Manejo de la mujer embarazada con enfermedad renal crónica / Management of the pregnant woman with chronic kidney disease

Actualmente existe una mayor prevalencia de enfermedad renal crónica en mujeres en edad fértil. Se proyecta que los embarazos en mujeres con enfermedad renal crónica se mantengan al alza, debido a la postergación de la maternidad, el aumento de las morbilidades asociadas y mejores terapias que logran mayores tasas de fecundidad en estas pacientes. En este contexto, el embarazo puede acelerar la progresión de la enfermedad renal crónica, lo cual depende de la etiología y etapa de la enfermedad al momento de la concepción. Asimismo, este grupo de mujeres presenta mayor riesgo de complicaciones del embarazo, principalmente preeclampsia, además de peores resultados obstétricos como parto prematuro, bajo peso al nacimiento, aborto y óbito fetal. El manejo se fundamenta en estabilizar la patología de base y prevenir complicaciones, mediante el ajuste de terapias farmacológicas, reducción de exposición a fármacos teratogénicos, optimización del control metabólico y de presión arterial. El monitoreo de la función renal desde el inicio del embarazo permite identificar oportunamente la progresión del daño renal y evaluar la necesidad de iniciar terapia dialítica. La presente revisión busca resumir las principales recomendaciones de las más recientes guías internacionales respecto al manejo de mujeres embarazadas con enfermedad renal crónica.

The prevalence of chronic kidney disease in women of childbearing age has risen. It is thought that pregnancy in women with chronic kidney disease is now higher because of delaying pregnancy, a rise in associated morbidities and improved therapies which achieve higher fertility in these patients. In this context, depending on the etiology and the stage of the disease at the time of conception, pregnancy may accelerate the progression of the chronic kidney disease. Similarly, this group of women has a higher risk of pregnancy complications, mainly eclampsia, and poorer obstetric results such as premature birth, low birthweight, spontaneous abortion, and stillbirth. Its management comprises establishing the underlying pathology and preventing complications through tailoring pharmacological therapy, reducing the exposure to teratogenic drugs, and optimizing metabolic control and blood pressure. Monitoring kidney function from the start of pregnancy follows the progression of kidney damage and facilitates evaluating the necessity of dialysis. This review seeks to summarize the principal recommendations of the most recent international guidelines in the management of pregnant women with chronic kidney disease.

Conversión de sandimmune a neoral en pacientes trasplantados renales que reciben ciclosporina-ketoconazol / Conversion of sandimmune to neoral in patients with renal transplantation treated with cyclosporine-ketoconazol

Patients and methods: Thirty four patients with more than one year after the transplantation, with stable renal function and receiving triple immunosuppression were studied. Conventional cyclosporine was changed to the microemulsion form maintaining the same daily dose. Drug serum levels, serum creatinine and blood pressure were measured within two to eight months after the conversion. Doses of microemulsion cyclosporine were adjusted to achieve serum levels of 150 ñ 40 ng/ml. Results: Microemulsion cyclosporine induced a slight initial increase in blood cyclosporine levels. Afterwards, levels were more stable than with conventional cyclosporine (165-185 and 145-210 ng/ml respectively) and the dispersion of values were lower (standard deviations of 70 and 100 ng/ml respectively). Twenty three patients did not require dose adjustments, in four it was reduced and in five it was increased. There were no changes in serum creatinine or blood pressure after the conversion. Conslusion: More stable serum levels without adverse reactions were obtained with microemulsion cyclosporine. Doses of cyclos porine need not to be changed during the conversion

Insuficiencia renal aguda en pacientes con y sin sepsis: pronóstico y evolución / Acute renal failure in septic and non septic patients: prognostic and evolution

The purpose of this prospective study was to determine whether the course and prognosis of acute renal failure (ARF) in patients with and without sepsis are different. 252 (8 percent) of 3086 consecutive patients admited to a medical surgical intensive care unit (ICU) developed ARE. One hundred forty-nine (59 percent) were septic and 103 (41 percent) were non-septic. No differences were founded between groups regarding the incidence of oliguria, hyperkalemia, hypercatabolism, gastrointestinal bleeding, duration of oliguria and renal deficit, severity of azotemia, dialysis requirements and duration of stay in the hospital. There were statistically significant differences between septic and non septic patients with respect to hyponatremia (67.8 vs 54.4 percent, p<0.04), respiratory failure (68 vs 54 percent, p<0.04), and thrombocytopenia (64 vs 48 percent, p<0.02). Mortality in septic patients was higher than in non-septics (56 vs 42.7 percent, p<0.009). Factors associated with increased mortality in ARF septic patients were respiratory failure, metabolic acidosis and oliguria while in the non-septics they were hepatic dysfunction, hyperkalemia, respiratory failure and infection acquired during the course of renal failure. We conclude that ARF developing in septic patients has a higher mortality than that of non-septic patients, whereas the incidence of hypercatabolism and oliguria was not different between both groups