Abstracts
Introduction:
Chronic kidney disease (CKD) is a major public health problem worldwide. Nonetheless, little is known about its features in Brazil.
Objective:
To identify prevalence and factors associated with CKD among hospitalized patients in a university hospital.
Methods:
We randomly selected 826 medical records of patients admitted in 2009 in the medical inpatient unit. We defined CKD as the presence of medical diagnosis or personal history. We collected a number of clinical and demographic information and these variables were compared between patients with and without CKD.
Results:
CKD prevalence was 12.7%. Patients with CKD differed from patients without (p < 0.05) regarding to: living with a partner (59.8% vs. 47.3%), older age (65.8 ± 15.6 vs. 55.3 ± 18.9 years-old), more comorbidities as hypertension (75.2% vs. 46.3%), diabetes (49.5% vs. 22.4%), dyslipidemia (23.8% vs. 14.9%), acute myocardial infarction (14.3% vs. 6.0%) and congestive heart failure (18.1% vs. 4.3%); length of hospitalization (11 (8-18) vs. 9 (6-12) days); and death occurrence (12.4% vs. 1.4%). The logistic regression analysis showed an independent association (OR, odds ratio, CI, confidence interval 95%) of CKD with age (OR 1.019, CI 1.003 to 1.036), hypertension (OR 2.032, CI 1.128 to 3.660), diabetes (OR 2.097, CI 1.232 to 3.570) and congestive heart failure (OR 2.665, CI 1.173 to 6.056).
Conclusion:
CKD prevalence among patients in a medical inpatient unit was high and CKD patients were more complex, as they were older and had a great number of co-morbidities, reflecting a greater risk of death during hospitalization.
hypertension; kidney failure, chronic; risk factors
Introdução:
A doença renal crônica (DRC) constitui importante problema de saúde pública mundial. Contudo, dados sobre prevalência e comorbidades são escassos no Brasil.
Objetivo:
Identificar a prevalência e fatores associados à DRC em pacientes internados em um hospital universitário.
Métodos:
Foram selecionados, aleatoriamente, 826 prontuários de pacientes internados em clínica médica. A DRC foi baseada no diagnóstico médico descrito no prontuário. Foram coletadas informações clínico-demográficas e feitas comparações entre pacientes com e sem DRC.
Resultados:
A prevalência de DRC foi 12,7%. Os pacientes com DRC se distinguiram daqueles sem a doença (p < 0,05) por terem companheiro (59,8% vs. 47,3%); idade mais elevada (65,8 ± 15,6 vs. 55,3 ± 18,9 anos); mais comorbidades como hipertensão arterial (75,2% vs. 46,3%), diabetes (49,5% vs. 22,4%), dislipidemia (23,8% vs. 14,9%), infarto do miocárdio (14,3% vs. 6,0%) e insuficiência cardíaca congestiva (18,1% vs. 4,3%); maior período de internação (11 (8-18) vs. 9 (6-12) dias) e; mais óbitos (12,4% vs. 1,4%). A análise de regressão logística indicou associação independente (OR, odds ratio; IC, intervalo de confiança de 95%) da DRC com idade (OR 1,019, IC 1,003-1,036), hipertensão arterial (OR 2,032, IC 1,128-3,660), diabetes (OR 2,097, IC 1,232-3,570) e insuficiência cardíaca congestiva (OR 2,665, IC 1,173-6,056).
Conclusão:
A prevalência de DRC em pacientes internados em clínica médica foi alta, sendo estes pacientes clinicamente mais complexos, visto apresentarem idade mais elevada e maior número de comorbidades, refletindo em maior risco de óbito durante internação hospitalar.
fatores de risco; hipertensão; insuficiência renal crônica
Introduction
Chronic kidney disease (CKD) has taken on the status of public health concern in
recent years, due to its increased prevalence among the world’s population and its
impact on morbidity and mortality in affected patients. Mainly a result of the
growing epidemic of cardiovascular risk factors, chronic kidney disease causes
frequent hospitalizations and high socioeconomic cost.11 Lessa I. Doenças crônicas não-transmissíveis no Brasil: um desafio para
a complexa tarefa da vigilância. Ciênc Saude Colet 2004;9:931-43. DOI:
http://dx.doi.org/10.1590/S1413-81232004000400014
http://dx.doi.org/10.1590/S1413-81232004...
2 Bastos MG, Carmo WB, Abrita RR, Almeida EC, Mafra D, Costa DMN, et al.
Doença renal crônica: problemas e soluções. J Bras Nefrol
2004;26:202-15.
3 Bastos MG, Bregman R, Kirsztajn GM. Doença renal crônica: frequente e
grave, mas também prevenível e tratável. Rev Assoc Med Bras 2010;56:248-53. DOI:
http://dx.doi.org/10.1590/S0104-42302010000200028
http://dx.doi.org/10.1590/S0104-42302010...
-44 Jaar BG, Khatib R, Plantinga L, Boulware LE, Powe NR. Principles of
screening for chronic kidney disease. Clin J Am Soc Nephrol 2008;3:601-9. DOI:
http://dx.doi.org/10.2215/CJN.02540607
http://dx.doi.org/10.2215/CJN.02540607...
In 2011, there were 91,314 individuals on dialysis in Brazil, corresponding to a
prevalence of 475 pmp.55 Sesso Rde C, Lopes AA, Thomé FS, Lugon JR, Watanabe Y, Santos DR.
Chronic dialysis in Brazil: report of the Brazilian dialysis census, 2011. J Bras
Nefrol 2012;34:272-7. DOI:
http://dx.doi.org/10.5935/0101-2800.20120009
http://dx.doi.org/10.5935/0101-2800.2012...
We have less patients
on renal replacement therapy when compared to developed countries.66 United States Renal Data System. 2012 Annual Data Report. Atlas of
Chronic Kidney Disease & End-Stage Renal Disease in the United States. Précis: An
introduction to end-stage renal disease in the U.S. Am J Kidney Dis
2013;61:e165-e92.
7 Jacquelinet C, Lange C, Briançon S; registre REIN. The prevalence of
ESRD in 2011. Nephrol Ther 2013;9:S39-64. DOI:
http://dx.doi.org/10.1016/S1769-7255(13)70039-7
http://dx.doi.org/10.1016/S1769-7255(13)...
-88 Akizawa T. Current satus of dialysistherapy and related clinical
guidelines in Japan. JMAJ 2010;53:185-7. One explanation for this discrepancy may be the low participation of
dialysis centers in the census; however, the most alarming hypothesis rests on the
poor access to healthcare services. It is believed that 50-70% of Brazilians who have
chronic kidney disease die without being submitted to any kind of treatment.22 Bastos MG, Carmo WB, Abrita RR, Almeida EC, Mafra D, Costa DMN, et al.
Doença renal crônica: problemas e soluções. J Bras Nefrol
2004;26:202-15.,99 Salgado Filho N, Brito DJA. Doença renal crônica: a grande epidemia
deste milênio. J Bras Nefrol 2006;28:1-5.
Data on morbidity and mortality of chronic renal failure patients in Brazil is still
very restricted to the dialysis population. In fact, kidney failure treated with
dialysis or transplantation is the outcome of chronic kidney disease that most stands
out. However, cardiovascular diseases are often associated with chronic kidney
disease, which is of great importance when we consider that chronic kidney patients
are more likely to die of cardiovascular disease than evolving into kidney
failure.1010 Sarnak MJ, Levey AS, Schoolwerth AC, Coresh J, Culleton B, Hamm LL, et
al.; American Heart Association Councils on Kidney in Cardiovascular Disease, High
Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Kidney
disease as a risk factor for development of cardiovascular disease: a statement from
the American Heart Association Councils on Kidney in Cardiovascular Disease, High
Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention.
Circulation 2003;108:2154-69. DOI:
http://dx.doi.org/10.1161/01.CIR.0000095676.90936.80
http://dx.doi.org/10.1161/01.CIR.0000095...
Thus, little is known on the
prevalence, morbidity and mortality of early-stage chronic kidney disease in
Brazil.
Faced with this problem, this study aims at identifying the prevalence and factors associated with chronic kidney disease in individuals who have undergone hospitalization in a university hospital.
Method
This was an exploratory, cross-sectional and quantitative study, carried out between December of 2010 and June of 2013.
The sample consisted of adult patients (age ≥ 18 years) admitted to the internal medicine ward of a university hospital in São Paulo, Brazil, during the year of 2009.
We collected data retrospectively from the medical records of each patient and by means of an instrument designed for this purpose. We also collected sociodemographic and anthropometric information, health history, lifestyle, medical diagnostics and hospitalization outcomes.
Pregnant women, patients staying less than 24 hours in the clinical wards, those
without serum creatinine measured in at least two occasions during the hospital stay
and patients who progressed during hospitalization to acute kidney injury according
to AKIN1111 Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al.;
Acute Kidney Injury Network. Acute Kidney Injury Network: report of an initiative to
improve outcomes in acute kidney injury. Crit Care 2007;11:R31. DOI:
http://dx.doi.org/10.1186/cc5713
http://dx.doi.org/10.1186/cc5713...
criteria (increased serum creatinine
equal to or higher than 0.3 mg/dL in the patients without clinical diagnosis of CKD)
or those on medical diagnosis of acute renal failure were taken off the study.
CKD was defined as the presence of a medical diagnosis of CKD reported on at least one occasion in the medical chart.
Statistical analysis
For sample size calculation we used the CKD prevalence estimation of 13%, as
described by Coresh et al.1212 Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al.
Prevalence of chronic kidney disease in the United States. JAMA 2007;298:2038-47.
PMID: 17986697 DOI: http://dx.doi.org/10.1001/jama.298.17.2038
http://dx.doi.org/10.1001/jama.298.17.20...
as a representative sample of the US population, with a 5%
variation, 5% type I error and 80% test power. Under these parameters, the size of
the representative sample of the population of patients admitted to the internal
medicine ward would be 386 individuals. The CKD prevalence value suggested for the
sample calculation is higher than those described in studies carried out with
Brazilian populations.1313 Lessa I. Níveis séricos de creatinina: hipercreatinemia em segmento da
população adulta de Salvador, Brasil. Rev Bras Epidemiol 2004;7:176-86. DOI:
http://dx.doi.org/10.1590/S1415-790X2004000200007
http://dx.doi.org/10.1590/S1415-790X2004...
,1414 Passos VM, Barreto SM, Lima-Costa MF; Bambuí Health and Ageing Study
(BHAS) Group. Detection of renal dysfunction based on serum creatinine levels in a
Brazilian community: the Bambuí Health and Ageing Study. Braz J Med Biol Res
2003;36:393-401. DOI:
http://dx.doi.org/10.1590/S0100-879X2003000300015
http://dx.doi.org/10.1590/S0100-879X2003...
However; we believe that our sample had a
higher frequency of CKD because it is an older population and with comorbidities -
although the CKD criterion was based solely on the presence of medical diagnosis
in medical records. The records were randomly chosen by a randomization tool
available in Microsoft Excel.
We assessed the association between categorical variables and the group with CKD using the chi-square test, likelihood ratio test or Fisher’s exact test. For quantitative variables, we used the Student t-test to compare the means of normally distributed variables or the Mann-Whitney test to compare the interquartile distributions. The variables that were statistically significant in the univariate analysis and reported in the literature as a potential risk factor for chronic kidney disease were used to adjust the multiple logistic regression model. P values < 0.05 were considered statistically significant.
Results
According to the hospital’s admissions record, 1,422 patients were admitted to the internal medicine ward during the study period.
After adopting the exclusion criteria, 105 subjects with CKD were identified, accounting for a prevalence of 12.7% within the 826 records analyzed (Figure 1). Among CKD patients, 27 (25.7%) had stage 5 CKD under dialysis. Finally, 386 patients were included in the final sample, 105 with CKD and 281 without CKD.
According to the biosocial characteristics depicted on Table 1, patients with CKD were distinguished from those without CKD for being older and having a steady partner (p < 0.05). Now, patients without CKD stood out because they had a higher prevalence of smoking (p < 0.05).
Biosocial characteristics of the patients admitted to the internal medicine ward according to having chronic renal disease or not. São Paulo, 2014
Regarding health history, a vast majority (89,5%) and just over half (55.2%) of the patients with and without CKD, respectively, had at least one comorbidity. Of the 105 patients identified as chronic renal failure patients, 53.3% already had a history of the disease recorded in their medical charts. There was a significant difference (p < 0.05) between groups with and without CKD regarding the presence of arterial hypertension (75.2% vs. 46.3%), diabetes (49.5% vs. 22.4%) and congestive heart failure (18.1% vs. 4.3%) - Figure 2.
Main clinical diagnosis of the patients admitted to an internal medicine Ward with and without chronic kidney disease. São Paulo, 2013.
Two thirds of the patients were being followed up in a healthcare service, a more frequent occurrence among those with CKD (87.8% vs. 58.0%, p < 0.001). It is noteworthy that more than 10% of patients with CKD were not under any follow-up care, although 36.4% of them had personal history of the disease.
CKD patients had longer hospital stays (p < 0.05) compared with those without the disease, as well as higher mortality rates (Table 2). Of patients diagnosed with stage 5 CKD, 65.4% started renal replacement therapy during hospitalization, and 58.8% had no previous history of CKD. Except for one patient who died, these patients were referred to dialysis clinics after hospital discharge.
Hospitalization outcomes of the patients admitted to an internal medicine ward, with and without chronic kidney disease. São Paulo, 2014
The multiple logistic regression model (Table 3) included the following variables: marital status, smoking, age and personal history significantly associated with CKD in the univariate analysis. We noticed that for each additional year in age, CKD likelihood was 1.9% higher. Hypertension or diabetes increased the likelihood of having CKD in two fold and heart failure in 2.6 fold.
Chronic kidney disease predictors in patients admitted to an internal medicine ward according to a multivariate analysis. São Paulo, 2014
Discussion
The main finding of this study revealed that CKD in patients a dmitted to an internal medicine ward was associated with the main cardiovascular risk factors amenable to intervention: hypertension and diabetes. Such risk factors, besides age, are recognized worldwide for their great impact on patient morbidity and mortality.
CKD Individuals were older than those without the disease. This finding is consistent
with several studies that have shown its association with age. The prevalence of CKD
among individuals older than 65 years ranged from 5.8 to 51% in different
international studies. Although the values are discrepant, they were all much larger
than those of younger age groups in their studies indicating an almost exponential
increase in the prevalence of chronic kidney disease with age.1515 Zhang QL, Rothenbacher D. Prevalence of chronic kidney disease in
population-based studies: systematic review. BMC Public Health 2008;8:117. PMID:
18405348 DOI: http://dx.doi.org/10.1186/1471-2458-8-117
http://dx.doi.org/10.1186/1471-2458-8-11...
,1616 Lamb EJ, O'Riordan SE, Delaney MP. Kidney function in older people:
pathology, assessment and management. Clin Chim Acta 2003;334:25-40. PMID: 12867274
DOI: http://dx.doi.org/10.1016/S0009-8981(03)00246-8
http://dx.doi.org/10.1016/S0009-8981(03)...
While the prevalence of hypertension in Brazilian studies was around 30%1717 Passos VMA, Assis TD, Barreto SM. Hipertensão arterial no Brasil:
estimativa de prevalência a partir de estudos de base populacional. Epidemiol Serv
Saúde 2006;15:35-45.,1818 Picon RV, Fuchs FD, Moreira LB, Riegel G, Fuchs SC. Trends in prevalence
of hypertension in Brazil: a systematic review with meta-analysis. PLoS One
2012;7:e48255. DOI: http://dx.doi.org/10.1371/journal.pone.0048255
http://dx.doi.org/10.1371/journal.pone.0...
in the general population, patients with CKD identified in this sample
were different due to a higher prevalence of hypertension (81.0% vs.
50.5%) compared to those without CKD.
In fact, high blood pressure has been considered a ubiquitous disease in CKD;
because, besides being one of the most important causes for the disease onset and
development, high blood pressure is a result of CKD.1919 Andersen MJ, Agarwal R. Etiology and management of hypertension in
chronic kidney disease. Med Clin North Am 2005;89:525-47. DOI:
http://dx.doi.org/10.1016/j.mcna.2004.12.001
http://dx.doi.org/10.1016/j.mcna.2004.12...
North American data from the Kidney Early Evaluation Program (KEEP),
reported an increased prevalence of hypertension in a population at risk of CKD,
according to glomerular filtration rate estimates (eGFR) in the period from 1994 to
2004: 56.6% for eGFR > 100 ml/ min/1.73 m2; 72.4% eGFR to 60-70
ml/min/1.73 m2; and 95.6% for eGFR < 30 mL/min/1.73 m2. The
same trend was observed in a population sample from the National-Health and Nutrition
Survey Examination (NHANES), following the same criteria and study period, although
the frequency of hypertension has been lower.2020 Rao MV, Qiu Y, Wang C, Bakris G. Hypertension and CKD: Kidney Early
Evaluation Program (KEEP) and National Health and Nutrition Examination Survey
(NHANES), 1999-2004. Am J Kidney Dis 2008;51:S30-7. DOI:
http://dx.doi.org/10.1053/j.ajkd.2007.12.012
http://dx.doi.org/10.1053/j.ajkd.2007.12...
The prevalence of diabetes mellitus found in this study (32.1%) was higher than the
prevalence reported by telephone survey for the adult population (5.2%) and the
elderly (18.8% for ages between 65 and 74 years, and 17.6% for age less than 75
years) in Brazil.2121 Schmidt MI, Duncan BB, Hoffmann JF, Moura L, Malta DC, Carvalho MRSC.
Prevalência de diabetes e hipertensão no Brasil baseada em inquérito de morbidade
auto-referida, Brasil, 2006. Rev Saúde Pública 2009;43:74-82. DOI:
http://dx.doi.org/10.1590/S0034-89102009000900010
http://dx.doi.org/10.1590/S0034-89102009...
the presence of diabetes
mellitus was significantly higher among patients with CKD: 50.5% vs.
25.3%. In fact, the prevalence of diabetes among chronic kidney patients has been
higher than that of individuals without CKD.2222 NKF KDOQI Guidelines [Internet]. KDOQI Clinical Practice Guidelines for
Chronic Kidney Disease: Evaluation C, and Stratification. Part 7. Stratification of
risk for progression of kidney disease and developement of cardiovascular disease
[Citado 2011 Jan 10]. Disponível em:
http://www.kidney.org/professionals/KDOQI/guidelines_ckd/p7_risk_g15.htm
http://www.kidney.org/professionals/KDOQ...
,2323 Parikh NI, Hwang SJ, Larson MG, Meigs JB, Levy D, Fox CS. Cardiovascular
disease risk factors in chronic kidney disease: overall burden and rates of treatment
and control. Arch Intern Med 2006;166:1884-91. PMID: 17000946 DOI:
http://dx.doi.org/10.1001/archinte.166.17.1884
http://dx.doi.org/10.1001/archinte.166.1...
The prevalence of diabetes in chronic renal failure patients in the present study was
higher than that reported in several studies with this population2222 NKF KDOQI Guidelines [Internet]. KDOQI Clinical Practice Guidelines for
Chronic Kidney Disease: Evaluation C, and Stratification. Part 7. Stratification of
risk for progression of kidney disease and developement of cardiovascular disease
[Citado 2011 Jan 10]. Disponível em:
http://www.kidney.org/professionals/KDOQI/guidelines_ckd/p7_risk_g15.htm
http://www.kidney.org/professionals/KDOQ...
23 Parikh NI, Hwang SJ, Larson MG, Meigs JB, Levy D, Fox CS. Cardiovascular
disease risk factors in chronic kidney disease: overall burden and rates of treatment
and control. Arch Intern Med 2006;166:1884-91. PMID: 17000946 DOI:
http://dx.doi.org/10.1001/archinte.166.17.1884
http://dx.doi.org/10.1001/archinte.166.1...
-2424 Fox CS, Muntner P. Trends in diabetes, high cholesterol, and
hypertension in chronic kidney disease among U.S. adults: 1988-1994 to 1999-2004.
Diabetes Care 2008;31:1337-42. or even than the prevalence reported in a sample of individuals on
renal replacement therapy in Brazil (30.6%),2525 Biavo BM, Tzanno-Martins C, Cunha LM, Araujo ML, Ribeiro MM, Sachs A, et
al. Nutritional and epidemiological aspects of patients with chronic renal failure
undergoing hemodialysis from Brazil, 2010. J Bras Nefrol 2012;34:206-15. DOI:
http://dx.doi.org/10.5935/0101-2800.20120001
http://dx.doi.org/10.5935/0101-2800.2012...
suggesting higher hospital morbidity among these individuals. There is also the
possibility that diabetes mellitus may become more relevant in the etiology and
comorbidity of CKD in Brazil in the near future.2626 Burmeister JE, Mosmann CB, Bau R, Rosito GA. Prevalence of diabetes
mellitus in chronic renal failure patients under haemodialysis in Porto Alegre,
Brazil. J Bras Nefrol 2012;34:117-21.
CKD was also significantly associated with heart failure in our country, almost three
times more common in affected individuals. Although the decrease in cardiac output
brought about by the disease itself or its treatment can participate in the genesis
of progressive kidney damage, 2727 Silverberg D, Wexler D, Blum M, Schwartz D, Iaina A. The association
between congestive heart failure and chronic renal disease. Curr Opin Nephrol
Hypertens 2004;13:163-70. DOI:
http://dx.doi.org/10.1097/00041552-200403000-00004
http://dx.doi.org/10.1097/00041552-20040...
it should be
noted that the main causes of congestive heart failure are hypertension and ischemia,
both closely associated with arterial hypertension.2828 Bocchi EA, Marcondes-Braga FG, Bacal F, Ferraz AS, Albuquerque D,
Rodrigues D, et al. Atualização da Diretriz Brasileira de Insuficiência Cardíaca
Crônica-2012. Arq Bras Cardiol 2012;98:1-33. DOI:
http://dx.doi.org/10.1590/S0066-782X2012001000001
http://dx.doi.org/10.1590/S0066-782X2012...
Another finding of epidemiological relevance, although secondary to the process of sample selection, was the prevalence of CKD. Considering the exclusion steps associated with the individuals, to which the criteria were applied to the total population, we found a chronic kidney disease prevalence of 12.7%.
The value found is right inside the reported prevalence in international studies (0.6
to 43.3%),29,30 and close those found among in the elderly (12.9%; 95% CI, 4.3 to
20.3)1313 Lessa I. Níveis séricos de creatinina: hipercreatinemia em segmento da
população adulta de Salvador, Brasil. Rev Bras Epidemiol 2004;7:176-86. DOI:
http://dx.doi.org/10.1590/S1415-790X2004000200007
http://dx.doi.org/10.1590/S1415-790X2004...
and in a small city (12.8% of
moderate to severe chronic renal failure patients)3131 Yokota RTC, Iser BPM, Andrade RLM, Meiners MMMA, Assis DM, Bernal RTI,
et al. Vigilância de fatores de risco e proteção para doenças e agravos não
transmissíveis em município de pequeno porte, Brasil, 2010. Epidemiol Serv Saúde
2012;21:55-68. DOI:
http://dx.doi.org/10.5123/S1679-49742012000100006
http://dx.doi.org/10.5123/S1679-49742012...
in Brazil. It is, nonetheless, higher than that found in a Brazilian
population screening (7.3%).3232 de Lima AO, Kesrouani S, Gomes RA, Cruz J, Mastroianni-Kirsztajn G.
Population screening for chronic kidney disease: a survey involving 38,721
Brazilians. Nephrol Dial Transplant 2012;27:iii135-8. Although the
CKD prevalence comparison is compromised by the specificity of the present study
sample and disease definition criteria, it stands out that CKD is very frequent in
hospitalized patients in an internal medicine ward. Brazilian data on hospital
morbidity, besides corresponding to the main diagnosis for hospitalization, refers to
the chapters and lists of morbidity in the International Classification of Diseases
(ICD-10), in which the different etiologies of CKD are diluted. If we consider “renal
failure” morbidity (not specified as acute or chronic), it appears that this
represented only 0.7% of the main admission diagnoses in 2009;3333 Brasil. Ministério da Saúde. Departamento de Informática do SUS.
DATASUS: informações de saúde [Internet]. Brasília, 2008 [Citado 2013 Abr 19].
Disponivel em: www.datasus.gov.br/tabnet/tabnet.htm
www.datasus.gov.br/tabnet/tabnet.htm...
while 4.1% of admitted patients to the internal medicine ward
of the present study had end-stage renal disease. Thus, it is clear the importance of
CKD in hospital morbidity in a general hospital unit in Brazil.
Nearly half of individuals with CKD had no personal history of the disease in their
medical charts, although most reported having been followed in a healthcare facility.
The frequency of patients who started renal replacement therapy and who had no
personal history of CKD suggests that a significant part of the Brazilian population
with chronic renal failure is only later referred to a nephrology service,3434 Bastos MG, Kirsztajn GM. Doença renal crônica: importância do
diagnóstico precoce, encaminhamento imediato e abordagem interdisciplinar estruturada
para melhora do desfecho em pacientes ainda não submetidos à diálise. J Bras Nefrol
2011;33:93-108. DOI:
http://dx.doi.org/10.1590/S0101-28002011000100013
http://dx.doi.org/10.1590/S0101-28002011...
and this may lead to the worsening in their
outcomes.3535 Jungers P, Joly D, Nguyen-Khoa T, Mothu N, Bassilios N, Grünfeld JP.
Continued late referral of patients with chronic kidney disease. Causes,
consequences, and approaches to improvement. Presse Med 2006;35:17-22. PMID:
16462659,3636 Chan MR, Dall AT, Fletcher KE, Lu N, Trivedi H. Outcomes in patients
with chronic kidney disease referred late to nephrologists: a meta-analysis. Am J Med
2007;120:1063-70. DOI:
http://dx.doi.org/10.1016/j.amjmed.2007.04.024
http://dx.doi.org/10.1016/j.amjmed.2007....
As for the associations observed in relation to hospitalization outcomes, longer
hospital stays of patients with CKD was congruent with the highest morbidity found in
this group. The high death rates among CKD patients compared to those without CKD in
our country has shown the important relationship between CKD and mortality, reported
by numerous international studies.3737 Chronic Kidney Disease Prognosis Consortium; Matsushita K, van der Velde
M, Astor BC, Woodward M, Levey AS, de Jong PE, et al. Association of estimated
glomerular filtration rate and albuminuria with all-cause and cardiovascular
mortality in general population cohorts: a collaborative meta-analysis. Lancet
2010;375:2073-81. PMID: 20483451
38 Tonelli M, Wiebe N, Culleton B, House A, Rabbat C, Fok M, et al. Chronic
kidney disease and mortality risk: a systematic review. Clin J Am Soc Nephrol
2006;17:2034-47. DOI: http://dx.doi.org/10.1681/ASN.2005101085
http://dx.doi.org/10.1681/ASN.2005101085...
39 Nitsch D, Grams M, Sang Y, Black C, Cirillo M, Djurdjev O, et al.;
Chronic Kidney Disease Prognosis Consortium. Associations of estimated glomerular
filtration rate and albuminuria with mortality and renal failure by sex: a
meta-analysis. BMJ 2013;346:f324. PMID: 23360717 DOI:
http://dx.doi.org/10.1136/bmj.f324
http://dx.doi.org/10.1136/bmj.f324...
-4040 United States Renal Data System. 2012 Annual Data Report. Atlas of
Chronic Kidney Disease & End-Stage Renal Disease in the United States. Morbidity
& Mortality in Patients With CKD. Am J Kidney Dis
2013;61:e65-e74.
Conclusion
Despite the limitations of this study - associated with its retrospective design, the frequent lack of data in medical records and CKD diagnosis be credited to non-confirmed information in the medical records, chronic kidney disease was associated to the main modifiable cardiovascular risk factors. Facing this, we reiterate the need to improve primary care follow-up of patients with hypertension and diabetes. While hospitalization continues to be the “gateway” in the Brazilian healthcare system for a significant portion of the population, the recognition of factors associated with CKD can be crucial to the proper continuity of treatment for chronic renal failure patients in the long term.
Referências
-
1Lessa I. Doenças crônicas não-transmissíveis no Brasil: um desafio para a complexa tarefa da vigilância. Ciênc Saude Colet 2004;9:931-43. DOI: http://dx.doi.org/10.1590/S1413-81232004000400014
» http://dx.doi.org/10.1590/S1413-81232004000400014 -
2Bastos MG, Carmo WB, Abrita RR, Almeida EC, Mafra D, Costa DMN, et al. Doença renal crônica: problemas e soluções. J Bras Nefrol 2004;26:202-15.
-
3Bastos MG, Bregman R, Kirsztajn GM. Doença renal crônica: frequente e grave, mas também prevenível e tratável. Rev Assoc Med Bras 2010;56:248-53. DOI: http://dx.doi.org/10.1590/S0104-42302010000200028
» http://dx.doi.org/10.1590/S0104-42302010000200028 -
4Jaar BG, Khatib R, Plantinga L, Boulware LE, Powe NR. Principles of screening for chronic kidney disease. Clin J Am Soc Nephrol 2008;3:601-9. DOI: http://dx.doi.org/10.2215/CJN.02540607
» http://dx.doi.org/10.2215/CJN.02540607 -
5Sesso Rde C, Lopes AA, Thomé FS, Lugon JR, Watanabe Y, Santos DR. Chronic dialysis in Brazil: report of the Brazilian dialysis census, 2011. J Bras Nefrol 2012;34:272-7. DOI: http://dx.doi.org/10.5935/0101-2800.20120009
» http://dx.doi.org/10.5935/0101-2800.20120009 -
6United States Renal Data System. 2012 Annual Data Report. Atlas of Chronic Kidney Disease & End-Stage Renal Disease in the United States. Précis: An introduction to end-stage renal disease in the U.S. Am J Kidney Dis 2013;61:e165-e92.
-
7Jacquelinet C, Lange C, Briançon S; registre REIN. The prevalence of ESRD in 2011. Nephrol Ther 2013;9:S39-64. DOI: http://dx.doi.org/10.1016/S1769-7255(13)70039-7
» http://dx.doi.org/10.1016/S1769-7255(13)70039-7 -
8Akizawa T. Current satus of dialysistherapy and related clinical guidelines in Japan. JMAJ 2010;53:185-7.
-
9Salgado Filho N, Brito DJA. Doença renal crônica: a grande epidemia deste milênio. J Bras Nefrol 2006;28:1-5.
-
10Sarnak MJ, Levey AS, Schoolwerth AC, Coresh J, Culleton B, Hamm LL, et al.; American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation 2003;108:2154-69. DOI: http://dx.doi.org/10.1161/01.CIR.0000095676.90936.80
» http://dx.doi.org/10.1161/01.CIR.0000095676.90936.80 -
11Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al.; Acute Kidney Injury Network. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007;11:R31. DOI: http://dx.doi.org/10.1186/cc5713
» http://dx.doi.org/10.1186/cc5713 -
12Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al. Prevalence of chronic kidney disease in the United States. JAMA 2007;298:2038-47. PMID: 17986697 DOI: http://dx.doi.org/10.1001/jama.298.17.2038
» http://dx.doi.org/10.1001/jama.298.17.2038 -
13Lessa I. Níveis séricos de creatinina: hipercreatinemia em segmento da população adulta de Salvador, Brasil. Rev Bras Epidemiol 2004;7:176-86. DOI: http://dx.doi.org/10.1590/S1415-790X2004000200007
» http://dx.doi.org/10.1590/S1415-790X2004000200007 -
14Passos VM, Barreto SM, Lima-Costa MF; Bambuí Health and Ageing Study (BHAS) Group. Detection of renal dysfunction based on serum creatinine levels in a Brazilian community: the Bambuí Health and Ageing Study. Braz J Med Biol Res 2003;36:393-401. DOI: http://dx.doi.org/10.1590/S0100-879X2003000300015
» http://dx.doi.org/10.1590/S0100-879X2003000300015 -
15Zhang QL, Rothenbacher D. Prevalence of chronic kidney disease in population-based studies: systematic review. BMC Public Health 2008;8:117. PMID: 18405348 DOI: http://dx.doi.org/10.1186/1471-2458-8-117
» http://dx.doi.org/10.1186/1471-2458-8-117 -
16Lamb EJ, O'Riordan SE, Delaney MP. Kidney function in older people: pathology, assessment and management. Clin Chim Acta 2003;334:25-40. PMID: 12867274 DOI: http://dx.doi.org/10.1016/S0009-8981(03)00246-8
» http://dx.doi.org/10.1016/S0009-8981(03)00246-8 -
17Passos VMA, Assis TD, Barreto SM. Hipertensão arterial no Brasil: estimativa de prevalência a partir de estudos de base populacional. Epidemiol Serv Saúde 2006;15:35-45.
-
18Picon RV, Fuchs FD, Moreira LB, Riegel G, Fuchs SC. Trends in prevalence of hypertension in Brazil: a systematic review with meta-analysis. PLoS One 2012;7:e48255. DOI: http://dx.doi.org/10.1371/journal.pone.0048255
» http://dx.doi.org/10.1371/journal.pone.0048255 -
19Andersen MJ, Agarwal R. Etiology and management of hypertension in chronic kidney disease. Med Clin North Am 2005;89:525-47. DOI: http://dx.doi.org/10.1016/j.mcna.2004.12.001
» http://dx.doi.org/10.1016/j.mcna.2004.12.001 -
20Rao MV, Qiu Y, Wang C, Bakris G. Hypertension and CKD: Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES), 1999-2004. Am J Kidney Dis 2008;51:S30-7. DOI: http://dx.doi.org/10.1053/j.ajkd.2007.12.012
» http://dx.doi.org/10.1053/j.ajkd.2007.12.012 -
21Schmidt MI, Duncan BB, Hoffmann JF, Moura L, Malta DC, Carvalho MRSC. Prevalência de diabetes e hipertensão no Brasil baseada em inquérito de morbidade auto-referida, Brasil, 2006. Rev Saúde Pública 2009;43:74-82. DOI: http://dx.doi.org/10.1590/S0034-89102009000900010
» http://dx.doi.org/10.1590/S0034-89102009000900010 -
22NKF KDOQI Guidelines [Internet]. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation C, and Stratification. Part 7. Stratification of risk for progression of kidney disease and developement of cardiovascular disease [Citado 2011 Jan 10]. Disponível em: http://www.kidney.org/professionals/KDOQI/guidelines_ckd/p7_risk_g15.htm
» http://www.kidney.org/professionals/KDOQI/guidelines_ckd/p7_risk_g15.htm -
23Parikh NI, Hwang SJ, Larson MG, Meigs JB, Levy D, Fox CS. Cardiovascular disease risk factors in chronic kidney disease: overall burden and rates of treatment and control. Arch Intern Med 2006;166:1884-91. PMID: 17000946 DOI: http://dx.doi.org/10.1001/archinte.166.17.1884
» http://dx.doi.org/10.1001/archinte.166.17.1884 -
24Fox CS, Muntner P. Trends in diabetes, high cholesterol, and hypertension in chronic kidney disease among U.S. adults: 1988-1994 to 1999-2004. Diabetes Care 2008;31:1337-42.
-
25Biavo BM, Tzanno-Martins C, Cunha LM, Araujo ML, Ribeiro MM, Sachs A, et al. Nutritional and epidemiological aspects of patients with chronic renal failure undergoing hemodialysis from Brazil, 2010. J Bras Nefrol 2012;34:206-15. DOI: http://dx.doi.org/10.5935/0101-2800.20120001
» http://dx.doi.org/10.5935/0101-2800.20120001 -
26Burmeister JE, Mosmann CB, Bau R, Rosito GA. Prevalence of diabetes mellitus in chronic renal failure patients under haemodialysis in Porto Alegre, Brazil. J Bras Nefrol 2012;34:117-21.
-
27Silverberg D, Wexler D, Blum M, Schwartz D, Iaina A. The association between congestive heart failure and chronic renal disease. Curr Opin Nephrol Hypertens 2004;13:163-70. DOI: http://dx.doi.org/10.1097/00041552-200403000-00004
» http://dx.doi.org/10.1097/00041552-200403000-00004 -
28Bocchi EA, Marcondes-Braga FG, Bacal F, Ferraz AS, Albuquerque D, Rodrigues D, et al. Atualização da Diretriz Brasileira de Insuficiência Cardíaca Crônica-2012. Arq Bras Cardiol 2012;98:1-33. DOI: http://dx.doi.org/10.1590/S0066-782X2012001000001
» http://dx.doi.org/10.1590/S0066-782X2012001000001 -
29McCullough K, Sharma P, Ali T, Khan I, Smith WC, MacLeod A, et al. Measuring the population burden of chronic kidney disease: a systematic literature review of the estimated prevalence of impaired kidney function. Nephrol Dial Transplant 2012;27:1812-21. DOI: http://dx.doi.org/10.1093/ndt/gfr547
» http://dx.doi.org/10.1093/ndt/gfr547 -
30Zhang QL, Rothenbacher D. Prevalence of chronic kidney disease in population-based studies: systematic review. BMC Public Health 2008;8:117. PMID: 18405348 DOI: http://dx.doi.org/10.1186/1471-2458-8-117
» http://dx.doi.org/10.1186/1471-2458-8-117 -
31Yokota RTC, Iser BPM, Andrade RLM, Meiners MMMA, Assis DM, Bernal RTI, et al. Vigilância de fatores de risco e proteção para doenças e agravos não transmissíveis em município de pequeno porte, Brasil, 2010. Epidemiol Serv Saúde 2012;21:55-68. DOI: http://dx.doi.org/10.5123/S1679-49742012000100006
» http://dx.doi.org/10.5123/S1679-49742012000100006 -
32de Lima AO, Kesrouani S, Gomes RA, Cruz J, Mastroianni-Kirsztajn G. Population screening for chronic kidney disease: a survey involving 38,721 Brazilians. Nephrol Dial Transplant 2012;27:iii135-8.
-
33Brasil. Ministério da Saúde. Departamento de Informática do SUS. DATASUS: informações de saúde [Internet]. Brasília, 2008 [Citado 2013 Abr 19]. Disponivel em: www.datasus.gov.br/tabnet/tabnet.htm
» www.datasus.gov.br/tabnet/tabnet.htm -
34Bastos MG, Kirsztajn GM. Doença renal crônica: importância do diagnóstico precoce, encaminhamento imediato e abordagem interdisciplinar estruturada para melhora do desfecho em pacientes ainda não submetidos à diálise. J Bras Nefrol 2011;33:93-108. DOI: http://dx.doi.org/10.1590/S0101-28002011000100013
» http://dx.doi.org/10.1590/S0101-28002011000100013 -
35Jungers P, Joly D, Nguyen-Khoa T, Mothu N, Bassilios N, Grünfeld JP. Continued late referral of patients with chronic kidney disease. Causes, consequences, and approaches to improvement. Presse Med 2006;35:17-22. PMID: 16462659
-
36Chan MR, Dall AT, Fletcher KE, Lu N, Trivedi H. Outcomes in patients with chronic kidney disease referred late to nephrologists: a meta-analysis. Am J Med 2007;120:1063-70. DOI: http://dx.doi.org/10.1016/j.amjmed.2007.04.024
» http://dx.doi.org/10.1016/j.amjmed.2007.04.024 -
37Chronic Kidney Disease Prognosis Consortium; Matsushita K, van der Velde M, Astor BC, Woodward M, Levey AS, de Jong PE, et al. Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet 2010;375:2073-81. PMID: 20483451
-
38Tonelli M, Wiebe N, Culleton B, House A, Rabbat C, Fok M, et al. Chronic kidney disease and mortality risk: a systematic review. Clin J Am Soc Nephrol 2006;17:2034-47. DOI: http://dx.doi.org/10.1681/ASN.2005101085
» http://dx.doi.org/10.1681/ASN.2005101085 -
39Nitsch D, Grams M, Sang Y, Black C, Cirillo M, Djurdjev O, et al.; Chronic Kidney Disease Prognosis Consortium. Associations of estimated glomerular filtration rate and albuminuria with mortality and renal failure by sex: a meta-analysis. BMJ 2013;346:f324. PMID: 23360717 DOI: http://dx.doi.org/10.1136/bmj.f324
» http://dx.doi.org/10.1136/bmj.f324 -
40United States Renal Data System. 2012 Annual Data Report. Atlas of Chronic Kidney Disease & End-Stage Renal Disease in the United States. Morbidity & Mortality in Patients With CKD. Am J Kidney Dis 2013;61:e65-e74.
Publication Dates
-
Publication in this collection
Jan-Mar 2015
History
-
Received
30 May 2014 -
Accepted
08 Sept 2014