Varicela herpes zóster: complicación en una vasculitis ANCA positiva / Varicella zoster virus: complications in an ANCA-positive vasculitis

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[Results of applying the Scientific Technical Quality Programme and Constant Quality Improvement for peritoneal dialysis]. / Resultados de la aplicación del plan de calidad científico-técnica y de mejora continua de calidad en diálisis peritoneal.

INTRODUCTION: In last time it was tried to homogenize the clinical activity and to make the decisions easier. In the field of Nephrology, the Spanish Society of Nephrology has developed different guidelines that have managed an improvement in patient s monitoring. That is the reason why the Quality Working Group in Nephrology was created, whose basic working field was haemodialysis, although its collaboration with an expert group in peritoneal dialysis (PD) has allowed the developement of a Scientific Technical Quality Programme and Constant Quality Improvement in PD. MATERIAL AND METHODS: We checked the clinical histories of all the patients in PD in the course of 2008 in the Peritoneal Dialysis Unit at our institution and we evaluated all the quality indicators that were described in the Scientific Technical Quality Programme and of Constant Quality Improvement in PD. RESULTS: During 2008 a total of 41 patients were treated in the Peritoneal Dialysis Unit at our institution, 43.9% women. Incidence was 14 (51.8%) and 21.4% were diabetics. No patients cames from transplant unit and 2 came from haemodilalysis unit (7.1%). Mean age in incident population was 60 +/- 13 years and in prevalent population was 53.9 +/- 14.4 years. Mean follow-up in PD was 25.9 +/- 19.9 months. Modified Charlson comorbility index average in incident patients was 6 and in prevalent patients was 5. 70.7% were included in transplant programme and 3 were transplanted in the year s course (10.3%). There were 19 hospital admissions (rate: 0.46 admission per patient/year in risk) with a mean stay of 7.3 days (rate: 3.4 days per patient/year in risk). During 2008 6 patients leaved PD (2 transfers to haemodialysis, 3 transplants and 1 death). 16 infective peritonitis (overall rate: 1 episode every 24 months) and 23 exit side infections were reported (rate: 1 episode every 18 months). Mean Kt/V was 2,4 +/- 0.06 (92.7% of patients achieved the stablished standards). All non-anuric patients had measured residual renal function and only 1 patient did not achieve the goal of fluid output > 1000 ml/day. No patient used 3.86-4.25% bags. Stablished standards were achieve by analitic indicators with regard to epoetin resistence index, LDL- cholesterol, phosphate, calcium-phosphate product and PTH. CONCLUSIONS: The application of the Scientific Technical Quality Programme and of Constant Quality Improvement in PD has made possible to know the current situation of our unit and to raise some matters when it is necessary to insist to get a better quality in our assistance.

Dosificación de vancomicina en pacientes en hemodiálisis / No disponible

Dado el amplio uso de vancomicina en hemodiálisis (HD) es necesario adecuar la dosificación a las actuales membranas de diálisis, asegurando niveles óptimos. Objetivo: Valorar si, en HD, tras 1 gramo intravenoso (IV) los niveles plasmáticos de vancomicina se encuentran en rango terapéutico. Material y métodos: Estudio de cohorte transversal que incluye 28 pacientes en HD 3 veces/semana tratados con vancomicina entre el 15/2/2006 y el 14/2/2007. Sead ministró 1 gramo IV durante la última hora de HD, determinando niveles antes y después de la sesión siguiente(preHD1, postHD1) y antes de la 2ª sesión siguiente(preHD2). Resultados: De los 28 pacientes, 5 presentaban 3determinaciones y 5 presentaban 2 y el resto 1. De las 43muestras, 19 eran hombres (44,2%) y 24 mujeres (55,8%),con edad media 70 ± 8,4 años. La dosis de 1 gramo correspondía a > 15 mg/kg en 31 pacientes (72,1%) y < 15 mg/kgen 12 (27,9%). El 44,2% utilizaban polietersulfona de alta permeabilidad (PES-AP), 7% eval, 32,5% polietersulfona de media-baja permeabilidad (PES-BP) y 16,3% poliacrilonitrilo. El nivel medio preHD1 fue 7,06 mcg/ml, 7,5 mcg/mlpara la dosis > 15 mg/kg y 6 mcg/ml para < 15 mg/kg (p <0,05). El 16,3% presentó niveles por debajo del rango terapéutico, siendo 6,45% para una dosis > 15 mg/kg frente a 41,67% para la dosis < 15 mg/kg. Respecto a los dializadores, los niveles más bajos se observaron con PES-AP (5,95 mcg/ml) y los más elevados con PES-BP (7,27 mcg/ml) (p no significativa). Ningún paciente con PES-BP se encontró en rango infraterapéutico, frente a 31,58% con PES-AP (p = 0,07). Los valores postHD1 y preHD2 se encontraban en niveles subóptimos, tanto la media como los que recibían > 15 mg/kg y < 15 mg/kg, y en todos los dializadores. Conclusiones: La administración de 1 gramo IV de vancomicina cada 5-7 días no es adecuado para pacientes en HD, sobre todo cuando se utilizan membranas de alto flujo. Mientras no se actualizan las pautas de dosificación es necesario monitorizar los niveles prediálisis del fármaco para evitar concentraciones infraterapéuticas (AU)

Vancomycin is widely used in haemodialysis (HD) patients for treating infections of vascular access due to St. Aureus. To avoid subtherapeutic levels it is important to know the adequate dosing in patients undergoing haemodialysis with high flux membranes. Objective: The aim of this study was to evaluate whether HD patients treated with 1 g intravenous (IV) vancomycin reached optimum plasma levels. Material and methods: In a crossover design we studied 28 chronic HD patients, 3 times a week, treated with vancomycin between 15/2/2006 and 14/2/2007. Antibiotic wasgiven at dose of 1 g during the last hour of dialysis session. Plasma levels of vancomycin were measured immediately before next HD (preHD1) and after (postHD1), and prior to the beginning of the second next session (preHD2). We evaluated age, sex, dry height, week Kt/V and the type of membrane used. Results: Of 28 patients, 5 were analysed 3 times, 2 were analysed twice and 9 were analysed once. There were 43 samples, 19 men (44.2%) and 24 women (55.8%), with a mean age of 70 ± 8,4 years. 1 g dose is equivalent to > 15 mg/kg in 31 patients (72.1%) and < 15 mg/kg in 12 (27.9%). The type of membrane used was high flux polyetersulfone (PES-AP) (44.2%), eval (7%), medium-low polyetersulfone (PES-BP) (32.5%) and polyacrylonitrile (16.3%). PreHD1 mean concentration results for the total population was 7.06 mg/ml, being 16.3% bellow optimum levels. There were not difference between patients treated with dose > 15 mg/kg (7.5 mg/ml) and < 15 mg/kg (6 m/ml). When the dose administered was > 15 mg/kg, 6.45% results were subtherapeutic, whereas if the dose was < 15 mg/kg, 41.67% values were bellow optimum levels (p < 0.05). With regard to the dialyzers used, the lowest concentrations were observed with PES-AP (5.95 mg/ml) and the highest values were observed with PES-BP (7.27 mg/ml) (p no significance). No patient using PESBP versus 31.58% patients using PES-AP showed suboptimum values (p = 0,07). All postHD1 and preHD2 results were in subtherapeutic range (mean values, dose > and < 15 mg/kg and all types of membrane). Conclusions: Based on the above results, the vancomycin dosing schedule of 1 g IV every 5-7 days is not recommended for patients undergoing haemodialysis with high flux membranes. Since there are not guidelines for handling this antibiotic in these patients our findings suggest that it may be necessary to monitorize predialysis plasma levels to avoid subtherapeutic values (AU)

Telemedicina aplicada a la nefrología. Otra forma de consulta / No disponible

En el año 2004, atendiendo a criterios sociodemográficos y de mejora en la calidad asistencial, incorporamos a la Cartera de Servicios de nuestra sección una herramienta de trabajo que suponía una tecnología novedosa, que es la Telemedicina. El Objetivo del presente trabajo ha sido valorarla utilidad de la telemedicina en el seguimiento de los pacientes renales acercando la consulta de nefrología al domicilio del paciente así como la relación entre dos niveles asistenciales. Material y método: Estudio retrospectivo y descriptivo de los pacientes con patología renal seguidos en la consulta de telenefrología de nuestro hospital en un periodo de tiempo de 27 meses (noviembre2004-enero 2007). Se realiza con centros de salud de nuestra área sanitaria (4 centros). El médico de atención primaria pone en marcha el sistema con la elaboración de un documento de derivación a la consulta de Telenefrología. Toda esta información se incluye en una base de datos informatizada que llega vía «Intranet» al Hospital donde desde la consulta de Telenefrología se da contestación al problema planteado apoyada por un sistema de vídeoconferencia y en tiempo real. Resultados: Se han realizado un total de 105 primeras consultas. 52 pacientes hombres y 53 mujeres. La edad ha oscilado en un rango entre 15-94 años. Los diagnósticos realizados en la consulta de Telenefrología han sido: HTA (esencial y secundaria): 90(85,7%). IRC: 61(58%). Nefropatía diabética: 17(16%). Poliquistosis renal: 3(2,8%). Litiasis urinaria: 2(1,9%). Malformaciones congénitas: 1(0,95%). Uropatía obstructiva: 1(0,95%). Glomerulonefritis crónica: 6(5,7%). Infección urinaria: 1(0,95%). Ausencia de patología renal: 5(4,8%). Varios de los diagnósticos realizados coinciden en varios pacientes. Las causas de la IRC han sido Nefroangioesclerosis: 33. Nefropatía diabética: 14. No filiada: 8. Enfermedad glomerular: 2. Litiasis urinaria: 2. Poliquistosis renal: 1. Nefropatía isquémica: 1. De los 90 pacientes con HTA, 82 eran hipertensión arterial esencial y 8 HTA secundaria. Las causas de esta fueron: 5 HTA de origen renal parenquimatoso. 2 HTA vasculorrenal y uno con un hiperaldosteronismo primario. Los factores de riesgo asociados a la HTA observados han sido: Dislipemia: 29. Diabetes mellitus: 29. Hiperuricemia: 11. Obesidad: 12. Conclusión: Es posible la teleasistencia en nefrología promoviendo además el acercamiento de dos niveles asistenciales sin merma en la calidad asistencial. Se consigue un menor número de desplazamientos y el subsiguiente ahorro en transporte sanitario así como en número de consultas hospitalarias (AU)

In 2004, according to socio-demographic criteria and to the improvement in the welfare quality, we incorporated to the portfolio of services of our section a work tool that meant a novel technology; the «telemedicine». The Objective has been to asses the utility of telemedicine in the follow- up of the renal patients, bringing the consultation of nephrology closer to the patient’s home as well as the relationship between two welfare levels. Material andmethod: Retrospective and descriptive study of the patients with renal pathology treated in the consultation of telenephrology a tour hospital in a period of time of 27 months (november 2004-january2007). Such study is carried out in primary care centers of our sanitary area (4 centers). The general practician (GP) starts up the system by elaborating a document of derivation to the consultation of «telenephrology». All this information is included in a computerized data base that arrives via «Intranet» at the Hospital. From the consultation of Telenephrology the question is answered in real- time and through a system of videoconference. Results: A total of 105 first consultations have been made. 52 men and 53 women between 18 and 94 years of age. The diagnoses made in the consultation of Telenephrology have been: HTA (essential and secondary): 90 (85.7%). IRC: 61 (58%). Diabetic Nefropathy: 17 (16%). Renal Polycystic: 3 (2.8%). Urinary Lithiasis: 2 (1.9%). Congenital malformations: 1 (0.95%). Obstructive Nefropathy: 1 (0.95%). Chronic Glomerulonephritis: 6 (5.7%). Urinary infection: 1 (0.95%). Absence of renal pathology: 5 (4.8%). Some of the diagnoses coincide in several patients. The causes of the IRC have been Nephroangioesclerosis: 33. Diabetic Nefropathy: 14. Not drafted: 8. Disease to glomerular: 2. Urinary Lithiasis: 2. Renal Polycystic: 1. Ischemic Nephropathy: 1. 82 out of the 90 patients with HTA had essential arterial hypertension and 8 suffered from secondary HTA. The causes of this were: 5 HTA of parenquimatous renal origin. 2 vasculorrenal HTA and one with a primary hyperaldosteronism. The associated factors of risk to the observed HTA have been: Dyslipemia: 29. Diabetes méllitus: 29. Hyperuricemia: 11. Obesity: 12. Conclusion: The telecare in nephrology is possible promoting also the approach between two welfare levels, without a decrease in the quality of assistance. That way, we can get a lower number of hospital visits and, subsequently, a saving in sanitary transport as well as in hospital consultations (AU)

Fracaso renal agudo tras ingestión de setas: síndrome orellánico / Oliguric acute renal failure as a complication of treatment of an infrarenal aortic aneurysm by implantation of an aortic stent

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