Feasibility and Safety of Percutaneous Kidney Biopsy in Small Kidneys: Breaking the Paradigm.

INTRODUCTION: The percutaneous kidney biopsy (PKB) is an essential tool in nephrology, small kidney size has been a relative contraindication to PKB and there is limited data on the safety and utility of performing PKB in this setting. Our aim was to describe the complications of PKB in small kidneys and to assess if kidney biopsy results have an impact on medical decisions and outcomes. METHODS: This was a retrospective, descriptive, and observational study. Patients older than 16 years of age with a decreased kidney size (≤ 8 cm), and undergoing PKB of native kidneys from July 2019 to December 2022 were included. RESULTS: Twenty-five patients were included, 19 women and 6 men. The mean age was 42.3 ± 18.04. The mean kidney length was 7.56 ±0.33 and the mean width was 4.2 cm. All patients received only one puncture, obtaining an average of 12 glomeruli. The mean BUN and serum creatinine were 36 mg/dl and 1.94 mg/dl, respectively and the mean Hgb (hemoglobin) was 12.87 ±2.81g/dL. Minor complications occurred in 5 patients, perirenal hematoma in 3 patients, hematuria in 1 patient, and hematoma plus hematuria in 1 patient. Histological examination showed FSGS, lupus nephritis, other Glomerular disease (GD), crescentic glomerulonephritis (GN), and tubulointerstitial nephritis in 36%, 20%, 16%, 16%, and 12% of the cases, respectively. Biopsy resulted in management modification in 64% of cases. In a bivariate analysis, kidney size was not associated with higher complication rates. CONCLUSIONS: Percutaneous kidney biopsy in small kidneys is a feasible and safe procedure when properly planned, providing an adequate sample in all cases, with an insignificant number of minor complications, and that is clinically relevant.

Exploring kidney biopsy findings in congenital heart diseases: Insights beyond cyanotic nephropathy.

BACKGROUND: The association between congenital heart disease and chronic kidney disease is well known. Various mechanisms of kidney damage associated with congenital heart disease have been established. The etiology of kidneydisease has commonly been considered to be secondary to focal segmental glomerulosclerosis (FSGS), however, this has only been demonstrated in case reports and not in observational or clinical trials. AIM: To identify baseline and clinical characteristics, as well as the findings in kidney biopsies of patients with congenital heart disease in our hospital. METHODS: This is a retrospective observational study conducted at the Nephrology Department of the National Institute of Cardiology "Ignacio Chávez". All patients over 16 years old who underwent percutaneous kidney biopsy from January 2000 to January 2023 with congenital heart disease were included in the study. RESULTS: Ten patients with congenital heart disease and kidney biopsy were found. The average age was 29.00 years ± 15.87 years with pre-biopsy proteinuria of 6193 mg/24 h ± 6165 mg/24 h. The most common congenital heart disease was Fallot's tetralogy with 2 cases (20%) and ventricular septal defect with 2 (20%) cases. Among the 10 cases, one case of IgA nephropathy and one case of membranoproliferative glomerulonephritis associated with immune complexes were found, receiving specific treatment after histopathological diagnosis, delaying the initiation of kidney replacement therapy. Among remaining 8 cases (80%), one case of FSGS with perihilar variety was found, while the other 7 cases were non-specific FSGS. CONCLUSION: Determining the cause of chronic kidney disease can help in delaying the need for kidney replacement therapy. In 2 out of 10 patients in our study, interventions were performed, and initiation of kidney replacement therapy was delayed. Prospective studies are needed to determine the usefulness of kidney biopsy in patients with congenital heart disease.

Resultados de un programa de detección temprana de nefropatía diabética / Results of a program of early detection of diabetic nephropathy

Resumen ANTECEDENTES: La nefropatía diabética constituye la primera causa de enfermedad renal crónica y sustitución de la función renal en todo el mundo. OBJETIVO: Evaluar los factores de riesgo del inicio y progresión de la nefropatía diabética. MATERIAL Y MÉTODO: Estudio descriptivo, retrospectivo, transversal, mediante análisis de pruebas de función renal, como la depuración de creatinina y albuminuria de 24 horas, en el que se realizó la búsqueda intencionada de hallazgos anormales en pacientes atendidos de enero a diciembre de 2016 en el área de consulta externa de un hospital general de segundo nivel de atención. Los datos se analizaron usando el paquete estadístico SPSS versión 15 para Windows. RESULTADOS: Se incluyeron 56 pacientes, fue posible detectar nefropatía diabética en 61% de la población contra 30% mediante técnicas tradicionalmente utilizadas en la consulta general de pacientes diabéticos. Se encontró al tabaquismo activo [OR 3.500 (IC95%, 1.188-22.511)] y a la hiperglucemia persistente como los principales factores asociados con la aparición de nefropatía [OR 2.143 (IC95%, 1.145-4.009)], el nivel de control subóptimo prolongado constituyó el denominador común que los diferenció de la población sin nefropatía diabética (p = 0.002). CONCLUSIONES: El tabaquismo activo y la hiperglucemia persistente fueron los principales factores asociados con la aparición de nefropatía.

Abstract BACKGROUND: Diabetic nephropathy is the first cause of chronic kidney disease and renal function replacement worldwide. OBJECTIVE: To evaluate the risk factors of initiation-progression of diabetic nephropathy. MATERIAL AND METHOD: A cross-sectional, retrospective, descriptive study, through analysis of renal function tests, such as the creatinine and albuminuria clearance of 24 hours, an intentional search of abnormal findings was carried out from January to December 2018 in the external consultation of a second level general hospital. The data was analyzed using the statistical package SPSS version 15 for Windows. RESULTS: There were included 56 patients. It was possible to detect diabetic nephropathy in 61% of the population against 30% by means of techniques traditionally used in the general consultation of diabetic patients. Active smoking [OR 3.500 (95%CI, 1188-22211)] and persistent hyperglycemia were found as the main factors associated with the development of nephropathy [OR 2.143 (95%CI, 1.145-4.009)], constituting the level of prolonged suboptimal control the common denominator that differentiates them from the population without diabetic nephropathy (p = 0.002). CONCLUSIONS: Active smoking and persistent hyperglycemia were found as the main factors associated with the development of nephropathy.

Detección temprana de nefropatía diabética, a propósito de su cribado / Early diagnosis of diabetic nephropathy and its screening

INTRODUCCIÓN: La nefropatía diabética constituye la primera causa de enfermedad renal crónica y sustitución de la función renal a nivel mundial sin excepción, esto debido al acelerado deterioro en la función renal sufrido por los pacientes que se mantienen lejos de las metas de control metabólico en diabetes, así como, las comorbilidades asociadas que contribuyen como factores de progresión adicionales, ocasionando una caída inevitable en la tasa de filtración glomerular con la subsecuente terapia dialítica. Considerando, que actualmente no existen intervenciones preventivas de nefrología enfocados en diabetes, presentamos los resultados de un programa realizado en la atención de primera vez de estos pacientes en el Hospital General Guillermo Álvarez Macías, Tula de Allende, Hidalgo, México. OBJETIVO: La detección temprana de nefropatía diabética y determinación de factores de riesgo asociados. MATERIAL Y MÉTODOS: Estudio descriptivo retrospectivo transversal, mediante análisis de pruebas de función renal, incluido el estudio de albuminuria de 24 horas, se realizó una búsqueda intencionada de hallazgos anormales. Los datos fueron analizados usando el paquete estadístico SPSS versión 15 para Windows. RESULTADOS: Fue posible detectar la nefropatía diabética en el 61% de la población contra 30% mediante técnicas tradicionalmente utilizadas en la consulta general de pacientes diabéticos. Se encontró a la hiperglicemia persistente como el principal factor asociado al desarrollo de nefropatía, constituyendo el nivel de control subóptimo prolongado el denominador común que los diferencia de la población sin nefropatía diabética (p 0.002). CONCLUSIONES: considerando que la nefropatía diabética es una enfermedad prevenible, es de fácil detección al realizar un cribado adecuado en el primer y segundo nivel de atención, que permita su referencia oportuna al especialista en nefrología para su apoyo en el tratamiento

INTRODUCTION: Diabetic nephropathy constitutes the leading cause of chronic kidney disease and renal function substitution all over the world and without exception, given the rapid deterioration of renal function suffered by patients who fail to achieve diabetes metabolic control goals and the associated comorbidities representing additional progression factors. All these cause an unavoidable drop in glomerular filtration rate and a subsequent dialysis treatment. Considering that nowadays there are not any preventive interventions in nephrology focused on diabetes, we present the results of a program conducted on patients treated for the first time at Hospital General Guillermo Álvarez Macías, Tula de Allende, Hidalgo, México. OBJECTIVE: Early diagnosis of diabetic nephropathy and identification of associated risk factors. METHODS: A descriptive, retrospective, cross-sectional study, which included a 24-hour albumin test, was conducted by means of renal function tests deliberately looking for abnormal findings. Data were analyzed using the SPSS 15 statistical software for Windows. RESULTS: By means of traditional techniques used to treat diabetic patients in general, it was possible to diagnose diabetic nephropathy in 61% of the patients vs. 30%. Persistent hyperglycemia was found to be the main factor associated with nephropathy, lengthy suboptimal control levels being the common factor that distinguishes these patients from the population not suffering from diabetic nephropathy (p 0.002). CONCLUSIONS: Given that diabetic nephropathy is a preventable disease, it is easy to diagnose it through an adequate screening at first- and second-level care, which allows a timely referral to a nephrology specialist to treat it

Classification of Acute Rejection Episodes in Kidney Transplantation: a Proposal Based on Factor Analysis.

INTRODUCTION: Kidney transplantation is considered the ideal treatment for end-stage renal disease. Acute rejection can influence graft survival. The aim of this study was to propose a classification system for acute rejection based on factor analysis. MATERIALS AND METHODS: Data were collected from kidney transplant recipients with acute rejection diagnosis based on standard histological variables, the presence of peritubular eosinophils, and immunolabeling for lysozyme and myeloperoxidase in kidney tissue. Factor analysis was employed for data reduction and generation of a new case classification, with orthogonal rotation as a strategy to simplify factors, and principal component analysis was used as an extraction method. RESULTS: Seventy-nine kidney biopsies were obtained from 74 patients. The total population was divided into humoral rejection (39.2%), cellular rejection (34.1%), and mixed acute rejection (26.7%). No significant differences were found between the three groups in clinical and biochemical variables. We extracted 4 factors using factor analysis. The 1st factor was characterized by the presence of capillaritis, plasma cells infiltration, tubulitis, and inflammation. The 2nd factor included positivity for lysozyme and myeloperoxidase, while the 3rd factor included the presence of eosinophils and glomerulitis. The 4th component consisted of the presence of C4d and endarteritis. The cases belonging to the 3rd factor showed the greatest increase in serum creatinine. The cases belonging to the 4th factor exhibited greater urinary excretion of proteins. CONCLUSIONS: This proposal of classification of acute rejection could contribute to evaluate the prognosis of kidney transplant recipients.

A pilot study on the impact of a low fructose diet and allopurinol on clinic blood pressure among overweight and prehypertensive subjects: a randomized placebo controlled trial.

Fructose and sodium intake have been associated with hypertension and metabolic syndrome. Although various mechanisms are involved, fructose causes hypertension partly through rising intracellular and serum uric acid. To date, there are no studies in adults that have evaluated the impact of low fructose diets and allopurinol on prehypertensive and overweight subjects. The objective of this study was to compare the effect of low fructose diet and allopurinol or placebo on blood pressure (BP) and metabolic syndrome components The study was a controlled clinical trial and consisted of two phases; in the first phase of intervention (4 weeks), patients were randomized to either low fructose diet (34 patients) or control diet (38 patients). In the second phase of intervention (weeks 4-8), the same groups continued with the same diet prescriptions but were further randomized to receive placebo or allopurinol (300 mg/d). Clinic and 24-hour ambulatory BP, anthropometric measures, and laboratory data were determined at baseline, weeks 4 and 8. Seventy-two patients were included in the trial. At the end of the dietary phase, both diet groups significantly reduced their BP, but there were no between-group differences. Compared to placebo, at the end of follow-up, subjects in the allopurinol group had a lower clinic systolic blood pressure and this was significant within- and between-group comparisons. The percentage of dippers was higher in the allopurinol group, and weight was reduced significantly despite the absence of caloric restriction Allopurinol was associated with a significant reduction in clinic BP, an increase in the percentage of dippers, and significant weight loss. Larger studies with longer follow-up are needed to confirm our findings.

Determinación del transporte peritoneal de fósforo como herramienta para el control del fósforo sérico / Determination of peritoneal phosphate transport as a tool for controlling serum phosphorus

Introducción: La hiperfosfatemia (fósforo sérico ≥ 5,5 mg/dl) es un factor independiente de mortalidad en la población en diálisis. Comparamos el transporte peritoneal de fósforo, creatinina y urea para demostrar diferencias y señalar la relevancia de estos parámetros en el control del fósforo sérico. Material y métodos: Se incluyeron 60 pacientes en diálisis peritoneal y se determinó el índice dializante/plasma de fósforo (D/P P) y creatinina (D/P Cr), el aclaramiento semanal de fósforo (AclP) y creatinina (AclCr), Kt/V de urea semanal y la excreción peritoneal de fósforo (ExP). Resultados: El D/P P fue superior en pacientes con normofosfatemia, comparados con los que presentaron hiperfosfatemia, 0,61 ± 0,13 frente a 0,54 ± 0,10 (p = 0,035). Se observó una adecuada correlación entre el D/P P y el D/P Cr, r = 0,90, p < 0,05, pero una pobre concordancia entre ambos, con un límite inferior de −0,17 (−0,24 a −0,09 IC 95 %) y límite superior de 0,47 (0,39-0,54 IC 95 %) para el D/P Cr respecto al D/P P. El AclP tuvo una adecuada correlación con el D/P P en pacientes con Kt/V ≥ 1,7 (r = 0,384, p = 0,04) y en anúricos (r = 0,392, p = 0,04), pero no con el D/P Cr. Hubo una pobre concordancia del AclCr respecto al AclP con límite inferior de -13,54 l/sem/1,73 m2 SC (-21,68 a -5,4 IC 95 %) y límite superior de 58,98 l/sem/1,73 m2 SC (50,84-67,12 IC 95 %). La ExP total se relacionó con el AclP (r = 0,643, p < 0,05), mientras que no lo hizo con el AclCr (r = 0,222, p = 0,23). Mediante el método CHAID se realizó un árbol de clasificación del transporte de fósforo con base en su D/P, obteniendo 5 nodos (≤ 0,5, 0,51-0,55, 0,56-0,66, 0,67-0,76, > 0,76), mostrando diferencias estadísticamente significativas entre nodos para niveles séricos de fósforo, AclP total y peritoneal, así como Kt/V de urea semanal. Conclusiones: Las mediciones de D/P P y AclP no concuerdan con las mediciones de D/P Cr y AclCr, respectivamente, por lo que su determinación es una herramienta clínica para el control del nivel de fósforo sérico (AU)

Background: Hyperphosphataemia (serum phosphorus ≥5.5mg/dl) is an independent mortality factor for the dialysis population. We compared phosphorus, creatinine and urea peritoneal transport to demonstrate differences and indicate the relevance of these parameters in the control of serum phosphorus. Material and method: We included 60 patients on peritoneal dialysis and determined the dialysate/plasma phosphorus (D/P P) and creatinine (D/P Cr) ratios, weekly creatinine clearance (CrCl) and phosphorus clearance (PCl), weekly Kt/V of urea, and peritoneal phosphorus excretion (PEx). Results: D/P P was higher in patients with normal phosphataemia, compared with those who were hyperphosphataemic 0.61±0.13 versus 0.54±0.10 (p=.035). We observed an adequate correlation between D/P P and D/P Cr, r=0.90, p<.05, but poor concordance between both, with a lower limit of -0.17 (-0.24 to -0.09 95% CI) and an upper limit of 0.47 (0.39-0.54 95% CI) for D/P Cr with respect to D/P P. PCl had an adequate correlation with D/P P in patients with a Kt/V ≥1.7 (r=0.384, p=.04) and in anuric patients (r=0.392, p=.04), but not with D/P Cr. There was poor concordance of the CrCl with respect to PCl with a lower limit of -13.54l/week/1.73m2 BSA (-21.68 to -5.4 95% CI) and an upper limit of 58.98l/week/1.73m2 BSA (50.84-67.12 95% CI). Total PEx was related to PCl (r=0.643, p<.05), while it was not related to CrCl (r=0.222, p=.23). Using the CHAID method, we created a classification tree for phosphorus transport based on its D/P, obtaining 5 nodes (≤0.5, 0.51-0.55, 0.56-0.66, 0.67-0.76, >0.76), with statistically significant differences between nodes for serum phosphorus, total and peritoneal PCl and weekly Kt/V of urea. Conclusions: D/P P and PCl are not concordant with D/P Cr and CrCl respectively and therefore their determination is a clinical tool to control serum phosphorus levels

Determination of peritoneal phosphate transport as a tool for controlling serum phosphorus.

BACKGROUND: Hyperphosphataemia (serum phosphorus ≥5.5mg/dl) is an independent mortality factor for the dialysis population. We compared phosphorus, creatinine and urea peritoneal transport to demonstrate differences and indicate the relevance of these parameters in the control of serum phosphorus. MATERIAL AND METHOD: We included 60 patients on peritoneal dialysis and determined the dialysate/plasma phosphorus (D/P P) and creatinine (D/P Cr) ratios, weekly creatinine clearance (CrCl) and phosphorus clearance (PCl), weekly Kt/V of urea, and peritoneal phosphorus excretion (PEx). RESULTS: D/P P was higher in patients with normal phosphataemia, compared with those who were hyperphosphataemic 0.61±0.13 versus 0.54±0.10 (p=.035). We observed an adequate correlation between D/P P and D/P Cr, r=0.90, p<.05, but poor concordance between both, with a lower limit of −0.17 (−0.24 to −0.09 95% CI) and an upper limit of 0.47 (0.39-0.54 95% CI) for D/P Cr with respect to D/P P. PCl had an adequate correlation with D/P P in patients with a Kt/V ≥1.7 (r=0.384, p=.04) and in anuric patients (r=0.392, p=.04), but not with D/P Cr. There was poor concordance of the CrCl with respect to PCl with a lower limit of −13.54l/week/1.73m2 BSA (−21.68 to −5.4 95% CI) and an upper limit of 58.98l/week/1.73m2 BSA (50.84-67.12 95% CI). Total PEx was related to PCl (r=0.643, p<.05), while it was not related to CrCl (r=0.222, p=.23). Using the CHAID method, we created a classification tree for phosphorus transport based on its D/P, obtaining 5 nodes (≤0.5, 0.51-0.55, 0.56-0.66, 0.67-0.76, >0.76), with statistically significant differences between nodes for serum phosphorus, total and peritoneal PCl and weekly Kt/V of urea. CONCLUSIONS: D/P P and PCl are not concordant with D/P Cr and CrCl respectively and therefore their determination is a clinical tool to control serum phosphorus levels.

Aldosterone synthase gene polymorphism and renal histopathologic changes in kidney transplant patients receiving a calcineurin inhibitor.

INTRODUCTION: Aldosterone participates in the pathogenesis of calcineurin inhibitor nephrotoxicity (CIN), producing renal vasoconstriction and transforming growth factor beta (TGFß) expression. The objective of this study was to assess aldosterone polymorphisms and relationships to plasma aldosterone levels and the development of renal histological lesions in kidney transplant patients. MATERIAL AND METHODS: Patients with kidney graft biopsy were divided according to the presence or absence of CIN. We determined aldosterone synthase (AS) -344 T/C and int 2 W/C gene polymorphisms and plasma aldosterone levels. Histological, biochemical and clinical variables were measured. RESULTS: Calcineurin inhibitor (CI) levels were significantly higher in patients with the int 2 WW genotype than in patients with WC or CC genotypes. There was a greater degree of interstitial fibrosis in patients with int 2 CC genotype. No relationship was found between the different polymorphisms and a higher degree and/or frequency of CIN. There was also no relationship with plasma aldosterone levels. CONCLUSION: The frequency of the different polymorphisms studied was not related to plasma aldosterone levels or the development of CIN; however, the int 2 CC genotype was related to a greater degree of interstitial fibrosis, whereas the WW genotype was related to higher CI serum levels.

Nefrocalcinosis y acidosis tubular renal distal en síndrome de Sjögren / Nephrocalcinosis and distal renal tubular acidosis in Sjögren's syndrome

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Síndrome de Sjögren y acidosis tubular renal distal reversible: una mirada a sus manifestaciones renales / Sjögren's syndrome and reversible distal renal tubular acidosis: Renal manifestations

Resumen Presentamos el caso de un paciente masculino con síndrome de Sjögren cuya manifestación clínica inicial fue extraglandular, teniendo el riñón como principal órgano afectado bajo la forma de acidosis tubular renal distal, que lo llevó a nefrocalcinosis como complicación en su evolución natural. Su hallazgo permitió el diagnóstico de esta exocrinopatía autoinmune, lográndose la remisión clínica y estabilización de la función renal con el uso de esteroides.

Abstract We describe a male patient with Sjögren's syndrome, whose initial clinical manifestation was extraglandular. The kidney was the main organ affected in the form of distal renal tubular acidosis that led to nephrocalcinosis as a complication during its natural progression. These findings led to the diagnosis of autoimmune exocrinopathy, with clinical remission and stabilization of renal function being achieved with the use of steroids.

Asociación entre excreción peritoneal de proteínas, episodios de peritonitis y D/P de fósforo en pacientes en diálisis peritoneal / Association between peritoneal protein excretion, peritonitis and D/P phosphate, in patients on peritoneal dialysis

Introducción: Se ha observado una relación entre el aumento de la transferencia de solutos (aumento del D/P de creatinina) y la disminución de la ultrafiltración, el aumento de la mortalidad y el riesgo de fracaso de la técnica en pacientes en diálisis peritoneal (DP). Las altas tasas de transporte de solutos se asocian con una mayor excreción peritoneal de proteínas (EPP) y esto se ha relacionado con un mayor riesgo de peritonitis. Nuestro objetivo fue evaluar la posible asociación entre la EPP, el número de episodios de peritonitis y el D/P de fósforo. Material y métodos: Se realizó un estudió longitudinal de cohorte prospectivo en pacientes en DP, a los que se les midió el D/P de fósforo, la EPP, el número de episodios de peritonitis, parámetros de adecuación, así como diferentes variables clínicas y bioquímicas. Resultados: Se incluyeron 60 pacientes en programa de DP ambulatoria. Se encontró una correlación significativa positiva (r = 0,369; p = 0,005) entre el D/P de fósforo y la EPP, al igual que entre la EPP y el número de episodios de peritonitis (r = 0,65; p = 0,044). Finalmente, se encontró que a mayor EPP y a mayor D/P de fósforo, menor nivel sérico de albumina (r = -0,50, p = 0,001 y r = -0,621, p = 0,000, respectivamente). Conclusiones: La EPP se asocia significativamente con el número de episodios de peritonitis y el D/P de fósforo (AU)

Introduction: There is a relationship between increased transfer of solutes (increased D/P creatinine) and decreased ultrafiltration, increased mortality and risk of technique failure in peritoneal dialysis patients. High rates of solute transport are associated with increased peritoneal protein excretion (PPE) and this has been associated with an increased risk of peritonitis. Our objective was to evaluate the possible association between the PPE, the number of episodes of peritonitis and the D/P phosphate. Material and methods: A prospective longitudinal cohort study in PD patients. D/P phosphate, PPE, the number of episodes of peritonitis, as well as adequacy parameters and clinical and biochemical variables were measured. Results: We included 60 patients on ambulatory peritoneal dialysis. We found a significant positive correlation (r=.369, P=.005) between the D/P phosphate and PPE, as well as between the PPE and the number of episodes of peritonitis (r=.65, p=.044). Finally, we found that the higher PPE and D/P phosphate, the lower serum albumin was (r=-0.50, p=.001 and r=-0.621, p=.000, respectively). Conclusions: The EPP is significantly associated with the number of episodes of peritonitis and the D/P phosphate (AU)

Presentación clínico-patológica de la nefropatía lúpica: experiencia de un centro mexicano / Clinicopathological presentation of lupus nephritis: Experience in a Mexican center

Antecedentes: La nefritis lúpica continúa siendo, en nuestro medio, la principal causa autoinmune de enfermedad renal crónica terminal, que requiere sustitución de la función renal. Existe poca información al respecto de su presentación clínico-patológica y de su evolución en la población mexicana. Objetivo: Describir una serie de pacientes con nefropatía lúpica atendidos en nuestra institución, sus características clínicas, comportamiento histológico y tratamiento. Métodos: Estudio observacional, longitudinal y retrospectivo, de pacientes con nefropatía lúpica a quienes se les realizó al menos una biopsia renal, entre enero de 2004 y enero de 2012. Resultados: Se incluyeron 100 pacientes, 85% perteneciente al género femenino; se destaca un largo tiempo de evolución de nefropatía lúpica con 13,1 ± 28,1 meses, un valor de creatinina ≤ 1,3 mg/dL en el 63% de los individuos, su forma más común de presentación como síndrome nefrítico y hematuria-proteinuria en 68% de los casos, compatible, en cierta medida, con la biopsia renal percutánea, que demostró hallazgos de nefropatía tipo proliferativa en 79% de los pacientes. Todos los sujetos recibieron una intervención terapéutica, siendo evaluados a los 12 meses en promedio los que tenían una segunda biopsia, lo cual representó el 57% de los sujetos, permitiendo, los hallazgos de esta, la modificación de su inmunosupresión en 81% de los casos (46/57). El 10% de la población total necesitó terapia dialítica a 12 meses. Conclusiones: La detección y referencia temprana de los pacientes con nefropatía lúpica permite un abordaje y tratamiento oportunos, que podrían limitar el rápido deterioro de su función renal y progresión a enfermedad renal crónica terminal a corto plazo.

Background: Lupus nephritis is the leading cause of chronic kidney disease, and requires renal replacement treatment. There is not much information about its clinicopathological presentation and evolution in the Mexican population. Objective: To describe the clinical, histological and treatment characteristics of lupus nephritis patients attended in our institution. Methods: This is an observational, longitudinal, and retrospective study. Lupus nephritis patients underwent at least one renal biopsy between January 2004 and January 2012. Results: A total of 100 patients were included, of whom 85% were female. The mean onset of lupus nephritis was 13.1±28.1 months, with 63% of patients with a creatinine below 1.3 mg/dL. The most common clinical presentation was nephritic and hematuria-proteinuria syndrome in 68% of cases. Proliferative nephropathy was found in 79% of patients. All patients received the treatment indicated by their nephrologist. A second biopsy was performed on 57% of the patients 12 months after the therapeutic intervention. The findings in the second biopsy led to a modification in immunosuppressive agents in 81% of patients (46/57). Only 10% of the population required dialysis at 12 months. Conclusions: Early detection and referral of patients with lupus nephritis allows a treatment that could limit the rapid deterioration of renal function and chronic kidney disease progression.

Association between peritoneal protein excretion, peritonitis and D/P phosphate, in patients on peritoneal dialysis.

INTRODUCTION: There is a relationship between increased transfer of solutes (increased D/P creatinine) and decreased ultrafiltration, increased mortality and risk of technique failure in peritoneal dialysis patients. High rates of solute transport are associated with increased peritoneal protein excretion (PPE) and this has been associated with an increased risk of peritonitis. Our objective was to evaluate the possible association between the PPE, the number of episodes of peritonitis and the D/P phosphate. MATERIAL AND METHODS: A prospective longitudinal cohort study in PD patients. D/P phosphate, PPE, the number of episodes of peritonitis, as well as adequacy parameters and clinical and biochemical variables were measured. RESULTS: We included 60 patients on ambulatory peritoneal dialysis. We found a significant positive correlation (r=.369, P=.005) between the D/P phosphate and PPE, as well as between the PPE and the number of episodes of peritonitis (r=.65, p=.044). Finally, we found that the higher PPE and D/P phosphate, the lower serum albumin was (r=­0.50, p=.001 and r=­0.621, p=.000, respectively). CONCLUSIONS: PPE is significantly associated with the number of episodes of peritonitis and the D/P phosphate.

Utilidad de la biopsia renal seriada en nefropatía lúpica / Use of serial renal biopsies in lupus nephritis

Introducción: la nefritis lúpica continúa siendo en nuestro medio la principal causa autoinmune de enfermedad renal crónica terminal que requiere sustitución de la función renal. Existe poca literatura acerca de la utilidad de la biopsia seriada en esta población. Nuestro objetivo fue evaluar la función renal de los pacientes con biopsias renales seriadas a 1 año de su seguimiento, comparándola con pacientes que sólo tienen una biopsia basal. Métodos: estudio observacional, comparativo,longitudinal y retrospectivo, de pacientes con nefropatía lúpica a quienes se les realizó al menos una biopsia renal entre enero del 2004 y enero del 2012. Resultados: se incluyeron 100 pacientes con nefropatía lúpica, 57 con biopsia seriada y 43 sin biopsia seriada. La población sin biopsiaseriada tuvo mayor proporción de pacientes con deterioro de la función renal (58.1% vs. 41.9%) y mayor proporción de pacientes con diálisis a 1 año de seguimiento en comparación al grupo con biopsia seriada (9% vs. 1%, p=0.002). En el grupo con biopsia seriada, el 80.7% vieron modificado su régimen de inmunosupresión en función del resultado de la biopsia renal seriada. De estos el 57.9% de los casos recibieron un tratamiento de inmunosupresión más agresivo o bien, un nuevo esquema. Conclusiones: la utilidad de la biopsia renal seriada en pacientes con nefropatía lúpica radica en permitir cambios oportunos de la inmunosupresión, lo cual puede contribuir a en lentecer la progresión del daño renal en esta población de riesgo(AU).

Introduction: In our working environment, lupus nephritis remains the leading autoimmune cause of terminal chronic kidney disease requiring renal function replacement. There is little literature on the use of a serial biopsy in this population. Our objective was to assess the renal function of patients with serial renal biopsies at 1 year of follow-up, compared with patients who had only one baseline biopsy. Methods: An observational, comparative, longitudinal and retrospective study in patients with lupus nephritis who underwent at least one renal biopsy between January 2004 and January 2012. Results: 100 patients with lupus nephritis were included: 57 with serial biopsy and 43 without serial biopsy. The population without a serial biopsy had a greater proportion of patients with impaired renal function (58.1% vs. 41.9%) and a higher proportion of dialysis patients at 1 year followup compared to the serial biopsy group (90% vs. 10%, p=0.002). In the serial biopsy group, the immunosuppressive regime was modified in 80.7% depending on the outcome of the renal biopsy serial. Of these, 57.9% of patients received either a more aggressive immunosuppressive treatment or a new scheme. Conclusions: the usefulness of a serial renal biopsy in patients with lupus nephritis lies in allowing for timely changes in immunosuppression, which may help to slow the progression of kidney damage in this risk population.

Síndrome pulmón-riñón en lupus severo asociado aANCA: ¿un síndrome de sobreposición? / Lung - kidney syndrome in severe lupus ANCA associated: overlap syndrome?

Presentamos el caso de una mujer de 30 años, mexicana, que luego de permanecer sin datos de actividad lúpica renal por 13 años, desde su diagnóstico, sin inmunosupresión crónica, experimenta un deterioro general por un estado autoinmune severo desencadenado tras un embarazo a término sin complicaciones, presentando, incluso, hemorragia alveolar difusa en 2 ocasiones,durante 12 meses, en el contexto de anticuerpos anti citoplasma de neutrófilos ANCA (+), volviendo su manejo difícil desde el punto de vista terapéutico con esquemas de inmuno-supresión triple y cuádruple. Durante su evolución ha desarrollado microangiopatía cerebral y laringitis, por lo que se plantea la posibilidad de un síndrome de sobreposición lupus eritematoso sistémico – vasculitispauciinmune, una entidad no bien descrita en la literatura, cuyo diagnóstico está plagado de dificultades al no existir criterios definidos, ni la verdadera implicación de los ANCA en un paciente con lupus.

We report the case of a woman of 30 years, Mexican, who after spending without renal lupus activity data for 13 years after diagnosis, without chronic immunosuppression, experienced a general decline for severe autoimmune condition triggered after an uncomplicated term preg-nancy presenting even diffuse alveolar hemorrhage in 2 occasions within 12 months, in the context of Anti neutrophil cytoplasmic ANCA (+), becoming its handling difficult from the point of view of therapeutic immunosuppression regimens triple and quadruple. During its evolution has developed cerebral microangiopathy and laryngitis which raises the possibility of an overlap syndrome lupuserythematosus – ANCA associated vasculitis, an entity not well described in the literature, whose diagnosis is fraught with difficulties in the absence of defined criteria or true ANCA involvement in a patient with lupus.

Utilidad de la biopsia renal seriada en nefropatía lúpica / Use of serial renal biopsies in lupus nephritis

Introducción: la nefritis lúpica continúa siendo en nuestro medio la principal causa autoinmune de enfermedad renal crónica terminal que requiere sustitución de la función renal. Existe poca literatura acerca de la utilidad de la biopsia seriada en esta población. Nuestro objetivo fue evaluar la función renal de los pacientes con biopsias renales seriadas a 1 año de su seguimiento, comparándola con pacientes que sólo tienen una biopsia basal. Métodos: estudio observacional, comparativo,longitudinal y retrospectivo, de pacientes con nefropatía lúpica a quienes se les realizó al menos una biopsia renal entre enero del 2004 y enero del 2012. Resultados: se incluyeron 100 pacientes con nefropatía lúpica, 57 con biopsia seriada y 43 sin biopsia seriada. La población sin biopsiaseriada tuvo mayor proporción de pacientes con deterioro de la función renal (58.1% vs. 41.9%) y mayor proporción de pacientes con diálisis a 1 año de seguimiento en comparación al grupo con biopsia seriada (9% vs. 1%, p=0.002). En el grupo con biopsia seriada, el 80.7% vieron modificado su régimen de inmunosupresión en función del resultado de la biopsia renal seriada. De estos el 57.9% de los casos recibieron un tratamiento de inmunosupresión más agresivo o bien, un nuevo esquema. Conclusiones: la utilidad de la biopsia renal seriada en pacientes con nefropatía lúpica radica en permitir cambios oportunos de la inmunosupresión, lo cual puede contribuir a en lentecer la progresión del daño renal en esta población de riesgo.

Introduction: In our working environment, lupus nephritis remains the leading autoimmune cause of terminal chronic kidney disease requiring renal function replacement. There is little literature on the use of a serial biopsy in this population. Our objective was to assess the renal function of patients with serial renal biopsies at 1 year of follow-up, compared with patients who had only one baseline biopsy. Methods: An observational, comparative, longitudinal and retrospective study in patients with lupus nephritis who underwent at least one renal biopsy between January 2004 and January 2012. Results: 100 patients with lupus nephritis were included: 57 with serial biopsy and 43 without serial biopsy. The population without a serial biopsy had a greater proportion of patients with impaired renal function (58.1% vs. 41.9%) and a higher proportion of dialysis patients at 1 year followup compared to the serial biopsy group (90% vs. 10%, p=0.002). In the serial biopsy group, the immunosuppressive regime was modified in 80.7% depending on the outcome of the renal biopsy serial. Of these, 57.9% of patients received either a more aggressive immunosuppressive treatment or a new scheme. Conclusions: the usefulness of a serial renal biopsy in patients with lupus nephritis lies in allowing for timely changes in immunosuppression, which may help to slow the progression of kidney damage in this risk population.

[Kidney transplant program at the Instituto Nacional de Cardiologia Ignacio Chavez]. / Programa de trasplante renal en el Instituto Nacional de Cardiología Ignacio Chávez.

The first renal transplant was done on July 22, 1968 and until December, 2010 a total of 865 procedures have been performed. Immunosuppressive protocols have changing with time: from 1968 to 1984 azathioprine + prednisone plus total radiation in some cases; from 1985 to 1998 cyclosporine + azathioprine + prednisone; in 1998 tacrolimus is used for first time; Mofetil micofenolate was available at 2005 and practically has displaced to azathioprine. As far as possible we use some induction therapy. Primary ESRD etiologies were: unknown (74.9%), glomerulonephritis (9.7%) and diabetic nephropathy (4.2%). Recipient's mean age was 29.9 +/- 11.6 years (12-70) and 35 +/- 9.8 years (18-62) in donors. Analysis group for graft and patient survival included 292 transplants (censured for death with functional graft) with a follow-up of 103 months (CI 95%: 99-108). Survival at 1, 5 and 10 years were: 95, 85 and 60% for graft as well as 100, 94 and 90% for patient. In year 2000 we started to perform renal biopsies at transplant (time zero biopsies), those results have been published and at present are a worldwide reference. In September, 2005 laparoscopic donor nephrectomy is initiated, 180 procedures have been done with excellent results. In year 2006, training in renal transplant acquires the endorsement as a Medicine Posgrade recognized by the UNAM School of Medicine. We have participated in 9 national clinical trials and 6 international multicentric ones. Our renal transplant program offers a good choice for patients with low resources with similar results reported in the literature using current immunosuppressive schemes and surgical procedures. Institutional authorities and humanitarian associations support in addition to participation on investigation studies have been of vital importance.