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INTRODUCTION: Chronic heart failure (HF) has high rates of mortality and hospitalization in patients with advanced chronic kidney disease (aCKD). However, randomized clinical trials have systematically excluded aCKD population. We have investigated current HF therapy in patients receiving clinical care in specialized aCKD units. METHODS: The Heart And Kidney Audit (HAKA) was a cross-sectional and retrospective real-world study including outpatients with aCKD and HF from 29 Spanish centers. The objective was to evaluate how the treatment of HF in patients with aCKD complied with the recommendations of the European Society of Cardiology Guidelines for the diagnosis and treatment of HF, especially regarding the foundational drugs: renin-angiotensin system inhibitors (RASi), angiotensin receptor blocker/neprilysin inhibitors (ARNI), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2i). RESULTS: Among 5,012 aCKD patients, 532 (13%) had a diagnosis of HF. Of them, 20% had reduced ejection fraction (HFrEF), 13% mildly reduced EF (HFmrEF), and 67% preserved EF (HFpEF). Only 9.3% of patients with HFrEF were receiving quadruple therapy with RASi/ARNI, BB, MRA, and SGLT2i, but the majority were not on the maximum recommended doses. None of the patients with HFrEF and CKD G5 received quadruple therapy. Among HFmrEF patients, approximately half and two-thirds were receiving RASi and/or BB, respectively, while less than 15% received ARNI, MRA, or SGLT2i. Less than 10% of patients with HFpEF were receiving SGLT2i. CONCLUSIONS: Under real-world conditions, HF in aCKD patients is sub-optimally treated. Increased awareness of current guidelines and pragmatic trials specifically enrolling these patients represent unmet medical needs.
Subject(s)
Adrenergic beta-Antagonists , Angiotensin Receptor Antagonists , Heart Failure , Mineralocorticoid Receptor Antagonists , Renal Insufficiency, Chronic , Sodium-Glucose Transporter 2 Inhibitors , Stroke Volume , Humans , Heart Failure/complications , Heart Failure/drug therapy , Heart Failure/physiopathology , Retrospective Studies , Male , Female , Renal Insufficiency, Chronic/complications , Renal Insufficiency, Chronic/physiopathology , Aged , Cross-Sectional Studies , Mineralocorticoid Receptor Antagonists/therapeutic use , Angiotensin Receptor Antagonists/therapeutic use , Adrenergic beta-Antagonists/therapeutic use , Sodium-Glucose Transporter 2 Inhibitors/therapeutic use , Stroke Volume/physiology , Middle Aged , Spain/epidemiology , Guideline Adherence , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Aged, 80 and overABSTRACT
Background: Current guidelines establish the same hemoglobin (Hb) and iron biomarkers targets for hemodialysis (HD) and peritoneal dialysis (PD) in patients receiving erythropoiesis-stimulating agents (ESAs) even though patients having PD are usually younger, more active and less comorbid. Unfortunately, specific renal anemia [anemia in chronic kidney disease (aCKD)] trials or observational studies on PD are scanty. The aims of this study were to describe current aCKD management, goals and adherence to clinical guidelines, identifying opportunities for healthcare improvement in PD patients. Methods: This was a retrospective, nationwide, multicentre study including patients from 19 PD units. The nephrologists collected baseline data, demographics, comorbidities and data related to anemia management (laboratory values, previously prescribed treatments and subsequent adjustments) from electronic medical records. The European adaptation of KDIGO guidelines was the reference for definitions, drug prescriptions and targets. Results: A total of 343 patients (mean age 62.9 years, 61.2% male) were included; 72.9% were receiving ESAs and 33.2% iron therapy [20.7% intravenously (IV)]. Eighty-two patients were receiving ESA without iron therapy, despite 53 of them having an indication according to the European Renal Best Practice guidelines. After laboratory results, iron therapy was only started in 15% of patients. Among ESA-treated patients, 51.9% had an optimal control [hemoglobin (Hb) 10-12 g/dL] and 28.3% between 12-12.9 g/dL. Seventeen patients achieved Hb >13 g/dL, and 12 of them remained on ESA after overshooting. Only three patients had Hb <10 g/dL without ESAs. Seven patients (2%) met criteria for ESA resistance (epoetin dose >300 IU/kg/week). The highest tertile of erythropoietin resistance index (>6.3 UI/kg/week/g/dL) was associated with iron deficiency and low albumin corrected by renal replacement therapy vintage and hospital admissions in the previous 3 months. Conclusion: Iron therapy continues to be underused (especially IV). Low albumin, iron deficiency and prior events explain most of the ESA hyporesponsiveness. Hb targets are titrated to/above the upper limits. Thus, several missed opportunities for adequate prescriptions and adherence to guidelines were identified.
Subject(s)
Humans , Male , Aged, 80 and over , Kidney Failure, Chronic , Rhabdomyolysis , Rosuvastatin Calcium , Abiraterone Acetate , HypothyroidismABSTRACT
We present the case of a male patient with severe SARS-CoV-2 pneumonia, with simultaneous onset of p-ANCA positive rapidly progressive glomerulonephritis. We discuss the different therapeutic possibilities, emphasising the appropriateness of their administration according to the time in the course of the infection.
Subject(s)
COVID-19 , Glomerulonephritis , Nephritis , Antibodies, Antineutrophil Cytoplasmic , COVID-19/complications , Glomerulonephritis/drug therapy , Glomerulonephritis/therapy , Humans , Male , SARS-CoV-2ABSTRACT
Background: Patients on hemodialysis are at high-risk for complications derived from coronavirus disease 2019 (COVID-19). The present analysis evaluated the impact of a booster vaccine dose and breakthrough severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections on humoral immunity 3 months after the booster dose. Methods: This is a multicentric and prospective study assessing immunoglobulin G anti-Spike antibodies 6 and 9 months after initial SARS-CoV-2 vaccination in patients on hemodialysis that had also received a booster dose before the 6-month assessment (early booster) or between the 6- and 9-month assessments (late booster). The impact of breakthrough infections, type of vaccine, time from the booster and clinical variables were assessed. Results: A total of 711 patients [67% male, median age (range) 67 (20-89) years] were included. Of these, 545 (77%) received an early booster and the rest a late booster. At 6 months, 64 (9%) patients had negative anti-Spike antibody titers (3% of early booster and 29% of late booster patients, P = .001). At 9 months, 91% of patients with 6-month negative response had seroconverted and there were no differences in residual prevalence of negative humoral response between early and late booster patients (0.9% vs 0.6%, P = .693). During follow-up, 35 patients (5%) developed breakthrough SARS-CoV-2 infection. Antibody titers at 9 months were independently associated with mRNA-1273 booster (P = .001), lower time from booster (P = .043) and past breakthrough SARS-CoV-2 infection (P < .001). Conclusions: In hemodialysis patients, higher titers of anti-Spike antibodies at 9 months were associated with mRNA-1273 booster, lower time from booster and past breakthrough SARS-CoV-2 infection.
Subject(s)
COVID-19 , Renal Insufficiency, Chronic , Antibodies, Viral , COVID-19/prevention & control , COVID-19 Vaccines , Female , Humans , Male , SARS-CoV-2 , VaccinationABSTRACT
Presentamos el caso de un varón afecto por neumonía SARS-CoV-2 grave, que a la vez comienza con una glomerulonefritis rápidamente progresiva p-ANCA positiva. Se comentan las distintas posibilidades terapéuticas haciendo hincapié en la idoneidad de su administración según el momento evolutivo de la infección. (AU)
We present the case of a male patient with severe SARS-CoV-2 pneumonia, with simultaneous onset of p-ANCA positive rapidly progressive glomerulonephritis. We discuss the different therapeutic possibilities, emphasising the appropriateness of their administration according to the time in the course of the infection. (AU)
Subject(s)
Humans , Male , Nephrology , Coronavirus Infections/epidemiology , Anti-Glomerular Basement Membrane Disease/therapy , Pneumonia/therapy , Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis/therapy , AortitisABSTRACT
BACKGROUND: Acute kidney injury (AKI) may develop in coronavirus disease 2019 (COVID-19) patients and may be associated with a worse outcome. The aim of this study is to describe AKI incidence during the first 45 days of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in Spain, its reversibility and the association with mortality. METHODS: This was an observational retrospective case-control study based on patients hospitalized between 1 March and 15 April 2020 with SARS-CoV-2 infection and AKI. Confirmed AKI cases were compared with stable kidney function patients for baseline characteristics, analytical data, treatment and renal outcome. Patients with end-stage kidney disease were excluded. RESULTS: AKI incidence was 17.22% among 3182 admitted COVID-19 patients and acute kidney disease (AKD) incidence was 6.82%. The most frequent causes of AKI were prerenal (68.8%) and sepsis (21.9%). Odds ratio (OR) for AKI was increased in patients with pre-existent hypertension [OR 2.58, 95% confidence interval (CI) 1.71-3.89] and chronic kidney disease (CKD) (OR 2.14, 95% CI 1.33-3.42) and in those with respiratory distress (OR 2.37, 95% CI 1.52-3.70). Low arterial pressure at admission increased the risk for Stage 3 AKI (OR 1.65, 95% CI 1.09-2.50). Baseline kidney function was not recovered in 45.73% of overall AKI cases and in 52.75% of AKI patients with prior CKD. Mortality was 38.5% compared with 13.4% of the overall sample population. AKI increased mortality risk at any time of hospitalization (hazard ratio 1.45, 95% CI 1.09-1.93). CONCLUSIONS: AKI is frequent in COVID-19 patients and is associated with mortality, independently of acute respiratory distress syndrome. AKD was also frequent and merits adequate follow-up.
ABSTRACT
We present the case of a male patient with severe SARS-CoV-2 pneumonia, with simultaneous onset of p-ANCA positive rapidly progressive glomerulonephritis. We discuss the different therapeutic possibilities, emphasising the appropriateness of their administration according to the time in the course of the infection.
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No disponible
Subject(s)
Humans , AIDS-Related Opportunistic Infections/diagnosis , Glomerulonephritis/diagnosis , Hepatitis C/complications , Leishmaniasis, Visceral/diagnosis , NecrosisABSTRACT
La relación entre parásitos y glomerulonefritis (GN) está bien documentada en determinadas parasitosis, no así en casos de Strongyloides stercolaris (S. stercolaris), donde hay pocos casos descritos, siendo la mayoría GN de cambios mínimos. Reportamos un caso de hiperinfestación por S. stercolaris en un paciente afectado de una GN membranosa tratado con corticoides por vía oral con resultado fatal para el paciente. Este caso nos aporta una doble enseñanza: en primer lugar, acerca de una asociación rara de estrongiloidiasis y GN membranosa, y en segundo lugar, sobre la importancia de establecer un diagnóstico de sospecha y tratamiento adecuados ante determinadas infecciones o enfermedades con poca expresividad clínica antes de iniciar cualquier tratamiento inmunosupresor
The relationship between parasites and glomerulonephritis (GN) is well documented in certain parasitoses, but not in cases of Strongyloides stercolaris (S. stercolaris) where there are few cases described being the majority GN of minimal changes. We report a case of hyperinfestation by S. stercolaris in a patient affected by a membranous GN treated with oral corticosteroids with fatal outcome for the patient. This case provides a double teaching: first about a rare association of strongyloid and membranous GN and second about the importance of establishing a diagnosis of suspected and appropriate treatment for certain infections or diseases with little clinical expression before starting any immunosuppressive treatment
Subject(s)
Humans , Animals , Male , Middle Aged , Glomerulonephritis, Membranous/complications , Immunosuppressive Agents/adverse effects , Prednisone/adverse effects , Strongyloides stercoralis , Strongyloidiasis/complications , Systemic Inflammatory Response Syndrome/etiology , Cryptococcosis/complications , Delayed Diagnosis , Drug Therapy, Combination , Ecuador/ethnology , Enterococcus faecium , Escherichia coli Infections/complications , Fatal Outcome , Glomerulonephritis, Membranous/drug therapy , Glomerulonephritis, Membranous/urine , Gram-Positive Bacterial Infections/complications , Immunocompromised Host , Immunosuppressive Agents/therapeutic use , Lung Diseases, Fungal/complications , Meningitis, Bacterial/complications , Pneumonia, Bacterial/complications , Prednisone/therapeutic use , Shock, Septic/etiology , Stenotrophomonas maltophilia , Strongyloidiasis/diagnosisABSTRACT
The relationship between parasites and glomerulonephritis (GN) is well documented in certain parasitoses, but not in cases of Strongyloides stercolaris (S. stercolaris) where there are few cases described being the majority GN of minimal changes. We report a case of hyperinfestation by S. stercolaris in a patient affected by a membranous GN treated with oral corticosteroids with fatal outcome for the patient. This case provides a double teaching: first about a rare association of strongyloid and membranous GN and second about the importance of establishing a diagnosis of suspected and appropriate treatment for certain infections or diseases with little clinical expression before starting any immunosuppressive treatment.
Subject(s)
Glomerulonephritis, Membranous/complications , Immunosuppressive Agents/adverse effects , Prednisone/adverse effects , Strongyloides stercoralis , Strongyloidiasis/complications , Systemic Inflammatory Response Syndrome/etiology , Animals , Cryptococcosis/complications , Delayed Diagnosis , Drug Therapy, Combination , Ecuador/ethnology , Enterococcus faecium , Escherichia coli Infections/complications , Fatal Outcome , Glomerulonephritis, Membranous/drug therapy , Glomerulonephritis, Membranous/urine , Gram-Positive Bacterial Infections/complications , Humans , Immunocompromised Host , Immunosuppressive Agents/therapeutic use , Lung Diseases, Fungal/complications , Male , Meningitis, Bacterial/complications , Middle Aged , Pneumonia, Bacterial/complications , Prednisone/therapeutic use , Shock, Septic/etiology , Spain , Stenotrophomonas maltophilia , Strongyloidiasis/diagnosisABSTRACT
No disponible
Subject(s)
Humans , Male , Middle Aged , Kidney Diseases/diagnosis , Cyanosis/diagnosis , Disease ProgressionABSTRACT
Introducción: En la hemodiafiltración en línea posdilucional (HDFOL) la única recomendación acerca del líquido de diálisis (LD) hace referencia a su pureza. No se ha definido si usar flujos de baño (Qd) elevados tiene alguna utilidad para aumentar el Kt o el volumen de ultrafiltración-infusión (VI). Objetivo: Estudiar cómo influye el Qd en el Kt y en el VI en la HDFOL. Material y métodos: Estudio cruzado prospectivo. Se incluyó a 37 pacientes a los que se les realizaron 6 sesiones de HDFOL con cada Qd: 500, 600 y 700ml/min. Veintiún pacientes se dializaron en monitor 5008® y 17 con AK-200®. Los dializadores utilizados fueron: 20 con FX800® y 17 con Polyflux-210®. El resto de los parámetros se mantuvieron constantes. Se recogieron del monitor: flujo efectivo de sangre, tiempo efectivo de diálisis, Kt final y VI. Resultados: Encontramos que usando un Qd=600 o 700ml/min, el Kt aumentó un 1,7% respecto al uso de Qd=500ml/min. Las diferencias de VI no fueron significativas. Aumentar el Qd de 500ml/min a 600 y 700ml/min aumenta el consumo de LD un 20 y un 40%, respectivamente. Conclusiones: En la HDFOL con los monitores y dializadores utilizados no son útiles los Qd superiores a 500ml/min para aumentar la eficacia del Kt ni el VI, por lo que su utilización implica un despilfarro de un recurso como el agua, tan importante tanto desde el punto de vista ecológico como económico (AU)
Introduction: In post-dilution online hemodiafiltration (OL-HDF), the only recommendation concerning the dialysate, or dialysis fluid, refers to its purity. No study has yet determined whether using a high dialysate flow (Qd) is useful for increasing Kt or ultrafiltration-infusion volume. Objective: Study the influence of Qd on Kt and on infusion volume in OL-HDF. Material and methods: This was a prospective crossover study. There were 37 patients to whom 6 sessions of OL-HDF were administered at 3 different Qds: 500, 600 and 700ml/min. A 5008® monitor was used for the dialysis in 21 patients, while an AK-200® was used in 17. The dialysers used were: 20 with FX 800® and 17 with Polyflux-210®. The rest of the parameters were kept constant. Monitor data collected were effective blood flow, effective dialysis time, final Kt and infused volume. Results: We found that using a Qd of 600 or 700ml/min increased Kt by 1.7% compared to using a Qd of 500ml/min. Differences in infusion volume were not significant. Increasing Qd from 500ml/min to 600 and 700ml/min increased dialysate consumption by 20% and 40%, respectively. Conclusions: With the monitors and dialysers currently used in OL-HDF, a Qd higher than 500ml/min is unhelpful for increasing the efficacy of Kt or infusion volume. Consequently, using a high Qd wastes water, a truly important resource both from the ecological and economic points of view (AU)
Subject(s)
Humans , Hemodiafiltration/methods , Ultrafiltration/methods , Hemodialysis Solutions/pharmacology , Renal Insufficiency, Chronic/therapy , Prospective Studies , Renal Plasma Flow, Effective/physiologyABSTRACT
INTRODUCTION: In post-dilution online hemodiafiltration (OL-HDF), the only recommendation concerning the dialysate, or dialysis fluid, refers to its purity. No study has yet determined whether using a high dialysate flow (Qd) is useful for increasing Kt or ultrafiltration-infusion volume. OBJECTIVE: Study the influence of Qd on Kt and on infusion volume in OL-HDF. MATERIAL AND METHODS: This was a prospective crossover study. There were 37 patients to whom 6 sessions of OL-HDF were administered at 3 different Qds: 500, 600 and 700ml/min. A 5008(®) monitor was used for the dialysis in 21 patients, while an AK-200(®) was used in 17. The dialysers used were: 20 with FX 800(®) and 17 with Polyflux-210(®). The rest of the parameters were kept constant. Monitor data collected were effective blood flow, effective dialysis time, final Kt and infused volume. RESULTS: We found that using a Qd of 600 or 700ml/min increased Kt by 1.7% compared to using a Qd of 500ml/min. Differences in infusion volume were not significant. Increasing Qd from 500ml/min to 600 and 700ml/min increased dialysate consumption by 20% and 40%, respectively. CONCLUSIONS: With the monitors and dialysers currently used in OL-HDF, a Qd higher than 500ml/min is unhelpful for increasing the efficacy of Kt or infusion volume. Consequently, using a high Qd wastes water, a truly important resource both from the ecological and economic points of view.
Subject(s)
Dialysis Solutions/pharmacokinetics , Hemodiafiltration/methods , Kidney Failure, Chronic/therapy , Rheology , Adult , Aged , Aged, 80 and over , Conservation of Natural Resources , Costs and Cost Analysis , Cross-Over Studies , Dialysis Solutions/economics , Female , Hemodiafiltration/economics , Hemodiafiltration/instrumentation , Humans , Male , Membranes, Artificial , Middle Aged , Prospective Studies , WaterABSTRACT
No disponible
