Hypovitaminosis D and its relationship with nutritional status and quality of life in patients undergoing haemodialysis / Hipovitaminosis D y su relación con el estado nutricional y la calidad de vida en pacientes incluidos en un programa de hemodiálisis

Objective: to assess the prevalence of hypovitaminosis D in patients undergoing haemodialysis (HD) and to determine its relationship with nutritional status and quality of life (QoL). Material and methods: 120 patients were included in the study. The Malnutrition-Inflammation Score (MIS) was used to detect nutritional risk. QoL was evaluated by Kidney Disease Quality of Life version 1.2 (KDQOL-SF). Patients were stratified into three groups according to their vitamin D status: sufficiency (≥ 30 ng/dl), insufficiency (29-10 ng/dl) and deficiency (< 10 ng/dl). Results: hypovitaminosis D was detected in 71 % of the patients studied. Multiple linear regression analysis showed that vitamin-D deficiency was the most significant predictor of low KDQOL-SF scores. It explained 21 % of the variance in the Kidney Disease Component Summary, 27 % of that in the Physical Component Summary, and 22 % of that in the Mental Component Summary. Multiple logistic regression analysis showed that only vitamin-D deficiency was significantly associated with malnutrition (OR, 14.6, p < 0.001). Conclusion: HD patients frequently present with hypovitaminosis D. There is a significant correlation between vitamin-D deficiency, poorer nutritional status, and worse QoL in dialysed patients. (AU)

Objetivo: evaluar la prevalencia de la hipovitaminosis D en pacientes en hemodiálisis (HD) y su relación con el estado nutricional y la calidad de vida (CV). Material y métodos: un total de 120 pacientes fueron incluidos. La escala de Malnutrición-Inflamación (MIS) se utilizó para la detección del riesgo nutricional. La CV fue evaluada por el cuestionario Kidney Disease Quality of Life versión 1.2 (KDQOL-SF). Los pacientes fueron estratificados en tres grupos de acuerdo con el estado de la vitamina D: suficiencia (≥ 30 ng/dl), insuficiencia (29-10 ng/dl) y deficiencia (< 10 ng/dl). Resultados: se observó hipovitaminosis D en el 71 % de los pacientes. El análisis de regresión lineal múltiple mostró que la deficiencia devitamina D fue el predictor más significativo de peores resultados en el cuestionario KDQOL-SF. La deficiencia de 25(OH)D explicó el 21 % de la varianza en el componente sumatorio de la enfermedad renal, el 27 % en el componente sumatorio físico y el 22 % en el componente sumatorio mental. Cuando evaluamos el estado nutricional, el análisis de regresión logística multivariante mostró que solo la deficiencia de vitamina D presenta un efecto significativo en la desnutrición (OR: 14.6, p < 0,001). Conclusión: de nuestros hallazgos concluimos que la hipovitaminosis D es muy frecuente entre los pacientes en HD y que su deficiencia está asociada un deterioro del estado nutricional y peor percepción de la calidad de vida. (AU)

Hypovitaminosis D and its relationship with nutritional status and quality of life in patients undergoing haemodialysis.

Introduction: Objective: to assess the prevalence of hypovitaminosis D in patients undergoing haemodialysis (HD) and to determine its relationship with nutritional status and quality of life (QoL). Material and methods: 120 patients were included in the study. The Malnutrition-Inflammation Score (MIS) was used to detect nutritional risk. QoL was evaluated by Kidney Disease Quality of Life version 1.2 (KDQOL-SF). Patients were stratified into three groups according to their vitamin D status: sufficiency (≥ 30 ng/dl), insufficiency (29-10 ng/dl) and deficiency (< 10 ng/dl). Results: hypovitaminosis D was detected in 71 % of the patients studied. Multiple linear regression analysis showed that vitamin-D deficiency was the most significant predictor of low KDQOL-SF scores. It explained 21 % of the variance in the Kidney Disease Component Summary, 27 % of that in the Physical Component Summary, and 22 % of that in the Mental Component Summary. Multiple logistic regression analysis showed that only vitamin-D deficiency was significantly associated with malnutrition (OR, 14.6, p < 0.001). Conclusion: HD patients frequently present with hypovitaminosis D. There is a significant correlation between vitamin-D deficiency, poorer nutritional status, and worse QoL in dialysed patients.

Introducción: Objetivo: evaluar la prevalencia de la hipovitaminosis D en pacientes en hemodiálisis (HD) y su relación con el estado nutricional y la calidad de vida (CV). Material y métodos: un total de 120 pacientes fueron incluidos. La escala de Malnutrición-Inflamación (MIS) se utilizó para la detección del riesgo nutricional. La CV fue evaluada por el cuestionario Kidney Disease Quality of Life versión 1.2 (KDQOL-SF). Los pacientes fueron estratificados en tres grupos de acuerdo con el estado de la vitamina D: suficiencia (≥ 30 ng/dl), insuficiencia (29-10 ng/dl) y deficiencia (< 10 ng/dl) Resultados: se observó hipovitaminosis D en el 71 % de los pacientes. El análisis de regresión lineal múltiple mostró que la deficiencia de vitamina D fue el predictor más significativo de peores resultados en el cuestionario KDQOL-SF. La deficiencia de 25(OH)D explicó el 21 % de la varianza en el componente sumatorio de la enfermedad renal, el 27 % en el componente sumatorio físico y el 22 % en el componente sumatorio mental. Cuando evaluamos el estado nutricional, el análisis de regresión logística multivariante mostró que solo la deficiencia de vitamina D presenta un efecto significativo en la desnutrición (OR: 14.6, p < 0,001). Conclusión: De nuestros hallazgos concluimos que la hipovitaminosis D es muy frecuente entre los pacientes en HD y que su deficiencia está asociada un deterioro del estado nutricional y peor percepción de la calidad de vida.

Risk-based versus GFR threshold criteria for nephrology referral in chronic kidney disease.

Chronic kidney disease (CKD) and kidney failure are global health problems associated with morbidity, mortality and healthcare costs, with unequal access to kidney replacement therapy between countries. The diversity of guidelines concerning referral from primary care to a specialist nephrologist determines different outcomes around the world among patients with CKD where several guidelines recommend referral when the glomerular filtration rate (GFR) is <30 mL/min/1.73 m2 regardless of age. Additionally, fixed non-age-adapted diagnostic criteria for CKD that do not distinguish correctly between normal kidney senescence and true kidney disease can lead to overdiagnosis of CKD in the elderly and underdiagnosis of CKD in young patients and contributes to the unfair referral of CKD patients to a kidney specialist. Non-age-adapted recommendations contribute to unnecessary referral in the very elderly with a mild disease where the risk of death consistently exceeds the risk of progression to kidney failure and ignore the possibility of effective interventions of a young patient with long life expectancy. The opportunity of mitigating CKD progression and cardiovascular complications in young patients with early stages of CKD is a task entrusted to primary care providers who are possibly unable to optimally accomplish guideline-directed medical therapy for this purpose. The shortage in the nephrology workforce has classically led to focused referral on advanced CKD stages preparing for kidney replacement, but the need for hasty referral to a nephrologist because of the urgent requirement for kidney replacement therapy in advanced CKD is still observed and changes are required to move toward reducing the kidney failure burden. The Kidney Failure Risk Equation (KFRE) is a novel tool that can guide wiser nephrology referrals and impact patients.

Improved nephrology referral of chronic kidney disease patients: potential role of smartphone apps.

In chronic kidney disease (CKD), referral to nephrology is based on Kidney Disease: Improving Global Outcomes 2012 guidelines and is generally indicated when the estimated glomerular filtration rate (eGFR) is <30 mL/min/1.73 m2 or when there is a rapid decline of eGFR, elevated urinary albumin:creatinine ratio (>300 mg/g) or other 'alert' signs such as the presence of urinary red blood cell casts. Since eGFR declines with ageing in otherwise healthy individuals, we propose that the eGFR threshold for nephrology referral should be adjusted according to age. According to current recommendations, young patients without rapidly progressing CKD are referred more often to nephrology when CKD is more severe, compared with age-matched controls with normal eGFRs, than elderly CKD patients. In this commentary, we discuss the age factor and other specific situations not considered in current guidelines for nephrology referral of CKD patients.

Lupus Podocytopathy: An Overview.

In systemic lupus erythematosus, nephrotic-range proteinuria typically signals the presence of a proliferative lupus nephritis (class III/IV) and/or membranous lupus nephritis (class V, with or without concomitant class III or IV lesions). However, in rare instances, systemic lupus erythematosus patients with nephrotic syndrome have kidney biopsy findings of normal glomeruli or focal segmental glomerulosclerosis lesions, with or without mesangial proliferation, on light microscopy; the absence of subepithelial or subendothelial deposits on immunofluorescence and electron microscopy; and diffuse foot process effacement on electron microscopy. This pattern, termed lupus podocytopathy, is a unique form of lupus nephritis that mimics minimal change disease or primary focal segmental glomerulosclerosis and represents approximately 1% of lupus nephritis biopsies. Here we review the clinical features, histological manifestations, diagnostic criteria and classification, pathogenesis, treatment, and prognosis of lupus podocytopathy.

Asymmetric (ADMA) and Symmetric (SDMA) Dimethylarginines in Chronic Kidney Disease: A Clinical Approach.

Asymmetric dimethylarginine (ADMA) and its enantiomer, Symmetric dimethylarginine (SDMA), are naturally occurring amino acids that were first isolated and characterized in human urine in 1970. ADMA is the most potent endogenous inhibitor of nitric oxide synthase (NOS), with higher levels in patients with end-stage renal disease (ESRD). ADMA has shown to be a significant predictor of cardiovascular outcome and mortality among dialysis patients. On the other hand, although initially SDMA was thought to be an innocuous molecule, we now know that it is an outstanding marker of renal function both in human and in animal models, with ESRD patients on dialysis showing the highest SDMA levels. Today, we know that ADMA and SDMA are not only uremic toxins but also independent risk markers for mortality and cardiovascular disease (CVD). In this review, we summarize the role of both ADMA and SDMA in chronic kidney disease along with other cardiovascular risk factors.

Impact of a phone app on nephrology referral.

BACKGROUND: Various factors can lead to inadequate nephrology referral decisions being taken by clinicians, but a major cause is unawareness of guidelines, recommendations and indications, or of appropriate timing. Today, tools such as smartphone applications (Apps) can make this knowledge more accessible to non-nephrologist clinicians. Our study aim is to determine the effectiveness of a purpose-built app in this respect. METHODS: In a retrospective study, nephrology referrals were compared before and after the introduction of the app in clinical practice. The initial study population consisted of first visits by patients referred to our department in 2015, before the introduction of the app. In 2016, the smartphone app NefroConsultor began to be implemented in our hospital. We compared the initial study population with the results obtained for patients referred in 2017, when the app was in use, taking into account clinical features considered, such as urinalysis, proteinuria or kidney ultrasound, to determine whether these patients met currently recommended criteria for referral. RESULTS: The total study population consisted of 628 patients, of whom 333 were examined before the introduction of the app (in 2015) and 295 when it was in use (in 2017). Among the first group, 132 (39.6%) met established KDIGO criteria for nephrology referral and were considered to be correctly referred. Among the second group, 200 (67.8%) met the criteria and were considered to be properly referred (P = 0.001). The increase in the rate of intervention success (before-after app) was 28.8% with a binomial effect size display (Cohen's d effect size) of 0.751. Before the introduction of the app, data for albuminuria were included in 62.5% of nephrology referrals; in 2017, the corresponding value was 87.5% (P = 0.001). In the same line, referrals including urinalysis rose from 68.5% to 85.8% (P = 0.001). Multivariate regression analysis, using referrals meeting KDIGO criteria as the dependent variable and adjusting for age, sex and referring department, showed that the 2017 group (after the introduction of NefroConsultor) was associated with an odds ratio of 3.57 (95% confidence interval 2.52-5.05) for correct referrals, compared with the 2015 group (P = 0.001). References to proteinuria as the reason for nephrology referral also increased from 23.7% to 34.2% (P = 0.004). CONCLUSIONS: Use of the app is associated with more frequent studies of albuminuria at the time of referral and a greater likelihood of proteinuria being cited as the reason for referral. The smartphone app considered can improve the accessibility of information concerning nephrology referrals and related studies.

Acute and Chronic Tubulointerstitial Nephritis of Rheumatic Causes.

Tubulointerstitial nephritis (TIN) is the second most common cause of acute intrinsic kidney injury after acute tubular necrosis. Although drug-induced forms of TIN represent the vast majority, rheumatic disease is another common cause and often underdiagnosed. Early diagnosis of acute interstitial nephritis and prompt withdrawal of the culprit medication or a correct treatment can avoid chronic damage and progressive chronic kidney disease. This review highlights the recent updates, clinical features, and treatment in TIN in autoimmune rheumatic disease.

Fluctuation of pre-hemodialysis serum sodium
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INTRODUCTION: Low pre-hemodialysis (pre-HD) serum sodium or hyponatremia is associated with higher mortality. Pre-HD serum sodium can be more stable over time with low fluctuation compared to other serum parameters. MATERIALS AND METHODS: We examined variation of pre-HD serum sodium in 24 months and after this point examined all-cause mortality in a cohort of 261 patients followed-up for 48.8 (standard deviation (SD) = 19.1) months. 6,221 determinations of pre-HD serum sodium were made and corrected for glucose concentrations. Serum sodium was measured pre-HD monthly, and the variability was calculated using the coefficient of variation (CV). RESULTS: The mean age was of 60 ± 14.1 years, 60.9% were men, 48% had diabetes mellitus, and diabetic nephropathy was the most frequent cause of end-stage renal disease. Median CV of sodium in 24 months was 1.7% with a mean of 1.78% (95% CI 1.73 - 1.83). Patients with CV > 1.7% had a higher mortality (53 patients a 36.8%) compared to CV < 1.7% (22 patients a 18.8%) (p = 0.002). In Kaplan-Meier analysis, patients with CV > 1.7% had significantly worse overall survival (log rank = 6.395, p = 0.011). We also stratified the sample in serum sodium tertiles (< 138 mEq/L; 138 - 140 mEq/L; > 140 mEq/L) and made a Kaplan-Meier analysis which showed persistent worse survival outcomes in patients with CV > 1.7% (log rank Mantel-Cox 7.64; p = 0.006). Cox regression multivariate model showed that CV of sodium was significantly associated with overall mortality after adjusting for confounder variables (hazard ratio 2.16, 95% CI 1.37 - 3.41; p = 0.001). CONCLUSION: Variation of pre-HD serum sodium in 2 years is less than a 2%. With the limitations of our study, a higher variability of pre-HD serum sodium in 2 years of treatment (CV > 1.7%) is associated with increased mortality.
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Asymmetric Dimethylarginine (ADMA) Levels Are Lower in Hemodialysis Patients Treated With Paricalcitol.

INTRODUCTION: Chronic kidney disease is a major public health problem. In the last decade, it has been shown that the early stages of chronic kidney disease are associated with an inflammatory condition involving an increased risk of cardiovascular morbidity and long-term mortality. In patients with chronic kidney disease and more specifically those on hemodialysis, cardiovascular events are the most common cause of death. Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide synthase and may be an independent risk factor for endothelial dysfunction and cardiovascular disease. METHODS: We performed a cross-sectional analysis to identify factors that were associated with ADMA such as certain medications related to cardiovascular disease in dialysis patients. RESULTS: Patients who were treated with paricalcitol had significantly lower levels of ADMA (0.21 ± 0.19 µmol/l) compared with those not treated with paricalcitol (0.42 ± 0.35 µmol/l) (P = 0.00027). Dividing ADMA levels by quartiles, patients treated with paricalcitol were less likely to have very high level ADMA (P = 0.014), whereas there were no significant differences with other medications. Higher dose of paricalcitol was also related to lower levels of ADMA noting an inverse correlation (r = -0.36, P = 0.013). DISCUSSION: Hemodialysis patients treated with paricalcitol presented significantly decreased ADMA levels compared with those who did not receive this treatment. Possible beneficial effects in terms of cardiovascular morbidity and mortality by paricalcitol and its association with ADMA and nitric oxide synthesis are unknown. Studies to confirm this effect and determine the underlying pathophysiological mechanism are necessary.

Presencia de sintomatología ansiosa y depresiva en pacientes ambulatorios con patología neurológica / Presence of anxiety and depression symptoms in outpatients with neurological disease

La información referente a la presencia de síntomas psiquiátricos en la práctica no psiquiátrica es escasa, cerca del 25% de los pacientes son reportados con esta sintomatología. Esto se observa más comúnmente en trastornos neurológicos dada la severidad de los síntomas y el grado de discapacidad que ocasionan. El objetivo de la presente investigación es identificar factores asociados a la presencia de síntomas de ansiedad y/o depresión en pacientes con patología neurológica. Se realizó un estudio transversal, descriptivo, tomando 209 pacientes de la consulta externa del servicio de neurología del Hospital General del Estado de Sonora a fin de obtener una prevalencia de periodo de la presencia de síntomas de ansiedad y depresión mediante la Escala de Malestar Psicológico de Kessler en su versión extendida (K10), así como una encuesta sociodemográfica para determinar su asociación con factores que pudieran influir en la presencia y severidad de dicha sintomatología. Todos los participantes otorgaron su consentimiento informado. Se encontraron puntuaciones superiores a 21 puntos en la escala K10 (altamente sugestiva de la presencia de un trastorno de ansiedad y/o depresión) en 63.2% de los pacientes. Estas puntuaciones fueron más frecuentes en los pacientes con enfermedades cerebrovasculares (85.7%), manteniéndose por arriba del 60% para el resto de los trastornos, con una mayor frecuencia en el sexo femenino (85%). Los resultados sugieren una mayor asociación, para más de la mitad de los pacientes que acuden a la consulta de neurología, de padecer sintomatología ansiosa y/o depresiva con una severidad suficiente para verse beneficiados por un tratamiento integral. Existe una mayor asociación en relación con padecimientos más severos o discapacitantes, así como con el sexo femenino, por lo que se proponen investigaciones subsecuentes a fin de determinar los componentes de esta asociación e identificar intervenciones eficaces a fin de mejorar no solamente el estado de salud de estos pacientes sino su propia calidad de vida.

There is little information available describing psychiatric symptoms in non-psychiatric patients, with 25% of the patients being reported with such symptoms. These are most commonly observed with neurological disorders given the severity and degree of disability that they cause. The objective of this research was to identify the factors associated with the presence of anxiety and/or depression symptoms in patients with a neurological disorder. A transversal, descriptive study was carried out, taking 209 outpatients from the neurology service, with the aim of obtaining a period prevalence of the presence of anxiety and depression symptoms using the extended version of the Kessler Psychological Distress Scale (K10), and a sociodemographic interview to determine the association with factors that might influence on the presence and severity of such symptoms. All the participants signed an informed consent. We found scores superior to 21 points on the K10 scale (highly suggestive of the presence of an anxiety and/or depressive disorder) on 63.2% of the patients. These scores were more frequently found on patients with cerebrovascular diseases (85.7%), maintaining themselves above the 60% of the rest of the disorders. These results suggest a bigger association for more than half of the neurology outpatients to suffer from an anxiety and/or depressive symptoms severe enough to have benefits from an integral approach, with a bigger association in relation with more severe or incapacitating disorders, also the association was bigger on women. Thus, we need further research to determine the components of this association and identify effective interventions aiming to improve not just the patients' health, but also their quality of life.