S obzirom na sve stariju populaciju pacijenata sa završnim stupnjem kronične bubrežne bolesti, a kako bi se na Listu čekanja uvrstilo što više pacijenata za presađivanje bubrega, potrebna je ...temeljitija i opširna obrada potencijalnih primatelja bubrežnog presatka. Nakon dijagnostičkih postupaka trebalo bi pokušati sa svim dostupnim terapijskim mogućnostima otklanjanja kontraindikacija. Nakon uvrštavanja na Listu čekanja, potencijalne primatelje potrebno je dalje pratiti i isključiti moguće kontraindikacije. U prilog ovome ide činjenica da je posljednjih godina sve manji broj apsolutnih kontraindikacija za presađivanje bubrega. Jednako važna je temeljita obrada potencijalnog darivatelja bubrežnog presatka jer omogućuje i olakšava samu odluku o presađivanju bubrega, kao i pripremu potencijalnog primatelja bubrega za operativni zahvat, odabir imunosupresivne terapije te daljnje postupke prije i nakon presađivanja bubrega. Cilj je što više pacijenata uvrstiti na Listu čekanja prije početka liječenja dijalizom (preemptivno presađivanje bubrega) te omogućiti presađivanje od živog darivatelja, jer dosadašnja istraživanja pokazuju kako se tada postižu najbolji rezultati.
Considering the growing number of elderly patients with end-stage renal disease, and the simultaneous goal of including as many patients on the waiting list for kidney transplantation, potential kidney transplant recipients should undergo a rigorous selection and evaluation. For the same reason, after diagnostic procedures, we have to try all available therapeutic possibilities to eliminate contraindications. After putting patients on the waiting list, it is necessary to further monitor potential recipients and to treat all contraindications. The supporting fact is the declining number of absolute contraindications for kidney transplantation over the past few years. Equally the extensive evaluation of a potential kidney transplant donor is important because it enables easier decision about kidney transplantation, as well as the preparation of a potential kidney recipient for surgery, selection of immunosuppressive therapy and further procedures before and after the kidney transplantation. The goal is to place as many patients as possible on the wthe aiting list before starting dialysis treatment (preemptive kidney transplantation) and to enable living donor transplant, because existing research shows that the best results are achieved then.
Background/Aims: Renal transplant recipients (RTRs) are at high risk for cardiovascular (CVD) mortality. Recently, nonalcoholic fatty liver disease (NAFLD) has been recognized as a new risk factor ...for adverse CVD events in the general population. We examined whether transient elastography (TE) defined NAFLD was associated with atherosclerosis in RTRs, as measured by ultrasound in the carotid arteries. Methods: Carotid atherosclerosis was assesses in 71 RTRs with a TE proven NAFLD. With the help of TE liver stiffness was used to assess liver fibrosis and Controlled Attenuation Parameter (CAP) was used to detect and quantify liver steatosis. NAFLD was defined by the presence of steatosis with CAP values ≥238 dB.m-1. Results: RTRs with NAFLD showed more carotid atherosclerosis than RTRs without NAFLD. RTRs-NAFLD patients had the mean intima-media measurements (ITM) of 1.1±0.1 mm and that was statistically significant higher than the mean ITM founded in RTRs without NAFLD (1.1±0.1 vs. 0.9±0.1 mm; p<0.0001). Furthermore, RTRs-NAFLD patients had statistically significant higher prevalence of plaques in comparison with RTRs without NAFLD (p=0.021). Conclusion: We showed for the first time that carotid atherosclerosis is advanced in RTRs with NAFLD. Detection of NAFLD by TE should alert to the existence of an increased cardiovascular risk in RTRs.
The role of renin-angiotensin system inhibitors (ACE-inhibitors) or angiotensin receptor blockers (ARB) in the renal transplant recipients (RTRs) is incompletely defined and according to the current ...guidelines they should be initiated after six months post-transplantation. The aim of the present paper is to evaluate the efficiency and safety of early (within six months post-transplantation) versus late (after six months post-transplantation) initiation of ACE-inhibitors or ARB in RTRs. The study group compromised of 108 RTRs (50 male and 58 female) who received a kidney transplant. Beside other prescribed antihypertensive drugs all of them took and ACE inhibitors or ARB in order to achieve blood pressure control. For this analysis purpose, recipients were stratified into two groups according to the time of ACE inhibitors/ARB initiation into early (within six months post-transplantation) and late (after six months after transplantation) group. For each patient haemoglobin, serum creatinine and potassium levels were analyzed at the beginning of ACE inhibitors/ARB introduction and at the end of the first, third, sixth and twelfth month. In the 54 (50%) of the 108 patients ACE inhibitors/ARB were initiated within six months post-transplantation and in 49 (90.7%) of them within three months (in 29 patients within one month; in 13 within two months; in 7 within 3 months) post-transplantation. In additional 54 (50%) patients ACE inhibitors/ARB were initiated, but after six months post-transplantation. There was no statistically significant difference between the two groups related to age or gender and due to the duration of dialysis treatment before the transplantation. Analyzing the haemoglobin, creatinine and potassium serum levels after initiation of therapy with ACE inhibitors/ARB trough observed period we did not found any statistically significant difference in all measured parameters between the two groups of patients and also within the same group of patients. Therefore, according to experience from our Institution early initiation of ACE inhibitors or ARB appears to be safe in carefully selected recipients with relatively good early graft function.
Severe malaria is a medical emergency that requires urgent recognition and treatment, because it may rapidly progress to serious complications and death. We report a case of imported severe malaria ...tropica in an adult traveller, with a parasitemia of 20%, complicated by acute renal failure. Patient was initially misdiagnosed by a physician unaware of the importance of patients travel history, as having a viral infection. Despite the treatment delay, the patient was successfully cured with parenteral artemether combined with peroral mefloquine and vigorous supportive measures including renal replacement therapy.
Uspješna transplantacija bubrega je optimalna metoda liječenja bolesnika koji se nalaze u završnom stadiju kronične bubrežne bolesti. Za uspjeh same transplantacije, kao i dugoročnog preživljenja ...bolesnika i njegovog transplantata, nužna je detaljna evaluacija primatelja i potencijalnog darivatelja organa, bilo da se radi o kadaveričnom ili živom darivatelju. Poseban problem u sklopu infektivnih bolesti su virusi hepatitisa, osobito virus hepatitisa B (HBV) i C (HCV), a u novije vrijeme sve se više spominje i virus hepatitisa E (HEV) kao značajan uzrok kroničnog hepatitisa u populaciji bolesnika s transplantatom. Unatoč poboljšanju preventivnih mjera posljednjeg desetljeća incidencija virusnih hepatitisa je u bolesnika koji se liječe postupcima hemodijalize značajno smanjena. Međutim, njihova incidencija i dalje je veća u toj skupini bolesnika kao i u bolesnika kojima je transplantiran bubreg u odnosu na opću populaciju. Virusni hepatitisi su značajan čimbenik povećanog morbiditeta i mortaliteta u tim populacijama bolesnika, ali i prema većini studija značajan čimbenik disfunkcije bubrežnog transplantata. Naime, u bolesnika koji su podvrgnuti transplantaciji bubrega primarni cilj je očuvanje dobre funkcije transplantata, uz primjenu učinkovite, a što manje toksične imunosupresivne terapije. Osim toga, nužno je praćenje i adekvatna terapija virusnih hepatitisa, s obzirom na dobro poznatu činjenicu da te infekcije vode prema kroničnom hepatitisu, cirozi jetre i hepatocelularnom karcinomu. Nadalje, HBV i HCV mogu inducirati nastanak de novo membranskog glomerulonefritisa u bubrežnom transplantatu.
In the past decade, in most regions of the world, an increasing number of adults aged 65 years and older were started on renal replacement therapy each year. In contrast to the general population for ...whom overnutrition or obesity is associated with increased cardiovascular risk, for patients who are maintained on hemodialysis (HD), malnutrition and malnutrition-inflammation complex syndrome are associated with poor outcome. In recent years, nonalcoholic fatty liver disease (NAFLD) has been considered to be the liver manifestation of metabolic syndrome, and the development of NAFLD is strongly associated with all components of metabolic syndrome (arterial hypertension, dyslipidemia, obesity, and diabetes mellitus type 2) in the general population. The primary end point of this study was to determine the patient's survival in relation to nutritional and inflammatory state and the presence or absence of NAFLD. The secondary end point of this analysis was the association among NAFLD and various clinical and laboratory data, with the nutritional and inflammatory state of our elderly HD patients.
Using a single-center, prospective, cohort study design, we followed the progress of 76 patients who were ≥ 65 years and treated with chronic HD for at least 6 months, at the Department of Nephrology, Dialysis and Transplantation. All patients were followed for a minimum of 18 months or until death. Survival was defined as the time from study initiation to death (or end of study, if still alive).
The main findings of our study were a remarkable positive correlation between NAFLD and high-sensitivity C-reactive protein (hs-CRP) (r=0.659; P<0.0001) and consequent negative correlation with the nutritional parameter, serum albumin (r=-0.321; P=0.004). Interestingly, we showed that in contrast to the general population, where NAFLD is associated with obesity, in the present study, there was no statistically significant association between NAFLD and overnutrition in elderly HD patients. Furthermore, the presence of NAFLD, low serum albumin levels, and high hs-CRP were strong predictors of poor outcome in our elderly HD patients.
Our results indicated that NAFLD probably interplays between inflammation, malnutrition, and atherosclerosis in elderly HD patients. NAFLD could be a new factor that contributes to type 2 malnutrition in elderly HD patients, who may be amenable to adequate nutritional and HD support.
Unatoč značajnom napretku u terapijskom smislu, akutno bubrežno zatajenje (ABZ) i
dalje je praćeno visokim morbiditetom i mortalitetom. Jedan od glavnih razloga kasna je detekcija
i odgođena ...inicijalna terapija.
Prikazani su noviji biomarkeri koji bi mogli pomoći u ranijem postavljanju dijagnoze ABZ.
Među njima najviše obećava neutrophil gelatinase-associated lipocalin (NGAL). Prikazana je
uloga i mjerenje NGAL-a u različitim kliničkim stanjima koja dovode do ABZ. U budućim kliničkim
istraživanjima potrebno je na velikom broju uzoraka ispitati senzitivnost i specifičnost mjerenja
koncentracije NGAL-a, a i drugih biomarkera.
Uspješna transplantacija je metoda izbora u liječenju pacijenata koji se nalaze u završnom stadiju kronične bubrežne bolesti, odnosno terminalne bolesti (akutne ili kronične) jetre, srca ili pluća. ...Uvođenje novih, potentnijih imunosupresivnih lijekova značajno je smanjilo učestalost kriza odbacivanja presađenog organa. Unatoč značajnom napretku transplantacijske medicine, dugoročno preživljavanje pacijenata s presađenim organom i dalje je značajno niže u odnosu na opću populaciju. Navedeno je posljedica povećane incidencije kardiovaskularnih bolesti u ovoj populaciji pacijenata, koje su i glavni uzrok povećanog mortaliteta. Pojava tradicionalnih čimbenika rizika za razvoj kardiovaskularnih bolesti, odnosno komponenti metaboličkog sindroma (arterijska hipertenzija, novonastala šećerna bolest ili pogoršanje od ranije poznate šećerne bolesti, pretilosti te poremećaj metabolizma masnoća) učestaliji su u pacijenata koji su podvrgnuti transplantaciji solidnih organa nego u općoj populaciji. Posljedica su primijenjene imunosupresivne terapije. U prvom redu nužne su redovite i stalne provjere zdravstvenog stanja pacijenata koji su podvrgnuti transplantaciji solidnih organa. Uz kontrolu laboratorijskih parametara funkcije presatka, vrlo je važna kontrola krvnog tlaka, metabolizma glukoze i masnoća sa svrhom sprječavanja razvoja kardiovaskularnih bolesti, poboljšanja funkcije presatka i kvalitete života te smanjenja mortaliteta ove populacije pacijenata.
Renal transplantation has significantly improved survival of patients with end-stage renal disease (ESRD). Transplantation is the best treatment in this population of patients. Despite the ...introduction of various preventive measures, viral hepatitis, i.e. hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, are still a major problem because they are common in patients on renal replacement therapy as well as in allograft recipients. They are a significant cause of morbidity and mortality in this patient population. In recent years, hepatitis E virus (HEV) infection has been added as an emergent cause of chronic hepatitis in solid organ transplantation, mainly in renal and liver allograft recipients. Most studies show higher mortality in renal transplant recipients (RTRs) infected with HBV, compared with RTRs without HBV infection, although this topic is still under debate. Furthermore, HCV infection in RTRs is associated with a significant reduction in patient and graft survival due to liver disease and septic complications related to cirrhosis and immunosuppressive therapy. The immunosuppressive therapy prescribed after transplantation modifies the natural history of chronic HCV infection. Given the high prevalence of HCV and HBV infections in RTRs, a growing incidence of hepatocellular carcinoma and the possible contribution of immunosuppression might be expected in these patients. Therefore, after renal transplantation, early screening with abdominal ultrasound (every 3 months in cirrhotic patients and every 6-12 months in non-cirrhotic RTRs) is necessary when the risk factors such as HBV and HCV are present. The European Association for the Study of the Liver (EASL) recommends that all HbsAg-positive patients who are candidates for solid organ transplantation should be treated with nucleoside analogs. The KDIGO guidelines recommend that all HbsAg-positive RTRs receive prophylaxis with tenofovir, entecavir or lamivudine; however, tenofovir and entecavir are preferable to lamivudin. Viral suppression by inhibiting necro-inflammation may result in reduced fibrosis, thereby improving transplant survival. Active HCV infection in a dialysis patient requires evaluation of liver fibrosis. Antiviral therapy should be given to all HCV-infected dialysis patients in order to achieve a sustained virologic response (SVR) not only to avoid subsequent hepatic deterioration but also to limit the risks of HCV-related posttransplant de novo glomerulonephritis. Systematic vaccination of all HbsAg-negative patients is the best preventive treatment of HBV infection. HbsAg positive donors are only used occasionally, whereas the use of hepatitis B core antibody (HbcAb)+, HbsAg negative donors is more common but remains somewhat controversial. The presence of antibody to HCV is indicative of HCV infection because antibody to HCV appears in peripheral blood within two months of HCV exposure. However, it is important to emphasize that detection of antibody to HCV by serologic screening of the donor is not predictive of HCV transmission. Approximately 50% of patients positive for antibody to HCV have detectable hepatitis C viremia by PCR analysis of peripheral blood. Therefore, all organ donors with PCR analysis positive for HCV will transmit HCV to RTRs. On the other hand, the risk of transmission from an organ donor with negative PCR analysis is unclear. Another problem in the evaluation of the potential donors of solid organs is the fact that antibody testing by enzyme-linked immunosorbent assays (ELISAs) will not detect recent infections. The use of nucleid acid testing (NAT) could be useful because it involves amplification of viral gene products and thus is not dependent on antibody formation. Therefore, by using this method the period between the infection and detectability, which is known as the window period, could be reduced. However, this method is expensive and time consuming.
The number of elderly patients with chronic kidney disease (CKD) stage 5 management with hemodialysis (HD) is steadily increasing. Therefore we analyzed the number of new CKD patients ≥80 years ...managed with HD and their survival through the study period. We aimed also, to identify which of several key variables might be independently associated with survival in this very elderly population of patients.
This was a single-center, retrospective cohort study that took place during the period from January 1987 to September 2012. The study consisted of 78 (50 male and 28 women) very elderly patients (≥80 years of age); the mean age at which HD was initiated was 83.2±2.5 years. Survival and factors associated with mortality were studied. Survival was defined as the time from start of HD treatment to death (or end of study, if still alive).
In the period from 1987 to 2002, patients ≥80 years of age were only sporadically treated with HD, but since 2003, the number of new patients has been steadily increasing. The mean survival for our group of patients was 25.1±22.4 months (range 1-115 months). Furthermore, 30.8% patients survived <12 months, 29.5% patients survived 12-24 months, 30.8% patients survived 24-60 months, and 9% patients survived >60 months on HD treatment. Older patients were less likely to have diabetes, and primary renal disease did not influence survival. Patients with high C-reactive protein levels and poor nutritional status, as well as those who did not have pre-HD nephrology care and those that had a catheter as vascular access for HD had poor survival. In about half of our patients, the cause of death was cardiovascular disease.
Among patients who were ≥80 years of age at the start of HD treatment, those who received pre-HD nephrology care that followed a planned management pathway, those who had a good nutritional status, and those with an arteriovenous fistula as vascular access for HD at the time of HD initiation had a better survival.
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