ABSTRACT
INTRODUCTION: Optimizing anemia treatment in hemodialysis (HD) patients remains a priority worldwide as it has significant health and financial implications. Our aim was to evaluate in a large cohort of chronic HD patients in Fresenius Medical Care centers in Spain the value of cumulative iron (Fe) dose monitoring for the management of iron therapy in erythropoiesis-stimulating agent (ESA)-treated patients, and the relationship between cumulative iron dose and risk of hospitalization. METHODS: Demographic, clinical and laboratory parameters from EuCliD(®) (European Clinical Dialysis Database) on 3,591 patients were recorded including ESA dose (UI/kg/week), erythropoietin resistance index (ERI) [U.I weekly/kg/gr hemoglobin (Hb)] and hospitalizations. Moreover the cumulative Fe dose (mg/kg of bodyweight) administered over the last 2 years was calculated. Univariate and multivariate analyses were performed to identify the main predictors of ESA resistance and risk of hospitalization. Patients belonging to the 4th quartile of ERI were defined as hypo-responders. RESULTS: The 2-year iron cumulative dose was significantly higher in the 4th quartile of ERI. In hypo-responders, 2-year cumulative iron dose was the only iron marker associated with ESA resistance. At case-mix adjusted multivariate analysis, 2-year iron cumulative dose was an independent predictor of hospitalization risk. DISCUSSION: In ESA-treated patients cumulative Fe dose could be a useful tool to monitor the appropriateness of Fe therapy and to prevent iron overload. To establish whether the associations between cumulative iron dose, ERI and hospitalization risk are causal or attributable to selection bias by indication, clinical trials are necessary.
Subject(s)
Anemia/drug therapy , Drug Resistance , Erythropoietin/therapeutic use , Iron/administration & dosage , Kidney Failure, Chronic/therapy , Renal Dialysis , Aged , Anemia/blood , Anemia/etiology , Biomarkers/blood , Dose-Response Relationship, Drug , Female , Follow-Up Studies , Hemoglobins/metabolism , Humans , Kidney Failure, Chronic/complications , Male , Middle Aged , Retrospective StudiesABSTRACT
BACKGROUND: Fluid overload is an important and modifiable cardiovascular risk factor for haemodialysis patients. So far, the diagnosis was based on clinical methods alone. Nowadays, we have new tools to assess more objectively the hydration status of the patients on haemodialysis, as BCM (Body Composition Monitor). A Relative Overhydration (AvROH) higher than 15% (it means, Absolute Overhydration or AWOH higher than 2.5 Litres) is associated to greater risk in haemodialysis. However, there is a group of maintained hyperhydrated patients. The aim of the present study is to identify the characteristics of patients with maintained hyperhydrated status (AvROH higher than 15% or AWOH higher than 2.5 liters). The secondary aim is to show the hemodynamic and analytical changes that are related to the reduction in hyperhydration status. METHODS: Longitudinal cohort study during six months in 2959 patients in haemodialysis (HD) that are grouped according to their hydration status by BCM. And we compare their clinical, analytical and bioimpedance spectroscopy parameters. RESULTS: The change in overhydration status is followed by a decrease in blood pressure and the need for hypotensive drugs (AHT) and erythropoiesis stimulating agents (ESA). The target hydration status is not reached by two subgroups of patients. First, in diabetic patients with a high comorbidity index and high number of hypotensive drugs (AHT) but a great positive sodium gradient during dialysis sessions; and, younger non-diabetic patients with longer time on hemodialysis and positive sodium gradient, lower fat tissue index (FTI) but similar lean tissue index (LTI) and albumin than those with a reduction in hyperhydration status. CONCLUSION: Those patients with a reduction in hyperhydration status, also show a better control in blood pressure and anemia with less number of AHT and ESA. The maintained hyperhydrated patients, diabetic patients with many comorbidities and young men patients with longer time on hemodialysis and non-adherence treatment, can profit from a constant monitoring of their hydration state as well as an individualized treatment (dialysis and drugs).
Subject(s)
Renal Dialysis/adverse effects , Water-Electrolyte Imbalance/physiopathology , Aged , Aged, 80 and over , Anemia/drug therapy , Anemia/etiology , Body Composition , Diabetic Nephropathies/complications , Diabetic Nephropathies/physiopathology , Diabetic Nephropathies/therapy , Electric Impedance , Female , Follow-Up Studies , Hematinics/therapeutic use , Hemodialysis Solutions/administration & dosage , Hemodialysis Solutions/adverse effects , Hemodynamics , Humans , Hypotension/drug therapy , Hypotension/etiology , Kidney Failure, Chronic/complications , Kidney Failure, Chronic/physiopathology , Kidney Failure, Chronic/therapy , Male , Middle Aged , Sodium/blood , Water-Electrolyte Imbalance/etiologyABSTRACT
BACKGROUND: To standardize therapy and improve the clinical outcome for chronic haemodialysis (HD) patients, guidelines have been developed for mineral metabolism management. We evaluated compliance with different mineral metabolism guidelines. METHODS: 2,951 chronic HD patients from 61 dialysis centres in Spain were studied. Mineral metabolism management data from a 1-year period were analysed according to KDOQI, KDIGO, and Spanish guidelines. RESULTS: Only 1% (KDOQI), 6% (KDIGO) and 11% (Spanish guidelines) of patients continuously achieved total calcium (Ca), phosphate (P) and parathyroid hormone (PTH) target-range values during the year with higher percentages if we considered the 1-year average. The yearly Ca, P and iPTH average accomplished Spanish guidelines with different percentage among centres: CA 62-100%, P 59-91%, PTH 61-89%, and 28-77% considering all three targets together. The KDIGO guidelines recommend similar percentages except for P (33-77%). No differences were found related to eKt/V, online haemodiafiltration/HD, weight, body mass index, or dialysis vintage. They were only related to age, blood flow, effective treatment time, and dialysate calcium but without relevant clinical differences. Patients outside the target ranges generated significantly higher treatment costs. CONCLUSIONS: Compliance with mineral metabolism targets in HD patients was poor and showed a wide variation between treatment centres.
Subject(s)
Bone and Bones/metabolism , Guideline Adherence , Minerals/metabolism , Practice Guidelines as Topic , Renal Dialysis , Aged , Aged, 80 and over , Blood Chemical Analysis , Calcium/blood , Female , Health Care Costs , Humans , Male , Middle Aged , Parathyroid Hormone/blood , Phosphates/blood , Reference Values , Renal Dialysis/economics , Renal Dialysis/methods , Renal Insufficiency, Chronic/blood , Renal Insufficiency, Chronic/etiology , Renal Insufficiency, Chronic/therapy , Treatment OutcomeABSTRACT
BACKGROUND: Symptomatic hypotension is the most frequent acute complication affecting patients during chronic hemodialysis treatment sessions. Many reports have demonstrated that the use of cool dialysate has a protective effect on blood pressure during hemodialysis treatments. In the present study, we investigated whether preventing the hyperthermic response had favourable effects on hemodynamic stability during the hemodialysis procedure while affording good tolerance to patients. METHODS: We investigated the effect of thermal control of dialysate on hemodynamic stability in hypotension-prone patients in our center. Patients were eligible for the study if they had symptomatic hypotensive episodes (> 3/12session/ month) during the screening phase. The study was designed with two phases for the same selected patients and two treatment arms, each phase lasting 4 weeks. In the first phase, we adjusted dialysate temperature on 36 masculineC for 12 sessions (cold dialysis) and in the second phase we used a device allowing the regulation of thermal balance (Blood Temperature Monitor; Fresenius Medical Care, Bad Homberg, Germany), that keep body temperature unchanged (isothermic dialysis). RESULTS: Nine HD patients were enrolled and completed the study. During the screening phase the mean ultrafiltration was 4 1% of dry weight, and blood pressure decreased from 9916 to 8016 mm Hg (p<0.001). In 5.01.7 sessions of 12 treatments were complicated by hypotension. In the first and second phase we observed a decrease of complicated treatments with symptomatic hypotension (5.01.7 versus 2.71.6 y 2.81.7; p<0.01). Both procedures: Cold dialysis and Isothermic dialysis was well tolerated by patients. CONCLUSION: Results show that active control of body temperature can significantly improve intradialytic tolerance in hypotension-prone patients.
Subject(s)
Hypotension/etiology , Hypotension/prevention & control , Renal Dialysis/adverse effects , Renal Dialysis/methods , Cold Temperature , Female , Humans , Hypotension/diagnosis , Male , Middle Aged , Prospective StudiesABSTRACT
BACKGROUND: Reports of successful treatment of liver cysts by the laparoscopic approach prompted the use of this technique in a series of patients. METHODS: Ten patients with symptomatic liver cysts were treated by the laparoscopic deroofing technique. Eight patients had one solitary cyst, one had two cysts and the remaining patient had polycystic disease with a giant cyst. Hydatid disease was excluded serologically and radiologically but albendazole was used before operation in six cases because hydatid disease is endemic in Argentina. RESULTS: There was no surgical morbidity or death. For between 6 months and 3 years all patients were asymptomatic. Computed tomography showed recurrence of a cyst in one patient, who was successfully reoperated on laparoscopically. CONCLUSION: Laparoscopic fenestration of either solitary or multiple liver cysts is the treatment of choice. It produces minimal surgical trauma, shorter hospital stay and avoids the morbidity of laparotomy. Reduced postoperative adhesions allows repeated procedures if the condition recurs.
Subject(s)
Cysts/surgery , Laparoscopy/methods , Liver Diseases/surgery , Adult , Aged , Female , Humans , Length of Stay , Male , Middle Aged , Recurrence , Tomography, X-Ray ComputedSubject(s)
Calcinosis/etiology , Lung Diseases/etiology , Renal Dialysis/adverse effects , Adult , Aged , Female , Humans , Male , Middle Aged , Parathyroid Hormone/bloodSubject(s)
Benzamides/therapeutic use , Gastroesophageal Reflux/drug therapy , Metoclopramide/therapeutic use , Adult , Double-Blind Method , Female , Humans , Male , Middle Aged , PlacebosABSTRACT
Analiza las transformaciones sufridas por la ecología en relación a los requerimientos generados por la problemática ambiental. Define la ecología y otros conceptos asociados y diferencia ecosistema de ambiente. Destaca la influencia de aplicaciones prácticas en el desarrollo de la ecología y describe la evolución de su estudio. Discute algunos conceptos que debe manejar quien trabaje en este tema, incluyendo los conceptos de ambiente potencial, ambiente operativo y ambiente valorizado. Concluye con las relaciones entre sociedad y naturaleza y los factores críticos que las afectan
Subject(s)
Ecosystem , Environment , Human EcologyABSTRACT
Analiza las transformaciones sufridas por la ecología en relación a los requerimientos generados por la problemática ambiental. Define la ecología y otros conceptos asociados y diferencia ecosistema de ambiente. Destaca la influencia de aplicaciones prácticas en el desarrollo de la ecología y describe la evolución de su estudio. Discute algunos conceptos que debe manejar quien trabaje en este tema, incluyendo los conceptos de ambiente potencial, ambiente operativo y ambiente valorizado. Concluye con las relaciones entre sociedad y naturaleza y los factores críticos que las afectan
Subject(s)
Human Ecology , Ecosystem , EnvironmentABSTRACT
Se estudio la evolutividad de 10 pancreatitis agudas graves mediante la tomografia computada, realizada cada 7 a 10 dias, correlacionables con la evolucion clinica (semiologia abdominal, curva termica, recuento de leucocitos y hemocultivos) y el estudio de amilasa total, isoamilasa P y ACCR. Mediante el estudio tomografico se diagnosticaron 1 necrosis cefalica, 1 necrosis corporocaudal, 1 necrosis difusa, 1 pseudoquiste del pancreas y 2 abscesos del pancreas, todos ellos confirmados por la cirugia. En 3 pacientes, a pesar de la evolucion clinica desfavorable, el estudio tomografico permitio detectar pequenos focos de necrosis en cuerpo y cola sin constituir una zona manifiesta de secuestro, por lo que no se operaron, siendo su evolucion favorable. Se considera la utilidad de este metodo en el seguimiento de las pancreatitis agudas graves, que sin ser de por si excluyente en la indicacion quirurgica, la union con la evolucion clinica proporciona fundamentos solidos para el manejo de las distintas contingencias que pueden surgir en el curso de esta enfermedad
Subject(s)
Adolescent , Adult , Middle Aged , Humans , Male , Female , Pancreatitis , Tomography, X-Ray Computed , Diagnosis, Differential , NecrosisABSTRACT
Se estudio la evolutividad de 10 pancreatitis agudas graves mediante la tomografia computada, realizada cada 7 a 10 dias, correlacionables con la evolucion clinica (semiologia abdominal, curva termica, recuento de leucocitos y hemocultivos) y el estudio de amilasa total, isoamilasa P y ACCR. Mediante el estudio tomografico se diagnosticaron 1 necrosis cefalica, 1 necrosis corporocaudal, 1 necrosis difusa, 1 pseudoquiste del pancreas y 2 abscesos del pancreas, todos ellos confirmados por la cirugia. En 3 pacientes, a pesar de la evolucion clinica desfavorable, el estudio tomografico permitio detectar pequenos focos de necrosis en cuerpo y cola sin constituir una zona manifiesta de secuestro, por lo que no se operaron, siendo su evolucion favorable. Se considera la utilidad de este metodo en el seguimiento de las pancreatitis agudas graves, que sin ser de por si excluyente en la indicacion quirurgica, la union con la evolucion clinica proporciona fundamentos solidos para el manejo de las distintas contingencias que pueden surgir en el curso de esta enfermedad
Subject(s)
Adolescent , Adult , Middle Aged , Aged , Humans , Male , Female , Pancreatitis , Tomography, X-Ray Computed , Diagnosis, Differential , NecrosisSubject(s)
Male , Female , Animals , Dogs , Anti-Bacterial Agents , Fluid Therapy , Pancreatectomy , PancreatitisSubject(s)
Male , Female , Animals , Dogs , Comparative Study , Anti-Bacterial Agents , Fluid Therapy , Pancreatectomy , PancreatitisABSTRACT
Nineteen patients have been treated with timolol maleate (a non selective beta-blocking) and the decrease of their blood arterial pressure was correlated with the suppression of renine secretion. The patients which controlled their arterial pressure (63%) as well as those who did not (37%) showed a significative decrease of the plasmatic renine. The patients were diagnosed of essential hypertension, with normal renal function and formed an homogenous group. The sodium intake was similar in all of them. The results showed that although the beta-blocking can act in hypertensive patients through the suppression of the renine angiotensine system, this is not the only maintenance factor of the arterial pressure, nor its only way of action. A relevant point to be stressed in the possibility of ARP stimulation by walking, in spite of the beta-blocking, which means that this is not a total blocking or that there are other factors regulating the ARP secretion, and that act together with the autonomous nervous system.
Subject(s)
Blood Pressure/drug effects , Hypertension/drug therapy , Propanolamines/therapeutic use , Renin/metabolism , Timolol/therapeutic use , Adult , Female , Heart Rate/drug effects , Humans , Male , Middle Aged , Renin/bloodABSTRACT
A group of 39 patients has been divided in three categories according to their plasmatic renine activity and the correlation of the hipotensive answer to the Timolol Maleate (betadrenergic blocking). The control is more favourable in the normorreninemic than in the hiporreninemic patients and, paradoxically, even more than in the hyperreninemic. This unexpected answer is probably due to the lowest sodium intake of this last group. Hyperreninemia is more than a factor determining their basal hypertension: it is a regulation factor by hiposodic diet and probably, drug resistant. Nor quantitative neither qualitative correlation among the basal plasmatic renine activity and the hipotensive activity has been observed.