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Background Dialysis patients are typically inactive and their physical activity (PA) decreases over time. Uremic toxicity has been suggested as a potential causal factor of low PA in dialysis patients. Post-dilution high-volume online hemodiafiltration (HDF) provides greater higher molecular weight removal and studies suggest better clinical/patient-reported outcomes compared with hemodialysis (HD). Methods HDFIT was a randomized controlled trial at 13 clinics in Brazil that aimed to investigate the effects of HDF on measured PA (step counts) as a primary outcome. Stable HD patients (vintage 3–24 months) were randomized to receive HDF or high-flux HD. Treatment effect of HDF on the primary outcome from baseline to 3 and 6 months was estimated using a linear mixed-effects model. Results We randomized 195 patients (HDF 97; HD 98) between August 2016 and October 2017. Despite the achievement of a high convective volume in the majority of sessions and a positive impact on solute removal, the treatment effect HDF on the primary outcome was +538 [95% confidence interval (CI) −330 to 1407] steps/24 h after dialysis compared with HD, and was not statistically significant. Despite a lack of statistical significance, the observed size of the treatment effect was modest and driven by steps taken between 1.5 and 24.0 h after dialysis, in particular between 20 and 24 h (+197 steps; 95% CI −95 to 488). Conclusions HDF did not have a statistically significant treatment effect on PA 24 h following dialysis, albeit effect sizes may be clinically meaningful and deserve further investigation., Graphical Abstract

Introduction: The vascular access cannulation technique varies among clinics, and guidelines on vascular access give little importance to cannulation techniques. The objective of this study was to evaluate the cannulation technique and to determine which factors are associated with each detail of the technique. Material and methods: The vascular access cannulation was evaluated in 260 patients undergoing hemodialysis. The type and anatomical location of the vascular access, the cannulation technique, direction, gauge, and distance between needles, besides bevel direction and needle rotation were registered. Results: The arteriovenous fistula was the most frequent vascular access (88%), the most used cannulation technique was area (100%), the needle direction was anterograde in most cases (79.5%), and the mean distance between the tips of needles was 7.57±4.43 cm. For arteriovenous grafts, the proximal anatomical location (brachial artery) and cannulation with 16G needles in anterograde position were more predominant. For arteriovenous fistulas, the distal anatomical location (radial artery) and cannulation through 15G needles were more common. Cannulation of vascular access in retrograde direction was associated with a greater distance between needles (13.2 ± 4.4 vs 6.1 ± 3 cm, p < 0.001). Kt/V was higher when the distance between needles was higher than 5 cm (1.61 ± 0.3 vs. 1.47 ± 0.28, p < 0.01). Conclusions: The vascular access cannulation technique depends on the vascular access characteristics and expertise of cannulators. Clinical trials are required for the formulation of guidelines for vascular access cannulation. RESUMO Introdução: A técnica de canulação do acesso vascular varia entre instituições de saúde, e as diretrizes sobre o acesso vascular dão pouca importância às técnicas de canulação. O objetivo deste estudo foi avaliar a técnica de canulação e determinar quais fatores estão associados a cada detalhe da técnica. Material e métodos: A canulação do acesso vascular foi avaliada em 260 pacientes em hemodiálise. Foram registrados o tipo e localização anatômica do acesso vascular, a técnica de canulação, a direção, a bitola e a distância entre as agulhas, além da direção do bisel e da rotação da agulha. Resultados: A fístula arteriovenosa foi o acesso vascular mais frequente (88%), a técnica de canulação mais utilizada foi a área (100%), a direção da agulha foi anterógrada na maioria dos casos (79,5%) e a distância média entre as pontas das agulhas foi de 7,57 ± 4,43 cm. Para enxertos arteriovenosos, a localização anatômica proximal (artéria braquial) e a canulação com agulhas 16G em posição anterógrada foram mais predominantes. Para as fístulas arteriovenosas, a localização anatômica distal (artéria radial) e a canulação através de agulhas 15G foram mais comuns. A canulação do acesso vascular na direção retrógrada foi associada a uma maior distância entre as agulhas (13,2 ± 4,4 v.s. 6,1 ± 3 cm, p < 0,001). O Kt / V foi maior quando a distância entre as agulhas foi superior a 5 cm (1,61 ± 0,3 vs. 1,47 ± 0,28, p < 0,01). Conclusões: A técnica de canulação do acesso vascular depende das características do acesso vascular e da experiência dos “canuladores”. Ensaios clínicos são necessários para a formulação de diretrizes para a canulação do acesso vascular.

Estimates suggest that 20-30% of the deaths of patients with chronic kidney disease with indication to undergo dialysis occur after refusal to continue dialysis, discontinuation of dialysis or inability to offer dialysis on account of local conditions. Contributing factors include aging, increased comorbidity associated with chronic kidney disease, and socioeconomic status. In several occasions nephrologists will intervene, but at times general practitioners or family physicians are on their own. Knowledge of the main etiologies of chronic kidney disease and the metabolic alterations and symptoms associated to end-stage renal disease is an important element in providing patients with good palliative care. This review aimed to familiarize members of multidisciplinary care teams with the metabolic alterations and symptoms arising from chronic kidney disease treated clinically without the aid of dialysis. RESUMO Estimativas sugerem que em torno de 20% a 30% dos óbitos de pacientes com doença renal crônica em estágio dialítico decorrem de renúncia à diálise, da interrupção do tratamento dialítico ou da incapacidade de oferecer tratamento dialítico em função das condições locais. O envelhecimento populacional, o aumento das comorbidades associadas à doença renal crônica e o nível socioeconômico do país contribuem para esse cenário. Em diversas ocasiões o nefrologista estará presente para intervir ativamente, mas em outras o médico generalista ou o médico de família estarão sós. O conhecimento das principais etiologias da doença renal crônica e das alterações metabólicas e dos sintomas associados à fase terminal da doença renal são condições importantes para a evolução do paciente sem sofrimento para uma boa morte. O objetivo desta revisão é familiarizar os membros da equipe multiprofissional para o reconhecimento e conduta quanto às alterações metabólicas e aos sintomas decorrentes da doença renal crônica tratada clinicamente sem suporte dialítico.

The world population is aging and diseases such as diabetes mellitus and systemic arterial hypertension are increasing the risk of patients developing chronic kidney disease, leading to an increase in the prevalence of patients on dialysis. The expansion of health services has made it possible to offer dialysis treatment to an increasing number of patients. At the same time, dialysis survival has increased considerably in the last two decades. Thus, patients on dialysis are becoming more numerous, older and with greater number of comorbidities. Although dialysis maintains hydroelectrolytic and metabolic balance, in several patients this is not associated with an improvement in quality of life. Therefore, despite the high social and financial cost of dialysis, patient recovery may be only partial. In these conditions, it is necessary to evaluate the patient individually in relation to the dialysis treatment. This implies reflections on initiating, maintaining or discontinuing treatment. The multidisciplinary team involved in the care of these patients should be familiar with these aspects in order to approach the patient and his/her relatives in an ethical and humanitarian way. In this study, we discuss dialysis in the final phase of life and present a systematic way to address this dilemma. RESUMO A população mundial está envelhecendo, e doenças como diabetes mellitus e hipertensão arterial sistêmica estão aumentando o risco de doença renal crônica, com consequente elevação na prevalência de pacientes em diálise. A expansão dos serviços de saúde permitiu oferecer tratamento dialítico para um número cada vez maior de pacientes. Paralelamente, a sobrevida em diálise aumentou consideravelmente nas últimas duas décadas. Dessa maneira, os pacientes em diálise são cada vez mais numerosos, mais idosos e com maior número de comorbidades. Embora a diálise mantenha o equilíbrio hidroeletrolítico e metabólico, em diversos pacientes isso não está associado à melhora da qualidade de vida. Então, apesar do elevado custo social e financeiro da diálise, a recuperação do paciente pode ser apenas parcial. Nessas condições, é necessário avaliar individualmente o paciente em relação ao tratamento dialítico, o que implica reflexões sobre iniciar, manter ou suspender o tratamento. A equipe multidisciplinar envolvida no cuidado desses pacientes deve estar familiarizada com esses aspectos para abordar o paciente e seus familiares de forma ética e humanitária. Neste estudo, foi discutido o tratamento dialítico na fase final da vida e apresentada uma maneira sistemática para enfrentar esse dilema.

Background/Aims: Ultrafiltration that occurs during hemodialysis (HD) promotes profound alterations in a relatively short period of time. The dialysate content of bicarbonate (DBic) and potassium (DK) may have impact over intradialytic hemodynamics, which goes beyond ultrafiltration, and its impact was evaluated in a prospective cohort. Methods: 30 patients under HD were submitted to hemodynamic assessment (HA) at the beginning and at the end of HD sessions, through a non-invasive method. Serum minus dialysate potassium concentration was expressed as K-Gap. Cardiac index (CI) and peripheral arterial resistance (PAR) variation (post-HD minus pre-HD) were expressed as ΔCI and ΔPAR. Dialysate content of sodium and calcium were expressed as DNa and DCa, respectively. Results: Mean DNa, DK and DBic were, respectively, 136.4 ± 1.1, 2.1 ± 0.6 and 38.2 ± 2.1 mEq/L. In 15 patients, DCa was >1.5 mmol/L and in the other 15 patients ≤ 1.5 mmol/L. The K-Gap ranged from 1.4 to 5.1 mEq/l (median 3.0 mEq/L). There was a reduction in post-HD CI and systolic blood pressure (ΔCI = -0.72l/min/m2 and -11.3±15.1mmHg, respectively, p5, pConclusion: We confirmed that Na and Ca dialysate content exerts and important role on hemodynamic during HD. In addition, our findings pointed out that higher dialysate concentrations of bicarbonate and potassium promote lower cardiac performance at the end of hemodialysis session.

There are no studies evaluating the impact of dialyzer reprocessing on solute removal in short-daily online hemodiafiltration (OL-HDF). Our aim was to evaluate the impact of dialyzer reuse on solute removal in daily OL-HDF and compare with that in high-flux short-daily hemodialysis (SDH). Fourteen patients undergoing a SDH program were included. Pre-dialysis and post-dialysis blood samples and effluent dialysate were collected in the 1st, 7th, and 13th dialyzer uses in SDH sessions and in daily OL-HDF sessions. Directly quantified small solute (urea, phosphorus, creatinine, and uric acid) total mass removal (TM(DQ)) and clearance (K(DQ)) were similar when the 1st, 7th, and 13th dialyzer SDH uses were compared with the 1st, 7th, and 13th daily OL-HDF uses. TMDQ and K(DQ) of small solutes were similar among analyzed dialyzer uses in SDH sessions and in daily OL-HDF sessions. β2-Microglobulin TM(DQ) and K(DQ) were statistically higher in daily OL-HDF dialyzer uses than in the respective SDH uses. There was no difference in β2-microglobulin TM(DQ) and K(DQ) among dialyzer uses in daily OL-HDF sessions or in SDH sessions. In daily OL-HDF, albumin loss was significantly different among dialyzer uses (P < 0.001), being lower in the 7th and 13th dialyzer uses than in the first use. Dialyzer reprocessing did not impair solute extraction in daily OL-HDF. β2-Microglobulin removal was greater in daily OL-HDF than in SDH sessions, without significant differences in other solutes extraction. There was a significant reduction in intradialytic albumin loss with dialyzer reprocessing in daily OL-HDF sessions.

Background/Aims: Acute activation of sympathetic activation during hemodialysis is essential to maintain blood pressure (BP), albeit long-term overactivity contributes to higher mortality. Low heart rate variability (HRV), a measure of autonomic nervous system activity, and abnormal ankle-brachial index (ABI) are associated with higher mortality in patients on hemodialysis. In this study, we assessed HRV and ABI pre and post dialysis in incident patients on hemodialysis using high (1.75mmol/l) and low (1.25mmol/l) dialysate calcium concentration (DCa). Methods: HRV was measured as the ratio between low frequency and high frequency power (LF/HF). Thirty patients (age 47±16 years, 67% men) were studied in two consecutive mid-week hemodialysis sessions. Results: Mean BP variation was positive with DCa 1.75 and negative with DCa 1.25 [4.0 (-6.0, 12.2 mmHg) vs. -3.2 (-9.8, 1.3 mmHg); p=0.050]. Reduction of ABI from pre to post HD was related to higher sympathetic activity (p=0.031). The increase in LF/HF ratio was higher with DCa 1.75 (58.3% vs. 41.7% in DCa 1.75 and 1.25, respectively, RR 2.8; p=0.026). Conclusion: Although higher DCa is associated with better hemodynamic tolerability during hemodialysis, this occurs at the expense of increased sympathetic activity. Higher sympathetic activity was associated with a decrease of ABI during hemodialysis.

Resumo Introdução: Alguns índices são utilizados para avaliar a qualidade da terapia dialítica oferecida aos pacientes com doença renal crônica (DRC). Em 2014, o Ministério da Saúde do Brasil publicou a Portaria n° 389/2014, que estabelece metas no cuidado desses pacientes. Objetivo: Avaliar o desempenho de diferentes clínicas de hemodiálise (HD) em relação às metas estabelecidas nessa Portaria. Métodos: Estudo transversal, prospectivo, observacional, envolvendo 1.633 pacientes em HD em oito clínicas. As características demográficas, Kt/V, hemoglobina, fósforo, paratormônio (PTH) e a taxa de mortalidade foram registradas. Os resultados foram comparados com as metas estabelecidas na Portaria: Kt/V > 1,2 em mais de 70% dos pacientes, hemoglobina entre 10 e 12g/dl em mais de 80%, fósforo entre 3,5 e 5,5mg/dl em mais de 50% e o PTH < 600pg/ml em mais de 80% dos pacientes. Resultados: A idade foi de 56,4 ± 15,2 anos, a mediana do tempo em diálise foi de 28,4 meses. A duração da HD foi de 3,74 ± 0,31 horas. Para o Kt/V, seis clínicas atingiram a meta. Para a hemoglobina, nenhuma clínica atingiu a meta. Para o fósforo, duas clínicas atingiram a meta e para o PTH quatro clínicas. Seis clínicas atingiram duas metas e duas clínicas não atingiram nenhuma meta. A mortalidade foi menor nas clínicas que atingiram metas (10,2 vs. 21,6% ao ano; p = 0,0546). Conclusão: Para o Kt/V a maioria das clínicas atingiu a meta estabelecida. Para a hemoglobina e fósforo, as metas não foram atingidas na maioria das clínicas. Para o PTH, a resposta foi variável e dependente de características da clínica. Abstract Introduction: Medical organizations have proposed indices to assess the quality of dialytic therapy offered to patients with chronic kidney disease (CKD). Recently, the Ministry of Health of Brazil published the ordinance n° 389/2014, which establishes targets in the care of patients with CKD. Objective: We evaluate the performance of hemodialysis (HD) clinics in relation to the goals established in this ordinance. Methods: Cross-sectional study, prospective, observational, involving 1,633 patients with CKD on HD in eight clinics. Demographic characteristics, Kt/V, hemoglobin, phosphorus, parathormone (PTH) and the mortality rate were recorded. The results were compared to the goals established in the ordinance No. 389/2014: Kt/V > 1.2 in more than 70% of patients, hemoglobin between 10 and 12 g/dl in more than 80%, phosphorus between 3.5 and 5.5 mg/dl in more than 50%, and PTH < 600pg/ml in more than 80% of patients. Results: The age was 56.4 ± 15.2 years, the median time on dialysis was 28.4 months. The HD session time was 3.74 ± 0.31 hours. For Kt/V, six clinics reached the goal. For hemoglobin, none of the clinics reached the goal. For phosphorus, only two clinics meet the goal and for PTH four clinics. Six clinics hit two goals and two clinics did not achieve any goal. Mortality was lower in clinics that reached targets (10.2 vs. 21.6% per year; p = 0.0546). Conclusion: For Kt/V most clinics reached the goal established by the ordinance. For hemoglobin and phosphorus, the objectives were not achieved in many clinics. For PTH, the response was variable and dependent on clinical features.

Introduction: Malnutrition is a frequent complication in patients on hemodialysis and early diagnosis is important to reduce the morbidity and mortality of treatment. Objective: To investigate the usefulness of biochemical tests performed monthly in order to identify hemodialysis patients with malnutrition. Methods: The nutritional status of 252 patients was evaluated by objective and subjective global assessment, and the patients classified as malnourished and not malnourished. Then, during 4 consecutive months, serum creatinine, phosphorus, urea pre-and post-dialysis and Kt/V were recorded for calculation of averages. After analysis of these variables by the ROC curve we calculated the sensitivity and specificity of these parameters to identify patients with malnutrition. Results: In ROC curve, the area under the curve for urea was 0.683, 0.71 for phosphorus, 0.724 for Kt/V and 0.765 for creatinine. For values of urea ≤ 90 mg/dL, phosphorus ≤ 4.2 mg/dL, Kt/V ≥ 1.6 and creatinine ≤ 6.5 mg/dL, the specificity ranged between 80 and 88% and sensitivity between 26 and 51%. The negative predictive value ranged between 90 and 92% and positive predictive value between 23 and 32%. The association of two or more of these indices did not change significantly these values. Conclusions: Our results suggest that serum urea ≤ 90 mg/dL, creatinine ≤ 6.5 mg/dL, phosphorus ≤ 4.2 mg/dL, and Kt/V ≥ 1.6 can be used for screening patients with malnutrition. However, using these cutoffs the parameters tend to overestimate the number

Although still uncommon, pregnancy frequency in women on maintenance hemodialysis therapy has increased in the past 20 years. Most published reports suggest that intensified hemodialysis regimens result in better pregnancy outcomes. The small number of patients investigated in all reported series is the main limitation of the available studies.Retrospective case series.Data for all pregnancies that occurred in 1988-2008 in women undergoing maintenance hemodialysis (52 pregnancies) at the São Paulo University Medical School (São Paulo, Brazil).We analyzed maternal and fetal outcomes of 52 pregnancies, as well as their relationship with various clinical, laboratory, and hemodialysis parameters, such as pre-eclampsia, pregnancy before or after dialysis therapy, hemodialysis dose, polyhydramnios, anemia, and predialysis serum urea level. In addition, logistic regression models for a composite adverse fetal outcome (perinatal death or extremely premature delivery) and linear regression models for birth weight were built.87% overall rate of successful delivery, with a mean gestational age of 32.7 +/- 3.1 weeks. Pre-eclampsia was associated with a poor prognosis compared with pregnancies without pre-eclampsia: a successful delivery rate of 60% versus 92.9% (P = 0.02), extremely premature delivery rate of 77.8% versus 3.3% (P0.001), lower gestational age (P0.001), and birth weight (P0.001). Patients with an adverse composite fetal outcome had a higher frequency of pre-eclampsia (P0.001), lower frequency of polyhydramnios (P = 0.03), lower third-trimester hematocrit (P = 0.03), and higher predialysis serum urea level (P = 0.03). The same results were seen for birth weight.Retrospective data analysis. The absence of creatinine clearance measurements did not allow evaluation of the impact of residual renal function on fetal outcome.Outcomes of pregnancy in women undergoing hemodialysis often are good. Pre-eclampsia, third-trimester hematocrit, polyhydramnios, and predialysis serum urea level are important variables associated with fetal outcome and birth weight.

Background The tunneled cuffed catheter (TCC) is used as a bridge access for hemodialysis. Few prospective studies have been designed to evaluate conversion from non-tunneled to TCC without the use of fluoroscopy when performed by nephrologists. Methods We performed an observational prospective cohort in incident patients receiving hemodialysis through a non-tunneled right jugular vein catheter. Results 130 procedures were performed in 122 patients (51±18 years). The success rate was 100%. There was a total of 26,546 catheter days. Ninety-one of the 130 catheters were removed during the study period. Life table analysis revealed primary patency rates of 92%, 82%, and 68% at 30, 60, and 120 days, respectively. Infection requiring catheter removal occurred at a frequency of 0.09 per 100 catheter days. Catheter malfunction requiring intervention occurred at a rate of 0.03 per 100 catheter days. Hypertension and duration of existing non-tunneled catheter of less than 2 weeks were independently associated with better TCC survival. Conclusion The conversion from non-tunneled to TCC performed by nephrologists and without fluoroscopy may be safe by using the internal right jugular vein. The ideal time to do this procedure is within less than 2 weeks of existing non-tunneled catheter.

Pruritus is still one of the most common and disturbing symptoms of end-stage renal disease. The objective of this study is to analyze the prevalence of pruritus in hemodialysis patients and the possible factors implicated in its genesis. In a cross-sectional study, 101 patients on hemodialysis at our center were screened for pruritus. The relationship of various factors with pruritus was evaluated. Of the 101 patients included, 31(30.7%) had pruritus at the time of examination. Patients with pruritus were significantly older than those without pruritus (P=0.0027). Pruritus tended to be more prevalent in patients undergoing dialysis 3 times a week than in those undergoing daily dialysis, but the difference did not reach statistical significance (P=0.0854). Lower transferrin saturation levels were found in patients with pruritus than in those without pruritus (P=0.0144). C-reactive protein levels were significantly higher in patients with pruritus than in those without pruritus (P=0.0013). There was no significant difference between the groups in the levels of the other inflammatory biomarkers measured. However, there was a tendency toward a correlation between the levels of alpha-1-glycoprotein and the intensity of pruritus (P=0.0834). Our results suggest a possible relationship of the inflammatory response upregulation to pruritus. Additionally, there was a positive relationship between pruritus and iron deficiency, possibly associated with inflammatory elevation of hepcidin. A better understanding of the factors implicated in the genesis of pruritus related to end-stage renal disease is crucial in the development of more effective treatments for this symptom.

Hyperleptinemia and metabolic acidosis (MA) are frequently observed in patients on hemodialysis (HD). While the role of leptin in patients on HD is not completely understood, HD only partially corrects MA. Both leptin and acidosis have effect on bone disease. The goal of the present study was to evaluate the effects of MA correction on chronic kidney disease–mineral and bone disorder laboratory parameters and leptin levels. Forty-eight patients on HD, aged 43 ± 19 years, were prospectively studied. Individual adjustments in the bicarbonate dialysate concentration were made to maintain pre-dialysis concentration ≥22 mEq/l. Blood gas analysis was done monthly for 4 months (M1–M4). From M0 to M4, serum albumin increased (from 3.5 ± 0.3 to 4.0 ± 0.3 g/l, p

RECOMENDACOES RECOMENDACAO 3.1 Niveis alvo de ferritina e saturacao de transferrina (Opiniao): RECOMENDACAO 3.1.1 Pacientes com DRC estagios 1 e 2 deverao receber suplementacao de ferro para manter os niveis de ferritina serica e saturacao de transferrina dentro dos valores da populacao geral. RECOMENDACAO 3.1.2 Pacientes com DRC estagios 3 e 4: com hemoglobina maior que11g/dl, deverao receber suplementacao de ferro para manter os niveis de ferritina serica maior que 100ng/mL e saturacao de transferrina maior que 20%. com [...]

OBJECTIVE: Poor sleep quality is one of the factors that adversely affects patient quality of life after kidney transplantation, and sleep disorders represent a significant cardiovascular risk factor. The objective of this study was to investigate the prevalence of changes in sleep quality and their outcomes in kidney transplant recipients and analyze the variables affecting sleep quality in the first years after renal transplantation. METHODS: Kidney transplant recipients were evaluated at two time points after a successful transplantation: between three and six months (Phase 1) and between 12 and 15 months (Phase 2). The following tools were used for assessment: the Pittsburgh Sleep Quality Index; the quality of life questionnaire Short-Form-36; the Hospital Anxiety and Depression scale; the Karnofsky scale; and assessments of social and demographic data. The prevalence of poor sleep was 36.7% in Phase 1 and 38.3% in Phase 2 of the study. RESULTS: There were no significant differences between patients with and without changes in sleep quality between the two phases. We found no changes in sleep patterns throughout the study. Both the physical and mental health scores worsened from Phase 1 to Phase 2. CONCLUSION: Sleep quality in kidney transplant recipients did not change during the first year after a successful renal transplantation.

Intradialytic fluid redistribution may cause hypotension. Short daily hemodialysis (SDH) is a technique that increases frequency, potentially reducing the hypotension risk and allowing better ultrafiltration tolerance. Previous studies on conventional hemodialysis (CHD) indicate that fluid loss during dialysis occurs mainly from the legs [1, 2], maintaining the central blood volume. Whether the fluid loss from the legs is associated with hypotension symptoms in patients on SDH is unknown. We therefore performed a cross-sectional study to compare CHD and SDH regarding segmental fluid removal and its association with hypotensive symptoms, by using bioimpedance analysis (BIA). BIA techniques enable assessment of extra and intracellular water and currently appears to be the most practical method for assessing fluid status in dialysis patients [3]. Thirty-five patients on CHD and 15 on SDH had segmental BIA (InBody10 Analyzer ) done preand post-midweek dialysis. Baseline characteristics were similar between CHD and SDH (for age, dialysis vintage, blood pressure, absence of diabetes, and cardiac congestive failure). For both dialysis techniques, from preto post-dialysis, there was a reduction in the extracellular water (ECW) for each of the segments (leg, arm, and trunk), total body water (TBW), and ECW/TBW (p \ 0.05). The delta of legs of ECW was lower in SDH than in CHD [-3.3 % (-4.8, -0.7) vs. -5.4 % (-7.3, -2.4), p = 0.009] (Fig. 1). The relation ECW leg/trunk was lower in SDH than in CHD. Hypotensive symptoms (hypo?) were observed in six patients on SDH (37.5 %) and six patients on CHD (17.1 %). As shown in Table 1, hemoglobin was lower in CHD hypo? group; Within SDH group, patients who had hypotensive symptoms presented lower ECW leg/trunk at baseline and post-dialysis. From preto post-dialysis, there was an increase in the relation ECW leg/trunk in both CHD and SDH, although reached significance only in SDH group. This increase in the ECW leg/trunk was lower in SDH (hypo? group, p = 0.0017). As UF rate was high in SDH group, hypotensive symptoms could be observed. This scenario gave us a unique opportunity to test whether leg fluid removal would be associated with hypotensive symptoms in SDH, which we have demonstrated. In conclusion, the distribution of fluids from the legs to the trunk and the velocity of refilling

INTRODUÇÃO: A canulação da fístula arteriovenosa (FAV) pode ser realizada pelas técnicas de punção por área, rotatória ou em casa de botão (CB); entretanto, a técnica ideal ainda não foi estabelecida. OBJETIVO: Avaliar as dificuldades e complicações na introdução da técnica de punção em CB em FAV construída com veia nativa. MÉTODOS: 16 pacientes com idade de 57±14 anos, em hemodiálise há 63±38 meses foram submetidos à punção em CB. Na fase de formação do túnel (T), as punções foram feitas com agulha cortante (AC) e na fase de manutenção com agulha romba (AR). Nas duas fases, os pacientes foram avaliados para a intensidade da dor em uma escala de 0 a 10. RESULTADOS: O nº de sessões de HD para formação do T foi de 9,5 ± 1,5 e o número de sessões na fase de manutenção foi de 29,7 ± 0,8. Nas 152 HD para formação do T não ocorreram complicações significativas. Durante 475 HD com AR as complicações foram: resistência na punção (7,6%), punção com AC por opção do puncionador (5,7%), troca de AR para AC durante a punção (4,2%) e sangramento local durante a HD (0,8%). Um paciente necessitou antibioticoterapia. A mediana do índice de dor foi 4 na fase de formação do T e 2 na fase de manutenção. Os valores de Kt/V pré- e pós-alteração na técnica de punção não foram diferentes (1,48 ± 0,27 e 1,45 ± 0,23). CONCLUSÃO: A implantação da punção em CB com AR é tecnicamente fácil, apresenta poucas complicações, reduz a dor e não induz variação na dose de diálise. INTRODUCTION: Cannulation of arteriovenous fistula (AVF) may be performed by the following techniques: area puncture, rope ladder, or buttonhole. The ideal technique has not yet been established. OBJECTIVE: To assess the complications and difficulties of introducing the buttonhole (BH) technique for cannulation of AVF created with a native vein in a dialysis unit. METHODS: Sixteen patients (mean age, 57 ± 14 years) undergoing hemodialysis for 63 ± 38 months were changed to BH AVF cannulation. In the phase of track formation cannulations were performed with sharp needles and, in the maintenance phase, with blunt needles. In both phases, patients were assessed for pain intensity on a 0 to 10 scale. RESULTS: The number of HD sessions required for the track formation was 9.5 ± 1.5 and the number of sessions during the maintenance phase was 29.7 ± 0.8 per patient. During the 152 HD for the track formation, no significant complications occurred. During the 475 HD sessions using the BH technique and a blunt needle, the complications were as follows: resistance to cannulation (7.6%); cannulation using a sharp needle due to cannulator choice (5.7%); change from a blunt to a sharp needle during cannulation (4.2%); and local bleeding (0.8%). One patient required antibiotic therapy. The median pain intensity reported by the patients was four during the track formation, and two during cannulation with a blunt needle. The Kt/V values before and after changing the cannulation technique did not differ (1.48 ± 0.27 and 1.48 ± 0.23). CONCLUSION: The introduction of the BH technique with a blunt needle is technically easy, has few complications, reduces pain, and does not induce change in dialysis dose.

Background. During haemodialysis, calcium balance can affect, or be affected by, mineral metabolism. However, when dialysate calcium concentration (d[Ca]) is chosen or kinetic models are employed to calculate calcium balance, bone remodelling is rarely considered. In this study, we examined whether bone remodelling affects calcium mass transfer during haemodialysis. Methods. We dialysed 23 patients using a d[Ca] of 1.0, 1.25, 1.5 or 1.75mmol/L. Calcium mass transfer was measured and associated with remodelling bone factors. Results. Calcium balance varied widely depending on the d[Ca]. Calcium removal was −578±389, −468±563, +46± 400 and +405±413mg when a d[Ca] of 1.0, 1.25, 1.5 or 1.75mmol/L was used, respectively (1.0 and 1.25 vs 1.5 and 1.75mmol/L, P

Fibrose sistêmica nefrogênica (FSN), também conhecida como dermopatia fibrosante nefrogênica (DFN), é uma condição que ocorre apenas em pacientes com disfunção renal. Além das lesões cutâneas, esta síndrome inclui fibrose de músculo esquelético, articulações, fígado, pulmão e coração e pode ser fatal. Esta doença foi primeiramente descrita em 1997 e vários estudos descrevem a relação etiológica da FSN com a exposição a agentes de contraste contendo gadolínio, usado em exames de ressonância magnética. Esta revisão tem como objetivo alertar médicos clínicos e nefrologistas sobre essa nova patologia que acomete pacientes com alteração da função renal, demonstrando aspectos demográficos e epidemiológicos, apresentação clínica, diagnóstico e prognóstico além das opções de prevenção e terapêuticas atuais. Concluímos que todo paciente apresentando creatinina sérica elevada deve ter sua função renal (clearance de creatinina) estimada, visando a segurança na realização da ressonância magnética. Nephrogenic systemic fibrosis (NSF), also known as nephrogenic fibrosing dermopathy (NFD), is a condition that has occurred only in patients with renal insufficiency. Besides lesions of the skin, this syndrome include fibrosis of skeletal muscle, joints, liver, lung, and heart, with possible fatal outcomes. This disease was first described in 1997 and several reports described the development of NSF after the exposure to gadolinium-based magnetic resonance imaging contrast agents. This review aims to alert physicians and nephrologists about this new pathology that affects patients with renal dysfunction, describing its demographic and epidemiologics aspects, clinic presentation, diagnosis and prognosis, beyond options to prevent and current treatment. We concluded that in all patient with elevated serum creatinine physicians should estimade his kidney function (creatinine clearence) in order to safety of magnetic resonance.

Acidosis is a common and deleterious aspect of maintenance dialysis. Traditionally, it is considered to be an elevated anion gap acidosis caused by the inability to excrete nonvolatile anions. Stewart's approach made it possible to identify real determinants of the acid-base status and allowed quantification of the components of these disturbances, especially the unmeasured anions. We performed a cross-sectional study to identify and quantify each component of acidosis in hemodialysis maintenance patients. Sixty-four maintenance hemodialysis patients and 14 controls were enrolled in this study. Gasometrical and biochemical analysis were performed before the midweek dialysis session. Quantitative physicochemical analysis was carried out using the Stewart methodology. Hemodialysis patients were found to have mild acidemia (mean pH: 7.33 +/- 0.06 versus 7.41 +/- 0.05) secondary to metabolic acidosis (serum bicarbonate: 18.8 +/- 0.26 versus 25.2 +/- 0.48 mEq/l). The metabolic acidosis was due to retention of unmeasured anions (6.5 +/- 0.29 versus 3.1 +/- 0.62 mEq/l), hyperchloremia (105.1 +/- 0.5 versus 101.8 +/- 0.7 mEq/l), and hyperphosphatemia (5.90 +/- 0.19 versus 3.66 +/- 0.14 mg/dl). Compared with control values, the unmeasured anions and hyperchloremia had a similar acidifying effect (3.4 and 3.3 mEq/l), corresponding to almost 90% of the metabolic acidosis. Unmeasured anions and hyperchloremia are important components of acidosis in maintenance hemodialysis, in addition to phosphorus. Future studies to determine the etiology and consequences of hyperchloremic acidosis are warranted.

Background. The double-pool urea kinetic model requires the measurement of the blood urea concentrations 30 min after haemodialysis (C t+30 ) to calculate equilibrated Kt/V. However, it has been suggested that urea concentrations 30 min before the end of dialysis (C t-30 ) may be representative of C t+30 . The aim of this study was to validate this suggestion. Methods. Twenty-two patients underwent haemodialysis for 180, 210, and 240 min. For each patient in each dialysis session, urea exponential decay curve was calculated. Because we measured C t+30 , we calculated the time (T c ) before the end of dialysis that blood urea concentrations would be the same as C t+30 , In an additional 33 patients, we measured blood urea concentrations at T c and in C t+30 . Results. We found that C t-30 was significantly lower than C t+30 independent of the duration of dialysis. However, there was a significant correlation between Kt/V t-30 and Kt/V t+30 . The T c was 45 min before the end of dialysis. In the additional 33 patients, C t 45 and C t+30 were 54 ± 17 and 52 ± 17 mg/dl (NS), and Kt/V t-45 and Kt/V t+30 were 1.27 ± 0.21 and 1.29 ± 0.18 (NS), respectively. There were significant correlations between C t-45 and C t+30 (r = 0.96; P < 0.001), and between Kt/V t-45 and Kt/V t+30 (r = 0.82; P < 0.001). However, when measurements were analysed individually, 48% of the data points from C t 45 vs C t+30 , and 42% of the data points from Kt/V t-45 vs Kt/V t+30 fell out of the 95% confidence interval of regression line. Conclusions. Although C t-45 is useful to estimate Kt/V when assessing mean values, it is not suitable when assessing patients individually. This study demonstrates that the best method to calculate equilibrated Kt/V was a blood sample for urea concentrations 30 min after haemodialysis.

Spontaneous bilateral rupture of quadriceps tendon in patients with chronic renal failure is a rare event. All patients reported until now had been on conventional haemodialysis three times a week. We report the first case of a patient on short daily haemodialysis (SDH) with hyperparathyroidism who refused surgical treatment. The serum alkaline phosphatase level had been increasing continuously until the day of tendon rupture. This report alerts about this diagnosis and also emphasizes the continuous increase in the serum alkaline phosphatase level prior to the tendon rupture. Even among well-dialysed patients, on SDH, spontaneous tendon rupture can occur.