Role of non-alcoholic fatty liver disease in the evolution of renal function in patients with diabetes mellitus.

BACKGROUND: The increasing prevalence of type 2 diabetes mellitus (T2DM) has influenced in an increasing prevalence of chronic kidney disease (CKD). Little is known about the influence of non-alcoholic fatty liver disease (NAFLD) on the progression of CKD. The aim of this study was to analyse the role of NAFLD and its severity in the progression of renal function in patients with T2DM. METHODS: We conducted a retrospective and observational study including patients with T2DM and estimated glomerular filtration rate (eGFR) >30 mL/min/1.73 m2. NAFLD was defined as the presence of compatible ultrasonography and/or the presence of fibrosis using the NAFLD score. Patients were classified into three groups according to the NAFLD score: Group 1: <-1.85; Group 2: -1.85-0.18 and Group 3: >0.18. RESULTS: A total of 102 patients were included [67.6% males, median age 59 years [interquartile range (IQR) 53-64)], with a median time of T2DM evolution of 70 months (IQR 39-131). Group 3 had lower eGFR (84.8 ± 40.4 versus 71.4 ± 30.6 mL/min/1.73 m2; P = 0.03) and higher proteinuria at baseline (0.56 ± 0.77 versus 1.59 ± 2.70 g/24 h; P = 0.05). After a follow-up time of 75.8 ± 23.9 months, Group 3 had a significant decrease in eGFR (66.6 ± 33.3 versus 36.8 ± 23.1 mL/min/1.73 m2; P ≤ 0.01) and a higher risk of CKD progression [odds ratio 7.50 (95% confidence interval 2.76-20.35); P ≤ 0.001] defined as a decrease in eGFR of >50%. CONCLUSIONS: The presence of NAFLD with high-risk fibrosis confers higher risk of CKD progression in patients with T2DM. Therefore NAFLD should be a risk factor evaluated in these patients to optimize treatment.

Nefritis intersticial tuberculosa, un diagnóstico difícil que precisa de una alta sospecha / Tuberculous interstitial nephritis: A difficult diagnosis that requires a high clinical suspicion

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¿Cuándo realizar biopsia renal en pacientes con diabetes mellitus tipo2? Modelo predictivo de enfermedad renal no diabética / When to perform renal biopsy in patients with type 2 diabetes mellitus? Predictive model of non-diabetic renal disease

INTRODUCCIÓN: La nefropatía diabética (ND) es una complicación frecuente de la diabetes mellitus (DM), y su diagnóstico suele ser clínico. Sin embargo, en numerosas ocasiones la enfermedad renal que presentan los pacientes diabéticos es debida a otras causas cuyo diagnóstico es histológico. El objetivo del estudio fue determinar los datos clínicos y analíticos predictores de ND y enfermedad renal no diabética (ERND), y elaborar un modelo predictivo (score) para confirmar o descartar ND. MATERIAL Y MÉTODOS: Estudio observacional, transversal y retrospectivo de biopsias renales realizadas en pacientes diabéticos tipo 2 entre 2000 y 2018. RESULTADOS: Se incluyeron 207 pacientes diabéticos con una edad media de 64,5 ± 10,6 años; el 74% eran varones. La biopsia mostró ND en 126 (61%) y en 81 ERND (39%). La retinopatía diabética estaba presente en el 58% de los pacientes con ND y en el 6% del grupo con ERND (p < 0,001). Histología encontrada en la ERND: glomerulopatías primarias (52%), nefroangioesclerosis (16%), nefritis intersticial inmunoalérgica (15%) y vasculitis (8,5%). En el análisis multivariable, la retinopatía (OR 26,7; IC 95%: 6,8-104,5), la isquemia crónica de miembros inferiores (OR 4,37; IC 95%: 1,33-14,3), la insulinoterapia (OR 3,05; IC 95%: 1,13-8,25), una evolución de la DM ≥ 10 años (OR 2,71; IC 95%: 1,1-6,62) y la proteinuria nefrótica (OR 2,91; IC 95%: 1,2-7,1) fueron predictores independientes de ND. La microhematuria, definida como ≥ 10 hematíes/campo (OR 0,032; IC 95%: 0,01-0,11) y el sobrepeso (OR 0,21; IC 95%: 0,08-0,55) lo fueron de ERND. Según el modelo predictivo resultante del estudio multivariable para ND, el rango de puntuación varió de -6 a 8 puntos. Todos los pacientes con un score > 3 era tenían ND, y el 94% de los casos con score ≤ 1 punto fueron ERND. CONCLUSIONES: La ERND es frecuente en pacientes con DM (39%). La etiología más frecuente son las glomerulonefritis primarias. La ausencia de retinopatía y la presencia de microhematuria son altamente sugestivas de ERND. La utilización de un sistema de puntuación facilita la indicación de biopsia renal en pacientes diabéticos

INTRODUCTION: Diabetic nephropathy (DN) is one of the most frequent complications in patients with diabetes mellitus (DM) and its diagnosis is usually established on clinical grounds. However, kidney involvement in some diabetic patients can be due to other causes, and renal biopsy might be needed to exclude them. The aim of our study was to establish the clinical and analytical data that predict DN and no-diabetic renal disease (NDRD), and to develop a predictive model (score) to confirm or dismiss DN. MATERIAL AND METHODS: We conducted a transversal, observational and retrospective study, including renal biopsies performed in type 2 DM patients, between 2000 and 2018. RESULTS: Two hundred seven DM patients were included in our study. The mean age was 64.5 ± 10.6 years and 74% were male. DN was found in 126 (61%) of the biopsies and NDRD in 81 (39%). Diabetic retinopathy was presented in 58% of DN patients, but only in 6% of NDRD patients (P < .001). Patients with NDRD were diagnosed of primary glomerulopathies (52%), nephroangiosclerosis (16%), inmunoallergic interstitial nephritis (15%) and vasculitis (8.5%). In the multivariate analysis, retinopathy (OR 26.7; 95% CI: 6.8-104.5), chronic ischaemia of lower limbs (OR 4,37; 95% CI: 1.33-14.3), insulin therapy (OR 3.05; 95% CI: 1.13-8.25), time course of DM ≥ 10 years (OR 2.71; 95% CI: 1.1-6.62) and nephrotic range proteinuria (OR 2.91; 95% CI: 1.2-7.1) were independent predictors for DN. Microhaematuria defined as ≥ 10 red blood cells per high-power field (OR 0.032; 95% CI: 0.01-0.11) and overweight (OR 0.21; 95% CI: 0.08-0.5) were independent predictors of NDRD. According to the predictive model based on the multivariate analysis, all patients with a score > 3 had DN and 94% of cases with a score ≤ 1 had NDRD (score ranked from -6 to 8 points). CONCLUSIONS: NDRD is common in DM patients (39%), being primary glomerulonephritis the most frequent ethology. The absence of retinopathy and the presence of microhematuria are highly suggestive of NDRD. The use of our predictive model could facilitate the indication of performing a renal biopsy in DM patients

When to perform renal biopsy in patients with type2 diabetes mellitus? Predictive model of non-diabetic renal disease. / ¿Cuándo realizar biopsia renal en pacientes con diabetes mellitus tipo2? Modelo predictivo de enfermedad renal no diabética.

INTRODUCTION: Diabetic nephropathy (DN) is one of the most frequent complications in patients with diabetes mellitus (DM) and its diagnosis is usually established on clinical grounds. However, kidney involvement in some diabetic patients can be due to other causes, and renal biopsy might be needed to exclude them. The aim of our study was to establish the clinical and analytical data that predict DN and no-diabetic renal disease (NDRD), and to develop a predictive model (score) to confirm or dismiss DN. MATERIAL AND METHODS: We conducted a transversal, observational and retrospective study, including renal biopsies performed in type2 DM patients, between 2000 and 2018. RESULTS: Two hundred seven DM patients were included in our study. The mean age was 64.5±10.6 years and 74% were male. DN was found in 126 (61%) of the biopsies and NDRD in 81 (39%). Diabetic retinopathy was presented in 58% of DN patients, but only in 6% of NDRD patients (P<.001). Patients with NDRD were diagnosed of primary glomerulopathies (52%), nephroangiosclerosis (16%), inmunoallergic interstitial nephritis (15%) and vasculitis (8.5%). In the multivariate analysis, retinopathy (OR26.7; 95%CI: 6.8-104.5), chronic ischaemia of lower limbs (OR4,37; 95%CI: 1.33-14.3), insulin therapy (OR3.05; 95%CI: 1.13-8.25), time course of DM ≥10years (OR2.71; 95%CI: 1.1-6.62) and nephrotic range proteinuria (OR2.91; 95%CI: 1.2-7.1) were independent predictors for DN. Microhaematuria defined as ≥10 red blood cells per high-power field (OR0.032; 95%CI: 0.01-0.11) and overweight (OR0.21; 95%CI: 0.08-0.5) were independent predictors of NDRD. According to the predictive model based on the multivariate analysis, all patients with a score >3 had DN and 94% of cases with a score ≤1 had NDRD (score ranked from -6 to 8points). CONCLUSIONS: NDRD is common in DM patients (39%), being primary glomerulonephritis the most frequent ethology. The absence of retinopathy and the presence of microhematuria are highly suggestive of NDRD. The use of our predictive model could facilitate the indication of performing a renal biopsy in DM patients.

¿Mejora la función renal tras la paratiroidectomía en el hiperparatirodismo primario? / Does renal function improve after parathyroidectomy in primary hyperparathyroidism?

Introducción: El hiperparatiroidismo primario (HPTP) es un trastorno endocrino frecuente, caracterizado por hipercalcemia y elevación de la parathormona. La disminución del filtrado glomerular ( < 60ml/min) se mantiene en la guías como un criterio para la realización de la paratiroidectomía (PTX) en el HPTP asintomático. La influencia que tiene la PTX sobre la evolución de la función renal es controvertida. Objetivos: Analizar las características clínicas, analíticas e histológicas de los pacientes intervenidos por HPTP, así como la evolución de la función renal tras la PTX. Material y métodos: Estudio retrospectivo de 297 pacientes con HPTP remitidos a cirugía en un único centro entre 1998 y 2016. Los parámetros analíticos se determinaron en situación basal, a la semana y al año de la PTX. Resultados: La incidencia de PTX fue de 38 casos/millón/año. La edad media fue 60 ± 14 años y el 80,5% de los pacientes eran mujeres. El 65,3% estaban asintomáticos. La nefrolitiasis fue el hallazgo clínico más frecuente (33%) seguido de la afectación ósea (29,5%). Las indicaciones de PTX fueron: síntomas clínicos (34,7%), hipercalcemia > 11,2 mg/dl (27%), litiasis renal (13%), baja masa ósea (12%), edad < 50 años (11%) y disminución del filtrado < 60 ml/min (2,3%). En el diagnóstico de localización el spect-MIBI presentó una sensibilidad del 92% y la ecografía cervical del 70%. El 94,3% de los casos de HPTP eran debidos a un adenoma paratiroideo. Tras la PTX se objetivó normalización de los parámetros relacionados con el HPTP. Objetivamos un incremento significativo de la creatinina sérica (0,81 vs. 0,85 mg/dl, p < 0,001) desde la primera semana del postoperatorio y que se mantiene al año. Cuando comparamos los pacientes según el filtrado glomerular basal, encontramos que el deterioro de la función renal solamente fue significativo en pacientes con filtrado glomerular > 60 ml/min (creatinina sérica basal 0,77 mg/dl vs. creatinina sérica al año 0,81 mg/dl, p < 0,001). Conclusiones: El HPTP cursó asintomático en la mayoría de los pacientes intervenidos. La hipercalcemia y la nefrolitiasis fueron las indicaciones más frecuentes de paratiroidectomía en los pacientes asintomáticos. El scan-MIBI fue el método de localización más útil. La curación quirúrgica del HPTP se sigue de un deterioro de la función renal, que se mantiene desde la primera semana de la cirugía

Introduction: Primary hyperparathyroidism (PHPT) is a common endocrine disorder characterised by hypercalcaemia and parathormone increase. Decreased glomerular filtration rate ( < 60 ml/min) continues to be a parathyroidectomy (PTX) criterion in asymptomatic PHPT. The influence of PTX on renal function evolution is the subject of debate. Objective: To analyse the clinical, laboratory and histological characteristics of patients undergoing PHPT, as well as renal function evolution after PTX. Material and methods: Retrospective study of 297 patients diagnosed with PHPT and referred to surgery in a single centre between 1998 and 2016. Laboratory parameters were determined at baseline, one week and one year after PTX. Results: The Incidence of PTX was 38 cases/million/year. Mean age was 60 ± 14 years and 80.5% of the patients were female. Approximately 65.3% were asymptomatic. Nephrolithiasis was the most common clinical finding (33%), followed by bone involvement (29.5%). PTX indications were: clinical symptoms (34.7%), hypercalcaemia > 11.2 mg/dl (27%), nephrolithiasis (13%), low bone mass (12%), age < 50 years (11%) and decreased glomerular filtration rate < 60 ml/min (2.3%). For diagnostic localisation, spect-MIBI had a sensitivity of 92% and cervical ultrasound of 70%. A total of 94.3% of PHPT cases were due to a parathyroid adenoma. After PTX, normalisation of PHPT-related parameters was observed. We found a significant increase in serum creatinine levels (0.81 vs 0.85 mg/dl, P < .001) from the first week post-PTX until the end of the first year. The renal function was only found to be significant in patients with glomerular filtration rate>60ml/min (baseline serum creatinine levels 0.77 mg/dl vs serum creatinine levels after one year 0.81 mg/dl, P < .001). Conclusions: PHPT was asymptomatic in most patients who underwent surgery. Hypercalcaemia and nephrolithiasis were the most common indications of parathyroidectomy in asymptomatic patients. MIBI scan was the most useful localisation method. Surgical treatment of PHPT is followed by renal function impairment, which persists after the first week post-PTX

Does renal function improve after parathyroidectomy in primary hyperparathyroidism? / ¿Mejora la función renal tras la paratiroidectomía en el hiperparatirodismo primario?

INTRODUCTION: Primary hyperparathyroidism (PHPT) is a common endocrine disorder characterised by hypercalcaemia and parathormone increase. Decreased glomerular filtration rate (<60ml/min) continues to be a parathyroidectomy (PTX) criterion in asymptomatic PHPT. The influence of PTX on renal function evolution is the subject of debate. OBJECTIVE: To analyse the clinical, laboratory and histological characteristics of patients undergoing PHPT, as well as renal function evolution after PTX. MATERIAL AND METHODS: Retrospective study of 297 patients diagnosed with PHPT and referred to surgery in a single centre between 1998 and 2016. Laboratory parameters were determined at baseline, one week and one year after PTX. RESULTS: The Incidence of PTX was 38 cases/million/year. Mean age was 60±14 years and 80.5% of the patients were female. Approximately 65.3% were asymptomatic. Nephrolithiasis was the most common clinical finding (33%), followed by bone involvement (29.5%). PTX indications were: clinical symptoms (34.7%), hypercalcaemia>11.2mg/dl (27%), nephrolithiasis (13%), low bone mass (12%), age<50 years (11%) and decreased glomerular filtration rate<60ml/min (2.3%). For diagnostic localisation, spect-MIBI had a sensitivity of 92% and cervical ultrasound of 70%. A total of 94.3% of PHPT cases were due to a parathyroid adenoma. After PTX, normalisation of PHPT-related parameters was observed. We found a significant increase in serum creatinine levels (0.81 vs 0.85mg/dl, P<.001) from the first week post-PTX until the end of the first year. The renal function was only found to be significant in patients with glomerular filtration rate>60ml/min (baseline serum creatinine levels 0.77mg/dl vs serum creatinine levels after one year 0.81mg/dl, P<.001). CONCLUSIONS: PHPT was asymptomatic in most patients who underwent surgery. Hypercalcaemia and nephrolithiasis were the most common indications of parathyroidectomy in asymptomatic patients. MIBI scan was the most useful localisation method. Surgical treatment of PHPT is followed by renal function impairment, which persists after the first week post-PTX.

Endoluminal colonization as a risk factor for coagulase-negative staphylococcal catheter-related bloodstream infections in haemodialysis patients.

BACKGROUND: Approximately 25% of haemodialysis (HD) patients use catheters as vascular access. Catheter-related bloodstream infections (CRBSI) are a major risk in this population. The objective of our study was to determine whether endoluminal catheter colonization (ECC) predicts CRBSI. METHODS: We followed up a cohort of HD patients in our institution who underwent HD with tunnelled cuffed central venous catheters (TCC) between December 2006 and June 2008. Colonization of the inner catheter lumen was assessed every 15 days immediately before HD by culture of blood-heparin mixture and the time to positivity (TTP) was recorded by the BacT/Alert automated system. CRBSI was confirmed by differential TTP (> 2 h) between TCC and peripheral blood cultures. RESULTS: We studied 51 patients who required 64 TCC. The incidence of CRBSI was 1.65 episodes per 1000 catheter-days, with Staphylococcus epidermidis being the most common cause of infection (76.2%). ECC was more frequent in the CRSBI group than in the non-CRBSI group (100 vs 5.4%, P < 0.001). For S. epidermidis CRBSIs, the median time from ECC to CRBSI was 31.5 days (interquartile range, 27.0-79.0). The sensitivity, specificity and negative and positive predictive values of arterial lumen cultures for S. epidermidis CRBSIs were 100, 96.3, 92.3 and 100%, respectively, while for venous culture, these values were 92.3, 96.3, 92.3 and 96.3%, respectively. For predicting S. epidermidis CRBSI, endoluminal cultures with a TTP of ≤ 14 h had sensitivity and specificity of 52.1 and 97.7%, respectively. CONCLUSIONS: This study shows that ECC may predict the risk of developing CRSBI. Surveillance cultures could, therefore, be used to triage individual HD patients who might benefit from specific intervention measures.