RESUMEN
There is no evidence about the potential role of body composition on cardiovascular mortality in dialysis patients. The aim of this study was to assess the relationship between body composition and changes in ventricular function. We conducted an observational study over a population of 78 patients on chronic hemodialysis. A transthoracic echocardiogram and a bioimpedance were performed at the beginning and at the end of the study. The mean follow-up time was 30.6 months. Patients who had a higher fat tissue index (FTI > 9.20 kg/m2 ) experienced a worsening in right and left ventricular function. They developed a greater fall in tricuspid annular plane systolic excursion (TAPSE) (-1 ± 4.3 mm) and left ventricular ejection fraction (LVEF)(-4.2 ± 6.8%), compared to those with lower FTI (p = 0.032 and p = 0.045, respectively). No associations were found between any other echocardiography or body composition parameters and overall mortality. Patients with right ventricular dysfunction (determined as TAPSE) experienced a tendency to higher mortality rate along the study (HR for mortality of 13.5 (95% CI, 1.1-166.7; p = 0.041)]. A higher fat tissue index could be associated with a deleterious effect over right and left ventricular function in dialysis patients.
Asunto(s)
Función Ventricular Izquierda , Función Ventricular Derecha , Composición Corporal , Humanos , Diálisis Renal/efectos adversos , Volumen SistólicoRESUMEN
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia emerged in Wuhan, China in December 2019. Unfortunately, there is a lack of evidence about the optimal management of novel coronavirus disease 2019 (COVID-19), and even less is available in patients on maintenance hemodialysis therapy than in the general population. In this retrospective, observational, single-center study, we analyzed the clinical course and outcomes of all maintenance hemodialysis patients hospitalized with COVID-19 from March 12th to April 10th, 2020 as confirmed by real-time polymerase chain reaction. Baseline features, clinical course, laboratory data, and different therapies were compared between survivors and nonsurvivors to identify risk factors associated with mortality. Among the 36 patients, 11 (30.5%) died, and 7 were able to be discharged within the observation period. Clinical and radiological evolution during the first week of admission were predictive of mortality. Among the 36 patients, 18 had worsening of their clinical status, as defined by severe hypoxia with oxygen therapy requirements greater than 4 L/min and radiological worsening. Significantly, 11 of those 18 patients (61.1%) died. None of the classical cardiovascular risk factors in the general population were associated with higher mortality. Compared to survivors, nonsurvivors had significantly longer dialysis vintage, increased lactate dehydrogenase (490 U/l ± 120 U/l vs. 281 U/l ± 151 U/l, P = 0.008) and C-reactive protein levels (18.3 mg/dl ± 13.7 mg/dl vs. 8.1 mg/dl ± 8.1 mg/dl, P = 0.021), and a lower lymphocyte count (0.38 ×103/µl ± 0.14 ×103/µl vs. 0.76 ×103/µl ± 0.48 ×103/µl, P = 0.04) 1 week after clinical onset. Thus, the mortality among hospitalized hemodialysis patients diagnosed with COVID-19 is high. Certain laboratory tests can be used to predict a worsening clinical course.
Asunto(s)
Infecciones por Coronavirus/mortalidad , Fallo Renal Crónico/complicaciones , Neumonía Viral/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Antimaláricos/uso terapéutico , Azitromicina/uso terapéutico , COVID-19 , Infecciones por Coronavirus/complicaciones , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/tratamiento farmacológico , Combinación de Medicamentos , Femenino , Mortalidad Hospitalaria , Humanos , Hidroxicloroquina/uso terapéutico , Fallo Renal Crónico/terapia , Lopinavir/uso terapéutico , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/complicaciones , Neumonía Viral/diagnóstico , Neumonía Viral/tratamiento farmacológico , Pronóstico , Diálisis Renal , Estudios Retrospectivos , Ritonavir/uso terapéutico , España/epidemiologíaRESUMEN
BACKGROUND: Patients with chronic kidney disease (CKD) are at high risk for developing cardiovascular events. However, limited evidence is available regarding the use of aspirin in CKD patients to decrease cardiovascular risk and to slow renal disease progression. STUDY DESIGN: Prospective, multicenter, open-label randomized controlled trial. SETTING AND PARTICIPANTS: One hundred eleven patients with estimated glomerular filtration rate (eGFR) 15-60 ml/min/1.73 m2 without previous cardiovascular events. INTERVENTION: Aspirin treatment (100 mg/day) (n = 50) or usual therapy (n = 61). Mean follow-up time was 64.8 ± 16.4 months. OUTCOMES: The primary endpoint was composed of cardiovascular death, acute coronary syndrome (nonfatal MI, coronary revascularization, or unstable angina pectoris), cerebrovascular disease, heart failure, or nonfatal peripheral arterial disease. Secondary endpoints were fatal and nonfatal coronary events, renal events (defined as doubling of serum creatinine, ≥ 50% decrease in eGFR, or renal replacement therapy), and bleeding episodes. RESULTS: During follow-up, 17 and 5 participants suffered from a primary endpoint in the control and aspirin groups, respectively. Aspirin did not significantly reduce primary composite endpoint (HR, 0.396 (0.146-1.076), p = 0.069. Eight patients suffered from a fatal or nonfatal coronary event in the control group compared to no patients in the aspirin group. Aspirin significantly reduced the risk of coronary events (log-rank, 5.997; p = 0.014). Seventeen patients in the control group reached the renal outcome in comparison with 3 patients in the aspirin group. Aspirin treatment decreased renal disease progression in a model adjusted for age, baseline kidney function, and diabetes mellitus (HR, 0.272; 95% CI, 0.077-0.955; p = 0.043) but did not when adjusted for albuminuria. No differences were found in minor bleeding episodes between groups and no major bleeding was registered. LIMITATIONS: Small sample size and open-label trial. CONCLUSIONS: Long-term treatment with low-dose aspirin did not reduce the composite primary endpoint; however, there were reductions in secondary endpoints with fewer coronary events and renal outcomes. ClinicalTrials.gov Identifier: NCT01709994.
Asunto(s)
Aspirina/uso terapéutico , Fármacos Cardiovasculares/uso terapéutico , Enfermedades Cardiovasculares/prevención & control , Riñón/efectos de los fármacos , Prevención Primaria/métodos , Insuficiencia Renal Crónica/tratamiento farmacológico , Anciano , Aspirina/efectos adversos , Fármacos Cardiovasculares/efectos adversos , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/mortalidad , Progresión de la Enfermedad , Femenino , Tasa de Filtración Glomerular/efectos de los fármacos , Hemorragia/inducido químicamente , Humanos , Riñón/fisiopatología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/mortalidad , Insuficiencia Renal Crónica/fisiopatología , Factores de Riesgo , España , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Vasculitis Asociada a Anticuerpos Citoplasmáticos Antineutrófilos , COVID-19 , Vasculitis Asociada a Anticuerpos Citoplasmáticos Antineutrófilos/inducido químicamente , Vasculitis Asociada a Anticuerpos Citoplasmáticos Antineutrófilos/tratamiento farmacológico , Vacunas contra la COVID-19 , ChAdOx1 nCoV-19 , Humanos , SARS-CoV-2 , VacunaciónRESUMEN
BACKGROUND: Asymptomatic hyperuricemia increases renal and cardiovascular (CV) risk. We previously conducted a 2-year, single-blind, randomized, controlled trial of allopurinol treatment that showed improved estimated glomerular filtration rate and reduced CV risk. STUDY DESIGN: Post hoc analysis of a long-term follow-up after completion of the 2-year trial. SETTING & PARTICIPANTS: 113 participants (57 in the allopurinol group and 56 in the control group) initially followed up for 2 years and 107 participants followed up to 5 additional years. INTERVENTION: Continuation of allopurinol treatment, 100mg/d, or standard treatment. OUTCOME: Renal event (defined as starting dialysis therapy and/or doubling serum creatinine and/or ≥50% decrease in estimated estimated glomerular filtration rate) and CV events (defined as myocardial infarction, coronary revascularization or angina pectoris, congestive heart failure, cerebrovascular disease, and peripheral vascular disease). RESULTS: During initial follow-up, there were 2 renal and 7 CV events in the allopurinol group compared with 6 renal and 15 CV events in the control group. In the long-term follow-up period, 12 of 56 participants taking allopurinol stopped treatment and 10 of 51 control participants received allopurinol. During long-term follow-up, an additional 7 and 9 participants in the allopurinol group experienced a renal or CV event, respectively, and an additional 18 and 8 participants in the control group experienced a renal or CV event, respectively. Thus, during the initial and long-term follow-up (median, 84 months), 9 patients in the allopurinol group had a renal event compared with 24 patients in the control group (HR, 0.32; 95% CI, 0.15-0.69; P=0.004; adjusted for age, sex, baseline kidney function, uric acid level, and renin-angiotensin-aldosterone system blockers). Overall, 16 patients treated with allopurinol experienced CV events compared with 23 in the control group (HR, 0.43; 95% CI, 0.21-0.88; P=0.02; adjusted for age, sex, and baseline kidney function). LIMITATIONS: Small sample size, single center, not double blind, post hoc follow-up and analysis. CONCLUSIONS: Long-term treatment with allopurinol may slow the rate of progression of kidney disease and reduce CV risk.
Asunto(s)
Alopurinol/uso terapéutico , Enfermedades Cardiovasculares/epidemiología , Progresión de la Enfermedad , Supresores de la Gota/uso terapéutico , Insuficiencia Renal Crónica/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Alopurinol/farmacología , Creatinina/sangre , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular/efectos de los fármacos , Supresores de la Gota/farmacología , Humanos , Incidencia , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Insuficiencia Renal Crónica/mortalidad , Factores de Riesgo , Resultado del Tratamiento , Ácido Úrico/sangreRESUMEN
OBJECTIVE: No consensus has been established as to which is the best fourth-line agent in patients with resistant hypertension (RHT). The aim of the present study was to assess the effect of intensifying diuretic treatment with loop diuretic (furosemide) or aldosterone antagonist (spironolactone) on blood pressure (BP) control in RHT. METHODS: The study population comprised 30 patients with RHT who were divided into two treatment arms. Fifteen patients received furosemide 40 mg/day and 15 patients received spironolactone 25 mg/day. Ambulatory BP monitoring was performed baseline, 3 and 6 months. RESULTS: Baseline BP was 162 ± 8/90 ± 6 mmHg, 70% men, mean age 63.3 ± 9.1 years 56.1% diabetic and estimated glomerular filtration rate (eGFR) 55.8 ± 16.5 mL/min per 1.73 m(2) . There were no significant differences between groups at baseline in age, gender, percentage diabetics, eGFR, BP, number of antihypertensive drugs, or aldosterone levels. At 6 months, systolic BP decreased by 24 ± 9.2 mmHg (from 163.6 ± 8.6 to 139.6 ± 8.1 mmHg) in the spironolactone group, compared with 13.8 ± 2.8 mmHg (from 162 ± 7.9 to 148 ± 6.4 mmHg) in the furosemide group (P < 0.01). Diastolic BP fell 11 ± 8.1 mmHg in the spironolactone group compared with 5.2 ± 2.2 mmHg in the furosemide group (P < 0.01). Significant reduction in urinary albumin creatinine ratio (from 173 ± 268 to 14 ± 24 mg/g, P < 0.01) was observed in the spironolactone group at 6 months. Multiple regression analysis showed that only treatment with spironolactone was associated with control of BP < 140/90 mmHg at 6 months. No severe adverse events were recorded. CONCLUSION: Spironolactone is more effective than furosemide for control of BP in RHT patients, with a positive added effect on albuminuria. Spironolactone is safe in patients with mild kidney impairment, although serum potassium should be closely monitored, especially in diabetics.
Asunto(s)
Antihipertensivos/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Resistencia a Medicamentos , Furosemida/uso terapéutico , Hipertensión/tratamiento farmacológico , Antagonistas de Receptores de Mineralocorticoides/uso terapéutico , Inhibidores del Simportador de Cloruro Sódico y Cloruro Potásico/uso terapéutico , Espironolactona/uso terapéutico , Anciano , Antihipertensivos/efectos adversos , Monitoreo Ambulatorio de la Presión Arterial , Quimioterapia Combinada , Femenino , Furosemida/efectos adversos , Tasa de Filtración Glomerular/efectos de los fármacos , Humanos , Hipertensión/diagnóstico , Hipertensión/fisiopatología , Riñón/efectos de los fármacos , Riñón/fisiopatología , Masculino , Persona de Mediana Edad , Antagonistas de Receptores de Mineralocorticoides/efectos adversos , Estudios Prospectivos , Inhibidores del Simportador de Cloruro Sódico y Cloruro Potásico/efectos adversos , Espironolactona/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Nonocclusive mesenteric ischemia (NOMI) is an emerging condition in hemodialysis (HD) patients not widely studied. MATERIALS AND METHODS: A retrospective study was conducted between 2003 and 2011. NOMI cases were recorded, and demographic, clinical, biochemical, and HD parameters were collected. This group was compared with a control group (n = 93). Risk factors, prognosis, and survival were analyzed. RESULTS: There were 57 episodes of NOMI (incidence, 2.29 episodes per 100 patients/y). Cecum was the most frequently affected segment. Nineteen patients (33%) underwent surgery. Twenty-six patients (59%) did not survive the acute episode. Cecal damage was the only protective factor associated with mortality (relative risk [RR], 0.712; P = 0.044). The incidence of NOMI was related to erythropoietin resistance index, diabetes mellitus, and longer time on HD compared with control group (RR, 6.92, P = 0.009; RR, 9.98, P = 0.005; and RR, 1.017, P < 0.001, respectively). Mortality in survival NOMI patients was higher at 4-y follow-up compared with that in the control group (log-rank, 15.5; P < 0.0001). CONCLUSIONS: NOMI is associated with erythropoietin resistance index, diabetes mellitus, and longer time on HD. Hypotension must be avoided in these high-risk patients to prevent NOMI.
Asunto(s)
Isquemia/etiología , Diálisis Renal/efectos adversos , Enfermedades Vasculares/etiología , Anciano , Femenino , Humanos , Isquemia/mortalidad , Modelos Logísticos , Masculino , Isquemia Mesentérica , Persona de Mediana Edad , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Enfermedades Vasculares/mortalidadRESUMEN
INTRODUCTION AND AIMS: Obesity is a risk factor for incident chronic kidney disease (CKD). C1q/TNF related protein 3 (CTRP3) is an adipokine with multiple effects and may modulate the association between obesity and vascular diseases. The aim of the study is to explore potential links between obesity, CTRP3 levels and CKD progression. METHODS: Patients with stage 3 and 4 CKD without previous cardiovascular events were enrolled and divided into groups according to body mass index (BMI) and sex. Demographic, clinical, analytical data and CTRP3 levels were collected at baseline. During follow-up, renal events (defined as dialysis initiation, serum creatinine doubling or a 50% decrease in estimated glomerular filtration rate were registered). RESULTS: 81 patients were enrolled. 27 were obese and 54 non-obese. Baseline CTRP3 was similar between both groups (90.1±23.8 vs 84.5±6.2; p=0.28). Of the sum, 54 were men and 27 women, with higher CTRP3 in women (81.4±24.7 vs 106±24.7;p<0.01). During a mean follow-up of 68 months, 15 patients had a renal event. Patients in the higher CTRP3 tertile had less events but without statistical significance (p=0.07). Obese patients in the higher CTRP3 tertile significantly had less renal events (p=0.049). By multiple regression analysis CTRP3 levels could not predict renal events (HR 0.98; CI95% 0.96-1.06). CONCLUSIONS: CTRP3 levels are higher in woman than men in patients with CKD, with similar levels between obese and non obese. Higher CTRP3 levels at baseline were associated with better renal outcomes in obese patients.
RESUMEN
BACKGROUND: Studies on renal histology results in very elderly patients are extremely rare. METHODS: We analyzed histology and clinical findings in patients aged over 85 years undergoing renal biopsy and whose data were included in the Spanish Registry of Glomerulonephritis between 1994 and 2009. RESULTS: A total of 17,680 native kidney biopsies were taken: 71 (0.4%) were from patients aged over 85 years. Acute kidney injury (AKI) was the main indication for biopsy (47%), followed by nephrotic syndrome (32%). Amyloidosis was the most common histological diagnosis (16.9%), followed by crescentic glomerulonephritis type 3 associated with systemic vasculitis (14.1%). When histological findings were correlated with clinical syndromes, we found that amyloidosis was the leading cause of AKI (18.8%), and also the main determinant of nephrotic syndrome, with the same frequency as membranous nephropathy (22%). Crescentic glomerulonephritis type 3 associated with vasculitis was related to a greater diversity of clinical syndromes, especially chronic kidney disease (40%) and AKI (40%). CONCLUSIONS: Renal biopsy in the very elderly provides us with useful information, despite the advanced age of the patients. AKI and nephrotic syndrome are the main indication for renal biopsy in this subgroup of patients, and amyloidosis is the most frequent histological pattern associated with both syndromes.
Asunto(s)
Lesión Renal Aguda/patología , Amiloidosis/patología , Glomerulonefritis/patología , Riñón/patología , Síndrome Nefrótico/patología , Insuficiencia Renal Crónica/patología , Anciano de 80 o más Años , Biopsia , Femenino , Humanos , Masculino , Sistema de Registros , Estudios Retrospectivos , EspañaRESUMEN
Kidney transplant recipients are at increased risk for infection, including coronavirus disease 2019 (COVID-19), given ongoing immunosuppression. In individuals with COVID-19, complications including thrombosis and endothelial dysfunction portend worse outcomes. In this report, we describe a kidney transplant recipient who developed severe thrombotic microangiopathy with a low platelet count (12 ×109/L), anemia (hemoglobin, 7.5 g/dL with 7% schistocytes on peripheral-blood smear), and severe acute kidney injury concurrent with COVID-19. The clinical course improved after plasma exchange. Given this presentation, we hypothesize that COVID-19 triggered thrombotic microangiopathy.
RESUMEN
Mixed cryoglobulinaemia (MCG) is one of the most severe extrahepatic hepatitis C virus (HCV)-associated complications, and could involve several organs, including the kidney. MCG prognosis relies on HCV response to antiviral treatment and has changed over the last years, especially after the introduction of new direct acting antivirals (DAA). MCG persistence despite sustained virological response (SVR) is uncommon and has a poorly known meaning and prognosis. We report a case of a patient with chronic HCV infection treated with DAA who developed MCG vasculitis despite the SVR.
RESUMEN
BACKGROUND: Pentoxifylline could reduce proteinuria and slow renal disease progression. We previously conducted a single-blind, randomized, controlled trial that showed that pentoxifylline decreases inflammatory markers and stabilizes renal function. SETTING AND PARTICIPANTS: 91 participants (46 in the pentoxifylline group and 45 in the control group) followed up for 7 additional years. STUDY DESIGN: Post hoc analysis of a long-term follow-up after completion of the 12-months trial. INTERVENTION: Pentoxifylline treatment (400 mg/twice a day) or standard treatment. OUTCOME: Renal event (defined as starting dialysis therapy and/or doubling serum creatinine and/or ≥ 50% decrease in estimated glomerular filtration rate) and cardiovascular mortality. RESULTS: During follow-up, a renal event was recorded in 24 patients from control group (13 initiated dialysis therapy and serum creatinine doubled in 11) and 11 patients from PTF group (7 initiated dialysis and serum creatinine doubled in 4) (log Rank: 5.822, p = 0.016). The possible protector effect of PTF was more significant in albuminuric patients and was independently of diabetes mellitus presence. Treatment with PTF reduced the renal events by 35% compared to the control group in a Cox model adjusted for diabetes mellitus, albuminuria and basal renal function (HR 0.65 (0.45-0.94), p = 0.022). Cardiovascular mortality was significantly reduced in PTF treatment (2 patients vs. 10 in control group) (log Rank 5.0977, p = 0.024). PTF treatment reduced cardiovascular mortality in 55% adjusted for diabetes mellitus and age (HR 0.45 (0.21-0.98), p = 0.044) (Table 3). LIMITATIONS: Small sample size, single center, not double blind and post hoc follow-up analysis. CONCLUSIONS: Long-term treatment with pentoxifylline may slow the rate of progression of kidney disease and reduce cardiovascular risk.
Asunto(s)
Enfermedades Cardiovasculares/mortalidad , Pentoxifilina/uso terapéutico , Inhibidores de Fosfodiesterasa/uso terapéutico , Insuficiencia Renal Crónica/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Albuminuria/etiología , Creatinina/sangre , Progresión de la Enfermedad , Estudios de Seguimiento , Tasa de Filtración Glomerular , Humanos , Persona de Mediana Edad , Pentoxifilina/efectos adversos , Inhibidores de Fosfodiesterasa/efectos adversos , Diálisis Renal , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/fisiopatología , Insuficiencia Renal Crónica/terapia , Método Simple Ciego , Factores de TiempoRESUMEN
Therapeutic drug monitoring (TDM) could optimise daptomycin use. However, no validated serum target levels have been established. This prospective study at a tertiary centre including hospitalised patients receiving daptomycin aimed to evaluate the adequacy of daptomycin doses in a real-life study, assess interpatient variability in serum levels, identify predictive factors for non-adequate serum levels and assess their clinical impact. Blood samples [trough (Cmin) and peak (Cmax) levels] were drawn ≥3 days post-treatment initiation. Serum daptomycin concentrations were determined by HPLC. Outcome was classified as: (i) favourable, if clinical improvement or cure occurred with no adverse events; or (ii) poor, in the case of no clinical response, recurrence, related mortality or if adverse events were detected. Sixty-three patients (63.5% male; median age 63.0 years) were included. The most common indications for daptomycin use were bacteraemia (46.0%), complicated skin and soft-tissue infection (30.2%) and endovascular infection (15.9%). The initial dosage was adequate in 43 patients (68.3%), low in 14 (22.2%) and high in 6 (9.5%). Large interindividual variability in serum levels was observed, with a median Cmin of 10.6 mg/L (range 1.3-44.7 mg/L) and median Cmax of 44.0 mg/L (range 3.0-93.7 mg/L). Multivariate analysis showed that Cmin < 3.18 mg/L was independently related to poor outcome (ORâ¯=â¯6.465, 95% CI 1.032-40.087; Pâ¯=â¯0.046). High variability in daptomycin use and serum levels was detected. Specific serum targets were identified as risk factors for poor outcome. TDM might be useful to optimise daptomycin doses and to avoid therapeutic failure.
Asunto(s)
Antibacterianos/farmacocinética , Antibacterianos/uso terapéutico , Daptomicina/farmacocinética , Daptomicina/uso terapéutico , Monitoreo de Drogas , Centros de Atención Terciaria , Anciano , Antibacterianos/sangre , Bacterias/efectos de los fármacos , Infecciones Bacterianas/tratamiento farmacológico , Daptomicina/sangre , Femenino , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Análisis MultivarianteRESUMEN
BACKGROUND: Obesity is a risk factor for incident chronic kidney disease (CKD) in the general population. C1q/tumour necrosis factor-related protein 1 (CTRP1) is a new adipokine with multiple vascular and metabolic effects and may modulate the association between obesity and vascular diseases. The aim of the study is to explore potential links between obesity, CTRP1 levels and CKD progression. METHODS: Patients with Stages 3 and 4 CKD without previous cardiovascular events were enrolled and divided into two groups according to body mass index (BMI). Demographic, clinical and analytical data and CTRP1 levels were collected at baseline. During follow-up, renal events [defined as dialysis initiation, serum creatinine doubling or a 50% decrease in estimated glomerular filtration rate (Modification of Diet in Renal Disease)] were registered. RESULTS: A total of 71 patients with CKD were divided into two groups: 25 obese (BMI >30 kg/m2) and 46 non-obese. CTRP1 in plasma at baseline was higher in obese patients [median (interquartile range) 360 (148) versus 288 (188) ng/mL, P = 0.041]. No significant association was found between CTRP1 levels and CKD stage, presence of diabetes, aldosterone and renin levels, or blood pressure. Obese patients had higher systolic blood pressure (P = 0.018) and higher high-sensitivity C-reactive protein (P = 0.019) and uric acid (P = 0.003) levels, without significant differences in the percentage of diabetic patients or albuminuria. During a mean follow-up of 65 months, 14 patients had a renal event. Patients with CTRP1 in the lowest tertile had more renal events, both in the overall sample (log rank: 5.810, P = 0.016) and among obese patients (log rank: 5.405, P = 0.020). Higher CTRP1 levels were associated with slower renal progression (hazard ratio 0.992, 95% confidence interval 0.986-0.998; P = 0.001) in a model adjusted for obesity, aspirin, albuminuria and renal function. CONCLUSIONS: CTRP1 levels are higher in obese than in non-obese patients with CKD. High CTRP1 levels may have a renal protective role since they were associated with slower kidney disease progression. Interventional studies are needed to explore this hypothesis.
RESUMEN
BACKGROUND AND OBJECTIVES: Some studies suggest that the incidence of IgA nephropathy is increasing in older adults, but there is a lack of information about the epidemiology and behavior of the disease in that age group. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective multicentric study, we analyzed the incidence, forms of presentation, clinical and histologic characteristics, treatments received, and outcomes in a cohort of 151 patients ≥65 years old with biopsy-proven IgA nephropathy diagnosed between 1990 and 2015. The main outcome was a composite end point of kidney replacement therapy or death before kidney replacement therapy. RESULTS: We found a significant increase in the diagnosis of IgA nephropathy over time from six patients in 1990-1995 to 62 in 2011-2015 (P value for trend =0.03). After asymptomatic urinary abnormalities (84 patients; 55%), AKI was the most common form of presentation (61 patients; 40%). Within the latter, 53 (86%) patients presented with hematuria-related AKI (gross hematuria and tubular necrosis associated with erythrocyte casts as the most important lesions in kidney biopsy), and eight patients presented with crescentic IgA nephropathy. Six (4%) patients presented with nephrotic syndrome. Among hematuria-related AKI, 18 (34%) patients were receiving oral anticoagulants, and this proportion rose to 42% among the 34 patients older than 72 years old who presented with hematuria-related AKI. For the whole cohort, survival rates without the composite end point were 74%, 48%, and 26% at 1, 2, and 5 years, respectively. Age, serum creatinine at presentation, and the degree of interstitial fibrosis in kidney biopsy were risk factors significantly associated with the outcome, whereas treatment with renin-angiotensin-aldosterone blockers was associated with a lower risk. Immunosuppressive treatments were not significantly associated with the outcome. CONCLUSIONS: The diagnosis of IgA nephropathy among older adults in Spain has progressively increased in recent years, and anticoagulant therapy may be partially responsible for this trend. Prognosis was poor. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_07_16_CJASNPodcast_19_08_.mp3.
Asunto(s)
Glomerulonefritis por IGA , Adulto , Anciano , Femenino , Glomerulonefritis por IGA/diagnóstico , Glomerulonefritis por IGA/epidemiología , Glomerulonefritis por IGA/terapia , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: Observational retrospective study with consecutive patients with CKD to assess the degree of accomplishment of the therapeutic objectives in hypertension and dyslipidaemia recommended by JNC 8 and KDIGO-2013 CKD guidelines the impact of their implementation compared with previous guidelines. RESULTS: 618 patients were included, mean age 67±15 years, 61.33% male. Mean eGFR was 45.99±18.94ml/min, with median albumin/creatinine 26 (0-151)mg/g. A total of 87.6% received antihypertensive treatment and 50.2% received statins. According to KDIGO guidelines, 520 patients (84.14%) should receive statins, but only 304 (58.46%) were receiving them. Patients on statin treatment had more diabetes and hypertension, and a greater cardiovascular history and lower levels of total and LDL-cholesterol. A total of 97.7% of patients were under 60 years of age or had eGFR<60ml/min/1.73m2 or were diabetic, so according to the JNC 8 report, they should have a target blood pressure<140/90mmHg. A total of 289 patients did (47.85%). According to the JNC 7 report, this group had a tighter target blood pressure<130/90mmHg, reducing the number of patients who fulfilled the target: 136 (22.52%). Patients reclassified were older, had a greater cardiovascular history and less DM. CONCLUSION: The new KDIGO guidelines for dyslipidaemia treatment increase the indication of statin therapy, especially in patients at high cardiovascular risk. The JNC 8 guidelines improve the percentage of patients with controlled blood pressure, especially the elderly and patients with increased cardiovascular risk, in whom the target blood pressure is currently controversial.
Asunto(s)
Dislipidemias/tratamiento farmacológico , Adhesión a Directriz/estadística & datos numéricos , Hipertensión/tratamiento farmacológico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Instituciones de Atención Ambulatoria , Estudios Transversales , Dislipidemias/etiología , Femenino , Humanos , Hipertensión/etiología , Masculino , Persona de Mediana Edad , Nefrología , Insuficiencia Renal Crónica/complicaciones , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND AND OBJECTIVES: Hyperuricemia plays a major role in the development and progression of chronic kidney disease (CKD). Many large observational studies have indicated that increased serum uric acid level predicts the development and progression of CKD in some population, however this hypothesis has not been yet studied in patients with reduced renal mass. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Retrospective study with a cohort of 324 patients with reduced renal mass from an outpatient basis, followed during 60 (36-98) months. Demographics variables, cardiovascular factors, concomitant medications, albuminuria and uric acid levels were recorded yearly. The primary endpoint was the annual fall of estimated glomerular filtration rate (eGFR) by MDRD-4. The sample was divided into three successive groups (A1: patients with fall of eGFR lower than median, A2: greater than median, B: without fall of eGFR). Factors associated and predictors of kidney function decline were analyzed. RESULTS: One hundred and seventy out of 324 patients suffered a fall of eGFR (group A), (median of fall -1.6ml/min/1.73m2/year (-3.0, -0.7)). Male gender, albuminuria>100mg/day and higher pulse pressure were associated to progression in our cohort (group A). Hyperuricemia was more frequent among patients with higher kidney disease progression (group A2) (33% vs 49%, p=0.04) when comparing to lower progression (group A1). Adjusted Cox regression models showed that hyperuricemia, pulse pressure and albuminuria were independent predictors of kidney disease progression (HR 1.67 (1.06-2.63), p=0.023; 1.02 (1.01-1.03), p=0.001 and HR: 2.14 (1.26-3.64), p=0.005, respectively). Kidney disease progression was higher in patients with unilateral renal atrophy or agenesis than nephrectomy (log rank: 7.433, p=0.006). CONCLUSIONS: Hyperuricemia is independently associated with kidney disease progression in patients with reduce functioning renal mass.
Asunto(s)
Hiperuricemia/etiología , Insuficiencia Renal Crónica/sangre , Anciano , Atrofia , Comorbilidad , Diabetes Mellitus/epidemiología , Progresión de la Enfermedad , Dislipidemias/epidemiología , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular , Humanos , Hipertensión/epidemiología , Hiperuricemia/epidemiología , Riñón/anomalías , Riñón/patología , Masculino , Persona de Mediana Edad , Nefrectomía , Tamaño de los Órganos , Complicaciones Posoperatorias/sangre , Insuficiencia Renal Crónica/epidemiología , Insuficiencia Renal Crónica/patología , Insuficiencia Renal Crónica/fisiopatología , Estudios Retrospectivos , Riñón Único/sangre , Riñón Único/epidemiologíaRESUMEN
BACKGROUND AND OBJECTIVE: There is controversy concerning the risk/benefit of anticoagulation/antiaggregation in chronic kidney disease (CKD) patients. We analysed the impact of anticoagulation/antiaggregation on anaemia and haemorrhagic events in CKD patients. PATIENTS AND METHODS: A total of 232 CKD patients stages 3 and 4 were followed during a mean follow-up time of 36.7 ± 11.6 months: 81 patients did not receive any anticoagulation or antiaggregation treatment, 91 received anticoagulation treatment and 60 patients received platelet antiaggregation. Haemorrhagic and cardiovascular events were recorded. RESULTS: Haemoglobin and ferritine levels were significantly higher in patients who did not receive anticoagulation or antiaggregation (Hb 13.7 ± 1.6, 13.3 ± 1.8 and 12.7±1.9g/dl, p=0.004; ferritine 170 ± 145, 140 ± 138, 105 ± 99µg/l, p=0.023). During follow up, 36 haemorrhagic events were registered: 4in the control group, 23 in the anticoagulation group and 9in the antiaggregation group (log rank 12.5; p=0.002). In a Cox model adjusted by age, renal function and haemoglobin levels, the anticoagulation increased the risk of bleeding by 4times (HR 4.180, 1.955-8.937); p=0,001) and antiaggregation by almost 3times (HR 2.780, 1.257-6.149, p=0.012). A total of 64 cardiovascular events were registered, 21 of which were classified as atherosclerotic events: 10 in the antiaggregation group, 8in the control group and 3in the anticoagulation group (log rank: 8.351; p=0.015). Anticoagulation treatment showed a reduction in the risk of atherosclerotic events (HR 0.136, 0.033-0.551, p=0.005) while platelet antiaggregation did not modified this risk (HR 1,566, 0.569-4.308). CONCLUSIONS: Anticoagulation and antiaggregation increase haemorrhagic risk in patients with CKD and worsen anaemia. Anticoagulation reduces atherosclerotic events by more than 85% while platelet antiaggregation does not modify this risk.
Asunto(s)
Anemia/inducido químicamente , Anticoagulantes/efectos adversos , Arteriosclerosis/complicaciones , Fibrilación Atrial/complicaciones , Hemorragia/inducido químicamente , Fallo Renal Crónico/complicaciones , Inhibidores de Agregación Plaquetaria/efectos adversos , Anciano , Estudios de Casos y Controles , Causas de Muerte , Ferritinas/sangre , Estudios de Seguimiento , Hemoglobina A/análisis , Humanos , Estimación de Kaplan-Meier , Fallo Renal Crónico/sangre , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Medición de RiesgoRESUMEN
INTRODUCTION: Scores underestimate the prediction of cardiovascular risk (CVR) as they are not validated in patients with chronic kidney disease (CKD). Two of the most commonly used scores are the Framingham Risk Score (FRS-CVD) and the ASCVD (AHA/ACC 2013). The aim of this study is to evaluate the predictive ability of experiencing a cardiovascular event (CVE) via these 2scores in the CKD population. MATERIAL AND METHODS: Prospective, observational study of 400 prevalent patients with CKD (stages 4 and 5 according the KDOQI; not on dialysis). Cardiovascular risk was calculated according to the 2scores and the predictive capacity of cardiovascular events (atherosclerotic events: myocardial infarction, ischaemic and haemorrhagic stroke, peripheral vascular disease; and non-atherosclerotic events: heart failure) was analysed. RESULTS: Forty-nine atherosclerotic cardiovascular events occurred in 40.3±6.6 months of follow-up. Most of the patients were classified as high CVR by both scores (59% by the FRS-CVD and 75% by the ASCVD). All cardiovascular events occurred in the high CVR patients and both scores (FRS-CVD log-rank 12.2, P<.001, HR 3.1 [95% CI: 1.3-7.1] P: 0.006 and ASCVD log-rank 8.5 P<.001, HR 3.2 [95% CI: 1.1-9.4] P: 0.03) were independent predictors adjusted to renal function, albuminuria and previous cardiovascular events. CONCLUSION: The cardiovascular risk scores (FRS-CVD and ASCVD [AHA/ACC 2013]) can estimate the probability of atherosclerotic cardiovascular events in patients with CKD regardless of renal function, albuminuria and previous cardiovascular events.
Asunto(s)
Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/etiología , Insuficiencia Renal Crónica/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Medición de RiesgoRESUMEN
BACKGROUND: Resolution of inflammation is regulated by endogenous lipid mediators, such as lipoxins and their epimers, including 15-epi-lipoxin A4 (15-epi-LXA4). However, there is no information on 15-epi-LXA4 and its in vivo regulation in chronic kidney disease (CKD) patients. STUDY DESIGN: Open label randomized clinical trial. SETTING AND PARTICIPANTS: 50 participants with chronic kidney disease (CKD) stage 3 and 4 without prior cardiovascular disease (25 in the aspirin group and 25 in the standard group) followed for 46 months. INTERVENTION: Aspirin (100mg/day) or standard treatment. AIM: To analyze the effect of aspirin on plasma 15-epi-LXA4 levels and inflammatory markers in CKD patients. RESULTS: Baseline plasma15-epi-LXA4 levels were lower in diabetic (1.22 ± 0.99ng/ml) than in non-diabetic CKD patients (2.05 ± 1.06ng/ml, p < 0.001) and inversely correlated with glycosylated hemoglobin levels (r = -0.303, p = 0.006). In multivariate analysis, diabetes was associated with lower 15-epi-LXA4 levels, adjusted for age, inflammatory markers and renal function (p = 0.005). In the whole study population, 15-epi-LXA4 levels tended to increase, but not significantly (p = 0.45), after twelve months on aspirin (from mean ± SD 1.84 ± 1.06 to 2.04 ± 0.75ng/ml) and decreased in the standard care group (1.60 ± 1.15 to 1.52 ± 0.68ng/ml, p = 0.04). The aspirin effect on 15-epi-LXA4 levels was more striking in diabetic patients, increasing from 0.94 ± 0.70 to 1.93 ± 0.74ng/ml, p = 0.017. CONCLUSIONS: Diabetic patients with CKD have lower circulating 15-epi-LXA4 levels than non-diabetic CKD patients. Low dose aspirin for 12 months increased 15-epi-LXA4 levels in diabetic patients. Given its anti-inflammatory properties, this increase in 15-epi-LXA4 levels may contribute to the beneficial effects of low dose aspirin.