Predictors of protein-energy wasting in haemodialysis patients: a cross-sectional study.

BACKGROUND: Protein-energy wasting (PEW) is a highly prevalent condition in haemodialysis patients (HD). The potential usefulness of nutritional-inflammatory markers in the diagnosis of PEW in chronic kidney disease has not been established completely. We hypothesised that a combination of serum albumin, percentage of mid-arm muscle circumference and standard body weight comprises a better discriminator than either single marker of nutritional status in HD patients. METHODS: A cross-sectional study was performed in 80 HD patients. Patients were categorised in two groups: well-nourished and PEW. Logistic regression analysis was applied to corroborate the reliability of the three markers of PEW with all the nutritional-inflammatory markers analysed. RESULTS: PEW was identified in 52.5% of HD patients. Compared with the well-nourished patients, PEW patients had lower body mass index, serum pre-albumin and body cell mass (all P < 0.001) and higher C-reactive protein (s-CRP) (P < 0.01). Logistic regression analyses showed that the combination of the three criteria were significantly related with s-CRP >1 mg dL(-1) , phase angle <4°, and serum pre-albumin <30 mg dL(-1) (all P < 0.05). Other indicators, such as lymphocytes <20% and Charlson comorbidity index, were significantly involved (both P < 0.01). A receiver operating characteristic curve (area under the curve) of 0.86 (P < 0.001) was found. CONCLUSIONS: The combined utilisation of serum albumin, percentage of mid-arm muscle circumference and standard body weight as PEW markers appears to be useful for nutritional-inflammatory status assessment and adds predictive value to the traditional indicators. Larger studies are needed to achieve the reliability of these predictor combinations and their cut-off values in HD patients and other populations.

[Intra-dialysis parenteral nutrition in chronic renal patients: consensus SEN-SENPE]. / Nutrición parenteral intradiálisis en el enfermo renal crónico: consenso SEN-SENPE.

Given the high prevalence of the hyponutrition state among haemodialysis patients and knowing that this implies an increase in the rates of infection, hospitalisation and hospital stay, which translates into an increase in global morbid-mortality, the Spanish Society of Nephrology (SEN) and the Spanish Society of Parenteral and Enteral Nutrition (SENPE) have reached a consensus on the indications, contraindications, and limitations of Intra-Dialysis Parenteral Nutrition (IDPN.) This consensus considers IDPN as a valid alternative to other types of nutritional support when these show their lack of efficacy. The bases are set regarding the timing of nutritional intervention with IDPN, its ideal composition, the time of administration, its controls, follow-up schedules, and the time at which the nutritional support has to be discontinued.

Evaluation of oxidant-antioxidant balance in patients on maintenance haemodialysis: a comparative study of dialyzers membranes.

BACKGROUND: Haemodialysis (HD) exacerbates oxidative stress (OS). The polymethyl-methacrylate (PMMA)-BK-F membrane ameliorates OS and inflammation markers compared to polyacrylonitrile (PAN/AN69) and cellulose membranes. This may be due to the size of pore radius, high flux or other specific properties of PMMA membranes. AIM: To compare OS and inflammatory status in HD-treated end stage renal disease patients with membranes of different pore size radius and flux. METHODS: 47 patients of both sexes were studied. The HD membranes with which the patients were normally treated were changed to BK-P or B-3 membranes for 6 months. Intracellular and extracellular components of the oxidant-antioxidant balance (OAB), C-reactive protein (CRP), beta2-micro-globulin (beta2mu-globulin), albumin and transferrin were measured. RESULTS: A significant decrease in red cell membrane thiobarbituric acid reacting substances and an increase in cytosolic superoxide dismutase (SOD) and plasma total antioxidant substances were observed in all patients after 6 months of treatment with BK-P and B-3 membranes except SOD and CRP in patients previously dialysed with triacetate cellulose membranes. Albumin and transferrin remained unmodified. beta2mu-globulin significantly decreased after treatment with PMMA membranes. CONCLUSION: BK-P and B-3 HD membranes improved the OAB, beta2mu-globulin and CRP compared to PAN/AN69 and cellulose diacetate membranes.

Short daily versus conventional hemodialysis quality of life: a cross-sectional multicentric study in Spain.

BACKGROUND: End-stage renal disease is a major health problem worldwide nowadays. Although conventional hemodialysis is the most widely used modality, short daily hemodialysis has been proposed as a more physiologic treatment. The objective of this article is to compare the quality of life of patients on each hemodialysis modality. METHODS: A multicentric cross-sectional study was performed in 9 Spanish hospitals. Patients treated for at least 3 months with conventional or short daily hemodialysis were included and quality of life measured using the Euroqol-5D quality of life questionnaire. Bayesian models were used for analyzing quality of life results. RESULTS: Ninety-three patients were included, 27 were on daily hemodialysis and 66 on conventional hemodialysis. All models demonstrated a better quality of life for daily hemodialysis versus conventional hemodialysis. Only 14% of the patients on conventional hemodialysis were willing to change to a daily schedule. CONCLUSIONS: Short daily hemodialysis shows a better quality of life than conventional hemodialysis with all Bayesian approaches considered.

Presence of HCV-RNA after ultracentrifugation of serum samples during the follow-up of chronic hepatitis C patients with a sustained virological response may predict reactivation of hepatitis C virus infection.

BACKGROUND: Concentration of viral particles by ultracentrifugation of serum prior to PCR allows detection of hepatitis C virus (HCV) RNA in patients with undetectable viral RNA by conventional PCR assays. AIM: To analyse if HCV-RNA is detected after serum ultracentrifugation in chronic hepatitis C patients with a sustained virological response to antiviral therapy (defined as serum HCV-RNA negativity by conventional assays 6 months after the end of therapy). METHODS: HCV-RNA was tested using real-time PCR in ultracentrifuged sera collected during the post-treatment follow-up (mean: 42 +/- 27 months) in 57 sustained virological responders (SVR). RESULTS: After serum ultracentrifugation, HCV-RNA was detected on at least one occasion during the follow-up in 29/57 (51%) SVR. Thirteen (23%) of these 57 SVR suffered a reactivation 18 +/- 8 months after the end of therapy (reappearance of serum HCV-RNA detectable by conventional assays). Among reactivated patients, 11/13 (85%) had HCV-RNA in ultracentrifuged serum samples (detectable 10 +/- 5 months before reactivation), while HCV-RNA was positive after ultracentrifugation in 18/44 (41%) long-term SVR (P = 0.01). Persistence of detectable HCV-RNA after serum ultracentrifugation was associated with reactivation (P = 0.001). CONCLUSIONS: Serum ultracentrifugation prior to PCR allows detection of HCV-RNA in SVR and its persistence may predict late reactivation.

[Vaccination scheme in advanced chronic kidney disease]. / Calendario de vacunas en la enfermedad renal cronica avanzada.

1. VACCINATION AGAINST HEPATITIS B a) All patients with chronic advanced renal disease and negative serology for HBsAg and antiHBs are to be vaccinated against hepatitis B (Evidence level: B). b) For classic vaccines (Engerix B and HBVAxpro) the adult vaccine dose is 40 mcg (20 mcg in the paediatric population). There are two dose regimens based on the medicinal product used: 0, 1 and 6 months with HBVAxpro and 0, 1, 2 and 6 months with Engerix B. With the new vaccine Fendrix, the dose is 20 mcg and the schedule 0, 1, 2 and 6 months (Evidence level: C). c) The antiHBs titre is to be measured 1-2 months after administration of the last dose. In patients whose antibody titres are below 10 mIU/mL, a booster may be administered, checking the response or administering a second full vaccination (Evidence level: B). d) In responders, antibody levels are to be tested at least once a year. If the antiHBs titre is below 10 mIU/mL, a booster is to be administered (Evidence level: C). 2. VACCINATION AGAINST INFLUENZA a) All patients with chronic advanced renal disease are to be vaccinated every year against influenza (Evidence level: B). b) The vaccination dose and regimen are the same as recommended for the general population (Evidence level: C) 3. VACCINATION AGAINST PNEUMOCOCCUS a) Vaccination against pneumococcus is recommended in patients with chronic renal disease associated with nephrotic syndrome or who may be future candidates for renal transplant (Evidence level: B). b) There is no evidence of the clinical value of the pneumococcal vaccine in adult patients with chronic renal failure, not transplanted. However, some regions are recommending routine vaccination in the population aged >or= 60 years, the age of a high percentage of our patients. c) To maintain immunisation, revaccination is required every 3- 5 years. 4. OTHER VACCINES a) Vaccination against hepatitis A is recommended in patients with renal failure associated with chronic liver disease or who are candidates for renal transplant (Evidence level: C). b) The recommendations for vaccination against tetanus and diphtheria are the same as for the general population (Evidence level: C). c) Chickenpox vaccine is indicated in children with chronic renal disease, particularly if they are candidates for transplant (Evidence level: B). Although there is no evidence of the value of this vaccine in adults, it is advisable to perform it in those who may be candidates for renal transplant with no protecting antibodies. d) There is no evidence of the clinical value of the vaccine against Staphylococcus aureus.

[Preliminary results of the Spanish Society of Nephrology multicenter study of quality performance measures: hemodialysis outcomes can be improved]. / Resultados del proyecto de mejora de la calidad de la asistencia en hemodiálisis: estudio multicéntrico de indicadores de calidad de la Sociedad Española de Nefrología (SEN).

INTRODUCTION: The Spanish Society of Nephrology "Quality in Nephrology Working Group" (QNWG) was created in 2002. The aims of this group are the identification, diffusion, implementation and consolidation of a systematic, objective and comprehensive set of quality performance measures (QPMs) to help along the improvement of patient care and outcomes on hemodialysis, by means of strategies of feedback and benchmarking, and the design of quality improvement projects. The objective of this study is to present the preliminary results of a set of quality performance measures obtained in a group of Spanish hemodialysis centers, as well as to evaluate the repercussion of the application of the aforementioned thecniques on the observed results. METHODS: During 2007 a total of 28 hemodialysis units participated in the study; 2516 patients were evaluated. A specific software was designed and used to facilitate the calculation of CPMs in each unit. The clinical indicators used refered to dialysis adequacy; anemia; mineral metabolisme; nutrition; viral infections; vascular access; mortality, morbidity (number and days of hospital admissions); and renal transplant. Every three months each center received its own data and its comparison with the rest of the group. RESULTS: Except for hemoglobin levels we observed a global improvement. The percentage of centers reaching the stablished standards defined by the QNWG passed from 65% to 90,9% for Kt/V Daugirdas II (> 1,3 in > that 80% of the patients); from 71,4 % to 77,2 % for PTH (> 30 % of patients with serum PTH between 150 and 300 pg/ml); and from 42,8 % to 63,5 % for phosphate (> 75 % of patients with a serum phsphate < 5,5 mg/dl). More than 50% of centers showed an improvement in their final results as compared with their own initial results in all analyzed CPMs. Those centers that did not obtained an improvement in their results started the study with better percentages of acomplishment than those that showed a significant improvement in QPMs. (80,6+/-15,4 versus 71,8+/-16,6 respectively; p<0,001) CONCLUSIONS: We are starting to make progresses in our knowledge of clinical results in our hemodialysis units, although there is still a long way to go over. To monitor and share CPMs results within hemodialysis centers might help to improve their results as well as to reduce intecenters variability.

[Unawareness of the K/DOQI guidelines for bone and mineral metabolism in predialysis chronic kidney disease: results of the OSERCE Spanish multicenter-study survey]. / Desconocimiento de las guías K/DOQI sobre la alteración del metabolismo óseo-mineral asociada a la enfermedad renal crónica no en diálisis: resultados de la encuesta en el estudio multicéntrico español OSERCE.

Since its publication in 2003, the K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease (CKD) have become a worldwide reference. The aim of this study was to analyze the observance to these guidelines in patients with a glomerular filtration rate < 60 ml/min/1,73m2 not yet included in dialysis in a Spanish multicenter cohort. A questionnaire by investigator/centre was completed by 32 different nephrologists participating in the OSERCE study and representing the overall Spanish public health net. We observed that biochemical parameters were measured less frequently than recommended, except in CKD stage 3. The therapeutic goals for intact PTH were not properly reported by 59 % of the consulted nephrologists for stages 3 and 4, whereas only 22% did not report them properly for stage 5. The goals for phosphorus were not adequately reported in 50 % of cases (stages 3 y 4) and 60 % (stage 5). For calcium, these values were 70 %, 73.3 % and 65.5 % for stages 3, 4 and 5, respectively. A corrected plasma calcium between 9.5 and 10.2 mg/dl is still considered adequate for 31%. As much as 87% nephrologists stated that they did not sistematically measure calcidiol plasma levels. In general, these results demonstrate that there is a great degree of unawareness of K/DOQITM predialysis guidelines. Thus, their poor implementation is probably not only due to the lower availability of approved therapeutic agents, the difficult achievement of goals or the disbelief on current recommendations. It would be desirable that forthcoming guidelines such as the KDIGO could also consider the need of educational efforts for CKD-Mineral and Bone Disorder.

Prevalence and clinical characteristics of HIV type 1-infected patients receiving dialysis in Spain: results of a Spanish survey in 2006: GESIDA 48/05 study.

End-stage renal diseases (ESRD) are becoming more frequent in HIV-infected patients. In Europe there is little information about HIV-infected patients on dialysis. A cross-sectional multicenter survey in 328 Spanish dialysis units was conducted in 2006. Information from 14,876 patients in dialysis was obtained (81.6% of the Spanish dialysis population). Eighty-one were HIV infected (0.54%; 95% CI, 0.43-0.67), 60 were on hemodialysis, and 21 were on peritoneal dialysis. The mean (range) age was 45 (28-73) years. Seventy-two percent were men and 33% were former drug users. The mean (range) time of HIV infection was 11 (1-27) years and time on dialysis was 4.6 (0.4-25) years. ESRD was due to glomerulonephritis (36%) and diabetes (15%). HIV-associated nephropathy was not reported. Eighty-five percent were on HAART, 76.5% had a CD4 T cell count above 200 cells, and 73% had undetectable viral load. Thirty-nine percent of patients met criteria for inclusion on the renal transplant (RT) waiting list but only 12% were included. Sixty-one percent had HCV coinfection. HCV-coinfected patients had a longer history of HIV, more previous AIDS events, parenteral transmission as the most common risk factor for acquiring HIV infection, and less access to the RT waiting list (p < 0.05). The prevalence of HIV infection in Spanish dialysis units in 2006 was 0.54% HCV coinfection was very frequent (61%) and the percentage of patients included on the Spanish RT waiting list was low (12%).

Anemia associated with pegylated interferon-alpha2a and alpha2b therapy in hemodialysis patients.

AIMS: Anemia is a well-known side effect of interferon therapy since interferons are potent inhibitors of erythropoiesis. The aim of this study was to compare the anemia associated with pegylated interferon (PEG-IFN) (alpha2a versus alpha2b therapy in hemodialysis patients (HD) with chronic hepatitis C. METHODS: In order to study the anemia, doses of erythropoietic growth factors (EGF), hemoglobin (Hb) and erythropoietin resistance index (ERI) were compared at baseline and after PEG-IFN-alpha2a or alpha2b therapy in 16 HD patients with chronic C hepatitis. Pharmacokinetic studies were performed in 4 of those treated with PEG-IFN-alpha2b and 2 patients treated with PEG-IFN-alpha2a. Secondary end-points were viral response and serious adverse events. RESULTS: At 4-6 months after the beginning of therapy, both PEG-IFN-alpha induced a significant increment in the erythropoietin resistance index. This increment was significantly higher in patients treated with PEG-IFN-alpha2a when compared with alpha2b (45 vs 9.9, p = 0.012). The pharmacokinetics of PEG-IFN-alpha2a and alpha2b in HD patients were different, the C(max), C(min) and the area under the serum concentration time curve, were all higher in patients treated with PEG-IFN-alpha2a compared with PEG-INF-alpha2b. Discontinuation of therapy occurred in 2 (28.5%) of the 7 patients in the PEG-IFN-alpha2a group and in 4 (44%) of the 9 patients in the PEG-IFN-alpha2b group. Three (42%) subjects in the alpha2a group and 5 (55%) in the alpha2b group had a response at the end of the 48 weeks of therapy. In 4 (44.4%) of the 9 patients treated with alpha2b the viral response was sustained. CONCLUSIONS: In summary, patients treated with PEG-IFN-alpha2a have a major inhibitory effect on erythropoiesis. This could be explained by the different pharmacokinetic properties of PEG-IFN-alpha2a and alpha2b. Further studies are needed to clarify how these findings influence the efficacy, safety and cost-effectiveness of the PEG-IFN-alpha2.

Pegylated interferon-alpha2a kinetics during experimental haemodialysis: impact of permeability and pore size of dialysers.

BACKGROUND: Therapeutics in end-stage renal disease (ESRD) patients undergoing haemodialysis (HD) has to consider potential drug clearance during the dialysis procedure. Pegylated interferon-alpha (PEG-IFN-alpha), a middle-size protein drug active against viral hepatitis, allows convenient once-weekly dosing due to prolonged plasma half-life. AIM: To investigate the impact of permeability and dialyser pore size on PEG-IFN-alpha blood levels during experimental HD. METHODS: Polymethylmetacrylate (PMMA) membrane 1.6 m2 dialysers with three different permeabilities/pore sizes were selected. RESULTS: A 40 kDa PEG-IFN-alpha2a (PEGASYS) was not cleared (< 5%) through low-flux/small pore size (25 A;B3A) and high-flux/middle-large pore size (60 A;BKP) dialysers, and was partially (approximately 15%) through intermediate permeability/large pore size (100 A;BKF) dialysers. In contrast, unmodified 17 kDa IFN-alpha2a(Roferon-A) was removed (65%-95%) through BKP or BKF, but not B3A, PMMA dialysers. Moreover, 12 kDa PEG-IFN-alpha2b(PegIntron) was cleared (40%-80%) through PMMA dialysers with pore sizes > or = 60 angstroms. When B3A or BKP were replaced every hour PEG-IFN-alpha2a plasma levels remained constant throughout three experimental-HD-sessions, but PEG-IFN-alpha2b was cleared partially every BKP replacement. Porosity differ among high-flux dialysers. Neither PEG-IFN-alpha2a nor PEG-IFN-alpha2b were removed after three HD sessions through (27/31/33 A) pore size polysulphone dialysers. Although PEG-IFN-alpha2a was not cleared through middle pore-size (43 A/AN69ST) polyacrylonitrile dialyser, PEG-IFN-alpha2b was partially removed. CONCLUSIONS: The pharmacokinetics of Peg-IFN-alpha may vary in a patient on dialysis.

[Guidelines on hemodialysis-associated viral infections]. / Guías sobre enfermedades víricas en hemodiálisis (HD).

The viric infections influence morbi-mortality in Chronic kidney Disease patients in hemodialysis therapy and can affect to the Staff of the Units. The guides considered the most relevant virus at the present moment: C Virus, B Virus and HIV. To prevent horizontal nosocomial transmission is necessary the observance always the universal precautions in the HD units, although sometimes can appeared seroconversions and epidemic bud when exist a break of these. Is analyzed different situations with special focus in units for acute patients. The following steps under the suspicious of the epidemic bud appeared in one of the annexes together with legislation according to this case. Respect to the staff in every one of the virus is shown prevention patterns, serologic markers to perform when an accident with infected blood occur, also is considered when treatment is indicated. The guides considered too the conditions necessary for include these patients on waiting list for kidney transplantation.

[Evaluation of osteodystrophy parameters in a pre-dialysis unit]. / Valoración de parámetros de osteodistrofia en una unidad de prediálisis.

A cross-sectional study was developed with 100 of the first-time pre-dialysis patients visiting the Princesa University Hospital's Advanced Chronic Kidney Disease (ACKD) unit, with the aim of analysing various parameters of osteodystrophy at this time. Parameters evaluated were: age, gender, renal function, osteodystrophy serum parameters, comorbidity index (ICED) and the patients' origin to establish correlations between these parameters. Mean iPTH levels were higher irrespective of the patients' origin, and were significantly higher in men than in women, the former also having poorer renal function and higher comorbidity score. The mean levels of calcium, phosphorous, alkaline phosphatase and CO2 did not justify this rise in iPTH. Nutritional parameters NPNA and albumin were adequate in spite of ageing. At early stages of ESRD, iPTH could be elevated and ACKD units play an important part its early detection and subsequent treatment.