COMPLEMENT-MEDIATED THROMBOTIC MICROANGIOPATHY AFTER KIDNEY TRANSPLANT: SHOULD TREATMENT WITH C5 INHIBITOR BE LIFELONG?

Complement-mediated thrombotic microangiopathy (CM-TMA) is a rare and life-threatening complication that can occur in kidney transplant recipients, with various potential triggers including immunosuppressive medications. The optimal management and duration of treatment with C5 inhibitors (C5i) for CM-TMA in this patient population remain areas of ongoing investigation. We present the case of a 38-year-old female with a history of IgA nephropathy who underwent preemptive living-related kidney transplantation and subsequently developed CM-TMA seven years post-transplant. Treatment with ravulizumab led to a rapid hematologic response and stabilized platelet counts. Serial measurements of complement functional tests and clinical stability guided the discontinuation of C5i therapy. The case highlights the complexity of managing CM-TMA in kidney transplant recipients, particularly in determining the appropriate duration of C5i therapy. The absence of an established protocol for discontinuation necessitates a personalized approach based on clinical and laboratory stability, absence of complement gene variants, and serial complement functional tests. Further prospective investigations are warranted to define the optimal strategies for monitoring and safely discontinuing C5i therapy in this unique patient population. This case underscores the importance of individualized care in the management of CM-TMA post-kidney transplantation, offering insights into potential criteria for therapy discontinuation.

Anticoagulation in renal replacement therapies: Why heparin should be abandoned in critical ill patients?

Extracorporeal circuits used in renal replacement therapy (RRT) can develop thrombosis, leading to downtimes and reduced therapy efficiency. To prevent this, anticoagulation is used, but the optimal anticoagulant has not yet been identified. Heparin is the most widely used anticoagulant in RRT, but it has limitations, such as unpredictable pharmacokinetics, nonspecific binding to plasma proteins and cells, and the possibility of suboptimal anticoagulation or bleeding complications, specifically in critically ill patients with acute renal failure who are already at high risk of bleeding. Citrate anticoagulation is a better alternative, being considered a standard for continuous renal replacement therapy, since it is associated with a lower risk of bleeding complications and better efficacy, even in patients with acute renal failure or liver disease. The aim of this article is to provide an updated review of the different strategies of anticoagulation in renal replacement therapies that can be implemented in critical scenarios, focusing on the advantages and disadvantages of each one and the beneficial aspects of using citrate over heparin in critical ill patients.

Validación del test Nuevo Signo Vital para la medición de la alfabetización en salud

Background: Health literacy is a determinant, powerful predictor of health. The Newest Vital Sign test (NVS) evaluates health literacy assessing the capacity of participants to understand the nutrition information label of an ice cream. Aim: To validate The NVS test for its application in the sociocultural context on primary care patients in Chile. Material and Methods: In a descriptive cross-sectional study, 1,117 people aged 58 ± 14 years (70% women) registered in the Cardiovascular Health Program of different Family Health Centers, answered the NVS test. They also answered the Test of Functional Health Literacy for Adults (TOFHLA) and the Health Literacy Survey, European Union (HLS-EU-32). An exploratory analysis was carried out. In addition, the Kuder-Richarson-20 reliability coefficient and Item-Test Point Biserial Correlations were calculated. The construct validity of the NVS was obtained using the Item Response Theory. The sensitivity and specificity of NVS were estimated using receiver operating characteristic curves using the TOFHLA score as gold standard. To establish the cutoff points, the Stratum-Specific Likelihood Ratio analysis was used. Results: The reliability of the test was adequate (KR-20 = 0.7478) and the values of the two logistic parameters model confirmed that the NVS items account for the health literacy construct. Conclusions: The NVS test turned out to be a valid and reliable instrument, and its application is recommended to measure the level of health literacy.

[Therapeutic plasma exchange. Experience in 102 patients]. / Intercambio plasmático terapéutico por plasmafiltración: experiencia de 11 años de un centro.

BACKGROUND: Therapeutic Plasma Exchange (TPE) is a procedure in which plasma and harmful macromolecules are separated from the rest of the blood components by centrifugation or filtration through membranes and are replaced with solutions with albumin and/or plasma. AIM: To communicate our experience using TPE by filtration. MATERIAL AND METHODS: Review of records of 655 TPE sessions performed in 102 patients aged 50 ± 18 years (64% women). The requirement of renal replacement therapy (RRT) and seven days and one year mortality were recorded. RESULTS: Forty five percent of patients had hypertension or diabetes. The main indications for TPE were pulmonary-renal syndrome (PRS) (62%) and antibody mediated graft rejection (29%), followed by neurological diseases (36%). Fifteen percent of patients required RRT for one year. Mortality at seven days and one year was 20 and 30%, respectively. Out of the total of deaths associated with kidney diseases, 88% corresponded to PRS and ANCA vasculitis. The main complications were thrombocytopenia in 41%, hypocalcemia in 18%, and hypotension in 16%. CONCLUSIONS: In our experience, TPE by filtration is a safe technique, with mild and preventable complications. Despite this, the reported mortality is high, which reflects the severity of the diseases that motivated the indication for TPE.

Intercambio plasmático terapéutico por plasmafiltración: experiencia de 11 años de un centro / Therapeutic plasma exchange: experience in 102 patients

BACKGROUND: Therapeutic Plasma Exchange (TPE) is a procedure in which plasma and harmful macromolecules are separated from the rest of the blood components by centrifugation or filtration through membranes and are replaced with solutions with albumin and/or plasma. AIM: To communicate our experience using TPE by filtration. MATERIAL AND METHODS: Review of records of 655 TPE sessions performed in 102 patients aged 50 ± 18 years (64% women). The requirement of renal replacement therapy (RRT) and seven days and one year mortality were recorded. RESULTS: Forty five percent of patients had hypertension or diabetes. The main indications for TPE were pulmonary-renal syndrome (PRS) (62%) and antibody mediated graft rejection (29%), followed by neurological diseases (36%). Fifteen percent of patients required RRT for one year. Mortality at seven days and one year was 20 and 30%, respectively. Out of the total of deaths associated with kidney diseases, 88% corresponded to PRS and ANCA vasculitis. The main complications were thrombocytopenia in 41%, hypocalcemia in 18%, and hypotension in 16%. CONCLUSIONS: In our experience, TPE by filtration is a safe technique, with mild and preventable complications. Despite this, the reported mortality is high, which reflects the severity of the diseases that motivated the indication for TPE.

[Bilateral renal papillary necrosis of spontaneous resolution as a cause of microscopic hematuria. Report of one case]. / Necrosis papilar renal bilateral de resolución espontánea como causa de hematuria microscópica. Caso clínico.

Renal papillary necrosis is an infrequent cause of hematuria characterized by ischemic necrosis of the renal medulla, especially the papilla. Its most common cause is analgesic abuse. Despite being oligo-symptomatic, in many cases its presence is associated with serious functional sequelae. Imaging, especially computed tomography, is essential to make the diagnosis. We report a 63-year-old female studied for an asymptomatic microscopic hematuria whose tomographic study showed a bilateral renal papillary necrosis. No etiology was found, and she evolved with a spontaneous complete remission.

Necrosis papilar renal bilateral de resolución espontánea como causa de hematuria microscópica. Caso clínico / Bilateral renal papillary necrosis of spontaneous resolution as a cause of microscopic hematuria. Report of one case

Renal papillary necrosis is an infrequent cause of hematuria characterized by ischemic necrosis of the renal medulla, especially the papilla. Its most common cause is analgesic abuse. Despite being oligo-symptomatic, in many cases its presence is associated with serious functional sequelae. Imaging, especially computed tomography, is essential to make the diagnosis. We report a 63-year-old female studied for an asymptomatic microscopic hematuria whose tomographic study showed a bilateral renal papillary necrosis. No etiology was found, and she evolved with a spontaneous complete remission.

¿Son efectivas las intervenciones psicológicas para mejorar el control de la Diabetes Mellitus tipo 2 en adultos?: una revisión sistemática y metaanálisis / Psychological interventions for patients with type 2 diabetes mellitus. A systematic review and meta-analysis

Background Affordable interventions to improve metabolic control of Type 2-Diabetes Mellitus are increasingly necessary. Aim To review systematically the existing literature on the effects of psychological interventions on Type-2 Diabetes Mellitus compensation. Material and Methods We performed a systematic literature review and meta-analysis on the effectiveness of psychological interventions implemented for Type-2 Diabetes Mellitus patients. Research included the following electronic databases: PubMed, Bireme, Web of Science, SciELO, Embase, EBSCOhost, SCOPUS, Psychology Database. Results Most studies showed a decrease in the level of glycated hemoglobin after interventions, which applied different initiatives complementary to standard medical treatment. Mainly, these interventions encompassed training for self-monitoring and control of diabetes based on cognitive behavioral psychology, counseling, self-assessment and physical-spiritual work based on transpersonal psychology. Conclusions Psychological tools could be an adjunct to the standard medical treatment for patients with Type-2 Diabetes Mellitus, reducing glycated hemoglobin levels and improving self-regulation, disease awareness and adherence from the self-efficacy perception perspective.

Entrenamiento físico en personas con enfermedad renal crónica avanzada: beneficios de su implementación en la práctica clínica / Exercise training in advanced chronic kidney disease

Chronic kidney disease is associated with an increase in cardiovascular risk and mortality, and a decrease in the health-related quality of life. It is known that the physical capacity of patients with chronic kidney disease is lower than their healthy counterparts. It also decreases progressively after the start of hemodialysis, even leading to the loss of functional independence. There is a positive association between exercise and improvement of many targets in chronic kidney disease, especially in dialysis patients, such as cellular apoptosis, immune improvement and inflammation. In addition, several clinical studies and systematic reviews show an improvement in different clinical and laboratory variables and suggest a lower mortality, proving a reduction of health care economic costs. Exercise intervention in dialysis is safe. Although different guidelines promote exercise, it is necessary to work on its implementation on a large scale.

[Type 2 diabetes mellitus as a challenge for chronic disease care models in Chile]. / Diabetes Mellitus tipo 2: desafíos para los modelos de cuidados crónicos en Chile.

The increase in chronic noncommunicable diseases is one of the main concerns worldwide. Therefore, it is pertinent to ask how care system organizations responded to the requirements currently being posed by chronic diseases, specifically type 2 diabetes mellitus (T2DM). In the world, different models have been developed considering elements that transcend the biological stability of the disease. Chile has the great challenge of exploring new models that emphasize the promotion and prevention of health rather than the management of the disease. The impact of variables such as health literacy, self-efficacy and subjective well-being on T2DM should be explored. In addition, it is necessary to validate and implement guidelines and protocols of care that incorporate the aforementioned variables.

[Prevalence of complications associated with central venous catheter instalation for hemodyalisis]. / Prevalencias de complicaciones asociadas a la instalación de catéter venoso central para hemodiálisis.

BACKGROUND: Placing central venous lines under ultrasonographic guidance reduces the complications of the procedure. AIM: To compare prevalences of complications of central venous line placements with or without ultrasonographic guidance. MATERIAL AND METHODS: Descriptive study that contemplated the comparison of two groups of patients subjected to a central venous line placement at a nephrology service for renal replacement therapy. In one group of 100 patients, the line was placed without ultrasonographic guidance between 2008 and 2012. Between 2015 and 2017 the line was placed in 138 patients using ultrasonographic guidance. The prevalences of complications with both types of procedures were recorded. RESULTS: The frequency of complications of procedures with and without ultrasonographic guidance was 0.7 and 18% respectively (prevalence ratio 0.04, 95% confidence interval 0-0.3). Ninety five percent of recorded complications were arterial puncture, followed by hematomas in 10% and pneumothorax in 5%. The higher prevalence of complications was observed in emergency line placement without ultrasonographic guidance. There was a direct association between the number of line placement attempts in a single procedure and the prevalence of complications. CONCLUSIONS: Ultrasonographic guidance is associated with a reduction in the prevalence of central venous line complications.

Prevalencias de complicaciones asociadas a la instalación de catéter venoso central para hemodiálisis / Prevalence of complications associated with central venous catheter instalation for hemodyalisis

Background: Placing central venous lines under ultrasonographic guidance reduces the complications of the procedure. Aim: To compare prevalences of complications of central venous line placements with or without ultrasonographic guidance. Material and Methods: Descriptive study that contemplated the comparison of two groups of patients subjected to a central venous line placement at a nephrology service for renal replacement therapy. In one group of 100 patients, the line was placed without ultrasonographic guidance between 2008 and 2012. Between 2015 and 2017 the line was placed in 138 patients using ultrasonographic guidance. The prevalences of complications with both types of procedures were recorded. Results: The frequency of complications of procedures with and without ultrasonographic guidance was 0.7 and 18% respectively (prevalence ratio 0.04, 95% confidence interval 0-0.3). Ninety five percent of recorded complications were arterial puncture, followed by hematomas in 10% and pneumothorax in 5%. The higher prevalence of complications was observed in emergency line placement without ultrasonographic guidance. There was a direct association between the number of line placement attempts in a single procedure and the prevalence of complications. Conclusions: Ultrasonographic guidance is associated with a reduction in the prevalence of central venous line complications.

Efectividad de intervenciones basadas en Mindfulness para mejorar el control de la Diabetes Mellitus tipo 2: una revisión sistemática e integración metanalitica preliminar / Effectiveness of Mindfulness-based interventions to improve control of type 2 diabetes mellitus: a systematic review and preliminary meta-analytic integration

Resumen El propósito de este trabajo fue estudiar la efectividad de intervenciones basadas en Mindfulness sobre el nivel de hemoglobina glicada —HbA1c— en pacientes con diabetes mellitus tipo 2 —DM2—. Se realizó una revisión sistemática e integración metanalítica preliminar. La búsqueda de los estudios se realizó en las siguientes bases: PubMed, Bireme, Web of Science, SciELO, Embase, EBSCOhost, SCOPUS, Psychology Database. Se identificaron 10 artículos: cuatro fueron llevados a cabo en Estados Unidos, dos en Irán, uno en Alemania, uno en Australia, uno en Tailandia y uno en Inglaterra. Se observó una reducción en los niveles de la HbA1c utilizando Mindfulness en comparación a los grupos controles (p < 0,02). Además, se observó un efecto diferenciado al analizar según número de participantes, sexo y tiempo de seguimiento. Se concluyó que el uso de intervenciones basadas en Mindfulness tendría un efecto indirecto sobre la reducción de la hemoglobina glicada.

Abstract The purpose of this paper was to study the effectiveness of Mindfulness-based interventions on the level of glycated hemoglobin —HbA1c— in patients with type 2 diabetes mellitus —DM2—. A systematic review and preliminary meta-analytic integration was performed. The search of the studies was carried out in the following bases: PubMed, Bireme, Web of Science, SciELO, Embase, EBSCOhost, SCOPUS, Psychology Database. Ten articles were identified: four were published in the United States, two in Iran, one in Germany, one in Australia, one in Thailand and one in England. A reduction in HbA1c levels was observed using Mindfulness compared to control groups (p <0,02). In addition, according to the number of participants, sex and time of follow-up a differentiated effect was found. It was concluded that the use of interventions based on Mindfulness would have an indirect effect on the reduction of glycated hemoglobin (HbA1c).

Diabetes Mellitus tipo 2: desafíos para los modelos de cuidados crónicos en Chile / Type 2 diabetes mellitus as a challenge for chronic disease care models in Chile

The increase in chronic noncommunicable diseases is one of the main concerns worldwide. Therefore, it is pertinent to ask how care system organizations responded to the requirements currently being posed by chronic diseases, specifically type 2 diabetes mellitus (T2DM). In the world, different models have been developed considering elements that transcend the biological stability of the disease. Chile has the great challenge of exploring new models that emphasize the promotion and prevention of health rather than the management of the disease. The impact of variables such as health literacy, self-efficacy and subjective well-being on T2DM should be explored. In addition, it is necessary to validate and implement guidelines and protocols of care that incorporate the aforementioned variables.

Percepción de stakeholders de Chile Crece Contigo, acerca de su implementación en la comuna de Concepción, Chile / Perception of Chile Crece Contigo stakeholders on its implementation in the Commune of Concepción, Chile

RESUMEN Objetivo Explorar la percepción de los stakeholders vinculados al subsistema de protección de la infancia "Chile Crece Contigo" en lo que respecta a su implementación en la comuna de Concepción, Chile. Métodos Estudio cualitativo. Se utilizaron entrevistas semiestructuradas y un focus group como técnicas de recolección de información. Se realizó un muestreo teórico en base a la representación de los niveles de decisión y poder respecto a la implementa-ción de Chile Crece Contigo en la comuna de Concepción. Los datos fueron analizados con el software ATLAS.ti 6.2. Resultados Destacaron como logros la alta valoración de Chile Crece Contigo, junto con, la capacidad de instalar temas tan relevantes como el cuidado de la primera infancia. El aspecto no logrado más importante fue el aprovechamiento de los beneficios entregados y la difusión de la política. El mayor facilitador de la implementación fue el compromiso con el Chile Crece Contigo, mientras la mayor barrera, la situación contractual de los profesionales. Finalmente, como aspectos a mejorar se apuntaron la infraestructura, la articulación de la red Chile Crece Contigo y los recursos asociados a la política. Conclusión La implementación de Chile Crece Contigo en la comuna de Concepción ha alcanzado una alta valoración y reconocimiento en la comunidad, sin embargo, aún se requiere trabajar en el logro de aspectos relacionados con la articulación de los distintos stakeholders que componen la red Chile Crece Contigo, la difusión de la política en todos los niveles y el mejor aprovechamiento de los beneficios entregados a la población.(AU)

ABSTRACT Objective To explore the perception of stakeholders on the implementation policy of the childhood protection subsystem "Chile Crece Contigo" in the Commune of Concepción, Chile. Materials and Methods Qualitative study. Semi-structured interviews and a focus group were used as information gathering techniques. A theoretical sampling was carried out based on the representation of decision and power levels with regard to the implementation of Chile Crece Contigo in the Commune of Concepción. The data were analyzed with the ATLAS.ti 6.2 software. Results The most notable achievements highlighted by interviewees were the high valuation of Chile Crece Contigo, along with the possibility of placing relevant subjects such as first childhood care into the agenda. On the contrary, taking advantage of benefits delivered by the program and the dissemination of the policy were deemed as not achieved. The main facilitator of the implementation was the commitment of the beneficiaries to Chile Crece Contigo, while the most important barrier identified was the contract modality of professionals. Finally, aspects to be improved included infrastructure of facilities, the Chile Crece Contigo network articulation and the funds to secure sustainability of the program over time. Conclusion The implementation of Chile Crece Contigo in the Commune of Concepción has achieved high recognition in the community, however, it is still necessary to work on the achievement of aspects related to the articulation of the different stakeholders that make up the Chile Crece Contigo network, the diffusion of politics at all levels, and the best use of the benefits delivered to the population.(AU)

[Psychological interventions for patients with type 2 diabetes mellitus. A systematic review and meta-analysis]. / ¿Son efectivas las intervenciones psicológicas para mejorar el control de la Diabetes Mellitus tipo 2 en adultos?: una revisión sistemática y metaanálisis.

Background Affordable interventions to improve metabolic control of Type 2-Diabetes Mellitus are increasingly necessary. Aim To review systematically the existing literature on the effects of psychological interventions on Type-2 Diabetes Mellitus compensation. Material and Methods We performed a systematic literature review and meta-analysis on the effectiveness of psychological interventions implemented for Type-2 Diabetes Mellitus patients. Research included the following electronic databases: PubMed, Bireme, Web of Science, SciELO, Embase, EBSCOhost, SCOPUS, Psychology Database. Results Most studies showed a decrease in the level of glycated hemoglobin after interventions, which applied different initiatives complementary to standard medical treatment. Mainly, these interventions encompassed training for self-monitoring and control of diabetes based on cognitive behavioral psychology, counseling, self-assessment and physical-spiritual work based on transpersonal psychology. Conclusions Psychological tools could be an adjunct to the standard medical treatment for patients with Type-2 Diabetes Mellitus, reducing glycated hemoglobin levels and improving self-regulation, disease awareness and adherence from the self-efficacy perception perspective.