[Detection and classification of chronic kidney disease in Primary Care and importance of albuminuria]. / Detección y clasificación de la enfermedad renal crónica en Atención Primaria y la importancia de la albuminuria.

INTRODUCTION: Chronic kidney disease (CKD) is a public health problem, and Primary Care (PC) plays a key role in its detection and classification based on estimated glomerular filtration rate (eGFR), as well as the level of albuminuria for its proper management. The aim of this study was to analyse the prevalence and classification of CKD in patients attended in PC. MATERIAL AND METHODS: An analysis was made of CKD prevalence and classification according to the Kidney Disease-Improving Global Outcomes guidelines in PC patients. All biochemical analyses requested from PC on patients 18 years and older over a 5-year period were collected. When several analyses were available on a patient, the biochemistry result with the best eGFR was selected. RESULTS: Between 2010 and 2014, PC requested 304,523 biochemical analyses on 97,470 adult patients, with a mean age of 53.4±19.4 years, of which 57.2% were women. CKD prevalence was 7.6%. Urine protein results were present in only 16.6% of analyses, and only 15.2% patients had a urine protein result. Urine albumin was measured 15.4% of biochemical controls with eGFR≥60mL/min/1.73m2, in 27.1% of patients with eGFR between 30-59mL/min/1.73m2 (G3a-3b stages), and in 23.4% of patients with eGFR<30mL/min/1.73m2 (G4-5 stages). Urine albumin was tested in 37.7% of diabetics and in 23.5% of impaired fasting glucose. CONCLUSIONS: Requests for the measurement of urine proteins/albumin in PC patients are low, leading to only one in 6 PC patients being classified correctly. The measurement of urine proteins/albumin is higher in CKD and diabetic patients.

Insuficiencia renal oculta en atención primaria. ¿Un problema exclusivo de mujeres? / Occult renal failure in primary care, a women problem ?

Introducción: La insuficiencia renal crónica se está convirtiendo en un problema de salud pública. La estimación del filtrado glomerular (FG) mediante fórmulas permite detectar las personas con daño renal. Objetivo: Conocer el porcentaje de personasatendidas en atención primaria con insuficiencia renal (IR) oculta definida por presentar un FG estimado < 60 mL/min/1,73 m2, con niveles de creatinina séricadentro de los límites de referencia del laboratorio (< 1,3 mg/dL en hombres y < 1,2 mg/dL en mujeres), que hubiesen pasado desapercibidas. Método: Personas mayores de 18 años atendidas en Atención Primaria del Área de Salud de Plasencia (Cáceres) a las que su médico de atención primaria solicitó la medición de niveles de creatinina, entre el 1 de marzo y el 31 de julio de 2006 (5 meses). Se estimó el FG usando la fórmula MDRD-4 y se clasificó el grado de IR de acuerdo con las guías DOQI de la NKF. Resultados: Se realizaron 13.784 mediciones de creatinina sérica en mayores de 18 años. 1.042 presentaron FG < 60 mL/min/1,73 m2, correspondientesa 960 personas (6,96%). Edad media 76,8 años (rango 40-98). De ellas, 418 (43,5%) presentaban IR «oculta», todas mujeres, con edad media 76,5 años y Crmedia 1 mg/dL. Conclusiones: Existe un elevado porcentaje de pacientes atendidos en atención primaria con FG < 60 mL/min/1,73 m2 que mantiene niveles de creatinina en los límites normales. La estimación del FG de forma sistemática permite detectar dichos pacientes, fundamentalmente mujeres mayores de 65 años, que pasarían desapercibidos, lo que se ha denominado IR «oculta»

Background: Chronic renal failure is becoming a public health problem. The estimation of glomerular filtration rate (GFR) using the MDRD-4 equation is importantto find out patients with impaired renal function. The aim of this study was to determinate the rate of patients took care in Primary Care with «occult» renal failure, defined as a GFR less than 60 mL/min/1.73 m2, and serum creatinine levels in the normal range of the laboratory (< 1.3 mg/dL for men, and < 1.2 mg/dL for women).Methods: Patients over 18 years-old took cared in Primary Care of the health area of Plasencia (Caceres), who were measured serum creatinine level between march to july 2006. We estimated GFR using MDRD-4 formula and classified the level of kidney function according to the NKF-DOQI guidelines.Results: We estimated GFR in 13.784 analyses. In 1.042 the GFR was less than 60 mL/min/1.73m2, from 960 patients(6.96%). Mean age 76.8 years (range 40-98 years). 418 keep normal serum creatinine levels (43.5%). Conclusion: Renal impairment seems to be prevalent in the general population took care in Primary Care. An elevated rate of patients with renal failure present serum creatinine levels in the laboratory normal range, «occult» renal failure. The systematic estimation of GFR using MDRD formula is necessary to detect this patients with renal impairment

[Occult renal failure in primary care. A women's problem?]. / Insuficiencia renal oculta en atención primaria. Un problema exclusivo de mujeres?

BACKGROUND: Chronic renal failure is becoming a public health problem. The estimation of glomerular filtration rate (GFR) using the MDRD-4 equation is important to find out patients with impaired renal function. The aim of this study was to determinate the rate of patients took care in Primary Care with "occult" renal failure, defined as a GFR less than 60 mL/min/1.73m2, and serum creatinine levels in the normal range of the laboratory (< 1.3 mg/dL for men, and < 1.2 mg/dL for women). METHODS: Patients over 18 years-old took cared in Primary Care of the health area of Plasencia (Caceres), who were measured serum creatinine level between March to July 2006. We estimated GFR using MDRD-4 formula and classified the level of kidney function according to the NKF-DOQI guidelines. RESULTS: We estimated GFR in 13.784 analyses. In 1.042 the GFR was less than 60 mL/min/1.73m2, from 960 patients (6.96%). Mean age 76.8 years (range 40-98 years). 418 keep normal serum creatinine levels (43.5%). CONCLUSION: Renal impairment seems to be prevalent in the general population took care in Primary Care. An elevated rate of patients with renal failure present serum creatinine levels in the laboratory normal range, "occult" renal failure. The systematic estimation of GFR using MDRD formula is necessary to detect this patients with renal impairment.

[The start of renal replacement therapy in a Spanish department]. / Comienzo de tratamiento renal sustitutivo en la provincia de Cáceres.

BACKGROUND: Early nephrological referral and planned start of dialysis are associated with better prognosis after the beginning of renal replacement therapy (RRT). The aim of our study was to analyse patient clinical and analytic characteristics at the time of initiating dialysis and to evaluate if morbimortality was affected by planned start. PATIENTS AND METHODS: We performed a retrospective study of all patients commencing RRT in a Spanish Hospital of The National Health System over two years (2003-2004). A total of 117 patients (47 female and 70 male) were included. We carried out a retrospective analysis of the demographic characteristics, patients' clinical and analytic conditions at the time of starting dialysis and hospitalization days and mortality in six months after starting dialysis. Patients were classified as planned (P) or unplanned (NP), depending on whether the first dialysis was planned or an emergency. RESULTS: Sixty five patients (56.4%) started dialysis in a planned group while 52 (43.6%) were unplanned. In the former group, 83.1% of the patients had a vascular or peritoneal access available when starting RRT, whereas in the later group only the 3.8% had it. Planned dialysis initiation was associated with a high level of serum haemoglobin, haematocrit, calcium and albumin (p < 0.001), and a low level of serum urea, creatinine (p < 0.001) and phosphate (p < 0.05). More patients of the unplanned group were admitted at hospital at the initiation of dialysis (90.4% vs. 6.1%) and during the first 6 months (48% vs. 15.3%). The period of hospitalization was longer for the unplanned group (23.6 days vs 3 days) (p < 0.001). The 6-month-mortality was lower in the planned group (4.6% vs. 11.5%), whitout statistical difference. CONCLUSIONS: Planned dialysis initiation is associated with better clinical and metabolical conditions, greater probability of a vascular or peritoneal access availability and lower rate of hospitalization and mortality within 6 months after starting RRT

Comienzo de tratamiento renal sustitutivo en la provincia de Cáceres / The start of renal replacement therapy in a spanish department

Introducción: La derivación precoz al nefrólogo y el inicio programado de diálisisse asocian a un mejor pronóstico tras el comienzo del tratamiento renal sustitutivo(TRS). El objetivo de nuestro estudio fue analizar las características clínicasy analíticas de los pacientes al comienzo de diálisis y valorar si el inicioprogramado influía en la morbi-mortalidad a los 6 meses.Pacientes y métodos: Estudio retrospectivo que incluye los 117 pacientes queiniciaron TRS en nuestra provincia en los años 2003-2004 (47 mujeres y 70 varones).Se revisaron las características demográficas, los datos clínicos y analíticosal inicio, los ingresos hospitalarios y la mortalidad a los 6 meses. Los pacientes sedividieron en programados (P) y no programados (NP) dependiendo si la primeradiálisis se realizó en situación de urgencia (NP) o si pudo ser diferida en eltiempo más de 24 horas (P).Resultados: Sesenta y cinco pacientes comenzaron TRS de forma programada(56,4%) y 52 de forma no programada (43,6%). Los pacientes P presentaban accesovascular o peritoneal útil en un porcentaje mayor (83,1% vs 3,8%). El inicioprogramado de diálisis se asoció a un nivel más elevado de hemoglobina, hematocrito,calcio y albúmina (p < 0,001), y a una tasa más baja de urea, creatinina(p < 0,001) y fósforo (p < 0,05). Un menor número de pacientes del grupo P requirieroningreso al inicio de TRS (6,1% vs 90,4%), y también entre el 2° y el6° meses (15,3% vs 48%). Los días de hospitalización fueron significativamenteinferiores en el grupo programado (3 vs 23,6) (p < 0,001). Aunque no hubo diferenciasestadísticamente significativas, la mortalidad a los 6 meses fue menor enel grupo programado (4,6% vs 11,5%).Conclusiones: El inicio programado de diálisis se asocia a una mejor situaciónclínico-metabólica, una mayor probabilidad de acceso útil y un menor número dehospitalizaciones y tasa de mortalidad en los 6 meses posteriores

Background: Early nephrological referral and planned start of dialysis are associatedwith better prognosis after the beginning of renal replacement therapy (RRT). The aim of our study was to analyse patient clinical and analytic characteristicsat the time of initiating dialysis and to evaluate if morbimortality was affected byplanned start.Patients and methods: We performed a retrospective study of all patients commencingRRT in a Spanish Hospital of The National Health System over two years(2003-2004). A total of 117 patients (47 female and 70 male) were included. Wecarried out a retrospective analysis of the demographic characteristics, patients’ clinicaland analytic conditions at the time of starting dialysis and hospitalizationdays and mortality in six months after starting dialysis. Patients were classified asplanned (P) or unplanned (NP), depending on whether the first dialysis was plannedor an emergency.Results: Sixty five patients (56.4%) started dialysis in a planned group while 52(43.6%) were unplanned. In the former group, 83.1% of the patients had a vascularor peritoneal access available when starting RRT, whereas in the later grouponly the 3.8% had it. Planned dialysis initiation was associated with a high levelof serum haemoglobin, haematocrit, calcium and albumin (p < 0.001), and a lowlevel of serum urea, creatinine (p < 0.001) and phosphate (p < 0.05). More patientsof the unplanned group were admitted at hospital at the initiation of dialysis(90.4% vs 6.1%) and during the first 6 months (48% vs 15.3%). The periodof hospitalization was longer for the unplanned group (23.6 days vs 3 days) (p <0.001). The 6-months-mortality was lower in the planned group (4.6% vs 11.5%),whitout statistical difference.Conclusions: Planned dialysis initiation is associated with better clinical and metabolicalconditions, greater probability of a vascular or peritoneal access availabilityand lower rate of hospitalization and mortality within 6 months after starting RRT

Estimación sistemática del filtrado glomerular en el Área Sanitaria de Plasencia / Systematic estimation of glomerular filtration in the Plasencia health care area

No disponible

Inicio de diálisis en una provincia española / No disponible

No disponible

[Vascular Aspergillus infection in two recipients of kidneys from the same donor]. / Infección vascular por Aspergillus en dos receptores de injertos renal del mismo donante.

We describe a clinical case of two patients who received a cadaveric renal graft from the same donor in a multi-organ extraction procedure. The donor was a 39-years-old woman who died of intracranial tumour. A benign ganglioma was shown in biopsy. The two recipients received the same immunosuppressive regimen. Induction comprised cyclosporin A, steroids and basiliximab while cyclosporin A and steroids were used in maintenance immunosuppression. The A patient was a 53-year-old woman with chronic renal failure due to chronic pyelonephritis. She had been undergoing periodic haemodialysis for five years. She was hospitalised for sciatic pain refractory to rest and analgesics 35 days after transplantation. Two days later, her graft function deteriorated. Ultrasonography ruled out a urinary tract obstruction. Cyclosporine levels was normal. It was interpreted as an acute rejection episode and was treated with boluses of methylprednisolone (500 mg for 3 days). At the same time, her right leg began to show paraesthesia, coldness and a decreased arterial pulse. A spinal magnetic nuclear resonance was performed. It showed an aneurysm of right common iliac artery (fig. 1). An arteriography confirmed the existence of a pseudoaneurysm and an arteriovenous fistula to inferior vena cava (fig. 2). The B recipient was a 56-year-old woman with chronic renal failure due to chronic pyelonephritis. She required haemodialysis for two years. In the 4th month after transplantation her graft function deteriorated. Graft biopsy did not show acute cellular rejection, so she was kept on immunosuppressive treatment. A second graft biopsy was taken and no changes with the previous one was observed. Renal function deteriorated and haemodialysis was required. During the 6th month she began to show paraesthesia, coldness and decreased arterial pulse in her right leg. Ultrasonography showed pyelocaliectasis with an adjacent solid-liquid mass, abdominal CT scan confirmed. Arteriography proved the presence of a pseudoaneurysm of the right common iliac artery (fig. 3). Transplantectomy and pseudoaneurysm resection was performed in the two cases. Culture analysis revealed fungi identified as Aspergillus in both pseudoaneurysms. Medical treatment was started immediately with liposomal amphotericin B. The clinical evolution of the two recipients were different. While recipient A died, B patient recovered, requiring haemodialysis.