How do disorders related to hospitalisation influence haemodialysis patients' nutrition?

INTRODUCTION: Hospitalizations are frequent in hemodialysis patients and is often accompanied by nutritional deterioration showed by a loss of weight and a reduction of albumin serum levels. This phenomenon is related with length of stay having its origin in a complex interplay of factors. Our aim in this study was to analyze if changes in body weight and other nutritional parameters are influenced by the illnesses presented during hospitalization. PATIENTS AND METHODS: Over a period of three years, we retrospectively chose chronic haemodialysis patients that were admitted for more than four days, excluding those cases that died in the hospital. We randomly chose one admission episode per patient so as to avoid excessive weighing of repeated admissions. We took data concerning weight changes, pre-admission and post-discharge analytical results, analytical results following first week of hospital stay, disorders causing hospital admission and those that developed during the hospital stay. We created a point score system to record the total of illnesses presented. RESULTS: The study included 77 patients, aged 67±12 years and having undergone haemodialysis for 31±34 months. Hospital stay was 17.8±12.6 days (median, 12 days). We observed that many patients admitted for digestive and osteoarticular disorders, heart failure or coronary syndrome lost more weight during their hospital stay, although no significant differences were reached. The total number of disorders suffered during the hospital stay was independent of the cause of hospitalisation. Anaemia,heart arrhythmias and signs of heart failure were associated with longer hospital stays, however it was only anaemia that was significantly related to greater weight loss. Weight loss was not related to surgery or infections. Albumin levels during the first week of hospital stay were different depending on the disorder upon admission. It was lower when the patients were admitted for digestive disorders (ANOVA, P=.05). Changes in albumin and creatinine levels before and after the hospital stay did not differ among disorders. We observed a relationship between having presented with more disorders during the stay and a longer stay, lower initial albumin and greater weight loss following discharge. In the multivariate analysis, we found the following weight loss predictors: stay, anaemia, and sepsis. We also found the following hospital stay predictors:Charlson's comorbidity index, heart arrhythmias, anaemia, sepsis and surgery. CONCLUSIONS: Malnutrition during the hospital stay depends on the duration and the number of disorders that develop during this time, the cause of admission having less impact on this. Albumin levels decrease earlier in patients that are going to develop more disorders during hospital stay.

[Loss of weight in hemodialysis patients after hospitalization is related with length of stay and degree of inflammation]. / La pérdida de peso en pacientes en hemodiálisis tras su hospitalización tiene relación con la duración de la estancia y con el grado de inflamación.

BACKGROUND: It is frequent to observe that hemodialysis patients suffer important loss of weight during hospital stay. This issue has not been investigated previously. Our aim in this study was to analyze factors associated with this loss of weight and what changes occur after admission in biochemical parameters with nutritional interest. PATIENTS AND METHODS: We retrospectively selected patients undergoing chronic hemodialysis who were admitted at hospital for acute or chronic pathologies, with a minimum length of stay of 4 days, taking only one episode of admission per patient. We chose loss of weight observed at hospital discharge, at 2 and 4 weeks later and we also collected routine laboratory data and adequacy parameters before and after the hospital admission and basic biochemical parameters in the first week of hospital stay. RESULTS: We included 77 patients, with 67±12 years and 30±34 months in dialysis. Forty (51.9%) were female (51.9%) and 22 diabetics (28.6%). Length of stay was 17.8±12.6 days (median 12). There were 70.4% patients who suffered a loss of weight at discharge and 81.4% at 4 weeks, without differences in sex or diabetes. Weight decreased significantly with a mean of -1.09 kg (95%CI -0.73 to -1.44). After 2 weeks the loss of weight was -1.64 kg (95%CI -1.21 a -2.07 kg) and after 4 weeks was -1.94 kg (95%CI -1.47 a -2.42 kg). Comparing parameters before and after admission, we observed a significantly decrease in serum urea levels (before 134±40 vs after 119±36 mg/dl; p= 0.001), creatinine (before 8.1±2.6 vs after 7.5±2.6 mg/dl; p < 0.001), phosphate (before 5.2±1.7 vs after 4.3±1.5 mg/dl; p < 0.001) and albumin (before 3.70±0.48 vs after 3.56±0.58 g/dl; p=0.05), without changes in adequacy parameters. Greater loss of weight at 4 weeks from discharge was correlated with larger length of stay (r= 0.41; p < 0.001), greater body mass index at admission (r= -0.23; p=0.05) and lower serum albumin at admission (r= 0.39; p= 0.012). It was also correlated with a lower serum albumin (r= 0.27; p=0.05), lower creatinine (r= 0.30; p= 0.02) and lower protein intake (nPNA) (r= 0.47; p= 0.002) after discharge. Lower serum albumin levels at admission were correlated with greater decreases of creatinine after discharge (r= 0.42; p= 0.009) and larger length of stay (r= -0.61; p < 0.001). Employing multivariate analysis we found that loss of weight was associated to length of stay and serum potassium levels before admission. CONCLUSIONS: Hospitalization of hemodialysis patients have a negative nutritional impact causing a significant loss of weight, probably reflecting a reduction of muscle mass. We found that length of stay in hospital is a basic factor associated with this nutritional impairment. The pathologies promoting hospitalization could influence this derangement through inflammation but this hypothesis should be investigated.

Análisis de la eficacia y de los factores que influyen en la respuesta del hiperparatiroidismo secundario de pacientes en hemodiálisis a cinacalcet / Analysis of the efficacy and factors influencing the response of secondary hyperparathyroidism patients on hemodialysis to cinacalcet

Introducción: Aunque el cinacalcet ha mejorado el control del hiperparatiroidismo secundario en hemodiálisis, todavía un 50% de los pacientes no alcanzan las cifras de PTH recomendadas por las guías K/DOQI. El objetivo de este estudio fue analizar la eficacia del tratamiento del hiperparatiroidismo secundario con cinacalcet en pacientes no seleccionados en hemodiálisis crónica, de acuerdo con los objetivos marcados por las guías K/DOQI y KDIGO. Además, investigamos qué factores pueden influir en el grado de respuesta del hiperparatiroidismo secundario a cinacalcet. Material y métodos: Recogimos retrospectivamente la evolución de 74pacientes en hemodiálisis con hiperparatiroidismo secundario que fueron tratados con cinacalcet durante al menos 6 meses. Resultados: De acuerdo con las guías K/DOQI, la proporción de pacientes con PTHi >300 pg/ml se redujo al 50%, la presencia de hiperfosforemia descendió del 38,4 al 23,3% y el producto Ca x P >55 mg2/dl2 bajó de 37,8 a 15,1%. La prevalencia de hipocalcemia aumentó de 2,7 al 12,3%. Con respecto a las guías KDIGO, la proporción con PTHi >600 pg/mlse redujo desde 41,1 al 16,4% y la de hiperfosforemia del68,5 al 52,1%; pero al considerar a pacientes con PTHi inicial>600 pg/ml, la prevalencia de P >4,5 mg/dl descendió de 83,3 del 55,2%. Observamos un incremento de la dosis de carbonato cálcico (basal 0,61 ± 1,53 g de calcio elemento/día frente a final 0,95 ± 1,98 g de calcio elementto/día; p = 0,03), debido más a la hipocalcemia que a la necesidad de quelar el fósforo. Encontramos menores descensos de la PTHi entre los pacientes que tenían prescrito inicialmente más sevelamer, y al final del seguimiento presentan mayores niveles séricos de PTHi (no sevelamer: 312 ± 245 pg/ml; sevelamer < _ 6,4 g/día: 510 ± 490 pg/ml; sevelamer >6,4 g/día: 526 ± 393 pg/ml; p = 0,04) y de fósforo (no sevelamer: 4,5 ± 1,2 mg/dl; sevelamer < _ 6,4 g/día: 4,2 ± 1,5 mg/dl; sevelamer >6,4 g/día: 5,7 ± 0,9 mg/dl; p = 0,01). El tratamiento asociado con paricalcitol no mostró ninguna in- fluencia en el grado de respuesta. Los pacientes que alcanzaron los objetivos de PTH mostraron ya a los 3 meses de tratamiento un mayor descenso en los niveles séricos de PTHi (159 ± 84 frente a 630 ± 377 pg/ml; p <0,001), con dosis significativamente menores de cinacalcet (33,8 ± 22,5 frente a 51,1 ± 25,1 mg/día; p = 0,003). Con análisis multivariante, el grado de reducción de la PTHi dependió de sus cifras séricas iniciales y de la dosis inicial de sevelamer. Conclusiones: Ci- nacalcet mejora el control del hiperparatiroidismo secunda- rio, si bien la respuesta es menor en los casos de mayor gra- vedad, representados por niveles más altos de PTH y mayores dosis iniciales de sevelamer. Por el contrario, un descenso im- portante de PTH a los 3 meses con dosis relativamente bajas de cinacalcet sería un marcador pronóstico de buena respuesta (AU)

Background: Treatment of secondary hyperparathyroidism with cinacalcet improves control of PTH, phosphorus, calcium and Ca X P product, enabling to achieve targets recommended by K/DOQI guidelines for PTHi in only 30-50%of patients, in studies with a very selected population. The aim of this study was to analyze its effectiveness in real clinical practice, comparing results with targets recommended by K/DOQI and KDIGO guidelines and to investigate factors having influence on PTH responsiveness to cinacalcet. Methods: We collected data of evolution of 74 patients on hemodialysis with secondary hyperparathyroidism who were treated with cinacalcet for at least 6months. Results: According K/DOQI targets we observed a reduction of proportion of patients with PTHi >300 pg/mlto 50%, a decrease of hyperphosphoremia from 38.4% to23.3% and proportion of patients with Ca x P product >55mg2/dl2 from 37.8% to 15.1%. By contrast, presence of hypocalcemia increases from 2.7% to 12.3%. Comparing with KDIGO targets, proportion of patients with PTHi >600pg/ml decreased from 41.1% to 16.4% and with hyperphosphoremia from 68.5% to 52.1%. However, when considering patients with baseline PTHi >600 pg/ml prevalence of P >4.5 mg/dl decreased from 83.3% to 55.2%. We observed significant changes of phosphate binders after cinacalcet treatment with an increase in calcium carbonate doses (pre 0.61 ± 1.53 g of calcium/day vs post-cinacalcet (..) (AU)

[Analysis of the efficacy and factors influencing the response of secondary hyperparathyroidism patients on hemodialysis to cinacalcet]. / Análisis de la eficacia y de los factores que influyen en la respuesta del hiperparatiroidismo secundario de pacientes en hemodiálisis a cinacalcet.

BACKGROUND: Treatment of secondary hyperparathyroidism with cinacalcet improves control of PTH, phosphorus, calcium and Ca x P product, enabling to achieve targets recommended by K/DOQI guidelines for PTHi in only 30-50% of patients, in studies with a very selected population. The aim of this study was to analyze its effectiveness in real clinical practice, comparing results with targets recommended by K/DOQI and KDIGO guidelines and to investigate factors having influence on PTH responsiveness to cinacalcet. METHODS: We collected data of evolution of 74 patients on hemodialysis with secondary hyperparathyroidism who were treated with cinacalcet for at least 6 months. RESULTS: According K/DOQI targets we observed a reduction of proportion of patients with PTHi > 300 pg/ml to 50%, a decrease of hyperphosphoremia from 38.4% to 23.3% and proportion of patients with Ca x P product > 55 mg2/dl2 from 37.8% to 15.1%. By contrast, presence of hypocalcemia increases from 2.7% to 12.3%. Comparing with KDIGO targets, proportion of patients with PTHi > 600 pg/ml decreased from 41.1% to 16.4% and with hyperphosphoremia from 68.5% to 52.1%. However, when considering patients with baseline PTHi > 600 pg/ml prevalence of P > 4.5 mg/dl decreased from 83.3% to 55.2%. We observed significant changes of phosphate binders after cinacalcet treatment with an increase in calcium carbonate doses (pre 0.61 +/- 1.53 g of calcium/day vs post-cinacalcet 0.95 +/- 1.98 g of calcium/day; p = 0.03) that was prescribed to prevent hypocalcemia and not as phosphate binder. Responsiveness were lower in patients who were taking higher doses of sevelamer at baseline, showing at the end of the study higher PTHi (no-sevelamer: 312 +/- 245 pg/ml; sevelamer < 6.4 g/day: 510 +/- 490 pg/ml; sevelamer > 6.4 g/day: 526 +/- 393 pg/ml; p = 0.04) and phosphorus (no-sevelamer: 4.5 +/- 1.2 mg/dl; sevelamer < 6.4 g/day: 4.2 +/- 1.5 mg/dl; sevelamer > 6.4 g/day: 5.7 +/- 0.9 mg/dl; p=0.01) serum levels. Use of paricalcitol did not show any influence on PTH response. Patients achieving targets for PTH at the end of the study showed a good response early, with a significant decrease of PTHi levels at three months (159 +/- 84 vs 630 +/- 377 pg/ml; p < 0.001) with significantly lower doses of cinacalcet (33.8 +/- 22.5 vs 51.1 +/- 25.1 mg/day; p = 0.003). Using multivariate analysis we found that percent of PTHi reduction was related with baseline PTHi levels and taking sevelamer as phosphate binder at baseline. CONCLUSION: Use of cinacalcet improves grade of control of secondary hyperparathyroidism in non-selected patients in hemodialysis, showing poor response in population with higher PTHi levels and who takes higher doses of sevelamer at baseline. By contrast, a reduction of PTHi levels at 3 months of treatment with relatively lower doses is a pronostic marker of good response to cinacalcet treatment.

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

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

[Acute renal failure in a case of nephrotic syndrome secondary to focal and segmental glomerulosclerosis]. / Fracaso renal agudo en síndrome nefrótico secundario a glomeruloesclerosis focal y segmentaria.

Nephrotic syndrome is infrequently complicated with appearance of acute renal failure and minimal change disease is the glomerulopathy more usually involved. Pathogenesis is unclear and three possible mechanisms it has been proposed to explain the decrease of glomerular filtration rate: a severe reduction of glomerular permeability, the presence of acute tubular necrosis or an increased intrarenal pressure related with interstitial oedema. Here we present a 36 years-old-male with a nephrotic syndrome caused by focal and segmental glomerulosclerosis who developed an anuric acute renal failure. Renal function did not change despite oedema removal with haemodialysis and only after corticosteroid and cyclophosphamide therapy introduction we observed a rapid recovery of urinary output and resolution of acute renal failure. Renal biopsy did not show signs of tubular damage or obstruction with proteins nor significant interstitial oedema. Therefore, in this case we think acute renal failure was caused by a severe reduction in glomerular ultrafiltration rate and steroids were the effective treatment that allowed recovery of renal function.

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

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

Disreflexia autonómica y crisis hipertensiva / Autonomic dysreflexia and hypertensive episode

La disreflexia autonómica es una causa poco conocida de crisis hipertensiva y está asociada a las lesiones medulares por encima de T6. Está producida por una excesiva e incontrolada respuesta simpática por un mecanismo reflejo que permanece intacto a pesar de la lesión medular. Se pueden encontrar manifestaciones compatibles con disreflexia autonómica en el 50 %-70 % de aquellos pacientes con lesión medular. La medida terapéutica básica de este cuadro son las medidas posturales que pueden evitar la aparición de crisis hipertensivas con sus potenciales complicaciones. Presentamos el caso de un paciente con lesión medular postraumática desde hacía doce años que presentaba cefalalgias episódicas. La monitorización ambulatoria de la presión arterial permitió mostrar una abolición del ritmo nictameral de la presión arterial y ascensos tensionales bruscos tras la manipulación de la vía urinaria

Autonomic dysreflexia is a little known cause of hypertensive episode and is associated to spinal cord injury above T6. It is caused by excessive and uncontrolled sympathetic response due to a reflex mechanism that remains intact in spite of the spinal cord injury. Manifestations consistent with autonomic dysreflexia may be found in 50 %-70 % of those patients with spinal cord injury. Basic therapeutic measure of this clinical picture is postural measures that may avoid the appearance of hypertensive episodes with their potential complications. We present the case of a patient with a post-traumatic spinal cord injury occurring twelve years before who had episodic headaches. Ambulatory blood pressure monitoring made it possible to demonstrate the loss of nictameral rhythm of blood pressure and sudden pressure increases after urinary tract manipulation

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

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

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

A pesar de la alta prevalencia de enfermedad cardiovascular en los pacientesen hemodiálisis (HD), la incidencia de amputación de miembros inferiores (MMII)es poco conocida.Objetivo: Analizar incidencia y factores condicionantes de amputación no traumáticade MMII en los pacientes en HD.Métodos: Analizamos los pacientes incluidos en HD de 1/1/88 a 31/12/02 eidentificamos amputados y amputaciones efectuadas. Realizamos análisis uni ymultivariante de la asociación de amputación con edad, sexo, tiempo en HD, historiade diabetes, hipertensión arterial, infarto de miocardio (IM), accidente cerebrovascular(ACV), tabaquismo y niveles de colesterol, triglicéridos, hematocrito,urea, creatinina, calcio, fósforo, PTH y albúmina.Resultados: Se incluyeron 516 pacientes (59,5 ± 17 años, 102 diabéticos), tiempoen HD 40,15 ± 37 meses, seguimiento de 1.726 pacientes-año. Veinte (3,9%)sufrieron una o varias amputaciones, con incidencia de 1,1 paciente amputados/100 p-año. Once (10,8%) eran diabéticos, incidencia 4,2 amputados/100p-año. Nueve (2,2%) no diabéticos, con 0,6 amputados/100 p-año. Las amputacionesfueron 32: 21 mayores (supra e infracondíleas) y 11 menores (pies y dedos).El 60% falleció al año de su primera amputación y las causas de muerte fueroncardiovasculares en el 60% de los casos. En el análisis univariante los amputadostenian mayor edad, presencia de diabetes, tabaquismo, antecedentes de IM y ACV,colesterol y menor PTH. En el multivariante, diabetes: OR: 5,9 (IC 95%: 2,4-16,p = 0,000), IM: OR: 7,2 (IC 95%: 2,1-24,7, p = 0,002) y ACV: OR: 4,8 (IC 95%:1,3-17, p = 0,015), se asociaron de forma independiente con el riesgo de amputación.Conclusiones: La incidencia de amputación de MMII en los pacientes en HDes elevada. Factores de riesgo conocidos como diabetes y patología cardiovascularaterosclerótica establecida son condicionantes de amputación. La creciente inclusiónen HD de pacientes diabéticos y de edades avanzadas hace previsible elaumento de arteriopatia periférica lo que hace necesario planificar estrategias queprevengan su aparición y progresión a isquemia crítica

Background and aims: The purpose of this study was to assess the incidenceand risk factors for non-traumatic lower extremity amputation (LEA) in patients onhaemodialysis (HD).Methods: We investigated our HD population attending our clinic between Jan1988 and Dec 2002, who had had LEA. Uni- and multivariate analyses were usedto determine association of LEA with demographic characteristics such as diabetes,hypertension, smoking, myocardial infarction, stroke, dyslipidaemia, haematocrit,urea, creatinine, calcium, phosphorous, parathyroid hormone (PTH) and albuminlevels.Results: Of 516 patients, 20 (3.9%) underwent 32 amputations; 21 major and11 minor. The incidence was 1.1 amputees/100 p-years. There were 11 (10.8%)diabetics and 9 (2.2%) non-diabetics; incidence of 4.2 and 0.6 amputees/100p-years, respectively. Non-diabetic amputees were older than non-amputees: 68.9vs 58.2 years (p = 0.013) and had been on HD longer: 71.4 ± 44 vs 42 ± 37months (p = 0.019). There were 60% deaths within the first year of amputationand the causes were 60% cardiovascular. Univariate analysis indicated significantassociation of LEA with ageing, diabetes, smoking, myocardial infarction, stroke,high cholesterol, and low PTH levels. Multivariate Cox regression identified independentassociations of amputation with diabetes, previous myocardial infarctionand stroke and/or transient ischaemic attack.Conclusions: The incidence of LEA in HD patients is very high and is associatedwith diabetes and previous cardiovascular events. Advanced age and longertime on HD are factors related to LEA in non-diabetics. With increasing numbersof diabetics and older people on HD, new strategies are needed for peripheral arterialdisease management so as to avoid its progression to critical ischaemia