Factores asociados a la compensación de la función renal tras la nefrectomía para donación

Introduction

Kidney transplant donors lose 50% of their renal mass after nephrectomy. The remaining kidney compensates for this loss and it is estimated that 70% of the baseline renal function prior to donation is recovered. Factors associated with post-donation renal compensation are not well understood.

Perfil metabolómico diferenciador asociado a la condición de normoalbuminuria en la población hipertensa

Background and aimAlbuminuria is an indicator of sub-clinical organ damage and a marker of cardiovascular risk and renal disease. A percentage of hypertensive patients develop albuminuria despite being under chronic suppression of the renin-angiotensin system (RAS). We previously identified urinary metabolites associated with the development of albuminuria. In this study, we searched for metabolic alterations which reflect different levels within the condition of normoalbuminuria.Patients, materials and methodsUrine from 48 hypertensive patients under chronic RAS suppression was analysed. They were classified according to the albumin/creatinine ratio (ACR) into 3 groups: Normoalbuminuria (<10 mg/g); high-normal (10-30 mg/g in men, or 20-40 mg/g in women); and moderately high albuminuria (microalbuminuria, 30-200 mg/g or 40-300 mg/g, respectively). The metabolome was analysed by mass spectrometry and a correlation analysis was performed between altered metabolite levels and ACR.ResultsOxaloacetate, 3-ureidopropionate, guanidoacetate and malate show significant variation between the normo and micro groups. Additionally, these metabolites are able to differentiate between patients in the normo and high-normal range. A significant correlation between metabolites and ACR was found. Observed variations point to alterations in the energy metabolism already in patients with albuminuria in the high-normal range.ConclusionsThe association between the molecular panel consisting of 3-ureidopropionate, oxaloacetate, malate and guanidoacetate and different levels of albuminuria is confirmed. A metabolic fingerprint was also identified showing variations within the condition of normoalbuminuria allowing an earlier molecular stratification of patients.     

Estrategias de curación de la infección por VIH

The disadvantages of the long-term administration of antiretroviral therapy as well as the huge number of affected persons have placed the cure of HIV as a primary goal of Public Health. HIV may persist in the organism by at least four mechanisms: a latently infected cellular reservoir, the persistent replication of HIV in spite of ART, anatomic sanctuaries, and the immune dysfunction. Several strategies directed against these mechanisms have been developed. With all this, a complete eradication of HIV has been achieved in a patient using the transplantation of haemopoietic stem cells that were resistant to HIV-infection, and there are examples of functional cure either spontaneously (elite controllers) or after antiretroviral therapy (post-treatment controllers). However, no strategies have been successful in reducing the reservoir size, nor in achieving constant, uniform remissions. The failure of isolated strategies makes it likely that the combination of several of them may be the future solution.     

Lo que el clínico debe saber sobre los mecanismos de conexión entre la inflamación y la formación de hueso. ¿Es suficiente el bloqueo de la inflamación para prevenir la osificación?

In spondyloarthropathies, the distinctive evidence of skeletal damage is de novo bone formation in the form of an ossifying enthesopathy, be it axial or peripheral, and bony ankylosis. Biologic therapy that neutralize the tumor necrosis factor have shown to be effective controlling the inflammatory activity of these diseases. However, data from animal models, clinical imaging studies and ecographic data seem to indicate that inflammation and bone formation could be independent processes and that control of inflammation might not be enough to impede the development of ankylosis in these patients. In the osteoblasts’ differentiation and activation that leads to bone formation, the Wnt (wingless) pathway and the bone morphogenic proteins acquire a special role and might be determinant in the onset and progression of enthesopathic ossification, as well as become therapeutic targets. On the other hand, clinical and imaging findings as well as the determination of bone markers support the hypothesis that that ossification is initially related to inflammation as a repair process. These facts are reviewed and the latest theories are exposed, in an attempt to establish a link between inflammation and bone formation.     

Métodos microbiológicos para la monitorización de la limpieza,desinfección y esterilización de dispositivos médicos

The use of reusable semi-critical devices has been extended in current medical practice for both diagnostic and therapeutic purposes. However, reuse of these instruments carries the risk of cross-transmission of microorganisms from one patient to another. The process of cleaning and disinfecting these devices is complex, long, expensive and very error-prone. This paper analyses the epidemiological aspects of infections associated with the reuse of semi-critical devices and the role of the Microbiology laboratory in monitoring the cleaning and disinfecting process through microbiological controls. The recommendations of different scientific societies on the relevance of such controls are reviewed and specific recommendations are proposed for the taking and processing of the samples, interpretation of the results and measures to be taken depending on the results obtained.     

Anticoagulación oral en la enfermedad renal crónica con fibrilación auricular

Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist, amplifying the risk of cardiovascular events and mortality. In patients with CKD stage 3 and non-valvular AF, direct oral anticoagulants (DOACs) have shown, compared to vitamin K antagonists (VKA), equal or greater efficacy in the prevention of stroke and systemic embolism, and greater safety. There are no randomized trials of the efficacy and safety of DOACs and VKA in advanced CKD. On the other hand, observational studies suggest that DOACs, compared to warfarin, are associated with a lower risk of acute kidney damage and generation/progression of CKD. This paper reviews the epidemiological and pathophysiological aspects of the CKD and AF association, the evidence of the efficacy and safety of warfarin and ACODs in various stages of CKD with AF as well as the comparison between warfarin and ACODs in efficacy and anticoagulant safety, and in its renal effects.     

La combinación de la determinación de parámetros bioquímicos del líquido pleural mejora la predicción diagnóstica de la infección pleural complicada/empiema

IntroductionIdentifying infectious pleural effusions (IPE) that will progress to complicated infection or empyema is challenging. The purpose of this study was to determine whether a model based on multiple biochemical parameters in pleural fluid can predict which IPEs will produce empyema.MethodsA prospective study was performed of all cases of IPEs treated in our unit. IPEs were classified as uncomplicated or complicated (empyema). Logistic regression was used to estimate the risk for complicated pleural infection (empyema). A predictive model was developed using biochemical parameters in pleural fluid. Discriminatory power (areas under the ROC curve), calibration, and diagnostic accuracy of the model were assessed.ResultsA total of 177 patients were included in the study (74 with uncomplicated infectious pleural effusion, and 103 with complicated pleural effusion/empyema). The area under the curve (AUC) for the model (pH, lactate dehydrogenase and interleukin 6) was 0.9783, which is significantly superior to the AUC of the individual biochemical parameters alone (0.921, 0.949, and 0.837, respectively; P<.001 using all parameters). The rate of correct classification of infectious pleural effusions was 96% [170/177: 72/74 (97.3%) for uncomplicated and 98/103 (95.1%) for complicated effusion (empyema)].ConclusionThe multiple-marker model showed better diagnostic performance for predicting complicated infectious pleural effusion (empyema) compared to individual parameters alone.     

Impacto pronóstico y factores predictores de la recuperación de la fracción de eyección en pacientes con miocardiopatía dilatada alcohólica

Introduction and objectives

Recovery of left ventricular ejection fraction (LVEF) has been described in alcoholic cardiomyopathy (ACM) after a period of alcohol withdrawal. Nevertheless, the prognostic impact of LVEF recovery in ACM and its determinants have not been studied. We sought to define the role of LVEF improvement in the long-term outcome of ACM and to identify predictors of LVEF recovery in these patients.

Revisión de la enfermedad relacionada con la IgG4

IgG4-related disease is a fibrous-inflammatory process related to immunomodulation. The most commonly affected organs are: the pancreas, bile duct, major salivary glands, lacrimal glands, retroperitoneum and lymphatic ducts.In recent decades, this disease has been recognised as a systemic disorder that includes many single organ disorders, previously unrelated and known as independent entities.The common characteristics shared by the different entities that make up the IgG4-related disease are: raised serum IgG4 levels, alterations in the imaging tests with neoplastic-like swelling of the affected organs, specific histopathological characteristics and in immunostaining, as well as good response to treatment with glucocorticoids.In this work, we will review this pathology with a special emphasis on the characteristics of autoimmune pancreatitis, sclerosing cholangitis related to IgG4 and the involvement of the retroperitoneum, mesenterium and the digestive tract.     

Validación pronóstica según los criterios de la GesEPOC 2017

IntroductionThe Spanish COPD guidelines (GesEPOC) have been recently modified. The aim of this study is to assess this revision and evaluate the prognosis of patients according to the new classification of severity.MethodsA total of 700 COPD patients (83.9% men) were prospectively followed up for a mean period of 5 years in tertiary hospitals in Spain and the USA. Anthropometric data, lung function tests, dyspnea (according to the mMRC scale), BODE and Charlson index were collected. We calculated mortality at 5 years following the risk criteria proposed by the new GesEPOC.ResultsMean age was 66 ± 9.6 years and mean FEV₁% was 59.7 ± 20.2. The proportion of patients in the low-risk group was 40.43%. Patients in the high-risk group had a significantly higher BODE index than those in the low-risk group (2.92 ± 0,66 vs. 0.52 ± 1.91, p < 0.001), while the Charlson index score was similar in both groups. Mortality at 60 months was significantly higher in the high-risk group (31.7% vs. 15.5%, p < 0.001). Dyspnea and FEV₁% were also independent predictors of mortality (p < 0.001), and neither was inferior to the risk classification proposed by GesEPOC.ConclusionsThe new severity index proposed by GesEPOC accurately predicts 5-year mortality. However, dyspnea and FEV₁% have the same strength in predicting mortality.     

Validación del método inverso para la determinación del flujo de acceso con termodilución

IntroductionThermodilution is a widely used method for measuring vascular access flow (Q_A). Among the possibilities of thermodilution, the reverse method (RM) can be beneficial in the execution time, without impact on the dialysis efficacy (K_t). However, it is not a sufficiently studied technique.MethodTransversal study of 117 arteriovenous fistulas. Two Q_A measurements were taken with the method described by the manufacturer (MR) and another with RM. RM is based on the obtention of an inverted recirculation registry at the beginning of the session and a single subsequent recirculation measurement with the lines in normal position. In the concordance analysis, the Bland-Altman method and Cohen's Kappa index were used.ResultsVery good concordance between MR and RM was evidenced for Q_A below 700 ml/min, but it worsens as flow increases. The median variability between the MR measurements (intra-method variability) was 3.4% (?17.13). This value did not differ from the median variability generated between MR and RM (inter-method variability), which was 2% (?14,12) (P = .287). The degree of agreement between the 2 to identify arteriovenous fistulas susceptible to intervention was very good (Kappa = 0.834). The time spent using the RM was significantly shorter (P = .000) without evidence of variations in the K_t of the measurement sessions (P = .201).ConclusionsThe thermodilution RM is valid to determine the flow of the vascular access, especially in Q_A lower than 700 ml/min, with great time savings, simplification of the procedure and without modifying the dialysis efficiency. The variability between the measurement by MR and RM is similar to that of MR. The concordance between methods in identifying potentially pathological arteriovenous fistulas is very good.     

Correlación entre la endoscopia y la ecografía intestinal para la evaluación de la recurrencia posquirúrgica de la enfermedad de Crohn

ObjectiveIntestinal ultrasound is considered to be a valid alternative for the evaluation of post-operative recurrence (POR) of Crohn's disease. The aim of this study is to assess the correlation between ultrasound and endoscopic findings.MethodsPatients with Crohn's disease were retrospectively recruited who had undergone ileocecal resection, and for whom a colonoscopy and intestinal ultrasound had been performed for the detection of POR. Recurrence was assessed using the Rutgeerts score (RS). The ultrasound findings analysed were bowel wall thickness (BWT), parietal hyperaemia using power Doppler, loss of layer pattern and mesenteric fat hypertrophy.ResultsA total of 31 patients were included, of which 15 (48.4%) had no POR (RS < 2b) and 16 (51.6%) had POR (RS ≥ 2b). A statistically significant association was identified between BWT and the presence of endoscopic recurrence (a mean of 2.75 mm vs. 5.68 mm, P>0.001). There was also a statistically significant difference in hyperaemia between the 2 groups (P=0.03). For wall thickness, an area under the ROC curve (AUC) of 92.9% was obtained, and with a cut-off point of 3.4 mm, a sensitivity of 100% and specificity of 86.6%. When comparing with the most frequent biomarkers (fecal calprotectin and serum CRP), a higher AUC was obtained for wall thickness (72.3% and 72.3% vs. 92.9%).ConclusionsIn our experience, ultrasound has high diagnostic efficacy in the detection of POR and can be considered a valid non-invasive alternative to endoscopy.