Chronic kidney disease (CKD) is a silent and poorly known killer. The current concept of CKD is relatively young and uptake by the public, physicians and health authorities is not widespread. Physicians still mix up CKD with chronic kidney insufficiency or failure, For the wider public and health authorities, CKD evokes kidney replacement therapy (KRT). In Spain, the prevalence of KRT is 0.13%. Thus, health authorities may consider CKD a non-issue: very few persons eventually need KRT and, for those in whom kidneys fail, the problem is “solved” by dialysis or kidney transplantation. However, KRT is the tip of the iceberg in the burden of CKD. The main burden of CKD is accelerated aging and premature death. The cut-off points for kidney function and kidney damage indexes that define CKD also mark an increased risk for all-cause premature death. CKD is the most prevalent risk factor for lethal COVID-19 and the factor that most increases the risk of death in COVID-19, after old age. Men and women undergoing KRT still have an annual mortality which is 10- o 100-fold higher than similar age peers, and life expectancy is shortened by around 40 years for young persons on dialysis and by 15 years for young persons with a functioning kidney graft. CKD is expected to become the fifth global cause of death by 2040 and the second cause of death in Spain before the end of the century, a time when 1 in 4 Spaniards will have CKD. However, by 2022, CKD will become the only top-15 global predicted cause of death that is not supported by a dedicated well-funded CIBER network research structure in Spain. Realizing the underestimation of the CKD burden of disease by health authorities, the Decade of the Kidney initiative for 2020-2030 was launched by the American Association of Kidney Patients (AAKP) and the European Kidney Health Alliance (EKHA). Leading Spanish kidney researchers grouped in the kidney collaborative research network REDINREN have now applied for the RICORS call of collaborative research in Spain with the support of the Spanish Society of Nephrology, ALCER and ONT: RICORS2040 aims to prevent the dire predictions for the global 2040 burden of CKD from becoming true.
Outcomes of kidney transplantation (KT) after controlled circulatory death (cDCD) with highly expanded criteria donors (ECD) and recipients have not been thoroughly evaluated. We analyzed in a multicenter cohort of 1161 consecutive KT, granular baseline donor and recipient factors predicting transplant outcomes, selected by bootstrapping and Cox proportional hazards, and were validated in a contemporaneous European KT cohort (n = 1585). 74.3% were DBD and 25.7% cDCD-KT. ECD-KT showed the poorest graft survival rates, irrespective of cDCD or DBD (log-rank < 0.001). Besides standard ECD classification, dialysis vintage, older age, and previous cardiovascular recipient events together with low class-II-HLA match, long cold ischemia time and combining a diabetic donor with a cDCD predicted graft loss (C-Index 0.715, 95% CI 0.675-0.755). External validation showed good prediction accuracy (C-Index 0.697, 95%CI 0.643-0.741). Recipient older age, male gender, dialysis vintage, previous cardiovascular events, and receiving a cDCD independently predicted patient death. Benefit/risk assessment of undergoing KT was compared with concurrent waitlisted candidates, and despite the fact that undergoing KT outperformed remaining waitlisted, remarkably high mortality rates were predicted if KT was undertaken under the worst risk-prediction model. Strategies to increase the donor pool, including cDCD transplants with highly expanded donor and recipient candidates, should be performed with caution.
Background and Aims cardiac surgery-associated acute kidney injury (CS-AKI) is a frequent complication that confers significant increase in morbility and mortality. It is still unclear how to identify patients at high risk to develop it, in order to apply to them early preventive strategies to avoid AKI. The study aimed to explore risk factors associated to CS-AKI. Method to analyze the association between demographic, pre-operative and intraoperative variables with all grades-AKI, we collected baseline characteristics, type of surgery, aortic time of clampage and extracorporeal circulation time, hemodinamic variables during surgery, Euroscore II, Clevelant Clinic Score and Leicester cardiosurgery score. The post-operative variables included monitorization of the first 24 h in the Intensive Care Units (ICU), consistent in: use of vasoactive drugs, total diuresis, use of furosemide, need of transfusions and need and duration of renal replacement therapy (RRT). Creatinine was collected for all the admision days in order to calculate the incidence of AKI. Also mortality and need of RRT at 30 th day was assessed. The inclusion criteria were: patients over 18 years old who underwent cardiac surgery with extracorporeal circulation. Only valve substitution (VS), Coronary Artery Bypass Graft (CABG) or a combination of both procedures (not including endocarditis surgery) were included. Patients who were already in dialysis or suffered an AKI just before the surgery were not included in the study. Results we included 130 patients who underwent heart surgery intervention in Hospital Clínic de Barcelona from 1st January to 31 st March 2015. 61,5% were men and the majority of them was 60 - 75 years old (46.9%), with hypertension (80.8%), without diabetes (68.5%), with stage 2-Chronic Kidney Disease (53.1%). Main surgical procedure was CABG (50.8%), followed by valve substitution (36.1%) and combination of both (13.1%). 73,1% of the procedures were done electively and 26.9% urgently. Out of the 130 patients, 60 (46.2%) suffered an AKI (36 AKIN 1, 16 AKIN 2 and 8 AKIN3). The majority of the episodes (55.2%) started between 24 and 48 hours after the intervention and 7 patients required RRT. AKI was not associated with mortality or need of renal replacement therapy at 30 days (OR 1.853, p= 0.397). Regarding risk factors for CS-AKI, basal eGFR <60 ml/min, history of hypertension, age and the clevelant/leicester and euroscore were preoperative risk factors associated with CS-AKI in our cohort (OR 5.571 p=<0.001; OR 2.621 p=0.043; OR 1.036 p<0.001; OR 1.453 p=0.045; OR 1.062 p<0.001; OR 1.351 p=0.006 respectively). Leicester cardiosurgery score >30 was the score who showed the best association with AKI (OR 5.167, p<0.001). Intraoperative significant risk factors that were identified were: ischaemia time over 70 minutes (OR 2.876, p=0.004), and the need to use phenylephrine (3.064, p=0.015); whereas the need to use nitroglycerin was identified as a protector (OR 0.441, p=0.031). Conclusion previous eGFR<60 ml/min, age, hypertension, use of phenylephrine during surgery and long ischaemia time are the main factors associated with CS-AKI. Scores like Leicester score can help physicians to identify people at risk and apply preventive strategies.
BackgroundAlprostadil is a drug widely used, among other indications, for the symptomatic treatment of arteriosclerotic occlusive disease of the lower limbs. Most marketed presentations of this drug for parenteral administration contain alfaciclodextrin as an excipient. In renal failure, this excipient can accumulate and cause nephrotoxicity.PurposeTo describe a clinical case of individualised drug selection based on the patient’s condition and establish strategies to optimise the treatment through dose fractionation.Material and methodsInpatient admitted with a diagnosis of spontaneous atheroembolism cholesterol and renal failure that required parenteral alprostadil. The responsible physician prescribed alprostadil 50 µg/24 h intravenously and prednisone 1 mg/kg/day orally.Our patient had a creatinine clearance of approximately 10 mL/min so the pharmacy service had to look for an alternative treatment or marketed presentation.The protocol created by the pharmacy service for this pharmacotherapy problem had the following steps:To search for a marketed alprostadil presentation without alfacyclodextrin as an excipient.To search handling stability information: specialty sheet and Stabilis 4.0.To develop a standard operating protocol (SOP) to carry out conditioning of the prescribed dose.Preparation of the daily dose in a horizontal laminar flow hood.ResultsOnly one of the alprostadil specialities marketed has no alfacyclodextrin in our country (Alprostadil Pfizer 0.5 mg/mL,1 mL ampoules). The pharmacy service decided to prepare a daily dose prescribed to employ the entire volume of the ampoule.According to the SOP, the total content of the ampoule is transferred into a glass vial under aseptic conditions in a horizontal laminar flow hood. Stability for 9 days at 2–8°C was assigned based on the available evidence.The pharmacy staff prepared the daily dose prescribe (0.1 mL for our patient) and incorporated it into a physiological saline solution of 100 mL.The solution for infusion in 0.9% sodium chloride is stable for only 24 h.The patient was treated with 4 ampoules of the selected specialty. This handling procedure had a real cost saving of 756€ (17 ampoules) compared with Sugiran 20 mg, included normally at our hospital.ConclusionIn special situations, such as kidney failure, individual selection of marketed drug presentations is important. Moreover, handling fractionation maintains the safety and quality of the pharmacotherapy and sometimes can achieve cost savings.No conflict of interest.
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