Documento de consenso sobre el manejo de la patología renal en pacientes con infección por VIH / Consensus document on the management of renal disease in HIV-infected patients

OBJETIVO: Actualizar las recomendaciones sobre la evaluación y el manejo de la afectación renal en pacientes con infección por el virus de la inmunodeficiencia humana (VIH). MÉTODOS: Este documento ha sido consensuado por un panel de expertos del Grupo de Estudio de Sida (GESIDA) de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), de la Sociedad Española de Nefrología (S.E.N.) y de la Sociedad Española de Química Clínica y Patología Molecular (SEQC). Para la valoración de la calidad de la evidencia y la graduación de las recomendaciones se ha utilizado el sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTADOS: La evaluación renal debe incluir la medida de la concentración sérica de creatinina, la estimación del filtrado glomerular (ecuación chronic kidney disease epidemiological collaboration [CKD-EPI]), la medida del cociente proteína/creatinina en orina y un sedimento urinario. El estudio básico de la función tubular ha de incluir la concentración sérica de fosfato y la tira reactiva de orina (glucosuria). En ausencia de alteraciones, el cribado será anual. En pacientes tratados con tenofovir o con factores de riesgo para el desarrollo de enfermedad renal crónica (ERC), se recomienda una evaluación más frecuente. Se debe evitar el uso de antirretrovirales potencialmente nefrotóxicos en pacientes con ERC o factores de riesgo para evitar su progresión. En este documento se revisan las indicaciones de derivación del paciente a Nefrología y las de la biopsia renal, así como las indicaciones y la evaluación y el manejo del paciente en diálisis o del trasplante renal. CONCLUSIONES: La función renal debe monitorizarse en todos los pacientes con infección por el VIH y este documento pretende optimizar la evaluación y el manejo de la afectación renal.(AU)

OBJECTIVE: To update the 2010 recommendations on the evaluation and management of renal disease in HIV-infected patients. METHODS: This document was approved by a panel of experts from the AIDS Working Group (GESIDA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Nephrology (S.E.N.), and the Spanish Society of Clinical Chemistry and Molecular Pathology (SEQC). The quality of evidence and the level of recommendation were evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS: The basic renal work-up should include measurements of serum creatinine, estimated glomerular filtration rate by CKD-EPI, Urine protein-to-creatinine ratio, and urinary sediment. Tubular function tests should include determination of serum phosphate levels and urine dipstick for glucosuria. In the absence of abnormal values, renal screening should be performed annually. In patients treated with tenofovir or with risk factors for chronic kidney disease (CKD), more frequent renal screening is recommended. In order to prevent disease progression, potentially nephrotoxic antiretroviral drugs are not recommended in patients with CKD or risk factors for CKD. The document advises on the optimal time for referral of a patient to the nephrologist and provides indications for renal biopsy. The indications for and evaluation and management of dialysis and renal transplantation are also addressed. CONCLUSIONS: Renal function should be monitored in all HIV-infected patients. The information provided in this document should enable clinicians to optimize the evaluation and management of HIV-infected patients with renal disease.(AU)

Consensus document. Recommendations on assessing proteinuria during the diagnosis and follow-up of chronic kidney disease.

The presence of persistently elevated urinary concentrations of protein or albumin is considered a sign of kidney damage. The diagnosis and staging of chronic kidney disease (CKD) is nowadays based upon the presence of signs of kidney damage together with the estimation of the glomerular filtration rate.The presence of either proteinuria or albuminuria identifies a group of patients with higher risk of CKD progression and higher cardiovascular risk. Treatment with angiotensin converting enzyme inhibitors or angiotensin-receptor blockers,for instance, decreases both the progression of CKD and the incidence of cardiovascular events and death in patients with CKD and proteinuria. Thus, proteinuria is currently considered a therapeutic target by itself. Despite of the importance of detecting and monitoring proteinuria in the diagnosis and follow-up of CKD, there is not a consensus among the clinical practice guidelines published by different scientific societies on the diagnostic cut-off levels, on different sampling procedures,on the units used in laboratory reports or just on whether it should be defined in terms of albumin or proteinuria. The goal of this document, created by the consensus of the Spanish Society of Clinical Biochemistry and Molecular Pathology(SEQC, representing its spanish acronym) and the Spanish Society of Nephrology (S.E.N.), is to recommend to medical and laboratory clinicians appropriate guidelines for the detection and monitorization of proteinuria as a marker of CKD in adults and children. These recommendations result from searching,evaluating and summarizing current scientific evidence published in the last years.

Documento de Consenso. Recomendaciones sobre la valoración de la proteinuria en el diagnóstico y seguimiento de la enfermedad renal crónica / Consensus Document. Recommendations on assessing proteinuria during the diagnosis and follow-up of chronic kidney disease

La presencia de concentraciones elevadas de proteína o albúmina en orina, de modo persistente, es un signo de lesión renal y constituye, junto con la estimación del filtrado glomerular, la base sobre la que se sustenta el diagnóstico de la enfermedad renal crónica (ERC). Su presencia identifica a un grupo de pacientes con un riesgo superior de progresión de la enfermedad renal y con mayor morbilidad cardiovascular. El tratamiento con inhibidores de la enzima de conversión de la angiotensina o antagonistas del receptor de la angiotensina, en individuos con ERC y proteinuria, ha demostrado que disminuye tanto la progresión de la enfermedad renal como la incidencia de eventos cardiovasculares y muerte, por lo que la disminución del valor de la proteinuria es considerado un objetivo terapéutico. Pese a la importancia de la detección y monitorización de la proteinuria en el diagnóstico y seguimiento de la ERC, no existe consenso entre las guías de práctica clínica publicadas por distintas Sociedades científicas sobre cuáles son los valores que indican su presencia, si ésta debe ser definida en términos de albúmina o de proteína, el espécimen más adecuado para su medida o el tipo de unidades en que deben ser expresados los resultados. La finalidad de este documento, elaborado con el consenso de la Sociedad Española de Bioquímica Clínica y Patología Molecular (SEQC) y la Sociedad Española de Nefrología (S.E.N.), es proporcionar recomendaciones, a los facultativos clínicos y de laboratorio, para la detección y monitorización de la proteinuria como marcador de la presencia de ERC en adultos y en niños. Las recomendaciones son el resultado de la búsqueda, evaluación y síntesis de la evidencia científica publicada sobre el tema en los últimos años (AU)

The presence of persistently high urinary concentrations of protein or albumin is considered a sign of kidney damage. Nowadays, the diagnosis of chronic kidney disease (CKD) is based on the presence of signs of kidney damage together with the estimation of the glomerular filtration rate. The presence of either proteinuria or albuminuria identifies a group of patients with a higher risk of progression of CKD and higher cardiovascular risk. Treatment with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers decreases both the progression of CKD and the incidence of cardiovascular events and death in patients with CKD and proteinuria. Thus, proteinuria is currently considered a therapeutic target by itself. Despite the importance of detecting and monitoring proteinuria in the diagnosis and follow-up of CKD, there is no consensus among the clinical practice guidelines published by different scientific societies on the diagnostic cut-off levels, on different sampling procedures, on the units used in laboratory reports or just on whether it should be defined in terms of albuminuria or proteinuria. The goal of this document, created with the agreement of the Spanish Society of Clinical Biochemistry and Molecular Pathology (SEQC, representing its Spanish acronym) and the Spanish Society of Nephrology (S.E.N.), is to recommend appropriate guidelines to medical and laboratory physicians for detecting and monitoring proteinuria as a marker of CKD in adults and children. These recommendations are the result of searching, evaluating and summarising current scientific evidence published in the last few years (AU)

Proyecto NEFRONA: banco de datos de libre utilización / No disponible

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[The Bahía 2008 Study: hydration barometer in the Spanish population]. / Estudio Bahía 2008: barómetro de la hidratación de la población española.

BACKGROUND: Vital functions require a balance between the loss and ingestion of liquids. There are no studies about hydration on Spanish population. MATERIAL AND METHODS: 6,508 questionnaires were applied to a randomly selected Spanish population, together with a 24-hour recall in order to measure liquid consumption and variables related to it. RESULTS: The average consumption of liquids was 2,089.5 +/- 771.4 and 6.05 drinking times/day. 3,423 persons (52.6% of the studied people, CI 95% 51.3%-53.8%) were well-hydrated when considering their individual intake. The frequency and volume of drinking decreased with age. 61% (CI 95% 58.64%-64.01%) of the population older than 65 years were badly hydrated. The greatest bottled water consumption corresponded to the youngest population (18-29 years). The greater the physical activity, the greater the beverages consumption (1,987.6 +/- 705.5 ml vs 2,345.8 +/- 928.1 ml, low vs. intense physical activity, respectively). With regard to the intake frequency and volume, mineral and tap water were the most consumed. Those who drank mineral water exceeded the 2 l-recommendation in order to maintain a good hydration status. 59.8% (CI 95% 57.83%-61.76%) of those who preferred mineral water drank more than 2 l/day and drank more times/day and in greater amounts. There was a greater frequency and amount of beverage consumption when people lived in the same house, and particularly more in houses where children were living (2,197.4 +/- 767.8 ml vs 2,055.7 +/- 769.86 ml and 6.4 +/- 2.2 times vs 5.9 +/- 1,9 times, in homes with or without children, respectively). Bottled water was preferred at home (79.07%) and at work (15.61%). CONCLUSIONS: Only half of the Spanish population is well hydrated. Sixty-one percent of people over the age of 65 years were poorly hydrated, consequence it is imperative to promote its consumption.

Corrección de la anemia en pacientes diabéticos con enfermedad renal crónica sin tratamiento sustitutivo: enseñanzas del estudio TREAT / No disponible

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La gripe A (H1N1) en el paciente nefrológico. La pandemia que nos ha puesto en guardia / No disponible

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More about clinical research

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[Acetate-free on-line PHF: how to improve hyperacetatemia and haemodynamic tolerance]. / PHF on-line sin acetato: cómo mejorar la hiperacetatemia y la tolerancia hemodinámica.

SUMMARY BACKGROUND: The small quantity of acetate present in the dialysis fluid exposes patient's blood to an acetate concentration 30-40 times the physiological levels. This amount is even greater in hemodiafiltration on-line. Our purpose was to evaluate the clinical-analytical effects using three different dialysis techniques in the same patient. METHODS: 35 patients on hemodialysis were included. All patients were treated with conventional bicarbonate dialysate for 3 months, after randomization were switched to first be treated with PHF online with standard bicarbonate dialysate for 6 months and then switched to PHF on-line acetate-free dialysate for the other 6 months or to invert the two last periods. Blood samples were drawn monthly throughout the study and clinical data were obtained. RESULTS: Postdialysis blood acetate levels were higher in patients treated with conventional bicarbonate dialysate with respect to the period of PHF with free-acetate dialysate. Moreover, the percentage of patients with postdialysis blood acetate levels in the pathologic range was higher in patients treated with conventional bicarbonate dialysate respect to PHF on-line acetate-free dialysate period (61% vs. 30%). Serum concentrations of chloride postdialysis were higher and serum concentrations of bicarbonate pre and posthemodialysis were lower in the PHF free-acetate period. The incidence of hypotensive episodes was significantly lower in the PHF on-line with conventional dialysate. CONCLUSIONS: PHF on-line with free-acetate dialysate allows that most of patients finished hemodialysis with blood acetate levels in the physiologic ranges. PHF on-line is a predilutional hemodiafiltration treatment with better tolerance than hemodialysis with standard bicarbonate dialysate.

PHF on-line sin acetato: cómo mejorar la hiperacetatemia y la tolerancia hemodinámica / No disponible

Antecedentes: la presencia de acético en el Líquido de Diálisis (LD) expone al paciente a una concentración de acetato 30-40 veces superior a la normal. Dicha exposición aumenta en técnicas de Hemodiafiltración (HDF) online. El objetivo de dicho estudio fue evaluar los cambios clínico-analíticos al usar tres técnicas de Hemodiálisis(HD) diferentes. Métodos: se reclutaron 35 pacientes en HD estable. Se dializaron tres meses con HD convencional y luego fueron aleatorizados para pasar a una técnica de PHF on-line con concentrado convencional seis meses, y después pasaron a PHF on-line sin acetato otros seis meses. El otro grupo invertía estos dos períodos. Se obtuvieron análisis de sangre y datos clínicos de HD. Resultados: las medias de los acetatos posdiálisis fueron significativamente superiores durante los períodos de tratamiento con acético respecto al período sin acetato. El porcentaje de valores patológicos de acetato posdiálisis fue significativamente superior durante los períodos de tratamiento con acético (61 respecto al 30%). Las concentraciones de cloro pos-HD fueron superiores y las de bicarbonato pre y pos-HD fueron menores durante el período sin acético. El número de hipotensiones fue significativamente inferior en el período de PHF on-line con LD estándar respecto a los otros períodos. Conclusiones: la técnica de PHF on-line sin acetato disminuye la exposición a concentraciones elevadas de acetato y consigue que la mayoría de pacientes termine la HD con una acetatemia en el rango fisiológico. La PHF on-line es un tratamiento de HDF predilucional con mejor tolerancia que la HD estándar con bicarbonato (AU)

Summary Background: the small quantity of acetate present in the dialysis fluid exposes patient’s blood to an acetate concentration 30-40 times the physiological levels. This amountis even greater in hemodiafiltration on-line. Our purpose was to evaluate the clinical-analytical effects using three different dialysis techniques in the same patient. Methods: 35 patients on hemodialysis were included. All patients were treated with conventional bicarbonate dialysate for 3 months, after randomization were switched to first be treated with PHF online with standard bicarbonate dialysate for 6 months and then switched to PHF on-line acetate-free dialysate for the other 6months or to invert the two last periods. Blood samples were drawn monthly throughout the study and clinical data were obtained. Results: Posdialysis blood acetate levels were higher in patients treated with conventional bicarbonate dialysate with respect to the period of PHF with free-acetate dialysate. Moreover, the percentage of patients with posdialysis blood acetate levels in the pathologic range was higher in patients treated with conventional bicarbonate dialysate respect to PHF on-line acetate-free dialysate period (61% vs. 30%). Serum concentrations of chloride posdialysis were higher and serum concentrations of bicarbonate pre and poshemodialysis were lower in the PHF free-acetate period. The incidence of hypotensive episodes was significantly lower in the PHF on-line with conventional dialysate. Conclusions: PHF on-line with free-acetate dialysate allows that most of patients finished hemodialysis with blood acetate levels in the physiologic ranges. PHF on-line is a predilutional hemodiafiltration treatment with better tolerance than hemodialysis with standard bicarbonate dialysate (AU)

Síndrome metabólico y nefropatía / No disponible

• El Síndrome Metabólico (SM) resume la existencia de toda una serie de enfermedades que, sumadas, incrementan el riesgo vascular más que la adición de sus riesgos individuales. La resistencia a la Insulina (RI) es uno de los componentes básicos del SM.• La distribución de la grasa abdominal es un marcador de RI y se asocia a factores que incrementan el riesgo vascular: dislipemia, hipertensión arterial, HTA, hiperglucemia, componentes del llamado Síndrome Metabólico.• La RI está ligada a la producción de esclerosis glomerulare insuficiencia renal, a través de diversos mecanismos: genéticos, factores ambientales y estimulación del Sistema Renina-Angiotensina-Aldosterona.• La RI suele preceder al desarrollo de la DM, con lo que contribuye a la identificación precoz de la misma. El SM incrementa el riesgo de complicaciones crónicas de la DM y se asocia con una mayor prevalencia de enfermedad cardiovascular, sobre todo de enfermedad coronaria, incrementando la mortalidad por esta causa.• La presencia de SM en la DM-2 suele acompañarse de mayor prevalencia de microalbuminuria o proteinuria y de polineuropatía periférica (AU)

• Metabolic syndrome (MS) encompasses a series of diseases which, when combined, increase vascular risk more than the sum of their individual risks. Insulin resistance (IR) is one of the basic components of MS.• Abdominal fat distribution is an IR marker and is associated to factors increasing vascular risk such as dyslipidemia, highblood pressure, and hyperglycemia, components of the so-called metabolic syndrome.• IR is related to glomerular sclerosis and renal failure through several mechanisms, Including genetic and environmental factors,and stimulation of the renin-angiotens in-aldosterone system.• IR usually precedes development of DM, and therefore contributes to its early identification. MS increases the risk of chronic complications from DM and is associated to an increased prevalence of cardiovascular disease, particularly coronary heart disease, increasing mortality from this cause.• The presence of MS in DM2 is usually associated to a greater prevalence of microalbuminuria or proteinuria and peripheral polyneuropathy (AU)

Avances en diabetes mellitus, nefropatía diabética, síndrome metabólico y riesgo cardio-vásculo-renal / No disponible

1. Aspectos epidemiológicos: existen indicios de que la pandemia de DM está entrando en fase de estabilización, con una discreta ralentización en las tasas ERCT por DM en EE.UU.2. Se plantean nuevos mecanismos patogénicos y de progresión de la enfermedad renal: 1) hiperpresión intraglomerular con modificaciones fenotípicas celulares, induciendo activación del TGFb. 2) Polimorfismos genéticos, con genes candidato en los cromosomas 18q, 3q, 7p y otros. 3) Disfunción endotelial como mecanismo iniciador de lesión, demostrado en la rata carente de eNOS.4) Isoformas de moléculas de la PKC favoreciendo la progresión de la nefropatía.3. Importancia del síndrome metabólico como factor de progresión de Enfermedad Renal Crónica.4. Incremento del riesgo CV en pacientes tratados con tiazolidinedionas (glitazonas) —retención hidrosalina e insuficienciacardíaca—.5. Estudios recientes: Estudio ADVANCE: el tratamiento combinado con IECAs (perindopril) y diuréticos (indapamida)en dosis fijas contribuyen a disminuir el riesgo CV y la mortalidad global. Estudio DREAM: Ramipril no disminuye la aparición de DM-2, pero sí mejora reversión hacia la normoglucemia. Estudio AVOID: los inhibidores directos de la renina añaden mayor eficacia antihipertensiva y antiproteinúrica.6. Nuevas dianas terapéuticas: efectos antifibróticos, antiinflamatoriosy antiproteinúricos de sulodexide, percorín,inhibidores de la PKC y otras.7. La estrategia más eficaz sigue siendo el manejo intensivo, multifactorial y multidisciplinar del paciente diabético tipo 2, como pone de manifiesto el seguimiento alargo plazo del estudio Steno-2 (AU)

1. Epidemiological aspects: There is evidence that the pandemic of DM is entering a stabilization phase, with a slight downturn in the rates of ESRD attributed to DM in the United States.2. New pathogenic and progression mechanisms of renal disease are proposed: 1) Intraglomerular hyperpressure with phenotypicalcell changes, inducing TGF-beta activation; 2) Genetic polymorphisms, with candidate genes in chromosomes18q, 3q, 7p and others; 3) Endothelial dysfunction as an injuryinitiating mechanism, demonstrated in the eNOS knockout rat; 4) Isoforms of PKC molecules that favor progression of nephropathy.3. Importance of metabolic syndrome as a progression factor of chronic renal disease.4. Increased CV risk in patients treated with thiazolidinediones(glitazones) —Hydrosaline retention and heart failure—.5. Recent studies: ADVANCE study: Combined treatment with an ACE inhibitor (perindropil) and a diuretic (indapamide) infixed doses helps to reduce CV risk and overall mortality. DREAM study: Ramipril does not reduce the occurrence ofDM2, but does improve reversion to normoglycemia. AVOID study: Direct renin inhibitors add greater antihypertensive and antiproteinuric efficacy.6. New therapeutic targets: Antifibrotic, anti-inflammatory and antiproteinuric effects of sulodexide, isosorbide mononitrate,PKC inhibitors and others.7. The most effective strategy continues to be intensive, multifactorial and multidisciplinary management of the type 2 diabetic patient, as shown by long-term follow-up in the Steno-2 study (AU)

[Metabolic syndrome and kidney disease]. / Sindrome metabolico y nefropatia.

Metabolic syndrome (MS) encompasses a series of diseases which, when combined, increase vascular risk more than the sum of their individual risks. Insulin resistance (IR) is one of the basic components of MS. - Abdominal fat distribution is an IR marker and is associated to factors increasing vascular risk such as dyslipidemia, high blood pressure, and hyperglycemia, components of the so-called metabolic syndrome. - IR is related to glomerular sclerosis and renal failure through several mechanisms, Including genetic and environmental factors, and stimulation of the renin-angiotensin-aldosterone system. - IR usually precedes development of DM, and therefore contributes to its early identification. MS increases the risk of chronic complications from DM and is associated to an increased prevalence of cardiovascular disease, particularly coronary heart disease, increasing mortality from this cause. - The presence of MS in DM2 is usually associated to a greater prevalence of microalbuminuria or proteinuria and peripheral polyneuropathy.

[Informed consent]. / Consentimiento informado.

- Basic law 41/2002 on patient autonomy regulates the rights and obligations of patients, users and professionals, as well as those of public and private health care centers and services. This regulation refers to patient autonomy, the right to information and essential clinical documentation. - This law establishes the minimum requirements for the information the patient should receive and the decision making in which the patient should take part. Diagnostic tests are performed and therapeutic decisions are taken in the ACKD unit in which patient information is an essential and mandatory requirement according to this law.

[Advances in diabetes mellitus, diabetic nephropathy, metabolic syndrome and cardio-vascular-renal risk]. / Avances en diabetes mellitus, nefropatía diabética, síndrome metabólico y riesgo cardio-vasculo-renal.

1. Epidemiological aspects: There is evidence that the pandemic of DM is entering a stabilization phase, with a slight downturn in the rates of ESRD attributed to DM in the United States. 2. New pathogenic and progression mechanisms of renal disease are proposed: 1) Intraglomerular hyperpressure with phenotypical cell changes, inducing TGF-beta activation; 2) Genetic polymorphisms, with candidate genes in chromosomes 18q, 3q, 7p and others; 3) Endothelial dysfunction as an injury initiating mechanism, demonstrated in the eNOS knockout rat; 4) Isoforms of PKC molecules that favor progression of nephropathy. 3. Importance of metabolic syndrome as a progression factor of chronic renal disease. 4. Increased CV risk in patients treated with thiazolidinediones (glitazones) -Hydrosaline retention and heart failure. 5. Recent studies: ADVANCE study: Combined treatment with an ACE inhibitor (perindropil) and a diuretic (indapamide) in fixed doses helps to reduce CV risk and overall mortality.DREAM study: Ramipril does not reduce the occurrence of DM2, but does improve reversion to normoglycemia. AVOID study: Direct renin inhibitors add greater antihypertensive and antiproteinuric efficacy. 6. New therapeutic targets: Antifibrotic, anti-inflammatory and antiproteinuric effects of sulodexide, isosorbide mononitrate, PKC inhibitors and others. 7. The most effective strategy continues to be intensive, multifactorial and multidisciplinary management of the type 2 diabetic patient, as shown by long-term follow-up in the Steno-2 study.

Prevalence and clinical characteristics of HIV type 1-infected patients receiving dialysis in Spain: results of a Spanish survey in 2006: GESIDA 48/05 study.

End-stage renal diseases (ESRD) are becoming more frequent in HIV-infected patients. In Europe there is little information about HIV-infected patients on dialysis. A cross-sectional multicenter survey in 328 Spanish dialysis units was conducted in 2006. Information from 14,876 patients in dialysis was obtained (81.6% of the Spanish dialysis population). Eighty-one were HIV infected (0.54%; 95% CI, 0.43-0.67), 60 were on hemodialysis, and 21 were on peritoneal dialysis. The mean (range) age was 45 (28-73) years. Seventy-two percent were men and 33% were former drug users. The mean (range) time of HIV infection was 11 (1-27) years and time on dialysis was 4.6 (0.4-25) years. ESRD was due to glomerulonephritis (36%) and diabetes (15%). HIV-associated nephropathy was not reported. Eighty-five percent were on HAART, 76.5% had a CD4 T cell count above 200 cells, and 73% had undetectable viral load. Thirty-nine percent of patients met criteria for inclusion on the renal transplant (RT) waiting list but only 12% were included. Sixty-one percent had HCV coinfection. HCV-coinfected patients had a longer history of HIV, more previous AIDS events, parenteral transmission as the most common risk factor for acquiring HIV infection, and less access to the RT waiting list (p < 0.05). The prevalence of HIV infection in Spanish dialysis units in 2006 was 0.54% HCV coinfection was very frequent (61%) and the percentage of patients included on the Spanish RT waiting list was low (12%).