[Detection and classification of chronic kidney disease in Primary Care and importance of albuminuria]. / Detección y clasificación de la enfermedad renal crónica en Atención Primaria y la importancia de la albuminuria.

INTRODUCTION: Chronic kidney disease (CKD) is a public health problem, and Primary Care (PC) plays a key role in its detection and classification based on estimated glomerular filtration rate (eGFR), as well as the level of albuminuria for its proper management. The aim of this study was to analyse the prevalence and classification of CKD in patients attended in PC. MATERIAL AND METHODS: An analysis was made of CKD prevalence and classification according to the Kidney Disease-Improving Global Outcomes guidelines in PC patients. All biochemical analyses requested from PC on patients 18 years and older over a 5-year period were collected. When several analyses were available on a patient, the biochemistry result with the best eGFR was selected. RESULTS: Between 2010 and 2014, PC requested 304,523 biochemical analyses on 97,470 adult patients, with a mean age of 53.4±19.4 years, of which 57.2% were women. CKD prevalence was 7.6%. Urine protein results were present in only 16.6% of analyses, and only 15.2% patients had a urine protein result. Urine albumin was measured 15.4% of biochemical controls with eGFR≥60mL/min/1.73m2, in 27.1% of patients with eGFR between 30-59mL/min/1.73m2 (G3a-3b stages), and in 23.4% of patients with eGFR<30mL/min/1.73m2 (G4-5 stages). Urine albumin was tested in 37.7% of diabetics and in 23.5% of impaired fasting glucose. CONCLUSIONS: Requests for the measurement of urine proteins/albumin in PC patients are low, leading to only one in 6 PC patients being classified correctly. The measurement of urine proteins/albumin is higher in CKD and diabetic patients.

¿Es el momento de aplicar las nuevas Tecnologías de la Información y Comunicación a la Nefrología? / No disponible

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[Telemedicine applied to Nephrology. Another form of consultation]. / Telemedicina aplicada a la nefrología. Otra forma de consulta.

UNLABELLED: 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 AND METHOD: Retrospective and descriptive study of the patients with renal pathology treated in the consultation of telenephrology at our hospital in a period of time of 27 months (November 2004-January 2007). Such study is carried out in primary care centers of our sanitary area (4 centers). The general practician (G.P) 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.

[The start of renal replacement therapy in a Spanish department]. / Comienzo de tratamiento renal sustitutivo en la provincia de Cáceres.

BACKGROUND: Early nephrological referral and planned start of dialysis are associated with better prognosis after the beginning of renal replacement therapy (RRT). The aim of our study was to analyse patient clinical and analytic characteristics at the time of initiating dialysis and to evaluate if morbimortality was affected by planned start. PATIENTS AND METHODS: We performed a retrospective study of all patients commencing RRT in a Spanish Hospital of The National Health System over two years (2003-2004). A total of 117 patients (47 female and 70 male) were included. We carried out a retrospective analysis of the demographic characteristics, patients' clinical and analytic conditions at the time of starting dialysis and hospitalization days and mortality in six months after starting dialysis. Patients were classified as planned (P) or unplanned (NP), depending on whether the first dialysis was planned or an emergency. RESULTS: Sixty five patients (56.4%) started dialysis in a planned group while 52 (43.6%) were unplanned. In the former group, 83.1% of the patients had a vascular or peritoneal access available when starting RRT, whereas in the later group only the 3.8% had it. Planned dialysis initiation was associated with a high level of serum haemoglobin, haematocrit, calcium and albumin (p < 0.001), and a low level of serum urea, creatinine (p < 0.001) and phosphate (p < 0.05). More patients of the unplanned group were admitted at hospital at the initiation of dialysis (90.4% vs. 6.1%) and during the first 6 months (48% vs. 15.3%). The period of hospitalization was longer for the unplanned group (23.6 days vs 3 days) (p < 0.001). The 6-month-mortality was lower in the planned group (4.6% vs. 11.5%), whitout statistical difference. CONCLUSIONS: Planned dialysis initiation is associated with better clinical and metabolical conditions, greater probability of a vascular or peritoneal access availability and lower rate of hospitalization and mortality within 6 months after starting RRT

Comienzo de tratamiento renal sustitutivo en la provincia de Cáceres / The start of renal replacement therapy in a spanish department

Introducción: La derivación precoz al nefrólogo y el inicio programado de diálisisse asocian a un mejor pronóstico tras el comienzo del tratamiento renal sustitutivo(TRS). El objetivo de nuestro estudio fue analizar las características clínicasy analíticas de los pacientes al comienzo de diálisis y valorar si el inicioprogramado influía en la morbi-mortalidad a los 6 meses.Pacientes y métodos: Estudio retrospectivo que incluye los 117 pacientes queiniciaron TRS en nuestra provincia en los años 2003-2004 (47 mujeres y 70 varones).Se revisaron las características demográficas, los datos clínicos y analíticosal inicio, los ingresos hospitalarios y la mortalidad a los 6 meses. Los pacientes sedividieron en programados (P) y no programados (NP) dependiendo si la primeradiálisis se realizó en situación de urgencia (NP) o si pudo ser diferida en eltiempo más de 24 horas (P).Resultados: Sesenta y cinco pacientes comenzaron TRS de forma programada(56,4%) y 52 de forma no programada (43,6%). Los pacientes P presentaban accesovascular o peritoneal útil en un porcentaje mayor (83,1% vs 3,8%). El inicioprogramado de diálisis se asoció a un nivel más elevado de hemoglobina, hematocrito,calcio y albúmina (p < 0,001), y a una tasa más baja de urea, creatinina(p < 0,001) y fósforo (p < 0,05). Un menor número de pacientes del grupo P requirieroningreso al inicio de TRS (6,1% vs 90,4%), y también entre el 2° y el6° meses (15,3% vs 48%). Los días de hospitalización fueron significativamenteinferiores en el grupo programado (3 vs 23,6) (p < 0,001). Aunque no hubo diferenciasestadísticamente significativas, la mortalidad a los 6 meses fue menor enel grupo programado (4,6% vs 11,5%).Conclusiones: El inicio programado de diálisis se asocia a una mejor situaciónclínico-metabólica, una mayor probabilidad de acceso útil y un menor número dehospitalizaciones y tasa de mortalidad en los 6 meses posteriores

Background: Early nephrological referral and planned start of dialysis are associatedwith better prognosis after the beginning of renal replacement therapy (RRT). The aim of our study was to analyse patient clinical and analytic characteristicsat the time of initiating dialysis and to evaluate if morbimortality was affected byplanned start.Patients and methods: We performed a retrospective study of all patients commencingRRT in a Spanish Hospital of The National Health System over two years(2003-2004). A total of 117 patients (47 female and 70 male) were included. Wecarried out a retrospective analysis of the demographic characteristics, patients’ clinicaland analytic conditions at the time of starting dialysis and hospitalizationdays and mortality in six months after starting dialysis. Patients were classified asplanned (P) or unplanned (NP), depending on whether the first dialysis was plannedor an emergency.Results: Sixty five patients (56.4%) started dialysis in a planned group while 52(43.6%) were unplanned. In the former group, 83.1% of the patients had a vascularor peritoneal access available when starting RRT, whereas in the later grouponly the 3.8% had it. Planned dialysis initiation was associated with a high levelof serum haemoglobin, haematocrit, calcium and albumin (p < 0.001), and a lowlevel of serum urea, creatinine (p < 0.001) and phosphate (p < 0.05). More patientsof the unplanned group were admitted at hospital at the initiation of dialysis(90.4% vs 6.1%) and during the first 6 months (48% vs 15.3%). The periodof hospitalization was longer for the unplanned group (23.6 days vs 3 days) (p <0.001). The 6-months-mortality was lower in the planned group (4.6% vs 11.5%),whitout statistical difference.Conclusions: Planned dialysis initiation is associated with better clinical and metabolicalconditions, greater probability of a vascular or peritoneal access availabilityand lower rate of hospitalization and mortality within 6 months after starting RRT

[Renal histological lesions in patients with type II diabetes mellitus]. / Lesiones histológicas renales en pacientes con diabetes mellitus tipo II.

Diabetic glomerulosclerosis is the most frequent cause of renal disease in patients with type II diabetes mellitus (DM), sometimes accompanied by vascular lesions. However, other glomerular pathologies are important in these patients. The aim of this study was to evaluate the prevalence of non-diabetic nephropathy (NDN) in selected patients with type II DM, and to identify clinical markers that may predict its presence in this population. We reviewed 20 renal biopsies performed on twenty patients with type II DM. Nine of them showed diabetic nephropathy (DN) (45%), whereas eleven showed NDN (55%): 1 IgA nephropathy, 3 vasculitis and 7 membranous nephropathy. We found no differences between the two groups with regard to sex, duration of DM, insulin therapy, glycosylated haemoglobin, proteinuria, presence of nephrotic syndrome, hypertension, serum IgA level or renal size. The NDN group had haematuria in 63.6%, whereas the patients with NDN had it in 44.4% (NS). Body mass index was higher in NDN patients (30 +/- 6.7 vs 22 +/- 2.9; p < 0.01), The same was true for creatinine clearance (82.2 +/- 51.4 ml/m vs 40.4 +/- 19.6 ml/m; p < 0.05). The age at the moment of diagnosis was higher in ND patients (67 +/- 11.2 vs 54.3 +/- 4.6; p < 0.05). The 3 patients who had diabetic retinopathy were found to have DN on renal biopsy (diagnostic specificity = 100%), although 66.7% of the patients with diabetic glomerulopathy had no retinopathy. We conclude that patients with type II DM with renal findings suggesting non-diabetic renal disease frequently it have NDN, and a renal biopsy must be performed. The presence of retinopathy has a predictive value of 100% in predicting DN, therefore its existence may make this diagnostic procedure unneccesary.

Lesiones histológicas renales en pacientes con diabetes mellitus tipo II / Renal histologic lesions in patients with type II DM

La glomeruloesclerosis diabética es la causa más frecuente de afectación renal en pacientes con diabetes mellitus (DM) tipo II, muchas veces con lesiones vasculares. Sin embargo, no es despreciable la importancia de otras patologías glomerulares. El objetivo de este estudio ha sido evaluar la prevalencia de nefropatía no diabética (NND) en biopsias renales realizadas en pacientes seleccionados afectos de DM, e identificar marcadores clínicos que pueden predecir su presencia en esta población.Revisamos 20 biopsias realizadas a otros tantos pacientes con DM tipo II. Los criterios para su indicación fueron la ausencia de retinopatía, presencia de hematuria, insuficiencia renal de aparición reciente, inexplicada o de rápida progresión, proteinuria de comienzo brusco y DM de corta evolución (inferior a 3 años). De los 20 casos, nueve correspondieron a nefropatías diabéticas (ND) (45 por ciento) y 11 a NND (55 por ciento). Entre éstos, hubo una nefropatía IgA, 7 glomerulonefritis membranosas y 3 vasculitis. No encontramos diferencias en cuanto al sexo, tiempo de evolución de DM, insulinoterapia, HbA1c, proteinuria, presencia de síndrome nefrótico, HTA, valor de IgA sérica o tamaño renal. El grupo de la NND presentó microhematuria en el 63,6 por ciento frente al 44,4 por ciento de los pacientes con ND (NS).El índice de masa corporal fue más elevado en los pacientes con NND (30 ñ 6,7 vs 22 ñ 2,9; p < 0,01), al igual que el CCr (82,2 ñ 51,4 ml/m vs 40,4 ñ 19,6 ml/m; p < 0,05), Aquéllos con ND tenían una edad más avanzada (67 ñ 11,2 vs 54,3 ñ 4,6; p < 0,05).Los 3 pacientes que mostraron retinopatía presentaron una ND en la biopsia renal (especificidad diagnóstica del 100 por ciento), aunque el 66,7 por ciento de los pacientes con glomeruloesclerosis diabética carecían de retinopatía.Podemos concluir que los pacientes con DM tipo II con signos clínicos de enfermedad renal no diabética, tales como insuficiencia renal de reciente comienzo o de rápida evolución, proteinuria de inicio brusco, presencia de sintomatología sistémica, ANCA positivo o sedimento patológico, presentan una incidencia de ésta lo suficientemente elevada como para justificar la realización de una biopsia renal. Aunque el número de pacientes es escaso, la presencia de retinopatía tiene un valor predictivo del 100 por ciento para la ND, por lo que su existencia podría obviar esta prueba diagnóstica. (AU)

[Remission of nephrotic syndrome caused by renal amyloidosis secondary to pulmonary tuberculosis after tuberculostatic treatment]. / Remisión de síndrome nefrótico por amiloidosis renal secundaria a tuberculosis pulmonar tras tratamiento tuberculostático.

Secondary systemic amyloidosis is a frequent complication in several chronic infectious and inflammatory states. Although initially amyloidosis was described in association with long-standing syphilis and tuberculosis, with the introduction of antiboitic and antituberculous therapy, rheumatoid arthritis is now the commonest cause of this illness. We present here the case of a 16 year-old woman, who was diagnosed one month ealier with pulmonary tuberculosis. She developed a nephrotic syndrome and her kidney biopsy confirmed the presence of amyloid. Treatment of the tuberculosis was accompanied by clinical remission of the nephrotic syndrome two years later.

[Acute kidney failure caused by paracetamol poisoning]. / Fracaso renal agudo debido a intoxicación por paracetamol.

Paracetamol poisoning is manifested by hepatotoxicity, but acute renal failure is very rare, especially when there is no fulminant hepatic damage with encephalopathy or severe haemodynamic alterations. We present here the case of a 22-year-old woman who presented with acute renal failure after the ingestion of 11.5 g of acetaminophen. The clinical course and laboratory data were consistent with tubular necrosis. The patient required hemodialysis, but finally renal function returned to normal. The acetaminophen pharmacology and the differential diagnosis of acute azotemia in paracetamol overdosage are reviewed.

Acute renal failure as presentation of a Burkitt's lymphoma.

Acute renal failure due to diffuse renal infiltration is rarely the presenting manifestation of non-Hodgkin's lymphoma. We report a patient with acute renal failure secondary to diffuse bilateral renal infiltration by a Burkitt's lymphoma. The presence of bilateral renal enlargement, an elevated serum lactate dehydrogenase (LDH), and lymphopenia should suggest the diagnosis, which can be confirmed by renal biopsy.

Hemophagocytic syndrome as an unusual form of presentation of tuberculosis in a hemodialysis patient: case report and review of the literature.

We present an unusual manifestation of tuberculosis in a patient on hemodialysis. A 73-year-old woman was admitted to our hospital with a picture of fever, dyspnea and weight loss. She had chronic renal failure and had started periodic hemodialysis 5 years before. Fifteen days after admission, she began with pancytopenia, abnormal liver function and coagulopathy. A bone marrow aspiration was made 1 week later showing macrophage elements with phagocytic activity. Eight weeks later, bone marrow culture in Lowenstein media confirmed the presence of tuberculosis. After the beginning of antituberculosis therapy, the laboratory disturbances disappeared and the clinical situation improved. We think that fever of unknown origin and pancytopenia in patients on maintenance hemodialysis must lead to an early bone marrow biopsy or aspiration since after the diagnosis a specific therapy can cure the disease.

Urinary prostaglandins (PGE2 and PGI2) in hyporeninaemic hypoaldosteronism in diabetic patients with chronic renal failure.

The present work studies the urinary excretion of PGE2 and PGI2 (6-keto PGF 1 alpha) in 11 insulin-dependent diabetic patients with chronic renal failure with a glomerular filtration rate of 33.9 +/- 9.03 ml/min who had hyporeninaemic hypoaldosteronism to evaluate the influence of these prostaglandins on the appearance of this latter process. The results obtained in this group of patients were compared with those of a control group of healthy individuals, another group of nine non-diabetic patients with CRF, and a last group of eight insulin-dependent diabetic patients with normal renal function to evaluate to what extent the possible variations in prostaglandin excretion could be related to the diabetes, CRF, or a conjunction of both processes. The results of the groups of diabetic patients with CRF were Ccr 33.9 +/- 9.03 ml/min, decreased (P < 0.0001) with respect to the control group and with no difference with the CRF group without diabetes; plasma potassium (4.7 +/- 0.4 mEq/l), increased (P < 0.005) with respect to the values found in the control group; plasma bicarbonate (17.8 +/- 1.8 mEq/l), decreased (P < 0.005) with respect to the control group and also, though not significantly, with respect to the group of non-diabetic patients with CRF. Plasma aldosterone (pg/ml): resting 44.3 +/- 14.9; standing 65.7 +/- 63.5 and post-frusemide 65.5 +/- 58.6, decreased (P < 0.01) with respect to the other three groups. Plasma renin activity (PRA) (ng/ml/h): resting 0.34 +/- 0.3; standing 0.6 +/- 0.4, post-frusemide 0.9 +/- 0.5, decreased significantly with respect to the other three groups.(ABSTRACT TRUNCATED AT 250 WORDS)