Diálisis peritoneal paliativa en pacientes con falla cardiaca sin enfermedad renal terminal / Palliative peritoneal dialysis in patients with heart failure without end-stage renal Failure

Resumen Dentro de los grandes problemas que se tienen en falla cardiaca, el manejo del volumen en algunos de los pacientes resulta muy difícil y ocasionalmente puede producir grandes alteraciones renales, por lo cual ha sido una de las principales preocupaciones dentro de las estrategias terapéuticas. La diálisis peritoneal ha surgido como una estrategia en algunos pacientes con presencia de disfunción ventricular y de disfunción renal; sin embargo, hay un grupo de pacientes en los cuales el deterioro de la función renal no es severo, pero hay imposibilidad para el manejo óptimo con diuréticos a dosis más altas y hay necesidad de mayor manejo de volumen. La diálisis peritoneal ha evidenciado beneficios clínicos, entre los cuales se encuentra la posibilidad de manejo ambulatorio, el cambio de su clase funcional de III/IV a I/II, la mejoría de la calidad de vida, la reducción en los días de hospitalización o el aumento de la función renal. Se ha realizado una revisión de este escenario específico con presentación de los primeros casos que se han dispuesto con esta finalidad en la clínica de falla cardíaca de la Fundación Cardiovascular de Colombia.

Abstract Within the great problems of heart failure, the management of volume in some of the patients is a difficult task and could occasionally produce severe renal alterations, thus becoming one of the main worries when it comes to therapeutic strategies. Peritoneal dialysis has emerged as a strategy in some patients with ventricular dysfunction and renal dysfunction; however, there is a group of patients where the deterioration of renal function is not severe, but there is an impossibility of optimal management with diuretics at higher doses and there is a need for a greater volume management. Peritoneal dialysis has evidenced clinical benefits, among which there is the possibility of outpatient management, the change from functional class III/IV to I/II, the improvement in quality of life, the decrease of hospitalization days or the increase in renal function. A review of this specific scenario with the presentation of the first cases that have been managed with this motivation in the heart failure clinic of the Cardiovascular Foundation of Colombia is conducted.

Caspofungin therapy of neonates with invasive candidiasis.

BACKGROUND: Invasive candidiasis is an increasing problem in neonatal intensive care units worldwide and is an important cause of morbidity, mortality and prolongation of hospital stay. Despite administration of amphotericin B, invasive candidiasis in neonates is sometimes complicated by persistent fungemia and refractory invasive candidiasis. The problem has been augmented by the increasing prevalence of non-albicans species that often are resistant to fluconazole and to amphotericin B. POPULATION AND METHODS: The population consisted of 1 term and 9 premature neonates with invasive candidiasis caused by Candida albicans (n = 4), Candida parapsilosis (n = 3), Candida tropicalis (n = 2) and Candida glabrata (n = 1). Despite initial therapy with deoxycholate amphotericin B, blood cultures remained positive in all patients for 13-49 days. Invasive candidiasis progressed to meningitis and enlarging renal Candida bezoars in the kidney of one patient and an enlarging atrial vegetation in another. Another patient developed severe hypokalemia refractory to potassium supplementation. Two of the C. albicans and all of the non-albicans Candida isolates were resistant to fluconazole; the C. glabrata isolate was resistant to amphotericin B. Amphotericin B was discontinued and caspofungin initiated in all patients in a dosage of 1 mg/kg/d for 2 days followed by 2 mg/kg/d. RESULTS: All positive blood cultures cleared between 3 and 7 days after initiation of caspofungin, the atrial vegetation resolved and the renal Candida bezoars disappeared. Renal and hepatic function tests did not show any values above normal throughout caspofungin therapy. There were no attributable clinical adverse events during the administration of caspofungin in any of the patients. CONCLUSIONS: Caspofungin was effective, safe and well-tolerated as an alternative therapy for persistent and progressive candidiasis in those neonates who were unresponsive to or intolerant of deoxycholate amphotericin B.