Revisión sistemática de los métodos predictores de la funcionalidad del trasplante renal / Systematic review of kidney transplantation functional predictors

Contexto: El trasplante renal de donantes con criterios expandidos ha aumentado el pool de riñones a costa de un riesgo superior de disfunción del injerto a corto y/o largo plazo. La cuestión principal reside en determinar qué riñones ofrecerán una función y supervivencia aceptables comparado con el riesgo que supone la cirugía y la posterior inmunosupresión. Objetivo: El objetivo de nuestro artículo es revisar la evidencia actual sobre las herramientas para predecir la funcionalidad del trasplante renal de donantes de cadáver con criterios expandidos y determinar la validez para su uso en la práctica habitual. Adquisición de evidencia: Hemos realizado una revisión sistemática de la literatura según los criterios PRISMA, a través de Medline (http://www.ncbi.nlm.nih.gov), utilizando las palabras clave, aisladas o conjuntamente: cadaveric renal transplantation; kidney graft function appraisal; graft function predictors. Se seleccionaron series prospectivas y retrospectivas, así como artículos de revisión. Un total de 375 artículos fueron analizados, de los cuales 39 fueron finalmente seleccionados para revisión. Síntesis de evidencia: Entre los predictores de la funcionalidad se encuentran: los índices de riesgo del donante; el cálculo del peso funcional renal o la valoración de la masa nefrónica; la medición de las resistencias vasculares durante la perfusión en hipotermia; la medición de biomarcadores en la orina del donante y en el líquido de perfusión; la medición de parámetros funcionales y de reperfusión en normotermia y la medición de los parámetros morfológicos, micro y macroscópicos, del órgano diana. En este artículo presentamos un resumen explicativo de cada uno de estos parámetros, así como su evidencia más reciente al respeto. Discusión: Ningún parámetro de los revisados fue capaz de predecir por sí mismo, con fiabilidad, la función renal y la supervivencia del trasplante. Existe un importante vacío en cuanto a la valoración macroscópica del trasplante renal. Conclusiones: Es necesario continuar desarrollando los predictores de la funcionalidad renal para definir con precisión la distribución de cada uno de los riñones de los donantes que disponemos en la actualidad

Context: Kidney transplantation from donors with expanded criteria has increased the pool of kidneys at the cost of a higher risk of short and long-term graft dysfunction. The main issue lies in determining which kidneys will offer acceptable function and survival compared with the risk represented by surgery and subsequent immunosuppression. Objective: The objective of our article is to review the current evidence on the tools for predicting the functionality of kidney transplantation from cadaveric donors with expanded criteria and determining the validity for their use in standard practice. Acquisition of evidence: We conducted a systematic literature review according to the PRISM criteria, through Medline (http://www.ncbi.nlm.nih.gov) and using the keywords (in isolation or in conjunction) "cadaveric renal transplantation; kidney graft function appraisal, graft function predictors". We selected prospective and retrospective series and review articles. A total of 375 articles were analysed, 39 of which were ultimately selected for review. Summary of the evidence: The predictors of functionality include the following: The donor risk indices; the calculation of the renal functional weight or the assessment of the nephronic mass; the measurement of vascular resistances during perfusion in hypothermia; the measurement of the donor's biomarkers in urine and in the perfusion liquid; the measurement of functional and reperfusion parameters in normothermia; and the measurement of morphological parameters (microscopic and macroscopic) of the target organ. In this article, we present an explanatory summary of each of these parameters, as well as their most recent evidence on this issue. Discussion: None of the reviewed parameters in isolation could reliably predict renal function and graft survival. There is a significant void in terms of the macroscopic assessment of kidney transplantation. Conclusions: We need to continue developing predictors of renal functionality to accurately define the distribution of each currently available donor kidney

Systematic review of kidney transplantation functional predictors. / Revisión sistemática de los métodos predictores de la funcionalidad del trasplante renal.

CONTEXT: Kidney transplantation from donors with expanded criteria has increased the pool of kidneys at the cost of a higher risk of short and long-term graft dysfunction. The main issue lies in determining which kidneys will offer acceptable function and survival compared with the risk represented by surgery and subsequent immunosuppression. OBJECTIVE: The objective of our article is to review the current evidence on the tools for predicting the functionality of kidney transplantation from cadaveric donors with expanded criteria and determining the validity for their use in standard practice. ACQUISITION OF EVIDENCE: We conducted a systematic literature review according to the PRISM criteria, through Medline (http://www.ncbi.nlm.nih.gov) and using the keywords (in isolation or in conjunction) "cadaveric renal transplantation; kidney graft function appraisal, graft function predictors". We selected prospective and retrospective series and review articles. A total of 375 articles were analysed, 39 of which were ultimately selected for review. SUMMARY OF THE EVIDENCE: The predictors of functionality include the following: The donor risk indices; the calculation of the renal functional weight or the assessment of the nephronic mass; the measurement of vascular resistances during perfusion in hypothermia; the measurement of the donor's biomarkers in urine and in the perfusion liquid; the measurement of functional and reperfusion parameters in normothermia; and the measurement of morphological parameters (microscopic and macroscopic) of the target organ. In this article, we present an explanatory summary of each of these parameters, as well as their most recent evidence on this issue. DISCUSSION: None of the reviewed parameters in isolation could reliably predict renal function and graft survival. There is a significant void in terms of the macroscopic assessment of kidney transplantation. CONCLUSIONS: We need to continue developing predictors of renal functionality to accurately define the distribution of each currently available donor kidney.

Función cognitiva y demencia en la hipertensión arterial / Cognitive function and dementia in high blood pressure

Como consecuencia del envejecimiento de la población las alteraciones de la función cognitiva y las demencias están aumentando. El 90 % corresponden a la enfermedad de Alzheimer y a las demencias vasculares. Para la primera, constituyen factores de riesgo la edad, los antecedentes familiares de demencia y el alelo E4 del gen de la apolipoproteína E. Para la demencia vascular lo son la edad, el género masculino, la hipertensión arterial, la enfermedad coronaria, la diabetes, la aterosclerosis generalizada, el tabaquismo, una concentración elevada de lípidos e historia previa de ictus. El diagnóstico de demencia y deterioro cognitivo está basado en criterios clínicos y pruebas que adolecen de una precisión adecuada, en este sentido las modernas técnicas de neuroimagen (tomografía axial computarizada y resonancia magnética) están aportando valiosísima información al relacionar los infartos lacunares y las lesiones de la sustancia blanca no sólo a la hipertensión arterial y otros factores de riesgo cardiovascular, sino también a la aparición de demencia. En base a la información actualmente disponible se ha postulado que una presión arterial sistólica inicial elevada conduciría a múltiples infartos lacunares y a lesiones de la sustancia blanca cerebral que conducirían a un deterioro cognitivo progresivo y a una posterior reducción de la presión arterial. Aunque los beneficios del control de la presión arterial sobre la longevidad están firmemente establecidos, los costes que pueda tener sobre la función cognitiva no están determinados. Los estudios observacionales en general han demostrado una mejoría de la función cognitiva al tratar la hipertensión arterial. En cuanto al tratamiento farmacológico, los resultados se han de interpretar con precaución. En general, los diuréticos y betabloqueantes no empeoran o mejoran la función cognitiva. Los antagonistas de la angiotensina II, los inhibidores de la enzima conversora de la angiotensina y los calcioantagonistas tienen una influencia positiva sobre la función cognitiva. Los grandes ensayos clínicos (grado de evidencia A), con unas muestras poblaciones y un tiempo de duración más apropiados, han mostrado una reducción de la demencia con calcioantagonsitas dihidropiridínicos (nitrendipino) y con la combinación inhibidor de la enzima conversora de la angiotensina y diurético (perindopril más indapamida)

As a consequence of aging of the population, cognitive function disorders and dementias are increasing. A total of 90 % correspond to Alzheimer's disease and vascular dementias. For the former, the risk factors are age, family background of dementia and E4 allele of the apolipoprotein E gene. For the vascular dementia one, they are age, male gender, HBP, coronary disease, diabetes, generalized atherosclerosis, smoking, elevated lipid concentration and previous history of stroke. Diagnosis of dementia and cognitive deterioration is based on clinical criteria and tests that lack adequate accuracy. In this sense, modern neuroimaging techniques (CT scan and MRI) are supplying very valuable information, as it relates lacunar infarction and white substance lesions not only to HBP and other cardiovascular risk factors but also to the appearance of dementia. Based on the presently available information, it has been hypothesized that an initially elevated systolic BP would lead to multiple lacunar infarctions and to lesions of the brain white substance that would lead to progressive cognitive deterioration and to a later reduction of BP. Although the benefits of controlling BP on longevity are firmly established, the costs that it may have on cognitive function have not been determined. Observational studies in general have demonstrated improvement of cognitive function when HPB is treated. Regarding drug treatment, the results must be interpreted with care. In general, diuretics and beta blockers do not worsen or improve cognitive function. The antagonists of angiotensin II, ACE inhibitors and calcium antagonist have a positive affect on cognitive function. The large clinical trials (evidence A grade), with more appropriate population samples and duration time have shown a reduction of dementia with dihydropyridine calcium antagonists (nitrendipine) and with the ACE inhibitor and diuretic combination (perindopril plus indapamide)As a consequence of aging of the population, cognitive function disorders and dementias are increasing. A total of 90 % correspond to Alzheimer's disease and vascular dementias. For the former, the risk factors are age, family background of dementia and E4 allele of the apolipoprotein E gene. For the vascular dementia one, they are age, male gender, HBP, coronary disease, diabetes, generalized atherosclerosis, smoking, elevated lipid concentration and previous history of stroke. Diagnosis of dementia and cognitive deterioration is based on clinical criteria and tests that lack adequate accuracy. In this sense, modern neuroimaging techniques (CT scan and MRI) are supplying very valuable information, as it relates lacunar infarction and white substance lesions not only to HBP and other cardiovascular risk factors but also to the appearance of dementia. Based on the presently available information, it has been hypothesized that an initially elevated systolic BP would lead to multiple lacunar infarctions and to lesions of the brain white substance that would lead to progressive cognitive deterioration and to a later reduction of BP. Although the benefits of controlling BP on longevity are firmly established, the costs that it may have on cognitive function have not been determined. Observational studies in general have demonstrated improvement of cognitive function when HPB is treated. Regarding drug treatment, the results must be interpreted with care. In general, diuretics and beta blockers do not worsen or improve cognitive function. The antagonists of angiotensin II, ACE inhibitors and calcium antagonist have a positive affect on cognitive function. The large clinical trials (evidence A grade), with more appropriate population samples and duration time have shown a reduction of dementia with dihydropyridine calcium antagonists (nitrendipine) and with the ACE inhibitor and diuretic combination (perindopril plus indapamide)As a consequence of aging of the population, cognitive function disorders and dementias are increasing. A total of 90 % correspond to Alzheimer's disease and vascular dementias. For the former, the risk factors are age, family background of dementia and E4 allele of the apolipoprotein E gene. For the vascular dementia one, they are age, male gender, HBP, coronary disease, diabetes, generalized atherosclerosis, smoking, elevated lipid concentration and previous history of stroke. Diagnosis of dementia and cognitive deterioration is based on clinical criteria and tests that lack adequate accuracy. In this sense, modern neuroimaging techniques (CT scan and MRI) are supplying very valuable information, as it relates lacunar infarction and white substance lesions not only to HBP and other cardiovascular risk factors but also to the appearance of dementia. Based on the presently available information, it has been hypothesized that an initially elevated systolic BP would lead to multiple lacunar infarctions and to lesions of the brain white substance that would lead to progressive cognitive deterioration and to a later reduction of BP. Although the benefits of controlling BP on longevity are firmly established, the costs that it may have on cognitive function have not been determined. Observational studies in general have demonstrated improvement of cognitive function when HPB is treated. Regarding drug treatment, the results must be interpreted with care. In general, diuretics and beta blockers do not worsen or improve cognitive function. The antagonists of angiotensin II, ACE inhibitors and calcium antagonist have a positive affect on cognitive function. The large clinical trials (evidence A grade), with more appropriate population samples and duration time have shown a reduction of dementia with dihydropyridine calcium antagonists (nitrendipine) and with the ACE inhibitor and diuretic combination (perindopril plus indapamide)

Función cognitiva y demencia en la hipertensión arterial / Cognitive function and dementia in high blood pressure

Como consecuencia del envejecimiento de la población las alteraciones de la función cognitiva y las demencias están aumentando. El 90 % corresponden a la enfermedad de Alzheimer y a las demencias vasculares. Para la primera, constituyen factores de riesgo la edad, los antecedentes familiares de demencia y el alelo E4 del gen de la apolipoproteína E. Para la demencia vascular lo son la edad, el género masculino, la hipertensión arterial, la enfermedad coronaria, la diabetes, la aterosclerosis generalizada, el tabaquismo, una concentración elevada de lípidos e historia previa de ictus. El diagnóstico de demencia y deterioro cognitivo está basado en criterios clínicos y pruebas que adolecen de una precisión adecuada, en este sentido las modernas técnicas de neuroimagen (tomografía axial computarizada y resonancia magnética) están aportando valiosísima información al relacionar los infartos lacunares y las lesiones de la sustancia blanca no sólo a la hipertensión arterial y otros factores de riesgo cardiovascular, sino también a la aparición de demencia. En base a la información actualmente disponible se ha postulado que una presión arterial sistólica inicial elevada conduciría a múltiples infartos lacunares y a lesiones de la sustancia blanca cerebral que conducirían a un deterioro cognitivo progresivo y a una posterior reducción de la presión arterial. Aunque los beneficios del control de la presión arterial sobre la longevidad están firmemente establecidos, los costes que pueda tener sobre la función cognitiva no están determinados. Los estudios observacionales en general han demostrado una mejoría de la función cognitiva al tratar la hipertensión arterial. En cuanto al tratamiento farmacológico, los resultados se han de interpretar con precaución. En general, los diuréticos y betabloqueantes no empeoran o mejoran la función cognitiva. Los antagonistas de la angiotensina II, los inhibidores de la enzima conversora de la angiotensina y los calcioantagonistas tienen una influencia positiva sobre la función cognitiva. Los grandes ensayos clínicos (grado de evidencia A), con unas muestras poblaciones y un tiempo de duración más apropiados, han mostrado una reducción de la demencia con calcioantagonsitas dihidropiridínicos (nitrendipino) y con la combinación inhibidor de la enzima conversora de la angiotensina y diurético (perindopril más indapamida)

As a consequence of aging of the population, cognitive function disorders and dementias are increasing. A total of 90 % correspond to Alzheimer's disease and vascular dementias. For the former, the risk factors are age, family background of dementia and E4 allele of the apolipoprotein E gene. For the vascular dementia one, they are age, male gender, HBP, coronary disease, diabetes, generalized atherosclerosis, smoking, elevated lipid concentration and previous history of stroke. Diagnosis of dementia and cognitive deterioration is based on clinical criteria and tests that lack adequate accuracy. In this sense, modern neuroimaging techniques (CT scan and MRI) are supplying very valuable information, as it relates lacunar infarction and white substance lesions not only to HBP and other cardiovascular risk factors but also to the appearance of dementia. Based on the presently available information, it has been hypothesized that an initially elevated systolic BP would lead to multiple lacunar infarctions and to lesions of the brain white substance that would lead to progressive cognitive deterioration and to a later reduction of BP. Although the benefits of controlling BP on longevity are firmly established, the costs that it may have on cognitive function have not been determined. Observational studies in general have demonstrated improvement of cognitive function when HPB is treated. Regarding drug treatment, the results must be interpreted with care. In general, diuretics and beta blockers do not worsen or improve cognitive function. The antagonists of angiotensin II, ACE inhibitors and calcium antagonist have a positive affect on cognitive function. The large clinical trials (evidence A grade), with more appropriate population samples and duration time have shown a reduction of dementia with dihydropyridine calcium antagonists (nitrendipine) and with the ACE inhibitor and diuretic combination (perindopril plus indapamide)