Toma de decisiones en hemodiálisis crónica: estudio cualitativo en adultos mayores / Decision making among older adults in hemodialysis. A qualitative assessment

Background: In Chile there are 22,310 people in Chronic Hemodialysis (CHD), 53% of them older adults (OA). Shared decision-making and advance directives (AD) are especially important in OA with end-stage chronic renal failure, since they have greater levels of disability, morbidity and mortality, raising doubts about the benefit of therapy. Aims: To understand the experience in decision making and explore ways to express AD, in OA in CHD. Material and Methods: A qualitative phenomenological study, performing 12 in-depth interviews to OA who had been at CHD for at least one year. Results: The analysis revealed four broad comprehensive categories, two related to participation in the decision to enter CHD, namely the experience of subjects as spectators and their lack of interest for decision support and two referred to the expression of AD, namely the difficulty in facing their own finitude and resistance to express AD. Conclusions: There is little participation of older adults in the decision about their admission to dialysis therapy, and once they enter the CHD program they are not prepared to discuss AD in general, nor an eventual suspension of dialysis in particular.

Donación y trasplante de órganos: propuesta desde la Academia Chilena de Medicina / A proposal of the Chilean Academy of Medicine to improve organ procurement and transplantation in Chile

The Chilean Academy of Medicine designated a group of specialists to evaluate the practice and to propose reforms for organ donation and transplantation, due to the general insufficiencies at the national level with these procedures. In the last six years the mean number of organ transplants in Chile was 340 cases per year while effective cadaveric donors ranged between 6 and 10 per million inhabitants. These averages remained stable during this period and are among the lowest in the region. Our analysis attributed these deficient results mainly to low organ donation and inefficient procurement due to lack of compliance with protocols and little accountability. The committee proposes several measures for improvement. These are a systematic and obligatory report of potential organ donors by all emergency and critical care centers, frequent evaluation of results, empowering of health authorities to correct insufficiencies in organ procurement, education programs for primary, secondary, technical and university students to improve their knowledge about the social significance and solidarity required for transplantation policies and specialized updated training of all health professionals involved. Organ donation and transplantation must be based on clear and fair ethical considerations in order to be accepted by the general public.

Compromiso renal en vasculitis asociadas a anticuerpos anticitoplasma de neutrófilos. Recomendaciones de consenso de las Sociedades Chilenas de Nefrología y Reumatología / Renal involvement in antineutrophil cytoplasmic antibodies (ANCA) associated vasculitides. Recommendations of the Chilean Societies of Nephrology and Rheumatology

Renal involvement is a frequent complication in antineutrophil cytoplasmic antibodies (ANCA)associated vasculitides, adding morbidity and mortality, such as chronic kidney disease and the need for renal replacement therapy. With the aim of reaching a consensus on relevant issues regarding the diagnosis, treatment and follow-up of patients with these diseases, the Chilean Societies of Nephrology and Rheumatology formed a working group that, based on a critical review of the available literature and their experience, raised and answered consensually a set of questions relevant to the subject. This document includes aspects related to the clinical diagnosis, the histological characteristics, the therapeutic alternatives to induce and maintain the remission of the disease, relapse surveillance strategies and complementary therapies.

Declaración de la Academia Chilena de Medicina sobre el Título V de la Ley 20. 850 (Ley Ricarte Soto) y su proyecto de reglamento "De los ensayos clínicos de productos farmacéuticos y elementos de uso médico" / Declaration of the Chilean Academy of Medicine of Law 20. 850 "On clinical trials of pharmaceutical products and medical devices" and of the bylaw that will regulate its application

In Chile, high cost treatments required by selected medical conditions are financed by the State, according to Law 20.850. A bylaw under discussion by the Senate regulates clinical trials, posing complex issues that will endanger local interest in front-line research: 1) The exclusive and mandatory control bestowed to the Institute of Public Health during all stages of the trials and also the surveillance of institutions performing clinical trials, overriding their Clinical Research Review Boards; 2) The 10 year period during which any adverse event is assumed to have been caused by the medication or devise evaluated by the trial, unless the contrary is proven in a judicial process; 3) Individuals submitted to the trials are entitled to free post trial access to the treatment received during the study, financed by the trial supporting entities and as long as the drug or devise is considered to be useful. While agreeing with the need to have a National Registry of Clinical Trials, we predict that the mentioned critical issues in the bylaw will lead to difficulties and unnecessary judicial processes, thus limiting clinicians’ interest in performing research. We propose to modify the bylaw, excluding responsibilities on events associated with the natural evolution of the medical condition, with patients’ ageing or with comorbidities and clinical events considered unpredictable when the protocol was accepted. We recommend that the free post trial access should be a joint decision involving the patient and the attending physician, taking in consideration that the volunteer has been exposed to risks and burdens, or when discontinuation of treatment entails a vital risk until the treatment under study has been approved and becomes available in the national market.

En Chile los tratamientos de alto costo requeridos por seleccionadas condiciones médicas son financiados por el Estado, de acuerdo a la Ley 20.85, que se hizo efectiva en noviembre de 2015. Un reglamento de esta ley -actualmente en discusión por el Senado- incluye la regulación de los ensayos clínicos y plantea importantes aspectos que van a poner en riesgo la realización de investigaciones clínicas avanzadas: 1) El control exclusivo y mandatorio otorgado al Instituto de Salud Pública durante todas las etapas de los ensayos y la vigilancia de las instituciones que los realizan, que sobrepasa las atribuciones de los Comités de Ética Científica Institucionales; 2) El período de hasta 10 años después de la aparición de cualquier efecto adverso, durante el cual se asume causado por el medicamento o dispositivo evaluado en el ensayo, mientras no se demuestre lo contrario en un proceso judicial; 3) Los participantes de los estudios tienen derecho a continuar con el tratamiento recibido durante el estudio una vez terminado este, financiado por las entidades que patrocinan los estudios y mientras el fármaco o dispositivo se consideren útil. Estamos de acuerdo con la necesidad de contar con un Registro Nacional de Ensayos Clínicos. Sin embargo, predecimos que los aspectos críticos del reglamento causarán dificultades y procesos judiciales innecesarios, lo que limitará el interés de los clínicos en realizar investigación. Proponemos que el reglamento debe modificarse a fin de excluir responsabilidades sobre eventos asociados con la evolución natural de la condición clínica, el envejecimiento del paciente, comorbilidades y eventos clínicos no predecibles cuando se aceptó el estudio. Recomendamos que el acceso gratuito posterior al estudio debe constituir una decisión conjunta del paciente y su médico tratante, considerando los riesgos y la carga a que se expuso el paciente, o al riesgo vital secundario a la suspensión del tratamiento del estudio mientras no esté disponible en el mercado nacional.

Conflictos de intereses en nefrología / Conflicts of interest in nephrology

Since doctors disposed of effective tools to serve their patients, they had to worry about the proper management of available resources and how to deal with the relationship with the industry that provides such resources. In this relation­ship, health professionals may be involved in conflicts of interest that they need to acknowledge and learn how to handle. This article discusses the conflicts of interest in nephrology. Its objectives are to identify those areas where such conflicts could occur; to help to solve them, always considering the best interest of patients; and to help health workers to keep in mind that they have to preserve their autonomy and professional integrity. Conflicts of interest of professionals in the renal area and related scientific societies, with the industry producing equipment, supplies and drugs are reviewed. Dichotomy, payment for referral, self-referral of patients and incentives for cost control are analyzed. Finally, recommendations to help preserve a good practice in nephrology are made.

Problemas ético-clínicos en hemodiálisis crónica: percepción de médicos y enfermeras / Ethical issues perceived by health care professionals working in chronic hemodialysis centers

Background: Clinical teams working at chronic hemodialysis centers (CHC) frequently have to face ethical problems, but there is no systematic approach to deal with them. Aim: To study the ethical problems perceived by health professionals at CHC. Material and Methods: Eighty randomly selected physicians and 139 nurses from 23 CHC, answered a structured questionnaire, devised by the research team. Results: Twenty-six percent of respondents had postgraduate studies in clinical ethics. The ethical problems mentioned by respondents were therapeutic disproportion in 66.7%, lack of communication between patients, their families and the clinical team in 25.9%, personal conflicts of interests related with hemodialysis prescription in 14.6% and conflicts of interests of other members of the clinical team in 30.6%. The percentage of respondents that experienced not starting or discontinuing hemodialysis treatment due to decision of patients’ relatives was 86.8%. Only 45.2% of health professionals had the opportunity to take part in decision-making meetings. Eighty seven percent of respondents supported the use of advanced directives in the event of a cardio respiratory arrest during treatment. Conclusions: To improve the approach to ethical problems in CHC, it is necessary to improve training in clinical ethics, promote an effective dialogue between the patients, their families and health professionals, and follow their advance directives in case of cardiac arrest during treatment.

Recomendaciones sobre el manejo del compromiso renal del lupus eritematoso sistémico: Documento de Consenso de las Sociedades Chilenas de Nefrología y Reumatología / A consensus of the Chilean Nephrology and Rheumatology Societies on renal involvement in systemic lupus erythematosus

Renal involvement affects over one half of patients with Systemic Lupus Erythematosus increasing their mortality and morbidity, including chronic renal disease and the need of renal replacement therapies. Aiming to achieve a consensus in the most relevant topics on diagnosis, therapy and follow-up of patients with lupus renal disease, the Chilean Societies of Nephrology and Rheumatology constituted a workgroup that, based on a critical review of the available literature and their experience, raised and answered by consensus a set of relevant questions. This document includes aspects related to the clinical diagnosis, the importance of a suitable histological classification, therapeutic alternatives to induce and maintain disease remission, strategies for follow-up, additional therapies and ginecological-obstetric issues.

Recomendaciones del Comité de Ética de la Sociedad Chilena de Nefrología para el manejo de los problemas ético-clínicos de pacientes adultos con enfermedad renal crónica terminal / Recommendations of the Ethics Committee of the Chilean Society of Nephrology for the management of ethical problems in adult end stage renal disease patients

There are different approaches to treat patients with End Stage Renal Disease (ESRD): hemodialysis, peritoneal dialysis, renal transplantation and conservative medical management. The choice of the best therapy for each patient, needs both clinical and ethical skills. The Ethics Committee of the Chilean Society of Nephrology has elaborated recommendations to help health workers to deal with the ethical and clinical problems related to patients suffering ESRD. Its goal is to guide, at a national level, the effective use of minimal standards in the treatment and care of patients with ESRD, including appropriate care and information for patients, therapy selection, management of difficult cases and potential conflicts.

El riñón en la endocarditis infecciosa / The kidney in infectious endocarditis

Se discuten las diferentes manifestaciones renales (estructurales, funcionales e inmunológicas) de la Endocarditis Infecciosa asociadas a casos clínicos vividos.