Estudio transversal comparativo de las fórmulas CKD-EPI y MDRD-4 a partir de la historia clínica informatizada de Atención Primaria de Barcelona / A comparative, cross-sectional study of the CKD-EPI and MDRD-4 equations from the Primary Care computerized clinical history of Barcelona

Antecedentes: La prevalencia de enfermedad renal crónica (ERC) en España supera el 7%. Su diagnóstico precoz puede ayudar a frenar la evolución. En Atención Primaria (AP) se calcula el filtrado glomerular estimado (FGe) mediante fórmulas basadas en la creatinina plasmática(CrP).Objetivos: Comparar los FG e según las fórmulas MDRD-4 y CKD-EPI a partir de la historia clínica informatizada (HCI) y la clasificación de ERC en una población de AP. Material y métodos: Estudio transversal. Se incluyó a pacientes de 20-99 años, asignados a centros de AP de Barcelona, con CrP entre julio de 2008 y junio de 2010. Se obtuvieron losdatos de la HCI. Se calculó el FGe mediante CKD-EPI y MDRD-4.Resultados: Se estudió a un total de 447.140 personas: 58,7% mujeres, 56,6 (DE 18,8) años. El 32,5% con diagnóstico de hipertensión arterial, 11% con diabetes mellitus y 9,3% con enfermedad cardiovascular asociada. La CrP media fue 0,89 (0,28) mg/dL, FGe por MDRD-4 de 80,59(21,04) mL/min/1,73 m2y por CKD-EPI de 85,03 (21,13) mL/min/1,73 m2. La CKD-EPI, respecto a MDRD-4, clasificó el 2,3% de los pacientes en estadios menos avanzados de ERC, el 96,8% en el mismo y el 0,9% en más avanzados. El índice kappa fue de 0,87. En números absolutos clasificó en estadios 3b-4-5 (posible derivación a nefrología) a 958 pacientes más, con 691 personas >69 años en estadio 3b.Conclusiones: Utilizar una u otra fórmula puede variar el FGe. La CKD-EPI tiende a clasificar enestadios más avanzados en > 69 años. El uso de cada fórmula puede hacer cambiar el número y tipo de derivaciones a nefrología

Background: The prevalence of chronic kidney disease (CKD) in Spain is higher than 7%. Its early diagnóstico can help to delay its progression. Glomerular filtration rate (GFR) based on serum creatinine (SC) is calculated in primary care (PC) to identify CKD. Objectives: To compare GFR by MDRD-4 and CKD-EPI equations obtained from clinical records(CR) and to compare the classification of CKD in a primary care population. Material and methods: A cross-sectional study was performed, including patients 20-99 years old, assigned to primary care centers of Barcelona, with a SC recorded between July 2008 and June 2010. Data were obtained from the CRs. GFR was calculated from MDRD-4 and CKD-EPI equations. Results: A total of 447,140 persons were studied (58.7% females, 56.6 [SD 18.8] years old).Of these 32.5% were diagnosed of hypertension, 11.0% diabetes and 9.3% had some associated cardiovascular disease. SC 0.89 (0.28) mg/dL (78.7 [SD 24.8] mol/L), GFR being 80.59(21.04) mL/min/1.73 m2by MDRD-4, and 85.03 (21.13) mL/min/1.73 m2by CKD-EPI. CKD-EPI compared to MDRD-4 classified 2.3% of patients in less advanced stages of CKD, 96.8% in the same stage and 0.9% in more advanced stages. Kappa coefficient: 0.87. In absolute numbers, CKD-EPI classified in 3b-4-5 stages (candidates for referral to nephrology) 958 patients more,691 of them being patients > 69 years old and stage 3b.Conclusions: Using one equation or another could vary the estimation of GFR. CKD-EPI tends to classify patients older than 69 into more advanced stages. Each equation can change the number and type of referral to nephrology (AU)

El filtrado glomerular reducido según las fórmulas de Cockcroft-Gault y MDRD no siempre predice la morbimortalidad cardiovascular en los pacientes hipertensos atendidos en atención primaria / Decreased glomerular filtration rate using the Cockgroft-Gaultand MDRD formulas does not always predict cardiovascular morbidity and mortality in hypertensive primary care patients

Antecedentes: El deterioro de la función renal se ha asociado con un incremento de la morbimortalidad cardiovascular. El objetivo del estudio fue analizar la asociación del filtrado glomerular (FG) basal, según las fórmulas de Cockcroft-Gault y MDRD, con la incidencia de eventos cardiovasculares (ECV) en una cohorte de personas hipertensas seguida durante 12 años. Métodos: Estudio prospectivo de una muestra aleatoria de 223 hipertensos libres de ECV atendidos en un centro de atención primaria urbano. Se estimó el FG mediante ambas fórmulas. Se consideró ECV la aparición de cardiopatía isquémica, insuficiencia cardíaca, accidente cerebrovascular, vasculopatía periférica o muerte por ECV. Se analizaron los datos mediante el método actuarial y modelos de regresión de Cox. Resultados: La mediana de tiempo de seguimiento fue de 10,7 años (rango intercuartílico,6,5-12,1). El seguimiento fue completo en 191 participantes (85,7%). La supervivencia acumulada fue del 64,7% (intervalo de confianza [IC] del 95%: 57,9-71,6%). La tasa media de incidencia de ECV durante todo el período de seguimiento fue de 3,6 (IC del 95%, 2,7-4,4%) por 100 personas hipertensas/año. El modelo multivariable final mostró que las variables con mayor poder predictivo de ECV en la población de estudio fueron la diabetes y la estimación del FG >60ml/min/1,73 m2mediante fórmula MDRD. Conclusiones: Se observó una relación entre la aparición de ECV y los valores de FG estimados por la fórmula MDRD al inicio del seguimiento superiores a 60 ml/min/1,73 m2, inversa a la eserada. La estimación del FG mediante fórmula de Cockcroft-Gault no se asoció con el riesgo cardiovascular (AU)

Background: Renal function decrease is associated with cardiovascular morbidity and mortality. The aim was to analyze the association of cardiovascular morbidity and mortality with baseline glomerular filtration rate (GFR), according Cockcroft-Gault and MDRD formulas, with incidence of major adverse cardiovascular events (MACEs) in a cohort of hypertensive individuals followed for 12 years. Methods: We performed a prospective study of a random sample of 223 hypertensive patients free of MACEs followed in an urban Primary Care Center. GFR was estimated using both formulas. MACEs were considered the onset of ischemic heart disease, heart failure, stroke, peripheral vascular disease or cardiovascular death. Data were analyzed using the life-table method and Cox regression modeling. Results: Follow-up median was 10.7 (interquartile range, 6.5-12.1) years. Follow-up was complete in 191 participants (85.7%). The cumulative survival was 64.7% (95%Confidence Interval (CI) 57.9%-71.6%). The incidence of MACEs during the follow-up period was 3.6 (95% CI, 2.7-4.4) per 100 subject-years. The final multivariable model showed that the most predictive variables of MACEs in the study population were the presence of diabetes and the estimation of GFR >60 ml/min/1.73 m2by MDRD equation. Conclusions: There was a relationship between the occurrence of MACEs and MDRD formula estimated GFR above60 ml/min/1.73 m2at study entry, inversely to what expected. C-G formula estimated GFR by was not associated with cardiovascular risk (AU)

[Decreased glomerular filtration rate using the Cockckroft-Gault and MDRD formulas does not always predict cardiovascular morbidity and mortality in hypertensive primary care patients]. / El filtrado glomerular reducido según las fórmulas de Cockcroft-Gault y MDRD no siempre predice la morbimortalidad cardiovascular en los pacientes hipertensos atendidos en atención primaria.

BACKGROUND: A decrease in renal function is associated with cardiovascular morbidity and mortality. The aim of this study was to analyse the association of cardiovascular morbidity and mortality with baseline glomerular filtration rate (GFR), calculated according to the Cockcroft-Gault and MDRD formulas, with the incidence of major adverse cardiovascular events (MACEs) in a cohort of hypertensive individuals followed for 12 years. METHOD: We performed a prospective study of a random sample of 223 hypertensive patients free of MACEs, who were followed in an urban Primary Care Centre. GFR was estimated using both formulas. MACEs were considered as the onset of ischaemic heart disease, heart failure, heart attacks, peripheral vascular disease or cardiovascular death. Data were analysed using the life-table method and Cox regression modeling. RESULTS: The median follow-up was 10.7 (interquartile range, 6.5-12.1) years. Follow-up was completed in 191 participants (85.7%). The cumulative survival was 64.7% (95% Confidence Interval (CI), 57.9-71.6). The incidence of MACEs during the follow-up period was 3.6 (95% CI, 2.7-4.4) per 100 subject-years. The final multivariable model showed that the most predictive variables of MACEs in the study population were the presence of diabetes mellitus and the estimation of GFR ≥60 ml/min/1.73 m2 by MDRD equation. CONCLUSIONS: There was a relationship between the occurrence of MACEs and an estimated GFR by MDRD above 60 ml/min/1.73 m2 at study entry, inversely to what was expected. GFR estimated by the C-G formula was not associated with cardiovascular risk.

Effect of ritonavir and saquinavir on Candida albicans growth rate and in vitro activity of aspartyl proteinases.

An in vitro study to evaluate the antifungal effect and activity of aspartyl proteinases of the HIV-proteinase inhibitors ritonavir and saquinavir was conducted. Ritonavir diminished the growth rate of Candida albicans as well as the activity of its secreted aspartyl proteinases (Saps) in a nitrogen-limited medium, yeast carbon base and bovine serum albumin (YCB-BSA). This inhibition occurred in a dose-dependent fashion; with 8 mg l(-1) of ritonavir a partial growth inhibition (44%) was produced. The growth rate of C. albicans in medium with saquinavir was similar to that seen in the control, and Sap activity was inhibited only at high concentrations. In conventional medium (RPMI-1640), which does not induce the production of yeast proteases, no inhibitory effect was detected with either HIV-protease inhibitor.

[Diagnosis and monitoring of hypertension in Catalonia. The DISEHTAC study]. / Diagnóstico y seguimiento de la hipertensión arterial en Cataluña. Estudio DISEHTAC.

OBJECTIVES: To evaluate the diagnosis, monitoring and control of hypertension in reformed primary care centres in Catalonia, on the basis of the evaluation indicators proposed in the primary care hypertension guidelines. DESIGN: Multi-centre cross-sectional descriptive study.Setting. Primary care.Participants. 31 reformed PCC in Catalonia. Randomised sampling of centres and hypertense patients (n = 2240). External audit. MEASUREMENTS AND MAIN RESULTS: a) Diagnosis indicator: in 19.4% of cases a triple double-take of blood pressure showed an average of = 140/90 mmHg. b) Monitoring indicator: 77.9% of patients had been seen for blood pressure in the previous 6 months. c) Indicator of degree of control of blood pressure: 38.8% of patients had pressure below the figures then recommended ((3/4) 65 < 140/90 mmHg, and > 65, < 160/95 mmHg). 25.7% of cases were found to have blood pressure figures < 140/90 mmHg. CONCLUSIONS: There was high compliance on the monitoring indicator. The degree of control of hypertense patients treated at reformed PCCs is still low.

Resistance to vancomycin, LY333328, ciprofloxacin and trovafloxacin of community-acquired and nosocomial strains of Enterococcus faecalis isolated in Badajoz (Spain) with and without high-level resistance to streptomycin and gentamicin.

In vitro resistance of community-acquired and nosocomial strains of Enterococcus faecalis isolated in Badajoz (Spain) were determined by a microdilution method. The isolates were identified with conventional MicroScan Pos Combo 4 I dehydrated panels. No resistance to glycopeptides was found, but LY333328 was 2-4 times more active than vancomycin. In the nosocomial strains, high-level resistance to streptomycin (HLRS) was 54.7%, and high-level resistance to gentamicin (HLRG) was 38.1%. Resistance to ciprofloxacin and trovafloxacin was 45.3 and 38.9%, respectively. In the community-acquired isolates, HLRS, HLRG, resistance to ciprofloxacin and resistance to trovafloxacin were 44.2, 17.3, 15.4 and 13.5%, respectively. Trovafloxacin was 2-4 times more active than ciprofloxacin against both groups of strains. An association between high-level resistance to aminoglycosides and resistance to fluoroquinolones was noted. The resistance to aminoglycosides did not influence the activity of vancomycin and LY333328.

Phagocytosis and killing of slime-producing Staphylococcus epidermidis bypolymorphonuclear leukocytes. Effects of sparfloxacin.

The interaction of slime-producing Staphylococcus epidermidis (S+ strain) with human polymorphonuclear leukocytes (PMNs) was analyzed. The phagocytosis index (PI) and the killing index (KI) were evaluated, and the effect of subinhibitory concentrations (sub-MICs) of sparfloxacin in this interaction was determined. The study was carried out in parallel with a non-slime-producing strain (S- strain). The MIC values of sparfloxacin against both strains was 0. 06 mg/ml. In the S- strain the mean values of PI and KI were 82% and 31%, respectively, whereas in the S+ strain these values diminished to 49% and 8%, respectively (p <0.05) when the inocula were prepared in aerobiosis. In a constant flow atmosphere of 5% CO2, the results were similar to the previous ones in the S- strain (PI = 79% and KI = 27%), whereas in the S+ strain a increase in the PI (59%) and a similar value to the KI (9%) were observed. Significant increases (p <0.05) in the PI were noted when PMNs were preincubated with 1/4 and 1/16 MIC of sparfloxacin, and S. epidermidis S+ grown in aerobiosis were used. In the other assays the variations in PI and KI were not statistically significant (p >0.05). Our results confirm that slime protects against phagocytosis and killing by PMNs, although they also suggest that the S+ strains possess additional properties which make them resistant to the action of the PMNs.

Influence of N-acetylcysteine on the formation of biofilm by Staphylococcus epidermidis.

The influence of various concentrations (0.003-8 mg/mL) of N-acetylcysteine on the formation of biofilms by 15 strains of Staphylococcus epidermidis has been studied. A dose-related decrease in biofilm formation was observed, except with the lowest concentrations. The 'slime' index relative to the control was 63%, 55%, 46%, 34%, 26% and 26% in the presence of 0.25, 0.5, 1, 2, 4, and 8 mg/mL of N-acetylcysteine, respectively. These data are statistically significant. The inhibitory effect of 2 mg/mL of N-acetylcysteine on slime formation was also verified by electron microscopy.

Incubation temperatures affect adherence to plastic of Candida albicans by changing the cellular surface hydrophobicity.

The influence of cellular surface hydrophobicity on the adherence capacity to plastic of Candida albicans was investigated at two culture temperatures (37 and 22 degrees C). The majority of the 42 strains studied were hydrophobic at 22 degrees C and hydrophilic at 36 degrees C. The hydrophobic cells showed a consistent adherence capacity which was absent from the hydrophilic strains. The culture temperatures affect adherence to plastic of C. albicans by changing the cellular surface hydrophobicity.

Influence of the incubation atmosphere on the production of slime by Staphylococcus epidermidis.

The influence of various incubation atmospheres on the growth and slime production of 23 Staphylococcus epidermidis strains was studied. The atmospheres evaluated were aerobiosis (control), anaerobiosis, candle jar, 5% CO2 and 10% CO2. As compared to the aerobic control, growth was 55.7 +/- 19% (p < 0.01) in anaerobic incubation, 113.7 +/- 12% (p < 0.01) in 5% CO2, 112.8 +/- 13% (p < 0.01) in 10% CO2 and 106.4 +/- 7% (p > 0.1) in the candle jar. The slime production in relation to the aerobic control was 20.3 +/- 19% in anaerobiosis (p < 0.01), 22.3 +/- 27% (p < 0.01) in 5% CO2, 29.4 +/- 39% (p < 0.01) in 10% CO2 and 68.3 +/- 26% (p > 0.1) in the candle jar. The results of this study may explain the discrepancies which have been noted on occasion between slime formation data and pathogenicity.

Effects of cefpirome in comparison with cefuroxime against human polymorphonuclear leucocytes in vitro.

The interaction of cefpirome and cefuroxime, with human polymorphonuclear leucocytes (PMNs) was examined. The effects of therapeutic concentration (1, 10, and 50 mg/L) of both antimicrobial agents on the adherence, spontaneous mobility, chemotaxis, chemokinesis, phagocytosis and candidacidal capacity were studied in vitro. No statistically significant variations, in relation to the control, were observed in the ability of PMNs to adhere to nylon fibre at the concentrations of cefuroxime and cefpirome used. With both antimicrobial agents, PMN mobility increased as the antibiotic concentration was increased. A statistically significant increase (P < 0.05) in spontaneous mobility, chemotaxis and chemokinesis was observed with cefpirome at only 10 mg/L. However, only spontaneous mobility was increased significantly with cefuroxime at 10 mg/L. The strongest effects were observed with cefpirome at 50 mg/L with variations of about 70% (P < 0.01), in chemotaxis and chemokinesis. In general, cefpirome had a positive effect on phagocytosis and candidacidal power, which was significant at a concentration of 50 mg/L (P < 0.01). Cefuroxime, in general, produced no modifications in either phagocytosis or candidacidal power.

In vitro studies of activities of some antifungal agents against Candida albicans ATCC 10231 by the turbidimetric method.

Different criteria (the drug concentration which inhibited 50% of growth [IC1/2], the lowest drug concentration at which growth was just less than 30% of that in a positive control well [IC30], the visual inhibitory concentration [ICv], and the minimum fungicidal concentration [MFC]) were applied to study the effects of some antifungal agents against Candida albicans. Amphotericin B, flucytosine, and bifonazole produced total growth inhibition. Clotrimazole, itraconazole, ketoconazole, and miconazole produced partial growth inhibition. The values of IC1/2 and IC30 were similar for all agents and avoided the problems of partial inhibition; the values of ICv and MFC were higher than those of IC1/2 and IC30.

Activity of vancomycin and teicoplanin against human polymorphonuclear leucocytes: a comparative study.

The in-vitro effects of therapeutic concentrations of teicoplanin and vancomycin on the adherence, spontaneous mobility, chemotaxis, phagocytic and candidacidal capacity of human polymorphonuclear leukocytes (PMNs) were studied. Adherence was not affected by the tested concentrations of teicoplanin. A progressive diminishing of adherence was observed in relation to the control, which reached 30% with the maximum concentration of vancomycin (50 mg/L), although this was not statistically significant. An increase in spontaneous mobility was noted after 30 min incubation in the presence of any one of the tested concentrations of both antibiotics, although the results were only significant (P less than 0.05) for 50 mg/L of teicoplanin. Chemotaxis increased, although not significantly (P greater than 0.05) in the presence of 10 and 50 mg/L of teicoplanin, and diminished with respect to the control very significantly (P less than 0.019) when 1 and 50 mg/L of vancomycin were tested. The study of the phagocytic and candidacidal capacity of the PMNs on Candida albicans showed that teicoplanin had a favourable effect on both functions, even though the differences were not statistically significant.

Phagocytic activity of polymorphonuclear leukocytes on Escherichia coli previously exposed to metronidazole.

A study was made of the action of different concentrations of metronidazole of the viability of Escherichia coli under aerobic and anaerobic conditions. The viability of E. coli was reduced by 60 to 99% after 24 hours of anaerobic incubation, according to the concentration of metronidazole tested. In addition, there were significant morphological changes in the bacteria. Exposure of antibiotic-induced filaments of E. coli LP 136 to phagocytosis caused the cfu/ml value to drop by 60% after 120 minutes. Under identical conditions, using the mutant strain E. coli RYC 819, which did not become filamented by metronidazole although it did present similar ultrastructural changes, this reduction reached 83%. These results may explain the therapeutic success of metronidazole in polymicrobial infections.

The in-vitro activity of metronidazole against Enterobacteriaceae alone and in mixed cultures with Bacteroides fragilis.

The in-vitro antimicrobial action of therapeutic concentrations of metronidazole against Bacteroides fragilis and six different strains of Enterobacteriaceae in pure and mixed cultures have been studied. Under anaerobic conditions, metronidazole suppressed the growth of pure cultures of the Enterobacteriaceae. A reduction in the viable counts from 10(9) cfu/ml, in the 24 h controls, to 10(8), 10(7) and 10(5) cfu/ml in the presence of 10, 50 and 100 mg/l of metronidazole respectively, was observed. These concentrations of drug produced a marked bactericidal effect against B. fragilis, as expected. The antimicrobial activity of metronidazole on mixed cultures of B. fragilis and each one of the Enterobacteriaceae studied was greater against both micro-organisms than the corresponding effect on their respective pure cultures, under the same experimental conditions.