Diferencias en mortalidad y hospitalización entre hemodiálisis de alto flujo y hemodiafiltración en pacientes mayores de edad colombianos con con enfermedad renal crónica terminal : Estudio cuasi-experimental retrospectivo multicéntrico.

La enfermedad renal crónica (ERC) es un problema de salud pública, dado por su creciente incidencia, impacto en la calidad de vida del paciente y su familia, los pacientes con ERC terminal tienen alta hospitalización y elevado riesgo de mortalidad; por ejemplo a cinco años se estima una mortalidad mayor al 50% la cual es excesiva en comparación con cánceres como el colo-rectal cuya mortalidad a 5 años es menos del 45% y el de mama invasivo menos del 20% a 10 años. Adicionalmente, la ERC terminal tiene un impacto directo en los costos de atención derivados de la tecnología usada tanto en la atención de la enfermedad misma como de las complicaciones asociadas. Estas situaciones han llevado a que se desarrollen nuevos tipos de tecnología hemodialitica. En Colombia la cuenta de alto costo genera datos de la población en hemodiálisis, como prevalencia, incidencia y mortalidad, sin diferenciar el tipo de tecnología hemodialitica. Varios estudios han mostrado diferencias en la calidad de vida y sobrevida de pacientes relacionados con el tipo de terapia dialítica, sin embargo, en Colombia no se ha explorado el impacto de las terapias convectivas de alto volumen (≥ 23 litros/sesión de recambio de agua) en resultados clínicos mayores. En consideración con lo anterior se desarrolló un estudio cuasi-experimental con el objetivo de comparar 2 modalidades de terapia hemodialitica en población atendida en unidades renales colombianas, (hemodiálisis de alto flujo (HD-HF) vs hemodiafiltración de alto volumen post dilucional (HV-HDF) con respecto a tasa de hospitalización y riesgo de mortalidad en personas mayores de edad con enfermedad renal crónica terminal prevalentes en hemodiálisis.MaestríaMAGISTER EN EPIDEMIOLOGÍ

Hipertensión arterial resistente

Introduction: Resistant arterial hypertension is a common entity that is associated with cerebrovascular accident, coronary artery disease and mortality from all associated causes, being found in studies of disease burden in 1.5%, 2.1% and 1.6%, respectively and is also related to a deterioration of renal function. Objective: It seeks to discuss the most important aspects of the disease, starting from the definition and pathophysiology, the criteria to achieve an early, specific diagnosis, using widely available studies and finally review the appropriate management. Results: Multiple pathophysiological and genetic factors contribute to the development of resistant arterial hypertension. Therefore, it can have different clinical phenotypes, as well as different levels of response to antihypertensive treatment. But before choosing a specific pharmacological therapy, it is essential to make the diagnosis with a blood pressure measurement technique and appropriate conditions, ruling out the presence of pseudoresistance or secondary arterial hypertension. Conclusion: The relationship between resistant arterial hypertension with major cardiovascular events and the development of comorbidities makes it necessary to emphasize its proper diagnosis and management by trained multidisciplinary personnel.Introducción: La hipertensión arterial resistente es una entidad común que se asocia a accidente cerebrovascular, arteriopatía coronaria y mortalidad por todas las causas asociadas, encontrándose en estudios de carga de la enfermedad en el 1.5%, 2.1% y 1.6%, respectivamente y además se relaciona con un deterioro de la función renal. Objetivo: Se busca discutir sobre los aspectos más importantes de la enfermedad, partiendo de la definición y la fisiopatología, los criterios para lograr un diagnóstico temprano, específico, usando estudios ampliamente disponibles y finalmente revisar el manejo adecuado. Resultados: Múltiples factores fisiopatológicos y genéticos contribuyen al desarrollo de la hipertensión arterial resistente. Por tanto, esta puede tener diversos fenotipos clínicos, así mismo como diversos niveles de respuesta al tratamiento antihipertensivo. Pero antes de elegir una terapia farmacológica específica es indispensable realizar el diagnóstico con una técnica de medición de la presión arterial y unas condiciones adecuadas, descartar la presencia de pseudoresistencia o de hipertensión arterial secundaria. Conclusión: La relación entre la hipertensión arterial resistente con eventos cardiovasculares mayores y el desarrollo de comorbilidades hace necesario hacer énfasis en su diagnóstico y manejo adecuados por un personal multidisciplinario capacitad

Canagliflozin and Cardiovascular and Renal Outcomes in Type 2 Diabetes Mellitus and Chronic Kidney Disease in Primary and Secondary Cardiovascular Prevention Groups

Background: Canagliflozin reduces the risk of kidney failure in patients with type 2 diabetes mellitus and chronic kidney disease, but effects on specific cardiovascular outcomes are uncertain, as are effects in people without previous cardiovascular disease (primary prevention). Methods: In CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation), 4401 participants with type 2 diabetes mellitus and chronic kidney disease were randomly assigned to canagliflozin or placebo on a background of optimized standard of care. Results: Primary prevention participants (n=2181, 49.6%) were younger (61 versus 65 years), were more often female (37% versus 31%), and had shorter duration of diabetes mellitus (15 years versus 16 years) compared with secondary prevention participants (n=2220, 50.4%). Canagliflozin reduced the risk of major cardiovascular events overall (hazard ratio [HR], 0.80 [95% CI, 0.67-0.95]; P=0.01), with consistent reductions in both the primary (HR, 0.68 [95% CI, 0.49-0.94]) and secondary (HR, 0.85 [95% CI, 0.69-1.06]) prevention groups (P for interaction=0.25). Effects were also similar for the components of the composite including cardiovascular death (HR, 0.78 [95% CI, 0.61-1.00]), nonfatal myocardial infarction (HR, 0.81 [95% CI, 0.59-1.10]), and nonfatal stroke (HR, 0.80 [95% CI, 0.56-1.15]). The risk of the primary composite renal outcome and the composite of cardiovascular death or hospitalization for heart failure were also consistently reduced in both the primary and secondary prevention groups (P for interaction >0.5 for each outcome). Conclusions: Canagliflozin significantly reduced major cardiovascular events and kidney failure in patients with type 2 diabetes mellitus and chronic kidney disease, including in participants who did not have previous cardiovascular disease

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 <90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], >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 <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<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<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

Compromiso renal atípico en amiloidosis de cadena ligera

Introduction: Light chain amyloidosis is an entity triggered by the proliferation of a clone of plasma cells that generates the accumulation of light chains, which are deposited in the form of amyloid fibrils generating organic dysfunction. Renal compromise generally manifests as nephrotic syndrome, with a slow and progressive decline of renal function that can lead to dialysis therapy. Purpose: The objective of this case report is to demonstrate the aggressive and subacute renal involvement of systemic amyloidosis. Case presentation: We present a case of a 35-year-old male patient who consulted for general malaise, blurred vision, dizziness and oliguria with elevated nitrogen levels that progressed fastly to the requirement of hemodialysis in approximately 3 months. It was also reveal peripheral polyneuropathy, cardiac infiltration, and slight elevation of transaminases. Given the negativity of extension studies, amyloid deposits were documented histopathologically with positive immunofluorescence for LA. He is currently receiving chemotherapy regimen with adequate clinical stability and tolerance. Conclusion and discussion: To conclude, AL amyloidosis is a rare entity, with significant multi-organ involvement and high rates of morbidity and mortality. In this case, the subacute involvement with an early requirement for dialysis therapy is emphasized, and the importance of suspicion and timely diagnosis in patients with kidney involvement and other systemic manifestations is emphasized.Introducción: la amiloidosis de cadena ligera (AL) es una entidad desencadenada por la proliferación de un clon de células plasmáticas que genera la acumulación de cadenas ligeras, las cuales se depositan en forma de fibrillas amiloides generando una disfunción orgánica. El compromiso renal generalmente se manifiesta como síndrome nefrótico, con un deterioro lento y progresivo de la función renal que puede llevar a un requerimiento de terapia dialítica. Objetivo: demostrar el compromiso renal agresivo y subagudo de la amiloidosis sistémica. Presentación del caso: paciente masculino de 35 años que consulta por malestar general, visión borrosa, mareos y oliguria con elevación de azoados, y que progresó rápidamente hasta el requerimiento de hemodiálisis en aproximadamente tres meses. Asociado se documenta polineuropatía periférica, infiltración cardiaca y ligera elevación de transaminasas. Ante negatividad de estudios de extensión, se logra documentar la presencia histopatológica de depósitos amiloides con inmunofluorescencia positiva para AL. Actualmente, se encuentra recibiendo esquema de quimioterapia con adecuada estabilidad clínica y tolerancia. Discusión y conclusión: la amiloidosis AL es una entidad infrecuente, con compromiso multiorgánico importante y altas tasas de morbilidad y mortalidad. Se recalca en este caso el compromiso subagudo con requerimiento temprano de terapia dialítica y además se enfatiza la importancia de una sospecha y un diagnóstico oportuno en pacientes con compromiso renal y otras manifestaciones sistémicas

Anosmia como manifestación inicial de COVID-19 en pacientes de hemodiálisis

Background. Hemodialysis patients are susceptible population for COVID-19 the disease caused by SARS-CoV-2, with early diagnosis being an urgent and needed because they are considered a population with high risk for severe and serious conditions. Purpose. The objective of our study was to estimate whether sudden-onset anosmia allow to detect COVID-19 infection early in hemodialysis patients without classic symptoms (who did not present malaise, respiratory or gastrointestinal symptoms at the beginning of the disease). Methodology. A diagnostic test study was accomplished during the months of September and October 2020 in three hemodialysis units in Colombia. Adult patients without classic symptoms for COVID-19 were included. Patients with previous COVID-19 infection or with a history of smell alteration were excluded. Demographic, clinical, and laboratory data were collected, prior signature of informed consent endorsed by the ethics committee. Anosmia was evaluated with objective test for odor detection before the start of hemodialysis session. Results. 587 patients were included. Anosmia prevalence was 0.85% (5 patients) and the incidence of COVID-19 was 1.19% (7 patients). There was no statistically difference in demographic, clinical, and laboratory comparison between patients with and without anosmia. The presence of anosmia had a sensitivity and a positive predictive value of 0%, but a specificity of 99.14% and a negative predictive value of 98.8%. The accuracy was 97.9%. Conclusions. The prevalence of anosmia in our hemodialysis population was low. Any symptoms (including altered sense of smell) should be investigated in TRIAGE as a strategy to detect early individual cases of COVID-19 or an outbreak in hemodialysis units. Methods: a diagnostic test study was accomplished in three hemodialysis units in Colombia. Adult patients without classic symptoms for COVID-19 were included. Patients with previous COVID-19 infection or with a history of smell alteration were excluded. Demographic, clinical, and laboratory data were collected. Anosmia was evaluated with objective test for odor detection before the start of hemodialysis session. Results: 587 patients were included. Anosmia prevalence was 0.85% (5 patients) and the incidence of COVID-19 was 1.19% (7 patients). There was no statistically difference in demographic, clinical, and laboratory comparison between patients with and without anosmia. The presence of anosmia had a sensitivity and a positive predictive value of 0%, but a specificity of 99.14% and a negative predictive value of 98.8%. The accuracy was 97.9%. Conclusion: Anosmia prevalence in hemodialysis population is low. Any symptoms should be investigated in the TRIAGE as a strategy to detect early individual cases of COVID-19 or outbreak in hemodialysis units. Keywords: Chronic Kidney Disease, Hemodialysis, Anosmia, COVID-19, Prevalence, pandemicsContexto. Los pacientes en hemodiálisis son una población susceptible para la enfermedad causada por el SARS-CoV-2, enfermedad por el coronavirus 2019 (COVID-19), siendo el diagnóstico temprano una necesidad urgente por considerarse una población de riesgo por presentar cuadros severos y graves. Objetivo. Estimar si la anosmia de inicio súbito permite una detección temprana de la infección por COVID-19, en pacientes de hemodiálisis sin síntomas clásicos (que no presentaron malestar general, síntomas respiratorios o gastrointestinales al inicio de la enfermedad). Metodología. Se realizó un estudio de prueba diagnóstica durante los meses de septiembre y octubre del 2020 en tres unidades de hemodiálisis en Colombia. Fueron incluidos pacientes adultos, sin síntomas clásicos para COVID-19. Se excluyó a los pacientes con infección previa por COVID-19 o con antecedentes de alteración del olfato. Se recolectaron datos demográficos, clínicos y de laboratorio, previa firma de consentimiento informado avalado por el comité de ética (CEI-487). La anosmia se exploró con una prueba subjetiva para detección de olores antes del inicio de la hemodiálisis. Resultados. Se incluyeron 587 pacientes. La prevalencia de anosmia fue de 0,85?% (cinco pacientes) y una incidencia de COVID-19 de 1,19?% (siete pacientes). No hubo diferencia estadística al comparar las variables demográficas, clínicas y de laboratorio entre pacientes con y sin anosmia. La presencia de anosmia tuvo una sensibilidad y un valor predictivo positivo del 0?%, pero una especificidad del 99,14?% y un valor predictivo negativo del 98,8?%. La exactitud fue del 97,9?%. Conclusiones. La prevalencia de anosmia en nuestra población de hemodiálisis fue baja. Se debería indagar en el triaje cualquier síntoma (incluida la alteración del sentido del olfato) como estrategia para detectar de forma temprana casos individuales de COVID-19 o un brote en las unidades de hemodiálisis. Métodos: se realizó un estudio de prueba diagnóstica en tres unidades de hemodiálisis en Colombia. Fueron incluidos pacientes adultos, sin síntomas clásicos para COVID-19. Se excluyeron pacientes con infección previa por COVID-19 o con antecedentes de alteración del olfato. Se recolectaron datos demográficos, clínicos y de laboratorio. La anosmia se exploró con una prueba objetiva para detección de olores antes del inicio de la hemodiálisis. Resultados: se incluyeron 587 pacientes. La prevalencia de anosmia fue de 0.85% (5 pacientes) y una incidencia de COVID-19 de 1.19% (7 pacientes). No hubo diferencia estadística al comparar las variables demográficas, clínicas y de laboratorio entre pacientes con y sin anosmia. La presencia de anosmia tuvo una sensibilidad y un valor predictivo positivo del 0%, pero una especificidad del 99.14% y un valor predictivo negativo del 98.8%. La exactitud fue del 97.9%. Conclusiones: la prevalencia de anosmia en la población de hemodiálisis es baja. Se debe indagar en el TRIAGE cualquier síntoma como estrategia para detectar de forma temprana casos individuales de COVID-19 o un brote en las Unidades Renales. Palabras claves: enfermedad renal crónica, hemodiálisis, anosmia, COVID-19, prevalencia, pandemia

Effect of SGLT2 Inhibitors on Stroke and Atrial Fibrillation in Diabetic Kidney Disease: Results From the CREDENCE Trial and Meta-Analysis

BACKGROUND AND PURPOSE: Chronic kidney disease with reduced estimated glomerular filtration rate or elevated albuminuria increases risk for ischemic and hemorrhagic stroke. This study assessed the effects of sodium glucose cotransporter 2 inhibitors (SGLT2i) on stroke and atrial fibrillation/flutter (AF/AFL) from CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) and a meta-analysis of large cardiovascular outcome trials (CVOTs) of SGLT2i in type 2 diabetes mellitus.METHODS: CREDENCE randomized 4401 participants with type 2 diabetes mellitus and chronic kidney disease to canagliflozin or placebo. Post hoc, we estimated effects on fatal or nonfatal stroke, stroke subtypes, and intermediate markers of stroke risk including AF/AFL. Stroke and AF/AFL data from 3 other completed large CVOTs and CREDENCE were pooled using random-effects meta-analysis.RESULTS: In CREDENCE, 142 participants experienced a stroke during follow-up (10.9/1000 patient-years with canagliflozin, 14.2/1000 patient-years with placebo; hazard ratio [HR], 0.77 [95% CI, 0.55-1.08]). Effects by stroke subtypes were: ischemic (HR, 0.88 [95% CI, 0.61-1.28]; n=111), hemorrhagic (HR, 0.50 [95% CI, 0.19-1.32]; n=18), and undetermined (HR, 0.54 [95% CI, 0.20-1.46]; n=17). There was no clear effect on AF/AFL (HR, 0.76 [95% CI, 0.53-1.10]; n=115). The overall effects in the 4 CVOTs combined were: total stroke (HRpooled, 0.96 [95% CI, 0.82-1.12]), ischemic stroke (HRpooled, 1.01 [95% CI, 0.89-1.14]), hemorrhagic stroke (HRpooled, 0.50 [95% CI, 0.30-0.83]), undetermined stroke (HRpooled, 0.86 [95% CI, 0.49-1.51]), and AF/AFL (HRpooled, 0.81 [95% CI, 0.71-0.93]). There was evidence that SGLT2i effects on total stroke varied by baseline estimated glomerular filtration rate (P=0.01), with protection in the lowest estimated glomerular filtration rate (<45 mL/min/1.73 m2]) subgroup (HRpooled, 0.50 [95% CI, 0.31-0.79]).CONCLUSIONS: Although we found no clear effect of SGLT2i on total stroke in CREDENCE or across trials combined, there was some evidence of benefit in preventing hemorrhagic stroke and AF/AFL, as well as total stroke for those with lowest estimated glomerular filtration rate. Future research should focus on confirming these data and exploring potential mechanisms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02065791

Kidney and Cardiovascular Effects of Canagliflozin According to Age and Sex: A Post Hoc Analysis of the CREDENCE Randomized Clinical Trial

Rationale & Objective: It is unclear whether the effect of canagliflozin on adverse kidney and cardiovascular events in those with diabetic kid-ney disease varies by age and sex. We assessed the effects of canagliflozin among age group categories and between sexes in the Canagli-flozin and Renal Endpoints in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) study.Study Design: Secondary analysis of a random-ized controlled trial. Setting & Participants: Participants in the CREDENCE trial. Intervention: Participants were randomly assigned to receive canagliflozin 100 mg/d or placebo.Outcomes: Primary composite outcome of kid-ney failure, doubling of serum creatinine con-centration, or death due to kidney or cardiovascular disease. Prespecified secondary and safety outcomes were also analyzed. Out-comes were evaluated by age at baseline (<60, 60-69, and >_70 years) and sex in the intention-to-treat population using Cox regression models.Results: The mean age of the cohort was 63.0 & PLUSMN; 9.2 years, and 34% were female. Older age and female sex were independently associ-ated with a lower risk of the composite of adverse kidney outcomes. There was no evidence that the effect of canagliflozin on the primary outcome (acomposite of kidney failure, a doubling of serum creatinine concentration, or death from kidney or cardiovascular causes) differed between age groups (HRs, 0.67 [95% CI, 0.52-0.87], 0.63 [0.4 8-0.82], and 0.89 [0.61-1.29] for ages <60, 60-69, and >_70 years, respectively; P = 0.3 for interaction) or sexes (HRs, 0.71 [95% CI, 0.5 4-0.95] and 0.69 [0.56-0.8 4] in women and men, respectively; P = 0.8 for interaction). No differences in safety outcomes by age group or sex were observed.Limitations: This was a post hoc analysis with multiple comparisons.Conclusions: Canagliflozin consistently reduced the relative risk of kidney events in people with diabetic kidney disease in both sexes and across age subgroups. As a result of greater background risk, the absolute reduction in adverse kidney outcomes was greater in younger participants.Funding: This post hoc analysis of the CREDENCE trial was not funded. The CREDENCE study was sponsored by Janssen Research and Development and was conducted collaboratively by the sponsor, an academic-led steering committee, and an academic research organization, George Clinical.Trial Registration: The original CREDENCE trial was registered at ClinicalTrials.gov with study number NCT02065791