Maite Rivera Gorrín

Innovando en la docencia de la biopsia renal ecodirigida

El aprendizaje de la Medicina se ha basado, hasta ahora, en el estudio y en la práctica clínica habitual. La preocupación por la mejora en la seguridad del paciente, por la reducción de las complicaciones en las técnicas invasivas y por la reducción del gasto sanitario ha conducido a la creación de simuladores y modelos experimentales para el desarrollo de habilidades médicas y quirúrgicas en el proceso de enseñanza-aprendizaje. El uso de simuladores en las especialidades quirúrgicas está ampliamente introducido. Sin embargo, en las especialidades médicas que realizan técnicas invasivas, su uso está poco extendido. Este es el caso de la biopsia renal (BR), nuestra técnica invasiva por excelencia, técnica que puede acarrear morbimortalidad para el paciente, y que se aprende, aunque monitorizada por facultativos con experiencia, sobre los propios pacientes1. Existen muy pocos trabajos en la literatura referidos estrictamente a la docencia de la BR2–5. Mrug et al.2 realizan la simulación de la BR con control ecográfico sobre un modelo ex vivo utilizando un riñón de cerdo o vaca introducido en un pavo2, con lo que se consiguen imágenes ecográficas parecidas a las obtenidas sobre el paciente real y las características de resistencia a la penetración de la aguja, tanto en el tejido muscular como en el renal, equiparables a un modelo real. También3 investigaron la utilidad sobre la mejora en la confianza de los residentes en la ejecución de la BR y sobre la tasa de complicaciones hemorrágicas posbiopsia en los 2 periodos (prey postimplantación del simulador). Encuentran una

Creación del Grupo de Trabajo en Nefrología Diagnóstica e Intervencionista de la Sociedad Española de Nefrología

c Departamento de Nefrología «Dr. Gustavo Gordillo Paniagua», Hospital. Infantil de México Federico Gómez, México, D.F., México d Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Infantil de México Federico Gómez, México, D.F., México e Departamento de Endocrinología, Hospital Infantil de México Federico Gómez, México, D.F., México f Departamento de Gastroenterología, Hospital Infantil de México Federico Gómez, México, D.F., México g Laboratorio de Errores Innatos del Metabolismo y Tamiz, Instituto Nacional de Pediatría, México, D.F., México h Departamento de Biología Molecular, Instituto Nacional de Pediatría, México, D.F., México i Departamento de Fisiología, Facultad de Medicina, Universidad Nacional Autónoma de México, México, D.F., Méxicoc Departamento de Nefrología «Dr. Gustavo Gordillo Paniagua», Hospital. Infantil de México Federico Gómez, México, D.F., México d Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Infantil de México Federico Gómez, México, D.F., México e Departamento de Endocrinología, Hospital Infantil de México Federico Gómez, México, D.F., México f Departamento de Gastroenterología, Hospital Infantil de México Federico Gómez, México, D.F., México g Laboratorio de Errores Innatos del Metabolismo y Tamiz, Instituto Nacional de Pediatría, México, D.F., México h Departamento de Biología Molecular, Instituto Nacional de Pediatría, México, D.F., México i Departamento de Fisiología, Facultad de Medicina, Universidad Nacional Autónoma de México, México, D.F., México

Hydrothorax secondary to a malpositioned peritoneal dialysis catheter.

11. Ogunc G. Malfunctioning peritoneal dialysis catheter and accompanying surgical pathology repaired by laparoscopic surgery. Perit Dial Int 2002; 22:454–62. 12. Julian T, Ribeiro U, Bruns F, Fraley D. Malfunctioning peritoneal dialysis catheter repaired by laparoscopic surgery. Perit Dial Int 1995; 15(8):363–6. 13. Latzko W. Postoperative vesicovaginal fistulas: genesis and therapy. Am J Surg 1942; 58(2):211–28. 14. Ansquer Y, Mellier G, Santulli P, Bennis M, Mandelbrot L, Madelenat P, et al. Latzko operation for vault vesicovaginal fistula. Acta Obstet Gynecol Scand 2006; 85:1248–51. doi: 10.3747/pdi.2014.00129

Elección de tratamiento conservador en la enfermedad renal crónica

INTRODUCTION Incidence of use for various renal replacement therapies is well-known, but no data are available on conservative treatment use. OBJECTIVE To assess the proportion of patients with chronic kidney failure receiving a conservative treatment. RESULTS From July 1, 2013 to June 30, 2014, 232 patients with stage 5 CKD were seen in the Nephrology Department. After having received information on existing therapeutic options and having known the opinion of their treating physicians, 81 patients (35%) selected hemodialysis, 56 (24%) preferred peritoneal dialysis, 5 (2%) selected a preemptive transplant from a living donor, and in 90 (39%) a conservative treatment option was selected. In a univariate analysis using logistic regression, variables associated to a preference for conservative treatment were age, Charlson index excluding age, degree of walking difficulties, and functional dependence level, with the first three factors achieving statistical significance in a multivariate analysis. Presence of a severe disease resulting in a poor prognosis was the main reason for selecting a conservative treatment (49%), with the second one being patient refusal to receive a renal replacement therapy (26%). Mortality rate was 8.2/100 patient-months in conservative therapy group versus 0.6/100 patient-months in patients receiving renal replacement therapy (P<.001). In patients receiving conservative therapy, baseline glomerular filtration rate at the time of study enrollment was the sole variable showing a significant impact on survival. CONCLUSIONS About 39% of patients with stage 5 CKD seen over a 1-year period in the Nephrology Department received conservative therapy. Age, co-morbidity, and functional disability were the factors associated to selecting a conservative therapy option.

Diagnostic and Interventional Nephrology in Spain: A snapshot of current situation

Background: Diagnostic and Interventional Nephrology has been a rising field in recent years worldwide. Catheter insertion, renal biopsy, renal ultrasound, and peritoneal dialysis catheter or permanent dialysis catheter insertion are vital to our specialty. At present, many of these procedures are delegated to other specialties, generating long waiting lists and limiting diagnosis and treatment. Methods: An online survey was emailed to all Nephrology departments in Spain. One survey response was allowed per center. Results: Of 195 Nephrology departments, 70 responded (35.8%). Of them, 72.3% (52) had ultrasound equipment, 77.1% insert temporary jugular catheters, and 92.8% femoral. Up to 75.7% (53 centers) perform native renal biopsies, of which 35.8% (19) are real-time ultrasound guided by nephrologists. Transplant kidney biopsies are done in 26 centers, of which 46.1% (12) by nephrologists. Tunneled hemodialysis catheters are inserted in 27 centers (38.5%), peritoneal catheter insertion in 18 (31.6%), and only 2 centers (2.8%) perform arteriovenous fistulae angioplasty. In terms of ultrasound imaging, 20 centers (28.5%) do native renal ultrasound and 16 (22.8%) transplanted kidneys. Of all units 71.4% offer carotid ultrasound to evaluate cardiovascular risk, only in 15 centers (21%) by nephrologists. AVF ultrasound scanning is done in 55.7% (39). Conclusion: Diagnostic and Interventional Nephrology is slowly spreading in Spain. It includes basic techniques to our specialty, allowing nephrologists to be more independent, efficient, and reducing waiting times and costs, overall improving patient care. Nowadays, more nephrologists aim to perform them. Therefore, appropriate training on different techniques should be warranted, implementing an official certification and teaching programs.

Diálisis peritoneal paliativa: implantación de un programa de atención domiciliaria a enfermos tratados con diálisis peritoneal (DP) en situación terminal

Terminal-stage patients on peritoneal dialysis (PD) are often transferred to haemodialysis as they are unable to perform the dialysis technique themselves since their functional capacities are reduced. We present our experience with five patients on PD with a shortterm life-threatening condition, whose treatment was shared by primary care units and who were treated with a PD modality adapted to their circumstances, which we call Palliative Peritoneal Dialysis.