[Pre-emptive kidney transplant]. / Trasplante renal anticipado.

- Kidney transplant is nowadays an indisputable treatment, which has been shown to improve both the quantity and quality of life of patients with end-stage kidney disease (Strength of Recommendation A). - Time on dialysis is one of the factors associated with poor prognosis for graft and patient survival (Strength of Recommendation B). - Early kidney transplant avoids the inconveniences caused by dialysis techniques and the expenditure generated by them (Strength of Recommendation B). - Early kidney transplant from a living or cadaver donor has shown better graft and recipient survival results than kidney transplant performed in patients on dialysis (Strength of Recommendation B). - Early kidney transplant should be offered to all patients who are candidates for a living donor kidney. In the case of a cadaver donor, early kidney transplant can be an ideal option for all candidates, but in particular for children and patients with diabetic nephropathy. However, it should not be forgotten that there is a limited supply of cadaver donors (Strength of Recommendation B). - In patients over 65 years of age, kidney transplant should be considered as a treatment option since it increase life expectancy compared to dialysis (Strength of Recommendation B). - We should promote strategies to combat the shortage of organs (promote living donor transplant, use of suboptimal donors, asystolic donors, etc.) and so be able to consider the option of early kidney transplant (Strength of Recommendation C). - The ideal time for patients with chronic kidney disease to be included on the waiting list for a kidney transplant should be when their glomerular filtration rate is less than 15-20 ml/min and we can foresee that the time for their inclusion in dialysis will no extend beyond 1 to 2 years (Strength of Recommendation C). - We should not forget that the time on the waiting list for a kidney transplant is exactly the same for all patients with chronic kidney disease whether or not they are on dialysis (Strength of Recommendation C). In conclusion, we can state that there is a sufficiently solid scientific basis for attempting that patients receive the option of a kidney transplant before their inclusion in dialysis.

[Determination of factors conditioning adherence and accomplishment of renal protection diet in patients with chronic renal failure: pilot study for the elaboration of a dietary guideline]. / Determinación de los factores condicionantes en la adhesión y cumplimiento de la dieta de protección renal en pacientes con insuficiencia renal crónica: estudio previo para la elaboración de una guía dietética.

There are seldom studies on dietary behavior of patients with chronic renal failure (CRF). The aim of this study has been to know, by means of a previously validated questionnaire, which are the psycho-sociocultural factors that affect, and to what extent, assumption and adherence the dietary therapy while determining the degree of disease perception and several factors related with it. The study population is comprised by 81 patients from the nephrology clinic of the "12 de Octubre" Hospital of Madrid, with CRF in a pre-dialysis status. Seventy-seven point seventy-four percent answered "well" or "very well" to questions relating to disease knowledge and perception. Emotional and auto-management factors have little relevance according to 69.87% of patients. Fifty-nine point twenty-six percent feel a high level of familial support, and 35.77% alters dietary behavior when environmental conditions change. Most of the interviewees (87.65%) do not have difficulties finding the prescribed foods, and 70.37% considers their cost is not excessive. For almost half of the patients (48.76%), renal protection diet represents a variation in their dietary habits, a similar percentage expresses difficulty with elaboration. Food palatability is not a problem in 67.90% of the cases. Fifty-one point twenty-four percent does not perceive difficulty with cooking procedures. Seventy point ninety-nine percent feels support in one way or the other, by health care staff, although just 56.79% reports that the diet has not been explained to them. Only 18.51% questions the diet effectiveness as regards to their disease course. As for the gender variable, there were significant differences (p < 0.05), with a higher influence on men, in sections relating to disease knowledge, and influence of apathy and family support, the women those having the highest scores for food management, diet transgression at family meetings, and less information received about the prescribed diet. As for family support, there are significant differences only by age groups, patients aged more than 65 years being those feeling more this psychological support. The group of patients with a creatinine clearance less than 25 mL/min is the one expressing less categorically their appreciation on diet effectiveness. There are factors in which significant difficulty percentages are observed and that may induce diet transgression, in some cases without the patient being completely aware of, such as environmental changes, change in traditional habits, the degree of diet explanation, the organoleptic characteristics, and the lack of knowledge of appropriate cooking procedures. All these indicators confirm the need for enhancing nutritional education of these patients and their family environment, also showing the need for a nutritional intervention that completely supports patients in the process of adaptation and maintenance of their new dietary habit.

Renal failure associated with intestinal transplantation: our experience in Spain.

BACKGROUND: Renal failure (RF) is a frequent complication in non-renal solid organ transplants. In the present study, we analyze our experience with intestinal transplants (ITx). METHODS: Between 2004 and 2012, we performed 21 ITx in 19 adult patients. Alemtuzumab was used as an induction agent followed by tacrolimus. Renal function was assessed before ITx and during the perioperative period. RESULTS: The main cause for transplants was non-resectable desmoids tumors (33.3%), followed by vascular thrombosis (19%) and others. Medical complications were frequent, especially infectious diseases, which were the most common (51%). Surgical complications were also frequent, but most of them (>50%) were mild but leading to a great number of re-operations and prolonged stays in hospital. Acute rejection is very frequent (66.6%) but mild in more than 70% of the cases. Finally, RF was very frequent (68.4%; 13/19 patients) and accounted for 15.6% of all medical complications. Causes were multiple. One patient is awaiting a kidney transplant, but no other patients need renal replacement therapy at the moment. Ileostomy closure was performed in 5 of 12 patients alive, showing improved renal function in 3 of them. CONCLUSIONS: RF is a problem in ITx and is always multifactorial. Increases in hospital stay, higher morbidity and is a cause for hospital readmission. Almost all patients had an impaired renal function when discharged. Immunosuppressants and ileostomy closure as soon as possible might prevent RF.

Determinacion de los factores condicionantes en la adhesion y cumplimiento de la dieta de protección renal en pacientes con insuficiencia renal crónica: estudio previo para la elaboración de una guía dietética / Determination of factors conditioning adherence and accomplishment of renal protection diet in patients with chronic renal failure: pilot study for the elaboration of a dietary guideline

Son escasos los estudios sobre el comportamiento alimentario en los pacientes con Insuficiencia Renal Crónica (IRC). El objetivo de este estudio, a través de una encuesta previamente validada, ha sido conocer cuales son los factores psico-socio-culturales, y en que grado inciden a la hora de asumir y cumplir el tratamiento dietoterápico, determinando, además, el grado de percepción de la enfermedad y de los diversos factores relacionados con ella. La población estudiada estaba formada por 81 pacientes de la consulta de nefrología del hospital "12 de Octubre" de Madrid, con IRC en prediálisis. A las preguntas relacionadas con el autoconocimiento y percepción de la enfermedad el 77,74% respondió dentro de los niveles "bien o muy bien". Los factores emocionales y de autocontrol tienen escasa relevancia, según afirma el 69,87% de los pacientes. El 59,26% siente en alto grado el apoyo familiar y el 35,77% altera el seguimiento dietético cuando cambian las condiciones medioambientales. La gran mayoría de los entrevistados, un 87,65%, no tienen dificultad en encontrar los alimentos pautados y para el 70,37% de la población su coste no es excesivo. Para casi la mitad de los pacientes (48,76%) la dieta de protección renal supone una variación de sus hábitos alimentarios, un porcentaje similar expresa, además, dificultad con la preparación. La palatabilidad de los alimentos no es un problema en el 67,90% de los casos. El 51,24% no percibe dificultad en los procesos culinarios. El 70,99% se siente apoyado, deuna u otra forma, por el personal sanitario, aunque sólo un 56,79% refiere que no le ha sido explicada la dieta. Únicamente el 18,51% cuestiona la efectividad de la dieta en relación con la evolución de su enfermedad. Dentro de la variable sexo, se observaron diferencias significativas (p < 0,05) con valores de influencia mayor en los hombres para los apartados relacionados con el conocimiento de la enfermedad, la influencia de la apatía y el apoyo familiar, siendo las mujeres las que obtenían valores más altos en cuanto al manejo de los alimentos, la trasgresión en reuniones familiares y una menor información recibida sobre la dieta a seguir. En cuanto al apoyo familiar, solamente se observan diferencias por grupos de edad, siendo los mayores de 65 años los que sienten más este soporte psicológico. El grupo de pacientes con un aclaramiento inferior a 25 ml/min, es el que expresa menor rotundidad en su apreciación de la efectividad de la dieta. Hay factores en los que se observan porcentajes significativos de dificultad, que pueden inducir a la trasgresión de la dieta, en algunos casos sin plena conciencia del paciente, tales como los cambios ambientales, la alteración de los hábitos tradicionales, el grado de explicación de la dieta, las características organolépticas y el desconocimiento de los tratamientos culinarios adecuados. Todos estos indicadores confirman la necesidad de profundizar en la educación nutricional en estos pacientes y en su entorno familiar, además de evidenciar la necesidad de una intervención nutricional que apoye integralmente al paciente en su proceso de adaptación y mantenimiento del nuevo hábito alimentario (AU)

There are seldom studies on dietary behavior of patients with chronic renal failure (CRF). The aim of this study has been to know, by means of a previously validated questionnaire, which are the psycho-sociocultural factors that affect, and to what extent, assumption and adherence the dietary therapy while determining the degree of disease perception and several factors related with it. The study population is comprised by 81 patients from the nephrology clinic of the "12 de Octubre" Hospital of Madrid, with CRF in a pre-dialysis status. Seventy-seven point seventy-four percent answered "well" or "very well" to questions relating to disease knowledge and perception. Emotional and auto-management factors have little relevance according to 69.87% of patients. Fifty-nine point twenty-six percent feel a high level of familial support, and 35.77% alters dietary behavior when environmental conditions change. Most of the interviewees (87.65%) do not have difficulties finding the prescribed foods, and 70.37% considers their cost is not excessive. For almost half of the patients (48.76%), renal protection diet represents a variation in their dietary habits, a similar percentage expresses difficulty with elaboration. Food palatability is not a problem in 67.90% of the cases. Fifty-one point twenty-four percent does not perceive difficulty with cooking procedures.Seventy point ninety-nine percent feels support in one way or the other, by health care staff, although just 56.79% reports that the diet has not been explained to them. Only 18.51% questions the diet effectiveness as regards to their disease course. As for the gender variable, there were significant differences (p < 0.05), with a higher influence on men, in sections relating to disease knowledge, and influence of apathy and family support, the women those having the highest scores for food management, diet transgression at family meetings, and less information received about the prescribed diet. As for family support, there are significant differences only by age groups, patients aged more than 65 years being those feeling more this psychological support. The group of patients with a creatinine clearance less than 25 mL/min is the one expressing less categorically their appreciation on diet effectiveness. There are factors in which significant difficulty percentages are observed and that may induce diet transgression,in some cases without the patient being completely aware of, such as environmental changes, change in traditional habits, the degree of diet explanation, the organoleptic characteristics, and the lack of knowledge of appropriate cooking procedures. All these indicators confirm the need for enhancing nutritional education of these patients and their family environment, also showing the need for a nutritional intervention that completely supports patients in the process of adaptation and maintenance of their new dietary habit (AU)

Trasplante renal anticipado / No disponible

• El trasplante renal es hoy día un tratamiento indiscutible, que ha demostrado mejorar la cantidad y la calidad de vida de los pacientes con enfermedad renal crónica terminal (Fuerza de Recomendación A).• El tiempo de permanencia en diálisis es uno de los factores de peor pronóstico para la supervivencia del injerto y del paciente (Fuerza de Recomendación B).• El trasplante renal anticipado evita los inconvenientes derivados de las técnicas de diálisis y disminuye el gasto generado por las mismas (Fuerza de Recomendación B).• El trasplante renal anticipado de donante de vivo o de cadáver ha demostrado mejores resultados de supervivencia del injerto y del receptor que el trasplante renal efectuado en pacientes en diálisis3,4 (Fuerza de Recomendación B).• El trasplante renal anticipado debe ser ofrecido a todos aquellos pacientes que tenga la posibilidad de un donante renal de vivo. En el caso de donante cadavérico, el trasplante renal anticipado puede ser una opción ideal para todos los candidatos pero en particular en los niños y en los pacientes con nefropatía diabética. Sin embargo, no hay que olvidar que existe una limitada oferta de donantes cadavéricos (Fuerza de Recomendación B).• En los pacientes mayores de 65 años, el trasplante renal debe ser considerado como una opción de tratamiento (..) (AU)

• Kidney transplant is nowadays an indisputable treatment, which has been shown to improve both the quantity and quality of life of patients with end-stage kidney disease (Strength of Recommendation A).• Time on dialysis is one of the factors associated with poor prognosis for graft and patient survival (Strength of Recommendation B).• Early kidney transplant avoids the inconveniences caused by dialysis techniques and the expenditure generated by them(Strength of Recommendation B).• Early kidney transplant from a living or cadaver donor has shown better graft and recipient survival results than kidney transplant performed in patients on dialysis3,4 (Strength of Recommendation B).• Early kidney transplant should be offered to all patients who are candidates for a living donor kidney. In the case of a cadaver donor, early kidney transplant can be an ideal option for all candidates, but in particular for children and patients with diabetic nephropathy. However, it should not be forgotten that there is a limited supply of cadaver donors (Strength of Recommendation B).• In patients over 65 years of age, kidney transplant should be (..) (AU)

Relación entre obesidad y desarrollo de insuficiencia renal / Relationship between obesity and development of kidney failure

La incidencia de la glomerulopatía asociada a la obesidad está alcanzando proporciones tremendas durante la última década. La lesión más frecuentemente encontrada en las biopsias renales de los pacientes obesos con proteinuria es la glomeruloesclerosis segmentaria y focal. Diversos estudios epidemiológicos han demostrado que la obesidad es un importante factor de riesgo para el desarrollo de proteinuria e insuficiencia renal en la población sana. Los mecanismos por los que la obesidad puede inducir proteinuria son desconocidos, aunque existen evidencias que apuntan hacia la participación de factores hemodinámicos, hiperlipidemia y un aumento de sustancias vasoactivas y fibrogénicas, entre las que se incluyen la angiotensina II, insulina, leptina y el factor transformador de crecimiento beta. La pérdida de peso produce una marcada reducción de los componentes del sistema renina-angiotensina-aldosterona. El aumento del índice de masa corporal es un factor de riesgo para el desarrollo de proteinuria o insuficiencia renal en pacientes con disminución de la masa renal funcionante (uninefrectomizados o agenesia renal). Aunque los inhibidores de la enzima convertidora de la angiotensina han mostrado una acusada influencia favorable sólo temporalmente, la pérdida de peso produce un descenso en la proteinuria en las nefropatías crónicas proteinúricas de cualquier entidad. La prevención y tratamiento de la obesidad debe ser un objetivo primordial dentro de los pacientes diabéticos y no diabéticos con enfermedad renal crónica (AU)

The incidence of obesity-related glomerulopathy has been reaching tremendous proportions over the last decade. The most frequently found lesion in kidney biopsies of obese patients with proteinuria is focal segmental glomerulosclerosis. Different epidemiological studies have demonstrated that obesity is an important risk factor for the development of proteinuria and renal failure in the normal population. The mechanisms by which obesity may induce proteinuria are unknown. However, there is evidence that points towards the participation of hemodynamic, hyperlipidemic factors and an increase of vasoactive and fibrogenic substances, which include angiotensin II, insulin, leptin and growth transforming factor-beta. Weight loss produces a marked reduction of the renin-angiotensin-aldosterone system. Body mass index increase is a risk factor for the development of proteinuria of kidney failure in patients with decreased functioning kidney mass (nephrectomized or renal agenesis). Although the angiotensin converting enzyme inhibitors have demonstrated a striking favorable influence, only temporally, weight loss produces a decrease in proteinuria in chronic proteinuric nephropathies of any disease. Prevention and treatment of obesity should be a primary objective within diabetic and no-diabetic patients with chronic kidney disease (AU)

¿Está disminuyendo la incidencia de la hipertensión arterial maligna o está cambiando su presentación clínica? / Is the incidence of accelerated (malignant) arterial hypertension decreasing, or is it merely changing in its clinical manifestation?

Numerosos estudios clínicos describen que la incidencia de la hipertensión arterial maligna (HTAM) va disminuyendo. La hipertensión arterial maligna es una entidad clínica caracterizada por una marcada elevación de la presión arterial (PA) junto a la presencia de hemorragias y exudados retinianos con o sin edema de papila. Es una forma severa de hipertensión arterial (HTA) con una afectación multiorgánica. Los mecanismos que inician o predisponen al desarrollo de la HTAM son aún desconocidos. Los mecanismos fisiopatológicos incluyen un incremento de la actividad nerviosa simpática y un aumento del sistema renina-angiotensina en íntima asociación con una disfunción endotelial. El grado de insuficiencia renal en el momento del diagnóstico sigue siendo el principal factor de riesgo para el desarrollo de una insuficiencia renal crónica avanzada. La importancia del diagnóstico precoz de esta entidad se basa en que los pacientes no tratados tienen un peor pronóstico. La utilización de fármacos hipotensores por vía intravenosa es de gran utilidad para el control de la presión en estos pacientes. Hemos estudiado la incidencia de la HTAM en nuestro centro entre los años 1974-1998. Se establecieron tres grupos en función de la década en la que fueron diagnosticados. Analizamos en cada década su forma de presentación clínica, etiología, incidencia de insuficiencia renal y el papel de los fármacos hipotensores en la evolución de estos pacientes. Nuestros datos muestran que la incidencia de la HTAM no ha disminuido en los últimos años, pero sí ha cambiado su presentación clínica, con cifras tensionales menores, inferiores complicaciones neurológicas y menor mortalidad (AU)