Lupus nephritis with preserved kidney function associated with poorer cardiovascular risk control: A call for more awareness / Nefropatía lúpica con función renal conservada, asociada a un peor control del riesgo cardiovascular: llamada de atención y concienciación

Background: Despite the improvement in the prognosis of lupus nephritis (LN), the cardiovascular morbimortality remains high. The early recognition and remission of flares, while trying to avoid the metabolic adverse effects of medication, must be mandatory. Aim: The aim of our study was to assess the cardiovascular (CV) risk profile in a cohort of lupus patients with preserved kidney function after a nephritis episode, compared to patients without a nephritis flare. Methods: 130 patients diagnosed of SLE (32 with previous nephritis flare and 98 without) were studied in order to evaluate the CV risk profile, despite the preserved kidney function. Results: The most prevalent risk factors were sedentary lifestyle (57.6%), overweight/obesity (38.3%) and dyslipidemia (36%), followed by smoking (32%) and hypertension (16%). Though more than a half (53.1%) was taking CV medication, a high percentage did not reach a therapeutic target value, especially regarding obesity (11.5%) and cholesterol levels (LDL-C of 16%). The prevalence of dyslipidemia (53.1% vs 30.6%), smoking (46.6% vs 27.5%), left ventricular hypertrophy (LVH) (21.4% vs 6.4%) and lower HDL-C (48.6 mg/dL vs 55.4 mg/dL) were significantly different in the group with previous nephritis flare. Moreover, young patients with lupus nephritis, received more pulses of corticosteroids and cyclophosphamide, had higher prevalence of hypertension, LVH, higher proteinuria, hospital admissions and waist circumference, constituting the subgroup of patients with greater aggregation of CV risk factors. Conclusions: Patients with previous nephritis flare showed a poor control of CV risk factors despite the preserved renal function, these patients would require a closer therapeutic management

Antecedentes: A pesar de la mejora en el pronóstico de la nefropatía lúpica (NL), la morbimortalidad cardiovascular sigue siendo elevada. El reconocimiento precoz y la remisión de los brotes, a la vez que los intentos de evitar los efectos metabólicos adversos de la medicación, deben ser de obligado cumplimiento. Objetivo: El objetivo de nuestro estudio fue valorar el perfil de riesgo cardiovascular (RCV) en una cohorte de pacientes de lupus, con función renal conservada tras un episodio nefrítico, en comparación con los pacientes sin brote nefrítico. Métodos: Se estudiaron 130 pacientes diagnosticados de LES (32 con brote nefrítico previo y 98 sin brote), a fin de evaluar el perfil del RCV, a pesar de la función renal conservada. Resultados: Los factores de riesgo con mayor prevalencia fueron el estilo de vida sedentario (57,6%), el sobrepeso/obesidad (38,3%) y la dislipidemia (36%), seguidos del tabaquismo (32%) y la hipertensión (16%). Aunque más de la mitad de los pacientes (53,1%) recibían medicación CV, un elevado porcentaje de ellos no alcanzaba un valor diana terapéutico, especialmente en lo concerniente a obesidad (11,5%) y niveles de colesterol (LDL-C del 16%). La prevalencia de dislipidemia (53,1 vs. 30,6%), tabaquismo (46,6 vs. 27,5%), hipertrofia ventricular izquierda (HVI) (21,4 vs. 6,4%) y bajo HDL-C (48,6 vs. 55,4 mg/dl) fue significativamente diferente en el grupo con brote nefrítico previo. Además, los pacientes jóvenes con nefropatía lúpica recibieron más pulsos de corticosteroides y ciclofosfamida, tuvieron mayores valores de prevalencia hipertensión, HVI, proteinuria, ingresos hospitalarios y perímetro de cintura, constituyendo el subgrupo de pacientes con mayor acumulación de factores de RCV. Conclusiones: Los pacientes con brotes nefríticos previos reflejaron un peor control de los factores de RCV a pesar de la función renal conservada, por lo que estos pacientes requerirían una gestión terapéutica más cercana

Lupus nephritis with preserved kidney function associated with poorer cardiovascular risk control: A call for more awareness.

BACKGROUND: Despite the improvement in the prognosis of lupus nephritis (LN), the cardiovascular morbimortality remains high. The early recognition and remission of flares, while trying to avoid the metabolic adverse effects of medication, must be mandatory. AIM: The aim of our study was to assess the cardiovascular (CV) risk profile in a cohort of lupus patients with preserved kidney function after a nephritis episode, compared to patients without a nephritis flare. METHODS: 130 patients diagnosed of SLE (32 with previous nephritis flare and 98 without) were studied in order to evaluate the CV risk profile, despite the preserved kidney function. RESULTS: The most prevalent risk factors were sedentary lifestyle (57.6%), overweight/obesity (38.3%) and dyslipidemia (36%), followed by smoking (32%) and hypertension (16%). Though more than a half (53.1%) was taking CV medication, a high percentage did not reach a therapeutic target value, especially regarding obesity (11.5%) and cholesterol levels (LDL-C of 16%). The prevalence of dyslipidemia (53.1% vs 30.6%), smoking (46.6% vs 27.5%), left ventricular hypertrophy (LVH) (21.4% vs 6.4%) and lower HDL-C (48.6mg/dL vs 55.4mg/dL) were significantly different in the group with previous nephritis flare. Moreover, young patients with lupus nephritis, received more pulses of corticosteroids and cyclophosphamide, had higher prevalence of hypertension, LVH, higher proteinuria, hospital admissions and waist circumference, constituting the subgroup of patients with greater aggregation of CV risk factors. CONCLUSIONS: Patients with previous nephritis flare showed a poor control of CV risk factors despite the preserved renal function, these patients would require a closer therapeutic management.

Acute kidney injury secondary to diarrhea caused by "sprue-like" enteropathy associated with olmesartan / Daño renal agudo secundario a diarrea debido a enteropatía "sprue-like" asociada al olmesartan

No disponible

¿Mejora la aproximación físico-química de Stewart-Fencl la valoración del equilibrio ácido-base en pacientes estables en hemodiafiltración? / Does Stewart-Fencl approach improve the evaluation of acidbase status in stable patients on hemodiafiltration?

Introducción: la evaluación del equilibrio ácido-base se basa en la ecuación de Henderson-Hasselbach. En 1983, P. Stewart desarrolló un análisis cuantitativo del equilibrio ácido-base en el que muestra un sistema con unas variables independientes entre las que se incluyen pCO2, diferencia iónica fuerte medida (SIDm), es decir, la diferencia entre la suma de cationes fuertes (Na+, K+, Ca++, Mg++) y la suma de aniones fuertes (Cl–, lactato) y la concentración total de todos los aniones débiles no volátiles (ATot), cuyos principales representantes son el fósforo inorgánico (P–) y la albúmina (Albúm.–). El objetivo de este estudio es evaluar desde ambas perspectivas el equilibrio ácido-base en pacientes en hemodiafiltración (HDF) crónica. Material y métodos: se estudian 35 pacientes (24 hombres y 11 mujeres, con una edad media de 67,2 ± 15,7 años y con un peso seco de 72,8 ± 19,2 kg. La duración media de la hemodiálisis (HD) fue de 253,6 ± 40,5 minutos. Se analizan los parámetros gasométricos (pH, pCO2, HCO3–y exceso de bases) y Na+, K+, Cl–, Ca++, Mg++ y lactato. Se calcularon la SIDm, la SIDe mediante la fórmula de Figge (1.000 x 2,46–11 x pCO2 /[10 – pH] + Albúm. g/dl x [0,123 x pH –0,631] + P en mmol/l x [0,309 x pH –0,469)] y gap del SID (SIDm-SIDe). Resultados: el pH pre-HD fue de 7,36 ± 0,08 y el pH post-HD de 7,44 ± 0,08 (p <0,001). No se apreciaron diferencias significativas entre pCO2 pre y post-HD. El HCO3 – y el exceso de bases se incrementaron durante la sesión (p <0,001). La SIDm descendió de manera significativa de 46,2 ± 2,9 preHD a 45 ± 2,3 post-HD (p <0,05). Por el contrario, la SIDe se elevó de 38,5 ± 3,8 a 42,9 ± 3,1 (p <0,001). El anion gap descendió de 18,6 ± 3,8 pre-HD a 12,8 ± 2,8 Eq/l post-HD (p <0,001) y el gap del SID de 7,6 ± 3 a 2,1 ± 2 (p <0,001). Se apreció una correlación entre el anion gap y el gap-SID tanto antes como después de la HDF. Asimismo, se apreció una correlación significativa entre el ?? exceso de bases y ?? del gap-SID. Conclusión: en conclusión, la aproximación físico-química de Stewart-Fencl no mejora la valoración del equilibrio ácido-base en pacientes en HDF crónica. En presencia de normocloremia la SIDm no refleja el proceso alcalinizante de la sesión de hemodiálisis. Bajo esta perspectiva, la sesión de hemodiálisis se concibe como una retirada de aniones inorgánicos no metabolizables, en especial el sulfato. El espacio dejado por estos aniones es reemplazado por OH–y secundariamente por HCO3–. La única ventaja vendría dada por una mejor valoración de los aniones no medidos mediante el gap del SID, sin el efecto de la albúmina y el fosfato (AU)

Introduction: The traditional evaluation of acid-base status relies on the Henderson-Hasselbach equation. In 1983, an alternative approach, based on physical and chemical principles was proposed by P. Stewart. In this approach, plasma pH is determined by 3 independent variables: pCO2, Strong Ion Difference (SIDm), which is the difference between the strong cations (Na+, K+, Ca++, Mg++) and the strong anions (Cl–, lactate) and total plasma concentration of nonvolatile weak acids (ATot), mainly inorganic phosphate and albumin. Bicarbonate is considered a dependent variable. The aim of this study was to evaluate the acid-base status using both perspectives, physical chemical and traditional approach. Material and methods: we studied 35 patients (24 male; 11 female) on hemodiafiltration, mean age was 67.2 ± 15.7, 8 ± 19.2 kg. We analyzed plasma chemistry including pH, pCO2, HCO3–, base excess and Na+, K+, Cl–, Ca++, Mg++, lactate and SIDm. The SID estimated (SIDe) was calculated by Figge’s formula (1,000 x 2.46–11 x pCO2/[10 – pH] + Album g/dl x [0.123 x pH –0.631] + P in mmol/l0 x [0.309 x pH –0.469]) and Gap of the SID as the difference SIDm-SIDe. Results: pH preHD was 7.36 ± 0.08 and pH post-HD 7.44 ± 0.08 (p <0.001). There was no significant differences between pCO2 pre- and post-HD. HCO3– and base excess increased during the session (p <0.001). SIDm decreased from 46.2 ± 2.9 pre-HD to 45 ± 2.3 mEq/l post-HD (p <0.05). On the opposite, SIDe increased from 38.5 ± 3.8 to 429 ± 3.1 mEq/l (p <0.001). The Gap Anion descended from 18.6 ± 3.8 pre-HD to 12.8 ± 2.8 mEq/l post-HD (p <0.001) and the Gap of the SID 7.6 ± 3 to 2.1 ± 2 (p <0.001). Anion Gap correlated with the Gap-SID so much pre-HDF as pos-HDF. ?? Base excess correlated only with ?? of the Gap SID. Conclusion: Stewart-Fencl’s approach does not improve characterization of acid-base status in patients on chronic HDF. In presence of normocloremia the SIDm does not reflect the alkalinizing process of the session of hemodialysis. According this approach, hemodialysis therapy can be viewed as a withdrawal of inorganic anions, especially the sulphate. These anions are replaced by OH– and secondarily for HCO3–. The approach only improves the evaluation of unmeasured anions by the Gap of the SID, without the effect of albumin and phosphate (AU)

[Does Stewart-Fencl improve the evaluation of acid-base status in stable patients on hemodiafiltration?]. / ¿Mejora la aproximación físico-química de Stewart-Fencl la valoración del equilibrio ácido-base en pacientes estables en hemodiafiltración?

INTRODUCTION: The traditional evaluation of acid-base status relies on the Henderson-Hasselbach equation. In 1983, an alternative approach, based on physical and chemical principles was proposed by P. Stewart. In this approach, plasma pH is determined by 3 independent variables: pCO2, Strong Ion Difference (SIDm), which is the difference between the strong cations (Na +, K +, Ca ++, Mg ++) and the strong anions (Cl-, lactate) and total plasma concentration of nonvolatile weak acids (ATot), mainly inorganic phosphate and albumin. Bicarbonate is considered a dependent variable. The aim of this study was to evaluate the acid-base status using both perspectives, physical chemical and traditional approach. MATERIAL AND METHODS: We studied 35 patients (24 M; 11F) on hemodiafiltration, mean age was 67,2+/-15,7, 8+/-19,2 kg. We analyzed plasma chemistry including pH, pCO2, HCO3-, base excess and Na+, K+, Cl-, Ca++, Mg++, lactate and SIDm. The SID estimated (SIDe) was calculated by Figge's formula (1000 x 2.46E-11 x pCO2 / (10-pH) + Album gr/dl x (0.123 x pH-0.631) + P in mmol/l x (0.309 x pH-0.469) and Gap of the SID as the difference SIDm-SIDe. RESULTS: pH preHD was 7,36+/-0,08 and pH posHD 7,44+/-0,08 (p < 0.001). There was no significant differences between pCO2 pre and pos-HD. HCO3 - and base excess increased during the session (p < 0.001). SIDm decreased from 46,2+/-2,9 preHD to 45+/-2,3 mEq/l postHD (p < 0.05). On the opposite, SIDe increased from 38,5+/-3,8 to 42,9+/-3,1 mEq/l (p < 0.001). The Gap Anion descended from 18,6+/-3,8 preHD to 12,8+/-2,8 mEq/l mEq/l postHD (p < 0.001) and the Gap of the SID 7,6+/-3 to 2,1+/-2 (p < 0.001). Anion Gap correlated with the Gap-SID so much pre-HDF as pos-HDF. Delta Base excess correlated only with Delta of the Gap SID. CONCLUSION: Stewart-Fencl's approach does not improve characterization of acid-base status in patients on chronic HDF. In presence of normocloremia the SIDm does not reflect the alkalinizing process of the session of hemodialysis. According this approach, hemodialysis therapy can be viewed as a withdrawal of inorganic anions, especially the sulphate. These anions are replaced by OH - and secondarily for HCO3-. The approach only improves the evaluation of unmeasured anions by the Gap of the SID, without the effect of albumin and phosphate.

[Determination of brain natriuretic peptide in patients undergoing different haemodiafiltration techniques]. / Determinación del péptido natriurético cerebral en pacientes sometidos a diferentes técnicas de hemodiafiltración.

UNLABELLED: IB-type natriuretic peptide is a cardíac neurohormone secreted by the cardíac ventricules in response to ventricular dilatation so plasma BNP level correlate with left ventricular mass and dysfunction. Dialysis patients have much greater levels of BNP due to the volume overload and because of reduced renal clearance. The aim of this study was to mesure and compare the BNP levels in three groups of patients who received different hemodiafiltration techniques: Daily online hemodiafiltration (HDFOLd), on-line hemodiafiltration (HDFOL) and low convective volume hemodiafiltration (HDF). Fifteen patients were included, five in each group. Pre and postdialysis BNP leves were measured during 8 weeks. The measure was done at the beginning of the week (long period), and at the end (short period), in order to study if there were significative differences between techniques and periods. We found significative differences between predialysis BNP levels in the short period (BNPpreC) and the long period (BNPpre-L). We also found significative differences with the posdialysis BNP in both periods; BNPpre- L vs. BNPpos-L (1069+/-1031 vs. 612 +/- 540). After comparing the three techniques the study showed significative differences between BNPpreC in HDF and HDFOL compared with HDFOld. And also after dialysis between BNPpos-C in HDFOLd compared with the other techniques. CONCLUSION: Although previous papers have shown that BNP levels have limited potential for assessment of hydration in hemodialysis patients, in this study our data demonstrate that after dialysis BNP levels decline in a significative way in the long and short period and we have found that patients on daily hemodialysis show lower BNP levels, and maybe this could be explained because daily on-line haemodiafiltration patients had lower weight rise between dialysis sessions and also better haemodynamic tolerance.

Determinación del péptido natriurético cerebral en pacientes sometidos a diferentes técnicas de hemodiafiltración / No disponible

El péptido natriurético cerebral (BNP) es una hormona que se libera a la circulación en respuesta de dilatación ventricular. Sus niveles se correlacionan con la masa del ventrículo izquierdo y con la disfunción ventricular. Los pacientes en diálisis presentan valores elevados a consecuencia de la situación de expansión de volumen y la reducción de su aclaramiento. Objetivo: analizar los niveles de BNP en pacientes sometidos a diferentes técnicas de hemodiafiltración: on-line diaria (HDFOLd), on-line (HDFOL) y con bajo volumen convectivo (HDF). Se determinaron las concentraciones séricas pre y posdiálisis de 15 pacientes (cinco de cada grupo) durante ocho semanas. Se efectuaron dos determinaciones, una a principio de semana (período largo) y otra al final de semana (período corto), con el fin de determinar si existían diferencias significativas entre técnicas y entre períodos. Al comparar los valores globales de BNP prehemodiálisis entre el período corto (BNPpreC) y el largo (BNP pre-L), se objetivaron diferencias significativas. Igualmente, se apreciaron diferencias entre el BNPpos del período corto y del largo. Asimismo, entre el BNP preC vs. BNPpos-C y entre BNPpre-L vs. BNPpos-L. El estudio comparativo entre técnicas mostró diferencias significativas en el período corto entre el BNPpre-C y BNPpos-C de HDFOLd con respecto a las mismas determinaciones en HDF y HDFOL. Conclusión: aunque la determinación del BNP tiene un potencial limitado para la evaluación del estado de hidratación en los pacientes en hemodiálisis, en este trabajo hemos comprobado que tras la sesión de diálisis se produce un descenso significativo del BNP, tanto en el período corto como en el largo, y que de manera significativa los pacientes del grupo de diaria presentan concentraciones inferiores de BNP, lo que se explicaría por la menor ganancia de peso interdiálisis y la mejor tolerancia hemodinámica a la técnica (AU)

IB-type natriuretic peptide is a cardíac neurohormone secreted by the cardíac ventricules in response to ventricular dilatation soplasma BNP level correlate with left ventricular mass and dysfunction. Dialysis patients have much greater levels of BNP due to the volume overload and because of reduced renal clearance. The aim of this study was to mesure and compare the BNP levels in three groups of patients who received different hemodia filtration techniques: Daily on-line hemodiafiltration (HDFOLd),on-line hemodiafiltration (HDFOL) and low convective volume hemodiafiltration (HDF). Fifteen patients were included, five ineach group. Pre and postdialysis BNP leves were measured during 8 weeks. The measure was done at the beginning of the week (long period), and at the end (short period), in order to study if there were significative differences between techniques and periods. We found significative differences between predialysis BNP levels in the short period (BNPpreC) and the long period (BNPpre-L). We also found significative differences with the posdialysis BNP in both periods; BNPpre-L vs. BNPpos-L(1069±1031 vs. 612 ± 540). After comparing the three techniques the study showed significative differences between BNPpreC in HDF and HDFOL compared with HDFOld. And also after dialysis between BNPpos-C in HDFOLd compared with the other techniques. Conclusion: Although previous papers have shown thatBNP levels have limited potential for assessment of hydration in hemodialysis patients, in this study our data demonstrate thatafter dialysis BNP levels decline in a significative way in the long and short period and we have found that patients on daily hemodialysis show lower BNP levels, and maybe this could be explained because daily on-line haemodiafiltration patients had lower weight rise between dialysis sessions and also better haemodynamic tolerance (AU)

Fracaso renal agudo recurrente y reversible en un paciente afecto de hematuria y púrpura de Schönlein-Henoch / No disponible

La purpura de Schönlein-Henoch es una vasculitis de pequeño vaso caracterizada por el depósito de inmunocomplejos, principalmente IgA y C3. Es un trastorno multisistémico que afecta predominantemente la piel, las articulaciones, el tracto gastro-intestinal y los riñones. A nivel renal la expresión clínica varía desde una microhematuria aislada transitoria, hasta el cuadro de nefropatía rápidamente progresiva. El fracaso renal agudo es raro y suele verse asociado a episodios de hematuria macroscópica. Estos episodios suelen cursar con daño y obstrucción tubular por cilindros eritrocitarios. En este caso clínico describimos un paciente que sufrió dos episodios de fracaso renal agudo reversibles precedidos por brotes de hematuria macroscópica y que precisaron hemodiálisis durante cuatro y seis meses respectivamente (AU)

Sumary Henoch- Schönelin purpura (HSP) is a small vessel vasculitis characterized by deposition of inmune complexes, mainlyIg A and C3. It is a multisystem disorder affecting predominantly the skin, joints, gastrointestinal tract and kidneys. Clinical expression of nephritis ranges from transient isolated microscopic hematuria to rapidly progressive nephropathy. Acute renal failure is rare and is associated with episodes of macroscopic hematuria. These episodes are frequently associated with tubular damage and tubular obstruction by erythrocyte casts. We describe a patient with two episodes of acute renal failure after the onset of gross hematuria. Both episodes were reversible after six and four months respectively on hemodialysis (AU)

Switching from three times a week to short daily online hemodiafiltration: effects on acid-base balance.

AIMS: This study examines the effect of a change from the standard 4-5 hours 3 times a week of online hemodiafiltration (OL-HDF) to 2-2.5 hours daily (6 times a week) OL-HDF, on acid-base balance, and attempts assess the modifications of acid-base parameters, ionic concentration, and electrical charges of albumin and phosphate available for diffusion and convection mechanisms across the membrane and subsequent infusion. METHODS: In 18 patients on online HDF, blood gas, electrolytes (Na, K, Cl), lactate, phosphate, albumin, apparent strong ion difference (SIDa), effective strong ion difference (SIDe), strong ion gap (SIG), anion gap (AG), and bicarbonate and pH time-averaged concentration (TAC) and time-averaged deviation (TAD) variables were evaluated at baseline, and 1, 3, 6, 9, and 12 months after patients were switched to daily OL-HDF. Additionally, in 12 patients, the same parameters measured simultaneously at dialyzer inlet, outlet, and after reinfusion were studied. RESULTS: Throughout the study, weekly single-pool Kt/V, equilibrated Kt/V, and TAC urea remained constant. However, standard Kt/V increased and TAD urea decreased on daily OL-HDF. There were no statistical differences during the time span of 12 months in pH, cations (Na, K), anions (Cl, HCO3(-) AG, and lactate), or SIDa, SIDe, and SIG pre-HDF; while pH and HCO3(-) TAD decreased from 0.02 and 1.02 +/- 0.74 mEq/L, to 0.01 and 0.64 +/- 0.52 mEq/L, respectively (p<0.01). Net albumin charge and AG increased significantly at dialyzer outlet and decreased after reinfusion. CONCLUSIONS: We did not observe changes in the acid-base balance in patients who switched from 3 times a week to short daily OL-HDF. The main benefit observed was a lower pH and bicarbonate TAD. This shows a better physiology for daily OL-HDF.

[Kinetic of calcium, phosphate, magnesium and PTH variations during hemodiafiltration]. / Cinéica del calcio, fósforo, magnesio y variaciones de la parathormona (PTH) en pacientes en hemodiafiltracion.

Hemodiafiltration (HDF) is a technique resulting from coupling of diffusive and convective transport and thereby increase the elimination of small and middle molecules. However, may induce a convective loss from others substances such as calcium and magnesium. The aim of this study was to evaluate the effects of Ultrafiltration on the kinetics of calcium, phosphate, magnesium and parathyroid hormone. A total of thirteen patients (7 males and 6 females) on hemodialysis, were studied. Each patient was randomly dialyzed with the same dialysate calcium concentration and three different ultrafiltration rate. Schedule A: High flux hemodialysis, schedule B: HDF with 10% of weight body and schedule C: HDF with 20% of weight body. The others parameters were kept identical. Total Ultrafiltration was 2,6+/-0,9 L (9,78+/-3,78 ml/min) in A, 9,3+/-1,7 L (34,54+/-6,22 ml/min) in B and 16,3+/-3,3 L (60,94+/-12,63 ml/min) in C. Replacement fluid during dialysis was 6,85+/-1,42 and 13,65+/-2,9 L. in C and C respectively. Postdialysis total,ionized calcium and magnesium were significantly lower in schedules B and C versus A. PTH levels did not differ significantly. However, PTH changes during dialysis was -36.6+/-38.6%, 6.3+/-69.8% and 32.2+/-63.2% in A, B and C, respectively (p<0.05 A vs. C). A significant inverse correlation was found between total Ultrafiltration and postdialysis levels of total calcium (r:-0.56, p<0.001), ionized calcium (r:-0.65, p<0.001) and magnesium (r:-0.47, p<0.01). No differences were observed in pre and postdialysis phosphate levels, neither mass transfer and clearance of phosphate. We concluded that high ultrafiltration flow rates and substitution fluid without divalent cations induces a negative calcium and magnesium balance. These changes may stimulate PTH secretion during HDF. This technique did not resulted in a higher clearance or phosphate removal.

[Oxidative stress analysis in patients on hemodiafiltration on-line]. / Análisis del estrés oxidativo en pacientes en hemodiafiltración en línea.

Patients with chronic renal disease have a very high mortality due to cardiovascular disease. However, the traditional risk factors are not the only one explanation. Nowadays, there are new risk factors becoming, and one of these is the oxidative stress. Besides today we know that when these patients receive haemodialysis are being exposed to an additional oxidative stress. The aim of this study was to measure and to compare the degree of oxidative stress in two groups of patients on different dialysis techniques: a) On-Line Haemodiafiltration three times / week (OL-HDF). b) Daily Om-Line haemodiafiltration ( six times / week ) ( dOL-HDF) We studied 9 patients with chronic renal disease stage 5 on hemodialysis. They all were men, with a medium age of 72,5 +/- 6 years. Five patients were on dOL-HDFand four on tOL-HDF. Glutathione (GSH) concentration of patients on dOL-HDF before dialysis was 742+/- 153 nmol/ml and post-dialysis de 878+/- 223. Blood GSSG concentration before and after dialysis was 34+/- 14 nmol/ml y 137+/- 74 nmol/ml (p< 0,03). GSSG/GSH ratio pre-dialysis was 58+/-10 and post-dialysis 169+/-65 ( p < 0,03). In OL-HDF group GSSG concentration and the ratio GSSG/GSH also increased in a significative way from 99+/-45 nmol/ml to 179+/-66 nmol/ml, and from 161+/- 99 to 337+/-143 ( p<0,05). We also found differences in pCR concentrations between both groups; 3+/-1,4 g/l in dOL-HDF and 8,75+/-5,8 g/l in HDF OL. (p< 0,05). We did not find differences between xatine-oxidase activity before and after hemodialysis and between groups. In conclusion, patient with terminal chronic renal disease on OL-HDF receive an additional load of oxidative stress, as the increase in GSSG/GSH ratio in both groups shows. However patients on dHDF-OL shows low ratios GSSG/GSH post-hemodialysis and low pCR concentrations, and maybe this could be explained because daily on line haemodiafiltration improves purification of inflammatory mediators. Clue words: Hemodialysis, oxidative stress, glutathione, gssg/gsh ratio, xantine oxidasa.

Cinética del calcio, fósforo,magnesio y variaciones de la parathormona (PTH) en pacientes en hemodiafiltración / Kinetic of calcium, phosphate, magnesium and PTH variations during hemodiafiltration

La hemodiafiltración (HDF) es una técnica que combina los mecanismos difusivo y convectivo para lograr mayor eficacia depurativa. La confluencia de ambos mecanismos puede dificultar la transferencia de sustancias como el calcio, cuyo gradiente difusivo sea líquido de diálisis-sangre. El objetivo de nuestro estudio fue valorar la importancia de la convección en la transferencias del calcio, fósforo, magnesio y la PTH. Se estudiaron 13 pacientes en programa de hemodiálisis. A cada paciente se le realizó en la sesión de mitad de semana y de manera aleatoria tres esquemas de hemodiálisis: Tipo A.: Hemodiálisis de alto flujo. Tipo B:HDF del 10% del peso seco. Tipo C:HDF del 20% del peso seco. Las características de la sesión de HD fueron las habituales en cada paciente. La concentración de calcio en el líquido de diálisis fue la misma en los 3 tipos de sesiones. La composición del líquido de sustitución era: Na 145 mEq/l, Cl 85 mEq/l, HCO3- 60 mEq/l. El monitor de hemodiálisis empleado fue Integra® que disponía del módulo Quantiscan. Se determinaron al inicio (pre-HD) y al final (pos-HD) de la diálisis, el calcio total, calcio iónico, fósforo, magnesio y PTH. En el líquido de diálisis recogido mediante el Quantiscan, se determinaron los niveles de fósforo.No encontramos diferencias significativas entre los tres tipos de sesión para las concentraciones de calcio total pre-HD, Ca++ pre-HD, Mg pre-HD, fósforo pre y pos-HD ni en la transferencia de masa de fósforo. El calcio total pos-HD fue 9,93 ± 0,75 en la sesión A, 9,30 ± 0,79 en la B y 8,79 ± 0,69 mg/dl en la C (p < 0,01 A vs B y C). El Ca++ pos-HD fue de 2,61 ± 0,25 en la sesión A, 2,36 ± 0,27 en la B y 2,13 ± 0,28 mEq/l. en la C. (p < 0,01 A vs C). El Mg pos-HD 2,04 ± 0,11, 1,78 ± 0,14 y 1,77 ± 0,22 mg/dl, respectivamente (p < 0,001 A vs B y C). No se evidenciaron diferencias significativas en la PTH pre ni pos-HD. El porcentaje de variación de PTH durante la sesión fue de -36,6 ± 38,6% en la A, 6,3 ± 69,8% en la B y 32,2 ± 63,2% en la tipo C (p < 0,05 A vs C). La ultrafiltración total se correlacionó de manera inversa con los niveles séricos pos-HD, tanto de Ca total (r: -0,56, p < 0,001), Ca++ (r: - 0,65, p < 0,001), como Mg (-0,47, p < 0,01). Concluimos que el incremento en las tasas de ultrafiltración con líquidos de sustitución carentes de cationes divalentes, originan un balance de calcio y magnesio negativo con descenso en los niveles séricos de estos cationes al final de la sesión. Estos cambios pueden provocar un incremento en los niveles de PTH.No hemos apreciado mejoría en las transferencias de masa de fósforo ni en su aclaramiento al aumentar la tasa de ultrafiltración

Hemodiafiltration (HDF) is a technique resulting from coupling of diffusive and convective transport and thereby increase the elimination of small and middle molecules. However, may induce a convective loss from others substances such as calcium and magnesium. The aim of this study was to evaluate the effects of Ultrafiltration on the kinetics of calcium, phosphate, magnesium and parathyroid hormone. A total of thirteen patients (7 males and 6 females) on hemodialysis, were studied. Each patient was randomly dialyzed with the same dialysate calcium concentration and three different ultrafiltration rate. Schedule A: High flux hemodialysis, schedule B: HDF with 10% of weight body and schedule C: HDF with 20% of weight body. The others parameters were kept identical. Total Ultrafiltration was 2.6 ± 0.9 L (9.78 ± 3.78 ml/min) in A, 9.3 ± 1.7 L (34.54 ± 6.22 ml/min) in B and 16.3 ± 3.3 L (60.94 ± 12.63 ml/min) in C. Replacement fluid during dialysis was 6.85 ± 1.42 and 13.65 ± 2.9 L. in C and C respectively. Posdialysis total, ionized calcium and magnesium were significantly lower in schedules B and C versus A. PTH levels did not differ significantly. However, PTH changes during dialysis was -36.6 ± 38.6%, 6.3 ± 69.8% and 32.2 ± 63.2% in A, B and C, respectively (p < 0.05 A vs C). A significant inverse correlation was found between total Ultrafiltration and posdialysis levels of total calcium (r: -0.56, p < 0.001), ionized calcium (r: -0.65, p < 0.001) and magnesium (r:- 0.47, p < 0.01). No differences were observed in pre and posdialysis phosphate levels, neither mass transfer and clearance of phosphate. We concluded that high ultrafiltration flow rates and substitution fluid without divalent cations induces a negative calcium and magnesium balance. These changes may stimulate PTH secretion during HDF. This technique did not resulte in a higher clearance or phosphate removal

Análisis del estrés oxidativo en pacientes en hemodiafiltración en línea / Stress oxidative analysis in patients on hemodiafiltration on line

Los pacientes afectos de enfermedad renal crónica presentan una elevada morbimortalidad debido a enfermedades cardiovasculares. Sin embargo, la elevada presencia de estas enfermedades no puede explicarse únicamente por los factores de riesgo tradicionales. En la actualidad, se considera la existencia de factores de riesgo emergentes, entre los que se encuentra el estrés oxidativo. Además se sabe que cuando reciben tratamiento con hemodiálisis, se ven sometidos a un estrés oxidativo adicional. El objetivo de este trabajo ha sido analizar y comparar el grado de estrés oxidativo en dos grupos de pacientes urémicos dializados con diferentes técnicas dialíticas: a. Hemodiafiltración on-line 3 veces/semana (HDFOL). b. Hemodiafiltración on-line diaria 6 veces semana(HDFOLD). Se estudiaron 9 pacientes afectos de enfermedad renal crónica terminal (Estadio 5), todos ellos varones con una edad media de 72,5 ± 6 años. Cinco pacientes pertenecían al grupo de HDFOLD y cuatro al grupo de HDFOL tres veces por semana. Los pacientes del grupo de HDF-OLD presentaban las siguientes concentraciones de glutatión reducido (GSH) en sangre, pre-diálisis de 742 ± 153 nmol/ml y post-diálisis de 878 ± 223, sin detectarse diferencias significativas entre ambos. Las concentraciones pre y post-diálisis de glutatión oxidado (GSSG) en sangre eran de 34 ± 14 nmol/ml y 137 ± 74 nmol/ml respectivamente (p < 0,03). Los cocientes GSSG/GSH obtenidos fueron: pre-diálisis de 58 ± 10 y post-diálisis 169 ± 65, con diferencias entre ambos valores (p < 0,03). Los pacientes del grupo HDF-OL 3 veces/semana también presentaron un incremento significativo de la concentración de GSSG y del ratio GSSG/GSH tras la sesión de diálisis, de 99 ± 45 nmol/ml a 179 ± 66 nmol/ml y de 161 ± 99 y a 337 ± 143, respectivamente (p < 0,05). La mediana de los valores de proteína C reactiva eran de 4,12 g/l en el grupo HDFOLD y 7,7 g/l en grupo de HDFOL (p < 0,05). No encontramos diferencias estadisticas en la actividad de la xantina oxidasa entre grupos ni tras la sesión de hemodiálisis. En resumen, podemos concluir que los pacientes afectos de enfermedad renal crónica terminal que reciben tratamiento sustitutivo se encuentran sometidos a un estrés oxidativo adicional, como muestra el incremento en los ratios GSSG/GSH en ambos grupos. Sin embargo los pacientes en el grupo HDFOLD presentan cocientes GSSG/GSH post-hemodiálisis y valores de PCR inferiores, lo que sugiere que la hemodiálisis diaria podría mejorar la depuración de medidores inflamatorios

Patients with chronic renal disease have a very high mortality due to cardiovascular disease. However, the traditional risk factors are not the only one explanation. Nowadays, there are new risk factors becoming, and one of these is the oxidative stress. Besides today we know that when these patients receive haemodialysis are being exposed to an additional oxidative stress. The aim of this study was to mesure and to compare the degree of oxidative stress in two groups of patients on different dialysis techniques: a) On-Line Haemodiafiltration three times / week (OL-HDF). b) Daily Om-Line haemodiafiltration (six times/week) (dOL-HDF) We studied 9 patients with chronic renal disease stage 5 on hemodialysis. They all were men, with a medium age of 72,5 ± 6 years. Five patiens were on dOL-HDFand four on tOL-HDF. Glutathione (GSH) concentration of patients on dOL-HDF before dialysis was 742 ± 153 nmol/ml and postdialysis de 878 ± 223. Blood GSSG concentration before and after dialysis was 34 ± 14 nmol/ml y 137 ± 74 nmol/ml (p < 0,03). GSSG/GSH ratio pre-dialysis was 58 ± 10 and post-dialysis 169 ± 65 (p < 0,03). In OL-HDF group GSSG concentration and the ratio GSSG/GSH also increased in a significative way from 99 ± 45 nmol/ml to 179 ± 66 nmol/ml, and from 161 ± 99 to 337 ± 143 (p < 0,05).We also found differences in pCR concentrations between both groups; 3 ± 1,4 g/l in dOL-HDF and 8,75 ± 5,8 g/l in HDF OL (p < 0,05).We did not find differences between xatine-oxidase activity before and after hemodialysis and between groups. In conclusion, patient with terminal chronic renal disease on OL-HDF receive an additional load of oxidative stress, as the increase in GSSG/GSH ratio in both groups shows. However patients on dHDF-OL shows low ratios GSSG/GSH post-hemodialysis and low pCR concentrations, and maybe this could be explained because daily on line haemodiafiltration improves purification of inflammatory mediators. Clue words: Hemodialysis, oxidative stress, glutathione, gssg/gsh ratio, xantine oxidasa

[Determination of the dose of dialysis with integrated modules in the same monitor]. / Medición de la dosis de diálisis mediante diferentes módulos integrados en un mismo monitor.

The "gold standard" method to measure the mass balance achieved during dialysis for a given solute is based on the total dialysate collection. This procedure is unfeasible and too cumbersome. For this reason, alternative methods have been proposed including the urea kinetic modelling (Kt/V), the measurement of effective ionic dialysance (Diascan), and the continuous spent sampling of dialysate (Quantiscan). The aim of this study was to compare the reliability and agreement of these two methods with the formulas proposed by the urea kinetic modelling for measuring the dialysis dose and others haemodialysis parameters. We studied 20 stable patients (16 men/4 women) dialyzed with a monitor equipped with the modules Diascan (DC) and Quantiscan (QC) (Integra. Hospal). The urea distribution volume (VD) was determined using anthropometric data (Watson equation) and QC data. Kt/V value was calculated according to Daurgidas 2nd generation formula corrected for the rebound (eKt/V), and using DC (Kt/VDC) and QC (Kt/VQC) data. The total mass of urea removed was calculated as 37,93 +/- 16 g/session. The VD calculated using Watson equation was 35.7 +/- 6.6 and the VDQC was 35.06 +/- 9.9. And they showed an significative correlation (r:0,82 p < 0.001). The (VDQC-VDWatson) difference was -0.64 +/- 5.8L (ns). Kt/VDC was equivalent to those of eKt/V (1.64 +/- 0.33 and 1.61 +/- 0.26, mean difference -0.02 +/- 0.29). However, Kt/VQC value was higher than eKt/V (1.67 +/- 0.22 and 1.61 +/- 0.26 mean difference 0.06 +/- 0.07 p < 0.01). Both values correlated highly (R2: 0.92 p < 0.001). Urea generation (C) calculated using UCM was 8.75 +/- 3.4 g/24 h and those calculated using QC was 8.64 +/- 3.21 g/24 h. Mean difference 0.10 +/- 1.14 (ns). G calculated by UCM correlated highly with that derived from QC (R2: 0.88 p < 0.001). In conclusion, Kt/VDC and Kt/VQC should be considered as valid measures for dialysis efficiency. However, the limits of agreement between Kt/VQC and eKt/V were closer than Kt/VDC.

El coste del tratamiento farmacológico en la enfermedad renal crónica / Estimation of the cost in the farmacologic treatment of chronic renal failure

La prevalencia e incidencia de la enfermedad renal crónica ha aumentado considerablementea lo largo de los últimos años. Sabemos que el tratamiento deestos pacientes conlleva un elevado coste. Actualmente disponemos de una informaciónlimitada en relación a los recursos empleados en los cuidados de lospacientes en su etapa prediálisis.El objetivo de este trabajo es determinar el gasto farmacéutico de los pacientesantes del inicio del tratamiento sustitutivo. Para ello analizamos el coste del tratamientode 200 pacientes seguidos en la consulta externa de Nefrología. La edadmedia de la muestra fue de 72,4 años, siendo el 59% hombres, y con una comorbilidaddistribuida en: hipertensión 87%, dislipemia 56% y diabetes 35%.El gasto por paciente y mes fue de 215,45 €, observándose un incremento continuodesde 84,64 € en la fase 1 hasta 352,59 € en la fase 5 de la enfermedadrenal crónica. Los estimulantes de la eritropoyesis fueron responsable del 46,5%de estos costes. Los fármacos prescritos con mayor frecuencia fueron hipotensores,hipolipemiantes y suplementos de hierro.Los pacientes con enfermedad renal crónica generan un gasto significativo durantela etapa prediálisis. Los recursos limitados, y el crecimiento de los gastos sanitarios,particularmente los debidos a la farmacia, son dos de los principales problemasde los sistemas sanitarios. Un mejor conocimiento de los costes asociadosal tratamiento de estos pacientes nos ayudará a incrementar nuestra eficiencia

The prevalence and incidence of end stage renal disease has increased considerablyin the past years. We know that the cost of treatment of these patients ishigh. Limited information exists on care resource utilization for maintenance of patientsbefore the initiation of replacement therapy.The purpose of this study is determine the cost of pharmaceutic treatment duringthe predialysis phase. Pharmacy cost was analyzed for 200 patients controled on outpatient nephrology departament. The mean age was 72.4 years, 59%were males, and the comorbidity distribution was: hypertension 87%, hyperlipidemia56% and diabetes 35%.The per-patient-per-month charges were 215,45 €, with a continous increasefrom 84.64 € on stage 1 to 352.59 € on stage 5 of chronic kidney disease. Erythropoiesisstimulants were reponsible of 46.5% of these cost. The most frequentprescribed medications were antihypertensive drugs, statins and iron preparations.Patients with end stage renal disease generate significant cost during the predialysisperiod. The limited resources, and the growth of health care expeditures,particulary the spending for prescriptions drugs, are two of the major problemsfor Healt Care Systems. A better knowledge of the associated costs to the treatmentof these patients will help us to increase our efficiency

Medición de la dosis de diálisis mediante diferentes módulos integrados en un mismo monitor / Determination of the dose of dialysis with integrated modules in the same monitor

La recolección total del líquido de diálisis para cuantificar la cantidad total deurea eliminada durante la hemodiálisis (HD) se ha considerado la técnica «goldestándar» para medir la dosis de diálisis. Dada la dificultad de este método sehan propuesto otros alternativos como el modelo cinético de la Urea (Kt/V), lamedición de la dialisancia iónica o la recogida de muestras representativas del líquidode diálisis total.El objetivo de este trabajo es comparar la fiabilidad y concordancia de dos dispositivosde medida (dialisancia iónica y recogida parcial de líquido de diálisis)integrados en el mismo monitor de diálisis y compararlos con los propuestos porel modela cinético de la urea (MCU) para la medición de la dosis de diálisis(Kt/V) y otros parámetros de HD.Para ello se estudiaron 20 pacientes (16V/4M) con una edad media de 64,5 ±13 años, estables en programa de HD y dializados con el monitor Integra® (Hospal)equipado con los biosensores Diascan (DC) y Quantiscan (QC). El volumende distribución de urea (VD) se calculó a partir de la fórmula de Watson y porel QC. La generación de urea se calculó a partir del MCU y el Kt/V se determinópor la fórmula de Daurgidas 2ª generación corregida para el rebote (eKt/V),por el DC y el QC.La transferencia de masa de urea medida por QC fue de 37,2 ± 13,8 g. El VDpor la fórmula de Watson y por QC fue de 35,7 ± 6,6 y de 35,06 ± 9,9 L respectivamente(ns) y mostraron una correlación significativa (r: 0,82 p < 0,001).Los valores de aclaramiento (K), mediante DC, y QC fueron similares KQC: 230,3± 56,5 ml/min, KDC: 214,05 ± 24,3 ml/min (ns) No se apreciaron diferencias enel Kt/V calculado por DC y el eKt/V (KtVDC: 1,64 ± 0,33 vs KtVeq; 1,61 ± 0,26).El coeficiente de correlación fue de r: 0,45 (p < 0,05). Por el contrario los valoresde Kt/VQC fueron superiores a los calculados por el eKtV (1,67± 0,22 vs. 1,61± 0,26). El coeficiente de correlación fue de r: 0,94 ( p < 0,001). La generaciónde urea por el MCU fue de 8,7 ± 3,4 y por QC de 8,6 ± 3,2 g/ 24h (ns) r: 0,94p < 0,001).Podemos concluir que tanto la medición de la dialisancia iónica mediante elDC, como la recogida de muestras representativas del líquido de diálisis medianteel QC, son métodos sencillos, fiables y reproducibles que nos permiten medirde manera rápida la eficacia dialítica y otros parámetros de hemodiálisis. En nuestra experiencia la cuantificación de la dosis de diálisis mediante el QC presentauna mayor concordancia que la realizada con DC

The «gold standard» method to measure the mass balance achieved during dialysisfor a given solute is based on the total dialysate collection. This procedure isunfeasible and too cumbersome. For this reason, alternative methods have beenproposed including the urea kinetic modelling (Kt/V), the measurement of effectiveionic dialysance (Diascan), and the continuous spent sampling of dialysate(Quantiscan).The aim of this study was to compare the reliability and agreement of thesetwo methods with the formulas proposed by the urea kinetic modelling for measuringthe dialysis dose and others haemodialysis parameters.We studied 20 stable patients (16 men/4 women) dialyzed with a monitor equippedwith the modules Diascan (DC) and Quantiscan (QC) (Integra®. Hospal). Theurea distribution volume (VD) was determined using anthropometric data (Watsonequation) and QC data. Kt/V value was calculated according to Daurgidas2nd generation formula corrected for the rebound (eKt/V), and using DC (Kt/VDC)and QC (Kt/VQC) data.The total mass of urea removed was calculated as 37,93 ± 16 g/session. TheVD calculated using Watson equation was 35.7 ± 6.6 and the VDQC was 35.06± 9.9. And they showed an significative correlation (r:0,82 p < 0.001). The (VDQCVDWatson)difference was –0.64 ± 5.8L (ns). Kt/VDC was equivalent to those ofeKt/V (1.64 ± 0.33 and 1.61 ± 0.26, mean difference –0.02 ± 0.29). However,Kt/VQC value was higher than eKt/V (1.67 ± 0.22 and 1.61 ± 0.26 mean difference0.06 ± 0.07 p < 0.01). Both values correlated highly (R2: 0.92 p < 0.001).Urea generation (G) calculated using UCM was 8.75 ± 3.4 g/24 h and those calculatedusing QC was 8.64 ± 3.21 g/24 h. Mean difference 0.10 ± 1.14 (ns). Gcalculated by UCM correlated highly with that derived from QC (R2: 0.88 p <0.001).In conclusion, Kt/VDC and Kt/VQC should be considered as valid measures fordialysis efficiency. However, the limits of agreement between Kt/VQC and eKt/Vwere closer than Kt/VDC