[Show abstract][Hide abstract] ABSTRACT: Vascular calcification (VC) has a significant effect in cardiovascular diseases on dialysis patients. However, VC is assessed with x-ray-based techniques, which do not inform about calcium localization (intima, media, atherosclerosis-related). The aim of this work is to study VC and its related factors using arterial ultrasound to report the exact location of calcium.
This was an observational, cross-sectional, case-control study that included 232 patients in dialysis and 208 age- and sex-matched controls with normal kidney function. Demographic data and laboratory values were collated. Carotid, femoral, and brachial ultrasounds were performed to assess VC and atherosclerosis burden using a standardized protocol.
Cardiovascular risk factors were predominantly found in controls, although the burden of atherosclerosis was higher in the dialysis group. VC was significantly more prevalent in the group of patients on dialysis than control subjects, and in both groups the most prevalent pattern of VC was linear calcification located in the intima of the artery wall. Age and undergoing dialysis (with or without previous cardiovascular diseases) were positively and significantly associated with linear calcification. Conversely, the absence of atherosclerosis and low levels of C-reactive protein and phosphorus significantly impeded the development of linear calcification.
VC in large, conduit arteries is more prevalent in patients on dialysis than controls and is predominantly located in a linear fashion in the intima of the arteries.
Clinical Journal of the American Society of Nephrology 10/2010; 6(2):303-10. DOI:10.2215/CJN.04290510 · 4.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cardiovascular risk scoring (Score) does not specifically address chronic kidney disease (CKD) patients. The aim of our study is to quantify atherosclerosis using carotid ultrasound and ankle-brachial index (ABI) and to assess its additional value in risk scoring.
In this cross-sectional, observational study, patients were studied according to a standardized protocol including carotid ultrasound and ABI to determine the atherosclerosis score (AS), ranging from absence of to severe atherosclerosis (AS 0 to AS 3).
We included 409 CKD-affected patients (231 on dialysis, 99 in CKD Stages IV-V and 79 in CKD Stages I-III) and 851 subjects with normal renal function. The presence and severity of atherosclerosis was significantly higher in the CKD group than in the controls at every decade of age studied. Among the CKD-affected subjects, the prevalence of carotid plaques was significantly higher in the dialysis group (78.3%) than in the group in CKD Stages I-III (55.6%, P < 0.001). We identified 174 patients at low-intermediate risk. Among them, 110 (63.2%) presented either moderate (AS 2) or severe (AS 3) atherosclerosis. Variables significantly (P < 0.05) and positively related to atherosclerosis were being on dialysis [OR = 3.40, 95% CI (1.73, 6.78) vs CKD Stages I-III], age [OR = 1.08, 95% CI (1.06-1.11)] and C-reactive protein [OR = 1.04, 95% CI (1.01-1.08)]. Conversely, female sex was negatively related to atherosclerosis [OR = 0.40, 95% CI (0.23-0.71), P = 0.002].
The use of carotid ultrasound and ABI identifies atherosclerosis in a population of CKD patients in which risk scoring underestimates atherosclerosis burden.
[Show abstract][Hide abstract] ABSTRACT: Calcitriol has traditionally been the most widely used treatment for secondary hyperparathyroidism (SHPT) in uremic patients. There are currently no crossover equivalence studies of alphacalcidol versus calcitriol establishing which of the two derivatives is more active and better tolerated. The objective of this study was to compare the long term effect on control of PTH of similar doses of alphacalcidol versus calcitriol in the treatment of SHPT in these patients. METHODS: We conducted a retrospective study on 21 hemodialysis patients with stable SHPT of varying severity treated with intravenous calcitriol. In July 2002, the pharmacy of the reference hospital decided to substitute calcitriol for alphacalcidol based on the similarity of the two drugs. The conversion was made substituting a similar amount of drug. Mean absolute serum levels and percentage change in PTH, calcium and phosphorus were compared between the two periods and at 0, 3, 6, 9, 12 and 15 months after starting treatment with alphacalcidol. Student's t-test for paired means was used to compare the values between the two periods. RESULTS: In the calcitriol period, mean PTH levels were 275.2 +/- 111.7 pg/ml. The mean dose of drug used was 1.7 +/- 0.8 mcg postdialysis, and serum calcium and phosphorus levels were 10.1 +/- 0,5 mg/dl and 5,2 +/- 0,9 mg/dl, respectively (p < 0.01). Mean dialysate calcium content was 2,9 +/- 0,3 mEq/l. In the alphacalcidol period, PTH increased (441.6 +/- 178.3 pg/ml) (p < 0.001) and the percentage of patients with PTH < 300 pg/ml decreased (24% at the end of the period), in spite of significantly increasing the mean drug dose (2,3 +/- 0,9 mcg postdialysis) (p < 0.05). Serum calcium levels did not show significant differences (10.2 +/- 0.7 mg/dl) (p = NS), but phosphorus control was improved (4,7 +/- 0,5 mg/dl) (p < 0.01). The percentage of patients with PTH < 300 pg/ml decreased progressively from the start of treatment with alphacalcidol from 75% to 24% at the end of follow-up. Our results seem to suggest that the dose of alphacalcidol and calcitriol are not equivalent and we need to increase the dose of alphacalcidol to obtain a similar result to calcitriol on suppression of PTH in uremic patients with SPTH.
Nefrologia: publicacion oficial de la Sociedad Espanola Nefrologia 02/2006; 26(2):226-33. · 1.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hypokalemia is generally associated to neuromuscular symtoms, acid-base disorders and even to rhabdomyolysis. However, chronic hypokalemia can induce chronic renal failure through a characteristic tubulointerstitial damage consisting on vacuolization of epithelial tubular cells and interstitial fibrosis. This entity is called hypokalemic nephropathy, quite unusual and probably little know in our speciality. We present a clinical report of a patient admitted to our hospital with a severe hypokalemia secondary to an aldosterone producing adrenal adenoma that was diagnosed during admission. Besides hypokalemia the patient presented renal failure. Renal biopsy proved characteristic tubulointerstitial damage as described in hypokaliemic nephropathy. In summary, we report a Conn syndrome presenting as a hypokalemic nephropathy.
Nefrologia: publicacion oficial de la Sociedad Espanola Nefrologia 02/2006; 26(2):274-7. · 1.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: One of the requirements of a health care quality management system is to be able to established clinical performance measures (CPM) for its key organisation processes. We described some of the performance measurement that has been used in our hemodialysis unit, since the implementation in the year 2001, of a Quality Management System (QMS). We analyze and compare the effect that the introduction of a ISO 9002 based QMS had in our CPM during the period 2001-2002 (post QMS) vs. the two previous years -1999-2000- (pre QMS).
We defined several CPM for assessment of hemodialysis adequacy and medical management that covered : Anemia, iron status renal osteodystrophy, hemodialysis prescription and nutritional status , follow up of the established guidelines for vascular access care and prevention of nosocomial infections water quality and general performance outcome like annual crude mortality rate and hospitalization (express as hospital days/patient year).
No significant difference was found between both periods regarding annual crude mortality( pre QMS 8.37% vs post QMS 8.95%) or the hospitalization rate ( pre 0.47 patient-days vs. post 0.52 patient-days) . There was a significant difference after implementation of the quality system in the average hemoglobin levels (pre 11.3 +/- 1.5 vs. post 11.9+ +/- .5 p <0,001). Ferritin levels (pre 220 +/- 162 vs. post 313 +/- 373 p<0.01), albumin levels (pre 3.61 +/- 0.46 vs. post 3.82 +/- 0.56 p<0.001) and KTV>1.2 (pre 1.41 +/- 0.26 vs. post 1.50 +/- 0.33 p<0.001). The transferring saturation index (TSI) was unchanged (pre 27.98 +/- 14.39 vs.. post 29.4 +/- 16.66 p=0.11). There was a significant decrease in the average PTH levels (pre 234.9 +/- 285 vs. post 174 +/- 174 p< 0.0001) PTH>300 pg/ml (pre 23.7% vs. post 16.4% p<0.001) calcium levels (pre 10.02 +/- 0.99 vs. 9.83 +/- 0.88 p<0.001), phosphorus (pre 5.50 +/- 1.55 vs. post 5.01 +/- 1.47 p<0.001) as well as serum calcium levels >11 mg/dl (pre 14.6% vs. post 11% p<0.001) and phosphorus >6 g/dl (pre 34% post 21.5% p<0.001). Although the average serum potassium levels decrease (pre 5.51 +/- 0.85 vs. post 5.40 +/- 0.87), the percentage of patients with potassium over 6.5 meq/l was similar in both periods (pre 11.5% vs. post 10. 1%). The number of native A-V vascular access was similar in both periods and above the current DOQI Recommendations. Nevertheless, there was a gradual decrease in native A-V fistula, associated with an increase on the use of permanent catheters. The number of incident patients with a permanent catheter as the only vascular access for hemodialysis increased from 0% in the year 1999, 2000 and 2001 to 6.98% in 2002. There was no hepatitis B and C seroconversión detected in both periods.
From our study we concluded that regular follow-up of quality performance measurement associated with an ongoing corrective action, promotes an improvement of the outcome measures results.
Nefrologia: publicacion oficial de la Sociedad Espanola Nefrologia 01/2004; 24(3):261-75. · 1.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There has been increasing interest to find instruments to assess the HRQL quickly and easily in daily clinical practice. The main objective of this study is to measure the HRQL inhemodialysis patients using the Coop-Wonca Charts and to analyse whether they can be a useful instrument to assess the patient functional status and the HRQL in this population.
A descriptive cross-sectional study was performed between March 2003 and May 2003 in 163 hemodialysis patients (106 males and 57 females). The HRQL has been measured according to the validated Spanish version of the Coop-Wonca Charts. The questionnaire has nine different scales with a single-item. The answers score from 1 to 5 with the higher scores indicating the worst health or functional problems.
The filling middle time of Coop-Wonca charts was less than five minutes. The charts were easily understood for the patients and can be self-administered. The dimensions of "Physical fitness" (3.66 +/- 0.8) and "Overall health" (3.43 +/- 0.8) showed the higher score, and the item aSocial activities) showed the lower scores (better quality of life) (1.98 +/- 1.3). The factors related to the worse health state are the variables: sex (females), the comorbility (diabetes and/or hepatopathy), the labour status (retired) and the way of transport (taxi/ambu lance). The time in hemodialysis was an independent variable and showed the worse score in the "general quality of life" (p < 0.05) and in the "perception of pain" (p < 0.01). The way of transport used (ambulances) was also an independent variable with worse scores for the dimensions "Physical fitness" (p < 0.01), "Daily activities" (p < 0.05) and "Health status" (p < 0.05). The older patients showed a worse score in the dimension "Physical fitness" (p < 0.01) and the patients with more than prescribed medicines scored worse in "Social activities" (p < 0.01). Males (p < 0.05), widows and single (p < 0.05) scored worse in social support.
The Coop-Wonca Charts could be a good instrument to measure of HRQL in the HD patients. Their application is easy, fast (less than 5 minutes), easily understood, and can be self-administered.
Nefrologia: publicacion oficial de la Sociedad Espanola Nefrologia 01/2004; 24(5):470-9. · 1.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Percutaneous transluminal renal angioplasty (PTRA) has a beneficial effect on renal function in some, but not all, patients with atheromatous renal artery stenosis. Our aim is to identify factors influencing clinical success after PTRA in this group of patients. Seventy-three patients undergoing PTRA were studied; 14 patients were excluded from final analysis because of restenosis. All patients had chronic renal failure secondary to vascular nephropathy and renal artery stenosis. The diagnosis of renal artery stenosis was based on carbon dioxide digital angiography showing greater than 60% luminal narrowing. The rate of renal failure progression was assessed by the slope of the regression line of serum creatinine versus time. At least three consecutive creatinine measurements before and after angioplasty were required for study entry. Response to PTRA was made by comparison of the slope before and after PTRA. The association of age, serum creatinine level, proteinuria, renal size, pre-PTRA slope value, diabetes, ischemic heart disease, peripheral vascular disease, and cerebrovascular disease with response to PTRA was assessed by multiple regression analysis, with changes in slope values as the dependent variable. Renal function improved in 34 of 59 patients (57.6%). Mean follow-up was 627 +/- 284 (SD) days. The slope of the reciprocal serum creatinine plot before PTRA was significantly associated with a favorable change in progression rate after PTRA (beta = -0.012; P = 0.004). A scatter plot showed a statistically significant inverse correlation between pre-PTRA slope values and post-PTRA slope changes (r = -0.46; P = 0.000). Rapidly progressive renal failure is associated with a favorable response on renal failure progression after PTRA in patients with vascular nephropathy and renal artery stenosis.
American Journal of Kidney Diseases 02/2002; 39(1):60-6. DOI:10.1053/ajkd.2002.29881 · 5.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BsmI vitamin D receptor (VDR) gene polymorphism has been associated with the severity of hyperparathyroidism in patients on hemodialysis. The aim of this study was to analyze the influence of this polymorphism on parathyroid function and serum calcitriol levels in patients with different degrees of chronic renal failure (CRF) before dialysis.
A total of 248 CRF patients, divided into three groups according to creatinine clearance (CCr; mild CRF group> 60 to </=85 ml/min, N = 54; moderate CRF group> 35 to </=60 ml/min, N = 113; severe CRF group> 10 to </=35 ml/min, N = 81), had their serum intact parathyroid hormone (iPTH) and calcitriol levels measured and BsmI genotype frequencies estimated by polymerase chain reaction (PCR) analysis. Diabetics, those on treatment with steroids, vitamin D or derivatives, and phosphorus binding agents were excluded. All those with serum calcium levels of <2.25 mmol/liter or> 2.5 mmol/liter and serum phosphorus levels of> 1.6 mmol/liter or who needed phosphorus binding agents were excluded. The statistical analysis was done with the general factorial analysis of variance entering first PTH and then calcitriol as the dependent variable; the genotype (BB, Bb and bb), sex and CCr group were defined as factors; and covariables included serum calcium, serum phosphorus, 1/creatinine versus time slope, PTH when calcitriol was the dependent variable, and calcitriol when PTH was the dependent variable.
When serum PTH levels were entered as the dependent variable, serum calcium, CCr group, and the interaction of genotype with the CCr group were found to be significant factors (P = 0.025, P <0.001 and P = 0.039, respectively). When serum calcitriol levels were entered as the dependent variable, genotype, the interaction of genotype with CCr, the CCr group, and the 1/creatine versus time slope were found to be significant (P = 0.027, P = 0.028, P <0.001 and P = 0.044, respectively). The marginal means of PTH, adjusted with the general factorial analysis of variance across the three groups were: (a) mild CRF group, BB 5.3 pmol/liter (CI 0 to 13.8), Bb 5.5 pmol/liter (CI 2 to 9), bb 5.4 pmol/liter (CI 0.6 to 10.2); (b) moderate CRF group, BB 6.2 pmol/liter (CI 1.5 to 10.9), Bb 7.8 pmol/liter (CI 5.3 to 10.3), bb 7.5 pmol/liter (CI 4.8 to 10.1); (c) severe CRF group, BB 9.3 pmol/liter (CI 4.2 to 14.3), Bb 17.1 pmol/liter (CI 13.9 to 20.2), bb 21.9 pmol/liter (CI 18.7 to 25.2). The marginal means of calcitriol adjusted with the general factorial analysis of variance across the three groups were: (a) mild CRF group, BB 47 pg/ml (CI 37 to 57), Bb 40.9 pg/ml (CI 37 to 44.8), bb 32.6 pg/ml (CI 26.8 to 38. 4); (b) moderate CRF group, BB 24.1 pg/ml (CI 18.3 to 29.8), Bb 26.6 pg/ml (CI 23.5 to 29.7), bb 25.3 pg/ml (CI 22 to 28.6); (c) severe CRF group, BB 27.4 pg/ml (CI 21.3 to 33.5), Bb 19.4 pg/ml (CI 15.5 to 23.2), bb 20.4 pg/ml (CI 16.1 to 24.7).
The progression of hyperparathyroidism is slower in predialysis patients with BB genotypes than in the other genotypes. Also, calcitriol levels are less reduced in the BB genotype, which may act to lessen the severity of secondary hyperparathyroidism.
Kidney International 11/1999; 56(4):1349-53. DOI:10.1046/j.1523-1755.1999.00678.x · 8.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: RESUMEN Se describe una paciente de 75 años que presentó insuficiencia renal avanzada (creatinina de 6 mg/dl) y síndrome nefrótico (proteinuria de 7,6 g/24 h). En la ex-ploración física no existía retinopatía diabética y tanto la glucemia como la hemo-globina glucosilada eran normales al ingreso. Se realizó una biopsia renal, que mostraba lesiones de glomerulosclerosis nodular extensa. La tinción de rojo Congo fue negativa, así como la inmunofluorescencia específica para cadenas ligeras, lo que descartó amiloidosis y nefropatía por cadenas ligeras, respectivamente. La glo-merulonefritis mesangiocapilar también se excluyó por la ausencia de prolifera-ción mesangial y por una inmunofluorescencia que mostraba únicamente atrapa-miento inespecífico de IgM en los nódulos mesangiales. Posteriormente la paciente precisó hemodiálisis y un mes después del ingreso presentó cifras elevadas de glucemia, que obligaron a la instauración de tratamien-to con insulina. Este caso muestra que la glomerulosclerosis nodular puede ser el hallazgo clini-co inicial en una minoría de pacientes con diabetes mellitus hasta entonces no diagnosticada y que la nefropatía diabética debe ser incluida en el diagnóstico di-ferencial de glomerulosclerosis nodular incluso en ausencia de retinopatía o de ci-fras elevadas de glucemia.
[Show abstract][Hide abstract] ABSTRACT: Serum aluminium and parathyroid hormone levels were measured in chronic dialysis patients at discovery of accidental exposure to high dialysate aluminium levels and followed after adequate water purification.
Twenty-nine patients with chronic renal failure on maintenance haemodialysis were accidently exposed to dialysate aluminium levels of 65 micrograms/L (recommended Food and Drug Administration values less than 10 micrograms/L) for 18 months. At discovery, oral aluminium was withdrawn and dialysate aluminium levels were corrected to less than 5 micrograms/L. Serum aluminium, parathyroid hormone, calcium, phosphorus and alkaline phosphatase levels were determined at discovery and two months and one year after the corrective measures.
Mean serum aluminium level was 167.6 +/- 15 micrograms/L at discovery and simultaneous serum parathyroid levels were 7.9 +/- 2.2 pmol/L (normal values 1.1 to 4.6 pmol/L). Two months after discontinuation of oral aluminium and correction of dialysate aluminium levels to less than 5 micrograms/L, the patients' mean serum aluminium dropped to 49.6 +/- 4.3 micrograms/L and simultaneous serum parathyroid hormone levels rose to 14.6 +/- 3.2-pmol/L (p < 0.001). Similar levels were maintained at one year. Serum calcium did not change significantly. There was a significant correlation between the drop in serum aluminium and the increase in parathyroid hormone.
These results confirm animal experiments and show convincingly that aluminium inhibits parathyroid secretion also in humans.
The European journal of medicine 12/1992; 1(8):482-4.
[Show abstract][Hide abstract] ABSTRACT: RESUMEN Uno de los requisitos de los programas de gestión de calidad es la medición sis-temática y planificada de indicadores de calidad. Se describen algunos de los in-dicadores definidos en el sistema de gestión de calidad (SGC) de nuestra unidad de hemodiálisis en el año 2001 y se analiza el impacto de su implantación en 2001 y 2002, comparando sus resultados con los obtenidos en los dos años previos (1999-2000). Métodos: Se definieron indicadores de prescripción y seguimiento clínico del pro-ceso de hemodiálisis (anemia, depósitos férricos, osteodistrofia, dosis de diálisis y estado nutricional), cumplimiento de protocolos (seguimiento y cuidado de accesos vasculares, prevención de transmisión nosocomial), indicadores de calidad de agua tratada e indicadores globales de resultado (mortalidad y tasa de ingresos anual). Resultados: Ni la mortalidad anual bruta ni la tasa global anual de ingresos mos-traron diferencias significativas entre ambos periodos. En la etapa postimplantación del SGC, las cifras medias de hemoglobina, ferritina, albúmina y KTV fueron signi-ficativamente superiores y el porcentaje de determinaciones que no cumplían el es-tándar establecido fue disminuyendo de forma significativa. El índice de saturación de la transferrina (IST) no mostró variaciones. Los niveles medios de PTH y de cal-cio, así como el porcentaje de pacientes con PTH superiores a 300 pg/mI o cifras de calcio superiores a 11 g/dl descendieron significativamente. La cifra media de potasio sérico descendió tras la implantación del sistema de gestión de calidad; sin embargo, el porcentaje de pacientes con potasio por encima de 6,5 meq/I se man-tuvo estable en los dos periodos. La cifra media de fósforo sérico también descen-dió en el periodo postcertificación, al igual que el porcentaje de pacientes con ni-veles de fósforo sérico por encima de 6 g/dl. El porcentaje de pacientes de la población prevalente que tenía una fístula arte-riovenosa autóloga como acceso vascular ha sido superior al estándar marcado en las dos etapas de estudio. No obstante, se detectó un descenso paulatino de dicho porcentaje, asociado a un incremento del de pacientes con catéteres permanentes. El número de pacientes incidentes cuya primera y única posibilidad de acceso vas-cular es un catéter permanente pasó de 0% en los años 1999, 2000 y 2001 a 6,98% en el 2002. La tasa de seroconversión a los virus C y B se mantuvo en cero en ambos periodos. Conclusión: De nuestro estudio se deduce que el seguimiento periódico de indi-cadores de calidad y la puesta en marcha de las acciones correctoras pertinentes, favorece la mejoría de los resultados obtenidos. Palabras clave: Indicadores de calidad asistencial; Calidad; Certificación; Sistema de gestión de la calidad.