ABSTRACT Introduction: Elderly patients are the most frequent patients admitted to dialysis units. Relatively little is known about standards on endof-life (EOL) care among dialysis patients. From international literature, these patients are exposed to more aggressive treatments at EOL than patients with cancer or other chronic diseases and palliative referral is infrequent. This study aims to describe some end-of-life (EOL) practices in patients undergoing hemodialysis in NephroCare clinics in several cities in Portugal. Material and Methods: We designed a prospective, multicenter, observational, cross-sectional study conducted between October 1st, 2020 and September 30th, 2021 in six hemodialysis clinics including 1265 patients (pts). Results: During the year in analysis, 158 pts died (12.4%). Mean age was 76 years (25% of pts were older than 85 years) and dialysis vintage was 84 (2-963) months. Regarding comorbidities, 50% were diabetic, 40% had congestive heart failure, 25% had cancer and 17% had dementia. Mean age-adapted Charlson index was 13 ± 3. For 82 pts (51.9%), nephrologists would not be surprised if they died in the next 6 months. Seventy-three had hospital admissions in the previous three months. Four pts withdrew dialysis. Of those who died, only two had advance care directives, 18 had an opioid prescription in the last month of life and 17 were referred to palliative intervention mostly because of oncologic disorders. Seventy four percent of these pts died at the hospital and 23% died at home/nursing home. Not a single patient died under hospice care. Conclusion: Most of our patients commonly die in hospital, undergo invasive procedures, spend much of their remaining life fulfilling a demanding dialysis schedule and are admitted to the hospital wards without formal palliative intervention or discussion of goals of care, even when death is an expected outcome.

Background: The efficacy and cost-effectiveness of drug-eluting balloon (DEB) in vascular access for dialysis remain unclear. Methods: Data obtained from using DEB in highly recurrent stenosis were retrospectively analyzed. These data were obtained from procedures performed in the Vascular Access Center, responsible for attending over 3600 patients from 30 dialysis centers. Highly recurrent stenosis is defined as stenosis having three or more previous interventions and/or associated with early recurrence defined as the last procedure in less than 90 days. Patency and cost-effectiveness were evaluated. Patency was defined as the number of days free of interventions after applying DEB. Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio (ICER) and an estimation of costs per day/patient/year. Results: Data from 37 consecutive procedures on 32 patients were assessed. The average patency time between interventions was 107.22 ± 104.428 days before DEB intervention. After the procedure, the average patency time intervention was 160.27 ± 96.472 days (ρ=0.001). The cost analysis revealed an ICER of 10.37€/ patency day gained. The costs estimation revealed improved patency of 14.5 days/patient/year, and an increased cost of 1028.4€/patient/year when compared to conventional balloon. Conclusions: This retrospective analysis may suggest a benefit of DEB on this highly recurrent stenosis. Although it appears to be more expensive, the increased patency at long term may be considered encouraging.

Resumo A atual pandemia de COVID-19 (doença clínica causada pelo SARS-CoV-2) teve disseminação mundial incluindo, desde 2 de março, Portugal. Por decisão de Conselho Executivo da José de Mello Saúde, interpretando o dever e a necessidade de cooperação com o Sistema Nacional de Saúde (SNS), foi decidido receber os seus beneficiários que procurassem os hospitais da rede, centrando toda a atividade COVID-19 da região Sul no Hospital CUF Infante Santo (HCIS). Apresentamos nesta narrativa todo o trabalho de preparação da infraestrutura, organização logística e resultados assistenciais da Unidade de Cuidados Intensivos Polivalente (UCIP) do HCIS desde o início a 23 de março até 30 de abril de 2020, numa homenagem a todos os que sem hesitações aderiram a esta aventura com o mesmo entusiasmo e espírito de serviço que sempre lhes conhecemos.

Abstract The current COVID-19 pandemic (clinical disease caused by SARS-CoV-2) has spread worldwide including, since March 2nd, Portugal. By decision of the Executive Council of José de Mello Saúde, interpreting the duty and need for cooperation with the National Health System (SNS), it was decided to receive all patients presenting to our hospitals’ network. All COVID-19 activity in the Center and South regions was referred to Hospital CUF Infante Santo (HCIS). We present in this narrative paper all our preparedness activity, preparing the infrastructure, logistical organization, patient management results of the HCIS General Intensive Care Unit (UCIP) from the beginning on March 23 to April 30, 2020, as a tribute to all those who without hesitation joined us on this adventure with their usual passion and resolve.

Background: Anemia is a common complication of Chronic Kidney Disease (CKD), in which iron deficiency's (ID) role is frequently underrated. In CKD, anemia has been associated with higher morbidity and lower quality of life. Nonetheless, reported treatment rates of anemia in CKD are low and guidelines' variability and/or absence for its management and treatment may be preventing patients from receiving optimal treatment. Within this context, we aimed to assess the agreement level on anemia and iron deficiency diagnosis, management, and treatment in CKD patients, by Portuguese physicians in Nephrology, through a Delphi Panel. Methods: A group of seven medical experts in Nephrology and Transfusion Medicine was assembled, and a focus group was conducted, in which 28 statements were agreed upon. Then, a two-round Delphi Panel using a Likert scale was conducted online, inviting Portuguese Society of Nephrology associates to participate. Results: Answers were collected from 76 participants in Round 1 and consensus level was obtained for 1 statement, 57 (75%) respondents fully disagreeing on transfusing all patients with hemoglobin below 9 g/dl, regardless of the clinical situation. The remaining 27 statements were used in Round 2, none obtaining consensus level and 14 statements being categorized as qualified majority: 4 on diagnosis, 3 on disease management, and 7 on treatment. Discussion: Our study showed a lack of consensus on diagnosis, management, and treatment of anemia in CKD patients among the nephrology community in Portugal. Overall, our results illustrated the heterogeneity of national clinical practices in: laboratory parameters' choice; cutoff values defining anemia and/or ID; parameter-based therapeutic decisions. Nonetheless, it was shown clear that patient's individual characteristics, clinical settings, and the physician's "clinical sense" seem to be considered to a further extent than the available guidelines. Future studies should be considered to develop recommendations that can be widely accepted.

Chronic kidney disease (CKD) is a burdensome disease that has been successfully managed with dialysis. But even if dialysis can prolong patients' survival in certain circumstances, it also brings a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Fragile patients may not benefit from starting dialysis. In this way, Palliative Care (PC) should be integrated into CKD care to control symptoms' burden, to discuss the shared decision to start or forgo dialysis when stage 5 CKD approaches, or to select conservative management of end-stage renal disease (ESRD) or withdrawal dialysis. As patients attended in private hemodialysis units get older and more fragile, incorporation of PC is associated with the highest quality care standards provided to our ESRD patients. That being so, we designed a project based on the World Health Organization (WHO) recommendations to implement palliative interventions in NephroCare Hemodialysis Units. In our project, we consider the following five steps: (i) assessment of palliative needs in dialysis patients; (ii) team education; (iii) contact and referral to specialized teams; (iv) registration (v) and trial of the pilot project. We also reflect on the barriers to implementation of this project. This article aims to raise awareness of the project and use it as a model or a first step to other projects in the actual area to be implemented in other health units.

Resumo Introdução: A hiperfosfatemia é uma grave consequência da doença renal crônica associada a risco aumentado de doença cardiovascular. O controle dos níveis séricos de fósforo dos pacientes em diálise é um desafio que requer, na maioria dos casos, o uso de quelantes de fosfato (QF). Parte da dificuldade se deve à baixa adesão ao tratamento oriunda do grande número de medicamentos receitados para esse grupo de pacientes. Objetivo: Avaliar a real eficácia do oxihidróxido sucroférrico (OHS) no controle dos níveis séricos de fósforo e determinar a carga de comprimidos associada. Métodos: Estudo multicêntrico, quantitativo, retrospectivo, antes e depois conduzido com pacientes em hemodiafiltração on-line. Pacientes remanejados para OHS como parte dos cuidados de rotina foram incluídos no estudo. Tratamento com QF, número de comprimidos, níveis séricos de fósforo, reposição férrica endovenosa e dosagens foram registrados mensalmente durante seis meses de tratamento com QF ou OHS. Resultados: Foram incluídos 42 pacientes no estudo. Após a mudança de QF para OHS, o número de comprimidos prescritos por dia caiu em 67%, de seis para duas unidades diárias (p < 0,001). A frequência de ingestão de comprimidos caiu de três para duas vezes ao dia (p < 0,001). Durante o tratamento com OHS, o percentual de pacientes com fósforo sérico ≤ 5,5 mg/dL aumentou de 33,3% no início para 45% após seis meses de tratamento. Conclusão: Durante os seis meses de seguimento com OHS, os níveis séricos de fósforo foram controlados com um terço dos comprimidos por dia em relação aos tratamentos com outros QF.

Abstract Introduction: Hyperphosphatemia is a serious consequence of chronic kidney disease and has been associated with an increased risk for cardiovascular disease. Controlling serum phosphorus levels in patients on dialysis is a challenge for the clinicians and implies, in most cases, the use of phosphate binders (PB). Part of the reason for this challenge is poor adherence to treatment because of the high pill burden in this patient group. Objective: To assess the real-world effectiveness of sucroferric oxyhydroxide (SO) in controlling serum phosphorus levels and determine the associated pill burden. Methods: A multicenter, quantitative, retrospective, before-after study was conducted with patients receiving online hemodiafiltration. Patients who switched to SO as a part of routine care were included in the study. PB treatment, number of pills, serum phosphorus levels, and intravenous iron medication and dosage were collected monthly during the six months of treatment with either PB or SO. Results: A total of 42 patients were included in the study. After switching from a PB to SO, the prescribed pills/day was reduced 67% from 6 pills/day to 2 pills/day (p < 0.001) and the frequency of pill intake was lowered from 3 times/day to 2 times/day (p < 0.001). During the treatment with SO, the proportion of patients with serum phosphorus ≤ 5.5 mg/dL increased from 33.3% at baseline to 45% after six months of treatment. Conclusion: During the six-month follow-up with SO, serum phosphorus levels were controlled with one third of the pills/day compared to other PB.

Vascular access is a crucial factor in the treatment of hemodialysis patients. Dialysis catheters are associated with higher mortality than fistulas, meaning they should be the last choice for most patients. Although they have many drawbacks, catheters play an important role in providing a reliable vascular access in some patients. Dialysis catheter dysfunction is a major cause of morbidity. Early dysfunction usually occurs as a result of mechanical issues while late dysfunction is most commonly due to thrombosis. The causes of dysfunction and their management are distinct, and understanding of them is essential to preserve catheter patency and improve dialysis patient outcomes

Fundamento Em algumas series, mais de 35% de todos os doentes tratados por hemodiálise, que estiveram internados num hospital, são readmitidos nos 30 dias após a alta, com elevadíssima morbilidade, mortalidade e custos económicos. Pensa-se que este problema preocupante possa estar associado a deficiências no manejo do estado de hidratação, no tratamento da anemia, ou até do metabolismo mineral, que não corrigidos precocemente após retorno à sua unidade de diálise de ambulatório. Tentámos quantificar este fenómeno e clarificar as suas causas e oportunidades de prevenção. Doentes e Métodos Estudo retrospectivo, baseado em registo, incluindo todos os doentes tratados na rede de clínicas NephroCare Portugal que foram submetidos a um internamento hospitalar (internamento 1) durante 2013 e 2014. Identificámos dois grupos: o grupo A - que agrupa os doentes que sofreram um reinternamento no período de 30 dias após a alta (internamento 2) do primeiro internamento, grupo B - os doentes que não foram reinternados nesse período. Analisámos os motivos de internamento: estado de hidratação, valores da hemoglobina, prescrições de peso seco e ESA, bem como o controlo da pressão arterial pré e pós o internamento hospitalar inicial. Resultados Foram incluidos 4546 doentes, que registaram uma taxa de hospitalização de 0.63 episódios / doente.ano. A incidência de reinternamento aos 30 dias foi de 34.9% (22.9% em 2013 e 44.7% em 2014). Quer no grupo A como no grupo B, com 634 e 1179 internamentos respectivamente, notou-se uma diferença significativa entre o peso normohidratado determinado por bioimpedância antes e após esse internamento, bem como no peso seco prescrito antes e após a hospitalização. Todos os doentes no grupo A e 46.9% dos do grupo B apresentavam hiperhidratação severa (> 15% do volume extra-celular considerado normal) após a alta do internamento index. Após a alta desse internamento, a prescrição do peso seco foi diminuida nos 30 dias que se lhe seguiram em 72% dos doentes do grupo A e em 39.1% dos doentes do grupo B, deixando 28.1% dos doentes do grupo A e 7.8% do grupo B sem a correcção atempada e apropriada do peso seco. As diferenças entre os 2 grupos no tratamento da anemia e control da pressão arterial não foram clinicamente relevantes. Conclusões A readmissão hospitalar nos 30 dias após a alta é extremamente elevada entre nós. Na nossa experiência, uma melhoria mais enérgica e tempestiva do manejo do estado de hidratação parece constituir a melhor oportunidade de prevenção

Rationale More than 35% of all haemodialysis (HD) patients admitted to a hospital are readmitted in the next 30 days after discharge, with high morbidity, mortality and costs. It is suspected that serious flaws in fluid and anaemia management during the hospitalization, which are not detected and corrected upon reentry in the outpatient programme, can be a cause. We tried to quantify this phenomenon and clarify its causes and opportunities for prevention. Patients and Methods Retrospective registry study including all patients of NephroCare Portugal network that were submitted to a hospital admission (admission 1) during 2013 and 2014. Two groups were identified: Group A - Patients that had a new admission (admission 2) in the 30 days after discharge of the index admission (admission 1), Group B - Patients that were not readmitted. Causes for hospital admission: hydration status, haemoglobin values, ESA and dry weight prescriptions, and blood pressure control were analysed pre-and post-hospital admission 1. Results A total of 4546 patients were included for analysis registering a hospitalization rate of 0.63 episodes/patient-year. The overall 30 days hospital readmission rate was 34.9% (22.9% in 2013 and 44.7% in 2014). In Group A, with 634 first admissions, there was a significant difference between the normohydrated weight as determined by BCM before and after the first admission: Average weight 65.6 (�± 14.7) vs. 63.7 (�± 13.9)kg, p < 0.0001 (CI 2.2 - 1.5), as well as a difference between the prescribed dry weight pre- and post-admission: 65.9 (�± 14.0) vs. 64.6 (�p < 0.0001 (CI 1.6 - 1.2). In group B there was a significant difference between the normohydrated weight as determined by BCM before and after the index admission: Average weight 65.6 (�± 14.6) vs. 64.3 (�± 14.3)kg, p < 0.0001 (95% CI 1.1 - 1.6), as well as a difference between the prescribed dry weight pre-and post-admission: 65.6 (�± 14.1) vs. 64.7 (�p < 0.0001 (95% CI 0.8 - 1.1). All patients in Group A and 46.9% of those in Group B were severely overhydrated (> 15%) after discharge from the index admission, Dry weight was decreased in that month in 72% of Group A patients and in 39.1% of Group B, leaving 28.1% of patients in group A without a proper prescription and only 7.8% in Group B. Differences between the two groups for anaemia treatment and B.P. measurements were not clinically relevant. Conclusions The 30 day-Hospital readmission rate is extremely elevated. In the present series, the best opportunity for prevention of these readmission events seems to be a better fluid management immediately after discharge

Introdução e Objectivos: A angioplastia percutânea transluminal tem sido a modalidade central no tratamento do acesso vascular (AV) disfuncionante. A modalidade de imagem gold standard utilizada é a angiografia digital de subtracção. Alguns centros publicaram recentemente a sua experiência com a angioplastia guiada por eco-doppler. Material e Métodos: Os autores reportam a sua primeira experiência com a modalidade ecográfica. Um doente do sexo masculino, diabético, em programa de hemodiálise através de uma fistula braquiocefálica desde há 4 anos, foi referenciado à consulta por aumento de aneurisma, hemostase prolongada, aumento da recirculação e redução do débito do acesso (Qa) > 25% ao seu valor de base (1300 ml/min). De salientar antecedente de síndrome de roubo ligeiro, após a construção de fistula, que melhorou com o tempo. O eco-doppler foi utilizado com sucesso para avaliação inicial do acesso, caracterização das estenoses e orientação do procedimento endovascular. Resultados: Foram identificadas 3 estenoses hemodinamicamente significativas; Qa 650 ml/min; índice resistência 0.62. A selecção de um balão de 8 mm de diâmetro permitiu uma dilatação adequada das estenoses. O Qa foi avaliado em tempo real, após cada uma das dilatações, para prevenir a sobrecorrecçao. A primeira angioplastia foi realizada na estenose da crossa cefálica, o que aumentou o Qa para 802 ml/min. A dilatação da estenose do terço médio originou um Qa de 930 ml/min. Finalmente, a dilatação da estenose pós-aneurisma resultou num último Qa de 1195 ml/min, com melhoria clínica, e sem recorrência do S. roubo ou qualquer complicação associada ao procedimento. Monitorizaçao após o primeiro trimestre revelou uma fistula funcionante com débitos estáveis. Conclusão: O eco -doppler tem um papel fundamental na monitorizaçao do AV, porque é o único exame cuja decisão se baseia numa avaliação morfológica e hemodinâmica. Mais do que diagnóstica, a ecografia pode ser uma ferramenta útil e segura no tratamento das estenoses periféricas. As suas principais vantagens incluem a ausência de radiação e contraste; menores custos; e possibilidade futura de realizar procedimentos na sala de diálise. Além do mais, doentes com elevado risco de S. roubo e insuficiência cardíaca poderão beneficiar de um procedimento “controlado” através de uma avaliação em tempo real, não apenas baseada em critérios anatómicos, mas sobretudo hemodinâmicos.

Introduction and Objectives: Percutaneous transluminal angioplasty has been the central therapeutic modality used to treat dialysis vascular access (VA) dysfunction. The gold standard imaging modality is digital subtraction angiography. Some centers recently reported their technical success with ultrasound-guided angioplasty. Material and Methods: The authors report their first case experience with this modality. A 73 -year -old, diabetic male, on hemodialysis through a brachiocephalic fistula for 4 years, was referred to consultation due to increase of aneurisms, prolongation of haemostasis, recirculation increase and access blood flow (ABF) decrease > 25% from the baseline (1300 ml/min). Regarding the patient’s history, there was a mild degree of steal syndrome after the fistula surgery, which improved over time. Doppler ultrasound was successfully used to evaluate VA, characterize stenosis, and guide endovascular procedure. Results: Three haemodynamic significant stenosis were diagnosed; BF 650 ml/min; resistance index 0.62. The guidance of an eight mm diameter angioplasty balloon allowed a successful dilation of the stenoses. The first angioplasty was performed in the cephalic arch stenosis, which increased the ABF to 802 ml/min. Then, the middle stenosis was dilated with a post -procedure ABF of 930 ml/min. Finally, the post -aneurism stenosis was also dilated with a final result of 1195 ml/min, and clinical improvement without any sign of steal syndrome recurrence or procedure-related complications. Monitoring and surveillance after first trimester show a well-functioning fistula with stable flow rates. Conclusion: Doppler ultrasound has a key role in the VA surveillance, because it is the only exam that bases decisions on a morphologic and haemodynamic assessment. More than a diagnostic exam, ultrasound guidance may provide a valid and safe tool in the treatment of peripheral VA stenosis. Main advantages of this modality include lack of radiation and contrast; lower costs; and possible future procedures in the dialysis chair. Furthermore, patients with high risk of steal syndrome or heart failure would benefit from a “controlled” procedure with real time evaluation, not only based on their anatomy, but mainly on haemodynamic features.

Introdução: A obtenção de um estado de normo-hidratação é um dos alvos mais relevantes na prescrição de diálise. Comparamos neste estudo a performance de um equipamento de espectroscopia de bioimpedância (BCM - body composition module) versus a avaliação clínica convencional para a determinação e prescrição do Peso Seco em doentes em hemodiálise. Material e Métodos: 189 doentes tratados por HDF online participaram neste estudo prospectivo, aleatório, multicêntrico. As unidades de diálise participantes foram aleatoriamente divididas em um grupo de acesso aberto aos resultados do BCM e um grupo cego para estes resultados. Foram determinados mensalmente, ao longo de 1 ano, em todos os doentes, o estado de hidratação, pressão arterial, ganho de peso inter-dialítico, a morbilidade e a mortalidade. Resultados: No inicio do estudo, 92 doentes no grupo aberto aos resultados do BCM e 79 doentes do grupo cego estavam hiperhidratados em média 3.8L acima do seu peso ideal. Após 1 ano, a percentagem de doentes com hidratação > 2.5L pré-diálise reduziu-se a 52.5% no grupo aberto e a 65.9% no grupo fechado. A morbilidade (hospitalizações) e mortalidade não variou significativamente entre os 2 grupos. Conclusão: O BCM revelou ser uma ferramenta útil como suporte à prescrição e obtenção do peso ideal em doentes em hemodiálise.

Introduction: Normohydration is an important target in dialysis patients. In this study, we compared the performance of a bioimpedance spectroscopy device versus conventional clinical judgment in assessing the hydration status of HD patients and determining their ideal weight. Materials and Methods: 189 HD patients on online haemodiafiltration participated in this prospective, controlled, multicentre study. Dialysis units were randomly divided into an open-access and a blinded BCM group. Hydration status, blood pressure, weight gain, morbidity and mortality were assessed. Results: At baseline, 92 patients of the BCM-open group and 79 patients of the BCM-blinded group were overhydrated by ~3.8L. After one year, the rate of patients with OH > 2.5L was reduced to 52.5% in the open, and to 65.9% in the blinded group. Hospitalization and survival rate was not significantly different between the two groups. Conclusion: Results suggest that BCM is a helpful tool in supporting the fluid management of HD patients.

Contexto: O controlo do hiperparatiroidismo nos doentes em diálise, passa pela adequação dos níveis do Fósforo e da PTH. A aderência dos doentes à terapêutica oral no domicílio é reconhecidamente deficiente e impossível de monitorizar. Estando estabelecida a evidência que terapêutica em “pulsus” orais (em dias alternados) com metabolitos activos da vitamina D é tão eficaz como a terapêutica diária, quisemos testar se o mesmo se aplicava à terapêutica com Cinacalcet. Objectivo: Avaliar o efeito no metabolism ósseo da mudança da terapia com Cinacalcet, de um regime diário no domicílio (H), para a administração supervisionada na clínica (C) 3 vezes por semana, no final de cada diálise. Doentes e Métodos: 93 doentes prevalentes em tratamento de hemodiálise em 6 clínicas foram incluídos neste estudo observacional, retrospectivo, cada doente servindo como seu próprio controlo histórico. Os critérios de inclusão exigiam valores de PTH > 500ng/L e tratamento com Cinacalcet há mais de 9 meses. A informação foi colhida de uma base de dados comum a todas as clínicas envolvidas - EuCliD©. As amostras de sangue foram colhidas no início de cada tratamento e analisadas em laboratório central. Os valores de cálcio, fósforo, albumina e PTH foram registados trimestralmente, bem como as doses de terapêutica com metabolitos da vitamina D e Cinacalcet, nos últimos 9 meses do período H e primeiros 9 meses do período C. Os valores durante a prescrição H foram comparados com os valores obtidos após a mudança para a prescrição C através de test-t emparelhado. Resultados: Verificámos existir uma acentuada redução na dose de Cinacalcet de um valor médio de 1221mg/ mês no período H para um valor médio de 674.4mg/mês no período C, p<0.0001 (95% CI 689.4 / 405.1), mantendo doses idênticas de vitamina D (Paricalcitol) de 21.3 mic/mês vs 31.9mic/mês, p=.167. Esta redução de dose teve uma tradução esperada de redução de custos de um custo médio de Cinacalcet de 256€/mês/doente para 137.6€/mês /doente, p< 0.0001. O valor de PTH foi mais elevado no grupo C 903.5 vs 807.9ng/L, p < 0.028, os níveis de fósforo foram idênticos, 5.0 no período H e 4.8mg/dl no período C, p=0.065. Conclusão: A administração supervisionada de Cinacalcet 3 vezes por semana, mostrou ser segura, garantir a aderência terapêutica e economizar consideravelmente para a mesma eficácia terapêutica.

Background: The treatment of hyperparathyroidism in dialysis patients relies on adequate control of serum phosphorus (Pi) and PTH levels. Patient (pt) compliance to oral therapy at home is known to be quite poor and cannot be monitored. There is evidence that pulse (every other day) therapy with vitamin D compounds is as effective as daily administration. We hypothesized that the same might apply to calcimimetics. Objective: To assess the effect on metabolic endpoints of changing cinacalcet oral treatment from a daily, home-based administration (H), to a three-times/week witnessed administration at the end of each dialysis session in the clinic (C). Patient and methods: 93 prevalent dialysis pts in 6 clinics were included in an observational retrospective study, each patient serving as his own historical control. Inclusion criteria were: ESRD treated by haemodialysis; PTH levels > 500 ng/L and cinacalcet prescription for more than 9 months. Data was drawn from a database common to all participating clinics - EuCliDc. Blood samples were collected at the beginning of dialysis and treated at a central laboratory. Calcium (Ca), phosphorus, albumin and PTH were registered every 3 months, as well as vitamin D and cinacalcet dosages, in the last 9 months of period H and first 9 months of period C. Values during H prescription were compared with values after change to C administration through paired samples t-test. Results: We detected a significant reduction in the dose of Cinacalcet from an average dose of 1221mg/month in period H to an average dose of 674.4mg/month in period C, p < 0.0001 (95% CI 689.4 / 405.1), keeping identical dosages of Vitamin D metabolite 21.3 mic/month vs. 31.9mic/month, p=.167. This dose reduction was translated, as expected, in cost savings, going from an average Cinacalcet cost of 256€/month/pt to 137.6€/month/patient, p < 0.0001. PTH was more elevated in the C group 903.5 vs. 807.9ng/L, < 0.028, phosphate levels were identical, 5.0 in period H and 4.8mg/dl in period C, p = 0.065. Conclusion: Administration of Cinacalcet under supervision 3 times per week, post -dialysis, was shown to be safe, guarantees compliance and saved considerable resources for the same therapeutic efficacy.

Background: Poor nutritional status and worse health-related quality of life (QoL) have been reported in haemodialysis (HD) patients. The utilization of generic and disease specific QoL questionnaires in the same population may provide a better understanding of the significance of nutrition in QoL dimensions. Objective: To assess nutritional status by easy to use parameters and to evaluate the potential relationship with QoL measured by generic and disease specific questionnaires. Methods: Nutritional status was assessed by subjective global assessment adapted to renal patients (SGA), body mass index (BMI), nutritional intake and appetite. QoL was assessed by the generic EuroQoL and disease specific Kidney Disease Quality of Life-Short Form (KDQoL-SF) questionnaires. Results: The study comprised 130 patients of both genders, mean age 62.7 ± 14.7 years. The prevalence of undernutrition ranged from 3.1% by BMI < 18.5 kg/m² to 75.4% for patients below energy and protein intake recommendations. With the exception of BMI classification, undernourished patients had worse scores in nearly all QoL dimensions (EuroQoL and KDQoL-SF), a pattern which was dominantly maintained when adjusted for demographics and disease-related variables. Overweight/obese patients (BMI > 25) also had worse scores in some QoL dimensions, but after adjustment the pattern was maintained only in the symptoms and problems dimension of KDQoL-SF (p = 0.011). Conclusion: Our study reveals that even in mildly undernourished HD patients, nutritional status has a significant impact in several QoL dimensions. The questionnaires used provided different, almost complementary perspectives, yet for daily practice EuroQoL is simpler. Assuring a good nutritional status, may positively influence QoL.

Antecedentes: En pacientes en hemodiálisis (HD) se han comunicado un estado nutricional deficiente y una peor calidad de vida (CdV) relacionada con la salud. El uso de cuestionarios de CdV genéricos y específicos de la enfermedad en la misma población puede proporcionar un mejor conocimiento del significado de la nutrición en las dimensiones de CdV. Objetivo: Evaluar el estado nutricional mediante parámetros fáciles de usar y evaluar la relación potencial con la CdV medida mediante cuestionarios genéricos y específicos de la enfermedad. Métodos: Se evaluó el estado nutricional mediante evaluación global subjetiva (EGS) adaptada a pacientes renales, índice de masa corporal (IMC), la ingesta nutricional y el apetito. La CdV se evaluó mediante el cuestionario genérico EuroQoL y el específico de la enfermedad Kidney Disease Quality of Life-Short Form (KDQoL-SF). Resultados: El estudio comprendía 130 pacientes de ambos sexos, edad media 62,7 ± 14,7 años. La prevalencia de la malnutrición varió desde 3,1% por un IMC < 18,5 kg/m² hasta el 75,4% de los pacientes por debajo de las recomendaciones de ingesta de energía y proteínas. Con la excepción de la clasificación por el IMC, los pacientes malnutridos tenían peores puntuaciones en casi todos los dominios de la CdV (EuroQoL y KDQoL-SF), un patrón que se mantenía de forma dominante cuando se ajustaba para las variables demográficas y relacionadas con la enfermedad. Los pacientes con sobrepeso/obesidad (IMC > 25) también mostraron peores puntuaciones en algunas dimensiones de la CdV, pero tras el ajuste el patrón sólo se mantenía en el dominio de síntomas y problemas de KDQoL-SF (p = 0,011). Conclusión: Nuestro estudio reveló que incluso en pacientes en HD malnutridos, el estado nutricional tienen un impacto significativo en diversos dominios de la CdV. Los cuestionarios empleados proporcionaron perspectivas distintas, casi complementarias, si bien para la práctica diaria el EuroQoL es más sencillo. El asegurar un buen estado nutricional podría influir positivamente en la CdV.

This paper focuses on gender from the perspective of the study of international relations, specifically on the discourse of the United Nations. The author argues that gender relations are defined in the discourse of international organizations, and that this definition has a positive association with changes in identity within different historical contexts. The article provides a review of gender identity, emphasizing change and stability as well as an examination of the importance of the emergence of gender in the study of international relations. Finally, using a critical standpoint, the author presents the identity put forth by the discourse of the UN.

El artículo aborda la problemática de género desde el campo de las relaciones internacionales. Se argumenta que las relaciones de género son definidas en el discurso de las organizaciones internacionales, y a su vez esta definición responde a los cambios en la identidad femenina en diferentes contextos históricos. Se hace una revisión de la identidad femenina, poniendo énfasis en los cambios y continuidades. Se distingue la importancia de la emergencia de la cuestión de género, tanto en nuestra época, como en el estudio de las relaciones internacionales. Finalmente, se analiza la identidad que propone la ONU, haciendo una revisión crítica de la misma, confrontándola con otros discursos antagónicos.