Infarto agudo de miocardio en un paciente sin factores de riesgo cardiovascular. Una mirada hacia atrás / Acute myocardial infarction in a patient with no cardiovascular risk factors. A look backwards

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Validation of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation in advanced chronic renal failure.

INTRODUCTION: The aim of this work was to study the accuracy of the CKD-EPI equation to estimate the glomerular filtrate in patients with advanced chronic renal failure. OBJECTIVE: We compared the estimations of Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Cockcroft-Gault (CG) equations to a glomerular filtration rate measured as the arithmetic mean of the urea and creatinine clearances (ClUrCr). MATERIAL AND METHODS: The study was made in 89 nondialyzed patients with chronic renal disease in stage 4 or 5. Serum creatinine values were recalibrated to standardized creatinine measurements. In each patient, the difference between each estimating equation and the measured glomerular filtration rate was calculated. The absolute difference expressed as a percentage of the measured glomerular filtration rate indicates the intermethod variability. RESULTS: Overall, the glomerular filtration rate measured as the ClUrCr was 14.5 ± 5.5 ml/min/1.73 m(2); and the results of the estimating equations were: MDRD 14.3 ± 5.5 (p = NS); CKD-EPI 13.6 ± 5.4 (p <0.01) and CG 16.8 ± 6.5 ml/min/1.73 m(2) (p <0.001). The variability of the estimating equations was 16 ± 12.2%, 16.7 ± 12,1% and 22 ± 15.6% (p <0.05), for MDRD, CKD-EPI and CG. The percentage of estimates within 30% above or below the measured glomerular filtration rate was 85% for MDRD, 88% for CKD-EPI and 70% for CG. The CG variability, but not MDRD variability or CKD-EPI variability, was influenced by gender (19.3 ± 15.1% in males vs 27.3 ± 15.5% in females, p <0.05) and showed a negative correlation with the glomerular filtration rate (r = -0.23, p <0.05) and the age (r = -0.24, p <0.05) and positive correlation with the body mass index (r = 0.37, p <0.001). In patients with chronic renal disease in stage 5, the variability of the different estimating equations was similar. CONCLUSIONS: We conclude that in our population with advanced chronic renal failure, the CKD-EPI equation is as accuracy as the MDRD equation. With standardized creatinine the CG equation has a lower accuracy and its utilization may be reconsiderated.

Causes of unplanned hemodialysis initiation.

Half of patients starting chronic hemodialysis used a transient vascular catheter as a vascular access (unplanned initiation). An objective of the Quality Management Group of the Spanish Society of Nephrology is to achieve that 80% of the patients starting hemodialysis do it with an arteriovenous fistula. We want to review the causes of non-planned hemodialysis nowadays. In 2010, 43 patients had started chronic hemodialysis in the Hospital Ramón y Cajal in Madrid (Spain). Mean age was 61 years, 79% were men, the most frequent cause of chronic renal disease was the diabetes (23%) and Charlson Comorbidity Index was 6.3 ± 2.6. The unplanned hemodialysis occurred in 20 patients (47%), without any differences with the 23 patients who began planned hemodialysis, in none of the clinical or demographic parameters analyzed. The main cause of unplanned hemodialysis was the acute exacerbation of chronic kidney disease stage 3 or 4, previously stable, secondary to an unforeseeable intercurrent process (8 patients, 40% of the cases). One patient began after a non-recovery acute renal failure and in other 6 patients, the reason of unplanned hemodialysis initiation was not attributable to the operation Health System (in 3 cases unknown kidney chronic disease and in the other 3 cases it was patient´s responsibility). Only in 5 cases (25%), the cause could be corrigible. Most causes of unplanned hemodialysis does not come from the healthcare organization and therefore not easy to resolve it. Consequently, the objective of the Quality Group will be difficult to be achieved.

Validación de la fórmula Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) en la insuficiencia renal crónica avanzada / Validation of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation in advanced chronic renal failure

Introducción: La ecuación clásica Modification of Diet in Renal Disease (MDRD) subestima el filtrado glomerular en los valores más altos. Para aumentar su concordancia en los estadios 1 y 2 de la enfermedad renal crónica se ha establecido una nueva fórmula: la ecuación Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI). Objetivo: El objetivo del presente estudio es comprobar si la nueva ecuación es mejor que la MDRD en la estimación del filtrado glomerular en la insuficiencia renal crónica avanzada, en una población como la nuestra que tiene unas características antropométricas distintas de las de la población norteamericana. Material y métodos: En 89 pacientes con enfermedad renal crónica en estadios 4 y 5, hemos estudiado el grado de concordancia entre el filtrado glomerular medido como la media de los aclaramientos de urea y creatinina (AclUrCr) y el estimado por las ecuaciones MDRD, CKD-EPI y Cockcroft-Gault (CG). La concentración de creatinina corresponde a creatinina estandarizada. La variabilidad de cada una de las ecuaciones fue estudiada mediante la diferencia relativa (diferencia absoluta con el AclUrCr expresada como porcentaje de la media entre el AclUrCr y la (..) (AU)

Introduction: The aim of this work was to study the accuracy of the CKD-EPI equation to estimate the glomerular filtrate in patients with advanced chronic renal failure. Objective: We compared the estimations of Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Cockcroft-Gault (CG) equations to a glomerular filtration rate measured as the arithmetic mean of the urea and creatinine clearances (ClUrCr). Material and methods: The study was made in 89 nondialyzed patients with chronic renal disease in stage 4 or 5. Serum creatinine values were recalibrated to standardized creatinine measurements. In each patient, the difference between each estimating equation and the measured glomerular filtration rate was calculated. The (..) (AU)

Causas de inicio no programado del tratamiento renal sustitutivo con hemodiálisis / Causes of unscheduled haemodialysis initiation

La mitad de los enfermos que comienzan tratamiento con hemodiálisis periódica lo hacen con un catéter venoso como acceso vascular (inicio no programado). Un objetivo del Grupo de Gestión de Calidad de la Sociedad Española de Nefrología es conseguir que el 80% de los enfermos comiencen la hemodiálisis a través de una fístula arteriovenosa. Hemos querido revisar las causas que condicionan en la actualidad el inicio no programado, para analizar cuáles pueden ser corregibles. En el año 2010, 43 enfermos comenzaron tratamiento con hemodiálisis periódica en el Hospital Ramón y Cajal de Madrid. La edad media fue de 61 años, el 79% eran hombres, la etiología más frecuente fue la diabetes mellitus (23%) y el índice de Charlson era de 6,3 ± 2,6. El inicio no programado de la hemodiálisis ocurrió en 20 enfermos (47%), sin objetivarse diferencias con los 23 enfermos que comenzaron (..) (AU)

Half of patients starting chronic hemodialysis used a transient vascular catheter as a vascular access (unplanned initiation). An objective of the Quality Management Group of the Spanish Society of Nephrology is to achieve that 80% of the patients starting hemodialysis do it with an arteriovenous fistula. We want to review the causes of non-planned hemodialysis nowadays. In 2010, 43 patients had started chronic hemodialysis in the Hospital Ramón y Cajal in Madrid (Spain). Mean age was 61 years, 79% were men, the most frequent cause of chronic renal disease was the diabetes (23%) and Charlson Comorbidity Index was 6.3 ± 2.6. The unplanned hemodialysis (..) (AU)

Acute kidney injury as a risk factor for chronic kidney diseases in disadvantaged populations.

Acute kidney injury (AKI) is considered to be a potential cause for developing chronic kidney disease (CKD); on the other hand, CKD predisposes to AKI. The lack of adequate epidemiological data makes it difficult to determine if AKI induces CKD in less developed countries. The etiology of AKI in rich populations, in whom sophisticated surgery, interventional radiology and oncology treatments are usually the cause of AKI, is very different from that of disadvantaged populations, where the origin of AKI is associated with endemic infections, obstetric problems, poisons, toxins and natural disasters. Any conclusions extrapolated from these two settings should be treated with caution. Moreover, people living in disadvantaged conditions are usually much younger than those in rich areas and this age factor could facilitate total recovery of renal function after AKI if treatment based on an adequate supply of water, rehydration and anti-infectious measures were provided. In the small segment of the population of less developed countries having an income per capita similar to that observed in the developed countries, the long-term outcome of AKI should also be expected to be similar. New data coming from two single centers analyzing only the long-term outcome of acute tubular necrosis (ATN) patients, with a normal or near normal renal function prior to the AKI episode, coincide in reporting a requirement for chronic dialysis among the surviving patients of 2%. If these data are confirmed, the importance of AKI as cause of CKD should be reconsidered, both in developed and less developed countries.

Mycophenolate mofetil absorption quotient: interest to clinical practice.

Use of mycophenolate mofetil (MMF) in kidney transplantation has led to significant improvements in the acute rejection index and graft survival. Posttransplant MMF levels are known to be of value for discriminating patients at risk of acute rejection. Trough MMF levels were measured in 153 patients who had undergone kidney transplantation more than 1 year before and showed stable graft function. MMF dosage was adjusted based on hematologic or gastrointestinal toxicity. The quotient between the weight-adjusted dose and through MMF levels was calculated in order to establish absorption type. We analyzed the diagnostic value of this quotient in relation to creatinine proteinuria, hematologic and gastrointestinal toxicity based upon percentiles of 10, 25, 50, 75, and 90, which were used as cutoff points. Mean MMF levels were 3.79 +/- 3.3 mg/L. Mean quotient value was 6.55 +/- 9.2. A significant correlation was found between MMF dosage and MMF trough levels (r = .34, P < .01). However, no correlation was seen between MMF dosage and the quotient. There were no significant differences in the analyzed parameters and the percentiles established as cutoff points. However, patients with gastrointestinal toxicity had a larger quotient (9.07 +/- 7.45.3 vs 5.28 +/- 4.9). The relationship between MMF dose and levels does not establish differences in kidney function and proteinuria among stable transplant patients; patients with diarrhea may show decreased absorption.

Complete switch to everolimus in long-term kidney transplants: evolution of the renal function.

INTRODUCTION: The use of M-tor inhibitors plus withdrawal of anticalcineurins after 3 months of posttransplantation is usually linked to improvements in renal function. The long-term effects of substitution of anticalcineurinis by everolimus remain unknown. The aim in this study was to evaluate the evolution of renal function and the proteinuria after a complete switch of long-term functioning allograft patients to everolimus. We treated 30 renal transplanted patients with everolimus, at a mean time posttransplantation of 123.8 +/- 74.2 months. The 27 patients, including 17 treated with tacrolimus and 10 with cyclosporine, who were controlled for at least 6 months were included in this study. Seventeen of them were diagnosed to display chronic allograft nephropathy (CAN). RESULTS: The patients with CAN showed a basal creatinine of 1.81 +/- 0.4; with after a year, 1.61 +/- 0.38; and after 2 years, 1.56 +/- 0.49 mg/dL (P < .05). No significant changes were observed among patients without CAN: 1.1 +/- 0.32, 0.97 +/- 0.15, and 0.97 +/- 0.15 mg/dL, respectively. In CAN patients, the protein/creatinine quotient was: basal = 0.30 +/- 0.13, one year = 0.63 +/- 0.68, and 2 years = 0.48 +/- 0.34. In the other patients the values were 0.2 +/- 0.07, 0.73 +/- 0.7, and 0.32 +/- 0.17, respectively, after a late switch to everolimus. CONCLUSION: The improved renal function occurred mainly in patients with CAN. Patients who did not suffer from it showed a greater rise in proteinuria. Nevertheless, both groups experienced decreased proteinuria after 2 years.

Evolution of rejection rates and kidney graft survival: a historical analysis.

INTRODUCTION: New immunosuppressive regimens have dramatically reduced rejection rates but this positive effect has not been followed by an improvement in long-term graft outcomes. The aim of the present work was to investigate the incidence of graft rejection and graft outcomes with various immunosuppressive protocols. PATIENTS AND METHODS: Included in our study were 1029 first renal transplantations performed at our unit between November 1979 and December 2007. Basal immunosuppression included azathioprine (AZA) in 198 recipients, cyclosporine (CsA) in 524 recipients, and tacrolimus (TAC) in 307 recipients. RESULTS: Recipient and donor ages increased progressively from the AZA to the TAC era. Delayed graft function was less frequent among AZA than CsA and TAC recipients (29.8 vs 39.3% vs 42.0%; P = .014). The incidence of acute rejection episodes was 68.7% on AZA, 38.2% on CsA, and 11.4% on TAC (P = .000). Graft survival rates at 1, 5, and 10 years were 69%, 56%, and 46% on AZA, 82%, 69%, and 54% on CsA, and 88%, 77%, and 60% on TAC, respectively (P = .001). However, the differences disappeared when only grafts surviving >12 months were analyzed. On multivariate analysis, the variables associated with worse graft outcomes after 12 months were older recipient age, male gender, longer time on dialysis, lower body weight, and higher serum creatinine level at 6 months. CONCLUSIONS: New immunosuppressants have decreased the incidence of acute rejection. But this was not followed by a significant improvement in graft outcomes after 12 months. The beneficial effects on rejection are possibly affected by the older age of donor and recipient and the worse early graft function.

Vitamin D deficiency in kidney transplant recipients: risk factors and effects of vitamin D3 supplements.

INTRODUCTION: The Kidney Disease Outcome Quality Initiative (K/DOQI) clinical practice guidelines in chronic kidney disease (CKD) give some recommendations about diagnosis and treatment of vitamin D deficiency. These guidelines may also be applied to renal transplant recipients. The aim of the present study was to assess the vitamin D status and the effects of vitamin D3 supplements among a cohort of kidney graft recipients. PATIENTS AND METHODS: Five hundred nine renal transplant recipients with a follow-up of more than 12 months were included in this retrospective cross-sectional study. A total of 189 patients were treated with vitamin D3 supplements, 171 with calcitriol (0.25 or 0.5 microg x 3 weekly) and 18 with cholecalciferol (400 IU/d). RESULTS: 25OHD deficiency was present in 38.3% of patients, insufficiency in 46.9%, and normal levels in 14.7%. There were no differences in the prevalence of deficiency or insufficiency between patients who were not treated or those who were treated with vitamin D3 supplements. Upon multivariate analysis, 25OHD concentrations correlated with gender, length of follow-up, season of 25OHD determination, iPTH and 1.25OHD concentrations, and treatment with ACEI/ARB (R(2) = 0.17; P = .000). CONCLUSIONS: 25OHD deficiency or insufficiency is frequent after renal transplantation even in sunny regions. The clinical significance of such a high prevalence of apparent 25OHD deficiency/insufficiency is unclear and requires further study.

Secondary hyperparathyroidism after kidney transplantation: a cross-sectional study.

INTRODUCTION: The purpose of the present study was to investigate the prevalence of hyperparathyroidism among a population of kidney graft recipients. PATIENTS AND METHODS: We investigated biochemical bone parameters of 509 renal transplant recipients with a mean follow-up of 113 +/- 76 months. Among these patients, 257 patients were treated with either vitamin D or calcium supplements or both. RESULTS: The mean estimated glomerular filtration rate (eGFR) was 47.2 +/- 18.4 mL/min/1.73 m(2) and the mean intact parathyroid hormone (iPTH) level was 144 +/- 149 pg/mL. A total of 70 patients (13.7%) had hypercalcemia defined by a corrected serum calcium >10.2 mg/dL. When the patients were classified according to iPTH concentrations following the Kidney Disease Outcome Quality Initiative (K/DOQI) clinical practice guidelines: 22.4% had iPTH <70 pg/mL; 30.8% between 70 and 110 pg/mL; 16.5% between 110 and 150 pg/mL; 24.3% between 150 and 300 pg/mL; and 6.9% >300 pg/mL. There were no differences in biochemical bone parameters between those that were or were not on calcium and vitamin D supplements, but there was a higher percentage of patients with normal iPTH among the treated group (28.0% vs 16.7%; P = 0.003). In patients not receiving calcium and/or vitamin D supplements, multiple linear regression demonstrated that only time on dialysis, eGFR, and serum 25-hydroxyvitamin D (25OHD) levels were significantly predictive of iPTH concentrations (R(2) = 0.21; P = .000). CONCLUSIONS: About 80% of patients displayed high iPTH concentrations. The persistence of hyperparathyroidism was associated with graft dysfunction, longer time on dialysis, and low concentrations of 25OHD. Treatment with vitamin D produced a slight improvement in the prevalence of hyperparathyroidism.

Aporte de calcio en la insuficiencia renal crónica / No disponible

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Trastorno adaptativo con delirio dermatozoico de infestación en paciente en hemodiálisis / Adaptative disorder with dermatozoic hallucinations in a patient on hemodialysis

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