Mejoría del control de la hipertensión en la consulta con el uso de un dispositivo oscilométrico automático de lectura diferida / Improved office blood pressure control by automatic delayed-reading oscillometric device

Introducción: La medición de la presión arterial (PA) en la consulta es un procedimiento recomendado, aunque, actualmente, se está generalizando el uso de las medidas ambulatorias. Objetivo: Conocer el grado de control de la hipertensión arterial (HTA), usando la medición en la clínica. Material y métodos: Durante noviembre del 2019, se recogieron datos demográficos, clínicos, la PA sistólica (PAS) y diastólica (PAD) en consulta con observador, usando un aparato automático con lectura diferida y datos de monitorización ambulatoria de la PA (MAPA) en caso de haberse realizado. Resultados: Se incluyeron 102 pacientes (67 varones), con edad media de 64,9 años, 30% diabéticos y 34% con complicaciones cardiovasculares. Un 70% tenían una PA clínica controlada (< 140/90 mmHg), la PAS media fue de 131 ± 16,5 mmHg y la PAD de 73 ± 9,5 mmHg. Los pacientes ancianos y diabéticos presentaban un peor control. Treinta y tres sujetos disponían de MAPA, lo que permitió clasificarlos según la PA de 24 horas en: normotensión verdadera 30%, HTA aislada en consulta 9%, HTA sostenida 15% y HTA enmascarada 45%. Conclusión: El uso de aparatos automáticos disminuye el fenómeno de bata blanca mejorando el porcentaje de pacientes con HTA controlada en la consulta. Sin embargo, este control no se confirma fuera de ella, lo que evidencia la importancia de la MAPA en la evaluación global de la HTA. La toma de la PA en la consulta es útil en la valoración inicial del paciente y aporta aspectos educativos, aunque hay que optimizar la metodología para definir su papel en la clínica. (AU)

Introduction: Office blood pressure (BP) measurement is a recommended procedure, although the out-of-office BP measurements are increasingly used. Objective: To know the degree of BP control by clinical measurement. Material and methods: During November 2019 demographic and clinical data, office attended systolic BP (SBP) and diastolic BP (DBP) measured with an automatic device with delayed reading and, if performed, data from ambulatory BP monitoring (ABPM) were collected. Results: 102 patients (67 men) were included, with a mean age of 64.9 years, 30% diabetic and 34% with cardiovascular complications. 70% had a controlled hypertesion (<140/90 mmHg) by office BP, the mean SBP was 131 ± 16.5 mmHg and the DBP was 73 ± 9.5 mmHg. Old age and diabetes were associated with uncontrolled hypertension. Thirty three patients had ABPM data, which allowed them to be classified according to the 24-hour BP into: 30% true normotension, 9% white-coat hypertension, 15% sustained hypertension, and 45% masked hypertension. Conclusion: The use of automatic devices reduces the white-coat phenomenon, improving the % of patients with office BP controlled. However, this is not confirmed outside the clinic, showing the importance of ABPM in the evaluation of hypertension control. Office BP measurement is useful in patients initial assessment and also provides educational aspects, although the methodology must be optimized to define its clinical role. (AU)

[Improved office blood pressure control by automatic delayed-reading oscillometric device]. / Mejoría del control de la hipertensión en la consulta con el uso de un dispositivo oscilométrico automático de lectura diferida.

INTRODUCTION: Office blood pressure (BP) measurement is a recommended procedure, although the out-of-office BP measurements are increasingly used. OBJECTIVE: To know the degree of BP control by clinical measurement. MATERIAL AND METHODS: During November 2019 demographic and clinical data, office attended systolic BP (SBP) and diastolic BP (DBP) measured with an automatic device with delayed reading and, if performed, data from ambulatory BP monitoring (ABPM) were collected. RESULTS: 102 patients (67 men) were included, with a mean age of 64.9 years, 30% diabetic and 34% with cardiovascular complications. 70% had a controlled hypertesion (<140/90 mmHg) by office BP, the mean SBP was 131 ± 16.5 mmHg and the DBP was 73 ± 9.5 mmHg. Old age and diabetes were associated with uncontrolled hypertension. Thirty three patients had ABPM data, which allowed them to be classified according to the 24-hour BP into: 30% true normotension, 9% white-coat hypertension, 15% sustained hypertension, and 45% masked hypertension. CONCLUSION: The use of automatic devices reduces the white-coat phenomenon, improving the % of patients with office BP controlled. However, this is not confirmed outside the clinic, showing the importance of ABPM in the evaluation of hypertension control. Office BP measurement is useful in patients initial assessment and also provides educational aspects, although the methodology must be optimized to define its clinical role.

Problemática del embarazo post-trasplante renal / Renal post transplantation pregnancy: problems

El embarazo después del trasplante renal debe considerarse de alto riesgo tanto por las complicaciones maternas como por las fetales que puedan producirse. No obstante, siguiendo una serie de recomendaciones es posible y las complicaciones pueden minimizarse realizando un abordaje multidisciplinar. El embarazo puede considerarse seguro si se da en pacientes con buena micción renal, son proteinuria, sin HTA y sin evidencia de rechazo 2 años después del trasplante renal

Pregnancy after transplantation should be considered a high-risk pregnancy and should be monitored by a multidisciplinar team. Pregnancy could be considered safe about 2 years after transplantation in women with good renal function, without proteinuria, without arterial hypertension and with no evidence of ongoing rejection

[Assessment of the living renal donor. Analysis of extra-renal pathology as a limitation for donation]. / Estudio del donante vivo renal. Análisis de la patologá extrarrenal como límite a la donación.

The goal of the donor evaluation is to ensure the suitability, safety and well being of the donor. In order to avoid important omissions, the evaluation of potential living kidney donors should be carried according to a protocol that includes a logical sequence of complementary explorations. Old age alone is not an absolute contraindication to donation but the evaluation should be more rigorous, because increased age may be associated with more post-operative complications after nephrectomy and renal function and long term graft survival could be shorter than the ones obtained from younger living donors. A body mass index of more than 35 kg/m2 should be an absolute contraindication to renal donation. Between 30 and 35 kg/m2 the donor evaluation should be more rigorous and it should be recommended to lose weight before nephrectomy. Hypertension is one of the most common reasons to declare a potential kidney donor unsuitable. Evidence of organ damage is an absolute contraindication to kidney donation. The donation is only reasonable when hypertension is well controlled with less than two drugs. To excluded diabetes mellitus all donors should have a fasting plasma glucose measurement. Diabetes mellitus is an absolute contraindication to living donation such as an impaired glucose tolerance or impaired fasting glucose with a family history of type 2 diabetes mellitus. Another contraindication to living donation is malignant disease, and the same standards should be adopted for cadaveric donors. The exceptions are low-grade non-melanoma skin cancer and carcinoma in situ of the uterine cervix. The presence of active infection usually precludes donation. It is very important to perform a routine test for viral infections. HIV, hepatitis B and C infection of the donor are usually a contraindication to living donor. CMV donor and recipient status should be taken into account before transplantation, and the recipients at risk for CMV disease should recieve prophylactic treatment according to the transplant unit policy.

[Outcomes of transplantation from living renal donor]. / Resultados del trasplante renal de donante vivo.

Living donors represent 30% of our kidneys for renal transplantation. Laparoscopic nephrectomy is the best surgical procedure to obtain them due to its clear advantages such as low morbidity, less blood supply and donor time in hospital. From March 2002 to August 2004 we performed 50 laparoscopic nephrectomies for renal transplantation. Kidneys were transplanted to recipients receiving tacrolimus 0.1 mg/kg/bid, mycophenolate mofetil 1 g/bid and prednisone 0.5-1 mg/kg/day p.o 48 hours before transplantation. Mean time for surgery was 170 minutes (120-260), warm ischaemia time 3.1 minutes (1.5-10) and cold ischaemia time 1.27 hours (0.85-4). Mean bleeding was 270 cc (100-900) and donor time in hospital 5.5 days (3-9). Four cases required conversion of the laparoscopic procedure to open surgery because of bleeding. 72 hours post-transplant mean plasmatic creatinine was 170 micromol/l. None of the patients suffered delayed graft function. 18% presented acute rejection. Survival of donor and recipient was 100% at 1 year and graft survival was 94% at 1 year (kidney losses were due to acute rejection, severe acute pancreatitis and surgical problem).

[The living kidney donor: laparoscopy versus open surgery]. / El donante vivo de riñón: laparoscopia versus cirugía abierta.

INTRODUCTION: Living renal donors are an important source of transplanted kidneys due to the number of patients on waiting list is progressively increasing. On the other side, they allow the pre-emptive kidney transplantation. With the aim of reducing donor obstacles such as pain, hospital stay or cosmetic results and in creasing the number of living donors, in 1995 Ratner performed the first laparoscopic nephrectomy (LLDN). By now, LLDN is a routine procedure in more than 200 centres worldwide. METHODS: Literature databases are searched. We have reviewed the data from our experience after performing 50 laparoscopic nephrectomies. RESULTS: Preoperative living donor assessment and contraindications to LLDN do not differ from the open approach. Results are very influenced by the surgeon's situation in the learnig curve. Operating times use to be longer in laparoscopic procedures. The overall complication rate and mortality of LLDN are the same for both of the approaches. Conversion to open-donor nephrectomy has been reported in 0-13% of cases (8% in our data). Postoperative pain and donor estimated blood loss are lower for LLDN, as well as the convalescence period. To avoid the possible negative effects of the laparoscopic technique on kidney graft function a lot of method's variations have been proposed for gaining access and harvesting the kidney, including the hand-assistance techniques, with the aim of minimizing operative time, pneumoperitoneus negative effect on graft function and warm ischemia time (WIT). The higher WIT is not related to delayed graft function or acute rejections when it is less than ten minutes. Delayed graft function does not differ in both approaches and creatinine values from the first month until the third year after transplantation show no differences in randomized studies. CONCLUSIONS: The laparoscopic approach to harvest the allograft from the living donor is a save and effective technique and has the advantage of being less invasive and allowing the donor a shorter convalescence. It has no negative effects on allograft function in the short term follow-up. Further studies are required to evaluate long term donor complications and allograft function and survival.

Estudio del donante vivo renal. Análisis de la patología extrarrenal como límite a la donación / Assessment of the living renal donor. Analysis of extra-renal pathology as a limitation for donation

El objetivo de la evaluación de un potencial donante vivo renal es garantizarque su estado de salud sea óptimo, identificar las contraindicaciones absolutas ala donación y evaluar minuciosamente las posibles causas de contraindicación relativacon el fin de minimizar los riesgos a largo plazo.El protocolo de evaluación del donante debe incluir una secuencia lógica deexploraciones complementarias que aseguren los objetivos anteriormente expuestos.La edad avanzada no es una contraindicación absoluta a la donación renal perohay que tener en cuenta que el estudio debe ser más exhaustivo dado que estosdonantes tienen más complicaciones postoperatorias y que la supervivencia delinjerto a largo plazo es inferior a la de los injertos de donantes más jóvenes.La obesidad se considera una contraindicación relativa a la donación renal. Solamentepuede plantearse la donación cuando el IMC es menor de 35 kg/m2, realizandopreviamente estudios más rigurosos y aconsejando perder peso antes dela nefrectomía.La hipertensión arterial es una contraindicación a la donación renal cuando seasocia a lesión de órgano diana. Solamente sería razonable la donación cuandola presión arterial esté bien controlada con un máximo de un fármaco.La presencia de diabetes mellitus, de intolerancia a la glucosa o de glucemiabasal alterada con antecedentes familiares de diabetes tipo 2 contraindicaría ladonación renal. En el resto de situaciones relacionadas con alteraciones del metabolismohidrocarbonato no habría problemas para plantear la donación.Una historia de tumor maligno en un potencial donante contraindica la donación,con la excepción de cáncer de piel tipo no-melanoma o un carcinoma insitu de cervix.La evaluación del donante incluye una serie de test serológicos encaminados aidentificar determinadas infecciones transmisibles. La presencia de serología positivapara HIV, virus hepatitis B y C, contraindicarían habitualmente la donación.La serología positiva para citomegalovirus y virus Epstein-Barr no contraindicaríanla donación pero exigiría plantear un tratamiento profiláctico según la serologíadel receptor

The goal of the donor evaluation is to ensure the suitability, safety and wellbeing of the donor.In order to avoid important omissions, the evaluation of potential living kidneydonors should be carried according to a protocol that includes a logical sequenceof complementary explorations.Old age alone is not an absolute contraindication to donation but the evaluationshould be more rigorous, because increased age may be associated with morepost-operative complications after nephrectomy and renal function and long termgraft survival could be shorter than the ones obtained from younger living donors.A body mass index of more than 35 kg/m2 should be an absolute contraindicationto renal donation. Between 30 and 35 kg/m2 the donor evaluation should bemore rigorous and it should be recommended to lose weight before nephrectomy.Hypertension is one of the most common reasons to declare a potencial kidneydonor unsuitable. Evidence of organ damage is an absolute contraindicationto kidney donation. The donation is only reasonable when hypertension is wellcontroled with less than two drugs.To excluded diabetes mellitus all donors should have a fasting plasma glucosemeasurement. Diabetes mellitus is an absolute contraindication to living donationsuch as an impaired glucose tolerance or impaired fasting glucose with a familyhistory of tipe 2 diabetes mellitus.Another contraindication to living donation is malignant disease, and the samestandars should be adopted as for cadaveric donors. The exceptions are low-gradenon-melanoma skin cancer and carcinoma in situ of the uterine cervix.The presence of active infection usually precludes donation. It is very importantto perform a routine test for viral infections. HIV, hepatitis B and C infection ofthe donor are usually a contraindication to living donor. CMV donor and recipientstatus should be taken into account before transplantation, and the recipienst atrisk for CMV disease should recieve prophylactic treatment according to the transplantunit policy

El donante vivo de riñón: laparoscopia versus cirugía abierta / The living kidney donor: laparoscopy versus open surgery

Los donantes vivos de riñón son una fuente importante de obtención de órganos.Con el fin de minimizar el trauma asociado al proceso de donación y aumentareste pool de donantes, en 1995 Ratner realiza la primera nefrectomía laparoscópica.En la actualidad es una técnica rutinaria en más de 200 centrostrasplantadores en todo el mundo substituyendo la nefrectomía abierta.Revisando la literatura actual y los datos de nuestra serie de 50 nefrectomíaslaparoscópicas, observamos que los resultados de la laparoscopia van muy ligadosa la curva de aprendizaje del cirujano. El tiempo quirúrgico es habitualmentesuperior que en la nefrectomía abierta, pero no presenta mayor índice de complicacionesni mortalidad. La reconversión a cirugía abierta es del 0-13% (8% ennuestra serie). La realización de la nefrectomía laparoscópica ha permitido disminuirde forma significativa la morbilidad del donante, el dolor postoperatorio y laspérdidas de sangre, así como los días de ingreso y la convalecencia. Es una técnicaen evolución y se realizan múltiples variaciones para minimizar algunos inconvenientesde la laparoscopia, como el tiempo quirúrgico, los efectos del pneumoperitoneoen la función renal y la mayor isquemia caliente del injerto. La funciónrenal en el receptor se recupera más lentamente en el periodo postoperatorio inmediato,sin presentar por ello una mayor incidencia de retraso en la función renalni rechazo agudo. Las cifras de creatinina no son diferentes a partir del primermes en estudios randomizados de hasta 3 años de seguimiento. Por todo ello, lalaparoscopia es una técnica segura para la extracción renal que ofrece ventajasen la recuperación del donante sin perjudicar el funcionamiento del injerto renal.Faltan estudios a largo plazo para evaluar posibles complicaciones tardías derivadasde la técnica en el donante y valorar función a largo plazo del injerto renal

Introduction: Living renal donors are an important source of transplanted kidneysdue to the number of patients on waiting list is progressively increasing. Onthe other side, they allow the pre-emptive kidney transplantation. With the aim ofreducing donor obstacles such as pain, hospital stay or cosmetic results and increasing the number of living donors, in 1995 Ratner performed the first laparoscopicnephrectomy (LLDN). By now, LLDN is a routine procedure in more than200 centres worldwide.Methods: Literature databases are searched. We have reviewed the data fromour experience after performing 50 laparoscopic nephrectomies.Results: Preoperative living donor assessment and contraindications to LLDN donot differ from the open approach. Results are very influenced by the surgeon´ssituation in the learnig curve. Operating times use to be longer in laparoscopicprocedures. The overall complication rate and mortality of LLDN are the same forboth of the approaches. Conversion to open-donor nephrectomy has been reportedin 0-13% of cases (8% in our data). Postoperative pain and donor estimatedblood loss are lower for LLDN, as well as the convalescence period. To avoid thepossible negative effects of the laparoscopic technique on kidney graft function alot of method’s variations have been proposed for gaining access and harvestingthe kidney, including the hand-assistance techniques, with the aim of minimizingoperative time, pneumoperitoneus negative effect on graft function and warm ischemiatime (WIT). The higher WIT is not related to delayed graft function oracute rejections when it is less than ten minutes. Delayed graft function does notdiffer in both approaches and creatinine values from the first month until the thirdyear after transplantation show no differences in randomized studies.Conclusions: The laparoscopic approach to harvest the allograft from the livingdonor is a save and effective technique and has the advantage of being less invasiveand allowing the donor a shorter convalescence. It has no negative effectson allograft function in the short term follow-up. Further studies are required toevaluate long term donor complications and allograft function and survival

Resultados del trasplante renal de donante vivo / Outcomes of transplantation from living renal donor

El donante vivo representa en nuestro Servicio un 30% de los órganos que segeneran para trasplante renal y la nefrectomía laparoscópica se ha convertido enla técnica rutinaria para dicha obtención. Presenta como ventajas su menor morbilidad,agresividad, necesidad de transfusión y estancia hospitalaria del donante.Desde marzo de 2002 hasta agosto de 2004 hemos realizado 50 nefrectomías víalaparoscópica. Los injertos fueron implantados a receptores tratados desde 48 horasantes del trasplante con tacrolimus 0,1 mg/kg/12 horas, micofenolato mofetil 1g/12 horas y prednisona 0,5-1 mg/kg/día v.o. El tiempo medio de nefrectomía fuede 170 minutos (120-260), la isquemia caliente de 3,1 minutos (1,5-10) y la isquemiafría de 1,27 horas (0,85-4). El sangrado de 270 cc (100-900) y la estanciamedia del donante de 5,5 días (3-9). En cuatro ocasiones se reconvirtió a cirugíaabierta por sangrado (uno de ellas post-nefrectomía). A las 72 horas deltrasplante la creatinina plasmática media fue de 170 μmol/l. Ninguno de los receptorespresentó disfunción inicial del injerto. Un 18% sufrió un episodio de rechazoagudo. La supervivencia de donante y receptor es del 100% al año y ladel injerto del 94% (una pérdida por pancreatitis grave, otra por rechazo vasculary otra por sangrado al mes del trasplante)

Living donors represent 30% of our kidneys for renal transplantation. Laparoscopicnephrectomy is the best surgical procedure to obtain them due to its clearadvantages such as low morbidity, less blood supply and donor time in hospital.From March 2002 to August 2004 we performed 50 laparoscopic nephrectomiesfor renal transplantation. Kidneys were transplanted to recipients receiving tacrolimus0.1 mg/kg/bid, mycophenolate mofetil 1 g/bid and prednisone 0.5-1mg/kg/day p.o 48 hours before transplantation. Mean time for surgery was 170minutes (120-260), warm ischaemia time 3.1 minutes (1.5-10) and cold ischaemiatime 1,27 hours (0,85-4). Mean bleeding was 270 cc (100-900) and donortime in hospital 5,5 days (3-9). Four cases required conversion of the laparoscopicprocedure to open surgery because of bleeding. 72 hours post-transplant meanplasmatic creatinine was 170 μmol/l. None of the patients suffered delayed graftfunction. 18% presented acute rejection. Survival of donor and recipient was 100% at 1 year and graft survival was 94% at 1 year (kidney losses were due to acuterejection, severe acute pancreatitis and surgical problem)

Trasplante renal único con riñones de donantes añosos / Single renal transplantation with kidneys from elderly donors

En la década de los 90 se han aceptado progresivamente donantes cadáver de riñón añoso (edad superiora 60 años) con los que se han obtenido resultados dispares Los grupos de trasplante han optado por distintas estrategias respecto a la utilización de estos injertos. Unos preconizan el trasplante renal doble a fin de aumentar la masa renal transferida al receptor. Nosotros optamos por practicar el trasplante único basándonos en la optimización de todo el proceso del trasplante. mantenimiento del donante, extracción e implante del órgano. Los resultados obtenidos son iguales o mejores que los conseguidos con el trasplante doble. Esto nos ha permitido incluso emplear este tipo de donante con receptores jóvenes (AU)