Reversed diastolic intrarenal flow in page kidney following renal biopsy.

Page's kidney is a condition that occurs due to external renal compression, usually caused by a subcapsular haematoma, generating a renal compartmental syndrome with parenchymal damage and renal perfusion alteration. Classically associated with renal trauma, Page's kidney can also arise after invasive renal procedures, such as renal biopsies or percutaneous nephrostomies. Clinically, it can trigger hypertension due to activation of the renin-angiotensin system induced by hypoperfusion secondary to renal parenchymal compression and can also present with varying degrees of renal function impairment. Furthermore, severe acute renal failure may be found particularly in patients with solitary kidneys or renal transplants. We present two cases of Page's kidney after renal biopsy and their PoCUS ultrasound findings. We would like to highlight the reversed diastolic flow on Doppler ultrasound in this entity, a pattern we have found in all two cases.

Individually adjusted absolute blood volume feedback control: A promising solution for intradialytic hypotension.

INTRODUCTION: Intradialytic hypotension (IDH) remains one of the most frequent complications associated to hemodialysis (HD), frequently triggered by a reduction in absolute blood volume (ABV) not compensated by vascular refilling. A recently developed dilutional method allows routinary measurement of ABV and, by a simple algorithm, may turn blood volume monitor (BVM) guided UF (ultrafiltration) biofeedback into an ABV control, automatically adjusting UF rate to maintain ABV above a preset threshold. The aim of this study is to identify an individual critical ABV threshold and test the ability of an ABV feedback control to avoid IDH. METHODS: We studied 24 patients throughout three consecutive midweek HD treatments. ABV and blood pressure (BP) were measured every 30 min and anytime the patient referred any symptoms to identify each patient's critical ABV (ABV at the time of hypotension). A fixed bolus dilution approach at the start of HD was used to calculate ABV. Then, patients were followed through three additional HD treatments and IDH development was analyzed. FINDINGS: Seventy-one treatments performed in 24 patients. ABV monitoring showed a constant decrease as HD treatment progressed. Thirteen IDH events were observed in eight different patients, with a mean systolic BP drop in IDH treatments of 37.38 ± 4.31 mmHg and a mean adjusted ABV at hypotension of 71.07 ± 14.88 mL/kg. Critical ABV was individually set in patients prone to IDH. As expected, ABV feedback control successfully maintained ABV over preset critical ABV. IDH events were avoided in 21 out of 22 treatments performed. ABV drop was successfully reduced, as well as SBP drop (despite similar UF than prior to ABV feedback control implementation). DISCUSSION: ABV feedback control avoided IDH in 21 out of 22 treatments performed by maintaining blood volume above critical ABV, significantly reducing ABV variations without compromising prescribed UF.

Lipid profile of patients treated with evolocumab in Spanish hospital nephrology units (RETOSS NEFRO).

BACKGROUND AND OBJECTIVE: To describe the clinical characteristics, the reasons for initiating therapy and the effects of treatment in the initial phase of evolocumab availability in the Nephrology Units of Spain. MATERIAL AND METHODS: Retrospective, observational and multicentric study that included patients initiating treatment with evolocumab (from February 2016 to August 2018), in 15 Nephrology Units in Spain. The demographic and clinical characteristics of the patients, the lipid lowering treatment and the evolution of the lipid profiles between 24 weeks pre-initiation and 12±4 weeks post-initiation of evolocumab were reviewed. RESULTS: 60 patients were enrolled: 53.3% women; mean (SD) age, 56.9 (12.8) years, 45.0% with familial hypercholesterolemia (FH) (5.0% homozygous and 40.0% heterozygous) and 65.0% with atherosclerotic cardiovascular disease. The mean (SD) eGFR was 62.6 (30.0) ml/min/1.73m2 (51.7% of patients had eGFR <60ml/min/1.73m2 [CKD stage>2]), 50.0% had proteinuria (>300mg/g) and 10.0% had nephrotic syndrome. Other CV risk factors were hypertension (75.0%), diabetes (25.0%), and smoking (21.7%). A 40.0% of patients were statin intolerant. At evolocumab initiation, 41.7% of patients were on a high intensity statin, 18.3% on moderate intensity statin and 50.0% were receiving ezetimibe. Mean (SD) LDL-c at evolocumab initiation was 179.7 (62.9) mg/dL (53.4% of patients with LDL-c ≥160mg/dL and 29.3% ≥190mg/dL). After 12 weeks, evolocumab resulted in LDL-c reductions of 60.1%. At week 12, 90.0% of patients reached LDL-c levels <100mg/dL, 70.0% <70mg/dL, and 55.0% <55mg/dL, while mean eGFR levels and statin use remained stable. CONCLUSION: In Nephrology Units of Spain, evolocumab was predominantly prescribed in patients with FH, chronic renal disease (CRD>2) and secondary prevention, with LDL-c levels above those recommended by the guidelines. Evolocumab used in clinical practice significantly reduced the LDL-c levels in all patients included in the study.

Kidney Autotransplantation and Orthotopic Kidney Transplantation: Two Different Approaches for Complex Cases.

Introduction: Transplantation surgery teams often have to face complex cases. In certain circumstances, such as occlusion of the iliac vessels or prior pelvic surgery, heterotopic kidney transplantation may not be feasible and orthotopic kidney transplantation (OKT) could be a good alternative. Kidney autotransplantation (KAT) has been described as a potential treatment for complex renovascular, ureteral, or neoplastic conditions. There are scarce data regarding the complications and outcomes of these procedures; therefore, we present our experience. Materials and Methods: We retrospectively analysed the medical records of both 21 patients who had received OKT and 19 patients who underwent KAT between 1993 and 2020. We collected demographic features and data regarding surgical technique, complications, and graft outcomes. Kidney graft survival was calculated using Kaplan-Meier survival analysis. Results: Regarding OKT, in 15 (71.43%) cases, it was the first kidney transplantation. The most common indication was the unsuitable iliac region due to vascular abnormalities (57.14%). The early postoperative complication rate was high (66.67%), with 23.81% of Clavien grade 3b complications. During the follow-up period (mean 5.76 -SD 6.15- years), we detected 9 (42.85%) graft losses. At 1 year, the survival rate was 84.9%. Concerning KAT, the most frequent indication was ureteral pathology (52.63%), followed by vascular lesions (42.11%). The overall early complication rate was 42.11%. During the follow-up period (mean of 4.47 years), 4 (15.79%) graft losses were reported. Conclusions: Although OKT and KAT have high complication rates, these techniques can be considered as two valuable approaches for complex cases, in the absence of other therapeutic options.

Incoercible Vomiting in a Polycystic (ADPKD) Patient on Peritoneal Dialysis.

Although gastrointestinal symptoms are not uncommon in PD patients due to several causes, such as infusion volume with early satiety, constipation, or peritonitis, sometimes the differential diagnosis is more challenging for nephrologists. We present the case of a woman with end-stage renal disease due to autosomal dominant polycystic kidney disease on PD who presented with swollen legs and incoercible vomiting. After ruling out constipation and infection, an abdominal CT was done, revealing extrinsic compression of the intrahepatic inferior cava vein (ICV) and massive venous thrombosis from ICV to bilateral iliofemoral deep veins. In addition, CT also showed displacement and extrinsic compression of the stomach, pylorus, and duodenum due to an enlarged liver cyst. Percutaneous drainage and sclerosis of the cyst compressing the stomach was performed, anticoagulation was started, and the patient clinically improved with complete resolution of symptoms.

Safety of renal biopsy bleeding prophylaxis with desmopressin.

BACKGROUND: Percutaneous renal biopsy (PRB) is invasive, and bleeding-related complications are a concern. Desmopressin (DDAVP) is a selective type 2 vasopressin receptor-agonist also used for haemostasis. AIM: To evaluate the side effects of intravenous (IV) weight-adjusted desmopressin preceding PRB. METHODS: This was a retrospective study of renal biopsies performed by nephrologists from 2013 to 2017 in patients who received single-dose DDAVP pre-PRB. RESULTS: Of 482 PRBs, 65 (13.5%) received DDAVP (0.3 µg/kg); 55.4% of the PRBs were native kidneys. Desmopressin indications were altered platelet function analyser (PFA)-100 results (75.3% of the patients), urea >24.9 mmol/L (15.5%), antiplatelet drugs (6.1%) and thrombocytopaenia (3%). Of the 65 patients, 30.7% had minor asymptomatic complications, and 3 patients had major complications. Pre-PRB haemoglobin (Hb) <100 g/L was a risk factor for Hb decrease >10 g/L, and altered collagen-epinephrine (Col-Epi) time was a significant risk factor for overall complications. Mean sodium decrease was 0.6 ± 3 mmol/L. Hyponatraemia without neurological symptoms was diagnosed in two patients; no cardiovascular events occurred. CONCLUSION: Hyponatraemia after single-dose DDAVP is rare. A single IV dose of desmopressin adjusted to the patient's weight is safe as pre-PRB bleeding prophylaxis.

Lipid profile of patients treated with evolocumab in Spanish hospital nephrology units (RETOSS NEFRO). / Perfil clínico de los pacientes tratados con evolocumab en unidades hospitalarias de nefrología en España (RETOSS-NEFRO).

BACKGROUND AND OBJECTIVE: To describe the clinical characteristics, the reasons for initiating therapy and the effects of treatment in the initial phase of evolocumab availability in the Nephrology Units of Spain. MATERIAL AND METHODS: Retrospective, observational and multicentric study that included patients initiating treatment with evolocumab (from February 2016 to August 2018), in 15 Nephrology Units in Spain. The demographic and clinical characteristics of the patients, the lipid lowering treatment and the evolution of the lipid profiles between 24 weeks pre-initiation and 12±4 weeks post-initiation of evolocumab were reviewed. RESULTS: Sixty patients were enrolled: 53.3% women; mean (SD) age, 56.9 (12.8) years, 45.0% with familial hypercholesterolemia (FH) (5.0% homozygous and 40.0% heterozygous) and 65.0% with atherosclerotic cardiovascular (CV) disease. The mean (SD) eGFR was 62.6 (30.0)ml/min/1.73m2 (51.7% of patients had eGFR<60ml/min/1.73m2 [CKD stage>2]), 50.0% had proteinuria (>300mg/g) and 10.0% had nephrotic syndrome. Other CV risk factors were hypertension (75.0%), diabetes (25.0%), and smoking (21.7%). A 40.0% of patients were statin intolerant. At evolocumab initiation, 41.7% of patients were on a high-intensity statin, 18.3% on moderate intensity statin and 50.0% were receiving ezetimibe. Mean (SD) LDL-c at evolocumab initiation was 179.7 (62.9)mg/dL (53.4% of patients with LDL-c≥160mg/dL and 29.3%≥190mg/dL). After 12 weeks, evolocumab resulted in LDL-c reductions of 60.1%. At week 12, 90.0% of patients reached LDL-c levels <100mg/dL, 70.0% <70mg/dL, and 55.0% <55mg/dL, while mean eGFR levels and statin use were remained stable. CONCLUSION: In Nephrology Units of Spain, evolocumab was predominantly prescribed in patients with FH, chronic renal disease (CRD>2) and secondary prevention, with LDL-c levels above those recommended by the guidelines. Evolocumab used in clinical practice significantly reduced the LDL-c levels in all patients included in the study.

Absolute blood volume variations and vascular refilling in hemodialysis patients.

The imbalance between ultrafiltration volume (UF) and vascular refilling is considered a major cause for intradialytic hypotension. Recent studies report a noninvasive method to estimate vascular refilling (VREF ) by determining absolute blood volume (ABV). It was the aim of the study to analyze variations in ABV in a group of hemodialysis (HD) patients and examine VREF . Thirty one stable chronic HD patients were studied, aged 71.07 ± 13.31 years. Dialysis duration and UF requirements were based on physician prescription. VREF was calculated as: VREF  = VUF  - ΔV where ΔV is ABV variation during dialysis treatment. ABV at the beginning of the dialysis was 6.00 ± 2.39 L (92.82 ± 33.17 ml/kg) and at the end 5.38 ± 2.32 L (82.07 ± 31.41 ml/kg). Prescribed UF was 2.64 ± 0.83 L. Mean VREF was 2.05 ± 0.80 L, with a refilling fraction of 75.75 ± 12.79%. VREF was strongly correlated with UF volume (r2 0.877), and with pre-dialysis volume overload (r2 0.617). Patients under beta-blocker treatment showed significantly lower FREF . ABV measurement is an easy and noninvasive method that allows us to study VREF during HD. We found a strong correlation between VREF and UF.

Loss-of-function mutation of PCSK9 as a protective factor in the clinical expression of familial hypercholesterolemia: A case report.

RATIONALE: Proprotein convertase subtilisin/kexin 9 or PCSK9 is a protein whose main function is to regulate the number of low-density lipoprotein receptors (LDLR) present on the cell surface. Loss-of-function mutations in PCSK9 have been related to low LDL-cholesterol levels and a decrease in the risk of cardiovascular events. PATIENT CONCERNS: We present the case of a 27-year-old woman, offspring of a patient with familial homozygous hypercholesterolemia, who presented with mild-moderate hypercholesterolemia. DIAGNOSIS: Genetic analysis was performed by next generation sequencing using a customized panel of 198 genes. Sanger sequencing was used to confirm the presence of the variants of interest. The genetic analysis showed a pathogenic heterozygous mutation in LDLR [exon 6:c.902A>G:p(Asp301Gly)], as well as a loss-of-function heterozygous variant in PCSK9 [exon1:c.137 G>T:p.(Arg46Leu)]. The genetic analysis of the index case's mother revealed compound heterozygosity for 2 different mutations in LDLR [c.902A>G:p.(Asp301Gly); c.1646G>T:p.(Gly549Val)] in exon 6 and in exon 11, respectively, and the same loss-of-function variant in PCSK9 that had been found in her daughter [(PCSK9:exon1:c.137G>T:p.(Arg46Leu)]. The maternal grandfather of the index case presented the same genetic variants as his granddaughter. INTERVENTIONS: The index case did not receive any specific treatment for hypercholesterolemia. The loss-of-function variant in PCSK9 protected her from higher LDL-cholesterol levels, provided she kept partial activity of the LDLR. In her mother, instead, a PCSK9 inhibitor was tried but failed to achieve lipid control. The reason for this may be the complete absence in LDL receptor activity. LDL apheresis was started afterwards, resulting in adequate lipid level control. OUTCOMES: To the date, the index case has achieved to maintain adequate total and LDL-cholesterol levels without any other intervention. She has had no known cardiovascular complication. LESSONS: Loss-of-function mutations in PCSK9 could protect from developing more severe forms of hypercholesterolemia. The finding of these mutations (LDLR-PCSK9) in three consecutive generations could imply an adaptive mechanism against the development of hypercholesterolemia.

Utility of Peritoneal Scintigraphy in Peritoneal Dialysis Patients: One Center Experience.

Background: Peritoneal dialysis (PD) is the RRT of choice in 15% of patients with CKD and has multiple advantages over hemodialysis. PD leaks can prompt technique failure and dropout. Use of peritoneal scintigraphy (PS) for diagnosis of PD leaks has declined in favor of more complex and expensive tests. We analyzed the utility of PS for PD leak diagnosis in our center. Methods: We retrospectively analyzed all PS done in our center from January 2000 until December 2018, inclusive, in all patients on PD with a suspected dialysate leak. Results: A total of 39 PS procedures were done in 36 patients on PD in the study period. Of those, 81% were male and 11% had CKD due to polycystic kidney disease. During this period, 23 leaks were diagnosed, showing an incidence of 6% (three episodes per patient per year). In all cases with negative PS, other tests did not confirm a peritoneal dialysate leak. Conclusions: PS is a safe, inexpensive, reproducible, and highly effective diagnostic tool for peritoneal dialysate leaks that allows nephrologists to tailor or stop PD therapy if required. In our opinion, it should be the first-line imaging test to diagnose PD leaks with minimum exposure to radiation, contrast, or other substances that could irritate the peritoneal membrane. We believe PS should be considered as the initial test of choice to diagnose this PD complication as soon as possible, minimizing technique failure and dropout due to leaks.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis. / Guía Clínica Española del Acceso Vascular para Hemodiálisis.

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Subphrenic abscess as a complication of hemodialysis catheter-related infection.

We describe an unusual case of subphrenic abscess complicating a central venous catheter infection caused by Pseudomonas aeruginosa in a 59-year-old woman undergoing hemodialysis. The diagnosis was made through computed tomography, and Pseudomonas aeruginosa was isolated from the purulent drainage of the subphrenic abscess, the catheter tip and exit site, and the blood culture samples. A transesophageal echocardiography showed a large tubular thrombus in superior vena cava, extending to the right atrium, but no evidence of endocarditis or other metastatic infectious foci. Catheter removal, percutaneous abscess drainage, anticoagulation, and antibiotics resulted in a favourable outcome.

Progression of residual renal function with an increase in dialysis: haemodialysis versus peritoneal dialysis.

OBJECTIVE: The main objective of the study was to analyse the progression of residual renal function according to the dialysis technique (peritoneal dialysis or haemodialysis) and the frequency of treatment (two or three sessions of haemodialysis per week). As secondary objectives, we studied the progression of the serum concentration levels of ß2 microglobulin and the response of anaemia to erythropoietic agents. MATERIAL AND METHOD: 193 non-anuric patients were included and began renal replacement therapy with dialysis in our hospital between 1 January 2006 and 31 December 2011, with a follow-up period of over three months. 61 patients (32%) began treatment with two haemodialysis sessions per week, 49 patients (25%) with three haemodialysis sessions per week and 83 patients (43%) with peritoneal dialysis. The glomerular filtration rate was measured as the mean of the renal clearances of urea and creatinine. RESULTS: The rate of decrease in glomerular filtration was the same in patients who began treatment with two haemodialysis sessions per week and with peritoneal dialysis (median 0.18 ml/min/month) and it was higher in patients who began treatment with three sessions of haemodialysis per week (median 0.33 ml/min/month, P<.05). Throughout progression, the glomerular filtration rate did not display differences between the group that began with two weekly sessions of haemodialysis and the group on peritoneal dialysis, and it was lower in the group that began treatment with three sessions of haemodialysis per week with statistical significance during the first 24 months of follow up. In the three patient groups, ß2-microglobulin concentration increased as the glomerular filtration rate decreased and it was higher in the group on three weekly haemodialysis sessions for the first 12 months of follow up. In all the controls carried out, there was a negative correlation between the beta-2 microglobulin concentration and the glomerular filtration rate (P<.001). The erythropoietin dose was negatively related to glomerular filtration. Patients who began with two sessions of haemodialysis per week required a lower dose of erythropoietin than patients that began renal replacement therapy with three weekly sessions. The erythropoietin dose in the peritoneal dialysis group was below that of the group of two weekly haemodialysis sessions despite maintaining a similar glomerular filtration rate. CONCLUSIONS: Patients who begin treatment with two sessions of haemodialysis per week experience the same rate of decrease in residual renal function as patients treated with peritoneal dialysis. The progression of the concentration of ß2-microglobulin is parallel to that of the glomerular filtration rate. Patients treated with two haemodialysis sessions require a lower dose of erythropoietin than those who receive three sessions per week, but a significantly higher dose than those treated with peritoneal dialysis, which suggests that the response of anaemia to erythropoietic agents is not only related to residual renal function, but also to other factors that are inherent to the dialysis technique.

A retrospective study on outcome of microscopic polyangiitis in chronic renal replacement therapy.

BACKGROUND: Pauci-immune vasculitis is a heterogeneous disorder with an unfavourable prognosis. Renal involvement is frequently observed in antineutrophil cytoplasm autoantibody (ANCA)-associated small-vessel vasculitis and is an important cause of end-stage renal disease (ESRD). Renal replacement therapy (RRT) is frequently required. Although better prognosis under dialysis is well known, the long-term follow-up of pauci-immune renal vasculitis with RRT is rarely reported. METHODS: We described 24 patients with pauci-immune vasculitis and requirement of dialysis who were admitted in our institutions from January 1989 to December 2008. Mean age was 65 ± 12 years at the beginning of dialysis. There were 12 males and 12 females. Patients with Wegener's granulomatosis, Churg-Strauss syndrome or evidence of anti-glomerular basement membrane were excluded. The study group was formed by patients with a diagnosis of necrotizing extracapillary glomerulonephritis and microscopic polyangiitis. RESULTS: The distribution according to ANCAs was 14 p-ANCA (58%), 5 c-ANCA (21%) and 5 ANCA-negative (21%) pauci-immune renal vasculitis. Pulmonary renal syndrome (PRS) was observed in 10 patients at the onset of vasculitis. Corticosteroids and daily cyclophosphamide were administered to 18 patients, and one patient had intravenous cyclophosphamide. Five patients received isolated corticosteroid therapy. Early reduction in cyclophosphamide dosage was required in five patients due to leucopaenia. Mean follow-up after first dialysis was 89 ± 66 months (range 2-208). Twenty patients were included in haemodialysis (HD), and four patients were included in peritoneal dialysis (PD). At the end of the study, nine patients had received a cadaveric kidney transplant (KT). Relapses rate after the onset of dialysis was 0.03 episode/patient/year. PRS-associated relapses after beginning dialysis were observed in four patients. Main therapy in relapses was also corticosteroids and cyclophosphamide. Survival rates for year 1, 2 and 5 was 91%, 91% and 85%, respectively. Overall mortality at the end of the study was 31.8%. Five patients died in the PRS group, but only one death was associated with progressive pulmonary fibrosis. Higher mortality was observed in PRS vasculitis present at the onset of RRT (50% vs 16.7%, P = NS). Better outcome in patients who received a renal transplantation was observed (88.8% vs 53.8%, P = NS). Conclusions. Despite a low number of patients in this series, pauci-immune vasculitis prognosis under dialysis seems equal to other causes of chronic kidney disease. This study observed a low rate of relapses after beginning dialysis. Poor prognosis is related to severe complications at the beginning of RRT. Today, kidney transplantation is an important therapeutic option for these patients.

[Evaluating renal function and indications for starting dialysis]. / Valoración de la función renal e indicaciones para el inicio de diálisis.

EVALUATION OF THE RENAL FUNCTION: For the follow-up of the graft renal function it must be measured the glomerular filtration rate by means of formulae that use the serum creatinine. The most used equation is the brief formula MDRD. - All patients transplanted must be included in the group of Renal Chronic Disease though the glomerular filtration rate is normal and there is no evidence of renal damage. - The measures of intervention proposed in the classification of the Renal Chronic Disease for its progressive establishment in the stage 1 to 3, must be applied to all the transplanted THE BEGINNING OF DIALYSIS: In spite of receiving attention of Nephrologists along the whole evolution, the patients with chronic dysfunction of the graft that need treatment with dialysis start later and with more uremic complications that the patients who start dialysis for the first time. - To change this trend, it is necessary to consider the treatment with dialysis when the glomerular filtration rate is lower than 15 ml/min/1,73 m2. If there appears any complication related to the uremia that cannot be handled by conservative treatment, the beginning of the dialysis is necessary. THE BEGINNING OF THE DIALYSIS OF PROGRAMMED FORM: The beginning of the dialysis of not programmed form in transplanted patients is difficult to justify if we take into account that such patients, have received nephrological attention along all their evolution. - To get a new vascular access in these patients can be difficult depending on the previous trombosis of arteriovenous fistulas. Therefore, it must be realized a prompt evaluation for de department of vascular surgery to guarantee a suitable vascular access. - As general norm, one must follow the same criterion advised for the not transplanted patient: the vascular access must be considered when the glomerular filtration rate is lower than 20 m/min/1,73 m2. - The patient who is going to be treated by dialysis peritoneal precise a very narrow follow-up to be able to programme the placement of the catheter peritoneal with a minimum of 15 days before beginning the training.

[Managing a failed kidney graft. Nephrectomy versus embolisation]. / Manejo del injerto renal fallido. Nefrectomía versus embolización.

The early diagnosis of the graft intolerance syndrome or a subclinical state of chronic inflammation due to a failed kidney allograft, is one of the goals that the nephrologists must fulfill to take a series of measures directed to solve this situation. Fever, haematuria, local pain and/or tenderness are the main clinical criteria to make a diagnosis. However, oftenly there are not any clinical symptoms and only the presence of parameters of chronic inflammation (elevated C-reactive protein, erythrocyte sedimentation rate, hypoalbuminemia and anemia resistant to erythropoietin therapy) are signs of this entity. Maintenance of immunosuppressive treatment is not advisable due to the risk of infections as well as the increase in cardiovascular risk (level evidence A). Transplantectomy is the best treatment if there are some associated complications such as allograft infection, neoplasia or high risk of graft rupture. However, surgical treatment is not exempt from risks and it is associated to a considerable rate of complications, with the consequent prolongation of the hospitalization stay. Therefore it is desirable to use less invasive procedures, such as embolization. This could be the first step unless the conditions enumerated in point 3 come up (Level evidence B). It is desirable to use prophylactic antibiotic before the embolization to avoid infectious complications (Level evidence B).

[Retransplant]. / Retrasplante.

Despite the advances in immunosuppressive therapy and in patient care, about 20-30% of patients will have lost their grafts after 3 years and this loss will continue by 3-4% per year. These patients are included in maintenance dialysis programmes and account for 4 to 10% of those admitted every year for maintenance dialysis therapy. Among those patients who loss their grafts 40-60% are included in transplant waiting lists. This increases the number of patients waiting for a graft and raises the dilemma about the rights to be included in deceased donor programmes. A common characteristic of these patients waiting for a second or even third transplant is the presence in the blood of antibodies to HLA antigens. A new transplant is the best therapeutic option for these patients, and the results are quite close to those achieved for the first graft. Moreover, a new transplant improves patient outcome when compared with those remaining in the waiting list. The best results are obtained in diabetic patients and in those between 18 to 50 years old (Evidence C). However, the percentage of patients retransplanted has not varied in the last years, possibly due to the wider criteria adopted on candidate selection that increases the waiting lists (Evidence B). In the second transplant, mismatched HLA-A,B antigens could be repeated if the recipient has not developed specific antibodies to these antigens. Recent cross-match has to be negative. Immunosuppressive therapy is similar to that used with first transplants. Lymphoproliferative diseases, BK virus nephropathy and primary glomerulonephritis do not preclude a second transplant (Evidence C).

Comparative effects of dietary supplementation with red grape juice and vitamin E on production of superoxide by circulating neutrophil NADPH oxidase in hemodialysis patients.

BACKGROUND: Atherosclerotic cardiovascular disease is the most common cause of death among hemodialysis patients; it has been attributed to increased oxidative stress, dyslipidemia, malnutrition, and chronic inflammation. Activation of neutrophils is a well-recognized feature in dialysis patients, and superoxide-anion production by neutrophil NADPH oxidase may contribute significantly to oxidative stress. OBJECTIVE: The aim of the study was to compare the effects of dietary supplementation with concentrated red grape juice (RGJ), a source of polyphenols, and vitamin E on neutrophil NADPH oxidase activity and other cardiovascular risk factors in hemodialysis patients. DESIGN: Thirty-two patients undergoing hemodialysis were recruited and randomly assigned to groups to receive dietary supplementation with RGJ, vitamin E, or both or a control condition without supplementation or placebo. Blood was obtained at baseline and on days 7 and 14 of treatment. RESULTS: RGJ consumption but not vitamin E consumption reduced plasma concentrations of total cholesterol and apolipoprotein B and increased those of HDL cholesterol. Both RGJ and vitamin E reduced plasma concentrations of oxidized LDL and ex vivo neutrophil NADPH oxidase activity. These effects were intensified when the supplements were used in combination; in that case, reductions in the inflammatory biomarkers intercellular adhesion molecule 1 and monocyte chemoattractant protein 1 also were observed. CONCLUSIONS: Regular ingestion of concentrated RGJ by hemodialysis patients reduces neutrophil NADPH-oxidase activity and plasma concentrations of oxidized LDL and inflammatory biomarkers to a greater extent than does that of vitamin E. This effect of RGJ consumption may favor a reduction in cardiovascular risk.