Papel de la denervación simpática de arterias renales en un paciente con hipertensión arterial refractaria / Role of renal sympathetic denervation in a refractory arterial hypertension patient

A pesar de los progresos en el tratamiento farmacológico de la hipertensión arterial (HTA) y el empleo de múltiples fármacos antihipertensivos, un pequeño pero significativo porcentaje de los pacientes con HTA refractaria severa verdadera continúa sin alcanzar su objetivo de control tensional. En estos casos, la denervación simpática renal (DNSR) parece mostrarse como un método seguro y eficaz para aquellos pacientes hipertensos severos refractarios al tratamiento farmacológico múltiple. Presentamos el caso de un paciente de 52 años de edad diagnosticado de HTA esencial refractaria a tratamiento con 7 fármacos antihipertensivos. Tras 10 ingresos hospitalarios sin conseguir un adecuado control de las cifras de presión arterial, decidimos plantear la DNSR como coadyuvante al tratamiento médico. El procedimiento se realizó sin complicaciones a corto y medio plazo, consiguiéndose una mejoría significativa de las cifras tensionales, con el objetivo de disminuir su riesgo vascular global (AU)

Despite advances in the pharmacological treatment of arterial hypertension (AHT) and the use of multiple antihypertensive drugs, a small but significant percentage of true severe refractory arterial hypertension patients are still not reaching their target blood pressure. In these cases, renal sympathetic denervation (RSD) seems to be a safe and effective method for severe hypertensive patients who are resistant to multiple drug treatment. We present the case of a 52-year-old patient diagnosed with essential hypertension, resistant to treatment with seven antihypertensive drugs. After 10 hospitalisations without achieving adequate blood pressure control, we decided to propose renal sympathetic denervation as an addition to medical treatment. The procedure was performed without complications in the short to medium-long term, achieving a significant improvement in blood pressure with the intention of reducing overall vascular risk (AU)

Role of renal sympathetic denervation in a refractory arterial hypertension patient.

Despite advances in the pharmacological treatment of arterial hypertension (AHT) and the use of multiple antihypertensive drugs, a small but significant percentage of true severe refractory arterial hypertension patients are still not reaching their target blood pressure. In these cases, renal sympathetic denervation (RSD) seems to be a safe and effective method for severe hypertensive patients who are resistant to multiple drug treatment. We present the case of a 52-year-old patient diagnosed with essential hypertension, resistant to treatment with seven antihypertensive drugs. After 10 hospitalisations without achieving adequate blood pressure control, we decided to propose renal sympathetic denervation as an addition to medical treatment. The procedure was performed without complications in the short to medium-long term, achieving a significant improvement in blood pressure with the intention of reducing overall vascular risk.

Efectos renoprotectores a largo plazo de dosis altas de irbesartán en la nefropatía diabética establecida / High doses of irbesartan offer long-term kidney protection in cases of established diabetic nephropathy

Antecedentes: Hipotéticamente, la utilización de dosis altas de antagonistas del receptor AT1 de angiotensina II, al bloquear más el receptor AT1, debería producir mayores beneficios que el uso de de dosis convencionales. Objetivo: Evaluar los efectos sobre proteinuria y función renal con dosis ultraaltas de irbesartán en la nefropatía diabética establecida. Material y método: Estudio prospectivo de intervención no controlado ni aleatorizado de 3 años de seguimiento, utilizando un tratamiento multifactorial basado en 600 mg diarios de irbesartán. Se analizan variables demográficas, antropométricas y analíticas al inicio y final del estudio. Se incluyeron 40 pacientes (75% con diabetes tipo 2) con promedio de edad de 57,1 ± 10 años, 29 (72,5%) hombres, con índice de masa corporal (IMC) de 30,7 ± 5 kg/m2. Resultados: La presión arterial sistólica (157,6 ± 27 vs. 130,1 ± 14) y diastólica (88,8 ± 10 vs. 76,2 ± 8 mmHg) se redujeron significativamente (p < 0,001) al final del estudio. El perfil lipídico mejoró significativamente. La kaliemia no se modificó. La creatinina sólo aumentó 0,17 mg/dl, aunque fue significativo (p < 0,05), y el filtrado glomerular estimado se redujo (69,8 ± 29,7 vs. 60,25 ± 23,0 ml/min/m2) (p < 0,05). La proteinuria se redujo de 2,4 ± 1,99 a 0,98 ± 1,18 g/24 h (p < 0,001). La reducción promedio fue 59,2%, y el 25% de los pacientes se hizo normoalbuminúrico. Salvo IMC y hemoglobina glucosilada, todos los objetivos recomendados por la American Diabetes Association se alcanzaron. Ningún paciente abandonó el estudio por efectos secundarios. Conclusión: El tratamiento de la nefropatía diabética establecida con dosis ultraaltas de irbesartán se mostró muy eficaz y seguro en reducir la proteinuria y retardar la progresión hacia la insuficiencia renal crónica terminal (AU)

Background: Hypothetically, the greater the blockade of angiotensin AT1 receptors from ultra-high doses of angiotensin receptors blockers (ARB), the greater the expected renoprotection effects. The aim of our study was to evaluate the effects of ultra-high doses of irbesartan on proteinuria and renal function in diabetics with established or overt diabetic nephropathy (ODN). Material and Method: Ours was a prospective, non-randomised 3-year follow-up study, using a multifactorial therapeutic approach based on irbesartan 600mg daily. Demographic variables, anthropometric data, and biochemical parameters were comparatively analysed at the beginning and end of the study. Forty patients (75% with type 2 diabetes) were included, average age 57.1±10, 29 male (72.5%). Results: SBP (157.6±27mm Hg vs 130.1±14mm Hg) and DBP (88.8±10mm Hg vs 76.2±8mm Hg) decreased significantly at the end of follow-up (P<.001). Serum creatinine increased by only 0.17mg/dl, although this was a statistically significant difference (P<.05). Proteinuria markedly decreased from 2.64±1.99 to 0.98±1.18 (P<.0001), i.e. 59.2%. Twenty-five percent of patients had normal albuminuria at the end of the follow-up period. Lipid profiles significantly improved. No patients withdrew from the study due to side effects, and serum potassium did not change significantly over the course of the study. Except for BMI and HbA1c, all other therapeutic targets set out by ADA recommendations improved significantly. Conclusions: The treatment of ODN with ultra-high doses of irbesartan was highly effective and safe in reducing proteinuria and slowing the progressive course to ESRD (AU)

High doses of irbesartan offer long-term kidney protection in cases of established diabetic nephropathy.

BACKGROUND: Hypothetically, the greater the blockade of angiotensin AT1 receptors from ultra-high doses of angiotensin receptors blockers (ARB), the greater the expected renoprotection effects. The aim of our study was to evaluate the effects of ultra-high doses of irbesartan on proteinuria and renal function in diabetics with established or overt diabetic nephropathy (ODN). MATERIAL AND METHOD: Ours was a prospective, non-randomised 3-year follow-up study, using a multifactorial therapeutic approach based on irbesartan 600mg daily. Demographic variables, anthropometric data, and biochemical parameters were comparatively analysed at the beginning and end of the study. Forty patients (75% with type 2 diabetes) were included, average age 57.1 +/- 10, 29 male (72.5%). RESULTS: SBP (157.6 +/- 27mm Hg vs 130.1 +/- 14mm Hg) and DBP (88.8 +/- 10mm Hg vs 76.2 +/- 8mm Hg) decreased significantly at the end of follow-up (P<.001). Serum creatinine increased by only 0.17mg/dl, although this was a statistically significant difference (P<.05). Proteinuria markedly decreased from 2.64 +/- 1.99 to 0.98 +/- 1.18 (P<.0001), i.e. 59.2%. Twenty-five percent of patients had normal albuminuria at the end of the follow-up period. Lipid profiles significantly improved. No patients withdrew from the study due to side effects, and serum potassium did not change significantly over the course of the study. Except for BMI and HbA1c, all other therapeutic targets set out by ADA recommendations improved significantly. CONCLUSIONS: The treatment of ODN with ultra-high doses of irbesartan was highly effective and safe in reducing proteinuria and slowing the progressive course to ESRD.

Haemodialysis using high cut-off dialysers for treating acute renal failure in multiple myeloma.

INTRODUCTION: Acute renal failure (ARF) occurs in 12%-20% of all multiple myeloma (MM) cases, and the survival of these patients depends on renal function recovery. Renal function is not recovered in 75% of dialysis-dependent patients, and their mean survival with replacement therapy is less than one year. Renal tubular disease is the most frequent cause of renal failure. It is present in more than 55% of renal failure cases and in 75% of those requiring dialysis. Rapid reduction of free light chain levels in the blood is necessary in order to recover renal function. One coadjuvant measure in treating the disease is reducing light chain levels with plasmapheresis, but its efficacy has not yet been clearly proven. Our proposal was therefore to use extended haemodialysis sessions with high cut-off dialysers (HCO-HD), obtaining a recovery rate of more than 60%. We present the progress of 6 patients with myeloma and acute renal failure who were treated with HCO-HD and the complications associated with using this type of haemodialysis. Then, we review the pros and cons of this technique. METHOD: Six patients diagnosed with MM and ARF requiring dialysis and with serum free light chain levels above 500 mg/l were treated with 8-hour haemodialysis sessions with an HCO-HD filter. Before and after each session, serum free light chain levels were measured by nephelometry; other parameters were recorded as well. At the same time, patients underwent chemotherapy according to protocols. RESULTS: The symptom onset times of the 3 men and 3 women diagnosed with MM and ARF were highly variable, from 7 days to more than 1 year. We performed 90 extended sessions with HCO-HD filters, and each patient underwent between 6 and 40 sessions. Free light chain levels decreased by a mean of 65% between treatment onset and completion, except in one patient who experienced a 12.6% reduction. The mean percentage of reduction of light chain levels per session was 54.98% ± 17.27%. A complication occurred during 28% of the sessions. Of these complications, 48% were due to system coagulation. There were no major changes in pre-dialysis albumin, calcium, phosphorous or magnesium levels, although lower values that were not clinically relevant were recorded in one case. Renal function was recovered in 3 patients, they are alive and dialysis-free. In biopsied cases that recovered renal function, the specimen showed tubular nephropathy only. Those patients who took longer to be diagnosed did not recover their renal function, and when biopsied, they were diagnosed with renal tubular disease and light chain deposition disease. CONCLUSION: We found extended haemodialysis with HCO-HD filters to be a reasonable alternative in ARF caused by renal tubular disease, and achieved a recovery rate of 50% in our cases. Function recovery was influenced by the elapsed time between symptom onset and myeloma diagnosis, histological findings, promptness of starting chemotherapy, response to chemotherapy, and effectiveness of light chain extraction. In any case, further studies are needed to examine new chemotherapy agents and new direct free light chain removal techniques.

Tratamiento con hemodiálisis del fracaso renal agudo en el mieloma múltiple con filtros de alto poro (high cut-off) / Haemodialysis using high cut-off dialysers for treating acute renal failure in multiple myeloma

Introducción: El fracaso renal agudo (FRA) en el mieloma múltiple (MM) se presenta entre el 12-20% de los casos y la supervivencia de estos pacientes depende de la recuperación de la función renal. El 75% de los pacientes dependientes de diálisis no recuperan la función renal y su supervivencia media en situación de tratamiento sustitutivo es inferior al año. La nefropatía por cilindros es la causa más frecuente de fracaso renal y acontece en más del 55% de los casos, y en el 75% de aquellos que requieren diálisis. Para facilitar la recuperación de la función renal es imprescindible la disminución rápida de los niveles en sangre de cadenas ligeras. Una medida coadyuvante al tratamiento específico de la enfermedad ha sido la reducción de estas cadenas ligeras con plasmaféresis, sin que se haya demostrado claramente su eficacia, por lo que se ha propuesto el uso de hemodiálisis largas con filtros de alto poro (HCO), consiguiendo una tasa de recuperación superior al 60%. Presentamos la evolución en seis casos de pacientes con mieloma y fracaso renal agudo que fueron tratados con dichos filtros HCO, las complicaciones con este tipo de hemodiálisis y revisamos los pros y los contras de esta técnica. Metodología: Seis pacientes diagnosticados de MM y FRA con necesidad de diálisis y niveles circulantes de cadena ligera por encima de 500 mg/l fueron tratados con hemodiálisis de 8 horas con filtro HCO. Al comienzo y al final de cada sesión se medían las cadenas ligeras séricas por nefelometría, así como otros parámetros. Al mismo tiempo los pacientes fueron tratados con quimioterapia según protocolos. Resultados: A tres hombres y tres mujeres diagnosticados de MM y FRA, con inicio de los síntomas muy variable, desde 7 días a más de un año, se les realizó 90 sesiones de hemodiálisis largas con filtros HCO con un rango de entre 6 y 40 sesiones. El porcentaje de reducción de las cadenas ligeras desde el inicio del tratamiento hasta su finalización fue el 65% de media, excepto en un paciente, que fue del 12,6%. La media del porcentaje de reducción de la cadena ligera por sesión fue de 54,98 ± 17,27%. En el 28% de las sesiones se registró alguna complicación. El 48% de las complicaciones se debieron a la coagulación del sistema. No hubo grandes cambios en los niveles de albúmina prediálisis, calcio, fósforo y magnesio, aunque en algún caso se registraron valores disminuidos que no comportaron relevancia clínica. En tres pacientes la función renal se recuperó y permanecen vivos e independientes de la diálisis. En los casos biopsiados y que recuperaron función renal, la nefropatía por cilindros fue pura. Los pacientes que tardaron más en ser diagnosticados fueron los pacientes que no recuperaron función renal, y cuando se les efectuó biopsia el diagnóstico fue de nefropatía por cilindros más enfermedad por depósitos. Conclusión: En nuestra experiencia, la hemodiálisis larga con filtros HCO es una alternativa razonable en el FRA causado por nefropatía por cilindros, alcanzando en nuestros casos una tasa de recuperación del 50%. En la recuperación influyeron: el tiempo transcurrido desde el inicio de los síntomas al diagnóstico de mieloma, los hallazgos histológicos, la rapidez de instauración del tratamiento quimioterápico y su respuesta y la eficacia en la extracción de cadenas ligeras. En cualquier caso, son necesarios nuevos estudios con nuevos agentes quimioterápicos y las nuevas técnicas de extracción directa de cadenas ligeras (AU)

Introduction: Acute renal failure (ARF) occurs in 12%-20% of all multiple myeloma (MM) cases, and the survival of these patients depends on renal function recovery. Renal function is not recovered in 75% of dialysis-dependent patients, and their mean survival with replacement therapy is less than one year. Renal tubular disease is the most frequent cause of renal failure. It is present in more than 55% of renal failure cases and in 75% of those requiring dialysis. Rapid reduction of free light chain levels in the blood is necessary in order to recover renal function. One coadjuvant measure in treating the disease is reducing light chain levels with plasmapheresis, but its efficacy has not yet been clearly proven. Our proposal was therefore to use extended haemodialysis sessions with high cut-off dialysers (HCO-HD), obtaining a recovery rate of more than 60%. We present the progress of 6 patients with myeloma and acute renal failure who were treated with HCO-HD and the complications associated with using this type of haemodialysis. Then, we review the pros and cons of this technique. Method: Six patients diagnosed with MM and ARF requiring dialysis and with serum free light chain levels above 500mg/l were treated with 8-hour haemodialysis sessions with an HCO-HD filter. Before and after each session, serum free light chain levels were measured by nephelometry; other parameters were recorded as well. At the same time, patients underwent chemotherapy according to protocols. Results: The symptom onset times of the 3 men and 3 women diagnosed with MM and ARF were highly variable, from 7 days to more than 1 year. We performed 90 extended sessions with HCO-HD filters, and each patient underwent between 6 and 40 sessions. Free light chain levels decreased by a mean of 65% between treatment onset and completion, except in one patient who experienced a 12.6% reduction. The mean percentage of reduction of light chain levels per session was 54.98%±17.27%. A complication occurred during 28% of the sessions. Of these complications, 48% were due to system coagulation. There were no major changes in pre-dialysis albumin, calcium, phosphorous or magnesium levels, although lower values that were not clinically relevant were recorded in one case. Renal function was recovered in 3 patients, they are alive and dialysis-free. In biopsied cases that recovered renal function, the specimen showed tubular nephropathy only. Those patients who took longer to be diagnosed did not recover their renal function, and when biopsied, they were diagnosed with renal tubular disease and light chain deposition disease. Conclusion: We found extended haemodialysis with HCO-HD filters to be a reasonable alternative in ARF caused by renal tubular disease, and achieved a recovery rate of 50% in our cases. Function recovery was influenced by the elapsed time between symptom onset and myeloma diagnosis, histological findings, promptness of starting chemotherapy, response to chemotherapy, and effectiveness of light chain extraction. In any case, further studies are needed to examine new chemotherapy agents and new direct free light chain removal techniques (AU)