Arterial hypertension in chronic renal disease. Educational intervention in patients with stage IV / V (Polyclinic of Nephrology Hospital de Clínicas) period July-September of 2016

Germán Chocho: Estudiante de Medicina, Ciclo Metodología Científica II, Facultad de Medicina, Universidad de la República, Uruguay. La contribución en la realización del trabajo fue equivalente a la de los demás estudiantes.-- Lía Escobar: Estudiante de Medicina, Ciclo Metodología Científica II, Facultad de Medicina, Universidad de la República, Uruguay. La contribución en la realización del trabajo fue equivalente a la de los demás estudiantes.-- Leonardo Pini: Estudiante de Medicina, Ciclo Metodología Científica II, Facultad de Medicina, Universidad de la República, Uruguay. La contribución en la realización del trabajo fue equivalente a la de los demás estudiantes.-- Rodrigo Fernández: Estudiante de Medicina, Ciclo Metodología Científica II, Facultad de Medicina, Universidad de la República, Uruguay. La contribución en la realización del trabajo fue equivalente a la de los demás estudiantes.-- Johanna Ramón: Estudiante de Medicina, Ciclo Metodología Científica II, Facultad de Medicina, Universidad de la República, Uruguay. La contribución en la realización del trabajo fue equivalente a la de los demás estudiantes.-- Patricia Larre Borges: Departamento de Nefrología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay.-- Xosé González: Departamento de Nefrología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay.-- Liliana Gadola (tutora): Departamento de Nefrología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay. E-mail: [email protected] Centro y Departamento de Nefrología, Hospital de Clínicas, Av. Italia s/nº, Tel (598) 2 4809850Los objetivos del estudio fueron evaluar la relación entre hipertensión arterial y la evolución en pacientes con Enfermedad renal crónica, asistidos en la Policlínica de Nefrología del Hospital de Clínicas y realizar una intervención educativa para mejorar su adherencia al tratamiento.El estudio se realizó en dos etapas.: A. Se analizó retrospectivamente el Registro del Programa de Salud Renal, para relacionar hiper-tensión arterial (Presión arterial promedio de la evolución ≥ 140/90 mm Hg) con la evolución de los pacientes asistidos en el período de estudio (1/7/2011 a 30/6/2016).B. Se planificó, ejecutó y evaluó una intervención educativa a pacientes con Enfermedad Renal Crónica estadios IV-V, respecto al control de presión arterial, consumo de sodio, y ejercicio físico. Resultados:A - En la población global, 374 individuos con tiempo de seguimiento > 3 meses, se encontraron 123 hipertensos y su supervivencia fue significativamente menor que el grupo normotenso. En la subpoblación en etapa IV-V (59 pacientes) la diferencia no fue significativa. El análisis estadístico de las Evaluaciones previas y posteriores a la intervención educativa evidenció una mejoría en la identificación del contenido de sodio del alimento seleccionado (test McNemar, p< 0.05) y la Encuesta de Satisfacción evidenció alta aceptación. En conclusión, la hipertensión arterial se asoció a mayor riesgo de ingreso a diálisis o fallecimiento y la intervención educativa fue exitosa, lo que alienta a difundir la experiencia, para mejorar el auto-cuidado y la evolución de los pacientes.The aims of the study were to evaluate the relationship between blood pressure and outcome in Chronic Kidney Disease (CKD) patients assisted at the Departamento de Nefrología del Hospital de Clínicas and perform an educational intervention to improve adherence to treatment.The study was conducted in two stages: A. A retrospective analysis (data from the Renal Health Program Registry), was performed to correlate blood pressure with outcome of patients assisted in the study period (1/7/2015-30/6/2016).B. An educational activity to CKD patients (stage IV-V) was planned, implemented and evaluated with the aim of improving the Blood Pressure control, sodium intake, and physical exercise. Results. A: In the overall population (374 individuals with more than three months of follow-up), 123 patients had high Blood Presure (mean BP ≥140/90 mmHg), and a signifi cantly lower survival than the normo-tensive group. Multiple linear regression analysis showed that hypertension increases the risk of RRT or death No difference was observed in the IV-V stage subpopulation (n=59). B: Educational activity Evaluation (Previous vs final) showed a significant improvement in identifying the sodium content of selected food (McNemar test, p <0.05) and a high grade of acceptance. Conclusions: The persistence of hypertension in evolution was associated with increased risk of admission to renal replacement therapy or death. The educational activity was successful, so it encou-rages developing similar strategies, to improve patients ́ self-care behaviors and survival

Functional status and physical activity in dialysis patients

Allison Armand Pilon: Estudiantes Carrera Doctor en Medicina.-- María José Bentancor: Estudiantes Carrera Doctor en Medicina.-- Carolina Echeverría: Estudiantes Carrera Doctor en Medicina.-- Sergio Pereira: Estudiantes Carrera Doctor en Medicina.-- Victoria Taglioretti: Estudiantes Carrera Doctor en Medicina.-- Sofía Zeballos: Estudiantes Carrera Doctor en Medicina.-- Sofía San Román: Centro de Nefrología Hospital de Clínicas, Facultad de Medicina, Universidad de la República – Uruguay.-- Cecilia Durán: Departamento, de Psicología Médica, Facultad de Medicina, Universidad de la República – Uruguay.-- Ricardo Silvariño: Centro de Nefrología Hospital de Clínicas, Facultad de Medicina, Universidad de la República – Uruguay.-- Liliana Gadola: Centro de Nefrología Hospital de Clínicas, Facultad de Medicina, Universidad de la República – Uruguay.-- Cecilia Baccino: Centro de Nefrología Hospital de Clínicas, Facultad de Medicina, Universidad de la República – Uruguay.Los pacientes con enfermedad renal crónica avanzada (ERCA) presentan menor capacidad funcional. El deterioro funcional se acentúa en los estadios más avanzados de la Enfermedad Renal Crónica (ERC) lo que aumenta la morbi-mortalidad. El objetivo del presente trabajo fue valorar el estado funcional de los pacientes con ERCA en tratamiento con diálisis en el Centro de Nefrología del Hospital de Clínicas, en el período comprendido de mayo a agosto del 2018. Es un estudio transversal, observacional, descriptivo. Los datos fueron extraídos por revisión de historia y entrevista presencial. Se evaluó el estado funcional y actividad física mediante: fuerza de prensión, test “up and go”; índice de Barthel. La presencia de deterioro cognitivo se determinó a través del “minimental state test examination”, y la calidad de vida percibida por el paciente, por medio del cuestionario SF-36 adaptado ERC. La población estudiada fue n= 47, edad media 58.5 ± 15.3 (DE) años. Modalidad hemodiálisis (29/47: 61,7%) siendo el resto pacientes en diálisis peritoneal (18/47: 38,3%). La mayoría (26) tuvieron fuerza conservada (prensión) y velocidad de marcha independiente (37) (rápidos por up and go). La presencia de menor capacidad funcional (debilidad o lentitud) se relacionó con menor masa magra, menores niveles de albúmina (3.9 ±0.52 vs 4.2 ±0.27 p 0.023), hemoglobina(10.7± 1.7 vs 11.7 ± 1.7 p 0.045), vitamina D ( 22.7 ± 14.5 vs 22.3 ± 8.1 p 0.917 ) y mayores niveles de hormona paratiroidea (308.1 ± 316.9 vs 378.4 ± 264.5 p 0.422). Concluimos que el Deterioro del estatus funcional en pacientes con ERC en terapia de sustitución renal (TSR) se relaciona con la disminución en la masa magra, menor nivel de albúmina, anemia y déficit de vitamina D.Chronic kidney disease (CKD) is associated with lower functional capacity. This condition is accentuated in the most Advanced stages of Chronic Kidney Disease (ACKD), which increases morbidity and mortality. The objective of this study was to assess the functional status of patients with ACKD undergoing dialysis treatment at the Nephrology Center of the Hospital de Clínicas, in the period from May to August 2018. It is a cross-sectional, observational, descriptive study. The data were obtained by review of history and face-to-face interview. Functional status and physical activity were evaluated by grip strength, “up and go” test; Barthel index. The presence of cognitive impairment was determined through the “mini mental state test examination”, and the quality of life perceived by the patient, through the adapted SF-36 ERC questionnaire. The studied population was n = 47, mean age 58.5 ± 15.3 (SD) years. Hemodialysis Group (29/47: 61.7%) and peritoneal dialysis Group (18/47: 38.3%). Most (26) had conserved strength (grip) and independent gait speed (37) (up and go fast). The presence of lower functional capacity (weakness or slowness) was related to lower lean mass, lower levels of albumin (3.9 ± 0.52 vs 4.2 ± 0.27 p 0.023), hemoglobin (10.7 ± 1.7 vs 11.7 ± 1.7 p 0.045), vitamin D ( 22.7 ± 14.5 vs 22.3 ± 8.1 p 0.917) and higher levels of parathyroid hormone (308.1 ± 316.9 vs 378.4 ± 264.5 p 0.422). We conclude that the Impairment of functional status in CKD patients on renal replacement therapy (RRT) is related to a decrease in lean mass, lower albumin level, anemia, and vitamin D deficiency

Calcium citrate improves the epithelial-to-mesenchymal transition induced by acidosis in proximal tubular cells

INTRODUCTION: Epithelial-to-mesenchymal transition (EMT) is a key event in renal fibrosis. The aims of the study were to evaluate acidosis induced EMT, transforming-growth-factor (TGF) β1 role and citrate effect on it. METHODS: HK2 cells (ATCC 2290) were cultured in DMEM/HAM F12 medium, pH 7.4. At 80% confluence, after 24 hr under serum free conditions, cells were distributed in three groups (24 hours): A) Control: pH 7.4, B) Acidosis: pH 7.0 and C) Calcium citrate (0.2 mmol/L) + pH 7.0. Change (Δ) of intracellular calcium concentration, basal and after Angiotensin II (10-6M) exposition, were measured to evaluate cellular performance. EMT was evaluated by the expression of α-smooth muscle actin (α-SMA) and E-cadherin by immunocytochemistry and/or Western blot. TGF-β1 secretion was determined by ELISA in cell supernatant. RESULTS: At pH 7.0 HK2 cells significantly reduced E-cadherin and increased α-SMA expression (EMT). Supernatant TGF-β1 levels were higher than in control group. Calcium citrate decreased acidosis induced EMT and improved cells performance, without reduction of TGF-β production. CONCLUSIONS: Acidosis induces EMT and secretion of TGF-β1 in tubular proximal cells in culture and citrate improves cellular performance and ameliorates acidosis induced EMT

Arterial hypertension in chronic renal disease. Educational intervention in patients with stage IV / V (Polyclinic of Nephrology Hospital de Clínicas) period July-September of 2016

The aims of the study were to evaluate the relationship between blood pressure and outcome in Chronic Kidney Disease (CKD) patients assisted at the Departamento de Nefrología del Hospital de Clínicas and perform an educational intervention to improve adherence to treatment. The study was conducted in two stages. A. A retrospective analysis (data from the Renal Health Program Registry), was performed to correlate blood pressure with the change outcome of patients assisted in the study period (1/7/2015-30/6/2016). B. An educational activity was planned, implemented and evaluated with the aim of improving the Blood Pressure control, sodium intake, and physical exercise.  Hypertension prevalence was 62.8%. In the overall population, 123 patients with mean Blood Pressure ≥140/90 mmHg (of 374 individuals with more than three months of follow-up), had a significantly lower survival than the normotensive group. In the overall population the multiple linear regression analysis showed that hypertension increases the risk of RRT or death No difference was observed in the IV-V stage subpopulation (n=59). B: Educational activity Evaluation (Previous vs final) showed a significant improvement in identifying the sodium content of selected food (McNemar test, p <0.05) and a high grade of acceptance. Conclusions: The persistence of hypertension in evolution was associated with increased risk of admission to renal replacement therapy or death. The successful; educational activity encourages to develop similar strategies, with the expectation of improving patients´ self-care behaviors and survival

Peritonitis por Acinetobacter en pacientes en diálisis peritoneal: prevalencia, características microbiológicas y resultados en una población de Uruguay

Introducción: La peritonitis en diálisis peritoneal (DP) es una complicación grave, y Acinetobacter raramente la causa. Analizamos la prevalencia, sensibilidad, tratamiento y evolución de peritonitis por Acinetobacter en tres centros de DP. Material y métodos: Se incluyeron pacientes mayores de 18 años, asistidos entre 1/1/2008 y 31/12/2018. Resultados: Se registraron 336 peritonitis (0,39 peritonitis/paciente-año): 139 (41.36%) por gram positivos, 95 (28.27%) por gram negativos, 18 (5.35%) por hongos y 80 (23.80%) por cultivos sin desarrollo. En 10 (2.97%) se aisló Acinetobacter. Tenían una edad media de 53.5 ± 15.7 años, el 50% eran diabéticos, en DP por 24 ± 19 meses, y 8 de los10 con antecedente de peritonitis previa. La especie de Acinetobacter más frecuente fue Baumannii (5/10), seguida por Ursingii (2/10) y Acinetobacter L woffii (1/10). El tratamiento inicial fue según el protocolo nacional: vancomicina y amikacina intraperitoneales, y en todos se realizó cambio de antibiótico al identificar microorganismo. Presentaron cura clínica y microbiológica 9 pacientes, y 1 falleció. La frecuencia de retiro de catéteres peritoneales y muerte no presentó diferencia comparada con las peritonitis por gram negativos (Chi2 p = 0.63) y gram positivos (Chi2 p = 0.58). Conclusión: La peritonitis por Acinetobacter es infrecuente en nuestro medio, mostró un perfil de sensibilidad antibiótica favorable y la tasa de curación y complicaciones no difirió con las peritonitis por otros microorganismos

Temporal trends in biopsy proven glomerular disease in Uruguay, 1990-2014.

Our aim is to describe variations in the incidence rates of glomerular disease diagnosed by renal biopsies performed in Uruguay over the last 25 years in relation to sex, age, clinical presentation and histological diagnosis. We analyzed all renal biopsies performed in Uruguay during the 25 years period and estimated incidence rates per million people per year (pmp/yr) for the population older than 14 years. Mann Kendall's trend analysis was used to assess incidence trends. In order to identify changes in trends, we compared annual incidence rates with the Joinpoint method. From 1990 to 2014, 3390 biopsies of native kidneys corresponding to glomerular disease were performed in patients older than 14 years. The average biopsy rate was 58 per pmp/yr. The glomerular disease incidence rate increased progressively over the period (p<0.05). Trends analysis over five-year periods demonstrated a progressive increase of IgA nephropathy (3.08 pmp/yr 1990-1994 to 12.53 pmp/yr 2010-2014 p<0.05), membranous nephropathy (2.38 pmp/yr 1990-1994 to 8.04 pmp/yr 2010-2014 p< 0.05) and lupus nephritis (4,23 pmp/yr 1990-1994 to 7,81 pmp/yr 2010-2014 p<0.05). There was a change in the trend of focal segmental glomerular sclerosis (FSGS) which increased until 1996 and decreased afterwards. The incidence rates of glomerular disease have doubled globally in the last quarter of a century in Uruguay, mainly related to the increase of IgA nephropathy, membranous nephropathy and lupus nephritis. There was a change in the slope of the incidence rate of FSGS

Lupus Nephritis in Males: Clinical Features, Course, and Prognostic Factors for End-Stage Renal Disease

Because of their rarity in men, systemic lupus erythematous and lupus nephritis (LN) are poorly understood in men. Our aim was to analyze the clinical presentation and course of histology-proven systemic lupus erythematous and LN in males and to determine the risk factors for progression to end-stage renal disease. Methods: Fifty patients from 2 historical cohorts in Spain (Hospital 12 de Octubre) and Uruguay were retrospectively analyzed and compared with a female cohort matched for age and disease characteristics. Results: The median age at the time of renal biopsy was 27 years (range, 8–79 years). The main forms of presentation were nephrotic syndrome in 26 of 50 patients (52%), and class IV LN in 34 of 50 (68%). After treatment, 21 patients (45.6%) achieved complete renal remission. During follow-up, 12 patients required renal replacement therapy, and 3 patients died of infectious causes. When patients who required renal replacement therapy were compared with those who did not require it, several parameters showed significant differences (P < 0.05) at the time of renal biopsy: estimated glomerular filtration rate < 60 ml/min, hypertension, hypoalbuminemia, and concomitant visceral involvement (neurologic, cardiovascular, and/or pulmonary). In the multivariate analysis, only estimated glomerular filtration rate < 60 ml/min persisted as a risk factor for progression to end-stage renal disease. When compared with a cohort of female patients with LN, there were no significant differences in remission or renal survival. Discussion: LN in males usually presents as nephrotic syndrome, and type IV LN is the most frequent form. An estimated glomerular filtration rate < 60 ml/min at the time of renal biopsy is associated with poor renal outcomes. There were no differences in remission or progression of LN in males when compared with a cohort of female patients with LN

ISPD recommendations for the evaluation of peritoneal membrane dysfunction in adults: Classification, measurement, interpretation and rationale for intervention.

A pathophysiological classification of membrane dysfunction, which provides mechanistic links to functional characteristics, should be used when prescribing individualized dialysis or when planning modality transfer (e.g. to automated peritoneal dialysis (PD) or haemodialysis) in the context of shared and informed decision-making with the person on PD, taking individual circumstances and treatment goals into account. (). It is recommended that the PSTR is determined from a 4-h peritoneal equilibration test (PET), using either 2.5%/2.27% or 4.25%/3.86% dextrose/glucose concentration and creatinine as the index solute. () This should be done early in the course dialysis treatment (between 6 weeks and 12 weeks) () and subsequently when clinically indicated. (). A faster PSTR is associated with lower survival on PD. () This risk is in part due to the lower ultrafiltration (UF) and increased net fluid reabsorption that occurs when the PSTR is above the average value. The resulting lower net UF can be avoided by shortening glucose-based exchanges, using a polyglucose solution (icodextrin), and/or prescribing higher glucose concentrations. () Compared to glucose, use of icodextrin can translate into improved fluid status and fewer episodes of fluid overload. () Use of automated PD and icodextrin may mitigate the mortality risk associated with fast PSTR. (). UF This is easy to measure and a valuable screening test. Insufficient UF should be suspected when either (a) the net UF from a 4-h PET is <400 ml (3.86% glucose/4.25% dextrose) or <100 ml (2.27% glucose /2.5% dextrose), () and/or (b) the daily UF is insufficient to maintain adequate fluid status. () Besides membrane dysfunction, low UF capacity can also result from mechanical problems, leaks or increased fluid absorption across the peritoneal membrane not explained by fast PSTR. Diagnosing intrinsic membrane dysfunction (manifesting as low osmotic conductance to glucose) as a cause of UF insufficiency: When insufficient UF is suspected, the 4-h PET should be supplemented by measurement of the sodium dip at 1 h using a 3.86% glucose/4.25% dextrose exchange for diagnostic purposes. A sodium dip ≤5 mmol/L and/or a sodium sieving ratio ≤0.03 at 1 h indicates UF insufficiency. (). in the absence of residual kidney function, this is likely to necessitate the use of hypertonic glucose exchanges and possible transfer to haemodialysis. Acquired membrane injury, especially in the context of prolonged time on treatment, should prompt discussions about the risk of encapsulating peritoneal sclerosis. (). measures of peritoneal protein loss, intraperitoneal pressure and more complex tests that estimate osmotic conductance and 'lymphatic' reabsorption are not recommended for routine clinical practice but remain valuable research methods. (). When resource constraints prevent the use of routine tests, consideration of membrane function should still be part of the clinical management and may be inferred from the daily UF in response to the prescription. ()