Agentes hemostáticos tópicos de uso quirúrgico / Topical hemostatic agents for surgical use

Introducción: La morbilidad, mortalidad y costes tras la cirugía se hallan influenciados en gran medida por la pérdida hemática o hemorragia y las consecuencias derivadas de la misma. Para controlar la hemorragia, es frecuente el uso de agentes hemostáticos tópicos en combinación o en adyuvancia a otras técnicas hemostáticas, cuando éstas resultan ineficaces o impracticables. Material y métodos: Se realizó una revisión sistemática en Cochrane y MEDLINE desde el año 2000 a 2017 para identificar las publicaciones relacionadas con el uso de hemostáticos pasivos, activos y sellantes en comparación con otros agentes hemostáticos en todos los tipos de intervenciones quirúrgicas. Resultados: Se seleccionaron 20 ensayos clínicos. La variable principal de eficacia en el 95% fue el tiempo hasta la hemostasia y en el 5% la disminución del sangrado. Las intervenciones quirúrgicas más frecuentes fueron; cirugía hepática (30%), vascular (20%), cardíaca (10%), espinal (10%), general (5%), plástica (5%), y otros tipos de cirugía (20%).Los estudios se dividieron en 7 grupos, en función del tipo de agente hemostático a estudio y el comparador: a) hemostáticos mixtos versus pasivos (10%), b) sellantes de fibrina versus hemostáticos activos (5%), c) sellantes de fibrina versus hemostáticos pasivos (50%), d) hemostáticos mixtos entre sí (15%), e) sellantes de fibrina entre sí (5%), f) hemostáticos pasivos entre sí (5%), g) hemostáticos activos entre sí (10%).Conclusiones: Los hemostáticos activos, mixtos y sellantes de fibrina demuestran superioridad frente a los pasivos en términos de eficacia clínica, con un coste superior y un perfil de efectos adversos similar. (AU)

Introduction: Morbidity, mortality, and costs after surgery are greatly influenced by blood loss or bleeding and the consequences of it.To control bleeding, the use of topical hemostatic agents in combination or adjuvant to other hemostatic techniques is frequent, when these are ineffective or impractical.Method: A systematic review was conducted in Cochrane and PubMed from 2000 to 2017 to identify publications related to the use of passive, active and sealant hemostatics compared to other hemostatic agents in all types of surgical interventions.Results: Twenty clinical trials were selected. The main variable of efficacy in 95% was the time to hemostasis and in 5% the decrease in bleeding.The most frequent surgical interventions were; liver surgery (30%), vascular (20%), cardiac (10%), spinal (10%), general (5%), plastic (5%), and other types of surgery (20%).The studies were divided into 7 groups, depending on the type of hemostatic agent under study and the comparator: a) mixed hemostatic versus passive (10%), b) fibrin sealants versus active hemostatic agents (5%), c) fibrin sealants versus passive hemostatic (50%), d) mixed hemostatic with each other (15%), e) fibrin sealants with each other (5%), f) passive hemostatic with each other (5%), g) active hemostatic with each other (10%).Conclusions: Active and mixed hemostatics and fibrin sealants showed superiority over the passive hemostatics in terms of clinical efficacy, with a higher cost and a similar profile of side effects. (AU)

Kidney Transplantation in Patients With Chronic Kidney Disease After a Previous Lung Transplantation.

BACKGROUND: The development of chronic kidney disease is a common complication after a lung transplantation, especially since the introduction of immunosuppressive treatments based on calcineurin inhibitors. Many of these patients reach end-stage renal disease and even need renal replacement therapy. Among the different options of renal replacement therapy, we consider kidney transplantation as a feasible option for these patients. METHODS: A single center, observational retrospective study including 8 lung transplanted patients who have received a kidney transplant in the period between 2013 and 2017 with at least 1 year of follow-up was used. RESULTS: Seven patients maintained an adequate function of the graft 1 year after kidney transplantation, and 1 patient died because of a pulmonary condition in spite of a previous kidney transplant. Two patients presented delayed graft function in the first days after surgery. CONCLUSIONS: The kidney transplantation is a technique of renal replacement therapy that should be considered in patients with previous lung transplantation. Experienced centers in double sequential lung and kidney transplantation should be established to assess and treat these types of patients.

(Pro)renin/renin receptor expression during normal and preeclamptic pregnancy in rats.

AIMS: Pregnancy is a physiological stage with profound cardiovascular changes leading to hypotension. Preeclampsia (PE) reverts these normal changes inducing hypertension. Renin-angiotensin system (RAS) has been related in PE genesis. It has been reported a novel receptor in the system, the Prorenin/Renin receptor (PRR), with several roles in renal and cardiovascular illnesses. It is not known, however, if PRR changes its expression or is activated during normal or PE-complicated pregnancy on tissues intimately related to hypertension. So, the aim of this work was to describe PRR expression during normal and hypertensive pregnancy in rats. METHODS: We used a subrenal aortic coarctation (SRAC) model in rats. Atria, septum and ventricular heart tissue, aorta and renal tissue samples were homogenized and immunoblotted using anti-PRR and anti-PLZF antibodies. We also measured gene expression by RT-PCR. KEY FINDINGS: Hypertension and proteinuria were observed in SRAC-pregnant rats. In pregnant, non-SRAC rats, PRR showed a higher expression of both, gene and protein compared to non-pregnant rats in heart, aorta and kidney tissues. PE induces a very high expression of PRR in cardiac tissues and, on the contrary, decreases PRR expression in both, aorta and kidney. PLZF, a marker of PRR function, was augmented only in aorta and kidney in non-SRAC pregnant rats. In SRAC-pregnant rats, PLZF increment disappeared. SIGNIFICANCE: These findings indicate that PRR expression changes differently during pregnancy and PE in tissues related to cardiovascular functions and suggest a probable participation of the receptor during normal and preeclamptic pregnancy in the rat.

Friction, lubrication, and in situ mechanics of poroelastic cellulose hydrogels.

The tribology between biphasic materials is challenging to predict and interpret due to the interrelationship between mechanical properties, microstructure and movement of the fluid phase contained within. A new approach is presented to deconvolute these effects for cellulose hydrogels, which have a fibrous network that is akin to the microstructure of articular cartilage and plant cell walls. This is achieved by developing a tribo-rheological technique that uniquely incorporates in situ mechanical characterisation (compression-relaxation and small amplitude oscillatory shear) immediately prior to measuring the tribological response between pairs of hydrogels. A radial pressure gradient is generated upon compression-relaxation of the poroelastic hydrogels that results in a non-uniform film thickness at the interface between them. Simulations of this process show that contact between gels occurs in an outer annulus region. Accounting for the predicted contact area between hydrogels varying in cellulose density and pectin solution viscosity causes measured tribology data to collapse onto a single curve; the apparent static friction between hydrogel tribopairs increases with the storage modulus of the hydrogels according to a power law with exponent 0.67. The method is used to compare the influence of plant cell wall polysaccharides, xyloglucan and arabinoxylan, on the interactive forces between cellulose fibres; xyloglucan is found to reduce the static friction between the hydrogels while arabinoxylan had no significant effect. The methodologies presented should provide a new framework for studying the friction between gels and other biphasic soft materials and polymeric surface films.

Midterm Results of Renal Transplantation From Controlled Cardiac Death Donors Are Similar to Those From Brain Death Donors.

BACKGROUND: The systematic use of grafts from controlled donors after cardiac death (cDCD) started in our country in 2012 and expanded with the strategic support of National Transplant Organization. We present our experience in kidney transplantation with organs from cDCD donors with a mean follow-up of 3 years. METHODS: Observational prospective study of all transplants performed in our center in 2012-2013 followed to 2016. The immunosuppression protocols were triple therapy for low-risk recipients from a standard brain death donor (DBD), adding basiliximab or thymoglobulin induction for extended-criteria donor or high-risk recipient, respectively, and thymoglobulin induction plus triple therapy for all cDCD recipients. RESULTS: A total of 42 donors were included (84 grafts in total, but 1 discarded due to multiple cysts); 25 DBD and 17 cDCD without differences in age or sex. The graft use rate was 98.9% for cDCD; 55 grafts were implanted in our hospital (26 DBD and 29 cDCD), and the remaining 28 grafts were transferred to other centers. There were no differences in primary failure (3.4% cDCD vs 7.4% DBD), but the cDCD organs had a higher incidence of delayed graft function (51.7% vs 25.9%). Despite that, graft and patient survivals, as well as glomerular filtration rate (66.3 vs 59.6 mL/min) were similar in both groups. Only 1 patient died at home with a functioning graft in the cDCD group. CONCLUSIONS: Despite a higher rate of delayed graft function with cDCD, the midterm outcomes are at least similar to those with DBD. The cDCD programs should be promoted to increase the chances of a transplant in our patients.

Micromechanical model of biphasic biomaterials with internal adhesion: Application to nanocellulose hydrogel composites.

The mechanical properties of hydrated biomaterials are non-recoverable upon unconfined compression if adhesion occurs between the structural components in the material upon fluid loss and apparent plastic behaviour. We explore these micromechanical phenomena by introducing an aggregation force and a critical yield pressure into the constitutive biphasic formulation for transversely isotropic tissues. The underlying hypothesis is that continual fluid pressure build-up during compression temporarily supresses aggregation. Once compression stops and the pressure falls below some critical value, internal aggregation occurs over a time scale comparable to the poroelastic time. We demonstrate this model by predicting the mechanical response of bacterial nanocellulose hydrogel composites, which are promising biomaterials and a structural mimetic for the plant cell wall. Cross-linking of cellulose by xyloglucan creates an extensional resistance and substantially increases the compressive modulus under large compression and densification. In comparison, incorporating non-crosslinking arabinoxylan into the hydrogel has little effect on its mechanics at the strain rates investigated. These results assist in elucidating the mechanical role of these polysaccharides in the complex plant cell wall structure. They also suggest xyloglucan is a suitable candidate to tailor the stiffness of nanocellulose hydrogels in biomaterial design, which includes modulating cell-adhesion in tissue engineering applications. The model and overall approach may be utilised to characterise and design a myriad of biomaterials and mammalian tissues, particularly those with a fibrillar structure. STATEMENT OF SIGNIFICANCE: The mechanical properties of hydrated biomaterials can be non-recoverable upon compression due to increased adhesion occurring between the structural components in the material. Cellulose-hemicellulose composite hydrogels constitute a classical example of this phenomenon, since fibres can freely re-orient and adhere upon fluid loss to produce significant variations in the mechanical response to compression. Here, we model their micromechanics by introducing an aggregation force and a critical yield pressure into the constitutive formulation for transversely isotropic biphasic materials. The resulting model is easy to implement for routine characterization of this type of hydrated biomaterials through unconfined compression testing and produces physically meaningful and reproducible mechanical parameters.

Three-dimensional structure and molecular dynamics studies of prorrenin/renin receptor: description of the active site.

The recent finding of a specific receptor for prorrenin/renin (PRR) has brought new insights into the physiology of the renin-angiotensin-aldosterone system. No undoubtable role has been described for this receptor so far. Its role seems to be important in chronic illnesses such as hypertension, possibly participating in the cardiovascular remodeling process, and diabetes where participation in inflammation development has been described. It is not possible, however, to explore the PRR function using classical pharmacological approaches due to the lack of specific agonists or antagonists. Two synthetic peptides have been described to accomplish these roles, but no conclusive data have been provided. There are no X-ray crystallography studies available to describe the structure and potential sites for drug development. So, the aim of this work was to model and theoretically describe the PRR. We describe and characterize the whole receptor protein, its spatial conformation and the potential interactions of PRR with the synthetic peptides available, describing the amino acid residues responsible for these interactions. This information provides the basis for directed development of drugs, seeking to agonize or antagonize PRR activity and study its function in health and ill stages.

Kidney transplantation with organs from donors after circulatory death type 3: a prospective multicentric Spanish study (GEODAS 3).

To increase the number of kidney donors, new strategies are needed such as living donor programs, expanded criteria donors, or donors after circulatory death (DCD) kidney transplantation programs. The GEODAS group has started an observational, prospective, multicenter clinical study, collecting data from all DCD type-3 kidney transplantations performed in seven Spanish hospitals from January 2012 to January 2014. The preliminary results have shown a delayed graft function of 40.4% and graft survival of 93.7% with a nadir creatinine of 1.3 mg/dL. From all 33 potential donors included in the study, 32 were effective and 63 kidney grafts were transplanted with a utilization rate of 98.5%. Creatinine evolution (median [range]) was in the first month: 2.1 [0.6-5.6]; third month: 1.6 [0.8, 4.2]; first year: 1.6 [0.9-2.2]. These results are similar to kidney transplantation from donors after brain death as shown in the literature, especially in the graft and recipient survival rates. In addition, the controlled programs are easier and less expensive than uncontrolled DCD programs with a higher rate of graft use.

Role of α1D -adrenoceptors in vascular wall hypertrophy during angiotensin II-induced hypertension.

The in vivo effect of continuous angiotensin II (Ang II) infusion on arterial blood pressure, vascular hypertrophy and α1 -adrenoceptors (α1 -ARs) expression was explored. Alzet(®) minipumps filled with Ang II (200 ng kg(-1)  min(-1) ) were subcutaneously implanted in male Wistar rats (3 months-old). Groups of rats were also treated with losartan, an AT1 R antagonist, or with BMY 7378, a selective α1D -AR antagonist. Blood pressure was measured by tail-cuff; after 2 or 4 weeks of treatment, vessels were isolated for functional and structural analyses. Angiotensin II increased systolic blood pressure. Phenylephrine-induced contraction in aorta was greater (40% higher) in Ang II-treated rats than in the controls, and similar effect occurred with KCl 80 mm. Responses in tail arteries were not significantly different among the different groups. Angiotensin II decreased α1D -ARs without modifying the other α1 -ARs and induced an increase in media thickness (hypertrophy) in aorta, while no structural change occurred in tail artery. Losartan prevented and reversed hypertension and hypertrophy, while BMY 7378 prevented and reversed the aorta's hypertrophic response, without preventing or reversing hypertension. Findings indicate that Ang II-induced aortic hypertrophic response involves Ang II-AT1 Rs and α1D -ARs. Angiotensin II-induced α1D -AR-mediated vascular remodeling occurs independently of hypertension. Findings identify a α1D -AR-mediated process whereby Ang II influences aortic hypertrophy independently of blood pressure elevation.

Micromechanics and poroelasticity of hydrated cellulose networks.

The micromechanics of cellulose hydrogels have been investigated using a new rheological experimental approach, combined with simulation using a poroelastic constitutive model. A series of mechanical compression steps at different strain rates were performed as a function of cellulose hydrogel thickness, combined with small amplitude oscillatory shear after each step to monitor the viscoelasticity of the sample. During compression, bacterial cellulose hydrogels behaved as anisotropic materials with near zero Poisson's ratio. The micromechanics of the hydrogels altered with each compression as water was squeezed out of the structure, and microstructural changes were strain rate-dependent, with increased densification of the cellulose network and increased cellulose fiber aggregation observed for slower compressive strain rates. A transversely isotropic poroelastic model was used to explain the observed micromechanical behavior, showing that the mechanical properties of cellulose networks in aqueous environments are mainly controlled by the rate of water movement within the structure.

Conversaciones informales en un programa de salud comunitaria: evaluación del proceso / Informal conversations in a community health program: process evaluation

Objetivo: Evaluar la calidad del proceso de las conversaciones informales (CI) con perspectiva de género, realizadas por dos agentes de salud, una mujer y un hombre de origen latinoamericano, en un programa dirigido a población inmigrante. Diseño: Se utiliza triangulación de técnicas cuantitativas y cualitativas con perspectiva de género. Método: Las CI transcritas se leen y analizan por tres investigadores, cuantificando variables socio-demográficas: sexo, edad y país de origen y seleccionando segmentos textuales que se agrupan en categorías. El análisis cualitativo se basa en la teoría fundamentada (grounded theory). Resultados: 165 (CI), el 53 % son con mujeres; fundamentalmente de Ecuador, Bolivia y Colombia. Se visibilizan los distintos roles de género en salud sexual y reproductiva y utilización de servicios. Conclusiones: Las CI cumplen los criterios de cobertura, transmisión de mensajes y derivación a recursos. Se manifiesta la necesidad de seguir trabajando por un sistema sexo-género igualitario en la población latinoamericana (AU)

Objective: Evaluate the process quality of informal conversations (CI) with a gender perspective, made by two health workers, a woman and a Latino man, in a program addressed at immigrants. Design: It uses triangulation technical quantitative and qualitative with gender perspective. Method: The CI are read transcribed and analyzed by three researchers, quantifying sociodemographic variables: sex, age and origin country and selecting text segments that are grouped into categories. The qualitative analysis is based on grounded theory (grounded theory). Results: 165 (CI), 53% are with women, mainly from Ecuador, Bolivia and Colombia. They make visible the different gender roles in sexual and reproductive health and use of services. Conclusions: The (CI) met criteria: coverage, messaging and referral resources. It highlights the need to continue working for a sex-gender system equal in the Latin American population (AU)

Fármacos e infertilidad: revisión / Drugs and infertility: a review

Introducción Estudio de los fármacos asociados con esterilidad. Material y métodos Se realizó una búsqueda sistemática bibliográfica. Resultados Antiinflamatorios, quimioterápicos, hormonas, antibióticos y otros como cafeína, clortetracoclina, dapsona, fenotiazinas, nifedipino, cimetidina, ciclosporina o espironolactona. Discusión Se podría recomendar intentar evitar su uso en pacientes con dificultad para concebir a no ser que sea estrictamente necesario (AU)

Introduction We performed a study of drugs associated with infertility. Material and methods A systematic search of the literature was performed. Results The drugs identified were antiinflammatory agents, chemotherapeutic drugs, hormones, antibiotics and other drugs such as caffeine chlortetracycline, dapsone, phenothiazines, nifedipine, cimetidine, ciclosporin and spironolactone.DiscussionThe use of these drugs should be avoided in patients having difficulties with conceiving, unless strictly necessary (AU)

Peritoneal dialysis and kidney transplant. A two-way ticket in an integrated renal replacement therapy model.

BACKGROUND: Peritoneal dialysis (PD) seems to be a good option to initiate renal replacement therapy (RRT), but patients with graft failure choose PD less frequently than incident patients (de novo). OBJECTIVE: To describe patient movements between PD and kidney transplantation (TX) and risk factors for failure of the PD technique. METHOD: Multicentre observational study of patients starting PD between 2003 and 2009 with follow-up up until January 2010. Survival analysis based on switching from PD to HD as an event using Kaplan-Meier (KM) and forward, stepwise Cox proportional hazards models. Hazard ratio and 95% confidence intervals (HR [CI]) are shown. MAIN VARIABLE: Switch from PD to HD. Two-group comparison: PD post transplant (post-TX) patients (76) compared to pure incident PD (de novo-PD) patients (830). PATIENTS: 906 PD patients from 19 public hospitals with a mean age of 54.8 years (64.9% male); main ESRD aetiology: glomerulonephritis (25.4%), diabetes (16.7%), vascular-ischaemic (10.7%), interstitial (13.6%) and polycystic (11.2%). Comorbidity conditions: Charlson Index 5.1 (SD 2.4); 21.6% diabetes mellitus (DM), 24.0% cardiovascular (CV) events. RESULTS: Mean follow-up period on PD: 1.85 years (95% CI [1.68-2.02 years]). KM estimation for switching to HD due to PD failure was 5.46 years [4.42-6.50 years]. At the end of follow-up, 88 patients had died, 154 had been transferred to HD and 306 had received a graft (annual rate for patients on waiting list: 0.49 TX per year on PD). The best Cox multivariate model for switching from PD to HD includes: post-TX (HR: 1.63 [1.01-2.63]), DM (HR: 1.69 [1.19-2.40]) and age (1.01 [1.00-1.02]) per year. Post-TX patients were younger (43.8 years vs 55.3 years) and with less comorbidity conditions than de novo-PD patients (DM 18.4% vs 21.9%; CV 15.8% vs 24.7%). However post-TX patients had worse clinical evolution with a rapid decline of renal function (∆-3.88 vs -1.8 ml/min per year); a higher admission rate (0.9 vs 0.62 per year) but similar peritonitis rate (0.45 vs 0.53 episodes per year). They also needed to be transferred to HD more frequently (28.9% vs 15.8%; P<.006) and needed more time to TX (4.8 years vs 1.7 years, Kaplan-Meier). Consequently, time spent on PD was higher in the post-TX group (2.8 vs 1.8 year). LIMITATIONS: Observational study with absence of a standard protocol to switch PD-HD. CONCLUSION: PD seems to be a good first choice technique due to low mortality and high TX ratio in our area. A previous graft failure is associated with a higher rate of PD-failure but time spent on PD is enough to consider this technique as a good option.

The methyl ester of rosuvastatin elicited an endothelium-independent and 3-hydroxy-3-methylglutaryl coenzyme A reductase-independent relaxant effect in rat aorta

The relaxant effect of the methyl ester of rosuvastatin was evaluated on aortic rings from male Wistar rats (250-300 g, 6 rats for each experimental group) with and without endothelium precontracted with 1.0 µM phenylephrine. The methyl ester presented a slightly greater potency than rosuvastatin in relaxing aortic rings, with log IC50 values of -6.88 and -6.07 M, respectively. Unlike rosuvastatin, the effect of its methyl ester was endothelium-independent. Pretreatment with 10 µM indomethacin did not inhibit, and pretreatment with 1 mM mevalonate only modestly inhibited the relaxant effect of the methyl ester. Nω-nitro-L-arginine methyl ester (L-NAME, 10 µM), the selective nitric oxide-2 (NO-2) inhibitor 1400 W (10 µM), tetraethylammonium (TEA, 10 mM), and cycloheximide (10 µM) partially inhibited the relaxant effect of the methyl ester on endothelium-denuded aortic rings. However, the combination of TEA plus either L-NAME or cycloheximide completely inhibited the relaxant effect. Inducible NO synthase (NOS-2) was only present in endothelium-denuded aortic rings, as demonstrated by immunoblot with methyl ester-treated rings. In conclusion, whereas rosuvastatin was associated with a relaxant effect dependent on endothelium and hydroxymethylglutaryl coenzyme A reductase in rat aorta, the methyl ester of rosuvastatin exhibited an endothelium-independent and only slightly hydroxymethylglutaryl coenzyme A reductase-dependent relaxant effect. Both NO produced by NOS-2 and K+ channels are involved in the relaxant effect of the methyl ester of rosuvastatin.

The methyl ester of rosuvastatin elicited an endothelium-independent and 3-hydroxy-3-methylglutaryl coenzyme A reductase-independent relaxant effect in rat aorta.

The relaxant effect of the methyl ester of rosuvastatin was evaluated on aortic rings from male Wistar rats (250-300 g, 6 rats for each experimental group) with and without endothelium precontracted with 1.0 µM phenylephrine. The methyl ester presented a slightly greater potency than rosuvastatin in relaxing aortic rings, with log IC50 values of -6.88 and -6.07 M, respectively. Unlike rosuvastatin, the effect of its methyl ester was endothelium-independent. Pretreatment with 10 µM indomethacin did not inhibit, and pretreatment with 1 mM mevalonate only modestly inhibited the relaxant effect of the methyl ester. Nω-nitro-L-arginine methyl ester (L-NAME, 10 µM), the selective nitric oxide-2 (NO-2) inhibitor 1400 W (10 µM), tetraethylammonium (TEA, 10 mM), and cycloheximide (10 µM) partially inhibited the relaxant effect of the methyl ester on endothelium-denuded aortic rings. However, the combination of TEA plus either L-NAME or cycloheximide completely inhibited the relaxant effect. Inducible NO synthase (NOS-2) was only present in endothelium-denuded aortic rings, as demonstrated by immunoblot with methyl ester-treated rings. In conclusion, whereas rosuvastatin was associated with a relaxant effect dependent on endothelium and hydroxymethylglutaryl coenzyme A reductase in rat aorta, the methyl ester of rosuvastatin exhibited an endothelium-independent and only slightly hydroxymethylglutaryl coenzyme A reductase-dependent relaxant effect. Both NO produced by NOS-2 and K+ channels are involved in the relaxant effect of the methyl ester of rosuvastatin.

[Approach to quality objectives in incidents of patients in peritoneal dialysis]. / Cumplimiento de objetivos de calidad y evolución de los pacientes incidentes en diálisis peritoneal.

INTRODUCTION: In 2007 the Scientific Quality-technical and Improvement of Quality in Peritoneal Dialysis was edited. It includes several quality indicators. As far as we know, only some groups of work had evaluated these indicators, with inconclusive results. AIM: To study the evolution and impact of guidelines in Peritoneal Dialysis. METHODS: Prospective cohort study of each incident of patients in Peritoneal Dialysis, in a regional public health care system (2003-2006). We prospectively collected baseline clinical and analytical data, technical efficacy, cardiovascular risk, events and deaths, hospital admissions and also prescription data was collected every 6 months. RESULTS: Over a period of 3 years, 490 patients (53.58 years of age; 61.6% males.) Causes of ERC: glomerular 25.5%, diabetes 16%, vascular 12.4%, and interstitial 13.3%. 26.48% were on the list for transplant. Dialysis efficacy: Of the first available results, the residual renal function was 6.37 ml/min, achieving 67.6% of all the objectives K/DOQI. 38.6% remained within the range during the entire first year. Anaemia: 79.3% received erythropoietic stimulating agents and maintained an average Hb of 12.1 g/dl. The percentage of patients in the range (Hb: 11-13 g/dl) improved after a year (58.4% vs 56.3% keeping in the range during this time of 25.6%). Evolution: it has been estimated that per patient-year the risk of: 1) mortality is 0.06 IC 95% [0.04-0.08]; 2) admissions 0.65 [0.58-0.72]; 3) peritoneal infections 0.5 [0.44-0.56]. CONCLUSION: Diabetes Mellitus patients had a higher cardiovascular risk and prevalence of events. The degrees of control during the follow-up in many topics of peritoneal dialysis improve each year; however they are far from the recommended guidelines, especially if they are evaluated throughout the whole study.

[Vascular access models cause heterogeneous results in the centres of one community]. / Los modelos de atención al acceso vascular condicionan resultados heterogéneos en los centros de una misma comunidad.

INTRODUCTION: Vascular access (VA) is the main difficulty in our hemodialysis Units and there is not adequate update data in our area. PURPOSE: To describe the vascular access management models of the Autonomous Community of Madrid and to analyze the influence of the structured models in the final results. MATERIAL AND METHODS: Autonomous multicenter retrospective study. Models of VA monitoring, VA distribution 2007-2008, thrombosis rate, salvage surgery and preventive repair are reviewed. The centers are classified in three levels by the evaluation the Nephrology Departments make of their Surgery and Radiology Departments and the existence of protocols, and the ends are compared. MAIN VARIABLES: Type distribution of VA. VA thrombosis rate, preventive repair and salvage surgery. RESULTS: Data of 2.332 patients were reported from 35 out of 36 centers. Only 19 centers demonstrate database and annual evaluation of the results. Seventeen centers have multidisciplinary structured protocols. Forty-four point eight percent of the patients started dialysis by tunneled catheter (TC). Twenty-nine point five percent received dialysis by TC in December-08 vs 24.7% in December-07. Forty-four point seven percent of TC were considered final VA due to non-viable surgery, 27% are waiting for review or surgery more than 3 months. For rates study data from 27 centers (1.844 patients) were available. Native AVF and graft-AVF thrombosis rates were 10.13 and 39.91 respectively. Centers with better valued models confirmed better results in all markers: TC rates, 24.2 vs 34.1 %, p: 0.002; native AVF thrombosis rate 5.3 vs 10.7 %; native AVF preventive repair 14.5 vs 10.2%, p: 0.17; Graft- AVF thrombosis rate 19.8 vs 44.4%, p: 0.001; Graft-AVF preventive repair 83.2 vs 26.2, p < 0.001.They also have less patients with TC as a final option (32.2 vs 45.3) and less patients with TC waiting for review or surgery more than 3 months (2.8 vs 0). LIMITS: Seventy-five percent of patients were reached for the analysis of thrombosis rate. Results are not necessarily extrapolated. CONCLUSIONS: For the first time detailed data are available. TC use is elevated and increasing. Guidelines objectives are not achieved. The difference of results observed in different centers of the same public health area; make it necessary to reevaluate the various models of care and TC follow-up.

Angiotensin-II type 1 receptor (AT1R) and alpha-1D adrenoceptor form a heterodimer during pregnancy-induced hypertension.

Pregnancy courses with low response to angiotensin II and adrenergic agonists. In preeclampsia, both effects are reverted. It is known that angiotensin II regulates adrenergic system. It is not known, however, the interaction between both systems receptors. Our aim was to study if AT(1)R and alpha1D adrenoceptor heterodimerize in preeclampsia. We used subrenal aorctic coarctation in pregnant rats. Aortic tissues were prepared for confocal imaging and coimmunoprecipitated for alpha1D and AT(1) receptors. We found that AT(1)R and alpha1D adrenoceptor heterodimerize in both, healthy and preeclamptic groups. In healthy pregnant rats, heterodimer is barely detected. In preeclamptic rats however, we found higher heterodimerization. These results suggest that AT(1)R and alpha1D -adrenoceptor may form heterodimers, and may play a role in preeclampsia.

[Patients on peritoneal dialysis with type 2 diabetes present poorer progress than non-diabetics at the expense of their cardiovascular comorbidity]. / Los pacientes diabéticos tipo 2 presentan peor evolución que los no diabéticos en diálisis peritoneal a expensas de su comorbilidad cardiovascular.

AIM: To describe the characteristics, practice patterns, targets and outcome of the Type 2 diabetic patients (DM 2) in peritoneal dialysis (PD) and to compare them with non-diabetic ones. METHODS: Prospective cohort study of every incident PD patient in a regional public health care system (2003-2006). We prospectively collected baseline data, hospital admissions, peritonitis, transplants, CV events and deaths. Every six months PD prescription data and results on efficacy, anaemia, blood pressure (BP) were collected. RESULTS: DM 2 patients (n = 65) were older and presented a higher rate of previous CV events (60.9% vs. 17.7% p<0001) than non-DM patients (n = 376) and worse BP control at inclusion on PD. There were no differences in dialysis efficacy targets and anaemia management. HOSPITAL ADMISSIONS: DM 2 patients present higher hospitalisation rates 1.1 [0.9-1.4] than NoDM ones 0.6 [0.5-0.7] admissions per year at risk. Survival: DM 2 patients present lower PD-technique survival than No DM ones (870 vs. 1002 days Kaplan-Mayer estimation p = 0.009) and higher annual mortality rate (13.7 vs. 4.1%, p: 0.021) with a crude mortality hazard ratio (HR) of 2.5 [1.1-5.6] after correction by age. However, the best predictive model for mortality by Cox proportional hazards model includes age, existence of previous CV events and forced inclusion on PD and excludes DM 2. The association between DM 2 and CV events ruled out DM 2 from the multivariate risk model. CONCLUSION: Type 2 DM patients had a higher prevalence of previous CV events, and a worse global outcome. Previous CV events may explain part of this risk.

[Clinical and economic repercussions of the use of tunneled haemodialysis catheters in a health area]. / Repercusiones clínicas y económicas del uso de catéteres tunelizados de hemodiálisis en un área sanitaria.

INTRODUCTION: Tunneled catheters in hemodialysis are associated with poor prognosis, however, few prospective studies have been designed to specifically evaluate this aspect. The objective has been evaluate the impact of tunneled catheter in patient mortality and costs attributable to this procedure. METHODS: A seven years prospective cohort study was performed in all patients starting hemodialysis in our health care area adjusting for comorbidity and albumin. The study comprised 260 patients with Charlson index 7.05 +/- 2.8 (age 65.5 years, 62.3% males, 25% with diabetes mellitus and 37.7% with a previous cardiovascular event. RESULTS: The first vascular access was a catheter in 47.3%, PTFE in 11.2% and native arteriovenous fistula in 41.5%. Minimum follow-up was one year, with an average of 2.31 years/patient. The mortality risk adjusted for comorbidity was greater among the patients that started with catheterization, HR: 1.86 [1.11-3.05]. This negative effect was observed in 57.30% of those subjected to catheterization at any stage (HR: 1.68 [1.00-2.84] and proved to be time dependent, i.e., the longer catheterization, the greater the risk: HR: 7.66 [3.34-17.54] third versus first tertil. The cost directly attributable to catheter use was 563.31 euros/month. All poor prognosis groups showed lower albumin and hemoglobin levels, without differences in efficacy. CONCLUSION: Tunneled catheter use at any time is associated with an increased risk of death. This effect increases with the duration of catheterization, both circumstances are independent of patient comorbidity at time start of hemodialysis and implies a higher net cost.