[Renal pathophysiology and pharmacological mechanisms of nephroprotection]

Several risk factors may affect the progression of chronic kidney disease (CKD). Arterial hypertension, proteinuria, obesity, intraglomerular hypertension, smoking and metabolic control in diabetes mellitus are the main modifiable risk factors for progression. The progression of CKD involves many cellular processes that originate in specific compartments of the kidney, the vascular compartment with nephroangiosclerosis and the tubulointerstitial compartment with fibrosis and tubulointerstitial atrophy, and there may be overlap between both mechanisms. Given the involvement of so many risk factors and so many pathogenic pathways in the progression of CKD, the best hope for delaying or preventing the progression of CKD lies in a combined and multidisciplinary therapeutic approach, based on the existing evidence and acting on all these processes and pathways from the mechanistic point of view, and on a global process that is cardiovascular and renal risk to improve the prognosis of patients.

[Positioning for the management of arterial hypertension in Primary Care from the critical analysis of the American (2017) and European (2018) guidelines. Spanish Society of Primary Care Physicians (SEMERGEN)]

The Scientific Societies of Primary Care, being the area in which there is a considerable prevalence of Arterial Hypertension (AHT), need to periodically evaluate the international guidelines for its management. This is particularly relevant when disparate guidelines make it difficult to make decisions in daily clinical practice. The present document has as its aim to analyse the changes and new developments proposed in the guidelines of the American College of Cardiology and the American Heart Association (ACC/AHA 2017), as well as in the guidelines of the European Society of Cardiology and European Society of Hypertension (ESC/ESH 2018). An analysis will be made of any differences, limitations, and their applicability to Primary Care in Spain. Finally, the most relevant available and appropriate information is extracted and integrated in order to homogenise the care of the hypertensive patient, from a critical, but also a reasoned, perspective. The discrepancies between the recommendations in such essential aspects as the management of the disease, require the compiling and critical analysis of the information that enables us as scientific society, interested in providing all PC physicians with the most relevant, and at the same time, sensible, recommendations of all the guidelines.

[Tools to improve efficiency in the clinical management of hypertensive patients]

OBJECTIVE

To create a tool to evaluate the efficiency of the clinical management of hypertensive patients in Primary Care.

MATERIAL AND METHODS

A web-based questionnaire was designed for Primary Care centres to self-evaluate the management of hypertension in five specific areas: information systems, diagnostic and analytical tests, organisational aspects, use of resources, and continuous training programmes for patients and healthcare professionals. A committee of experts previously defined these questions and their ideal responses or "control", based on the scientific literature or, if there were no published references, by consensus of the committee. A descriptive analysis was performed on the data, and an adherence score was created that ranged from 0 (no adherence) to 1 (total adherence).

RESULTS

A total of 35 Primary Care centres entered their data into the website for the clinical management of hypertensive patients. The highest adherence to the ideal algorithm was observed in the area "Diagnostic and analytical tests" (0.69±0.10), and the lowest in "Continuous training programmes for patients and professionals" (0.42±0.21).

CONCLUSIONS

The efficiency of clinical management in hypertensive patients can be analysed using the website tool created for this purpose. Its use allows an internal audit to detect the areas that need improvement, and also serves to make comparative evaluations in the different areas of management over time.

[Medical expert consensus in AH on the clinical use of triple fixed-dose antihypertensive therapy in Spain]

INTRODUCTION

The opinion of experts (different specialties) on the triple fixed-dose antihypertensive therapy in clinical practice may differ.

MATERIALS AND METHODS

Online questionnaire with controversial aspects of the triple therapy answered by panel of experts in hypertension (HT) using two-round modified Delphi method.

RESULTS

The questionnaire was completed by 158 experts: Internal Medicine (49), Nephrology (26), Cardiology (83). Consensus was reached (agreement) on 27/45 items (60%); 7 items showed differences statistically significant. Consensus was reached regarding: Predictive factors in the need for combination therapy and its efficacy vs. increasing the dose of a pretreatment, and advantage of triple therapy (prescription/adherence/cost/pressure control) vs. free combination.

CONCLUSIONS

This consensus provides an overview of the clinical use of triple therapy in moderate-severe and resistant/difficult to control HT.

[Unawareness of the K/DOQI guidelines for bone and mineral metabolism in predialysis chronic kidney disease: results of the OSERCE Spanish multicenter-study survey]

Since its publication in 2003, the K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease (CKD) have become a worldwide reference. The aim of this study was to analyze the observance to these guidelines in patients with a glomerular filtration rate < 60 ml/min/1,73m2 not yet included in dialysis in a Spanish multicenter cohort. A questionnaire by investigator/centre was completed by 32 different nephrologists participating in the OSERCE study and representing the overall Spanish public health net. We observed that biochemical parameters were measured less frequently than recommended, except in CKD stage 3. The therapeutic goals for intact PTH were not properly reported by 59 % of the consulted nephrologists for stages 3 and 4, whereas only 22% did not report them properly for stage 5. The goals for phosphorus were not adequately reported in 50 % of cases (stages 3 y 4) and 60 % (stage 5). For calcium, these values were 70 %, 73.3 % and 65.5 % for stages 3, 4 and 5, respectively. A corrected plasma calcium between 9.5 and 10.2 mg/dl is still considered adequate for 31%. As much as 87% nephrologists stated that they did not sistematically measure calcidiol plasma levels. In general, these results demonstrate that there is a great degree of unawareness of K/DOQITM predialysis guidelines. Thus, their poor implementation is probably not only due to the lower availability of approved therapeutic agents, the difficult achievement of goals or the disbelief on current recommendations. It would be desirable that forthcoming guidelines such as the KDIGO could also consider the need of educational efforts for CKD-Mineral and Bone Disorder.

[Seasonal perodicity in vascular access thrombosis for haemodialysis]

Different studies have shown that some clinical events, particularly cardiovascular and thrombotic events, show a regularity in its appearance. The aim of our study was to analyse the possible existence of seasonal periodicity in the incidence of the vascular access thrombosis in patients on chronic haemodialysis. Prospectively, we collected information of 164 patients with 250 episodes of vascular access thrombosis referred to our hospital from january 1995 to december 1999. An ANOVA test for comparison of the means, and a time series analysis were performed. During the five year study the consecutive number of thrombosis were 43, 57, 55, 59 and 36. When the different seasons were analysed, the cumulative number of events in summer during the study period were 91, a significant increase compared to spring, autumn, and winter (54, 54, and 51, respectively; p<0.001). Time series analysis confirmed that thrombolic events during summer showed an increased incidence over the mean (p<0.001), and it occurred every year. The same results were obtained when the PTFE grafts were analyzed separetely (july RR 2.62, p=0.002; august, RR 2.37, p=0.04), but not with the arteriovenous fistulae. In conclusion, this study showed a seasonal periodicity of vascular access thrombosis, with a PTFE graft. Although the causes were unknown, these data alert us on the convenience of an increased attention to the vascular access during the summer months in order to prevent its thrombosis.

[Renal transplantation with positive crossmatch]

INTRODUCTION

Lymphocytotoxic antibodies reduce the expectancy of renal transplantation due to the increased risk of a positive crossmatch.

MATERIAL AND METHODS

We analyzed the evolution of eight kidney transplants performed in our unit in presence of a positive crossmatch with historical T and/or B lymphocyte positive crossmatches.

RESULTS

Mean panel reactivity was 76,6 +/- 25,7% (r: 22-100%), been higher than 75% in six patients. Six patients were recipients of a second or third transplant. Immunosuppression consisted of quadruple therapy including induction with thymoglobuline. Five patients had delayed graft function, and one had primary non-function of the graft. One patient lost her graft due to chronic allograft nephropathy in the second year postransplantation. Six patients maintained a good renal function (serum creatinine 1,2 +/- 0,5 mg/dl, proteinuria 0,20 +/- 0,34 g/day).

CONCLUSION

Renal transplantation in presence of a positive cross-match with historical serum and T lymphocytes and/or B lymphocytes, was followed by a satisfactory graft survival.

[Vascular access guidelines for hemodialysis]

Quality of vascular access (VA) has a remarkable influence in hemodialysis patients outcomes. Dysfunction of VA represents a capital cause of morbi-mortality of these patients as well an increase in economical. Spanish Society of Neprhology, aware of the problem, has decided to carry out a revision of the issue with the aim of providing help in comprehensión and treatment related with VA problems, and achieving an homogenization of practices in three mayor aspects: to increase arteriovenous fistula utilization as first vascular access, to increment vascular access monitoring practice and rationalise central catheters use. We present a consensus document elaborated by a multidisciplinar group composed by nephrologists, vascular surgeons, interventional radiologysts, infectious diseases specialists and nephrological nurses. Along six chapters that cover patient education, creation of VA, care, monitoring, complications and central catheters, we present the state of the art and propose guidelines for the best practice, according different evidence based degrees, with the intention to provide help at the professionals in order to make aproppiate decissions. Several quality standars are also included.

[Guidelines on hemodialysis-associated viral infections]

The viric infections influence morbi-mortality in Chronic kidney Disease patients in hemodialysis therapy and can affect to the Staff of the Units. The guides considered the most relevant virus at the present moment: C Virus, B Virus and HIV. To prevent horizontal nosocomial transmission is necessary the observance always the universal precautions in the HD units, although sometimes can appeared seroconversions and epidemic bud when exist a break of these. Is analyzed different situations with special focus in units for acute patients. The following steps under the suspicious of the epidemic bud appeared in one of the annexes together with legislation according to this case. Respect to the staff in every one of the virus is shown prevention patterns, serologic markers to perform when an accident with infected blood occur, also is considered when treatment is indicated. The guides considered too the conditions necessary for include these patients on waiting list for kidney transplantation.

[Prognostic significance of programmed dialysis in patients who initiate renal substitutive treatment. Multicenter study in Spain]

BACKGROUND

The aim of our study was to analyse patient characteristics, mortality and costs, all of them in relation to whether starting dialysis was planned or unplanned.

METHODS

A total of 362 patients (227 male and 135 female) from five hospitals of the National Health System, who were started on chronic renal replacement therapy (RRT) during 1996 and 1997 were included. Patients who were started on RRT after acute renal failure were excluded. We carried out a retrospective analysis of the demographic characteristics, patients' conditions at the time of initiating dialysis and outcome and costs at six and thirty-six months of treatment. Patients were classified as planned (PL-D) or unplanned dialysis (UNPL-D), depending on whether or not the patient had a vascular or peritoneal access ready to use for initiating RRT.

RESULTS

One hundred and eighty-six patients (51.4%) started on dialysis in the PL-D group whereas 176 (48.6%) did it as UNPL-D. In this latter group, 135 (37.3% of the total) had previously been monitored by a nephrologist, and 41 (11.3%) initiated dialysis without previous nephrological follow-up. UNPL-D was associated with older age (p < 0.001), non-nephrological follow-up (p < 0.001), diabetes (34.7% vs 22.6%) (p = 0.011), haemodialysis as a first mode of RRT (94.9 vs 81.7%) (p < 0.001), higher comorbidity risk (p < 0.001), dialysis initiation with uraemic symptoms or fluid overload (p < 0.001), increased blood transfusion requirement (p < 0.001) and lower serum albumin (p < 0.001), creatinine clearance (p < 0.001), haemoglobin concentration (p < 0.001), and weight (p = 0.002). In the PL-D group the main primary renal diseases were glomerular and polycystic disease, whereas interstitial and diabetic nephropathy were higher in UNPL-D group (p = 0.005). Multivariate analysis showed that previous non nephrological follow-up, uraemic symptoms, interstitial nephritis as primary renal disease correlated with UNPL-D initiation, and it was followed by choosing haemodialysis as first RRT. UNPL-D was also associated with increased number of days of hospitalization at the initiation of dialysis, and during the first 6 months (p < 0.001), increase of hospitalization days (p = 0.009), and increased 6-month-mortality (10.2% vs 3.2%) (p = 0.015, log rank test), and three-year mortality (24.2 vs 36.9%) (p = 0.006, log rank test). The costs of UNPL-D were fivefold that of the PL-D group.

CONCLUSION

UNPL-D has been associated with worse overall clinical conditions at the initiation of chronic replacement therapy, choosing haemodialysis as first RRT, increased morbi-mortality and subsequent increase of costs.

[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.

[Endoluminal percutaneous thrombectomy as a treatment for acute vascular access thrombosis: long-term results of 123 procedures]

Percutaneous treatment of thrombosis of occluded vascular access (VA) for haemodialysis (HD) has been an alternative to surgical and pharmacological treatments, but long term results are not well defined. The aim of our study was to analyse the long term results of percutaneous thrombectomy as a treatment of occluded VA for HD. We conducted a prospective study from june 1995 to april 1999, including 123 consecutive thrombectomies in 64 VA in patients submitted to our hospital because of recent thrombosis of VA for HD. We used two different techniques, hydrodynamic catheter thrombectomy (Hydrolyser) in the 42 first procedures (34.1%), and since october 1996 we used mechanical balloon thrombolysis in the remaining 81 patients (65.9%). Underlying stenoses were evaluated by angiography, and treated by angioplasty. After the procedure, intravenous heparin was administered for 24 hours. The VA were 28 Brescia-Cimino arteriovenous fistulae (30.4%) and 64 PTFE grafts (69.6%).

PATIENT CHARACTERISTICS

mean age: 63 +/- 15 years (18-84), previous VA: 3.3 +/- 2.5 (0-9). The mean follow-up was 10.5 +/- 8.6 months (3-35). Percutaneous thrombectomy was able to remove the clots in 120 instances (technical success: 97.5%). After the thrombectomy 15 patients (16.3%) were immediately referred to the surgeon to perform a new VA due to vascular lesions in which percutaneous treatment was not indicated. Thirteen cases (14.1%) showed early thrombosis (< 72 hours). During the follow-up, 27 cases developed thrombosis (30%) and 26 VA were still patent (28.3%). In 23% of perfusion lung scans and in 2 of the 5 angiographies performed after thrombectomy, subsegmentary or segmentary perfusion defects were detected, without clinical significance. There were no relevant undesirable effects related to the technique and no symptomatic pulmonary embolism. In summary, percutaneous thrombectomy, whether hydrodynamic or mechanical, has shown to be an efficacious treatment of VA thrombosis for HD, preserving the VA with satisfactory long-term results.

Prevalence and risk factors for hepatitis C virus infection in continuous ambulatory peritoneal dialysis patients

BACKGROUND

Studies on hepatitis C virus antibodies (Anti-HCV) in CAPD patients are scarce and include a small number of patients. Nevertheless, risk factors related to Anti-HCV in these patients are still subject to controversy. Purpose of the study. To analyse the incidence and risk factors associated with the presence of Anti-HCV in CAPD patients.

METHODS

We studied 255 patients from five different treatment centres of our region. The analysis was repeated after excluding 161 patients who had previously received haemodialysis treatment at least once. Anti-HCV testing was made by the 2nd-generation ELISA: As a supplementary test we used RIBA-4 in three centers and INNOLIA in the other two. Risk factors were analysed using logistic regression model for multivariate analysis.

RESULTS

In the whole group, 29 patients (11.4%) were anti-HCV positive. Logistic regression analysis determined the following variables as independent risk factors: hepatitis previous to CAPD (P<0.001, odds ratio (OR):44.9), Anti HBc positivity (P=0.019, OR:9. 24), blood transfusions previous to CAPD (P=0.015, OR:1.05) and CAPD duration were excluded, the prevalence of HCV antibodies was 8.5% (8/94). In this group multivariate analysis showed that Anti-HCV positivity correlated with hepatitis previous to CAPD (P<0.0003, OR: 126) and Anti HBc positivity (P=0.002, OR:41.9).

CONCLUSIONS

Our prevalence of hepatitis C virus (HCV) infection in CAPD patients was lower than other renal replacement therapy modalities, and correlated to events occurring mainly before starting CAPD treatment. This technique could be considered as low risk for HCV infection.

[Acute renal failure after the administration of enalapril as presentation form of Takayasu's arteritis]

The case of a 19 year old patient with Takayasu arteritis with exclusive involvement of the abdominal aorta and without involvement of the renal arteries who presented severe arterial hypertension during the acute phase of the disease is referred. The administration of a dose of 20 mg of enalapril maleate was followed in less than 24 hours by lameness of the lower limbs and acute oligoanuric renal failure, both of which were reversible after discontinuation of the drug. During the inflammatory phase of the disease, treatment with high doses of prednisone was effective in the control of the general symptoms and the biologic parameters of inflammation. Surgical revascularization was successfully carried out 5 months after diagnosis. Two years later the patient continues to be normotense and asymptomatic.

[Acute rhabdomyolysis. A study of 44 cases]

Fourty four patients suffering non traumatic rhabdomyolysis (RM) are studied. The most frequently encountered etiologies were neurologic abnormalities in 26 patients, followed by infections in 7 patients and metabolic abnormalities in four cases. Eleven patients (25%) presented several associated factors. The clinical manifestations of RM were not very significant, with only 18% of patients presenting muscle pain, 38.6% proteinuria and 36.4% hematuria. A significant increase in K, CPK, LDH, and ASAT values was observed after the RM episode (p less than 0.05). Those patients with an infectious RM were older (p less than 0.05) and presented higher urea (p less than 0.01) and creatinine (p less than 0.05) values. Only two patients presented renal failure. One patient with septic shock died. RM is a relatively common condition, often secondary to multiple systemic processes, which can go unnoticed due to the underlying disease.