Heart and renal failure in renovascular hypertension caused by giant cell arteritis--case report.

We report a case of a male teenager with severe heart and acute renal failure as the dominant clinical manifestations of renovascular hypertension (RVH) caused by atypical giant cell arteritis (GCA). Unrecognized RVH and treatment of the consequent heart failure by angiotensin-converting enzyme inhibitors (ACEI) probably contributed to progression of renovascular disease to bilateral renal artery occlusion. Recurrent "flash" pulmonary edemas could not be prevented until surgical revascularization of the only functioning right kidney was achieved by an aortorenal bypass. Prompt post-operative normalization of heart function and arterial hypertension occurred despite the histopathological finding of the resected renal artery compatible with GCA and 4-year duration of significant renovascular disease. At the last check-up, the patient was asymptomatic, with normal arterial pressure on the prescribed treatment: carvedilol, hydrochlorothiazide, prednisolone 20 mg daily and aspirin. Subsequent follow-up is necessary to observe the evolution of GCA as an exceptionally rare cause of RVH.

Epidemiology of end-stage renal disease and current status of hemodialysis in Yugoslavia.

Maintenance hemodialysis (HD) in Yugoslavia started in the sixties and followed the dialysis trends in the Western Europe. However, in the last decade the development of renal replacement therapy (RRT) slowed down. In this report the epidemiology of ESRD from 1997-1999 and the survey of the status of HD treatment in Yugoslavia in 1999 are presented. Epidemiological data are obtained by the annual center questionnaires (response rate: 92.6 -94.2%). The survey of HD status is based on a specific questionnaire and covered 2108 patients (65%). At the end of 1999 there were 56 RRT centers in Yugoslavia treating 3939 patients: 3232 (82%) patients by HD, 248 (6.3%) by peritoneal dialysis, and 459 (11.7%) living with transplanted kidney. In a three year period, incidence of ESRD ranged from 108-128 pmp, point prevalence from 435-463 pmp and mortality rate from 20.7-17.9. Numerous refugee patients were treated over the last 10 years. Main causes of ESRD were glomerulonephritis (30%); Balkan nephropathy represented 11% and diabetic nephropathy 7% of all primary renal diseases. Cardiovascular and cerebrovascular diseases were the most common causes of death of RRT patients. Most centers are overcrowded and HD machines are worn out. Mean Kt/V was 1.19+/-0.08, mean URR% 58.8+/-7.4. The shortage of drugs prevented adequate management: 83% of HD patients had hemoglobin level less than 100 g/L but only 10.3 -17.8% were treated with rHuEpo; 64.5% of patients had phosphate levels higher than 1.7 mmol/L but only 33.5% used phosphate binders; 47% of patients had hypertension despite the antihypertensive therapy. The prevalence of hepatitis B remained unchanged (about 14%) in HD population during the last three years, but the prevalence of anti-HCV positive patients decreased (31-23%). In conclusion, there is a well developed dialysis service in Yugoslavia but insufficient conditions for adequate treatment.

Relationship between IL-1beta and TNFalpha production by PBMC and clinical features of hemodialysis patients.

The relationship between production of IL-1beta and TNFalpha by peripheral blood mononuclear cells (PBMC) of hemodialysis (HD) patients and clinical disorders characteristic for HD patients was examined. The study included 28 HD patients divided in the 4 groups: group 1--6 patients with malnutrition; group 2--6 patients with secondary hyperparathyroidism; group 3--6 patients with eosinophilia; group 4--10 stable HD patients without clinical complication. The control group consisted of 9 healthy volunteers. All patients were dialyzed with cuprophane membrane more than one years. Blood samples were taken immediately before the beginning of hemodialysis and PBMC were isolated by centrifugation on the density gradient. Concentrations of IL-1beta and TNFalpha were measured in the supernatants of the cultures by ELISA tests. The results showed marked individual differences in cytokine production both in healthy controls and in HD patients. Spontaneous and LPS stimulated production of IL-1beta by PBMC of HD patients was significantly higher compared to PBMC of healthy controls. There were no significant differences between group of patients with different clinical complications in cytokine production. However, a positive correlation was found between IL-1beta concentration and body mass index for patients with malnutrition and between concentration of IL-1alpha and parathyroid hormone (PTH) for patients with secondary hyperparathyroidism. The results suggest that PBMC of HD patients are chronically stimulated to produce IL-1beta, which may contribute to the development of particular chronic complications.

Serum erythropoietin and interleukin-6 levels in hemodialysis patients with hepatitis virus infection.

The influence of hepatitis B (HBV) and hepatitis C virus (HCV) infection on blood hemoglobin (Hb) and serum erythropoietin (Epo) and interleukin-6 (IL-6) concentrations was studied in 48 anemic patients on regular hemodialysis. They were grouped as follows: (I) 19 patients whose Hb values improved after infection (Hb > 85 g/L), (II) 10 patients with persisting anemia after infection (Hb < 75 g/L), and, without hepatitis virus markers (III) 8 patients with Hb > 85 g/L and (IV) 11 patients with Hb < 75 g/L. Serum immunoreactive Epo levels were significantly higher in group I (34.4+/-47.1 U/L) than in the other groups (II, 10.8+/-6.0; III, 7.9+/-3.2; IV, 8.4+/-4.3). Serum IL-6 was higher in group I than group III (7.7+/-7.8 pg/ml vs. 3.6+/-2.4; p = 0.05) but similar to the other groups. Hb levels in group I were maximal at the time of serum alanine aminotransferase normalization. Red cell production increases as a result of elevated circulating Epo during hepatic regeneration after HBV or HCV infection.

Acute renal failure in polytraumatized patients: prediction of outcome.

Prediction of outcome of acute renal failure (ARF), particularly in patients with multisystem organ failure (MSOF), is a very important issue and a very difficult task. In patients with ARF as a consequence of severe polytrauma, frequent complications (e.g., sepsis, respiratory insufficiency, DIC, hepatic insufficiency, etc.) contribute to a hyperbolic state, and in the case of synergistic action, they start the mechanism of MSOF. In 33 patients (1 female, 32 male, 38.61 +/- 8.79 years) with severe polytrauma acquired in war combat, ARF developed requiring hemodialysis (HD) treatment. Seventeen out of 33 (51.4%) recovered renal function. In 12 out of 33 patients, MSOF occurred with less successful recovery results. The analysis of pathophysiologic mechanisms of MSOF appearance and ARF outcome has shown the importance of blast injuries, bowel injury, respiratory insufficiency requiring assisted ventilation, and sepsis. Although severe hemorrhage and shock are the common mechanism of ARF appearance in these patients, it seems that wounds by themselves can be of great importance, as abdominal wounds are more frequently associated with ARF and MSOF than in other types.

Validity of prediction scores in acute renal failure due to polytrauma.

During a 36-month period from 1992 to 1994, 33 patients with severe polytrauma acquired in war combat (1 female, 32 male, 38.61 +/- 8.79 years) developed acute renal failure (ARF) which required hemodialysis (HD) treatment. In 12 patients, multiple system organ failure (MSOF) occurred as a complication of either general conditions or septic complications. In 17 patients (51.4%), and in 3 patients with MSOF, recovery of renal function occurred. We compared the outcome of ARF and several predictive scores (APACHE II and ATNISS). The APACHE II score did not correlate with the outcome of ARF, and ATNISS significantly correlated with the outcome of ARF. The maximum value of ATNISS in the patients with lethal outcome was 1.004, and the minimal value with the same outcome was 0.182. Although ATNISS is a very good score of severity, it seems to underestimate very influential factors in patients with severe polytrauma with ARF (MSOF, mechanism of trauma).

[Progression of chronic renal insufficiency in chronic rejection: the role of chronic transplantation glomerulopathy]. / Progresija hronicne insuficijencije bubrega kod hronicnog odbacivanja: ucesce hronicne transplantacione glomerulopatije.

Chronic rejection of kidney transplant is a chronic and progressive decline of kidney transplant function related to certain morphologic changes, such as obliterate vasculopathy, interstitial fibrosis, tubular atrophy, and transplant glomerulopathy [1]. The purpose of this study was to investigate the involvement of chronic transplant glomerulopathy in the progression of chronic renal failure. METHOD, PATIENTS: Of 16 transplant patients with histologic diagnosis of chronic kidney transplant rejection in biopsy specimens, 8 patients had chronic transplant glomerulopathy (ChR-1), and in the other 8 patients glomeruli were relatively preserved (ChR-2). Transplant biopsies were performed between the seventh and the 15th month in ChR-1, and between the ninth and the 34th month in ChR-2 group. Morphologic vasculopathy cv2 changes, tubular atrophy ct1 and ct2 in the half of each group, and interstitial fibrosis ci2, were graded according to the BANFF criteria [2]. During the follow up the patients received similar doses of prednisone, as well as of azathioprine and cyclosporine A. IMMUNOHISTOCHEMICAL INVESTIGATION: The expression of MHC I antigen, MHC II antigens, CD3, CD25, CD54 (ICAM-1) was analyzed by indirect immunoperoxidase technique of staining on the frozen sections, (DAKOPATTS). The immunoreactivity score was 0 to 3. BIOCHEMICAL INVESTIGATION: The renal function was expressed as reciprocal serum creatinine values (1/mumol/L) reflecting the mean monthly levels, over the period between the third and the 22nd month following the transplantation. In each patient a decline in kidney functioning was determined in two ways: 1. by the slope of the curve representing the function of regression of the reciprocal serum creatinine over time, started from the third month after the transplantation, 2. by the rate of regression (percent) of the reciprocal serum creatinine values at the sixth, the ninth, the 18th and the 22nd month, compared to the attained serum creatinine level at the third posttransplantation month. RESULTS AND DISCUSSION: Glomeruli with present chronic transplant glomerulopathy (patients of the ChR-1 group) had moderate expression of MHC I antigen [1-2], week expression of ICAM-1 (CD54), whereas DR antigens were almost absent. In cortical tubuli the expression of MHC I antigen was very low. The relatively preserved glomeruli in patients without chronic transplant glomerulopathy (ChR-2 group) showed high expression of MHC I antigen [2], moderate expression of ICAM-1, and low (up to 1) DR expression. The CD25 molecules were not detected in any analyzed glomeruli (62 in total), except a positive cellular crescent formation, seen in 3 patients with chronic transplant glomerulopathy. The regression slopes of reciprocal serum creatinine values according to months, over the third and the 22nd month were similar in both groups of patients, and the speculating mean graft survival time was 44 months, in both groups. However, 4 of 8 patients of the ChR-1 group, and only 1 of 8 patients of the ChR-2 group returned to the haemodialyses because of the graft functioning loss. Besides, the mean percentual rate of the decline in renal functioning, as the rate of decrease of serum reciprocal creatinine values in the chosen growing periods in time after the third month were higher in group ChR-1 with present chronic transplant glomerulopathy in biopsy specimens. The difference was of statistical significance at the end of the 18th month, t = 4.10, p less than 0.01. In this period proteinuria exceeding 3 grams a day was discovered in 6 patients of ChR-1 group, and in 4 patients in ChR-2 group. Our results suggest that the early appearance of chronic transplant glomerulopathy induces a slightly higher loss of function of the kidney transplant with chronic rejection, despite of the absence of the immune activation in the glomeruli with the present chronic transplant glomerulopathy. (ABSTRACT TRUNCATED)

[Incidence and clinical manifestations of hepatitis C virus infection in patients on hemodialysis]. / Ucestalost i klinicke pojave infekcije virusom hepatitisa C kod bolesnika na hemodijalizi.

Hepatitis C virus infection is a very important problem among patients on maintenance hemodialysis. To determine incidence and clinical manifestations of hepatitis C virus infection, we tested blood samples of patients on hemodialysis in 1992 and 1994 using ELISA a HCV test of second generation. In 1992 46 out of 119 patients (38%), and in 1994 36 out of 122 (29%) patients on hemodialysis were aHCV positive. Duration of dialysis program and level of serum aminotransferases were significantly higher in the group of aHCV positive patients had received more blood transfusions per year, but not significantly higher than HCV negative patients. These results with knowledge about common routes of HCV transmission, demand strict preventive measures in dialysis units, routine and regular HCV testing of patients' blood samples and serum aminotransferases level, and isolation of HCV positive patients and machines.

[Monitoring the nutritional status in patients on hemodialysis]. / Pracenje stanja uhranjenosti kod bolesnika na hemodijalizi.

In order to monitor changes of the nutritive status of hemodialyzed patients, antropometric and laboratory parameters of the population of hemodialyzed patients in 1988 vs. 1994 have been compared. Antropometric parameters were measured by the same investigator. The results show absence of significant difference between antropometric parameters (body weight after hemodialysis, body mass index, triceps fold, circumference of upper arm and percentage of fat) in the patients hemodialyzed in 1988. The laboratory parameters (albumin and transferrin), however, show significant increase in the 1994 group. In the group of patients subjected to hemodialysis in 1988 as well, albumin was significantly elevated. Nevertheless, no differences in laboratory parameters in healthy populations of 1988 and 1994 were noted (controls). It was concluded that no significant changes in the nutritive status were present among either the population or the same patients, while elevation of laboratory parameters necessitate further investigation.

[The effect of septic complications on recovery in acute renal insufficiency in patients with multiple injuries]. / Uticaj septickih komplikacija na oporavak akutne insuficijencije bubrega kod politraumatizovanih bolesnika.

Septic complication in patients (pts) with ARF are among the most important causes of mortality, especially in pts with polytrauma and multiple-organ failure. Prevention procedures, early and accurate diagnosis and persistent treatment in time are necessary to avoid septic shock. During the period od 27 months (1992-1994), 25 pts with wounds inflicted in war and AFT were treated by haemodialysis. Eighteen (72%) pts had septic complication. Eleven (71%) of them recovered from ARF, while 7 (39%) pts died despite the undertaken procedures. Nine pts (81%) with septic complication and ARF who improved their renal function were treated by one or more nephrotoxic antibiotics. Haemodialysis was initiated when average BUN concentration was 35.7 mmol/l and plasma creatinine level about 0.8 mmol/l. Simultaneously with symptomatic and substituting therapy, and surgical correction of polytrauma, approximately 9 haemodialysis in the period of 21 day were necessary for ARF recovery. In the group of pts who had no improvement of renal function, 6 (85%) received 1 or more nephrotoxic drugs. Approximately 5 haemodialysis were done in these pts, in a shorter period of time. In polytraumatized pts with ARF with septic complication, factors which potentiate hypercatabolism aggravate the prognosis of ARF, increase mortality, require a greater number of haemodialysis and significantly prolong the recovery time of ARF.

[Analysis of data on hemodialyzed patients for the development of a data base]. / Analiza podataka o bolesnicima na hemodijalizi radi razvoja baze podataka.

Needs for state-of-the-art records on haemodialyzed patients implies abandoning of conventional paper work and development of a computer data base on haemodialyzed patients. Thus, data on haemodialyzed patients were analyzed. Since haemodialysis is a specific mode of treatment and differs from out-patient and in-patient management, the records also differ from conventional files and histories. The analysis has shown that the data can be groupedinto two sets: dialysis list and history of a haemodialyzed patient. The list contains the data at the onset of dialysis, and the end of the process, and in hourly intervals. The history contains mainly relatively permanent data (personal data and basal medical parameters), annual (records and primary data) and monthly (dialysis records, history and current condition, laboratory analyses and therapy). Most of the data are systematic, i.e. periodic and necessitate tabular presentation. It has been concluded that due to the tabular presentation and predominance of systematic information, the data base will be superior to conventional records.

Unruptured congenital aneurysm of the right sinus of Valsalva. Dissecting into the interventricular septum.

We report the case of a congenital aneurysm of the right sinus of Valsalva dissecting into the interventricular septum in a 21-year-old man. This condition was diagnosed by echocardiography and magnetic resonance imaging. In particular, transthoracic and transesophageal color-coded Doppler echocardiography showed that there was no communication between the aneurysm and the surrounding heart chambers. The findings were confirmed by angiography. Heart enlargement and other symptoms and signs of heart failure indicated surgical repair of the lesion. Early postoperative dehiscence of the sutured orifice was accurately diagnosed with Doppler echocardiography and angiography. Reintervention was successful in filling and sealing the septal cavity. This case confirms the reported difficulties in the surgical correction of aneurysms of sinus of Valsalva lying within the interventricular septum.

Epidemiology of hepatitis D virus (delta) infection in Yugoslavia.

In 614 HBsAg-positive Yugoslavian patients, radioimmunoassay testing for anti-delta showed the presence of this antibody in serum in 11.2%. Of the patients, 213 belonged to a risk group (i.v. drug users, hemophiliacs, hemodialysed patients and patients with posttransfusion hepatitis); a significant number of these patients (63; 29.6%) were found to have anti-delta. A second group was composed of 401 HBsAg-positive patients from the general population (patients with acute hepatitis B, with fulminant hepatitis B and patients with chronic HBV infection); delta infection was found only in six (1.5%). Immunohistochemical methods failed to demonstrate the delta antigen in the livers of 73 patients with chronic HBV infection. Testing the liver of 36 patients with fulminant hepatitis B for delta antigen demonstrated this reactivity in only one (2.8%) liver sample. Delta antigen was also found in the liver of a female patient who underwent biopsy in 1972. The results of this study suggest the HDV is not endemic in Yugoslavia; however, it is frequently found in patients at risk of blood exposure, primarily i.v. drug users.

[Characteristics of renal failure in chronic liver disease]. / Karakteristike bubrezne insuficijencije u hronicnih oboljenjima jetra.

The aim of this study was to establish the characteristics of renal failure in patients with cirrhosis and compare their laboratory data on blood and urine with those of patients with chronic renal failure without liver disease; and then to correlate the data of patients with cirrhosis and renal failure with that of patients with cirrhosis without renal failure in relation to liver function There were three groups of patients: group A - patients with cirrhosis and renal failure; group K1-patients with cirrhosis without renal failure; and group K2-patients with chronic renal failure. The parameters of renal and liver function were also compared. The laboratory data on blood and urine in patients with cirrhosis and renal failure revealed characteristics of prerenal failure in a higher degree (functional renal failure). When liver failure was concerned there was no difference between patients with cirrhosis and renal failure and subjects with cirrhosis and no renal failure. The degree of renal failure was not always the same regarding the degree of liver failure although they can sometimes paralell.