Pronóstico de pacientes nonagenarios ingresados por fracaso renal agudo / Prognosis of in hospital nonagenarians with acute kidney injury

Fundamento: El desarrollo de un fracaso renal agudo(FRA, definido siguiendo las guías KDIGO) durante unahospitalización en pacientes nonagenarios ha sido pocoestudiado. El objetivo del presente estudio es analizar lamortalidad en pacientes nonagenarios hospitalizados quedesarrollan un FRA. Métodos: Se recogieron todos los pacientes nonagenariosque desarrollaron FRA durante el ingreso hospitalarioentre 2013 y 2014. Basalmente, se recogieron variablesepidemiológicas, comorbilidades y, durante el ingreso, variables analíticas y mortalidad. Se analizaron las variablesasociadas a mortalidad durante el episodio de FRA y lospredictores independientes mediante regresión logística. Resultados: Se incluyeron 264 pacientes nonagenarioscon FRA. La edad media fue 93±3 años, siendo 73 (27,7 %)varones. Durante la hospitalización fallecieron 79 pacientes (29,9 %). Las comorbilidades asociadas a mortalidadfueron la insuficiencia cardiaca (p = 0,018), la disfuncióndiastólica (p = 0,042) y un mayor nivel o grado de dependencia (p = 0,003). Las variables clínicas en el momentodel ingreso que se asociaron a mortalidad fueron presiónarterial sistólica y diastólica más baja (p = 0,016 y 0,013,respectivamente), leucocitosis (p = 0,003), mayor severidad del FRA valorado por AKIN (p = 0,003) y valor deácido L- láctico más alto (p = 0,005). Los predictores independientes de mortalidad fueron la insuficiencia cardiaca(OR = 2,31; IC95%: 1,07-5,00; p = 0,036), la dependencia valorada por el índice de Barthel modificado (OR = 0,80; IC95%:0,67-0,97; p < 0,016) y el L- láctico al ingreso (OR = 1,31;IC95%: 1,06-1,61; p = 0,005). Conclusión: La insuficiencia cardiaca, el nivel de dependencia y el ácido L- láctico al ingreso son predictores independientes de mortalidad en pacientes nonagenarioshospitalizados con FRA.(AU)

Background:Ñ There has been little in the way of studyof nonagenarians with acute kidney injury (AKI, definedin lines with KDIGO guidelines), but the rise in their lifeexpectancy makes further study of this population necessary. The aim of this study is to assess mortality in nonagenarians with AKI during hospitalization. Methods: In this retrospective study, patients with AKIduring hospitalization between 2013-2014 were included.At baseline, epidemiological variables, comorbidities andtreatments were collected. Analytics and mortality werestudied during hospitalisation. Univariate analysis wascarried out to evaluate mortalityssociated variables.A logistic regression analysis was carried out to demonstrate independent predictors for mortality. Results: Two hundred and sixty four nonagenarian patients were included. Mean age was 93±3 years, 73 (27.7 %)of whom were men. During hospitalization, 79 patients(29.9 %) died. Comorbidities related to mortality werehistory of heart failure (p = 0.018), diastolic dysfunction(p < 0.042) and higher dependence according to the modified Barthel index (p = 0.003). The clinical variables related to mortality at hospital admission were lower systolic(p = 0.016) and diastolic blood pressure (p = 0.013), higherwhite blood cell count (p = 0.003), greater severity of AKI(p = 0.003) and L- lactic (p = 0.005). In an adjusted multivariate analysis, history of heart failure (OR = 2.31, 95%CI:1.07-5.00, p = 0.036), dependence according to the Barthelindex (OR = 0.80, 95%CI: 0.67-0.97, p = 0.016) and L- lacticacid (OR = 1.31, 95%IC: 1.06-1.61, p = 0.005) were independent predictors of mortality. Conclusion: Heart failure, dependence according to theBarthel index and L- lactic acid at admission are independent predictors of mortality in nonagenarians hospitalizedwith AKI.

COVID-19 vaccination among Spanish nephrologists: Acceptance and side effects.

INTRODUCTION: Four vaccines against Covid-19 have been approved to date. Their acceptance and safety have not been addressed on healthcare workers. The aim of the present study is to evaluate vaccination rates and side effects among Spanish nephrologists. METHODS: All the Spanish nephrologists were invited to participate in this survey. Data on demographics, Covid-19 infection status, received vaccine doses and side effects were collected. Acceptance and side effects were analyzed for Covid-19 vaccination. Factors associated to vaccination were assessed and a multivariate adjusted model was constructed to determine independent predictors for Covid-19 vaccine side effects. RESULTS: A total of 708 nephrologists answered the survey (460 [65%] women, mean age 44±11 years). Six-hundred and eight (86%) had received the first dose and 513 (72%) were fully vaccinated. Most of the subjects (565, 93%) received BNT162b2 (Pfizer-BioNTech®) vaccine. Among vaccinated nephrologists, 453 (75%) presented any side effect; the most frequent was local reaction (68%), followed by myalgia (44%), tiredness (39%) and headache (34%). Age (OR 0.97, 95%CI [0.95-0.99], p<0.0001) and prior Covid-19 infection (OR 2.37, 95%CI [1.27-4.42], p=0.007) were independent predictors for developing side effects with Covid-19 vaccine. Overall side effects were similar with both vaccines, being myalgia (p=0.006) and tiredness (p=0.032) more frequent with the Pfizer-BioNTech® one. CONCLUSION: Age and prior Covid-19 infection were predictors of vaccination side effects among Spanish nephrologists.

[Prognosis of in hospital nonagenarians with acute kidney injury].

BACKGROUND: There has been little in the way of study of nonagenarians with acute kidney injury (AKI, defined in lines with KDIGO guidelines), but the rise in their life expectancy makes further study of this population necessary. The aim of this study is to assess mortality in nonagenarians with AKI during hospitalization. METHODS: In this retrospective study, patients with AKI during hospitalization between 2013-2014 were included. At baseline, epidemiological variables, comorbidities and treatments were collected. Analytics and mortality were studied during hospitalisation. Univariate analysis was carried out to evaluate mortality-associated variables. A logistic regres-sion analysis was carried out to demonstrate independent predictors for mortality. RESULTS: Two hundred and sixty-four nonagenarian patients were included. Mean age was 93±3 years, 73 (27.7?%) of whom were men. During hospitalization, 79 patients (29.9?%) died. Comorbidities related to mortality were history of heart failure (p?=?0.018), diastolic dysfunction (p?

Crescentic glomerulonephritis: data from the Spanish Glomerulonephritis Registry.

BACKGROUND: Crescentic glomerulonephritis (CGN) is a histological finding that implies rapid deterioration of renal function and can be related to different diseases, such as type 1 or anti-glomerular basement membrane antibody (Goodpasture) disease, type 2 or immune complex CGN and type 3 or pauci-immune disease. AIM: The present study describes CGN and its characteristics based on the data from the Spanish Glomerulonephritis Registry. METHODS: An analysis was made of all native renal biopsies obtained from patients during 1994-2013 and classified as CGN. A patient epidemiological and clinical data questionnaire was completed by the 120 centres involved. RESULTS: A total of 21,774 biopsies was performed, of which 2089 (8.1%) corresponded to CGN (211 type 1, 177 type 2 and 1701 type 3). Renal function was poorer in type 1 compared with types 2 and 3, and proteinuria was higher in type 2 compared to types 1 and 3. Patients diagnosed with CGN type 3 were older than those with types 1 and 2, but less hypertensive than the type 2 patients. No differences in the urine test findings were found between types 1 and 2. Microhaematuria was the most frequent feature in general, as well as in type 3 compared with types 1 and 2. The main indication for biopsy was acute renal injury. Age was the only difference between type 1 patients with and without alveolar haemorrhage (53 [33-67] vs 64 [46-73], P = 0.008). CONCLUSION: Although classified as the same entity, the different types of CGN have different features that must be taken into account.

Dose equivalence between continuous erythropoietin receptor activator (CERA), Darbepoetin and Epoetin in patients with advanced chronic kidney disease.

BACKGROUND: Anemia is a prevalent situation in patients with chronic kidney disease (CKD) and can be well managed with erythropoiesis-stimulating agents (ESAs). Continuous erythropoietin receptor activator (CERA) has a long half-life that allows to be administered once monthly. The lowest recommended dose for patients with non dialysis CKD is 120 µg per month. The objectives were to assess the efficacy of subcutaneous monthly dosing of CERA in CKD stages 4 and 5 not on dialysis, and to determine the equivalent dose to epoetin ß and darbepoetin α. METHODS: This is a cohort study. A 30-patient group that ESAs was changed to CERA (µg/month) was used as treatment group. We used the following clinically-based equivalent dosing: epoetin ß (IU/week) and darbepoetin α (µg/week): 3000/15= 50; 4000/20=75; 6000/30=100; 8000/40=150. Another group of 30 patients with similar characteristics was used as control group and received the same epoetin ß and darbepoetin α doses. RESULTS: The mean CERA initial dose and at 6 months was 81.9 ± 35.2 and 82.0 ± 37.82 µg/month (p=0.37). The mean erythropoietin resistance index (ERI) and hemoglobin at baseline and at 6 months in the CERA group and in the control group were not statistically significant. CONCLUSION: Monthly dosing treatment with CERA is safe and effective. A dose of 75-100 µg/month is enough to maintain stable levels of hemoglobin. Hippokratia 2014; 18 (4): 315-318.

[Dyspnea caused by Coxiella Burnetii]. / Disnea causada por Coxiella burnetii.

Dyspnea is a subjective sensation of difficult or uncomfortable breathing caused by increased excitation of brain respiratory centres,(1) and is usually secondary to pulmonary or cardiac disease.(2) Heart failure is a serious public health problem in industrialised countries, with an increasing prevalence and incidence. It is more common in the elderly, and is usually caused by a defect in myocardial contraction, coronary atherosclerosis, or less frequently, valvular disease.(3) Aortic insufficiency (AI) is one of them. It may originate from infective endocarditis, congenital or valvular heart disease, or rheumatic fever. It may lead to a medical emergency due to the inability of the left ventricle to adapt to the rapid increase in the end-diastolic volume caused by regurgitation of blood from aorta to left ventricle. If not corrected, the AI can lead to acute cardiogenic shock.(4.)

Disnea causada por Coxiella burnetii / Dyspnea caused by Coxiella Burnetii

La insuficiencia cardiaca es un grave problema de salud pública en los países industrializados, cuya prevalencia e incidencia están en aumento. Es más frecuente en ancianos y suele ser causada por algún defecto en la contracción del miocardio, ateroesclerosis coronaria o, menos frecuentemente por enfermedad valvular. De estas últimas destaca la insuficiencia aórtica (IA), entre cuyas etiologías se encuentra la endocarditis infecciosa, las valvulopatías congénitas o, la fiebre reumática, y constituye una emergencia médica, debido a la incapacidad del ventrículo izquierdo para adaptarse al veloz aumento en el volumen diastólico final, causado por la regurgitación sanguínea desde aorta a ventrículo izquierdo. Si no se corrige, la IA aguda puede desencadenar un shock cardiogénico. La disnea es una sensación subjetiva de respiración difícil o desagradable, causada por el aumento de la excitación de los centros respiratorios del tronco encefálico. Suele ser secundaria a enfermedades pulmonares o cardiológicas (AU)

Dyspnea is a subjective sensation of difficult or uncomfortable breathing caused by increased excitation of brain respiratory centres, and is usually secondary to pulmonary or cardiac disease. Heart failure is a serious public health problem in industrialised countries, with an increasing prevalence and incidence. It is more common in the elderly, and is usually caused by a defect in myocardial contraction, coronary atherosclerosis, or less frequently, valvular disease. Aortic insufficiency (AI) is one of them. It may originate from infective endocarditis, congenital or valvular heart disease, or rheumatic fever. It may lead to a medical emergency due to the inability of the left ventricle to adapt to the rapid increase in the end-diastolic volume caused by regurgitation of blood from aorta to left ventricle. If not corrected, the AI can lead to acute cardiogenic shock (AU)

High-sensitivity troponin T levels in kidney transplant recipients.

Cardiovascular disease (CVD) is still the leading cause of death among kidney transplant recipients. Validated biomarkers are important to identify patients at high risk for cardiovascular events and mortality. Cardiac troponins are one of the best available prognostic markers in this clinical situation, especially in chronic kidney disease and kidney transplant (KT) patients. The recently appeared high-sensitivity immunoassay to measure troponin T (hsTnT) has not yet been widely studied in the transplant population. We designed a cross-sectional study to evaluate hsTnT levels among 177 stable, asymptomatic patients, including 44.1% (78) males of overall mean age of 56.14 ± 14.25 years. Mean glomerular filtration rate estimated with the MDRD-4 (eGFR MDRD) formula was 48.93 ± 26.46 mL/min/1.73 m(2). Median hsTnT was 11 (interquartile range = 11-26) ng/L. Patients were classified according to their hsTnT levels: normal, below 14 ng/L (57.6%, n = 102 patients), and those with basally elevated levels. Upon univariate analysis, a significant association was found between higher hsTnT levels and several variables, including clinical features, such as age, sex or prior CVD; renal function indicators: creatinine, eGFR MDRD, and proteinuria; nutritional and inflammation markers: albumin, ferritin, and C-reactive protein; and several cardiac enzymes: creatine kinase myocardial band (CKMB), B-type natriuretic peptide, and its N-terminal fragment. A logistic regression model adjusted for age, sex, and variables significantly associated with higher hsTnT levels, showed that male gender, age, CKMB, and lower glomerular filtration rate to show independent relation to basally elevated levels of hsTnT among asymptomatic kidney transplant recipients.

The non-casual relation between eosinophilia and thrombotic microangiopathy.

There are only a few cases in the literature that describes the association between hypereosinophilic syndromes and thrombotic microangiopathy (TMA). Here we present the case of a man who suddenly developed a TMA in the context of eosinophilic pneumonia, who recovered successfully with six sessions of plasmapheresis and corticoids. Although the Pathophysiology is unknown, we hypothesize about the prothrombotic effects of the eosinophils. Also we describe a literature review.

Fracaso renal agudo en el contexto de un síndrome de Takotsubo / Acute kidney failure in the context of a Tako-Tsubo syndrome

No disponible

Programa de formación de residentes en un sistema de emergencias extrahospitalarias / Emergency medicine residency training for out-of-hospital emergencies

En el nuevo programa de la especialidad de Medicina Familiar y Comunitaria (MFyC) se incluye un periodo de rotación en formato de guardias en servicios de urgencias de atención primaria y de emergencias. Este periodo varía entre el 25% de las guardias de los residentes de primer año y el 75% de los de cuarto año. En este sentido en la Comunidad de Madrid toda la asistencia de urgencias y emergencias es competencia del Servicio de Urgencia Médica de Madrid SUMMA112, por lo que este Servicio ha puesto en marcha un programa específico para dar cabida a estos residentes, lo cual resulta novedoso para los Servicios de Emergencias Médicas en general al carecer en España, a día de hoy, de una especialidad específica de Medicina de Urgencias y Emergencias. Se ha creado una unidad docente de MFyC con coordinador, tutores y comisión asesora. Se ha redactado un programa formativo del SUMMA112 que se extrae del programa formativo de la comisión nacional de la especialidad de MFyC. Pero, además, se ha ampliado con algunas competencias muy específicas de los servicios de emergencias que no venían recogidas en el documento anterior. Asimismo, se ha elaborado un plan sobre la metodología docente a aplicar y un plan evaluativo global para que todos los tutores lleven una línea educativa similar. El objetivo de este artículo es explicar estas mejoras, puesto que puede constituir un buen punto de partida para cuando se apruebe la especialidad de Medicina de Urgencias y Emergencias en España (AU)

The new residency training program in family and community medicine requires a rotation responding to calls received by primary care and emergency services. The intensity of these rotations ranges from 25% of calls for first-year residents to 75% for fourth-year trainees. All emergencies in the Spanish autonomous community of Madrid are handled by the SUMMA112 emergency medical service, which has developed and launched a program specifically for these residents. The program is new to Spain, where until now no specialty training in emergency medicine has been offered. The developers created an educational unit with a coordinator, instructors in family and community medicine, and an organizing committee. The SUMMA112 syllabus is compatible with the training program of the Spanish national board for the specialty of family and community medicine, although additional competencies that are highly specific to emergency health services have been incorporated. Teaching and assessment methods have also been planned so that instructors will take a similar educational approach. This article explains these improvements to the syllabus so that the description can serve as a starting point once the specialty in emergency medicine is approved in Spain (AU)

[Why do our patients go to hospital emergency departments?]. / Por qué acuden nuestros pacientes a urgencias del hospital?

OBJECTIVE: To analyse the causes of overuse of hospital emergency services (HES). DESIGN: Cross sectional, descriptive study. SETTING: Emergency service at a general hospital. PATIENTS: Patients who attended the HES on their own initiative. MEASUREMENTS AND MAIN RESULTS: Telephone poll to a representative sample of patients attending on their own initiative the emergency department of the 12 de Octubre Hospital in Madrid between October 5th and 12th. Average age: 46.95 (SD, 20.81); 52.2% women and 47.8% men, 50% were ignorant of the existence of primary care emergencies. 77% were ignorant of the existence of ongoing care points. Main motives for attendance at HES were: ignorance of non-hospital emergency services (32%), better technical means (25.6%), quicker care (21%), sensation of vital urgency (11.4%), poor quality of care in PC (8%). The care received at HES was evaluated as positive in 90% of cases, though 33% thought the information provided insufficient, and 34% the waiting-time excessive. Although 40% believed afterwards that their problem could have been resolved in PC, as many as 75% would return to the hospital. CONCLUSIONS: Widespread ignorance of the existence of non-hospital emergency services affects the over-use of HES. Most users use the HES as a service of immediate PC, a rapid way of obtaining health care. Users have a very favourable opinion of HES care, which is not stated in the case of non-hospital emergency services. In order to improve use of the HES, the population needs to receive better health education.

¿Por qué acuden nuestros pacientes a urgencias del hospital? / Why do our patients attend hospital emergency departments?

Objetivo. Analizar las causas de sobreutilización de los servicios de urgencias hospitalarios (SUH). Diseño. Estudio descriptivo transversal. Emplazamiento. Servicio de urgencias de un hospital general. Pacientes. Pacientes que acudieron al SUH por iniciativa propia. Mediciones y resultados principales. Encuesta telefónica a una muestra representativa de pacientes que acudieron a urgencias del Hospital 12 de Octubre de Madrid del 5 al 12 de octubre de 1998 por iniciativa propia. Edad media, 46,95 años (DE, 20,81), un 52,2 por ciento mujeres y el 47,8 por ciento varones. Un 50 por ciento desconoce la urgencia en atención primaria (AP), el 77 por ciento desconoce la existencia de puntos de atención continuada. Principales motivos por los que acuden al SUH: desconocimiento de urgencias extrahospitalarias (SUEH) (32 por ciento), empleo de mejores medios técnicos (25,6 por ciento), asistencia más rápida (21 por ciento), sensación de urgencia vital (11,4 por ciento), mala calidad asistencial en AP (8 por ciento). La valoración de la atención recibida en SUH es positiva en un 90 por ciento, el 33 por ciento considera insuficiente la información facilitada y un 34 por ciento el tiempo de espera excesivo. Aunque un 40 por ciento cree a posteriori que su problema era solucionable en AP, hasta el 75 por ciento retornaría al hospital. Conclusiones. El gran desconocimiento del SUEH influye en la sobreutilización de los SUH. La mayoría de los usuarios utiliza los SUH como servicio de AP inmediata, siendo una forma rápida de conseguir atención. La opinión de los usuarios sobre la asistencia en un SUH es muy favorable, hecho que no se objetiva con los SUHE. Debería mejorarse la educación sanitaria de la población para mejorar el uso de los SUH (AU)