Millions of workers around the world are exposed to high temperatures, intense physical activity, and lax labor practices that do not allow for sufficient rehydration breaks. The extent and consequences of heat exposure in different occupational settings, countries, and cultural contexts is not well studied. We conducted an in-depth review to examine the known effects of occupational heat stress on the kidney. We also examined methods of heat-stress assessment, strategies for prevention and mitigation, and the economic consequences of occupational heat stress. Our descriptive review summarizes emerging evidence that extreme occupational heat stress combined with chronic dehydration may contribute to the development of CKD and ultimately kidney failure. Rising global temperatures, coupled with decreasing access to clean drinking water, may exacerbate the effects of heat exposure in both outdoor and indoor workers who are exposed to chronic heat stress and recurrent dehydration. These changes create an urgent need for health researchers and industry to identify work practices that contribute to heat-stress nephropathy, and to test targeted, robust prevention and mitigation strategies. Preventing occupational heat stress presents a great challenge for a concerted multidisciplinary effort from employers, health authorities, engineers, researchers, and governments.

Objective: To evaluate the effects on the nutritional and metabolic parameters of a very-low-protein diet supplemented with ketoacids (VLPD þ KA) in comparison with a conventional low-protein diet (LPD) in chronic kidney disease (CKD) patients. Design: Prospective, randomized, controlled clinical study. Setting: Outpatient Clinic of the Nephrology Division of Federal University of São Paulo, Brazil. Subjects: The study involved 24 patients with advanced CKD (creatinine clearance o25 ml/min) that were randomly assigned to either a VLPD þ KA (VLPD þ KA group, 12 patients) or to a conventional LPD with 0.6 g/kg/day (LPD group, 12 patients). The patients were followed for 4 months. Results: Nutritional status was adequately maintained with both diets for the studied period. Protein intake and serum urea nitrogen decreased significantly only in the VLPD þ KA group (from 0.6870.17 to 0.4370.12 g/kg/day, Po0.05; from 61.4712.8 to 43.6714.9 mg/dl, Po0.001; respectively). Ionized calcium did not change in the VLPD þ KA group but tended to decrease in the LPD group. Serum phosphorus tended to decrease in the VLPD þ KA group probably as a result of a significant reduction in dietary phosphorus (5297109 to 3737125 mg/day, Po0.05) associated to the phosphorus-binding effect of the ketoacids. No change in these parameters was found in the LPD group. Serum parathormone increased significantly only in the LPD group (from 2417138 to 4947390 pg/ml, Po0.01). The change in PTH concentration was negatively correlated with changes in ionized calcium concentration (r ¼ À0.75, P ¼ 0.02) and positively correlated with changes in serum phosphorus (r ¼ 0.71, P ¼ 0.03) only in the LPD group. Conclusion: This study indicates that a VLPD þ KA can maintain the nutritional status of the patients similarly to a conventional LPD. Besides, an improvement in calcium and phosphorus metabolism and a reduction in serum urea nitrogen were attained only with the VLPD þ KA. Thus, VLPD þ KA can constitute another efficient therapeutic alternative in the treatment of CKD patients. Sponsorship: This study was supported by CAPES, Oswaldo Ramos Foundation and Fresenius Kabi, Ltda.

Introduction: National data on chronic dialysis treatment are essential to support the development of health policies aimed at improving the treatment for thousands of people. Objective: To report epidemiological data from the 2020 Brazilian Dialysis Survey, sponsored by the Brazilian Society of Nephrology. Methods: A survey was carried out in Brazilian chronic dialysis centers using an online questionnaire for the year, covering clinical and epidemiological aspects of patients in a chronic dialysis program, data on dialysis therapy, characteristics of dialysis units and the impact of the COVID-19 pandemic. Results: 235 (28%) of the centers responded to the questionnaire. In July 2020, the estimated total number of patients on dialysis was 144,779. The estimated prevalence and incidence rates of patients per million population (pmp) were 684 and 209, respectively. Of the prevalent patients, 92.6% were on hemodialysis (HD) and 7.4% were on peritoneal dialysis (PD); 23% were on the transplant waiting list. A central venous catheter was used by a quarter of patients on HD. The incidence rate of confirmed COVID-19 between February and July 2020 was 684/10,000 dialysis patients, and the lethality rate was 25.7%. The estimated overall mortality and COVID-19 crude annual mortality rates were 24.5 and 4.2%, respectively. Conclusion: The absolute number of patients on chronic dialysis and prevalence rate continued to increase. The low use of PD as dialysis therapy was maintained and the use of long-term catheters for HD increased. The COVID-19 pandemic contributed to the increase in the overall mortality rate.

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