Prevalencija arterijske hipertenzije vrlo je velika u bolesnika s kroničnom bubrežnom bolesti (KBB), ovisno o stadiju KBB-a, između 60% i 90%. Postoji međusobna povezanost KBB-a i arterijske ...hipertenzije. KBB je često uzrok povišenoga arterijskog tlaka, a s druge strane, arterijska hipertenzija je među najčešćim uzrocima bubrežnog oštećenja, tj. KBB-a. Neregulirana arterijska hipertenzija značajno pridonosi ubrzanom pogoršanju bubrežne funkcije te kardiovaskularnom morbiditetu i mortalitetu. U većine bolesnika, uz nefarmakološke mjere,
neophodno je liječenje kombinacijom antihipertenziva. Ne postoji konsenzus o optimalnim vrijednostima arterijskog tlaka u KBB-u. U radu se kratko opisuje važnost pravilne dijagnoze arterijske hipertenzije, mogućnosti liječenja te se raspravlja o novim ciljnim vrijednostima arterijskog tlaka u KBB-u.
Anti-glomerular basement membrane (anti-GBM) disease is an acute and life-threatening systemic autoimmune disorder. The coexistence of circulating anti-neutrophil cytoplasmic antibodies (ANCA) and ...anti-GBM disease, the so-called double-positive disease (DPD), is exceptionally rare. We report a unique case of DPD manifesting as pulmonary-renal syndrome (PRS) in a 46-year-old woman who first presented with clinical and radiological suspicion of pneumonia. Chest computed tomography scan later revealed bilateral alveolar hemorrhage. Kidney biopsy showed necrotizing crescentic (100% glomeruli) glomerulonephritis. On immunofluorescence microscopy, glomeruli were global linear positive for IgG, confirming anti-GBM disease. Double positivity was detected for circulating anti-myeloperoxidase ANCA (p-ANCA) and anti-GBM antibodies. Acute renal failure evolved rapidly. Therapeutic plasma exchange (TPE) and hemodialysis (HD) were initiated early in combination with intravenous pulse corticosteroid therapy followed by oral methylprednisolone and cyclophosphamide. Pulmonary hemorrhage resolved, but renal function could not be preserved. The patient remains HD dependent. This case report highlights that pulmonary symptomatology may be the leading clinical presentation of PRS, with initially normal renal function at DPD onset. Early recognition and diagnosis are therefore crucial to timely clinical intervention. The role of prompt kidney biopsy and initiation of TPE and HD in PRS must not be underestimated.
Bolesti paratireoidnih žlijezda često dovode do oštećenja bubrega poput primarnog hiperparatireoidizma ili se javljaju kao posljedica insuficijencije bubrega u sekundarnom i tercijarnom ...hiperparatireoidizmu. Bolesnici razvijaju hiperkalcemiju s povišenom razinom PTH, a većina ima smanjenu mineralnu gustoću kostiju uz deformitete, bolove i sklonost prijelomima, ali i oštećenje bubrežne funkcije, nefrokalcinozu ili nefrolitijazu uz opstruktivnu uropatiju. Cilj izvješća je predstaviti nuklearno-medicinske metode u dijagnostici i liječenju bolesnika s poremećajima paratireoidnih žlijezda. Najčešće korištene slikovne metode u dijagnostici jesu ultrazvuk visoke rezolucije s obojenim doplerom, zatim SPECT/CT scintigrafija u kombinaciji s kompjutoriziranom tomografijom s tehnecij-99m sestamibijem (Tc-99m-MIBI), te po potrebi PET/CT s fluor 18-kolinom. Ultrazvuk može biti praćen ciljanom citološkom punkcijom, a iz punktata se može odrediti i razina PTH koji također služi za potvrdu dijagnoze u slučaju da citološka analiza ne pokaže pravo podrijetlo epitelnih stanica iz punktata. U odjelima nuklearne medicine određuju se i laboratorijski parametri, odnosno razina PTH u serumu, važna u praćenju bolesnika. Najčešće se koriste kombinacije nekoliko različitih slikovnih metoda za određivanje veličine, položaja i odnosa paratireoidnih žlijezdi s okolnim strukturama, a u radu su prezentirane glavne indikacije te prednosti i ograničenja svake od metoda uz slikovni materijal.
Cilj: Ispitati pojavnost znakova ishemijske periferne arterijske bolesti (PAB), ulkusa nogu (UN) i amputacija nogu (AN) u bolesnika liječenih kroničnom intermitentnom hemodijalizom (HD) te njihovu ...povezanost s drugim kliničkim i laboratorijskim parametrima. Metode: U presječno istraživanje, provedeno od siječnja do svibnja
2023. godine, uključeno je 329 bolesnika iz 5 HD centara. Osim anamneze, pregleda dokumentacije te kliničkog pregleda (posebice pulzacija), praćeni su i zadnji laboratorijski nalazi bolesnika određivani u rutinskoj kliničkoj praksi. Za ispitivanje neovisnih rizičnih čimbenika za UN te AN korištena je multivarijatna logistička regresija. Rezultati: Uključeno je 202 muškarca (61,4%), 119 bolesnika s dijabetesom (36,2%), medijana HD liječenja 40 mjeseci. PAB nogu imalo je 98 (27,8%) bolesnika, UN 42 (12,8%), a AN 40 (12,2%) bolesnika. UN bolesnici imali su češće PAB, dijabetes, ishemijsku srčanu bolest, češće su bili pušači, češće su imali odsutne ili oslabljene pulzacije na svim lokalizacijama nogu te češće amputacije i hipoalbuminemiju. AN bolesnici češće su imali PAB, dijabetes, ulkuse nogu, češće su bili pušači i imali odsutne ili oslabljene pulzacije na svim lokalizacijama nogu i hipoalbuminemiju te su bili značajno mlađi i viši. U multivarijatnoj logističkoj regresiji kao nezavisni čimbenici rizika za UN nađeni su: PAB, dijabetes, duži HD staž i hipoalbuminemija. Nezavisni rizični čimbenici za AN bili su: PAB, UN, dijabetes, pušenje, mlađa dob i hipoalbuminemija. Zaključak: učestalost znakova PAB-a veća je u HD bolesnika u usporedbi s općom populacijom, a dijabetes, pušenje i dužina liječenja HD-om dodatni su rizični čimbenici. Potrebna su prospektivna istraživanja te kliničko praćenje statusa nogu u ovih bolesnika radi sprječavanja komplikacija.
- This prospective study in prevalent dialysis patients investigated prognostic properties of low triiodothyronine syndrome, protein-energy wasting and chronic inflammation. Ninety-four prevalent ...dialysis patients were followed-up for a median of 39 months. Demographic, anthropometric and biochemical parameters were collected at baseline. Univariate and multivariate analysis was done using Cox regression analysis. ROC curve analysis using survival status as a classification variable was performed with the goal of determining optimal cut-off values for numerical variables. In our population, low total triiodothyronine (hazard ratio (HR) 2.19, p=0.038), catheter as vascular access (HR 2.76, p=0.023), higher vintage (HR 1.01, p=0.014) and higher Charlson comorbidity index (HR 1.28, p=0.017) were statistically significantly associated with inferior survival. In our group of steady-state dialysis patients, total triiodothyronine seemed to be the strongest predictor of inferior survival among thyroid hormones. Taking this parameter into account, it was possible to identify patients at an increased risk of death even after adjustment for other prognostically relevant variables. However, after further adjustment for significant risk factors, the impact of C-reactive protein and albumin on survival disappeared due to the overlapping prognostic properties. We concluded that triiodothyronine was an independent prognostic factor in our study group.
Control of serum phosphate is important for patients on hemodialysis. The aim of the study was to determine if education based on phosphorus-reducing techniques in food preparation and thermal ...processing, and accordingly prepared and applied diets, will lead to better outcomes than a standard education program to improve phosphate control in patients on hemodialysis.
Forty-seven patients on hemodialysis were divided between an intervention and a control group. All subjects received training about nutrition for hemodialysis patients by trained dietitian. In addition, subjects in the intervention group received additional training in phosphorus-reducing techniques in food preparation and received two hospital meals prepared using suggested cooking methods to reduce the phosphate content of food during dialysis treatment. Serum phosphate, serum albumin, and anthropometric parameters were measured, while nPCR was calculated, at the baseline and during the 1-year study.
No differences in serum phosphate levels were observed between intervention (1.68 mmol/L 1.48-2.03) and control group (1.88 mmol/L 1.57-2.2) at baseline (P = 0.130). Although not statistically significant between groups the mean reduction was more apparent in the intervention group (-0.3 mmol/L (-0.4 to 0.1) vs. -0.2 (-0.5 to 0.1)), and lead to significantly reduction of phosphate binder therapy. During the study, the nPCR and anthropometric status of the patients did not change significantly.
Providing additional education to hemodialysis patients on the specific cooking methods and accordingly prepared meals may decrease serum phosphate levels without significantly affecting nutritional status which may be useful in helping to prevent and treat hyperphosphatemia.
Cardiovascular disease is a well-known public health problem. In the last ten years nephrologists have recognized chronic kidney disease not only as a public health problem but also as one of the ...major cardiovascular risk factors. There are observational data that support the concept that vitamin D is involved in the pathogenesis of cardiovascular and renal disease or that at least vitamin D deficiency is a risk factor for these diseases. In this brief review epidemiological data will be presented and the biological mechanism of the vitamin D effect on cardiovascular and renal disease will be discussed.
Chronic kidney disease – mineral bone disease (CKD-MBD) is a syndrome
defined as a systemic mineral metabolic disorder associated with
CKD. The term renal osteodystrophy, as a part of CKD-MBD, ...indicates a
pathomorphological concept of bone lesions. High morbidity and mortality
of CKD patients is a consequence of CKD-MBD. The pathogenesis of this
syndrome is not completely understood, but undoubtedly the development of mineral and bone disorder begins in the earliest stages of CKD. The diagnosis is made by non-invasive methods (biochemistry, x-ray, ultrasound, etc.) and bone biopsy as an invasive method. In addition to new drugs, e.g. non-calcium phosphate binders, vitamin D analogs, calcimimetics, prevention and treatment is still a major challenge for the nephrologist. In this article we will briefly discuss the pathophysiology, diagnosis, prevention and treatment of CKD-MBD.
Summary
Cardiovascular disease is a well-known public health problem. In the last ten years nephrologists have recognized chronic kidney disease not only as a public health problem but also as one of ...the major cardiovascular risk factors. There are observational data that support the concept that vitamin D is involved in the pathogenesis of cardiovascular and renal disease or that at least vitamin D deficiency is a risk factor for these diseases. In this brief review epidemiological data will be presented and the biological mechanism of the vitamin D effect on cardiovascular and renal disease will be discussed.
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