Clinical usefulness of lanthanum carbonate for serum phosphate control in difficult patients.

BACKGROUND: The adequate control of phosphataemia is of major importance in end-stage renal disease patients on maintenance dialysis. Recently, lanthanum carbonate (LC) has been added to the phosphate binder armamentarium. To our knowledge, no studies have yet evaluated the usefulness of this drug in uncontrolled hyperphosphataemic patients. METHODS: This was a 6-month prospective observational study. Patients on chronic hemodialysis who had previously failed to achieve serum phosphate control were enrolled. Thirty-four patients (i.e. 11% out of 305 from three dialysis units) met the inclusion criteria. Lanthanum carbonate was introduced and titrated to achieve serum phosphate control, according to the KDOQI guidelines. Clinical targets, gastrointestinal symptoms, and patients' satisfaction with therapy were assessed at baseline and after 6 months. RESULTS: Eight patients (23.5%) were withdrawn from the study due to side effects. In the remaining patients, serum phosphate level significantly decreased from 5.8 to 4.4 mg/dl and calcium-phosphate product also decreased significantly from 55.6 to 41.8 mg(2)/dl(2). The average number of all phosphate binder tablets taken per day was reduced from 6.7 to 4.7. Evaluation scores of dyspeptic symptoms and of patient's satisfaction with therapy also improved: from 7.5 to 5.3 and from 6.6 to 8.1, respectively. CONCLUSIONS: The introduction of LC improved serum phosphate control in over 70% of these "difficult patients". A lower pill burden was also obtained, which might help to simplify treatment and increase patients' compliance. Dyspeptic symptoms and overall satisfaction with treatment also improved.

[Analysis of psychological factors influencing peritoneal dialysis selection]. / Análisis de la influencia de los factores psicológicos en la elección de diálisis peritoneal.

BACKGROUND: Peritoneal dialysis (PD) is not frequently used in our setting. OBJECTIVE: To analyze the psychological factors involved in the choice of renal replacement therapy (RRT). MATERIAL AND METHODS: A prospective observational study of stable patients without cognitive or sensory deficits who were informed about RRT from January 2004 to July 2006 and agreed to participate. The patients were given and completed the Beck Depression Inventory and the Eysenck personality questionnaire. Clinical and sociodemographic data and RRT choice were recorded. End of follow-up: 2007/10/31. RESULTS: 44 patients were studied: age, 65.4 +/- 13.1 years, 48% male, 34% diabetic. When choosing RRT, 36% of patients had symptoms of depression. Neither depression symptoms nor personality traits were related to the choice of dialysis type. The youngest patients chose PD (41%). After a mean followup of 8 +/- 8 months, 70% of patients started RRT (68% haemodialysis [HD], 32% PD). None of the patients who chose HD changed their mind, but 3 of the 13 patients (23%) who chose PD finally commenced HD, usually in the context of a worsening of the disease. Half of the patients with depression symptoms when choosing PD and a third of the patients with higher levels of neuroticism changed their decision and finally opted for HD. CONCLUSIONS: When choosing RRT, the prevalence of depression symptoms is high. Neither depression nor personality traits influenced the initial choice of RRT, although these factors may be involved in subsequent changes to the decision.

Análisis de la influencia de los factores psicológicos en la elección de diálisis peritoneal / Analysis of psychological factors influencing peritoneal dialysis selection

Antecedentes: La diálisis peritoneal (DP) se utiliza poco en nuestro medio. Objetivo: Analizar los factores psicológicos implicados en la elección del tratamiento sustitutivo renal (TSR).Material y métodos: Estudio observacional prospectivo de los enfermos estables y sin déficit cognitivo o sensorial que recibieron información del TSR entre enero de 2004 y julio de 2006y que aceptaron participar. Se les entregaron para su cumplimentación el inventario de depresión de Beck y el cuestionario de personalidad de Eysenck, y se recogieron datos sociodemográficos, clínicos y el TSR elegido. El final del seguimiento fue el 31 de octubre de 2007. Resultados: Se estudiaron 44 pacientes: edad, 65,4 ± 13,1 años; 48% hombres; 34% diabéticos. Un36% tenían síntomas depresivos. Ni éstos ni los rasgos de personalidad se relacionaron con la elección de la técnica. Eligieron DP (41%) los enfermos más jóvenes. Un 70% de los enfermos iniciaron TSR (68% hemodiálisis [HD], 32% DP) a los 8 ± 8 meses. Ninguno de los pacientes que eligieron HD cambió de opinión, pero tres de los 13 pacientes (23%) que habían elegido DP realizaron finalmente HD, en general en el contexto de agudizaciones . La mitad de los pacientes con síntomas depresivos y un tercio de los pacientes con mayores niveles de neuroticismo cambiaron su decisión inicial y optaron finalmente por la HD. Conclusiones: La prevalencia de síntomas depresivos en el momento de elegir TSR es elevada. Ni los síntomas depresivos ni los rasgos de personalidad influyeron en el TSR inicialmente elegido, aunque pueden ser factores implicados en los cambios de decisión posteriores(AU)

Background: Peritoneal dialysis (PD) is not frequently used in our setting. Objective: To analyze the psychological factors involved in the choice of renal replacement therapy (RRT).Material and methods: Prospective observational study of stable patients without cognitive or sensory deficits, who were informed about RRT from January 2004 to July 2006, and agreed to participate. The Beck Depression Inventory and the Eysenck personality questionnaire were administered. Clinical and sociodemographic data, and RRT choice were recorded. End of follow-up: 2007/10/31. Results: We studied 44 patients: age, 65.4 ± 13.1 years, 48% male, 34% diabetic. When choosing RRT, 36% of patients had depressive symptoms. Neither depressive symptoms nor personality traits were related to the choice of the dialysis type. Patients who chose PD (41%) were younger. After a mean follow-up of 8 ± 8 months, 70% of patients started RRT (68% hemodialysis [HD], 32% PD). None of the patients who chose HD changed their mind, but 3 of the 13 patients (23%) who chose PD finally commenced HD, usually in the context of disease exacerbations. Half of the patients with depressive symptoms when choosing PD, and at hird of the patients with higher levels of neuroticism changed their decision and finally opted for HD. Conclusions: When choosing RRT, the prevalence of depressive symptoms is high. Neither depression nor personality traits influenced the initial choice of RRT, but these factors may be involved in subsequent changes of the initial choice (AU)

[Prognostic significance of hemoperitoneum in peritoneal dialysis]. / Significado pronóstico del hemoperitoneo en diálisis peritoneal.

According to previous reviews, hemoperitoneum episodes appear in 6.1-8.4% of the peritoneal dialysis patients, and they are severe in a 20% of them. Due to the absence of severe hemoperitoneum in our peritoneal dialysis program, we retrospectively reviewed hemoperitoneum non-related with abdominal surgery or catheter placing. We analyzed its incidence, etiology, prognostic and clinical outcome, as well as the possible effect of recurrent hemoperitoneum on peritoneal function. A total of 132 patients were treated in our centre during a period of 173 months. Mean age at the beginning of peritoneal dialysis was 59+/-17.1 years, 43.2% were females, and 22.8% of them were menstruating women. Twenty-two patients had at least one hemoperitoneum episode during follow-up, with an incidence of 17%. The mean time interval between the start of peritoneal dialysis and the first hemoperitoneum episode was 0.66+/-0.94 years (range: 0.01-3.20 years). 73% were women. Most cases (59%) were due to menstruation. Remarkably, all the menstruating women presented hemoperitoneum at least once with a high incidence of recurrent episodes. The other hemoperitoneum episodes were mainly of unknown etiology (32% of patients), being this one the main cause in males. We only observed two more cases: a male who presented hemoperitoneum related to dicumarinic overdose and a female who presented hemoperitoneum due to mesenteric ischemia. All the 22 patients had a favourable outcome, except for the woman with mesenteric ischemia, what represented an incidence of 4.5% of severe hemoperitoneum. No significant association was found between episodes of hemoperitoneum and aspirin treatment, dicumarinic treatment or the presence of coagulopathy. There was no association either between recurrent hemoperitoneum and the number of peritonitis episodes, peritoneal function or technique survival. In conclusion, hemoperitoneum is a common and usually benign problem in peritoneal dialysis patients, frequently due to retrograde menstruation, and no deleterious long-term effects were found in patients with recurrent hemoperitoneum.

[Advance directives in chronic dialysis patients]. / Documento de voluntades anticipadas de pacientes con insuficiencia renal crónica terminal en tratamiento sustitutivo mediante diálisis.

BACKGROUND AND OBJECTIVE: Knowledge of the life-sustaining treatment preferences of the dialysis patients would be extremely helpful to substitute decision-makers and nephrologists in deciding whether to continue or stop a treatment. The population of the Mediterranean countries show this opinion with less frequency. The objective of this study is: 1) the knowledge of the patient's view for the advance directives; it may increase the likelihood to get the correct decisions of the staff when complications break the normal course of chronic dialysis, and 2) the statement of the advance directives. MATERIAL AND METHOD: We distributed 135 questionnaires to patients with chronic renal failure in dialysis treatment of the Sabadell's Hospital to explore demographic information about responders and not-responders and explore the rate of questionnaires was completed about the cardiopulmonary resuscitation, respirator, tube feeding and dialysis in case of coma, persistent vegetative state, severe dementia and terminal illness. We explore about the representative of patients and in case of not-responders about the cause to not answer. RESULTS: Sixty-four of 135 patients (47,8%) did not want cardiopulmonary resuscitation, respirator, tube feeding or dialysis in case of coma, persistent vegetative state, severe dementia or terminal illness. Compared with patients who wanted the treatments, those who did not were older (71,2 versus 62,2 years; p = 0.002). There was no difference in the other demographic questions, including sex (p=0.674), cause of kidney failure (p=0.815), comorbid conditions (p=0.824), and social status (language of questionnaire -0.155- and standard of education -0.288-). Advance care planning does not occur solely within the context of the physician-patient relationship; the respondents reported the representative in the family, essentially. The patients not-responders doesn t want to think in those situations and also they show doubt about the interpretation of their answers. CONCLUSIONS: near 50% patients in chronic dialysis want to stop certain treatments in case of resuscitation cardiopulmonary, coma, persistent vegetative state, severe dementia or terminal illness. The older patients want the limitation of treatments more frequently.

[Choosing not to dialysis in chronic renal failure in stage V (Renal Failure). Evolution of the characteristics of patients between 1992-1995 and 2000-2003]. / Elección de no diálisis en insuficiencia renal crónica en estadio V (fallo renal). Evolución de las características de los pacientes entre 1992-1995 y 2000-2003.

BACKGROUND: The incidence of chronic renal failure increase with the age. The selection of patient to dialysis has been increasing in spite of the high comorbidity. Moreover, in our clinical practice the aged patient is not contraindicated to dialysis. However, in the nephrology clinical practice not all the patients start the treatment with dialysis. OBJECTIVE The aim of our study has been to compare the characteristics of the patients who had not been dialyzed between the periods 1992-1995 and 2000-2003 to analyze the trend of the nephrology clinical practice. MATERIAL AND METHODS: Comparative study of the characteristics and the evolution of patients with chronic renal failure in stage V, (renal failure) not incorporated to dialysis in one hospital during four years between the periods the 1992-1995 ( period A) and 2000-2003 (period B). RESULTS: Start dialysis (period A versus period B): 116 patients, age 59.9+15.5 years vs. 229 patients, age 64.0+15.8 years (p<0.05). Non-dialysis (period A versus period B): 38 patients, age 77.5+9.3 years vs. 37 patients, age 81.7+6.2 years (p<0.01). Renal function: serum creatinina 7.4+2.4 mg/dl vs. 5.3+1.2 mg/dl (p<0.001), MDRD estimate glomerular filtration 6.9+2.4 mg/dl ml/min/1.73 m2 vs. 10.0+2.3 ml/min/1.73 m2 (p<0.001). Primary renal disease: unknown etiology 31.5 % vs. 24.3 %, nephroangiosclerosis 23.6 % vs. 32.4 %, diabetes 28.9 % vs. 21.6 %. Functional status: dependent patients 34.2 % vs 83.8 % (p<0.001). The principal reason for non-dialysis were: personal decision: 26.3 % vs. 35.1 %, dementia 15.8 % vs. 29.7 %, brief life expectancy because of serious co-existing diseases 13.1 % vs. 21.7 % and serious chronic illness with inability for themselves care 44.7 % vs. 13.1 %. Comorbid conditions: 2.3+1.0 vs. 3.0+1.5 (p<0.05). Survival: 55+168 days vs. 168+236 days (p<0.001). CONCLUSION: Most of the patients that don't begin dialysis are elderly together with a poor functional capacity and with more autonomy in their decisions. The identification of patients with renal failure (stage V) was detected early in the last period than in the following one. The conservative management of non-dialyzed uremic patients is a significative nephrology clinical practice due to more survival of those persons.

[Secondary amyloidosis (AA-type) due to localized cutaneous vasculitis]. / Amiloidosis secundaria asociada a vasculitis cutánea localizada.

We report a case of a 49 year old man, diagnosed soon after the outcome of casual proteinuria, of AA-type amyloidosis in relation to small and medium vessel cutaneous vasculitis without systemic involvement. This combination is a rare entity and only two cases of cutaneous hypersensibility vasculitis complicated with AA-type amyloidosis had been reported. We describe the results of the use of several immunosuppressive drugs during four years follow up with temporally total remission of the disease.

Elección de no diálisis en insuficiencia renal crónica en estadio V (fallo renal). Evolución de las características de los pacientes entre 1992-1995 y 2000-2003 / Choosing not to dialysis in chronic renal failure in stage V (renal failure). Evolution of the characteristics of patients between 1992-1995 and 2000-2003

Introducción: La insuficiencia renal crónica (IRC) es una patología que aumenta su incidencia con la edad. La aceptación de pacientes para diálisis ha ido aumentando en los últimos años a pesar del incremento de la comorbilidad, no considerándose la edad como contraindicación para el tratamiento sustitutivo renal. No obstante, en la práctica clínica nefrológica hay pacientes que no son incluidos en diálisis. Objetivo: Comparar las características de los pacientes con IRC no incluidos en diálisis en los períodos 1992-1995 y 2000-2003 para analizar las tendencias evolutivas de la práctica clínica nefrológica. Material y método: Estudio comparativo de las características basales y la evolución de los pacientes con IRC en estadio de fallo renal (estadio V) en quienes se decidió la elección de No-Diálisis atendidos en un sólo hospital durante 4 años entre los períodos de 1992-1995 (período A) y 2000-2003 (período B). La elección de No-Diálisis fue por decisión del paciente si era autónomo o de sus representantes legales en caso contrario. Resultados: SI-Diálisis: (período A versus período B): n:116 pacientes, edad: 59,9 + 15,5 años vs n: 229 pacientes, edad: 64,0 + 15,8 años (p < 0,05). NO-Diálisis: (período A versus período B): n: 38 pacientes, 24,6% de la IRC que inició diálisis, edad: 77,5 + 9,3 años vs n: 37 pacientes, 13,9% de la IRC que inició diálisis, edad: 81,7 + 6,2 años (p < 0,01). Funcionalismo renal: creatinine sérica 7,4 + 2,4 mg/dl vs 5,3 + 1,2 mg/dl (p < 0,001); filtrado glomerular estimado por MDRD abreviado: 6,9 + 2,4 ml/min/1,73 m2 vs 10,0 + 2,3 ml/min/1,73 m2 (p < 0,001). Enfermedad renal primaria principales: etiologia no aclarada 31,5% vs 24,3%, nefroangiosclerosis 23,6% vs 32,4%, diabetes 28,9 vs 21,6. Los motivos principales de la elección de no diálisis fueron: decisión personal 26,3% vs 35,1%, incompetencia mental persistente 15,8% vs 29,7%, pronóstico mortal a corto plazo 13,1% vs 21,7% y deterioro crónico severo con incapacidad de cuidarse 44,7% vs 13,5%. Autonomia funcional: pacientes dependientes 34,2% vs 83,8% (p < 0,001). Comorbilidades: 2,3 + 1,0 vs 3,0 + 1,5 procesos (p < 0,05), insuficiencia cardíaca 36,8% vs 48,8%, enfermedad cerebro-vascular 47,3% vs 51,3%, artropatía invalidante 13,1% vs 43,2%. Supervivencia media 55 + 168 días vs 168 + 236 días (p < 0,001). Conclusión: Los pacientes que no inician diálisis en los últimos años son más viejos, tienen peor capacidad física y son más autónomos en su capacidad de decisión. La identificación de los pacientes con IRC en estadio V se hace de forma más precoz y el seguimiento es más prolongado en el último período. El manejo nefrológico conservador de la IRC estadio V es una práctica clínica nefrológica significativa debido a la mayor supervivencia de estos pacientes

Background: The incidence of chronic renal failure increase with the age. The selection of patient to dialysis has been increasing in spite of the high comorbidity. Moreover, in our clinical practice the aged patient is not contraindicated to dialysis. However, in the nephrology clinical practice not all the patients start the treatment with dialysis. Objective: The aim of our study has been to compare the characteristics of the patients who had not been dialyzed between the periods 1992-1995 and 2000- 2003 to analyze the trend of the nephrology clinical practice. Material and met- hods: Comparative study of the characteristics and the evolution of patients with chronic renal failure in stage V (renal failure) not incorpored to dialysis in one hospital during four years between the periods the 1992-1995 (period A) and 2000-2003 (period B). Results: Start dialysis (period A versus period B): 116 patients, age 59.9 + 15.5 years vs 229 patients, age 64.0 + 15.8 years (p < 0.05). Non-dialysis (period A versus period B): 38 patients, age 77.5 + 9.3 years vs 37 patients, age 81.7 + 6.2 years (p < 0.01). Renal function: serum creatinina 7.4 + 2.4 mg/dl vs 5.3 + 1.2 mg/dl (p < 0.001), MDRD estimate glomerular filtration 6.9 + 2.4 mg/dl ml/min/1.73 m2 vs 10.0 + 2.3 ml/min/1.73 m2 (p < 0.001). Primary renal disease: unknown etiology 31.5% vs 24.3%, nephroangiosclerosis 23.6% vs 32.4%, diabetes 28.9% vs 21.6%. Functional status: dependent patients 34.2% vs 83.8% (p < 0.001). The principal reason for non-dialysis were: personal decision: 26.3% vs 35.1%, dementia 15.8% vs 29.7%, brief life expectancy because of serious co-existing diseases 13.1% vs. 21.7% and serious chronic illness with inability for themselves care 44.7% vs 13.1%. Comorbid conditions: 2.3 + 1.0 vs 3.0 + 1.5 (p < 0.05). Survival: 55 + 168 days vs 168 + 236 days (p < 0.001). Conclusión: Most of the patients that don’t begin dialysis are elderly together with a poor functional capacity and with more autonomy in their decisions. The identification of patients with renal failure (stage V) was detected early in the last period than in the following one. The conservative management of non-dialyzed uremic patients is a significative nephrology clinical practice due to more survival of those persons

Documento de voluntades anticipadas de pacientes con insuficiencia renal crónica terminal en tratamiento sustitutivo mediante diálisis / Advance directives in chronic dialysis patients

Fundamento y objetivo: En la cultura latina no hay experiencia sobre estudios que definan la opinión de los pacientes con enfermedades crónicas acerca de cómo quisieran ser tratados en caso de complicaciones severas que inhabiliten su calidad de vida y su capacidad para decidir. El objetivo del estudio es: 1) tener el conocimiento de esas opiniones que podrían facilitar las decisiones de los médicos que tratan a estos enfermos, en el caso especial de surgir complicaciones que alteren esa capacidad de decidir de los pacientes, y 2) la invitación a la verdadera elaboración de un documento de voluntades anticipadas. Material y método: Se facilita un cuestionario a 135 pacientes de la Unidad de Hemodiálisis del hospital de Sabadell, en el que se les pregunta si desearían limitaciones terapéuticas (resucitación cardiopulmonar en caso de paro cardiorrespiratorio, ventilación mecánica, alimentación artificial, seguir en proceso de diálisis) en caso de estar en coma profundo, estado vegetativo, demencia profunda irreversible o enfermedad crónica en fase terminal. Se establecen diferencias epidemiológicas entre los pacientes que manifiestan desear esas limitaciones en esas circunstancias y los que no lo hacen. Se pregunta sobre el representante en caso de incapacidad y acerca de los motivos por los que no contestan a los pacientes que no responden el cuestionario. Resultados: Entre los dos grupos de pacientes, tan sólo la edad les diferencia significativamente (p = 0,002) pues el promedio de edad de los enfermos que quisieran limitaciones es de 71,2 años y el del que no manifiestan querer limitaciones es de 62,2 años. El sexo (p = 0,674), comorbilidad (p = 0,824), estudios (p = 0,288), factores culturales como el idioma (p = 0,155) y nefropatía primaria (p = 0,815) no ofrecen diferencias entre ambos grupos. Un 47,8% de los pacientes de nuestro medio tratados con diálisis crónica, se manifiestan abiertamente partidarios de limitar esfuerzos terapéuticos en alguna de las circunstancias mencionadas. La mayoría de pacientes que realizan voluntades anticipadas tienen como representante un familiar, especialmente hijos. Los que no responden al cuestionario no lo hacen principalmente por rechazar la posibilidad de pensar en ello y también por desconfianza. Conclusiones: En nuestro medio, casi el 50% de los pacientes tratados mediante hemodiálisis periódica son partidarios de limitar ciertos tratamientos en circunstancias de pronóstico infausto, siendo los enfermos más ancianos los más partidarios a manifestar la voluntad sobre esas limitaciones

Background and objective: Knowledge of the life-sustaining treatment preferences of the dialysis patients would be extremely helpful to substitute decision-makers and nephrologists in deciding whether to continue or stop a treatment. The population of the Mediterranean countries show this opinion with less frequency. The objective of this study is: 1) the knowledge of the patient´s view for the advance directives; it may increase the likelihood to get the correct decisions of the staff when complications break the normal course of chronic dialysis, and 2) the statement of the advance directives. Material and method: We distributed 135 questionnaires to patients with chronic renal failure in dialysis treatment of the Sabadell´s Hospital to explore demographic information about responders and not-responders and explore the rate of questionnaires was completed about the cardiopulmonary resuscitation, respirator, tube feeding and dialysis in case of coma, persistent vegetative state, severe dementia and terminal illness. We explore about the representative of patients and in case of notresponders about the cause to not answer. Results: Sixty-four of 135 patients (47,8%) did not want cardiopulmonary resuscitation, respirator, tube feeding or dialysis in case of coma, persistent vegetative state, severe dementia or terminal illness. Compared with patients who wanted the treatments, those who did not were older (71,2 versus 62,2 years; p = 0.002). There was no difference in the other demographic questions, including sex (p = 0.674), cause of kidney failure (p = 0.815), comorbid conditions (p = 0.824), and social status (language of questionnaire —0.155— and standard of education —0.288—). Advance care planning does not occur solely within the context of the physician-patient relationship; the respondents reported the representative in the family, sons and daughters, particulary. The patients not-responders doesn´t want to think in those situations and also they show doubt about the interpretation of their answers. Conclusions: Near 50% patients in chronic dialysis want to stop certain treatments in case of resuscitation cardiopulmonary, coma, persistent vegetative state, severe dementia or terminal illness. The older patients want the limitation of treatments more frequently

¿Influye la agitacion intensa del efluente peritoneal para el calculo de la dosis de dialisis en dialisis peritoneal automatica? / Peritoneal fluid agitation and dialysis dose estimation in automatic peritoneal analysis

No disponible

[Allopurinol-induced chronic granulomatous interstitial nephritis]. / Nefritis intersticial granulomatosa cronica por alopurinol.

Although drug induced interstitial nephritis is a relatively common cause of renal failure,granulomatous forms remain a rare condition. The development of a chronic granulomatous interstitial nephritis due to allopurinol is exceptional, only three cases have been described previously. We report on a patient who presented a granulomatous interstitial nephritis after 10 years of allopurinol administration (300 mg/day). At diagnosis, he had end stage renal disease and dialysis treatment was needed. Two months after drug withdrawal and on corticoid treatment a slow recovery of renal function was observed, allowing the interruption of dialysis. Two years after, the creatinine clearance is 23 ml/min,being dialysis free. We discuss the differential diagnosis of granulomatous interstitial nephritis and its rare association with allopurinol treatment.

¿Influye la agitación intensa del efluente peritoneal para el cálculo de la dosis de diálisis en diálisis peritoneal automática? / No disponible

No disponible

Estudio detallado de las causas de transferencia de Diálisis Peritoneal a hemodiálisis en un Servicio de Nefrología / A detailed study of the causes of tranference from peritonal dialysis to hemodialysis in a nephrology service

Objetivo: Analizar las causas y los factores de riesgo de transferencia a HD de un programa de DP. Material y métodos: Estudio retrospectivo y descriptivo. La DP se ofrece en un plano de igualdad a todos los enfermos con IRCT. Se han recogido variables demográficas, clínicas, existencia de deficiencias físicas, autonomía funcional, peritonitis, tiempo de seguimiento y motivo de finalización de la técnica; causa de transferencia inmediata a hemodiálisis, clasificándolas en potencialmente solucionables o no. De los enfermos transferidos se analizaron: datos clínicos, estado funcional y datos sociales. Resultados: De un total de 103 pacientes, un 58,25 por ciento varones, con una edad media al inicio de la DP de 59 ñ 18, se han transferido a HD un 29 por ciento, se han trasplantado un 16,5 por ciento y fallecieron el 29 por ciento, mientras que 26 enfermos siguen en programa. Las causas inmediatas del paso a HD fueron: fallo de ultrafiltración (UF) y/o infradiálisis 30 por ciento, peritonitis 17 por ciento, problemas relacionados con el catéter o la pared abdominal 17 por ciento, intolerancia a la DP 17 por ciento, problema social y/o enfermedad grave 13 por ciento y deseo del paciente 6 por ciento. Del total de transferencias, el 46,7 por ciento eran por problemas relacionados con la DP no solucionables. Los pacientes transferidos tuvieron más peritonitis que el resto y una mayor proporción de deficiencias físicas que dificultaban realizar la DP. Se observó una gran influencia de los factores personales y sociales en la supervivencia de la técnica de DP (AU)

[Patients with end-stage chronic renal insufficiency on programmed withdrawal from dialysis]. / Pacientes con insuficiencia renal crónica terminal retirados de diálisis bajo protocolización.

UNLABELLED: The voluntary discontinuation of dialysis by patients is a common mode of death in dialysis programmes. Unfortunately the Spanish experience has not been related in the nephrological literature. Initiation of, and withdrawal from, dialysis pose ethical questions for medicine in the 21st century. The dialysis population is aging and they have multiple medical problems. The choice may be between prolongation of quantity or quality of life. We evaluated a protocol for initiation of dialysis in patients with end stage renal failure and their subsequent withdrawal. We determined the factors predicting withdrawal of dialysis and revised the protocol to take account of these. We carried out an opinion poll of doctors and nurses about the effectiveness of the protocol. We studied prospectively the reasons for death of patients in the last seven years. RESULTS: Thirty patients were withdrawn from dialysis out of 116 who died during treatment by hemodialysis or continuous ambulatory peritoneal dialysis (CAPD) in the last seven years. Vascular nephropathy is the principal disease predicting withdrawal from dialysis; the main precipitating cause is mental incapacity. The availability of a protocol for withdrawal of dialysis is well received by doctors and nurses and it engenders moral and legal calm when facing difficult decisions. Twenty-six per cent of deaths on regular dialysis are the result of withdrawal of treatment.

Pacientes con insuficiencia renal crónica terminal retirados de diálisis bajo protocolización / Voluntary discontinuation of dialysis

La retirada de diálisis no es motivo de investigación ni de tratamiento habitual en la literatura nefrológica española. Es un tema de debate que conlleva disyuntivas de tipo ético. Su presentación es frecuente actualmente en la clínica diaria. Con la prolongación de expectativas de vida de los pacientes, aumentan los dilemas acerca de la prolongación de esa vida en las mínimas condiciones de calidad.Se comprueba la utilidad de un protocolo de entrada/retirada de pacientes con insuficiencia renal crónica terminal, diseñando los parámetros pronósticos de retirada de diálisis, y revisando los parámetros que inciden en la toma de decisión de esa retirada. Se realiza una encuesta a los profesionales sobre la efectividad del protocolo. Se revisan prospectivamente las causas de muerte acaecidas en los últimos siete años.Los resultados muestran 30 pacientes retirados del total de 116 enfermos fallecidos durante ese tiempo. La nefropatía vascular es la enfermedad que plantea con mayor frecuencia la retirada de diálisis, siendo la causa inmediata la incapacidad mental.La disponibilidad de un protocolo de retirada de diálisis confiere un aceptable grado de satisfacción entre los profesionales y les da tranquilidad moral y tal vez legal, a pesar del vacío existente en ese sentido, ante unas tomas de decisiones eventualmente conflictivas, dado que un 26 por ciento de los fallecimientos son debidos a esa retirada. (AU)

Effects of polyunsaturated fatty acids on rat glomerulosclerosis induced by hypercholesterolaemic diet.

Association between lipids and renal disease has been reported recently. Its pathogenic mechanisms remain unknown. The aims of this study were to establish: (1) if a cholesterol-rich diet, alone or associated with nephrectomy, produces nephropathy; and (2) if a treatment with omega-3 polyunsaturated fatty acids (PUFA) reduces glomerulosclerotic lesions. Sixty Sprague-Dawley rats were randomized in two different groups: (A) sham operated rats and (B) uninephrectomized rats. Rats in both groups were divided into three subgroups (A1-3, B1-3) according to the diet they were fed: normal chow diet, cholesterol-rich diet (4.5%) or cholesterol-rich diet supplemented with omega-3 PUFA. Twenty weeks later, serum creatinine, creatinine clearance, serum cholesterol, triglycerides, albumin, proteinuria, mesangial cell score and focal glomerulosclerosis were assessed. Results showed that a cholesterol-rich diet significantly increased serum cholesterol, proteinuria and glomerular lesions and decreased creatinine clearance, especially in nephrectomized rats. Glomerular lesions, serum cholesterol and proteinuria ameliorated when cholesterol-rich diet was supplemented with PUFA. Hypertension was noticed only in nephrectomized rats following a normal chow diet. Simple correlation analysis showed that glomerulosclerosis correlated with renal weight, blood creatinine, cholesterol and proteinuria. In spite of some significant differences in urinary prostaglandins, no correlation with glomerular lesions was found. Multiple logistic regression analysis showed that cholesterol and proteinuria were independent risk factors for induction of glomerular sclerosis. In conclusion, a diet rich in cholesterol induces glomerulosclerosis, especially if it is associated with unilateral nephrectomy. Omega-3 PUFA administration reduces serum cholesterol, proteinuria and glomerular injury.