Jose Luis Merino

A retrospective study on outcome of microscopic polyangiitis in chronic renal replacement therapy

BACKGROUND Pauci-immune vasculitis is a heterogeneous disorder with an unfavourable prognosis. Renal involvement is frequently observed in antineutrophil cytoplasm autoantibody (ANCA)-associated small-vessel vasculitis and is an important cause of end-stage renal disease (ESRD). Renal replacement therapy (RRT) is frequently required. Although better prognosis under dialysis is well known, the long-term follow-up of pauci-immune renal vasculitis with RRT is rarely reported. METHODS We described 24 patients with pauci-immune vasculitis and requirement of dialysis who were admitted in our institutions from January 1989 to December 2008. Mean age was 65 ± 12 years at the beginning of dialysis. There were 12 males and 12 females. Patients with Wegeners granulomatosis, Churg-Strauss syndrome or evidence of anti-glomerular basement membrane were excluded. The study group was formed by patients with a diagnosis of necrotizing extracapillary glomerulonephritis and microscopic polyangiitis. RESULTS The distribution according to ANCAs was 14 p-ANCA (58%), 5 c-ANCA (21%) and 5 ANCA-negative (21%) pauci-immune renal vasculitis. Pulmonary renal syndrome (PRS) was observed in 10 patients at the onset of vasculitis. Corticosteroids and daily cyclophosphamide were administered to 18 patients, and one patient had intravenous cyclophosphamide. Five patients received isolated corticosteroid therapy. Early reduction in cyclophosphamide dosage was required in five patients due to leucopaenia. Mean follow-up after first dialysis was 89 ± 66 months (range 2-208). Twenty patients were included in haemodialysis (HD), and four patients were included in peritoneal dialysis (PD). At the end of the study, nine patients had received a cadaveric kidney transplant (KT). Relapses rate after the onset of dialysis was 0.03 episode/patient/year. PRS-associated relapses after beginning dialysis were observed in four patients. Main therapy in relapses was also corticosteroids and cyclophosphamide. Survival rates for year 1, 2 and 5 was 91%, 91% and 85%, respectively. Overall mortality at the end of the study was 31.8%. Five patients died in the PRS group, but only one death was associated with progressive pulmonary fibrosis. Higher mortality was observed in PRS vasculitis present at the onset of RRT (50% vs 16.7%, P = NS). Better outcome in patients who received a renal transplantation was observed (88.8% vs 53.8%, P = NS). Conclusions. Despite a low number of patients in this series, pauci-immune vasculitis prognosis under dialysis seems equal to other causes of chronic kidney disease. This study observed a low rate of relapses after beginning dialysis. Poor prognosis is related to severe complications at the beginning of RRT. Today, kidney transplantation is an important therapeutic option for these patients.

Effects of a Single, High Oral Dose of 25-Hydroxycholecalciferol on the Mineral Metabolism Markers in Hemodialysis Patients

Vitamin D deficiency is common in dialysis patients with chronic kidney disease. Low levels have been associated with increased cardiovascular risk and mortality. We evaluated the administration of a high, single oral dose of 25‐OH cholecalciferol (3 mg of Hidroferol, 180 000 IU) in patients on chronic hemodialysis. The 94 chronic hemodialysis patients with vitamin D deficiency 25 (OH)D <30 ng/mL included in the study were randomized into two groups. Follow‐up time was 16 weeks. Neither the usual treatment for controlling Ca/P levels nor the dialysis bath (calcium of 2.5 mEq/L) were modified. Of the 86 patients who finished the study, 42 were in the treated group and 44 in the control group. An increase in 25(OH)D levels was observed in the treated group that persisted after 16 weeks and was associated with a significant decrease in parathyroid hormone (PTH) levels during the 8 weeks post‐treatment. Baseline 1,25(OH)2D levels of the treated group increased two weeks after treatment (5.9 vs. 21.9 pg/mL, P < 0.001) but gradually reduced to 8.4 at week 16. The administration of a single 3 mg dose of 25‐OH cholecalciferol seems safe in patients on hemodialysis and maintains sufficient levels of 25(OH)D with a decrease in PTH for 3 months.

Implantación de la pauta de hemodiálisis incremental (2 sesiones a la semana) en pacientes que inician tratamiento renal sustitutivo. Experiencia de un centro

La hemodialisis incremental (HDI), con 2 sesiones a la semana, basada en la diuresis residual, es una practica poco extendida. En nuestra unidad la pauta de dialisis incremental ha sido una alternativa para nuestros pacientes. Mostramos los resultados de su desarrollo en nuestro hospital desde marzo de 2008 hasta septiembre de 2014. Material y metodos: Para indicar HDI los pacientes debian presentar una diuresis residual de al menos 1.000 ml/24 h, encontrarse en una situacion de estabilidad clinica, en ausencia de edemas, sin evidencia de hiperpotasemia >6,5 mEq/L ni de fosforemia >6 mg/dl de forma persistente y con una aceptable compresion de cuidados dieteticos. Resultados: En este periodo de tiempo, 25 pacientes han sido incluidos en tecnica incremental, 11 de ellos no cumplieron al menos 6 meses en esta modalidad (5 porque requirieron pasar a 3 HD/semana por motivos clinicos, 5 porque recuperaron funcion renal y uno porque en el momento del estudio no habia cumplido 6 meses en tecnica incremental). El resto de los pacientes (14) cumplieron al menos 6 meses en HDI. Su edad media al inicio de TRS era de 60 ± 16 anos. La permanencia media en TRS fue de 24 ± 21 meses, rango: 74-6, con un tiempo medio en tecnica incremental de 16 ± 18 meses, rango de 74-6 meses. La diuresis residual al ano es de 1.400 ± 300 ml/dia, aunque desciende respecto a la inicial de 2.100 ± 600 ml/dia (p = 0,15). El aclaramiento de urea y la funcion renal residual calculada, basal de 5,7 ± 1,5 vs. 3,5 ± 2,1 ml/min al ano (p = 0,02) y basal de 8,8 ± 2,3 vs. 6,9 ± 4,3 ml/min al ano (p = 0,15), tambien descienden respectivamente. Conclusiones: La HDI puede preservar la funcion renal residual. Es una opcion que debe valorarse al inicio del tratamiento renal sustitutivo y, aunque probablemente no sea aplicable a todos los enfermos, puede ser una alternativa en un grupo seleccionado de pacientes.