Crescentic glomerulonephritis: data from the Spanish Glomerulonephritis Registry.

BACKGROUND: Crescentic glomerulonephritis (CGN) is a histological finding that implies rapid deterioration of renal function and can be related to different diseases, such as type 1 or anti-glomerular basement membrane antibody (Goodpasture) disease, type 2 or immune complex CGN and type 3 or pauci-immune disease. AIM: The present study describes CGN and its characteristics based on the data from the Spanish Glomerulonephritis Registry. METHODS: An analysis was made of all native renal biopsies obtained from patients during 1994-2013 and classified as CGN. A patient epidemiological and clinical data questionnaire was completed by the 120 centres involved. RESULTS: A total of 21,774 biopsies was performed, of which 2089 (8.1%) corresponded to CGN (211 type 1, 177 type 2 and 1701 type 3). Renal function was poorer in type 1 compared with types 2 and 3, and proteinuria was higher in type 2 compared to types 1 and 3. Patients diagnosed with CGN type 3 were older than those with types 1 and 2, but less hypertensive than the type 2 patients. No differences in the urine test findings were found between types 1 and 2. Microhaematuria was the most frequent feature in general, as well as in type 3 compared with types 1 and 2. The main indication for biopsy was acute renal injury. Age was the only difference between type 1 patients with and without alveolar haemorrhage (53 [33-67] vs 64 [46-73], P = 0.008). CONCLUSION: Although classified as the same entity, the different types of CGN have different features that must be taken into account.

Factors predicting mortality in elderly patients on dialysis.

UNLABELLED: Elderly patients are increasingly enrolled in dialysis programs and present a series of special characteristics due to their high morbidity and mortality. OBJECTIVE: To describe the characteristics of incident dialysis patients aged >75 years, their comorbidities and their admissions, with a view to determining the factors that influence their course and mortality. PATIENTS AND METHODS: The study included all patients aged >75 years who started dialysis in our center since January 2000. The mean duration of follow-up was 3.3 +/- 2.2 years. Data were collected on incident comorbidity, admissions and their causes. A total of 139 patients were included, with a mean age of 78.6 +/- 2.6 years (67.6% males, 33.8% diabetic and 7.9% on peritoneal dialysis). Three groups were established according to age: 75-79, 80-85 and >85 years. The most frequent comorbidities were chronic obstructive pulmonary disease (25.9%), ischemic heart disease (25.2%), heart failure (25.9%), neoplasms (23.7%), peripheral vascular disease (23.7%), cerebrovascular disease (18.7%) and arterial hypertension (81%). The Charlson index was calculated, not adjusted for age, and comorbidity tertiles were established. RESULTS: During follow-up, the patients presented 0.82 +/- 0.99 admissions/patient/year, with a duration of 12.1 +/- 20.6 days/patient/year. The main causes of admission were infection (33%), vascular access problems (27%) and peripheral vascular events (14%). A total of 61 patients died (44%), and 4 underwent kidney transplantation (2.9%). The mean duration of follow-up of the transplanted patients was 3.6 +/- 1.8 years. The main causes of death were infection (32%), cardiovascular problems (28.3%) and neoplastic disease (11.3%). The global survival rate was 90, 82 and 53% after 1, 2 and 5 years, respectively. No significant differences in survival or annual admission rate were found in relation to age group and dialysis technique. In contrast, the annual admission rate and days of admission were directly correlated to the Charlson index (p = 0.009 and p = 0.032, respectively). No significant differences in the Charlson index were found between the patients on hemodialysis and those subjected to peritoneal dialysis. In the univariate model, the factors associated to mortality were diabetes, chronic obstructive pulmonary disease, heart failure and the Charlson index. In the multivariate model, only the Charlson index remained as an independent predictive factor (p = 0.006). CONCLUSIONS: Unlike the general population, age does not influence mortality or admissions in elderly patients on dialysis. Incident comorbidity is the factor exerting the greatest influence upon mortality and admissions. Advanced age in itself should not be regarded as an excluding factor for starting dialysis.

[Evolution of the darbepoetin alpha resistance index in patients on dialysis who change from weekly to fortnightly treatments in clinical practice]. / Evolución del índice de resistencia a darbepoetina alfa en pacientes dializados que cambian de administración semanal a quincenal en la práctica clínica.

BACKGROUND: Darbepoetin alpha (DA) administered every-other-week (Q2W) is efficacious and safe for the treatment of anaemia in patients undergoing dialysis. There are no data available regarding the evolution of erythropoietic resistance index (ERI) after conversion from weekly (QW) to Q2W administration of DA in clinical practice. MATERIAL AND METHODS: Multicenter, observational, retrospective, 16-weeks study, which included stable patients undergoing dialysis who were converted from DA QW to DA Q2W in clinical practice. Conversion was done according to product specifications (duplicating QW dose). The ERI to DA was calculated by dividing the weekly DA dose per kilogram of weight (microg/wk.kg)*200 by the Hb level (g/dL). ERI evolution with time was evaluated by multivariate repeated measures ANOVA, adjusting for significant covariates. RESULTS: A total of 202 patients were included (137 patients undergoing haemodialysis [HD], intravenous (IV) DA, and 65 patients receiving peritoneal dialysis [PD], subcutaneous DA). Mean (SD) age was 66 (17) years; 61% of patients were men. Large intercentre variability was observed for the ERI at conversion time (coefficient of variation of 88%, p < 0.001 for differences between centres). In the univariate analysis, predictor factors for high baseline ERI were low albumin level (r = -0.29; p =0.001), HD (mean ERI of 9.3 [8.4] vs 6.8 [4.6] for PD; p = 0.005), or previous cardiovascular disease (9.9 [8.7] vs 7.4 [6.3] for patients without history; p =0.025). During the follow up, the ERI was slightly increased in HD patients (9.3 [8.4] at conversion vs 11.1 [7.3] at 16 weeks; p < 0.05), and remained stable in PD patients (6.8 [4.6] vs 6.7 [4.0], respectively; NS). In the multivariate analysis, there were no significant differences in ERI during the 16 weeks post-conversion after adjusting for albumin levels and centre (adjusted baseline mean [95% CI] of 10.0 [8.7-11.4] vs 10.5 [9.3-11.8] at 16 weeks, adjusted change of +0.5 [-0.67; 1.67]; NS). After 16 weeks, only 7 patients (3.5%) had discontinued Q2W administration. CONCLUSIONS: Extension from weekly to once every other-week darbepoetin alpha allows to simplify anaemia treatment without increasing the resistance index, regardless of dialysis type. The multivariate analysis shows that, after adjusting by center and inflammation/nutritional status, there were no changes in the response to darbepoetin alpha during the first 16 weeks after conversion in clinical practice.

[Approach to quality objectives in incidents of patients in peritoneal dialysis]. / Cumplimiento de objetivos de calidad y evolución de los pacientes incidentes en diálisis peritoneal.

INTRODUCTION: In 2007 the Scientific Quality-technical and Improvement of Quality in Peritoneal Dialysis was edited. It includes several quality indicators. As far as we know, only some groups of work had evaluated these indicators, with inconclusive results. AIM: To study the evolution and impact of guidelines in Peritoneal Dialysis. METHODS: Prospective cohort study of each incident of patients in Peritoneal Dialysis, in a regional public health care system (2003-2006). We prospectively collected baseline clinical and analytical data, technical efficacy, cardiovascular risk, events and deaths, hospital admissions and also prescription data was collected every 6 months. RESULTS: Over a period of 3 years, 490 patients (53.58 years of age; 61.6% males.) Causes of ERC: glomerular 25.5%, diabetes 16%, vascular 12.4%, and interstitial 13.3%. 26.48% were on the list for transplant. Dialysis efficacy: Of the first available results, the residual renal function was 6.37 ml/min, achieving 67.6% of all the objectives K/DOQI. 38.6% remained within the range during the entire first year. Anaemia: 79.3% received erythropoietic stimulating agents and maintained an average Hb of 12.1 g/dl. The percentage of patients in the range (Hb: 11-13 g/dl) improved after a year (58.4% vs 56.3% keeping in the range during this time of 25.6%). Evolution: it has been estimated that per patient-year the risk of: 1) mortality is 0.06 IC 95% [0.04-0.08]; 2) admissions 0.65 [0.58-0.72]; 3) peritoneal infections 0.5 [0.44-0.56]. CONCLUSION: Diabetes Mellitus patients had a higher cardiovascular risk and prevalence of events. The degrees of control during the follow-up in many topics of peritoneal dialysis improve each year; however they are far from the recommended guidelines, especially if they are evaluated throughout the whole study.

[Management of anemia in chronic kidney disease]. / Manejo de la anemia en la enfermedad renal cronica.

1. All patients with anemia secondary to CKD should be treated and evaluated for possible treatment, irrespective of underlying disease, associated comorbidity or possibility of kidney replacement therapy. 2. In patients treated with ESAs, Hb concentrations should be monitored at least monthly. 3. Hb targets: In all patients with CKD, Hb concentration should be > 11 g/dl and there is no evidence to justify total correction of anemia on a routine basis. Normalization of Hb levels in CKD is associated with an improvement in health-related quality of life, but without differences in mortality or the rate of loss of kidney function (Strength of Recommendation A). 4. Indications for iron therapy: Iron therapy is required in the large majority of patients with CKD treated with ESAs to achieve a Hb equal to or greater than 11 g/dl (Strength of Recommendation B). The recommended serum concentration of ferritin is > 100 mg/dl, which should be associated with a TSI > 20% (Strength of Recommendation C). Iron therapy in patients with CKD can be given orally or intravenously, although the IV route is more effective (Strength of Recommendation A). 5. The initial dose of ESA and its adjustments will depend on the patients clinical condition, baseline Hb levels, the Hb target and the rate of increase in Hb levels observed (Strength of Recommendation C). 6. In all cases and for all ESAs, the subcutaneous route is the recommended route of administration for patients with CKD (Strength of Recommendation C). 7. Resistance to ESAs: A hyporesponse to ESAs is considered to be present when an Hb level of 11 g/dl is not achieved with a dose of epoetin > 300 IU/kg/week or a dose of darbepoetin alpha > 1.5 microg/kg/week (Strength of Recommendation B). 8. There is insufficient evidence in patients with CKD to justify routine use of coadjuvant treatments.

[Updates in clinical hemodialysis: vascular accessess and elderly patients]. / Avances en hemodiálisis clínica: accesos vasculares y pacientes de edad avanzada.

SUMMARY In most current hemodialysis (HD) units, two of the most significant problems are vascular access and the steady increase in incident elderly patients. Both are risk factors for morbidity and mortality that require frequent hospitalizations and have a very considerable health cost. The aim of this review is to show the most interesting studies published in 2007 on these two aspects. Regarding vascular access for hemodialysis, a very worrying fact is the progressive increase in incident and prevalent patients dialyzed with a permanent catheter, even though the catheter is a known risk factor of great morbidity and mortality. The dialysis units should have as their goals to reduce the percentage of catheters and to detect early arteriovenous fistulas at risk of thrombosis. In recent years, the incidence of patients of very advanced age is experiencing a notable increase. This type of patients has a high rate of morbidity and mortality. The great challenge for nephrologists is know which patients can really benefit from dialysis treatment. Furthermore, this type of patients have different characteristics than the rest of the general dialysis population, which makes it necessary to adopt different clinical criteria.

[Peripheral vascular disease: prevalence, mortality and relationship with inflammation in hemodialysis]. / Enfermedad Vascular Periférica: Prevalencia, Mortalidad y Asociación con Inflamación en Hemodiálisis.

Peripheral vascular disease (PVD) is a common disease among patients undergoing hemodialysis leading to increase morbidity and mortality with a high risk of inflammation and sepsis. The aim of the present study was to determinate PVD prevalence in our hemodialysis population and association with inflammation. The study sample consisted of 220 patients prevalents in hemodialysis. A basal study was made in 2001 and a follow up for 47 months. Data were collected retrospectively. PVD diagnosis was made attending to limb pulses and doppler in revisions. Diagnosis was classified as rest pain, ischemic ulceration and gangrene. Among a total of 220 patients, 89 had prevalent PVD. Thirty per cent had rest pain, 6,5% had ischemic ulceration and 3% had gangrene. Ninety five per cent underwent medical treatment, 0,5% were treated by percutaneous transluminal angioplasty (PTA), 2% were treated with surgical revascularization and 2,5% were treated with amputation. Patients with PVD were older, with higher Charlson index, diabetes, they hay higher CRP and fibrinogen serum levels; and lower albumin and prealbumine serum levels. Survival PVD was decreased in Kaplan-Meier (log rank =12,4; p<0,000). Adjusted Cox regression analysis revealed that PVD (p =0,034; OR =2,10; IC [1,06 ; 4,23]) ; age (p =0,001; OR =1,06; IC [1,03 ; 1,09]) and low serum albumin levels (p =0,012; OR =0,93; IC [0,89 ; 0,98]) predicted significantly the risk of mortality. PVD is an independent mortality risk factor in hemodialysis patients. An early diagnosis and treatment are able with examination and doppler. In our sample, a few patients are treated with PTA or surgical revascularization. There is an association between PVD and inflammation.

[Calciphylaxis: fatal complication of cardiometabolic syndrome in patients with end stage kidney disease]. / Calcifilaxis: complicación grave del síndrome cardio-metabólico en pacientes con enfermedad renal crónica terminal (ERCT).

UNLABELLED: Calciphylaxis characterized by schemic skin ulceration due to subcutaneous small arterioles calcification, is a rare disease but usually fatal. Disorders of calcium metabolism and vascular calcifications are common in dialysis patients but calciphylaxis prevalence is low in patients with end stage renal disease. So we proposed other emergent factors implicated in calciphylaxis development. METHODS: We studied retrospective 8 patients who developed calciphylaxis in our service from january 2001 to december 2006. RESULTS: All patients were female with mean age at diagnosis 68.5+/-6.7 years. All patients were receiving hemodialysis therapy and 6 patients had been receiving hemodialysis less than four months. Six patients had diabetes mellitus type II and all patients were obese (BMI >25 kg/m2). All patients had metabolic syndrome (APTIII) with bad control hypertension and 6 (75%) were receiving anticoagulation therapy with warfarin. Patients didn t have severe alterations of calcium metabolism, all had product calcium-phosphorus <55. All patients developed low blood pressure at the beginning of dialysis treatment (98.3+/-22.7/60+/-18,29 mmHg). 7 patients present proximal lesions in fatty regions like abdomen and thighs. Histopathologic examination reveals calcium deposits in arteriole-sized and small vessels with vascular thrombosis. Prognosis was poor, seven patients died secondary to a sepsis originated in infected cutaneous ulcers. CONCLUSIONS: calciphylaxis is a disease with poor prognosis and high mortality, without specific treatment actually. Female gender, obesity associated with diabetes mellitus and cardiometabolic syndrome, anticoagulant therapy with warfarin and low blood pressure associated with hemodialysis therapy, are risk factors to develop calciphylaxis, in absence of severe disorders of calcium metabolism. In these patients is important to avoid hypotension episodes during dialysis, dialysis hypotension appears to be an important risk factor who promotes ischemia of subcutaneous adipose tissue.

[Resistance index to epoetin alpha and to darbepoetin-alpha in chronic hemodialysis patients: a cohort study]. / Estudio de dos cohortes de pacientes para evaluar el índice de resistencia a epoetina alfa y a darbepoetin alfa en pacientes en hemodiálisis crónica.

The effectiveness of the erythropoietic response can be evaluated using the resistance index (RI) to erythropoietic agents (EA) that measures the relationship between the dose administered and the hemoglobin levels attained. In a hemodialysis population, the RI is associated with several clinical and biochemical parameters, such as albumin levels, C-reactive protein (CRP), body mass index (BMI) and Kt/V. This index therefore reflects an important group of parameters that indicate comorbidities and measures the effectiveness of the treatment received. A substantial proportion of chronic hemodialysis patients show a relative resistance to human recombinant erythropoietin (rHuEPO) and require high doses to reach hemoglobin levels above 11 g/dl. Darbepoetin alpha is a new erythropoietic agent with a longer half-life than rHuEPO and greater biological activity in vivo. Furthermore, it remains at clinically effective plasma levels for much longer than rHuEPO. This study evaluated the effect on RI of switching from epoetin alpha to darbepoetin alpha in hemodialysis patients requiring i.v. rHuEPO at either high ( >10,000 UI/w) or low ( <4,000 UI/w) doses, compared to a control group receiving epoetin alpha. Unlike the control group, both groups of patients who switched to darbepoetin alpha showed a reduction in RI and a progressive reduction in the dose required of darbepoetin alpha with respect to the equivalent dose at treatment conversion. In the group requiring high doses, darbepoetin alpha RI (DRI) at week 24 was a significant 23.9% lower than epoetin alpha RI (ERI) at conversion (week 0) (p <0.01). In the group requiring low doses, DRI at week 24 was 13.4% lower than the ERI at conversion (p = NS). In both control groups, ERI at week 24 was higher than ERI at week 0. All groups showed stable hemoglobin levels across the study, with mean levels between 11.5 and 13.3 g/dl. CRP at week 24 was significantly related to albumin levels (p <0.001). In conclusion, switching hemodialysis patients from epoetin alpha to darbepoetin alpha was associated with a significant improvement in RI in the group of patients with high doses of EA, which we consider to be an important indicator of the effectiveness and quality of the treatment administered.

[Clinical and analytical changes in hemodialysis without acetate]. / Cambios clínicos y analíticos al sustituir el líquido de diálisis convencional por uno sin acetato.

BACKGROUND: the purpose of this study was to evaluate blood acetate levels and its correlation with clinical and analytical changes in hemodialysis patients treated with standard bicarbonate dialysate compared to treatment with acetate-free bicarbonate dialysate. METHODS: fourteen patients on hemodialysis (11 male) with mean age of 61 15 years, were treated with conventional bicarbonate dialysate for 1 month and then switched to acetate-free bicarbonate dialysate for another month. Blood samples were drawn at the third session of first and fourth week of each type of dialysis. RESULTS: Pre-dialysis blood acetate levels were similar in both groups, whereas post-dialysis blood acetate levels were higher in patients treated with conventional bicarbonate dialysate (0.48+/- 0.64 vs. 0.18+/-0.23 mmol/L, p=0.024). Moreover, both periods had similar percentage of patients with pre-dialysis blood acetate levels in the pathologic range, whereas this percentage was higher in post-dialysis samples from patients treated with conventional bicarbonate dialysate respect to acetate-free dialysate (67% vs. 21%, p=0.001). Serum levels of interleukin-6 were statistically higher in the period with conventional bicarbonate dialysate (31.7+/- 24.7 vs. 18.7+/- 10.3 pg/ml, p=0.014), even though other inflammatory markers such as LBP, TNF- and CRP failed to increase in the same period. We didn't found significant differences in the other parameters studied except for the changes in serum concentrations of sodium, chloride and bicarbonate. CONCLUSIONS: Acetate-free bicarbonate dialysate does not expose patients to a big amount of acetate and allows that the majority of patients finished hemodialysis with blood acetate levels in the physiologic ranges. Acetate-free dialysate was safe and well tolerated by our hemodialysis patients, although clinical advantages derived from its use should be evaluated in long-term prospective studies.

[Cardiovascular risk in hemodialysis in Spain: prevalence, management and target results (MAR study)]. / Riesgo cardiovascular en hemodiálisis en españa: prevalencia, pautas de actuación y objetivos (estudio MAR).

Cardiovacular disease is the main cause of morbidity and mortality in hemodialysis (HD) patients. However, there are no reliable data neither on the prevalence of cardiovacular disease nor its risk factors in Spain. The Morbidity and mortality Anemia Renal study (MAR) is a two-year multicenter, open-label, prospective cohorts study. Its main objective is to assess the general morbidity and mortality, particularly of a cardiovascular cause, and its relationship with the degree of anemia. Secondary objectives are: a/ the description of current clinical practices in anemia, dialysis, vascular access, and CV risk factor management; and b/ the description of hospitalization and mortality causes. This paper describes the prevalence of cardiovascular disease and risk factors of the HD population in Spain. A total of 1.710 patients were included (60% male, aged 64.4 years, 16.2 months on HD). The mean co-morbidity Charlson index was 6.5 +/- 2.3. Cardiovascular disease was the most prevalent comorbidity, 16.7% had a coronary disease, and 13.9% had different degrees of heart failure, while 11.6% had arrhythmia, 1.7% stroke and 5.5% peripheral artery disease. The prevalence of hypertension was 75.8%, 74.4% of patients received antihypertensive drugs, and still 40% of patients had an inadequate blood pressure control. The investigators considered as dyslipidemic 34.1% of patients, and prescribed treatment to 69.5% of them, while the remaining 30.5% (10.4% of the total) had hyperlipidemia with no drug therapy. Eleven percent was active smoker, and 26.6% former smoker. There was 47.4% of patients with a corporal mass index above 25. Secondary hyperparathyroidism with PTH above of 300 pg/ml was present in 22.2% of patients. Despite the EBPG and K-DOQI recommendations, only 68.8% of prevalent hemodialysis patients attained a hemoglobin (Hb) above 11 g/dl, 89.4% ferritin levels above 100 ng/ml, 66.5 degrees/a a transferrin saturation index (TSI) above 20%, and 61.1% met all three objectives. In summary, this first cross-sectional analysis has allowed us to know in detail the standard practice in multiple aspects of management of HD population in Spain. It has also established clear differences in the prevalence of cardiovascular disease and risk factors from the US registries. Last but not least we have identified therapeutic opportunities to improve the course and prognosis of our patients.

[Analysis of non-EU immigrant population within the hemodialys program of the region of Madrid]. / Análisis de la población extracomunitaria en programa de hemodiálisis (HD) en la comunidad de Madrid.

Many hemodialysis patients from foreign countries arrived to be dialized in Madrid. They cames from all around the world, especially South America and Morroco. This group is younger (46.2 + 14.2 years) than the control group. Most of them initiated dialysis without a previous Nephrological check-up (62 %). In the foreign group the primary renal diseases were similar to the control group, however they also had many other health unusual problems. Most of them (71 %) started hemodialysis without ever having permanent hemodialysis vascular access, and 25 % were not able to speak spanish, or other European languages. This caused many problems in administering correct treatment.

Quality of life in end-stage renal disease patients.

Health-related quality of life (QOL) refers to the measure of a patient's functioning, well-being, and general health perception in each of three domains: physical, psychological, and social. Along with survival and other types of clinical outcomes, patient QOL is an important indicator of the effectiveness of the medical care they receive. QOL of patients with end-stage renal disease is influenced by the disease itself and by the type of replacement therapy. Numerous studies have identified the effect of such factors as anemia, age, comorbidity, and depression on QOL. Most of these factors appear during the predialysis period, and the adequate management of some of them could influence patient outcomes. Among replacement therapies, transplantation appears to give the best QOL for large groups of patients. No conclusive data exist to prove differences in QOL between hemodialysis patients and peritoneal dialysis patients. In the case of elderly patients or those with a high degree of comorbidity, the best treatment option should be assessed in each individual case, taking all possible factors into account. Finally, it has been proven that physical and mental function are inversely correlated with the risk for hospitalization and mortality.

Changes in quality of life after renal transplantation.

The objective of this study was to evaluate the modifications that renal transplantation produces on the quality of life (QOL) of patients with chronic renal failure (CRF) previously undergoing hemodialysis (HD) and to analyze the possible factors implicated. A multicenter study of QOL was performed on 1,023 patients undergoing dialysis, using as QOL indicators the Karnofsky Scale (KS) and the Sickness Impact Profile (SIP). Among this group, 93 patients received a renal transplant and QOL was re-studied in them; each subject, therefore, was his own control. In the 88 patients with a functioning graft, an improvement in QOL indices was globally observed; this improvement was much more marked in men than in women, for unclear reasons. Older age and greater prior comorbidity diminished the beneficial effects of transplantation.

Blood pressure, left ventricular hypertrophy and long-term prognosis in hemodialysis patients.

Cardiovascular events are the main cause of death in patients with chronic renal failure who are treated with hemodialysis. Hypertension is frequent among dialysis patients and may be a major cause of mortality, although epidemiological studies are controversial in this regard. This disparity in results may be the consequence of an inadequate definition of hypertension in dialysis patients as well as the interaction with hypertension with other risk factors such as malnutrition or left ventricular hypertrophy (LVH), which are strong predictors of death. Although the goal of blood pressure in dialysis has not been established yet, it seems that predialysis blood pressure levels lower than 150/90 mm Hg must be achieved for patients to avoid complications. LVH is very frequent among dialysis patients and starts early in the progression of chronic renal failure. Hypertension is the main cause for its development, but other potentially reversible factors such as anemia, volume overload, secondary hyperparathyroidism, dose of dialysis or malnutrition may also be implicated. Hence, an adequate management of patients on hemodialysis must include the strict control of blood pressure, preferably with angiotensin converting enzyme (ACE) inhibitors, together with those early measures in order to avoid the development of the other causes of LVH or to treat them when they already exist.

[Cardiovascular risk factors in chronic renal failure]. / Factores de riesgo cardiovascular en la enfermedad renal crónica.

Cardiovascular complications are the main cause of death in patients with chronic renal disease. These complications are due to two important morphological changes. Firstly, left ventricular hypertrophy together with the changes in the cardiac remodelling and myocardiac fibrosis constitute the lesion with the highest incidence in renal chronic disease. Secondly, disease in the large arteries (macrovascular disease) involve two types lesions: Artherosclerosis, which is characterised by the formation of plaques in the intima arterial membrane and artherosclerosis due to lesions in the media arterial membrane, which causes a loss in elasticity of the arterial tree.

[Cardiovascular risk in patients with chronic renal failure. Patients in renal replacement therapy]. / Riesgo cardiovascular en pacientes con insuficiencia renal crónica. Pacientes en tratamiento sustitutivo renal.

Dialysis patients constitute a high-risk subset of patients for developing cardiovascular disease, which accounts for nearly 50% of deaths. After stratification for age, race and gender, cardiovascular mortality is 10-20 times higher in dialysis patients than in the general population. Cardiovascular disease in this population cannot be fully explained by the high prevalence of classical cardiovascular risk factors (age, hypertension, diabetes, hyperlipidemia, smoking, etc.). Thus, the involvement of "new" cardiovascular risk factors (hyperhomocysteinemia, hyperfibrinogenemia, high lipoprotein (a) levels, oxidative stress, inflammation, etc.), and uremia-related factors (anemia, impaired calcium-phosphorus metabolism, hyperparathyroidism, accumulation of endogenous inhibitors of nitric oxide synthesis, etc.) has been also invoked to play a role in the increased cardiovascular risk in these patients. Endothelial dysfunction is the initial event in the development of atherosclerosis. Uremic patients exhibit an endothelial dysfunction, even before starting dialysis, which persists o is even aggravated under dialysis treatment. Uremic patients must be considered at high risk of developing cardiovascular disease. Thus cardiovascular risk factors in these patients should be managed early, aggressive and multifactorially in order to reduce their high cardiovascular morbidity and mortality.

[Differences in health-related quality of life between male and female hemodialysis patients]. / Diferencias en la calidad de vida relacionada con la salud entre hombres y mujeres en tratamiento en hemodíalisis.

BACKGROUND: Previous studies in renal patients have reported that women perceive a lower health-related quality of life (HRQOL) than men: however, these studies have been carried out without taking into account the gender-related differences shown in general population samples. The aims of the present study are: a) to define the HRQOL dimensions in which there are differences between men and women on chronic hemodialysis (HD), correcting then the differences on the generic dimensions by means of standardization by age and gender of the obtained scores, using Spanish normative data, and b) to identify the variables that cause these possible gender-related differences on HRQOL. METHODS: A cross-sectional multi-center study was carried out with 152 patients (69 men and 83 women) receiving HD treatment in 43 Spanish centers, using the KDQOL-SF to evaluate their HRQOL. The generic KDQOL-SF scores were standardized by age and gender using Spanish normative data. Sociodemographic, clinical and psychosocial variables were also collected on each patient. A MANOVA was carried out to study the variables associated with the gender-related differences on HRQOL. The sociodemographic, clinical and psychosocial variables showing significant differences between men and women in the previous univariate analysis were entered as covariates. RESULTS: The KDQOL-SF scores showed statistically significant differences between men and women in four scales: physical functioning, emotional role limitation, social function and emotional well-being. In contrast, standardized scores showed no differences between men and women in the profile or degree of HRQOL impairment. Although statistically significant gender-related differences were shown in educational level, employment, haemoglobin, Kt/V, trait anxiety and depressive symptoms, only the last two variables showed an independent effect on the differences in HRQOL. CONCLUSION: Impaired HRQOL in women on HD reflects the gender-related differences that are also shown in the general population, and they are related to the higher prevalence of trait anxiety and depressive symptoms in women.

[IgA mesangial glomerulonephritis (author's transl)]. / La glomerulonefritis mesangial IgA.

Glomerulonephritis with mesangial deposition of IgA was diagnosed in 31 patients. In Spain this disease is the second more frequent primary glomerulonephritis, representing 27% of them. One out of every four patients with IgA mesangial glomerulonephritis ends the clinical course in renal failure. Such bad evolution might be predicted by the existence of arterial hypertension, severe proteinuria, degree of glomerular sclerosis, presence of HLA Bw35, and increased polymeric IgA in serum. The present pathogenetic concepts are reviewed.

[Nephronophthisis: study of 10 cases. Incidence, natural history and associated pathology (author's transl)]. / Nefronoptisis: análisis de 10 casos. Incidencia, historia natural y patología asociada.

Nephronophthisis is a chronic interstitial nephropathy which in childhood may lead to terminal renal failure. Between January 1975 and July 1980, 41 children with terminal renal failure were seen in our service, of which 10 (21.9%) presented with nephronophthisis. Age of the patients ranged from 3.5-18 years, boys were in the majority (8/2). Three cases were isolated and 7 were familial (3 families). Onset was during the first year of life in 8 patients, and polydipsia-polyuria were the first symptoms. Retarded growth and anemia proportionate to the degree of renal failure were present in all patients. When diagnosed, 5 patients (50%) presented terminal renal failure, and the other 5 had renal failure of different degrees. Moderate proteinuria was found in 4 patients, without changes in urine sediment. Sodium depletion in urine was high in 5 cases and maximal urine osmolarity was less than 500 muOsm/l after hydropenia in all cases. Four had associated mental deficiency with cerebellar ataxia associated in two and congenital hepatic fibrosis (confirmed histologically) in one. The diagnosis was confirmed by biopsy in 8 and in two of these on frozen section during nephrectomy prior to kidney transplantation. At present, five of the patients are in maintenance hemodialysis, two died at home due to cardiovascular complications in terminal renal insufficiency and the remaining ones presented different degrees of renal insufficiency. Time elapsed between onset of the symptoms and inclusion in hemodialysis or death ranges form 6 months to 13 years (mean 6.7 years).