Survival with low- and high-flux dialysis

FUNDING COSMOS is sponsored by the Bone and Mineral Research Unit (Hospital Universitario Central de Asturias), SAFIM (Sociedad Asturiana Fomento Investigaciones O´ seas), the European Renal Association–European Dialysis and Transplant Association, the National Program of I þ D þ I 2008–2011 and Instituto de Salud Carlos III (ISCIII), the ISCIII Retic REDinREN (RD06/0016/1013, RD12/0021/0023 and RD16/ 0009/0017), the ISCIII (ICI14/00107, PI17/00384 and PI20/ 00633), Fondo Europeo de Desarrollo Regional (FEDER), Plan Estatal de I þ D þ I 2013–2016, Plan de Ciencia, Tecnologia e Innovacion 2013–2017 y 2018–2022 del Principado de Asturias (GRUPIN14-028, IDI-2018-000152), Fundacio´n Renal I ´nigo A ~ ´ lvarez de Toledo (FRIAT) and the Spanish Society of Nephrology (Estudio Estrate´gico de la SEN). Logistics (meetings, secretarial help, printing of materials, development of website for data entry, etc.) have been financially supported by AMGEN Europe and FRIAT. The authors are not aware of any additional relationships, funding or financial holdings that might be perceived as affecting the objectivity of this study. COSMOS participating centres: see Supplementary Appendix.Background. Besides advances in haemodialysis (HD), mortality rates are still high. The effect of the different types of HD membranes on survival is still a controversial issue. The aim of this COSMOS (Current management Of Secondary hyperparathyroidism: a Multicentre Observational Study) analysis was to survey, in HD patients, the relationship between the use of conventional low- or high-flux membranes and all-cause and cardiovascular mortality. Methods. COSMOS is a multicentre, open-cohort, 3-year prospective study, designed to evaluate mineral and bone disorders in the European HD population. The present analysis included 5138 HD patients from 20 European countries, 3502 randomly selected at baseline (68.2%), plus 1636 new patients with <1 year on HD (31.8%) recruited to replace patients who died, were transplanted, switched to peritoneal dialysis or lost to follow-up by other reasons. Cox-regression analysis with timedependent variables, propensity score matching and the use of an instrumental variable (facility-level analysis) were used. Results. After adjustments using three different multivariate models, patients treated with high-flux membranes showed a lower all-cause and cardiovascular mortality risks fhazard ratio (HR) = 0.76 [95% confidence interval (CI) 0.61-0.96] and HR = 0.61 (95% CI 0.42-0.87), respectivelyg, that remained significant after matching by propensity score for all-cause mortality (HR = 0.69, 95% CI 0.52-0.93). However, a facility-level analysis showed no association between the case-mix-adjusted facility percentage of patients dialysed with high-flux membranes and all-cause and cardiovascular mortality. Conclusions. High-flux dialysis was associated with a lower relative risk of all-cause and cardiovascular mortality. However, dialysis facilities using these dialysis membranes to a greater extent did not show better survival.publishersversionpublishe

Consensus document for the detection and management of chronic kidney disease.

Chronic kidney disease (CKD) is a major public health problem that, in its different stages, may affect up to 10% of the Spanish population and results in high morbidity and mortality, as well as high consumption of National Health System resources. Ten scientific societies involved in the management of kidney patients agreed to update the 2007 CKD consensus document. The current version is an abridged edition of the detailed general document, which can be consulted on the webpages of each signatory society. It includes the following aspects: CKD definition, epidemiology and risk factors and criteria on diagnosis, assessment and staging of CKD, albuminuria and glomerular filtration estimation. Progression factors and concept. Criteria for referral to Nephrology. Patient follow-up, attitudes and objectives by specialty. Prevention of nephrotoxicity. Detection of cardiovascular damage. Attitudes, lifestyle and treatment: management of high blood pressure, dyslipidaemia, hyperglycaemia, smoking, obesity, hyperuricaemia, anaemia and mineral and bone metabolism disorders. Coordinated follow-up by Primary Care - other specialties - Nephrology. Management of renal replacement therapy, haemodialysis, peritoneal dialysis and renal transplantation patients. Palliative treatment of terminal uraemia. We hope that this document will be very useful in the multidisciplinary management of CKD patients, in view of the updated recommendations

What is the optimal level of vitamin D in non-dialysis chronic kidney disease population?

AIM: To evaluate thresholds for serum 25(OH)D concentrations in relation to death, kidney progression and hospitalization in non-dialysis chronic kidney disease (CKD) population. METHODS: Four hundred and seventy non-dialysis 3-5 stage CKD patients participating in OSERCE-2 study, a prospective, multicenter, cohort study, were prospectively evaluated and categorized into 3 groups according to 25(OH)D levels at enrollment (less than 20 ng/mL, between 20 and 29 ng/mL, and at or above 30 ng/mL), considering 25(OH)D between 20 and 29 ng/mL as reference group. Association between 25(OH)D levels and death (primary outcome), and time to first hospitalization and renal progression (secondary outcomes) over a 3-year follow-up, were assessed by Kaplan-Meier survival curves and Cox-proportional hazard models. To identify 25(OH)D levels at highest risk for outcomes, receiver operating characteristic (ROC) curves were performed. RESULTS: Over 29 ± 12 mo of follow-up, 46 (10%) patients dead, 156 (33%) showed kidney progression, and 126 (27%) were hospitalized. After multivariate adjustment, 25(OH)D < 20 ng/mL was an independent predictor of all-cause mortality (HR = 2.33; 95%CI: 1.10-4.91; P = 0.027) and kidney progression (HR = 2.46; 95%CI: 1.63-3.71; P < 0.001), whereas the group with 25(OH)D at or above 30 ng/mL did not have a different hazard for outcomes from the reference group. Hospitalization outcomes were predicted by 25(OH) levels (HR = 0.98; 95%CI: 0.96-1.00; P = 0.027) in the unadjusted Cox proportional hazards model, but not after multivariate adjusting. ROC curves identified 25(OH)D levels at highest risk for death, kidney progression, and hospitalization, at 17.4 ng/mL [area under the curve (AUC) = 0.60; 95%CI: 0.52-0.69; P = 0.027], 18.6 ng/mL (AUC = 0.65; 95%CI: 0.60-0.71; P < 0.001), and 19.0 ng/mL (AUC = 0.56; 95%CI: 0.50-0.62; P = 0.048), respectively. CONCLUSION: 25(OH)D < 20 ng/mL was an independent predictor of death and progression in patients with stage 3-5 CKD, with no additional benefits when patients reached the levels at or above 30 ng/mL suggested as optimal by CKD guidelines.Abbott and the Spanish Society of Nephrolog

Association of candidate gene polymorphisms with chronic kidney disease : Results of a case-control analysis in the NEFRONA cohort

Chronic kidney disease (CKD) is a major risk factor for end-stage renal disease, cardiovascular disease and premature death. Despite classical clinical risk factors for CKD and some genetic risk factors have been identified, the residual risk observed in prediction models is still high. Therefore, new risk factors need to be identified in order to better predict the risk of CKD in the population. Here, we analyzed the genetic association of 79 SNPs of proteins associated with mineral metabolism disturbances with CKD in a cohort that includes 2,445 CKD cases and 559 controls. Genotyping was performed with matrix assisted laser desorption ionization-time of flight mass spectrometry. We used logistic regression models considering different genetic inheritance models to assess the association of the SNPs with the prevalence of CKD, adjusting for known risk factors. Eight SNPs (rs1126616, rs35068180, rs2238135, rs1800247, rs385564, rs4236, rs2248359, and rs1564858) were associated with CKD even after adjusting by sex, age and race. A model containing five of these SNPs (rs1126616, rs35068180, rs1800247, rs4236, and rs2248359), diabetes and hypertension showed better performance than models considering only clinical risk factors, significantly increasing the area under the curve of the model without polymorphisms. Furthermore, one of the SNPs (the rs2248359) showed an interaction with hypertension, being the risk genotype affecting only hypertensive patients. We conclude that 5 SNPs related to proteins implicated in mineral metabolism disturbances (Osteopontin, osteocalcin, matrix gla protein, matrix metalloprotease 3 and 24 hydroxylase) are associated to an increased risk of suffering CKD

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to &lt;90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], &gt;300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of &lt;15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P&lt;0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P&lt;0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

The use of scenarios and models to evaluate the future of nature values and ecosystem services in Mediterranean forests

Science and society are increasingly interested in predicting the effects of global change and socio-economic development on natural systems, to ensure maintenance of both ecosystems and human well-being. The Intergovernmental Platform on Biodiversity and Ecosystem Services has identified the combination of ecological modelling and scenario forecasting as key to improving our understanding of those effects, by evaluating the relationships and feedbacks between direct and indirect drivers of change, biodiversity, and ecosystem services. Using as case study the forests of the Mediterranean basin (complex socio-ecological systems of high social and conservation value), we reviewed the literature to assess (1) what are the modelling approaches most commonly used to predict the condition and trends of biodiversity and ecosystem services under future scenarios of global change, (2) what are the drivers of change considered in future scenarios and at what scales, and (3) what are the nature and ecosystem service indicators most commonly evaluated. Our review shows that forecasting studies make relatively little use of modelling approaches accounting for actual ecological processes and feedbacks between different socio-ecological sectors; predictions are generally made on the basis of a single (mainly climate) or a few drivers of change. In general, there is a bias in the set of nature and ecosystem service indicators assessed. In particular, cultural services and human well-being are greatly underrepresented in the literature. We argue that these shortfalls hamper our capacity to make the best use of predictive tools to inform decision-making in the context of global change.This work was supported by the Spanish Government through the INMODES project (grant number CGL2017-89999-C2-2-R), the ERA-NET FORESTERRA project INFORMED (grant number 29183), and the project Boscos Sans per a una Societat Saludable funded by Obra Social la Caixa (https://obrasociallacaixa.org/). AMO and AA were supported by Spanish Government through the “Juan de la Cierva” fellowship program (IJCI-2016-30349 and IJCI-2016-30049, respectively). JVRD was supported by the Government of Asturias and the FP7-Marie Curie-COFUND program of the European Commission (Grant “Clarín” ACA17-02)

Multichannel Seismic Imaging of the Rivera Plate Subduction at the Seismogenic Jalisco Block Area (Western Mexican Margin)

Bartolomé, Rafael ... et al.-- 9ª Asamblea Hispano Portuguesa de Geodesia y Geofísica, del 28 al 30 de junio de 2016, Madrid[EN] During the TSUJAL marine geophysical survey, conducted in February and March 2014 Spanish, Mexican and British scientists and technicians explored the western margin of Mexico, considered one of the most active seismic zones in America. This work aims to characterize the internal structure of the subduction zone of the Rivera plate beneath the North American plate in the offshore part of the Jalisco Block, to link the geodynamic and the recent tectonic deformation occurring there with the possible generation of tsunamis and earthquakes. For this purpose, it has been carried out acquisition, processing and geological interpretation of a multichannel seismic reflection profile running perpendicular to the margin. Crustal images show an oceanic domain, dominated by subduction-accretion along the lower slope of the margin with a subparallel sediment thickness of up to 1.6 s twtt (approx. 2 km) in the Middle American Trench. Further, from these data the region appears to be prone to giant earthquake production. The top of the oceanic crust (intraplate reflector) is very well imaged. It is almost continuous along the profile with a gentle dip (<10°); however, it is disrupted by normal faulting resulting from the bending of the plate during subduction. The continental crust presents a well-developed accretionary prism consisting of highly deformed sediments with prominent slumping towards the trench that may be the result of past tsunamis. High amplitude reflections at around 7-8 s twtt clearly image a discontinuous Moho, defining a very gentle dipping subduction plane[ES] Durante la campaña geofísica marina TSUJAL (2014), científicos españoles, mexicanos y británicos exploraron el margen occidental de México, considerado una de las zonas sísmicas más activas de América. Este trabajo caracteriza la estructura interna de la zona de subducción de la placa de Rivera bajo la placa Norte Americana, estudiando la geodinámica y la deformación tectónica reciente y su vinculación con la posible generación de tsunamis y terremotos. Para este fin, se ha llevado a cabo la adquisición, procesado e interpretación geológica de un perfil de sísmica multicanal perpendicular al margen. Las imágenes de la corteza terrestre muestran un dominio oceánico, dominado por la subducción-acreción a lo largo de la pendiente inferior del margen con un espesor de sedimentos subparalela de hasta 1.6 s tiempo doble de viaje (aprox. 2 km) en la Fosa Mesoamericana. Además, a partir de estos datos la región parece ser propensa a la producción de grandes terremotos. La parte superior de la corteza oceánica (reflector intraplaca) está muy bien determinada siendo casi continua con una inclinación suave (<10 °); sin embargo, se ve interrumpida por una falla normal resultante de la flexión de la placa durante la subducción. La corteza continental presenta un prisma de acreción bien desarrollado compuesto de sedimentos altamente deformados con prominente caída de bloques hacia la fosa, que pueden ser el resultado de terremotos anteriores. La alta reflectividad en torno a 7-8 s (doble tiempo) muestra claramente una imagen de Moho discontinua definiendo un plano de subducción muy suavePeer Reviewe

The effect of cholecalciferol for lowering albuminuria in chronic kidney disease: a prospective controlled study

Background. Growing evidence indicates that vitamin D receptor activation may have antiproteinuric effects. We aimed to evaluate whether vitamin D supplementation with daily cholecalciferol could reduce albuminuria in proteinuric chronic kidney disease (CKD) patients. Methods. This 6-month prospective, controlled, intervention study enrolled 101 non-dialysis CKD patients with albuminuria. Patients with low 25(OH) vitamin D [25(OH)D] and high parathyroid hormone (PTH) levels (n = 50; 49%) received oral cholecalciferol (666 IU/day), whereas those without hyperparathyroidism (n = 51; 51%), independent of their vitamin D status, did not receive any cholecalciferol, and were considered as the control group. Results. Cholecalciferol administration led to a rise in mean 25(OH)D levels by 53.0 ± 41.6% (P < 0.001). Urinary albumin-to-creatinine ratio (uACR) decreased from (geometric mean with 95% confidence interval) 284 (189–425) to 167 mg/g (105–266) at 6 months (P < 0.001) in the cholecalciferol group, and there was no change in the control group. Reduction in a uACR was observed in the absence of significant changes in other factors, which could affect proteinuria, like weight, blood pressure (BP) levels or antihypertensive treatment. Six-month changes in 25(OH)D levels were significantly and inversely associated with that in the uACR (Pearson's R = −0.519; P = 0.036), after adjustment by age, sex, body mass index, BP, glomerular filtration rate and antiproteinuric treatment. The mean PTH decreased by −13.8 ± 20.3% (P = 0.039) only in treated patients, with a mild rise in phosphate and calcium–phosphate product [7.0 ± 14.7% (P = 0.002) and 7.2 ± 15.2% (P = 0.003), respectively]. Conclusions. In addition to improving hyperparathyroidism, vitamin D supplementation with daily cholecalciferol had a beneficial effect in decreasing albuminuria with potential effects on delaying the progression of CKD

Baseline characteristics of patients with chronic kidney disease stage 3 and stage 4 in Spain: the MERENA observational cohort study.

To obtain information on cardiovascular morbidity, hypertension control, anemia and mineral metabolism based on the analysis of the baseline characteristics of a large cohort of Spanish patients enrolled in an ongoing prospective, observational, multicenter study of patients with stages 3 and 4 chronic kidney diseases (CKD)Ye