Pre-Transplant Assessment of Vascular Calcification as a Risk Factor of Mortality, Graft Loss, and Cardiovascular Events in Renal Transplant Recipients.

BACKGROUND: Vascular calcification (VC) is known as an independent predictor of mortality in patients undergoing hemodialysis; nevertheless, there is a lack of studies about the impact of vascular calcification in renal transplant recipients, and none of them use the Kauppila Index (KI) as a predictor of patient and graft prognosis. METHODS: We conducted an observational, retrospective study of 119 renal transplants, evaluating abdominal aortic calcifications (L4-S1) with the KI. We established 2 categories: absence (KI = 0-2) and presence (KI = 3-24) of VCs before transplantation. We analyzed the impact of calcification in graft and patient survival, new-onset diabetes mellitus, hypertension, cardiovascular events, renal function, and mineral metabolism. RESULTS: VCs were observed in 50 patients (42%) before renal transplantation. Patients with VCs were older, but no statistical differences were found in the pre-transplant study between sex, diabetes, body mass index, and cardiovascular events. We found a major patient survival (limited to first 2 years after transplantation), graft survival, and death-censored graft survival in those without VCs (P = .037, P = .015, and P = .023, respectively). In line with results, a higher incidence of major cardiovascular events (MACE) and cardiovascular death was observed in the group with preexisting calcification (P = .016/P = .019). In the multivariable analysis, VCs were not an independent predictor for graft loss, death-censored graft loss, or major cardiovascular events. CONCLUSIONS: Simple evaluation of VCs with the use of the KI at the time of transplantation relates with graft and patient survival and with MACE after renal transplantation.

Dietary intervention focused on phosphate intake in hemodialysis patients with hyperphosphoremia.

BACKGROUND: Elevated serum phosphorus has been identified as a cardiovascular risk factor. This study aimed to assess the effectiveness of dietary intervention to reduce phosphorus intake and to improve the calcium-phosphorus metabolism in hemodialysis patients. DESIGN: Patients were included in a 6-month, 2-group experimental study if their previous 3-month average serum phosphorus was over 5.5 mg/dl. Patients were allocated to intensive dietary intervention or usual dietary recommendations. The clinical end-points were the multivariate-adjusted change in serum phosphorus and the number of patients who achieved serum phosphorus levels of < 5.5 mg/dl and serum phosphorus levels of < 5 mg/dl. RESULTS: 80 dialysis patients completed the study, 41 in the experimental group and 39 in the control group. After 6 months, phosphorus intake (702 ± 168 vs. 872 ± 242 mg/24 h; p = 0.002) was lower in the experimental group than in the control group, with no inter-group differences in protein-caloric intake. Serum phosphorus decreased 1.67 mg/dl in the experimental group and 0.58 mg/dl in the control group (multivariate-adjusted difference 0.93 mg/ dl; 95% CI 0.34 - 1.52; p = 0.003). Serum phosphorus < 5.5 mg/dl and serum phosphorus < 5 mg/dl were attained more frequently in the experimental group (51 vs. 18%, p = 0.002 and 31.7 vs. 15.4%, p = 0.08 respectively). CONCLUSIONS: Intensive dietary intervention focusing on phosphorus intake may be useful to reduce phosphorus retention and to improve calcium-phosphorus metabolism in hemodialysis patients.

[Nutrient intake and eating habits in hemodialysis patients: comparison with a model based on mediterranean diet]. / Principales déficits del consumo alimentario de los pacientes en hemodiálisis: aproximación a un modelo de alimentación saludable basado en la dieta mediterránea.

OBJECTIVES: Inadequate nutrient intake seems to be one of the most important cause of malnutrition in hemodialysis patients. The purpose of this study was to analyse their nutrient intake and eating habits, comparing food groups' intake with standard Mediterranean diet values (Healthy Diet Guide 2004, Nutrition Community Spanish Society). MATERIAL AND METHODS: There were 28 stable hemodialysis (HD) patients, 15 males and 13 females, mean age 62,9 +/- 16 years. Dietary evaluation was based on 7-day dietary recalls conducted by a single observer. We compare nutrients intake with recommended hemodialysis intake and we contrast food groups consumption with the theoretical ideal based on Mediterranean diet. RESULTS: The protein intake was 1,33 +/- 0,2 g/kg/day and the energy intake 29,5 +/- 2,1 kcal/kg/day. Carbohydrates accounted 43,1% of energy intake, proteins 19% and lipids 37,9% (55,5% monounsaturated fatty acids, 16,4% polyunsaturated fatty acids and 28,1% saturated fatty acids). Complex carbohydrates (potatoes, cereals, vegetables, fruits) and olive oil consumption was lower than that recommended to the Spanish healthy population and to the chronic hemodialysis patients. The animal protein intake (meat, fish, eggs) was correct, although excessive in red and processed meats. Results: Potatoes and cereals recommended frequency (RF) 4-6 portions/day, HD patients frequency (HDF) 4,1 portions/day; vegetables RF > 2 portions/day, HDF 1,2; fruits RF > 3 portions/day, HDF 1,3; olive oil RF 3-6 portions/day, HDF 1,5; Fish RF 3-4 portions/week, HDF 4,2; White meat RF 3-4 portions/week, HDF 1,5; Poultry RF 3-4 portions/week, HDF 2,3; Eggs RF 3-4 portions/week, HDF 3,6; Pulses RF 3-4 portions/week, HDF 1,7; Nuts RF 3-7 portions/week, HDF 0; Red meat RF occasionally, HDF 4,8 portions/week; Processed meats RF occasionally, HDF 4,6 portions/week; Sweets, snacks, soft drinks RF occasionally, HDF 1,7 portions/week; Butter, margarine, processed bakery products, biscuits RF occasionally , HDF 0,5 portions/week. CONCLUSIONS: Nutritional abnormalities are frequently found even in apparently stable patients on chronic hemodialysis. Caloric rather than protein undernutrition is the major abnormality. Inadequate caloric intake (< 35 kcal/kg/day) can lead to a negative nitrogen balance. Their eating habits are healthy and natural, but there is a deficit in slowly absorbed carbohydrates and olive oil intake (with caloric intake reduction), and an excessive consumption of red and processed meats (with saturated fats increase). The individual correction of these dietary patterns could reduce the saturated fats and increase the energy intake, obtaining a balanced diet integrated into our geographic region and culture.

[Huesca and Teruel survey on hemodialysis management]. / Estudio epidemiológico sobre el tratamiento con hemodiálisis en Huesca y Teruel.

A cross sectional study was performed in order to evaluate the treatment conditions and medical outcomes among 131 prevalent hemodialysis patients (57% males; mean age 66 +/- 12 years) in Huesca and Teruel. Data were collected at 5 hemodialysis units in Huesca and Teruel. Diabetes mellitus, at 30 percent, was the most common cause of renal insufficiency. The mean (+/- SD) urea-reduction ratio (URR) was 66.0 +/- 8.8%. We observed that 56.5% of the population reached an URR higher than 65%. The duration of dialysis session was 220 +/- 24 minutes, with a rate of blood flow 297 +/- 47 ml/min. 36% of patients used high-flux membranes. The patterns of vascular access were: 69% arteriovenous fistula, 5% synthetic graft and 26% catheter. Eighty nine percent of patients were treated with erythropoietin. The mean dose of erythropoietin was 109 +/- 62 UI/Kg weight/week. Thirty nine percent of patients had haemoglobin below 11.0 g/dl (mean 11.2 +/- 1.4 g/dl). Ferritin levels were below 100 ng/ml in 24% of the patients and 25% showed a transferrin saturation index below 20%. Fifty percent of patients were receiving vitamin D. Serum calcium 9.3 +/- 0.8 mg/dl; phosphorous 5.5 +/- 1.5 mg/dl; calcium-phosphorous product 51.5 +/- 14.3 mg/dl; PTHi 433 +/- 459 pg/ml; and aluminium 26.8 +/- 14.5 mcg/l were the mean of main biochemical markers of mineral metabolism. Sixty eight percent of patients had phosphorous levels below 6.0 mg/dl. Thirty seven percent of patients had aluminium levels lower than 20 mcg/l. The mean serum albumin was 3.4 +/- 0.4 g/dl. Forty five percent of patients had albumin below 3.5 g/dl.

Estudio epidemiológico sobre el tratamiento con hemodiálisis en Huesca y Teruel / Huesca and Teruel survey on hemodialysis management

Nos planteamos evaluar el manejo de los pacientes en hemodiálisis (HD) enHuesca y Teruel. Presentamos resultados de 131 pacientes en HD prevalentes enel año 2001. La diabetes mellitus con un 30% fue la causa más frecuente de insuficienciarenal. La media de la dosis de diálisis aplicada, utilizando el porcentajede reducción de urea (PRU), fue 66,0 ± 8,8%. El 56,5% de la población alcanzóun PRU superior a 65%. La duración media de la sesión de HD fue de220 ± 24 minutos, y el flujo sanguíneo de 29,7 ± 47 ml/min. En un 36% de pacientesse emplearon membranas de alta permeabilidad. Los patrones de accesovascular fueron: 69% fístulas arteriovenosas, 5% injerto sintético y 26% catéteres.El 88,5% de la población estaba en tratamiento con eritropoyetina. La dosismedia utilizada fue de 109 ± 62 UI/kg de peso/semana. El 39% de los pacientespresentaba hemoglobina inferior a 11,0 g/dl (media 11,2 ± 1,4 g/dl). Un 24%de los enfermos tenía niveles de ferritina inferiores a 100 ng/ml y un 25% mostrabaíndice de saturación de la transferrina inferior al 20%. Un 50% de pacientesrecibía vitamina D en alguna de sus formas. La media de los principales marcadoresdel metabolismo mineral fue: calcio sérico 9,3 ± 0,8 mg/dl; fósforo 5,5± 1,5 mg/dl; producto calcio-fósforo 51,5 ± 14,3 mg/dl; PTHi 433 ± 459 pg/ml;y aluminio 26,8 ± 14,5 mcg/l. Un 68% de pacientes tenía niveles de fósforo inferiora 6,0 mg/dl y el 37% niveles de aluminio inferior a 20 mcg/l. La albúminasérica media fue 3,4 ± 0,4 g/dl. Un 41% de pacientes presentaba albúmina inferiora 3,5 g/dl

A cross sectional study was performed in order to evaluate the treatment conditionsand medical outcomes among 131 prevalent hemodialysis patients (57%males; mean age 66 ± 12 years) in Huesca and Teruel. Data were collected at 5 hemodialysis units in Huesca and Teruel. Diabetes mellitus, at 30 percent, was themost common cause of renal insufficiency. The mean (± SD) urea-reduction ratio(URR) was 66.0 ± 8.8%. We observed that 56.5% of the population reached anURR higher than 65%. The duration of dialysis session was 220 ± 24 minutes,with a rate of blood flow 297 ± 47 ml/min. 36% of patients used high-flux membranes.The patterns of vascular access were: 69% arteriovenous fistula, 5% synthetycgraft and 26% catheter. Eighty nine percent of patients were treated witherythropoietin. The mean dose of erythropoietin was 109 ± 62 UI/Kg weight/week.Thirty nine percent of patients had haemoglobin below 11.0 g/dl (mean 11.2 ±1.4 g/dl). Ferritin levels were below 100 ng/ml in 24% of the patients and 25%showed a transferrin saturation index below 20%. Fifty percent of patients werereceiving vitamin D. Serum calcium 9.3 ± 0.8 mg/dl; phosphorous 5.5 ± 1.5 mg/dl;calcium-phosphorous product 51.5 ± 14.3 mg/dl; PTHi 433 ± 459 pg/ml; andaluminium 26.8 ± 14.5 mcg/l were the mean of main biochemical markers of mineralmetabolism. Sixty eight percent of patients had phosphorous levels below6.0 mg/dl. Thirty seven percent of patients had aluminium levels lower than 20mcg/l. The mean serum albumin was 3.4 ± 0.4 g/dl. Forty five percent of patientshad albumin below 3.5 g/dl

[Study of immutable variables determining rHuEPO dose requirements on hemodialysis patients]. / Estudio de causas no modificables de pobre respuesta al tratamiento con eritropoyetina en pacientes en hemodiálisis.

Patients receiving recombinant human erythropoietin (rHuEPO) therapy show wide variability in their responsiveness to the drug. Variables that affect rHuEPO dose requirements can be broadly divided into modificable and immutable characteristics. Most of the scientific research on rHuEPO hyporesponsiveness has focused on modificable variables (iron status, dialysis adequacy), while immutable variables such as gender, etiology of chronic renal failure (CRF) and age have been insufficiently explored. A cross sectional study was performed in order to evaluate if immutable patient characteristics determine rHuEPO dose requirements among 215 patients (52% males; mean age 66 +/- 14 years) on hemodialysis (HD) for more than twelve months. Data were collected at 10 hemodialysis units in Aragon. Patients were divided into three groups according to their gender, their cause of CRF (diabetic nephropathy, vascular nephropathy, tubulointerstitial nephropathy and primary glomerulonephritis) and their age (younger than 60 years, from 60 to 75 years, older than 75 years). Despite a similar dose of rHuEPO, women had lower mean hemoglobin (11.1 +/- 1.5 versus 11.6 +/- 1.7 g/dl; p = 0.0258) than men. The greater hemoglobin in men than women may be attributed to greater serum albumin in men (3.5 +/- 0.3 versus 3.7 +/- 0.3 mg/dl; p = 0.0001). Requirements of rHuEPO were higher in the patients with etiology of primary glomerulonephritis compared with those with the other etiologies, even those with diabetic nephropathy (p = 0.0374). The rHuE-PO doses required to obtain similar hemoglobin levels were higher in patients younger than 60 years (p = 0.0249). We conclude that women, patients with primary glomerulonephritis as cause of CRF, and patients younger than 60 years showed the highest requirements of rHuEPO doses.

[Evaluation of food intake in hemodialysis using a food consumption and appetite questionnaire]. / Valoración de la ingesta en hemodiálisis mediante un cuestionario de consumo alimentario y apetito.

Protein calorie malnutrition is a common complication in chronic hemodialysis patients (CHP). Although many factors could promote malnutrition, inadequate nutrient intake seems to be one of the most important. An Appetite and Diet Assessment Questionnaire (ADAQ) was developed, and we have performed a cross-sectional study in 44 CHP to investigate its capacity to predict an inadequate intake. Dietary evaluation was based on a diet diary-assisted recalls (DDAR). On the other hand, the validity of PCR and the differences in the DDAR and ADAQ between the days of dialysis and the days without dialysis were studied. The predictive value of inadequate intake of the ADAQ and the PCR were analysed with the ROC curve. The protein intake was 1.3 +/- 0.3 g/kg/day and the energy intake 29.2 +/- 0.6 kcal/kg/day. The average PCR was 1.14 +/- 0.3. The ROC curve to predict inadequate intake from the ADAQ shows an area under the curve of 0.84 for the protein intake and 0.73 for the energy intake. A cut-off ponit of 18 gives a sensitivity of 100% and a specificity of 44% for the detection of poor protein intake (< 1.2 g/kg/day) and of 74% and 56% for the detection of poor energy intake (< 30 kcal/kg/day). The ROC curve to predict inadequate protein intake from the PCR obtains an area under the curve of 0.81. The cut-off 1.06 gives the best sensitivity (100%) and specificity (64%) for the detection of insufficient protein intake. We did not find any significant difference in the DDAR or in the ADAQ between the days of dialysis and the days without dialysis. Despite the subjective interpretation, the relationship between ADAQ and protein-energy intakes analysed by DDAR was highly significant. The questionnaire is simple and can therefore be used as a screening rest to detect and correct alterations in the diet which could otherwise lead to malnutrition. The determination of PCR gives a good sensitivity and specificity for the detection of poor protein intake, although the results are modified in anabolic or catabolic states which can clinically go undetected. We do not register differences in diet between the days of dialysis and the days without dialysis.

Epidemiología, aspectos clínicos y manejo del fracaso renal agudo en una población envejecida dependiente de un hospital comarcal / Characteristics of acute renal failure in elderly patients admitted to a small town hospital

El objetivo de nuestro trabajo es analizar las características del fracaso renal agudo (FRA) en un hospital comarcal desprovisto de unidad de cuidados intensivos que atiende a una población envejecida en una zona rural, con el fin de reconocer los factores etiológicos e instaurar medidas de prevención y tratamiento adecuadas.Revisamos de manera prospectiva todos los casos de FRA registrados a lo largo de un año. Se detectaron 99 episodios, con una incidencia de 1.238 casos por millón de población y año y un 1,78 por ciento de los pacientes ingresados. La edad media fue de 80,3 ñ 10 años. Existía importante patología asociada (hipertensión 54 por ciento, diabetes 39 por ciento) y frecuente tratamiento cardiovascular previo (bloqueo sistema renina-angiotensina 35,4 por ciento, diuréticos 50,5 por ciento). En el 79 por ciento de los casos el FRA fue extrahospitalario, y en el 21 por ciento hospitalario. El 60 por ciento fueron prerrenales, el 31 por ciento renales y el 9 por ciento obstructivos. El 44,4 por ciento fueron oligoanúricos. Entre las causas desencadenantes destacan un 34,7 por ciento por disminución de volumen circulante efectivo, un 23 por ciento por infección y un 20,4 por ciento por bajo gasto. En un 35,3 por ciento de los casos la actuación médica contribuyó a iniciar o mantener el FRA, en el extrahospitalario por tratamiento antihipertensivo y/o diurético en situaciones de depleción de volumen y en el hospitalario por mal manejo o tóxicos.El desarrollo de FRA duplicó la estancia (14,4 ñ 7 frente a 6,5 ñ 4 días) y se registró una mortalidad de 36,4 por ciento, superior en el hospitalario (54 por ciento) frente al extrahospitalario (24 por ciento, p < 0,05). Los principales factores que influyeron en la mortalidad fueron el total de patología asociada, la presencia de oligoanuria, la etiología de origen parenquimatoso y la hipoalbuminemia.Podemos concluir que el FRA presenta una elevada incidencia en esta población envejecida y una morbi-mortalidad importante. Es fundamental su detección y prevención en el ámbito extrahospitalario, con especial vigilancia de pacientes ancianos, con reducción de la reserva funcional renal por afectación vascular sistémica y tratamiento farmacológico (principalmente bloqueantes del sistema reni- na-angiotensina y diuréticos), que pueden desarrollarlo ante moderadas depleciones de volumen. En el ámbito hospitalario, es primordial el manejo adecuado de procesos que cursan con depleción de líquidos, bajo gasto cardíaco, hipoalbuminemia u otras situaciones que comportan una hipoperfusión renal y la vigilancia de la nefrotoxicidad de los fármacos, en especial los aminoglucósidos y los antiinflamatorios no esteroideos (AU)

Valoración de la ingesta en hemodiálisis mediante un cuestionario de consumo alimentario y apetito / Evaluation of nutrient intake in hemodialysis patients validity of an appetite and diet assessment and of protein catabolic rate determination

Dentro del origen multifactorial de la malnutrición en hemodiálisis periódica (HDP) la ingesta inadecuada es una causa importante, valorándose habitualmente mediante registro de consumo alimentario (RCA). Con el objetivo de detectar de forma sencilla y rápida una pobre ingesta, se desarrolla un Cuestionario de Consumo Alimentario y Apetito (CCAA) y se estima su capacidad para predecir un aporte proteico-calórico inadecuado, tomando como patrón de referencia el RCA. Así mismo se analiza la capacidad predictiva de insuficiente ingesta proteica que ofrece la tasa de catabolismo proteico (PCR) y se estudia si existen diferencias en los valores del RCA y del CCAA entre los días de diálisis y los días sin diálisis. Se incluyen en el estudio 44 pacientes en HDP en situación clínica estable. Para la evaluación de la ingesta se utilizó el método de RCA mixto (mediante pesada y entrevista) de dos días (uno de diálisis y uno de no diálisis). Se determinó el PCR y se desarrolló el CCAA, un cuestionario de 34 ítems acerca de la adecuación de la dieta y el nivel de apetito. Se realiza una baremación del CCAA y se constrastan estos datos y los valores del PCR con el RCA mediante el análisis de curva ROC. La ingesta proteica media fue de 1,3 ñ 0,3 g/kg/día y la calórica de 29,2 ñ 6 kcal/kg/día según RCA. El PCR medio fue de 1,14 ñ 0,3. Al relacionar el CCAA con el RCA obtenemos un área bajo curva de 0,84 (IC 0,70-0,93) para la ingesta proteica y de 0,73 (IC 0,57-0,85) para la calórica. El punto de corte en 18 ofrece unos valores de sensibilidad del 100 por ciento y especificidad del 44 por ciento para la detección de pobre ingesta proteica (< 1,2 g/kg/día) y del 74 por ciento y 56 por ciento para la detección de pobre ingesta calórica (< 30 kcal/kg/día). Al relacionar el PCR con la ingesta proteica según RCA obtenemos un área bajo curva de 0,81 (IC 0,660,91). El puto de corte en 1,06 nos ofrece la mejor sensibilidad (100 por ciento) y especificidad (64 por ciento) en la detección de ingesta proteica insuficiente. No encontramos diferencias significativas entre los días de diálisis y los días sin diálisis en el RCA ni en el CCAA. Consideramos que el CCAA, a pesar de la subjetividad de su interpretación, se correlaciona bien con la ingesta alimentaria analizada mediante RCA. Su realización es sencilla, por lo que puede utilizarse de forma repetitiva como screening para detectar y corregir de forma precoz alteraciones en la ingesta alimentaria que pueden conducir a déficits nutricionales. La determinación del PCR presenta una buena sensibilidad y especificidad en la detección de pobre ingesta proteica, aunque sus resultados se alteran ante estados anabólicos o catabólicos que clínicamente pueden pasar desapercibidos. No registramos diferencias en la dieta entre los días de diálisis y los días sin diálisis (AU)

[Comparison of clinical arterial pressure, home-arterial pressure measurement, and ambulatory arterial pressure monitoring in patients with type II diabetes mellitus and diabetic nephropathy]. / Comparación de presión arterial clínica, automedida domiciliaria de presión arterial y monitorización ambulatoria de presión arterial en el paciente con diabetes mellitus tipo 2 y nefropatía diabética.

BACKGROUND: Hypertension is common in type 2 diabetes with diabetic nephropathy, and increases the risk of cardiovascular complications and renal chronic insufficiency. The aim of our evaluation in these patients was: a) to study the correlation between office blood pressure (BP), self-monitored (SMBP) and 24-hour ambulatory blood pressure monitoring (ABPM). b) To study the correlation between these methods and cardiovascular and renal complications. METHODS: We studied 60 patients (mean age 66.7 +/- 9 years, mean duration of diabetes 11.3 +/- 7 years) with arterial hypertension, type 2 diabetes and diabetic nephropathy. Macroangiopathy and echocardiography were recorded. We measured, SMBP and ABPM without modifying the antihypertensive treatment. The white coat phenomenon (WCP) was determined and patients were classified as dippers or non dippers according to their blood pressure diurnal rhythm. RESULTS: Mean glycated haemoglobin was 7.8% and mean serum creatinine 1.2 +/- 0.5 mg/dl, 30% of patients had proteinuria and 70% microalbuminuria The mean number of antihypertensive drugs was 2.2 +/- 1. The mean BP was: Office BP: 158.2 +/- 24/85.3 +/- 9 mmHg, pulse pressure (PP) 72.9 +/- 21 mmHg; SMBP: 145.4 +/- 18/77.5 +/- 7 mmHg, PP 67.9 +/- 18 mmHg and BP in the early morning 150.2 +/- 20/79.9 +/- 9 mmHg; ABPM: diurnal mean 138.9 +/- 15/74.1 +/- 6 mmHg, PP 64.8 +/- 15 mmHg and BP in the early morning 146.5 +/- 16/78.5 +/- 7 mmHg. The three techniques showed a good correlation and WCP was detected in 46.7% of patients with SMBP and in 56.7% with ABPM. We found no correlation between BP and macroangiopathy, but an increase of systolic BP in SMBP and ABPM in proteinuric patients were found and correlation between mass left ventricular index (MLVI) and PP in office and systolic BP and PP in SMBP and ABPM was significant. 70% of patients were non dippers, with a higher MLVI. CONCLUSIONS: Decreases in BP in type 2 diabetes with diabetic nephropathy are difficult of maintain despite combinations of different antihypertensive drugs. These patients present an important WCP and worse prognosis data, such as elevation of systolic BP, increased PP, poor night BP fall and a BP rise in the early morning. Also, we can't reduced the BP during 24 hours in an important number of patients. These characteristics can be detected by combining the office BP measurement, SMBP and ABPM. The alternative possibility would be lifestyle modification, appropriate drug combinations and to start treatment at lower levels than those currently used as thresholds (the guidelines for antihypertensive treatment have been drastically shifted in this direction over the past years).

Comparación de presión arterial clínica, automedida domiciliaria de presión arterial y monitorización ambulatoria de presión arterial en el paciente con diabetes mellitus tipo 2 y nefropatía diabética / Comparison of office blood pressure, self-monitored blood pressure and ambulatory blood pressure in type 2 diabetes with diabetic nephropathy

Objetivo: Se estudian las características de la hipertención arterial en el paciente con diabetes mellitus (DM) tipo 2 y nefropatía diabética con el objetivo de analizar la concordancia entre la presión arterial en consulta (PAC), la automedida domiciliaria de PA (AMPA) y la monitorización ambulatoria de PA (MAPA) y el grado de asociación de las tres técnicas con la afectación cardiovascular y renal.Material y método: Los criterios de inclusión en el estudio fueron la existencia de DM tipo 2, hipertensión arterial y nefropatía diabética. Se recogen las determinaciones bioquímicas, la afectación macrovascular y se realiza ecocardiograma. Sin modificar el tratamiento antihipertensivo se determinan las cifras de PA mediante tres técnicas: PAC, AMPA y MAPA.Resultados: Se estudian 60 pacientes con una edad media de 66,7 ñ 9 años y una duración de la diabetes de 11,3 ñ 7 años. La hemoglobina glicada fue de 7,8 por ciento, la creatinina plasmática de 1,2 ñ 0,5 mg/dl, el 70 por ciento presentaban microalbuminuira y el 30 por ciento proteinuria. La media de fármacos antihipertensivos administrados fue de 2,2 ñ 1. Las cifras de PA fueron: PAC: 158,2 ñ 24 / 85,3 ñ 9 mmHg, con presión del pulso (PP) 72,9 ñ 21 mmHg; AMPA: media diurna 145,4 ñ 18 / 77,5 ñ 7 mmHg, PP 67,9 ñ 18 mmHg y toma matutina 150,2 ñ 20 / 79,9 ñ 9 mmHg; MAPA: media diurna 138,9 ñ 15 / 74,1 ñ 6 mmHg, PP 64,8 ñ 15 mmHg y media en las 2 primeras horas de la mañana 146,5 ñ 16 / 78,5 ñ 7 mmHg. Las tres técnicas mostraron buena correlación entre sí y el fenómeno de bata blanca (FBB) se detectó en un 46,7 por ciento según AMPA y en un 56,7 por ciento según MAPA. No se encuentra correlación entre las cifras de PA y la macroangiopatía, y sí mayor elevación de PAS en AMPA y MAPA en los pacientes con proteinuria NEFROLOGÍA. Vol. XXII. Número 2. 2002 y correlación significativa del índice de masa ventricular izquierda (IMVI) con la PP en consulta y con la PA sistólica y la PP en AMPA y MAPA. El 70 por ciento fue non dipper, con un mayor IMVI.Conclusiones: La hipertensión arterial en la DM tipo 2 con nefropatía diabética es difícil de controlar a pesar de la combinación de distintos fármacos antihipertensivos, presenta un importante FBB y datos de mayor agresividad como la elevación a expensas principalmente de la PA sistólica, una presión del pulso aumentada, un pobre descenso nocturno y una cifras elevadas enlas primeras horas de la mañana. Estas características suponen una dificultad añadida en su manejo y pueden ser detectadas combinando las tomas en consulta con la AMPA y la MAPA. En su control, se debe considerar la modificación del estilo de vida, una adecuada combinación de fármacos y un inicio precoz del tratamiento con umbrales de PA más bajos de los habitualmente utilizados, orientación que han tomado las guías de tratamiento antihipertensivo en los últimos años. a pesar de ello, en un número importante de pacientes no se consigue controlar de forma adecuada la PA durante las 24 horas (AU)

[Characteristics of acute renal failure in elderly patients admitted to a small town hospital]. / Epidemiología, aspectos clínicos y manejo del fracaso renal agudo en una población envejecida dependiente de un hospital comarcal.

We studied the features of acute renal failure (ARF) in elderly patients treated in a hospital, without an intensive care unit, to identify etiological factors and establish adequate preventive measures and treatment. During twelve consecutive months we studied prospectively 99 patients with ARF diagnosed by conventional criteria, an incidence of 1,238 cases per million per year. ARF affected 1.78% of patients admitted to hospital. We analyzed age, sex, serum creatinine, diuresis, etiology, type of ARF, preexisting chronic diseases, treatment, complications and outcome. Preexisting chronic diseases were common, the most frequent being hypertension (54%) and diabetes (39%). Previous treatments for cardiovascular diseases were frequent (angiotensin-renin system blockade 35.4%, diuretics 50.5%). 79% of ARF arose in hospital, 21% outside hospital. ARF was pre-renal in 60%, renal in 31% and post-renal in 9%. 34.7% were caused by volume depletion, 23.4% by low cardiac output and 23.4% by infection. 44.4% of ARF patients had oliguria or anuria latrogenic factors contributed to the ethiology of ARF in 35.3% of patients. Hospital stay was doubled by ARF the presence of ARF and the mortality was 36.4%. The rate was higher in ARF arising in hospital than in ARF acquired before admission. Factors that had a significant influence on the mortality rate were comorbid conditions, oliguroanuria, ARF of renal origin and serum albumin. We conclude that ARF has a high incidence, morbidity and mortality in this elderly population. Volume depletion, associated cardiovascular pathology and pharmacological treatment are important etiological factors in those with ARF outside hospital. Adequate treatment of ARF and avoidance of nephrotoxic medications are necessary in hospital.

[Nutritional status and plasma amino acid levels in hemodialysis]. / Estado nutricional y niveles plasmáticos de aminoácidos en hemodiálisis.

The objective of this work is to study the relation between the variations of the plasmatic aminogram, and the nutritional state of the patient with chronic kidney failure on hemodialysis. We studied 79 patients with chronic kidney failure undergoing hemodialysis treatment, with and evolution of 46 +/- 37 months. They were subjected to a dietary questionnaire, and anthropometric study after dialysis (body mass index, triceps skin fold, muscular circumference of the arm), and determination of the levels of serum amino acids after a pre-dialysis nocturnal fast half way through the week, and finally a record is made of the number of times each patient was hospitalized in the 6 months prior to the study. In the amino acids with a pyruvate origin, there is a significant reduction of alanine (p: 0.002), serine (p: 0.004), and methionine (p: 0.001), and a significant increase of glycine, cystathionine, and cystine (p: 0.0001), with the Glycine/Serine coefficient being elevated (p: 0.001). All amino acids with a ketoglutarate origin are increased significantly (p < 0.007), except glutamine which is decreased (p: 0.0009), and arginine which does not show any significant differences. The essential amino acids are decreased in relation to the non-essential ones (p: 0.0001), although if they are compared with the normal values, only threonine is decreased (p: 0.001). Of the rest, histidine, isoleucine (p: 0.0001) and phenylalanine (p: 0.001) are significantly increased. The tyrosine/phenylalanine coefficient is decreased (p: 0.001). The daily ingestion of protein is correlated negatively with alanine, proline, hydroxyproline, and aspartic acid. The anthropometric parameters are correlated positively with the branched amino acids, alanine and proline. Finally, the number of hospital admissions in the last 6 months, is correlated positively with valine, leucine, phenylalanine, and glutamic acid. In conclusion, we consider that the increase of the glycine/serine, phenylalanine/serine and non essential/essential coefficients, is related to alterations of the metabolism, intrinsic to the condition of uremia, while the alterations of the levels of branched amino acids is related to the nutritional condition of the patients.