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Background There is scarce evidence on the fourth dose of severe acute respiratory syndrome coronavirus 2 vaccines in chronic kidney disease (CKD) patients. We evaluated the humoral response and effectivity of the fourth dose in the CKD spectrum: non-dialysis CKD (ND-CKD), haemodialysis (HD), peritoneal dialysis (PD) and kidney transplant (KT) recipients. Methods This is a prespecified analysis of the prospective, observational, multicentric SENCOVAC study. In patients with CKD who had received a complete initial vaccination and one or two boosters and had anti-Spike antibody determinations 6 and 12 months after the initial vaccination, we analysed factors associated with persistent negative humoral response and higher anti-Spike antibody titres as well as the efficacy of vaccination on coronavirus disease 2019 (COVID-19) severity. Results Of 2186 patients (18% KT, 8% PD, 69% HD and 5% ND-CKD), 30% had received a fourth dose. The fourth dose increased anti-Spike antibody titres in HD (P = .001) and ND-CKD (P = .014) patients and seroconverted 72% of previously negative patients. Higher anti-Spike antibody titres at 12 months were independently associated with repeated exposure to antigen (fourth dose, previous breakthrough infections), previous anti-Spike antibody titres and not being a KT recipient. Breakthrough COVID-19 was registered in 137 (6%) patients, 5% of whom required admission. Admitted patients had prior titres Conclusions A fourth vaccine dose increased anti-Spike antibody titres or seroconverted many CKD patients, but those with the highest need for a vaccine booster (i.e. those with lower pre-booster antibody titres or KT recipients) derived the least benefit in terms of antibody titres. Admission for breakthrough COVID-19 was associated with low anti-Spike antibody titres.

Novel solutions need to be further developed to continue to improve the energy efficiency of buildings achieved over the last few decades. One of these innovative systems is the use of sunspaces to preheat the ventilation intake air and reduce heating consumption. The main goal of this research is to determine the optimal configuration of these sunspaces. For that purpose, a prototype was built to calibrate a simulation model. Once validated, the model was used to calculate the energy savings obtained with 96 sunspace configurations in the different Spanish climate zones. Different key factors were analyzed and the optimal configurations were established in each zone. The results show that, although these systems are based on solar gains, a low thermal transmittance of the glazing has a higher impact on the energy savings than a high solar heat gain coefficient. In addition, introducing inertia tanks is not convenient when the ventilation includes a heat recovery system. While combining sunspaces with heat recovery ventilation is not interesting in warmer climates; in cold climates, heat recovery becomes a determining factor to reduce energy consumption. The use of sunspaces is more efficient as the winter severity increases: while in the warmest Spanish climate zone, only 2.51 kWh.m(-2).year(-1) savings are achieved; in the coldest zone, 39.54 kWh.m(-2).year(-1) savings are obtained, which represents important energy savings of 60%. This research contributes to evaluating and quantifying the impact of key variables on the design, configuration, and operation of sunspaces to improve the energy efficiency of buildings. We would like to thank the Thermal Area of The Laboratory for the Quality Control in Buildings of the Basque Government for their assistance. We would also like to thank AEMET, the State Meteorological Agency, for providing the weather information. This research is included in the activities related to the CAVESIA project.

In the context of the current planetary environmental and social emergency, it is essential to seek strategies for sustainable development. In line with the Social Development Goals (SDG), these strategies must facilitate action from an energy perspective and give citizens a central role. Given that global challenges must be addressed through local action, the transition towards energy decentralisation through Local Energy Communities (LEC) is of central importance. The general objective of this research is to identify characteristics that are key in order for a LEC to act as a driver of local sustainable development and social innovation. This paper has deepened knowledge around these structures in order to identify the keys to their effective operation. Attention is also focused on actions carried out by these communities in the field of energy and beyond. This research corroborates that while some of them only engage with energy, others are more integrative. These latter implement a number of different actions – in line with SDGs— that promote local sustainable development. This study concludes that LECs are high-potential structures that can act as drivers of local sustainable development.

Cities are the main contributors to pollution, resource consumption and social inequalities. Therefore, they should play a key role in the path towards a more sustainable scenario in line with SDGs and different Urban Agendas. However, there are still difficulties in their implementation and citizen can play a central role. This paper presents the Urban Action Structures (UAS), understood as entities with a catalytic capacity with respect to innovative urban policies. Methodologically, firstly, a prospective analysis from regional to international level has been developed, making it possible to identify innovative lines of action in the field of sustainable cities. Secondly, the study has focused on identifying and studying UAS that can make it possible to implement the lines of action previously identified. This paper has shown that there are already social structures that can be understood as UAS, since they implement actions aligned with the priorities of the Urban Agenda for the Basque Country and, therefore, of the SDGs. The research concludes that UAS can play a key role in facilitating the implementation of Urban Agendas. Hence, urban policies should favor the generation of UAS, in order to promote long-term urban development and to foster a more sustainable spatial planning. This research was funded by the Directorate of territorial planning and urban agenda of the department of territorial planning, housing and transport of the Basque government as part of the financing for CISO30 project, “Action plan for the promotion and implementation of the PCTI Euskadi 2020–2030 in the field of sustainable cities”.

The main objective of this article is to demonstrate that passive energy refurbishment interventions influence comfort conditions of households for both cold and hot annual periods, while they help to avoid or promote temperature-related health risk situations. However, improving the thermal efficiency of the building envelope is encouraged in order to reduce energy demand for heating and cooling instead of considering also their impact on users' health. The calculation methodology to quantify improvements, on the other hand, is drawn from regulation-based standards, which describe the optimal achievable efficiency levels and energy cost savings. The present study, however, addresses how diverse thermal performance variables are (climate, thermal comfort range and occupancy rate), and shows that different thermal assessment standards influence the obtained results. An energy simulation approach was developed to evaluate different scenarios and compare the results. In conclusion, the results contribute to an understanding or to a discussion of the suitability of current energy renovation policies with regard to indoor thermal comfort and temperature-related health risk situations. The corresponding author would like to acknowledge the Department of Education, Language Policy and Culture of the Basque Government for the Predoctoral Training Programme for Non-Doctor Research Personnel from which was beneficent (PRE_2015_1_002) during the research period. Furthermore, the authors thank the Department of Architecture of the University of the Basque Country for the financial support given for this research.

We advocate the widespread use of UV-C light as a short-term, easily deployable, and affordable way to limit virus spread in the current SARS-CoV-2 pandemic. Radical social distancing with the associated shutdown of schools, restaurants, sport clubs, workplaces, and traveling has been shown to be effective in reducing virus spread, but its economic and social costs are unsustainable in the medium term. Simple measures like frequent handwashing, facial masks, and other physical barriers are being commonly adopted to prevent virus transmission. However, their efficacy may be limited, particularly in shared indoor spaces, where, in addition to airborne transmission, elements with small surface areas such as elevator buttons, door handles, and handrails are frequently used and can also mediate transmission. We argue that additional measures are necessary to reduce virus transmission when people resume attending schools and jobs that require proximity or some degree of physical contact. Among the available alternatives, UV-C light satisfies the requirements of rapid, widespread, and economically viable deployment. Its implementation is only limited by current production capacities, an increase of which requires swift intervention by industry and authorities.

An increasing number of studies apply life-cycle assessment methodology to assess the impact of a new building or to prioritize between different building refurbishment strategies. Among the different hypotheses to consider during the application of this methodology, the selection of the impact indicator is critical, as this choice will completely change the interpretation of the results. This article proposes applying four indicators that allow analysing the results of a refurbishment project of a residential building with the life-cycle approach: non-renewable primary energy use reduction (NRPER), net energy ratio (NER), internal rate of return (IRR), and life-cycle payback (LC-PB). The combination of environmental and economic indicators when evaluating the results has allowed to prioritize among the different strategies defined for this case study. Furthermore, an extensive sensitivity assessment reflects the high uncertainty of some of the parameters and their high influence on the final results. To this end, new hypotheses related to the following parameters have been considered: reference service life of the building, estimated service life of material, operational energy use, conversion factor, energy price, and inflation rate. The results show that the NRPE use reduction value could vary up to &minus, 44%. The variation of the other indicators is also very relevant, reaching variation rates such as 100% in the NER, 450% in the IRR, and 300% in the LC-PB. Finally, the results allow to define the type of input or hypothesis that influences each indicator the most, which is relevant when calibrating the prioritization process for the refurbishment strategy.

La hemicránea continua es un tipo de cefalea primaria que pertenece al grupo de las llamadas cefaleas trigémino-autonómicas. Se caracteriza por dolor estrictamente unilateral, sin desplazamiento lateral, de intensidad generalmente moderada, que puede además asociar exacerbaciones. El dolor suele ser diario y continuo. Uno de los parámetros que mejor definen esta entidad es su extraordinaria respuesta a indometacina. Se seleccionaron 78 pacientes diagnosticados de hemicránea continua por la Unidad de Cefaleas del servicio de Neurología del Hospital Clínico Universitario de Valladolid. Se recopilaron una serie de datos a través de las historias clínicas de dichos pacientes en un estudio descriptivo de carácter retrospectivo. De nuestros pacientes, un 70,5% fueron mujeres. La edad media del diagnóstico fue de 51,06 (DT: 13,7). Un 29,5% de los pacientes referían otras cefaleas. La intensidad media del dolor basal fue de 5,41 (DT: 1,7), escala EVA; el dolor basal era cualitativamente opresivo en un 66,7% de los pacientes; unilateral en un 100% de la muestra y de localización frontal en un 42,3%. El 93,6% de los pacientes presentaron exacerbaciones con una media de dolor de 8,47 (DT: 1,3); de estos, tan sólo un 4,4% referían algún factor desencadenante. El 50% de los pacientes presentaron síntomas trigémino-autonómicos acompañantes; entre los que predominaban lagrimeo (37,2%) e inyección conjuntival (29,5%); además, un 13% de los pacientes presentaron otros síntomas acompañantes como fotofobia, fonofobia, nauseas, traqueteo y alodinia. El 47,4% de los pacientes no respondían a analgésicos convencionales; un 33,3% abusaban de la medicación; y un 97,4% se trataron con indometacina consiguiendo una respuesta satisfactoria a distintas dosis. Se llevaron a cabo infiltraciones como tratamiento alternativo en un 29,4% de los pacientes. La hemicránea continua es una entidad con características clínicas y terapéuticas específicas que la definen. Existen tratamientos potencialmente eficaces para su abordaje., Grado en Medicina

Eraikuntza-sektorerako bizi-ziklo analisiaren metodologia estandarizatu arren, ikertzaileek sistemaren irismenaren inguruan sinplifikazio batzuk aplikatzeko joera dute bizi-zikloaren fase batzuk alde batera utziz. Birgaitze energetikoetan, erabile-ra-etapan jartzen da arreta bereziki, energiaren erabilera murriztea baita birgaitze horien helburu nagusia. Artikulu honek etxebizitzen birgaitze energetikoko proiektuetan, ingu-rumen- eta ekonomia-inpaktu orokorrarekin alderatuta, bizi-zikloko etapa bakoitzaren garrantzia ebaluatzen du. Azterketa kasuko birgaitze-estrategien analisiaren emaitzen arabera, garraio- eta deuseztatze-etapek garrantzi txikia dutela ikusten da. Eraikuntza-prozesuaren etapak ere garrantzi txikia du ingurumen-azterketan. Ekoizpen-, mantentze- eta ordezkatze-etapek, oro har, garrantzi handiagoa dute, batez ere, ebaluazio ekonomi-korako. Sentsibilitate-analisi zabal batek bizi-zikloaren mugak sinplifikatzeak dakartzan zailtasunak erakusten ditu, azterketa hauek klima, eraikinaren tipologia, edo aurreikusi-tako erabilera-bizitza bezalako aldagaiekin duten lotura zuzena azalduz.; Despite the standardization of the life-cycle assessment methodology for the construction sector, analysts tend to apply some simplifications in relation to the system boundaries, omitting some of the life-cycle stages. In particular, for building energy refurbishment projects, there is a general focus on the operational stage, linked to the main objective of reducing operational energy use. This paper evaluates the relevance of each life-cycle stage in relation to the overall environmental and economic impact on residential building energy refurbishment projects. The results from the anal-ysis of the refurbishment strategies at a case study in Spain show the relatively minor importance of the transport and end of life stages. The construction process stage is also of relatively minor importance regarding the environmental performance. The product, maintenance and replacement stages are generally of higher importance, par-ticularly for economic evaluation. An extensive sensitivity analysis demonstrates the difficulties of simplifying the life-cycle boundaries, suggesting that potential simplifi-cations should take into account various parameters, including the climate region, building typologies, and expected service life.

The Ekihouse is an industrialized solar house prototype, designed and developed by the University of the Basque Country for the SOLAR DECATHLON EUROPE 2012 competition held in Madrid (Spain). The building design strategies are based on the full integration of active—passive solar technologies and passive design criteria in order to achieve an energy self-sufficient proposal, providing high quality of life to its occupants. Despite its intentionally small surface area (54.6 m2), the house can be adapted to suit a wide range of lifestyles thanks to its flexible, multifunctional open plan design that can be visually and physically expanded outdoors by removing the northern and southern glazed facades (PVC joinery and 0.9 kW/h m2 °C glass). For ease of transportation and assembly, the Ekihouse consists of a modular CLT structure system (two 12.60 m × 3 m modules) that supports the photovoltaic roof (10 kWp) which functions as a canopy to protect the southern facade from direct solar radiation thereby reducing overheating problems in the building interior. In order to control the indoor temperature, PCM panels are mounted in the ceiling. When passive strategies are insufficient in extreme conditions, the house is also equipped with a ventilation and air-conditioning system that allows a 90% energy recovery. Furthermore, an outdoor evaporative cooling system helps lower the ambient temperature by up to 4 °C. A rain and grey water treatment and purification system is also installed. The operation of all this active technology is controlled by an optical domotics system.

Despite the standardization of the life-cycle assessment methodology for the construction sector, analysts tend to apply some simplifications in relation to the system boundaries, omitting some of the life-cycle stages. In particular, for building energy refurbishment projects, there is a general focus on the operational stage, linked to the main objective of reducing operational energy use. This paper evaluates the relevance of each life-cycle stage in relation to the overall environmental and economic impact on residential building energy refurbishment projects. The results from the analysis of the refurbishment strategies at a case study in Spain show the relatively minor importance of the transport and end of life stages. The construction process stage is also of relatively minor importance regarding the environmental performance. The product, maintenance and replacement stages are generally of higher importance, particularly for economic evaluation. An extensive sensitivity analysis demonstrates the difficulties of simplifying the life-cycle boundaries, suggesting that potential simplifications should take into account various parameters, including the climate region, building typologies, and expected service life. As an example, the results have shown that for cold climate zones and buildings, where large energy savings from energy refurbishment strategies can be achieved, the other life-cycle phases are less important and, in most cases, represent less than 10% of life-cycle environmental impacts. This paper is part of the PhD research of Xabat Oregi Isasi who thanks the Basque Government for the financial support given for his PhD research (BFI-2011-92).

This paper analyses the energy efficiency of a Ventilated Active Façade –VAF– applied to office buildings in Spain to reduce heating demand. This façade system consists of an outer layer element of 2 mm galvanized steel panels and a 3 cm air cavity where the ventilation air is preheated in winter and exhausted in summer. After defining 8 typical office typologies in Spain, 192 study cases are obtained where different parameters like the percentage of glass in façade, the orientation and the climatic zone of the buildings are considered. The energy demand of all these study cases is obtained using the official simulation tool of the Spanish Technical Building Regulation – CTE called LIDER. The results, in terms of reduction of heating demand, are presented in comparison with the minimum energetic requirements of CTE., En este artículo se analiza la eficiencia energética de una Fachada Ventilada Activa –FVA– aplicada a edificios de oficinas en España para reducir la demanda de calefacción. El sistema de fachada consiste en una hoja exterior de 2 mm de acero galvanizado y una cavidad de 3 cm donde el aire de ventilación es precalentado en invierno y extraído en verano. Tras definir 8 tipologías típicas, se han obtenido 192 casos de estudio en los que se consideran diferentes parámetros: la superficie acristalada, la orientación y la zona climática. El cálculo de la demanda energética de los casos de estudio ha sido llevado a cabo mediante el programa LIDER, el método general del Código Técnico de la Edificación – CTE. Los resultados obtenidos en términos de reducción de la demanda de calefacción, se muestran comparados con los mínimos requerimientos exigidos en el CTE.

Introducción: En un estudio publicado en 2011 se observó que en la Comunidad Canaria la supervivencia de los pacientes incidentes en diálisis peritoneal (DP) es mejor que la de los pacientes incidentes en hemodiálisis (HD). El inicio de HD con catéter venoso central condiciona un peor pronóstico, por lo que el acceso vascular de inicio podría condicionar la comparación de la supervivencia entre ambas modalidades. Objetivo: Realizar un estudio comparativo en nuestra comunidad de la supervivencia a medio plazo de los pacientes incidentes en tratamiento renal sustitutivo según la modalidad, separando a los pacientes incidentes en HD según el acceso vascular de inicio: acceso vascular arteriovenoso desarrollado o catéter venoso central. Material y métodos: Se trata de un estudio de cohortes longitudinal retrospectivo, que incluyó todos los pacientes incidentes en tratamiento renal sustitutivo entre enero de 2005 y diciembre de 2010 seguidos hasta diciembre de 2011 en tres de los grandes hospitales de la Comunidad Canaria y se dividieron, según la modalidad de inicio, en DP, HD con acceso vascular desarrollado (HD-FAV) y HD con catéter venoso central (HD-Cat). Se estimaron las curvas de supervivencia en los distintos grupos mediante Kaplan-Meier y se aplicó un modelo de riesgos proporcionales de Cox de supervivencia para estimar los riesgos relativos de mortalidad de DP, frente a HD-FAV y HD-Cat, ajustando para edad e índice de comorbilidad de Charlson. Posteriormente se realizó el mismo análisis por subgrupos definidos por la edad y presencia de diabetes. Resultados: Se incluyeron 1110 pacientes, mediana de edad 63 años, 56 % diabéticos. El análisis de Kaplan-Meier muestra una mejor supervivencia de DP (66 meses) frente a HD-Cat (41 meses), log-rank p < 0,001, no existiendo diferencia entre DP y HD-FAV (67 meses). En la regresión de Cox el riesgo relativo de mortalidad de la HD-Cat frente a la DP fue de 2,270 (1,573-3,276); p < 0,001. No se observó diferencia entre los pacientes HD-FAV y DP 0,993 (0,646-1,525). El análisis por subgrupos muestra estos mismos resultados en diabéticos y no diabéticos, y en los pacientes más jóvenes y en los más añosos. Conclusiones: La mejor supervivencia en DP frente a HD observada en el registro de enfermos renales de la Comunidad Canaria parece a expensas de los pacientes incidentes en HD-Cat, no observándose diferencia entre DP y HD-FAV. Estos resultados podrían sugerir que, en nuestro medio, aquellos pacientes en los que, optando inicialmente por HD, no se consigue un acceso vascular desarrollado en la etapa prediálisis podrían obtener un beneficio de supervivencia ofreciéndoles la DP como técnica de inicio, al menos hasta disponer de un acceso vascular definitivo. Introduction: A study published in 2011 showed that patients in the Canary Islands, who were incident in peritoneal dialysis (PD) had better survival than those who were incident in hemodialysis (HD). Since initiating hemodialysis with central venous catheter is associated with worse prognosis, it would be possible that the initial vascular access influences the results of survival comparison between both groups. Objective: To conduct a comparative medium-term survival study of patients incident in renal replacement therapy with different modalities in our community, classifying those incident in hemodialysis according to the initial vascular access: established arteriovenous vascular access or central venous catheter. Material and method: Retrospective longitudinal cohort study including all patients who were incident in renal replacement therapy between January 2005 and December 2010, with follow-up until December 2011, in three large hospitals of the Canary Islands. Patients were classified according to the initial modality: PD, HD with established vascular access (HD-FAV) or HD with central venous catheter (HD-Cat). Kaplan-Meier survival curves were estimated for each group and a Cox proportional hazards survival model was used to estimate relative mortality risk for DP as compared to HD-FAV and HD-Cat, adjusting for age and Charlson comorbidity index. An equivalent analysis was then conducted on subgroups defined by age or by the presence of diabetes. Results: 1110 patients were included, with a median age of 63 years, 56% of them were diabetic. A Kaplan-Meier analysis showed better survival for PD (66 months) as compared to HD-Cat (41 months), Log Rank p

Approximately 15-20% of patients on the waiting list for cadaveric renal transplant are highly HLA-sensitized. It is well known that the presence of alloantibodies against human class I (A, B, C) and class II (DR, DQ) HLA antigens in transplant recipients waiting for a renal transplant has a significant increase in acute and chronic rejection rates and a poor graft outcome. There are interesting options for minimizing these immunological problems such as national paired kidney exchange program or acceptable mismatch program similar to the one developed by Eurotransplant program. However, despite these efforts, these patients can wait up to 5 years for a kidney graft and just get it finally only 30% of them. It is therefore vital to develop strategies to reduce waiting time and decrease the risk of transplant rejection, through the elimination or reduction of circulating lymphocytotoxic antibodies. There have been several retrospective and prospective studies that have used immunoabsorption or plasmapheresis together with immunosuppressants and intravenous immune globulins with highly variable success rates that, while not providing a high level of evidence, constitutes a promising therapeutic alternative for these patients. In addition, the use of rituximab in living donor transplantation ABO incompatible, hypersensitive patients with positive crossmatch, acute rejection resistant to standard treatments and pretransplant desensitization are running with very interesting results. Moreover, newer approaches for treating acute humoral rejection such as the proteosome inhibitor (bortezomib) or eculizumab (an anticomplement monoclonal antibody), are emerging as successful therapeutic options (Gloor J Stegall, 2010). Long-term followup of these patients and the application on a wider scale of these treatments, will provide the definitive answers about their real efficacy (Nocera, 2009). Nevertheless, acute antibody-mediated rejection (AMR), occurring in 20-50% of patients, and subclinical AMR even in the absence of allograft dysfunction, may decrease allograft survival by chronic histological abnormalities. The aim of this chapter is to review the current data about approach therapy in highly HLAsensitized patients receiving deceased renal allograft.

Introducción: La plasmaféresis (PF) es una técnica de aféresis terapéutica utilizada en el tratamiento de diversas enfermedades renales y sistémicas con distintos grados de eficacia clínica demostrada. Objetivo: Analizar los resultados globales de la indicación de PF en el Hospital Universitario de Canarias, enfocados a resultados de su efectividad y seguridad en diversos grupos de enfermedades. Material y métodos: Se trata de un análisis descriptivo retrospectivo de una serie de casos que analiza los resultados de la indicación de PF desde el uno de enero de 2006 hasta el 31 de diciembre de 2009 en nuestro centro. Se revisaron las historias clínicas y se recogieron datos demográficas (sexo y edad), parámetros bioquímicos, enfermedad de base, volumen y tipo de reposición utilizado en la sesión de PF (albúmina humana al 5% y/o plasma fresco congelado), complicaciones asociadas con la técnica, días transcurridos desde la sospecha clínica diagnóstica hasta el inicio de la técnica de aféresis, número de sesiones de PF recibidas, mortalidad del paciente, grado de afectación renal y evolución de la función renal. Resultados: Estudiamos a 51 pacientes, de 50 ± 18 años, el 60% eran hombres, 331 sesiones de PF. Las enfermedades tratadas se agruparon como: 11 vasculitis, 15 inmunoactivaciones del trasplante renal, cinco síndromes hemolítico urémicos, siete casos de púrpura trombótica trombocitopénica o idiopática, dos inmunizaciones Rh fetal, dos enfermedades hematológicas y cuatro casos de enfermedades neurológicas, entre otras. La mortalidad global fue del 19,6 % (n = 10); en seis de los casos, secundaria a shock séptico y en el resto como resultado de la evolución de la enfermedad de base y uno por shock hemorrágico en el área de la biopsia renal. No hubo fallecimientos en el grupo de inmunoactivación del trasplante. En el grupo de vasculitis se produjeron tres fallecimientos (dos de ellos secundarios a un shock séptico). Nueve de los 10 pacientes que fallecieron lo hicieron dentro de los tres primeros meses tras el diagnóstico. De las 26 biopsias renales realizadas, las indicaciones más frecuentes fueron: vasculitis (23%), rechazos humorales (42%), rechazo humoral más toxicidad por anticalcineurínicos (12%) y síndrome hemolítico-urémico (8%), entre otros. Veinticuatro pacientes precisaron hemodiálisis al inicio del cuadro clínico, nueve de los 11 pacientes con vasculitis, cuatro de los cinco pacientes con síndrome hemolítico-urémico y cinco de los 15 pacientes con inmunoactivación del trasplante. Al final de la evolución, 14 de ellos permanecieron en programa de hemodiálisis. Concretamente, cinco de 11 pacientes con vasculitis, dos de 15 pacientes sometidos a trasplante y tres de cinco pacientes con síndrome hemolítico-urémico. De forma significativa, los pacientes que evolucionaron hacia enfermedad renal terminal en el grupo de las vasculitis eran de mayor edad y tenían una mayor creatinina en el comienzo de la enfermedad. En los pacientes sometidos a trasplante en quienes se monitorizaron anticuerpos anti-HLA de clases I o II medidos por luminex pre y post-PF se objetivó una media de descenso del título de anticuerpos en todos excepto en un caso; el descenso medio fue del 51 al 31%. En general, la técnica de PF transcurrió prácticamente libre de complicaciones. Se constataron cinco reacciones al plasma fresco (3%) de carácter leve-moderado (hormigueo peribucal y reacciones urticariformes) que requirieron premedicación con esteroides y no supusieron la interrupción del tratamiento. Conclusión: Teniendo en cuenta la gran variedad de enfermedades que pueden beneficiarse de la PF y el carácter esporádico de algunas de ellas, la publicación de la experiencia con esta modalidad terapéutica cobra gran importancia, ya que si incrementamos la descripción de series de casos por centros, podemos ayudar a ampliar el nivel de evidencia en términos de supervivencia y función renal en múltiples patologías infrecuentes. Nuestro estudio aporta una información útil y valiosa para la práctica clínica habitual y, sin duda, nos hace reflexionar sobre estrategias futuras que optimicen el pronóstico en nuestros enfermos.

Introducción: La plasmaféresis (PF) es una técnica de aféresis terapéutica utilizada en el tratamiento de diversas enfermedades renales y sistémicas con distintos grados de eficacia clínica demostrada. Objetivo: Analizar los resultados globales de la indicación de PF en el Hospital Universitario de Canarias, enfocados a resultados de su efectividad y seguridad en diversos grupos de enfermedades. Material y métodos: Se trata de un análisis descriptivo retrospectivo de una serie de casos que analiza los resultados de la indicación de PF desde el uno de enero de 2006 hasta el 31 de diciembre de 2009 en nuestro centro. Se revisaron las historias clínicas y se recogieron datos demográficas (sexo y edad), parámetros bioquímicos, enfermedad de base, volumen y tipo de reposición utilizado en la sesión de PF (albúmina humana al 5% y/o plasma fresco congelado), complicaciones asociadas con la técnica, días transcurridos desde la sospecha clínica diagnóstica hasta el inicio de la técnica de aféresis, número de sesiones de PF recibidas, mortalidad del paciente, grado de afectación renal y evolución de la función renal. Resultados: Estudiamos a 51 pacientes, de 50 ± 18 años, el 60% eran hombres, 331 sesiones de PF. Las enfermedades tratadas se agruparon como: 11 vasculitis, 15 inmunoactivaciones del trasplante renal, cinco síndromes hemolítico urémicos, siete casos de púrpura trombótica trombocitopénica o idiopática, dos inmunizaciones Rh fetal, dos enfermedades hematológicas y cuatro casos de enfermedades neurológicas, entre otras. La mortalidad global fue del 19,6 % (n = 10); en seis de los casos, secundaria a shock séptico y en el resto como resultado de la evolución de la enfermedad de base y uno por shock hemorrágico en el área de la biopsia renal. No hubo fallecimientos en el grupo de inmunoactivación del trasplante. En el grupo de vasculitis se produjeron tres fallecimientos (dos de ellos secundarios a un shock séptico). Nueve de los 10 pacientes que fallecieron lo hicieron dentro de los tres primeros meses tras el diagnóstico. De las 26 biopsias renales realizadas, las indicaciones más frecuentes fueron: vasculitis (23%), rechazos humorales (42%), rechazo humoral más toxicidad por anticalcineurínicos (12%) y síndrome hemolítico-urémico (8%), entre otros. Veinticuatro pacientes precisaron hemodiálisis al inicio del cuadro clínico, nueve de los 11 pacientes con vasculitis, cuatro de los cinco pacientes con síndrome hemolítico-urémico y cinco de los 15 pacientes con inmunoactivación del trasplante. Al final de la evolución, 14 de ellos permanecieron en programa de hemodiálisis. Concretamente, cinco de 11 pacientes con vasculitis, dos de 15 pacientes sometidos a trasplante y tres de cinco pacientes con síndrome hemolítico-urémico. De forma significativa, los pacientes que evolucionaron hacia enfermedad renal terminal en el grupo de las vasculitis eran de mayor edad y tenían una mayor creatinina en el comienzo de la enfermedad. En los pacientes sometidos a trasplante en quienes se monitorizaron anticuerpos anti-HLA de clases I o II medidos por luminex pre y post-PF se objetivó una media de descenso del título de anticuerpos en todos excepto en un caso; el descenso medio fue del 51 al 31%. En general, la técnica de PF transcurrió prácticamente libre de complicaciones. Se constataron cinco reacciones al plasma fresco (3%) de carácter leve-moderado (hormigueo peribucal y reacciones urticariformes) que requirieron premedicación con esteroides y no supusieron la interrupción del tratamiento. Conclusión: Teniendo en cuenta la gran variedad de enfermedades que pueden beneficiarse de la PF y el carácter esporádico de algunas de ellas, la publicación de la experiencia con esta modalidad terapéutica cobra gran importancia, ya que si incrementamos la descripción de series de casos por centros, podemos ayudar a ampliar el nivel de evidencia en términos de supervivencia y función renal en múltiples patologías infrecuentes. Nuestro estudio aporta una información útil y valiosa para la práctica clínica habitual y, sin duda, nos hace reflexionar sobre estrategias futuras que optimicen el pronóstico en nuestros enfermos. Introduction: Plasmapheresis (PP) is a therapeutic apheresis technique used in the treatment of various renal and systemic diseases with varying degrees of proven clinical efficacy. Objective: To review our experience with PP at the Hospital Universitario de Canarias, focused on effectiveness and safety results in different disease groups. Material and methods: A retrospective-descriptive study of patients treated with PP from 01/01/2006 to 31/12/2009 at the hospital. We analysed medical histories and demographic data (sex, age), biochemical parameters, underlying disease, volume and type of replacement used in the PP sessions (5% human albumin and/or fresh frozen plasma), complications with the technique, delay in starting PP treatment after suspected clinical diagnosis, number of PP sessions received, patient mortality, degree of renal impairment and evolution of renal function. Results: There were 51 patients studied, aged 50±18 years, of whom 60% were male; 331 PP sessions were performed. The diseases treated were grouped as: 11 vasculitis, 15 transplant immune activation, 5 haemolytic-uraemic syndrome (HUS), 7 idiopathic or thrombotic thrombocytopaenic purpura, 2 foetal Rh immunisations, 2 haematological diseases, 4 neurological diseases, among others. Overall mortality was 19.6% (n=10): 6 cases secondary to septic shock and the rest as a result of the evolution of the underlying disease, with 1 due to haemorrhagic shock in the renal biopsy area. There were no deaths in the transplant immune activation group. In the vasculitis group, there were 3 deaths (2 secondary to septic shock). Of the 10 patients who died, 9 did so within the first three months after diagnosis. Of the 26 renal biopsies performed, the most frequent indications were: vasculitis (23%), humoral rejection (42%), humoral rejection with calcineurin-inhibitor toxicity (12%) and HUS (8%), among others. Haemodialysis (HD) was required by 24 patients at the start of clinical symptoms: 9 of the 11 patients with vasculitis, 4 of the 5 patients with HUS and 5 of the 15 patients with transplant immune activation. At the end of evolution, 14 of them remained on the HD programme: 5 of the 11 patients with vasculitis, 2 of the 15 transplant patients and 3 of the 5 HUS patients. Significantly, patients who developed TKD in the vasculitis group were older and had higher creatinine at the onset of the disease. The transplant patients were monitored for anti-HLA class I or II before and after PP; there was a mean decrease of antibody titres in all but one patient; with an average decrease of 51% to 31%. In general, the PP technique was virtually free of complications. There were only 5 (3%) mild-moderate reactions to fresh plasma (perioral tingling and urticarial reactions) requiring pre-medication with steroids, but which did not lead to discontinuation of the treatment. Conclusion: Taking into account the wide variety of diseases that can benefit from PP and the nature of some of them, publishing our experience with this therapeutic method is of great importance. By increasing the description of case series by centre, we can add survival and renal function evidence in many uncommon diseases. Our study provides useful information for clinical practice and has also led us to reflect on future strategies to optimise outcomes in our patients.

Desensitization and Induction Immunosuppressive Therapy in Highly HLA-Sensitized Patients Receiving Cadaveric Renal Allograft)

En el Hospital Universitario de Canarias pusimos en marcha, en mayo de 2008, un protocolo de tratamiento de inducción para pacientes hipersensibilizados que reciben injerto renal de cadáver utilizando inmunoglobulinas intravenosas, plasmaféresis y rituximab más una inmunosupresión triple con prednisona, tacrolimus y micofenolato mofetil. Presentamos los resultados de 4 pacientes. Todos ellos presentaban una tasa de anticuerpos anti-HLA (PRA por CDC) superior al 75%, llevaban en lista de espera de 4 a 17 años, el tiempo de seguimiento posterior al trasplante fue de 10-14 meses y la supervivencia de paciente y del injerto en este período fue del 100%. Sólo un paciente sufrió un rechazo agudo mediado por anticuerpos y otro uno celular, en ambos casos reversibles con el tratamiento. En la evolución no se objetivó aparición de novo de anticuerpos donante-específicos. Todos los pacientes habían reducido significativamente el número de células CD19+ después de la infusión de rituximab. No se han detectado síntomas neurológicos indicativos de leucoencefalopatía multifocal progresiva ni infecciones virales graves después del trasplante y tampoco se han observado efectos secundarios inmediatos tras la administración de la medicación. En resumen, el tratamiento de inducción combinado con inmunoglobulinas, plasmaféresis y rituximab en pacientes hipersensibilizados permite la realización del trasplante renal procedente de donante cadáver con buenos resultados a corto y medio plazo y sin graves efectos secundarios. Queda por conocer si estos buenos resultados se mantendrán a más largo plazo.

En el Hospital Universitario de Canarias pusimos en marcha, en mayo de 2008, un protocolo de tratamiento de inducción para pacientes hipersensibilizados que reciben injerto renal de cadáver utilizando inmunoglobulinas intravenosas, plasmaféresis y rituximab más una inmunosupresión triple con prednisona, tacrolimus y micofenolato mofetil. Presentamos los resultados de 4 pacientes. Todos ellos presentaban una tasa de anticuerpos anti-HLA (PRA por CDC) superior al 75%, llevaban en lista de espera de 4 a 17 años, el tiempo de seguimiento posterior al trasplante fue de 10-14 meses y la supervivencia de paciente y del injerto en este período fue del 100%. Sólo un paciente sufrió un rechazo agudo mediado por anticuerpos y otro uno celular, en ambos casos reversibles con el tratamiento. En la evolución no se objetivó aparición de novo de anticuerpos donante-específicos. Todos los pacientes habían reducido significativamente el número de células CD19+ después de la infusión de rituximab. No se han detectado síntomas neurológicos indicativos de leucoencefalopatía multifocal progresiva ni infecciones virales graves después del trasplante y tampoco se han observado efectos secundarios inmediatos tras la administración de la medicación. En resumen, el tratamiento de inducción combinado con inmunoglobulinas, plasmaféresis y rituximab en pacientes hipersensibilizados permite la realización del trasplante renal procedente de donante cadáver con buenos resultados a corto y medio plazo y sin graves efectos secundarios. Queda por conocer si estos buenos resultados se mantendrán a más largo plazo. In our Universitary Hospital of Canarias we iniciated in May 2008 a induction therapy protocol for sensitized patients receiving cadaveric renal graft using intravenous immunoglobulins, plasmapheresis and rituximab plus immunosuppression with prednisone, tacrolimus and mycophenolate mofetil. We present the results of four patients. Everyone had anti-HLA antibodies rate (PRA by CDC) more than 75%, were on a waiting list during 4 to 17 years and follow-up time was 10-14 months after transplantation. Patient and graft survival in this period was 100%. Only one patient suffered a humoral acute rejection and another one cellular rejection, in both cases reversible with treatment. During the first year, no evidence of de novo donor-specific antibodies was detected. All patients had significantly reduced the CD19+ cells percentage after infusion of rituximab. Neurological symptoms suggestive of progressive multifocal leukoencephalopathy or serious viral infections after transplantation have not been observed. Additionally, no immediate side effects were observed after administration of medication. In summary, induction therapy by combining immunoglobulin, plasmapheresis and rituximab in hypersensitive patients allows the realization of deceased kidney transplantation with good results in the short and medium-term without serious side effects. It remains to know whether this success will continue in the long term.

In our Universitary Hospital of Canarias we iniciated in May 2008 a induction therapy protocol for sensitized patients receiving cadaveric renal graft using intravenous immunoglobulins, plasmapheresis and rituximab plus immunosuppression with prednisone, tacrolimus and mycophenolate mofetil. We present the results of four patients. Everyone had anti-HLA antibodies rate (PRA by CDC) more than 75%, were on a waiting list during 4 to 17 years and follow-up time was 10-14 months after transplantation. Patient and graft survival in this period was 100%. Only one patient suffered a humoral acute rejection and another one cellular rejection, in both cases reversible with treatment. During the first year, no evidence of de novo donor-specific antibodies was detected. All patients had significantly reduced the CD19+ cells percentage after infusion of rituximab. Neurological symptoms suggestive of progressive multifocal leukoencephalopathy or serious viral infections after transplantation have not been observed. Additionally, no immediate side effects were observed after administration of medication. In summary, induction therapy by combining immunoglobulin, plasmapheresis and rituximab in hypersensitive patients allows the realization of deceased kidney transplantation with good results in the short and medium-term without serious side effects. It remains to know whether this success will continue in the long term.

En una época dominada por la simplicidad de principios y de búsquedas, la pretensión de una obra de alcanzar el arcaico y parece que olvidado equilibrio vitrubiano puede antojarse una tarea estéril. Vivimos en la era de los medios. Un momento en el que el valor de un objeto, de una idea, de una persona, se mide por su presencia en los medios de comunicación. Una presencia siempre escueta e impactante, como exige la parca dedicación que se espera del destinatario. El resultado: imágenes fragmentarias, frases llamativas, currículos delirantes. Poco importan la concepción espacial de la obra, su adecuación al uso o la correcta y ajustada utilización de medios físicos. Podríamos pensar que existe una deuda con la creación virtual de la ficción cinematográfica, pero no cabe tal ya que ésta pretende de forma opuesta generar una idea total a partir de materiales y técnicas fragmentarias mientras aquélla sólo busca una imagen parcial o una idea falsa.