[Efficacy of rasburicase therapy in obstructive renal failure secondary to urolithiasis: a novel therapeutic option]. / Eficacia de la rasburicasa en el fracaso renal agudo obstructivo por litiasis: una nueva opción terapéutica.

The overall incidence of nephrolithiasis-related acute and chronic renal failure is poorly known and surely underestimated. However, obstructive nephropathy represents a potentially curable form of kidney disease that often requires for managing an instrumentation of urinary tract. Rasburicase is an enzyme that transforms uric acid to allantoin, a compound more water soluble that will be excreted by the kidney more easily. Rasburicase has been proven to be an effective therapy for prevention of tumour lysis syndrome. But it also represents an interesting new option in managing hyperuricemia in patients with severe tophaceous gout. We administered rasburicase intravenously (0.20 mg/kg/day, for 2 days) in 2 adults with acute obstructive nephropathy from renal calculi, which was receiving temporary haemodialysis. Rasburicase produced a sharp polyuria 12-18 hours after its administration accompanied with a fast reduction of serum creatinine levels, that returned to normal range without further dialysis. If we suppose that rasburicase can pass through glomerular filter by its relatively low molecular weight, it could dissolve tubular uric acid crystals in acute renal failure associated to tumour lysis syndrome, providing the restoration of renal function. But we also could postulate that rasburicase can act in urinary tract, fragmentating renal calculi, promoting relief of obstructive uropathy and the resolution of renal failure. We suggest rasburicase should be tried in this new indication to prove its potential efficacy.

Eficacia de la rasburicasa en el fracaso renal agudo obstructivo por litiasis: una nueva opción terapéutica / Efficacy of rasburicase therapy in obstructive renal failure secondary to urolithiasis: a novel therapeutic option

La incidencia global de la insuficiencia renal crónica o aguda asociada a la litiasis renal es desconocida y probablemente esté infraestimada. Sin embargo, la uropatía obstructiva constituye una causa potencialmente curable de nefropatía que precisa con frecuencia manipulación quirúrgica de la vía urinaria. Rasburicasa es una enzima recombinante que metaboliza el ácido úrico en alantoína, un compuesto más hidrosoluble y fácilmente eliminable por el riñón. Su principal indicación es la prevención de la nefropatía por ácido úrico del síndrome de lisis tumoral. Pero, actualmente, también se considera una posible alternativa al alopurinol en el manejo de la hiperuricemia del paciente con gota tofácea crónica. Presentamos dos casos de fracaso renal agudo anúrico obstructivo provocados por litiasis que precisaron hemodiálisis y a los que se les administró rasburicasa por vía intravenosa (0,20 mg/kg/día durante 2 días).Tras 12-18 horas se observó una poliuria brusca y eficaz que se acompañó de rápida recuperación de la función renal y permitió suspender la hemodiálisis. En virtud del relativo bajo peso molecular de la rasburicasa podemos suponer que es capaz de atravesar el filtro glomerular y aparecer en la orina. Podría así disolver los cristales de ácido úrico formados en el fracaso renal agudo asociado al síndrome de lisis tumoral. Pero también podemos hipotetizar que la rasburicasa actuaría en la vía urinaria fragmentando los cálculos, facilitando su eliminación y liberando la obstrucción, lo que posibilitaría la resolución del fallo renal. Sugerimos que la rasburicasa debería ser ensayada con esta nueva indicación para probar su posible eficacia (AU)

The overall incidence of nephrolithiasis-related acute and chronicrenal failure is poorly known and surely underestimated. However, obstructive nephropathy represents a potentially curable form of kidney disease that often requires for managing an instrumentation of urinary tract. Rasburicase is an enzyme that transforms uric acid to allantoin, a compound more water soluble that will be excreted by the kidney more easily. Rasburicase has been proven to be an effective therapy for prevention of tumourlys is syndrome. But it also represents an interesting new option in managing hyperuricemia in patients with severe tophaceousgout. We administered rasburicase intravenously (0,20mg/kg/day, for 2 days) in 2 adults with acute obstructive nephropathy from renal calculi, which was receiving temporary haemodialysis. Rasburicase produced a sharp polyuria 12-18 hours after its administration accompanied with a fast reduction of serum creatinine levels, that returned to normal range without further dialysis. If we suppose that rasburicase can pass through glomerular filter by its relatively low molecular weight, it could dissolve tubular uric acid crystals in acute renal failure associated to tumourlys is syndrome, providing the restoration of renal function. But we also could postulate that rasburicase can act in urinary tract, fragmentating renal calculi, promoting relief of obstructive uropathy and the resolution of renal failure. We suggest rasburicase should be tried in this new indication to prove its potential efficacy (AU)

[Complete remission of nephrotic syndrome with methylprednisolone pulses in an adult with Schönlein-Henoch purpura]. / Remisión completa de síndrome nefrótico con pulsos de metil-prednisolona en un adulto con púrpura de Schönlein-Henoch.

Henoch-Schönlein purpura is a systemic vasculitis that occurs most frequently in childhood. Massive proteinuria, renal impairement at onset and histologic severity in renal biopsy are considered the main risk factors for deterioration of renal function at long-term. We report a 24 years-old woman with Henoch-Schönlein purpura who developped a severe nephrotic syndrome with microhematuria and normal renal function. Renal biopsy showed a diffuse endocapillary proliferative glomerulonephritis with less than 50% crescents (type IIIB of ISKDC classification). As their potential bad prognosis we decided to treat with methyl-prednisolone pulses (3 x 500 mg in months 0, 3 and 5) accompanied by maintenance treatment with prednisone (0,5 mg/kg/every other day) for 9 months. We observed with this protocol complete remission of nephritis with preservation of renal function.

Remisión completa de síndrome nefrótico con pulsos de metil-prednisona en un adulto con púrpura de Schönlein-Henoch / Complete remission of nephrotic syndrome with methyl-prednisolone pulse therapy in adult with Henoch-schönlein purpura

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[Incidence and risk factors for non-traumatic lower extremity amputation in hemodialysis patients]. / Incidencia y factores de riesgo de amputación no traumática de miembros inferiores en los pacientes en hemodiálisis.

BACKGROUND AND AIMS: The purpose of this study was to assess the incidence and risk factors for non-traumatic lower extremity amputation (LEA) in patients on haemodialysis (HD). METHODS: We investigated our HD population attending our clinic between Jan 1988 and Dec 2002, who had had LEA. Uni- and multivariate analyses were used to determine association of LEA with demographic characteristics such as diabetes, hypertension, smoking, myocardial infarction, stroke, dyslipidaemia, haematocrit, urea, creatinine, calcium, phosphorous, parathyroid hormone (PTH) and albumin levels. RESULTS: Of 516 patients, 20 (3.9%) underwent 32 amputations; 21 major and 11 minor. The incidence was 1. I amputees/100 p-years. There were 11 (10.8%) diabetics and 9 (2.2%) non-diabetics; incidence of 4.2 and 0.6 amputees/100 p-years, respectively. Non-diabetic amputees were older than non-amputees: 68.9 vs 58.2 years (p = 0.013) and had been on HD longer: 71.4 +/- 44 vs 42 +/- 37 months (p = 0.019). There were 60% deaths within the first year of amputation and the causes were 60% cardiovascular. Univariate analysis indicated significant association of LEA with ageing, diabetes, smoking, myocardial infarction, stroke, high cholesterol, and low PTH levels. Multivariate Cox regression identified independent associations of amputation with diabetes, previous myocardial infarction and stroke and/or transient ischaemic attack. CONCLUSIONS: The incidence of LEA in HD patients is very high and is associated with diabetes and previous cardiovascular events. Advanced age and longer time on HD are factors related to LEA in non-diabetics. With increasing numbers of diabetics and older people on HD, new strategies are needed for peripheral arterial disease management so as to avoid its progression to critical ischaemia.

Resolución rápida de fracaso renal agudo tras uso de rasburicasa en síndrome de lisis tumoral / No disponible

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[Fistulae or catheter for elderly who start hemodialysis without permanent vascular access?]. / Acceso vascular permanente en pacientes de edad avanzada que inician hemodiálisis: fístula o catéter?

UNLABELLED: Autologous access is the best vascular access for dialysis also in older patients and it should be mature when patient needs hemodialysis. It is not always possible. Surgeon availability and demographic characteristics of patients (age, diabetes, vascular disease...) are factors that determine primary vascular access. AIM: To analyse outcome and vascular access complications in elderly who start hemodialysis without vascular access. PATIENTS AND METHODS: All patients older than 75 years who initiated hemodialysis without vascular access between January 2000 and June 2002 were included, They were divided en two groups depending on primary vascular access. GI: arterio-venous fistulae. GIIl: Tunnelled cuffed catheter. Epidemiological and analytical data, vascular access complications related, as well as patient and first permanent vascular access survival from their inclusion in dialysis up to December 2002 were analysed and compared in both groups. RESULTS: 32 patients were studied. GI: n = 17 (4 men) and GIIl: n =1 5 (8 men), age: 79.9 +/- 3.8 and 81.7 +/- 4 years respectively (ns). There were no differences in sex and comorbidity (diabetes, ischemic heart disease, peripheral vascular disease and hypertension). It took GI 3 months to get a permanent vascular access suitable for using, while it took GIIl 1.3 months (p < 0.005) The number of temporary untunnelled catheters was higher in GI (3.35 vs 1.87 p < 0.05). Vascular access complications: 70.6% of infections occur in GI (incidence (I) = 48 infections/100 patients-year) while only 29.4% were detected in GII (I = 25 infections/100 patients-year). 70% of central venous thrombosis happen in GI (I: 25 CVT/100 patients-year) vs 30% in GIIl (I = 14.4/100 patients-year) (ns). No significant differences neither in bleeding (66.7% vs 33.3%) nor ischemia (75% vs 25%) were found. Dialysis dose (Kt/V) as well as anaemia degree were similar in both groups. Permanent vascular access survival after 2 years was 45.8% in GI and 24% in GII (ns). Patient survival was similar in GI and GII (72% vs 51% ns). CONCLUSIONS: Elderly who start hemodialysis without vascular access took longer to get a suitable permanent vascular access when arterio-venous fistulae is placed than with a tunnelled cuffed hemodialysis catheter. As a consequence, vascular access complications are larger, infection ones are the most common. In these patients a tunnelled catheter should be inserted at the time a peripheral arterio-venous access is created, in order to avoid temporary untunnelled catheters.

Acceso vascular permanente en pacientes de edad avanzada que inician hemodiálisis: ¿Fístula o catéter? / Permanent vascular access in the elderly patient who starts on hemodialysis: fistulae or catheter?

Introducción: La fístula arteriovenosa (FAV) autóloga es el acceso vascular permanente (AVP) de elección en los pacientes en hemodiálisis y debería realizarse en prediálisis. Esta situación ideal no siempre es posible. La disponibilidad del cirujano vascular y las características del paciente (edad, comorbilidad...) son factores que, entre otros, determinan el acceso vascular de inicio. Objetivo: Estudiar la evolución y complicaciones derivadas del acceso vascular en pacientes de edad avanzada, que comienzan hemodiálisis sin acceso vascular funcionante. Pacientes y métodos: Incluimos los pacientes mayores de 75 años que iniciaron hemodiálisis desde enero del 2000 hasta junio del 2002 sin acceso vascular permanente funcionante. Los clasificamos en dos grupos según el primer AVP realizado (Grupo I: FAV, Grupo II: Catéter Permanente). Analizamos y comparamos en ambos grupos datos epidemiológicos, analíticos, complicaciones derivadas del acceso vascular y supervivencia de pacientes y del primer AVP funcionante desde su inclusión en diálisis hasta diciembre de 2002. Resultados: Estudiamos 32 pacientes. GI: n = 17 (4 hombres) y GII: n = 15 (8 hombres), edad 79,9 ± 3,8 y 81,7 ± 4 años respectivamente (ns). No existían diferencias en sexo, nefropatía de base y comorbilidad (diabetes, cardiopatía isquémica, arteriopatía periférica e HTA). El GI tardó 3 meses en conseguir un AVP funcionante y el GII 1,3 meses (p < 0,05). El número de catéteres transitorios fue mayor en GI (3,35 vs 1,87 p < 0,05). Complicaciones derivadas del acceso vascular: El 70,6% de las infecciones ocurren en GI (incidencia (I): 48 infecciones/100 pacientes-año) frente al 29,4% en GII (I = 24 infecciones/100 pacientes-año) p < 0,05. El 70% de las trombosis venosas profundas se dan en GI (I: 25 TVP/100 pacientes-año) frente 30% en GII (I = 14,4/100 pacientes-año) (ns). No se encontraron diferencias en hemorragias (66,7% vs 33,3%) ni isquemia (75% vs 25%). La eficacia de diálisis (Kt/V) y el grado de anemia fue similar en ambos grupos. La supervivencia del AVP a los 2 años en GI fue 45,8% y en GII 24 % (ns). La supervivencia de los pacientes fue similar en GI y GII (72% vs 51% ns) Conclusiones: Los pacientes de edad avanzada que inician hemodiálisis sin acceso vascular tardan más tiempo en conseguir un AVP funcionante cuando se opta por una FAV frente a un catéter permanente. Como consecuencia, las complicaciones derivadas del acceso vascular son mayores, siendo más frecuentes las infecciosas. Una opción para estos pacientes sería la colocación de un catéter permanente como primer acceso vascular y la realización simultánea de una FAV, manteniendo el catéter hasta el desarrollo de la misma

Autologous access is the best vascular access for dialysis also in older patients and it should be mature when patient needs hemodialysis. It is not always possible. Surgeon availability and demographic characteristics of patients (age, diabetes, vascular disease...) are factors that determine primary vascular access. Aim: To analyse outcome and vascular access complications in elderly who start hemodialysis without vascular access. Patients and methods: All patients older than 75 years who initiated hemodialysis without vascular access between january 2000 and june 2002 were included, They were divided en two groups depending on primary vascular access. GI: arterio-venous fistulae. GII: Tunnelled cuffed catheter. Epidemiological and analytical data, vascular access complications related, as well as patient and first permanent vascular access survival from their inclusion in dialysis up to december 2002 were analysed and compared in both groups. Results: 32 patients were studied. GI: n = 17 (4 men) and GII: n =1 5 (8 men), age: 79.9 ± 3.8 and 81.7 ± 4 years respectively (ns). There were no differences in sex and comorbidity (diabetes, ischemic heart disease, peripheral vascular disease and hypertension). It took GI 3 months to get a permanent vascular access suitable for using, while it took GII 1.3 months (p < 0.005) The number of temporary untunnelled catheters was higher in GI (3.35 vs 1.87 p < 0.05). Vascular access complications: 70.6% of infections occur in GI (incidence (I) = 48 infections/100 patients-year) while only 29.4% were detected in GII (I = 25 infections/100 patients-year). 70% of central venous thrombosis happen in GI (I: 25 CVT/100 patients-year) vs 30% in GII (I = 14.4/100 patients-year) (ns). No significant differences neither in bleeding (66.7% vs 33.3%) nor ischemia (75% vs 25%) were found. Dialysis dose (Kt/V) as well as anaemia degree were similar in both groups. Permanent vascular access survival after 2 years was 45.8% in GI and 24% in GII (ns). Patient survival was similar in GI and GII (72% vs 51% ns). Conclusions: Elderly who start hemodialysis without vascular access took longer to get a suitable permanent vascular access when arterio-venous fistulae is placed than with a tunnelled cuffed hemodialysis catheter. As a consequence, vascular access complications are larger, infection ones are the most common. In these patients a tunnelled catheter should be inserted at the time a peripheral arterio- venous access is created, in order to avoid temporary untunnelled catheters

[Acute renal failure secondary to hepatic veno-occlusive disease in a bone marrow transplant patient]. / Insuficiencia renal aguda secundaria a enfermedad veno-oclusiva hepática en un paciente con trasplante de médula ósea.

Acute renal failure following bone marrow transplantation is a frequent complication with an incidence ranging 15-30% and with high rates of morbidity and mortality. Numerous potential etiologies can be implicated as chemotherapy regimen, use of nephrotoxic antibiotics, sepsis-induced damage, cyclosporine toxicity and other especific pathologies as graft-v-host disease or veno-occlusive disease of the liver. We report the case of a 41-year-old man who underwent autologous peripheral blood stem cell transplantation and developed and acute renal failure secondary to a fatal veno-occlusive disease of the liver. Incidence, potential predisposing factors, outcome and possibilities of treatment are reviewed.

Insuficiencia renal aguda secundaria a enfermedad veno-oclusiva hepática en un paciente con trasplante de médula ósea / Acute renal failure secondary to hepatic veno-occlusive disease in a bone marrow transplant patient

La incidencia de insuficiencia renal aguda es frecuente en el trasplante de médula ósea con frecuencias que alcanzan 25-30% en algunos trabajos. Entre las causas de insuficiencia renal aguda está la enfermedad veno-oclusiva hepática, entidad con alta mortalidad y con tratamientos en discusión. Presentamos un caso de enfermedad veno-oclusiva hepática con insuficiencia renal aguda y con evolución desfavorable. Se revisa esta patología centrándose en los criterios diagnósticos, las formas de presentación, las medidas preventivas y tratamientos ensayados

Acute renal failure following bone marrow transplantation is a frequent complication with an incidence ranging 15-30% and with high rates of morbidity and mortality. Numerous potential etiologies can be implicated as chemotherapy regimen, use of nephrotoxic antibiotics, sepsis-induced dammage, cyclosporine toxicity and other especific pathologies as graft-v-host disease or veno-occlusive disease of the liver. We report the case of a 41-year-old man who underwent autologous peripheral blood stem cell transplantation and developed and acute renal failure secondary to a fatal veno-occlusive disease of the liver. Incidence, potential predisposing factors, outcome and posibilities of treatment are reviewed

[Health-related quality of life in elderly patients in haemodialysis]. / Calidad de vida relacionada con la salud en pacientes ancianos en hemodiálisis.

INTRODUCTION: In view of the increasing interest in measuring health-related quality of life (HRQOL) and that is widely accepted Quality of life (QL) is a valid marker of results of treatment in chronic dialysis, we marked the aim to determine QL of the patients > or = 75 years in chronic haemodialysis and to determine the influence of different factors (comorbidity, analytical, cognitive deterioration, depression and self-sufficiency) over the results. METHODS: We used the Kidney Disease Quality of Life (KDQOL-SF), questionnaire of health that has been become an useful instrument for measuring CV into this population. Demographic and analytical data, comorbidity (Charlson Index), depression (Yesavage), self-sufficiency (Karnofsky) and impaired cognitive function (Cognitive Mini-Exam) were collected. We evaluated the influence of these factors on the different dimensions of the KDQOI-SF and compared our scores with general Spanish population scores standardised according to age and sex. RESULTS: We included 51 patients (24 men) with a mean age 79.5 +/- 3.7 years and 39 +/- 56 months in dialysis. Women had lower scores than men in all scales of KDQOL-SF. We found that months in dialysis, depression scale, Karnofsky scale and cognitive deterioration test were also influencing about these scores. Multivariate analysis showed that CV is especially associated with sex, depression, cognitive deterioration and self-sufficiency. After we calculated standardised scores according to age and gender, out population showed a level of CV lower than general population, especially in female gender. CONCLUSIONS: In our population the women had worse CV than men. The CV of the elders in HD is lower than general population of equal sex and age and it was not modified with factors related to the end-stage renal disease and its treatment. Suffering from cognitive deterioration or depression had an important impact on the well-being of our patients, which would justify a wider diagnostic and therapeutic boarding in these patients.

[Platelet antiaggregation and hemorrhagic risk in hemodialysis]. / Antiagregación plaquetaria y riesgo hemorrágico en hemodiálisis.

UNLABELLED: Although the efficacy of antiplatelet therapy in the prevention of cardiovascular disease in chronic renal failure is not clearly defined, the improvement in cardiovascular disease outcomes in the general population has resulted in its use in dialysis patients. The hemorrhagic risk of hemodialysis patients treated with anti-platelet agents has not been clarified. Our aim was to evaluate the risk of bleeding in hemodialysis patients treated with antiplatelet agents. We assessed haemorrhagic complications (HC) in 190 haemodialysis patients from May 1998 to August 2000. HC was defined an event that required hospitalization and/or blood product transfusion. We evaluated the bleeding events in the haemodialysis patients treated with antiplatelet agents and compare them to those not receiving this therapy to establish the relative risk of bleeding. Uni- and multivariate analyses were conducted to establish the relationships between the haemorrhagic event and the following variables: age, gender, time on dialysis, dialysis membrane (synthetic or cellulosic), systemic anticoagulation during haemodialysis, anaemia (haematocrit), PTH, urea, dialysis efficacy (Kt/V), hypertension, diabetes, use of erythropoietin and antisecretory gastric agents. RESULTS: 81 (42.6%) were treated with antiplatelet agents. Of the 190 patients, 28 (14.7%) had 36 haemorrhagic events (10.3 episodes/100 patient-years); 31 digestive-tract haemorrhages, 4 intracranial and 1 pulmonary. Twenty (24.7%) of patients treated with antiplatelet agents had 16.2 episodes/100 patient-years and 8 (7.3%) without this therapy had 6 episodes/100 patient-years (p < 0.01). In the multivariate analysis the antiplatelet therapy remained associated with higher probability of having a haemorrhagic complication (OR 3.8; CI 95%: 1.52-9.76, p = 0.004). Older age (OR 1.03; CI 95%: 1-1.06, p = 0.043), anaemia (OR 0.91; CI 95%; 0.84-0.9, p = 0.027) and hypertension (OR 2.99; CI 95%: 1.05-8.48, p = 0.039) remained associated with the risk of bleeding. 88.2% of patients that had a digestive-tract haemorrhage with antiplatelet therapy were receiving an antisecretory agent (histamine H2-receptor antagonist or a proton-pump inhibitor). CONCLUSIONS: 1) dialysis patients with antiplatelet therapy had a higher haemorrhagic risk. The relative risk of bleeding was more than three times that of the dialysis population without antiplatelet therapy, and 2) older age and hypertension were associated with the haemorrhagic risk. Optimal correction of anaemia was associated with less probability of bleeding.

Antiagregación plaquetaria y riesgo hemorrágico en hemodiálisis / Antiplatelet therapy and risk of bleeding in hemodialysis patients

La alta morbi-mortalidad cardiovascular de los pacientes en hemodiálisis condiciona una gran utilización del tratamiento antiagregante plaquetario, en ocasiones de forma empírica y con fines para los que su eficacia no ha sido suficientemente documentada. No está definido el riesgo hemorrágico que esta práctica conlleva. Nuestro objetivo ha sido valorar el riesgo hemorrágico que presentan los pacientes en hemodiálisis que son sometidos a tratamiento con antiagregantes plaquetarios. Analizamos las complicaciones hemorrágicas sufridas por 190 pacientes en hemodiálisis desde mayo de 1998 a agosto 2000. Consideramos complicación hemorrágica la que motivó hospitalización y/o transfusión. Comparamos el riesgo hemorrágico de los pacientes en tratamiento con antiagregantes con el de los no tratados y realizamos análisis uni y multivariante de factores demográficos (sexo, edad, tiempo de diálisis), relacionados con la diátesis hemorrágica urémica (anemia, hiperparatiroidismo, toxinas urémicas), con la técnica (dializador, anticoagulación del circuito), presencia de diabetes e hipertensión arterial y uso de eritropoyetina e inhibidores de la secreción ácida gástrica. Resultados: Ochenta y uno (42,6 por ciento) seguían tratamiento antiagregante. De los 190 pacientes, 28 (14,7 por ciento) presentaron 36 complicaciones hemorrágicas (10,3 episodios/100 p-año). Treinta y uno fueron digestivas, 4 intracraneales y 1 pulmonar.24,7 por ciento de los pacientes antiagregados presentaron 16,2 episodios/100 p-año y 7,3 por ciento de los que no lo estaban presentaron 6 episodios/100 p-año (p < 0,01). En el análisis multivariante la antiagregación se comportó como el mayor predictor de probabilidad de sangrado (OR 3,8; IC 95 por ciento: 1,52-9,76, p = 0,004). Mayor edad (OR 1,03; IC 95 por ciento: 1-1,06, p = 0,043), anemia (OR 0,91; IC 95 por ciento: 0,84-0,99, p = 0,027) e hipertensión arterial (OR 2,99; IC 95 por ciento: 1,05-8,48, p = 0,039) se asociaron, así mismo, de forma independiente con el riesgo hemorrágico. El 88,2 por ciento de los pacientes antiagregados que sufrieron hemorragias digestivas seguían tratamiento con inhibidores de la secreción ácida gástrica. Conclusiones: 1) el uso de los antiagregantes plaquetarios en la población en hemodálisis ha incrementado más de tres veces la aparición de complicación hemorrágica; 2) la eficacia reconocida de la antiagregación plaquetaria como terapia antitrombótica debe confrontarse al riesgo hemorrágico que conlleva, y 3) cuando se estime adecuada su indicación, debe optimizarse la corrección de la anemia y considerar mayor edad e hipertensión arterial como factores de riesgo hemorrágico añadidos (AU)

[Rhabdomyolysis and acute renal failure secondary to statins]. / Rabdomiolisis y fracaso renal agudo secundario a estatinas.

Statins are competitive inhibitors of hydroxy-methyl-glutaryl coenzyme A (HMG-CoA) reductase and are the most commonly used drugs to treat hyperlipidaemia. Muscle toxicity is an adverse effect reported with a low incidence and rarely associated with acute renal failure due to rhabdomyolysis. We describe two patients with chronic renal failure treated with pravastatin and simvastatin who suffered rhabdomyolysis and acute renal failure. One patient started pravastatin several days after cessation of bezafibrate and developed acute renal failure without needing dialysis. The other was treated with simvastatin three years ago and suffered rhabdomyolysis when renal function was impaired after indomethacin was prescribed for backache. He needed hemodialysis because of acute cardiac failure and died from a respiratory infection while on mechanical ventilation. Myopathy was reversible in both patients. We recommend starting statins with the lower doses in chronic renal failure and monitoring muscle enzymes when renal function changes or when new drugs with potential interactions are prescribed.

[Ileocecal tuberculosis during hemodialysis simulating carcinoma of the colon]. / Tuberculosis ileocecal en hemodiálisis simulando un carcinoma de colon.

Extrapulmonary tuberculosis is more frequent in hemodialysis patients than in the general population but intestinal localization is an unusual presentation of this infectious disease. We report a 60 year old patient on regular hemodialysis with intestinal tuberculosis masquerading as colon cancer. The patient presented with rectal bleeding, abdominal pain and fever and the radiological findings were compatible with ileocecal carcinoma. After surgery histological examination showed non-caseating granulomas but mycobacterial culture was not available. We performed a colonoscopy and obtained a biopsy of colonic mucosa for culture and other analyses. We identified acid-fast bacilli with Ziehl-Neelsen staining of formaldehyde preserved, paraffin-embedded tissue from the hemicolectomy and the colonic mucosal biopsy. Treatment with isoniazid, rifampicin and pyrazinamide for nine months was successful and well tolerated. Intestinal tuberculosis is a rare entity that we must keep in mind in a patient with abdominal pain, unexplained fever, digestive bleeding and particularly with a positive tuberculin reaction. When culture is not possible we can obtain intestinal samples by colonoscopy and use appropriate staining of paraffin-embedded tissues.

Efecto beneficioso de las membranas de AN69 sobre la anemia de los pacientes en hemodiálisis / Effects of biocompatible membranes on uremic anemia in hemodialysis patients

La utilización de membranas de AN69 generalmente, aumenta el aclaramiento de toxinas urémicas de mayor peso molecular e induce una menor activación de mediadores inflamatorios que las membranas celulósicas, ambos procesos podrían tener un efecto beneficioso sobre la eritropoyesis.Objetivo: Valorar la influencia de las membranas de AN69 sobre la anemia en pacientes con Insuficiencia Renal Crónica en programa de hemodiálisis (HD).Material y métodos: Estudiamos 25 pacientes en HD, dializados con membrana de cuprofán durante un mínimo de 6 meses, en situación estable, en los que se descartó otras causas de anemia (ferritina > 200 ng/ml. IST > 20 por ciento). Se dividieron en 2 grupos homogéneos. Los pacientes del grupo I (GI, n = 14) pasaron a dializarse con membrana de AN69 y los del grupo II (GII, n = 11) permanecieron con membrana cuprofán. El seguimiento fue de 5 meses. Se analizaron hematocrito ( por ciento), ferritina (ng/ml), IST ( por ciento), KTV, PCR (g/kg/día) y dosis de EPO (UI/semana) mensual en GI y Basal 2, 4 y 5 meses en GII. El hematocrito diana fue de 33 por ciento-35 por ciento.Resultados: El hematocrito en el GI aumentó de forma significativa a partir del 2º mes de tratamiento, sin modificaciones en la dosis de EPO ni en la dosis de diálisis. La ferritina e IST disminuyeron de forma significativa como reflejo de una mayor utilización. En GII no se modificó el hematocrito durante los 5 meses que duró el estudio.Conclusión: La utilización de membranas de AN69 aumenta el hematocrito de forma significativa sin modificaciones en la dosis de Eritropoyetina. (AU)

Tuberculosis ileocecal en hemodiálisis simulando un carcinoma de colon / Pseudotomoral ileocecal tuberculosis mimicking a colon carcinoma in a hemodialysis patient

La tuberculosis de localización extrapulmonar es más frecuente en pacientes en hemodiálisis que en la población general. Presentamos un caso de tuberculosis intestinal ileocecal que debutó con rectorragia y posteriormente con fiebre y dolor abdominal. En la exploración radiológica se encontró una tumoración en ciego y fue intervenido con el diagnóstico de carcinoma de colon, no remitiendo por tanto muestras para cultivo. El examen anatomopatológico reveló la presencia de granulomas no caseosos de aspecto tuberculoide. La tinción de Ziehl-Neelsen permitió orientar la etiología al descubrir bacilos ácido-alcohol resistentes en muestras quirúrgicas conservadas en parafina y en muestras de mucosa obtenidas por colonoscopia. El tratamiento con isoniacida, rifampicina y pirazinamida fue bien tolerado, dejando libre de síntomas a la paciente.Si bien la localización intestinal es rara se debe plantear como diagnóstico diferencial ante un paciente con rectorragia, masa intestinal, antígenos tumorales normales y Mantoux positivo. La realización de biopsias mediante colonoscopia, con búsqueda de micobacterias mediante tinciones apropiadas permitirá un diagnóstico correcto. (AU)

Rabdomiolisis y fracaso renal agudo secundario a estatinas / Rhabdomyolysis and acute renal failure associated with pravastatin and simvastatin

Las estatinas son los fármacos más empleados en el tratamiento de las hipercolesterolemias en la actualidad. Normalmente son bien toleradas, aunque en ocasiones causan toxicidad muscular que normalmente no deteriora la función renal.Presentamos dos pacientes con insuficiencia renal crónica en tratamiento con estatinas que desarrollaron rabdomiolisis y fracaso renal agudo. Un paciente inició pravastatina tras suspender un tratamiento previo con bezafibrato, sin mediar período de lavado, sufriendo fracaso renal agudo con diuresis conservada. La función renal se recuperó sin requerir diálisis. El otro paciente estaba siendo tratado con simvastatina desde hacía años y desarrolló rabdomiolisis y fracaso renal agudo, con necesidad de diálisis por insuficiencia cardíaca aguda, falleciendo finalmente de sepsis respiratoria. La toxicidad muscular fue reversible en los dos casos. Recomendamos iniciar dosis bajas de estatinas en pacientes con insuficiencia renal crónica, monitorizar las enzimas musculares y revisar los fármacos que se prescriben a estos pacientes. (AU)

[Beneficial effect of AN69 membranes on anemia in hemodialyzed patients]. / Efecto beneficioso de las membranas de AN69 sobre la anemia de los pacientes en hemodiálisis.

UNLABELLED: Biocompatible hemodialysis membranes induce a smaller inflammatory response in hemodialysis patients, and remove a larger amount of higher molecular weight retention products, then cellulose membranes. These phenomena could improve uremic anemia in hemodialysis patients. The objective was to evaluate the effects of biocompatible AN69 membranes on anemia in hemodialysis patients. Twenty-five stable patients undergoing hemodialysis with cuprophane membrane for more than 6 months were studied prospectively. These patients were stratified in 2 groups. Group I (GI): 14 patients switched over to a more biocompatible dialyzer (from cuprophan to AN69) and Group II (GII): 11 patients continued treatment with the same cuprophan membrane. The study lasted 5 months. Baseline hematocrit (%), ferritin (ng/mL), transferrin saturation (%), KTV, PCR (g/kg/day) and dose of erythropoietin (EPO) (UI/week) were measured and were revised monthly. Target hematocrit was 33%-35%. A significant increase of hematocrit became obvious after 2 months in GI without changes in dose of EPO and intensity of dialysis, meanwhile GII remains stable. CONCLUSION: Hemodialysis using AN69 membranes increases hematocrit without modifying intensity of dialysis.