Francisco Espinoza

Embarazos exitosos en hemodiálisis crónica: experiencia de un único centro

BACKGROUND The frequency of pregnancies during dialysis is increasing. This condition requires changes in the dialysis schedule and nutritional approach. AIM To report the experience in six patients with terminal kidney disease who became pregnant. MATERIAL AND METHODS Retrospective review of medical records of women with terminal kidney disease in dialysis who became pregnant in a period of 27 years. RESULTS We recorded six successful pregnancies among women in hemodialysis treatment aged 32 ± 4 years. The mean dialysis-time per week was 19.5 ± 2.7 hours and Kt/V was 1.55 ± 0.17. The mean systolic blood pressure was 130 ± 13.3 mmHg. The mean packed cell volume of the group increased from 22.7% during pre-gestational stage to 30.2% during third trimester of pregnancy. All patients received an intensive treatment for anemia. The most common symptom of pregnancy was hyperemesis. The mean gestational age (GA) at diagnosis was 13.4 ± 4.7 weeks. All patients had preterm deliveries at a GA of 33 ± 1.7 weeks, and 66% of offspring were appropriate for gestational age. CONCLUSIONS A multidisciplinary approach allows high rate of successful pregnancies during hemodialysis.

Handgrip strength measured by a dynamometer connected to a smartphone: a new applied health technology solution for the self-assessment of rheumatoid arthritis disease activity

OBJECTIVE The aim was to analyse the accuracy of a hand dynamometer connected to a smartphone to assess RA disease activity through the measurement of handgrip strength (HGS). METHODS Eighty-two RA patients participated in this prospective study. Three types of HGS were assessed: power (Po), pinch (Pi) and tripod (T). An interactive mobile application was developed to capture grip measures. A unilinear regression analysis between HGS and DAS28 was performed. A multivariate regression analysis to identify independent variables related to HGS was also conducted. RESULTS Sixty-three patients (76.8%) were female. Mean age was 61.3 years. At baseline, a negative correlation between the three HGS measures and DAS28 score was found, as follows: Po, r = -0.65 (95% CI: -0.76, -0.51, P < 0.001); Pi, r= -0.42 (95% CI: -0.59, -0.23, P < 0.001); and T, r = -0.47 (95% CI: -0.63, -0.29, P < 0.001). In a longitudinal analysis of 32 patients, a negative correlation between ΔPo grip and ΔDAS28 was found (r = -0.76, 95% CI: -0.88, -0.56). Po grip was independently correlated with male sex (95% CI: 1.49, 4.14, P = 0.002), whereas variables inversely correlated with Po grip were disease duration (95% CI: -2.71, -1.34, P = 0.03), patient global assessment (95% CI: -2.41, -1.1, P < 0.001) and CRP level (95% CI: -3.56, -1.08, P < 0.001). CONCLUSION HGS assessed by a hand dynamometer connected to a smartphone represents an innovative health technology solution that could prompt the self-assessment of RA disease activity in an outpatient setting.

Remission-induction therapies for early rheumatoid arthritis: evidence to date and clinical implications

Recent guidelines on rheumatoid arthritis (RA) point to the importance of achieving remission as soon as possible during the course of the disease. The appropriate use of antirheumatic drugs is critical, particularly in early RA patients, before 24 weeks, since this is a ‘window of opportunity’ for treatment to modify disease progression. A treat-to-target strategy added to an aggressive therapeutic approach increases the chance of early remission, particularly in early RA patients. We conducted an overview of current therapeutic strategies leading to remission in early RA patients. We also provide interesting predictive factors that can guide the RA management strategy with regard to disease-modifying treatment and/or drug-free remission.

Efficacy of Tocilizumab in the treatment of Eosinophilic fasciitis: Report of one case

A 43-year-old man was diagnosed with an Eosinophilic fasciitis with cutaneous and articular involvement. The patient experienced an early response with high-dose corticosteroids achieving a global remission of disease. Nevertheless, during the steroids tapering phase, he presented a new flare and subsequently developed a corticosteroid refractory disease. The addition of Methotrexate in monotherapy then associated with an anti-tumor necrosis factor agent did not show any additional benefit. Therefore Tocilizumab, a humanized monoclonal antibody against the interleukin-6 receptor, was initiated achieving an immediate response that persists after 36 months of follow-up. The use of this biological agent allows prednisone withdrawal at 3 months and remission of both articular and cutaneous manifestations at 6 months. This report describes for the first time the efficacy of an anti interleukin-6 agent in Eosinophilic fasciitis treatment.

Daño arterial asociado a la enfermedad renal crónica: evaluación mediante técnicas de laboratorio no invasivo en pacientes hemodializados

BACKGROUND Hemodialysis patients (HD) display high rates of cardiac disease and mortality. The cardiovascular morbidity and mortality of HD patients is attributable in a significant proportion to endothelial dysfunction, arterial stiffness, and vascular calcifications. AIM To measure vascular reactivity in HD subjects and compare them with healthy volunteers. MATERIAL AND METHODS Forty eight non diabetic patients aged 58 ± 4.6 years (29 males) on hemodialysis for a mean lapse of 4.8 years were studied. Arterial stiffness was measured in the radial artery. Pulse wave velocity was measured by noninvasive peripheral arterial tonometry in carotid and femoral arteries. Endothelial function was assessed, measuring reactive hyperemia response after a 5 min period of ischemia. As a control, all values were also measured in age and gender-matched healthy volunteers. RESULTS Arterial stiffness was significantly higher in HD patients than controls (23.9 ± 3.3 and 18.4 ± 3.4% respectively, p < 0.05). HD subjects had an increased pulse wave velocity (10.0 ± 0.8 and 7.6 ± 0.9 m/s respectively, p < 0.05). A reduction in the change in pulse amplitude pressure, as a measure of arterial dysfunction, was only observed in male patients (1.7 ± 0.4 and 2.7 ± 0.4 respectively p < 0.01). CONCLUSIONS Noninvasive assessment of peripheral vascular function may be useful for the identification of patients at risk for late cardiac events.

Púrpura trombocitopénico trombótico con respuesta exitosa a vincristina

Thrombotic thrombocytopenic purpura presents as a multisystemicdisease with thrombocytopenia, microangiopathic hemolytic anemia, fever, neurological andrenal involvement. We report a 24 years-old male presenting with purpura and a generalizedseizure. His blood tests showed an hemolytic anemia, unconjungated hyperbilirubinemia,increased lactated dehydrogenase, thrombocytopenia and impairment of renal function. Hewas initially treated with daily plasmapheresis and steroids without improvement. Due topersistence of the disease, he was treated with two doses of intravenous vincristine in four days,with clinical and laboratory improvement. He was discharged 40 days after the last dose ofvincristine, in good conditions (Rev Med Chile 2007; 135: 1572-6).(Key words: Purpura, thrombocytopenic; Purpura, thrombotic thrombocytopenic; vincristine)

Secreted α-Klotho maintains cartilage tissue homeostasis by repressing NOS2 and ZIP8-MMP13 catabolic axis

Progressive loss of tissue homeostasis is a hallmark of numerous age-related pathologies, including osteoarthritis (OA). Accumulation of senescent chondrocytes in joints contributes to the age-dependent cartilage loss of functions through the production of hypertrophy-associated catabolic matrix-remodeling enzymes and pro-inflammatory cytokines. Here, we evaluated the effects of the secreted variant of the anti-aging hormone α-Klotho on cartilage homeostasis during both cartilage formation and OA development. First, we found that α-Klotho expression was detected during mouse limb development, and transiently expressed during in vitro chondrogenic differentiation of bone marrow-derived mesenchymal stem cells. Genome-wide gene array analysis of chondrocytes from OA patients revealed that incubation with recombinant secreted α-Klotho repressed expression of the NOS2 and ZIP8/MMP13 catabolic remodeling axis. Accordingly, α-Klotho expression was reduced in chronically IL1β-treated chondrocytes and in cartilage of an OA mouse model. Finally, in vivo intra-articular secreted α-Kotho gene transfer delays cartilage degradation in the OA mouse model. Altogether, our results reveal a new tissue homeostatic function for this anti-aging hormone in protecting against OA onset and progression.