Risk factors for non-diabetic renal disease in diabetic patients.

BACKGROUND: Diabetic patients with kidney disease have a high prevalence of non-diabetic renal disease (NDRD). Renal and patient survival regarding the diagnosis of diabetic nephropathy (DN) or NDRD have not been widely studied. The aim of our study is to evaluate the prevalence of NDRD in patients with diabetes and to determine the capacity of clinical and analytical data in the prediction of NDRD. In addition, we will study renal and patient prognosis according to the renal biopsy findings in patients with diabetes. METHODS: Retrospective multicentre observational study of renal biopsies performed in patients with diabetes from 2002 to 2014. RESULTS: In total, 832 patients were included: 621 men (74.6%), mean age of 61.7 ± 12.8 years, creatinine was 2.8 ± 2.2 mg/dL and proteinuria 2.7 (interquartile range: 1.2-5.4) g/24 h. About 39.5% (n = 329) of patients had DN, 49.6% (n = 413) NDRD and 10.8% (n = 90) mixed forms. The most frequent NDRD was nephroangiosclerosis (NAS) (n = 87, 9.3%). In the multivariate logistic regression analysis, older age [odds ratio (OR) = 1.03, 95% CI: 1.02-1.05, P < 0.001], microhaematuria (OR = 1.51, 95% CI: 1.03-2.21, P = 0.033) and absence of diabetic retinopathy (DR) (OR = 0.28, 95% CI: 0.19-0.42, P < 0.001) were independently associated with NDRD. Kaplan-Meier analysis showed that patients with DN or mixed forms presented worse renal prognosis than NDRD (P < 0.001) and higher mortality (P = 0.029). In multivariate Cox analyses, older age (P < 0.001), higher serum creatinine (P < 0.001), higher proteinuria (P < 0.001), DR (P = 0.007) and DN (P < 0.001) were independent risk factors for renal replacement therapy. In addition, older age (P < 0.001), peripheral vascular disease (P = 0.002), higher creatinine (P = 0.01) and DN (P = 0.015) were independent risk factors for mortality. CONCLUSIONS: The most frequent cause of NDRD is NAS. Elderly patients with microhaematuria and the absence of DR are the ones at risk for NDRD. Patients with DN presented worse renal prognosis and higher mortality than those with NDRD. These results suggest that in some patients with diabetes, kidney biopsy may be useful for an accurate renal diagnosis and subsequently treatment and prognosis.

C.E.R.A. administered once monthly corrects and maintains stable hemoglobin levels in chronic kidney disease patients not on dialysis: the observational study MICENAS II.

BACKGROUND AND OBJECTIVE: C.E.R.A. (continuous erythropoietin receptor activator, pegilated-rHuEPO ß) corrects and maintains stable hemoglobin levels in once-monthly administration in chronic kidney disease (CKD) patients. The aim of this study was to evaluate the management of anemia with C.E.R.A. in CKD patients not on dialysis in the clinical setting. METHODS: Two hundred seventy two anemic CKD patients not on dialysis treated with C.E.R.A. were included in this retrospective, observational, multicentric study during 2010. Demographical characteristics, analytical parameters concerning anemia, treatment data and iron status were recorded. RESULTS: C.E.R.A. achieved a good control of anemia in both naïve patients (mean Hemoglobin 11.6g/dL) and patients converted from a previous ESA (mean Hemoglobin 11.7g/dL). Most naïve patients received C.E.R.A. once monthly during the correction phase and required a low monthly dose (median dose 75 µg/month). The same median dose was required in patients converted from a previous ESA, and it was lower than recommended in the Summary of Product Characteristics (SPC). Iron status was adequate in 75% of anemic CKD patients, but only 50% of anemic patients with iron deficiency received iron supplementation. CONCLUSIONS: C.E.R.A. corrects and maintains stable hemoglobin levels in anemic CKD patients not on dialysis, requiring conversion doses lower than those recommended by the SPC, and achieving target hemoglobin levels with once-monthly dosing frequency both in naïve and converted patients.

Spanish Society of Nephrology document on KDIGO guidelines for the assessment and treatment of chronic kidney disease.

The new Kidney Disease: Improving Global Outcomes (KDIGO) international guidelines on chronic kidney disease (CKD) and the management of blood pressure (BP) in CKD patients are an update of the corresponding 2002 and 2004 KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines. The documents aim to provide updated guidelines on the assessment, management and treatment of patients with CKD. The first guidelines retain the 2002 definition of CKD but present an improved prognosis classification. Furthermore, concepts about prognosis of CKD, recommendations for management of patients, and criteria for referral to the nephrologist have been updated. The second guideline retains the <130/80 mm Hg-goal for management of BP in patients with CKD presenting increased albuminuria or proteinuria (albumin-to-creatinine ratio 30-300 mg/g, and >300 mg/g, respectively) but recommends a less-strict goal of <140/90 mm Hg in patients with normoalbuminuria. The development of the guidelines followed a predetermined process in which the evidence available was reviewed and assessed. Recommendations on management and treatment are based on the systematic review of relevant studies. The GRADE system (Grading of Recommendations Assessment, Development and Evaluation) was used to assess the quality of evidence and issue the grade of recommendation. Areas of uncertainty are also discussed for the different aspects addressed.

Design and patient characteristics of ESHOL study, a Catalonian prospective randomized study.

BACKGROUND: Retrospective studies showed that online hemodiafiltration (OL-HDF) is associated with a risk reduction of mortality over standard hemodialysis (HD) in patients with end-stage renal disease. Until now, no information was available from prospective randomized clinical trials. METHODS: A prospective, randomized, multicenter, open study was designed to be conducted in HD units from Catalonia (Spain). The aim of the study is to compare 3-year survival in prevalent end-stage renal disease patients randomized to OL-HDF or to continue on standard HD. The minimum sample size was calculated according to Catalonian mortality of patients on dialysis and assuming a risk reduction associated with OL-HDF of 35% (1-sided p<0.05 and a statistical power of 0.8) and a rate of dropout due to renal transplantation or loss to follow-up of 30%. RESULTS: From May 2007 to September 2008, 906 patients were included and randomized to OL-HDF (n=456) or standard HD (n=450). Demographics and analytical data at the time of randomization were not different between both groups of patients. Patients will be followed during a 3-year period. CONCLUSION: The present study will contribute to evaluating the benefit for patient survival of OL-HDF over standard HD.

Cardiovascular morbidity and mortality and left ventricular geometric patterns in hypertensive patients treated in primary care.

INTRODUCTION AND OBJECTIVES: Numerous hospital studies have shown that different left ventricular (LV) geometric patterns have different effects on cardiovascular risk. The aims of this study were to estimate the risk of major adverse cardiovascular events (MACEs) in hypertensive patients seen in primary care and to identify any association with LV geometric pattern. METHODS: In total, 265 hypertensive subjects attending primary care were randomly selected and followed up for 12 years. Those with cardiovascular disease, secondary hypertension, complete bundle branch block or electrocardiographic signs of ischemic heart disease were excluded. The LV geometric pattern was characterized as either concentric hypertrophy, eccentric hypertrophy, concentric remodeling or normal. A MACE was the occurrence of ischemic heart disease, heart failure, stroke, peripheral vascular disease, arrhythmia or cardiovascular death. Data were analyzed using the life-table method and Cox regression modeling. RESULTS: Although 14% of patients were lost to follow-up, their baseline characteristics were similar to those of patients who completed the study. The cumulative survival rate was 56.3% (95% confidence interval [CI], 49.8%-62.8%). The incidence of MACEs was 4.67 (95% CI, 3.79-5.55) per 100 subject-years. Moreover, the incidence was similar in the four LV geometric pattern groups (P=.889). Only age (hazard ratio [HR]=1.03; 95% CI, 1-1.05) and the presence of diabetes at study entry (HR=1.67; 95% CI, 1.03-2.69) were associated with an increased risk of a MACE. CONCLUSIONS: In the study population, only age and diabetes at study entry were associated with the occurrence of a MACE. There was no evidence for an association between MACEs and the LV geometric pattern.

Morbimortalidad cardiovascular y patrones geométricosdel ventrículo izquierdo en pacientes hipertensos atendidosen atención primaria / Cardiovascular Morbidity and Mortality and Left Ventricular Geometric Patterns in Hypertensive Patients Treated in Primary Care

Introducción y objetivos. Numerosos estudios hospitalariosmuestran el diferente impacto de los patronesgeométricos ventriculares izquierdos (VI) en el riesgo cardiovascular.El objetivo fue determinar el riesgo de eventoscardiovasculares (ECV) entre los hipertensos atendidosen atención primaria y analizar su relación con elpatrón geométrico VI.Métodos. Se seleccionó aleatoriamente a 265 hipertensosentre todos los atendidos que fueron seguidosdurante 12 años. Se excluyó a los que presentaban enfermedadcardiovascular, hipertensión arterial secundaria,bloqueo completo de rama o signos de cardiopatíaisquémica electrocardiográficos. Se los clasificó según elpatrón geométrico VI en hipertrofia concéntrica o excéntrica,remodelado concéntrico y normal. Se consideróECV la aparición de cardiopatía isquémica, insuficienciacardiaca, accidente cerebrovascular, vasculopatía periférica,arritmias o muerte por ECV. Se analizaron los datosmediante el método actuarial y modelos de regresión deCox.Resultados. Se perdió un 14% de los pacientes duranteel seguimiento, cuyas características basales fueronsimilares a las de los que lo completaron. La supervivenciaacumulada fue del 56,3% (intervalo de confianza[IC] del 95%, 49,8%-62,8%). La tasa de incidencia deECV fue 4,67 (IC del 95%, 3,79-5,55)/100 hipertensos/año. La incidencia de ECV fue similar en los cuatro gruposde patrón geométrico VI (p = 0,889). Únicamente laedad (años) (hazard ratio [HR] = 1,03; IC del 95%, 1-1,05)y la diabetes (HR = 1,67; IC del 95%, 1,03-2,69) al iniciodel estudio se asociaron con un mayor riesgo de ECV.Conclusiones. En la población de estudio sólo la edady la diabetes al inicio del estudio se asociaron con laaparición de ECV. No se evidenció asociación entre eltipo de patrón geométrico VI y los ECV (AU)

Introduction and objectives. Numerous hospitalstudies have shown that different left ventricular (LV)geometric patterns have different effects on cardiovascularrisk. The aims of this study were to estimate the riskof major adverse cardiovascular events (MACEs) inhypertensive patients seen in primary care and to identifyany association with LV geometric pattern.Methods. In total, 265 hypertensive subjects attendingprimary care were randomly selected and followed up for12 years. Those with cardiovascular disease, secondaryhypertension, complete bundle branch block orelectrocardiographic signs of ischemic heart disease wereexcluded. The LV geometric pattern was characterizedas either concentric hypertrophy, eccentric hypertrophy,concentric remodeling or normal. A MACE was theoccurrence of ischemic heart disease, heart failure, stroke,peripheral vascular disease, arrhythmia or cardiovasculardeath. Data were analyzed using the life-table method andCox regression modeling.Results. Although 14% of patients were lost to followup,their baseline characteristics were similar to those ofpatients who completed the study. The cumulative survivalrate was 56.3% (95% confidence interval [CI], 49.8%-62.8%). The incidence of MACEs was 4.67 (95% CI, 3.79-5.55) per 100 subject-years. Moreover, the incidence wassimilar in the four LV geometric pattern groups (P=.889).Only age (hazard ratio [HR]=1.03; 95% CI, 1-1.05) andthe presence of diabetes at study entry (HR=1.67; 95% CI, 1.03-2.69) were associated with an increased risk ofa MACE.Conclusions. In the study population, only age anddiabetes at study entry were associated with the occurrenceof a MACE. There was no evidence for an associationbetween MACEs and the LV geometric pattern (AU)

Hipotensión grave y mantenida por inhibidores de la enzima de conversión de angiotensina durante la anestesia intradural / No disponible

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Ambulatory blood pressure monitoring in hypertensive patients with high cardiovascular risk: a cross-sectional analysis of a 20,000-patient database in Spain.

OBJECTIVE: To evaluate ambulatory blood pressure monitoring (ABPM) parameters in a broad sample of high-risk hypertensive patients. METHODS: The Spanish Society of Hypertension is developing a nationwide project in which more than 900 physicians send ABPM registries and corresponding clinical records to a central database via www.cardiorisc.com. Between June 2004 and July 2005 a 20 000-patient database was obtained; 17 219 were valid for analysis. RESULTS: We identified 6534 patients with high cardiovascular risk according to the 2003 European Society of Hypertension/European Society of Cardiology guidelines stratification score. Office blood pressure (BP) was 158.8/89.9 mmHg and 24-h BP was 135.8/77.0 mmHg. Patients with grade 3 BP in the office showed ambulatory systolic BP values less than 160 mmHg in more than 80%. A non-dipping pattern was observed in 3836 cases (58.7%), whereas this abnormality was present in 47.9% of patients with low-to-moderate risk [odds ratio (OR) 1.54; 95% confidence interval (CI) 1.45-1.64]. The prevalence of non-dippers was higher as ambulatory BP increased ( approximately 70% when 24-h systolic BP > 155 mmHg) and was similar in both groups. At the lowest levels of BP (24-h systolic BP < 135 mmHg) a non-dipping pattern was more prevalent in high-risk cases (56.6 versus 45.7%; OR 1.51; 95% CI 1.40-1.64). CONCLUSION: There was a remarkable discrepancy between office and ambulatory BP in high-risk hypertensive patients. The prevalence of a non-dipper BP pattern was almost 60%. In the lowest levels of ambulatory BP, high-risk patients showed a higher prevalence of non-dipping BP than lower-risk cases. These observations support the recommendation of a wider use of ABPM in high-risk hypertensive patients.