Clinical Efficacy of SARS-CoV-2 Vaccination in Hemodialysis Patients.

Introduction: The COVID-19 pandemic is a global public health problem. Patients with end-stage renal disease on hemodialysis are at a higher risk of infection and mortality than the general population. Worldwide, a vaccination campaign has been developed that has been shown to reduce severe infections and deaths in the general population. However, there are currently limited data on the clinical efficacy of vaccinations in the hemodialysis population. Methods: A national multicenter observational cohort was performed in Chile to evaluate the clinical efficacy of anti-SARS-CoV-2 vaccination in end-stage renal disease patients on chronic hemodialysis from February 2021 to August 2021. In addition, the BNT162b2 (Pfizer-BioNTech) and CoronaVac (Sinovac) vaccines were evaluated. The efficacy of vaccination in preventing SARS-CoV-2 infection, hospitalizations, and deaths associated with COVID-19 was determined. Results: A total of 12,301 patients were evaluated; 10,615 (86.3%) received a complete vaccination (2 doses), 490 (4.0%) received incomplete vaccination, and 1196 (9.7%) were not vaccinated. During follow-up, 1362 (11.0%) patients developed COVID-19, and 150 died (case fatality rate: 11.0%). The efficacy of the complete vaccination in preventing infection was 18.1% (95% confidence interval [CI]:11.8-23.8%), and prevention of death was 66.0% (95% CI:60.6-70.7%). When comparing both vaccines, BNT162b2 and CoronaVac were effective in reducing infection and deaths associated with COVID-19. Nevertheless, the BNT162b2 vaccine had higher efficacy in preventing infection (42.6% vs. 15.0%) and deaths (90.4% vs. 64.8%) compared to CoronaVac. Conclusion: The results of our study suggest that vaccination against SARS-CoV-2 in patients on chronic hemodialysis was effective in preventing infection and death associated with COVID-19.

[Survival of older patients starting hemodialysis in Chile]. / Análisis de sobrevida en pacientes de edad avanzada que inician hemodiálisis crónica en Servicio de Salud Chileno.

UNLABELLED: The proportion of older people with end stage renal disease is increasing. Their prognosis is characterized by a high mortality and poor quality of life. AIM: To analyze the survival of patients starting chronic hemodialysis (CHD) according to their age. MATERIAL AND METHODS: Patients admitted to CHD in the East Metropolitan Health Service of Santiago in a 2-year period were analyzed. Four age groups were created, separating patients older than 70 years in a special group. RESULTS: During the study period, 459 patients were admitted to CHD and were followed for an average of 27 months. The frequency of cardiovascular comorbidity, cancer, and chronic renal disease of unknown cause (attributed to nephrosclerosis) increased along with age. Mortality was higher at older ages. There was a significant association between starting CHD with a catheter, Charlson comorbidity index and increasing age with mortality. For those aged over 80 years, mortality at three months and one year was 25 and 43% respectively. CONCLUSIONS: Age, Charlson index and vascular access are predictors of mortality in older adults entering hemodialysis. This study suggests the importance of considering comorbidities, assessment by specialists and creating an arteriovenous fistula in this age group.

Análisis de sobrevida en pacientes de edad avanzada que inician hemodiálisis crónica en Servicio de Salud Chileno / Survival of older patients starting hemodialysis in Chile

The proportion of older people with end stage renal disease is increasing. Their prognosis is characterized by a high mortality and poor quality of life. Aim: To analyze the survival of patients starting chronic hemodialysis (CHD) according to their age. Material and Methods: Patients admitted to CHD in the East Metropolitan Health Service of Santiago in a 2-year period were analyzed. Four age groups were created, separating patients older than 70 years in a special group. Results: During the study period, 459 patients were admitted to CHD and were followed for an average of 27 months. The frequency of cardiovascular comorbidity, cancer, and chronic renal disease of unknown cause (attributed to nephrosclerosis) increased along with age. Mortality was higher at older ages. There was a significant association between starting CHD with a catheter, Charlson comorbidity index and increasing age with mortality. For those aged over 80 years, mortality at three months and one year was 25 and 43% respectively. Conclusions: Age, Charlson index and vascular access are predictors of mortality in older adults entering hemodialysis. This study suggests the importance of considering comorbidities, assessment by specialists and creating an arteriovenous fistula in this age group.

[Long-term outcomes with expanded criteria donors in kidney transplantation]. / Resultados a largo plazo en trasplante renal de donantes con criterios expandidos.

BACKGROUND: Kidney transplantation of expanded criteria deceased donors (DCE) has become a common clinical practice. However, DCE outcomes are inferior compared to kidney transplants from standard criteria donors (DCS). AIM: To evaluate intermediate and long-term outcomes of DCE transplanted patients. MATERIAL AND METHODS: Cadaveric kidney transplants were evaluated using a retrospective cohort of eight consecutive years. Complications and long-term function of the transplant were assessed in DCE and DCS kidney recipients. RESULTS: Of 213 patients analyzed, 34 (16%) underwent DCE transplantation. DCS recipients spent more time on the waiting list for transplantation (p = 0.04). DCE recipients showed higher frequency of surgical complications (p = 0.04), vascular complications (p = 0.02), acute transplant rejection (p = 0.05), and hospitalizations (p = 0.01). Creatinine (mg/dL) in DCE and DCS recipients was 2.3 and 1.5 respectively at year one (p < 0.01) and 2.6 and 1.6 respectively at year five (p < 0.01). Graft survival in the DCE group was significantly lower at 5 years (61 and 89% respectively, p < 0.01). CONCLUSIONS: DCE grafts are associated with lower survival, higher hospitalization rate and commonly develop surgical complications and rejections.

Resultados a largo plazo en trasplante renal de donantes con criterios expandidos / Long-term outcomes with expanded criteria donors in kidney transplantation

Background: Kidney transplantation of expanded criteria deceased donors (DCE) has become a common clinical practice. However, DCE outcomes are inferior compared to kidney transplants from standard criteria donors (DCS). Aim: To evaluate intermediate and long-term outcomes of DCE transplanted patients. Material and Methods: Cadaveric kidney transplants were evaluated using a retrospective cohort of eight consecutive years. Complications and long-term function of the transplant were assessed in DCE and DCS kidney recipients. Results: Of 213 patients analyzed, 34 (16%) underwent DCE transplantation. DCS recipients spent more time on the waiting list for transplantation (p = 0.04). DCE recipients showed higher frequency of surgical complications (p = 0.04), vascular complications (p = 0.02), acute transplant rejection (p = 0.05), and hospitalizations (p = 0.01). Creatinine (mg/dL) in DCE and DCS recipients was 2.3 and 1.5 respectively at year one (p < 0.01) and 2.6 and 1.6 respectively at year five (p < 0.01). Graft survival in the DCE group was significantly lower at 5 years (61 and 89% respectively, p < 0.01). Conclusions: DCE grafts are associated with lower survival, higher hospitalization rate and commonly develop surgical complications and rejections.

[Massive pulmonary thromboembolism treated successfully with streptokinase. Report of one case]. / Tromboembolismo pulmonar masivo con respuesta exitosa a trombolisis farmacológica. Caso clínico.

Massive pulmonary thromboembolism has a high mortality. Early thrombolysis is the treatment of choice. We report a 79-year-old man admitted in shock. A chest angio-CAT scan showed a massive pulmonary thromboembolism. A transthoracic echocardiography showed a right cardiac dysfunction. Although the patient was in hemodynamic instability, he was subjected to thrombolysis with streptokinase, assisted with noradrenaline support and invasive mechanical ventilation. Parenteral anticoagulation was started thereafter. A second echocardiography, performed 72 hours later showed an improvement in right ventricular function. The patient had a nosocomial pneumonia that was treated. Noradrenalin and mechanical ventilation were discontinued nine and 15 days after thrombolysis. A new angio-CAT scan, 23 days after the procedure, was normal. The patient was discharged in good conditions 27 days after admission.

Tromboembolismo pulmonar masivo con respuesta exitosa a trombolisisfarmacológica: Caso clínico / Massive pulmonary thromboembolism treated successfully with streptokinase: Report of one case

Massive pulmonary thromboembolism has a high mortality. Early thrombolysis is the treatment of choice. We report a 79-year-old man admitted in shock. A chest angio-CAT scan showed a massive pulmonary thromboembolism. A transthoracic echocardiography showed a right cardiac dysfunction. Although the patient was in hemodynamic instability, he was subjected to thrombolysis with streptokinase, assisted with noradrenaline support and invasive mechanical ventilation. Parenteral anticoagulation was started thereafter. A second echocardiography, performed 72 hours later showed an improvement in right ventricular function. The patient had a nosocomial pneumonia that was treated. Noradrenalin and mechanical ventilation were discontinued nine and 15 days after thrombolysis. A new angio-CAT scan, 23 days after the procedure, was normal. The patient was discharged in good conditions 27 days after admission.

[Addition of an arterio-venous shunt during veno-arterial extracorporeal life support in a patient with Hantavirus pulmonary syndrome]. / Adición de un cortocircuito arterio-venoso durante el soporte vital extracorpóreo veno-arterial de un paciente con síndrome cardiopulmonar por Hantavirus. Caso clínico.

A subgroup of patients infected with the Hantavirus develops a pulmonary syndrome (HPS) characterized by severe acute respiratory failure and myocardial depression, that has a high mortality rate. Extracorporeal life support (ECLS) could be a valuable therapeutic tool in such patients. We report a 24 years old male with HPS that was successfully managed when an arterio-venous shunt was added to a conventional veno-arterial ECLS technique. Precise criteria have been developed to predict which patients should be considered for this treatment.

[Liver transplantation in adults: a caseload from Clínica Alemana de Santiago, Chile]. / Trasplante hepático en adultos: casuística de Clínica Alemana de Santiago.

BACKGROUND: The success of orthotopic liver transplantation (OLT) has resulted in its widespread use for different liver diseases. AIM: To report our 8 years experience with adult OLT at Clinica Alemana de Santiago. PATIENTS AND METHODS: In all transplantations done at the center, we recorded patient's overall data and survival, postoperative medical and surgical complications and causes of death. RESULTS: Between November 1993 and September 2001, 51 consecutive OLT were performed in 44 patients (22 females, median age 45 years old). Thirty eight patients presented with chronic and 6 with acute or sub-acute liver failure. Cryptogenic cirrhosis and hepatitis C infection were the most common causes for OLT. Postoperative bleeding and extrahepatic biliary complications were seen in 17.6 and 21.5% of cases respectively. Acute rejection, bacterial infections, CMV infection or disease and post OLT hemodialysis were the most common medical complications (51, 31, 19.6 and 19.6% of cases respectively). The overall 1 and 5 years survival rates were 80% and 73% respectively. Considering exclusively the last 22 OLT performed since January 1999, the 1 year survival rate has improved to 91%. CONCLUSIONS: Liver transplantation in Chile provides a good long term survival with acceptable morbidity, due to a multidisciplinary approach management. The survival rates have improved over the last few years probably due to better surgical techniques, ICU care and immunosuppression. These overall results are comparable with those from other Centers in developed countries.

[Hemolytic-uremic syndrome and Streptococcus pneumoniae]. / Síndrome hemolítico-urémico y Streptococcus pneumoniae.

Hemolytic-uremic syndrome (HUS) is an uncommon complication of pneumococcal infection. Highly suggesting findings in a patient with Streptococcus pneumoniae infection are: microangyopatic hemolytic anemia, thrombocytopenia and acute renal failure. We report a 41 years old woman, admitted to the hospital due to a severe pneumonia, that required the surgical drainage of an empyema. On admission, a drop in packed red cell volume from 41 to 25%, the presence of schistocytes in the blood smear, an elevation of LDH to 1,700 IU/L, a fall in haptoglobin to 5.8 mg/dL and a thrombocytopenia of 72,000 per mm3 were detected. These alterations coincided with an oliguric acute renal failure. She was treated with hemodialysis and the hemolytic syndrome was managed with plasmapheresis. She was discharged 35 days after admission and in the follow up, after 2.5 months, her serum creatinine is 1.2 mg/dL and her packed red cell volume is 41%.