Pruritus in dialysis patients. Review and new perspectives.

Uremic pruritus (UP) is one of the most uncomfortable symptoms for patients in dialysis. UP has a great impact on dialysis patients' quality of life and has a great prevalence between those (28-70%). Physiopathology of UP is unknown and usually is unnoticed for most nephrologists (in more than 65% of centers is underdiagnosed). This lack of awareness drives to the unsuccessful treatment of this symptom. Moreover, the fact that most studies have been carried out on small populations and the difficulty assessing UP complicates a correct therapeutical approach. For this reason, we have designed treatment algorithms based on the efficacy of the drugs but also its safeness to avoid adverse effects.

Pruritus in dialysis patients. Review and new perspectives. / Prurito en pacientes en diálisis. Revisión de la literatura y nuevas perspectivas.

Uremic pruritus (UP) is one of the most uncomfortable symptoms for patients in dialysis. UP has a great impact on dialysis patients' quality of life and has a great prevalence between those (28-70%). Physiopathology of UP is unknown and usually is unnoticed for most nephrologists (in more than 65% of centers is underdiagnosed). This lack of awareness drives to the unsuccessful treatment of this symptom. Moreover, the fact that most studies have been carried out on small populations and the difficulty assessing UP complicates a correct therapeutical approach. For this reason, we have designed treatment algorithms based on the efficacy of the drugs but also its safeness to avoid adverse effects.

A case-control study to assess the role of polyomavirus in transplant complications: Where do we stand?

PURPOSE: The study's aim was to assess whether polyomavirus DNAemia screening was associated with different outcomes in patients with positive viremia compared with negative viremia. METHODS: Case-control retrospective study of patients with polyomavirus DNAemia (viremia > 1000 copies/mL) matched 1:1 with controls. Control group consists of the patient who received a transplant immediately before or after each identified case and did have nil viremia. FINDING: Ultimately, 120 cases of BK polyomavirus (BKPyV) were detected and matched with 130 controls. Of these, 54 were adult kidney transplant recipients (KTRs), 43 were pediatric KTRs, and 23 were undergoing hemato-oncologic therapy, of which 20 were undergoing hematopoietic stem cell transplantation. The odds ratio (OR) for overall risk of poorer outcomes in cases versus controls was 16.07 (95% CI: 5.55-46.54). The unfavorable outcome of switching the immunosuppressive drug (ISD) (14/40,35%) was no different from that of those treated with reduced ISD doses (31/71, 43.6%, P = .250). Acute rejection or graft-versus-host disease, previous transplant, and intensity of immunosuppression (4 ISDs plus induction or conditioning) were risk factors for BKPyV-DNAemia (OR: 13.96, 95% CI: 11.25-15.18, P < .001; OR: 6.14, 95% CI: 3.91-8.80, P < .001; OR: 5.53, 95% CI: 3.37-7.30, P < .001, respectively). CONCLUSIONS: Despite viremia screening, dose reduction, and change in therapeutic protocol, patients with positive BKPyV-DNAemia present poorer outcomes and unfavorable results.

[Assessment of diet in patients with chronic kidney diseases without dialysis and relationship with the nutritional status]. / Evaluación de la dieta en pacientes con enfermedad renal crónica sin diálisis y su relación con el estado nutricional.

BACKGROUND: Diet is one of the pillars of the treatment for patients with chronic kidney disease without dialysis (NDD-CKD). Despite this, very few studies have evaluated the diet in Spanish population. OBJECTIVE: To evaluate the diet of a group of patients with advanced CKD, comparing it with the recommendations, and its relation with nutritional status. MATERIAL AND METHODS: A cross-sectional study of 74 patients (39 men), with a mean age of 70.9 ± 13.6 years and creatinine clearance of 15.3 ± 2.1 mL/min. Biochemical, anthropometric and intake variables (3-day dietary record) were collected, comparing them with the recommendations for patients with CKD and, if they did not exist, with nutritional recommendations and objectives for the Spanish population. The nutritional status was assessed by modified criteria of protein-energy wasting (PEW). RESULTS: The mean energy intake was 23.2 ± 6.5 kcal/kg body weight/day, and the protein intake was 0.93 ± 0.2 g/kg body weight/day. Men had a higher intake of alcohol and vitamin D whereas women presented a higher intake of trans fatty acids and vitamin B1. In addition, 91.4% of patients had high intake of phosphorus and 73% of potassium. Only 2.7% showed an adequate intake of vitamin D and 21.6% of folates; 18.9% of patients presented PEW. A positive correlation was found between albumin, body mass index (BMI) and creatinine clearance. CONCLUSION: Most patients with non-dialysis CKD do not meet dietary recommendations or nutritional goals, regardless of gender and PEW status, considering renal function as a limiting factor.

[Bioimpedance vector analysis as a tool for the determination and adjustment of dry weight in patients undergoing hemodialysis]. / VECTORES DE IMPEDANCIA BIOELÉCTRICA COMO HERRAMIENTA PARA LA DETERMINACIÓN Y AJUSTE DEL PESO SECO EN PACIENTES SOMETIDOS A HEMODIÁLISIS.

BACKGROUND AND OBJECTIVE: Overhydration in hemodialysis patients is associated with cardiovascular mortality. Adequate removal of liquids and achievement of dry weight is one of the main goals of therapy. So far there are no clinical or laboratory parameters that are reliable, simple and affordable for its determination. The bioelectrical impedance vector analysis (BIVE) is a tool that allows identifying and monitoring hydration status, so the aim of this study was to use BIVE to adjust the intensity of ultrafiltration and achieve dry weight in hemodialysis patients. METHODS: We studied 26 patients on hemodialysis, which were performed monthly measurements of bioelectrical impedance for four months. Corresponding vectors were plotted to know in an individual way the state of hydration, according to which the dry weight was adjusted when necessary. RESULTS: Dry weight adjustment was performed in 13 patients, 7 of which required increase and 6 decrease of dry weight. The displacement of vectors on the ellipses corresponded to the type of intervention made. Dry weight was reached in 84.6% of patients at the end of the study with a significant decrease in mean arterial blood pressure and an increase in phase angle in the group of decrease of dry weight. CONCLUSIONS: Bioelectrical impedance vector analysis is an useful tool for adjusting the dry weight in patients undergoing hemodialysis.

Antecedentes y objetivo: La sobrehidratación en los pacientes en hemodiálisis se asocia con mortalidad cardiovascular, por lo que la adecuada remoción de líquidos y el logro del peso seco es uno de los principales objetivos de la terapia. Hasta el momento no hay parámetros clínicos ni de laboratorio que sean confiables, sencillos y accesibles para su determinación. El análisis de vectores de impedancia (VIBE) es una herramienta que permite identificar y monitorizar el estado de hidratación, por lo que el objetivo de este estudio fue usar el VIBE para ajustar la intensidad del ultrafiltrado y alcanzar el peso seco en pacientes en hemodiálisis. Material y método: Se estudiaron 26 pacientes en hemodiálisis a los cuales se les realizaron medidas mensuales de impedancia bioeléctrica durante cuatro meses. Se graficaron los vectores correspondientes para conocer de manera individual el estado de hidratación, de acuerdo con lo cual se ajustó el peso seco en los casos necesarios. Resultados: Se realizó ajuste de peso seco en 13 pacientes, 7 de ellos necesitaron aumento de peso y 6 disminución del mismo. El desplazamiento de los vectores sobre las elipses correspondió al tipo de intervención realizada. Se logró alcanzar el peso seco en el 84.6% de los pacientes al final del estudio, con una disminución significativa de la presión arterial media y aumento del ángulo de fase en el grupo de disminución de peso seco. Conclusiones: El análisis de vectores de impedancia es útil para el ajuste del peso seco en los pacientes sometidos a hemodiálisis.

Thirty years in a peritoneal dialysis unit: long-term survival.

INTRODUCTION: Peritoneal dialysis (PD) is an established renal replacement therapy technique which thanks to the technological and clinical advances has improved its survival rates in recent years. OBJECTIVES: The aim of this study was to evaluate patient and technique survival in PD over 30 years, according to the different decades in order to consolidate its usefulness in healthcare. METHOD: Retrospective cohort study including all patients in the PD programme of the Hospital Universitario La Paz (Madrid), from 1980 to 2010. Demographic and clinical variables were collected from medical records. RESULTS: A total of 667 patients were included, 54.4% male, with a mean age of 51.47 years and a median follow-up period of 23.1 months. There was a progressive increase in PD incident patients, especially in automated PD (APD). Patient survival at 5 years was 54%, with a median of 64.66 months, increasing significantly in the last decade (P=.000). Age, comorbidity, male sex, chronic ambulatory PD (CAPD) and diabetes were predictors of patient survival. Technique survival at 5 years was 64.2% with a median of 82 months. The success of the technique was greater in younger patients on APD and with lower comorbidity. CONCLUSIONS: Over 30 years, we found an increase in incident patients. Age, comorbidity and diabetes still continue to be the main determining factors for survival.

Encapsulating peritoneal sclerosis in peritoneal dialysis. a review and European initiative for approaching a serious and rare disease.

Encapsulating peritoneal sclerosis (EPS) represents a rare complication in peritoneal dialysis (PD) with high mortality. It is characterised by diffuse peritoneal membrane fibrosis, which develops into encapsulation and manifests as clinical signs and symptoms of intestinal obstruction. Its incidence varies from 0.7%to 3.3%. The most significant risk factor in its development is exposure time to PD solutions, although young age and peritonitis episodes can also contribute. Its aetiopathogeny has not been clearly explained and it is thought that a second hit like peritonitis, hemoperitoneum, surgery, genetic predisposition, etc on an already damaged peritoneal membrane, could also trigger the development of EPS. Some cases appear after transfer to haemodialysis or after transplant. In these cases, the use of calcineurin inhibitors is believed to be related. The presence of clinical symptoms and signs of intestinal obstruction, along with compatible radiological and/or anatomical findings could also confirm the diagnosis. At present there are no clinical or biochemical markers capable of predicting its onset. Therapeutic management comprises the use of immunosuppressors like steroids and tamoxifen, nutritional management and even surgery in advanced cases, all of which provide varying results. This article discusses the diagnosis and treatment of EPS, it encourages the participation in the European Registry and it advocates the need to centralise the management of this medical complication.

[Prokinetic agents as a cause of granulomatous interstitial nephritis]. / Procinéticos como causantes de nefritis intersticial granulomatosa.

Granulomatous interstitial nephritides are uncommon entities in routine clinical practice. These entities are usually associated with infectious diseases such as tuberculosis, or immune diseases, such as sarcoidosis, systemic lupus erythematosus or cryoglobulinemia. However, these diseases are most frequently associated with drug intake, especially antibiotics, proton pump inhibitors and nonsteroidal anti inflammatory drugs. An association with prokinetic agents has not previously been reported. We report the case of a 64-year-old woman who developed acute renal failure with this histological pattern after taking the motility promoter cinitapride without her physician's knowledge.