Podocyte and tubular involvement in AngioJet-induced kidney injury.

The AngioJet technique combines localized thrombolysis and percutaneous mechanical thrombectomy (PMT). However, PMT may cause acute kidney injury (AKI), which has been ascribed to severe mechanical haemolysis, although no renal biopsies have been reported. We now report the first renal biopsy in a patient with AKI following PMT. There is histological evidence of haemoglobin (Hb)-induced tubular injury and podocyte stress characterized by intracellular Hb and staining for ferritin and hemo-oxygenase-1, suggestive of an adaptive response to oxidative stress. This confirms that Hb is involved in kidney cell injury and supports the existence of several different kidney cellular targets.

Hematuria Is Associated with More Severe Acute Tubulointerstitial Nephritis.

Acute tubulointerstitial nephritis (ATIN) is a common cause of acute kidney injury. Although haematuria is a risk factor for the development of renal disease, no previous study has analyzed the significance of haematuria in ATIN. Retrospective, observational analysis of 110 patients with biopsy-proven ATIN was conducted. Results: Haematuria was present in 66 (60%) ATIN patients. A higher percentage of ATIN patients with haematuria had proteinuria than patients without haematuria (89.4% vs. 59.1%, p = 0.001) with significantly higher levels of proteinuria (median (interquartile range) protein:creatinine ratio 902.70 (513-1492) vs. 341.00 (177-734) mg/g, p <0.001). Moreover, those patients with more haematuria intensity had a higher urinary protein:creatinine ratio (1352.65 (665-2292) vs. 849.60 (562-1155) mg/g, p = 0.02). Those patients with higher proteinuria were more likely to need renal replacement therapy (22.7 vs. 0%, p = 0.03) and to suffer relapse (4 vs. 0%, p = 0.03). At the end of follow up, haematuric ATIN patients had higher serum creatinine levels (3.19 ± 2.91 vs. 1.91 ± 1.17 mg/dL, p = 0.007), and a trend towards a higher need for acute dialysis (7 vs. 1%, p = 0.09) and renal replacement therapy (12.1 vs. 2.3%, p = 0.12). Haematuria is common in ATIN and it is associated with worse renal function outcomes.

Reactions to Synthetic Membranes Dialyzers: Is there an Increase in Incidence?

BACKGROUND: Reactions to dialyzers used in dialysis have been reported more frequently in recent years. Evidence, however, shows that the reaction rate has remained stable for years. SUMMARY: One explanation for the apparent increase in publication frequency could be the lack of knowledge that dialyzer reactions may well occur with biocompatible membranes. Studies showed that the cause of these reactions is very diverse and varied, involving multiple materials. However, polyvinylpyrrolidone continues to be the main suspect, but without conclusive results. There are no differences between the different fibers, and although polysulfone is the most described, it is also the most used. Key Messages: The change to cellulose triacetate continues to be the most appropriate form of treatment. The classification of these reactions into type A and B complicates the diagnosis, and its true usefulness is in doubt.

Uso exitoso del balón de Bakri en un caso de hemorragia postaborto de segundo trimestre y cesárea anterior / Successful use of Bakri balloon in a case of second trimester postabortion hemorrhage and prior caesarean section

Presentamos el caso de una secundigesta de 24 años (19+1 semanas de gestación) con cesárea anterior que presenta un aborto espontáneo y posterior hemorragia tras la evacuación uterina. Durante la exploración se constata una dehiscencia uterina. Ante el fracaso del tratamiento médico se coloca un balón de Bakri, consiguiendo detener el sangrado. Este caso pone de manifiesto la eficacia del taponamiento uterino en otras indicaciones diferentes a la hemorragia postparto. El manejo conservador con el balón de Bakri evitó una histerectomía, con la consiguiente preservación de la fertilidad y reducción de la morbi-mortalidad asociada

This article introduces the case of a 24-year-old gravida 2 (19+1 weeks of gestation) having had performed a previous cesarean, who presents a spontaneous abortion and a hemorrhage after uterine evacuation. Throughout the examination, it is remarkable a cesarean scar dehiscence and placenta accreta is suspected to be present. Having the starting therapies failed to work, a Bakri balloon is set managing to stop the bleeding. This case highlights the efficacy of uterine tamponade in situations different from postpartum hemorrhage. A hysterectomy was avoided with the Bakri balloon, resulting in the subsequent preservation of fertility and associated morbi-mortality reduction

Incidence of Hypersensitivity Reactions During Hemodialysis.

BACKGROUND/AIMS: A recent alert from Spanish health authorities warned of a higher incidence of reported hypersensitivity reactions to hemodialysis membranes with polysulfone, in the 2017 review of acute reactions to dialyzers found only published reports in the 21st century on polysulfone and its derivatives. The aim is to assess/evaluate the current incidence and characteristics of hypersensitivity reactions in hemodialysis patients. METHODS: A retrospective multicentre study in 9 Spanish hospitals evaluated patients in whom a hypersensitivity reaction required a change in dialyzer membrane. RESULTS: A total of 37 patients out of 1561 (2.37%) had hypersensitivity reactions and clinical, epidemiological and analytical data were available for 33 patients (2.11%). The membranes involved were polysulfone (n=23), polynephron (n=8), polyethersulfone (n=1) and polyacrylonitrile (n=1). This distribution reflected the frequency of use of membranes in the participating dialysis units. The reactions were described as type A in 18 cases and type B in 15 cases. There were no significant differences between the two types in clinical symptoms, the composition of the membrane involved, the method of sterilization, the season, or the time during the session in which they occurred. The most frequent symptom was dyspnea/breathlessness (64% of reactions). Eosinophilia was common (74%). 54% of the reactions occurred within the first 30 minutes of hemodialysis, 64% occurred during the first year of dialysis, and 54% required discontinuation of dialysis session. Cellulose triacetate was used as an alternative dialyzer in 78% of the cases. CONCLUSION: The incidence of hypersensitivity reactions was in the range found in reports from 20 years ago and is observed associated with synthetic membranes, not just polysulfones. Cellulose triacetate appears to be a good alternative for these patients.

Impact of Altered Intestinal Microbiota on Chronic Kidney Disease Progression.

In chronic kidney disease (CKD), accumulation of uremic toxins is associated with an increased risk of CKD progression. Some uremic toxins result from nutrient processing by gut microbiota, yielding precursors of uremic toxins or uremic toxins themselves, such as trimethylamine N-Oxide (TMAO), p-cresyl sulphate, indoxyl sulphate and indole-3 acetic acid. Increased intake of some nutrients may modify the gut microbiota, increasing the number of bacteria that process them to yield uremic toxins. Circulating levels of nutrient-derived uremic toxins are associated to increased risk of CKD progression. This offers the opportunity for therapeutic intervention by either modifying the diet, modifying the microbiota, decreasing uremic toxin production by microbiota, increasing toxin excretion or targeting specific uremic toxins. We now review the link between nutrients, microbiota and uremic toxin with CKD progression. Specific focus will be placed on the generation specific uremic toxins with nephrotoxic potential, the decreased availability of bacteria-derived metabolites with nephroprotective potential, such as vitamin K and butyrate and the cellular and molecular mechanisms linking these toxins and protective factors to kidney diseases. This information provides a conceptual framework that allows the development of novel therapeutic approaches.

Nutrients Turned into Toxins: Microbiota Modulation of Nutrient Properties in Chronic Kidney Disease.

In chronic kidney disease (CKD), accumulation of uremic toxins is associated with an increased risk of death. Some uremic toxins are ingested with the diet, such as phosphate and star fruit-derived caramboxin. Others result from nutrient processing by gut microbiota, yielding precursors of uremic toxins or uremic toxins themselves. These nutrients include l-carnitine, choline/phosphatidylcholine, tryptophan and tyrosine, which are also sold over-the-counter as nutritional supplements. Physicians and patients alike should be aware that, in CKD patients, the use of these supplements may lead to potentially toxic effects. Unfortunately, most patients with CKD are not aware of their condition. Some of the dietary components may modify the gut microbiota, increasing the number of bacteria that process them to yield uremic toxins, such as trimethylamine N-Oxide (TMAO), p-cresyl sulfate, indoxyl sulfate and indole-3 acetic acid. Circulating levels of nutrient-derived uremic toxins are associated to increased risk of death and cardiovascular disease and there is evidence that this association may be causal. Future developments may include maneuvers to modify gut processing or absorption of these nutrients or derivatives to improve CKD patient outcomes.

Diagnostic accuracy of fetal scalp lactate for intrapartum acidosis compared with scalp pH.

OBJECTIVE: To determine the diagnostic accuracy of fetal scalp lactate sampling (FSLS) and to establish an optimal cut-off value for intrapartum acidosis compared with fetal scalp pH. METHODS: A 20-month retrospective cohort study was conducted of all neonates delivered in our institution for whom fetal scalp blood sampling (FSBS) was performed, matching their intrapartum gasometry to their cord gasometry at delivery (n=243). The time taken from the performance of scalp blood sampling to arterial umbilical cord gas acquisition was 45 min at most. Five arterial cord gasometry patterns were set for assessing the predictive ability of both techniques. Subsequent obstetric management for a pathological value was analysed considering the use of both techniques. RESULTS: The optimal cut-off value for FSLS was 4.8 mmol/L: this value has 100% sensitivity and 63% specificity for umbilical arterial cord gas pH≤7.0 and base deficit (BD)≥12 detection, and 100% sensitivity and 64% specificity for umbilical arterial cord gas pH≤7.10 and BD≥12 detection, with a false negative rate of <1.3%, improving fetal scalp pH performance. FSLS showed the best area under the curve (AUC) of 0.86 and 0.84 for both arterial cord gasometry patterns, respectively. Expedite birth following lactate criteria would have been the same as following pH criteria (92 obstetric interventions) with no cases of missed metabolic acidosis. In the cohort, 19.8% of cases were discordant, but no cases of metabolic acidosis were in this group. CONCLUSIONS: FSLS improves the detection of metabolic acidosis via fetal scalp pH with an optimal cut-off value of 4.8 mmol/L. FSLS can be used without increasing obstetrical interventions or missing metabolic acidosis.

Combination use of medicines from two classes of renin-angiotensin system blocking agents: risk of hyperkalemia, hypotension, and impaired renal function.

European and United States regulatory agencies recently issued warnings against the use of dual renin-angiotensin system (RAS) blockade therapy through the combined use of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs) or aliskiren in any patient, based on absence of benefit for most patients and increased risk of hyperkalemia, hypotension, and renal failure. Special emphasis was made not to use these combinations in patients with diabetic nephropathy. The door was left open to therapy individualization, especially for patients with heart failure, when the combined use of an ARB and ACEI is considered absolutely essential, although renal function, electrolytes and blood pressure should be closely monitored. Mineralocorticoid receptor antagonists were not affected by this warning despite increased risk of hyperkalemia. We now critically review the risks associated with dual RAS blockade and answer the following questions: What safety issues are associated with dual RAS blockade? Can the safety record of dual RAS blockade be improved? Is it worth trying to improve the safety record of dual RAS blockade based on the potential benefits of the combination? Is dual RAS blockade dead? What is the role of mineralocorticoid antagonists in combination with other RAS blocking agents: RAAS blockade?

Repercusión en los resultados neonatales del intervalo de tiempo de nacimiento entre gemelos / Effect of twin-to-twin delivery time interval on neonatal outcome

Objetivo. Evaluar los factores que pueden influir sobre el intervalo de tiempo de nacimiento entre gemelos y sobre el resultado neonatal a corto plazo del segundo gemelo. Material y métodos. Se realizó un estudio descriptivo retrospectivo a través de la base de datos informatizada y la revisión de las historias clínicas de las pacientes atendidas en el Hospital Universitario Miguel Servet desde enero de 2005 hasta diciembre de 2007. Se ha realizado un análisis estadístico para determinar los factores que potencialmente pueden afectar el intervalo de tiempo de nacimiento entre gemelos incluyendo: características maternas, edad gestacional, tipo de parto, discordancia de pesos fetales, pH de arteria umbilical y puntuaciones en el test de Apgar. Resultados. De los 13.340 partos registrados durante el periodo de estudio, 206 gestaciones gemelares se ajustaron a los criterios de inclusión. La mayoría de los segundos gemelos (79,6%) nacieron en los 5 min siguientes al parto del primer gemelo. Las características maternas como la edad, la paridad, la obesidad y el tabaquismo no se relacionaron con el incremento del intervalo al nacimiento. Un mayor intervalo se asoció a un aumento de riesgo de puntuaciones bajas en el test de Apgar y a un descenso de los valores de pH de arteria umbilical. El parto instrumental se asoció a un incremento del intervalo de tiempo. Conclusión. Basándonos en nuestros datos y los reflejados por estudios previos podemos decir que el intervalo de tiempo al nacimiento entre gemelos parece ser un factor de riesgo independiente para un resultado neonatal adverso (AU)

Objective. To evaluate the factors influencing twin-to-twin delivery time interval and the short-term outcome of the second twin. Material and methods. We performed a retrospective, descriptive study by reviewing a computerized database and the medical records of pregnant women attending the Miguel Servet University Hospital from January 2005 to December 2007. A statistical analysis was performed to determine the factors potentially affecting twin-to-twin delivery time interval, including maternal characteristics, gestational age, mode of delivery, fetal weight discordance, umbilical artery pH and Apgar score. Results. Of the 13,430 deliveries registered during the study period, 206 twin pregnancies met the inclusion criteria. Most (79.6%) of the second twins were born within 5min of delivery of the first twin. Maternal characteristics such as age, parity, obesity and smoking were not related to twin-to-twin delivery time interval. A longer time interval was associated with an increased risk of low Apgar scores and a decline in umbilical artery pH in the second twin. Vaginal operative delivery was associated with an increased time interval. Conclusion. Based on our data and the results of previous studies, twin-to-twin delivery time interval seems to be an independent risk factor for adverse neonatal outcome (AU)

Complicaciones obstétricas y perinatales de la amniocentesis genética del segundo trimestre en las gestaciones gemelares / Obstetrical and perinatal complications of mid-trimester genetic amniocentesis in twin pregnancies

Objetivo: Evaluar el resultado de la amniocentesis del segundo trimestre en las gestaciones gemelares. Diseño: Estudio descriptivo retrospectivo. Institución: Unidad de Diagnóstico Prenatal, Hospital Universitario Miguel Servet, Instituto Aragonés de Ciencias de la Salud, Zaragoza, España. Participantes: Mujeres con gestaciones gemelares. Métodos: Se realizó un estudio mediante la base de datos informatizada y la revisión de las historias clínicas de las pacientes atendidas entre enero de 2004 y febrero de 2008. Las gestaciones gemelares sometidas a amniocentesis fueron comparadas con las gestaciones simples también sometidas a la técnica y con las gestaciones gemelares no sometidas a amniocentesis. Principales medidas de resultados: Complicaciones obstétricas y perinatales. Resultados: Durante los cuatro años del estudio se realizaron 4 263 amniocentesis, de las cuales 112 casos correspondieron a gestaciones gemelares y 4 151 a gestaciones simples. La edad materna avanzada y la ansiedad fueron las indicaciones más frecuentes de amniocentesis. La pérdida fetal durantelas 4 semanas posteriores al procedimiento fue de 1,78% para las gestaciones gemelares y 0,40% para las gestaciones únicas. Las gestaciones gemelares que se sometieron a una amniocentesis genética no presentaron otras complicaciones obstétricas ni peores resultados perinatales. Conclusiones: Basándonos en nuestros datos y los reflejados por estudios previos podemos decir que las gestaciones gemelares sometidas a una amniocentesis del segundo trimestre tienen un riesgo de pérdida fetal ligeramente superior a las gestaciones simples. No obstante, en manos de operadores experimentados, la amniocentesis es una técnica segura y efectiva para el diagnóstico prenatal en las gestaciones gemelares.

Objectives: To determine genetic mid-trimester amniocentesis outcomes in twin gestations. Design: Descriptive retrospective study. Setting: Prenatal Diagnosis Unit, Hospital Universitario Miguel Servet, Instituto Aragones de Ciencias de la Salud, Zaragoza, España. Patients: Women with twin gestations. Methods: Computerized database and medical records of pregnant women attended from January 2004 to February 2008 were reviewed. Twin pregnancies undergoing amniocentesis were compared with singleton pregnancies also exposed to amniocentesis and with unexposed twin pregnancies. Main outcome measures: Obstetrical and perinatal complications. Results: During the four years study 4 263 amniocentesis were performed, 112 in twin gestations and 4 151 in singleton gestations. Advanced maternal age and anxiety were the most common indications for amniocentesis. Fetal loss within four weeks after the procedure was 1,78% for twin pregnancies and 0,40% for singleton pregnancies.Twin gestations exposed to amniocentesis did not present other obstetrical complications or worse neonatal results. Conclusions: Based on our data and previous studies, we can advise patients undergoing mid-trimester twin amniocentesis that fetal loss rate may be slightly higher than for singleton amniocentesis. Although in hands of experienced operators amniocentesis is a safe and effective technique for prenatal diagnosis in twin gestations.

Complicaciones perinatales de la hiperdatia gestacional / Perinatal complications of post-term pregnancy

Objetivo. El propósito de este estudio es evaluar la morbilidad y mortalidad perinatales asociadas a las gestaciones que finalizan en la semana 41. Sujetos y métodos. Se ha diseñado un estudio de cohortes históricas. Los resultados perinatales de 230 gestaciones de 41 semanas se compararon con 234 gestaciones que finalizaron entre las 37 y las 40 semanas de gestación en el Hospital Universitario Miguel Servet en 2005. Resultados. Las tasas de oligoamnios, líquido amniótico teñido, macrosomía, puntuación en el test de Apgar a los 5minutos < 7 y valores bajos de pH arterial umbilical aumentan a las 41 semanas de gestación respecto a los embarazos entre las 37 y 40 semanas de gestación (significación estadística p<0,05). Conclusiones. Se ha encontrado que la tasa de complicaciones perinatales se incrementa cuando se alcanza la semana 41 de gestación. La apropiada investigación de este hecho es importante en la determinación de la edad gestacional a la cual el riesgo de continuar el embarazo supera el riesgo de una inducción de parto(AU)

Objective. The aim of this study was to evaluate the perinatal morbidity and mortality associated with pregnancies ending at 41 weeks. Subjects and methods. We designed a retrospective cohort study. The perinatal outcomes of 230 pregnancies ending at 41 weeks’ gestation were compared with those of 234 pregnancies ending at between 37 and 40 weeks’ gestation at the Miguel Servet University Hospital in 2005. Results. The rates of oligohydramnios, meconium-stained amniotic fluid, macrosomia, 5-minute Apgar score < 7 and low umbilical artery pH were all increased at 41 weeks’ gestation compared with pregnancies ending at between 37 and 40 weeks’ gestation (P<.05). Conclusions. We found that the rates of perinatal complications increased as pregnancy was prolonged to 41 weeks. Accurate investigation of these rates is important to determine the gestational age at which the risk of continuing the pregnancy outweighs the risk of labor induction(AU)

[Prenatal diagnosis of retroperitoneal neuroblastoma. Case report]. / Diagnóstico prenatal de neuroblastoma retroperitoneal. Reporte de un caso.

Neuroblastoma is the foremost malignant neoplasm of the fetus and neonate. It is a tumor of the sympathetic nervous system that originates from the neural crest which etiology is largely unknown. Due to its general variability in outcome, neuroblastoma has long been considered one of the most enigmatic of cancers. Although technological advances in ultrasonography have possible intrauterine detection, prenatal diagnosis is still a rare event. This kind of tumor has a high morbidity and mortality rate due to the metastatic risk. Early detection of the tumor is critical to improve outcome. We report a case of retroperitoneal neuroblastoma diagnosed at 32 week of gestation.

Adenocarcinoma de pulmón en gestante / Lung cancer in pregnancy

El cáncer de pulmón es la neoplasia más frecuente en los países desarrollados y la primera causa de mortalidad por cáncer en el varón, con un alarmante incremento en la mujer en los últimos años. Su diagnóstico durante el embarazo es infrecuente, pero su incidencia está aumentando en los últimos años. Parece tener un comportamiento más agresivo y diagnosticarse en estadios más avanzados durante la gestación. La elección del tratamiento más apropiado es difícil y no existe suficiente información para establecer su manejo. Presentamos el caso de una gestante de 38 años diagnosticada de cáncer de pulmón estadio IIIA, a las 27 semanas. Se decidió finalizar gestación en la semana 29 y, al tratarse de una tumoración no resecable, se le realizó un tratamiento combinado con quimioterapia y radioterapia (AU)

Lung cancer is the most common neoplasm in developed countries and the first cause of cáncer related death in men, although currently there has been a significant increase in women. It remains arare condition during pregnancy, but the association of lung cancer and gestation has been increasing in recent years. It seems to be more aggressive and diagnosed mainly at advances stages during pregnancy. Choosing the most appropriate treatment is very difficult and there is not enough information to establish the management. We report a case of a 38 year-old pregnant woman with stage IIIA lung adenocarcinoma diagnosed in the 27th week. At week 29 a decision was made to terminate the pregnancy. As the tumour was unrespectable, she subsequently underwent combined chemotherapy and radiotherapy (AU)

Tumores borderline de ovario. Estudio retrospectivo de 60 casos / Borderline ovarian tumors. Retrospective study of 60 cases

Objetivo: Describir las características clínicas, diagnósticas, terapéuticas y evolutivas de las pacientes con tumor borderline de ovario (TBO) tratadas en nuestro servicio durante un período de 15 años. Sujetos y métodos: Estudio retrospectivo basado en 60 pacientes diagnosticadas y tratadas en el Servicio de Ginecología del Hospital Universitario Miguel Servet de Zaragoza entre los años 1990 y 2004. Resultados: Se confirma el valor pronóstico del estadio de la enfermedad y la utilidad de la cirugía conservadora en las pacientes que desean mantener su capacidad fértil. En las pacientes no estadificadas inicialmente y en aparente estadio I, la supervivencia global es del 100%. Conclusiones: Los TBO presentan un pronóstico excelente, con buenos resultados de la cirugía conservadora en pacientes jóvenes y con deseo de descendencia. En el caso de pacientes no estadificadas inicialmente y en aparente estadio I de la enfermedad no parece útil recurrir a la cirugía de restadificación

Objective: To describe the clinical findings, treatment, and outcome of borderline ovarian tumors in 60 patients admitted to the Miguel Servet hospital over a 15-year period. Subjects and methods: Sixty patients diagnosed and treated from 1990 to 2004 for borderline ovarian tumors were retrospectively evaluated. Results: The results of this study confirm the prognostic value of surgical staging and the utility of fertility-sparing surgery in patients wishing to preserve fertility. In unstaged patients with apparent stage I tumors, overall survival was 100%. Conclusions: Borderline ovarian tumors have an excellent prognosis. Good results are provided by conservative surgery in young patients wishing to preserve fertility. In initially unstaged patients with apparent stage I tumors, surgical restaging does not appear to be useful