Efficacy of dialysis in peritoneal dialysis: utility of bioimpedance to calculate Kt/V and the search for a target Kt.

BACKGROUND: To calculate Kt/V, volume (V) is usually obtained by Watson formula, but bioimpedance spectroscopy (BIS) is a simple and applicable technique to determinate V, along with other hydration and nutrition parameters, in peritoneal dialysis (PD) patients. Dialysis efficacy can also be measured with Kt, but no experience exists in PD, so there is no reference/target value for Kt that must be achieved in these patients to be considered adequately dialyzed. We evaluated the efficacy of PD with Kt/V using Watson formula and BIS for V calculation, assessed hydration status in a PD unit by data obtained by BIS, and attempted to find a reference Kt from the Kt/V previously obtained by BIS. METHODS: In this observational prospective study of 78 PD patients, we measured V using BIS (V bis) and Watson formula (V w) and calculated weekly Kt/V using both volumes (Kt/V bis/V bis and Kt/V w). With the BIS technique, we obtained and subsequently analyzed other hydration status parameters. We achieved a reference Kt, extrapolating the value desired (weekly Kt/V 1.7) to the target Kt using the simple linear regression statistical technique, basing it on the results of the previously calculated Pearson's linear correlation coefficient. RESULTS: Volume was 1.8 l higher by Watson formula than with BIS (p < 0.001). Weekly Kt/V bis was 2.33 ± 0.68, and mean weekly Kt/V w was 2.20 ± 0.63 (p < 0.0001); 60.25 % of patients presented overhydration according to the BIS study (OH >1.1 l). The target value of Kt for the reference weekly Kt/V bis (1.7) was 64.87 l. CONCLUSIONS: BIS is a simple, applicable technique for calculating V in dialysis that can be especially useful in PD patients compared with the anthropometric formulas, by the abnormally distributed body water in these patients. Other parameters obtained by BIS will serve to assess both the distribution of body volume and nutritional status in the clinical setting. The target Kt value obtained from Kt/V bis allowed us to measure the efficacy of PD in a practical way, omitting V measurement.

[Short cold ischaemia time optimises transplant results for kidneys from expanded criteria donors]. / El tiempo de isquemia fría corto optimiza los resultados de los trasplantes renales efectuados con donantes con criterios expandidos.

INTRODUCTION: Outcome of renal transplant from expanded criteria donors (ECD) is usually inferior than those from standard criteria donors (SCD) and may be improved decreasing cold ischemia time (CIT) and minimizing preservation injury. We compare the results obtained with CIT <15 hours in kidney transplants from ECD vs SCD. SUBJECTS AND METHODS: Prospective, single center study of kidney transplants performed since June 2003 to December 2007. Minimum follow-up period was 12 months. Data of donors, receptors and transplant outcome from ECD and SCD are compared. RESULTS: CIT (mean +/- SD) was 9.3+/-2.5 hours in transplants from ECD (n=24) and 8.3+/-3.3 hours in those from SCD (N=50), p=0.18. We did not find significant differences among recipients of grafts from ECD and those from SCD regarding: primary non-function (4.2% vs 2%, respectively), delayed graft function (16.7% vs 10%), surgical complications (25% vs 16%) or acute rejection episodes (8.3% vs 2%). Glomerular filtration rate at one year follow-up was 65.8+/-14.9 ml/min in ECD recipients and 49.4+/-12.5 ml/min (p<0.0001). One year graft survival was 95.8% in ECD recipients and 94% in SCD recipients (p=0.75). CONCLUSIONS: Short CIT in kidney transplant from ECD leads to similar outcome than that obtained from SCD, although renal function is inferior in ECD grafts.

Analysis of Kidney Donation and Its Relationship With Graft Failure of the Recipient at 1 Year.

INTRODUCTION: Currently, the shortage of organs available for kidney transplantation and a change in donors' and recipients' profiles (elderly, with cardiovascular risk, donors after cardiac death), it is becoming necessary to assess grafts from expanded-criteria donors (ECD) in order to have methods that allow us to predict viability and graft survival. OBJECTIVE: The aim of this study was to analyze the different methods of renal donor assessment (estimated glomerular filtration rate [eGFR], preimplantation biopsy, and Kidney Donor Profile Index [KDPI] score) as predictors of graft survival and renal function of our recipient at 1 year. METHODS: We performed a descriptive and retrospective study of 183 deceased donor kidney transplantations performed at our center between 2011 and 2015. We calculated the KDPI scores, donor eGFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration Formula equation, and biopsies were evaluated using Banff classification. RESULTS: ECDs comprised 59.60%, 93% of donors had an eGFR ≥ 60 mL/min/1.73 m2, and 41% presented with a KDPI score ≥ 90%. The most frequent range in the biopsy score was 0-3. The 1-year graft survival rate was 86.90%. Factors that negatively influenced graft survival were donor/recipient age, ECD, KDPI, and cold ischemia time (CIT). CONCLUSION: Prolonged CIT and KDPI ≥ 90% were donor variables that were related to graft failure at 1 year in our center.

Anti-HLA Antibodies After Precocious Transplantectomy by Vascular Thrombosis.

BACKGROUND: Our objective in this study was to determine the effects of early renal transplantectomy on patients and the production of anti-human leukocyte antigen (anti-HLA) antibodies. METHODS: Between January 2003 and May 2017, we analyzed a group of patients for the presence of specific HLA class I and/or II donor-specific antibodies (DSA), their panel-reactive antibodies (PRA), and the time period in which the antibodies were still detectable after transplantectomy. RESULTS: Anti-HLA antibodies were detected in 60.8% of patients, 60.8% and 52.2% of those patients had anti-class I and anti-class II antibodies, respectively. DSA were detected in 91.7% of the anti-HLA class I patients. Class II DSA were detected all of the patients with anti-HLA class II antibodies. The average (mean ± SD) PRA levels in our patients after transplantectomy was 60 ± 34% in class I and 63 ± 36% in class II. CONCLUSION: Anti-HLA antibodies can be detected well after transplantectomy. Even if the kidney allograft had been transplanted for only a short time, when the intensity of immunosuppression was the highest, many patients developed anti-HLA antibodies. The patients who continued with immunosuppression after transplantectomy did not develop anti-HLA antibodies.

[Giant adrenal myelolipoma: hypertension, renal failure and spontaneous rupture]. / Mielolipoma suprarrenal gigante: hipertensión, insuficiencia renal y rotura espontánea.

Adrenal myelolipoma is a rare, benign, slow-growing tumor composed of adipose tissue and hematopoietic elements. It is usually diagnosed incidentally, although there are reports of patients with symptoms and descriptions of retroperitoneal hemorrhage due to rupture of large tumors. The condition has been associated with obesity, high blood pressure and adrenal dysfunction. We present a patient with retroperitoneal hemorrhage due to spontaneous rupture of a myelolipoma, hypertension, and renal failure secondary to nephroangiosclerosis.

[Embolization of non-functioning renal allograft: efficacy and control of systemic inflammation]. / Embolización del injerto renal no funcionante: eficacia y control del estado inflamatorio crónico.

BACKGROUND: The graft intolerance syndrome (fever, pain, haematuria) may lead to a chronic inflammatory disease, with cardiovascular repercussion. Nephrectomy is considered the classical treatment of these cases but nowadays renal vascular embolization has been suggested as a possible alternative treatment. The present study concerns seven cases trated with renal vascular embolization in our hospital summarizing data of graft intolerance syndrome and the chronic inflammatory disease. MATERIAL AND METHODS: Between january 2000 and december 2003 seven renal vascular embolization were performed in nonfunctioning renal allograft. The procedure was made with calibrated particles of 300-500micron. Data about complications related to the technique the same as analitic inflammatory parameters before and after treatment (CRP, ferritin, serum albumin, hemoglobin, erythropoietin) were registered. RESULTS: The patients were two men and five women, with median age of 39,7 +/- 8,8 years. The period beween the dialysis and the embolization was of 10,0 +/-8,2 months. Comparing the perion of admission in the hospital due to nephrectomy which was of 17,86+/-4,41 days, the period because of embolization was shorter, being 8,14 +/- 4,53 days. All analitic parameters studied, clearly improved after embolization with decrease of ferritin and CRP, increase of albumin and better hemoglobin level with lower erythropoietin dose. In five of the seven patients there was no renal captation with CT or gammagraphy. Four patients presented a postembolization syndrome, but no other important complication was registered. Neither reembolization nor renal nephrectomy was neccesary in any of the seven cases. CONCLUSION: Percutaneous renal embolization is a simple, easy, safety and effective technique that must be considered as an alternative treatment to nephrectomy, resolving the chronic inflammatory disease secondary to the graft intolerance syndrome.

[Nephropathia caused by hantavirus puumala: a case report]. / Nefropatía por hantavirus puumala: a propósito de un caso.

We present a patient from Germany with Hantavirus infection, admitted in the Emergency room of our hospital, with fever, thrombocytopenia, acute renal failure, oliguria, mild proteinuria and hematuria. Percutaneous renal biopsy revealed an acute interstitial nephritis without medulla haemorrhages. The virus infection confirmation was made by detection of IgM against Hantavirus Puumala. This infection should be considered in patients with thrombocytopenia, fever and acute renal failure, over all if they are from North and Central Europe.

[Meningoencephalitis by Listeria in the lupus disease]. / Meningoencefalitis por Listeria en el lupus.

We present a patient with lupus nephropathy of 20 years of evolution in treatment with oral steroids who developed a meningoencephalitis associated to bacteraemia by Listeria monocytogenes. The patient was treated successfully with gentamicin and ampicillin for 6 weeks. Infection by Listeria monocytogenes occurs more frequently in individuals with some form of immunodeficiency like lupus disease, with a mortality around 30%.

[Influence of early or late referral to nephrologist over morbidity and mortality in hemodialysis]. / Referencia precoz y tardía al nefrólogo, su influencia en la morbi-mortalidad en hemodiálisis.

OBJECTIVE: We studied the influence of early vs late referral to nephrologist of patients with chronic renal failure over clinical situation at the onset of hemodialysis and outcome. SUBJECTS AND METHODS: From january 1994 to december 1998, 139 patients started hemodialysis for end-stage renal disease at the Hospital General de Albacete, all of them included in the study and clinical follow-up concluded in december 2001. Patients with rapidly progressive glomerulonephritis were excluded. Early (ER) and late referral (LR) were defined by the time of first nephrology encounter greater than or less than 6 months respectively, before iniciation of hemodialysis. RESULTS: 106 patients (76.25%) were referred early; mean follow-up time 6.3 +/- 4.5 years. 33 patients (23.74%) had late referral, follow-up time was less then six months, 18 patients were followed during less than 4 weeks. There were no differences in demographic data and comorbid conditions between LR and ER patients (age, cardiac and vascular disease, diabetes, neoplasia...). Mean plasma concentration of creatinine and urea was significantly greater, whereas hematocrit and albumin were less in the LRA than the ER group. Emergency dialysis through central vein catheterisation was more frequent in the LR group. Number of admissions and duration of hospital stay were higher in the LR group. No significant differences in nutrition, dialysis doses or anemia were found between the two groups after 6 and 12 months of hemodialysis. Long term outcome was similar in both groups: no significant differences were found in percentage of patients transplanted or deceased after 3 years of treatment. Survival analysis failed to show a difference between ER and LR groups (mean survival time was 73.6 +/- 4.3 months and 73.0 +/- 6 months respectively). CONCLUSION: Late referral to the nephrologist is associated with increased early morbidity vs early referral, although long term outcome is not worse if predialysis comorbid conditions are comparable and dialysis care achieve equal results in dialysis doses, nutrition and anemia in both groups in the first months of treatment. Improvement of outcome of patients referred early to the nephrologist will depend on the adoption of preventive measures over comorbidity factors that should be applied in early stages of renal disease.

[Primary amyloidosis associated to severe factor X deficiency]. / Amiloidosis primaria (AL) asociada a déficit severo de factor X.

Amyloidosis is a systemic disease characterized by generalized deposition of beta-organized proteic fibrillar material with green birefringence under polarized light, in different tissues and organs, the most frequent kidney, liver and heart, with important clinical repercussion. Primary or AL amyloidosis is the most common subtype of amyloidosis (1), confirmed by biopsy-proved amyloid deposition in abdominal fat pad, rectum, kidney or liver, if necessary, in which fragments of monoclonal light chains are deposited. Cases with factor X (Stuart factor) of coagulation deficiency associated are described, due to adsorption of this factor to amyloid fibrills. Normally, evolution is fatal, with only few months of survival. We report a case of primary amyloidosis with nephrotic syndrome, severe factor X deficiency (without bleeding complications), possible heart affection and short-term good response to chemotherapic treatment.

Antimicrobial susceptibility patterns and high-level gentamicin resistance among enterococci isolated in a Mexican tertiary care center.

AIM: To describe the antimicrobial susceptibility pattern of enterococcal clinical isolates. SETTING: A 200-bed tertiary-care center in Mexico City. STUDY DESIGN: Prospective surveillance of enterococcal clinical isolates identified according to Facklam's method since 1990. Susceptibility tests were performed by a commercial micromethod, agar diffusion and microbroth dilution. We present data from 1990 to 1992. RESULTS: A total of 407 enterococci were recovered during the study period: 245 from inpatients and 162 from outpatients; 325 of the isolates were Enterococcus faecalis, 61 E. faecium, seven E. avium, four each for E. raffinosus and, E. hirae; two, E. pseudoavium; and one each E. gallinarum, E. durans; E. mundtii, and E. faecales var asacharolyticus. Resistance to ampicillin and imipenem among E. faecium was 59%. Among E. faecalis, 0.3% were resistant to ampicillin and 2% to imipenem; no beta-lactamase production was detected. All were susceptible to vancomycin. Overall, a 12% high-level gentamicin resistance (HLGR) was found without a difference between species; 25% of bloodstream clinical isolates were HLGR enterococci. More than half (63%) of the HLGR clinical isolates were susceptible to streptomycin; a-hemolysis in human blood agar as well as nitrofurantoin resistance were observed in all E. faecium isolates and in two E. avium. CONCLUSIONS: In our center, HLGR has a prevalence of 12%. Streptomycin may be a therapeutic alternative in 63% of the HLGR cases. The pattern of hemolysis in human blood agar plus the susceptibility to nitrofurantoin could be used as an initial screening to identify enterococci.

Impact of peritonitis on long-term survival of peritoneal dialysis patients.

UNLABELLED: The impact of each episode of peritonitis on long-term survival of peritoneal dialysis (PD) patients has yet to be defined. OBJECTIVES: To determine the risk that each episode of peritonitis poses for patient survival and for the PD technique. PATIENTS: 1515 patients included in the Levante registry from 1 January 1993 to 31 December 2005. METHODS: Retrospective analysis of a multicentre registry using Cox regression for time-dependent variables. RESULTS: We analysed 1609 episodes of peritonitis in 716 patients (47.2%). In the univariate analysis, each case of peritonitis treated in the outpatient unit was associated with an increase in mortality (hazard ratio [HR] 1.99, P<.001), which was greater for episodes that required hospitalisation (HR 3.62, P<.001). Mortality increased with each successive episode in the same patient. Multivariate analysis confirmed the association of each case of peritonitis with lower long-term survival (HR 2.01, P<.001), with a different risk for episodes due to gram-positive and gram-negative bacteria and fungi (HR 1.73, 2.43 and 5.71, respectively; P<.001). Other variables associated with mortality were age, low residual renal function, absence of vascular access and comorbidity. Peritonitis was the only independent variable associated with technique failure (HR 1.29, P<.001), with a different risk for episodes due to gram-positive and gram-negative bacteria and fungi (HR 1.73, 2.43 and 5.71, respectively; P<.001). CONCLUSIONS: Episodes of peritonitis negatively influence long-term survival of patients on PD.

Conversion to tacrolimus extended-release formulation: short-term clinical results.

OBJECTIVE: To determine the short-term clinical results of conversion of treatment from tacrolimus twice daily (BID TAC) to the extended-release formulation (OD TAC), milligram for milligram, and whether such conversion is safe in stable kidney transplant recipients. PATIENTS AND METHODS: The study included 38 kidney transplant recipients (median [SD] age, 54.3 [14.4] years) with stable renal function (mean [SD] serum creatinine concentration 1.29 [0.38] mg/dL). Posttransplantation follow-up was 3.4 (3.1) years (range, 4-168 months). All patients had been receiving BID TAC (2.45 [1.52] mg/d) when treatment was converted to OD TAC, milligram for milligram. Follow-up including clinical evaluation and laboratory tests was at 7, 21, and 90 days postconversion. RESULTS: No significant differences were observed during follow-up in serum creatinine concentration, blood glucose level, hemoglobin level, or proteinuria. There were no episodes of acute rejection. No de novo posttransplantation diabetes mellitus was diagnosed; patients with diabetes required similar dosage of hypoglycemia treatment. Arterial pressure remained stable without changes in antihypertension treatment. Tacrolimus doses were not modified (2.45 [1.52] mg/d at baseline vs 2.45 [1.67] mg/d at 3 months postconversion; however, tacrolimus concentration decreased significantly (7.6 [1.8] ng/mL at baseline vs 6.42 [1.13] ng/mL at 3 months postconversion. Reduction in tacrolimus concentration was more remarkable in patients receiving a dose of less than 0.025 mg/kg/d. CONCLUSIONS: Conversion from BID TAC to OD TAC, milligram for milligram, is clinically safe; however, monitoring of tacrolimus concentration in patients receiving low dosage is mandatory to prevent subtherapeutic levels.

Prevalence and risk factors for hepatitis C virus infection in continuous ambulatory peritoneal dialysis patients.

BACKGROUND: Studies on hepatitis C virus antibodies (Anti-HCV) in CAPD patients are scarce and include a small number of patients. Nevertheless, risk factors related to Anti-HCV in these patients are still subject to controversy. Purpose of the study. To analyse the incidence and risk factors associated with the presence of Anti-HCV in CAPD patients. METHODS: We studied 255 patients from five different treatment centres of our region. The analysis was repeated after excluding 161 patients who had previously received haemodialysis treatment at least once. Anti-HCV testing was made by the 2nd-generation ELISA: As a supplementary test we used RIBA-4 in three centers and INNOLIA in the other two. Risk factors were analysed using logistic regression model for multivariate analysis. RESULTS: In the whole group, 29 patients (11.4%) were anti-HCV positive. Logistic regression analysis determined the following variables as independent risk factors: hepatitis previous to CAPD (P<0.001, odds ratio (OR):44.9), Anti HBc positivity (P=0.019, OR:9. 24), blood transfusions previous to CAPD (P=0.015, OR:1.05) and CAPD duration were excluded, the prevalence of HCV antibodies was 8.5% (8/94). In this group multivariate analysis showed that Anti-HCV positivity correlated with hepatitis previous to CAPD (P<0.0003, OR: 126) and Anti HBc positivity (P=0.002, OR:41.9). CONCLUSIONS: Our prevalence of hepatitis C virus (HCV) infection in CAPD patients was lower than other renal replacement therapy modalities, and correlated to events occurring mainly before starting CAPD treatment. This technique could be considered as low risk for HCV infection.