Utilidad de la monitorización ambulatoria de la presión arterial en la evaluación de la rigidez arterial. Correlaciones con la velocidad de onda de pulso y las tensiones arteriales centrales / Utility of ambulatory blood pressure monitoring in the evaluation of arterial stiffness. Correlations with pulse wave velocity and central arterial blood pressures

Introducción y objetivos La rigidez arterial es un potente predictor de riesgo cardiovascular. La velocidad de onda de pulso (VOPcf) es considerado el marcador «gold standard». Los parámetros derivados de la MAPA representan una buena aproximación a la rigidez arterial. Un nuevo índice, el Ambulatory Arterial Stiffness Index (AASI), ha conseguido buenos resultados. Material y métodos Estudio transversal de pacientes hipertensos mayores de 55 años; con otros factores de riesgo cardiovascular (FRCV) y todos ellos polimedicados. Resultados Incluimos en el estudio un total de 276 pacientes. Destacamos el condicionante del paciente diabético y las correlaciones entre la VOPcf y la PP de 24 h (r=0,473 y p<0,001) y entre la VOPcf y el AASI (r=0,298 y p<0,001).Conclusiones Nuestros resultados refuerzan la utilización práctica de los índices de -rigidez arterial derivados de la monitorización ambulatoria de la presión arterial (MAPA) (AU)

Introduction and objectives Arterial stiffness is a powerful predictor of cardiovascular risk. Carotid-femoral pulse wave velocity (cfPWV) is considered the gold standard. Parameters derived from ambulatory blood pressure represent a good approach to arterial stiffness. Good results have been achieved with a new index, ambulatory arterial stiffness index (AASI).Material and methods A cross-sectional study was performed of hypertensive patients over 55 years. All of the patients had other cardiovascular risk factors (CVRF) and were polymedicated. Results A total of 276 patients were enrolled in the study. We highlight the determining factor of the diabetic patient and the correlations found between cfPWV and 24h PP (r=0.473 and p<0.001) and cfPWV and AASI (r=0.298 and p<0.001).Conclusions Our results reinforce the practical use of arterial stiffness indexes derived from ambulatory blood pressure monitoring (ABPM) (AU)

Evolucion de los pacientes criticos con fracaso renal agudo y disfuncion multiorganica tratados con hemodiafiltracion venovenosa continua / Outcome of critically ill patients with acute renal failure and multiple organ failure treated with continuous venovenous haemodiafiltration

Objetivo: En los pacientes críticos el fracaso renal agudo (FRA) está asociado a disfunción multiorgánica (DMO) y su mortalidad es alta. El objetivo principal fue evaluar la evolución de los pacientes críticos con FRA y DMO tratados con hemodiafiltración venovenosa continua (HDFVVC). Diseño: Estudio retrospectivo y observacional en pacientes críticos. Ámbito: Unidad de Cuidados Intensivos (UCI) medicoquirúrgica del Hospital Universitario de Girona. Pacientes: Pacientes ingresados en la UCI con FRA y DMO tratados con HDFVVC. Principales variables de interés: Se recogieron variables demográficas, de gravedad y de DMO (SOFA [Sepsis-related Organ Failure Assessment score]). Análisis estadístico comparativo y de regresión logística múltiple con la mortalidad a los 30 días como efecto principal de estudio. Resultados: Se estudió a 139 pacientes. Los factores predisponentes más frecuentes fueron hipotensión (98%) y sepsis (82%). Los órganos más frecuentemente afectados fueron los del sistema cardiocirculatorio (94%) y los del sistema respiratorio (47%) asociados al FRA. El SOFA medio fue de 11,4±2,7. Los pacientes traumáticos y los no oligúricos tuvieron una mejor supervivencia. La mortalidad a los 30 días fue del 61% y el análisis de regresión logística mostró que la edad superior o igual a 60 años (OR [odds ratio]=3,3 [intervalo de confianza {IC} del 95%: 1,5-7,0]) y el SOFA superior o igual a 11 puntos (OR=2,5 [IC del 95%: 1,1-5,3]) se relacionaron con la mortalidad. Conclusiones: La mortalidad de los pacientes críticos con FRA y DMO es alta. Los pacientes traumáticos y los no oligúricos tuvieron una mejor supervivencia. La edad superior o igual a 60 años y el SOFA superior o igual a 11 puntos fueron factores de riesgo independientes de mortalidad (AU)

Objective: Acute renal failure (ARF) is associated to multiple organ failure (MOF) in critically ill patients and its mortality is high. The main objective was to evaluate the outcome of critically ill patients with ARF and MOF treated with continuous venovenous hemodiafiltration (CVVHDF). Design: Retrospective and observational study on critically ill patients. Setting: Medical-surgical Intensive Care Unit (ICU) in a University Hospital of Girona. Patients: Patients admitted in ICU that developed ARF and MOF and were treated with CVVHDF. Primary variables of interest: We collected data on demographic, and severity and organic dysfunction scores (SOFA). To study the risk factors for mortality, a comparative and multiple regression statistical analysis was performed, with the main effect of the study being mortality at 30 days. Results: We studied 139 patients. The most frequent predisposing factors were hypotension (98%) and sepsis (82%). the most frequently affected organs were cardiocirculatory (94%) and respiratory (47%) associated to ARF. Mean SOFA score was 11.4±2.7 points. Survival was better in traumatic and in non-oliguric patients. The 30-day mortality was 61% and the logistic regression analysis showed that age >60 years [OR=3.3 (95% CI 95=1.5-7.0)] and SOFA score >11 points [OR=2.5 (95% CI=1.1-5.3)] were related to mortality. Conclusions: The mortality rate of critically ill patients with acute renal failure and multiple organ failure remains high. Traumatic and non-oliguric patients have a better survival. Age >60 years and SOFA >11 points were independent risk factors associated with mortality (AU)

[Outcome of critically ill patients with acute renal failure and multiple organ failure treated with continuous venovenous haemodiafiltration]. / Evolución de los pacientes críticos con fracaso renal agudo y disfunción multiorgánica tratados con hemodiafiltración venovenosa continua.

OBJECTIVE: Acute renal failure (ARF) is associated to multiple organ failure (MOF) in critically ill patients and its mortality is high. The main objective was to evaluate the outcome of critically ill patients with ARF and MOF treated with continuous venovenous hemodiafiltration (CVVHDF). DESIGN: Retrospective and observational study on critically ill patients. SETTING: Medical-surgical Intensive Care Unit (ICU) in a University Hospital of Girona. PATIENTS: Patients admitted in ICU that developed ARF and MOF and were treated with CVVHDF. PRIMARY VARIABLES OF INTEREST: We collected data on demographic, and severity and organic dysfunction scores (SOFA). To study the risk factors for mortality, a comparative and multiple regression statistical analysis was performed, with the main effect of the study being mortality at 30 days. RESULTS: We studied 139 patients. The most frequent predisposing factors were hypotension (98%) and sepsis (82%). the most frequently affected organs were cardiocirculatory (94%) and respiratory (47%) associated to ARF. Mean SOFA score was 11.4 + or - 2.7 points. Survival was better in traumatic and in non-oliguric patients. The 30-day mortality was 61% and the logistic regression analysis showed that age > or = 60 years [OR=3.3 (95% CI 95=1.5-7.0)] and SOFA score > or = 11 points [OR=2.5 (95% CI=1.1-5.3)] were related to mortality. CONCLUSIONS: The mortality rate of critically ill patients with acute renal failure and multiple organ failure remains high. Traumatic and non-oliguric patients have a better survival. Age > or = 60 years and SOFA > or = 11 points were independent risk factors associated with mortality.

Plasma exchange for acute attacks of CNS demyelination: Predictors of improvement at 6 months.

BACKGROUND: Plasma exchange (PE) is used to treat severe episodes of CNS demyelination unresponsive to corticosteroids. Predictors of long-term response are not well known. METHODS: We retrospectively reviewed the medical records of 41 patients consecutively treated by PE between January 1995 and July 2007. The primary outcome was improvement at 6 months after PE defined as decrease of >or=1 point in the Expanded Disability Status Scale (EDSS) score for patients with EDSS or=8.0 or improvement of more than 2 lines in the visual acuity chart for patients with optic neuritis (ON). RESULTS: Twenty-five patients (61%) were women, and the median age was 33 years (range 14-57 years). Twenty-three (56%) had multiple sclerosis, 2 (5%) had clinically isolated syndrome, 2 (5%) had Marburg disease, 7 (17%) had acute disseminated encephalomyelitis, 4 (10%) had neuromyelitis optica, 2 (5%) had idiopathic ON, and 1 (2%) had idiopathic transverse myelitis. The median EDSS score before the attack was 1.0 (range 0-6.5). At PE onset, the median EDSS score was 7.0 (range 3.0-9.5). Sixteen patients (39%) improved at discharge, and 26 (63%) improved at 6 months. In the multivariate analysis, early initiation of PE (odds ratio [OR] 6.29, 95% confidence interval [CI] 1.18-52.96) and improvement at discharge (OR 7.32, 95% CI 1.21-44.38) were significantly associated with response at 6 months. CONCLUSIONS: Plasma exchange (PE) was associated with clinical improvement in 63% of patients at 6 months. Early initiation of PE and improvement at discharge were predictors of this response. Twelve patients (48%) who did not improve early did so during follow-up.

[Prophylactic and pre-emptive therapy for cytomegalovirus infection in kidney transplant patients using oral valganciclovir]. / Tratamiento profiláctico y anticipado de la infección por citomegalovirus en pacientes trasplantados renales mediante valganciclovir oral.

UNLABELLED: Prophylactic and pre-emptive therapy with oral valganciclovir for cytomegalovirus infection in renal transplant recipients. BACKGROUND: Cytomegalovirus infection is a very important health problem in solid organ transplant recipients (SOT). Once-daily valganciclovir has been shown to be as clinically effective and well tolerated as oral ganciclovir tid in the prevention of CMV infection in high risk SOT recipients. METHODS: The aim of the present study was to evaluate the incidence and severity of CMV disease in 150 renal transplant recipients that received either prophylactic [high risk group (HR), N = 66] or pre-emptive [low risk group (LR), N = 84] therapy with oral valganciclovir (900 mg/day vo) for three months according to their basal risk. Patients were monitored for signs and symptoms of CMV disease and CMV plasma viral load was assessed weekly. RESULTS: A total of 31 patients (47%) of the HR and 26 patients (31%) of the LR presented a positive CMV PCR result. Twelve patients (14.3%) in the LR that had a high viral load (CMV PCR > 1,000 copies/mL) but remained asymptomatic received pre-emptive therapy. Four patients (4.7%) in the LR, after an average time of 35 days after transplant and two patients (4.5%) in the HR, after prophylactic treatment was completed, developed CMV disease. The disease was mild-moderate in most of the cases. Those patients that developed CMV disease responded to treatment with iv ganciclovir for 14 days followed by treatment with oral valganciclovir for up to three months. CONCLUSION: Prophylactic treatment with oral valganciclovir for CMV prevention is only required in high risk solid organ transplant recipients.

Tratamiento profiláctico y anticipado de la infección por citomegalovirus en pacientes trasplantados renales mediante vanglanciclovir oral / Prophylactic and pre-emptive therapy for cytomegalovirus infection in kidney transplant patients using oral valganciclovir

Antecedentes: La enfermedad por citomegalovirus (CMV) es un problema sanitario muy importante en receptores de trasplante de órgano sólido (TOS). Una dosis diaria de valganciclovirha demostrado ser tan clínicamente efectiva y bien tolerada como ganciclovir oral dos veces al día en la prevención de la infección por CMV en los receptores de TOS de alto riesgo. Métodos: El objetivo del presente estudio fue evaluar la incidencia y severidad de la enfermedad por CMV en 150 receptores de trasplante renal que recibieron tratamiento profiláctico(grupo de alto riesgo, N = 66) o anticipado (grupo de bajo riesgo, N = 84) con valganciclovir oral (900 mg/día)durante tres meses según el riesgo basal de sufrir la misma. Se hizo un seguimiento de los síntomas clínicos de la enfermedad por CMV en los pacientes y la carga viral de CMV en plasma fue monitorizada semanalmente. Resultados: Un total de 31 pacientes (47%) del grupo de alto riesgo y 26 pacientes (31%) del grupo de riesgo estándar presentaron un resultado de PCR-CMV positivo. Doce pacientes (14,3%) del grupo de riesgo estándard que presentaron una elevada carga viral (PCR-CMV > 1.000 copias/mL) pero que permanecieron asintomáticos recibieron tratamiento anticipado. Cuatro pacientes (4,7%) del grupo de alto riesgo, en un tiempo medio de 35 días después del trasplante y dos pacientes (4,5%) del grupo de alto riesgo, tras completar el tratamiento profiláctico, desarrollaron la enfermedad por CMV, que fue de intensidad media a moderada en la mayoría de los casos. Aquellos pacientes que desarrollaron la enfermedad respondieron al tratamiento con ganciclovir ev durante 14 días seguido de valganciclovir oral hasta tres meses. Conclusión: El tratamiento profiláctico con valgancicloviroral para la prevención de CMV sólo es requerida en receptores de TOS de alto riesgo (AU)

Prophylactic and pre-emptive therapy with oral valganciclovir for cytomegalovirus infection in renal transplant recipients. Background: Cytomegalovirus infection is a very important health problem in solid organ transplant recipients (SOT). Once daily valganciclovir has been shown to be as clinically effective and well tolerated as oral ganciclovir tid in the prevention of CMV infection in high risk SOT recipients. Methods: The aim of the present study was to evaluate the incidence and severity of CMV disease in 150 renal transplant recipients that received either prophylactic [high risk group (HR), N =66] or pre-emptive [low risk group (LR), N = 84] therapy with oral valganciclovir (900 mg/day vo) for three months according to their basal risk. Patients were monitored for signs and symptoms of CMV disease and CMV plasma viral load was assessed weekly. Results: A total of 31 patients (47%) of the HR and 26 patients(31%) of the LR presented a positive CMV PCR result. Twelve patients(14.3%) in the LR that had a high viral load (CMV PCR >1,000 copies/mL) but remained asymptomatic received pre-emptive therapy. Four patients (4.7%) in the LR, after an average time of 35 days after transplant and two patients (4.5%) in the HR, after prophylactic treatment was completed, developed CMV disease. The disease was mild-moderate in most of the cases. Those patients that developed CMV disease responded to treatment with iv ganciclovir for 14 days followed by treatment with oral valganciclovir for up to three months. Conclusion: Prophylactic treatment with oral valganciclovir for CMV prevention is only required in high risk solid organ transplant recipients (AU)

Assessment of the arteries in living kidney donors: correlation of magnetic resonance angiography with intraoperative findings.

Comprehensive imaging evaluation of kidney donor anatomy is crucial for selecting candidates for living kidney transplantation and for determining the surgical technique to procure the renal graft. In 76 living renal donors we compared the results of preoperative magnetic resonance angiography (MRA) with the intraoperative findings of arterial anatomy. Donors were evaluated for the number of main renal arteries and the presence of any polar arteries. A total of 80 main renal arteries and five polar arteries were observed at MRA. At surgery, 90 main renal arteries and eight polar arteries were identified. MRA demonstrated a sensitivity, specificity, and overall accuracy of 18%, 98%, and 87%, respectively, for main arteries and 25%, 96%, and 88% for polar arteries. Eleven (14.5%) kidneys displayed more than one main artery and MRA only detected two cases. Eight kidneys had polar arteries and MRA only detected two cases. MRA is a reliable method for presurgical evaluation of renal arteries in potential donors, providing valuable information required by the surgeon. But, as the technique misses small-diameter vessels, it cannot be recommended as the sole diagnostic tool in unclear cases.

Tratamiento de la glomerulopatía membranosa / No disponible

La glomerulopatía membranosa (GNM) es una de las causas más frecuentes de síndrome nefrótico en el adulto. Dos tercios de los sujetos afectos desarrollan una insuficiencia renal o mantienen una proteinuria de rango nefrótico durante los 10 primeros años después de la biopsia renal, el otro tercio remite espontáneamente. Es difícil individualizar en el momento del diagnóstico los pacientes que van a evolucionar hacia la insuficiencia renal terminal. Sólo algunos datos bioquímicos son claros factores de pronóstico: una proteinuria inferior a 3g/24h durante más de 6 meses se asocia a un buen pronóstico, una insuficiencia renal en el momento de la BR o aparecida durante el seguimiento es factor de mal pronóstico. Un modelo matemático que utiliza el factor tiempo y la proteinuria permite calcular el riesgo de evolución de un paciente hacia la insuficiencia renal. Frente a estos datos, los nefrólogos han propuesto alternativas terapéuticas opuestas adoptar una actitud conservadora intentando evitar a pacientes que hubieran presentado una remisión espontánea los riesgos de un tratamiento agresivo o administrar corticoides e inmmunosupresores para evitar a dos tercios de los pacientes la evolución hacia una insuficiencia renal o las complicaciones de un síndrome nefrótico persistente (AU)

Idiopathic membranous nephropathy is a common cause of nephrotic syndrome in adults and is characterized by great variability of the evolution. Studies on its natural history show that up to 40% of the untreated patients progress to end stage renal disease, up to 30% experience spontaneous remission and another one third of patients have a slow progression and remain proteinuric. Its treatment is a controversial issue. Some nephrologist recommend and immunosupresive therapy and others prone toward a more conservative approach. The first group have proposed several protocols: steroids and chlorambucil for six months, oral or intravenous cyclophosphamide and steroids for one to two years, low-dose oral azathioprine plus steroids for very prolonged periods. Several risk factors that do predict a worse outcome (sex, age, massive proteinuria, elevation of serum creatinine, histologic changes such as tubular intersticial damage and glomeruloesclerosis) have been proposed to select individuals worth treating. Cattran et al. have suggested that time must be added to the pronostic factors to improve prediction. Their algorithm, which uses only the presenting creatinine level, the quantity of proteinuria and change in renal function over the initial 6 month of observation improve the ability to separate patients with poor from those with good prognosis (AU)

Nuevos conceptos sobre la enfermedad renal crónica y sus implicaciones / No disponible

La National Kidney Foundation americana ha definido recientemente criterios que definen un nuevo concepto denominado enfermedad renal crónica. Más o menos discutibles, suponen un importante método de estandarización de rápida aceptación internacional. En este artículo se revisa la nueva definición y estadios, los métodos de diagnóstico y evaluación, sus complicaciones y asociaciones, así como sus factores de progresión a estadios terminales con necesidad de tratamiento sustitutivo. Asimismo se establece el importante nuevo vínculo de la enfermedad renal crónica como factor de riesgo cardiovascular (AU)

The American National Kidney Foundation has recently defined new criteria to define the concept of chronic Kidney disease (CKD). Althougt they are partially under discussion, they have become a very helpful way of standarization and widely internationally accepted. In this article, we review the new definition and stages, the diagnostic and evaluation methods, complications and associations, as well as progression factors to end stage renal disease. It is also underlined the important newly recognized link between chronic kidney disease and cardiovascular risk (AU)