[Show abstract][Hide abstract] ABSTRACT: The new Kidney Disease: Improving Global Outcomes (KDIGO) international guidelines on chronic kidney disease (CKD) and the management of blood pressure (BP) in CKD patients are an update of the corresponding 2002 and 2004 KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines. The documents aim to provide updated guidelines on the assessment, management and treatment of patients with CKD. The first guidelines retain the 2002 definition of CKD but present an improved prognosis classification. Furthermore, concepts about prognosis of CKD, recommendations for management of patients, and criteria for referral to the nephrologist have been updated. The second guidelines retain the <130/80mmHg BP target for patients with CKD presenting with increased albuminuria (albumin/creatinine ratio in an isolated urine sample 30-300mg/g) or proteinuria (albumin/creatinine ratio in an isolated urine sample >300 mg/g) but recommends a less strict BP target of <140/90mmHg in patients with normal albuminuria. The development of the guidelines followed a predetermined process in which the evidence available was reviewed and assessed. Recommendations on management and treatment are based on the systematic review of relevant studies. The GRADE system (Grading of Recommendations Assessment, Development and Evaluation) was used to assess the quality of evidence and issue the grade of recommendation. Areas of uncertainty are also discussed for the different aspects addressed.
Nefrologia: publicacion oficial de la Sociedad Espanola Nefrologia 03/2014; 34(3). DOI:10.3265/Nefrologia.pre2014.Feb.12464 · 1.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The causes of the high cardiovascular mortality observed in chronic kidney disease (CKD) are unknown. Here, we report data on prevalence of subclinical atherosclerosis in the NEFRONA population and a stratified multivariate logistic analysis of factors associated with the presence of plaque.
We analysed 2445 patients with an estimated glomerular filtration rate (eGFR) <60 mL/min (CKD 3: 937; CKD 4-5: 820; CKD 5D: 688) and 559 non-CKD subjects (eGFR >60 mL/min), 18-75 years old, without previous cardiovascular events. An itinerant team of professionals performed carotid and femoral arterial ultrasound.
The already high prevalence of plaques in CKD 3 is even higher in more severe CKD. Multivariate logistic analysis showed that, at any CKD stage, age and being male are independently associated with the presence of plaques. In CKD 3, there was a significant interaction of the smoking status and triglycerides levels which were independently associated with the presence of plaque. Furthermore, being diabetic was also associated with the presence of subclinical atherosclerosis. In stage 4-5 there was a significant association with smoking, high phosphate and hsCRP levels. In dialysis patients, being diabetic, having low levels of 25(OH)-vitamin D3 and smoking status also showed a significant association with the presence of plaque. Furthermore, the association of phosphate levels with the presence of subclinical atheromatosis showed a U-shaped curve.
This analysis demonstrates the magnitude of subclinical atheromatous disease in a large CKD population. The patient characteristics associated with the presence of plaque differ in every CKD stage.
[Show abstract][Hide abstract] ABSTRACT: Background and aims: SureClick® is a prefilled pen for administration of darbepoetin alfa (DA) that is ready-to-use. We explored patient satisfaction with SureClick® compared with prefilled syringes (PFS). Methods: Multicenter, prospective, 6-months, observational study in non-dialyzed patients with chronic kidney disease (CKD) treated with DA in PFS who switched to SureClick® at baseline. Main outcomes were: change in Anemia Treatment Satisfaction Questionnaire (ATSQ-S), Perceived Competence for Anemia Scale (PCAS) and self-administration rate. Results: We enrolled 132 patients with a mean(SD) age of 71.3 (14.6) years, 57.6% women. Mean(SD) ATSQ-S scores at baseline and final records were 25.5 (7.9) and 31.6 (4.9) (on a scale from 0 to 36 –maximum satisfaction-, mean change: 6.2, 95%CI: 4.6-7.8, p<0.0001). The PCAS also increased significantly (4.3 (2.0) vs 5.6 (1.6), on a scale from 1 to 7 –maximum competence, p<0.0001). At baseline 47.7% of patients self-administered DA with PFS, vs 74.2% with SureClick® (p<0.001). No significant changes in hemoglobin were observed (11.4 (0.5) vs 11.6 (1.3) g/dl, p=0.193). Two patients (1.5%) had adverse reactions to SureClick® (pain on application). Conclusions: Our results suggest that the change from PFS to SureClick® could increase patient satisfaction and perceived competence in anemia management in non-dialyzed CKD patients, and could increase the self-administration rate, thereby reducing use of health resources.
Nefrologia: publicacion oficial de la Sociedad Espanola Nefrologia 03/2013; 33(2):214-222. DOI:10.3265/Nefrologia.pre2012.Oct.11535 · 1.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: In 2007, the Spanish Society of Family and Community Medicine (semFYC) and the Spanish Society of Nephrology (S.E.N.) created a consensus document in order to reduce the variability in clinical practices for the detection, treatment, and referral of cases of chronic kidney disease (CKD). Objectives: To evaluate the level of awareness, dissemination, agreement, and application of the S.E.N.-semFYC consensus document on chronic kidney disease. Method: Ours was a cross-sectional, descriptive, and observational study carried out among 476 primary health care doctors and nephrologists using a survey. Results: Of the 326 primary care doctors and 150 nephrologists surveyed, 51.1% and 89.6% respectively knew of the consensus document. A total of 70.8% of nephrologists considered the document to be highly necessary, and were very much in agreement with the content. Primary care doctors placed more value on the practical usefulness of the document (63.2% AP vs. 52.1% nephrologists).The sections that reported the greatest level of unfamiliarity among primary care doctors (>20% of those surveyed) included recommendations regarding the suitability of ultrasound examinations in male patients with CKD older than 60 years of age and in regards to the criteria for patient referral to the nephrology department. The level of application of the recommendations set forth in the document varied widely between the two specialties, with greater compliance among nephrologists. Age, sex, field of medicine, professional experience, the population treated, and health care workload were not significantly associated with differences in awareness, perceived need, or application of the consensus document. Conclusions: This survey demonstrates that the level of implementation of the S.E.N.-semFYC consensus document for CKD has much room for improvement, above all among primary care physicians. The application of this consensus document can improve clinical practice. Several critical aspects have been identified in the evaluation and referral of patients with CKD that must be addressed through the establishment of strategies for disseminating information and continued training for the scientific societies involved in treating these patients.
Nefrologia: publicacion oficial de la Sociedad Espanola Nefrologia 11/2012; 32(6):797-808. DOI:10.3265/Nefrologia.pre2012.Sep.11367 · 1.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We presented a clinical case of a patient affection of secondary chronic renal insufficiency to renal poliquistosis of the carrying adult of a renal graft of cadaver that after the cyclosporin conversion to sirolimus, displays sn erythematous injury, nonpruirginosa, that yilds after the retirement of the drug. We valued the farmacoterapia of sirolimus in the transplant and made a review medical literature.
Gaceta Medica de Bilbao 12/2004; 101(3):97–99. DOI:10.1016/S0304-4858(04)74477-7
[Show abstract][Hide abstract] ABSTRACT: 18 hilabetez hemodialisi bidez tratatutako nefropatia lupiko terminal kasu bat aurkezten dugu, giltzurrun-funtzioaren berezko suspertze partzialarekin. Halaber, literatura biomedikoaren berrikuspena ere egiten dugu.
Gaceta Medica de Bilbao 12/2004; 101(1):29–31. DOI:10.1016/S0304-4858(04)74459-5
[Show abstract][Hide abstract] ABSTRACT: Secondary hyperparathyrodism (SH) is an early manifestation of chronic renal failure (CRF), which has serious complications. Moreover, treating SH is not a risk-free process. Once in its advanced state, it is extremely difficult to reverse and therefore it is critical an early intervention and prevention. An excess of phosphorus and a deficit of calcium and calcitriol are key factors in the evolution of SH. Despite the fact that plasma phosphorus levels remain normal until an extremely advanced stage of CRF, and even apparent hyperphosphatemia in mild CRF, it has been shown that restricting dietary levels of protein and phosphorus impedes the progression of SH. A decrease of protein in the diet also decreases the amount of calcium, thus the calcium levels must be supplemented in order to prevent their deficit. In addition to that slightly diminished levels of calcitriol can be observed in the early stages of CRF, thus it is logical to provide this hormone. However, administering calcitriol may induce hypercalcemia and hyperphosphatemia, which in turn risks the onset of cardiovascular calcifications and complications. Therefore, the calcitriol dosage should be small and then adjusted according to the degree of SH. Neither the PTH levels nor alterations in the phospho-calcium metabolism follow a linear increase appropriate to the decrease in renal function, therefore we propose a treatment strategy which adapts to the different degrees of renal failure.
Nefrologia: publicacion oficial de la Sociedad Espanola Nefrologia 02/2003; 23 Suppl 2:57-63. · 1.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Valuation of doxazosin, system formulation modified, in the hypertension in the hemodialysis population.
Arterial Hypertension (AHT) has been studied in 77 patients (p) subjected to hemodialysis (HD). Mean age (mag) was 61 years (y), range 84y-25y; 66% were males. The underlying etiology was glomerular in 19%, tubulo-interstitial in 18%, congenital in 18%, vascular in 19% and diabetic in 26%.
Doxazosin (system formulation modified, single daily dose (4 mg), treatment follow-up was completed in 16 patients subjected to HD for 24 weeks (wk).
It is concluded that AHT is of great importance in HD, and can be adequately controlled with the new antihypertensive drugs. In this context, doxazosin affords excellent therapeutic control, efficiency and good pharmacological tolerance.
Anales de medicina interna (Madrid, Spain: 1984) 05/2002; 19(4):176-8.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to find out the relationship between body iron stores and serum aluminum levels among 82 stable CAPD patients. The influence of other factors such as time on CAPD and residual renal function was also considered. Thirty-three patients received aluminum hydroxide as a phosphate binder, and they had significantly higher aluminum levels (36.45 microg/l) than the patients who were not taking aluminum preparations (17.2 microg/l, p = 0.001). A statistically-significant correlation between serum aluminum levels and residual renal function and time on CAPD was also observed (p <0.05). However, there was no relationship between serum aluminum levels and serum iron, ferritin and transferrin saturation, neither between body iron stores and total excretion of aluminum (p >0.05). In previous reports, low serum iron levels were associated with high serum aluminum concentration among hemodialysis patients. However, this effect was not observed in the CAPD population under study. The highest risk of hyperaluminemia was found in the patients who were taking aluminum hydroxide, had worse residual renal function and had been longer on CAPD.
[Show abstract][Hide abstract] ABSTRACT: The i-PTH response to changes in the peritoneal calcium balance was studied prospectively in a group of 13 stable CAPD patients, who presumably had adynamic bone disease, with low or normal i-PTH values and low aluminum in plasma. Five days after the reduction of dialysate calcium concentration from 1.75 mmol/l to 1 mmol/l, there was a significant elevation in the serum i-PTH. These increased PTH levels returned to baseline values when patients were changed to the 1.75 mmol/l Ca solution (p = 0.004). The changes in i-PTH mirrored the changes in peritoneal calcium balances. These results support the notion that the low or normal levels of i-PTH frequently seen in peritoneal dialysis patients are due to the hypercalcemic effects of the standard peritoneal dialysis solutions; in these patients, the parathyroid hormone production is normal since negative peritoneal balances of calcium are associated with an increase in serum i-PTH.
[Show abstract][Hide abstract] ABSTRACT: Diabetic patients on dialysis have lower levels of parathyroid hormone (PTH); however, there is no data regarding PTH levels with different degrees of chronic renal failure (CRF). We compared 58 diabetic patients with different degrees of CRF with 268 non-diabetic patients with CRF (serum creatinine >1.2 mg/dl). In both groups, we investigated the main biochemical parameters together with plasma calcium, phosphorus, magnesium, PTH and calcitriol. Diabetic patients showed lower levels of PTH than non-diabetics (P=0.003). The differences were observed in patients with creatinine clearance <70ml/min. We also observed differences in phosphorus, magnesium and tubular resorption of phosphate. In the group of diabetic patients, serum glucose correlated inversely with PTH. Our study suggests that poor control of diabetes (hyperglycaemia) may play a role in the pathogenesis of the hypoparathyroidism observed in patients with diabetes and CRF.
[Show abstract][Hide abstract] ABSTRACT: Secondary hyperparathyroidism (HPT) develops early in chronic renal failure (CRF) at a time when plasma calcitriol levels are normal. At this time, PTH are higher than normal controls and serum phosphorous levels are lower. A decrement in total serum Ca is noted, after an oral phosphate load, only in patients with ERF. These data suggest that factors, other than a decrease in calcitriol synthesis, may be involved in the pathogenesis of HPT. A hypothesis is forwarded suggesting that an alteration in the newly cloned calcium sensor receptor may be the earliest abnormality in the HPT, preceding a decrease in plasma calcitriol levels.
[Show abstract][Hide abstract] ABSTRACT: Candida peritonitis was treated with fluconazole in ten continuous ambulatory peritoneal dialysis (CAPD) patients without immediate removal of the peritoneal catheter. Shortly prior to diagnosis, six patients (60%) had received broad-spectrum antibiotics. Gram stain of peritoneal fluid detected yeast in 70% of cases. In eight patients the peritoneal dialysis catheter was removed within one week of diagnosis because of clinical deterioration. In the majority of cases (90%), candida peritonitis resolved only after catheter removal in spite of ongoing fluconazole therapy. Fluconazole was well tolerated by all patients.
[Show abstract][Hide abstract] ABSTRACT: We have developed a catheter extension/continuous ambulatory peritoneal dialysis (CAPD) set (ANDY high flow set) of larger lumen (minimum internal diameter 3.25 mm), and compared peritoneal dialysate flow rates in two groups of 6 stable CAPD patients of comparable age, sex distribution, and time on dialysis according to type of catheter. Both groups were studied with two different extension/sets, standard ANDY and ANDY high flow set. The shortest infusion time was observed with the combination Cruz catheter/ANDY high flow set. The switch to a high flow set decreased significantly the inflow time of both types of catheter, and the infusion time of the Tenckhoff catheter/ANDY high flow combination approximated that of the Cruz/ANDY combination. Likewise, the dialysate outflow rates were highest with the Cruz catheter/ANDY high flow set than with any other catheter/set combination (p = 0.005). This was apparent, not only in the total outflow time, but also in the vol/min during the first 4 min (p = 0.005). None of the patients experienced discomfort during the dialysis exchanges with the high flow system. This combination of Cruz catheter/high flow set effectively reduces the dialysis exchange time and is very much appreciated by the patients.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/1994; 10:218-21.
[Show abstract][Hide abstract] ABSTRACT: One hundred and fifty calcium (Ca) balance studies were performed in 50 patients treated with CAPD using dialysate with a 1.75 mmol/l (7 mg/dl) Ca content, in order to calculate the peritoneal balance of Ca by measuring the Ca in all the effluent for a 24-h period, and looking at the influence of serum ionized Ca and the ultrafiltration rate in the calcium balance. Of the 150 balance studies, 77 were made using four exchanges of dialysate per day and 73 using three exchanges per day. The serum ionized Ca was 1.17 +/- 0.09 mmol/l, the ultrafiltration 844 +/- 723 ml/day and the peritoneal Ca transfer 39 +/- 46 m/day. The net Ca abortion with four exchanges was less than that with three exchanges per day. There was a strong negative correlation between the peritoneal Ca absorption and the ultrafiltration (r = -0.7, P < 0.00001) and with the ionized Ca (r = -0.49, P < 0.0001). Thirty-three peritoneal balance studies showed a negative Ca balance and in all 33 cases ultrafiltration was greater than 350 ml/day. We conclude that the peritoneal balance of Ca depends not only on the serum ionized Ca, but also on ultrafiltration. The lesser Ca gain observed with four dialysis exchanges per day is due to greater ultrafiltration rates present in this setting.
[Show abstract][Hide abstract] ABSTRACT: The peritoneal clearance (Kp) and renal clearance (Kr) of beta 2 microglobulin (beta 2 m) were studied prospectively on 50 ESRD patients treated with CAPD, in order to determine the effect of the number of daily exchanges on Kp and to investigate the factors which influence the serum levels of beta 2m. Kr and Kp of beta 2m and creatinine (Cr) were calculated using standard formulae at the initiation of study and again at 6, 12, 18 and 24 months by collecting 24 hour urinary output and dialysate effluent. Kp of beta 2m of patients on 3 exchanges/day was .94 +/- .08 ml/min at the initiation of study and 1.1 +/- .08 at the end. For patients on 4 exchanges/day it was .99 +/- .14 ml/min and 1.1 +/- .12 respectively. There was no significant difference. Serum levels of beta 2m were lower on patients with significant residual renal function (RRF) (17 +/- .9 mg/L) than on patients without RRF (38 +/- 2 mg/L. p = .001). Serum levels of beta 2m correlated inversely with Kr of Cr and beta 2m at the initiation of study and at the end (r = .67 and .77 respectively, p = .0001). We conclude that serum levels of beta 2m correlate inversely with Kr of Cr and are expected to rise as RRF decreases. The combined peritoneal and renal excretion of beta 2m is less than its daily production. The number of dialysis exchanges does not influence Kp of beta 2m.
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis 02/1992; 8:369-72.