Emilio González Parra

Glomerular haematuria, renal interstitial haemorrhage and acute kidney injury.

Macroscopic haematuria of glomerular origin has been associated with acute kidney injury. We report a patient with IgA nephropathy, macroscopic haematuria and acute kidney injury. Systemic anticoagulation may have aggravated haematuria. There was extensive interstitial and intratubular red blood cell extravasation, and interstitial haemosiderin deposits. The abundant presence of macrophages expressing the haemoglobin scavenger receptor CD163 and of cells stained for oxidative stress markers (NADPH-p22 phox and heme-oxigenase-1) in areas of interstitial haemorrhage and red blood cell cast-containing tubules provided evidence for a role for free haemoglobin in tubulointerstitial renal injury in human glomerular disease.

Guía de gestión de calidad del líquido de diálisis (LD) (segunda edición, 2015)

A Best Practice Guideline about Dialysis fluid purity was developed under the leadership of the Spanish Society of Nephrology in 2004. The second edition revised Guideline considered new evidences and International Standard. The Guideline has established recommendations for standards for preparing dialysate: water, concentrates and hemodialysis proportioning systems. This Guideline is based on the ISO13959, European Pharmacopoeia, the Real Farmacopea Española, the AAMI Standards and Recommended Practices, European Best Practice Guidelines for Haemodialysis, literature reviews, according to their level of evidence, and the opinion of the expert Spanish group. Two levels of quality of water were defined: purified water and high purified water (ultra pure) and for dialysate: ultra pure dialysate. Regular use of ultra pure dialysate is recommended for all type of hemodialysis to prevent and delay the occurrence of complications: inflammation, malnutrition, anaemia and amiloidosis. Water, concentrates and dialysate quality requirements are defined as maximum allowable contaminant levels: chemicals (4.1.2), conductivity, microbial and endotoxins (4.1.1): Monitoring frequency, maintenance and corrective actions were specified. Methods of sampling and analysis were described in appendix (anexos). For microbiological monitoring, R2A medium is recommended, incubated during 7-14 days at a temperature of 17-23°C. The dialysate quality assurance process involves all dialysis staff members and requires strict protocols. The physician in charge of hemodialysis has the ultimate responsibility for dialysate quality. All suggestions and questions about this Guideline are wellcome to www.senefro.org.

Atrasentan for the treatment of diabetic nephropathy.

ABSTRACT Introduction: Endothelin-1 (ET-1) is the most potent vasoconstrictor, and is involved in the renal regulation of salt and water homeostasis. When produced in excess in the kidney, ET-1 promotes proteinuria and tubulointerstitial injury. There is great interest in the clinical use of endothelin receptor antagonists (ERAs) in chronic kidney disease (CKD), mainly in diabetic nephropathy (DN). Areas covered: Physiopathological actions of ET-1 on the kidney. Both dual ETAR/ETBR (bosentan) or ETAR specific endothelin antagonists (avosentan and atrasentan, among others), which have progressed to early clinical development, with particular emphasis on atrasentan. Expert opinion: Different phase I and II clinical trials with ERAs in DN, mostly with atrasentan, have shown that these drugs have a marked anti-proteinuric effect on residual proteinuria when administered as add-on therapy in addition to ACEi or ARAII treatment. In the past few years, a series of randomized controlled trials investigating new approaches to DN have provided negative or inconclusive data, or even were terminated due to safety concerns or lack of efficacy. Therefore, we eagerly but cautiously await the results of the ongoing SONAR trial with atrasentan in more than 4,000 patients including assessment of renal and cardiovascular hard-end points (estimated primary completion date, July 2018).

Use of sevelamer in chronic kidney disease: beyond phosphorus control

espanolEl sevelamer es un captor no calcico de fosforo que se utiliza en la ERC avanzada y en dialisis para el control de la hiperfosforemia. Varios estudios experimentales, observacionales y ensayos clinicos han mostrado que el sevelamer tiene efectos pleiotropicos, mas alla del control de la hiperfosforemia, incluyendo acciones sobre la inflamacion, el estres oxidativo, el perfil lipidico y la aterogenesis, la calcificacion vascular, la disfuncion endotelial y la disminucion de diversas toxinas uremicas, todo lo cual seria la base biologica de su efecto global sobre la morbilidad y la mortalidad cardiovascular en pacientes con enfermedad renal cronica. En esta revision, se hace enfasis en estas acciones pleiotropicas del sevelamer y su impacto en la salud cardiovascular, con la experiencia publicada despues de mas de 10 anos de experiencia clinica EnglishSevelamer is a calcium-free phosphate binder used in advanced chronic kidney disease (CKD) and in dialysis to control hyperphosphatemia. Several experimental and observational studies and clinical trials have shown that sevelamer has pleiotropic effects that go beyond controlling hyperphosphatemia; these pleiotropic effects include acting on inflammation, oxidative stress, lipid profile and atherogenesis, vascular calcification, endothelial dysfunction and decreasing various uremic toxins. All of these represent the biological basis for the global effect of sevelamer on cardiovascular morbidity and mortality in patients with CKD. In this review, we emphasis these pleiotropic actions of sevelamer and their impact on cardiovascular health, with the experience published after more than 10 years of clinical experience.Sevelamer is a non-calcium phosphate binder used in advanced chronic kidney disease (CKD) and in dialysis for hyperphosphataemia control. Several experimental, observational studies and clinical trials have shown that sevelamer has pleiotropic effects, beyond hyperphosphataemia control, including actions on inflammation, oxidative stress, lipid profile and atherogenesis, vascular calcification, endothelial dysfunction and the reduction of several uremic toxins. This is the biological basis for its global effect on cardiovascular morbidity and mortality in patients with chronic kidney disease. This review focuses on these pleiotropic actions of sevelamer and their impact on cardiovascular health, with the experience published after more than ten years of clinical expertise.

Vitamin D and Diabetes in Chronic Kidney Disease

The relation between the kidney and vitamin D is well known. Vitamin D has also been recognized to regulate endocrine pancreatic function; it stimulates pancreatic beta cells proliferation and insulin secretion. And several studies suggest that vitamin D status may have a significant role in glucose homeostasis in general, and on the pathophysiology and progression of metabolic syndrome and type-2 diabetes in particular. The deficiency in vitamin D is associated with a reduced insulin secretion, which might be an important factor for the susceptibility of developing diabetes. Vitamin D has been proposed also as a possible therapeutic agent in the prevention and treatment of type-1 and type-2 diabetes. In diabetic patients at various CKD stages, circulating 25(OH)D levels are negatively correlated with glycosylated hemoglobin (HbA1c) values, which suggests that increasing circulating vitamin levels may have a beneficial effect of the glycemic control. Likewise, the activation of the vitamin D receptor (VDR) can reduce proteinuria and contribute to the nephroprotection. Low circulating 25(OH)D levels in CKD patients have been associated with a higher risk of all-cause mortality and faster progression of kidney disease. Unfortunately, the level of evidence to support 25(OH)D therapy for CKD or diabetes mellitus is low. Several studies of nutritional vitamin D supplementation in patients with CKD and type-2 diabetes are actually ongoing, although their results are not yet available.