Chronic Kidney Disease-Associated Pruritus and Quality of Life: Learning from Our Patients.

Chronic kidney disease-associated pruritus is itching directly related to kidney disease that cannot be explained by any other condition. Despite technological advances in the different aspects of dialysis sessions and the best treatment for chronic kidney disease patients, it is still a common problem in our patients. The many complex physiological mechanisms involved, the different hypotheses made over the years on the aetiology of the condition, and the great clinical variability may partially explain the limited knowledge about this problem and the difficulties in treating it. The presence of all these factors leads to the persistence of unpleasant symptoms, which must affect the disease burden and quality of life of kidney patients. Through the presentation of an illustrative clinical case, the aim of this review article is to highlight the need for adequate diagnosis and an improved approach to all aspects of chronic kidney disease-associated pruritus, in view of the heavy burden of the disease and the huge impact on the patient's quality of life.

Etiopathogenesis of chronic kidney disease-associated pruritus: putting the pieces of the puzzle together.

Defined as the unpleasant sensation that causes the desire to scratch, pruritus is the most common skin symptom associated with uremia and appears in almost half of patients with advanced chronic kidney disease (CKD). Beyond its direct impact on quality of life, CKD-associated pruritus (CKD-aP) is an independent predictor of mortality that also has a synergistic effect with other quality of life-related symptoms, such as insomnia, depression, and anxiety. Although different mechanisms have been proposed to explain the origin of Pa-ERC, its etiopathogenesis is still not fully understood. Since new therapeutic targets have been identified and several clinical trials have recently shown promising results, our current understanding of the interrelationships has expanded significantly and the pathophysiological mechanisms underlying CKD-aP are now considered to be multifactorial. The potential triggers of pruritus in patients with CKD are discussed in this review, including hypotheses about skin xerosis, accumulation of uremic toxins, dysregulation of the immune system and systemic inflammation, uremic neuropathy, and imbalances in the endogenous opioid system. Other non-uremic causes of pruritus are also discussed, with the aim of guiding the physicians to apply an adequate aetiopathogenic approach to CKD-aP in their day-to-day clinical practice.

Perception of Spanish nephrologists on an old unsolved problem: Pruritus associated with chronic kidney disease (CKD-aP).

INTRODUCTION: Pruritus associated with chronic kidney disease is defined as the sensation of itching, in people with chronic kidney disease, in a one area or all over the body that causes the need to scratch, after having ruled out other dermatological or systemic causes. It is an old and known problem whose prevalence has been able to decrease with the improvement of dialytic techniques but which still persists and is underdiagnosed. OBJECTIVES: The objective of this study was to analyse the current perception of nephrologists about this problem that influences the quality of life of people with chronic kidney disease through a survey. RESULTS: 135 nephrologists, most of them engaged in haemodialysis, participated. 86% considered that pruritus associated with chronic kidney disease is still a problem today that affects the quality of life. Most nephrologists believe that the main pathophysiological cause is uremic toxins (60%) and only 16% believe that it is due to the dysregulation of the opioid system/endorphins-dynorphins. Only 16% comment that the prevalence of pruritus in their centre is greater than 20%. 40% believe that the diagnosis is made because it is manifested by the patient and only 27% because it is asked by the doctor. Moreover, it is not usual to use scales to measure it or the codification in the medical records. The main treatment used is antihistamines (96%), followed by moisturizers/anaesthetics (93%) and modification of the dialysis regimen (70%). CONCLUSIONS: Pruritus associated with chronic kidney disease is still a current problem, it is underdiagnosed, not codified and with a lack of indicated, effective and safe treatments. Nephrologists do not know its real prevalence and the different pathophysiological mechanisms involved in its development. Many therapeutic options are used with very variable results, ignoring their efficacy and applicability at the present time. The new emerging kappa-opioid-receptor agonist agents offer us an opportunity to reevaluate this age-old problem and improve the quality of life for our patients with chronic kidney disease.

Etiopatogenia del prurito asociado a la enfermedad renal crónica: recomponiendo las piezas del puzle / Etiopathogenesis of chronic kidney disease-associated pruritus: Putting the pieces of the puzzle together

Definido como la sensación desagradable que provoca el deseo de rascarse, el prurito es el síntoma cutáneo más frecuente asociado a la uremia, pudiendo aparecer en casi la mitad de los pacientes con enfermedad renal crónica (ERC) avanzada. Más allá de su repercusión directa sobre la calidad de vida, el prurito asociado a la ERC (Pa-ERC) es un predictor independiente de mortalidad que además ejerce un efecto sinérgico con otros síntomas también relacionados con la calidad de vida, como la depresión y el insomnio. Aunque se han propuesto diferentes mecanismos para explicar su origen, la etiopatogenia del Pa-ERC sigue sin conocerse por completo. Dado que se han identificado nuevas dianas terapéuticas y recientemente varios ensayos clínicos han mostrado resultados prometedores, nuestra comprensión actual de las interrelaciones se ha ampliado significativamente, considerando multifactoriales los mecanismos fisiopatológicos subyacentes al Pa-ERC. En la presente revisión se discuten los potenciales factores desencadenantes de prurito en el paciente con ERC, incluyendo las hipótesis sobre la xerosis cutánea, el acúmulo de toxinas urémicas, la desregulación del sistema inmune y la inflamación sistémica, la neuropatía urémica y los desequilibrios en el sistema opioide endógeno, así como otras causas no urémicas de prurito, con el objetivo de orientar al clínico para realizar un adecuado abordaje etiopatogénico del Pa-ERC en su día a día. (AU)

Defined as the unpleasant sensation that causes the desire to scratch, pruritus is the most common skin symptom associated with uremia and appears in almost half of patients with advanced chronic kidney disease (CKD). Beyond its direct impact on quality of life, CKD-associated pruritus (CKD-aP) is an independent predictor of mortality that also has a synergistic effect with other quality of life-related symptoms, such as insomnia, depression, and anxiety. Although different mechanisms have been proposed to explain the origin of Pa-ERC, its etiopathogenesis is still not fully understood. Since new therapeutic targets have been identified and several clinical trials have recently shown promising results, our current understanding of the interrelationships has expanded significantly and the pathophysiological mechanisms underlying CKD-aP are now considered to be multifactorial. The potential triggers of pruritus in patients with CKD are discussed in this review, including hypotheses about skin xerosis, accumulation of uremic toxins, dysregulation of the immune system and systemic inflammation, uremic neuropathy, and imbalances in the endogenous opioid system. Other non-uremic causes of pruritus are also discussed, with the aim of guiding the physicians to apply an adequate etiopathogenic approach to CKD-aP in their day-to-day clinical practice. (AU)

Oral Anticoagulation in Patients with Chronic Kidney Disease and Non-Valvular Atrial Fibrillation: The FAERC Study.

Atrial fibrillation (AF) is the most common arrhythmia in patients with chronic kidney disease (CKD), and its presence is associated with a higher risk of stroke and mortality. MATERIAL AND METHODS: The FAERC study performed a retrospective multicentre analysis of historical cohorts in which data were collected from arrhythmia diagnosis onwards. RESULTS: We analysed a Spanish cohort of 4749 patients with CKD (mean eGFR 33.9 mL/min) followed up in the nephrology clinic, observing a 12.2% prevalence of non-valvular AF. In total, 98.6% of these patients were receiving anticoagulant treatment, mainly with coumarins (79.7%). Using direct-acting oral anticoagulants (DOACs) was associated with fewer cerebrovascular events than using acenocoumarol, but in contrast with other studies, we could not corroborate the association of risk of bleeding, coronary events, or death with a type of anticoagulant prescribed. CONCLUSIONS: Atrial fibrillation is highly prevalent in renal patients. Direct-acting anticoagulants seem to be associated with fewer ischemic-embolic complications, with no differences in bleeding, coronary events, or mortality rates.

Distinct Solute Removal Patterns by Similar Surface High-Flux Membranes in Haemodiafiltration: The Adsorption Point of View.

INTRODUCTION: Haemodialysis (HD) allow depuration of uraemic toxins by diffusion, convection, and adsorption. Online haemodiafiltration (HDF) treatments add high convection to enhance removal. There are no prior studies on the relationship between convection and adsorption in HD membranes. The possible benefits conferred by intrinsic adsorption on protein-bound uraemic toxins (PBUTs) removal are unknown. METHODS: Twenty-two patients underwent their second 3-days per week HD sessions with randomly selected haemodialysers (polysulfone, polymethylmethacrylate, cellulose triacetate, and polyamide copolymer) in high-flux HD and HDF. Blood samples were taken at the beginning and at the end of the treatment to assess the reduction ratio (RR) in a wide range of molecular weight uraemic toxins. A mid-range removal score (GRS) was also calculated. An elution protocol was implemented to quantify the amount of adsorbed mass (Mads) for each molecule in every dialyser. RESULTS: All synthetic membranes achieved higher RR for all toxins when used in HDF, specially the polysulfone haemodialyser, resulting in a GRS = 0.66 ± 0.06 (p < 0.001 vs. cellulose triacetate and polyamide membranes). Adsorption was slightly enhanced by convection for all membranes. The polymethylmethacrylate membrane showed expected substantial adsorption of ß2-microglobulin (MadsHDF = 3.5 ± 2.1 mg vs. MadsHD = 2.1 ± 0.9 mg, p = 0.511), whereas total protein adsorption was pronounced in the cellulose triacetate membrane (MadsHDF = 427.2 ± 207.9 mg vs. MadsHD = 274.7 ± 138.3 mg, p = 0.586) without enhanced PBUT removal. DISCUSSION/CONCLUSION: Convection improves removal and slightly increases adsorption. Adsorbed proteins do not lead to enhanced PBUTs depuration and limit membrane efficiency due to fouling. Selection of the correct membrane for convective therapies is mandatory to optimize removal efficiency.

Eficacia y seguridad de un programa de ejercicio físico intradiálisis / Impact and safety outcomes of an intradialytic physical exercise program

Introducción: Los pacientes en hemodiálisis (HD) suelen tener una condición física mermada y elevado sedentarismo. La consolidación de programas de ejercicio físico en las unidades de diálisis está limitada por barreras como la seguridad inherente a estos programas y la falta de recursos. Objetivos: Evaluar la eficacia y seguridad en la implantación de un programa de ejercicio físico intradiálisis (EFI) sobre la condición física de los pacientes con un equipo multidisciplinar (fisioterapeuta y auxiliares de enfermería). Material y métodos: Estudio cuasiexperimental pre-post unicéntrico prospectivo de 6 meses en 34 pacientes. Intervención con EFI combinado 2 días a la semana, evaluándose de forma basal y final la capacidad cardiorrespiratoria (6MWT), fuerza muscular (HG, dinamometría de cuádriceps y 10STS), la composición corporal (bioimpedanciometría) y la capacidad coordinativa (Timed Up and Go test). La seguridad se valoró registrando las incidencias relacionadas con el acceso vascular, la estabilidad hemodinámica y el perfil de rellenado vascular (RBV) durante las sesiones. También se registró la adherencia al programa así como parámetros analíticos habituales. Resultados: La adherencia al programa de EFI fue elevada (70,8%). Se constató una mejora significativa de 47m (p<0,001) en el 6MWT; un incremento medio de 1,6kg (p=0,007) en el HG para la fuerza de extremidades superiores y en las extremidades inferiores (10STS p=0,003; dinamometría p<0,05). Respecto a la seguridad, no se detectaron incidencias ni diferencias significativas en el RBV. Conclusiones: Un programa de EFI combinado favorece la mejora de la condición física de los pacientes en HD sin comprometer la seguridad del tratamiento. Es aconsejable un equipo multidisciplinar para implantar y dar continuidad eficazmente a un programa de EFI. (AU)

Introduction: Patients undergoing hemodialysis (HD) are characterized by a poor physical condition and a substantial sedentary profile. The implementation of physical exercise programs in the hemodialysis units is usually limited by the inherent safeness and the lack of appropriate resources. Objectives: We aimed to evaluate the impact and safety outcomes of the implementation of an intradialytic physical exercise program (IPE) by a multidisciplinary team (physiotherapist and nursing assistant) in the physical condition of the patients. Material and methods: This six months single-centre and experimental pre-post prospective study was carried out in 34 patients. A two day-week combined IPE intervention was implemented. The cardiopulmonary capacity (6MWT), muscular strength (HG, leg dynamometry and 10STS), body composition (bioimpedance) and coordination capacity (Timed Up and Go test) was assessed at the beginning and at the end of the study. Safety was evaluated by means of the number of issues regarding the vascular access, the hemodynamic stability as well as the vascular refilling profile (RBV) in each session. The adhesion to the program was also registered. Additionally, analytical parameters were recorded. Results: The adhesion to an IPE program was high (70.8%). A significant improvement of the cardiopulmonary capacity (6MWT average increase 47m; p<0.001), superior limbs (HG average increase of 1.6kg; p=0.007) as well as the lower extremities (10STS; p=0.003; dynamometry p<0.05). Regarding safeness, there were no incidences neither significant difference in the RBV. Conclusions: A combined IPE may contribute to the improvement of the physical condition of the patients as well as ensures a safe development of the HD treatment. We suggest a multidisciplinary team in order to efficiently establish an IPE program. (AU)

The Spanish Version of the Fear of Kidney Failure Questionnaire: Validity, Reliability, and Characterization of Living Donors With the Highest Fear of Kidney Failure.

BACKGROUND: Measures of fear of progression or recurrence of illnesses have been criticized for neglecting cross-cultural validity. Therefore, we assessed the psychometric properties of the Spanish version of the Fear of Kidney Failure Questionnaire (FKFQ), to determine whether postdonation fear of kidney failure (FKF) influenced the donors' psychosocial status, and define variables that characterized donors with high FKFQ scores. METHODS: We included 492 participants (211 donors) in a multicenter, 11-year, retrospective, cross-sectional study. Donors were classified with a Latent Class Analysis of the FKFQ-item scores and characterized with a multivariable logistic regression analysis. We calculated the risk ratio based on predicted marginal probabilities. RESULTS: The Spanish version of the FKFQ showed acceptable psychometric properties. FKF was uncommon among donors, but we detected a small subgroup (n = 21, 9.9%) with high FKF (mean FKFQ score = 14.5, 3.1 SD). Compared with other donors, these donors reported higher anxiety and depression (38% and 29% of potential anxiety and depressive disorders), worse quality of life, and less satisfaction with the donation. Donors with high FKFQ scores were characterized by higher neuroticism combined with postdonation physical symptoms that interfered with daily activities. CONCLUSIONS: The FKFQ was cross-culturally valid, and thus, it may be used to assess the FKF in Spanish-speaking donors. New interventions that promote positive affectivity and evidence-based treatments for worry could be adapted for treating FKF.

Impact and safety outcomes of an intradialytic physical exercise program.

INTRODUCTION: Patients undergoing hemodialysis (HD) are characterized by a poor physical condition and a substantial sedentary profile. The implementation of physical exercise programs in the hemodialysis units is usually limited by the inherent safeness and the lack of appropriate resources. OBJECTIVES: We aimed to evaluate the impact and safety outcomes of the implementation of an intradialytic physical exercise program (IPE) by a multidisciplinary team (physiotherapist and nursing assistant) in the physical condition of the patients. MATERIAL AND METHODS: This six months single-centre and experimental pre-post prospective study was carried out in 34 patients. A two day-week combined IPE intervention was implemented. The cardiopulmonary capacity (6MWT), muscular strength (HG, leg dynamometry and 10STS), body composition (bioimpedance) and coordination capacity (Timed Up and Go test) was assessed at the beginning and at the end of the study. Safety was evaluated by means of the number of issues regarding the vascular access, the hemodynamic stability as well as the vascular refilling profile (RBV) in each session. The adhesion to the program was also registered. Additionally, analytical parameters were recorded. RESULTS: The adhesion to an IPE program was high (70.8%). A significant improvement of the cardiopulmonary capacity (6MWT average increase 47 m; p < 0.001), superior limbs (HG average increase of 1.6 kg; p = 0.007) as well as the lower extremities (10STS; p = 0.003; dynamometry p < 0.05). Regarding safeness, there were no incidences neither significant difference in the RBV. CONCLUSIONS: A combined IPE may contribute to the improvement of the physical condition of the patients as well as ensures a safe development of the HD treatment. We suggest a multidisciplinary team in order to efficiently establish an IPE program.

Hemodiafiltration with ultrafiltrate regeneration reduces free light chains without albumin loss in multiple myeloma patients.

BACKGROUND: Acute kidney injury (AKI) occurs in 12-20% of multiple myeloma (MM) patients. Several studies have shown a reduction of free light chains (FLC) using hemodialysis with High-Cut-Off membranes. However, this technique entails albumin loss. Hemodiafiltration with ultrafiltrate regeneration is a technique that includes a process of adsorption. The aim of this study was to evaluate the effectiveness of hemodiafiltration with ultrafiltrate regeneration in reducing FLC levels without causing albumin loss. METHODS: This is an observational study (2012 to 2018) including nine patients with MM (5 kappa, 4 lambda) and AKI. All patients were treated with chemotherapy and hemodiafiltration with ultrafiltrate regeneration. Blood Samples (pre and post-dialysis) and ultrafiltrate were collected pre and post-resin at 5 min after initiation of the session and 5 min before the end of the procedure. RESULTS: The serum levels of kappa and lambda were reduced by a 57.6 ± 10% and 33.5 ± 25% respectively. Serum albumin concentration remained unchanged after the procedure. In the ultrafiltrate, the mean FLC reduction ratio shortly after initiation of the dialysis procedure was: 99.2 and 97.06% for kappa and lambda respectively, and only 0.7% for albumin; and at the end of the session the percent reduction was: 63.7 and 33.62% for kappa and lambda respectively, and 0.015% for albumin. Patients clinical outcome was: 33.3% recovered renal function, 22.2% died during the first year and 44.4% required maintenance dialysis. CONCLUSIONS: Hemodiafiltration with ultrafiltrate regeneration reduces FLC levels without producing a significant loss of albumin; and, FLC removal is maintained throughout the session. Therefore, hemodiafiltration with ultrafiltrate regeneration may be considered an effective adjunctive therapy in patients with MM.

Valoración técnica de la pertinencia sobre la toma de declaración a niños, niñas y adolescentes en el proceso penal / Technical appraisal of belonging about children and adolescents declaring in criminal proceedings / Valoració tècnica de la pertinença sobre la presa de declaració a nens, nenes I adolescents en el procés penal

La prueba preconstituida es un buen instrumento jurídico de protección a los menores de edad en el proceso penal, a la vez que garantiza los derechos fundamentales y la preservación del testimonio. El cómo se realice y el momento en que se practica es crucial para que tenga validez en base a los referidos objetivos. En este trabajo se propone una "valoración técnica de la pertinencia sobre la toma de declaración a niños, niñas y adolescentes como prueba preconstituida", entendida como criterios de oportunidad, adecuación y conveniencia

The pre-constituted evidence is a good legal instrument for the protection of minors in criminal proceedings, at the same time as it guarantees fundamental rights and the preservation of testimony. How and when it is performed is crucial for its validity, based on the objective references. This work proposes a "technical assessment of belonging on the pre-constituted proof of children, infants and adolescents", understood as criteria of opportunity, adequacy and coexistence

La prova preconstituïda és un bon instrument jurídic de protecció als menors d'edat en el procés penal, al mateix temps que garanteix els drets fonamentals I la preservació del testimoni. El com es realitzi I el moment en què es practiqui és crucial perquè tingui validesa en base als referits objectius. En aquest treball es proposa una "valoració tècnica de la pertinença sobre la presa de declaració a nens, nenes I adolescents com a prova preconstituïda", entesa com a criteris d'oportunitat, adequació I convivència

Percutaneous left atrial appendage closure, a safe alternative to anticoagulation for patients with nonvalvular atrial fibrillation and end-stage renal disease on hemodialysis: A single center experience.

The evidence about the effectiveness and safety of oral anticoagulation in patients on hemodialysis is conflicting and scarce. Percutaneous left atrial appendage occlusion (LAAO) has demonstrated to be a valid alternative therapeutic option for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). The aim of this study is to present the outcomes of percutaneous LAAO in patients with end-stage renal disease (ESRD) on hemodialysis and NVAF in our center. We conducted a retrospective review of clinical records, demographics, LAAO procedure, complications, and outcomes of patients with NVAF and ESRD on hemodialysis who underwent a percutaneous LAAO in our center between January 2017 and January 2019. In the period of the study, eight patients with ESRD on hemodialysis underwent a percutaneous LAAO in our center. The overall mean age was 67.5 years (range 56-81; SD ± 7.2). All patients had permanent NVAF. The total mean dialysis duration was 8.49 years (range 0.83-14.8; SD ± 6.2). The mean CHA2DS2-VASc and HAS-BLED scores were high (4.75 [SD ± 1.16] and 4.62 [SD ± 0.91], respectively). All patients had history of a major hemorrhagic event (BARC Score ≥3). Most patients (n = 6) showed left ventricular hypertrophy, and the average LVEF was 54% (SD ± 6.5). All devices were implanted successfully. Postprocedural antithrombotic regimen prescribed was based on antiplatelet therapy. No deaths, cardioembolic events, or major bleeding (according to the BARC scale) were reported during a mean follow-up of 14.24 months (SD ± 9.44). Percutaneous LAAO could be of particular interest in patients with NVAF and CKD in hemodialysis. Further studies will be necessary to confirm this hypothesis.

Study of Biocompatibility of Membranes in Online Hemodiafiltration.

BACKGROUND: The biocompatibility of dialysis membranes is a determining factor in avoiding chronic microinflammation in patients under haemodialysis. Lower biocompatibility has been related to increased inflammatory status, which is known to be associated with cardiovascular events. Classically, cellulose membranes have been considered bioincompatible. A new-generation of asymmetric cellulose triacetate (CTA) membranes allows the performance of high convective transport techniques, but there have been no studies of their biocompatibility. The aim of the present study was to analyze and compare the biocompatibility characteristics of 4 membranes, including CTA, in online hemodiafiltration (OL-HDF) patients. METHODS: We included 15 patients in -OL-HDF. After a 2-week washout period with helixone membrane, each patient was treated with the 4 membranes (polyamide, polynephron, helixone and CTA) for 4 weeks in a randomized order. The other dialysis parameters were kept stable throughout the study. We studied changes in markers of the activation of the complement system, monocytes, platelets, and adhesion molecules with the 4 membranes, as well as inflammatory parameters. RESULTS: Biocompatibility was similar among the membranes. There were no sustained differences in complement activation, measured by C3a and C5a levels, or in platelet activation, determined by levels of P-selectin and platelet-derived microparticles (CD41a+). No differences were observed in activated monocyte levels (CD14+/CD16+) or in plasma levels of interleukin (IL)-1, IL-6, IL-10 or high-sensitivity C-reactive protein, although tumour necrosis factor-α levels decreased when the patients were dialyzed with CTA. No significant differences were found in markers of endothelial damage, assessed by levels of plasminogen activator inhibitor-1 and adhesion molecules (intercellular adhesion molecule-1 and vascular cell adhesion molecule-1). CONCLUSION: The 4 membranes evaluated in this study in stable patients on OL-HDF, including the new-generation CTA, show similar biocompatibility with the methods applied.

Fístulas arteriovenosas nativas humerobasílicas con superficialización y trasposición en un solo acto quirúrgico. Revisión de cinco años de experiencia / Brachiobasilic arteriovenous fistula with superficialisation and transposition the basilic vein in a one stage surgical technique. Five years of single experience

INTRODUCCIÓN: La vena basílica se caracteriza por ser un vaso profundo que en la mayoría de los casos requiere superficialización y trasposición quirúrgica. MATERIAL Y MÉTODOS: Estudio retrospectivo de 119 FAVn HB S-T en pacientes con insuficiencia renal crónica 5D implantadas en un solo acto quirúrgico (2011-2015). Se analiza el porcentaje de permeabilidades primaria (PP), primaria asistida (PPA) y secundaria (PS), así como las complicaciones asociadas. Análisis de permeabilidades mediante curvas de supervivencia Kaplan-Meier y análisis univariante mediante Log Rank (Mantel-Cox). Se considera significativa una p ≤ 0,05. RESULTADOS: Edad media 67,9 años y 63,8% hombres. Durante el período de seguimiento se objetivaron un total de 57 complicaciones: 24 estenosis (42,1%), 11 trombosis (19,2%), 7 síndromes de robo vascular (12,2%), 7 edemas de extremidad superior (12,2%), 6 hematomas pospunción (10,5%) y 2 infecciones (3,5%). Los porcentajes de PP obtenidos a 1, 6, 12 y 24 meses: 92,4, 79,8, 66,3 y 52; PPA: 94,1, 87,3, 80,4 y 65,6%, y PS: 95, 89,1, 84 y 67,5%. Se constataron diferencias significativas en las curvas de PP, PPA y PS según la etiología, presentando peores permeabilidades los diabéticos respecto a la vascular e idiopática (p = 0,037, 0,009 y 0,019). CONCLUSIONES: La implantación quirúrgica de FAVn HB S-T en un solo acto ofrece buenas tasas de permeabilidad y escaso número de complicaciones asociadas. La diabetes mellitus representa un factor de peor pronóstico quirúrgico. Entre las mayores ventajas destacan una mejor optimización de los recursos sanitarios y menor tiempo de permanencia del catéter venoso central

BACKGROUND: The basilic vein is a deep vein which usually requires superficialisation and surgical transposition. MATERIAL AND METHODS: This is a retrospective study of 119 BBAVF-ST in patients with stage 5D chronic kidney disease who received an implant with a one-stage surgical technique (2011-2015). The percentage of primary (PP), assisted primary (APP) and secondary (SP) permeabilities were assessed, as well as the related complications. We analysed the permeabilities using Kaplan-Meier survival curves and a univariate Log Rank analysis (Mantel-Cox). P values less than or equal to 0.05 were considered as significant. RESULTS: The mean age of the study group was 67.9 years, with 63.8% of the subjects being male. A total of 57 complications were detected during the follow-up period: 24 stenosis (42.1%), 11 thrombosis (19.2%), 7 vascular access steal syndromes (12.2%), 7 upper limb oedemas (12.2%), 6 post-puncture haematomas (10.5%) and 2 infections (3.5%). The percentages of PP obtained at 1, 6, 12 and 24months were 92.4%, 79.8%, 66.3% and 52%; APP: 94.1%, 87.3%, 80.4% and 65.6%, and SP: 95%, 89.1%, 84% and 67.5%, respectively. Diabetic patients presented with significantly worse permeabilities than vascular or idiopathic patients: (P = .037, .009 and .019, respectively). CONCLUSIONS: According to the results obtained in our study, the one-stage surgical implementation of BBAVF-ST presents high permeability rates and a small number of related complications. Diabetes mellitus is a factor related to a worse surgical prognosis. Some of the biggest advantages are the greater optimisation of health resources and a shorter time in which the central venous catheter needs to remain in the body

Brachiobasilic arteriovenous fistula with superficialisation and transposition the basilic vein in a one stage surgical technique. Five years of single experience. / Fístulas arteriovenosas nativas humerobasílicas con superficialización y trasposición en un solo acto quirúrgico. Revisión de cinco años de experiencia.

BACKGROUND: The basilic vein is a deep vein which usually requires superficialisation and surgical transposition. MATERIAL AND METHODS: This is a retrospective study of 119 BBAVF-ST in patients with stage 5D chronic kidney disease who received an implant with a one-stage surgical technique (2011-2015). The percentage of primary (PP), assisted primary (APP) and secondary (SP) permeabilities were assessed, as well as the related complications. We analysed the permeabilities using Kaplan-Meier survival curves and a univariate Log Rank analysis (Mantel-Cox). P values less than or equal to 0.05 were considered as significant. RESULTS: The mean age of the study group was 67.9years, with 63.8% of the subjects being male. A total of 57 complications were detected during the follow-up period: 24 stenosis (42.1%), 11 thrombosis (19.2%), 7 vascular access steal syndromes (12.2%), 7 upper limb oedemas (12.2%), 6 post-puncture haematomas (10.5%) and 2 infections (3.5%). The percentages of PP obtained at 1, 6, 12 and 24months were 92.4%, 79.8%, 66.3% and 52%; APP: 94.1%, 87.3%, 80.4% and 65.6%, and SP: 95%, 89.1%, 84% and 67.5%, respectively. Diabetic patients presented with significantly worse permeabilities than vascular or idiopathic patients: (P=.037, .009 and .019, respectively). CONCLUSIONS: According to the results obtained in our study, the one-stage surgical implementation of BBAVF-ST presents high permeability rates and a small number of related complications. Diabetes mellitus is a factor related to a worse surgical prognosis. Some of the biggest advantages are the greater optimisation of health resources and a shorter time in which the central venous catheter needs to remain in the body.

Elimination of hepatitis C virus infection from a hemodialysis unit and impact of treatment on the control of anemia / Eliminación de la hepatitis C de una unidad de hemodiálisis e impacto del tratamiento en el control de la anemia

Introduction: In the interferon era, the treatment of hepatitis C virus (HCV) infection in patients on haemodialysis (HD) was limited due to the significant number of treatment-related adverse events (AEs). Direct-acting antivirals (DAAs) have demonstrated their efficacy and safety in the treatment of HCV in patients with advanced chronic kidney disease on haemodialysis. The objective of the study was to evaluate the success in eliminating HCV infection from our dialysis unit using DAAs, and to assess the impact of HCV elimination on clinical and analytical outcomes. Patients and methods: This is a prospective, interventional, single-center study at Hospital Clínic de Barcelona. All HCV-RNA positive patients who received antiviral therapy with DAAs within a 3-year period (2014-2017) were analyzed (n=20). Data on virologic response, adverse events, and biochemical and hematological parameters during and after DAA therapy were analyzed. Results: All patients achieved sustained virologic response (SVR) and only 40% of patients presented with mild AEs. None of the patients presented with HCV reinfection after a 1-year follow-up period, and thus HCV was eliminated from our HD unit. SVR was associated with a significant increase in hemoglobin and hematocrit, and a tendency toward the need for lower doses of iron supplementation with no changes in darbepoetin dose. Conclusion: HCV infection can be safely eliminated from HD units with the use of DAAs, preventing new infections in patients and healthcare staff. In the short term, the achievement of SVR is associated with an improvement in the control of anemia

Introducción: En la época del interferón, el tratamiento del virus de la hepatitis C (VHC) en pacientes en hemodiálisis (HD) se veía limitado por la presencia de efectos adversos relacionados con el tratamiento. Los agentes antivirales directos (AAD) han demostrado ser seguros y eficaces en el tratamiento del VHC en pacientes con insuficiencia renal crónica en hemodiálisis. El objetivo del estudio fue evaluar el éxito en eliminar la infección por VHC de nuestra unidad de diálisis con el uso de AAD, y determinar el impacto clínico y analítico de la curación de la infección. Pacientes y métodos: Para ello se realizó un estudio prospectivo de intervención en el Hospital Clinic de Barcelona y su centro de diálisis. Se incluyeron todos los pacientes (n=20) con ARN-VHC positivo que recibieron tratamiento antiviral con AAD durante un periodo de 3 años (2014-2017). Se analizaron los datos de respuesta virológica, efectos adversos y parámetros hematológicos y bioquímicos durante y después del tratamiento. Resultados: Todos los pacientes alcanzaron una respuesta viral sostenida (RVS) y solo una 40% presentaron efectos adversos leves. Ningún paciente presentó reinfección por el VHC y por ello tras un año de seguimiento se consideró la eliminación del VHC de nuestra unidad de diálisis. La RVS se asoció con aumento significativo de la hemoglobina y el hematocrito, y una tendencia a la necesidad de una dosis más baja de suplemento de hierro sin cambios en la dosis de darbepoetina. Conclusión: Con la utilización de AAD, la infección por el VHC puede ser eliminada de forma segura de las unidades de diálisis, previniendo la transmisión de la infección a pacientes y personal sanitario. A corto plazo, la RVS se asoció con una mejoría en el control de la anemia

A phase 1b randomized, placebo-controlled clinical trial with SNF472 in haemodialysis patients.

AIMS: SNF472 is a calcification inhibitor that is being studied as a novel treatment for calciphylaxis and cardiovascular calcification (CVC). A first study showed acceptable safety and tolerability in a single ascending dose administration in healthy volunteers and a single dose administration in haemodialysis (HD) patients. This study aimed to assess the safety, tolerability, and pharmacokinetics/pharmacodynamics relationship of intravenous SNF472 in HD patients in a multiple ascending dose administration trial with 5 doses tested for 1 week (3 administrations) and 1 dose tested for 4 weeks (12 administrations). METHODS: This double blind, randomized, placebo-controlled Phase 1b study investigated the safety, tolerability, pharmacokinetics and pharmacodynamics of SNF472 after repeated administrations to HD patients for up to 28 days. A pharmacodynamic assessment was performed to evaluate the potential for SNF472 to inhibit hydroxyapatite (HAP) formation. Patients were grouped into 2 cohorts, receiving multiple ascending doses for 1 week (1 to 20 mg/kg, Cohort 1) and 1 dose of 10 mg/kg for 4 weeks (Cohort 2) of intravenous SNF472. RESULTS: Physical status, body weight, cardiorespiratory function, body temperature and laboratory parameters were in the normal range. No clinically relevant effects on heart rate or blood pressure were observed. No abnormal electrocardiogram or QTcB period were reported. The peak plasma concentration (7.6, 16.1, 46.0 and 66.9 µg/mL for 3, 5, 12.5 and 20 mg/kg, respectively) was observed at the end of the 4-hour infusion and thereafter concentrations declined rapidly with half-life between 32 and 65 min. SNF472 at 10 mg/kg inhibited dose dependently HAP crystallization in plasma samples after 28 days of treatment (78% inhibition, P < .001). CONCLUSIONS: SNF472 is safe and well tolerated in HD patients after 2 schemes: multiple ascending doses for 1 week and after repeated dosing of 10 mg/kg for 4 weeks. In both schemes, SNF472 inhibits the induction of HAP crystallization. These results provide support for the use of SNF472 as a novel treatment for CVC in end-stage renal disease.

Improved Control of Secondary Hyperparathyroidism in Hemodialysis Patients Switching from Oral Cinacalcet to Intravenous Etelcalcetide, Especially in Nonadherent Patients.

BACKGROUND: Etelcalcetide is a novel second-generation calcimimetic that, because of its intravenous administration, could improve treatment adherence in secondary hyperparathyroidism (SHPT). The aim of this study was to evaluate the effectiveness of etelcalcetide compared with that of cinacalcet in controlling SHPT in patients under hemodialysis. METHODS: A prospective observational study was performed in 29 patients with SHPT under hemodialysis who switched from cinacalcet to etelcalcetide with a follow-up of 6 months. A survey was conducted of adherence to the oral calcimimetic. The primary end-point of the study was to assess whether etelcalcetide was more effective than cinacalcet in controlling SHPT. RESULTS: After the switch of treatment, none of the patients developed clinical intolerance or new adverse effects. Etelcalcetide was more effective than cinacalcet in controlling intact parathyroid hormone (iPTH), with an overall decrease in iPTH levels that was significant from the second month. Average calcium levels remained within the normal range, with a higher percentage of hypocalcemia with etelcalcetide (6.9 vs. 13.8%), which was asymptomatic in all cases. Patients who were nonadherent to cinacalcet (38%) showed a significant reduction in calcium and iPTH during follow-up with etelcalcetide. The adherent group (62%) also showed a trend to lower iPTH levels reaching statistical significance after 5 months of follow-up. The dose conversion factor for the switch from cinacalcet to etelcalcetide was etelcalcetide/session = 0.111*mg cinacalcet/day + 0.96, R2 = 0.57. CONCLUSIONS: Etelcalcetide was more effective than cinacalcet in this patient population, especially in the nonadherent subgroup, leading to better SHPT control without adverse effects.

Elimination of hepatitis C virus infection from a hemodialysis unit and impact of treatment on the control of anemia.

INTRODUCTION: In the interferon era, the treatment of hepatitis C virus (HCV) infection in patients on haemodialysis (HD) was limited due to the significant number of treatment-related adverse events (AEs). Direct-acting antivirals (DAAs) have demonstrated their efficacy and safety in the treatment of HCV in patients with advanced chronic kidney disease on haemodialysis. The objective of the study was to evaluate the success in eliminating HCV infection from our dialysis unit using DAAs, and to assess the impact of HCV elimination on clinical and analytical outcomes. PATIENTS AND METHODS: This is a prospective, interventional, single-center study at Hospital Clínic de Barcelona. All HCV-RNA positive patients who received antiviral therapy with DAAs within a 3-year period (2014-2017) were analyzed (n=20). Data on virologic response, adverse events, and biochemical and hematological parameters during and after DAA therapy were analyzed. RESULTS: All patients achieved sustained virologic response (SVR) and only 40% of patients presented with mild AEs. None of the patients presented with HCV reinfection after a 1-year follow-up period, and thus HCV was eliminated from our HD unit. SVR was associated with a significant increase in hemoglobin and hematocrit, and a tendency toward the need for lower doses of iron supplementation with no changes in darbepoetin dose. CONCLUSION: HCV infection can be safely eliminated from HD units with the use of DAAs, preventing new infections in patients and healthcare staff. In the short term, the achievement of SVR is associated with an improvement in the control of anemia.