Monitorización de la vacomicina en administración intraperitoneal en pacientes sometidos a diálisis peritoneal continua ambulatoria / Monitoring of intraperitoneal administration of vancomycin in patients on continuous ambulatory peritoneal dialysis

Objetivo: Validar un modelo para la monitorización farmacocinética de los tratamientos con vancomicina intraperitoneal en pacientes sometidos a diálisis peritoneal continua ambulatoria con peritonitis bacteriana. Método Se realiza un estudio prospectivo, abierto, en 2 cohortes: la primera incluye a 10 pacientes de 56±14 años y 65±5kg y la segunda, otros 10 pacientes (12 episodios de peritonitis) de 52±13 años y 64±8kg. El tratamiento consiste en la instilación y retención durante 6h en la cavidad peritoneal de una solución conteniendo 2g de vancomicina y 1g de ceftazidima, en 2 l de dializante. Tras la instilación del antibiótico, se obtuvieron muestras de sangre a las 4, 6, 8, 10, 24, 48 y 168h, en la primera cohorte y a las 6 y 120h (CVAN120) en la segunda. El modelo farmacocinético se desarrolla a partir de los parámetros obtenidos en la primera cohorte y se valida en la segunda cohorte calculando el error medio (EM) y el error cuadrático medio de predicción (ECM) de la CVAN120.ResultadosLas concentraciones séricas de vancomicina decaen desde 39,63±7,62 mcg/ml a las 4h, hasta 8,55±2,87 mcg/ml a las 168h, en la primera cohorte, y desde 37,65±6,84 mcg/ml a las 6h, hasta 10,82±2,66 mcg/ml a las 120h (CVAN120), en la segunda. Los parámetros farmacocinéticos fueron: Cl=0,006 l/h/kg y Vd:=0,52 l/kg en la primera cohorte, y Cl=0,006 l/h/kg y Vd:=0,53 l/kg, en la segunda. El EM y el ECM de predicción de la CVAN120 fueron, respectivamente, 0,59 mcg/ml ([EM*100/CVAN120]=5,5%) y 10,38 mcg2/ml2 ([ECM*100/(CVAN120)2]=8,9%).Conclusión El modelo presentado muestra una exactitud y precisión adecuadas para la monitorización de la vancomicina intraperitoneal en pacientes sometidos a diálisis peritoneal continua ambulatoria con peritonitis bacteriana (AU)

Objective: To validate a pharmacokinetic model of the treatments with intraperitoneal vancomycin applied to patients on continuous ambulatory peritoneal dialysis with bacterial peritonitis. Methods: To carry out a prospective study divided in 2 cohorts: the first one including ten patients of 56 ± 14 years and 65 ± 5 kg, and the second one with 10 patients (12 episodes of peritonitis) aged 52 ± 13 years and 64 ± 8 kg. The treatment consists of administering and retaining for 6 h in the peritoneal cavity a solution containing 2 g of vancomycin and 1 g of ceftazidime into 2 l of ‘‘dialysis solution’’. After the antibiotic administration, blood samples were obtained at 4, 6, 8, 10, 24, 48 and 168 h in the first cohort and at 6 and 120 h (CVAN120) in the second. The pharmacokinetic model was developed from the parameters obtained from the first cohort and was validated by the second cohort, calculating the mean error (ME) and the mean squared prediction error (MSPE) of the CVAN120.Results: Vancomycin serum concentrations fell from 39.63 ± 7.62 mcg/ml at 4 h to 8.55 ± 2.87mcg/ml at 168 h for the first cohort, and from 37.65 ± 6.84 mcg/ml at 6 h to 10.82 ± 2.66 mcg/mlat 120 h (CVAN120) for the second cohort. The pharmacokinetics parameters were: C1 = 0.0061/h/kg and Vd: = 0.52 1/kg for the first cohort, and C1 = 0.006 1/h/kg and Vd: = 0.53 1/kg for the second. The predictive ME and MSPE of the CVAN120. were 0.59 mcg/ml ([EM*100/CVAN120 = 5.5%)and 10.38 mcg2/ml2([MES*100/(CVAN120)2]) respectively. Conclusion: The presented model shows an adequate exactitude and precision for the monitoring of intraperitoneal vancomyc in in patients submitted to continuous ambulatory peritoneal dialysis with peritonitis (AU)

[Monitoring of intraperitoneal administration of vancomycin in patients on continuous ambulatory peritoneal dialysis]. / Monitorización de la vacomicina en administración intraperitoneal en pacientes sometidos a diálisis peritoneal continua ambulatoria.

OBJECTIVE: To validate a pharmacokinetic model of the treatments with intraperitoneal vancomycin applied to patients on continuous ambulatory peritoneal dialysis with bacterial peritonitis. METHODS: To carry out a prospective study divided in 2 cohorts: the first one including ten patients of 56±14 years and 65±5 kg, and the second one with 10 patients (12 episodes of peritonitis) aged 52±13 years and 64±8 kg. The treatment consists of administering and retaining for 6 h in the peritoneal cavity a solution containing 2 g of vancomycin and 1 g of ceftazidime into 2 l of "dialysis solution". After the antibiotic administration, blood samples were obtained at 4, 6, 8, 10, 24, 48 and 168 h in the first cohort and at 6 and 120 h (C(VAN)(120)) in the second. The pharmacokinetic model was developed from the parameters obtained from the first cohort and was validated by the second cohort, calculating the mean error (ME) and the mean squared prediction error (MSPE) of the C(VAN)(120). RESULTS: Vancomycin serum concentrations fell from 39.63±7.62 mcg/ml at 4h to 8.55±2.87 mcg/ml at 168 h for the first cohort, and from 37.65±6.84 mcg/ml at 6h to 10.82±2.66 mcg/ml at 120 h (C(VAN)(120)) for the second cohort. The pharmacokinetics parameters were: C1=0.006 1/h/kg and Vd:=0.52 1/kg for the first cohort, and C1=0.006 1/h/kg and Vd:=0.53 1/kg for the second. The predictive ME and MSPE of the C(VAN)(120). were 0.59 mcg/ml ([EM*100/C(VAN)(120)=5.5%) and 10.38 mcg(2)/ml(2) ([MES*100/(C(VAN)(120))(2)]) respectively. CONCLUSION: The presented model shows an adequate exactitude and precision for the monitoring of intraperitoneal vancomycin in patients submitted to continuous ambulatory peritoneal dialysis with peritonitis.

Peritonitis por Saccharomyces cerevisiae en un paciente sometido a diálisis peritoneal ambulatoria / No disponible

No disponible

Fracaso renal agudo recurrente y reversible en un paciente afecto de hematuria y púrpura de Schönlein-Henoch / No disponible

La purpura de Schönlein-Henoch es una vasculitis de pequeño vaso caracterizada por el depósito de inmunocomplejos, principalmente IgA y C3. Es un trastorno multisistémico que afecta predominantemente la piel, las articulaciones, el tracto gastro-intestinal y los riñones. A nivel renal la expresión clínica varía desde una microhematuria aislada transitoria, hasta el cuadro de nefropatía rápidamente progresiva. El fracaso renal agudo es raro y suele verse asociado a episodios de hematuria macroscópica. Estos episodios suelen cursar con daño y obstrucción tubular por cilindros eritrocitarios. En este caso clínico describimos un paciente que sufrió dos episodios de fracaso renal agudo reversibles precedidos por brotes de hematuria macroscópica y que precisaron hemodiálisis durante cuatro y seis meses respectivamente (AU)

Sumary Henoch- Schönelin purpura (HSP) is a small vessel vasculitis characterized by deposition of inmune complexes, mainlyIg A and C3. It is a multisystem disorder affecting predominantly the skin, joints, gastrointestinal tract and kidneys. Clinical expression of nephritis ranges from transient isolated microscopic hematuria to rapidly progressive nephropathy. Acute renal failure is rare and is associated with episodes of macroscopic hematuria. These episodes are frequently associated with tubular damage and tubular obstruction by erythrocyte casts. We describe a patient with two episodes of acute renal failure after the onset of gross hematuria. Both episodes were reversible after six and four months respectively on hemodialysis (AU)

[Kinetic of calcium, phosphate, magnesium and PTH variations during hemodiafiltration]. / Cinéica del calcio, fósforo, magnesio y variaciones de la parathormona (PTH) en pacientes en hemodiafiltracion.

Hemodiafiltration (HDF) is a technique resulting from coupling of diffusive and convective transport and thereby increase the elimination of small and middle molecules. However, may induce a convective loss from others substances such as calcium and magnesium. The aim of this study was to evaluate the effects of Ultrafiltration on the kinetics of calcium, phosphate, magnesium and parathyroid hormone. A total of thirteen patients (7 males and 6 females) on hemodialysis, were studied. Each patient was randomly dialyzed with the same dialysate calcium concentration and three different ultrafiltration rate. Schedule A: High flux hemodialysis, schedule B: HDF with 10% of weight body and schedule C: HDF with 20% of weight body. The others parameters were kept identical. Total Ultrafiltration was 2,6+/-0,9 L (9,78+/-3,78 ml/min) in A, 9,3+/-1,7 L (34,54+/-6,22 ml/min) in B and 16,3+/-3,3 L (60,94+/-12,63 ml/min) in C. Replacement fluid during dialysis was 6,85+/-1,42 and 13,65+/-2,9 L. in C and C respectively. Postdialysis total,ionized calcium and magnesium were significantly lower in schedules B and C versus A. PTH levels did not differ significantly. However, PTH changes during dialysis was -36.6+/-38.6%, 6.3+/-69.8% and 32.2+/-63.2% in A, B and C, respectively (p<0.05 A vs. C). A significant inverse correlation was found between total Ultrafiltration and postdialysis levels of total calcium (r:-0.56, p<0.001), ionized calcium (r:-0.65, p<0.001) and magnesium (r:-0.47, p<0.01). No differences were observed in pre and postdialysis phosphate levels, neither mass transfer and clearance of phosphate. We concluded that high ultrafiltration flow rates and substitution fluid without divalent cations induces a negative calcium and magnesium balance. These changes may stimulate PTH secretion during HDF. This technique did not resulted in a higher clearance or phosphate removal.

Cinética del calcio, fósforo,magnesio y variaciones de la parathormona (PTH) en pacientes en hemodiafiltración / Kinetic of calcium, phosphate, magnesium and PTH variations during hemodiafiltration

La hemodiafiltración (HDF) es una técnica que combina los mecanismos difusivo y convectivo para lograr mayor eficacia depurativa. La confluencia de ambos mecanismos puede dificultar la transferencia de sustancias como el calcio, cuyo gradiente difusivo sea líquido de diálisis-sangre. El objetivo de nuestro estudio fue valorar la importancia de la convección en la transferencias del calcio, fósforo, magnesio y la PTH. Se estudiaron 13 pacientes en programa de hemodiálisis. A cada paciente se le realizó en la sesión de mitad de semana y de manera aleatoria tres esquemas de hemodiálisis: Tipo A.: Hemodiálisis de alto flujo. Tipo B:HDF del 10% del peso seco. Tipo C:HDF del 20% del peso seco. Las características de la sesión de HD fueron las habituales en cada paciente. La concentración de calcio en el líquido de diálisis fue la misma en los 3 tipos de sesiones. La composición del líquido de sustitución era: Na 145 mEq/l, Cl 85 mEq/l, HCO3- 60 mEq/l. El monitor de hemodiálisis empleado fue Integra® que disponía del módulo Quantiscan. Se determinaron al inicio (pre-HD) y al final (pos-HD) de la diálisis, el calcio total, calcio iónico, fósforo, magnesio y PTH. En el líquido de diálisis recogido mediante el Quantiscan, se determinaron los niveles de fósforo.No encontramos diferencias significativas entre los tres tipos de sesión para las concentraciones de calcio total pre-HD, Ca++ pre-HD, Mg pre-HD, fósforo pre y pos-HD ni en la transferencia de masa de fósforo. El calcio total pos-HD fue 9,93 ± 0,75 en la sesión A, 9,30 ± 0,79 en la B y 8,79 ± 0,69 mg/dl en la C (p < 0,01 A vs B y C). El Ca++ pos-HD fue de 2,61 ± 0,25 en la sesión A, 2,36 ± 0,27 en la B y 2,13 ± 0,28 mEq/l. en la C. (p < 0,01 A vs C). El Mg pos-HD 2,04 ± 0,11, 1,78 ± 0,14 y 1,77 ± 0,22 mg/dl, respectivamente (p < 0,001 A vs B y C). No se evidenciaron diferencias significativas en la PTH pre ni pos-HD. El porcentaje de variación de PTH durante la sesión fue de -36,6 ± 38,6% en la A, 6,3 ± 69,8% en la B y 32,2 ± 63,2% en la tipo C (p < 0,05 A vs C). La ultrafiltración total se correlacionó de manera inversa con los niveles séricos pos-HD, tanto de Ca total (r: -0,56, p < 0,001), Ca++ (r: - 0,65, p < 0,001), como Mg (-0,47, p < 0,01). Concluimos que el incremento en las tasas de ultrafiltración con líquidos de sustitución carentes de cationes divalentes, originan un balance de calcio y magnesio negativo con descenso en los niveles séricos de estos cationes al final de la sesión. Estos cambios pueden provocar un incremento en los niveles de PTH.No hemos apreciado mejoría en las transferencias de masa de fósforo ni en su aclaramiento al aumentar la tasa de ultrafiltración

Hemodiafiltration (HDF) is a technique resulting from coupling of diffusive and convective transport and thereby increase the elimination of small and middle molecules. However, may induce a convective loss from others substances such as calcium and magnesium. The aim of this study was to evaluate the effects of Ultrafiltration on the kinetics of calcium, phosphate, magnesium and parathyroid hormone. A total of thirteen patients (7 males and 6 females) on hemodialysis, were studied. Each patient was randomly dialyzed with the same dialysate calcium concentration and three different ultrafiltration rate. Schedule A: High flux hemodialysis, schedule B: HDF with 10% of weight body and schedule C: HDF with 20% of weight body. The others parameters were kept identical. Total Ultrafiltration was 2.6 ± 0.9 L (9.78 ± 3.78 ml/min) in A, 9.3 ± 1.7 L (34.54 ± 6.22 ml/min) in B and 16.3 ± 3.3 L (60.94 ± 12.63 ml/min) in C. Replacement fluid during dialysis was 6.85 ± 1.42 and 13.65 ± 2.9 L. in C and C respectively. Posdialysis total, ionized calcium and magnesium were significantly lower in schedules B and C versus A. PTH levels did not differ significantly. However, PTH changes during dialysis was -36.6 ± 38.6%, 6.3 ± 69.8% and 32.2 ± 63.2% in A, B and C, respectively (p < 0.05 A vs C). A significant inverse correlation was found between total Ultrafiltration and posdialysis levels of total calcium (r: -0.56, p < 0.001), ionized calcium (r: -0.65, p < 0.001) and magnesium (r:- 0.47, p < 0.01). No differences were observed in pre and posdialysis phosphate levels, neither mass transfer and clearance of phosphate. We concluded that high ultrafiltration flow rates and substitution fluid without divalent cations induces a negative calcium and magnesium balance. These changes may stimulate PTH secretion during HDF. This technique did not resulte in a higher clearance or phosphate removal

Estudio retrospectivo de las denuncias por malpraxis* médica en la provincia de Málaga / Retrospective study of medical malpractice suits in the province of Malaga (Spain)

Las denuncias contra los médicos son cada vez más frecuentes. Un hecho que hasta hace poco era relativamente anecdótico, se ha convertido en una situación jurídica habitual en la actualidad. El propósito de este estudio es recopilar los datos que desde nuestro punto de vista son más relevantes, de los existentes en los archivos del IML de Málaga, correspondientes a las denuncias por malpraxis en esta provincia. El objetivo es realizar una aproximación global, dada la nueva estructura del trabajo medico legal, a determinados aspectos periciales y aportar nuevos criterios a la hora de realizar dichas periciales. Al mismo tiempo se analiza la práctica de la medicina en esta provincia y su relación con los pacientes

Suits against doctors are now more frequent than ever. A situation that was almost anecdotic some years ago have become very common nowadays. The aim of this study is to compile main data which, from our point of view, are more relevant of the obtained from the files of the Institute of Legal Medicine of Malaga (Spain) related to the medical malpractice suits in this province. The objective is to carry out an approach, taken into account the new structure of the medico-legal work, to some expert witness report and to propose new criteria to perform those evaluations. At the same time, the practice of medicine in this province and its relation with the patients are analyzed

[Guidelines of the Spanish Society of Nephrology. Clinical practice guidelines for peritoneal dialysis]. / Guías Sociedad Española de Nefrología. Guías de práctica clínica en diálisis peritoneal.

In Spain and in each of its autonomous communities, the dialysis treatment of chronic renal disease stage 5 is totally covered by public health. Peritoneal dialysis, in any of its modalities, is established as the preferred home dialysis technique and is chosen by high percentage of patients as their choice in dialysis treatment. The Spanish Society of Nephrology has promoted a project of creation of performance guides in the field of peritoneal dialysis, entrusting a work group composed of members of the Spanish Society of Nephrology a with the development of these guides. The information offered is based on levels of evidence, opinion and clinical experience of the most relevant publications of the topic. In these guides, after defining the concept of << peritoneal dialysis>>, the obligations and responsibilities of the sanitation team of the peritoneal dialysis unit are determined, and protocols and performance procedures that try to include all the aspects that concern the patient with chronic renal disease in substitute treatment with this technique are developed. They propose prescription objectives based on available clinical evidence and, lacking this, on the consensus of the experts' opinions. The final aim is to improve the care and quality of the of the patient in peritoneal dialysis, optimizing in this way the survival of the patient and of the technique. In Spain, as in other neighbouring countries, peritoneal dialysis has an incidence and prevalence that is much lower than that of hemodialysis, ranging in the last evaluation by the Spanish Society of Nephrology between 5 and 24% in the different autonomous communities. The great majority of peritoneal dialysis units form part of the public network of the Spanish state, with special representation as a Satellite Unit or Concerted Center related to the public hospital of reference, on which it must depend.

[Determination of the dose of dialysis with integrated modules in the same monitor]. / Medición de la dosis de diálisis mediante diferentes módulos integrados en un mismo monitor.

The "gold standard" method to measure the mass balance achieved during dialysis for a given solute is based on the total dialysate collection. This procedure is unfeasible and too cumbersome. For this reason, alternative methods have been proposed including the urea kinetic modelling (Kt/V), the measurement of effective ionic dialysance (Diascan), and the continuous spent sampling of dialysate (Quantiscan). The aim of this study was to compare the reliability and agreement of these two methods with the formulas proposed by the urea kinetic modelling for measuring the dialysis dose and others haemodialysis parameters. We studied 20 stable patients (16 men/4 women) dialyzed with a monitor equipped with the modules Diascan (DC) and Quantiscan (QC) (Integra. Hospal). The urea distribution volume (VD) was determined using anthropometric data (Watson equation) and QC data. Kt/V value was calculated according to Daurgidas 2nd generation formula corrected for the rebound (eKt/V), and using DC (Kt/VDC) and QC (Kt/VQC) data. The total mass of urea removed was calculated as 37,93 +/- 16 g/session. The VD calculated using Watson equation was 35.7 +/- 6.6 and the VDQC was 35.06 +/- 9.9. And they showed an significative correlation (r:0,82 p < 0.001). The (VDQC-VDWatson) difference was -0.64 +/- 5.8L (ns). Kt/VDC was equivalent to those of eKt/V (1.64 +/- 0.33 and 1.61 +/- 0.26, mean difference -0.02 +/- 0.29). However, Kt/VQC value was higher than eKt/V (1.67 +/- 0.22 and 1.61 +/- 0.26 mean difference 0.06 +/- 0.07 p < 0.01). Both values correlated highly (R2: 0.92 p < 0.001). Urea generation (C) calculated using UCM was 8.75 +/- 3.4 g/24 h and those calculated using QC was 8.64 +/- 3.21 g/24 h. Mean difference 0.10 +/- 1.14 (ns). G calculated by UCM correlated highly with that derived from QC (R2: 0.88 p < 0.001). In conclusion, Kt/VDC and Kt/VQC should be considered as valid measures for dialysis efficiency. However, the limits of agreement between Kt/VQC and eKt/V were closer than Kt/VDC.

Medición de la dosis de diálisis mediante diferentes módulos integrados en un mismo monitor / Determination of the dose of dialysis with integrated modules in the same monitor

La recolección total del líquido de diálisis para cuantificar la cantidad total deurea eliminada durante la hemodiálisis (HD) se ha considerado la técnica «goldestándar» para medir la dosis de diálisis. Dada la dificultad de este método sehan propuesto otros alternativos como el modelo cinético de la Urea (Kt/V), lamedición de la dialisancia iónica o la recogida de muestras representativas del líquidode diálisis total.El objetivo de este trabajo es comparar la fiabilidad y concordancia de dos dispositivosde medida (dialisancia iónica y recogida parcial de líquido de diálisis)integrados en el mismo monitor de diálisis y compararlos con los propuestos porel modela cinético de la urea (MCU) para la medición de la dosis de diálisis(Kt/V) y otros parámetros de HD.Para ello se estudiaron 20 pacientes (16V/4M) con una edad media de 64,5 ±13 años, estables en programa de HD y dializados con el monitor Integra® (Hospal)equipado con los biosensores Diascan (DC) y Quantiscan (QC). El volumende distribución de urea (VD) se calculó a partir de la fórmula de Watson y porel QC. La generación de urea se calculó a partir del MCU y el Kt/V se determinópor la fórmula de Daurgidas 2ª generación corregida para el rebote (eKt/V),por el DC y el QC.La transferencia de masa de urea medida por QC fue de 37,2 ± 13,8 g. El VDpor la fórmula de Watson y por QC fue de 35,7 ± 6,6 y de 35,06 ± 9,9 L respectivamente(ns) y mostraron una correlación significativa (r: 0,82 p < 0,001).Los valores de aclaramiento (K), mediante DC, y QC fueron similares KQC: 230,3± 56,5 ml/min, KDC: 214,05 ± 24,3 ml/min (ns) No se apreciaron diferencias enel Kt/V calculado por DC y el eKt/V (KtVDC: 1,64 ± 0,33 vs KtVeq; 1,61 ± 0,26).El coeficiente de correlación fue de r: 0,45 (p < 0,05). Por el contrario los valoresde Kt/VQC fueron superiores a los calculados por el eKtV (1,67± 0,22 vs. 1,61± 0,26). El coeficiente de correlación fue de r: 0,94 ( p < 0,001). La generaciónde urea por el MCU fue de 8,7 ± 3,4 y por QC de 8,6 ± 3,2 g/ 24h (ns) r: 0,94p < 0,001).Podemos concluir que tanto la medición de la dialisancia iónica mediante elDC, como la recogida de muestras representativas del líquido de diálisis medianteel QC, son métodos sencillos, fiables y reproducibles que nos permiten medirde manera rápida la eficacia dialítica y otros parámetros de hemodiálisis. En nuestra experiencia la cuantificación de la dosis de diálisis mediante el QC presentauna mayor concordancia que la realizada con DC

The «gold standard» method to measure the mass balance achieved during dialysisfor a given solute is based on the total dialysate collection. This procedure isunfeasible and too cumbersome. For this reason, alternative methods have beenproposed including the urea kinetic modelling (Kt/V), the measurement of effectiveionic dialysance (Diascan), and the continuous spent sampling of dialysate(Quantiscan).The aim of this study was to compare the reliability and agreement of thesetwo methods with the formulas proposed by the urea kinetic modelling for measuringthe dialysis dose and others haemodialysis parameters.We studied 20 stable patients (16 men/4 women) dialyzed with a monitor equippedwith the modules Diascan (DC) and Quantiscan (QC) (Integra®. Hospal). Theurea distribution volume (VD) was determined using anthropometric data (Watsonequation) and QC data. Kt/V value was calculated according to Daurgidas2nd generation formula corrected for the rebound (eKt/V), and using DC (Kt/VDC)and QC (Kt/VQC) data.The total mass of urea removed was calculated as 37,93 ± 16 g/session. TheVD calculated using Watson equation was 35.7 ± 6.6 and the VDQC was 35.06± 9.9. And they showed an significative correlation (r:0,82 p < 0.001). The (VDQCVDWatson)difference was –0.64 ± 5.8L (ns). Kt/VDC was equivalent to those ofeKt/V (1.64 ± 0.33 and 1.61 ± 0.26, mean difference –0.02 ± 0.29). However,Kt/VQC value was higher than eKt/V (1.67 ± 0.22 and 1.61 ± 0.26 mean difference0.06 ± 0.07 p < 0.01). Both values correlated highly (R2: 0.92 p < 0.001).Urea generation (G) calculated using UCM was 8.75 ± 3.4 g/24 h and those calculatedusing QC was 8.64 ± 3.21 g/24 h. Mean difference 0.10 ± 1.14 (ns). Gcalculated by UCM correlated highly with that derived from QC (R2: 0.88 p <0.001).In conclusion, Kt/VDC and Kt/VQC should be considered as valid measures fordialysis efficiency. However, the limits of agreement between Kt/VQC and eKt/Vwere closer than Kt/VDC

Medición de la dosis de diálisis mediante diferentes módulos integrados en un mismo monitor / Measure of dialysis dose by different integrated modules within the same monitoring device

La recolección total del líquido de diálisis para cuantificar la cantidad total de urea eliminada durante la hemodiálisis (HD) se ha considerado la técnica «gold estándar» para medir la dosis de diálisis. Dada la dificultad de este método se han propuesto otros alternativos como el modelo cinético de la Urea (Kt/V), la medición de la dialisancia iónica o la recogida de muestras representativas del líquido de diálisis total. El objetivo de este trabajo es comparar la fiabilidad y concordancia de dos dispositivos de medida (dialisancia iónica y recogida parcial de líquido de diálisis) integrados en el mismo monitor de diálisis y compararlos con los propuestos por el modela cinético de la urea (MCU) para la medición de la dosis de diálisis (Kt/V) y otros parámetros de HD. Para ello se estudiaron 20 pacientes (16V/4M) con una edad media de 64,5 ± 13 años, estables en programa de HD y dializados con el monitor Integra® (Hospal) equipado con los biosensores Diascan (DC) y Quantiscan (QC). El volumen de distribución de urea (VD) se calculó a partir de la fórmula de Watson y por el QC. La generación de urea se calculó a partir del MCU y el Kt/V se determinó por la fórmula de Daurgidas 2ª generación corregida para el rebote (eKt/V), por el DC y el QC. La transferencia de masa de urea medida por QC fue de 37,2 ± 13,8 g. El VD por la fórmula de Watson y por QC fue de 35,7 ± 6,6 y de 35,06 ± 9,9 L respectivamente (ns) y mostraron una correlación significativa (r: 0,82 p < 0,001). Los valores de aclaramiento (K), mediante DC, y QC fueron similares KQC: 230,3 ± 56,5 ml/min, KDC: 214,05 ± 24,3 ml/min (ns) No se apreciaron diferencias en el Kt/V calculado por DC y el eKt/V (KtVDC: 1,64 ± 0,33 vs KtVeq; 1,61 ± 0,26). El coeficiente de correlación fue de r: 0,45 (p < 0,05). Por el contrario los valores de Kt/VQC fueron superiores a los calculados por el eKtV (1,67± 0,22 vs. 1,61 ± 0,26). El coeficiente de correlación fue de r: 0,94 ( p < 0,001). La generación de urea por el MCU fue de 8,7 ± 3,4 y por QC de 8,6 ± 3,2 g/ 24h (ns) r: 0,94 p < 0,001). Podemos concluir que tanto la medición de la dialisancia iónica mediante el DC, como la recogida de muestras representativas del líquido de diálisis mediante el QC, son métodos sencillos, fiables y reproducibles que nos permiten medir de manera rápida la eficacia dialítica y otros parámetros de hemodiálisis. En nuestra experiencia la cuantificación de la dosis de diálisis mediante el QC presenta una mayor concordancia que la realizada con DC

The «gold standard» method to measure the mass balance achieved during dialysis for a given solute is based on the total dialysate collection. This procedure is unfeasible and too cumbersome. For this reason, alternative methods have been proposed including the urea kinetic modelling (Kt/V), the measurement of effective ionic dialysance (Diascan), and the continuous spent sampling of dialysate (Quantiscan). The aim of this study was to compare the reliability and agreement of these two methods with the formulas proposed by the urea kinetic modelling for measuring the dialysis dose and others haemodialysis parameters. We studied 20 stable patients (16 men/4 women) dialyzed with a monitor equipped with the modules Diascan (DC) and Quantiscan (QC) (Integra®. Hospal). The urea distribution volume (VD) was determined using anthropometric data (Watson equation) and QC data. Kt/V value was calculated according to Daurgidas 2nd generation formula corrected for the rebound (eKt/V), and using DC (Kt/VDC) and QC (Kt/VQC) data. The total mass of urea removed was calculated as 37,93 ± 16 g/session. The VD calculated using Watson equation was 35.7 ± 6.6 and the VDQC was 35.06 ± 9.9. And they showed an significative correlation (r:0,82 p < 0.001). The (VDQCVDWatson) difference was –0.64 ± 5.8L (ns). Kt/VDC was equivalent to those of eKt/V (1.64 ± 0.33 and 1.61 ± 0.26, mean difference –0.02 ± 0.29). However, Kt/VQC value was higher than eKt/V (1.67 ± 0.22 and 1.61 ± 0.26 mean difference 0.06 ± 0.07 p < 0.01). Both values correlated highly (R2: 0.92 p < 0.001). Urea generation (G) calculated using UCM was 8.75 ± 3.4 g/24 h and those calculated using QC was 8.64 ± 3.21 g/24 h. Mean difference 0.10 ± 1.14 (ns). G calculated by UCM correlated highly with that derived from QC (R2: 0.88 p < 0.001). In conclusion, Kt/VDC and Kt/VQC should be considered as valid measures for dialysis efficiency. However, the limits of agreement between Kt/VQC and eKt/V were closer than Kt/VDC

Evaluación de costes en un servicio de nefrología mediante la contabilidad analítica / An evaluation of costs in nephrology by means of analytical accounting system

La contabilidad analítica es una técnica contable dirigida a la evaluación directa,mediante criterios de reparto preestablecidos, de los hechos económicos internos delhospital, con objeto de conocer los costes y productos de cada uno de los Servicios.El objetivo de este estudio es analizar el coste de los principales productos intermediosy finales elaborados por el Servicio de Nefrología del Hospital General deCastellón, utilizando esta herramienta contable.Se ha analizado la estructura de costes de los Centros de Actividad de Hospitalización(CAH) y Consulta Externa (CACEX). Para ello se han definido tres productosintermedios: Estancia, Primera Visita y Visita Sucesiva, y los productos finales(GRDs) elaborados por el Servicio. La metodología aplicada en los productos finaleses la asignación de costes en función del peso relativo de cada GRD (método «topdown») y posteriormente se añadieron los costes de las distintas exploraciones diagnósticaso terapéuticas realizadas.El coste total del CAH fue de 560.434,9 € y del CACEX de 176.317,8 €. El costede los productos intermedios Estancia, Primera Visita y Visita Sucesiva fueron de200,01, 63,26 y 31,63 €, respectivamente. El 80% de los 232 de episodios de hospitalizaciónse agrupó en 9 GRDs. El GRD más frecuente fue el 316 (InsuficienciaRenal), que representó el 30% de la casuística del Servicio. Su coste ascendió a3.178,2 € y el 16% de este correspondió a las exploraciones diagnósticas y terapéuticas.Podemos concluir que la implantación y desarrollo de la contabilidad analíticaes una necesidad en los Servicios de Nefrología. Esto nos permitirá conocer la estructurade costes de los Servicios, la complejidad de la casuística y por tanto la adecuadaplanificación de los recursos necesarios para atenderla

Background: The analytical accounting is a countable technique directed to theevaluation, by means of pre-established criteria of distribution, of the internal economyof the hospital, in order to know the effectiveness and efficiency of Clinical Units. The aim of this study was to analyze the activity and costs of the Nephrology Departmentof General Hospital of Castellón.Methods: Activity of Hospitalization and Ambulatory Care, during 2003 wasanalysed. Hospitalization discharges were grouped in DGR and the costs per DGRwere determinated.Results: Total costs Hospitalisation and Ambulatory Care were 560.434,9 and146.317,8 Euros, respectively. And the costs of one stay, one first outpatient visit andmaintenance visit were 200, 63, and 31,6 Euros, respectively. Eighty per cent of thedischarges were grouped in 9 DGR and DRG number 316 (Renal Failure) represented30% of the total productivity. Costs of DGR 316 were 3.178,2 Euros and 16%represented laboratory cost and costs of diagnostic or therapeutic procedures.Conclusion: With introduction of analytical accounting and DGR system, theNephrology Departments can acquire more full information on the results and costsof treatment. These techniques permits to improve the financial and economic performance

[An evaluation of costs in nephrology by means of analytical accounting system]. / Evaluación de costes en un servicio de nefrología mediante la contabilidad analítica.

BACKGROUND: The analytical accounting is a countable technique directed to the evaluation, by means of pre-established criteria of distribution, of the internal economy of the hospital, in order to know the effectiveness and efficiency of Clinical Units. The aim of this study was to analyze the activity and costs of the Nephrology Department of General Hospital of Castellón. METHODS: Activity of Hospitalization and Ambulatory Care, during 2003 was analysed. Hospitalization discharges were grouped in DGR and the costs per DGR were determinated. RESULTS: Total costs Hospitalisation and Ambulatory Care were 560.434,9 and 146.317,8 Euros, respectively. And the costs of one stay, one first outpatient visit and maintenance visit were 200, 63, and 31,6 Euros, respectively. Eighty per cent of the discharges were grouped in 9 DGR and DRG number 316 (Renal Failure) represented 30% of the total productivity. Costs of DGR 316 were 3.178,2 Euros and 16% represented laboratory cost and costs of diagnostic or therapeutic procedures. CONCLUSION: With introduction of analytical accounting and DGR system, the Nephrology Departments can acquire more full information on the results and costs of treatment. These techniques permits to improve the financial and economic performance.

[Outcome of tunneled hemodialysis catheters as permanent vascular access]. / Seguimiento a largo plazo de catéteres permanentes en pacientes con dificultad en la obtención de un acceso vascular definitivo.

UNLABELLED: Tunneled cuffed hemodialysis catheters (THC) are developed as a means of short hemodialysis access while a more permanent form of access are maturing. The aim of this study is to investigate the effectiveness, survival and complications of the THC used for long-term vascular access. METHODS: In a retrospective study we looked at 42 THC inserted between November 2000 and October 2003, in 40 elderly patients, with systemic disease or when other vascular access was not possible. RESULTS: Procedural complications occurred in 5 cases (11.9%), which included: local haemorrhage (3), hemothorax (1) and one fatal venous tear. 6 catheters (14.2%) were removed due to complications (non-function 3 and bacteraemia 3). The total incidence of THC related infections was 0.18 episodes/1,000 catheters-days. Patients were followed up for a mean 379 days (range 1-1,140) and a total of 15,946 catheter-days. Qb and KT/V achieved at one month were 278.3 +/- 34.1 ml/min and 1.48 +/- 0.27 respectively. At the end of the follow-up, 23 patients (54.7%) were alive with catheter functioning. One, three and twelve months survival was 90.4%, 73.1% and 59.5% respectively. CONCLUSION: The THC may be a useful alternative permanent vascular access for hemodialysis patients when others vascular access are not possible.

[Secondary amyloidosis (AA) and renal disease]. / Amiloidosis secundaria (AA) y afectación renal.

Amyloidosis is a disease resulting from extracellular deposition of fibrillar protein in various organs. AA amyloidosis may complicate chronic inflammatory diseases, chronic infections and another chronic diseases. We review 31 patients (13 males and 18 females) with biopsy proven renal or rectal AA amyloidosis, referred to out hospital between january 1999 and november 2002. Renal failure was defined as serum creatinine > or = 1.5 mg/dl. Mean age was 58.4 +/- 15.7 years. The causes of AA amyloidosis were an underlying chronic rheumatologic disease (51.6%), chronic infection (41.9%) and a chronic inflammatory intestinal disorder (6.5%). Renal failure (RF) was detected in 20 patients (61.2%) and proteinuria and hematuria were found in 90.3% and 45.5 respectively. Proteinuria at diagnosis was 5.2 +/- 3.9 g/24 h and mean serum creatinine 3.5 +/- 3.7 mg/dl. Survival of patients without dialysis was 66.8 (51.1% RF, 90.9% non-RF) and 53.4% (38.2 RF, 77.9% non-RF) at 12 and 24 months respectively (p = 0.017). End-stage renal disease developed in 13 patients (41.9%). Ten patients were maintained on hemodialysis and 3 on CAD. Survival in dialysis at 6 and 12 months was 68.3% and 42.7% respectively. Fifteen patients died and the main causes of death were: infections (46.6) haemorrhagic complications (33.3%), cardiovascular events (13.3%) and cachexia (6.6%).

Amiloidosis secundaria (AA) y afectación renal / Secondary Y amyloidosis (AA) and renal disease

La amiloidosis es una enfermedad sistémica caracterizada por el depósito extracelular de proteínas fibrilares en disposición beta-plegada. La amiloidosis secundaria a AA está constituida por fibrillas de proteína A, reactante de fase aguda elaborado por los hepatocitos. Se asocia a infecciones crónicas, enfermedades reumatológicas y neoplásicas. La clínica depende fundamentalmente del órgano afectado. La afectación renal es una manifestación frecuente de la enfermedad. El objetivo de este estudio es conocer la evolución clínica y la afectación renal de la amiloidosis secundaria en un grupo de pacientes. Se realizó un análisis retrospectivo de pacientes con amiloidosis secundaria desde enero de 1988 hasta noviembre de 2002. Criterios diagnósticos: amiloide AA en biopsia renal o rectal. Tinción rojo congo e inmunohistoquímica. Se definió la insuficiencia renal como valores de creatinina ≥ 1,5 mg/dl. Se recogieron los datos de un total de 31 pacientes. La edad media fue de 58,43 ± 15,7 años, 13 varones y 18 mujeres. Como factores de riesgo 16 (52%) presentaban patología autoinmune, 13 patología infecciosa (42%) y 2 inflamatoria intestinal (6%). Los principales síntomas clínicos fueron: astenia (81%), disnea (48%), anorexia (45%). El 61% (20) de los pacientes presentaban insuficiencia renal en el momento del diagnóstico, el 90% proteinuria, edemas el 77% y hematuria el 45%. Entre los datos bioquímicos destacaron: Hb 10 ± 2 g/dl, creatinina 3,5 ± 3,7 mg/dl, urea 99 ± 72 mg/dl, VSG 83 mm/1.ª hora y PCR 50 mcg/l. La proteinuria media fue de 5 ± 3,9 g/24 h. La supervivencia libre de diálisis fue del 67% (90,9% no IR, 51,1% IR) a los 12 meses y 54% (77,9% no IR, 38,2% IR) a los 24 meses (p = 0,017). El 42% (13) de los pacientes entraron en programa de diálisis (10 hemodiálisis y 3 DPCA). La supervivencia de estos pacientes a partir de la entrada en diálisis fue del 68% a los 6 meses y del 43% a los 12 meses. Las principales complicaciones fueron la infección (55%) y la hemorragia (25%). Las causas de muerte fueron infecciosas (46,6%), hemorragia (33,3%) y cardiovascular (6,6%)

Amyloidosis is a disease resulting from extracellular deposition of fibrillar protein in various organs. AA amyloidosis may camplicate chronic inflammatory diseases, chronic infections and another chronic diseases. We review 31 patients (13 males and 18 females) with biopsy proven renal or rectal AA amyloidosis, referred to out hospital between january 1999 and november 2002. Renal failure was defined as serum creatinine ≥ 1,5 mg/dl. Mean age was 58,4 ± 15,7 years. The causes of AA amyloidosis were an underlying chronic rheumatologic disease (51.6%), chroic infection (41.9%) and a chronic inflammatory intestinal disorder (6.5%). Renal failure (RF) was detected in 20 patients (61,2%) and proteinuria and hematuria were found in 90,3% and 45,5 respectively. Proteinuria at diagnosis was 5.2 ± 3.9 g/24 h and mean serum creatinine 3.5 ± 3.7 mg/dl. Survival of patients without dialysis was 66.8 (51.1% RF, 90.9% non- RF) and 53.4% (38.2 RF, 77.9% non-RF) at 12 and 24 months respectively (p = 0.017). End-stage renal disease developed in 13 patients (41.9%). Ten patients were maintained on hemodialysis and 3 on CAD. Survival in dialysis at 6 and 12 months was 68.3% and 42.7% respectively. Fifteen patients died and the main causes of death were: infections (46.6) haemorragic complications (33.3%), cardiovascular events (13.3%) and cachexia (6.6%)

[Usefulness of the Biofeedback Diacontrol module in the automatic programming of plasmatic conductivity and ionic mass transfer]. / Utilidad del módulo de "Biofeedback" Diacontrol en la programación automática de la conductividad plasmática y la transferencia de masa iónica.

Programmed variable sodium in the dialysate can improve hypotension during hemodialysis but may also alter sodium balance and thus resulting in a increase of water intake and weight gain between dialysis sessions. The aim of this study was to evaluate the changes on plasma volume (PV), Ionic Mass Transfer (IMT) and plasma conductivity (PC) with two different hemodialysis techniques. We studied 10 patients during a four-period protocol (one week each: PF1-DC1-DC2PF2): 120 dialysis sessions. During periods PF1 and PF2, the dialysis procedure was as usual, with exponential decrease of dialysate conductivity (DC) profile (15.7 mS/cm at start, 14.4 mS/cm at middle and 13.8 mS/cm at the end of the session) and UF profile (1.7 1/h at start and 0.1 1/h at the end). During periods DC1 and DC2, DC was automatically determined by a biofeedback modulae (Diacontrol) in order to reach a plasma water conductivity fixed at 14 mS/cm. All hemodialysis parameters were the same for the four periods: duration, blood and dialysate flow rates, dialysis membrane. A lower reduction of PV was evident on PF1 and PF2 (104 +/- 3.26% and -4.36 +/- 2.7%) compared with DC 1 and DC2 (-6.53 +/- 3.31% and -6.67 +/- 3.12%) (p < 0.001). No significant differences were seen in systolic, mean and diastolic blood pressure pre-HD or post-HD, UF, and weight gain, between the four periods. Hypotensive episodes were seen in 33.3% of PF1, 20% of DC1, 23.3% of DC2 and 26.6% of PF2 sessions (NS). PF1 and PF2 periods resulted in a significantly higher 30', mid and post-dialysis PC as compared to DC1 and DC2 periods (p < 0.001). The mean difference between the actual value and the prescribed value of PC at the end of the session was -0.01 +/- 0.07 mS/cm (n: 60). There was a negative correlation between the mean DC during session and the PC at 30' of session. IMT was 420.73 +/- 126.9 mEq in PF1, 311.96 +/- 161.75 in DC1, 278.34 +/- 153.14 in DC2 and 417.66 +/- 152.17 in PF2 (p > 0.001 PF1 and PF2 vs. DC1 and DC2). Diacontrol determines automatically an individualized DC profile for each patient, and accurately reaches the prescribed PC target. By reaching both the dry weight and PC settings, the water and sodium pool is maintained lower in the hemodialysis session using a biofeedback module. Clinical tolerance was similar in the two different dialysis procedures.

Utilidad del módulo de «Biofeedback» DiacontrolTM en la programación automática de la conductividad plasmática y la transferencia de masa iónica / Biofeedback diacontrolTM module in the automatic programation of plasmatic conductivity ad ionic mass transfer

La utilización de perfiles descendentes de conductividad en el dializado (CD) ha disminuido el número de complicaciones intradiálisis. No obstante, la presencia de una mayor concentración de sodio puede originar un balance positivo de este catión y favorecer los episodios de sed y el desarrollo de hipertensión arterial. El objetivo de este estudio fue comparar la tolerancia, así como la evolución de la Conductividad Plasmática (CP) y la Transferencia de Masa lónica (TMI), al pasar de un tipo se sesión con alto contenido en Na (perfiles de CI) y UF) a otro tipo de sesión que emplea un sistema de «biofeedback» (DiacontroITM ) y repetir el proceso inverso. Se han estudiado 120 sesiones de diálisis en 10 pacientes durante cuatro periodos de tratamiento (PF1-DC1-DC2-PF2). Durante los períodos PF1 y PF2 los pacientes se dializaban con perfiles logarítmicos descendentes de conductividad (C1) al inicio de la sesión 15,7 mS/cm, a la mitad 14,4 mS/cm y 13,8 mS/cm al final) y UF (1,7 I/h al inicio y 0,1 I/h al final) y en los períodos DC1 y DC2 se realizaron con el sistema DiacontroITM, fijando la CP final en 14 mS/cm. No se detectaron diferencias significativas en la TAS, TAM y TAD pre o postsesión entre los cuatro períodos. El porcentaje de sesiones con al menos un episodio de hipotensión fue del 33,3% en PF1, 20% en DC1, 23,3% en DC2 y 26.6% en PF2 (ns). El descenso del VP fue de -4,04 +- 3,26% en PF1, -6,53 +- 3,31% en DC1, -6,67 +- 3,12% en DC2 y 4,36 +- 2,7% en PF2 (p < 0,00l PF1 y PF2 vs DC1 y DC2). La CP fue significativamente superior tanto a los 30’, mitad de sesión, post-HD, así como a lo largo de toda la sesión, en los períodos PF1 y PF2 vs DC1 y DC2 (p < 0,001). En las sesiones con Diacontrol, la diferencia media entre la CP final conseguida y programada fue de 0,01 +- 0,07 mS/cm (intervalo de confianza al 95% -0,03-0,008). Asimismo se apreció una correlación inversa entre los valores de CD media y los de la CP prediálisis (r: -0,42, p < 0,05 en DC1 y r: - 0,65, p < 0,001 en DC2). La TMI fue de 420,73 +- 126,9 mEq en PF1, 311,96 +- 161,75 en DCI, 278,34 +- 153,14 en DC2 y 417,66 +- 152,17 en PF2 (p < 0,001 PF1 y PF2 vs DCI yDC2). Podemos concluir que el sistema «biofeedback» Diacontrol permite programar un valor de conductividad plasmática al final de la sesión de hemodiálisis, en lugar de programar los valores de conductividad en el dializado. Por tanto, permite mantener una CP plasmática y una TMI inferior a aquellas logradas en las sesiones con perfiles descendentes de conductividad en el líquido de diálisis, manteniendo una estabilidad hemodinámica similar

Programmed variable sodium in the dialysate can improve hypotension during hemodialysis but may also alter sodium balance and thus resulting in a increase of water intake and weight gain between dialysis sessions. The aim of this study was to evaluate the changes on plasma volume (PV), Ionic Mass Transfer (IMT) and plasma conductivity (PC) with two different hemodialysis techniques. We studied 10 patients during a four-period protocol (one week each: PF1-DC1 -DC2PF2): 120 dialysis sessions. During periods PF1 and PF2, the dialysis procedure was as usual, with exponential decrease of dialysate conductivity (DC) profile (15.7 mS/cm at start, 14.4 mS/cm at middle and 13.8 mS/cm at the end of the session) and UF profile (1.7 1/h at start and 0.1 1/h at the end). During periods DC1 and DC2, DC was automatically determined by a biofeedback module (DiacontroITM) in order to reach a plasma water conductivity fixed at 14 mS/cm. All hemodialysis parameters were the same for the four periods: duration, blood and dialysate flow rates, dialysis membrane. A lower reduction of PV was evident on PF1 and PF2 (104 +- 3.26% and -4.36 +- 2.7%) compared with DC 1 and DC2 (-6.53 +- 3.31% and -6.67 +- 3.12%) (p 0.001 PF1 and PF2 vs. DC1 and DC2). DiacontrolTM determines automatically an individualized DC profile for each patient, and accurately reaches the prescribed PC target. By reaching both the dry weight and PC settings, the water and sodium pool is mantained lower in the hemodialysis session using a biofeedback module. Clinical tolerance was similar in the two different dialysis procedures