M Heras

Assessment of glomerular filtration rate in transplant recipients with severe renal insufficiency by Nankivell, Modification of Diet in Renal Disease (MDRD), and Cockroft-Gault equations

Measurement of glomerular filtration rate (GFR) is time consuming and cumbersome. Several formulas have been developed to predict creatinine clearance (CrCl) or GFR using serum creatinine (Cr) concentrations and demographic characteristics. However, few studies have been performed to discern the best formula to estimate GFR in kidney transplantation. In this study, Cockroft-Gault (CG), Nankivell, and Levey (MDRD) formulas were tested to predict GFR in 125 cadaveric renal transplant patients with severe renal insufficiency (GFR less than 30 mL/min per 1.73 m2). The GFR was estimated as the average Cr and urea clearances. The mean GFR estimated by averaged Cr and urea clearances (22.18+/-5.23 mL/min per 1.73 m2) was significantly different from the mean values yielded by the MDRD formula (20.42+/-6.65 mL/min per 1.73 m2, P=.000), the Nankivell formula (30.14+/-11.98 mL/min per 1.73 m2, P=.000), and the CG formula (29.42+/-8.64 mL/min per 1.73 m2, P=.000). The MDRD formula showed a better correlation (R=0.741, P=.000) than the CG (R=0.698, P=.000) and the Nankivell formulas (R=0.685, P=.000). Analysis of differences using the Bland-Altmann method demonstrated that MDRD gave the lowest bias (MDRD: -1.65+/-4.4 mL/min per 1.73 m2; CG: 7.33+/-6.24 mL/min per 1.73 m2; Nankivell: 8.05+/-9.23 mL/min per 1.73 m2) and narrower limits of agreement (Nankivell: -10.41-26.51 mL/min per 1.73 m2; CG: -5.15-19.81 mL/min per 1.73 m2; MDRD: -10.61-7.31 mL/min per 1.73 m2). In transplant patients with severe renal insufficiency, the MDRD equation seems better than the other formulas to estimate GFR.

Significance of age in the survival of diabetic patients after kidney transplantation

Background: In recent years acceptance ofdiabetic patients for renal replacement therapyhas increased. Renal transplantation for Type Idiabetic patients is widely accepted but theappropriate treatment for Type II diabeticpatients is still a matter of dispute. Ourstudy was done to determine whether the age ofType II diabetic patients constituted anadditional risk factor.Methods: We analyzed the outcome of renaltransplantation in 56 diabetic patients, 31Type I and 25 Type II diabetics (we excludedany who had combined kidney-pancreastransplants). We compared them with 51non-diabetic patients who were transplantedbecause of end-stage renal failure due tonephrosclerosis and age-matched to type IIdiabetic patients. We assessed the one- andthree-year patient and graft survival, thequality of renal function, the maincomplications and causes of mortality.Results: The overall one- and three-yearpatient survival was 69% and 60% in Type IIpatients; 73% and 69% in Type I diabetespatients and 88% and 80% in patients withnephrosclerosis. The overall one- andthree-year actuarial graft survival was 50%and 38% in patients with Type II disease and58% and 50% in Type I diabetes, and 76% and64% in nephrosclerosis. The main cause ofgraft loss in all groups was death (withfunctioning kidney) due to infections andcardiovascular complications.Conclusions: Diabetes itself is the mostimportant variable in patients who have poorresults after kidney transplantation.Increasing age increases slightly the risk forpoor graft and patient survival. Both groups ofdiabetic patients have poorer results thancontrols but in this comparison age was anindependent factor.

Hemodiafiltration with On-Line Endogenous Reinfusion

Paired filtration dialysis is a modified form of hemodiafiltration with a double-chamber hollow fiber. Convection is separated from diffusion, eliminating the potential risk of backfiltration (which can contain endotoxin or cytokine-inducing substances).The regeneration of high volumes of plasma ultrafiltrate obtained in the first filter allows a large plasma volume to be treated, and at the same time enables the return of many beneficial substances such as hormones, small peptides and many vitamins. Ultrafiltrate is regenerated with a charcoal-resin device and reinfused to the patient. Hemodiafiltration with on-line endogenous reinfusion is an easy and safe procedure. In addition, the method avoids risks associated with exogenous fluid infusion (endotoxin, pyrogens), allows exchange at no extra costs of large volumes of fluids and reduction in storage of fluid bags. Clinical advantages also include infusion of physiological fluid containing bicarbonate and calcium, good clinical tolerance and cardiovascular stability.

Past, present and future of erythropoietin Use in the elderly

More than a decade has passed since the firstpatient with end-stage renal failure wastreated with erythropoietin (EPO) and more than85% of patients now receive thistherapy. In the year 2002 more than 60% ofdialysis patients will be elderly, and thetreatment of anemia will be more complex due tothe aditional causes: folate, iron and vitamindeficiency in this population.Correction of anemia with EPO brings aboutpartial regression of left ventricularhypertrophy and some data suggest that suchtreatment reduces cardiovascular mortality inpatients without advance cardiac disease.Normalization of hematocrit with EPO increasesoxygen supply to the brain tissue withimprovement in brain function. The improvementin the ability to recognize, discriminate andhold stimuli in memory for difficult tasks isparticularly important for elderly people.No differences have been noted in the incidenceof clotting of vascular access in patientstreated with EPO compared with hemodialysispatients not so treated. Also no one hasdemostrated that treatment with EPO acceleratesrenal decline in patients with progressiverenal insufficiency.In elderly people with anemia secondary toadvanced renal failure, EPO therapy improvesphysical, cognitive and sexual function, andhealth related quality of life.

Comparación de los sistemas de clasificación del fracaso renal agudo en la sepsis

BACKGROUND Since 2004, various criteria have been proposed to define and stage acute kidney injury (AKI). Nevertheless, fixed criteria for assessing severe sepsis-related AKI have not yet been established. OBJECTIVES To assess the ability of the different AKI classification methods to predict mortality in a cohort of patients with sepsis. METHODS A prospective study of patients>18 years with septic shock admitted to the intensive care unit (ICU) of our hospital from April 2008 to September 2010 was conducted. Plasma creatinine levels were measured daily in the ICU. Patients were classified retrospectively according to RIFLE, AKIN, KDIGO and creatinine kinetics (CK) criteria. RESULTS The AKI rate according to the different criteria was 74.3% for RIFLE, 81.7% for AKIN, 81.7% for KDIGO and 77.5% for CK. AKI staging by RIFLE (OR 1.452, P=.003), AKIN (OR 1.349, P=.028) and KDIGO criteria (OR 1.452, P=.006), but not CK criteria (OR 1.188, P=.148) were independently related to in-hospital mortality. CONCLUSIONS A high rate of patients with severe sepsis developed AKI, which can be classified according to different criteria. Each stage defined by RIFLE, AKIN and KDIGO related to a higher risk of in-hospital mortality. In contrast, the new CK criteria did not relate to higher mortality in patients with severe sepsis and this classification should not be used in these patients without further studies assessing its suitability.

Model of a Telematic Network for Communication Between Centers in a Kidney Transplant Area

LUID transfer of information between a transplant center and the peripheral centers (where patients are dialyzed and pretransplant follow-up is performed) is crucial for optimal functioning of a transplant program. Updated information about a patient’s condition is essential at the time of recipient selection, with regard to cardiovascular events, recent transfusions, infections or other complications, hospital admissions, and so on. This information is usually transmitted to the transplant center via normal mail with a considerable delay, in addition to other inherent problems. The development of a communication system with on-line transmission of information to the transplant center might considerably improve the performance and accuracy of organ allocation and recipient selection. We describe the system established at our hospital to communicate with the peripheral centers in our transplant area.

Insuficiencia renal aguda (II). Manifestaciones clínicas. Historia natural. Manejo terapéutico

Manifestaciones clinicas. El diagnostico de la insuficiencia renal aguda (IRA) se basa habitualmente en el analisis seriado de la urea y la creatinina plasmatica ? Algunos parametros analiticos pueden ser de ayuda para distinguir entre IRA pre-renal y necrosis tubular aguda (NTA) ? En la IRA, ademas de las variaciones en el volumen urinario, se pueden encontrar distintos problemas clinicos: sobrecarga de volumen, trastornos electroliticos y acido-base y la uremia ? La ecografia abdominal es un elemento diagnostico fundamental en todos los pacientes con IRA. Historia natural. Clasicamente, la evolucion de la NTA se ha dividido arbitrariamente en las fases de iniciacion, mantenimiento y recuperacion, siendo la aparicion de poliuria el marcador de comienzo de la fase de recuperacion. Medidas preventivas. La aparicion de IRA se puede prevenir en algunos pacientes prestando una atencion cuidadosa al mantenimiento adecuado de la volemia y del gasto cardiaco y evitando los farmacos nefrotoxicos. Factores higienicos. En los pacientes con IRA se deben extremar las medidas higienicas habituales. Tratamiento. La IRA pre-renal revierte rapidamente al recuperar la perfusion renal, ? Para tratar la IRA post-renal es fundamental la desobstruccion precoz del tracto urinario ? El manejo de la IRA por NTA se basa en la prevencion y tratamiento de las distintas complicaciones de la uremia, hasta que la funcion renal se recupera espontaneamente ? Ningun agente reduce la aparicion de NTA, la necesidad de dialisis ni la mortalidad ? No hay reglas absolutas para decidir cuando hay que iniciar dialisis en la IRA, pero si se conoce que el tratamiento debe iniciarse antes de que aparezcan las complicaciones de la uremia. Manejo de farmacos. En el manejo de la IRA es fundamental revisar completamente los medicamentos prescritos, suspendiendo todos los farmacos que no sean esenciales y ajustando las dosis o el intervalo entre dosis de todos los que se eliminen por via renal.