¿Podemos prescindir de la biopsia renal en la nefropatía membranosa en caso de anticuerpos anti-PLA2R positivos? / Can we manage without biopsy in membranous nephropathy with positive anti-PLA2R antibodies?

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Association between recurrence of acute kidney injury and mortality in intensive care unit patients with severe sepsis.

BACKGROUND: Acute kidney injury (AKI) occurs in more than half critically ill patients admitted in intensive care units (ICU) and increases the mortality risk. The main cause of AKI in ICU is sepsis. AKI severity and other related variables such as recurrence of AKI episodes may influence mortality risk. While AKI recurrence after hospital discharge has been recently related to an increased risk of mortality, little is known about the rate and consequences of AKI recurrence during the ICU stay. Our hypothesis is that AKI recurrence during ICU stay in septic patients may be associated to a higher mortality risk. METHODS: We prospectively enrolled all (405) adult patients admitted to the ICU of our hospital with the diagnosis of severe sepsis/septic shock for a period of 30 months. Serum creatinine was measured daily. 'In-ICU AKI recurrence' was defined as a new spontaneous rise of ≥0.3 mg/dl within 48 h from the lowest serum creatinine after the previous AKI episode. RESULTS: Excluding 5 patients who suffered the AKI after the initial admission to ICU, 331 patients out of the 400 patients (82.8%) developed at least one AKI while they remained in the ICU. Among them, 79 (19.8%) developed ≥2 AKI episodes. Excluding 69 patients without AKI, in-hospital (adjusted HR = 2.48, 95% CI 1.47-4.19), 90-day (adjusted HR = 2.54, 95% CI 1.55-4.16) and end of follow-up (adjusted HR = 1.97, 95% CI 1.36-2.84) mortality rates were significantly higher in patients with recurrent AKI, independently of sex, age, mechanical ventilation necessity, APACHE score, baseline estimated glomerular filtration rate, complete recovery and KDIGO stage. CONCLUSIONS: AKI recurred in about 20% of ICU patients after a first episode of sepsis-related AKI. This recurrence increases the mortality rate independently of sepsis severity and of the KDIGO stage of the initial AKI episode. ICU physicians must be aware of the risks related to AKI recurrence while multiple episodes of AKI should be highlighted in electronic medical records and included in the variables of clinical risk scores.

Comparación de los sistemas de clasificación del fracaso renal agudo en la sepsis / A comparison of acute kidney injury classification systems in sepsis

Antecedentes: Desde 2004 se han propuesto diversos criterios para definir y estadiar el fracaso renal agudo (FRA), sin embargo, no se conoce cuál de ellos debe ser empleado cuando se desarrolla FRA en el contexto de la sepsis grave. Objetivo: Valorar la capacidad predictiva de mortalidad en una cohorte de pacientes con sepsis de los distintos métodos de clasificación del FRA. Métodos: Estudio prospectivo de los pacientes>18 años ingresados en la Unidad de Cuidados Intensivos (UCI) de nuestro hospital desde abril de 2008 hasta septiembre de 2010 con shock séptico. La creatinina plasmática se determinó diariamente en UCI. Los pacientes se clasificaron de forma retrospectiva según las clasificaciones RIFLE, AKIN, KDIGO y cinética de la creatinina (CK). Resultados: El porcentaje de pacientes que desarrolló FRA según cada clasificación fue: 74,3% RIFLE; 81,7% AKIN; 81,7% KDIGO y 77,5% CK. Cada estadio de FRA por RIFLE (OR 1,452; p=0,003), por AKIN (OR 1,349; p=0,028) y por KDIGO (OR 1,452; p=0,006) se relacionaba de forma independiente con la mortalidad intrahospitalaria, pero no por CK (OR 1,188; p=0,148). Conclusiones: Un porcentaje elevado de pacientes con sepsis grave desarrolla FRA que se puede clasificar según los distintos métodos propuestos. Los estadios de las clasificaciones RIFLE, AKIN y KDIGO se relacionan con un mayor riesgo de muerte intrahospitalaria. Por el contrario, la nueva definición de CK no se relaciona con una mayor mortalidad y no se debería usar en estos pacientes con sepsis grave sin confirmar su utilidad en estudios posteriores (AU)

Background: Since 2004, various criteria have been proposed to define and stage acute kidney injury (AKI). Nevertheless, fixed criteria for assessing severe sepsis-related AKI have not yet been established. Objectives: To assess the ability of the different AKI classification methods to predict mortality in a cohort of patients with sepsis. Methods: A prospective study of patients>18 years with septic shock admitted to the intensive care unit (ICU) of our hospital from April 2008 to September 2010 was conducted. Plasma creatinine levels were measured daily in the ICU. Patients were classified retrospectively according to RIFLE, AKIN, KDIGO and creatinine kinetics (CK) criteria. Results: The AKI rate according to the different criteria was 74.3% for RIFLE, 81.7% for AKIN, 81.7% for KDIGO and 77.5% for CK. AKI staging by RIFLE (OR 1.452, P=.003), AKIN (OR 1.349, P=.028) and KDIGO criteria (OR 1.452,P=.006), but not CK criteria (OR 1.188, P=.148) were independently related to in-hospital mortality. Conclusions: A high rate of patients with severe sepsis developed AKI, which can be classified according to different criteria. Each stage defined by RIFLE, AKIN and KDIGO related to a higher risk of in-hospital mortality. In contrast, the new CK criteria did not relate to higher mortality in patients with severe sepsis and this classification should not be used in these patients without further studies assessing its suitability (AU)

A comparison of acute kidney injury classification systems in sepsis. / Comparación de los sistemas de clasificación del fracaso renal agudo en la sepsis.

BACKGROUND: Since 2004, various criteria have been proposed to define and stage acute kidney injury (AKI). Nevertheless, fixed criteria for assessing severe sepsis-related AKI have not yet been established. OBJECTIVES: To assess the ability of the different AKI classification methods to predict mortality in a cohort of patients with sepsis. METHODS: A prospective study of patients>18 years with septic shock admitted to the intensive care unit (ICU) of our hospital from April 2008 to September 2010 was conducted. Plasma creatinine levels were measured daily in the ICU. Patients were classified retrospectively according to RIFLE, AKIN, KDIGO and creatinine kinetics (CK) criteria. RESULTS: The AKI rate according to the different criteria was 74.3% for RIFLE, 81.7% for AKIN, 81.7% for KDIGO and 77.5% for CK. AKI staging by RIFLE (OR 1.452, P=.003), AKIN (OR 1.349, P=.028) and KDIGO criteria (OR 1.452, P=.006), but not CK criteria (OR 1.188, P=.148) were independently related to in-hospital mortality. CONCLUSIONS: A high rate of patients with severe sepsis developed AKI, which can be classified according to different criteria. Each stage defined by RIFLE, AKIN and KDIGO related to a higher risk of in-hospital mortality. In contrast, the new CK criteria did not relate to higher mortality in patients with severe sepsis and this classification should not be used in these patients without further studies assessing its suitability.

Significance of age in the survival of diabetic patients after kidney transplantation.

BACKGROUND: In recent years acceptance of diabetic patients for renal replacement therapy has increased. Renal transplantation for Type I diabetic patients is widely accepted but the appropriate treatment for Type II diabetic patients is still a matter of dispute. Our study was done to determine whether the age of Type II diabetic patients constituted an additional risk factor. METHODS: We analyzed the outcome of renal transplantation in 56 diabetic patients, 31 Type I and 25 Type II diabetics (we excluded any who had combined kidney-pancreas transplants). We compared them with 51 non-diabetic patients who were transplanted because of end-stage renal failure due to nephrosclerosis and age-matched to type II diabetic patients. We assessed the one- and three-year patient and graft survival, the quality of renal function, the main complications and causes of mortality. RESULTS: The overall one- and three-year patient survival was 69% and 60% in Type II patients; 73% and 69% in Type I diabetes patients and 88% and 80% in patients with nephrosclerosis. The overall one- and three-year actuarial graft survival was 50% and 38% in patients with Type II disease and 58% and 50% in Type I diabetes, and 76% and 64% in nephrosclerosis. The main cause of graft loss in all groups was death (with functioning kidney) due to infections and cardiovascular complications. CONCLUSIONS: Diabetes itself is the most important variable in patients who have poor results after kidney transplantation. Increasing age increases slightly the risk for poor graft and patient survival. Both groups of diabetic patients have poorer results than controls but in this comparison age was an independent factor.

Past, present and future of erythropoietin use in the elderly.

More than a decade has passed since the first patient with end-stage renal failure was treated with erythropoietin (EPO) and more than 85% of patients now receive this therapy. In the year 2002 more than 60% of dialysis patients will be elderly, and the treatment of anemia will be more complex due to the aditional causes: folate, iron and vitamin deficiency in this population. Correction of anemia with EPO brings about partial regression of left ventricular hypertrophy and some data suggest that such treatment reduces cardiovascular mortality in patients without advance cardiac disease. Normalization of hematocrit with EPO increases oxygen supply to the brain tissue with improvement in brain function. The improvement in the ability to recognize, discriminate and hold stimuli in memory for difficult tasks is particularly important for elderly people. No differences have been noted in the incidence of clotting of vascular access in patients treated with EPO compared with hemodialysis patients not so treated. Also no one has demostrated that treatment with EPO accelerates renal decline in patients with progressive renal insufficiency. In elderly people with anemia secondary to advanced renal failure, EPO therapy improves physical, cognitive and sexual function, and health related quality of life.