[Incorporation of a psychologist into a nephrology service: criteria and process]. / Incorporación de un psicólogo en un servicio de nefrología: criterios y proceso.

Chronic kidney disease is associated with a wide range of stressful situations causing important physical and psychological repercussions. It is not usual that psychology professionals are active members of the nephrology teams. In consequence, these alterations are not properly assisted. Our aim is to present the introduction process of a psychologist in a nephrology department and its preliminary results. We designed a clearly defined introduction process, starting with a therapeutic communication training program for all the staff. In the model we have priorized pre-emptive interventions in order to promote the adaptation process, far from simple psychological symptom control. It is assumed the binomial patient-family as the major objective for care, choosing an interdisciplinary approach. We worked more from a health psychology perspective than from a mental health perspective. Over the year 2008 the number of patients assisted by the psychologist were 571 (mean 48 patients/month). The total number of interventions was 1,022. Majority of cases (45.2%) were derived from the advanced chronic kidney disease program, mostly related to demands about emotional impact of renal replacement therapy commencement. Others were: suspect of depression episode, adherence, primary caregiver emotional overwhelming, bereavement, anxiety and support in decision making process. This experience is a stimulus for the integral approach of the renal patient.

Incorporación de un psicólogo en un servicio de nefrología: criterios y proceso / Incorporation of a psychologist into a nephrology service: criteria and process

La insuficiencia renal es una enfermedad que genera un amplio rango de situaciones estresantes, que ocasionan trastornos tanto de tipo físico como psicológico. Es anecdótico que profesionales de la psicología sean miembros activos de los equipos de nefrología, por lo que dichas necesidades pueden no ser atendidas adecuadamente. Nos proponemos describir el proceso de incorporación de este profesional en un servicio de nefrología y presentar resultados preliminares de su actividad. El proceso se inició con un programa formativo en comunicación difícil. En el modelo elegido se prioriza el trabajo preventivo; se trata de facilitar los procesos de adaptación más allá del mero control de síntomas psicológicos; se asume como prioridad asistencial el binomio paciente familia y se opta por un estilo de relación sinérgica interdisciplinaria. Se trabaja más desde la perspectiva de la psicología de la salud que desde la óptica de la salud mental. A lo largo del año 2008 el número de pacientes atendidos por el psicólogo ha sido de 571 (media de 48pacientes al mes). El número total de intervenciones fue de 1.022. La mayoría de los casos atendidos en consulta(45,2%) procedían de la consulta de enfermedad renal crónica avanzada (ERCA). Otros motivos de derivación fueron: sospecha de depresión, cumplimiento, sobrecarga del cuidador principal, duelo, ansiedad y apoyo en la toma de decisiones. Este tipo de experiencias son un estímulo para el abordaje integral del paciente con enfermedad renal (AU)

Chronic kidney disease is associated with a wide range of stressful situations causing important physical and psychological repercussions. It is not usual that psychology professionals are active members of the nephrology teams. Inconsequence, these alterations are not properly assisted. Our aim is to present the introduction process of a psychologist in a nephrology department and its preliminary results. We designed a clearly defined introduction process, starting with a therapeutic communication training program for all the staff. In the model we have priorized pre-emptive interventions in order to promote the adaptation process, far from simple psychological symptom control. It is assumed the binomial patient-family as the major objective for care, choosing an interdisciplinary approach. We worked more from a health psychology perspective than from a mental health perspective. Over the year 2008 the number of patients assisted by the psychologist were 571 (mean 48 patients/month). The total number of interventions was 1,022. Majority of cases (45.2%)were derived from the advanced chronic kidney disease program, mostly related to demands about emotional impact of renal replacement therapy commencement. Others were: suspect of depression episode, adherence, primary caregiver emotional overwhelming, bereavement, anxiety and support in decision making process. This experience is a stimulus for the integral approach of the renal patient (AU)

[Effect of using icodextrin as a starting therapy for peritoneal permeability]. / Efecto del uso de icodextrina de inicio sobre la permeabilidad peritoneal.

UNLABELLED: Peritoneal permeability differs between patients at the time of starting peritoneal dialysis (PD) and it can increase along with time on the technique. This fact is related to peritonitis, the biocompatibility of the dialysis fluids and the use of glucose as osmotic agent. The aim of the present study was to evaluate if the use of one exchange a day of icodextrine from the time of DP initiation affects the evolution of peritoneal permeability. PATIENTS AND METHODS: 56 patients starting PD (mean age: 48.3 +/- 14.0; 62.5% males; 17.9% diabetics) that used one exchange a day with icodextrine from the time of starting PD. We performed a peritoneal transport kinetic study at the time of starting PD and then every 6 months during two years. We calculated the peritoneal mass transfer area coefficient of creatinine (Cr-MTAC) and urea (U-MTAC) as well as the D/P creatinine relationship (D/P Cr). As a control group we used the results of Cr-MTC of 249 patients that had used glucose as the only osmotic agent from the time of starting PD. RESULTS: The peritoneal transport, calculated using Cr-MTC, U-MTC and D/P Cr, diminished at 12 months (11.7+/-5.7 vs. 8.1+/-3.1; 23.5+/-7.3 vs. 18.9+/-3.8; 0.72+/-0.09 vs. 0.67+/-0.08; respectively), staying stable afterwards.We found that high transporters (HA) patients (higher quatril Cr-MTC ) showed a higher diminution of Cr-MTAC along the first year of treatment. The diminution of Cr-MTAC after 12 months using icodextrine was significantly higher (p<0.001) that the one observed in the control group that only used glucose as osmotic agent (10.5+/-5.3 vs. 10.1+/-4.6). We found that high transporters (HA) patients (higher quatril Cr-MTC) showed a higher decrease of Cr-MTAC along the first year of treatment. CONCLUSION: the use of icodextrine at the time of starting PD might help to correct the high transport status observed in some patients during the first months of treatment. The peritoneal transport kinetic studies performed at 6 and 12 months after starting PD are more representative of the long term peritoneal transport characteristics of the patients than those performed at the time of starting PD.

Efecto del uso de icodextrina de inicio sobre la permeabilidad peritoneal / No disponible

La permeabilidad peritoneal es diferente entre sujetos al inicio de la Diálisis Peritoneal (DP) y puede aumentar con el tiempo en la técnica. Este último fenómeno está condicionado por las peritonitis, la biocompatibilidad de los líquidos de diálisis y el abuso de glucosa como agente osmótico. Objetivo: evaluar si el uso de icodextrina desde el inicio de la DP afecta a la evolución de la permeabilidad peritoneal. Pacientes y métodos: incluimos 56 pacientes incidentes en DP (edad media: 48,3 ± 14; 62,5% varones; 17,9% diabéticos) que utilizan desde el inicio un cambio con icodextrina. Se les realizó una cinética peritoneal basal y cada seis meses, determinando la relación D/P creatinina (D/P cr) y los coeficientes de transferencia de masa de urea (MTC urea) y creatinina (MTC cr). La evolución de los MTC cr en el primer año se comparó con un grupo «histórico» de 249 pacientes que desde el inicio de la DP habían utilizado exclusivamente glucosa. Resultados: la permeabilidad peritoneal determinada por MTC cr, MTC urea y D/P cr descendió durante los primeros 12 meses (11,7 ± 5,7 vs. 8,1 ± 3,1; 23,5 ± 7,3 vs. 18,9 ± 3,8; 0,72 ± 0,09 vs. 0,67 ± 0,08, respectivamente), manteniéndose posteriormente estable. Los pacientes con Alto Transporte (AT) peritoneal basal (cuartil mayor de MTC cr) presentaron una mayor disminución de MTC cr a lo largo del primer año. El descenso del MTC cr al inicio y tras doce meses de DP usando icodextrina fue significativamente mayor (p <0,001) que el obtenido en el grupo «histórico» que sólo usaba glucosa (10,5 ± 5,3 vs. 10,1 ± 4,6). Los pacientes con AT peritoneal basal (cuartil mayor de MTC cr) son los que presentaron una mayor disminución de MTC cr a lo largo del primer año. Conclusión: el uso de icodextrina al inicio de la DP podría ayudar a corregir la alta permeabilidad basal en los primeros meses de diálisis. Las cinéticas realizadas a los 6 y 12 meses tras el inicio de diálisis son más representativas de la función peritoneal a largo plazo que las basales (AU)

Peritoneal permeability differs between patients at the time of starting peritoneal dialysis (PD) and it can increase along with time on the technique. This fact is related to peritonitis, the biocompatibility of the dialysis fluids and the use of glucose as osmotic agent. The aim of the present study was to evaluate if the use of one exchange a day of icodextrine from the time of DP initiation affects the evolution of peritoneal permeability. Patients and methods: 56 patients starting PD (mean age: 48.3 ± 14.0; 62.5% males; 17.9% diabetics) that used one exchange a day with icodextrine from the time of starting PD. We performed a peritoneal transport kinetic study at the time of starting PD and then every 6 months during two years. We calculated the peritoneal mass transfer area coefficient of creatinine (Cr-MTAC) and urea (U-MTAC) as well as the D/P creatinine relationship (D/P Cr). As a control group we used the results of Cr-MTC of 249 patients that had used glucose as the only osmotic agent from the time of starting PD. Results: The peritoneal transport, calculated using Cr-MTC, U-MTC and D/P Cr, diminished at 12 months (11.7±5.7 vs. 8.1±3.1; 23.5±7.3 vs. 18.9±3.8; 0.72±0.09 vs. 0.67±0.08; respectively), staying stable afterwards.We found that high transporters (HA) patients (higher quatril Cr-MTC ) showed a higher diminution of Cr-MTAC along the first year of treatment. The diminution of Cr-MTAC after 12 months using icodextrine was significantly higher (p<0.001) that the one observed in the control group that only used glucose as osmotic agent (10.5±5.3 vs. 10.1±4.6). We found that high transporters (HA) patients (higher quatril Cr-MTC) showed a higher decrease of Cr-MTAC along the first year of treatment. Conclusion: the use of icodextrine at the time of starting PD might help to correct the high transport status observed in some patients during the first months of treatment. The peritoneal transport kinetic studies performed at 6 and 12 months after starting PD are more representative of the long term peritoneal transport characteristics of the patients than those performed at the time of starting PD (AU)

Heterocigosis compuesta para las mutaciones intrón 9 + 1 g > T y Leu 850pro en el gen SLC12A3 en el Síndrome de Gitelman / No disponible

No disponible

Early steroid treatment improves the recovery of renal function in patients with drug-induced acute interstitial nephritis.

The role of steroid treatment in drug-induced acute interstitial nephritis (DI-AIN) is controversial. We performed a multicenter retrospective study to determine the influence of steroids in 61 patients with biopsy-proven DI-AIN, 52 of whom were treated with steroids. The responsible drugs were antibiotics (56%), non-steroidal anti-inflammatory drugs (37%) or other drugs. The final serum creatinine was significantly lower in treated patients while almost half of untreated patients remained on chronic dialysis. Among treated patients, over half showed a complete recovery of baseline renal function, whereas the rest remained in renal failure. There were no significant initial differences between these two subgroups in terms of duration or dosage of steroids. After withdrawal of the presumed causative drug, we found that when steroid treatment was delayed (by an average of 34 days) renal function did not return to baseline levels compared to those who received steroid treatment within the first 2 weeks after withdrawal of the offending agent. We found a significant correlation between the delay in steroid treatment and the final serum creatinine. Renal biopsies, including three patients who underwent a second biopsy, showed a progression of interstitial fibrosis related to the delay in steroid treatment. Our study shows that steroids should be started promptly after diagnosis of DI-AIN to avoid subsequent interstitial fibrosis and an incomplete recovery of renal function.

[Pasteurella multocida and Candida albicans peritonitis]. / Peritonitis por pasteurella multocida y Candida albicans.

Peritonitis is a well-known complication of peritoneal dialysis (PD) treatment. Repetitive episodes may induce an irreversible damage of the peritoneal membrane and are a frequent cause of PD drop-out. The great majority of the episodes are due to Staphylococci, Streptococci or gram- negative organisms. Unusual organisms have been reported, specially in immunosuppressed hosts. Few cases of Pasteurella Multocida (PM) have been described in PD patients. To our knowledge, we describe the first case preceding a Candida Albicans (CA) peritonitis. A review of the literature of PM peritonitis and the relation between these two microorganisms is discussed.

Peritonitis por Pasteurella multocida y Candida albicans / Pasteurella multocida and Candida albicans peritonitis

Las peritonitis son una complicación frecuente en pacientes en tratamiento condiálisis peritoneal. Las peritonitis reiteradas pueden conducir a un daño irreversiblede la membrana peritoneal que en ocasiones provoca la suspensión de la técnica.La mayoría de los episodios son producidos por Streptoccocus, Staphiloccocusy otros gérmenes gram negativos. Se han descrito mecanismos infrecuentes enpacientes inmunodeprimidos. Existen escasas referencias en la literatura sobre peritonitisproducidas por Pasteurella Multocida en pacientes en diálisis peritoneal.A continuación describimos un caso de peritonitis por Pasteurella Multocida queprecede a una peritonitis por Candida Albicans. A propósito del caso se discutiránlas peritonitis por Pasteurella Multocida y la relación entre ambos microorganismos

Peritonitis is a well-known complication of peritoneal dialysis (PD) treatment.Repetitive episodes may induce an irreversible damage of the peritoneal membraneand are a frequent cause of PD drop-out. The great majority of the episodesare due to Staphylococci, Streptococci or gram- negative organisms. Unusualorganisms have been reported, specially in immunosuppressed hosts. Few cases ofPasteurella Multocida (PM) have been described in PD patients. To our knowledge,we describe the first case preceding a Candida Albicans (CA) peritonitis. A reviewof the literature of PM peritonitis and the relation between these two microorganismsis discussed

[Calcineurin-inhibitor-free immunosuppression in early renal transplantation]. / Terapia inmunosupresora en trasplante renal de novo sin anticalcineurínicos.

Calcineurin inhibitors are one of the most common drugs used for prevention of acute rejection in recipients of renal allografts. New immunosuppressors have reduced the incidence of acute renal allograft rejection. There have been numerous recent attempts to develop alternative patterns of immunosuppressors for prevention of chronic renal allograft failure, and enhancing its survival. We described a patient who developed numerous complications after the initial postransplant period. He was treated with a calcineurin inhibitors-free immunosuppression in order to avoid nephrotoxicity, but had over 30 ng/ml of sirolimus. Renal function was impaired after cyclosponne withdrawal. Sirolimus was used in association with mycofenolate mofetil and prednisone.

[Familial Henoch-Schönlein purpura manifested with lung hemorrhage]. / Púrpura de Schönlein-Henoch de carácter familiar exteriorizada como hemorragia pulmonar.

Henoch-Schönlein purpura (HSP) is a necrotizing vasculitis affecting small vessels characterized by nontrombocytopenic purpura. The most characteristic clinical manifestations are purpura, arthritis, abdominal pain, abdominal bleeding and nephritis. Lung hemorrhage is a rare symptom associated with the HSP. Although the subclinical alterations of pulmonary function are frequent in patients with PSH without clinical lung manifestations, the presence of lung hemorrhage is an unusual symptom. We report a case of a patient with hemoptysis and HSP previously asymptomatic.

Terapia inmunosupresora en trasplante renal de novo sin anticalcineurínicos / Calcineurin inhibitors-free immunosuppression in early renal transplantation

La mayoría de las pautas inmunosupresoras fueron diseñadas para disminuir la incidencia de rechazo agudo. Con la disminución de las tasas de rechazo agudo, tras la aparición de nuevos inmunosupresores en la década de los noventa, el objetivo en el futuro es disminuir la nefropatía crónica del injerto, aumentando su supervivencia. A continuación presentamos un paciente trasplantado renal que en el post-trasplante reciente se decidió, con el fin de evitar la nefrotoxicidad, utilizar una pauta inmunosupresora sin anticalcineurínicos. Durante un período de tiempo presentó niveles por encima de 30 ng/ml. Existe, por ahora, poca experiencia en el empleo de sirolimus en asociación con Micofenolato mofetil y prednisona, en el post-trasplante inmediato (AU)

Calcineurin inhibitors are one of the most common drugs used for prevention of acute rejection in recipients of renal allografts. New immunosuppressors have reduced the incidence of acute renal allograft rejection. There have been numerous recent attempts to develop alternative patterns of immunosuppressors for prevention of chronic renal allograft failure, and enhancing its survival. We described a patient who developed numerous complications after the initial postransplant period. He was treated with a calcineurin inhibitors-free immunosuppression in order to avoid nephrotoxicity, but had over 30 ng/ml of sirolimus. Renal function was impaired after cyclosponne withdrawal. Sirolimus was used in association with mycofenolate mofetil and prednisone (AU)

Enfermedad de Fabry: diagnóstico clínico y enzimático de homocigotos y heterocigotos. Nuevas perspectivas terapéuticas / Fabry disease: clinic and enzymatic diagnosis of hemizygous and heterozygous. New therapeutic prospects

La enfermedad de Fabry es una enfermedad de depósito, con herencia recesiva ligada al cromosoma X, causada por un déficit parcial o completo en la síntesis de la enzima lisosomal -galactosidasa A. El depósito intracelular de glicoesfingolípidos (globotriaosilceramida), el sustrato de esta enzima, da lugar a una grave y dolorosa neuropatía con disfunción progresiva renal, cardiovascular y cerebrovascular que conduce a la muerte precoz. Aunque existe un predominio de afectación en los varones, muchas mujeres portadoras tienen igual afectación clínica, incluyendo el riesgo de ictus. Los estigmas físicos corno los angioqueratomas de la piel y mucosas, y las características anomalías corneales facilitan la identificación de la enfermedad. El hallazgo de una ausencia o disminución marcada de la actividad de la enzima -galactosidasa A en el plasma, los leucocitos o los fibroblastos de la piel confirma el diagnóstico. Los avances de los últimos años han permitido optimizar, en gran medida, el diagnóstico de pacientes y portadoras, así como el desarrollo de una terapia enzimática sustitutiva. En este artículo describimos una familia con enfermedad de Fabry compuesta de sujetos homocigotos y heterocigotos, a partir de un propositus que desarrolló insuficiencia renal terminal y recibió un trasplante renal de cadáver que ha permanecido funcionante durante más de 15 años (AU)

[Use of icodextrin for diurnal exchange in patients undergoing automatic peritoneal dialysis. Comparison with glucose solutions]. / Uso de icodextrina en el intercambio diurno en pacientes en diálisis peritoneal automática. Comparación con soluciones con glucosa.

Icodextrin (IC) is an osmotic agent that produces sustained ultrafiltration (UF) during long dwell time periods in peritoneal dialysis patients. The aim of this study was to evaluate the effects of 7.5% IC for the diurnal exchange in automated peritoneal dialysis (APD) patients and to compare them with that of 2.27% glucose solutions. Seventeen patients treated on APD during 13.9 +/- 12.7 months were included. The study was divided into three eight weeks phases. During the baseline period patients used 2.27% glucose for the daytime, second, IC 7.5% was prescribed for the day-exchange, and finally 2.27% glucose solution was used for the last eight weeks. Daytime UF increased in all patients during IC use (-53 +/- 22 to 270 +/- 304 ml/day, p < 0.01). Patients with higher peritoneal permeability capacity obtained more benefits. Daytime urea KT/V and weekly creatinine clearance (WCC) augmented significantly during IC use, but the increase of weekly urea KT/V and WCC was not significant (2.18 +/- 0.45 to 2.26 +/- 0.41 and 62.7 +/- 18 to 66.6 +/- 15 l/week/1.73 m2; respectively). On IC, nightly glucose load significantly decreased (289 +/- 82 to 266 +/- 94 g, p < 0.05), returning to previous value after withdrawal. Plasma osmolality did not change, although plasma sodium levels decreased during IC use (140 +/- 3 to 136 +/- 2, p < 0.001). Serum amylase levels significantly declined during IC use (279 +/- 151 to 29 +/- 9 U/l), returning to previous values after transfer to glucose. Peritoneal function transport parameters and peritoneal protein losses did not change. IC metabolite plasma levels increased during the use of this solution, returning to previous values after withdrawal. In conclusion, IC dialysate is an excellent alternative to glucose dialysate for the day-exchange in APD patients. Daytime UF increased in all patients, but those with higher peritoneal permeability capacity obtained more benefits. The decrease of the glucose peritoneal load overnight and the reduction for more than 50% of exposure time of the peritoneal membrane to glucose solutions, probably make IC solution a more biocompatible fluid.

Uso de icodextrina en el intercambio diurno en pacientes en diálisis peritoneal automática. Comparación con soluciones con glucosa / Icodextrin in automated peritoneal dialysis. Comparisons with glucose solutions

La icodextrina (IC) es un agente osmótico que tiene la capacidad de mantener la ultrafiltración (UF) de forma sostenida durante períodos largos de tiempo. El objetivo de este estudio fue evaluar los efectos de la utilización de soluciones con IC 7,5 por ciento durante el intercambio diurno en pacientes tratados con diálisis peritoneal automática (DPA) y compararlos con los obtenidos con soluciones que contienen glucosa. Se incluyeron 17 pacientes en tratamiento con DPA durante 13,9 ñ 12,7 meses. El estudio se realizó en tres fases de 8 semanas de duración cada una. En la primera los pacientes usaron durante el intercambio diurno soluciones con glucosa al 2,27 por ciento, en la segunda soluciones con IC 7,5 por ciento y en la tercera glucosa 2,27 por ciento. La prescripción de la DPA nocturna no se modificó. La ultrafiltración diurna se incrementó en todos los pacientes durante la utilización de IC (-53 ñ 22 a 270 ñ 304 ml/día, p < 0,01), siendo los más beneficiados aquellos con mayor permeabilidad peritoneal. Los valores de Kt/V y de CCrs diurnos aumentaron significativamente durante el uso de IC; mientras que en los totales las diferencias no fueron significativas (2,18 ñ 0,45 a 2,26 ñ 0,41 y 62,7 ñ 18 a 66,6 ñ 15 l/semana/1,73 m2; respectivamente). La carga nocturna de glucosa absorbida descendió durante el uso de IC (289 ñ 82 a 266 ñ 94 g, p < 0,05), volviendo a valores similares a los previos tras su suspensión. Los niveles plasmáticos de sodio descendieron durante el uso de IC (140 ñ 3 vs 136 ñ 2, p < 0,001) aunque la osmolaridad plasmática no se modificó. La amilasa sérica disminuyó durante la utilización de IC (279 ñ 151 a 29 ñ 9 U/l, p < 0,001), volviendo a valores previos tras reiniciar la glucosa. El transporte de solutos y las pérdidas proteicas peritoneales no se modificaron. Se observó un aumento significativo de los niveles plasmáticos de IC y sus metabolitos durante el uso de IC. Concluimos que las soluciones con IC son una excelente alternativa a las que contienen glucosa para el intercambio diurno en DPA. El incremento en la UF se observó en todos los pacientes estudiados, aunque aquellos con una mayor superficie peritoneal efectiva fueron los más beneficiados. La reducción de la carga diaria de glucosa absorbida y la disminución de más del 50 por ciento del tiempo diario de exposición de la membrana peritoneal a la glucosa, la convierten probablemente en una solución más bicocompatible (AU)

[Fabry disease: clinic and enzymatic diagnosis of homozygous and heterozygous. New therapeutic prospects]. / Enfermedad de Fabry: diagnóstico clínico y enzimático de homocigotos y heterocigotos. Nuevas perspectivas terapéuticas.

Fabry disease is an X-linked recessive lysosomal storage disorder caused by a partial or complete deficiency of alpha-galactosidase A. Intracellular accumulation of globotriaosylceramide, the glycolipid substrate of this enzyme, leads to severe painful neuropathy with progressive renal, cardiovascular, and cerebrovascular dysfunction and early death. Men are predominantly affected but many female carriers have similar clinical involvement, including increased risk of stroke. Physical stigmata, such as angiokeratomas in skin and mucous membranes and characteristic benign corneal abnormalities, facilitate identification of Fabry disease. The finding of a marked decreased activity of (alpha-galactosidase A in plasma, white blood cells or cultured skin fibroblasts confirms the diagnosis. Treatment thus far has been symptomatic only. Etiology-based therapies are being developed that include enzyme replacement therapy, gene therapy, and substrate deprivation. The recently completed double-blind, placebo-controlled trials of intravenous infusions of (alpha-galactosidase A in patients with Fabry disease demonstrated the safety and efficacy of this treatment. We report a family with Fabry disease composed of hemicygous and heterocygous. The propositus developed chronic renal failure and received a cadaver renal transplant, which remained with adequate renal function during 15 years.