RESUMO
INTRODUCTION: Coding variants in apolipoprotein L-1 (APOL1) are associated with an increased risk of end-stage kidney disease (ESRD) in African American individuals under a recessive model of inheritance. The effect of the APOL1 risk alleles on kidney disease has been observed in studies in African American and African populations. Despite the 130 million individuals of recent African ancestry in South America, the impact of APOL1 has not been explored. METHODS: In this case-control study, we tested APOL1 genotype in 106 Brazilian HD (hemodialysis) patients with African ancestry and compared risk allele frequency with 106 healthy first-degree relatives. The association of risk alleles and ESRD was calculated with a linear mixed model and was adjusted for relatedness and additional confounders. In a broader survey, the age of dialysis initiation and APOL1 variants were analyzed in 274 HD patients. RESULTS: Two APOL1 risk alleles were 10 times more common in patients with ESRD than in controls (9.4% vs. 0.9%; odds ratio [OR]: 10.95, SE = 1.49, P = 0.0017). Carriers of 2 risk alleles initiated dialysis 12 years earlier than patients with zero risk alleles. CONCLUSION: The APOL1 risk variants were less frequent in dialysis patients of African ancestry in Brazil than in the United States. Nonetheless, carriers of 2 risk variants had 10-fold higher odds of ESRD. Age of dialysis initiation was markedly lower in 2-risk allele carriers, suggesting a more aggressive disease phenotype. The Brazilian population represents an opportunity to identify different sets of genetic modifiers or environmental triggers that might be present in more extensively studied populations.
RESUMO
A good catheter implantation technique is important to allow for effective peritoneal access function and long-term technique survival. Studies regarding results obtained by nephrologists in comparison with surgeons have been limited to small single-center experiences. Thus, the objective of this study was to explore the impact of the peritoneal dialysis (PD) catheter insertion operator on early catheter complications and on technique survival in a large national multicentric cohort study (Brazilian Peritoneal Dialysis Multicentric Study, BRAZPD). Adult incident patients recruited in the BRAZPD from December 2004 to October 2007 having undergone first PD catheter implantation were included in the analysis. Mechanical and infectious early complication rates were defined as time to the first event occurring up to 3 months after catheter insertion and adjusted for comorbidities. Valid data of 736 patients (mean age of 59 ± 16 years old, 52% women, 61% white) were analyzed. Mechanical (HR 0.99 [CI 0.56-1.76]; p = 0.98) and infectious (HR 0.63 [CI 0.32-1.23]; p = 0.17) early complication rates were similar between groups. Long-term catheter survival was also similar between groups. Early complications rates and catheter survival were similar between groups defined by operator profile (nephrologist or surgeon), supporting the role of interventional nephrology in the placement of PD catheters.
Assuntos
Cateterismo/métodos , Diálise Peritoneal/instrumentação , Padrões de Prática Médica/estatística & dados numéricos , Idoso , Brasil/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Modelos de Riscos Proporcionais , Fatores de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
Vascular access complications are one of the main causes associated with an increase in morbidity and mortality in stage 5 chronic kidney disease patients. The arteriovenous fistula is regarded as the vascular access of choice for hemodialysis (HD) because of its superior patency and lower complication rates. Stenosis is considered the major cause of dysfunction of arteriovenous fistula. Despite the relatively low thrombosis rates of arteriovenous fistula, surveillance programs are necessary for detection of stenosis. We report a case of a HD patient who had never achieved an adequate Kt/V since the start of maintenance HD. During the investigation, abnormal findings were found on physical examination of the fistula, in addition to an alteration in intra-access pressure (IAP) measurements. A venous stenosis was diagnosed by Doppler ultrasound and then promptly treated with percutaneous transluminal angioplasty. The purpose of the discussion is to highlight the peculiarities of arteriovenous fistulae, methods of surveillance, including physical examination, IAP, recirculation, and measurements of blood flow, and the importance of the correction procedures for the stenosis.
Assuntos
Angioplastia com Balão , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Competência Clínica , Oclusão de Enxerto Vascular/terapia , Diálise Renal/métodos , Brasil , Educação de Pós-Graduação em Medicina , Oclusão de Enxerto Vascular/diagnóstico por imagem , Humanos , Internato e Residência , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Nefrologia/educação , Prognóstico , Medição de Risco , Ultrassonografia Doppler , Grau de Desobstrução VascularRESUMO
The antibiotic treatment currently recommended by the International Society for Peritoneal Dialysis (ISPD) for peritonitis consists of a combination of a first- and a third-generation cephalosporin. The schedule formerly recommended combined a first-generation cephalosporin and an aminoglycoside. No comparison between the treatment schedules has been performed until now. We compared the effectiveness of these two regimens in peritoneal dialysis-related peritonitis at our center. From January 1999 to April 2000, we followed 107 patients in our PD clinic (period 1: 47% men; 32% with diabetes; mean age: 52 +/- 13 years). We followed a similar number of patients from January 2002 to July 2003 (period 2: 109 patients; 54% men; 51% with diabetes; mean age: 56 +/- 18 years). In each period, diagnosis and treatment of peritonitis were based on the recommendations of the ISPD as earlier described. Negative culture rates were similar in period 1 and period 2 (32% vs. 30%). In both study groups, the bacteria that most commonly caused peritonitis were Staphylococcus epidermidis (period 1: 41%; period 2: 39%) and S. aureus (period 1: 27%; period 2: 18%). Gram-positive infections occurred in 59% of patients during period 1 and in 57% during period 2. Gram-negative infections occurred in 16% of patients during period 1 and in 18% during period 2. We observed no significant difference in the peritonitis cure rate from period 1 to period 2 (78% vs. 83%; chi-square: 0.98; p = 0.3), but changes in the primary antibiotic schedule were necessary in 4 patients in period 1 as compared with 1 patient in period 2. The rates of catheter removal were not significantly different during the two periods (period 1: 14%; period 2: 5%; chi-square: 2.5; p = 0.11). Mortality was also not significantly different during the two periods (period 1: 7%; period 2: 5%; chi-square: 0.23; p = 0.62). The two antibiotic schedules were equally effective in the treatment of peritonitis. Cost-effectiveness, impact on residual renal function, and potential development of bacterial resistance must be considered when selecting the antibiotic schedule for peritonitis treatment.