Early Steroid Withdrawal in Recipients of a Kidney Transplant From a Living Donor: Experience of a Single Mexican Center.

BACKGROUND: Early steroid withdrawal (ESW) can improve lipid and hemodynamic profiles without severe acute rejection (AR) events in renal transplant patients. Our objective was to evaluate the effects of ESW on the frequency and severity of AR. METHODS: A randomized, open-label, controlled clinical trial was performed on renal transplant recipients with a follow-up of 12 months. In the ESW group, patients were selected for corticosteroid treatment withdrawal on the fifth day post transplantation. In the Control group, patients continued with steroid treatment. All patients were over 18 years of age with panel reactive antibody (PRA) class I and II HLA <20%. RESULTS: In total, 71 patients, 37 in the ESW group (52.1%) and 34 in the Control group (47.9%), had comparable AR incidences at the end of the follow-up (16% vs 15%) (NS) (RR = 1.20, 95% CI = 0.32-3.33). Although renal graft survival was similar between the ESW and Control groups (87% vs 94%), renal function was superior in the ESW group (85 vs 75 mL/min). Additionally, hypertension was less frequent in the ESW group (3% vs 35%), requiring the use of fewer antihypertensives (8% vs 50%). CONCLUSIONS: ESW was also associated with better blood pressure control and similar AR risk. The ESW group exhibited stable renal function.

Management of chronic kidney disease: primary health-care setting, self-care and multidisciplinary approach.

INTRODUCTION: End-stage renal disease (ESRD) is a growing problem, particularly in developing countries. Factors closely related with lifestyle and dietary habits that negatively affect kidney function are rarely modified by isolated medical intervention. Therefore, the present study was designed to determine the effect of an educational program with a multidisciplinary health-care approach supported by self-help groups on the lifestyle and dietary habits of patients at high risk of developing chronic kidney disease (CKD). PATIENTS: 51 patients with overweight/obesity, 45 with hypertension and 88 with Type 2 diabetes mellitus (DM2) from a Family Medicine Unit, who had failed to meet clinical practice recommendations, were studied over 6 months. Patients received educational intervention guided by a multidisciplinary health team for 4 weeks (including topics such as emotional management, nutritional patterns, exercise and health-related problems). Reinforcement of goals and group dynamics were performed every 3 months. Additionally, self-help groups were constituted during the first month, and functioned with free activities, selected by patients and supported by the health team, for the duration of the study. A lifestyle questionnaire was administered at baseline and the end of the study; clinical and biochemical evaluations were performed every 3 months. RESULTS: Baseline lifestyle and dietary habits were unhealthy in all groups, particularly with regard to diet and exercise, and clinical and biochemical variables were concordant with inadequate achievement of clinical practice recommendations. After 6 months experience within this program, many of the negative lifestyle characteristics significantly improved. All groups reported a notable improvement in nutritional and exercise habits, as well as in management of the emotions. Only diabetic and hypertensive patients significantly improved the knowledge of their disease and adherence to treatment. None of the groups managed to reduce smoking or to cut their alcohol intake habits; however, relatively few participants had displayed these behaviors at the start of the study. Compared to baseline, all the groups significantly reduced body mass index and waist circumference. Additionally, diabetics and overweight/ obese patients significantly reduced blood glucose and increased GFR, and hypertensive patients significantly decreased systolic blood pressure and tended, although not significantly, to increase GFR. Remarkably, all these changes were independent of drug treatment, because none of the therapeutic interventions that had been formerly prescribed by family physicians had been significantly changed by the end of the follow-up in any of the groups. CONCLUSIONS: The implementation of educational strategies comprising multiple interventions for patients, guided by health professionals (multidisciplinary teams including primary doctors, dietitians, nurses, social workers), and probably supported by self-help groups, may be very helpful in modifying negative lifestyle and dietary habits. Educational interventions by both doctors and patients should be adopted concurrently and may help to control the enormous and growing problem of ESRD.

El tipo de transporte peritoneal puede ser diferente en las distintas poblaciones de diálisis peritoneal de México / Transport and peritoneal dialysis

Introducción: La prueba de equilibrio peritoneal (PEP) esla más utilizada para clasificar el transporte peritoneal(TP). Los valores de referencia para población mexicanase establecieron en el Instituto Nacional de Nutrición SalvadorZubirán (INNSZ) hace más de 10 años. El objetivode este estudio fue evaluar el TP en población del occidentedel país, y comparar los resultados con los de Twardowskiy colaboradores y del INNSZ.Resultados: Se realizaron 159 pruebas; 48% pacienteseran diabéticos y 62% hombres. La edad fue 46±16años, peso 66.8±17.0 kg, y superficie corporal1.70±0.23 m2. No hubo diferencias entre grupos endiabetes ni peritonitis. El tiempo en diálisis fue menor ennuestro estudio que en del INNSZ (14.6±17.8 vs20.8±21.4 meses; p<0.05). Comparados con Twardowskie INNSZ, las D/P de creatinina 0, 2 y 4-h fueronmayores, y las D/D0 2 y 4-h, así como el volumen drenadofueron menores en el presente estudio. Utilizandovalores de referencia propios, el transporte alto (A) seobservó en 18%, promedio alto (PA) en 33%, promediobajo (PB) en 34% y bajo (B) en 15%, mientras que usandovalores del INNSZ el transporte A fue 23%, PA 36%,PB 33% y B 8%. Conclusión: Los pacientes de la población estudiada tuvieronvalores promedio de transporte peritoneal más altos que losde otros estudios, incluyendo población mexicana. En condicionesideales, es recomendable determinar valores de referenciaen cada centro, puesto que extrapolarlos de otrasregiones podría llevar a errores en el diagnóstico del tipo de TP

Introduction: Peritoneal equilibration test (PET) is the mostcommon test to classify peritoneal transport (PT). Referencevalues from Mexican population were established in the InstitutoNacional de la Nutrición Salvador Zubirán (INNSZ)more than 10 years ago. The aims of this study were to evaluatePT in a west of Mexico population (Hospital de Especialidades,Centro Médico Nacional de Occidente [HE,CMNO]), and to compare results with those obtained byTwardowski et al and in the INNSZ.Results: One-hundred fifty-nine PETs were performed; 48%patients were diabetics and 62% were male. Mean age was46±16 years, weight 66.8±17.0 kg and body surface area1.70±0.23 m2. There were no differences between groupsregarding diabetes or peritonitis frequency. Time on dialysis wasshorter in the present study than in the INNSZ (14.6±17.8 vs20.8±21.4 months; p<0.05). Compared to the Twardowskiand INNSZ studies, creatinine D/P ratio at 0, 2 and 4-h werehigher, and the D/D0 ratio at 2 and 4-h, and drained volumewere lower in our population. Using values obtained in the presentstudy, high transport (H) was present in 18%, high average(HA) in 33%, low average (LA) in 34% and low (L) in 15%,whereas employing the INNSZ reference values, H was presentin 23%, HA in 36%, LA in 33% and L in 8%. Conclusions: Patients from this studied population hadmean peritoneal transport values higher than those obtainedin other studies, including Mexican values. Ideally, it isrecommendable to determine reference values in every center,as extrapolating results from other regions may lead toerrors in diagnosing the peritoneal transport type

[Hypoalbuminemia in dialysis. Is it a marker for malnutrition or inflammation?]. / Hipoalbuminemia en diálisis. Es marcador de desnutrición o de inflamación?

Hypoalbuminemia in dialysis is a highly prevalent condition associated with morbidity and mortality. Hypoalbuminemia, although not synonymous of malnutrition, is highly related to it. Poor nutrient intake, frequently observed in uremia, may cause malnutrition and subsequently hypoalbuminemia. In addition, it has been recently reported that a systemic inflammatory response may participate in developing hypoalbuminemia in chronic renal failure. Uremia per se, or through mechanisms stimulated by the use of current dialysis membranes and/or solutions, seems to trigger the inflammatory process, remarkably associated with hypoalbuminemia. Infections, to which patients on dialysis are particularly predisposed, stimulate production of the inflammatory response as well. Other conditions non-associated to inflammatory response, such as the protein losses through dialysis, may cause and increase malnutrition. Overhydration, frequently present in patients with renal failure, on the one hand causes dilution of serum albumin concentrations, and on the other hand, is cause of onset and/or enhancement of congestive cardiac failure, which in turn may be associate with malnutrition. Patients with chronic renal failure develop hypoalbuminemia due to a complex setting of conditions, with systemic inflammatory response as a major cause; notwithstanding, other factors such as malnutrition and overhydration can also play a relevant role. Therefore, diagnostic and therapeutic approaches should be individualized.

Peritoneal protein loss in patients with high peritoneal permeability: comparison between continuous ambulatory peritoneal dialysis and daytime intermittent peritoneal dialysis.

BACKGROUND: Dialysate protein loss is involved in the etiology of hypoalbuminemia and malnutrition on continuous ambulatory peritoneal dialysis (CAPD). Patients with high peritoneal membrane permeability had the lowest serum albumin (Alb) and highest dialysate protein concentrations and achieved higher small solute dialysis/plasma equilibration in a shorter time than patients with low peritoneal transport. The aim of this prospective crossover study was to evaluate whether protein loss might be decreased in patients with high peritoneal permeability on short dwell-time (DT) peritoneal dialysis. METHODS: Five high and nine high-average peritoneal transport patients were subjected to the following sequential dialysis schemes (four exchanges/day, glucose 1.5%): scheme A, three daytime exchanges (4-6 h DT) and one nightly (8-12 h DT) for 2-3 days, scheme B, 3-h DT each and dry peritoneum at night during 5 days, a wash-out period similar to scheme A, and scheme C, 2-h DT each and dry peritoneum the remainder of day and night during 5 days. Dialysate Alb, IgG, IgA, and IgM losses and adequacy of dialysis were evaluated at the end of each scheme. RESULTS: Dialysate IgM was not detected. All protein losses were reduced with the short DT dialysis schemes; however, dialysis CCl and KT/V(urea) were also decreased. In patients with high peritoneal transport type, the 3-h DT dialysis scheme achieved a reduction in Alb loss without significant reduction of adequacy of dialysis. CONCLUSIONS: Peritoneal Alb, IgG, and IgA losses are significantly reduced in patients with high peritoneal permeability on short dwell-time dialysis and extended dry periods. However, a reduction of dialysis contribution to small solute clearances was also observed, Three-hour dwell-time dialysis may be particularly useful in patients with high peritoneal transport type, as it tends to reduce peritoneal protein loss without notably reducing adequacy of dialysis.

Association of sex hormone status with the bone loss of renal transplant patients.

BACKGROUND: Bone loss is an important problem in renal transplantation recipients. The role of sex hormones in this setting has not been previously addressed. The objective was to investigate whether sex hormone status is associated with bone mass loss in renal transplant recipients. METHODS: Thirty patients (16 men and 14 women, of which eight were post-menopausal) were studied by bone densitometry and bone biopsy. In women, serum oestradiol levels and menopausal status were determined; in men, serum testosterone levels were assessed. RESULTS: Mean age was 48+/-11 years. Time on dialysis was 13+/-17 months, and time since transplantation was 125+/-67 months. Thirteen patients were on cyclosporine A (CsA) monotherapy, 12 on azathioprine plus prednisolone (PRED) dual therapy, and five on CsA, azathioprine and PRED triple therapy. In men, serum testosterone levels were 19.7+/-6.8 nmol/l (mean+/-SD). In pre-menopausal women, oestradiol serum levels were 209(128-289) pmol/l (median (percentiles 25-75%)), and in post-menopausal women 93(54-299) pmol/l (non-significant). Univariate analysis in women demonstrated that serum oestradiol levels were positively correlated with Z scores of osteoblast surface (r=0.70, P=0.005), osteoid surface (r=0.75, P=0.002) and trabecular wall thickness (r=0.68, P=0.008). In men, a weak correlation was seen between serum testosterone levels and the cumulative dose of PRED (r=-0.52, P=0.06). In the multivariate analysis, two models of multiple regression were employed (one for women and one for men), considering the densitometric and histomorphometric variables (Z scores) as dependent variables. Serum testosterone in men did not predict any of the densitometric nor histomorphometric variables analysed, while serum oestradiol in women was an independent predictor for the osteoblast surface (r=0.81, P=0.003), osteoid surface (r=0.82, P=0.009) and trabecular wall thickness (r=0.54, P=0.05). CONCLUSIONS: In female renal transplant recipients, serum oestradiol levels independently predict the bone status, while in men, factors other than testosterone seem to influence bone loss. Our results give rise to the hypothesis that sex hormone replacement therapy may play a role in prevention and/or treatment of the bone loss in women following renal transplantation.

Long-term CAPD survival and analysis of mortality risk factors: 12-year experience of a single Mexican center.

OBJECTIVE: To evaluate patient and technique survival, and to analyze mortality risk factors in a large Mexican single-center continuous ambulatory peritoneal dialysis (CAPD) program. DESIGN: Cohort study. SETTING: Tertiary care, teaching hospital located in Mexico City. PATIENTS: All patients from our CAPD program (1985-1997) were retrospectively studied. INTERVENTIONS: Clinical and biochemical variables at the start of dialysis were recorded and considered in the analysis of risk factors. MAIN OUTCOME MEASURES: End points were patient (alive, dead, or lost to follow-up) and technique status at the end of the study (December 1997). RESULTS: 627 patients, 37% with diabetes mellitus (DM), were included. Median patient survival (+/- SE) was 5.1 +/- 0.6 years. In the univariate analysis, the following variables were associated (p < 0.05) with mortality: DM, old age, hypoalbuminemia, low serum creatinine, low serum phosphate, and lymphopenia. In the multivariate analysis, the only significant mortality risk factors were DM (RR 2.56, p < 0.0001), old age (RR 1.01, p = 0.01), hypoalbuminemia (RR 0.77, p = 0.04), and lymphopenia (RR 0.98, p = 0.05). Median technique survival was 4.0 +/- 0.2 years. Peritonitis, hypoalbuminemia, lymphopenia, old age, and DM were all significantly associated (p < 0.05) with technique failure in the univariate analysis, while in the multivariate analysis, only DM (RR 1.78, p = 0.001), peritonitis (RR 1.13, p = 0.004), lymphopenia (0.98, p = 0.04), and hypoalbuminemia (RR 0.80, p = 0.06) were technique failure predictors. CONCLUSIONS: Patient survival in our setting is similar to that reported in other series. Diabetes mellitus, lymphopenia, and hypoalbuminemia were the strongest predictive factors for mortality and technique failure on CAPD. Our 12-year CAPD program is one of the largest single-centers reported in CAPD literature.

Effect of 1,25-dihydroxyvitamin D3 and calcium carbonate on bone loss associated with long-term renal transplantation.

To investigate the effect of calcitriol plus calcium carbonate on the bone loss associated with long-term renal transplantation, 30 patients with serum creatinine levels less than 2.0 mg/dL were randomly allocated to a control (n = 14) or treatment group (n = 16) and studied with bone biopsy and densitometry at baseline and after 1 year of follow-up. Calcitriol (0.25 microg/d) plus calcium carbonate (500 mg/d of elemental calcium) were administered to patients in the treatment group. Comparing the baseline and final data of each group at a time, no change in bone mineral density (BMD) z score was observed at the distal radius (control, -0.8 +/- 0.8 versus -0.6 +/- 0.9; treatment, -1.0 +/- 1.0 versus -1.0 +/- 1.1). However, a significant increase (P < 0.05) was found at the lumbar spine in both groups (control, 0.1 +/- 1.6 versus 0.4 +/- 1.6; treatment, -0.1 +/- 1.5 versus 0.3 +/- 1.5) and only in the treatment group at the femoral neck (control, -0.9 +/- 1.0 versus -0.8 +/- 1.0; treatment, -0.5 +/- 0.9 versus -0.3 +/- 1.1). When BMD was compared between groups, no significant differences were observed at the evaluated anatomic sites at baseline or after 1 year of follow-up. After 1 year of follow-up, adjusting for age and sex (z score), the control group showed a trend to reduce the value of several histomorphometric parameters, including osteoblast surface (-2.2 +/- 6.1 versus -3.4 +/- 3.9), osteoid surface (-2.3 +/- 3.5 versus -3.1 +/- 3.9), and osteoclast surface (0.2 +/- 5.0 versus -1.3 +/- 3.3). Consequently, there was a significant reduction (P < 0.05) in mineralizing surface (-9.8 +/- 11.0 versus -15.8 +/- 12.3) and appositional rate (-5.8 +/- 2.7 versus -7.6 +/- 2.2). In the treatment group, a significant reduction (P < 0.05) in osteoclast surface was observed at the end of the study (3.9 +/- 6.8 versus -1.2 +/- 4.1), and although a trend to reduce osteoblast surface (-2.5 +/- 2.6 versus -3.2 +/- 5.7) and osteoid surface (-2.1 +/- 2.5 versus -3.2 +/- 2.8) was also found, patients maintained approximately the same level of wall thickness (-5.2 +/- 5.3 versus -5.3 +/- 3.3) and bone volume (-2.7 +/- 1.8 versus -2.5 +/- 1.7). However, there was no improvement in mineralizing surface (-4.2 +/- 2.9 versus -10.4 +/- 3.6) or appositional rate (-5.8 +/- 3.1 versus -8.1 +/- 2.6). No significant differences in bone histomorphometric variables were observed between groups after 1 year of follow-up. In conclusion, 1,25-dihydroxyvitamin D3 and calcium carbonate did not significantly improve bone loss in long-term renal transplant recipients. However, significant osteoclast suppression and a trend to maintain trabecular bone volume and wall thickness as well as improve the axial BMD were observed in the treatment group.

Is high peritoneal transport rate an independent risk factor for CAPD mortality?

UNLABELLED: Is high peritoneal transport rate an independent risk factor for CAPD mortality? BACKGROUND: Patients with high peritoneal transport display the lowest serum albumin (SAlb) and the highest peritoneal protein loss. An association between high peritoneal membrane permeability and diabetes mellitus (DM) has been suggested. As malnutrition, hypoalbuminemia, and DM cause high mortality, it is probable that a high peritoneal transport rate is associated with high mortality on continuous ambulatory peritoneal dialysis (CAPD). The aim of the study was to identify whether a high peritoneal transport rate is an independent risk factor for mortality on CAPD. METHODS: We included 167 patients with a peritoneal equilibration test that was performed between January 1994 and July 1997. The endpoint was the patient's status (alive, dead, or lost) in December 1997. Survival analysis was done by the Kaplan-Meier method and multivariate Cox proportional-hazard model. RESULTS: DM was significantly more frequent in the high (H) peritoneal transport type (20 out of 33) and was less frequent in the low (L) transport group (3 out of 18). SAlb (g/dL) was significantly lower as the peritoneal transport type was higher [H 2.7 +/- 0.5, high average (HA) 2.9 +/- 0.7, low average (LA) 3.2 +/- 0.6, and L 3.6 +/- 0.5]. Serum creatinine (SCr) was significantly higher in the L transport type (12.0 +/- 4.3 mg/dL) than in the other transport groups (H 8.7 +/- 3.1, HA 8.6 +/- 3.7, and LA 9.6 +/- 4.5). No other differences were found between peritoneal transport types. In the univariate analysis, high peritoneal transport rate, DM, low SCr, low SAlb, and older age significantly predicted mortality. However, in the multivariate analysis (chi2 = 40.55, P < 0.0001), only DM (b = 1.34, P = 0.0001), low SCr (b = -0.11, P = 0.02), and high peritoneal transport rate (b = 2.6, P = 0.06) were shown as mortality risk factors. CONCLUSIONS: DM was the most important risk factor for mortality on CAPD. A high peritoneal transport rate also predicted mortality, yet its role seems to be related to the presence of DM. The role of higher SCr predicting a better survival might have been associated with a better nutritional status. Hypoalbuminemia, previously shown as risk factor for mortality, did not play an important role in this study, probably because of its collinearity with DM.

Quantification and characterization of protein loss in continuous ambulatory peritoneal dialysis.

BACKGROUND/AIMS: Dialysate protein loss is involved in the etiology of hypoalbuminemia and malnutrition on CAPD. There is no information regarding the peritoneal transport of proteins in neither Mexican nor LatinAmerican CAPD patients. Therefore, the aim of this study was to quantify and characterize the peritoneal membrane transport of albumin (Alb), IgG, IgA, and IgM in CAPD patients. In addition, factors associated to protein losses were investigated. METHODS: Thirty-seven CAPD patients were randomly selected and subjected to a standard peritoneal equilibration test (PET). Alb, IgG, IgA, and IgM were measured during the PET in both serum and dialysate. RESULTS: Dialysate IgM was not detected with the employed nephelometry method. A significant continuous and gradual increasing pattern in Alb, IgG and IgA losses was observed throughout the PET. During the PET, patients with the fastest transport type displayed the lowest serum concentration of Alb (but not Igs) and the greatest dialysate loss of all the assayed proteins. The strongest predictor for Alb, IgG, and IgA losses was peritoneal transport rate in both the univariate and multivariate analyses. CONCLUSIONS: Peritoneal Alb, IgG, and IgA losses in Mexican CAPD patients are mainly dependent on peritoneal transport rate and dialysate dwell-time.

Bone loss in long-term renal transplantation: histopathology and densitometry analysis.

BACKGROUND: There is little information of the spectrum and factors implicated in the bone loss in long-term renal transplantation, and virtually no data using both histomorphometric and densitometric analysis. METHODS: Twenty-three males and 22 females (13 postmenopausal) were studied with a bone biopsy and densitometry. Sixteen patients were on cyclosporine A monotherapy, 20 on azathioprine + prednisolone, and 9 on cyclosporine A + prednisolone or triple therapy. The mean time after transplantation was 127 +/- 70 months. RESULTS: No group had a significant decrease in bone mineral density (BMD) of the axial skeleton compared with an age- and sex-matched normal population. Compared with sex-matched young controls, osteopenia was observed in all groups at the femoral neck (except premenopausal women and triple therapy) and in the triple-therapy group at the L1-L4 spine region. At the distal radius, osteopenia was found in all the groups. Histopathological diagnosis was mixed uremic osteodystrophy in 46.5%, adynamic bone in 23.2%, hyperparathyroid disease in 13.9%, and normal bone in 16.3%. The diagnosis was not different according to immunosuppressive therapy, but men tended to show more mixed uremic bone disease. There was no significant difference in BMD between histopathological subtypes. In general, patients showed slight osteoclast function increase, osteoblast function decrease, and marked retardation of dynamic parameters. The cyclosporine A monotherapy group had a significantly lower appositional rate than azathioprine + prednisolone. Men had a significantly lower bone volume than women, and premenopausal women had a significantly lower mineralizing surface than postmenopausal women and men. In the multivariate analysis, male gender, time after transplantation, old age, and time on dialysis prior to transplantation were significant predictive factors for a negative effect on bone mass. CONCLUSIONS: Long-term renal transplant-patients showed reduced BMD in both trabecular and cortical bone. This reduction in BMD was not as severe as in short-term reports and was associated with osteoclast stimulation, osteoblast suppression, and retardation of mineral apposition and bone formation rates. Bone mass loss was not different between the immunosuppression therapy groups. Male gender and age were the strongest predictive factors for low bone mass.

Analysis of the peritoneal equilibration test in Mexico and factors influencing the peritoneal transport rate.

OBJECTIVE: To validate the peritoneal equilibration test (PET), establish reference values in the Mexican population, compare our results with those reported by Twardowski et al., and analyze the influence of some factors on the peritoneal transport rate (PTR). DESIGN: Retrospective, cross-sectional study. PATIENTS: Eighty-six PETs were performed in 45 female and 41 male patients; 35 of the patients were diabetics. Creatinine D/P and glucose D/D0 ratios were calculated and compared with those from Twardowski et al. In a multivariate analysis, age, gender, diabetes mellitus (DM), time on dialysis, and peritonitis rate were considered as independent factors influencing the PTR. RESULTS: Creatinine D/P and glucose D/D0 ratios at 4 hours were not significantly different from those reported by Twardowski et al. Creatinine D/P at 4 hours was not different between DM and non-DM patients when the rate of peritonitis and time on dialysis were not taken into account. Multivariate analysis did not result in any significant model predicting the creatinine D/P at 4 hours. CONCLUSIONS: PET validation is reported for the first time in a Latin American population. The PET results of this study are similar to those in the literature. We found that DM, peritonitis rate, time on dialysis, age, and gender did not clearly influence the PTR.

Peritoneal transport kinetics correlate with serum albumin but not with the overall nutritional status in CAPD patients.

The present study evaluates the influence of the peritoneal transport rate (PTR) on the nutritional status of continuous ambulatory peritoneal dialysis (CAPD) patients. Additionally, protein intake, dialysis adequacy, and other clinical variables were analyzed. Forty-two CAPD patients were concurrently subjected to the peritoneal equilibration test, a nutritional evaluation that included 24-hour dietary recall, and nutritional scoring system that included anthropometric, biochemical, and subjective parameters. Eight patients were high, 14 were high-average, 16 were low-average, and four were low transporters. Nine patients had normal nutritional status; six had mild, nine had moderate, and 18 had severe malnutrition. Malnutrition was inversely correlated (P < 0.05) with body surface, hemoglobin, and residual renal function, but not with PTR (r = 0.14; P = 0.38). In the multivariate analysis, the nutritional status was not predicted by the PTR, protein intake, or dialysis adequacy variables. When serum albumin (SA) level was evaluated as an isolated nutritional indicator, the most significant predictors were dialysate to plasma creatinine ratio at 4 hours (D/P4), body surface area, age, and diabetes mellitus. High transporters receiving a high dose of dialysis displayed a trend of having lower SA levels, whereas low-average transporters receiving a high dose of dialysis showed a trend of have higher SA levels. In conclusion, there was no correlation between PTR and nutritional status. In the multivariate analysis, no association was found between nutritional status and PTR, dialysis adequacy, and protein intake. The best predictors for SA are PTR, body surface area, age, and diabetes mellitus.

Prevalence of malnutrition in Mexican CAPD diabetic and nondiabetic patients.

Malnutrition is often present on continuous ambulatory peritoneal dialysis (CAPD), and contributes to morbidity and mortality. Diabetics (DM) have an increased risk for developing malnutrition. Our purpose was to assess the nutritional status (NS) of our CAPD population, to define NS differences between DM and nondiabetics (NoDM), and to identify NS-related factors. Patients were subjected to a nutritional assessment, which included a 24-hour dietary recall and a nutritional scoring system including anthropometric, biochemical, and subjective evaluation, and that classifies patients as: normal, and mildly, moderately, and severely malnourished. We studied 90 patients: 35 DM and 55 NoDM. In our whole population we observed a high frequency of malnutrition: NS was normal in 18%, and 20% had mild, 24% had moderate, and 38% had severe malnutrition. Ninety-one percent of DM and 76% of NoDM showed some degree of malnutrition. DM patients had significantly higher levels of malnutrition (p = 0.02), were significantly older, had more body fat, and spent less time on dialysis. There were 37 males and 53 females. Sex distribution was similar between DM and NoDM. Seventy-six percent of males and 86% of females had malnutrition. Moderate and severe malnourishment were more frequent in females. DM and female sex were the strongest predictors for moderate and severe malnutrition.

[Hepatitis C virus infection and membranoproliferative glomerulonephritis]. / Infección por virus de la hepatitis C y glomérulonefritis membranoproliferativa.

BACKGROUND AND METHODS: A possible association between hepatitis C virus infection (HCV) and membranoproliferative glomerulonephritis (MPGN) or membranous glomerulonephritis has recently been reported. The pathogenesis of this entity appears to be immunologically mediated. The purpose of this report is to describe the clinical, laboratory, and histopathological features of three patients with chronic HCV infection, without hepatitis B virus disease or autoimmune diseases, but with glomerular disease. RESULTS: All three patients had chronic hepatopathy stigmata, ascitis, peripheral edema, and normal blood pressure values. Laboratory results showed mild liver function abnormalities and normal levels of blood nitrogenous waste products. Microscopic hematuria, hypoalbuminemia, and variable proteinuria without hypercholesterolemia were found in all cases. All three had positive rheumatoid factor. Only one patient had positive antinuclear antibodies and antimitochondrial antibodies at low levels, and another displayed low C3 and C4 serum levels. Renal histology in the three cases showed type I membranoproliferative glomerulonephritis and hepatic cirrhosis in the liver biopsy. CONCLUSIONS: This report supports the association between chronic HCV infection and membranoproliferative glomerulonephritis. However, further studies are needed to establish more firmly the association as well as the mechanisms of pathogenesis and causality between them.

Consistency of the peritoneal equilibration test in a cohort of nonselected Mexican CAPD patients.

The peritoneal equilibration test (PET) is a useful tool in continuous ambulatory peritoneal dialysis (CAPD) prescription. PET D/P ratios are reproducible in the same patient when performed within a short period. However, peritoneal transport consistency in nonselected patients over longer periods of time is debated. The PET was performed twice in 19 randomly selected patients (13 female) from a cohort of 55 patients on CAPD for 32 +/- 24 months, age 44 +/- 18 years. Mean time between the first and second PET was 9.6 +/- 4 months. All patients were peritonitis-free at least 6 weeks before each PET. Fifteen patients did not change transport type between the two PETs: 3 low (L), 8 low-average (LA), 3 high-average (HA), and 1 high (H). Only 4 changed: 1 H to HA, 2 LA to HA, and 1 L to LA. In these 4 patients the change was centripetal (towards the mean) and less than 1 SD and not considered clinically significant. No differences between both groups in peritonitis rate, gender, age, time on dialysis, and diabetes mellitus status were observed. Transport type, as evaluated by the PET, was consistent over time in our group of patients.