Risk Factors for Liver Fibrosis in Diabetic Patients with End-stage Renal Disease

Introduction: Liver cirrhosis is the fourth cause of death in the world. Fatty liver disease is the most common cause of chronic liver disease (CKD) in most countries. Identifying risk factors for liver fibrosis in a population with end-stage renal disease (ESRD) may facilitate early diagnosis of this complication and allow the activation of follow-up protocols to reduce morbidity and mortality in these patients. Materials and methods: A cross-sectional and analytical study was carried out. Patients on hemodialysis, older than 18 years with a diagnosis of diabetes mellitus and ESRD were included. The hypotheses were contrasted through the chi-square test and Student's T-test, as appropriate. Statistical significance was established at a p-value = 0.05. Results: A prevalence of significant liver fibrosis and cirrhosis of 17% was found. Factors associated with liver fibrosis were a history of cerebrovascular disease, peripheral vascular disease, body mass index (BMI), total cholesterol, glycosylated hemoglobin, sodium, and aspartate aminotransferase (AST). No relationship was observed between the NAFLD (non-alcoholic fatty liver disease) score, the APRI index (AST to Platelet Ratio Index), and fibrosis. Conclusion: The prevalence of significant liver fibrosis in patients with diabetes and ESRD is similar to that reported in other populations of patients with diabetes. However, some factors, such as BMI, could behave differently and favor the appearance of liver injury with lower degrees of obesity than previously reported in the literature.

Introducción: la cirrosis hepática es la cuarta causa de muerte en el mundo. Actualmente, la enfermedad hepática por depósito de grasa es la causa más frecuente de hepatopatía crónica en la mayoría de los países. La identificación de factores de riesgo para la presencia de fibrosis hepática en una población con enfermedad renal crónica terminal puede facilitar el diagnóstico temprano de esta complicación y permitir la activación de protocolos de seguimiento para disminuir la morbimortalidad en estos pacientes. Metodología: se realizó un estudio de corte transversal y analítico. Se incluyeron pacientes en hemodiálisis, mayores de 18 años con diagnóstico de diabetes mellitus y de enfermedad renal crónica terminal. El contraste de hipótesis se realizó a través de la prueba de chi cuadrado y la T de Student, según correspondiera. La significación estadística se estableció con un valor p = 0,05. Resultados: se observó una prevalencia de fibrosis hepática significativa y cirrosis del 17%. Los factores asociados a la presencia de fibrosis hepática fueron los antecedentes de enfermedad cerebrovascular, la enfermedad vascular periférica, el índice de masa corporal (IMC), el colesterol total, la hemoglobina glicosilada, el sodio y el aspartato-aminotransferasa (AST). No se observó relación entre el puntaje de NAFLD (enfermedad del hígado graso no alcohólico), el índice APRI (AST to Platelet Ratio Index) y la presencia de fibrosis. Conclusión: la prevalencia de fibrosis hepática significativa en pacientes con diabetes y ERCT es similar a la reportada en otras poblaciones de pacientes con diabetes. Sin embargo, algunos factores, como el IMC, podrían comportarse de forma diferente y favorecer la aparición de lesión hepática con grados menores de obesidad a los reportados previamente en la literatura.

Quality and Content Concordance of International Clinical Guidelines on Hypertensive Disorders of Pregnancy Using the AGREE II Instrument: An Updated Systematic Review.

Utilization of high-quality clinical practice guidelines has the potential to positively impact health outcomes. This study aimed to assess the quality and content concordance of national and international recommendations on hypertensive disorders of pregnancy (HDPs). Searches were conducted of the MEDLINE database and reference lists generated from national and international agencies. Covidence software was used for the management of the systematic review process, the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was used to assess guidelines for quality, and three reviewers independently screened records. The research team identified and screened a total of 399 records of which 10 were deemed high quality. Guidelines were assessed and compared regarding the treatment, prevention, and categorization of disorders. The quality of guidelines varied across different domains, with significant variation in domain scores even within individual guidelines. Not all recommendations showed a high level of methodologic rigor, and the highest-rated guidelines were from the American Heart Association, the World Health Organization, and South Africa national guidelines. Classification of hypertension differed among the guidelines, particularly in defining chronic hypertension, severe hypertension, and preeclampsia. Prevention modalities varied across guidelines, with recommendations for aspirin, calcium supplementation, and against the use of certain approaches. Treatment modalities highlighted the importance of delivery as the definitive way to terminate hypertensive disorders of pregnancy, with other management strategies provided for symptom control. The variability in guidelines and consensus statements across different contexts may reflect regional differences in healthcare practices, available resources, and research evidence. There is potential to harmonize guidelines for HDP globally while considering the unique needs of individual countries. Where guidelines may be synthesized and condensed into an accessible format, doing so could improve their use in clinical decision-making.

Recomendaciones sobre la vacunación contra SARS-CoV-2 en pacientes en diálisis y lista de espera de trasplante renal

Contexto las personas con diálisis se consideran una población de alto riesgo de infección por SARS-CoV-2, complicaciones y muerte. En Colombia, cerca del 44 % de la población en diálisis es menor de 60 años, adicionalmente, por los mismos retos que ha impuesto la pandemia a los programas de trasplantes, se ha incrementado notoriamente la población joven que debe seguir en diálisis al no tener opción a corto plazo de un trasplante renal, por lo tanto, las limitaciones en el acceso temprano a la vacunación contra SARS-CoV-2 agudizarían los problemas de esta población, provocando pérdidas considerables en años de vida que la vacuna podría salvar. Objetivo el objetivo del presente documento es sintetizar los principales motivos por los que se recomienda la priorización de la vacunación de los pacientes en diálisis crónica y lista de espera para trasplante renal. Metodología se realizó una búsqueda rápida de información sobre la vacunación en pacientes con ERC en diálisis o en espera de trasplante renal. La información resultante fue analizada críticamente por expertos en nefrología para la formulación de recomendaciones. Los resultados de la búsqueda se presentan a manera de síntesis narrativa. Resultados a partir de la información revisada y discutida por los expertos en nefrología se proponen 4 recomendaciones para la vacunación contra el virus SARS-Cov-2. Conclusiones la Asociación Colombiana de Nefrología e Hipertensión Arterial, la Asociación Colombiana de Nefrología Pediátrica y la Asociación Colombiana de Trasplante de Órganos, comprometidos con la salud de los pacientes con enfermedad renal en diálisis y listas de espera de trasplantes en Colombia, se unen a la solicitud mundial de generar recomendaciones para la vacunación contra SARS-CoV-2.

Background People on dialysis are considered a high-risk population for SARS-CoV-2 infection, complications, and death. In Colombia, about 44% of the population on dialysis is under 60 years of age. In addition, due to the same challenges that the pandemic has imposed on transplant programs, the young population that must continue on dialysis has increased markedly, as they have no option in the short term of a kidney transplant, therefore, the limitations in early access to vaccination against SARS-CoV-2 would exacerbate the problems of this population, causing considerable losses in years of life that the vaccine could save. Purpose The objective of this document is to summarize the main reasons why the prioritization of vaccination of patients on chronic dialysis and on the kidney transplant waiting list is recommended. Methodology A rapid search for information on vaccination in patients with CKD on dialysis or awaiting kidney transplantation was performed. The resulting information was critically analyzed by experts in nephrology for the formulation of recommendations. The search results are presented as a narrative synthesis. Results Based on the information reviewed and discussed by nephrology experts, 4 recommendations are proposed for vaccination against the SARS-Cov-2 virus. Conclusions The Colombian Association of Nephrology and Arterial Hypertension (ASOCOLNEF), the Colombian Association of Pediatric Nephrology (ACONEPE) and the Colombian Association of Organ Transplantation (ACTO), committed to the health of patients with kidney disease on dialysis and transplant waiting lists in Colombia, join to generate recommendations for prioritization and vaccination against SARS-CoV-2.

Recommendations of high-quality clinical practice guidelines related to the process of starting dialysis: A systematic review.

BACKGROUND: The optimal time for initiation of dialysis and which modality to choose as the starting therapy is currently unclear. This systematic review aimed to assess the recommendations across high-quality clinical practice guidelines (CPGs) related to the start of dialysis. METHODS: We systematically searched MEDLINE, EMBASE, Web of Science, LILACS, and databases of organisations that develop CPGs between September 2008 to August 2021 for CPGs that addressed recommendations on the timing of initiation of dialysis, selection of dialysis modality, and interventions to support the decision-making process to select a dialysis modality. We used the Appraisal of Guidelines for Research and Evaluation instrument to assess the methodological quality of the CPGs and included only high-quality CPGs. This study is registered in PROSPERO, number CRD42018110325. RESULTS: We included 12 high-quality CPGs. Six CPGs addressed recommendations related to the timing of initiating dialysis, and all agreed on starting dialysis in the presence of symptoms or signs. Six CPGs addressed recommendations related to the selection of modality but varied greatly in their content. Nine CPGs addressed recommendations related to interventions to support the decision-making process. Eight CPGs agreed on recommended educational programs that include information about dialysis options. One CPG considered using patient decision aids a strong recommendation. LIMITATIONS: We could have missed potentially relevant guidelines since we limited our search to CPGs published from 2008, and we set up a cut-off point of 60% in domains of the rigour of development and editorial independence. CONCLUSION: High-quality CPGs related to the process of starting dialysis were consistent in initiating dialysis in the presence of symptoms or signs and offering patients education at the point of decision-making. There was variability in how CPGs addressed the issue of dialysis modality selection. CPGs should improve strategies on putting recommendations into practice and the quality of evidence to aid decision-making for patients. REGISTRATION: The protocol of this systematic review has been registered in the international prospective register of systematic reviews (PROSPERO) under the registration number: CRD CRD42018110325. https://clinicaltrials.gov/ct2/show/CRD42018110325.

Clinical and histopathological characteristics of diabetic patients with nephrotic proteinuria. A case series / Características clínicas e histopatológicas de pacientes diabéticos con proteinuria nefrótica. Una serie de casos

Abstract Objective: to describe the clinical and histopathological characteristics of diabetic patients with nephrotic-range proteinuria. Materials and methods: the kidney biopsies of diabetic patients with nephrotic proteinuria were reviewed. Descriptive analyses were performed along with a comparison of three groups according to the histopathological findings. Results: the medical charts of 19 patients from 2018 through 2020 were collected, most of whom (94.7%) were diagnosed with type 2 diabetes mellitus (DM), with an average age of 58 years, and an average duration of DM of 9.9 years (SD: ±7.3). The findings from biopsies performed throughout the years prior to data collection showed that 26.3% had diabetic nephropathy as the only finding, 31.6% had a nephropathy other than diabetic nephropathy, and 42.1% had findings of both diabetic and nondiabetic nephropathy. A comparison of the groups showed a significant difference in the duration of DM, which was greater in patients with diabetic nephropathy (16.4 vs. 5 vs. 9.5 years, respectively, p: 0.024). Conclusions: we present a case series of diabetic patients with nephrotic-range proteinuria in Colombia, showing that kidney biopsy lesions other than diabetic nephropathy may be a cause of proteinuria. We found that patients with a report of DN alone had a much longer duration of diabetes. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2231).

Resumen Objetivo: describir las características clínicas e histopatológicas de pacientes diabéticos con proteinuria en rango nefrótico. Material y métodos: se revisaron biopsias renales de pacientes diabéticos con proteinuria ne frótica, se realizaron análisis descriptivos y comparación entre tres grupos de acuerdo con hallazgos histopatológicos. Resultados: se recolectaron historias de 19 pacientes, entre los años 2018 y 2020, la mayoría (94.7%) con diagnóstico de diabetes mellitus (DM) tipo 2, edad promedio de 58 años, con un tiempo de evolución de la DM en promedio de 9.9 años (DE: ±7.3). En los hallazgos de la biopsia, practica das a lo largo de años anteriores a la recolección, se encontró que 26.3% tenían nefropatía diabética como único hallazgo, el 31.6% otra nefropatía diferente a la diabética y 42.1% hallazgos tanto de nefropatía diabética como no diabética. Al comparar los grupos se encontró diferencia significativa en el tiempo de evolución de la DM, siendo mayor en pacientes con nefropatía diabética (16.4 vs 5 vs 9.5 años respectivamente, p: 0.024). Conclusiones: se presenta una serie de casos de pacientes diabéticos con proteinuria en rango nefrótico en Colombia, mostrando que existen lesiones diferentes a la nefropatía diabética en la biopsia renal como posible causa de la proteinuria. Se encontró que los pacientes en quienes se reportó ND únicamente, tenían un tiempo de evolución de la diabetes mucho mayor. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2231).

Concordance of estimated glomerular filtration rate according to the formulas used in Colombia for patients with chronic kidney disease not on dialysis / Concordancia de la filtración glomerular estimada según las fórmulas utilizadas en Colombia en pacientes con enfermedad renal crónica no en diálisis

Abstract Introduction: the Colombian guidelines for chronic kidney disease (CKD) recommend estimating glomerular filtration (GF) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. No studies have been performed in the Colombian population to compare the accuracy of this equation to that of others used in clinical practice. Design and methods: we evaluated the GF estimation performance of the Modification of Diet in Renal Disease (MDRD-4), Cockroft-Gault (CG) and body surface area adjusted Cockroft-Gault (CG-BSA) equations against the CKD-EPI equation in 757 adult patients. Performance was evaluated using bias, precision and accuracy measurements. Results: the mean GF by CKD-EPI was 37.32±12.71 mL/min/1.73m2; by MDRD-4 it was 39.8±13.2 mL/min/1.73m2, by CG it was 35±12.6 mL/min and by CG-BSA it was 34.52±11.34 mL/ min/1.73m2. All the equations had bias with respect to GF by CKD-EPI. The most accurate equation was GF estimated by MDRD-4 (MeGF) with 97.1 and 99.74% of measurements within 15 and 30%, respectively; and the least accurate was GF estimated by CG (CGeGF) with 59.7 and 81.77% of the measurements within 15 and 30%, respectively. The concordance correlation coefficient between GF by CKD-EPI and MDRD-4 was 0.97, with CG and CG-BSA at 0.78 and 0.85, respectively Conclusions: the most accurate alternative equation for estimating glomerular filtration in this Colombian population is MDRD-4, which has a high concordance with the CKD-EPI equation. Estimation of GF with the CG equation is not recommended.

Resumen Introducción: las guías colombianas de enfermedad renal crónica (ERC) recomiendan estimar la filtración glomerular (FG) con la fórmula de epidemiología de la enfermedad renal crónica (CKD-EPI). No se han realizado estudios que comparen en la población colombiana la exactitud de esta fórmula con otras utilizadas en la práctica clínica. Diseño y métodos: en 757 pacientes adultos evaluamos el desempeño para estimar la FG por las fórmulas de la modificación de la dieta en la enfermedad renal (MDRD-4), Cockroft-Gault (CG) y Cockroft-Gault corregida para la superficie corporal (CG-SC) comparada con la fórmula de CKD-EPI. El desempeño se evaluó con mediciones del sesgo, precisión y exactitud. Resultados: la media de la FG por CKD-EPI fue 37.32±12.71 mL/min/1.73m2, por MDRD-4 de 39.8±13.2 mL/min/1.73m2, por CG fue 35±12.6 mL/min y por CG-SC de 34.52±11.34 mL/ min/1.73m2. Todas las fórmulas tuvieron un sesgo con relación a la FG por CKD-EPI. La fórmula más exacta fue la FG estimada por MDRD-4 (FGeM) con una proporción de mediciones dentro del 15 y 30% en 97.1 y 99.74% de las mediciones respectivamente, y la menos exacta fue la FG estimada por CG (FGeCG) con 59.7 y 81.77% de las mediciones dentro del 15 y 30% respectivamente. El coeficiente de correlación de concordancia entre la FG por CKD-EPI y MDRD-4 fue de 0.97, con CG y CG-SC de 0.78 y 0.85, respectivamente. Conclusiones: la fórmula alterna más exacta para estimar la filtración glomerular en esta población colombiana es la MDRD-4 que tiene una alta concordancia con la fórmula de CKD-EPI. Se sugiere no utilizar la estimación de la FG con la fórmula de CG.

Recomendaciones para el uso racional de la prueba 25-hidroxivitamina D Resumen de política

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The exponential increase in the request for laboratory tests of 25-Hydroxyvitamin D or [25 (OH) D has ignited the alarms and generated a strong call for attention, since it may reflect deficiencies in the standardization of clinical practice and in the use non-systematic scientific evidence for decision-making in real life, which allows to analyze the indications of the test, its frequency, interpretation and even to assess the impact for health systems, especially when contrasted with the minimum or almost. No effects of the strategy of screening or supplying indiscriminately to the general population, without considering a comprehensive clinical assessment of risks and needs of people. From a purely public health impact point of view, the consequence of massive and unspecified requests is affecting most of the health systems and institutions at the global level. The primary studies that determined average population intake values have been widely used in the formulation of recommendations in Clinical Practice Guidelines, but unfortunately misinterpreted as cut points to diagnose disease and allow the exaggerated prescription of nutritional substitution. The coefficient of variation in routine tests to measure blood levels of 25 (OH) D is high (28%), decreasing the overall accuracy of the test and simultaneously, increasing both the falsely high and falsely low values. The most recent scientific evidence analyzes and seriously questions the usefulness and the real effect of the massive and indiscriminate practice of prescribing vitamin D without an exhaustive risk analysis. The available evidence is insufficient to recommend a general substitution of vitamin D to prevent fractures, falls, changes in bone mineral density, incidence of cardiovascular diseases, cerebrovascular disease, neoplasms and also to modify the growth curve of mothers' children. They received vitamin D as a substitute during pregnancy. The recommendations presented in the document are based on the critical analysis of current evidence and the principles of good clinical practice and invite to consider a rational use of 25 (OH) D tests in the context of a clinical practice focused on people and a comprehensive assessment of needs and risks. The principles of good practice suggest that clinicians may be able to justify that the results of the 25 (OH) D test strongly influence and define clinical practice and modify the outcomes that interest people and impact their health and wellness. Currently there is no clarity on how to interpret the results, and the relationship between symptoms and 25 (OH) D levels, which may not be consistent with the high prevalence of vitamin D deficiency reported. For this reason, it is suggested to review the rationale of the request for tests for systematic monitoring of levels of 25 (OH) D or in all cases where substitution is performed. Consider the use of 25 (OH) D tests within the comprehensive evaluation of people with suspicion or confirmation of the following conditions: rickets, osteomalacia, osteoporosis, hyper or hypoparathyroidism, malabsorption syndromes, sarcopenia, metabolic bone disease.

Quality assessment of clinical practice guidelines for chronic kidney disease: a systematic review.

BACKGROUND: Chronic kidney disease (CKD) is a worldwide public health problem. Clinical practice guidelines (CPGs) are being developed and implemented in order to improve clinical practice related to the detection and treatment of CKD. The objective of our study was to evaluate the quality of CPGs regarding the CKD and to examine whether there are factors which influence their quality. METHODS: A systematic search was conducted to identify all CPGs regarding the early diagnosis and treatment of CKD. The CPGs quality were evaluated by three reviewers using the AGREE II instrument to decide if the guidelines are recommended for their use in clinical practice. RESULTS: In total, 13 CPGs were identified: five from America, six from Europe, one from Asia, and one from Oceania. Five CPGs were recommended for their use in clinical practice; since all their domains achieved the medium or high category. Furthermore, six CPGs were recommended with modifications, as the stakeholders' involvement, applicability, and editorial independence domains were evaluated as low category. These domains, as well as the rigor of the development domain, reached the very low category in those CPGs that were not recommended for its use in clinical practice. In all CPGs, the domains with the lowest average were the stakeholder involvement and the applicability. When comparing the domains of the CPGs according to the origin, type of developer group, the checklist used during the development and the publication period, a significantly higher average in the domain stakeholder involvement was found in the CPGs from Asia and Oceania compared to the ones in Latin America. Additionally, a significantly higher average in the applicability domain was found in the CPGs developed by CPGs developer organizations compared to those developed by medical societies. CONCLUSIONS: In total, 85% of the CPGs regarding CKD were recommended or recommended with modifications. The stakeholder involvement and applicability domains are assessed in the low category, which might affect the CPGs implementation. In order to save resources in low- and middle-income countries, an adaptation of the recommended CPGs should be considered.

Early versus delayed erythropoietin for the anaemia of end-stage kidney disease.

BACKGROUND: Anaemia is a common complication in people with chronic kidney disease (CKD) and mainly develops as a consequence of relative erythropoietin (EPO) deficiency. Anaemia develops early in the course of disease and peaks among people with end-stage kidney disease (ESKD). Many types of EPO - also called erythropoiesis-stimulating agents (ESAs) - are used to treat anaemia in people with ESKD.ESAs have changed treatment of severe anaemia among people with CKD by relieving symptoms and avoiding complications associated with blood transfusion. However, no benefits have been found in relation to mortality rates and non-cardiac fatal events, except quality of life. Moreover, a relationship between ESA use and increased cardiovascular morbidity and mortality in patients with CKD has been reported in studies with fully correcting anaemia comparing with partial anaemia correction. Until 2012, guidelines recommended commencing ESA treatment when haemoglobin was less than 11 g/dL; the current recommendation is EPO commencement when haemoglobin is between 9 and 10 g/dL. However, advantages in commencing therapy when haemoglobin levels are greater than 10 g/dL but less than 11 g/dL remain unknown, especially among older people whose life expectancy is limited, but in whom EPO therapy may improve quality of life. OBJECTIVES: To assess the clinical benefits and harms of early versus delayed EPO for anaemia in patients with ESKD undergoing haemodialysis or peritoneal dialysis SEARCH METHODS: We searched the Cochrane Kidney and Transplant Specialised Register to 8 July 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA: We planned to include randomised controlled trials (RCTs) and quasi-RCTs evaluating at the clinical benefits and harms of early versus delayed EPO for anaemia in patients with ESKD undergoing haemodialysis or peritoneal dialysis. Studies comparing EPO with another EPO, placebo or no treatment were eligible for inclusion. DATA COLLECTION AND ANALYSIS: It was planned that two authors would independently extract data from included studies and assess risk of bias using the Cochrane risk of bias tool. For dichotomous outcomes (all-cause mortality, cardiovascular mortality, overall myocardial infarction, overall stroke, vascular access thrombosis, adverse effects of treatment, transfusion), we planned to use the risk ratio (RR) with 95% confidence intervals (CI). We planned to calculate the mean difference (MD) and CI 95% for continuous data (haemoglobin level) and the standardised mean difference (SMD) with CI 95% for quality of life if different scales had been used. MAIN RESULTS: Literature searches yielded 1910 records, of these 1534 were screened after duplicates removed, of which 1376 were excluded following title and abstract assessment. We assessed 158 full text records and identified 18 studies (66 records) that were potentially eligible for inclusion. However, none matched our inclusion criteria and were excluded. AUTHORS' CONCLUSIONS: We found no evidence to assess the benefits and harms of early versus delayed EPO for the anaemia of ESKD.