Salomón Algranati

Hospital Italiano de Buenos Aires, Buenos Aires, Buenos Aires F.D., Argentina

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Publications (19)36.04 Total impact

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    ABSTRACT: 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. 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). 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. 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.
    Nefrologia: publicacion oficial de la Sociedad Espanola Nefrologia 04/2012; 32(3):359-66. DOI:10.3265/Nefrologia.pre2012.Jan.11284 · 1.44 Impact Factor
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    ABSTRACT: 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.
    Nefrologia: publicacion oficial de la Sociedad Espanola Nefrologia 12/2011; 32(3):359-366. · 1.44 Impact Factor
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    ABSTRACT: The MDRD equation to estimate glomerular filtration rate (GFR) is the most widely used strategy to assess chronic kidney disease. Nonetheless, for the individual patient the true GFR can be underestimated with the risk of diagnosing a more elevated CKD stage. This novel CKD-EPI equation would improve accuracy and precision of estimations, and several authors recommend this new equation replace the former. In our country there is only a limited registration of these comparisons performed on a large number of patients. Therefore, our aim was to develop a comparison in a wide cohort of patients. The concordance between both equations to assign the GFR stages was determined by using the MDRD formula as a reference. The mean difference of GFR obtained with both equations as well as the Bland-Altman analysis were calculated. A cohort of 9319 individuals, of whom 67% were females, aged 58 ± 20 years, with serum creatinine values of 1.6 ± 1.03 mg/dl, was studied. In the whole group, CKD-EPI displayed an average GFR 0.61 ml/min/1.73 m2 larger than MDRD (p: NS). For CKD stages 2 and 3A the mean estimated GFR difference was 6.95 ± 4.76 and 3.21 ± 3.31, while the concordance was 81 and 74% respectively. The percentage of patients with GFR < 60 ml/min/1.73 m2, decreased from 76.3% with the former equation to 70.1% with the latter. The novel equation CKD-EPI reduces the number of patients with GFR values lower than 60 ml/min/1.73 m2 and consequently assigns a higher GFR stage to a considerable quantity of individuals.
    Medicina 08/2011; 71(4):323-330. · 0.42 Impact Factor
  • Gastroenterology 01/2011; 140(5). DOI:10.1016/S0016-5085(11)63681-0 · 13.93 Impact Factor
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    ABSTRACT: The MDRD equation to estimate glomerular filtration rate (GFR) is the most widely used strategy to assess chronic kidney disease. Nonetheless, for the individual patient the true GFR can be underestimated with the risk of diagnosing a more elevated CKD stage. This novel CKD-EPI equation would improve accuracy and precision of estimations, and several authors recommend this new equation replace the former. In our country there is only a limited registration of these comparisons performed on a large number of patients. Therefore, our aim was to develop a comparison in a wide cohort of patients. The concordance between both equations to assign the GFR stages was determined by using the MDRD formula as a reference. The mean difference of GFR obtained with both equations as well as the Bland-Altman analysis were calculated. A cohort of 9319 individuals, of whom 67% were females, aged 58 ± 20 years, with serum creatinine values of 1.6 ± 1.03 mg/dl, was studied. In the whole group, CKD-EPI displayed an average GFR 0.61 ml/min/1.73 m2 larger than MDRD (p: NS). For CKD stages 2 and 3A the mean estimated GFR difference was 6.95 ± 4.76 and 3.21 ± 3.31, while the concordance was 81 and 74% respectively. The percentage of patients with GFR < 60 ml/min/1.73 m2, decreased from 76.3% with the former equation to 70.1% with the latter. The novel equation CKD-EPI reduces the number of patients with GFR values lower than 60 ml/min/1.73 m2 and consequently assigns a higher GFR stage to a considerable quantity of individuals.
    Medicina 01/2011; 71(4):323-30. · 0.42 Impact Factor
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    ABSTRACT: Acute renal failure due to viral infections is rare. We assessed the development of acute kidney injury (AKI) in critically compromised patients due to the H1N1 influenza virus. All patients with a PCR -confirmed diagnosis of H1N1 influenza infection admitted to the intensive care unit between May and July 2009 were retrospectively studied. Thereafter, the risk factors associated with the development of acute renal injury, the requirements of acute hemodialysis (HD) and death were analyzed. Twenty-two patients with H1N1 pneumonia were included: age: 52.91 ± 18.89 years; gender: males 11 (50%); chronic airway disease: 9 (41%); oncohematological disease: 8 (36.7%); cardiovascular disease 5 (22.7%); chronic renal insufficiency: 4 (18.2%); obesity 3 (13.6%); concomitant pregnancy: 2 (9.1%); diabetes mellitus: 2 (9.1%); previous influenza A vaccination: 9 (41%). All patients received oseltamivir within 48 hours of presumed diagnosis. Seventeen patients (77.3%) developed fever initially. Six patients (27.3%) required noninvasive ventilation assistance and 15 patients (68.2%) received invasive ventilatory support. Mean days on mechanical respiratory assistance: 11 ± 10.35. Arterial partial pressure of oxygen/fraction of inspired oxygen ratio: 140.11 ± 83.03 mmHg. Inotropic drugs were administered to 15 patients (68.2%). Fourteen patients (63.6%) developed AKI. Mean highest creatinine levels: 2.74 ± 2.83 mg/dl. Four patients (18.2%) needed renal replacement therapy with a mean duration of 15 ± 12 days. Six patients (42.9%) recovered renal function. AKI was associated with pregnancy, immunosuppression, high APAC HE, SOFA and MURRA Y scores, and less time on mechanical ventilation assistance, hemodynamical instability and thrombocytopenia. HD requirements were associated with elevated SOFA scores (12.25 ± 1.75 vs. 6.22 ± 0.8, p<0.05), elevated creatine phosphokinase (933 ± 436.6 vs. 189.9 ± 79.3 U/L, p<0.05) and alanine transferase levels (843.3 ± 778.8 vs. 85.33 ± 17.4 U/L, p<0.05). Twelve patients died (54.6%), 10 of whom had acute renal failure (83.3%) and 3 had been on acute HD (25%). Mortality was associated with higher APACHE, SOFA and Murray scores, a higher oseltamivir dose (253.1 ± 25.8 vs. 183.8 ± 27.6 mg, p<0.05), lower oxygen inspired fraction/alveolar pressure ratio (99.3 ± 12.2 vs. 196.3 ± 33.9 mmHg, p<0.01), thrombocytopenia (88966 ± 22977 vs. 141200 ± 17282 mm3, p<0.05), hypoalbuminemia (1.82 ± 0.1 vs. 2.61 ± 0.2 g/dl, p<0.01), acute renal failure (10 vs. 4, p<0.05), oligoanuria (5 vs. 0, p<0.05) and lack of recovery of renal function (2 vs. 4, p<0.01). Three out of 4 (75%) of the hemodialyzed patients died. In the critically ill due to H1N1 pneumonia, renal insufficiency was a frequent complication, demanding renal replacement therapy in 18% of cases. The need for HD was associated with an elevated risk of death. Mortality was mainly associated with multiple organ failure, oligoanuria, acute renal injury and a lack of recovery of renal function.
    Journal of nephrology 03/2010; 23(6):725-31. · 2.00 Impact Factor
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    ABSTRACT: The development of colonoscopy has increased the oral sodium phosphate (OSP) laxative use. OSP complications like hyperphosphatemia with acute and chronic kidney impairment with nephrocalcinosis have been reported. To describe and analyze acute and one year after OSP complications in low risk well hydrated patients. We performed a prospective study in 100 consecutive patients undergoing colonic cleansing with OSP for colonoscopy aged 35-74 year, ASA I-II. Exclusion criteria were congestive heart failure, chronic kidney disease, diabetes, liver cirrhosis, intestinal obstruction, decreased bowel motility, increased bowel permeability, hyperparathyroidism. Arterial pressure, hematocrit, serum osmolality, serum phosphate, ionic calcium, electrolytes (Na+, Cl-, K+), creatinine and urea were measured before and after OSP. The day before colonoscopy all the participants entered a 24 hr-period diet consisting in 4 litres of clear fluids and standard OSP dose (30 g at 17:00 and 30 gr at 22:00). Phosphatemia levels post OSP according to patient's weight (> or =, < or = 70 kg) and one year later kidney function were compared. Mean age was 58.9 +/- 8.4 years, 66% of patients were women and mean weight was 71 +/- 13 kg. Kidney function showed no significant difference between pre and post OSP, and after one year values. Hyperphosphatemia appeared in 87%. Hyperphosphatemia was higher in patients with low weight (5.8 mg/dl vs 5.3 mg/dl, P < 0.05). OSP complications were reduced through an adequate patient selection in order to avoid risk factors and an effective hydration. Phosphate overload was tolerated without symptoms. Considering high hyperphosphatemia incidence and its relation with weight, to adjust dose related to weight should be evaluated. There was no acute or a year later renal damage.
    Acta gastroenterologica Latinoamericana 03/2010; 40(1):54-60.
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    ABSTRACT: BACKGROUND: Low vitamin D serum levels represent an additional risk factor for end-stage renal disease (ESRD)– associated bone disorders. The aim of this study was to evaluate the prevalence of vitamin D defi ciency in both the summer and winter seasons, as well as to defi ne the associated risk factors, and to establish the link between secondary hyperparathyroidism and circulating 25-hydroxy vitamin D (25 [OH]-D) serum levels. METHODS: Seventy-eight hemodialysis (HD)–requiring ESRD outpatients living in Buenos Aires, Argentina, age 57.2 2.07 years (21–86 years) were evaluated at the end of summer (SUM) and the end of winter (WIN). Then 25 (OH)-D, serum calcium (Ca), intact parathormone, ionized Ca (Ca), phosphate, alkaline phosphatase, creatinine, C-reac-tive protein, and serum albumin were evaluated. The participants were evaluated according to the 25 (OH)-D levels following KDOQI guidelines. The participants were assigned to 2 groups according to their Karnofsky scores for functional capacity (FC): FC 1–2 (normal physical capacity full-time to only part-time) and FC 3–4 (limited capacity only for self care to needs permanent assistance). RESULTS: Seasonal variations in 25 (OH)-D (WIN 18.1 1.15 ng/mL vs. SUM 29.2 1.35 ng/mL, p 0.001) were verifi ed. Male patients displayed higher 25 (OH)-D serum levels than female participants (20.3 1.5 ng/mL vs. 15.4 1.6 ng/mL, p 0.01). We observed (WIN/SUM) vitamin D defi ciency in 48.7/11.8%, insuffi ciency in 41/39.5%, and target levels in 10.3/48.7% of the population. Severe defi ciency was not detected. The mean variation in WIN/SUM 25 (OH)-D level was 11.08 1.04 ng/mL, which correlated with age (r 0.59, p 0.02). Patients with FC 3–4 displayed the lowest 25 (OH)-D levels, and this was associated with older age (70.8 3.12 years vs. 50.4 2.16 years, p 0.01), severe disease (C-reactive protein: 22.8 6.26 mg/L vs. 10.2 2.8 mg/L, p 0.02), and poor nutritional status (albumin: 3.8 0.09 vs. 4.1 0.04, p 0.0049; creatinine: 7.4 0.4 mg/dL vs. 8.4 0.29 mg/dL, p 0.04). Multivariate analysis with 25 (OH)-D as the dependent variable demonstrated that both FC and sex independently predicted serum levels of 25 (OH)-D. No association between intact parathormone and 25 (OH)-D was detected.
    Dialysis & Transplantation 10/2008; 37(10):(388-390). DOI:10.1002/dat.20260 · 0.19 Impact Factor
  • Medicina 08/2008; 68(4):346-347. · 0.42 Impact Factor
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    Medicina 02/2008; 68(4):346-7. · 0.42 Impact Factor
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    Nephrology Dialysis Transplantation 10/2007; 22(9):2731-2. DOI:10.1093/ndt/gfm389 · 3.49 Impact Factor
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    Nephrology Dialysis Transplantation 08/2006; 21(7):2031-3. DOI:10.1093/ndt/gfl020 · 3.49 Impact Factor
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    ABSTRACT: Pamidronate (APD), a third-generation bisphosphonate, has proven to be useful in haemodialysis (HD) patients with ectopic calcifications and hypercalcaemia. Little is known about bisphosphonates clearance in patients undergoing HD. The authors’ main objective was to study HD removal and clearance of APD. In total, 23 HD-requiring anuric end-stage renal disease (ESRD) adult individuals (12 men) aged 61.7 ± 13 (mean ± SD) years were admitted into the study. APD clearance and elimination were evaluated by 99mTechnetium APD (half-life 6 h). In total, 1 mg of labelled APD was injected via the arteriovenous graft prior to the start of HD. Blood samples were then drawn from the arterial (predialyser) and venous (postdialyser) lines of the extracorporeal circuit 2 h after the HD onset. In a subgroup of patients (n: 15) the dialysate was collected and quantified during the three initial HD hours. Venous APD concentrations (postdialyser) were 72 + 7% of arterial (predialyser) concentrations. Mean APD clearance was 69.3 + 16.6 mL/min, and mean APD extraction during dialysis session was 31.6 + 10.1%. In the present study involving HD-requiring anuric ESRD patients APD was successfully eliminated by HD. At the dose administered here none of the participants reported adverse events. APD is a potentially useful drug to be administered to HD-requiring ESRD patients, the understanding of its removal during HD as well as its dialytic clearance allows for a safer management of a drug that is usually eliminated by renal excretion.
    Nephrology 05/2006; 11(3):197 - 200. DOI:10.1111/j.1440-1797.2006.00569.x · 1.86 Impact Factor
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    ABSTRACT: The percutaneous ethanol injection (PEI) with ultrasound guidance has been suggested for the treatment of patients with hyperparathyroidism who are on dialysis, with the aim of selectively treating the parathyroid glands with nodular hyperplasia. We present our experience in 25 patients with chronic renal failure followed during 13.4 +/- 10.6 months. A decrease in the levels of parathormone (PTH) (1,236.32 +/- 129.8 vs. 721.66 +/- 142.24 pg/ml), phosphatemia (6.16 +/- 0.35 vs. 4.93 +/- 0.36 mg/dl) and calcium-phosphorous product (60.82 +/- 3.81 vs. 46.47 +/- 3.46 mg2/dl2) was verified. In 56% of patients, PTH levels decreased (>50% of the baseline value) and 36% had final values <300 pg/ml. Patients in whom ultrasound showed a single gland responded better than those with more than one gland (83.3 vs. 30.8% of responders in each group). The procedures performed had a 4.9% complication rate: hematoma, symptomatic hypocalcemia, temporary paresis of the vocal cords. In summary, treatment with PEI is useful for the management of patients with hyperparathyroidism who are on dialysis, and the results achieved are better in patients who have a single gland identified by ultrasonography.
    Nephron Clinical Practice 02/2005; 101(2):c53-7. DOI:10.1159/000086222 · 1.65 Impact Factor
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    ABSTRACT: Here we report on the impact of completely unpurified islet transplantation on the portal vein pressure (PVP) and the hepatic biochemistry in the peritransplant period and on follow-up. Type I diabetic patients underwent simultaneous kidney and islet transplantation. Islets were not purified from the acinar tissue to prevent loss of endocrine mass. Each patient received a mean 521,846 +/- 201,539.4 islet equivalents (7812.1 islet equivalents/kg/recipient). Immunosuppression and peritransplant medication were given according to the Giessen protocol. The islets were injected into the left hepatic lobe through the umbilical vein. PVP was recorded at time 0 and every 5 min throughout cell infusion. Liver function was assessed daily for the first 10 days, and on follow-up. Basal, peak, and final PVP were 12 +/- 3.8, 25.1 +/- 7.9, and 19.5 +/- 6.2 mmHg, respectively (basal vs. final, p < 0.05). Bilirubin, alkaline phosphatase, prothrombin time, and APTT stayed within normal range. Peak aspartate aminotransferase (AST), alanine aminotransferase (ALT), and serum amylase were 109.4 +/- 61.2 IU/L (basal vs. peak, not significant), 79.5 +/- 56.9 IU/L (basal vs. peak, not significant), and 887.5 +/- 153.6 IU/L (basal vs. peak, p = 0.02), respectively. In all cases AST, ALT, and amylase normalized within 6 days posttransplant and remained so on follow-up (longest control, 33 months posttransplant). Although the intrahepatic infusion of unpurified pancreatic islets affects both the portal vein pressure and the hepatic biochemical profile, this effect is transient and does not compromise the safety of the procedure.
    Cell Transplantation 02/2004; 13(1):61-5. DOI:10.3727/000000004772664905 · 3.57 Impact Factor
  • International Urology and Nephrology 02/2003; 35(4):563-4. DOI:10.1023/B:UROL.0000025609.29810.67 · 1.29 Impact Factor
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