Renin–angiotensin–aldosterone system blockers effect in chronic kidney disease progression in hypertensive elderly patients without proteinuria: PROERCAN trial / Efecto de los bloqueantes del sistema renina-angiotensina-aldosterona en la progresión de enfermedad renal crónica en pacientes hipertensos añosos sin proteinuria: ensayo clínico Progresión de Enfermedad Renal Crónica en Ancianos

Introduction: Evidence about nefroprotective effect with RAAS blockers in elderly patients with chronic kidney disease (CKD) without proteinuria is lacking. The primary outcome of our study is to evaluate the impact of RAAS blockers in CKD progression in elderly patients without proteinuria. Materials and methods: Multicenter open-label, randomized controlled clinical trial including patients over 65 year-old with hypertension and CKD stages 3–4 without proteinuria. Patients were randomized in a 1:1 ratio to either receive RAAS blockers or other antihypertensive drugs and were followed up for three years. Primary outcome is estimated glomerular filtration rate (eGFR) decline at 3 years. Secondary outcome measures include BP control, renal and cardiovascular events and mortality. Results: 88 patients were included with a mean age of 77.9±6.1 years and a follow up period of 3 years: 40 were randomized to RAAS group and 48 to standard treatment. Ethiology of CKD was: 53 vascular, 16 interstitial and 19 of unknown ethiology. In the RAAS group eGFR slope during follow up was −4.3±1.1ml/min, whereas in the standard treatment group an increase on eGFR was observed after 3 years (+4.6±0.4ml/min), p=0.024. We found no differences in blood pressure control, number of antihypertensive drugs, albuminuria, potassium serum levels, incidence of cardiovascular events nor mortality during the follow up period. Conclusions: In elderly patients without diabetes nor cardiopathy and with non proteinuric CKD the use of RAAS blockers does not show a reduction in CKD progression. The PROERCAN (PROgresión de Enfermedad Renal Crónica en ANcianos) trial (trial registration: NCT03195023). (AU)

Introducción: Actualmente no existe suficiente evidencia sobre el efecto nefroprotector de los bloqueantes del sistema renina-angiotensina-aldosterona (BSRAA) en pacientes añosos con enfermedad renal crónica (ERC) sin proteinuria y sin cardiopatía. El objetivo es evaluar el efecto de los BSRAA en la progresión de la ERC en este grupo poblacional. Métodos: Se trata de un estudio prospectivo, aleatorizado, que compara la eficacia de los BSRAA vs. otros tratamientos antihipertensivos en la progresión renal en personas mayores de 65 años con ERC estadios 3 y 4 e índice albúmina/creatinina<30mg/g. Aleatorización 1:1 BSRAA o tratamiento antihipertensivo estándar. Se recogieron cifras tensionales y parámetros analíticos de un año previo a la aleatorización y durante el seguimiento. Resultados: Se incluyeron 88 pacientes seguidos durante tres años con edad media de 77,9±6,1 años. De estos, se aleatorizaron 40 al grupo BSRAA y 48 al estándar. La etiología de ERC fue: 53 vascular, 16 intersticial y 19 no filiada. En el primer grupo se observó una progresión de la ERC con una caída del filtrado glomerular estimado (FGe) de -4,3±1,1mL/min, mientras que en el grupo estándar un aumento del FGe durante el seguimiento de 4,6±0,4mL/min, p=0,024. No se apreciaron diferencias entre ambos en el control tensional, el número de antihipertensivos, la albuminuria, los niveles de potasio, la incidencia de eventos cardiovasculares ni la mortalidad durante el seguimiento. Conclusiones: En pacientes añosos no diabéticos con ERC no proteinúrica y sin cardiopatía el uso de BSRAA no añade beneficio en la progresión de la ERC. Ensayo clínico Progresión de Enfermedad Renal Crónica en Ancianos (PROERCAN) (NCT03195023). (AU)

Renin-angiotensin-aldosterone system blockers effect in chronic kidney disease progression in hypertensive elderly patients without proteinuria: PROERCAN trial.

INTRODUCTION: Evidence about nefroprotective effect with RAAS blockers in elderly patients with chronic kidney disease (CKD) without proteinuria is lacking. The primary outcome of our study is to evaluate the impact of RAAS blockers in CKD progression in elderly patients without proteinuria. MATERIALS AND METHODS: Multicenter open-label, randomized controlled clinical trial including patients over 65 year-old with hypertension and CKD stages 3-4 without proteinuria. Patients were randomized in a 1:1 ratio to either receive RAAS blockers or other antihypertensive drugs and were followed up for three years. Primary outcome is estimated glomerular filtration rate (eGFR) decline at 3 years. Secondary outcome measures include BP control, renal and cardiovascular events and mortality. RESULTS: 88 patients were included with a mean age of 77.9±6.1 years and a follow up period of 3 years: 40 were randomized to RAAS group and 48 to standard treatment. Ethiology of CKD was: 53 vascular, 16 interstitial and 19 of unknown ethiology. In the RAAS group eGFR slope during follow up was -4.3±1.1ml/min, whereas in the standard treatment group an increase on eGFR was observed after 3 years (+4.6±0.4ml/min), p=0.024. We found no differences in blood pressure control, number of antihypertensive drugs, albuminuria, potassium serum levels, incidence of cardiovascular events nor mortality during the follow up period. CONCLUSIONS: In elderly patients without diabetes nor cardiopathy and with non proteinuric CKD the use of RAAS blockers does not show a reduction in CKD progression. The PROERCAN (PROgresión de Enfermedad Renal Crónica en ANcianos) trial (trial registration: NCT03195023).

Obesity related risk for chronic kidney disease progression and cardiovascular disease after propensity score matching / Riesgo relacionado con la obesidad para la progresión de insuficiencia renal crónica y enfermedad cardiovascular tras emparejamiento por puntaje de propensión

Introduction: Obesity is a major health problem worldwide. It carries a markedly increased risk for multiple diseases such as type 2 diabetes mellitus, hypertension, cardiovascular disease (CVD) and chronic kidney disease (CKD). To complicate an already difficult topic a new subtype of obesity has been defined lately, the metabolically healthy obese. Our study aimed to clarify the association between obesity, metabolic syndrome and kidney disease progression. Methods: Observational retrospective single centre study including 212 patients with stage 3–4 CKD with no previous history of rapid kidney disease progression. Patients were divided according to BMI status and presence of metabolic syndrome. Anthropometric, clinical and laboratory data were collected to follow-up. Propensity score matching was performed for age, albuminuria and baseline renal function. During follow-up renal and cardiovascular events were recorded. Results: After a mean follow-up of 88.44±36.07 months a total of 18 patients reached the renal outcome in the non-obese group and 21 in the obese group. Differences were not statistically significant (log rank=0.21: p=0.64). Multiple Cox regression analysis showed that obesity was not predictor for worse renal outcomes [HR 1.01, 95% CI 0.45–2.24; p=0.97]. When stratifying the sample according to baseline metabolic syndrome and obesity presence there was no difference in renal survival (log rank=0.852; p=0.35) (AU)

Introducción: La obesidad es un problema mayor de salud a nivel mundial. Comporta un considerable incremento del riesgo de múltiples enfermedades tales como diabetes mellitus tipo 2, hipertensión, enfermedad cardiovascular (ECV) e insuficiencia renal crónica (IRC). Para complicar un tema ya difícil, se ha definido recientemente un nuevo subtipo de obesidad: el obeso metabólicamente sano. El objetivo de nuestro estudio fue aclarar la asociación entre obesidad, síndrome metabólico y progresión de la enfermedad renal. Métodos: Estudio observacional retrospectivo unicéntrico que incluyó a 212 pacientes con IRC estadio 3 a 4, sin antecedentes de progresión rápida de la enfermedad renal. Se dividió a los pacientes conforme a su situación de índice de masa corporal (IMC) y presencia de síndrome metabólico (SM). Durante el seguimiento se recopilaron los datos antropométricos, clínicos y de laboratorio. Se realizó el emparejamiento por puntaje de propensión (Propensity score matching) para edad, albuminuria y función renal nasal. Durante el seguimiento se registraron los episodios renales y cardiovasculares. Resultados: Tras un seguimiento medio de 88,44 ± 36,07 meses, un total de 18 pacientes logró el resultado renal en el grupo de no obesos, y 21 en el grupo de obesos. Las diferencias no fueron estadísticamente significativas (log rank=0,21: p = 0,64). El análisis de regresión múltiple de Cox mostró que la obesidad no era un factor predictivo para peores resultados renales [HR 1,01, IC95% 0,45–2,24; p 0,97]. Al estratificar la muestra con arreglo a síndrome metabólico basal y presencia de obesidad no existió diferencia en cuanto a la supervivencia renal (log rank = 0,852; p = 0,35). (AU)

Obesity related risk for chronic kidney disease progression and cardiovascular disease after propensity score matching.

INTRODUCTION: Obesity is a major health problem worldwide. It carries a markedly increased risk for multiple diseases such as type 2 diabetes mellitus, hypertension, cardiovascular disease (CVD) and chronic kidney disease (CKD). To complicate an already difficult topic a new subtype of obesity has been defined lately, the metabolically healthy obese. Our study aimed to clarify the association between obesity, metabolic syndrome and kidney disease progression. METHODS: Observational retrospective single centre study including 212 patients with stage 3-4 CKD with no previous history of rapid kidney disease progression. Patients were divided according to BMI status and presence of metabolic syndrome. Anthropometric, clinical and laboratory data were collected to follow-up. Propensity score matching was performed for age, albuminuria and baseline renal function. During follow-up renal and cardiovascular events were recorded. RESULTS: After a mean follow-up of 88.44±36.07 months a total of 18 patients reached the renal outcome in the non-obese group and 21 in the obese group. Differences were not statistically significant (log rank=0.21: p=0.64). Multiple Cox regression analysis showed that obesity was not predictor for worse renal outcomes [HR 1.01, 95% CI 0.45-2.24; p=0.97]. When stratifying the sample according to baseline metabolic syndrome and obesity presence there was no difference in renal survival (log rank=0.852; p=0.35) A total of 48 cardiovascular events were registered: seventeen in the non-obese group and thirty-one in the obese group. Differences in event-free time between both groups were statistically significant (log rank=4.44;p=0.035), especially after four years of follow-up. After stratifying for MS and obesity presence at baseline the event-free time differences where again statistically significant (log rank=16.86;p=0.001), specially for the obese patients with metabolic syndrome. CONCLUSIONS: Obesity has little impact on chronic kidney disease progression despite the presence or absence of metabolic syndrome in a cohort matched for age, baseline renal function and albuminuria. Obesity conferred greater cardiovascular risk when combined with metabolic syndrome.

The effect of renin–angiotensin–aldosterone system blockers on the progression of chronic kidney disease in hypertensive elderly patients without proteinuria: PROERCAN study. Rationale and design / Efecto de los bloqueantes del sistema renina-angiotensina-aldosterona en la progresión de la enfermedad renal crónica en pacientes añosos sin proteinuria: ensayo clínico PROERCAN. Diseño y justificación del estudio

INTRODUCTION: Blood pressure (BP) control is fundamental to the care of patients with chronic kidney disease (CKD), and is relevant at all stages of CKD. Renin-angiotensin-aldosterone system (RAAS) blockers have shown to be effective, not only in BP control but also in reducing proteinuria and slowing CKD progression. However, there is a lack of evidence for recommending RAAS blockers in elderly patients with CKD without proteinuria. The primary outcome of the present study is to evaluate the impact of RAAS blockers on CKD progression in elderly patients without proteinuria. MATERIALS AND METHODS: The PROERCAN trial (trial registration, NCT03195023) is a multicentre open-label, randomized controlled clinical trial with 110 participants over 65 years-old with hypertension and CKD stages 3-4 without proteinuria. Patients will be randomized in a 1:1 ratio to either receive RAAS blockers or other antihypertensive drugs, and will be followed up for three years. Primary outcome is the estimated glomerular filtration rate (eGFR) decline at 3 years. Secondary outcomes include BP control, renal and cardiovascular events, and mortality. RESULTS AND CONCLUSIONS: The design of this trial is presented here. The results will show if antihypertensive treatment with RAAS blockers has an impact on CKD progression in elderly patients without proteinuria. Any differences in BP control, cardiovascular events, and mortality with each antihypertensive treatment will be also clarified

INTRODUCCIÓN: El control de la presión arterial (PA) es fundamental para los pacientes con enfermedad renal crónica (ERC) y es relevante en todos los estadios de ERC. Los bloqueantes del sistema renina-angiotensina-aldosterona (BSRAA) han demostrado su efectividad no solo en el control de la PA sino también en la reducción de la proteinuria y de la progresión de la ERC. Sin embargo, no existe evidencia para recomendar el uso de BSRAA en pacientes añosos con ERC sin proteinuria. El objetivo principal del estudio es evaluar el impacto de los BSRAA en la progresión de ERC en pacientes añosos sin proteinuria. MATERIAL Y MÉTODOS: El estudio PROERCAN (NCT03195023) es un ensayo clínico multicéntrico, abierto, aleatorizado de 110 pacientes hipertensos, mayores de 65 años con ERC estadios3 y4 sin proteinuria. Los pacientes son aleatorizados 1:1 a recibir tratamiento con BSRAA u otros antihipertensivos y el seguimiento será de 3años. La variable principal es el descenso del filtrado glomerular estimado durante el tiempo de seguimiento. Las variables secundarias incluyen las cifras de PA, eventos renales y cardiovasculares y mortalidad. RESULTADOS Y CONCLUSIÓN: El diseño del ensayo clínico se desarrolla en el presente artículo. Los resultados determinarán si el tratamiento antihipertensivo con BSRAA tiene un impacto en la progresión de la ERC en pacientes añosos sin proteinuria. Así mismo, se aclararán las diferencias en el control de la PA, los eventos cardiovasculares y la mortalidad con los distintos tratamientos antihipertensivos

The effect of renin-angiotensin-aldosterone system blockers on the progression of chronic kidney disease in hypertensive elderly patients without proteinuria: PROERCAN study. Rationale and design.

INTRODUCTION: Blood pressure (BP) control is fundamental to the care of patients with chronic kidney disease (CKD), and is relevant at all stages of CKD. Renin-angiotensin-aldosterone system (RAAS) blockers have shown to be effective, not only in BP control but also in reducing proteinuria and slowing CKD progression. However, there is a lack of evidence for recommending RAAS blockers in elderly patients with CKD without proteinuria. The primary outcome of the present study is to evaluate the impact of RAAS blockers on CKD progression in elderly patients without proteinuria. MATERIALS AND METHODS: The PROERCAN trial (trial registration, NCT03195023) is a multicentre open-label, randomized controlled clinical trial with 110 participants over 65 years-old with hypertension and CKD stages 3-4 without proteinuria. Patients will be randomized in a 1:1 ratio to either receive RAAS blockers or other antihypertensive drugs, and will be followed up for three years. Primary outcome is the estimated glomerular filtration rate (eGFR) decline at 3 years. Secondary outcomes include BP control, renal and cardiovascular events, and mortality. RESULTS AND CONCLUSIONS: The design of this trial is presented here. The results will show if antihypertensive treatment with RAAS blockers has an impact on CKD progression in elderly patients without proteinuria. Any differences in BP control, cardiovascular events, and mortality with each antihypertensive treatment will be also clarified.

Progresión de la enfermedad renal crónica en pacientes con hipertensión resistente sometidos a 2 estrategias terapéuticas: intensificación con diuréticos de asa vs. antagonistas de la aldosterona / Chronic kidney disease progression in patients with resistant hypertension subject to 2 therapeutic strategies: Intensification with loop diuretics vs aldosterone antagonists

INTRODUCCIÓN: En la actualidad, existen pocos datos sobre la evolución de la función renal en pacientes con hipertensión arterial (HTA) resistente y enfermedad renal crónica (ERC), así como de la influencia de diferentes tipos de tratamiento en dicha progresión. OBJETIVO: Evaluar la progresión de la ERC en pacientes con ERC e HTA resistente tratados mediante 2 estrategias terapéuticas diferentes: tratamiento con espironolactona vs. furosemida. MÉTODOS: Incluimos a 30 pacientes (21 H, 9M) con una edad media de 66,3 ± 9,1 años, FGe 55,8 ± 16,5 ml/min/1,73 m2, PAS 162,8 ± 8,2 y PAD 90,2 ± 6,2 mmHg: 15 tratados con espironolactona y 15 con furosemida, seguidos durante un tiempo medio de 32 meses (28-41). RESULTADOS: El descenso medio anual del FGe fue de -2,8 ± 5,4 ml/min/1,73 m2. En el grupo de espironolactona fue de -2,1 ± 4,8ml/min/1,73 m2 y en el de furosemida -3,2 ± 5,6 ml/min/1,73 m2, p < 0,01. En los pacientes con espironolactona la PAS disminuyó 23 ± 9 mmHg vs. 16 ± 3mmHg en el grupo de furosemida (p < 0,01). La PAD se redujo 10 ± 8 mmHg y 6 ± 2 mmHg, respectivamente (p < 0,01). El tratamiento con espironolactona redujo la albuminuria de una mediana de 210 (121-385) mg/g a 65 (45-120) mg/g al final del seguimiento, p < 0,01. En el grupo de furosemida la albuminuria no descendió. La progresión más lenta en la enfermedad renal se asoció con una menor PAS (p = 0,04), mayor FGe basal (p = 0,01), menor albuminuria (p = 0,01), no tener diabetes mellitus (p = 0,01) y recibir tratamiento con espironolactona (p = 0,02). El tratamiento con espironolactona (OR 2,13; IC 1,89-2,29) y la menor albuminuria (OR 0,98; IC 0,97-0,99) mantienen su poder predictivo independiente en un modelo multivariante. CONCLUSIONES: El tratamiento con espironolactona reduce más la presión arterial y la albuminuria en pacientes con HTA resistente comparado con la furosemida y esto se asocia con una progresión más lenta de la ERC a largo plazo

INTRODUCTION: Actualy, there are few data about glomerular filtration rate (eGFR) drop in patients with resistant hypertension and how diferent therapies can modify chronic kidney disease progression (CKD). OBJECTIVE: To evaluate CKD progression in patients with resistant hypertension undergoing 2 diferent therapies: treatment with spironolactone or furosemide. METHODS: We included 30 patients (21 M, 9 W) with a mean age of 66.3 ± 9.1 years, eGFR 55.8 ± 16.5 ml/min/1.73 m2, SBP 162.8 ± 8.2 and DBP 90.2 ± 6.2 mmHg: 15 patients received spironolactone and 15 furosemide and we followed up them a median of 32 months (28-41). RESULTS: The mean annual eGFR decrease was -2.8 ± 5.4 ml/min/1.73 m2. In spironolactone group was -2.1 ± 4.8 ml/min/1.73 m2 and in furosemide group was -3.2 ± 5.6 ml/min/1.73 m2, P < 0.01. In patients received spironolactone, SBP decreased 23 ± 9 mmHg and in furosemide group decreased 16 ± 3 mmHg, P<.01. DBP decreased 10 ± 8 mmHg and 6 ± 2mmHg, respectively (P<.01). Treatment with spironolactone reduced albuminuria from a serum albumin/creatine ratio of 210 (121-385) mg/g to 65 (45-120) mg/g at the end of follow-up, P<.01. There were no significant changes in the albumin/creatinine ratio in the furosemide group. The slower drop in kidney function was associated with lower SBP (P=.04), higher GFR (P=.01), lower albuminuria (P=.01), not diabetes mellitus (P=.01) and treatment with spironolactone (P=.02). Treatment with spironolactone (OR 2.13, IC 1.89-2.29) and lower albuminuria (OR 0.98, CI 0.97-0.99) maintain their independent predictive power in a multivariate model. CONCLUSION: Treatment with spironolactone is more effective reducing BP and albuminuria in patients with resistant hypertension compared with furosemide and it is associated with a slower progression of CKD in the long term follow up

Chronic kidney disease progression in patients with resistant hypertension subject to 2 therapeutic strategies: Intensification with loop diuretics vs aldosterone antagonists. / Progresión de la enfermedad renal crónica en pacientes con hipertensión resistente sometidos a 2 estrategias terapéuticas: intensificación con diuréticos de asa vs. antagonistas de la aldosterona.

INTRODUCTION: Actualy, there are few data about glomerular filtration rate (eGFR) drop in patients with resistant hypertension and how diferent therapies can modify chronic kidney disease progression (CKD). OBJECTIVE: To evaluate CKD progression in patients with resistant hypertension undergoing 2diferent therapies: treatment with spironolactone or furosemide. METHODS: We included 30 patients (21M, 9W) with a mean age of 66.3±9.1 years, eGFR 55.8±16.5ml/min/1.73 m2, SBP 162.8±8.2 and DBP 90.2±6.2mmHg: 15 patients received spironolactone and 15 furosemide and we followed up them a median of 32 months (28-41). RESULTS: The mean annual eGFR decrease was -2.8±5.4ml/min/1.73 m2. In spironolactone group was -2.1±4.8ml/min/1.73 m2 and in furosemide group was -3.2±5.6ml/min/1.73 m2, P<0.01. In patients received spironolactone, SBP decreased 23±9mmHg and in furosemide group decreased 16±3mmHg, P<.01. DBP decreased 10±8mmHg and 6±2mmHg, respectively (P<.01). Treatment with spironolactone reduced albuminuria from a serum albumin/creatine ratio of 210 (121-385) mg/g to 65 (45-120) mg/g at the end of follow-up, P<.01. There were no significant changes in the albumin/creatinine ratio in the furosemide group. The slower drop in kidney function was associated with lower SBP (P=.04), higher GFR (P=.01), lower albuminuria (P=.01), not diabetes mellitus (P=.01) and treatment with spironolactone (P=.02). Treatment with spironolactone (OR 2.13, IC 1.89-2.29) and lower albuminuria (OR 0.98, CI 0.97-0.99) maintain their independent predictive power in a multivariate model. CONCLUSION: Treatment with spironolactone is more effective reducing BP and albuminuria in patients with resistant hypertension compared with furosemide and it is associated with a slower progression of CKD in the long term follow up.

Intoxicación por etilenglicol tras la ingesta del contenido de un extintor / No disponible

No disponible

Dose equivalence between continuous erythropoietin receptor activator (CERA), Darbepoetin and Epoetin in patients with advanced chronic kidney disease.

BACKGROUND: Anemia is a prevalent situation in patients with chronic kidney disease (CKD) and can be well managed with erythropoiesis-stimulating agents (ESAs). Continuous erythropoietin receptor activator (CERA) has a long half-life that allows to be administered once monthly. The lowest recommended dose for patients with non dialysis CKD is 120 µg per month. The objectives were to assess the efficacy of subcutaneous monthly dosing of CERA in CKD stages 4 and 5 not on dialysis, and to determine the equivalent dose to epoetin ß and darbepoetin α. METHODS: This is a cohort study. A 30-patient group that ESAs was changed to CERA (µg/month) was used as treatment group. We used the following clinically-based equivalent dosing: epoetin ß (IU/week) and darbepoetin α (µg/week): 3000/15= 50; 4000/20=75; 6000/30=100; 8000/40=150. Another group of 30 patients with similar characteristics was used as control group and received the same epoetin ß and darbepoetin α doses. RESULTS: The mean CERA initial dose and at 6 months was 81.9 ± 35.2 and 82.0 ± 37.82 µg/month (p=0.37). The mean erythropoietin resistance index (ERI) and hemoglobin at baseline and at 6 months in the CERA group and in the control group were not statistically significant. CONCLUSION: Monthly dosing treatment with CERA is safe and effective. A dose of 75-100 µg/month is enough to maintain stable levels of hemoglobin. Hippokratia 2014; 18 (4): 315-318.

The phase angle of the electrical impedance is a predictor of long-term survival in dialysis patients.

INTRODUCTION: Protein-energy malnutrition is a risk factor for mortality in dialysis patients; however, its clinical assessment has not been well defined. Electrical bioimpedance (EBI) is a non-invasive and objective procedure, which is increasingly being used for this assessment. OBJECTIVE: The aim of this study is to analyse the relationship between the phase angle determined by EBI at a frequency of 50kHz (AF50) and other nutritional parameters, and prospectively evaluate its ability as a marker for long-term mortality. PATIENTS AND METHODS: We included 164 patients (127 on haemodialysis and 37 on peritoneal dialysis) who underwent an EBI analysis while simultaneously determining inflammation and nutrition parameters. The Charlson comorbidity index was then calculated. RESULTS: In the linear correlation analysis, we found that the AF50 had a direct association with lean mass, intracellular water, extracellular water and interdialytic weight gain, while having an inverse association with age and fat mass. Patients with AF50 >8º had a better nutritional status, were younger and had significantly longer survival at the six-year follow-up. Among the patients studied, both the AF50 and the other body composition parameters were better in peritoneal dialysis than in haemodialysis, but these differences may be attributable to the fact that the first patients were younger. In the multivariate analysis, only the AF50 <8º and comorbidity adjusted for age persisted as independent risk factors for mortality. CONCLUSIONS: We conclude that AF50 has a good correlation with nutritional parameters and is a good marker of survival in dialysis patients. Nevertheless, intervention studies are needed to demonstrate if the improvement in EBI parameters is associated with better survival.

El ángulo de fase de la impedancia eléctrica es un predictor de supervivencia a largo plazo en pacientes en diálisis / The phase angle of the electrical impedance is a predictor of long-term survival in dialysis patients

Introducción: La malnutrición calórico-proteica es un factor de riesgo de mortalidad en pacientes en diálisis, sin embargo, su valoración clínica no ha sido bien definida. La bioimpedancia eléctrica (BIE) es un procedimiento no invasivo y objetivo, cada vez más empleado en su valoración. Objetivo: El objetivo de este estudio es analizar la relación entre el ángulo de fase determinado por BIE a una frecuencia de 50 kHz (AF50) con otros parámetros de nutrición y valorar prospectivamente su capacidad como marcador pronóstico de mortalidad a largo plazo. Pacientes y métodos: Incluimos a 164 pacientes, 127 en hemodiálisis y 37 en diálisis peritoneal, a los que se les realiza un análisis de BIE al tiempo que se solicitan parámetros de inflamación y nutrición y se calcula el índice de comorbilidad de Charlson. Resultados: En el análisis de correlación lineal, encontramos que el AF50 tiene una asociación directa con la masa magra, con el agua intracelular, con el agua extracelular y con la ganancia de peso interdiálisis, mientras que se asocia de forma inversa con la edad, con la masa grasa y con el log PCR. Los pacientes con AF50 >8o presentan un mejor estado nutricional, son más jóvenes y tienen una supervivencia significativamente mejor a los seis años de seguimiento. Entre los pacientes (..) (AU)

Introduction: Protein-energy malnutrition is a risk factor for mortality in dialysis patients; however, its clinical assessment has not been well defined. Electrical bioimpedance (EBI) is a non-invasive and objective procedure, which is increasingly being used for this assessment. Objective: The aim of this study is to analyse the relationship between the phase angle determined by EBI at a frequency of 50kHz (AF50) and other nutritional parameters, and prospectively evaluate its ability as a marker for long-term mortality. Patients and methods: We included 164 patients (127 on haemodialysis and 37 on peritoneal dialysis) who underwent an EBI analysis while simultaneously determining inflammation and nutrition parameters. The Charlson comorbidity index was then calculated. Results: In the linear correlation analysis, we found that the AF50 had a direct association with lean mass, intracellular water, extracellular water and interdialytic weight gain, while having an inverse association with age and fat mass. Patients with AF50 >8o had a better nutritional status, were younger and had significantly longer survival at the six-year follow-up. Among the patients studied, both the AF50 and the other body composition parameters were better in peritoneal dialysis than in haemodialysis, but these differences may be attributable to the fact that the first patients were younger. In the multivariate analysis, only the AF50 <8o and comorbidity adjusted for age persisted as independent risk factors for mortality. Conclusions: We conclude that AF50 has a good correlation with nutritional parameters and is a good marker of survival in dialysis patients. Nevertheless, intervention studies are needed to demonstrate if the improvement in EBI parameters is associated with better survival (..) (AU)

Fracaso renal agudo en el contexto de un síndrome de Takotsubo / Acute kidney failure in the context of a Tako-Tsubo syndrome

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Factors predicting mortality in elderly patients on dialysis.

UNLABELLED: Elderly patients are increasingly enrolled in dialysis programs and present a series of special characteristics due to their high morbidity and mortality. OBJECTIVE: To describe the characteristics of incident dialysis patients aged >75 years, their comorbidities and their admissions, with a view to determining the factors that influence their course and mortality. PATIENTS AND METHODS: The study included all patients aged >75 years who started dialysis in our center since January 2000. The mean duration of follow-up was 3.3 +/- 2.2 years. Data were collected on incident comorbidity, admissions and their causes. A total of 139 patients were included, with a mean age of 78.6 +/- 2.6 years (67.6% males, 33.8% diabetic and 7.9% on peritoneal dialysis). Three groups were established according to age: 75-79, 80-85 and >85 years. The most frequent comorbidities were chronic obstructive pulmonary disease (25.9%), ischemic heart disease (25.2%), heart failure (25.9%), neoplasms (23.7%), peripheral vascular disease (23.7%), cerebrovascular disease (18.7%) and arterial hypertension (81%). The Charlson index was calculated, not adjusted for age, and comorbidity tertiles were established. RESULTS: During follow-up, the patients presented 0.82 +/- 0.99 admissions/patient/year, with a duration of 12.1 +/- 20.6 days/patient/year. The main causes of admission were infection (33%), vascular access problems (27%) and peripheral vascular events (14%). A total of 61 patients died (44%), and 4 underwent kidney transplantation (2.9%). The mean duration of follow-up of the transplanted patients was 3.6 +/- 1.8 years. The main causes of death were infection (32%), cardiovascular problems (28.3%) and neoplastic disease (11.3%). The global survival rate was 90, 82 and 53% after 1, 2 and 5 years, respectively. No significant differences in survival or annual admission rate were found in relation to age group and dialysis technique. In contrast, the annual admission rate and days of admission were directly correlated to the Charlson index (p = 0.009 and p = 0.032, respectively). No significant differences in the Charlson index were found between the patients on hemodialysis and those subjected to peritoneal dialysis. In the univariate model, the factors associated to mortality were diabetes, chronic obstructive pulmonary disease, heart failure and the Charlson index. In the multivariate model, only the Charlson index remained as an independent predictive factor (p = 0.006). CONCLUSIONS: Unlike the general population, age does not influence mortality or admissions in elderly patients on dialysis. Incident comorbidity is the factor exerting the greatest influence upon mortality and admissions. Advanced age in itself should not be regarded as an excluding factor for starting dialysis.

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[Therapeutic guidelines fulfillment in clinical practice in patients with chronic kidney disease (CKD)]. / Evaluación del cumplimiento de las guías terapéuticas en la práctica clínica en pacientes con enfermedad renal crónica (ERC).

OBJECTIVE: The present study was designed to determine the degree of fulfillment of the therapeutic objectives recommended in the clinical guidelines in patients with chronic kidney disease (CKD) in a nephrology outpatient clinic and the treatment that the patients were receiving to control these objectives. METHODS: A descriptive, cross-sectional study was performed in unselected patients with CKD (stages 1-5) who attended the nephrology outpatient clinic of the Hospital General Universitario Gregorio Marañón for follow up between 1st January and 1st April 2006. RESULTS: Data from 600 patients with a mean age of 62.8 years (56.5% male) were collected. The distribution of patients according to the stage (S) of CKD was as follows: S1: 11.5%, S2: 18%, S3: 36.7%, S4: 27.5% and S5: 6.3%. The target blood pressure (BP) < 130/80 mmHg was reached in 35.5%. The target diastolic blood pressure was controlled in 70%. However, systolic blood pressure increasing significantly with age and the degree of renal failure was controlled only in 42%. Total cholesterol was or=50 mg/l in 64.1% of patients. Triglyceride level was related to renal function (p=0.04). Most of the patients (94%) had hemoglobin (Hb) levels >or=11 g/dl, because of a significant increase in the percentage of patients treated with erythropoiesis-stimulating agents as the degree of renal function is reduced. Target levels of calcium-phosphorus (CaXP) product (<55 mg2/dl 2) were maintained in all the stages at the expense of decreased Ca and increased P in relation to the decrease in glomerular filtrate (p=0.001). Target Ca (8.4-9.5 mg/dl) was reached in 85% of cases (2% of patients in S3, 37% of patients in S4 and 54% in S5 were receiving calcitriol). Phosphorus levels were adequate in 80% of patients, but target levels of parathyroid hormone (PTH) were maintained only in 28.6% of patients in S3 (35-70 pg/ml), 14% of patients in S4 (70-110 pg/ml) and 28% in S-5 (115-300 pg/ml). CONCLUSIONS: Anemia is the best controlled factor of all the factors related to renal function. The degree of control of blood pressure (BP) has improved in recent years. However, it is still poor, particularly the control of systolic blood pressure getting worse with renal failure and age. It is difficult to reach the target PTH, despite adequate levels of Ca and P. Cholesterol levels, unlike triglyceride levels, do not depend on renal function and require an increase in the use and/or doses of cholesterol-lowering drugs.

Evaluación del cumplimiento de las guías terapéuticas en la práctica clínica en pacientes con enfermedad renal crónica (ERC) / therapeutic guidelines fulfilment in patients with chronic kidney disease (CKD)

Objetivo: El presente estudio se diseñó para determinar el grado de cumplimiento de los objetivos terapéuticos recomendados por las guías de actuación clínica en los pacientes con ERC en una consulta externa de nefrología y el tratamiento que recibían los pacientes para el control de los mismos. Métodos: Se realizó un estudio descriptivo y transversal con pacientes no seleccionados con ERC (estadios 1-5) que acudieron a revisión a la consulta ambulatoria de nefrología del Hospital General Universitario Gregorio Marañón entre el 1 de enero y el 1 de abril del 2006. Resultados: Se recogieron los datos de 600 pacientes con una edad media de 62,8 años (56,5% varones). La distribución de los pacientes según los estadios (E) de ERC fue: E1: 11,5%, E2: 18%, E3: 36,7%, E4: 27,5% y E5: 6,3%. El objetivo de presión arterial (PA) = 50 mg/l. El nivel de triglicéridos se relacionó con la función renal (p = 0,04). La mayor parte de los pacientes (94%) tenía cifras de Hb >= 11 g/dl, gracias a un aumento significativo en el % de pacientes tratados con agentes estimulantes de la eritropoyesis conforme disminuye el grado de función renal. El CaxP se mantuvo en cifras objetivo (< 55 mg2/dl2) en todos los estadios a expensas de disminución del Ca y aumento del P en relación con la disminución del filtrado glomerular (p = 0,001). El objetivo de Ca (entre 8,4-9,5 mg/dl) se alcanzaba en el 85% de los casos (2% de pacientes en E3, 37% de E4 y 54% de E5 recibían calcitriol). Los niveles de fósforo fueron adecuados en el 80%, pero sólo 28,6% de los pacientes en E-3 mantuvo cifras objetivo de PTH (35-70 pg/ml), 14% en E-4 (70-110 pg/ml) y 28% en E-5 (115-300 pg/ml). Conclusiones: De los factores relacionados con la función renal la anemia es el mejor controlado. El grado de control de la PA aunque ha mejorado en los últimos años, sigue siendo pobre, sobre todo de la PA sistólica que empeora con la insuficiencia renal y la edad. Es difícil alcanzar el objetivo de PTH, a pesar de cifras adecuadas de Ca y P. Los niveles de colesterol, al contrario que los niveles de triglicéridos, no dependen de la función renal y requieren incrementar el uso y/o dosis de fármacos hipocolesterolemiantes

Objective: The present study was designed to determine the degree of fulfilment of the therapeutic objectives recommended in the clinical guidelines in patients with chronic kidney disease (CKD) in a nephrology outpatient clinic and the treatment that the patients were receiving to control these objectives. Methods: A descriptive, cross-sectional study was performed in unselected patients with CKD (stages 1-5) who attended the nephrology outpatient clinic of the Hospital General Universitario Gregorio Marañón for follow up between 1st January and 1st april 2006. Results: Data from 600 patients with a mean age of 62.8 years (56.5% male) were collected. The distribution of patients according to the stage (S) of CKD was as follows: S1: 11.5%, S2: 18%, S3: 36.7%, S4: 27.5% and S5: 6.3%. The target blood pressure (BP) = 50 mg/l in 64.1% of patients. Triglyceride level was related to renal function (p=0.04). Most of the patients (94%) had hemoglobin (Hb) levels >= 11 g/dl, because of a significant increase in the percentage of patients treated with erythropoiesis- stimulating agents as the degree of renal function is reduced. Target levels of calcium-phosphorus (CaXP) product (< 55 mg2/dl2) were maintained in all the stages at the expense of decreased Ca and increased P in relation to the decrease in glomerular filtrate (p = 0.001). Target Ca (8.4-9.5 mg/dl) was reached in 85% of cases (2% of patients in S3, 37% of patients in S4 and 54% in S5 were receiving calcitriol). Phosphorus levels were adequate in 80% of patients, but target levels of parathyroid hormone (PTH) were maintained only in 28.6% of patients in S3 (35-70 pg/ml), 14% of patients in S4 (70-110 pg/ml) and 28% in S-5 (115-300 pg/ml). Conclusions: Anemia is the best controlled factor of all the factors related to renal function. The degree of control of blood pressure (BP) has improved in recent years. However, it is still poor, particularly the control of systolic blood pressure getting worse with renal failure and age. It is difficult to reach the target PTH, despite adequate levels of Ca and P. Cholesterol levels, unlike triglyceride levels, do not depend on renal function and require an increse in the use and/or doses of cholesterol-lowering drugs