Publications by authors named "Alfonso M Cueto-Manzano"

45 Publications

Donor-specific antibodies development in renal living-donor receptors: Effect of a single cohort.

Int J Immunopathol Pharmacol 2021 Jan-Dec;35:20587384211000545

Department of Physiology, University Health Sciences Center, University of Guadalajara, Guadalajara, Jalisco, México.

Minimization in immunosuppression could contribute to the appearance the donor-specific HLA antibodies (DSA) and graft failure. The objective was to compare the incidence of DSA in renal transplantation (RT) in recipients with immunosuppression with and without steroids. A prospective cohort from March 1st, 2013 to March 1st, 2014 and follow-up (1 year), ended in March 2015, was performed in living donor renal transplant (LDRT) recipients with immunosuppression and early steroid withdrawal (ESW) and compared with a control cohort (CC) of patients with steroid-sustained immunosuppression. All patients were negative cross-matched and for DSA pre-transplant. The regression model was used to associate the development of DSA antibodies and acute rejection (AR) in subjects with immunosuppressive regimens with and without steroids. Seventy-seven patients were included (30 ESW and 47 CC). The positivity of DSA class I (13% vs 2%;  < 0.05) and class II (17% vs 4%,  = 0.06) antibodies were higher in ESW versus CC. The ESW tended to predict DSA class II (RR 5.7; CI (0.93-34.5,  = 0.06). T-cell mediated rejection presented in 80% of patients with DSA class I ( = 0.07), and 86% with DSA II ( = 0.03), and was associated with DSA class II, (RR 7.23; CI (1.2-44),  = 0.03). ESW could favor the positivity of DSA. A most strictly monitoring the DSA is necessary for the early stages of the transplant to clarify the relationship between T-cell mediated rejection and DSA.
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http://dx.doi.org/10.1177/20587384211000545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020398PMC
March 2021

Supportive care for end-stage kidney disease: an integral part of kidney services across a range of income settings around the world.

Kidney Int Suppl (2011) 2020 Mar 19;10(1):e86-e94. Epub 2020 Feb 19.

UK Renal Registry, Learning and Research, Southmead Hospital, Bristol, UK.

A key component of treatment for all people with advanced kidney disease is supportive care, which aims to improve quality of life and can be provided alongside therapies intended to prolong life, such as dialysis. This article addresses the key considerations of supportive care as part of integrated end-stage kidney disease care, with particular attention paid to programs in low- and middle-income countries. Supportive care should be an integrated component of care for patients with advanced chronic kidney disease, patients receiving kidney replacement therapy (KRT), and patients receiving non-KRT conservative care. Five themes are identified: improving information on prognosis and support, developing context-specific evidence, establishing appropriate metrics for monitoring care, clearly communicating the role of supportive care, and integrating supportive care into existing health care infrastructures. This report explores some general aspects of these 5 domains, before exploring their consequences in 4 health care situations/settings: in people approaching end-stage kidney disease in high-income countries and in low- and middle-income countries, and in people discontinuing KRT in high-income countries and in low- and middle-income countries.
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http://dx.doi.org/10.1016/j.kisu.2019.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031687PMC
March 2020

Capturing and monitoring global differences in untreated and treated end-stage kidney disease, kidney replacement therapy modality, and outcomes.

Kidney Int Suppl (2011) 2020 Mar 19;10(1):e3-e9. Epub 2020 Feb 19.

Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia.

A large gap between the number of people with end-stage kidney disease (ESKD) who received kidney replacement therapy (KRT) and those who needed it has been recently identified, and it is estimated that approximately one-half to three-quarters of all people with ESKD in the world may have died prematurely because they could not receive KRT. This estimate is aligned with a previous report that estimated that >3 million people in the world died each year because they could not access KRT. This review discusses the reasons for the differences in treated and untreated ESKD and KRT modalities and outcomes and presents strategies to close the global KRT gap by establishing robust health information systems to guide resource allocation to areas of need, inform KRT service planning, enable policy development, and monitor KRT health outcomes.
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http://dx.doi.org/10.1016/j.kisu.2019.11.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031690PMC
March 2020

Interactions Between Diet Quality and Interleukin-6 Genotypes Are Associated With Metabolic and Renal Function Parameters in Mexican Patients With Type 2 Diabetes Mellitus.

J Ren Nutr 2020 05 10;30(3):223-231. Epub 2019 Oct 10.

Molecular Medicine Division, Centro de Investigación Biomédica de Occidente (CIBO), Jalisco Delegation, Instituto Mexicano del Seguro Social (IMSS), Guadalajara, Mexico. Electronic address:

Objective: The aim of this study was to evaluate the interaction between diet quality and interleukin (IL)-6 genotypes and its association with metabolic and renal function parameters in Mexican patients with type 2 diabetes mellitus (T2DM).

Design And Methods: Using an analytical cross-sectional design, 219 patients with T2DM (92 men; age 62 ± 10 years) were evaluated for selected metabolic and renal function parameters. Diet quality according to the Healthy Eating Index was evaluated and classified as good diet or poor diet in all patients. IL-6 serum concentrations and genotypes and haplotypes for IL6-597G > A (rs180097), -572G > C (rs180096), and -174G > C (rs180095) polymorphisms were determined.

Results: Eighty-two percent of patients reported having a poor diet. Carriers of alleles -572C and -174C showed higher high-density lipoprotein cholesterol levels (44 ± 12 vs. 40 ± 9 mg/dL; P = .01) and lower total cholesterol levels (184 ± 33 vs. 197 ± 42 mg/dL; P = .03) than did those homozygous for G/G. Neither IL6 genotypes nor haplotypes were significantly associated with serum concentrations of IL-6. Some significant interactions between IL6 genotypes/haplotypes and diet quality were associated with body mass index, waist circumference, high-density lipoprotein cholesterol levels, and estimated glomerular filtration rate.

Conclusions: Interactions between diet quality and IL6 genotypes/haplotypes were associated with the main metabolic and renal function parameters in Mexican patients with T2DM. It will be important to consider genetic profiles in designing dietary portfolios and nutritional interventions for the management of such patients.
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http://dx.doi.org/10.1053/j.jrn.2019.08.002DOI Listing
May 2020

Clinical Taste Perception Test for Patients With End-Stage Kidney Disease on Dialysis.

J Ren Nutr 2020 01 9;30(1):79-84. Epub 2019 Apr 9.

Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, CMNO, IMSS, Guadalajara, México. Electronic address:

Objective: The aim of this study was to validate a direct taste perception test (TPT) and evaluate its performance in patients on dialysis.

Methods: This cross-sectional study was carried out in a tertiary-care hospital. A TPT was validated on 112 healthy subjects and applied on 43 patients on hemodialysis and 32 patients on peritoneal dialysis. All participants were presented a 10-mL sample to identify and rate intensity of primary tastes: sweet (sucrose 2%), sour (citric acid 0.1%), bitter (caffeine 0.06%), salty (sodium chloride 0.5%), and umami (sodium glutamate 0.25%). The internal consistency and repeatability of TPT was assessed by Cronbach's alpha and intraclass correlation coefficient. Chi-square and Mann-Whitney U tests were used to compare groups.

Results: TPT had Cronbach's alpha of 0.77. Intraclass correlation coefficient was 0.74 for sweet, P < .0001; 0.57 for salty, P = .001; 0.62 for sour, P < .0001; 0.78 for bitter, P < .0001; and 0.76 for umami, P < .0001. Compared with controls, patients on peritoneal dialysis were less able to identify sweet and umami tastes (P < .05) and marginally (P = .06) sour taste, whereas patients on hemodialysis were marginally (P = .06) less able to identify sweet and salty tastes. Bitter was not differently identified between groups. According to the visual analog scale (0-10), all patients on dialysis perceived sour taste less intensely than control subjects (P < .05).

Conclusions: This TPT for patients on dialysis had adequate reliability to identify five primary tastes in a clinical setting. Except for bitter taste, perception of all the primary tastes was altered in patients on dialysis compared with control subjects. A broader use of this test would help identify taste alterations and implement strategies for malnutrition.
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http://dx.doi.org/10.1053/j.jrn.2019.02.003DOI Listing
January 2020

Frequency and Risk Factors of Kidney Alterations in Children and Adolescents who Are Overweight and Obese in a Primary Health-care Setting.

J Ren Nutr 2019 09 21;29(5):370-376. Epub 2019 Jan 21.

Unit of Medical Research in Renal Diseases, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico. Electronic address:

Objective: Obesity is clearly associated to kidney disease in adult population; however, there is scarce evidence in children and adolescents. The aim was to compare frequency of renal damage according to the presence of overweight-obesity in children and adolescents, as well as to compare nutritional and biochemical risk factors, according to the presence of kidney alterations.

Methods: Cross-sectional study; 172 children and adolescents, 6-16 years old, without malnutrition, diabetes mellitus, hypertension and independent comorbid conditions associated to obesity or kidney disease, as well as transitory causes of microalbuminuria (MA) from a Primary Health-Care Unit were included. Clinical, biochemical, anthropometric and dietetic evaluations were measured in all subjects; subsequently they were classified as normal weight, overweight and obesity groups according to sex- and age-adjusted body mass index (BMI). Glomerular filtration rate (GFR, estimated by Schwartz equation) and albuminuria (albumin/creatinine ratio) were determined. Presence of kidney alterations was measured as decreased GFR (<90 mL/min/1.73m), hyperfiltration (>170 mL/min/1.73m) and MA (30-300 mg/g).

Results: Compared with controls, subjects with overweight-obesity had significantly (P<.05) abdominal obesity (0 vs 69%), hypertension (19 vs 26%), hypertriglyceridemia (11 vs 47%), high low-density lipoprotein cholesterol (2 vs 8%) and low high-density lipoprotein cholesterol (HDL-cholesterol; 2 vs 28%), hyperuricemia (11 vs 28%) and hyperinsulinemia (8 vs 70%). Hyperfiltration and MA were present in 5 and 4 subjects with overweight/obesity, respectively, whereas decreased GFR was present in only 1 subject with obesity. Normal weight subjects had no kidney alterations. In multivariate analysis, kidney alterations were significantly predicted by higher BMI and lower HDL-cholesterol.

Conclusions: Kidney alterations were observed only in subjects with overweight (3.6%) and obesity (9.9%), who additionally, displayed cardiometabolic and kidney disease risk factors more frequently than normal weight subjects.
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http://dx.doi.org/10.1053/j.jrn.2018.11.005DOI Listing
September 2019

Prevalence of Pica in Patients on Dialysis and its Association With Nutritional Status.

J Ren Nutr 2019 03 12;29(2):143-148. Epub 2018 Oct 12.

Departamento de Nefrología, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México.

Objective: Pica could be strongly implicated in nutritional status of patients on dialysis; however, very scarce data are currently available. The objective of this study was to evaluate the prevalence of pica and its association with nutritional status in dialysis patients.

Design And Methods: This is a cross-sectional study in a tertiary care teaching hospital. Four-hundred patients on dialysis, without previous pica diagnosis or transplant, pregnancy, mental illness, or infection, were included in the study. Pica, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, was classified as no pica, ice pica, or hard pica. Dialysis Malnutrition Score, 24-hour dietary recall, and biochemical measurements were obtained from patients. As part of statistical analysis, point prevalence and 95% confidence interval of pica were calculated. Comparisons between groups were performed by means of analysis of variance, Kruskal-Wallis test, χ, or Fisher exact tests, as appropriate. A multivariate analysis was performed by multinomial logistic regression.

Results: Prevalence of pica was 42% (ice pica, 46%; soil, 29%; two substances, 14%; red brick, 5%; paper, 3%; soap, 2%; and cattle pasture, 1%). Comparing patients with pica (hard pica and ice pica) versus no pica, subjects with pica were of younger age (25 ± 7, 27 ± 9, 30 ± 11 years, respectively), were more frequently educated <9 years (57%, 46%, 30%, respectively), and had longer dialysis duration (36 ± 19, 32 ± 18, 27 ± 16 months, respectively). Patients with pica achieved the recommended calorie and macronutrients intake target less frequently than those without pica (40-64% vs. 66-77%, P <.05). Malnutrition was present in 74% of the whole sample: (1) 67% in no pica group, (2) 80% in ice pica group, and (3) 89% in hard pica group (P = .001). In the multivariate analysis (R, 0.27; P < .0001), malnutrition, C-reactive protein, and lower educational level significantly predicted both ice and hard pica.

Conclusions: A worse nutritional status was observed in patients with pica, who additionally were younger, had lower educational level, longer dialysis duration, and worse macronutrient intake routine than patients without pica. Malnutrition, C-reactive protein, and lower educational level significantly predicted both ice and hard pica.
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http://dx.doi.org/10.1053/j.jrn.2018.08.002DOI Listing
March 2019

[Prevalence of cardiovascular risk factors in a population of health-care workers].

Rev Med Inst Mex Seguro Soc 2016 Sep-Oct;54(5):594-601

Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Jalisco, México.

Background: To determine the prevalence of cardiovascular risk factors (CVRF) in healthcare workers from two tertiary-care hospitals of the Mexican Institute of Social Security, as well as their association with professional activities (PA).

Methods: Descriptive study. One-thousand eighty-nine health-care workers ≥ 18 years were included. Clinical history, physical exam, and blood tests were performed.

Results: Mean age 41 ± 9 years, 76% women. Hypertension prevalence was 19%, diabetes mellitus 9.6%, dyslipidemia 78%, overweight and obesity 73%, metabolic syndrome (MS) 32.5%, and smoking 19%. The following significant associations (p < 0.05) were found: MS with medical asisstants (OR: 2.73, CI 95%: 1.31-5.69) and nutritionist (OR: 2.6, CI 95%: 1.31-5.24); obesity with administrative personnel (OR: 3.64, CI 95%: 1.40-7.46); dyslipidemia with medical asisstants (OR: 2.58, CI 95%: 1.15-6.34). In the whole sample, the probability to have a vascular event in the following 10 years was 10%.

Conclusion: Prevalence of CVRF was high in this sample of health-care workers and did not seem to be different from those in general population. Medical assistants, nutritionist, and administrative personnel displayed a higher risk. It is necessary to create programs to promote healthy lifestyle and to improve the epidemiological profile of health-care workers.
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May 2017

Prevalence of pre-diabetes in young Mexican adults in primary health care.

Fam Pract 2015 Apr 8;32(2):159-64. Epub 2014 Sep 8.

Medical Research Unit in Renal Disease, Specialities Hospital, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico.

Background: Pre-diabetes in young people is frequently unrecognized or not treated on time, with the consequent loss of opportunity for diabetes prevention. In Mexico, there is scarce information about the prevalence of pre-diabetes in young adults.

Objective: To determine the prevalence and risk factors for pre-diabetes in young Mexican adults in primary health care.

Methods: In a cross-sectional study, 288 subjects, aged 18-30 years, from a primary care unit were included. Pre-diabetes was diagnosed (according to the criteria of the American Diabetes Association) as impaired fasting glucose (8-12 hours fasting plasma glucose level: 100-125 mg/dl) or impaired glucose tolerance (140-199 mg/dl after a 2-hour oral glucose tolerance test).

Results: Prevalence of pre-diabetes was 14.6% [95% confidence interval (CI): 10.7-19.2], whereas that of diabetes was 2.4% (95% CI: 1.0-4.9). A high proportion of patients had history of obesity, diabetes, hypertension and consumption of tobacco and alcohol. Pre-diabetic patients were older than normoglycaemics (pre-diabetic patients: 26±4 years versus normoglycaemic subjects: 24±3 years, P = 0.003) and had higher body mass index (BMI; pre-diabetic patients: 29.4±6.8 kg/m(2) versus normoglycaemic subjects: 26.8±5.8 kg/m(2); P = 0.009), particularly in the case of men (pre-diabetic men: 29.3±7.0 kg/m(2) versus normoglycaemic men: 26.4±5.1 kg/m(2); P = 0.03). Although waist circumference showed a trend to be higher among pre-diabetics, no significant differences were found according to gender (among males: pre-diabetics: 99.5±18.8 cm versus normoglycaemics: 93.3±14.4 cm, P = 0.09; among females: pre-diabetics: 91.5±13.8 cm versus normoglycaemics: 85.8±15.9 cm, P = 0.16). Only age and BMI were significantly associated with the presence of pre-diabetes.

Conclusions: Almost 15% of these young adults had pre-diabetes. Many modifiable and non-modifiable risk factors were present in these patients, but only age and a higher BMI were independent variables significantly associated with pre-diabetes. Timely interventions in primary health care are needed to prevent or delay the progression to diabetes.
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http://dx.doi.org/10.1093/fampra/cmu047DOI Listing
April 2015

Prevalence of chronic kidney disease in an adult population.

Arch Med Res 2014 Aug 1;45(6):507-13. Epub 2014 Jul 1.

Dirección General, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Jalisco, México.

Background And Aims: One strategy to prevent and manage chronic kidney disease (CKD) is to offer screening programs. The aim of this study was to determine the percentage prevalence and risk factors of CKD in a screening program performed in an adult general population.

Methods: This is a cross-sectional study. Six-hundred ten adults (73% women, age 51 ± 14 years) without previously known CKD were evaluated. Participants were subjected to a questionnaire, blood pressure measurement and anthropometry. Glomerular filtration rate estimated by CKD-EPI formula and urine tested with albuminuria dipstick.

Results: More than 50% of subjects reported family antecedents of diabetes mellitus (DM), hypertension and obesity, and 30% of CKD. DM was self-reported in 19% and hypertension in 29%. During screening, overweight/obesity was found in 75%; women had a higher frequency of obesity (41 vs. 34%) and high-risk abdominal waist circumference (87 vs. 75%) than men. Hypertension (both self-reported and diagnosed in screening) was more frequent in men (49%) than in women (38%). CKD was found in 14.7%: G1, 5.9%; G2, 4.5%; G3a, 2.6%; G3b, 1.1%, G4, 0.3%; and G5, 0.3%. Glomerular filtration rate was mildly/moderately reduced in 2.6%, moderately/severely reduced in 1.1%, and severely reduced in <1%. Abnormal albuminuria was found in 13%. CKD was predicted by DM, hypertension and male gender.

Conclusions: A percentage CKD prevalence of 14.7% was found in this sample of an adult population, with most patients at early stages. Screening programs constitute excellent opportunities in the fight against kidney disease, particularly in populations at high risk.
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http://dx.doi.org/10.1016/j.arcmed.2014.06.007DOI Listing
August 2014

Early steroid withdrawal in a renal transplant cohort treated with tacrolimus, mycophenolate mofetil and basiliximab.

Nefrologia 2014 ;34(2):216-22

Background: Acute rejection and graft function have not been completely clarified in early-steroid-withdrawal (ESW) patients. The objective of this study was to compare the effect of early steroid withdrawal on GFR, graft survival/rejection in recipients in a cohort treated with tacrolimus/mycophenolate mofetil compared to a control cohort.

Material And Method: Retrospective cohort, in 60 low immunological risk recipients between December 2005 and July 2010. Study cohort (ESW-C N=32), steroid withdrawal was carried out after 5 days, while they were receiving tacrolimus/mycophenolate mofetil. The control cohort (C-C, N=28) received prednisone/tacrolimus/mycophenolate mofetil. Clinical, biochemical and histological variables were assessed at baseline and after 3, 6, and 12 months of follow-up. Kaplan-Meier and the Cox proportional hazards model were used to assess survival. Comparisons between cohorts were carried out by the Student's t and c2 tests.

Results: At follow-up, C-C displayed significantly higher systolic (125 ± 10 vs. 114 ± 8) and diastolic (81 ± 8 vs. 72 ± 7) blood pressure, serum glucose (96 ± 13 vs. 86 ± 10), triglycerides (177 ± 61 vs. 129 ± 34), total (183 ± 43 vs. 148 ± 34) and LDL-cholesterol (100 ± 22 vs. 87 ± 25). C-C had a higher proportion of antihypertensive (57 vs. 13%), and statins (27 vs. 9%) use. eGFR was better in ESW-C than in C-C (85.4 ± 20.6 vs. 70.6 ± 17.0, p=.004). AR frequency was lower in ESW-C.

Conclusions: Graft survival, GFR, AR rate and metabolic profile were better in the ESW-C than in C-C.
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http://dx.doi.org/10.3265/Nefrologia.pre2013.Dec.12028DOI Listing
July 2015

Multidisciplinary strategies in the management of early chronic kidney disease.

Arch Med Res 2013 Nov 8;44(8):611-5. Epub 2013 Nov 8.

Medical Research Unit in Kidney Disease, Specialty Hospital, CMNO, IMSS, Guadalajara, Jalisco, Mexico.

Chronic kidney disease (CKD) is a worldwide epidemic especially in developing countries, with clear deficiencies in identification and treatment. Better care of CKD requires more than only economic resources, utilization of health research in policy-making and health systems changes that produce better outcomes. A multidisciplinary approach may facilitate and improve management of patients from early CKD in the primary health-care setting. This approach is a strategy for improving comprehensive care, initiating and maintaining healthy behaviors, promoting teamwork, eliminating barriers to achieve goals and improving the processes of care. A multidisciplinary intervention may include educational processes guided by health professional, use of self-help groups and the development of a CKD management plan. The complex and fragmented care management of patients with CKD, associated with poor outcome, enhances the importance of implementing a multidisciplinary approach in the management of this disease from the early stages. Multidisciplinary strategies should focus on the needs of patients (to increase their empowerment) and should be adapted to the resources and health systems prevailing in each country; its systematic implementation can help to improve patient care and slow the progression of CKD.
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http://dx.doi.org/10.1016/j.arcmed.2013.10.013DOI Listing
November 2013

Vascular calcification in Mexican hemodialysis patients.

Arch Med Res 2013 Nov 8;44(8):628-32. Epub 2013 Nov 8.

Medical Research Unit in Renal Diseases, Specialty Hospital, CMNO, IMSS, Guadalajara, Mexico.

Background And Aims: Vascular calcification (VC) is a predictor of poor survival and cardiovascular outcome in end-stage renal disease (ESRD) patients; however, there is scarce information of VC in Latin America, and virtually no data in our setting. We undertook this study to evaluate the prevalence and characteristics of VC in a hemodialysis (HD) population from western Mexico and to determine possible associated factors.

Methods: This was a cross-sectional study performed in 52 patients. VC was evaluated using plain X-ray films (Adragao's score) of hands and pelvis; clinical and biochemical variables were also collected. Statistical analysis was carried out with Student t and χ(2) tests performed as appropriate and logistic regression to determine predictors of VC.

Results: Mean age was 43 years, 48% were female, 23% had diabetes mellitus (DM), and median time on dialysis was 46 months. Percentage prevalence was 52% with a mean calcification score of 2.0 ± 2.6; 23% of patients had severe calcification. VC was present in about 23-37% among the different vascular territories evaluated (radial, digital, femoral and iliac). Patients with calcification were significantly older, had a higher frequency of DM, higher alkaline phosphatase and lower HDL lipoproteins than those without VC. In the multivariate analysis, VC in these patients was significantly predicted only by an older age (OR [95% CI]: 1.15 [1.01-1.31], p = 0.04); lower HDL-cholesterol and higher alkaline phosphatase were marginal predictors.

Conclusions: Half of our HD patients had VC. Territories of radial, iliac, femoral and digital arteries were roughly equally affected, and 25% of patients had a calcification considered as severe. Older age was the only significant predicting variable for VC, with low HDL-cholesterol and high alkaline phosphatase as marginal predictors.
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http://dx.doi.org/10.1016/j.arcmed.2013.10.018DOI Listing
November 2013

Anti-inflammatory interventions in end-stage kidney disease: a randomized, double-blinded, controlled and crossover clinical trial on the use of pravastatin in continuous ambulatory peritoneal dialysis.

Arch Med Res 2013 Nov 8;44(8):633-7. Epub 2013 Nov 8.

Medical Research Unit Kidney Disease, Specialty Hospital, CMNO, Guadalajara, Mexico. Electronic address:

Background And Aims: Inflammation is highly prevalent in patients on dialysis. Statins have anti-inflammatory actions but their use has been scarcely studied in continuous ambulatory peritoneal dialysis (CAPD). We undertook this study to compare the effect of pravastatin vs. placebo on the serum concentrations of C-reactive protein (CRP) in patients on CAPD.

Methods: In a double-blind, controlled and crossover clinical trial, 76 CAPD patients were randomized to either pravastatin or placebo for 2 months. After this first period of treatment, patients had a 1-month wash-out period and, finally, they were crossed-over to receive the other drug (or placebo) for 2 more months. Measurement of clinical and biochemical variables and CRP was performed at the beginning and at the end of each treatment period.

Results: Median CRP was only significantly decreased in the pravastatin group in both periods of treatment: first period (baseline vs. final, mg/L): pravastatin 7.4 (2-21) vs. 2.6 (1-6), p <0.05; placebo 3.9 (2-10) vs. 6.8 (3-12), pNS; second period: pravastatin 4.3 (2-15) vs. 1.9 (1-7), p <0.05; placebo 4.9 (2-17) vs. 6.8 (2-19), p <0.05. Results were significantly different (p <0.05) between groups only at the end of each treatment period. Additionally, total and LDL-cholesterol significantly decreased in the pravastatin group.

Conclusions: Pravastatin significantly reduced serum levels of CRP and total and LDL-cholesterol compared to placebo. This treatment may be of great help to decrease the inflammatory status and probably the cardiovascular disease of CAPD patients.
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http://dx.doi.org/10.1016/j.arcmed.2013.10.016DOI Listing
November 2013

Comparison of primary health-care models in the management of chronic kidney disease.

Kidney Int Suppl (2011) 2013 May;3(2):210-214

Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades , Jalisco, Mexico.

Negative lifestyle habits (potential risks for chronic kidney disease, CKD) are rarely modified by physicians in a conventional health-care model (CHCM). Multidisciplinary strategies may have better results; however, there is no information on their application in the early stages of CKD. Thus, the aim of this study was to compare a multiple intervention model versus CHCM on lifestyle and renal function in patients with type 2 diabetes mellitus and CKD stage 1-2. In a prospective cohort study, a family medicine unit (FMU) was assigned a multiple intervention model (MIM) and another continued with conventional health-care model (CHCM). MIM patients received an educational intervention guided by a multidisciplinary team (family physician (FP), social worker, dietitian, physical trainer); self-help groups functioned with free activities throughout the study. CHCM patients were managed only by the FP, who decided if patients needed referral to other professionals. Thirty-nine patients were studied in each cohort. According to a lifestyle questionnaire, no baseline differences were found between cohorts, but results reflected an unhealthy lifestyle. After 6 months of follow-up, both cohorts showed significant improvement in their dietary habits. Compared to CHCM diet, exercise, emotional management, knowledge of disease, and adherence to treatment showed greater improvement in the MIM. Blood pressure decreased in both cohorts, but body mass index, waist circumference, and HbA significantly decreased only in MIM. Glomerular filtration rate (GFR) was maintained equally in both cohorts, but albuminuria significantly decreased only in MIM. In conclusion, MIM achieves better control of lifestyle-related variables and CKD risk factors in type 2 diabetes mellitus (DM2) patients with CKD stage 1-2. Broadly, implementation of a MIM in primary health care may produce superior results that might assist in preventing the progression of CKD.
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http://dx.doi.org/10.1038/kisup.2013.16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4089658PMC
May 2013

Comparison of direct medical costs between automated and continuous ambulatory peritoneal dialysis.

Perit Dial Int 2013 Nov-Dec;33(6):679-86. Epub 2013 Apr 1.

Unidad de Investigación Médica en Enfermedades Renales,1 Hospital de Especialidades, CMNO, and Coordinación de Salud Pública,2 Delegación Jalisco, IMSS, Guadalajara;

Objective: We set out to estimate the direct medical costs (DMCs) of peritoneal dialysis (PD) and to compare the DMCs for continuous ambulatory PD (CAPD) and automated PD (APD). In addition, DMCs according to age, sex, and the presence of peritonitis were evaluated.

Methods: Our retrospective cohort analysis considered patients initiating PD, calculating 2008 costs and, for comparison, updating the results for 2010. The analysis took the perspective of the Mexican Institute of Social Security, including outpatient clinic and emergency room visits, dialysis procedures, medications, laboratory tests, hospitalizations, and surgeries.

Results: No baseline differences were observed for the 41 patients evaluated (22 on CAPD, 19 on APD). Median annual DMCs per patient on PD were US$15 072 in 2008 and US$16 452 in 2010. When analyzing percentage distribution, no differences were found in the DMCs for the modality groups. In both APD and CAPD, the main costs pertained to the dialysis procedure (CAPD 41%, APD 47%) and hospitalizations (CAPD 37%, APD 32%). Dialysis procedures cost significantly more (p = 0.001) in APD (US$7 084) than in CAPD (US$6 071), but total costs (APD US$15 389 vs CAPD US$14 798) and other resources were not different. The presence of peritonitis increased the total costs (US$16 075 vs US$14 705 for patients without peritonitis, p = 0.05), but in the generalized linear model analysis, DMCs were not predicted by age, sex, dialysis modality, or peritonitis. A similar picture was observed for costs extrapolated to 2010, with a 10% - 20% increase for each component--except for laboratory tests, which increased 52%, and dialysis procedures, which decreased 3%, from 2008.

Conclusions: The annual DMCs per patient on PD in this study were US$15 072 in 2008 and US$16 452 in 2010. Total DMCs for dialysis procedures were higher in APD than in CAPD, but the difference was not statistically significant. In both APD and CAPD, 90% of costs were attributable to the dialysis procedure, hospitalizations, and medications. In a multivariate analysis, no independent variable significantly predicted a higher DMC.
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http://dx.doi.org/10.3747/pdi.2011.00274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3862098PMC
September 2014

Pentoxifylline decreases serum levels of tumor necrosis factor alpha, interleukin 6 and C-reactive protein in hemodialysis patients: results of a randomized double-blind, controlled clinical trial.

Nephrol Dial Transplant 2012 May 3;27(5):2023-8. Epub 2011 Oct 3.

Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, México.

Aim: The aim of this study was to compare the effect of pentoxifylline versus placebo on serum concentrations of tumor necrosis factor-alpha (TNF-α), interleukin 6 (IL-6) and C-reactive protein (CRP) of hemodialysis (HD) patients.

Methods: This is a randomized double-blind, controlled clinical trial. HD patients without infection or drugs with anti-inflammatory effect were randomly allocated to a study (n = 18, pentoxifylline 400 mg/day) or control (n = 18, placebo) group; all patients had arteriovenous fistula. Besides clinical and laboratory monthly assessments, serum TNF-α and IL-6 (ELISA) and CRP (nephelometry) were measured at 0, 2 and 4 months.

Results: All the inflammation markers significantly (P < 0.05) decreased in the pentoxifylline group: TNF-α [baseline 0.4 (0-2) versus final 0 (0-0) pg/mL], IL-6 [baseline 9.4 (5-14) versus final 2.9 (2-5) pg/mL] and CRP [baseline 7.1 (3-20) versus final 2.6 (1-8) mg/L], whereas no significant changes were observed in the placebo group: TNF-α [baseline 0 (0-0) versus final 1.2 (0-4) pg/mL], IL-6 [baseline 8.0 (5-11) versus final 8.7 (4-11) pg/mL] and CRP [baseline 4.5 (2-9) versus final 3.8 (3-23) mg/L].

Conclusions: Pentoxifylline significantly decreased serum concentrations of TNF-α, IL-6 and CRP compared to placebo. Pentoxifylline could be a promising and useful strategy to reduce the systemic inflammation frequently observed in patients on HD.
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http://dx.doi.org/10.1093/ndt/gfr579DOI Listing
May 2012

Dietary micronutrient intake in peritoneal dialysis patients: relationship with nutrition and inflammation status.

Perit Dial Int 2012 Mar-Apr;32(2):183-91. Epub 2011 Jul 31.

Medical Research Unit for Renal Diseases, Hospital de Especialidades, CMNO, Guadalajara, Mexico.

Objective: To compare dietary intake of micronutrients by peritoneal dialysis (PD) patients according to their nutrition and inflammatory statuses.

Design: This cross-sectional study evaluated 73 patients using subjective global assessment, 24-hour dietary recall, and markers of inflammation [C-reactive protein (CRP), tumor necrosis factor α, and interleukin 6].

Results: Half the patients had an inadequate micronutrient intake. Compared with dietary reference intakes, malnourished patients had lower intakes of iron (11 mg) and of vitamins C (45 mg) and B6 (0.8 mg). Malnourished and well-nourished patients both had lower intakes of sodium (366 mg, 524 mg respectively), potassium (1555 mg, 1963 mg), zinc (5 mg, 7 mg), calcium (645 mg, 710 mg), magnesium (161 mg, 172 mg), niacin (8 mg, 9 mg), folic acid (0.14 mg, 0.19 mg), and vitamin A (365 μg, 404 μg). Markers of inflammation were higher in malnourished than in well-nourished subjects. Compared with patients in lower quartiles, patients in the highest CRP quartile had lower intakes (p < 0.05) of sodium (241 mg vs 404 mg), calcium (453 mg vs 702 mg), vitamin B2 (0.88 mg vs 1.20 mg), and particularly vitamin A (207 μg vs 522 μg).

Conclusions: Among PD patients, half had inadequate dietary intakes of iron, zinc, calcium and vitamins A, B6, C, niacin, and folic acid. Lower micronutrient intakes were associated with malnutrition and inflammation. Patients with inflammation had lower intakes of sodium, calcium, and vitamins A and B2. Micronutrient intake must be investigated in various populations so as to tailor adequate supplementation.
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http://dx.doi.org/10.3747/pdi.2010.00245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3525406PMC
June 2012

Is systemic inflammation of hemodialysis patients improved with the use of enalapril? Results of a randomized, double-blinded, placebo-controlled clinical trial.

ASAIO J 2010 Jan-Feb;56(1):37-41

Unit of Medical Research in Renal Diseases, Hospital de Especialidades, CMNO, Guadalajara, Mexico.

This study compared the effect of enalapril versus placebo on serum tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and C-reactive protein (CRP) in hemodialysis in a randomized, double- blinded, controlled clinical trial. Patients without infection or antiinflammatory drugs were randomly allocated to a study (n = 13, enalapril, 20 mg/day) or control (n = 12, placebo) group; all had arteriovenous fistula. Serum TNF-alpha, IL-6, and CRP were measured at 0, 1, and 3 months. Systolic blood pressure (baseline vs. final) was 151 +/- 25 vs. 135 +/- 19 mm Hg (p < 0.05) in the study group and 154 +/- 21 vs. 144 +/- 27 mm Hg in control group; diastolic blood pressure was 86 +/- 9 vs. 76 +/- 13 and 91 +/- 16 vs. 81 +/- 18 mm Hg, respectively; median (percentiles 25%-75%) IL-6 (baseline vs. final) was 4.2 (3-8) vs. 4.1 (2-9) pg/mL and 6.3 (3-9) vs. 6.7 (3-8) pg/mL; and CRP was 1.9 (1-7) vs. 3.0 (1-12) mg/L and 4.7 (1-16) vs. 3.9 (2-16) mg/L, respectively. TNF-alpha was detected in only two patients. Enalapril significantly reduced blood pressure in hemodialysis patients, but it did not decrease IL-6 and CRP compared with placebo.
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http://dx.doi.org/10.1097/MAT.0b013e3181c1d830DOI Listing
March 2010

Conventional nutritional counselling maintains nutritional status of patients on continuous ambulatory peritoneal dialysis in spite of systemic inflammation and decrease of residual renal function.

Nephrology (Carlton) 2009 Aug;14(5):493-8

Unit of Medical Research in Renal Diseases, Hospital de Especialidades, CMNO, Guadalajara, Mexico.

Aim: To evaluate the effect of nutritional counselling on nutritional status in peritoneal dialysis patients.

Methods: Twenty-nine peritoneal dialysis patients were randomly selected to receive conventional nutritional counselling during 6 months of follow up. All patients had monthly clinical and biochemical evaluations, and assessments of dialysis adequacy, inflammation and nutritional status at 0, 3 and 6 months.

Results: Moderate-severe malnutrition decreased 28% whereas normal nutrition increased 23% at final evaluation (non-significant). Calorie and protein intake remained stable throughout the study (baseline vs final, calorie: 24 +/- 8 vs 23 +/- 5 Kcal/kg; protein: 1.1 +/- 0.5 vs 1.0 +/- 0.3 g/Kg, respectively). On the other hand, triceps (16 +/- 6 vs 18 +/- 8 mm) and subscapular (17 +/- 8 vs 20 +/- 5 mm) skinfold thicknesses, and mid-arm circumference (27 +/- 3 vs 28 +/- 3 mm) significantly increased; mid-arm muscle area displayed a non-significant trend to increase (30 +/- 9 vs 31 +/- 9 cm(2)) whereas serum albumin significantly increased at the end of study (2.67 +/- 0.46 vs 2.94 +/- 0.48 g/dL). At final evaluation, median renal creatinine clearance decreased (6.3 (0.8-15.3) vs 2.0 (0.1-6.3) L/week per 1.73 m(2)) whereas interleukin-6 increased (2.33 (1.9-7.0) vs 4.02 (2.1-8.4) pg/mL).

Conclusion: Even though conventional nutritional counselling, as an isolated measure, did not significantly improve all nutritional parameters, it prevented a greater deterioration during 6 months. Nutritional counselling maintained the nutritional status in spite of a decrease in residual renal function and higher systemic inflammation.
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http://dx.doi.org/10.1111/j.1440-1797.2008.01081.xDOI Listing
August 2009

Anthropometric and dietary evaluations in a sample of "healthy" Mexican older adults.

J Nutr Elder 2009 Jul;28(3):287-300

Medical Research Unit in Renal Diseases, Hospital de Especialidades, CMNO, Guadalajara, Mexico.

The purpose of this study was to describe anthropometric, metabolic, and nutritional characteristics in healthy elderly adults in a primary health care setting. It was conducted through a cross-sectional study of 80 subjects 60 years of age and older. After confirming healthy status, clinical, biochemical, dietetic, and anthropometric evaluations were performed. The findings indicated 22% had anemia, 22% had impaired glucose tolerance, 46% had hypertriglyceridemia, and 51% had hypercholesterolemia. More than 50% had obesity, and almost 80% had a high risk waist circumference measure. Mean energy intake was normal; however, more than 50% of participants did not have adequate intakes of potassium, calcium, magnesium, zinc, folic acid, and vitamins B(12) and A. Inadequate food intakes were common. Specific examples are that 16% of the subjects ate no meat/egg, 31% ate no dairy products, 56% ate no legumes, 22% ate no fruits, and 41% ate no vegetables. Additionally, 31% consumed soft drinks. Therefore, we can conclude that elderly people otherwise considered as "healthy" nonetheless had a high proportion of obesity and cardiovascular risk factors. Inadequate dietary patterns were also observed and corresponded with poor micronutrient intake.
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http://dx.doi.org/10.1080/01639360903140270DOI Listing
July 2009

Role of the primary care physician in diagnosis and treatment of early renal damage.

Ethn Dis 2009 ;19(1 Suppl 1):S1-68-72

Unidad de Investigación Medica en Enfermedades Renales, UMAE Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico.

In spite of all the technical advances and resources dedicated to the treatment of endstage renal disease (ESRD), it is still a growing problem all over the world. To address this issue adequately, it is crucial to detect chronic kidney disease patients early and optimize their care. However, a lack of awareness and appropriate management of potential underlying kidney disease, even in high-risk patients, seems to be common in many parts of the world, even though many of the measures recognized to decrease the risk and slow the progression of kidney disease are most effective when initiated early. Type 2 diabetes mellitus patients (a high-risk population) with early nephropathy treated by nephrologists have better preservation of their renal function than do patients treated only by family physicians. However, referral of patients to the nephrologist at earlier stages of disease than is recommended is not always feasible. A more plausible alternative may be that general practitioners learn to diagnose and treat these patients. We have demonstrated that an educational intervention increased family practitioners' clinical competence, which resulted in preserved renal function in diabetic patients with early renal disease. Variables not well controlled either by the nephrologist or the primary care physicians are those related to lifestyle and diet. These unhealthy habits are common in Westernized societies, and primary care physicians may be the most suitably positioned to promote health. Even so, counseling by physicians is not always effective in reducing risky habits, particularly when the health team is overworked; strategies such as community resources (including support groups) may also play a role. Preliminary results of an ongoing study based on a self-help and support group strategy that is coordinated by a multidisciplinary team (family practitioner, social worker, dietician, and physical trainer) show improvements in the lifestyle and dietary habits of patients with overweight or obesity, diabetes, or hypertension. All these findings support the need to implement health promotion programs with the participation of multidisciplinary teams.
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July 2009

Rapid solute transport in the peritoneum: physiologic and clinical consequences.

Perit Dial Int 2009 Feb;29 Suppl 2:S90-5

Unidad de Investigación Médica en Enfermedades Renales, UMAE Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico.

This review focuses on the physiologic and clinical consequences of rapid solute transport in the peritoneum. The concept, the current understanding of related factors, and the possible causes implicated in rapid solute transport are discussed first. Then, the consequences, with particular emphasis on mortality, are highlighted. Finally, based on recent advances and clinical studies, some strategies for the treatment of fast peritoneal transport are reviewed.
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February 2009

[The role of primary physicians in the early detection and treatment of chronic renal disease: challenges and opportunities].

Rev Invest Clin 2008 Nov-Dec;60(6):517-26

Unidad de Investigación Médica en Enfermedades Renales, UMAE Hospital de Especialidades, CMNO, IMSS, Guadalajara.

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May 2009

How frequently the clinical practice recommendations for nephropathy are achieved in patients with type 2 diabetes mellitus in a primary health-care setting?

Rev Invest Clin 2008 May-Jun;60(3):217-26

Unidad de Investigación Social, Epidemiología y en Servicios de Salud.

Objective: To determine the proportion of DM2 patients in primary health-care setting who meet clinical practice recommendations for nephropathy.

Material And Methods: 735 patients were included in this cross-sectional study. Nephropathy was defined as glomerular filtration rate < 60 mL/min/1.73 m2 or albuminuria > or = 30 mg/day. To estimate the proportion of patients meeting clinical practice recommendations, the achieved level was classified according to NKF -K/DOQI, ADA, IDF, JNC 7 report, and NCEP-ATPIII.

Results: A high frequency of kidney disease and cardiovascular risk factors (smoking, alcoholism, obesity) was observed. Adequate levels were attained in 13% for fasting glucose, 45% for blood pressure, 71% for albuminuria, and 30% for lipids. Nephropathy was diagnosed in 41%. Adequate systolic blood pressure was observed in 40% of patients with nephropathy vs. 49% without nephropathy (p = 0.03). In both groups, body mass index was acceptable in one fifth of patients, and waist circumference in two thirds of men and one third of women (p = NS). Patients with nephropathy used more antihypertensives, particularly angiotensin converting enzyme inhibitors (nephropathy 49% vs. no nephropathy 38%, p = 0.004). Subjects with nephropathy received more frequently (p = 0.05) insulin (11%) than those without nephropathy (7%). In both groups, there was low use of statins (nephropathy 14% vs. no nephropathy 17%, p = 0.23), and aspirin (nephropathy 7% vs. no nephropathy 5%, p = 0.39).

Conclusions: Recommended goals for adequate control of DM2 patients attending primary health-care units are rarely achieved, and this was independent of the presence of nephropathy. These findings are disturbing, as poor clinical and metabolic control may eventually cause that patients without nephropathy develop renal damage, and those subjects already with renal disease progress to renal insufficiency.
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December 2008

Improving care of patients with diabetes and CKD: a pilot study for a cluster-randomized trial.

Am J Kidney Dis 2008 May;51(5):777-88

Unidad de Investigación Médica en Enfermedades Renales, Hospital de Especialidades, CMNO, IMSS, Belisario Domínguez No. 1000, Col. Independencia, Guadalajara, Mexico.

Background: Family physicians may have the main role in managing patients with type 2 diabetes mellitus with early nephropathy. It is therefore important to determine the clinical competence of family physicians in preserving renal function of patients. The aim of this study is to evaluate the effect of an educational intervention on family physicians' clinical competence and subsequently determine the impact on kidney function of their patients with type 2 diabetes mellitus.

Study Design: Pilot study for a cluster-randomized trial.

Setting & Participants: Primary health care units of the Mexican Institute of Social Security, Guadalajara, Mexico. The study group was composed of 21 family physicians from 1 unit and a control group of 19 family physicians from another unit. 46 patients treated by study physicians and 48 treated by control physicians also were evaluated.

Intervention: An educative strategy based on a participative model used during 6 months in the study group. Allocation of units to receive or not receive the educative intervention was randomly established.

Outcomes: Clinical competence of family physicians and kidney function of patients.

Measurements: To evaluate clinical competence, a validated questionnaire measuring family physicians' capability to identify risk factors, integrate diagnosis, and correctly use laboratory tests and therapeutic resources was applied to all physicians at the beginning and end of educative intervention (0 and 6 months). In patients, serum creatinine level, estimated glomerular filtration rate, and albuminuria were evaluated at 0, 6, and 12 months.

Results: At the end of the intervention, more family physicians from the study group improved clinical competence (91%) compared with controls (37%; P = 0.001). Family physicians in the study group who increased their competence improved renal function significantly better than physicians in the same group who did not increase competence and physicians in the control group (with or without increase in competence): change in estimated glomerular filtration rate, 0.9 versus -33, -21, and -16 mL/min/1.73 m(2) (P < 0.05); and change in urinary albumin excretion of -18 versus 226, 142, and 288 mg/d, respectively (P < 0.05). Compared with other groups, study family physicians with clinical competence also controlled systolic blood pressure significantly better and were more likely to increase the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and statins and to discontinue nonsteroidal anti-inflammatory drugs.

Limitations: Our analysis did not adjust for clustering. Physicians in only 2 units were randomly assigned; thus, it is not possible to distinguish the effect of the intervention from the effect of the unit.

Conclusions: Educative intervention to primary physicians is feasible. Our data may be the basis for additional prospective studies with a cluster-randomized trial design and larger numbers of centers, physicians, and patients.
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http://dx.doi.org/10.1053/j.ajkd.2007.12.039DOI Listing
May 2008

Patient and technique survival in continuous ambulatory peritoneal dialysis in a single center of the west of Mexico.

Rev Invest Clin 2007 May-Jun;59(3):184-91

Unidad de Investigación Médica en Enfermedades Renales, UMAE, Hospital de Especialidades, CMNO.

Introduction: In Mexico, CAPD survival has been analyzed in few studies from the center of the country. However, there are concerns that such results may not represent what occurs in other province centers of our country, particularly in our geographical area.

Aim: To evaluate the patient and technique survival on CAPD of a single center of the west of Mexico, and compare them with other reported series.

Design: Retrospective cohort study.

Setting: Tertiary care, teaching hospital located in Guadalajara, Jalisco.

Patients: Patients from our CAPD program (1999-2002) were retrospectively studied. Interventions. Clinical and biochemical variables at the start of dialysis and at the end of the follow-up were recorded and considered in the analysis of risk factors.

Main Outcome Measures: Endpoints were patient (alive, dead or lost to follow-up) and technique status at the end of the study (June 2002).

Results: 49 patients were included. Mean patient survival (+/- SE) was 3.32 +/- 0.22 years (CI 95%: 2.9-3.8 years). Patients in the present study were younger (39 +/- 17yrs), had larger body surface area (1.72 +/- 0.22 m2), lower hematocrit (25.4 +/- 5.2%), albumin (2.6 +/- 0.6g/dL), and cholesterol (173 +/- 44 mg/dL), and higher urea (300 +/- 93 mg/dL) and creatinine (14.9 +/- 5.6 mg/ dL) than those in other Mexican series. In univariate analysis, the following variables were associated (p < 0.05) to mortality: pre-dialysis age and creatinine clearance, and serum albumin and cholesterol at the end of follow-up. In multivariate analysis, only pre-dialysis creatinine clearance (RR 0.66, p = 0.03) and age (RR 1.08, p = 0.005) significantly predicted mortality. Mean technique survival was 2.83 +/- 0.24 years (CI 95%: 2.4-3.3). Pre-dialysis age (p < 0.05), peritonitis rate (p < 0.05), and serum phosphorus at the end of follow-up (p < 0.05) were associated with technique failure in univariate analysis, while in multivariate analysis, only pre-dialysis age (RR 1.07, p = 0.001) and peritonitis rate (RR 481, p < 0.0001) were technique failure predictors.

Conclusions: Patients from this single center of the west of Mexico were younger, had higher body surface area and initiated peritoneal dialysis with a more deteriorated general status than patients reported in other Mexican series; in spite of the latter, patient and technique survival were not different. In our setting, pre-dialysis older age and lower CrCl significantly predicted mortality, while older predialysis age and higher peritonitis rate predicted technique failure.
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November 2007

Inflammation in peritoneal dialysis: a Latin-American perspective.

Perit Dial Int 2007 May-Jun;27(3):347-52

Unidad de Investigación Médica en Enfermedades Renales, UMAE Hospital de Especialidades, CMNO, IMSS, Guadalajara, Mexico.

Peritoneal dialysis (PD) patients present an extremely high mortality rate, but the mechanisms mediating the increased risk of mortality observed in this group of patients are still largely unknown, which limits the perspective of effective therapeutic strategies. The leading hypothesis that tries to explain this high mortality risk is that PD patients are exposed to a number of traditional risk factors for cardiovascular disease (CVD) already at the onset of their chronic kidney disease (CKD), since many of these risk factors are common to both CVD and CKD. Of particular importance, chronic inflammation recently emerged as an important novel risk factor related to multiple complications of CKD. There are many stimuli of the inflammatory response in CKD patients, such as fluid overload, decreased cytokine clearance, presence of uremia-modified proteins, presence of chronic infections, metabolic disturbances (including hyperglycemia), obesity. Many of these factors are related to PD. Latin America has made some progress in economic issues; however, a large portion of the population is still living in poverty, in poor sanitary conditions, and with many health-related issues, such as an increasing elderly population, low birth weights, and increasingly high energy intake in the adult population, which, in combination with changes in lifestyle, has provoked an increase in the prevalence of obesity, diabetes, and CVD. Therefore, in Latin America, there seems to be a peculiar situation combining high prevalence of low education level, poor sanitary conditions, and poverty with increases in obesity, diabetes, and sedentary lifestyle. Since inflammation and mortality risk are intimately related to both sides of those health issues, in this review we aim to analyze the peculiarities of inflammation and mortality risk in the Latin-American PD population.
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August 2007

Overview of peritoneal dialysis in Latin America.

Perit Dial Int 2007 May-Jun;27(3):316-21

Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná, Imaculada Conceicão 1155, Curitiba, PR 80215-901, Brazil.

Latin America is a heterogeneous region comprised of 20 countries, former colonies of European countries, in which Latin-derived languages are spoken. According to the Latin American Society of Nephrology and Hypertension/Sociedad Latino Americana de Nefrologia e Hipertensión (SLANH), the acceptance rate for renal replacement therapy is 103 new patients per million population. In Latin America, hemodialysis is the predominant form of replacement therapy for end-stage renal disease; however, some countries employ peritoneal dialysis (PD) in 30% or more patients. In particular, Mexico is the country with the largest PD utilization in the world, and furthermore, it is estimated that approximately 25% of the world's PD population may be found Latin America. Data concerning clinical practice and long-term outcome of PD in Latin America are scarce, although regional registries are increasing in number and quality. In this review article, we present an overview of the situation of PD in several countries of Latin America, based on the registry of the SLANH, national registries, and personal communication with PD experts from different countries.
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August 2007