Sodium zirconium cyclosilicate: a new potassium binder for the treatment of hyperkalemia.

Hyperkalemia is one of the most common electrolyte disturbances, especially among some groups of patients, such as in those with chronic kidney disease, diabetes or heart failure. Hyperkalemia has been associated with increased risks of mortality, arrhythmias, hospitalization and costs, as well as the need to down titrate/discontinue renin-angiotensin-aldosterone system inhibitors (RAASIs), despite their well-known cardiovascular and nephroprotective benefits. Current potassium binders have limitations (slow onset of action, limited selectivity for potassium binding, risk of drug interactions or gastrointestinal intolerance). Sodium zirconium cyclosilicate (SZC) is a new potassium binder recently approved for the treatment of chronic hyperkalemia. It is a nonabsorbable, inorganic crystal which selectively binds potassium and ammonium in exchange of Na+ and H+ in the whole gastrointestinal tract, achieving a rapid correction of serum potassium levels (within 2 days) and maintaining normokalemia in the long term (up to 1 year), with a good safety profile (common adverse reactions include gastrointestinal events and a dose-dependent risk of edema), excellent tolerability and a low potential for drug interactions. Its potassium-lowering efficacy is maintained irrespective of the use of RAASIs. In summary, SZC is a new potassium binder recently approved for the treatment of hyperkalemia. Its differences with respect to currently available potassium binders make SZC an attractive therapeutic option.

Mortality due to bleeding, myocardial infarction and stroke in dialysis patients.

Essentials Mortality due to bleeding vs. arterial thrombosis in dialysis patients is unknown. We compared death causes of 201 918 dialysis patients with the general population. Dialysis was associated with increased mortality risks of bleeding and arterial thrombosis. Clinicians should be aware of the increased bleeding and thrombosis risks. SUMMARY: Background Dialysis has been associated with both bleeding and thrombotic events. However, there is limited information on bleeding as a cause of death versus arterial thrombosis as a cause of death. Objectives To investigate the occurrence of bleeding, myocardial infarction and stroke as causes of death in the dialysis population as compared with the general population. Methods We included 201 918 patients from 11 countries providing data to the ERA-EDTA Registry who started dialysis treatment between 1994 and 2011, and followed them for 3 years. Age-standardized and sex-standardized mortality rate ratios for bleeding, myocardial infarction and stroke as causes of death were calculated in dialysis patients as compared with the European general population. Associations between potential risk factors and these causes of death in dialysis patients were investigated by calculating hazard ratios (HRs) with 95% confidence intervals (CIs) by the use of Cox proportional-hazards regression. Results As compared with the general population, the age-standardized and sex-standardized mortality rate ratios in dialysis patients were 12.8 (95% CI 11.9-13.7) for bleeding as a cause of death (6.2 per 1000 person-years among dialysis patients versus 0.3 per 1000 person-years in the general population), 13.4 (95% CI 13.0-13.9) for myocardial infarction (22.5 versus 0.9 per 1000 person-years), and 12.4 (95% CI 11.9-12.9) for stroke (14.3 versus 0.7 per 1000 person-years). Conclusion Dialysis patients have highly increased risks of death caused by bleeding and arterial thrombosis as compared with the general population. Clinicians should be aware of the increased mortality risks caused by these conditions.

Anemia en la enfermedad renal crónica: protocolo de estudio, manejo y derivación a Nefrología / Anemia of chronic kidney disease: protocol of study, management and referral to Nephrology

El objetivo del protocolo es conocer qué estudios deben solicitarse ante una anemia en un paciente con enfermedad renal crónica, el diagnóstico diferencial de la anemia renal, conocer y corregir otras anemias carenciales y los criterios de remisión del paciente anémico con enfermedad renal crónica a Nefrología u otras especialidades (AU)

The objective of this protocol is to know which test are needed to study an anaemia in a patient with chronic kidney disease, the differential diagnosis of renal anaemia, to know and correct other deficiency anaemias, and the criteria for referral to Nephrology or other specialties of the anaemic patient with chronic kidney disease (AU)

[Anemia of chronic kidney disease: Protocol of study, management and referral to Nephrology]. / Anemia en la enfermedad renal crónica: protocolo de estudio, manejo y derivación a Nefrología.

The objective of this protocol is to know which test are needed to study an anaemia in a patient with chronic kidney disease, the differential diagnosis of renal anaemia, to know and correct other deficiency anaemias, and the criteria for referral to Nephrology or other specialties of the anaemic patient with chronic kidney disease.

Efficacy of a simple dosage scheme to convert from shorter-acting erythropoiesis-stimulating agent to continuous erythropoietin receptor activator in kidney transplantation patients.

INTRODUCTION: Anemia after kidney transplantation (KT) has a negative impact on graft and patient survival. Anemia management includes iron supplements and erythropoiesis-stimulating agents (ESAs). Most ESAs require short frequency of administration and conversion to ESAs with longer half-life are complex. OBJECTIVE: This study was performed to assess the efficacy of continuous erythropoietin receptor activator (CERA) in hemoglobin (Hb) maintenance after conversion from shorter-acting ESAs with a simple conversion scheme in kidney transplant recipients. METHOD: This is an open-label, prospective, single-arm, single-center, 12-month follow-up study including 77 anemic KT patients with stable renal function. Baseline and monthly measurements of Hb, iron, and creatinine were performed. The conversion scheme from darbepoetin alfa or epoetin was as follows: <30 µg or 5000 IU/week was switched to 75 µg/mo; between 30-50 or 5000-8000 was switched to 100 µg/mo; >50 µg or 8000 IU was changed to 150 µg/month of CERA. Dose adjustments were performed to maintain Hb levels between 10 g/dL and 12 g/dL. RESULTS: The mean age was 57 ± 19 years. The mean time of conversion after KT was 61 ± 49 months. Before conversion, 62.9% of patients were administered epoetin and 37.1% with darbepoetin alfa. Baseline Hb is noted at 10.6 ± 1.3 g/dL. Thirteen percent of patients started receiving CERA at doses of 50 µg/mo, 66% at 75 µg/mo, 13% at 100 µg/mo, and 8% at 150 µg/mo. During the first month, 21% required dose adjustment (6% were increased, 15% were decreased). The final Hb was 11.2 ± 0.8 g/dL. Iron and creatinine levels remained stable during the follow-up examination. CONCLUSION: We propose a simple scheme of conversion from short-acting ESAs to a once-monthly dose of CERA that provides sustained Hb levels within the recommended target with small dose adjustments and low CERA doses.

Montelukast treatment (cysteinyl leukotriene receptor antagonist) in a model of food allergy: modifications in lymphatic cell population from rectal mucosa.

OBJECTIVE: The aim is to determine immunopathological modifications in rectal mucosa from rabbits after local challenge in ovalbumin (OVA) sensitized animals previously treated with montelukast. EXPERIMENTAL DESIGN: thirty two rabbits divided into four groups: G1: normal; G2: subcutaneously OVA sensitized; G3: sensitized, locally OVA challenged and sampled 4 hours after challenge; and G4: sensitized, locally OVA challenged and treated 4 hours before challenge with montelukast (0.15 mg/kg). Specific anti-OVA IgE levels were evaluated by passive cutaneous anaphylaxis test (PCA). In each group 200 high microscopical power fields (HPF) were counted. Results were expressed as arithmetic mean and SE. Anti -CD4, CD5, micro chain monoclonal antibodies were used. Avidin biotin horseradish peroxidase system was used. RESULTS: CD 4: G1: 8.3 +/- 0.06; G2: 13.4 +/- 0.08, G3: 8.25 +/- 0.06, G4: 11.8 +/- 0.02. CD 5: G1: 7.3 +/- 0.05; G2: 9.4 +/- 0.05, G3: 11.3 +/- 0.06, G4: 8.1 +/- 0.06. mu chain: G1: 10.4 +/- 0.06; G2: 3.8 +/- 0.02, G3: 6.0 +/- 0.10, G4: 2.2 +/- 0.10. In all cases, experimental groups (G3 vs. G4) presented statistical significant differences (p < 0.05). CD4+, CD5+ cells and mu chain+ decrease in experimental group (G4), probably due to lymphocyte migration inhibition to challenged mucosa. mu chain+ cell decrease could be based on B cell activation and expression of different surface immunoglobulins. Cells expressing mu chain decreased in G2 and G3 likely due to activation of B cells and subsequent expression of other immunoglobulin chains in cell surface. CONCLUSIONS: We conclude that obtained data are important to elucidate immunopathology of local anaphylactic reaction in rectal mucosa from systemic sensitized animals after treatment with montelukast.

Montelukast treatment (cysteinyl leukotriene receptor antagonist) in a model of food allergy: modifications in lymphatic cell population from rectal mucosa

Objective: the aim is to determine immunopathological modifications in rectal mucosa from rabbits after local challenge in ovalbumin (OVA) sensitized animals previously treated with montelukast. Material and methods: experimental design: thirty two rabbits divided into four groups: G1: normal; G2: subcutaneously OVA sensitized; G3: sensitized, locally OVA challenged and sampled 4 hours after challenge; and G4: sensitized, locally OVA challenged and treated 4 hours before challenge with montelukast (0.15 mg/kg). Specific anti-OVA IgE levels were evaluated by passive cutaneous anaphylaxis test (PCA). In each group 200 high microscopical power fields (HPF) were counted. Results were expressed as arithmetic mean and SE. Anti -CD4, CD5, micro chain monoclonal antibodies were used. Avidin biotin horseradish peroxidase system was used. Results: CD 4: G1: 8.3 ± 0.06; G2: 13.4 ± 0.08, G3: 8.25 ± 0.06, G4: 11.8 ± 0.02. CD 5: G1: 7.3 ± 0.05; G2: 9.4 ± 0.05, G3: 11.3 ± 0.06, G4: 8.1 ± 0.06. ì chain: G1: 10.4 ± 0.06; G2: 3.8 ± 0.02, G3: 6.0 ± 0.10, G4: 2.2 ± 0.10. In all cases, experimental groups (G3 vs. G4) presented statistical significant differences (p < 0.05). CD4+, CD5+ cells and micro chain+ decrease in experimental group (G4), probably due to lymphocyte migration inhibition to challenged mucosa. micro chain+ cell decrease could be based on B cell activation and expression of different surface immunoglobulins. Cells expressing micro chain decreased in G2 and G3 likely due to activation of B cells and subsequent expression of other immunoglobulin chains in cell surface. Conclusions: we conclude that obtained data are important to elucidate immunopathology of local anaphylactic reaction in rectal mucosa from systemic sensitized animals after treatment with montelukast(AU)

[Prevalence of cardiovascular disease in uraemia and relevance of cardiovascular risk factors]. / Prevalencia de enfermedad cardiovascular en la uremia y relevancia de los factores de riesgo cardiovascular.

AIM: To evaluate the prevalence of cardiovascular disease (CVD) and its association with cardiovascular risk factors, as well as their control in end-stage renal disease (ESRD) patients under maintenance hemodialysis (HD). PATIENTS AND METHODS: A total of 265 patients with ESRD on maintenance HD from a University Hospital and 4 dialysis units were included in this multicenter and cross-sectional study that analyzed the prevalence of CVD and the possible association with classic and new cardiovascular risk factors. Usual biochemical and haemathological parameters were analyzed, as well as plasma levels of homocysteine, troponin-I, BNP, lipoprotein(a), C reactive protein, IL-6, fibrinogen, asymmetrical dimethylarginine (ADMA), advanced oxidation protein products (AOPP), malondialdehyde, adiponectin, osteoprotegerin, and fetuin. In a subset of patients an echocardiography and carotid artery Doppler echography were also performed. RESULTS: The prevalence of CVD was 52.8%. Factors positively associated with prevalent CVD were age, BMI, left ventricular hypertrophy, hypertension, dyslipidemia and diabetes mellitus, dialysis vintage, Charlson s comorbility index, levels of fibrinogen, osteoprotegerin, BNP and CRP, as well as carotid intima-media thickness, left ventricular mass and pulse pressure. Factors negatively associated with prevalent CVD were: previous renal transplant, ejection fraction or levels of LDL-c and phosphorous. In the multivariate analysis dyslipidemia, left ventricular hypertrophy, age and LDL-c (negatively) were associated with CVD. CONCLUSIONS: In HD patients the prevalence of CVD is high and is associated with the presence of cardiovascular risk factors and subclinical CVD.

[Guidelines for automated manual infusion: a practical way of prescribing postdilution on-line hemodiafiltration]. / Pauta de infusión manual automatizada: una forma práctica de prescribir la hemodiafiltración on-line posdilucional.

Post-dilution on-line hemodiafiltration (OL-HDF) is the most efficient infusion mode to obtain maximum clearances of uremic toxins, with a recommended manual infusion flow (Qi) of 25% of the blood flow with the main limitation that causes alarms by hemoconcentration throughout the session. Recent technical advances allow automatic prescription of Qi if hematocrit and total protein (TP) values are specified. As these analytical results are not possible to obtain in each dialysis session, a practical way to prescribe Qi is to make an automatic prescription adjusting the hematocrit and total protein values at the beginning of the session to obtain the manual prescription required and we will call it automatic-manual prescription. The aim of this study was to compare manual Qi with automatic-manual Qi in postdilution OL-HDF. 30 patients (16 men and 14 women), 59.9 +/- 15 years old, in hemodialysis program for 50.1 +/- 67 months were included. Every patient underwent four OL-HDF sessions, two with manual Qi (4008-S and 5008 monitors) and two with automatic-manual Qi (A-M), one with the same Qi and one with manual Qi +20 (A-M+20). The same usual dialysis parameters were maintained: helixone dialyzer, dialysis time of 266 +/- 39 minutes, blood flow of 420 +/- 36. Recirculation, Kt and intradialysis alarms were measured at each session. No significant differences in the fistula recirculation or dialysis dose measured using Kt. Total infusion volume was 24.9 +/- 4 (4008 S), 23.4 +/- 4 L (5008) with manual Qi, 23.6 +/- 4 L (A-M) Qi (NS) and 25.8 +/- 5 L (A-M+20). Only 14% of patients had no incidents. The number of alarms was significantly higher with manual prescription 55 alarms with 4008 and 40 with 5008 vs. AM (11) p < 0.01) and A-M+20 (16 alarms) We concluded that automatic-manual Qi is a practical way for post-dilutional OL-HDF prescription where the same efficiency and total reinfusion volume with an important reduction of intradialysis alarms are obtained, allowing to rise Qi by 20% without increasing intradialysis alarms.

Prevalencia de enfermedad cardiovascular en la uremia y relevancia de los factores de riesgo cardiovascular / Prevalence of cardiovascular disease in uraemia and relevance of cardiovascular risk factors

Objetivo: Evaluar la prevalencia de ECV y su asociación con FRCV clásicos y nuevos, así como el control de los mismos en pacientes con IRCT en programa de HD. Pacientes y métodos: Se incluyeron 265 enfermos prevalentes con IRCT en HD de un hospital universitario y cuatro centros de diálisis. Estudio multicéntrico y transversal que analizó la prevalencia de ECVy su posible asociación con FRCV clásicos y nuevos. Se analizaron parámetros bioquímicos y hematológicos habituales, así como niveles de homocisteína, troponina-I, BNP, Lp(a), PCR,IL-6, fibrinógeno, ADMA, AOPP, malondialdehído, adiponectina, osteoprotegerina y fetuína. En un subgrupo de enfermos también se realizaron ecocardiografía y ecografía Doppler carotídea. Resultados: La prevalencia de ECV fue del52,8%. Los factores asociados positivamente a ECV prevalente fueron la edad, el índice de masa corporal, los antecedentes de HVI, la HTA, la dislipemia y la diabetes mellitus, el tiempo en diálisis, el índice de comorbilidad de Charlson, los niveles elevados de fibrinógeno, la osteoprotegerina, el BNPy la PCR, así como el grosor del complejo íntima-media carotídeo, la masa ventricular izquierda o la presión de pulso. Se asociaron negativamente: los antecedentes de trasplante previo, la fracción de eyección cardíaca y los niveles de cLDL ofósforo. En el análisis multivariante, los factores asociados con ECV fueron la dislipemia, la presencia de HVI, la edad y los niveles de cLDL (negativamente). Conclusiones: En los pacientes con IRCT en HD, la prevalencia de ECV es elevada y se asocia con la presencia de FRCV clásicos y ECV subclínica (AU)

Aim: To evaluate the prevalence of cardiovascular disease (CVD)and its association with cardiovascular risk factors, as well as their control in end-stage renal disease (ESRD) patients undermaintenance hemodialysis (HD). Patients and methods: A total of265 patients with ESRD on maintenance HD from a University Hospital and 4 dialysis units were included in this multicenter and cross-sectional study that analyzed the prevalence of CVD and the possible association with classic and new cardiovascular risk factors. Usual biochemical and haemathological parameters were analyzed, as well as plasma levels of homocysteine, troponin-I, BNP, lipoprotein(a), C reactive protein, IL-6,fibrinogen, asymmetrical dimethylarginine (ADMA), advanced oxidation protein products (AOPP), malondialdehyde,adiponectin, osteoprotegerin, and fetuin. In a subset of patients an echocardiography and carotid artery Doppler echography were also performed. Results: The prevalence of CVD was52.8%. Factors positively associated with prevalent CVD were age, BMI, left ventricular hypertrophy, hypertension, dyslipidemia and diabetes mellitus, dialysis vintage, Charlson´s comorbility index, levels of fibrinogen, osteoprotegerin, BNP and CRP, as well as carotid intima-media thickness, left ventricular mass and pulse pressure. Factors negatively associated with prevalent CVD were: previous renal transplant, ejection fraction or levels of LDL-c and phosphorous. In the multivariate analysis dyslipidemia, left ventricular hypertrophy, age and LDL-c (negatively) were associated with CVD. Conclusions: In HD patients the prevalence of CVD is high and is associated with the presence of cardiovascular risk factors and subclinical CVD (AU)

Pauta de infusión manual automatizada: una forma práctica de prescribir la hemodiafiltración on-line posdilucional / Guidelines for Automated Manual Infusion: A Practical Way of Prescribing Postdilution On-line Haemodiafiltration

La hemodiafiltración on-line (HDF-OL) posdilucional es la modalidad más eficaz para obtener la máxima depuración de toxinas urémicas, con un flujo de infusión (Qi) recomendable del 25% del flujo sanguíneo y con el principal inconveniente de provocar alarmas por hemoconcentración a lo largo de la sesión. Recientes avances técnicos permiten la prescripción automática del Qi si se especifican los valores del hematocrito y de las proteínas totales. Como no es posible disponer en cada sesión de estos valores, una forma práctica de pautar la HDF-OL posdilucional es realizar una prescripción automática ajustando el hematocrito y las proteínas totales para obtener al inicio de la sesión la prescripción manual prescrita, a la que llamaremos prescripción manual automatizada. El objetivo del estudio fue comparar la pauta convencional de Qi manual respecto a la manual automatizada. Se incluyeron 30 pacientes (16 varones y 14 mujeres), de 59,9 ± 15 años de edad, en programa de hemodiálisis durante 50,1 ± 67 meses. Cada paciente recibió cuatro sesiones de HDF-OL, dos con Qi manual (monitores 4008-S y 5008) y dos con Qi manual automatizada (M-A), una con Qi igual a la manual y otra incrementando el Qi 20 ml/min (M-A+20). El resto de parámetros de diálisis no variaron: filtro de helixona, tiempo de diálisis 266 ± 39 minutos, flujo de sangre 420 ± 36 ml/min. En cada sesión se recogieron el Kt, la recirculación y las alarmas. No se observaron diferencias significativas en el índice de recirculación ni en la dosis de diálisis medida con el Kt. El volumen total de infusión fue de 24,9 ± 4 l (4008S), 23,4 ± 4 l (5008) con Qi manual, 23,6 ± 4 l (M-A) y 25,8 ± 5 l (M-A+20). En sólo el 14% de los pacientes no hubo incidencias. El número de alarmas fue significativamente superior con la prescripción manual, 55 alarmas con 4008 y 40 con 5008, respecto a la M-A (11, p <0,01) y M-A+20 (16 alarmas). Concluimos que la prescripción del Qi manual automatizada es una forma práctica de prescribir la HDF-OL posdilucional consiguiendo el mismo volumen convectivo y la misma eficacia, con una importante reducción de las alarmas intradiálisis, lo que permite un incremento del Qi un 20% sin aumento del número de alarmas (AU)

Post-dilution on-line hemodiafiltration (OL-HDF) is the most efficient infusion mode to obtain maximum clearances of uremic toxins, with a recommended manual infusion flow (Qi) of 25% of the blood flow with the main limitation that causes alarms by hemoconcentration throughout the session. Recent technical advances allow automatic prescription of Qi if hematocrit and total protein (TP) values are specified. As these analytical results are not possible to obtain in each dialysis session, a practical way to prescribe Qi is to make an automatic prescription adjusting the hematocrit and total protein values at the beginning of the session to obtain the manual prescription required and we will call it automatic-manual prescription. The aim of this study was to compare manual Qi with automatic- manual Qi in postdilution OL-HDF. 30 patients (16 men and 14 women), 59.9 ± 15 years old, in hemodialysis program for 50.1 ± 67 months were included. Every patient underwent four OL-HDF sessions, two with manual Qi (4008-S and 5008 monitors) and two with automatic- manual Qi (A-M), one with the same Qi and one with manual Qi +20 (A-M+20). The same usual dialysis parameters were maintained: helixone dialyzer, dialysis time of 266 ± 39 minutes, blood flow of 420 ± 36. Recirculation, Kt and intradialysis alarms were measured at each session. No significant differences in the fistula recirculation or dialysis dose measured using Kt. Total infusion volume was 24.9 ± 4 (4008S), 23.4 ± 4 L (5008) with manual Qi, 23.6 ± 4 L (A-M) Qi (NS) and 25.8 ± 5 L (A-M+20). Only 14% of patients had no incidents. The number of alarms was significantly higher with manual prescription 55 alarms with 4008 and 40 with 5008 vs. AM (11) p <0.01) and A-M+20 (16 alarms) We concluded that automatic-manual Qi is a practical way for post-dilutional OL-HDF prescription where the same efficiency and total reinfusion volume with an important reduction of intradialysis alarms are obtained, allowing to rise Qi by 20% without increasing intradialysis alarms (AU)

[Anemia in chronic kidney disease and its cardiovascular implications]. / Anemia en la insuficiencia renal crónica y sus implicaciones cardiovasculares.

Cardiovascular disease is the leading cause of death in patients with chronic kidney disease (CKD). Anemia is a common complication of CKD and it is an important independent risk factor for the development and progression of left ventricular hypertrophy (LVH) and heart failure. Anemia is also independently and synergistically associated with an enhanced risk of cardiovascular morbidity and mortality in CKD patients. The availability of erythropoiesis stimulating agents (ESA), such as recombinant human erythropoietin, has greatly improved the management of anemia in CKD patients. By increasing hemoglobin levels, ESA therapy has demonstrated to significantly improve quality of life and decrease morbidity and mortality among these patients. Earlier studies suggested that partial correction of anemia in CKD patients with LVH induced a partial regression of LV mass, while mainly uncontrolled and small-sized studies have suggested that anemia treatment with ESA in CKD patients with congestive heart failure improved NYHA class, cardiac function and reduced hospitalization rates. On the other hand, recent randomized controlled trials have reported no benefit of full anemia correction on LVH and no benefit, or even worse outcomes, in CKD patients versus partial anemia correction. Thus, recent anemia guidelines recommend target haemoglobin levels between 11-12 g/dl in CKD patients receiving ESA.

Influencia renal y enfermedad cadiovascular. Introducción / No disponible

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Anemia en la insuficiencia renal crónica y sus implicaciones cardiovasculares / Anemia in chronic kidney disease and its cardiovascular implications

La enfermedad cardiovascular es la principal causa de mortalidad en los pacientes con insuficiencia renal crónica (IRC). La anemia es una complicación frecuente en la IRC y contribuye al desarrollo y la progresión de la hipertrofia ventricular izquierda (HVI) y la insuficiencia cardíaca en estos pacientes. Asimismo, la anemia se asocia de forma independiente y sinérgica con un riesgo aumentado de morbimortalidad cardiovascular en la IRC. La aparición de los agentes estimuladores de la eritropoyesis (ESA), como la eritropoyetina recombinante humana, ha revolucionado el tratamiento de la anemia renal al aumentar los valores de hemoglobina, mejorar la calidad de vida y disminuir la morbimortalidad en los pacientes con IRC. Los estudios iniciales demostraron que la corrección parcial de la anemia con ESA en pacientes renales con HVI inducía una regresión parcial de ésta. En pacientes con insuficiencia cardíaca e IRC, el tratamiento mejora los parámetros clínicos. Sin embargo, la corrección total de la anemia en los pacientes renales no se asocia con un efecto beneficioso adicional ni en la HVI, ni en la morbimortalidad, e incluso se ha indicado un peor pronóstico, respecto a la corrección parcial. Por ello, en pacientes con IRC que reciben tratamiento con ESA, los valores objetivo de hemoglobina propuestos en las guías están entre 11 y 12 g/dl (AU)

Cardiovascular disease is the leading cause of death in patients with chronic kidney disease (CKD). Anemia is a common complication of CKD and it is an important independent risk factor for the development and progression of left ventricular hypertrophy (LVH) and heart failure. Anemia is also independently and synergistically associated with an enhanced risk of cardiovascular morbidity and mortality in CKD patients. The availability of erythropoiesis stimulating agents (ESA), such as recombinant human erythropoietin, has greatly improved the management of anemia in CKD patients. By increasing hemoglobin levels, ESA therapy has demonstrated to significantly improve quality of life and decrease morbidity and mortality among these patients. Earlier studies suggested that partial correction of anemia in CKD patients with LVH induced a partial regression of LV mass, while mainly uncontrolled and small-sized studies have suggested that anemia treatment with ESA in CKD patients with congestive heart failure improved NYHA class, cardiac function and reduced hospitalization rates. On the other hand, recent randomized controlled trials have reported no benefit of full anemia correction on LVH and no benefit, or even worse outcomes, in CKD patients versus partial anemia correction. Thus, recent anemia guidelines recommend target haemoglobin levels between 11-12 g/dl in CKD patients receiving ESA (AU)

Conclusiones / No disponible

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¿Cuánto tiempo es necesario aumentar la prescripción de hemodiálisis con la utilización de catéteres? / No disponible

En los últimos años hemos observado un aumento progresivo en el porcentaje de pacientes de hemodiálisis que utilizan catéteres centrales tunelizados como acceso vascular permanente, situándose las tasas de prevalencia e incidencia entorno al 7 y 25%, respectivamente. A pesar de que los catéteres actuales permiten la obtención de mayores flujos sanguíneos y menores complicaciones infecciosas, las dosis de diálisis obtenidas resultan inferiores a las alcanzadas mediante la utilización de fístulas arterio-venosas nativas (FAV) y prótesis vasculares. El objetivo principal del presente estudio fue valorar el tiempo adicional para obtener una dosis óptima de diálisis mediante la utilización de catéteres centrales venosos tunelizados. Dicha premisa se basa en la obtención de menores flujos sanguíneos (Qb) así como de posibles disfunciones vasculares que en diferentes ocasiones obligan a invertir las líneas arterio-venosas. Se analizaron un total de 48 pacientes (31 varones/17 mujeres) con una edad media de 61,6 ± 14 años (rango: 28-83); 20 con catéteres centrales tunelizados y 28 con FAV nativas. Todos los pacientes incluidos en el estudio se dializaron con la modalidad de hemodiálisis de alto flujo, con polisulfona de 1,9 m2, con una duración de 240 minutos, con flujo baño a 500 ml/min y monitores equipados con dialisancia iónica (DI). El objetivo principal de análisis fue la obtención de un Kt de 45 litros con cada uno de los diferentes accesos vasculares. Los pacientes portadores de una FAV recibieron 3 sesiones con variaciones de Qb a 300, 350 y 400 ml/min. Los pacientes con catéteres tunelizados recibieron dos sesiones de diálisis al máximo Qb, una con conexión de líneas normales y otra con líneas invertidas. Entre los resultados obtenidos cabe destacar que sólo los pacientes portadores de una FAV con un Qb de 400 ml/min alcanzaron el objetivo de Kt de 45 litros. Los sujetos con FAV precisaron incrementar 12 minutos de hemodiálisis con Qb de 350 ml/min y 28 minutos con Qb de 300 ml/min; los catéteres tunelizados en posición normal 24 minutos y los invertidos un total de 59 minutos. Concluimos que los pacientes dializados con catéteres centrales venosos tunelizados necesitan para alcanzar una dosis mínima de diálisis (Kt de 45 litros), incrementar por término medio 30 minutos el tiempo de la sesión si funciona en posición normal y 60 minutos en posición invertida de líneas arterio-venosas (AU)

The use of central catheters in hemodialysis patients as a permanent vascular access has increased during the last years, reaching numbers of around 7% of prevalent patients and between 25% of incident patients. Although the current catheters allow higher sanguineous flows with smaller incidence of infectious complications and dysfunction, the dose of dialysis that is reached is still inferior to that obtained with native arterio-venous fistula (AVF) and grafts. The aim of the present study was to evaluate the possible additional time supposed by dialysis using central venous catheters with respect to habitual vascular access as a consequence of the lesser blood flow (Qb) and the irregularity of its function (frequent lowering of the Qb and necessity of inverting the lines on many occasions). A total of 48 patients (31 men/17 women) with an average age of 61.6 ± 14 years old (rank: 28-83), 20 with tunnelled catheter and the remaining with AVF, were included in the study. All the patients were dialyzed in the modality of high flux hemodialysis with a polisulphone of 1.9 m2 dialyzer, dialysis time of 240 minutes, dialysate flow 500 ml/min and monitors equipped with ionic dialysance (ID) with the objective of obtaining a Kt of 45 litres with each one of the different vascular accesses. The patients with AVF received 3 sessions, with variations of Qb to 300, 350 and 400 ml/min. The patients with tunnelled catheter received two sessions, to the maximum Qb, one with normal connection and other with inverted one. In the results obtained it is possible to emphasize that only the patients with AVF and 400 ml/min reached the objective of 45 L of Kt. The patients with AVF needed to increase 12 minutes of hemodialysis with a Qb of 350 ml/min and 28 minutes with a Qb of 300 ml/min; the catheters on normal position needed to increase 24 minutes and finally in the inverted catheters an increase of 59 minutes was necessary to reach the same Kt objective. We concluded that the patients dialyzed with central catheters on average needed to increase by 30 minutes the time of dialysis if the catheter worked in a normal position but 60 minutes if the arterio-venous lines were inverted so as to reach the minimum dose of dialysis (AU)