Decrease in platelet count in patients with AKI and its association with major adverse kidney events.

INTRODUCTION: A reduction in platelet count in critically ill patients is a marker of severity of the clinical condition. However, whether this association holds true in acute kidney injury (AKI) is unknown. We analyzed the association between platelet reduction in patients with AKI and major adverse kidney events (MAKE). METHODS: In this retrospective cohort, we included AKI patients at the Hospital Civil of Guadalajara, in Jalisco, Mexico. Patients were divided according to whether their platelet count fell >21% during the first 10 days. Our objectives were to analyze the associations between a platelet reduction >21% and MAKE at 10 days (MAKE10) or at 30-90 days (MAKE30-90) and death. RESULTS: From 2017 to 2023, 400 AKI patients were included, 134 of whom had a > 21% reduction in platelet count. The mean age was 54 years, 60% were male, and 44% had sepsis. The mean baseline platelet count was 194 x 103 cells/µL, and 65% of the KDIGO3 patients met these criteria. Those who underwent hemodialysis (HD) had lower platelet counts. After multiple adjustments, a platelet reduction >21% was associated with MAKE10 (OR 4.2, CI 2.1-8.5) but not with MAKE30-90. The mortality risk increased 3-fold (OR 2.9, CI 1.1-7.7, p = 0.02) with a greater decrease in the platelets (<90 x 103 cells/µL). As the platelets decreased, the incidence of MAKE was more likely to increase. These associations lost significance when accounting for starting HD. CONCLUSION: In our retrospective cohort of patients with AKI, a > 21% reduction in platelet count was associated with MAKE. Our results are useful for generating hypotheses and motivating us to continue studying this association with a more robust design.

A reduction in platelet count in critically ill patients has been associated with a worse prognosis, but it is not yet known whether this relationship also exists in patients with acute kidney injury, who are more susceptible to platelet decrease due to the syndrome or due to the onset of hemodialysis. In our study of acute kidney injury patients, we found that those whose platelet count decreased >21% during the first days were more likely to experience a major kidney event. In addition, the greater the decrease in platelet count was, the more likely these events were to occur. The significance of this association was lost in patients who start hemodialysis. Our conclusions could serve to generate hypotheses about this interesting relationship.

Systolic Blood Pressure and the Risk of Kidney Replacement Therapy and Mortality in Patients with Chronic Kidney Disease Stages 4-5.

INTRODUCTION: In patients with chronic kidney disease stages 4 and 5 (CKD stages 4-5) without dialysis and arterial hypertension, it is unknown if the values of systolic blood pressure (SBP) considered in control (<120 mm Hg) are associated with kidney replacement therapy (KRT) and mortality. METHODS: In this retrospective cohort study, hypertensive CKD stages 4-5 patients attending the Renal Health Clinic at the Hospital Civil de Guadalajara were enrolled. We divided them into those that achieved SBP <120 mm Hg (controlled group) and those who did not (>120 mm Hg), the uncontrolled group. Our primary objective was to analyze the association between the controlled group and KRT; the secondary objective was the mortality risk and if there were subgroups of patients that achieved more benefit. Data were analyzed using Stata software, version 15.1. RESULTS: During 2017-2022, a total of 275 hypertensive CKD stages 4-5 patients met the inclusion criteria for the analysis: 62 in the controlled group and 213 in the uncontrolled group; mean age 61 years; 49.82% were male; SBP was significantly lower in the controlled group (111 mm Hg) compared to the uncontrolled group (140 mm Hg); eGFR was similar between groups (20.41 mL/min/1.73 m2). There was a tendency to increase the mortality risk in the uncontrolled group (HR 6.47 [0.78-53.27]; p = 0.082) and an association by the Kaplan-Meir analysis (Log-rank p = 0.043). The subgroup analysis for risk of KRT in the controlled group revealed that patients ≥61 years had a lower risk of KRT (HR 0.87 [95% CI, 0-76-0.99]; p = 0.03, p of interaction = 0.005), but no differences were found in the subgroup analysis for mortality. In a follow-up of 1.34 years, no association was found in the risk of KRT according to the controlled or uncontrolled groups in a multivariate Cox analysis. CONCLUSION: In a retrospective cohort of patients with CKD stages 4-5 and hypertension, SBP >120 mm Hg was not associated with risk of KRT but could be associated with the risk of death. Clinical trials are required in this group of patients to demonstrate the impact of reaching the SBP goals recommended by the KDIGO guidelines.

Urea Reduction in Acute Kidney Injury and Mortality Risk.

INTRODUCTION: Urea is a toxin present in acute kidney injury (AKI). We hypothesize that reduction in serum urea levels might improve clinical outcomes. We examined the association between the reduction in urea and mortality. METHODS: Patients with AKI admitted to the Hospital Civil de Guadalajara were enrolled in this retrospective cohort study. We create 4 groups of urea reduction ratio (UXR) stratified by their decrease in urea from the highest index value in comparison to the value on day 10 (0%, 1-25%, 26-50%, and >50%), or at the time of death or discharge if prior to 10 days. Our primary endpoint was to observe the association between UXR and mortality. Secondary observations included determination of which types of patients achieved a UXR >50%, whether the modality of kidney replacement therapy (KRT) effected changes in UXR, and if serum creatinine (sCr) value changes were similarly associated with patient mortality. RESULTS: A total of 651 AKI patients were enrolled. The mean age was 54.1 years, and 58.6% were male. AKI 3 was present in 58.5%; the mean admission urea was 154 mg/dL. KRT was started in 32.4%, and 18.9% died. A trend toward decreased risk of death was observed in association with the magnitude of UXR. The best survival (94.3%) was observed in patients with a UXR >50%, and the highest mortality (72.1%) was observed in patients achieving a UXR of 0%. After adjusting for age, sex, diabetes mellitus, CKD, antibiotics, sepsis, hypovolemia, cardio-renal syndrome, shock, and AKI stage, the 10-day mortality was higher in groups that did not achieve a UXR of at least 25% (OR: 1.20). Patients achieving a UXR >50% were most likely initiated on dialysis due to a diagnosis of the uremic syndrome or had a diagnosis of obstructive nephropathy. Percentage change in sCr was also associated with increased mortality risk. CONCLUSIONS: In our retrospective cohort of AKI patients, the percent decrease in UXR from admission was associated with a stratified risk of death. Patients with a UXR >25% had the best associated outcomes. Overall, a greater magnitude in UXR was associated with improved patient survival.

Methemoglobinemia in Hemodialysis Patients due to Acute Chlorine Intoxication: A Case Series Calling Attention on an Old Problem.

INTRODUCTION: Hemodialysis uses municipal water that must be strictly purified and sterilized to be used for that procedure. Large amounts of decontaminants are often used, such as chlorine, and if these compounds are not subsequently removed they can be transferred to the blood of patients causing complications including methemoglobinemia. METHODS: In this case series study, dialysis patients in one unit were evaluated. We reviewed clinical characteristics and laboratory findings obtained on the day when the water supply was disinfected with chlorine, with the aim to quantify methemoglobin concentrations. Our objective was to characterize the clinical presentation and management of patients who presented with methemoglobinemia on a specific index day. We also reviewed reported cases in the literature regarding this underreported complication. RESULTS: Eight patients who presented with chlorine intoxication were evaluated. The methemoglobin concentrations were between 1.3% and 7.9% (reference value 0-1%). We believe this to be caused by water containing 0.78 mg/L of total chlorine. Seven patients presented with cyanosis, 4 with dizziness, 6 with dark brown blood, 4 with dyspnea, and 4 with headache and hemolytic anemia. Subjects were treated with supplemental oxygen, methylene blue, intravenous vitamin C, blood transfusions, and increased doses of erythropoietin. No patient died, and all continued with their usual hemodialysis sessions. CONCLUSION: Acute chlorine intoxication transferred by the water used during hemodialysis sessions can present with methemoglobinemia accompanied by cyanosis, oxygen desaturation, and hemolytic anemia. Chlorine levels should be carefully monitored in the water used for hemodialysis treatment.

Probiotics in septic acute kidney injury, a double blind, randomized control trial.

INTRODUCTION: During acute kidney injury (AKI) due to sepsis, the intestinal microbiota changes to dysbiosis, which affects the kidney function recovery (KFR) and amplifies the injury. Therefore, the administration of probiotics could improve dysbiosis and thereby increase the probability of KFR. METHODS: In this double-blind clinical trial, patients with AKI associated with sepsis were randomized (1:1) to receive probiotics or placebo for 7 consecutive days, with the objectives of evaluate the effect on KFR, mortality, kidney replacement therapy (KRT), urea, urine volume, serum electrolytes and adverse events at day 7. RESULTS: From February 2019 to March 2022, a total of 92 patients were randomized, 48 to the Probiotic and 44 to Placebo group. When comparing with placebo, those in the Probiotics did not observe a higher KFR (HR 0.93, 0.52-1.68, p = 0.81), nor was there a benefit in mortality at 6 months (95% CI 0.32-1.04, p = 0.06). With probiotics, urea values decreased significantly, an event not observed with placebo (from 154 to 80 mg/dl, p = 0.04 and from 130 to 109 mg/dl, p = 0.09, respectively). Urinary volume, need for KRT, electrolyte abnormalities, and adverse events were similar between groups. (ClinicalTrial.gov NCT03877081) (registered 03/15/2019). CONCLUSION: In AKI related to sepsis, probiotics for 7 consecutive days did not increase the probability of KFR, nor did other variables related to clinical improvement, although they were safe.

Vascular Access and Clinical Outcomes in Underserved Hemodialysis Patients in Mexico.

INTRODUCTION: Central venous catheter (CVC) as vascular access in hemodialysis (HD) associates with adverse outcomes. Early CVC to fistula or graft conversion improves these outcomes. While socioeconomic disparities between the USA and Mexico exist, little is known about CVC prevalence and conversion rates in uninsured Mexican HD patients. We examined vascular access practice patterns and their effects on survival and hospitalization rates among uninsured Mexican HD patients, in comparison with HD patients who initiated treatment in the USA. METHODS: In this retrospective study of incident HD patients at Hospital Civil (HC; Guadalajara, MX) and the Renal Research Institute (RRI; USA), we categorized patients by the vascular access at the first month of HD and after the following 6 months. Factors associated with continued CVC use were identified by a logistic regression model. We developed multivariate Cox proportional hazards models to investigate the effects of access and conversion on mortality and hospitalization over an 18-month follow-up period. RESULTS: In 1,632 patients from RRI, the CVC prevalence at month 1 was 64% and 97% among 174 HC patients. The conversion rate was 31.7% in RRI and 10.6% in HC. CVC to non-central venous catheter (NON-CVC) conversion reduced the risk of hospitalization in both HC (aHR 0.38 [95% CI: 0.21-0.68], p = 0.001) and RRI (aHR 0.84 [95% CI: 0.73-0.93], p = 0.001). NON-CVC patients had a lower mortality risk in both populations. DISCUSSION/CONCLUSION: CVC prevalence and conversion rates of CVC to NON-CVC differed between the US and Mexican patients. An association exists between vascular access type and hospitalization and mortality risk. Prospective studies are needed to evaluate if accelerated and systematic catheter use reduction would improve outcomes in these populations.

The Effect in Renal Function and Vascular Decongestion in Type 1 Cardiorenal Syndrome Treated with Two Strategies of Diuretics, a Pilot Randomized Trial.

AIM: The main treatment strategy in type 1 cardiorenal syndrome (CRS1) is vascular decongestion. It is probable that sequential blockage of the renal tubule with combined diuretics (CD) will obtain similar benefits compared with stepped-dose furosemide (SF). METHODS: In a pilot double-blind randomized controlled trial of CRS1 patients were allocated in a 1:1 fashion to SF or CD. The SF group received a continuous infusion of furosemide 100 mg during the first day, with daily incremental doses to 200 mg, 300 mg and 400 mg. The CD group received a combination of diuretics, including 4 consecutive days of oral chlorthalidone 50 mg, spironolactone 50 mg and infusion of furosemide 100 mg. The objectives were to assess renal function recovery and variables associated with vascular decongestion. RESULTS: From July 2017 to February 2020, 80 patients were randomized, 40 to the SF and 40 to the CD group. Groups were similar at baseline and had several very high-risk features. Their mean age was 59 ± 14.5 years, there were 37 men (46.2%). The primary endpoint occurred in 20% of the SF group and 15.2% of the DC group (p = 0.49). All secondary and exploratory endpoints were similar between groups. Adverse events occurred frequently (85%) with no differences between groups (p = 0.53). CONCLUSION: In patients with CRS1 and a high risk of resistance to diuretics, the use of CD compared to SF offers the same results in renal recovery, diuresis, vascular decongestion and adverse events, and it can be considered an alternative treatment. ClinicalTrials.gov with number NCT04393493 on 19/05/2020 retrospectively registered.

What did we learn about coronavirus disease-19-associated acute kidney injury during the pandemic?

Initial reports suggested that kidney involvement after coronavirus disease 19 (COVID-19) infection was uncommon, but this premise appears to be incorrect. Acute kidney injury can occur through various mechanisms and complicate the course of up to 25% of patients with COVID-19 hospitalized in our Institution, and of over 50% of those on invasive mechanical ventilation. Mechanisms of injury include direct kidney injury and predominantly tubular, although glomerular injury has been reported, and resulting from severe hypoxic respiratory failure, secondary infection, and exposure to nephrotoxic drugs. The mainstay of treatment remains the prevention of progressive kidney damage and, in some cases, the use of renal replacement therapy. Although the use of blood purification techniques has been proposed as a potential treatment, results to date have not been conclusive. In this manuscript, the mechanisms of kidney injury by COVID-19, risk factors, and the mainstays of treatment are reviewed.

[Consensus on the use of iSGLT2 in the treatment of patients with type 2 diabetes mellitus]. / Documento de consenso sobre el uso de los iSGLT2 en el tratamiento de pacientes con diabetes mellitus tipo 2.

Although in recent years in Mexico the quality of diabetes mellitus (DM) care has improved and access to health services and medications has increased, there is a lack of adherence to the recommendations of the clinical guidelines, which could explain the poor glycemic control in many of the patients with DM. Sodium-glucose cotransporter type 2 (iSGLT2) inhibitors have been the last class of antidiabetic agents to receive approval from the Food and Drug Administration (FDA) and COFEPRIS (Mexico). In order to improve the use of SGLT2i in clinical practice in Mexico, this paper presents the recommendations issued by a panel of eleven Mexican experts based on the new published evidence for the treatment of patients with DM2.

Aunque en los últimos años en México ha mejorado la calidad de la atención de la diabetes mellitus (DM) y ha aumentado el acceso a servicios de salud y medicamentos, existe una falta de apego a las recomendaciones de las guías de práctica clínica, que podría explicar la falta de un control glucémico adecuado en muchos de los pacientes con DM. Los inhibidores del cotransportador de sodio-glucosa tipo 2 (iSGLT2) han sido la última clase de agentes antidiabéticos en recibir la aprobación de la Food and Drug Administration (FDA) y de la Comisión Federal para la Protección contra Riesgos Sanitarios de México (COFEPRIS). Con el fin de mejorar el uso de los iSGLT2 en la práctica clínica en México, en este documento se presentan las recomendaciones emitidas por un panel de 11 expertos mexicanos con base en las nuevas evidencias publicadas para el tratamiento de los pacientes con DM2.

Nephrologist Interventions to Avoid Kidney Replacement Therapy in Acute Kidney Injury.

BACKGROUND: Based on the pathophysiology of acute kidney injury (AKI), it is plausible that certain early interventions by the nephrologist could influence its trajectory. In this study, we investigated the impact of 5 early nephrology interventions on starting kidney replacement therapy (KRT), AKI progression, and death. METHODS: In a prospective cohort at the Hospital Civil of Guadalajara, we followed up for 10 days AKI patients in whom a nephrology consultation was requested. We analyzed 5 early interventions of the nephrology team (fluid adjustment, nephrotoxic withdrawal, antibiotic dose adjustment, nutritional adjustment, and removal of hyperchloremic solutions) after the propensity score and multivariate analysis for the risk of starting KRT (primary objective), AKI progression to stage 3, and death (secondary objectives). RESULTS: From 2017 to 2020, we analyzed 288 AKI patients. The mean age was 55.3 years, 60.7% were male, AKI KDIGO stage 3 was present in 50.5% of them, sepsis was the main etiology 50.3%, and 72 (25%) patients started KRT. The overall survival was 84.4%. Fluid adjustment was the only intervention associated with a decreased risk for starting KRT (odds ratio [OR]: 0.58, 95% confidence interval [CI]: 0.48-0.70, and p ≤ 0.001) and AKI progression to stage 3 (OR: 0.59, 95% CI: 0.49-0.71, and p ≤ 0.001). Receiving vasopressors and KRT were associated with mortality. None of the interventions studied was associated with reducing the risk of death. CONCLUSIONS: In this prospective cohort study of AKI patients, we found for the first time that early nephrologist intervention and fluid prescription adjustment were associated with lower risk of starting KRT and progression to AKI stage 3.

Rectus abdominis muscle thickness as a predictor of peritoneal catheter dysfunction in emergency-start peritoneal dialysis patients.

BACKGROUND: Percutaneous insertion of a peritoneal dialysis catheter (PDc) is an alternative to open surgical techniques, and the anatomical characteristics of the abdominal wall may predict PDc dysfunction. We evaluated the role of rectus abdominis muscle (RAM) thickness as a predictor of PDc dysfunction. MATERIALS AND METHODS: A prospective cohort of emergency-start PD patients (EmPD) who had their first percutaneous PDc insertion were included. PDc failure was defined as the removal of a PDc due to mechanical failure within the first 30 PD fluid exchanges. Clinical variables were recorded. The skin to parietal peritoneum depth and RAM thickness were determined by abdominal ultrasound. Univariate and multivariate logistic regression models were developed to test associations between clinical parameters and PDc dysfunction. RESULTS: Over 6 months, 119 patients underwent PDc insertion; 73 (61.3%) were males, with a mean age of 46.0 ± 17.8 years. The mean skin-to-peritoneum depth was 2.5 ± 1.0 cm, the RAM thickness was 0.91 ± 0.3 cm, and catheter implantation was successful in 116 (97.4%) patients. Insertion failed in 3 (2.5%) cases, and 30 (25.8%) patients presented with catheter dysfunction. Univariate analysis indicated that RAM thickness ≥ 1.0 cm, skin-to-peritoneum depth > 2.88 cm, abdominal waist > 92.5 cm, and skin-to-RAM fascia distance > 2.3 cm were associated with PDc dysfunction; in multivariate logistic regression analysis, only greater RAM thickness remained a significant predictor (OR 1.6, 95% CI 1.38 - 1.88, p < 0.001). CONCLUSION: In EmPD patients, RAM thickness is associated with PDc dysfunction and could aid in identifying patients at risk for PDc dysfunction in emergency settings. Additional adequately powered studies are needed to confirm our findings.

Acute kidney injury in renal trauma patients.

BACKGROUND: The kidney is the most commonly injured organ of the genitourinary system during trauma. We describe the associated risk factors for the development of acute kidney injury (AKI) in patients with renal trauma (RT). MATERIALS AND METHODS: We prospectively analyzed data from 65 patients who suffered RT from 2015 to 2019 at the Hospital Civil de Guadalajara. Demographic variables, clinical characteristics, and AKI risk factors were described. We assessed the risk factors related to AKI development. RESULTS: In our study cohort, 60 (92.3%) patients were men, mean age 25 (20 - 30) years; the most common cause of RT was firearm injury in 26 (40%) of patients and 46 (70%) required surgery. AKI associated with RT developed in 39 (60%) patients. There were no differences between patients with or without AKI requiring nephrectomy (35.9 vs. 19.2%, p = 0.15). RT was classified as high-grade in 37 (56.9%) cases; high-grade RT increased four-fold the probability of AKI (adjusted OR 3.95, p = 0.05). A model for AKI prediction during RT was built with the most relevant variables: firearm injury, shock, emergency surgery, high-grade RT, and liver injury, all predicting AKI (ROC-AUC of 0.74 p = 0.02). CONCLUSION: AKI occurred in 60% of cases with RT, and it was significantly associated with high-grade RT. Further studies will be required to confirm this association in other populations, which could lead to an earlier and proactive management of AKI in this setting.

The impact of anatomical variables on haemodialysis tunnelled catheter replacement without fluoroscopy.

AIM: Tunnelled haemodialysis (HD) catheters can be used instantly, but there are several anatomical variables that could impact it survival. This study aimed to examine the impact of different novel anatomic variables, with catheter replacement. METHODS: In a single-centre a prospective cohort in chronic kidney disease G5 patients were conducted. The primary outcome was to determine the factors associated with catheter replacement during the first 6-month of follow-up. All procedures were performed without fluoroscopy. Three anatomic regions for catheter tip position were established: considered as superior vena cava (SVC), cavo-atrial junction (CAJ) and mid-to deep atrium (MDA). Many other anatomical variables were measured. Catheter-related bloodstream infection was also included. RESULTS: Between January 2019 and January 2020 a total of 75 patients with tunnelled catheter insertion were analysed. Catheter replacement at 6-month occur in 10 (13.3%) patients. By multivariate analysis, the incorrect catheter tip position (SVC) (OR 1.23, 95% CI 1.07-1.42, p <.004), the presence of extrasystoles during the procedure (OR 0.88, 95% CI 0.78-0.98, p = .03), incorrect catheter tug (OR 1.31, 95% CI 1.10-1.55, p = .003), incorrect catheter top position (kinking; OR 1.40, 95% CI 1.04-1.88, p = .02) and catheter-related bloodstream infection (OR 2.60, 95% CI 2.09-3.25, p <.001) were the only variables associated with catheter replacement at 6-month follow-up. CONCLUSION: The risk of catheter replacement at 6-month follow-up could be attenuated by avoiding incorrect catheter tug and top position, and by placing the vascular catheter tip in the CAJ and MDA.

Access to kidney transplantation in Mexico, 2007-2019: a call to end disparities in transplant care.

BACKGROUND: Access to kidney transplantation is limited to more than half of the Mexican population. A fragmented health system, gender, and sociocultural factors are barriers to transplant care. We analyzed kidney transplantation in Mexico and describe how public policies and sociocultural factors result in these inequities. METHODS: Kidney transplant data between 2007 to 2019 were obtained from the National Transplant Center database. Transplant rates and time spent on the waiting list, by age, gender, health system, and insurance status, were estimated. RESULTS: During the study period 34,931 transplants were performed. Recipients median age was 29 (IQR 22-42) years, 62.4% were males, and 73.9% were insured. 72.7% transplants were from living-donors. Annual transplant rates increased from 18.9 per million population (pmp) to 23.3 pmp. However, the transplant rate among the uninsured population remained low, at 9.3 transplants pmp. In 2019, 15,890 patients were in the waiting list; 60.6% were males and 88% were insured. Waiting time to transplant was 1.55 (IQR 0.56-3.14) years and it was shorter for patients listed in the Ministry of Health and private facilities, where wait lists are smaller, and for males. Deceased-organ donation rates increased modestly from 2.5 pmp to 3.9 pmp. CONCLUSIONS: In conclusion, access to kidney transplantation in Mexico is unequal and restricted to patients with medical insurance. An inefficient organ procurement program results in low rates of deceased-donor kidneys. The implementation of a comprehensive kidney care program, recognizing kidney transplantation as the therapy of choice for renal failure, offers an opportunity to correct these inequalities.

The Sum of Kidney Donor Profile Index and Estimated Post-Transplant Survival Scale and Their Correlation with eGFR Decline in Deceased Donor Kidney Recipients.

BACKGROUND: The impact of donor quality on post-kidney transplant survival may vary by candidate condition. OBJECTIVE: Analyzing the combined use of the Kidney Donor Profile Index (KDPI) and the estimated post-transplant survival (EPTS) scale and their correlation with the estimated glomerular filtration rate (eGFR) decline in deceased-donor kidney recipients (DDKR). METHODS: This was a retrospective, observational cohort study. We included DDKRs between 2015 and 2017 at a national third-level hospital. RESULTS: We analyzed 68 DDKR. The mean age at transplant was 41 ± 14 years, 47 (69%) had sensitization events, 18 (26%) had delayed graft function, and 16 (23%) acute rejection. The graft survival at 12 and 36 months was 98.1% (95% CI 94-100) and 83.7% (95% CI 65-100), respectively. The Pearson correlation coefficient between the percentage reduction in the annual eGFR and the sum of EPTS and KDPI scales was r = 0.61, p < 0.001. The correlation coefficient between the percentage reduction in the annual eGFR and the EPTS and KDPI scales separately was r = 0.55, p < 0.001, and r = 0.53, p < 0.001, respectively. CONCLUSIONS: The sum of EPTS and KDPI scales can provide a better donor-recipient relationship and has a moderately positive correlation with the decrease in eGFR in DDKR.

Chronic kidney disease of unknown cause in Mexico: The case of Poncitlan, Jalisco.

Chronic kidney disease of unknown cause (CKDu) is relatively common in low- and middle-income countries. A high prevalence of CKDu has been reported among the inhabitants of Poncitlan, Mexico. We did a cross-sectional study to compare the characteristics of residents in Poncitlan, a very poor municipality, with those from other municipalities in Jalisco state. We also estimated the prevalence of renal replacement therapy (RRT) in this region. We assessed 51,789 individuals in Jalisco: 16,351 (32.1%) were men, mean age 51.8 ± 15.3 years; 650 (1.3%) were aged < 18 years. Overall the prevalence of CKD (10.5%) and proteinuria (11.5%), were similar to the overall Mexican population. There were 283 adult and 144 child participants who resided in Poncitlan: adults were more likely to be female (78.0 vs. 67.9%, p = 0.000) but were of similar age as compared to those from other municipalities; children were younger (8.78 ± 3.97 vs. 15.03 ± 2.57 years, p = 0.000) but had a similar proportion of females compared to children from other municipalities. In Poncitlan, the prevalence of CKD and proteinuria were both higher in adults compared to those from other municipalities (CKD: 20.1 vs. 10.4%, p = 0.002; proteinuria: 36.1 vs. 11.0%, p = 0.000), and the prevalence of proteinuria in children was also higher (44.4 vs. 4.8%, p = 0.000). However, the prevalence of diabetes mellitus and obesity were lower in Poncitlan than elsewhere. The prevalence of RRT in Poncitlan was 2,228 pmp, twice as high as the prevalence for Jalisco state as a whole. In conclusion, CKD and proteinuria were detected frequently in residents of the Poncitlan community. Future studies should consider the possibility that CKDu is due to multifactorial causes, especially in poor communities.
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Oral acyclovir induced hypokalemia and acute tubular necrosis a case report.

BACKGROUND: Acyclovir is one of the most common prescribed antiviral drugs. Acyclovir nephrotoxicity occurs in approximately 12-48% of cases. It can present in clinical practice as acute kidney injury (AKI), crystal-induced nephropathy, acute tubulointerstitial nephritis, and rarely, as tubular dysfunction. Electrolytes abnormalities like hypokalemia, were previously described only when given intravenously. CASE PRESENTATION: A 54 year-old female presented with weakness and lower extremities paresis, nausea and vomiting after receiving oral acyclovir. Physical examination disclosed a decrease in the patellar osteotendinous reflexes (++ / ++++). Laboratory data showed a serum creatinine level of 2.1 mg/dL; serum potassium 2.1 mmol/L. Kidney biopsy was obtained; histological findings were consistent with acute tubular necrosis and acute tubulointerstitial nephritis. The patient was advised to stop the medications and to start with oral and intravenous potassium supplement, symptoms improved and continued until serum potassium levels were > 3.5 meq/L. CONCLUSIONS: The case reported in this vignette is unique since it is the first one to describe hypokalemia associated to acute tubular necrosis induced by oral acyclovir.

[Principios y modalidades en terapia de reemplazo renal continua].

La terapia de reemplazo renal continuo (CRRT, por sus siglas en inglés) se utiliza en pacientes críticamente enfermos con lesión renal aguda (LRA). Este tratamiento tiene una historia cargada de tintes pasionales y ambiciosos que han revolucionado el tratamiento en las Unidades de terapia intensiva. Avances tecnológicos permiten remover toxinas y ajustar líquidos y moléculas de manera paulatina y segura, lo que que plausiblemente mejora el pronóstico clínico. Las terapias continuas requieren una estrecha colaboración del equipo multidisciplinario. Aunque los datos no demuestran ventaja entre las distintas modalidades de tratamiento de sustitución renal, creemos que avanzamos hacia una estandarización del tratamiento con base en la evidencia, que ha de promover una continua mejoría en el tratamiento de pacientes críticos con LRA. En el presente artículo se comenta la evolución tecnológica, los componentes del circuito extracorpóreo, los pasos iniciales en el uso de las máquinas, los principios en mecanismos de transporte y, finalmente, las modalidades de mayor uso en CRRT.Continuous renal replacement therapy (CRRT) is used in critically ill patients with acute kidney injury. This modality of treatment, loaded with a history full of passion and ambition, has revolutionized treatment in intensive care units. Technological advances allow the removal of toxins and management of fluids and molecules in a gradual and safe way that plausibly improves the clinical prognosis. This technique requires close collaboration of the multidisciplinary team. Although data do not demonstrate an advantage among the different modalities of renal replacement therapy, we firmly believe that we are moving towards an evidence-based standardization of treatment, which should promote a continuous improvement in the management of critically ill patients with acute renal injury. The present study accomplishes the evolution of technology, the components of the extracorporeal circuit, the initial steps while using these dedicated machines, the principles of mechanisms of solute and water transport, and finally the most frequently prescribed modalities in CRRT.

[Epidemiología y desenlaces de la lesión renal aguda en Latinoamérica].

La lesión renal aguda (LRA) o injuria renal aguda, como se describe en Sudamérica, está sobreestimada por estudios epidemiológicos de países de alto nivel económico. En Latinoamérica (LA) existe un vacío de información sobre la epidemiología de la LRA. Se realizó una búsqueda de artículos publicados en LA referentes a la LRA y se hallaron 61 estudios, que representan a 10,670 pacientes latinoamericanos, en los cuales se distingue entre población adulta y pediátrica, LRA adquirida en la comunidad (LRA-AC) y adquirida en el hospital (LRA-AH), y se describen sus etiologías y desenlaces. El conocimiento de la incidencia y características de los pacientes con LRA en LA nos permitirá el desarrollo de estrategias preventivas y mejor acceso a un tratamiento de apoyo adecuado.Acute kidney injury (AKI) is over represented by epidemiological studies of high-income countries. In Latin America there is a lack of information on the epidemiology of AKI. We conducted a search of articles on AKI published in Latin America, finding 61 studies that represent 10,670 Latin American patients. Data were segmented by adult and pediatric populations, and community-acquired AKI and hospital-acquired AKI. Finally, etiology and outcomes are described. The knowledge of the incidence and characteristics of patients with AKI in Latin America will allow us to develop preventive strategies and better access to adequate support treatment.

Kidney Replacement Therapies and Ultrafiltration in Cardiorenal Syndrome.

BACKGROUND: Some patients with cardiorenal syndrome 1 and congestion exhibit resistance to diuretics. This scenario complicates management and is associated with a worse prognosis. In some cases, rescue treatment may be considered by starting kidney replacement therapies or ultrafiltration. This decision is complex and necessitates a profound understanding of these techniques and the pathophysiology of this syndrome. These modalities are classified into continuous, intermittent, and ultrafiltration therapies, each with its own advantages and disadvantages that are pertinent in selecting the optimal treatment. SUMMARY: In patients with diuretic-resistant cardiorenal syndrome, extracorporeal ultrafiltration and kidney replacement therapies have the potential to relieve congestion, restore the neurohormonal system, and improve quality of life. KEY MESSAGES: (i) In cardiorenal syndrome, the resistance to diuretics is common. (ii) Extracorporeal ultrafiltration and renal replacement therapies are rescue options that may improve the management of these patients. (iii) Better understanding of these modalities will help the development of new devices which are friendlier, safer, and more affordable for patients in these clinical settings.