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Protein-energy wasting (PEW) and poor health-related quality of life (HRQoL) are independently associated with morbi-mortality in continuous ambulatory peritoneal dialysis (CAPD). PEW may reduce HRQoL; however, we hypothesized HRQoL is affected differentially by PEW degrees or by individual criteria of nutritional status. AIM: To evaluate HRQoL according to PEW severity and nutritional status indicators in CAPD. This is a cross-sectional study in 151 patients. Subjective global assessment (SGA) was employed, and nutritional status classified as normal, mild-moderate PEW, and severe PEW. HRQoL was evaluated using Kidney Disease Quality of Life Short Form™, including physical (PCS), mental (MCS) and kidney disease (KDCS) components, and their subscales. Dietary intake, anthropometric and biochemical variables were measured. Forty-six percent of patients were well-nourished, 44% had mild-moderate PEW, and 10% severe PEW. Compared with well-nourished patients, those with mild-moderate (p=0.06) and severe (p=0.005) PEW had lower HRQoL score [68 (52-75), 55 (45-72), 46 (43-58), respectively]. PCS, MCS, and KDCS and their subscales had lower values as PEW was more severe. Patients with obesity and hypoalbuminemia had significantly lower HRQoL overall and component scores than their counterparts. Dietary intake was not associated with quality of life. In multivariate analysis obesity, PEW (by SGA), hypoalbuminemia, and low educational level predicted poor HRQoL (χ2 58.2, p

Summary Background & aims Evidence suggests that multiple-behavior interventions (with a specialist) have a greater impact on public health than single-behavior interventions, particularly in a chronic patient. However, there is little understanding of some very basic principles concerning multiple health behavior change, especially in situations such as kidney transplantation, which requires a great willingness to change negative lifestyle behaviors to achieve intermediate and long-term success. We compared healthy lifestyles and nutritional status according to the willingness to change dietary and exercise behavior in dialysis patients from a living donor kidney transplant program. Methods 400 dialysis patients had a dietetic, anthropometric, protein-energy wasting [subjective global assessment (SGA)] and biochemical evaluation. Lifestyle was evaluated with an adapted instrument to measure lifestyle in chronic disease. Willingness to change behaviors was evaluated by the trans-theoretical model; 2 groups were formed: willingness to change dietary and exercise behaviors and unwillingness to change. Results Willingness to change dietary behavior was 50% and exercise 25%. Patients with willingness to change dietary and exercise behaviors had better healthy lifestyle scores, and higher frequency of healthy food consumption. Healthy lifestyle score (R2=0.37, p Conclusions Willingness to change dietary and exercise behaviors was associated with healthy lifestyle, as well as with higher frequency of healthy food consumption and with lower frequency of unhealthy food consumption.

Objective The aim of this study was to evaluate the interaction between diet quality and interleukin (IL)-6 genotypes and its association with metabolic and renal function parameters in Mexican patients with type 2 diabetes mellitus (T2DM). Design and Methods Using an analytical cross-sectional design, 219 patients with T2DM (92 men; age 62 ± 10 years) were evaluated for selected metabolic and renal function parameters. Diet quality according to the Healthy Eating Index was evaluated and classified as good diet or poor diet in all patients. IL-6 serum concentrations and genotypes and haplotypes for IL6–597G > A (rs180097), –572G > C (rs180096), and –174G > C (rs180095) polymorphisms were determined. Results Eighty-two percent of patients reported having a poor diet. Carriers of alleles –572C and –174C showed higher high-density lipoprotein cholesterol levels (44 ± 12 vs. 40 ± 9 mg/dL; P = .01) and lower total cholesterol levels (184 ± 33 vs. 197 ± 42 mg/dL; P = .03) than did those homozygous for G/G. Neither IL6 genotypes nor haplotypes were significantly associated with serum concentrations of IL-6. Some significant interactions between IL6 genotypes/haplotypes and diet quality were associated with body mass index, waist circumference, high-density lipoprotein cholesterol levels, and estimated glomerular filtration rate. Conclusions Interactions between diet quality and IL6 genotypes/haplotypes were associated with the main metabolic and renal function parameters in Mexican patients with T2DM. It will be important to consider genetic profiles in designing dietary portfolios and nutritional interventions for the management of such patients.

A key component of treatment for all people with advanced kidney disease is supportive care, which aims to improve quality of life and can be provided alongside therapies intended to prolong life, such as dialysis. This article addresses the key considerations of supportive care as part of integrated end-stage kidney disease care, with particular attention paid to programs in low- and middle-income countries. Supportive care should be an integrated component of care for patients with advanced chronic kidney disease, patients receiving kidney replacement therapy (KRT), and patients receiving non-KRT conservative care. Five themes are identified: improving information on prognosis and support, developing context-specific evidence, establishing appropriate metrics for monitoring care, clearly communicating the role of supportive care, and integrating supportive care into existing health care infrastructures. This report explores some general aspects of these 5 domains, before exploring their consequences in 4 health care situations/settings: in people approaching end-stage kidney disease in high-income countries and in low- and middle-income countries, and in people discontinuing KRT in high-income countries and in low- and middle-income countries.

The aim of this study was to validate a direct taste perception test (TPT) and evaluate its performance in patients on dialysis.This cross-sectional study was carried out in a tertiary-care hospital. A TPT was validated on 112 healthy subjects and applied on 43 patients on hemodialysis and 32 patients on peritoneal dialysis. All participants were presented a 10-mL sample to identify and rate intensity of primary tastes: sweet (sucrose 2%), sour (citric acid 0.1%), bitter (caffeine 0.06%), salty (sodium chloride 0.5%), and umami (sodium glutamate 0.25%). The internal consistency and repeatability of TPT was assessed by Cronbach's alpha and intraclass correlation coefficient. Chi-square and Mann-Whitney U tests were used to compare groups.TPT had Cronbach's alpha of 0.77. Intraclass correlation coefficient was 0.74 for sweet, P.0001; 0.57 for salty, P = .001; 0.62 for sour, P.0001; 0.78 for bitter, P.0001; and 0.76 for umami, P.0001. Compared with controls, patients on peritoneal dialysis were less able to identify sweet and umami tastes (P.05) and marginally (P = .06) sour taste, whereas patients on hemodialysis were marginally (P = .06) less able to identify sweet and salty tastes. Bitter was not differently identified between groups. According to the visual analog scale (0-10), all patients on dialysis perceived sour taste less intensely than control subjects (P.05).This TPT for patients on dialysis had adequate reliability to identify five primary tastes in a clinical setting. Except for bitter taste, perception of all the primary tastes was altered in patients on dialysis compared with control subjects. A broader use of this test would help identify taste alterations and implement strategies for malnutrition.

End-stage kidney disease (ESKD) represents a major challenge for Latin America (LA). The Latin American Dialysis and Renal Transplantation Registry (LADRTR) has published several reports, and its continuity has implied a sustained effort of the nephrology community to improve care of ESKD in the region; this paper summarizes results of the year 2014. Methods have been reported previously; participant countries complete annual surveys collecting data on incident and prevalent patients undergoing renal replacement therapy (RRT) in all modalities. 20 countries participated in the surveys (more than 90% of the region). Prevalence of treated ESKD in RRT increased from 119 patients per million population (pmp) in 1991 to 709 pmp in 2014; hemodialysis continues to be the treatment of choice in the region (68%). A wide variation was observed in the incidence rate, from 421 pmp in Jalisco (Mexico) to 23 pmp in Paraguay; diabetes was the cause of 36% of incident cases. Additionally, great heterogeneity was observed in the number of nephrologists by country, from 2 pmp in Colombia to 53 pmp in Uruguay. Heterogeneity, or even absence of registries in some LA countries, is concordant with inequities in RRT access as well as with the limited availability of qualified personnel. The LADRTR is leading the personnel training to develop and strengthen national dialysis and transplant registries in LA within the frame of the Pan-American Health Organization (PAHO) - Sociedad Latinoamericana de Nefrología e Hipertension (SLANH) cooperation program.

Summary Background & aims Mexico has one of the highest mortality rates by COVID-19 worldwide. This may be partially explained by the high prevalence of overweight/obesity found in general population; however, there is limited information in this regard. Furthermore, acute kidney injury (AKI) and need for renal replacement therapy (RRT) associated to obesity in patients with COVID-19 are still topics of discussion. Aim: To explore the association of obesity, particularly morbid obesity, with mortality and kidney outcomes in a Mexican population of hospitalized patients with COVID-19. Methods Retrospective cohort study of 773 patients with COVID-19 hospitalized in a tertiary-care teaching hospital in the Mexican state of Jalisco. Baseline body mass index was classified as: normal weight (18.5–24.9 kg/m2), overweight (25–29.9 kg/m2), obesity (30–39.9 kg/m2), and morbid obesity (≥40 kg/m2). AKI was diagnosed according to KDIGO clinical practice guidelines. Results At baseline, 35% of patients had overweight, 39% obesity and 8% morbid obesity. Patients with obesity were younger, more frequently women and with hypertension than normal weight and overweight patients. Frequency of complications in the univariate analysis were not significantly associated to obesity, however in the multivariate analysis (after adjusting for baseline clinical and biochemical differences), morbid obesity was significantly associated to an increased risk of AKI [OR = 2.70 (1.01–7.26), p = 0.05], RRT [OR = 14.4 (1.46–42), p = 0.02], and mortality [OR = 3.54 (1.46–8.55), p = 0.005]. Conclusions Almost half of the sample had obesity and morbid obesity. Morbid obesity was significantly associated to an increased risk of AKI, RRT and mortality in hospitalized patients with COVID-19.

Triggering receptor expressed on myeloid cells (TREM)-1 is a potent and early amplifier of the inflammatory response expressed on neutrophils and monocytes/macrophages. TREM-1, and its soluble form (sTREM-1), are increased in sepsis and other noninfectious inflammatory conditions. However, virtually no data are available in kidney disease. To determine serum sTREM-1 and its associated variables in patients on hemodialysis (HD), cross-sectional study including 264 HD patients and 148 controls. sTREM-1 was measured by quantitative sandwich enzyme immunoassay; soluble tumor necrosis factor receptor-1 (sTNF-R1), interleukin-6 (IL-6), and C-reactive protein (CRP) were also measured. All inflammation markers were significantly higher in HD patients than controls. Median (IQR) sTREM-1 was 1,006 (613-1,650) pg/mL but undetectable in controls. Considering only HD patients, sTREM-1 was positively correlated with IL-6 (r = 0.19, p = 0.008), and its levels were significantly higher in patients with arteriovenous fistula than in those with temporary catheter (1,226 vs. 743 pg/mL), in patients with 3 HD sessions/week than in those with 2 sessions/week (1,150 vs. 646 pg/mL), and in patients with >1 year on HD than in those with ≤1 year (1,100 vs. 948 pg/mL), whereas they were not different regarding age or presence of infection. Serum sTREM-1, sTNF-R1, IL-6, and CRP were higher in HD patients compared to controls. In HD patients, sTREM-1 displayed higher levels in individuals with arteriovenous fistula, 3 sessions/week and longer vintage, but not in those with infection or older age; in multivariate analysis, only the first two variables significantly predicted higher sTREM-1 levels.

ObjectiveTo describe mortality of in-hospital patients with COVID-19 and compare risk factors between survivors and non-survivors.DesignProspective cohort of adult inpatients.SettingTertiary healthcare teaching hospital in Guadalajara, Mexico.ParticipantsAll patients with confirmed COVID-19 hospitalised from 25 March to 7 September 2020 were included. End of study: 7 November 2020.Primary outcome measuresPatient survival analysed by the Kaplan-Meier method and comparison of factors by the log-rank test. Mortality risk factors analysed by multivariate Cox’s proportional-hazard model.ResultsOne thousand ten patients included: 386 (38%) died, 618 (61%) alive at discharge and six (0.6%) remained hospitalised. There was predominance of men (63%) and high frequency of overweight–obesity (71%); hypertension (54%); diabetes (40%); and lung (9%), cardiovascular (8%) and kidney diseases (11%); all of them significantly more frequent in non-survivors. Overweight–obesity was not different between groups, but severity of disease (Manchester Triage System and quick Sequential Organ Failure Assessment) was significantly worse in non-survivors, who were also significantly older (65 vs 45 years, respectively) and had haematological, biochemical, coagulation and inflammatory biomarkers more altered than survivors. Mortality predictors were invasive mechanical ventilation (IMV; OR 3.31, pConclusionsMortality in hospitalised patients with COVID-19 in this emerging country centre seemed to be higher than in developed countries. Patients displayed a high frequency of risk factors for poor outcome, but the need for IMV, ICU admission, older age, more severe disease at admission, antecedent of kidney disease and higher CRP levels significantly predicted mortality.

Obesity is clearly associated to kidney disease in adult population; however, there is scarce evidence in children and adolescents. The aim was to compare frequency of renal damage according to the presence of overweight-obesity in children and adolescents, as well as to compare nutritional and biochemical risk factors, according to the presence of kidney alterations.Cross-sectional study; 172 children and adolescents, 6-16 years old, without malnutrition, diabetes mellitus, hypertension and independent comorbid conditions associated to obesity or kidney disease, as well as transitory causes of microalbuminuria (MA) from a Primary Health-Care Unit were included. Clinical, biochemical, anthropometric and dietetic evaluations were measured in all subjects; subsequently they were classified as normal weight, overweight and obesity groups according to sex- and age-adjusted body mass index (BMI). Glomerular filtration rate (GFR, estimated by Schwartz equation) and albuminuria (albumin/creatinine ratio) were determined. Presence of kidney alterations was measured as decreased GFR (90 mL/min/1.73mCompared with controls, subjects with overweight-obesity had significantly (P.05) abdominal obesity (0 vs 69%), hypertension (19 vs 26%), hypertriglyceridemia (11 vs 47%), high low-density lipoprotein cholesterol (2 vs 8%) and low high-density lipoprotein cholesterol (HDL-cholesterol; 2 vs 28%), hyperuricemia (11 vs 28%) and hyperinsulinemia (8 vs 70%). Hyperfiltration and MA were present in 5 and 4 subjects with overweight/obesity, respectively, whereas decreased GFR was present in only 1 subject with obesity. Normal weight subjects had no kidney alterations. In multivariate analysis, kidney alterations were significantly predicted by higher BMI and lower HDL-cholesterol.Kidney alterations were observed only in subjects with overweight (3.6%) and obesity (9.9%), who additionally, displayed cardiometabolic and kidney disease risk factors more frequently than normal weight subjects.

Minimization in immunosuppression could contribute to the appearance the donor-specific HLA antibodies (DSA) and graft failure. The objective was to compare the incidence of DSA in renal transplantation (RT) in recipients with immunosuppression with and without steroids. A prospective cohort from March 1st, 2013 to March 1st, 2014 and follow-up (1 year), ended in March 2015, was performed in living donor renal transplant (LDRT) recipients with immunosuppression and early steroid withdrawal (ESW) and compared with a control cohort (CC) of patients with steroid-sustained immunosuppression. All patients were negative cross-matched and for DSA pre-transplant. The regression model was used to associate the development of DSA antibodies and acute rejection (AR) in subjects with immunosuppressive regimens with and without steroids. Seventy-seven patients were included (30 ESW and 47 CC). The positivity of DSA class I (13% vs 2%; P

Background Cognitive deterioration decreases quality of life, self-care and adherence to treatment, increasing mortality risk. There is scarce information of cognitive impairment in peritoneal dialysis (PD) and data are controversial. Our aim was to determine the frequency and associated factors of cognitive impairment in patients on automated PD (APD). Methods In this cross-sectional study, 71 patients on APD underwent clinical, biochemical and cognitive function evaluation by means of the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). Cognitive function was also evaluated in healthy controls. Results Participants mean age was 42 ± 16 years, 79% were men and dialysis vintage was 17 months ( interquartile range 7–32). In APD patients, cognitive impairment was present in 7% (mild deterioration) and 68% according to the MMSE and MoCA, respectively, and 4 and 37% in the healthy controls. Patients with cognitive impairment (according to MoCA) were older, with less education, had diabetes more frequently and higher serum glucose as well as lower serum creatinine, phosphorus and sodium concentrations than patients with normal cognitive function. In multiple linear regression analysis, predictors for the MoCA score (R2 = 0.63, P = 0.002) were education {B = 0.54 [95% confidence interval (CI) 0.20–0.89]; P = 0.003}, age [B = −0.11 (95% CI −0.21 to −0.01); P = 0.04], serum sodium [B = 0.58 (95% CI 0.05–1.11); P = 0.03] and creatinine concentration [B = 3.9 (95% CI 0.03–0.83); P = 0.03]. Conclusions In this sample of APD patients, the prevalence of cognitive impairment by the MoCA was 65% and was associated with older age, lower education level and lower serum concentrations of sodium and creatinine.

Diabetic nephropathy is a leading cause of chronic kidney disease (CKD). In diabetes, changes in serum levels of both soluble alpha Klotho (sKL) and fibroblast growth factor 23 (FGF-23) have been associated with CKD progression.To evaluate the associations of circulating levels of sKL and FGF-23 with the presence of early nephropathy (EN) in diabetic patients.A cross-sectional study in 136 Mexicans with type 2 diabetes mellitus (T2DM). Early nephropathy was defined as an estimated glomerular filtration rate (≥60 ml/min) and urinary albumin excretion (≥30 mg/g). Serum concentrations of sKL and FGF-23 were measured using ELISA. Associations were evaluated with multiple logistic regression.Fifty-two subjects had EN. Median values of sKL and FGF-23 for all individuals were 244 pg/mL (interquartile range [IQR]: 201-402) and 92 pg/mL (IQR: 39-507), respectively. A positive correlation was found between levels of sKL and FGF-23 (r = 0.38; p 0.001). FGF-23 levels correlated negatively with angiotensin-II receptor blocker therapy (ARB, r = 0.24; p 0.01). Subjects without EN were younger (59 vs. 63 years old, p = 0.02). Elevated concentrations of FGF-23 were negatively associated with EN (Odds Ratio [ORIn Mexican diabetic patients, serum levels of FGF-23 were positively correlated with sKL but negatively correlated with ARB therapy. In addition, a higher concentration of FGF-23 reduced the odds of early nephropathy in patients with T2DM.

Resumen Antecedentes La disminucion de hormonas tiroideas (HT) y el dano miocardico son frecuentes en pacientes en dialisis y estan asociados con la mortalidad. Sin embargo, poco se conoce de la importancia de las HT como factor de dano miocardico, como se ha descrito en las enfermedades tiroideas primarias. El objetivo de este estudio fue explorar si existe interaccion entre la disminucion de triyodotironina total (tT3) y los marcadores de dano miocardico y la relacion de esta interaccion entre ambos con la mortalidad, para establecer si el dano cardiovascular es el vinculo entre la disminucion de HT y el riesgo de muerte en pacientes con ERC en dialisis. Material y metodos Se estudiaron los niveles plasmaticos de HT, de marcadores de nutricion, inflamacion y de dano al miocardio en 296 pacientes en dialisis peritoneal o en hemodialisis, a los que se vigilo por 16 meses para conocer la asociacion de las variables bioquimicas con la mortalidad. Resultados En el 45% de los pacientes se encontro tT3 disminuida, lo cual tuvo correlacion inversa con la proteina C reactiva (PCR) y con el NT-proBNP y directa con la albumina y la transferrina. La diabetes, la PCR y la tT3 fueron factores de riesgo para la mortalidad por cualquier causa y la PCR, el NT-proBNP y la tT3 para mortalidad cardiovascular. Conclusiones Los niveles bajos de tT3 son frecuentes en pacientes en dialisis, se asocian con inflamacion, desnutricion y dano miocardico: este ultimo puede ser el vinculo entre la disminucion de HT y la mortalidad por cualquier causa y la mortalidad cardiovascular.

A large gap between the number of people with end-stage kidney disease (ESKD) who received kidney replacement therapy (KRT) and those who needed it has been recently identified, and it is estimated that approximately one half to three quarters of all people with ESKD in the world may have died prematurely because they could not receive KRT. This estimate is aligned with a previous report that estimated that more than 3 million people in the world died each year because they could not access KRT. In this article, we discuss the reasons for the differences in treated and untreated ESKD, KRT modalities and outcomes, and present strategies to close the global KRT gap by establishing robust health information systems to guide resource allocation to areas of need, inform KRT service planning, enable policy development, and monitor KRT health outcomes.

The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle–income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide.

Background Early steroid withdrawal (ESW) can improve lipid and hemodynamic profiles without severe acute rejection (AR) events in renal transplant patients. Our objective was to evaluate the effects of ESW on the frequency and severity of AR. Methods A randomized, open-label, controlled clinical trial was performed on renal transplant recipients with a follow-up of 12 months. In the ESW group, patients were selected for corticosteroid treatment withdrawal on the fifth day post transplantation. In the Control group, patients continued with steroid treatment. All patients were over 18 years of age with panel reactive antibody (PRA) class I and II HLA Results In total, 71 patients, 37 in the ESW group (52.1%) and 34 in the Control group (47.9%), had comparable AR incidences at the end of the follow-up (16% vs 15%) (NS) (RR = 1.20, 95% CI = 0.32–3.33). Although renal graft survival was similar between the ESW and Control groups (87% vs 94%), renal function was superior in the ESW group (85 vs 75 mL/min). Additionally, hypertension was less frequent in the ESW group (3% vs 35%), requiring the use of fewer antihypertensives (8% vs 50%). Conclusions ESW was also associated with better blood pressure control and similar AR risk. The ESW group exhibited stable renal function.

Pica could be strongly implicated in nutritional status of patients on dialysis; however, very scarce data are currently available. The objective of this study was to evaluate the prevalence of pica and its association with nutritional status in dialysis patients.This is a cross-sectional study in a tertiary care teaching hospital. Four-hundred patients on dialysis, without previous pica diagnosis or transplant, pregnancy, mental illness, or infection, were included in the study. Pica, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, was classified as no pica, ice pica, or hard pica. Dialysis Malnutrition Score, 24-hour dietary recall, and biochemical measurements were obtained from patients. As part of statistical analysis, point prevalence and 95% confidence interval of pica were calculated. Comparisons between groups were performed by means of analysis of variance, Kruskal-Wallis test, χPrevalence of pica was 42% (ice pica, 46%; soil, 29%; two substances, 14%; red brick, 5%; paper, 3%; soap, 2%; and cattle pasture, 1%). Comparing patients with pica (hard pica and ice pica) versus no pica, subjects with pica were of younger age (25 ± 7, 27 ± 9, 30 ± 11 years, respectively), were more frequently educated9 years (57%, 46%, 30%, respectively), and had longer dialysis duration (36 ± 19, 32 ± 18, 27 ± 16 months, respectively). Patients with pica achieved the recommended calorie and macronutrients intake target less frequently than those without pica (40-64% vs. 66-77%, P.05). Malnutrition was present in 74% of the whole sample: (1) 67% in no pica group, (2) 80% in ice pica group, and (3) 89% in hard pica group (P = .001). In the multivariate analysis (RA worse nutritional status was observed in patients with pica, who additionally were younger, had lower educational level, longer dialysis duration, and worse macronutrient intake routine than patients without pica. Malnutrition, C-reactive protein, and lower educational level significantly predicted both ice and hard pica.

Background. Pre-diabetes in young people is frequently unrecognized or not treated on time, with the consequent loss of opportunity for diabetes prevention. In Mexico, there is scarce information about the prevalence of pre-diabetes in young adults. Objective. To determine the prevalence and risk factors for pre-diabetes in young Mexican adults in primary health care. Methods. In a cross-sectional study, 288 subjects, aged 18–30 years, from a primary care unit were included. Pre-diabetes was diagnosed (according to the criteria of the American Diabetes Association) as impaired fasting glucose (8–12 hours fasting plasma glucose level: 100–125 mg/dl) or impaired glucose tolerance (140–199 mg/dl after a 2-hour oral glucose tolerance test). Results. Prevalence of pre-diabetes was 14.6% [95% confidence interval (CI): 10.7–19.2], whereas that of diabetes was 2.4% (95% CI: 1.0–4.9). A high proportion of patients had history of obesity, diabetes, hypertension and consumption of tobacco and alcohol. Pre-diabetic patients were older than normoglycaemics (pre-diabetic patients: 26 ± 4 years versus normoglycaemic subjects: 24 ± 3 years, P = 0.003) and had higher body mass index (BMI; pre-diabetic patients: 29.4 ± 6.8 kg/m 2 versus normoglycaemic subjects: 26.8 ± 5.8 kg/m 2 ; P = 0.009), particularly in the case of men (pre-diabetic men: 29.3 ± 7.0 kg/m 2 versus normoglycaemic men: 26.4 ± 5.1 kg/m 2 ; P = 0.03). Although waist circumference showed a trend to be higher among pre-diabetics, no significant differences were found according to gender (among males: pre-diabetics: 99.5 ± 18.8 cm versus normoglycaemics: 93.3 ± 14.4 cm, P = 0.09; among females: pre-diabetics: 91.5 ± 13.8 cm versus normoglycaemics: 85.8 ± 15.9 cm, P = 0.16). Only age and BMI were significantly associated with the presence of pre-diabetes. Conclusions. Almost 15% of these young adults had pre-diabetes. Many modifiable and nonmodifiable risk factors were present in these patients, but only age and a higher BMI were independent variables significantly associated with pre-diabetes. Timely interventions in primary health care are needed to prevent or delay the progression to diabetes.

One strategy to prevent and manage chronic kidney disease (CKD) is to offer screening programs. The aim of this study was to determine the percentage prevalence and risk factors of CKD in a screening program performed in an adult general population.This is a cross-sectional study. Six-hundred ten adults (73% women, age 51 ± 14 years) without previously known CKD were evaluated. Participants were subjected to a questionnaire, blood pressure measurement and anthropometry. Glomerular filtration rate estimated by CKD-EPI formula and urine tested with albuminuria dipstick.More than 50% of subjects reported family antecedents of diabetes mellitus (DM), hypertension and obesity, and 30% of CKD. DM was self-reported in 19% and hypertension in 29%. During screening, overweight/obesity was found in 75%; women had a higher frequency of obesity (41 vs. 34%) and high-risk abdominal waist circumference (87 vs. 75%) than men. Hypertension (both self-reported and diagnosed in screening) was more frequent in men (49%) than in women (38%). CKD was found in 14.7%: G1, 5.9%; G2, 4.5%; G3a, 2.6%; G3b, 1.1%, G4, 0.3%; and G5, 0.3%. Glomerular filtration rate was mildly/moderately reduced in 2.6%, moderately/severely reduced in 1.1%, and severely reduced in1%. Abnormal albuminuria was found in 13%. CKD was predicted by DM, hypertension and male gender.A percentage CKD prevalence of 14.7% was found in this sample of an adult population, with most patients at early stages. Screening programs constitute excellent opportunities in the fight against kidney disease, particularly in populations at high risk.

Background Acute kidney injury (AKI) has increasingly been recognized as an important public health issue due to its rising frequency, its associations with early and late adverse outcomes and its economic burden. Methods Given the importance of determining the available resources to address this serious issue, the AKI Committee of SLANH conducted a survey to obtain information about infrastructure, human resources and equipment devoted to the treatment of AKI in Latin America Results A total of 246 units from 14 countries participated in the survey, the majority of them pertaining to nephrology divisions in teaching hospitals. Intermittent hemodialysis was universally performed by all of the units, and less frequently, slow extended dialysis (40%) and continuous renal replacement therapy (23%) were performed. Seventy-nine units (30%) perform peritoneal dialysis, but only 51 (19%) of them reported having treated at least 1 patient with this technique in the last 3 months pre-survey. The vast majority of the units reported adequate water treatment and use of modern filter membranes. Most of the patients received renal replacement therapy (RRT) in the intensive care unit. Specific causes of AKI were reported in different frequencies, with a heterogeneous pattern among the countries. Septic abortion, hemolytic-uremic syndrome, community-acquired diarrhea and leptospirosis were the etiologies most frequently associated with AKI. Conclusions To our knowledge, this report was the first available study of the equipment and human resources utilized for RRT in AKI patients in Latin America.

Background and Aims An increasing number of studies have been published concerning meeting targets of clinical guidelines for different aspects of the diagnosis and treatment of patients with end-stage renal disease. Most of these studies have shown that guideline recommendations are not always satisfied, and results outside target limits have been associated with high rates of mortality and morbidity. The objective of this study was to analyze the frequency of reaching mineral and bone metabolism-related guideline targets and its impact on clinical outcomes in Mexican chronic dialysis patients. Methods A cohort of prevalent peritoneal dialysis (PD) and hemodialysis (HD) patients were analyzed at baseline and followed for at least 16 months. Patients were on continuous ambulatory peritoneal dialysis (CAPD), automated peritoneal dialysis (APD), and HD and contracted HD modalities where patients received HD sessions outside institution facilities. Results We studied 753 patients. The percentage of patients within target limits for phosphorus was 35%, for calcium 32%, and for PTH 12%. The most frequent pattern was hyperphosphatamia, hypercalcemia, and low PTH. This was even more frequent in CAPD patients, probably due to the high percentage of diabetic patients. Hypercalcemia was found as an independent risk factor for mortality. Conclusions The most important results suggest that guideline recommendations are not usually satisfied and that hypercalcemia, in addition to other traditional risk factors, is associated with high mortality rates. The study also detected some opportunities to improve the quality of treatment by reducing the calcium content of dialysis solutions and reducing the use of calcium carbonate as a phosphate binder.

Renal transplantation (RT), has been considered the best therapeutic option for end stage renal disease (ESRD).Objective. To determine the effect of RT on the evolution of oxidative DNA status.Methods. Prospective cohort (N=50receptors of RT); genotoxic damage, 8-hydroxy-2′-deoxyguanosine (8-OHdG), and DNA repair enzyme, human 8-oxoguanine-DNA-N- glycosylase-1 (hOGG1); and antioxidants, superoxide dismutase (SOD) and glutathione peroxidase (GPx), were evaluated.Results. Before RT,8-OHdG were significantly elevated (11.04±0.90versus 4.73 ± 0.34 ng/mL) compared to healthy controls (p=0.001), with normalization after 6 months of4.78±0.34 ng/mL (p<0.001). The same phenomenon was observed with hOGG1 enzyme before RT with 2.14 ± 0.36 ng/mL (p=0.01) and decreased significantly at the end of the study to 1.20 ng/mL (p<0.001) but was higher than controls, 0.51 ± 0.07 ng/mL (p<0.03). Antioxidant SOD was elevated at 24.09 ± 1.6 IU/mL versus healthy controls (p=0.001) before RT; however, 6 months after RT it decreased significantly to 16.9 ± 1.6 IU/mL (p=0.002), without achieving the levels of healthy controls (p=0.01). The GPx, before RT, was significantly diminished with 24.09 ± 1.6 IU/mL versus healthy controls (39.0 ± 1.58) (p=0.01), while, in the final results, levels increased significantly to 30.38 ± 3.16 IU/mL (p=0.001).Discussion. Patients with ESRD have important oxidative damage before RT. The RT significantly reduces oxidative damage and partially regulates the antioxidant enzymes (SOD and GPx).

Aim. The aim of this study was to compare the effect of pentoxifylline versus placebo on serum concentrations of tumor necrosis factor-alpha (TNF-a), interleukin 6 (IL-6) and C-reactive protein (CRP) of hemodialysis (HD) patients. Methods. This is a randomized double-blind, controlled clinical trial. HD patients without infection or drugs with anti-inflammatory effect were randomly allocated to a study (n ¼ 18, pentoxifylline 400 mg/day) or control (n ¼ 18, placebo) group; all patients had arteriovenous fistula. Besides clinical and laboratory monthly assessments, serum TNF-a and IL-6 (ELISA) and CRP (nephelometry) were measured at 0, 2 and 4 months. Results. All the inflammation markers significantly (P < 0.05) decreased in the pentoxifylline group: TNF-a [baseline 0.4 (0–2) versus final 0 (0–0) pg/mL], IL-6 [baseline 9.4 (5–14) versus final 2.9 (2–5) pg/mL] and CRP [baseline 7.1 (3–20) versus final 2.6 (1–8) mg/L], whereas no significant changes were observed in the placebo group: TNFa [baseline 0 (0–0) versus final 1.2 (0–4) pg/mL], IL-6 [baseline 8.0 (5–11) versus final 8.7 (4–11) pg/mL] and CRP [baseline 4.5 (2–9) versus final 3.8 (3–23) mg/L]. Conclusions. Pentoxifylline significantly decreased serum concentrations of TNF-a, IL-6 and CRP compared to placebo. Pentoxifylline could be a promising and useful strategy to reduce the systemic inflammation frequently observed in patients on HD.

This review focuses on the physiologic and clinical consequences of rapid solute transport in the peritoneum. The concept, the current understanding of related factors, and the possible causes implicated in rapid solute transport are discussed first. Then, the consequences, with particular emphasis on mortality, are highlighted. Finally, based on recent advances and clinical studies, some strategies for the treatment of fast peritoneal transport are reviewed.

Latin America is a heterogeneous region comprised of 20 countries, former colonies of European countries, in which Latin-derived languages are spoken. According to the Latin American Society of Nephrology and Hypertension/ Sociedad Latino Americana de Nefrologia e Hipertensión (SLANH), the acceptance rate for renal replacement therapy is 103 new patients per million population. In Latin America, hemodialysis is the predominant form of replacement therapy for end-stage renal disease; however, some countries employ peritoneal dialysis (PD) in 30% or more patients. In particular, Mexico is the country with the largest PD utilization in the world, and furthermore, it is estimated that approximately 25% of the world's PD population may be found Latin America. Data concerning clinical practice and long-term outcome of PD in Latin America are scarce, although regional registries are increasing in number and quality. In this review article, we present an overview of the situation of PD in several countries of Latin America, based on the registry of the SLAHN, national registries, and personal communication with PD experts from different countries.

Mexico is struggling to gain a place among developed countries; however, there are many socioeconomic and health problems still waiting for resolution. While Mexico has the twelfth largest economy in the world, a large portion of its population is impoverished. Treatment for end-stage renal disease (377 patients per million population) is determined by the individual's access to resources such as private medical care (approximately 3%) and public sources (Social Security System: approximately 40%; Health Secretariat: approximately 57%). With only 6% of the gross national product spent on healthcare and most treatment providers being public health institutions that are often under economic restrictions, it is not surprising that many Mexican patients do not receive renal replacement therapy. Mexico is still the country with the largest utilization of peritoneal dialysis (PD) in the world, with 18% on automated PD, 56% on continuous ambulatory PD (CAPD), and 26% on hemodialysis. Results of PD (patient morbi-mortality, peritonitis rate, and technique survival) in Mexico are comparable to other countries. However, malnutrition and diabetes mellitus are highly prevalent in Mexican patients on CAPD programs, and these conditions are among the most important risk factors for a poor outcome in our setting.

Background Patients with high peritoneal permeability have the greatest degree of inflammation on continuous ambulatory peritoneal dialysis (CAPD), which may be associated with their higher mortality. Nocturnal intermittent peritoneal dialysis (NIPD; “dry day”) may decrease inflammation by reducing the contact between dialysate and peritoneum and/or providing better fluid overload control. Therefore, the aims of this study were to determine and compare serum and dialysate concentrations of C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-α) of patients with high or high-average peritoneal transport on CAPD, changed to NIPD, and ultimately to continuous cyclic peritoneal dialysis (CCPD). Methods Crossover clinical trial in 11 randomly selected patients. All subjects had been on CAPD and were changed to NIPD, and ultimately to CCPD (6.4 ± 3.1 months after initiation of study). All patients used glucose-based dialysate. Evaluations of clinical and biochemical parameters, dialysis adequacy, and serum and dialysis inflammation markers were performed at baseline on CAPD, 7 – 14 days after changing to NIPD, 7 – 14 days after switching to CCPD, and after 1 year of follow-up. All patients used only 1.5% glucose dialysate during evaluation days. CRP was determined by nephelometry, and IL-6 and TNF-α by ELISA. Results Seven patients were high transporters and 4 high average. Ultrafiltration increased ( p < 0.05) when patients changed from CAPD [0.38 L (-0.3 – 1.1 L)] to NIPD [2.64 L (0.7 – 4.7 L)]; it then decreased on CCPD [0.88 L (0.4 – 1.3 L) and at the end of study [0.65 L (0.3 – 1.0 L)]. This better fluid overload control was accompanied by decreased weight and systolic and diastolic blood pressure when patients changed from CAPD (89 ± 13 kg, 160 ± 23 and 97 ± 9 mmHg, respectively) to NIPD (86 ± 17 kg, 145 ± 14 and 86 ± 9 mmHg, respectively), and increased weight and systolic and diastolic blood pressure on CCPD (85 ± 15 kg, 143 ± 23 and 88 ± 14 mmHg, respectively) and at the end of follow-up (87 ± 16 kg, 155 ± 24 and 89 ± 12 mmHg, respectively). Median serum CRP decreased ( p = 0.03), from 3.8 (1.6 – 8.5) mg/L on CAPD to 1.0 (0.4 – 4.4) mg/L on NIPD, but increased on CCPD [1.8 (1.3 – 21) mg/L] and at the end of the study [3.2 (0.3 – 8.2) mg/L]. Dialysate CRP decreased nonsignificantly, from 0.10 (0 – 0.5) mg/L on CAPD to 0 (0 – 0.03) mg/L on NIPD, to 0.01 (0 – 0.08) mg/L on CCPD, and to 0 (0 – 0) mg/L at final evaluation. Serum TNF-α concentration decreased, from 0.14 (0.04 – 0.6) pg/mL on CAPD to 0.01 (0 – 0.08) pg/mL on NIPD, and then increased to 0.06 (0 – 0.4) pg/mL on CCPD and to 0.11 (0 – 0.2) pg/mL at the end of the study; whereas dialysate TNF-α decreased, from 0.08 (0.03 – 0.2) pg/mL on CAPD to 0.04 (0 – 0.2) pg/mL on NIPD, and to 0 (0 – 0) pg/mL and 0 (0 – 0.05) pg/mL on CCPD and final evaluation respectively. Serum IL-6 decreased ( p = 0.07), from 2.5 (2.0 – 4.2) pg/mL on CAPD to 1.0 (0.7 – 2.0) pg/mL on NIPD, and to 1.0 (0.8 – 2.9) pg/mL on CCPD and 1.0 (0.5 – 9.8) pg/mL at the end of the study; whereas dialysate levels remained similar on CAPD [8.0 (3.7 – 13) pg/mL] and NIPD [7.8 (5.1 – 23) pg/mL], and increased on CCPD [11.2 (9.5 – 19) pg/mL] and at final evaluation [11.2 (8.3 – 15) pg/mL]. Conclusions NIPD significantly decreased serum CRP and displayed a trend to decrease TNF-α and IL-6 serum concentrations compared with CAPD; whereas CCPD tended to reverse these effects. These results did not appear to be due to decreased local peritoneal inflammation, but they could be associated with better control of fluid overload on NIPD. Thus, NIPD, as long as the residual renal function allows it, may be useful in reducing the systemic inflammation of patients with high peritoneal membrane permeability.

Background/AimMalnutrition is highly prevalent in patients on continuous ambulatory peritoneal dialysis (CAPD) and is a strong predictor of increased morbidity and mortality. Therefore, the aim of this study was to evaluate the effect of oral administration of an egg albumin-based protein supplement on the nutritional status of CAPD patients.MethodsIn this randomized, open label, controlled clinical trial, 28 CAPD patients were allocated to a study ( n = 13) or a control ( n = 15) group. Both groups received conventional nutritional counseling; the study group received, additionally, an oral egg albumin-based supplement. During a 6-month follow-up, all patients had monthly clinical and biochemical evaluations and quarterly assessments of adequacy of dialysis and nutrition.ResultsSerum albumin levels were not different between groups; however, a significant increase (baseline vs final) was observed in the study group (2.64 ± 0.35 vs 3.05 ± 0.72 g/dL) but not in the control group (2.66 ± 0.56 vs 2.80 ± 0.54 mg/dL). Calorie and protein intake increased more in the study group (calories 1331 ± 432 vs 1872 ± 698 kcal; proteins 1.0 ± 0.3 vs 1.7 ± 0.7 g/kg) than in the control group (calories 1423 ± 410 vs 1567 ± 381 kcal; proteins 1.0 ± 0.4 vs 1.0 ± 0.3 g/kg). Similarly, non-protein nitrogen appearance rate (nPNA) increased significantly more in the study (1.00 ± 0.23 vs 1.18 ± 0.35 g/kg/day) than in the control group (0.91 ± 0.11 vs 0.97 ± 0.14 g/kg/day). Triceps skinfold thickness (TSF) and midarm muscle area (MAMA) displayed a nonsignificant trend to a greater increase in the study group (TSF 16.7 ± 8.7 vs 18.3 ± 10.7 mm; MAMA 23.8 ± 6.2 vs 25.8 ± 5.9 cm2) than in controls (TSF 16.4 ± 5.7 vs 16.9 ± 7.0 mm; MAMA 28.7 ± 7.8 vs 30.0 ± 7.9 cm2). At the end of follow-up, the frequency of patients with moderate or severe malnutrition decreased 6% in the control group and decreased 28% in the study group. At the final evaluation, the most important predictors of serum albumin were the oral egg albumin-based supplement administration and protein intake ( p < 0.05); secondary predictors ( p = 0.06) were peritoneal transport rate and MAMA.ConclusionsIn the study group, oral administration of the egg albumin-based supplement significantly improved serum albumin, calorie and protein intake, and nPNA, and, compared to controls, this maneuver was associated with a trend to increased anthropometric parameters and improved Subjective Global Assessment evaluation. Oral administration of the albumin supplement and protein intake were the most significant predictors of serum albumin at the end of follow-up. This oral supplement may be a safe, effective, and cheap method to improve nutritional status in peritoneal dialysis patients.

Negative lifestyle habits (potential risks for chronic kidney disease, CKD) are rarely modified by physicians in a conventional health-care model (CHCM). Multidisciplinary strategies may have better results; however, there is no information on their application in the early stages of CKD. Thus, the aim of this study was to compare a multiple intervention model versus CHCM on lifestyle and renal function in patients with type 2 diabetes mellitus and CKD stage 1–2. In a prospective cohort study, a family medicine unit (FMU) was assigned a multiple intervention model (MIM) and another continued with conventional health-care model (CHCM). MIM patients received an educational intervention guided by a multidisciplinary team (family physician (FP), social worker, dietitian, physical trainer); self-help groups functioned with free activities throughout the study. CHCM patients were managed only by the FP, who decided if patients needed referral to other professionals. Thirty-nine patients were studied in each cohort. According to a lifestyle questionnaire, no baseline differences were found between cohorts, but results reflected an unhealthy lifestyle. After 6 months of follow-up, both cohorts showed significant improvement in their dietary habits. Compared to CHCM diet, exercise, emotional management, knowledge of disease, and adherence to treatment showed greater improvement in the MIM. Blood pressure decreased in both cohorts, but body mass index, waist circumference, and HbA1C significantly decreased only in MIM. Glomerular filtration rate (GFR) was maintained equally in both cohorts, but albuminuria significantly decreased only in MIM. In conclusion, MIM achieves better control of lifestyle-related variables and CKD risk factors in type 2 diabetes mellitus (DM2) patients with CKD stage 1–2. Broadly, implementation of a MIM in primary health care may produce superior results that might assist in preventing the progression of CKD.

The mechanisms responsible for the problem status of high transporters are diverse. High transporters have increased protein losses that may play a role in the presence of hypoalbuminemia and malnutrition. On the other hand, high transport induces increased glucose absorption, which may in turn be responsible for anorexia and increased atherogenesis--issues not discussed here, but clearly of major importance. And finally, the impaired ultrafiltration present in the high transporter leads to fluid overload, which is one of the driving forces for ventricular hypertrophy, hypertension, and increased cardiovascular risk--cardiovascular events being most prevalent cause of death in dialysis patients. All of the factors previously discussed--and others--may preclude some high transporters from being good candidates for peritoneal dialysis. Yet many others may still do well if the prescription is individually tailored to the particular patient.

Background Dialysate protein loss is involved in the etiology of hypoalbuminemia and malnutrition on continuous ambulatory peritoneal dialysis (CAPD). Patients with high peritoneal membrane permeability had the lowest serum albumin (Alb) and highest dialysate protein concentrations and achieved higher small solute dialysis/plasma equilibration in a shorter time than patients with low peritoneal transport. The aim of this prospective crossover study was to evaluate whether protein loss might be decreased in patients with high peritoneal permeability on short dwell-time (DT) peritoneal dialysis. Methods Five high and nine high-average peritoneal transport patients were subjected to the following sequential dialysis schemes (four exchanges/day, glucose 1.5%): scheme A, three daytime exchanges (4–6 h DT) and one nightly (8–12 h DT) for 2–3 days, scheme B, 3-h DT each and dry peritoneum at night during 5 days, a wash-out period similar to scheme A, and scheme C, 2-h DT each and dry peritoneum the remainder of day and night during 5 days. Dialysate Alb, IgG, IgA, and IgM losses and adequacy of dialysis were evaluated at the end of each scheme. Results Dialysate IgM was not detected. All protein losses were reduced with the short DT dialysis schemes; however, dialysis CCl and KT/V urea were also decreased. In patients with high peritoneal transport type, the 3-h DT dialysis scheme achieved a reduction in Alb loss without significant reduction of adequacy of dialysis. Conclusions Peritoneal Alb, IgG, and IgA losses are significantly reduced in patients with high peritoneal permeability on short dwell-time dialysis and extended dry periods. However, a reduction of dialysis contribution to small solute clearances was also observed, Three-hour dwell-time dialysis may be particularly useful in patients with high peritoneal transport type, as it tends to reduce peritoneal protein loss without notably reducing adequacy of dialysis.

Objective To evaluate patient and technique survival, and to analyze mortality risk factors in a large Mexican single-center continuous ambulatory peritoneal dialysis (CAPD) program. Design Cohort study. Setting Tertiary care, teaching hospital located in Mexico City. Patients All patients from our CAPD program (1985 – 1997) were retrospectively studied. Interventions Clinical and biochemical variables at the start of dialysis were recorded and considered in the analysis of risk factors. Main Outcome Measures End points were patient (alive, dead, or lost to follow-up) and technique status at the end of the study (December 1997). Results 627 patients, 37% with diabetes mellitus (DM), were included. Median patient survival (± SE) was 5.1 ± 0.6 years. In the univariate analysis, the following variables were associated ( p < 0.05) with mortality: DM, old age, hypoalbuminemia, low serum creatinine, low serum phosphate, and lymphopenia. In the multivariate analysis, the only significant mortality risk factors were DM (RR 2.56, p < 0.0001), old age (RR 1.01, p = 0.01), hypoalbuminemia (RR 0.77, p = 0.04), and lymphopenia (RR 0.98, p = 0.05). Median technique survival was 4.0 ± 0.2 years. Peritonitis, hypoalbuminemia, lymphopenia, old age, and DM were all significantly associated ( p < 0.05) with technique failure in the univariate analysis, while in the multivariate analysis, only DM (RR 1.78, p = 0.001), peritonitis (RR 1.13, p = 0.004), lymphopenia (0.98, p = 0.04), and hypoalbuminemia (RR 0.80, p = 0.06) were technique failure predictors. Conclusions Patient survival in our setting is similar to that reported in other series. Diabetes mellitus, lymphopenia, and hypoalbuminemia were the strongest predictive factors for mortality and technique failure on CAPD. Our 12-year CAPD program is one of the largest single-centers reported in CAPD literature.

Is high peritoneal transport rate an independent risk factor for CAPD mortality? Background Patients with high peritoneal transport display the lowest serum albumin (S Alb ) and the highest peritoneal protein loss. An association between high peritoneal membrane permeability and diabetes mellitus (DM) has been suggested. As malnutrition, hypoalbuminemia, and DM cause high mortality, it is probable that a high peritoneal transport rate is associated with high mortality on continuous ambulatory peritoneal dialysis (CAPD). The aim of the study was to identify whether a high peritoneal transport rate is an independent risk factor for mortality on CAPD. Methods We included 167 patients with a peritoneal equilibration test that was performed between January 1994 and July 1997. The endpoint was the patient's status (alive, dead, or lost) in December 1997. Survival analysis was done by the Kaplan–Meier method and multivariate Cox proportional-hazard model. Results DM was significantly more frequent in the high (H) peritoneal transport type (20 out of 33) and was less frequent in the low (L) transport group (3 out of 18). S Alb (g/dL) was significantly lower as the peritoneal transport type was higher [H 2.7 ± 0.5, high average (HA) 2.9 ± 0.7, low average (LA) 3.2 ± 0.6, and L 3.6 ± 0.5]. Serum creatinine (S Cr ) was significantly higher in the L transport type (12.0 ± 4.3 mg/dL) than in the other transport groups (H 8.7 ± 3.1, HA 8.6 ± 3.7, and LA 9.6 ± 4.5). No other differences were found between peritoneal transport types. In the univariate analysis, high peritoneal transport rate, DM, low S Cr , low S Alb , and older age significantly predicted mortality. However, in the multivariate analysis (k; 2 = 40.55, P b = 1.34, P = 0.0001), low S Cr (b = -0.11, P = 0.02), and high peritoneal transport rate (b = 2.6, P = 0.06) were shown as mortality risk factors. Conclusions DM was the most important risk factor for mortality on CAPD. A high peritoneal transport rate also predicted mortality, yet its role seems to be related to the presence of DM. The role of higher S Cr predicting a better survival might have been associated with a better nutritional status. Hypoalbuminemia, previously shown as risk factor for mortality, did not play an important role in this study, probably because of its collinearity with DM.

Objective To validate the peritoneal equilibration test (PET), establish reference values in the Mexican population, compare our results with those reported by Twardowski et al., and analyze the influence of some factors on the peritoneal transport rate (PTR). Design Retrospective, cross-sectional study. Patients Eighty-six PETs were performed in 45 female and 41 male patients; 35 of the patients were diabetics. Creatinine D/P and glucose D/D0 ratios were calculated and compared with those from Twardowski et al. In a multi-variate analysis, age, gender, diabetes mellitus (DM), time on dialysis, and peritonitis rate were considered as independent factors influencing the PTR. Results Creatinine D/P and glucose D/D0 ratios at 4 hours were not significantly different from those reported by Twardowski et al. Creatinine D/P at 4 hours was not different between DM and non-DM patients when the rate of peritonitis and time on dialysis were not taken into account. Multivariate analysis did not result in any significant model predicting the creatinine D/P at 4 hours. Conclusions PET validation is reported for the first time in a Latin American population. The PET results of this study are similar to those in the literature. We found that DM, peritonitis rate, time on dialysis, age, and gender did not clearly influence the PTR.

The present study evaluates the influence of the peritoneal transport rate (PTR) on the nutritional status of continuous ambulatory peritoneal dialysis (CAPD) patients. Additionally, protein intake, dialysis adequacy, and other clinical variables were analyzed. Forty-two CAPD patients were concurrently subjected to the peritoneal equilibration test, a nutritional evaluation that included 24-hour dietary recall, and nutritional scoring system that included anthropometric, biochemical, and subjective parameters. Eight patients were high, 14 were high-average, 16 were low-average, and four were low transporters. Nine patients had normal nutritional status; six had mild, nine had moderate, and 18 had severe malnutrition. Malnutrition was inversely correlated (P < 0.05) with body surface, hemoglobin, and residual renal function, but not with PTR (r = 0.14; P = 0.38). In the multivariate analysis, the nutritional status was not predicted by the PTR, protein intake, or dialysis adequacy variables. When serum albumin (SA) level was evaluated as an isolated nutritional indicator, the most significant predictors were dialysate to plasma creatinine ratio at 4 hours (D/P4), body surface area, age, and diabetes mellitus. High transporters receiving a high dose of dialysis displayed a trend of having lower SA levels, whereas low-average transporters receiving a high dose of dialysis showed a trend of have higher SA levels. In conclusion, there was no correlation between PTR and nutritional status. In the multivariate analysis, no association was found between nutritional status and PTR, dialysis adequacy, and protein intake. The best predictors for SA are PTR, body surface area, age, and diabetes mellitus.

Inflammation is highly prevalent in patients on dialysis. Statins have anti-inflammatory actions but their use has been scarcely studied in continuous ambulatory peritoneal dialysis (CAPD). We undertook this study to compare the effect of pravastatin vs. placebo on the serum concentrations of C-reactive protein (CRP) in patients on CAPD.In a double-blind, controlled and crossover clinical trial, 76 CAPD patients were randomized to either pravastatin or placebo for 2 months. After this first period of treatment, patients had a 1-month wash-out period and, finally, they were crossed-over to receive the other drug (or placebo) for 2 more months. Measurement of clinical and biochemical variables and CRP was performed at the beginning and at the end of each treatment period.Median CRP was only significantly decreased in the pravastatin group in both periods of treatment: first period (baseline vs. final, mg/L): pravastatin 7.4 (2-21) vs. 2.6 (1-6), p0.05; placebo 3.9 (2-10) vs. 6.8 (3-12), pNS; second period: pravastatin 4.3 (2-15) vs. 1.9 (1-7), p0.05; placebo 4.9 (2-17) vs. 6.8 (2-19), p0.05. Results were significantly different (p0.05) between groups only at the end of each treatment period. Additionally, total and LDL-cholesterol significantly decreased in the pravastatin group.Pravastatin significantly reduced serum levels of CRP and total and LDL-cholesterol compared to placebo. This treatment may be of great help to decrease the inflammatory status and probably the cardiovascular disease of CAPD patients.

Chronic kidney disease (CKD) is a worldwide epidemic especially in developing countries, with clear deficiencies in identification and treatment. Better care of CKD requires more than only economic resources, utilization of health research in policy-making and health systems changes that produce better outcomes. A multidisciplinary approach may facilitate and improve management of patients from early CKD in the primary health-care setting. This approach is a strategy for improving comprehensive care, initiating and maintaining healthy behaviors, promoting teamwork, eliminating barriers to achieve goals and improving the processes of care. A multidisciplinary intervention may include educational processes guided by health professional, use of self-help groups and the development of a CKD management plan. The complex and fragmented care management of patients with CKD, associated with poor outcome, enhances the importance of implementing a multidisciplinary approach in the management of this disease from the early stages. Multidisciplinary strategies should focus on the needs of patients (to increase their empowerment) and should be adapted to the resources and health systems prevailing in each country; its systematic implementation can help to improve patient care and slow the progression of CKD.

Objective We set out to estimate the direct medical costs (DMCs) of peritoneal dialysis (PD) and to compare the DMCs for continuous ambulatory PD (CAPD) and automated PD (APD). In addition, DMCs according to age, sex, and the presence of peritonitis were evaluated. Methods Our retrospective cohort analysis considered patients initiating PD, calculating 2008 costs and, for comparison, updating the results for 2010. The analysis took the perspective of the Mexican Institute of Social Security, including outpatient clinic and emergency room visits, dialysis procedures, medications, laboratory tests, hospitalizations, and surgeries. Results No baseline differences were observed for the 41 patients evaluated (22 on CAPD, 19 on APD). Median annual DMCs per patient on PD were US$15 072 in 2008 and US$16 452 in 2010. When analyzing percentage distribution, no differences were found in the DMCs for the modality groups. In both APD and CAPD, the main costs pertained to the dialysis procedure (CAPD 41%, APD 47%) and hospitalizations (CAPD 37%, APD 32%). Dialysis procedures cost significantly more ( p = 0.001) in APD (US$7084) than in CAPD (US$6071), but total costs (APD US$15 389 vs CAPD US$14 798) and other resources were not different. The presence of peritonitis increased the total costs (US$16 075 vs US$14 705 for patients without peritonitis, p = 0.05), but in the generalized linear model analysis, DMCs were not predicted by age, sex, dialysis modality, or peritonitis. A similar picture was observed for costs extrapolated to 2010, with a 10% – 20% increase for each component—except for laboratory tests, which increased 52%, and dialysis procedures, which decreased 3%, from 2008. Conclusions The annual DMCs per patient on PD in this study were US$15 072 in 2008 and US$16 452 in 2010. Total DMCs for dialysis procedures were higher in APD than in CAPD, but the difference was not statistically significant. In both APD and CAPD, 90% of costs were attributable to the dialysis procedure, hospitalizations, and medications. In a multivariate analysis, no independent variable significantly predicted a higher DMC.

Peritoneal dialysis in Mexico. While Mexico has the thirteenth largest economy, a large portion of the population is impoverished. About 90% of the population is Mestizo, the result of the admixture of Mexican Indians and Spaniards, with the Indigenous peoples concentrated in the southeastern region. Treatment for end-stage renal disease (estimated 268 patients per million population) is largely determined by the limited healthcare system and the individual's access to resources such as private insurance (~15%) and governmental sources (~85%). With only 5% of the gross national product spent on healthcare and most treatment providers being public health institutions that are often under severe economic restrictions, it is not surprising that many Mexican patients do not receive renal replacement therapy. Mexico uses proportionately more peritoneal dialysis than other countries; 1% of the patients are on automated peritoneal dialysis, 19% on hemodialysis and 80% on CAPD. Malnutrition and diabetes, important risk factors for poor outcome, are prevalent among the patients in CAPD programs.

Introduction: End-stage renal disease (ESRD) is a growing problem, particularly in developing countries. Factors closely related with lifestyle and dietary habits that negatively affect kidney function are rarely modified by isolated medical intervention. Therefore, the present study was designed to determine the effect of an educational program with a multidisciplinary health-care approach supported by self-help groups on the lifestyle and dietary habits of patients at high risk of developing chronic kidney disease (CKD). Patients: 51 patients with overweight/obesity, 45 with hypertension and 88 with Type 2 diabetes mellitus (DM2) from a Family Medicine Unit, who had failed to meet clinical practice recommendations, were studied over 6 months. Patients received educational intervention guided by a multidisciplinary health team for 4 weeks (including topics such as emotional management, nutritional patterns, exercise and health-related problems). Reinforcement of goals and group dynamics were performed every 3 months. Additionally, self-help groups were constituted during the first month, and functioned with free activities, selected by patients and supported by the health team, for the duration of the study. A lifestyle questionnaire was administered at baseline and the end of the study; clinical and biochemical evaluations were performed every 3 months. Results: Baseline lifestyle and dietary habits were unhealthy in all groups, particularly with regard to diet and exercise, and clinical and biochemical variables were concordant with inadequate achievement of clinical practice recommendations. After 6 months experience within this program, many of the negative lifestyle characteristics significantly improved. All groups reported a notable improvement in nutritional and exercise habits, as well as in management of the emotions. Only diabetic and hypertensive patients significantly improved the knowledge of their disease and adherence to treatment. None of the groups managed to reduce smoking or to cut their alcohol intake habits; however, relatively few participants had displayed these behaviors at the start of the study. Compared to baseline, all the groups significantly reduced body mass index and waist circumference. Additionally, diabetics and overweight/ obese patients significantly reduced blood glucose and increased GFR, and hypertensive patients significantly decreased systolic blood pressure and tended, although not significantly, to increase GFR. Remarkably, all these changes were independent of drug treatment, because none of the therapeutic interventions that had been formerly prescribed by family physicians had been significantly changed by the end of the follow-up in any of the groups. Conclusions: The implementation of educational strategies comprising multiple interventions for patients, guided by health professionals (multidisciplinary teams including primary doctors, dietitians, nurses, social workers), and probably supported by self-help groups, may be very helpful in modifying negative lifestyle and dietary habits. Educational interventions by both doctors and patients should be adopted concurrently and may help to control the enormous and growing problem of ESRD.

The purpose of this study was to describe anthropometric, metabolic, and nutritional characteristics in healthy elderly adults in a primary health care setting. It was conducted through a cross-sectional study of 80 subjects 60 years of age and older. After confirming healthy status, clinical, biochemical, dietetic, and anthropometric evaluations were performed. The findings indicated 22% had anemia, 22% had impaired glucose tolerance, 46% had hypertriglyceridemia, and 51% had hypercholesterolemia. More than 50% had obesity, and almost 80% had a high risk waist circumference measure. Mean energy intake was normal; however, more than 50% of participants did not have adequate intakes of potassium, calcium, magnesium, zinc, folic acid, and vitamins B(12) and A. Inadequate food intakes were common. Specific examples are that 16% of the subjects ate no meat/egg, 31% ate no dairy products, 56% ate no legumes, 22% ate no fruits, and 41% ate no vegetables. Additionally, 31% consumed soft drinks. Therefore, we can conclude that elderly people otherwise considered as "healthy" nonetheless had a high proportion of obesity and cardiovascular risk factors. Inadequate dietary patterns were also observed and corresponded with poor micronutrient intake.

This study compared the effect of enalapril versus placebo on serum tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and C-reactive protein (CRP) in hemodialysis in a randomized, double- blinded, controlled clinical trial. Patients without infection or antiinflammatory drugs were randomly allocated to a study (n = 13, enalapril, 20 mg/day) or control (n = 12, placebo) group; all had arteriovenous fistula. Serum TNF-alpha, IL-6, and CRP were measured at 0, 1, and 3 months. Systolic blood pressure (baseline vs. final) was 151 +/- 25 vs. 135 +/- 19 mm Hg (p < 0.05) in the study group and 154 +/- 21 vs. 144 +/- 27 mm Hg in control group; diastolic blood pressure was 86 +/- 9 vs. 76 +/- 13 and 91 +/- 16 vs. 81 +/- 18 mm Hg, respectively; median (percentiles 25%-75%) IL-6 (baseline vs. final) was 4.2 (3-8) vs. 4.1 (2-9) pg/mL and 6.3 (3-9) vs. 6.7 (3-8) pg/mL; and CRP was 1.9 (1-7) vs. 3.0 (1-12) mg/L and 4.7 (1-16) vs. 3.9 (2-16) mg/L, respectively. TNF-alpha was detected in only two patients. Enalapril significantly reduced blood pressure in hemodialysis patients, but it did not decrease IL-6 and CRP compared with placebo.

Background. N-terminal fragment of B-type natriuretic peptide (NT-proBNP) is a marker of both fluid volume overload and myocardial damage, and it has been useful as a predictor of mortality in patients with end-stage renal disease (ESRD). It has been suggested that continuous ambulatory peritoneal dialysis (CAPD), automated peritoneal dialysis (APD) and haemodialysis (HD) may have different effects on fluid volume and blood pressure control; however, whether the independent predictive value of NT-proBNP for mortality is preserved when analysed in conjunction with fluid overload and dialysis modality is not clear. Methods. A prospective multicentre cohort of 753 prevalent adult patients on CAPD, APD and HD was followed up for 16 months. Plasmatic levels of NT-proBNP, extracellular fluid volume/total body water ratio (ECFv/TBW) and traditional clinical and biochemical markers for cardiovascular damage risk were measured, and their role as predictors of all-cause and cardiovascular mortality was analysed. Results. NT-proBNP level, ECFv/TBW and other cardiovascular damage risk factors were not evenly distributed among the different dialysis modalities. NT-proBNP levels and ECFv/TBW were correlated with several inflammation, malnutrition and myocardial damage markers. Multivariate analysis showed that NT-proBNP levels and ECFv/TBW were predictors of both all-cause and cardiovascular mortality, independently of dialysis modality and the presence of other known clinical and biochemical risk factors. Conclusions. NT-proBNP is a reliable predictor of death risk independently of the effect of dialysis modality on fluid volume control, and the presence of other clinical and biochemical markers recognized as risk factors for all-cause and cardiovascular mortality. NT-pro-BNP is a good predictor of mortality independently of fluid volume overload and dialysis modality.