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.

Unveiling the Clinical Benefits of High-Volume Hemodiafiltration: Optimizing the Removal of Medium-Weight Uremic Toxins and Beyond.

Dialysis treatment has improved the survival of patients with kidney failure. However, the hospitalization and mortality rates remain alarmingly high, primarily due to incomplete uremic toxin elimination. High-volume hemodiafiltration (HDF) has emerged as a promising approach that significantly improves patient outcomes by effectively eliminating medium and large uremic toxins, which explains its increasing adoption, particularly in Europe and Japan. Interest in this therapy has grown following the findings of the recently published CONVINCE study, as well as the need to understand the mechanisms behind the benefits. This comprehensive review aims to enhance the scientific understanding by explaining the underlying physiological mechanisms that contribute to the positive effects of HDF in terms of short-term benefits, like hemodynamic tolerance and cardiovascular disease. Additionally, it explores the rationale behind the medium-term clinical benefits, including phosphorus removal, the modulation of inflammation and oxidative stress, anemia management, immune response modulation, nutritional effects, the mitigation of bone disorders, neuropathy relief, and amyloidosis reduction. This review also analyzes the impact of HDF on patient-reported outcomes and mortality. Considering the importance of applying personalized uremic toxin removal strategies tailored to the unique needs of each patient, high-volume HDF appears to be the most effective treatment to date for patients with renal failure. This justifies the need to prioritize its application in clinical practice, initially focusing on the groups with the greatest potential benefits and subsequently extending its use to a larger number of patients.

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.

[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.

Efecto de las variantes de CYP2C9 sobre la dosis de losartán en hipertensos chilenos / Association between cytochrome p4502c9 polymorphisms and losartan dosing in hypertensive patients

Background Losartan is widely used in many clinicals settings. Its dosage is related to the genetic characteristics of CYP2C9 enzymatic activity, which metabolizes losartan to its active form E-3174, responsible for the antihypertensive effect. Aims To identify the frequency of allelic variants CYP2C9*2 and CYP2C9*3 in hypertensive patients and to compare genotypes with a healthy Chilean population. To relate polymorphisms with the losartan dosing to obtain an optimal blood pressure. Material and Methods We studied 30 patients with controlled essential hypertension using losartan with normal liver function, and 202 healthy people. Peripheral blood DNA genotyping was performed by polymerase chain reaction to identify the polymorphisms. Allelic and genotypic frequencies were compared. Results In hypertensive patients, allelic frequencies were 0.85 (CYP2C9*1), 0.05 (CYP2C9*2) and 0.1 (CYP2C9*3). Genotypic frequencies were 73.3% (CYP2C9*1/*1), 6.7% (CYP2C9*1/*2), 16.7% (CYP2C9*1/*3) and 3.3% (CYP2C9*2/3); observing a significantly higher frequency of the allele CYP2C9*3 (p=0.041) and CYP2C9*1/*3 genotype (p=0.04). A non-significant tendency to need a larger dose of losartan was observed with the CYP2C9 * 3 allele, with an odds ratio (OR) of 1.46 (95% confidence intervals (CI) 0.01-18.64). The same tendency was observed with the need to use losartan twice a day, obtaining an OR of 5.88 (CI 0.54 -62.14). Conclusions There could be a relationship between the presence of CYP2C9 polymorphisms and the pathogenesis of hypertension. The presence of CYP2C9*3 is associated with the need for higher doses of losartan, possibly due to a decrease in the conversion of losartan to E-3174.

¿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.

[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).

[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.

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

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.

[Association between cytochrome p4502c9 polymorphisms and losartan dosing in hypertensive patients]. / Efecto de las variantes de CYP2C9 sobre la dosis de losartán en hipertensos chilenos.

Background Losartan is widely used in many clinicals settings. Its dosage is related to the genetic characteristics of CYP2C9 enzymatic activity, which metabolizes losartan to its active form E-3174, responsible for the antihypertensive effect. Aims To identify the frequency of allelic variants CYP2C9*2 and CYP2C9*3 in hypertensive patients and to compare genotypes with a healthy Chilean population. To relate polymorphisms with the losartan dosing to obtain an optimal blood pressure. Material and Methods We studied 30 patients with controlled essential hypertension using losartan with normal liver function, and 202 healthy people. Peripheral blood DNA genotyping was performed by polymerase chain reaction to identify the polymorphisms. Allelic and genotypic frequencies were compared. Results In hypertensive patients, allelic frequencies were 0.85 (CYP2C9*1), 0.05 (CYP2C9*2) and 0.1 (CYP2C9*3). Genotypic frequencies were 73.3% (CYP2C9*1/*1), 6.7% (CYP2C9*1/*2), 16.7% (CYP2C9*1/*3) and 3.3% (CYP2C9*2/3); observing a significantly higher frequency of the allele CYP2C9*3 (p=0.041) and CYP2C9*1/*3 genotype (p=0.04). A non-significant tendency to need a larger dose of losartan was observed with the CYP2C9 * 3 allele, with an odds ratio (OR) of 1.46 (95% confidence intervals (CI) 0.01-18.64). The same tendency was observed with the need to use losartan twice a day, obtaining an OR of 5.88 (CI 0.54 -62.14). Conclusions There could be a relationship between the presence of CYP2C9 polymorphisms and the pathogenesis of hypertension. The presence of CYP2C9*3 is associated with the need for higher doses of losartan, possibly due to a decrease in the conversion of losartan to E-3174.

Remodelación ventricular post infarto agudo al miocardio: caso clínico / Ventricular remodeling post acute infarct to myocardium: clinical case

Se presenta el caso de una paciente de 64 años que tras sufrir un IAM, sufre un proceso de remodelación ventricular en un período menor 7 meses que la conduce a una insuficiencia cardíaca severa.