Oxidative Stress in Non-Dialysis-Dependent Chronic Kidney Disease Patients

Background: Cardiovascular complications are the leading cause of morbidity and mortality at any stage of chronic kidney disease (CKD). Moreover, the high rate of cardiovascular mortality observed in these patients is associated with an accelerated atherosclerosis process that likely starts at the early stages of CKD. Thus, traditional and non-traditional or uremic-related factors represent a link between CKD and cardiovascular risk. Among non-conventional risk factors, particular focus has been placed on anaemia, mineral and bone disorders, inflammation, malnutrition and oxidative stress and, in this regard, connections have been reported between oxidative stress and cardiovascular disease in dialysis patients. Methods: We evaluated the oxidation process in different molecular lines (proteins, lipids and genetic material) in 155 non-dialysis patients at different stages of CKD and 45 healthy controls. To assess oxidative stress status, we analyzed oxidized glutathione (GSSG), reduced glutathione (GSH) and the oxidized/reduced glutathione ratio (GSSG/GSH) and other oxidation indicators, including malondialdehyde (MDA) and 8-oxo-2’-deoxyguanosine (8-oxo-dG). Results: An active grade of oxidative stress was found from the early stages of CKD onwards, which affected all of the molecular lines studied. We observed a heightened oxidative state (indicated by a higher level of oxidized molecules together with decreased levels of antioxidant molecules) as kidney function declined. Furthermore, oxidative stress-related alterations were significantly greater in CKD patients than in the control group. Conclusions: CKD patients exhibit significantly higher oxidative stress than healthy individuals, and these alterations intensify as eGFR declines, showing significant differences between CKD stages. Thus, future research is warranted to provide clearer results in this area.

From kraepelin to the present. Dementia praecox – a case study

Introduction

In the late XIX^th century Kraepelin described a new nosologic division for the psycothic disorders – Paranoia and Dementia Praecox. He emphasized that dementia praecox is a central nervous system disease, involving permanent lesions on cerebral cortex. Besides biological deterioration, it appears as the result of psychic degenerative process. From the mid-20th century onward, antipsychotic drugs had been robustly generalized, and in parallel to the current classifications, residual symptoms in schizophrenia tend to be rare but still prevail in our patients.

Objectives

The aim of our work is to report a clinical case of residual schizophrenia in parallel with the classic classification of Dementia Praecox and also do an overview of this disorder and its historical perspective.

Methods

We conducted clinical interviews with the patient and family members, reviewed clinical records and conducted a query in the MEDLINE database using the terms " Dementia Praecox ", “Psychosis”, “Paranoia”, “Kraepelin”, “History”.

Results

We present the clinical case of a 74-year-old man with onset of psychotic symptoms on his twenties and diagnosed with Schizophrenia. In the past years, after acute psychotic episodes it was increasingly difficult to return to prior levels of functioning. Currently, he was brought to psychiatric emergency ward presenting bizarre behavior, stereotyped movements and speech disturbances, which reveal disorganized thinking and inability to express his emotions.

Conclusions

Although these syndromes are nowadays relatively rare, it is important to keep them in mind, in order to understand the natural progression of psychotic diseases, improve their rehabilitative treatment and prognosis.

Disclosure

No significant relationships.

Vascular depression – regarding a case report

Introduction

Age-related vascular changes have long been documented as an etiopathogenic factor of some geriatric depressive syndromes. More recently, it has emerged the concept of “Vascular Depression” recognizing that cardiovascular disease may predispose, precipitate or perpetuate late life depression. This condition was defined by an episode of major depressive disorder within the preceding 12 months in elderly with cardiovascular/cerebrovascular disease, or major cardiovascular risk factors. Vascular Depression isn`t described in DSM-V, and that difficults clinical recognition and affects clinically informed systematic studies.

Objectives

Regarding a clinical case, we enphasize the clinical impact of Vascular Depression`s hypothesis.

Methods

We present a qualitative review of this topic using the Pubmed Central database.

Results

74 years old male patient, with major depressive disorder about ten years. Depressive and cognitive symptoms didn`t respond to antidepressive treatment and his functional state has gradually declined.

Conclusions

Vascular depression develops after the 60 – 65 years in the absence of personal and family history of affective disorder. The key symptoms are low energy, anhedonia, deficits in selfinitiation, psychomotor retardation, reduced processing speed and lack of insight into mood symptoms. Clinical assessment includes a review of history of vascular risk factors or/and disease, but also an imagiological evidence demonstrating subcortical white matter abnormalities. Insidious and chronic course tends to delay its recognition and management. This becomes critical because Vascular Depression is associated with poor response to antidepressant treatment and persistent depressive symptoms. It`s also associated with poor selfmanagement of comorbidities and impairment in daily function. Increased mortality from all causes is widely documented.

A software for quantification of vessel density in glaucoma: An OCT-Angiography study

PURPOSE

To assess the capillary vessel density in the peripapillary region of glaucoma patients in comparison to controls using automated software.

METHODS

We performed an observational, cross-sectional case-control study with 72 eyes of glaucoma patients (with strict selection criteria) and 30 age-matched healthy controls. We used an optical coherence tomography angiography device (Triton, Topcon) with scans of 4.5×4.5mm centered on the optic nerve head, excluding images of poor quality. Since this device does not quantify vessel density, we wrote software (with Visual Studio©) that allowed us to remove large blood vessels and quantify the capillary density in the peripapillary region. We tested the ability of OCT-A to differentiate glaucoma from controls using the receiver operating characteristic curve (ROC). We also verified whether VD was correlated with visual field mean deviation.

RESULTS

VD was significantly lower in glaucoma than in controls, notably the whole-image VD of 72.45±7.45% in glaucoma and 77.87±3.77% in controls (P<0.001). VD values were correlated with visual fields (Spearman correlation of 0.33; P 0.0017). ROC was moderate (color VD of 0.629±0.143), but better than that of the visual field (0.229±0.077) or the retinal nerve fiber layer thickness assessed by OCT (0.326±0.064).

CONCLUSIONS

This software is useful for quantifying vessel density at the optic disc, peripapillary and capillary levels and for documenting glaucomatous changes in vascularization. OCT-A might be useful in diagnosis of glaucoma.

BOMET-QoL-10 questionnaire for breast cancer patients with bone metastasis: the prospective MABOMET GEICAM study

Background

Bone metastasis (BM) is the most common site of disease in metastatic breast cancer (MBC) patients. BM impacts health-related quality of life (HRQoL). We tested prospectively the psychometric properties of the Bone Metastasis Quality of Life (BOMET-QoL-10) measure on MBC patients with BM.

Methods

Patients completed the BOMET-QoL-10 questionnaire, the Visual Analogue Scale (VAS) for pain, and a self-perceived health status item at baseline and at follow-up visits. We performed psychometric tests and calculated the effect size of specific BM treatment on patients´ HRQoL.

Results

Almost 70% of the 172 patients reported symptoms, 23.3% experienced irruptive pain, and over half were receiving chemotherapy. BOMET-QoL-10 proved to be a quick assessment tool performing well in readability and completion time (about 10 min) with 0–1.2% of missing/invalid data. Although BOMET-QoL-10 scores remained fairly stable during study visits, differences were observed for patient subgroups (e.g., with or without skeletal-related events or adverse effects). Scores were significantly correlated with physician-reported patient status, patient-reported pain, symptoms, and perceived health status. BOMET-QoL-10 scores also varied prospectively according to changes in pain intensity.

Conclusions

BOMET-QoL-10 performed well as a brief, easy-to-administer, useful, and sensitive HRQoL measure for potential use for clinical practice with MBC patients.

Trial registration

NCT03847220. Retrospectively registered on clinicaltrials.gov (February the 20th 2019).

Trends in dialysis modality choice and related patient survival in the ERA-EDTA Registry over a 20-year period

BACKGROUND

Although previous studies suggest similar patient survival for peritoneal dialysis (PD) and haemodialysis (HD), PD use has decreased worldwide. We aimed to study trends in the choice of first dialysis modality and relate these to variation in patient and technique survival and kidney transplant rates in Europe over the last 20 years.

METHODS

We used data from 196 076 patients within the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry who started renal replacement therapy (RRT) between 1993 and 2012. Trends in the incidence rate and prevalence on Day 91 after commencing RRT were quantified with Joinpoint regression. Crude and adjusted hazard ratios (HRs) for 5-year dialysis patient and technique survival were calculated using Cox regression. Analyses were repeated using propensity score matching to control for confounding by indication.

RESULTS

PD prevalence dropped since 2007 and HD prevalence stabilized since 2009. Incidence rates of PD and HD decreased from 2000 and 2009, respectively, while the incidence of kidney transplantation increased from 1993 onwards. Similar 5-year patient survival for PD versus HD patients was found in 1993-97 [adjusted HR: 1.02, 95% confidence interval (95% CI): 0.98-1.06], while survival was higher for PD patients in 2003-07 (HR: 0.91, 95% CI: 0.88-0.95). Both PD (HR: 0.95, 95% CI: 0.91-1.00) and HD technique survival (HR: 0.93, 95% CI: 0.87-0.99) improved in 2003-07 compared with 1993-97.

CONCLUSIONS

Although initiating RRT on PD was associated with favourable patient survival when compared with starting on HD treatment, PD was often not selected as initial dialysis modality. Over time, we observed a significant decline in PD use and a stabilization in HD use. These observations were explained by the lower incidence rate of PD and HD and the increase in pre-emptive transplantation.

Urinary KIM-1, NGAL and L-FABP for the diagnosis of AKI in patients with acute coronary syndrome or heart failure undergoing coronary angiography

Acute kidney injury (AKI) is a common complication after coronary angiography. Early biomarkers of this disease are needed since increase in serum creatinine levels is a late marker. To assess the usefulness of urinary kidney injury molecule-1 (uKIM-1), neutrophil gelatinase-associated lipocalin (uNGAL) and liver-type fatty acid-binding protein (uL-FABP) for early detection of AKI in these patients, comparing their performance with another group of cardiac surgery patients. Biomarkers were measured in 193 patients, 12 h after intervention. In the ROC analysis, AUC for KIM-1, NGAL and L-FABP was 0.713, 0.958 and 0.642, respectively, in the coronary angiography group, and 0.716, 0.916 and 0.743 in the cardiac surgery group. Urinary KIM-1 12 h after intervention is predictive of AKI in adult patients undergoing coronary angiography, but NGAL shows higher sensitivity and specificity. L-FABP provides inferior discrimination for AKI than KIM-1 or NGAL in contrast to its performance after cardiac surgery. This is the first study showing the predictive capacity of KIM-1 for AKI after coronary angiography. Further studies are still needed to answer relevant questions about the clinical utility of biomarkers for AKI in different clinical settings.

Comparative antitumor effect among GM-CSF, IL-12 and GM-CSF+IL-12 genetically modified tumor cell vaccines

Genetically modified cells have been shown to be one of the most effective cancer vaccine strategies. An evaluation is made of the efficacy of both preventive and therapeutic antitumor vaccines against murine melanoma, using C57BL/6 mice and irradiated B16 tumor cells expressing granulocyte and macrophage colony-stimulating factor (GM-CSF), interleukin-12 (IL-12) or both. Tumor was transplanted by the injection of wild-type B16 cells. Tumor growth and survival were measured to evaluate the efficacy of vaccination. Specific humoral response and immunoglobulin G (IgG) switch were evaluated measuring total IgG and IgG1 and IgG2a subtypes against tumor membrane proteins of B16 cells. In preventive vaccination, all treated groups showed delayed tumor growth. In addition, the group vaccinated to express only GM-CSF achieved 100% animal survival (P<0.005). Vaccination with GM-CSF+IL-12-producing B16 cells yielded lesser results (60% survival, P<0.005). Furthermore, all surviving animals remained disease-free after second tumor implantation 1 year later. The therapeutic vaccination strategies resulted in significantly delayed tumor growth, mainly using B16 cells producing GM-CSF+IL-12 cytokines, with 70% tumor growth inhibition (P<0.001)-although none of the animals reached overall survival. The results obtained suggest that the GM-CSF+IL-12 combination only increases the efficacy of therapeutic vaccines. No differences in classical regulatory T cells were found among the different groups.

Spectral study of the stimulated emission of Nd3+ in fluorotellurite bulk glass

In this work we present, for the first time to our knowledge, laser emission under wavelength selective laser-pulsed pumping in Nd(3+)-doped TeO(2)-ZnO-ZnF(2) bulk glass for two different Nd(3+) concentrations. The fluorescence properties of Nd(3+) ions in this matrix which include, Judd-Ofelt calculation, stimulated emission cross-section of the laser transition and lifetimes are also presented. The site-selective emission and excitation spectra along the (4)I(9/2)→(4)F(3/2) absorption band show the inhomogeneous behaviour of the crystal field felt by Nd(3+) ions in this fluorotellurite glass which allows for spectral tuning of the laser output pulse as a function of the pumping wavelength. The emission cross-section obtained from the Judd-Ofelt analysis and spectral data (4.9x10(-20) cm(2)) is in fairly good agreement with the value obtained from the analysis of the laser threshold data (4x10(-20) cm(2)).

Continuous ambulatory peritoneal dialysis as a therapeutic alternative in patients with advanced congestive heart failure

AIMS

Continuous ambulatory peritoneal dialysis (CAPD) has been proposed as an additional therapeutic resource for patients with advanced congestive heart failure (CHF). The objective of this study was to determine the therapeutic role of CAPD, in terms of surrogate endpoints, in the management of patients with advanced CHF and renal dysfunction.

METHODS AND RESULTS

A total of 57 candidates with New York Heart Association (NYHA) class III/IV CHF, renal dysfunction (glomerular filtration rate < 60 mL/min/1.73 m(2)), persistent fluid congestion despite loop diuretic treatment, and at least two previous hospitalizations for acute heart failure (AHF) were invited to be included in the CAPD programme; however, 25 patients were finally included. The primary outcome was evaluated by the change at 6 and 24 weeks for the Minnesota Living With Heart Failure Questionnaire (MLWHFQ), the 6 min walk test (6MWT), NYHA class, serum natriuretic peptides [brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP)], serum carbohydrate antigen 125 (CA125), and hospitalization rates for AHF. CAPD was associated with a substantial improvement in the MLWHFQ (-21.3, P < 0.001; and -20.4, P < 0.001), the 6MWT (54.0, P < 0.001; and 45.6, P = 0.023), and NYHA class (-1.0, P < 0.001; and -1.4, P < 0.001) at 6 and 24 weeks, respectively. The Ln(CA125) decreased markedly (-0.8, P = 0.003; and -0.98, P = 0.003), with no effect on BNP and NT-proBNP. There was a marked reduction in the number of days hospitalized for AHF (6 month post-CAPD vs. 6 months pre-CAPD: -84%; P < 0.001).

CONCLUSIONS

In advanced CHF and renal dysfunction, CAPD was associated with short/mid-term improvement in severity parameters, with an acceptable rate of side effects.

Impact of peritonitis on long-term survival of peritoneal dialysis patients

The impact of each episode of peritonitis on long-term survival of peritoneal dialysis (PD) patients has yet to be defined.

OBJECTIVES

To determine the risk that each episode of peritonitis poses for patient survival and for the PD technique.

PATIENTS

1515 patients included in the Levante registry from 1 January 1993 to 31 December 2005.

METHODS

Retrospective analysis of a multicentre registry using Cox regression for time-dependent variables.

RESULTS

We analysed 1609 episodes of peritonitis in 716 patients (47.2%). In the univariate analysis, each case of peritonitis treated in the outpatient unit was associated with an increase in mortality (hazard ratio [HR] 1.99, P<.001), which was greater for episodes that required hospitalisation (HR 3.62, P<.001). Mortality increased with each successive episode in the same patient. Multivariate analysis confirmed the association of each case of peritonitis with lower long-term survival (HR 2.01, P<.001), with a different risk for episodes due to gram-positive and gram-negative bacteria and fungi (HR 1.73, 2.43 and 5.71, respectively; P<.001). Other variables associated with mortality were age, low residual renal function, absence of vascular access and comorbidity. Peritonitis was the only independent variable associated with technique failure (HR 1.29, P<.001), with a different risk for episodes due to gram-positive and gram-negative bacteria and fungi (HR 1.73, 2.43 and 5.71, respectively; P<.001).

CONCLUSIONS

Episodes of peritonitis negatively influence long-term survival of patients on PD.

New mutation in female patient with renal variant of Fabry disease and HIV

We describe the case of a 27-year-old woman with a family history of Anderson-Fabry disease (AFD). Urinary sediment presented microhematuria and 0.9 g/24 hours proteinuria. The alpha-galactosidase A measurement in fibroblasts showed partial deficit of the enzyme, which was compatible with being a carrier of the illness. Renal biopsy gave evidence of kidney lesions from Fabry disease. Genetic study revealed mutation C52Y or Cys52Tyr, which has not been previously described and had also been detected in the father of the patient. During follow-up, the presence of hypergammaglobulinemia revealed an underlying HIV disease. She is now awaiting enzymatic substitution treatment.

[Evolution of kidney function and progression factors in nephrectomised patients]

Data recorded from external visit in hospitals, reflects high number of nephrectomized patients. Most of these patients were remitted after any surgery or deteriorizated renal function or any other associated pathology. Several studies of nephrectomized patients are reported in literature concerning both healthy patients and comorbidity factors, and renal function and its evolution are evaluated. However, obtained results present a wide variability, which needs to be assessed. In this study we present a retrospective observational study of 92 one-kidney surgical patients, visited in Nephrology surgery of University Clinic Hospital. Patients presented an average age of 67 years old (range 22-89 years old), and a post-surgery monitoring of 21 years. Population was divided in two groups according with their glomerular filtration (FG). Before surgery, group 1 presented FG < 60 ml/min and group 2 > 60 ml/min, respectively. Group 1 patients (a total of 24 patients) presented an FG average of 48 ml/min, 8% had proteinuria and 63% presented high blood pressure. 21% of them needed an average of 20 years (10-30 years) to reach E4 and E5 steps and in general, most of them progressed to insufficient renal chronic disease. Five cases achieved renal therapy replacement. Group 2 patients, composed of a total of 68 patients, had an FG average of 76.5 ml/min, and 10% of patients presented proteinuria and 34% HTA; however, 80% of group 2 patients achieve E3 step with average age of 17 years, and a post-surgery of 47 years (1-48 years). A total of 19.1 % presented an FG higher 60 ml/min with an average development of 22 years along their evolution. According to the results obtained it is suggested that monorrenal surgical patients present a low progression of renal disease and it is also observed a progressive tendency to the chronic renal failure due to emerging of proteinuria.

[Study of diastolic function in peritoneal dialysis patientes. Comparison between pulsed and Tissue Doppler]

INTRODUCTION

Left ventricular hypertrophy (LVH) is the main expression of uremic cardiomyopathy. Alteration of the diastolic function is frequently associated with LVH, indicating future cardiovascular events. Recent studies suggest that the Tissue Doppler (TID) of the mitral annulus obtains parameters of diastolic function that are not influenced by other factors, unlike what occurs with the pulsed Doppler (PD), and that the relationship between the velocity of the proto-diastolic waves of both techniques (E/E') would be the most important datum to diagnose a diastolic malfunction. The objective of this study is to verify LVH prevalence in a population of End Stage Renal Disease patients (ESRD) in peritoneal dialysis (CAPD), and to study diastolic function, comparing the results of both techniques (PD/TID), as well as the possible causes that determine the appearance of diastolic malfunction in these patients.

PATIENTS AND METHODS

We carried out a cross-section study with 42 patients in peritoneal dialysis. All patients had an ejection fraction of over 50% and had no clinical signs of heart failure, valvular heart disease or arrhytmia. A basic biochemistry, residual renal function, C-reactive protein and an ultrasonic study with M-mode doppler, pulsed doppler and tissue doppler of the mitral annulus, were performed in all patients.

RESULTS

26.2% of the patients had a concentric LVH, 14.3% an asymmetric LVH and 23.8% a concentric growth. The PD showed an E/A ratio under 0.75 in 20 cases (which would indicate an alteration of ventricular relaxation), an E/A between 0.75 and 1.5 in 22 (normal or pseudonormal pattern) and none with an E/A over 1.5. On the other hand, the TID showed: 24 patients with an E/A < 0.75, 16 between 0.75 and 1.5, and 2 with an E/A > 1.5. The E/E' proportion was normal in 13 cases(< 8), intermediate in 12 (8-10), and greater than 10 in 17, expressing a clear diastolic malfunction. Twelve of the 17 with diastolic malfunction had a pseudo-normal pattern with the PD. A relationship was observed between the E/A and age and hs-CRP. A relationship was also found between RRF, ejection fraction and diastolic pressure (p = 0.03, r = 0.32 and p = 0.006, r = 0.29), while, in the multivariant study, the presence of LVH was the only variable with enough significance to influence the diastolic malfunction (odds ratio of 7.6).

CONCLUSIONS

Patients in CAPD have a high incidence of diastolic malfunction. LVH, present in a high percentage of patients, is one of the factors that favours its appearance. The non-invasive TID technique and the E/E' ratio have shown to be more sensitive than the PD in diagnosing a diastolic malfunction.

[Implementation of a protocol of management of chronic kidney disease between Nephrology and Primary Health Care. Preliminary results]

During the last years there has been an important advance in the knowledge of chronic kidney disease (CKD). In order to adapt our clinical practice to these new data, a protocol of management of CKD between Nephrology and Primary Health Care has been developed. The protocol includes several items like cardiac and renal protection strategies, diagnosis and treatment of complications, use of drugs and clear derivation criteria. Implementation of the protocol has been only partial and has implied, for the Renal Unit, an increase in the number of patients,specially the oldest ones, but a clear improve in the quality of the information too,and a first positive step in the right way to face the challenge of CKD. In view of analysed data we propose some modifications for the protocol.

Intravenous N-acetylcysteine for preventing contrast-induced nephropathy: a randomised trial

BACKGROUND

Studies evaluating the role of N-acetylcysteine in patients undergoing coronary angiography have yielded inconsistent data. Less is known about patients with normal renal function at baseline.

METHODS

Prospective, double-blind, placebo-controlled trial to determine the benefits of intravenous N-acetylcysteine as an adjunct to hydration in this kind of population. Patients were randomly assigned to receive either N-acetylcysteine (600 mg twice daily) or placebo, in addition to 0.45% intravenous saline. The primary end point was development of contrast-induced nephropathy, defined as an acute increase in the serum creatinine concentration > or = 0.5 mg/dl and/or > 25% increase above baseline level at 48 h after contrast dosing.

RESULTS

A total of 216 patients were studied: N-acetylcysteine = 107 and placebo = 109. Treatment groups were similar with respect to baseline clinical characteristics. Overall incidence of contrast-induced nephropathy was 10.2%, 10.3% in the N-acetylcysteine group and 10.1% in the placebo group. Furthermore, no significant differences were observed when considering the non-diabetic population, although there was a trend towards a protective effect of N-acetylcysteine in the subgroup of 47 patients with both hypertension and diabetes. There were no significant changes in serum urea nitrogen concentrations. The incidence of in-hospital adverse clinical events was low: no patient with contrast-induced nephropathy required dialysis, the median Coronary Unit stay was 4.5 vs. 4 days, and the mortality rate was 2.8% vs. 4.6% in the N-acetylcysteine and placebo groups, respectively (p=NS).

CONCLUSIONS

The prophylactic administration of intravenous N-acetylcysteine provides no additional benefit to saline hydration in high-risk coronary patients with normal renal function.

Classification and scoring systems in myelodysplastic syndromes: a retrospective analysis of 311 patients

The main objective of this study was to evaluate the role of the recent World Health Organization (WHO) classification for assessing prognosis in patients with myelodysplastic syndromes (MDS). To this effect, we analyzed the prognostic impact of the WHO and French-American-British (FAB) morphologic classifications and of four different scoring systems in a series of 311 patients with primary MDS diagnosed between October 1990 and June 2001. Both the FAB and WHO classifications identified groups with different prognoses (p<0.0001), those presenting refractory anemia (RA) and refractory anemia with ringed sideroblasts (RARS) showing the best prognosis. The WHO classification subdivided RA into RA with only red cell dysplasia, and refractory cytopenia with multilineage dysplasia (RCMD), and RARS into RARS plus refractory cytopenia with multilineage dysplasia and ringed sideroblast (RCMD-RS). In our population, we have shown that the two subtypes characterized by dysplasia affecting exclusively the erythroid population (RA and RARS) have a better prognosis, with a median survival of 122.2 and 81.9 months, respectively, than those with multilineage dysplasia (RCMD and RCMD-RS) with a median survival of 32.3 and 43.2 months, respectively. There were no significant differences in median survival comparing RA with RAS (p<0.95), or comparing RCMD with RSCMD (p<0.97). Besides, the four scoring systems discriminated our MDS patients in terms of survival, and an increase in prognostic capacity was achieved on adding the score to the morphological classifications. Risk scoring had a greater prognostic impact than the FAB and WHO classifications. Prognostic scoring systems may be an important tool for risk stratification in hematological practice, and add significance to morphological classification. Combined application of the WHO classification and score system is useful for improving the identification of patients with a poorer prognosis. The WHO classification establishes more homogeneous subcategories than the FAB classification and is also able to identify groups with different prognoses.

[Effect of oxidative stress in patients with chronic renal failure]

BACKGROUND

Cardiovascular disease remains the single most common cause of excess morbidity and mortality in end-stage renal disease (ESRD) patients and the traditional risk factors can't explain the high incidence of these events. New "non-traditional" risk factors are analysed in uremic patients and the increased oxidative stress is postulated to be an important contributor to uremic cardiovascular risk.

METHODS

In order to evaluate the effects of the hemodialysis treatment, a complete oxidative stress study was performed in fifteen uremic patients. Representative antioxidant enzymes such as superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx), together with oxidized/reduced glutathione ratio (GSSG/GSH) and other oxidation indicators including malondialdehyde (MDA) and 8-oxo-2'-deoxyguanosine (8-oxo-dG), were analysed to assess oxidative stress status in normal control volunteers and in uremic patients treated with hemodialysis (HD). In the latter group blood samples were taken prior and after HD to evaluate the effect of the session of HD over the oxidative markers.

RESULTS

Low levels of antioxidant enzyme activities were observed in the uremic patients as compared with normal control subjects. HD treatment results in a significant recovery of these enzyme activities but remain lower as compared with control values. Levels of GSSG and GSH concentrations were increased and reduced respectively in uremic patients. These differences were even higher before the HD and were reduced upon treatment to levels closer to those observed in controls. MDA levels and 8-oxo-dG levels were also increased in uremic patients with the highest values observed in the pre-treated HD group. Even though HD treatment decreases the levels of oxidation products in mononuclear cells of uremic patients the values of the control group are not reached.

CONCLUSIONS

Our results suggest that hemodialysis by itself could correct the oxidative status in these patients. The possible mechanisms involved in the oxidative stress changes with the hemodialysis treatment will be discussed below.

[Guidelines of the Spanish Society of Nephrology. Clinical practice guidelines for peritoneal dialysis]

In Spain and in each of its autonomous communities, the dialysis treatment of chronic renal disease stage 5 is totally covered by public health. Peritoneal dialysis, in any of its modalities, is established as the preferred home dialysis technique and is chosen by high percentage of patients as their choice in dialysis treatment. The Spanish Society of Nephrology has promoted a project of creation of performance guides in the field of peritoneal dialysis, entrusting a work group composed of members of the Spanish Society of Nephrology a with the development of these guides. The information offered is based on levels of evidence, opinion and clinical experience of the most relevant publications of the topic. In these guides, after defining the concept of << peritoneal dialysis>>, the obligations and responsibilities of the sanitation team of the peritoneal dialysis unit are determined, and protocols and performance procedures that try to include all the aspects that concern the patient with chronic renal disease in substitute treatment with this technique are developed. They propose prescription objectives based on available clinical evidence and, lacking this, on the consensus of the experts' opinions. The final aim is to improve the care and quality of the of the patient in peritoneal dialysis, optimizing in this way the survival of the patient and of the technique. In Spain, as in other neighbouring countries, peritoneal dialysis has an incidence and prevalence that is much lower than that of hemodialysis, ranging in the last evaluation by the Spanish Society of Nephrology between 5 and 24% in the different autonomous communities. The great majority of peritoneal dialysis units form part of the public network of the Spanish state, with special representation as a Satellite Unit or Concerted Center related to the public hospital of reference, on which it must depend.

[Fungal peritonitis episodes in a peritoneal dialysis centre during a 10-year period: a report of 11 cases]

Fungal peritonitis is a rare cause of peritonitis, but it is associated to poorer prognosis and higher mortality than bacterial peritonitis. Until now, predisposing factors and treatment have not been well established. We retrospectively reviewed all the cases of fungal peritonitis diagnosed for ten years in 218 patients undergoing continuous ambulatory peritoneal dialysis. In all we detected 11 episodes of fungal peritonitis in 11 patients, that means the 4% of continuous ambulatory peritoneal dialysis peritonitis. All the cases of fungal peritonitis were caused by Candida species. As a result of fungal peritonitis 36% of the patients died, 55% had to change to long-term hemodialysis because of failure in peritoneal dialysis technique. Only one case (9%) managed to continue peritoneal dialysis. The factors associated with the development of fungal peritonitis were: the presence of antibiotic use within 1 month before fungal peritonitis, patient older than 70 years old, low levels in albumine plasmatic and long permanence in continuous ambulatory peritoneal dialysis. The treatment consisted in intraperitoneal fluconazol combined with oral 5-flucytosine for 4 to 6 weeks. In the two last cases we associated intravenous caspofungine too. Given that no improvement was seen within 72 hours of treatment, the catheter must be removed in all the cases.

Sepsis and SOFA score: related outcome for critically ill renal patients

AIMS

To evaluate the influence of sepsis in critically ill patients with acute renal failure (ARF), and to analyze the value of the sequential organ failure assessment (SOFA) score for assessing the morbidity and related mortality of these patients.

MATERIAL AND METHODS

A prospective observational study developed in a medical intensive care unit (ICU) of a tertiary care university hospital. Data were collected from January 1, 2001 - July 31, 2002. The inclusion criterion was either a creatinine plasma level > or = 2 mg/dl on ICU admission or increases > or = 30% from its initial value. Sepsis was evaluated at the time of study inclusion, and patients were distributed into 2 groups (septic and nonseptic patients).

RESULTS

Two hundred patients with ARF were prospectively enrolled in the study (91 (45.5%) septic and 109 (54.5%) nonseptic patients). Median age was 68 years in septic patients and 72 in nonseptic ones while the percentage of males in both groups was 66% vs 69%, respectively. Septic patients showed more organ failures and more respiratory, cardiovascular and coagulation failures at the time of study admission as well as a worse mean SOFA score during the first 4 days after inclusion (p < 0.01). Mortality rate at the ICU was significantly higher in the septic group when compared to the nonseptic one (55% vs 19.3%, OR = 2.21 (1.65 - 2.97)). Using stepwise logistic regression, acute tubular necrosis and oliguria in septic patients as well as cardiovascular failure (evaluated by SOFA score) in nonseptic patients were identified as independent risk factors for mortality.

CONCLUSIONS

Septic and nonseptic ICU patients with ARF have an increased risk of ICU mortality depending on the type of organ failure. Although SOFA score does not predict outcome, it is a useful tool to categorize these patients and to describe a sequence of complications in critically ill patients.

[Hypokalemic metabolic alkalosis: apropos of a case of Gitelman's syndrome]

We present a case of Gitelman's Syndrome in a 20 year-old woman who came to our service with weakness, asthenia, leg cramps and tetany. Laboratory studies revealed metabolic alkalosis with hypokalemia, hypomagnesemia and low calcium in a 24-hour urine test. The diagnosis of this syndrome is made in some cases during adult life because this syndrome is asymptomatic over several years. Gitelman's Syndrome is autosomal recessive as is Bartter's Syndrome. The gene is located in chromosome 16q, which encodes the cotransporter Na/Cl sensitive to thiazide in the distal convoluted tubule. The defect of cotransporter produces an alteration of sodium reabsorption that causes electrolytic disorders typical of this Syndrome and different from Bartter's Syndrome. The typical electrolytic alterations are hypocalciuria and hypomagnesemia secondary to high urinary magnesium excretion. The prognosis of this syndrome is excellent and treatment consists in correction of serum electrolytes with oral administration of magnesium and potassium. In spite of this treatment, in some cases it is very difficult to reach normal serum levels of magnesium because of the high doses of oral magnesium, which produce common crises of diarrhea that increase magnesium gastrointestinal losses.

A randomized study of intermediate as compared with high doses of interferon-alpha for chronic myeloid leukemia: no differences in cytogenetic responses

Interferon-alpha (IFN-alpha) is a therapy of unquestionable efficacy in chronic myeloid leukemia (CML) patients. The best dose of IFN-alpha in the treatment of CML still remains controversial. Our primary objective was to compare cytogenetic responses in patients treated with intermediate versus high doses of IFN-alpha. A multicenter randomized controlled trial was conducted involving 109 patients with untreated CML in chronic phase from 26 Spanish hospitals. Patients were assigned to receive either an intermediate (2.5 MU/m(2) per day) or high (5 MU/m(2) per day) target dose of IFN-alpha. Hydroxyurea was allowed in both groups. In total, 108 patients were analyzed, 53 in the intermediate- and 55 in the high-dose group. Median follow-up was 47.5 months. The dose of IFN-alpha actually given was lower in the intermediate-dose group (3.83 MU/day) than in the high-dose group (6.6 MU/day) ( p<0.001). The rate of complete cytogenetic response was 24.5% in the intermediate- and 12.7% in the high-dose group (NS). A partial cytogenetic response was obtained in 7.5% and 10.9%, respectively. Cox analysis did not reveal any influence of the randomization arm on cytogenetic response rate. Ten patients in each group discontinued IFN-alpha because of toxicity. Albeit not our primary objective, no differences were found in terms of survival or transformation rate between both groups. Median survival was 73 months; 64% of patients remained free of transformation at 5 years. In terms of cytogenetic response, intermediate doses of IFN-alpha are as effective as high doses in the treatment of CML.

[Analysis of survival in dialysis: hemodialysis versus peritoneal dialysis and the significance of comorbidity]

To choose the best possible dialysis technique for those patients with end-stage renal disease continues to be a matter of debate. Even after putting aside the evident influence that economic and geographic factors as well as the health politics may have in the selection of the technique, different studies comparing survival between hemodialysis (HD) and peritoneal dialysis (PD) have shown contradictory results which could be explained by the differing methodological and statistical methods used together with the different influence assigned to the comorbidity found when starting the treatment, a situation that has increased the confusion about this topic. Based on this we performed a retrospective analysis with a follow-up time of seven years including all those patients who started dialytic treatment in our area, with a final number of 3.106 hemodialysis patients and 542 peritoneal dialysis patients. Those patients who were transferred to another treatment technique during the time of the study were excluded. Age higher than 70 years, cardiovascular disease, liver disease, diabetes mellitus and the presence of dyslipidemia were included as comorbidity factors. Peritoneal dialysis patients were younger than those treated by hemodialysis (54.53 vs 60.1 years), but suffered from higher cardiovascular comorbidity and were more often diabetic. The global survival was the same in both groups up to 32 months of treatment. Although no differences were found when comparing those patients without comorbidity factors, those with comorbidity had better survival on hemodialysis. Age higher than 70 years was the only comorbidity factor with statistically significant difference for a better survival in hemodialysis.

Comorbidity and mortality in peritoneal dialysis: a comparative study of type 1 and 2 diabetes versus nondiabetic patients. Peritoneal dialysis and diabetes

We conducted a retrospective study with 750 peritoneal dialysis (PD) patients in a Spanish multicenter registry between 1993 and 1999 to analyze comorbidity and mortality in type 1 diabetes (T1D), type 2 diabetes (T2D) and nondiabetic (ND) patients. 163 patients (21.7%) were diabetic--96 T1D (58.8%) and 67 T2D (42.2%)--while 587 were not (78.3%). Different comorbidity factors such as the presence of cardiovascular disease, age over 70 and dyslipidemia at the start of PD were analyzed as well as the incidence of peritonitis, the peritonitis-free interval, need for hospitalization, mortality rate, early mortality rate, survival curves (log rank) and the impact factor (Cox) on mortality for the different variables. The comorbidity index (number of comorbidity factors when starting the treatment) and the peritonitis incidence were higher for T2D. Hospitalization rates were similar, but mortality rates were higher for T2D and early mortality rates (death during the 1st year of treatment) were higher for T1D. The actuarial survival curves showed a higher mortality for T2D with no differences between ND and T1D after adjustment for age. The mortality odds ratio was 1.78 for T2D and 1.13 for T1D, differences which were not significant after adding age over 70 and cardiovascular disease to the variables analyzed. Our results show that associated comorbidity is the most important difference between ND, T1D and T2D. While cardiovascular comorbidity is responsible for the higher percentage of early mortality found in T1D when compared to ND, both age and cardiovascular disease are responsible for the higher comorbidity and mortality found in T2D.

A predictive formula of the contraction stress in restorative and luting materials attending to free and adhered surfaces, volume and deformation

OBJECTIVES

To find a predictive formula of stress, considering the surfaces (free, adhered) involved, the volume and characteristics of material and the deformation of the measuring system.

MATERIALS AND METHODS

231 samples of five chemically cured restoratives (Silar (SIL, 23), Clearfil F2 (CLE, 39), P10 (P10, 33), Concise (CON, 30), Isopast (ISO, 28)) and four luting (3M Experimental 241 (EXM, 20), Variolink II (VAR, 13), Vitremer LC (VTM, 20) and Dyract Cem (DYR, 25)) materials were allowed to polymerize until they reached a maximum tension (T(max), 25 min) between six pairs (null 5.81, 8.5, 11.26, 12.42, 17.02, 23.14 mm) of polished metallic discs (range of distances: 0.02-5.9 mm) mounted in a tension machine. The deformation of the measuring system was measured for the recorded forces.

RESULTS

A descriptive non-linear formula T(max)=KVol(-3.267)FS(3.283)AS(0.642)Def(0.561) was found that individualizes the material's characteristics (K) that considers volume (Vol), free (FS) and adhered (AS) surfaces and deformation (Def) of the system for each force. This formula renders good correlation (material K (r(2) coefficient)): SIL 0.9998 (0.995), CLE 1.0062 (0.989), P10 1.0224 (0.990), CON 0.9908 (0.992), ISO 0.9648 (0.974), EXM 1.0083 (0.991), VAR 0.9777 (0.996), VTM 0.9925 (0.993), DYR 0.9971 (0.997) between actual T(max) and calculated Tension. There are statistically significant differences (p=0.002) between K values of both (restorative and luting) groups.

SIGNIFICANCE

Predictive parameters have influence in a different way to what is actually considered, if the system is allowed to have deformation, as occurs naturally and volume and material's characteristics are considered.

[Risk factors associated with survival in patients in a peritoneal dialysis program]

The aim of this study was to quantify the effect of different mortality risk factors in peritoneal dialysis and to establish a prognostic index that could predict mortality risk when patients start dialysis. A prospective study was performed on 103 patients included in our peritoneal dialysis program. The mean follow-up time was 26 +/- 21 months. A multivariate analysis (Cox regression was made to identify different risk factors that could influence patient survival during peritoneal dialysis. Age, gender, parathyroid hormone, albumin, cholesterol, and the presence of diabetes mellitus were evaluated as potential risk factors. Patients were distributed in three groups (high, medium and low risk), according to the risk factors with a significant influence in multivariate analysis, and patient survival was studied depending on the prognostic index using Kaplan-Meier estimator. Overall patient survival was 90% (95%CI: 83 to 96%) after the first year and 40% (95%IC: 32 to 58%) after 5 years of follow-up. The Cox regression analysis identified albumin below 4 g/dL (RR: 2.57; 95% CI: 1.16 to 5.72), age older than 65 years RR: 3.10; 95%IC: 1.20 to 7.98) and diabetes mellitus (relative risk, RR: 4.36; 95%IC: 1.43 to 13.31) as independent risk factors for mortality in patients receiving peritoneal dialysis. Patient survival after two years was 40% (95%IC: 31 to 59%), 73% (95%IC: 60 a 86%) and 100% (p < 0.05), respectively. Malnutrition and related factors in patients receiving peritoneal dialysis are associated with a higher mortality rate.

Can the creatinine dialysate-to-plasma ratio from the peritoneal equilibration test be replaced by the sodium dialysate-to-plasma ratio and the sodium level in the dialysate?

The peritoneal equilibration test (PET) is a useful tool that categorizes peritoneal transport. However, the method has some inconveniences. Some authors suggest that measuring the sodium level in the dialysate (NaD) or the dialysate-to-plasma ratio for sodium (D/PNa) can substitute for the PET. We applied a mathematical analysis [Fisher intraclass correlation coefficient (FICC)] to 43 PETs performed in 43 peritoneal dialysis patients (29 males, 14 females) with a mean age of 55.3 years (range: 28-85 years). Determinations of NaD, of sodium level in plasma (NaP), and of D/PNa at times 0, 30, 60, 120, and 240 minutes were added to the usual PET determinations. After using the NaD240 and the D/PNa240 values to calculate the cut-off values for the various peritoneal transport categories, we obtained a transport distribution very similar to that of the PET dialysate-to-plasma ratio for creatinine after 240 minutes (D/PCr240). At the same time, the FICC showed good (0.69) and excellent (0.77) correlation of NaD240 and D/PNa240 respectively with the D/PCr240. Therefore either of these two methods, which are cheaper and quicker than a PET, can be used to categorize peritoneal transport with a high degree of reliability.

A prospective multicenter comparison of peritonitis in peritoneal dialysis patients aged above and below 65 years. Levante PD Multicenter Group

Various authors have found peritonitis rates in older peritoneal dialysis (PD) patients to be higher, similar, or even lower when compared to rates in younger populations. We prospectively analyzed all episodes of peritonitis registered in the 381 patients (219 males, 162 females; mean age, 55.5 +/- 17.0 years) who were treated with PD during four years (1993-1996) in our multicenter group. Patients were distributed into two groups. Group A included 138 patients aged 65 years or over (mean age: 72.3 +/- 5.1 years); group B included 243 patients aged below 65 years (mean age: 46.0 +/- 13.6 years). No differences were seen in general PD characteristics. Normalized protein catabolic rate (nPCR) was higher in younger patients (p = 0.001). Patients in group A experienced more peritonitis (135 episodes; 1 episode per 16.7 patient-months) than patients in group B (198 episodes; 1 episode per 21.7 patient-months; p = 0.01). Although no differences were seen in the general characteristics of the peritonitis episodes, gram-negative peritonitis and peritonitis not achieving a cure were more commonly secondary to enteric bacteria in group A (p = 0.03). We conclude that PD patients aged 65 years or over are at higher risk of peritonitis. Also, in this age group, gram-negative peritonitis and peritonitis with any evolution except cure are more likely to be due to enteric bacteria.

Porosity of resin cements and resin-modified glass-ionomers

PURPOSE

To quantify the internal free surface in various resin cements and glass-ionomer-based materials.

MATERIALS AND METHODS

Materials tested were Nexus fluid (NXF) and viscous (NXV), Vitremer (VTM), Fuji II LC (FII), Vitremer Luting Cement (VLC), Dyract (DYR) and Compoglass (COM). Samples (n=5) were made of each material between two microscopic glass slides under same weight. With a transmitted light microscopy, four zones of each sample were evaluated, finding the number of porosities per mm2 (NP), the average radius of porosities (RP), the ratio of total area of surface porosities (micron2) to area (mm2) of specimen surface (TA) and the ratio of total volume of porosities (micron2) to area (mm2) of material surface (VP).

RESULTS

Median test was used. NP: NXV, NXF and DYR had smaller NP than VTM and FII and (likely) than VLC (P> 0.0000001). RP was smaller for DYR than for VLC and (likely) than for NXV (P= 0.00019). TA: NXV, NXF and DYR had smaller TA than VTM, FII and VLC (P< 0.0000001). VP: NXV and DYR had smaller VP than FII and (likely) than VTM and VLC (P< 0.0000001).

[Is the correlation between adequate dialysis in peritoneal dialysis and nutritional parameters mathematical or biological? Influence of residual renal function and comorbidity]

The relationship between urea Kt/V and nPCR (nPNA) is partly due to a mathematical coupling and greatly depends on the residual renal function (RRF). On the other hand, albumin could be just a comorbidity marker. Our objective in this study was to verify whether dialysis dose in peritoneal dialysis (PD) is biologically related to the nutritional state measured by the mean values of several parameters not mathematically related while analyzing the influence of RRF and comorbidity (C). 101 stable PD patients, 60M and 41F with a mean age of 59.3 +/- 14.3 years, were studied and followed up every six months for a mean time of 35.8 +/- 22.3 months (8-112). The variables studied were initial comorbidity, plasma albumin, normalized protein nitrogen appearance (nPNA), lean body weight % (LBW%) and fat-free mass index (FFMI) derived from creatinine, and RRF. In every study (n = 471) the 24 hours dialysate and urine volumes were collected and the total (T), dialytic (P) and renal (R) urea KT/V and normalized creatinine clearance (CCR) were determined and compared with the nutritional parameters. When starting PD 48 patients (47.5%) had some C and 34 (33.7%) were already anuric. The correlations of nPNA with T-KT/V and T-CCR (n = 101) were r = 0.67 and 0.50 (p < 0.0005) while the correlations of LBW% with T-KT/V and T-CCR were r = 0.36 and 0.40 (p < 0.0005) respectively. The correlations of albumin with T, P and R KT/V and CCR did not reach significance. The nutritional state was better in patients with a higher RRF and albumin showed significant differences when related to morbidity. KT/V and CCR correlations with nutritional variables not mathematically related verify the hypothesis that dialysis dose is biologically associated with the nutritional state.

Induction of heme oxygenase-1 expression in macrophages by diesel exhaust particle chemicals and quinones via the antioxidant-responsive element

Diesel exhaust particles (DEP) contain organic chemicals that contribute to the adverse health effects of inhaled particulate matter. Because DEP induce oxidative stress in the lung and in macrophages, effective antioxidant defenses are required. One type of defense is through the expression of the antioxidant enzyme, heme oxygenase I (HO-1). HO-1 as well as phase II detoxifying enzymes are induced via antioxidant response elements (ARE) in their promoters of that gene. We show that a crude DEP total extract, aromatic and polar DEP fractions, a benzo(a)pyrene quinone, and a phenolic antioxidant induce HO-1 expression in RAW264.7 cells in an ARE-dependent manner. N-acetyl cysteine and the flavonoid, luteolin, inhibited HO-1 protein expression. We also demonstrate that the same stimuli induce HO-1 mRNA expression in parallel with the activation of the SX2 enhancer of that gene. Mutation of the ARE core, but not the overlapping AP-1 binding sequence, disrupted SX2 activation. Finally, we show that biological agents, such as oxidized 1-palmitoyl-2-arachidonoyl-sn-glycero-3-phosphocholine, could also induce HO-1 expression via an ARE-dependent mechanism. Prior induction of HO-1 expression, using cobalt-protoporphyrin, protected RAW264.7 cells against DEP-induced toxicity. Taken together, these data show that HO-1 plays an important role in cytoprotection against redox-active DEP chemicals, including quinones.

Stage, percentage of basophils at diagnosis, hematologic response within six months, cytogenetic response in the first year: the main prognostic variables affecting outcome in patients with chronic myeloid leukemia in chronic phase treated with interferon-alpha. Results of the CML89 trial of the Spanish Collaborative Group on interferon-alpha2a and CML

BACKGROUND AND OBJECTIVE

Interferon-a (IFN) is increasingly being used as the drug of choice in chronic myeloid leukemia patients. The main objectives of the study were to study the influence of the classic prognostic variables and response to IFN, and to assess the influence of this response on the course of the disease and survival.

DESIGN AND METHODS

Single arm, prospective, multicenter study, without a control group. Only Ph1-positive CML patients were included. The treatment scheme was biphasic: the patients first received standard chemotherapy and thereafter IFN-a2a was used as monotherapy, with a target dose of 9 MU/d/s.c.

RESULTS

Twenty-one centers in Spain enrolled 132 patients (72 men, 60 women). The median dose of IFN given was 5.8 MU/d, and the median treatment duration was 431 days (range: 18-2,597). Seventy-two percent of patients obtained a hematologic response in the first six months of IFN treatment. Genetic response was obtained in 47% of the patients, and the response was major or complete in 27% and 19%, respectively. The median time to obtain this response was 7, 9, and 18 months for minimal, partial and complete genetic response, respectively. Multivariant analysis showed that only a higher percentage of basophils at diagnosis was associated with a worse hematologic response at six months (p=0.001) (OR: 1.23) and with a worse cytogenetic response in the first year of IFN therapy (p=0.018) (OR: 1.4). Over an observation period of 8 years, 35.6% of the patients died, and 85 (64.4%) remained alive. With a median follow-up of 42 months (3.7-98), the 6-year projected probabilities of survival and transformation-free survival were 0.61+/-0.07 vs. 0.54+/-0.07, respectively. Patients with Kantarjian's stage 3 disease or in a high-risk Sokal group had lower probabilities of survival, but these systems did not adequately discriminate in our series. Obtaining a complete hematologic response in the first six months of IFN therapy was favorable in terms of overall survival (p=0.05; HR=0.33). Cox's analysis demonstrated that obtaining a cytogenetic response in the first year was independently associated with better overall survival (p=0.04; HR=0.19) and better transformation-free survival (p=0.0035; HR=0.11).

INTERPRETATION AND CONCLUSIONS

Nearly half of the patients obtained some degree of Philadelphia suppression, which was major in 27%, and complete in 19%. A higher percentage of basophils at diagnosis was the only variable associated with a lower probability of cytogenetic response. Obtaining a cytogenetic response during the first year of IFN treatment was a favorable and independent variable in terms of survival and transformation-free survival. Obtaining a major cytogenetic response during this period decreased the risk of transformation twenty times. Our results suggest that the effect of IFN on survival is independent of the classic prognostic variables.