More difficult still: Treating severe rapidly progressive glomerulonephritis in the context of COVID-19 pneumonia.

We present the case of a male patient with severe SARS-CoV-2 pneumonia, with simultaneous onset of p-ANCA positive rapidly progressive glomerulonephritis. We discuss the different therapeutic possibilities, emphasising the appropriateness of their administration according to the time in the course of the infection.

Análisis del grado de conocimiento e interés de los profesionales sanitarios de nefrología sobre la planificación anticipada de la asistencia sanitaria / Analysis of the degree of knowledge and interest of nephrology healthcare professionals in advance care planning

Introduction:Los enfermos renales crónicos se ven obligados a tener que tomar decisiones continuamente. En este proce-so los profesionales sanitarios no suelen preguntarles cómo querrían planificar el final de sus días. En una sociedad donde la “no limitación al esfuerzo terapéutico” parece una cons-tante en nuestra práctica, el reflexionar sobre nuestros pro-pios límites podría ayudarnos en la atención a los pacientes.Objetivo: Conocer el grado de conocimiento e interés por la Planificación Anticipada de la Asistencia Sanitaria (PAAS) en profesionales que atienden a pacientes con Enfermedad Re-nal Crónica.Material y Método: Estudio observacional descriptivo trans-versal mediante cuestionario autoadministrado a sanitarios participantes voluntarios a nivel nacional. El cuestionario incluía 22 preguntas sobre conocimiento e interés sobre la planificación anticipada de la asistencia sanitaria.Resultados: Respondieron 422 profesionales: 53,3% médi-cos; 45,0% enfermeras y 1,4% técnicos en cuidados auxilia-res de enfermería. El 79,9% no conocen cuantos pacientes tienen registrado el Documento de Voluntades Anticipadas. El 63,5% han oído hablar de la Planificación Anticipada de la Asistencia Sanitaria. Un 28,7% conoce la diferencia en-tre la Planificación Anticipada de la Asistencia Sanitaria y el Documento de Voluntades Anticipadas. Un 96,2% afirma que tener esta información ayudaría a los pacientes a que estu-vieran mejor atendidos en sus últimos días. El 97,6% de los profesionales piensan que está en nuestra mano hacer algo más, a un 94,5% les gustaría recibir formación.Conclusión: Existe falta de conocimiento y un gran interés por los profesionales sanitarios sobre la Planificación Antici-pada de la Asistencia Sanitaria. (AU)

Introduction:Chronically ill kidney patients are forced to make decisions all throughout their lives. In this process, healthcare professionals often do not ask them how they would like to plan the end of their days. In today’s society “no limitation to therapeutic effort” seems to be a constant in clinical practice, so reflecting on one’s own limits could help in patient care.Objective: To determine the degree of knowledge and inte-rest in advance care planning among professionals caring for patients with chronic kidney disease.Material and Method: Cross-sectional descriptive observa-tional study using a nationwide self-administered question-naire to health care volunteers. The questionnaire included 22 questions on knowledge of and interest in advance care planning. Results:422 professionals replied: 53.3% physicians; 45.0% nurses and 1.4% auxiliary nursing care technicians. 79.9% did not know how many patients have registered an advance directives document. 63.5% had heard of advance care planning. 28.7% were aware of the difference between advance care planning and the advance directive. 96.2% affirmed that having this information would help patients to be better cared for in the last days of their life. 97.6% of the professionals thought that they could do more and 94.5% would like to receive training. Conclusion: There is a lack of knowledge and a significant inte-rest among healthcare professionals in advance care planning (AU)

Más difícil todavía: tratar una glomerulonefritis rápidamente progresiva grave en el seno de una neumonía por COVID-19 / More difficult still: Treating severe rapidly progressive glomerulonephritis in the context of COVID-19 pneumonia

Presentamos el caso de un varón afecto por neumonía SARS-CoV-2 grave, que a la vez comienza con una glomerulonefritis rápidamente progresiva p-ANCA positiva. Se comentan las distintas posibilidades terapéuticas haciendo hincapié en la idoneidad de su administración según el momento evolutivo de la infección. (AU)

We present the case of a male patient with severe SARS-CoV-2 pneumonia, with simultaneous onset of p-ANCA positive rapidly progressive glomerulonephritis. We discuss the different therapeutic possibilities, emphasising the appropriateness of their administration according to the time in the course of the infection. (AU)

Acute kidney injury in 3182 patients admitted with COVID-19: a single-center, retrospective, case-control study.

BACKGROUND: Acute kidney injury (AKI) may develop in coronavirus disease 2019 (COVID-19) patients and may be associated with a worse outcome. The aim of this study is to describe AKI incidence during the first 45 days of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in Spain, its reversibility and the association with mortality. METHODS: This was an observational retrospective case-control study based on patients hospitalized between 1 March and 15 April 2020 with SARS-CoV-2 infection and AKI. Confirmed AKI cases were compared with stable kidney function patients for baseline characteristics, analytical data, treatment and renal outcome. Patients with end-stage kidney disease were excluded. RESULTS: AKI incidence was 17.22% among 3182 admitted COVID-19 patients and acute kidney disease (AKD) incidence was 6.82%. The most frequent causes of AKI were prerenal (68.8%) and sepsis (21.9%). Odds ratio (OR) for AKI was increased in patients with pre-existent hypertension [OR 2.58, 95% confidence interval (CI) 1.71-3.89] and chronic kidney disease (CKD) (OR 2.14, 95% CI 1.33-3.42) and in those with respiratory distress (OR 2.37, 95% CI 1.52-3.70). Low arterial pressure at admission increased the risk for Stage 3 AKI (OR 1.65, 95% CI 1.09-2.50). Baseline kidney function was not recovered in 45.73% of overall AKI cases and in 52.75% of AKI patients with prior CKD. Mortality was 38.5% compared with 13.4% of the overall sample population. AKI increased mortality risk at any time of hospitalization (hazard ratio 1.45, 95% CI 1.09-1.93). CONCLUSIONS: AKI is frequent in COVID-19 patients and is associated with mortality, independently of acute respiratory distress syndrome. AKD was also frequent and merits adequate follow-up.

More difficult still: Treating severe rapidly progressive glomerulonephritis in the context of COVID-19 pneumonia. / Más difícil todavía: tratar una glomerulonefritis rápidamente progresiva grave en el seno de una neumonía por COVID-19.

We present the case of a male patient with severe SARS-CoV-2 pneumonia, with simultaneous onset of p-ANCA positive rapidly progressive glomerulonephritis. We discuss the different therapeutic possibilities, emphasising the appropriateness of their administration according to the time in the course of the infection.

Glomerulonefritis necrosante en un paciente con VIH, VHC y leishmaniasis visceral / Necrotizing glomerulonephritis in patients with HIV, HCV and visceral leishmaniasis

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Inmunosupresión como desencadenante de un síndrome de hiperinfestación por Strongyloides stercolaris en la nefropatía membranosa / Immunosuppression as a trigger for hyperinflammatory syndrome due to Strongyloides stercolaris in membranous nephropathy

La relación entre parásitos y glomerulonefritis (GN) está bien documentada en determinadas parasitosis, no así en casos de Strongyloides stercolaris (S. stercolaris), donde hay pocos casos descritos, siendo la mayoría GN de cambios mínimos. Reportamos un caso de hiperinfestación por S. stercolaris en un paciente afectado de una GN membranosa tratado con corticoides por vía oral con resultado fatal para el paciente. Este caso nos aporta una doble enseñanza: en primer lugar, acerca de una asociación rara de estrongiloidiasis y GN membranosa, y en segundo lugar, sobre la importancia de establecer un diagnóstico de sospecha y tratamiento adecuados ante determinadas infecciones o enfermedades con poca expresividad clínica antes de iniciar cualquier tratamiento inmunosupresor

The relationship between parasites and glomerulonephritis (GN) is well documented in certain parasitoses, but not in cases of Strongyloides stercolaris (S. stercolaris) where there are few cases described being the majority GN of minimal changes. We report a case of hyperinfestation by S. stercolaris in a patient affected by a membranous GN treated with oral corticosteroids with fatal outcome for the patient. This case provides a double teaching: first about a rare association of strongyloid and membranous GN and second about the importance of establishing a diagnosis of suspected and appropriate treatment for certain infections or diseases with little clinical expression before starting any immunosuppressive treatment

Immunosuppression as a trigger for hyperinflammatory syndrome due to Strongyloides stercolaris in membranous nephropathy. / Inmunosupresión como desencadenante de un síndrome de hiperinfestación por Strongyloides stercolaris en la nefropatía membranosa.

The relationship between parasites and glomerulonephritis (GN) is well documented in certain parasitoses, but not in cases of Strongyloides stercolaris (S. stercolaris) where there are few cases described being the majority GN of minimal changes. We report a case of hyperinfestation by S. stercolaris in a patient affected by a membranous GN treated with oral corticosteroids with fatal outcome for the patient. This case provides a double teaching: first about a rare association of strongyloid and membranous GN and second about the importance of establishing a diagnosis of suspected and appropriate treatment for certain infections or diseases with little clinical expression before starting any immunosuppressive treatment.

Nefropatía por cianosis. A propósito de un caso / A case report of cyanotic nephropathy

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El líquido de diálisis con citrato no induce in vitro estrés oxidativo ni inflamación en comparación con el acetato / Citrate dialysate does not induce oxidative stress or inflammation in vitro as compared to acetate dialysate

El líquido de diálisis con citrato no induce in vitro estrés oxidativo ni inflamación en comparación con el acetato. El incremento de la acetatemia durante la sesión de hemodiálisis se ha asociado a una serie de alteraciones: aumento del estrés oxidativo, de las citocinas proinflamatorias y de la síntesis de óxido nítrico. El ácido cítrico puede jugar un papel alternativo al acetato como estabilizante del líquido de diálisis (LD). El citrato en comparación con el acetato tiene un patrón diferente en cuanto a la activación leucocitaria y del complemento. El objetivo de este estudio es comparar el acetato con el citrato en el LD respecto a su efecto inflamatorio en las células inmunocompetentes de la sangre. Material y métodos: El efecto del acetato o citrato fue investigado en sangre completa de pacientes urémicos y controles sanos in vitro, enfrentada a 4tipos de LD: el LD 1, con 1mmol/L de citrato y libre de acetato; LD 2, con 0,8mmol/L de citrato y 0,3mmol/L de acetato; LD 3, con 3mmol/L de acetato sin citrato y LD 4, con 4mmol/L de acetato sin citrato. Los tipos de células utilizados fueron: cultivo de monocitos humanos (THP-1); células mononucleares de sangre periférica (PBMC) de controles sanos y pacientes urémicos en HD. Se determinó ICAM-1, la cuantificación de los niveles de especies reactivas de oxígeno (ROS) y la cuantificación de microvesículas totales. Resultados: Los LD con acetato (L3 y L4) indujeron un incremento en la densidad de expresión de ICAM-1 en las células THP-1, no así los de citrato; con células inmunocompetentes de sujetos sanos los LD con acetato (L3 y L4) respecto a los con citrato (L1 y L2) observamos un incremento en la expresión de ICAM-1; con células de pacientes en hemodiálisis no existían diferencias significativas entre los diferentes LD. Tanto en las células de sujetos sanos como en las de los dializados, se incrementaron significativamente la expresión de especies reactivas de oxígeno y las microvesículas con los LD con acetato y no con citrato. Conclusiones: El acetato en el LD, en las concentraciones que se utilizan habitualmente en la práctica clínica, aumenta el estrés oxidativo y las microvesículas totales, y puede actuar como coadyuvante de los otros estímulos proinflamatorios a los que están sometidos los pacientes urémicos en hemodiálisis. Los LD con citrato no producen esta activación, por lo que podrían ser una alternativa en la clínica (AU)

Increased acetataemia during haemodialysis sessions has been associated with a number of abnormalities, including increased oxidative stress, pro-inflammatory cytokines and nitric oxide synthesis. However, citric acid may play an alternative role to acetate as a dialysate stabiliser given that the effect of citrate on complement and leukocyte activation is different to that of acetate. The purpose of this study was to compare the inflammatory effect in immunocompetent blood cells of acetate dialysate and citrate dialysate. Material and methods: The effect of acetate and/or citrate was investigated in the whole blood of uraemic patients and in healthy in vitro samples. Four types of dialysate were tested: dialysate 1, acetate-free with 1mmol/L of citrate; dialysate 2, with 0.8mmol/L of citrate and 0.3mmol/L of acetate; dialysate 3, citrate-free with 3mmol/L of acetate; and dialysate 4, citrate-free with 4mmol/L of acetate. The cell types used were: human monocyte culture (THP-1); and peripheral blood mononuclear cells (PBMCs) from healthy subjects and uraemic patients on haemodialysis. ICAM-1 was determined and levels of reactive oxygen species and total microvesicles were quantified. Results: Unlike the citrate dialysates, the dialysates with acetate (dialysate 3 and dialysate 4) induced increased ICAM-1 expression density in THP-1 cells; an increase in ICAM-1 expression was observed in the immunocompetent cells of healthy subjects with acetate dialysate (dialysate 3 and dialysate 4) but not with citrate dialysate (dialysate 1 and dialysate 2). No significant ICAM-1 differences were found between the different dialysates in the cells of haemodialysed patients. Reactive oxygen species expression and the number of microvesicles increased significantly with acetate dialysate but not with citrate dialysate in the cells of both healthy subjects and haemodialysed patients. Conclusions: At the concentrations in which it is generally used in clinical practice, acetate-based dialysate increases oxidative stress and the total number of microvesicles and may induce other pro-inflammatory stimuli typical of uraemic patients on haemodialysis. Citrate dialysates do not induce this activation, which could make them a suitable alternative in clinical practice (AU)

Citrate dialysate does not induce oxidative stress or inflammation in vitro as compared to acetate dialysate. / El líquido de diálisis con citrato no induce in vitro estrés oxidativo ni inflamación en comparación con el acetato.

Increased acetataemia during haemodialysis sessions has been associated with a number of abnormalities, including increased oxidative stress, pro-inflammatory cytokines and nitric oxide synthesis. However, citric acid may play an alternative role to acetate as a dialysate stabiliser given that the effect of citrate on complement and leukocyte activation is different to that of acetate. The purpose of this study was to compare the inflammatory effect in immunocompetent blood cells of acetate dialysate and citrate dialysate. MATERIAL AND METHODS: The effect of acetate and/or citrate was investigated in the whole blood of uraemic patients and in healthy in vitro samples. Four types of dialysate were tested: dialysate 1, acetate-free with 1mmol/L of citrate; dialysate 2, with 0.8mmol/L of citrate and 0.3mmol/L of acetate; dialysate 3, citrate-free with 3mmol/L of acetate; and dialysate 4, citrate-free with 4mmol/L of acetate. The cell types used were: human monocyte culture (THP-1); and peripheral blood mononuclear cells (PBMCs) from healthy subjects and uraemic patients on haemodialysis. ICAM-1 was determined and levels of reactive oxygen species and total microvesicles were quantified. RESULTS: Unlike the citrate dialysates, the dialysates with acetate (dialysate 3 and dialysate 4) induced increased ICAM-1 expression density in THP-1 cells; an increase in ICAM-1 expression was observed in the immunocompetent cells of healthy subjects with acetate dialysate (dialysate 3 and dialysate 4) but not with citrate dialysate (dialysate 1 and dialysate 2). No significant ICAM-1 differences were found between the different dialysates in the cells of haemodialysed patients. Reactive oxygen species expression and the number of microvesicles increased significantly with acetate dialysate but not with citrate dialysate in the cells of both healthy subjects and haemodialysed patients. CONCLUSIONS: At the concentrations in which it is generally used in clinical practice, acetate-based dialysate increases oxidative stress and the total number of microvesicles and may induce other pro-inflammatory stimuli typical of uraemic patients on haemodialysis. Citrate dialysates do not induce this activation, which could make them a suitable alternative in clinical practice.

¿Cuál es el flujo de baño óptimo en la hemodiafiltración on-lineposdilucional? / What is the optimum dialysate flow in post-dilution online haemodiafiltration?

Introducción: En la hemodiafiltración en línea posdilucional (HDFOL) la única recomendación acerca del líquido de diálisis (LD) hace referencia a su pureza. No se ha definido si usar flujos de baño (Qd) elevados tiene alguna utilidad para aumentar el Kt o el volumen de ultrafiltración-infusión (VI). Objetivo: Estudiar cómo influye el Qd en el Kt y en el VI en la HDFOL. Material y métodos: Estudio cruzado prospectivo. Se incluyó a 37 pacientes a los que se les realizaron 6 sesiones de HDFOL con cada Qd: 500, 600 y 700ml/min. Veintiún pacientes se dializaron en monitor 5008® y 17 con AK-200®. Los dializadores utilizados fueron: 20 con FX800® y 17 con Polyflux-210®. El resto de los parámetros se mantuvieron constantes. Se recogieron del monitor: flujo efectivo de sangre, tiempo efectivo de diálisis, Kt final y VI. Resultados: Encontramos que usando un Qd=600 o 700ml/min, el Kt aumentó un 1,7% respecto al uso de Qd=500ml/min. Las diferencias de VI no fueron significativas. Aumentar el Qd de 500ml/min a 600 y 700ml/min aumenta el consumo de LD un 20 y un 40%, respectivamente. Conclusiones: En la HDFOL con los monitores y dializadores utilizados no son útiles los Qd superiores a 500ml/min para aumentar la eficacia del Kt ni el VI, por lo que su utilización implica un despilfarro de un recurso como el agua, tan importante tanto desde el punto de vista ecológico como económico (AU)

Introduction: In post-dilution online hemodiafiltration (OL-HDF), the only recommendation concerning the dialysate, or dialysis fluid, refers to its purity. No study has yet determined whether using a high dialysate flow (Qd) is useful for increasing Kt or ultrafiltration-infusion volume. Objective: Study the influence of Qd on Kt and on infusion volume in OL-HDF. Material and methods: This was a prospective crossover study. There were 37 patients to whom 6 sessions of OL-HDF were administered at 3 different Qds: 500, 600 and 700ml/min. A 5008® monitor was used for the dialysis in 21 patients, while an AK-200® was used in 17. The dialysers used were: 20 with FX 800® and 17 with Polyflux-210®. The rest of the parameters were kept constant. Monitor data collected were effective blood flow, effective dialysis time, final Kt and infused volume. Results: We found that using a Qd of 600 or 700ml/min increased Kt by 1.7% compared to using a Qd of 500ml/min. Differences in infusion volume were not significant. Increasing Qd from 500ml/min to 600 and 700ml/min increased dialysate consumption by 20% and 40%, respectively. Conclusions: With the monitors and dialysers currently used in OL-HDF, a Qd higher than 500ml/min is unhelpful for increasing the efficacy of Kt or infusion volume. Consequently, using a high Qd wastes water, a truly important resource both from the ecological and economic points of view (AU)

What is the optimum dialysate flow in post-dilution online haemodiafiltration?

INTRODUCTION: In post-dilution online hemodiafiltration (OL-HDF), the only recommendation concerning the dialysate, or dialysis fluid, refers to its purity. No study has yet determined whether using a high dialysate flow (Qd) is useful for increasing Kt or ultrafiltration-infusion volume. OBJECTIVE: Study the influence of Qd on Kt and on infusion volume in OL-HDF. MATERIAL AND METHODS: This was a prospective crossover study. There were 37 patients to whom 6 sessions of OL-HDF were administered at 3 different Qds: 500, 600 and 700ml/min. A 5008(®) monitor was used for the dialysis in 21 patients, while an AK-200(®) was used in 17. The dialysers used were: 20 with FX 800(®) and 17 with Polyflux-210(®). The rest of the parameters were kept constant. Monitor data collected were effective blood flow, effective dialysis time, final Kt and infused volume. RESULTS: We found that using a Qd of 600 or 700ml/min increased Kt by 1.7% compared to using a Qd of 500ml/min. Differences in infusion volume were not significant. Increasing Qd from 500ml/min to 600 and 700ml/min increased dialysate consumption by 20% and 40%, respectively. CONCLUSIONS: With the monitors and dialysers currently used in OL-HDF, a Qd higher than 500ml/min is unhelpful for increasing the efficacy of Kt or infusion volume. Consequently, using a high Qd wastes water, a truly important resource both from the ecological and economic points of view.

Efecto agudo del baño con citrato sobre la alcalemia postdiálisis / Acute effect of citrate baths on post-dialysis alkalemia

INTRODUCCIÓN: La corrección de la acidosis metabólica provocada por la insuficiencia renal se consigue aportando bicarbonato durante la diálisis. Para evitar la precipitación de carbonato cálcico y magnésico que se produce en el líquido de diálisis (LD) al añadir bicarbonato, es necesario añadir un ácido, habitualmente acetato, que no está exento de efectos secundarios. Así, el citrato se presenta como una alternativa ventajosa al acetato, aunque sus efectos agudos no se conocen con precisión. OBJETIVO: Evaluar el efecto agudo sobre los parámetros del equilibrio ácido base y del metabolismo calcio-fósforo con la utilización de un líquido de diálisis con citrato en lugar de acetato. MATERIAL Y MÉTODOS: Estudio prospectivo y cruzado realizado en veinticuatro pacientes (15 hombres y 9 mujeres). Todos los pacientes se dializaron con monitor AK- 200-Ultra-S con líquido de diálisis SoftPac®, elaborado con 3 mmol/l de acetato y con SelectBag Citrate®, con 1 mmol/l de citrato, libre de acetato. Se extrajeron pre y post-diálisis: gasometría venosa, calcio (Ca), calcio iónico (Cai), fósforo (P) y hormona paratiroidea (PTH). RESULTADOS: Encontramos diferencias (p < 0,05) cuando utilizamos el baño con citrato (C) frente a acetato (A) en los valores postdiálisis de: pH (C: 7,43 (0,04) vs. A: 7,47 (0,05)), bicarbonato (C: 24,7 (2,7) vs. A: 27,3 (2,1) mmol/L), exceso de base (BEecf) (C: 0,4 (3,1) vs A: 3,7 (2,4) mmol/L), calcio corregido (Cac) (C: 9,8 (0,8) vs A: 10,1 (0,7) mg/dl) y Cai (C: 1,16 (0,05) vs A: 1,27 (0,06) mmol/L). No encontramos diferencias en ninguno de los parámetros medidos prediálisis. CONCLUSIÓN: La diálisis con citrato consigue un mejor control de equilibrio ácido base postdiálisis disminuyendo/evitando la alcalemia postdiálisis y un menor aumento de calcio corregido (Cac) y Cai. Este hallazgo es de especial interés en pacientes con factores predisponentes a arritmias, pacientes con insuficiencia respiratoria, retención de carbónico, calcificaciones y hepatopatía avanzada

Introduction: Correcting metabolic acidosis provoked by renal failure is achieved by supplying bicarbonate during dialysis. To prevent the precipitation of calcium and magnesium carbonate produced in the dialysis fluid (DF) when bicarbonate is added, it is necessary to add an acid(normally acetate), which involves secondary effects. Consequently, citrate is presented as an advantageous alternative to acetate, although its acute effects are not known with precision. Objective: Our objective was to assess the acute effect of using a DF with citrate instead of acetate on the parameters of acid-base balance and of phosphorus-calcium metabolism. Material and methods: We carried out a prospective, cross-over study on 24 patients (15 males and 9 females). All the patients were dialysed using an AK 200 ULTRA-S monitor with SoftPacRDF, prepared with 3 mmol/l of acetate, and with SelectBag CitrateR, with 1 mmol/l of acetate freecitrate. Before and after dialysis we extracted: venous blood gases, calcium (Ca), ionized calcium (Cai), phosphorus (P) and parathyroid hormone (PTH).Results: We found differences (P<.05) when we used a dialysate with citrate (C) compared with using acetate (A) in the post-dialysis values of pH (C: 7.43 [0.04] vs A: 7.47 [0.05]), bicarbonate(C: 24.7 [2.7] vs A: 27.3 [2.1] mmol/L), base excess of extracellular fluid (BEecf) (C: 0.4 [3.1] vs A: 3.7[2.4] mmol/L), corrected calcium (cCa) (C: 9.8 [0.8] vs A: 10.1 [0.7] mg/dl) and Cai (C: 1.16 [0.05] vsA: 1.27 [0.06] mmol/L). We found no differences in any of the parameters measured before dialysis. Conclusion: Dialysis with citrate achieves better post-dialysis acid-base balance, lowering/avoiding post-dialysis alkalemia and producing a lower increase in corrected calcium (Cac) and Cai. This finding is of special interest for patients with predisposing factors to arrhythmia and patients with respiratory failure, carbon dioxide retention, calcifications or advanced hepatopathy (AU)