Development of a predictive model for early death in diabetic patients entering hemodialysis: a population-based study.

The aim of this study was to investigate whether early death following the start of dialysis treatment can be explained by predialysis comorbid conditions, and to develop a prognostic model to predict early death in these patients. All patients with diabetes mellitus (DM) over 19 years of age entering hemodialysis in Catalonia in the 1997-2002 period (n = 1,365) were assessed from prospectively obtained data in the Catalan Renal Registry. Logistic regression was used to identify the risk factors associated with mortality at 3, 6 and 12 months of hemodialysis. Mortality at 3 months was found to be associated with age (RR: 1.53/10 years), low grades of functional autonomy, defined as "limited" (RR: 2.28) or "special care" (RR: 4.60), heart disease (RR: 2.23), and use of a catheter as the first vascular access (RR: 2.45). Malignant conditions and malnutrition were found to be additional significant risk factors for mortality at 12 months (RR: 1.68 and 1.74, respectively). Based on the multivariate analysis results, an individual prognostic model was formulated. This study confirms previous data suggesting that predialysis comorbid conditions are significantly associated with mortality in DM patients on dialysis and provides a prognostic model to help clinicians focus on various factors that may require attention before initiating this treatment.

Reproducibilidad de la MAPA en pacientes con diabetes mellitus 2 / Reproducibility of ABPM in diabetes mellitus

Objetivo. Estudiamos la reproducibilidad de las cifras tensionales y de los trastornos del ritmo nictameral en pacientes afectos de diabetes mellitus 2. Asimismo valoramos la concordancia del estudio tensional con las complicaciones micro y macrovasculares presentes. Pacientes y método. Se estudia a 58 pacientes afectos de diabetes mellitus 2 con dos registros ambulatorios de presión arterial (MAPA) en un período inferior a las 8 semanas sin cambios en la medicación hipotensora. Resultados. La concordancia de las cifras de PA sistólica y PA diastólica tanto de las 24 horas como de día y noche es superior al 73 %. La reproducibilidad para la situación dipper/no dipper es muy baja. Doce de los pacientes se comportan repetidamente como dipper, otros 12 como no dipper y el resto son dipper variables. Sin alcanzar significación estadística los diabéticos repetidamente no dipper tienen una excreción urinaria de albúmina más elevada. Conclusiones. En el diabético tipo 2 las cifras de PA medidas por MAPA tienen una elevada reproducibilidad. Sin embargo, los trastornos del ritmo nictameral la tienen muy baja. La condición no dipper persistente comporta, probablemente, mayor repercusión visceral

Aim. We study the reproducibility of the blood pressure values and circadian pattern in diabetes mellitus 2 patients. We also evaluated the concordance of the blood pressure study with the micro and macrovascular complications present. Material and methods. A total of 58 patients with diabetes mellitus 2 who had two ambulatory blood pressure monitorings (ABPM) in a period less than 8 weeks without changes in their hypotensive medications were studied. Results. Concordance of the 24 hour and day and night time systolic and diastolic BP levels is superior to 73 %. Reproducibility for the dipper/non-dipper situation is very low. Twelve of the patients repeated were dipper, 12 others were non-dipper and the rest were variable dippers. Although not statistically significant, the repeatedly non-dipper diabetics had a very elevated urinary excretion of albumin. Discussion. ABPM blood pressure levels had elevated reproducibility among diabetic 2 patients. However, the circadian pattern reproducibility was very low. Persistent non-dipper condition probably has major visceral repercussion

Information program about organ and tissue transplant-donation process at the secondary schools in the province of Girona (Spain).

We believe that it is important to spread information about the organ and tissue transplant-donation (T-D) process to obtain the participation of all society. We prepared an information program about the T-D process for secondary school students in collaboration with the Education Department. We chose these students because they wish to receive information about life and are already conscious about its possible loss, and because they take risks practicing sports or driving cars. We spoke about the frequency of the T-D process in our hospitals, the organs and tissues that can be transplanted the number of people on the waiting list, as well as the origin and circumstances of potential donors. During the last 3 years we have done more than 200 lessons at 44 secondary schools. We consider our experience to be pleasant and useful. Students have accepted us and 96.5% of them have recommended the T-D lessons to future classmates.

Evaluación de las variaciones de la volemia en las distintas maniobras empleadas durante la hemodiálisis / Evaluation of plasma volume variation during different hemodialysis maneuvers

La hipotensión intradiálisis está íntimamente ligada a la hipovolemia y asociada al grado de ultrafiltración. Las maniobras utilizadas para corregir la hipotensión son: la maniobra de Trendelenburg, la infusión de suero salino isotónico o expansores del plasma y el cese de la ultrafiltración. El objetivo de dicho estudio es cuantificar el efecto en la volemia de las distintas maniobras empleadas para la corrección de la hipovolemia mediante el dispositivo del Crit-Line. Hemos evaluado 32 pacientes en programa de hemodiálisis estable durante 5 sesiones de hemodiálisis consecutivas. Las maniobras evaluadas han sido: administración de suero fisiológico, expansores del plasma, suero salino hipertónico, la maniobra de Trendelenburg y el cese de la ultrafiltración. Se valora la máxima volemia conseguida tras el inicio de la maniobra y el tiempo transcurrido hasta recuperar la volemia basal. Resultados: El suero fisiológico produce un incremento de la volemia al final de la tercera hora del 2,9 por ciento, superior a la primera (2,6 por ciento) y segunda horas (2,4 por ciento).La maniobra de Trendelenburg al final de la primera hora consigue un incremento mínimo de la volemia del 0,4 por ciento. La administración de expansores del plasma al final de la tercera hora produce el mayor incremento de la volemia, del 3,1 por ciento, y el más duradero (37 minutos). El cese de la ultrafiltración al final de la primera y tercera horas consigue un incremento de la volemia (del 2 por ciento y del 2,3 por ciento, respectivamente). Finalmente, la administración de suero salino hipertónico produce un mínimo incremento de la volemia del 0,7 por ciento. Conclusión: La infusión rápida de suero fisiológico y expansores del plasma son las maniobras más rápidas, eficaces y duraderas para la expansión de la volemia, seguidas del cese de la ultrafiltración. La maniobra de Trendelenburg y la administración de suero fisiológico hipertónico son maniobras muy poco eficaces en la recuperación rápida de la volemia (AU)

[Evaluation of plasma volume variation during different hemodialysis maneuvers]. / Evaluación de las variaciones de la volemia en las distintas maniobras empleadas durante la hemodiálisis.

UNLABELLED: Intradialytic hypotension is closely linked to hypovolemia and ascribed to the degree of ultrafiltration. Among the maneuvers used to recovery hypotension, we have the Trendelenburg position, the infusion of isotonic saline serum or plasma extenders as well as shutting of the ultrafiltration. The objective of this study is to quantify the influence that the different maneuvers employed for recovery hypovolemia will have on blood volume, employing the Crit-Line system. We have studied 32 hemodialysis patients over 5 consecutive hemodialysis sessions. The different maneuvers evaluated were: administration of saline serum, plasma extenders, Trendelenburg position, shutting off the ultrafiltration and administration of hypertonic saline serum. RESULTS: The administration of saline serum causes an increase of 2.9% in blood volume at the end of the third hour, which is higher than the increase achieved in the first hour (2.6%) and second hour (2.4%). The Trendelenburg position achieves a minimal blood volume increase of 0.4%. The administration of plasma extenders achieves the most significant increase in blood volume of 3.1% and the longer lasting one as well (37 minutes). The cessation of ultrafiltration at the end of the first and third hours, achieves a blood volume increase of 2% and 2.3% respectively. Lastly, the administration of hypertonic saline serum causes a minimal blood volume increase of 0.7%. CONCLUSION: The infusion of isotonic saline serum and plasma extenders, are the quickest, most efficient and long lasting maneuvers for blood volume expansion, followed by the cessation of ultrafiltration. In concerning to quick plasma volume recovery, the Trendelenburg position and the administration of hypertonic saline serum are not very efficient maneuvers.

[Catastrophic antiphospholipid syndrome in the immediate puerperium]. / Síndrome antifosfolipídico catastrófico en el puerperio inmediato.

We describe a female previously diagnosed of primary antiphospholipid antibody syndrome who presented a preclampsia in the second pregnancy. An urgent caesaria was made because of a worsening high blood pressure and oliguria. In the immediated puerperium she showed low platelets and persistent high blood pressure. Afterwards acute renal failure and neurological signs with a severe aortic valvulopathy were diagnosed. An haemolytic anemia was also detected. Definitive diagnosis was made by kidney biopsy with the result of a thrombotic microangiopathy. Treatment with low weight heparin and aspirin and systemic corticosteroids was started in the immediate puerperium and fresh frozen plasma was then added with a good response to treatment. Actually she is still with high blood pressure, aortic valvulopathy. Renal function is normal one year later.

[Immunonegative necrotizing glomerulonephritis: an atypical case of lupus nephropathy]. / Glomerulonefritis necrotizante inmunonegativa: un caso de nefropatía lúpica atípico.

We report here a case of systemic lupus erythematosus with severe, active pauci-immune necrotizing and crescentic glomerulonephritis. This patient had been diagnosed of a lupus nephritis type III previously and treated with steroids and azathioprine. After a renal symptomless period of nine years, she developed heavy proteinuria and hypertension. A second kidney biopsy was then performed. The pathological study disclosed a pauci-immune necrotizing crescentic and segmental glomerulonephritis. The absence of subendothelial and mesangial deposits was confirmed by both immunofluorescent microscopy and electron microscopy. The simultaneous immunological study showed normal ANCA levels while complement, anti-dsDNA and ANA were altered. The patient was treated with steroids and cyclophosphamide eith good response. This case points out the possibility previously recognized by others of an association between lupus and an pauci-immune necrotizing glomerulonephritis.

Síndrome antifosfolipídico catastrófico en el puerperio inmediato / Catastrophic antiphospholipid syndrome in the inmediate puerperium

Se presenta el caso de una paciente con síndrome antifosfolipídico primario conocido que se diagnosticó de preeclampsia grave en el segundo trimestre de embarazo. Se practicó cesárea urgente de parto gemelar por hipertensión arterial y oliguria. En el puerperio inmediato se observaron trombocitopenia e hipertensión. En la evolución posterior se diagnosticó un fracaso renal agudo con aparición de focalidad neurológica y afectación severa de la válvula aórtica. También se diagnosticó una anemia de tipo hemolítico. La histología renal mostró la existencia de microangiopatía trombótica. La paciente había iniciado tratamiento anticoagulante con heparina de bajo peso molecular por clínica neurológica a las 21 semanas de embarazo. El tratamiento con aspirina y heparina de bajo peso molecular a dosis anticoagulantes y corticoides sistémicos se hizo desde el puerperio inmediato y posteriormente se añadió plasma fresco congelado. La respuesta al tratamiento fue buena, presentando hipertensión arterial, valvulopatía aórtica con normalización de la función renal al año de evolución (AU)

Anàlisi prospectiva Delphi: el futur de la salut infantil i de la pediatria a Espanya / Delphi´s prospective analysis: the future of childhood health and pediatrics in Spain

No disponible

[Mortality and risk factors in patients with acute renal failure and multiple organ dysfunction]. / Mortalidad y factores de riesgo de los pacientes con fracaso renal agudo y disfunción multiorgánica.

BACKGROUND: Acute renal failure (ARF) associated to multiple organ dysfunction (MOD) deserves currently a poor survival. The aim of this study was to analyze the risk factors for mortality in ARF-MOD patients treated by means of continuous renal replacements strategies. PATIENTS AND METHODS: All the ARF-MOD patients treated by means of continuous renal replacement techniques (CRRT) in a single center in the period 1989-1995 have been evaluated. MOD was defined by the 1992 American Conference criteria. Both demographic and the scored clinical data were analysed by means of descriptive and comparative statistics and by multiple logistic regression for the mortality risk factors. RESULTS: 103 patients have been evaluated. The median age was 62 years (range 20-80), 73.8% were males and the mean APACHE II score was 22.7 (SD 5.5). In the 17.4% the ARF-MOD condition corresponded to multiple trauma, the other medical and surgical pathologies represented the 82.6% of cases. At least two organic systems were involved in all patients. Both urea and creatinine values significantly decreased in all the patients and the fluid removal was of 8.9 (2.6) l/24 h. The mortality rate was 78.6%. The risk for death, as evaluated by logistic regression, was higher in patients older than 60 years (OR: 3.45; Cl 95%: 1.1-10.78; p = 0.03), and lower in those with remaining diuresis (OR: 0.65; Cl 95%: 0.48-0.9; p = 0.008). Survival was better among ARF-MOD traumatic patients. CONCLUSIONS: The mortality rates among ARF-MOD patients remains high. The CRRT were useful for removing uremic toxins and fluids. By logistic regression only advanced age and low urine output were the main risk factors for mortality.

[Prevalence of arterial hypertension and other cardiovascular risk factors among hospital workers]. / Prevalencia de hipertensión arterial y otros factores de riesgo cardiovascular en trabajadores de un hospital.

BACKGROUND: The attitude of sanitary workers is essential for the control of arterial hypertension (HT). The aim of the study was to identify the prevalence of HT and some cardiovascular risk factors in both sanitary and non-sanitary hospital workers and the knowledge, therapeutic compliance and control of hypertense individuals. SUBJECTS AND METHODS: Two tensional measurements were obtained by using a manometer of mercury at the beginning and at the end of an epidemiological request. A logistic regression model was obtained to evaluate the association between HT and risk factors. RESULTS: One thousand and one individuals (762 females) with a median age of 37.2 years were studied. Prevalence of HT was 9.7%. Men showed a higher age-related prevalence than women (19.7 vs 6.6%, p < 0.001). Body mass index was higher in HT individuals. Thirty eight per cent of the hospital workers were smokers. HT prevalence increased with alcohol consumption. Sex, mass body index and age were significantly associated with HT. Knowledge, therapeutic compliance and control of HT were 73.2, 19.7 and 28%, respectively, in the total group and 61, 26.3 and 0%, respectively, in the group of physicians and nurses. CONCLUSIONS: Hospital workers showed a high prevalence of cardiovascular risk factors. Inadequate therapeutic and control measures were observed on both nurses and physicians with high blood pressure.

Effects of recombinant interleukin-2 and revaccination for hepatitis B in previously vaccinated, non-responder, chronic uraemic patients. Collaborative Group of Girona.

BACKGROUND: Growing evidence suggests that it is possible to seroconvert chronic renal failure patients who are absolute non-responders to hepatitis B vaccine by means of either additional booster vaccine doses or associated IL-2 administration or both. We have studied the possibilities of hepatitis B seroconversion by revaccination and its dependence on vaccine dose, and the effects of a concurrent low-dose rHuIL-2 regime. METHODS: Forty known absolute non-responders with chronic renal failure were entered into a complete revaccination protocol. Patients were randomly assigned to two dosage groups of either 20 or 40 micrograms hepatitis B vaccine administered at 0, 1, 2 and 6 months. Further randomly selected patients from each dosage group were given 500,000 U of rHuIL-2 in the same deltoid area 4 h after vaccine administration. RESULTS: Sixty-seven per cent of patients revaccinated with 40 micrograms attained antibody protecting levels compared to only 20% of those receiving doses of 20 micrograms (P < 0.025). When compared with initial values, the ThCD4/CD25 cell count was significantly reduced immediately after HuR-IL2 administration (P < 0.003) and significantly increased 1 month after the last dose was given (P < 0.0003). A definite rHuIL-2 effect on HBV antibody synthesis could not be demonstrated, nor was erythropoietin found to enhance seroconversion. CONCLUSIONS: From these results we suggest that more intense and frequent antigenic stimulation as obtained by revaccination using four doses of 40 micrograms may effectively reduce the pool of hepatitis B vaccine nonresponders in chronic renal failure patients.

[Early diabetic nephropathy in a patient with agenesis of one kidney]. / Nefropatía diabética temprana sobre riñón único.

A 24 year old male diagnosed of type II diabetes mellitus of 2 years of known clinical evolution discovered by an episode of hyperglycemic decompensation without ketoacidosis is presented. In the study of possible visceral involvement of the disease agenesis of the left kidney with compensating hypertrophy of the right kidney, increase of glomerular filtrate and proteinuria of 1.8 g/24 hours were observed. Renal histologic study demonstrated the existence of diffuse intercapillar glomerulosclerosis compatible with diabetic glomerulopathy. From these data and review of the literature the possibility of the greater risk of individuals with a single kidney to present nephropathy in the case of coexistence of associated diabetes mellitus.