Early start hemodialysis with a catheter may be associated with greater mortality: A propensity score analysis.

INTRODUCTION: Deciding when and how to initiate hemodialysis (HD) is still controversial. An early start (ES) seems to show a lack of benefit. "Lead time bias" and comorbidities have been associated with different outcomes in ES groups. On the other hand, it is well accepted that the impact the type of vascular access (VA) has on patient survival. Our aim was to evaluate survival with early start (ES) versus late start (LS) on HD, taking into account the vascular access (VA) used. METHODS: Between 01/1995 and 06/2018, 503 incidental patients initiated HD at our Dialysis Unit. eGFR was estimated by the CKD-EPI equation. Diabetes mellitus (DM), coronary disease (CD), and peripheral vascular disease (PVD) were considered comorbid conditions. According to eGFR and VA, patients were divided into four groups: G1: ES (eGFR > 7 mL/min) with catheter (ES + C), G2: ES with fistula or graft (F/G) (ES + F/G), G3: LS (eGFR< 7 mL/min) with catheter (LS + C), and G4: LS with F/G (LS + F/G). The cut-off value to define ES or LS was based on median eGFR for these 503 patients. We compared patient's survival rates by Kaplan-Meier and log-rank test. The four groups were compared before and after matching with propensity scores (PS). Cox analysis was performed to determine the impact of predictors of mortality. RESULTS: Median eGFR was 7 (5.3-9.5) mL/min/1.73 m2 , median follow-up time was 30.9 (13-50) months, 52.1% had F/G access at entry, and 46.9% died during the observation period. Among the four groups, the ES + C were significantly older, and there were more diabetics and comorbid conditions, while phosphatemia, iPTH, albumin, and hemoglobin were significantly higher in the LS groups. Before propensity score (PS) matching, the ES + C group had a poor survival rate (p < 0.0001), while LS + F/G access had the best survival. After PS, a total of 180 patients were selected in the same four groups and ES + C kept showing a statistically significant poorer survival. Multivariate analysis revealed that ES + C was an independent predictor of mortality. CONCLUSION: In this retrospective study, ES + C on HD was associated with a higher mortality rate than LS. This association persisted after PS matching.

Assessment of the humoral response to the homologous Gam-COVID-Vac (Sputnik V) or heterologous Sputnik V/mRNA-1273 (Moderna) vaccination against SARS-CoV-2 in dialysis patients.

BACKGROUND AND AIM: Dialysis patients are a high-risk population and have a reduced immune response to vaccination against SARS-CoV-2. The aim of this study was to assess the humoral response to homologous Gam-COVID-Vac (Sputnik V) and heterologous Sputnik V/mRNA-1273 (Moderna) vaccination in dialysis patients. The vaccination scheme depended on dose availability and the prioritization of risk populations as established by the Argentine Ministry of Health. METHODS: Previous COVID-19 infection was determined in symptomatic patients. Binding IgG antibodies against the spike (S) receptor-binding domain (RBD) of SARS-CoV-2 (anti-S-RBD) concentration was assessed between 3 and 16 weeks after the boost dose. Anti-S-RBD antibodies were quantified using the Abbott Diagnostics SARS-CoV-2 IgG II Quant chemiluminescent microparticle immunoassay (CMIA) on an Architect i2000 SR and an Alinity I analyzer (Abbott Diagnostics, Abbott Park, Illinois, USA). To standardize the results to WHO binding antibody units (BAU), a correction factor for Abbott arbitrary units (AU) was applied where 1 BAU/mL equals 0.142 AU, as previously established by Abbott with the WHO international standard NIBSC 20-136. Following the manufacturer's recommendations, samples were considered reactive for anti-S-RBD when titers were above 50 AU/mL (7.2 BAU/mL). An 80% protective effect (PROT-80) against symptomatic SARS-CoV-2 infection was assumed when anti-S-RBD titers were 506 BAU/ml or higher. Charlson Comorbidity Index (CCI) score was classified as mild = 1-2, moderate = 3-4, and severe ≥ 5. Side effects were evaluated until day 7 by patients´ self-reported questionnaire. RESULTS: One hundred seven participants were enrolled [n = 84 homologous (SpV/SpV), nn 23 heterologous (SpV/Mod)]. Median (IQR) age was 64 (50-75) years old and 79 (73.8%) were male. Additionally, 19 (22.6%) of the SpV/SpV and 4 (17.4%) of the SpV/Mod group had a prior confirmed SARS-CoV-2 infection (p = 0.589). In the overall population, 103 patients reached seroconversion (96.3%). Anti-S-RBD IgG median titers (IQR) were higher in the heterologous [1222 (288-5680) BAU/mL] than in the homologous scheme [447 (100-1551) BAU/mL], p = 0.022. In a linear model adjusted for age, gender, days from first vaccination to boost dose and days from the boost dose to the anti-S-RBD IgG determination, previous SARS-COV-2 infection (B: 2062.2; CI95: 1231.8-2892.6; p < 0.001), and SpV/Mod vaccination scheme (B: 1294.6; CI95: 435.58-2147.6; p = 0.003) were independently associated with anti-S-RBD levels. Finally, a higher frequency of adverse effects was associated with the heterologous scheme, although they were well tolerated by all individuals. CONCLUSIONS: The present study provides evidence that the homologous SpV/SpV and heterologous SpV/Mod schemes showed good efficacy and safety in patients on chronic dialysis. These results could be useful for designing future vaccination strategies, especially aimed at this risk group.

Litiasis renal y riesgo cardiovascular / Nephrolithiasis and cardiovascular risk

La litiasis renal es una enfermedad frecuente cuya prevalencia ha aumentado en los últimos años. En la actualidad se la considera como una patología sistémica; no limitada al riñón y a las vías urinarias, sino relacionada en gran medida a diabetes mellitus, obesidad, hipertensión arterial, hiperuricemia, hipercolesterolemia y enfermedad renal crónica, todos factores de riesgo cardiovascular que suelen vincularse a eventos severos como accidentes cerebrovasculares, enfermedad coronaria o infarto agudo de miocardio. Numerosos estudios transversales y meta-análisis han demostrado la asociación entre estas dos entidades. En esta revisión intentaremos demostrar los mecanismos involucrados en la fisiopatología de la litiasis renal y su relación con enfermedad cardiovascular. Como mecanismos involucrados, se mencionan tres asociaciones. La primera se refiere al estrés oxidativo y la inflamación. La segunda asociación se refiere a la presencia de mecanismos litogénicos que contribuyen a la calcificación vascular. Como última teoría se realiza la asociación ya conocida, de obesidad, síndrome metabólico, diabetes e hipertensión arterial, todos factores de riesgo para el desarrollo de litiasis renal así como de enfermedad cardiovascular, recordando que la litiasis renal es causa, en un 8%, del desarrollo de enfermedad renal crónica, otro factor de riesgo para enfermedad y muerte cardiovascular. Como conclusión se confirma la teoría de que la litiasis renal no es una enfermedad limitada al riñón y la vía urinaria, si no que se trata de una enfermedad sistémica, con riesgo de eventos cardiovasculares tan severos que pueden llevar a la muerte.

Renal lithiasis is a frequent disease whose prevalence has increased in recent years. Nowadays it is considered as a systemic pathology, not limited to the kidney and the urinary tract, but largely related to diabetes mellitus, obesity, hypertension, hyperuricemia, hypercholesterolemia and chronic kidney disease; all cardiovascular risk factors that are usually linked to severe events such as stroke, coronary heart disease or acute myocardial infarction. Numerous cross-sectional studies and meta-analyzes have proved the association between renal lithiasis and cardiovascular disease. In this review we will try to demonstrate the mechanisms involved in the pathophysiology of these two entities. Three associations are mentioned. The first one refers to oxidative stress and inflammation. The second association refers to the presence of lithogenetic mechanisms contributing to vascular calcification. The last theory is the already known correlation with obesity, metabolic syndrome, diabetes and hypertension; all risk factors for the development of renal lithiasis as well as cardiovascular disease. Let us remember that renal lithiasis is the cause, in 8% of cases, of the development of chronic kidney disease, another risk factor for cardiovascular disease and death. In conclusion, the theory that renal lithiasis is not a disease limited to the kidney and the urinary tract is confirmed; it is rather a systemic disease, with a risk of cardiovascular events so severe that they can lead to death.

[Rapidly progressive crescentic glomerulonephritis in the elderly]. / Glomerulonefritis rápidamente progresiva en ancianos.

Rapidly progressive glomerulonephritis (RPGN) is a syndrome characterized by glomerular lesions giving rise to acute renal injury that develops within a brief period of time, usually days or a few months. It is classified according to the underlying mechanism of injury and the immunofluorescence findings into four main disorders. In the last decade, nephrologists have witnessed a steady rise in the mean age of the patients diagnosed with RPGN. This observation may reflect an increase in the incidence of this entity and also a more timely diagnosis. We present 3 cases of RPGN in elderly patients, diagnosed within a 3 month period at our institution which illustrates the spectrum of these conditions.

Glomerulonefritis rápidamente progresiva en ancianos / Rapidly progressive crescentic glomerulonephritis in the elderly

La glomerulonefritis rápidamente progresiva (GNRP) es un síndrome clínico que se caracteriza por la presencia de signos urinarios de enfermedad glomerular e insuficiencia renal de desarrollo en un lapso de días a pocos meses. La inmunofluorescencia permite clasificar a las GNRP en cuatro tipos según se identifiquen o no depósitos inmunes y, si están presentes, de acuerdo con su naturaleza. En la última década se ha demostrado un aumento constante en el promedio de edad de los pacientes con GNRP. Este fenómeno podría reflejar tanto una mayor incidencia de la enfermedad, como un incremento en la tasa de diagnóstico. Se presentan 3 casos de GNRP en adultos mayores de 65 años, diagnosticados en un periodo de 3 meses en nuestra institución.(AU)

Rapidly progressive glomerulonephritis (RPGN) is a syndrome characterized by glomerular lesions giving rise to acute renal injury that develops within a brief period of time, usually days or a few months. It is classified according to the underlying mechanism of injury and the immunofluorescence findings into four main disorders. In the last decade, nephrologists have witnessed a steady rise in the mean age of the patients diagnosed with RPGN. This observation may reflect an increase in the incidence of this entity and also a more timely diagnosis. We present 3 cases of RPGN in elderly patients, diagnosed within a 3-month period at our institution which illustrates the spectrum of these conditions.(AU)

Glomerulonefritis rápidamente progresiva en ancianos / Rapidly progressive crescentic glomerulonephritis in the elderly

La glomerulonefritis rápidamente progresiva (GNRP) es un síndrome clínico que se caracteriza por la presencia de signos urinarios de enfermedad glomerular e insuficiencia renal de desarrollo en un lapso de días a pocos meses. La inmunofluorescencia permite clasificar a las GNRP en cuatro tipos según se identifiquen o no depósitos inmunes y, si están presentes, de acuerdo con su naturaleza. En la última década se ha demostrado un aumento constante en el promedio de edad de los pacientes con GNRP. Este fenómeno podría reflejar tanto una mayor incidencia de la enfermedad, como un incremento en la tasa de diagnóstico. Se presentan 3 casos de GNRP en adultos mayores de 65 años, diagnosticados en un periodo de 3 meses en nuestra institución.

Rapidly progressive glomerulonephritis (RPGN) is a syndrome characterized by glomerular lesions giving rise to acute renal injury that develops within a brief period of time, usually days or a few months. It is classified according to the underlying mechanism of injury and the immunofluorescence findings into four main disorders. In the last decade, nephrologists have witnessed a steady rise in the mean age of the patients diagnosed with RPGN. This observation may reflect an increase in the incidence of this entity and also a more timely diagnosis. We present 3 cases of RPGN in elderly patients, diagnosed within a 3-month period at our institution which illustrates the spectrum of these conditions.

Glomerulonefritis rápidamente progresiva en ancianos. / [Rapidly progressive crescentic glomerulonephritis in the elderly].

Rapidly progressive glomerulonephritis (RPGN) is a syndrome characterized by glomerular lesions giving rise to acute renal injury that develops within a brief period of time, usually days or a few months. It is classified according to the underlying mechanism of injury and the immunofluorescence findings into four main disorders. In the last decade, nephrologists have witnessed a steady rise in the mean age of the patients diagnosed with RPGN. This observation may reflect an increase in the incidence of this entity and also a more timely diagnosis. We present 3 cases of RPGN in elderly patients, diagnosed within a 3 month period at our institution which illustrates the spectrum of these conditions.