Enfermedad renal crónica y aparición de metástasis posterior a nefrectomía radical y parcial por carcinoma renal de células claras / Chronic kidney disease and clear renal cell carcinoma metastasis following radical or partial nephrectomy

RESUMEN Introducción: El uso de la nefrectomía parcial para el tratamiento del carcinoma de células renales en estadios tempranos se ha convertido en una de las intervenciones preferidas para estos pacientes en la Argentina. Sin embargo, sus resultados en el país a largo plazo aún se desconocen. En este estudio analizamos la progresión a enfermedad renal crónica y aparición de metástasis posterior a nefrectomía parcial y radical, en pacientes con carcinoma de células renales. Material y métodos: Se realizó un estudio de cohorte retrospectivo. Se incluyeron a todos los pacientes con carcinoma renal de células claras en estadio T1 que, entre 2006 y 2012, se sometieron a nefrectomía parcial en nuestro hospital. Se realizó un seguimiento hasta enero del 2018. Resultados: Se incluyeron 32 pacientes (19 con nefrectomía radical y 13 con nefrectomía parcial). Comparado con el grupo de nefrectomía parcial, los individuos sometidos a nefrectomía radical presentaron mayor progresión a enfermedad renal crónica (nefrectomía radical 63,2% vs nefrectomía parcial 15,4%; p=0,007). No existieron diferencias en el tiempo de seguimiento de ambos grupos (nefrectomía radical 69,3 ± 23,8 vs nefrectomía parcial 72,5 ± 26,9 meses; p=0,73). Los sujetos sometidos a nefrectomía radical tuvieron 11 veces mayor riesgo de progresión a enfermedad renal crónica que los de nefrectomía parcial (HR ajustado 11,12, IC95 1,24-99,9; p=0,031) ajustado por los demás factores de riesgo tradicionales. Ningún paciente con estadio T1a presentó metástasis durante todo el seguimiento, independientemente del tipo de cirugía. Conclusión: En nuestro estudio, la nefrectomía parcial preserva mejor la función renal a largo plazo que la nefrectomía radical y tiene un excelente perfil de seguridad oncológico en pacientes con carcinoma de células renales en estadio T1a. La nefrectomía radical fue un factor de riesgo independiente de progresión a enfermedad renal crónica.

ABSTRACT Introduction: Partial nephrectomy to treat early-stage renal cell carcinoma has become one of the surgeries of choice for patients in Argentina. However, long-term results in the country are unknown. In this study, we analyzed the progression to chronic kidney disease and the appearance of metastasis after partial or radical nephrectomy in renal cell carcinoma patients. Methods: A retrospective, cohort study was conducted. We included all patients suffering from T1 stage clear cell renal carcinoma who, between 2006 and 2012, underwent partial nephrectomy in our hospital. Follow-up continued until January 2018. Results: Thirty-two patients were included (19 had undergone radical nephrectomy and 13, partial nephrectomy). Subjects who had radical nephrectomy showed a more rapid progression to chronic kidney disease as compared to the subjects in the partial nephrectomy group (radical nephrectomy 63.2% vs. partial nephrectomy 15.4%; p=0.007). There were no differences in the follow-up period in both groups (radical nephrectomy 69.3% ± 23.8 months vs. partial nephrectomy 72.5 ± 26.9 months; p=0.73). Risk of progression to end-stage chronic kidney disease was 11 times higher for subjects who had undergone radical nephrectomy as compared to subjects who had had partial nephrectomy (adjusted HR 11.12; 95% CI: 1.24-99.9; p=0.031), adjusted by the rest of traditional risk factors. None of the T1a patients had metastasis during follow-up, regardless of the type of surgery. Conclusion: According to the findings of our study, partial nephrectomy preserves long-term renal function better than radical nephrectomy and has an excellent oncologic safety profile in T1a stage renal cell carcinoma patients. Radical nephrectomy was an independent risk factor of progression to chronic kidney disease.

Medición y estimación del filtrado glomerular posdonación renal / Post-kidney donation glomerular filtration rate measurement and estimation

INTRODUCCIÓN: Las consecuencias a largo plazo asociadas con la donación renal resultan controvertidas. La tasa de filtración glomerular (TFG) pre y posdonación resulta determinante en la ponderación del riesgo renal y cardiovascular. En Latinoamérica, existe escasa experiencia sobre la evaluación de la función renal por técnicas de medición del filtrado glomerular en donantes renales. Las ecuaciones MDRD y la CKD-EPI son consideradas alternativas razonables. El objetivo del trabajo fue evaluar el rendimiento de las ecuaciones MDRD y CKD-EPI en la dinámica del filtrado glomerular posnefrectomía en donantes renales. MATERIALES Y MÉTODOS: Estudio prospectivo de cohorte con medición (mTFG) y estimación de la tasa de filtrado glomerular (eTFG) en 189 donantes renales con nefrectomía entre 2007 y 2016 en el Hospital Privado Universitario de Córdoba, Argentina. Las TFG se evaluaron, previo y posterior a la nefrectomía, mediante el aclaramiento de iotalamato determinado por cromatografía líquida de alta eficacia y por las ecuaciones para estimación de TFG: MDRD y CKD-EPI. Se constituyeron 2 grupos de estudio: grupo 1 (n = 107) con un tiempo de evaluación posterior a la estabilización de la TFG posdonación (3 meses) hasta los 5 años y grupo 2 (n = 82) con un tiempo entre 5 y 10 años posdonación. RESULTADOS: El valor de compensación renal fue del 61,9% (52,0-71,1%) y 75,6% (64,9-84,4%) para los grupos 1 (n = 107) y 2 (n = 82), respectivamente. La ecuación MDRD subestimó la TFG en el 3,2% (90ml/min/1,73 m2) y el 38,6% (60 ml/min/1,73 m2) respecto a la mTFG y la CKD-EPI subestimó en un 2,6% (90 ml/min/1,73 m2) y un 13,8% (60 ml/min/1,73 m2). Se evaluó el rendimiento diagnóstico con curva ROC (mTFG < 60 ml/min/1,73 m2) para MDRD (ABC = 0,66, IC: 0,59-0,73), sensibilidad: 98,7% y especificidad: 63,3%, y para CKD-EPI (ABC = 0,79, IC: 0,73-0,85), sensibilidad: 96,9% y especificidad: 76,4%. Las eTFG mostraron un bajo desempeño para estimar el filtrado en el seguimiento posnefrectomía de los donantes mayores de 50 años. CONCLUSIONES: Las ecuaciones de estimación de la TFG muestran un bajo desempeño para el seguimiento a largo plazo del filtrado posnefrectomía y la medición del filtrado sería recomendable en la selección como en el seguimiento de ciertos donantes bajo los criterios actuales de selección

BACKGROUND: Long-term consequences associated with kidney donation are controversial. Pre- and post-donation glomerular filtration rates (GFRs) are determinants of renal and cardiovascular risk weighting. In Latin America, there is limited experience in evaluating kidney function using GFR measurement techniques in kidney donors. The MDRD 4-variable and CKD-EPI equations are considered reasonable options. The objective of this study was to evaluate the performance of the MDRD and CKD-EPI equations in post-nephrectomy GFR dynamics in kidney donors. MATERIALS AND METHODS: A prospective cohort study with GFR measurement and estimation in 189 kidney donors who underwent nephrectomy between 2007 and 2016 at the Hospital Privado Universitario de Córdoba [Private University Hospital of Córdoba] in Córdoba, Argentina. GFRs were evaluated before and after nephrectomy by iothalamate clearance determined by HPLC and by the MDRD and CKD-EPI equations for estimating GFR. Two groups were formed for this study: Group 1 (n = 107), with an evaluation time subsequent to GFR stabilization (3 months) of up to 5 years, and Group 2 (n = 82), with an evaluation time of 5-10 years following donation. Measured GFR (mGFR) was assessed by iothalamate clearance determined by HPLC. RESULTS: Renal compensation values were 61.9% (52.0%-71.1%) and 75.6% (64.9%-84.4%) for Group 1 (n = 107) and Group 2 (n = 82), respectively. MDRD underestimated the GFR in 3.2% (90 ml/min/1.73 m2) and 38.6% (60 ml/min/1.73 m2) compared to the mGFR, and CKD-EPI underestimated the GFR in 2.6% (90ml/min/1.73 m2) and 13.8% (60 ml/min/1.73 m2). Diagnostic performance was evaluated with a ROC curve (mGFR < 60 ml/min/1.73 m2) for MDRD (ABC = 0.66; CI: 0.59-0.73; sensitivity: 98.7%; specificity: 63.3%) and for CKD-EPI (ABC = 0.79 CI: 0.73-0.85; sensitivity: 96.9%; specificity: 76.4%. Estimated GFR (eGFR) showed poor performance for estimating the glomerular filtration rate in the post-nephrectomy follow-up of donors over 50 years of age. CONCLUSIONS: Equations for estimating GFRs showed poor performance for long-term follow-up of post-nephrectomy GFRs. Measuring GFRs to determine kidney function is recommended in the screening and follow-up of some donors under the current selection criteria

Elevada prevalencia de hiperparatiroidismo secundario en pacientes con enfermedad renal crónica en diálisis en Argentina / High prevalence of secondary hyperparathyroidism in chronic kidney disease patients on dialysis in Argentina

ANTECEDENTES: Existen pocos datos acerca de la prevalencia de los trastornos del metabolismo óseo y mineral (MOM) y su forma de manejo en pacientes con enfermedad renal crónica en Argentina. Objetivos y métodos: Mediante una encuesta realizada en 2010 en centros de diálisis, determinamos la prevalencia y las formas de tratamiento de los trastornos del MOM en Argentina y los comparamos con los datos publicados por otros grandes estudios poblacionales. Consignamos las características de los centros de diálisis y de los pacientes participantes, la frecuencia de las determinaciones y los resultados individuales de los marcadores bioquímicos del MOM y el tipo de manejo utilizado para controlar la hiperfosfatemia y el hiperparatiroidismo secundario. RESULTADOS: Participaron 1210 pacientes de 25 centros de diálisis de 10 provincias de Argentina (lo cual representaba el 4,7 % de la población prevalente en diálisis del país en 2010). La población estudiada tenía una edad media de 55,3 ± 17,6 años, 60,8 % eran varones, el 3,3 % en diálisis peritoneal y el 29,1 % eran diabéticos. El 100 % de los centros determinaban calcemia y fosfatemia mensualmente, el 60 % hormona paratiroidea intacta (PTHi) semestralmente, el 36 % cada 3 o 4 meses y el 4 % de forma anual. Según las recomendaciones de K/DOQI, el 51,6 % de los pacientes tenían niveles adecuados de calcio (8,4-9,5 mg/dl), el 51,6 % de fósforo (3,5-5,5 mg/dl) y el 21,1 % de PTHi (150 a 300 pg/ml). El 24,4 % tenían PTHi < 150 pg/ml y el 54,5 % > 300 pg/ml, con un 28,3 % con valores de PTHi > 600 pg/ml y un 13,3 % > 1000 pg/ml. Estos datos diferían de los publicados por el estudio DOPPS II, donde el 51,1 % de los pacientes presentaban PTHi < 150 pg/ml, y solo un 26,7 % PTHi > 300 pg/ml. El 83,6 % utilizaban un captor del fosfato basado en calcio, el 5,6 % sevelamer y el 4,0 % compuestos con aluminio. Para el control del hiperparatiroidismo se utilizaba predominantemente calcitriol oral o endovenoso (50,5 %), con un pequeño porcentaje de pacientes recibiendo paricalcitol o doxercalciferol. CONCLUSIONES: El presente estudio muestra una elevada prevalencia de hiperparatiroidismo secundario, lo cual difiere de lo publicado por otros grandes estudios poblacionales. Existe una elevada proporción de pacientes con marcadores del MOM por fuera de los niveles sugeridos por K/DOQI. Para el control de la hiperfosfatemia y el hiperparatiroidismo, se continúan utilizando mayormente captores del fosfato basados en calcio y calcitriol, respectivamente

BACKGROUND: There are few data in Argentina on the prevalence and management of bone and mineral metabolism (BMM) in patients with chronic kidney disease (CKD). Objectives and methods: A survey was carried out in dialysis units in 2010 to measure the prevalence of and types of treatments for BMM disorders in Argentina. The data obtained was then compared to the published results from other large population studies. We recorded characteristics of dialysis centres and participating patients, the frequency of measurements and individual results for BMM biochemical markers, as well as the type of management used to control hyperphosphataemia and secondary hyperparathyroidism. RESULTS: 1210 patients from 25 dialysis centres in Argentina participated in the study (representing 4.7% of the country's prevalent dialysis population in 2010). The mean patient age was 55.3±17.6 years, 60.8% were male, 3.3% were on peritoneal dialysis and 29.1% suffered diabetes. In all centres, phosphataemia and calcaemia were measured on a monthly basis, 60% of centres measured intact parathyroid hormone (iPTH) every 6 months, 36% every 3 to 4 months, and 4% annually. As recommended by K/DOQI, 51.6% of patients had adequate levels of calcium (8.4-9.5mg/dl), 51.6% had adequate phosphorus (3.5-5.5mg/dl) and 21.1% displayed acceptable iPTH levels (150-300pg/ml). 24% had iPTH <150pg/ml and 54.5% >300pg/ml. iPTH >600pg/ml was present in 28.3%, and 13.3% had values >1000pg/ml. These figures differed from those published by the DOPPS II study, in which 51.1% of patients had iPTH <150pg/ml, and only 26.7% had iPTH >300pg/ml. Calcium-based phosphate binders were used in 83.6% of the patients, 5.6% used sevelamer and 4.0% used aluminium-containing compounds. To achieve control of hyperparathyroidism, oral or intravenous calcitriol was predominantly used (50.5%) with a small percentage of patients receiving paricalcitol or doxercalciferol. CONCLUSIONS: The present study shows a high prevalence of secondary hyperparathyroidism, which differs from that published by other large population studies. There was a high proportion of patients with BMM markers outside the ranges suggested by K/DOQI. Mainly phosphate binders based on calcium and calcitriol continue to be used for the management of hyperphosphatemia and hyperparathyroidism respectively

[Renal abnormalities in HIV infected patients]. / Compromiso renal en pacientes HIV(+).

Several renal complications may occur during HIV infection, especially in advanced stages related to HIV, to other infectious agents and/or drugs. Little is known about the prevalence of renal diseases that may occur as a complication of or related to HIV infection in asymptomatic patients. This is a single center cross-sectional study of asymptomatic HIV(+) patients referred to a nefrology care service at an Argentine hospital to look for the presence of renal abnormalities. Fifty two consecutive patients were studied between April and November 2008. Patients underwent plasma and urine analysis, ultrasound, and kidney biopsy as needed. Mean age was 39.9 +/- 10.6 years, 88% were male, time from HIV diagnosis 53.2 +/- 41.2 months (2-127); 71% had HIV-disease and 77% were on antiretroviral therapy. Mean plasma HIV-RNA copies number was 7.043 +/- 3.322 and CD4+ cell count: 484 +/- 39. Pathologic findings in urine analysis were present in 30.7% of patients: albuminuria 16.6%, microscopic hematuria 11.5%, hypercalciuria 10.8% and crystalluria 6%. Mean glomerular filtration rate was 102.2 +/- 22.95 ml/min (34-149) and 41% of patients could be classified in stages 1 to 3 of chronic kidney disease. Renal abnormalities prevaled in older patients without relationship with presence of HIV-disease. Two patients were biopsied and the findings included: tubulointerstitial nephritis with presence of crystal deposition in one and IgA nephropathy in the other. No HIV-associated nephropathy was detected. The broad spectrum and the high prevalence of lesions found in this series suggest that asymptomatic HIV-infected patients should routinely undergo renal evaluation.

Tratamiento del hiperparatiroidismo secundario con punción alcoholización de paratiroides: la importancia del volumen glandular / Treatment of refractory secondary hyperparathyroidism with ethanol injection: the importance of glandular volume

El tratamiento con inyección percutánea de etanol de las glándulas paratiroides (Percutaneous ethanol injection treatment (PEIT)) fue propuesto como alternativa a la cirugía para pacientes con hiperparatiroidism o secundario. El presente estudio tiene como objetivo determinar los factores que podrían predecir los resultados de este tratamiento. Se realizó PEIT en 19 pacientes con insuficiencia renal crónica en tratamiento con hemodiálisis ehiperparatiroidismo secundario refractario al tratamiento médico. Méto dos : El procedimiento fue efectuado en forma ambulatoria, bajo control ecográfico y con anestesia local. Inmediatamente antes de la última sesión de diálisis, se realizaron análisis bioquímicos (basal) y luego entre 1 a 7 días del PEIT (pos-PEIT). R e s u l t a d o s : Los niveles de PTH, calcio y fósforo séricos disminuyeron significativamente luego del tratamiento. El porcentaje de cambio en la PTH sérica se correlacionó significativamente con el volumen nodular total (r 0,73; p< 0,0004) y los niveles basales de PTH (r 0,48;p< 0,03). Tanto el fosfato sérico pos-PEIT como el producto calcio por fósforo mostraron una correlación negativa ysignificativa con los niveles basales de PTH, (r-0,60; p< 0,009 y r-0,60; p< 0,01 respectivamente). El volumen glandular total se correlacionó significativamente con el porcentaje de cambio de los niveles de calcio sérico (r0,60; p< 0,01), de fósforo (r0,64, p<0,009) y de producto calcio por fósforo (r0,66; p<0,01). Conclusiones: Nuestros hallazgos sugieren que los pacientes con hiperparatiroidismo secundario no controlado podrían beneficiarse del tratamiento con PEIT sipresentan niveles muy altos de PTH y/o un tamaño nodular grande.

Analísis de supervivencia actuarial de pacientes en dialísis / Actuarial survival analysis of patients in dialysis

The survival rate of our end stage renal disease (ESRD) population was calculated by means of actuarial survival curves. A total of 167 patients undergoing hemodialysis or CAPD during the 1977-1991 period were studied. They had been treated and closely followed for at least three months. Mean age for starting dialysis was 40.6 +/- 17 years; 107 (64) were males and 60 (36) females. Glomerulonephritis (25), diabetes (14) and nephroangiosclerosis (12) were the primary causes of ESRD. Survival rates were analysed by actuarial curves as designed by Kaplan and Meier. Statistical significance between curves was calculated with the Log Rank test. The level of significance considered was below 0.05. Multivariate analysis of survival was performed using the Cox proportional hazards regression model. Survival rates were in all cases expressed for the 1 degree, 5 degree and 10 degree year. They were for the whole group of 89, 63, and 38 respectively. When analysed according to their age: those under 30 years; between 30 and 50 and over 50 years old (at time to start dialysis); survival rates were of 97, 86, and 81 for the first group; 89, 66 and 29 for the second group, and 85, 44, and 10 for the third group. Significant differences were found between the first and second group (p < 0.025); the first and the third group (p < 0.001) and second and third group (p < 0.001) (Fig. 4).(ABSTRACT TRUNCATED AT 250 WORDS)(Au)

Analísis de supervivencia actuarial de pacientes en dialísis / Actuarial survival analysis of patients in dialysis

The survival rate of our end stage renal disease (ESRD) population was calculated by means of actuarial survival curves. A total of 167 patients undergoing hemodialysis or CAPD during the 1977-1991 period were studied. They had been treated and closely followed for at least three months. Mean age for starting dialysis was 40.6 +/- 17 years; 107 (64) were males and 60 (36) females. Glomerulonephritis (25), diabetes (14) and nephroangiosclerosis (12) were the primary causes of ESRD. Survival rates were analysed by actuarial curves as designed by Kaplan and Meier. Statistical significance between curves was calculated with the Log Rank test. The level of significance considered was below 0.05. Multivariate analysis of survival was performed using the Cox proportional hazards regression model. Survival rates were in all cases expressed for the 1 degree, 5 degree and 10 degree year. They were for the whole group of 89, 63, and 38 respectively. When analysed according to their age: those under 30 years; between 30 and 50 and over 50 years old (at time to start dialysis); survival rates were of 97, 86, and 81 for the first group; 89, 66 and 29 for the second group, and 85, 44, and 10 for the third group. Significant differences were found between the first and second group (p < 0.025); the first and the third group (p < 0.001) and second and third group (p < 0.001) (Fig. 4).(ABSTRACT TRUNCATED AT 250 WORDS)