[Current peritoneal dialysis compared with haemodialysis: medium-term survival analysis of incident dialysis patients in the Canary Islands in recent years]. / Diálisis peritoneal actual comparada con hemodiálisis: análisis de supervivencia a medio plazo en pacientes incidentes en diálisis en la Comunidad Canaria en los últimos años.

INTRODUCTION: Important differences in patient survival exist between peritoneal dialysis (PD) and haemodialysis (HD). Several different studies have shown that PD yields a better survival rate than HD in the first and second years of treatment, especially in younger patients and non-diabetic patients with low comorbidity, whereas HD produces better results in diabetic patients, elderly patients, and in patients with greater comorbidity. In recent years, interesting changes have occurred in PD units in the Canary Islands, such as the introduction of peritoneal dialysis solutions with bicarbonate dialysate and low content of glucose degradation products, extended use of automated dialysis, and continuity of physicians and nurses in PD units, in addition to enhancing visits for advanced chronic kidney disease (ACKD). OBJECTIVE: This situation led us to perform our study with the primary objective of comparing medium-term survival among incident dialysis patients on HD versus PD in recent years in the Canary Islands, and as a secondary objective, to compare survival between these two types of dialysis by subgroups as defined by age, sex and diabetes. MATERIAL AND METHODS: This was a retrospective cohort study comparing survival between HD and PD patients starting dialysis in the Canary Islands between 01/01/2006 and 31/12/2009, with adjustment based on the propensity score analysis. We analysed data from the RERCAN database, which collects data on demographic variables, changes in type of dialysis, province and hospital of the patient, and mortality and its causes. We calculated Kaplan-Meier estimates of survival based on the overall population and stratified by age, sex and diabetes. We applied a Cox proportional hazards model for survival to estimate the relative mortality risk of PD compared with HD, using as independent variables: age, sex, quartiles of propensity score, the province of the patient, and diabetes. Finally, we applied a Cox model with time-dependent effects, using as a fixed risk factor the initial type of dialysis in order to assess the effect of PD versus HD on short and medium-term survival. RESULTS: The cohort included 1469 patients (173 PD and 1296 HD), with a mean age of 62.5 years, 65% male. Mean follow-up was 16.2±12.4 months. Factors associated with greater probability of choosing PD were younger age and living in the province of Las Palmas. The cumulative mortality in the intention to treat (ITT) analysis was 27.1% in the HD group and 8.7% in the PD group, P<.0001. The cumulative probability of survival by ITT using PD vs HD was 96.6% versus 89% at 6 months (P<.001), 96% versus 80% at 12 months (P<.001), 90% versus 65% at 24 months (P<.001), 82% versus 58% at 36 months (P<.001) and 73% versus 45% at 46 months (P<.001). In the subgroup analysis, survival was also higher in PD patients compared to HD patients both over and under 65 years old, in both diabetic and non-diabetic patients, and in both genders. The same analysis from the 90th day onward produced similar results. In the ITT analysis, the Cox-adjusted mortality risk for PD was 61% lower than for HD (RR: 0.398, 95% CI 0.237-0.669, P=.001), adjusted for age, diabetes, sex, patient's province and propensity score. Broken down by years of survival on the technique used, the relative risk of death for PD compared with HD in the first year was also significantly lower (RR 0.509, 95% CI: 0.259-0.999, P=.049). From year 2 onwards, only age was a risk factor for mortality (RR: 2.785, 95% CI: 1.525-5.086, P=.001) and no differences were shown between the two dialysis techniques. CONCLUSION: In the Canary Islands, PD has demonstrated survival advantages over HD in the short and medium term. It is remarkable that this benefit was found in young and old patients, men and women, and diabetic and non-diabetic patients, and that this advantage was maintained even after years of being on dialysis.

Diálisis peritoneal actual comparada con hemodiálisis: análisis de supervivencia a medio plazo en pacientes incidentes en diálisis en la Comunidad Canaria en los últimos años / Current peritoneal dialysis compared with haemodialysis: medium–term survival analysis of incident dialysis patients in the Canary Islands in recent years

Introducción: Existen importantes diferencias en los resultados de supervivencia de paciente y técnica entre diálisis peritoneal (DP) y hemodiálisis (HD) en las distintas series publicadas. Varios estudios han demostrado que la DP tiene mejor supervivencia que la HD en el primer y segundo año de tratamiento, sobre todo en los pacientes más jóvenes, no diabéticos y con menor comorbilidad, mientras que la HD parece mejor en los pacientes diabéticos, de más edad y mayor comorbilidad. En la Comunidad Canaria, en los últimos años se han ido introduciendo cambios asistenciales interesantes en las unidades de DP, como son la introducción de las soluciones de DP con baño de diálisis con bicarbonato y con bajo contenido en productos de degradación de la glucosa, la extensión del uso de la diálisis automatizada y la continuidad del médico y de la enfermera en las unidades de DP, además de la potenciación de las consultas de enfermedad renal crónica avanzada (ERCA). Objetivo: Esta situación nos condujo a realizar nuestro estudio con el objetivo principal de comparar la supervivencia a medio plazo entre pacientes incidentes en HD frente a DP en los últimos años en Canarias y como objetivos secundarios comparar la supervivencia entre dichas modalidades por subgrupos definidos por edad, sexo y diabetes. Material y métodos: Se trata de un trabajo de cohorte retrospectivo que compara la supervivencia entre HD y DP de pacientes que inician diálisis en la Comunidad Canaria entre el 1–1–2006 y 31–12–2009, con ajuste basado en el (..) (AU)

Introduction: Important differences in patient survival exist between peritoneal dialysis (PD) and haemodialysis (HD). Several different studies have shown that PD yields a better survival rate than HD in the first and second years of treatment, especially in younger patients and non–diabetic patients with low comorbidity, whereas HD produces better results in diabetic patients, elderly patients, and in patients with greater comorbidity. In recent years, interesting changes have occurred in PD units in the Canary Islands, such as the introduction of peritoneal dialysis solutions with bicarbonate dialysate and low content of glucose degradation products, extended use of automated dialysis, and continuity of physicians and nurses in PD units, in addition to enhancing visits for advanced chronic kidney disease (ACKD). Objective: This situation led us to perform our study with the primary objective of comparing medium–term survival among incident dialysis patients on HD versus PD in recent years in the Canary Islands, and as a secondary objective, to compare survival between these two types of dialysis by subgroups as defined by age, sex and diabetes. Material and methods: This was a retrospective cohort study comparing survival between HD and PD patients starting dialysis in the Canary Islands between 01/01/2006 and 31/12/2009, with adjustment based on the propensity score analysis. We analysed data from the RERCAN database, which collects data on demographic variables, changes in type of dialysis, province and hospital of the patient, and mortality and its causes. We calculated Kaplan–Meier estimates of (..) (AU)

A study on the efficacy and safety of losartan in elderly patients with mild to moderate essential hypertension.

Despite progress in the detection and treatment of hypertension the percentage of patients with controlled hypertension has failed to increase. The problem of poor blood pressure control is even more serious in elderly hypertensives than in the rest of the population. The antihypertensive drugs of the AIIRA (non-peptide angiotension II receptor antagonist) class are drugs whose use and experience are increasing and whose properties make them particularly useful in the elderly. We tried to assess the efficacy of treatment with losartan, the first AIIRA drug in a cohort of elderly patients with essential hypertension and to assess the percentage of patients achieving optimum BP control and to evaluate its safety, tolerability and metabolic effects. The intervention proved to be highly effective, achieving the anticipated blood pressure levels in the elderly in 77% of subjects after a 16-week follow-up, with very good tolerability. Renal function remained unchanged, as did the subjects' lipid profile.

Tratamiento de la hipertensión arterial en el diabético. De la prédica a la cruda realidad / Treatment of arterial hypertension in the diabetic patient. From theory to hard reality

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HLA-DR class II and ICAM-1 expression on tubular cells taken by fine-needle aspiration biopsy in renal allograft dysfunction.

BACKGROUND: Percutaneous biopsy is the method of choice for differential diagnosis of renal allograft dysfunction, although it is not risk-free. The use of less aggressive methods for diagnosis should limit the need for percutaneous biopsy to some specific situations. METHODS: We analysed 42 fine-needle aspiration biopsies from 36 kidney allograft recipients immunosuppressed with quadruple sequential therapy who suffered renal allograft dysfunction. Seven cases with stable renal function were used as controls and included as non-rejection cases in the analysis. In all aspirates the Corrected Increment was calculated and an immunocytochemical analysis of renal tubular cells with the monoclonal antibodies HLA-DR and ICAM-1 was performed. RESULTS: The Corrected Increment was increased in 13 out of 18 acute rejection cases and in one out of 31 non-rejection cases. HLA-DR expression was found in more than 30% of tubular cells from the aspirates in 16 out of 18 acute rejection cases and in eight out of 31 cases without rejection (P < 0.001). ICAM-1 expression was detected in more than 30% of tubular cells in 14 out of 18 cases with acute rejection, and in four out of 31 cases without acute rejection (P < 0.001). Interestingly, all acute vascular rejection cases (n = 6), and six out of 12 acute cellular rejection cases expressed both, HLA-DR and ICAM-1, in more than 30% of tubular cells. On the other hand, none of the non-rejection allograft dysfunctions or control samples showed more than 30% of tubular cells immunostained with both HLA-DR and ICAM-1 antibodies. CONCLUSIONS: The immunocytochemical analysis of HLA-DR and ICAM-1 on renal tubular cells taken by fine-needle aspiration biopsy, allows the diagnosis of acute cellular rejection and acute vascular rejection even when the Corrected Increment is not increased. Moreover, the risk of a core renal biopsy can be avoided when both tests are negative since an acute rejection is a remote possibility.

Monoclonal analysis of fine-needle aspiration biopsy in kidney allografts.

To evaluate changes in T-lymphocyte subsets and DR expression on tubular cells, 74 fine-needle allograft aspirates (FNAB) were evaluated in 31 patients with cadaver kidney transplants. Monoclonal antibodies against T helper CD4+, cytotoxic/suppressor CD8+, and HLA-DR were used with an indirect alkaline-phosphatase-staining technique. Cases with acute rejection (n = 11) showed a significant increase of CD8+: CD4+ ratio versus those with stable function (n = 21), acute tubular necrosis (n = 10) or CsA toxicity (n = 7) (ANOVA F = 10; P less than 0.01). Cases with chronic rejection or CMV infection showed no differences in the CD8+: CD4+ ratio with the other groups. DR expression on tubular cells was frequently found in cases of acute rejection, chronic rejection and CMV (73%, 66%, and 43% respectively), occasionally found in CsA toxicity (14%), but never seen in controls or ATN. Both tests, the CD8+: CD4+ ratio and the DR expression on tubular cells, had a high sensitivity and specificity in differentiating acute rejection versus controls, acute tubular necrosis, and CsA toxicity. When both tests are taken together no case without rejection showed a CD8+:CD4+ ratio greater than 1.6 and DR expression on tubular cells. Cases with acute rejection who lost the graft (n = 6) had a CD8+:CD4+ ratio significantly greater than those who responded to antirejection therapy (n = 5) (t = 2.9; P less than 0.05).