Searching for a prognostic index in lupus nephritis.

BACKGROUND: Currently we do not have an ideal biomarker in lupus nephritis (LN) that should help us to identify those patients with SLE at risk of developing LN or to determine those patients at risk of renal progression. We aimed to evaluate the development of a prognostic index for LN, through the evaluation of clinical, analytical and histological factors used in a cohort of lupus. We have proposed to determine which factors, 6 months after the diagnosis of LN, could help us to define which patients will have a worse evolution of the disease and may be, more aggressive treatment and closer follow-up. METHODS: A retrospective study to identify prognostic factors was carried out. We have included patients over 18 years of age with a clinical diagnosis of systemic lupus erythematosus (SLE) and kidney involvement confirmed by biopsy, who are followed up in our centre during the last 20 years. A multi-step statistical approach will be used in order to obtain a limited set of parameters, optimally selected and weighted, that show a satisfactory ability to discriminate between patients with different levels of prognosis. RESULTS: We analysed 92 patients with LN, although only 73 have been able to be classified according to whether or not they have presented poor renal evolution. The age of onset (44 vs. 32; p = 0.024), the value of serum creatinine (1.41 vs. 1.04; p = 0.041), greater frequency of thrombocytopenia (30 vs. 7%; p = 0.038), higher score in the renal chronicity index (2.47 vs. 1.04; p = 0.015), proliferative histological type (100%) and higher frequency of interstitial fibrosis (67 vs. 32%; p = 0.017) and tubular atrophy (67 vs. 32%; p = 0.018) was observed between two groups. The multivariate analysis allowed us to select the best predictive model for poor outcome at 6 months based on different adjustment and discrimination parameters. CONCLUSION: We have developed a prognostic index of poor renal evolution in patients with LN that combines demographic, clinical, analytical and histopathological factors, easy to use in routine clinical practice and that could be an effective tool in the early detection and management.

[The antiproteinuric effect of the blockage of the renin-angiotensin-aldosterone system (RAAS) in obese patients. Which treatment option is the most effective? ]. / Efecto antiproteinúrico del bloqueo del sistema renina-angiotensina-aldosterona (SRAA) en los pacientes obesos. ¿Cuál es la opción terapéutica más eficaz?

BACKGROUND: Obesity increases the risk of proteinuria and chronic renal insufficiency and hastens the progression of renal diseases. Increased activity of renin-angiotensin-aldosterone system and elevated levels of aldosterone are common in obese patients. No studies have compared the efficacy of the currently available antiproteinuric strategies (ACE inhibitors -ACEI-, angiotensin receptor blockers -ARB-, aldosterone antagonists) in obese patients with proteinuric renal diseases. METHODS: Single centre, prospective, randomized study. Twelve obese patients (body mass index > 30 Kg/m2) with proteinuria > 0.5 g/24 h were selected from our outpatient renal clinic. Patients were consecutively treated during 6 weeks with an ACEI (lisinopril 20 mg/day), combined therapy ACEI+ARB (lisinopril 10 mg/day + candesartan 16 mg/day) and eplerenone (25 mg/day) in random order. A drug washout period of 6 weeks was established between the different treatment periods. The primary outcome point was the change in 24-h proteinuria at the end of each treatment period and the number of patients showing a proteinuria reduction greater than 25% of baseline. RESULTS: The reduction in proteinuria induced by lisinopril (11.3+/-34.8%) was not statistically significant with respect to baseline, whereas that of lisinopril plus candesartan (26.9+/-30.6%) and eplerenone (28.4+/-31.6%) showed a statistically significant difference both with respect to baseline values and to lisinopril group. The number of patients who showed a greater than 25% proteinuria reduction was significantly higher with eplerenone (67%) and lisinopril+candesartan (67%) than with lisinopril (25%). CONCLUSIONS: Monotherapy with an aldosterone antagonist and combination therapy with ACEI+ARB were more effective than ACEI monotherapy to reduce proteinuria in obese patients with proteinuric renal diseases.

Extended-release tacrolimus therapy in de novo kidney transplant recipients: single-center experience.

BACKGROUND: Available data for extended-release tacrolimus (Tac) except in clinical trials are limited. OBJECTIVE: To describe our initial experience with once-daily Tac in combination with corticosteroids and mycophenolate mofetil therapy in patients undergoing de novo renal transplantation. PATIENTS AND METHODS: In this retrospective, observational, single-center study, data were obtained for 49 adult recipients treated with extended-release Tac and 30 patients treated with standard-release Tac (control group). Mean (SD) follow-up in the 2 groups was 3.5 (2.5) months and 4.0 (2.6) months, respectively. The primary characteristics were comparable between the groups. RESULTS: The acute rejection rate in the extended-release group was 10%, and 13% in the standard-release group. Patient and graft survival rates were 98% and 96% vs 100% and 90%, respectively. Renal function in the 2 groups was comparable: serum creatinine concentration 1.3 (0.2) mg/dL vs 1.45 (0.4) mg/dL. At day 14 posttransplantation, Tac doses were 0.17 mg/kg/d vs 0.14 mg/kg/d, and blood concentrations were 9.0 ng/mL vs 14.0 ng/mL. In recipients older than 60 years, lower dosages of Tac resulted in blood concentrations similar to those in younger patients, with less variation in dosage. CONCLUSIONS: Short-term experience with extended-release Tac therapy in de novo renal recipients confirms its efficacy and safety. Adjusting blood concentrations in the immediate posttransplantation period is less difficult with extended-release Tac compared with the twice-daily formulation.

Enfermedad renal ateroembólica: un análisis de los factores clínicos y terapéuticos que influyen en su evolución / Atheroembolic renal disease: analysis of clinical and therapeutic factors that influence its progression

El embolismo de colesterol es una enfermedad causada por la suelta de cristales de colesterol desde las placas arterioscleróticas ulceradas de la aorta. Esta suelta puede ocurrir de forma espontánea o más frecuentemente tras procedimientos vasculares invasivos o tras tratamientos anticoagulantes o fibrinolíticos. Entre 1989 y 2005, en tres hospitales españoles, se diagnosticaron 45 casos de embolismo renal de colesterol. El diagnóstico fue confirmado mediante biopsia de cualquier órgano afectado o hallazgos típicos en el fondo de ojo. La mayoría de los pacientes eran varones (93,3%), ancianos (el 55,7% era mayor de 70 años), fumadores (91,1%), hipertensos (95,6%) y con varios factores de riesgo cardiovascular. Todos los pacientes presentaron un fracaso renal agudo en el momento del diagnóstico. La creatinina media al inicio fue de 4,3 ± 2,4 mg/dl. El fracaso renal agudo se acompañó frecuentemente de eosinofilia (64,4%) y lesiones cutáneas (57,7%). El 20% de los casos ocurrieron espontáneamente y el 46,7% tras manipulación endovascular (cateterismo/arteriografía); tan sólo un 8,9% ocurrió tras cambios en la anticoagulación. Tras un seguimiento de 12 ± 16,3 meses, el 55,6% (25) de los pacientes requerían diálisis crónica y un 64,4% (29) había fallecido, ocho de ellos tras haber entrado en diálisis crónica. Se observó una recuperación parcial de función renal en 9 pacientes (20%), que presentaban una creatinina media al final del seguimiento de 3 ± 1,7 mg/dl. La comorbilidad cardiovascular y la gravedad clínica del embolismo de colesterol no tuvieron impacto sobre la supervivencia renal o del individuo. La supervivencia renal (Kaplan-Meier) fue mayor en los casos de ateroembolismo espontáneo que en los iatrogénicos. 15 de los 45 pacientes recibieron esteroides. En los tratados se observó una mayor incidencia de fallecimientos (73,3% frente a 60%) y un menor porcentaje de recuperación de función renal (13,3% frente a 23%), aunque sin diferencias estadísticamente significativas. El tiempo medio de evolución a la diálisis fue significativamente más corto entre los tratados con esteroides (p = 0,017). El uso de estatinas no se asoció con una mejoría en el pronóstico renal o vital del individuo. En conclusión, la enfermedad renal ateroembólica constituye un tipo de fracaso renal agudo con unas características clínicas muy determinadas. La supervivencia renal y del paciente es mala, pero existe un porcentaje significativo de recuperaciones espontáneas de la función renal. La supervivencia renal fue significativamente mejor en los casos espontáneos y no observamos efectos beneficiosos del tratamiento esteroideo (AU)

Cholesterol embolism is a disease caused by distal showering of cholesterol crystal released from disintegration of arterial atheromatous plaques. It may occur spontaneously or more often after invasive vascular procedures or thrombolytic/anticoagulant agents. Forty five cases were diagnosed between 1989 and 2005 in three Spanish hospitals. The diagnosis was confirmed by histology or diagnostic ophthalmoscopic findings. The majority were male (93.3%), elder (55.5% were older than 70 years), smoker (91.1%), had hypertension (95.6%), with high prevalence of cardiovascular risk factors. At the time of diagnosis all patients presented acute renal failure. Mean serum creatinine at diagnosis was 4.3± 2.4mg/dl. The acute renal failure was accompanied with eosinophilia (64.4%) and cutanous lesions (57.7%). 20% of cases occur spontaneously and 46.7% after endovascular manipulation (coronary angiography/arteriography) and only 8% after changes in anticoagulant treatment. After a follow-up of 12 ± 16.3 months the 55.6% of patients need chronic dialysis, 64.4% died, 8 of them after the beginning of dialysis. Nine patients recovered renal function, with a mean creatinine of 3 ± 1.7 mg/dl at the end of follow-up. The cardiovascular comorbididy and the clinical severity of the embolism don´t have impact in the renal or patient survival. Renal survival (Kaplan-Mier) were better in spontaneous than in iatrogenic cholesterol embolism. Fifteen of 45 patients were treated with steroids. In treated patients we observed a high incidence of death (73.3% versus 60%) and fewer recovery of renal function (13.3% versus 23%), without statistical significance. The mean time to dialysis was shorter in treatment patients (p= 0.017). Statins treatment was not associated with outcome (renal or individual). In summary, atheroembolic renal disease represents an acute renal failure with special characteristics. Renal and individual outcome is poor, but some patients have spontaneous recovery of renal function. Renal survival was significantly better in spontaneous disease. We don´t observe beneficial effect of steroid treatment (AU)

Efecto antiproteinúrico del bloqueo del sistema renina-angiotensina-aldosterona (SRAA) en los pacientes obesos. ¿Cuál es la opción terapéutica más eficaz? / No disponible

Introducción: La obesidad aumenta el riesgo de proteinuria e insuficiencia renal crónica, y acelera la progresión de enferme- dades renales. En los pacientes obesos existe un aumento de la actividad del sistema renina-angiotensina-aldosterona (SRAA) y de los niveles de aldosterona. Ningún estudio ha comparado la eficacia de las diferentes estrategias antiproteinúricas actual- mente disponibles (inhibidores de la enzima convertidora de la angiotensina [IECA], antagonistas de los receptores de la an- giotensina [ARA], antagonistas de la aldosterona) en pacientes obesos con nefropatías proteinúricas. Métodos: Es un estudio prospectivo y aleatorizado, realizado en un único centro. Fue- ron seleccionados doce pacientes obesos (índice de masa cor- poral >30 kg/m 2 ), con proteinuria >0,5 g/24 h, de nuestras con- sultas de Nefrología. Los pacientes fueron tratados consecutivamente durante seis semanas y en orden aleatorio con un IECA (lisinopril 20 mg/día), una terapia combinada con IECA más ARA (lisinopril 10 mg/día más candesartán 16 mg/día) y eplerenona (25 mg/día). Se estableció un período de lavado de seis semanas entre los diferentes períodos de tratamiento. El objetivo principal del estudio fue el cambio en la proteinu- ria de 24 h al final de cada período de tratamiento y el núme- ro de pacientes que mostraban una reducción de la proteinu- ria superior al 25% con respecto al valor basal. Resultados: La reducción de la proteinuria obtenida por lisinopril (11,3 ± 34,8%) no fue estadísticamente significativa con respecto al va- lor basal, mientras que la reducción con lisinopril y candesar- tán (26,9 ± 30,6%) y eplerenona (28,4 ± 31,6%) mostró una di- ferencia estadísticamente significativa frente a sus valores basales (comparación intragrupo) y frente al grupo de lisino- pril (comparación entre grupos). El número de pacientes que mostraron una reducción mayor al 25% de la proteinuria fue significativamente mayor con eplerenona (67%) y lisinopril + candesartán (67%) que con lisinopril (25%). Conclusiones: La monoterapia con antagonistas de la aldosterona (eplerenona) y la terapia de combinación con IECA + ARA fueron más efectivos que los IECA en monoterapia para reducir la proteinuria en pacientes obesos con diferentes tipos de nefropatías crónicas proteinúricas (AU)

Background: Obesity increases the risk of proteinuria and chronic renal insufficiency and hastens the progression of renal diseases. Increased activity of renin-angiotensin-aldosterone system and elevated levels of aldosterone are common in obese patients. No studies have compared the efficacy of the currently available antiproteinuric strategies (ACE inhibitors –ACEI-, angiotensin receptor blockers –ARB-, aldosterone antagonists) in obese patients with proteinuric renal diseases. Methods: Single centre, prospective, randomized study. Twelve obese patients (body mass index >30 Kg/m 2 ) with proteinuria >0.5 g/24 h were selected from our outpatient renal clinic. Patients were consecutively treated during 6 weeks with an ACEI (lisinopril 20 mg/day), combined therapy ACEI + ARB (lisinopril 10 mg/day + candesartán 16 mg/day) and eplerenone (25 mg/day) in random order. A drug washout period of 6 weeks was established between the different treatment periods. The primary outcome point was the change in 24-h proteinuria at the end of each treatment period and the number of patients showing a proteinuria reduction greater than 25% of baseline. Results: The reduction in proteinuria induced by lisinopril (11.3 ± 34.8%) was not statistically significant with respect to baseline, whereas that of lisinopril plus candesartán (26.9 ± 30.6%) and eplerenone (28.4 ± 31.6%) showed a statistically significant difference both with respect to baseline values and to lisinopril group. The number of patients who showed a greater than 25% proteinuria reduction was significantly higher with eplerenone (67%) and lisinopril+candesartán (67%) than with lisinopril (25%). Conclusions: Monotherapy with an aldosterone antagonist and combination therapy with ACEI + ARB were more effective than ACEI monotherapy to reduce proteinuria in obese patients with proteinuric renal diseases (AU)

¿Cuándo y cómo tratar a los pacientes con glomerulonefritis membranosa? / When and how to treat patients with membranous glomerulonephritis?

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Influencia de la prediabetes en el pronóstico cardiovascular del paciente hipertenso / Influence of prediabetes in the cardiovascular prognosis of the hypertensive patient

Las diversas características de los pacientes que presentan un riesgo elevado de desarrollar diabetes mellitus han sido descritas de forma reciente, siendo las principales una concentración de glucosa sérica más elevada, índice de masa corporal aumentado, presión arterial sistólica elevada, una cifra de colesterol HDL bajo y la presencia de tratamiento antihipertensivo previo. Sin embargo, se sabe poco respecto al pronóstico a largo plazo de este grupo de pacientes, también denominados «prediabéticos». El estado prediabético ha sido definido por la presencia de intolerancia hidrocarbonada o glucemia anómala en ayunas. Las evidencias acumuladas sugieren que los individuos con hiperglucemia en rango no diabético (prediabéticos) presentan riesgo aumentado de enfermedades cardiovasculares. Esta revisión analiza la necesidad de reconocer de forma precoz a los pacientes hipertensos prediabéticos para desarrollar estrategias de protección cardiovascular y de esta forma disminuir las consecuencias de la precipitación del desarrollo de diabetes y sus efectos deletéreos cardiovasculares y renales

The different characteristics of patients who have an elevated risk of developing diabetes mellitus have recently been described, the main ones being higher serum glucose concentration, increased body mass index, elevated systolic blood pressure, low HDL-cholesterol value and presence of previous antihypertensive treatment. However, little is known about the long term prognosis of this group of patients, also called "prediabetics". The prediabetic state has been defined by the presence of hydrocarbonate intolerance of abnormal fasting glycemia. The accumulated evidence suggests that individuals with hyperglycemia in the non-diabetic range (prediabetics) have increased risk of cardiovascular diseases. This review analyzes the need to recognize prediabetic hypertensive patients early to develop cardiovascular protection strategies and, in this way, to decrease the consequences of the precipitation of the development of diabetes and its cardiovascular and renal harmful effects