Anticoagulación oral en la fibrilación auricular no valvular: ¿son efectivas y seguras las recomendaciones científicas en la práctica clínica diaria?

INTRODUCTION AND OBJECTIVES: To study the efficacy and safety of an oral anticoagulation protocol for the treatment of nonvalvular atrial fibrillation, based on scientific associations' recommendations, in unselected patients seen in daily clinical practice. METHODS: The study included all consecutive patients with permanent nonvalvular atrial fibrillation who attended two outpatient cardiology clinics between February 1, 2000 and February 1, 2002. They were treated according to an anticoagulation protocol based on Spanish Society of Cardiology and American College of Cardiology/American Heart Association/European Society of Cardiology guidelines. Patients were followed up prospectively for major events, such as death, stroke, transient ischemic attack, peripheral embolism and severe hemorrhage, which were recorded by treatment group. RESULTS: A total of 624 patients were included in the study. Those receiving anticoagulation therapy (n=425; 68%) more frequently had hypertension, diabetes and previous embolism as well as a greater number of cardioembolic risk factors (P< .001). Overall, 93% of non-anticoagulated patients received platelet aggregation inhibitors (92% received aspirin). After a median follow-up of 21 months, the probability of an embolic event was lower in anticoagulated patients (0.81% vs 14.04%; P< .001), as was all-cause mortality (3.27% vs 6.42%; P=.003). However, there was no significant difference in the probability of severe bleeding (2.75% vs 2.93%; P=.96). Results were unchanged after adjustment for age, sex, and previous embolic events. CONCLUSIONS: Oral anticoagulation therapy for nonvalvular atrial fibrillation implemented according to scientific associations' recommendations is effective and safe in daily clinical practice.     

Hierro liposomal en la enfermedad renal crónica moderada

Introduction and objectiveThe optimal iron supplementation route of administration (intravenous vs oral) in patients with chronic kidney disease (CKD) not on dialysis is a hot topic of debate. An oral preparation (liposomal iron, FeSu) has recently been developed with high bioavailability and low incidence of side effects. The objective was to evaluate the efficacy of FeSu in patients with stage 3 CKD and gastrointestinal intolerance to conventional oral iron therapy.Material and methodsProspective observational study of patients with stable stage 3 CKD and gastrointestinal intolerance to conventional oral iron therapy. An oral 30 mg/day dose of FeSu was administered for 12 months. The primary outcome measure was haemoglobin increase at 6 and 12 months. Treatment adherence and adverse effects were also evaluated.Results37 patients aged 72.6 ± 14.7 years and with an estimated glomerular filtration rate (eGFR) of 42 ± 10 ml/min/1.73m² were included. 32 patients had received previous treatment with conventional oral formulations, 73% of which exhibited gastrointestinal intolerance with treatment adherence of 9.4%. After 6 months with FeSu, an increase in haemoglobin was observed versus baseline, which was sustained at 12 months (0.49 ± 0.19 and 0.36 ± 0.19 g/dl, respectively, P < .05), despite a significant eGFR decrease of 3.16 ± 1.16 and 4.20 ± 1.28 ml/min/1.73 m² at 6 and 12 months, respectively. None of the patients experienced adverse reactions that required the treatment to be suspended. Adherence was 100% at both 6 and 12 months.ConclusionsFeSu is effective in a cohort of patients with stage 3 CKD with similar characteristics to the general population of moderate CKD patients, with a low rate of adverse reactions and excellent tolerability.     

Nuevos mecanismos implicados en el desarrollo de la enfermedad cardiovascular en la enfermedad renal crónica

Chronic kidney disease (CKD) is a pathology with a high worldwide incidence and an upward trend affecting the elderly. When CKD is very advanced, the use of renal replacement therapies is required to prolong its life (dialysis or kidney transplantation). Although dialysis improves many complications of CKD, the disease does not reverse completely. These patients present an increase in oxidative stress, chronic inflammation and the release of extracellular vesicles (EVs), which cause endothelial damage and the development of different cardiovascular diseases (CVD). CKD patients develop premature diseases associated with advanced age, such as CVD. EVs play an essential role in developing CVD in patients with CKD since their number increases in plasma and their content is modified. The EVs of patients with CKD cause endothelial dysfunction, senescence and vascular calcification. In addition, miRNAs free or transported in EVs together with other components carried in these EVs promote endothelial dysfunction, thrombotic and vascular calcification in CKD, among other effects. This review describes the classic factors and focuses on the role of new mechanisms involved in the development of CVD associated with CKD, emphasizing the role of EVs in the development of cardiovascular pathologies in the context of CKD. Moreover, the review summarized the EVs’ role as diagnostic and therapeutic tools, acting on EV release or content to avoid the development of CVD in CKD patients.     

¿Influyen la estación y el clima en la etiología de la neumonía adquirida en la comunidad?

Introduction

Community acquired pneumonia (CAP) is a highly prevalent pathology whose etiology is determined by the characteristics of the geographic region, and the patient. The study of these features is essential for a proper therapeutic approach. Our aim was to study the changes of the causative agent of CAP brought about by the influence of seasonal and climatic changes in our geographic area.

Patients and method

A prospective and longitudinal study of patients admitted with CAP was done from January 2006 to December 2009. We analyzed demographic data, comorbidities, severity, etiologic agent, complications and mortality. We correlated mean temperature and mean cumulative rainfall for each season with Streptococcus pneumoniae and Legionella pneumophila. Statistical analyses included: Chi squared test, Student's t test for independent samples, variance analysis and Spearman's correlation.

Results

We included 243 patients, 64.6% men and 54.7% over the age of 65. The highest incidence of CAP was in the winter. Streptococcus pneumoniae was the most common causative agent for all seasons except in summer when the main agent was Legionella pneumophila. We observed a significant correlation between the lowest seasonal average temperature and pneumococcal etiology of CAP; inversely, with higher temperatures, Legionella pneumophila was more common. No etiological differences were found by season when related with environmental humidity.

Conclusions

In our area, Streptococcus pneumoniae was the most common etiological agent in winter with low temperatures; in summer, with high temperatures, the most frequent was Legionella pneumophila.     

Bloqueantes del receptor mineralcorticoide en la enfermedad renal crónica

There are many experimental data supporting the involvement of aldosterone and mineralcorticoid receptor (MR) activation in the genesis and progression of chronic kidney disease (CKD) and cardiovascular damage.Many studies have shown that in diabetic and non-diabetic CKD, blocking the renin- angiotensin-aldosterone (RAAS) system with conversion enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) decreases proteinuria, progression of CKD and mortality, but there is still a significant residual risk of developing these events.In subjects treated with ACEi or ARBs there may be an aldosterone breakthrough whose prevalence in subjects with CKD can reach 50%. Several studies have shown that in CKD, the aldosterone antagonists (spironolactone, eplerenone) added to ACEi or ARBs, reduce proteinuria, but increase the risk of hyperkalemia. Other studies in subjects treated with dialysis suggest a possible beneficial effect of antialdosteronic drugs on CV events and mortality. Newer potassium binders drugs can prevent / decrease hyperkalemia induced by RAAS blockade, and may reduce the high discontinuation rates or dose reduction of RAAS-blockers.The nonsteroidal MR blockers, with more potency and selectivity than the classic ones, reduce proteinuria and have a lower risk of hyperkalemia. Several clinical trials, currently underway, will determine the effect of classic MR blockers on CV events and mortality in subjects with stage 3b CKD and in dialysis patients, and whether in patients with type 2 diabetes mellitus and CKD, optimally treated and with high risk of CV and kidney events, the addition of finerenone to their treatment produces cardiorenal benefits.Large randomized trials have shown that sodium glucose type 2 cotransporter inhibitors (SGLT2i) reduce mortality and the development and progression of diabetic and nondiabetic CKD. There are pathophysiological arguments, which raise the possibility that the triple combination ACEi or ARBs, SGLT2i and aldosterone antagonist provide additional renal and cardiovascular protection.     

Recomendaciones para el manejo de la comorbilidad en la práctica clínica en pacientes con espondiloartritis axial

Objectives

To identify priorities among comorbidities in axial spondyloarthritis (AxSpA) and recommend how to follow them from an eminently practical perspective.

Resultados funcionales del trasplante pulmonar en la enfermedad pulmonar obstructiva crónica

IntroductionLung transplantation (LT) is a therapeutic option with controversial results in chronic obstructive pulmonary disease (COPD). We aimed to analyze the outcomes of transplantation in terms of lung function and to identify prognostic factors.MethodA retrospective analysis of 107 patients with COPD receiving lung transplants in the La Fe Hospital between 1991 and 2008 was performed. Preoperative variables, pulmonary function tests before and after LT, surgical procedure variables and long-term monitoring, expressed as mean or percentage, as applicable, were analyzed. Spirometric results before and after LT were analyzed. Linear or logistic regression were used for multivariate analysis depending on the variable.ResultsNinety-four men (87.9%) and 13 women (12.1%) were transplanted, with a mean age ± standard deviation of 52.58 ± 8.05 years; 71% of LTs were double-lung transplantations. Spirometric values improved after LT: FVC: +1.22 L (+34.9%), FEV₁: +1.66 L (+56.7%) and FEF_25-75: +1.85 L (+50.8%); P = .001. This functional improvement was maintained after 5 years only in the group with BODE score > 7 (P = .001). Recipient height, type of LT, use of extracorporeal circulation during the surgical procedure, presence of bronchiolitis obliterans syndrome and the age and cause of death of the donor significantly influenced lung function over time.ConclusionsLT improves lung function in COPD patients. This improvement was maintained at 5 years only in patients with BODE > 7. Double lung transplantation provides better functional results than single-lung transplantation.     

Impacto del consumo de alimentos ultraprocesados en la enfermedad renal crónica

The modern diet is closely linked to the consumption of processed foods, causing an increase in the intake of salt, simple sugars, phosphorus and added potassium. This excess intake is associated with an increased risk of obesity, diabetes, hypertension and chronic kidney disease (CKD). CKD, which according to data from the ENRICA study affects 15% of the population, magnifies its impact due to the higher prevalence of diabetes and hypertension and due to limitations in the management of sodium and phosphorus. The intake of these products far exceeds the established recommendations, assuming 72% of total sodium, 25-35% of phosphorus, 12-18% of potassium and exceeding 10% of the caloric intake in simple sugars. Measures are necessary to reduce their contribution through nutritional advice, labeling review, education campaigns on healthy habits, fees and institutional actions that involve food safety agencies, industry, distribution and scientific societies.     

Aportaciones de las técnicas moleculares en la fase crónica de la Enfermedad de Chagas en ausencia de tratamiento

IntroductionThe chronic phase of Chagas disease (CD) is characterised by a low and intermittent parasitaemia. The Polymerase Chain Reaction (PCR) presents a variable sensitivity in this stage limiting its use as a diagnostic tool. Despite this, the use of PCR in untreated patients can provide information on the parasite behaviour and its presence in peripheral blood.MethodsA timely real-time PCR determination was performed on a cohort of 495 untreated chronic CD patients. Also, a subcohort of 29 patients was followed-up by serial real-time PCR during a period from 8 to 12 months in which they could not have access to the treatment due to lack of supply.ResultsThe positive percentage of real-time PCR in our series was 42%. Nevertheless, real-time PCR positive results were significantly higher in patients with five years or less of residence in Spain (P = .041). The detection of DNA was not related to the existence of cardiac and/or gastrointestinal abnormalities.In the follow-up subgroup, real-time PCR was consistently positive in 13.8% of patients, consistently negative in 31%, and intermittent in 55.2%.ConclusionsThe different real-time PCR results regarding the time of residence suggests the possible relationship of external factors in the parasite presence in peripheral blood. On the other hand, specific host factors may be involved in the behaviour of parasitaemia over time.     

Prueba de marcha de 6 min y ejercicio máximo en cicloergómetro en la enfermedad pulmonar obstructiva crónica, ¿son sus demandas fisiológicas equivalentes?

Background and objectives

The physiological load imposed by the six minute walk test (SMWT) in chronic obstructive pulmonary disease (COPD) patients come from small studies where the influence of disease severity has not been assessed. The aim of the present study was to compare the SMWT with an incremental cardiopulmonary exercise test (CPET) in patients classified by disease severity according to FEV₁ (cutoff 50% predicted).

Patients and methods

Eighty-one COPD patients (53 with FEV₁ ≥50%) performed both tests on two consecutive days. Oxygen consumption (O₂), carbon dioxide production (CO₂), minute ventilation (_E), heart rate (HR) and pulse oximetry (SpO₂) were measured during SMWT and CPET using portable equipment. Dyspnea and leg fatigue were measured with the Borg scale.

Results

In both groups, walking speed was constant during the SMWT and O₂ showed a plateau after the 3rd minute. When comparing SMWT (6th min) and peak CPET, patients with FEV₁ ≥50% showed a greater O₂, but lower values of CO₂,V_E, HR, dyspnea, leg fatigue, and SpO₂ during walking. In contrast, in those with FEV₁ <50% predicted values were similar. Distance walked during the SMWT strongly correlated with O₂ at peak CPET (r=0.78; P=0.0001).

Conclusion

The SMWT is a constant load exercise in COPD patients, regardless of disease severity. It imposes high metabolic, ventilatory and cardiovascular requirements, which were closer to those of CPET in severe COPD. These findings may explain the close correlation between distance walked and peak CPET O₂.     

Actualización en la insuficiencia hepática aguda sobre crónica

Acute-on-chronic liver failure (ACLF) is a recently defined syndrome characterised by acute decompensation of chronic liver disease, associated with organ failures and high mortality. ACLF is a common condition and may affect up to 30% of patients admitted to hospital for cirrhosis complications. Bacterial infections, alcoholism and reactivation of viral hepatitis are the most common precipitating factors in ACLF, although in up to 40% of patients no precipitating factor can be identified. Although the pathophysiology of ACLF is not completely understood, the presence of an excessive inflammatory response appears to play a key role. There is no specific treatment for patients with ACLF and management is based on organ support and liver transplantation. New treatment strategies based on liver support systems and immunomodulatory treatments are being evaluated but existing data are still limited.     

Nuevo enfoque en el tratamiento nutricional de la enfermedad renal crónica avanzada

IntroductionPatients with advanced chronic kidney disease (ACKD) have a high prevalence of malnutrition. The dietary restrictions that we usually apply in terms of macro and micronutrients force our patients to follow dietary guidelines that deviate from healthy patterns.ObjectivesTo determine if a personalized nutritional intervention program, minimizing the usual restrictions would be justified in case it improved the evolution of kidney disease compared to standard treatment.Secondary objectivesTo determine changes in nutrient intakes and in anthropometric and biochemical parameters, as well as quantify episodes of hyperkalemia.Material and methodsA single-center, randomized and controlled educational intervention clinical trial was conduct in patients from the ERCA outpatients clinic at the Complejo Hospitalario Universitario de Albacete. 75 patients were included, assigning 35 to a Control group and 40 to the Intervention group with 1-year follow-up. The nutritional status was determined using anthropometric data, body composition by Bioimpedance, blood and urine biochemical parameters and a 24-h recall questionnaire. The nutritional intervention was carried out in three different ways: individual, collective and telephone recall.ResultsAt the beginning of the study, the BMI showed a situation of weight excess with a mean of 28.83 kg/m² (5.4) in men and 26.96 kg/m² (4.09) in women. 70% of our patients had overweight. The abdominal circumference was 105.3 cm (10.2) and 92.3 cm (13.7) for men and women respectively without significant changes throughout the study. The percentage of fat mass (FM) was high in both groups for men and women throughout the study. We did not find biochemical parameters of malnutrition and only significant differences were observed in glomerular filtration rate (GFR), which increased in the intervention group. No patient presented any episodes of hyperkalemia during the study. The energy intake in both groups showed an inadequate distribution of macronutrients with a poor intake of carbohydrates (CH) that was supplemented with an excess of fat. In the case of micronutrients, we did observe an increase in potassium and fiber intakes with a decrease in sodium and phosphorus in the intervention group.ConclusionsMalnutrition is not exclusively an intake deficit and encompasses both the problems derived from a deficit and an excess of nutrients intake. Un to 70% of our patients showed weight excess and a fat mass higher than desirable. The implementation of an individualized nutritional education program, including a vegetables and fiber rich diet, less atherogenic, not only did not cause electrolyte alterations but also slowed the progression of kidney disease.     

Asociación entre hiperkaliemia y evolución clínica en la enfermedad renal crónica avanzada

IntroductionPatients with advanced chronic kidney disease (CKD) are at greatest risk of hyperkalemia (HK). The relationship between HK and negative outcomes (mortality or progression of renal insufficiency) in non-dialysis dependent CKD patients is controversial.AimsTo determine the incidence, prevalence, and factors related with HK in a cohort of CKD patients, and its relationship with mortality, hospitalization rate, CKD progression, and dialysis initiation.Material and methodsA retrospective, observational study in an incident cohort of adult patients with stage 4 or 5 CKD not on dialysis. Inclusion criteria were: having at least three consecutive estimated glomerular filtration rate (eGFR) measurements in a follow-up period >3 months. Decline in renal function was estimated as the slope of the individual linear regression line of eGFR over follow-up time. HK was defined as serum K levels ≥5.5 meq/l. Associations of HK with outcomes were adjusted for major confounding variables in the multivariate analysis.ResultsThe study group consisted of 1079 patients (574 males, mean age: 65±14 years) with mean baseline eGFR 14.8±4.5 ml/min/1,73 m². Mean follow-up time was 15 months with a median of 7 serum sample determinations per patient. HK was observed at baseline in 26% of patients; in at least one serum sample during the individual follow-up period in 68%; or chronically (>50% of samples) in 33% of patients. By multivariate logistic regression, the best determinants of chronic HK were: male sex (OR = 1.529; 95% CI [1.154-2.025], p = .003), serum bicarbonate (OR = 0.863 [0.829-0.900], p <.0001), diuretic treatment (OR = 0.743 [0.556-0.992], p = .044), and angiotensin converting enzyme inhibitor and/or angiotensin receptor blockers (OR = 4.412 [2.915-6.678], p <.0001). Patients whose serum K levels were in the upper quartile showed a significantly faster CKD progression (?4.05±5.22 vs. ?2.69±5.61 ml/min/1.73 m²/year, p <.0001), and more frequent dialysis initiation (63% vs. 57%, p = .115), though lower mortality (9% vs. 17%, p = .003) and hospitalization rates (2.68±5.94 vs. 3.16±6.77 days per year, p = .301) than the other study patients. However, in the multivariate analysis, average serum K levels were not independently associated with the clinical outcomes investigated.ConclusionHK is a common biochemical finding in non-dialysis dependent CKD patients, mainly associated with prescribed medication. However, HK was not independently associated with major negative clinical outcomes.     

Ferroterapia en el manejo de la anemia en la enfermedad renal crónica no en diálisis: perspectiva del grupo de anemia de la S.E.N

This work presents an update on the management of iron deficiency in patients with chronic renal failure (CRF), either with or without anaemia. A review is made of the recommendations of the guidelines for the treatment of iron deficiency in CRF. It also presents new studies on iron deficiency in patients with CRF, as well as new findings about iron deficiency and its impact on clinical outcomes.Anaemia is a common complication of CRF, and is associated with a decrease in the quality of life of the patients, as well as an increase in morbidity and mortality. Iron deficiency (absolute or functional) is common in non-dialysis chronic renal failure patients, and may cause anaemia or a low response to erythropoiesis-stimulating agents. For this reason, the clinical guidelines for the treatment of the anaemia in Nephrology advise the correction of the deficiency in the presence of anaemia. Iron replacement therapy is indicated in patients with CRF and anaemia (Hb < 12 g/dL) in accordance with the guidelines. There is no unanimity in the indication of iron replacement therapy in patients with Hb>12 g/dL, regardless of whether they have an absolute or functional iron deficiency.Intravenous iron replacement therapy is safe, more efficient and rapid than oral therapy for achieving an increase haemoglobin levels and reducing the dose of erythropoiesis-stimulating agents. For the administration of intravenous iron in non-dialysis chronic renal failure patients a strategy of high doses and low frequency would be preferred on being more convenient for the patient, better conserving of the venous tree, and on being safe and cost-effective. Iron plays an essential role in energy metabolism and other body functions beyond the synthesis of haemoglobin synthesis, for which the iron deficiency, even in the absence of anaemia, could have a harmful effect in patients with CRF. The correction of the iron deficiency, in the absence of anaemia is associated with functional improvement in patients with heart failure, and in muscle function or fatigue in patients without CRF.Despite the evidence of benefits in the correction of iron deficiency in patients with CRF, more studies are required to evaluate the impact of the correction of the iron deficiency in the absence of anaemia on morbidity and mortality, quality of life and physical capacity, as well as the long-term effect of oral and intravenous iron replacement therapy in this population.     

¿Podemos descartar infección congénita por citomegalovirus cuando la reacción en cadena de la polimerasa viral es negativa en la prueba del talón?

Introduction

The detection of cytomegalovirus (CMV) DNA by real time polymerase chain reaction (rt-PCR) in dried blood spots collected routinely for metabolic screening has been assessed for the retrospective diagnosis of congenital CMV (cCMV) infection in many studies, but not in Spain. The aim of this study is to analyze the diagnostic accuracy of this technique in our hospital.

Methods

A cross-sectional retrospective observational study was conducted including all patients born between January, 2007 and September, 2012 with confirmed cCMV infection.The assessment of CMV DNA was made by using rt-PCR in dried blood spots of these patients.

Results

Fourteen patients were included: 4/14 were symptomatic and 4/14 had sequelae. The detection of CMV DNA by rt-PCR was positive in only 7 patients. A statistically significant relationship between low viral load at birth and negative rt-PCR in dried blood spots was demonstrated.

Conclusions

Despite the low number of patients included, our data highlight an important amount of false negative results in the DNA CMV detection by rt-PCR in these samples for the retrospective diagnosis of cCMV infection, especially in cases with low viral load at birth.