9 research outputs found
Renal Biopsy in Type 2 Diabetic Patients
The majority of diabetic patients with renal involvement are not biopsied. Studies evaluating histological findings in renal biopsies performed in diabetic patients have shown that approximately one third of the cases will show pure diabetic nephropathy, one third a non-diabetic condition and another third will show diabetic nephropathy with a superimposed disease. Early diagnosis of treatable non-diabetic diseases in diabetic patients is important to ameliorate renal prognosis. The publication of the International Consensus Document for the classification of type 1 and type 2 diabetes has provided common criteria for the classification of diabetic nephropathy and its utility to stratify risk for renal failure has already been demonstrated in different retrospective studies. The availability of new drugs with the potential to modify the natural history of diabetic nephropathy has raised the question whether renal biopsies may allow a better design of clinical trials aimed to delay the progression of chronic kidney disease in diabetic patients
Embolismo de arteria renal : algoritmo diagnóstico mediante determinación de lacto deshidrogenasa y opciones terapéuticas /
Consultable des del TDXTÃtol obtingut de la portada digitalitzadaResumen El embolismo de arteria renal (EAR) incluye el diagnostico y las distintas opciones terapéuticas aún no resueltas. En primer lugar los estudios post-mortem han demostrado que el EAR es una patologÃa infradiagnosticada.. Debe sospecharse en pacientes que refieren dolor lumbar, asociado o no a fallo renal y que presentan ciertos factores de riesgo tales como; enfermedad cardiaca embolÃgena, fibrilación auricular o ateromatosis aortica. Sin embargo, cuando la presentación clÃnica es atÃpica y no existen factores de riesgo evidentes asociados durante la presentación del cuadro agudo, el diagnostico puede pasar desapercibido si este diagnóstico no es considerado de forma sistemática. En segundo lugar hay que considerar que existe controversia sobre el tratamiento apropiado en cada situación. Desde la primera publicación con referencia a la enfermedad por EAR citada en la literatura, han sido descritos varios casos, la mayorÃa de forma descriptiva, correspondientes a estudios de carácter retrospectivo en la que los pacientes fueron tratados sin un criterio uniforme pre-definido. No existen en la literatura datos de estudios prospectivos en que los pacientes se hayan tratado con arreglo a un mismo criterio. El presente estudio describe la aplicación clÃnica de un algoritmo diagnóstico, previamente validado, basado en la determinación de Lactato Deshidrogenasa (LDH), que nos permitió identificar a los pacientes con EAR y distribuirlos en los diferentes protocolos de tratamiento. El EAR es una entidad infradiagnosticada que conduce al fallo renal agudo en pacientes con solo un riñón funcionante. Estudiamos de forma prospectiva 41 pacientes, con arreglo a un algoritmo previamente validado. El sÃntoma más frecuente fue el dolor lumbar atÃpico. La fibrilación auricular crónica se detectó en el 65 % de los pacientes. El lugar más frecuente de embolización fue a nivel de la arteria renal principal de un solo riñón. Se practicó cirugÃa de la arteria renal en 13 pacientes, tratamiento fibrinolÃtico en 17 y anticoagulación en 11 pacientes. La media de los valores de LDH fue de 28,16 ± 18,46 µkat/L. La oliguria se constató en 15 pacientes. Los requerimientos de hemodiálisis no fueron distintos entre los pacientes con embolismo de arteria renal principal o intrarrenal o con respecto al tipo de tratamiento empleado. Conclusión Los datos de nuestra cohorte de pacientes confirman que la utilización de un algoritmo diagnóstico, basado en la determinación de LDH en las unidades de urgencias, es útil para identificar a los pacientes con embolismo renal que presentan un cuadro clÃnico atÃpico. Hasta que no dispongamos de estudios clÃnicos randomizados que comparen los resultados de la embolectomÃa versus fibrinolÃticos en el embolismo de al arteria renal principal y la fibrinolisis local versus anticoagulación sistémica en el embolismo intrarrenal, sugerimos la embolectomÃa quirúrgica en aquellos pacientes con embolismo de arteria renal principal y no-contraindicación para la cirugÃa por su capacidad de proporcionar la mejor evolución técnica en el menor tiempo posible. En los casos de embolismo intrarrenal, juzgamos que la indicación de fibrinolisis local debe ser determinada en función de la extensión del embolismo y la severidad del fallo renal. En pacientes con solo un riñón funcionante y múltiples embolismos intrarrenales, el tratamiento local con fibrinolÃticos, es probable que reduzca la duración de la isquemia renal y ayude a la preservación del parénquima renal, por lo que se preconiza como el tratamiento de elección en estos pacientes. En los casos de embolismo unilateral intrarrenal, sin compromiso de la función renal, la elección del tratamiento es más compleja, toda vez que el riesgo asociado a la perfusión intrarrenal de fibrinolÃticos puede sobrepasar el potencial beneficio obtenido con la revascularización
Risk of hyperkalemia in patients with moderate chronic kidney disease initiating angiotensin converting enzyme inhibitors or angiotensin receptor blockers : a randomized study
Background: Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are renoprotective but both may increase serum potassium concentrations in patients with chronic kidney disease (CKD). The proportion of affected patients, the optimum follow-up period and whether there are differences between drugs in the development of this complication remain to be scertained. Methods: In a randomized, double-blind, phase IV, controlled, crossover study we recruited 30 patients with stage 3 CKD under restrictive eligibility criteria and strict dietary control. With the exception of withdrawals, each patient was treated with olmesartan and enalapril separately for 3 months each, with a 1-week wash-out period between treatments. Patients were clinically assessed on 10 occasions via measurements of serum and urine samples. We used the Cochran-Mantel-Haenszel statistics for comparison of categorical data between groups. Comparisons were also made using independent two-sample t-tests and Welch's t-test. Analysis of variance (ANOVA) was performed when necessary. We used either a Mann-Whitney or Kruskal-Wallis test if the distribution was not normal or the variance not homogeneous. Results: Enalapril and olmesartan increased serum potassium levels similarly (0.3 mmol/L and 0.24 mmol/L respectively). The percentage of patients presenting hyperkalemia higher than 5 mmol/L did not differ between treatments: 37% for olmesartan and 40% for enalapril. The mean e-GFR ranged 46.3 to 48.59 ml/mint/1.73 m2 in those treated with olmesartan and 46.8 to 48.3 ml/mint/1.73 m2 in those with enalapril and remained unchanged at the end of the study. The decreases in microalbuminuria were also similar (23% in olmesartan and 29% in enalapril patients) in the 4 weeks time point. The percentage of patients presenting hyperkalemia, even after a two month period, did not differ between treatments. There were no appreciable changes in sodium and potassium urinary excretion. Conclusions: Disturbances in potassium balance upon treatment with either olmesartan or enalapril are frequent and without differences between groups. The follow-up of these patients should include control of potassium levels, at least after the first week and the first and second month after initiating treatment
Results of the HepZero study comparing heparin-grafted membrane and standard care show that heparin-grafted dialyzer is safe and easy to use for heparin-free dialysis
International audienceHeparin is used to prevent clotting during hemodialysis, but heparin-free hemodialysis is sometimes needed to decrease the risk of bleeding. The HepZero study is a randomized, multicenter international controlled open-label trial comparing no-heparin hemodialysis strategies designed to assess non-inferiority of a heparin grafted dialyzer (NCT01318486). A total of 251 maintenance hemodialysis patients at increased risk of hemorrhage were randomly allocated for up to three heparin-free hemodialysis sessions using a heparin-grafted dialyzer or the center standard-of-care consisting of regular saline flushes or pre-dilution. The first heparin-free hemodialysis session was considered successful when there was neither complete occlusion of air traps or dialyzer, nor additional saline flushes, changes of dialyzer or bloodlines, or premature termination. The current standard-of-care resulted in high failure rates (50%). The success rate in the heparin-grafted membrane arm was significantly higher than in the control group (68.5% versus 50.4%), which was consistent for both standard-of-care modalities. The absolute difference between the heparin-grafted membrane and the controls was 18.2%, with a lower bound of the 90% confidence interval equal to plus 7.9%. The hypothesis of the non-inferiority at the minus 15% level was accepted, although superiority at the plus 15% level was not reached. Thus, use of a heparin-grafted membrane is a safe, helpful, and easy-to-use method for heparin-free hemodialysis in patients at increased risk of hemorrhage