Bases clínicas y genéticas de la nefroesclerosis hipertensiva. Estudio NEFROSEN / Clinical and genetic bases of hypertensive nephrosclerosis. NEFROSEN Study

Justificación: Se conoce como nefroesclerosis la enfermedad renal crónica (ERC) que complica la hipertensión arterial (HTA) esencial. La ausencia de correlación entre el control de la HTA y la progresión a ERC terminal sugiere la existencia de una enfermedad intrínseca y primitiva. Recientemente se ha asociado con polimorfismos del gen MYH9 en individuos afroamericanos. El objetivo del trabajo que presentamos es determinar si algún polimorfismo de dicho gen se relaciona en raza caucásica con la asociación de HTA esencial y nefroesclerosis y, además, conocer los marcadores de progresión a ERC terminal. Será un estudio retrospectivo que comparará a pacientes con nefroesclerosis frente a pacientes con HTA esencial sin enfermedad renal y, además, se incluirán pacientes con nefroesclerosis y progresión de la enfermedad renal frente a los que se mantienen estables. Métodos: Entre octubre de 2009 y octubre de 2010 se incluirán 500 pacientes con ERC (estadios 3-5) atribuida a nefroesclerosis según criterios clínicos habituales, y 300 pacientes afectados de HTA esencial (FGe >60ml/min/1,73 m2; microalbuminuria <300 mg/g). Para el estudio genético también se incluirán 200 controles sanos de población general. Habrá dos cortes del estudio, la primera visita en el hospital y la visita final (en estadio 5 el inicio del tratamiento sustitutivo constituirá el final del seguimiento). Se registrarán datos clínicos y analíticos, y se recogerán muestras de sangre para el estudio genético. Discusión: Nuestro estudio, con la doble vertiente genética y clínica, tratará de determinar si en la raza caucásica existe relación entre el diagnóstico de nefroesclerosis y el gen MYH9, y estudiará, además, los posibles marcadores de progresión (AU)

Background: Hypertensive nephrosclerosis is a chronic kidney disease (CKD) associated to essential hypertension. The lack of correlation between strict control of hypertension and progression of CKD suggests an intrinsic and primary disease. New evidence suggests that MYH9 gene alterations are associated with nephrosclerosis in African Americans. The aim of this study is to investigate whether a polymorphism of MYH9 in Caucasians is linked to the association of essential hypertension and nephrosclerosis. The secondary objective is to identify the clinical risk factors of progression to end-stage renal disease (ESRD). This is a retrospective study that will compare patients with nephrosclerosis versus essential hypertensives without renal disease, and also patients with nephrosclerosis and impaired rena l function versu s those that are stable .Methods: Between October 2009 and October 2010, 500patients stages 3-5 CKD attributed to nephrosclerosis according to usual clinical criteria, and 300 essential hypertensives (eGFR > 60 mL/min/1.73m2; mi c roalbuminur ia<300 mg/g) will be recruited. 200 healthy controls from general population will also be included for the genetic study. There will be two sections of the study, first and final visit to the clinic (stage 5, the start of replacement therapy will be the end of follow-up). Clinical and laboratory data will be recorded, and blood samples will be collected. Discussion: Our study will seek to determine if there exists a relationship between the diagnosis of nephrosclerosis and MYH9 gene in the Caucasian race, and to study possible risk factors for progression to ESRD, on both clinical and genetic basis (AU)

[Clinical and genetic basis of hypertensive nephrosclerosis. NEFROSEN Study]. / Bases clínicas y genéticas de la nefroesclerosis hipertensiva. Estudio NEFROSEN.

BACKGROUND: Hypertensive nephrosclerosis is a chronic kidney disease (CKD) associated with essential hypertension. The lack of correlation between hypertension control and progression to end-stage CKD suggests an intrinsic and primitive disease. New evidence suggests that MYH9 gene alterations are associated with polymorphisms in African Americans. The aim of this study is to investigate whether a polymorphism of MYH9 in Caucasians is linked to essential hypertension and nephrosclerosis. The secondary objective is to identify the clinical risk factors of progression to end-stage CKD. This is a retrospective study that will compare patients with nephrosclerosis and essential hypertensives without renal disease, and also patients with nephrosclerosis and impaired renal function with those that are stable. METHOD: Between October 2009 and October 2010, 500 patients with stages 3-5 CKD attributed to nephrosclerosis according to usual clinical criteria, and 300 essential hypertensives (eGFR>60 mL/min/1.73 m2; microalbuminuria <300 mg/g) are to be recruited. A total of 200 healthy controls from the general population are also to be included for the genetic study. There are two study sections, being the first and final visits to the clinic (for stage 5 cases, the start of replacement therapy will be the end of follow-up). Clinical and laboratory data will be recorded, and blood samples will be collected. DISCUSSION: Our study will aim to determine if there is a relationship between the diagnosis of nephrosclerosis and the MYH9 gene in Caucasians, and to study possible risk factors for progression to end-stage CKD, on both clinical and genetic bases.

Nefroangiosclerosis. La cenicienta de la enfermedad renal crónica / No disponible

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Imagen radiológica del carbonato de lantano / No disponible

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Three-month experience with tacrolimus once-daily regimen in stable renal allografts.

INTRODUCTION: MR-4, the new oral formulation of tacrolimus that allows once-daily dosing, may improve patient compliance. The purpose of this study was to evaluate the safety and efficacy parameters among a group of stable renal allografts after conversion to MR-4. METHODS: We enrolled 82 stable kidney recipients, who had received their grafts 43.9 +/- 38.3 months prior. They were of mean age 56 +/- 12 years and included 70.7% men. Sixty-six patients were converted on a milligram-for-milligram basis from their total daily dose; the remaining patients were converted at the physician's discretion. Three patients were excluded: 1 because of the development of abdominal pain, and 2 because of dosing errors. Tacrolimus trough levels and renal function tests were evaluated at entry and on days 7, 30, and 90. RESULTS: Only 5 (7.6%) converted patients required a later dose adjustment. In the group of 61 patients who did not require this adjustment, the mean tacrolimus trough levels decreased during the first week (6.8 +/- 1.7 to 5.8 +/- 2.0; P < .000). Thirty-eight patients completed 3 months of follow-up. Their tacrolimus trough levels, serum creatinine levels, and proteinuria remained stable. The number of capsules per patient needed after the conversion to MR-4 was lower (3.9 +/- 1.6 versus 2.9 +/- 1.0; P < .000). There were no cases of acute rejection episodes. CONCLUSION: Based on a milligram-for-milligram conversion, only 7.6% of our patients required a dose adjustment. With this conversion, an initial decrease in tacrolimus trough levels was documented at day 7, which remained stable to the end of the study. The patients needed a lower number of capsules. These results supported the safety of MR-4.

[Peritoneal dialyisis role in heart failure treatment, experience in our center]. / Papel de la diálisis peritoneal en el tratamiento de la insuficiencia cardíaca. Experiencia en nuestro centro.

Peritoneal dialysis is a renal replacement therapy indicated in patients with an unstable hemodynamic status. It has been used, by ultrafiltration, preferably in those patients with congestive heart failure refractory to conventional medical therapy. We present the experience of our center with five patients who were affected by severe congestive heart failure [Class IV on the New York Heart Association (NYHA) scale] and diverse stages of chronic renal failure, who received this therapy. Icodextrin has been used as an osmotic agent to induce ultrafiltration. The follow-up period ranged between 5 and 14 months (9.8 +/- 3.7 months). The results that we have found are similar to those of other studies: we observed a significant improvement in quality of life and a reduction in morbidity and hospitalization rates in all our patients. But it seems to be necessary to make a prospective randomized controlled trial with more number of individuals to confirm these promising facts, to clarify the impact on the survival, and to analyze the cost-benefit for treating patients suffering from refractory, end stage congestive heart failure.

Papel de la diálisis peritoneal en el tratamiento de la insuficiencia cardíaca. Experiencia en nuestro centro / Peritoneal dialysis role in heart failure treatment. Experience in our center

La diálisis peritoneal es una técnica sustitutiva de la función renal indicada en pacientes con inestabilidad hemodinámica. Por ello, se ha utilizado preferentemente en aquellos pacientes con insuficiencia cardíaca refractaria al tratamiento médico convencional. Presentamos la experiencia de nuestro centro con cinco pacientes que presentaban diversos grados de enfermedad renal crónica e insuficiencia cardíaca congestiva, que recibieron este tratamiento. Los resultados que hemos encontrado son superponibles a otros estudios realizados: en todos nuestros pacientes mejoró la clase funcional según la Clasificación de la New York Heart Association y disminuyeron los tiempos de hospitalización. Parece necesario realizar estudios prospectivos con mayor número de individuos para confirmar estas afirmaciones, aclarar el impacto sobre la supervivencia, y analizar el coste-beneficio

Peritoneal dialysis is a renal replacement therapy indicated in patients with an unstable hemodynamic status. It has been used, by ultrafiltration, preferably in those patients with congestive heart failure refractory to conventional medical therapy.We present the experience of our center with five patients who were affected by severe congestive heart failure [Class IV on the New York Heart Association (NYHA) scale] and diverse stages of chronic renal failure,who received this therapy. Icodextrin has been used as an osmotic agent to induce ultrafiltration. The follow-up period ranged between 5 and 14 months (9.8 ± 3.7 months). The results that we have found are similar to those of other studies:we observed a significant improvement in quality of life and a reduction in morbidity and hospitalization rates in all our patients. But it seems to be necessary to make a prospective randomized controlled trial with more number of individuals to confirm these promising facts, to clarify the impact on the survival, and to analyze the cost-benefit for treating patients suffering from refractory, end stage congestive heart failure

Study of the renal function in nonrenal organ transplantation.

Kidney disease after transplantation of a nonrenal organ has been described to be the result of the nephrotoxicity from the commonly used calcineurin-inhibitors as well as other factors. The aim of this study was to evaluate renal function and potential risk factors for the development of chronic renal failure among nonrenal organ recipients. We designed a single-center retrospective study including all 165 of our cardiac and liver recipients between February 1998 and October 2003, collecting clinical, analytic, and therapeutic data. We excluded double transplants and patients with survival less than 6 months. Creatinine clearance was calculated according to the Cockcroft-Gault and the Levey Modification of Diet in Renal Disease (MDRD)-5 equations. Although 165 patients received a cardiac or liver transplantation, 17 died in the first 6 months and three were double transplants; therefore we analyzed 145 patients: 107 (74%) cardiac transplantations and 38 (26%) liver transplantations. There were 106 male and 39 female recipients. The mean age (+/-SD) at the time of transplantation was 54 +/- 10 years and the mean follow-up was 2.9 +/- 1.7 years. Urinalysis before transplantation was only performed in 33 patients (22.8%) including three (2.1%) who had proteinuria. Serum creatinine increased until 12 months after transplantation (P < .001), then it recovered its average level. Creatinine clearance calculated using the aforementioned equations showed a similar pattern, with a progressive decline to 12 months (P < .05), with eventual stabilization or even improvement. The factors that we observed to increase the risk of renal damage were age, female sex, obesity, and the presence of proteinuria prior to transplantation. There was a good correlation (r = 0.96) between cyclosporine but not tacrolimus trough levels and serum creatinine at 48 hours after transplantation.

Trombosis carotída como primera manifestación de un síndrome nefrótico a cambios mínimos / Carotidartery thrombosis as the first manifestation of minimal changes nephrotic syndrome

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Función renal y riesgo cardiovascular en pacientes con hipertensión arterial esencial. Estudio FRESHA / Renal function and cardiovascular risk in patients with essential hypertension. The «FRESHA» study

Introducción: Se ha descrito una relación entre el descenso del filtrado glomerulary el riesgo cardiovascular. Los objetivos de este estudio fueron verificar si lafunción renal es un marcador independiente de riesgo cardiovascular en casos conHTA esencial y estimar la prevalencia de insuficiencia renal en estos pacientes.Métodos: Estudio multicéntrico, observacional y transversal realizado en 50 centrosde Atención Primaria de España por 88 investigadores. Cada médico incluyóde modo consecutivo 25 pacientes con HTA esencial no seleccionados. Se estudiarondatos demográficos, factores de riesgo cardiovascular, comorbilidad vasculary utilización de fármacos cardioprotectores. La función renal fue determinadapor la concentración de creatinina sérica y mediante el filtrado glomerular estimadosegún la ecuación abreviada del estudio Modification of Diet in Renal Disease(MDRD). La insuficiencia renal se definió por un filtrado glomerular < 60ml/min/1,73 m2.Resultados: Se estudiaron 2.130 individuos con una edad media de 65,6 ± 11años, 53% mujeres. El 68,4% de los pacientes tenía PA ≥ 140/90 mmHg. La prevalenciade insuficiencia renal fue 32,4% (IC 95% 30,4-34,4). La prevalencia deenfermedad cardiovascular fue más elevada en los casos con insuficiencia renal(56,2% vs 35,3%, OR 2,35; IC 95% 1,95-2,82, p < 0,001). En el análisis de regresiónlogística múltiple se verificó que esta relación fue independiente del restode factores (sexo, edad, diabetes mellitus, tabaquismo, hipercolesterolemia y presiónarterial sistólica). El uso de agentes antihipertensivos, estatinas y antiagregantesplaquetarios fue mayor en los pacientes con insuficiencia renal.Conclusiones: Uno de cada 3 pacientes con HTA esencial seguidos en AtenciónPrimaria presentó insuficiencia renal. Los casos con insuficiencia renal presentaronun riesgo cardiovascular más elevado que aquellos con función renal másconservada. Los pacientes hipertensos con disfunción renal podrían ser candidatosal manejo terapéutico que se aplica a otros grupos de alto riesgo cardiovascular

Background: In the past few years there has been a growing amount of informationabout renal dysfunction and cardiovascular risk. The objectives of this studywere to assess the prevalence of renal dysfunction and evaluate the relation betweenrenal function and cardiovascular risk in patients with essential hypertension.Methods: A multicenter, cross-sectional survey of unselected patients with essentialhypertension attending primary care settings in Spain was performed betweenjune and november 2004. Renal function was evaluated with the abbreviatedequation of the Modification of Diet in Renal Disease study. Renal insufficiencywas defined as an estimated glomerular filtration rate 60 ml/min/1.73 m2 (56.2% vs 35.3%, OR 2.35, 95% CI 1.95-2.82,p < 0.001). A logistic regression analysis showed that the relation of renal dysfunctionwith cardiovascular disease was independent of other variables or classicalcardiovascular risk factors as age, female sex, diabetes, smoking, hypercholesterolemia,and systolic blood pressure.Conclusions: Renal insufficiency was present in 32.4% of patients with essentialhypertension attending primary care settings. Cases with renal dysfunction showeda higher cardiovascular risk. Hypertensive patients with renal insufficiencyshould be considered as candidates for an aggressive approach of cardiovascularrisk management