Influenza A (H1N1) in nephrology patients. The pandemic disease that has put us on guard
La gripe A (H1N1) en el paciente nefrológico. La pandemia que nos ha puesto en guardia
Alberto Martínez Castelaoa, J.. Carratalàa, X.. Fulladosa Oliverasa, G.. Fernández Fresnedob, J.L.. Górrizc, J.M.. Portolésd, C.. Queredae, R.. Sánchez Hernándezf
a Hospital Universitario de Bellvitge. IDIBELL, L¿Hospitalet de Llobregat, Barcelona, España,
b Hospital Universitario Valdecilla, Santander, España,
c Hospital Universitario Dr. Peset, Valencia, Valencia, España,
d Fundación Hospital de Alcorcón, Madrid, Madrid, España,
e Hospital Universitario Ramón y Cajal, Madrid, Madrid, España,
f Hospital General de Segovia, Segovia, España,
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IDIBELL, L¿Hospitalet de Llobregat, Barcelona, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => " Hospital Universitario Valdecilla, Santander, España, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => " Hospital Universitario Dr. Peset, Valencia, Valencia, España, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => " Fundación Hospital de Alcorcón, Madrid, Madrid, España, " "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] 4 => array:3 [ "entidad" => " Hospital Universitario Ramón y Cajal, Madrid, Madrid, España, " "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] 5 => array:3 [ "entidad" => " Hospital General de Segovia, Segovia, España, " "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "afff" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La gripe A (H1N1) en el paciente nefrológico. La pandemia que nos ha puesto en guardia" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION. JUSTIFICATION TO ACTION GUIDELINES</span></p><p class="elsevierStylePara">The influenza A virus (H1N1) is a new influenza virus resulting from the association of RNA segments of swine, avian and human influenza viruses. Its transmission capacity is high but its virulence is low for people with no associated diseases.</p><p class="elsevierStylePara">The virus transmits through the air (large-particle droplet > 5μm) and it can survive on inert surfaces for 10 hours. It usually causes a mild influenza-like syndrome, with rapidonset high fever (usually > 38º C) with shivers, general discomfort, intense asthenia and myalgia, and headache, as well as respiratory tract illness with dry cough. Odynophagia, rhinorrhoea, and nasal congestion are usually less intense than in seasonal influenza. Digestive symptoms may add up, such as nausea, vomiting and diarrhoea. The process requires symptomatic treatment and it may resolve spontaneously. Provided there are no complications, these symptoms usually last from 4 to 7 days.</p><p class="elsevierStylePara">The incubation period is usually 7 days and its onset should be suspected when fever > 38° C and signs or symptoms of acute respiratory infection appear, non-filiated pneumonia (acute respiratory infection) or when the affected patient has died due to acute respiratory disease of unknown origin. Patients with signs or symptoms of acute respiratory infection meet the criterion for hospital admission.<span class="elsevierStyleSup">1-5</span></p><p class="elsevierStylePara">Action guidelines for influenza A caused by H1N1 virus<span class="elsevierStyleSup">5</span> are justified by the combination of inter-dependant risk factors dependent on the influenza A virus and patients. Among the factors dependent on the virus, it should be highlighted an expected high incidence of influenza A, 30-40% in the general population, high transmission and potentially fatal evolution, in cases of associated co-morbidity. Among the factors dependent on patients, it should be highlighted the inclusion of patients with chronic kidney disease (CKD) in the risk groups and their high rate of hospitalisation.<span class="elsevierStyleSup">3-5</span></p><p class="elsevierStylePara">Some groups of experts are studying the hypothesis of a final accumulated incidence of 30%.<span class="elsevierStyleSup">6</span> Up to 2% of the cases are severe. The majority of cases occur in young adults aged between 20-45 years and between 30 and 50% in previously healthy persons; the rest occur in patients with added comorbidity.</p><p class="elsevierStylePara">Dialysis patients with CKD-5 present a high added comorbidity rate (diabetes mellitus 21%, AHTN 90%, obesity 15%), and a high hospitalisation rate as well. Frequent interaction with health staff during care that requires proximity to patients justifies special attention to isolation and staff protective measures.</p><p class="elsevierStylePara">In June 2009 WHO increased alert level to phase 6 for global pandemic influenza A (H1N1) due to evidence of its spreading growth in five continents. As of 29 September, 2009, 318,925 people had been infected all over the world, with 3,917 deaths. Hospitalisation rate varies from 7.8% in Chile up to 21.71% in New Zealand. The media may have exaggerated the danger of this pandemic disease in many cases,<span class="elsevierStyleSup">7</span> but it is also true that from the health care area we have to adopt measures to plan an adequate assistance to the affected population in order to avoid the collapse of primary care and hospital emergency centres.<span class="elsevierStyleSup">1-5</span></p><p class="elsevierStylePara">Risk groups to host the H1N1 virus include patients with moderate to acute CKD, patients with chronic heart disease (excluding AHTN), diabetics undergoing treatment, and patients under immunosuppression (kidney transplanted or with kidney condition requiring immunosuppression).</p><p class="elsevierStylePara">For these reasons and despite the proliferation of documents from health departments at various Spanish Autonomous Regions or even from multinational departments regulating dialysis centres, the SEN considered necessary to clarify and unify criteria, facing the numerous requests received in this sense from various nephrology services and dialysis units in Spain.</p><p class="elsevierStylePara">For those who may want to consult it, this document is available at www.senefro.org.<span class="elsevierStyleSup">5</span> We summarise its main indications as follows:</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DEFINITIONS. LABORATORY SAMPLE COLLECTION AND DIAGNOSIS</span></p><p class="elsevierStylePara">In its introduction the document takes up the definitions of epidemic and pandemic, as well as the definitions of influenza A H1N1 and acuteness degree criteria by which the patients have to be hospitalised.</p><p class="elsevierStylePara">Special emphasis is set on sample collection to confirm diagnosis (naso-pharyngeal exudates, whole blood with or without EDTA).</p><p class="elsevierStylePara"><span class="elsevierStyleBold">LABORATORY DIAGNOSIS</span></p><p class="elsevierStylePara">At least one of the following tests with positive results is required:</p><p class="elsevierStylePara">1. New influenza A (H1N1) virus RT-PCR detection, realtime polymerase chain reaction. It is the most affordable test; its result can be ready in less than 24 hours.</p><p class="elsevierStylePara">2. Increase by four times the titre of neutralising antibodies with respect to the new influenza A virus/H1N1 (this requires two types of saline solution, one from the acute phase of the disease and the other from the convalescent phase, 10 to 14 days subsequently).</p><p class="elsevierStylePara">3. Virus culture of new influenza A virus (H1N1).</p><p class="elsevierStylePara"><span class="elsevierStyleBold">PREVENTION AND INTERVENTION MEASURES. PERITONEAL HAEMODIALYSIS AND DIALYSIS</span></p><p class="elsevierStylePara">In relation to the patient on haemodialysis a series of prevention and intervention measures are established. Since the main transmission route is through respiratory secretions, general hygienic measures are specified: hand-washing with soap or alcohol solutions, surgical mask-wearing, surfacecleaning (where the virus can live for hours at room temperature), etc.</p><p class="elsevierStylePara">Instructions are provided to take advantage of the data obtained by telephone consultation, as well as the criteria for patient referral to emergency wards in cases considered complicated or at risk of becoming severe.</p><p class="elsevierStylePara">Taking into account the high transmission rate, measures that can be useful for transport of patients are taken, and also recommendations for health staff in close contact with the patients.</p><p class="elsevierStylePara">A standard is set to adopt prevention measures in haemodialysis units and on how to implement personal protection measures: respiratory isolation (use of mask, gloves, white coat, etc.), cleaning of monitors, dialysis ward, and rooms. Likewise, environmental control measures are established.</p><p class="elsevierStylePara">Regarding peritoneal dialysis the measures applied will be the same as for haemodialysis, insisting specially in instructing the patient so that they detect themselves possible signs of alarm or severe risk.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">PREVENTION MEASURES BY IMMUNISATION</span></p><p class="elsevierStylePara">The Health Ministry regulation is already available, and from 16 November there are two vaccines with adjuvant Pandemrics (GSK) and Focetria (Novartis). In the groups considered at risk, such as kidney patient or receiving inmunosuppression is recommended for vaccination of seasonal ainfluenza and then, one dose of vaccine virusspecific H1N1.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ANNEXES</span></p><p class="elsevierStylePara">The document has 4 annexes associated to it that make reference to: 1) definitions of suspicious case, probability or confirmation of influenza A H1N1; 2) personal protection equipments; 3) signs and symptoms of severity and hospital admission criteria, and 4) specially set aside, an addition with explicit reference to antiviral treatment in patients with impaired renal function.</p><p class="elsevierStylePara">The board of experts calls special attention to this respect, as Oseltamivir, a neuraminidase inhibitor, is eliminated by the kidneys,<span class="elsevierStyleSup">8-10</span> which is why its doses in patients with reduced glomerular filtration have to be corrected. Precisely for this reason we believe it is especially important to consult this document to dispel doubts, as there are only two reports in the literature<span class="elsevierStyleSup">9,10</span> with studies in pharmacokinetics of Oseltamivir in the renal patient undergoing peritoneal haemodialysis or dialysis.</p><p class="elsevierStylePara">We also make a warning in relation to dealing with influenza A H1N1 in the organ donor for transplant and in the solid organ transplantpatient, with the corresponding reference to the document issued by the board of experts of the ONT (Spanish national transplant organisation) of the Ministry of Health, where members representing the S.E.N. were also present.<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara">The experience of all nephrologists and people caring for nephrology patients is highly important for us to deal with an issue that we consider a key aspect.</p><p class="elsevierStylePara">We have to record our own experience if we want to confirm the facts. We know this may entail an overload to the already overwhelming task of daily endeavour. In spite of this fact, we encourage everyone to record all confirmed cases, by means of a simple file, that is also shown in the document at www.senefro.org and that will easily be filled out online.</p><p class="elsevierStylePara">Knowledge about the disease, epidemiological data, and definitions may all rapidly change; for this reason the action guidelines will be updated whenever new data makes it worthwhile. The measures may change when the seasonal influenza overlaps pandemic influenza A, next autumn and winter.</p><p class="elsevierStylePara">As usual, we thank everyone for their generous and essential effort and collaboration. </p>" "pdfFichero" => "P-E-S-A436-EN.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Información sobre la gripe A (H1N1). Ministerio de Sanidad y Política Social. España. http://www.msc.es/servCiudadanos/alertas/gripe-AH1N1.htm" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Información sobre la gripe A (H1N1). 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Ministerio de Sanidad y Política Social. http://www.ont.es" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000002900000006/v0_201502091611/X2013251409033677/v0_201502091611/en/main.assets" "Apartado" => array:4 [ "identificador" => "35429" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorials" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000002900000006/v0_201502091611/X2013251409033677/v0_201502091611/en/P-E-S-A436-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251409033677?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 9 | 13 |
| 2024 October | 53 | 27 | 80 |
| 2024 September | 45 | 39 | 84 |
| 2024 August | 55 | 57 | 112 |
| 2024 July | 40 | 25 | 65 |
| 2024 June | 53 | 39 | 92 |
| 2024 May | 54 | 26 | 80 |
| 2024 April | 51 | 24 | 75 |
| 2024 March | 32 | 25 | 57 |
| 2024 February | 42 | 34 | 76 |
| 2024 January | 26 | 26 | 52 |
| 2023 December | 20 | 26 | 46 |
| 2023 November | 40 | 30 | 70 |
| 2023 October | 39 | 33 | 72 |
| 2023 September | 31 | 30 | 61 |
| 2023 August | 39 | 30 | 69 |
| 2023 July | 34 | 29 | 63 |
| 2023 June | 31 | 15 | 46 |
| 2023 May | 53 | 37 | 90 |
| 2023 April | 19 | 13 | 32 |
| 2023 March | 30 | 21 | 51 |
| 2023 February | 23 | 23 | 46 |
| 2023 January | 32 | 37 | 69 |
| 2022 December | 34 | 34 | 68 |
| 2022 November | 29 | 29 | 58 |
| 2022 October | 25 | 41 | 66 |
| 2022 September | 38 | 33 | 71 |
| 2022 August | 37 | 40 | 77 |
| 2022 July | 28 | 33 | 61 |
| 2022 June | 26 | 20 | 46 |
| 2022 May | 33 | 28 | 61 |
| 2022 April | 45 | 28 | 73 |
| 2022 March | 33 | 37 | 70 |
| 2022 February | 40 | 40 | 80 |
| 2022 January | 47 | 24 | 71 |
| 2021 December | 39 | 34 | 73 |
| 2021 November | 37 | 37 | 74 |
| 2021 October | 65 | 50 | 115 |
| 2021 September | 50 | 30 | 80 |
| 2021 August | 34 | 26 | 60 |
| 2021 July | 33 | 32 | 65 |
| 2021 June | 20 | 23 | 43 |
| 2021 May | 28 | 25 | 53 |
| 2021 April | 97 | 31 | 128 |
| 2021 March | 46 | 22 | 68 |
| 2021 February | 51 | 14 | 65 |
| 2021 January | 37 | 16 | 53 |
| 2020 December | 30 | 10 | 40 |
| 2020 November | 30 | 4 | 34 |
| 2020 October | 22 | 9 | 31 |
| 2020 September | 23 | 6 | 29 |
| 2020 August | 51 | 6 | 57 |
| 2020 July | 51 | 7 | 58 |
| 2020 June | 55 | 11 | 66 |
| 2020 May | 59 | 9 | 68 |
| 2020 April | 77 | 25 | 102 |
| 2020 March | 103 | 8 | 111 |
| 2020 February | 49 | 18 | 67 |
| 2020 January | 70 | 18 | 88 |
| 2019 December | 54 | 14 | 68 |
| 2019 November | 38 | 11 | 49 |
| 2019 October | 15 | 7 | 22 |
| 2019 September | 20 | 12 | 32 |
| 2019 August | 20 | 10 | 30 |
| 2019 July | 22 | 16 | 38 |
| 2019 June | 20 | 13 | 33 |
| 2019 May | 18 | 15 | 33 |
| 2019 April | 49 | 28 | 77 |
| 2019 March | 16 | 16 | 32 |
| 2019 February | 17 | 11 | 28 |
| 2019 January | 21 | 14 | 35 |
| 2018 December | 68 | 27 | 95 |
| 2018 November | 105 | 15 | 120 |
| 2018 October | 126 | 16 | 142 |
| 2018 September | 79 | 16 | 95 |
| 2018 August | 41 | 13 | 54 |
| 2018 July | 58 | 21 | 79 |
| 2018 June | 58 | 17 | 75 |
| 2018 May | 67 | 11 | 78 |
| 2018 April | 49 | 9 | 58 |
| 2018 March | 41 | 4 | 45 |
| 2018 February | 24 | 8 | 32 |
| 2018 January | 19 | 2 | 21 |
| 2017 December | 34 | 12 | 46 |
| 2017 November | 14 | 6 | 20 |
| 2017 October | 27 | 5 | 32 |
| 2017 September | 20 | 10 | 30 |
| 2017 August | 20 | 8 | 28 |
| 2017 July | 16 | 10 | 26 |
| 2017 June | 24 | 13 | 37 |
| 2017 May | 29 | 13 | 42 |
| 2017 April | 23 | 8 | 31 |
| 2017 March | 13 | 3 | 16 |
| 2017 February | 27 | 6 | 33 |
| 2017 January | 21 | 10 | 31 |
| 2016 December | 63 | 9 | 72 |
| 2016 November | 65 | 5 | 70 |
| 2016 October | 73 | 8 | 81 |
| 2016 September | 132 | 2 | 134 |
| 2016 August | 210 | 8 | 218 |
| 2016 July | 154 | 5 | 159 |
| 2016 June | 116 | 0 | 116 |
| 2016 May | 140 | 0 | 140 |
| 2016 April | 98 | 0 | 98 |
| 2016 March | 54 | 0 | 54 |
| 2016 February | 59 | 0 | 59 |
| 2016 January | 71 | 0 | 71 |
| 2015 December | 81 | 0 | 81 |
| 2015 November | 85 | 0 | 85 |
| 2015 October | 71 | 0 | 71 |
| 2015 September | 61 | 0 | 61 |
| 2015 August | 46 | 0 | 46 |
| 2015 July | 59 | 0 | 59 |
| 2015 June | 30 | 0 | 30 |
| 2015 May | 33 | 0 | 33 |
| 2015 April | 5 | 0 | 5 |
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