Patients with chronic kidney disease (CKD) are at an increased risk of premature mortality, mainly from cardiovascular causes. The association between CKD on hemodialysis and accelerated atherosclerosis was described >40 years ago. However, more recently, it has been suggested that the increase in atherosclerosis risk is actually observed in early CKD stages, remaining stable thereafter. In this regard, interventions targeting the pathogenesis of atherosclerosis, such as statins, successful in the general population, have failed to benefit patients with very advanced CKD. This raises the issue of the relative contribution of atherosclerosis versus other forms of cardiovascular injury such as arteriosclerosis or myocardial injury to the increased cardiovascular risk in CKD. In this review, the pathophysiogical contributors to atherosclerosis in CKD that are shared with the general population, or specific to CKD, are discussed. The NEFRONA study (Observatorio Nacional de Atherosclerosis en NEFrologia) prospectively assessed the prevalence and progression of subclinical atherosclerosis (plaque in vascular ultrasound), confirming an increased prevalence of atherosclerosis in patients with moderate CKD. However, the adjusted odds ratio for subclinical atherosclerosis increased with CKD stage, suggesting a contribution of CKD itself to subclinical atherosclerosis. Progression of atherosclerosis was closely related to CKD progression as well as to the baseline presence of atheroma plaque, and to higher phosphate, uric acid, and ferritin and lower 25(OH) vitamin D levels. These insights may help design future clinical trials of stratified personalized medicine targeting atherosclerosis in patients with CKD. Future primary prevention trials should enroll patients with evidence of subclinical atherosclerosis and should provide a comprehensive control of all known risk factors in addition to testing any additional intervention or placebo.

Atherosclerosis in Chronic Kidney Disease: More, Less, or Just Different?

Background: Two previous national epidemiological studies, IBERPOC in 1997 and EPISCAN in 2007, determined the COPD burden in Spain. Changes in demographics and exposure to risk factors demand the periodic update of COPD prevalence and its determinants. Methods: EPISCAN II aimed to estimate the prevalence of COPD in the general population aged 40 years or older in all 17 regions of Spain. A random population screening sample, requiring 600 participants per region performed a questionnaire plus post-bronchodilator (post-BD) spirometry. Results: A total of 12,825 subjects were initially contacted, and 9433 (73.6%) agreed to participate, of whom 9092 performed a valid spirometry. Baseline characteristics were: 52.6% women, mean ± SD age 60 ± 11 years, 19.8% current- and 34.2% former-smokers. The prevalence of COPD measured by post-BD fixed ratio FEV1/FVC < 0.7 was 11.8% (95% C.I. 11.2–12.5) with a high variability by region (2.4-fold). Prevalence was 14.6% (95% C.I. 13.5–15.7) in males and 9.4% (95% C.I. 8.6–10.2) in females; according to the lower limit of normal (LLN) was 6.0% (95% C.I. 5.5–6.5) overall, by sex being 7.1% (95% C.I. 6.4–8.0) in males and 4.9% (95% C.I. 4.3–5.6) in females. Underdiagnosis of COPD was 74.7%. Cases with COPD were a mean of seven years older, more frequently male, of lower attained education, and with more smokers than the non-COPD population (p < 0.001). However, the number of cigarettes and pack-years in non-COPD participants was substantial, as it was the reported use of e-cigarettes (7.0% vs. 5.5%) (p = 0.045). There were also significant social and clinical differences including living alone, previous respiratory diagnoses, more comorbidities measured with the Charlson index, greater BODE and COTE scores, cognitive impairment, and depression (all p < 0.001). Conclusions: COPD remains prevalent in Spain and frequently underdiagnosed.

Prevalence and Determinants of COPD in Spain: EPISCAN II.

The Global Burden of Disease (GBD) study measures the health of populations worldwide and by country on an annual basis and aims at helping guide public policy on health issues. The GBD estimates for Spain in 2016 and recent trends in mortality and morbidity from 2006 to 2016 were recently published. According to these estimates, chronic kidney disease was the 8th cause of death in Spain in 2016. Among the top ten causes of death, chronic kidney disease was the fastest growing from 2006 to 2016, after Alzheimer disease. At the current pace of growth, chronic kidney disease is set to become the second cause of death in Spain, after Alzheimer disease, by 2100. Additionally, among major causes of death, chronic kidney disease also ranked second only to Alzheimer as the fastest growing cause of Years Lived with Disability (YLDs) and Disability Adjusted Life Years (DALYs). Public resources devoted to prevention, care and research on kidney disease should be in line with both its current and future burden.

The Spanish Society of Nephrology (SENEFRO) commentary to the Spain GBD 2016 report: Keeping chronic kidney disease out of sight of health authorities will only magnify the problem

Objective The aim of this study was to evaluate the quality of diagnosis and treatment of COPD using Big Data methodology on the Savana Manager 2.1 clinical platform. Materials and methods A total of 59,369 patients with a diagnosis of COPD were included from a population of 1,219,749 adults over 40 years of age. Results In total, 78% were men. Spirometry data were available for only 26,453 (43.5%) subjects. Disease severity was classified in 18,172 patients: 4396 mild, 7100 moderate, and 6676 severe, although only 27%, 34%, and 28%, respectively, presented obstructive spirometry. The clinical management of COPD is mainly the responsibility of the primary care and pulmonology departments, while internal medicine and, to a lesser extent, geriatrics also participate. Drug treatment was based on bronchodilators and inhaled corticosteroids (ICS). A marked decline in the use of long-acting beta-2 agonists (LABA) in monotherapy and a slight reduction in ICS/LABA combinations, associated with a long-acting anticholinergic (LAMA) in 74% of cases, were observed. All-cause in-hospital mortality among the overall population was 5.6% compared to 1% of the general population older than 40 years. In total, 35% were admitted to hospital, with an average stay of 6.6 days and an in-hospital mortality rate in this group of 10.74%. Discussion This study identifies the main features of an unselected COPD population and the main errors made in the management of the disease.

Clinical Management of COPD in a Real-World Setting. A Big Data Analysis.

Containment policies and other restrictions introduced by the Spanish government in response to the COVID-19 pandemic present challenges for marginalised populations, such as people who use drugs. Harm reduction centres are often linked to social services, mental health services, and infectious disease testing, in addition to tools and services that help to reduce the harms associated with injecting drugs. This study aimed to explore the impact of the pandemic on these services in four autonomous communities in Spain. This is a cross-sectional study that employed a seven-section structured survey administered electronically to 20 centres in July 2020. Data from the most heavily affected months (March–June) in 2020 were compared to data from the same period in 2019. Averages were calculated with their ranges, rates, and absolute numbers. All 11 responding centres reported having had to adapt or modify their services during the Spanish state of alarm (14 March–21 June 2020). One centre reported complete closure for 2 months and four reported increases in their operating hours. The average number of service users across all centres decreased by 22% in comparison to the same period in the previous year and the average needle distribution decreased by 40% in comparison to 2019. Most centres reported a decrease in infectious disease testing rates (hepatitis B and C viruses, human immunodeficiency virus, and tuberculosis) for March, April, and May in 2020 compared to the previous year. Reported deaths as a result of overdose did not increase during the state of alarm, but 2/11 (18%) centres reported an increase in overdose deaths immediately after finalisation of the state of alarm. Overall, Spanish harm reduction centres were able to continue operating and offering services by adjusting operating hours. The number of overall service users and needles distributed fell during the Spanish state of alarm lockdown period, suggesting that fewer clients accessed harm reduction services during this time, putting them at greater risk of reusing or sharing injecting equipment, overdosing, acquiring infectious diseases with decreased access to testing or discontinuing ongoing treatment such as methadone maintenance therapy, hepatitis C treatment, or antiretroviral therapy.

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The impact of the COVID-19 pandemic on harm reduction services in Spain.

Resumen Antecedentes y objetivo El estudio de la carga global de las enfermedades, conocido como GBD por sus siglas en ingles (global burden of disease), mide la salud poblacional en todo el mundo de forma anual y sus resultados estan disponibles por pais. Utilizamos las estimaciones GBD para resumir el estado de salud poblacional en Espana en 2016 y describir las tendencias en morbimortalidad de 1990 a 2016. Material y metodos GBD 2016 estima la carga debida a 333 enfermedades y lesiones, y a 84 factores de riesgo. La lista de causas de GBD es jerarquica e incluye 3 categorias de nivel superior: 1) enfermedades transmisibles, maternas, neonatales y nutricionales; 2) enfermedades no transmisibles (ENT), y 3) accidentes. Se presentan la mortalidad, los anos de vida ajustados por discapacidad (AVAD), los factores de riesgo y el progreso hacia los objetivos de desarrollo sostenible (ODS) a partir de los datos de GBD 2016 en Espana. Resultados En 2016 en Espana hubo 418.516 muertes, de una poblacion total de 46,5 millones, y el 80,5% de ellas ocurrieron en personas de 70 anos o mas. Las ENT fueron la principal causa de muerte (92,8%), con 388.617 (intervalo de incertidumbre del 95% 374.959-402.486), seguidas de los accidentes (3,6%), con 15.052 (13.902-17.107), y de las enfermedades transmisibles (3,5%), con 14.847 (13.208-16.482) muertes. Las 5 principales causas especificas de muerte fueron la cardiopatia isquemica (CI), con el 14,6% de todas las muertes, la enfermedad de Alzheimer y otras demencias (13,6%), el accidente cerebrovascular (7,1%), la enfermedad pulmonar obstructiva cronica (6,9%) y el cancer de pulmon (5,0%). Se observaron incrementos notables en la mortalidad de 1990 a 2016 en otros canceres, infecciones respiratorias del tracto inferior, enfermedad renal cronica y otras enfermedades cardiovasculares, entre otros. Por el contrario, los accidentes de trafico bajaron del puesto 8 al 32 y la diabetes del 6 al 10. Los dolores de espalda y cervicales se convirtieron en la causa principal de AVAD en Espana en 2016, superando a la CI, mientras que la enfermedad de Alzheimer paso del puesto 9 al 3. Los mayores cambios en AVAD se observaron para accidentes de trafico, que cayeron de la posicion 4 a la posicion 16, y los trastornos congenitos, de la 17 a la 35; por el contrario, los trastornos orales aumentaron, pasando del puesto 25 al 17. En general, fumar es, con mucho, el factor de riesgo mas relevante en Espana, seguido de presion arterial alta, indice de masa corporal alto, consumo de alcohol y glucemia alta en ayunas. Finalmente, Espana obtuvo 74,3 sobre 100 puntos en la clasificacion del indice ODS en 2016, y los principales determinantes de salud nacionales relacionados con los ODS fueron el consumo de alcohol, el tabaquismo y la obesidad infantil. Se proyecta un aumento a 80,3 puntos en 2030. Conclusion Los dolores de espalda y cervical fueron el contribuyente mas importante de discapacidad en Espana en 2016. Hubo un aumento notable de la carga poblacional debida a la enfermedad de Alzheimer y otras demencias. El tabaco sigue siendo el riesgo para la salud mas importante que debe abordarse en Espana.

Stefanos Tyrovolas

Papers

La carga de enfermedad en España: resultados del Estudio de la Carga Global de las Enfermedades 2016

Relationship Quality Scale