Álvaro Molina

High Stable Serum Adiponectin Levels Are Associated with a Better Outcome in Prevalent Dialysis Patients

Aims: Our aim was to evaluate the prognostic value of 2 measurements of serum adiponectin levels for all-cause mortality and cardiovascular (CV) mortality in uremic patients. Methods: We analyzed 184 patients (19–86 years) undergoing peritoneal dialysis (n = 86) or hemodialysis (n = 98). All patients had 2 measurements of serum adiponectin levels (at baseline and after 1 year). Relationships between adiponectin and mortality were studied by means of survival analysis and Cox regression analysis. Results: During a median follow-up time of 31.2 months, 67 patients (36.4%) died, 26 (14.1%) as a result of CV disease. Mean survival time for CV mortality in patients with 1-year adiponectin values in the upper tertile was significantly higher than that found in patients in the middle and lower tertiles. Hazard ratios (HR) for all-cause mortality per SD change were 0.70 (95% CI, 0.50–0.98; p < 0.05) for baseline adiponectin levels and 0.68 (0.49–0.95; p < 0.05) for mean baseline and 1-year adiponectin levels. Mean adiponectin levels were also negatively related with CV mortality [HR 0.43 (0.21–0.86); p < 0.05] and CV events [HR 0.74 (0.55–0.99); p < 0.05]. Conclusions: In this population of dialysis patients, adiponectin seems to behave as a CV protective factor. Patients with high mean adiponectin levels had a better survival rate.

Are low concentrations of serum triiodothyronine a good marker for long-term mortality in hemodialysis patients?

INTRODUCTION Low serum free triiodothyronine (FT3) concentrations have been reported in a high percentage of chronic renal failure patients and have been considered as an independent predictor of mortality in dialysis patients. OBJECTIVE Our aim has been to evaluate the prognostic value of FT3 levels for long-term mortality in stable hemodialysis patients surviving at least 12 months. PATIENTS AND MEASUREMENTS We retrospectively analyzed 89 stable hemodialysis patients (50 males; mean age 67.9 +/- 11.8 years). All patients had a baseline clinical and analytical evaluation. We analyzed the relationship between baseline FT3 and mortality by means of survival analysis (Kaplan-Meier) and Cox regression analysis. RESULTS Mean values of thyroid function test were: thyrotropin (TSH) 2.02 +/- 1.5 microU/ml, free thyroxine (FT4) 1.26 +/- 0.23 ng/dl, and FT3 2.7 +/- 0.4 pg/ml. During a median follow-up time of 33.6 +/- 14.9 (12 - 62) months, 41 patients died. FT3 was similar in patients who died or survived (2.6 +/- 0.5 vs. 2.7 +/- 0.4 pg/ml ns). Kaplan-Meier analysis did not show significant differences in mean survival according to tertiles of FT3. In multivariate Cox regression analysis, FT3 was not a predictor of mortality (RR 0,001; 95% CI; 0.000 to 1.73). CONCLUSIONS These data suggest that low FT3 levels are not predictive for mortality in a subgroup of stable HD patients who could survive more than 12 months.

Las manifestaciones analíticas asociadas a la insuficiencia renal crónica: a partir de qué grado de filtrado glomerular estimado las detectamos en ancianos?

OBJECTIVE A classification of chronic kidney disease (CKD) based on stages of glomerular filtration (GF) has recently been developed. Thus, chronic renal failure (CRF) is based on GF <60 ml/min. Our goal was to study the presence of typical manifestations of CRF in elderly individuals with a GF of <60 ml/min (stage 3-5) and to determine the cut-off value at which GF can be used to detect these manifestations. MATERIAL AND METHODS We performed a cross-sectional study in clinically-stable elderly patients attending the geriatrics and nephrology outpatient department. The estimated GF (GFe) was established with the Cockroft-Gault and abbreviated Modification of Diet in Renal Disease Study (MDRD) formulae. Because these patients had a GF of less than 60 ml/min, they were expected to show the manifestations associated with CRF (anaemia, metabolic acidosis, abnormal bone and mineral metabolism). We evaluated the occurrence of these manifestations and the GF cut-off at which they were detected. To do this, the population was divided into two groups: group A: patients with GFe > or = 30 ml/min (stage 3, N=48); and group B: patients with GFe <30 ml/min (stages 4-5, N=8). RESULTS Seventy percent of the patients had a GFe (MDRD) <60 ml/min (stage 3-5). Despite reduced GF, these patients did not show the typical manifestations of CRF. Group B showed higher plasmatic levels of creatinine, urea, uric acid, and potassium and required treatment with erythropoietin and calcium salts. CONCLUSIONS Many elderly people diagnosed with CKD with the current classification do not show manifestations of CRF. Estimation of the GF in elders should be generalized to correctly adjust medication to renal impairment rather than to classify elders into CKD stage.

Acute Responses of Gastrointestinal Hormones to Both Oral and Parenteral Intradialytic Nutrition

Introduction: Intradialytic nutrition (IDN) has been used to improve the nutritional status of malnourished hemodialysis (HD) patients. Objective: To evaluate the different effects of parenteral IDN (IDPN) and oral IDN (IDON) on nutrition-related gastrointestinal hormones. Patients and Methods: Seven clinically stable HD patients with malnutrition were included. All patients were treated for 1 month with either IDPN or IDON, with a 4-week period of no nutritional support between each type of therapy. On the first day of each nutritional support (IDON or IDPN) we analyzed the acute responses of insulin, ghrelin, and glucagon-like peptide 1 (GLP-1). We compared the areas under the secretory curves (AUC) and the maximum peaks of serum glucose, insulin, ghrelin, and GLP-1. A group of 6 clinically stable HD patients without any type of IDN served as the control group. Results: The acute responses of glucose and insulin to IDN were significantly higher with IDPN than with IDON. The AUC of glucose (602 ± 81 vs. 495 ± 81 mg/dl/h, p < 0.01) and insulin (232 ± 103 vs. 73.8 ± 69 µU/ml/h, p < 0.01) as well as the maximum peaks of glucose (228 ± 41 vs. 177 ± 47 mg/dl, p < 0.05) and insulin (104 ± 46 vs. 29 ± 24 µU/ml, p < 0.01) were significantly higher after IDPN than after IDON. Ghrelin decreased after both IDPN and IDON; however, the decrease was significantly higher with IDPN compared to IDON. The ghrelin nadir was significantly lower in IDPN than in IDON (0.77 ± 0.5 vs. 1.5 ± 0.3, p < 0.05) although the AUC of ghrelin was not significantly different. GLP-1 was significantly increased at 1 h after starting both IDPN and IDON with no significant differences between the groups. Conclusion: IDPN induces a higher increase in serum glucose and insulin levels and a greater reduction in serum ghrelin concentrations compared with an equivalent orally administered nutritional supplement.

Estimacion del filtrado glomerular en personas de 69 anos o mas: concordancia entre diferentes metodos de calculo

MATERIAL Estimation of glomerular filtration rate (eGFR) is the most widely accepted marker of renal function. Precise calculation is not routinely performed in clinical practice. Several methods have been developed for eGFR: creatinine clearance (CCr) calculation or the use of formulae derived from serum creatinine (sCr). The present study aimed to analyze the agreement between distinct methods of calculating eGFR. MATERIAL AND METHODS We performed a cross-sectional study between January and April, 2006 in 32 stable elders, aged 69 years or older, evaluated in a general nephrology unit. eGFR was calculated by CCr (considered the gold standard), Cockcroft-Gault (CG) and Modification of Renal Diet in Disease (MDRD) equations. The Mann Whitney U-test, Spearmans correlation coefficient and the Kappa coefficient were used to compare means and determine the concordance between methods. RESULTS The overall means+/-SD of GFRe for CCr were 36.14+/-16 ml/min (range 11.75-69.6); CG: 37.02+/-16 ml/min (range 13.3-72.3) and MDRD: 45.52+/-16 ml/min (range 19.2-75.36). Variations in eGFR on comparison of methods were CCr and MDRD: -9.37 ml/min (95% CI:-13.85, -4.9); CCr and CG:-2.54 ml/min (95% CI: -6.95, 1.80); MDRD and CG: 9.0 ml/min (95% CI: 5.96, 12). The correlation between the gold standard (CCr) and sCr-derived formulae was r=0.74 for MDRD (P<0.001) and r=0.77 for CG (P<0.001). The Kappa value for CCr and CG was 0.44 and was 0.35 for CCr and MDRD. When patients were classified by stage of chronic renal disease, discrepancies were found according to the method used: stage 5 (eGFR<15 ml/min) was diagnosed in 13.63% with CG while none were diagnosed with stage 5 with MDRD. CONCLUSIONS In the estimation of the renal function in the elderly, eGFRe levels can differ in the same patient according to the method used: in view of the degree of concordance between CG and CCr, this mathematical formula should be used in preference to MDRD.

Evaluation of a polynephron dialysis membrane considering new aspects of biocompatibility.

Purpose The biocompatibility of dialyzers may influence the inflammatory state of hemodialysis patients. This study compares the effect of a high-flux polynephron membrane with other high-flux membranes, helixone and polyamide, on some inflammation biomarkers based on the analysis of circulating mononuclear cells (MC). Methods The study included 47 patients on hemodialysis with helixone and polyamide; 9 formed the control group, without changes in their dialyzers throughout the study, and 38 formed the intervention group, in which their dialyzers were replaced by polynephron. In both groups, blood samples were taken at the beginning of the study before and after hemodialysis session, and at the end of the study 4 months later. In each extraction, biochemical parameters were determined, and MC isolated using Ficoll gradient. Production of reactive oxygen species and the percentage of activated MC (CD14+CD16+) were measured by flow cytometry, and protein levels of heat-shock proteins (Hsp70/Hsp90) studied by Western blot. Results After 1 hemodialysis session with different membranes, no significant differences were observed in the different parameters considered. After 4 months of dialysis with polynephron, a significant reduction in the percentage of CD14+CD16+ and in the β2-microglobulin reduction ratio were found, with respect to helixone and polyamide, without changes in the other parameters analyzed. Conclusions The use of polynephron for 4 months reduces the percentage of CD14+CD16+ compared to helixone and polyamide, suggesting a better profile regarding activation of the inflammatory response. These findings could be explained by a better biocompatibility or an increased reduction of medium-sized toxic molecules.

Otro paciente más con historia natural de nefropatía diabética: ¿dónde estamos y hacia dónde vamos para evitarla?

We present the case of a 79-year-old man with a history of with drugcontrolled hypertension, benign prostatic hyperplasia and chronic kidney disease stage 4 in outpatient nephrology follow-up for 8 months. He underwent surgery for a prosthetic left knee in a local hospital on 18 March 2010, and needed subsequent surgical cleaning for prosthetic infection on April 26, when antibiotic treatment with linezolid and levofloxacin was started. He was discharged on 28 May. The patient maintained treatment with linezolid for 7 weeks. The germ causing the prosthetic infection was unknown.

Contributions of throughfall, forest and soil characteristics to near-surface soil water-content variability at the plot scale in a mountainous Mediterranean area

Soil water-content (SWC) variability in forest ecosystems is affected by complex interactions between climate, topography, forest structure and soil factors. However, detailed studies taking into account the combined effects of these factors are scarce. This studys main aims were to examine the control that throughfall exerts on local spatial variation of near-surface soil water-content and to combine this information with forest structure and soil characteristics, in order to analyze all their effects together. Two stands located in the Vallcebre Research Catchments (NE Spain) were studied: one dominated by Quercus pubescens and the other by Pinus sylvestris. Throughfall and the related shallow SWC were monitored in each plot in 20 selected locations. The main characteristics of the nearest tree and soil parameters were also measured. The results indicated that mean SWC increment at the rainfall event scale showed a strong linear relationship with mean throughfall amount in both forest plots. The % of locations with SWC increments increased in a similar way to throughfall amount in both forest plots. The analyses considering all the effects together indicated again that throughfall had a significant positive effect in both forest plots, while soil litter depth showed a significant negative effect for the oak plot but lower statistical significance for the pine plot, showing a comparable -although more erratic- influence of the organic forest floor for this plot. These results, together with lower responses of SWC to throughfall than expected in rainfall events characterized by low preceding soil water-condition and high rainfall intensity, suggest that litter layer is playing an important role in controlling the soil water-content dynamics. The biometric characteristics of the nearest trees showed significant but very weak relationships with soil water-content increment, suggesting that stemflow and throughfall may act at lower distances from tree trunk than those presented in our study.

Vasculitis asociada a anticuerpo anticitoplasma de neutrófilo en paciente con enfermedad de Crohn en tratamiento con adalimumab

El factor de necrosis tumoral alfa (TNF alfa) es una citocina involucrada en el daño renal, que promueve inflamación glomerular y daño tisular mediado por células T1. La inhibición del TNF alfa es una terapia efectiva para el tratamiento de enfermedades autoinmunes, con efecto favorable en vasculitis asociadas a anticuerpo anticitoplasma de neutrófilo (ANCA). Presentamos el caso de un varón de 54 años, diagnosticado de enfermedad de Crohn (EC) en el año 2003, y en tratamiento crónico con 40 mg de adalimumab subcutáneo cada 15 días, desde el año 2014. Posteriormente desarrolló una artropatía inflamatoria, polineuropatía sensitivo-motora y una neuritis óptica. El paciente acudió a Urgencias por fiebre de más de un mes de evolución, malestar general, astenia y edemas leves en extremidades inferiores. A la exploración física presentaba buen estado general, presión arterial de 135/60 mmHg, frecuencia cardiaca de 65 latidos por minuto, edemas con fóvea y signos de insuficiencia venosa crónica en las extremidades inferiores. El resto de la exploración física fue anodina. La analítica urgente en sangre mostraba hemoglobina de 9 g/dL, hematocrito de 27,1%, creatinina de 3,6 mg/dL (la previa fue de 0,8 mg/dl), proteína C reactiva de 7,9 mg/dl, pH de 7,40, bicarbonato de 19,2 mmol/l y pCO2 de 31 mmHg. En el estudio inmunológico diferido se detectó positividad para ANCA (anti-PR3 positivo, anti-MPO negativo), el resto fue normal. La analítica urinaria mostraba: sodio de 74 mmol/l, potasio de 36 mmol/l, osmolalidad de 437 mOsm/kg; sistemático: proteínas ++, sangre +++ y sedimento con más de 50 hematíes por campo, 10-15 leucocitos por campo y cilindros granulosos. La cuantificación de proteínas en orina de 24 h fue de 1,2 g/día. La radiografía de tórax objetivó una consolidación parenquimatosa en hemitórax derecho y derrame pleural izquierdo. En la ecografía abdominal se encontraron unos riñones hiperecogénicos, sin signos de dilatación pielocalicial. El primer día de ingreso, el paciente presentó esputos hemoptoicos aislados que, junto con anemización y condensación parenquimatosa, hicieron que se sospechara una hemorragia pulmonar, confirmada en TAC de tórax de alta resolución (fig. 1). Ante la sospecha de síndrome pulmón riñón, se inició tratamiento para la hemorragia pulmonar con pulsos de 500 mg de 6-metilprednisolona durante 2 días y se realizó una biopsia renal que demostró la sospecha de una glomerulonefritis extracapilar pauciinmune. Al ser el resultado de los ANCA positivos, se incrementó la dosis de 6-metilprednisolona a 1 g, con otros 2 pulsos, seguidos de 1 mg/kg/día prednisona oral. Además se indicó un pulso intravenoso de 1,2 g de ciclofosfamida. Con estas medidas, el paciente mejoró clínicamente, remitió la expectoración hemoptoica y fue dado de alta con creatinina de 3,2 mg/dl. En nuestra consulta externa, se ha mantenido pauta de 1 mg/kg oral de prednisona, con otros 2 pulsos de 1,2 g mensuales de ciclofosfamida: en el último control analítico presentó una creatinina de 1,7 mg/dl y ANCA (anti-PR3) negativos. Para valorar si la vasculitis era un efecto secundario del adalimumab se solicitaron niveles, que fueron negativos (el paciente ya había recibido un pulso de ciclofosfamida); los anticuerpos frente al adalimumab también fueron negativos. Describimos el caso de un paciente con EC, en tratamiento crónico activo con un agente anti-TNF que, años después, se complicó con una vasculitis ANCA positiva con afectación

Asociación de nefropatía por cambios mínimos y policitemia en un paciente muy anciano

Presentamos el caso de un varón de 85 años que ingresa por síndrome nefrótico a estudio. Entre sus antecedentes personales destacaban: hipertensión arterial, fibrilación auricular, hernia de hiato e hipertrofia benigna de próstata; había sido intervenido de adenocarcinoma colorrectal (año 2006). Sin antecedentes de hábito tabáquico ni de enfermedad pulmonar. Recibía tratamiento habitual con amlodipino 5 mg/día, enalapril 5 mg/día, dabigatrán 110 mg/12 h (desde hacía 10 días), tamsulosina 0,4 mg/día, dutasterida 0,5 mg/día, omeprazol 40 mg/día. En los 5 días previos al ingreso, el paciente había acudido al Servicio de Urgencias en 2 ocasiones por edemas en las manos y los miembros inferiores, y se pautó tratamiento con furosemida 80 mg por vía oral. Sin lograr mejoría clínica acudió por tercera vez a Urgencias, y es cuando se consultó con el Servicio de Nefrología por edemas y sistemático de orina con proteínas +++. En la exploración física el paciente presentaba un aceptable estado general, estaba consciente y orientado, la presión arterial al ingreso era de 126/78 mmHg, la frecuencia cardíaca, de 73 lpm, y la temperatura, de 37 ◦C. La auscultación cardíaca era arrítmica, sin soplos, y la auscultación pulmonar, con crepitantes bibasales. Tenía edemas con fóvea (+++/+++) en ambas extremidades, siendo el resto de la exploración física anodina. En la tabla 1 se presenta la