Guía clínica española del acceso vascular para hemodiálisis / Spanish clinical guidelines on vascular access for haemodialysis

El acceso vascular para hemodiálisis es esencial para el enfermo renal tanto por su morbimortalidad asociada como por su repercusión en la calidad de vida. El proceso que va desde la creación y mantenimiento del acceso vascular hasta el tratamiento de sus complicaciones constituye un reto para la toma de decisiones debido a la complejidad de la patología existente y a la diversidad de especialidades involucradas. Con el fin de conseguir un abordaje consensuado, el Grupo Español Multidisciplinar del Acceso Vascular (GEMAV), que incluye expertos de las cinco sociedades científicas implicadas (nefrología [S.E.N.], cirugía vascular [SEACV], radiología vascular e intervencionista [SERAM-SERVEI], enfermedades infecciosas [SEIMC] y enfermería nefrológica [SEDEN]), con el soporte metodológico del Centro Cochrane Iberoamericano, ha realizado una actualización de la Guía del Acceso Vascular para Hemodiálisis publicada en 2005. Esta guía mantiene una estructura similar, revisando la evidencia sin renunciar a la vertiente docente, pero se aportan como novedades, por un lado, la metodología en su elaboración, siguiendo las directrices del sistema GRADE con el objetivo de traducir esta revisión sistemática de la evidencia en recomendaciones que faciliten la toma de decisiones en la práctica clínica habitual y, por otro, el establecimiento de indicadores de calidad que permitan monitorizar la calidad asistencial.

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support.

Aneurysmal degeneration of the inflow artery after arteriovenous access for hemodialysis.

OBJECTIVES: After arteriovenous fistula creation, the arterial flow increase can lead to aneurysmal degeneration, even increased after fistula ligation or renal transplant immunosuppression. The aim of this study is to describe the therapeutic options and outcomes of true aneurysms of the inflow artery after arteriovenous fistula for hemodialysis. METHODS: Prospectively collected data of patients with true aneurysmal degeneration of the inflow artery after fistula creation (excluding pseudoaneuryms, anastomotic or infected aneurysms, or surgical complications), surgically repaired between January 2010 and February 2014 (cohort study) have been included. Patient demographics and access characteristics, symptoms, treatment, and follow-up have been reviewed. RESULTS: 12 patients (75% men, median age 63 years) were treated for aneurysmal degeneration of the axillary (1), brachial (6), or radial (5) artery. They had had a previous distal arteriovenous fistula (7 radiocephalic, 3 brachiocephalic, 2 brachiobasilic) created 15.6 years before (range 9.9-28.5) and the majority of them were currently ligated or thrombosed. Most patients were symptomatic (pain [6], distal embolization [1]). They were treated by means of a bypass (using the cephalic [3], basilic [4], or saphenous vein [2]), direct ligature (2), or excision with end-to-end reconstruction (1). No major complications or ischemic symptoms occurred before discharge. After a median follow-up of 8.6 months (3.1-36.5), one patient needed re-operation for new proximal brachial aneurysmal degeneration, and another presented with an asymptomatic post-traumatic thrombosis of the proximal axillary artery and brachial bypass. No other complications, bypass dilatation or ischemic symptoms occurred during follow-up. CONCLUSIONS: Inflow artery aneurysmal degeneration can occur after long-term arteriovenous access. Surgical treatment by autogenous bypass exclusion in most cases (or ligation or end-to-end reconstructions in selected cases) is a safe and effective option.

Elimination of large uremic toxins by a dialyzer specifically designed for high-volume convective therapies.

BACKGROUND: Unlike conventional hemodialysis treatments, which rely almost solely on diffusion-related mechanisms for solute removal, hemodiafiltration (HDF) allows more efficient removal of higher molecular weight toxins due to convective transport mechanisms. To facilitate the removal of these toxins in HDF treatment modalities, dialyzers with highly efficient high-flux membranes are necessary. This study assessed the large uremic toxin removal ability of a high-flux dialyzer (FX CorDiax 60) specifically designed to facilitate convective therapies compared with a standard high-flux dialyzer (FX 60). METHODS: In an open, randomized, cross-over, single-center, controlled, prospective clinical study, 30 adult chronic hemodialysis patients were treated by post-dilution online HDF with the FX 60 or the FX CorDiax 60 dialyzer. All other dialysis parameters were kept constant in both study arms. The reduction rate (RR) of blood urea nitrogen, phosphate, ß2-microglobulin (ß2-m), myoglobin, prolactin, α1-microglobulin, α1-acid glycoprotein, albumin and total protein as well as the elimination into dialysate was intraindividually compared for the two dialyzer types. RESULTS: For FX CorDiax 60 versus FX 60, the RR was significantly higher for blood urea nitrogen (86.23 ± 4.14 vs. 84.89 ± 4.59%, p = 0.015), ß2-m (84.67 ± 3.79 vs. 81.30 ± 4.82%, p < 0.0001), myoglobin (75.23 ± 10.48 vs. 58.60 ± 12.1%, p < 0.0001), prolactin (72.96 ± 9.68 vs. 56.91 ± 13.01%, p < 0.0001) and α1-microglobulin (20.89 ± 18.27 vs. 13.60 ± 12.50%, p = 0.016). There were no significant differences in the RR for phosphate, α1-acid glycoprotein, albumin and total protein. Mass removal was significantly higher with the FX CorDiax 60 than with the FX 60 for ß2-m (0.26 ± 0.09 vs. 0.24 ± 0.09 g, p = 0.0006), myoglobin (1.83 ± 0.89 vs. 1.51 ± 0.76 mg, p = 0.0017), prolactin (0.17 ± 0.13 vs. 0.14 ± 0.08 mg, p = 0.02) and albumin (4.25 ± 3.49 vs. 3.01 ± 2.37 g, p = 0.03). CONCLUSIONS: This study demonstrates that treating patients with an FX CorDiax 60 instead of an FX 60 dialyzer in post-dilution HDF mode significantly increases the elimination of middle molecules.

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)

¿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)

[How much should dialysis time be increased when catheters are used?]. / ¿Cuánto tiempo es necesario aumentar la prescripción de hemodiálisis con la utilización de catéteres?

SUMMARY: 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.

Enfermedad de Graves, hipotiroidismofarmacológico y síndrome nefrótico por enfermedad de cambios mínimos / Graves disease, drug-related hypothyroidism, and nephrotic syndrome due to minimal changes disease

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Acidosis láctica severa por metformina y fracaso renal agudo tras realización de cateterismo cardíaco / Metformin-associated lactic acidosis and acute renal failure secondary to cardiac catheterism

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Hipokaliemia sintomática asociada a enfermedad de Cacchi-Ricci / Hipokaliemia sintomática asociada a enfermedad de Cacchi-ricci

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Estudio sobre el grado de cumplimiento ambulatorio del documento de consenso 2002 para el control de la nefropatía diabética en Cataluña (ECCODIAB) / Compliance with the document of the Spanish society of nephrology 2002 document for the control of diabetic nephropathy in Catalonia. (ECODIAB)

Objetivo: Evaluar el grado de cumplimiento del documento de consenso 2002 (SEN) sobre pautas de detección, prevención y tratamiento de la nefropatía diabética en Cataluña. Pacientes y métodos: Estudio multicéntrico de corte transversal (23 centros hospitalarios), observacional y descriptivo, realizado sobre un total de 413 pacientes diabéticos (61,7% hombres y 38,3% mujeres) con una edad media de 66,2 ± 11,5 años (26-93 años). Para el análisis estadístico entre los diferentes grados de nefropatía diabética y las variables del estudio, se utilizó un test de ANOVA con valoración post-hoc (p 30 kg/m2: 48,7%) y perímetro de cintura 104,1 ± 14 cm (48,6% hombres > 102 cm y 78,9% mujeres > 88 cm). El valor de la creatinina sérica 1,9 ± 1,3 mg/dl y el GFR estimado con la ecuación MDRD simplificada (MDRDs) 45,3 ± 25,0 ml/min/1,73 m2 [65,8% con ERC estadios 3 y 4]. El 80% de los pacientes tenían examen oftalmológico y el 52,8% recibía tratamiento antiagregante. La Hb A1c fue 7,3 ± 1,3%, pero el porcentaje de pacientes con glicadas > 7% y 8% resultó del 54,9 y 28,6% respectivamente [tan sólo el 50,2% había sido visitado por el endocrinólogo en los últimos 6 meses]. El 52,8% de los pacientes se encontraban en tratamiento con insulina y el 44,1% con ADOs, pero tan sólo un 19,6% con antidiabéticos de metabolización hepática. El 61% de la muestra tenia un LDLc > 100 mg/dl (61% tratados) y el 44% triglicéridos (TG) > 150 mg/dl (72% tratados). El 95% de los pacientes presentaban antecedentes de hipertensión arterial (>= 130/80 mmHg) y de estos el 91% se encontraban con tratamiento hipotensor (79,7% con IECAS y/o ARA tipo II). El 81% de los microalbuminúricos y el 78% de los macroalbuminúricos recibía algún tipo de tratamiento antiproteinúrico. Entre el grupo de pacientes considerados con HTA refractaria (>3 fármacos), tan sólo el 29% tenía un MAPA. Se obtuvieron relaciones significativas entre los diferentes estadios de nefropatía diabética y el control glucémico (HBA1c; p = 0,048), tensión arterial sistólica (TAS; p = 0,024), perfil lipídico (HDLc; p = 0,015 y TG; p = 0,034), anemia (Hb; p = 0,010) y grado de ERC (creatinina sérica y MDRDs; p = 0,000). El grado de cumplimiento terapéutico sobre el control lipídico (LDL <= 100 mg/dl y TG <= 150 mg/dl), TA <= 130/80 mmHg y HbA1c <= 7%; fue 1 objetivo: 68%, 2 objetivos: 21,8% y 3 objetivos: sólo el 4% de la muestra. Conclusiones: Según los resultados obtenidos en nuestro estudio, tan sólo un reducido porcentaje de pacientes cumplieron los diferentes «end points» terapéuticos marcados. Futuras acciones deberán ir encaminadas a potenciar la relación entre médico-paciente, con el principal objetivo de intensificar aquellas medidas terapéuticas encaminadas a un mejor control metabólico y tensional, nefroprotector y prevención de los eventos cardiovasculares

Objective: To evaluate the level of compliance with the 2002 consensus document (Spanish Society of Nephrology) on guidelines for the detection, prevention and treatment of diabetic nephropathy in Catalonia. Subjects and methods: Multicenter (23 hospitals), observational, cross-sectional, descriptive study conducted in 413 diabetic patients (61.7% men, 38.3% women) with a median age of 66.2 ± 11.5 years (26-93 years). The ANOVA test (post-hoc analysis; p value 30 kg/m2: 48.7%) and waist circumference 104.1 ± 14 cm (48.6% men > 102 cm and 78.9% women > 88 cm). Serum creatinine 1.9 ± 1.3 mg/dl and simplified MDRD equation 45.3 ± 25.0 ml/min/1.73 m2 [65.8% with CKD stages 3 and 4]. 80% of patients had ophthalmologic examination and 52.8% antiplatelet treatment. Hb A1c was 7.3 ± 1.3%, but the percentage of patients with glycated hemoglobin > 7% and 8% was 54.9 and 28.6% [only 50.2% had been seen by an endocrinologist in the last 6 months]. 52.8% of patients were treated with insulin and 44.1% with anti-diabetic drugs, although only 19.6% used the new anti-diabetic drugs. 61% of patients had an LDLc > 100 mg/dl (61% treated) and 44% had triglycerides (TG) > 150 mg/dl (72% treated). 95% of patients presented with hypertension (BP >= 130/80 mmHg), 91% were undergoing antihypertensive treatment (79.7% with angiotensin-converting enzyme inhibitors and / or angiotensin receptor blockers). 81% with microalbuminuria and 78% with established proteinuria were receiving antiproteinuric treatment. Of the patients considered to be refractory to BP (>3 drugs), only 28.9% underwent ambulatory BP monitoring. Significant differences were observed between stages of diabetic nephropathy and glycated hemoglobin (HBA1c; p = 0.048), systolic blood pressure (SBP; p = 0.024), lipidic control (HDLc; p = 0.015 and TG; p = 0.034), anemia (Hb; p = 0.010) and CKD (creatinine and sMDRD; p = 0.000). The levels of compliance with the therapeutic objectives regarding lipid control (LDL <= 100 mg/dl and TG <= 150 mg/dl), BP <= 130/80 mmHg and HbA1c <= 7% were 1 objective: 68%, 2 objectives: 21.8% and 3 objectives: only 4% of patients. Conclusions: According to the results of our study, only a reduced proportion of patients fulfilled the different therapeutic end-points indicated. Future measures will be directed at improving physician-patient relationships with the main aim of intensifying the therapeutic measures to attain better metabolic and blood pressure control, nephroprotection and prevention in the appearance of cardiovascular events

[Compliance with the 2002 consensus document of the Spanish Society of Nephrology for the control of diabetic nephropathy in Catalonia (ECCODIAB)]. / Estudio sobre el grado de cumplimiento ambulatorio del documento de consenso 2002 para el control de la nefropatía diabética en Cataluña (ECCODIAB).

OBJECTIVE: To evaluate the level of compliance with the 2002 consensus document (Spanish Society of Nephrology) on guidelines for the detection, prevention and treatment of diabetic nephropathy in Catalonia. SUBJECTS AND METHODS: Multicenter (23 hospitals), observational, cross-sectional, descriptive study conducted in 413 diabetic patients (61.7% men, 38.3% women) with a median age of 66.2 +/-11.5 years (26-93 years). The ANOVA test (post-hoc analysis; p value< 0.05) was used to study the relationships between the stages of diabetic nephropathyand different variables. RESULTS: 90.3% of the patients had type 2 DM. The following anthropometric parameters were observed: BMI 29.8 +/- 5 kg/m2 (BMI > 30 kg/m2: 48.7%) and waist circumference 104.1 +/- 14 cm (48.6% men > 102 cm and 78.9% women > 88 cm). Serum creatinine 1.9 +/- 1.3 mg/dl and simplified MDRD equation 45.3 +/- 25.0 ml/min/1.73 m2 [65.8%with CKD stages 3 and 4]. 80% of patients had ophthalmologic examination and 52.8% antiplatelet treatment. Hb A1c was 7.3 +/- 1.3%, but the percentage of patients with glycated hemoglobin > 7% and 8% was 54.9 and 28.6% [only 50.2% had been seen by an endocrinologist in the last 6 months]. 52.8% of patients were treated with insulin and 44.1% with anti-diabetic drugs, although only 19.6% used the new anti-diabetic drugs. 61% of patients had an LDLc > 100 mg/dl (61% treated) and 44% had triglycerides (TG) > 150 mg/dl (72% treated). 95% of patients presented with hypertension (BP > or = 130/80 mmHg),91% were undergoing antihypertensive treatment (79.7% with angiotensin-converting enzyme inhibitors and / or angiotensin receptor blockers). 81% with microalbuminuria and 78%with established proteinuria were receiving anti-proteinuric treatment. Of the patients considered to be refractory to BP (>3 drugs), only 28.9% underwent ambulatory BP monitoring. Significant differences were observed between stages of diabetic nephropathy and glycated hemoglobin (HBA1c; p = 0.048), systolic blood pressure (SBP; p = 0.024), lipidic control (HDLc; p = 0.015 and TG; p = 0.034), anemia (Hb; p = 0.010) and CKD (creatinine and sMDRD; p = 0.000). The levels of compliance with the therapeutic objectives regarding lipid control (LDL < or = 100 mg/dl and TG< or = 150 mg/dl), BP < or = 130/80 mmHg and HbA1c < or =7% were 1 objective: 68%, 2 objectives: 21.8% and 3 objectives: only 4% of patients. CONCLUSIONS: According to the results of our study, only a reduced proportion of patients fulfilled the different therapeutic end-points indicated. Future measures will be directed at improving physician-patient relationships with the main aim of intensifying the therapeutic measures to attain better metabolic and blood pressure control, nephroprotection and prevention in the appearance of cardiovascular events.

[Abdominal bruit associated with hypertension]. / Hipertensión arterial y soplo abdominal.

First cause of secondary hypertension is renovascular hypertension which presents abdominal bruit in 16 to 20% of cases. This clinical sign is also associated with other vascular disease of the abdomen such as celiac trunk stenosis and/or aneurysms located on the pancreaticoduodenal or gastroduodenal arcs level, with little representation among aneurysm. They usually appear on a context of digestive complications like neoplasias, chronic pancreatitis or gastric obstructions possibly with obstructive icterus, hemorrhage and acute abdomen episodes. Its presentation in other contexts is rare and constitutes a diagnostic challenge. Diagnosis is made by abdominal arteriography which is the best method because you can locate the problem as well as intervene therapeutically with embolization of the aneurysme. We would like to emphasize the importance of a quick diagnosis due to the risk of rupture and the high morbi-mortality associated.

Hipertensión arterial y soplo abdominal / Abdominal bruit associaated to hypertension

La primera causa de hipertensión secundaria es la hipertensión vasculorrenal y suele presentar un soplo abdominal en un 16 a 20% de los casos. Dicho signo clínico también puede acompañar otros procesos vasculares abdominales como la estenosis del tronco celíaco y/o aneurismas localizados a nivel de las arcadas pancreático-duodenales y gastroduodenales, que representan una entidad poco frecuente entre los aneurismas digestivos. Suelen presentarse en el contexto de complicaciones digestivas, como neoplasias, pancreatititis crónica u obstrucciones gástricas, pudiendo cursar clínicamente con ictericia obstructiva, hemorragias y episodios de abdomen agudo. Su presentación en otros contextos representa una rareza y un verdadero reto diagnóstico. El diagnóstico se realiza a través de la arteriografía abdominal que representa la mejor exploración al permitir tanto la localización topográfica como la intervención terapéutica mediante la embolización aneurismática. Especial énfasis merece la celeridad diagnóstica de este tipo de lesiones debido del riesgo intrínseco de ruptura y elevada morbi-mortalidad asociada, si ello ocurre (AU)

First cause of secondary hypertension is renovascular hypertension wich presents abdominal bruit in 16 to 20% of cases. This clinical sign is also associated to other vascular disease of the abdomen such as celiac trunk stenosis and/or aneurysms located on the pancreaticoduodenal or gastroduodenal arcs level, with little representation among aneurysm. They usually appear on a context of digestive complications like neoplasias, cronic pancreatitis or gastric obstruccions possibly with obstructive icterice, hemorrage and acute abdomen episodes. Its presentation in other contexts is rare and constitutes a diagnostic challenge. Diagnostic is made by abdominal artereography wich is the best one as you can locate the problem as well as intervene terapeutically with embolization of the aneurysme. We would like to emphasys on the importance of a quick diagnostic due to the risk of breack and the high morbi-mortality associated (AU)

Disseminated varicella infection in adult renal allograft recipients: role of mycophenolate mofetil.

Disseminated varicella zoster virus (VZV) infection is a rare complication after renal transplantation in adults. We report 4 cases diagnosed in our transplant patients. One of which was a primary infection (chicken pox) with multivisceral involvement (hepatitis, pneumonitis, myocarditis, and disseminated intravascular coagulation). The other 3 patients VZV-seropositive before transplantation suffered from disseminated zoster. No immunosuppressive drug was significantly associated with a higher risk of disseminated VZV infection. However, from our experience, we believe that mycophenolate mofetil (MMF), plays a part in the clinical presentation of the disease. Early treatment with high doses of acyclovir is fundamental in infection control. It is essential to perform a pretransplantation serological VZV study on all patients.

[Hepatic tuberculosis in a patient with diabetic nephropathy. An unusual clinical presentation]. / Tuberculosis hepática en paciente con nefropatía diabética. Una presentación infrecuente.

Hepatic tuberculosis is an exceptional form of presentation of extrapulmonary tuberculosis, but in the last years a greater incidence has been found in patients with HIV infection and/or consumptive diseases or immunosuppressive treatment. For this condition, the diagnosis of hepatic tuberculosis in other population groups represents a true clinical challenge because of the scarce specificity of both the clinical and biological manifestations. Despite deferral of the diagnosis, fast improvement is observed in the clinical symptomatology in most cases following initiation of tuberculostatic treatment.