[Dispositional optimism in patients on chronic haemodialysis and its possible influence on their clinical course]. / Optimismo disposicional en pacientes en hemodiálisis y su influencia en el curso de la enfermedad.

INTRODUCTION: Dispositional optimism is a personality trait significantly associated with the use of positive adaptive coping strategies as well as with perceived psychological and physical well-being, and it appears to be an important predictor of illness. OBJECTIVES: To analyse if dispositional optimism is significantly associated with the number of hospital admissions of our chronic haemodialysis patients, as well as its relationship with perceived state of health. METHODS: We studied 239 patients on chronic haemodialysis. Patients were categorised into two groups according to the variables: hospital admissions/no. of admissions in the last year and dispositional optimism (DO). We used the following variables and questionnaires: 1) Dispositional O/P using the Spanish-validated cross-cultural adaptation of the revised version of the Life Orientation Test (LOT-R) (Scheier, 1994): higher scores mean a higher degree of dispositional optimism. 2) Health-related quality of life (HRQoL) using the different aspects of the COOP/WONCA (CW) charts and its total score. In this case higher scores mean lower HRQoL. 3) Modified Charlson Comorbidity Index (mCCI). 4) Age, gender, and time on dialysis. RESULTS: Mean age was 64.8 ± 14.3 years; median time on dialysis 2.9 years (range: 0-32); and median LOT-R 21 (range 6-30). Patients considered DO had a lower risk of hospital admissions than pessimists (DP) (OR: 0.55; IC 95%: 0.32-0.94; P<.05). PD Patients that were admitted in the last year showed a significantly lower score on LOT-R (they were more pessimistic) than those that had no hospital admissions (19.4 ± 5.7 vs 22.3 ± 4.6; P=.001). We found no significant differences between admitted and not admitted patients in age, gender, time on haemodialysis and comorbidity. Admitted patients showed worse HRQoL (higher scores in total CW) than those that were not (Total CW: 22.37 vs 19.42; P<.001). PD patients had significantly higher scores than OD patients in all COOP-WONCA aspects except in aspect 1 (physical fitness) and 5 (change in health). CONCLUSIONS: Pessimistic personality trait is significantly associated with hospital admissions in chronic haemodialysis patients, regardless of age, gender and comorbidity. Optimistic patients perceived a better state of health.

Optimismo disposicional en pacientes en hemodiálisis y su influencia en el curso de la enfermedad / Dispositional optimism in patients on chronic haemodialysis and its possible influence on their clinical course

Introducción: El optimismo disposicional es un rasgo de personalidad que se relaciona significativamente con el empleo de estrategias positivas de afrontamiento y con el grado de bienestar psicológico y físico percibidos por el paciente, y que parece ser, también, un importante predictor de enfermedad. Objetivo: Analizar si el optimismo disposicional guarda relación con el número de ingresos hospitalarios que han presentado en el último año los enfermos renales crónicos estadio Vd en nuestros centros. Material y métodos: Se estudiaron 239 pacientes en hemodiálisis que fueron categorizados en dos grupos respecto a las variables ingresos /no ingresos hospitalarios en el último año y optimismo/pesimismo disposicional. Se utilizaron los siguientes cuestionarios y variables: 1) O/P disposicional mediante el LOT–R de Scheier (1994) en su versión española: a mayor puntuación, mayor grado de optimismo disposicional. 2) Calidad de vida relacionada con la salud (CVRS) mediante las láminas COOP/WONCA: a mayor puntuación peor calidad de vida referida. 3) Índice de comorbilidad de Charlson (ICM). 4) Edad, tiempo en HD y sexo. Resultados: La edad media fue de 64,8 ± 14,3 años; la mediana de tiempo en hemodiálisis de 2,9 años (rango: 0–32), y la mediana en el LOT–R 21 (rango: 6–30). Los pacientes optimistas (OD) presentaban un menor riesgo de ser ingresados que los pesimistas (PD) (OR: 0,55; IC 95%: 0,32–0,94; p <0,05) y los pacientes con ingresos hospitalarios (..) (AU)

Introduction: Dispositional optimism is a personality trait significantly associated with the use of positive adaptive coping strategies as well as with perceived psychological and physical well–being, and it appears to be an important predictor of illness. Objectives: To analyse if dispositional optimism is significantly associated with the number of hospital admissions of our chronic haemodialysis patients, as well as its relationship with perceived state of health. Methods: We studied 239 patients on chronic haemodialysis. Patients were categorised into two groups according to the variables: hospital admissions/no. of admissions in the last year and dispositional optimism (DO). We used the following variables and questionnaires: 1) Dispositional O/P using the Spanish–validated cross–cultural adaptation of the revised version of the Life Orientation Test (LOT–R) (Scheier, 1994): higher scores mean a higher degree of dispositional optimism. 2) Health–related quality of life (HRQoL) using the different aspects of the COOP/WONCA (CW) charts and its total score. In this case higher scores mean lower HRQoL. 3) Modified Charlson Comorbidity Index (mCCI). 4) Age, gender, and time on dialysis. Results: Mean age was 64.8±14.3 years; median time on dialysis 2.9 years (range: 0–32); and median LOT–R 21 (range 6–30). Patients considered DO had a lower risk of hospital admissions than pessimists (..) (AU)

Captores del fósforo: preferencias de los pacientes en hemodiálisis y su repercusión sobre el cumplimiento del tratamiento y el control del fósforo / Phosphorus binders: preferences of patients on haemodialysis and its impact on treatment compliance and phosphorus control

Introducción: En la actualidad disponemos de un amplio abanico de captores del fósforo (CF), pero sabemos poco acerca de las preferencias de los pacientes y de su repercusión sobre el cumplimiento del tratamiento y el control de los niveles de fósforo. Objetivo: Estudiar las preferencias y creencias de los pacientes respecto a los CF, y su influencia sobre el cumplimiento del tratamiento y el control de los niveles de fósforo. Pacientes y métodos: Estudio observacional transversal. Se incluyeron 121 pacientes que respondieron un cuestionario genérico de cumplimiento del tratamiento (SMAQ) y a un cuestionario específico sobre cumplimiento del tratamiento con CF, tipo de CF preferido y razones de dicha preferencia. Todos los pacientes entrevistados habían probado dos o tres CF. Las consecuencias de la falta de cumplimiento del tratamiento con CF se estimaron indirectamente analizando los valores promedio de fósforo sérico. Resultados: El 40% de los pacientes era incumplidor según el cuestionario SMAQ; se encontró una asociación estadísticamente significativa entre la falta de cumplimiento en general y no alcanzar el objetivo de fósforo sérico promedio <5,5 mg/dl (OR = 4,8; IC 95%, 1,0-6,6; p = 0,02). El 21,4% de los pacientes reconocía un incumplimiento específico para los CF; estos pacientes presentaban una mayor probabilidad de tener cifras medias de fósforo >5,5 mg/dl (OR = 4,7; IC 95%, 1,1-6,5; p = 0,03). Un 43,8% de los pacientes no refirió tener preferencias entre los diferentes tipos de CF; para el resto de pacientes, el CF preferido fue Royen(R), seguido de Fosrenol(R), Renagel(R) y Pepsamar(R). Las razones expresadas para el desagrado con el Renagel® fueron las siguientes: incomodidad en la toma por su gran tamaño (28,8%), necesidad de tomar muchos comprimidos y gran consumo de agua (57,7%) e intolerancia gástrica (13,3%). En el caso del Fosrenol(R) incómodo de tomar (72,7%) e intolerancia gástrica (27,2%); para el Pepsamar(R): mal sabor (54,5%) e intolerancia gástrica (45,4%). Sólo al 9,4% no le gustaba el Royen(R). Al analizar los conocimientos de los pacientes respecto a la utilidad de los CF, un 42% sabía que servían para controlar el fósforo; un 52% no lo sabía y un 6% tenía ideas equivocadas. En cuanto a su importancia: un 47% no conocía por qué son importantes; un 2% tenía ideas erróneas; un 9% creía que era beneficioso para la salud; un 11% creía que era bueno «porque lo dice el medico»; un 26% porque controla el fósforo y un 5% lo relacionaba con el hueso. Ningún paciente relacionó los CF con la enfermedad cardiovascular. Un 24,4% no se llevaba los CF cuando salía fuera de casa o estaba con los amigos; eran pacientes más jóvenes a quienes se les habían prescrito un mayor número de comprimidos de CF y que presentaban un mayor riesgo de no cumplir el objetivo de fósforo (OR = 10,5; IC 95%, -1,8 a -16,4; p <0,001). El porcentaje de pacientes a quienes no les gustaba el CF prescrito fue del 54,5%; dichos pacientes presentaban un mayor riesgo de tener niveles séricos de fósforo >5,5 mg/dl (OR = 13.3; IC 95%, 1,1-1,5; p = 0,0001). Paradójicamente, los pacientes que no cumplían con el tratamiento demostraban un mejor conocimiento de su uso (OR = 17,3; IC 95%, 2,2-10,1; p <0.0001) e importancia (OR = 10,4; IC 95%, 1,5-6,6; p = 0,001). Conclusión: Los pacientes a los que se les habían prescrito CF que no les gustaban tenían un peor control de los niveles de fósforo sérico y se les habían recomendado dosis más altas de los fármacos. El conocimiento de las preferencias de los pacientes acerca de las medicaciones que se les prescriben puede ser un factor esencial para conseguir un mayor cumplimiento del tratamiento y, por ende, lograr mejores resultados en la consecución de los objetivos terapéuticos (AU)

Introduction: Non-adherence to phosphate binding (PB) medication may play a role in the difficulty in achieving the targets for phosphorus. We have a wide spectrum of PB but preferences of patients are poorly understood. Objective: to study the patients’ preferences and beliefs regarding PB and their influence on adherence and serum phosphate. Methods: A cross-sectional cohort study was performed. A total of 121 hemodialysis patients answered a specific questionnaire in which they were questioned about adherence, the type of PB they preferred and the reasons for their choice. All patients questioned tasted two or three PB. The consequence of non-adherence to PB was estimated indirectly by determination of serum phosphorus. Results: Specific noncompliance with PB medication was recognized by 21.4% of patients. Patients non-adherent specifically to PB were more likely to have P levels >5.5 mg/dl (χ2: 4.7; 95% CI 1.07-6.5; p = 0.03). Paradoxically, non-adherent patients showed greater knowledge of the use (χ2: 17.3; 95% CI -2.2-10.1; p <0.0001) and importance of the drug (χ2: 10.4; 95% CI -1.5-6.6; p = 0.001). The percentage of patients prescribed binders that they did not like was 54.5%. Patients who were taking PB that they did not like had a greater risk of having P levels >5.5 mg/dl) (χ2: 13.3; 95% CI -1.1-1.5; p = 0.0001). Calcium acetate was the prefered PB in 47.1% of patients, lanthanum carbonate in 40%, sevelamer in 20.6% and aluminum hydroxide in 19.4%. The reasons claimed by patients for their negative ratings of PB were the type of dosage form, the taste, the number of tablets and gastric intolerance. Gastric intolerance and bad taste were more frequent in aluminum hydroxide patients (19.4% and 22.2%, respectively). Sevelamer received complaints about its dosage form because the tablets were too large and a large number of tablets were required (27.2%). 17.7% of patient who were taking lanthanum carbonate did not like the chewable tablets. Conclusion: patients who were taking binders that they did not like had worse serum P levels and were prescribed higher doses of binders. Knowing patients' preferences about the drugs prescribed may be a key factor in achieving adequate adherence to treatment (AU)

Spontaneous retroperitoneal hemorrhage in dialysis: a presentation of 5 cases and review of the literature.

BACKGROUND: Spontaneous retroperitoneal hemorrhage (SRH) is a rare but potentially fatal entity. Despite published case reports of SRH in dialysis, little systematic information is available. METHODS: Report of 5 cases and review of MEDLINE database from 1971 until 2008. RESULTS: Incidence of SRH in our unit was 0.86 cases per 100 patients; annual incidence rate 8/10,000 patients. We identified 34 publications, comprising 55 cases. The existing cases and the 5 reported were analyzed: 74.5 % male, average age 53.3 years (range 27-78), average time on dialysis 7.1 years (range 3 weeks-27.5 years), 95% on hemodialysis and 5% on peritoneal dialysis. There was significant heterogeneity in clinical presentation. The kidney was the most commonly reported origin (87.8%), and acquired cystic kidney disease (ACKD) was the most frequent underlying cause. 91.8% received some kind of anticoagulation. Treatment was conservative, included angioembolization or surgery in 33.3%, 17.6% and 49% of the cases respectively. Mortality rate was 18.3%. CONCLUSIONS: More than 85% of SRH in dialysis had a renal cause, ACKD being predominant. The complication occurs mainly in the HD modality, possibly in relation to anticoagulation. There is no evidence that screening of ACKD is of benefit predicting SRH. Therefore, awareness of ACKD as a manifestation of ESRD patients and its risk of bleeding is necessary. Because of the summation of risk factors that appears in the population on dialysis, SRH should be considered in the differential diagnosis of unexplained pain before drop in blood pressure or hematocrit occurs.

[Phosphorus binders: preferences of patients on haemodialysis and its impact on treatment compliance and phosphorus control]. / Captores del fósforo: preferencias de los pacientes en hemodiálisis y su repercusión sobre el cumplimiento del tratamiento y el control del fósforo.

INTRODUCTION: Non-adherence to phosphate binding (PB) medication may play a role in the difficulty in achieving the targets for phosphorus. We have a wide armamentarium of PB but preferences of patients are poorly understood. OBJECTIVE: to study the patients' preferences and beliefs regarding PB and their influence on adherence and serum phosphate. METHODS: A cross-sectional cohort study was performed. A total of 121 hemodialysis patients answered a specific questionnaire in which they were questioned about adherence, the type of PB they preferred and the reasons for their choice. All patients questioned tasted two or three PB. The consequence of non-adherence to PB was estimated indirectly by determination of serum phosphorus. RESULTS: Specific noncompliance with PB medication was recognized by 21.4% of patients. Patients non-adherent specifically to PB were more likely to have P levels >5.5 mg/dl (χ(2): 4.7; 95% CI 1.07-6.5; p = 0.03). Paradoxically, patients non-adherent showed greater knowledge of the use (χ(2): 17.3; 95% CI -2.2-10.1; p <0.0001) and importance of the drug (χ(2): 10.4; 95% CI -1.5-6.6; p = 0.001). The percentage of patients prescribed binders they did not like was 54.5%. Patients who were taking PB they did not like had a greater risk of having P levels >5.5 mg/dl) (χ(2): 13.3; 95% CI -1.1-1.5; p = 0.0001). Calcium acetate was the preferred PB in 47.1% of patients, lanthanum carbonate in 40%, sevelamer in 20.6% and aluminum hydroxide in 19.4%. The reasons claimed by patients for their negative ratings of PB were the type of dosage form, the taste, the number of tablets and gastric intolerance. Gastric intolerance and bad taste were more frequent in aluminum hydroxide patients (19.4% and 22.2%, respectively). Sevelamer received complaints about its dosage form because the tablets were too large and a large number of tablets were required (27.2%). 17.7% of patient who were taking lanthanum carbonate did not like the chewable tablets. CONCLUSION: patients who were taking binders that they did not like had worse serum P levels and were prescribed higher doses of binders. Knowing patients' preferences about the drugs prescribed may be a key factor in achieving adequate adherence to treatment.

A case of endocarditis of difficult diagnosis in dialysis: could "pest" friends be involved?

We report a case of A. xylosoxidans endocarditis of larvate clinical presentation in a central venous catheter-dependent hemodialysis patient of difficult diagnosis and poor evolution despite a high index of suspicion and consequent assessment. A 50-year-old man on hemodialysis presented with inflammatory-malnutrition parameters during the months prior to diagnosis of endocarditis, whilst he was otherwise asymptomatic. No vegetations were detectable on his cardiac valves at repeated echocardiography until third transesophageal echocardiography was performed, and confirmed intraoperatively. On the occasion of positive peripheral blood culture for Alcaligenes (Achromobacter) xylosoxidans, the etiological diagnosis was retrospectively explained given his history of animal exposure - hunting rabbits using his pet ferrets. This bacterium is an emergent and resistant organism, mostly related to nosocomial infections and environmental water sources. Reservoirs include the microflora of the nasal cavity of rabbits and the dentogingival sulcus of ferrets. We presume that A. xylosoxidans endocarditis was transmitted from the patient's pets. It highlights the importance of early recognition of an inflammatory status and investigation of the underlying cause. Additionally, the causative bacterium emphasizes the importance of registering exposure to animals in CVC-dependent patients as well as the need for their awareness of hygienic precautions and the infectious risk associated to catheters.

Nephrotic syndrome as paraneoplastic manifestation of a primary pulmonary lymphoepithelioma-like carcinoma.

We present a case of nephrotic syndrome secondary to a membranous glomerulonephritis (MG), in a nonsmoking female with a solitary pulmonary nodule, which did not show growth during 2 years of followup. A biopsy by videothoracoscopy showed a granulomatous non-neoplastic process with giant multinucleated cells. The appearance of a nephrotic syndrome and its interpretation as paraneoplastic revealed the existence of a primary pulmonary lymphoepithelioma-like carcinoma (LELC), a very rare pulmonary tumor. After resection of tumor there was a complete recovery from the nephrotic syndrome. This case highlights how the investigation of paraneoplastic syndromes can help in the early diagnosis of some malignancies.

[Operation to remove tunnelled venous catheters in a dialysis unit. Is it possible to reverse the trend in their growing use?]. / Operación retirada de catéteres venosos tunelizados en una unidad de diálisis. ¿Es posible cambiar la tendencia en el uso creciente de éstos?

INTRODUCTION: Introduction In an attempt to reduce unnecessary central venous catheters (CVC) dependence in prevalent population, a "CVC removal" programme was initiated in our unit. The objective was to diminish the number of CVC and to analyze the causes of their insertion and maintenance. On 09/01/07, 38 out of 173 prevalent patients on hemodialysis. Methods were CVC dependant (21.9%): 16 incident patients (42,1%) and 22 (57,8%) prevalent patients. All of them were re-evaluated for permanent vascular access utilization, included those previously rejected for surgery. Physical, psychical and vascular aspects regarding each patient were taken into consideration. The following variables were age, Body mass index, time on hemodialysis, Charlson analyzed comorbidity index, DM or vascular comorbidities and number of vascular accesses created prior to CVC placement. In those patients in whom AVF creation was feasible, the following were registered after 18 months of 1.Primary failure rate. 2. Related complications. 3. up follow Percentage of usable AVF or AVG. 4. Percentage of removed CVC. 5. Mortality and hospitalization. The decision of no realization of a new vascular access and? Results maintenance of TVC was performed in 21 patients (55.2%). In 9 of them was decision of the nephrologists and the family. In 11 patients was decision of vascular surgeon due to vascular bed exhaustion. A permanent VA was achieved in 17 patients (44.7%), 50% of them was incident patients and 45% prevalent patients. The primary failure rate was 0%. The TVC was withdrawn in 11/17 (64.7%). Only 4 patients remain without TVC after 18 months of follow-up: 5 patients died (4 with a AVF functioning and 1 VA closure due to steal syndrome) and in 8 patients was mandatory to reintroduce the TVC again. Immediate complications after the surgery were: 1 severe haematoma, 2 infections and 2 severe sequestrations. 3 patients required hospital admission following complications directly related to VA. Mean time of free of TVC was 5.2 months (range: 0.7- 14.3 months). The mortality was 29,4% (5/17) in the group of patients with a new VA and 9,5% (2/21) in the other group(RR 3,19; IC 95%: 0,68-13,98; p: 0,11). No significant differences were observed between patients who transitioned to a permanent vascular access and those who remained TVC dependant in regards to age, gender, BMI, time on dialysis, DM, comorbidity or number of previous VA, Transition from CVC use to hospitalizations or mortality. Conclusions permanent vascular access is possible in prevalent patients in dialysis. Improvement was achieved by a modest amount, and after a prolonged process with gravel complications, some of which proved severe. Need for CVC dependence is confirmed in a high percentage of prevalent patients on dialysis. Comorbidity might have influenced the results. The quality standard should be adequate to reality of current population on hemodialysis.

Operation to remove tunnelled venous catheters in a dialysis unit. Is it possible to reverse the trend in their growing use?

Introduction: In an attempt to reduce unnecessary tunnelled venous catheters (TVC) dependence in a prevalent population, a "TVC removal" programme was initiated in our unit. The objective was to diminish the number of TVC and to analyze the causes of their insertion and continuation. Methods: On 09/01/07, 38 out of 173 prevalent patients on haemodialysis were TVC dependant (21.9%), 16 incident patients (42.1%) and 22 (57.8%) prevalent patients. All of them were re-evaluated for placement of permanent vascular access including those previously rejected for surgery. Physical, psychic and vascular aspects of each patient were taken into consideration. The following variables were collected; age, body mass index (BMI), time on haemodialysis, Charlson Comorbidity Index, DM and vascular comorbidities and number of vascular accesses created prior to TVC placement. In those patients in whom AVF creation was feasible, after 18 months of follow-up the following parameters were evaluated: 1.Primary failure rate. 2. Surgical complications. 3. Percentage of usable AVF or AVG. 4. Percentage of removed TVC. 5. Mortality and hospitalization. Results: The decision not to carry out a permanent vascular access and to maintain TVC was made in 21 patients (55.2%). For 9 of them this was decided by the nephrologists and the family and for the remaining 11 patients, by the vascular surgeon after all vascular options were exhausted. A permanent VA was achieved in 17 patients (44.7%), 50% of them were incident patients and 45% prevalent patients. The primary failure rate was 0%. The TVC was withdrawn in 11 patients out of 17 (64.7%). Only 4 patients remained without TVC after 18 months of follow-up: 5 patients died (4 with AVF functioning and 1 underwent AVF ligation due to steal syndrome) and for 8 patients it was necessary to reintroduce the TVC again. Immediate complications after surgery were: 1 tense haematoma, complicated with skin necrosis, 2 infections and 2 steel syndromes with one requiring fistula ligation. Three patients required hospital admission following complications directly related to VA. The average time free from TVC was 5.2 months (range: 0.7- 14.3 months). The mortality rate was 29.4% (5/17) in the group of patients with a new VA and 9.5% (2/21) in the other group (RR 3.19; IC 95%: 0.68-13.98; p: 0.11). No significant differences were observed between patients who transitioned to a permanent vascular access and those who remained TVC in age, gender, BMI, time on dialysis, DM, comorbidity or number of previous VA attempts, hospitalizations or mortality. Conclusions: Permanent vascular access was possible in prevalent dialysis patients but this was achieved in a modest number of patients after a prolonged period and not without complications, some of which severe. The need for TVC dependence was confirmed in a high percentage of prevalent patients on dialysis. Comorbidity might have influenced the results. The quality standard should be adapted to the actual population on haemodialysis (AU)

Introducción: En base a la premisa de que los pacientes portadores de catéteres tienen un peor pronóstico que los portadores de FAV, las guías de acceso vascular (AV) plantean unos objetivos ambiciosos (< 10% de Catéteres venosos tunelizados (CVT). En un intento de cambiar esta tendencia creciente en el uso de CVT iniciamos la “operación retirada de CVT”. Métodos: Al inicio del estudio 38 de los 173 pacientes dializados en la unidad lo hacían mediante un CVT (21.9%): 16 pacientes (42,1%) incidentes y 22 (57,8%) prevalentes. Se evaluaron aspectos físicos, psíquicos y vasculares de cada paciente portador de CVT. Se recogió edad, Indice de masa corporal, tiempo en HD, índice de comorbilidad de charlson (ICM), presencia de cardiopatía y diabetes mellitas, y número de AV previos. Tras 18 meses de seguimiento se evaluó la tasa de fallo primario, las complicaciones de la cirugía, el porcentaje de AV puncionables, el porcentaje de CVT retirados, la mortalidad y los ingresos hospitalarios Resultados: En 21 pacientes (55,2%) la decisión fue la no realización de un nuevo AV y el mantenimiento del CVT. En 9 pacientes por decisión del nefrólogo y familiares y en 11 por decisión del cirujano ante el agotamiento del lecho vascular. En 17 pacientes (44,7%) se realizó una FAV(50% incidentes y 45% prevalentes). La tasa de fallo primario fue del 0%. Se retiró el CVT al 64,7% (11/17). 18 meses después solo 4 pacientes permanecían sin CVT: 5 pacientes habían fallecido (4 con FAV funcionante y 1 con CVT tras ligadura de FAV por robo severo) y en 8 hubo que reintroducir de nuevo el CVT. Las complicaciones inmediatas de la cirugía vascular fueron: Un hematoma a tensión con necrosis de piel secundaria que requirió ingreso; dos síndrome de robo, uno que se solucionó con ejercicio y otro que precisó cierre quirúrgico; 2 infecciones, una en relación con hiperaflujo y trombosis de cava superior que precisó cierre quirúrgico. El tiempo medio libre de CVT fue de 5,2 meses (rango: 0,7- 14,3 meses).La mortalidad fue 29,4% (5/17) en el grupo en el que se actúo y 9,5% (2/21) en el otro grupo (RR 3,19; IC al 95%: 0,68-13,98; p: 0,11). Los pacientes a los que se realizó una FAV no mostraron diferencias significativas con el grupo al que no se le realizó una FAV en cuanto a edad, obesidad, Tiempo en HD, ICM, DM, sexo, nº AV, ingresos ni mortalidad. Conclusiones: Es posible mejorar la tendencia en el uso de catéteres permanentes, en un grado discreto y a lo largo de un proceso prolongado y no exento de complicaciones, algunas de ellas graves. En un porcentaje elevado de pacientes se confirma la imposibilidad de retirar el CVT. La patología asociada puede haber influido en los resultados. Los estándares de calidad deberían adecuarse a la realidad de la población que estamos tratando (AU)

Allergy to latex and repeated vascular access thrombosis in haemodialysis

No disponible

No disponible

[Superficialization of autologous vascular access: an alternative to the use of vascular prostheses and permanent catheters]. / Superficialización de accesos venosos autólogos: una alternativa al uso de prótesis vasculares y catéteres permanentes.

INTRODUCTION: We review our experience with autologous veins Superficialization (Spf), to establish the actual possibilities of this kind of vascular access in our area. METHODS: Between January/2001 and January/2008, Spf was performed in 48 patients. Mean follow-up time was 18.8 (0.2-75.7) months. Primary failure rate was recorded; primary and secondary survival were estimated using the Kaplan-Meier method; and its possible associations with several variables were analyzed. RESULTS: the maturity rate was 97.9%; and the rate of primary failure 2.0%. After Spf, mean time of primary and secondary survival were 65 months and 67 months, respectively. Four vascular thromboses were observed. None of the presurgery variables analyzed (age; sex; diabetes mellitus; ipsilateral central catheter; the number of previous VA attempts; and obesity) were significantly associated with maturity rate, primary or secondary survivals. CONCLUSION: the Spf can be a good option alternative to the use of prosthetic grafts or permanent central vascular catheters.

Superficialization of autologous vascular access: an alternative to the use of vascular prostheses and permanent catheters

Introduction: We review our experience with autologous veins Superficialization (Spf), to establish the actual possibilities of this kind of vascular access in our area. Methods: Between January/2001 and January/2008, Spf was performed in 48 patients. Mean follow-up time was 18.8(0.2-75.7) months. Primary failure rate was recorded; primary and secondary survival were estimated using the Kaplan–Meier method; and its possible associations with several variables were analyzed. Results: the maturity rate was 97.9%; and the rate of primary failure 2.0%. After Spf, mean time of primary and secondary survival were 65months and 67 months, respectively. Four vascular thromboses were observed. None of the presurgery variables analyzed (age; sex; diabetes mellitus; ipsilateral central catheter; the number of previous VA attempts; and obesity) were significantly associated with maturity rate, primary or secondary survivals. Conclusion: the Spf can be a good option alternative to the use of prosthetic grafts or permanent central vascular catheters (AU)

Introducción: se analizan los resultados de la Superficialización (Spf ) de venas autólogas para establecer sus posibilidades reales en nuestro medio. Métodos: la Spf se realizó en 48 pacientes. El tiempo medio de seguimiento fue de 18,8 (0,2-75,7) meses . Se calculó la tasa de fallo primario, la Supervivenc ia (SV) primaria y la SV secundaria, y se estudiaron las posibles asociaciones con distintas variables . Resultados : la tasa de maduración fue del 97,9%, y la tasa de fallo primario, del 2,0%. El tiempo medio de SV primaria t ras la superficialización fue de 65,5 ± 4,8 meses, y el de SV secundaria, de 66,7 ± 4,3 meses . Ninguna de las variables preintervención estudiadas (edad, sexo, Diabetes Mel l i tus [DM] , presenc ia de catéter ipsilateral , número de Acceso Vascular (AV) u obesidad) tuvieron un impacto sobre las mismas. Se detectaron cuatro trombosis. Conclusión: la Spf de venas autólogas puede ser un método alternativo aceptable a la colocación de una prótesis vascular o un catéter (AU)

¿Es el cinacalcet un tratamiento coste-efectivo en el hiperparatiroidismo secundario severo en pacientes en hemodiálisis? / No disponible

Introducción: Un estudio previo mostró que la adición de cinacalcet a la vitamina D conseguía una mejor respuesta del Hiperparatiroidismo secundario (HPTS) en pacientes en hemodiálisis. El objetivo del presente estudio fue conocer el coste adicional que supone la adición de cinacalcet al tratamiento estándar en pacientes con HPTS severo teniendo en cuenta los objetivos terapéuticos obtenidos. Métodos: Estudio prospectivo durante 12 meses en 23 pacientes con HPTS severo, en los que no se podía mantener un tratamiento continuado con vitamina D por presentar hipercalcemia y/o hiperfosforemia. Se analizaron 2 regímenes de tratamiento: tratamiento estándar (m 0) y tratamiento estándar asociado a cinacalcet (m 12). Se analizaron las siguientes variables: iPTH, calcio, fósforo, producto CaxP, dosis de vitamina D, dosis de captores del fósforo y% de cumplimiento de indicadores. Los resultados del análisis se expresan en términos de coste-incremental y coste consecuencia por paciente que consigue el objetivo terapéutico en base a 5 marcadores: PTH < 800 pg/ml, PTH entre 150 y 300 pg/ml, Calcio < 9,5 mg/dl, Fósforo < 5,5mg/dl y Ca x P < 55.Resultados: A los 12 meses de tratamiento con cinacalcet, la proporción de pacientes que alcanzaron los 4 objetivos simultáneamente pasó de 0% a 52,1%. Cinacalcet permitió un ahorro en medicación concomitante (sevelamer, vitamina D e hidróxido de aluminio), que minimizó su coste adicional, suponiendo un incremento global de 149 e/mes. En términos de costes y consecuencias, cinacalcet conseguía una reducción del porcentaje de pacientes con PTH > 800 pg/ml a la mitad de coste que el tratamiento estándar. (651,35 e vs 1.363,68 e). La falta de pacientes con PTH entre 150 y 300 pg/ml en el m0 (sin cinacalcet) no permitió la comparación entre el momento basal y el final del estudio. Cinacalcet permitía una consecución de los objetivos de calcio, fósforo y producto calcio-fósforo en su conjunto más coste-efectiva (2.164,2 e vs 2.684,8 e). Conclusiones: Los pacientes tratados con cinacalcet presentan un coste por éxito terapéutico menor que los pacientes sin cinacalcet (pre-tratamiento), a pesar del mayor coste de adquisición de cinacalcet. La capacidad de cinacalcet de reducir la secreción de PTH, junto a la reducción en el Ca, P, y producto Ca x P, proporciona una alternativa al tratamiento tradicional y debe ser tenida en cuenta en el HPTS sever (AU)

Background: A previous study using cinacalcet, as compared to vitamin D alone, showed a better reduction response of PTH levels and a significant diminution of secondary effects. The objective of present study was to evaluate the additional cost of adding cinacalcet to the standard treatment of patients with severe secondary hyperparathyroidism (SHPT) taking into account the treatment goals achieved. Methods: 12 month prospective study of 23 patients with severe SHPT. Two treatment regimens were considered: standard treatment (m 0) and standard treatment plus cinacalcet (m 12). Four consequences of inadequate control of SHPT were registered: parathiroid hormone (PTH), Calcium (Ca), Phosphorus (P) and the Ca x P product serum levels. Treatment effectiveness was measured as percentage of patients who achieved treatment goal according to each indicator: PTH < 800 pg/mL, PTH between 150 and 300 pg/mL, Calcium < 9.5 mg/dL, Phosphorus < 5.5 mg/dL, and Ca x P product < 55. Annual and monthly costs were calculated for both treatment regimens using Spanish 2007 tariffs, and taking into account the dose reduction in some other treatments. Results are presented as incremental costs and cost per patient who achieved treatment goal. Results: At 12 month it was observed a higher percentage of patients who achieved simultaneously the 4 therapeutic goals with respect to basal moment, from 0% to 52.1%. Cinacalcet allowed to save costs in concomitant drugs, achieving a total saving of 149 e per patient and month. At 12 month, Cinacalcet achieved a reduction of percentage of patients with PTH > 800 pgr/mL with half of costs than standard treatment (651.35 e vs 1,363.68 e). It was not possible to calculate the cost for PTH indicator since at the study onset, there was no patient who achieved a level between 150 and 300 pg/mL. Cinacalcet allowed reaching treatment goals in Calcium, Phosphorus and Ca x P product in a more cost-effective way (2,164.2 e vs 2,684.8 e). Conclusions: Although Cinacalcet is expensive, patients treated with Cinacalcet showed a minor cost per patient who achieved treatment goal than patients without Cinacalcet. The ability of cinacalcet to reduce PTH secretion, along with the reductions in the serum Ca, P, and Ca x P product, provides an alternative to the traditional treatment paradigm, and should be a welcomed addition in the management of SHPT (AU)

Cambios en el acceso vascular en una unidad de diálisis en los últimos años: ¿problemas de planificación, cambio de preferencias o cambio demográfico? / No disponible

Introducción: El incremento en el uso de catéteres permanentes (CP) en los pacientes en hemodiálisis, tanto en España como en los países analizados en el Dialysis Outcomes and Practice Patterns Study (DOPSS), es una realidad, pero se desconoce cuales son las razones subyacentes que lo justifican. Métodos: Analizamos los cambios en la distribución de los diversos tipos de acceso vascular en 398 pacientes de nuestra unidad de hemodiálisis, desde enero de 2000 hasta diciembre de 2005, así como las causas que pudieron influir en estos cambios. Al mismo tiempo se estudiaron, de manera retrospectiva, los factores de riesgo asociados al uso de CP en los 95 pacientes que utilizaron ese tipo de acceso vascular entre enero de 1997 y abril de 2006. Resultados: El porcentaje de fístulas arteriovenosas en pacientes prevalentes disminuyó progresivamente a lo largo del periodo estudiado (de 95% a 77,9%); y el uso de CP se incrementó (de 4,2% a 21,5%). El porcentaje de pacientes incidentes que tenía un acceso vascular utilizable (fístula o injerto) al inicio de la diálisis disminuyó (83,4% en 2000; 69,3% en 2005), al tiempo que hubo un aumento significativo en el porcentaje de pacientes que utilizaban CP (de 0 a 23%) (p < 0,0001), y un descenso en el uso de catéteres temporales (de 16% a 7%) (p < 0,01) Coincidentemente, se observó un cambio en las características demográficas de los pacientes: mayor edad (71,3 vs 60,5 años), y mayor porcentaje de pacientes diabéticos (7,1% vs 18,5%) aunque las diferencias no fueron estadísticamente significativas; y menor tiempo en diálisis (93,2 vs 37 meses, p < 0,03). Las causas de colocación de CP variaron en el tiempo: en el primer periodo (hasta 2003) la causa más frecuente fue el agotamiento de otros accesos vasculares, en tanto que en el segundo periodo (de 2003 a 2007) lo fue la presencia de un mal lecho vascular. Conclusiones: A pesar de la política de favorecer la realización de fístulas arteriovenosas en nuestra unidad, nuestros resultados empeoraron, tanto en los pacientes prevalentes como en los incidentes, y ello coincidiendo con un cambio en las características de los pacientes, lo que parece haber influido en el cambio de tendencia observado. Se necesitan nuevos estudios con programas de mejora para evaluar si es posible un cambio de tendencia, a pesar de las peores condiciones de los nuevos pacientes incidentes en diálisis (AU)

Background: Evidence on the reasons for the general and discouraging overutilization of catheters in DOPPS countries is lacking. Methods: We analysed the changes in distribution of the different types of vascular access in all 398 patients ongoing hemodialysis at our unit, from january 2000 until december 2005,as well as patients’ characteristics. Secondly, risk factors associated with the use of permanent catheters were evaluated in all 95patients who used that kind of vascular access from january1997 until april 2006.Results: The percentage of fistulas in prevalent patients diminished from year 2000 until year 2005 (from 95% to 77.9%); concurrently there was an increase in the use of permanent catheters(from 4.2% to 21.5%). The percentage of incident patients having a usable fistula or graft at the beginning of hemodialysis diminished progressively (83.4% in 2000; 69.3% in 2005), and there was a significant increase in the percentage of incident patients using a permanent catheter (from 0 to 23%). Coincidentally ,there was a change in patients characteristics: increasing age (71.3 vs 60.5 years); greater diabetes percentage (7.1% vs18.5%) and less time on dialysis (93.2 vs 37 months; p < 0.03).Causes of permanent catheter insertion varied. (AU)

Management of calcific uremic arteriolopathy (calciphylaxis) with a combination of treatments, including hyperbaric oxygen therapy.

Calcific uremic arteriolopathy (CUA) is a rare but serious complication of end-stage renal disease presenting as painful cutaneous lesions and progressing to non-healing ulcers and gangrene. This syndrome is associated with calcium and phosphorus deposits within small arteries of the skin. The pathognomonic lesion is vascular calcification with intimal arterial hypertrophy and superimposed small-vessel thrombosis. The condition is being increasingly recognized and reported as a contributing factor to death in dialysis patients, with secondary infection and sepsis as the major cause of mortality. No standard treatment has been established for this syndrome. We present the therapeutic approach employed in two patients, which successfully resulted in healing of the lesions, using a combination of measures to control the factors potentially related to development of CUA and hyperbaric oxygen therapy.

[Is Cinacalcet a cost-effective treatment in severe secondary hyperparathyroidism in patients on hemodialysis?]. / Es el cinacalcet un tratamiento coste-efectivo en el hiperparatiroidismo secundario severo en pacientes en hemodiálisis?

BACKGROUND: A previous study using cinacalcet, as compared to vitamin D alone, showed a better reduction response of PTH levels and a significant diminution of secondary effects. The objective of present study was to evaluate the additional cost of adding cinacalcet to the standard treatment of patients with severe secondary hyperparathyroidism (SHPT) taking into account the treatment goals achieved. METHODS: 12 month prospective study of 23 patients with severe SHPT. Two treatment regimens were considered: standard treatment (m 0) and standard treatment plus cinacalcet (m 12). Four consequences of inadequate control of SHPT were registered: parathiroid hormone (PTH), Calcium (Ca), Phosphorus (P) and the Ca x P product serum levels. Treatment effectiveness was measured as percentage of patients who achieved treatment goal according to each indicator: PTH < 800 pg/mL, PTH between 150 and 300 pg/mL, Calcium < 9.5 mg/dL, Phosphorus < 5.5 mg/dL, and Ca x P product < 55. Annual and monthly costs were calculated for both treatment regimens using Spanish 2007 tariffs, and taking into account the dose reduction in some other treatments. Results are presented as incremental costs and cost per patient who achieved treatment goal. RESULTS: At 12 month it was observed a higher percentage of patients who achieved simultaneously the 4 therapeutic goals with respect to basal moment, from 0% to 52.1%. Cinacalcet allowed to save costs in concomitant drugs, achieving a total saving of 149 euros per patient and month. At 12 month, Cinacalcet achieved a reduction of percentage of patients with PTH > 800 pgr/mL with half of costs than standard treatment (651.35 euros vs 1363.68 euros). It was not possible to calculate the cost for PTH indicator since at the study onset, there was no patient who achieved a level between 150 and 300 pg/mL. Cinacalcet allowed reaching treatment goals in Calcium, Phosphorus and Ca x P product in a more cost-effective way (2164.2 euros vs 2684.8 euros). CONCLUSIONS: Although Cinacalcet is expensive,p atients treated with Cinacalcet showed a minor cost per patient who achieved treatment goal than patients without Cinacalcet. The ability of cinacalcet to reduce PTH secretion, along with the reductions in the serum Ca, P, and Ca x P product, provides an alternative to the traditional treatment paradigm, and should be a welcomed addition in the management of SHPT.

[Changes in vascular access in a dialysis unit in recent years: planning problems, change in preferences, or demographic change?]. / Cambios en el acceso vascular en una unidad de diálisis en los últimos años: problemas de planificación, cambio de preferencias o cambio demográfico?

BACKGROUND: Evidence on the reasons for the general and discouraging overutilization of catheters in DOPPS countries is lacking. METHODS: We analysed the changes in distribution of the different types of vascular access in all 398 patients ongoing hemodialysis at our unit, from January 2000 until December 2005, as well as patients' characteristics. Secondly, risk factors associated with the use of permanent catheters were evaluated in all 95 patients who used that kind of vascular access from January 1997 until April 2006. RESULTS: The percentage of fistulas in prevalent patients diminished from year 2000 until year 2005 (from 95% to 77.9%); concurrently there was an increase in the use of permanent catheters (from 4.2% to 21.5%). The percentage of incident patients having a usable fistula or graft at the beginning of hemodialysis diminished progressively (83.4% in 2000; 69.3% in 2005), and there was a significant increase in the percentage of incident patients using a permanent catheter (from 0 to 23%). Coincidentally, there was a change in patients characteristics: increasing age (71.3 vs. 60.5 years); greater diabetes percentage (7.1% vs. 18.5%) and less time on dialysis (93.2 vs 37 months; p < 0.03). Causes of permanent catheter insertion varied, exhaustion of all other arteriovenous options being the most frequent in the first period of the study and the presence of an unsuitable vascular anatomy in the second. CONCLUSIONS: Despite our policy favoring arteriovenous angioaccess, our results with regards to vascular access worsened in both prevalent and incident patients, coinciding with a change in patients' characteristics. We believe that reversing this trend may become more complicated as the population on dialysis grows older and becomes more prone to diabetes.

¿Es posible mejorar nuestros resultados en hemodiálisis? Establecimiento de objetivos de calidad, retroalimentación (Feedback) y Benchmarking / No disponible

Uno de los retos a los que actualmente se enfrenta la Nefrología es conseguir reducir la variabilidad entre centros, tanto en la asistencia que se presta como en los resultados que obtenemos con la misma. La medición sistemática y planificada de Indicadores de Calidad, la retroalimentación(Feedback) y el Benchmarking son herramientas que nos pueden ayudar a conseguir dichos objetivos. En este estudio evaluamos la repercusión que la aplicación de esas técnicas tuvo en los resultados obtenidos en tres unidades de hemodiálisis. Métodos: Se han analizado los resultados obtenidos en311 pacientes de tres unidades de hemodiálisis, durante el periodo 2006-2007. Los objetivos establecidos y evaluados fueron: 1.- Aumentar el porcentaje de pacientes con calcio inferior a 9,5 mg/dl por encima del 70%. 2.- Aumentar el porcentaje de pacientes con fósforo inferior a 5,5 mg/dl por encima del 80%. 3.- Aumentar el porcentaje de pacientes con PTH entre 150-300 pg/ml por encima del 40%. 4.-Disminuir el porcentaje de pacientes ferropénicos (ferritina< 100 ng/dl) por debajo del 10%, en una unidad que no cumplía este objetivo. Trimestralmente los resultados de los tres centros se enviaban a cada unidad. Resultados: En las tres unidades se observó un aumento significativo en el porcentaje de pacientes con calcio inferior a 9,5 mg/dl (54,6%, 56,1% y 55,6% al inicio y 87,7%,82,9% y 75,1% al final del estudio, respectivamente; p <0,001). Igual sucedió con el porcentaje de pacientes con fósforo inferior a 5,5 mg/dl (77,9%, 73,6% y 66,0% al inicio y 81,7%, 78,0% y 85,9%, respectivamente; p: NS) y con el porcentaje de pacientes con PTH entre 150-300 pg/ml (32,9%, 43,1% y 26,4% frente a 47,5%, 41,4% y 39,5%, respectivamente; p: NS). En la unidad B el porcentaje de pacientes ferropénicos (ferritina < 100 ng/ml) pasó del 30% a 5,3% (p < 0,001), unificando los resultados con los de las otras dos unidades. El consumo medio de EPO en el año 2005 fue 145,5 ± 13,2 U/kg/semana en la unidad A, 226,2 ± 39,8 U/kg/semana en la unidad B y 175,5 ± 13,9 U/kg/semana en la unidad C; al final del año 2007 se obtuvo un consumo medio de EPO significativamente inferior en la unidad B (144,2 ± 15 U/kg/semana), similar al de las otras dos unidades (140 ± 14,2 en la unidad A, y 135,1 ± 13,8 en la unidad C). En el periodo de estudio el Índice de Resistencia a la Eritropoyetina disminuyó de 26,1 a 11,3 en la unidad B. En conclusión, este estudio demuestra que una actitud activa, basada en el uso de indicadores de calidad y el establecimiento de objetivos, la retroalimentación y el benchmarking, permite conseguir una mejora de los resultados. Independientemente de los estándares de calidad definidos, cada centro debería marcarse unos objetivos, bien para alcanzar dicho estándar o bien para mejorarlo. En general las tres unidades tendieron a mejorar sus resultados, así como a igualar los correspondientes al mismo proceso asistencial (AU)

To diminish inter centres variability in applied medical treatments, as well as in the results obtained with them, is one of the main challenges that Nephrology faces now a days. The systematic and planned use of Clinical Performance Measures (CPMs),Feedback and Benchmarking are tools that can help clinicians to reach such an objective. In this study we evaluate the consequences of applying those techniques in the results obtained in three haemodialysis units. Methods: We analyzed the results obtained in 311 patients dialyzed in the three units during the period 2006-2007. Established and evaluated objectives were as follows: 1.- To increase the percentage of patients with a serum calcium below 9,5mg/dl over 70%; 2.- To increase the percentage of patients with a serum phosphorus under 5,5 mg/dl over 80%; 3.- To increase the percentage of patients with a serum PTH in between 150 –300 pg/ml over 40%; 4.- To diminish the percentage of patients with a serum ferritine below 100 ng/ml under 10%, in one of the units that at the beginning of the study was not accomplishing that objective. Every three months each unit received their own results as well as the results of the two other units. Results: The percentage of patients with serum calcium below9.5 mg/dl increased significantly in the three units (54.6%,56.1% and 55.6% at the beginning; 87.7%, 82.9% and 75.1%at the end of the study, respectively; p < 0.001). The same was observed for the percentage of patients with a serum phosphorus below 5,5 mg/dl (77.9%, 73.6% and 66.0% at the beginning; 81.7%, 78.0% and 85.9% at the end, respectively; p: not significant), and for the percentage of patients with PTH between 150-300 pg/ml (32.9%, 43.1% and 26.4% versus 47.5%, 41.4% and 39.5%, respectively; p: not significant). The percentage of patients with a serum ferritin below 100 ng/ml in unit B diminished from 30% to 5.3% (p < 0.001), reaching results similar the the two other units. Mean erythropoietin (EPO) consumption during the year 2005 was 145.5 ± 13.2 U/kg/week in unit A; 226.2 ± 39.8 U/kg/week in unit B, and 175.5 ± 13.9 U/kg/week in unit C. At the end of year 2007, mean EPO consumption was significantly lower in unit B (144.2 ± 15 U/kg/week), and similar to the other two units (140 ± 14.2 in unit A and 135.1 ± 13.8 in unit C). Conclusion: The results of this study permit to conclude that the use of QPM´s and quality targets, combined with feedback and benchmarking, allows for the improvement of clinical results. Each centre should establish their own objectives, independently of the defined quality standards, so as to reach such standards or even to improve them. In this study, the three units showed a general improvement in their results, tending towards similar outcomes for the same clinical processes (AU)

[Can we improve our results in hemodialysis? Setting quality objectives, feedback, and benchmarking]. / Es posible mejorar nuestros resultados en hemodiálisis? Establecimiento de objetivos de calidad, retroalimentación (Feedback) y benchmarking.

UNLABELLED: To diminish inter centres variability in applied medical treatments, as well as in the results obtained with them, is one of the main challenges that Nephrology faces now a days. The systematic and planned use of Clinical Performance Measures (CPMs), Feedback and Benchmarking are tools that can help clinicians to reach such an objective. In this study we evaluate the consequences of applying those techniques in the results obtained in three haemodialysis units. METHODS: we analyzed the results obtained in 311 patients dialyzed in the three units during the period 2006-2007. Established and evaluated objectives were as follows: 1.- To increase the percentage of patients with a serum calcium below 9,5 mg/dl over 70%; 2.- To increase the percentage of patients with a serum phosphorus under 5,5 mg/dl over 80%; 3.- To increase the percentage of patients with a serum PTH in between 150-300 pg/ml over 40%; 4.- To diminish the percentage of patients with a serum ferritine below 100 ng/ml under 10%, in one of the units that at the beginning of the study was not accomplishing that objective. Every three months each unit received their own results as well as the results of the two other units. RESULTS: the percentage of patients with serum calcium below 9,5 mg/dl increased significantly in the three units (54,6%, 56,1% and 55,6% at the beginning; 87,7%, 82.9% and 75,1% at the end of the study, respectively; p<0,001). The same was observed for the percentage of patients with a serum phosphorus below 5,5 mg/dl (77,9%, 73,6% and 66,0% at the beginning; 81,7%, 78,0% and 85.9% at the end, respectively; p: not significant), and for the percentage of patients with PTH between 150-300 pg/ml (32,9%, 43,1% and 26,4% versus 47,5%, 41,4% and 39.5%, respectively; p: not significant). The percentage of patients with a serum ferritin below 100 ng/ml in unit B diminished from 30% to 5,3% (p<0,001), reaching results similar the the two other units. Mean erythropoietin (EPO) consumption during the year 2005 was 145,5+/-13,2 U/kg/week in unit A; 226,2+/-39,8 U/kg/week in unit B, and 175,5+/-13,9 U/kg/week in unit C. At the end of year 2007, mean EPO consumption was significantly lower in unit B (144,2+/-15 U/kg/week), and similar to the other two units (140+/-14,2 in unit A and 135,1+/-13,8 in unit C). CONCLUSION: The results of this study permit to conclude that the use of QPM's and quality targets, combined with feedback and benchmarking, allows for the improvement of clinical results. Each centre should establish their own objectives, independently of the defined quality standards, so as to reach such standards or even to improve them. In this study, the three units showed a general improvement in their results, tending towards similar outcomes for the same clinical processes.