Garcia-Fernandez, N. (Nuria)

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    Timing of renal replacement therapy after cardiac surgery: a retrospective multicenter Spanish Cohort Study
    (Karger Publishers, 2011) Herreros, J. (Jesús); Perez-Valdivieso, J.R. (José Ramón); Lavilla, J. (Javier); Bes-Rastrollo, M. (Maira); Vives, M. (Marc); Monedero, P. (Pablo); Garcia-Fernandez, N. (Nuria)
    Background: The optimal time to initiate renal replacement therapy (RRT) in cardiac surgery-associated acute kidney injury (CSA-AKI) is unknown. Evidence suggests that the early use of RRT in critically ill patients is associated with improved outcomes. We studied the effects of time to initiation of RRT on outcome in patients with CSA-AKI. Methods: This was a retrospective observational multicenter study (24 Spanish hospitals). We analyzed data on 203 patients who required RRT after cardiac surgery in 2007. The cohort was divided into 2 groups based on the time at which RRT was initiated: in the early RRT group, therapy was initiated within the first 3 days after cardiac surgery; in the late group, RRT was begun after the 3rd day. Multivariate nonconditional logistic and linear regression models were used to adjust for potential confounders. Results: In-hospital mortality was significantly higher in the late RRT group compared with early RRT patients (80.4 vs. 53.2%; p < 0.001; adjusted odds ratio of 4.1, 95% CI: 1.6–10.0). Also, patients in the late RRT group had longer adjusted hospital stays by 11.6 days (95% CI: 1.4–21.9) and higher adjusted percentage increases in creatinine at discharge compared with baseline by 67.7% (95% CI: 28.5–106.4). Conclusions: Patients who undergo early initiation of RRT after CSA-AKI have improved survival rates and renal function at discharge and decreased lengths of hospital stay.
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    MMP-10 is Increased in Early Stage Diabetic Kidney Disease and can be Reduced by Renin-Angiotensin System Blockade
    (2020) Paramo, J.A. (José Antonio); Escalada, F.J. (Francisco Javier); Riera, M. (Marta); Orbe, J. (Josune); Rodriguez, J.A. (José Antonio); Fernández-Seara, M.A. (María A.); Mora-Gutiérrez, J.M. (José María); Garcia-Fernandez, N. (Nuria); Slon-Roblero, M.F. (María Fernanda); Soler, M.J. (María José)
    Matrix metalloproteinases have been implicated in diabetic microvascular complications. However, little is known about the pathophysiological links between MMP-10 and the renin-angiotensin system (RAS) in diabetic kidney disease (DKD). We tested the hypothesis that MMP-10 may be up-regulated in early stage DKD, and could be down-regulated by angiotensin II receptor blockade (telmisartan). Serum MMP-10 and TIMP-1 levels were measured in 268 type 2 diabetic subjects and 111 controls. Furthermore, histological and molecular analyses were performed to evaluate the renal expression of Mmp10 and Timp1 in a murine model of early type 2 DKD (db/db) after telmisartan treatment. MMP-10 (473±274pg/ml vs. 332±151; p=0.02) and TIMP-1 (573±296ng/ml vs. 375±317; p<0.001) levels were signifcantly increased in diabetic patients as compared to controls. An early increase in MMP-10 and TIMP-1 was observed and a further progressive elevation was found as DKD progressed to endstage renal disease. Diabetic mice had 4-fold greater glomerular Mmp10 expression and signifcant albuminuria compared to wild-type, which was prevented by telmisartan. MMP-10 and TIMP-1 are increased from the early stages of type 2 diabetes. Prevention of MMP-10 upregulation observed in diabetic mice could be another protective mechanism of RAS blockade in DKD.
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    Diabetic Kidney Disease, Cardiovascular Disease and Non-Alcoholic Fatty Liver Disease: A New Triumvirate?
    (MDPI AG, 2021) Perdomo-Zelaya, C.M. (Carolina M.); Garcia-Fernandez, N. (Nuria); Escalada, J. (Javier)
    Non-alcoholic fatty liver disease is a highly prevalent disease worldwide with a renowned relation to cardiovascular disease and chronic kidney disease. These diseases share a common pathophysiology including insulin resistance, oxidative stress, chronic inflammation, dysbiosis and genetic susceptibilities. Non-alcoholic fatty liver disease is especially prevalent and more severe in type 2 diabetes. Patients with non-alcoholic fatty liver disease should have liver fibrosis assessment in order to identify those at the highest risk of adverse outcomes so that appropriate management strategies can be implemented. Early diagnosis and treatment of non-alcoholic fatty liver disease could ameliorate the burden of cardiovascular disease and chronic kidney disease.
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    Risk factors for non-diabetic renal disease in diabetic patients
    (Oxford University Press, 2020) López-Revuelta, K. (Katia); Garcia-Osuna, R. (Rosa); Bonet, J. (Josep); Martín-Gómez, A. (Adoración); Poch, E. (Esteban); Martínez, M.I. (Maria Isabel); González, E. (Ester); Fernández, B. (Beatriz); Galceran, J.M. (Josep M.); Coloma, A. (Ana); Praga, M. (Manuel); Ibernon, M. (Meritxell); Martín, N. (Nadia); Goicoechea, M. (Marian); Liaño, F. (Fernando); López, D. (Diana); Linares, T. (Tania); Rodas, L. (Lida); Garcia-Fernandez, N. (Nuria); Pascual, J. (Julio); Hernández, E. (Eduardo); Marco, H. (Helena); Barros, X. (Xoana); Díaz, M. (Montserrat); Agraz, I. (Irene); Robles, N.R. (Nicolás Roberto); Fulladosa, X. (Xavier); Soler, M.J. (María José); Elias, S. (Sandra); Bermejo, S. (Sheila); Navarro, M.I. (Maruja Isabel); Moirón, J.P. (José Pelayo); Calero, F. (Francesca); Esparza, N. (N.); Stanescu, R.I. (Ramona Ionela); Lozano, V. (Victor)
    Background. Diabetic patients with kidney disease have a high prevalence of non-diabetic renal disease (NDRD). Renal and patient survival regarding the diagnosis of diabetic nephropathy (DN) or NDRD have not been widely studied. The aim of our study is to evaluate the prevalence of NDRD in patients with diabetes and to determine the capacity of clinical and analytical data in the prediction of NDRD. In addition, we will study renal and patient prognosis according to the renal biopsy findings in patients with diabetes. Methods. Retrospective multicentre observational study of renal biopsies performed in patients with diabetes from 2002 to 2014. Results. In total, 832 patients were included: 621 men (74.6%), mean age of 61.7 6 12.8 years, creatinine was 2.8 6 2.2 mg/dL and proteinuria 2.7 (interquartile range: 1.2–5.4) g/24 h. About 39.5% (n ¼ 329) of patients had DN, 49.6% (n ¼ 413) NDRD and 10.8% (n ¼ 90) mixed forms. The most frequent NDRD was nephroangiosclerosis (NAS) (n ¼ 87, 9.3%). In the multivariate logistic regression analysis, older age [odds ratio (OR) ¼ 1.03, 95% CI: 1.02–1.05, P < 0.001], microhaematuria (OR ¼ 1.51, 95% CI: 1.03–2.21, P ¼ 0.033) and absence of diabetic retinopathy (DR) (OR ¼ 0.28, 95% CI: 0.19–0.42, P < 0.001) were independently associated with NDRD. Kaplan–Meier analysis showed that patients with DN or mixed forms presented worse renal prognosis than NDRD (P < 0.001) and higher mortality (P ¼ 0.029). In multivariate Cox analyses, older age (P < 0.001), higher serum creatinine (P < 0.001), higher proteinuria (P < 0.001), DR (P ¼ 0.007) and DN (P < 0.001) were independent risk factors for renal replacement therapy. In addition, older age (P < 0.001), peripheral vascular disease (P ¼ 0.002), higher creatinine (P ¼ 0.01) and DN (P ¼ 0.015) were independent risk factors for mortality. Conclusions. The most frequent cause of NDRD is NAS. Elderly patients with microhaematuria and the absence of DR are the ones at risk for NDRD. Patients with DN presented worse renal prognosis and higher mortality than those with NDRD. These results suggest that in some patients with diabetes, kidney biopsy may be useful for an accurate renal diagnosis and subsequently treatment and prognosis.
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    Cardiac-surgery associated acute kidney injury requiring renal replacement therapy. A Spanish retrospective case-cohort study
    (BioMed Central, 2009-09) Perez-Valdivieso, J.R. (José Ramón); Bes-Rastrollo, M. (Maira); Vives, M. (Marc); Monedero, P. (Pablo); Garcia-Fernandez, N. (Nuria)
    Acute kidney injury is among the most serious complications after cardiac surgery and is associated with an impaired outcome. Multiple factors may concur in the development of this disease. Moreover, severe renal failure requiring renal replacement therapy (RRT) presents a high mortality rate. Consequently, we studied a Spanish cohort of patients to assess the risk factors for RRT in cardiac surgery-associated acute kidney injury (CSA-AKI). METHODS: A retrospective case-cohort study in 24 Spanish hospitals. All cases of RRT after cardiac surgery in 2007 were matched in a crude ratio of 1:4 consecutive patients based on age, sex, treated in the same year, at the same hospital and by the same group of surgeons. RESULTS: We analyzed the data from 864 patients enrolled in 2007. In multivariate analysis, severe acute kidney injury requiring postoperative RRT was significantly associated with the following variables: lower glomerular filtration rates, less basal haemoglobin, lower left ventricular ejection fraction, diabetes, prior diuretic treatment, urgent surgery, longer aortic cross clamp times, intraoperative administration of aprotinin, and increased number of packed red blood cells (PRBC) transfused. When we conducted a propensity analysis using best-matched of 137 available pairs of patients, prior diuretic treatment, longer aortic cross clamp times and number of PRBC transfused were significantly associated with CSA-AKI.Patients requiring RRT needed longer hospital stays, and suffered higher mortality rates. CONCLUSION: Cardiac-surgery associated acute kidney injury requiring RRT is associated with worse outcomes. For this reason, modifiable risk factors should be optimised and higher risk patients for acute kidney injury should be identified before undertaking cardiac surgery.
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    Multiparametric renal magnetic resonance imaging: A reproducibility study in renal allografts with stable function
    (Wiley, 2023) Martín-Moreno, P.L. (Paloma L.); Echeverría-Chasco, R. (Rebeca); Bastarrika, G. (Gorka); Aramendía-Vidaurreta, V. (Verónica); Cano, D. (David); Vidorreta, M. (Marta); Fernández-Seara, M.A. (María A.); Garcia-Fernandez, N. (Nuria); Villanueva, A. (Arantxa)
    Monitoring renal allograft function after transplantation is key for the early detection of allograft impairment, which in turn can contribute to preventing the loss of the allograft. Multiparametric renal MRI (mpMRI) is a promising noninvasive technique to assess and characterize renal physiopathology; however, few studies have employed mpMRI in renal allografts with stable function (maintained function over a long time period). The purposes of the current study were to evaluate the reproducibility of mpMRI in transplant patients and to characterize normal values of the measured parameters, and to estimate the labeling efficiency of Pseudo-Continuous Arterial Spin Labeling (PCASL) in the infrarenal aorta using numerical simulations considering experimental measurements of aortic blood flow profiles. The subjects were 20 transplant patients with stable kidney function, maintained over 1 year. The MRI protocol consisted of PCASL, intravoxel incoherent motion, and T1 inversion recovery. Phase contrast was used to measure aortic blood flow. Renal blood flow (RBF), diffusion coefficient (D), pseudo-diffusion coefficient (D*), flowing fraction ( f ), and T1 maps were calculated and mean values were measured in the cortex and medulla. The labeling efficiency of PCASL was estimated from simulation of Bloch equations. Reproducibility was assessed with the within-subject coefficient of variation, intraclass correlation coefficient, and Bland-Altman analysis. Correlations were evaluated using the Pearson correlation coefficient. The significance level was p less than 0.05. Cortical reproducibility was very good for T1, D, and RBF, moderate for f , and low for D*, while medullary reproducibility was good for T1 and D. Significant correlations in the cortex between RBF and f (r = 0.66), RBF and eGFR (r = 0.64), and D* and eGFR (r = -0.57) were found. Normal values of the measured parameters employing the mpMRI protocol in kidney transplant patients with stable function were characterized and the results showed good reproducibility of the techniques.
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    External validation and comparison of three scores to predict renal replacement therapy after cardiac surgery: A multicenter cohort
    (SAGE Publications, 2011) Herreros, J. (Jesús); Perez-Valdivieso, J.R. (José Ramón); Lavilla, J. (Javier); Bes-Rastrollo, M. (Maira); Vives, M. (Marc); Monedero, P. (Pablo); Garcia-Fernandez, N. (Nuria)
    Purpose: Cardiac surgery-associated acute kidney injury requiring renal replacement therapy (RRT) is independently associated with mortality. Several risk scores have been developed to predict the need for RRT after cardiac surgery. We have compared and verified the external validity of the three main available scores for RRT prediction after cardiac surgery: the Thakar score, the Mehta tool, and the Simplified Renal Index. Methods: The risk scores were calculated in a cohort of 1084 adult patients, 248 of whom required RRT, who underwent open-heart surgery in 24 Spanish hospitals in 2007. The performance of the systems was determined by examining their discrimination (areas under the receiver operating characteristic curves (aROC) and calibration (Lemeshow-Hosmer chi-square goodness-of-fit statistics). Results: The aROCs in the Thakar score, the Mehta tool, and the Simplified Renal Index were 0.82, 0.76 and 0.79, respectively. The three scoring systems were poorly calibrated and tended to underestimate the actual need for RRT. Conclusions: The Thakar score and the Simplified Renal Index discriminated well between low - and high-risk patients in our cohort, and Thakar outperformed the Mehta tool. These best-performing scores may aid in the selection of optimal therapy, facilitate the planning of hospital resource utilization, improve preoperative counseling, select participants for clinical trials of renal-protective therapies and enable an accurate comparison between different institutions or surgeons.
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    Perspectives on the role of magnetic resonance imaging (Mri) for noninvasive evaluation of diabetic kidney disease
    (2021) Echeverría-Chasco, R. (Rebeca); Fernández-Seara, M.A. (María A.); Mora-Gutiérrez, J.M. (José María); Garcia-Fernandez, N. (Nuria)
    Renal magnetic resonance imaging (MRI) techniques are currently in vogue, as they provide in vivo information on renal volume, function, metabolism, perfusion, oxygenation, and microstructural alterations, without the need for exogenous contrast media. New imaging biomarkers can be identified using these tools, which represent a major advance in the understanding and study of the different pathologies affecting the kidney. Diabetic kidney disease (DKD) is one of the most important diseases worldwide due to its high prevalence and impact on public health. However, its multifactorial etiology poses a challenge for both basic and clinical research. Therefore, the use of novel renal MRI techniques is an attractive step forward in the comprehension of DKD, both in its pathogenesis and in its detection and surveillance in the clinical practice. This review article outlines the most promising MRI techniques in the study of DKD, with the purpose of stimulating their clinical translation as possible tools for the diagnosis, follow-up, and monitoring of the clinical impacts of new DKD treatments.
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    Pre-emptive antimicrobial locks decrease long-term catheter-related bloodstream infections in hemodialysis patients
    (2022) Oteiza-Ubanell, A.C. (Amaya Concepción); Leiva, J. (José); Pozo, J.L. (José Luis) del; Carmona-Torre, F. (Francisco de A.); Aguinaga, A. (Aitziber); Garcia-Fernandez, N. (Nuria); Blanco-Di-Matteo, A. (Andrés)
    This study aimed to prove that pre-emptive antimicrobial locks in patients at risk of bacteremia decrease infection. We performed a non-randomized prospective pilot study of hemodialysis patients with tunneled central venous catheters. We drew quantitative blood cultures monthly to detect colonization. Patients with a critical catheter colonization by coagulase-negative staphylococci (defined as counts of 100-999 CFU/mL) were at high risk of developing a catheter-related bloodstream infection. We recommended antimicrobial lock for this set of patients. The nephrologist in charge of the patient decided whether to follow the recommendation or not (i.e., standard of care). We compared bloodstream infection rates between patients treated with antimicrobial lock therapy versus patients treated with the standard of care (i.e., heparin). We enrolled 149 patients and diagnosed 86 episodes of critical catheter colonization by coagulase-negative staphylococci. Patients treated with antimicrobial lock had a relative risk of bloodstream infection of 0.19 when compared with heparin lock (CI 95%, 0.11-0.33, p < 0.001) within three months of treatment. We avoided one catheter-related bloodstream infection for every ten catheter-critical colonizations treated with antimicrobial lock [number needed to treat 10, 95% CI, 5.26-100, p = 0.046]. In conclusion, pre-emptive antimicrobial locks decrease bloodstream infection rates in hemodialysis patients with critical catheter colonization.
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    Supervivencia de circuitos de técnicas de depuración extrarrenal continua en pacientes críticos con o sin anticoagulación convencional: estudio observacional prospectivo
    (2017) Hidalgo, F. (Francisco); Sanz-Ganuza, M. (Maria); Garcia-Fernandez, N. (Nuria)
    Fundamento. El objetivo del presente estudio es describir la eficacia, seguridad y viabilidad, en pacientes críticos con técnica de depuración extrarrenal continua (TDEC) y diferente riesgo de hemorragia, de un sistema de anticoagulación convencional con perfusión continua de heparina no fraccionada (HNF) frente a no anticoagular usando lavados son suero fisiológico. Material y métodos. Se trata de un estudio observacional prospectivo realizado en la Unidad de Cuidados Intensivos (UCI) desde octubre de 2013 hasta abril de 2016. Se incluyeron 61 pacientes que presentaron insuficiencia renal aguda (IRA) con requerimientos de TDEC y un total de 122 circuitos. Tanto los pacientes como los circuitos fueron divididos para su análisis en dos grupos: anticoagulados (AC) y no anticoagulados (No AC). La variable principal fue la supervivencia de los circuitos. Además se recogieron diferentes parámetros analíticos al comienzo del tratamiento y en el momento de coagulación del circuito. Resultados. La distribución de pacientes anticoagulados y no anticoagulados fue similar. No se han encontrado diferencias significativas en la supervivencia de los circuitos entre ambos grupos (30,5 horas AC vs 34,9 horas No AC). Los pacientes con mayor morbilidad (trombopenia severa, coagulopatía, etc.) pertenecían al grupo que no recibió anticoagulación, sino lavados con suero fisiológico. Conclusiones. En pacientes críticos con alto riesgo de sangrado las TDEC son viables sin anticoagulación más el empleo de lavados periódicos con suero fisiológico se comporta como una medida viable, segura y eficaz obteniendo una supervivencia de los circuitos similar a la de pacientes anticoagulados con HNF, evitando los riesgos y costes asociados a la anticoagulación.