Gloria Ruiz-Roso

Therapeutic variability in adult minimal change disease and focal segmental glomerulosclerosis

Background Variability in the management of glomerulonephritis may negatively impact efficacy and safety. However, there are little/no data on actual variability in the treatment of minimal change disease (MCD)/focal segmental glomerulosclerosis (FSGS) in adults. We assessed Spanish practice patterns for the management of adult nephrotic syndrome due to MCD or FSGS. The absence of reasonably good evidence on treatment for a disease often increases the variability substantially. Identification of evidence–practice gaps is the first necessary step in the knowledge-to-action cyclical process. We aim to analyse the real clinical practice in adults in hospitals in Spain and compare this with the recently released Kidney Disease: Improving Global Outcomes clinical practice guideline for glomerulonephritis. Methods Participating centres were required to include all adult patients (age >18 years) with a biopsy-proven diagnosis of MCD or FSGS from 2007 to 2011. Exclusion criteria included the diagnosis of secondary nephropathy. Results We studied 119 Caucasian patients with biopsy-proven MCD (n = 71) or FSGS (n = 48) from 13 Spanish hospitals. Of these patients, 102 received immunosuppressive treatment and 17 conservative treatment. The initial treatment was steroids, except in one patient in which mycophenolate mofetil was used. In all patients, the steroids were given as a single daily dose. The mean duration of steroid treatment at initial high doses was 8.7 ± 13.2 weeks and the mean global duration was 38 ± 32 weeks. The duration of initial high-dose steroids was <4 weeks in 41% of patients and >16 weeks in 10.5% of patients. We did find a weak and negative correlation between the duration of whole steroid treatment in the first episode and the number of the later relapses (r = −0.24, P = 0.023). There were 98 relapses and they were more frequent in MCD than in FSGs patients (2.10 ± 1.6 versus 1.56 ± 1.2; P = 0.09). The chosen treatment was mainly steroids (95%). Only seven relapses were treated with another drug as a first-line treatment: two relapses were treated with mycophenolate and five relapses were treated with anticalcineurinics. A second-line treatment was needed in 29 patients (24.4%), and the most frequent drugs were the calcineurin inhibitors (55%), followed by mycophenolate mofetil (31%). Although cyclophosphamide is the recommended treatment, it was used in only 14% of the patients. Conclusions We found variation from the guidelines in the duration of initial and tapered steroid therapy, in the medical criteria for classifying a steroid-resistant condition and in the chosen treatment for the second-line treatment. All nephrologists started with a daily dose of steroids as the first-line treatment. The most frequently used steroid-sparing drug was calcineurin inhibitors. Cyclophosphamide use was much lower than expected.

Recuperación de la función renal en enfermos tratados con hemodiálisis

The aim of this study was to review all cases of recovery of renal function in chronic haemodialysis patients, observed in the last ten years. During the study period, 218 chronic renal failure patients were managed on haemodialysis for a minimum of 90 days. In 17 cases (8%), it was possible to interrupt dialysis after 95 to 529 days. The probability of renal function recovery was higher in patients with chronic interstitial nephritis (P=.04) or autoimmune diseases (P=.07), as well as in those starting haemodialysis treatment at a frequency of two sessions per week (P=.02). No significant differences in age, gender, glomerular filtration rate at the beginning of haemodialysis treatment, or comorbidity rate were observed. Seven patients returned to haemodialysis treatment after a dialysis-free period of 11 +/- 7 months. Two patients died for reasons unrelated to renal failure treatment, and another patient was moved to another hospital following 35 months without dialysis. The other 14 patients are alive and 8 are dialysis-free, with a monitoring period of 13 to 106 months. The conclusion reached is that there is no reason why residual kidney function should inexorably worsen after the start of haemodialysis treatment, and that functional recovery is possible in some patients.

Incremental Hemodialysis Schedule in Patients with Higher Residual Renal Function at the Start of Dialysis

We present an observational study to evaluate a progressive schedule of dose of dialysis, starting with 2 HD/week, when the renal clearance of urea was equal to or greater than 2,5 mL/min/1,73 m2 and the patient is in a stable clinical situation. From 2006 to 2011, 182 patients started hemodialysis in our center, of which 134 were included in the study. Residual renal function (RRF), Kt/V, eKru, nPCR, hemoglobin, weekly erythropoietin dose, and beta-2-microglobulin were determined at 6, 12, 18, 24, and 30 months after dialysis initiation. Seventy patients (52%) began with the progressive schedule of 2 HD/week and 64 (48%) patients began with the conventional thrice-weekly schedule (3 HD/week). The decline of RRF was lower in the group of 2 HD/week: 0,20 (0,02–0,53) versus 0,50 (0,14–1,08) mL/min/month (median and interquartile range, ). No relationship was found between the decline rate and the basal RRF. Survival analysis did not show differences between both groups. Our experience demonstrates that patients with higher residual renal function may require less than conventional 3 HD sessions per week at the start of dialysis. Twice-weekly hemodialysis schedule is safe and cost-effective and may have additional benefit in maintaining the residual renal function.

Analysis of concordance between the bioelectrical impedance vector analysis and the bioelectrical impedance spectroscopy in haemodialysis patients.

INTRODUCTION The values of body composition provided by the two most commonly used bioelectrical impedance systems in Spain, single-frequency bioelectrical impedance vector analysis (SF-BIVA) and multi-frequency bioelectrical impedance spectroscopy (MF-BIS) are different and not comparable. OBJECTIVE Analyse whether the inter-method variability is due to bioelectrical variables measured by the different monitors, or rather due to the equations used to calculate body volume and mass. Another objective was to determine whether, despite the inter-method variability, the classification of hydration status by the two methods is consistent. MATERIAL AND METHODS Bioelectrical impedance was measured by SF-BIVA and MF-BIS immediately before a dialysis session in 54 patients on haemodialysis. In 38 patients, the study was repeated by SF-BIVA at the end of the same dialysis session. RESULTS Resistance and phase angle values provided by the two monitors at a frequency of 50kHz were consistent. For resistance, variability was 1.3% and the intra-class correlation coefficient was 0.99. For phase angle, variability and the intra-class correlation coefficient were 11.5% and 0.92, respectively. The volume values for total body water, extracellular water, fat mass and body cell mass were biased, with a level of variability that would not be acceptable in clinical practice. The intra-class correlation coefficient also suggested a poor level of agreement. SF-BIVA systems define overhydration or dehydration as a vector below or above the tolerance ellipse of 75% on the longitudinal axis. MF-BIS uses two criteria for pre-dialysis hyper-hydration: overhydration (OH) greater than 2.5 litres, or greater than 15% of extracellular water. The degree of equivalence with the results of the SF-BIVA monitor was better with the second criterion (kappa: 0.81, excellent agreement) than with the first one (kappa: 0.71, acceptable agreement). The MF-BIS system defines post-dialysis normal hydration as a difference between OH and ultrafiltratation volume between –1.1 and 1.1 litres and agreement with the SF-BIVA system for this parameter was acceptable (weighted kappa index: 0.64). CONCLUSIONS The MF-BIS and SF-BIVA systems provide similar readings for bioelectrical parameters, and the wide variation in the quantification of volume and body mass must be attributed to the different equations used for calculation. Furthermore, the criteria used by both systems to define both pre- and post-dialysis hydration have an acceptable level of equivalence.

Efectos de la suspensión de IECA y ARAII en enfermedad crónica avanzada

To the Editor, Renin-angiotensin system inhibition is a commonly used therapeutic measure for slowing the progression of kidney disease in diabetic nephropathy and nephropathies with proteinuria. It has also been established that activation of this system is necessary for maintaining glomerular filtration when renal perfusion is severely impaired, as occurs in ischaemic nephropathy and cases of hypotension and dehydration. In these situations, the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) can deteriorate renal function.

Precaución con el uso de los nuevos antivirales de acción directa para el tratamiento del virus de la hepatitis C en pacientes con enfermedad renal asociada

l virus de la hepatitis C (VHC) y la enfermedad renal crónica ERC) a menudo están vinculados, lo que provoca un aumento ignificativo de la morbimortalidad en estos pacientes. Los uevos antivirales de acción directa (AAD) frente al VHC logran na respuesta eficaz en un corto periodo de tiempo1. Sin mbargo, en pacientes con ERC relacionada con el VHC su uso s bastante escaso. Presentamos una serie de 5 pacientes con ERC y VHC trataos con AAD (tabla 1). Todos los pacientes eran varones, con dades comprendidas entre los 52 y los 57 años, con ERC y iferentes grados de proteinuria y microhematuria. Se realizó iopsia renal solo en un paciente, que fue diagnóstica de gloerulonefritis membranoproliferativa secundaria a vasculitis rioglobulinémica. En el resto de los pacientes se desestimó a realización de biopsia renal porque presentaban elevado iesgo de sangrado (trombocitopenia o tratamiento antiagreante). Cuatro pacientes comenzaron tratamiento con sofosbuvir SOF) y daclatasvir (DAC), mientras que el quinto recibió ratamiento con DAC y simeprevir (SIM). En todos los pacienes se consiguó negativización de la carga viral del VHC en n corto periodo de tiempo (14-30 días), pero se produjo na disminución de la función renal, así como un drástico umento de la proteinuria en los pacientes tratados con l esquema SOF + DAC. El único paciente que había sido iopsiado recibió tratamiento con esteroides y rituximab 375 mg/m2, 4 dosis) 4 semanas después de comenzar el ratamiento antiviral, con lo que consiguió la recuperación e la función renal y disminución de la proteinuria. El paciente