[Telemedicine applied to Nephrology. Another form of consultation]. / Telemedicina aplicada a la nefrología. Otra forma de consulta.

UNLABELLED: In 2004, according to socio- demographic criteria and to the improvement in the welfare quality, we incorporated to the portfolio of services of our section a work tool that meant a novel technology; the "telemedicine". The Objective has been to asses the utility of telemedicine in the follow- up of the renal patients, bringing the consultation of nephrology closer to the patient's home as well as the relationship between two welfare levels. MATERIAL AND METHOD: Retrospective and descriptive study of the patients with renal pathology treated in the consultation of telenephrology at our hospital in a period of time of 27 months (November 2004-January 2007). Such study is carried out in primary care centers of our sanitary area (4 centers). The general practician (G.P) starts up the system by elaborating a document of derivation to the consultation of "telenephrology". All this information is included in a computerized data base that arrives via "Intranet" at the Hospital. From the consultation of Telenephrology the question is answered in real- time and through a system of videoconference. RESULTS: A total of 105 first consultations have been made. 52 men and 53 women between 18 and 94 years of age. The diagnoses made in the consultation of Telenephrology have been: HTA (essential and secondary): 90 (85.7%). IRC: 61 (58%). Diabetic Nefropathy: 17 (16%). Renal Polycystic: 3 (2.8%). Urinary Lithiasis: 2 (1.9%). Congenital malformations: 1 (0.95%). Obstructive Nefropathy: 1 (0.95%). Chronic Glomerulonephritis: 6 (5.7%). Urinary infection: 1 (0.95%). Absence of renal pathology: 5 (4.8%). Some of the diagnoses coincide in several patients. The causes of the IRC have been Nephroangioesclerosis: 33. Diabetic Nefropathy: 14. Not drafted: 8. Disease to glomerular: 2. Urinary Lithiasis: 2. Renal Polycystic: 1. Ischemic Nephropathy: 1. 82 out of the 90 patients with HTA had essential arterial hypertension and 8 suffered from secondary HTA. The causes of this were: 5 HTA of parenquimatous renal origin. 2 vasculorrenal HTA and one with a primary hyperaldosteronism. The associated factors of risk to the observed HTA have been: Dyslipemia: 29. Diabetes méllitus: 29. Hyperuricemia: 11. Obesity: 12. CONCLUSION: The telecare in nephrology is possible promoting also the approach between two welfare levels, without a decrease in the quality of assistance. That way, we can get a lower number of hospital visits and, subsequently, a saving in sanitary transport as well as in hospital consultations.

Nuestra experiencia en el hiperaldosteronismo primario / Our experience in primary hiperaldos dosteronism

Objetivo: Analizar las formas de presentación, características clínicas, diagnóstico y tratamiento de los pacientes diagnosticados de hiperaldosteronismo primario (HA1º) en la consulta externa de nefrología desde su apertura. Método: Se realizó un estudio retrospectivo revisando todas las historias clínicas de pacientes diagnosticados de HA1º desde 1981-2005. Resultados: Se diagnosticaron un total de 35 pacientes con una edad media de 50 años con predominio de varones (82%). El motivo principal de inicio de estudio de HA1º fue la hipertensión arterial (HTA) rebelde, seguido de hipertensión más hipopotasemia(34%). Dieciséis casos eran adenomas (7 adenomas clásicos y 9 renino-dependientes) y 14 hiperplasias (10 hiperplasias bilaterales y 4 hiperplasias adrenales primarias). Cinco casos fueron excluidos del estudio por encontrarse en el momento de realización del estudio pendientes de pruebas complementarias. Para diagnóstico de localización la prueba que mostró más concordancia con el diagnóstico final fue la gammgrafía I-131colesterol seguida de la RMN y la TAC. En 8 casos se realizó muestreo venoso suprarrenal. Fueron intervenidos 10 de los 16 adenomas con resultado de normalización de cifras tensionales sin tratamiento en el 60% de ellos. El resto de los casos se encuentran en tratamiento con espironolactona con adecuado control tensional. El efecto adverso más frecuente fue la ginecomastia. Conclusión: En contra de lo publicado en la literatura, en nuestra serie observamos un claro predominio de varones. Obtuvimos una similar incidencia de adenomas e hiperplasias. La forma de presentación más frecuente fue la hipertensión arterial rebelde al tratamiento. La opción quirúrgica de los adenomas no significa un resultado curativo, pero sí un mejor controlde las cifras tensionales con menos fármacos y una disminución de los niveles de aldosterona con el consiguiente descenso de la toxicidad miocárdica y vascular (AU)

Aims: The aim of this paper is to analyze the ways of appearance, clinical characteristics, diagnosis and treatment related to patients suffering from primary hyperaldosteronism (HA1º) in external nephrology consultation since their opening. Methodology: A retrospective study was carried out, checking out all HA1º diagnosed patients of clinicalrecords from 1981-2005. Results: 35 patients were diagnosed,with an average age of 50 and a predominance of men (82%). The main reason for starting the HA1º study was persistent hypertension; other reasons were hypertension and hypopotassemia (34%). Sixteen of the cases were adenomas (7 classic adenomas and 9 renin-dependents) and fourteen of them were hyperplasia (10 bilateral hyperplasias and 4 primary adrenals hyperplasia). Five cases were excluded because they were waiting for complementary tests. For location diagnosis, gammagrafía I-131cholesterol was the test showing more agreement with final diagnosis, and then RMN and TAC. In eight of the cases, an adrenal vein sampling was made. Ten of sixteen adenomas suffered a surgery performance. The result showed standardization of tensional levels, without any treatment in 60% of the cases. The rest of them are currently treated with spironolactone under an appropriate tensionalcontrol. Gynecomastia was the most usual adverse effect found. Conclusion: Contrary to other published papers, we found out a male predominance in our database. A similar incidence of adenomas e hyperplasias was obtained. The most usual way of appearance was persistent hypertension to treatment. Adenomas surgery does not implyhealing results, though it achieves a better tensional levels control, using less drugs and diminishing aldosterone levels. It implies a descent in myocardic and vascular toxicity (AU)

[Our experience in primary hyperaldosteronism]. / Nuestra experiencia en el hiperaldosteronismo primario.

UNLABELLED: The aim of this paper is to analyze the ways of appearance, clinical characteristics, diagnosis and treatment related to patients suffering from primary hyperaldosteronism (HA1 masculine) in external nephrology consultation since their opening. METHODOLOGY: a retrospective study was carried out, checking out all HA1 masculine diagnosed patients of clinical records from 1981-2005. RESULTS: 35 patients were diagnosed, with an average age of 50 and a predominance of men (82%). The main reason for starting the HA1 masculine study was persistent hypertension; other reasons were hypertension and hypopotassemia (34%). Sixteen of the cases were adenomas (7 classic adenomas and 9 renin-dependents) and fourteen of them were hyperplasia (10 bilateral hyperplasias and 4 primary adrenals hyperplasia). Five cases were excluded because they were waiting for complementary tests. For location diagnosis, gammagrafía I131cholesterol was the test showing more agreement with final diagnosis, and then RMN and TAC. In eight of the cases, an adrenal vein sampling was made. Ten of sixteen adenomas suffered a surgery performance. The result showed standardization of tensional levels, without any treatment in 60% of the cases. The rest of them are currently treated with spironolactone under an appropriate tensional control. Gynecomastia was the most usual adverse effect found. CONCLUSION: Contrary to other published papers, we found out a male predominance in our database. A similar incidence of adenomas e hyperplasias was obtained. The most usual way of appearance was persistent hypertension to treatment. Adenomas surgery does not imply healing results, though it achieves a better tensional levels control, using less drugs and diminishing aldosterone levels. It implies a descent in myocardic and vascular toxicity.

[Renal histological lesions in patients with type II diabetes mellitus]. / Lesiones histológicas renales en pacientes con diabetes mellitus tipo II.

Diabetic glomerulosclerosis is the most frequent cause of renal disease in patients with type II diabetes mellitus (DM), sometimes accompanied by vascular lesions. However, other glomerular pathologies are important in these patients. The aim of this study was to evaluate the prevalence of non-diabetic nephropathy (NDN) in selected patients with type II DM, and to identify clinical markers that may predict its presence in this population. We reviewed 20 renal biopsies performed on twenty patients with type II DM. Nine of them showed diabetic nephropathy (DN) (45%), whereas eleven showed NDN (55%): 1 IgA nephropathy, 3 vasculitis and 7 membranous nephropathy. We found no differences between the two groups with regard to sex, duration of DM, insulin therapy, glycosylated haemoglobin, proteinuria, presence of nephrotic syndrome, hypertension, serum IgA level or renal size. The NDN group had haematuria in 63.6%, whereas the patients with NDN had it in 44.4% (NS). Body mass index was higher in NDN patients (30 +/- 6.7 vs 22 +/- 2.9; p < 0.01), The same was true for creatinine clearance (82.2 +/- 51.4 ml/m vs 40.4 +/- 19.6 ml/m; p < 0.05). The age at the moment of diagnosis was higher in ND patients (67 +/- 11.2 vs 54.3 +/- 4.6; p < 0.05). The 3 patients who had diabetic retinopathy were found to have DN on renal biopsy (diagnostic specificity = 100%), although 66.7% of the patients with diabetic glomerulopathy had no retinopathy. We conclude that patients with type II DM with renal findings suggesting non-diabetic renal disease frequently it have NDN, and a renal biopsy must be performed. The presence of retinopathy has a predictive value of 100% in predicting DN, therefore its existence may make this diagnostic procedure unneccesary.

Lesiones histológicas renales en pacientes con diabetes mellitus tipo II / Renal histologic lesions in patients with type II DM

La glomeruloesclerosis diabética es la causa más frecuente de afectación renal en pacientes con diabetes mellitus (DM) tipo II, muchas veces con lesiones vasculares. Sin embargo, no es despreciable la importancia de otras patologías glomerulares. El objetivo de este estudio ha sido evaluar la prevalencia de nefropatía no diabética (NND) en biopsias renales realizadas en pacientes seleccionados afectos de DM, e identificar marcadores clínicos que pueden predecir su presencia en esta población.Revisamos 20 biopsias realizadas a otros tantos pacientes con DM tipo II. Los criterios para su indicación fueron la ausencia de retinopatía, presencia de hematuria, insuficiencia renal de aparición reciente, inexplicada o de rápida progresión, proteinuria de comienzo brusco y DM de corta evolución (inferior a 3 años). De los 20 casos, nueve correspondieron a nefropatías diabéticas (ND) (45 por ciento) y 11 a NND (55 por ciento). Entre éstos, hubo una nefropatía IgA, 7 glomerulonefritis membranosas y 3 vasculitis. No encontramos diferencias en cuanto al sexo, tiempo de evolución de DM, insulinoterapia, HbA1c, proteinuria, presencia de síndrome nefrótico, HTA, valor de IgA sérica o tamaño renal. El grupo de la NND presentó microhematuria en el 63,6 por ciento frente al 44,4 por ciento de los pacientes con ND (NS).El índice de masa corporal fue más elevado en los pacientes con NND (30 ñ 6,7 vs 22 ñ 2,9; p < 0,01), al igual que el CCr (82,2 ñ 51,4 ml/m vs 40,4 ñ 19,6 ml/m; p < 0,05), Aquéllos con ND tenían una edad más avanzada (67 ñ 11,2 vs 54,3 ñ 4,6; p < 0,05).Los 3 pacientes que mostraron retinopatía presentaron una ND en la biopsia renal (especificidad diagnóstica del 100 por ciento), aunque el 66,7 por ciento de los pacientes con glomeruloesclerosis diabética carecían de retinopatía.Podemos concluir que los pacientes con DM tipo II con signos clínicos de enfermedad renal no diabética, tales como insuficiencia renal de reciente comienzo o de rápida evolución, proteinuria de inicio brusco, presencia de sintomatología sistémica, ANCA positivo o sedimento patológico, presentan una incidencia de ésta lo suficientemente elevada como para justificar la realización de una biopsia renal. Aunque el número de pacientes es escaso, la presencia de retinopatía tiene un valor predictivo del 100 por ciento para la ND, por lo que su existencia podría obviar esta prueba diagnóstica. (AU)

Fracaso renal agudo debido a intoxicación por paracetamol / Acute renal failure secondary to paracetamol intoxication

La intoxicación por paracetamol se manifiesta clásicamente por hepatotoxicidad, siendo la insuficiencia renal un evento inusual, sobre todo en ausencia de daño hepático fulminante o alteraciones hemodinámicas severas. Presentamos el caso de una mujer de 22 años que, tras la ingestión de 11,5gramos de acetaminofén presentó un fracaso renal agudo. El curso clínico y los datos de laboratorio apoyaron el diagnóstico de necrosis tubular aguda. La paciente precisó hemodiálisis, pero la recuperación de la función renal fue completa. Revisamos el metabolismo del paracetamol y las posibles causas de fallo renal en los casos de ingesta masiva de dicho fármaco (AU)

Paracetamol poisoning is manifested by hepatotoxicity, but acute renal failureis very rare, especially when there is no fulminant hepatic damage with encephalopathy or severe haemodynamic alterations. We present here the case of a 22-year-old woman who presented with acuterenal failure after the ingestion of 11.5 g of acetaminophen. The clinical course and laboratory data were consistent with tubular necrosis. The patient required hemodialysis, but finally renal function returned to normal. The acetaminophen pharmacology and the differential diagnosis of acute azotemia in paracetamol overdosage are reviewed (AU)

[Remission of nephrotic syndrome caused by renal amyloidosis secondary to pulmonary tuberculosis after tuberculostatic treatment]. / Remisión de síndrome nefrótico por amiloidosis renal secundaria a tuberculosis pulmonar tras tratamiento tuberculostático.

Secondary systemic amyloidosis is a frequent complication in several chronic infectious and inflammatory states. Although initially amyloidosis was described in association with long-standing syphilis and tuberculosis, with the introduction of antiboitic and antituberculous therapy, rheumatoid arthritis is now the commonest cause of this illness. We present here the case of a 16 year-old woman, who was diagnosed one month ealier with pulmonary tuberculosis. She developed a nephrotic syndrome and her kidney biopsy confirmed the presence of amyloid. Treatment of the tuberculosis was accompanied by clinical remission of the nephrotic syndrome two years later.

Remisión de síndrome nefrótico por amiloidosis renal secundaria a tuberculosis pulmonar tras tratamiento tuberculostático / Clinical remission of amyloidotic nephrotic syndrome after antituberculous therapy

La amiloidosis secundaria es una complicación frecuente de distintos trastornos inflamatorios e infecciosos crónicos. Aunque inicialmente la patología asociada con mayor frecuencia eran las infecciones crónicas, como la tuberculosis o la sífilis, en la actualidad se presenta más frecuentemente en relación con procesos reumatológicos, fundamentalmente la artritis reumatoide. Presentamos el caso de una mujer de 16 años, diagnosticada de tuberculosis pulmonar con un síndrome nefrótico, y cuya biopsia renal demuestra la presencia de una amiloidosis. El tratamiento de la enfermedad causal llevó a la remisión clínica del cuadro renal dos años más tarde (AU)

[Acute kidney failure caused by paracetamol poisoning]. / Fracaso renal agudo debido a intoxicación por paracetamol.

Paracetamol poisoning is manifested by hepatotoxicity, but acute renal failure is very rare, especially when there is no fulminant hepatic damage with encephalopathy or severe haemodynamic alterations. We present here the case of a 22-year-old woman who presented with acute renal failure after the ingestion of 11.5 g of acetaminophen. The clinical course and laboratory data were consistent with tubular necrosis. The patient required hemodialysis, but finally renal function returned to normal. The acetaminophen pharmacology and the differential diagnosis of acute azotemia in paracetamol overdosage are reviewed.

Apuntes para el diseño de políticas públicas para la niñez y adolescencia a nivel local / Notes on Design of Public Policies for Childhood and Adolescence to Local Level

Esta propuesta pretende valorizar la participación ciudadana como elemento fundamental en la formulacíon, negociación, toma de decisión, implementación y evaluación de políticas, para ser aplicado a nivel local, dentro de los municipios y consejos provinciales. Se ha intentado conjugar un esfuerzo teórico con reflexiones de la práctica, ejemplificando el caso de las políticas sobre infancia y adolescencia...

Metastasizing renal cell carcinoma and acquired renal cystic disease in a hemodialysis patient.

Acquired renal cystic disease is an entity which is characterized by the progressive substitution of the atrophic renal parenchyma by multiple cysts in patients with renal insufficiency. Its main complications are hemorrhage and tumorous degeneration. The case discussed is a 57-year-old patient with terminal renal insufficiency secondary to interstitial nephropathy, who, following 6 years of treatment with hemodialysis and renal transplantation, developed a state of persistent hematuria requiring nephrectomy of the left kidney. Histological study revealed multiple cysts of monostratified epithelium with intracavitary projections, multiform adenomas and multifocal malignant tumorous polymorphism. The patient died in a state of progressive cachexia with pleural and hepatic metastasis.

Small kidney and hypertension: selection of patients for surgery.

We studied 37 patients with various degrees of hypertension and a small unilateral kidney. Renal vein renin studies were shown to be positive on 19 occasions and negative on 18. Of those positive, 10 had severe and 1 moderate hypertension. Surgery cured 63.3%. In 27% blood pressure improved and 1 patient failed to respond. Eight patients had mild hypertension with a positive renal vein renin ratio (RVRR), but on observation their home blood pressures were normal without medication and they were not considered for surgery. Eighteen patients with mild hypertension and negative RVRR were also not operated. We believe that RVRR is important for a surgical decision, but only in severe and moderate hypertensives. In mild hypertension, measurement of blood pressure at home is normal on most occasions. These are hyperreactive patients and should not have surgery, regardless of the results of their RVRRs.

Renal tuberculosis and hypertension: value of the renal vein renin ratio.

We applied the central renal vein renin ratios in a group of patients with unilateral renal tuberculosis and hypertension to see whether the diseased kidney was involved in the pathogenesis of the elevated blood pressure. Of 20 patients 11 were nephrectomized, 7 had positive renal vein renin ratios and normal peripheral plasma renin activity; only 2 kept their blood pressure in control without medication. From 5 without a positive index, only 1 kept his blood pressure in control without medicine 1 year after surgery. The renal vein renin ratio has to be interpreted in light of other parameters, such as blood pressure, peripheral renin--if high the more the chance of being significant--and global renal function. The renal vein renin ratio alone per se gives poor information on the pressor role of a unilateral tuberculous kidney.