Pruritus in dialysis patients. Review and new perspectives.

Uremic pruritus (UP) is one of the most uncomfortable symptoms for patients in dialysis. UP has a great impact on dialysis patients' quality of life and has a great prevalence between those (28-70%). Physiopathology of UP is unknown and usually is unnoticed for most nephrologists (in more than 65% of centers is underdiagnosed). This lack of awareness drives to the unsuccessful treatment of this symptom. Moreover, the fact that most studies have been carried out on small populations and the difficulty assessing UP complicates a correct therapeutical approach. For this reason, we have designed treatment algorithms based on the efficacy of the drugs but also its safeness to avoid adverse effects.

Prurito en pacientes en diálisis. Revisión de la literatura y nuevas perspectivas / Pruritus in dialysis patients. Review and new perspectives

El prurito es uno de los síntomas más incómodos y que más impacta en la calidad de vida de los pacientes en diálisis. Su prevalencia es bastante elevada en pacientes en diálisis (28-70%). La fisiopatología del prurito urémico es desconocida, y este síntoma a menudo pasa desapercibido para el personal sanitario, siendo infradiagnosticado en más del 65% de los centros. Esta falta de reconocimiento deriva en un abordaje terapéutico ineficaz del prurito urémico. Por otro lado, la mayoría de los ensayos farmacológicos para el tratamiento del prurito urémico han sido realizados en poblaciones reducidas y están sujetos a la subjetiva medición del propio síntoma. Por este motivo, hemos propuesto algoritmos de tratamiento, teniendo en cuenta la evidencia que avala a cada fármaco y a la vez la pluripatología y la polifarmacia de cada paciente, con el fin de evitar efectos adversos. (AU)

Uremic pruritus (UP) is one of the most uncomfortable symptoms for patients in dialysis. UP has a great impact on dialysis patients’ quality of life and has a great prevalence between those (28–70%). Physiopathology of UP is unknown and usually is unnoticed for most nephrologists (in more than 65% of centers is underdiagnosed). This lack of awareness drives to the unsuccessful treatment of this symptom. Moreover, the fact that most studies have been carried out on small populations and the difficulty assessing UP complicates a correct therapeutical approach. For this reason, we have designed treatment algorithms based on the efficacy of the drugs but also its safeness to avoid adverse effects. (AU)

Pruritus in dialysis patients. Review and new perspectives. / Prurito en pacientes en diálisis. Revisión de la literatura y nuevas perspectivas.

Uremic pruritus (UP) is one of the most uncomfortable symptoms for patients in dialysis. UP has a great impact on dialysis patients' quality of life and has a great prevalence between those (28-70%). Physiopathology of UP is unknown and usually is unnoticed for most nephrologists (in more than 65% of centers is underdiagnosed). This lack of awareness drives to the unsuccessful treatment of this symptom. Moreover, the fact that most studies have been carried out on small populations and the difficulty assessing UP complicates a correct therapeutical approach. For this reason, we have designed treatment algorithms based on the efficacy of the drugs but also its safeness to avoid adverse effects.

Síndrome de desgaste proteico energético en la enfermedad renal crónica avanzada: prevalencia y características clínicas específicas / Protein-energy wasting syndrome in advanced chronic kidney disease: prevalence and specific clinical characteristics

Introducción: El desgaste proteico energético (DPE) se asocia a mayor mortalidad y difiere dependiendo del estadio de la enfermedad renal y de la técnica de diálisis. Su prevalencia en pacientes sin diálisis se encuentra poco estudiada y oscila entre el 0 y el 40,8%. Objetivo: Evaluar el estado nutricional según criterios de DPE y por valoración global subjetiva (VGS) de un colectivo de pacientes españoles con enfermedad renal crónica avanzada (ERCA). Pacientes y métodos: Estudio transversal de 186 pacientes (101 hombres) con edad media de 66,1±16 años. Se realizó evaluación nutricional mediante: VGS, criterios de DPE, registro dietético de 3 días, parámetros antropométricos y bioimpedancia vectorial. Resultados: Un 30,1% presentaba DPE, con diferencias significativas entre hombres y mujeres (22,8 vs. 33,8%; p<0,005) y un 27,9% tenía valores de VGS en rangos de desnutrición. Sin diferencia entre los 2 métodos estudiados. Los hombres presentaron mayores niveles de proteinuria, porcentaje de masa muscular e ingesta de nutrientes. Las mujeres tuvieron mayores niveles de colesterol total, HDL y porcentaje de masa grasa. Las características de los pacientes con DPE fueron: bajos valores de albúmina y recuento total de linfocitos, elevada proteinuria, baja masa grasa, baja masa muscular y cociente Na/K elevado. El análisis multivariante mostró asociación de DPE con proteinuria (OR: 1,257; IC 95%: 1,084-1,457; p=0,002), porcentaje de ingesta lipídica (OR: 0,903; IC 95%: 0,893-0,983; p=0,008), recuento total de linfocitos (OR: 0,999; IC 95%: 0,998-0,999; p=0,001) y el índice de masa celular (OR: 0,995; IC 95%: 0,992-0,998). Conclusión: Existe malnutrición en población española con ERCA, medida por diferentes herramientas. Consideramos conveniente adecuar nuevos elementos diagnósticos a los criterios de DPE (AU)

Introduction: Protein-energy wasting (PEW) is associated with increased mortality and differs depending on the chronic kidney disease (CKD) stage and the dialysis technique. The prevalence in non-dialysis patients is understudied and ranges from 0 to 40.8%. Objective: To evaluate the nutritional status of a group of Spanish advanced CKD patients by PEW criteria and subjective global assessment (SGA). Patients and methods: Cross-sectional study of 186 patients (101 men) with a mean age of 66.1±16 years. The nutritional assessment consisted of: SGA, PEW criteria, 3-day dietary records, anthropometric parameters and bioelectrical impedance vector analysis. Results: The prevalence of PEW was 30.1%, with significant differences between men and women (22.8 vs. 33.8%, p < 0.005), while 27.9% of SGA values were within the range of malnutrition. No differences were found between the 2methods. Men had higher proteinuria, percentage of muscle mass and nutrient intake. Women had higher levels of total cholesterol, HDL and a higher body fat percentage. The characteristics of patients with PEW were low albumin levels and a low total lymphocyte count, high proteinuria, low fat and muscle mass and a high Na/K ratio. The multivariate analysis found PEW to be associated with: proteinuria (OR: 1.257; 95% CI: 1.084-1.457, p=0.002), percentage of fat intake (OR: 0.903; 95% CI: 0.893-0.983, p=0.008), total lymphocyte count (OR: 0.999; 95% CI: 0.998-0.999, p=0.001) and cell mass index (OR: 0.995; 95% CI: 0.992-0.998). Conclusion: Malnutrition was identified in Spanish advanced CKD patients measured by different tools. We consider it appropriate to adapt new diagnostic elements to PEW criteria (AU)

Protein-energy wasting syndrome in advanced chronic kidney disease: prevalence and specific clinical characteristics. / Síndrome de desgaste proteico energético en la enfermedad renal crónica avanzada: prevalencia y características clínicas específicas.

INTRODUCTION: Protein-energy wasting (PEW) is associated with increased mortality and differs depending on the chronic kidney disease (CKD) stage and the dialysis technique. The prevalence in non-dialysis patients is understudied and ranges from 0 to 40.8%. OBJECTIVE: To evaluate the nutritional status of a group of Spanish advanced CKD patients by PEW criteria and subjective global assessment (SGA). PATIENTS AND METHODS: Cross-sectional study of 186 patients (101 men) with a mean age of 66.1±16 years. The nutritional assessment consisted of: SGA, PEW criteria, 3-day dietary records, anthropometric parameters and bioelectrical impedance vector analysis. RESULTS: The prevalence of PEW was 30.1%, with significant differences between men and women (22.8 vs. 33.8%, p < 0.005), while 27.9% of SGA values were within the range of malnutrition. No differences were found between the 2methods. Men had higher proteinuria, percentage of muscle mass and nutrient intake. Women had higher levels of total cholesterol, HDL and a higher body fat percentage. The characteristics of patients with PEW were low albumin levels and a low total lymphocyte count, high proteinuria, low fat and muscle mass and a high Na/K ratio. The multivariate analysis found PEW to be associated with: proteinuria (OR: 1.257; 95% CI: 1.084-1.457, p=0.002), percentage of fat intake (OR: 0.903; 95% CI: 0.893-0.983, p=0.008), total lymphocyte count (OR: 0.999; 95% CI: 0.998-0.999, p=0.001) and cell mass index (OR: 0.995; 95% CI: 0.992-0.998). CONCLUSION: Malnutrition was identified in Spanish advanced CKD patients measured by different tools. We consider it appropriate to adapt new diagnostic elements to PEW criteria.

Barreras para el desarrollo de la hemodiálisis domiciliaria en España. Encuesta a nefrólogos españoles / Barriers for the development of home hemodialysis in Spain. Spanish nephrologists survey

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Hemodiálisis domiciliaria en España / Home haemodialysis in Spain

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Experiencia de 30 años en una unidad de diálisis peritoneal: supervivencia a largo plazo / Thirty years in a peritoneal dialysis unit: long-term survival

INTRODUCCIÓN: La diálisis peritoneal (DP) es una técnica establecida de tratamiento renal sustitutivo que gracias a los avances tecnológicos y clínicos ha mejorado sus tasas de supervivencia en los últimos años. OBJETIVOS: Evaluar la supervivencia del paciente y la técnica en DP a lo largo de 30 años y según las décadas para consolidar su utilidad sanitaria. MÉTODOS: Estudio retrospectivo de cohorte de todos los pacientes del programa de DP del Hospital Universitario La Paz (Madrid) desde 1980 a 2010. Variables demográficas y clínicas fueron recolectadas de los registros clínicos. RESULTADOS: Se incluyeron 667 pacientes, 54,4 % varones, con edad media de 51,47 años y una mediana de seguimiento de 23,1 meses. Se observó un aumento progresivo de pacientes incidentes, especialmente en DP automatizada (DPA). La supervivencia del paciente a 5 años fue de 54 %, con una mediana de 64,66 meses, con un aumento significativo en la última década (p = 0,000). La edad, la comorbilidad, el sexo masculino, la DP crónica ambulatoria (DPCA) y la diabetes fueron predictores de la supervivencia del paciente. La supervivencia de la técnica a los 5 años fue del 64,2 % y la mediana de 82 meses. El éxito de la técnica fue mayor en jóvenes, en DPA y con menor comorbilidad

BACKGROUND AND OBJECTIVE: Peritoneal dialysis (PD) is an establish renal replacement therapy that has evolved in the last decades thanks to technological and clinical advances showing improving survival rates. The aim of this study was to evaluate the patient and technique survival in PD over 30 years of experience and in the different decades. PATIENTS AND METHOD: Retrospective cohort study including all patients in the PD unit of the Hospital Universitario La Paz (Madrid), from 1980 to 2010. Demographics and clinical variables were collected from medical records. RESULTS: A total of 667 patients were included, 54.4% males, with a mean age of 51.47 years and a median follow-up of 23.1 months. There was an increased in PD incident patients, especially in automatic PD (APD). Patient survival at 5 years was 54%, with a median of 64.66 months, increasing significantly in the last decade (p = 0.000). Age, comorbidity, male sex, chronic ambulatory PD and diabetes were independently predictor of patient survival. Technique survival at 5 years was 64.2% and median 82 months. Younger patients, in APD and with less comorbity showed better technique survival. CONCLUSIONS: Over 30 years of experience we found an increased in incident patients. Age, comorbidity and diabetes were still the main predictors of survival

Thirty years in a peritoneal dialysis unit: long-term survival.

INTRODUCTION: Peritoneal dialysis (PD) is an established renal replacement therapy technique which thanks to the technological and clinical advances has improved its survival rates in recent years. OBJECTIVES: The aim of this study was to evaluate patient and technique survival in PD over 30 years, according to the different decades in order to consolidate its usefulness in healthcare. METHOD: Retrospective cohort study including all patients in the PD programme of the Hospital Universitario La Paz (Madrid), from 1980 to 2010. Demographic and clinical variables were collected from medical records. RESULTS: A total of 667 patients were included, 54.4% male, with a mean age of 51.47 years and a median follow-up period of 23.1 months. There was a progressive increase in PD incident patients, especially in automated PD (APD). Patient survival at 5 years was 54%, with a median of 64.66 months, increasing significantly in the last decade (P=.000). Age, comorbidity, male sex, chronic ambulatory PD (CAPD) and diabetes were predictors of patient survival. Technique survival at 5 years was 64.2% with a median of 82 months. The success of the technique was greater in younger patients on APD and with lower comorbidity. CONCLUSIONS: Over 30 years, we found an increase in incident patients. Age, comorbidity and diabetes still continue to be the main determining factors for survival.

Peritonitis esclerosante encapsulante asociada a la diálisis peritoneal. Una revisión y una iniciativa unitaria europea para abordar el cuidado de una enfermedad rara / ncapsulating Peritoneal Sclerosis in Peritoneal Dialysis. A review and European initiative for approaching a serious and rare disease

La peritonitis esclerosante encapsulante (EPS) representa una complicación rara de la diálisis peritoneal (DP) con una alta mortalidad. Se caracteriza por la fibrosis difusa de la membrana peritoneal que progresa a encapsulamiento y se manifiesta con signos y síntomas de obstrucción intestinal. Su incidencia varía desde el 0,7 al 3,3 %. El factor de riesgo más importante en su desarrollo es el tiempo de exposición a las soluciones de DP, aunque posiblemente la edad joven y los episodios de peritonitis puedan contribuir. Su etiopatogenia no está claramente dilucidada y se cree que, sobre una membrana peritoneal lesionada, un segundo estímulo (second hit) como las peritonitis, hemoperitoneos, cirugías, predisposición genética, etc., puedan desencadenar el desarrollo de EPS. Algunos casos aparecen tras la transferencia a hemodiálisis o tras el trasplante, lo que quizá tenga relación con el uso de inhibidores de la calcineurina. La presencia de síntomas y signos de obstrucción intestinal, junto con los hallazgos radiológicos y/o anatómicos compatibles, permiten confirmar el diagnóstico. Su detección precoz es imprescindible, aunque en la actualidad no existen marcadores clínicos ni bioquímicos capaces de predecir su aparición. En el manejo terapéutico se emplean inmunosupresores como los esteroides y el tamoxifeno, la nutrición y, en casos más avanzados, la cirugía de adhesiolisis, con resultados variables. En esta revisión se discute el diagnóstico y tratamiento de la EPS, se promueve la participación en el Registro Europeo y se aboga por la necesidad de centralizar el manejo de esta complicación (AU)

Encapsulating peritoneal sclerosis (EPS) represents a rare complication in peritoneal dialysis (PD) with high mortality. It is characterised by diffuse peritoneal membrane fibrosis, which develops into encapsulation and manifests as clinical signs and symptoms of intestinal obstruction. Its incidence varies from 0.7%to 3.3%. The most significant risk factor in its development is exposure time to PD solutions, although young age and peritonitis episodes can also contribute. Its aetiopathogeny has not been clearly explained and it is thought that a second hit like peritonitis, hemoperitoneum, surgery, genetic predisposition, etc on an already damaged peritoneal membrane, could also trigger the development of EPS. Some cases appear after transfer to haemodialysis or after transplant. In these cases, the use of calcineurin inhibitors is believed to be related. The presence of clinical symptoms and signs of intestinal obstruction, along with compatible radiological and/or anatomical findings could also confirm the diagnosis. At present there are no clinical or biochemical markers capable of predicting its onset. Therapeutic management comprises the use of immunosuppressors like steroids and tamoxifen, nutritional management and even surgery in advanced cases, all of which provide varying results. This article discusses the diagnosis and treatment of EPS, it encourages the participation in the European Registry and it advocates the need to centralise the management of this medical complication (AU)

Encapsulating peritoneal sclerosis in peritoneal dialysis. a review and European initiative for approaching a serious and rare disease.

Encapsulating peritoneal sclerosis (EPS) represents a rare complication in peritoneal dialysis (PD) with high mortality. It is characterised by diffuse peritoneal membrane fibrosis, which develops into encapsulation and manifests as clinical signs and symptoms of intestinal obstruction. Its incidence varies from 0.7%to 3.3%. The most significant risk factor in its development is exposure time to PD solutions, although young age and peritonitis episodes can also contribute. Its aetiopathogeny has not been clearly explained and it is thought that a second hit like peritonitis, hemoperitoneum, surgery, genetic predisposition, etc on an already damaged peritoneal membrane, could also trigger the development of EPS. Some cases appear after transfer to haemodialysis or after transplant. In these cases, the use of calcineurin inhibitors is believed to be related. The presence of clinical symptoms and signs of intestinal obstruction, along with compatible radiological and/or anatomical findings could also confirm the diagnosis. At present there are no clinical or biochemical markers capable of predicting its onset. Therapeutic management comprises the use of immunosuppressors like steroids and tamoxifen, nutritional management and even surgery in advanced cases, all of which provide varying results. This article discusses the diagnosis and treatment of EPS, it encourages the participation in the European Registry and it advocates the need to centralise the management of this medical complication.

Experiencia en la administración de quimioterapia intraperitoneal en una unidad de diálisis peritoneal / No disponible

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