La fragilidad en el anciano con enfermedad renal crónica

ResumenEn los últimos años el concepto de fragilidad como «estado de prediscapacidad» se ha extendido de forma amplia en todos los que trabajamos en beneficio de la persona mayor. Su importancia radica no solo en su elevada prevalencia —superior al 25% en mayores de 85 años—, sino a que es considerada un factor de riesgo independiente, que confiere a los ancianos que lo presentan un riesgo elevado de discapacidad, institucionalización y mortalidad.El estudio de la función renal es relevante en pacientes que soportan gran carga de comorbilidad, habiéndose encontrado una importante asociación entre la enfermedad renal crónica y el desarrollo de eventos clínicos adversos como la enfermedad cardiovascular, la insuficiencia cardiaca, la enfermedad renal terminal, el incremento de la susceptibilidad a infecciones y el mayor deterioro funcional.La fragilidad puede ser una situación reversible, por lo que su estudio en el paciente con enfermedad renal crónica es de especial interés. Este artículo tiene por objeto describir las interrelaciones existentes entre envejecimiento, fragilidad y enfermedad renal crónica a la luz de la bibliografía pertinente más relevante y reciente publicada.AbstractIn recent years, the concept of frailty as a “state of pre-disability” has been widely accepted by those involved in the care of the elderly. Its importance lies not only in its high prevalence - more than 25% in people over 85 years of age - but it is also considered an independent risk factor of disability, institutionalisation and mortality amongst the elderly.The study of renal function is relevant in patients with major comorbidities. Studies have shown a significant association between chronic kidney disease and the development of adverse clinical outcomes such as heart disease, heart failure, end-stage renal disease, increased susceptibility to infections and greater functional impairment.Frailty can be reversed, which is why a study of frailty in patients with chronic kidney disease is of particular interest. This article aims to describe the association between ageing, frailty and chronic kidney disease in light of the most recent and relevant scientific publications

Spanish study of anticoagulation in haemodialysis

This study's objectives were to determine which anticoagulation methods are commonly used in patients who are undergoing haemodialysis (HD) in Spain, on what criteria do they depend, and the consequences arising from their use. MATERIAL AND METHOD: Ours was a cross-sectional study based on two types of surveys: a "HD Centre Survey" and a "Patient Survey". The first survey was answered by 87 adult HD units serving a total of 6093 patients, as well as 2 paediatric units. Among these units, 48.3% were part of the public health system and the remaining 51.7% units were part of the private health system. The patient survey analysed 758 patients who were chosen at random from among the aforementioned 78 HD units. RESULTs: A) HD Centre Survey: The majority of adult HD units (n=61, 70.2%) used both kinds of heparin, 19 of them (21.8%) only used LMWH and 7 of them (8%) only used UFH. The most frequently applied criteria for the use of LMWH were medical indications (83.3% of HD units) and ease of administration (29.5%). The most frequently used methods for adjusting the dosage were clotting of the circuit (88.2% of units), bleeding of the vascular access after disconnection (75.3%), and patient weight (57.6%). B) Patient Survey: The distribution of the types of heparin used was: UFH: 44.1%, LMWH: 51.5%, and dialysis without heparin in 4.4% of patients. LMWH was more frequently used in public medical centres (64.2% of patients) than in private medical centres (46.1%) (P<.001). LMWH was more frequently used in on-line haemodiafiltration (HF) than in high-flux HD (P<.001). Antiplatelet agents were given to 45.5% of patients, oral anticoagulants to 18.4% of patients, and both to 5% of patients. Additionally, 4.4% of patients had suffered bleeding complications during the previous week, and 1.9% of patients suffered thrombotic complications. Bleeding complications were more frequent in patients with oral anticoagulants (P=.001), although there was no association between the type of heparin and the occurrence of bleeding or thrombotic complications. CONCLUSIONS: We are able to conclude that there is a great amount of disparity in the criteria used for the medical prescription of anticoagulation in HD. It is advisable that each HD unit revise their own results as well as those from other centres, and possibly to create an Anticoagulation Guide in Haemodialysis

Lipoprotein(A) Concentrations In Rheumatoid Arthritis On Biologic Therapy: Results From The Cardiovascular In Rheumatology [Carma] Study Project

Background Plasma concentrations of lipoprotein (a) (Lp(a)), a lipoprotein with atherogenic and thrombogenic properties, have a strong genetic basis, although high concentrations of Lp(a) have also been reported in the context of inflammation, as in rheumatoid arthritis (RA). Few studies evaluate the impact of biologic therapies (BT) on Lp(a) in RA, taking into account that with these new therapies a better control of inflammation is achieved. Objective The aim of the study was to evaluate the plasma concentrations of Lp(a) in Spanish RA patients on BT attending rheumatology outpatient clinics. Methods Baseline analysis of the CARdiovascular in rheuMAtology project, a 10-year prospective study, evaluating the risk of cardiovascular events in RA and other forms of inflammatory arthritis. RA patients were classified according to treatment: no biologic, anti-tumor necrosis factor, anti-interleukin-6 receptor tocilizumab (TCZ), and other biologic (rituximab or abatacept). A model of linear multivariate regression was built in which the dependent variable was Lp(a) concentration and the explanatory variable was BT. The model was adjusted for confounding factors. Results Seven hundred and seventy-five RA patients were analyzed. Plasma concentrations of total cholesterol and triglyceride were significantly higher in TCZ-treated patients. Nevertheless, no significant difference in the atherogenic index between TCZ-treated patients and patients without BT was found. After adjusting for confounding factors, patients with BT had lower concentrations of Lp(a) than those without BT; however, only TCZ-treated patients achieved statistically significant differences (?: ?0.303, 95% confidence interval: ?0.558 to ?0.047; P = .02). Conclusions RA patients treated with TCZ show lower plasma concentrations of Lp(a) compared with patients without BT.This project has been supported by an unrestricted grant from Abbvie, Spain. The design, analysis, interpretation of results, and preparation of the article have been done independently of Abbvie. Dr González-Gay's studies have been supported by grants from “Fondo de Investigaciones Sanitarias” PI06/0024, PS09/00748, and PI12/00060 and RD12/0009/0013 (RIER) from “Instituto de Salud Carlos III” (ISCIII) (Spain)

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 ionizationtime 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

Frailty in elderly people with chronic kidney disease

In recent years, the concept of frailty as a “state of pre-disability” has been widely accepted by those involved in the care of the elderly. Its importance lies not only in its high prevalence – more than 25% in people over 85 years of age – but it is also considered an independent risk factor of disability, institutionalisation and mortality amongst the elderly. The study of renal function is relevant in patients with major comorbidities. Studies have shown a significant association between chronic kidney disease and the development of adverse clinical outcomes such as heart disease, heart failure, end-stage renal disease, increased susceptibility to infections and greater functional impairment. Frailty can be reversed, which is why a study of frailty in patients with chronic kidney disease is of particular interest. This article aims to describe the association between ageing, frailty and chronic kidney disease in light of the most recent and relevant scientific publications

Spanish study of anticoagulation in haemodialysis

This study's objectives were to determine which anticoagulation methods are commonly used in patients who are undergoing haemodialysis (HD) in Spain, on what criteria do they depend, and the consequences arising from their use. MATERIAL AND METHOD: Ours was a cross-sectional study based on two types of surveys: a "HD Centre Survey" and a "Patient Survey". The first survey was answered by 87 adult HD units serving a total of 6093 patients, as well as 2 paediatric units. Among these units, 48.3% were part of the public health system and the remaining 51.7% units were part of the private health system. The patient survey analysed 758 patients who were chosen at random from among the aforementioned 78 HD units. RESULTs: A) HD Centre Survey: The majority of adult HD units (n=61, 70.2%) used both kinds of heparin, 19 of them (21.8%) only used LMWH and 7 of them (8%) only used UFH. The most frequently applied criteria for the use of LMWH were medical indications (83.3% of HD units) and ease of administration (29.5%). The most frequently used methods for adjusting the dosage were clotting of the circuit (88.2% of units), bleeding of the vascular access after disconnection (75.3%), and patient weight (57.6%). B) Patient Survey: The distribution of the types of heparin used was: UFH: 44.1%, LMWH: 51.5%, and dialysis without heparin in 4.4% of patients. LMWH was more frequently used in public medical centres (64.2% of patients) than in private medical centres (46.1%) (P<.001). LMWH was more frequently used in on-line haemodiafiltration (HF) than in high-flux HD (P<.001). Antiplatelet agents were given to 45.5% of patients, oral anticoagulants to 18.4% of patients, and both to 5% of patients. Additionally, 4.4% of patients had suffered bleeding complications during the previous week, and 1.9% of patients suffered thrombotic complications. Bleeding complications were more frequent in patients with oral anticoagulants (P=.001), although there was no association between the type of heparin and the occurrence of bleeding or thrombotic complications. CONCLUSIONS: We are able to conclude that there is a great amount of disparity in the criteria used for the medical prescription of anticoagulation in HD. It is advisable that each HD unit revise their own results as well as those from other centres, and possibly to create an Anticoagulation Guide in Haemodialysis

Methodological approach to designing a telecare system for pre-dialysis and peritoneal dialysis patients

Antecedentes: Un importante obstáculo que dificulta el despliegue de soluciones tecnológicas en sanidad es el rechazo que encuentran los sistemas desarrollados por los usuarios que tienen que utilizarlos (ya sean profesionales sanitarios o pacientes), que consideran que no se adaptan a sus necesidades reales. Objetivos: (1) Diseñar una arquitectura tecnológica para la asistencia remota de pacientes nefrológicos aplicando una metodología que prime la implicación de los usuarios (profesionales y pacientes) en todo el diseño y desarrollo; (2) ilustrar cómo las necesidades de los usuarios pueden ser recogidas y respondidas mediante la tecnología, aumentando el nivel de aceptación de los sistemas finales. Métodos: Para obtener las principales necesidades que existen actualmente en Nefrología se implicó a un conjunto de servicios españoles de la especialidad. Se realizó una recogida de necesidades mediante entrevistas semiestructuradas al equipo médico y cuestionarios a profesionales y pacientes. Resultados: Se extrajeron un conjunto de requisitos tanto de profesionales como de pacientes y, paralelamente, el grupo de ingenieros biomédicos identificó requisitos de la asistencia remota de pacientes desde un punto de vista tecnológico. Todos estos requisitos han dado pie al diseño de una arquitectura modular para la asistencia remota de pacientes en diálisis peritoneal y prediálisis. Conclusiones: Este trabajo ilustra cómo es posible implicar a los usuarios en todo el proceso de diseño y desarrollo de un sistema. Fruto de este trabajo es el diseño de una arquitectura modular adaptable para asistencia remota de pacientes nefrológicos respondiendo a las preferencias y necesidades de los usuarios pacientes y profesionales consultados.Background: A major obstacle that hinders the implementation of technological solutions in healthcare is the rejection of developed systems by users (healthcare professionals and patients), who consider that they do not adapt to their real needs. Objectives: (1) To design technological architecture for the telecare of nephrological patients by applying a methodology that prioritises the involvement of users (professionals and patients) throughout the design and development process; (2) to show how users’ needs can be determined and addressed by means of technology, increasing the acceptance level of the final systems. Methods: In order to determine the main current needs in Nephrology, a group of Spanish Nephrology Services was involved. Needs were recorded through semi-structured interviews with the medical team and questionnaires for professionals and patients. Results: A set of requirements were garnered from professionals and patients. In parallel, the group of biomedical engineers identified requirements for patient telecare from a technological perspective. All of these requirements drove the design of modular architecture for the telecare of peritoneal dialysis and pre-dialysis patients. Conclusions: This work shows how it is possible to involve users in the whole process of design and development of a system. The result of this work is the design of adaptable modular architecture for the telecare of nephrological patients and it addresses the preferences and needs of patient and professional users consulted