Negative Impact of Borderline Creatinine Concentration and Glomerular Filtration Rate at Baseline on the Outcome of Patients With Multiple Myeloma Treated With Autologous Stem Cell Transplant.

BACKGROUND: Renal impairment (RI) is one of the multiple myeloma (MM)-defining events for initiating therapy. After induction therapy, high-dose chemotherapy followed by autologous peripheral blood stem cell transplant (ASCT) remains the standard of care for transplant-eligible patients with MM. According to the International Myeloma Working Group (IMWG), the organ criterion for kidney damage is defined by a serum creatinine concentration (CrC) > 2 mg/dL or estimated glomerular filtration rate (eGFR) < 40 mL/min. In this long-term study, we evaluated the impact of CrC and eGFR calculated by the Modification of Diet in Renal Disease equation on progression-free and overall survival using a lower threshold than the IMWG criteria. PATIENTS AND METHODS: We studied the longitudinal outcomes as measured by progression-free survival and overall survival in 59 transplant-eligible patients with MM: 38 patients with normal renal function and 21 patients with RI defined as a CrC higher than upper limit of normal (≥ 1.1 mg/dL), eGFR < 60 mL/min, treated with ASCT from 1998 to 2004. RESULTS: The risk of disease progression and death following ASCT increased by 16.5% (P = .005) and 19% (P < .0009) per 1 mg/dL of CrC, respectively. The thresholds for the association of renal insufficiency and negative outcomes were CrC > 1.4 mg/dL and eGFR < 55mL/min. CONCLUSIONS: We observed a negative correlation between minimal renal insufficiency and long-term outcomes. Management of patients with even marginally increased CrC and/or decreased eGFR not fulfilling IMWG RI criteria requires more concentrated effort to reverse even minimal renal insufficiency.

Activities of daily living at different levels of renal function in elderly hospitalized heart failure patients.

BACKGROUND: Renal function (RF) and activities of daily living (ADL) are risk factors for heart failure (HF) patients. AIMS: We evaluated differences in motor and cognitive ADL in relation to RF in elderly hospitalized HF patients. METHODS: Participants were selected from 414 consecutive hospitalized HF patients based on certain criteria. We investigated patient characteristics including Functional Independence Measure (FIM) and estimated glomerular filtration rate (eGFR). Subjects were divided into three groups by RF level and analyzed with one-way ANOVA and Chi-square tests and two-way ANCOVA and multiple comparison tests. RESULTS: Of the 414 patients, 165 met the inclusion criteria (high RF: 41, moderate RF: 84, low RF: 40). There were significant differences between the three groups in age, eGFR, hemoglobin level, mobility, cognitive function, and length of hospital stay (p < 0.05). Motor FIM showed an interaction between term and group, and cognitive FIM showed a main effect on the group (p < 0.05). In the multiple comparisons, motor FIM of all groups indicated significant recovery, but it was significantly lower after 1 week in the low RF versus moderate/high RF groups (p < 0.05). Cognitive FIM showed no significant recovery in the low RF group; the FIM score after 2 weeks was significantly lower than that in the moderate/high RF groups (p < 0.05). CONCLUSIONS: In elderly hospitalized HF patients, the motor ADL recovery process in the low RF group was delayed compared to the high RF group. Cognitive ADL in hospitalized HF patients is difficult to recover, especially in those with low RF.

Chronic renal failure in equine due to ascending pyelonephritis predisposed by cauda equina syndrome: case report / Insuficiência renal crônica em equino devido à pielonefrite ascendente predisposta por síndrome da cauda equina: relato de caso

Descreve-se o caso de uma égua, da raça Campeiro, utilizada como doadora de embriões, que apresentava quadros de cistite recorrente e incontinência urinária. Os sinais clínicos evoluíram para emagrecimento progressivo, anorexia, apatia e isolamento do plantel. Ao exame físico, foi identificada hipotonia da cauda, hipoalgesia da região perineal, flacidez retal e vesical, compatíveis com sinais relacionados à síndrome da cauda equina. Exames complementares laboratoriais, exame ultrassonográfico e necropsia confirmaram o diagnóstico de insuficiência renal crônica (IRC), a qual foi atribuida à pielonefrite ascendente. O exame de urocultura demonstrou crescimento de bactérias do gêneroStreptococcus sp. Este é um caso raro em equinos em que a disfunção de neurônio motor inferior propiciou o desenvolvimento de processo infeccioso no trato urinário, progredindo para um quadro crônico renal incompatível com a vida.(AU)

Descreve-se o caso de uma égua, da raça Campeiro, utilizada como doadora de embriões, que apresentava quadros de cistite recorrente e incontinência urinária. Os sinais clínicos evoluíram para emagrecimento progressivo, anorexia, apatia e isolamento do plantel. Ao exame físico, foi identificada hipotonia da cauda, hipoalgesia da região perineal, flacidez retal e vesical, compatíveis com sinais relacionados à síndrome da cauda equina. Exames complementares laboratoriais, exame ultrassonográfico e necropsia confirmaram o diagnóstico de insuficiência renal crônica (IRC), a qual foi atribuida à pielonefrite ascendente. O exame de urocultura demonstrou crescimento de bactérias do gênero Streptococcus sp. Este é um caso raro em equinos em que a disfunção de neurônio motor inferior propiciou o desenvolvimento de processo infeccioso no trato urinário, progredindo para um quadro crônico renal incompatível com a vida.(AU)

Adaptación en español del nuevo sistema de codificación de enfermedad renal primaria de la European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) / A Spanish version for the new ERA-EDTA coding system for primary renal disease

Antecedentes: La European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) ha publicado, en lengua inglesa, una nueva lista de códigos de enfermedad renal primaria (ERP), con el fin de solventar los problemas detectados en la «Lista de diagnóstico renal primario» que se venía utilizando desde hacía más de 40 años. Objetivos: En el seno del Registro Español de Enfermos Renales (REER) se consideró conveniente traducir y adaptar los términos, definiciones y notas de los nuevos códigos de la ERA-EDTA para facilitar su uso por parte de quienes usan como lengua de trabajo el español. Métodos: Se realizó un proceso de traducción profesional y adaptación terminológica que contó con la participación de nefrólogos bilingües con varias fases de contraste del resultado de la traducción, en las que se revisaron los códigos, literales, definiciones y criterios diagnósticos y se marcaron los acuerdos y discrepancias surgidos para cada término. Finalmente se acordó la versión aceptada por la mayoría de los revisores. Resultados: El acuerdo en la primera fase de revisión fue amplio, con solo 5 puntos de discrepancia que se acordaron en la fase final. Conclusiones: La traducción y adaptación al español representa una mejora para la introducción y uso del nuevo sistema de codificación de ERP, ya que puede contribuir a reducir el tiempo dedicado a la codificación y también el período de adaptación de los profesionales a los nuevos códigos (AU)

Background: The European Renal Association and the European Dialysis and Transplant Association (ERA-EDTA) have issued an English-language new coding system for primary kidney disease (PKD) aimed at solving the problems that were identified in the list of “Primary renal diagnoses” that has been in use for over 40 years. Purpose: In the context of Registro Español de Enfermos Renales (Spanish Registry of Renal Patients, [REER]), the need for a translation and adaptation of terms, definitions and notes for the new ERA-EDTA codes was perceived in order to help those who have Spanish as their working language when using such codes. Methods: Bilingual nephrologists contributed a professional translation and were involved in a terminological adaptation process, which included a number of phases to contrast translation outputs. Codes, paragraphs, definitions and diagnostic criteria were reviewed and agreements and disagreements aroused for each term were labelled. Finally, the version that was accepted by a majority of reviewers was agreed. Results: A wide agreement was reached in the first review phase, with only 5 points of discrepancy remaining, which were agreed on in the final phase. Conclusions: Translation and adaptation into Spanish represent an improvement that will help to introduce and use the new coding system for PKD, as it can help reducing the time devoted to coding and also the period of adaptation of health workers to the new codes (AU)

Necrosis peneana como síntoma debut de calcifilaxis sistémica. Análisis de 2 casos y revisión de la literatura / Penile necrosis as clinical presentation of systemic Calciphylaxis: Report of two cases and bibliographic review

OBJETIVOS: La calcifilaxia es un síndrome potencialmente letal descrito primordialmente en pacientes con insuficiencia renal crónica en diálisis. La etiopatogenia es incierta y existe controversia en cuanto al manejo diagnóstico y terapéutico. La necrosis peneana como manifestación de esta enfermedad es extremadamente infrecuente. Analizamos dos casos clínicos tratados en nuestro centro y realizamos una revisión de la literatura. MÉTODOS: Se recogió la información clínica de ambos pacientes y se realizó una búsqueda bibliográfica en Pubmed bajo los criterios de búsqueda "penile necrosis", "penile calciphylaxis", "sodium thiosulfate" y "systemic calciphylaxis". RESULTADOS: Ambos pacientes fueron sometidos a penectomía parcial debido a extensa necrosis peneana. Tras la misma, iniciaron un régimen de Tiosulfato de Sodio 20 mg i.v. durante sus sesiones de hemodiálisis. En ambos pacientes se apreció estabilización del proceso isquémico. CONCLUSIÓN: La biopsia de las lesiones en la necrosis isquémica de pene, por sospecha de calcifilaxis sistémica, es controvertido. Igualmente, el papel de la cirugía agresiva de entrada puede ser discutible; más aún con la aparición de nuevos fármacos específicos, como el Tiosulfato de sodio, que parecen ser eficaces en la estabilización de las lesiones

OBJECTIVE: Calciphylaxis is a potentially lethal syndrome reported mainly in patients with ESRD on hemodialysis. Etiopathogenesis remains unclear and there is much controversy regarding optimal diagnostic and therapeutic approach. Penile necrosis as a disease presentation is extremely rare. We report two clinical cases treated in our center and perform an evidence review. METHODS: Clinical data was obtained from both patients and an evidence review was performed on PubMed under the criteria "penile necrosis" and "Calciphylaxis". RESULTS: Both patients underwent partial penectomy due to severe penile necrosis. After surgery both patients received treatment with sodium thiosulfate (STS) 20mg in every hemodialysis session. Both patients showed stabilization of necrotic lesions. DISCUSSION: The same way that biopsying the ischemic lesions produced by Calciphylaxis is discussed and even misadvised, the role of aggressive surgery as first line therapy might be uncertain specially with the raising of new specific drugs such as sodium thiosulfate (STS) that have shown efficacy stopping disease progression

A new classification of Diabetic Nephropathy 2014: a report from Joint Committee on Diabetic Nephropathy.

The Joint Committee on Diabetic Nephropathy has revised its Classification of Diabetic Nephropathy (Classification of Diabetic Nephropathy 2014) in line with the widespread use of key concepts such as the estimated glomerular filtration rate (eGFR) and chronic kidney disease. In revising the Classification, the Committee carefully evaluated, as relevant to current revision, the report of a study conducted by the Research Group of Diabetic Nephropathy, Ministry of Health, Labour and Welfare of Japan. Major revisions to the Classification are summarized as follows: (1) eGFR is substituted for GFR in the Classification; (2) the subdivisions A and B in stage 3 (overt nephropathy) have been reintegrated; (3) stage 4 (kidney failure) has been redefined as a GFR less than 30 mL/min/1.73 m(2), regardless of the extent of albuminuria; and (4) stress has been placed on the differential diagnosis of diabetic nephropathy versus non-diabetic kidney disease as being crucial in all stages of diabetic nephropathy.

Documento de consenso para la detección y manejo de la enfermedad renal crónica / Consensus document for the detection and management of chronic kidney disease

La enfermedad renal crónica (ERC) es un importante problema de salud pública que puede afectar en sus diferentes estadios a cerca del 10% de la población española y que supone una elevada morbimortalidad, así como un importante consumo de recursos al Sistema Nacional de Salud. Diez sociedades científicas involucradas en el manejo del paciente renal nos hemos puesto de acuerdo para hacer una puesta al día del anterior documento de consenso sobre ERC de 2007. El presente es la edición abreviada del documento general extenso, que puede ser consultado en las páginas Web de cada una de las sociedades firmantes. Contiene los siguientes aspectos: definición, epidemiología y factores de riesgo de la ERC; criterios de diagnóstico, evaluación y estadificación de la ERC, albuminuria y estimación del filtrado glomerular; concepto y factores de progresión; criterios de derivación a nefrología; seguimiento del paciente, actitudes y objetivos por especialidad; prevención de la nefrotoxicidad; detección del daño cardiovascular; actitudes, estilo de vida y tratamiento: manejo de la hipertensión arterial, dislipidemia, hiperglucemia, tabaquismo, obesidad, hiperuricemia, anemia, alteraciones del metabolismo mineral y óseo; seguimiento coordinado por atención primaria-otras especialidades-nefrología; manejo del paciente en tratamiento renal sustitutivo, hemodiálisis, diálisis peritoneal y trasplante renal; tratamiento paliativo de la uremia terminal. Esperamos que sirva de gran ayuda en el manejo multidisciplinar del paciente con ERC, a la vista de las recomendaciones más actualizadas (AU)

Chronic kidney disease (CKD) is an important global health problem, involving to 10% of the Spanish population, promoting high morbidity and mortality for the patient and an elevate consumption of the total health resources for the National Health System. This is a summary of an executive consensus document of ten scientific societies involved in the care of the renal patient, that actualizes the consensus document published in 2007. The central extended document can be consulted in the web page of each society. The aspects included in the document are: Concept, epidemiology and risk factors for CKD. Diagnostic criteria, evaluation and stages of CKD, albuminuria and glomerular filtration rate estimation. Progression factors for renal damage. Patient remission criteria. Follow-up and objectives of each speciality control. Nephrotoxicity prevention. Cardio-vascular damage detection. Diet, life-style and treatment attitudes: hypertension, dyslipidaemia, hyperglycemia, smoking, obesity, hyperuricemia, anemia, mineral and bone disorders. Multidisciplinary management for Primary Care, other specialities and Nephrology. Integrated management of CKD patient in haemodialysis, peritoneal dialysis and renal transplant patients. Management of the uremic patient in palliative care. We hope that this document may be of help for the multidisciplinary management of CKD patients by summarizing the most updated recommendations (AU)

Distribution of cardiovascular disease and retinopathy in patients with type 2 diabetes according to different classification systems for chronic kidney disease: a cross-sectional analysis of the renal insufficiency and cardiovascular events (RIACE) Italian multicenter study.

BACKGROUND: The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (NKF's KDOQI) staging system for chronic kidney disease (CKD) is based primarily on estimated GFR (eGFR). This study aimed at assessing whether reclassification of subjects with type 2 diabetes using two recent classifications based on both eGFR and albuminuria, the Alberta Kidney Disease Network (AKDN) and the Kidney Disease: Improving Global Outcomes (KDIGO), provides a better definition of burden from cardiovascular disease (CVD) and diabetic retinopathy (DR) than the NKF's KDOQI classification. METHODS: This is a cross-sectional analysis of patients with type 2 diabetes (n = 15,773) from the Renal Insufficiency And Cardiovascular Events Italian Multicenter Study, consecutively visiting 19 Diabetes Clinics throughout Italy in years 2007-2008. Exclusion criteria were dialysis or renal transplantation. CKD was defined based on eGFR, as calculated from serum creatinine by the simplified Modification of Diet in Renal Disease Study equation, and albuminuria, as measured by immunonephelometry or immunoturbidimetry. DR was assessed by dilated fundoscopy. Prevalent CVD, total and by vascular bed, was assessed from medical history by recording previous documented major acute events. RESULTS: Though prevalence of complications increased with increasing CKD severity with all three classifications, it differed significantly between NKF's KDOQI stages and AKDN or KDIGO risk categories. The AKDN and KDIGO systems resulted in appropriate reclassification of uncomplicated patients in the lowest risk categories and a more graded independent association with CVD and DR than the NKF's KDOQI classification. However, CVD, but not DR prevalence was higher in the lowest risk categories of the new classifications than in the lowest stages of the NKF's KDOQI, due to the inclusion of subjects with reduced eGFR without albuminuria. CVD prevalence differed also among eGFR and albuminuria categories grouped into AKDN and KDIGO risk category 1 and moderate, respectively, and to a lesser extent into higher risk categories. CONCLUSIONS: Though the new systems perform better than the NKF's KDOQI in grading complications and identifying diabetic subjects without complications, they might underestimate CVD burden in patients assigned to lower risk categories and should be tested in large prospective studies. TRIAL REGISTRATION: ClinicalTrials.gov; NCT00715481.

Peritoneal ultrafiltration in patients with advanced decompensated heart failure.

The aim of the Best Practice guidelines on peritoneal ultrafiltration (UF) in patients with treatment-resistant advanced decompensated heart failure (TR-AHDF) is to achieve a common approach to the management of decompensated heart failure in those situations in which all conventional treatment options have been unsuccessful, and to stimulate a closer cooperation between nephrologists and cardiologists. The standardization of the case series of different centers would allow a better definition of the results published in the literature, without which they are nothing more than anecdotes. TR-AHDF is characterized by the persistence of severe symptoms even when all possible pharmacological and surgical options have been exhausted. These patients are often treated with methods that allow extracorporeal UF - slow continuous ultrafiltration (SCUF) and continuous renal replacement therapy (CRRT) - which have to be performed in hospital facilities. Peritoneal ultrafiltration (PUF) can be considered a treatment option in patients with TR-AHDF when, despite the fact that all treatment options have been used, patients meet the following criteria: • stage D decompensated heart failure (ACC/AHA classification); • INTERMACS level 4 decompensated heart failure; • INTERMACS frequent flyer profile; • chronic renal failure (estimated glomerular filtration rate <50 ml/min per 1.73 m2: KDOQI classification stage 3 chronic kidney disease); • no obvious contraindications to peritoneal UF. PUF treatment modes are derived from the treatment regimens proposed by various authors to obtain systemic UF in patients with severe decompensated heart failure, using manual and automated incremental peritoneal dialysis involving various glucose concentrations in addition to the single icodextrin exchange. These guidelines also identify a minimum set of tests and procedures for the follow-up phase, to be supplemented, according to the center's resources and policy, with other tests that are less routine or more complex also from a logistic/organizational standpoint, emphasizing the need for the patient's clinical and treatment program to involve both the nephrologist and the cardiologist. The pathophysiological aspects of a deterioration in kidney function in patients with decompensated heart failure are also considered, and the results of PUF in patients with decompensated heart failure reported in the various case series are reviewed.

Long-term renal outcomes of consecutive patients undergoing open type IV thoracoabdominal aneurysm repair.

OBJECTIVE: To evaluate long-term renal outcomes after open type IV thoracoabdominal aneurysm (TAAA) repair. DESIGN: Retrospective analysis of a prospectively collected database of consecutive operated non-ruptured type IV TAAAs (2007-2011). METHODS: Renal function was analysed by serum creatinine concentration, estimated glomerular filtration rate (eGFR) and Kidney Disease Outcomes Quality Initiative (KDOQI) stage. The primary outcome was the change in creatinine concentration from before surgery to defined time points after surgery: peak postoperative; discharge; at follow-up (>1 year postoperatively). Secondary outcomes were change in eGFR, change in KDOQI stage, dialysis requirement, and 30-day mortality. RESULTS: Between 2007 and 2011, 53 open type IV TAAA repairs were performed. Median creatinine levels significantly increased in the immediate postoperative period, but returned to baseline by discharge. Thirteen patients (28.2%) had an improvement in follow-up eGFR of at least 20% compared with pre-operative eGFR or improved by one KDOQI stage. Twelve patients (26.1%) had a decline in eGFR of at least 20% or one KDOQI stage at follow-up. Three patients (7.5%) required temporary dialysis and one patient (1.9%) required permanent dialysis. The 30-day mortality was 1.9%. CONCLUSIONS: This study demonstrates acceptable renal outcomes following open type IV TAAA repair. Open type IV repair remains the standard against which newer techniques should be compared.

Current concepts in the diagnosis and classification of renal dysfunction in cirrhosis.

BACKGROUND: Renal dysfunction is one of the most common complications of cirrhosis with high morbidity and mortality. SUMMARY: In subjects with cirrhosis, renal dysfunction can present either as a direct consequence of cirrhosis (e.g. hepatorenal syndrome type I and type II) or secondary to etiologies other than cirrhosis (chronic kidney disease due to diabetic nephropathy, prerenal azotemia), or patients with cirrhosis may have renal dysfunction resulting directly from cirrhosis and an underlying chronic kidney disease. KEY MESSAGES: Given the challenges in the differential diagnosis of renal dysfunction and insufficient accuracy of serum creatinine and creatinine-based glomerular filtration rate estimating equations in cirrhosis, there is an urgent need for more accurate biomarkers of renal dysfunction in this population. This review will discuss novel concepts for the diagnosis and classification of renal dysfunction in cirrhosis to overcome at least some of the diagnostic and therapeutic challenges. Additionally, a new classification will be proposed for renal dysfunction in cirrhosis.

[Cardiorenal syndromes]. / Cardiorenalis szindrómák.

Cardiac and kidney diseases are very common, and increasingly coexist. Classification for cardiorenal syndrome and for its specific subtypes has been developed and published recently by a consensus group of the Acute Dialysis Quality Initiative. Cardiorenal syndromes have been classified according to whether the impairment of each organ is primary, secondary or whether heart and kidney dysfunction occurs simultaneously as a systemic disease. The different syndromes were classified into five subtypes. Type-1: acute cardiorenal syndrome: an abrupt worsening of cardiac function leading to acute kidney injury and/or dysfunction. Type-2: chronic cardiorenal syndrome: chronic abnormalities in cardiac function causing kidney injury and/or dysfunction. Type-3: acute renocardiac syndrome: abrupt worsening of kidney function leading to heart injury and/or dysfunction. Type-4: chronic renocardiac syndrome: chronic kidney diseases leading to heart injury, disease and/or dysfunction. Type-5: secondary cardiorenal syndrome: acute or chronic systemic diseases leading to simultaneous injury and/or dysfunction of heart and kidney. The identification of patients and the pathophysiological mechanisms underlying each syndrome subtype will help cardiologists, nephrologists and physicians working on intensive care units to characterize groups of their patients with cardiac and renal impairment and to provide a more accurate treatment for them.

Pathological classification of anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis.

What drives human beings to classify? It seems as if it is within our nature to do so. Clinical classification systems for the systemic vasculitides were composed a long time ago, and they are constantly being revised and altered. The histopathological features of many diseases are so diverse that classification is called for. The histopathological classification for anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis was the culmination of results produced from a number of clinicopathological studies conducted within the European Vasculitis Study Group (EUVAS). The classification scheme has four general categories, named focal, crescentic, sclerotic and mixed. The first three categories are based on the predominance of normal glomeruli, glomeruli with cellular crescents and globally sclerotic glomeruli. The mixed category represents a heterogeneous phenotype of biopsies in which none of the aforementioned features is dominant. Results from a validation study incorporating 100 patients with at least 1-year follow-up showed that the phenotypical order of the four classes corresponded to the severity of renal function impairment. The new histopathological classification for ANCA-associated glomerulonephritis provides a logical structure for the categorization of patients into four subgroups defined according to glomerular features. This classification will be of use for future studies, such as clinical trials.