Efecto de la hiperuricemia en el endotelio y en la función renal de pacientes con trasplante renal

La tesis “Efecto de la hiperuricemia en el endotelio y en la función renal de pacientes con trasplante renal” intenta aproximarse al papel del ácido úrico sérico como factor de disfunción endotelial e inflamación en una población de pacientes trasplantados renales. A lo largo de la historia de la medicina, al ácido úrico se ha postulado, por un lado, como una molécula con propiedades beneficiosas como factor evolutivo en el homo sapiens y, por otro lado, como molécula patogénica implicada en la fisiopatología de algunas enfermedades. Sin embargo, hasta el día de hoy, no existe una explicación plausible con la suficiente evidencia que justifique el papel causal del ácido úrico sérico en ciertas enfermedades cardiovasculares como en la hipertensión arterial en el adulto, enfermedad renal crónica, diabetes mellitus tipo II o síndrome metabólico. Un mecanismo fisiopatológico propuesto para explicar la acción del ácido úrico en las enfermedades cardiovasculares es la disfunción endotelial. En este estudio hemos seleccionado una muestra de pacientes con elevada carga de enfermedad cardiovascular (pacientes con trasplante renal) y hemos analizado el efecto de los niveles de ácido úrico sérico y su relación con marcadores de disfunción endotelial e inflamación (VCAM, ICAM, IL10, CD40, TNFa, E-selectina, P-selectina, PCR). Se trata de un estudio observacional, prospectivo con seguimiento durante el primer año postrasplante de un total de 38 pacientes. La obtención de muestras para el análisis se realizó en los meses tres y doce del trasplante renal. El análisis estadístico fue llevado a cabo con el software SPSS en su versión 22 para Windows. Tanto para las pruebas paramétricas como no paramétricas utilizadas en el análisis de los datos se consideraron significativos los valores de p inferiores a 0,05. En nuestro estudio hemos observado una mejoría de los marcadores endoteliales VCAM e ICAM durante el primer año del trasplante. En el estudio comparativo hemos encontrado que los pacientes con niveles de uricemia por encima del cuartil 3 presentaron niveles superiores de TNFa y VCAM a los tres meses del trasplante y de MAU a los doce meses. Sin embargo, no hemos podido demostrar correlación positiva entre niveles de urato sérico con marcadores de disfunción endotelial y de inflamación en nuestra muestra. Tras estratificar la muestra para minimizar el efecto de factores de confusión, hemos observado que los pacientes con diabetes mellitus tenían niveles superiores de TNFa y urato sérico al año del trasplante renal. Los pacientes tratados con inhibidores de la enzima convertidora de la angiotensina (IECA) o antagonistas del receptor de la angiotensina (ARA-II) presentaron niveles inferiores de P- selectina sin relación con los niveles de urato sérico. En el caso de los pacientes con infección por citomegalovirus (CMV) presentaron niveles más elevados de TNFa al tercer mes y de ácido úrico sérico al decimosegundo mes del trasplante renal. Por último, los pacientes con función retrasada del injerto renal (RFI) presentaron aumento de PCR y VCAM al tercer mes y de PCR al mes doce del trasplante renal. En definitiva, este estudio fue proyectado con una finalidad exploratoria, con la idea de conocer que perfil de marcadores de disfunción endotelial e inflamación podríamos encontrar en los trasplantados renales e investigar la relación entre la disfunción endotelial y los niveles de ácido úrico sérico en este tipo de población.The thesis "Effect of hyperuricemia on the endothelium and renal function of patients with renal transplantation" attempts to approximate the role of serum uric acid as a factor of endothelial dysfunction and inflammation in a population of kidney transplant patients. Throughout the history of medicine, uric acid has been postulated, on the one hand, as a molecule with beneficial properties as an evolutionary factor in homo sapiens and, on the other hand, as a pathogenic molecule involved in the pathophysiology of some diseases . However, to this day, there is no plausible explanation with sufficient evidence to justify the causal role of serum uric acid in certain cardiovascular diseases such as in adult hypertension, chronic kidney disease, type II diabetes mellitus or syndrome. metabolic. A pathophysiological mechanism proposed to explain the action of uric acid in cardiovascular diseases is endothelial dysfunction. In this study we have selected a sample of patients with a high burden of cardiovascular disease (patients with renal transplantation) and we have analyzed the effect of serum uric acid levels and their relationship with markers of endothelial dysfunction and inflammation (VCAM, ICAM, IL10, CD40, TNFa, E-selectin, P-selectin, PCR). This is an observational, prospective study with follow-up during the first post-transplant year of a total of 38 patients. The collection of samples for analysis was performed in months three and twelve of the kidney transplant. The statistical analysis was carried out with the SPSS software in its version 22 for Windows. For both the parametric and non-parametric tests used in the analysis of the data, p values ​​below 0.05 were considered significant. In our study we have observed an improvement of the endothelial markers VCAM and ICAM during the first year of the transplant. In the comparative study we found that patients with uricemia levels above quartile 3 had higher levels of TNFa and VCAM at three months after transplantation and MAU at twelve months. However, we have not We were able to demonstrate positive correlation between serum urate levels with markers of endothelial dysfunction and inflammation in our sample. After stratifying the sample to minimize the effect of confounding factors, we have observed that patients with diabetes mellitus had higher levels of TNFa and serum urate one year after renal transplantation. Patients treated with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor antagonists (ARA-II) had lower levels of P-selectin without relation to serum urate levels. In the case of patients with cytomegalovirus (CMV) infection, they presented higher levels of TNFa at the third month and serum uric acid at the twelfth month of renal transplantation. Finally, patients with delayed renal graft function (RFI) presented an increase in CRP and VCAM at the third month and at CRP 12 months after renal transplantation. In short, this study was projected with an exploratory purpose, with the idea of ​​knowing what profile of markers of endothelial dysfunction and inflammation we could find in kidney transplants and investigating the relationship between endothelial dysfunction and serum uric acid levels in this type of population

Impact of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients: A nationwide study in Spain

Objective To assess the effect of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients in Spain. Settings The initial flood of COVID-19 patients overwhelmed an unprepared healthcare system. Different measures were taken to deal with this overburden. The effect of these measures on neurosurgical patients, as well as the effect of COVID-19 itself, has not been thoroughly studied. Participants This was a multicentre, nationwide, observational retrospective study of patients who underwent any neurosurgical operation from March to July 2020. Interventions An exploratory factorial analysis was performed to select the most relevant variables of the sample. Primary and secondary outcome measures Univariate and multivariate analyses were performed to identify independent predictors of mortality and postoperative SARS-CoV-2 infection. Results Sixteen hospitals registered 1677 operated patients. The overall mortality was 6.4%, and 2.9% (44 patients) suffered a perioperative SARS-CoV-2 infection. Of those infections, 24 were diagnosed postoperatively. Age (OR 1.05), perioperative SARS-CoV-2 infection (OR 4.7), community COVID-19 incidence (cases/10 5 people/week) (OR 1.006), postoperative neurological worsening (OR 5.9), postoperative need for airway support (OR 5.38), ASA grade =3 (OR 2.5) and preoperative GCS 3-8 (OR 2.82) were independently associated with mortality. For SARS-CoV-2 postoperative infection, screening swab test <72 hours preoperatively (OR 0.76), community COVID-19 incidence (cases/10 5 people/week) (OR 1.011), preoperative cognitive impairment (OR 2.784), postoperative sepsis (OR 3.807) and an absence of postoperative complications (OR 0.188) were independently associated. Conclusions Perioperative SARS-CoV-2 infection in neurosurgical patients was associated with an increase in mortality by almost fivefold. Community COVID-19 incidence (cases/10 5 people/week) was a statistically independent predictor of mortality. Trial registration number CEIM 20/217

Incidencia de enfermedades neoplásicas en pacientes con trasplante renal según tipo de inmunosupresión de inducción

El trasplante renal (TR) es actualmente la mejor opción de terapia renal sustitutiva. Entre las estrategias dirigidas a mejorar tanto la supervivencia del TR como la del paciente, aquellas encaminadas a reducir y adaptar la inmunosupresión junto a las que intentan lograr una mayor tolerancia inmunológica están cobrando un protagonismo creciente El basiliximab y la timoglobulina son actualmente los dos fármacos inmunosupresores más empleados en la terapia de inducción al TR. Sus mecanismos de acción son diferentes, mientras que sus efectos son similares en cuanto a la supervivencia del injerto y del paciente. Los estudios prospectivos en este campo entrañan múltiples dificultades y, por tanto, son escasos, por lo que nuestra evidencia científica se basa en trabajos retrospectivos. Haciendo uso de nuestra amplia casuística en TR, proponemos un estudio para comparar incidencia de neoplasias malignas (objetivo primario), infecciones, rechazo agudo, supervivencia del injerto censurada por mortalidad y supervivencia del paciente (objetivos secundarios) según el esquema de inmunosupresión de inducción recibid

Patients awaiting surgery for neurosurgical diseases during the first wave of the COVID-19 pandemic in Spain: a multicentre cohort study.

The large number of infected patients requiring mechanical ventilation has led to the postponement of scheduled neurosurgical procedures during the first wave of the COVID-19 pandemic. The aims of this study were to investigate the factors that influence the decision to postpone scheduled neurosurgical procedures and to evaluate the effect of the restriction in scheduled surgery adopted to deal with the first outbreak of the COVID-19 pandemic in Spain on the outcome of patients awaiting surgery. This was an observational retrospective study. A tertiary-level multicentre study of neurosurgery activity between 1 March and 30 June 2020. A total of 680 patients awaiting any scheduled neurosurgical procedure were enrolled. 470 patients (69.1%) were awaiting surgery because of spine degenerative disease, 86 patients (12.6%) due to functional disorders, 58 patients (8.5%) due to brain or spine tumours, 25 patients (3.7%) due to cerebrospinal fluid (CSF) disorders and 17 patients (2.5%) due to cerebrovascular disease. The primary outcome was mortality due to any reason and any deterioration of the specific neurosurgical condition. Second, we analysed the rate of confirmed SARS-CoV-2 infection. More than one-quarter of patients experienced clinical or radiological deterioration. The rate of worsening was higher among patients with functional (39.5%) or CSF disorders (40%). Two patients died (0.4%) during the waiting period, both because of a concurrent disease. We performed a multivariate logistic regression analysis to determine independent covariates associated with maintaining the surgical indication. We found that community SARS-CoV-2 incidence (OR=1.011, p Patients awaiting neurosurgery experienced significant collateral damage even when they were considered for scheduled procedures