El índice de resistencia vascular renal no tiene implicaciones pronósticas en el trasplante renal / Vascular renal resistance index is not related with prognosis in kidney transplantation

No disponible

Valoración del flujo de la fístula arteriovenosa en pacientes en tratamiento con quelantes con calcio / Evaluation of arteriovenous fistula blood flow in patients with calcium chelation therapy

No disponible

Las calcificaciones valvulares al inicio de diálisis predicen la aparición de eventos cardiovasculares en la evolución / Valvular calcification upon initiating dialysis predict the appearance of cardiovascular events in patient evolution

La calcificación valvular (CV) en la enfermedad renal crónica es frecuente, aunque la mayor parte de la información procede de pacientes prevalentes en diálisis. Son pocos los estudios que analicen la CV en los pacientes que inician diálisis. Objetivo: Analizar la presencia de CV al inicio de diálisis y su relación con eventos y/o muerte cardiovascular en la evolución. Métodos: Incluimos en el estudio los pacientes incidentes en diálisis entre nov/03 y sept/07. En el 1o mes de tratamiento analizamos la presencia de CV mediante Ecocardiograma-doppler, junto a factores demográficos y de riesgo cardiovascular, enfermedad coronaria, accidente cerebrovascular (ACV), fibrilación auricular (FA) y parámetros de electro y ecocardiográficos dimensionales y funcionales cardiacos. Los valores bioquímicos analizados fueron: hemoglobina, metabolismo calcio/fósforo/iPTH, colesterol y fracciones, triglicéridos, troponina I, albúmina, PCR y hemoglobina glicosilada. Analizamos la asociación de la CV con la presentación de infarto de miocardio (IAM), ACV y/o muerte cardiovascular hasta el trasplante, muerte, o fin del estudio (dic/2012). Resultados: De 256 pacientes incluidos (83% hemodiálisis, 17% diálisis peritoneal), 128 (50%) presentaban CV (mitral: 39, aórtica: 20, ambas: 69). En el análisis multivariante la CV se asoció a mayor edad (OR: 1,110; IC 95%: 1,073-1,148; p = 0,000) y menor albúmina (OR: 0,29; IC 95%: 0,14-0,61; p = 0,001). En un seguimiento de 42,1 ± 30,2 meses (898,1 pacientesaño), 68 pacientes presentaron IAM, ACV y/o murieron por causa cardiovascular. En el análisis de regresión de Cox, la mayor edad (HR: 1,028; IC 95%: 1,002-1,055; p = 0,037), la enfermedad coronaria y/o ACV (HR: 1,979; IC95%: 1,111-3,527; p = 0,021), la FA (HR: 2,474; IC 95%: 1,331-4,602; p = 0,004) y la presencia de CV antes de entrar en diálisis (HR: 1,996; IC 95%: 1,077-3,700; p = 0,028), fueron predictores independientes de la presentación de los eventos analizados. Conclusiones: La prevalencia de CV en el momento de iniciar diálisis es alta y su presencia predice la presentación de eventos y/o muerte cardiovascular en la evolución (AU)

The estimated frequency of cardiac valvular calcification (VC) in patients on dialysis is high, although the majority of studies published to date regarding the rate of VC have dealt with prevalent patients in dialysis. There are few studies of VC at the commencement of dialysis and its relationship to future events or cardiovascular mortality. Objective: To establish the prevalence of VC at the start of dialysis and the relationship between VC and the presentation of composite endpoints of acute myocardial infarction (MI), stroke or death from cardiovascular causes in the follow-up of incident dialysis patients. Methods: We conducted an analysis of dialysis patients (haemodialysis or peritoneal dialysis) who commenced dialysis between November 03 and September 07. VC was assessed by Doppler-echocardiography and its association with MI, stroke or cardiovascular mortality in the follow-up until death, transplant, or study end in December 2012 was analysed. Other variables assessed in the first month of dialysis were ECG, age, gender, smoking habit, diabetes, hypertension, previous ischemic stroke, coronary arterial disease and atrial fibrillation. Biochemical analyses included: haemoglobin, urea, creatinine, lipids, calcium, phosphorus, parathyroid hormone, albumin, troponin I, glycosylated haemoglobin and C-reactive protein. Results: Of 256 enrolled patients (83% Haemodialysis, 17% Peritoneal dialysis), 128 (50%) had VC at the commencement of dialysis (aortic 20, mitral 39, both 69). VC was associated with older age (OR: 1.110; CI 95%: 1.073-1.148; P=.000) and lower albumin levels (OR: 0.29; CI 95%: 0.14-0.61; P=.001). In a follow-up lasting a mean of 42.1±30.2 months (898.1 patient-years), 68 patients suffered an MI, a stroke or died from cardiovascular causes. The factors that predicted the presentation of the endpoint (Cox regression analysis) were older age (HR: 1.028; CI 95%: 1.002-1.055; P=.037), previous coronary arterial disease or stroke (HR: 1.979; CI 95%: 1.111-3.527; P=.021), atrial fibrillation (HR: 2.474; CI 95%: 1.331-4.602; P=.004) and VC at the start of dialysis (HR: 1.996; CI 95%: 1.077-3.700; P=.028). Conclusions: The prevalence of VC at the commencement of dialysis is very high and its presence is an independent predictor of event and cardiovascular mortality presentation in the course of follow-up (AU)

Sudden death in incident dialysis patients.

BACKGROUND: Sudden death (SD) constitutes one of the principal causes of death and is an important problem in healthcare provision. Cardiovascular diseases have a high prevalence in dialysis patients and constitute the principal cause of death. We sought to analyze retrospectively the incidence of SD in patients commencing dialysis and the factors related to its presence. METHODS: We evaluated all the patients who began dialysis in our center between 1/11/2003 and 15/9/2007, and who were followed up until death, transplant, or study completion on 31/12/2012. We determined the presence of SD according to the following criteria: SD at 24 h (SD 24H): unexpected death occurring in the 24 h following the start of symptoms, or when the patient was found dead and had been seen alive 24 h earlier; SD at 1 h (SD 1H): death witnessed as occurring in the first hour following the start of symptoms. RESULTS: We evaluated 285 patients, mean age 65.67 ± 15.7 years. In a follow-up of 39.9 ± 34.2 months (947.6 patient-years of follow-up) 168 died (59%), 28 (10%) patients presented SD 24H (2.9/100 patient-years), and 16 (6%) patients presented SD 1H (1.7/100 patient-years). In the multivariate analysis, having had a myocardial infarction or having had electrocardiographic abnormalities (Q wave, negative T wave, subendocardial lesion or QRS >120 ms) were the principal independent predictors of SD 24H (OR 7.83; 95% CI 2.20-27.86; p = 0.001) and of SD 1H (OR 13.43; 95% CI 1.56-115.42; p = 0.018). CONCLUSIONS: SD on dialysis is very frequent. Two groups can be identified easily, with risk profiles clearly differentiated.

Tratamiento con hemodiálisis larga con filtros de alto cut-off en la nefropatía por cilindros del mieloma: nuestra experiencia / Treatment by long haemodialysis sessions with high cut-off filters in myeloma cast nephropathy: our experience

El mieloma múltiple (MM) consiste en la proliferación incontrolada de células plasmáticas con producción de cantidades variables de inmunoglobulinas o sus cadenas. La insuficiencia renal aguda puede ser un síntoma del MM, y a veces su forma de presentación. Las cadenas ligeras libres circulantes (CLL) pueden dar lugar al fallo renal por la precipitación intratubular de ellas, causando una nefropatía por cilindros. El tratamiento del mieloma, una adecuada hidratación y la eliminación de CLL mediante técnicas de aféresis son los tratamientos admitidos actualmente para esta entidad. Se han intentado diversas técnicas de aféresis para intentar eliminar las CLL, siendo la hemodiálisis de larga duración con filtros para eliminar dichas cadenas ligeras (alto cut-off) la que se postula como el tratamiento más eficaz para la nefropatía del mieloma. MÉTODOS: Presentamos cinco casos de nefropatía de mieloma: tres con nefropatía por cilindros (NC) diagnosticada por biopsia renal y dos con alta probabilidad de NC (niveles de CLL > 500 mg/l) tratados con hemodiálisis larga con membrana de alto cut-off. Todos presentaban insuficiencia renal aguda, en cuatro de ellos con necesidad de terapia sustitutiva y uno en situación de insuficiencia renal avanzada. En todos ellos los niveles de CLL fueron muy elevados. Recibieron tratamiento específico para el mieloma más hemodiálisis de alto cut-off hasta alcanzar niveles de CLL < 500 mg/l. RESULTADOS: Cuatro de los cinco pacientes recuperaron función renal, quedando independientes de diálisis. El tiempo de evolución del mieloma desde el inicio de la clínica fue variable (1-6 m). El número de sesiones varió entre 8-16. El paciente de más tiempo de evolución precisó más sesiones y no recuperó función renal. CONCLUSIONES: La hemodiálisis larga con filtros de alto cut-off más tratamiento con quimioterapia del mieloma parece ser un tratamiento eficaz en la insuficiencia renal aguda debida a nefropatía del mieloma. La precocidad en el inicio del tratamiento puede ser un factor determinante de la respuesta

Multiple myeloma (MM) is the uncontrolled proliferation of plasma cells with variable amounts of production of immunoglobulin or their chains. Acute renal failure can be a symptom of MM, and it is sometimes their presentation form. Circulating free light chains (FLC) could led to renal failure by intratubular precipitation of themselves causing a cast nephropathy. Myeloma's treatment, an adequate hydration and FLC's elimination by aphaeresis treatments are currently eligible therapy for this entity. Several aphaeresis techniques have been tried to eliminate the FLC being long-term hemodialysis with filters to remove these light chains (High Cut-Off filters). This treatment is postulated as the most effective treatment for myeloma nephropathy. METHODS: We report 5 cases of myeloma nephropathy: three of them with cast nephropathy (CN) diagnosed by renal biopsy and another two with high probability of NC (FLC levels >500mg/L). All of them were treated by hemodialysis with membrane high Cut-Off. The five patients had had an acute renal failure; in four of them need replacement renal therapy. The fifth patient only had an advanced renal failure. In all patients, FLC levels were very high. All patients received specific treatment for myeloma in addiction on hemodialysis high Cut-Off until the FLC levels were <500mg/ L. RESULTS: Four of the five patients recovered renal function, being independent of dialysis. The evolution time of myeloma since the first symptoms appeared was variable (1-6 months). The number of treatment sessions ranged from 8-16. The patient whose evolution time was the longest one required more sessions and did not recovered the renal function. CONCLUSIONS: Length hemodialysis with filters high cut-off plus specific myeloma chemotherapy seems to be an effective treatment in acute renal failure due to cast myeloma. The early initiation of treatment could be an important factor for the response

Treatment by long haemodialysis sessions with high cut-off filters in myeloma cast nephropathy: our experience.

UNLABELLED: Multiple myeloma (MM) is the uncontrolled proliferation of plasma cells with variable amounts of production of immunoglobulins or their chains. Acute renal failure can be a symptom of MM, and it is sometimes its form of presentation. Circulating free light chains (FLC) could lead to renal failure due to their intratubular precipitation, causing a cast nephropathy. The treatment of myeloma, adequate hydration and the removal of FLC by apheresis techniques are currently the treatments that are accepted for this disease. Several apheresis techniques have been attempted for the removal of FLC, with long haemodialysis sessions with filters for the removal of these light chains (high cut-off filters) being proposed as the most effective treatment for myeloma nephropathy. METHODS: We report 5 cases of myeloma nephropathy: three had cast nephropathy (CN) diagnosed by renal biopsy and the other two had a high probability of CN (FLC levels >500 mg/l). They were treated with long haemodialysis sessions with a high cut-off membrane. All patients had suffered acute renal failure; four required renal replacement therapy and one patient had advanced renal failure. In all patients, FLC levels were very high. They received specific treatment for myeloma in addition to high cut-off haemodialysis until they achieved FLC levels of <500 mg/l. RESULTS: Four of the five patients recovered renal function, and became independent of dialysis. The progression time for myeloma from the time the first symptoms appeared varied (1-6 months). The number of treatment sessions ranged from 8-16. The patient with the longest progression time required more sessions and did not recover renal function. CONCLUSIONS: Long haemodialysis sessions with high cut-off filters in addition to specific myeloma chemotherapy seems to be an effective treatment for acute renal failure due to myeloma nephropathy. The early initiation of treatment could be a determining factor for the response.

Incidencia del infarto agudo de miocardio en la evolución de los pacientes en tratamiento con diálisis / Incidence of acute myocardial infarction in the evolution of dialysis patients

Introducción: Aunque la frecuencia de la enfermedad coronaria (EAC) en los pacientes en diálisis se estima muy elevada, existe una gran variabilidad en los estudios en la tasa de infarto agudo de miocardio (IAM). Objetivo: Establecer la incidencia IAM y analizar sus características y repercusión en la evolución de los pacientes incidentes en diálisis. Métodos: Estudiamos los pacientes incidentes en diálisis entre el 1/1/1999 y el 31/12/2007, y analizamos la presentación del primer IAM en diálisis. Valoramos diagnósticos previos de diabetes, hipertensión arterial, EAC (IAM o lesiones en coronariografía), accidente cerebrovascular isquémico, arteriopatía periférica avanzada y tabaquismo. Se analizaron urea, creatinina, hematocrito, calcio/fósforo, hormona paratiroidea intacta, lípidos y albúmina. El seguimiento fue hasta trasplante, muerte, pérdida o cierre del estudio el 31/12/2010. Resultados: De 576 pacientes incluidos (64,6 ± 16 años; 24,7% diabéticos; 82,3% hemodiálisis/17,7% diálisis peritoneal), 34 (5,9%) (..) (AU)

Background: Although the estimated frequency of coronary artery disease (CAD) in patients on dialysis is very high, there is considerable variation in the studies published to date regarding the rate of acute myocardial infarction (AMI) in these patients. Objective: To establish the incidence of AMI and to analyse the characteristics and consequences of this entity on the clinical progression of incident dialysis patients. Methods: We recorded AMI in the patients treated in our dialysis unit between 01/01/1999 and 31/12/07. The variables assessed were: prior diagnosis of diabetes, hypertension, CAD (AMI or lesions observed in coronary angiography), ischaemic cerebrovascular accident, advanced peripheral artery disease (PAD), atrial fibrillation and tobacco use. Biochemical analyses included: urea, creatinine, haematocrit, calcium, phosphorous, iPTH, lipids and albumin. Follow-up lasted until transplant, death, loss to follow-up or study end in Dec. 2010. Results: Of the 576 patients recruited (aged 64.6±16 years), 24.7% had diabetes, 82.3% were on haemodialysis (17.7% on peritoneal dialysis), and 34 (5.9%) had a previous diagnosis of CAD. In a follow-up lasting a mean of 40.2±32 months (1931.5 patient-years), 40 patients (6.9%) suffered an AMI. The incidence was 2.13/100 patient-years. The patients without CAD had an incidence of 1.84/100 patient-years and those with a previous (..) (AU)

Incidence of acute myocardial infarction in the evolution of dialysis patients.

BACKGROUND: Although the estimated frequency of coronary artery disease (CAD) in patients on dialysis is very high, there is considerable variation in the studies published to date regarding the rate of acute myocardial infarction (AMI) in these patients. OBJECTIVE: To establish the incidence of AMI and to analyse the characteristics and consequences of this entity on the clinical progression of incident dialysis patients. METHODS: We recorded AMI in the patients treated in our dialysis unit between 01/01/1999 and 31/12/07. The variables assessed were: prior diagnosis of diabetes, hypertension, CAD (AMI or lesions observed in coronary angiography), ischaemic cerebrovascular accident, advanced peripheral artery disease (PAD), atrial fibrillation and tobacco use. Biochemical analyses included: urea, creatinine, haematocrit, calcium, phosphorous, iPTH, lipids and albumin. Follow-up lasted until transplant, death, loss to follow-up or study end in Dec. 2010. RESULTS: Of the 576 patients recruited (aged 64.6 ± 16 years), 24.7% had diabetes, 82.3% were on haemodialysis (17.7% on peritoneal dialysis), and 34 (5.9%) had a previous diagnosis of CAD. In a follow-up lasting a mean of 40.2 ± 32 months (1931.5 patient-years), 40 patients (6.9%) suffered an AMI. The incidence was 2.13/100 patient-years. The patients without CAD had an incidence of 1.84/100 patient-years and those with a previous diagnosis of CAD had an incidence of 7.53/100 patient-years. In 22.5% of patients, AMI happened in the first 3 months of dialysis, and 37.5% in the 1st year. Of the 40 AMI, 15 were with ST-segment elevation (incidence: 0.79/100 patient-years) and 25 were non ST-segment elevation (incidence: 1.33/100 patient-years). The factors that predicted the occurrence of AMI in dialysis were older age (OR: 1.037; 95% CI: 1.009-1.067; P=.011), previous CAD (OR: 3.35; 95% CI: 1.48-7.16; P=.004), and diabetes as a cause of nephropathy (OR: 2.96; 95% CI: 1.49-5.86; P=.002). In-hospital mortality was 30%, with 72.5% of deaths occurring in the 1st year and 82.5% in the 2nd; 80% of the patients who underwent a coronary angiography had multi-vessel disease. CONCLUSIONS: The incidence of AMI in incident dialysis patients is high. In previous coronary disease patients, the incidence is 3-fold higher. Post-infarction mortality is very high and multi-vessel disease is very frequent.

Ischaemic stroke in incident dialysis patients.

BACKGROUND: Despite the high frequency of cardiovascular disease among the population on dialysis, there are few studies on ischaemic stroke and associated factors. The objective of the present study is to assess the prevalence of ischaemic stroke at the start of dialysis, its incidence in the course of follow-up and possible factors associated in its presentation. METHODS: All patients in our dialysis programme between 1 January 1999 and 31 December 2005 were included in the study and followed up until death, transplant, transfer out of our catchment area, or conclusion of the study on 31 December 2008. Factors analysed were age, gender, smoking habit, diabetes, hypertension, previous ischaemic stroke, ischaemic coronary disease, peripheral vascular disease and atrial fibrillation. Other factors measured in the first month of dialysis were haematocrit, urea, creatinine, lipids, calcium, phosphorus, parathyroid hormone and albumin. RESULTS: Of 449 patients included in the study (age 64.4 ± 16 years), 30 commenced dialysis having had previous stroke (prevalence 6.7%). In a follow-up of 38.77 ± 29 months, 34 patients presented with one or more strokes; an incidence of 2.41/100 patient-years. Greater age [odds ratio (OR): 1.05; 95% confidence interval (CI): 1.01-1.09; P = 0.007], diabetes (OR: 2.29; 95% CI: 1.15-4.55; P = 0.018) and presence of atrial fibrillation (OR: 3.11; 95% CI: 1.53-6.32; P = 0.002) were independent predictors of stroke occurrence. Conclusions. The prevalence of ischaemic stroke is high at the commencement of dialysis, and its incidence is elevated in the course of follow-up. As with the general population, atrial fibrillation is an important factor predictive of ischaemic stroke, and as such, the clinical implication is that prophylactic anti-coagulation therapy needs to be considered for these individuals.

Ought dialysis patients with atrial fibrillation be treated with oral anticoagulants?

BACKGROUND: Dialysis patients with atrial fibrillation have an increased thrombolic risk. Dicoumarin anticoagulant therapy is often considered contra-indicated in chronic renal insufficiency in which the risk of haemorrhage, though not defined, is perceived to be high. We assessed haemorrhage complications in dialysis patients receiving dicoumarin anticoagulant therapy to establish whether the haemorrhage risk justifies the contra-indication of anticoagulant therapy in patients with atrial fibrillation. PATIENTS AND METHODS: Over a period of a decade in our dialysis centre, 29 patients receiving anticoagulant therapy over a protracted period presented haemorrhage complications. These were classified with respect to severity and location and compared with 211 patients not receiving anticoagulant therapy. The relative risk of haemorrhage was calculated and was compared to risk of thrombo-embolism in dialysis patients with atrial fibrillation. RESULTS: Of the 29 patients, nine had 13 episodes of haemorrhage complications (26 episodes/100 patient-years). None was fatal, nor intra-cranial nor with serious clinical sequelae. In the group without anticoagulants, 29 patients had 39 haemorrhage complications (11 episodes/100 patient-years); four (10.2%) intra-cranial and all fatal. The relative risk of bleeding with anticoagulant therapy was 2.36 (95% confidence interval=1.19-4.27). CONCLUSIONS: (1) Dialysis patients with anticoagulant therapy presented with a higher risk of haemorrhage; (2) the relative risk of bleeding was double that of the dialysis population without anticoagulant therapy; (3) despite the high risk of haemorrhage that we observed, the high risk of thrombo-embolism and the attendant serious sequelae to which dialysis patients with atrial fibrillation are predisposed indicates that oral anticoagulation therapy ought not to be considered automatically contra-indicated in this patient group but that an exhaustive evaluation of the risk-benefit needs to be conducted on an individual patient basis.