[Anemia of chronic kidney disease: Protocol of study, management and referral to Nephrology]. / Anemia en la enfermedad renal crónica: protocolo de estudio, manejo y derivación a Nefrología.

The objective of this protocol is to know which test are needed to study an anaemia in a patient with chronic kidney disease, the differential diagnosis of renal anaemia, to know and correct other deficiency anaemias, and the criteria for referral to Nephrology or other specialties of the anaemic patient with chronic kidney disease.

[Consensus document on pneumococcal vaccination in adults at risk by age and underlying clinical conditions. 2017 Update]. / Consenso sobre la vacunación anti-neumocócica en el adulto por riesgo de edad y patología de base. Actualización 2017.

Invasive pneumococcal disease (IPD) and pneumococcal pneumonia (PP) represent an important health problem among aging adults and those with certain underlying pathologies and some diseases, especially immunosuppressed and some immunocompetent subjects, who are more susceptible to infections and present greater severity and worse evolution. Among the strategies to prevent IPD and PP, vaccination has its place, although vaccination coverage in this group is lower than desirable. Nowadays, there are 2 vaccines available for adults. Polysacharide vaccine (PPV23), used in patients aged 2 and older since decades ago, includes a greater number of serotypes (23), but it does not generate immune memory, antibody levels decrease with time, causes an immune tolerance phenomenon, and have no effect on nasopharyngeal colonization. PCV13 can be used from children 6 weeks of age to elderly and generates an immune response more powerful than PPV23 against most of the 13 serotypes included in it. In the year 2013 the 16 most directly related to groups of risk of presenting IPD publised a series of vaccine recommendations based on scientific evidence regarding anti-pneumococcal vaccination in adults with underlying pathologies and special conditions. A commitment was made about updating it if new scientific evidence became available. We present an exhaustive revised document focusing mainly in recommendation by age in which some more Scientific Societies have been involved.

Midterm Results of Renal Transplantation From Controlled Cardiac Death Donors Are Similar to Those From Brain Death Donors.

BACKGROUND: The systematic use of grafts from controlled donors after cardiac death (cDCD) started in our country in 2012 and expanded with the strategic support of National Transplant Organization. We present our experience in kidney transplantation with organs from cDCD donors with a mean follow-up of 3 years. METHODS: Observational prospective study of all transplants performed in our center in 2012-2013 followed to 2016. The immunosuppression protocols were triple therapy for low-risk recipients from a standard brain death donor (DBD), adding basiliximab or thymoglobulin induction for extended-criteria donor or high-risk recipient, respectively, and thymoglobulin induction plus triple therapy for all cDCD recipients. RESULTS: A total of 42 donors were included (84 grafts in total, but 1 discarded due to multiple cysts); 25 DBD and 17 cDCD without differences in age or sex. The graft use rate was 98.9% for cDCD; 55 grafts were implanted in our hospital (26 DBD and 29 cDCD), and the remaining 28 grafts were transferred to other centers. There were no differences in primary failure (3.4% cDCD vs 7.4% DBD), but the cDCD organs had a higher incidence of delayed graft function (51.7% vs 25.9%). Despite that, graft and patient survivals, as well as glomerular filtration rate (66.3 vs 59.6 mL/min) were similar in both groups. Only 1 patient died at home with a functioning graft in the cDCD group. CONCLUSIONS: Despite a higher rate of delayed graft function with cDCD, the midterm outcomes are at least similar to those with DBD. The cDCD programs should be promoted to increase the chances of a transplant in our patients.

Peritoneal dialysis and kidney transplant. A two-way ticket in an integrated renal replacement therapy model.

BACKGROUND: Peritoneal dialysis (PD) seems to be a good option to initiate renal replacement therapy (RRT), but patients with graft failure choose PD less frequently than incident patients (de novo). OBJECTIVE: To describe patient movements between PD and kidney transplantation (TX) and risk factors for failure of the PD technique. METHOD: Multicentre observational study of patients starting PD between 2003 and 2009 with follow-up up until January 2010. Survival analysis based on switching from PD to HD as an event using Kaplan-Meier (KM) and forward, stepwise Cox proportional hazards models. Hazard ratio and 95% confidence intervals (HR [CI]) are shown. MAIN VARIABLE: Switch from PD to HD. Two-group comparison: PD post transplant (post-TX) patients (76) compared to pure incident PD (de novo-PD) patients (830). PATIENTS: 906 PD patients from 19 public hospitals with a mean age of 54.8 years (64.9% male); main ESRD aetiology: glomerulonephritis (25.4%), diabetes (16.7%), vascular-ischaemic (10.7%), interstitial (13.6%) and polycystic (11.2%). Comorbidity conditions: Charlson Index 5.1 (SD 2.4); 21.6% diabetes mellitus (DM), 24.0% cardiovascular (CV) events. RESULTS: Mean follow-up period on PD: 1.85 years (95% CI [1.68-2.02 years]). KM estimation for switching to HD due to PD failure was 5.46 years [4.42-6.50 years]. At the end of follow-up, 88 patients had died, 154 had been transferred to HD and 306 had received a graft (annual rate for patients on waiting list: 0.49 TX per year on PD). The best Cox multivariate model for switching from PD to HD includes: post-TX (HR: 1.63 [1.01-2.63]), DM (HR: 1.69 [1.19-2.40]) and age (1.01 [1.00-1.02]) per year. Post-TX patients were younger (43.8 years vs 55.3 years) and with less comorbidity conditions than de novo-PD patients (DM 18.4% vs 21.9%; CV 15.8% vs 24.7%). However post-TX patients had worse clinical evolution with a rapid decline of renal function (∆-3.88 vs -1.8 ml/min per year); a higher admission rate (0.9 vs 0.62 per year) but similar peritonitis rate (0.45 vs 0.53 episodes per year). They also needed to be transferred to HD more frequently (28.9% vs 15.8%; P<.006) and needed more time to TX (4.8 years vs 1.7 years, Kaplan-Meier). Consequently, time spent on PD was higher in the post-TX group (2.8 vs 1.8 year). LIMITATIONS: Observational study with absence of a standard protocol to switch PD-HD. CONCLUSION: PD seems to be a good first choice technique due to low mortality and high TX ratio in our area. A previous graft failure is associated with a higher rate of PD-failure but time spent on PD is enough to consider this technique as a good option.

Reincorporación laboral en pacientes con amputación traumática de extremidad superior / Return to work in traumatic upper limb amputees

Objetivo. Evaluar el retorno a la actividad laboral de pacientes amputados de extremidad superior como resultado de un accidente de trabajo. Pacientes y método. Estudio transversal y descriptivo. Variables recogidas mediante entrevista telefónica: retorno al trabajo, tipo de trabajo antes y después del accidente, protetización, uso de la prótesis, dolor. Resultados. De 65 pacientes (60 varones), con media de edad de 44,4 años, los reincorporados al trabajo (n=38) presentaban dolor con menos frecuencia (p=0,009) y menor intensidad (p=0,004) y usaban más su prótesis, aunque de forma marginalmente significativa (p=0,07). El resto de las variables no presentaban diferencias entre reincorporados y no reincorporados. Conclusiones. Desde el punto de vista clínico, la variable con más influencia en el retorno a la actividad laboral de los pacientes amputados de extremidad superior por accidente durante el trabajo fue el dolor. En el estudio no se recoge la influencia de variables socioeconómicas(AU)

Objective. To evaluate the return to the work environment of patients with upper limb amputations due to work accidents. Patients and methods. A descriptive cross-sectional study was performed. The variables evaluated were obtained by telephone interview, this being return to work, occupation after and before the amputation, prosthesis requirement, use of prosthesis and pain. Results. Sixty-five patients (60 male) mean age 44.4 years were enrolled. The subjects who returned to work (38 cases) reported pain less frequently (P=.009) and when present, the pain was less intense (P=.004). Use of prosthesis was slightly significantly higher in this group of patients (P=.07). No significant differences were found for the rest of variables between the reinstated and non-reinstated patients. Conclusions. From a clinical point of view, pain was the most important factor conditioning return to work in subjects with traumatic upper limb amputation. However, the influence of socioeconomic variables was not studied(AU)

Genetic diversity among Campylobacter jejuni isolates from healthy livestock and their links to human isolates in Spain.

This study was aimed at determining the genetic diversity of Campylobacter jejuni from healthy ruminants and poultry, and study by multilocus sequence typing (MLST) their links to human isolates in Spain. MLST analysis of 160 animal isolates generated 45 sequence types (STs, nine of them new to this study), that clustered into 18 clonal complexes (CC) and nine singletons. The 71 isolates from humans generated 28 STs (13 CC plus four singletons). Only 11 STs and nine CCs were shared by humans and animals (particularly from dairy cattle and sheep), mainly corresponding to sporadic cases rather than outbreaks, probably as an adaptation of the general human population to the types commonly circulating in livestock. PCR analysis of the distribution of four virulence-associated genes detected the cdtABC gene cluster in all 160 isolates but with a 700-bp deletion in four of them, and amplified the virB11, cgtB and wlaN genes in 4.7%, 21.3% and 21.9% respectively. A subset of 87 C. jejuni animal isolates analysed using flaA PCR-RFLP, MLST and pulsed-field gel electrophoresis generated 31, 38 and 55 types respectively. The combined typing approach used provided reliable inter-strain relationships, confirming the co-existence of several strains in some farms, but also identifying identical genotypes sampled over a wide temporal span in different environments and hosts. Typing results confirmed a high genetic diversity of C. jejuni in our region and suggested that ruminants are also important sources for human infection. MLST data provided will help to obtain a more comprehensive image of the population structure of C. jejuni and establish reliable source attribution schemes.

El tratamiento de pacientes diabéticos en diálisis peritoneal sigue siendo un reto 25 años después / No disponible

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[Approach to quality objectives in incidents of patients in peritoneal dialysis]. / Cumplimiento de objetivos de calidad y evolución de los pacientes incidentes en diálisis peritoneal.

INTRODUCTION: In 2007 the Scientific Quality-technical and Improvement of Quality in Peritoneal Dialysis was edited. It includes several quality indicators. As far as we know, only some groups of work had evaluated these indicators, with inconclusive results. AIM: To study the evolution and impact of guidelines in Peritoneal Dialysis. METHODS: Prospective cohort study of each incident of patients in Peritoneal Dialysis, in a regional public health care system (2003-2006). We prospectively collected baseline clinical and analytical data, technical efficacy, cardiovascular risk, events and deaths, hospital admissions and also prescription data was collected every 6 months. RESULTS: Over a period of 3 years, 490 patients (53.58 years of age; 61.6% males.) Causes of ERC: glomerular 25.5%, diabetes 16%, vascular 12.4%, and interstitial 13.3%. 26.48% were on the list for transplant. Dialysis efficacy: Of the first available results, the residual renal function was 6.37 ml/min, achieving 67.6% of all the objectives K/DOQI. 38.6% remained within the range during the entire first year. Anaemia: 79.3% received erythropoietic stimulating agents and maintained an average Hb of 12.1 g/dl. The percentage of patients in the range (Hb: 11-13 g/dl) improved after a year (58.4% vs 56.3% keeping in the range during this time of 25.6%). Evolution: it has been estimated that per patient-year the risk of: 1) mortality is 0.06 IC 95% [0.04-0.08]; 2) admissions 0.65 [0.58-0.72]; 3) peritoneal infections 0.5 [0.44-0.56]. CONCLUSION: Diabetes Mellitus patients had a higher cardiovascular risk and prevalence of events. The degrees of control during the follow-up in many topics of peritoneal dialysis improve each year; however they are far from the recommended guidelines, especially if they are evaluated throughout the whole study.

[Outpatient surgeries of patients with arteriovenous fistulas for hemodialysis. Integrated activity in a general surgery unit]. / Cirugía sin ingreso de pacientes con fístulas arteriovenosas para hemodiálisis. Actividad integrada en un servicio de cirugía general.

INTRODUCTION: The increase of prevalent haemodialysis patients is a challenge for surgery units. Vascular access related complications are the main cause of hospital admissions in many dialysis units. Outpatient surgery could decrease waiting lists, cost related and complications associated to vascular access. MATERIAL AND METHODS: We have performed a prospective study of the vascular access related surgery in a ten years period. Outpatient surgery was included with the rest of the activity in a general surgery unit and was performed by not exclusive dedicated surgeons. RESULTS: Since 1998 to December 2009 we performed 2,413 surgical interventions for creating and repairing arteriovenous fistula in 1,229 patients, including elective and emergency surgery (74.8% and 25.2% respectively). Outpatient procedures were performed in 82% of cases (89% in elective and 60% in emergency surgery). There were unexpected admissions secondary to surgical complications in 6% of patients. There wasn't postoperative mortality. The rate of admissions were 0,09 episodes and 0,2 days per patient/year. CONCLUSIONS: Outpatient surgery is possible in a high percentage of patients to perform or to repair an arteriovenous fistula, including emergency surgery. Vascular access surgery can be included in ordinary activity of a surgical unit. Outpatient vascular access surgery decreases unnecessary hospital admissions, reduces costs and nosocomial complications.

Study of the molecular mechanisms involved in high-level macrolide resistance of Spanish Campylobacter jejuni and Campylobacter coli strains.

OBJECTIVES: To investigate the molecular mechanisms involved in the high-level erythromycin resistance of clinical Spanish Campylobacter jejuni and Campylobacter coli strains. METHODS: Overall susceptibilities of 678 C. jejuni and 119 C. coli strains, collected from 10 Spanish provinces during 2006 and 2007, were determined by Etest. In high-level erythromycin-resistant strains, molecular determinants were studied. The analysis was focused on region V of the 23S rRNA gene, the rplD and rplV ribosomal genes, and the regulatory region of the CmeABC efflux pump. RESULTS: The global resistance rate to erythromycin was 3.8%. Among the resistant strains, 93% were C. coli and 7% were C. jejuni. The A2075G mutation in the 23S rRNA gene was detected in all of the resistant strains except for two, which carried the A2074G mutation. None of the ribosomal rplD and rplV genes harboured the described mutations that confer resistance to macrolides. Different mutations affecting the regulatory region of the CmeABC efflux pump were also found. CONCLUSIONS: C. coli strains are clearly more resistant to erythromycin than C. jejuni. The mutation A2075G in the 23S rRNA gene was responsible for the resistance in most of the strains; A2074G was only found in two strains. Further studies are required to ascertain the effect of mutations in the regulatory region of cmeABC. Our data indicate that the rate of resistance was similar to that of other European countries.

[Vascular access models cause heterogeneous results in the centres of one community]. / Los modelos de atención al acceso vascular condicionan resultados heterogéneos en los centros de una misma comunidad.

INTRODUCTION: Vascular access (VA) is the main difficulty in our hemodialysis Units and there is not adequate update data in our area. PURPOSE: To describe the vascular access management models of the Autonomous Community of Madrid and to analyze the influence of the structured models in the final results. MATERIAL AND METHODS: Autonomous multicenter retrospective study. Models of VA monitoring, VA distribution 2007-2008, thrombosis rate, salvage surgery and preventive repair are reviewed. The centers are classified in three levels by the evaluation the Nephrology Departments make of their Surgery and Radiology Departments and the existence of protocols, and the ends are compared. MAIN VARIABLES: Type distribution of VA. VA thrombosis rate, preventive repair and salvage surgery. RESULTS: Data of 2.332 patients were reported from 35 out of 36 centers. Only 19 centers demonstrate database and annual evaluation of the results. Seventeen centers have multidisciplinary structured protocols. Forty-four point eight percent of the patients started dialysis by tunneled catheter (TC). Twenty-nine point five percent received dialysis by TC in December-08 vs 24.7% in December-07. Forty-four point seven percent of TC were considered final VA due to non-viable surgery, 27% are waiting for review or surgery more than 3 months. For rates study data from 27 centers (1.844 patients) were available. Native AVF and graft-AVF thrombosis rates were 10.13 and 39.91 respectively. Centers with better valued models confirmed better results in all markers: TC rates, 24.2 vs 34.1 %, p: 0.002; native AVF thrombosis rate 5.3 vs 10.7 %; native AVF preventive repair 14.5 vs 10.2%, p: 0.17; Graft- AVF thrombosis rate 19.8 vs 44.4%, p: 0.001; Graft-AVF preventive repair 83.2 vs 26.2, p < 0.001.They also have less patients with TC as a final option (32.2 vs 45.3) and less patients with TC waiting for review or surgery more than 3 months (2.8 vs 0). LIMITS: Seventy-five percent of patients were reached for the analysis of thrombosis rate. Results are not necessarily extrapolated. CONCLUSIONS: For the first time detailed data are available. TC use is elevated and increasing. Guidelines objectives are not achieved. The difference of results observed in different centers of the same public health area; make it necessary to reevaluate the various models of care and TC follow-up.

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

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Reproducibilidad de la medida de la fuerza muscular de la rodilla mediante dinamometría manual en pacientes con gonartrosis grave / Reliability of knee muscle strength measurement with manual dynamometry in patients with severe knee arthritis

Introducción. El objetivo fue valorar la reproducibilidadde la dinamometría manual para medir lafuerza muscular de la rodilla en pacientes con gonalgia porgonartrosis grave, con el dinamómetro Nicholas ManualMuscle Tester (NMMT).Métodos. Se reclutaron los pacientes antes de realizaruna artroplastia total de rodilla. Se midió la fuerza muscularde los flexores y los extensores de la rodilla (FR, ER) con eldinamómetro NMMT, mediante un protocolo estándar, conuna prueba isométrica y un diseño test-retest. Se calcularonlos coeficientes de correlación intraclases (CCI) y elerror técnico de medida (ETM), y se realizó una prueba devarianza para descartar un sesgo entre los observadores.Resultados. El CCI inter-observador (n = 20) fue 0,85 (intervalode confianza [IC] 95 % 0,66-0,94) para ER, y 0,90(IC 95 % 0,68-0,96) para FR. El CCI intra-observador(n = 13) fue 0,99 (IC 95 % 0,97-0,99) para ER, y 0,95 (IC 95 %0,84-0,98) para FR. El ETM fue 1,487 kg para ER, y 1,153 kgpara FR. Se encontró una diferencia significativa entre lasfuerzas medidas por los dos exploradores de una media de1,0 kg para la fuerza de los FR (p = 0,01, IC 95 % 0,28-1,78).Conclusiones. La reproducibilidad inter-observador de ladinamometría manual fue entre moderada y alta, mientrasque la reproducibilidad intra-observador fue alta(AU)

Background. The aim of the study was to determinethe reliability of the knee muscle strength measurementwith the Nicholas Manual Muscle Tester (NMMT) dynamometerin patients with pain due to severe knee arthritis.Methods. Patients were recruited before a total knee arthroplasty.The flexor and extensor knee muscle strength wasmeasured with the NMMT using a standardised protocol forisometric “make” tests, and a test-retest design was done. Theintra-class correlation coefficients (ICC), and the technical errorof measurement (TEM) were determined. A paired samplet-test was performed to detect any possible rater bias.Results. The inter-rater ICC (n = 20) was 0.85 (95 % CI0.66-0.94) for knee extensor force (KEF), while it was 0.90(95 % CI 0.68-0.96) for knee flexor force (KFF). The intra-rater ICC (n = 13) for KEF was 0.99 (95 % CI 0.97-0.99),whereas for KFF it was 0.95 (95 % CI 0.84-0.98). The TEMwas 1.487 kg for KEF, and 1.153 kg for KFF. The paired samplet-test showed a significant difference of an average of1.0 kg between the two raters in the KFF measurement(p = 0.01, 95 % CI 0.28-1.78).Conclusions. With this protocol, dynamometry was reliablefor patients with knee pain, achieving moderate to highinter-rater reliability for KFF and KEF, and high intra-raterreliability for both KFF and KEF(AU)

[Patients on peritoneal dialysis with type 2 diabetes present poorer progress than non-diabetics at the expense of their cardiovascular comorbidity]. / Los pacientes diabéticos tipo 2 presentan peor evolución que los no diabéticos en diálisis peritoneal a expensas de su comorbilidad cardiovascular.

AIM: To describe the characteristics, practice patterns, targets and outcome of the Type 2 diabetic patients (DM 2) in peritoneal dialysis (PD) and to compare them with non-diabetic ones. METHODS: Prospective cohort study of every incident PD patient in a regional public health care system (2003-2006). We prospectively collected baseline data, hospital admissions, peritonitis, transplants, CV events and deaths. Every six months PD prescription data and results on efficacy, anaemia, blood pressure (BP) were collected. RESULTS: DM 2 patients (n = 65) were older and presented a higher rate of previous CV events (60.9% vs. 17.7% p<0001) than non-DM patients (n = 376) and worse BP control at inclusion on PD. There were no differences in dialysis efficacy targets and anaemia management. HOSPITAL ADMISSIONS: DM 2 patients present higher hospitalisation rates 1.1 [0.9-1.4] than NoDM ones 0.6 [0.5-0.7] admissions per year at risk. Survival: DM 2 patients present lower PD-technique survival than No DM ones (870 vs. 1002 days Kaplan-Mayer estimation p = 0.009) and higher annual mortality rate (13.7 vs. 4.1%, p: 0.021) with a crude mortality hazard ratio (HR) of 2.5 [1.1-5.6] after correction by age. However, the best predictive model for mortality by Cox proportional hazards model includes age, existence of previous CV events and forced inclusion on PD and excludes DM 2. The association between DM 2 and CV events ruled out DM 2 from the multivariate risk model. CONCLUSION: Type 2 DM patients had a higher prevalence of previous CV events, and a worse global outcome. Previous CV events may explain part of this risk.

[Clinical and economic repercussions of the use of tunneled haemodialysis catheters in a health area]. / Repercusiones clínicas y económicas del uso de catéteres tunelizados de hemodiálisis en un área sanitaria.

INTRODUCTION: Tunneled catheters in hemodialysis are associated with poor prognosis, however, few prospective studies have been designed to specifically evaluate this aspect. The objective has been evaluate the impact of tunneled catheter in patient mortality and costs attributable to this procedure. METHODS: A seven years prospective cohort study was performed in all patients starting hemodialysis in our health care area adjusting for comorbidity and albumin. The study comprised 260 patients with Charlson index 7.05 +/- 2.8 (age 65.5 years, 62.3% males, 25% with diabetes mellitus and 37.7% with a previous cardiovascular event. RESULTS: The first vascular access was a catheter in 47.3%, PTFE in 11.2% and native arteriovenous fistula in 41.5%. Minimum follow-up was one year, with an average of 2.31 years/patient. The mortality risk adjusted for comorbidity was greater among the patients that started with catheterization, HR: 1.86 [1.11-3.05]. This negative effect was observed in 57.30% of those subjected to catheterization at any stage (HR: 1.68 [1.00-2.84] and proved to be time dependent, i.e., the longer catheterization, the greater the risk: HR: 7.66 [3.34-17.54] third versus first tertil. The cost directly attributable to catheter use was 563.31 euros/month. All poor prognosis groups showed lower albumin and hemoglobin levels, without differences in efficacy. CONCLUSION: Tunneled catheter use at any time is associated with an increased risk of death. This effect increases with the duration of catheterization, both circumstances are independent of patient comorbidity at time start of hemodialysis and implies a higher net cost.

Repercusiones clínicas y económicas del uso de catéteres tunelizados de hemodiálisis en un área sanitaria / No disponible

Introducción: el uso de catéteres en hemodiálisis se asocia a un gran número de complicaciones. Sin embargo, se han realizado pocos estudios diseñados específicamente para evaluar este problema. Los objetivos del estudio han sido conocer el impacto en la supervivencia del paciente y el gasto económico que implica la utilización de catéteres. Métodos: estudio observacional y prospectivo histórico de siete años de duración en 260 pacientes incidentes en hemodiálisis en nuestra área de salud, ajustado a la comorbilidad y albúmina al inicio de la hemodiálisis. La media de edad fue de 65,5 ± 15,2 años, 62,3% varones, 25% diabéticos. La media del índice de comorbilidad de Charlson fue de 7,05 ± 2,8. Resultados: el 47,3% de los pacientes inicia hemodiálisis con catéter, el 41,5% con FAV-auto y 11,2% con FAV-PTFE. El seguimiento medio fue 2,31 años/paciente. El riesgo de mortalidad ajustado por comorbilidad fue mayor para los que inician hemodiálisis con un catéter, HR:1,86 (1,11-3,05). Este efecto negativo también se observó en el 57,3% de pacientes que a lo largo del seguimiento requirieron un catéter, HR: 1,68 (1,00-2,84) y, además, fue tiempo dependiente; a mayor tiempo con catéter, mayor mortalidad: HR 7,66 (3,34-17,54), tertil 3 vs. tertil 1. El coste del empleo mes/catéter fue de 561,31 euros. Conclusiones: el uso de catéteres tunelizados es un factor independientemente asociado con la mortalidad de los pacientes, tanto al inicio como a lo largo del seguimiento, es tiempo dependiente y conlleva un elevado coste económico (AU)

Introducction: Tunneled catheters in hemodialysis are associated with poor prognosis, however, few prospective studies have been designed to specifically evaluate this aspect. The objective has been evaluate the impact of tunneled catheter inpatient mortality and costs attributable to this procedure. Methods: A seven years prospective cohort study was performed in all patients starting hemodialysis in our health care area adjusting for comorbidity and albumin. The study comprised 260patients with Charlson index 7.05 ± 2.8 (age 65.5 years, 62.3%males, 25% with diabetes mellitus and 37.7% with a previous cardiovascular event. Results: The first vascular access was a catheter in 47.3%, PTFE in 11.2% and native arteriovenous fistula in 41.5%. Minimum follow-up was one year, with an average of 2.31 years/patient. The mortality risk adjusted for comorbidity was greater among the patients that started with catheterization, HR: 1.86 [1.11-3.05]. This negative effect was observed in 57.30% of those subjected to catheterization at any stage (HR: 1.68 [1.00-2.84] and proved to be time dependent, i.e., the longer catheterization, the greater the risk: HR:7.66 [3.34-17.54] third versus first tertil. The cost directly attributable to catheter use was 563.31 euros/month. All poor prognosis groups showed lower albumin and hemoglobin levels, without differences in efficacy. Conclusion: Tunneled catheter use at any time is associated with an increased risk of death. This effect increases with the duration of catheterization, both circumstances are independent of patient comorbidity at time start of hemodialysisand implies a higher net cost (AU)