Is peritoneal dialysis suitable technique CKD patients over 65 years? A prospective multicenter study.

BACKGROUND: Chronic kidney disease (CKD) is increasing in patients older than 65 years and is related to morbidity, frailty, and dependence. Peritoneal dialysis (PD) has classically been associated with young patients with an active life. HYPOTHESIS: PD should be offered to patients over 65 years. We search for any unfavorable results that may advice not to recommend PD therapy for this group. OBJECTIVE: To describe PD treatment and outcomes in patients > 65 years, to compare their results with patients < 65 years and to identify areas with room for improvement in a real-life study. STUDY: Prospective, observational, and multicenter study performed in incident PD patients, from January 2003 until January 2018. RESULTS: We included 2,435 PD patients, 31.9% were older than 65 years; there was a difference of 25 years between both groups. Median follow up was 2.1 years. Older than 65 years group had more comorbidity: Diabetes (29.5% vs 17.2%; p < 0.001), previous CV events 34.5% vs 14.0%; p < 0.001), Charlson index (3.8 vs 3.0; p < 0.001). We did not find differences in efficacy and PD adequacy objectives fulfillment, anaemia management or blood pressure during follow-up. Peritonitis rate was higher in older 65 years group (0.65 vs 0.45 episodes/patient/year; p < 0.001), but there was not differences in germs, admission rate and follow up. Mortality was higher in older 65 years group (28.4% vs 9.4%) as expected. PD permanence probability was similar (2.1 years). The main cause of PD withdrawal was transplant in group < 65 years (48.3%) and transfer to HD in group > 65 years. The main reason was caregiver or patient fatigue (20.2%), and not technique failure (7.3%). Multivariate Cox regression analysis showed a relation (HR [95%CI]) between mortality and age > 65 years 2.4 [1.9-3.0]; DM 1.6 [1.3-2.1]; CV events 2.1 [1.7-2.7]. Multivariate Cox regression analysis identify a relation between technique failure and age > 65 years 1.5 [1.3-1.9]; DM 1.6 [1.3-1.9] and previous transplant 1.5 [1.2-2.0]. CONCLUSION: Patients older than 65 years fulfilled PD adequacy criteria during the follow up. We believe PD is a valid option for patients older 65 years. It is necessary to try to prevent infections and patient/caregiver fatigue, to avoid HD transfer for reasons not related to technique failure.

Síndrome de secreción inadecuada de hormona antidiurética (SIADH) secundario a bortezomib en mieloma múltiple de cadenas ligeras. Tratamiento con tolvaptán / Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) due to bortezomib in a case of light chain multiple mieloma. Treatment with tolvaptan

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La sombra del RALES es alargada / The shadow of ‘‘RALES’’ is long

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Spontaneous remission of nephrotic syndrome in idiopathic membranous nephropathy.

Spontaneous remission is a well known characteristic of idiopathic membranous nephropathy, but contemporary studies describing predictors of remission and long-term outcomes are lacking. We conducted a retrospective, multicenter cohort study of 328 patients with nephrotic syndrome resulting from idiopathic membranous nephropathy that initially received conservative therapy. Spontaneous remission occurred in 104 (32%) patients: proteinuria progressively declined after diagnosis until remission of disease at 14.7 +/- 11.4 months. Although spontaneous remission was more frequent with lower levels of baseline proteinuria, it also frequently occurred in patients with massive proteinuria: 26% among those with baseline proteinuria 8 to 12 g/24 h and 22% among those with proteinuria >12 g/24 h. Baseline serum creatinine and proteinuria, treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists, and a >50% decline of proteinuria from baseline during the first year of follow-up were significant independent predictors for spontaneous remission. Only six patients (5.7%) experienced a relapse of nephrotic syndrome. The incidence of death and ESRD were significantly lower among patients with spontaneous remission. In conclusion, spontaneous remission is common among patients with nephrotic syndrome resulting from membranous nephropathy and carries a favorable long-term outcome with a low incidence of relapse. A decrease in proteinuria >50% from baseline during the first year predicts spontaneous remission.

Association between C-reactive protein levels and N-terminal pro-B-type natriuretic peptide in pre-dialysis patients.

BACKGROUND: The prevalence of inflammation is high among patients with chronic renal failure but the reason of inflammation is unclear. We test the hypothesis that inflammation in chronic renal failure could be the consequence of an increased left-ventricular wall tension related to ventricular dysfunction, hypervolemia or both. METHODS: For assessing left-ventricular filling pressure, plasma level of N-terminal pro-B-type natriuretic peptide (N-BNP) was used, as B-type natriuretic peptide is secreted from the cardiac ventricles in response to increased wall tension. N-BNP levels and C-reactive protein (CRP) were measured on the same day in 75 pre-dialysis patients. A previous history of cardiomiopathy with systolic dysfunction was present in 27 (36%) of them. RESULTS: The levels of N-BNP were not normally distributed (mean: 2,589 +/- 4,514 pg/ml; median: 789 pg/ml). The distribution of CRP levels was also not normal (mean: 15 +/- 27 mg/l; median: 5 mg/l). Both parameters correlated significantly (r: 0.41; p < 0.005). N-BNP was higher (p < 0.001) in patients with known ventricular dysfunction. Excluding these patients, the correlation between N-BNP and CRP was stronger (r: 0.88; p < 0.001). Univariate analysis in these patients without known cardiomyopathy showed that N-BNP levels also correlated with systolic and diastolic blood pressure (r: 0.54; p < 0.005) and inversely with creatinine clearance (r: -0.43; p < 0.01), serum albumin (r: 0.6; p < 0.001) and hemoglobin levels (r: 0.37; p < 0.05). CRP levels correlated significantly (p < 0.01) with the same parameters as N-BNP in univariate analysis. However, in multiple stepwise regression analysis in which CRP was the dependent variable, only the association with N-BNP remained significant (r: 0.87; p < 0.001). CONCLUSIONS: Our results suggest a link between left-ventricular filling pressure and inflammation in patients with advanced renal insufficiency. The importance of strict volume control in these patients, in order to reduce left-ventricular pressure and therefore inflammation, should be considered.

Significance of high C-reactive protein levels in pre-dialysis patients.

BACKGROUND: An elevated serum C-reactive protein (CRP) has been shown to be strongly predictive of morbidity and mortality in dialysis patients. However, the significance of high CRP levels in the pre-dialysis period has not been studied extensively. The aim of our study was to analyse the evolution of our pre-dialysis population according to their basal levels of CRP. METHODS: A cohort of 66 pre-dialysis patients was followed for 1 year, after initial determination of serum CRP. The evolution of blood pressure (BP) control, CRP levels, nutritional data (body mass index, serum albumin, prealbumin, transferrin, cholesterol), proteinuria, calcium-phosphorus product, bicarbonate, haemoglobin (Hb), the weekly dose of erythropoietin (Epo)/kg body weight, and the Hb/Epo dose ratio were measured and compared between patients with high (>6 mg/l) or low (<6 mg/l) CRP levels at baseline. The decline in renal function, hospitalization, and death also were measured and compared between the two groups. RESULTS: At baseline, 23 patients (35%) showed high (>6 mg/l) CRP levels. CRP was higher in patients with a previous history of cardiovascular disease (P<0.01), as well as in patients in whom ischaemic nephropathy or nephrosclerosis was the cause of end-stage renal disease (P<0.01). There were no differences between diabetic and non-diabetic patients. During the study period, patients with higher CRP levels at baseline maintained higher levels (P<0.001). During this period, these patients showed lower (P<0.05) albumin concentration, higher bicarbonate levels, lower Hb concentration, and lower Hb/Epo ratio and needed higher Epo doses. There were no differences in systolic BP, the degree of proteinuria, and the decline in renal function between groups; diastolic BP was lower in patients with high CRP levels. Hospitalization was higher (P<0.005) in this group. Only one patient died. CONCLUSIONS: The prevalence of inflammation is high in pre-dialysis patients. High serum CRP levels predict a constant inflammatory state on follow-up. As occurs in dialysis patients, pre-dialysis inflammation predicts lower serum albumin concentration, poorer response to Epo, and a higher hospitalization rate. The decline in renal function does not seem to be related to the inflammatory state. Mortality was not affected on short-term follow-up.

Conservative versus immunosuppressive treatment of patients with idiopathic membranous nephropathy.

BACKGROUND: Treatment of idiopathic membranous glomerulonephritis (MGN) is a controversial issue. Whereas some authors recommend early immunosuppressive treatment of all patients with nephrotic syndrome, others do not support aggressive therapies, based on the spontaneous long-term favorable outcome of most patients. However, 20 to 50% of untreated patients develop progressive renal insufficiency. METHODS: All of the patients with biopsy-proven MGN who developed renal insufficiency at our Hospital during the period of 1975 to 2000 were studied. Selected patients (N=39) were separated into two groups according to the two different therapeutic policies followed at our department: a conservative approach during the first period, 1975 to 1989 (group I, N=20), and a course of immunosuppressive therapy (oral prednisone for six months and concurrent oral chlorambucil, 0.15 mg/kg/day, during the first 14 weeks) during the second period, 1990 to 2000 (group II, N=19). RESULTS: There were no significant differences between both groups at the time of renal biopsy, nor at the onset of renal function decline. All group I patients showed a progressive renal insufficiency; at the end of the follow-up 13 patients (65%) were on chronic dialysis, 2 (10%) showed advanced renal failure, and 5 (25%) had died. In contrast, most of group II patients showed an improvement or stabilization of serum creatinine (SCr; 2.3 +/- 0.9 mg/dL at onset of treatment, 2 +/- 1.5 mg/dL at the end of follow-up) together with decreased proteinuria (11.2 +/- 3.3 vs. 5.2 +/- 6.7 g/24 h). At the end of the follow-up 58% of group II patients had a SCr value < or =1.5 mg/dL and 36% showed a complete or partial remission, whereas no patient in group I showed remission. After four years of follow-up the probability of renal survival without dialysis was 55% in group I and 90% in group II (P < 0.001), and after seven years the renal survival was 20% and 90%, respectively (P < 0.001). Side effects of immunosuppressive treatment were uncommon but severe, as two patients suffered Pneumocystis carinii pneumonia. CONCLUSION: A course of immunosuppressive treatment administered early at the onset of renal function decline induces a favorable effect in most of patients with MGN and deteriorating renal function. Untreated patients progressed without exception toward advanced renal failure.