Learning to implement Smart Healthy Age-Friendly Environments.

To develop trainings on the implementation of smart healthy age-friendly environments for people who aim to support, for example, their parents, their neighbours or local community, there are precautionary measures that have to be taken into account: the role of the facilitator (volunteer or self-employed), the level of skills, the needs of the end-users, training content and methodologies together with the sustainability of the learning. This article examines these aspects, based on desk research and expert interviews in the Smart Healthy Age-Friendly Environments (SHAFE) fields.

Treatment of transplant renal artery stenosis by percutaneous transluminal angioplasty and/or stenting: study in 63 patients in a single institution.

OBJECTIVE: Our aim was a retrospective evaluation of technical procedures, clinical success, and follow-up of renal transplant patients with stenosis in the transplant renal artery (TRAS) after endovascular treatment. METHODS: From January 1981 to September 2009, 2,150 allograft renal transplants included 62 patients who underwent endovascular procedures for TRAS >75%. Parameters included technical success, arterial blood pressure, antihypertensive drugs, and creatinine level before and after the intervention. RESULTS: Percutaneous transluminal angioplasty (PTA)/stent placement success was 90.3%. Seventy-nine PTAs with 11 stents were primary interventions with 6 PTAs and 4 stent procedures subsequently performed due to restenosis (mean time to event, 1.5 months). The median follow-up was 39 months (range, 1-236). The mean preprocedure creatinine level was 2.8 ± 1.7 mg/dL, and the 1-month postprocedure value was decreased to 2.1 ± 1.2 mg/dL (P < .001). Systolic arterial blood pressure fell from 147.2 ± 18.7 mm Hg to 131.6 ± 14.2 mm Hg (P < .001) and diastolic blood pressure from 84.4 ± 9.8 mm Hg to 76 ± 9.4 mm Hg (P < .001). Postprocedure number of antihypertensive drugs was reduced from 2.3 ± 1.1 to 1.6 ± 1 (P < .0001). The patency rates were: 95 ± 2.8% at 1 month, 87.9 ± 4.3% at 3 months, and 85 ± 4.7% at 12 months. Secondary patency was 100% with no restenosis on follow-up. Allograft survival after primary and secondary PTA/stenting was 97% at 1, 93% at 3.89% at 5, and 85% at 10 years. The complication included 2 renal artery thromboses, a dissection treated with stents, and a late arterial graft pseudoaneurysm. CONCLUSIONS: TRAS, a problem after kidney transplantation, is detected to be a significant stenosis through the use of Doppler ultrasound. Revascularization is recommended to improve hypertension and graft function. PTA should be primarily planned with stenting for patients with a restenosis or after a lack of response to PTA.

Incidence of cardiovascular events in renal transplant recipients and clinical relevance of modifiable variables.

INTRODUCTION: The aims of this study were to quantify the incidence of cardiovascular events and identify the clinical relevance of modifiable variables. MATERIALS AND METHODS: The 1729 patients who underwent renal transplantation from 1981 to 2004 were evaluated in an observational, prospective follow-up study with no exclusions. A cardiovascular event was defined as the presence of ischemic cardiac disease (chest pain-myocardial infarction), cardiac insufficiency, arrhythmia (auricular fibrillation), peripheral vascular disease, or cerebrovascular accident. A survival analysis was performed using the Kaplan-Meier method. A Cox regression analysis was applied. Having identified the predictive variables of cardiovascular events, the population attributable fraction (PAF) and the etiological fraction (EF) were estimated. A risk score was calculated using Cox regression coefficients. RESULTS: The accumulated incidence of cardiovascular events was 22.2%, with an incidence rate of 468.6 x 10,000 follow-up years. From the Cox regression model, the variables with an independent effect close to statistical significance to predict cardiovascular events were as follows: recipient age (RR = 1.05), smoking at the time of the transplantation (RR = 2.1), left ventricle hypertrophy during follow-up (RR = 2.4), prior diabetes mellitus, and obesity (body mass index >or=30). At the time of transplantation, 41.7% were smokers. During follow-up, a clear difference was observed in the incidence rates of cardiovascular events between smokers and nonsmokers. Similar phenomena were observed for left ventricle hypertrophy and obesity. The resulting scores ranged between 0 and 5. The area under the ROC curve of the score for the prediction of cardiovascular events was 0.74. CONCLUSION: The incidence of cardiovascular events was consistent with the literature. A series of modifiable variables of major clinical relevance exist to decrease the frequency of cardiovascular events following renal transplantation.

Evaluation of renal grafts in patients with lupus nephritis as cause of end-stage renal disease.

INTRODUCTION: Kidney transplantation is the best option in end-stage renal disease (ESRD). For many years patients affected with lupus nephritis have had poor graft results. However, this has been changing over recent years with the development of new immunosuppressive drugs and a better comprehension of the natural evolution of the entity. METHODS: We studied 20 patients with lupus nephritis who received 22 kidney grafts: 15 women and five men (n = 11) who were treated with cyclosporine or with tacrolimus (n = 11). Secondary immunosuppression included mycophenolate match (MMF) (n = 13) or azathioprine (n = 9). We analyzed human leukocyte antigen, cold ischemia time, acute tubular necrosis, creatinine, cholesterol, triglycerides, glucose, blood pressure, acute rejection episodes, immunosuppression, infections, disease recurrences, as well as graft and patient survival. RESULTS: After a mean cold ischemia time of 22 +/- 4 hours, nine patients displayed delayed graft function of an average duration 9 +/- 4 days. At 36 +/- 35 months nine grafts were lost: two due to acute rejection; five to chronic allograft nephropathy; and two to venous thrombosis. One patient died of hemorrhagic shock. There were five cytomegalovirus infections. Graft survival was dependent on the type of secondary immunosuppression, incidence of acute rejection episodes and occurrence of delayed graft function. CONCLUSIONS: We found no clinical recurrence of lupus nephritis after transplantation and a low incidence of complications, although there was a trend toward thrombosis. The presence of delayed graft function, episodes of acute rejection, and receiving azathioprine instead of MMF as secondary immunosuppression were associated with poorer graft survival.

Basiliximab (Simulect) in renal transplantation with high risk for delayed graft function.

BACKGROUND: Basiliximab (Simulect) is effective in reducing episodes of acute rejection in renal transplantation. Delayed graft function (DGF) predisposes to acute rejection and shortens graft survival. The aim of this study was to determine the effects of basiliximab in renal transplantation recipients at high risk for DGF. METHODS: We studied 87 patients (mean age, 59 years), 42 of whom received basiliximab, 20 mg before transplantation and 20 mg on day 4. This cohort was compared with 45 patients without basiliximab. All received cyclosporine (51%) or tacrolimus (49%), mycophenolate mofetil, and steroids. DGF was defined as the requirement for dialysis within the first week after transplantation or failure to improve preexisting renal function. High-risk factors for DGF were cold ischemia time, recipient and donor age, non-heart-beating donor, HLA matching, and panel reactive antibody (PRA). RESULTS: The incidence of DGF was 18 (43%) in the basiliximab group versus 28 (62%) in the other patients (P = .07). When allografts from non-heart-beating donors were excluded, this incidence was 14 (38%) in the basiliximab group versus 28 (62%) in the other patients (P = .04). Regression analysis showed basiliximab to be a protective factor: 0.26 (range, 0.09-0.76). Basiliximab was well tolerated, and complications were similar in both groups. CONCLUSIONS: Basiliximab reduced the incidence of DGF in patients who received a high-risk allograft. It was well tolerated, and no adverse events were reported. The use of basiliximab may be considered in patients receiving an allograft who are at high risk for DGF.

Guía de acceso vascular en hemodiálisis / Vascular access guideliness for hemodialysis

Introducción. La calidad del acceso vascular (AV) condiciona los resultados clínicos de los enfermos tratados mediante hemodiálisis periódicas. Las complicaciones originadas por la disfunción del AV constituyen una de las principales causas de morbimortalidad de estos pacientes y contribuyen de forma sustancial al aumento del coste sanitario. La Sociedad Española de Nefrología considera que este problema requiere una atención prioritaria, y ha decidido realizar una revisión de las guías de actuación de este capítulo, con la finalidad de mejorar nuestros estándares colectivos y elevar la calidad de nuestra práctica asistencial. Objetivos. La finalidad esencial ha sido la de elaborar un informe que pueda proporcionar una ayuda para la comprensión y tratamiento de los problemas relacionados con el AV y obtener una homogeneización de actuaciones con el propósito de alcanzar tres objetivos principales: aumentar la utilización de fístulas arteriovenosas autólogas como AV inicial, detectar la disfunción de AV permanente antes de la trombosis y racionalizar la utilización de catéteres venosos centrales (CVC). Desarrollo y conclusiones. Se presenta un documento consensuado de forma multidisciplinar en la que han participado nefrólogos, cirujanos vasculares, radiólogos intervencionistas, especialistas en enfermedades infecciosas y diplomados en enfermería nefrológica. En él se define el estado de la situación en seis capítulos: preparación del paciente, creación del AV, cuidados, vigilancia, tratamiento de las complicaciones y CVC. Estas guías constan de una serie de enunciados con diferentes grados de evidencia según la literatura disponible, que no pretenden ser normas de obligado cumplimiento, sino referentes del estado actual del problema y sus soluciones. La práctica clínica diaria, al depender de las condiciones intrínsecas, no siempre nos permite alcanzar el ideal, pero sí dirigir nuestros esfuerzos a una mejora de resultados. Cada recomendación se complementa con la exposición de su razonamiento. El documento se acompaña de una serie de indicadores de calidad

Introduction. Quality of vascular access (VA) has aremarkable influence in hemodialysis patients outcomes. Dysfunction of VA represents a capital cause of morbi-mortality of these patients as well an increase in economical. Aims. Spanish Society of Nephrology, aware of the problem, has decided to carry out a revision of the issue with the aim of providing help in comprehensión and treatment related with VA problems, and achieving an homogenization of practices in three mayor aspects: to increase arteriovenous fistula utilization as first vascular access, to increment vascular access monitoring practice and rationalise central catheters use. Development and conclusions.We present a consensus document elaborated by a multidisciplinar group composed by nephrologists, vascular surgeons, interventional radiologysts, infectious diseases specialists and nephrological nurses. Along six chapters that cover patient education, creation of VA, care ,monitoring, complications and central catheters, we present the state of the art and propose guidelines for the best practice, according different evidence based degrees, with the intention to provide help at the professionals in order to take aproppiate decissions. Several quality standars are also included

[Vascular access guidelines for hemodialysis]. / Guías de acceso vascular en hemodiálisis.

Quality of vascular access (VA) has a remarkable influence in hemodialysis patients outcomes. Dysfunction of VA represents a capital cause of morbi-mortality of these patients as well an increase in economical. Spanish Society of Neprhology, aware of the problem, has decided to carry out a revision of the issue with the aim of providing help in comprehensión and treatment related with VA problems, and achieving an homogenization of practices in three mayor aspects: to increase arteriovenous fistula utilization as first vascular access, to increment vascular access monitoring practice and rationalise central catheters use. We present a consensus document elaborated by a multidisciplinar group composed by nephrologists, vascular surgeons, interventional radiologysts, infectious diseases specialists and nephrological nurses. Along six chapters that cover patient education, creation of VA, care, monitoring, complications and central catheters, we present the state of the art and propose guidelines for the best practice, according different evidence based degrees, with the intention to provide help at the professionals in order to make aproppiate decissions. Several quality standars are also included.

Renal transplantation from non-heart-beating donors: a single-center 10-year experience.

BACKGROUND: Reluctance to accept non-heart-beating donors (NHBD) as a source of kidneys, is due to medical, ethical, and logistical reasons. Evidence suggest that the short-term graft survival is similar to that of kidneys obtained from heart-beating donors (HBD). However, few studies, with long-term follow-up are available. We conducted a single-center study of kidneys obtained from NHBD, in a 14-year period. METHODS: We studied 100 patients transplanted with kidneys between 1989 and 2004, using NHBD, supported by heart compression and mechanical ventilation (n = 24), intravascular in situ cooling (n = 59), or cardiorespiratory resuscitation plus manual abdominal counterpulsation without cooling (n = 17), the last technique being used from 1998. The median follow-up was 51 +/- 51 months (range, 1 to 170). The outcomes of these procedures were compared to those of 1025 transplantations of kidneys from HBD performed during the same period. RESULTS: The characteristics of the recipients did not differ significantly between the two groups. Kidneys from NHBD showed a significantly higher rate of delayed graft function (DGF; 84% vs 26%; (P < .001), furthermore, the primary nonfunction (PNF) incidence was significantly higher with NHBD vs HBD (16% vs 10%; P < .001). The incidence of acute rejection episodes (ARE) within 3 months and at 1 year did not differ between the groups of donors; however, more NHBD kidneys were lost from ARE. The short-term (3-month and 1 year) and long-term (5 and 10 years) renal function, determined by the serum creatinine levels, and patient and graft survival were not different for kidneys obtained from NHBD. CONCLUSIONS: The incidences of PNF and DGF were significantly higher with NHBD, which produced poorer renal function at the time of hospital discharge. One-, 5-, and 10-year graft survivals and renal function did not differ between NHBD and HBD grafts. In our series, PNF was the main barrier to the use of NHBD.

Influence of the management of asystolic donors on kidney transplantation outcome.

Two methods of donor management were analysed, namely, with and without in situ cooling perfusion of the kidney in an attempt to determine the optimal management and preservation methods for asystolic kidney donors. The group of recipients of in situ cooling perfusion kidneys showed more days of oliguria (P <.05), needed more dialysis sessions (P <.05), and showed no transplant function during the first week after surgery. This group also had a greater probability of acute rejection (P =.071) and a higher rate of nonfunctioning grafts (P =.09). We conclude that in situ cooling perfusion of asystolic kidney donors impairs graft function.

Diabetes mellitus y riesgo cardiovascular / Diabetes mellitus and cardiovascular risk

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Rabdomiolisis masiva tras sobredosis de drogas intravenosas complicada con fracaso renal agudo y síndrome compartimental generalizado / Acute renal failure and multiple compartment syndrome as complications of drugs-induced massive rhabdomyolisis

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A comparative analysis on the incidence of peritonitis and exit-site infection in CAPD and automated peritoneal dialysis.

OBJECTIVE: To compare the incidence of peritonitis and exit-site infection in an ample group of patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis in a single center during a 10-year period. DESIGN: Nonrandomized, prospective study. SETTING: Public, tertiary care hospital providing peritoneal dialysis care to a population of (approximately) 750 000 people. PATIENTS: We studied 213 patients on CAPD and 115 on automated peritoneal dialysis (APD) starting therapy between January 1989 and August 1998, with a minimum follow-up of 3 months. MAIN OUTCOME MEASURES: Using a multivariate approach, we compared the incidence, clinical course, and outcome of peritonitis and exit-site infections in both groups, controlling for other risk factors for the complications studied. RESULTS: The incidence of peritonitis was higher in CAPD than in APD (adjusted difference 0.20 episodes/ patient/year, 95% confidence interval 0.08 - 0.32). There was a trend for CAPD patients to present earlier with peritonitis than APD patients, yet the incidence of and survival to the first exit-site infection were similar in both groups. The etiologic spectrum of infections displayed minor differences between groups. Automated PD patients were more frequently hospitalized for peritonitis, but otherwise, the complications and outcome of peritonitis and exit-site infections did not differ significantly between patients on CAPD and those on APD. CONCLUSIONS: Automated PD is associated with a lower incidence of peritonitis than is CAPD, while exit-site infection is similarly incident under both modes of therapy. The etiologic spectrum, complications, and outcome of peritonitis and exit-site infection do not differ markedly between CAPD and APD. Prevention of peritonitis should be included among the generic advantages of APD over CAPD.

Early immunologic and nonimmunologic predictors of arterial hypertension after renal transplantation.

We followed up a cohort of 680 renal transplant recipients receiving cyclosporine (CsA) immunosuppression with the aim of establishing an early-risk profile for early and late hypertension (HT) after renal transplantation (RTx), specifically comparing the predictive role of immunologic and nonimmunologic markers of graft prognosis. HT was defined as the need for antihypertensive drugs. The prevalence of HT was 65% at the time of RTx, increased to a peak of 78% at the end of the first year, and stabilized between 71% and 73% thereafter. Multivariate analysis identified HT at the time of RTx, basal renal disease, and grafting the right kidney as independent predictors of HT 3 months after RTx. The risk profile for HT 12 months after RTx included HT present at RTx, grafting the right kidney, markers of early ischemia-reperfusion injury (delayed graft function, cold and warm ischemia), and transplant from an elderly or female donor. Polytransfusion before RTx was associated with a decreased risk for HT, but retransplantation, increased reactivity against the lymphocyte panel, poor HLA compatibility, and early acute rejection did not portend an increased risk for the complication under study. The CsA schedule (dose, trough levels) correlated poorly with the blood pressure status of the patients, but simultaneous graft function was independently associated with late HT. In conclusion, the early predictive profile for HT after RTx includes, preferentially, nonimmunologic markers of graft prognosis. Hyperfiltration damage may be a significant pathogenic mechanism for this complication of RTx.

Complications of permanent catheter implantation for peritoneal dialysis: incidence and risk factors.

We reviewed the incidence and risk factors for complications after insertion of permanent catheters for peritoneal dialysis (PD). We implanted 192 peritoneal catheters in 137 patients over ten years. Fifty-three complications were observed in 50 catheters (27.6%) implanted in 42 patients (30.6%): malposition or omental entrapment (13%), dialysate leak (8.9%), hemoperitoneum (3.6%), peritonitis (1%), surgical wound infection (0.5%), and chylous ascites (0.5%). The only significant risk factors for a complicated insertion were previous abdominal surgery, particularly if it affected the peritoneal membrane, and early use of the catheter after implantation (< 5 days), independent of surgical or closed insertion.

Treatment of peritonitis in CAPD with ciprofloxacin: long-term experience.

We present the long-term results of a protocol of empirical monotherapy of continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis with ciprofloxacin. One hundred and fifteen episodes of peritonitis were studied. The treatment protocol included 5 days of intraperitoneal (IP) administration of the drug, followed by 10 days of oral therapy. A good clinical response was obtained in 83% of the cases, while treatment failure was observed in 4% and relapse in 7%. A decrease in the sensitivity to ciprofloxacin of the peritonitis agents was observed in the study, with Staphylococcus spp. in particular. Three episodes of peritonitis due to bacteria resistant in vitro to ciprofloxacin responded to the treatment protocol. Ciprofloxacin attained good plasma levels both after oral and IP administration. However, dialysate levels were poor after oral administration. The most frequent side effect was gastric intolerance to oral ciprofloxacin. Two patients experienced severe adverse reactions to the drug. Ciprofloxacin may be a good choice for empirical monotherapy of CAPD-related peritonitis. However, the emergence of bacterial resistances must be carefully monitored. The drug should be administered intraperitoneally, at least to induce remission of the infection. Side effects are not frequent, but ciprofloxacin should not be considered an innocuous drug.

Treatment of Staphylococcus aureus nasal carriers in CAPD with mupirocin.

We have studied the efficacy of topical Mupirocin for elimination of Staphylococcus aureus (Staph. aureus) nasal carriage in CAPD patients. Staph. aureus nasal carriers in our CAPD program were randomized to one of two groups: Group 1, treated with Mupirocin, and Group 2, treated with neomycin sulphate nasal ointment. The prevalence of Staph. aureus nasal colonization was 44% for patients (24/54) and 17% for dialysis partners (5/29). Group 1 included 11 patients and 1 partner, and Group 2, 8 patients and 2 partners. In Group 1, the eradication rate was 100%, and the recolonization rate was 0, 8, 41, 55 and 66% at 1, 2, 3, 6 and 10 months. In Group 2, the eradication rate was 40%, with a recolonization rate of 0.25 and 75% at 1, 2 and 3 months. Re-treatment with mupirocin was successful in 66% of the cases, compared to 20% for neomycin. The MIC90 of mupirocin for Staph. aureus was 0.5 mcg/mL, with an increase to 4 mcg/mL towards the end of the study. During the study period, there was a very low incidence of Staph. aureus peritonitis or catheter-related infections in patients treated with mupirocin. Secondary effects of mupirocin were negligible. Mupirocin is more effective than neomycin sulphate for the elimination of Staph. aureus nasal colonization in patients undergoing CAPD. Periodic re-treatment is frequently necessary, given the significant recolonization rate.