Type A chronic aortic dissection with obesity and preeclampsia. / Disección aórtica crónica tipo A en un paciente con obesidad mórbida y preeclampsia.

Aortic dissection is a potentially lethal disease whose incidence in pregnant women can be up to 100 times that of the remaining adult population. In most cases, it presents as typical chest pain. We report the case of a 37yo obese woman diagnosed with chronic type A aortic dissection documented by a radiological finding 10 months after delivery.

Kidney transplantation outcomes in African-, Hispanic- and Caucasian-Americans with lupus.

African-American recipients of kidney transplants with lupus have high allograft failure risk. We studied their risk adjusting for: (1) socio-demographic factors: donor age, gender and race-ethnicity; recipient age, gender, education and insurance; donor-recipient race-ethnicity match; (2) immunologic factors: donor type, panel reactive antibodies, HLA mismatch, ABO blood type compatibility, pre-transplant dialysis, cytomegalovirus risk and delayed graft function (DGF); (3) rejection and recurrent lupus nephritis (RLN). Two thousand four hundred and six African-, 1132 Hispanic-, and 2878 Caucasian-Americans were followed for 12 years after transplantation. African- versus Hispanic- and Caucasian-Americans received more kidneys from deceased donors (71.6%, 57.3% and 55.1%) with higher two HLA loci mismatches for HLA-A (50%, 39.6% and 32.4%), HLA-B (52%, 42.8% and 35.6%) and HLA-DR (30%, 24.5% and 21.1%). They developed more DGF (19.5%, 13.6% and 13.4%). More African- versus Hispanic- and Caucasian-Americans developed rejection (41.7%, 27.6% and 35.9%) and RLN (3.2, 1.8 and 1.8%). 852 African-, 265 Hispanic-, and 747 Caucasian-Americans had allograft failure (p < 0.0001). After adjusting for transplant era, socio-demographic-immunologic differences, rejection and RLN, the increased hazard ratio for allograft failure of African- compared with Caucasian-Americans became non-significant (1.26 [95% confidence interval 0.78-2.04]). African-Americans with lupus have high prevalence of risk factors for allograft failure that can explain poor outcomes.

Repercussions of early versus late initiation of dialysis.

  Despite the widespread use of chronic dialysis, there remains a lack of consensus about the optimal time for initiation of renal replacement therapy. Recommendations from the National Kidney Foundation Kidney Disease Outcome Quality Initiative are generally used as the guideline. This has resulted in a trend in the past decade toward earlier initiation of dialysis, especially in the elderly. The associated burden of comorbidities in the elderly population has resulted in greatly reduced survival outcomes. Here, the data obtained from retrospective cohort studies have been corroborated with a recent randomized control trial conducted in Australia and New Zealand (IDEAL study). There are limitations to consider from the IDEAL study that originate from different confounding factors that intervene in the test population. The present paper is an evidence-based review of the literature, focusing on diminution of survival outcomes following the early initiation of dialysis.

Review: Lupus nephritis: pathologic features, epidemiology and a guide to therapeutic decisions.

Systemic lupus erythematosus may present with renal manifestations that frequently are difficult to categorize and lupus nephritis is an important predictor of poor outcome. The type and spectrum of renal injury may remain undiagnosed until full-blown nephritic and/or nephrotic syndrome appear with increased risk of end-stage renal disease. These abnormalities occur within the first few years after the diagnosis of lupus is made on clinical grounds and with the support of laboratory tests in high risk patients. An early renal biopsy is helpful in patients with an abnormal urinalysis and/or reduced glomerular filtration rate and the results form the basis for therapeutic decisions. The biopsy also provides vital prognostic information based on histological categorization of different types of lupus nephritis, the degree of activity, chronicity and the immunopathogenesis. In the current armamentarium, the use of cyclophosphamide and azathioprine and recently mycophenolate mofetil, reduce morbidity and maintenance therapies reduce the risk of end-stage renal disease. Clinical trials underway promise new, effective and safe immunosuppressive regimens for the treatment of proliferative lupus nephritis.

[The clinical impact of the physiological effects of erythropoietin and erythropoietin-stimulating agents on the incidence of malignancy, and hypertension: beyond anaemia]. / El impacto clínico de los efectos fisiológicos de la eritropoyetina y de los agentes estimulantes de la eritropoyetina en la incidencia de malignidad, trombosis e hipertensión: más allá de la anemia.

The glycoprotein hormone erythropoietin is an essential viability and frowth factor for the erythrocytic progenitors. EPO signaling involves tyrosine phosphorylation of the homodimeric EPO receptor and subsequent activation on intracellular proteins, kinases and transcription factors. Treatment with recombinant human EPO(rHu EPO) is efficient and safe in improving the management of the anemia associated with chronic kidney disease, and allowing avoidance of transfusions with blood products. however, the unanticipated increase in mortality found in recent randomized studies is prompting a reassessment of this view. The present review will show what is known about the physiology of this plasma factor that, it is now clear, is more than just an erythrocyte production factor, and its pleitropic effects influencing the incidence of malignancy, thrombosis, hypertension and retinopathy.

[Nephrogenic fibrosing dermopathy or nephrogenic systemic fibrosis? What do we know and what do we have to learn?]. / Dermopatía fibrosante nefrogénica o fibrosis sistémica nefrogénica? Qué es lo que sabemos y qué debemos aprender?

Nephrogenic systemic fibrosis (NSF) was first recognized as a unique entity in 1997 and subsequently defined in the literature in 2000 as a novel fibrosing disorder occurring in the setting of renal disease. Prevention, early recognition and treatment are essential to limiting its impact. The most important risk factors for developing NSF are chronic or significant acute kidney disease (especially dialysis dependent patients) and the administration of gadolinium (GD3) containing contrast agents, agents that cause NSF by releasing free gadolinium (GD3) into tissues based on their pharmacokinetics. International commissions in drug control and medicinal products recommend to avoid gadolinium based contrast agents in patients with GFR < 30 ml/minute/1.73 m(2). Unfortunately there is lack of universally effective therapy at this time and the literature is based on case reports and small case series. Recommendations to guide the use of gadolinium based contrast agents in patients with underlying kidney disease should be individualized and considered in consultation with the ordering physician, radiologist and nephrologist.