Déficit de testosterona en los pacientes en diálisis: diferencias según la técnica de diálisis / Testosterone deficiency in dialysis patients: Difference between dialysis techniques

Los varones con enfermedad renal crónica cursan a menudo con deficiencia en testosterona. Se desconoce si el déficit de testosterona que acompaña a la pérdida de función renal se asocia con el tipo de tratamiento sustitutivo de la función renal. Métodos: El estudio de corte transversal incluyó 79 varones prevalentes en diálisis, 43 en hemodiálisis (HD) y 36 en diálisis peritoneal (DP). Con una edad media de 69 años, el 31,6% eran diabéticos. Se evaluaron los niveles de testosterona endógena (inmunoluminiscencia: N 3-10,5ng/ml), marcadores nutricionales/inflamatorios, marcadores de metabolismo óseo mineral, anemia, tipo de técnica y permanencia. La composición corporal fue estimada mediante bioimpedancia vectorial y espectroscópica. Se considera déficit de testosterona cuando los niveles son inferiores a 3ng/ml. Resultados: Los niveles de testosterona medios fueron 8,81±6,61ng/ml. El 39,5% de los pacientes en HD y el 5,6% de los de DP presentaban déficit de testosterona. Los niveles de testosterona se correlacionaron directamente con el tipo de técnica, HD (rho Spearman 0,366; p < 0,001) y el tiempo de permanencia (Rho −0,412; p=0,036) en el análisis univariante y solo con la técnica de HD en el multivariante. No se encontraron otras correlaciones significativas. Conclusiones: Los niveles circulantes de testosterona en hombres en diálisis se asocian de manera independiente con la técnica de HD. Se puede concluir que, en la reducción de testosterona que acompaña de manera natural a la pérdida de masa muscular e inflamación, se asocia un nuevo factor que es la técnica dialítica. Se necesitan estudios para elucidar si la técnica per se favorece la eliminación de testosterona (AU)

Testosterone deficiency is a prevalent condition in male patients with chronic kidney disease. However, it is not known whether the type of renal replacement therapy has an impact on testosterone deficiency that accompanies loss of renal function. Methods: The cross-sectional study enrolled 79 prevalent male patients on dialysis; 43 on haemodialysis (HD) and 36 on peritoneal dialysis (PD). The median age was 69 years and 31.6% were diabetics. Endogenous testosterone levels were measured by immunoluminescence assay (normal range 3-10.5ng/ml), while nutritional/inflammatory markers, bone and mineral metabolism markers, anaemia, type of dialysis technique and time on dialysis were also assessed. Body composition was evaluated by bioimpedance vector analysis and bioimpedance spectroscopy. Testosterone deficiency was defined as levels below 3ng/ml. Results: Mean testosterone levels were 8.81±6.61ng/ml. Testosterone deficiency affected 39.5% of HD patients and only 5.6% of PD patients. In the univariate analysis, testosterone levels were directly correlated with type of dialysis technique (HD) (Rho Spearman 0.366; P<.001) and time on dialysis (Rho −0.412; P=.036) and only with the HD technique in the multivariate analysis. No other significant correlations were found. Conclusions: Circulating testosterone levels in men on dialysis were independently associated with HD technique. It can be concluded that a new factor —namely the dialysis technique— may be associated with falling testosterone levels and the associated loss of muscle mass and inflammation. Further studies are needed to establish whether the dialysis technique itself triggers testosterone elimination (AU)

Testosterone deficiency in dialysis patients: Difference between dialysis techniques. / Déficit de testosterona en los pacientes en diálisis: diferencias según la técnica de diálisis.

Testosterone deficiency is a prevalent condition in male patients with chronic kidney disease. However, it is not known whether the type of renal replacement therapy has an impact on testosterone deficiency that accompanies loss of renal function. METHODS: The cross-sectional study enrolled 79 prevalent male patients on dialysis; 43 on haemodialysis (HD) and 36 on peritoneal dialysis (PD). The median age was 69 years and 31.6% were diabetics. Endogenous testosterone levels were measured by immunoluminescence assay (normal range 3-10.5ng/ml), while nutritional/inflammatory markers, bone and mineral metabolism markers, anaemia, type of dialysis technique and time on dialysis were also assessed. Body composition was evaluated by bioimpedance vector analysis and bioimpedance spectroscopy. Testosterone deficiency was defined as levels below 3ng/ml. RESULTS: Mean testosterone levels were 8.81±6.61ng/ml. Testosterone deficiency affected 39.5% of HD patients and only 5.6% of PD patients. In the univariate analysis, testosterone levels were directly correlated with type of dialysis technique (HD) (Rho Spearman 0.366; P<.001) and time on dialysis (Rho -0.412; P=.036) and only with the HD technique in the multivariate analysis. No other significant correlations were found. CONCLUSIONS: Circulating testosterone levels in men on dialysis were independently associated with HD technique. It can be concluded that a new factor -namely the dialysis technique- may be associated with falling testosterone levels and the associated loss of muscle mass and inflammation. Further studies are needed to establish whether the dialysis technique itself triggers testosterone elimination.

Linfoma no-Hodgkin simulando una peritonitis en un paciente en diálisis peritoneal / Non-Hodgkin lymphoma mimicking peritonitis in a patient on peritoneal dialysis

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Comment on Kaposi's sarcoma in the early post-transplant period in a kidney transplant recipient

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Influencia de las soluciones glucosadas en el desarrollo de hiperglucemia en diálisis peritoneal. Comportamiento de la hemoglobina glucosilada y el perfil lipídico / Influence of glucose solutions on the development of hyperglycaemia in peritoneal dialysis. Behaviour of glycated haemoglobin and the lipid profile

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Fallo precoz de trasplante renal y vuelta a diálisis peritoneal: estudio preliminar de permeabilidad y eficacia de diálisis / Early kidney transplant failure and return to peritoneal dialysis: preliminary study of permeability and dialysis efficacy

La vuelta a diálisis tras fallo de trasplante renal (TX) es una situación cada vez más frecuente. En la vuelta a diálisis tras TX fallido suele darse una situación clínica similar o peor a la de los pacientes nuevos en hemodiálisis o diálisis peritoneal (DP). Aunque existen bastantes estudios sobre la situación clínica de los pacientes que vuelven a DP tras períodos largos con TX funcionante, no hay apenas información sobre la evolución de un subgrupo de pacientes que vuelven a DP tras fallo de TX a los pocos días o semanas de su realización. Objetivo: Evaluar si un corto período de tiempo con TX subóptimo y tratamientos/medidas agresivas pueden influir en la permeabilidad de membrana, la situación clínica y la eficacia dialítica al volver a DP. Pacientes y métodos: En 9 pacientes (53,5 ± 15,4 años, 5 hombres, 4 mujeres) procedentes de DP con fallo precoz de TX y vuelta a DP (25 ± 23 días, rango 10-64) de los cinco últimos años, se estudian datos analíticos de inflamación, nutrición, función renal, permeabilidad y eficacia de DP, en cuatro momentos de la evolución: previo al TX, inmediatamente a la vuelta a DP, al primer mes y al tercer mes de DP. Resultados: No se detectan diferencias significativas en la evolución de los parámetros de nutrición e inflamación. La diuresis desciende de forma significativa del volumen previo al trasplante al de la vuelta a DP y al primer mes en DP (p = 0,032), manteniéndose en niveles reducidos a los tres meses en DP. La UF se reduce de 1407 a 951 ml/día (p = 0,022) y de 314 a 260 ml/4 h (p = 0,018) en el test de equilibrio peritoneal al tercer mes en DP, sin cambios en el cociente dializado/plasma de creatinina. Kt/V y aclaramiento semanal de creatinina descienden ligeramente, manteniéndose en niveles adecuados de eficacia. Conclusiones: En esta pequeña muestra de pacientes que vuelven a DP tras fallo precoz de TX, no parece que las medidas que comporta el manejo de un injerto en riesgo en un corto espacio de tiempo afecten de forma importante a parámetros clínicos y de permeabilidad o eficacia peritoneal

The return to dialysis after kidney transplant (TX) failure is increasingly common. On returning to dialysis after TX failure, there is usually a similar or worse clinical situation than in patients who are on haemodialysis or peritoneal dialysis (PD) for the first time. Although there are several studies on the clinical situation of patients who return to PD after long periods with a functioning TX, there is hardly any information on the progression of a patient subgroup returning to PD after TX failure a few days or weeks after transplantation. Objective: Assess whether a short period of time on suboptimal TX and aggressive treatment/measures may influence membrane permeability, the clinical situation and dialysis efficacy on returning to PD. Patients and method: In 9 patients (53.5±15.4 years of age, 5 males and 4 females) who had previously been on PD before early TX failure and had returned to PD (25±23 days, range 10-64) over the last five years, we studied laboratory data including inflammation, nutrition, kidney function, permeability and PD efficacy, at four points during progression: before TX, immediately after returning to PD and after one month and three months on PD. Results: We did not detect significant differences in the progression of nutrition and inflammation parameters.Diuresis decreased significantly from pre-TX volume to diuresis on return to PD and after one month on PD (p=.032), remaining at low levels after three months on PD. UF decreased from 1407 to 951ml/day (p=.022) and from 314 to 260ml/4h (p=.018) in the peritoneal equilibration test after three months on PD, without changes being observed in the creatinine dialysate/plasma ratio. Kt/V and weekly creatinine clearance decreased slightly and remained at adequate efficacy levels. Conclusions: In this small sample of patients, who returned to PD after early TX failure, it does not appear that the measures involved in managing a graft at risk over a short period of time have a major effect on clinical parameters and permeability or peritoneal efficacy

[Early kidney transplant failure and return to peritoneal dialysis: preliminary study of permeability and dialysis efficacy]. / Fallo precoz de trasplante renal y vuelta a diálisis peritoneal: estudio preliminar de permeabilidad y eficacia de diálisis.

UNLABELLED: The return to dialysis after kidney transplant (TX) failure is increasingly common. On returning to dialysis after TX failure, there is usually a similar or worse clinical situation than in patients who are on haemodialysis or peritoneal dialysis (PD) for the first time. Although there are several studies on the clinical situation of patients who return to PD after long periods with a functioning TX, there is hardly any information on the progression of a patient subgroup returning to PD after TX failure a few days or weeks after transplantation. OBJECTIVE: Assess whether a short period of time on suboptimal TX and aggressive treatment/measures may influence membrane permeability, the clinical situation and dialysis efficacy on returning to PD. PATIENTS AND METHOD: In 9 patients (53.5 ± 15.4 years of age, 5 males and 4 females) who had previously been on PD before early TX failure and had returned to PD (25 ± 23 days, range 10-64) over the last five years, we studied laboratory data including inflammation, nutrition, kidney function, permeability and PD efficacy, at four points during progression: before TX, immediately after returning to PD and after one month and three months on PD. RESULTS: We did not detect significant differences in the progression of nutrition and inflammation parameters. Diuresis decreased significantly from pre-TX volume to diuresis on return to PD and after one month on PD (p=.032), remaining at low levels after three months on PD. UF decreased from 1407 to 951 ml/day (p=.022) and from 314 to 260 ml/4h (p=.018) in the peritoneal equilibration test after three months on PD, without changes being observed in the creatinine dialysate/plasma ratio. Kt/V and weekly creatinine clearance decreased slightly and remained at adequate efficacy levels. CONCLUSIONS: In this small sample of patients, who returned to PD after early TX failure, it does not appear that the measures involved in managing a graft at risk over a short period of time have a major effect on clinical parameters and permeability or peritoneal efficacy.

Oral paricalcitol as antiproteinuric agent in chronic kidney disease.

BACKGROUND: Vitamin D has an important regulatory effect on the renin-angiotensin-aldosterone system, playing a central role in the regulation of proteinuria. We therefore studied the antiproteinuric effect of paricalcitol. METHODS: 36 patients with an estimated GFR of 30-90 mL/min/1.73 m² and proteinuria >400 mg/d with a stable dose of ACE inhibitor or ARB for at least 3 months were recruited. Patients received oral paricalcitol 1 µg/day for 12 months. Primary endpoint was decrease in proteinuria from baseline. Secondary endpoints were changes in creatinine, eGFR, serum levels of calcium, phosphorus, iPTH, 25(OH)vitD, C-Reactive Protein and blood presure. RESULTS: Mean proteinuria was 2806 mg/d and fell to 2199 mg/d at month 6 (p<.0001) and 1931.5 mg/d at month 12 (P<.0001). Patients with >3000 mg/d baseline proteinuria (n=12) saw smaller relative reductions in proteinuria (5956.9±2492.6 mg/d to 4220.4±2613 mg/d at 12 months) than patients with <3000 mg/d baseline proteinuria (1371±627.5 mg/d to 821.3±491.5mg/d at 12 months). There were no changes in BP, eGFR and CRP. We observed significant changes in serum levels of calcium, phosphorus, iPTH, 25(OH) vitamin D. CONCLUSION: Our study shows an important reduction in proteinuria with a low dose of oral paricalcitol in CKD, that is particularly robust with baseline proteinuria between 1-3 g/d.

Oral paricalcitol as antiproteinuric agent in chronic kidney disease

Background: Vitamin D has an important regulatory effect on the renin-angiotensin-aldosterone system, playing a central role in the regulation of proteinuria. We therefore studied the antiproteinuric effect of paricalcitol. Methods: 36 patients with an estimated GFR of 30-90mL/min/1.73m2 and proteinuria >400mg/d with a stable dose of ACE inhibitor or ARB for at least 3 months were recruited. Patients received oral paricalcitol 1µg/day for 12 months. Primary endpoint was decrease in proteinuria from baseline. Secondary endpoints were changes in creatinine, eGFR, serum levels of calcium, phosphorus, iPTH, 25(OH)vitD, C-Reactive Protein and blood presure. Results: Mean proteinuria was 2806mg/d and fell to 2199mg/d at month 6 (p<.0001) and 1931.5mg/d at month 12 (p<.0001). Patients with >3000mg/d baseline proteinuria (n=12) saw smaller relative reductions in proteinuria (5956.9±2492.6mg/d to 4220.4±2613mg/d at 12 months) than patients with <3000mg/d baseline proteinuria (1371±627.5 mg/d to 821.3±491.5mg/d at 12 months). There were no changes in BP, eGFR and CRP. We observed significant changes in serum levels of calcium, phosphorus, iPTH, 25(OH) vitamin D. Conclusion: Our study shows an important reduction in proteinuria with a low dose of oral paricalcitol in CKD, that is particularly robust with baseline proteinuria between 1-3g/d (AU)

Introducción: La vitamina D posee un efecto regulatorio del eje renina-angiotensina-aldosterona, jugando, por lo tanto, un papel importante en cuanto a proteinuria se refiere. Presentamos nuestra experiencia en el uso de paricalcitol como antiproteinúrico. Métodos: Incluimos 36 pacientes con un eGFR of 30-90 ml/min/1,73 m2 y proteinuria > 400 mg/d con dosis estables de inhibidores del SRAA durante 3 meses. Se le admistró durante 12 meses 1 µg/día de paricalcitol. Como objetivo primario estudiamos el descenso de proteinuria; como secundarios cambios en Cr, eFG, calcio, fósforo, iPTH, 25(OH)vitD, PCR y tension arterial. Resultados: La proteinuria media fue 2806 mg/d cayendo hasta 2199 mg/d en el mes 6 (p < 0,0001) y 1931,5 mg/d a los 12 meses (p < 0,0001). Aquellos con una proteinuria basal > 3000 mg/d (n=12) sufrieron una menor disminución (5956,9 ± 2492,6 mg/d a 4220,4 ± 2613 mg/d en mes 12) respecto a aquellos con una proteinuria < 3000 mg/d (1371 ± 627,5 mg/d a 821,3 ± 491,5 mg/d en mes 12). No se objetivaron cambios en tension arterial, eGFR y PCR. Los cambios en calcio, fósforo, iPTH y vitamina D 25(OH) fueron estadísticamente significativos. Conclusión: Nuestro estudio demuestra una reducción importante de proteinuria con dosis bajas de paricalcitol en pacientes con IRC, que es de particular importancia en aquellos con porteinuria basal entre 1-3 g/d (AU)

Endogenous testosterone, muscle strength, and fat-free mass in men with chronic kidney disease.

OBJECTIVE: Testosterone deficiency is a common finding in men with chronic kidney disease (CKD). Testosterone is thought to play an important anabolic role in muscle synthesis, and muscle wasting is an important and deleterious characteristic of protein-energy wasting (PEW) in CKD. It is presently unknown if reduced endogenous testosterone associates with features of muscle wasting in men with CKD. METHODS: This was a cross-sectional observational study of 267 men with CKD stages 2-4 (mean ± standard deviation age 67 ± 13 years, estimated glomerular filtration rate 42.9 [interquartile range 30.2-56.7] mL/min/1.73 m²) with measurements of endogenous testosterone and surrogates of PEW such as albumin, prealbumin, high-sensitivity C-reactive protein (CRP) and normalized protein nitrogen appearance (nPNA). Fat-free mass was estimated by bioelectrical impedance vector analysis (BIVA) and muscle strength by handgrip dynamometry. RESULTS: Across decreasing thirds of testosterone distribution, patients were incrementally older and CRP levels rose significantly. Prealbumin, hemoglobin, nPNA, handgrip strength, and BIVA estimated surrogates of muscle mass and nutritional status (fat-free mass, body cell mass, and phase angle) were progressively reduced (P < .05 for all). In multivariate regression analyses including age, renal function, and other important confounders, testosterone significantly and independently contributed to explain the variances of handgrip strength and fat-free mass (P < .05 for all). CONCLUSIONS: Endogenous testosterone independently associates with muscle strength and fat-free mass in men with moderate CKD. It is plausible that the reduction in testosterone levels that accompanies CKD may further contribute to the procatabolic environment leading to muscle wasting.

A propósito de las discrepancias entre documentos de consenso, guías de práctica clínica y normativa legal en el tratamiento de la diabetes tipo 2 / About the discrepancies between consensus documents, clinical practice guidelines, and legal regulations in the treatment of type 2 diabetes

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Changes in peritoneal membrane permeability and proteinuria in patients on peritoneal dialysis after treatment with paricalcitol − a preliminary study.

BACKGROUND: Patients on peritoneal dialysis (PD) have protein loss through peritoneal membrane (PM) and experience changes in permeability of the membrane. Paricalcitol is a selective vitamin D receptor activator with an effect upon systemic inflammation and an inhibitory effect upon the renin-angiotensin-aldosterone system (RAAS). METHODS: This study explores the possible effect of paricalcitol upon the PM in 23 patients on PD with high iPTH levels. Peritoneal kinetic studies were performed before and after paricalcitol, measuring also ultrafiltration/ day, peritoneal protein losses and proteinuria. Results were compared with a control group of 15 patients not receiving any form of vitamin D. RESULTS: With a mean dose of 1.3 µg/day, peritoneal protein loss decreased from 0.91 ± 0.35 to 0.76 ± 0.26 g/l (15.4%) (p = 0.007) and from 7.55 to 6.46 g/d (p < 0.033), and ultrafiltration increased from 844 to 1,002 ml/d (15.8%) (p = 0.037) and from 284 to 323 ml/4 h. (NS), with minimal change in the creatinine dialysate/plasma ratio 0.67 ± 0.12 vs. 0.65 ± 0.11. Proteinuria decreased from 1.65 to 1.25 g/l (21.9%) (p = 0.01) and iPTH decreased from 668 ± 303 to 291 ± 148 pg/ml (p < 0.001). In the control group, no changes in peritoneal membrane permeability and proteinuria were found. CONCLUSIONS: The results of the study indicate that paricalcitol is effective in treating hyperparathyroidism in patients on PD, and suggest an effect upon proteinuria and PM permeability (not previously reported), with diminished peritoneal protein loss and increased ultrafiltration. The antiinflammatory, antifibrotic and RAAS-modulating actions described for paricalcitol may be responsible for these findings, and could be important for preserving the peritoneum as a dialyzing membrane.

Effects of oral paricalcitol on hyperparathyroidism and proteinuria in peritoneal dialysis patients.

Severe secondary hyperparathyroidism is a complication of chronic kidney disease. Paricalcitol is a vitamin D receptor activator with efficacy in the treatment of hyperparathyroidism that also has the minor side effects of hypercalcemia and hyperphosphatemia. As a pleiotropic effect, paricalcitol reduces proteinuria in patients with chronic kidney disease stages 2-4. Oral paricalcitol offers an alternative way to treat hyperparathyroidism and proteinuria in peritoneal dialysis patients. Our prospective study enrolled 18 patients with hyperparathyroidism (6 with diabetes also) who were given oral paricalcitol at initial dose of 1-2 microg daily, depending on their level of intact parathyroid hormone (iPTH). In the 1st month, iPTH levels declinedsignificantly to 295 +/- 147 pg/mL from 670 +/- 318 pg/mL, and by the 3rd month, they declined to 192 +/- 340 pg/mL (p < 0.001). Without modifications to doses of angiotensin converting-enzyme inhibitor or angiotensin II receptor blocker, proteinuria declined in the 1st month to 1.41 +/- 1.5 g/L from 1.68 +/- 1.7 (p = 0.006) and, in the 3rd month, without statistical significance. In some patients, the dose of paricalcitol was reduced because of iPTH levels that were too low at 1 month. The patients whose doses of paricalcitol were maintained at 3 months showed a reduction in proteinuria to 2.1 +/- 2.1 g/L daily from 3.1 +/- 2. 7 g/L (p = 0.04) and to 2.3 +/- 2.1 g/day from 5.0 +/- 6.1 g/day (p = 0.012). In conclusion, paricalcitol is effective for treating hyperparathyroidism in patients on peritoneal dialysis and seems also to have an antiproteinuric effect in these patients.