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ObjectiveTo describe the experiences of nephrologists on caring for patients undergoing in-centre haemodialysis during the COVID-19 pandemic in Latin America.DesignTwenty-five semistructured interviews were conducted by Zoom videoconference in English and Spanish languages during 2020 until data saturation. Using thematic analysis, we conducted line-by-line coding to inductively identify themes.Setting25 centres across nine countries in Latin America.ParticipantsNephrologists (17 male and 8 female) were purposively sampled to include diverse demographic characteristics and clinical experience.ResultsWe identified five themes: shock and immediate mobilisation for preparedness (overwhelmed and distressed, expanding responsibilities to manage COVID-19 infection and united for workforce resilience); personal vulnerability (being infected with COVID-19 and fear of transmitting COVID-19 to family); infrastructural susceptibility of dialysis units (lacking resources and facilities for quarantine, struggling to prevent cross-contamination, and depletion of personal protective equipment and cleaning supplies); helplessness and moral distress (being forced to ration life-sustaining equipment and care, being concerned about delayed and shortened dialysis sessions, patient hesitancy to attend to dialysis sessions, being grieved by socioeconomic disparities, deterioration of patients with COVID-19, harms of isolation and inability to provide kidney replacement therapy); and fostering innovative delivery of care (expanding use of telehealth, increasing uptake of PD and shifting focus on preventing syndemics).ConclusionNephrologists felt personally and professionally vulnerable and reported feeling helpless and morally distressed because they doubted their capacity to provide safe care for patients undergoing dialysis. Better availability and mobilisation of resources and capacities to adapt models of care, including telehealth and home-based dialysis, are urgently needed.

OBJECTIVES As part of the HEARTS in the Americas initiative, Chilean primary healthcare centers have implemented novel hypertension management strategies, including new diagnostic approaches. This study evaluated the concordance between attended automated office blood pressure (AOBP) measurements with an oscillometric device and ambulatory blood pressure monitoring (ABPM). METHODS This was an observational cohort study to evaluate and compare attended AOBP and ABPM for the diagnosis of hypertension in adults in a primary healthcare setting. RESULTS The study evaluated 309 participants (54.2 ± 15.7 years; 50.5% male) from four primary healthcare centers in Santiago, Chile. Attended AOBP measurements were obtained at the clinic on two separate days, followed by ABPM. AOBP values indicated that 69.6% of patients had a systolic blood pressure (SBP) of ≥140 mm Hg and 34.6% had a diastolic blood pressure (DBP) of ≥90 mm Hg. A total of 83.5% had hypertension, 45.3% had high SBP, and 56.0% had high DBP. ABPM values indicated that 65.0% of patients had hypertension. The combined AOBP and ABPM analysis showed that 57.0% of patients had sustained hypertension, 26.5% had white coat hypertension, 8.1% had masked hypertension, and 8.4% were normotensive. The concordance between AOBP and ABPM (κ coefficient) was low (κ = 0.133; 95% confidence interval 0.028-0.237). The comparison of AOBP and ABPM measurements (Bland-Altman plots and bias calculations) showed an important bias in BP as measured using the AOBP method, especially for SBP (13.7 ± 11.6, 95% confidence interval -9.1 to 36.5). CONCLUSIONS Attended AOBP alone may not be sufficient for adequate classification, diagnosis, and management of hypertension in Chile or other countries with similar demographics.

Supplemental Digital Content is available in the text., OBJECTIVES: Respiratory failure, multiple organ failure, shortness of breath, recovery, and mortality have been identified as critically important core outcomes by more than 9300 patients, health professionals, and the public from 111 countries in the global coronavirus disease 2019 core outcome set initiative. The aim of this project was to establish the core outcome measures for these domains for trials in coronavirus disease 2019. DESIGN: Three online consensus workshops were convened to establish outcome measures for the four core domains of respiratory failure, multiple organ failure, shortness of breath, and recovery. SETTING: International. PATIENTS: About 130 participants (patients, public, and health professionals) from 17 countries attended the three workshops. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Respiratory failure, assessed by the need for respiratory support based on the World Health Organization Clinical Progression Scale, was considered pragmatic, objective, and with broad applicability to various clinical scenarios. The Sequential Organ Failure Assessment was recommended for multiple organ failure, because it was routinely used in trials and clinical care, well validated, and feasible. The Modified Medical Research Council measure for shortness of breath, with minor adaptations (recall period of 24 hr to capture daily fluctuations and inclusion of activities to ensure relevance and to capture the extreme severity of shortness of breath in people with coronavirus disease 2019), was regarded as fit for purpose for this indication. The recovery measure was developed de novo and defined as the absence of symptoms, resumption of usual daily activities, and return to the previous state of health prior to the illness, using a 5-point Likert scale, and was endorsed. CONCLUSIONS: The coronavirus disease 2019 core outcome set recommended core outcome measures have content validity and are considered the most feasible and acceptable among existing measures. Implementation of the core outcome measures in trials in coronavirus disease 2019 will ensure consistency and relevance of the evidence to inform decision-making and care of patients with coronavirus disease 2019.

The Covid-19 pandemic has been responsible for millions of deaths worldwide. Patients with comorbidities– such as those on peritoneal dialysis (PD)– present higher morbidity and mortality than the general population. We prospectively evaluated all Chilean patients on PD (48 centres) and followed those who had Covid-19 from the beginning of the Covid-19 pandemic in Chile (March 2020) to January 2021 (start of vaccination campaign). We described demographic history, comorbidities, factors related to infection, need for hospitalisation and death due to Covid-19. During the study period, 106 adults on PD were infected by SARS-CoV-2, with a mean age of 53.1 (±16.3) and of which 53.9% were female. From that group, 54.8% required hospitalisation and 24.5% ( n = 26) died due to Covid-19. Most of the patients (63.4%) were infected at home and 22.8% during hospitalisation for other reasons. There was a significant association for Covid-19 mortality with: being ≥60 years old, diabetes, time on PD ≥5 years, need for hospitalisation and hospital-acquired infection. At 90 days of follow-up, all deaths associated to Covid-19 occurred before 40 days. We conclude that patients on PD without Covid-19 vaccination have a high mortality and need for hospitalisation associated to Covid-19. To avoid this negative outcome, it is necessary to intensify strategies to avoid contagion, especially in those ≥60 years old, with diabetes and/or ≥5 years spent on PD.

To evaluate the effectiveness of a standardized and simplified protocol based on the technical pillars of the HEARTS Initiative for the control of hypertensive patients in the Cardiovascular Health Program at the first level of care in Chile.Longitudinal observational study (historical cohort) in two family health centers at the first level of care in Santiago. The control of blood pressure in hypertensive adults using a standardized and simplified protocol was compared to the usual protocol based on national guidelines. Innovations in the standardized protocol included changes in how the health team is coordinated, initiation of pharmacological treatment immediately after confirmed diagnosis, standardized pharmacological treatment with a combination of at least two or three antihypertensive drugs taken daily in a single tablet. Follow-up was conducted after one year to assess the percentage of adherence to treatment and achievement of blood pressure control targets (140/90 mmHg).A total of 1490 patients were evaluated: 562 who followed the standardized and simplified protocol, and 928 who were treated with the usual protocol (family health centers: 650; family health centers: 278). After one year, patients in the standardized and simplified protocol group had a higher proportion of adherence to blood pressure control targets (65% versus 37% and 41%, p0.001) and higher adherence to treatment compared to those following the usual protocol (71% versus 18% and 23%, p0.001).The results show that the standardized and simplified protocol is more effective than the usual protocol in controlling arterial hypertension in patients undergoing treatment at the first level of care in Chile. Its implementation at the national level could contribute to a decrease in major cardiovascular events.Avaliar a eficácia de um protocolo padronizado e simplificado, com base nos pilares técnicos da iniciativa HEARTS, para o controle de pacientes com hipertensão arterial do Programa de Saúde Cardiovascular na atenção primária à saúde do Chile.Estudo observacional longitudinal (coorte histórica) em 2 centros de atenção primária de saúde da família em Santiago, que comparou o controle da pressão arterial em adultos com hipertensão, atingido com o protocolo padronizado e simplificado, versus o protocolo habitual, de acordo com as diretrizes nacionais. As inovações do protocolo padronizado incluíram mudanças na coordenação da equipe de saúde, início do tratamento farmacológico imediatamente após a confirmação do diagnóstico e tratamento farmacológico padronizado com associação de pelo menos 2 ou 3 anti-hipertensivos em um único comprimido, tomados uma vez ao dia. O acompanhamento foi realizado por 1 ano para avaliar o percentual de adesão ao tratamento e o cumprimento das metas de controle da pressão arterial (menor que 140/90 mmHg).Foram avaliados 1.490 pacientes: 562 que utilizaram o protocolo padronizado e simplificado e 928 que foram tratados com o protocolo habitual (unidade de saúde da família 1: 650, unidade de saúde da família 2: 278). Em 1 ano de seguimento, os pacientes do grupo do protocolo padronizado e simplificado apresentaram maior proporção de cumprimento das metas de controle da pressão arterial (65% versus 37% e 41%, p0,001) e maior percentual de adesão ao tratamento, em comparação com aqueles que utilizaram o protocolo habitual (71% versus 18% e 23%, p0,001).Os resultados mostram que o protocolo padronizado e simplificado é mais eficaz que o protocolo habitual no controle da hipertensão arterial em pacientes que estão em tratamento na atenção primária do Chile. Sua implementação no nível nacional poderia contribuir para a redução de eventos cardiovasculares maiores.

BACKGROUND: The coronavirus (COVID-19) pandemic has seen a global surge in anxiety, depression, post-traumatic stress disorder (PTSD), and stress. AIMS: This study aimed to describe the perspectives of patients with COVID-19, their family, health professionals, and the general public on the impact of COVID-19 on mental health. METHODS: A secondary thematic analysis was conducted using data from the COVID-19 COS project. We extracted data on the perceived causes and impact of COVID-19 on mental health from an international survey and seven online consensus workshops. RESULTS: We identified four themes (with subthemes in parenthesis): anxiety amidst uncertainty (always on high alert, ebb and flow of recovery); anguish of a threatened future (intense frustration of a changed normality, facing loss of livelihood, trauma of ventilation, a troubling prognosis, confronting death); bearing responsibility for transmission (fear of spreading COVID-19 in public; overwhelming guilt of infecting a loved one); and suffering in isolation (severe solitude of quarantine, sick and alone, separation exacerbating grief). CONCLUSION: We found that the unpredictability of COVID-19, the fear of long-term health consequences, burden of guilt, and suffering in isolation profoundly impacted mental health. Clinical and public health interventions are needed to manage the psychological consequences arising from this pandemic.

The COVID-19 pandemic is a global public health problem. Patients with end-stage renal disease on hemodialysis are at a higher risk of infection and mortality than the general population. Worldwide, a vaccination campaign has been developed that has been shown to reduce severe infections and deaths in the general population. However, there are currently limited data on the clinical efficacy of vaccinations in the hemodialysis population.A national multicenter observational cohort was performed in Chile to evaluate the clinical efficacy of anti-SARS-CoV-2 vaccination in end-stage renal disease patients on chronic hemodialysis from February 2021 to August 2021. In addition, the BNT162b2 (Pfizer-BioNTech) and CoronaVac (Sinovac) vaccines were evaluated. The efficacy of vaccination in preventing SARS-CoV-2 infection, hospitalizations, and deaths associated with COVID-19 was determined.A total of 12,301 patients were evaluated; 10,615 (86.3%) received a complete vaccination (2 doses), 490 (4.0%) received incomplete vaccination, and 1196 (9.7%) were not vaccinated. During follow-up, 1362 (11.0%) patients developed COVID-19, and 150 died (case fatality rate: 11.0%). The efficacy of the complete vaccination in preventing infection was 18.1% (95% confidence interval [CI]:11.8-23.8%), and prevention of death was 66.0% (95% CI:60.6-70.7%). When comparing both vaccines, BNT162b2 and CoronaVac were effective in reducing infection and deaths associated with COVID-19. Nevertheless, the BNT162b2 vaccine had higher efficacy in preventing infection (42.6% vs. 15.0%) and deaths (90.4% vs. 64.8%) compared to CoronaVac.The results of our study suggest that vaccination against SARS-CoV-2 in patients on chronic hemodialysis was effective in preventing infection and death associated with COVID-19.

Background Globally, over 1.2 million people die from chronic kidney disease (CKD) every year. Patients with CKD are up to 10 times more likely to die prematurely than progress to kidney failure requiring kidney replacement therapy. The burden of symptoms and impaired quality of life in CKD may be compounded by comorbidities and treatment side effects. However, patient-important outcomes remain inconsistently and infrequently reported in trials in patients with CKD, which can limit evidence-informed decision-making. The Standardised Outcomes in Nephrology – Chronic Kidney Disease (SONG-CKD) aims to establish a consensus-based core outcome set for trials in patients with CKD not yet requiring kidney replacement therapy to ensure outcomes of relevance to patients, caregivers and health professionals are consistently reported in trials. Methods SONG-CKD involves four phases: a systematic review to identify outcomes (domains and measures) that have been reported in randomised controlled trials involving adults with CKD who do not require kidney replacement therapy; stakeholder key informant interviews with health professionals involved in the care of adults with CKD to ascertain their views on establishing core outcomes in CKD; an international two-round online Delphi survey with patients, caregivers, clinicians, researchers, policy makers and industry representatives to obtain consensus on critically important outcome domains; and stakeholder consensus workshops to review and finalise the set of core outcome domains for trials in CKD. Discussion Establishing a core outcome set to be reported in trials in patients with CKD will enhance the relevance, transparency and impact of research to improve the lives of people with CKD. Trial registration Not applicable. This study is registered with the Core Outcome Measures in Effectiveness Trials (COMET) database: http://www.comet-initiative.org/Studies/Details/1653.

Background : Chronic kidney disease (CKD) is a growing public health concern, and available treatments are insufficient in limiting disease progression. New strategies, including regenerative cell-based therapies, have emerged as therapeutic alternatives. Results : from several groups, including our own, have reported evidence of a supportive role for mesenchymal stromal cells (MSCs) in functional recovery and prevention of tissue damage in murine models of CKD. Prompted by these data, an open pilot study was conducted to assess the safety and efficacy of a single injection of autologous adipose tissue-derived MSCs (AT-MSCs) for treatment of CKD. Methods : AT-MSCs were infused intravenously into six CKD patients at a dose of 1 million cells/kg. Patients were stabilized and followed for one year prior to MSC infusion and one year following infusion. Results : No patients presented with adverse effects. Statistically significant improvement in urinary protein excretion was observed in AT-MSCs transplanted patients, from a median of 0.75 g/day (range, 0.15-9.57) at baseline to 0.54 g/day (range, 0.01v2.66) at month 12 (P = 0.046). The glomerular filtration rate was not significantly decreased post-infusion of AT-MSCs. Conclusion : Findings from this pilot study demonstrate that intravenous infusion of autologous expanded AT-MSCs into CKD patients was not associated with adverse effects and could benefit patients already undergoing standard medical treatment.

Supplemental Digital Content is available in the text., Objectives: There are over 4,000 trials conducted in people with coronavirus disease 2019. However, the variability of outcomes and the omission of patient-centered outcomes may diminish the impact of these trials on decision-making. The aim of this study was to generate a consensus-based, prioritized list of outcomes for coronavirus disease 2019 trials. Design: In an online survey conducted in English, Chinese, Italian, Portuguese, and Spanish languages, adults with coronavirus disease 2019, their family members, health professionals, and the general public rated the importance of outcomes using a 9-point Likert scale (7–9, critical importance) and completed a Best-Worst Scale to estimate relative importance. Participant comments were analyzed thematically. Setting: International. Subjects: Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public, and health professionals (including clinicians, policy makers, regulators, funders, and researchers). Interventions: None. Measurements: None. Main Results: In total, 9,289 participants from 111 countries (776 people with coronavirus disease 2019 or family members, 4,882 health professionals, and 3,631 members of the public) completed the survey. The four outcomes of highest priority for all three groups were: mortality, respiratory failure, pneumonia, and organ failure. Lung function, lung scarring, sepsis, shortness of breath, and oxygen level in the blood were common to the top 10 outcomes across all three groups (mean > 7.5, median ≥ 8, and > 70% of respondents rated the outcome as critically important). Patients/family members rated fatigue, anxiety, chest pain, muscle pain, gastrointestinal problems, and cardiovascular disease higher than health professionals. Four themes underpinned prioritization: fear of life-threatening, debilitating, and permanent consequences; addressing knowledge gaps; enabling preparedness and planning; and tolerable or infrequent outcomes. Conclusions: Life-threatening respiratory and other organ outcomes were consistently highly prioritized by all stakeholder groups. Patients/family members gave higher priority to many patient-reported outcomes compared with health professionals.

Objectives: The outcomes reported in trials in coronavirus disease 2019 are extremely heterogeneous and of uncertain patient relevance, limiting their applicability for clinical decision-making. The aim of this workshop was to establish a core outcomes set for trials in people with suspected or confirmed coronavirus disease 2019. Design: Four international online multistakeholder consensus workshops were convened to discuss proposed core outcomes for trials in people with suspected or confirmed coronavirus disease 2019, informed by a survey involving 9,289 respondents from 111 countries. The transcripts were analyzed thematically. The workshop recommendations were used to finalize the core outcomes set. Setting: International. Subjects: Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public and health professionals (including clinicians, policy makers, regulators, funders, researchers). Interventions: None. Measurements: None. Main Results: Six themes were identified. “Responding to the critical and acute health crisis” reflected the immediate focus on saving lives and preventing life-threatening complications that underpinned the high prioritization of mortality, respiratory failure, and multiple organ failure. “Capturing different settings of care” highlighted the need to minimize the burden on hospitals and to acknowledge outcomes in community settings. “Encompassing the full trajectory and severity of disease” was addressing longer term impacts and the full spectrum of illness (e.g. shortness of breath and recovery). “Distinguishing overlap, correlation and collinearity” meant recognizing that symptoms such as shortness of breath had distinct value and minimizing overlap (e.g. lung function and pneumonia were on the continuum toward respiratory failure). “Recognizing adverse events” refers to the potential harms of new and evolving interventions. “Being cognizant of family and psychosocial wellbeing” reflected the pervasive impacts of coronavirus disease 2019. Conclusions: Mortality, respiratory failure, multiple organ failure, shortness of breath, and recovery are critically important outcomes to be consistently reported in coronavirus disease 2019 trials.

Cette recherche pretend explorer l’organisation du travail dans les transports publics de Santiago du Chili. On prend comme analyseur le suicide d’un chauffeur, lequel est interprete comme une denonciation de la souffrance des travailleurs. Une equipe cherche a explorer cette interpretation en se disposant a l’ecoute des chauffeurs. La methodologie constitue une tentative exploratoire pour appliquer la clinique du travail francaise. Les resultats montrent les effets subjectifs qu’a eut l’integration de ces travailleurs a un modele de gestion exemplaire du neoliberalisme, qui sous couvert d’un savoir scientifique et dans la faille de la regulation de l’Etat, perpetue une organisation du travail pathogene. On observe une ideologie defensive a fort cout psychique qui donne comme resultat la degradation et la deterioration subjective des travailleurs.

Objective Omega-3 fatty acids may reduce albuminuria and cardiovascular risk factors in patients with chronic kidney disease (CKD). We aimed to assess the effects of omega-3 fatty acid supplementation on albuminuria, blood pressure, pulse wave velocity, and inflammatory markers in patients with CKD. Methods Patients with CKD and a urine albumin excretion of at least 30 mg/g creatinine were supplemented for 3 months with 3,666 mg/day of docosahexaenoic and eicosapentaenoic acids or a corn oil supplement. The study was double blind. At baseline, 6 weeks, and 12 weeks, fasting blood and morning spot urine samples were obtained. Blood pressure, carotid intima media thickness, and pulse wave velocity were measured. The main outcome measure was a reduction of ≥20% in urine albumin. Results One hundred patients were randomized (50 received omega-3 fatty acids and 50 received corn oil). Four patients who received omega-3 fatty acids and 5 who received vegetable oil were lost to follow-up. In patients receiving omega-3 fatty acids, the omega-3 index increased from 3.08 (2.32-3.81) to 5.48 (3.045-7.04) percent. A 20% reduction in urine albumin excretion was observed in 13 participants of the control group and 19 participants of omega-3 group (Fisher's exact P = .274). However, the supplement had a significant and positive effect on pulse wave velocity and triglyceride level. Conclusion An omega-3 fatty acid supplement of 3,666 mg/day did not modify urine albumin excretion in patients with CKD but did improve pulse wave velocity and serum triglyceride levels.

espanolIntroduccion: la restriccion proteica es fundamental en el manejo de la enfermedad renal cronica. Objetivo: evaluamos la utilidad de la medicion de nitrogeno ureico urinario como marcador de restriccion proteica. Metodos: participantes jovenes sanos fueron divididos aleatoriamente en dos grupos. Un grupo recibio una dieta con 30 kcal/dia/kg peso corporal y 1 g/proteina/dia/kg peso corporal y el otro recibio una dieta con la misma cantidad de calorias pero con 0,6 g/kg peso corporal de proteina. Al inicio, a los siete y a los 14 dias, los participantes respondieron una encuesta dietaria de recordatorio de 24 horas. Ademas, recolectaron orina de 24 horas y se les tomo una muestra aislada de orina al comienzo y a los 14 dias de la intervencion para medir creatinina y nitrogeno ureico. Resultados: cuarenta y un participantes de 29 ± 5 anos completaron el estudio. El grupo que consumio 0,6 g/kg de proteinas redujo su ingesta proteica de 0,88 ± 0,06 a 0,59 ± 0,05 g/kg/dia durante la intervencion. En este grupo se observo una reduccion significativa en la excrecion urinaria de nitrogeno ureico en 24 horas. No se observo tal reduccion en el grupo que consumio 1 g/kg de proteinas. La tasa de probabilidad de detectar una reduccion en la ingesta proteica en las encuestas dietarias, cuando se observaba una disminucion en la excrecion urinaria de nitrogeno ureico/mg creatinina de 24 horas, fue de 5,75 (intervalos de confianza de 95% = 1,29-25,55, p = 0,02). No hubo cambios significativos en la excrecion de nitrogeno ureico en las muestras aisladas de orina. Conclusion: las mediciones repetidas de nitrogeno ureico urinario en 24 horas son un marcador de restriccion dietaria de proteinas. EnglishBackground: protein restriction is the mainstay of dietary management of chronic kidney disease. Aim: to assess the usefulness of urine urea nitrogen measurement as a marker of protein restriction. Methods: healthy young participants were randomly divided in two groups. During 14 days, one group received a diet containing 30 kcal/kg body weight and 1 g protein/kg body weight and the other group received a diet with the same amount of calories and 0.6 g/kg of proteins. At baseline, seven days and 14 days, 24 h dietary recalls were answered by the participants. They collected 24 hour urine and provided spot urine samples at baseline and at the end of the intervention, to measure creatinine and urea nitrogen. Results: forty-one participants aged 29 ± 5 years completed the follow-up. According to 24h dietary recalls, the group receiving 0.6 g/kg protein reduced significantly the protein intake during the intervention from 0.88 ± 0.06 to 0.59 ± 0.05 g/kg/day. A significant reduction in 24 h urea nitrogen excretion was also observed in this group. In the group receiving 1 g/kg of protein, no significant changes in 24 h urea nitrogen excretion were observed. Among all participants, the odds ratio of observing a reduction in protein intake in the dietary survey was 5.75 (95% confidence intervals 1.29-25.55, p = 0.02), when a reduction in 24 h urea nitrogen excretion corrected by creatinine was observed. No changes were observed in urea nitrogen excretion in spot urine samples. Conclusions: repeated urea nitrogen excretion measured in 24 h urine samples can be a reliable indicator of dietary protein restriction.

Chronic renal disease (CRD) in its pre-dialysis stage is an important risk factor for mortality among adults. The aim of this study was to assess the effects of CRD on mortality among consultants in Chilean public primary care clinics. We obtained information about serum creatinine, urinary albumin excretion (UAE), blood pressure, and body mass index of 5224 consultants [3379 females aged 67 (59-75) years and 1845 males aged 68 (59-75) years] in three clinics of Metropolitan Santiago. Kaplan-Meier curves and Cox proportional hazard regression models were used to determine risk factors for mortality, determined 41 months after obtaining the blood samples. During the follow-up period, 262 patients died (33% due to circulatory causes and 29% due to tumors). Kaplan-Meier curves showed that there was a significant association between survival, estimated glomerular filtration rate, and UAE. Cox models showed that serum creatinine, UAE, a lower body mass index, and a history of diabetes were significant mortality predictors. A sensitivity analysis performed eliminating extreme ages (less than 50 and more than 80 years), included high diastolic pressure as a predictor of survival. We conclude that among patients with CRD in its pre-dialysis stage, UAE is an important predictor of survival, along with serum creatinine. A low body mass index was associated with a higher mortality.

The most frequent primary glomerular diseases (PGD) associated with nephrotic syndrome (NS) in the elderly are membranous nephropathy (MN), minimal change nephropathy (MCN), and focal and segmental glomerulosclerosis (FSGS). In older patients MN may be secondary to drugs or neoplasia in 20 to 25% of cases. The natural renal outcome of idiopathic MN is similar in elderly patients and in those of the second age. However, elderly patients are more exposed to the extra-renal complications of NS. Corticosteroids alone do not seem to modify the course of the disease. A 6-month regimen with corticosteroids alternated to chlorambucil, which has proven to improve the outcome of MN in adults, may increase the chances of remission and protect renal function also in the elderly patients but side effects increase with age. Elderly patients with MCN are more prone than younger adults to the complications of the NS and to the development of renal failure. Only 60% of older patients enter remission with an 8-week course of prednisone, but about 80% can achieve complete remission with corticosteroids if treatment is prolonged to 12–16 weeks. Relapses are more rare in the elderly. In patients with contraindications to prolonged corticosteroid therapy, a course of 12 weeks with a cytotoxic agent may obtain stable remission in most cases. Little information is available about the natural course and the management of idiopathic FSGS in the elderly. A recent report showed that more than 40% of older patients may obtain stable remission after an initial treatment with corticosteroids for 6 months. For those patients who do not respond or have contraindications to steroid therapy, a cautious trial with cyclophosphamide may be tried.

Type 2 Diabetes Mellitus is not always treated successfully, in part due to the difficulties perceived by the medical community about the use of insulin.To identify the constraints perceived by primary care physicians (PCPs) in the prescription and use of insulin.Six PCPs were subjected to a semi-structured interview about self-perceived management difficulties, behaviors and beliefs on the use of insulin among diabetics. According to their responses a questionnaire about the subject was devised and PCPs were invited by e-mail to answer it.There were 88 replies and 48% of respondents recognized to have management deficiencies in at least one aspect of insulin prescription. The most common deficiencies were determining the type of insulin and treatment of complications. The perceived difficulties were lack of training (58.0%), lack of medical hours (46.6%), lack of communication with specialists (46.6%), lack of reactive strips for capillary blood glucose determination (43.2%) and rotation of doctors (40.9%). The most common behaviors towards patients reluctant to use insulin were persuasion (83.0%), education and supervisión (63.6%) and signature of an ad-hoc document (38.6%). Ninety percent considered that timely use of insulin is more beneficial than its prescription as a last resort and 94.3% did not consider that insulin should be prescribed by a specialist.A significant percentage of physicians do not trust their own knowledge about insulin prescription. These professionals should receive training in not only technical aspects of prescribing insulin, but also in the psychological and persuasión strategies. There is willingness among PCPs to prescribe insulin.

Background: Type 2 Diabetes Mellitus is not always treated successfully, in part due to the difficulties perceived by the medical community about the use of insulin. Aim: To identify the constraints perceived by primary care physicians (PCPs) in the prescription and use of insulin. Material and Methods: Six PCPs were subjected to a semi-structured interview about self-perceived management difficulties, behaviors and beliefs on the use of insulin among diabetics. According to their responses a questionnaire about the subject was devised and PCPs were invited by e-mail to answer it. Results: There were 88 replies and 48% of respondents recognized to have management deficiencies in at least one aspect of insulin prescription. The most common deficiencies were determining the type of insulin and treatment of complications. The perceived difficulties were lack of training (58.0%), lack of medical hours (46.6%), lack of communication with specialists (46.6%), lack of reactive strips for capillary blood glucose determination (43.2%) and rotation of doctors (40.9%). The most common behaviors towards patients reluctant to use insulin were persuasion (83.0%), education and supervisión (63.6%) and signature ofan ad-hoc document (38.6%). Ninety percent considered that timely use of insulin is more beneficial than its prescription as a last resort and 94.3% did not consider that insulin should be prescribed by a specialist. Conclusions: A significant percentage of physicians do not trust their own knowledge about insulin prescription. These professionals should receive training in not only technical aspects of prescribing insulin, but also in the psychological and persuasión strategies. There is willingness among PCPs to prescribe insulin.

The study RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan) demonstrated that Losartan was more effective lo reduce the progression of kidney disease in diabetic patients with proteinuria and a reduction in glomerular filtration rate.To perform a cost benefit analysis of Losartan use from provider and payer points of view.Published data of the RENAAL study was analyzed. The costs of the use or not use of Losartan in patients with diabetic nephropathy were compared in terms of total costs of the disease including medications, hospital admissions for myocardial infarction, cerebrovascular accidents and congestive cardiac failure and the costs of chronic hemodialysis.The reduction in antihypertensive medication use, hospital admissions, and the delay in dialysis requirement from a mean of 65 to 79 months induced by Losartan use, results in net savings of $7,576,135 per patient, at 3.5 years of intervention. The figure does not change using different sensitivity scenarios.The eventual use of Losartan in type 2 diabetic patients results in important savings.

Objetivo: Utilizando los resultados del estudio RENAAL, se propone analizar los costos y beneficios del uso de losartan desde las opticas del prestador y pagador ambulatorio (consultorios de atencion primaria), del prestador y pagador de las hospitalizaciones (Hospital del Salvador) y del pagador de la dialisis (Fondo Nacional de Salud). Metodologia: Se emplearon los datos publicados del estudio RENAAL para comparar las estrategias de uso o no uso de losartan, en pacientes portadores de nefropatia diabetica, respecto de sus costos totales, que incluyen farmacos antihipertensivos, hospitalizaciones por infarto miocardico, accidente cerebrovascular e insuficiencia cardiaca congestiva, ademas de hemodialisis cronica. Con estos datos y los costos de los recursos farmacologicos y hospitalarios locales se realizo un analisis de Markov para calcular la estrategia mas economica. Resultados: Encontramos que losartan, al reducir las frecuencias de uso de farmacos antihipertensivos convencionales , disminuir las frecuencias de ocurrencia de hospitalizaciones por complicaciones cardiovasculares y aumentar el numero de meses estimado para llegar al umbral de requerimiento de terapia de sustitucion de la funcion renal de 64,6 a 79,3 meses, consigue un ahorro neto para el sistema publico de salud de $7.576.135 por paciente a 3,5 anos de intervencion. Lo anterior, no se modifica importantemente con los distintos escenarios modelados en el analisis de sensibilidad. Conclusiones: El uso eventual de losartan en pacientes chilenos diabeticos tipo 2 con nefropatia diabetica, no solamente reduciria la ocurrencia de complicaciones cardiovasculares y la incidencia de insuficiencia renal terminal, sino tambien resulta en importantes ahorros netos sobre los costos.