Síndrome de Pickering: insuficiencia cardiaca aguda con un actor inesperado / Pickering syndrome: acute heart failure with an unexpected actor

El síndrome de Pickering es una entidad clínica descrita en 1988 que consiste en la presentación de edemas agudos de pulmón «flash» recurrentes y de predominio nocturno e hipertensión arterial secundarios a estenosis bilateral de las arterias renales o unilateral en pacientes monorrenos. Describimos el caso de un varón de 74 años que tras el tratamiento percutáneo de exclusión de un aneurisma aórtico infrarrenal presentó síndrome de Pickering debido a obstrucción hemodinámica de la arteria renal izquierda por la endoprótesis aórtica; con evolución clínica satisfactoria después de la revascularización. (AU)

Pickering's syndrome is a clinical entity described in 1988 that consists of the presentation of recurrent and predominantly nocturnal acute flash pulmonary oedema and arterial hypertension secondary to bilateral renal artery stenosis or unilateral in single-kidney patients. We describe the case of a 74-year-old man who, after percutaneous exclusion treatment of an aortic infrarenal aneurysm, developed Pickering syndrome due to haemodynamic obstruction of the left renal artery because of the aortic endoprosthesis; with satisfactory clinical evolution after revascularization. (AU)

[Pickering syndrome: acute heart failure with an unexpected actor]. / Síndrome de Pickering: insuficiencia cardiaca aguda con un actor inesperado.

Pickering's syndrome is a clinical entity described in 1988 that consists of the presentation of recurrent and predominantly nocturnal acute flash pulmonary oedema and arterial hypertension secondary to bilateral renal artery stenosis or unilateral in single-kidney patients. We describe the case of a 74-year-old man who, after percutaneous exclusion treatment of an aortic infrarenal aneurysm, developed Pickering syndrome due to haemodynamic obstruction of the left renal artery because of the aortic endoprosthesis; with satisfactory clinical evolution after revascularization.

Desensitization Protocol in Recipients of Deceased Kidney Donor With Donor-Specific Antibody-Low Titers.

BACKGROUND: Kidney transplantation is the better option for end-stage renal disease (ESRD), but for patients with human leukocyte antigen (HLA) sensitization, the wait times are significantly longer than for patients without antibodies. Many desensitization protocols have been described involving strong immunosuppression, the use of apheresis, and B-cell-modulating therapies. We have designed a desensitization protocol from day 0 for deceased donor kidney transplantation. Our aim was to present our initial experience with five kidney transplant patients. METHODS: All patients had a negative complement-dependent cytotoxicity cross-match. The desensitization protocol included five to seven doses of thymoglobulin (1.25 mg/kg) and three sessions of plasmapheresis (PP) within the first week after transplantation, with intravenous immunoglobulin (500 mg/kg) after each PP session and one dose of rituximab on day 8. The presence of donor-specific antibodies (DSA) was analyzed by use of Luminex technology; levels between 1000 and 3000 mean fluorescence intensity were considered for desensitization. RESULTS: The median age was 44 years and median renal replacement therapy time was 9 years. All recipients presented 1 to 3 DSA specificities. There were no severe side effects related to PP, infusion of intravenous immunoglobulin, or rituximab. The median follow-up period was 19.3 months. Median serum creatinine level at last follow-up was 1.7 mg/dL. A kidney biopsy was performed in all patients. Graft and patient survival was 100%. CONCLUSIONS: Until now, few data are available concerning whether HLA-incompatible kidney transplantation after desensitization would benefit patients with ERSD. The desensitization strategy using the combination of PP, low doses of intravenous immunoglobulin, and rituximab at our center resulted in a satisfactory clinical outcome.

Assessment of Corneal Epithelial Thickness in Asymmetric Keratoconic Eyes and Normal Eyes Using Fourier Domain Optical Coherence Tomography.

Purpose. To compare the characteristics of asymmetric keratoconic eyes and normal eyes by Fourier domain optical coherence tomography (OCT) corneal mapping. Methods. Retrospective corneal and epithelial thickness OCT data for 74 patients were compared in three groups of eyes: keratoconic (n = 22) and normal fellow eyes (n = 22) in patients with asymmetric keratoconus and normal eyes (n = 104) in healthy subjects. Areas under the curve (AUC) of receiver operator characteristic (ROC) curves for each variable were compared across groups to indicate their discrimination capacity. Results. Three variables were found to differ significantly between fellow eyes and normal eyes (all p < 0.05): minimum corneal thickness, thinnest corneal point, and central corneal thickness. These variables combined showed a high discrimination power to differentiate fellow eyes from normal eyes indicated by an AUC of 0.840 (95% CI: 0.762-0.918). Conclusions. Our findings indicate that topographically normal fellow eyes in patients with very asymmetric keratoconus differ from the eyes of healthy individuals in terms of their corneal epithelial and pachymetry maps. This type of information could be useful for an early diagnosis of keratoconus in topographically normal eyes.

Trasplante renal en bloque de donantes pediátricos en receptores adultos: un reto quirúrgico / Pediatric en bloc kidney transplantation to adult recipients: a surgical challenge

Introducción: Aportar y analizar los resultados de nuestra experiencia quirúrgica en 19 casos de trasplante renal en adulto utilizando injertos en bloque de donantes pediátricos. Material y método: Entre noviembre de 1996 y agosto de 2011 se han realizado en nuestro servicio 647 trasplantes renales en adultos, utilizando en 19 ocasiones (2,9%) injertos en bloque de donantes pediátricos. La media de edad de los donantes fue de 17,6 meses (intervalo: 5 días-48 meses). La media de edad de los receptores fue de 41,3 años (intervalo: 19-59 años). El peso medio de los donantes fue de 10,6 kg (intervalo: 3,5-23 kg) y el de los receptores fue de 63,6 kg (intervalo: 43-93 kg). Se valoró la función renal (creatinina sérica y aclaramiento de creatinina) en el postoperatorio inmediato y durante el seguimiento, así como la incidencia de complicaciones vasculares y su resolución. Resultados: La mediana del seguimiento fue de 22 meses (media: 34,9 meses; intervalo: 1-141 meses), siendo funcionantes 17 de los 19 injertos con creatinina dentro de la normalidad en 13 de los casos. Hubo complicaciones vasculares en 5 casos (26,3%), de los que solo 2 precisaron trasplantectomía precoz y 3 se resolvieron mediante angioplastia simple con mejoría morfológica y de la función renal. Conclusiones: Los trasplantes renales en bloque pediátrico suponen una alternativa válida en el trasplante renal del adulto, pero presentan mayores tasas de complicaciones vasculares postimplante. Una selección correcta de los donantes, una técnica vascular depurada y un tratamiento intensivo mediante angioplastia simple permite resolverlas en la mayoría de los casos (AU)

Introduction: To evaluate the outcome of our surgical experience in 19 cadaveric kidneys from pediatric donors, transplanted en bloc into adults recipients. Material and method: From November 1996 to August 2011, we have performed 647 adult renal transplantations, using pediatric en bloc grafts in 19 cases (2.9%). The mean age of donors was 17.6 months (range: 5 days to 48 months). The mean age of recipients was 41.3 years (range: 19-59 years). The mean weight of donors was 10.6 kg (range: 3.5-23 kg) and the mean weight of recipients was 63.6 kg (range: 43-93 kg). We evaluated the renal function (serum creatinine and creatinine clearance) in the immediate postoperative period and during the follow-up, as well as the incidence of vascular complications and their resolution. Results: The median follow-up was 22 months (mean: 34.9 months; range: 1-141 months). At the end of follow-up, 17 of the 19 grafts were functioning, with creatinine at normal levels in 13 of them. There were vascular complications in five cases (26.3%), only two cases required early transplantectomy, and the other three cases were resolved by renal or aortic graft angioplasty with morphological and renal function improvement. Conclusions: Pediatric en bloc kidneys are a valid alternative in adult renal transplantation, but show higher rates of vascular complications. A correct selection of donors, a correct vascular technique, an intensive treatment through simple angioplasty enable them to be resolved in most of the cases (AU)

Pretransplant donor-specific HLA antibodies detected by single antigen bead flow cytometry: risk factors and outcomes after kidney transplantation.

BACKGROUND: The clinical significance of pretransplant donor-specific antibodies (pre-Tx DSAs) detected by single antigen bead flow cytometry (SAB-FC) remains unclear. Our aim was to investigate the impact that pre-Tx DSAs detected by SAB-FC have on the early and late clinical outcomes. PATIENTS AND METHODS: We retrospectively tested stored frozen pre-Tx sera from 222 deceased-donor kidney transplants performed between November 1997 and November 2006. All patients had a negative complement-dependent cytotoxicity (CDC) cross-match with the donor. Median follow up was 5.1 years. RESULTS: Twenty-two (10%) patients had pre-Tx HLA antibodies detected by CDC. Pre-Tx HLA antibodies were detected using SAB-FC in the sera of 46 (20.7%) patients; 36 (16.2%) of them presented pre-Tx DSAs, 18 had class I antibodies, 9 class II, and 9 patients presented both classes. Mean pre-Tx DSA class I/II was 2360/1972 (MFI) mean fluorescence index in non CDC-sensitized patients. Pre-Tx DSAs were associated with female sex, retransplants, and pretransplant transfusions. Patients with Pre-Tx DSAs more than 1000 MFI and negative CDC screening presented a higher percentage of delayed graft function (61.1% versus 38.9%), more episodes of acute vascular rejection (33.3% versus 13.7%), and chronic rejection as the cause of allograft failure (22.2% versus 9.7%) compared with non-pre-Tx DSAs patients. Five-year allograft survival was significantly worse in patients with pre-Tx DSA (68.5% versus 82%, P = .006) and in patients with pre-Tx DSA class II more than 1000 MFI (43% versus 82%, P = .009). We didn't find differences in patient survival. DISCUSSION: Pre-Tx DSAs detected by SAB-FC were more frequent in female recipients, and they were associated with acute vascular and chronic rejection and a poorer graft outcome.

Donor-specific HLA antibodies: risk factors and outcomes after kidney transplantation.

BACKGROUND: Anti-human leukocyte antigen antibodies (HLA Abs) have been associated with reduced kidney allograft survival. Our aim was to analyze the prevalence and impact on allograft function of donor-specific HLA antibodies (DSA) among a cohort of kidney transplant recipients. PATIENTS AND METHODS: The 321 recipients had received deceased-donor kidneys followed for a median of 70 ± 43 months. We performed a cross-sectional analysis of the presence of HLA Abs with the use of Luminex technology. RESULTS: Fifty patients (15.6%) displayed HLA Abs after transplantation including 21 (6.7%) as de novo HLA Abs. Eight patients (2.5%) developed DSA, and 42 (13%) showed no DSA. We compared 3 groups of patients: with DSA, without DSA, and without HLA sensitization. The DSA patients were younger (P = .03) with a higher percentage of men (P = .00), and having received less frequent induction treatment with basiliximab or thymoglobulin (P = .02). Patients without DSA revealed a higher percentage of pretransplantation HLA sensitization (P = .00), more pretransplantation transfusions (P = .08), and more frequent retransplantations (P = .00). The incidence of acute rejections was higher for DSA patients (P = .02) than for the other 2 groups, behaving as an independent risk factor (relative risk, 4.7; 95% confidence interval, 1.1-18.8; P = .03). Graft survival at 5 years was lower among patients with compared to those without HLA Abs (P = .00). CONCLUSIONS: HLA donor-specific sensitization, an uncommon situation in our study, was associated with younger male recipients and less induction treatment. An acute rejection episode was an independent risk factor for the development of DSA; therefore, we think that monitoring of HLA Abs should be included in evaluation of the early postransplantation period.

Delayed graft function after renal transplantation: an unresolved problem.

Unlike other areas in renal transplantation, delayed graft function (DGF) remains an apparently unavoidable complication owing to the characteristics of current donors. The aim of this study was to analyze risk factors for DGF in relation to graft and patient survivals. We retrospectively analyzed 507 renal transplant recipients with a median follow-up of 74.83 ± 45.06 months. DGF, which occurred among 189 patients (36.8%) was defined as requirement for dialysis within the first week after transplantation. Donor (P = .000) and recipient (P = .000) age were greater in the DGF group without differences in recipient or donor gender, HLA sensitization, or dialysis time before transplantation. Donor factors as the cause of death associated with DGF were secondary cerebrovascular stroke (P = .002) and hypertensive history (P = .000). Recipient characteristics associated therewith were higher body mass index (P = .000), smoking habit (P = .003), ischemic cardiopathy (P = .01), and dyslipidemia (P = .05). Moreover, the DGF group showed longer cold ischemia (P = .01) and vascular anastomosis (P = .02) times. On multivariate analysis, recipient age (P = .00) and smoking habit (P = .01) together with a donor history of hypertension (P = .02) were independent risk factors for DGF. No differences were observed in acute rejection incidence (P = .07) with worse renal function during follow-up (P < .05). Graft (81% vs 88%; P = .00) and patient (89% vs 95%; P = .00) survivals at 5 years were lower among the DGF group. In conclusion, DGF which was associated with factors related to the donor, the recipient, and the surgical times, produced worse graft and patient survivals. Shortening the cold ischemia time seems to be a modifiable variable to reduce DGF.

Vitamin D deficiency in a renal transplant population: safe repletion with moderate doses of calcidiol.

BACKGROUND: Deficits of vitamin D are a common finding in the general population, especially among patients with chronic kidney disease. However, there are not much data about its prevalence after renal transplantation. Our aim was to analyze the calcidiol status among a cohort of kidney transplant recipients, in a region of Spain with a high number of annual sunshine hours, as well as the effects of supplementation with oral calcidiol. PATIENTS AND METHODS: We included 110 kidney transplant recipients in a retrospective observational study. Measurements of 25-hydroxyvitamin D (25OHD), calcium, phosphate, intact parathyroid hormone (iPTH), serum creatinine and albumin, 24-hour microalbuminuria, and proteinuria were performed at the same time. Patients were classified based on their serum 25OHD levels: normal (>30 ng/mL); insufficiency (16-30 ng/mL); and deficiency (<16 ng/mL). In a second analysis, we included 63 patients with 25OHD<30 ng/mL with adjusted calcium levels below 10.2 mg/dL for treatment with oral calcidiol to approach target levels of 30 to 40 ng/mL. Mineral metabolism parameters were monitored at baseline as well as 6 and 12 months after beginning treatment. RESULTS: Insufficient or deficient 25OHD levels were present in 106/110 patients (96.3%); they were normal in just four patients (3.6%). Patients with calcidiol deficiency were older. We observed no differences in sex, posttransplant follow up, serum calcium, phosphate, iPTH, glomerular filtration rate, or 24- hour albuminuria or proteinuria. The 63 patients treated with oral calcidiol received a mean dose of 8044±4087 IU/wk at baseline. The 61.3% of them with deficient 25OHD levels at baseline decreased to 2.1% at 6 months and 7.5% at 12 months after treatment. No significant changes in calcium, phosphate or iPTH were observed during the treatment. CONCLUSIONS: Deficits of 25 OHD was frequent after renal transplantation but improved safely with moderate doses of oral calcidiol without negative secondary effects.

Genetic polymorphisms and individualized tacrolimus dosing.

BACKGROUND: Genetic polymorphisms of metabolism enzymes or intestinal drug transporters may affect pharmacokinetic responses to immunosuppressive drugs in renal transplant recipients. We sought to identify the frequency of genetic polymorphisms and their importance for individualization of tacrolimus doses. PATIENTS AND METHODS: We performed an observational study in 35 renal transplant recipients treated with tacrolimus, mycophenolate mofetil, and corticosteroids. Tacrolimus concentrations were determined by immunoanalysis (IMx method; Abbott Diagnostics, Abbott Park, Ill), on 11 blood samples per patient during the first 6 weeks after renal transplantation. For each patient, we calculated the mean value and its standard error (SEM) of the concentration/dose ratio (ng/mL/mg) of tacrolimus. The pharmacogenetic analysis included single nucleotide polymorphisms (SNPs) in the CYP3A5 (CYP3A5*3 (A6986G), CYP3A5*6 (G14690A), MDR1 (C3435T and G2677T/A) and PXR (C-25385T) genes. RESULTS: Of the patients, 62.8% (n=22) were men and the overall mean age was 55 years (95% confidence interval, 48.7-62.7). The SNP distribution was: CYP3A5*3: G/G=82.9%, A/G=17.1%; CYP3A5*6: G/G=88.6%, G/A=11.4%; MDR1 C3435T: C/C=25.7%, C/T=62.9%, T/T=11.4%; for MDR1 G2677T/A: G/G=22.9%, G/T=65.7%, T/T=11.4% and for PXR: C/T=85.7%, T/T=14.3%. Tacrolimus concentration/dose ratios in heterozygote patients for CYP3A5*3 genotypes was >120% lower than for the homozygote CYP3A5*3 genotype (0.65±0.04 vs 1.45±0.05; P<.0001). Wild-type MDR1 (3435 C/C) genotype patients showed up to 40% lower concentration/dose ratios compared with heterozygote and homozygote genotypes (C/C; 1±0.07 vs C/T; 1.4±0.06 vs T/T; 1.37±0.09; P<.0001). CONCLUSION: Intestinal absorption and metabolism of tacrolimus was significantly affected by the SNPs in the CYP3A5 and MDR1 genes, which may offer a useful tool to optimize tacrolimus dosing after renal transplantation.

Cambios inducidos por la enfermedad renal crónica en los pacientes con diabetes / Induced changes by chronic kidney disease in patients with diabetes

La nefropatía diabética afecta al 25-40% de los pacientes diabéticos y es unmarcador de morbimortalidad. Las complicaciones relacionadas con la insuficienciarenal presentes en estos pacientes se hacen más relevantes a medidaque disminuye el filtrado glomerular. La enfermedad cardiovascular es la complicacióncon más relevancia pronóstica. Ésta incluye la enfermedad coronaria,la hipertensión arterial, la hipertrofia ventricular izquierda, la insuficiencia cardiaca,las arritmias y la pericarditis. Otras complicaciones derivadas de la afectaciónrenal influirán en el pronóstico y evolución del paciente con diabetes,como la anemia, las complicaciones hemorrágicas, los fenómenos trombóticos,las alteraciones en la respuesta inmunitaria y la susceptibilidad a las infecciones.Todas las complicaciones presentes en el paciente con nefropatía diabéticaobligan a un abordaje multifactorial que incluye, en primer lugar, laprevención de la aparición/progresión de las complicaciones mediante el controlde los factores de riesgo de desarrollo de macroangiopatía y microangiopatía:control de la glucemia y de la hipertensión arterial, reducción de la proteinuria,evitación del tabaquismo, mantenimiento del peso ideal, reducción dela ingestión de sal y tratamiento con antiagregantes y estatinas, así como prevenirla nefrotoxicidad(AU)

Diabetic nephropathy affects about 25-40% of diabetic patients and is a markerof morbimortality. Complications related to kidney failure in these patientsbecome even more relevant with decreasing glomerular filtration rate.Cardiovascular disease is the most relevant complication, which include coronarydisease, arterial hypertension, left ventricular hypertrophy, congestive cardiacinsufficiency, arrhythmias and pericarditis. Other related renal complicationswill influence the prognosis and evolution of diabetic patients such asanemia, hemorrhagic complications, thrombotic phenomena, alterations of immune response and susceptibility to infections. All these complications, which are present in the patient with diabetic nephropathy, force towards a multifactor approach, which includes firstly the prevention of the appearance/progression of the complications through a control of the risk factors for macro and microangiopathyas glycemic and blood pressure control, proteinuria reduction,avoiding nicotine abuse, keeping closed to the ideal weight, salt intake reduction,antiaggregant treatment and statins therapy, as well as preventing additional renal toxicity(AU)

Hemodiálisis en pacientes con diabetes: indicaciones, ventajas y posibles complicaciones / Haemodialysis in diabetic patients: indications, advantages and possible complications

El número de pacientes diabéticos que inician diálisis está aumentando en todo el mundo, hasta llegar a constituir una verdadera epidemia. Estos pacientes presentan diferencias significativas con el resto de pacientes en diálisis en cuanto a sus características demográficas, complicaciones, comorbilidades y objetivos de tratamiento. Necesitan un manejo especial en la mayoría de áreas de la hemodiálisis como son las pautas de diálisis, el acceso vascular o el control de la diabetes, así como de la anemia, la vasculopatía y la retinopatía que suelen tener asociadas estos pacientes. En este trabajo hacemos un repaso de las indicaciones del tratamiento dialítico, el momento más idóneo para iniciarlo, el manejo de las complicaciones y comorbilidades, y el control de la diabetes en este tipo de pacientes(AU)

The number of diabetic patients starting dialysis is increasing in the world, evolving to a true epidemic. These patients showed significant differences with the rest of dialysis patients in their demographic characteristics, complications, comorbidities and treatment goals. They need special handling in most areas of haemodialysis such as dialysis modalities, vascular access, control of diabetes and anaemia, vascular disease and retinopathy, which often are associated to these patients. In this paper we review dialysis indications, when to start dialysis, management of complications and comorbidities and metabolic control of these patients(AU)

[Strongyloides stercoralis infection in renal transplant recipients]. / Infección por Strongyloides stercoralis en pacientes trasplantados renales.

We present two cases of strongyloides stercoralis infection in renal transplant recipients in our centre. We describe clinical presentation characteristics, treatment and resolution.

Infección por Strongyloides stercoralis en pacientes trasplantados renales / No disponible

Presentamos dos casos de infección por Strongyloides stercoralis (S. stercoralis) en pacientes trasplantados renales en nuestro centro. Se describen las características de su presentación clínica, el tratamiento y la resolución del mismo (AU)

We present two cases of Strongyloides stercoral is infection in renal transplant recipients in our centre. We describe clinical presentation characteristics ,treatment and resolution (AU)

Very low-grade proteinuria at 3 months posttransplantation is an earlier marker of graft survival.

Proteinuria is an early finding that appears in the first 3 months after transplantation in half of patients. Frequently, it is very low grade (VLP; <0.5 g/24 h). The aim of this study was to analyze the risk factors and prognostic significance of VLP at 3 months posttransplantation, which was maintained for the first year among our renal recipients. We compared 141 patients (39.7%) who showed VLP with 214 patients (60.3%) without proteinuria. VLP was associated with older recipients (P = .002), HLA incompatibilities (P = .001), older donors (P = .000), nontraumatic cause of brain death (P = .033) and previous hypertension (P = .030), tacrolimus (P = .000) and induction treatment with Thymoglobulin (P = .018) or anti-CD25 monoclonal antibodies (P = .000), as well as delayed graft function (DGF; P = .000). VLP patients showed worse renal function (P < .05) and greater requirement for antihypertensive drugs (P = .001). Multivariate analysis confirmed the impact of donor age, HLA incompatibilities, DGF, and tacrolimus treatment to predict the presence of VLP. Graft (P = .0019) and patient (P = .0146) survivals were lower among the VLP group. Cox analysis showed that VLP (RR: 2.047; P = .018) and DGF (RR: 2.062; P = .0017) were independently associated with reduced graft survival. The positive predictive value of VLP on graft survival was low. In conclusion, VLP was related to increasing acceptance of marginal donors, DGF, and worse renal function. Proteinuria was a noninvasive, readily determined parameter which was related to reduced graft and patient survivals, so renoprotective measures are mandatory from the early stages after transplantation.

Use of basiliximab induction in low-immunological risk renal transplant recipients receiving tacrolimus-based immunosuppression.

Basiliximab induction treatment has been shown to reduce the incidence of acute rejection episodes without the secondary side effects observed with antilymphocyte polyclonal antibodies. We analyzed our experience with basiliximab induction associated with tacrolimus-based immunosuppression among low-immunological risk renal transplant recipients. We retrospectively analyzed 55 renal transplantation patients of low inmunological risk who received organs from donors younger than 55 years. We compared a group of 21 patients (38.9%; group 1) treated with basiliximab (Simulect, Novartis, Basel, Switzerland) with 33 patients (61.1%; group 2) without induction. The patient groups did not differ in recipient age (46.39 +/- 11.1 in group 1 vs 41.82 +/- 11.02 years in group 2; P = .25), donor age (36.71 +/- 14.72 vs 35.09 +/- 14.63 years; P = .69), or recipient and donor gender. No differences were observed in dose or tacrolimus levels during follow-up. The incidences of delayed graft function (DGF; 28.6% vs 28.1%; P = .97) and of acute rejection episodes (9.5% vs 15.6%; P = .52) were similar in both groups. Serum creatinine and proteinuria levels (P > .05) and hospital admissions due to infections (36.4 vs 35.7%; P = .97) were also similar in both groups. At 1 year graft survival rates were 92% and 96% (P = .97) in groups 1 and 2, respectively. Considering our findings and the costs of basiliximab treatment, we conclude that routine administration of basiliximab cannot be justified in young, low-immunological risk transplant recipients undergoing tacrolimus-based immunosuppression.

Induction treatment with low-dose thymoglobulin or basiliximab in renal transplants from older donors.

Transplantation of kidneys from older donors is followed by an increase in delayed graft function (DGF) and acute rejection episodes (ARE). In these circumstances, induction treatment, whether with antithymocyte globulin or with interleukin-2 receptor blockers, may delay the introduction of calcineurin inhibitors (CNI) with effective prevention of ARE. We examined the efficacy and safety of induction treatment with 2 low doses of thymoglobulin compared with 2 doses of basiliximab. A group of 27 patients were treated with thymoglobulin and another 36 with basiliximab. CNI introduction was delayed until day 3 posttransplantation. The thymoglobulin group received 2 doses of 1.25 mg/kg on alternate days and the basiliximab group 2 doses of 20 mg. A trend to a lower incidence of DGF was observed in the thymoglobulin group (33% vs 55.6%; P = .08), with lower levels of serum creatinine on days 7 (P = .02) and 14 (P = .02) posttransplantation. No patient in the thymoglobulin group experienced ARE, but 11 patients (30.6%) in the basiliximab group did (P < .001), and 5 needed rescue treatment with thymoglobulin. We found no differences in the incidence of cytomegalovirus (CMV) disease (P = .945), admission due to infections (P = .274), or neoplasia (P = .340), or differences in graft (P = .69) and patient (P = .21) survivals at 1 and 3 years. Low-dose thymoglobulin was more effective at preventing DGF and ARE in renal transplant recipients of organs from older donors, with no differences in infectious complications or graft and patient survivals.

Tratamiento de la hipertensión arterial en la diabetes mellitus / Treatment of hypertension in type 2 diabetes mellitus

La hipertensión arterial es una complicación con una prevalencia en la diabetes mellitus tipo 2 muy alta, y supone un factor de riesgo para el desarrollo de complicaciones cardiovasculares. El control estricto de la presión arterial hasta cifras menores de 130/80 mmHg reduce la morbimortalidad cardiovascular y renal en mayor grado que el control del resto de las complicaciones. Para conseguir este nivel se requieren, al menos, 2 o 3 fármacos en la mayoría de los pacientes. El tratamiento de la hipertensión arterial en el diabético se basa en la realización de medidas higienico dietéticas o cambios en el estilo de vida, tratamiento farmacológico y control del resto de los factores de riesgo cardiovascular. Para el tratamiento farmacológico, los fármacos de elección son los bloqueadores del sistema renina-angiotensina-aldosterona (inhibidoresde la enzima conversiva de la angiotensina y antagonistas de los receptores de la angiotensina II). En el siguiente escalón terapéutico se sitúan los diuréticos y antagonistas del calcio. Otros fármacos que se pueden utilizar son los bloqueadores beta, los bloqueadores alfa y los agentes de acción central. El conocimiento de la fisiopatología de la hipertensión arterial en la diabetes mellitus tipo 2, así como los distintos fármacos que utilizar, es importante para un tratamiento óptimo de estafrecuente complicación, con claros beneficios en la morbimortalidad de los diabéticos (AU)

Hypertension is a highly prevalent complication in patients with type 2 diabetes mellitus and is a major risk factor for the development of cardiovascular disease. Reducing blood pressure to less than 130/80mm Hg decreases cardiovascular and renal morbidity and mortality more than control of other associated complications. To obtain this blood pressure level, most patients need no less than 2 or 3antihypertensive drugs. Treatment of hypertension in diabetic patients includes lifestyle changes, as well as antihypertensive agents and control of other potential cardiovascular and renal risk factors. The first line pharmacologic treatment of hypertension includes angiotensin converting enzyme inhibitors and/or angiotensin II receptor blockers. The second step includes diuretics and calcium channel blockers. Other useful drugs are beta blockers, alpha-blockers and central alpha agonists. Knowledge of the physiopathology of hypertension in type 2 diabetic patients, and of the mechanisms of action of the different antihypertensive drugs allows appropriate treatment of this frequent complication in diabetic patients, with well-established beneficial effects on morbidity and mortality (AU)

Effect of albumin and polyvinyl alcohol on the vitality, motility and acrosomal integrity of canine spermatozoa incubated in vitro.

Sperm culture media used for in vitro fertilization (IVF) procedures are important factors concerning the viability, motility and acrosomal integrity of spermatozoa. The aim of this study was to investigate the effects of three different sperm diluting media, tissue culture medium (TCM-199), sperm culture medium (Sp-TALP) and human tubular fluid (HTF) supplemented with varying concentrations of bovine serum albumin (1, 4 and 6%) or polyvinyl alcohol (0.8%) on the acrosomal integrity, motility and viability of canine spermatozoa. Ejaculates collected from four dogs were diluted in all media and spermatozoa were separated from seminal plasma by the swim-up technique. Sperm progressive motility was assessed using a phase contrast microscope. Viability and acrosomal integrity were evaluated using a dual stain technique (Giemsa-Trypan blue). The results demonstrated that the number of live canine spermatozoa was similar in culture media supplemented or not supplemented with macromolecules. A minimal concentration of albumin (1%) in the three media showed similar effects on vitality, motility and acrosomal integrity, as had higher concentrations (4 and 6%). The percentage of acrosome-intact spermatozoa was markedly higher after HTF (94.1%) than after TCM-199 (70.1%) or Sp-TALP (71.0%) without supplementation. It is concluded that serum bovine albumin, irrespective of the concentration, preserved sperm viability and function, and HTF is the most suitable medium for preserving the acrosome in canine spermatozoa prepared for in vitro manipulation through short incubation.