Currently used diagnostic criteria in different endemic (Balkan) nephropathy (EN) centers involve different combinations of parameters, various cut-off values and many of them are not in agreement ...with proposed international guidelines. Leaders of EN centers began to address these problems at scientific meetings, and this paper is the outgrowth of those discussions. The main aim is to provide recommendations for clinical work on current knowledge and expertise. This document is developed for use by general physicians, nephrologists, urologist, public health experts and epidemiologist, and it is hoped that it will be adopted by responsible institutions in countries harboring EN. National medical providers should cover costs of screening and diagnostic procedures and treatment of EN patients with or without upper urothelial cancers.
Balkan endemic nephropathy (BEN) is chronic tubulointersticial nephritis of unknown aetiology characterized by an insidious onset and gradual progression to end stage renal disease (ESRD). Endemic ...regions of Bosnia and Herzegovina are Posavina and Semberija, sited at basin of Sava River. In BEN, just like in other chronic renal diseases (CKD), glomerular filtration rate (GFR), is assumed a marker of overall renal function. The aim of this study was to compare GFR in examinees of endemic and non-endemic region for BEN, and between examinees with and without risk factors for BEN within endemic region. Study included 603 inhabitants of Bosnian Posavina, out of whom 386 (65%) from endemic (Domaljevac) and 217 (36%) from non-endemic (Svilaj) village, and it was performed in two phases. The first phase encompassed obtaining anamnestic data (demographic, personal and family history), measurement of arterial blood pressure, and urine dipstick testing (specific gravity, pH, proteins, leukocytes, glucose, ketones, and microalbuminuria). In the second phase, besides repeated urine dipstick test, laboratory blood testing and abdominal ultrasound, with special attention to urinary tract, was also performed. We have compared GFR between examinees of endemic and non-endemic regions for BEN, and between examinees with and without family burden for BEN within endemic region, using MDRD formula for calculating GFR, with cut-off value (5th percentile) based on result of studies performed in European Caucasians in screening for CKD and for establishing stages of CKD in BEN. Medical was used for statistical testing. Out of total number of examined inhabitants (603), 145 examinees were included in the second phase. After exclusion of 17 diabetic patients, 94 (73%) examinees from endemic and 34 (27%) examinees from non-endemic region remained. In the endemic region there were 46 (49%) examinees with and 48 (51%) without family burden for BEN. Overall GFR in examined groups was within physiologic range. There was not statistically significant difference in calculated GFR between examinees of endemic and non-endemic regions for BEN (Mann-Whitney test p=0.104; Fisher's test p=1), neither between examinees with and without family burden for BEN within endemic region (Mann-Whitney test p=0,7393; Fisher's test p=0,263). Overall GFR in examined groups was within physiologic range. There wasn't statistically significant difference in calculated GFR between examinees of endemic and non-endemic regions for BEN, neither between examinees with and without family burden for BEN within endemic region. GFR, no matter how accurately calculated and estimated, does not represent significant biomarker for diagnosis, especially early diagnosis, of BEN, until maybe its overt advanced form.
The aim of this study was to present a patient (acute allograft dysfunction after a kidney transplantation) with previously detected minimum plaque on both iliac arteries by scintigram and afterward ...a pathological Color Doppler Ultrasound (CDU) record and to point on possibility of avoiding toxic computed tomography (CT) angiography in certain renal graft recipients. Ultrasound (US) findings showed normal graft size, whereas Doppler signals detected parvus-tardus waveforms pointing to arterial stenosis. Isotope perfusion scintigraphy registered a slow flow on both iliac arteries and normal graft perfusion. CT angiography has not been performed because of the possible toxic effects to the graft. We believe that favorable clinical and biochemical findings along with US and isotope ratio monitoring are sufficient to avoid CT contrast angiography.
Aim. The aim of this study was to compare urinary alpha 1 microglobulin (A1MG) in healthy individuals with and without family burden for Balkan endemic nephropathy (BEN) in an endemic village. ...Methods. Otherwise healthy inhabitants with microalbuminuria or proteinuria were divided into two groups: with ( n = 24 ) and without ( n = 32 ) family BEN burden and screened for urinary A1MG and A1MG/urine creatinine ratio. Results. Average value of urinary A1MG was 10.35 ± 7.01 mg/L in group with and 10.79 ± 8.27 mg/L in group without family history for BEN (NS, P = 0.87 ). A1MG was higher than 10 mg/L in eight (33.33%) inhabitants with family history and in 12 (37.5%) without (NS, P = 0.187 ). Average values of urinary A1MG/creatinine ratio were 1.30 ± 1.59 and 0.94 ± 0.78 in group with and group without family BEN history (NS, P = 0.39 , resp.). Elevated values of this ratio were found in 13 (54.17%) inhabitants with and 14 (43.75%) without family history for BEN (NS, P = 0.415 ). Conclusion. We did not find statistically significant difference in the examined markers between healthy individuals with and without family burden for BEN. We concluded that these markers are not predictive of risk for BEN.
ABSTRACT
It has now been more than two decades since the end of the 1992-95 war in Bosnia and Herzegovina. This may well be the proper time to provide the nephrology community with an appraisal of ...the care of patients with chronic kidney disease in the pre-war, war and post-war periods in the European transitional country. This report on nephrology in Bosnia and Herzegovina draws attention to the hurdles faced for three turbulent years on that burdensome path of providing quality care, and the chance it offered in developing a successful transplant programme while facing the dreadful chaos of war and a migrant crisis. The perception of war and natural disasters is quite different, from the victim's point of view, from the standardized and well-arranged healthcare systems in the developed world. The guidelines, written in peace, are extremely useful, but are often hard to follow during natural disasters or barbarous wars. Each of the periods described had its specificities as well as its good and bad sides. Despite the unquestionable destructive nature of the war, it was a catalyst for nephrology in Bosnia and Herzegovina to move forward.
Balkan endemic nephropathy (BEN) is a chronic irreversible interstitial sclerosis, for which over the last 25 years, chronic exposure to aristolochic acid from the contaminated cereal seeds has been ...considered the most likely cause. The aim of our research is to reevaluate trends of disease and to try to obtain new information about practical implementing of in-field screening of BEN, and to find indicators or a reliable biomarker for an early detection of the disease, especially for in field conditions.
Study was conducted in two phases (two groups of respondents). The first group related to respondents with BEN and microalbuminuria in the family. After filling out the questionnaire and following the consent of the respondents, their medical records were taken, and they were subjected to clinical examination and laboratory tests as well as to abdominal ultrasound and urinary tract examination.
For a long time, the disease is asymptomatic, with no hypertension, anemia or disturbed glucoregulation. Only A1M values were increased in the second group (16.22 mg), whereas A1M/CrUrine value was normal in both groups. Renal function in form of creatinine clearence and size of kidneys were in their referent values.
The early stages of the disease are nonspecific, with no hypertension and disturbed glucoregulation, with normal renal function and blood count. The kidney size was in referent values. The only reliable symptom in the early stage of the renal disease was microalbuminuria.
Aim of the article was to present a case of post transplantation invasive aspergillosis, successfully treated with conservative and surgical treatment.
Patient, male, 44 years old, with second kidney ...transplant, required special preparation therapy, because he was sensitized, with concentration of Panel Reactive Antibody (PRA) class I 11% and PRA class II 76%. On the day of transplantation, induction was done with
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and glucocorticosteroids. After transplantation, plasmapheresis with ATG was performed. On the fourth day patient was anuric. Fine-needle biopsy of the graft was performed and showed positive CD4 antibodies for peritubular capillaries and humoral rejection. 14 plasmaphereses through 14 days, were negative and ATG treatment was suspended completely. Full therapeutic dosage of tacrolimus and mycophenolate mofetil were given during treatment. Four days after treatment patient was stable, but next day clinical status had worsened with dyspnea and fever. In sputum, spores of Aspergillus species were microscopically found, and radiologically by computerised tomography. Caspofungin was administered for seven days. Voriconazole therapy was given for first ten days by intravenous route and after then orally. Even with this treatment, there was no improvement in clinical picture, while CT scan of the lungs showed abscess collection in right lung. Lobectomy was performed and pus collection was found. After graft-nephroctomy, patient was treated with continous veno-venous hemodiafiltration (CV-VHDF) dialyses, with constant voriconazole therapy for the next three months (200mg two times per day). After one month of diagnosis, Galactomannan (GM) test was negative.
Although highly sensitized patients, those who are on hemodialysis, in preparation for transplantation, receive intensive immunosuppressive therapy that suppress the immune system. Occurrence of secondary fungal infections especially infection by aspergillosis, is cause of high mortality of infected. Application GM test that detects existence of antibodies against Aspergillus antigens and usage of different type of immunosuppressive preparation can increase longevity of graft and patients in solid organ transplantation program. Aspergillosis is treated with voriconazole and surgery, and sometimes graft-nephrectomy if needed. Recommendation is that in all immunocompromised hosts and organ transplant recipient should have been tested with GM test.
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