Nefrología basada en investigación clínica: bases conceptuales para la constitución de un grupo de trabajo en Nefrología Basada en la Evidencia de la Sociedad Española de Nefrología / No disponible

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Informe de diálisis y trasplante correspondiente al año 2002 de la Sociedad Española de Nefrología y Registros Autonómicos / The year 2002 Spanish Nephrology Society Report on Dialysis and Transplantation and Autonomic Registries

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[Role of diet in the management of osteodystrophy during progressive renal insufficiency]. / Papel de la dieta en el manejo de la osteodistrofia en la insuficiencia renal progresiva.

Secondary hyperparathyrodism (SH) is an early manifestation of chronic renal failure (CRF), which has serious complications. Moreover, treating SH is not a risk-free process. Once in its advanced state, it is extremely difficult to reverse and therefore it is critical an early intervention and prevention. An excess of phosphorus and a deficit of calcium and calcitriol are key factors in the evolution of SH. Despite the fact that plasma phosphorus levels remain normal until an extremely advanced stage of CRF, and even apparent hyperphosphatemia in mild CRF, it has been shown that restricting dietary levels of protein and phosphorus impedes the progression of SH. A decrease of protein in the diet also decreases the amount of calcium, thus the calcium levels must be supplemented in order to prevent their deficit. In addition to that slightly diminished levels of calcitriol can be observed in the early stages of CRF, thus it is logical to provide this hormone. However, administering calcitriol may induce hypercalcemia and hyperphosphatemia, which in turn risks the onset of cardiovascular calcifications and complications. Therefore, the calcitriol dosage should be small and then adjusted according to the degree of SH. Neither the PTH levels nor alterations in the phospho-calcium metabolism follow a linear increase appropriate to the decrease in renal function, therefore we propose a treatment strategy which adapts to the different degrees of renal failure.

Papel de la dieta en el manejo de la osteodistrofia en la insuficiencia renal progresiva / Role of the diet in the management of renal osteodystrophy progressive renal failure

El hiperparatiroidismo secundario (HPT 2º) se desarrolla desde fases iniciales de la insuficiencia renal crónica. Las complicaciones del HPT 2º son graves. El tratamiento del HPT 2º no está exento de riesgo. Cuando esta patología está evolucionada es muy difícil lograr su regresión, por todo ello, es imprescindible prevenirla. El tratamiento preventivo debe instaurarse lo antes posible, desde el comienzo de la enfermedad renal. La sobrecarga de fósforo y el déficit de calcio y calcitriol son los factores que favorecen su evolución. Aunque los niveles de fósforo plasmático permanecen normales hasta fases muy avanzadas de la IRC, e incluso puede observarse hipofosfatemia en la IRC leve, se demuestra que la restricción dietética de proteínas y fósforo tiene un efecto inhibidor en la progresión del HPT 2º. La restricción proteica, conlleva también una restricción en el aporte dietético de calcio, por ello es necesario asegurar un aporte correcto de calcio para que el efecto beneficioso de la dieta no se vea contrarrestado por un déficit de calcio. En la IRC se observan, de forma precoz, niveles discretamente disminuidos de calcitriol, por tanto parece coherente aportar suplementos de dicha hormona. Esto puede condicionar efectos negativos como hiperfosfatemia e ipercalcemia con riesgo de calcificaciones y complicaciones vasculares, por lo que es importante iniciar el tratamiento con dosis bajas, realizando ajustes según evolucionen los parámetros bioquímicos del HPT 2º. Los niveles de PTH no siguen un curso lineal a lo largo de la insuficiencia renal, tampoco lo hacen las alteraciones en el metabolismo fosfo-cálcico, por ello proponemos un esquema de tratamiento adaptado a los diferentes grados de insuficiencia renal (AU)

Secondary hyperparathyroidism (SH) is an early manifestation of chronic renal failure (CRF), which has serious complications. Moreover, treating SH is not a riskfree process. Once in its advanced state, it is extremely difficult to reverse and therefore it is critical an early intervention and prevention. An excess of phosphorus and a deficit of calcium and calcitriol are key factors in the evolution of SH. Despite the fact that plasma phosphorus levels remain normal until an extremely advanced stage of CRF, and even apparent hyperphosphatemia in mild CRF, it has been shown that restricting dietary levels of protein and phosphorus impedes the progression of SH. A decrease of protein in the diet also decreases the amount of calcium, thus the calcium levels must be supplemented in order to prevent their deficit. In addition to that slightly diminished levels of calcitriol can be observed in the early stages of CRF, thus it is logical to provide this hormone. However, administering calcitriol may induce hypercalcemia and hyperphosphatemia, which in turn risks the onset of cardiovascular calcifications and complications. Therefore, the calcitriol dosage should be small and then adjusted according to the degree of SH. Neither the PTH levels nor alterations in the phospho-calcium metabolism follow a linear increase appropiate to the decrease in renal function, therefore we propose a treatment strategy which adapts to the different degrees of renal failure (AU)

[Doxazosin, of modified liberation, in hemodialyzed patients]. / Doxazosina, de liberación modificada, en pacientes de hemodiálisis.

INTRODUCTION: Valuation of doxazosin, system formulation modified, in the hypertension in the hemodialysis population. METHOD: Arterial Hypertension (AHT) has been studied in 77 patients (p) subjected to hemodialysis (HD). Mean age (mag) was 61 years (y), range 84y-25y; 66% were males. The underlying etiology was glomerular in 19%, tubulo-interstitial in 18%, congenital in 18%, vascular in 19% and diabetic in 26%. RESULTS: Doxazosin (system formulation modified, single daily dose (4 mg), treatment follow-up was completed in 16 patients subjected to HD for 24 weeks (wk). CONCLUSION: It is concluded that AHT is of great importance in HD, and can be adequately controlled with the new antihypertensive drugs. In this context, doxazosin affords excellent therapeutic control, efficiency and good pharmacological tolerance.

Informe de diálisis y trasplante de la Sociedad Española de Nefrología y Registros Autonómicos, año 2000 / Rapport of the dialysis and transplant registry in Spain. The Spanish Society of Nephrology and Regional Registries

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Doxazosina, de liberación modificada, en pacientes de hemodiálisis / Doxazosin, system formulation modified, in hemodialysis patients

Introducción: Valorar la doxazosina, de liberación modificada, en pacientes en hemodiálisis. Método: Hemos estudiado la hipertensión arterial (HTA) en una población de 77 pacientes (p) en tratamiento en hemodiálisis con unas características de edad, media (med) 61 años (a) rango (84a-25a), varones 66 por ciento. La etiología ha sido glomerular era 19 por ciento, tubulointersticial 18 por ciento, congénitas 18 por ciento, vascular 19 por ciento y diabetes 26 por ciento. Resultados: Hemos completado un seguimiento terapéutico con 16 pacientes en HD durante 24 semanas (se) con doxazosina, de liberación modificada, a dosis única diaria de 4 mg. Conclusión: La HTA tiene una gran importancia en la HD, su control es aceptable con los nuevos antihipertensivos, consiguiendo con doxazosina, de liberación modificada, un excelente control terapéutico, una eficiencia y una buena tolerancia farmacológica en pacientes con HTA en hemodiálisis (AU)

Introduction: Valuation of doxazosin, system formulation modified, in the hipertension in the hemodialysis population. Method: Arterial Hypertension (AHT) has been studied in 77 patients (p) subjected to hemodialysis (HD). Mean age (mag) was 61 years (y), range 84y-25y; 66% were males. The underlying etiology was glomerular in 19%, tubulo-interstitial in 18%, congenital in 18%, vascular in 19% and diabetic in 26%. Results: Doxazosin (system formulation modified, single daily dose (4 mg), treatment follow-up was completed in 16 patients subjected to HD for 24 weeks (wk). Conclusion: It is concluded that AHT is of great importance in HD, and can be adequately controlled with the new antihipertensive drugs. In this context, doxazosin affords excellent therapeutic control, efficency and good pharmacological tolerance (AU)

Informe de diálisis y trasplante de la sociedad española de nefrología y registros autonómicos correspondientes al año 1999 / Dyalisis and transplant registry of the Spanish Society of Nephrology

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Exit-site care with ciprofloxacin otologic solution prevents polyurethane catheter infection in peritoneal dialysis patients.

OBJECTIVE: Mupirocin ointment and antiseptics are standard cleansing agents in routine exit-site care of peritoneal dialysis (PD) catheters, but these agents have a deleterious effect on polyurethane devices. We assessed the effectiveness of topical use of ciprofloxacin otologic solution for preventing exit-site infection (ESI) in PD patients with polyurethane catheters. DESIGN: Prospective study. SETTING: Service of Nephrology of an acute-care teaching hospital in Galdácano, Bizkaia, Spain. PATIENTS: A total of 164 patients with polyurethane catheters inserted was studied from start of continuous ambulatory PD to the end of a 24-month period. Patients were divided into two groups according to exit-site treatment protocols. INTERVENTION: Patients in group 1 (n = 86) were instructed on daily exit-site care with soap and water only; whereas patients in group 2 (n = 78) cleansed with soap and water, followed by application of a single-dose vial of 0.5 mL ciprofloxacin (1 mg) for application around the insertion site. MAIN OUTCOME MEASURES: Episodes of ESI and peritonitis. RESULTS: There were 67 episodes of ESI among patients in group 1 versus 9 episodes among patients in group 2 (p < 0.05), resulting in a rate of 0.41 and 0.06 episodes per patient-year of exposure, respectively (p < 0.001). Staphylococcus aureus ESI rate was 0.34 in group 1 versus 0.06 in group 2 (p = 0.001). Infections caused by Pseudomonas aeruginosa and other pathogens occurred in 11 patients in group 1 and in no patients in group 2 (p = 0.05). Peritonitis due to S. aureus ESI was significantly less frequent among patients treated with ciprofloxacin (1 vs 9 cases, p = 0.001). Removal of the catheter was necessary in 5 patients in group 1 and in no patients in group 2 (p < 0.05). CONCLUSION: Daily application of ciprofloxacin otologic solution at the exit site of PD patients with polyurethane catheters inserted significantly reduces the rate of ESI caused by S. aureus and other organisms, particularly P. aeruginosa.

Vitamin D receptor genotype influences parathyroid hormone and calcitriol levels in predialysis patients.

BACKGROUND: BsmI vitamin D receptor (VDR) gene polymorphism has been associated with the severity of hyperparathyroidism in patients on hemodialysis. The aim of this study was to analyze the influence of this polymorphism on parathyroid function and serum calcitriol levels in patients with different degrees of chronic renal failure (CRF) before dialysis. METHODS: A total of 248 CRF patients, divided into three groups according to creatinine clearance (CCr; mild CRF group> 60 to 35 to 10 to 2.5 mmol/liter and serum phosphorus levels of> 1.6 mmol/liter or who needed phosphorus binding agents were excluded. The statistical analysis was done with the general factorial analysis of variance entering first PTH and then calcitriol as the dependent variable; the genotype (BB, Bb and bb), sex and CCr group were defined as factors; and covariables included serum calcium, serum phosphorus, 1/creatinine versus time slope, PTH when calcitriol was the dependent variable, and calcitriol when PTH was the dependent variable. RESULTS: When serum PTH levels were entered as the dependent variable, serum calcium, CCr group, and the interaction of genotype with the CCr group were found to be significant factors (P = 0.025, P <0.001 and P = 0.039, respectively). When serum calcitriol levels were entered as the dependent variable, genotype, the interaction of genotype with CCr, the CCr group, and the 1/creatine versus time slope were found to be significant (P = 0.027, P = 0.028, P <0.001 and P = 0.044, respectively). The marginal means of PTH, adjusted with the general factorial analysis of variance across the three groups were: (a) mild CRF group, BB 5.3 pmol/liter (CI 0 to 13.8), Bb 5.5 pmol/liter (CI 2 to 9), bb 5.4 pmol/liter (CI 0.6 to 10.2); (b) moderate CRF group, BB 6.2 pmol/liter (CI 1.5 to 10.9), Bb 7.8 pmol/liter (CI 5.3 to 10.3), bb 7.5 pmol/liter (CI 4.8 to 10.1); (c) severe CRF group, BB 9.3 pmol/liter (CI 4.2 to 14.3), Bb 17.1 pmol/liter (CI 13.9 to 20.2), bb 21.9 pmol/liter (CI 18.7 to 25.2). The marginal means of calcitriol adjusted with the general factorial analysis of variance across the three groups were: (a) mild CRF group, BB 47 pg/ml (CI 37 to 57), Bb 40.9 pg/ml (CI 37 to 44.8), bb 32.6 pg/ml (CI 26.8 to 38. 4); (b) moderate CRF group, BB 24.1 pg/ml (CI 18.3 to 29.8), Bb 26.6 pg/ml (CI 23.5 to 29.7), bb 25.3 pg/ml (CI 22 to 28.6); (c) severe CRF group, BB 27.4 pg/ml (CI 21.3 to 33.5), Bb 19.4 pg/ml (CI 15.5 to 23.2), bb 20.4 pg/ml (CI 16.1 to 24.7). CONCLUSION: The progression of hyperparathyroidism is slower in predialysis patients with BB genotypes than in the other genotypes. Also, calcitriol levels are less reduced in the BB genotype, which may act to lessen the severity of secondary hyperparathyroidism.

Evaluation of the Losartan in Hemodialysis (ELHE) Study.

Angiotensin converting enzyme inhibitors (ACEIs) have been shown to be effective in the treatment of dialysis patients with high blood pressure, however, they also have been associated with anaphylactoid reactions at the start of dialysis, when they have been used concomitantly with AN69 membranes. A multicenter, open six-month study was designed to test the tolerability and efficacy of losartan as antihypertensive in patients under hemodialysis (HD), with particular emphasis on the appearance of anaphylactoid reactions. HD patients with systolic blood pressure (SBP) levels > or = 140 and/or diastolic blood pressure (DBP) > or = 90 mm Hg, previously nontreated, treated but uncontrolled, or treated with a poor tolerability, were included. The study performed three controls: baseline, at month 3, and at study completion. DBP and SBP levels were measured on the six HD sessions previous to the three visits in addition to biochemical and hematology measurements. Four hundred and six patients were included. The mean age was 55 years, 42% were women, and 23.6% of the patients were dialyzed with AN69 membranes. There was a significant reduction in pre- and postdialysis SBP and DBP at three and six months. Fifteen patients discontinued the study due to adverse reactions related to losartan, and in seven of them the adverse reaction was hypotension. Only two patients have reported a possible anaphylactoid reaction on treatment with AN69, in one of them the HD session had to be stopped and losartan was discontinued. On the contrary, nine patients with a history of previous anaphylactoid reaction, with ACEIs and AN69, have not shown this complication with losartan and AN69. We conclude that losartan is a well tolerated antihypertensive by HD patients, with a very low incidence of adverse reactions, and a lower prevalence of anaphylactoid reactions than those detected with ACEIs and AN69.

Factors influencing serum aluminum in CAPD patients.

The aim of this study was to find out the relationship between body iron stores and serum aluminum levels among 82 stable CAPD patients. The influence of other factors such as time on CAPD and residual renal function was also considered. Thirty-three patients received aluminum hydroxide as a phosphate binder, and they had significantly higher aluminum levels (36.45 microg/l) than the patients who were not taking aluminum preparations (17.2 microg/l, p = 0.001). A statistically-significant correlation between serum aluminum levels and residual renal function and time on CAPD was also observed (p <0.05). However, there was no relationship between serum aluminum levels and serum iron, ferritin and transferrin saturation, neither between body iron stores and total excretion of aluminum (p >0.05). In previous reports, low serum iron levels were associated with high serum aluminum concentration among hemodialysis patients. However, this effect was not observed in the CAPD population under study. The highest risk of hyperaluminemia was found in the patients who were taking aluminum hydroxide, had worse residual renal function and had been longer on CAPD.

Is there a lesser hyperparathyroidism in diabetic patients with chronic renal failure?

Diabetic patients on dialysis have lower levels of parathyroid hormone (PTH); however, there is no data regarding PTH levels with different degrees of chronic renal failure (CRF). We compared 58 diabetic patients with different degrees of CRF with 268 non-diabetic patients with CRF (serum creatinine >1.2 mg/dl). In both groups, we investigated the main biochemical parameters together with plasma calcium, phosphorus, magnesium, PTH and calcitriol. Diabetic patients showed lower levels of PTH than non-diabetics (P=0.003). The differences were observed in patients with creatinine clearance <70ml/min. We also observed differences in phosphorus, magnesium and tubular resorption of phosphate. In the group of diabetic patients, serum glucose correlated inversely with PTH. Our study suggests that poor control of diabetes (hyperglycaemia) may play a role in the pathogenesis of the hypoparathyroidism observed in patients with diabetes and CRF.