Minerva Rodríguez - Academia.edu (original) (raw)

Papers by Minerva Rodríguez

Research paper thumbnail of Mineral and Bone Disorders in Chronic Kidney Disease

Springer eBooks, 2014

Chronic kidney disease (CKD) is now recognized as a major public health issue. One consequence of... more Chronic kidney disease (CKD) is now recognized as a major public health issue. One consequence of this condition is disturbance of mineral and bone homeostasis. Bone disease (renal osteodystrophy) as a consequence of CKD has long been recognized. However, it is now appreciated that the mineral and bone disturbances of CKD (and perhaps treatment of them) lead to vascular calcification, which is a cause of significant morbidity. In recognition of the widespread nature of the condition, the term CKD-mineral bone disorder (CKD-MBD) is now in general use to describe the biochemical, skeletal and vascular changes that occur in CKD. The pathogenesis of CKD-MBD is incompletely understood but has recently been redefined with the emergence of fibroblast growth factor 23 (FGF-23) as a major influence on control of vitamin D and parathyroid hormone. This review describes the classification of CKD and current understanding of the mechanisms underlying CKD-MBD (incorporating FGF-23). It describes and evaluates the means of identifying CKD-MBD in the clinical setting and the interventions available for treatment. It then reviews current clinical guidelines for the use of biochemical markers in clinical decision-making. In acknowledgement of the paucity of evidence upon which these guidelines are based, areas where clinical research might be directed in the future will be identified.

Research paper thumbnail of Osteoporosis, densidad mineral ósea y complejo CKD-MBD (I): consideraciones diagnósticas

Nefrologia, Sep 1, 2018

Osteoporosis (OP) y enfermedad renal crónica (ERC) influyen de manera independiente en la salud ó... more Osteoporosis (OP) y enfermedad renal crónica (ERC) influyen de manera independiente en la salud ósea y cardiovascular. Un número significativo de pacientes con ERC, especialmente desde estadios 3a a 5D, presentan una disminución significativa de la densidad mineral ósea condicionando un alto riesgo de fractura y un incremento importante de la morbimortalidad asociada. Independientemente de la OP clásica asociada a edad y/o sexo, las propiedades mecánicas del hueso se encuentran afectadas adicionalmente por factores intrínsecos a la ERC («OP urémica»). En la primera parte de esta revisión, analizaremos conceptos generales sobre densidad mineral ósea, OP y fracturas, en gran parte infravalorados hasta ahora por los nefrólogos debido a la falta de evidencias y a las dificultades diagnósticas en el contexto de la ERC. Actualmente se ha demostrado que una densidad mineral ósea disminuida es realmente predictiva del riesgo de fracturas en pacientes con ERC, aunque no permite distinguir entre las causas que la originan (hiperparatiroidismo, enfermedad adinámica del hueso y/o osteoporosis senil, etc.). Por ello, en la segunda parte analizaremos las implicaciones terapéuticas en distintos * Autor para correspondencia.

Research paper thumbnail of Hyperphosphataemia as a cardiovascular risk factor - how to manage the problem

Nephrology Dialysis Transplantation, Nov 1, 2002

Hyperphosphataemia is a frequent and important cardiovascular risk factor in patients with chroni... more Hyperphosphataemia is a frequent and important cardiovascular risk factor in patients with chronic kidney disease (CKD). High phosphate levels may influence vascular calcifications by two separate mechanisms: by worsening secondary hyperparathyroidism, which in turn facilitates calcification, and by promoting calcium phosphate deposition in pre-formed endothelial plaques and in the arterial wall. Recent studies have shown that hyperphosphataemia induces the proliferation and differentiation of endothelial vascular cells into osteoblast-like cells, promoting vascular calcification. High phosphate levels also increase the risk of mortality in patients with CKD. To reduce the negative impact of high phosphate, serum phosphate levels should be-5 mgudl and serum calcium-10 mgudl. This allows the calcium 3 phosphate product to be maintained at O50 mg 2 udl 2 , reducing the risk of vascular, valvular, and extraskeletal calcification. A multiple-factor approach can be used to reduce serum phosphate: (i) decrease bone resorption by maintaining adequate serum parathyroid hormone levels; (ii) reduce phosphorous intake in the diet, (iii) use phosphate binders efficiently; and (iv) avoid underdialysis. The patient's diet should be high in nutrition but with the lowest possible phosphorous content. Doses of phosphate binders should be tailored to individual dietary habits and must be taken during meals in a dose proportional to the phosphorous content of the meal. Because of the risk of increased extraskeletal calcification, calcium-containing phosphate-binder intake should not exceed 2-3 guday. Sevelamer hydrochloride, a non-calcium and nonaluminium phosphate binder with a potency similar to that of calcium salts has shown beneficial effects on lipid profiles. Better control of serum phosphate is achieved in patients on continuous ambulatory peritoneal dialysis than in those on haemodialysis. Removal of phosphate is directly correlated with duration and frequency of dialysis sessions. Thus, it is advisable not to reduce the duration of dialysis sessions to-4 h three times per week.

Research paper thumbnail of Progression of vascular calcifications is associated with greater bone loss and increased bone fractures

Osteoporosis International, Jan 8, 2008

In this prospective study, we found a positive relationship between the prevalence of aortic calc... more In this prospective study, we found a positive relationship between the prevalence of aortic calcifications and age. Aortic calcifications at baseline were positively associated with osteoporotic fractures. In addition, progression of aortic calcifications was also positively associated with the rate of decline in BMD at lumbar spine. The aim of this study was to analyze the relationship between the progression of abdominal aortic calcification and osteoporosis in a Spanish cohort of men and women older than 50. Men and women (n=624) aged 50 and over underwent two lateral X-rays of thoracic and lumbar spine and a dual X-ray absorptiometry (DXA) study at lumbar spine and hip, and were followed during 4 years. Abdominal aortic calcifications were classified as absent, mild-moderate and severe. There was a positive relationship between the prevalence of aortic calcifications and age. In both sexes, prevalent severe aortic calcifications were positively associated with prevalent osteoporotic fractures [odds ratio (OR)=1.93 (1.02-3.65)]. The association was stronger when only vertebral fracture was considered [OR=2.45 (1.23-4.87)]. In addition, progression of aortic calcifications showed a positive association with the rate of decline in bone mineral density (BMD) at lumbar spine. Aortic calcifications at baseline were positively associated with osteoporotic fractures. The progression of aortic calcifications was also positively associated with the rate of decline in BMD at lumbar spine.

Research paper thumbnail of Es el tiempo de la hemodiálisis domiciliaria

Research paper thumbnail of Osteoporosis, bone mineral density and CKD-MBD (II): Therapeutic implications

Nefrología, May 1, 2019

Osteoporosis (OP) and chronic kidney disease (CKD) both independently affect bone health. A signi... more Osteoporosis (OP) and chronic kidney disease (CKD) both independently affect bone health. A significant number of patients with CKD have decreased bone mineral density (BMD), are at high risk of fragility fractures and have an increased morbidity and mortality risk. With an aging population, these observations are not only dependent on "renal osteodystrophy" but also on the associated OP. As BMD predicts incident fractures in CKD patients (part I), we now aim to analyze the potential therapeutic consequences. Post hoc analyses of randomized studies have shown that the efficacy of drugs such as alendronate, risedronate, raloxifene, teriparatide and denosumab is similar to that of the general population in patients with a mild/moderate decline in their glomerular filtration rate (especially CKD-3). These studies have some flaws however, as they included mostly "healthy" women with no known diagnosis of CKD and generally with normal lab

Research paper thumbnail of Osteoporosis, densidad mineral ósea y complejo CKD-MBD (II): implicaciones terapéuticas

Nefrologia, May 1, 2019

La osteoporosis (OP) y la enfermedad renal crónica (ERC) influyen independientemente en la salud ... more La osteoporosis (OP) y la enfermedad renal crónica (ERC) influyen independientemente en la salud ósea. Numerosos pacientes con ERC presentan una disminución de densidad mineral ósea (DMO), un elevado riesgo de fracturas por fragilidad ósea y un incremento de su morbimortalidad. Con el envejecimiento de la población estos hechos no son dependientes solo de la «osteodistrofia renal» sino también de la OP asociada. Dado que la DMO tiene capacidad predictiva en pacientes con ERC (parte I), ahora analizaremos las implicaciones terapéuticas derivadas. Análisis post hoc de estudios aleatorizados han mostrado que fármacos como alendronato, risedronato, raloxifeno, teriparatida o denosumab tienen una eficacia comparable a la población general en pacientes con una disminución leve-moderada del filtrado glomerular (especialmente ERC-3). Estos estudios tienen limitaciones, pues incluyen mayoritariamente mujeres «sanas», sin diagnóstico conocido de ERC y habitualmente con parámetros normales de laboratorio; sin embargo, también existen datos positivos preliminares en estadios más avanzados (ERC-4) y más limitados en ERC-5D. Por todo ello, al menos en ausencia de alteraciones significativas del metabolismo mineral (i.e., hiperparatiroidismo severo), el beneficio potencial de dichos fármacos debería ser considerado en * Autor para correspondencia.

Research paper thumbnail of Mecanismo de acción del ranelato de estroncio

DOAJ (DOAJ: Directory of Open Access Journals), Mar 1, 2010

Research paper thumbnail of Manejo de la osteoporosis en el paciente con enfermedad renal crónica (Estudio ERCOS): un desafío en la asistencia nefrológica

Research paper thumbnail of The Non-invasive Diagnosis of Bone Disorders in CKD

Calcified Tissue International, 2021

Abnormal bone metabolism is an integral part of the chronic kidney disease-mineral bone disorder ... more Abnormal bone metabolism is an integral part of the chronic kidney disease-mineral bone disorder (CKD-MBD). For several reasons, the difficult bone compartment was neglected for some time, but there has been renewed interest as a result of the conception of bone as a new endocrine organ, the increasing recognition of the cross-talk between bone and vessels, and, especially, the very high risk of osteoporotic fractures (and associated mortality) demonstrated in patients with CKD. Therefore, it has been acknowledged in different guidelines that action is needed in respect of fracture risk assessment and the diagnosis and treatment of osteoporosis in the context of CKD and CKD-MBD, even beyond renal osteodystrophy. These updated guidelines clearly underline the need to improve a non-invasive approach to these bone disorders in order to guide treatment decisions aimed at not only controlling CKD-MBD but also decreasing the risk of fracture. In this report, we review the current role of the most often clinically used or promising biochemical circulating biomarkers such as parathyroid hormone, alkaline phosphatases, and other biochemical markers of bone activity as alternatives to some aspects of bone histomorphometry. We also mention the potential role of classic and new imaging techniques for CKD patients. Information on many aspects is still scarce and heterogeneous, but many of us consider that it is indeed time for action, recognizing our definitely limited ability to base certain treatment decisions only on our current non-comprehensive knowledge.

Research paper thumbnail of Consulta de enfermedad renal crónica avanzada: ¿influye la educación sanitaria sobre la modalidad de tratamiento elegido?

Nefrología, 2019

Introducción: Las peritonitis fúngicas (PF) son poco frecuentes en diálisis peritoneal (DP), pero... more Introducción: Las peritonitis fúngicas (PF) son poco frecuentes en diálisis peritoneal (DP), pero asocian un peor pronóstico y mayor mortalidad que las bacterianas. Hasta el momento los factores predisponentes y su tratamiento no están esclarecidos. Hipótesis de trabajo/objetivos: Describimos las características de los pacientes con PF. Valoramos causas potencialmente modificables que condicionan la aparición de PF. Material y método: Revisamos retrospectivamente los casos de PF a lo largo de 25 años en un total de 870 pacientes DP: características demográficas, antecedentes patológicos, causas de inmunosupresión, variables asociadas a técnica, existencia de infecciones y vinculadas con PF. Resultados: Detectamos 12 episodios de PF. Edad media: 70 años. 50% eran varones, tenían sobrepeso (IMC 25,23). 33% diabéticos. La etiología de ERC más frecuente fue la nefroangiosclerosis (33,3% vs nefropatía DM 25%). Albúmina: 2,7 g/dl, pero no se correlacionó con PF (p = 0,6). Tiempo en DP: 4 años; cuanto más tiempo en DP, más riesgo de PF (p = 0,010). El 91,7% CAPD; el 66,7% realizaban 3 intercambios y la mitad usaban icodextrina; no encontramos asociación de uso de icodextrina con PF (p = 0,77). La CAPD asocia riesgo a desarrollar PF (p = 0,006), mayor con más intercambios (p < 0,042). El 50% asociaban infección del OS, mayoritariamente S. aureus (16,7%) y Pseudomonas (16,7%). Las peritonitis bacterianas previas fueron 66,7% por S. aureus, no se asoció con PF (p = 0,38). La etiología más frecuente fue Candida albicans (58,3%, p = 0,023), seguida de C. parapsilosis (16,7%). Habían recibido profilaxis con fluconazol el 58,3%. A todos ellos se les retiró el catéter de DP (p = 0,006). Conclusiones: La PF es una complicación infrecuente. Ocurre en mayor parte en pacientes que llevan un período prolongado en programa de DP, con mayor riesgo cuantos más intercambios realicen. Proponemos aumentar los reentrenamientos como medida de protección.

Research paper thumbnail of Stenosis of the iliac artery after kidney transplantation as a cause of refractory hypertension and intermittent claudication

Nefrologia : publicacion oficial de la Sociedad Espanola Nefrologia

Heyde syndrome: Correction of anaemia after aortic valve replacement in a hemodialysis patient ଝ ... more Heyde syndrome: Correction of anaemia after aortic valve replacement in a hemodialysis patient ଝ Síndrome de Heyde: resolución de anemia tras reemplazo valvular aórtico en paciente en hemodiálisis Dear Editor, The coexistence of aortic stenosis (AS) and iron-deficiency anaemia due to gastrointestinal bleeding caused by angiodysplasia is known as Heyde syndrome.

Research paper thumbnail of FP402RELATIVE Risk of Mortality in Hemodialysis Patients Prescribed Calcium-Free and Calcium-Containing Phosphate Binding Agents

Nephrology Dialysis Transplantation, 2015

Research paper thumbnail of SP350THE Expression of Vimentin is Suppressed in Vascular Calcification

Nephrology Dialysis Transplantation, 2017

Research paper thumbnail of Progression of vascular calcifications is associated with greater bone loss and increased bone fractures

Osteoporosis International, 2008

In this prospective study, we found a positive relationship between the prevalence of aortic calc... more In this prospective study, we found a positive relationship between the prevalence of aortic calcifications and age. Aortic calcifications at baseline were positively associated with osteoporotic fractures. In addition, progression of aortic calcifications was also positively associated with the rate of decline in BMD at lumbar spine. The aim of this study was to analyze the relationship between the progression of abdominal aortic calcification and osteoporosis in a Spanish cohort of men and women older than 50. Men and women (n=624) aged 50 and over underwent two lateral X-rays of thoracic and lumbar spine and a dual X-ray absorptiometry (DXA) study at lumbar spine and hip, and were followed during 4 years. Abdominal aortic calcifications were classified as absent, mild-moderate and severe. There was a positive relationship between the prevalence of aortic calcifications and age. In both sexes, prevalent severe aortic calcifications were positively associated with prevalent osteoporotic fractures [odds ratio (OR)=1.93 (1.02-3.65)]. The association was stronger when only vertebral fracture was considered [OR=2.45 (1.23-4.87)]. In addition, progression of aortic calcifications showed a positive association with the rate of decline in bone mineral density (BMD) at lumbar spine. Aortic calcifications at baseline were positively associated with osteoporotic fractures. The progression of aortic calcifications was also positively associated with the rate of decline in BMD at lumbar spine.

Research paper thumbnail of The effect of vertebral fracture as a risk factor for osteoporotic fracture and mortality in a Spanish population

Osteoporosis International, 2003

There is little data concerning the morbidity, mortality, and epidemiology of vertebral fracture.... more There is little data concerning the morbidity, mortality, and epidemiology of vertebral fracture. The aim of this study was to evaluate the effect of prevalent and incident vertebral fractures as risk factors for further osteoporotic fractures and mortality. The study was performed on a cohort of 316 women and 308 men older than 50 belonging to the EVOS study, randomly selected from our city register. At the beginning of the study and 4 years later, lateral dorsal and lumbar X-rays were performed. In addition, evaluation of the incidence of osteoporotic nonvertebral fractures was performed throughout 8 years. The incidence of all osteoporotic fractures was higher in women than in men (two-fold increase in vertebral fracture incidence and five-fold increase in Colles&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; and femur incidence). Vertebral fracture was a strong risk factor for a new vertebral fracture [RR=4.7 (1.8-11.9)], hip fracture [RR=6.7 (2.0-22.7)] and Colles&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; fracture [RR=3.0 (1.1-7.8)]. Prevalent and incident vertebral fractures were associated with a higher risk of having a hip fracture [RR=10.0 (2.0-50.2)] and Colles&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; fracture [RR=5.5 (1.3-23.4)]. In addition, in women, the vertebral fracture was associated with a higher mortality. By contrast, no association was found in men. These results demonstrate the association between a previous vertebral fracture with increments in the incidence of osteoporotic fractures of any type. In addition, we found a significantly higher mortality rate in women having vertebral fractures. These findings support the necessity of preventing the occurrence of vertebral fractures to limit their strong negative impact on mortality.

Research paper thumbnail of Pathophysiology of bone disease in chronic kidney disease: from basics to renal osteodystrophy and osteoporosis

Frontiers in Physiology

Chronic kidney disease (CKD) is a highly prevalent disease that has become a public health proble... more Chronic kidney disease (CKD) is a highly prevalent disease that has become a public health problem. Progression of CKD is associated with serious complications, including the systemic CKD-mineral and bone disorder (CKD-MBD). Laboratory, bone and vascular abnormalities define this condition, and all have been independently related to cardiovascular disease and high mortality rates. The “old” cross-talk between kidney and bone (classically known as “renal osteodystrophies”) has been recently expanded to the cardiovascular system, emphasizing the importance of the bone component of CKD-MBD. Moreover, a recently recognized higher susceptibility of patients with CKD to falls and bone fractures led to important paradigm changes in the new CKD-MBD guidelines. Evaluation of bone mineral density and the diagnosis of “osteoporosis” emerges in nephrology as a new possibility “if results will impact clinical decisions”. Obviously, it is still reasonable to perform a bone biopsy if knowledge of ...

Research paper thumbnail of Granulocitos de baja densidad: un nuevo marcador de deterioro óseo en pacientes en diálisis peritoneal

Revista de Osteoporosis y Metabolismo Mineral, Dec 1, 2022

Objetive: In kidney patients, bone-metabolic disease, systemic inflammation and malnutrition exac... more Objetive: In kidney patients, bone-metabolic disease, systemic inflammation and malnutrition exacerbate the risk of vascular calcification (VC) and morbidity and mortality. Given the strong association between VC and fragility fractures, the objective of this study is to assess the contribution of the major determinants of VC to bone deterioration in patients on peritoneal dialysis (PD). Methods: In 31 non-diabetic patients on PD (>6 months), markers of alterations in bone metabolism, vascular damage, inflammation and malnutrition, and their impact on bone deterioration (radiological osteopenia and/or history of fragility fracture) were studied. Results: In these patients (20 men and 11 women; age=54±15 and 60±11 years, respectively (p=0.24)), the prevalence of fragility fractures was 5% in men and 27% in women. Bone deterioration was greater in older people, females, high Charlson and Kauppila indexes, lower muscle mass and with expansion of a highly inflammatory subpopulation of immature low-density granulocytes (iLDG). A logistic regression analysis showed that bone deterioration risk is more influenced by the female sex than by age and that, of the multiple factors associated with greater bone deterioration studied, only the expansion of iLDG estimates the risk of bone alterations in these patients regardless of age and sex. Conclusion: The expansion of iLDG provides an accurate biomarker for the diagnosis of bone deterioration and to monitor strategies that attenuate its progression in PD patients of any age and sex.

Research paper thumbnail of Novel Immune Cell Subsets Exhibit Different Associations With Vascular Outcomes in Chronic Kidney Disease Patients—Identifying Potential Biomarkers

Frontiers in Medicine, 2021

Background and Aims: Alterations in novel immune cell subsets, such as angiogenic T cells (Tang),... more Background and Aims: Alterations in novel immune cell subsets, such as angiogenic T cells (Tang), senescent T cells (CD4+CD28null), and monocyte subsets are associated with impaired vascular homeostasis in several inflammatory conditions. However, mediators underlying vascular deterioration in chronic kidney disease (CKD) are poorly characterized. This study assessed their role in the vascular deterioration of CKD using a broad spectrum of surrogate markers ranging from altered functionality to overt calcification.Methods: Tang (CD3+CD31+CXCR4+), CD4+CD28null cells, and monocytes [CD14/CD16 subsets and angiotensin-converting enzyme (ACE) expression] were measured in peripheral blood by flow cytometry in 33 CKD stage 5 patients undergoing peritoneal dialysis (CKD5-PD) and 15 healthy controls (HCs). Analyses were replicated in a hemodialysis cohort. Vascular surrogate markers (including adventitial vasa vasorum, pulse wave velocity, intima-media thickness, and vascular calcification) ...

Research paper thumbnail of Improvement of mineral and bone metabolism markers is associated with better survival in haemodialysis patients: the COSMOS study

Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, Jan 28, 2015

Abnormalities in serum phosphorus, calcium and parathyroid hormone (PTH) have been associated wit... more Abnormalities in serum phosphorus, calcium and parathyroid hormone (PTH) have been associated with poor survival in haemodialysis patients. This COSMOS (Current management Of Secondary hyperparathyroidism: a Multicentre Observational Study) analysis assesses the association of high and low serum phosphorus, calcium and PTH with a relative risk of mortality. Furthermore, the impact of changes in these parameters on the relative risk of mortality throughout the 3-year follow-up has been investigated. COSMOS is a 3-year, multicentre, open-cohort, prospective study carried out in 6797 adult chronic haemodialysis patients randomly selected from 20 European countries. Using Cox proportional hazard regression models and penalized splines analysis, it was found that both high and low serum phosphorus, calcium and PTH were associated with a higher risk of mortality. The serum values associated with the minimum relative risk of mortality were 4.4 mg/dL for serum phosphorus, 8.8 mg/dL for seru...

Research paper thumbnail of Mineral and Bone Disorders in Chronic Kidney Disease

Springer eBooks, 2014

Chronic kidney disease (CKD) is now recognized as a major public health issue. One consequence of... more Chronic kidney disease (CKD) is now recognized as a major public health issue. One consequence of this condition is disturbance of mineral and bone homeostasis. Bone disease (renal osteodystrophy) as a consequence of CKD has long been recognized. However, it is now appreciated that the mineral and bone disturbances of CKD (and perhaps treatment of them) lead to vascular calcification, which is a cause of significant morbidity. In recognition of the widespread nature of the condition, the term CKD-mineral bone disorder (CKD-MBD) is now in general use to describe the biochemical, skeletal and vascular changes that occur in CKD. The pathogenesis of CKD-MBD is incompletely understood but has recently been redefined with the emergence of fibroblast growth factor 23 (FGF-23) as a major influence on control of vitamin D and parathyroid hormone. This review describes the classification of CKD and current understanding of the mechanisms underlying CKD-MBD (incorporating FGF-23). It describes and evaluates the means of identifying CKD-MBD in the clinical setting and the interventions available for treatment. It then reviews current clinical guidelines for the use of biochemical markers in clinical decision-making. In acknowledgement of the paucity of evidence upon which these guidelines are based, areas where clinical research might be directed in the future will be identified.

Research paper thumbnail of Osteoporosis, densidad mineral ósea y complejo CKD-MBD (I): consideraciones diagnósticas

Nefrologia, Sep 1, 2018

Osteoporosis (OP) y enfermedad renal crónica (ERC) influyen de manera independiente en la salud ó... more Osteoporosis (OP) y enfermedad renal crónica (ERC) influyen de manera independiente en la salud ósea y cardiovascular. Un número significativo de pacientes con ERC, especialmente desde estadios 3a a 5D, presentan una disminución significativa de la densidad mineral ósea condicionando un alto riesgo de fractura y un incremento importante de la morbimortalidad asociada. Independientemente de la OP clásica asociada a edad y/o sexo, las propiedades mecánicas del hueso se encuentran afectadas adicionalmente por factores intrínsecos a la ERC («OP urémica»). En la primera parte de esta revisión, analizaremos conceptos generales sobre densidad mineral ósea, OP y fracturas, en gran parte infravalorados hasta ahora por los nefrólogos debido a la falta de evidencias y a las dificultades diagnósticas en el contexto de la ERC. Actualmente se ha demostrado que una densidad mineral ósea disminuida es realmente predictiva del riesgo de fracturas en pacientes con ERC, aunque no permite distinguir entre las causas que la originan (hiperparatiroidismo, enfermedad adinámica del hueso y/o osteoporosis senil, etc.). Por ello, en la segunda parte analizaremos las implicaciones terapéuticas en distintos * Autor para correspondencia.

Research paper thumbnail of Hyperphosphataemia as a cardiovascular risk factor - how to manage the problem

Nephrology Dialysis Transplantation, Nov 1, 2002

Hyperphosphataemia is a frequent and important cardiovascular risk factor in patients with chroni... more Hyperphosphataemia is a frequent and important cardiovascular risk factor in patients with chronic kidney disease (CKD). High phosphate levels may influence vascular calcifications by two separate mechanisms: by worsening secondary hyperparathyroidism, which in turn facilitates calcification, and by promoting calcium phosphate deposition in pre-formed endothelial plaques and in the arterial wall. Recent studies have shown that hyperphosphataemia induces the proliferation and differentiation of endothelial vascular cells into osteoblast-like cells, promoting vascular calcification. High phosphate levels also increase the risk of mortality in patients with CKD. To reduce the negative impact of high phosphate, serum phosphate levels should be-5 mgudl and serum calcium-10 mgudl. This allows the calcium 3 phosphate product to be maintained at O50 mg 2 udl 2 , reducing the risk of vascular, valvular, and extraskeletal calcification. A multiple-factor approach can be used to reduce serum phosphate: (i) decrease bone resorption by maintaining adequate serum parathyroid hormone levels; (ii) reduce phosphorous intake in the diet, (iii) use phosphate binders efficiently; and (iv) avoid underdialysis. The patient's diet should be high in nutrition but with the lowest possible phosphorous content. Doses of phosphate binders should be tailored to individual dietary habits and must be taken during meals in a dose proportional to the phosphorous content of the meal. Because of the risk of increased extraskeletal calcification, calcium-containing phosphate-binder intake should not exceed 2-3 guday. Sevelamer hydrochloride, a non-calcium and nonaluminium phosphate binder with a potency similar to that of calcium salts has shown beneficial effects on lipid profiles. Better control of serum phosphate is achieved in patients on continuous ambulatory peritoneal dialysis than in those on haemodialysis. Removal of phosphate is directly correlated with duration and frequency of dialysis sessions. Thus, it is advisable not to reduce the duration of dialysis sessions to-4 h three times per week.

Research paper thumbnail of Progression of vascular calcifications is associated with greater bone loss and increased bone fractures

Osteoporosis International, Jan 8, 2008

In this prospective study, we found a positive relationship between the prevalence of aortic calc... more In this prospective study, we found a positive relationship between the prevalence of aortic calcifications and age. Aortic calcifications at baseline were positively associated with osteoporotic fractures. In addition, progression of aortic calcifications was also positively associated with the rate of decline in BMD at lumbar spine. The aim of this study was to analyze the relationship between the progression of abdominal aortic calcification and osteoporosis in a Spanish cohort of men and women older than 50. Men and women (n=624) aged 50 and over underwent two lateral X-rays of thoracic and lumbar spine and a dual X-ray absorptiometry (DXA) study at lumbar spine and hip, and were followed during 4 years. Abdominal aortic calcifications were classified as absent, mild-moderate and severe. There was a positive relationship between the prevalence of aortic calcifications and age. In both sexes, prevalent severe aortic calcifications were positively associated with prevalent osteoporotic fractures [odds ratio (OR)=1.93 (1.02-3.65)]. The association was stronger when only vertebral fracture was considered [OR=2.45 (1.23-4.87)]. In addition, progression of aortic calcifications showed a positive association with the rate of decline in bone mineral density (BMD) at lumbar spine. Aortic calcifications at baseline were positively associated with osteoporotic fractures. The progression of aortic calcifications was also positively associated with the rate of decline in BMD at lumbar spine.

Research paper thumbnail of Es el tiempo de la hemodiálisis domiciliaria

Research paper thumbnail of Osteoporosis, bone mineral density and CKD-MBD (II): Therapeutic implications

Nefrología, May 1, 2019

Osteoporosis (OP) and chronic kidney disease (CKD) both independently affect bone health. A signi... more Osteoporosis (OP) and chronic kidney disease (CKD) both independently affect bone health. A significant number of patients with CKD have decreased bone mineral density (BMD), are at high risk of fragility fractures and have an increased morbidity and mortality risk. With an aging population, these observations are not only dependent on "renal osteodystrophy" but also on the associated OP. As BMD predicts incident fractures in CKD patients (part I), we now aim to analyze the potential therapeutic consequences. Post hoc analyses of randomized studies have shown that the efficacy of drugs such as alendronate, risedronate, raloxifene, teriparatide and denosumab is similar to that of the general population in patients with a mild/moderate decline in their glomerular filtration rate (especially CKD-3). These studies have some flaws however, as they included mostly "healthy" women with no known diagnosis of CKD and generally with normal lab

Research paper thumbnail of Osteoporosis, densidad mineral ósea y complejo CKD-MBD (II): implicaciones terapéuticas

Nefrologia, May 1, 2019

La osteoporosis (OP) y la enfermedad renal crónica (ERC) influyen independientemente en la salud ... more La osteoporosis (OP) y la enfermedad renal crónica (ERC) influyen independientemente en la salud ósea. Numerosos pacientes con ERC presentan una disminución de densidad mineral ósea (DMO), un elevado riesgo de fracturas por fragilidad ósea y un incremento de su morbimortalidad. Con el envejecimiento de la población estos hechos no son dependientes solo de la «osteodistrofia renal» sino también de la OP asociada. Dado que la DMO tiene capacidad predictiva en pacientes con ERC (parte I), ahora analizaremos las implicaciones terapéuticas derivadas. Análisis post hoc de estudios aleatorizados han mostrado que fármacos como alendronato, risedronato, raloxifeno, teriparatida o denosumab tienen una eficacia comparable a la población general en pacientes con una disminución leve-moderada del filtrado glomerular (especialmente ERC-3). Estos estudios tienen limitaciones, pues incluyen mayoritariamente mujeres «sanas», sin diagnóstico conocido de ERC y habitualmente con parámetros normales de laboratorio; sin embargo, también existen datos positivos preliminares en estadios más avanzados (ERC-4) y más limitados en ERC-5D. Por todo ello, al menos en ausencia de alteraciones significativas del metabolismo mineral (i.e., hiperparatiroidismo severo), el beneficio potencial de dichos fármacos debería ser considerado en * Autor para correspondencia.

Research paper thumbnail of Mecanismo de acción del ranelato de estroncio

DOAJ (DOAJ: Directory of Open Access Journals), Mar 1, 2010

Research paper thumbnail of Manejo de la osteoporosis en el paciente con enfermedad renal crónica (Estudio ERCOS): un desafío en la asistencia nefrológica

Research paper thumbnail of The Non-invasive Diagnosis of Bone Disorders in CKD

Calcified Tissue International, 2021

Abnormal bone metabolism is an integral part of the chronic kidney disease-mineral bone disorder ... more Abnormal bone metabolism is an integral part of the chronic kidney disease-mineral bone disorder (CKD-MBD). For several reasons, the difficult bone compartment was neglected for some time, but there has been renewed interest as a result of the conception of bone as a new endocrine organ, the increasing recognition of the cross-talk between bone and vessels, and, especially, the very high risk of osteoporotic fractures (and associated mortality) demonstrated in patients with CKD. Therefore, it has been acknowledged in different guidelines that action is needed in respect of fracture risk assessment and the diagnosis and treatment of osteoporosis in the context of CKD and CKD-MBD, even beyond renal osteodystrophy. These updated guidelines clearly underline the need to improve a non-invasive approach to these bone disorders in order to guide treatment decisions aimed at not only controlling CKD-MBD but also decreasing the risk of fracture. In this report, we review the current role of the most often clinically used or promising biochemical circulating biomarkers such as parathyroid hormone, alkaline phosphatases, and other biochemical markers of bone activity as alternatives to some aspects of bone histomorphometry. We also mention the potential role of classic and new imaging techniques for CKD patients. Information on many aspects is still scarce and heterogeneous, but many of us consider that it is indeed time for action, recognizing our definitely limited ability to base certain treatment decisions only on our current non-comprehensive knowledge.

Research paper thumbnail of Consulta de enfermedad renal crónica avanzada: ¿influye la educación sanitaria sobre la modalidad de tratamiento elegido?

Nefrología, 2019

Introducción: Las peritonitis fúngicas (PF) son poco frecuentes en diálisis peritoneal (DP), pero... more Introducción: Las peritonitis fúngicas (PF) son poco frecuentes en diálisis peritoneal (DP), pero asocian un peor pronóstico y mayor mortalidad que las bacterianas. Hasta el momento los factores predisponentes y su tratamiento no están esclarecidos. Hipótesis de trabajo/objetivos: Describimos las características de los pacientes con PF. Valoramos causas potencialmente modificables que condicionan la aparición de PF. Material y método: Revisamos retrospectivamente los casos de PF a lo largo de 25 años en un total de 870 pacientes DP: características demográficas, antecedentes patológicos, causas de inmunosupresión, variables asociadas a técnica, existencia de infecciones y vinculadas con PF. Resultados: Detectamos 12 episodios de PF. Edad media: 70 años. 50% eran varones, tenían sobrepeso (IMC 25,23). 33% diabéticos. La etiología de ERC más frecuente fue la nefroangiosclerosis (33,3% vs nefropatía DM 25%). Albúmina: 2,7 g/dl, pero no se correlacionó con PF (p = 0,6). Tiempo en DP: 4 años; cuanto más tiempo en DP, más riesgo de PF (p = 0,010). El 91,7% CAPD; el 66,7% realizaban 3 intercambios y la mitad usaban icodextrina; no encontramos asociación de uso de icodextrina con PF (p = 0,77). La CAPD asocia riesgo a desarrollar PF (p = 0,006), mayor con más intercambios (p < 0,042). El 50% asociaban infección del OS, mayoritariamente S. aureus (16,7%) y Pseudomonas (16,7%). Las peritonitis bacterianas previas fueron 66,7% por S. aureus, no se asoció con PF (p = 0,38). La etiología más frecuente fue Candida albicans (58,3%, p = 0,023), seguida de C. parapsilosis (16,7%). Habían recibido profilaxis con fluconazol el 58,3%. A todos ellos se les retiró el catéter de DP (p = 0,006). Conclusiones: La PF es una complicación infrecuente. Ocurre en mayor parte en pacientes que llevan un período prolongado en programa de DP, con mayor riesgo cuantos más intercambios realicen. Proponemos aumentar los reentrenamientos como medida de protección.

Research paper thumbnail of Stenosis of the iliac artery after kidney transplantation as a cause of refractory hypertension and intermittent claudication

Nefrologia : publicacion oficial de la Sociedad Espanola Nefrologia

Heyde syndrome: Correction of anaemia after aortic valve replacement in a hemodialysis patient ଝ ... more Heyde syndrome: Correction of anaemia after aortic valve replacement in a hemodialysis patient ଝ Síndrome de Heyde: resolución de anemia tras reemplazo valvular aórtico en paciente en hemodiálisis Dear Editor, The coexistence of aortic stenosis (AS) and iron-deficiency anaemia due to gastrointestinal bleeding caused by angiodysplasia is known as Heyde syndrome.

Research paper thumbnail of FP402RELATIVE Risk of Mortality in Hemodialysis Patients Prescribed Calcium-Free and Calcium-Containing Phosphate Binding Agents

Nephrology Dialysis Transplantation, 2015

Research paper thumbnail of SP350THE Expression of Vimentin is Suppressed in Vascular Calcification

Nephrology Dialysis Transplantation, 2017

Research paper thumbnail of Progression of vascular calcifications is associated with greater bone loss and increased bone fractures

Osteoporosis International, 2008

In this prospective study, we found a positive relationship between the prevalence of aortic calc... more In this prospective study, we found a positive relationship between the prevalence of aortic calcifications and age. Aortic calcifications at baseline were positively associated with osteoporotic fractures. In addition, progression of aortic calcifications was also positively associated with the rate of decline in BMD at lumbar spine. The aim of this study was to analyze the relationship between the progression of abdominal aortic calcification and osteoporosis in a Spanish cohort of men and women older than 50. Men and women (n=624) aged 50 and over underwent two lateral X-rays of thoracic and lumbar spine and a dual X-ray absorptiometry (DXA) study at lumbar spine and hip, and were followed during 4 years. Abdominal aortic calcifications were classified as absent, mild-moderate and severe. There was a positive relationship between the prevalence of aortic calcifications and age. In both sexes, prevalent severe aortic calcifications were positively associated with prevalent osteoporotic fractures [odds ratio (OR)=1.93 (1.02-3.65)]. The association was stronger when only vertebral fracture was considered [OR=2.45 (1.23-4.87)]. In addition, progression of aortic calcifications showed a positive association with the rate of decline in bone mineral density (BMD) at lumbar spine. Aortic calcifications at baseline were positively associated with osteoporotic fractures. The progression of aortic calcifications was also positively associated with the rate of decline in BMD at lumbar spine.

Research paper thumbnail of The effect of vertebral fracture as a risk factor for osteoporotic fracture and mortality in a Spanish population

Osteoporosis International, 2003

There is little data concerning the morbidity, mortality, and epidemiology of vertebral fracture.... more There is little data concerning the morbidity, mortality, and epidemiology of vertebral fracture. The aim of this study was to evaluate the effect of prevalent and incident vertebral fractures as risk factors for further osteoporotic fractures and mortality. The study was performed on a cohort of 316 women and 308 men older than 50 belonging to the EVOS study, randomly selected from our city register. At the beginning of the study and 4 years later, lateral dorsal and lumbar X-rays were performed. In addition, evaluation of the incidence of osteoporotic nonvertebral fractures was performed throughout 8 years. The incidence of all osteoporotic fractures was higher in women than in men (two-fold increase in vertebral fracture incidence and five-fold increase in Colles&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; and femur incidence). Vertebral fracture was a strong risk factor for a new vertebral fracture [RR=4.7 (1.8-11.9)], hip fracture [RR=6.7 (2.0-22.7)] and Colles&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; fracture [RR=3.0 (1.1-7.8)]. Prevalent and incident vertebral fractures were associated with a higher risk of having a hip fracture [RR=10.0 (2.0-50.2)] and Colles&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; fracture [RR=5.5 (1.3-23.4)]. In addition, in women, the vertebral fracture was associated with a higher mortality. By contrast, no association was found in men. These results demonstrate the association between a previous vertebral fracture with increments in the incidence of osteoporotic fractures of any type. In addition, we found a significantly higher mortality rate in women having vertebral fractures. These findings support the necessity of preventing the occurrence of vertebral fractures to limit their strong negative impact on mortality.

Research paper thumbnail of Pathophysiology of bone disease in chronic kidney disease: from basics to renal osteodystrophy and osteoporosis

Frontiers in Physiology

Chronic kidney disease (CKD) is a highly prevalent disease that has become a public health proble... more Chronic kidney disease (CKD) is a highly prevalent disease that has become a public health problem. Progression of CKD is associated with serious complications, including the systemic CKD-mineral and bone disorder (CKD-MBD). Laboratory, bone and vascular abnormalities define this condition, and all have been independently related to cardiovascular disease and high mortality rates. The “old” cross-talk between kidney and bone (classically known as “renal osteodystrophies”) has been recently expanded to the cardiovascular system, emphasizing the importance of the bone component of CKD-MBD. Moreover, a recently recognized higher susceptibility of patients with CKD to falls and bone fractures led to important paradigm changes in the new CKD-MBD guidelines. Evaluation of bone mineral density and the diagnosis of “osteoporosis” emerges in nephrology as a new possibility “if results will impact clinical decisions”. Obviously, it is still reasonable to perform a bone biopsy if knowledge of ...

Research paper thumbnail of Granulocitos de baja densidad: un nuevo marcador de deterioro óseo en pacientes en diálisis peritoneal

Revista de Osteoporosis y Metabolismo Mineral, Dec 1, 2022

Objetive: In kidney patients, bone-metabolic disease, systemic inflammation and malnutrition exac... more Objetive: In kidney patients, bone-metabolic disease, systemic inflammation and malnutrition exacerbate the risk of vascular calcification (VC) and morbidity and mortality. Given the strong association between VC and fragility fractures, the objective of this study is to assess the contribution of the major determinants of VC to bone deterioration in patients on peritoneal dialysis (PD). Methods: In 31 non-diabetic patients on PD (>6 months), markers of alterations in bone metabolism, vascular damage, inflammation and malnutrition, and their impact on bone deterioration (radiological osteopenia and/or history of fragility fracture) were studied. Results: In these patients (20 men and 11 women; age=54±15 and 60±11 years, respectively (p=0.24)), the prevalence of fragility fractures was 5% in men and 27% in women. Bone deterioration was greater in older people, females, high Charlson and Kauppila indexes, lower muscle mass and with expansion of a highly inflammatory subpopulation of immature low-density granulocytes (iLDG). A logistic regression analysis showed that bone deterioration risk is more influenced by the female sex than by age and that, of the multiple factors associated with greater bone deterioration studied, only the expansion of iLDG estimates the risk of bone alterations in these patients regardless of age and sex. Conclusion: The expansion of iLDG provides an accurate biomarker for the diagnosis of bone deterioration and to monitor strategies that attenuate its progression in PD patients of any age and sex.

Research paper thumbnail of Novel Immune Cell Subsets Exhibit Different Associations With Vascular Outcomes in Chronic Kidney Disease Patients—Identifying Potential Biomarkers

Frontiers in Medicine, 2021

Background and Aims: Alterations in novel immune cell subsets, such as angiogenic T cells (Tang),... more Background and Aims: Alterations in novel immune cell subsets, such as angiogenic T cells (Tang), senescent T cells (CD4+CD28null), and monocyte subsets are associated with impaired vascular homeostasis in several inflammatory conditions. However, mediators underlying vascular deterioration in chronic kidney disease (CKD) are poorly characterized. This study assessed their role in the vascular deterioration of CKD using a broad spectrum of surrogate markers ranging from altered functionality to overt calcification.Methods: Tang (CD3+CD31+CXCR4+), CD4+CD28null cells, and monocytes [CD14/CD16 subsets and angiotensin-converting enzyme (ACE) expression] were measured in peripheral blood by flow cytometry in 33 CKD stage 5 patients undergoing peritoneal dialysis (CKD5-PD) and 15 healthy controls (HCs). Analyses were replicated in a hemodialysis cohort. Vascular surrogate markers (including adventitial vasa vasorum, pulse wave velocity, intima-media thickness, and vascular calcification) ...

Research paper thumbnail of Improvement of mineral and bone metabolism markers is associated with better survival in haemodialysis patients: the COSMOS study

Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, Jan 28, 2015

Abnormalities in serum phosphorus, calcium and parathyroid hormone (PTH) have been associated wit... more Abnormalities in serum phosphorus, calcium and parathyroid hormone (PTH) have been associated with poor survival in haemodialysis patients. This COSMOS (Current management Of Secondary hyperparathyroidism: a Multicentre Observational Study) analysis assesses the association of high and low serum phosphorus, calcium and PTH with a relative risk of mortality. Furthermore, the impact of changes in these parameters on the relative risk of mortality throughout the 3-year follow-up has been investigated. COSMOS is a 3-year, multicentre, open-cohort, prospective study carried out in 6797 adult chronic haemodialysis patients randomly selected from 20 European countries. Using Cox proportional hazard regression models and penalized splines analysis, it was found that both high and low serum phosphorus, calcium and PTH were associated with a higher risk of mortality. The serum values associated with the minimum relative risk of mortality were 4.4 mg/dL for serum phosphorus, 8.8 mg/dL for seru...