed to control fluid overload, they can change Chronic kidney disease-mineral and bone disorder (CKD-MBD) parameters. Previous studies have shown an association between diuretic prescription and changes in both calciuria and parathormone levels. However, the causal relationship could not be confirmed. In addition, the effects of diuretics on bone mineral density and turnover markers are yet to be established. To evaluate the effects of diuretics on CKD-MBD, we have performed a prospective randomized trial comparing hydrochlorothiazide with furosemide in a stage 3CKD population followed for 1 year. Furosemide increased bone remodeling and parathormone levels, whereas hydrochlorothiazide attenuated parathyroid hormone rise and decreased bone turnover markers.
RESUMEN
INTRODUCTION: Body composition is critical for the evaluation of patients with Chronic Kidney Disease (CKD) and can be obtained from either multifrequency bioelectrical impedance analysis (BIA) or dual-energy absorptiometry (DXA). Although the discrepancy between the results obtained from both methods has already been described, reasons are unknown, and might be related to secondary hyperparathyroidism, which is associated with bone loss. METHODS: We have evaluated 49 patients (25 males and 24 females): 20 with CKD not on dialysis and 29 on maintenance hemodialysis [18 with severe hyperparathyroidism (HD-SHPT) and 11 submitted to parathyroidectomy (HD-PTX)]. All patients underwent DXA and BIA. RESULTS: The median age and body mass index (BMI) were 49 years and 25.6 kg/m2, respectively. Patients exhibited low bone mineral content (BMC) measured by DXA, particularly those from the HD-SHPT group. The largest BMC measurement disagreement between DXA and BIA was found in the HD-SHPT group (p=0.004). Factors independently associated with this discrepancy in BMC measurement were serum phosphate (p=0.003) and patient group (p=0.027), even after adjustments for age, BMI, and gender (adjusted r2=0.186). PTX attenuated this difference. DISCUSSION: BIA should be interpreted with caution in patients with SHPT due to a loss of accuracy, which can compromise the interpretation of body composition.
Asunto(s)
Densidad Ósea , Hiperparatiroidismo Secundario , Absorciometría de Fotón , Índice de Masa Corporal , Impedancia Eléctrica , Femenino , Humanos , Masculino , Diálisis RenalRESUMEN
Mineral and bone metabolism disorders are relatively common among patients with end-stage renal disease on maintenance hemodialysis. Corneal and conjunctival calcification is the main extravascular site for calcification. Recently, this form of calcification has been linked to vascular calcification. Secondary hyperparathyroidism can lead to high levels of calcium and phosphorus and increase the risk of calcification. Here, we report a case of a 38-year-old female with severe hyperparathyroidism who underwent eye examination before and after parathyroidectomy. Anterior segment optical coherence tomography showed an improvement in the number and size of ocular calcifications 6 months after surgery. This case calls attention to the importance of eye examination in patients on dialysis and brings the possibility of recovery of calcification in a short-term follow-up.