La diálisis peritoneal es la mejor alternativa coste-efectiva para la sostenibilidad del tratamiento con diálisis / Peritoneal dialysis is the best cost-effective alternative for maintaining dialysis treatment

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Análisis del transporte peritoneal de potasio mediante pruebas de equilibrio peritoneal con diferentes concentraciones de glucosa / Correlates of potassium transport during peritoneal equilibration tests using different dialysate glucose concentrations

Introducción: El conocimiento de los factores que determinan el transporte peritoneal de potasio en diálisis peritoneal (DP) es incompleto. Los objetivos de este estudio fueron comparar el transporte peritoneal de potasio en pruebas de equilibrio peritoneal (PEP) con soluciones de glucosa al 2,27 y al 3,86%, y desvelar factores con influencia en este fenómeno. Método: Noventa pacientes en DP fueron sometidos a PEP al 2,27 y al 3,86%, en orden aleatorio. Comparamos el transporte de potasio en ambas pruebas, buscando correlaciones del cociente D/P de potasio a 240 minutos (variable principal) con marcadores de función peritoneal durante PEP, y con diferentes variables demográficas, clínicas y bioquímicas, usando una estrategia multivariante. Resultados: El D/P de potasio presentó buena concordancia en ambas PEP, mostrando asociación univariante con el D/P de creatinina, pero no con potasio plasmático, ultrafiltración o descenso de sodio. La edad, tipo de DP, carga peritoneal de glucosa, icodextrina, tratamiento con IECA-ARA o calcioantagonistas, potasio urinario y filtrado glomerular tuvieron una correlación univariante con el transporte de potasio. En el análisis multivariante, el D/P de creatinina a 240 minutos (B = 0,40 [IC 95%: 0,26-0,53] 2,27%; B = 0,36 [0,21-0,51] 3,86%; p <0,0005) fue el predictor esencial del D/P de potasio a 240’. La excreción urinaria de potasio también tuvo una correlación inversa con la variable principal. Asimismo, el tratamiento con IECA-ARA se asoció de forma consistente con el transporte peritoneal de potasio, pero sólo en la PEP al 3,86% (B = 0,08 [0,04-0,12]; p <0,0005). Conclusiones: Las PEP al 2,27 y al 3,86% estiman de manera concordante el transporte peritoneal de potasio. Aunque el transporte de creatinina es el predictor principal del de potasio, la excreción urinaria de potasio y el tratamiento con IECA-ARA se asocian de manera independiente con el fenómeno citado (AU)

BBackground: There are gaps in the knowledge of factors which influence peritoneal potassium transport in peritoneal dialysis (PD). The aims of this study were to compare peritoneal potassium transport in PD patients undergoing 2.27% and 3.86% peritoneal equilibration tests (PET), and to disclose clinical correlates of this phenomenon. Method: Ninety PD patients underwent 2.27% and 3.86% PET, in a random order. We compared peritoneal potassium transport in both tests, and searched for correlations between D/P potassium at 240 minutes (main study variable) and PET-derived markers of peritoneal function and selected demographic, clinical and biochemical variables, using a multivariate approach. Main results: D/P potassium showed a good agreement between both PET, and presented a univariate association with creatinine transport, but not with plasma potassium, ultrafiltration or sodium dip. Age, PD modality, peritoneal glucose load, icodextrin, ACEI-ARA and calcium antagonist therapy, urinary potassium and glomerular filtration rate were other univariate correlates of potassium transport. Multivariate analysis confirmed D/P creatinine at 240 minutes (B = 0.40 [95% CI 0.26-0.53] 2.27%, B = 0.36 [0.21-0.51] 3.86%,p <0.0005) as the main predictor of D/P potassium at 240’. Urinary potassium, rather than glomerular filtration rate, sustained also an inverse correlation with the dependent variable. Treatment with ACEI-ARA was consistently associated with peritoneal potassium transport (3.86% PET) (B = 0,08 [0.04-0.12], p <0.0005). Conclusions: The 2.27% and the 3.86% PET show a good agreement at the time of estimating peritoneal potassium transport. Urinary potassium excretion and treatment with ACEI-ARA (3.86% test) show an independent association with peritoneal potassium transport rate (AU)

[Changing the frequency of administration of darbepoetin alfa (from weekly to fortnightly) maintains the haemoglobin levels in patients undergoing peritoneal dialysis]. / El cambio en la frecuencia de administración de darbepoetin alfa (de semanal a quincenal) mantiene los niveles de hemoglobina en pacientes en diálisis peritoneal.

SUMMARY BACKGROUND: Less frequent dosing regimens during anemia treatment could benefit Peritoneal Dialysis (PD) patients. We investigated the effectiveness of darbepoetin alfa dosed every-other-week (Q2W) for maintaining hemoglobin (Hb) levels (11-13 g/dL). PATIENTS AND METHODS: One hundred and nine PD patients from 14 centers participated in an 8-month observational, prospective study. Patients (Hb 11-13 g/dL) receiving weekly (QW) darbepoetin alfa switched to Q2W dosing at the investigator's discretion. Doses were adjusted according to published guidelines. RESULTS: Sixty-nine percent (75 out of 109) of patients switched to Q2W dosing. Thirty-three percent maintained the g/week, equivalent to twice the previous mean weekly dose (26.1-25.8 g/week, QW dose). Forty-seven percent received a dose reduction (35.8-20.2 equivalent to the previous QW dose). More patients in the maintenance dose group 11 g/dL than those receiving a reduced weekly dose (80% vs. had Hb levels 51.4%, respectively, p = 0.0236). During the Q2W phase, the mean Hb level ranged from 12.0-12.5 g/dL for the maintenance dose group and 11.5-12.0 g/dL for the reduced dose group. From the switch to the end of the study, the mean (SD) change in Hb was -0.7 g/dL (0.98 g/dL, p = 0.0557) and -0.6 g/dL (1.6 g/dL, p = 0.1296) for the maintenance and reduced dose groups, respectively. The Q2W darbepoetin alfa was well tolerated. Only a single treatment-related adverse event (polycythemia) occurred. CONCLUSION: The majority of PD patients receiving QW darbepoetin alfa can be effectively switched to Q2W and still maintain their Hb level.

Inflamación, función renal residual, sobrehidratación y fallo de membrana. El cubo de Rubik de la diálisis peritoneal / No disponible

En los últimos años se han acumulado gran cantidad de evidencias, experimentales y clínicas, que apoyan la existencia de interacciones entre el declive de la función renal residual, el estado de hidratación, la aparición de estados inflamatorios y el deterioro funcional y estructural de la membrana peritoneal, en pacientes tratados con Diálisis Peritoneal. Estas interacciones son complejas, y distan de haber sido entendidas en su totalidad, pero cada una de las alteraciones citadas parece capaz de potenciar los efectos lesivos de las otras, afectando de manera clara a las probabilidades de supervivencia de estos pacientes. La preservación de la función renal residual y de la capacidad funcional de la membrana peritoneal, junto con otras medidas destinadas a prevenirla sobre hidratación y reducir la intensidad de los fenómenos inflamatorios constituyen mecanismos esenciales de prevención de riesgo en estos pacientes, y deben ser abordados desde una perspectiva conjunta. Las nuevas soluciones de Diálisis Peritoneal, aparentemente más biocompatibles, podrían jugar un papel esencial en la consecución de estos objetivos (AU)

Over the last years, a large amount of experimental and clinical evidence has been accumulated that supports the existence of interactions between the decline in residual renal function, hydration status, inflammatory states and functional and structural deterioration of the peritoneal membrane in patients treated with peritoneal dialysis. These interactions are complex and remain far from being fully understood, but each one of these alterations appears to be capable of aggravating the harmful effects of the others, clearly affecting the probabilities of survival of these patients. Preservation of residual renal function and functional capacity of the peritoneal membrane, together with other measures to prevent over hydration and reduce the intensity of inflammatory phenomena, are essential mechanisms for risk prevention in these patients, and should be addressed from a joint perspective. New peritoneal dialysis solutions, apparently more biocompatible, could play an essential role in the achievement of these objectives (AU)

Tratamiento inmunosupresor en el paciente que inicia diálisis peritoneal tras el cese funcional del trasplanterenal. ¿Qué hacer? / No disponible

El número creciente de pacientes renales que han de reiniciar diálisis tras el cese funcional de un trasplante renal ha trasladado a este ámbito la polémica general sobre los criterios de elección de modalidad de diálisis. Éstos han de aplicarse siguiendo planteamientos a largo plazo, ya que cada paciente puede beneficiarse más de uno u otro tratamiento en distintos momentos de su evolución. Cuando se analiza la cuestión desde una perspectiva general, la Diálisis Peritoneal y la Hemodiálisis parecen proporcionar resultados similares en pacientes procedentes de trasplante renal, aunque la información disponible es todavía insuficiente. El carácter pronóstico crucal de la función renal residual en pacientes incidentes en Diálisis Peritoneal pone sobre el tapete la posible conveniencia de mantener algún tipo de inmunosupresión tras el reinicio de diálisis, al menos hasta el cese total de la función del injerto. Esta decisión se basa actualmente en planteamientos puramente empíricos, ya que no disponemos de información fiable para contestar a las preguntas fundamentales. Así, no sabemos si la función renal residual tiene la misma importancia en este contexto que en el general. Tampoco la retirada o mantenimiento de la inmunosupresión tendrá, presumiblemente, el mismo efecto en todos los casos. Los efectos secundarios de mantener una inmunosupresión parcial y la rentabilidad clínica global para el paciente tampoco están bien definidos. Por último, tampoco está claro qué inmunosupresión se debe mantener, aunque hay acuerdo en que ésta debe ser de bajo grado; los esteroides y, en menor medida los anticalcineurínicos, gozan de más predicamento, pero siempre sobre bases empíricas. Dada la importancia creciente de esta subpoblación de pacientes renales, las preguntas planteadas deberán ser contestadas de manera sistematizada en los próximos años (AU)

The growing number of kidney patients who have to restart dialysis after functional failure of a kidney transplant has brought to this context the general controversy on dialysis modality selection criteria. These should be applied from a longterm perspective, since each patient may benefit more from one treatment or another at different times in his clinical course. When the issue is analyzed from a general perspective, peritonealdialysis and hemodialysis seem to provide similar results in renal transplant patients, although the available information is still insufficient. The crucial prognostic nature of residual renal function in incident patients on peritoneal dialysis brings up the issue of wether it is appropriate to maintain some type of immunosuppression after restarting dialysis, at least until total failure of graft function. This decision is currently based on purely empirical considerations, since we do not have reliable information toanswer the key questions. Thus, we do not know if residual renal function has the same importance in this context as in the overall renal population. Neither if withdrawal of maintenace of immunosuppression will presumably have the same effect in all cases. The side effects of maintaning partial immunosuppression and the overall clinical yield for the patient are also not well defined. Finally, it is unclear what immunosuppression should be maintained, although there is agreement that it should be low grade; steroids and to lesser extent calcineurin inhibitors are the preferred agentes, but always on empirical grounds. Because of the growing importance of this subpopulation of renal patients, these questions should be answered in a systematic manager incoming years (AU)

[Inflammation, residual renal function, overhydration, and membrane failure. The Rubik's cube of peritoneal dialysis]. / Inflamación, función renal residual, sobrehidratación y fallo de membrana. El cubo de Rubik de la diálisis peritoneal.

Over the last years, a large amount of experimental and clinical evidence has been accumulated that supports the existence of interactions between the decline in residual renal function, hydration status, inflammatory states and functional and structural deterioration of the peritoneal membrane in patients treated with peritoneal dialysis. These interactions are complex and remain far from being fully understood, but each one of these alterations appears to be capable of aggravating the harmful effects of the others, clearly affecting the probabilities of survival of these patients. Preservation of residual renal function and functional capacity of the peritoneal membrane, together with other measures to prevent overhydration and reduce the intensity of inflammatory phenomena, are essential mechanisms for risk prevention in these patients, and should be addressed from a joint perspective. New peritoneal dialysis solutions, apparently more biocompatible, could play an essential role in the achievement of these objectives.

[Immunosuppressive treatment in patients starting peritoneal dialysis after functional arrest of kidney transplant. What to do?]. / Tratamiento inmunosupresor en el paciente que inicia diálisis peritoneal tras el cese funcional del trasplante renal. ¿Qué hacer?

The growing number of kidney patients who have to restart dialysis after functional failure of a kidney transplant has brought to this context the general controversy on dialysis modality selection criteria. These should be applied from a longterm perspective, since each patient may benefit more from one treatment or another at different times in his clinical course. When the issue is analyzed from a general perspective, peritoneal dialysis and hemodialysis seem to provide similar results in renal transplant patients, although the available information is still insufficient. The crucial prognostic nature of residual renal function in incident patients on peritoneal dialysis brings up the issue of wether it is appropriate to maintain some type of immunosuppression after restarting dialysis, at least until total failure of graft function. This decision is currently based on purely empirical considerations, since we do not have reliable information to answer the key questions. Thus, we do not know if residual renal function has the same importance in this context as in the overall renal population. Neither if withdrawal of maintenance of immunosuppression will presumably have the same effect in all cases. The side effects of maintaining partial immunosuppression and the overall clinical yield for the patient are also not well defined. Finally, it is unclear what immunosuppression should be maintained, although there is agreement that it should be lowgrade; steroids and to lesser extent calcineurin inhibitors are the preferred agents, but always on empirical grounds. Because of the growing importance of this subpopulation of renal patients, these questions should be answered in a systematic manager in coming years.

Benefits of preserving residual renal function in peritoneal dialysis.

Residual renal function (RRF) is of paramount importance in patients with end-stage renal disease, with benefits that go beyond contributing to achievement of adequacy targets. Several studies have found that RRF rather than overall adequacy (as estimated from total small solute removal rates) is an essential marker of patient and, to a lesser extent, technique survival during chronic peritoneal dialysis (PD) therapy. In addition, RRF is associated with a reduction in blood pressure and left ventricular hypertrophy, increased sodium removal and improved fluid status, lower serum beta(2)-microglobulin, phosphate and uric acid levels, higher serum hemoglobin and bicarbonate levels, better nutritional status, a more favorable lipid profile, decreased circulating inflammatory markers, and lower risk for peritonitis in PD. As compared with conventional hemodialysis, PD is associated with a slower decrease in RRF. This highlights the usefulness of strategies oriented to preserve both RRF and the long-term viability of the peritoneal membrane. Several factors contributing to the loss of RRF have been identified and should be avoided. Renoprotective drugs and new glucose-sparing, more biocompatible PD regimes may prove useful tools to preserve RRF and peritoneal membrane function in the near future.

[Economic study of dialysis using the cost-per-procedure method according to clinical protocols]. / Estudio económico de la diálisis por el método de coste por procedimiento ajustado a protocolo clínico.

Studies analyzing the economic cost of dialysis therapy have raised a considerable interest in the nephrologic community, both inside and outside our country. The objective of the present study was to approach this question from a different point of view, by applying the cost-per-procedure method, according to clinical protocol, to all the routine clinical procedures in our dialysis unit (both Hemodialysis and Peritoneal Dialysis). We analyzed 68 routine protocols (42 for Hemodialysis and 26 for peritoneal Dialysis), carrying out a pormenorized study of all the components of the economic cost of each procedure (personnel, laboratory, surgical and sanitary material, drugs and other concepts). We calculated the final cost of all these procedures after individualizing the different components of the economic spends, with the informatic support of the management department of our center, and in coordination with the data bases of the Pharmacy and General Supplies units. Although the initial implementation of this method is tedious, it subsequently allows to analyze the global cost of therapy in the Unit, as also the cost of certain subsets, or even particular patients, in a simple and flexible way. Moreover, the system is easy to update, as clinical protocols undergo changes or the economic cost of individual components vary. Finally, this method is a useful tool at the time of comparing the cost of clinical procedures in different centres, according to their varying clinical protocols, economic spends and clinical results.

Estudios de costes en diálisis. Un instrumento esencial para optimizar recursos / Economic studies in dialysis. An essential tool for optimization of resources

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Estudio económico de diálisis por el método de coste por procedimiento ajustado a protocolo clínico / Economic study of dialysis using the cost-per-procedure method according to clinical protocols

El estudio de costes de diálisis ha generado un importante interés entre los nefrólogos suscitando estudios comparativos entre las diferentes modalidades dentro1, 2 y fuera de nuestro país3-5. El objetivo del presente trabajo es describir el método de análisis de coste por procedimiento ajustado a protocolo clínico de todos los protocolos realizados en nuestra Unidad de Diálisis (hemodiálisis y diálisis peritoneal). Analizamos un total de 68 protocolos realizados de manera rutinaria en nuestra Unidad (42 en Hemodiálisis y 26 en Diálisis Peritoneal) con estudio pormenorizado de todos los componentes del coste (personal, laboratorio, material quirúrgico y sanitario, fármacos y otros conceptos). Tras la descripción de los diferentes componentes del coste y mediante un trabajo informático del área de gestión (conectada a los servicios de Farmacia y Compras de Suministros) se calcularon los costes de cada uno de los procedimientos. Este método, laborioso en su implantación inicial, genera posteriormente, de forma sencilla, la posibilidad de estudio de los costes globales de la Unidad y de cada enfermo en particular. Asimismo, resulta fácilmente actualizable según cambien los protocolos y los costes de cada uno de los componentes del mismo. Por otro lado, resulta una herramienta clave para comparar los costes entre los diferentes hospitales según los protocolos y resultados de cada uno (AU)

Studies analyzing the economic cost of dialysis therapy have raised a considerable interest in the nephrologic community, both inside and outside our country. The objective of the present study was to approach this question from a different point of view, by applying the cost-per-procedure method, according to clinical protocol, to all the routine clinical procedures in our dialysis unit (both Hemodialysis and Peritoneal Dialysis). We analyzed 68 routine protocols (42 for Hemodialysis and 26 for peritoneal Dialysis), carrying out a pormenorized study of all the components of the economic cost of each procedure (personnel, laboratory, surgical and sanitary material, drugs and other concepts). We calculated the final cost of all these procedures after individualizing the different components of the economic spends, with the informatic support of the management department of our center, and in coordination with the data bases of the Pharmacy and General Supplies units. Although the initial implementation of this method is tedious, it subsequently allows to analyze the global cost of therapy in the Unit, as also the cost of certain subsets, or even particular patients, in a simple and flexible way. Moreover, the system is easy to update, as clinical protocols undergo changes or the economic cost of individual components vary. Finally, this method is a useful tool at the time of comparing the cost of clinical procedures in diferent centres, according to their varying clinical protocols, economic spends and clinical results

[Guidelines of the Spanish Society of Nephrology. Clinical practice guidelines for peritoneal dialysis]. / Guías Sociedad Española de Nefrología. Guías de práctica clínica en diálisis peritoneal.

In Spain and in each of its autonomous communities, the dialysis treatment of chronic renal disease stage 5 is totally covered by public health. Peritoneal dialysis, in any of its modalities, is established as the preferred home dialysis technique and is chosen by high percentage of patients as their choice in dialysis treatment. The Spanish Society of Nephrology has promoted a project of creation of performance guides in the field of peritoneal dialysis, entrusting a work group composed of members of the Spanish Society of Nephrology a with the development of these guides. The information offered is based on levels of evidence, opinion and clinical experience of the most relevant publications of the topic. In these guides, after defining the concept of << peritoneal dialysis>>, the obligations and responsibilities of the sanitation team of the peritoneal dialysis unit are determined, and protocols and performance procedures that try to include all the aspects that concern the patient with chronic renal disease in substitute treatment with this technique are developed. They propose prescription objectives based on available clinical evidence and, lacking this, on the consensus of the experts' opinions. The final aim is to improve the care and quality of the of the patient in peritoneal dialysis, optimizing in this way the survival of the patient and of the technique. In Spain, as in other neighbouring countries, peritoneal dialysis has an incidence and prevalence that is much lower than that of hemodialysis, ranging in the last evaluation by the Spanish Society of Nephrology between 5 and 24% in the different autonomous communities. The great majority of peritoneal dialysis units form part of the public network of the Spanish state, with special representation as a Satellite Unit or Concerted Center related to the public hospital of reference, on which it must depend.

Agreement between two routine methods of estimation of glomerular filtration rate in patients with advanced and terminal chronic renal failure.

BACKGROUND: Estimations of glomerular filtration rate (GFR) obtained either by the modification of diet in renal disease study equation (MDRD-GFR) or by classic 24-hour urine collection-based methods (mean of creatinine and urea clearance (Ccr-ur)) are considered to be equivalent in patients with chronic renal failure (CRF). However, the agreement between both methods has been insufficiently studied in patients during the most advanced stages of CRF. METHODS: We compared 615 estimations of GFR performed by both methods simultaneously in adult (> 18 years) patients with advanced (aCRF) (15 - 30 ml/min/1.73m2) and preterminal (tCRF) (< 15 ml/min/1.73m2) chronic renal failure. We also analyzed the influence of some relevant covariables (demographic characteristics, inflammatory and nutritional markers) with respect to the concordance between both methods. RESULTS: In aCRF, mean GFR were 19.7 +/- 5.5 (MDRD-GFR) and 19.3 +/- 3.7 ml/min/1.73m2 (Ccr-ur) (mean difference 0.4 ml/min/1.73m2, 95% confidence interval CI -0.3/1.1, p = 0.26), with an intraclass correlation coefficient of 0.46. In tCRF, mean GFR was 12.5 +/- 4.2 and 10.4 +/- 2.7 ml/min/1.73m2, respectively (mean difference 2.1 ml/min/1.73m2, 95% CI 1.7/2.4, p < 0.0005), with an intraclass correlation co-efficient of 0.43. Multivariate analysis identified lean body mass, body mass index, protein nitrogen appearance, proteinuria, gender, age, albumin (aCRF) and prealbumin (tCRF) as variables independently correlated with the difference MDRD-GFR minus Ccr-ur. Lean body mass was by far the strongest predictor of deviations between both methods, both in aCRF (R2 = 0.66, p < 0.0005) and tCRF (R2 = 0.49, p < 0.0005). CONCLUSIONS: MDRD-GFR and Ccr-ur show an acceptable agreement in advanced stages of chronic renal failure. However, MDRD-GFR produces estimations of GFR systematically higher than those given by the Ccr-ur method, in patients with tCRF. Moreover, this overestimation is particularly marked in some high risk subsets, including elderly patients and those presenting markers of a poor nutritional condition. Until this issue is further clarified, GFR should be estimated using Ccr-ur rather than MDRD-GFR in patients with tCRF, as also in older and malnourished patients with aCRF, as this may represent a more conservative and safer approach at the time of planning initiation of renal replacement therapy.

Effects of two simplified methods of dialysate sampling on estimations of adequacy indices in automated peritoneal dialysis.

OBJECTIVE: To assess the effects of two simplified methods of dialysate sampling on the estimation of adequacy markers in automated peritoneal dialysis (APD). DESIGN: Cross-sectional noninterventional study. SETTING: Tertiary-care hospital. PATIENTS: Forty-nine patients undergoing standard APD therapy (36 nontidal, 13 tidal with low reserve volume). INTERVENTION: We estimated creatinine clearance (CCr), Kt/V urea, sodium removal, and peritoneal protein loss using two simplified methods. We calculated separate diurnal and nocturnal adequacies. Nocturnal concentrations of urea, creatinine, sodium, and proteins were extrapolated from dialysate samples taken after the first (method A) or the last (method B) cycle of the night. For the reference method, we estimated adequacy from a complete 24-hour dialysate collection. RESULTS: Spearman correlations versus the reference method were, for CCr, 0.82 for method A and 0.87 for method B; and for Kt/V, 0.78 (A) and 0.72 (B). Method A overestimated CCr by 19.6% (4.5 L/week)(median values) and Kt/V by 8.8% (0.12). Method B overestimated CCr by 5.0% (1.7 L/week) and Kt/V by 4.4% (0.06). Both methods estimated sodium removal accurately, but estimated protein loss poorly. Tidal APD was associated with a clear overestimation of adequacy indices with both methods. In fact, when only nontidal patients were considered, method B slightly underestimated CCr and Kt/V. CONCLUSIONS: In APD, estimation of nocturnal adequacy from dialysate samples taken after the first cycle is inaccurate. Estimation from samples taken after the last cycle yields suboptimal but acceptable results; the deviation is small and the dose of dialysis delivered to the patients is not overestimated.

Diabetes mellitus y riesgo cardiovascular / Diabetes mellitus and cardiovascular risk

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Insuficiencia renal crónica VI: prevención de su progresión / Chronic renal insufficiency. VI: Progression prevention

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