Cardiometabolic effects of direct-acting antivirals in patients with hepatitis C.

Hepatitis C virus (HCV) has long been associated with several extrahepatic manifestations, including increased cardiovascular risk. The emergence of direct-acting antivirals (DAAs) has allowed us to evaluate the potential reversal of these manifestations after successful treatment. Therefore, many studies have provided significant takeaways regarding the positive effect of DAAs therapy on insulin resistance, type 2 diabetes mellitus, cardiovascular disease and atherosclerosis. In contrast, studies have shown detrimental effects on lipid metabolism and indeterminate results regarding renal function and uric acid metabolism. Nevertheless, as more and more patients achieve sustained virological response, the effects of HCV eradication on cardiometabolic processes will be extensively studied, allowing more reliable conclusions on the extent of extrahepatic outcomes.

Desempeño de las ecuaciones para estimar la tasa de filtración glomerular en pacientes mexicanos receptores de trasplante renal.

INTRODUCTION: The management of kidney transplant recipients requires glomerular filtration rate (GFR) monitoring, which is an indicator of graft primary function and patient survival. OBJECTIVE: To evaluate the performance of different creatinine or cystatin-based formulas in the estimation of glomerular filtration rate in Mexican patients receiving kidney transplantation. METHOD: 30 transplant recipients were included, in whom the glomerular filtration rate was measured by means of iothalamate, and was also calculated using seven equations based on cystatin or creatinine. RESULTS: The formula with the best performance was the one proposed by the chronic kidney disease epidemiology collaboration (CKD-EPI), with a bias of -2.4 mL/min/1.73 m2 and an accuracy of 9.6; 96.7 % of patients were within 30 % of the measured GFR. The second best formula was the modification of diet in renal disease (MDRD) equation. Cystatin-based equations showed a poor performance. CONCLUSIONS: Our study suggests that, in Mexican patients receiving kidney transplantations, the best equations to estimate GFR are the CKD-EPI and MDRD equations.

INTRODUCCIÓN: El manejo de los pacientes receptores de trasplante renal requiere vigilancia de la tasa de filtrado glomerular (TFG), la cual es un indicador de la función primaria del injerto y de la supervivencia del paciente. OBJETIVO: Evaluar el rendimiento en la estimación de la función renal de diferentes fórmulas basadas en creatinina o cistatina en pacientes mexicanos receptores de trasplante renal. MÉTODO: Se incluyeron 30 pacientes receptores de trasplante renal en quienes se midió tasa de filtrado glomerular por iodotalamato, la cual también se calculó por siete ecuaciones basadas en cistatina o creatinina. RESULTADOS: La fórmula con mejor desempeño fue la propuesta por CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration), con un sesgo de −2.4 mL/minuto/1.73 m2 y precisión de 9.6; 96.7 % estaba dentro de 30 % de la tasa de filtrado glomerular medida. La segunda mejor ecuación fue la MDRD (Modification of Diet in Renal Disease). Las ecuaciones basadas en cistatina mostraron pobre desempeño. CONCLUSIONES: Nuestro estudio sugiere que en pacientes mexicanos receptores de trasplante renal las mejores ecuaciones para estimar la TFG son CKD y MDRD.

Current practice in continuous renal replacement therapy: An epidemiological multicenter study. / Manejo actual de las terapias continuas de reemplazo renal: Estudio epidemiológico multicéntrico.

OBJECTIVE: The aim of the study is to ascertain the most relevant aspects of the current management of renal replacement therapy (RRT) in critically ill patients, and to analyze renal function recovery and mortality in patients undergoing RRT. METHODS: A non-interventional three-month observational study was made in 2012, with a follow-up period of 90 days, in 21 centers in Catalonia (Spain). Demographic information, severity scores and clinical data were obtained, as well as RRT parameters. INCLUSION CRITERIA: patients aged ≥ 16 years admitted to Intensive Care Units (ICUs) and subjected to RRT. RESULTS: A total of 261 critically ill patients were recruited, of which 35% had renal dysfunction prior to admission. The main reason for starting RRT was oliguria; the most widely used RRT modality was hemodiafiltration; and the median prescribed dose at baseline was 35mL/kg/h. The median time of RRT onset from ICU admission was one day. The mortality rate at 30 and 90 days was 46% and 54%, respectively, and was associated to greater severity scores and a later onset of RRT. At discharge, 85% of the survivors had recovered renal function. CONCLUSIONS: Current practice in RRT in Catalonia abides with the current clinical practice guidelines. Mortality related to RRT is associated to later onset of such therapy. The renal function recovery rate at hospital discharge was 85% among the patients subjected to RRT.

Renal impairment in HIV-infected patients initiating tenofovir-containing antiretroviral therapy regimens in a Primary Healthcare Setting in South Africa.

OBJECTIVE: Long-term use of tenofovir disoproxil fumarate is associated with declines in glomerular function and chronic kidney disease in HIV-infected patients. We aimed to assess the prevalence and incidence of renal impairment in a primary care setting in sub-Saharan Africa. METHODS: We analysed data from 1092 HIV-infected patients initiating tenofovir at a primary care clinic in Cape Town, South Africa. Renal function was assessed for the first 12 months on ART by estimating glomerular filtration rate (eGFR) calculated using the Cockroft-Gault equation categorised into normal, mild, moderate and severe reduction in renal function based on values >90, 60-89, 30-59 and <30 ml/min/1.73 m(2) , respectively. Associations were assessed using logistic regression, and average GFR trajectory over time was modelled using linear mixed-effects models. RESULTS: The cohort consisted of 62% women; median age was 34 years (IQR 29; 41 years). The majority had normal renal function pre-ART (79%), 19% had mildly reduced GFR, and 2% had moderate renal impairment. Older age, more advanced WHO stage and anaemia were independently associated with prevalent renal impairment. On average, estimated glomerular function improved over the first year on tenofovir [1.10 ml/min/1.73 m(2) average increase over 12 months (95% CI: 0.80; 1.40)]. Male gender, anaemia and immunosuppression (WHO Stage III/IV and CD4 cell counts <100 cells/mm(3) ) were associated with lower average eGFR levels over time. Overall, 3% developed eGFR <50 ml/min/1.73 m(2) during this period. Serum creatinine tests conducted before 4 months on ART had low predictive value for predicting change in eGFR after a year on ART. CONCLUSION: Generally, renal function improved in HIV-infected adults initiating ART in this primary healthcare setting during the first year on ART. While monitoring of renal function is recommended in the first 4 months on ART, renal impairment appears uncommon during the first 12 months of tenofovir-containing ART in primary care populations.

Impact of natriuresis on worsening renal function during episodes of acute heart failure.

INTRODUCTION AND OBJECTIVES: Worsening renal function (WRF) is a frequent complication in acute heart failure (AHF) with a controversial prognostic value. We aimed to study the usefulness of natriuresis to evaluate WRF. METHODS: We conducted an observational, prospective, multicenter study of patients with AHF who underwent a furosemide stress test. The patients were classified according to whether WRF was present or absent and according to the median natriuretic response. The main endpoint was the combination of mortality, rehospitalization due to HF, and heart transplant at 6 months of follow-up. RESULTS: One hundred and fifty-six patients were enrolled, and WRF occurred in 60 (38.5%). The patients were divided into 4 groups: a) 47 (30.1%) no WRF/low UNa (UNa ≤ 109 mEq/L); b) 49 (31.4%) no WRF/high UNa (UNa >109 mEq/L); c) 31 (19.9%) WRF/low UNa and d) 29 (18.6%) WRF/high UNa. The parameters of the WRF/low UNa group showed higher clinical severity and worse diuretic and decongestive response. The development of WRF was associated with a higher risk of the combined event (HR, 1.88; 95%CI, 1.01-3.50; P=.046). When stratified by natriuretic response, WRF was associated with an increased risk of adverse events in patients with low natriuresis (HR, 2.28; 95%CI, 1.15-4.53; P=.019), but not in those with high natriuresis (HR, 1.18; 95%CI, 0.26-5.29; P=.826). CONCLUSIONS: Natriuresis could be a useful biomarker for interpreting and prognosticating WRF in AHF. WRF is associated with a higher risk of adverse events only in the context of low natriuresis.

Sex differences in clinical characteristics and outcomes in the CLOROTIC (combining loop with thiazide diuretics for decompensated heart failure) trial.

AIMS: The addition of hydrochlorothiazide (HCTZ) to furosemide improved the diuretic response in patients with acute heart failure (AHF) in the CLOROTIC trial. Our aim was to evaluate if there were differences in clinical characteristics and outcomes according to sex. METHODS: This is a post-hoc analysis of the CLOROTIC trial, including 230 patients with AHF randomized to receive HCTZ or placebo in addition to an intravenous furosemide regimen. The primary and secondary outcomes included changes in weight and patient-reported dyspnoea 72 and 96 h after randomization, metrics of diuretic response and mortality/rehospitalizations at 30 and 90 days. The influence of sex on primary, secondary and safety outcomes was evaluated. RESULTS: One hundred and eleven (48%) women were included in the study. Women were older and had higher values of left ventricular ejection fraction. Men had more ischemic cardiomyopathy and chronic obstructive pulmonary disease and higher values of natriuretic peptides. The addition of HCTZ to furosemide was associated to a greatest weight loss at 72/96 h, better metrics of diuretic response and higher 24-h diuresis compared to placebo without significant differences according to sex (all p-values for interaction were not significant). Worsening renal function occurred more frequently in women (OR [95%CI]: 8.68 [3.41-24.63]) than men (OR [95%CI]: 2.5 [0.99-4.87]), p = 0.027. There were no differences in mortality or rehospitalizations at 30/90 days. CONCLUSION: Adding HCTZ to intravenous furosemide is an effective strategy to improve diuretic response in AHF with no difference according to sex, but worsening renal function was more frequent in women. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov: NCT01647932; EudraCT Number: 2013-001852-36.

Clinical guideline on adequacy and prescription of peritoneal dialysis.

In recent years, the meaning of adequacy in peritoneal dialysis has changed. We have witnessed a transition from an exclusive achievement of specific objectives -namely solute clearances and ultrafiltration- to a more holistic approach more focused to on the quality of life of these patients. The purpose of this document is to provide recommendations, updated and oriented to social and health environment, for the adequacy and prescription of peritoneal dialysis. The document has been divided into three main sections: adequacy, residual kidney function and prescription of continuous ambulatory peritoneal dialysis and automated peritoneal dialysis. Recently, a guide on the same topic has been published by a Committee of Experts of the International Society of Peritoneal Dialysis (ISPD 2020). In consideration of the contributions of the group of experts and the quasi-simultaneity of the two projects, references are made to this guide in the relevant sections. We have used a systematic methodology (GRADE), which specifies the level of evidence and the strength of the proposed suggestions and recommendations, facilitating future updates of the document.

Impact of renal function on the prognostic value of mineral metabolism in patients with chronic ischaemic heart disease patients with chronic ischaemic heart disease. / Impacto de la función renal en el valor pronóstico del metabolismo mineral en pacientes con cardiopatía isquémica crónica.

BACKGROUND: Parathormone (PTH) is a component of the Mineral Metabolism (MM) system that has been shown recently to add prognostic value in pts. with stable coronary artery disease (SCAD) and average renal function. However, the influence of renal function on the prognostic role of PTH in pts. with SCAD has not been shown yet. PURPOSE: To assess the influence of estimated glomerular filtration rate (eGFR) on the prognostic role of PTH and other MM markers in pts. with SCAD. METHODS: We analyzed the prognostic value of MM markers (PTH, klotho, phosphate, calcidiol [25-hydroxyvitamin D], and fibroblast growth factor-23 [FGF23]) in 964 pts. with SCAD and eGFR<60ml/min/1.73 m2 (LGFR) vs pts. with eGFR≥60ml/min/1.73 m2 (HGFR) included in five hospitals of Madrid. The main outcome was the combination of death with ischemic events (any acute coronary syndrome, ischemic stroke or transient ischemic attack). eGFR was calculated by the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI). RESULTS: Age was 60.0 (52.0-72.0) years, 76.2% of patients were men, and eGFR was 80.4 (65.3-93.1) ml/min/1,73 m2. Median follow-up was 5.39 (2.81-6.92) years. There were 790 pts. with HGFR and 174 with LGFR. In HGFR pts., predictors of ischemic events or death were plasma levels of calcidiol [HR=0.023 (0.94-0.99) p=0.023], FGF23 [HR=1.00 (1.00-1.003) p=0.036], non-HDL cholesterol [HR=1.01 (1.00-1.01) p=0.026] and high sensitivity troponin I [HR=5.12 (1.67-15.59) p=0.004], along with age [HR=1.03 (1.01-1.05) p=0.01], treatment with statins [HR=0.36 (0.19-0.68) p=0.002], nitrates [HR=1.13 (1.07-2.79) p=0.027], dihydropyridines [HR=1.71 (1.05-2.77) p=0.032], verapamil [HR=5.71 (1.35-24.1) p=0.018], and proton-pump inhibitors [HR=2.23 (1.36-3.68) p= 0.002]. In the LGFR subgroup, predictors of death or ischemic events were PTH plasma levels, [HR=1.01 (1.00-1.01) p=0.005], eGFR [HR=0.96 (0.94-0.99) p=0.004], age [HR=1.06 (1.02-1.10) p=0.003], caucasian race [HR=0.04 (0.004-0.380) p=0.005], and treatment with insulin [HR=2.6 (1.20-5.63) p=0.015]. CONCLUSIONS: In pts. with SCAD, PTH is an independent predictor of poor outcomes only in those with eGFR<60ml/min/1.73 m2, while in pts. with eGFR≥60ml/min/1.73 m2 calcidiol and FGF23 become the only components of MM that may predict prognosis. Then, renal function influences the predictive power of MM markers in pts. with SCAD.

Evolution of renal function in patients with cT1 renal tumors after laparoscopic partial and radical nephrectomy. Predictive factors for renal function impairment.

INTRODUCTION AND OBJECTIVES: To analyze the evolution of kidney function after laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) and to identify predictive factors for renal function impairment. MATERIALS AND METHOD: Retrospective study of patients with two kidneys, glomerular filtration rate (GFR) > 60 mL/min/1.73 m2 and single renal tumor cT1, treated in our center between 2005 and 2018. RESULTS: A total of 372 patients met the inclusion criteria for the study; 156 (41.9%) were treated with RN and 216 (58.1%) with PN. There was a difference of 26.75 mL/min/1.73 m2 in GFR between RN and PN at discharge. Age >60 years, postoperative complications (OR 2.97, p = 0.005) and RN (OR 10.03, p = 0.0001) were predictors of GFR <60 mL/min/1.73 m2 at discharge. Only RN (OR 7.69, p = 0.0001) behaved as an independent prognostic factor for GFR <45 mL/min/1.73 m2 at discharge. The median follow-up of the series was 57 (IQR 28-100) months. At the end of the follow-up period, nine (6%) patients treated with RN developed severe chronic kidney disease (CKD) and three (2%) developed end stage renal disease (ESRD). Age >70 years, diabetes mellitus (DM) (HR 2.12, p = 0.001), arterial hypertension (AHT) (HR 1.73, p = 0.01) and RN (HR 2.88, p = 0.0001) behaved as independent predictors of GFR <60 mL/min/1.73 m2. The independent predictors for GFR <45 mL/min/1.73 m2 were age >70 years, DM (HR 1.99 CI 95% 1.04-3.83, p = 0.04) and RN (HR 5.88 CI 95% 2.57-13.45, p = 0.0001). CONCLUSIONS: RN is a short- and long-term risk factor for CKD although with a low probability of severe CKD or ESRD in patients with preoperative GFR >60 mL/min/1.73 m2. Age, DM and AHT contribute to worsening renal function during follow-up.

Baseline renal functions predict the effect of canakinumab on regression of proteinuria in patients with familial Mediterranean fever.

INTRODUCTION AND OBJECTIVES: Canakinumab, an IL-1 blocking drug, decreases the frequency and severity of the attacks and decreases the proteinuria level in colchicine resistant/intolerant familial Mediterranean fever (FMF) patients. However, it is not known whether patients with impaired or preserved renal functions respond differently to IL-1 blocking therapies in terms of proteinuria reduction and progression of kidney dysfunction which was the aim of this study. MATERIALS AND METHODS: Adult FMF subjects with biopsy proven amyloidosis who had 24-h urine protein excretion>150mg/day before initiation of canakinumab were divided into two groups as patients with preserved renal function (GFR≥60mL/min) and patients with impaired renal function (GFR<60mL/min). The response in proteinuria and renal functions are compared between two groups in this cross-sectional study. RESULTS: A total of 18 patients (11 with preserved and 7 with impaired renal function) were included in this study. Although proteinuria levels of both groups were similar at the baseline and at six months after initiation of canakinumab, proteinuria at 12 months was significantly lower for patients with preserved renal function compared to patients with impaired renal function (2462±1760mg/day vs. 7065±3035mg/day respectively, p=0.02). All of the patients with preserved renal function had more than 50% decrease in proteinuria at 12 months compared to baseline values, while none of the patients with impaired renal function had more than 50% decrease in proteinuria. CONCLUSIONS: Canakinumab, an IL-1 blocking agent, is not effective in decreasing proteinuria in FMF patients with already impaired renal functions and should be started early in the course of disease to prevent renal impairment.

Baseline renal functions predict the effect of canakinumab on regression of proteinuria in patients with familial Mediterranean fever.

INTRODUCTION AND OBJECTIVES: Canakinumab, an IL-1 blocking drug, decreases the frequency and severity of the attacks and decreases the proteinuria level in colchicine resistant/intolerant familial Mediterranean fever (FMF) patients. However, it is not known whether patients with impaired or preserved renal functions respond differently to IL-1 blocking therapies in terms of proteinuria reduction and progression of kidney dysfunction which was the aim of this study. MATERIALS AND METHODS: Adult FMF subjects with biopsy proven amyloidosis who had 24-h urine protein excretion>150mg/day before initiation of canakinumab were divided into two groups as patients with preserved renal function (GFR≥60mL/min) and patients with impaired renal function (GFR<60mL/min). The response in proteinuria and renal functions are compared between two groups in this cross-sectional study. RESULTS: A total of 18 patients (11 with preserved and 7 with impaired renal function) were included in this study. Although proteinuria levels of both groups were similar at the baseline and at six months after initiation of canakinumab, proteinuria at 12 months was significantly lower for patients with preserved renal function compared to patients with impaired renal function (2462±1760mg/day vs. 7065±3035mg/day respectively, p=0.02). All of the patients with preserved renal function had more than 50% decrease in proteinuria at 12 months compared to baseline values, while none of the patients with impaired renal function had more than 50% decrease in proteinuria. CONCLUSIONS: Canakinumab, an IL-1 blocking agent, is not effective in decreasing proteinuria in FMF patients with already impaired renal functions and should be started early in the course of disease to prevent renal impairment.

Evolution of renal function in patients with CT1 renal tumors after laparoscopic partial and radical nephrectomy. Predictive factors for renal function impairment. / Evolución de la función renal en pacientes con cáncer renal cT1 después de nefrectomía parcial y radical laparoscópica. Factores predictores de deterioro de función renal.

INTRODUCTION AND OBJECTIVES: To analyze the evolution of kidney function after laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) and to identify predictive factors for deterioration in kidney function. MATERIALS AND METHOD: Retrospective study of patients with two kidneys, glomerular filtration rate (GFR) > 60 mL/min/1.73 m2, and single renal tumor cT1, treated in our center between 2005 and 2018. RESULTS: A total of 372 patients met the inclusion criteria for the study; 156 (41.9%) were treated by RN and 216 (58.1%) by PN. There was a difference of 26.75 mL/min/1.73 m2 in GFR between RN and PN at discharge. Age > 60 years, postoperative complications (OR 2.97, p = 0.005) and RN (OR 10.03, p = 0.0001) were predictors of GFR < 60 mL/min/1.73 m2 at discharge. Only RN (OR 7.69, p = 0.0001) behaved as an independent prognostic factor for GFR < 45 mL/min/1.73m2 at discharge. The median follow-up of the series was 57 (IQR 28-100) months. At the end of the follow-up period, nine (6%) patients treated with RN developed severe chronic kidney disease (CKD) and three (2%) developed end stage renal disease (ESRD). Age > 70 years, diabetes mellitus (DM) (HR 2.12, p = 0.001), arterial hypertension (AHT) (HR 1.73, p = 0.01) and RN (HR 2.88, p = 0.0001) behaved as independent predictors of GFR < 60 mL/min/1.73 m2. The independent predictors for GFR< 45 mL/min/1.73m2 were age >70 years, DM (HR 1.99 CI 95% 1.04-3.83, p = 0.04) and RN (HR 5.88 CI 95% 2.57-13.45, p = 0.0001). CONCLUSIONS: RN is a short- and long-term risk factor for CKD, although with a low probability of severe CKD or ESRD in patients with preoperative GFR > 60 mL/min/1.73 m2. Age, DM and AHT contribute to worsening renal function during follow-up.

[Basal renal function in paediatric patients: correlation of methods that depend on a 24h urine collection with simpler methods that do not require a timed urine]. / Función renal basal en pediatría: correlación de métodos que dependen de la recogida de orina de 24h con otros más sencillos que no requieren orina minutada.

INTRODUCTION: In daily clinical practice a quick, easy and accessible method is needed to adequately assess renal function. The objectives of this study were: 1. To quantify the relationship and concordance of the glomerular filtration rate (GF) calculated by the clearance of creatinine in 24h urine (CCr) and the original and modified Schwartz equation (SE); and 2. To correlate urine elimination of substances that depends on the volume of excreted urine in a unit of time with other parameters that are calculated measuring the concentration of these substances in blood and urine. MATERIAL AND METHODS: The study included 401 healthy children with ages between 3 to 14 years (187 male and 214 female). The analysis between the variables was carried out using Pearson's correlation coefficient and the intraclass correlation coefficient (ICC). RESULTS: The correlation between values of CCr and the original SE (non-standardised creatinine measurement) was r=0.58 (P<0.001) and the concordance, ICC=0.74. The correlation between CCr values and the modified SE (standardised creatinine measurement) was r=0.68 (P<.001), and the concordance ICC=0.78. There was a very significant correlation between the elimination of sodium in a 24h urine (mEq/kg/24h) and the Na-Fractional-Excretion (EFNa): r=0.8 (P<.001). There was a correlation between the potassium elimination in 24h (mEq/kg/24h) and EFK: r=0.85 (P<.001). Between volume/min/1.73m2 and the urine volume percent of GF was: r=0.88 (P<.001). CONCLUSIONS: These equations provide valuable information of the state of the basal renal function without having to use a timed urine.

Renal safety outcomes of spironolactone in patients with resistant hypertension. / Seguridad renal de espironolactona en pacientes con hipertensión arterial resistente.

INTRODUCTION: Resistant hypertension (RH) is a significant health problem with complex management. The aim of this study was to evaluate the risks and benefits of adding spironolactone to treat RH. MATERIAL AND METHODS: In total, 216 patients with RH in whom spironolactone (12.5-25mg daily) was added as an antihypertensive were evaluated. One-hundred and twenty-five (125) were analysed retrospectively and 91 prospectively. Blood pressure (BP) and laboratory parameters (serum creatinine [sCrea], estimated glomerular filtration rate [eGFR] and serum potassium [sK]) were analysed at baseline and at 3-6-12 months after introducing spironolactone. RESULTS: A change of systolic/diastolic BP (mean±standard deviation) of -10.9±2.7/-4.3±1.6mmHg at 3 months and -13.6±2.8/-6.0±1.6mmHg at 12 months; p<0.001 was observed. These values were confirmed with ambulatory-BP monitoring at 12 months. At 3 months, an increase in sCrea of 0.10±0.04mg/dl, a decrease in eGFR of -5.4±1.9ml/min/1.73m2 and an increase in sK of 0.3±0.1mmol/l; p<0.001 was observed for all cases. These changes were maintained after 12 months. There were no significant differences in changes of BP, sCrea, eGFR and sK between 3 and 12 months. Results of the retrospective and prospective cohorts separately were superimposable. In the prospective cohort, spironolactone was withdrawn in 9 patients (9.9%) because of adverse effects. CONCLUSIONS: After 3 months with spironolactone, a decrease in BP associated with a decrease in the eGFR and an increase in sCrea and sK was observed. These changes were maintained at 12 months. Spironolactone is an effective and safe treatment for RH in patients with baseline eGFR ≥30ml/min/1.73m2.

Does renal function improve after parathyroidectomy in primary hyperparathyroidism? / ¿Mejora la función renal tras la paratiroidectomía en el hiperparatirodismo primario?

INTRODUCTION: Primary hyperparathyroidism (PHPT) is a common endocrine disorder characterised by hypercalcaemia and parathormone increase. Decreased glomerular filtration rate (<60ml/min) continues to be a parathyroidectomy (PTX) criterion in asymptomatic PHPT. The influence of PTX on renal function evolution is the subject of debate. OBJECTIVE: To analyse the clinical, laboratory and histological characteristics of patients undergoing PHPT, as well as renal function evolution after PTX. MATERIAL AND METHODS: Retrospective study of 297 patients diagnosed with PHPT and referred to surgery in a single centre between 1998 and 2016. Laboratory parameters were determined at baseline, one week and one year after PTX. RESULTS: The Incidence of PTX was 38 cases/million/year. Mean age was 60±14 years and 80.5% of the patients were female. Approximately 65.3% were asymptomatic. Nephrolithiasis was the most common clinical finding (33%), followed by bone involvement (29.5%). PTX indications were: clinical symptoms (34.7%), hypercalcaemia>11.2mg/dl (27%), nephrolithiasis (13%), low bone mass (12%), age<50 years (11%) and decreased glomerular filtration rate<60ml/min (2.3%). For diagnostic localisation, spect-MIBI had a sensitivity of 92% and cervical ultrasound of 70%. A total of 94.3% of PHPT cases were due to a parathyroid adenoma. After PTX, normalisation of PHPT-related parameters was observed. We found a significant increase in serum creatinine levels (0.81 vs 0.85mg/dl, P<.001) from the first week post-PTX until the end of the first year. The renal function was only found to be significant in patients with glomerular filtration rate>60ml/min (baseline serum creatinine levels 0.77mg/dl vs serum creatinine levels after one year 0.81mg/dl, P<.001). CONCLUSIONS: PHPT was asymptomatic in most patients who underwent surgery. Hypercalcaemia and nephrolithiasis were the most common indications of parathyroidectomy in asymptomatic patients. MIBI scan was the most useful localisation method. Surgical treatment of PHPT is followed by renal function impairment, which persists after the first week post-PTX.

Factors that impact kidney function during open and endovascular reconstruction of aortic aneurysms.

BACKGROUND: To analyze the factors that influence the deterioration of postoperative renal function in patients undergoing open or endovascular aortic reconstruction, and the impact on survival. METHOD: Retrospective review of patients who underwent invasive treatment was conducted. Demographics, laboratory data, clinical, intraoperative and postoperative variables were recorded; renal function was determined, Fisher's exact test was used to find associations and Kaplan Meier analysis to estimate survival. RESULTS: From 2007 to 2017, 80 patients (mean age: 70 years) were studied. Fifty-eight (73%) were male, none of these patients had known diagnosis of chronic kidney insufficiency. Twelve (15%) patients had elevated creatinine in the postoperative period; variables such as intraoperative bleeding greater than 1500 ml were associated with acute renal failure (p = 0.005). During the follow-up period of 60 months, 8 (10%) patients progressed to chronic renal failure, 2 (2.5%) requiring hemodialysis, 18 (22%). Age, gender, comorbidities and anatomic characteristics of the aneurysm, type of intervention or level of aortic cross-clamping did not impact the postoperative renal function. CONCLUSIONS: The repair of complex aortic aneurysms continues to be a challenge. Intraoperative bleeding greater than 1500 ml and the need of blood transfusion was associated with deterioration of postoperative renal function, affecting the 5-year survival of patients.

OBJETIVO: Analizar qué factores influyen en el deterioro de la función renal en pacientes sometidos a reconstrucción aórtica abierta o endovascular, y su impacto en la supervivencia. MÉTODO: Estudio retrospectivo. Se analizaron variables demográficas, de laboratorio, transoperatorias y posoperatorias. Se determinó la función renal y se utilizó la prueba exacta de Fisher en la búsqueda de asociaciones, y el análisis de Kaplan-Meier para estimar la supervivencia. RESULTADOS: De 2007 a 2017, 80 pacientes (media de edad: 70 años) fueron sometidos a procedimientos de reconstrucción aórtica. Cincuenta y ocho (73%) eran de sexo masculino. Doce (15%) tuvieron elevación de creatinina en el posoperatorio y sangrado mayor de 1500 ml con necesidad de transfusión que se asoció a insuficiencia renal aguda (p = 0.005). Durante el periodo de seguimiento de 60 meses, 8 (10%) pacientes desarrollaron insuficiencia renal crónica, 2 (2.5%) requirieron hemodiálisis y 18 (22%) fallecieron. La edad, el sexo, la comorbilidad y las características anatómicas del aneurisma, así como el tipo de intervención o el nivel de pinzamiento aórtico, no impactaron la función renal posoperatoria. CONCLUSIONES: La reparación de los aneurismas aórticos complejos continúa siendo un reto. Un sangrado superior a 1500 ml, con necesidad de transfusión, se asoció a deterioro de la función renal posoperatoria e impactó en la supervivencia a 5 años.

Metformin-associated hyperlactacidaemia acidosis: Diagnosis rate in standard clinical practice and its relationship with renal failure. / Acidosis con hiperlactacidemia por metformina: frecuencia de su diagnóstico en la práctica clínica habitual y relación con la insuficiencia renal.

BACKGROUND AND OBJECTIVES: Observational study on the difference between the number of cases of acidosis with hyperlactacidaemia suspected of being caused by metformin diagnosed in standard clinical practice and the incidence of this condition according to the datasheet. The study also explored the relationship between renal function and metformin-associated hyperlactacidaemia acidosis. PATIENTS: We identified cases of acidosis between 2013 and 2014 by analysing the minimum basic data set and laboratory requests. We selected patients who presented venous lactate levels >2.7 mmol/L at the time they were treated and for whom the use of outpatient metformin was confirmed. The causal relationship with metformin was independently evaluated by several researchers. The incident cases were calculated based on the number of patients who had been dispensed a drug containing metformin during the same period in the study area. RESULTS: We identified 476 cases of acidosis. Metformin was suspected of causing the condition of acidosis with hyperlactacidaemia in 20 of these cases, which represents an incidence rate of 6.57/10,000 patients. Eighty-five percent of the cases presented acute renal failure. CONCLUSIONS: The apparent incidence of acidosis with hyperlactacidaemia in patients treated with metformin is greater than that established in the datasheet (<1/10,000). The onset of metformin-associated hyperlactacidaemia acidosis is related to acute renal impairment.

[How do renal function and dilation change after pieloplasty surgery in children?] / ¿Cómo varía la función y dilatación renal después de la cirugía de pieloplastia en edad pediátrica?

OBJECTIVE: The effects of pyeloplasty on renal function are not fully well defined. Our objective is to determine if renal function and renal dilation change after pyeloplasty and the risk factors that may influence in both parameters. METHODS: Retrospective study of patients who underwent pyeloplasty. The parameters analyzed included: age, differential renal function, renal dilation, infection and complications. We compared ultrasound findings with measurement of the anterior-posterior diameter of the renal pelvis (mm) and the time/activity upload curve of the 99mTc- Mercaptoacetyltriglycine renography before and after surgery. Patients were divided in groups by renal function: bad (<20%), diminished (20-40%), normal (40-55%) and supranormal (>55%). RESULTS: A total of 129 patients were included in the study. The normal renal function group was the one undergoing surgery most frequently. Comparison of function before and after surgery showed a statistically significant improvement when preoperative function was bad (<20%) (mean 9.2+/-8.9) or supranormal (>55%) (mean -8.7+/-8.5). In the subgroup of patients under 12 months, it was notable there were significant results only when renal function was diminished (20-40%) (mean 5.6+/-2.2). Renal dilation presented significant changes after surgery in all groups (mean 5.6+/-2.2) (p<0.0001), except in cases presenting complications. CONCLUSIONS: Previous renal function has prognostic value on pieloplasty results. Supranormal renal function should be considered pathologic, but recoverable and it may improve after pieloplasty. In the absence of intra or postoperative complications, pyelocalycial dilation diminished after pieloplasty.

OBJETIVO: Los efectos de la pieloplastia sobre la función renal no están totalmente definidos. Nuestro objetivo es determinar si cambia la función renal y la dilatación renal después de la cirugía de pieloplastia y los factores que pueden influir en ambos parámetros.MÉTODOS: Estudio retrospectivo de pacientes intervenidos de pieloplastia. Se analizaron los parámetros: edad, función renal diferencial, dilatación renal, infección y complicaciones. Se compararon los hallazgos en la ecografía con la medición del diámetro anteroposterior de la pelvis (mm) y la curva de captación tiempo/ actividad en el renograma 99m Tc- Mercaptoacetiltriglicina antes y después de la cirugía. Dividimos a los pacientes en función mala (<20%), regular (20-40%), normal (40-55%) y supranormal (>55%). RESULTADOS: Se incluyeron un total de 129 pacientes, el grupo de pacientes intervenidos más frecuentemente fueron aquéllos que presentaban una función renal normal (40-55%). Al comparar la función antes y después de la cirugía, se observó una mejoría estadísticamente significativa cuando la función preoperatoria es mala <20% (media 9,2 +/-8,9) o cuando es supranormal >55% (media -8,7+/-8,5). En el subgrupo de pacientes menores de 12 meses destacó que sólo hubo resultados significativos cuando la función era regular 20-40% (media 5,6+/-2,2). La dilatación renal presentó cambios significativos (p<0,0001) tras la cirugía en todos los grupos de pacientes (media -12,4 +/-1,2), excepto cuando se habían producido complicaciones. CONCLUSIONES: La función renal previa tuvo valor pronóstico en cuanto a resultados de la pieloplastia. La función supranormal debe considerarse patológica, pero recuperable y puede mejorar tras pieloplastia. En ausencia de incidencias intra o postoperatorias, la dilatación pielocalicial disminuyó tras la pieloplastia.

Diagnóstico y manejo de la congestión en insuficiencia cardíaca aguda / Diagnosis and management of congestion in acute heart failure / Diagnóstico e tratamento da congestão na insuficiência cardíaca aguda

La congestión en pacientes con insuficiencia cardíaca representa una manifestación de diversos procesos estructurales y funcionales cardiovasculares, asociada a alta morbimortalidad y reducción de calidad de vida, se considera la principal causa de ingreso a hospitalización y reingreso por insuficiencia cardíaca. Durante las últimas décadas, se ha logrado un mejor entendimiento de los diversos eventos fisiopatológicos desencadenantes, lo cual ha mejorado su pronóstico, diagnóstico y tratamiento. Por estos constantes avances, es necesaria su frecuente revisión y análisis. La atención del paciente con insuficiencia cardíaca y episodios de congestión es compleja y crucial. Su abordaje inicia con el reconocimiento temprano de las manifestaciones clínicas, uso de métodos no invasivos diagnósticos, delimitación del perfil de congestión; consecuentemente, es necesario brindar un manejo oportuno, intensivo y eficaz que contemple el empleo temprano de diuréticos intravenosos, la evaluación de metas de descongestión y, en casos específicos, terapia diurética combinada e incluso medicamentos vasoactivos o ultrafiltración continua.

Congestion in patients with heart failure represents a manifestation of various cardiovascular structural and functional processes, associated with high morbidity and mortality and reduced quality of life, being considered the main cause of hospitalization and readmission due to heart failure. During the last decades, a better understanding of the various triggering pathophysiological events has been achieved, modifying their prognosis, diagnosis, and treatment. Due to these constant advances, its frequent review and analysis is necessary. The care of patients with heart failure and episodes of congestion is complex and crucial. Its approach begins with early recognition of clinical manifestations, use of non-invasive diagnostic methods, delimitation of the congestion profile; followed by timely, intensive, and effective management that contemplates the early use of intravenous diuretics, evaluation of decongestion goals and, in specific cases, combined diuretic therapy, and even vasoactive medications or continuous ultrafiltration.

A congestão em pacientes com insuficiência cardíaca representa manifestação de diversos processos cardiovasculares estruturais e funcionais, associada a elevada morbidade e mortalidade e redução da qualidade de vida, é considerada a principal causa de internação e reinternação por insuficiência cardíaca. Durante as últimas décadas, conseguiu-se uma melhor compreensão dos vários eventos fisiopatológicos desencadeantes, o que melhorou o seu prognóstico, diagnóstico e tratamento. Devido a esses constantes avanços, sua revisão e análise frequente se fazem necessárias. O cuidado de pacientes com insuficiência cardíaca e episódios de congestão é complexo e crucial. Sua abordagem inicia-se com reconhecimento precoce das manifestações clínicas, utilização de métodos diagnósticos não invasivos, delimitação do perfil de congestão. Consequentemente, é necessário proporcionar manejo oportuno, intensivo e eficaz que inclua o uso precoce de diuréticos intravenosos, a avaliação das metas de descongestão e, em casos específicos, terapia diurética combinada e até mesmo medicações vasoativas ou ultrafiltração contínua.

Discrepancies between the use of MDRD-4 IDMS and CKD-EPI equations, instead of the Cockcroft-Gault equation, in the determination of the dosage of direct oral anticoagulants in patients with non-valvular atrial fibrillation. / Discrepancias entre el empleo de las ecuaciones MDRD-4 IDMS y CKD-EPI en vez de la de Cockcroft-Gault en la determinación de la posología de los anticoagulantes orales directos en pacientes con fibrilación auricular no valvular.

BACKGROUND AND OBJECTIVE: Direct oral anticoagulants (DOACs) require dose adjustment according to estimated clearance creatinine (eClCr) using the Cockcroft-Gault (CG) equation. There are discrepancies with the equations that estimate glomerular filtration rate (eGFR). We analyse how the use of the CKD-EPI and MDRD-4 IDMS equations affect the recommended dosage for ACODs. PATIENTS AND METHODS: Retrospective study of patients with non-valvular atrial fibrillation seen at a cardiology clinic between November 2012 and August 2014. Patients were reclassified according to the recommended dosage for dabigatran, rivaroxaban, apixaban and edoxaban, based on the eGFR equation used. Other clinical factors are taken into account, according to the product label. We analysed the percentage of discordance. RESULTS: Four hundred and fifty-four patients, 53.3% men, with a mean age of 68.7±13.8 years were studied. The mean intra-individual differences recorded for the CG equation were 3.9ml/min/1.73m2 with MDRD-4 IDMS (95% CI 1.4-6.4, P=.003) and 11.3ml/min/1.73m2 with CKD-EPI (95% CI 8.9-13.7, P<.001). A gradient is observed in the discordance of the posology (apixaban 1.1%, dabigatran 3.5%, edoxaban 5.7%, rivaroxaban 8.4% with MDRD-4 IDMS). Differences were limited to patients with eClCr<60ml/min and were more evident in≥75 years in which the eGFR equations overestimate renal function. CONCLUSIONS: In patients with non-valvular atrial fibrillation, especially with renal failure and in the elderly, eGFR equations tend to overestimate renal function relative to CG and therefore suggest an overdose of DOACs.