ROSILENE MOTTA ELIAS
Projetos de Pesquisa
Unidades Organizacionais
Instituto Central, Hospital das Clínicas, Faculdade de Medicina
LIM/16 - Laboratório de Fisiopatologia Renal, Hospital das Clínicas, Faculdade de Medicina
LIM/16 - Laboratório de Fisiopatologia Renal, Hospital das Clínicas, Faculdade de Medicina
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- A critical appraisal of chronic kidney disease mineral and bone disorders clinical practice guidelines using the AGREE II instrument(2017) SEKERCIOGLU, Nigar; AL-KHALIFAH, Reem; EWUSIE, Joycelyne Efua; ELIAS, Rosilene M.; THABANE, Lehana; BUSSE, Jason W.; AKHTAR-DANESH, Noori; IORIO, Alfonso; ISAYAMA, Tetsuya; MARTINEZ, Juan Pablo Diaz; FLOREZ, Ivan D.; GUYATT, Gordon H.Patients with chronic kidney disease mineral and bone disorders (CKD-MBD) suffer high rates of morbidity and mortality, in particular related to bone and cardiovascular outcomes. The management of CKD-MBD remains challenging. The objective of this systematic survey is to critically appraise clinical practice guidelines (CPGs) addressing CKD-MBD. Data sources included MEDLINE, EMBASE, the National Guideline Clearinghouse, Guideline International Network and Turning Research into Practice up to May 2016. Teams of two reviewers, independently and in duplicate, screened titles and abstracts and potentially eligible full text reports to determine eligibility and subsequently appraised the guidelines using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE). Sixteen CPGs published from 2003 to 2015 addressing the diagnosis and management of CKD-MBD in adult patients (11 English, two Spanish, one Italian, one Portuguese and one Slovak) proved eligible. The National Institute for Health and Care Excellence guideline performed best with respect to AGREE II criteria; only three other CPGs warranted high scores on all domains. All other guidelines received scores of under 60% on one or more domains. Major discrepancies in recommendations were not, however, present, and we found no association between quality of CPGs which was not associated with resulting recommendations. Most guidelines assessing CKD-MBD suffer from serious shortcomings using AGREE criteria although limitations with respect to AGREE criteria do not necessarily lead to inappropriate recommendations.
- Impact of Compression Stockings vs. Continuous Positive Airway Pressure on Overnight Fluid Shift and Obstructive Sleep Apnea among Patients on Hemodialysis(2017) SILVA, Bruno C.; SANTOS, Roberto S. S.; DRAGER, Luciano F.; COELHO, Fernando M.; ELIAS, Rosilene M.Introduction: Obstructive sleep apnea (OSA) is common in edematous states, notably in hemodialysis patients. In this population, overnight fluid shift can play an important role on the pathogenesis of OSA. The effect of compression stockings (CS) and continuous positive airway pressure (CPAP) on fluid shift is barely known. We compared the effects of CS and CPAP on fluid dynamics in a sample of patients with OSA in hemodialysis, through a randomized crossover study. Methods: Each participant performed polysomnography (PSG) at baseline, during CPAP titration, and after 1 week of wearing CS. Neck circumference (NC) and segmental bioelectrical impedance were done before and after PSG. Results: Fourteen patients were studied (53 9 years; 57% men; body mass index 29.7 6.8 kg/m(2)). Apnea hypopnea index (AHI) decreased from 20.8 (14.2; 39.6) at baseline to 7.9 (2.8; 25.4) during CPAP titration and to 16.7 (3.5; 28.9) events/h after wearing CS (CPAP vs. baseline, p = 0.004; CS vs. baseline, p = 0.017; and CPAP vs. CS, p = 0.017). Nocturnal intracellular trunk water was higher after wearing CS in comparison to baseline and CPAP (p = 0.03). CS reduced the fluid accumulated in lower limbs during the day, although not significantly. Overnight fluid shift at baseline, CPAP, and CS was -183 +/- 72, 343 +/- 220, and 290 +/- 213 ml, respectively (p = 0.006). Overnight NC increased at baseline (0.7 +/- 0.4 cm), decreased after CPAP (-1.0 +/- 0.4 cm), and while wearing CS (-0.4 +/- 0.8 cm) (CPAP vs. baseline, p < 0.0001; CS vs. baseline, p = 0.001; CPAP vs. CS, p = 0.01). Conclusion: CS reduced AHI by avoiding fluid retention in the legs, favoring accumulation of water in the intracellular component of the trunk, thus avoiding fluid shift to reach the neck. CPAP improved OSA by exerting local pressure on upper airway, with no impact on fluid redistribution. CPAP performed significantly better than CS for both reduction of AHI and overnight reduction of NC. Complementary studies are needed to elucidate the mechanisms by which CPAP and CS reduce NC.
- Elderly patients with chronic kidney disease have higher risk of hyperparathyroidism(2017) ELIAS, Rosilene M.; MOYSES, Rosa M. A.As the world's population ages, the incidence of chronic kidney disease (CKD) is growing. There is ongoing debate regarding whether high levels of parathyroid hormone (PTH) would be more common in elderly than young patients, and which factors are driven the risk of secondary hyperparathyroidism (SHPT), independent of renal function. Elderly patients (age ae 65 years, N = 518) were compared to a 1:1 sex- and estimated glomerular filtration rate (eGFR)-matched sample of young patients (age < 65 years), in a cross-sectional analysis. Demographic, biochemical and drug prescription data were collected from electronic charts. The main outcome measure was the prevalence of SHPT, defined as PTH > 65 pg/mL. Elderly patients presented higher serum calcium and PTH levels and lower serum phosphate, and were taking more diuretics than young patients. SHPT was more frequent among elderly patients (49.4 vs. 38.6%, p = 0.005), and it was associated with lower eGFR, low levels of 25(OH) vitamin D and with furosemide therapy, while thiazide use was a protector factor. Elderly patients with 25(OH) vitamin D > 40 ng/mL were protected against SHPT. The Ca/PTH ratio was lower in elderly than in young patients [0.15 (0.10, 0.20) vs. 0.16 (0.11, 0.23), respectively, p = 0.003]. CKD elderly patients have higher risk of SHPT than young, which cannot be explained solely by renal function. Besides low levels of vitamin D, furosemide therapy and a distinct relationship between calcium and PTH are possible factors contributing to SHPT. Whether this is a result of renal resistance to PTH or an altered set point to calcium deserves further investigation.
- The complexity of chronic kidney disease-mineral and bone disorder across stages of chronic kidney disease(2017) GRACIOLLI, Fabiana G.; NEVES, Katia R.; BARRETO, Fellype; BARRETO, Daniela V.; REIS, Luciene M. dos; CANZIANI, Maria E.; SABBAGH, Yves; CARVALHO, Aluizio B.; JORGETTI, Vanda; ELIAS, Rosilene M.; SCHIAVI, Susan; MOYSES, Rosa M. A.Chronic Kidney Disease (CKD)-Mineral and Bone Disorder (CKD-MBD) is a complex disease that is not completely understood. However, some factors secreted by the osteocytes might play an important role in its pathophysiology. Therefore, we evaluated the bone expression of proteins in a group of patients with CKD 2-3, CKD 4, and CKD 5 on dialysis and healthy individuals. We also tested several bone remodeling markers, and correlated these levels with bone biopsy findings. As expected, as serum calcium decreased, serum phosphate, alkaline phosphatase, fibroblast growth factor-23 (FGF-23), parathyroid hormone, and osteoprotegerin increased, as CKD progressed. Additionally, there was a gradual increase in bone resorption associated with a decrease in bone formation and impairment in bone mineralization. Bone expression of sclerostin and parathyroid hormone receptor-1 seemed to be increased in earlier stages of CKD, whereas FGF-23 and phosphorylated beta-catenin had increased expression in the late stages of CKD, although all these proteins were elevated relative to healthy individuals. Immunohistochemical studies showed that FGF-23 and sclerostin did not co-localize, suggesting that distinct osteocytes produce these proteins. Moreover, there was a good correlation between serum levels and bone expression of FGF-23. Thus, our studies help define the complex mechanism of bone and mineral metabolism in patients with CKD. Linkage of serum markers to bone expression of specific proteins may facilitate our understanding and management of this disease.
- Pneumatic Compression, But Not Exercise, Can Avoid Intradialytic Hypotension: A Randomized Trial(2017) ALVARES, Valeria R. C.; RAMOS, Camila D.; PEREIRA, Benedito J.; PINTO, Ana Lucia; MOYSES, Rosa M. A.; GUALANO, Bruno; ELIAS, Rosilene M.Background: Conventional hemodialysis (HD) is associated with dialysis-induced hypotension (DIH) and ineffective phosphate removal. As the main source of extracellular fluid removed during HD are the legs, we sought to reduce DIH and increase phosphate removal by using cycling and pneumatic compression, which would potentially provide higher venous return, preserving central blood flow and also offering more phosphate to the dialyzer. Methods: We evaluated 21 patients in a randomized crossover fashion in which each patient underwent 3 different HD: control; cycling exercise during the first 60 min; and pneumatic compression during the first 60 min. Data obtained included bioelectrical impedance, hourly blood pressure measurement, biochemical parameters, and direct quantification of phosphate through the dialysate. DIH was defined as a drop in mean arterial pressure (MAP) >= 20 mm Hg. Results: There was no difference in the ultrafiltration rate (p = 0.628), delta weight (p = 0.415), delta of total, intra and extracellular body water among the control, cycling, and pneumatic compression (p = 0.209, p = 0.348, and p = 0.467 respectively). Delta MAP was less changed by pneumatic compression when compared to control, cycling, and pneumatic compression respectively (-4.7 [-17.2, 8.2], -4.7 [-20.5, -0.2], and -2.3 [-8.1, 9.0] mm Hg; p = 0.021). DIH occurred in 43, 38, and 24% of patients in control, cycling, and pneumatic compression respectively (p = 0.014). Phosphate removal did not increase in any intervention (p = 0.486). Higher phosphate removal was dependent on ultrafiltration, pre dialysis serum phosphate, and higher parathyroid hormone. Conclusion: Pneumatic compression during the first hour of dialysis was associated with less DIH, albeit there was no effect on fluid parameters. Neither exercise nor pneumatic compression increased phosphate removal. (C) 2017 S. Karger AG, Basel
- Effect of Mineral and Bone Metabolism on Restless Legs Syndrome in Hemodialysis Patients(2017) NEVES, Precil D. M. M.; GRACIOLLI, Fabiana G.; OLIVEIRA, Ivone B.; BRIDI, Ramaiane A.; MOYSES, Rosa M. A.; ELIAS, Rosilene M.Study Objectives: Restless legs syndrome (RLS) is a highly prevalent sleep disease among patients on hemodialysis. The physiopathology is still unclear, and may be multifactorial. Because of the association between iron metabolism and chronic kidney disease-mineral and bone disorders (CKD-MBD), we hypothesized that both factors would be associated with RLS. Methods: We have evaluated hemodialysis patients, in a face-to-face interview for the diagnosis and severity of RLS, as measured by the International Restless Legs Syndrome Study Group. Clinical, demographic, and biochemical characteristics were measured. Results: Out of 101 adult patients included, RLS was found in 29 (28.7%). Adjusted multinomial regression analysis revealed that age older than 35 years, transferrin saturation less than 47%, serum ferritin level less than 700 ng/mL, hemoglobin level less than 9.8 g/dL, serum phosphate level higher than 5.2 mg/dL, FGF-23 higher than 2,000 RU/mL, and C-reactive protein less than 1.24 mg/dL were independently associated with RLS. RLS was classified as mild, moderate, severe, and very severe in 3.4%, 41.7%, 44.8%, and 10.1% of patients, respectively. Scores of severity correlated significantly with erythropoietin dose/kg/w (p = 0.046), phosphate (p = 0.003), and inversely with serum albumin (p = 0.003) and calcium (p = 0.008). Phosphate and 25(OH)-vitamin D correlated with transferrin saturation. Patients with severe/very severe symptoms were mostly women, presented with lower serum iron, ionic calcium, and serum albumin levels and higher levels of serum phosphate, and higher percentage of 25(OH)-vitamin D deficiency and levels of FGF-23 higher than 2,000 RU/mL than did those with mild/moderate symptoms. Conclusions: CKD-MBD factors besides iron metabolism are associated with RLS in patients on hemodialysis, providing new insights into the understanding of RLS in this population.
- Biopsy vs. peripheral computed tomography to assess bone disease in CKD patients on dialysis: differences and similarities(2017) MARQUES, I. D. B.; ARAUJO, M. J. C. L. N.; GRACIOLLI, F. G.; REIS, L. M. dos; PEREIRA, R. M.; CUSTODIO, M. R.; JORGETTI, V.; ELIAS, R. M.; DAVID-NETO, E.; MOYSES, R. M. A.Results from bone biopsy and high-resolution peripheral quantitative computed tomography (HR-pQCT) were compared in 31 CKD patients. There was an agreement mainly for cortical compartment that may represent a perspective on the fracture risk assessment. HR-pQCT also provided some clues on the turnover status, which warrants further studies. Chronic kidney disease (CKD) patients are at high risk of bone disease. Although bone biopsy is considered the best method to evaluate bone disease, it is expensive and not always available. Here we have compared, for the first time, data obtained from bone biopsy and HR-pQCT in a sample of CKD patients on dialysis. HR-pQCT and dual-energy X-ray absorptiometry (DXA) were performed in 31 CKD patients (30 on dialysis). Biopsies were analyzed by quantitative histomorphometry, and classified according to TMV. We have found an inverse correlation between radius cortical density measured by HR-pQCT, with serum, as well as histomorphometric bone remodeling markers. Trabecular density and BV/TV measured through HR-pQCT in the distal radius correlated with trabecular and mineralized trabecular bone volume. Trabecular number, separation, and thickness obtained from HR-pQCT and from bone biopsy correlated with each other. Patients with cortical porosity on bone histomorphometry presented lower cortical density at the distal radius. Cortical density at radius was higher while bone alkaline phosphatase was lower in patients with low turnover. Combined, these parameters could identify the turnover status better than individually. There was an agreement between HR-pQCT and bone biopsy parameters, particularly in cortical compartment, which may point to a new perspective on the fracture risk assessment for CKD patients. Besides classical bone resorption markers, HR-pQCT provided some clues on the turnover status by measurements of cortical density at radius, although the significance of this finding warrants further studies.
- Thiazide increases serum calcium in anuric patients: the role of parathyroid hormone(2017) VASCO, Raquel F. V.; REIS, Eduardo T.; MOYSES, Rosa M. A.; ELIAS, Rosilene M.A Summary We evaluated the effect of hydrochlorothiazide in a sample of anuric patients on hemodialysis and found an increase in serum calcium, which occurred only in those with parathyroid hormone > 300 pg/ml. This finding highlights the extra-renal effect of this diuretic and a possible role of parathyroid hormone in the mechanism. Purpose Thiazide diuretics are commonly used in patients with chronic kidney disease to treat hypertension. Their effects on calcium and bone metabolism are not well established, once calciuria may not fully explain levels of calcium and parathyroid hormone (PTH) in this population. A previous study has suggested that thiazides require the presence of PTH as a permissive condition for its renal action. In anuric patients, however, the role of PTH, if any, in the thiazide effect is unknown. Methods To assess thiazide extra renal effect on serum calcium and whether such an effect is reliant on PTH, hydrochlorothiazide (HCTZ) 100 mg was given orally once a day to a sample of 19 anuric patients on hemodialysis for 2 weeks. Laboratories' analyses were obtained in three phases: baseline, after diuretic use, and after a 2-week washout phase. Results We demonstrated that serum calcium (Ca) increased in ten patients (52.6%) after HCTZ use, returning to previous levels after the washout period. Out of the 19 patients, ten presented PTH >= 300 pg/ml, and Ca has increased in eight of them, whereas in the other nine patients with PTH < 300 pg/ml, serumCa has increased only in two individuals (RR risk of increase Ca 3.9; p = 0.012). Conclusions HCTZ was capable of increasing serum Ca in a sample of anuric patients on hemodialysis and seems this effect is highly dependent on PTH levels. Caution is required while interpreting this result, as the small sample size might implicate in a finding caused by chance.
bookPart Doença renal crônica(2017) SILVA, Bruno Caldin da; ELIAS, Rosilene Motta- Predictive Factors of One-Year Mortality in a Cohort of Patients Undergoing Urgent-Start Hemodialysis(2017) MAGALHAES, Luciene P.; REIS, Luciene M. dos; GRACIOLLI, Fabiana G.; PEREIRA, Benedito J.; OLIVEIRA, Rodrigo B. de; SOUZA, Altay A. L. de; MOYSES, Rosa M.; ELIAS, Rosilene M.; JORGETTI, VandaBackground Chronic kidney disease (CKD) affects 10-15% of adult population worldwide. Incident patients on hemodialysis, mainly those on urgent-start dialysis at the emergency room, have a high mortality risk, which may reflect the absence of nephrology care. A lack of data exists regarding the influence of baseline factors on the mortality of these patients. The aim of this study was to evaluate the clinical and laboratory characteristics of this population and identify risk factors that contribute to their mortality. Patients and methods We studied 424 patients who were admitted to our service between 01/2006 and 12/2012 and were followed for 1 year. We analyzed vascular access, risk factors linked to cardiovascular disease (CVD) and mineral and bone disease associated with CKD (CKD-MBD), and clinical events that occurred during the follow-up period. Factors that influenced patient survival were evaluated by Cox regression analysis. Results The patient mean age was 50 18 years, and 58.7% of them were male. Hypertension was the main cause of primary CKD (31.8%). Major risk factors were smoking (19.6%), dyslipidemia (48.8%), and CVD (41%). Upon admission, most patients had no vascular access for hemodialysis (89.4%). Biochemical results showed that most patients were anemic with high C-reactive protein levels, hypocalcemia, hyperphosphatemia, elevated parathyroid hormone and decreased 25-hydroxy vitamin D. At the end of one year, 60 patients died (14.1%). These patients were significantly older, had a lower percentage of arteriovenous fistula in one year, and low levels of 25-hydroxy vitamin D. Conclusions The combined evaluation of clinical and biochemical parameters and risk factors revealed that the mortality in urgent-start dialysis is associated with older age and low levels of vitamin D deficiency. A lack of a permanent hemodialysis access after one year was also a risk factor for mortality in this population.