Can the implementation of clinical practice guidelines improve clinical competence of physicians and kidney function of patients with type 2 diabetes mellitus?

Background

There are many clinical practice guidelines (CPGs) in Nephrology; however, there is no evidence that their availability has improved the clinical competence of physicians or the outcome of patients with chronic kidney disease (CKD). This study was aimed to evaluate the effect of implementation of CPGs for early CKD on family physicians (FP) clinical competence and subsequently on kidney function preservation of type 2 diabetes mellitus (DM2) patients at a primary healthcare setting.

Methods

A prospective educative intervention (40-h) based on CPGs for Prevention, Diagnosis and Treatment of Early CKD was applied to FP; a questionnaire to evaluate clinical competence was applied at the beginning and end of the educative intervention (0 and 2 months), and 12 months afterwards. DM2 patients with CKD were evaluated during 1-year of follow-up with estimated glomerular filtration rate (eGFR) and albuminuria.

Results

After educative intervention, there was a significant increase in FP clinical competence compared to baseline; although it was reduced after 1 year, it remained higher compared to baseline. One-hundred thirteen patients with early nephropathy (58 stage 1, 55 stage 2) and 28 with overt nephropathy (23 stage 3, 5 stage 4) were studied. At final evaluation, both groups maintained eGFR [(mean change) early 0.20 ± 19 pNS; overt 0.51 ± 13 mL/min pNS], whereas albuminuria/creatinuria (early -67 ± 155 p < 0.0001; overt -301 ± 596 mg/g p < 0.0001), systolic blood pressure (early -10 ± 18 p < 0.05; overt -8 ± 20 mmHg p < 0.05), and total cholesterol (early -11 ± 31 p < 0.05; overt -17 ± 38 mg/dL p < 0.05) decreased. Diastolic blood pressure, waist circumference and LDL-cholesterol were also controlled in early nephropathy patients.

Conclusions

CPGs for Prevention, Diagnosis and Treatment of CKD, by means of an educative intervention increases FP clinical competence and improves renal function in DM2 patients with CKD.

Cytomegalovirus in renal transplant recipients from living donors with and without valganciclovir prophylaxis and with immunosuppression based on anti-thymocyte globulin or basiliximab

BACKGROUND

In our population, anti-thymocyte globulin (ATG) of 1 mg/Kg/day for 4 days is used; which permits not using valgancyclovir (VGC) prophylaxis in some renal transplant recipients (RTR) with moderate risk (R+), to reduce costs. This study aimed to determine the incidence and risk of developing cytomegalovirus (CMV), with or without prophylaxis, when exposed to low doses of ATG or basiliximab (BSL).

PATIENTS AND METHODS

A retrospective cohort included 265 RTR with follow-up of 12 months. Prophylaxis was used in R-/D+ and some R+. Tacrolimus (TAC), mycophenolate mofetil, and prednisone were used in all patients. Logistic regression analysis was performed to estimate the risk of CMV in RTR with or without VGC.

RESULTS

Cytomegalovirus was documented in 46 (17.3%) patients: 20 (43.5%) with CMV infection, and 26 (56.5%) with CMV disease. Anti-thymocyte globulin was used in 39 patients (85%): 32 R+, six D+/R-, and one D-/R-. ATG was used in 90% (27 of 30) of patients with CMV and without prophylaxis. The multivariate analysis showed an association of risk for CMV with the absence of prophylaxis (RR 2.29; 95% CI 1.08-4.86), ATG use (RR 3.7; 95% CI 1.50-9.13), TAC toxicity (RR 3.77; 95% CI 1.41-10.13), and lymphocytes at the sixth post-transplant month (RR 1.77; 95% CI 1.0-3.16).

CONCLUSIONS

Low doses of ATG favored the development of CMV and a lower survival free of CMV compared with BSL. In scenarios where resources for employing VGC are limited, BSL could be an acceptable strategy.

Epidemiological Characteristics of the Largest Kidney Transplant Program in Mexico: Western National Medical Center, Mexican Institute of Social Security

BACKGROUND

According to the National Transplant Center (CENATRA), in 2013, a total of 2707 transplantations were performed in Mexico; of them, 10% (270 transplantations) were done in our Tertiary Care Hospital (Western National Medical Center). This means that one in 10 transplant recipients undergoes transplantation at our medical center. The aim of our study was to describe the characteristics of and to compare changes in the kidney transplantation program over time.

MATERIALS AND METHODS

This was a cross-sectional study. Data were collected from the hospital transplant registry from January 1994 to December 2014.

RESULTS

During the study period, 3643 kidney transplantations were conducted; most were living donor 3236 (89%), and only 407 patients (11%) received a graft from a deceased donor. Of living donors, 2786 (87%) were related, and 450 (13%) were genetically unrelated. The average recipient age was 28 years, and the average age of the donor was 34 years. It was observed that siblings donated more frequently (51%), followed by parents (34%). Among unrelated donors, spouses donated the most (66%). In 80% of cases, the cause of end-stage renal disease (ESRD) was unknown (80%). The most frequent renal replacement therapy was peritoneal dialysis (54%), followed by hemodialysis (18%); only 5% of patients received preemptive kidney transplant. The most frequent immunosuppression scheme was tacrolimus, mycophenolate mofetil, and prednisone in 70% of patients.

CONCLUSION

The Western National Medical Center is the largest kidney transplantation program in Mexico. The main activity is living donor transplantation. Recipients are relatively young persons with unknown etiology of ESRD.

Vascular calcification in Mexican hemodialysis patients

BACKGROUND AND AIMS

Vascular calcification (VC) is a predictor of poor survival and cardiovascular outcome in end-stage renal disease (ESRD) patients; however, there is scarce information of VC in Latin America, and virtually no data in our setting. We undertook this study to evaluate the prevalence and characteristics of VC in a hemodialysis (HD) population from western Mexico and to determine possible associated factors.

METHODS

This was a cross-sectional study performed in 52 patients. VC was evaluated using plain X-ray films (Adragao's score) of hands and pelvis; clinical and biochemical variables were also collected. Statistical analysis was carried out with Student t and χ(2) tests performed as appropriate and logistic regression to determine predictors of VC.

RESULTS

Mean age was 43 years, 48% were female, 23% had diabetes mellitus (DM), and median time on dialysis was 46 months. Percentage prevalence was 52% with a mean calcification score of 2.0 ± 2.6; 23% of patients had severe calcification. VC was present in about 23-37% among the different vascular territories evaluated (radial, digital, femoral and iliac). Patients with calcification were significantly older, had a higher frequency of DM, higher alkaline phosphatase and lower HDL lipoproteins than those without VC. In the multivariate analysis, VC in these patients was significantly predicted only by an older age (OR [95% CI]: 1.15 [1.01-1.31], p = 0.04); lower HDL-cholesterol and higher alkaline phosphatase were marginal predictors.

CONCLUSIONS

Half of our HD patients had VC. Territories of radial, iliac, femoral and digital arteries were roughly equally affected, and 25% of patients had a calcification considered as severe. Older age was the only significant predicting variable for VC, with low HDL-cholesterol and high alkaline phosphatase as marginal predictors.

Infection by human parvovirus B19: "gloves and socks" papular purpuric syndrome

Human parvovirus B19 is the cause of erythema infectiosum a benign and self-limited infection, but sometimes the virus causes an acute and self-limiting dermatosis. It consists of a edema and erythema of the hands and feet in a gloves and sock distribution and is associated with oral lesions and fever. We report a case of a "gloves and socks" infection by human parvovirus B19.

New lineal immunoenzymatic assay for simultaneous detection of p24 antigen and HIV antibodies

The aim of this study was to evaluate a new lineal immunoenzymatic assay for the simultaneous detection of HIV-1/HIV-2 antibodies and p24 antigen. A total of 320 serum samples were obtained from individuals infected by HIV (HIV 1, n = 183; HIV 2, n = 2), individuals with risk factors for HIV infection (n =49), recipients of multiple transfusions (n =40), and blood donors (n = 46). The Western blot for detection of HIV antibodies and an enzyme immunoassay for detection of p24 antigen, both established techniques, were used for direct comparison. In cases of recent infection, p24 antigen was generally detected at the same time by the lineal test and the established assay. The p24 antigen sensitivity was about 200 pg of HIV antigen per milliliter. The results seem to indicate that the new test could be used with sufficient reliability for screening biological samples (sensitivity, 99.5%; specificity, 94.8%). Use of the lineal immunoenzymatic assay may shorten the amount of time needed to diagnose acute infection with HIV to approximately 2 weeks.

[Is stated income a valid indicator of the socioeconomic status?]

OBJECTIVE

1) To analyse the validity of the reply to the question on socio-economic income included in health questionnaires. 2) To identify other valid indicators of socio-economic status.

DESIGN

Crossover and retrospective observation study.

SETTING

Community (Molina de Segura Health District).

PARTICIPANTS

1,071 people over 18, selected by means of simple random sampling.

INTERVENTIONS

Analysis of 16 questions relating to home furnishing, consumer goods and stated income. We used Factorial Analysis and the ji2 test.

RESULTS

We identified three levels by means of the factorial analysis: a) basic--consisting of hot water, washing-machine, absence of damp patches in the house, individual heating and television. b) Intermediate--consisting of car, video and telephone. c) High--with dishwasher, domestic help and air-conditioning. On analysing the relationship between stated income and socio-economic status we detected association to p < 0.001. The basic level answered more often than expected that their income was less than 50,000 pesetas; the intermediate, between 50 and 100,000; and the high, over 101,000.

CONCLUSIONS

1) It is possible to identify the socio-economic profile of the general population by the belonging of selected of determined consumer items. 2) Stated income is a reliable indicator of socio-economic status. Despite a tendency to a low reply to the question on income, income is not generally under-declared.