Serum chloride as a marker of cardiovascular and all-cause mortality in chronic hemodialysis patients: 5-Year follow-up study.

BACKGROUND: Hypochloremia has been associated with increased mortality in patients with hypertension, heart failure, sepsis, and chronic kidney disease (CKD). The pathophysiological mechanisms of this finding are not clear. There are no studies describing an association between serum chloride levels (Cl-) and mortality in incident chronic hemodialysis (HD) patients. METHOD: Retrospective cohort study of the incident population in our chronic outpatient hemodialysis program between January 1, 2016, and January 1, 2021 (N=374). Survival time was collected in all patients and analyzed using the Kaplan-Meyer method. A multivariate Cox regression model was performed to predict the probability of survival, applying a stepwise procedure. RESULTS: During the median follow-up period of 20 months, 83 patients died. The 5-year overall survival rate for our patients was 45%. Both natremia and chloremia had no significant differences when compared by sex, vascular access, or etiology. There was an inverse correlation between Cl- and interdialytic weight gain (r=-0.15) (p=0.0038). Patients belonging to the quartile with lower Cl- levels had less probability of survival than patients in the quartile with higher Cl- levels (27% and 68%, respectively, p=0.019). On the other hand, in the multivariate Cox regression model, variables significantly associated with higher mortality were being older, having higher baseline comorbidity by modified Charlson index, not taking diuretics and having lower albumin and chloride levels. Particularly, higher Cl- levels was independently associated with both lower all-cause mortality (adjusted hazard ratio [HR]=0.84; 95% confidence interval [CI], 0.77-0.92; p=0.0001) and cardiovascular mortality (HR 0.9; 95% CI, 0.83-0.97; p<0.0057). CONCLUSIONS: Lower Cl- levels were associated with higher all-cause and cardiovascular mortality in incident patients on chronic hemodialysis in our health area.

Consensus document on autosomal dominant polycystic kindey disease from the Spanish Working Group on Inherited Kindey Diseases. Review 2020.

Autosomal dominant polycystic kidney disease (ADPKD) is the most frequent cause of genetic renal disease and accounts for 6-10% of patients on kidney replacement therapy (KRT). Very few prospective, randomized trials or clinical studies address the diagnosis and management of this relatively frequent disorder. No clinical guidelines are available to date. This is a revised consensus statement from the previous 2014 version, presenting the recommendations of the Spanish Working Group on Inherited Kidney Diseases, which were agreed to following a literature search and discussions. Levels of evidence mostly are C and D according to the Centre for Evidence-Based Medicine (University of Oxford). The recommendations relate to, among other topics, the use of imaging and genetic diagnosis, management of hypertension, pain, cyst infections and bleeding, extra-renal involvement including polycystic liver disease and cranial aneurysms, management of chronic kidney disease (CKD) and KRT and management of children with ADPKD. Recommendations on specific ADPKD therapies are provided as well as the recommendation to assess rapid progression.

Silent challenge: Early kidney transplant failure and cardiomyopathy.

Differentiation of hypertrophic cardiomyopathy phenotypes is challenging but crucial for appropriate management. We report a case of myocardial oxalate deposition as an infrequent cause of infiltrative cardiomyopathy.

Inflammation and hemodialysis adequacy: are C-reactive protein levels influenced by the dose of dialysis?

INTRODUCTION: Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the "dialysis dose" with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the "dialysis dose" (Kt / V) using ionic dialysance. METHODS: Multicenter cross-sectional study. 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into two groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence. RESULTS: Median CRP was 4.10 mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48 ± 0.308. Kt/V was lower in the patients included in the high inflammation group (p = 0.01). In the multivariate logistic regression, the "high" levels of CRP were directly correlated with the Log INL (p < 0.001) and inversely proportional with serum albumin values (p = 0.014), Kt/V (p = 0.037) and serum iron (p < 0.001). CONCLUSION: The poorer adequacy in terms of dialysis doses, lower Kt / V values, may contribute to a higher degree of inflammation in chronic hemodialysis patients.

Documento de consenso de poliquistosis renal autosómica dominante del grupo de trabajo de enfermedades hereditarias de la Sociedad Española de Nefrología. Revisión 2020 / Consensus document on autosomal dominant polycystic kindey disease from the Spanish Working Group on Inherited Kindey Diseases. Review 2020

La poliquistosis renal autosómica dominante (PQRAD) es la causa más frecuente de nefropatía genética y representa entre el 6 y el 10% de los pacientes en terapia de reemplazo renal (TRR).Muy pocos ensayos prospectivos, aleatorizados o estudios clínicos abordan el diagnóstico y el tratamiento de este trastorno relativamente frecuente. No hay guías clínicas disponibles hasta la fecha. Este es un documento de consenso revisada de la versión anterior del 2014, que presenta las recomendaciones del Grupo de Trabajo Español de Enfermedades Renales Hereditarias, acordadas tras la búsqueda bibliográfica y discusiones. Los niveles de evidencia en su mayoría son C y D según el Centro de Medicina Basada en Evidencia (Universidad de Oxford). Las recomendaciones se relacionan, entre otros temas, con el uso de diagnóstico por imágenes y genético, el manejo de la hipertensión, el dolor, las infecciones y el sangrado quístico, la afectación extrarrenal, incluida la enfermedad poliquística hepática y los aneurismas craneales, el manejo de la enfermedad renal crónica y el TRR, así como el seguimiento de niños con PQRAD. Se proporcionan recomendaciones sobre terapias específicas para la PQRAD, así como la recomendación para evaluar la rápida progresión. (AU)

Autosomal dominant polycystic kidney disease (ADPKD) is the most frequent cause of genetic renal disease and accounts for 6–10% of patients on kidney replacement therapy (KRT).Very few prospective, randomized trials or clinical studies address the diagnosis and management of this relatively frequent disorder. No clinical guidelines are available to date. This is a revised consensus statement from the previous 2014 version, presenting the recommendations of the Spanish Working Group on Inherited Kidney Diseases, which were agreed to following a literature search and discussions. Levels of evidence mostly are C and D according to the Centre for Evidence-Based Medicine (University of Oxford). The recommendations relate to, among other topics, the use of imaging and genetic diagnosis, management of hypertension, pain, cyst infections and bleeding, extra-renal involvement including polycystic liver disease and cranial aneurysms, management of chronic kidney disease and KRT and management of children with ADPKD. Recommendations on specific ADPKD therapies are provided as well as the recommendation to assess rapid progression. (AU)

Estimated GFR in autosomal dominant polycystic kidney disease: errors of an unpredictable method.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) causes about 10% of cases of end stage renal disease. Disease progression rate is heterogeneous. Tolvaptan is presently the only specific therapeutic option to slow kidney function decline in adults at risk of rapidly progressing ADPKD with chronic kidney disease (CKD) stages 1-4. Thus, a reliable evaluation of kidney function in patients with ADPKD is needed. METHODS: We evaluated the agreement between measured (mGFR) and estimated glomerular filtration rate (eGFR) by 61 formulas based on creatinine and/or cystatin-C (eGFR) in 226 ADPKD patients with diverse GFR values, from predialysis to glomerular hyperfiltration. Also, we evaluated whether incorrect categorization of CKD using eGFR may interfere with the indication and/or reimbursement of Tolvaptan treatment. RESULTS: No formula showed acceptable agreement with mGFR. Total Deviation Index averaged about 50% for eGFR based on creatinine and/or cystatin-C, indicating that 90% of the estimations of GFR showed bounds of error of 50% when compared with mGFR. In 1 out of 4 cases with mGFR < 30 ml/min, eGFR provided estimations above this threshold. Also, in half of the cases with mGFR between 30 and 40 ml/min, formulas estimated values < 30 ml/min. CONCLUSIONS: The evaluation of renal function with formulas in ADPKD patients is unreliable. Extreme deviation from real renal function is quite frequent. The consequences of this error deserve attention, especially in rapid progressors who may benefit from starting treatment with tolvaptan and in whom specific GFR thresholds are needed for the indication or reimbursement. Whenever possible, mGFR is recommended.

Inflamación y adecuación de la hemodiálisis: ¿están los niveles de proteína C reactiva influidos por la dosis de diálisis recibida? / Inflammation and hemodialysis adequacy: Are C-reactive protein levels influenced by dialysis dose?

Introducción : La inflamación crónica y la subyacente comorbilidad cardiovascular aún son problemas vigentes en los pacientes en hemodiálisis crónica. Existen pocos estudios que comparen la «dosis de diálisis» (Kt/V) con el grado de inflamación del paciente. Nuestro objetivo principal fue determinar si existe una relación entre los niveles séricos de proteína C reactiva (PCR) y el Kt/V utilizando la dialisancia iónica.Métodos : Estudio transversal multicéntrico. Se incluyeron 536 pacientes prevalentes en hemodiálisis crónica. Se recogieron los niveles de PCR, el índice neutrófilo-linfocito y el índice plaqueta-linfocito. Se obtuvo el Kt por dialisancia iónica y el volumen de distribución de la urea mediante la fórmula de Watson. Se dividió la muestra en 2 grupos tomando como punto de corte la mediana de PCR y se comparó la adecuación de diálisis en cada uno. Finalmente, se realizó un modelo de regresión logística para determinar las variables de mayor influencia.Resultados : La mediana de PCR fue 4,10mg/L (q25-q75: 1,67-10). El Kt/V medio fue de 1,48±0,308. El Kt/V fue menor en los pacientes incluidos en el grupo de inflamación alta (p=0,01). En la regresión logística multivariante, los niveles «altos» de PCR tuvieron una correlación directa con el Log índice neutrófilo-linfocito (p<0,001) e inversamente proporcional con los valores de albúmina sérica (p=0,014), Kt/V (p=0,037) y hierro sérico (p<0,001).Conclusión : La peor adecuación en términos de dosis de diálisis (valores de Kt/V más bajos) puede contribuir a un mayor grado de inflamación en los pacientes en hemodiálisis crónica. (AU)

Introduction : Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the “dialysis dose” (Kt/V) with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the Kt/V using ionic dialysance.Methods : Multicenter cross-sectional study. A total of 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into 2 groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence.Results : Median CRP was 4.10mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48±0.308. Kt/V was lower in the patients included in the high inflammation group (P=.01). In the multivariate logistic regression, the “high” levels of CRP were directly correlated with the Log neutrophil-lymphocyte ratio (P<.001) and inversely proportional with serum albumin values (P=.014), Kt/V (P=.037) and serum iron (P<.001).Conclusion : The poorer adequacy in terms of dialysis doses (lower Kt/V values) may contribute to a higher degree of inflammation in chronic hemodialysis patients. (AU)

Inflammation and hemodialysis adequacy: Are C-reactive protein levels influenced by dialysis dose? / Inflamación y adecuación de la hemodiálisis: ¿están los niveles de proteína C reactiva influidos por la dosis de diálisis recibida?

INTRODUCTION: Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the "dialysis dose" (Kt/V) with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the Kt/V using ionic dialysance. METHODS: Multicenter cross-sectional study. A total of 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into 2 groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence. RESULTS: Median CRP was 4.10mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48±0.308. Kt/V was lower in the patients included in the high inflammation group (P=.01). In the multivariate logistic regression, the "high" levels of CRP were directly correlated with the Log neutrophil-lymphocyte ratio (P<.001) and inversely proportional with serum albumin values (P=.014), Kt/V (P=.037) and serum iron (P<.001). CONCLUSION: The poorer adequacy in terms of dialysis doses (lower Kt/V values) may contribute to a higher degree of inflammation in chronic hemodialysis patients.

No todas las tormentas de citoquinas son por COVID-19: Síndrome hemofagocítico con afectación renal, secundario a linfoma extranasal y virus de Epstein-Barr. A propósito de un caso durante la pandemia / Not all cytokin storms are due to COVID-19: Hemophagotic syndrome with renal involvement secondary to extranasal lymphoma and Epstein-Barr virus. A case report during the pandemic

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[Teaching nephrology as part of a degree in medicine]. / La docencia de la nefrología en el grado de medicina.

The teaching of nephrology as part of a degree in medicine is potentially one of the most decisive factors when choosing a speciality. Until now, however, we have not had an overview of the teaching of nephrology in Spain. We have integrated information available in public databases with a survey and personal interviews with those responsible for teaching in Spanish medical faculties. In 2019, there were 44 universities offering a medicine degree in Spain, in 16 Autonomous Communities (34 of which were public and 10 private). For learning purposes, students have a number of hospital beds ranging from 0.2 to 4.7, and there are Autonomous Communities that have a higher proportion of students per inhabitant or per physician, such as Madrid or the Community of Navarra. In 16 universities there are tenured teaching staff (professors and lecturers), in 8 contracted medical lecturers, and in 2 assistant lecturers. In 21 medical faculties, theoretical and practical nephrology is taught by associate lecturers. The subject is taught between the third and fifth years of the degree, the median being the fourth year. It is usually integrated with another subject and only in the University of Navarra is it an independent subject, with 3 credits. The total number of hours devoted to theoretical teaching (both theoretical classes and seminars) is highly variable and ranges from 11 to 35, with a median of 17.5. Variability is observed in both the number of theoretical subjects (range 11 to 31) and seminars (range 0 to 9). Among the faculties that teach seminars, the ratio of theoretical topics to seminars ranges from 1.6 to 18. Most faculties evaluate clinical practices with various modalities and percentage of assessment. Knowledge is mostly assessed by a multiple choice exam. In conclusion, there is a high level of variability in the curriculum for the teaching of nephrology as part of a degree in medicine in Spain. Teaching staff who are tenured or who have a stable affiliation with universities make up just 23% of the total and, in many faculties, teaching depends exclusively on associate professors.