Background: High serum phosphorus (hPhos) is common in chronic kidney disease (CKD) and increases the risk of metastatic calcification. Guidelines advise patients with hPhos to restrict dietary phoshorus intake to 800-1000mg/day, and compliance with this diet can be challenging. Innovative education may improve compliance. Hypothesis: Intensive dietary education using the Phosphorus Point System Tool© (PPS) will result in lower serum phosphorus levels compared to standard education (SE). Methods: This study compared the effectiveness of the PPS to SE on 1) serum phosphorus, 2) dietary phosphate intake, knowledge and satisfaction in pre-dialysis CKD. Results: The PPS reduced 12 week serum phosphorus by 0.16 mmol/L (95% CI 0.37 to -0.05, p=0.130) when controlling for baseline. Dietary phosphorus and protein intake decreased significantly at week 6 on PPS compared to SE (p= 0.026, p=0.050; respectively). Summary: Although there was a trend indicating the tool may reduce serum phosphorus levels, further research is needed.

Background: High serum phosphorus (hPhos) is common in chronic kidney disease (CKD) and increases the risk of metastatic calcification. Guidelines advise patients with hPhos to restrict dietary phoshorus intake to 800-1000mg/day, and compliance with this diet can be challenging. Innovative education may improve compliance. Hypothesis: Intensive dietary education using the Phosphorus Point System Tool© (PPS) will result in lower serum phosphorus levels compared to standard education (SE). Methods: This study compared the effectiveness of the PPS to SE on 1) serum phosphorus, 2) dietary phosphate intake, knowledge and satisfaction in pre-dialysis CKD. Results: The PPS reduced 12 week serum phosphorus by 0.16 mmol/L (95% CI 0.37 to -0.05, p=0.130) when controlling for baseline. Dietary phosphorus and protein intake decreased significantly at week 6 on PPS compared to SE (p= 0.026, p=0.050; respectively). Summary: Although there was a trend indicating the tool may reduce serum phosphorus levels, further research is needed.

INTRODUCTION Chronic kidney disease (CKD) affects 50 million people globally. Several studies show the importance of implementing interventions that enhance patients’ knowledge about their disease. In 2011 the Kidney Disease Knowledge Survey (KiKS) was developed: a questionnaire that assesses the specific knowledge about chronic kidney disease in pre-dialysis patients. OBJECTIVE To translate to Spanish, culturally adapt and validate the Kidney Disease Knowledge Survey questionnaire in a population of patients with pre-dialysis chronic kidney disease. METHODS We carried out a Spanish translation and cross-cultural adaptation of the Kidney Disease Knowledge Survey questionnaire. Subsequently, we determined its validity and reliability. We determined the validity through construct validity; and reliability by evaluating its internal consistency and its intra- observer reliability (test-retest). RESULTS We found a good internal consistency (Kuder-Richardson = 0.85). The intra-observer reliability was measured by the intra-class correlation coefficient that yielded a value of 0.78 (95% CI: 0.5-1.0). This value indicated a good reproducibility; also, the mean difference of -1.1 test-retest SD 6.0 (p = 0.369) confirms this finding. CONCLUSION The translated Spanish version of the Kidney Disease Knowledge Survey is acceptable and equivalent to the original version; it also has a good reliability, validity and reproducibility. Therefore, it can be used in a population of patients with pre-dialysis chronic kidney disease.

<p> Physical activity improves physical and psychological functioning in patients with chronic kidney disease (CKD). However, no studies have investigated the determinants of physical activity in the CKD population. The purpose of the study was to evaluate the utility of the Theory of Planned Behaviour (TPB) for understanding physical activity in the CKD population. A secondary purpose of this study was to examine alternate conceptualizations of the subjective norm construct within the TPB framework. We hypothesized that attitude, subjective norm (injunctive and descriptive norms), perceived behavioural control (PBC), and social support would predict intention to engage in physical activity and that both intention and PBC would predict physical activity behaviour.</p> <p> Participants (52 male, 28 female, mean age = 68.43 (13.21)) were recruited from nephrologists' clinics and were all predialysis (mean serum creatinine = 310.55 (148.75) μmol/L). Participants completed a questionnaire assessing attitude, subjective norm, PBC, and social support. One week later, participants were phoned for a follow-up interview to assess their physical activity during the preceding week.</p> <p> In a regression model, 61% of the variance in intention to perform physical activity was explained, with PBC (β=.69,p<.001) emerging as the sole significant predictor, while attitude (β=.17, p=.10), subjective norm (β=.02, p=.89), informational support from family (β=-.10,p=.33), and informational support from doctors (β=-.05, p=.54) were non-significant predictors. In a regression model to explain physical activity, 28% of the variance in physical activity was explained, with intention emerging as a significant predictor (β=.53, p=.02), but not PBC (β=.18, p=.29).</p> <p> The hypotheses were only partially supported, as PBC emerged as a significant predictor of physical activity intention, while attitude, subjective norm, and social support did not. Furthermore, intention, but not PBC, predicted physical activity behaviour. These results demonstrate the utility of the TPB for explaining physical activity in the CKD population. Additional research is required to clarify if targeting PBC may be an effective means for intervention to increase physical activity in the CKD population.</p> / Thesis / Master of Science (MSc)

Orientador: André Luis Balbi / Resumo: Introdução: A Doença Renal Crônica (DRC) é uma condição clínica com elevada e crescente prevalência, com repercussão sistêmica, podendo cursar com hipervolemia e consequente congestão de órgãos como os pulmões. O tratamento dialítico também gera uma série de alterações nos sistemas muscular, ósseo, cardiovascular, metabólico e também respiratório. Existem muitos estudos avaliando o sistema respiratório na fase dialítica e poucos avaliam na fase pré-diaítica. Objetivo: Avaliar a função pulmonar e a força muscular respiratória de pacientes com DRC na fase pré-dialítica. Metodologia: Foram assistidos 132 pacientes e 43 avaliados no Ambulatório de Pré-Diálise do Hospital das Clínicas da Faculdade de Medicina de Botucatu, SP (HCFMB), com retornos mensais, em tratamento clínico e programação de diálise. Todos os pacientes estudados foram submetidos inicialmente à avaliação da função pulmonar através da espirometria e logo em seguida avaliação da força muscular respiratória através da manovacuometria, realizadas no laboratório de função pulmonar do HCFMB, pelo mesmo pesquisador em único dia para o mesmo paciente. Resultados: Foram incluídos no estudo 40 pacientes com média de idade de 61 ± 14 anos, sendo 60% do sexo masculino. Com relação à causa, 22 pacientes apresentaram nefropatia diabética (n=13; 32,5%) e nefropatia hipertensiva (n=9; 22,5%).Todos os resultados da espirometria (CVF, VEF1 e VEF1/CVF) foram abaixo do valor predito, com diferença estatística. A maioria dos paciente... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Chronic Kidney Disease (CKD) is a clinical condition with high and increasing prevalence, with systemic repercussions, which can develop with hypervolemia and consequent congestion of organs such as the lungs. The dialysis treatment also generates a series of changes in the muscular, bone, cardiovascular, metabolic and also respiratory systems. There are many studies evaluating the respiratory system in the dialysis phase and few assess it in the pre-dialysis phase. Objective: To evaluate pulmonary function and respiratory muscle strength in patients with pre-dialysis CKD. Methodology: 132 patients were assisted and 43 were evaluated at the Pre-Dialysis Outpatient Clinic of the Hospital das Clínicas, Faculty of Medicine of Botucatu, SP (HCFMB), with monthly returns, in clinical treatment and dialysis schedule. All patients studied were initially submitted to pulmonary function assessment using spirometry and then respiratory muscle strength was assessed using manovacuometry, performed at the HCFMB pulmonary function laboratory, by the same researcher on a single day for the same patient. Results: The study included 40 patients with a mean age of 61 ± 14 years, 60% of whom were male. Regarding the cause, 22 patients had diabetic nephropathy (n = 13; 32.5%) and hypertensive nephropathy (n = 9; 22.5%). All spirometry results (FVC, FEV1 and FEV1 / FVC) were below predicted value, with statistical difference. Most patients (37.5%) had a restrictive ventilatory disord... (Complete abstract click electronic access below) / Mestre

A acidose metabólica é um achado comum em pacientes portadores de Doença Renal Crônica (DRC). Acredita-se que a dieta pode afetar o equilíbrio ácidobase do corpo por meio do fornecimento de precursores ácidos ou de base. No entanto, os resultados inconclusivos apontados na literatura indicam que ainda são necessários estudos bem delineados para comprovar a existência dessa associação. O principal objetivo desse estudo foi determinar o potencial de carga ácida renal (PRAL) proveniente da dieta e avaliar a sua associação com o bicarbonato sérico (HCO3) em pacientes com DRC enquanto em suas dietas habituais. Associações do HCO3 com o gasto energético de repouso (GER) e com oxidações proteicas e lipícas também foram estudadas. Trata-se de um estudo transversal realizado com 100 pacientes distribuídos igualmente nos estágios 3 e 4 da DRC entre 20 e 69 anos. Avaliação do estado nutricional foi feita por meio da antropometria, registro alimentar e exames bioquímicos, o qual incluiu os produtos proteicos de oxidação avançada e os isoprostanos. O HCO3 foi determinado por meio da gasometria venosa. GER foi medido pela calorimetria indireta. O PRAL foi determinado por meio do registro alimentar usando um algoritmo que inclui dados dietéticos da ingestão de proteína, fósforo, magnésio, cálcio e potássio descritos por Remer e Manz (1995). Também foi feita a diferenciação no consumo de proteína animal e vegetal. A análise dos resultados foi feita em quartis de HCO3 para as variáveis GER e parâmetros de oxidação, o restante das análises foram feitas por quartis de PRAL. Para comparação das variações médias dos quartis foi utilizado o teste one-way ANOVA. A associação entre a estimativa do PRAL e o HCO3 foi avaliada por modelos de regressão linear ajustados. A maior parte dos nossos pacientes portadores de DRC encontravam-se com excesso de peso associado a um aumento da circunferência abdominal e da porcentagem de gordura corporal. A mediana do PRAL foi de 6,8 mEq/dia com uma variação entre -24 a 52 mEq/dia. O PRAL mais elevado foi associado com o HCO3 mais baixo de uma forma graduada (p < 0.02). Encontramos uma diferença de 2,07 mmol/L no HCO3 entre o primeiro e o último quartil, sendo o valor do último quartil de PRAL menor em relação ao primeiro. A proteína animal apresentou uma correlação inversa com o bicarbonato sérico. O GER e os marcadores de oxidação lipíca e proteica não apresentaram associações com os níveis de HCO3. Esses resultados reforçam a possibilidade de que dietas com alto teor de carga ácida podem desempenhar um papel relevante no equilíbrio ácidobase em pacientes portadores de DRC, além de consolidar o uso da carga ácida da dieta como uma abordagem diferencial e complementar às outras estratégias no tratamento dietético da DRC. / Metabolic acidosis is a common complication in patients with chronic kidney disease (CKD). Acid-inducing diets are believed to impact on acid-base balance. However, well-designed studies are still needed to prove the association between dietary acid load and serum bicarbonate. The main aim of this study was to calculate the potential renal acid load (PRAL) of selected, frequently consumed foods and to evaluate its association with serum bicarbonate (HCO3) in patients with CKD. Associations of HCO3 with resting energy expenditure (REE) and with protein and lipid oxidation were also studied. It is a cross-sectional study with 100 patients equally distributed in stages 3 and 4 of CKD between 20 and 69 years. Nutritional status was assessed by anthropometric measurements, 3-day food recall, biochemical analysis including advanced oxidation protein products and isoprostanes. Venous blood gases was used to measure HCO3. GER was measured by indirect calorimetry. PRAL was determined by food record using an algorithm that includes protein, phosphorus, magnesium, calcium and potassium intake described by Remer and Manz (1995). Dietary intake of animal and vegetable protein were also evaluate. For analysis, we used quartiles of HCO3 for GER and oxidation parameters and for the others variables we used quartilhes of PRAL. ANOVA one-way test was used to compare the mean of the quartiles. The association between PRAL and HCO3 was assessed by linear regression models. Most of the patients were overweight with increased waist circumference and body fat. The median PRAL was 6.8 mEq/day with a variation between -24 to 52 mEq/day. Higher PRAL was associated with lower serum bicarbonate in a graded fashion (P trend 0.02). Serum bicarbonate was 2.07 mEq/L lower among those in the highest compared with the lowest quartile of PRAL. Animal protein was inversely correlated with serum bicarbonate. REE and lipid and protein oxidation markers showed no association with HCO3 levels. These results reinforce the possibility that diets with high dietary acid load may play a relevant role in the acid-base balance in CKD patients. In addition to consolidating the use of PRAL as a differential and complementary approach to other strategies in the nutritional treatment of CKD.

A acidose metabólica é um achado comum em pacientes portadores de Doença Renal Crônica (DRC). Acredita-se que a dieta pode afetar o equilíbrio ácidobase do corpo por meio do fornecimento de precursores ácidos ou de base. No entanto, os resultados inconclusivos apontados na literatura indicam que ainda são necessários estudos bem delineados para comprovar a existência dessa associação. O principal objetivo desse estudo foi determinar o potencial de carga ácida renal (PRAL) proveniente da dieta e avaliar a sua associação com o bicarbonato sérico (HCO3) em pacientes com DRC enquanto em suas dietas habituais. Associações do HCO3 com o gasto energético de repouso (GER) e com oxidações proteicas e lipícas também foram estudadas. Trata-se de um estudo transversal realizado com 100 pacientes distribuídos igualmente nos estágios 3 e 4 da DRC entre 20 e 69 anos. Avaliação do estado nutricional foi feita por meio da antropometria, registro alimentar e exames bioquímicos, o qual incluiu os produtos proteicos de oxidação avançada e os isoprostanos. O HCO3 foi determinado por meio da gasometria venosa. GER foi medido pela calorimetria indireta. O PRAL foi determinado por meio do registro alimentar usando um algoritmo que inclui dados dietéticos da ingestão de proteína, fósforo, magnésio, cálcio e potássio descritos por Remer e Manz (1995). Também foi feita a diferenciação no consumo de proteína animal e vegetal. A análise dos resultados foi feita em quartis de HCO3 para as variáveis GER e parâmetros de oxidação, o restante das análises foram feitas por quartis de PRAL. Para comparação das variações médias dos quartis foi utilizado o teste one-way ANOVA. A associação entre a estimativa do PRAL e o HCO3 foi avaliada por modelos de regressão linear ajustados. A maior parte dos nossos pacientes portadores de DRC encontravam-se com excesso de peso associado a um aumento da circunferência abdominal e da porcentagem de gordura corporal. A mediana do PRAL foi de 6,8 mEq/dia com uma variação entre -24 a 52 mEq/dia. O PRAL mais elevado foi associado com o HCO3 mais baixo de uma forma graduada (p < 0.02). Encontramos uma diferença de 2,07 mmol/L no HCO3 entre o primeiro e o último quartil, sendo o valor do último quartil de PRAL menor em relação ao primeiro. A proteína animal apresentou uma correlação inversa com o bicarbonato sérico. O GER e os marcadores de oxidação lipíca e proteica não apresentaram associações com os níveis de HCO3. Esses resultados reforçam a possibilidade de que dietas com alto teor de carga ácida podem desempenhar um papel relevante no equilíbrio ácidobase em pacientes portadores de DRC, além de consolidar o uso da carga ácida da dieta como uma abordagem diferencial e complementar às outras estratégias no tratamento dietético da DRC. / Metabolic acidosis is a common complication in patients with chronic kidney disease (CKD). Acid-inducing diets are believed to impact on acid-base balance. However, well-designed studies are still needed to prove the association between dietary acid load and serum bicarbonate. The main aim of this study was to calculate the potential renal acid load (PRAL) of selected, frequently consumed foods and to evaluate its association with serum bicarbonate (HCO3) in patients with CKD. Associations of HCO3 with resting energy expenditure (REE) and with protein and lipid oxidation were also studied. It is a cross-sectional study with 100 patients equally distributed in stages 3 and 4 of CKD between 20 and 69 years. Nutritional status was assessed by anthropometric measurements, 3-day food recall, biochemical analysis including advanced oxidation protein products and isoprostanes. Venous blood gases was used to measure HCO3. GER was measured by indirect calorimetry. PRAL was determined by food record using an algorithm that includes protein, phosphorus, magnesium, calcium and potassium intake described by Remer and Manz (1995). Dietary intake of animal and vegetable protein were also evaluate. For analysis, we used quartiles of HCO3 for GER and oxidation parameters and for the others variables we used quartilhes of PRAL. ANOVA one-way test was used to compare the mean of the quartiles. The association between PRAL and HCO3 was assessed by linear regression models. Most of the patients were overweight with increased waist circumference and body fat. The median PRAL was 6.8 mEq/day with a variation between -24 to 52 mEq/day. Higher PRAL was associated with lower serum bicarbonate in a graded fashion (P trend 0.02). Serum bicarbonate was 2.07 mEq/L lower among those in the highest compared with the lowest quartile of PRAL. Animal protein was inversely correlated with serum bicarbonate. REE and lipid and protein oxidation markers showed no association with HCO3 levels. These results reinforce the possibility that diets with high dietary acid load may play a relevant role in the acid-base balance in CKD patients. In addition to consolidating the use of PRAL as a differential and complementary approach to other strategies in the nutritional treatment of CKD.