Murilo Guedes

All Publications

• Authors' reply to "Residual confounding in the prognostic interpretation of iron deficiency in incident peritoneal dialysis". Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis Rigodon, V., Guedes, M., Pecoits, P. G., Hartley, B., Jiao, Y., Usvyat, L. A., Chatoth, D. K., Hymes, J. L., Maddux, F. W., Kooman, J., Moraes, T. P., Raimann, J. G., Kotanko, P., Larkin, J. W., Pecoits-Filho, R. 2026: 8968608261476550

  View details for DOI 10.1177/08968608261476550

  View details for PubMedID 42560146

• Multinational Real-World Practice Patterns in the Use of Antithrombotic Therapy Among Patients on Hemodialysis and Peritoneal Dialysis. Kidney medicine Guedes, M., Andrews, C., Zhao, J., Atkins, G. B., Barash, I., Bash, L. D., Coyle, C. R., Ke, X., Ramey, D. R., Johnson, D. W., Ureña-Torres, P., Ferraro, P. M., Al Ghonaim, M., Bonaca, M. P., Pecoits-Filho, R., Karaboyas, A. 2026; 8 (3): 101211

  Abstract

  Patients with kidney failure requiring maintenance dialysis have a high risk of cardiovascular events warranting antithrombotic therapies, including oral anticoagulant (OAC) or antiplatelet therapy (APT). However, chronic use of antithrombotic therapy can increase the bleeding risk in patients receiving dialysis. However, little is known about medication use patterns and risk of bleeding events in real-world clinical practice.Retrospective analysis of data from 2 prospective cohort studies.We included 27,612 patients from the Dialysis Outcomes and Practice Patterns Study (DOPPS) and 5,289 patients from the Peritoneal DOPPS (PDOPPS), international cohorts of hemodialysis (HD) and peritoneal dialysis (PD) patients.Patient demographics and comorbid conditions; OAC and APT use.OAC and APT use; a bleeding composite outcome including a hospitalization or death because of a major bleeding event.Descriptive analyses to explore OAC and APT utilization and crude rates of the bleeding composite outcome and Kaplan-Meier analyses to estimate medication discontinuation.Baseline OAC and APT use was 9% and 10% in HD patients and 4% and 7% in PD patients, respectively. Patients prescribed antithrombotic drugs were older and more likely to have a history of cardiovascular disease. After 36 months, the Kaplan-Meier estimated proportions of baseline users who remained on therapy were 57% for OAC and 53% for APT. The composite bleeding rates per 100 patient-years among patients with baseline OAC use versus baseline APT use versus neither were 8.6, 5.6, and 4.1 in HD patients and 12.0, 6.1, and 3.9 in PD patients, respectively.Potential for event misclassification; no over-the-counter medication data; rates unadjusted.Antithrombotic drugs are infrequently prescribed and often discontinued in patients receiving HD or PD. With major bleeding event rates high among antithrombotic users, new strategies are needed to optimize the risks and benefits of antithrombotic agents in the dialysis setting.

  View details for DOI 10.1016/j.xkme.2025.101211

  View details for PubMedID 41675209

  View details for PubMedCentralID PMC12887883

• Anemia-independent prognostic value of iron deficiency in incident peritoneal dialysis patients. Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis Rigodon, V., Guedes, M., Pecoits, P. G., Hartley, B., Jiao, Y., Usvyat, L. A., Chatoth, D. K., Hymes, J. L., Maddux, F. W., Kooman, J., Moraes, T. P., Raimann, J. G., Kotanko, P., Larkin, J. W., Pecoits-Filho, R. 2026: 8968608251412935

  Abstract

  Background and objectivesIron plays a critical role beyond erythropoiesis, yet the prognostic significance of iron deficiency (ID) independent of anemia remains poorly defined in the peritoneal dialysis (PD) population. This study aimed to evaluate the association between iron status, specifically transferrin saturation (TSAT), and mortality in PD patients, independent of hemoglobin levels.Design, setting, participants, and measurementsWe conducted a retrospective cohort study of 11,013 adults who initiated PD at a large US dialysis network between December 2004 and January 2011. Patients had at least 180 days on PD and baseline data on TSAT, ferritin, hemoglobin, albumin, and white blood cell count. The primary outcome was all-cause mortality. Broadly adjusted associations between iron parameters and mortality were assessed using Cox proportional hazards models and restricted cubic splines, with adjustments for demographic, clinical, treatment-related, and laboratory variables including hemoglobin and ESA use.ResultsIron deficiency, defined as TSAT ≤20%, was present in 10% of patients at PD initiation. The cohort was 54% male and 70% Caucasian, with a mean age of 55 years; 39% had diabetes. While 91% received erythropoiesis-stimulating agents, only 34% received IV iron. After comprehensive adjustment, TSAT ≤20% remained independently associated with increased mortality (adjusted HR: 1.26; 95% CI: 1.12-1.42). Spline analyses showed a sharp rise in mortality risk at TSAT levels below 25%. Ferritin was inconsistently associated with mortality risk. During follow-up, 2704 deaths occurred (24.6% of the cohort) over a median 440-day follow-up.ConclusionsIron deficiency is common in incident PD patients and is associated with increased mortality risk, independent of anemia. These findings challenge current anemia-centric treatment paradigms and suggest that iron status, particularly TSAT, should be routinely assessed in PD patients regardless of hemoglobin levels. A prospective, randomized trial is warranted to evaluate whether proactive iron management improves outcomes in this population.

  View details for DOI 10.1177/08968608251412935

  View details for PubMedID 41558040

• International variations in chronic kidney disease patients' pain experience and its management. Clinical kidney journal Raina, R., Nair, N., Kumar, R., Doshi, K., Alencar-de Pinho, N., Tu, C., Bieber, B., Liabeuf, S., Combe, C., Reichel, H., Argyropoulos, C., Guedes, M., Pecoits-Filho, R. 2026; 19 (1): sfaf346

  Abstract

  Background: Chronic pain significantly impacts health-related quality of life (HRQOL) in patients with non-dialysis chronic kidney disease (ND-CKD), yet the management of pain in this population is challenging. We hypothesized that analgesic prescription practices vary internationally, influencing the pain experience and HRQOL of patients with stage 3-5 ND-CKD.Methods: This descriptive, observational, multinational cohort study utilized data from the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps), enrolling adult patients from nephrology practices in Brazil, France and the USA between 2013 and 2020. Analgesic prescriptions within 6months before HRQOL assessment were categorized as non-steroidal anti-inflammatory drugs (NSAIDs), opioids or other analgesics. HRQOL was measured using the Kidney Disease Quality of Life Short Form, assessing multiple subdomains.Results: Among 3945 patients, analgesics were most frequently prescribed in the USA across all CKD stages, with opioids prescribed nearly twice as often compared with Brazil and France. NSAIDs are frequently prescribed in Brazil, including in advanced CKD stages, contrasting sharply with practices in France and the USA. Higher reported pain intensity consistently correlated with poorer outcomes across all HRQOL subdomains.Conclusions: This study identifies considerable international variability in pain reporting and analgesic prescription patterns in patients with stage 3-5 ND-CKD. Randomized controlled trials evaluating the efficacy and safety of analgesics are warranted to improve key patient-reported outcomes such as pain in patients with ND-CKD.

  View details for DOI 10.1093/ckj/sfaf346

  View details for PubMedID 41498063

• Systematic Review of the Effects of Iron on Cardiovascular, Kidney, and Safety Outcomes in Patients With CKD KIDNEY INTERNATIONAL REPORTS Chan, B., Varghese, A., V. Badve, S., Pecoits-Filho, R., Guedes, M., Arnott, C., Kozor, R., O'Lone, E., Jun, M., Kotwal, S., Block, G. A., Chertow, G. M., Solomon, S. D., Vaduganathan, M., Perkovic, V., Neuen, B. L. 2025; 10 (4): 1037-1049

  View details for DOI 10.1016/j.ekir.2025.01.029

  View details for Web of Science ID 001468597200001

• Systematic Review of the Effects of Iron on Cardiovascular, Kidney, and Safety Outcomes in Patients With CKD. Kidney international reports Chan, B., Varghese, A., Badve, S. V., Pecoits-Filho, R., Guedes, M., Arnott, C., Kozor, R., O'Lone, E., Jun, M., Kotwal, S., Block, G. A., Chertow, G. M., Solomon, S. D., Vaduganathan, M., Perkovic, V., Neuen, B. L. 2025; 10 (4): 1037-1049

  Abstract

  Heart failure and chronic kidney disease (CKD) are closely associated, and iron deficiency is highly prevalent in both conditions. However, major cardiovascular and nephrology guidelines offer contrasting recommendations for iron use. We evaluated the effects of iron versus usual care or placebo on the clinical outcomes in patients with CKD.We conducted a systematic review and meta-analysis of randomized trials on i.v. or oral iron in patients with CKD (PROSPERO CRD42023453468). We searched Medline, Embase, and the Cochrane Register from database inception until February 1, 2024 to identify eligible trials. We determined the overall results and stratified them by dialysis- and nondialysis-requiring CKD using random effects models, with certainty of evidence assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. The primary composite endpoint was hospitalization for heart failure or cardiovascular death.We identified 45 trials that met the inclusion criteria. Compared with usual care or placebo, iron reduced the risk of the primary composite endpoint (1659 events; risk ratio [RR]: 0.84, 95% confidence interval [CI]: 0.75-0.94; moderate certainty), an effect consistent across dialysis and nondialysis requiring CKD (P-heterogeneity = 0.70). The effect on the primary endpoint appeared driven by both components of hospitalization for heart failure (RR: 0.77; 95% CI: 0.61-0.96; moderate certainty) and cardiovascular death (RR: 0.81; 95% CI: 0.65-1.02; low certainty). The incidence of serious adverse events was lower for iron compared with usual care or placebo (RR: 0.90, 95% CI: 0.82-0.98; moderate certainty; P-heterogeneity = 0.09).Iron therapy may reduce the risk of heart failure and cardiovascular death in patients with CKD. Randomized trials evaluating the effects of iron on clinical outcomes are needed, especially in nondialysis patients with CKD with or without anemia.

  View details for DOI 10.1016/j.ekir.2025.01.029

  View details for PubMedID 40303218

  View details for PubMedCentralID PMC12034885

• Arteriovenous Access Creation Does Not Appear to Slow the Estimated Glomerular Filtration Rate Decline in Patients with CKD JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Tabcheh, A., Coscas, R., Lambert, O., Stengel, B., Frimat, L., Massy, Z., Combe, C., Guedes, M., Pecoits-Filho, R., Boucquemont, J., De Pinho, N., CKD-REIN Study Collaborators 2024; 35 (11): 1570-1573

  View details for DOI 10.1681/ASN.0000000000000443

  View details for Web of Science ID 001272318600001

• High volume online hemodiafiltration: a global perspective and the Brazilian experience JORNAL BRASILEIRO DE NEFROLOGIA Canziani, M., Strogoff-de-Matos, J., Guedes, M., Barra, A., Canhada, S., Carvalho, L., Gemente, D., Poli-de-Figueiredo, C., Pecoits-Filho, R. 2023: e20230104

  Abstract

  Online hemodiafiltration (HDF) is a rapidly growing dialysis modality worldwide. In Brazil, the number of patients with private health insurance undergoing HDF has exceeded the number of patients on peritoneal dialysis. The achievement of a high convection volume was associated with better clinical imprand patient - reported outcomes confirming the benefits of HDF. The HDFit trial provided relevant practical information on the implementation of online HDF in dialysis centers in Brazil. This article aims to disseminate technical information to improve the quality and safety of this new dialysis modality.

  View details for DOI 10.1590/2175-8239-JBN-2023-0104en

  View details for Web of Science ID 001183255600001

  View details for PubMedID 38134298

  View details for PubMedCentralID PMC11210529

• Searching for the Risk-Benefit Profile of Higher Potassium Intake in CKD: <i>Primum Non Nocere</i> JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Guedes, M., Pecoits-Filho, R. 2022; 33 (9): 1633-1635

  View details for DOI 10.1681/ASN.2022060695

  View details for Web of Science ID 000835978900001

  View details for PubMedID 35926981

  View details for PubMedCentralID PMC9529186

• Fatigue in incident peritoneal dialysis and mortality: A real-world side-by-side study in Brazil and the United States PLOS ONE Guedes, M., Wallim, L., Guetter, C. R., Jiao, Y., Rigodon, V., Mysayphonh, C., Usvyat, L. A., Barretti, P., Kotanko, P., Larkin, J. W., Maddux, F. W., Pecoits-Filho, R., de Moraes, T. 2022; 17 (6): e0270214

  Abstract

  We tested if fatigue in incident Peritoneal Dialysis associated with an increased risk for mortality, independently from main confounders.We conducted a side-by-side study from two of incident PD patients in Brazil and the United States. We used the same code to independently analyze data in both countries during 2004 to 2011. We included data from adults who completed KDQOL-SF vitality subscale within 90 days after starting PD. Vitality score was categorized in four groups: >50 (high vitality), ≥40 to ≤50 (moderate vitality), >35 to <40 (moderate fatigue), ≤35 (high fatigue; reference group). In each country's cohort, we built four distinct models to estimate the associations between vitality (exposure) and all-cause mortality (outcome): (i) Cox regression model; (ii) competing risk model accounting for technique failure events; (iii) multilevel survival model of clinic-level clusters; (iv) multivariate regression model with smoothing splines treating vitality as a continuous measure. Analyses were adjusted for age, comorbidities, PD modality, hemoglobin, and albumin. A mixed-effects meta-analysis was used to pool hazard ratios (HRs) from both cohorts to model mortality risk for each 10-unit increase in vitality.We used data from 4,285 PD patients (Brazil n = 1,388 and United States n = 2,897). Model estimates showed lower vitality levels within 90 days of starting PD were associated with a higher risk of mortality, which was consistent in Brazil and the United States cohorts. In the multivariate survival model, each 10-unit increase in vitality score was associated with lower risk of all-cause mortality in both cohorts (Brazil HR = 0.79 [95%CI 0.70 to 0.90] and United States HR = 0.90 [95%CI 0.88 to 0.93], pooled HR = 0.86 [95%CI 0.75 to 0.98]). Results for all models provided consistent effect estimates.Among patients in Brazil and the United States, lower vitality score in the initial months of PD was independently associated with all-cause mortality.

  View details for DOI 10.1371/journal.pone.0270214

  View details for Web of Science ID 000892027900076

  View details for PubMedID 35749444

  View details for PubMedCentralID PMC9231740

• Clinical performance, intermediate and long-term outcomes of high-volume hemodiafiltration in patients with kidney failure SEMINARS IN DIALYSIS Guedes, M., Vernooij, R. W. M., Davenport, A., Kuhlmann, M. K., Aregger, F., Pecoits-Filho, R. 2022; 35 (5): 420-426

  Abstract

  Hemodiafiltration (HDF), in which both convective and diffusion methods are combined, yields an increased overall solute clearance compared with hemodialysis (HD), specifically for medium and larger molecular weight uremic toxins. Due to uncertainty in the treatment effects, the nephrology community still perceives the implementation of HDF and the achievement of high convective volume as complex. In this article, we review practical aspects of the implementation of HDF that can effectively deliver a high-volume HDF therapy and assure clinical performance to most patients. We also present an overview of the impact of high-volume HDF (compared to HD) on a series of relevant biochemical, patient-reported, and clinical outcomes, including uremic toxin removal, phosphate, Inflammation and oxidative stress, hemodynamic stability, cardiac outcomes, nutritional effects, health-related quality of life, morbidity, and mortality.

  View details for DOI 10.1111/sdi.13105

  View details for Web of Science ID 000809319400001

  View details for PubMedID 35689437

• Inflammation, Serum Iron, and Risk of Mortality and Cardiovascular Events in Nondialysis CKD Patients Reply JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Guedes, M., Robinson, B., Bieber, B., Pecoits-Filho, R. 2022; 33 (3): 655-656

  View details for DOI 10.1681/ASN.2021111504

  View details for Web of Science ID 000747551300001

  View details for PubMedID 35046129

  View details for PubMedCentralID PMC8975058

• Peritoneal dialysis modality transition and impact on phosphate and potassium serum levels PLOS ONE Peruzzo, D., Guedes, M., Larkin, J. W., Yokoyama, G., dos Santos, T., Pecoits-Filho, R., Ribeiro, S., Ramos, A., Barretti, P., de Moraes, T., BRAZPD Investigators 2021; 16 (10): e0257140

  Abstract

  Peritoneal dialysis (PD) modalities affect solute removal differently. However, the impacts of switching PD modalities on serum levels of biomarkers of different sizes are not known. Our objective was to analyze whether a change in the PD modality associates with the levels of two routine biochemical laboratories. In this multicentric prospective cohort study. we selected all patients who remained on a PD modality for at least 6 months and switched PD modality. Patients were also required to be treated with the same PD modality for at least 3 months before and after the modality change. The primary outcome was change in potassium and phosphate serum levels. We identified 737 eligible patients who switched their PD modality during the study. We found mean serum phosphate levels increased during the 3 months after switching from CAPD to APD and conversely decreased after switching to from APD to CAPD. In contrast, for potassium the difference in the mean serum levels was comparable between groups switching from CAPD to APD, and vice versa. In conclusion, CAPD seems to be as efficient as APD for the control of potassium serum levels, but more effective for the control of phosphate serum levels. The effect of a higher removal of middle size molecules as result of PD modalities in terms of clinical and patient-reported outcomes should be further explored.

  View details for DOI 10.1371/journal.pone.0257140

  View details for Web of Science ID 000755689200007

  View details for PubMedID 34653195

  View details for PubMedCentralID PMC8519456

• Worldwide Early Impact of COVID-19 on Dialysis Patients and Staff and Lessons Learned: A DOPPS Roundtable Discussion KIDNEY MEDICINE Robinson, B. M., Guedes, M., Alghonaim, M., Cases, A., Dasgupta, I., Gan, L., Jacobson, S. H., Kanjanabuch, T., Kim, Y., Kleophas, W., Labriola, L., Perlman, R. L., Reboldi, G., Srivatana, V., Suri, R. S., Tsuruya, K., Torres, P., Pisoni, R. L., Pecoits-Filho, R. 2021; 3 (4): 619-634

  Abstract

  As the worst global pandemic of the past century, coronavirus disease 2019 (COVID-19) has had a disproportionate effect on maintenance dialysis patients and their health care providers. At a virtual roundtable on June 12, 2020, Dialysis Outcomes and Practice Patterns Study (DOPPS) investigators from 15 countries in Asia, Europe, and the Americas described and compared the effects of COVID-19 on dialysis care, with recent updates added. Most striking is the huge difference in risk to dialysis patients and staff across the world. Per-population cases and deaths among dialysis patients vary more than 100-fold across participating countries, mirroring burden in the general population. International data indicate that the case-fatality ratio remains at 10% to 30% among dialysis patients, confirming the gravity of infection, and that cases are much more common among in-center than home dialysis patients. This latter finding merits urgent study because in-center patients often have greater community exposure, and in-center transmission may be uncommon under optimal protocols. Greater telemedicine use is a welcome change here to stay, and our community needs to improve emergency planning and protect dialysis staff from the next pandemic. Finally, the pandemic's challenges have prompted widespread partnering and innovation in kidney care and research that must be sustained after this global health crisis.

  View details for DOI 10.1016/j.xkme.2021.03.006

  View details for Web of Science ID 000685916200018

  View details for PubMedID 34007963

  View details for PubMedCentralID PMC8120787

• Serum Biomarkers of Iron Stores Are Associated with Increased Risk of All-Cause Mortality and Cardiovascular Events in Nondialysis CKD Patients, with or without Anemia JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Guedes, M., Muenz, D. G., Zee, J., Bieber, B., Stengel, B., Massy, Z. A., Mansencal, N., Wong, M. M. Y., Charytan, D. M., Reichel, H., Waechter, S., Pisoni, R. L., Robinson, B. M., Pecoits-Filho, R., CKDopps Investigators 2021; 32 (8): 2020-2030

  Abstract

  Approximately 30%-45% of patients with nondialysis CKD have iron deficiency. Iron therapy in CKD has focused primarily on supporting erythropoiesis. In patients with or without anemia, there has not been a comprehensive approach to estimating the association between serum biomarkers of iron stores, and mortality and cardiovascular event risks.The study included 5145 patients from Brazil, France, the United States, and Germany enrolled in the Chronic Kidney Disease Outcomes and Practice Patterns Study, with first available transferrin saturation (TSAT) and ferritin levels as exposure variables. We used Cox models to estimate hazard ratios (HRs) for all-cause mortality and major adverse cardiovascular events (MACE), with progressive adjustment for potentially confounding variables. We also used linear spline models to further evaluate functional forms of the exposure-outcome associations.Compared with patients with a TSAT of 26%-35%, those with a TSAT ≤15% had the highest adjusted risks for all-cause mortality and MACE. Spline analysis found the lowest risk at TSAT 40% for all-cause mortality and MACE. Risk of all-cause mortality, but not MACE, was also elevated at TSAT ≥46%. Effect estimates were similar after adjustment for hemoglobin. For ferritin, no directional associations were apparent, except for elevated all-cause mortality at ferritin ≥300 ng/ml.Iron deficiency, as captured by TSAT, is associated with higher risk of all-cause mortality and MACE in patients with nondialysis CKD, with or without anemia. Interventional studies evaluating the effect on clinical outcomes of iron supplementation and therapies for alternative targets are needed to better inform strategies for administering exogenous iron.

  View details for DOI 10.1681/ASN.2020101531

  View details for Web of Science ID 000686111200022

  View details for PubMedID 34244326

  View details for PubMedCentralID PMC8455257

• Effect of hemodiafiltration on measured physical activity: primary results of the HDFIT randomized controlled trial NEPHROLOGY DIALYSIS TRANSPLANTATION Pecoits-Filho, R., Larkin, J., Poli-de-Figueiredo, C., Cuvello-Neto, A., Lesqueves Barra, A., Goncalves, P., Sheth, S., Guedes, M., Han, M., Calice-Silva, V., Martins de Castro, M., Kotanko, P., de Moraes, T., Raimann, J. G., Canziani, M. F., HDFIT Study Investigators 2021; 36 (6): 1057-1070

  Abstract

  Dialysis patients are typically inactive and their physical activity (PA) decreases over time. Uremic toxicity has been suggested as a potential causal factor of low PA in dialysis patients. Post-dilution high-volume online hemodiafiltration (HDF) provides greater higher molecular weight removal and studies suggest better clinical/patient-reported outcomes compared with hemodialysis (HD).HDFIT was a randomized controlled trial at 13 clinics in Brazil that aimed to investigate the effects of HDF on measured PA (step counts) as a primary outcome. Stable HD patients (vintage 3-24 months) were randomized to receive HDF or high-flux HD. Treatment effect of HDF on the primary outcome from baseline to 3 and 6 months was estimated using a linear mixed-effects model.We randomized 195 patients (HDF 97; HD 98) between August 2016 and October 2017. Despite the achievement of a high convective volume in the majority of sessions and a positive impact on solute removal, the treatment effect HDF on the primary outcome was +538 [95% confidence interval (CI) -330 to 1407] steps/24 h after dialysis compared with HD, and was not statistically significant. Despite a lack of statistical significance, the observed size of the treatment effect was modest and driven by steps taken between 1.5 and 24.0 h after dialysis, in particular between 20 and 24 h (+197 steps; 95% CI -95 to 488).HDF did not have a statistically significant treatment effect on PA 24 h following dialysis, albeit effect sizes may be clinically meaningful and deserve further investigation.

  View details for DOI 10.1093/ndt/gfaa173

  View details for Web of Science ID 000704006300018

  View details for PubMedID 33160281

  View details for PubMedCentralID PMC8160948

• Serum biomarkers of iron stores are associated with worse physical health-related quality of life in nondialysis-dependent chronic kidney disease patients with or without anemia NEPHROLOGY DIALYSIS TRANSPLANTATION Guedes, M., Muenz, D., Zee, J., Lopes, M., Waechter, S., Stengel, B., Massy, Z. A., Speyer, E., Ayav, C., Finkelstein, F., Sesso, R., Pisoni, R. L., Robinson, B. M., Pecoits-Filho, R. 2021; 36 (9): 1694-1703

  Abstract

  Iron deficiency (ID) is a common condition in nondialysis-dependent chronic kidney disease (NDD-CKD) patients that is associated with poorer clinical outcomes. However, the effect of ID on health-related quality of life (HRQoL) in this population is unknown. We analyzed data from a multinational cohort of NDD-CKD Stages 3-5 patients to test the association between transferrin saturation (TSAT) index and ferritin with HRQoL.Patients from Brazil (n = 205), France (n = 2015) and the USA (n = 293) in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps, 2013-2019) were included. We evaluated the association of TSAT and ferritin (and functional and absolute ID, defined as TSAT ≤20% and ferritin ≥300 or <50 ng/mL) on pre-specified HRQoL measures, including the 36-item Kidney Disease Quality of Life physical component summary (PCS) and mental component summary (MCS) as the primary outcomes. Models were adjusted for confounders including hemoglobin (Hb).TSAT ≤15% and ferritin <50 ng/mL and ≥300 ng/mL were associated with worse PCS scores, but not with MCS. Patients with composite TSAT ≤20% and ferritin <50 or ≥300 ng/mL had lower functional status and worse PCS scores than those with a TSAT of 20-30% and ferritin 50-299 ng/mL. Patients with a lower TSAT were less likely to perform intense physical activity. Adjustment for Hb only slightly attenuated the observed effects.Low TSAT levels, as well as both low TSAT with low ferritin and low TSAT with high ferritin, are associated with worse physical HRQoL in NDD-CKD patients, even after accounting for Hb level. Interventional studies of iron therapy on HRQoL among NDD-CKD individuals are needed to confirm these findings.

  View details for DOI 10.1093/ndt/gfab050

  View details for Web of Science ID 000715360600019

  View details for PubMedID 33624825

  View details for PubMedCentralID PMC8396397

• A real-world longitudinal study of anemia management in non-dialysis-dependent chronic kidney disease patients: a multinational analysis of CKDopps SCIENTIFIC REPORTS Lopes, M., Tu, C., Zee, J., Guedes, M., Pisoni, R. L., Robinson, B. M., Foote, B., Hedman, K., James, G., Lopes, A., Massy, Z., Reichel, H., Sloand, J., Waechter, S., Wong, M. M. Y., Pecoits-Filho, R. 2021; 11 (1): 1784

  Abstract

  Previously lacking in the literature, we describe longitudinal patterns of anemia prescriptions for non-dialysis-dependent chronic kidney disease (NDD-CKD) patients under nephrologist care. We analyzed data from 2818 Stage 3-5 NDD-CKD patients from Brazil, Germany, and the US, naïve to anemia medications (oral iron, intravenous [IV] iron, or erythropoiesis stimulating agent [ESA]) at enrollment in the CKDopps. We report the cumulative incidence function (CIF) of medication initiation stratified by baseline characteristics. Even in patients with hemoglobin (Hb) < 10 g/dL, the CIF at 12 months for any anemia medication was 40%, and 28% for ESAs. Patients with TSAT < 20% had a CIF of 26% and 6% for oral and IV iron, respectively. Heart failure was associated with earlier initiation of anemia medications. IV iron was prescribed to < 10% of patients with iron deficiency. Only 40% of patients with Hb < 10 g/dL received any anemia medication within a year. Discontinuation of anemia treatment was very common. Anemia treatment is initiated in a limited number of NDD-CKD patients, even in those with guideline-based indications to treat. Hemoglobin trajectory and a history of heart failure appear to guide treatment start. These results support the concept that anemia is sub-optimally managed among NDD-CKD patients in the real-world setting.

  View details for DOI 10.1038/s41598-020-79254-6

  View details for Web of Science ID 000676336800030

  View details for PubMedID 33469061

  View details for PubMedCentralID PMC7815803

• Impacts of dialysis adequacy and intradialytic hypotension on changes in dialysis recovery time BMC NEPHROLOGY Guedes, M., Pecoits-Filho, R., Leme, J., Jiao, Y., Raimann, J. G., Wang, Y., Kotanko, P., de Moraes, T., Thadhani, R., Maddux, F. W., Usvyat, L. A., Larkin, J. W. 2020; 21 (1): 529

  Abstract

  Dialysis recovery time (DRT) surveys capture the perceived time after HD to return to performing regular activities. Prior studies suggest the majority of HD patients report a DRT > 2 h. However, the profiles of and modifiable dialysis practices associated with changes in DRT relative to the start of dialysis are unknown. We hypothesized hemodialysis (HD) dose and rates of intradialytic hypotension (IDH) would associate with changes in DRT in the first years after initiating dialysis.We analyzed data from adult HD patients who responded to a DRT survey ≤180 days from first date of dialysis (FDD) during 2014 to 2017. DRT survey was administered with annual KDQOL survey. DRT survey asks: "How long does it take you to be able to return to your normal activities after your dialysis treatment?" Answers are: < 0.5, 0.5-to-1, 1-to-2, 2-to-4, or > 4 h. An adjusted logistic regression model computed odds ratio for a change to a longer DRT (increase above DRT > 2 h) in reference to a change to a shorter DRT (decrease below DRT < 2 h, or from DRT > 4 h). Changes in DRT were calculated from incident (≤180 days FDD) to first prevalent (> 365-to- ≤ 545 days FDD) and second prevalent (> 730-to- ≤ 910 days FDD) years.Among 98,616 incident HD patients (age 62.6 ± 14.4 years, 57.8% male) who responded to DRT survey, a higher spKt/V in the incident period was associated with 13.5% (OR = 0.865; 95%CI 0.801-to-0.935) lower risk of a change to a longer DRT in the first-prevalent year. A higher number of HD treatments with IDH episodes per month in the incident period was associated with a 0.8% (OR = 1.008; 95%CI 1.001-to-1.015) and 1.6% (OR = 1.016; 95%CI 1.006-to-1.027) higher probability of a change to a longer DRT in the first- and second-prevalent years, respectively. Consistently, an increased in incidence of IDH episodes/months was associated to a change to a longer DRT over time.Incident patients who had higher spKt/V and less sessions with IDH episodes had a lower likelihood of changing to a longer DRT in first year of HD. Dose optimization strategies with cardiac stability in fluid removal should be tested.

  View details for DOI 10.1186/s12882-020-02187-9

  View details for Web of Science ID 000598038200001

  View details for PubMedID 33287719

  View details for PubMedCentralID PMC7720452

• Achieving high convective volume in hemodiafiltration: Lessons learned after successful implementation in theHDFittrial HEMODIALYSIS INTERNATIONAL Guedes, M., Dambiski, A., Canhada, S., Barra, A. L., Poli-de-Figueiredo, C., Cuvello Neto, A., Canziani, M. F., Strogoff-de-Matos, J., Raimann, J. G., Larkin, J., Canaud, B., Pecoits-Filho, R., HDFIT Study Investigators 2021; 25 (1): 50-59

  Abstract

  High-volume online hemodiafiltration (OL-HDF) associates with improved outcomes compared to hemodialysis (HD), provided adequate dosing is achieved as estimated from convective volume (CV). Achievement of high CV and its impact on biochemical indicators following a standardized protocol converting HD patients to OL-HDF has not been systematically reported. We assessed the success of implementation of OL-HDF in clinics naïve to the modality.We analyzed the results of the implementation of postdilution OL-HDF in patients randomized to the HDF arm of a clinical trial (impact of hemoDiaFIlTration on physical activity and self-reported outcomes: a randomized controlled trial (HDFit) trial [ClinicalTrials.gov:NCT02787161]). The day before randomization of the first patient to OL-HDF at each clinic staff started a 3-day in-person training module on operation of Fresenius 5008 CorDiax machine in HDF mode. Patients were converted from high-flux HD to OL-HDF under oversight of trainers. OL-HDF was performed over a 6-months follow-up with a CV target of 22 L/treatment. We characterized median achieved CV >22 L/treatment record and analyzed the impact of HDF on biochemical variables.Ninety-seven patients (mean age 53 ± 16 years, 29% with diabetes, and 11% had a catheter) from 13 clinics randomized to the OL-HDF arm of the trial were converted from HD to HDF. Median CV > 22 L/treatment was achieved in 99% (94/95) of OL-HDF patients throughout follow-up. Monthly mean CV ranged from 27.1 L to 27.5 L. OL-HDF provided an increased single pool Kt/V at 3-months (0.2 [95% CI: 0.1-0.3]) and 6-months (0.2 [95% CI: 0.1-0.4]) compared to baseline, and reduced phosphate at 3-months (-0.4 mg/dL [95% CI: -0.8 to -0.12]) of follow-up.High-volume online hemodiafiltration was successfully implemented with 99% of patients achieving protocol defined CV target. Monthly mean CV was consistently >22 L/treatment during follow-up. Kt/V increased, and phosphate decreased with OL-HDF. Findings resulting from a short training period in several dialysis facilities appear to suggest HDF is an easily implementable technique.

  View details for DOI 10.1111/hdi.12891

  View details for Web of Science ID 000577734300001

  View details for PubMedID 33058473

• Associations of Hemoglobin Levels With Health-Related Quality of Life, Physical Activity, and Clinical Outcomes in Persons With Stage 3-5 Nondialysis CKD JOURNAL OF RENAL NUTRITION Hoshino, J., Muenz, D., Zee, J., Sukul, N., Speyer, E., Guedes, M., Lopes, A. A., Asahi, K., van Haalen, H., James, G., Dhalwani, N., Pecoits-Filho, R., Bieber, B., Robinson, B. M., Pisoni, R. L., CKDopps Investigators 2020; 30 (5): 404-414

  Abstract

  Conflicting findings and knowledge gaps exist regarding links between anemia, physical activity, health-related quality of life (HRQOL), chronic kidney disease (CKD) progression, and mortality in moderate-to-advanced CKD. Using the CKD Outcomes and Practice Patterns Study, we report associations of hemoglobin (Hgb) with HRQOL and physical activity, and associations of Hgb and physical activity with CKD progression and mortality in stage 3-5 nondialysis (ND)-CKD patients.Prospectively collected data were analyzed from 2,121 ND-CKD stage 3-5 patients, aged ≥18 years, at 43 nephrologist-run US and Brazil CKD Outcomes and Practice Patterns Study-participating clinics. Cross-sectional associations were assessed of Hgb levels with HRQOL and physical activity levels (from validated Kidney Disease Quality of Life Instrument and Rapid Assessment of Physical Activity surveys). CKD progression (first of ≥40% estimated glomerular filtration rate [eGFR] decline, eGFR<10 mL/min/1.73 m2, or end-stage kidney disease) and all-cause mortality with Hgb and physical activity levels were also evaluated. Linear, logistic, and Cox regression analyses were adjusted for country, demographics, smoking, eGFR, serum albumin, very high proteinuria, and 13 comorbidities.HRQOL was worse, with severe anemia (Hgb<10 g/dL), but also evident for mild/moderate anemia (Hgb 10-12 g/dL), relative to Hgb>12 g/dL. Odds of being highly physically active were substantially greater at Hgb>10.5 g/dL. Lower Hgb was strongly associated with greater CKD progression and mortality, even after extensive adjustment. Physical inactivity was strongly associated with greater mortality and weakly associated with CKD progression. Possible residual confounding is a limitation.This multicenter international study provides real-world observational evidence for greater HRQOL, physical activity, lower CKD progression, and greater survival in ND-CKD patients with Hgb levels >12 g/dL, exceeding current treatment guideline recommendations. These findings help inform future studies aimed at understanding the impact of new anemia therapies and physical activity regimens on improving particular dimensions of ND-CKD patient well-being and clinical outcomes.

  View details for DOI 10.1053/j.jrn.2019.11.003

  View details for Web of Science ID 000575125800007

  View details for PubMedID 31980326

• Patient perception of vitality and measured physical activity in patients receiving haemodialysis NEPHROLOGY Leme, J., Guedes, M., Larkin, J., Han, M., Barra, A., Canziani, M. F., Cuvello Neto, A., Poli-de-Figueiredo, C., de Moraes, T., Pecoits-Filho, R., HDFIT Study Investigators 2020; 25 (11): 865-871

  Abstract

  Fatigue in haemodialysis (HD) patients can be captured in quality of life questionnaires and by the dialysis recovery time (DRT) question. The associations between fatigue and measured physical activity has not been explored until the present. We tested our hypothesis that the patient perception of chronic and post dialysis fatigue would be associated with lower physical activity.This study was a cross sectional evaluation of baseline data from HD patients recruited in the HDFIT trial. Vitality scores from the Kidney Disease Quality of Life (KDQOL-36) and the dialysis recovery time (DRT) question were used as indicators of chronic and post dialysis fatigue, respectively. Granular physical activity was measured by accelerometers as part of the study protocol.Among 176 patients, Vitality score was 63 ± 21 and the DRT was ≤30 minutes in 57% of patients. The mean number of steps was 5288 ± 3540 in 24 hours after HD and 953 ± 617 in the 2-hour post-HD period. The multivariable analysis confirmed Vitality scores were associated with physical activity in the 24-hour post-HD period. In contrast, DRT was not associated with physical activity captured by the accelerometer in the period immediately (2 hours) after the HD session.Chronic fatigue was negatively associated with step counts, while patient perception of post-dialysis fatigue was not associated with physical activity. These patterns indicate limitations in interpretation of DRT. Since physical activity is an important component of a healthy life, our results may partially explain the associations between fatigue and poor outcomes in HD patients.

  View details for DOI 10.1111/nep.13758

  View details for Web of Science ID 000558070700001

  View details for PubMedID 32706161

• Physical health-related quality of life at higher achieved hemoglobin levels among chronic kidney disease patients: a systematic review and meta-analysis BMC NEPHROLOGY Guedes, M., Guetter, C. R., Erbano, L. H. O., Palone, A. G., Zee, J., Robinson, B. M., Pisoni, R., de Moraes, T., Pecoits-Filho, R., Baena, C. P. 2020; 21 (1): 259

  Abstract

  The impact of anemia treatment with erythropoietin stimulating agents (ESA) on health-related quality of life (HRQOL) in chronic kidney disease (CKD) patients is controversial, particularly regarding optimal hemoglobin (Hb) target ranges.We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCT) with ESA to estimate the effect of different achieved Hb values on physical HRQOL and functionality. We searched PubMed, EMBASE, CENTRAL, PEDro, PsycINFO and Web of Science databases, until May 2020. Two authors independently extracted data from studies. We included observational and RCTs that enrolled CKD patients undergoing anemia treatment with ESA with different achieved Hb levels among groups. We excluded studies with achieved Hb < 9 g/dL. For the meta-analysis, we included RCTs with control groups achieving Hb 10-11.5 g/dL and active groups with Hb > 11.5 g/dL. We analyzed the standardized mean difference (SMD) between groups for physical HRQOL.Among 8496 studies, fifteen RCTs and five observational studies were included for the systematic review. We performed the meta-analysis in a subset of eleven eligible RCTs. For physical role and physical function, SMDs were 0.0875 [95% CI: - 0.0025 - 0.178] and 0.08 [95% CI: - 0.03 - 0.19], respectively. For fatigue, SMD was 0.16 [95% CI: 0.09-0.24]. Subgroup analysis showed that trials with greater achieved Hb had greater pooled effects sizes - 0.21 [95% CI: 0.07-0.36] for Hb > 13 g/dL vs. 0.09 [95% CI: 0.02-0.16] for Hb 11.5-13 g/dL. Proportion of older and long-term diabetic patients across studies were associated with lower effect sizes.Achieved hemoglobin higher than currently recommended targets may be associated with small but potentially clinically significant improvement in fatigue, but not in physical role or physical function. Younger and non-diabetic patients may experience more pronounced benefits of higher Hb levels after treatment with ESAs.

  View details for DOI 10.1186/s12882-020-01912-8

  View details for Web of Science ID 000551764400001

  View details for PubMedID 32641153

  View details for PubMedCentralID PMC7346455

• Impact of hemodialysis and post-dialysis period on granular activity levels BMC NEPHROLOGY Larkin, J. W., Han, M., Han, H., Guedes, M. H., Goncalves, P., Poli-de-Figueiredo, C., Cuvello-Neto, A., Barra, A. L., de Moraes, T., Usvyat, L. A., Kotanko, P., Canziani, M. F., Raimann, J. G., Pecoits-Filho, R., HDFIT Study Investigators 2020; 21 (1): 197

  Abstract

  Physical activity (PA) is typically lower on hemodialysis (HD) days. Albeit intradialytic inactivity is expected, it is unknown whether recovery after HD contributes to low PA. We investigated the impact of HD and post-HD period on granular PA relative to HD timing.We used baseline data from the HDFIT trial conducted from August 2016 to October 2017. Accelerometry measured PA over 1 week in patients who received thrice-weekly high-flux HD (vintage 3 to 24 months), were clinically stable, and had no ambulatory limitations. PA was assessed on HD days (0 to ≤24 h after start HD), first non-HD days (> 24 to ≤48 h after start HD) and second non-HD day (> 48 to ≤72 h after start HD). PA was recorded in blocks/slices: 4 h during HD, 0 to ≤2 h post-HD (30 min slices), and > 2 to ≤20 h post-HD (4.5 h slices). Blocks/slices of PA were captured at concurrent/parallel times on first/second non-HD days compared to HD days.Among 195 patients (mean age 53 ± 15 years, 71% male), step counts per 24-h were 3919 ± 2899 on HD days, 5308 ± 3131 on first non-HD days (p < 0.001), and 4926 ± 3413 on second non-HD days (p = 0.032). During concurrent/parallel times to HD on first and second non-HD days, patients took 1308 and 1128 more steps (both p < 0.001). Patients took 276 more steps and had highest rates of steps/hour 2-h post-HD versus same times on first non-HD days (all p < 0.05). Consistent findings were observed on second non-HD days.PA was higher within 2-h of HD versus same times on non-HD days. Lower PA on HD days was attributable to intradialytic inactivity. The established PA profiles are of importance to the design and development of exercise programs that aim to increase activity during and between HD treatments.HDFIT was prospectively registered 20 April 2016 on ClinicalTrials.gov (NCT02787161).

  View details for DOI 10.1186/s12882-020-01853-2

  View details for Web of Science ID 000537697700001

  View details for PubMedID 32450793

  View details for PubMedCentralID PMC7249440

• Intradialytic Hypotension: Mechanisms and Outcome Han, M., Guedes, M., Larkin, J., Raimann, J. G., Lesqueves Barra, A., Fernandes Canziani, M., Cuvello Neto, A., Poli-de-Figueiredo, C., Kotanko, P., Pecoits-Filho, R. KARGER. 2020: 168-177

  Abstract

  Dialysis patients suffer from poor sleep duration and quality. We examined the self-reported sleep duration in patients randomized to either high-volume hemodiafiltration (HDF) or high flux hemodialysis (HD).Patients from 13 Brazilian dialysis clinics were enrolled in the HDFIT randomized controlled trial (RCT) investigating the impact of HDF on physical activity and self-reported outcomes. Self-reported sleep duration was taken from patient diaries recording sleep start and end time over a week during baseline, months 3 and 6, respectively. Sleep duration was analyzed by shift and nights relative to dialysis.The HDFIT study enrolled 197 patients; sleep data were available in 173 patients (87 HD; 86 HDF). Patients' age was 53 ± 15 years, 57% were white, 72% were male, 34% had diabetes, Kt/V was 1.54 ± 0.40, and albumin 3.97 ± 0.36 g/dL. Most patients reported sleeping 510-530 min/night. At 3 months, HDF patients slept 513 ± 71 min/night, HD patients 518 ± 76 min/night. At 6 months, HDF patients slept 532 ± 74 min/night, HD patients 519 ± 80 min/night. At baseline, 1st shift patients slept 406 ± 86 min the night before HD, 534 ± 64 min the night after HD, and 496 ± 99 min the night between 2 non-HD days. Compared to patients in the 2nd and 3rd shifts, patients dialyzed in the 1st shift slept less in the night before dialysis. Similar patterns were seen after 3 and 6 months.In our RCT, the dialysis modality (HDF vs. HD) had no effect on self-reported sleep duration. In both groups, dialysis in the 1st shift adversely affected self reported sleep duration.

  View details for DOI 10.1159/000504242

  View details for Web of Science ID 000519204000025

  View details for PubMedID 31851982

• Noninvasive ventilation in acute hypoxemic respiratory failure: A systematic review and meta-analysis. Response to letter JOURNAL OF CRITICAL CARE David-Joao, P. G., Guedes, M. H., Rea-Neto, A., de Oliveira Chaiben, V. B., Baena, C. P. 2019; 50: 310

  View details for DOI 10.1016/j.jcrc.2018.11.035

  View details for Web of Science ID 000458375800049

  View details for PubMedID 30558841

• Noninvasive ventilation in acute hypoxemic respiratory failure: A systematic review and meta-analysis JOURNAL OF CRITICAL CARE David-Joao, P. G., Guedes, M. H., Rea-Neto, A., de Oliveira Chaiben, V. B., Baena, C. P. 2019; 49: 84-91

  Abstract

  Evaluate current recommendation for the use of noninvasive ventilation (Bi-level positive airway pressure- BiPAP modality) in hypoxemic acute respiratory failure, excluding chronic obstructive pulmonary disease.Electronic searches in MEDLINE, Web of Science, Clinical Trials, and The Cochrane Central Register of Controlled Clinical Trials. We searched for randomized controlled trials comparing BiPAP to a control group in patients with hypoxemic acute respiratory failure. Endotracheal intubation and death were the assessed outcomes.Of the 563 studies found, nine met the inclusion criteria for this systematic review. The pooled RR (95% CI) for intubation in patients with acute pulmonary edema (APE)/community acquired pneumonia (CAP) and in immunosuppressed patients (cancer and transplants) were 0.61 (0.39-0.84) and 0.77 (0.60-0.93), respectively. For Intensive Care Units (ICU) mortality, the RR (95% CI) in patients with APE/CAP was 0.51 (0.22-0.79). The heterogeneity was low in all comparisons.NIV showed a significant protective effect for intubation in immunosuppressed patients (cancer and transplants) and in patients with APE/CAP. However, the benefits of NIV for other etiologies are not clear and more trials are needed to prove these effects.

  View details for DOI 10.1016/j.jcrc.2018.10.012

  View details for Web of Science ID 000451728600014

  View details for PubMedID 30388493

• Achieved systolic blood pressure in older people: a systematic review and meta-analysis BMC GERIATRICS Moraes, A. A. I., Baena, C. P., Muka, T., Bano, A., Buitrago-Lopez, A., Zazula, A., Erbano, B. O., Schio, N. A., Guedes, M. H., Bramer, W. M., Franco, O. H., Faria-Neto, J. 2017; 17: 279

  Abstract

  It remains unclear into which level the systolic blood pressure (SBP) should be lowered in order to provide the best cardiovascular protection among older people. Hypertension guidelines recommendation on attaining SBP levels <150 mmHg in this population is currently based on experts' opinion. To clarify this issue, we systematically reviewed and quantified available evidence on the impact of achieving different SBP levels <150 mmHg on various adverse outcomes in subjects aged ≥60 years old receiving antihypertensive drug treatment.We searched 8 databases to identify randomized controlled trials (RCTs) and post-hoc analyses or subanalyses of RCTs reporting the effects of attaining different SBP levels <150 mmHg on the risk of stroke, acute myocardial infarction, heart failure, cardiovascular mortality and all-cause mortality in participants aged ≥60 years. We performed random-effects meta-analyses stratified by study design.Eleven studies (> 33,600 participants) were included. Compared with attaining SBP levels ≥140 mmHg, levels of 130 to <140 mmHg were not associated with lower risk of outcomes in the meta-analysis of RCTs, whereas there was an associated reduction of cardiovascular mortality (RR 0.72, 95% CI 0.59-0.88) and all-cause mortality (RR 0.86, 95% CI 0.75-0.99) in the meta-analysis of post-hoc analyses or subanalyses of RCTs. Limited and conflicting data were available for the SBP levels of <130 mmHg and 140 to <150 mmHg.Among older people, there is suggestive evidence that achieving SBP levels of 130 to <140 mmHg is associated with lower risks of cardiovascular and all-cause mortality. Future trials are required to confirm these findings and to provide additional evidence regarding the <130 and 140 to <150 mmHg SBP levels.

  View details for DOI 10.1186/s12877-017-0672-4

  View details for Web of Science ID 000417522400001

  View details for PubMedID 29207946

  View details for PubMedCentralID PMC5717809