Evaluation of dialysis centres: values and criteria of the stakeholders.

BACKGROUND: Evaluation of renal replacement therapy with haemodialysis is essential for its improvement. Remarkably, outcomes vary across centres. In addition, the methods used have important epistemological limitations, such as ignoring significant features (e.g., quality of life) or no relevance given to the patient's perspective in the indicator's selection. The present study aimed to determine the opinions and preferences of stakeholders (patients, clinicians, and managers) and establish their relative importance, considering the complexity of their interactions, to facilitate a comprehensive evaluation of haemodialysis centres. METHODS: Successive working groups (WGs) were established using a multicriteria methodology. WG1 created a draft of criteria and sub-criteria, WG2 agreed, using a qualitative structured analysis with pre-established criteria, and WG3 was composed of three face-to-face subgroups (WG3-A, WG3-B, and WG3-C) that weighted them using two methodologies: weighted sum (WS) and analytic hierarchy process (AHP). Subsequently, they determined a preference for the WS or AHP results. Finally, via the Internet, WG4 weighted the criteria and sub-criteria by the method preferred by WG3, and WG5 analysed the results. RESULTS: WG1 and WG2 identified and agreed on the following evaluation criteria: evidence-based variables (EBVs), annual morbidity, annual mortality, patient-reported outcome measures (PROMs), and patient-reported experience measures (PREMs). The EBVs consisted of five sub-criteria: type of vascular access, dialysis dose, haemoglobin concentration, ratio of catheter bacteraemia, and bone mineral disease. The patients rated the PROMs with greater weight than the other stakeholders in both face-to-face WG3 (WS and AHP) and WG4 via the Internet. The type of vascular access was the most valued sub-criterion. A performance matrix of each criterion and sub-criterion is presented as a reference for assessing the results based on the preferences of the stakeholders. CONCLUSIONS: The use of a multicriteria methodology allows the relative importance of the indicators to be determined, reflecting the values of the different stakeholders. In a performance matrix, the inclusion of values and intangible aspects in the evaluation could help in making clinical and organizational decisions.

Dependencia para las actividades instrumentales de la vida diaria en pacientes en hemodiálisis: influencia sobre la calidad de vida relacionada con la salud / Disability in instrumental activities of daily living in hemodialysis patients: Influence on quality of life related to health

INTRODUCCIÓN: Las actividades instrumentales de la vida diaria (AIVD) requieren un mayor nivel de autonomía personal e interacción con el entorno que las actividades básicas de la vida diaria (ABVD). Pocos estudios analizan el déficit funcional en AIVD. La detección temprana del déficit es importante, pues una acción temprana puede retrasar la evolución del proceso de dependencia. OBJETIVO: El objetivo de este estudio fue conocer la prevalencia de déficit funcional en AIVD de pacientes en hemodiálisis (HD), su relación con el déficit funcional en la ABVD y su influencia en la calidad de vida relacionada con la salud (CVRS). MÉTODOS: Estudio transversal en 66 pacientes en HD. Se utilizaron diferentes escalas: Lawton y Brody (dependencia AIVD), Delta (dependencia ABVD), y COOP-WONCA (CVRS). Se recogieron datos clínicos (edad, sexo, etiología de la ERC, meses en HD, estado civil, situación laboral). RESULTADOS: El 80,3% de los pacientes estudiados tenía algún grado de dependencia para el AIVD (57,5% en grado moderado/severo) y 40,8% para el ABVD (9% en grado moderado/severo). Ambos tipos de dependencia mostraron correlación (R: -0.583; p = 0,000). La edad y la situación laboral influyen en la dependencia de las AIVD y las ABVD. Los pacientes con mayor dependencia de la AIVD tuvieron una peor CVRS (p < 0,000) con mayores diferencias en las dimensiones: "actividades diarias", "actividades sociales" y "apoyo social". CONCLUSIONES: Los pacientes de HD presentan más dependencia a las AIVD que a las ABVD, y con mayor severidad y ambos tipos de dependencia influyen sobre la CVRS. Detectar precozmente la discapacidad en las AIVD puede servir para iniciar programas de intervención y prevenir, revertir o retrasar la progresión

INTRODUCTION: Instrumental Activities of Daily Life (IADL) requires a higher level of personal autonomy and interaction with the environment than the basic activities of daily life (BADL). Few studies analyze the deficit on IADL. Early detection is important because an early action can delay the evolution of the dependency process. AIM: to know the prevalence of functional deficit in IADL of hemodialysis patients, its relationship with the functional deficit in the BADL and its influence on the health related quality of life (HRQoL). METHODS: Cross-sectional study in 66 patients on HD. Different scales were used: Lawton and Brody (AIVD dependency), Delta (BADL dependency), and COOP-WONCA (HRQOL). Clinical data were collected (age, sex, CKD etiology, months in HD, marital status, employment situation). RESULTS: 80.3% of the patients had some degree of dependence for the IADL (57.5% in moderate/severe degree) and 40.8% for the BADL (9% in moderate/severe degree). There was a correlation between dependence to the BADL and AIVD. Age and employment status influence the dependence on IADL and BADL. Patients with greater dependence on IADL had worse HRQoL (P < .000). The dimensions in which they showed greater differences were "Daily activities", "Social activities" and "Social support". CONCLUSIONS: HD patients are more dependent on IADL than on ADL and with a higher degree of severity and the level of dependence in both types of activities has important influence on HRQoL. Early detection of the occurrence of disability in the realization of IADL can be used to initiate intervention programs that help to prevent, reverse or delay the progression

Disability in instrumental activities of daily living in hemodialysis patients: Influence on quality of life related to health. / Dependencia para las actividades instrumentales de la vida diaria en pacientes en hemodiálisis: influencia sobre la calidad de vida relacionada con la salud.

INTRODUCTION: Instrumental Activities of Daily Life (IADL) requires a higher level of personal autonomy and interaction with the environment than the basic activities of daily life (BADL). Few studies analyze the deficit on IADL. Early detection is important because an early action can delay the evolution of the dependency process. AIM: to know the prevalence of functional deficit in IADL of hemodialysis patients, its relationship with the functional deficit in the BADL and its influence on the health related quality of life (HRQoL). METHODS: Cross-sectional study in 66 patients on HD. Different scales were used: Lawton and Brody (AIVD dependency), Delta (BADL dependency), and COOP-WONCA (HRQOL). Clinical data were collected (age, sex, CKD etiology, months in HD, marital status, employment situation). RESULTS: 80.3% of the patients had some degree of dependence for the IADL (57.5% in moderate/severe degree) and 40.8% for the BADL (9% in moderate/severe degree). There was a correlation between dependence to the BADL and AIVD. Age and employment status influence the dependence on IADL and BADL. Patients with greater dependence on IADL had worse HRQoL (P<.000). The dimensions in which they showed greater differences were "Daily activities", "Social activities" and "Social support". CONCLUSIONS: HD patients are more dependent on IADL than on ADL and with a higher degree of severity and the level of dependence in both types of activities has important influence on HRQoL. Early detection of the occurrence of disability in the realization of IADL can be used to initiate intervention programs that help to prevent, reverse or delay the progression.

Estrategias para aumentar la seguridad del paciente en hemodiálisis: Aplicación del sistema de análisis modal de fallos y efectos (sistema AMFE) / Strategies to increase patient safety in Hemodialysis: Application of the modal analysis system of errors and effects (FEMA system)

Antecedentes: La población en hemodiálisis (HD) es de alto riesgo. En estos pacientes un fallo puede tener consecuencias catastróficas, por lo que son necesarios sistemas que garanticen su seguridad en un entorno con alta tecnología y gran interacción del factor humano. Objetivos: Mostrar una sistemática de trabajo, reproducible en cualquier unidad de HD, que consiste en registrar las complicaciones y fallos ocurridos durante la sesión, definir cuáles de estas complicaciones podrían ser consideradas eventos adversos (EA) y, por tanto, prevenibles y realizar un análisis sistemático tanto de ellos como de los fallos reales o potenciales subyacentes, evaluando su gravedad, frecuencia y detección, y estableciendo prioridades de actuación (sistema de análisis modal de fallos y efectos [AMFE]). Métodos: Examen retrospectivo de las gráficas de diálisis de todas las sesiones practicadas durante un mes (octubre de 2015) en 97 pacientes, y análisis de las complicaciones registradas. La consideración de estas complicaciones como EA se basó en el consenso entre 13 profesionales y 2 pacientes. Se valoró la severidad, frecuencia y detección de cada fallo real o potencial mediante el sistema AMFE. Resultados: Se practicaron 1.303 sesiones de HD en 97 pacientes en las que se registraron un total de 383 complicaciones (1 cada 3,4 tratamientos). De ellas, el 87,9% fueron consideradas EA y el 23,7% complicaciones relacionadas con la enfermedad de base. Se detectó un EA cada 3,8 tratamientos. Los EA más frecuentes fueron la hipertensión y la hipotensión (42,7 y 27,5% del total de EA registrados, respectivamente). Los EA relacionados con el acceso vascular fueron uno de cada 68,5 tratamientos. Se registraron un total de 21 fallos en la asistencia (1 cada 62 tratamientos), los cuales estaban relacionados con fallos en la aplicación de la técnica y en la administración de la medicación. El mayor número de prioridad de riesgo lo obtuvieron los fallos relacionados con errores en el peso, disfunción o rotura del catéter y salida de agujas. Conclusiones: Las complicaciones en HD son frecuentes y la consideración de algunas de ellas como EA podría mejorar la seguridad en la asistencia, al poner en marcha medidas preventivas. La implementación del sistema AMFE permite estratificar y priorizar los posibles fallos de las unidades de diálisis, y actuar con mayor o menor premura, desarrollando las acciones de mejora necesarias (AU)

Background: Haemodialysis (HD) patients are a high-risk population group. For these patients, an error could have catastrophic consequences. Therefore, systems that ensure the safety of these patients in an environment with high technology and great interaction of the human factor is a requirement. Objectives: To show a systematic working approach, reproducible in any HD unit, which consists of recording the complications and errors that occurred during the HD session; defining which of those complications could be considered adverse event (AE), and therefore preventable; and carrying out a systematic analysis of them, as well as of underlying real or potential errors, evaluating their severity, frequency and detection; as well as establishing priorities for action (Failure Mode and Effects Analysis system [FMEA systems]). Methods: Retrospective analysis of the graphs of all HD sessions performed during one month (October 2015) on 97 patients, analysing all recorded complications. The consideration of these complications as AEs was based on a consensus among 13 health professionals and 2 patients. The severity, frequency and detection of each AE was evaluated by the FMEA system. Results: We analysed 1303 HD treatments in 97 patients. A total of 383 complications (1 every 3.4 HD treatments) were recorded. Approximately 87.9% of them was deemed AEs and 23.7% complications related with patients'underlying pathology. There was one AE every 3.8 HD treatments. Hypertension and hypotension were the most frequent AEs (42.7 and 27.5% of all AEs recorded, respectively). Vascular-access related AEs were one every 68.5 HD treatments. A total of 21 errors (1 every 62 HD treatments), mainly related to the HD technique and to the administration of prescribed medication, were registered. The highest risk priority number, according to the FMEA, corresponded to errors related to patient body weight; dysfunction/rupture of the catheter; and needle extravasation. Conclusions: HD complications are frequent. Consideration of some of them as AEs could improve safety by facilitating the implementation of preventive measures. The application of the FMEA system allows stratifying real and potential errors in dialysis units and acting with the appropriate degree of urgency, developing and implementing the necessary preventive and improvement measures (AU)

Strategies to increase patient safety in Hemodialysis: Application of the modal analysis system of errors and effects (FEMA system). / Estrategias para aumentar la seguridad del paciente en hemodiálisis: Aplicación del sistema de análisis modal de fallos y efectos (sistema AMFE).

BACKGROUND: Haemodialysis (HD) patients are a high-risk population group. For these patients, an error could have catastrophic consequences. Therefore, systems that ensure the safety of these patients in an environment with high technology and great interaction of the human factor is a requirement. OBJECTIVES: To show a systematic working approach, reproducible in any HD unit, which consists of recording the complications and errors that occurred during the HD session; defining which of those complications could be considered adverse event (AE), and therefore preventable; and carrying out a systematic analysis of them, as well as of underlying real or potential errors, evaluating their severity, frequency and detection; as well as establishing priorities for action (Failure Mode and Effects Analysis system [FMEA systems]). METHODS: Retrospective analysis of the graphs of all HD sessions performed during one month (October 2015) on 97 patients, analysing all recorded complications. The consideration of these complications as AEs was based on a consensus among 13 health professionals and 2 patients. The severity, frequency and detection of each AE was evaluated by the FMEA system. RESULTS: We analysed 1303 HD treatments in 97 patients. A total of 383 complications (1 every 3.4 HD treatments) were recorded. Approximately 87.9% of them was deemed AEs and 23.7% complications related with patients' underlying pathology. There was one AE every 3.8 HD treatments. Hypertension and hypotension were the most frequent AEs (42.7 and 27.5% of all AEs recorded, respectively). Vascular-access related AEs were one every 68.5 HD treatments. A total of 21 errors (1 every 62 HD treatments), mainly related to the HD technique and to the administration of prescribed medication, were registered. The highest risk priority number, according to the FMEA, corresponded to errors related to patient body weight; dysfunction/rupture of the catheter; and needle extravasation. CONCLUSIONS: HD complications are frequent. Consideration of some of them as AEs could improve safety by facilitating the implementation of preventive measures. The application of the FMEA system allows stratifying real and potential errors in dialysis units and acting with the appropriate degree of urgency, developing and implementing the necessary preventive and improvement measures.

Assessing value-based health care delivery for haemodialysis.

RATIONALE, AIMS AND OBJECTIVES: Disparities in haemodialysis outcomes among centres have been well-documented. Besides, attempts to assess haemodialysis results have been based on non-comprehensive methodologies. This study aimed to develop a comprehensive methodology for assessing haemodialysis centres, based on the value of health care. The value of health care is defined as the patient benefit from a specific medical intervention per monetary unit invested (Value = Patient Benefit/Cost). This study assessed the value of health care and ranked different haemodialysis centres. METHOD: A nephrology quality management group identified the criteria for the assessment. An expert group composed of stakeholders (patients, clinicians and managers) agreed on the weighting of each variable, considering values and preferences. Multi-criteria methodology was used to analyse the data. Four criteria and their weights were identified: evidence-based clinical performance measures = 43 points; yearly mortality = 27 points; patient satisfaction = 13 points; and health-related quality of life = 17 points (100-point scale). Evidence-based clinical performance measures included five sub-criteria, with respective weights, including: dialysis adequacy; haemoglobin concentration; mineral and bone disorders; type of vascular access; and hospitalization rate. The patient benefit was determined from co-morbidity-adjusted results and corresponding weights. The cost of each centre was calculated as the average amount expended per patient per year. RESULTS: The study was conducted in five centres (1-5). After adjusting for co-morbidity, value of health care was calculated, and the centres were ranked. A multi-way sensitivity analysis that considered different weights (10-60% changes) and costs (changes of 10% in direct and 30% in allocated costs) showed that the methodology was robust. The rankings: 4-5-3-2-1 and 4-3-5-2-1 were observed in 62.21% and 21.55%, respectively, of simulations, when weights were varied by 60%. CONCLUSIONS: Value assessments may integrate divergent stakeholder perceptions, create a context for improvement and aid in policy-making decisions.

Gestión clínica en nefrología: resultados y costes / Clinical management in nephrology: outcomes and costs

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Outcomes weighting for comprehensive haemodialysis centre assessment.

BACKGROUND: At present, there is no adequate system available for evaluating dialysis centres. OBJECTIVES: To construct an overall haemodialysis results weighting system, acceptable to the different stakeholders involved which allows the comparison of centres using a compound marker. METHOD: The Quality Management Work Group of the Spanish Society of Nephrology (WG) established a set of preselected indicators. A Focus Group, independent of the WG, was established. It was made up of nine individuals: three patients, three clinicians and three clinical managers, who assessed these indicators using an approved methodology and established the selected indicators. Finally, the indicators were weighted through three weighting stages, each separated by two debate periods, which involved the distribution of 100 points between each variable, according to the personal assessment and the debate sustained. RESULTS: The clinical results included: haemodialysis doses, anaemia, plasma calcium and phosphorus, type of vascular access, and hospitalisation days. The weighting given to each variable following the third weighting process, expressed as an average of all the factors, was as follows: clinical results 38.9; annual mortality 25.0; satisfaction with the centre 12.2; health-related quality of life 15.6; and cost 8.3 (total 100). CONCLUSIONS: The weighting structure covers relevant and overall results and includes the opinion of all stakeholders involved; all of which will increase its acceptability and widespread use and contribute to the analysis of the value produced by the centres and the improvement of the results.

Ancianos con enfermedad renal crónica: ¿qué ocurre a los cinco años de seguimiento? / Elderly patients with chronic kidney disease: outcomes after 5 years of follow-up

Introducción: En los últimos años, la enfermedad renal crónica (ERC) se ha llegado a considerar una epidemia, por lo que se ha prestado un gran interés a su diagnóstico precoz, con la finalidad de frenar su progresión a nefropatía terminal (NT) y preparar con tiempo a los pacientes para programas de diálisis y trasplante. Muchos ancianos son etiquetados de enfermos renales crónicos basándose únicamente en un filtrado glomerular estimado < 60 ml/min. Objetivo: realizar un seguimiento clínico de la función renal (FR) y de los pronósticos asociados a la ERC (morbilidad, mortalidad, desarrollo de NT) en ancianos. Pacientes y métodos: 80 pacientes clínicamente estables con mediana de edad de 83 años (rango 69-97); 69% mujeres, 35% diabéticos, 83% hipertensos; fueron reclutados aleatoriamente en las consultas externas de Geriatría y Nefrología entre enero y abril de 2006, y seguidos durante 5 años. En el reclutamiento establecimos dos grupos según la concentración de creatinina plasmática (Crp) basal (mg/dl): grupo 1: 38 pacientes con Crp ≤ 1,1 (rango 0,7-1,1) y grupo 2: 42 pacientes, con Crp > 1,1 (rango 1,2-3). Medimos en sangre Crp, urea, y estimamos filtrado glomerular con MDRD abreviado, basalmente y a los 5 años. Registramos la comorbilidad basal (..) (AU)

Introduction: In recent years, chronic kidney disease (CKD) has come to be considered an epidemic problem, and there is considerable interest in early diagnosis in order to slow its progression to end-stage renal disease (ESRD) and prepare patients for dialysis and transplantation programmes. Many elderly patients are labelled as having CKD based solely on having a glomerular filtration rate (GFR) of <60 ml/min. Objective: Monitor renal function (RF) and outcomes associated with CKD (morbidity, mortality and progress to ESRD) in an elderly cohort. Patients and method: A total of 80 clinically stable patients, with a median age of 83 years (range 69-97; 69% female, 35% diabetic, 83% hypertensive) were recruited at random in our Geriatric Medicine and Nephrology Departments between January and April 2006, and monitored for 5 years. During the recruitment stage we established two groups based on baseline serum creatinine (SCr) concentration: Group 1, 38 patients with SCr <1.1mg/dl (range 0.7-1.1) and Group 2, 42 patients with SCr >1.1mg/dl (range 1.2-3). We determined baseline blood levels of creatinine and urea, calculated eGFR using an abbreviated Modification of Diet in Renal Disease (..) (AU)

Elderly patients with chronic kidney disease: outcomes after 5 years of follow-up.

INTRODUCTION: In recent years, chronic kidney disease (CKD) has come to be considered an epidemic problem, and there is considerable interest in early diagnosis in order to slow its progression to end-stage renal disease (ESRD) and prepare patients for dialysis and transplantation programmes. Many elderly patients are labelled as having CKD based solely on having a glomerular filtration rate (GFR) of <60 ml/min. OBJECTIVE: Monitor renal function (RF) and outcomes associated with CKD (morbidity, mortality and progress to ESRD) in an elderly cohort. PATIENTS AND METHOD: A total of 80 clinically stable patients, with a median age of 83 years (range 69-97; 69% female, 35% diabetic, 83% hypertensive) were recruited at random in our Geriatric Medicine and Nephrology Departments between January and April 2006, and monitored for 5 years. During the recruitment stage we established two groups based on baseline serum creatinine (SCr) concentration: Group 1, 38 patients with SCr <1.1mg/dl (range 0.7-1.1) and Group 2, 42 patients with SCr >1.1mg/dl (range 1.2-3). We determined baseline blood levels of creatinine and urea, calculated eGFR using an abbreviated Modification of Diet in Renal Disease (MDRD) formula, and repeated these measurements after 5 years. We recorded baseline comorbidity according to the Charlson comorbidity index (CCI); hospital admissions; new cardiovascular events; treatments; progression to ESRD requiring dialysis; and mortality. RESULTS: In the 39 patients surviving after 5 years there were no significant differences between Groups 1 and 2 in total number of hospital admissions, episodes of heart failure and new ischaemic heart disease. Overall, the most commonly used drugs were diuretics (76.9%), while beta-blockers were used the least (10.3%). There were 41 deaths (51.3%): of these patients, 15 died due to overall decline, 8 due to infections, 4 due to stroke, 4 due to neoplasia, 3 due to cardiovascular problems, 2 due to complications from fractures and 5 due to unknown causes. Mortality was higher in Group 2 (66.7% vs 34.2%, P=.004) and patient age was also higher in that group (84.73 ± 5.69 vs 80.12 ± 6.5, P=.001). No significant differences in mortality were attributable to sex, diabetes, hypertension or CCI. Only 2 patients in Group 2 progressed to ESRD, they received conservative treatment due to comorbidity (no patients in the study have started dialysis). The evolution of RF (baseline/5 years) in all patients surviving at 5 years was as follows: SCr (mg/dl): 1.15 ± 0.41/1.21 ± 0.49 (not significant [NS]), urea (mg/dl) 52.21 ± 13.0/61.21 ± 27.0 (P=.047), MDRD (ml/min/1.73m2) 57.47 ± 15/54.86 ± 17 (NS). There were no differences in progression between the 2 groups. In the logistic regression analysis for overall mortality (independent variables: age, sex, CCI, cardiovascular history, SCr and group), only age (relative risk [RR]: 1.12; 1.03-1.23, P=.009) and group (RR: 3.06; 1.10-8.40, P=.031) were independently associated with mortality. CONCLUSION: Screening for CKD using GFR only may lack clinical relevance in this population since RF slowly deteriorates in elderly patients without proteinuria. Mortality due to all causes was higher in elderly patients with a poorer baseline RF, and mortality rates were higher than rates of CKD progression to ESRD.

Renal supportive care and palliative care: revision and proposal in kidney replacement therapy.

Patients with chronic kidney disease may receive sustained renal supportive care and renal palliative care (RPC) starting with the diagnosis of the disease, throughout the various stages of renal replacement therapy (RRT), the cessation of the RRT, and in the decision of whether to provide conservative treatment or non-initiation of RRT. This article reviews the literature on the development of renal palliative care and proposed RPC models. We describe the progression of disease in organ failure, which is very different from other areas of palliative care (PC). We describe important components of resident nephrology training in PC. We discuss the management of pain and symptom control, as well as communication skills and other psychological and ethical aspects in the renal patient. We conclude that in chronic renal patients, a palliative care approach can provide a positive impact on the quality of life of patients and their families, as well as optimizing the complex treatment of the renal patient.

Serum uric acid as a marker of all-cause mortality in an elderly patient cohort.

INTRODUCTION: There is growing evidence of the role of serum uric acid (SUA) as a risk factor for cardiovascular and renal disease. We analysed the association between baseline SUA and overall mortality in a cohort of elderly patients followed prospectively for 5 years. PATIENTS AND METHODS: Eighty clinically stable patients, median age 83 years (range 69-97), 31.3% men, 35% diabetics, 83% hypertensives were randomly recruited at Geriatrics and Nephrology visits between January and April 2006 and followed for 5 years. We measured baseline SUA and serum creatinine and estimated glomerular filtration rate (GFR) with MDRD abbreviated. In Nephrology Department patients, we measured proteinuria in 24-hour urine and in Geriatrics department patients we measured proteinuria (mg/dl)/creatinine (mg/dl) in urine (first morning urine). Predictive variables were: baseline SUA and plasma creatinine; estimated GFR (abbreviated MDRD formula); and we recorded age, gender, baseline comorbidity (Charlson index), individualised cardiovascular treatment and mortality. STATISTICAL ANALYSIS: SPSS15.0. RESULTS: baseline SUA was normally distributed and its median was 5.85 mg/dl. We found no significant differences in levels of SUA by gender, history of diabetes mellitus, hypertension, diuretic drug use, heart disease, peripheral arterial disease or stroke. Patients with a history of heart failure had significantly higher SUA (7.00 ± 1.74 vs 5.90 ± 1.71, P=.031). Some 41 deaths occurred during follow-up (15 men and 26 women): 15 due to general deterioration, 8 due to infections, 4 due to stroke, 4 due to tumours, 3 due to cardiovascular disease, 2 due to complications of fractures and 5 due to unknown causes. Patients with SUA higher than the median had significantly lower GFR and higher mortality at 5 years. In the Cox analysis for overall mortality [independent variables: age, gender, Charlson Index, history of heart failure, SUA, creatinine, proteinuria and GFR (MDRD)] only SUA levels (HR: 1.35; 1.17-1.56 P=.000) were independently associated with mortality. CONCLUSIONS: In our study, levels of SUA are an independent risk factor for mortality in elderly patients.

Cuidados de soporte renal y cuidados paliativos renales: revisión y propuesta en terapia renal sustitutiva / Renal supportive care and palliative care: revision and proposal in kidney replacement therapy

El paciente con enfermedad renal crónica es susceptible de recibir tratamiento de soporte y cuidados paliativos renales (CPR) desde el diagnóstico de la enfermedad, durante las distintas etapas de tratamiento sustitutivo renal (TSR), en el cese de dicho TRS y también si se decide tratamiento conservador o no inicio de TRS. Este artículo revisa la literatura referente al desarrollo de cuidados CPR y los modelos propuestos. Exponemos la trayectoria de la enfermedad en el fallo de órgano, que marca diferencias respecto a otros campos de los cuidados paliativos (CP). Se describen componentes de formación importantes para el residente de nefrología en CP. Abordamos el manejo del dolor y el control de síntomas, así como habilidades de comunicación y otros aspectos psicológicos y éticos en el paciente renal. Concluimos que en la atención al paciente renal crónico, un enfoque desde la medicina paliativa puede suponer un provechoso impacto en la calidad de vida del paciente y su familia, además de optimizar el complejo tratamiento nefrológico del paciente (AU)

Patients with chronic kidney disease may receive sustained renal supportive care and renal palliative care (RPC) starting with the diagnosis of the disease, throughout the various stages of renal replacement therapy (RRT), the cessation of the RRT, and in the decision of whether to provide conservative treatment or non-initiation of RRT. This article reviews the literature on the development of RPC and the models proposed. We describe how organ failure differs compare to other areas of palliative care (PC). We describe important training components in RPC for the resident nephrologist and we approach the management of pain and symptom control, communication skills and other psychological and ethical aspects in the renal patient. We conclude a palliative care approach may have a profitable impact on the quality of life for chronic renal patients and their families as well as optimizing the complex renal patient's treatment (AU)

Utilidad del ácido úrico como marcador de mortalidad global en una cohorte de ancianos / Serum uric acid as a marker of all-cause mortality in an elderly patient cohort

Introducción: Existe evidencia creciente del papel del ácido úrico (AU) como factor de riesgo cardiovascular y renal. En este trabajo analizamos la asociación entre niveles basales de AU y mortalidad global en una cohorte de ancianos seguidos prospectivamente durante 5 años. Pacientes y métodos: 80 pacientes clínicamente estables; mediana de edad, 83 años (rango 69-97); 31,3% varones; 35% diabéticos; 83% hipertensos; reclutados aleatoriamente en consultas de Geriatría y Nefrología entre enero y abril de 2006 y seguidos durante 5 años. Medimos basalmente AU y creatinina en plasma y estimamos filtrado glomerular (FG) con fórmula MDRD abreviada. Asimismo, en los pacientes de Nefrología se midió la proteinuria mediante la recogida de orina de 24 horas, y en los vistos en Geriatría se estimó a partir del cociente proteínas (mg/dl)/creatinina (mg/dl) en primera orina de la mañana. Registramos edad, género, comorbilidad basal (Índice de Charlson), patologías cardiovasculares individualizadas, tratamientos y mortalidad. Estadística: SPSS15.0. Resultados: El AU basal presentaba una distribución normal y su mediana era de 5,85 mg/dl. No encontramos diferencias significativas en los niveles de AU según género, antecedentes de diabetes méllitus, hipertensión arterial, uso de diuréticos, cardiopatía isquémica, arteriopatía periférica o ictus. Los pacientes con antecedentes de insuficiencia cardíaca tenían AU significativamente mayor (7,00 ± 1,74 vs. 5,90 ± 1,71; p = 0,031). 41 pacientes (15 varones y 26 mujeres) fallecieron: 15 por deterioro en el estado general; 8 por infecciones; 4 por ictus; 4 por tumores; 3 por causas cardiovasculares; 2 por complicaciones de fracturas y 5 por causas desconocidas. Los pacientes con AU superior a la mediana tenían un FG significativamente menor y una mortalidad a los 5 años más elevada. En el análisis de Cox para mortalidad global (variables independientes: edad, género, Charlson, antecedentes de insuficiencia cardíaca, AU, creatinina, proteinuria y filtrado glomerular-MDRD) sólo los niveles de AU (riesgo relativo: 1,35; 1,17-1,56, p = 0,000) se asociaban de forma independiente a la mortalidad. Conclusiones: en nuestro estudio, los niveles de AU se muestran como factor de riesgo independiente de mortalidad en ancianos (AU)

Introduction: There is growing evidence of the role of serum uric acid (SUA) as a risk factor for cardiovascular and renal disease. We analysed the association between baseline SUA and overall mortality in a cohort of elderly patients followed prospectively for 5 years. Patients and Methods: Eighty clinically stable patients, median age 83 years (range 69-97), 31.3% men, 35% diabetics, 83% hypertensives were randomly recruited at Geriatrics and Nephrology visits between January and April 2006 and followed for 5 years. We measured baseline SUA and serum creatinine and estimated glomerular filtration rate (GFR) with MDRD abbreviated. In Nephrology Department patients, we measured proteinuria in 24-hour urine and in Geriatrics department patients we measured proteinuria (mg/dl)/creatinine (mg/dl) in urine (first morning urine). Predictive variables were: baseline SUA and plasma creatinine; estimated GFR (abbreviated MDRD formula); and we recorded age, gender, baseline comorbidity (Charlson index), individualised cardiovascular treatment and mortality. Statistical analysis: SPSS15.0. Results: baseline SUA was normally distributed and its median was 5.85mg/dl. We found no significant differences in levels of SUA by gender, history of diabetes mellitus, hypertension, diuretic drug use, heart disease, peripheral arterial disease or stroke. Patients with a history of heart failure had significantly higher SUA (7.00±1.74 vs 5.90±1.71, P=.031). Some 41 deaths occurred during follow-up (15 men and 26 women): 15 due to general deterioration, 8 due to infections, 4 due to stroke, 4 due to tumours, 3 due to cardiovascular disease, 2 due to complications of fractures and 5 due to unknown causes. Patients with SUA higher than the median had significantly lower GFR and higher mortality at 5 years. In the Cox analysis for overall mortality [independent variables: age, gender, Charlson Index, history of heart failure, SUA, creatinine, proteinuria and GFR (MDRD)] only SUA levels (HR: 1.35; 1.17-1.56 P=.000) were independently associated with mortality. Conclusions: In our study, levels of SUA are an independent risk factor for mortality in elderly patients (AU)

La biopsia renal en pacientes de 65 o más años: ¿existen diferencias en la indicación y en la histopatología respecto al resto de pacientes? / Renal biopsy in patient aged 65 years or older: Are there differences in the indication and histopathology compared to other patients?

Introducción. La biopsia renal (BR) representa el patrón de oro para diagnosticar las enfermedades renales. En este trabajo analizamos si la indicación de BR y la histopatología en pacientes de 65 años o más es diferente respecto al resto de pacientes. Material y métodos. Estudio retrospectivo de 93 biopsias de riñón nativo realizadas en el Hospital General de Segovia en el periodo 2004–2008. La BR se realiza de forma percutánea con control ecográfico a tiempo real, usando agujas automáticas de 16G. Resultados. La edad media de los pacientes biopsiados fue de 56,89±19 (rango 14–89), 57% varones. Se realizaron 39 BR en personas de ≥65 años. Globalmente el síndrome nefrótico es la indicación más frecuente de BR y la glomerulonefritis IgA la histología más común. En personas de ≥65 años, el fracaso renal agudo (FRA) es la indicación más habitual de BR siendo la GN extracapilar/vasculitis el diagnóstico más detectado. Al considerar la edad, no hay diferencias significativas en el número de glomérulos obtenidos por BR ni en el número de BR hechas a un mismo paciente. Conclusiones. En personas de 65 años o más, el FRA es la principal indicación de BR y la glomerulonefritis extracapilar/vasculitis el diagnóstico más frecuente(AU)

Background. Renal biopsy (RB) represents the gold standard for diagnosis of kidney diseases. In this paper we analyse whether the indication of RB and histopathology in patients 65 years or older is different from the other patients. Material and methods. Retrospective study of 93 native renal biopsies performed in the General Hospital of Segovia in the period 2004–2008. The RB was performed percutaneously under ultrasound guidance in real time, using a 16G automatic needle. Results. Mean age of biopsied patients was 56.89±19 (range 14–89) , and 57% were males. A total of 39RB were performed on people aged 65 years or older. Overall, nephrotic syndrome (NS) is the most common indication of RB, and IgA glomerulonephritis the most common histology. In people ≥65 years, acute renal failure (ARF) is the most common indication for RB, and rapidly progressing (crescentic) glomerulonephritis/vasculitis the most detected the diagnosis. When taking age into account, no significant differences in the number of glomeruli obtained by RB or in the number of RB performed on the same patient. Conclusions. In people 65 years or older, ARF is the main indication of RB and crescentic glomerulonephritis/vasculitis the most frequent diagnosis(AU)

[Renal biopsy in patients aged 65 years or older: are there differences in the indication and histopathology compared to other patients?]. / La biopsia renal en pacientes de 65 o más años: ¿existen diferencias en la indicación y en la histopatología respecto al resto de pacientes?

BACKGROUND: Renal biopsy (RB) represents the gold standard for diagnosis of kidney diseases. In this paper we analyse whether the indication of RB and histopathology in patients 65 years or older is different from the other patients. MATERIAL AND METHODS: Retrospective study of 93 native renal biopsies performed in the General Hospital of Segovia in the period 2004-2008. The RB was performed percutaneously under ultrasound guidance in real time, using a 16G automatic needle. RESULTS: Mean age of biopsied patients was 56.89 ± 19 (range 14-89) , and 57% were males. A total of 39RB were performed on people aged 65 years or older. Overall, nephrotic syndrome (NS) is the most common indication of RB, and IgA glomerulonephritis the most common histology. In people ≥ 65 years, acute renal failure (ARF) is the most common indication for RB, and rapidly progressing (crescentic) glomerulonephritis/vasculitis the most detected the diagnosis. When taking age into account, no significant differences in the number of glomeruli obtained by RB or in the number of RB performed on the same patient. CONCLUSIONS: In people 65 years or older, ARF is the main indication of RB and crescentic glomerulonephritis/vasculitis the most frequent diagnosis.

Acute responses of gastrointestinal hormones to both oral and parenteral intradialytic nutrition.

INTRODUCTION: Intradialytic nutrition (IDN) has been used to improve the nutritional status of malnourished hemodialysis (HD) patients. OBJECTIVE: To evaluate the different effects of parenteral IDN (IDPN) and oral IDN (IDON) on nutrition-related gastrointestinal hormones. PATIENTS AND METHODS: Seven clinically stable HD patients with malnutrition were included. All patients were treated for 1 month with either IDPN or IDON, with a 4-week period of no nutritional support between each type of therapy. On the first day of each nutritional support (IDON or IDPN) we analyzed the acute responses of insulin, ghrelin, and glucagon-like peptide 1 (GLP-1). We compared the areas under the secretory curves (AUC) and the maximum peaks of serum glucose, insulin, ghrelin, and GLP-1. A group of 6 clinically stable HD patients without any type of IDN served as the control group. RESULTS: The acute responses of glucose and insulin to IDN were significantly higher with IDPN than with IDON. The AUC of glucose (602 ± 81 vs. 495 ± 81 mg/dl/h, p < 0.01) and insulin (232 ± 103 vs. 73.8 ± 69 µU/ml/h, p < 0.01) as well as the maximum peaks of glucose (228 ± 41 vs. 177 ± 47 mg/dl, p < 0.05) and insulin (104 ± 46 vs. 29 ± 24 µU/ml, p < 0.01) were significantly higher after IDPN than after IDON. Ghrelin decreased after both IDPN and IDON; however, the decrease was significantly higher with IDPN compared to IDON. The ghrelin nadir was significantly lower in IDPN than in IDON (0.77 ± 0.5 vs. 1.5 ± 0.3, p < 0.05) although the AUC of ghrelin was not significantly different. GLP-1 was significantly increased at 1 h after starting both IDPN and IDON with no significant differences between the groups. CONCLUSION: IDPN induces a higher increase in serum glucose and insulin levels and a greater reduction in serum ghrelin concentrations compared with an equivalent orally administered nutritional supplement.