Produção Nacional
Revisado por pares
The Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD): Characterization of the cohort
2008; Elsevier BV; Volume: 73; Linguagem: Inglês
10.1038/sj.ki.5002616
ISSN1523-1755
AutoresNatália Maria da Silva Fernandes, Marcus Gomes Bastos, Hélio Vida Cassi, N Machado, Joaquim A. Ribeiro, Gladys Aires Martins, Oto G. Mourão, Kleyton de Andrade Bastos, Sebastião Rodrigues Ferreira Filho, Valdebrando Mendonça Lemos, Mohamed Abdo, M.T.I. Vannuchi, Altair Jacob Mocelin, Serena Bettoni, Raúl Valenzuela, Mariana Martins Lima, Sérgio Wyton Lima Pinto, Miguel C. Riella, Abdul Rashid Qureshi, José C. Divino Filho, Roberto Pecoits–Filho,
Tópico(s)Health Systems, Economic Evaluations, Quality of Life
ResumoThe Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) was launched in December 2004 aiming to collect data monthly and continuously from a representative cohort, allowing for a continuous snapshot of the peritoneal dialysis (PD) reality in the country. This is an observational study of PD patients comprising follow-up from December 2004 to February 2007 (mean follow-up of 13.6 months—ranging from 1 to 26 months) in 114 Brazilian centers. All centers report data through a central web-based database. After an initial baseline retrospective data collection, all patients are followed prospectively every month until they drop out from the PD program. Total number of patients recruited until February 2007 was 3226 (2094 incident patients). Mean age was 54±19 years (37% above 65 years old), with 55% females and 64% Caucasians. The more frequent causes of renal failure were diabetic nephropathy (34%), renal vascular disease associated with hypertension (26%), and glomerulopathies (13%). The most common comorbidities were hypertension (76%), diabetes (36%), and ischemic heart disease (23%). Automated PD (APD) was the modality utilized in 53%. The estimated overall peritonitis rate was 1 episode per 30 patient-months (most frequently due to Staphylococcus aureus). The total dropout rate was 33%, mainly due to deaths, whereas 20% of dropouts were due to renal transplant. The gross mortality was 17.6% and the main causes of mortality were cardiovascular diseases (40%) and infections (15%). The initial results of this first Brazilian PD registry provide a unique opportunity to develop future clinical studies addressing specific PD questions in the Brazilian reality and context. The Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) was launched in December 2004 aiming to collect data monthly and continuously from a representative cohort, allowing for a continuous snapshot of the peritoneal dialysis (PD) reality in the country. This is an observational study of PD patients comprising follow-up from December 2004 to February 2007 (mean follow-up of 13.6 months—ranging from 1 to 26 months) in 114 Brazilian centers. All centers report data through a central web-based database. After an initial baseline retrospective data collection, all patients are followed prospectively every month until they drop out from the PD program. Total number of patients recruited until February 2007 was 3226 (2094 incident patients). Mean age was 54±19 years (37% above 65 years old), with 55% females and 64% Caucasians. The more frequent causes of renal failure were diabetic nephropathy (34%), renal vascular disease associated with hypertension (26%), and glomerulopathies (13%). The most common comorbidities were hypertension (76%), diabetes (36%), and ischemic heart disease (23%). Automated PD (APD) was the modality utilized in 53%. The estimated overall peritonitis rate was 1 episode per 30 patient-months (most frequently due to Staphylococcus aureus). The total dropout rate was 33%, mainly due to deaths, whereas 20% of dropouts were due to renal transplant. The gross mortality was 17.6% and the main causes of mortality were cardiovascular diseases (40%) and infections (15%). The initial results of this first Brazilian PD registry provide a unique opportunity to develop future clinical studies addressing specific PD questions in the Brazilian reality and context. Brazil is the largest country in Latin America, with an area of over 8 million m2 and a population of 180 million inhabitants.1.Instituto Brasileiro de Geografia e Estatística, In: http://www.ibge.gov.brAccessed October 2007.Google Scholar The country is considered to be among the 15 largest economies of the world,2.Oliveira M.B. Romao Jr, J.E. Zatz R. End-stage renal disease in Brazil: epidemiology, prevention, and treatment.Kidney Int. 2005; 97: S82-S86Abstract Full Text Full Text PDF Scopus (23) Google Scholar,3.Rodriguez-Iturbe B. Bellorin-Font E. End-stage renal disease prevention strategies in Latin America.Kidney Int. 2005; 68: S30-S36Abstract Full Text Full Text PDF Scopus (18) Google Scholar and regarding healthcare, provides its population with universal coverage. There is a paucity of epidemiological data on chronic kidney disease in Brazil,4.Política Nacional de Atenção ao Portador de Doença Renal. In: complexidade (ed). MdSSdAECgdA 2004, p 64.Google Scholar but concerning renal replacement therapy, there are over 70 000 patients on dialysis, making Brazil the third largest in number of dialysis patients, after the United States and Japan.5.Pecoits-Filho R. Abensur H. Cueto-Manzano A.M. et al.Overview of peritoneal dialysis in Latin America.Perit Dial Int. 2007; 27: 316-321Crossref PubMed Scopus (34) Google Scholar The vast majority of patients are on hemodialysis (HD), and peritoneal dialysis (PD) is used at the present in approximately 10% of the patients. From the historical perspective, it is important to mention that continuous ambulatory PD (CAPD) was initiated in Brazil in 1980;6.Riella M.C. Locatelli A.J. History of peritoneal dialysis in Latin America.Perit Dial Int. 2007; 27: 322-327PubMed Google Scholar however, there have been only a few publications on the epidemiology and clinical experience with PD.7.Cubas J. Riella M.C. [Present status of continuous ambulatory peritoneal dialysis (CAPD) in Brazil].AMB Rev Ass Med Bras. 1987; 33: 11-14PubMed Google Scholar, 8.Ianhez L.E. Salomao Filho A. Laffitte A. et al.Present status of treatment of the chronic terminal renal patient in Brazil].AMB Rev Ass Med Bras. 1978; 24: 400-402PubMed Google Scholar, 9.Sesso R. Ancao M.S. Madeira S.A. [Epidemiologic aspects of the dialysis treatment in Grande Sao Paulo. Comissao Regional de Nefrologia da Secretaria da Saude de Sao Paulo and Centro de Informatica da Escola Paulista de Medicina].Rev Ass Med Bras (1992). 1994; 40: 10-14PubMed Google Scholar, 10.Thome F.S. Rodrigues A.T. Bruno R. et al.CAPD in southern Brazil: an epidemiological study.Adv Perit Dial. 1997; 13: 141-145PubMed Google Scholar Observational studies, which can be exploratory or confirmatory in nature, serve as the important substrate for generating interesting ideas to be tested in the appropriate clinical studies to generate medical evidence. Several observational studies have been important in shifting paradigms in the field of PD, such as the multicenter studies in the United States and Canada (CANUSA):11.Churchill D.N. Thorpe K.E. Vonesh E.F. et al.Lower probability of patient survival with continuous peritoneal dialysis in the United States compared with Canada. Canada-USA (CANUSA) peritoneal dialysis study group.J Am Soc Nephrol. 1997; 8: 965-971PubMed Google Scholar COOR,12.Perez R.A. Blake P.G. Jindal K.A. et al.Changes in peritoneal dialysis practices in Canada 1996-1999.Perit Dial Int. 2003; 23: 53-57PubMed Google Scholar USRDS;13.Mujais S. Story K. Peritoneal dialysis in the US: evaluation of outcomes in contemporary cohorts.Kidney Int. 2006; 70: S21-S26Abstract Full Text Full Text PDF Scopus (175) Google Scholar Europe: NECOSAD,14.Jager K.J. Merkus M.P. Dekker F.W. et al.Mortality and technique failure in patients starting chronic peritoneal dialysis: results of the Netherlands cooperative study on the adequacy of dialysis. NECOSAD study group.Kidney Int. 1999; 55: 1476-1485Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar EAPOS;15.Brown E.A. Davies S.J. Rutherford P. et al.Survival of functionally anuric patients on automated peritoneal dialysis: the European APD outcome study.J Am Soc Nephrol. 2003; 14: 2948-2957Crossref PubMed Scopus (338) Google Scholar Asia: ASPD;16.Lam M.F. Tang C. Wong A.K. et al.ASPD: A prospective study of adequacy in Asian patients on long term, small volume, continuous ambulatory peritoneal dialysis.Perit Dial Int. 2006; 26: 466-474PubMed Google Scholar and Australasia: ANZDATA.17.McDonald S.P. Russ G.R. Kerr P.G. et al.ESRD in Australia and New Zealand at the end of the millennium: a report from the ANZDATA registry.Am J Kidney Dis. 2002; 40: 1122-1131Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar So far, the data on clinical practice and long-term results on PD in Latin America are restricted to the REDTJAL study in Mexico.18.Garcia-Garcia G. Monteon-Ramos J.F. Garcia-Bejarano H. et al.Renal replacement therapy among disadvantaged populations in Mexico: a report from the Jalisco Dialysis and Transplant Registry (REDTJAL).Kidney Int. 2005; 97: S58-S61Abstract Full Text Full Text PDF Scopus (65) Google Scholar The absence of a national PD database in Brazil, the limited research about the treatment done in last 10 years, and the relative lack of motivation to treat patients with the method motivated the development of an observational multicenter prospective study covering a significant and representative proportion of Brazilian PD patients. Thus, the aim of this study was to collect data on prevalent and incident CAPD and automated PD (APD) patients recruited in a significant number of centers in Brazil, searching for clinical, biochemical, nutritional, educational, social, psychological and quality of life information. In addition, the Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) will serve as the basis for a continuous national database that will provide information for future decision making in both preventive and corrective actions for PD programs in Brazil. During the period from December 2004 to February 2007, 3226 enrolled patients were followed for a mean time of 13.6 months (range 1–26 months). Most patients were Caucasians (64%), with a predominance of females (55%). The mean age was 54±19 years, with a higher number of elderly patients among the 2094 incident patients included in the study (Table 1). As observed in other cohorts, the main cause of chronic kidney disease was diabetic nephropathy, and there was a widespread use of APD (53%). Regarding educational profile, there was a large proportion of illiterate patients. The minimum monthly individual wage in Brazil is approximately US$190, and in our study, 42% of the patients (together with their families) had a monthly income of less than US$380.Table 1Demographic data of the CAPD and APD populations at baselineTotalPatientspopulationIncidentPrevalentNumber of patients (n)322620941132CAPD/APD47%/53%42%/58%56%/44%Age (years)54±1956±2052±18Patients >65 years old34%37%27%Female55%54%56%Caucasians64%68%58%Primary kidney disease Diabetic nephropathy34%38%29% Hypertensive renal disease36%24%28% Chronic glomerulonephritis13%11%16% Miscellaneous9%9%9% Chronic pielonephritis4%4%5% Unknown14%14%13%APD, automated peritoneal dialysis; CAPD, continuous ambulatory peritoneal dialysis. Open table in a new tab APD, automated peritoneal dialysis; CAPD, continuous ambulatory peritoneal dialysis. Reflecting late patient referral, almost half of the patients (47%) analyzed were not followed by a nephrologist until the time of the initiation of dialysis. Interestingly, 15% of patients were referred to the nephrology clinic from the emergency room. Also relevant to patient selection, 39% of patients either transferred from HD or had a failing transplant. Indeed, PD was considered the only alternative of renal replacement therapy in 51% of cases, although it represented the patient's choice in 46% of the evaluations. Patients were mainly referred to nephrologists from internists (28%), cardiologists (15%), general practitioners (10%), and endocrinologists (7%). The most common comorbidity observed was hypertension (76%), followed by diabetes (36%), ischemic heart disease (23%), peripheral vascular disease (11%), and malignancies (2%). Davies comorbidity score was 0 in 30% of patients, lower than 2 in 32% and higher than 2 in 32% of the patients. In addition, 38% of patients were considered obese (body mass index >30) and 28% were overweight (body mass index >25). The Karnofsky index was higher than 70 in 85% of patients. When medications prescribed was analyzed, we observed that 80% of patients were utilizing erythropoietin and 42% received iron. Most patients (61%) were using phosphate binders, mainly calcium based (46%). Among hypertensive patients, 47% used angiotensin-converting enzyme inhibitors and 13% were treated with angiotensin receptor blockers. Regarding the dialysis prescription, approximately 95% of CAPD patients were prescribed four exchanges of 2 l, many times utilizing at least one hypertonic exchange (in the case of 4.25% of glucose: 14% of the morning exchanges, 4% of the second, 9% of the third, and in 13% of cases in the overnight exchange; in the case of 2.5%: 9% of the morning exchanges, 9% of the second, 9% of the third, and in 36% of cases in the overnight exchange). Patients on APD received a mean of 12.1±3.2 l during a total treatment time of 9±1 h. At least one-third of patients utilized one or more hypertonic solutions in the cycler. A wet day was prescribed in 56% of patients. Laboratory data were collected continuously in the study, and the main baseline data for prevalent and incident patients is presented in Table 2. On average, values for hemoglobin, calcium, and phosphorus met the recommendations of international guidelines. Interestingly, the mean serum fasting glucose levels could be considered higher (118 mg per 100 ml) than recommended.Table 2Mean laboratory values of the study population at baselineTotalPatientspopulationIncidentPrevalentCreatinine (mg per 100 ml)7.4±4.66.9±4.18.5±5.3Potassium (mEq l−1)4.5±8.14.4±1.14.7±3.7Calcium (mg per 100 ml)8.5±3.98.4±4.38.8±3.1Phosphorus (mg per 100 ml)5.1±5.75.1±5.55.3±6.2Glucose (mg per 100 ml)117±74116±72118±76Hemoglobin (g per 100 ml)11±311±311±4 Open table in a new tab The incidence of peritonitis was 1 episode/30 patient-months experience, and the overall exit-site infection rate was 1 episode/54 patient-months. The most prevalent agent identified in culture was Staphylococcus aureus (28%), whereas a high prevalence of negative culture (40%) was identified. Despite of that, the centers achieved a mean cure rate of 87%. Thirty-three percent of patients dropped out during the follow-up period, mostly due to fatal events, which were due to vascular causes in the majority of cases. The main causes of mortality in the patient population are described in Figure 1. If death is not included in the analysis, peritonitis becomes the most important cause of dropout (23% of cases). In addition, there was a high rate of renal transplantation (20%) and recovery of renal function (5%) in this study population. Finally, the survival rate at 26 months was 75% for prevalent patients and 72% in the group of incident patients (Figure 2).Figure 2Kaplan–Meier survival curves of incident and prevalent patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Large and detailed observational studies in the PD population are scarce, and represent an important tool in defining targets for future studies, which will generate evidence to guide clinical practice. In this paper, we describe the main characteristics and baseline information of one of the largest and most complete observational studies published in the area of PD, the BRAZPD. In this study, we evaluated and followed 3226 patients, making this study the largest performed observational study, if registries are excluded. Other studies of similar design, such as CANUSA11.Churchill D.N. Thorpe K.E. Vonesh E.F. et al.Lower probability of patient survival with continuous peritoneal dialysis in the United States compared with Canada. Canada-USA (CANUSA) peritoneal dialysis study group.J Am Soc Nephrol. 1997; 8: 965-971PubMed Google Scholar (680 patients), EAPOS15.Brown E.A. Davies S.J. Rutherford P. et al.Survival of functionally anuric patients on automated peritoneal dialysis: the European APD outcome study.J Am Soc Nephrol. 2003; 14: 2948-2957Crossref PubMed Scopus (338) Google Scholar (177 patients), ASPD16.Lam M.F. Tang C. Wong A.K. et al.ASPD: A prospective study of adequacy in Asian patients on long term, small volume, continuous ambulatory peritoneal dialysis.Perit Dial Int. 2006; 26: 466-474PubMed Google Scholar (294 patients), and REDTJAL18.Garcia-Garcia G. Monteon-Ramos J.F. Garcia-Bejarano H. et al.Renal replacement therapy among disadvantaged populations in Mexico: a report from the Jalisco Dialysis and Transplant Registry (REDTJAL).Kidney Int. 2005; 97: S58-S61Abstract Full Text Full Text PDF Scopus (65) Google Scholar (2456 patients), analyzed a significant, but lower number of patients in comparison to BRAZPD. These studies were highly important and provided relevant information concerning the population characteristics, defined risk factors for poor outcome and shaped the concept of PD adequacy. It should be noted that the ADEMEX study, although of interventional design, provides an important source of epidemiological and clinical information in a large (965) number of patients.19.Paniagua R. Amato D. Vonesh E. et al.Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized, controlled trial.J Am Soc Nephrol. 2002; 13: 1307-1320Crossref PubMed Scopus (1576) Google Scholar Additionally, registries such as the COOR,12.Perez R.A. Blake P.G. Jindal K.A. et al.Changes in peritoneal dialysis practices in Canada 1996-1999.Perit Dial Int. 2003; 23: 53-57PubMed Google Scholar USRDS,13.Mujais S. Story K. Peritoneal dialysis in the US: evaluation of outcomes in contemporary cohorts.Kidney Int. 2006; 70: S21-S26Abstract Full Text Full Text PDF Scopus (175) Google Scholar NECOSAD,14.Jager K.J. Merkus M.P. Dekker F.W. et al.Mortality and technique failure in patients starting chronic peritoneal dialysis: results of the Netherlands cooperative study on the adequacy of dialysis. NECOSAD study group.Kidney Int. 1999; 55: 1476-1485Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar and ANZDATA17.McDonald S.P. Russ G.R. Kerr P.G. et al.ESRD in Australia and New Zealand at the end of the millennium: a report from the ANZDATA registry.Am J Kidney Dis. 2002; 40: 1122-1131Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar are numerically very large and perhaps most importantly, provide continued information regarding characteristics of the PD population, complications of the method, survival, quality of life, comparison between subgroups, as well as comparison with HD. The sample evaluated in BRAZPD corresponds to 48% of the patients on PD in Brazil, which is representative, and allows for extrapolation of conclusions to the overall PD population in the country. However, the fact that only centers with more than 10 patients on PD were included in the study could have generated a selection bias, because centers with less experience and fewer patients on treatment tend to perform worse than large experience centers. On the other hand, including centers with few patients could have created bias toward the other direction. Despite the fact that the majority of the patients are still in their economically productive years, we observed in this cohort a significant percentage over 65 years of age, notably when we evaluated incident patients separately, confirming an international trend of growth in the elderly population, particularly in PD.20.Danovitch G.M. A kidney for all ages.Am J Transplant. 2006; 6: 1267-1268Crossref PubMed Scopus (15) Google Scholar The PD population in Brazil at the time represents only 10% of the total patients on dialysis.21.Sociedade Brasileira de Nefrologia, In: http://www.sbn.org.br/censo/2006 Accessed October 2007.Google Scholar One of the reasons for the low number of patients on PD in Brazil has been traditionally associated with the concept that the low educational level represents a contraindication for PD, as it requires active participation on the part of the patient. Our data show a high percentage of illiterate patients (13%), which is greater than observed in the general the Brazilian population.1.Instituto Brasileiro de Geografia e Estatística, In: http://www.ibge.gov.brAccessed October 2007.Google Scholar In addition, we also observed that the majority of the patients have a very low income. Indeed a recent study called attention to these factors and proposed a re-analysis of the high rates of social contraindications for PD,22.Jager K.J. Korevaar J.C. Dekker F.W. et al.The effect of contraindications and patient preference on dialysis modality selection in ESRD patients in the Netherlands.Am J Kidney Dis. 2004; 43: 891-899Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar based on the lack of convincing data in the literature supporting this concept. The unique characteristics of our population (large number of poor and illiterate patients on PD) provide a unique opportunity to evaluate outcomes in this population, what will be performed in future studies using the database. The large observational national registries available12.Perez R.A. Blake P.G. Jindal K.A. et al.Changes in peritoneal dialysis practices in Canada 1996-1999.Perit Dial Int. 2003; 23: 53-57PubMed Google Scholar, 13.Mujais S. Story K. Peritoneal dialysis in the US: evaluation of outcomes in contemporary cohorts.Kidney Int. 2006; 70: S21-S26Abstract Full Text Full Text PDF Scopus (175) Google Scholar, 17.McDonald S.P. Russ G.R. Kerr P.G. et al.ESRD in Australia and New Zealand at the end of the millennium: a report from the ANZDATA registry.Am J Kidney Dis. 2002; 40: 1122-1131Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 23.Jager K.J. Merkus M.P. Boeschoten E.W. et al.Dialysis in the Netherlands: the clinical condition of new patients put into a European perspective. NECOSAD study group. Netherlands cooperative study on the adequacy of dialysis phase 1.Nephrol Dial Transplant. 1999; 14: 2438-2444Crossref PubMed Scopus (19) Google Scholar reflect more homogenous geographic characteristics. Some studies have correlated geographic variables in PD, demonstrating a greater indication of this modality for populations geographically distant from the dialysis centers.24.Stack A.G. Determinants of modality selection among incident US dialysis patients: results from a national study.J Am Soc Nephrol. 2002; 13: 1279-1287PubMed Google Scholar The majority of patients analyzed here were concentrated in the southeast and south of Brazil, areas of greatest urban population,1.Instituto Brasileiro de Geografia e Estatística, In: http://www.ibge.gov.brAccessed October 2007.Google Scholar and contain a greater number of dialysis centers.21.Sociedade Brasileira de Nefrologia, In: http://www.sbn.org.br/censo/2006 Accessed October 2007.Google Scholar A separate evaluation of the data for each region in the BRAZPD will provide important information on the PD population characteristics of locations geographically and socially underprivileged. According to the present analysis, a substantial number of patients did not receive prior nephrological treatment and were on another renal replacement therapy before PD. Similar to the situation of renal care, it is possible to speculate that dialysis patients received suboptimal care regarding the management of the main comorbidities, namely diabetes, hypertension, and cardiovascular disease, with potential repercussions not only in the rate of progression to chronic kidney disease, but also enhancing morbid-mortality in this population. Patients with diabetic nephropathy, more comorbidities and elderly patients presented a worse prognosis in several clinical studies.13.Mujais S. Story K. Peritoneal dialysis in the US: evaluation of outcomes in contemporary cohorts.Kidney Int. 2006; 70: S21-S26Abstract Full Text Full Text PDF Scopus (175) Google Scholar, 25.Bloembergen W.E. Port F.K. Mauger E.A. et al.A comparison of cause of death between patients treated with hemodialysis and peritoneal dialysis.J Am Soc Nephrol. 1995; 6: 184-191PubMed Google Scholar, 26.Held P.J. Port F.K. Turenne M.N. et al.Continuous ambulatory peritoneal dialysis and hemodialysis: comparison of patient mortality with adjustment for comorbid conditions.Kidney Int. 1994; 45: 1163-1169Abstract Full Text PDF PubMed Scopus (204) Google Scholar, 27.Lupo A. Cancarini G. Catizone L. et al.Comparison of survival in CAPD and hemodialysis: a multicenter study.Adv Perit Dial. 1992; 8: 136-140PubMed Google Scholar, 28.Vonesh E.F. Snyder J.J. Foley R.N. et al.Mortality studies comparing peritoneal dialysis and hemodialysis: what do they tell us?.Kidney Int. 2006; 70: S3-S11Abstract Full Text Full Text PDF PubMed Scopus (238) Google Scholar Because late referral and bad management of comorbidities are clearly associated with poor outcome, further measures will need to optimize management of comorbidity and pre-dialytic care in Brazil to improve clinical results of patients on dialysis. We observed a very large number of both incident and prevalent patients on APD. We also observed that the standard prescription for APD is similar to that seen in other studies,12.Perez R.A. Blake P.G. Jindal K.A. et al.Changes in peritoneal dialysis practices in Canada 1996-1999.Perit Dial Int. 2003; 23: 53-57PubMed Google Scholar which provides a great opportunity for analyzing the outcome of APD patients in comparison to CAPD. With regard to dialysis prescription there was a large percentage of patients using hypertonic solutions, which could reflect the profile of PD patients in Brazil, many coming from HD already anuric. The standard prescription for CAPD is also similar to other studies and as in APD presents a large utilization of hypertonic solutions. The low use of 2.5% dextrose solutions in this cohort points to the need for educational strategies aimed at reducing the glucose load and glucose exposure, thereby preserving the peritoneal membrane and increasing time on PD. With respect to laboratory results, we observed mean levels of hemoglobin, calcium, and phosphorus within the Kidney Disease Outcomes Quality Initiative guidelines.29.II Clinical practice guidelines and clinical practice recommendations for anemia in chronic kidney disease in adults.Am J Kidney Dis. 2006; 47: S16-S85PubMed Google Scholar However, this is a superficial analysis, and refers only to the average. It would be necessary to evaluate the percentage of patients that achieve the target of the current guidelines. Peritonitis and exit-site infections rates were similar to those recommended by the International Society of Peritoneal Dialysis with a satisfactory cure rate (87%). This demonstrates an improvement in the quality of dialysis in Brazil when we compare this data with the previous historic descriptions.30.Barretti P. Bastos K.A. Dominguez J. et al.Peritonitis in latin america.Perit Dial Int. 2007; 27: 332-339PubMed Google Scholar The most frequent etiology to those infections was S. aureus. This may not represent the true situation, because there is a large percent of negative cultures, and in addition, there may be regional differences principally associated with tropical climate in some Brazilian states. Understanding regional differences will be important to develop appropriated guidelines based on the local flora and resistance profile, with potential impact on improving the management of peritonitis in the country. The dropout rate was 33% in the 26-month period, similar to rates observed in other studies13.Mujais S. Story K. Peritoneal dialysis in the US: evaluation of outcomes in contemporary cohorts.Kidney Int. 2006; 70: S21-S26Abstract Full Text Full Text PDF Scopus (175) Google Scholar, 19.Paniagua R. Amato D. Vonesh E. et al.Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized, controlled trial.J Am Soc Nephrol. 2002; 13: 1307-1320Crossref PubMed Scopus (1576) Google Scholar, 31.Jaar B.G. Coresh J. Plantinga L.C. et al.Comparing the risk for death with peritoneal dialysis and hemodialysis in a national cohort of patients with chronic kidney disease.Ann Intern Med. 2005; 143: 174-183Crossref PubMed Scopus (269) Google Scholar, 32.Korevaar J.C. Boeschoten E.W. Dekker F.W. et al.What have we learned from NECOSAD? Practical implications for peritoneal dialysis patients.Perit Dial Int. 2007; 27: 11-15PubMed Google Scholar and accordingly, the main reason for dropout was cardiovascular death. Peritonitis continues to be a problem both related to dropout and mortality, corroborating with other studies in Latin America,33.Garcia-Garcia G. Tachiquin-Bautista N. Luquin-Arellano V.H. et al.Risk of Peritonitis among disadvantaged CAPD patients in Mexico.Contrib Nephrol. 2007; 154: 145-152PubMed Google Scholar and represents a major target for dropout-reducing interventions. The high rate of negative cultures observed in this study could be at least in part responsible for the technique failure and should be a target for the development of more effective protocols. Finally, although the survival curves do not differ significantly from others described in the literature, the survival rate among the prevalent patients was slightly greater than that among incident patients, confirming other studies that have shown a greater mortality in the first 3 months and then, subsequently after 2 years.34.Sesso R. Belasco A.G. Late diagnosis of chronic renal failure and mortality on maintenance dialysis.Nephrol Dial Transplant. 1996; 11: 2417-2420Crossref PubMed Scopus (177) Google Scholar In conclusion, we present the characterization of the cohort for the BRAZPD, a large and detailed observational study that will provide in the near future
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