Service Utilization Patterns and Direct Medical Costs of Hospitalization in Patients With Renal Failure Before and After Initiating Home Peritoneal Dialysis.

OBJECTIVES: This study aimed to determine the hospital service utilization patterns and direct healthcare hospital costs before and during peritoneal dialysis (PD) at home. METHODS: A retrospective cohort study of patients with kidney failure (KF) was conducted at a Mexican Social Security Institute hospital for the year 2014. Cost categories included inpatient emergency room stays, inpatient services at internal medicine or surgery, and hospital PD. The study groups were (1) patients with KF before initiating home PD, (2) patients with less than 1 year of home PD (incident), and (3) patients with more than 1 year of home PD (prevalent). Costs were actualized to international dollars (Int$) 2023. RESULTS: We found that 53% of patients with KF used home PD services, 42% had not received any type of PD, and 5% had hospital dialysis while waiting for home PD. The estimated costs adjusting for age and sex were Int$5339 (95% CI 4680-9746) for patients without home PD, Int$17 556 (95% CI 15 314-19 789) for incident patients, and Int$7872 (95% CI 5994-9749) for prevalent patients; with significantly different averages for the 3 groups (P < .001). CONCLUSIONS: Although the use of services and cost is highest at the time of initiating PD, over time, using home PD leads to a significant reduction in use of hospital services, which translates into institutional cost savings. Our findings, especially considering the high rates of KF in Mexico, suggest a pressing need for interventions that can reduce healthcare costs at the beginning of renal replacement therapy.

Association of Serum Fibroblast Growth Factor 23 and FGF23 Gene Variants with Chronic Kidney Disease in Patients with Type 2 Diabetes and Essential Hypertension.

INTRODUCTION: Fibroblast growth factor 23 (FGF23) gene variants could influence the production of FGF23 in subjects at risk for chronic kidney disease (CKD). Our purpose was to analyze the association of serum levels of FGF23 and two FGF23 gene variants with metabolic and renal function parameters in Mexican patients with Type 2 Diabetes (T2D) and/or essential hypertension (HTN). MATERIALS/METHODS: The study included 632 individuals diagnosed with T2D and/or HTN, of which 269 (43%) were diagnosed with CKD. FGF23 serum levels were determined and FGF23 gene variants rs11063112 and rs7955866 were genotyped. Genetic association analysis included binary and multivariate logistic regressions adjusted for age and sex. RESULTS: Patients with CKD were older, had higher systolic blood pressure, uric acid, and glucose levels than those without CKD. Also, patients with CKD had higher FGF23 levels (106 vs. 73 pg/mL p = 0.003). No correlation of any gene variants with FGF23 levels was found, but minor allele for rs11063112 and haplotype rs11063112A-rs7955866A were associated with low probability of CKD (Odds Ratio [OR] = 0.62 and 0.58, respectively). Conversely, the haplotype rs11063112T-rs7955866A was associated with increased FGF23 levels and risk for CKD (OR = 6.90). CONCLUSIONS: In addition to the traditional risk factors, levels of FGF23 are higher in Mexican patients with diabetes and/or essential hypertension and CKD, compared to those without renal damage. In contrast, the two minor alleles of two variants of the FGF23 gene, rs11063112 and rs7955866, as well as the haplotype carrying these two alleles, were found to be protective against renal disease in this Mexican patients' sample.

Association of Variants of the NFE2L2 Gene with Metabolic and Kidney Function Parameters in Patients with Diabetes and/or Hypertension.

Background: Type 2 diabetes mellitus (T2DM) and high blood pressure (HBP) are the main risk factors for chronic kidney disease (CKD). Relationships between variants within the NFE2L2 gene and the presence of environmental risk factors for CKD, such as HBP and hyperglycemia have been suggested; however, their interactions remains unclear. Aim: To analyze the association of NFE2L2 variants with metabolic and kidney parameters. Materials and Methods: Six-hundred and fifty-one patients grouped according to the diagnosis of T2DM (n =166), T2DM+HBP (n =348) and HBP (n =137) were included. Metabolic characteristics were evaluated to identify risk factors and presence of CKD. Genotyping was performed by polymerase chain reaction (PCR) using two pairs primers for rs35652124 and rs6721961 and by real-time PCR for rs2364723. Logistic regression analyses, adjusted for confounding factors and correction for multiple tests were performed. Results: Significant associations between decreased risk for presenting with CKD and the rs35652124 (A allele) and the rs2364723 (G allele) variants were detected. Other variables consistently associated with these alleles were HBP, BMI, waist circumference, uric acid and triglycerides. Haplotypes AAC and GCG (loci order: rs35652124-rs6721961-rs2364723) showed similar trends. After adjustment for age and sex and correction for multiple tests, only rs35652124 (Odds Ratio [OR] = 0.5; Confidence Interval at 95% (CI95%), 0.3-0.9; p = 0.04) and rs2364723 (OR = 0.3; CI95%, 0.1-0.8; p = 0.009) variants remained associated with deceased risk for CKD in T2DM patients. Conclusion: This study showed for the first time that NFE2L2 variants are associated with decreased risk for CKD in the presence of environmental/metabolic risk factors related to kidney damage, including HBP, hyperuricemia and albuminuria in Mexican patients with diabetes.

Circulating Levels of Soluble Klotho and Fibroblast Growth Factor 23 in Diabetic Patients and Its Association with Early Nephropathy.

INTRODUCTION: Diabetic nephropathy is a leading cause of chronic kidney disease (CKD). In diabetes, changes in serum levels of both soluble alpha Klotho (sKL) and fibroblast growth factor 23 (FGF-23) have been associated with CKD progression. OBJECTIVE: To evaluate the associations of circulating levels of sKL and FGF-23 with the presence of early nephropathy (EN) in diabetic patients. METHODS: A cross-sectional study in 136 Mexicans with type 2 diabetes mellitus (T2DM). Early nephropathy was defined as an estimated glomerular filtration rate (≥60 ml/min) and urinary albumin excretion (≥30 mg/g). Serum concentrations of sKL and FGF-23 were measured using ELISA. Associations were evaluated with multiple logistic regression. RESULTS: Fifty-two subjects had EN. Median values of sKL and FGF-23 for all individuals were 244 pg/mL (interquartile range [IQR]: 201-402) and 92 pg/mL (IQR: 39-507), respectively. A positive correlation was found between levels of sKL and FGF-23 (r = 0.38; p <0.001). FGF-23 levels correlated negatively with angiotensin-II receptor blocker therapy (ARB, r = 0.24; p <0.01). Subjects without EN were younger (59 vs. 63 years old, p = 0.02). Elevated concentrations of FGF-23 were negatively associated with EN (Odds Ratio [ORadjusted] = 0.29, 95% Confidence Interval [95% CI] = 0.13, 0.65). CONCLUSIONS: In Mexican diabetic patients, serum levels of FGF-23 were positively correlated with sKL but negatively correlated with ARB therapy. In addition, a higher concentration of FGF-23 reduced the odds of early nephropathy in patients with T2DM.

Economic impact of the chronic kidney disease: Perspective of the Instituto Mexicano del Seguro Social / Impacto económico de la enfermedad renal crónica: Perspectiva del Instituto Mexicano del Seguro Social

In Mexico, as in other parts of the world, end-stage renal disease (ESRD) constitutes a public health problem associated with high morbidity, mortality, costs and a diminished quality of life. The Instituto Mexicano del Seguro Social (IMSS) attends to, approximately, 73% of the Mexican population requiring dialysis or transplant. In 2014, the treatment of ESRD represented 15% of the total annual expenditure of IMSS major program (Disease and Maternity Security), i.e. approximately $13 250 million Mexican pesos (MP); this expense was invested in only 0.8% of patients (those with ERSD). There are few economic evaluation studies showing the real cost of kidney replacement therapies from institution's perspective. In order to reduce the global cost of ESRD, it is necessary to implement appropriate strategies of prevention, diagnosis and treatment to reduce incidence and progression of chronic kidney disease; to intensify research studies for a better understanding of etiological factors, mechanism of kidney damage progression and identification of new therapeutic agents; to create a national kidney disease registry, and to incorporate the economic evaluation methodology in the decision-making, in order to identify improved cost-benefit or cost-effective strategies.

En México, al igual que en otras partes del mundo, la enfermedad renal crónica terminal (ERCT) constituye un problema de salud pública asociado a elevada morbilidad, mortalidad, grandes costos y una calidad de vida disminuida. El Instituto Mexicano del Seguro Social (IMSS) atiende aproximadamente al 73% de la población mexicana que requiere diálisis o trasplante. En el año 2014, el tratamiento de la ERCT representó para el Instituto el 15% del gasto total anual de su mayor programa (Seguro de Enfermedades y Maternidad), aproximadamente $13 250 millones de pesos; este gasto se invirtió en tan solo el 0.8% de los derechohabientes (población con ERCT). Con el objetivo de disminuir la carga global de la ERCT, es necesario: 1) Implementar estrategias de prevención, diagnóstico y tratamiento de la ERC desde estadios más tempranos; 2) Fortalecer estudios de investigación dirigidos a una mejor comprensión de factores etiológicos, mecanismos de progresión de daño renal e identificar nuevos agentes terapéuticos; 3) Contar con un registro nacional de enfermedades renales; 4) Incorporar en la toma de decisiones, estudios de evaluación económica para identificar estrategias con un mayor costo-beneficio o costo-efectividad en el tratamiento de la ERC.

Model of chronic kidney disease care in primary health care / Modelo de atención de la enfermedad renal crónica en la atención primaria de la salud

Multidisciplinary attention models include the joined and coordinated participation of different professionals within the health team (physicians, nurses, social workers, dietitians, physical trainers, among others). A multidisciplinary approach facilitates and improves management of patients from early chronic kidney disease (CKD) in the primary health-care setting. This approach is a strategy for improving comprehensive care, initiating and maintaining healthy behaviors, promoting teamwork, eliminating barriers to achieve goals and improving the processes of care. A multidisciplinary intervention may include educational processes guided by health professional, use of self-help groups and the development of a CKD management plan. The complex and fragmented care management of patients with CKD, associated with poor outcome, enhances the importance of implementing a multidisciplinary approach in the management of this disease from the early stages. Multidisciplinary strategies should focus on the needs of patients and should be adapted to the resources and health systems; its systematic implementation can help to improve patient care and prevent/slow the progression of CKD.

Los modelos de atención multidisciplinaria incluyen la participación conjunta y coordinada de diferentes profesionales miembros del equipo de salud (médicos, enfermeras, trabajadoras sociales, nutriólogas, entrenadores físicos, entre otros). Un abordaje multidisciplinario facilita y mejora el manejo de los pacientes con enfermedad renal crónica (ERC) en el primer nivel de atención médica. Este abordaje es una estrategia para mejorar el cuidado de una forma más completa, iniciando y manteniendo conductas saludables, promoviendo el trabajo en equipo, eliminando barreras para alcanzar objetivos y mejorando los procesos de la atención. Una intervención multidisciplinaria puede incluir procesos educativos guiados por profesionales, el empleo de grupos de autoayuda y el desarrollo de un plan de manejo de la ERC. La atención actual de los pacientes con ERC, fragmentada y compleja, asociada con los malos resultados frecuentemente observados, pone de manifiesto la importancia de la implementación de un abordaje multidisciplinario desde las etapas más tempranas de la enfermedad. Las estrategias multidisciplinarias deben enfocarse en las necesidades de los pacientes y deben ser adaptadas a los recursos disponibles en los sistemas de salud; su implementación sistematizada podrá ayudar a mejorar el cuidado del paciente y prevenir y/o retrasar el avance de la ERC.

Diagnosis and clinical implications of vascular calcification of chronic kidney disease in Mexico / Diagnóstico e implicaciones clínicas de la calcificación vascular de la enfermedad renal crónica en México

Vascular calcification (VC), it is a clinical condition highly associated to Chronic Kidney Disease (CKD), CKD patients had as a primary death cause, the cardiovascular disease (CVD), among many non-traditional factors for CKD appears VC. The pathogenesis of VC it´s multifactorial and it´s in short terms a change of muscle vessels cells to a bone cell; this transformation it´s close related to Chronic Kidney Disease-Bone Metabolism Disorder (CKD-BMD), Vitamin D, phosphorus, calcium and parathyroid hormone are close related to VC. The diagnosis of VC can be done by different methods from Electron Beam Computed Tomography to plain X ray studies; there are many scores base on plain X ray studies that can predict mortality in patients with VC. In our setting there is scarce information regarding VC in dialysis patients, the available information show a higher frequency (~50%) and severe; predictors to the VC in our setting are: age, serum HDL and alkaline phosphatase. It is necessary in the primary care setting the evaluation of VC in order to prevent it appearing. There is not an effective treatment to VC so it´s necessary search for strategies to prevent it.

La calcificación vascular es un problema asociado a la ERC, los pacientes con ERC tienen como primera causa de muerte la enfermedad cardiovascular (ECV); entre los múltiples factores de riesgo no tradicionales de ECV se encuentra la calcificación vascular (CV). La patogenia de la CV es multifactorial, y se puede resumir en un cambio en el fenotipo de las células del músculo liso vascular, dicho cambio es a volverse células de tipo óseo. El diagnóstico de la CV puede llevarse a cabo mediante varios métodos, desde la tomografía computarizada por emisión de electrones (EBCT), hasta métodos como las placas simples de rayos X. En el caso de nuestro país hay pocos estudios que hayan evaluado la CV de pacientes en diálisis, donde la frecuencia es muy alta (~50%) y desafortunadamente grave; los predictores de presencia de CV que han sido evaluados en nuestro medio son: la edad, las concentraciones séricas de HDL y las concentraciones de fosfatasa alcalina. Es necesario que en el primer nivel de atención se evalúe la presencia de CV con el objeto de prevenir el desarrollo y agravamiento de los pacientes. Aunque no existe un tratamiento efectivo para el manejo de la CV es necesario buscar medidas de prevención en su desarrollo.

Role of dietitian in prevention and treatment of early chronic kidney disease / El rol del nutriólogo en la prevención y tratamiento temprano de la enfermedad renal crónica

Mexico occupies one of the first places worldwide in terms of incidence and prevalence of end-stage renal disease (ESRD). As renal function decreases, morbi-mortality increases; therefore, early interventions could more positively influence on the evolution of disease and delay/avoid fatal outcome. Unfortunately, dietitian´s participation in treatment of patients with chronic kidney disease (CKD) has been mainly focused on the late stages, when the goal of nutritional care is to manage complications, and preparation of patients to initiate dialysis. Notwithstanding, it is worthy to remark that, within the multidisciplinary team of the primary health-care, dietitian is the professional on charge of the nutritional care of patients with early CKD, or without CKD but at high risk to develop it; therefore, dietitian is responsible to promote and strength healthy eating habits. Strengthening the role of the dietitian in the prevention and treatment of early CKD must be an outstanding activity in the agenda to fight against the epidemics of ESRD in our country and the world.

México ocupa uno de los primeros lugares a nivel mundial en incidencia y prevalencia de enfermedad renal crónica terminal (ERCT). A medida que la función renal disminuye, la morbimortalidad aumenta, por lo que las intervenciones tempranas pueden influir más satisfactoriamente en el curso de la enfermedad y retrasar/evitar sus desenlaces fatales. Desafortunadamente, la participación del nutriólogo en el tratamiento de pacientes con enfermedad renal crónica (ERC) se ha enfocado principalmente en las etapas avanzadas de la enfermedad, cuando el objetivo del cuidado nutricional es el manejo de las complicaciones y la preparación para el inicio de diálisis. Por lo tanto, es indispensable recalcar que, dentro del equipo multidisciplinario del primer nivel de atención, el nutriólogo es el profesional de la salud a cargo de la atención nutricional del paciente con ERC temprana, o aun sin ella, pero con factores de riesgo para desarrollarla, y por lo tanto, es el responsable de promover y fortalecer hábitos saludables de alimentación. Fortalecer el rol del nutriólogo en la prevención y tratamiento de la ERC temprana debería ser una actividad a destacar en la agenda para disminuir la epidemia de la ERCT en nuestro país y en el mundo.

Prevalence and risk factors of chronic kidney disease in the comprehensive care program DiabetIMSS / Prevalencia de enfermedad renal crónica y factores de riesgo en el programa de atención DiabetIMSS

BACKGROUND: The aim of this paper is to determine prevalence and risk factors of chronic kidney disease (CKD) in the comprehensive care program DiabetIMSS. METHODS: Cross-sectional study in 488 patients with type 2 diabetes mellitus (DM2) included in the program DiabetIMSS. Sociodemographic, clinical, biochemical, and kidney function variables were collected. RESULTS: Prevalence of CKD was 32% [early nephropathy (EN) 19% and overt nephropathy (ON) 13%]. Patients with more severe nephropathy significantly (p < 0.05) had: older age [normal kidney function (NKF) 54±11, EN 54±10, ON 63±9, years)], cardiovascular disease (NKF 1%, EN 5%, ON 11%), hypertension (NKF 65%, EN 63%, ON 85%), longer duration of DM2 (NKF 5%, EN 5%, ON 9%,) and of hypertension (NKF 5%, EN 6%, ON 9%), glycemic lack of control (NKF 46%, EN 62%, ON 60%), hyperuricemia (NKF 7%, EN 13%, ON 23%), anemia (NKF 1%, EN 4%, ON 10%) and metabolic syndrome (NKF 79%, EN 82%, ON 93%). Uncontrolled hypertension and DM2, cardiovascular disease and hyperuricemia significantly predicted the presence of nephropathy CONCLUSIONS: A third of patients attending to DiabetIMSS had CKD and has not been previously diagnosed. Multiple risk factors are present in this high-risk population; their identification and control are extraordinarily important. Moreover, educative interventions for primary health-care professionals to improve health of this kind of patients are needed.

INTRODUCCIÓN: el objetivo de este trabajo es determinar la prevalencia de enfermedad renal crónica (ERC) e identificar factores de riesgo para nefropatía en el programa DiabetIMSS. MÉTODOS: estudio transversal analítico en 488 pacientes con diabetes mellitus tipo 2 (DM2) atendidos en el programa de atención integral DiabetIMSS. Se recolectaron variables sociodemográficas, clínicas, bioquímicas y de función renal. RESULTADOS: la prevalencia de ERC fue 32% [nefropatía temprana (NT) 19% y nefropatía establecida (NE) 13%]. A nefropatía más avanzada, los pacientes tenían significativamente (p < 0.05): mayor edad [función renal normal (FRN) 54 ± 11, NT 54 ± 10, NE 63 ± 9 años)], enfermedad cardiovascular (FRN 1%, NT 5%, NE 11%), hipertensión (FRN 65%, NT 63%, NE 85%), mayor evolución de DM2 (FRN 5%, NT 5%, NE 9%,) y de hipertensión (FRN 5%, NT 6%, NE 9%), descontrol glucémico (FRN 46%, NT 62%, NE 60%), hiperuricemia (FRN 7%, NT 13%, NE 23%), anemia (FRN 1%, NT 4%, NE 10%) y síndrome metabólico (FRN 79%, NT 82%, NE 93%). La hipertensión y DM2 descontroladas, la enfermedad cardiovascular y la hiperuricemia predijeron significativamente la presencia de nefropatía. CONCLUSIONES: un tercio de los pacientes atendidos en DiabetIMSS tenían ERC y no habían sido identificados. Múltiples factores de riesgo están presentes en esta población de alto riesgo; su identificación y control son de extraordinaria importancia. Son necesarias, además, intervenciones educativas para el personal del primer nivel de atención médica para mejorar la salud de este tipo de pacientes.

The Beneficial Effects of Renal Transplantation on Altered Oxidative Status of ESRD Patients.

Renal transplantation (RT), has been considered the best therapeutic option for end stage renal disease (ESRD). Objective. To determine the effect of RT on the evolution of oxidative DNA status. Methods. Prospective cohort (N = 50 receptors of RT); genotoxic damage, 8-hydroxy-2'-deoxyguanosine (8-OHdG), and DNA repair enzyme, human 8-oxoguanine-DNA-N- glycosylase-1 (hOGG1); and antioxidants, superoxide dismutase (SOD) and glutathione peroxidase (GPx), were evaluated. Results. Before RT, 8-OHdG were significantly elevated (11.04 ± 0.90 versus 4.73 ± 0.34 ng/mL) compared to healthy controls (p = 0.001), with normalization after 6 months of 4.78 ± 0.34 ng/mL (p < 0.001). The same phenomenon was observed with hOGG1 enzyme before RT with 2.14 ± 0.36 ng/mL (p = 0.01) and decreased significantly at the end of the study to 1.20 ng/mL (p < 0.001) but was higher than controls, 0.51 ± 0.07 ng/mL (p < 0.03). Antioxidant SOD was elevated at 24.09 ± 1.6 IU/mL versus healthy controls (p = 0.001) before RT; however, 6 months after RT it decreased significantly to 16.9 ± 1.6 IU/mL (p = 0.002), without achieving the levels of healthy controls (p = 0.01). The GPx, before RT, was significantly diminished with 24.09 ± 1.6 IU/mL versus healthy controls (39.0 ± 1.58) (p = 0.01), while, in the final results, levels increased significantly to 30.38 ± 3.16 IU/mL (p = 0.001). Discussion. Patients with ESRD have important oxidative damage before RT. The RT significantly reduces oxidative damage and partially regulates the antioxidant enzymes (SOD and GPx).

[The peritoneal transport type might be distinctive among different Mexican populations on CAPD]. / El tipo de transporte peritoneal puede ser diferente en las distintas poblaciones de pacientes en diálisis peritoneal de México.

INTRODUCTION: The peritoneal equilibration test (PET), standardized by Twardowski et al. more than 20 years ago, is the most common test to classify peritoneal transport. Some reference values from Mexican population were established in the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ) 10 years ago. The aims of this study were to evaluate the peritoneal transport in a population from the west of Mexico, and compare results with those obtained in the studies of Twardowski and the INCMNSZ. MATERIAL AND METHODS: Cross-sectional study, performed in 156 patients. All consecutive CAPD patients to whom a PET was performed between January 2000 and January 2004 were included. Each patient had a standard PET consistent on infusion of a freshly 2L dialysis exchange at 2.5% after drainage of the previous nocturnal exchange; 3 dialysis aliquots at 0, 2 and 4 hours, and a blood sample at 2 hours, are obtained after infusion. Results were compared to those reported by Twardowski and INCMNSZ. RESULTS: From the total of patients, 48% were diabetics and 62% were men. Mean age was 46 +/- 16 years and body surface area was 1.70 +/- 0.23 m2. There were no differences between groups regarding diabetes and peritonitis. Time on dialysis was shorter in our study than in the INCMNSZ (14.6 +/- 17.8 vs. 20.8 +/- 21.4 months; p < 0.05). Compared to those from Twardowski and INCMNSZ, creatinine D/P ratios at 0, 2 and 4 h of our study were higher, whereas D/D0 ratios at 2 and 4 h, and PET drained volume, were lower. Using reference values obtained in the present study, 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 INCMNSZ reference values, H was present in 23%, HA in 36%, LA in 33% and L in 8%. CONCLUSIONS: Patients from this studied population had mean peritoneal transport values higher than those obtained in other studies, including Mexican values. Ideally, it is recommendable to determine reference values in all peritoneal dialysis centers, as extrapolating results from other regions may lead to errors in diagnosing the peritoneal transport type.

Hipoalbuminemia en diálisis. ¿Es marcador de desnutrición o de inflamación? / Hypoalbuminemia in dialysis: Is a malnutrition or inflammation marker?

La hipoalbuminemia en diálisis es una condición altamente prevalente y asociada con morbimortalidad. Aunque no es sinónimo de desnutrición, la hipoalbuminemia en diálisis está estrechamente relacionada a este fenómeno. La pobre ingestión de nutrientes frecuentemente observada en la uremia, puede condicionar desnutrición, y subsecuentemente hipoalbuminemia; pero además, recientemente se ha documentado la presencia de una respuesta inflamatoria sistémica que puede participar en el desarrollo de hipoalbuminemia en la falla renal crónica. La uremia per se, o por medio de mecanismos estimulados por el uso de las membranas dializantes y/o de las soluciones de diálisis actuales, parecen disparar el proceso de inflamación, estrechamente asociado a hipoalbuminemia. Las infecciones, a las que estan especialmente predispuestos los pacientes en diálisis, también estimulan la producción de respuesta inflamatoria. Otros fenómenos no asociados a la respuesta inflamatoria, como las pérdidas proteínicas a través de la diálisis, pueden condicionar y agravar la desnutrición. La sobrehidratación que frecuentemente presentan los pacientes con falla renal provoca dilución de la concentración sérica de albumina, y a la vez el desarrollo o agravamiento de falla cardiaca congestiva, la cual consecutivamente puede condicionar mayor desnutrición. Entonces, la hipoalbuminemia en diálisis parece traducir una compleja red de condiciones dentro de las que sobresale un estado inflamatorio; sin embargo, otros eventos como desnutrición y sobrehidratación también pueden jugar un papel relevante en esta entidad. Por lo tanto, los abordajes diagnóstico y terapéutico deben ser individualizados en cada paciente.

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

Antecedentes y métodos. Recientemente se ha informado una posible asociación entre la infección por virus de hepatitis C (VHC) y las glomérulonefritis membranoproliferativa (GNMP) y membranosa. La fisipatogenia de esta entidad parece estar mediada por depósito de complejos inmunes en los glomérulos. El objetivo de este informe es describir las característias clínicas, de laboratorio e histopatológicas de tres pacientes con infección crónica por VHC, sin infección por virus de la hepatitis B ni enfermedades autoinmunes, y con evidencia de enfermedad glomerular. Resultados. Todos los pacientes presentaron estigmas de hepatopatía crónica, ascitis y edema periférico, y presión arterial normal. Los resultados de laboratorio no mostraron alteraciones significativas en pruebas de función hepática y en las cifras de elementos azoados; los tres casos presentaron hematuria microscópica, hipoalbuminemia y albuminuria de grado variable, sin hipercolesterolemia y factor reumatoide positivo. Sólo un paciente tuvo anticuerpos antinucleares y anticuerpos antimitocondriales positivos a títulos bajos, y otro más presentó niveles bajos de C3 y C4. En los tres casos, las biopsias de riñón fueron interpretadas como glomérulonefritis membranoproliferativa tipo I, y las de hígado como cirrosis. Conclusiones. Las evidencias presentadas apoyan la asociación de la enfermedad crónica por virus de la hepatitis C y la glomérulonefritis membranoproliferativa. Es necesario realizar otros estudios para establecer más firmemente la asociación, fisiopatogenia y causalidad entre estas entidades