Prevalence and prognostic meaning of interstitial lung abnormalities in remote CT scans of patients with interstitial lung disease treated with antifibrotic therapy.

OBJECTIVES: To describe the prevalence and characteristics of interstitial lung abnormalities (ILA) in CT scans performed prior to the initiation of antifibrotics in a series of patients with interstitial lung disease (ILD), and to identify characteristics apparent on early CT scans that could help to predict outcomes. METHODS: We conducted a retrospective observational study. The original cohort consisted of 101 patients diagnosed with ILD and treated with antifibrotics in a tertiary hospital. Patients were included if they had a thoracic CT scan performed at least one year before initiation of therapy. They were classified radiologically in three groups: without ILA, with radiological ILA and extensive abnormalities. ILA were classified as subpleural fibrotic, subpleural non-fibrotic and non-subpleural. The initial scan and the latest CT scan performed before treatment were read for assessing progression. The relationship between CT findings of fibrosis and the radiological progression rate and mortality were analyzed. RESULTS: We included 50 patients. Only 1 (2%) had a normal CT scan, 25 (50%) had extensive alterations and 24 (48%) had radiological criteria for ILA, a median of 98.2 months before initiation of antifibrotics, of them 18 (75%) had a subpleural fibrotic pattern. Significant bronchiectasis and obvious honeycombing in the lower zones were associated with shorter survival (p = 0.04). Obvious honeycombing in the lower zones was also significantly (p < 0.05) associated with a faster progression rate. CONCLUSIONS: Fibrotic ILAs are frequent in remote scans of patients with clinically relevant ILD, long before they require antifibrotics. Findings of traction bronchiectasis and honeycombing in the earliest scans, even in asymptomatic patients, are related to mortality and progression later on.

Hunting for B + → K + τ + τ - imprints on the B + → K + µ + µ - dimuon spectrum.

We investigate the possibility of indirectly constraining the B + → K + τ + τ - decay rate using precise data on the B + → K + µ + µ - dimuon spectrum. To this end, we estimate the distortion of the spectrum induced by the B + → K + τ + τ - → K + µ + µ - re-scattering process, and propose a method to simultaneously constrain this (non-standard) contribution and the long-distance effects associated to hadronic intermediate states. The latter are constrained using the analytic properties of the amplitude combined with data and perturbative calculations. Finally, we estimate the sensitivity expected at the LHCb experiment with present and future datasets. We find that constraints on the branching fraction of O ( 10 - 3 ) , competitive with current direct bounds, can be achieved with the current dataset, while bounds of O ( 10 - 4 ) could be obtained with the LHCb upgrade-II luminosity.

Identification of stable fly attractant compounds in vinasse, a byproduct of sugarcane-ethanol distillation.

The stable fly, Stomoxys calcitrans (Diptera: Muscidae), is a worldwide pest of livestock. Recent outbreaks of stable flies in sugarcane fields in Brazil have become a serious problem for livestock producers. Larvae and pupae found inside sugarcane stems after harvesting may indicate that stable flies use these stems as potential oviposition or larval development sites. Field observations suggest that outbreaks of stable flies are associated with the vinasse and filter cake derived from biomass distillation in sugarcane ethanol production that are used as fertilizers in sugarcane fields. Adult stable flies are attracted to vinasse, which appears to present an ideal larval development site. The primary goal of the present study is to demonstrate the role of vinasse in influencing the sensory physiological and behavioural responses of stable flies, and to identify its associated volatile attractant compounds. Both laboratory and field studies showed that vinasse is extremely attractive to adult stable flies. Chemical analyses of volatiles collected revealed a wide range of carboxylic acids, alcohols, phenols and aldehydes as potential attractant compounds. These newly identified attractants could be used to develop a tool for the attractant-baited mass trapping of stable flies in order to reduce infestations.

Intra-institutional second opinion diagnosis can reduce unnecessary surgery for indeterminate thyroid FNA: A preliminary report on 34 cases.

INTRODUCTION: Indeterminate diagnoses are rendered on 15%-30% of thyroid fine-needle aspirates (FNA). Thus, a second diagnostic opinion given by an outside expert pathologist is a common practice that facilitates a more appropriate clinical management. Conversely, the role of an intra-institutional second opinion diagnosis (iSOD), which is usually informally performed in-house, has not been well established. METHODS: To assess the contribution of iSOD, a retrospective series of 34 thyroid FNA diagnosed as follicular neoplasm/suspicious follicular neoplasm (FN/SFN) with matched histological follow-up and a malignancy rate of 17.6% was selected and independently reviewed by two cytopathologists (CYT1 and 2). Cases with discrepant diagnoses were referred to a third in-house senior cytopathologist for the iSOD. The malignancy rates (MR) obtained after single independent reviews and iSOD were compared. RESULTS: MR obtained after CYT1 and CYT2 re-screening was similar (14.28% and 19.04%, respectively) and did not improve the original MR (17.64%). Conversely, after the iSOD of discrepant diagnoses, the overall malignancy rate increased up to the 27.27%, potentially sparing unnecessary surgical procedures. CONCLUSIONS: Intra-institutional second opinion practice for "indeterminate" thyroid FNA avoids unnecessary surgeries and maximises the detection of malignant cases diagnosed as FN/SFN.

Radiofrequency versus microwave ablation for treatment of the lung tumours: LUMIRA (lung microwave radiofrequency) randomized trial.

The LUMIRA trial evaluated the effectiveness of radiofrequency (RFA) and microwave ablation (MWA) in lung tumours ablation and defining more precisely their fields of application. It is a controlled prospective multi-centre random trial with 1:1 randomization. Fifty-two patients in stage IV disease (15 females and 37 males, mean age 69 y.o., range 40-87) were included. We randomized the patients in two different subgroups: MWA group and RFA group. For each group, we evaluated the technical and clinical success, the overall survival and complication rate. Inter-group difference was compared using Chi-square test or Fisher's exact test for categorical variables and one-way ANOVA test for continuous variables. For RFA group, there was a significant reduction in tumour size only between 6 and 12 months (p value = 0.0014). For MWA group, there was a significant reduction in tumour size between 6 and 12 months (p value = 0.0003) and between pre-therapy and 12 months (p value = 0.0215). There were not significant differences between the two groups in terms of survival time (p value = 0.883), while the pain level in MWA group was significantly less than in RFA group (1.79 < 3.25, p value = 0.0043). In conclusion, our trial confirms RFA and MWA are both excellent choices in terms of efficacy and safety in lung tumour treatments. However, when compared to RFA therapy, MWA produced a less intraprocedural pain and a significant reduction in tumour mass.

Entero-colpo-defecography vs supine entero-MRI: which one is the best tool in the differentiation of enterocele, elytrocele and edrocele?

Pelvic floor disorders represent a significant cause of morbidity associated with a severe reduction of quality of life. It represents a very common clinical problem that afflicts women three to seven time more often than men. The purpose of this study was to assess the diagnostic tools available to define the imaging strategy in patients with pelvic floor dynamic dysfunctions and to investigate their abilities in the diagnosis of enterocele, elytrocele and edrocele. From January 2008 to May 2011, 614 patients with symptoms related to pelvic floor dynamic dysfunctions were enrolled in our retrospective study. After anamnesis and clinical examination, entero-colpo-defecography (ECD) and supine entero-magnetic resonance (SE-MR) exams were performed in all patients. This study showed that the diagnostic efficacy of ECD is higher than that of SE-MR in the detection of enterocele and edrocele. Furthermore, elytrocele can be visualized only with ECD considering the position of patient during SE-MR examination. In addition, in patients planned for surgery, SE-MR is more useful to clarify the intra-pelvic interaction of multiple organ prolapse and to better define the pelvic anatomy and functioning.

Dermatitis atópica en pacientes pediátricos y su relación con algunos factores desencadenantes: Estudio DERMAT-4 / Atopic dermatitis in paediatric patients and its relationship with some triggering factors: the DERMAT-4 study

Introducción: La dermatitis atópica (DA) es una enfermedad multifactorial, en la que tanto los factores endógenos como los exógenos intervienen en el desarrollo, el mantenimiento y la exacerbación de la patología. Objetivo: El objetivo del estudio fue investigar los factores endógenos y exógenos relacionados con la DA, y su influencia sobre la gravedad y la frecuencia de los brotes agudos. Pacientes y métodos: Estudio epidemiológico transversal sobre la DA y sus factores asociados, en el que han participado 115 pediatras. Se incluyeron pacientes en fase de brote agudo. Se registraron diversos datos, como los factores sociodemográficos, las características de la DA, el tipo de piel, la presencia de otras atopias, nevos y factores ambientales (exposición a contaminación ambiental, humo del tabaco y radiación solar), potencialmente causantes de estrés oxidativo, la sobreinfección de las lesiones y el tipo de alimentación. Los posibles factores se relacionaron con las características de la DA mediante un análisis univariante y multivariante, utilizando como variables la gravedad del brote agudo (índice SCORAD) y el número de brotes en el último año. Resultados: Se incluyeron 528 pacientes con brote agudo, con una media de edad de 3,7 años. El SCORAD fue de 33,6 y la media de brotes en el último año de 4,7. Se observó que tanto la presencia de asma/broncoespasmo, polución, signos de sobreinfección y lesiones de rascado se asociaron tanto a un número mayor de brotes como a una mayor gravedad (p <0,05). La presencia de nevos sólo se asoció a una mayor frecuencia de brotes (p <0,05). Algunos factores, como piel seca, aparición de brotes previos, alergias alimentarias, urticaria, antecedentes familiares de atopia y exposición a factores ambientales (radiación solar y humo del tabaco), se relacionaron con brotes de mayor gravedad (p <0,05). Se observó una relación entre el uso del mismo tipo de emoliencia y la menor gravedad de los brotes (p <0,05) (AU)

Conclusiones: Los resultados obtenidos confirman que existe una relación entre los factores medioambientales, la sobreinfección de las lesiones, la presencia de otras atopias y las lesiones de rascado, y la frecuencia y la gravedad de los brotes de DA. El uso de emolientes específicos aporta beneficios al tratamiento de dicha patología (AU)

Introduction: Atopic dermatitis (AD) is a multifactorial illness in which both endogenous factors and exogenous ones intervene in the onset, progress and aggravation of the pathology. Aim: The aim of the study was to research the endogenous and exogenous factors related to AD, and their influence on the seriousness and frequency of acute attacks. Patients and methods: A transversal epidemiological study of AD and its associated factors, in which 115 paediatricians took part. Patients suffering acute attacks were included. Several items of data were recorded, including social/demographic factors, the features of the AD, skin type, the presence of other atopies, naevi and environmental factors (exposure to environmental pollution, tobacco smoke and solar radiation), potential causes of oxidative stress, the surinfection of wounds and food types. Possible factors were related to the features of the AD by means of a univariate and multivariate analysis, taking the seriousness of the acute attack (SCORAD score) and the number of attacks in the last year. Results: 528 patients with acute attacks were included, with an average age of 3.7 years. The SCORAD was 33.6 and the average number of attacks in the previous year 4.7. It was observed that the presence of asthma/bronchospasm, pollution, signs of surinfection and scratching wounds were all associated with both a large number of attacks and greater seriousness (p <0.05). The presence of naevi was only associated with higher frequency of attacks (p <0.05). Some factors, such as dry skin, the appearance of previous attacks, food allergies, urticaria, a family history of atopies and exposure to environmental factors (the sun's rays and tobacco smoke), were related to more serious attacks (p <0.05). A relationship was observed between the use of the same type of emollient and less serious attacks (p <0.05) (AU)

Conclusions: The results obtained confirm that there is a relationship between environmental factors, surinfection of wounds, the presence of other atopies and scratching lesions and the frequency and seriousness of AD attacks. The use of specific emollients brings benefits in the treatment of this pathology (AU)

APOA5 gene expression in the human intestinal tissue and its response to in vitro exposure to fatty acid and fibrate.

BACKGROUND AND AIMS: APOA5, a key gene regulating triglyceride (TG) levels, is reported to be expressed exclusively in the liver where it may regulate TG-rich particle synthesis and secretion. Since the same lipoprotein processing occurs in the intestine, we have postulated that this organ would also express APOA5. METHODS AND RESULTS: We have detected the APOA5 gene expression in C57BL/6J mouse and in human small intestine samples. In humans, it is expressed mainly in the duodenum and colon, with messenger RNA (mRNA) levels four orders of magnitude lower than in the liver, and the protein product being one-sixth of the liver equivalent. Subsequently, we carried out in vitro experiments in TC-7/CaCo(2) human intestinal cells to analyse the expression of APOA5, APOC3, APOB and MTP genes after the incubation with long- and short-chain fatty acids, and a peroxisome proliferator-activated receptor alpha (PPARα) agonist (Wy 14643, a fibrate therapeutic agent). In the TC-7 cell line, APOA5 expression was significantly upregulated by saturated fatty acids. The short-chain fatty acid butyrate increased APOA5 expression almost fourfold while APOB was downregulated by increasing butyrate concentrations. When TC-7 cells were incubated with PPARα agonist, the APOA5 expression was increased by 60%, while the expression of APOB, MTP and APOC3 was decreased by 50%, 30% and 45%, respectively. CONCLUSION: Our results demonstrate that APOA5 is expressed in the intestine, albeit at a much lower concentration than in the liver. While it remains to be determined whether intestinal apo A-V is functional, our in vitro experiments show that its expression is modifiable by dietary and pharmacological stimuli.

Experimental constraints from flavour changing processes and physics beyond the Standard Model.

Flavour physics has a long tradition of paving the way for direct discoveries of new particles and interactions. Results over the last decade have placed stringent bounds on the parameter space of physics beyond the Standard Model. Early results from the LHC, and its dedicated flavour factory LHCb, have further tightened these constraints and reiterate the ongoing relevance of flavour studies. The experimental status of flavour observables in the charm and beauty sectors is reviewed in measurements of CP violation, neutral meson mixing, and measurements of rare decays.

Factors associated with blood pressure control in diabetic patients treated in nephrology units. PRESDIAB Study.

BACKGROUND AND OBJECTIVE: Most hypertensive patients do not reach target blood pressure (BP), especially if they are diabetic. The objective of the study is to assess the percentage of tight BP control, defined as BP<130/80mm Hg and identify factors associated with it in diabetic type 2 (DM2) patients treated in nephrology units. PATIENTS AND METHODS: Observational and cross-sectional study; we included 526 patients with DM2 and arterial hypertension (AHT). We collected data on: demographics, anthropometrics, harmful habits, history of cardiovascular disease (CVD), blood pressure, kidney function, glycaemic control, lipid profile, and drug treatment, among others. RESULTS: The mean age (SD) was 66 (10.6) years, 61% were male, 12.8% were smokers, 39.4% had a history of CVD, 72% had hypercholesterolemia, and 44% were obese. Seventeen point five percent of patients had tight BP control (<130/80mm Hg) (95% confidence interval [CI]:14.3-21.0), while 36.9% had BP below 140/85mm Hg. Seventy-one percent of patients were prescribed two or more anti-hypertensive treatments. Several factors are associated with tight BP control not being achieved, and the logistic regression analysis revealed that LDL cholesterol levels were significantly associated (odds ratio [OR] 0.55; 95% CI:0.41-0.75 for one standard deviation increase). CONCLUSIONS: Of the DM2 patients that attended the nephrology units, less than 20% achieved a tight BP control. Cholesterol levels seem to be the main factor associated with unsatisfactory BP control within our study population.

Factores asociados al control de la presión arterial en pacientes con diabetes tratados en unidades de nefrología. Estudio PRESDIAB / Factors associated with blood pressure control in diabetic patients treated in nephrology units. PRESDIAB Study

Fundamento y objetivo: La mayoría de pacientes hipertensos no alcanza los objetivos de control de la presión arterial (PA), especialmente si son diabéticos. El objetivo del estudio fue evaluar el porcentaje de control estricto de la PA definida como PA <130/80 mmHg e identificar factores asociados al mismo en pacientes diabéticos tipo 2 (DM2) tratados en unidades de nefrología. Pacientes y método: Estudio observacional y transversal, en el que se incluyeron 526 pacientes con DM2 e hipertensión arterial (HTA). Se recogieron datos demográficos, antropométricos, hábitos tóxicos, antecedentes de enfermedad cardiovascular (ECV), medidas de PA, función renal, control glicémico, perfil lipídico y tratamiento farmacológico, entre otros. Resultados: La edad media (DE) fue de 66 (10,6) años, con un 61% de hombres, un 12,8% de fumadores, un 39,4% con antecedentes de ECV, un 72% con hipercolesterolemia, y 44% con obesidad. El porcentaje de control estricto de la PA (<130/80 mmHg) fue del 17,5% (intervalo de confianza [IC] 95%: 14,3-21,0), mientras que un 36,9% tenían la PA por debajo de 140/85 mmHg. Un 71,1% de pacientes recibía dos o más tratamientos antihipertensivos. Diversos factores se asociaron con falta de control estricto de la PA, de los cuales, tras análisis de regresión logística, destacaban los valores de colesterol LDL (odds ratio [OR] 0,55; IC 95%: 0,41-0,75 para un aumento de 1 DE). Conclusiones: En pacientes con DM2 atendidos en unidades de nefrología, el porcentaje del control estricto de la PA es inferior al 20% en la clínica. Los niveles de colesterol parece el principal factor asociado con el control insuficiente de PA en la población estudiada (AU)

Background and objective: Most hypertensive patients do not reach target blood pressure (BP), especially if they are diabetic. The objective of the study is to assess the percentage of tight BP control, defined as BP<130/80mm Hg and identify factors associated with it in diabetic type 2 (DM2) patients treated in nephrology units. Patients and methods: Observational and cross-sectional study; we included 526 patients with DM2 and arterial hypertension (AHT). We collected data on: demographics, anthropometrics, harmful habits, history of cardiovascular disease (CVD), blood pressure, kidney function, glycaemic control, lipid profile, and drug treatment, among others. Results: The mean age (SD) was 66 (10.6) years, 61% were male, 12.8% were smokers, 39.4% had a history of CVD, 72% had hypercholesterolemia, and 44% were obese. Seventeen point five percent of patients had tight BP control (<130/80mm Hg) (95% confidence interval [CI]:14.3-21.0), while 36.9% had BP below 140/85mm Hg. Seventy-one percent of patients were prescribed two or more anti-hypertensive treatments. Several factors are associated with tight BP control not being achieved, and the logistic regression analysis revealed that LDL cholesterol levels were significantly associated (odds ratio [OR] 0.55; 95% CI:0.41-0.75 for one standard deviation increase). Conclusions: Of the DM2 patients that attended the nephrology units, less than 20% achieved a tight BP control. Cholesterol levels seem to be the main factor associated with unsatisfactory BP control within our study population (AU)

Efectividad del tratamiento de las úlceras venosas con vendaje compresivo multicapa asociado a protección de la piel perilesional con Cavilon® (película barrera no irritante) / Effectiveness of the association of multilayer compression therapy and periwound protection with Cavilon® (no sting barrier film) in the treatment of venous leg ulcers

Introducción: el adecuado tratamiento de las úlceras de extremidad inferior de etiología venosa es fundamental para mejorar la calidad de vida de los pacientes. El uso de terapia compresiva con vendaje multicapa es el tratamiento que mejores resultados presenta. En la práctica, se utiliza en combinación con unos adecuados cuidados locales de la herida y de la piel perilesional. El objetivo del estudio fue evaluar la efectividad clínica de un vendaje multicapa de compresión y el impacto de la utilización de la película barrera Cavilon® en úlceras vasculares de origen venoso.Metodología: ensayo clínico controlado, aleatorizado, abierto, multicéntrico y pragmático en España. Todos los pacientes incluidos fueron tratados con terapia de compresión con el mismo vendaje multicapa y asignados aleatoriamente al grupo de intervención, tratados con la PBNI Cavilon®,o al grupo control. Se realizaron un máximo de 13 visitas de estudio separadas entre ellas por una semana. El estudio fue evaluado y aprobado por los comités éticos de investigación clínica (CEIC) de los siete centrosparticipantes. Resultados: participaron 98 pacientes en el estudio (49 en elgrupo intervención y 49 como control). Tras cuatro semanas, el grupo intervención presentó una reducción media (DE) del tamaño de úlcerasuperior al grupo control (56,7% (30,3) vs. 45,5% (47,4); p = 0,087).A las 12 semanas de tratamiento, las diferencias observadas fueron estadísticamente significativas (83,4% (31,1) vs. 71,6% (44,1); p = 0,046) (..) (AU)

Aim: appropriate treatment of venous leg ulcers is essential to improve the quality of life of patients. Compression therapy using multilayer bandages show to the best clinical results. In practice, it is used in combination with a suitable local care of the wound and periwound skin. The aim of this study was toevaluate the clinical effectiveness of a multi-layer compression bandageand the impact on it of the use of barrier film Cavilon® in venous leg ulcers. Methods: controlled clinical trial, randomized, open, multicentre and pragmaticin Spain. All included patients were treated with compression therapy with the same multilayer bandages and randomized to the intervention group, treated with NSBF Cavilon®, or to the control group. Up to 13 weekly visits were performed. The study was reviewed and approved by the institutional research board (IRB) of the 7 participating centres. Results: ninety eight patients were included in the study (49 in the intervention group and 49 in control group).At 4 weeks of treatment, the intervention group showed a mean ulcer size reduction (SD) greater than the control group (56.7% (30.3) vs. 45.5% (47.4),(p=0.087). At 12 weeks of treatment, differences were statistically significant(83.4% (31.1) vs. 71.6% (44.1), p=0.046). In the intervention group, 69.4%of patients reduced the ulcer area * 50% in the first 4 weeks of treatment,instead of 46.9% of patients in the control group (p <0.01). Conclusions: the clinical effectiveness of a multi-layer compression bandage (Coban® 2) in patients with venous leg ulcers, assessed in terms of percentage reduction of area, is increased by concomitant use of a protective treatment of periwound skin withNSBF (Cavilon®) (AU)

Trasplante renal ABO incompatible: de un sueño a una realidad. Experiencia del Hospital Clínic de Barcelona / ABO incompatible living donor kidney transplantation: a dream come true. Experience of Hospital Clínic of Barcelona

Introducción: En los últimos años se ha mantenido estable el número de pacientes en lista de espera para un trasplante renal. El trasplante renal de donante vivo representa actualmente una vía para aumentar el pool de donantes, pero hay un grupo de pacientes que presentan incompatibilidad de grupo sanguíneo ABO, lo que contraindicaba hasta ahora que pudiera llevarse a cabo el trasplante. Nuestro objetivo consiste en describir nuestra experiencia con el programa de trasplante renal de donante vivo con incompatibilidad de grupo ABO. Material y métodos: Se trata de un estudio de retrospectivo-descriptivo de los primeros 11 pacientes sometidos a trasplante renal de donante vivo ABO incompatible en el Hospital Clínic de Barcelona desde octubre de 2006 a enero de 2009. Se utilizó un protocolo de acondicionamiento basado en inmunoadsorción específica (con número sesiones necesarias hasta conseguir títulos de isoaglutininas aceptables pretrasplante), inmunoglobulina policlonal inespecífica y anticuerpo monoclonal anti-CD20, seguido del tratamiento inmunosupresor adaptado a cada receptor. Se determinaron títulos de isoaglutininas antes del tratamiento de acondicionamiento, pretrasplante y postrasplante durante las primeras 2 semanas. La valoración inmunológica, médica y quirúrgica fue la habitual en el programa de trasplante renal de donante vivo. Resultados: La edad media de los donantes y receptores fue de 47,8 ± 12,4 y 44,4 ± 14,1 años, respectivamente. Un 90,1% de los donantes fue mujer y un 72,7% de los receptores, hombres. El tiempo de seguimiento medio fue de 10,2 ± 10,2 meses. Hermanos y esposos fueron las relaciones más frecuentes (n = 4, 36,4%, respectivamente), al igual que la causa de nefropatía fueron la glomerulopatía, poliquistosis y el síndrome de Alport (n = 2, 18,2% para cada enfermedad renal primaria). Todos los pacientes adquirieron un título de isoaglutininas correctos pretrasplante (<8) y requirieron 5,54 ± 2,6 sesiones de inmunoadsorción pretrasplante y 2,82 sesiones postrasplante. Un paciente no requirió ninguna sesión de inmunoadsorción (única con incompatibilidad anti-B) y otro requirió recambios plasmáticos, en vez de inmunoadsorciones, por tratarse de un potencial receptor hipersensibilizado con crossmatch por citometría de flujo positivo. Los títulos de isoaglutininas postrasplante se mantuvieron a títulos bajos. Dos pacientes presentaron un episodio de rechazo agudo celular (Banff IA e IB), con buena respuesta al tratamiento. La supervivencia de paciente y del injerto fue de un 90,9% en el primer año y se mantuvo estable a lo largo del seguimiento. Únicamente se registró una pérdida del injerto por fallecimiento en relación con una complicación hemorrágica en las primeras 72 horas sin relación con la incompatibilidad de grupo ABO. La función de injerto renal al año es excelente, con valores de creatinina sérica de 1,3 ± 0,8 mg/dl, con aclaramiento de creatinina ajustado a superficie corporal 62,6 ml/min/1,73 m2 y proteinuria de 244,9 mg/orina de 24 horas. Conclusiones: El trasplante renal de donante vivo con incompatibilidad de grupo sanguíneo representa una alternativa eficaz y segura en determinados pacientes en lista de espera de trasplante renal, obteniendo resultados excelentes de supervivencia de paciente e injerto y con una buena función de injerto renal (AU)

Introduction: During the last years the number of patients on waiting list for kidney transplantation has been stable. Living donor kidney transplantation is nowadays a chance to increase the pool of donors. However, there are a group of patients with ABO incompatibility, making impossible the transplant until now. The aim of the present study is to describe the experience of Hospital Clinic Barcelona on ABO incompatible living transplantation. Material and methods: A retrospective-descriptive study was made based on 11 living donor kidney recipients with ABO incompatibility in Hospital Clinic of Barcelona from October’06 to January’09. Selective blood group, antibody removal with specific immunoadsortion, immunoglobulin and anti-CD20 antibody were made until the immunoglobulin (IgG) and isoaglutinine (IgM) antibody titters were 1/8 or lower. Immunosuppressive protocol was adjusted to particular recipient characteristics. Isoaglutinine titters were set before, during and post desensitization treatment and two weeks after transplant. Immunological, medical and surgical evaluation was the standard in living donor kidney transplant program. Results: Medium age of donors and recipients were 47.8 ±12.4 and 44.4 ± 14.1 years, respectively. 90% of donors were females and 73% of recipients males. Follow-up time was 10.2 ±10.2 months. Siblings and spouses were the most frequent relation (n = 4, 36.4%, respectively). Chronic glomerulonephritis, adult polycystic kidney disease and Alport syndrome, the most frequent cause of end-stage renal disease. All the patients acquire appropriate isoaglutinine titters pre transplant (<1/8), requiring 5.54 ± 2.6 immunoadsorption sessions pretransplant and 2.82 postransplant. One patient didn´t need any immunoadsorption session (incompatibility blood group B) and another patient plasma exchange instead of immunoadsorption for being hipersensitized with positive flow cytometry crossmath. Postransplant isoaglutinine titters remained low. Two patients had cellular acute rejection episode (type IA and IB of Banff classification) with good response to corticosteroid treatment. Patient and graft survival were 91% at first year and remain stable during the follow-up. A graft lost by death of patient in relation to haemorrhagic shock developed within the first 72 hours after transplantation. Renal graft function at first year was excellent with serum creatinina of 1.3 ± 0.8 mg/dl, creatinine clearance of 62.6 ml/min/1.73 m2 and proteinuria of 244.9 mg/U 24 h. Conclusion: ABO incompatible living donor kidney transplantation represent an effective and safe alternative in certain patients on waiting list for renal transplant, obtaining excellent results in patient and graft survival, with good renal graft function (AU)

[ABO incompatible living donor kidney transplantation: a dream come true. Experience of Hospital Clínic of Barcelona]. / Trasplante renal ABO incompatible: de un sueño a una realidad. Experiencia del Hospital Clínic de Barcelona.

INTRODUCTION: During the last years the number of patients on waiting list for kidney transplantation has been stable. Living donor kidney transplantation is nowadays a chance to increase the pool of donors. However, there are a group of patients with ABO incompatibility, making impossible the transplant until now. The aim of the present study is to describe the experience of Hospital Clinic Barcelona on ABO incompatible living transplantation. METHODS: A retrospective- descriptive study was made based on 11 living donor kidney recipients with ABO incompatibility in Hospital Clinic of Barcelona from October'06 to January'09. Selective blood group, antibody removal with specific immunoadsortion, immunoglobulin and anti- CD 20 antibody were made until the immunoglobulin (IgG) and isoaglutinine (IgM) antibody titters were 1/8 or lower. Immunosuppressive protocol was adjusted to particular recipient characteristics. Isoaglutinine titters were set before, during and post desensitization treatment and two weeks after transplant. Immunological, medical and surgical evaluation was the standard in living donor kidney transplant program. RESULTS: Medium age of donors and recipients were 47.8 +/- 12.4 and 44.4 +/- 14.1 years, respectively. 90% of donors were females and 73% of recipients males. Follow-up time was 10.2 +/- 10.2 months. Siblings and spouses were the most frequent relation (n=4, 36.4%, respectively). Chronic glomerulonephritis, adult polycystic kidney disease and Alport syndrome, the most frequent cause of end-stage renal disease. All the patients acquire appropriate isoaglutinine titters pre transplant (< 1/8), requiring 5.54 +/- 2.6 immunoadsorption sessions pretransplant and 2.82 posttransplant. One patient didn t need any immunoadsorption session (incompatibility blood group B) and another patient plasma exchange instead of immunoadsorption for being hypersensitized with positive flow cytometry crossmatch. Posttransplant isoaglutinine titters remained low. Two patients had cellular acute rejection episode (type IA and IB of Banff classification) with good response to corticosteroid treatment. Patient and graft survival were 91% at first year and remain stable during the follow-up. A graft lost by death of patient in relation to haemorrhagic shock developed within the first 72 hours after transplantation. Renal graft function at first year was excellent with serum creatinine of 1.3 +/- 0.8 mg/dl, creatinine clearance of 62.6 ml/min/1.73 m2 and proteinuria of 244.9 mg/U-24h. CONCLUSION: ABO incompatible living donor kidney transplantation represent an effective and safe alternative in certain patients on waiting list for renal transplant, obtaining excellent results in patient and graft survival, with good renal graft function.

¿Cuánto tiempo es necesario aumentar la prescripción de hemodiálisis con la utilización de catéteres? / No disponible

En los últimos años hemos observado un aumento progresivo en el porcentaje de pacientes de hemodiálisis que utilizan catéteres centrales tunelizados como acceso vascular permanente, situándose las tasas de prevalencia e incidencia entorno al 7 y 25%, respectivamente. A pesar de que los catéteres actuales permiten la obtención de mayores flujos sanguíneos y menores complicaciones infecciosas, las dosis de diálisis obtenidas resultan inferiores a las alcanzadas mediante la utilización de fístulas arterio-venosas nativas (FAV) y prótesis vasculares. El objetivo principal del presente estudio fue valorar el tiempo adicional para obtener una dosis óptima de diálisis mediante la utilización de catéteres centrales venosos tunelizados. Dicha premisa se basa en la obtención de menores flujos sanguíneos (Qb) así como de posibles disfunciones vasculares que en diferentes ocasiones obligan a invertir las líneas arterio-venosas. Se analizaron un total de 48 pacientes (31 varones/17 mujeres) con una edad media de 61,6 ± 14 años (rango: 28-83); 20 con catéteres centrales tunelizados y 28 con FAV nativas. Todos los pacientes incluidos en el estudio se dializaron con la modalidad de hemodiálisis de alto flujo, con polisulfona de 1,9 m2, con una duración de 240 minutos, con flujo baño a 500 ml/min y monitores equipados con dialisancia iónica (DI). El objetivo principal de análisis fue la obtención de un Kt de 45 litros con cada uno de los diferentes accesos vasculares. Los pacientes portadores de una FAV recibieron 3 sesiones con variaciones de Qb a 300, 350 y 400 ml/min. Los pacientes con catéteres tunelizados recibieron dos sesiones de diálisis al máximo Qb, una con conexión de líneas normales y otra con líneas invertidas. Entre los resultados obtenidos cabe destacar que sólo los pacientes portadores de una FAV con un Qb de 400 ml/min alcanzaron el objetivo de Kt de 45 litros. Los sujetos con FAV precisaron incrementar 12 minutos de hemodiálisis con Qb de 350 ml/min y 28 minutos con Qb de 300 ml/min; los catéteres tunelizados en posición normal 24 minutos y los invertidos un total de 59 minutos. Concluimos que los pacientes dializados con catéteres centrales venosos tunelizados necesitan para alcanzar una dosis mínima de diálisis (Kt de 45 litros), incrementar por término medio 30 minutos el tiempo de la sesión si funciona en posición normal y 60 minutos en posición invertida de líneas arterio-venosas (AU)

The use of central catheters in hemodialysis patients as a permanent vascular access has increased during the last years, reaching numbers of around 7% of prevalent patients and between 25% of incident patients. Although the current catheters allow higher sanguineous flows with smaller incidence of infectious complications and dysfunction, the dose of dialysis that is reached is still inferior to that obtained with native arterio-venous fistula (AVF) and grafts. The aim of the present study was to evaluate the possible additional time supposed by dialysis using central venous catheters with respect to habitual vascular access as a consequence of the lesser blood flow (Qb) and the irregularity of its function (frequent lowering of the Qb and necessity of inverting the lines on many occasions). A total of 48 patients (31 men/17 women) with an average age of 61.6 ± 14 years old (rank: 28-83), 20 with tunnelled catheter and the remaining with AVF, were included in the study. All the patients were dialyzed in the modality of high flux hemodialysis with a polisulphone of 1.9 m2 dialyzer, dialysis time of 240 minutes, dialysate flow 500 ml/min and monitors equipped with ionic dialysance (ID) with the objective of obtaining a Kt of 45 litres with each one of the different vascular accesses. The patients with AVF received 3 sessions, with variations of Qb to 300, 350 and 400 ml/min. The patients with tunnelled catheter received two sessions, to the maximum Qb, one with normal connection and other with inverted one. In the results obtained it is possible to emphasize that only the patients with AVF and 400 ml/min reached the objective of 45 L of Kt. The patients with AVF needed to increase 12 minutes of hemodialysis with a Qb of 350 ml/min and 28 minutes with a Qb of 300 ml/min; the catheters on normal position needed to increase 24 minutes and finally in the inverted catheters an increase of 59 minutes was necessary to reach the same Kt objective. We concluded that the patients dialyzed with central catheters on average needed to increase by 30 minutes the time of dialysis if the catheter worked in a normal position but 60 minutes if the arterio-venous lines were inverted so as to reach the minimum dose of dialysis (AU)

[How much should dialysis time be increased when catheters are used?]. / ¿Cuánto tiempo es necesario aumentar la prescripción de hemodiálisis con la utilización de catéteres?

SUMMARY: The use of central catheters in hemodialysis patients as a permanent vascular access has increased during the last years, reaching numbers of around 7% of prevalent patients and between 25% of incident patients. Although the current catheters allow higher sanguineous flows with smaller incidence of infectious complications and dysfunction, the dose of dialysis that is reached is still inferior to that obtained with native arterio-venous fistula (AVF) and grafts. The aim of the present study was to evaluate the possible additional time supposed by dialysis using central venous catheters with respect to habitual vascular access as a consequence of the lesser blood flow (Qb) and the irregularity of its function (frequent lowering of the Qb and necessity of inverting the lines on many occasions). A total of 48 patients (31 men/17 women) with an average age of 61,6 +/- 14 years old (rank: 28-83), 20 with tunnelled catheter and the remaining with AVF, were included in the study. All the patients were dialyzed in the modality of high flux hemodialysis with a polisulphone of 1,9 m2 dialyzer, dialysis time of 240 minutes, dialysate flow 500 ml/min and monitors equipped with ionic dialysance (ID) with the objective of obtaining a Kt of 45 litres with each one of the different vascular accesses. The patients with AVF received 3 sessions, with variations of Qb to 300, 350 and 400 ml/min. The patients with tunnelled catheter received two sessions, to the maximum Qb, one with normal connection and other with inverted one. In the results obtained it is possible to emphasize that only the patients with AVF and 400 ml/min reached the objective of 45 L of Kt. The patients with AVF needed to increase 12 minutes of hemodialysis with a Qb of 350 ml/min and 28 minutes with a Qb of 300 ml/min; the catheters on normal position needed to increase 24 minutes and finally in the inverted catheters an increase of 59 minutes was necessary to reach the same Kt objective. We concluded that the patients dialyzed with central catheters on average needed to increase by 30 minutes the time of dialysis if the catheter worked in a normal position but 60 minutes if the arterio-venous lines were inverted so as to reach the minimum dose of dialysis.

[Kt as control and follow-up of the dose at a hemodialysis unit]. / Kt como control y seguimiento de la dosis en una unidad de hemodiálisis.

To ensure our patients are receiving an adequate dose in every dialysis session there must be a target to achieve this in the short or medium term. The incorporation during the last years of the ionic dialysance (ID) in the monitors, has provided monitoring of the dialysis dose in real time and in every dialysis session. Lowrie y cols., recommend monitoring the dose with Kt, recommending at least 40 L in women and 45 L in men or individualizing the dose according to the body surface area. The target of this study was to monitor the dose with Kt in every dialysis session for 3 months, and to compare it with the monthly blood test. 51 patients (58% of our hemodialysis unit), 32 men and 19 women, 60.7+/-14 years old, in the hemodialysis programme for 37.7+/-52 months, were dialysed with a monitor with IC. The etiology of their chronic renal failure was: 3 tubulo-interstitial nephropathy, 9 glomerulonephritis, 12 vascular disease, 7 polycystic kidney disease, 7 diabetic nephropathy and 13 unknown. 1,606 sessions were analysed during a 3 month period. Every patient was treated with the usual parameters of dialysis with 2.1 m2 cellulose diacetate (33.3%), 1.9 m2 polisulfone (33.3%) or 1.8 m2 helixone, dialysis time of 263+/-32 minutes, blood flow of 405+/-66, with dialysate flow of 712+/-138 and body weight of 66.7+/-14 kg. Initial ID, final ID and Kt were measured in each session. URR and Kt/V were obtained by means of a monthly blood test. The initial ID was 232+/-41 ml/min, the final ID was 197+/-44 ml/min, the mean of Kt determinations was 56.6+/-14 L, the mean of Kt/V was 1.98+/-0.5 and the mean of URR was 79.2+/-7%. Although all patients were treated with a minimum recommended dose of Kt/V and URR when we used the Kt according to gender, we observed that 31% of patients do not get the minimum dose prescribed (48.1+/-2.4 L), 34.4% of the men and 26.3% of the women. If we use the Kt individualized for the body surface area, we observe that 43.1% of the patients do not get the minimum dose prescribed with 4.6+/-3.4 L less than the dose prescribed. We conclude that the monitoring of dialysis dose with the Kt provides a better discrimination detecting that between 30 and 40% of the patients perhaps do not get an adequate dose for their gender or body surface area.

[Control of hypertension refractory to medical management by means of short daily hemodialysis]. / Control de HTA refractaria a tratamiento médico con hemodiálisis corta diaria.

Hypertension is a very frequent complication in patients in hemodialysis. A high percentage of the patients on standard hemodialysis remain hypertense in spite of intensive pharmacologic treatment. We presented the case of a hypertense patient with difficult control in spite of antihypertensive treatment with five drugs and several secondary complications. The change to a short daily hemodialysis was successful to hypertension control and allowed a gradual suspension of drugs.

Kt como control y seguimiento de la dosis en una unidad de hemodiálisis / Kt as control and follow-up of the dose at a hemodialysis unit

Asegurar que el paciente recibe la dosis adecuada en cada sesión de diálisis debe ser un objetivo a conseguir a corto o medio plazo. La incorporación de la dialisancia iónica (DI) en los monitores durante los últimos años ha permitido monitorizar la dosis de hemodiálisis en tiempo real y en cada sesión. Lowrie y cols., recomiendan el seguimiento de la dosis con el Kt, recomendando un mínimo de 40 L en mujeres y 45 en hombres o individualizar la dosis por área de superficie corporal. El objetivo del presente estudio era hacer un seguimiento de la dosis con el Kt en cada sesión durante 3 meses, y comparar con la analítica mensual habitual. 51 pacientes (58% de la Unidad de hemodiálisis), 32 varones y 19 mujeres, de 60,7 ± 14 años de edad, en programa de hemodiálisis durante 37,7 ± 52 meses, se dializaron con monitor con DI de forma rutinaria. La etiología de su IRC era de 3 NTI, 9 GNC, 12 nefroangiosclerosis, 7 poliquistosis renal, 7 diabetes mellitus y 13 no filiada. Se analizaron 1.606 sesiones durante 3 meses. Cada paciente recibió la pauta habitual de HD, con dializadores de diacetato de celulosa de 2,1 m2 (33,3%), polisulfona de 1,9 m2 (33,3%) y helixona de 1,8 m2, con duración de 263 ± 32 minutos, con un flujo sanguíneo de 405 ± 66, con flujo baño a 712 ± 138 ml/min, peso seco de 66,7 ± 14 kg. Se valoró la DI inicial, la DI final y el Kt en cada sesión y el PRU y el Kt/V mediante la analítica mensual. La DI inicial fue de 232 ± 41 ml/min, la DI final de 197 ± 44 ml/min, la dosis media de Kt fue de 56,6 ± 14 L, el Kt/V medio de 1,98 ± 0,5 y el PRU de 79,2 ± 7%. Todos los pacientes recibieron una dosis mínima de Kt/V y PRU de 1,3 y 70%, respectivamente. No obstante, si utilizamos el Kt según el sexo, observamos que el 31% de los pacientes no alcanzaban la dosis mínima prescrita (48,1 ± 2,4 L), 34,4% de los hombres y el 26,3% de las mujeres. Si utilizamos el Kt individualizado por su superficie corporal, (49,1 ± 4 L), observamos que el 43.1% de los pacientes no alcanzaban la dosis mínima prescrita, con 4,6 ± 3,4 L menos de dosis. Concluimos que el seguimiento de la dosis de diálisis con el Kt, permite una mejor discriminación de la adecuación de diálisis, identificando entre el 30 y el 40% de pacientes que quizá no alcanzasen una dosis adecuada para su género o para su superficie corporal (AU)

To ensure our patients are receiving an adequate dose in every dialysis session there must be a target to achieve this in the short or medium term. The incorporation during the last years of the ionic dialysance (ID) in the monitors, has provided monitoring of the dialysis dose in real time and in every dialysis session. Lowrie y cols., recommend monitoring the dose with Kt, recommending at least 40 L in women and 45 L in men or individualizing the dose according to the body surface area. The target of this study was to monitor the dose with Kt in every dialysis session for 3 months,and to compare it with the monthly blood test. 51 patients (58%of our hemodialysis unit), 32 men and 19 women, 60.7 ± 14 years old, in the hemodialysis program me for 37.7 ± 52 months, were dialysed with a monitor with IC. The etiology of their chronic renalfailure was: 3 tubulo-interstitial nephropathy, 9 glomerulonephritis,12 vascular disease, 7 polycystic kidney disease, 7 diabetic nephropathy and 13 unknown. 1,606 sessions were analysed during a 3 month period. Every patient was treated with the usual parameters of dialysis with 2.1 m2 cellulose diacetate (33.3%), 1.9m2 polisulfone (33.3%) or 1.8 m2 helixone, dialysis time of 263 ±32 minutes, blood flow of 405 ± 66, with dialysate flow of 712 ±138 and body weight of 66.7 ± 14 kg. ITo ensure our patients are receiving an adequate dose in every dialysis session there must be a target to achieve this in the short or medium term. The incorporation during the last years of the ionic dialysance (ID) in the monitors, has provided monitoring of the dialysis dose in real time and in every dialysis session. Lowrie y cols., recommend monitoring the dose with Kt, recommending at least 40 L in women and 45 L in men or individualizing the dose according to the body surface area. The target of this study was to monitor the dose with Kt in every dialysis session for 3 months, and to compare it with the monthly blood test. 51 patients (58% of our hemodialysis unit), 32 men and 19 women, 60.7 ± 14 years old, in the hemodialysis programme for 37.7 ± 52 months, were dialysed with a monitor with IC. The etiology of their chronic renal failure was: 3 tubulo-interstitial nephropathy, 9 glomerulonephritis, 12 vascular disease, 7 polycystic kidney disease, 7 diabetic nephropathy and 13 unknown. 1,606 sessions were analysed during a 3 month period. Every patient was treated with the usual parameters of dialysis with 2.1 m2 cellulose diacetate (33.3%), 1.9 m2 polisulfone (33.3%) or 1.8 m2 helixone, dialysis time of 263 ± 32 minutes, blood flow of 405 ± 66, with dialysate flow of 712 ± 138 and body weight of 66.7 ± 14 kg. Initial ID, final ID and Kt were measured in each session. URR and Kt/V were obtained by means of a monthly blood test. The initial ID was 232 ± 41 ml/min, the final ID was 197 ± 44 ml/min, the mean of Kt determinations was 56.6 ± 14 L, the mean of Kt/V was 1.98 ± 0.5 and the mean of URR was 79.2 ± 7%. Although all patients were treated with a minimum recommended dose of Kt/V and URR when we used the Kt according to gender, we observed that 31% of patients do not get the minimum dose prescribed (48.1 ± 2.4 L), 34.4% of the men and 26.3% of the women. If we use the Kt individualized for the body surface area, we observe that 43.1% of the patients do not get the minimum dose prescribed with 4.6 ± 3.4 L less than the dose prescribed. We conclude that the monitoring of dialysis dose with the Kt provides a better discrimination detecting that between 30 and 40% of the patients perhaps do not get an adequate dose for their gender or body surface areanitial ID, final ID and Kt (..) (AU)