Reflexión sobre el screening de neoplasias en glomerulonefritis / Review on the screnning of cancer in glomerulonephritis

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Intermediate steroid withdrawal after renal transplantation and anti-HLA antibodies (HLA-Abs) development / Retirada intermedia de esteroides después del trasplante renal y desarrollo de anticuerpos anti-HLA (Ac-antiHLA)

Introduction: Steroid withdrawal in renal transplantation is desirable to avoid their adverse effects. However, by decreasing the immunosuppression, could lead to an increased risk for the development of HLA-Abs. Objective: Evaluate the relationship between steroid withdrawal and development of HLA-Abs in renal transplantation. Methods: We analyzed sera by Luminex from 182 kidney transplants performed from 1998 to 2011, before and two years after transplantation. All the patients had a pretransplant PRA (panel reactive of antibodies) <20% by complement-dependent cytotoxicity (CDC) and maintenance immunosuppression with tacrolimus and mycophenolate mofetil (MMF). We compared a group of steroid withdrawal at 7 months (group-I; n=130) and another control with non-withdrawal (group-II; n=52). Results: 22 patients (16.9%) in group-I and 11 patients in group-II (21.1%) had HLA-Abs after two years (pNS). Despite excluding patients with PRA >20%, we detected HLA-Abs pretransplant by Luminex in 11.5% of patients in both groups, of which, 66.6%, versus 53% (p 0.058), developed new specificities, with a similar percentage of donor specific antibodies (DSA) in both groups (33.33% vs 36.36%), pNS. In the subgroup without pretransplant HLA-Abs (group-I; n=115, group-II; n=45), 6.08% developed de novo HLA-Abs, being DSA 3.4% (Group-I) versus 7.69% in group II with 3.84% DSA (pNS). Conclusions: Steroid withdrawal at 7 months of renal transplantation does not entail a higher risk in terms of HLA-Abs development in patients without pretransplant HLA-Abs and treatment with tacrolimus and MMF, although larger studies are needed to confirm these findings (AU)

Introducción: La retirada de esteroides en el trasplante renal es deseable por sus efectos adversos, sin embargo, al disminuir la inmunosupresión podría conllevar un riesgo superior para el desarrollo de Ac-anti-HLA. Objetivo: Evaluar la relación entre la retirada de esteroides y el desarrollo de Ac-anti-HLA en el trasplante renal. Métodos: Se evaluaron los sueros por Luminex de 182 trasplantados renales desde 1998 a 2011, antes y a los 2 años del trasplante. Todos tenían un panel reactivo frente a anticuerpos (PRA)<20% pretrasplante por citotoxicidad dependiente de complemento y mantuvieron la inmunosupresión con tacrolimús y micofenolato mofetilo (MMF). Comparamos un grupo de retirada de esteroides a los 7 meses (grupo I; n=130) y otro de no retirada (grupo II; n=52). Resultados: 22 pacientes (16,9%) en el grupo I y 11 pacientes en el grupo II (21,1%) presentaban Ac-anti-HLA a los 2 años (pNS). A pesar de excluir a los pacientes con PRA>20%, detectamos Ac-anti-HLA pretrasplante por Luminex en el 11,5% de los pacientes en ambos grupos, de los cuales, desarrollaron nuevas especificidades el 66,6% del grupo Iy el 53% en el grupo II (p 0,058), con un similar porcentaje de anticuerpos donante específicos (DSA) (33,3% vs. 36,36%), pNS. En el subgrupo sin Ac-anti-HLA pretrasplante (grupo I; n=115; grupo II; n=45), el 6,08% desarrollaron Ac-anti-HLA de novo, siendo DSA el 3,4% (grupo-I) vs. 7,69% con DSA en el 3,84% (grupo-II), pNS. Conclusiones: La retirada de esteroides a los 7 meses del trasplante renal no conlleva un riesgo superior en términos de desarrollo de Ac-anti-HLA en aquellos pacientes sin anticuerpos pretrasplante y en tratamiento con tacrolimús y MMF, aunque se requieren estudios más amplios para confirmar estos hallazgos (AU)

Intermediate steroid withdrawal after renal transplantation and anti-HLA antibodies (HLA-Abs) development.

INTRODUCTION: Steroid withdrawal in renal transplantation is desirable to avoid their adverse effects. However, by decreasing the immunosuppression, could lead to an increased risk for the development of HLA-Abs. OBJECTIVE: Evaluate the relationship between steroid withdrawal and development of HLA-Abs in renal transplantation. METHODS: We analyzed sera by Luminex from 182 kidney transplants performed from 1998 to 2011, before and two years after transplantation. All the patients had a pretransplant PRA (panel reactive of antibodies) <20% by complement-dependent cytotoxicity (CDC) and maintenance immunosuppression with tacrolimus and mycophenolate mofetil (MMF). We compared a group of steroid withdrawal at 7 months (group-I; n=130) and another control with non-withdrawal (group-II; n=52). RESULTS: 22 patients (16.9%) in group-I and 11 patients in group-II (21.1%) had HLA-Abs after two years (pNS). Despite excluding patients with PRA >20%, we detected HLA-Abs pretransplant by Luminex in 11.5% of patients in both groups, of which, 66.6%, versus 53% (p 0.058), developed new specificities, with a similar percentage of donor specific antibodies (DSA) in both groups (33.33% vs 36.36%), pNS. In the subgroup without pretransplant HLA-Abs (group-I; n=115, group-II; n=45), 6.08% developed de novo HLA-Abs, being DSA 3.4% (Group-I) versus 7.69% in group II with 3.84% DSA (pNS). CONCLUSIONS: Steroid withdrawal at 7 months of renal transplantation does not entail a higher risk in terms of HLA-Abs development in patients without pretransplant HLA-Abs and treatment with tacrolimus and MMF, although larger studies are needed to confirm these findings.

Diagnóstico de obstrucción de catéter peritoneal mediante peritoneografía fluoroscópica / Diagnosis of obstruction peritoneal catheter by fluoroscopic peritoneography

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Peritonitis causada por Pantoea agglomerans en diálisis peritoneal / Peritonitis caused by Pantoea agglomerans in peritoneal dialysis

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La ingesta elevada de sodio disminuye la respuesta antiproteinúrica del bloqueo del eje renina-angiotensina-aldosterona en el trasplante renal / A high sodium intake reduces antiproteinuric response to renin-angiotensin-aldosterone system blockade in kidney transplant recipients

Antecedentes: La proteinuria postrasplante renal se asocia a una disminución en la supervivencia del injerto y del paciente. Para reducir la proteinuria y mejorar el pronóstico renal se recomienda asociar fármacos bloqueantes del sistema renina-angiotensina-aldosterona (RAA). Aunque en los pacientes no trasplantados se ha demostrado que la dieta rica en sal reduce el efecto antiproteinúrico de los IECA y ARA-II, este efecto no se ha estudiado en los trasplantados renales. Objetivo: Valorar la relación entre la ingesta de sodio y el efecto antiproteinúrico de los IECA/ARA-II en los trasplantados renales. Métodos: Seleccionamos a 103 trasplantados tratados con IECA/ARA-II más de 6 meses por proteinuria>1g/día. La proteinuria se analizó al inicio del tratamiento y a los 6 meses. La ingesta de sal se estimó con el cociente urinario sodio/creatinina (uNa/Cr). Resultados: En 46 pacientes (44,7%) la proteinuria disminuyó<1g/día. Un uNa/Cr elevado se relaciona con un menor descenso de la proteinuria (r=−0,251; p=0,011). El porcentaje de reducción de la proteinuria fue significativamente menor en los pacientes en el tercil más alto de uNa/Cr [63,9% (RIC 47,1%); 60,1% (RIC 55,4%); 38,9% (RIC 85,5%); p=0,047]. Un uNa/Cr elevado se relaciona de forma independiente (OR 2,406 por 100 mEq/g; IC 95%: 1,008-5,745; p=0,048) a una respuesta antiproteinúrica<50% tras el bloqueo del eje RAA. Conclusiones: En los trasplantados renales con proteinuria tratados con IECA/ARA-II una ingesta elevada de sal se asocia con un menor descenso de la proteinuria (AU)

Background: Post-transplant proteinuria is associated with lower graft and patient survival. Renin-angiotensin-aldosterone system blockers are used to reduce proteinuria and improve renal outcome. Although it is known that a high salt intake blunts the antiproteinuric effect of ACEI and ARB drugs in non-transplant patients, this effect has not been studied in kidney transplant recipients. Objective: To analyse the relationship between sodium intake and the antiproteinuric effect of ACEI/ARB drugs in kidney transplant recipients. Methods: We selected 103 kidney transplant recipients receiving ACEI/ARB drugs for more than 6 months due to proteinuria>1 g/day. Proteinuria was analysed at baseline and at 6 months after starting ACEI/ARB treatment. Salt intake was estimated by urinary sodium to creatinine ratio (uNa/Cr). Results: Proteinuria fell to less than 1g/day in 46 patients (44.7%). High uNa/Cr was associated with a smaller proteinuria decrease (r=−0.251, P=.011). The percentage proteinuria reduction was significantly lower in patients in the highest uNa/Cr tertile [63.9% (IQR 47.1%), 60.1% (IQR 55.4%), 38.9% (IQR 85.5%),P=.047]. High uNa/Cr independently relates (OR 2.406 per 100 mEq/g, 95% CI: 1.008-5.745, P=.048) to an antiproteinuric response <50% after renin-angiotensin-aldosterone system blockade. Conclusions: A high salt intake results in a smaller proteinuria decrease in kidney transplant recipients with proteinuria treated with ACEI/ARB drugs (AU)

Factores de riesgo asociados a hernias en diálisis peritoneal / Risk factors associated with hernias on peritoneal dialysis

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Peritonitis causada por Paracoccus yeei en diálisis peritoneal / Paracoccus yeei peritonitis in peritoneal dialysis

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A high sodium intake reduces antiproteinuric response to renin-angiotensin-aldosterone system blockade in kidney transplant recipients. / La ingesta elevada de sodio disminuye la respuesta antiproteinúrica del bloqueo del eje renina-angiotensina-aldosterona en el trasplante renal.

BACKGROUND: Post-transplant proteinuria is associated with lower graft and patient survival. Renin-angiotensin-aldosterone system blockers are used to reduce proteinuria and improve renal outcome. Although it is known that a high salt intake blunts the antiproteinuric effect of ACEI and ARB drugs in non-transplant patients, this effect has not been studied in kidney transplant recipients. OBJECTIVE: To analyse the relationship between sodium intake and the antiproteinuric effect of ACEI/ARB drugs in kidney transplant recipients. METHODS: We selected 103 kidney transplant recipients receiving ACEI/ARB drugs for more than 6 months due to proteinuria>1 g/day. Proteinuria was analysed at baseline and at 6 months after starting ACEI/ARB treatment. Salt intake was estimated by urinary sodium to creatinine ratio (uNa/Cr). RESULTS: Proteinuria fell to less than 1g/day in 46 patients (44.7%). High uNa/Cr was associated with a smaller proteinuria decrease (r=-0.251, P=.011). The percentage proteinuria reduction was significantly lower in patients in the highest uNa/Cr tertile [63.9% (IQR 47.1%), 60.1% (IQR 55.4%), 38.9% (IQR 85.5%), P=.047]. High uNa/Cr independently relates (OR 2.406 per 100 mEq/g, 95% CI: 1.008-5.745, P=.048) to an antiproteinuric response <50% after renin-angiotensin-aldosterone system blockade. CONCLUSIONS: A high salt intake results in a smaller proteinuria decrease in kidney transplant recipients with proteinuria treated with ACEI/ARB drugs.

Sodium Excretion Pattern at 1 Year After Kidney Transplantation and High Blood Pressure.

BACKGROUND: High blood pressure (BP) after kidney transplantation decreases graft and patient survival. There is a causal relationship between high salt intake and increased BP in the general population, but the role of salt intake on post-transplant hypertension remains controversial. The aims of our study were to determine the pattern of salt intake in the first year post-transplantation and its influence on BP in our kidney transplant population. MATERIAL AND METHODS: We selected 270 deceased-donor kidney transplant recipients with graft survival longer than 1 year and at least 1 adequate 24-h urinary sodium excretion measurement at the first year visit in order to be included in the analysis. RESULTS: Some 87.0% patients had a sodium excretion (mean 165±73 mmol/day) higher than recommended. Male and younger recipients with a high body mass index had a higher sodium excretion. Among other variables, sodium excretion was independently related to higher systolic (b 3.529 per 100 mmol/day, 95%CI 0.725-6.334, p=0.014) and diastolic (b 1.866 per 100 mmol/day, 95%CI 0.237-3.496, p=0.025) BP. CONCLUSIONS: A high percentage of kidney transplant recipients have salt intake higher than recommended, contributing to increased BP. Measurement of 24-h urinary sodium excretion identifies non-compliant kidney transplant recipients who need intervention to improve BP control and graft outcome.

Ictus en pacientes en hemodiálisis: incidencia, tiempo de aparición y factores asociados / Strokes in patients on haemodialysis: incidence, onset time and associated factors

La incidencia de ictus es mayor entre los pacientes en hemodiálisis (HD) que en la población general. En este estudio observacional se analizaron los datos de los pacientes incidentes en HD en el Hospital Universitario Marqués de Valdecilla de Santander (España), durante un período de 40 años (1971-2011). El número total de pacientes que iniciaron hemodiálisis fue de 1453. El período total de seguimiento fue de 4982,22 pacientes/año. Ochenta y cuatro pacientes sufrieron un accidente cerebrovascular. La incidencia acumulada de accidentes cerebrovasculares fue de 5,8 %, con una tasa de incidencia de 1686 ictus por 100 000 pacientes-año. La tasa de incidencia en el primer año en HD fue de 1803 ictus por cada 100 000 pacientes-año, un 6,5 % superior a la media observada a lo largo de todo el período estudiado. En el resto del período, las tasas oscilaron entre 356 y 1626 ictus por cada 100 000 pacientes-año. Factores significativos relacionados con la aparición de ictus fueron: diabetes, infarto de miocardio o angina de pecho, hipertensión, arteriosclerosis/claudicación intermitente, antecedentes de accidente cerebrovascular antes de la HD y fibrilación auricular. Los niveles de hemoglobina en el grupo con ictus fueron prácticamente idénticos a los de la cohorte no ictus (11,92 ± 2,07 g/dl, en comparación con 11,68 ± 2,12 g/dl). Por último, el 60,7 % de la población ictus recibió eritropoyetina con dosis media de 9611 UI/semana, en comparación con el 51,9 % y una dosis de 9544 UI/semana en la cohorte no ictus, sin diferencias significativas entre los grupos. En conclusión, en la población en HD la incidencia de ictus es 7-10 veces superior a la población general y se asocia a factores tradicionales, pero no con niveles de hemoglobina ni dosis de eritropoyetina (AU)

The incidence of stroke is higher substantially among hemodialysis patients than in the overall population. In this observational cohort study, we analysed data from incident hemodialysis patients at Valdecilla University Hospital in Santander (Spain) during a 40-year period (1971-2011). A total number of 1453 patients were started on hemodialysis The total follow-up period was 4982.22 patients/year, with 84 patients having stroke. The cumulative incidence of stroke in our patients was 5.8%, with an incidence rate of 1686 strokes per 100 000 patient-years. The incidence rate in the first year was 1803 strokes per 100 000 patients-year, 6.5% higher than its average over the period studied. In the remaining period, the rates ranged between 356 and 1626 strokes per 100 000 patients-year. Significative factors related to stroke were: diabetes, myocardial infarction or angina, hypertension, arteriosclerosis/intermittent claudication, history of stroke before the HD and atrial fibrillation. Haemoglobin levels in the cohort stroke were virtually identical to those of the not stroke cohort (11.92±2.07g/dL, compared to 11, 68±2.12g/dL). Finally, 60.7% of the population of the stroke cohort received erythropoietin with mean dose of 9611IU/week, compared to 51.9% and a dose of 9544IU/week in the not stroke cohort, without significative differences among groups. In conclusion, in haemodialysis population the incidence of stroke is 7-10 times higher than in the general population. It is associated with well known factors for stroke but not with haemoglobin levels or erythropoietin dose (AU)

Strokes in patients on haemodialysis: incidence, onset time and associated factors.

The incidence of stroke is higher substantially among hemodialysis patients than in the overall population. In this observational cohort study, we analysed data from incident hemodialysis patients at Valdecilla University Hospital in Santander (Spain) during a 40-year period (1971-2011). A total number of 1453 patients were started on hemodialysis The total follow-up period was 4982.22 patients/year, with 84 patients having stroke. The cumulative incidence of stroke in our patients was 5.8%, with an incidence rate of 1686 strokes per 100 000 patient-years. The incidence rate in the first year was 1803 strokes per 100 000 patients-year, 6.5% higher than its average over the period studied. In the remaining period, the rates ranged between 356 and 1626 strokes per 100 000 patients-year. Significative factors related to stroke were: diabetes, myocardial infarction or angina, hypertension, arteriosclerosis/intermittent claudication, history of stroke before the HD and atrial fibrillation. Haemoglobin levels in the cohort stroke were virtually identical to those of the not stroke cohort (11.92±2.07 g/dL, compared to 11, 68±2.12 g/dL). Finally, 60.7% of the population of the stroke cohort received erythropoietin with mean dose of 9611 IU/week, compared to 51.9% and a dose of 9544 IU/week in the not stroke cohort, without significative differences among groups. In conclusion, in haemodialysis population the incidence of stroke is 7-10 times higher than in the general population. It is associated with well known factors for stroke but not with haemoglobin levels or erythropoietin dose.

Cystatin C and albuminuria as predictors of long-term allograft outcomes in kidney transplant recipients.

Although cystatin C (Cys) and albuminuria (Alb) are predictors of end-stage renal disease in the general population, there are limited data about the performance of these markers alone or combined with respect to the prediction of the kidney transplant outcome. We assessed the ability of one-yr creatinine (Cr), MDRD equation, Cys, Hoek equation, Alb, the logarithm of albuminuria (LogAlb), and two products of these variables for predicting death-censored graft loss (DCGL) in 127 kidney transplant recipients. Mean follow-up time was 5.6 ± 1.7 yr. During this time, 18 patients developed DCGL. The area under the receiver operating characteristic curve for DCGL ranged from 71.1% to 85.4%, with Cys*LogAlb being the best predictor. Cys-based variables and variables combining LogAlb and renal function estimates have better discrimination ability than Cr-based variables alone. After multivariate analysis, quartiles of all one-yr variables (except of Cr and MDRD) were independent predictors for DCGL. Predictors combining Alb and a Cr- or Cys-based estimate of renal function performed better than those markers alone to predict DCGL. Cys-based predictors performed better than Cr-based predictors. Using a double-marker in kidney transplantation, it is possible to identify the highest risk group in which to prioritize specialty care.