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BACKGROUND AND AIMS The interactions of both organs in Cardiorenal Syndrome (CRS) exacerbate the damage and determine a worse prognosis in these patients [1]. The aim of our study is to compare the development and prognosis of CRS patients compared with control patients. METHOD: In a retrospective fashion, we assigned 60 patients with CRS who underwent dialysis, and we compared them with a control population of 60 patients without CRS in dialysis. We analyzed baseline characteristics of the patients and the dialysis parameters. Survival rates at 1 and 5 years were determined. RESULTS The baseline characteristics were similar between groups. The mean age was 72 ± 9 years in CRS and 68 ± 12 years in the control group. Men were more prevalent in both groups CRS (55%) and control (53%). Charlson's Score was 8 ± 2 points in the CRS group and 7 ± 3 points in the control group. Diabetic nephropathy was the most frequent etiology of end-stage renal disease in CRS patients (37%), followed by nephroangiosclerosis (20%). In the control group, the most common etiologies were nephroangiosclerosis (32%), diabetic (22%) and interstitial nephropathy (11%). CRS patients had more diabetes mellitus (55% versus 35%; P Haemodialysis was the most common technique in both groups CRS (98%) and control (95%). The use of permanent tunneled catheters as definite vascular access was more common in CRS patients (60% versus 26%; P The median time in dialysis was inferior in the CRS group [24 (8–42) versus 61 (26–106) months; P The main cause of death was the cardiovascular events in both groups (35% versus 20%; P = 0.06). However, tumor as a cause of death was superior in the control group (18% versus 0%; P CONCLUSION CRS patients have more cardiovascular risk factors and cardiovascular disease as expected, as well as more hospitalizations caused by heart failure before starting dialysis. They have more frequent use of a permanent tunneled catheter. It could be explained because of worse tolerance to the use of arteriovenous fistula in these patients. - The survival rates at 1 and 5 years are significantly inferior in the CRS group, which highlights the poor prognosis of these patients [2,3]. - The tumor as a cause of death was superior in the control group due to greater time in dialysis of these patients compared with CRS patients

BACKGROUND AND AIMS The coronavirus disease 2019 (COVID-19) has affected our patients not only in renal replacement therapy (RRT), but also in advanced chronic kidney disease (ACKD) consultation. Our aim is to assess the impact of COVID-19 in a group of patients of our ACKD consultation. METHOD Retrospective observational study in our centre of patients from ACKD consultation with hospitalization due to COVID-19 infection in the period from March to December 2020. We have studied demographic parameters, characteristics during hospitalization, analytics values (3 months before and 1, 3, 6 and 12 months after infection) and final status at the end of follow-up on 31 December 2021. A value comparison is made with the Wilcoxon test for paired data. RESULTS In an ACKD consultation with 90 patients, 12 (13%) required hospitalization due to COVID-19. 75% were male, with a mean age of 77.6 years (SD 7) (range 59–89 years) and 25% due to Diabetic Kidney Disease. Mean time in consultation 28 months (SD 14) (range 12–58). Mean Comorbidity Charlson Index 8.2 (SD 1.2) (range 7–11), all hypertensive, 42% treatment with insulin, 25% ischemic heart disease and 42% chronic obstructive pulmonary disease. In COVID-19 hospitalizations, 83% they had pneumonia, 50% steroid treatment, 75% hydroxychloroquine, 92% several antibiotics, 33% low molecular weight heparin, only two required tocilizumab, and none required admission to the intensive care unit. During hospitalization, 3 (25%) patients died, and one died during follow-up, all were males. The consequences after infection: 42% pneumology (cough, varying degrees of shortness of breath), 8% neurological (headaches, varying degrees of memory loss) and 8% loss of smell (from 1 to 6 moths). At the follow-up, only one patient needs RRT with haemodialysis (at 19 months after COVID-19). Table 1 shows analytics comparison before and after COVID. From 6 months after COVID, the results are like 3 months after the disease. CONCLUSION With the important limitation of few patients and without a control group, ACKD patients with hospitalization to COVID-19 show similar patterns to those with RRT: more frequent in males, advanced age, lung comorbidity and diabetics, elevation of inflammatory parameters, anemia and increase in creatinine during hospitalization. Recovery to values prior to admission occurs from the first month after infection.

In December 2019, a series of pneumonia cases of unknown etiology, which were epidemiologically linked to a seafood market, was reported in Wuhan, Hubei province, China. The disease has rapidly spread around the world, becoming a global pandemic. A coronavirus, which was named 2019 novel coronavirus (2019-nCov), was isolated from respiratory tract samples1 and later identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The name of the disease was officially changed to coronavirus disease 2019 (COVID-19). Pulmonary involvement with alveolar damage and acute respiratory failure has been the most remarkable clinical condition of COVID-19 patients. However, there is increasing evidence that this virus also affects other organs, kidney injury being relatively common in this infection and associated with an increased mortality rate.2 In a large prospective cohort of 701 COVID-19 patients in China, 44% had proteinuria and 27% had hematuria on admission. During hospitalization, 5.1% of them developed acute kidney injury.2 We report a patient who developed systemic symptoms and renal involvement after being hospitalized because of a COVID-19 infection. A mesangial proliferation and IgA deposits in the glomeruli were seen on the kidney biopsy specimen.

La patología glomerular más relacionada con enfermedad COVID-19 hasta la fecha parece ser la glomerulopatía colapsante, principalmente en pacientes de raza afroamericana y con alelos de riesgo para el gen APOL1. No obstante, en nuestra población, conformada por pacientes añosos de raza caucásica, la patología más biopsiada desde el inicio de la pandemia ha sido la nefritis IgA o púrpura de Schönlein-Henoch. Desde la descripción del primer caso de esta entidad tras infección por SARS-CoV-2 por nuestro grupo de investigación hemos objetivado otros tres, los cuales se describen a continuación. En contraste con el resto de los casos publicados de vasculitis IgA, nuestros pacientes presentaban mayor deterioro de función renal y todos requirieron tratamiento inmunosupresor. Además, algunos presentaron recuperación incompleta de función renal. Esta serie de casos afianza la posibilidad de que la infección por SARS-CoV-2 sea un desencadenante más de esta patología.

COVID-19 most related glomerular disease to date seems to be collapsing glomerulopathy, mostly in young Afroamerican patients with APOL1 gene risk alleles. However, in our population, predominant in elderly Caucasian patients, most biopsied pathology since the beginning of the pandemic has been IgA nephritis or Schönlein-Henoch purpura. Since the description of the first case of this entity after SARS-CoV-2 infection by our research group, three more cases have arisen, which are described in the following article. In contrast to the rest of IgA vasculitis cases reported, our patients presented more renal function deterioration and all of them required immunosupresive therapy. Moreover, some showed incomplete recovery of renal function. This case series strengthens the hypothesis that SARS-CoV-2 infection may be another trigger of this pathology.

Background and Aims Due to COVID-19 pandemic we must continue attending in our hospital consultations and, at the same time, avoid transfers and visit that involve risks to our patients. For this reason, we implemented new forms of care. Mainly electronic consultation (eConsult) using institutional email as way of contact between Primary Care Providers (PCPs) and nephrologist, trying to decrease in-person visit. Objective To analyze the results of the creation in June 2020 of a Nephrology electronic consultation in our hospital. Method Retrospective observational study of eConsults made to our department, which serves a population of 200.000 people, with total of 9 primary care centers. The study period was June 10, 2020 to December 31, 2020. We have studied the number of eConsults, response time, type of consult made, problem resolution and subsequent follow up. Results Of 141 workdays, in 61 days (43%) there was eConsult, total 80 eConsults, mean 1.3 and median 1 daily (range 1 to 3). All primary care centers used this communication way, as well as 50 PCPs. Median response time for eConsult was 1 day (range 1-4). 55% patient was male, mean age 70.8 years (SD 13.9) (range 16-95 years). 64% it was his first assessment for Nephrology. The most frequent causes of eConsult: increase of creatinine (41.3%), uncontrolled blood pressure (12.5%), sodium and potassium disturbances (11.3%), treatment adjustment (11.3%) and changes in previous appointment (8.8%). After assessment eConsult, to 55% of patients was treatment adjustment, 22.5% were converted to an in-person visit, 11% they didn´t need any action but only 1 patient was referred to the emergency room. 44% patient is subsequent follow up by PCPs, 39% by nephrologist, 15% joint assessment PCP and nephrologist and 2% by other specialists. Only 2 patients (2.5%) made second eConsult. Conclusion The eConsult is an important help to PCPs to solve doubts quickly, avoid unnecessary the travels to hospital the patients, treatment adjustment above all in control of hypertension an ionic disturbance, and guide in handling of chronic kidney disease. The diffusion and empowerment of this type of consultation in a next future may decrease, partly, the usual saturation of face-to-face visit and optimize the patient population being seen by nephrologist.

An amendment to this paper has been published and can be accessed via the original article.

Artículo escrito por un elevado número de autores, solo se referencian el que aparece en primer lugar, el nombre del grupo de colaboración, si le hubiere, y los autores pertenecientes a la UAM, Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations., Hay una corrección posterior a este artículo: http://hdl.handle.net/10486/703679, Background X-linked hypophosphatemia (XLH) is a hereditary rare disease caused by loss-of-function mutations in PHEX gene leading tohypophosphatemia and high renal loss of phosphate. Rickets and growth retardation are the major manifestations of XLH in children, but there is a broad phenotypic variability. Few publications have reported large series of patients. Current data on the clinical spectrum of the disease, the correlation with the underlying gene mutations, and the long-term outcome of patients on conventional treatment are needed, particularly because of the recent availability of new specific medications to treat XLH. Results The RenalTube database was used to retrospectively analyze 48 Spanish patients (15 men) from 39 different families, ranging from 3 months to 8 years and 2 months of age at the time of diagnosis (median age of 2.0 years), and with XLH confirmed by genetic analysis. Bone deformities, radiological signs of active rickets and growth retardation were the most common findings at diagnosis. Mean (± SEM) height was − 1.89 ± 0.19 SDS and 55% (22/40) of patients had height SDS below—2. All cases had hypophosphatemia, serum phosphate being − 2.81 ± 0.11 SDS. Clinical manifestations and severity of the disease were similar in both genders. No genotype—phenotype correlation was found. Conventional treatment did not attenuate growth retardation after a median follow up of 7.42 years (IQR = 11.26; n = 26 patients) and failed to normalize serum concentrations of phosphate. Eleven patients had mild hyperparathyroidism and 8 patients nephrocalcinosis. Conclusions This study shows that growth retardation and rickets were the most prevalent clinical manifestations at diagnosis in a large series of Spanish pediatric patients with XLH confirmed by mutations in the PHEX gene. Traditional treatment with phosphate and vitamin D supplements did not improve height or corrected hypophosphatemia and was associated with a risk of hyperparathyroidism and nephrocalcinosis. The severity of the disease was similar in males and females, This research has been partially funded by Kyowa Kirin Farmacéutica S.L.U., project PI17/01745 from Instituto de Salud Carlos III, Acción Estratégica en Salud 2017-2020 and FEDER funds, Fondo de Investigaciones Sanitarias (FIS), Fundación Nutrición y Crecimiento (FUNDNYC), Instituto de Investigación Sanitaria del Principado de Asturias (ISPA) and Fundación para la Investigación y la Innovación Biosanitaria del Principado de Asturias (FINBA)

Background: Chronic fluid overload is frequent in hemodialysis patients (P) and it associates with hypertension, left ventricular hypertrophy (LVH) and higher mortality. Moreover, echocardiographic data assessing fluid overload is limited. Our aim was to evaluate the relationship between fluid overload measured by bioimpedance spectroscopy (BIS) and different echocardiographic parameters. Methods: Cross-sectional observational study including 76 stable patients. Dry weight was clinically assessed. BIS and echocardiography were performed. Weekly time-averaged fluid overload (TAFO) and relative fluid overload (FO/ECW) were calculated using BIS measurements. Results: Based on TAFO three groups were defined: A- dehydrated, TAFO < -0.25 L 32 P (42%); B- normohydrated, TAFO between -0.25 and 1.5 l: 26 (34%); C- overhydrated, TAFO>1.5 l: 18 (24%). We found significant correlation between TAFO and left atrial volume index (LAVI) (r: 0.29; p = 0.013) but not with FO/ECW (r: 0.06; p = 0.61). TAFO, but not FO/ECW kept a significant relationship with LAVI (p = 0.03) using One-Way ANOVA test and linear regression methods. LVH was present in 73.7% (concentric 63.2%, eccentric in 10.5%). No differences between groups in the presence of LVH or left ventricular mass index were found. Conclusions: We found that left atrial volume index determined by echocardiographic Area-length method, but not left ventricle hypertrophy or dimensions of cavities, are related on hydration status based on bioimpedance measured time-averaged fluid overload (TAFO), and not with FO/ECW.

Background. Predicting the progression of kidney failure in patients with chronic kidney disease is difficult. The aim of this study was to assess the predictors of rapid kidney decline in a cohort of patients referred to a single outpatient nephrology clinic. Design. Longitudinal, prospective cohort study with a median follow-up of 3.39 years. Methods. Data were obtained from 306 patients with chronic renal failure based on serum creatinine-estimated glomerular filtration rate (eGFRcreat) < 90 mL/min/1.73 m2. After excluding patients who died (n=30) and those who developed end-stage renal failure (n=6), 270 patients were included. This population was grouped according to the rate of kidney function decline. Rapid kidney function decline was defined as an annual eGFRcreat loss > 4 mL/min/1.73 m2. We recorded nonfatal cardiovascular events at baseline and during follow-up in addition to biochemical parameters. Results. The mean loss in renal function was 1.22 mL/min/1.73 m2 per year. The mean age was 75 ± 8.8 years old, and the mean baseline eGFRcreat was 42 ± 14 mL/min/1.73 m2. Almost one-fourth of the sample (23.3% [63 patients]) suffered a rapid decline in renal function. In a logistic regression model with rapid decline as the outcome, baseline characteristics, lower serum albumin (OR: 0.313, 95% CI: 0.114–0.859), previous cardiovascular disease (OR: 1.903 95% CI: 1.028–3.523), and higher proteinuria (g/24 h) (OR: 1.817 CI 95%: 1.213–2.723) were the main predictors of rapid kidney decline. On multivariate analysis, including baseline and follow-up data, we obtained similar adjusted associations of rapid kidney decline with baseline serum albumin and proteinuria. The follow-up time was also shorter in the group with rapid rates of decline in renal function. Conclusion. Renal function remained stable in the majority of our population. Previous cardiovascular disease and cardiovascular incidents, lower serum albumin, and higher proteinuria at baseline were the main predictors of rapid kidney decline in our population.

Background: Mycophenolate (MF) is effective as induction and maintenance treatment in patients with lupus nephritis (LN). This study evaluates the efficacy and safety of MF in patients with refractory and relapsing LN. Methods: Data were retrospectively obtained for 85 patients (35 refractory and 50 relapsing) from 11 nephrology departments in Spain. The primary endpoints were the incidence and cumulative number of renal responses and relapses and their relationship with baseline clinical and analytical data. The secondary endpoint was the appearance of side effects. Results: The main clinical and analytical variables were similar both in refractory and relapsing LN. Most of the patients had received cyclophosphamide, and all of them switched to MF. 74 patients (87%) achieved a response (69% partial, 31% complete). Age at starting MF, gender, pathological classification, body mass index, blood pressure, baseline renal function, and proteinuria were not associated with achieving response. After stopping MF, 3 of 19 patients (15.7%) relapsed, all at 6 months of follow-up. No differences were found between clinical and analytical variables and number of relapses. Side effects were unremarkable, except for 1 patient, who died of thrombocytopenia and ovarian hemorrhage. Conclusions: Switching to MF from other immunosuppressive treatments is effective and safe in refractory and relapsing LN.

Background: High levels of alkaline phosphatase (ALP) have been associated with increased mortality in patients with advanced chronic kidney disease (CKD). We hypothesize that elevated ALP could be partly explained by subclinical liver congestion related to left ventricular diastolic dysfunction. Methods: Doppler echocardiography was performed in 68 patients with advanced CKD followed up for a median of 2.1 years. Time-averaged levels of ALP and γ-glutamyl transferase (GGT) were compared between patients with and without diastolic dysfunction. We also evaluated the effect of intensifying diuretic treatment on ALP levels in a small group of 16 patients with high ALP and signs of volume overload. Results: ALP correlated significantly (p < 0.001) with GGT but not with parathyroid hormone (p = 0.09). Patients with diastolic dysfunction showed higher ALP (p = 0.01), higher GGT (p = 0.03) and lower albumin (p = 0.04). The highest values of ALP were observed in patients with diastolic dysfunction plus pulmonary hypertension (p = 0.01). Intensifying diuretic therapy in a subgroup of patients with signs of fluid overload induced a significant reduction in body weight, GGT (p < 0.001) and ALP levels (p < 0.001). Conclusions: Elevated ALP in patients with advanced CKD could be partly explained by subclinical liver congestion related to left ventricular diastolic dysfunction, hypervolemia or both. The worse prognosis of these patients could be explained by their myocardial damage.

Spontaneous remission is a well known characteristic of idiopathic membranous nephropathy, but contemporary studies describing predictors of remission and long-term outcomes are lacking. We conducted a retrospective, multicenter cohort study of 328 patients with nephrotic syndrome resulting from idiopathic membranous nephropathy that initially received conservative therapy. Spontaneous remission occurred in 104 (32%) patients: proteinuria progressively declined after diagnosis until remission of disease at 14.7 ± 11.4 months. Although spontaneous remission was more frequent with lower levels of baseline proteinuria, it also frequently occurred in patients with massive proteinuria: 26% among those with baseline proteinuria 8 to 12 g/24 h and 22% among those with proteinuria >12 g/24 h. Baseline serum creatinine and proteinuria, treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists, and a >50% decline of proteinuria from baseline during the first year of follow-up were significant independent predictors for spontaneous remission. Only six patients (5.7%) experienced a relapse of nephrotic syndrome. The incidence of death and ESRD were significantly lower among patients with spontaneous remission. In conclusion, spontaneous remission is common among patients with nephrotic syndrome resulting from membranous nephropathy and carries a favorable long-term outcome with a low incidence of relapse. A decrease in proteinuria >50% from baseline during the first year predicts spontaneous remission.

Background: Our aim was to analyze the longitudinal changes in cardiac biomarker levels in hemodialysis patients with high comorbidity treated in our special hospital unit. We hypothesize that strict volume control strategy (salt-restricted diet, extended dialysis sessions and dry weight clinical assessment and reassessment in every session) could prevent progression of left-ventricular damage and, therefore, progressive increment in cardiac biomarker levels over time. Methods: This is a longitudinal cohort study including 46 dialysis patients in which a strategy of strict volume control has been adopted. N-terminal pro-B-type natriuretic peptide (NT-proBNP), troponin T and C-reactive protein (CRP) levels were measured at baseline and prospectively at 4, 8 and 12 months. The possible association between volume control and cardiac biomarker levels was analyzed. Results: Dry weight could be reduced (p < 0.01) over time. A reduction in systolic BP (p < 0.05) and in CRP levels (p < 0.05) was observed, whereas NT-proBNP and troponin T values remained stable. However, patients in the high quartile of NT-proBNP at baseline showed a reduction (p = 0.02) in troponin T over time with no significant trend (p = 0.08) to progressive reduction in NT-proBNP values. Conclusions: Strict volume control in dialysis patients may prevent progressive increment in cardiac biomarker levels over time. The impact seems to be higher among patients with higher levels at baseline in whom strict volume control can even reduce cardiac biomarker levels on follow-up.

Visceral leishmaniasis due to Leishmania Infantum is an endemic parasitic infection in the Mediterranean area. Since 2009, Europe's largest outbreak of Leishmaniasis has been reported in the region of Madrid (Spain). Renal involvement is an unusual complication. Different forms of renal disease have been described: interstitial, glomerular, and vascular damage. Direct invasion of renal parenchyma by the parasite has been described as a mechanism of kidney damage, especially in the immunocompromised. Immune complex deposition and T cells adhesion molecules activation have demonstrated that a pathogenic role in glomerulonephritis related to visceral leishmaniasis. The association between mixed cryoglobulinemia and visceral leishmaniasis has been previously reported in six patients. Renal involvement is only described in one of them. From July 2009 to October 2012, 4 patients with membranoproliferative glomerulonephritis and mixed cryoglobulinemia with negative serology for hepatitis B and C were diagnosed in our hospital. Serology of Leishmania in serum bank samples was performed; it was positive in 3 patients. Leishmania parasite was confirmed by other tests. We present 3 patients with mixed cryoglobulinemia and membranoproliferative glomerulonephritis as first clinical manifestation of visceral leishmaniasis.

Background: The prevalence of inflammation is high among patients with chronic renal failure but the reason of inflammation is unclear. We test the hypothesis that inflammation in chronic renal failure could be the consequence of an increased left-ventricular wall tension related to ventricular dysfunction, hypervolemia or both. Methods: For assessing left-ventricular filling pressure, plasma level of N-terminal pro-B-type natriuretic peptide (N-BNP) was used, as B-type natriuretic peptide is secreted from the cardiac ventricles in response to increased wall tension. N-BNP levels and C-reactive protein (CRP) were measured on the same day in 75 pre-dialysis patients. A previous history of cardiomiopathy with systolic dysfunction was present in 27 (36%) of them. Results: The levels of N-BNP were not normally distributed (mean: 2,589 ± 4,514 pg/ml; median: 789 pg/ml). The distribution of CRP levels was also not normal (mean: 15 ± 27 mg/l; median: 5 mg/l). Both parameters correlated significantly (r: 0.41; p < 0.005). N-BNP was higher (p < 0.001) in patients with known ventricular dysfunction. Excluding these patients, the correlation between N-BNP and CRP was stronger (r: 0.88; p < 0.001). Univariate analysis in these patients without known cardiomyopathy showed that N-BNP levels also correlated with systolic and diastolic blood pressure (r: 0.54; p < 0.005) and inversely with creatinine clearance (r: –0.43; p < 0.01), serum albumin (r: 0.6; p < 0.001) and hemoglobin levels (r: 0.37; p < 0.05). CRP levels correlated significantly (p < 0.01) with the same parameters as N-BNP in univariate analysis. However, in multiple stepwise regression analysis in which CRP was the dependent variable, only the association with N-BNP remained significant (r: 0.87; p < 0.001). Conclusions: Our results suggest a link between left-ventricular filling pressure and inflammation in patients with advanced renal insufficiency. The importance of strict volume control in these patients, in order to reduce left-ventricular pressure and therefore inflammation, should be considered.

Background/Aims: Lower serum sodium levels have been associated with increased mortality among patients with chronic kidney disease (CKD). Our aim was to analyze the independent factors associated with lower sodium levels among nondialysis patients with advanced CKD and to evaluate the evolution of these patients in comparison to those with higher plasma sodium over a 1-year period. Methods: We included 72 patients with CKD stages 4 and 5 without clinically evident cardiopathy or liver disease. Bioelectrical impedance and echocardiography were performed to analyze the possible relation between plasma sodium and volume status and subclinical left ventricular (LV) dysfunction. During follow-up, we compared the evolution of patients with lower baseline plasma sodium (low quartile: Results: At baseline, the independent predictors of lower plasma sodium were C-reactive protein (CRP; OR 0.96; 95% CI 0.91-0.99) and body mass index (OR 0.89; 95% CI 0.78-0.99). An inverse correlation between plasma sodium and CRP was observed (r = -0.32; p = 0.01). Plasma sodium did not correlate with extracellular water and was not different between patients with or without echocardiographic data of LV dysfunction (p = 0.7). During follow-up, patients with lower sodium at baseline showed persistently lower sodium values (p = 0.04), higher CRP (p = 0.05), lower serum albumin (p < 0.01) and higher erythropoietin-stimulating agent resistance index (p = 0.05). Conclusions: Our results suggest an association between lower plasma sodium and a microinflammatory state among patients with advanced CKD. Inflammation could be an underlying confounding factor explaining the increased mortality in these patients.

Background Although tacrolimus is recommended by KDIGO Clinical Practice Guideline for Glomerulonephritis for the treatment of idiopathic membranous nephropathy (MN), little is known about factors that influence response and relapse of the disease after tacrolimus therapy. Methods Multicentre study that collected 122 MN patients with nephrotic syndrome and stable renal function treated with tacrolimus. Duration of treatment was 17.6 ± 7.2 months, including a full-dose and a tapering period. Results The percentage of remission was 60, 78 and 84% after 6, 12 and 18 months of treatment, respectively. The amount of proteinuria at baseline significantly predicted remission, the lower the baseline proteinuria the higher the probability of remission. Only 10 patients (8%) received concomitantly corticosteroids, and their rate of remission was similar (80% at 18 months). Among responders, 42% achieved complete remission (CR) and 58% partial remission (PR). Almost half (44%) of the responder patients relapsed. The amount of proteinuria at the onset of tacrolimus tapering was significantly higher in relapsing patients. By multivariable analysis, the presence of a PR versus CR at the onset of tacrolimus tapering and a shorter duration of the tapering period significantly predicted relapses. Tolerance was good and the number of adverse events low. Conclusions Tacrolimus monotherapy is an effective and safe option for the treatment of MN with stable renal function. Relapses are frequent in patients with PR and can be partially prevented by a longer tapering period.

Familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC) is an autosomal recessive tubular disease caused by mutations in the CLDN16 or CLDN19 gene. Previous studies using microsatellite markers flanking the CLDN19 locus estimated that p.G20D (c.59G>A), a recurrent mutation in Spanish families, is a founder mutation. In the present study, we assessed the haplotype of Spanish patients using single nucleotide polymorphisms (SNPs). Twenty-seven FHHNC patients were included in this study. We analyzed four SNPs located in CLDN19 introns 3 and 4 by polymerase chain reaction amplification and DNA sequencing. Three new patients with homozygous p.G20D were identified. The SNP genotyping analysis showed that alleles carrying this mutation shared a common SNP haplotype. Our findings suggest the existence of a founder effect responsible for FHHNC in our cohort. Testing for the presence of mutation p.G20D should be the first genetic screening in Spanish patients.

Background/Aim: Sodium and water retention is common in peritoneal dialysis patients and contributes to cardiovascular disease. As peritoneal sodium removal depends partly on dwell time, and automated peritoneal dialysis (APD) often uses short dwell time exchanges, the aim of this study was to compare the 24-hour peritoneal sodium removal in APD and standard continuous ambulatory peritoneal dialysis (CAPD) patients and to analyze its possible influence on blood pressure control. Methods: A total of 53 sodium balance studies (30 in APD and 23 in CAPD) were performed in 36 stable peritoneal dialysis patients. The 24-hour net removal of sodium was calculated as follows: M = ViCi – VdCd, where Vd is the 24-hour drained volume, Cd is the solute sodium concentration in Vd, Vi is the amount of solution used during a 24-hour period, and Ci is the sodium concentration in Vi. Peritoneal sodium removal was compared between APD and CAPD patients. Residual renal function, serum sodium concentration, daily urinary sodium losses, weekly peritoneal Kt/V and creatinine clearance, 4-hour dialysate/plasma creatinine ratio, proportion of hypertonic solutions, net ultrafiltration, systolic and diastolic blood pressures, and need for antihypertensive therapy were also compared between the groups. Results: Peritoneal sodium removal was higher (p < 0.001) in CAPD than in APD patients. There were no significant differences in residual renal function, serum sodium concentration, urinary sodium losses, peritoneal urea or creatinine clearances, 4-hour dialysate/plasma creatinine ratio, or proportion of hypertonic solutions between groups. The net ultrafiltration was higher in CAPD patients and correlated strongly (r = 0.82; p < 0.001) with peritoneal sodium removal. In APD patients, peritoneal sodium removal increased significantly only in those patients with a second daytime exchange. The systolic blood pressure was higher (p < 0.05) in APD patients, and the proportion of patients with antihypertensive therapy was also higher in APD patients, although no significant relationship between blood pressure values and amount of peritoneal sodium removal was found. Conclusions: The 24-hour sodium removal is higher in CAPD than in APD patients, and there is a trend towards better hypertension control in CAPD patients. As hypertension control and volume status are important indices of peritoneal dialysis adequacy, our results have to be considered in the choice of the peritoneal dialysis modality.

In patients older than 75 years with advanced chronic kidney disease (CKD), the decision between treatment with dialysis [intention to treat with dialysis (ITD)] or conservative care (CC) is a challenge. Geriatric assessment can be helpful. The aim was to identify which factors had had an influence on decision-making. Methods: We recruited 56 patients. At baseline we analyzed age, frailty (defined following the criteria of Fried et al. [J Gerontol A Biol Sci Med Sci 2001;56:146-156]), dependence for activities of daily living (ADL), cognitive impairment, depression, comorbidity, cardiovascular disease, and diabetes. After full information about prognosis and treatment options, the preferences of the patients and families were taken into consideration as determinants in the decision-making process. During the follow-up, we evaluated clinical and laboratory parameters, hospitalization, mortality and reevaluated frailty. Results: Twenty patients opted for CC, and 36 patients opted for ITD. On univariate analysis, the predictive factors of the election of CC were age, prefrailty, cognitive impairment, and dependence for ADL. In the multivariate analysis, age and prefrailty remained as predictors for the choice of CC. Hospitalizations were more frequent in CC. Survival was similar in both groups (p = 0.098). Conclusions: Frailty assessment could be useful for decision-making about the treatment in elderly patients with CKD. CC may be a good treatment option.

Background. We examine whether cystatin C, a surrogate marker of renal function, could identify patients with chronic kidney disease (CKD) with an increased risk of renal disease progression, death, or cardiovascular events.Methods. Data were obtained for 180 patients, with a diagnosis of chronic renal failure based on serum creatinine estimated glomerular filtration rate (eGFRcreat) 2. This population was grouped in tertiles according to cystatin C and creatinine values at baseline. Cardiovascular events and overall mortality were estimated for each tertile. Predictors of overall mortality and for the development of renal disease progression were analyzed.Results. The median age was 75 years (interquartile range 69–82) and the median eGFRcreat38 mL/min m2(interquartile range 33–49). Overall mortality was lower on the first and on the second tertiles of cystatin C than on the third one (HR = 0.060; 95% CI: 0.008–0.447 and HR = 0.094; 95% CI: 0.022–0.406, resp.). Deaths related to the creatinine tertiles followed the same pattern, but differences were not as large. Cardiovascular mortality was lower on the second than on the third cystatin C tertile (HR = 0.198; 95% CI: 0.040–0.987), but it did not show differences on the first and the second creatinine tertiles compared with the third one (HR = 0.126; 95% CI: 0.013–1.265 and HR = 0.403; 95% CI: 0.093–1.740). The only independent predictors of mortality during followup were baseline cystatin C (OR = 0.100; 95% CI: 0.021–0.463) and baseline uric acid (OR = 1.377; 95% CI: 1.070–1.773).Conclusion. Cystatin C may be an alternative to creatinine for detecting a high risk of death and cardiovascular events in a population with CKD.

Background. Low serum magnesium has been associated with an increased cardiovascular risk in the general population and in dialysis patients. Our aim was to analyze the influence of serum magnesium on overall mortality and cardiovascular outcomes in patients with advanced CKD not yet on dialysis. Methods. Seventy patients with CKD stages 4 and 5 were included. After a single measurement of s-magnesium, patients were followed a mean of 11 months. Primary end-point was death of any cause, and secondary end-point was the occurrence of fatal or nonfatal CV events. Results. Basal s-magnesium was within normal range (2.1±0.3 mg/dL), was lower in men (P=0.008) and in diabetic patients (P=0.02), and was not different (P=0.2) between patients with and without cardiopathy. Magnesium did not correlate with PTH, calcium, phosphate, albumin, inflammatory parameters (CRP), and cardiac (NT-proBNP) biomarkers but correlated inversely (r=−0.23; P=0.052) with the daily dose of loop diuretics. In univariate and multivariate Cox proportional hazard models, magnesium was not an independent predictor for overall mortality or CV events. Conclusions. Our results do not support that serum magnesium can be an independent predictor for overall mortality or future cardiovascular events among patients with advanced CKD not yet on dialysis.

Overweight and obesity are associated to a higher cardiovascular risk and mortality in the general population and conflicting findings exist in the dialysis population. Adipokines (Leptin, adiponectin) produced in adipocytes may play a role in that process, and inflammatory parameters (CRP, IL-6) may be markers for it. Nevertheless, obtaining dry weight is today one of the main aims of adequacy in dialysis because overhydration is a clear mortality predictor.The aim of this study was to analyse body composition using an impedance spectroscopy technique in patients on haemodialysis (HD): and evaluate overweight and overhydration prevalence and its possible relation with adipokines, inflammatory and nutritional parameters, HD technique (Conventional [CHD], on-line haemodiafiltration [OL-HFD]) and erythropoietin needs.In a cross-sectional observational study, a pre-HD multifrequency bioimpedance spectroscopy (BIS) was performed in the middle of the week on 77 HD outpatients: 56 CHD and 21 OL-HFD. Patients were considered overweight when Body Mass Index (BMI) was ≥25kg/m² and overhydrated when overhydration normalised for extracellular water was higher than 0.15l. Clinical and biochemical parameters were analysed and IL-6, leptin and adiponectin levels were determined. This information was analysed in overweight and non-overweight, regular and overhydrated patients and both HD techniques.50% of patients fulfilled overweight criteria and 21% were pre-HD overhydrated. Overweight patients had a superior fat and extracellular water content (P.001). Leptin (P=.001) and CRP (P=.036) levels were higher and adiponectin levels were lower (P=.003). An inverse correlation did exist between BMI and lean mass (P=.01). Nutritional markers (prealbumin, albumin, total proteins, creatinine and transferrin) were related to lean mass (P=.05). Comparing both HD techniques, a lower fat content was observed in OL-HFD (P=.049) without overhydration differences. In the univariate analysis, age, fat, extracellular/intracellular water ratio, leptin, hipoadiponectinaemia, lower lean mass and CHD technique were predictors of overweight. In the multivariate analysis, hipoadiponectinaemia (OR: 0.86; IC: 0.76-0.98), lean mass (OR: 0.89; IC: 0.84-0.94) and OL-HFD technique (OR: 0.200; IC: 0.04-0.99) predicted the absence of overweight.This observational study emphasises the high prevalence of overweight in the outpatient haemodialysis population, as long as overweight is related with fat and extracellular water. Furthermore, it is accompanied by higher inflammation and leptin levels and lower levels of adiponectin. The use of the OL-HFD technique is associated to less overweight and fat content. Bioimpedance may prove to be a valuable ally for decisions regarding weight changes in dialysis patients.

Background: Mycophenolate (MF) is effective as induction therapy for lupus nephritis (LN) in patients with normal renal function; however, little is known about its role in patients with impaired renal failure. The purpose of this study was to evaluate the response to MF in LN and its association with baseline renal function. Methods: Data were obtained for 90 patients from 12 Spanish renal units who were receiving MF as induction therapy for LN. Patients were classified into 2 groups: group 1 (estimated glomerular filtration rate [eGFR] ≥60 ml/min/1.73 m2) and group 2 (eGFR 2). The primary outcome measure was the percentage of patients who achieved any response and its relationship with initial eGFR. The secondary outcome measures were the percentage of patients who achieved a complete response (CR) or partial response (PR) and the appearance of relapses during treatment and side effects. Results: At initiation of MF treatment, there were no differences in the main parameters between group 1 (n = 63; eGFR 87 ± 23 ml/min/ 1.73 m2) and group 2 (n = 27; eGFR 44 ± 12 ml/min/1.73 m2). Exposure to prednisone and MF was similar. The percentages of patients who achieved a response in groups 1 and 2 were, respectively, 69.2 and 43.8% at 6 months and 81.3 and 73.7% at 12 months. CR was more frequent in group 1, whereas PR was similar in both groups. Four patients relapsed and side effects were unremarkable. Conclusions: MF is effective and safe as induction therapy for LN, and response is even achieved in patients with baseline renal impairment.

We evaluated the use of telemedicine in the long-term control of stable patients undergoing peritoneal dialysis at home. From September 2003 to August 2005, patients were randomly selected from current cases and invited to join study group A, in which they had telemedicine support. Patients not selected for this group, or who refused the invitation, were placed in study group B, and used for comparison. There were 25 patients in group A and 32 patients in group B. Videoconferencing equipment was installed in each patient's home, connected to a videoconferencing unit at the hospital by three ISDN lines. Patients in group A were followed for a mean of 8 months (range 3–24) with alternate months of teleconsultations and hospital visits. A total of 172 teleconsultations were conducted. A mean of 22 min (SD 9) were spent on each teleconsultation, significantly less than in hospital consultations, which took a mean of 33 min (SD 8) ( P

We report a patient who developed type II heparin-induced thrombocytopenia (HIT) and accidentally received a recombinant hirudin (r-hirudin) overdosage. Treatment with hemodialysis (HD) using high-flux polysulfone dialyzer and hemofiltration was performed. Length of treatment was adjusted, monitoring activated partial thromboplastin time (aPTT) to 1.5-2.5 times the mean of the normal range. She developed deep venous thrombosis and occlusion of vascular access. Only after cessation of heparin lock catheter, platelet count began to increase. After one year of treatment with acenocoumarol and additional low-dose r-hirudin, neither bleeding nor thrombotic episodes have been reported.

Background. An elevated serum C-reactive protein(CRP) has been shown to be strongly predictive ofmorbidity and mortality in dialysis patients. However,the significance of high CRP levels in the pre-dialysisperiod has not been studied extensively. The aim of ourstudy was to analyse the evolution of our pre-dialysispopulation according to their basal levels of CRP.Methods. A cohort of 66 pre-dialysis patients wasfollowed for 1 year, after initial determination ofserum CRP. The evolution of blood pressure (BP)control, CRP levels, nutritional data (body mass index,serum albumin, prealbumin, transferrin, cholesterol),proteinuria, calcium-phosphorus product, bicarbonate,haemoglobin (Hb), the weekly dose of erythropoietin(Epo)ukg body weight, and the HbuEpo dose ratio weremeasured and compared between patients with high()6mgul) or low (-6mgul) CRP levels at baseline. Thedecline in renal function, hospitalization, and deathalso were measured and compared between the twogroups.Results. At baseline, 23 patients (35%) showed high()6mgul) CRP levels. CRP was higher in patients witha previous history of cardiovascular disease (P-0.01),as well as in patients in whom ischaemic nephropathyor nephrosclerosis was the cause of end-stage renaldisease (P-0.01). There were no differences betweendiabetic and non-diabetic patients. During the studyperiod, patients with higher CRP levels at baselinemaintained higher levels (P-0.001). During thisperiod, these patients showed lower (P-0.05) albuminconcentration, higher bicarbonate levels, lower Hbconcentration, and lower HbuEpo ratio and neededhigher Epo doses. There were no differences in systolicBP, the degree of proteinuria, and the decline in renalfunction between groups; diastolic BP was lower inpatients with high CRP levels. Hospitalization washigher (P-0.005) in this group. Only one patient died.Conclusions. The prevalence of inflammation is highin pre-dialysis patients. High serum CRP levels predicta constant inflammatory state on follow-up. As occursin dialysis patients, pre-dialysis inflammation predictslower serum albumin concentration, poorer responseto Epo, and a higher hospitalization rate. The declinein renal function does not seem to be related to theinflammatory state. Mortality was not affected onshort-term follow-up.Keywords: erythropoietin response; hospitalization;hypoalbuminaemia; inflammation; pre-dialysis

Although hypoalbuminemia is a fundamental characteristic of nephrotic syndrome (NS), there are many patients with massive proteinuria that do not develop hypoalbuminemia. We have studied the clinical and biochemical characteristics of 19 patients with persistent massive proteinuria (greater than 5 g/d) and normal serum albumin (group I) in comparison with 16 patients with similar proteinuria excretion, but persistent hypoalbuminemia (group II). Most of group I patients had diagnoses suggesting glomerular hyperfiltration (focal glomerulosclerosis [FGS] associated with vesicoureteral reflux [VUR], reduction of renal mass, proteinuria associated with obesity, sclerotic phase of idiopathic crescentic glomerulonephritis [GN] in contrast with those of group II, in which membranous GN was the most frequent diagnosis. We prospectively investigated differences in the antiproteinuric effect of captopril, an antiotensin-converting enzyme inhibitor (ACEI); after 6 months of treatment, proteinuria decreased clearly in group I (7.1 +/- 1.7 to 3.7 +/- 1.7 g/d; P less than 0.001), whereas no significant changes were observed in group II (8.1 +/- 2.4 to 8.8 +/- 4 g/d). Serum creatinine (Scr) remained stable during captopril treatment in group I, whereas three patients in group II showed a worsening of renal function.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of intravenously administered fenoldopam on diuresis and natriuresis was investigated in a group of 10 patients with advanced chronic renal failure. After an initial basal period of 1 h, a fenoldopam infusion was started and maintained for 12 h at rates varying between 0.025 and 0.1 microgram/kg per min. During the study, blood pressure was measured every 10 min and urine volume, natriuresis and creatinine clearance were measured hourly. Fenoldopam induced a significant increase in urine volume, natriuresis and creatinine clearance (P less than 0.05-0.001) accompanied by a small but significant drop in blood pressure (P less than 0.05-0.01). These results show that for advanced chronic renal failure, fenoldopam has diuretic and natriuretic properties that could be of clinical relevance.

In order to elucidate whether or not the natriuretic properties of calcium entry blockers persist during the long-term administration of the drug, we have investigated the renal capacity to excrete an intravenous sodium load (2,000 ml of isotonic saline in 4 h) in a group of eight mild to moderate essential hypertensive patients, before and after 1, 8, and 24 weeks of treatment with nitrendipine. The following parameters were measured before and hourly during saline infusion: blood pressure, and plasma and urine sodium and potassium. For 5 days prior to the performance of the test, the patients received a diet containing 120 mEq of sodium daily. Nitrendipine induced a significant fall of both systolic and diastolic blood pressure (p less than 0.05-0.01) that was maintained throughout the study. A significant increase of the cumulative renal sodium output (microEq/min/h) was observed after 1, 8, and 24 weeks (p less than 0.05-0.001) of therapy with the calcium entry blocker. Meanwhile, plasma sodium and potassium and the kaliuresis did not change significantly. These results indicate that the natriuretic effect of calcium entry blockers is still present after long-term treatment.

We studied the long-term effect of an angiotensin converting enzyme (ACE) inhibitor, captopril, on the progression of chronic renal failure and on the rate of urinary protein excretion. When compared with standard triple therapy, captopril slowed the progression of renal failure. Captopril was also able to reduce the proteinuria of non-diabetic glomerular origin. This reduction was not dependent on the presence or absence of arterial hypertension but was limited by the presence of low serum albumin levels, and only occurred in patients with proteinuria in excess of 3 g/24 h.