Serum phosphate is associated with increased risk of bone fragility fractures in hemodialysis patients.

BACKGROUND: Bone fragility fractures are associated with high morbidity and mortality. This study analysed the association between the current biochemical parameters of CKD-MBD and bone fragility fractures in the COSMOS project. METHODS: COSMOS is a 3-year, multicentre, open cohort, prospective, observational study carried out in 6797 hemodialysis patients (227 centres from 20 European countries). The association of bone fragility fractures (outcome) with serum calcium, phosphate and PTH (exposure), was assessed using Standard Cox proportional hazards regression and Cox proportional hazards regression for recurrent events. Additional analyses were performed considering all-cause mortality as a competitive event for bone fragility fracture occurrence. Multivariable models were used in all strategies, with the fully adjusted model including a total of 24 variables. RESULTS: During a median follow-up of 24 months 252 (4%) patients experienced at least one bone fragility fracture (incident bone fragility fracture rate 28.5 per 1000 patient-years). In the fractured and non-fractured patients, the percentage of men was 43.7% and 61.4%, mean age 68.1 and 63.8 years and a haemodialysis vintage of 55.9 and 38.3 months respectively. Baseline serum phosphate > 6.1 mg/dL (reference value 4.3-6.1 mg/dL) was significantly associated with a higher bone fragility fracture risk in both regression models (HR: 1.53[95%CI: 1.10-2.13] and HR: 1.44[95%CI: 1.02-2.05]. The significant association persisted after competitive risk analysis (subHR: 1.42[95%CI: 1.02-1.98]) but the finding was not confirmed when serum phosphate was considered as a continuous variable. Baseline serum calcium showed no association with bone fragility fracture risk in any regression model. Baseline serum PTH > 800 pg/mL was significantly associated with a higher bone fragility fracture risk in both regression models, but the association disappeared after a competitive risk analysis. CONCLUSIONS: Hyperphosphatemia was independently and consistently associated with an increased bone fracture risk, suggesting serum phosphate could be a novel risk factor for bone fractures in hemodialysis patients.

Comprehensive Cardiovascular and Renal Protection in Patients with Type 2 Diabetes.

Type 2 diabetes (T2DM) is one of the main public health care problems worldwide. It is associated with a marked increased risk of developing atherosclerotic vascular disease, heart failure, chronic kidney disease and death. It is essential to act during the early phases of the disease, through the intensification of lifestyle changes and the prescription of those drugs that have been shown to reduce these complications, with the aim not only of achieving an adequate metabolic control, but also a comprehensive vascular risk control. In this consensus document, developed by the different specialists that treat these patients (endocrinologists, primary care physicians, internists, nephrologists and cardiologists), a more appropriate approach in the management of patients with T2DM or its complications is provided. A particular focus is given to the global control of cardiovascular risk factors, the inclusion of weight within the therapeutic objectives, the education of patients, the deprescription of those drugs without cardiovascular benefit, and the inclusion of GLP-1 receptor agonists and SGLT2 inhibitors as cardiovascular protective drugs, at the same level as statins, acetylsalicylic acid, or renin angiotensin system inhibitors.

Optimizing the timing of nephrology referral for patients with diabetic kidney disease.

Age-standardized rates of diabetes mellitus (DM)-related complications, such as acute myocardial infarction, stroke or amputations, have decreased in recent years, but this was not associated with a clear reduction of the incidence of advanced chronic kidney disease (CKD) requiring renal replacement therapy. The early detection of diabetic kidney disease (DKD) is a key to reduce complications, morbidity and mortality. Consensus documents and clinical practice guidelines recommend referral of DM patients to nephrology when the estimated glomerular filtration rate falls below 30 mL/min/1.73 m2 or when albuminuria exceeds 300 mg/g urinary creatinine. Conceptually, it strikes as odd that patients with CKD are referred to the specialist caring for the prevention and treatment of CKD only when >70% of the functioning kidney mass has been lost. The increasing global health burden of CKD, driven in large part by DKD, the suboptimal impact of routine care on DKD outcomes as compared with other DM complications, the realization that successful therapy of CKD requires early diagnosis and intervention, the advances in earlier diagnosis of kidney injury and the recent availability of antidiabetic drugs with a renal mechanism of action and lack of hypoglycaemia risk, which additionally are cardio- and nephroprotective, all point towards a paradigm shift in the care for DM patients in which they should be referred earlier to nephrology as part of a coordinated and integrated care approach.

Consideraciones respecto a ezetimiba y deterioro renal / Considerations for ezetimibe and renal impairment

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Valoración de la afección renal mediante la cistatina C: un biomarcador olvidado. Respuesta / Assessment of renal involvement by Cystatin C: a forgotten biomarker. Response

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Valoración de afección renal, disfunción renal aguda e hiperpotasemia por fármacos usados en cardiología y nefrotoxicidad por contrastes / Assessment of renal function, iatrogenic hyperkalemia and acute renal dysfunction in cardiology. Contrast-induced nephropathy

La afección renal en los pacientes con enfermedad cardiovascular confiere un carácter pronóstico y un incremento del riesgo cardiovascular. La disfunción renal es un marcador de lesiones en otras partes del árbol vascular. Su detección permite la identificación precoz de individuos con riesgo elevado de acontecimientos cardiovasculares. La valoración de la afección renal del paciente con enfermedad cardiovascular se llevará a cabo mediante la determinación de albuminuria en una muestra aislada de orina y por la estimación del filtrado glomerular a partir de fórmulas o ecuaciones predictivas derivadas de la creatinina. Se recomienda la fórmula de la Chronic Kidney Disease Epidemiology Collaboration o la de Modification of Diet in Renal Disease. Como alternativa, puede utilizarse la fórmula de Cockcroft-Gault. La administración de fármacos que bloqueen el sistema renina-angiotensina puede asociarse en determinadas ocasiones a disfunción renal aguda o hiperpotasemia. Es importante conocer las situaciones con riesgo de que se produzcan estas complicaciones para dar el mejor tratamiento posible: la prevención. Dado el incremento progresivo de los procedimientos diagnósticos y terapéuticos con contraste intravenoso en el ámbito de la cardiología, la nefrotoxicidad por contraste supone un problema relevante. Es de interés detectar los factores de riesgo y a los pacientes con mayor probabilidad de sufrirla, así como prevenir su aparición (AU)

Renal impairment influences the prognosis of patients with cardiovascular disease and increases cardiovascular risk. Renal dysfunction is a marker of lesions in other parts of the vascular tree and detection facilitates early identification of individuals at high risk of cardiovascular events. In patients with cardiovascular disease, renal function is assessed by measuring albuminuria in a spot urine sample and by estimating the glomerular filtration rate using creatinine-derived predictive formulas or equations. We recommend the Chronic Kidney Disease Epidemiology Collaboration or the Modification of Diet in Renal Disease formulas. The Cockcroft-Gault formula is a possible alternative. The administration of drugs that block the angiotensin-renin system can, on occasion, be associated with acute renal dysfunction or hyperkalemia. We need to know when risk of these complications exists so as to provide the best possible treatment: prevention. Given the growing number of diagnostic and therapeutic procedures in the field of cardiology that use intravenous contrast media, contrast-induced nephrotoxicity represents a significant problem. We should identify the risk factors and patients at greatest risk, and prevent it from appearing (AU)

[Assessment of renal function, iatrogenic hyperkalemia and acute renal dysfunction in cardiology. Contrast-induced nephropathy]. / Valoración de afección renal, disfunción renal aguda e hiperpotasemia por fármacos usados en cardiología y nefrotoxicidad por contrastes.

Renal impairment influences the prognosis of patients with cardiovascular disease and increases cardiovascular risk. Renal dysfunction is a marker of lesions in other parts of the vascular tree and detection facilitates early identification of individuals at high risk of cardiovascular events. In patients with cardiovascular disease, renal function is assessed by measuring albuminuria in a spot urine sample and by estimating the glomerular filtration rate using creatinine-derived predictive formulas or equations. We recommend the Chronic Kidney Disease Epidemiology Collaboration or the Modification of Diet in Renal Disease formulas. The Cockcroft-Gault formula is a possible alternative. The administration of drugs that block the angiotensin-renin system can, on occasion, be associated with acute renal dysfunction or hyperkalemia. We need to know when risk of these complications exists so as to provide the best possible treatment: prevention. Given the growing number of diagnostic and therapeutic procedures in the field of cardiology that use intravenous contrast media, contrast-induced nephrotoxicity represents a significant problem. We should identify the risk factors and patients at greatest risk, and prevent it from appearing.

Importancia de la detección temprana de la enfermedad renal crónica en grupos de riesgo / Importance of early detection of chronic kidney disease in risk groups

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Glomerulosclerosis nodular diabética sin diabetes mellitus conocida previamente / Nodular diabetic glomerulosclerosis without previously known diabetes mellitus

La nefropatía es una de las complicaciones crónicas de la diabetes mellitus relacionadas con un incremento de la morbimortalidad en la población afectada. Puede detectarse tras varios años de evolución de la enfermedad en el caso de la diabetes tipo 1, al poco tiempo del diagnóstico en la diabetes tipo 2 e incluso al inicio de ésta, y es muy infrecuente sin diabetes mellitus previamente conocida. Presentamos 2 casos de nefropatía diabética en pacientes sin historia previa de diabetes mellitus. Uno de ellos fue diagnosticado posteriormente de intolerancia a los hidratos de carbono. En el otro, el estudio del metabolismo hidrocarbonado fue normal. Se revisa la bibliografía y se discute sobre los mecanismos genéticos y ambientales implicados en el desarrollo de la intolerancia. Se discute también la importancia de incluir la nefropatía diabética en el diagnóstico diferencial de la glomerulosclerosis nodular, incluso en casos sin diabetes mellitus previamente conocida

Nephropathy is one of the chronic complications of diabetes mellitus associated with an increase in morbidity and mortality in the affected population. This complication can be detected after several years of disease evolution in type 1 diabetes mellitus and soon after diagnosis in diabetes type 2 or even at its onset. The development of nephropathy without previously known diabetes mellitus is highly infrequent. We describe two patients with diabetic nephropathy and no previous history of diabetes mellitus. One of the patients was subsequently diagnosed with carbohydrate intolerance. In the other patient, study of carbohydrate metabolism was normal. We review the literature on the topic and the genetic and environmental mechanisms involved in the development of this disease. The importance of including diabetic nephropathy in the differential diagnosis of nodular glomerulosclerosis, even in patients without previously known diabetes mellitus, is also discussed