[Intensive care to facilitate organ donation. ONT-SEMICYUC recommendations]. / Cuidados intensivos orientados a la donación de órganos. Recomendaciones ONT-SEMICYUC.

Intensive care to facilitate organ donation (ICOD) is defined as the initiation or continuation of life-sustaining measures, such as mechanical ventilation, in patients with a devastating brain injury with high probability of evolving to brain death and in whom curative treatment has been completely dismissed and considered futile. ICOD incorporates the option to organ donation allowing a holistic approach to end-of-life care, consistent with the patients wills and values. Should the patient not evolve to brain death, life-supportive treatment must be withdrawal and controlled asystolia donation could be evaluated. ICOD is a legitimate practice, within the ethical and legal regulations that contributes increasing the accessibility of patients to transplantation, promoting health by increasing deceased donation by 24%, and with a mean of 2.3 organs transplanted per donor, and collaborating with the sustainability of health-care system. This ONT-SEMICYUC recommendations provide a guide to facilitate an ICOD harmonized practice in spanish ICUs.

Suture pattern does not influence outcomes of endoscopic sleeve gastroplasty in obese patients.

Background and study aims ESG is an effective and safe medium-term procedure for obesity treatment. A variety of suture patterns have been reported. We aimed to compare whether there are differences in efficacy depending on suture pattern used. Patients and methods Retrospective and comparative review of 5 years of prospectively collected data, including consecutive obese patients undergoing ESG at two collaborative centers. Primary outcomes included weight loss (mainly % total body weight loss [TBWL] and % exces weight loss [EWL]) at 12 months and safety profile. We compared them according to three suture patterns (transverse bilinear [TBp], longitudinal [Lp] and transverse monolinear [TMp]), and number of sutures (4 - 7) and stitches (< 25, 25 to 30 and > 30) applied. Evolution of major obesity-associated morbidities (hypertension, dyslipidemia, Type 2 diabetes mellitus (T2DM), sleep obstructive apnea syndrome, and arthropathy) were also described. Results 88 patients (mean age 46.1±12.3 years, 69.3 % female) underwent ESG. Mean body mass index (BMI) at baseline was 39.40 ±â€Š4.69 kg/m². At 1 year, %TBWL was 17.36 ±â€Š6.09 % (%EWL 46.41±20.6 %) with TBWL > 10 % in 95.5 % of patients (EWL > 25 % in 94.3 % of patients). According to pattern, there were no differences in %TBWL but there were in %EWL (43.7 ±â€Š20.4 %, 59.8 ±â€Š18.9 % and 45.4 ±â€Š14.9 % in TBp, Lp and TMp patterns, respectively) ( P  = 0.034). No differences were found related to number of sutures (mean 5.2 ±â€Š0.73, r = 4 - 7) or stitches (mean 27.4 ±â€Š6.50, r = 18 - 50) applied. Forty-three of 72 (59.7 %) major comorbidities were resolved. No serious adverse events were observed with any pattern. Conclusions ESG is an effective procedure at 12-month follow-up for weight loss and comorbidity resolution. All three analyzed patterns are safe and effective without differences in %TBWL, but there was a slight increase in %EWL in Lp, regardless of the number of sutures or stitches applied.

Rehabilitación tras rotura completa de los músculos isquiotibiales: a propósito de un caso / Rehabilitation after total rupture of the hamstrings: apropos of a case

Las lesiones de los músculos isquiotibiales ocurren más frecuentemente en actividades en las que se combinan la contracción excéntrica y velocidad. Su biomecánica es compleja debido a su condición biarticular que hace que participen en la estabilización de la pelvis, rodilla de forma individual y de ambas articulaciones durante la marcha. Su lesión puede ir de una simple distensión (que conlleva un buen pronóstico de recuperación a corto plazo) a una rotura total de la inserción proximal (asociada más frecuentemente a una recuperación más compleja). Presentamos el caso clínico de una rotura total de la inserción proximal de los isquiotibiales con recidiva a las dos semanas y realizamos una revisión de la literatura (AU)

Hamstring injuries occur more frequently in activities combining eccentric contraction and speed. The biomechanics of these injuries are complex due to their bi-articular status, as the hamstrings are involved in the stabilization of the pelvis, knee individually, and both joints during gait. Hamstring injuries can range from a simple strain (which has a good prognosis for recovery in the short term) to total rupture of the proximal insertion (most frequently associated with more complex recovery). We present the clinical case of a total rupture of the proximal insertion of the hamstring that relapsed within two weeks and provide a review of the literature (AU)

Prácticas clínicas al final de la vida en pacientes con daño cerebral catastrófico en España: implicaciones para la donación de órganos / End-of-life practices in patients with devastating brain injury in Spain: implications for organ donation

OBJETIVO: Describir las prácticas clínicas al final de la vida relevantes para la donación de órganos en pacientes con daño cerebral catastrófico en España. DISEÑO: Estudio multicéntrico prospectivo de una cohorte retrospectiva. Periodo: 1 de noviembre de 2014 al 30 de abril de 2015. Ámbito: Sesenta y ocho hospitales autorizados para donación. PACIENTES: Pacientes fallecidos por daño cerebral catastrófico (posibles donantes). Edad: 1 mes-85 años. Variables de interés principales: Cuidado recibido, donación en muerte encefálica, donación en asistolia controlada, intubación/ventilación, notificación al coordinador de trasplantes. RESULTADOS: Se identificaron 1.970 posibles donantes. La mitad recibió tratamiento activo en una Unidad de Críticos (UC) hasta evolucionar a muerte encefálica (27%), sufrir una parada cardiorrespiratoria (5%), o hasta la limitación de tratamiento de soporte vital (19%). Del resto, un 10% ingresó en una UC para facilitar la donación y el 39% nunca ingresó en una UC. De los pacientes que evolucionaron a muerte encefálica (n=695), la mayoría derivaron en una donación eficaz (n=446; 64%). De los pacientes fallecidos tras limitación de tratamiento de soporte vital (n=537), 45 (8%) se convirtieron en donantes en asistolia eficaces. La ausencia de un programa de donación en asistolia controlada fue el motivo más frecuente de no donación. El 37% de los posibles donantes falleció sin intubar/ventilar, fundamentalmente porque el profesional responsable no consideró la donación tras descartar intubación terapéutica. El 36% de los posibles donantes no fue notificado al coordinador de trasplantes. CONCLUSIONES: Aunque el proceso de donación está optimizado en España, existen oportunidades para la mejora en la detección de posibles donantes fuera de UC y en la consideración de la donación en asistolia controlada en pacientes fallecidos tras limitación de tratamiento de soporte vital

OBJECTIVE: To describe end-of-life care practices relevant to organ donation in patients with devastating brain injury in Spain. DESIGN: A multicenter prospective study of a retrospective cohort. Period: 1 November 2014 to 30 April 2015. SETTING: Sixty-eight hospitals authorized for organ procurement. PATIENTS: Patients dying from devastating brain injury (possible donors). Age: 1 month-85 years. Primary endpoints: Type of care, donation after brain death, donation after circulatory death, intubation/ventilation, referral to the donor coordinator. RESULTS: A total of 1,970 possible donors were identified, of which half received active treatment in an Intensive Care Unit (ICU) until brain death (27%), cardiac arrest (5%) or the withdrawal of life-sustaining therapy (19%). Of the rest, 10% were admitted to the ICU to facilitate organ donation, while 39% were not admitted to the ICU. Of those patients who evolved to a brain death condition (n=695), most transitioned to actual donation (n=446; 64%). Of those who died following the withdrawal of life-sustaining therapy (n=537), 45 (8%) were converted into actual donation after circulatory death donors. The lack of a dedicated donation after circulatory death program was the main reason for non-donation. Thirty-seven percent of the possible donors were not intubated/ventilated at death, mainly because the professional in charge did not consider donation alter discarding therapeutic intubation. Thirty-six percent of the possible donors were never referred to the donor coordinator. CONCLUSIONS: Although deceased donation is optimized in Spain, there are still opportunities for improvement in the identification of possible donors outside the ICU and in the consideration of donation after circulatory death in patients who die following the withdrawal of life-sustaining therapy

How Spain Reached 40 Deceased Organ Donors per Million Population.

With 40 donors and more than 100 transplant procedures per million population in 2015, Spain holds a privileged position worldwide in providing transplant services to its patient population. The Spanish success derives from a specific organizational approach to ensure the systematic identification of opportunities for organ donation and their transition to actual donation and to promote public support for the donation of organs after death. The Spanish results are to be highlighted in the context of the dramatic decline in the incidence of brain death and the changes in end-of-life care practices in the country since the beginning of the century. This prompted the system to conceive the 40 donors per million population plan, with three specific objectives: (i) promoting the identification and early referral of possible organ donors from outside of the intensive care unit to consider elective non-therapeutic intensive care and incorporate the option of organ donation into end-of-life care; (ii) facilitating the use of organs from expanded criteria and non-standard risk donors; and (iii) developing the framework for the practice of donation after circulatory death. This article describes the actions undertaken and their impact on donation and transplantation activities.

End-of-life practices in patients with devastating brain injury in Spain: implications for organ donation. / Prácticas clínicas al final de la vida en pacientes con daño cerebral catastrófico en España: implicaciones para la donación de órganos.

OBJECTIVE: To describe end-of-life care practices relevant to organ donation in patients with devastating brain injury in Spain. DESIGN: A multicenter prospective study of a retrospective cohort. PERIOD: 1 November 2014 to 30 April 2015. SETTING: Sixty-eight hospitals authorized for organ procurement. PATIENTS: Patients dying from devastating brain injury (possible donors). Age: 1 month-85 years. PRIMARY ENDPOINTS: Type of care, donation after brain death, donation after circulatory death, intubation/ventilation, referral to the donor coordinator. RESULTS: A total of 1,970 possible donors were identified, of which half received active treatment in an Intensive Care Unit (ICU) until brain death (27%), cardiac arrest (5%) or the withdrawal of life-sustaining therapy (19%). Of the rest, 10% were admitted to the ICU to facilitate organ donation, while 39% were not admitted to the ICU. Of those patients who evolved to a brain death condition (n=695), most transitioned to actual donation (n=446; 64%). Of those who died following the withdrawal of life-sustaining therapy (n=537), 45 (8%) were converted into actual donation after circulatory death donors. The lack of a dedicated donation after circulatory death program was the main reason for non-donation. Thirty-seven percent of the possible donors were not intubated/ventilated at death, mainly because the professional in charge did not consider donation alter discarding therapeutic intubation. Thirty-six percent of the possible donors were never referred to the donor coordinator. CONCLUSIONS: Although deceased donation is optimized in Spain, there are still opportunities for improvement in the identification of possible donors outside the ICU and in the consideration of donation after circulatory death in patients who die following the withdrawal of life-sustaining therapy.

Donación en asistolia no controlada: necesidad, oportunidad y reto / Uncontrolled non-heart beating donation: need, opportunity and challenge

No disponible

Benchmarking in the process of donation after brain death: a methodology to identify best performer hospitals.

A benchmarking approach was developed in Spain to identify and spread critical success factors in the process of donation after brain death. This paper describes the methodology to identify the best performer hospitals in the period 2003-2007 with 106 hospitals throughout the country participating in the project. The process of donation after brain death was structured into three phases: referral of possible donors after brain death (DBD) to critical care units (CCUs) from outside units, management of possible DBDs within the CCUs and obtaining consent for organ donation. Indicators to assess performance in each phase were constructed and the factors influencing these indicators were studied to ensure that comparable groups of hospitals could be established. Availability of neurosurgery and CCU resources had a positive impact on the referral of possible DBDs to CCUs and those hospitals with fewer annual potential DBDs more frequently achieved 100% consent rates. Hospitals were grouped into each subprocess according to influencing factors. Hospitals with the best results were identified for each phase and hospital group. The subsequent study of their practices will lead to the identification of critical factors for success, which implemented in an adapted way should fortunately lead to increasing organ availability.

[Prevalence of cardiovascular disease in uraemia and relevance of cardiovascular risk factors]. / Prevalencia de enfermedad cardiovascular en la uremia y relevancia de los factores de riesgo cardiovascular.

AIM: To evaluate the prevalence of cardiovascular disease (CVD) and its association with cardiovascular risk factors, as well as their control in end-stage renal disease (ESRD) patients under maintenance hemodialysis (HD). PATIENTS AND METHODS: A total of 265 patients with ESRD on maintenance HD from a University Hospital and 4 dialysis units were included in this multicenter and cross-sectional study that analyzed the prevalence of CVD and the possible association with classic and new cardiovascular risk factors. Usual biochemical and haemathological parameters were analyzed, as well as plasma levels of homocysteine, troponin-I, BNP, lipoprotein(a), C reactive protein, IL-6, fibrinogen, asymmetrical dimethylarginine (ADMA), advanced oxidation protein products (AOPP), malondialdehyde, adiponectin, osteoprotegerin, and fetuin. In a subset of patients an echocardiography and carotid artery Doppler echography were also performed. RESULTS: The prevalence of CVD was 52.8%. Factors positively associated with prevalent CVD were age, BMI, left ventricular hypertrophy, hypertension, dyslipidemia and diabetes mellitus, dialysis vintage, Charlson s comorbility index, levels of fibrinogen, osteoprotegerin, BNP and CRP, as well as carotid intima-media thickness, left ventricular mass and pulse pressure. Factors negatively associated with prevalent CVD were: previous renal transplant, ejection fraction or levels of LDL-c and phosphorous. In the multivariate analysis dyslipidemia, left ventricular hypertrophy, age and LDL-c (negatively) were associated with CVD. CONCLUSIONS: In HD patients the prevalence of CVD is high and is associated with the presence of cardiovascular risk factors and subclinical CVD.

Prevalencia de enfermedad cardiovascular en la uremia y relevancia de los factores de riesgo cardiovascular / Prevalence of cardiovascular disease in uraemia and relevance of cardiovascular risk factors

Objetivo: Evaluar la prevalencia de ECV y su asociación con FRCV clásicos y nuevos, así como el control de los mismos en pacientes con IRCT en programa de HD. Pacientes y métodos: Se incluyeron 265 enfermos prevalentes con IRCT en HD de un hospital universitario y cuatro centros de diálisis. Estudio multicéntrico y transversal que analizó la prevalencia de ECVy su posible asociación con FRCV clásicos y nuevos. Se analizaron parámetros bioquímicos y hematológicos habituales, así como niveles de homocisteína, troponina-I, BNP, Lp(a), PCR,IL-6, fibrinógeno, ADMA, AOPP, malondialdehído, adiponectina, osteoprotegerina y fetuína. En un subgrupo de enfermos también se realizaron ecocardiografía y ecografía Doppler carotídea. Resultados: La prevalencia de ECV fue del52,8%. Los factores asociados positivamente a ECV prevalente fueron la edad, el índice de masa corporal, los antecedentes de HVI, la HTA, la dislipemia y la diabetes mellitus, el tiempo en diálisis, el índice de comorbilidad de Charlson, los niveles elevados de fibrinógeno, la osteoprotegerina, el BNPy la PCR, así como el grosor del complejo íntima-media carotídeo, la masa ventricular izquierda o la presión de pulso. Se asociaron negativamente: los antecedentes de trasplante previo, la fracción de eyección cardíaca y los niveles de cLDL ofósforo. En el análisis multivariante, los factores asociados con ECV fueron la dislipemia, la presencia de HVI, la edad y los niveles de cLDL (negativamente). Conclusiones: En los pacientes con IRCT en HD, la prevalencia de ECV es elevada y se asocia con la presencia de FRCV clásicos y ECV subclínica (AU)

Aim: To evaluate the prevalence of cardiovascular disease (CVD)and its association with cardiovascular risk factors, as well as their control in end-stage renal disease (ESRD) patients undermaintenance hemodialysis (HD). Patients and methods: A total of265 patients with ESRD on maintenance HD from a University Hospital and 4 dialysis units were included in this multicenter and cross-sectional study that analyzed the prevalence of CVD and the possible association with classic and new cardiovascular risk factors. Usual biochemical and haemathological parameters were analyzed, as well as plasma levels of homocysteine, troponin-I, BNP, lipoprotein(a), C reactive protein, IL-6,fibrinogen, asymmetrical dimethylarginine (ADMA), advanced oxidation protein products (AOPP), malondialdehyde,adiponectin, osteoprotegerin, and fetuin. In a subset of patients an echocardiography and carotid artery Doppler echography were also performed. Results: The prevalence of CVD was52.8%. Factors positively associated with prevalent CVD were age, BMI, left ventricular hypertrophy, hypertension, dyslipidemia and diabetes mellitus, dialysis vintage, Charlson´s comorbility index, levels of fibrinogen, osteoprotegerin, BNP and CRP, as well as carotid intima-media thickness, left ventricular mass and pulse pressure. Factors negatively associated with prevalent CVD were: previous renal transplant, ejection fraction or levels of LDL-c and phosphorous. In the multivariate analysis dyslipidemia, left ventricular hypertrophy, age and LDL-c (negatively) were associated with CVD. Conclusions: In HD patients the prevalence of CVD is high and is associated with the presence of cardiovascular risk factors and subclinical CVD (AU)

The 40 donors per million population plan: an action plan for improvement of organ donation and transplantation in Spain.

INTRODUCTION: Spain has been showing the highest rate of deceased donor organ recovery in the world for a whole country, namely, 33-35 donors per million population (pmp) during the last years. This activity is attributed to the so-called Spanish Model of organ donation, an integrated approach to improve organ donation since the start of the Organización Nacional de Trasplantes (ONT) in 1989. However, in 2007 there were 7/17 regions with >40 donors pmp and a marked regional variability. Thus, ONT has set a large-scale, comprehensive strategy to achieve a substantial improvement in donation and transplantation in Spain in the coming years: The 40 Donors pmp Plan. PURPOSE AND SCOPE: The overall objective is to increase the average rate of deceased donors to 40 pmp between 2008 and 2010. The areas of improvement, specific objectives, and actions have come from deep reflection on the data and the material generated from multidisciplinary discussions and open consultation with the donation and transplantation community. KEY AREAS SELECTED FOR ACTION: Detection and management of brain-dead donors, with 4 specific subareas: access to intensive care units, new forms of hospital management, foreigners and ethnic minorities, and evaluation/maintenance of thoracic organ donors. Expanded criteria donors, with 3 subareas: aging, donors with positive tests to certain viral serologies, and donors with rare diseases. Special surgical techniques. Donation after cardiac death.

[Anemia in chronic kidney disease and its cardiovascular implications]. / Anemia en la insuficiencia renal crónica y sus implicaciones cardiovasculares.

Cardiovascular disease is the leading cause of death in patients with chronic kidney disease (CKD). Anemia is a common complication of CKD and it is an important independent risk factor for the development and progression of left ventricular hypertrophy (LVH) and heart failure. Anemia is also independently and synergistically associated with an enhanced risk of cardiovascular morbidity and mortality in CKD patients. The availability of erythropoiesis stimulating agents (ESA), such as recombinant human erythropoietin, has greatly improved the management of anemia in CKD patients. By increasing hemoglobin levels, ESA therapy has demonstrated to significantly improve quality of life and decrease morbidity and mortality among these patients. Earlier studies suggested that partial correction of anemia in CKD patients with LVH induced a partial regression of LV mass, while mainly uncontrolled and small-sized studies have suggested that anemia treatment with ESA in CKD patients with congestive heart failure improved NYHA class, cardiac function and reduced hospitalization rates. On the other hand, recent randomized controlled trials have reported no benefit of full anemia correction on LVH and no benefit, or even worse outcomes, in CKD patients versus partial anemia correction. Thus, recent anemia guidelines recommend target haemoglobin levels between 11-12 g/dl in CKD patients receiving ESA.

Anemia en la insuficiencia renal crónica y sus implicaciones cardiovasculares / Anemia in chronic kidney disease and its cardiovascular implications

La enfermedad cardiovascular es la principal causa de mortalidad en los pacientes con insuficiencia renal crónica (IRC). La anemia es una complicación frecuente en la IRC y contribuye al desarrollo y la progresión de la hipertrofia ventricular izquierda (HVI) y la insuficiencia cardíaca en estos pacientes. Asimismo, la anemia se asocia de forma independiente y sinérgica con un riesgo aumentado de morbimortalidad cardiovascular en la IRC. La aparición de los agentes estimuladores de la eritropoyesis (ESA), como la eritropoyetina recombinante humana, ha revolucionado el tratamiento de la anemia renal al aumentar los valores de hemoglobina, mejorar la calidad de vida y disminuir la morbimortalidad en los pacientes con IRC. Los estudios iniciales demostraron que la corrección parcial de la anemia con ESA en pacientes renales con HVI inducía una regresión parcial de ésta. En pacientes con insuficiencia cardíaca e IRC, el tratamiento mejora los parámetros clínicos. Sin embargo, la corrección total de la anemia en los pacientes renales no se asocia con un efecto beneficioso adicional ni en la HVI, ni en la morbimortalidad, e incluso se ha indicado un peor pronóstico, respecto a la corrección parcial. Por ello, en pacientes con IRC que reciben tratamiento con ESA, los valores objetivo de hemoglobina propuestos en las guías están entre 11 y 12 g/dl (AU)

Cardiovascular disease is the leading cause of death in patients with chronic kidney disease (CKD). Anemia is a common complication of CKD and it is an important independent risk factor for the development and progression of left ventricular hypertrophy (LVH) and heart failure. Anemia is also independently and synergistically associated with an enhanced risk of cardiovascular morbidity and mortality in CKD patients. The availability of erythropoiesis stimulating agents (ESA), such as recombinant human erythropoietin, has greatly improved the management of anemia in CKD patients. By increasing hemoglobin levels, ESA therapy has demonstrated to significantly improve quality of life and decrease morbidity and mortality among these patients. Earlier studies suggested that partial correction of anemia in CKD patients with LVH induced a partial regression of LV mass, while mainly uncontrolled and small-sized studies have suggested that anemia treatment with ESA in CKD patients with congestive heart failure improved NYHA class, cardiac function and reduced hospitalization rates. On the other hand, recent randomized controlled trials have reported no benefit of full anemia correction on LVH and no benefit, or even worse outcomes, in CKD patients versus partial anemia correction. Thus, recent anemia guidelines recommend target haemoglobin levels between 11-12 g/dl in CKD patients receiving ESA (AU)

[Acetate-free on-line PHF: how to improve hyperacetatemia and haemodynamic tolerance]. / PHF on-line sin acetato: cómo mejorar la hiperacetatemia y la tolerancia hemodinámica.

SUMMARY BACKGROUND: The small quantity of acetate present in the dialysis fluid exposes patient's blood to an acetate concentration 30-40 times the physiological levels. This amount is even greater in hemodiafiltration on-line. Our purpose was to evaluate the clinical-analytical effects using three different dialysis techniques in the same patient. METHODS: 35 patients on hemodialysis were included. All patients were treated with conventional bicarbonate dialysate for 3 months, after randomization were switched to first be treated with PHF online with standard bicarbonate dialysate for 6 months and then switched to PHF on-line acetate-free dialysate for the other 6 months or to invert the two last periods. Blood samples were drawn monthly throughout the study and clinical data were obtained. RESULTS: Postdialysis blood acetate levels were higher in patients treated with conventional bicarbonate dialysate with respect to the period of PHF with free-acetate dialysate. Moreover, the percentage of patients with postdialysis blood acetate levels in the pathologic range was higher in patients treated with conventional bicarbonate dialysate respect to PHF on-line acetate-free dialysate period (61% vs. 30%). Serum concentrations of chloride postdialysis were higher and serum concentrations of bicarbonate pre and posthemodialysis were lower in the PHF free-acetate period. The incidence of hypotensive episodes was significantly lower in the PHF on-line with conventional dialysate. CONCLUSIONS: PHF on-line with free-acetate dialysate allows that most of patients finished hemodialysis with blood acetate levels in the physiologic ranges. PHF on-line is a predilutional hemodiafiltration treatment with better tolerance than hemodialysis with standard bicarbonate dialysate.

PHF on-line sin acetato: cómo mejorar la hiperacetatemia y la tolerancia hemodinámica / No disponible

Antecedentes: la presencia de acético en el Líquido de Diálisis (LD) expone al paciente a una concentración de acetato 30-40 veces superior a la normal. Dicha exposición aumenta en técnicas de Hemodiafiltración (HDF) online. El objetivo de dicho estudio fue evaluar los cambios clínico-analíticos al usar tres técnicas de Hemodiálisis(HD) diferentes. Métodos: se reclutaron 35 pacientes en HD estable. Se dializaron tres meses con HD convencional y luego fueron aleatorizados para pasar a una técnica de PHF on-line con concentrado convencional seis meses, y después pasaron a PHF on-line sin acetato otros seis meses. El otro grupo invertía estos dos períodos. Se obtuvieron análisis de sangre y datos clínicos de HD. Resultados: las medias de los acetatos posdiálisis fueron significativamente superiores durante los períodos de tratamiento con acético respecto al período sin acetato. El porcentaje de valores patológicos de acetato posdiálisis fue significativamente superior durante los períodos de tratamiento con acético (61 respecto al 30%). Las concentraciones de cloro pos-HD fueron superiores y las de bicarbonato pre y pos-HD fueron menores durante el período sin acético. El número de hipotensiones fue significativamente inferior en el período de PHF on-line con LD estándar respecto a los otros períodos. Conclusiones: la técnica de PHF on-line sin acetato disminuye la exposición a concentraciones elevadas de acetato y consigue que la mayoría de pacientes termine la HD con una acetatemia en el rango fisiológico. La PHF on-line es un tratamiento de HDF predilucional con mejor tolerancia que la HD estándar con bicarbonato (AU)

Summary Background: the small quantity of acetate present in the dialysis fluid exposes patient’s blood to an acetate concentration 30-40 times the physiological levels. This amountis even greater in hemodiafiltration on-line. Our purpose was to evaluate the clinical-analytical effects using three different dialysis techniques in the same patient. Methods: 35 patients on hemodialysis were included. All patients were treated with conventional bicarbonate dialysate for 3 months, after randomization were switched to first be treated with PHF online with standard bicarbonate dialysate for 6 months and then switched to PHF on-line acetate-free dialysate for the other 6months or to invert the two last periods. Blood samples were drawn monthly throughout the study and clinical data were obtained. Results: Posdialysis blood acetate levels were higher in patients treated with conventional bicarbonate dialysate with respect to the period of PHF with free-acetate dialysate. Moreover, the percentage of patients with posdialysis blood acetate levels in the pathologic range was higher in patients treated with conventional bicarbonate dialysate respect to PHF on-line acetate-free dialysate period (61% vs. 30%). Serum concentrations of chloride posdialysis were higher and serum concentrations of bicarbonate pre and poshemodialysis were lower in the PHF free-acetate period. The incidence of hypotensive episodes was significantly lower in the PHF on-line with conventional dialysate. Conclusions: PHF on-line with free-acetate dialysate allows that most of patients finished hemodialysis with blood acetate levels in the physiologic ranges. PHF on-line is a predilutional hemodiafiltration treatment with better tolerance than hemodialysis with standard bicarbonate dialysate (AU)

Tissue factor-bearing microparticles derived from tumor cells: impact on coagulation activation.

BACKGROUND: Tissue factor (TF)-bearing microparticles (MP) from different origins are thought to be involved in the pathogenesis of cancer-associated thrombosis. However, the role of circulating tumor cell-derived TF is not well understood. METHODS: TF antigen and activity were measured in MP generated in vitro from human TF-expressing cancer cells by ELISA and clotting or thrombin generation assays, respectively. TF antigen and activity were also measured in vivo in cell-free plasmas from mice previously injected with in vitro-generated MP or in cell-free plasmas from nude mice bearing orthotopically injected human cancer cells. RESULTS: Tumor cell-derived MP (TMP) exhibited strong TF-dependent procoagulant activity (PCA) in vitro and in vivo. Injection of TMP into mice was associated with acute thrombocytopenia and signs of shock, which were prevented by prior heparinization. Human TF antigen and activity could be detected in mouse cell-free plasmas up to 30 min after TMP injections. Human TF was detected in the spleen of injected mice and its clearance from circulation was delayed in splenectomized mice, suggesting the involvement of the spleen in the rapid clearance of circulating MP in vivo. Detectable levels of TF-dependent PCA and thrombin-antithrombin complex were found in cell-free plasmas from mice growing pancreatic human tumors, suggesting that circulating tumor-derived TF causes coagulation activation in vivo. CONCLUSIONS: MP derived from certain cancer cells exhibit TF-dependent PCA both in vitro and in vivo. These results provide new information about the specific contribution of tumor-derived MP to the hypercoagulable state observed in cancer.