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BACKGROUND: Lupus nephritis affects 40 to 70% of Systemic Lupus Erythematous(SLE) patients increasing their morbi-mortality; therefore, successful treatments are required to improve outcomes. RESEARCH DESIGN AND STUDY SAMPLE: In this paper 20 patients who participated in the BLISS LN trial at a single center (OMI) in Argentina were studied. All the patients continued Mycophenolate (MMF) treatment when the trial was finished and until a second biopsy was performed to determine the withdrawal of the immunosuppression according to the achieved clinical and histological response. Ten patients treated with MMF + Placebo versus 10 receiving MMF + Belimumab, were compared evaluating the complete clinical (CCR) and complete histological response (CHR) and the flares in each group. RESULTS: All the patients in the Belimumab group showed a CCR and 7 in the Placebo one; CHR was found in 9 and 5 patients of the Belimumab and Placebo group, respectively. None of the patients in the Belimumab group flared meanwhile two of the Placebo one did it. CONCLUSIONS: Although the number of patients is insufficient to be able to draw unquestionable conclusions, adding Belimumab to the standard of care treatment with MMF would seem to increase the possibility of achieving a CCR, CHR, and a lower rate of relapses during treatment and long follow-up.
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Lupus Eritematoso Sistémico , Nefritis Lúpica , Humanos , Inhibidores Enzimáticos/uso terapéutico , Inmunosupresores/efectos adversos , Riñón , Lupus Eritematoso Sistémico/tratamiento farmacológico , Nefritis Lúpica/tratamiento farmacológico , Nefritis Lúpica/inducido químicamente , Nivel de Atención , Resultado del TratamientoRESUMEN
INTRODUCTION: Given the vulnerability of chronic kidney disease individuals to SARS-CoV-2, nephrology societies have issued statements calling for prioritization of these patients for vaccination. It is not yet known whether COVID-19 vaccines grant the same high level of protection in patients with kidney disease compared to the non-dialysis population. The aims of this study were to evaluate the safety - measured by the adverse events potentially attributed to vaccines (ESAVI) - and the effectiveness - evaluated by the presence of antibodies - in dialysis patients immunized with the COVID-19 Sputnik V vaccine. METHODS: multicenter, observational and analytical study of a prospective cohort of hemodialysis patients from the Ciudad Autónoma de Buenos Aires participating in an official vaccination program. Dialysis requiring individuals older than 18 years, who received both components of the COVID-19 vaccine were included. RESULTS: Data from 491 patients were included in the safety analysis. ESAVI with either the first or second component was detected in 186 (37.9%, 95% CI 33.6%-42.3%). Effectiveness analysis measuring antibodies levels against SARS-CoV-2 were performed in 102 patients; 98% presented these IgG antibodies at day 21 after the second component. In patients with COVID-19 prior to vaccination, antibodies at day 21 after the first component reached almost the highest levels compared to patients without previous COVID-19, but IgG rise among patients with previous COVID-19 was lower than in those without this previous disease. CONCLUSION: The Sputnik V vaccine has been shown to be safe and effective in this patient's population.
Introducción: Dada la vulnerabilidad al SARS-CoV-2 de las personas con enfermedad renal crónica, las sociedades de nefrología han emitido declaraciones pidiendo priorizar a estos pacientes para la vacunación. Aún no se sabe si las vacunas COVID-19 confieren el mismo nivel de protección en pacientes con enfermedad renal. Los objetivos de este estudio fueron evaluar la seguridad, medida por eventos supuestamente atribuidos a las vacunas (ESAVI) y la efectividad, evaluada por la presencia de anticuerpos en pacientes en diálisis inmunizados con la vacuna COVID-19 Sputnik V. Métodos: estudio multicéntrico, observacional y analítico de una cohorte prospectiva de pacientes en hemodiálisis, en la Ciudad Autónoma de Buenos Aires, con plan de vacunación. Se incluyeron pacientes mayores de 18 años en diálisis que recibieron ambos componentes de la vacuna COVID-19. Resultados: 491 pacientes fueron incluidos en el análisis de seguridad. Se detectó ESAVI con el primer o el segundo componente en 186 (37.9% IC 95%: 33.6%-42.3%). La efectividad medida por presencia de anticuerpos IgG contra SARS-Cov-2 se realizó en 102 pacientes, 98% presentaba IgG contra SARS-CoV-2, 21 días después del segundo componente. En pacientes con COVID-19 previo a la vacunación, los anticuerpos al día 21 del primer componente alcanzaron niveles casi mayores que en aquellos que no habían sufrido COVID-19, aunque el aumento de los niveles a los 21 días del segundo componente fue menor que en los pacientes sin COVID-19 previo. Conclusión: Los pacientes en diálisis constituyen una población vulnerable para la infección por SARS-CoV-2, por lo tanto, más allá de las recomendaciones implementadas por las unidades de diálisis, la vacunación completa es mandatoria. Se ha demostrado que la vacuna Sputnik V es segura y eficaz en esta población de pacientes.
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Vacunas contra la COVID-19 , COVID-19 , Insuficiencia Renal Crónica , Eficacia de las Vacunas , Humanos , Anticuerpos Antivirales , COVID-19/prevención & control , Vacunas contra la COVID-19/efectos adversos , Vacunas contra la COVID-19/inmunología , Inmunoglobulina G , Estudios Prospectivos , Diálisis Renal , SARS-CoV-2 , Vacunas de Productos Inactivados , Insuficiencia Renal Crónica/complicaciones , ArgentinaRESUMEN
Abstract Introduction: Given the vulnerability of chronic kidney disease individuals to SARS-CoV-2, nephrology societies have issued statements calling for prioritization of these patients for vaccination. It is not yet known whether COVID-19 vaccines grant the same high level of protection in patients with kidney disease compared to the non-dialysis population. The aims of this study were to evaluate the safety - measured by the adverse events potentially attributed to vaccines (ESAVI) - and the effectiveness - evaluated by the presence of antibodies - in dialysis patients immunized with the COVID-19 Sputnik V vaccine. Methods: multicenter, ob servational and analytical study of a prospective cohort of hemodialysis patients from the Ciudad Autónoma de Buenos Aires participating in an official vaccination program. Dialysis requiring individuals older than 18 years, who received both components of the COVID-19 vaccine were included. Results: Data from 491 patients were included in the safety analysis. ESAVI with either the first or second component was detected in 186 (37.9%, 95% CI 33.6%-42.3%). Effectiveness analysis measuring antibodies levels against SARS-CoV-2 were performed in 102 patients; 98% presented these IgG antibodies at day 21 after the second component. In patients with COVID-19 prior to vaccination, antibodies at day 21 after the first component reached almost the highest levels compared to patients without previous COVID-19, but IgG rise among patients with previous COVID-19 was lower than in those without this previous disease. Conclusion: The Sputnik V vaccine has been shown to be safe and effective in this patient's population.
Resumen Introducción: Dada la vulnerabilidad al SARS-CoV-2 de las personas con enfermedad renal crónica, las sociedades de nefrología han emitido declaraciones pidiendo priorizar a estos pacientes para la vacunación. Aún no se sabe si las vacunas COVID-19 confieren el mismo nivel de protección en pacientes con enfermedad renal. Los objetivos de este estudio fueron evaluar la seguridad, medida por eventos supuestamente atribuidos a las vacunas (ESAVI) y la efectividad, evaluada por la presencia de anticuerpos en pacientes en diálisis inmuniza dos con la vacuna COVID-19 Sputnik V. Métodos: estudio multicéntrico, observacional y analítico de una cohorte prospectiva de pacientes en hemodiálisis, en la Ciudad Autónoma de Buenos Aires, con plan de vacunación. Se incluyeron pacientes mayores de 18 años en diálisis que recibieron ambos componentes de la vacuna COVID-19. Resultados: 491 pacientes fueron incluidos en el análisis de seguridad. Se detectó ESAVI con el primer o el segundo componente en 186 (37.9% IC 95%: 33.6%-42.3%). La efectividad medida por presencia de anticuerpos IgG contra SARS-Cov-2 se realizó en 102 pacientes, 98% presentaba IgG contra SARS-CoV-2, 21 días después del segundo componente. En pacientes con COVID-19 previo a la vacunación, los anticuerpos al día 21 del primer componente alcanzaron niveles casi mayores que en aquellos que no habían sufrido COVID-19, aunque el aumento de los niveles a los 21 días del segundo componente fue menor que en los pacientes sin COVID-19 previo. Conclusión: Los pacientes en diálisis constituyen una población vulnerable para la infección por SARS-CoV-2, por lo tanto, más allá de las recomendaciones implementadas por las unidades de diálisis, la vacunación completa es mandatoria. Se ha demostrado que la vacuna Sputnik V es segura y eficaz en esta población de pacientes.
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The main aim of the study was to determine the prevalence of vascular calcifications in patients with chronic kidney disease on dialysis in our population assessed by X-ray. The secondary objectives were to determine the cardiovascular risk factors associated with the presence of vascular calcifications and to evaluate the complementary use of the echocardiogram in a cross-sectional, observational, multicentric study. We included patients with chronic kidney disease on dialysis, age =18 years with at least 3 months of renal replacement therapy in 8 dialysis centres in Argentina. The degree of vascular calcification was determined using Adragao and Kauppila scores. The presence of valvular calcifications was established through a trans-thoracic doppler echocardiogram. Univariate and multivariate analysis were undertaken, considering the degree of vascular calcification as the dependent variable; 443 adult patients were evaluated at 8 centres across 5 provinces in Argentina. The prevalence of vascular calcifications by the X-rays was 63%, while 73% presented calcifications in hands and pelvis, with an Adragao score > 3, and 60% presented calcifications in the abdominal aorta with a Kauppila score > 4. The prevalence of valvular calcifications: 28%. We have shown a higher rate of vascular calcifications with the use of plain X-rays when compared to the prevalence of valvular calcifications obtained with echocardiograms. In this regard, valvular calcifications were present particularly in those patients with a severe level of radiological vascular calcification.
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Enfermedades Cardiovasculares/epidemiología , Diálisis Renal , Insuficiencia Renal Crónica/complicaciones , Calcificación Vascular/epidemiología , Argentina/epidemiología , Enfermedades Cardiovasculares/diagnóstico por imagen , Enfermedades Cardiovasculares/etiología , Estudios Transversales , Ecocardiografía , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Radiografía , Diálisis Renal/estadística & datos numéricos , Insuficiencia Renal Crónica/epidemiología , Factores de Riesgo , Calcificación Vascular/clasificación , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/etiologíaRESUMEN
The main aim of the study was to determine the prevalence of vascular calcifications in patients with chronic kidney disease on dialysis in our population assessed by X-ray. The secondary objectives were to determine the cardiovascular risk factors associated with the presence of vascular calcifications and to evaluate the complementary use of the echocardiogram in a cross-sectional, observational, multicentric study. We included patients with chronic kidney disease on dialysis, age =18 years with at least 3 months of renal replacement therapy in 8 dialysis centres in Argentina. The degree of vascular calcification was determined using Adragao and Kauppila scores. The presence of valvular calcifications was established through a trans-thoracic doppler echocardiogram. Univariate and multivariate analysis were undertaken, considering the degree of vascular calcification as the dependent variable; 443 adult patients were evaluated at 8 centres across 5 provinces in Argentina. The prevalence of vascular calcifications by the X-rays was 63%, while 73% presented calcifications in hands and pelvis, with an Adragao score >3, and 60% presented calcifications in the abdominal aorta with a Kauppila score >4. The prevalence of valvular calcifications: 28%. We have shown a higher rate of vascular calcifications with the use of plain X-rays when compared to the prevalence of valvular calcifications obtained with echocardiograms. In this regard, valvular calcifications were present particularly in those patients with a severe level of radiological vascular calcification.
El objetivo primario del estudio fue determinar la prevalencia de calcificaciones vasculares en pacientes con enfermedad renal crónica (ERC) en diálisis, a través de métodos accesibles y reproducibles. Como objetivo secundario: determinar los factores de riesgo cardiovascular asociados a la presencia de calcificaciones vasculares y evaluar la utilidad complementaria del ecocardiograma. Fue un estudio prospectivo, transversal y multicéntrico sobre pacientes prevalentes con ERC en diálisis. Se les realizaron radiografía de columna lumbar, de manos y panorámica de pelvis, para la determinación de las escalas de Adragao y Kauppila. La presencia de calcificaciones valvulares fue establecida por ecocardiograma doppler color transtorácico. Se obtuvieron los datos de 30 variables determinadas para el análisis uni y multivariado (regresión logística) de los factores de riesgo asociados. Se evaluaron 443 pacientes adultos de 8 centros de 5 provincias de la Argentina. La prevalencia de calcificaciones vasculares, determinada por las radiografías, fue 63%. La prevalencia de calcificaciones valvulares fue 28%. Las calcificaciones valvulares estuvieron presentes en aquellos pacientes con graves calcificaciones radiológicas. Las calcificaciones estuvieron asociadas a la edad (>55 años), sexo masculino, diabetes, tiempo de diálisis, tabaquismo y la presencia de enfermedad vascular periférica. Este es el estudio con mayor número de pacientes evaluados en Latinoamérica. Se encuentra alta prevalencia de calcificaciones vasculares en Argentina, fácilmente medibles con técnicas no invasivas como la radiografía simple, que resulta más sensible que el ecocardiograma. Ambos estudios deben ser utilizados de manera complementaria.
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Humanos , Masculino , Persona de Mediana Edad , Enfermedades Cardiovasculares/epidemiología , Diálisis Renal/estadística & datos numéricos , Insuficiencia Renal Crónica/complicaciones , Calcificación Vascular/epidemiología , Argentina/epidemiología , Ecocardiografía , Radiografía , Enfermedades Cardiovasculares/etiología , Enfermedades Cardiovasculares/diagnóstico por imagen , Prevalencia , Estudios Transversales , Factores de Riesgo , Insuficiencia Renal Crónica/epidemiología , Calcificación Vascular/clasificación , Calcificación Vascular/etiología , Calcificación Vascular/diagnóstico por imagenRESUMEN
BACKGROUND: Sevelamer has been associated with less progression of vascular calcifications. This effect could be due to a reduction in serum phosphate levels but also to other additive effects. Magnesium has been also shown to prevent vascular calcification but the effect of sevelamer on serum magnesium levels has not been thoroughly evaluated. Our aim was to analyze whether the use of sevelamer reduces the risk of hypomagnesemia in hemodialysis (HD)-requiring end-stage renal disease patients. METHODS: All prevalent patients from the dialysis unit of the Hospital Italiano de Buenos Aires as of 1 June 2015 were evaluated. They were on three times per week bicarbonate/citrate-buffered HD. They were not receiving phosphate binders or magnesium-containing drugs. The average of three successive monthly magnesium serum levels was considered as the baseline magnesium concentration. Sevelamer carbonate use was retrieved from the patient's clinical records. RESULTS: One hundred and fifty-one patients were included. A large proportion of individuals were on proton pump inhibitors (PPIs) (66%) and more than 50% were using sevelamer carbonate. Serum magnesium levels were significantly higher in those receiving sevelamer compared with those who did not (2.05 ± 0.3 versus 1.8 ± 0.4 mg/dL; P < 0.05). A larger proportion of individuals receiving sevelamer were among those with normal serum magnesium (P = 0.02), while among those with hypomagnesemia, a larger proportion were on PPIs. In the multivariate model including the use of PPIs, sevelamer carbonate resulted in an independent protective factor for hypomagnesemia (odds ratio: 0.44; 95% confidence interval: 0.21-0.87). CONCLUSIONS: Hemodialysis patients receiving sevelamer show higher serum magnesium levels and a reduced risk of hypomagnesemia. This effect remains even after adjustment for PPI use. This effect could contribute to the still controversial superiority of sevelamer in preventing vascular calcifications.
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The presence of distal extremity pain in children and adolescents usually triggers the search of rheumatologic diseases without considering non-rheumatologic causes of joint pain. Approaching distal extremity pain with a complete differential diagnosis, including non-rheumatologic entities, may hasten diagnosis, thus decreasing cost and aiding in earlier initiation of appropriate therapy. To present a case of a patient who after years of work up of arthralgia, which was actually attributed to rheumatologic causes, had an inherited metabolic disease. A 32-year-old male presented to the clinic with complaints of distal pain in his four limbs, predominantly in the hands, since he was 8 years. After 6 years of consultation in various pediatric centers, he was diagnosed with growing pains. At the age of 15 years, laboratory investigations began targeting rheumatologic causes of his symptomatology, and after 9 years, the diagnosis of chronic kidney disease of unknown etiology was made. Because of the constellation of signs and symptoms and his family history, an analysis of α-galactosidase A enzyme activity was conducted and Fabry disease was confirmed. Rheumatologists and immunologists may be the first encounter patients with Fabry disease. Thus, if Fabry disease is not considered at the differential diagnosis, an opportunity is missed for early initiation of a therapy.
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BACKGROUND: 3% sodium chloride solution is the accepted treatment for hyponatremic encephalopathy, but evidence-based guidelines for its use are lacking. STUDY DESIGN: A case series. SETTING & PARTICIPANTS: Adult patients presenting to the emergency department of a university hospital with hyponatremic encephalopathy, defined as serum sodium level < 130 mEq/L with neurologic symptoms of increased intracranial pressure without other apparent cause, and treated with a continuous infusion of 500mL of 3% sodium chloride solution over 6 hours through a peripheral vein. PREDICTORS: Hyponatremic encephalopathy defined as serum sodium level < 130 mEq/L with neurologic symptoms of increased intracranial pressure without other apparent cause. OUTCOMES: Change in serum sodium level within 48 hours, improvement in neurologic symptoms, and clinical evidence of cerebral demyelination, permanent neurologic injury, or death within 6 months' posttreatment follow-up. RESULTS: There were 71 episodes of hyponatremic encephalopathy in 64 individuals. Comorbid conditions were present in 86% of individuals. Baseline mean serum sodium level was 114.1±0.8 (SEM) mEq/L and increased to 117.9±1.3, 121.2±1.2, 123.9±1.0, and 128.3±0.8 mEq/L at 3, 12, 24, and 48 hours following the initiation of 3% sodium chloride solution treatment, respectively. There was a marked improvement in central nervous system symptoms within hours of therapy in 69 of 71 (97%) episodes. There were 12 deaths, all of which occurred following the resolution of hyponatremic encephalopathy and were related to comorbid conditions, with 75% of deaths related to sepsis. No patient developed neurologic symptoms consistent with cerebral demyelination at any point during the 6-month follow-up period. LIMITATIONS: Lack of a comparison group and follow-up neuroimaging studies. Number of cases is too small to provide definitive assessment of the safety of this protocol. CONCLUSIONS: 3% sodium chloride solution was effective in reversing the symptoms of hyponatremic encephalopathy in the emergency department without producing neurologic injury related to cerebral demyelination on long-term follow-up in this case series.
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Edema Encefálico/diagnóstico , Edema Encefálico/tratamiento farmacológico , Hiponatremia/diagnóstico , Hiponatremia/tratamiento farmacológico , Solución Salina Hipertónica/administración & dosificación , Anciano , Edema Encefálico/sangre , Estudios de Cohortes , Femenino , Humanos , Hiponatremia/sangre , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Solución Salina Hipertónica/química , Resultado del TratamientoRESUMEN
BACKGROUND: The occurrence of contrast-induced acute kidney injury (CIAKI) has paralleled the increased number of diagnostic interventions requiring radiographic contrast media (CM). Several strategies aimed at preventing renal injury following iodine have been carried out over the last several years. The aim of this study was to evaluate the impact of three different strategies aimed at preventing CIAKI in patients with renal dysfunction (serum creatinine >1.25 mg/dl or estimated creatinine clearance <45 ml/min) receiving low osmolar CM for diagnostic-therapeutic procedures. METHODS: Candidates received 154 mmol NaHCO3 solution (B0) at a rate of 3 ml/kg/h from at least 2 h before the procedure and at 1 ml/kg/h during and for the next 6-12 h; the same schedule plus N-acethyl-cysteine (NAC) 600 mg twice daily the day before and the day of the procedure (BN) or NAC as above plus 154 mmol NaCl solution at a rate of 3 ml/kg/h from at least 2 h before the procedure and at 1 ml/kg/h during and for the next 6-12 h (SN). Serum creatinine (SCr) was measured at baseline and on days 2 or occasionally 3 after CM. The main outcome measure was the occurrence of CIAKI, defined as a ≥25% increase in SCr within 2-3 days of CM. RESULTS: The three groups were similar with regard to age, gender distribution, weight, baseline serum levels of creatinine, sodium, potassium, urate and estimated creatinine clearance. A larger proportion of individuals received ACEIs/ARAs in the BN group (p < 0.05), but in the SN group, more patients declared a past history of acute myocardial infarction or had high blood pressure, and few displayed mild-moderate left ventricular dysfunction (p < 0.05). CIAKI occurred in 24/123 (19.5%) assessable patients (15/42 in the B0 group, 3/43 in the BN group and 6/38 in the SN group; p < 0.01). Thus, 15/42 patients who did not receive NAC developed CIAKI in contrast to 9/81 who did (p < 0.01). Multivariate logistic regression models showed that the use of NAC was the unique factor associated with a statistically significant influence for the occurrence of CIAKI (OR: 0.18; 95% CI: 0.04-0.72; p = 0.016). CONCLUSIONS: The results from this study show that: (1) the occurrence of CIAKI after low-osmolar CM administration is similar to that reported worldwide. (2) NAC-based renoprotective measures are superior for the prevention of CIAKI in patients with previous renal dysfunction. (3) They also demonstrate that bicarbonate expansion alone has limited value in preventing CIAKI. For those individuals at risk, combination prophylaxis including volume expansion plus NAC should be recommended to reduce the chance of overt kidney injury following CM administration.
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Acetilcisteína/uso terapéutico , Lesión Renal Aguda/prevención & control , Medios de Contraste/efectos adversos , Bicarbonato de Sodio/administración & dosificación , Lesión Renal Aguda/inducido químicamente , Adulto , Anciano , Creatinina/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sustitutos del Plasma/administración & dosificación , Insuficiencia Renal/diagnóstico , Cloruro de Sodio/administración & dosificación , Ácidos Triyodobenzoicos/efectos adversosRESUMEN
Introducción: En la insuficiencia renal aguda (IRA), la dosis administrada no suele controlarse y se estima que resulta inferior a la prescrita. Objetivo: Evaluar la diferencia entre la dosis prescrita y la dosis administrada en pacientes con IRA en Unidades de Cuidados Intensivos (UCI), así como los factores que la determinan, utilizando la determinación del Kt por dialisancia iónica. Material y método: Se incluyeron 394 terapias de reemplazo renal (TRR) en 105 pacientes adultos, con IRA oligúrica ingresados en UCI, con requerimiento de TRR , tratados con hemodiálisis intermitente (HDI) y/o extendida (HDE). Las TRR fueron realizadas con un monitor de aclaramiento on line (OCM®, Fresenius) para la determinación del Kt. Se registraron las características de los pacientes, la prescripción y el desarrollo de TRR. Todas estas variables fueron incluidas en un modelo uni y multivariado, teniendo como variable dependiente la incapacidad de lograr la dosis umbral u objetivo (DU). Resultados: Edad 66 ± 15 años, 37% del sexo femenino, etiología más frecuente: sepsis (70%), hipotensión y/o requerimientos de inotrópicos (71%), asistencia respiratoria mecánica (70%); el índice de severidad individualizado promedio fue de 0,7 ± 0,26. Se efectuaron 201 HDI y 193 HDE, la vía de acceso vascular más frecuente fue la femoral (79%). El Kt prescrito fue de 53,5 ± 14 litros, y un 21% de las prescripciones estaban (..) (AU)
Background: Estimating the dialysis dose is a requirement commonly used to assess the quality of renal replacement therapy (RRT) in patients with chronic kidney disease (CKD). In patients with acute kidney injury (AKI), this value is not always evaluated and it has been estimated that the prescribed dose is seldom obtained. Reports addressing this issue in AKI individuals are scarce and most have not included an adequate number of patients or treatments, nor were patients treated with extended therapies. Kt values obtained by the ionic dialysance method have been validated for the evaluation of the dialysis dose and it has also been shown that, compared with Kt/V, this is the most sensitive strategy for revealing inadequate dialysis treatment in critically ill AKI individuals. The main aim of this study was to assess the difference between the prescribed and the administered dialysis dose in critically ill AKI patients, and to evaluate what factors determine this gap using Kt values assessed through ionic dialisance. Material and Method: Data from 394 sessions of renal replacement therapy in 105 adult haemodialysis (HD) patients with oliguric acute kidney injury and admitted to ICU were included in this analysis. RRT was carried out with Fresenius 4008E dialysis machines equipped with on-line clearance monitoring (OCM® Fresenius), which use non-invasive techniques to monitor the effective ionic dialysance, equivalent to urea clearance. The baseline characteristics of the study population as well as the prescription and outcome of RRT were analysed. These variables were (..) (AU)
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Humanos , Lesión Renal Aguda/terapia , Diálisis Renal/métodos , Soluciones para Hemodiálisis/administración & dosificación , Insuficiencia Renal Crónica/complicaciones , Estudios Retrospectivos , Dosificación/métodosRESUMEN
BACKGROUND: Estimating the dialysis dose is a requirement commonly used to assess the quality of renal replacement therapy (RRT) in patients with chronic kidney disease (CKD). In patients with acute kidney injury (AKI), this value is not always evaluated and it has been estimated that the prescribed dose is seldom obtained. Reports addressing this issue in AKI individuals are scarce and most have not included an adequate number of patients or treatments, nor were patients treated with extended therapies. Kt values obtained by the ionic dialysance method have been validated for the evaluation of the dialysis dose and it has also been shown that, compared with Kt/V, this is the most sensitive strategy for revealing inadequate dialysis treatment in critically ill AKI individuals. The main aim of this study was to assess the difference between the prescribed and the administered dialysis dose in critically ill AKI patients, and to evaluate what factors determine this gap using Kt values assessed through ionic dialisance. MATERIAL AND METHOD: Data from 394 sessions of renal replacement therapy in 105 adult haemodialysis (HD) patients with oliguric acute kidney injury and admitted to ICU were included in this analysis. RRT was carried out with Fresenius 4008E dialysis machines equipped with on-line clearance monitoring (OCM® Fresenius), which use non-invasive techniques to monitor the effective ionic dialysance, equivalent to urea clearance. The baseline characteristics of the study population as well as the prescription and outcome of RRT were analysed. These variables were included in a multivariate model in which the dependent variable was the failure to obtain the threshold dose (TD). RESULTS: The main baseline characteristics of the study population/treatments were: age 66 ± 15 years, 37% female, most frequent cause of AKI: sepsis (70%). Low BP and/or vasoactive drug requirement (71%), mechanical ventilation (70%) and average individual severity index: 0.7 ± 0.26. Two hundred and one intermittent HD (IHD) and 193 extended HD (EHD) sessions were performed; the most frequently used temporary vascular access was the femoral vein catheter (79%). Prescribed Kt was 53.5 ± 14L and 21% of prescriptions fell below the TD. Sixty-one percent of treatments did not fulfill the TD (31 ± 8L) compared with 56 ± 12L obtained in the subgroup that achieved the target. Compared to IHD, EHD provided a significantly larger Kt (46 ± 16L vs 33L ± 9L). Univariate analysis showed that inadequate compliance was associated with age (>65y), male gender, intra-dialytic hypotension, low Qb, catheter line reversal, and IHD. The same variables with the exception of age and gender were independently associated in the multivariate analysis. CONCLUSIONS: The dialysis dose obtained was significantly lower than that prescribed. EHD achieved values closer to the prescribed KT and significantly higher than in IHD. Ionic Kt measurement facilitates monitoring and allows HD treatments to be extended based upon a previously established TD. Besides the chosen strategy to dispense the dose of dialysis, a well-functioning vascular access allowing for optimal blood flow and other approaches aimed at avoiding hemodynamic instability during RRT are the most important factors to achieve TD, mainly in elderly male patients. The dialysis dose should be prescribed and monitored for all critically ill AKI patients.
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Lesión Renal Aguda/terapia , Soluciones para Hemodiálisis/administración & dosificación , Errores Médicos , Diálisis Renal/métodos , Lesión Renal Aguda/etiología , Factores de Edad , Anciano , Anciano de 80 o más Años , Algoritmos , Conductividad Eléctrica , Femenino , Soluciones para Hemodiálisis/análisis , Humanos , Hipotensión/epidemiología , Hipotensión/etiología , Iones/análisis , Masculino , Persona de Mediana Edad , Oliguria/etiología , Oliguria/terapia , Complicaciones Posoperatorias/terapia , Prescripciones , Estudios Prospectivos , Diálisis Renal/efectos adversos , Factores de Riesgo , Sepsis/complicaciones , Índice de Severidad de la EnfermedadRESUMEN
UNLABELLED: Proteinuria >0.5 g/d (HP) and serum creatinine (Scr) >120 micromol/L (HSC) at three months, two and five yr were compared as prognostic factors in kidney transplantation. We retrospectively analyzed 454 first transplants (follow-up: 100 +/- 3.2 months). Donor/recipient age, sex, panel reactive antibody (PRA), HLA mismatches, cold ischemia time, delayed graft function, acute rejection, blood pressure and its treatment, diabetes and anti-calcineurin use were also evaluated. Cox proportional hazard regression with time-dependent covariates to control for potentially confounding factors was used to analyze survival. The Kaplan-Meier product-limit estimate for survival according to urine protein excretion (< or = or >0.5 g/d) or Scr (< or = or >120 micromol/L) along with the log-rank test for all comparisons were computed. Statistical significance was set with p-value < 0.05. RESULTS: HSC is a prognostic factor of graft survival (HR: 2.54; 95% CI: 1.98-3.10; p < 0.01) only at five yr, but it does not predict mortality at any period. HP at three months (HR: 2.07; 95% CI: 1.70-2.43; p < 0.001) and at two yr 3.03 (2.54-3.51; p < 0.001) significantly predicts graft failure. HP at two yr is the prevailingly prognostic factor of patient survival in kidney transplantation (HR: 3.30; 95% CI: 1.94-5.62; p < 0.0001).
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Supervivencia de Injerto , Trasplante de Riñón/mortalidad , Trasplante de Riñón/fisiología , Adulto , Creatinina/sangre , Femenino , Supervivencia de Injerto/fisiología , Humanos , Estimación de Kaplan-Meier , Masculino , Análisis Multivariante , Pronóstico , Proteinuria , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: The renal reserve (RR), assessed after an oral protein challenge or the intravenous administration of amino acids, is still present in healthy pregnant women (NP), although resting glomerular filtration rate (GFR) and renal plasma flow (RPF) increase progressively throughout normal gestation. No studies have addressed this issue in hypertensive gravidas; the aim of this trial was to evaluate renal response to an acute protein load (PL) in NP and pregnant women with borderline hypertension (HP). METHODS: Five NP, eight HP and eight healthy non-pregnant women (CG) were evaluated. After fasting overnight, all subjects received an oral water load (20 mL/kg of body weight), the urinary output was then replaced orally with equal volumes of water. After two 30 min periods, an 80 g PL was provided. Creatinine clearance (CCr) was measured every 30 min from 1 h before and for 4 h following PL. Participants remained recumbent during the study, bladder emptiness was assessed by ultrasound immediately after each micturition. Baseline CCr was taken as the average of two 30 min periods before PL and peak Ccr as the maximal CCr recorded thereafter. RESULTS: The groups were similar with regard to age, weight or gestation age. Baseline CCr (NP: 118.5+/-6.0, HP: 127.4+/-6.7 and CG: 99.8+/-2.9 mL/min, P=0.004 (CG vs NP and HP), increased after PL to NP: 223.5+/-9.8 to HP: 178.5+/-13 and to CG: 149.1+/-4.0 mL/min, P<0.0004 (CG vs HP, CG vs NP and NP vs HP)). Peak minus baseline CCr was 97.3+/-10.1; 46.3+/-12.7 and 48.3+/-4.8 for NP, HP and CG, respectively (P<0.006 HP vs CG and NP). The peak CCr was obtained significantly earlier in both pregnant groups (Period 3) compared with the healthy non-pregnant women (Period 5) (P=0.02). The fractional proximal reabsorption of sodium (FPRNa+) at peak CCr was similar in the groups (NP: 0.74+/-0.01 HP: 0.78+/-0.02 and CG: 0.74+/-0.03, P=not significant (NS)) as was the distal delivery of sodium (DDNa+) (NP: 5.8+/-0.5; HP: 4.1+/-0.5 and CG: 4.3+/-0.4 meq/min, P=NS). Fractional excretion of urea (%) increased from 91.4+/-5.5 to 105.5+/-9.8%; 80.7+/-8.0 to 97.3+/-9.8; and 44.4+/-7.8 to 86.0+/-7.1 in NP, HP and CG, respectively (P=NS). There was a trend towards a poorer maternal and fetal outcome in the HP group. CONCLUSION: Mid-term borderline HP failed to increase CCr as much as NP did after a protein challenge, suggesting altered functional response of the nephron or lessened sensitivity of renal vasculature to additional vasodilator stimuli. These results support the interest of additional prospective studies with a larger number of patients to confirm these findings and evaluate the value of RR tests as predictors of outcome of pregnancies at risk.
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Hipertensión/fisiopatología , Riñón/fisiología , Proteínas/administración & dosificación , Adulto , Análisis de Varianza , Cloruros/sangre , Cloruros/orina , Creatina/sangre , Creatina/orina , Femenino , Humanos , Concentración Osmolar , Potasio/sangre , Potasio/orina , Embarazo , Sodio/sangre , Sodio/orina , Urea/sangre , Urea/orinaRESUMEN
Despite repeated campaigns promoting transplantation, the high donation refusal rate remains unchanged. We targeted a well-educated population to assess the impact of our current transplantation promoting programs and personal feelings toward new approaches to organ donation. A questionnaire was proposed in five universities to students and university staffs that would have been likely to benefit from previous information campaigns in two South American and three European countries. All of the 2321 people interviewed replied to at least one question. Organ shortage was considered as a serious public health issue. However, there was a widespread ignorance of religious precepts concerning transplantation that contributed to the low acceptance rate of organ sharing after death. Financial rewards for donors or their families remain controversial. There was a general agreement for early educational programs in schools. Most people still consider organ donation as a gift, but many would now agree to readily share body parts after death. This biased population of well-educated people has still little knowledge of organ donation. The negative impact of ignorance surrounding religious precepts and the high acceptance rate of educational programs in schools, justify supporting an intensive international effort in education that should also include Church leaders.
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Opinión Pública , Obtención de Tejidos y Órganos/ética , Trasplante/psicología , Concienciación , Educación , Escolaridad , Emociones , Europa (Continente) , Femenino , Humanos , Masculino , Religión , América del Sur , Encuestas y Cuestionarios , Trasplante/educaciónRESUMEN
BACKGROUND: Hyperhomocysteinaemia is an independent risk factor for cardiovascular disease with a remarkable prevalence in patients with chronic renal failure (CRF). Low doses of folic acid (FA) with or without vitamin B6 and B12 has been shown to effectively reduce plasma homocysteine (Hcy). The aim of this study was to compare the short-term effects of two different oral doses of FA (5 vs 15 mg/d) on plasma Hcy levels in subjects suffering from moderate-severe CRF. METHODS: A double-blind, double-dummy, comparative, two-stage randomised study was performed. Seventeen patients aged 45-71 years, with glomerular filtration rates between 15.4-50 mL/min 1.73/m2 were randomly assigned to receive FA 5 mg/d (FA-5, n: 8) or FA 15 mg/d (FA-15, n: 9) for 30 days. At the end of this 30-day double-blind period, all the participants were placed on FA 5 mg/d (open period), for 5 additional months. Both groups were also supplemented with vitamins B1, B6 and B12 throughout the trial. Blood samples were drawn at 0, 15, 30, 90 and 180 days to assess Hcy, complete blood count (CBC) and sequential multichannel analysis (SMA). Chest X-ray and a 12-lead electrocardiogram (ECG) were also performed. RESULTS: Plasma Hcy (mean +/- SEM) decreased from 27.9 +/- 1.4 (baseline) to 15.1 +/- 0.6, 13.3 +/- 0.9, 14.1 +/- 0.5 and 13.8 +/- 0.5 micromol/L (FA-5) and from 28.8 +/- 2.7 to 15.6 +/- 1.2, 14.4 +/- 1.3, 13.0 +/- 0.7 and 13.1 +/- 0.6 micromol/L (FA-15) at days 15, 30, 90 and 180, respectively. (P < 0.01 from day 15 to 180 vs baseline for both groups with no differences between them). Renal function remained stable throughout the entire period of the study in all but one patient in whom it deteriorated to pre-end stage disease. No adverse cardiovascular events developed during the trial. CONCLUSION: Both folic acid doses induced a significant and similar decrease in plasma Hcy in subjects with moderate-severe chronic renal failure. The possible dose-related effect of this approach in reducing the risk of accelerated sclerotic vascular disease and cardiovascular events in this especially vulnerable population should be a matter of further investigation.
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Ácido Fólico/administración & dosificación , Homocisteína/sangre , Hiperhomocisteinemia/tratamiento farmacológico , Fallo Renal Crónico/sangre , Complejo Vitamínico B/administración & dosificación , Anciano , Método Doble Ciego , Humanos , Fallo Renal Crónico/terapia , Persona de Mediana Edad , Terapia de Reemplazo RenalRESUMEN
Streptococcus pneumoniae (Sp) and Haemophilus influenzae (Hi) are the leading bacterial cause of acute otitis media (AOM), having the nasopharynx (NP) as their reservoir. In October 2001 we began a prospective, multicenter, randomized, evaluator blind study, comparing the efficacy of amoxicillin-sulbactam (Ax/S) and amoxicillin-clavulanic acid (Ax/C) for the treatment of non-recurrent AOM (nr-AOM). Both antimicrobial susceptibility (AS) to Ax/S and Ax/C from Sp and Hi carried by study children (aged 6-48 months with nr-AOM) and, clinical outcome after treatment with high dose of either Ax/C (7:1) or Ax/S (4:1) (amoxicillin dose: 80 mg/(kg day), b.i.d. for 10 days) were assessed. Nasal cultures (NCs) were taken at Day 0. Follow-up NCs, were done only for Sp carriers. On final analysis 247/289 pts (85.5%) were fully evaluable (120 Ax/S and 127 Ax/C). NP carriage rate of Hi and Sp at Day 0 was 32.2% (93/289 pts) and 28.7% (83/289 pts), respectively. Persistent Sp carriage was detected only in 2 pts. Hi betalactamase positive rate was 13% (12/93). MICs for Ax/S and Ax/C were identical when tested against Sp and Hi isolates (range < or = 0.016-1.0 and < or = 0.016-0.25 mg/L, respectively). Clinical efficacy at Days 12-14 and 28-42 were 98.3% (115/117) and 94.2% (97/103) for Ax/S; and 98.3% (115/117) and 95.1% (98/103) for Ax/C, respectively (pNS). We conclude, that Sp and Hi isolated from NCs of nr-AOM pts were highly sensitive to both drugs and correlated with high clinical efficacy rate.
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Combinación Amoxicilina-Clavulanato de Potasio/uso terapéutico , Amoxicilina/uso terapéutico , Antibacterianos/uso terapéutico , Otitis Media/tratamiento farmacológico , Sulbactam/uso terapéutico , Enfermedad Aguda , Amoxicilina/administración & dosificación , Combinación Amoxicilina-Clavulanato de Potasio/administración & dosificación , Antibacterianos/administración & dosificación , Argentina , Portador Sano/tratamiento farmacológico , Portador Sano/microbiología , Preescolar , Esquema de Medicación , Combinación de Medicamentos , Femenino , Infecciones por Haemophilus/tratamiento farmacológico , Haemophilus influenzae/aislamiento & purificación , Humanos , Lactante , Masculino , Otitis Media/microbiología , Infecciones Neumocócicas/tratamiento farmacológico , Estudios Prospectivos , Método Simple Ciego , Streptococcus pneumoniae/aislamiento & purificación , Sulbactam/administración & dosificación , Resultado del TratamientoRESUMEN
BACKGROUND: Hyperkalaemia is common in patients with advanced renal disease. In this double-blind, randomized, three-sequence, crossover study, we compared the effect of three dialysate bicarbonate concentrations ([HCO3-]) on the kinetics of serum potassium (K+) reduction during a conventional haemodialysis (HD) session in chronic HD patients. METHODS: We studied eight stable HD patients. The choice of dialysate [HCO3-] followed a previously assigned treatment protocol and the [HCO3-] used were low bicarbonate (LB; 27 mmol/l), standard bicarbonate (SB; 35 mmol/l) and high bicarbonate (HB; 39 mmol/l). Polysulphone dialysers and automated machines provided blood flow rates of 300 ml/min and dialysis flow rates of 500 ml/min for each HD session. Blood samples were drawn at 0 (baseline), 15, 30, 60 and 240 min from the arterial extracorporeal line to assess blood gases and serum electrolytes. In three of the eight patients, we measured serum K+ 1 h post-dialysis as well as K+ removal by the dialysis. The same procedures were followed until the completion of the three arms of the study, with a 1 week interval between each experimental arm. RESULTS: Serum K+ decreased from 5.4+/-0.26 (baseline) to 4.96+/-0.20, 4.90+/-0.19, 4.68+/-0.13 and 4.24+/-0.15 mmol/l at 15, 30, 60 and 240 min, respectively, with LB; from 5.38+/-0.21 to 5.01+/-0.23, 4.70+/-0.25, 4.3+/-0.15 and 3.8+/-0.19 mmol/l, respectively, with SB; and from 5.45+/-0.25 to 4.79+/-0.17, 4.48+/-0.17, 3.86+/-0.16 and 3.34+/-0.11 mmol/l, respectively, with HB (P<0.05 for high vs standard and low [HCO3-] at 60 and 240 min). The decrease in serum K+ correlated with the rise in serum [HCO3-] in all but LB (P<0.05). Potassium rebound was 3.9+/-10.2%, 5.2+/-6.6% and 8.9+/-4.9% for LB, SB and HB dialysates, respectively (P=NS), while total K+ removal (mmol/dialysis) was 116.4+/-21.6 for LB, 73.2+/-12.8 for SB and 80.9+/-15.4 for HB (P=NS). CONCLUSIONS: High dialysate [HCO3-] was associated with a faster decrease in serum K+. Our results strongly suggest that this reduction was due to the enhanced shifting of K+ from the extracellular to the intracellular fluid compartment rather than its removal by dialysis. This finding could have an impact for those patients with life-threatening pre-HD hyperkalaemia.