Magnetic resonance in patients with cardiovascular devices. SEC-GT CRMTC/SEC-Heart Rhythm Association/SERAM/SEICAT consensus document.

Magnetic resonance has become a first-line imaging modality in various clinical scenarios. The number of patients with different cardiovascular devices, including cardiac implantable electronic devices, has increased exponentially. Although there have been reports of risks associated with exposure to magnetic resonance in these patients, the clinical evidence now supports the safety of performing these studies under specific conditions and following recommendations to minimize possible risks. This document was written by the Working Group on Cardiac Magnetic Resonance Imaging and Cardiac Computed Tomography of the Spanish Society of Cardiology (SEC-GT CRMTC), the Heart Rhythm Association of the Spanish Society of Cardiology (SEC-Heart Rhythm Association), the Spanish Society of Medical Radiology (SERAM), and the Spanish Society of Cardiothoracic Imaging (SEICAT). The document reviews the clinical evidence available in this field and establishes a series of recommendations so that patients with cardiovascular devices can safely access this diagnostic tool.

Heart disease in eosinophilic granulomatosis with polyangiitis (EGPA) patients: a screening approach proposal.

OBJECTIVE: To define the pattern of cardiac involvement in eosinophilic granulomatosis and polyangiitis (EGPA) and propose an algorithm for heart disease screening. METHODS: This was a retrospective study of EGPA patients attending a specialized vasculitis clinic (1989-2016). Clinical characteristics and cardiovascular evaluation (CE) results (serum troponin, ECG, echocardiography and cardiac magnetic resonance) were collected and compared according to symptoms and inflammatory cardiac disease (ICD). RESULTS: A total of 131 EGPA patients were included, of whom 96 (73%) had undergone CE. The median (interquartile range) age was 50 (38-58) years and 36% showed ANCA+. Asthma preceded diagnosis by a median of 97 (36-240) months. Among the 96 patients who underwent CE, 43% were symptomatic, with dyspnea (47%) and chest pain (29%) being the predominant symptoms. In asymptomatic patients, CE reported abnormalities in 45% of cases, with a subsequent earlier diagnosis (4 vs 11 months). Overall, 27 patients had EGPA-related ICD (EGPA-rICD) that was already present at diagnosis in 20 cases, preceded it in 2 cases and developed later in 5 cases. EGPA-rICD patients were younger (46 vs 50 years; P = 0.04), had more frequently abnormal ECG (30.8 vs 2.1%; P < 0.001), negative ANCA (85 vs 69%; NS), higher BVAS score (3 vs 1; P = 0.005), higher eosinophil count (5.60 vs 1.60 × 109/l; P = 0.029) and higher CRP (52 vs 15 mg/l; P = 0.017). Overall, 11% of cases with EGPA-rICD were asymptomatic. CONCLUSION: In our study, 45% of asymptomatic patients had an abnormal baseline cardiac evaluation, which allowed an earlier diagnosis of cardiac disease. We recommend prompt cardiac screening in all EGPA patients, instead of a symptoms-guided algorithm.

Fluid-structure interaction simulations outperform computational fluid dynamics in the description of thoracic aorta haemodynamics and in the differentiation of progressive dilation in Marfan syndrome patients.

Abnormal fluid dynamics at the ascending aorta may be at the origin of aortic aneurysms. This study was aimed at comparing the performance of computational fluid dynamics (CFD) and fluid-structure interaction (FSI) simulations against four-dimensional (4D) flow magnetic resonance imaging (MRI) data; and to assess the capacity of advanced fluid dynamics markers to stratify aneurysm progression risk. Eight Marfan syndrome (MFS) patients, four with stable and four with dilating aneurysms of the proximal aorta, and four healthy controls were studied. FSI and CFD simulations were performed with MRI-derived geometry, inlet velocity field and Young's modulus. Flow displacement, jet angle and maximum velocity evaluated from FSI and CFD simulations were compared to 4D flow MRI data. A dimensionless parameter, the shear stress ratio (SSR), was evaluated from FSI and CFD simulations and assessed as potential correlate of aneurysm progression. FSI simulations successfully matched MRI data regarding descending to ascending aorta flow rates (R 2 = 0.92) and pulse wave velocity (R 2 = 0.99). Compared to CFD, FSI simulations showed significantly lower percentage errors in ascending and descending aorta in flow displacement (-46% ascending, -41% descending), jet angle (-28% ascending, -50% descending) and maximum velocity (-37% ascending, -34% descending) with respect to 4D flow MRI. FSI- but not CFD-derived SSR differentiated between stable and dilating MFS patients. Fluid dynamic simulations of the thoracic aorta require fluid-solid interaction to properly reproduce complex haemodynamics. FSI- but not CFD-derived SSR could help stratifying MFS patients.

Decreased rotational flow and circumferential wall shear stress as early markers of descending aorta dilation in Marfan syndrome: a 4D flow CMR study.

BACKGROUND: Diseases of the descending aorta have emerged as a clinical issue in Marfan syndrome following improvements in proximal aorta surgical treatment and the consequent increase in life expectancy. Although a role for hemodynamic alterations in the etiology of descending aorta disease in Marfan patients has been suggested, whether flow characteristics may be useful as early markers remains to be determined. METHODS: Seventy-five Marfan patients and 48 healthy subjects were prospectively enrolled. In- and through-plane vortexes were computed by 4D flow cardiovascular magnetic resonance (CMR) in the thoracic aorta through the quantification of in-plane rotational flow and systolic flow reversal ratio, respectively. Regional pulse wave velocity and axial and circumferential wall shear stress maps were also computed. RESULTS: In-plane rotational flow and circumferential wall shear stress were reduced in Marfan patients in the distal ascending aorta and in proximal descending aorta, even in the 20 patients free of aortic dilation. Multivariate analysis showed reduced in-plane rotational flow to be independently related to descending aorta pulse wave velocity. Conversely, systolic flow reversal ratio and axial wall shear stress were altered in unselected Marfan patients but not in the subgroup without dilation. In multivariate regression analysis proximal descending aorta axial (p = 0.014) and circumferential (p = 0.034) wall shear stress were independently related to local diameter. CONCLUSIONS: Reduced rotational flow is present in the aorta of Marfan patients even in the absence of dilation, is related to aortic stiffness and drives abnormal circumferential wall shear stress. Axial and circumferential wall shear stress are independently related to proximal descending aorta dilation beyond clinical factors. In-plane rotational flow and circumferential wall shear stress may be considered as an early marker of descending aorta dilation in Marfan patients.

The nephrologist's role in metformin-induced lactic acidosis.

Metformin is an antihyperglycemic agent commonly used in diabetic patients. It is very effective and is able to reduce the plasma glucose and HbA1C. However, in some patients, specially those with comorbidities, metformin can provoke severe lactic acidosis with high morbimortality. Treatment of the lactic acidosis induced by metformin is based on the use of supportive general measures; in severe cases, procedures of extrarrenal purification like hemodialysis or continuous hemodiafiltration have been successfully used.

Tratamiento de la anorexia urémica con acetato de megestrol / Treatment of uremic anorexia with megestrol acetate

Introducción: La anorexia es un trastorno frecuente en el enfermo tratado con hemodiálisis periódica, y factor contribuyente de la malnutrición. El objetivo del presente trabajo es comprobar la eficacia del acetato de megestrol, un estimulador del apetito utilizado en enfermos con cáncer, como tratamiento de la anorexia del enfermo sometido a diálisis. Material y métodos: En el año 2009, 16 enfermos de nuestra unidad de hemodiálisis, tres de ellos con diabetes mellitus, fueron tratados con acetato de megestrol (160 mg/día en dosis única), por anorexia definida según una escala Likert de apetito. La pauta y la dosis de diálisis no fueron modificadas durante el estudio. Resultados: Al tercer mes de tratamiento se objetivó, en el grupo total, un aumento del peso seco (60,8 frente a 58,9 kg; p <0,01), de la concentración de albúmina (4,02 frente a 3,8 g/dl; p <0,05), de la concentración de creatinina (9,73 frente a 8,26 mg/dl; p <0,01) y de la tasa de catabolismo proteico (1,24 frente a 0,97 g/kg/día; p <0,001). No hemos constatado variaciones significativas en la concentración de hemoglobina, dosis de eritropoyetina y concentración de lípidos. En un enfermo con diabetes mellitus hubo que aumentar la dosis de insulina y en otros 2 enfermos se detectó una hiperglucemia leve. El acetato de megestrol no suprimió la secreción de hormonas sexuales hipofisarias, pero en 3 de 10 enfermos estudiados se constató una inhibición de la secreción de corticotropina. La respuesta no fue homogénea: un enfermo no respondió y disminuyó su peso seco, en cinco el incremento de peso fue discreto (inferior a 1 kg) y en los 10 restantes la respuesta fue buena, con un incremento de peso seco que osciló entre 1,5 y 5,5 kg. Conclusiones: El acetato de megestrol puede mejorar el apetito y los parámetros nutricionales en enfermos tratados con hemodiálisis periódica que refieran anorexia. El acetato de megestrol puede inducir hiperglucemia e inhibir la secreción de corticotropina en algunos pacientes. Estos efectos secundarios deben ser valorados cuando se administre este tratamiento (AU)

Background: Anorexia is a common disorder in patients treated with regular haemodialysis and is a contributing factor to malnutrition. The aim of this study was to evaluate the effectiveness of megestrol acetate, an appetite stimulant used in cancer patients, as a treatment for anorexia in dialysis patients. Material and method: In 2009, 16 patients in our haemodialysis unit, three with diabetes mellitus, were treated with megestrol (160 mg/day single dose) for anorexia defined according to a Likert scale of appetite. The schedule and dialysis dose were not changed during the study. Results: In the third month of treatment there was, in the overall group, an increase in dry weight (60.8 vs 58.9 kg, P<.01), in albumin concentration (4.02 vs 3.8 g/dl, P<.05), in creatinine concentration (9.73 vs 8.26 mg/dl, P<.01), and protein catabolic rate (1.24 vs. 0.97 g/kg/day, P<.0001). Non-significant variations in the concentration of haemoglobin, erythropoietin dose, and lipid concentrations were found. One patient with diabetes mellitus had to increase the dose of insulin and two other patients suffered mild hyperglycaemia. Megestrol acetate did not suppress the secretion of pituitary sex hormones, but in 3 of 10 patients studied inhibition of ACTH secretion was found. The response was not homogeneous: one patient did not respond and reduced his dry weight, in 5 the weight gain was minimal (less than 1 kg) and in the remaining ten the response was good, with an increase in dry weight ranging between 1.5 and 5.5 kg. Conclusions: Megestrol acetate can improve appetite and nutritional parameters in patients treated with periodic haemodialysis who report anorexia. Megestrol acetate may induce hyperglycaemia and inhibit the secretion of ACTH in some patients. These side effects should be assessed when administering this treatment (AU)

[Treatment of uraemic anorexia with megestrol acetate]. / Tratamiento de la anorexia urémica con acetato de megestrol.

BACKGROUND: Anorexia is a common disorder in patients treated with regular haemodialysis and is a contributing factor to malnutrition. The aim of this study was to evaluate the effectiveness of megestrol acetate, an appetite stimulant used in cancer patients, as a treatment for anorexia in dialysis patients. MATERIAL AND METHOD: In 2009, 16 patients in our haemodialysis unit, three with diabetes mellitus, were treated with megestrol (160 mg/day single dose) for anorexia defined according to a Likert scale of appetite. The schedule and dialysis dose were not changed during the study. RESULTS: In the third month of treatment there was, in the overall group, an increase in dry weight (60.8 vs 58.9 kg, P<.01), in albumin concentration (4.02 vs 3.8 g/dl, P<.05), in creatinine concentration (9.73 vs 8.26 mg/dl, P<.01), and protein catabolic rate (1.24 vs. 0.97 g/kg/day, P<.0001). Non-significant variations in the concentration of haemoglobin, erythropoietin dose, and lipid concentrations were found. One patient with diabetes mellitus had to increase the dose of insulin and two other patients suffered mild hyperglycaemia. Megestrol acetate did not suppress the secretion of pituitary sex hormones, but in 3 of 10 patients studied was found inhibition of ACTH secretion. The response was not homogeneous: one patient did not respond and reduced his dry weight, in 5 the weight gain was minimal (less than 1 kg) and in the remaining ten the response was good, with an increase in dry weight ranging between 1.5 and 5.5 kg. CONCLUSIONS: Megestrol acetate can improve appetite and nutritional parameters in patients treated with periodic haemodialysis who report anorexia. Megestrol acetate may induce hyperglycaemia and inhibit the secretion of ACTH in some patients. These side effects should be assessed when administering this treatment.

[Approach to quality objectives in incidents of patients in peritoneal dialysis]. / Cumplimiento de objetivos de calidad y evolución de los pacientes incidentes en diálisis peritoneal.

INTRODUCTION: In 2007 the Scientific Quality-technical and Improvement of Quality in Peritoneal Dialysis was edited. It includes several quality indicators. As far as we know, only some groups of work had evaluated these indicators, with inconclusive results. AIM: To study the evolution and impact of guidelines in Peritoneal Dialysis. METHODS: Prospective cohort study of each incident of patients in Peritoneal Dialysis, in a regional public health care system (2003-2006). We prospectively collected baseline clinical and analytical data, technical efficacy, cardiovascular risk, events and deaths, hospital admissions and also prescription data was collected every 6 months. RESULTS: Over a period of 3 years, 490 patients (53.58 years of age; 61.6% males.) Causes of ERC: glomerular 25.5%, diabetes 16%, vascular 12.4%, and interstitial 13.3%. 26.48% were on the list for transplant. Dialysis efficacy: Of the first available results, the residual renal function was 6.37 ml/min, achieving 67.6% of all the objectives K/DOQI. 38.6% remained within the range during the entire first year. Anaemia: 79.3% received erythropoietic stimulating agents and maintained an average Hb of 12.1 g/dl. The percentage of patients in the range (Hb: 11-13 g/dl) improved after a year (58.4% vs 56.3% keeping in the range during this time of 25.6%). Evolution: it has been estimated that per patient-year the risk of: 1) mortality is 0.06 IC 95% [0.04-0.08]; 2) admissions 0.65 [0.58-0.72]; 3) peritoneal infections 0.5 [0.44-0.56]. CONCLUSION: Diabetes Mellitus patients had a higher cardiovascular risk and prevalence of events. The degrees of control during the follow-up in many topics of peritoneal dialysis improve each year; however they are far from the recommended guidelines, especially if they are evaluated throughout the whole study.

Epidemiología de la insuficiencia renal aguda / Epidemiology of acute renal failure

Hasta los años noventa, el estudio de la epidemiología de la IRA fue muy limitado. Desde entonces disponemos de más información aunque no siempre uniforme. El primer análisis sobre la incidencia de la IRA en una región española lo publicaron Sánchez Rodríguez y cols. en Nefrología en 19921. Como ocurre en general con la IRA (ver Definiciones y terminología del FRA), la mayor dificultad con que nos encontramos al analizar su epidemiología son los criterios empleados para definirla, pues no suelen ser homogéneos (tabla I). De manera similar, hay que considerar el tipo de pacientes incluidos en los estudios epidemiológicos de la IRA, ya que algunas series excluyen ciertas formas del síndrome como los casos de etiología prerrenal, los obstructivos y los individuos con enfermedad renal crónica que han sufrido una IRA sobreañadida, mientras que otras sólo analizan los enfermos ingresados en unidades de cuidados intensivos (UCI) o los que requieren diálisis. Aunque la epidemiología del fracaso renal agudo depende también de factores económicos y geográficos2,3, en esta guía nos limitaremos, en general, a considerar los aspectos epidemiológicos relacionados con nuestro entorno

The epidemiology of acute renal failure is reviewed. The causes affecting its incidence, particularly that of the definition criteria used, are discussed. Depending on the criteria chosen the incidence can vary between 200 and 600 per million in-habitants in the adult population. The epidemiological information related with the need of dialysis in acute renal failure is analysed. The different incidences in geographical areas where the acute renal failure develops are reviewed. The present general trend to a higher incidence in acute renal failure is commented

Pronóstico en la insuficiencia renal aguda / Prognosis in acute renal failure

Tres factores son los que subrayan la importancia de la insuficiencia renal aguda tanto para el enfermo, como para la sociedad donde vive: 1) La alta incidencia del fracaso renal agudo en los países industrializados, en España 209 casos por millón de población adulta1. 2) Su elevada mortalidad que oscila entre el 40 y el 80 por ciento de los casos, dependiendo fundamentalmente de que el fallo renal se presente de forma aislada o asociado al de otros órganos en el seno de un síndrome de disfunción multiorgánica2, y 3) El elevado coste que genera la atención de los enfermos afectos de este síndrome3. Como en cualquier contexto médico, pero en especial en procesos graves como los que se atienden en la medicina intensiva, en la insuficiencia renal aguda la necesidad de informar al paciente, o a su familia, sobre sus expectativas de supervivencia; junto con la necesidad de los médicos de estimar la gravedad de un grupo de enfermos para poder valorar la eficacia de distintos tratamientos conllevó, ayudados por la difusión informática, al desarrollo de sistemas de estimación pronóstica. Además de los dos objetivos indicados, los sistemas pronósticos deberían satisfacer otros fines que se especifican en la tabla I. Los métodos de estimación pronóstica se basan en la interrelación que existe entre tres conceptos: la gravedad, la evolución y el pronóstico de un proceso dado. Mientras que la evolución es el curso real que sigue la enfermedad y depende de la gravedad de la misma, el pronóstico es la estimación de la evolución antes de que ésta se cumpla5. A su vez el pronóstico será tanto más certero cuanto mejor sea capaz de valorar algo tan sutil como es la gravedad de la enfermedad5. La figura 1, donde se representa la interdependencia de los tres conceptos, explica porque muchas veces se utilizan como sinónimos entre sí. Adicionalmente, un índice o sistema pronóstico ideal debería ser4: 1) Eficaz, lo que implica valores elevados de sensibilidad y especificidad. 2) Precoz, esto es que su estimación sea adecuada desde los momentos iniciales del proceso. 3) Sencillo de calcular. 4) Sin generar gastos al estimarlo. 5) Reproducible fuera del lugar donde fue diseñado. 6) Universal, entendiendo por tal que sea útil en todo tipo de enfermos dentro de una patología, tanto en los enfermos muy graves como en los menos graves. 7) Dinámico, para lo que debe funcionar, estimando un pronóstico exacto, en diversos momentos evolutivos de la enfermedad, y 8) Capaz de discriminar aquellos enfermos que no sobrevivirán al proceso patológico

A review of prognosis and its relationship with severity of acute kidney injury and outcome is given. Different prognosis systems, specific for acute renal failure and ofr more general scores used in the intensive care setting, are discussed. The general attirbutes that prognosis scores should have as well as the main indications for their use are analysed. Particular insight is given with respect to ISI (Individual Severity Index), CCF (Cleveland Clinic Foundation), SHARF (Stuivenberg Hospital Acute Renal Failure), APACHE II, SOFA and SAPS II scores in the acute kidney injury field

[Guidelines of the Spanish Society of Nephrology. Clinical practice guidelines for peritoneal dialysis]. / Guías Sociedad Española de Nefrología. Guías de práctica clínica en diálisis peritoneal.

In Spain and in each of its autonomous communities, the dialysis treatment of chronic renal disease stage 5 is totally covered by public health. Peritoneal dialysis, in any of its modalities, is established as the preferred home dialysis technique and is chosen by high percentage of patients as their choice in dialysis treatment. The Spanish Society of Nephrology has promoted a project of creation of performance guides in the field of peritoneal dialysis, entrusting a work group composed of members of the Spanish Society of Nephrology a with the development of these guides. The information offered is based on levels of evidence, opinion and clinical experience of the most relevant publications of the topic. In these guides, after defining the concept of << peritoneal dialysis>>, the obligations and responsibilities of the sanitation team of the peritoneal dialysis unit are determined, and protocols and performance procedures that try to include all the aspects that concern the patient with chronic renal disease in substitute treatment with this technique are developed. They propose prescription objectives based on available clinical evidence and, lacking this, on the consensus of the experts' opinions. The final aim is to improve the care and quality of the of the patient in peritoneal dialysis, optimizing in this way the survival of the patient and of the technique. In Spain, as in other neighbouring countries, peritoneal dialysis has an incidence and prevalence that is much lower than that of hemodialysis, ranging in the last evaluation by the Spanish Society of Nephrology between 5 and 24% in the different autonomous communities. The great majority of peritoneal dialysis units form part of the public network of the Spanish state, with special representation as a Satellite Unit or Concerted Center related to the public hospital of reference, on which it must depend.

Síndrome aórtico agudo. Aspectos clínicos y diagnósticos / Acute aortic syndrome. Clinical aspects and diagnosis

Introducción. El síndrome aórtico agudo es un proceso agudo de la pared aórtica que afecta a la capa media; incluye la disección aórtica, el hematoma intramural y la úlcera penetrante. En los últimos años los avances en las técnicas de imagen han ayudado a conocer la historia natural de estas entidades y a comprender mejor el importante dinamismo de esta patología. Desarrollo. En este artículo se revisan los conocimientos actuales de la historia natural, presentación clínica y diagnóstico de este síndrome. Conclusión. A pesar de los importantes progresos en el tratamiento quirúrgico, la mortalidad en la fase aguda podría reducirse con una sospecha clínica precoz y una óptima experiencia quirúrgica. La incorporación del tratamiento endovascular ha abierto nuevas perspectivas en el tratamiento de las complicaciones de esta enfermedad y podría mejorar el pronóstico a largo plazo

Introduction. Acute aortic syndrome, an acute lesion of the aortic wall involving the middle layer, includes aortic dissection, intramural haematoma and penetrating ulcer. Recent advances in imaging techniques have contributed to understanding of the natural history of these entities and the dynamics of these diseases. Development. This article aims to review the current understanding of the natural history, clinical presentation and therapeutic management of the syndrome. Conclusion. Despite considerable advances in surgical treatment, the current high mortality rate in acute phase could be reduced by early clinical suspicion and improved surgical expertise. The advent and incorporation of endovascular treatment has opened up new perspective in the management of complications of these diseases and may improve the long-term prognosis

Modificaciones en el metabolismo del hierro y requerimientos de eritropoyetina tras el paso de gluconato férrico a hierro sacarosa. ¿Compensa el incremento del gasto? / No disponible

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Supervivencia en un caso de intoxicación por etilenglicol con acidemia extrema

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Sepsis y fracaso renal agudo en paciente portador de marcapasos / Sepsis and acute kidney failure in a pacemaker-wearing patient

La glomerulonefritis aguda es un cuadro cada vez menos frecuente con el desarrollo de tratamientos antibióticos adecuados. Sin embargo, en los últimos años encontramos casos más graves, en pacientes con peor pronóstico y más comprometidos. Suele asociarse a infecciones de distinto origen, pero la glomerulonefritis secundaria a la infección de los cables de un marcapasos permanente es muy infrecuente y en la literatura sólo hemos encontrado dos casos previos (AU)