Spanish Clinical Guidelines on Vascular Access for Haemodialysis. / Guía Clínica Española del Acceso Vascular para Hemodiálisis.

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Guía Clínica Española del Acceso Vascular para Hemodiálisis / Spanish Clinical Guidelines on Vascular Access for Haemodialysis

El acceso vascular para hemodiálisis es esencial para el enfermo renal tanto por su morbimortalidad asociada como por su repercusión en la calidad de vida. El proceso que va desde la creación y mantenimiento del acceso vascular hasta el tratamiento de sus complicaciones constituye un reto para la toma de decisiones debido a la complejidad de la patología existente y a la diversidad de especialidades involucradas. Con el fin de conseguir un abordaje consensuado, el Grupo Español Multidisciplinar del Acceso Vascular (GEMAV), que incluye expertos de las cinco sociedades científicas implicadas (nefrología [S.E.N.], cirugía vascular [SEACV], radiología vascular e intervencionista [SERAM-SERVEI], enfermedades infecciosas [SEIMC] y enfermería nefrológica [SEDEN]), con el soporte metodológico del Centro Cochrane Iberoamericano, ha realizado una actualización de la Guía del Acceso Vascular para Hemodiálisis publicada en 2005. Esta guía mantiene una estructura similar, revisando la evidencia sin renunciar a la vertiente docente, pero se aportan como novedades, por un lado, la metodología en su elaboración, siguiendo las directrices del sistema GRADE con el objetivo de traducir esta revisión sistemática de la evidencia en recomendaciones que faciliten la toma de decisiones en la práctica clínica habitual y, por otro, el establecimiento de indicadores de calidad que permitan monitorizar la calidad asistencial (AU)

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare (AU)

Assessment of biomarkers and predictive model for short-term prospective abdominal aortic aneurysm growth-A pilot study.

BACKGROUND: Abdominal aortic aneurysms (AAAs) are currently followed with serial ultrasound or computed tomography scanning diameter measurements, but evidence shows that AAA expansion is mostly discontinuous and quite unpredictable in any given patient. A reliable predictive model of AAA growth and/or rupture risk could help individualize treatment, follow-up protocols, and cost-effectiveness. Our objective is to set a predictive model of short-term prospective AAA growth, after clinical, serologic, and anatomic data. METHODS: A prospective pilot cohort was designed. We recruited 96 consecutive, asymptomatic, infrarenal, atherosclerotic AAA patients. We registered clinical data (age, gender, cardiovascular risk factors, comorbidity, and statin intake), baseline aortic diameter, prospective 1-year AAA growth, and the concentration of metalloprotease-2, metalloprotease-9, cystatin C, α1-antitrypsin, myeloperoxidase, monocyte chemoattractant protein-1, homocysteine, D-dimer, plasmin-antiplasmin complex (PAP), and C-reactive protein in peripheral blood at the time of baseline assessment. With all these data, we elaborated predictive models for 1-year AAA growth assessed both as a continuous variable (mm/year) and a dichotomic one (defined as stability, if AAA growth rate was ≤2 mm/year, versus expansion, if AAA growth rate was >2 mm/year), using simple and multiple linear and logistic regression. RESULTS: The multivariate model confirmed the independent impact of D-dimer levels and chronic renal failure (CRF) on increasing AAA growth rates. Every increase by 1 ng/mL in the plasma concentration of D-dimer was related to a mean 1-year increase of 0.0062 mm in the AAA growth. Likewise, CRF increased the 1-year prospective AAA growth by a mean of 2.95 mm. When we assessed AAA growth as a dichotomic variable, the increase in the peripheral concentrations of PAP slightly increased the risk of AAA expansion (odds ratio [OR]: 1.01; 95% confidence interval [CI]: 1.00-1.02), but the presence of CRF increased the risk dramatically (OR: 14,523.62; 95% CI: 0-7.39E+40). CONCLUSIONS: Plasma D-dimer and PAP levels seem promising biomarkers of short-term AAA activity. CRF is an important independent prognostic factor of AAA expansion. The dichotomic classification of AAA growth, as stability versus progression, can be useful in the development of management models and their clinical application.

Prevalence of abdominal aortic aneurysm is still high in certain areas of southern Europe.

BACKGROUND: Ultrasound screening of abdominal aortic aneurysm (AAA) has proved to reduce mortality from AAA rupture and has been implemented in several countries. Recent reports show a decreasing prevalence of AAA in Western countries. We report the results from a screening program among 65-year-old men in a defined area in the North of Spain. METHODS: We invited the 1,413 men born in 1943 and registered in the health area under our care to participate in the study. We registered their medical history and cardiovascular risk factors and we performed an abdominal ultrasound scan. We diagnosed an AAA when the infrarenal aortic diameter was ≥3 cm. We performed univariate and multivariate analysis to assess independent factors associated with the development of an AAA, using logistic regression. RESULTS: The participation rate was 70.8%. The prevalence of active smoking, hypertension, diabetes, and hypercholesterolemia was 19.6%, 52.1%, 25.7%, and 76.9%, respectively. Including 3 previously known and repaired AAAs, the total prevalence of AAA was 4.7% (n=37). The mean diameter of the AAA was 35.7±7.9 mm (range, 30-62 mm). Multivariate analysis confirmed the independent impact of active smoking (Exp[B], 3.47 [95% confidence interval {CI}: 1.67-7.22]), hypertension (Exp[B], 2.43 [95% CI: 1.08-5.45]), and peripheral arterial disease (Exp[B], 3.00 [95% CI: 1.16-7.80]) on the incidence of AAA. CONCLUSIONS: The prevalence of AAA remains high in the studied area in the North of Spain. The potential benefit of lowering smoking rates has not been observed yet. The current international recommendations of screening for 65-year-old men are still applicable in our population.

Valor pronóstico de marcadores inflamatorios y perfil lipídico en pacientes con claudicación intermitente. Estudio piloto / Prognostic value of inflammatory markers and lipid profile in patients suffering from intermittent claudication – a pilot study

Fundamento y objetivo: Analizar variables clínicas y serológicas (perfil lipídico, marcadores inflamatorios) como potenciales factores de riesgo para el desarrollo de eventos cardiovasculares y mortalidad a corto plazo en pacientes con claudicación intermitente. Pacientes y método: Incluimos todos los pacientes con diagnóstico inicial de claudicación intermitente vascular en nuestro centro durante 2005-2006. Analizamos datos clínicos, parámetros serológicos (creatinina, colesterol total, colesterol unido a lipoproteínas de baja densidad [colesterol LDL], colesterol unido a lipoproteínas de alta densidad [colesterol HDL], apolipoproteína A1, apolipoproteína B100, lipoproteína(a), homocisteína, proteína C reactiva, velocidad de sedimentación globular [VSG], fibrinógeno), eventos cardiovasculares y mortalidad durante el seguimiento a 1-3 años. Resultados:Incluimos 162 pacientes, de los que 143 (88,3%) eran varones. La edad media (DE) fue de 66 (10,4) años (extremos 41-86), 76 (46,9%) eran fumadores activos, 96 (59,3%) hipertensos, 56 (34,6%) diabéticos y 129 (79,6%) hipercolesterolémicos. Registramos 16 (9,9%) eventos coronarios/cerebrovasculares, 18 (11,1%) eventos vasculares en extremidades inferiores y 9 (5,9%) muertes tardías durante el seguimiento (media de 18,2 [8] meses). La hipertensión arterial fue el único predictor de eventos coronarios o cerebrovasculares (p=0,013); la cardiopatía y el colesterol HDL<45mg/dL se asociaron de forma independiente a eventos vasculares de extremidades inferiores (p=0,021 y 0,049), y la VSG>20mm/h a mortalidad (p=0,008). Conclusiones: Las cifras reducidas de colesterol HDL y elevadas de VSG han resultado factores de riesgo independientes para eventos vasculares periféricos y mortalidad a corto plazo (AU)

Background and objective: To analyse clinical and serological variables (lipid profile, inflammatory biomarkers) as potential risk factors for the development of short-term cardiovascular events and mortality in patients suffering from intermittent claudication. Patients and methods: We included all patients with a first-time diagnosis of vascular intermittent claudication in our center during 2005-2006. We analysed clinical data, serological parameters (creatinine, total cholesterol, LDL-cholesterol, HDL-cholesterol, ApolipoproteinA1, ApolipoproteinB100, lipoprotein(a), homocysteine, C-reactive protein, erythrocyte sedimentation rate [ESR], fibrinogen), cardiovascular events and mortality during 1-3 year follow-up.Results: We included 162 patients: 143 (88.3%) men, mean (SD) age 66 (10.4) (41-86) years, 76 (46.9%) active smokers, 96 (59.3%) hypertensive, 56 (34.6%) diabetic, 129 (79.6%) hypercholesterolemic. We registered 16 (9.9%) coronary/cerebrovascular events, 18 (11.1%) lower limb vascular events and 9 (5.9%) late deaths during follow-up (mean [SD] 18.2 [8] months). Hypertension was the only predictor of coronary or cerebrovascular events (p=0.013); heart disease and HDL-cholesterol<45mg/dL were independent risk factors for lower limb vascular events (p=0.021 and 0.049), and ESR>20mm/h was associated with all-cause death (p=0.008). Conclusions: Reduced HDL-cholesterol and elevated ESR have emerged as independent risk factors for short-term lower limb vascular events and death

[Prognostic value of inflammatory markers and lipid profile in patients suffering from intermittent claudication - a pilot study]. / Valor pronóstico de marcadores inflamatorios y perfil lipídico en pacientes con claudicación intermitente. Estudio piloto.

BACKGROUND AND OBJECTIVE: To analyse clinical and serological variables (lipid profile, inflammatory biomarkers) as potential risk factors for the development of short-term cardiovascular events and mortality in patients suffering from intermittent claudication. PATIENTS AND METHODS: We included all patients with a first-time diagnosis of vascular intermittent claudication in our center during 2005-2006. We analysed clinical data, serological parameters (creatinine, total cholesterol, LDL-cholesterol, HDL-cholesterol, ApolipoproteinA1, ApolipoproteinB100, lipoprotein(a), homocysteine, C-reactive protein, erythrocyte sedimentation rate [ESR], fibrinogen), cardiovascular events and mortality during 1-3 year follow-up. RESULTS: We included 162 patients: 143 (88.3%) men, mean (SD) age 66 (10.4) (41-86) years, 76 (46.9%) active smokers, 96 (59.3%) hypertensive, 56 (34.6%) diabetic, 129 (79.6%) hypercholesterolemic. We registered 16 (9.9%) coronary/cerebrovascular events, 18 (11.1%) lower limb vascular events and 9 (5.9%) late deaths during follow-up (mean [SD] 18.2 [8] months). Hypertension was the only predictor of coronary or cerebrovascular events (p=0.013); heart disease and HDL-cholesterol<45 mg/dL were independent risk factors for lower limb vascular events (p=0.021 and 0.049), and ESR>20 mm/h was associated with all-cause death (p=0.008). CONCLUSIONS: Reduced HDL-cholesterol and elevated ESR have emerged as independent risk factors for short-term lower limb vascular events and death.