Política andina de salud pública para enfrentar la enfermedad renal crónica / Andean public health policy to confront chronic kidney disease

El presente documento tiene por finalidad alcanzar una mejora en la acción coordinada, intersectorial, descentralizada, con enfoque de derechos, con enfoque intercultural y por curso de vida, sobre los determinantes de la salud que conlleven a medidas eficientes, eficaces, integrales y de calidad, mediante los lineamientos que han sido analizados por el equipo técnico de los Ministerios de Salud y del ORAS-CONHU a fin de fortalecer la estrategia para la promoción, prevención, diagnóstico oportuno y el tratamiento de las personas que padecen de Enfermedad Renal Crónica en los países andinos

Cardiac Metastasis From Solid Cancers: A 35-Year Single-Center Autopsy Study.

CONTEXT.­: Cardiac metastases are more prevalent than primary cardiac tumors, and although rare, the incidence is anticipated to increase with the extended survival of oncology patients. OBJECTIVE.­: To estimate the current incidence of cardiac metastasis from solid tumors in adult autopsies. DESIGN.­: Adult autopsy cases from 1984 through 2019 from patients diagnosed with any type of solid cancer were retrieved. The medical charts and pathologic autopsy data were reviewed in detail. RESULTS.­: A total of 1294 adult autopsies performed on patients diagnosed with any type of cancer within the past 35 years were reviewed. We found 124 secondary cardiac tumors. Eighty-five were due to cardiac involvement by solid tumors. Of these, 61 were true cardiac metastases of solid cancers. We focused on these 61 cases. The age range was 32 to 85 years. Forty-four patients were men and 17 were women. The lung was the most common primary site, with 21 cases (34.43%). The most frequent histologic type was carcinoma, with 54 cases (88.52%). The predominant layer of the heart involved was the pericardium, with 35 cases (57.38%). Twenty-one cases (34.43%) had pericardial effusion, with 4 being hemorrhagic. All cases had multiple extracardiac metastases, with 56 cases (91.8%) having distant metastases in 4 or more different organs. CONCLUSIONS.­: Cardiac metastasis is a rare occurrence, with an incidence of 4.71% (61 of 1294 cases) in our series. Lung cancer accounted for most of the cardiac metastases seen, and carcinomas were the most frequent histologic type. The pericardium was the most frequent location. Cardiac metastases occurred most frequently in cases of massive metastatic dissemination.

Papillary Renal Neoplasm With Reverse Polarity: A Clinical, Pathologic, and Molecular Study of 8 Renal Tumors From a Single Institution.

CONTEXT.­: In 2019, papillary renal neoplasm with reverse polarity (PRNRP) was defined as a new neoplasm because it has a predominately tubulopapillary pattern lined by a single layer of cuboidal and eosinophilic cells with apically located round nuclei. Immunohistochemically, this neoplasm showed expression of GATA-3 and L1CAM and had recurrent KRAS mutations. OBJECTIVE.­: To estimate the incidence of PRNRP and provide 8 additional cases with some variations in the morphology. DESIGN.­: We reviewed 1627 renal tumors from our hospital during a 21-year period (2000-2020). We reexamined 196 papillary renal cell carcinomas and selected those that met the diagnostic criteria for PRNRP. RESULTS.­: We found 8 cases consistent with PRNRP. The median age of the patients was 64.75 years; 7 patients were male, and 1 was female. Two patients had end-stage renal disease. No recurrence, metastasis, or tumor-related death occurred in a mean follow-up period of 67.62 months. Tumor size ranged from 1.6 to 3.7 cm. All cases were pT1. Seven cases (7 of 8; 87.5%) had predominantly cystic changes, and 1 had solid architecture. No foamy cells, clear cell change, or psammoma bodies were seen in any cases. All cases were positive for CK7, EMA, GATA3, and L1CAM. KRAS gene mutation was detected in 5 cases (5 of 8; 62.5%). CONCLUSIONS.­: PRNRP represents 4.08% (8 of 196 cases) of papillary renal cell carcinomas and 0.49% (8 of 1627 cases) of all renal tumors in the 21-year period in our series. In our study, all cases exhibited an indolent clinical course. This supports that PRNRP has characteristic morphologic and molecular features.

Neuroprotective and Anti-Inflammatory Effects of Linoleic Acid in Models of Parkinson's Disease: The Implication of Lipid Droplets and Lipophagy.

Parkinson's disease (PD) is the second most prevalent neurodegenerative disease after Alzheimer's disease. The principal pathological feature of PD is the progressive loss of dopaminergic neurons in the ventral midbrain. This pathology involves several cellular alterations: oxidative stress, mitochondrial dysfunction, loss of proteostasis, and autophagy impairment. Moreover, in recent years, lipid metabolism alterations have become relevant in PD pathogeny. The modification of lipid metabolism has become a possible way to treat the disease. Because of this, we analyzed the effect and possible mechanism of action of linoleic acid (LA) on an SH-SY5Y PD cell line model and a PD mouse model, both induced by 6-hydroxydopamine (6-OHDA) treatment. The results show that LA acts as a potent neuroprotective and anti-inflammatory agent in these PD models. We also observed that LA stimulates the biogenesis of lipid droplets and improves the autophagy/lipophagy flux, which resulted in an antioxidant effect in the in vitro PD model. In summary, we confirmed the neuroprotective effect of LA in vitro and in vivo against PD. We also obtained some clues about the novel neuroprotective mechanism of LA against PD through the regulation of lipid droplet dynamics.

Reestenosis de stents liberadores de paclitaxel frente a stents convencionales

RESUMEN Introducción: La reestenosis de los stents liberadores de paclitaxel utilizados en Cuba no ha sido estudiada. Objetivo: Evaluar la reestenosis de los stents liberadores de paclitaxel y los convencionales. Métodos: Se incluyeron 64 pacientes con reestenosis de stent, de un estudio prospectivo previo; en 318 pacientes seguidos por 3 años luego de intervención coronaria percutánea; 25 con stent liberador de paclitaxel y 39 stent metálico convencional. Se consideró reestenosis como nueva lesión ≥ 50 % de la luz del vaso con isquemia demostrada. Se describió el tiempo de aparición, patrón angiográfico y alternativa de revascularización. Resultados: La reestenosis en el grupo de stents liberadores de paclitaxel fue 15,7 % con tiempo medio de supervivencia sin reestenosis de 32,4 meses vs. 24,5 % en stents convencionales, con supervivencia sin reestenosis de 29,8 meses, (p= 0,047). En el grupo de stents liberadores de paclitaxel predominó el patrón IB, (30,3 %) y stent convencional el III (28,3 %). En el 28,0 % del grupo de stents liberadores de paclitaxel, se recurrió a la cirugía de revascularización vs. 5,1 % en el grupo de stent convencional. Conclusiones: El stent liberador de paclitaxel logra una supervivencia libre de reestenosis superior y más perdurable que el stent convencional. La reestenosis en los de stents liberadores de paclitaxel es focal, con mayor frecuencia de nueva revascularización por cirugía y en los stents convencionales es mayormente difusa.

ABSTRACT Introduction: The restenosis of the paclitaxel-eluting stents used in Cuba has not been studied. Objective: To evaluate the restenosis of paclitaxel-eluting stents and conventional stents. Methods: 64 patients with stent restenosis were included, from a previous prospective study; in 318 patients followed up for 3 years after percutaneous coronary intervention; 25 with a paclitaxel-eluting stent and 39 conventional metal stent. Restenosis was considered as a new lesion ≥ 50 % of the vessel lumen with proven ischemia. The time to onset, angiographic pattern and alternative revascularization were described. Results: Restenosis in the group with paclitaxel-eluting stents was 15.7 % with a mean survival time without restenosis of 32.4 months vs. 24.5 % in conventional stents, with restenosis-free survival of 29.8 months, (p = 0.047). In the group with paclitaxel-eluting stents, the IB pattern predominated (30.3 %) and the conventional stent III (28.3 %). In 28.0 % of the paclitaxel-eluting stent group, revascularization surgery was used vs. 5.1 % in the conventional stent group. Conclusions: The paclitaxel-eluting stent achieves a superior and more durable restenosis-free survival than the conventional stent. Restenosis in paclitaxel-eluting stents is focal, with a higher frequency of revascularization by surgery, and in conventional stents it is mostly diffuse.

Glomerular Diseases in the Colombian Caribbean: Data from the Colombian Nephropathy Registry (NEFRORED®).

Our study aimed to describe the glomerular diseases, both primary glomerular disease (PGD) and secondary glomerular disease (SGD) in the Colombian Caribbean based on the first regional Colombian Nephropathy Registry (NEFRORED®). A descriptive and retrospective study of adult patients with glomerular diseases from the Colombian Caribbean region was made. All diagnoses by renal biopsy with light microscopy and immunofluorescence obtained between January 2008 and June 2018 were recorded. Eight hundred and seventy-one renal biopsies were obtained. The main clinical indication for biopsy was nephritic syndrome (36%). SGD was more frequent than PGD (55% vs. 45%). Within SGD group, lupus nephritis (LN) was the most frequent etiology (83%). Within PGD group, membranous nephropathy (33%) and focal segmental glomerulosclerosis (FSGS) (19%) were the most common glomerular diseases. At a 24-month follow-up, the patients with FSGS and paraproteinemia-mediated glomerular disease had the worst renal survival prognosis. This is the first Colombian Nephropathy Registry in a Caribbean population, demonstrating a high predominance of SGD due to LN.

Cuidado de enfermería a pacientes en diálisis peritoneal: de la teoría a la práctica / Nursing care of patients in peritoneal dialysis: from theory to practice

Resumen Introducción: la diálisis peritoneal (DP) es el procedimiento médico en el que se eliminan los desechos y el líquido excedente en la sangre, esta terapia conlleva una activa labor de autocuidado por parte del paciente en el domicilio, previo entrenamiento de enfermería para fomentar la adherencia al tratamiento. Objetivo: describir la relación de cuidado que lleva a cabo la enfermera de diálisis peritoneal de una unidad renal basada en guías y protocolos establecidos, con la teoría del autocuidado (teoría de los sistemas) de Dorotea Orem. Materiales y métodos: para la realización de este estudio se aplicó un diseño de investigación descriptiva con enfoque cualitativo, participaron seis enfermeras que laboraban en un programa de DP y se consultaron bibliografías para relacionar la situación con los modelos y las teorías en enfermería. Resultados: el personal de enfermería planificó el entrenamiento al paciente al crear estrategias educativas que favorecen el autocuidado, según el modelo de Dorotea Orem. Conclusiones: al tener en cuenta los conceptos teóricos de Dorotea Orem, aplicados en el cuidado de enfermería en el paciente de DP, se lograron resultados óptimos en el desarrollo de la terapia del paciente, se fortaleció la capacidad de autocuidado y se desarrollaron habilidades y conocimientos que permiten la adhesión a las recomendaciones de enfermería dadas en el entrenamiento.

Abstract Introduction: Peritoneal Dialysis (PD) is the medical procedure in which waste and excess fluid are eliminated in the blood, this therapy involves active self-care work by the patient at home, prior nursing training promoting adherence to treatment. Objective: to describe the relationship of care carried out by the peritoneal dialysis nurse of a renal unit based on established guidelines and protocols, with the theory of Self-care (systems theory) of Dorotea Orem. Materials and methods: to carry out this study, a descriptive research design with a qualitative approach was applied, six nurses who worked in a peritoneal dialysis program participated, in addition, bibliographies were consulted and thus relate the situation with the models and theories in nursing. Results: The nursing staff planned the training of the patient creating educational strategies that favored self-care according to the Dorotea Orem model. Conclusions: Considering the theoretical concepts of Dorotea Orem, applied in the nursing care in the Peritoneal Dialysis patient, optimal results were achieved in the development of the patient's therapy, strengthening the capacity for self-care, developing skills and knowledge that allow adhere to the nursing recommendations given in the training.

[Intraepidermal Merkel cell carcinoma with INSM1 expression. A case report]. / Carcinoma de Merkel intraepidérmico. Presentación de un caso con expresión de INSM1.

We report the case of a 90-year-old male who presented with an erythematous desquamative plaque on his left cheek. Histopathology demonstrated an epidermal lesion with multifocal epithelial growth. The cells were small, with scant cytoplasm and hyperchromatic nuclei with molding and a high mitotic and apopototic rate. Immunohistochemistry showed positivity for CK20, CK7, synaptophysin and INMS1. These findings are consistent with a Merkel cell carcinoma in situ. This tumor corresponds to a primary neuroendocrine neoplasm of the skin, which usually affects elderly people with sun-exposed skin. Usually, it presents as a dermal tumor but intraepidermal involvement alone is extremely rare. In this scenario, a broad differential diagnosis should be considered, excluding all neoplasms that may present intraepidermal forms. The evolution of this entity is unknown.

Estratificación de riesgo en pacientes con infarto agudo de miocardio mediante el uso de varias escalas

RESUMEN Introducción: Existen varias escalas a nivel mundial en la predicción de riesgo de los pacientes con infarto, pero aún no se ha encontrado la "escala ideal". Objetivos: Determinar la capacidad de discriminación para la mortalidad hospitalaria por infarto agudo de miocardio de las escalas GRACE, TIMI Risk Score, InTIME e ICR. Método: Se realizó un estudio prospectivo en el Servicio de Cardiología del Hospital General Docente Dr. Ernesto Guevara de la Serna de Las Tunas, Cuba, entre 2018 y 2019. El universo estuvo conformado por 452 pacientes ingresados en las primeras 24 horas del infarto y la muestra, por 430 casos a los cuales se les pudo recoger la totalidad de las variables en estudio. Se utilizó la estadística descriptiva. Para determinar la capacidad de discriminación de la escalas de riesgo se determinaron sensibilidad, especificidad y área bajo la curva. Resultados: El 70% de los pacientes fallecidos eran del sexo masculino y su media de edad fue 10 años mayor que en los egresados vivos. La hipertensión arterial fue el factor asociado más frecuente tanto en los pacientes fallecidos (90%) como en los egresados vivos (73.4%). El 70% de los fallecidos presentaron algún grado de disfunción sistólica del ventrículo izquierdo. El área bajo la curva de las escalas ICR, InTIME y GRACE fue de 0,683; 0,681 y 0,662, respectivamente. El TIMI Risk Score presentó un área bajo la curva de 0,598. Conclusiones: Las escalas ICR, InTime y GRACE presentaron pobre capacidad predictiva para la mortalidad hospitalaria. La escala TIMI Risk Score presentó una fallida capacidad predictiva.

ABSTRACT Introduction: There are several scores worldwide for risk stratification in patients with myocardial infarction, but the "ideal score" has not yet been found. Objectives: To determine the discriminatory capacity of GRACE, TIMI Risk Score, InTIME and ICR scores for in-hospital mortality due to acute myocardial infarction. Method: A prospective study was carried out in the Department of Cardiology of the Hospital General Docente Dr. Ernesto Guevara de la Serna of Las Tunas, Cuba, between 2018 and 2019. The study's population consisted of 452 patients admitted in the first 24 hours after myocardial infarction, and the sample consisted of 430 cases from which all the variables under study could be collected. Descriptive statistics were used. Sensitivity, specificity and area under the curve were determined to be able to determine the discriminatory capacity of the risk scores as well. Results: The 70% of the deceased patients were male and their mean age was 10 years older than in the patients discharged alive. High blood pressure was the most frequent associated risk factor in both deceased patients (90%) and in those who left the hospital alive (73.4%). The 70% of deaths had certain degree of left ventricular systolic dysfunction. The area under the curve of ICR, InTIME and GRACE scores was of 0.683; 0.681 and 0.662 respectively. TIMI Risk Score had an area under the curve of 0.598. Conclusions: ICR, InTime and GRACE scores had poor predictive capacity for in-hospital mortality. TIMI Risk Score had a very poor predictive capacity.

Population Kidney Health. A New Paradigm for Chronic Kidney Disease Management.

Statistical data extracted from national databases demonstrate a continuous growth in the incidence and prevalence of chronic kidney disease (CKD) and the ineffectiveness of current policies and strategies based on individual risk factors to reduce them, as well as their mortality and costs. Some innovative programs, telemedicine and government interest in the prevention of CKD did not facilitate timely access to care, continuing the increased demand for dialysis and transplants, high morbidity and long-term disability. In contrast, new forms of kidney disease of unknown etiology affected populations in developing countries and underrepresented minorities, who face socioeconomic and cultural disadvantages. With this background, our objective was to analyze in the existing literature the effects of social determinants in CKD, concluding that it is necessary to strengthen current kidney health strategies, designing in a transdisciplinary way, a model that considers demographic characteristics integrated into individual risk factors and risk factors population, incorporating the population health perspective in public health policies to improve results in kidney health care, since CKD continues to be an important and growing contributor to chronic diseases.

Recomendaciones de bioseguridad para el nefrólogo en salas de atención a pacientes con enfermedad renal ante la pandemia de la COVID-19 / Biosafety recommendations for the nephrologist in care rooms for patients with renal disease in the face of the COVID-19 pandemic

Resumen Revisión narrativa sobre la prevención de infección por SARS-CoV-2 en personal de salud y en especial en los nefrólogos de los servicios de nefrología y unidades de hemodiálisis dada la poca disponibilidad de documentos en la literatura sobre este tema en particular. La escasa literatura no favorece la realización de una revisión sistemática sobre el mencionado tema. El desarrollo de esta revisión incluye una descripción del nuevo virus, sus mecanismos de transmisión, la cadena epidemiológica y sus condiciones de aparición en el panorama mundial, los principales aspectos que favorecen la mayor susceptibilidad del personal de salud y en especial a los nefrólogos. Finalmente se hacen las recomendaciones sobre la prevención, la atención de los casos y el retorno a la actividad laboral.

Abstract Narrative review on the prevention of SARS-CoV-2 infection in health personnel and especially in nephrologists from nephrology services and hemodialysis units given the limited availability of documents in the literature on this particular topic. The scarce literature does not favor the performance of a systematic review on the mentioned topic. The development of this review includes a description of the new virus, its transmission mechanisms, the epidemiological chain and its appearance conditions on the world scene, the main aspects that favor the greater susceptibility of health personnel and especially nephrologists. Finally, recommendations are made on prevention, case management and return to work.

Reporte de cuatro casos COVID-19 hospitalizados en unidad de cuidados intensivos en una institución hospitalaria en Barranquilla, Colombia / Original article: Case-Serie of 4 COVID-19 patients hospitalized in an intensive care unit in a hospital institution in Barranquilla, Colombia

Resumen Presentar una serie de casos de COVID-19 con requerimiento de ingreso a Unidad de Cuidados Intensivos. La información fue tomada de las historias clínicas, y su evaluación y diagnóstico fue realizado mediante estudios paraclínicos en sangre, orina, PCR e imágenes diagnósticas en 4 pacientes con diferentes comorbilidades y nexo epidemiológico presente para desarrollo de la enfermedad. Los cuatro casos fueron manejados con cloroquina 300 mg vía oral, cada 12 horas, y azitromicina 1 gr vía oral, cada 24 horas, durante 5 días, sin complicaciones ni toxicidad asociada. El caso 1 desarrolló falla orgánica múltiple, incluyendo injuria renal aguda con una estancia en UCI de 4 días antes de su fallecimiento, mientras los casos 2, 3 y 4 tuvieron una evolución favorable y fueron dados de alta de UCI. Se requieren estudios multicéntricos rápidos que orienten científicamente hacia un mejor abordaje diagnóstico y manejo, en el contexto de una enfermedad con un comportamiento clínico-epidemiológico que debe estudiarse en profundidad y que probablemente cobrará muchas vidas; además, debido a la ausencia de pruebas diagnósticas rápidas, la utilización de una clasificación basada en la severidad de lesiones radiológicas llamada CO-RADS (Covid-19 Imaging Reporting and Data System) podría ser de gran importancia para instalar de manera temprana los tratamientos farmacológicos disponibles y la asistencia respiratoria mecánica precoz.

Abstract To present a COVID-19 case series with clinical admission criteria to Intensive Care Unit. Patients information was obtained from medical records, and daily clinical evaluation whereas diagnosis was carried out through paraclinical studies in blood, urine, PCR and diagnostic images in 4 patients with different comorbidities and epidemiological link for the development of COVID-19. All four cases were managed with chloroquine 300 mg orally every 12 hours and azithromycin orally every 24 hours for 5 days without complications or associated toxicity. The case 1 developed multiple organ failure, including acute kidney injury with an ICU stay of 4 days before his death, while cases 2, 3 and 4 had a favorable evolution and were discharged from the ICU. Rapid multicenter studies are required to scientifically guide a better diagnostic and management approach, in the context of a disease with a clinical-epidemiological behavior that must be studied in depth and will probably take many lives. In addition, due to the absence of sufficiently rapid tests, the use of a classification based on the severity of radiological lesions called CO-RADS (Covid-19 Imaging Reporting and Data System) could be of great importance to install available pharmacological treatments early and early mechanical respiratory support.