Intercambio plasmático terapéutico por plasmafiltración: experiencia de 11 años de un centro / Therapeutic plasma exchange: experience in 102 patients

BACKGROUND: Therapeutic Plasma Exchange (TPE) is a procedure in which plasma and harmful macromolecules are separated from the rest of the blood components by centrifugation or filtration through membranes and are replaced with solutions with albumin and/or plasma. AIM: To communicate our experience using TPE by filtration. MATERIAL AND METHODS: Review of records of 655 TPE sessions performed in 102 patients aged 50 ± 18 years (64% women). The requirement of renal replacement therapy (RRT) and seven days and one year mortality were recorded. RESULTS: Forty five percent of patients had hypertension or diabetes. The main indications for TPE were pulmonary-renal syndrome (PRS) (62%) and antibody mediated graft rejection (29%), followed by neurological diseases (36%). Fifteen percent of patients required RRT for one year. Mortality at seven days and one year was 20 and 30%, respectively. Out of the total of deaths associated with kidney diseases, 88% corresponded to PRS and ANCA vasculitis. The main complications were thrombocytopenia in 41%, hypocalcemia in 18%, and hypotension in 16%. CONCLUSIONS: In our experience, TPE by filtration is a safe technique, with mild and preventable complications. Despite this, the reported mortality is high, which reflects the severity of the diseases that motivated the indication for TPE.

Evaluación y Comparación de dos Sistemas de Cánula Nasal de Alto Flujo Artesanales / Evaluation and Comparison of Two Artisan alternative of High Flow Nasal Cannula Systems

Introducción: Una de las estrategias principales de atención para los pacientes con infección por SARS-CoV2 es el soporte respiratorio, incluida la terapia de oxígeno para pacientes con hipoxemia, en la que se ha informado que la cánula nasal de alto flujo (CNAF) es efectiva para mejorar la oxigenación, existiendo reportes de disminución en la intubación en pacientes con insuficiencia respiratoria hipoxémica aguda, en comparación con dispositivos de oxigenoterapia convencional. Dada la falta de insumos y equipos durante el periodo de pandemia, han surgido diversas formas de construir de manera artesanal equipos de alto flujo. Objetivo: Medir y comparar dos sistemas de alto flujo artesanales, en relación con su rendimiento teórico, en la entrega real de flujo total y en la fracción inspirada de oxígeno (FiO2). Métodos: Se confeccionaron dos modelos de CNAF artesanales. El primer equipo (CNAF-A) se confeccionó utilizando 2 flujómetros de aire y un flujómetro de oxígeno unidos a un conector que recibe los flujos provenientes de los 3 flujómetros mencionados y cuya mezcla de aire pasa por un sistema de termo-humidificación. El segundo modelo (CNAF-B) se construyó usando un inyector de un equipo de oxigenoterapia de concentración variable (tipo "Venturi"), conectado a un flujómetro de oxígeno, en donde se realiza una mezcla con aire ambiental para entregar un flujo final y una concentración de oxígeno determinada. Se confeccionaron 10 equipos de cada modelo de sistema de CNAF artesanal. Se evaluó el flujo final y la FiO2 entregada por cada CNAF. Los resultados obtenidos fueron comparados con los valores teóricos que debiera entregar cada equipo de CNAF artesanal y se evaluó la correlación entre los valores medidos. Resultados: Se observó una baja correlación entre el flujo esperado teórico y el flujo medido. Resultados similares se encontraron al evaluar valores teóricos y medidos de FiO2. El modelo CNAF-A demostró generar flujos mas altos de lo esperado logrando cumplir con niveles requeridos para considerarse un sistema de alto flujo. El sistema CNAF-B entregó flujos significativamente menores a los valores esperados. Conclusiones: Ambos modelos de CNAF presentan bajo nivel de concordancia con sus valores teóricos, tanto en la FiO2 como en el flujo entregado. Sin embargo, la CNAF-A se logra comportar como sistema de alto flujo. Un sistema de CNAF confeccionado con un sistema Venturi no es suficiente para generar terapia de alto flujo.

Introduction: One of the main care strategies for patients with SARS-CoV2 infection is respiratory support, including oxygen therapy for patients with hypoxemia, in which the high-flow nasal cannula (CNAF) has been reported to be effective to improve oxygenation, there are reports of decreased intubation in patients with acute hypoxemic respiratory failure, compared to conventional oxygen therapy devices. Given the lack of supplies and equipment during the pandemic period, various ways have emerged to build high-flow equipment by hand. Objective: Measure and compare two artisanal high-flow systems, in relation to their theoretical performance, in the actual delivery of total flow and in the fraction of inspired oxygen (FiO2). Methods: Two models of artisanal CNAF were made. The first equipment (CNAF-A) was made using 2 air flow meters and an oxygen flow meter connected to a connector that receives the flows from the 3 mentioned flow meters and whose air mixture passes through a thermo-humidification system. The second model (CNAF-B) was built using an injector of a variable concentration oxygen therapy equipment ("Venturi" type), connected to an oxygen flow meter, where a mixture is made with ambient air to deliver a final flow and a given oxygen concentration. 10 kits of each model of the artisanal CNAF system were made. The final flow and the FiO2 delivered by each CNAF were evaluated. The results obtained were compared with the theoretical values ​​that each artisanal CNAF equipment should deliver and the correlation between the measured values ​​was evaluated. Results: A low correlation was observed between the theoretical expected flow and the measured flow. Similar results were found when evaluating theoretical and measured FiO2 values. The CNAF-A model proved to generate higher flows than expected, achieving the required levels to be considered a high flow system. The CNAF-B system delivered flows significantly lower than the expected values. Conclusions: Both CNAF models show a low level of agreement with their theoretical values, both in FiO2 and in the delivered flow. However, CNAF-A manages to behave as a high-flux system. A CNAF system made with a Venturi system is not sufficient to generate high-flow therapy.

Necrosis papilar renal bilateral de resolución espontánea como causa de hematuria microscópica. Caso clínico / Bilateral renal papillary necrosis of spontaneous resolution as a cause of microscopic hematuria. Report of one case

Renal papillary necrosis is an infrequent cause of hematuria characterized by ischemic necrosis of the renal medulla, especially the papilla. Its most common cause is analgesic abuse. Despite being oligo-symptomatic, in many cases its presence is associated with serious functional sequelae. Imaging, especially computed tomography, is essential to make the diagnosis. We report a 63-year-old female studied for an asymptomatic microscopic hematuria whose tomographic study showed a bilateral renal papillary necrosis. No etiology was found, and she evolved with a spontaneous complete remission.

Efecto de las variantes de CYP2C9 sobre la dosis de losartán en hipertensos chilenos / Association between cytochrome p4502c9 polymorphisms and losartan dosing in hypertensive patients

Background Losartan is widely used in many clinicals settings. Its dosage is related to the genetic characteristics of CYP2C9 enzymatic activity, which metabolizes losartan to its active form E-3174, responsible for the antihypertensive effect. Aims To identify the frequency of allelic variants CYP2C9*2 and CYP2C9*3 in hypertensive patients and to compare genotypes with a healthy Chilean population. To relate polymorphisms with the losartan dosing to obtain an optimal blood pressure. Material and Methods We studied 30 patients with controlled essential hypertension using losartan with normal liver function, and 202 healthy people. Peripheral blood DNA genotyping was performed by polymerase chain reaction to identify the polymorphisms. Allelic and genotypic frequencies were compared. Results In hypertensive patients, allelic frequencies were 0.85 (CYP2C9*1), 0.05 (CYP2C9*2) and 0.1 (CYP2C9*3). Genotypic frequencies were 73.3% (CYP2C9*1/*1), 6.7% (CYP2C9*1/*2), 16.7% (CYP2C9*1/*3) and 3.3% (CYP2C9*2/3); observing a significantly higher frequency of the allele CYP2C9*3 (p=0.041) and CYP2C9*1/*3 genotype (p=0.04). A non-significant tendency to need a larger dose of losartan was observed with the CYP2C9 * 3 allele, with an odds ratio (OR) of 1.46 (95% confidence intervals (CI) 0.01-18.64). The same tendency was observed with the need to use losartan twice a day, obtaining an OR of 5.88 (CI 0.54 -62.14). Conclusions There could be a relationship between the presence of CYP2C9 polymorphisms and the pathogenesis of hypertension. The presence of CYP2C9*3 is associated with the need for higher doses of losartan, possibly due to a decrease in the conversion of losartan to E-3174.

¿Son efectivas las intervenciones psicológicas para mejorar el control de la Diabetes Mellitus tipo 2 en adultos?: una revisión sistemática y metaanálisis / Psychological interventions for patients with type 2 diabetes mellitus. A systematic review and meta-analysis

Background Affordable interventions to improve metabolic control of Type 2-Diabetes Mellitus are increasingly necessary. Aim To review systematically the existing literature on the effects of psychological interventions on Type-2 Diabetes Mellitus compensation. Material and Methods We performed a systematic literature review and meta-analysis on the effectiveness of psychological interventions implemented for Type-2 Diabetes Mellitus patients. Research included the following electronic databases: PubMed, Bireme, Web of Science, SciELO, Embase, EBSCOhost, SCOPUS, Psychology Database. Results Most studies showed a decrease in the level of glycated hemoglobin after interventions, which applied different initiatives complementary to standard medical treatment. Mainly, these interventions encompassed training for self-monitoring and control of diabetes based on cognitive behavioral psychology, counseling, self-assessment and physical-spiritual work based on transpersonal psychology. Conclusions Psychological tools could be an adjunct to the standard medical treatment for patients with Type-2 Diabetes Mellitus, reducing glycated hemoglobin levels and improving self-regulation, disease awareness and adherence from the self-efficacy perception perspective.

Entrenamiento físico en personas con enfermedad renal crónica avanzada: beneficios de su implementación en la práctica clínica / Exercise training in advanced chronic kidney disease

Chronic kidney disease is associated with an increase in cardiovascular risk and mortality, and a decrease in the health-related quality of life. It is known that the physical capacity of patients with chronic kidney disease is lower than their healthy counterparts. It also decreases progressively after the start of hemodialysis, even leading to the loss of functional independence. There is a positive association between exercise and improvement of many targets in chronic kidney disease, especially in dialysis patients, such as cellular apoptosis, immune improvement and inflammation. In addition, several clinical studies and systematic reviews show an improvement in different clinical and laboratory variables and suggest a lower mortality, proving a reduction of health care economic costs. Exercise intervention in dialysis is safe. Although different guidelines promote exercise, it is necessary to work on its implementation on a large scale.

Efectividad de intervenciones basadas en Mindfulness para mejorar el control de la Diabetes Mellitus tipo 2: una revisión sistemática e integración metanalitica preliminar / Effectiveness of Mindfulness-based interventions to improve control of type 2 diabetes mellitus: a systematic review and preliminary meta-analytic integration

Resumen El propósito de este trabajo fue estudiar la efectividad de intervenciones basadas en Mindfulness sobre el nivel de hemoglobina glicada —HbA1c— en pacientes con diabetes mellitus tipo 2 —DM2—. Se realizó una revisión sistemática e integración metanalítica preliminar. La búsqueda de los estudios se realizó en las siguientes bases: PubMed, Bireme, Web of Science, SciELO, Embase, EBSCOhost, SCOPUS, Psychology Database. Se identificaron 10 artículos: cuatro fueron llevados a cabo en Estados Unidos, dos en Irán, uno en Alemania, uno en Australia, uno en Tailandia y uno en Inglaterra. Se observó una reducción en los niveles de la HbA1c utilizando Mindfulness en comparación a los grupos controles (p < 0,02). Además, se observó un efecto diferenciado al analizar según número de participantes, sexo y tiempo de seguimiento. Se concluyó que el uso de intervenciones basadas en Mindfulness tendría un efecto indirecto sobre la reducción de la hemoglobina glicada.

Abstract The purpose of this paper was to study the effectiveness of Mindfulness-based interventions on the level of glycated hemoglobin —HbA1c— in patients with type 2 diabetes mellitus —DM2—. A systematic review and preliminary meta-analytic integration was performed. The search of the studies was carried out in the following bases: PubMed, Bireme, Web of Science, SciELO, Embase, EBSCOhost, SCOPUS, Psychology Database. Ten articles were identified: four were published in the United States, two in Iran, one in Germany, one in Australia, one in Thailand and one in England. A reduction in HbA1c levels was observed using Mindfulness compared to control groups (p <0,02). In addition, according to the number of participants, sex and time of follow-up a differentiated effect was found. It was concluded that the use of interventions based on Mindfulness would have an indirect effect on the reduction of glycated hemoglobin (HbA1c).

Prevalencias de complicaciones asociadas a la instalación de catéter venoso central para hemodiálisis / Prevalence of complications associated with central venous catheter instalation for hemodyalisis

Background: Placing central venous lines under ultrasonographic guidance reduces the complications of the procedure. Aim: To compare prevalences of complications of central venous line placements with or without ultrasonographic guidance. Material and Methods: Descriptive study that contemplated the comparison of two groups of patients subjected to a central venous line placement at a nephrology service for renal replacement therapy. In one group of 100 patients, the line was placed without ultrasonographic guidance between 2008 and 2012. Between 2015 and 2017 the line was placed in 138 patients using ultrasonographic guidance. The prevalences of complications with both types of procedures were recorded. Results: The frequency of complications of procedures with and without ultrasonographic guidance was 0.7 and 18% respectively (prevalence ratio 0.04, 95% confidence interval 0-0.3). Ninety five percent of recorded complications were arterial puncture, followed by hematomas in 10% and pneumothorax in 5%. The higher prevalence of complications was observed in emergency line placement without ultrasonographic guidance. There was a direct association between the number of line placement attempts in a single procedure and the prevalence of complications. Conclusions: Ultrasonographic guidance is associated with a reduction in the prevalence of central venous line complications.

Remodelación ventricular post infarto agudo al miocardio: caso clínico / Ventricular remodeling post acute infarct to myocardium: clinical case

Se presenta el caso de una paciente de 64 años que tras sufrir un IAM, sufre un proceso de remodelación ventricular en un período menor 7 meses que la conduce a una insuficiencia cardíaca severa.