Serum phosphate is associated with increased risk of bone fragility fractures in hemodialysis patients.

BACKGROUND: Bone fragility fractures are associated with high morbidity and mortality. This study analysed the association between the current biochemical parameters of CKD-MBD and bone fragility fractures in the COSMOS project. METHODS: COSMOS is a 3-year, multicentre, open cohort, prospective, observational study carried out in 6797 hemodialysis patients (227 centres from 20 European countries). The association of bone fragility fractures (outcome) with serum calcium, phosphate and PTH (exposure), was assessed using Standard Cox proportional hazards regression and Cox proportional hazards regression for recurrent events. Additional analyses were performed considering all-cause mortality as a competitive event for bone fragility fracture occurrence. Multivariable models were used in all strategies, with the fully adjusted model including a total of 24 variables. RESULTS: During a median follow-up of 24 months 252 (4%) patients experienced at least one bone fragility fracture (incident bone fragility fracture rate 28.5 per 1000 patient-years). In the fractured and non-fractured patients, the percentage of men was 43.7% and 61.4%, mean age 68.1 and 63.8 years and a haemodialysis vintage of 55.9 and 38.3 months respectively. Baseline serum phosphate > 6.1 mg/dL (reference value 4.3-6.1 mg/dL) was significantly associated with a higher bone fragility fracture risk in both regression models (HR: 1.53[95%CI: 1.10-2.13] and HR: 1.44[95%CI: 1.02-2.05]. The significant association persisted after competitive risk analysis (subHR: 1.42[95%CI: 1.02-1.98]) but the finding was not confirmed when serum phosphate was considered as a continuous variable. Baseline serum calcium showed no association with bone fragility fracture risk in any regression model. Baseline serum PTH > 800 pg/mL was significantly associated with a higher bone fragility fracture risk in both regression models, but the association disappeared after a competitive risk analysis. CONCLUSIONS: Hyperphosphatemia was independently and consistently associated with an increased bone fracture risk, suggesting serum phosphate could be a novel risk factor for bone fractures in hemodialysis patients.

Comprehensive Cardiovascular and Renal Protection in Patients with Type 2 Diabetes.

Type 2 diabetes (T2DM) is one of the main public health care problems worldwide. It is associated with a marked increased risk of developing atherosclerotic vascular disease, heart failure, chronic kidney disease and death. It is essential to act during the early phases of the disease, through the intensification of lifestyle changes and the prescription of those drugs that have been shown to reduce these complications, with the aim not only of achieving an adequate metabolic control, but also a comprehensive vascular risk control. In this consensus document, developed by the different specialists that treat these patients (endocrinologists, primary care physicians, internists, nephrologists and cardiologists), a more appropriate approach in the management of patients with T2DM or its complications is provided. A particular focus is given to the global control of cardiovascular risk factors, the inclusion of weight within the therapeutic objectives, the education of patients, the deprescription of those drugs without cardiovascular benefit, and the inclusion of GLP-1 receptor agonists and SGLT2 inhibitors as cardiovascular protective drugs, at the same level as statins, acetylsalicylic acid, or renin angiotensin system inhibitors.

Optimizing the timing of nephrology referral for patients with diabetic kidney disease.

Age-standardized rates of diabetes mellitus (DM)-related complications, such as acute myocardial infarction, stroke or amputations, have decreased in recent years, but this was not associated with a clear reduction of the incidence of advanced chronic kidney disease (CKD) requiring renal replacement therapy. The early detection of diabetic kidney disease (DKD) is a key to reduce complications, morbidity and mortality. Consensus documents and clinical practice guidelines recommend referral of DM patients to nephrology when the estimated glomerular filtration rate falls below 30 mL/min/1.73 m2 or when albuminuria exceeds 300 mg/g urinary creatinine. Conceptually, it strikes as odd that patients with CKD are referred to the specialist caring for the prevention and treatment of CKD only when >70% of the functioning kidney mass has been lost. The increasing global health burden of CKD, driven in large part by DKD, the suboptimal impact of routine care on DKD outcomes as compared with other DM complications, the realization that successful therapy of CKD requires early diagnosis and intervention, the advances in earlier diagnosis of kidney injury and the recent availability of antidiabetic drugs with a renal mechanism of action and lack of hypoglycaemia risk, which additionally are cardio- and nephroprotective, all point towards a paradigm shift in the care for DM patients in which they should be referred earlier to nephrology as part of a coordinated and integrated care approach.

Hemodiálisis incremental como forma de inicio del tratamiento sustitutivo renal / Incremental hemodialysis schedule at the start of renal replacement therapy

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Bone fractures and lumbar mineral density after renal transplantation. A long-term cross-sectional study.

BACKGROUND: The purpose of this work was to investigate the association of vertebral and peripheral fractures 10 yr after grafting with bone metabolic markers and body mass density (BMD). PATIENTS AND METHODS: One hundred thirty-eight recipients with stable graft function were included in a cross-sectional study. Graft function, biochemical mineral metabolism markers and body mass density (DEXA) were measured. Vertebral fractures were assessed by a semiquantitative analysis of lateral spine X-ray exam. RESULTS: At the time of the study, intact parathyroid hormone levels were 127.5 ± 78.4 pg/mL and serum calcidiol 20.4 ± 9.3 ng/mL. DEXA showed osteopenia in 47% and osteoporosis in 23% at lumbar spine, 51% and 14% at femoral neck, and 53% and 8% at trochanter. Eighty-five recipients presented vertebral fractures, 69 mild and 16 moderate/severe fractures. In the multivariate analysis, vertebral fractures were associated with older age (p = 0.010), length of follow-up (p = 0.022) and trochanter T-score (p = 0.038). Twenty-three patients presented peripheral fractures and 19 of them also had vertebral fractures. Patients with peripheral fractures were younger, mostly women and had lower BMD. CONCLUSIONS: Vertebral fractures were associated with lower BMD at trochanter. Most fractures were mild and were several times more frequent than in general population. Their clinical significance needs to be determined.

Choosing conservative therapy in chronic kidney disease.

INTRODUCTION: Incidence of use for various renal replacement therapies is well-known, but no data are available on conservative treatment use. OBJECTIVE: To assess the proportion of patients with chronic kidney failure receiving a conservative treatment. RESULTS: From July 1, 2013 to June 30, 2014, 232 patients with stage 5 CKD were seen in the Nephrology Department. After having received information on existing therapeutic options and having known the opinion of their treating physicians, 81 patients (35%) selected hemodialysis, 56 (24%) preferred peritoneal dialysis, 5 (2%) selected a preemptive transplant from a living donor, and in 90 (39%) a conservative treatment option was selected. In a univariate analysis using logistic regression, variables associated to a preference for conservative treatment were age, Charlson index excluding age, degree of walking difficulties, and functional dependence level, with the first three factors achieving statistical significance in a multivariate analysis. Presence of a severe disease resulting in a poor prognosis was the main reason for selecting a conservative treatment (49%), with the second one being patient refusal to receive a renal replacement therapy (26%). Mortality rate was 8.2/100 patient-months in conservative therapy group versus 0.6/100 patient-months in patients receiving renal replacement therapy (P<.001). In patients receiving conservative therapy, baseline glomerular filtration rate at the time of study enrollment was the sole variable showing a significant impact on survival. CONCLUSIONS: About 39% of patients with stage 5 CKD seen over a 1-year period in the Nephrology Department received conservative therapy. Age, co-morbidity, and functional disability were the factors associated to selecting a conservative therapy option.

Consideraciones respecto a ezetimiba y deterioro renal / Considerations for ezetimibe and renal impairment

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Elección de tratamiento conservador en la enfermedad renal crónica / Choosing conservative therapy in chronic kidney disease

Introducción: La incidencia de las diversas modalidades de tratamiento sustitutivo renal es conocida, pero no sucede así con la opción de tratamiento conservador. Objetivo: Conocer la proporción de pacientes con insuficiencia renal crónica sometidos a tratamiento conservador. Resultados: Entre el 1 de julio de 2013 y el 30 de junio de 2014 fueron atendidos en el Servicio de Nefrología 232 casos con ERC en estadio 5. Tras recibir una información sobre las diversas alternativas terapéuticas y con la opinión del médico responsable, 81 enfermos (35%) optaron por el tratamiento con hemodiálisis, 56 (24%) mostraron preferencia por la diálisis peritoneal, 5 (2%) por el trasplante de vivo prediálisis, y en 90 enfermos (39%) se decidió realizar tratamiento conservador. En el análisis univariante de regresión logística las variables asociadas a la elección de tratamiento conservador fueron la edad, el índice de Charlson sin contar la edad, el grado de dificultad para la marcha y el grado de dependencia funcional, quedando los 3 primeros con significación significativa en el análisis multivariante. La existencia de una enfermedad grave con mal pronóstico a corto plazo fue la principal causa por la que se indicó el tratamiento conservador (49%), y la segunda fue la negativa del enfermo a recibir tratamiento sustitutivo renal (26%). La tasa de mortalidad fue de 8,2/100 enfermos-mes en el grupo de tratamiento conservador y de 0,6/100 enfermos-mes en el grupo que decidió optar al tratamiento sustitutivo renal (p<0,001). En el grupo tratado de forma conservadora, el filtrado glomerular en el momento de inclusión en el estudio fue la única variable que influyó de forma estadísticamente significativa sobre la supervivencia. Conclusiones: El 39% de los pacientes con ERC en estadio 5 atendidos durante un año en el Servicio de Nefrología fueron tratados de forma conservadora. Edad, comorbilidad y discapacidad funcional fueron las variables que se relacionaron con la elección de tratamiento conservador (AU)

Introduction: Incidence of use for various renal replacement therapies is well-known, but no data are available on conservative treatment use. Objective: To assess the proportion of patients with chronic kidney failure receiving a conservative treatment. Results: From July 1, 2013 to June 30, 2014, 232 patients with stage 5 CKD were seen in the Nephrology Department. After having received information on existing therapeutic options and having known the opinion of their treating physicians, 81 patients (35%) selected hemodialysis, 56 (24%) preferred peritoneal dialysis, 5 (2%) selected a preemptive transplant from a living donor, and in 90 (39%) a conservative treatment option was selected. In a univariate analysis using logistic regression, variables associated to a preference for conservative treatment were age, Charlson index excluding age, degree of walking difficulties, and functional dependence level, with the first three factors achieving statistical significance in a multivariate analysis. Presence of a severe disease resulting in a poor prognosis was the main reason for selecting a conservative treatment (49%), with the second one being patient refusal to receive a renal replacement therapy (26%). Mortality rate was 8.2/100 patient-months in conservative therapy group versus 0.6/100 patient-months in patients receiving renal replacement therapy (P<.001). In patients receiving conservative therapy, baseline glomerular filtration rate at the time of study enrollment was the sole variable showing a significant impact on survival. Conclusions: About 39% of patients with stage 5 CKD seen over a 1-year period in the Nephrology Department received conservative therapy. Age, co-morbidity, and functional disability were the factors associated to selecting a conservative therapy option (AU)

Effects of a single, high oral dose of 25-hydroxycholecalciferol on the mineral metabolism markers in hemodialysis patients.

Vitamin D deficiency is common in dialysis patients with chronic kidney disease. Low levels have been associated with increased cardiovascular risk and mortality. We evaluated the administration of a high, single oral dose of 25-OH cholecalciferol (3 mg of Hidroferol, 180 000 IU) in patients on chronic hemodialysis. The 94 chronic hemodialysis patients with vitamin D deficiency 25 (OH)D <30 ng/mL included in the study were randomized into two groups. Follow-up time was 16 weeks. Neither the usual treatment for controlling Ca/P levels nor the dialysis bath (calcium of 2.5 mEq/L) were modified. Of the 86 patients who finished the study, 42 were in the treated group and 44 in the control group. An increase in 25(OH)D levels was observed in the treated group that persisted after 16 weeks and was associated with a significant decrease in parathyroid hormone (PTH) levels during the 8 weeks post-treatment. Baseline 1,25(OH)2 D levels of the treated group increased two weeks after treatment (5.9 vs. 21.9 pg/mL, P<0.001) but gradually reduced to 8.4 at week 16. The administration of a single 3 mg dose of 25-OH cholecalciferol seems safe in patients on hemodialysis and maintains sufficient levels of 25(OH)D with a decrease in PTH for 3 months.

Subphrenic abscess as a complication of hemodialysis catheter-related infection.

We describe an unusual case of subphrenic abscess complicating a central venous catheter infection caused by Pseudomonas aeruginosa in a 59-year-old woman undergoing hemodialysis. The diagnosis was made through computed tomography, and Pseudomonas aeruginosa was isolated from the purulent drainage of the subphrenic abscess, the catheter tip and exit site, and the blood culture samples. A transesophageal echocardiography showed a large tubular thrombus in superior vena cava, extending to the right atrium, but no evidence of endocarditis or other metastatic infectious foci. Catheter removal, percutaneous abscess drainage, anticoagulation, and antibiotics resulted in a favourable outcome.

Are low levels of 25-hydroxyvitamin D a risk factor for cardiovascular diseases or malignancies in renal transplantation?

BACKGROUND: Observational studies in healthy people suggest an inverse relationship between 25-hydroxy-vitamin D (25(OH)D levels) and cardiovascular diseases and malignancies. We performed an observational prospective study in renal transplant recipients to investigate the effects of vitamin D deficiency on cardiovascular and malignancy risks. METHODS: From 389 renal transplant recipients, 331 with a functioning graft at 12 months were included in the study. Mineral metabolism parameters were measured at 1, 3, 4 and 12 months. Information regarding the cardiovascular events and malignancies were collected from an electronic database. RESULTS: According to the 1-year mean of 25(OH)D levels, 75 recipients (22.7%) had a normal vitamin D status, 161 (48.6%) had insufficiency and 95 (28.7%) had deficiency in vitamin D levels. During the follow-up, 80 recipients presented at least one cardiovascular event. The total cardiovascular diseases included: 27 patients with coronary diseases, 25 with cardiac failure, 18 with arrhythmia, 11 with acute cerebrovascular events and 19 with peripheral vascular disease. Cardiovascular events were not associated with 25(OH)D levels or vitamin D status, and the 10-year cumulative incidence was 29.3% for normal vitamin D status and 31.6% for insufficiency and 51.9% for deficiency (P = 0.216). Furthermore, Cox univariate analysis showed no association between cardiovascular events and vitamin D levels or vitamin D status. In addition, 53 recipients presented at least one malignancy: 33 non-melanoma skin malignancies and 20 non-skin malignancies (5 prostate, 3 kidney and urinary tract, 2 colon, 2 lung, 2 lymphoma, 2 breast and 4 from other locations). The cumulative incidence of malignancies was 21.3% for normal vitamin D status, 22.7% for insufficiency and 16.7% for deficiency (P = 0.818). CONCLUSIONS: Our data suggested that low vitamin D levels were not associated with an increased risk of cardiovascular diseases or malignancies. However, due to the small number of patients and events, the results should not be considered as definitive. Additional studies with a higher number of patients are required to elucidate the true impact of vitamin D status on cardiovascular and malignancy risks.

Valoración de la afección renal mediante la cistatina C: un biomarcador olvidado. Respuesta / Assessment of renal involvement by Cystatin C: a forgotten biomarker. Response

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Valoración de afección renal, disfunción renal aguda e hiperpotasemia por fármacos usados en cardiología y nefrotoxicidad por contrastes / Assessment of renal function, iatrogenic hyperkalemia and acute renal dysfunction in cardiology. Contrast-induced nephropathy

La afección renal en los pacientes con enfermedad cardiovascular confiere un carácter pronóstico y un incremento del riesgo cardiovascular. La disfunción renal es un marcador de lesiones en otras partes del árbol vascular. Su detección permite la identificación precoz de individuos con riesgo elevado de acontecimientos cardiovasculares. La valoración de la afección renal del paciente con enfermedad cardiovascular se llevará a cabo mediante la determinación de albuminuria en una muestra aislada de orina y por la estimación del filtrado glomerular a partir de fórmulas o ecuaciones predictivas derivadas de la creatinina. Se recomienda la fórmula de la Chronic Kidney Disease Epidemiology Collaboration o la de Modification of Diet in Renal Disease. Como alternativa, puede utilizarse la fórmula de Cockcroft-Gault. La administración de fármacos que bloqueen el sistema renina-angiotensina puede asociarse en determinadas ocasiones a disfunción renal aguda o hiperpotasemia. Es importante conocer las situaciones con riesgo de que se produzcan estas complicaciones para dar el mejor tratamiento posible: la prevención. Dado el incremento progresivo de los procedimientos diagnósticos y terapéuticos con contraste intravenoso en el ámbito de la cardiología, la nefrotoxicidad por contraste supone un problema relevante. Es de interés detectar los factores de riesgo y a los pacientes con mayor probabilidad de sufrirla, así como prevenir su aparición (AU)

Renal impairment influences the prognosis of patients with cardiovascular disease and increases cardiovascular risk. Renal dysfunction is a marker of lesions in other parts of the vascular tree and detection facilitates early identification of individuals at high risk of cardiovascular events. In patients with cardiovascular disease, renal function is assessed by measuring albuminuria in a spot urine sample and by estimating the glomerular filtration rate using creatinine-derived predictive formulas or equations. We recommend the Chronic Kidney Disease Epidemiology Collaboration or the Modification of Diet in Renal Disease formulas. The Cockcroft-Gault formula is a possible alternative. The administration of drugs that block the angiotensin-renin system can, on occasion, be associated with acute renal dysfunction or hyperkalemia. We need to know when risk of these complications exists so as to provide the best possible treatment: prevention. Given the growing number of diagnostic and therapeutic procedures in the field of cardiology that use intravenous contrast media, contrast-induced nephrotoxicity represents a significant problem. We should identify the risk factors and patients at greatest risk, and prevent it from appearing (AU)

[Assessment of renal function, iatrogenic hyperkalemia and acute renal dysfunction in cardiology. Contrast-induced nephropathy]. / Valoración de afección renal, disfunción renal aguda e hiperpotasemia por fármacos usados en cardiología y nefrotoxicidad por contrastes.

Renal impairment influences the prognosis of patients with cardiovascular disease and increases cardiovascular risk. Renal dysfunction is a marker of lesions in other parts of the vascular tree and detection facilitates early identification of individuals at high risk of cardiovascular events. In patients with cardiovascular disease, renal function is assessed by measuring albuminuria in a spot urine sample and by estimating the glomerular filtration rate using creatinine-derived predictive formulas or equations. We recommend the Chronic Kidney Disease Epidemiology Collaboration or the Modification of Diet in Renal Disease formulas. The Cockcroft-Gault formula is a possible alternative. The administration of drugs that block the angiotensin-renin system can, on occasion, be associated with acute renal dysfunction or hyperkalemia. We need to know when risk of these complications exists so as to provide the best possible treatment: prevention. Given the growing number of diagnostic and therapeutic procedures in the field of cardiology that use intravenous contrast media, contrast-induced nephrotoxicity represents a significant problem. We should identify the risk factors and patients at greatest risk, and prevent it from appearing.

A retrospective study on outcome of microscopic polyangiitis in chronic renal replacement therapy.

BACKGROUND: Pauci-immune vasculitis is a heterogeneous disorder with an unfavourable prognosis. Renal involvement is frequently observed in antineutrophil cytoplasm autoantibody (ANCA)-associated small-vessel vasculitis and is an important cause of end-stage renal disease (ESRD). Renal replacement therapy (RRT) is frequently required. Although better prognosis under dialysis is well known, the long-term follow-up of pauci-immune renal vasculitis with RRT is rarely reported. METHODS: We described 24 patients with pauci-immune vasculitis and requirement of dialysis who were admitted in our institutions from January 1989 to December 2008. Mean age was 65 ± 12 years at the beginning of dialysis. There were 12 males and 12 females. Patients with Wegener's granulomatosis, Churg-Strauss syndrome or evidence of anti-glomerular basement membrane were excluded. The study group was formed by patients with a diagnosis of necrotizing extracapillary glomerulonephritis and microscopic polyangiitis. RESULTS: The distribution according to ANCAs was 14 p-ANCA (58%), 5 c-ANCA (21%) and 5 ANCA-negative (21%) pauci-immune renal vasculitis. Pulmonary renal syndrome (PRS) was observed in 10 patients at the onset of vasculitis. Corticosteroids and daily cyclophosphamide were administered to 18 patients, and one patient had intravenous cyclophosphamide. Five patients received isolated corticosteroid therapy. Early reduction in cyclophosphamide dosage was required in five patients due to leucopaenia. Mean follow-up after first dialysis was 89 ± 66 months (range 2-208). Twenty patients were included in haemodialysis (HD), and four patients were included in peritoneal dialysis (PD). At the end of the study, nine patients had received a cadaveric kidney transplant (KT). Relapses rate after the onset of dialysis was 0.03 episode/patient/year. PRS-associated relapses after beginning dialysis were observed in four patients. Main therapy in relapses was also corticosteroids and cyclophosphamide. Survival rates for year 1, 2 and 5 was 91%, 91% and 85%, respectively. Overall mortality at the end of the study was 31.8%. Five patients died in the PRS group, but only one death was associated with progressive pulmonary fibrosis. Higher mortality was observed in PRS vasculitis present at the onset of RRT (50% vs 16.7%, P = NS). Better outcome in patients who received a renal transplantation was observed (88.8% vs 53.8%, P = NS). Conclusions. Despite a low number of patients in this series, pauci-immune vasculitis prognosis under dialysis seems equal to other causes of chronic kidney disease. This study observed a low rate of relapses after beginning dialysis. Poor prognosis is related to severe complications at the beginning of RRT. Today, kidney transplantation is an important therapeutic option for these patients.