Publications by authors named "Paula Garcia Chiarello"

26 Publications

  • Page 1 of 1

Comparison between dual-energy x-ray absorptiometry and bioelectrical impedance for body composition measurements in adults with chronic kidney disease: A cross-sectional, longitudinal, multi-treatment analysis.

Nutrition 2021 02 18;82:111059. Epub 2020 Nov 18.

Department of Health Sciences, Ribeirão Preto Faculty of Medicine, University of São Paulo, Ribeirão Preto City, São Paulo State, Brazil.

Objective: The aim of this study was to evaluate the agreement between bioelectrical impedance spectroscopy (BIS) and dual-energy x-ray absorptiometry (DXA) for assessment of body composition in patients with chronic kidney disease (CKD).

Methods: We performed cross-sectional and prospective analyses by DXA and BIS in whole body (BISWB) and segmental (BISSEG) protocols in CKD non-dialysis-dependent (n = 81), hemodialysis (n = 83), peritoneal dialysis (n = 24), and renal transplantation (n = 80) patients. Intraclass correlation coefficient (ICC) and Bland-Altman plots were evaluated. Linear regression analysis was performed for bias assessment and development of equations. Receiver operating characteristics curve was constructed for diagnosis of inadequate error tolerance (DXA - BIS >±2kg).

Results: The agreement with DXA was greater for BISWB than BISSEG; for fat mass (FM; ICC men = 0.894; women = 0.931) than fat-free mass (FFM; ICC men = 0.566; women = 0.525), with greater bias for FFM as muscle increases and for FM in body fat extremes. The agreement was lower for body change analysis (ICC FFM men = 0.196; women = 0.495; ICC FM men = 0.465; women = 0.582). The ratio of extra- to intracellular water (ECW/ICW), body mass index, fat mass index, waist circumference, resistance, and reactance interfered in bias between methods. An ECW/ICW cutoff point of ≥0.7250 for inadequate error tolerance was determined. New prediction equations for FFM (r = 0.913) and FM (r = 0.887) presented adequate error tolerance in 55% and 63% compared with 30% and 39% of the original equation, respectively.

Conclusion: For body composition evaluation in patients with CKD, BIS applied using the whole body protocol, in normal hydration patients with CKD is as reliable as DXA; BIS must be used with caution in overhydration patients with ECW/ICW ≥ 0.7250. The newly developed equations are indicated for greater precision.
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February 2021

Chronic kidney disease under non-dialysis dependent, hemodialysis, peritoneal dialysis and kidney transplant treatment: Body composition data.

Data Brief 2020 Dec 28;33:106601. Epub 2020 Nov 28.

Nephrology Department, Hospital Universitario de la Princesa, Diego de León Street, 62, Madrid 28006, Spain.

This article presents a dataset of body composition in chronic kidney disease (CKD) non-dialysis-dependent (NDD), hemodialysis (HD) and peritoneal dialysis (PD) (for at least 3 months), and kidney transplantation (KTx) (for at least 6 months) patients. The data were collected as part of a PhD research project, an observational cross-sectional study followed by a prospective analysis (about 6 months later). Adult CKD patients (18≤age≤60 years old) from a tertiary hospital were recruited: CKD in stages 3b to 5 for NDD patients; PD patients without peritonitis in the last 30 days; HD patients in 4-hour dialysis session, 3 times per week, through an arteriovenous fistula; and KTx patients with CKD in stages 1 to 3a. Patients with presence of amputated limbs or an electronic implant, wheelchair user or inpatient, body weight above 140 kg or BMI higher than 40 kg/m, acute infections, cancer diagnosis, acquired immunodeficiency syndrome, and others that could alter body composition were excluded. The dataset in this publication consist of some clinical measurements for characterization of the sample, body composition measurements by dual-energy X-ray absorptiometry and by bioelectrical impedance spectroscopy in tetra-polar whole-body wrist to ankle (BISWB) and segmental (BISSEG) protocols of 266 CKD patients, being 137 men and 129 women; 81 in NDD treatment, 83 in HD, 24 in PD, and 80 in KTx. Measurements were performed consecutively by the same professional after an 8-hour fast, empty urinary bladder, drainage of the peritoneal dialysate, and just after the midweek hemodialysis session. To analyze differences among subgroups according to sex and CKD treatment, unpaired T test or ANOVA and Chi-square, adjusted by Bonferroni post-test, were applied. Agreement in fat free mass and fat mass measurements between BISWB and BISSEG, for cross-sectional data and for body composition changes (prospective measurement - cross-sectional measurement), was checked using intraclass correlation coefficient and 95% confidence intervals. Agreement on individual level was evaluated using the Bland-Altman method with limits of agreement. The data can be valuable in the study of body composition in CKD under all types of treatment and also for agreement analysis among body composition measurements by different instruments and techniques. The data are analysed and interpreted in the research article Bellafronte et al., 2020 [1].
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December 2020

Bed-side measures for diagnosis of low muscle mass, sarcopenia, obesity, and sarcopenic obesity in patients with chronic kidney disease under non-dialysis-dependent, dialysis dependent and kidney transplant therapy.

PLoS One 2020 20;15(11):e0242671. Epub 2020 Nov 20.

Nephrology Department, Hospital Universitario La Princesa, Madrid, Spain.

Muscle depletion and sarcopenic obesity are related to a higher morbimortality risk in chronic kidney disease (CKD). We evaluated bed-side measures/indexes associated with low muscle mass, sarcopenia, obesity, and sarcopenic obesity in CKD and proposed cutoffs for each parameter. Sarcopenia was diagnosed according to the European Working Group on Sarcopenia in Older People revised consensus applying dual energy X-ray absorptiometry (DXA) and hand grip strength (HGS), and obesity according to the International Society for Clinical Densitometry. Anthropometric parameters including calf (CC) and waist (WC) circumferences and WC/height (WC/H); bioelectrical impedance data including appendicular fat free mass (AFFM) and fat mass index (FMI) were assessed. ROC analysis and area under the curve (AUC) were applied for performance analyses. AFFM and CC presented the best performances for low muscle mass diagnosis-AFFM AUC for women was 0.96 and for men, 0.94, and CC AUC for women was 0.89 and for men, 0.85. FMI and WC/H were the best parameters for obesity diagnosis-FMI AUC for women was 0.99 and for men, 0.96, and WC/H AUC for women was 0.94 and for men, 0.95. The cutoffs (sensibility and specificity, respectively) for women were AFFM≤15.87 (90%; 96%), CC≤35.5 (76%; 94%), FMI>12.58 (100%; 93%), and WC/H>0.66 (91%; 84%); and for men, AFFM≤21.43 (98%; 84%), CC≤37 (88%; 69%), FMI>8.82 (93%; 88%), and WC/H>0.60 (95%; 80%). Sensibility and specificity for sarcopenia diagnosis were for AFFM+HGS in women 85% and 99% and in men, 100% and 99%; for CC+HGS in women 85% and 99% and in men, 100% and 100%; and for sarcopenic obesity were for FMI+AFFM in women 75% and 97% and in men, 75% and 95%. The tested bed-side measures/indexes presented excellent performance.
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January 2021

Association of dietary acid load with serum bicarbonate in chronic kidney disease (CKD) patients.

Eur J Clin Nutr 2020 08;74(Suppl 1):69-75

Department of Health Science, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil.

Background/objectives: Diet can affect the acid-base status depending on the balance between the intake of acid-inducing foods and base-inducing foods. The purpose of this study was to estimate the dietary acid load and evaluate its association with serum bicarbonate in patients with stages 3 and 4 chronic kidney disease.

Subjects/methods: One hundred adults (aged ≥ 20 years) with chronic kidney disease (CKD) stages 3 and 4 were enrolled in a cross-sectional study. A food diary was used to estimate the animal and plant protein intakes, which were used in the potential renal acid load (PRAL) formula described by Remer and Manz. PRAL was divided into quartiles. Regression models unadjusted and adjusted for age, gender, body mass index, diabetes, systolic and diastolic blood pressure, creatinine clearance were performed using the stepwise regression method.

Results: The median level (25th, 75th percentiles) of PRAL was 8.3 mEq/day (1.6, 15.6). The highest quartile of PRAL had a higher consumption of animal protein (77.8 ± 10.9%) and a reduced consumption of plant protein (22.2 ± 10.9%), compared to the lowest quartile (59.5 ± 18.6% animal protein, 40.5 ± 18.6% plant protein), p for trend <0.0001. In the adjusted analysis, a significant association was observed between the highest quartile of PRAL and serum bicarbonate in CKD patients compared to the lowest quartile (β: 2.07, 95% CI: 0.21-3.92). According to the multiple linear regression, for each increase of 1 unit of PRAL there was a reduction of 0.25 mmol/L in serum bicarbonate (HCO). Using the stepwise method, animal protein intake and PRAL were determinants of HCO (r = 0.49).

Conclusions: In CKD patients of stages 3 and 4, the dietary acid load was associated with HCO. Limiting dietary acid load could be a complementary approach in the dietary treatment of CKD. In addition, studies are needed to analyze the effect of replacing animal protein with plant protein.
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August 2020

Phase angle as a severity indicator for liver diseases.

Nutrition 2020 02 11;70:110607. Epub 2019 Oct 11.

Hospital of Clinics, School of Medicine of Ribeirão Preto, Department of Internal Medicine, Division of Nutrition and Metabolism, University of São Paulo, Brazil.

Objective: The aim of this study was to evaluate the applicability of phase angle (PhA) as a severity indicator of chronic liver diseases.

Methods: We examined the medical records of 54 patients-27 with hepatocellular carcinoma (HCC) and 27 with non-alcoholic fatty liver disease (NAFLD). The patients were ≥18 y of age. Clinical data, such as Child-Pugh and Barcelona Clinic Liver Cancer (HCC), aspartate aminotransferase-to-platelet ratio index (APRI) and fibrosis (FIB)-4 (NAFLD), nutritional parameters (body mass index [BMI], handgrip strength [HGS], and bioelectrical impedance [BIA] data) were collected. Nutritional Risk Index (NRI) was calculated. Analysis was performed using Mann-Whitney test and analysis of variance. Simple multiple linear regression for predictions (Child-Pugh in HCC, APRI and FIB-4 in NAFLD). Receiver operating characteristic curve was estimated to search a cutoff for PhA. For survival, we used the Kaplan-Meier estimator. To verify whether PhA affected patients' survival, we used the Mantel-Haenszel.

Results: The prevalence of cirrhosis was high in HCC (n = 25) and low in the NAFLD (n = 4). No patient was classified as undernourished based on BMI; however, NRI showed that 74.1% of patients with HCC had nutritional risk. Child-Pugh was positively correlated with the edema index (extracellular water/total body water [ECW/TBW]) and negatively correlated with PhA and HGS. Higher Child-Pugh and BCLC scores were associated with worse NRI. APRI and FIB-4 were positively correlated with weight and BMI. A significant difference between groups was found for the median values of R, ECW/TBW, PhA, HGS, and albumin. There was a trend toward lower survival in patients with HCC, according to the cutoff point of 5.1 degrees for PhA.

Conclusion: PhA was shown to be an independent prognostic indicator for cirrhosis and may be related to survival in these patients.
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February 2020

Alkaline Diet and Metabolic Acidosis: Practical Approaches to the Nutritional Management of Chronic Kidney Disease.

J Ren Nutr 2018 05 6;28(3):215-220. Epub 2017 Dec 6.

Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil.

The kidneys play an extremely important role in maintaining the body acid-base balance by excreting nonvolatile acids and regenerating and reabsorbing bicarbonate in the kidney tubules. As the individual loses their kidney function, renal excretion of nonvolatile acid produced by metabolism of the diet is impaired, resulting in low-grade metabolic acidosis. With this in mind, it is relevant to better understand the dietary aspects related to the acid-base balance in chronic kidney disease metabolic acidosis and try to provide possible strategies for the nutritional management of these cases. The type of diet can deeply affect the body by providing acid or base precursors. Generally speaking, foods such as meat, eggs, cheese, and grains increase the production of acid in the organism, whereas fruit and vegetables are alkalizing. On the other hand, milk is considered neutral as well as fats and sugars, which have a small effect on acid-base balance. The modern Western-type diet is deficient in fruits and vegetables and contains excessive animal products. Thus metabolic acidosis may be exacerbated by a contemporary Western diet, which delivers a high nonvolatile acid load. The remaining acid is neutralized or stored within the body. Bone and muscle are lost to neutralize the acid and serum bicarbonate falls. Early studies suggest that lowering the dietary acid load with a reduced protein content and vegetable proteins replacements, associated with an increase in fruits and vegetables intake can improve the metabolic parameters of acidosis, preserve bone and muscle, and slow the glomerular filtration rate decline. More studies focusing on the effects of controlled dietary interventions among chronic kidney disease patients are needed to determining the optimal target for nutritional therapy.
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May 2018

Nutritional status, energy expenditure, and protein oxidative stress after kidney transplantation.

Redox Rep 2017 Nov 12;22(6):439-444. Epub 2017 May 12.

a Department of Internal Medicine, Ribeirao Preto Medical School , University of Sao Paulo , Ribeirao Preto , Brazil.

Objectives: To evaluate the association between nutritional status, resting energy expenditure (REE), and protein oxidative stress in patients after kidney transplantation (KT).

Methodology: The study evaluated 35 patients transplanted at the time of hospital discharge and 3 months after regarding: body composition, REE (by indirect calorimetry), and injury factor (IF); serum urea, creatinine, glucose, albumin, total protein, advanced oxidation protein products (AOPP), vitamin C.

Results: Three months after discharge, there was an improvement in renal function, nutritional status, and oxidative stress, with a standardization in the REE/kg. There was an increase in body weight, mainly in fat mass. The correlations showed that a greater cold ischemia time resulted in a deeper decline in vitamin C; a longer hospital length stay resulted in a greater reduction in AOPP; the higher preoperative body weight showed greater increases in body fat and glucose after transplantation. For decreases in REE and IF, there were increases in total protein. Finally, at hospital discharge there was a greater gain in weight, lower albumin, and total protein among individuals who had rejection episodes.

Discussion: The KT improves many of metabolic abnormalities, with the improvement of nutritional status, oxidative stress, and normalization of REE.
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November 2017

Omega-3 Fatty Acid Supplementation is Associated With Oxidative Stress and Dyslipidemia, but Does not Contribute to Better Lipid and Oxidative Status on Hemodialysis Patients.

J Ren Nutr 2017 09 20;27(5):333-339. Epub 2017 Apr 20.

Department of Clinical Medicine, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil.

Objective: The aim of the study was to explore the effects of n-3 polyunsaturated fatty acids (PUFA) supplementation in physiological doses on oxidative stress (OS) and dyslipidemia in patients on hemodialysis (HD).

Design And Methods: Randomized, double-blind, controlled, experimental trial. A total of 88 HD patients ≥18 years old and on HD for at least 6 months. A total of 43 patients received 1.28 g/day of n-3 PUFA, and 45 other patients received soybean oil for 12 weeks. Both oil supplements were vitamin E standardized. Routine tests, lipid profile, advanced oxidation protein products, isoprostanes, vitamins C and E, total antioxidant capacity, serum fatty acids, and adverse effects were evaluated.

Results: Supplementation was not able to alter lipid or OS profiles. There was an increase in the serum n-3 PUFA levels (eicosapentaenoic acid: +116%; docosahexaenoic acid: +100%) and an improvement in the n-6/n-3 ratio (-49%) in the supplemented group. Associations between n-3 PUFA and improvement in isoprostane and advanced oxidation protein product and HDL were observed. Treatment was well tolerated.

Conclusion: Although the n-3 PUFA supplementation was associated with lower concentrations of isoprostane and advanced oxidation protein product and higher HDL levels, it was not sufficient for the improvement of highly prevalent risk factors, such as OS and dyslipidemia in HD patients.
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September 2017

Variation of resting energy expenditure after the first chemotherapy cycle in acute leukemia patients.

Nutr Cancer 2016 28;68(1):86-93. Epub 2015 Dec 28.

b Department of Internal Medicine , Faculty of Medicine of Ribeirão Preto, University of São Paulo , Av. Bandeirantes, São Paulo , Brazil.

Changes in resting energy expenditure (REE) of cancer patients vary depending on type of tumor, treatment time point and kind of treatment. Little is known about REE of acute leukemia adult patients after treatment, especially with results related to body weight or fat free mass (FFM). This study aimed to assess changes in REE of acute leukemia adult patients before and after the first remission induction. Evaluation of REE was performed by indirect calorimetry and predicted REE was calculated by Harris-Benedict equation. Weight and height were measured and compared to a control group of healthy individuals. FFM was assessed by bioelectrical impedance for adjusting REE values. We evaluated 18 patients and 26 healthy individuals. At diagnosis, patients presented REE, REE/weight, and REE/FFM higher than the controls. Reductions of REE, REE/weight, and REE/FFM were also observed in patients after the first cycle of chemotherapy. The predicted REE for the patients group showed significant lower value compared with measured REE. Before the first cycle of chemotherapy REE was increased but undergoes a reduction after treatment, reaching values similar to the controls. For predictive Harris-Benedict equation, stress factors should be added to avoid underestimation of REE before and after chemotherapy.
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December 2016

Nutritional status according to the stages of Alzheimer's disease.

Aging Clin Exp Res 2015 Aug 25;27(4):507-13. Epub 2014 Dec 25.

Department of Internal Medicine, Faculty of Medicine of Ribeirão Preto (FMRP), University of São Paulo (USP), São Paulo, Brazil,

Objective: To assess the nutritional status of Alzheimer's disease (AD) patients with no other associated dementia, according to disease stage.

Design: Cross-sectional observational study.

Setting: Neurobehavioral Diseases Outpatient Clinic, Clinical Hospital, Ribeirao Preto Medical School (University of São Paulo).

Participants: The sample consisted of 36 individuals of both genders with AD diagnosis, and no other associated type of dementia, in various stages of the disease, according to the Clinical Dementia Rating (CDR 0.5-3).

Measurements: Nutritional status was evaluated using the Mini Nutritional Assessment (MNA) and anthropometric measurements such as weight, body mass index (BMI) and arm, waist, abdomen and hip circumferences. In addition, body composition was assessed by bioelectrical impedance analysis (BIA).

Results: The mean age of the group was 74.2 ± 10.1 years, 72.2 % of them were women. The MNA showed that most of these individuals were at risk for malnutrition (55.5 %) and many of them (43.7 %) were underweight according to BMI. Data from BIA analysis revealed that 41.7 % of these individuals had a quantity of body fat classified as malnutrition and 11.1 % had a phase angle (PA) below recommended values for age group. There was a negative and significant correlation of lean mass and PA with age, and of global MNA evaluation with CDR, as well as a positive correlation of MNA total score with fat mass and BMI. Worse classifications of nutritional status obtained by MNA scores were also observed in the more severe stages of the disease, according to the CDR.

Conclusion: Patients with AD are mostly elderly with changes in body composition that are typical of aging, with signs of peripheral malnutrition and preservation of abdominal fat. However, greater impairment of general nutritional status was observed in the more advanced stages of AD, creating a situation of greater vulnerability for these patients.
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August 2015

Study of Protein Oxidative Stress, Antioxidant Vitamins and Inflammation in Patients Undergoing either Hemodialysis or Peritoneal Dialysis.

Int J Vitam Nutr Res 2014 ;84(5-6):261-8

1 Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, Brazil.

Background: The influence of dialysis modality on oxidative stress (OS) and inflammation is not yet clear. Elucidating this influence could provide novel therapy concepts for cardiovascular diseases.

Aim: To compare protein OS, antioxidant vitamins and inflammation in patients undergoing either hemodialysis (HD) or peritoneal dialysis (PD).

Methods: A cross-sectional study was performed with 19 PD and 21 HD patients treated for ≥ 6 months. The control group was composed of 17 healthy individuals. Advanced oxidation protein products (AOPP), advanced glycation end products (AGEs), vitamins C, A and E, C-reactive protein and interleukin 6 were measured in plasma samples.

Results: OS was higher in the dialysis group when compared with controls, but HD patients showed higher AOPP compared with PD (HD:141.9 ± 75.2 µmol/L; PD: 112.5 ± 69.3 µmol/L, P< 0.01) and AGEs (HD: 32.2 ± 10.6 AU x10³; PD: 26.6 ± 4.9 AUx10³, P< 0.05). There was no difference in inflammation and vitamin levels among dialysis patients. In HD patients, AGEs correlated moderately with serum vitamin C (r = 0.46; P< 0.05).

Conclusion: The dialysis modality adopted influences protein OS, but it has no effect on antioxidant status or inflammation. Hemodialysis probably exacerbates OS due to the increased bioincompatibility of the dialysis procedure, and this scenario seems to be related to the intravenous supplementation of vitamin C. Peritoneal dialysis allows for a better oxidative balance, which may reduce cardiovascular risk.
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September 2015

Late referral for chronic kidney disease patients: nutritional point of view.

Nutr Hosp 2014 Sep 12;31(3):1286-93. Epub 2014 Sep 12.

Medical School of Ribeirão Preto, University of São Paulo. Brazil..

Unlabelled: The prevalence of late referral of patients with chronic kidney disease (CKD) is high and has been associated with a worse CKD prognosis, however few studies have been conducted from a nutritional perspective.

Objective: Characterize the nutritional status of patients with CKD at first attendance in a nephrology service, with early (ER) and late referral (LR).

Methodology: It was a cross-sectional study with patients older than 18 years referred to the Nephrology service of a University Hospital. The referral groups were classified according to estimated glomerular filtration rate (eGFR) as: LR (eGFR15 ml/min/1.73m2) based on the Kidney Disease Outcomes Quality Initiative. Nutritional evaluation included subjective global assessment (SGA), anthropometric, laboratory and bioelectrical impedance data. The SAS software was used for statistical analysis.

Results: Seventy-five patients were evaluated, 29% of them belonging to the LR group. This group showed a greater previous weight loss (-7.0 ± 3.5 versus -2.8 ± 7.0 Kg) and lower values for all anthropometric and body composition variables. In general, the laboratory results of the LR group also were worse. According to the SGA, all LR patients had some degree of malnutrition (50% with severe malnutrition against 28.8% in ER), showing significantly lower results for GFR (21.4 + 12.2 ml/ min/1.73 m2), albumin (3.9 + 0.3 g/dL), serum bicarbonate (22.8 + 5.1 mmol/L) and phase angle (5.3+ 0.6 θ). Renal function was positively correlated with percent adequacy of arm circumference (r=0,40; p<0,01) and albumin (r=0,45; p<0,01).

Conclusion: The LR group showed a worse nutritional status showing that, for the nutritional point of view, the delayed referral brings substantial losses that can make difference in future treatment, thus demonstrating the importance of early nutritional monitoring for this population.
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September 2014

Microbiological profile and nutritional quality of raw foods for neutropenic patients under hospital care.

Rev Bras Hematol Hemoter 2013 ;35(2):94-8

Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo - USP, Ribeirão Preto, SP, Brazil.

Objective: This study aimed to analyze and compare the microbiological profile and vitamin C content of raw and cooked foods destined for neutropenic inpatients.

Methods: Three vegetables and nine fruits, raw and boiled, washed and sanitized were examined. Heat-tolerant coliforms and coagulase-positive staphylococci were counted and the presence of Salmonella spp was investigated. The vitamin C content was analyzed by a colorimetric reaction. The Statistical Package for Social Sciences (SPSS) software was used for statistical analysis and the nonparametric Wilcoxon test was used to compare the mean vitamin C values of the cooked and raw foods. The Spearman correlation test was applied to determine the associations between the parameters evaluated.

Results: Salmonella spp was absent in all samples and the populations of coagulase-positive staphylococci and heat-tolerant coliforms were below the minimum detectable limits of the methods employed (< 100 colony forming units (CFU)/g and < 3 most probable number (MPN)/g, respectively). There was a significant loss of vitamin C in the cooked foods, 38.9% on average, compared to the raw foods, a loss that was positively correlated with cooking time.

Conclusion: The fresh fruits and vegetables properly sanitized in this study had a microbiological profile consistent with that required by Brazilian law. Furthermore, the nutritional value of the neutropenic diet is diminished, at least in terms of the vitamin C content.
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June 2013

Association of body fat with inflammation in peritoneal dialysis.

Inflammation 2013 Jun;36(3):689-95

Department of Internal Medicine, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil.

Peritoneal dialysis (PD) frequently leads to body weight gain, which appears to be a potential cause of the chronic inflammation frequently present in these patients. The consequences of this inflammation are impaired nutritional status, accelerated atherosclerosis, and increased mortality. To assess the association between inflammation and body fat in female patients treated with PD. Nineteen female patients on PD for at least 6 months with no infectious complications or malignant or acute inflammatory diseases. Nutritional status was determined by measuring weight, height, body mass index (BMI), waist (WC), and mid-arm circumferences (MAC), mid-arm muscle area, and tricipital fold (TCF). Bioelectrical impedance (BIA) was used to determine body composition. Biochemical evaluation included the determination of serum albumin, urea, creatinine, and C-reactive protein (CRP). The glucose absorbed from the dialysis solution was quantitated. According to BMI, two patients were classified as malnourished and ten as overweight/obese. Sixteen individuals had high WC measurements and 12 had excess body fat (BF) as measured by BIA. High CRP levels were observed in 12 patients, who had higher WC, MAC, BMI, TCF, and BF measurements compared to non-inflamed patients. Positive associations were detected between CRP and BMI, MAC, WC, and TCF. Associations between BF and CRP suggest that adiposity may be a potent exacerbating factor of inflammation in this population, especially visceral fat. Thus, obesity may be considered to be one more factor responsible for the early atherosclerosis and high cardiovascular mortality observed in these patients.
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June 2013

Intestinal permeability and nutritional status in developmental disorders.

Altern Ther Health Med 2012 Mar-Apr;18(2):19-24

Ribeirao Preto School of Medicine, São Paulo University, [corrected] Brazil.

Context: Autism is a developmental disorder with a possible connection between dietary components and triggering or worsening of symptoms. An altered intestinal permeability might allow absorption of incompletely digested peptides (gluten and casein) that could produce opioid-like activity on the brain, causing significant changes in behavior.

Objective: To assess the intestinal permeability and nutritional status of participants with developmental disorders to determine if changes in the intestinal mucosal barrier and/or injury to the intercellular junctions have occurred that might justify application of further dietary modifications.

Design: To assess intestinal permeability, the research team analyzed participants urine under fasting conditions, using gas chromatography to determine chromatographic peaks. To assess nutritional status, the team determined participants heights and weights and performed a bioelectric bioimpedance examination at least 4 hours after their most recent meal. In addition, the team determined food intake using three diet diaries. They asked participants and caregivers to register each food consumed during 2 nonconsecutive weekdays and 1 weekend day.

Setting: The study occurred at the Ribeirao Preto School of Medicine, Sao Paulo University.

Participants: Seven participants aged 9 to 23 years with developmental disorders (the developmental group, DG) completed the study. The research team recruited them through the Association of Friends of the Autistic Persons of Ribeirao Preto in Ribeirao Preto, Brazil. The control group (CG) consisted of nonsmoking healthy volunteers in the general population who were similar in age to the experimental group and did not suffer from diseases that potentially could influence nutritional status and intestinal function.

Intervention: To assess intestinal permeability, participants ingested 150 mL of an isosmolar solution of the sugars mannitol (2 g) and lactulose (7.5 g) under fasting conditions and the researchers collected all voided urine over a period of 5 hours.

Outcome Measures: Using chromatographic peaks, the research team quantified the mannitol and lactulose in participants urine by calculating the percentage excreted in relation to the ingested amounts of sugar. This calculation gave them the lactulose-to-mannitol ratio (L/M). To evaluate nutritional status, they used data regarding bioimpedance resistance, heights, and weights to estimate lean mass and body water (in liters). They classified adults and adolescents using the body mass index (BMI). For children (2-10 y), they classified participants height-to-age and weight-to-height ratios. The research team used food intake to examine the macronutrient interval, the mean added sugar consumption, and the quantity of protein, in g/kg weight.

Results: Participants with developmental disorders (n = 7) were more likely to be overweight. Their usual diet revealed a high intake of lipids (%) and proteins (g/kg) (compared to reference values) and a high intake of calories (kcal) and carbohydrates (%) (compared to CG) as well as a high intake of food sources that are important contributors of casein and gluten. The DGs (n = 7) mean mannitol excretion was lower, and their L/M higher than the CGs (n = 7) (P < .05). Their increased L/M may indicate atrophy of the intestinal-mucosa surface and/or injury to the intercellular junctions or the effect of some other abnormality. The small number of participants, however, prevented more complex statistical analysis.

Conclusions: Researchers need to complete additional studies to confirm the existence of abnormalities in autistic individuals intestines and to justify the use of dietary restrictions on gluten and casein to improve the symptoms of autism.
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May 2012

Protein oxidative stress and dyslipidemia in dialysis patients.

Ther Apher Dial 2012 Feb 3;16(1):68-74. Epub 2011 Nov 3.

Internal Medicine, University of São Paulo, Ribeirao Preto, Brazil.

Our aim was to investigate and determine the associations between oxidative stress (OS), dyslipidemia and inflammation in patients treated with continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) using observational cross-sectional study. Twenty patients in CAPD and 48 in HD for at least 8 weeks and aged ≥18 years were included in the study. Individuals with malignant or acute inflammatory disease were excluded. A control group of 17 healthy individuals was also recruited. The biochemical parameter evaluations were analyzed using colorimetric kits for albumin, serum glucose, total cholesterol (TC) and lipid fractions. To determine the inflammatory status, CRP, IL-6 and TNF-α were analyzed by automated chemiluminescence kits. Plasma advanced oxidation protein products (AOPP) were determined by spectrophotometry. Mean AOPP levels were significantly higher for the HD group compared to the control, and there was no difference in AOPP concentrations between the control and CAPD groups. Dialysis patients had levels of inflammatory parameters higher than controls, and showed a high prevalence of patients with dyslipidemia, especially in CAPD. In the HD group, AOPP was positively correlated with triglycerides (TG) and inversely associated with HDL. Also the HD group was observed to have negative associations between TNF-α and HDL, LDL and TC. In the CAPD group, CRP was inversely correlated with HDL. Hemodialysis patients had increased protein OS and associations of inflammation and dyslipidemia were also observed in these dialysis groups. A more detailed characterization of the relations between oxidative stress and other more traditional risk factors has therapeutic importance, since cardiovascular diseases are the leading cause of death among dialysis patients.
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February 2012

What is the meaning of homocysteine in patients on dialysis?

J Ren Nutr 2011 Sep 25;21(5):394-400. Epub 2011 Mar 25.

Department of Internal Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.

Objective: To evaluate the determinants of total plasma homocysteine levels and their relations with nutritional parameters, inflammatory status, and traditional risk factors for cardiovascular disease in renal failure patients on dialysis treatment.

Design: The study was conducted on 70 clinically stable patients, 50 of them on hemodialysis (70% men; 55.3 ± 14.5 years) and 20 on peritoneal dialysis (50% men; 62 ± 13.7 years). Patients were analyzed in terms of biochemical parameters (serum lipids, creatinine, homocysteine [Hcy], creatine-kinase [Ck], folic acid, and vitamin B(12)), anthropometric data, markers of inflammatory status (tumor necrosis factor-alpha, C-reactive protein, interleukin-6), and adapted subjective global assessment.

Results: The total prevalence of hyperhomocysteinemia (>15 μmol/L) was 85.7%. Plasma folic acid and plasma vitamin B(12) were within the normal range. Multiple regression analysis (r(2) = 0.20) revealed that the determinants of total Hcy were type of dialysis, creatinine, Ck, folic acid, and total cholesterol. Hcy was positively correlated with albumin and creatinine and negatively correlated with total cholesterol, high density lipoprotein cholesterol, folic acid, and vitamin B(12).

Conclusions: The determinants of total Hcy in the study sample were type of dialysis, creatinine, Ck, folic acid, and total cholesterol. Evidently, the small sample size might have had an effect on the statistical analyses and further studies are needed. However, Hcy in patients on dialysis treatment may not have the same effect as observed in the general population. In this respect, the association between malnutrition and inflammation may be a confounding factor in the determination of the true relationship between Hcy, nutritional status, and cardiovascular risk factors in this group.
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September 2011

Short-term carbohydrate-restricted diet for weight loss in severely obese women.

Obes Surg 2011 Aug;21(8):1194-202

Department of Internal Medicine, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil.

Background: Weight loss in bariatric pre-surgery period reduces surgical complications, surgery time, blood loss, and length of hospital stay. Carbohydrate-restricted diets have been used as an alternative for weight loss. We tested the efficacy of a low-calorie carbohydrate-restricted diet (RD) for short-term weight loss in women with severe obesity and evaluate its metabolic effects in relation to a conventional low-calorie diet (CD).

Methods: The subjects received a 1,200-kcal diet with or without carbohydrate restriction for a period of 1 week in the hospital. Nineteen obesity class III women were distributed into two groups: experimental (n = 10) and control (n = 9). The following variables were assessed at the beginning and end of the study: anthropometric measurements, body composition, resting energy expenditure, substrate oxidation, and biochemical tests.

Results: Compared with CD, RD led to larger weight loss (2.6 and 4.4 kg, respectively; p = 0.01) and waist circumference reduction (p < 0.01). Among the assessed biochemical indicators, only plasma and urine acetone levels were different (p < 0.01); higher values were found in the experimental group with no symptoms and other diet-related complaints. There was also a significant decrease in triglycerides and carbohydrate oxidation, as well as a significant enhancement in lipid oxidation in the RD group.

Conclusion: Short-term RD was more efficient than CD regarding quick weight loss and waist circumference reduction, which may favor gastroplasty. Also, RD did not lead adverse metabolic effects.
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August 2011

Anti-oxidative systems in rat skeletal muscle after acute physical exercise.

Appl Physiol Nutr Metab 2007 Apr;32(2):190-6

Department of Pathology, Ribeirão Preto School of Medicine, University of São Paulo, 14.049-900, Ribeirão Preto, SP, Brazil.

The objective of this study was to analyze the oxidative stress of skeletal muscle of sedentary rats at the morphological and biochemical level, due to acute physical effort performed at different intensities and during different periods of time. Forty-two male sedentary Wistar rats were divided into two groups, group A (swimming for 50 min) and group B (swimming for 100 min), which were further subdivided into 3 different exercise intensities, non-weight bearing (subgroup I), 3% weight load (subgroup II), and 5% weighted load (subgroup III), as well as a control-rested group (C). The animals were killed by ether inhalation and fragments of the gastrocnemius muscle were removed for the determination of malondialdehyde (MDA), reduced glutathione (GSH), and vitamin E concentrations. When all groups were compared with the control-rested group (C), gastrocnemius MDA levels at 50 and 100 min were higher at all swimming intensities. GSH consumption was greater at all intensities in group A, and only at 100 min in group BI; vitamin E consumption was significantly higher only in groups BII and BIII. When groups were compared by intensity at each swimming time there were no differences between I, II, and III at 50 min for any of the substances analyzed (MDA, GSH, and vitamin E), but at 100 min opposite effects were observed for GSH and vitamin E, with vitamin E consumption and GSH recovery occurring with increasing weight load. Higher concentrations of skeletal muscle MDA could indicate elevated lipid peroxidation at each time and exercise intensity, with highest MDA levels observed after the longest exercise duration and at the highest intensity. The layer-line mode of utilization of body antioxidants could explain the concentrations of GSH and vitamin E: first the use of GSH, even with minor oxidative stress, and then vitamin E consumption only in the presence of greater and more prolonged oxidative stress, indicating the necessity of adequate body levels of both antioxidants for proper utilization by the body antioxidant defense system.
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April 2007

Intestinal permeability and oxidative stress in patients with alcoholic pellagra.

Clin Nutr 2006 Dec 18;25(6):977-83. Epub 2006 May 18.

Internal Medicine Department, Division of Nutrition, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Av. Bandeirantes, 3900, 14049-900 Ribeirão Preto, SP, Brazil.

Background & Aims: Increased intestinal permeability is one of the grastointestinal changes observed in alcoholic patients. However, there are no objective definitions as yet of how alcohol induces pathological changes in the various organs. The action of oxygen-free radicals during ethanol metabolism has been considered a determinant factor of these alterations. The present study was undertaken to determine the effect of niacin supplementation on intestinal permeability and oxidative stress in patients with alcoholic pellagra.

Methods: The study was divided into two phases: in Phase 1 we studied ten patients with pellagra before treatment with niacin, and in Phase 2 we studied the same patients after 27 days of treatment with niacin. Intestinal permeability was assessed by the (51)CrEDTA test and the antioxidant action of niacin supplementation was assessed by the determination of lipid peroxidation (plasma malondialdehyde, MDA), protein oxidation (plasma carbonyl group) and of the antioxidants plasma vitamin E and erythrocyte glutathione peroxidase.

Results: Comparison of intestinal permeability by the (51)CrEDTA test before and after niacin treatment showed a significant decrease in permeability from 4.29+/-1.92% to 1.90+/-1.19% (P<0.05). Assessment of oxidative stress showed a significant decrease (P<0.05) in lipid and protein peroxidation (MDA: 1.19+/-0.40-0.89+/-0.27 micromol/l; carbonyl groups: 2.22+/-0.36-1.84+/-0.40 nmol/mg protein).

Conclusions: The results suggest that niacin and vitamin E deficiency in patients with pellagra could be important factors in increased intestinal permeability and decreased antioxidant conditions, recovering to normal values after treatment with niacin, associated to alcohol abstinence and a balanced diet.
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December 2006

Homocysteine and its determinants in nondialyzed chronic kidney disease patients.

J Am Diet Assoc 2006 Feb;106(2):267-70

Nutrition Program, Federal University of São Paulo, SP, Brazil.

This cross-sectional study aimed to investigate the prevalence of hyperhomocysteinemia, the determinants of plasma total homocysteine concentrations, and the relationship of total homocysteine with nutritional parameters in a sample of patients with chronic kidney disease (CKD) and not yet on dialysis. The study was done with outpatients from the Nephrology Division of the Federal University of São Paulo and Oswaldo Ramos Foundation. Sixty-six patients with CKD (70% male; age 58.6+/-15.6 years [mean+/-standard deviation]) with moderate to severe renal impairment (creatinine clearance=29.8+/-14.3 mL/min [0.5+/-0.24 mL/sec]), clinically stable, and older than 18 years were included. A group of 20 healthy subjects from the clinic staff was also studied for reference values for plasma homocysteine, folate, and vitamin B-12 concentration. Fasting blood samples were collected to determine plasma total homocysteine, folate, vitamin B-12, and creatinine. To calculate creatinine clearance, a 24-hour urine collection sample was obtained. The assessment of nutritional status included anthropometric parameters. Pearson correlation, Mann-Whitney test, and multiple linear regression analysis were used for statistical analyses. The main results showed that the concentration of total homocysteine in the patients was significantly increased compared with the healthy subjects (3.4+/-1.7 vs 1.41+/-0.42 mg/L [25.4+/-12.2 vs 10.4+/-3.1 micromol/L]; P<0.001). Plasma folate and plasma vitamin B-12 were in the normal range and did not differ between patients and healthy individuals. A high prevalence of hyperhomocysteinemia (total homocysteine >1.89 mg/L [14 micromol/L]) was found in the patients (89%). Plasma total homocysteine did not correlate with any of the nutritional parameters studied and did not differ between patients in terms of whether they were using or not using folic acid supplementation (3.07+/-1.09 vs 3.55+/-1.78 mg/L [22.7+/-8.1 vs 26.3+/-13.2 micromol/L]; P=0.47), although plasma folate was significantly higher in the supplemented group (12.6+/-3.0 vs 8.0+/-3.6 ng/mL [28.5+/-6.8 nmol/L vs 18.1+/-8.2 nmol/L]; P<0.001). According to the multiple regression analysis, the determinants of total homocysteine were only plasma folate, plasma vitamin B-12, and creatinine clearance (r2=0.20). In conclusion, a high prevalence of hyperhomocysteinemia was found in our sample of nondialyzed patients with CKD. The determinants of total homocysteine levels were plasma folate, plasma vitamin B-12, and creatinine clearance. No association between nutritional parameters and total homocysteine was observed.
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February 2006

Niacin metabolite excretion in alcoholic pellagra and AIDS patients with and without diarrhea.

Nutrition 2004 Sep;20(9):778-82

Nutrition School of Medical School of Ribeirão Preto, University of São Paulo, Brazil.

Objective: Malnourished patients with the acquired immunodeficiency syndrome (AIDS) can develop pellagra-like manifestations such as dermatitis, diarrhea, and dementia; therefore, we tested the hypothesis that patients with AIDS and diarrhea would have niacin depletion. This study compared 24-h urine excretion of N1-methyl-nicotinamide (N1MN) among patients with pellagra and patients with AIDS who did and did not have diarrhea.

Methods: Three groups were studied: G1 (patients with AIDS and diarrhea, n = 5); G2 (patients with AIDS and no diarrhea, n = 7), and G3 (patients with alcoholic pellagra and without the human immunodeficiency virus, n = 8). Diarrhea was defined as the production of at least three liquid stools per day over 3 to 5 d. Studies included mucosal intestinal biopsy, malabsorption tests, detection of parasites in stool, and serum albumin measurements. Semiquantitative food-frequency questionnaire, anthropometry, and daily urinary N1MN excretion were also determined. Groups were matched in relation to age, sex, presence of parasites in stool, and intestinal absorption results.

Results: G1 had normal intestinal examination by light microscopy and no parasites in stools. G2 group showed lower levels of serum albumin (2.6 +/- 0.3 g/dL) when compared with G1 (3.4 +/- 0.3 g/dL) and G3 (3.1 +/- 0.7 g/dL). Except for patients with pellagra, groups met their energy requirements. Patients in G3 (0.013, 0.01-0.081 mg/dL) and G1 (0.062, 0.001-0.33 mg/dL) excreted smaller amounts of N1MN in urine than did those in G2 (0.63, 0.02-2.9 mg/dL).

Conclusions: Patients with AIDS and diarrhea excreted less N1MN in urine than did those without diarrhea. These patients may have an impaired niacin nutritional status, possibly associated with increased metabolic needs.
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September 2004

Effect of an acute dose of ethanol on lipid peroxidation in rats: action of vitamin E.

Food Chem Toxicol 2004 Mar;42(3):459-64

Postgraduation in Food Science, Faculty of Pharmaceutical Sciences, University of São Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirão Preto-SP, Brazil.

Free radical generation is an important step in the pathogenesis of ethanol-associated liver injury. Administration of ethanol induces an increase in lipid peroxidation both by enhancing the production of oxygen reactive species and by decreasing the levels of endogenous antioxidants. This work focuses on the generation of free radicals provoked by an acute ethanol dose in rats, and the role of different dietary levels of vitamin E. The objective of this investigation was to study the effect of three different dietary levels of vitamin E (deficient, control and supplemented with 20 times higher levels) on plasma and liver lipid peroxidation (assayed by TBARS), vitamin E in plasma and liver, and hepatic glutathione concentration, in rats receiving the different diets. The animals were submitted to an acute dose of ethanol (5 g/kg body weight) administered by gavage at the end of an experimental 4 week period and were sacrificed at 0, 2, 4, 8 and 24 h after ethanol administration. Dietary vitamin E caused a dose-dependent increase in liver and plasma concentration of the vitamin, but ethanol administration decreased hepatic vitamin E in all groups. TBARS concentrations were higher in liver of rats that received the deficient diet, independent of ethanol, however, liver TBARS concentrations were low in control and supplemented groups, but increased with ethanol ingestion. Glutathione levels were lowered by ethanol administration in all groups, in different times, but recovered to this original level in 24 h time. In conclusion, vitamin E deficiency alone induces liver lipid peroxidation in rats, acute administration of ethanol affect vitamin E and GSH level and maintenance of adequate or higher vitamin E levels acts as a protective factor against free radical generation.
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March 2004

Hyperhomocysteinemia and oxidative stress in hemodialysis: effects of supplementation with folic acid.

Int J Vitam Nutr Res 2003 Nov;73(6):431-8

Faculty of Medicine of Ribeiräo Preto, University of Säo Paulo, Ribeirão Preto, Brazil.

This study was undertaken to evaluate two different doses of folic acid and their effects on the control of hyperhomocysteinemia, and on pro-oxidant and antioxidant changes in a group of 32 hemodialysis (HD) patients. Blood samples were collected in a group of patients at three different times: before (basal; B), after the first (S1), and after the second (S2) three-month supplementation periods, and compared to samples from a group of healthy individuals. Analysis of vitamins (C, E, folate, and B12), oxidant parameters (lipid and protein oxidation), and homocysteine were performed. Hyperhomocysteinemia of different degrees was observed in all patients on HD (45.30 +/- 24.89 microM). Oxidative stress was also detected, with lipoperoxidation and protein oxidation being associated with lower concentrations of antioxidant substances (vitamins E and C). The first folate dose (2.5 mg after each dialysis session) reduced by half the initial concentrations of homocysteine (44.92 +/- 22.05 to 20.56 +/- 6.79 microM; p < 0.05) but did not normalize its values. The second dose (15 mg) did not show an additional effect, but it was at this time that lipoperoxidation was significantly reduced, although the protein oxidation showed no change. It was concluded that the first dose of folic acid was efficient in reducing homocysteine concentrations, without normalization of values. The participation of hyperhomocysteinemia in oxidative stress appeared to be partial, but in combination with dialysis treatment, may contribute to the induction of an oxidative environment in this group. The possible antioxidant action of folate must also be considered in this case, acting directly against lipoperoxidation or through hyperhomocysteinemia control. Routine supplementations of folic acid and other antioxidant vitamins should be considered in hemodialysis in order to reduce homocysteine levels to lower values, that although not normal, may be more beneficial in minimizing the cardiovascular risk in this group.
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November 2003

Hyperhomocysteinemia and oxidative stress during dialysis treatment.

Ren Fail 2003 Mar;25(2):203-13

Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil.

Background/aims: The concomitant presence of hyperhomocysteinemia and oxidative stress may represent a determinant factor for the occurrence of vascular alterations and cardiac diseases, the main cause of death among dialysis patients. The aim was to analyze the occurrence of hyperhomocysteinemia and oxidative stress and their possible relationship in dialysis patients.

Methods: Antioxidant substances, homocysteine, folate, and vitamin B12 were determined in blood from 32 patients on hemodialysis (HD), 21 patients on peritoneal dialysis (PD), and 12 healthy individuals.

Results: Different degrees of hyperhomocysteinemia were observed in all HD patients and in 95% of the PD patients (45.30 +/- 24.89 microM in HD and 35.50 +/- 26.53 microM in PD). Oxidative stress defined as an imbalance between oxidant and antioxidant forces was observed in all dialysis patients, but was more intense in HD individuals. In this group, lipoperoxidation and protein oxidation were associated with lower concentrations of antioxidants such as erythrocyte vitamin E and vitamin C.

Conclusions: Hyperhomocysteinemia and oxidative stress occur in both types of dialysis treatment, possibly contributing to the establishment of complications in these patients.
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March 2003