Deficiencia de hierro en enfermedad renal crónica

Contexto: la deficiencia de hierro es un trastorno frecuentemente observado en pacientes con enfermedad renal crónica (ERC), sobre todo en estadios avanzados. Su presencia se asocia a una mayor morbilidad y mortalidad. La deficiencia de hierro puede ser absoluta o funcional. La deficiencia absoluta se refiere a una ausencia o una reducción de las reservas de hierro, mientras que la deficiencia funcional se define por la presencia de depósitos de hierro adecuados pero con una disponibilidad insuficiente de hierro para su incorporación en los precursores eritroides. Varios factores de riesgo contribuyen a la deficiencia absoluta y funcional de hierro en ERC, incluyendo pérdidas hemáticas, absorción alterada de hierro e inflamación crónica. Objetivo: con esta revisión narrativa se pretende presentar las definiciones, los aspectos fisiopatológicos, los criterios diagnósticos y las medidas terapéuticas en el paciente con diagnóstico de ERC con deficiencia de hierro. Metodología: se realizó una revisión no sistemática de la literatura en la base de datos PubMed, incluyendo además las guías internacionales más utilizadas que abordan el tema de deficiencia de hierro en ERC. Resultados: se incluyeron un total de 30 referencias bibliográficas. La deficiencia de hierro puede ser absoluta o relativa y el déficit absoluto de hierro se produce con valores de ferritina 100 mcg/l, pero con una TSAT < 20 %. El tratamiento del déficit absoluto consta de reposición de hierro oral o endovenoso y en pacientes que aún no reciben diálisis, se puede hacer una prueba terapéutica con hierro oral, de no haber respuesta se optará por hierro endovenoso, mientras que en pacientes que sí reciben diálisis, la medida ideal es el hierro endovenoso, preferiblemente en preparaciones que permitan esquemas de altas dosis y bajas frecuencias de administración. Las metas propuestas por las distintas guías presentan variaciones entre 500 y 700 mcg/l de ferritina. Conclusiones: el déficit de hierro debe buscarse activamente en pacientes con ERC, ya que su presencia y la falta de intervención conlleva a un incremento en los desenlaces adversos. La terapia con hierro es el pilar del tratamiento y la elección del agente a utilizar dependerá de las características individuales del paciente y de la disponibilidad de las preparaciones de hierro oral o endovenoso.

Background: Iron deficiency is a disorder frequently observed in patients with chronic kidney disease (CKD), especially in advanced stages. Its presence is associated with increased morbidity and mortality. Iron deficiency can be absolute or functional. Absolute deficiency refers to absent or reduced iron stores, while functional deficiency is defined by the presence of adequate iron stores but insufficient iron availability for incorporation into erythroid precursors. Several risk factors contribute to absolute and functional iron deficiency in CKD, including blood fi, impaired iron absorption, and chronic inflammation. Purpose: With this narrative review, it is intended to present the details, pathophysiological aspects, diagnostic criteria and therapeutic options in patients diagnosed with chronic kidney disease with iron deficiency. Methodology: A non-systematic review of the fi ron ra was carried out, in the PubMed database, also including the most used international guidelines that address the issue fi ron deficiency in chronic kidney disease. Results: A total of 30 bibliographical references were included. Iron deficiency can be absolute or relative. The absolute iron deficiency occurs with ferritin values 100 mcg/l but with a TSAT <20 % Treatment of absolute deficiency consists of oral or intravenous iron replacement. In a patient who is not yet receiving dialysis, a therapeutic trial with oral iron can be done, if there is no response, intravenous iron will be chosen. In patients receiving dialysis, the ideal measure is intravenous iron, preferably in preparations that allow high-dose schemes and low frequencies of administration. The goals proposed by the different guidelines present variations between 500 and 700 mcg/l d ferritin. Conclusions: iron deficiency should be actively sought in patients with CKD, since its presence and lack of intervention leads to an increase in adverse outcomes. Iron therapy is the mainstay of treatment; the choice of the agent to be used depends on the individual characteristics of the patient and the availability of oral or intravenous iron preparations.

Lidocaine infusión, basics and clinical issues / Lidocaína endovenosa, fundamentos y usos clínicos

Abstract Optimum pain management, minimizing chronic complications and ensuring a good safety profile, is growing in importance day by day. Lidocaine infusion has an adequate safety profile and several desirable characteristics in the clinical setting. This review describes the characteristics of this drug, as well as its potential indications. Moreover, it describes the basic concepts around lidocaine use, mechanisms of action and clinical applications, as well as the use of infusions in acute pain and repercussions in chronic pain. A review of the literature in English and Spanish was conducted in several databases, with no publication date limit. Articles considered relevant, without including the grey literature, were selected independently. Lidocaine infusion is an option for acute postoperative pain control in major surgery and contributes to opioid sparing and reduced length of stay, with ample evidence in abdominal surgery, rendering it an option to recommend in various protocols. It has an acceptable safety profile in special populations and it is considered useful to diminish the incidence of persistent, chronic and neuropathic pain related to the surgical procedure.

Resumen El manejo óptimo del dolor, minimizando las complicaciones crónicas y cumpliendo con un buen perfil de seguridad, cada día resulta más importante. La lidocaína en infusión tiene un perfil de seguridad adecuado con diversas propiedades deseables en el ámbito clínico. En la presente revisión se describen las características de este medicamento, así como sus potenciales indicaciones. Este artículo describe los conceptos básicos de la lidocaína, sus mecanismos de acción y utilidades clínicas, así como su uso en infusión en el dolor agudo y su repercusión en el dolor crónico. Se realizó una revisión de la literatura en varias bases de datos, sin fecha límite de publicación, en inglés y español. Se realizó la selección independiente de los artículos considerados relevantes, sin incluir literatura gris. La lidocaína en infusión es una alternativa para el control del dolor agudo postoperatorio en la cirugía mayor y contribuye a la disminución del consumo de opioides y la estancia hospitalaria, con amplia evidencia en cirugía abdominal que permite recomendarla en diversos protocolos. Tiene un perfil de seguridad aceptable en poblaciones especiales y se considera útil para disminuir la incidencia de dolor postoperatorio persistente, crónico y neuropático ligado al procedimiento quirúrgico.

Profilaxia da pancreatite pós-colangiopancreatografia retrógrada endoscópica: avaliação de dois regimes com AINEs diferentes / Post endoscopic retrograde cholangiopancreatography pancreatitis prophylaxis: evaluation of two different nsaid regimens

ABSTRACT BACKGROUND: Endoscopic retrograde cholangiopancreatography is a widely used therapeutic modality for the pancreaticobiliary tree. However, it is responsible for the highest rates of complications among the endoscopic procedures, especially post-endoscopic retrograde cholangiopancreatography pancreatitis. The preventive methods include mechanical and pharmacological approaches, such as the use of non-steroidal anti-inflammatory drugs. OBJECTIVE: To compare the efficacy of two different strategies using non-steroidal anti-inflammatory drugs for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis, and to clarify the uncertainty about the route of administration of non-steroidal anti-inflammatory drugs in the prevention of this complication. METHODS: This was a prospective trial. Two therapeutic groups were compared with a control group that was composed of patients who underwent endoscopic retrograde cholangiopancreatography, performed in the same service and by the same team in the period preceding the study (historical series), without the administration of any type of prophylaxis. The first group received 100 mg rectal diclofenac. The second group received 100 mg intravenous ketoprofen. Both groups were compared, separately and jointly, with the control group. RESULTS: Post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in 4.39% (12/273) of the participants. In the group without prophylaxis, the incidence was 6.89% (10/145). Among those who received intravenous ketoprofen, the incidence was 2.56% (2/78). No cases of acute post-procedural pancreatitis were observed in the group that received rectal diclofenac (0/52). Although there was no statistical difference between the therapeutic groups when they were separately analyzed, a statistical difference in the prevention of post-procedural pancreatitis was observed when they were analyzed together (P=0.037). CONCLUSION: This study provides evidence for the efficacy of non-steroidal anti-inflammatory drugs in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis.

RESUMO CONTEXTO: A colangiopancreatografia retrógrada endoscópica (CPRE) é uma modalidade terapêutica amplamente utilizada para vias biliopancreáticas, responsável pelas taxas mais elevadas de complicações entre os procedimentos endoscópicos, especialmente a pancreatite pós-CPRE (PPC). Os métodos preventivos incluem abordagens mecânicas e farmacológicas, entre elas, a utilização de antinflamatórios não esteroidais (AINEs). OBJETIVO: Comparar a eficácia de duas estratégias diferentes utilizando AINEs para a prevenção de PPC. Elucidar o cenário incerto sobre a via de administração do AINEs na prevenção da PPC. MÉTODOS - Ensaio clínico prospectivo. Duas estratégias terapêuticas foram comparadas a um grupo controle, composto por pacientes submetidos a CPRE no mesmo serviço e com a mesma equipe no período anterior ao estudo (série histórica), que não recebeu qualquer tipo de profilaxia. O primeiro grupo experimental recebeu 100 mg de diclofenaco via retal, o segundo grupo recebeu 100 mg de cetoprofeno endovenoso. Ambos os grupos foram comparados separadamente e em associação com o grupo de controle. RESULTADOS: A PPC ocorreu em 4,39% (12/273) dos participantes. No grupo sem profilaxia, esta incidência foi de 6,89% (10/145); entre os que receberam cetoprofeno endovenoso foi de 2,56% (2/78). Não houve casos de pancreatite aguda após o procedimento no grupo que recebeu diclofenaco via retal (0/52). Apesar de não haver diferença estatística entre estes grupos analisados separadamente, quando os dois grupos terapêuticos são analisados em conjunto estes apresentam diferenças estatísticas na prevenção da PPC (P=0,037). CONCLUSÃO: Este estudo foi capaz de corroborar a eficácia da utilização de AINEs para a profilaxia de pancreatite pós-CPRE.

Trombose induzida pelo calor endovenoso: relato de dois casos tratados com rivaroxabana e revisão da literatura / Endothermal heat-induced thrombosis (EHIT): reports on two case treated with rivaroxaban and literature review

Define-se trombose induzida pelo calor endovenoso como a propagação do trombo a partir de uma veia superficial em direção a uma veia mais profunda. Em geral, é considerada clinicamente insignificante quando não há propagação do trombo para o sistema venoso profundo. Essa condição pode ser tratada com terapia anticoagulante, embora a observação pareça ser suficiente, principalmente para graus menores. Neste estudo, relatamos dois casos de trombose induzida pelo calor endovenoso que teriam indicação de heparina de baixo peso molecular até a resolução do quadro. Porém, optou-se pelo uso da rivaroxabana (15 mg de 12 em 12h), com resolução completa do trombo em 4 semanas (caso 1) e em 7 dias (caso 2). A rivaroxabana pode ser uma alternativa promissora no tratamento da trombose induzida pelo calor endovenoso avançada, pela simplicidade da posologia, sem comprometimento da eficácia ou da segurança. São necessários estudos prospectivos, randomizados e controlados que possibilitem melhor entendimento da condição e o desenvolvimento de recomendações mais definitivas sobre opções de prevenção e tratamento.

Endothermal heat-induced thrombosis (EHIT) is defined as propagation of a thrombus from a superficial vein into a deeper vein and is generally considered clinically insignificant if the thrombus does not propagate to the deep venous system. The condition can be treated with anticoagulation therapy, although monitoring may be sufficient, especially in less severe cases. In this paper we report on two cases of EHIT that met the criteria for indication of low molecular weight heparin until resolution of symptoms. However, the treatment actually chosen was 15 mg of rivaroxaban every 12 h and the outcomes were complete thrombus resolution in 4 weeks in Case 1 and 7 days in Case 2. Rivaroxaban may be a promising alternative for treatment of severe EHIT because the dosage regimen is simplified without compromising efficacy or safety. Prospective, randomized, controlled studies are needed to better understand EHIT and to develop more definitive recommendations on prevention and treatment options for this condition.

Utilidad de la neurografía por IRM en el diagnóstico de la meralgia parestésica / Usefulness of MRI neurography in the diagnosis of meralgia paresthetica

Objetivo: Evidenciar cómo la Imagen Resonancia magnética (IRM) con equipo de 3 Tesla, utilizando secuencias neurográficas específicas y uso de contraste endovenoso permite ubicar el área de lesión nerviosa. Caso clínico: Mujer de 17 años con hipoestesia y parestesias en la región anterior y lateral del muslo izquierdo, se le realiza un estudio de Resonancia Magnética (RM) en equipo Philips Achieva 3 T, usando protocolo neurográfico y contraste endovenoso, demostrando engrosamiento y cambios de señal del nervio y realce post-contraste característico de la neuropraxia. Conclusión: el caso presentado demuestra el valor actual de los estudios de IRM con técnica neurográfica en la evaluación de la patología de los nervios periféricos. Es fundamental utilizar secuencias adecuadas, realizar un estudio comparativo bilateral y en lo posible usar medios de contraste endovenoso para aumentar la sensibilidad. Estos hallazgos resultan de gran importancia a la hora de planificar la estrategia quirúrgica.

Objective: Demonstrate the usefulness of Magnetic Resonance Imaging (MRI) with equipment 3 Tesla using neurographics specific sequences and use of intravenous contrast can locate the area of nerve injury.Clinical case: 17 year old woman with hypoesthesia and paresthesia in the anterior and lateral region of the left thigh, the study of Magnetic Resonance Imaging (MRI) equipment Philips Achieva 3 T, using neurographic protocol and intravenous contrast, showing thickening and changes signal nerve and post-contrast enhancement characteristic in neuropraxia.Conclusión: the case presented shows the current value of MRI studies with neurographics technique in assessing the pathology of peripheral nerves. It is essential to use appropriate sequences, make a bilateral comparative study and possible use of intravenous contrast media to increase sensitivity. These findings are of great importance when planning the surgical strategy.

Factores relacionados con la incidencia de flebitis por cateter endovenoso. centro médico Cemesa, San Pedro Sula- Honduras. mayo - julio 2015

OBJETIVO: Determinar los factores relacionados con la incidencia de casos deflebitis por catéter endovenoso en el centro médico San Pedrano mayo a juniodel 2015. DISEÑO: es un estudio descriptivo de corte transversal, se analizaron 48 expedientes que contenían datos de los pacientes que estuvieron expuestos auna canalización de la vía endovenosa. RESULTADOS: Se encontraron 48 pacientes que cumplieron con la definición decaso, la tasa de incidencia se dio en el mes de julio y el menor en el mes de mayo, el grupo más alto fue el de 60 años con 4 casos (8.33%), de 41 a 50 años con 3 casos (6.25%), de 21 a 40 años solo 1 caso (2.08%). Es relevante que un 100 % presentaron flebitis por administración de glóbulos rojos empacados, Recurso humano que realiza el procedimiento auxiliares de enfermería 4 (8.33%) enfermera profesional 3 casos (6.25%) Médicos anestesiólogos 2(4.17%).

Síndrome cardio-renal anémico / Cardio-renal anemia syndrome

Las interacciones entre el corazón y el riñón se han convertido en un área de considerable interés, dada la interdependencia de los mismos. Esto motivó la definición y conceptualización del síndrome cardio-renal anémico, que incluye interacciones bidireccionales, donde alteraciones, tanto agudas como crónicas de cualquier órgano, pueden afectar indistintamente la función renal o la ventricular. El tratamiento, involucra el bloqueo del eje renina angiotensina aldosterona y durante una descompensación aguda es válido el soporte dialítico para control de la volemia. La anemia, es multifactorial, se debe tratar de manera oportuna con hierro endovenoso y eritropoyetina recombinante, reduciendo al mínimo el soporte transfusional. El manejo, la definición y el pronóstico del síndrome cardio-renal anémico aún sigue siendo controversial y es un reto para el internista moderno (Acta Med Colomb 2011; 36: 141-144).

The interactions between the heart and the kidney have become an area of considerable interest, given their interdependence. This led to the definition and conceptualization of cardio-renal anemic syndrome, which includes a bidirectional interaction: acute or chronic injuries of any organ indiscriminately affect renal or ventricular function. Treatment involves blocking the rennin-angiotensin-aldosterone axis and, during acute decompensation, dialytic support for volemic control. Anemia is due to multiple causesand must be treated promptly with intravenous iron and recombinant erythropoietin, to minimize the need for transfusions. Management, definition and prognosis of cardio-renal anemic syndrome are still controversial and represent a challenge for the modern internist (Acta Med Colomb 2011; 36: 141-144).

Optimización del tratamiento con hierro endovenoso en hemodiálisis: Estudio clínico prospectivo a largo plazo / Optimizing iron therapy in hemodialysis: a prospective long term clinical study

A pesar del amplio uso del hierro endovenoso en hemodiálisis, resta aún identificar un índice adecuado para optimizar esta terapéutica en el largo plazo. Con ese objetivo, se diseñó un estudio prospectivo de cohorte, de larga duración, que consistió en un período basal (PB) y dos períodos experimentales: PI y PII. Se infundió hierro dextran de bajo peso molecular a 100, 150 y 200 mg/mes, respectivamente, durante 6 meses y al final de cada periodo se determinaron: saturación de transferrina (TSAT), ferritina (FERR), porcentaje de eritrocitos hipocrómicos (HYPO) y contenido de hemoglobina en reticulocitos (HCr). Durante el estudio la albúmina aumentó significativamente, pero la Hgb, la dosis de EPO y la proteína C-reactiva se mantuvieron sin cambios. Los cambios en HYPO y FERR fueron inespecíficos. Sólo TSAT (desde 21.4 ± 6 en PB a 34 ± 7.1% en PII, p = 0.01) y HCr (desde 27.5 ± 1.3 en PB a 29.3 ± 1.7 pg en PII, P = 0.045) respondieron específicamente, pero el porcentaje de aumento de TSAT fue de 65% (IC95% 22), y el de HCr sólo 6% (IC95% 2.3; p = 0.0002). Esta diferencia a favor de TSAT se observó en todos los pacientes. Los resultados sugieren la utilización de 200 mg/FeIV/mes y que, de los índices estudiados, TSAT sería el más adecuado para optimizar el uso a largo plazo del hierro endovenoso en hemodiálisis.

The usefulness of intravenous iron therapy in hemodialysis is evidence-based. However, controversy still arises about the most suitable iron marker to optimize this treatment in the long term. We aimed to determine the most suitable marker with a prospective, cohort study, designed to comprise a basal period (BP) and two consecutive experimental periods (PI, PII). Low molecular weight iron dextran was infused at 100, 150 and 200 mg/month respectively, on a biweekly basis, during 6 months. At the end of each period, the following were determined: transferrin saturation (TSAT), ferritin (FERR), percentage of hypochromic eritrocytes (HYPO) and haemoglobin content in reticulocytes (HCr). During the study, albumin increased significantly, whereas no significant changes in hemoglobin, EPO doses and C-reactive protein were observed. Changes in HYPO and FERR were unspecific. Only TSAT (from 21.4 ± 6 in PB to 34 ± 7.1% in PII, p < 0.01) and HCr (from 27.5 ± 1.3 in PB to 29.3 ± 1.7 pg in PII, P < 0.05 ) responded specifically to changes in Fe doses, but change of TSAT was 65% (CI 95% 22), whereas change of HCr was just 6% (CI 95% 2.3; p = 0.0002). The difference was observed in all patients. Results suggest that 200 mg/FeIV/month is effective and that, of the markers tested in this study, TSAT would be the most suitable one to the practicing nephrologist to optimize intravenous iron in the long term.

Ferro endovenoso melhora sintomas de pacientes com insuficiência cardíaca que têm deficiência / Intravenous iron improves symptoms in patients with heart failure who have disabilities

Em pacientes portadores de insuficiência cardíaca crônica sintomática que têm uma fração de ejeção ventricular reduzida e evidência de deficiência de ferro, o tratamento prolongado com ferro endovenoso melhora os sintomas, a capacidade funcional e a qualidade de vida. Esse benefício é observado em pacientes com e sem anemia.