Nutrición e insuficiencia renal crónica / Nutrition and chronic renal failure

En los pacientes con insuficiencia renal crónica es frecuente la malnutrición calórico-proteica y además es un buen predictor de morbilidad y mortalidad. En este artículo, se resumen las causas y las diferentes aproximaciones terapéuticas para revertir esta situación, destacando la suplementación nutricional mediante la administración oral o parenteral especialmente en el momento de la diálisis. Son necesarios más estudios sobre las diferentes intervenciones nutricionales para evaluar su eficacia en cuanto a calidad de vida, morbilidad y mortalidad (AU)

Protein-calorie malnutrition is common in chronic kidney disease patients and is a powerful predictor of morbidity and mortality. Causes and management are shown in this article, highlighting nutritional supplementation, administered orally or parenterally, especially during dialysis. Further larger scale randomized, controlled trials of nutritional interventions should be performed to assess their efficacy regarding quality of life, morbidity and mortality (AU)

Fracaso renal agudo en paciente tratado con antifactor de necrosis tumoral-alfa / Acute renal failure in patient treated with anti-tumour necrosis factor alpha

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Inflamación y aterotrombosis. Precocidad de la lesión vascular. Opciones diagnósticas y terapéuticas para prevención primaria / No disponible

La aterosclerosis, una enfermedad inflamatoria, se desarrolla precozmente en la ERC (Fuerza de Recomendación B). Por ello se plantea la indicación de la realización de pruebas para el diagnóstico de aterosclerosis subclínica y de inflamación sistémica.• Los pacientes con ERC tienen un alto riesgo vascular, lo que implica un tratamiento por objetivos de los factores de riesgo vascular.• En este contexto, se puede considerar la realización de pruebas de imagen para el diagnóstico de aterosclerosis subclínica a fin de individualizar las decisiones terapéuticas sobre el manejo de los factores de riesgo cardiovascular cuando el paciente no esté recibiendo ya un tratamiento consistente con el máximo nivel de riesgo (..) (AU)

Atherosclerosis, an inflammatory disease, develops prematurely in CKD (Strength of Recommendation B). The performance of tests for the diagnosis of subclinical atherosclerosis and systemic inflammation should therefore be considered in these patients.• Patients with CKD are at high risk of vascular disease, implying the need for goal-based treatment of the vascular riskfactors.• In this context, imaging tests for the diagnosis of subclinical atherosclerosis can be considered with the goal of individualizing treatment decisions on the management of cardiovascular risk factors when the patient is no longer receiving treatment consistent with the maximum risk level (..) (AU)

[Inflammation and atherothrombosis. Premature vascular injury. Diagnostic and therapeutic options for primary prevention]. / Inflamación y aterotrombosis. Precocidad de la lesión vascular. Opciones diagnósticas y terapéuticas para prevención primaria.

Atherosclerosis, an inflammatory disease, develops prematurely in CKD (Strength of Recommendation B). The performance of tests for the diagnosis of subclinical atherosclerosis and systemic inflammation should therefore be considered in these patients. - Patients with CKD are at high risk of vascular disease, implying the need for goal-based treatment of the vascular risk factors. - In this context, imaging tests for the diagnosis of subclinical atherosclerosis can be considered with the goal of individualizing treatment decisions on the management of cardiovascular risk factors when the patient is no longer receiving treatment consistent with the maximum risk level (Strength of Recommendation C). - The presence of subclinical atherosclerosis would raise cardiovascular risk to the maximum level (Strength of Recommendation C). - Carotid artery ultrasound with determination of carotid intima- media thickness (CIMT) and the presence of atheromatous plaques would be the technique of choice for the assessment of subclinical atherosclerosis in ACKD (Strength of Recommendation C). - C-reactive protein, measured by high-sensitivity assay (hs-CRP), is the only marker of inflammation used routinely in clinical practice. However, there is no evidence that routine determination of hs-CRP improves the outcomes of therapeutic decisions on cardiovascular protection in either the general population or ACKD population. Therefore, routine CRP determination cannot be recommended in patients with CKD to stratify their cardiovascular risk (Strength of Recommendation C).

OPGLl/RANKL y remodelado óseo / OPGL/RANKL and bone remodeling

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[Septic pulmonary embolism in patients on chronic hemodialysis with Staphylococcus aureus bacteremia]. / Embolismo séptico pulmonar en pacientes en hemodiálisis crónica con bacteriemia por Staphylococcus aureus.

Twenty-one cases of septic pulmonary embolism were selected from a series of 76 patients on chronic haemodialysis diagnosed of S. aureus bacteremia. Ninety percent of patients underwent dialysis through an arteriovenous fistula and 10% by means of a prosthetic access. The most common symptoms were fever (100%), pleuritic pain (66%) and productive cough (55%); twenty-four percent of patients had inflammatory signs at vascular accesses. All patients had some symptoms indicative of pulmonary pathology and all of them had positive blood cultures and findings in the chest X-ray. The clinical course was favourable in 100% of cases. Accesses were lost only in the two cases with prosthetic material. The diagnosis was obtained by chest X-ray and blood cultures. Other more sophisticated tests did not improve the diagnostic yielding.

Regulation of Fas and Fas ligand expression in cultured murine renal cells and in the kidney during endotoxemia.

Fas ligand (FasL) and Fas belong to a recently described family of cytokines and receptors with similarities to tumor necrosis factor (TNF) and its receptors. Upon engagement by specific antibodies or by FasL, Fas transduces a signal for apoptosis in permissive cells. Although apoptosis occurs during renal development and following injury to mature cells, the factors responsible for programmed renal cell death are uncertain. We have studied Fas expression by renal cells in vitro and during endotoxemia in mice. Several renal cell types, including glomerular mesangial cells and tubular epithelial cells express a Fas transcript in culture. Lipopolysaccharides (LPS), interleukin-1 beta, interferon-gamma (IFN-gamma), and TNF-alpha increase the levels of Fas mRNA in cultured mesangial and tubular cells. TNF-alpha and LPS raise the level of Fas mRNA in a time- and dose-dependent manner with Fas receptor expression peaking after 72 h of exposure to LPS. Anti-Fas antibodies can induce the death of cultured mesangial cells. This cell death shows the characteristic changes of apoptosis, including DNA fragmentation and pyknotic changes of the nucleus. Increases in Fas by LPS, TNF-alpha, and IFN-gamma enhance the killing induced by the anti-Fas antibody. FasL is also expressed by cultured renal cells, and TNF-alpha treatment of mesangial cells increases its expression. In vivo, Fas mRNA is present at low level in normal kidney. LPS increases the levels of Fas mRNA and protein in kidney and produces evidence of apoptosis along nephrons. These data suggest that transcripts encoding natural FasL and Fas are induced by LPS and may play a role in endotoxemia-induced acute renal failure and organ dysfunction.

Epithelial differentiation of metanephric mesenchymal cells after stimulation with hepatocyte growth factor or embryonic spinal cord.

Mammalian kidney emerges from metanephric mesenchyme following the insertion of a migrating ureteric bud. The pattern morphology of mesenchymal specialization during tubular segmentation is remarkably complex, and the relative contribution of pattern gradients from the microenvironment versus the instructive role of individual cells is not known. We have started to examine the differentiation of metanephric mesenchyme using cultures of metanephric ridge (MMR) cells from day 13.5 mouse embryos to investigate the conversion of mesenchyme toward kidney epithelium in vitro. One of our mesenchymal clones, MMR1, expresses little Pax2, uvomorulin, or cytokeratin but does express neural cell adhesion molecule, bc12, and desmin; these are properties consistent with an early stem cell. Coculture of MMR1 cells with embryonic spinal cord leads to the induction of a more differentiated cell phenotype characterized by decreased expression of neural cell adhesion molecule, the appearance of uvomorulin, and the emergence of cytokeratin, all consistent with an evolution toward epithelium. We were also able to detect the hepatocyte growth factor receptor c-met on MMR1 cells by indirect immunofluorescence. When MMR1 cells were stimulated with hepatocyte growth factor, neural cell adhesion molecule expression decreased and uvomorulin appeared. This effect of hepatocyte growth factor, as a single cytokine, may be important in the early assemblage of kidney, since we were able to detect mRNA transcripts encoding c-met from mouse embryo metanephric kidneys.

[Common variable immunodeficiency and sarcoidosis]. / Inmunodeficiencia variable común y sarcoidosis.

Variable Common Immunodeficiency (VCI) can course with non necrotizing epithelioid granulomatosis of sarcoid type. Although this entity is frequently referred, it is rare and its significance is not clear. The immunological study and response to treatment with corticoids and i.v. immunoglobulins of a patient is who suffered VIC with sarcoid granulomas on lymph node, liver and skin biopsies is here presented. The association between VCI and granulomatosis is discussed.

[Cranial sarcoidosis with an unusual location in the orbital vertex]. / Sarcoidosis craneal con localización excepcional en el vértice orbitario.

Bone sarcoidosis preferentially localizes in skull bones with long lasting skin lesions, (its manifestation in skull are rare and there are only 12 or 13 published cases) and the bone involvement of the cranial basis has been referred, until now, as extensive lesions of granulomas localized in neighbouring structures. We present a case of cranial basis granulomatosis, in a patient diagnosed of multiple sarcoidosis by repetitive biopsies of lymph nodes, liver, and skin with chronic skin lesions, the rare localization of which in the orbital vertex with an original bone procedence, is discussed in the neuroradiologic findings. Such rareness has been found in a carrier of a form of common variable immunodeficiency, a disease which is also rare.

[Gastroenteritis with eosinophilia caused by Giardia lamblia]. / Gastroenteritis con eosinofilia por Giardia lamblia.

A case of gastroenteritis due to Giardia lamblia with severe dehydration and complicated with arterial thrombosis, accompanied by eosinophilia and increased serum IgE levels, is presented. The relationship between Giardia and eosinophilia and allergic manifestations is discussed as well as its pathogenesis.

[Future perspectives of kidney transplant: towards a specific immunosuppression?]. / Perspectivas futuras del trasplante renal: hacia una inmunosupresión específica?

The current status of immunosuppression in renal transplants is reviewed: non-specific (corticosteroids and cytostatics), lymphocyte-specific (polyclonal antilymphocyte globulin), T-specific (cyclosporine, antithymocyte polyclonal gamma globulin) with special attention to the OKT3 and monoclonal antibodies. Supported by the current experience of the use of PAN-T (OKT3) antiidiotypic monoclonal antibodies in the graft rejection treatment, a hypothesis is elaborated--feasible to demonstrate--to determine what would happen if anti-clonotypic monoclonal antibodies (the idiotypes of T lymphocytes) are used when looking for a specific immunosuppression. We conclude that the immunosuppression with anti-idiotypes, if it is confirmed, would be almost ideal.