Effect of Immunosuppressive Treatments on Kidney Outcomes After Gross Hematuria-Related Acute Kidney Injury in Older Patients With IgA Nephropathy.

Introduction: Macroscopic hematuria (MH) bouts, frequently accompanied by acute kidney injury (AKI-MH) are one of the most common presentations of IgA nephropathy (IgAN) in the elderly. Immunosuppressive therapies are used in clinical practice; however, no studies have analyzed their efficacy on kidney outcomes. Methods: This is a retrospective, multicenter study of a cohort of patients aged ≥50 years with biopsy-proven IgAN presenting with AKI-MH. Outcomes were complete, partial, or no recovery of kidney function at 1 year after AKI-MH, and kidney survival at 1, 2, and 5 years. Propensity score matching (PSM) analysis was applied to balance baseline differences between patients treated with immunosuppression and those not treated with immunosuppression. Results: The study group consisted of 91 patients with a mean age of 65 ± 15 years, with a mean follow-up of 59 ± 36 months. Intratubular red blood cell (RBC) casts and acute tubular necrosis were found in all kidney biopsies. The frequency of endocapillary hypercellularity and crescents were low. Immunosuppressive therapies (corticosteroids alone or combined with mycophenolate mofetil or cyclophosphamide) were prescribed in 52 (57%) patients, whereas 39 (43%) received conservative treatment. There were no significant differences in the proportion of patients with complete, partial, or no recovery of kidney function at 1 year between patients treated with immunosuppression and those not treated with immunosuppression (29% vs. 36%, 30.8% vs. 20.5% and 40.4 % vs. 43.6%, respectively). Kidney survival at 1, 3, and 5 years was similar among treated and untreated patients (85% vs. 81%, 77% vs. 76% and 72% vs. 66%, respectively). Despite the PSM analysis, no significant differences were observed in kidney survival between the two groups. Fourteen patients (27%) treated with immunosuppression had serious adverse events. Conclusions: Immunosuppressive treatments do not modify the unfavorable prognosis of patients with IgAN who are aged ≥50 years presenting with AKI-MH, and are frequently associated with severe complications.

The role of copeptin in kidney disease.

Copeptin is a 39-amino acid glycopeptide that is secreted equimolecularly with arginine-vasopressin (AVP) from the prepro-hormone AVP in the posterior pituitary. While AVP is a very unstable molecule and is accompanied by significant technical troubles in its quantification, copeptin is a stable and easily quantifiable molecule. For this reason, circulating copeptin is currently used as a surrogate for AVP in different pathological conditions, including renal diseases. In recent years it has been shown that copeptin is associated with an increased risk of developing chronic kidney disease in the general population. In addition, copeptin has also been associated with multiple renal diseases with relevant clinical consequences and potential therapeutic implications. In the present review, we update and summarize the clinical significance of copeptin as a surrogate marker for AVP concentrations in different kidney diseases, as well as in renal replacement therapy (hemodialysis and peritoneal dialysis) and renal transplantation.

IgA Nephropathy in Elderly Patients.

BACKGROUND AND OBJECTIVES: Some studies suggest that the incidence of IgA nephropathy is increasing in older adults, but there is a lack of information about the epidemiology and behavior of the disease in that age group. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective multicentric study, we analyzed the incidence, forms of presentation, clinical and histologic characteristics, treatments received, and outcomes in a cohort of 151 patients ≥65 years old with biopsy-proven IgA nephropathy diagnosed between 1990 and 2015. The main outcome was a composite end point of kidney replacement therapy or death before kidney replacement therapy. RESULTS: We found a significant increase in the diagnosis of IgA nephropathy over time from six patients in 1990-1995 to 62 in 2011-2015 (P value for trend =0.03). After asymptomatic urinary abnormalities (84 patients; 55%), AKI was the most common form of presentation (61 patients; 40%). Within the latter, 53 (86%) patients presented with hematuria-related AKI (gross hematuria and tubular necrosis associated with erythrocyte casts as the most important lesions in kidney biopsy), and eight patients presented with crescentic IgA nephropathy. Six (4%) patients presented with nephrotic syndrome. Among hematuria-related AKI, 18 (34%) patients were receiving oral anticoagulants, and this proportion rose to 42% among the 34 patients older than 72 years old who presented with hematuria-related AKI. For the whole cohort, survival rates without the composite end point were 74%, 48%, and 26% at 1, 2, and 5 years, respectively. Age, serum creatinine at presentation, and the degree of interstitial fibrosis in kidney biopsy were risk factors significantly associated with the outcome, whereas treatment with renin-angiotensin-aldosterone blockers was associated with a lower risk. Immunosuppressive treatments were not significantly associated with the outcome. CONCLUSIONS: The diagnosis of IgA nephropathy among older adults in Spain has progressively increased in recent years, and anticoagulant therapy may be partially responsible for this trend. Prognosis was poor. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_07_16_CJASNPodcast_19_08_.mp3.

Enfermedad renal «oculta» en ancianos: ¿deja de ocultarse a los 10 años de seguimiento? / Hidden renal disease in the elderly is not longer buried after 10 years of follow up

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Concentraciones séricas de potasio: importancia de la normopotasemia / Serum potassium concentrations: Importance of normokalaemia

Las anomalías en las concentraciones de potasio se asocian con morbimortalidad. En los últimos años se está considerando que pequeñas variaciones en las concentraciones séricas de potasio dentro del intervalo de la normalidad también pueden asociarse con mortalidad. Las estrategias para conseguir la normopotasemia incluyen medidas dietéticas, limitar el uso de fármacos que retienen potasio y emplear resinas de intercambio catiónico clásicas (poliestireno sulfonato cálcico/sódico) o el nuevo polímero no absorbible de intercambio catiónico (patiromer) (AU)

Abnormalities in potassium concentrations are associated with morbidity and mortality. In recent years it has been considered that small variations in serum potassium concentrations within normal intervals may also be associated with mortality. Strategies for achieving normokalaemia include dietary measures, limiting the use of potassium retaining drugs, and use of conventional cation exchange resins (calcium/sodium polystyrene sulfonate) and/or the new non-absorbed cation exchange polymer (patiromer) (AU)

Serum potassium concentrations: Importance of normokalaemia. / Concentraciones séricas de potasio: importancia de la normopotasemia.

Abnormalities in potassium concentrations are associated with morbidity and mortality. In recent years it has been considered that small variations in serum potassium concentrations within normal intervals may also be associated with mortality. Strategies for achieving normokalaemia include dietary measures, limiting the use of potassium retaining drugs, and use of conventional cation exchange resins (calcium/sodium polystyrene sulfonate) and/or the new non-absorbed cation exchange polymer (patiromer).

La ecuación berlin initiative study, una herramienta útil y específica para estimar el filtrado glomerular en centenarios / The berlin initiative study equation: a useful and specific tool for estimating glomerular filtration rate in centenarian patients

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Fracturas de cadera en una cohorte de ancianos con filtrado glomerular disminuido (no diálisis) / Hip fractures in an elderly cohort with decreased glomerular filtration rate (non-dialysis)

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Remisión completa de síndrome nefrótico en mujer con amiloidosis renal por fiebre mediterránea familiar / Complete remission of nephrotic syndrome in a woman with renal amyloidosis due to familial mediterranean fever

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Nuevas herramientas para abordar la función renal en ancianos: la ecuación Berlin Initiative Study y la fórmula hematocrito, urea y género / New tools for the management of renal function in the elderly: Berlin Initiative Study equation and hematocrit, urea and gender formulae

En los últimos años se ha generado un debate sobre el rango normal de función renal en el anciano, y si todo anciano con filtrado glomerular estimado por fórmulas (Cockroft-Gault, MDRD, CKD-EPI) menor de 60 ml/min/1,73 m2 tiene una enfermedad renal. En esta revisión analizamos, con base en los datos del estudio Ancianos con enfermedad renal crónica del Hospital de Segovia, las nuevas ecuaciones para medir la función renal en ancianos: la Berlin Initiative Study, diseñada para estimar el filtrado glomerular en personas de 70 años o más, y la fórmula hematocrito, urea y género para diferenciar si un anciano con FG menor de 60 ml/min/1,73 m2 tiene enfermedad renal (AU)

In the last few years a debate has emerged on the range of normal renal function in the elderly, and if every elderly person with a glomerular filtration rate estimated using formulas (Cockroft-Gault, MDRD, CKD-EPI) of less than 60 ml/min/1.73 m2 has kidney disease. In this review we analysed, based on the results of the study Elderly people with chronic kidney disease of the Hospital de Segovia, the new equations to measure kidney function in the elderly: the Berlin Initiative Study equation designed to estimate the glomerular filtration rate in people aged 70 or more, and the hematocrit, urea and gender formula to establish whether an elderly person with a glomerular filtration rate lower than 60 mL/min/1.73 m2 has kidney disease (AU)

Cómo debemos analizar y describir la mortalidad de nuestros pacientes: experiencia del Grupo Centro Diálisis Peritoneal / How should we analyze and present mortality in our patients?: A multicentre GCDP experience

Introducción: Existen distintas estrategias para analizar la mortalidad en diálisis peritoneal (DP), con diferentes definiciones de caso, evento, tiempo en riesgo y análisis estadístico. Un método común entre los distintos registros permitiría compararlos adecuadamente y entender mejor las diferencias reales de mortalidad de nuestros pacientes. Métodos: Revisamos y describimos las estrategias de análisis de los registros autonómicos, nacional e internacionales. Incluimos análisis de supervivencia actuarial, Kaplan-Meier (KM) y riesgos-competitivos (RC). Aplicamos los diferentes enfoques a la misma base de datos (GCDP), lo que permite mostrar las diferencias aparentes con cada método. Resultados: Se incluyeron 1.890 pacientes incidentes en DP en el periodo 2003-2013 (55 años; 64,2% varones), con FRR inicial de 7ml/min; el 25% presentaba diabetes y un índice de Charlson de 3 [2-4]. Fallecieron 261 pacientes, 380 pasaron a hemodiálisis (HD) y 682 recibieron trasplante. Las tasas de mortalidad anual llegan a variar hasta un 20% en números relativos (6,4 vs. 5,2%) según el sistema aplicado. La estimación de probabilidad de mortalidad por RC es inferior a KM en todos los años: 3,6 vs. 4,0% el 1.er año; 9,0 vs. 11,9%; 15,6 vs. 28,3% y 18,5 vs. 43,3% los siguientes. Conclusiones: Aunque cada método pueda ser correcto en sí mismo y expresar diferentes enfoques, la impresión final que queda en el lector es un número que sobrestima la mortalidad. El modelo de RC expresa mejor la realidad en DP, donde el número de pacientes que pierden seguimiento (trasplante, paso a HD) cuadruplica al de los fallecidos y solo una cuarta parte continúa en DP al final del seguimiento (AU)

Introduction: There are different strategies to analyse mortality in peritoneal dialysis (PD) with different definitions for case, event, time at risk, and statistical tests. A common method for the different registries would enable proper comparison to better understand the actual differences in mortality of our patients. Methods: We review and describe the analysis strategies of regional, national and international registries. We include actuarial survival, Kaplan-Meier (KM) and competitive risk (CR) analyses. We apply different approaches to the same database (GCDP), which show apparent differences with each method. Results: A total of 1,890 incident patients in PD from 2003-2013 were included (55 years; men 64.2%), with initial RRF of 7 ml/min; 25% had diabetes and a Charlson index of 3 [2-4]; 261 patients died, 380 changed to haemodialysis (HD) and 682 received a transplant. Annual mortality rates varied up to 20% in relative numbers (6.4 vs. 5.2%) depending on the system applied. The estimated probability of mortality measured by CR progressively differs from the KM over the years: 3.6 vs. 4.0% the first year, then 9.0 vs. 11.9%, 15.6 vs. 28.3%, and 18.5 vs. 43.3% the following years. Conclusions: Although each method may be correct in themselves and express different approaches, the final impression left on the reader is a number that under/overestimates mortality. The CR model better expresses the reality of PD, where the number of patients lost to follow-up (transplant, transfer to HD) it is 4 times more than deceased patients and only a quarter remain on PD at the end of follow up (AU)

[New tools for the management of renal function in the elderly: Berlin Initiative Study equation and hematocrit, urea and gender formulae]. / Nuevas herramientas para abordar la función renal en ancianos: la ecuación Berlin Initiative Study y la fórmula hematocrito, urea y género.

In the last few years a debate has emerged on the range of normal renal function in the elderly, and if every elderly person with a glomerular filtration rate estimated using formulas (Cockroft-Gault, MDRD, CKD-EPI) of less than 60ml/min/1.73m(2) has kidney disease. In this review we analysed, based on the results of the study Elderly people with chronic kidney disease of the Hospital de Segovia, the new equations to measure kidney function in the elderly: the Berlin Initiative Study equation designed to estimate the glomerular filtration rate in people aged 70 or more, and the hematocrit, urea and gender formula to establish whether an elderly person with a glomerular filtration rate lower than 60mL/min/1.73m(2) has kidney disease.

How should we analyze and present mortality in our patients?: A multicentre GCDP experience.

INTRODUCTION: There are different strategies to analyse mortality in peritoneal dialysis (PD) with different definitions for case, event, time at risk, and statistical tests. A common method for the different registries would enable proper comparison to better understand the actual differences in mortality of our patients. METHODS: We review and describe the analysis strategies of regional, national and international registries. We include actuarial survival, Kaplan-Meier (KM) and competitive risk (CR) analyses. We apply different approaches to the same database (GCDP), which show apparent differences with each method. RESULTS: A total of 1,890 incident patients in PD from 2003-2013 were included (55 years; men 64.2%), with initial RRF of 7ml/min; 25% had diabetes and a Charlson index of 3 [2-4]; 261 patients died, 380 changed to haemodialysis (HD) and 682 received a transplant. Annual mortality rates varied up to 20% in relative numbers (6.4 vs. 5.2%) depending on the system applied. The estimated probability of mortality measured by CR progressively differs from the KM over the years: 3.6 vs. 4.0% the first year, then 9.0 vs. 11.9%, 15.6 vs. 28.3%, and 18.5 vs. 43.3% the following years. CONCLUSIONS: Although each method may be correct in themselves and express different approaches, the final impression left on the reader is a number that under/overestimates mortality. The CR model better expresses the reality of PD, where the number of patients lost to follow-up (transplant, transfer to HD) it is 4 times more than deceased patients and only a quarter remain on PD at the end of follow up.

Asociación de nefropatía por cambios mínimos y policitemia en un paciente muy anciano / Association of minimal-change disease and polycythaemia in a very elderly patient

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Rabdomiólisis severa tras una agresión física y agravada por anfetaminas / Rhabdomyolysis after physical aggression and aggravated by amphetamines

(AU) Describimos el caso de un varón joven, con un fracaso renal agudo anúrico severo e hiperpotasemia tóxica, relacionados con una rabdomiólisis tras una agresión física y que había pasado desapercibida en 2 visitas previas a Urgencias y, posteriormente, agravada por consumo de anfetaminas. Este caso ilustra la necesidad de considerar la posibilidad de una rabdomiólisis ante paciente con cualquier grado de daño muscular