Evidence in chronic kidney disease–mineral and bone disorder guidelines: is it time to treat or time to wait?

Chronic kidney disease\u2013mineral and bone disorder (CKD\u2013MBD) is one of the many important complications associated with CKD and may at least partially explain the extremely high morbidity and mortality among CKD patients. The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline document was based on the best information available at that time and was designed not only to provide information but also to assist in decision-making. In addition to the international KDIGO Work Group, which included worldwide experts, an independent Evidence Review Team was assembled to ensure rigorous review and grading of the existing evidence. Based on the evidence from new clinical trials, an updated Clinical Practice Guideline was published in 2017. In this review, we focus on the conceptual and practical evolution of clinical guidelines (from eMinence-based medicine to eVidence-based medicine and \u2018living\u2019 guidelines), highlight some of the current important CKD\u2013MBD-related changes, and underline the poor or extremely poor level of evidence present in those guidelines (as well as in other areas of nephrology). Finally, we emphasize the importance of individualization of treatments and shared decision-making (based on important ethical considerations and the \u2018best available evidence\u2019), which may prove useful in the face of the uncertainty over the decision whether \u2018to treat\u2019 or \u2018to wait\u2019

Creatine Kinase Elevation in Autosomal Dominant Polycystic Kidney Disease Patients on Tolvaptan Treatment

Background: Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary cause of end-stage kidney disease. Currently, tolvaptan is the only treatment that has proven to delay disease progression. The most notable side effect of this therapy is drug-induced liver injury; however, recently, there have been two reports of creatine kinase (CK) elevation in ADPKD patients on tolvaptan treatment. We set out to monitor and determine the actual incidence of CK elevation and evaluate its potential association with other clinical factors. Methods: This is an observational retrospective multicenter study performed in rapidly progressive ADPKD patients on tolvaptan treatment from Barcelona, Spain. Laboratory tests, demographics, treatment dose, and reported symptoms were collected from October 2018 to March 2021. Results: Ninety-five patients initiated tolvaptan treatment during follow-up. The medication had to be discontinued in 31 (32.6%) patients, primarily due to aquaretic effects (12.6%), elevated liver enzymes (8.4%), and symptomatic or persistently elevated CK levels (3.2%). Moreover, a total of 27 (28.4%) patients had elevated CK levels, with most of them being either transient (12.6%), mild and asymptomatic (4.2%), or resolved after dose reduction (3.2%) or temporary discontinuation (2.1%). Conclusion: We pre-sent the largest cohort that has monitored CK levels in a real-life setting, finding them elevated in 28.4% of patients. More research and monitoring will help us understand the clinical implications and the pathophysiological mechanism of CK elevation in this population

Creatine Kinase Elevation in Autosomal Dominant Polycystic Kidney Disease Patients on Tolvaptan Treatment

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary cause of end-stage kidney disease. Currently, tolvaptan is the only treatment that has proven to delay disease progression. The most notable side effect of this therapy is drug-induced liver injury; however, recently, there have been two reports of creatine kinase (CK) elevation in ADPKD patients on tolvaptan treatment. We set out to monitor and determine the actual incidence of CK elevation and evaluate its potential association with other clinical factors. This is an observational retrospective multicenter study performed in rapidly progressive ADPKD patients on tolvaptan treatment from Barcelona, Spain. Laboratory tests, demographics, treatment dose, and reported symptoms were collected from October 2018 to March 2021. Ninety-five patients initiated tolvaptan treatment during follow-up. The medication had to be discontinued in 31 (32.6%) patients, primarily due to aquaretic effects (12.6%), elevated liver enzymes (8.4%), and symptomatic or persistently elevated CK levels (3.2%). Moreover, a total of 27 (28.4%) patients had elevated CK levels, with most of them being either transient (12.6%), mild and asymptomatic (4.2%), or resolved after dose reduction (3.2%) or temporary discontinuation (2.1%). We pre­sent the largest cohort that has monitored CK levels in a real-life setting, finding them elevated in 28.4% of patients. More research and monitoring will help us understand the clinical implications and the pathophysiological mechanism of CK elevation in this population

Pathophysiology of bone disease in chronic kidney disease : from basics to renal osteodystrophy and osteoporosis

Chronic kidney disease (CKD) is a highly prevalent disease that has become a public health problem. Progression of CKD is associated with serious complications, including the systemic CKD-mineral and bone disorder (CKD-MBD). Laboratory, bone and vascular abnormalities define this condition, and all have been independently related to cardiovascular disease and high mortality rates. The "old" cross-talk between kidney and bone (classically known as "renal osteodystrophies") has been recently expanded to the cardiovascular system, emphasizing the importance of the bone component of CKD-MBD. Moreover, a recently recognized higher susceptibility of patients with CKD to falls and bone fractures led to important paradigm changes in the new CKD-MBD guidelines. Evaluation of bone mineral density and the diagnosis of "osteoporosis" emerges in nephrology as a new possibility "if results will impact clinical decisions". Obviously, it is still reasonable to perform a bone biopsy if knowledge of the type of renal osteodystrophy will be clinically useful (low versus high turnover-bone disease). However, it is now considered that the inability to perform a bone biopsy may not justify withholding antiresorptive therapies to patients with high risk of fracture. This view adds to the effects of parathyroid hormone in CKD patients and the classical treatment of secondary hyperparathyroidism. The availability of new antiosteoporotic treatments bring the opportunity to come back to the basics, and the knowledge of new pathophysiological pathways [OPG/RANKL (LGR4); Wnt-ß-catenin pathway], also affected in CKD, offers great opportunities to further unravel the complex physiopathology of CKD-MBD and to improve outcomes

Liposarcoma Retroperitoneal Gigante: A Propósito de un Caso

The retroperitoneal tumors represent 0.07 to 0.2% of all neoplasias. The liposarcomas are predominant forms of sarcomas, they can reach big size in the retroperitoneum, and they show like voluminous mass without specific symptomatology. The metastasis is improbable; the specific mortality is from 40 to 50% in 5 years since the diagnostic, and the prognostic depends of the histopathologic variety. The conduct is surgical and this consists in radical excision of the tumor, together with radiotherapy and chemotherapy, like palliative treatments. We present a case of giant retroperitoneal liposarcoma, differentiated of fusiforms cells; it is shown as a progressive abdominal distension with oppressive pain of moderate intensity; and the treatment effectuated was the radical surgical excision.Los tumores retroperitoneales representan un 0,07 a 0,2% de todas las neoplasias del organismo. Los liposarcomas, formas predominantes de sarcomas, se originan del mesodermo embrionario y pueden alcanzar grandes dimensiones en el retroperitoneo, presentándose en forma de masas voluminosas sin sintomatología específica. Las metástasis a distancia son poco probables; la mortalidad específica es del 40 al 50% a los 5 años del diagnóstico y su pronóstico depende de su variedad histopatológica. La conducta es quirúrgica y consiste en exéresis radical del tumor; junto con la radioterapia y la quimioterapia como tratamiento paliativo. Se presenta un caso del liposarcoma retroperitoneal gigante bien diferenciado de células fusiformes; manifestado por distensión abdominal progresiva acompañado de dolor tipo opresivo de moderada intensidad y el tratamiento efectuado, la resección quirúrgica radical

Valores Espirométricos en Estudiantes de Medicina de la Universidad Mayor de San Simón (Junio ; Diciembre 2009)

Background: Spirometric values are an invaluable test of health screening of the respiratory and identifying individuals at risk for lung disease, it is therefore important to establish reference values of each community. Objectives: To determine the values of peak expiratory flow (PEF) and Forced Expiratory Volume in one second (FEV-1) students of the Faculty of Medicine of the Universidad Mayor de San Simón, period June-December 2009; also determine average values FEM in students who smoke and nonsmokers, and those who do physical exercise and students not healthy or lung disease and / or heart disease. Materials and methods: In this prospective, longitudinal study. Sample 221 students (18-25 years). We used the preset measurement technique using a spirometer internationally Microlife ® manual. Data were collected on a log sheet and statistical analysis (t-Student and correlation) was performed in SPSS. Results: The mean values of PEF in L / min were 517,28 ± 145,19 in healthy subjects, 421,42 ± 156,04 in people with lung disease and / or heart rate (p = 0,00) in people smokers and 523,74 ± 151,03 426,31 ± 154,81 in nonsmokers (p = 0,00) and between people and athletes 466,72 ± 160 424,86 ± 155,61 in non-athletes (p = 0,071) The average values of FEV-1 in L / sec were: 3,39 male (18-20 years) and 3,76 (21-25 years), women 2,79 (18-20 years) and 2,72 (21-25 years). Conclusion: The values of PEF and FEV-1 are lower than international values, and are in direct relation to height. Healthy people, smokers have a higher PEF value.Introducción: Los valores espirométricos constituyen un test de detección invaluable de salud del aparato respiratorio e identifican individuos en riesgo de enfermedad pulmonar, por tanto es importante establecer valores de referencia de cada comunidad. Objetivos: Determinar los valores del Flujo Espiratorio Máximo (FEM) y Volumen Espiratorio Forzado en el primer segundo (FEV-1) en estudiantes de la Facultad de Medicina de la Universidad Mayor de San Simón, período Junio � Diciembre 2009; además determinar valores promedio de FEM en estudiantes que fuman y no fuman, realizan deporte y aquellos que no, y estudiantes sanos o con patología pulmonar y/o cardíaca. Materiales y métodos: Estudio descriptivo, prospectivo y longitudinal. Muestra 221 estudiantes (18 a 25 años). Se utilizó la técnica de medición preestablecida internacionalmente empleando un espirómetro manual. Los datos se recolectaron en una hoja de registro y el análisis estadístico (t-Student y correlación) se realizó en SPSS. Resultados: Los valores promedio de FEM en L/min fueron: 517,28±145,19 en personas sanas, 421,42±156,04 en personas con patología pulmonar y/o cardíaca (p<0,001); en personas fumadoras 523,74±151,03, en no fumadores 426,31±154,81 (p<0,001); entre personas deportistas 466,72±160 y 424,86±155,61 en no deportistas (p=0,071). Los valores promedio de FEV-1 en L/seg fueron: varones 3,39 (18-20 años) y 3,76 (21-25 años), mujeres 2,79 (18- 20 años) y 2,72 (21-25 años). Conclusión: Los valores de FEM y FEV-1 son inferiores a valores internacionales, y están en relación directa con la estatura. Las personas sanas, fumadoras poseen un valor de FEM más alto

Estudio Exploratorio de los Postulantes al Sistema Nacional de Residencia Médica de Cochabamba, Bolivia, el año 2011

The work aims to analyze how physicians trained in the Faculty of Medicine �Dr. Aurelio Meleán� at University Mayor de San Simón), approve the selection process to continue postgradual studies training in the National Médical Residency. Also determine the number of qualified médical professionals involved in this process, establishing the percentage of admitted in the system and the relationship between the source of information, documentation of the admission system, the records of the admissions process and results of the Graduate School and Continuing Education of the Faculty of Medicine, using descriptive statistic techniques for processing and analysis of data, that show a favorable percentage of applicants from the UMSS Faculty of Medicine in the Médical Residency System ( of 97 eligible candidates, 67 belong to this institution) compared to doctors trained in other public and private universities in the country. However, this study raises questions relating to the training aspect and the process of selection of the Médical Residency that should be addressed in future researchesEl siguiente trabajo está orientado a analizar en qué medida los médicos formados en la Facultad de Medicina �Dr. Aurelio Meleán� de la Universidad Mayor de San Simón, superan el proceso de selección para continuar estudios de formación postgradual en el Sistema Nacional de la Residencia Médica . Así mismo determinar el número de médicos titulados que participan en dicho proceso, estableciendo el porcentaje de admitidos en el sistema y la relación existente entre el número de plazas ofertadas y los aceptados de acuerdo a la procedencia de formación universitaria de los postulantes. Para esto se recurrió como fuente principal de la información, a la documentación normativa del sistema, los registros del proceso de admisión y de resultados de la Escuela de Graduados y Educación Continua de la Facultad de Medicina, utilizándose para su elaboración y análisis, técnicas de estadística descriptiva que muestran una relación porcentual favorable de postulantes de la Facultad de Medicina de la UMSS admitidos en el Sistema de Residencia Médica (de 97 postulantes admitidos, 67 corresponden a esta institución) frente a médicos formados en otras universidades públicas y privadas del país. Sin embargo este estudio plantea interrogantes referidas al aspecto formativo y al proceso de selección de la residencia médica que deberían ser abordados en futuros estudios de investigació