Mycophenolate as maintenance therapy for lupus nephritis with impaired renal function.

BACKGROUND: Mycophenolate (MF) is effective as a maintenance therapy after induction therapy in patients with lupus nephritis (LN). However, little is known about its role in patients with impaired renal function. The purpose of this study was to evaluate the efficacy and safety of MF as a maintenance therapy for LN and its association with renal function. METHODS: Data were obtained for 56 Spanish patients who were receiving MF as a maintenance therapy for LN. Patients were classified into two groups according to renal function at the initiation of MF treatment: group 1 [estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m(2)] and group 2 (eGFR <60 ml/min/1.73 m(2)). The primary endpoints of the study were the rates of renal relapse and responses, and their relationship with baseline renal function. Secondary outcomes were the appearance of side effects during treatment. RESULTS: At initiation of MF treatment, the only differences between the groups were for age, hemoglobin levels, anti-DNA antibody titer, proteinuria, and renal function. In group 1 (n = 38), the eGFR was 98 ± 34 ml/min/1.73 m(2) and in group 2 (n = 18) the eGFR was 43 ± 14 ml/min/1.73 m(2). Only 3 cases had an eGFR <30 ml/min/1.73 m(2). No significant differences were observed in the rate of relapse at 6 months (group 1: 20%; group 2: 23%) or at 12 months (group 1: 25%; group 2: 17%). Response rates were also similar in both groups. Side effects were unremarkable. CONCLUSIONS: MF is effective and safe as a maintenance therapy for LN both in patients with normal renal function and in those with renal impairment.

[Embolization of non-functioning renal allograft: efficacy and control of systemic inflammation]. / Embolización del injerto renal no funcionante: eficacia y control del estado inflamatorio crónico.

BACKGROUND: The graft intolerance syndrome (fever, pain, haematuria) may lead to a chronic inflammatory disease, with cardiovascular repercussion. Nephrectomy is considered the classical treatment of these cases but nowadays renal vascular embolization has been suggested as a possible alternative treatment. The present study concerns seven cases trated with renal vascular embolization in our hospital summarizing data of graft intolerance syndrome and the chronic inflammatory disease. MATERIAL AND METHODS: Between january 2000 and december 2003 seven renal vascular embolization were performed in nonfunctioning renal allograft. The procedure was made with calibrated particles of 300-500micron. Data about complications related to the technique the same as analitic inflammatory parameters before and after treatment (CRP, ferritin, serum albumin, hemoglobin, erythropoietin) were registered. RESULTS: The patients were two men and five women, with median age of 39,7 +/- 8,8 years. The period beween the dialysis and the embolization was of 10,0 +/-8,2 months. Comparing the perion of admission in the hospital due to nephrectomy which was of 17,86+/-4,41 days, the period because of embolization was shorter, being 8,14 +/- 4,53 days. All analitic parameters studied, clearly improved after embolization with decrease of ferritin and CRP, increase of albumin and better hemoglobin level with lower erythropoietin dose. In five of the seven patients there was no renal captation with CT or gammagraphy. Four patients presented a postembolization syndrome, but no other important complication was registered. Neither reembolization nor renal nephrectomy was neccesary in any of the seven cases. CONCLUSION: Percutaneous renal embolization is a simple, easy, safety and effective technique that must be considered as an alternative treatment to nephrectomy, resolving the chronic inflammatory disease secondary to the graft intolerance syndrome.

[Influence of early or late referral to nephrologist over morbidity and mortality in hemodialysis]. / Referencia precoz y tardía al nefrólogo, su influencia en la morbi-mortalidad en hemodiálisis.

OBJECTIVE: We studied the influence of early vs late referral to nephrologist of patients with chronic renal failure over clinical situation at the onset of hemodialysis and outcome. SUBJECTS AND METHODS: From january 1994 to december 1998, 139 patients started hemodialysis for end-stage renal disease at the Hospital General de Albacete, all of them included in the study and clinical follow-up concluded in december 2001. Patients with rapidly progressive glomerulonephritis were excluded. Early (ER) and late referral (LR) were defined by the time of first nephrology encounter greater than or less than 6 months respectively, before iniciation of hemodialysis. RESULTS: 106 patients (76.25%) were referred early; mean follow-up time 6.3 +/- 4.5 years. 33 patients (23.74%) had late referral, follow-up time was less then six months, 18 patients were followed during less than 4 weeks. There were no differences in demographic data and comorbid conditions between LR and ER patients (age, cardiac and vascular disease, diabetes, neoplasia...). Mean plasma concentration of creatinine and urea was significantly greater, whereas hematocrit and albumin were less in the LRA than the ER group. Emergency dialysis through central vein catheterisation was more frequent in the LR group. Number of admissions and duration of hospital stay were higher in the LR group. No significant differences in nutrition, dialysis doses or anemia were found between the two groups after 6 and 12 months of hemodialysis. Long term outcome was similar in both groups: no significant differences were found in percentage of patients transplanted or deceased after 3 years of treatment. Survival analysis failed to show a difference between ER and LR groups (mean survival time was 73.6 +/- 4.3 months and 73.0 +/- 6 months respectively). CONCLUSION: Late referral to the nephrologist is associated with increased early morbidity vs early referral, although long term outcome is not worse if predialysis comorbid conditions are comparable and dialysis care achieve equal results in dialysis doses, nutrition and anemia in both groups in the first months of treatment. Improvement of outcome of patients referred early to the nephrologist will depend on the adoption of preventive measures over comorbidity factors that should be applied in early stages of renal disease.

Long-term experience with the Thomas shunt, the forgotten permanent vascular access for haemodialysis.

BACKGROUND: Vascular access complications are the main cause of hospitalization in dialysis patients. The difficulty in creating and maintaining vascular access after several years on haemodialysis (HD) remains the primary problem in these patients. The femoro-femoral Thomas shunt is a permanent vascular access that was used in the 1970s and is all but forgotten at present. We analysed our experience with the Thomas shunt since 1979 in patients with no other possibility of regular vascular access. METHODS: We retrospectively studied 27 Thomas shunts implanted in 10 patients, aged 27-75 years at the time of first shunt implantation. Prior to implantation of the Thomas shunt, these patients had experienced 80 failed vascular accesses (plus four patients on CAPD), with an average of 8.6 accesses per patient. All Thomas shunts were implanted in femoral vessels. Clinical data were extracted from hospital and dialysis unit records and were analysed for efficacy, complications, and duration of patency. RESULTS: Total follow-up was 1176 months, with an average shunt duration of 43.7 months (range 3-151 months). One-, 2-, 3- and 6-year survival rates were 85, 57, 49 and 25% respectively. Five patients spent more than 10 years on HD using the Thomas shunt, and one patient had the same unit for 12.5 years. A high blood flow (450 ml/min) was obtained, without recirculation, due to the characteristics of this shunt. Efficacy, measured as percentage urea reduction (PRU), was high (on average 77.8+/-1.5%). The infection incidence was one episode every 37.5 patient-months, Staphylococcus species being the most commonly isolated. There were no shunt removals because of infection. The most important cause of shunt withdrawal was thrombosis, with an incidence of one episode every 7 patient-months. Percutaneous angioplasty was successful in the majority of stenosis episodes. CONCLUSIONS: This study indicates that the Thomas shunt provides a good permanent vascular access for HD patients who have no other possibility of a regular vascular access. This shunt offers high dialysis efficacy without recirculation and an access duration comparable to AV fistulae. For these reasons the Thomas shunt should continue to be used as a vascular access in HD.