Hipovitaminosis D en pacientes hemodiálizados (HD): factores relacionados e influencia sobre la fuerza muscular / Hypovitaminosis D in patients on hemodialysis (HD): related factors and influence on muscle strength

Introducción: La deficiencia de 25 (OH) vitamina D es una alteración prevalente en los pacientes con enfermedad renal crónica (ERC) , sin embargo en nuestro medio no es medida de manera rutinaria y por ende no suele hacerse reposición vitamínica. Nuestro objetivo fue determinar la prevalencia y los factores relacionados a deficiencia de 25 (OH) D en pacientes con ERC en hemodiálisis (HD), particularmente la relación con la función y masa muscular. Métodos: Efectuamos un estudio prospectivo, multicéntrico, en pacientes adultos en HD crónica que no estuvieran recibiendo ningún derivado de la vitamina D. Se midieron en sangre los niveles de 25(OH) D, Hemoglobina, PCR, Albúmina, Ca, P, FAL, PTHi. Se realizó la medición de la fuerza del puño con dinamómetro, y la prueba de sentado-parado. Se aplicó el índice de Karnofsky para clasificar el estado funcional., Se realizó una bioimpedanciometría (BCM; Frese nius Medical Care) en aquellos pacientes sin, contraindicación. Resultados: Se incluyeron 138 pacientes. La 25(OH) vitamina fue de 20.43 ± 10.5 ng/ml, la prevalencia de insuficiencia /defi ciencia 87% (37% con menos de 15 ng/ml). Las concentraciones de vitamina D/deficiencia mostraron correlación/relación significativa con la edad, la presencia de diabetes, los niveles de hemoglobina y albúmina, la fuerza y la masa muscular y la clase funcional (p<0.05) . Conclusión: Alta prevalencia de hipovitaminosis D en pacientes hemodializados particularmente gerontes y diabéticos. Esto estaría relacionado con la desnutrición, anemia, clase funcional y la fuerza/masa muscular de los pacientes, estos últimos dos factores no reportados hasta ahora. Todos estos factores deben ser considerados al momento de la sustitución vitamínica y en la evaluación de la efectividad de la misma.

Background: 25 (OH) vitamin D deficiency is a prevailing alteration in patients with chronic kidney disease (CKD); however, in our environment, it is not routinely measured and, therefore, vitamin replacement is unusual. Our purpose was assessing the prevalence of and the factors related to 25 (OH) vitamin D deficiency in patientswith CKD in hemodialysis (HD), especially the relation to function and muscle mass. Methods: We conducted a prospective, multicenter study in adult patients on chronic HD who were not receiving any vitamin D derivative. Blood levels of 25 (OH) D, Hemoglobin, CRP, Albumin, Ca,P, ALP and PTHi were measured. The handgrip strength was measured with a dynamometer and the sitting-rising test was carried out. A bioimpedance analysis (BCM; Fresenius Medical Care) was conducted in the patients who had no contraindications. Results: 138 patients were included. The levels of 25 (OH) vitamin D were 20.43±10.5 ng/ml; the insufficiency/deficiency had 87% prevalence (and 37% prevalence with less than 15 ng/ml). Vitamin D concentrations/ deficiency showed a significant correlation with/ relation to age, diabetes, hemoglobin and albumin levels, muscle strength and mass, and functional class (p<0.05). Conclusion: High prevalence of hypovitaminosis D in patients on hemodialysis, particularly in the elderly and in patients with diabetes. This should be related to undernutrition, anemia, the functional class and the muscle strength/mass of patients, the latter two being unreported factors until now. All these factors should be considered when vitamin replacement is conducted and when its effectiveness is assessed.

Hipovitaminosis D en pacientes hemodiálizados (HD): factores relacionados e influencia sobre la fuerza muscular / Hypovitaminosis D in patients on hemodialysis (HD): related factors and influence on muscle strength

Introducción: La deficiencia de 25 (OH) vitamina D es una alteración prevalente en los pacientes con enfermedad renal crónica (ERC) , sin embargo en nuestro medio no es medida de manera rutinaria y por ende no suele hacerse reposición vitamínica. Nuestro objetivo fue determinar la prevalencia y los factores relacionados a deficiencia de 25 (OH) D en pacientes con ERC en hemodiálisis (HD), particularmente la relación con la función y masa muscular. Métodos: Efectuamos un estudio prospectivo, multicéntrico, en pacientes adultos en HD crónica que no estuvieran recibiendo ningún derivado de la vitamina D. Se midieron en sangre los niveles de 25(OH) D, Hemoglobina, PCR, Albúmina, Ca, P, FAL, PTHi. Se realizó la medición de la fuerza del puño con dinamómetro, y la prueba de sentado-parado. Se aplicó el índice de Karnofsky para clasificar el estado funcional., Se realizó una bioimpedanciometría (BCM; Frese nius Medical Care) en aquellos pacientes sin, contraindicación. Resultados: Se incluyeron 138 pacientes. La 25(OH) vitamina fue de 20.43 ± 10.5 ng/ml, la prevalencia de insuficiencia /defi ciencia 87% (37% con menos de 15 ng/ml). Las concentraciones de vitamina D/deficiencia mostraron correlación/relación significativa con la edad, la presencia de diabetes, los niveles de hemoglobina y albúmina, la fuerza y la masa muscular y la clase funcional (p<0.05) . Conclusión: Alta prevalencia de hipovitaminosis D en pacientes hemodializados particularmente gerontes y diabéticos. Esto estaría relacionado con la desnutrición, anemia, clase funcional y la fuerza/masa muscular de los pacientes, estos últimos dos factores no reportados hasta ahora. Todos estos factores deben ser considerados al momento de la sustitución vitamínica y en la evaluación de la efectividad de la misma.(AU)

Background: 25 (OH) vitamin D deficiency is a prevailing alteration in patients with chronic kidney disease (CKD); however, in our environment, it is not routinely measured and, therefore, vitamin replacement is unusual. Our purpose was assessing the prevalence of and the factors related to 25 (OH) vitamin D deficiency in patientswith CKD in hemodialysis (HD), especially the relation to function and muscle mass. Methods: We conducted a prospective, multicenter study in adult patients on chronic HD who were not receiving any vitamin D derivative. Blood levels of 25 (OH) D, Hemoglobin, CRP, Albumin, Ca,P, ALP and PTHi were measured. The handgrip strength was measured with a dynamometer and the sitting-rising test was carried out. A bioimpedance analysis (BCM; Fresenius Medical Care) was conducted in the patients who had no contraindications. Results: 138 patients were included. The levels of 25 (OH) vitamin D were 20.43±10.5 ng/ml; the insufficiency/deficiency had 87% prevalence (and 37% prevalence with less than 15 ng/ml). Vitamin D concentrations/ deficiency showed a significant correlation with/ relation to age, diabetes, hemoglobin and albumin levels, muscle strength and mass, and functional class (p<0.05). Conclusion: High prevalence of hypovitaminosis D in patients on hemodialysis, particularly in the elderly and in patients with diabetes. This should be related to undernutrition, anemia, the functional class and the muscle strength/mass of patients, the latter two being unreported factors until now. All these factors should be considered when vitamin replacement is conducted and when its effectiveness is assessed.(AU)

Understanding the mechanisms of proteinuria: therapeutic implications.

A large body of evidence indicates that proteinuria is a strong predictor of morbidity, a cause of inflammation, oxidative stress and progression of chronic kidney disease, and development of cardiovascular disease. The processes that lead to proteinuria are complex and involve factors such as glomerular hemodynamic, tubular absorption, and diffusion gradients. Alterations in various different molecular pathways and interactions may lead to the identical clinical end points of proteinuria and chronic kidney disease. Glomerular diseases include a wide range of immune and nonimmune insults that may target and thus damage some components of the glomerular filtration barrier. In many of these conditions, the renal visceral epithelial cell (podocyte) responds to injury along defined pathways, which may explain the resultant clinical and histological changes. The recent discovery of the molecular components of the slit diaphragm, specialized structure of podocyte-podocyte interaction, has been a major breakthrough in understanding the crucial role of the epithelial layer of the glomerular barrier and the pathogenesis of proteinuria. This paper provides an overview and update on the structure and function of the glomerular filtration barrier and the pathogenesis of proteinuria, highlighting the role of the podocyte in this setting. In addition, current antiproteinuric therapeutic approaches are briefly commented.

[Measuring Kt by ionic dialysance is a useful tool for assessing dialysis dose in critical patients]. / La determinación del Kt por dialisancia iónica es una herramienta útil para la evaluación de la dosis de diálisis en pacientes críticos.

AIM: To evaluate the Kt assessed through ionic dializance (KtOCM) in UCI patients undergoing renal replacement therapy for acute kidney injury, comparing the results with those obtained through the urea removal rate method determined by dialyzate collection (Kturea). MATERIAL AND METHODS: 18 adult UCI staying individuals suffering from renal replacement therapy requiring oliguric acute kidney injury were included in this study. RRT consisted in intermittent or extended hemodialysis performed through a Fresenius 4008E dialysis machine equipped with an on-line clearance monitor (OCM Fresenius). The KtOCM results were provided automatically. The Spearman correlation test was used to assess the relationship between the two exploratory methods and the Student s t test to compare the results obtained by the KtOCM and the Kturea. RESULTS: 35 treatments were analyzed. There were not statistically significant differences between the results form the KtOCM and the Kturea (34.9 +/- 10.69 vs 32.78 +/- 11.31, p = NS). A remarkable association was find between both methods (r = 0.87; 95CI, 0.76-0.94; p < 0.001). CONCLUSIONS: The assessment of Kt through ionic dialyzance is a simple method to estimate the dose of dialysis in critically ill patients and is and useful tool to monitor and adjust the RRT in real time according to a target dose.

La determinación del Kt por dialisancia iónica es una herramienta útil para la evaluación de la dosisde diálisis en pacientes críticos / Measuring Kt by ionic dialysance is a useful tool for assessing dialysis dose in critical patients

Objetivo: Evaluar la determinación de Kt (KtOCM) por dialisancia iónica en los pacientes sometidos a terapia de reemplazo renal (TRR) por insuficiencia renal aguda (IRA) atendidos en una unidad de cuidados intensivos (UCI), comparándola con el Kt obtenido mediante el cálculo del índice de remoción de urea obtenido por recogida del dializado (Kturea). Materiales y métodos: Se incluyeron 18 pacientes adultos, con IRA oligúrica ingresados en la UCI, con requerimiento de TRR, tratados con hemodiálisis intermitente y/o diálisis extendida. Las TRR fueron realizadas con equipos Fresenius 4008E equipados con un monitor de aclaramiento «on-line» (OCM Fresenius). La determinación de KtOCM fue realizada automáticamente por el monitor. Se efectuaron la correlación y la comparación entre KtOCM y Kturea utilizando el análisis de correlación de Spearman y el test de la t, respectivamente. Resultados: Sobre 35 tratamientos efectuados, la media de KtOCM no fue estadísticamente diferente de la del Kturea (34,9 ± 10,69 frente a 32,78 ± 11,31; NS). Se obtuvo una importante correlación y una relación lineal significativa entre los dos métodos (r = 0,87; p <0,001; intervalo de confianza [IC] 95%, 0,76-0,94%). Conclusiones: La determinación del Kt por dialisancia iónica es un método simple para estimar la dosis de diálisis en pacientes críticos y es una herramienta útil para monitorizar y ajustar las TRR en tiempo real de acuerdo con una dosis objetivo (AU)

Aim: To evaluate the Kt assessed through ionic dializance (KtOCM) in UCI patients undergoing renal replacement therapy for acute kidney injury, comparing the results with those obtained through the urea removal rate method determined by dialyzate collection (Kturea). Material and methods: 18 adult UCI staying individuals suffering from renal replacement therapy requiring oliguric acute kidney injury were included in this study. RRT consisted in intermitent or extended hemodialysis performed through a Fresenius 4008E dialysis machine equiped with an on-line clearance monitor (OCM Fresenius). The KtOCM results were provided automatically. The Spearman correlation test was used to assess the relationship between the two exploratory methods and the Student´s t test to compare the results obtained by the KtOCM and the Kturea. Results: 35 treatments were analyzed. There were not statistically significant differences between the results form the KtOCM and the Kturea (34.9 ± 10.69 vs 32.78 ± 11.31, p = NS). A remarkable association was find between both methods (r = 0.87; 95CI, 0.76-0.94; p <0.001). Conclusions: The assessment of Kt through ionic dialyzance is a simple method to estimate the dose of dialysis in critically ill patients and is and useful tool to monitor and adjust the RRT in real time according to a target dose (AU)