¿Se infectan más los catéteres tunelizados para hemodiálisis cuando los pacientes ingresan en el hospital? / Are tunneled catheters for hemodialysis more infected when patients are admitted to the hospital?

La infección de los catéteres para hemodiálisis constituye una de las causas de mayor morbimortalidad. La hipótesis intuitiva de que los catéteres se infectan más durante la hospitalización no ha sido verificada en la literatura. Objetivo: Conocer si la hospitalización es un factor de riesgo de bacteriemia relacionada con catéter. Material y Método: Análisis retrospectivo de las bacteriemias asociadas a catéter durante un período de 4 años de un centro periférico extrahospitalario de hemodiálisis dependiente de un Servicio de Nefrología de un hospital de tercer nivel durante el período 2014-2017. Se recogieron los tiempos de empleo de catéteres y las bacteriemias relacionadas con catéter divididos en 2 escenarios: Hospital y centro periférico. Se aplicó el Modelo de Regresión de Poisson para comparar las bacteriemias Hospital vs centro periférico. Un mismo paciente pudo padecer bacteriemia más de una vez y en los dos escenarios. Resultados: Se emplearon 361 catéteres en 174 pacientes con tiempo total de uso 91.491 días, con 103 episodios de bacteriemia. Tasas de bacteriemias: hospitalizado 7,81/1000 días/catéter y centro periférico 0,81/1000 días/catéter. El riesgo de sufrir bacteriemia se multiplicó por 9,6 durante la hospitalización vs centro periférico (p<0,001). Conclusiones: El riesgo de bacteriemia relacionada con catéter aumenta cuando el paciente está hospitalizado. Las circunstancias relacionadas con la hospitalización son factores de riesgo. Aunque la mayor comorbilidad de estos pacientes puede explicar en parte la mayor incidencia de bacteriemias, la optimización de los cuidados de enfermería -para personal no habituado- es el espacio de mejora del que nos advierten los resultados

Infection of catheters for hemodialysis is one of the major causes of morbidity and mortality. The intuitive hypothesis that catheters become more infected during hospitalization has not been verified in the literature. Objective: To know if hospitalization is a risk factor for catheter-related bacteraemia. Material and Method: Retrospective analysis of catheter-associated bacteraemias in dialysis center dependent on a Nephrology Department of a third level hospital during the 2014-2017 period. Catheter use times and catheter-related bacteraemias were divided into 2 scenarios: hospital and dialysis center. The Poisson Regression Model was applied to compare bacteremia in hospital and dialysis center. The same patient could suffer bacteremia more than once and in both scenarios. Results: 361 catheters were used in 174 patients with a total time of use of 91,491 days, with 103 episodes of bacteraemia. Bacteremia rates: in hospital was 7.81/1000 days/catheter and in dialysis center was 0.81/1000 days/catheter. The risk of bacteraemia was multiplied by 9.6 during hospitalization versus dialysis center (p <0.001). Conclusions: The risk of catheter-related bacteraemia increases when patients are hospitalized. Circumstances related to hospitalization are risk factors. Although the greater comorbidity of these patients may partly explain the higher incidence of bacteraemias, the optimization of nursing care -for uninhabited personnel- is the focus of improvement, according to our results

Utilidad de los parámetros urinarios en la enfermedad renal crónica avanzada / Usefulness of urinary parameters in advanced chronic kidney disease

En esta revisión discutimos el valor diagnóstico de los parámetros urinarios en la enfermedad renal crónica avanzada y exponemos los conceptos clave que resumen las sugerencias del manuscrito. Volumen de orina: La cantidad de líquido ingerida puede ser un factor de riesgo de enfermedad renal crónica no establecido. Alcanzar una diuresis ≥ 2-3 l al día es una propuesta razonable, no aplicable al síndrome cardiorrenal y riesgo de retención hidrosalina. Naur_ determinación útil para vigilar la ingesta salina. Reducir la natriuresis < 120 mEq/d (≅ingesta sal ≤5 - 6g) es un objetivo razonable. Nitrógeno ureico urinario (NUU). Útil para estimar la ingesta proteica (ecuación de Maroni). Una ingesta proteica entre 48-72 g (0,8 - 0,9 g/kg/día según peso) ≅NUU 7-10 g/día aproximadamente. Carga ácida y potasio. La reducción de la carga ácida puede ser una estrategia adicional en el manejo nutricional de esta población. Puede estimarse de forma indirecta desde la encuesta dietética o midiendo la eliminación de NUU y Kur. Los límites en la recomendación no están establecidos; proponemos una liberación prudente de verduras y frutas. Fósforo: Existe estrecha asociación entre proteínas y fósforo, tanto en registro dietético como eliminación urinaria. El análisis combinado sugiere que para pacientes con FG<25 mil/min, una fosfaturia < 800mg/día, y con FG < 15 mil/min, una fosfaturia<600mg son objetivos razonables. Conclusión: Los parámetros urinarios proporcionan conocimiento sensible y de utilidad para la práctica clínica; aportan información de los hábitos dietéticos del paciente y de la adherencia a nuestras recomendaciones

This review discusses the diagnostic value of urinary parameters in the setting of advanced chronic kidney disease and we present the key concepts that summarise the suggestions of the manuscript. Urinary volume: The amount of fluid intake may be a non-established risk factor for CKD. For these patients, a urinary output ≥ 2-3 l/day is a reasonable proposal. This recommendation is not applicable to patients with cardiorenal syndrome or fluid overload risk. Naur:This determination is very useful to monitor salt intake. Reducing urinary Na < 120 mEq/day (≅salt intake ≤ 5-6 g) is a reasonable objective. Urinary urea nitrogen (UUN): This parameter is useful to estimate protein intake (Maroni BJ equation). A protein intake between 48-72 g (0.8-0.9 g/kg/day according to weight) is equivalent to UUN 7-10 g/day approximately. Acid load and potassium: Acid load reduction may be an additional strategy in the nutritional management of this population. It may be estimated indirectly from a diet survey or by measuring the elimination of UUN and Kur. The limits of this recommendation have not been established, but we propose a cautious and prudent diet of fruit and vegetables. Phosphorus: There is a significant positive correlation between phosphorus and protein, both in dietary records and urine elimination. Based on this information, we suggest a urinary P excretion < 800 mg/day or < 600 mg/day for patients with GFR < 25 ml/min or < 15 ml/min, respectivel

Usefulness of urinary parameters in advanced chronic kidney disease. / Utilidad de los parámetros urinarios en la enfermedad renal crónica avanzada.

This review discusses the diagnostic value of urinary parameters in the setting of advanced chronic kidney disease and we present the key concepts that summarise the suggestions of the manuscript. URINARY VOLUME: The amount of fluid intake may be a non-established risk factor for CKD. For these patients, a urinary output ≥2-3 l/day is a reasonable proposal. This recommendation is not applicable to patients with cardiorenal syndrome or fluid overload risk. NA: This determination is very useful to monitor salt intake. Reducing urinary Na<120 mEq/day (≅salt intake≤5-6g) is a reasonable objective. URINARY UREA NITROGEN (UUN): This parameter is useful to estimate protein intake (Maroni BJ equation). A protein intake between 48-72g (0.8-0.9g/kg/day according to weight) is equivalent to UUN 7-10g/day approximately. ACID LOAD AND POTASSIUM: Acid load reduction may be an additional strategy in the nutritional management of this population. It may be estimated indirectly from a diet survey or by measuring the elimination of UUN and Kur. The limits of this recommendation have not been established, but we propose a cautious and prudent diet of fruit and vegetables. PHOSPHORUS: There is a significant positive correlation between phosphorus and protein, both in dietary records and urine elimination. Based on this information, we suggest a urinary P excretion<800mg/day or<600mg/day for patients with GFR<25ml/min or<15ml/min, respectively. CONCLUSION: Urinary parameters provide sensitive and useful knowledge for clinical practice, provide information about the dietary habits of patients and the adherence to our recommendations.

Análisis de la frecuentación de Urgencias en consulta ERCA (enfermedad renal crónica avanzada): enseñanzas para optimizar el inicio programado en tratamiento renal sustitutivo / Analysis of emergency Department Frequentation among patients with advanced CKD (chronic kidney disease): Lessons to optimise scheduled renal replacement therapy initiation

La decisión de empezar tratamiento renal sustitutivo (TRS) conlleva un amplio margen de incertidumbre. El filtrado glomerular (FG) nos dice la magnitud del daño. La proteinuria, la velocidad de progresión. A pesar de estas premisas, más del 50% de los pacientes continúan iniciando TRS de forma precipitada y con riesgo vital. Hipótesis: Analizando la frecuentación de Urgencias (Urg) y las causas determinantes de un inicio precipitado, podremos programar mejor el momento de iniciar un TRS. Método: Estudio retrospectivo, observacional, de la frecuentación de Urg y del tiempo de hospitalización (Hos) de todos los pacientes de la consulta ERCA, durante un período de 12 meses. Se analizó: 1) tiempo en riesgo, destino (modalidad de TRS), comorbilidad previa. 2) Causas de frecuentación de Urg y Hos. 3) Tipo de inicio: "programado" vs. "no programado" y, dentro de estos, "no planificables" vs. "potencialmente planificables". Resultados: De 267 pacientes (con un tiempo en riesgo de 63.987 días; 70 ± 13 años; 67% varones; 38% diabéticos), 68 (25%) pacientes acudieron al hospital en 97 ocasiones: 39 solo Urg, 46 Urg + Hos y 12 solo Hos. La frecuentación de Urg fue de un paciente cada 4,3 días y la ocupación de camas fue de casi 3 diarias. Causas predominantes: 47% cardiopulmonar (1/3 insuficiencia cardíaca), 11% vascular periférico + cerebral, 11% digestivo: 8/11 por sangrado (todos con anticoagulantes/antiagregantes). Iniciaron TRS: 31 (12%): de estos, 14 (45%) de forma programada (6 DP, 6 HD y 2 TxR de donante vivo); 17 (55%) no programados o precipitados, todos con catéter venoso. Siguiendo los objetivos del estudio, estos últimos se desglosaron en 2 grupos: 9 no planificables (indicación inicial de manejo conservador o negativa del paciente a dializarse, y circunstancias sociales diversas no controlables por el nefrólogo) y 8 que consideramos potencialmente planificables (6 con fallo cardíaco, uno con hemorragia digestiva y uno vascular periférico). Estos últimos (potencialmente planificables), comparados con los 14 que iniciaron de forma programada, tenían significativamente mayor edad, más eventos cardíacos previos y el FG casi duplicaba al del otro grupo; todos entraron por Urg. Conclusión: Este análisis nos aporta conocimiento sobre aquellos pacientes que pueden beneficiarse de una preparación más precoz en TRS: proponemos que en los enfermos con eventos cardíacos previos, especialmente con riesgo de sangrado digestivo, se inicie la preparación para TRS aun con tasas de FG de 20-25 ml/min. A pesar de la naturaleza retrospectiva del estudio y ante la dificultad práctica de ensayos clínicos en esta población, proponemos esta medida como complemento a las recomendaciones actuales para un inicio programado en esta técnica

The decision to initiate renal replacement therapy (RRT) implies a wide margin of uncertainty. Glomerular filtration rate (GFR) tells us the magnitude of renal damage. Proteinuria indicates the speed of progression. However, nowadays more than 50% of patients are still initiating RRT hastily, and it is life threatening. Hypothesis: By analysing Emergency Department (ED) frequentation and causes of a hurried initiation, we can better schedule the timing of the start of RRT. Method: Retrospective and observational study of all CKD patients in our outpatient clinic. ED frequentation and hospitalisation (Hos) time were reviewed during a 12-month period. We analysed: 1) time at risk, purpose (modality of RRT), previous comorbidity; 2) causes of ED frequentation and Hos; 3) type of initiation: "scheduled" vs. "non-scheduled", and within these "non-planned" vs. "potentially planned". Results: Of a total of 267 patients (time at risk 63.987 days, 70 ± 13 years, 67% males, 38% diabetics), 68 (25%) patients came to hospital on 97 occasions: 39 only ED, 46 ED + Hos and 12 only Hos. ED frequentation was one patient every 4.3 days, and bed occupation was almost 3 per day. Main causes: 47% cardiopulmonary (1/3 heart failure), 11% vascular peripheral + cerebral, 11% gastrointestinal: 8/11 due to bleeding (all with anticoagulants/antiplatelet agents). Thirty-one (12%) patients initiated RRT: of these, 14 (45%) were scheduled (6 PD, 6 HD, and 2 living donor RTx), and 17 (55%) were not scheduled or were rushed, all with venous central catheter. Following the objectives of this study, the non-scheduled group were itemised into 2 groups: 9 non-planned (initial indication of conservative management or patient's refusal to undergo dialysis, and diverse social circumstances not controllable by the nephrologist) and 8 were considered potentially planned (6 heart failure, one gastrointestinal bleeding and one peripheral vascular complication). This last group (potentially planned), when compared with the 14 patients who started treatment in a scheduled manner, had significant differences in that they were older, with more previous cardiac events, and GFR almost double that of the other group. All of them started treatment in the ED. Conclusion: This analysis provides us with knowledge on those patients who may benefit from an earlier preparation in RRT. We suggest that patients with previous cardiac events, especially with a risk of gastrointestinal bleeding, should start the preparation for RRT even with GFR rates of 20-25 ml/min. In spite of the retrospective nature of this study, and taking into account the difficulties of carrying out clinical trials in this population, we propose this suggestion as complementary to the current recommendations for a scheduled start using this technique

Analysis of emergency Department Frequentation among patients with advanced CKD (chronic kidney disease): Lessons to optimise scheduled renal replacement therapy initiation. / Análisis de la frecuentación de Urgencias en consulta ERCA (enfermedad renal crónica avanzada): enseñanzas para optimizar el inicio programado en tratamiento renal sustitutivo.

The decision to initiate renal replacement therapy (RRT) implies a wide margin of uncertainty. Glomerular filtration rate (GFR) tells us the magnitude of renal damage. Proteinuria indicates the speed of progression. However, nowadays more than 50% of patients are still initiating RRT hastily, and it is life threatening. HYPOTHESIS: By analysing Emergency Department (ED) frequentation and causes of a hurried initiation, we can better schedule the timing of the start of RRT. METHOD: Retrospective and observational study of all CKD patients in our outpatient clinic. ED frequentation and hospitalisation (Hos) time were reviewed during a 12-month period. We analysed: 1) time at risk, purpose (modality of RRT), previous comorbidity; 2) causes of ED frequentation and Hos; 3) type of initiation: «scheduled¼ vs. «non-scheduled¼, and within these «non-planned¼ vs. «potentially planned¼. RESULTS: Of a total of 267 patients (time at risk 63.987 days, 70±13 years, 67% males, 38% diabetics), 68 (25%) patients came to hospital on 97 occasions: 39 only ED, 46 ED+Hos and 12 only Hos. ED frequentation was one patient every 4.3 days, and bed occupation was almost 3 per day. Main causes: 47% cardiopulmonary (1/3 heart failure), 11% vascular peripheral+cerebral, 11% gastrointestinal: 8/11 due to bleeding (all with anticoagulants/antiplatelet agents). Thirty-one (12%) patients initiated RRT: of these, 14 (45%) were scheduled (6 PD, 6 HD, and 2 living donor RTx), and 17 (55%) were not scheduled or were rushed, all with venous central catheter. Following the objectives of this study, the non-scheduled group were itemised into 2 groups: 9 non-planned (initial indication of conservative management or patient's refusal to undergo dialysis, and diverse social circumstances not controllable by the nephrologist) and 8 were considered potentially planned (6 heart failure, one gastrointestinal bleeding and one peripheral vascular complication). This last group (potentially planned), when compared with the 14 patients who started treatment in a scheduled manner, had significant differences in that they were older, with more previous cardiac events, and GFR almost double that of the other group. All of them started treatment in the ED. CONCLUSION: This analysis provides us with knowledge on those patients who may benefit from an earlier preparation in RRT. We suggest that patients with previous cardiac events, especially with a risk of gastrointestinal bleeding, should start the preparation for RRT even with GFR rates of 20-25ml/min. In spite of the retrospective nature of this study, and taking into account the difficulties of carrying out clinical trials in this population, we propose this suggestion as complementary to the current recommendations for a scheduled start using this technique.

Fracaso renal agudo en un hospital de tercer nivel, causa relevante de enfermedad renal crónica y mortalidad a medio plazo / Acute renal failure in a tertiary referal hospital, a relevant cause of chronic renal failure and mortality

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Análisis de costes y perfil sociocultural del enfermo renal. Impacto de la modalidad de tratamiento / Cost analysis and sociocultural profile of kidney patients. Impact of the treatment method

Antecedentes: El análisis del coste de la enfermedad renal crónica basado en datos individuales, por componentes y modalidades terapéuticas no ha sido publicado en España. Objetivos: a) Estudiar los costes sanitarios de un año de tratamiento con hemodiálisis (HD), trasplante renal (TxR) de cadáver y reno-páncreas (TxRP), y de la enfermedad renal crónica avanzada (ERCA) E4 y E5. b) Evaluar la eventual relación entre disparidad sociocultural, costes y modalidad de tratamiento. Métodos: Estudio observacional de: 1) 81 pacientes con ERCA (53 E4 y 28 E5); 2) 162 con más de 3 meses en HD y 3) 173 con más de 6 meses Tx (140 TxR y 33 TxRP). Los costes se evaluaron en cinco categorías: 1) sesiones de HD, 2) consumo farmacéutico, 3) hospitalizaciones, 4) atención ambulatoria y 5) transporte. Se realizó una encuesta de parámetros sociodemográficos. Resultados: El impacto económico de la HD fue de 47 714 ± 18 360 euros (media ± DS), el del Tx de 13 988 ± 9970 euros, y el de la ERCA 9654 ± 9412 euros. El coste de la HD fue el más elevado en todas las partidas económicas. Los costes fueron similares entre TxR y TxRP. En ERCA, a mayor deterioro renal, mayor coste (E4 7846 ± 8901 frente a E5 13 300 ± 9820, p < 0,01). Los pacientes Tx tenían mejor estatus sociocultural, mientras que los de HD presentaban el peor perfil. No encontramos diferencias en los costes entre los tres grupos socioculturales. Conclusiones: La HD conlleva el mayor impacto económico en todas las partidas, incrementando cinco veces el coste del paciente ERCA y tres veces el del Tx. Optimizar la prevención precoz y el Tx, llegado el caso, deben ser estrategias prioritarias. Este análisis invita a reflexionar acerca de si el estatus sociocultural puede influir en ventajas de oportunidades para el Tx (AU)

Background: The cost analysis of chronic kidney disease based on individual data for treatment methods and components has not been published in Spain. Objectives: a) To study the health costs of a year of treatment with haemodialysis (HD), deceased donor renal transplantation (RTx), renal-pancreas transplantation (RPTx), and S4 and S5 advanced chronic kidney disease (ACKD) b) Assess the potential relationship between sociocultural diversity, costs and treatment method. Methods: Observational study of: 1) 81 patients with ACKD (53 S4 and 28 S5) 2) 162 with more than 3 months on HD and 3) 173 with a Tx for more than 6 months (140 RTx and 33 RPTx). The costs were assessed in five categories: 1) HD sessions, 2) drug intake, 3) hospitalisation, 4) outpatient care and 5) transportation. We carried out a survey with socio-demographic parameters. Results: The financial impact of HD was euros 47,714 ± 18,360 (mean ± SD), that of Tx euros 13,988 ± 9970, and that of ACKD euros 9654 ± 9412. The cost of HD was the highest in all financial items. The costs were similar between RTx and RPTx. In ACKD, the greater the renal deterioration, the greater the cost is (S4 euros 7846 ± 8901 versus S5 euros 13,300 ± 9820, P<.01). Tx patients had the best sociocultural status, while HD patients had the worst profile. We did not find differences in costs between the three sociocultural groups. Conclusions: HD has the greatest financial impact in all items, five times higher than the ACKD patient cost and three times than the Tx patient cost. Optimising early prevention and Tx, if appropriate, must be priority strategies. This analysis invites us to think about whether sociocultural status can have an influence on opportunities for Tx (AU)

Cost analysis and sociocultural profile of kidney patients. Impact of the treatment method.

BACKGROUND: The cost analysis of chronic kidney disease based on individual data for treatment methods and components has not been published in Spain. OBJECTIVES: a) To study the health costs of a year of treatment with haemodialysis (HD), deceased donor renal transplantation (RTx), renal-pancreas transplantation (RPTx), and S4 and S5 advanced chronic kidney disease (ACKD) b) Assess the potential relationship between sociocultural diversity, costs and treatment method. METHODS: Observational study of: 1) 81 patients with ACKD (53 S4 and 28 S5) 2) 162 with more than 3 months on HD and 3) 173 with a Tx for more than 6 months (140 RTx and 33 RPTx). The costs were assessed in five categories: 1) HD sessions, 2) drug intake, 3) hospitalisation, 4) outpatient care and 5) transportation. We carried out a survey with socio-demographic parameters. RESULTS: The financial impact of HD was €47,714±18,360 (mean±SD), that of Tx €13,988±9970, and that of ACKD €9654±9412. The cost of HD was the highest in all financial items. The costs were similar between RTx and RPTx. In ACKD, the greater the renal deterioration, the greater the cost is (S4 €7846±8901 versus S5 €13,300±9820, P<.01). Tx patients had the best sociocultural status, while HD patients had the worst profile. We did not find differences in costs between the three sociocultural groups. CONCLUSIONS: HD has the greatest financial impact in all items, five times higher than the ACKD patient cost and three times than the Tx patient cost. Optimising early prevention and Tx, if appropriate, must be priority strategies. This analysis invites us to think about whether sociocultural status can have an influence on opportunities for Tx.

Vitamin D and proteinuria: a critical review of molecular bases and clinical experience.

Proteinuria is the main predictor of chronic kidney disease progression. Drugs that block the renin-angiotensin-aldosterone (RAA) system reduce proteinuria and slow down the progression of the disease. However, their effect is suboptimal, and residual proteinuria persists as an important predictor of renal impairment. Vitamin D has pleiotropic effects that could have an impact on these parameters. In this study, we critically review the molecular and experimental bases that suggest an antiproteinuric effect of vitamin D receptor (VDR) activation and the available evidence on its antiproteinuric effect in clinical practice. In animal models, we have observed the antiproteinuric effect of VDR activation, which could be due to direct protective action on the podocyte or other pleiotropic effects that slow down RAA system activation, inflammation and fibrosis. Clinical trials have generally been conducted in patients with a vitamin D deficiency or insufficiency and the main trial (VITAL) did not demonstrate that paricalcitol improved the study's primary endpoint (decrease in the urine albumin to creatinine ratio). In this sense, the information available is insufficient to advise the use of native vitamin D or VDR activators as renoprotective antiproteinuric drugs beyond the experimental level. Two Spanish clinical trials and one Italian trial attempted to determine the effect of paricalcitol and vitamin D on residual proteinuria in various clinical circumstances (PALIFE, NEFROVID and PROCEED).

Vitamina D y proteinuria: revisión crítica de las bases moleculares y de la experiencia clínica / Vitamin D and proteinuria: a critical review of molecular bases and clinical experience

La proteinuria es el principal predictor de progresión de la enfermedad renal crónica. Los fármacos que bloquean el eje renina-angiotensina-aldosterona (RAA) reducen la proteinuria y retrasan la progresión de la enfermedad. Sin embargo, su efecto es subóptimo, y la proteinuria residual persiste como predictor relevante de deterioro renal. La vitamina D tiene efectos pleiotrópicos que podrían impactar en estos parámetros. En este trabajo revisamos críticamente las bases moleculares y experimentales que sugieren un efecto antiproteinúrico de la activación del receptor de vitamina D (VDR), así como la evidencia disponible sobre su efecto antiproteinúrico en la práctica clínica. En modelos animales se ha observado un efecto antiproteinúrico de la activación del VDR, que podría deberse a una acción protectora directa sobre el podocito u otros efectos pleiotrópicos que frenen la activación del sistema RAA, la inflamación y la fibrosis. Los ensayos clínicos se han realizado en general en pacientes con déficit o insuficiencia de vitamina D y el mayor de ellos (VITAL) no demostró que el paricalcitol mejorara el objetivo primario del estudio (descenso del cociente albúmina creatinina urinario). En este sentido, la información disponible es insuficiente para aconsejar el empleo de la vitamina D nativa o de activadores del VDR como fármacos antiproteinúricos renoprotectores más allá del ámbito experimental. Dos ensayos clínicos españoles y uno italiano intentan aclarar cuál es el efecto del paricalcitol y la vitamina D sobre la proteinuria residual en diversas circunstancias clínicas (PALIFE, NEFROVID y PROCEED) (AU)

Proteinuria is the main predictor of chronic kidney disease progression. Drugs that block the renin-angiotensin-aldosterone system (ARBs) reduce proteinuria and slow down the progression of the disease. However, their effect is suboptimal, and residual proteinuria persists as an important predictor of renal impairment. Vitamin D has pleiotropic effects that could have an impact on these parameters. In this study, we critically review the molecular and experimental bases that suggest an antiproteinuric effect of vitamin D receptor (VDR) activation and the available evidence on its antiproteinuric effect in clinical practice. In animal models, we have observed the antiproteinuric effect of VDR activation, which could be due to direct protective action on the podocyte or other pleiotropic effects that slow down RAA system activation, inflammation and fibrosis. Clinical trials have generally been conducted in patients with a vitamin D deficiency or insufficiency and the main trial (VITAL) did not demonstrate that paricalcitol improved the study's primary endpoint (decrease in the urine albumin to creatinine ratio). In this sense, the information available is insufficient to advise the use of native vitamin D or VDR activators as renoprotective antiproteinuric drugs beyond the experimental level. Two Spanish clinical trials and one Italian trial attempted to determine the effect of paricalcitol and vitamin D on residual proteinuria in various clinical circumstances (PALIFE, NEFROVID and PROCEED) (AU)

Patients treated with plasmapheresis: a case review from University Hospital of the Canary Islands.

INTRODUCTION: Plasmapheresis (PP) is a therapeutic apheresis technique used in the treatment of various renal and systemic diseases with varying degrees of proven clinical efficacy. OBJECTIVE: To review our experience with PP at the Hospital Universitario de Canarias, focused on effectiveness and safety results in different disease groups. MATERIAL AND METHODS: A retrospective-descriptive study of patients treated with PP from 01/01/2006 to 31/12/2009 at the hospital. We analysed medical histories and demographic data (sex, age), biochemical parameters, underlying disease, volume and type of replacement used in the PP sessions (5% human albumin and/or fresh frozen plasma), complications with the technique, delay in starting PP treatment after suspected clinical diagnosis, number of PP sessions received, patient mortality, degree of renal impairment and evolution of renal function. RESULTS: There were 51 patients studied, aged 50±18 years, of whom 60% were male; 331 PP sessions were performed. The diseases treated were grouped as: 11 vasculitis, 15 transplant immune activation, 5 haemolytic-uraemic syndrome (HUS), 7 idiopathic or thrombotic thrombocytopaenic purpura, 2 foetal Rh immunisations, 2 haematological diseases, 4 neurological diseases, among others. Overall mortality was 19.6% (n=10): 6 cases secondary to septic shock and the rest as a result of the evolution of the underlying disease, with 1 due to haemorrhagic shock in the renal biopsy area. There were no deaths in the transplant immune activation group. In the vasculitis group, there were 3 deaths (2 secondary to septic shock). Of the 10 patients who died, 9 did so within the first three months after diagnosis. Of the 26 renal biopsies performed, the most frequent indications were: vasculitis (23%), humoral rejection (42%), humoral rejection with calcineurin-inhibitor toxicity (12%) and HUS (8%), among others. Haemodialysis (HD) was required by 24 patients at the start of clinical symptoms: 9 of the 11 patients with vasculitis, 4 of the 5 patients with HUS and 5 of the 15 patients with transplant immune activation. At the end of evolution, 14 of them remained on the HD programme: 5 of the 11 patients with vasculitis, 2 of the 15 transplant patients and 3 of the 5 HUS patients. Significantly, patients who developed end kiney disease (EKD) in the vasculitis group were older and had higher creatinine at the onset of the disease. The transplant patients were monitored for anti-HLA class I or II before and after PP; there was a mean decrease of antibody titres in all but one patient; with an average decrease of 51% to 31%. In general, the PP technique was virtually free of complications. There were only 5 (3%) mild-moderate reactions to fresh plasma (perioral tingling and urticarial reactions) requiring pre-medication with steroids, but which did not lead to discontinuation of the treatment. CONCLUSION: Taking into account the wide variety of diseases that can benefit from PP and the nature of some of them, publishing our experience with this therapeutic method is of great importance. By increasing the description of case series by centre, we can add survival and renal function evidence in many uncommon diseases. Our study provides useful information for clinical practice and has also led us to reflect on future strategies to optimise outcomes in our patients.

Management of hyperphosphataemia in dialysis patients: role of phosphate binders in the elderly.

Phosphorus control remains a relevant clinical problem in dialysis patients. With age, however, serum phosphorus level decreases significantly because of a spontaneous decrease in protein intake. Older patients usually need lower doses of phosphorus binders. Nevertheless, hyperphosphataemia is observed in a quarter of patients aged >65 years. Phosphorus retention is related to an imbalance between phosphorus intake and removal by dialysis, and is usually aggravated when vitamin D analogues are employed. Hyperphosphataemia induces secondary hyperparathyroidism and the development of osteitis fibrosa. Recent publications describe an association between phosphorus retention and increased calcium and phosphorus product (Ca2+ x P), with significant progression of tissue calcification and higher mortality risk. Dietary intervention, phosphorus removal during dialysis and phosphorus binders are current methods for the management of hyperphosphataemia. However, the phosphorus removed by standard haemodialysis is insufficient to achieve a neutral phosphorus balance when protein intake is >50 g/day. Additional protein restriction may impose the risk of a negative protein balance. More frequent dialysis may help to control resistant hyperphosphataemia. Phosphorus binders constitute the mainstay of serum phosphorus level control in end-stage renal disease patients. Aluminium-based phosphorus binders, associated with toxic effects, have largely been substituted by calcium-based phosphorus binders. However, widespread use of calcium-based phosphorus binders has evidenced the frequent appearance of hypercalcaemia and long-term progressive cardiovascular calcification. Sevelamer, a relatively new phosphorus binder, has proved efficacious in lowering serum phosphorus and parathyroid hormone (PTH) levels without inducing hypercalcaemia. Furthermore, several investigators have reported that sevelamer may prevent progression of coronary calcification. However, its efficacy in severe cases of hyperphosphataemia remains to be confirmed in large series. There are no specific guidelines for phosphorus control in the elderly. Until more information is available, levels of mineral metabolites should be targeted in the same range as those recommended for the general population on dialysis (calcium 8.7-10.2 mg/dL, phosphorus 3.5-5.5 mg/dL and Ca2+ x P 50-55 mg2/dL2). PTH values over 120 ng/L help to avoid adynamic bone disease. Since elderly patients have a higher incidence of adynamic bone (which buffers less calcium) and vascular calcification, sevelamer should be the phosphorus binder of choice in this population; but sevelamer is costly and its long-term efficacy has not been definitively validated. Patients with low normal levels of calcium may receive calcium-based phosphorus binders with little risk. Patients with low values of PTH and high normal calcium should receive sevelamer. Tailored combinations of calcium-based phosphorus binders and sevelamer should be considered, and calcium dialysate concentration adjusted accordingly.