Exploring Thyroid Function after Kidney Transplantation: The Complex Interplay Unacknowledged in Post-Transplant Care.

Background/Objectives: The interplay between thyroid function and kidney graft function following kidney transplantation remains incompletely understood. Thyroid disorders are more prevalent in kidney transplant recipients than in the general population and are associated with poorer outcomes. Methods: This prospective, single-center study was designed to estimate thyroid function (thyroid-stimulating hormone (TSH), triiodothyronine (T3), free triiodothyronine (FT3), thyroxine (T4), free thyroxine (FT4), as well as anti-thyroid peroxidase antibody (anti-TPO), anti-thyroglobulin antibody (anti-Tg), and thyroid-stimulating immunoglobulin (TSI)) and its influence on kidney graft function among a cohort of 23 kidney transplant recipients during a follow-up period of 12 months. Results: Significantly increased levels of T4 and T3 were observed 12 months post-transplantation, with FT3 levels increasing significantly after 6 months. The prevalence of immeasurably low anti-Tg antibodies rose during follow-up. Initially, 8% of patients showed positive TSI, which turned negative for all after 6 months. A statistically significant correlation was found between the initial TSH and the estimated glomerular filtration rate (eGFR) value 6 months after transplantation (p = 0.023). The graft function was stable. Proteinuria was statistically significantly lower 12 months after transplantation. Conclusions: Identifying additional risk factors, understanding their impact on kidney graft function, and recognizing cardiovascular comorbidities could enhance patient care. Notably, this study marks the first prospective investigation into thyroid function after kidney transplantation in Croatia, contributing valuable insights to the global understanding of this complex interplay.

The ERA-EDTA Registry Annual Report 2017: a summary.

BACKGROUND: This article presents a summary of the 2017 Annual Report of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry and describes the epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in 37 countries. METHODS: The ERA-EDTA Registry received individual patient data on patients undergoing RRT for ESRD in 2017 from 32 national or regional renal registries and aggregated data from 21 registries. The incidence and prevalence of RRT, kidney transplantation activity and survival probabilities of these patients were calculated. RESULTS: In 2017, the ERA-EDTA Registry covered a general population of 694 million people. The incidence of RRT for ESRD was 127 per million population (pmp), ranging from 37 pmp in Ukraine to 252 pmp in Greece. A total of 62% of patients were men, 52% were ≥65 years of age and 23% had diabetes mellitus as the primary renal disease. The treatment modality at the onset of RRT was haemodialysis for 85% of patients. On 31 December 2017, the prevalence of RRT was 854 pmp, ranging from 210 pmp in Ukraine to 1965 pmp in Portugal. The transplant rate in 2017 was 33 pmp, ranging from 3 pmp in Ukraine to 103 pmp in the Spanish region of Catalonia. For patients commencing RRT during 2008-12, the unadjusted 5-year patient survival probability for all RRT modalities combined was 50.8%.

The European Renal Association - European Dialysis and Transplant Association Registry Annual Report 2014: a summary.

Background: This article summarizes the European Renal Association - European Dialysis and Transplant Association Registry's 2014 annual report. It describes the epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in 2014 within 35 countries. Methods: In 2016, the ERA-EDTA Registry received data on patients who in 2014 where undergoing RRT for ESRD, from 51 national or regional renal registries. Thirty-two registries provided individual patient level data and 19 provided aggregated patient level data. The incidence, prevalence and survival probabilities of these patients were determined. Results: In 2014, 70 953 individuals commenced RRT for ESRD, equating to an overall unadjusted incidence rate of 133 per million population (pmp). The incidence ranged by 10-fold; from 23 pmp in the Ukraine to 237 pmp in Portugal. Of the patients commencing RRT, almost two-thirds were men, over half were aged ≥65 years and a quarter had diabetes mellitus as their primary renal diagnosis. By day 91 of commencing RRT, 81% of patients were receiving haemodialysis. On 31 December 2014, 490 743 individuals were receiving RRT for ESRD, equating to an unadjusted prevalence of 924 pmp. This ranged throughout Europe by more than 10-fold, from 157 pmp in the Ukraine to 1794 pmp in Portugal. In 2014, 19 406 kidney transplantations were performed, equating to an overall unadjusted transplant rate of 36 pmp. Again this varied considerably throughout Europe. For patients commencing RRT during 2005-09, the 5-year-adjusted patient survival probabilities on all RRT modalities was 63.3% (95% confidence interval 63.0-63.6). The expected remaining lifetime of a 20- to 24-year-old patient with ESRD receiving dialysis or living with a kidney transplant was 21.9 and 44.0 years, respectively. This was substantially lower than the 61.8 years of expected remaining lifetime of a 20-year-old patient without ESRD.

Renal replacement therapy in Europe: a summary of the 2013 ERA-EDTA Registry Annual Report with a focus on diabetes mellitus.

BACKGROUND: This article provides a summary of the 2013 European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report (available at http://www.era-edta-reg.org), with a focus on patients with diabetes mellitus (DM) as the cause of end-stage renal disease (ESRD). METHODS: In 2015, the ERA-EDTA Registry received data on renal replacement therapy (RRT) for ESRD from 49 national or regional renal registries in 34 countries in Europe and bordering the Mediterranean Sea. Individual patient data were provided by 31 registries, while 18 registries provided aggregated data. The total population covered by the participating registries comprised 650 million people. RESULTS: In total, 72 933 patients started RRT for ESRD within the countries and regions reporting to the ERA-EDTA Registry, resulting in an overall incidence of 112 per million population (pmp). The overall prevalence on 31 December 2013 was 738 pmp (n = 478 990). Patients with DM as the cause of ESRD comprised 24% of the incident RRT patients (26 pmp) and 17% of the prevalent RRT patients (122 pmp). When compared with the USA, the incidence of patients starting RRT pmp secondary to DM in Europe was five times lower and the incidence of RRT due to other causes of ESRD was two times lower. Overall, 19 426 kidney transplants were performed (30 pmp). The 5-year adjusted survival for all RRT patients was 60.9% [95% confidence interval (CI) 60.5-61.3] and 50.6% (95% CI 49.9-51.2) for patients with DM as the cause of ESRD.

Survival of chronic hemodialysis patients over 80 years of age.

BACKGROUND/AIM: 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. PATIENTS AND METHODS: 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). RESULTS: 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. CONCLUSION: 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.

Acute antibody-mediated rejection of the kidney transplant - experience of a single center in Croatia.

AIM: To describe the experience of the Department of Nephrology and Dialysis, University Hospital Rijeka, Croatia, in the treatment of patients with acute humoral rejection (AHR) of kidney transplant by using high dose of intravenous immunoglobulin (IVIG) alone and as a first line treatment. METHODS: Eight kidney transplant recipients in whom the AHR appeared at different time after the transplantation were reported. At the time of transplantation cross-match in all patients was negative for both T and B cells. At the time of presentation, all patients had signs of renal allograft dysfunction and the rejection was proven by biopsy of the kidney transplant with positive C4d-staining and histopathological evidence of antibody-mediated injury. Early rejection was considered within 180 days after the transplantation and the late one 180 days after the transplantation. In two cases plasmapheresis (PAF) with albumin as replacement fluid was performed. Plasma exchange was done with a 35 mL/kg/body weight volume exchange with albumin for six times. RESULTS: Acute humoral rejection was classified as early in three patients and in five as late one. In two patients PAF had been performed as the first line treatment. After the completion of PAF, recuperation of severe graft dysfunction was incomplete and in addition IVIG (as a single dose of 2.0 g/kg) was administered to these patients. In six patients IVIG as a single dose of 2.0 g/kg was applied as the first line treatment. CONCLUSION: Usage of high dose IVIG in the treatment of the acute humoral rejection is efficient, safe and relatively well tolerated.

[Assessment of nutritional status in patients with chronic kidney disease on maintance hemodialysis]. / Procjena nutricijskog statusa u bolesnika s kronicnom bubreznom bolesti koji se lijece redovitom hemodijalizom.

INTRODUCTION: It is well established that nutritional status is an important factor affecting the outcome and recovery from disease or injury. Assessment of nutritional status is an integral part of care for patients with chronic kidney disease, especially for those treated with dialysis procedures. According to available literature, 18%-80% of patients on dialysis have some form of nutritional deficiency. Furthermore, in patients treated with dialysis procedures there is a rule called 'reverse epidemiology', according which patients with better nutritional status have better survival rate. Therefore, nutritional assessment should detect malnutrition and rate the overall nutritional status of each patient through clinical data categories: medical history, physical examination, nutrition physical examination, psychosocial history, demographics, physical activity, and current medical/surgical issues. Consequently, the main aim of our study was to analyze the nutritional status of our patients treated with hemodialysis procedures. Another aim was to analyze the applicability of measuring skinfold by caliper as a method of nutritional status assessment. SUBJECTS AND METHODS: During a six-month period, we analyzed 129 patients (57.4% of men and 42.6% of women), mean age 68.1 ± 12.4 years, treated with hemodialysis procedures (24.8% of patients were treated with online hemodiafiltration and 75.2% with standard, conventional hemodialysis) as the method of choice of renal replacement therapy (RRT) for more than 6 months. All patients were dialyzed three times a week for four hours on biocompatible synthetic membranes. The patients treated with online hemodiafiltration were dialyzed on high-flux helixone membranes, while those treated with standard, conventional hemodialysis were dialyzed on polysulfone membranes and helixone low-flux membranes. The mean time of RRT was 71.2 ± 56.7 months. During the study period, in each patient we followed medical history, and clinical and laboratory parameters of nutritional status at 3 and 6 months. To assess the nutritional status, we used dry weight (DW), body mass index (BMI), skinfold caliper measurement (result is correlated with total body fat, FAT), and common laboratory indicators of nutritional status (serum albumin and cholesterol). RE- SULTS: Analyzing the efficiency of skinfold thickness measurement with caliper, we found that the FAT obtained by caliper showed a statistically significant positive correlation with clinical indicators of nutritional status, and with BMI (r = 0.364, p < 0.0001), DW (r = 0.206, p = 0.005) and volume of muscle circumference (r = 0.399, p < 0.0001). Also, FAT showed statistically significant positive correlation with laboratory indicators of nutritional status, including serum albumin (r = 0.299, p = 0.01) and cholesterol (r = 0.225, p = 0.002). There was no statistically significant correlation between the duration of RRT and FAT (p = NS). CONCLUSION: In clinical practice, as well as for regular evaluation of nutritional status, it is important that the method we used proved efficient, precise, relatively fast and posing less economic burden. From our experience, the measurement of skinfold with caliper is an applicable, relatively quick and inexpensive method for regular assessment of nutritional status in patients treated with hemodialysis proce- dures. Therefore, all patients treated with RRT should undergo nutritional screening and expert help should be available from dietitians or nutritional support teams in order to identify this problem properly in its early stage and to reduce its high prevalence.

[Consensus statement of the Croatian Society for Nephrology, Dialysis and Transplantation regarding the use of generic immunosuppressive drugs]. / Stav hrvatskog drustva za nefrologiju, dijalizu i transplantaciju bubrega prema uporabi generickih imunosupresiva u transplantaciji bubrega.

The use of generic immunosuppressive drugs may decrease the cost of immunosuppressive medication, although total cost sav- ings are still a matter of debate since patients need close monitoring after conversion from original to the generic formulation. A working group of the Croatian Society of Transplantation was established to develop recommendations on the use of generic immunosuppression in renal transplant recipients based on a review of the available data. Immunosuppressive drugs belong to the 'narrow therapeutic index' drugs, with huge pharmacokinetic variations secondary to the impact of food, other drugs, as well as of kidney and liver function. Failure to maintain an appropriate balance of immunosuppression seriously influences graft and patient survival. Published evidence supporting therapeutic equivalence of generic formulations is scarce or completely lacking. Different generic formulations may expose patients to uncontrolled product switching by pharmacists or general practitioners, which is very dangerous for patients, since generic preparations are not required to demonstrate bioequivalence with each other. The Croatian Society for Nephrology, Dialysis and Transplantation is not against the use of generic immunosuppressive drugs, but it requires close supervision of nephrologists and respecting the strict rules of their use. More efforts should be invested in education of primary care physicians as well as of patients to be aware of differences between the original and generic, as well as between different generic formulations.

[Treatment of anemia in chronic kidney disease--position statement of the Croatian Society for Nephrology, Dialysis and Transplantation and review of the KDIGO and ERPB guidelines]. / Lijecenje anemije u kronicnoj bubreznoj bolesti--stav hrvatskog drustva za nefrologiju, dijalizu i transplantaciju i osvrt na preporuke KDIGO i ERBP.

Renal anemia is the result of chronic kidney disease (CKD) and deteriorates with disease progression. Anemia may be the first sign of kidney disease. In all patients with anemia and CKD, diagnostic evaluation is required. Prior to diagnosing renal anemia, it is necessary to eliminate the other possible causes. Direct correlation between the concentration of hemoglobin and the stage of renal failure is well known. Early development of anemia is common in diabetic patients. Correction of anemia may slow the progression of CKD. Anemia is an independent risk factor for developing cardiovascular disease in patients with CKD. Treatment of anemia in patients with CKD is based on current guidelines. Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) group has produced comprehensive clinical practice guidelines for the management of anemia in CKD patients and ERBP (European Renal Best Practice) group its position statement and comments on the KDIGO guidelines. The Croatian Society of Nephrology, Dialysis and Transplantation (HDNDT) has already published its own guidelines based on the recommendations and positive experience of European and international professional societies, as well as on own experience. The latest version of Croatian guidelines was published in 2008. Since then, on the basis of research and clinical practice, there have been numerous changes in the modern understanding of the treatment of anemia in CKD. Consequently, HDNDT hereby publishes a review of the recent recommendations of international professional societies, expressing the attitude about treating anemia in CKD as a basis for new guidelines tailored to the present time.

Use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in the early period after kidney transplantation.

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.

BCM--body composition monitor: a new tool for the assessment of volume-dependent hypertension in patients on maintenance haemodialysis.

Hypertension is a common finding in end-stage renal disease patients with the prevalence between 20 to 85%. Although the etiology of arterial hypertension (AH) in this patient group is multifactorial, sodium and volume excess leading to extracellular volume overload are one of the most important and potentially adjustable causes. Control of volume status can either normalize the blood pressure (BP) or make the AH easier to control in the great majority of dialysis patients. Heavy reliance is placed on the dialysis procedure to gradually remove fluid over a period of days to weeks until a stable dry weight is achieved. Numerous attempts have been made to utilize alternative methods to more accurately assessment of dry weight, and the newest and most interesting method is multifrequency bioelectrical impedance spectroscopy (BIS). In this prospective study we used BIS in 65 haemodialysis (HD) patients in order to detect those with volume-dependent hypertension and to further investigate the role of dry weight management in BP control. Dry weight was corrected at the beginning, and after 1, and 3 months. Final data were collected after six months. Our data showed that assessment of fluid overload using BIS provides better management of fluid status and BP control in the patients on maintenance HD, and that dry weight correction can lead to significantly better control of volume-dependent hypertension in this patient group.

Chronic kidney disease and nonalcoholic Fatty liver disease proven by transient elastography.

BACKGROUND/AIM: Preliminary data suggest an association between chronic kidney disease (CKD) and non-alcoholic fatty liver disease (NAFLD). The aim of this study was to further investigate the association between NAFLD and decreased kidney function. METHODS: A total of 62 patients with CKD were enrolled in the study. Liver stiffness was used to detect liver fibrosis and CAP (controlled attenuation parameter) was used to detect and quantify liver steatosis (Fibroscan®). NAFLD was defined by CAP values ≥238 dB.m(-1). RESULTS: CKD stage III was present in 29 patients (46.8%) and CKD stage IV in 33 patients (53.2%). Out of 62 CKD patients 53 (85.5%) had NAFLD and of these 14/53 patients (26.4%) had also liver stiffness >7 kPa. The severity of liver steatosis was positively correlated with serum creatinine (r=0.399;p<0.01) and CRP (r=0.261; p<0.05) and negatively correlated with eGFR (r=-0.413; p<0.01) and serum iron concentration (r=-0.365; p<0.01). CONCLUSION: The results suggest a high prevalence of NAFLD in CKD patients. The severity of liver steatosis is negatively correlated with kidney function. The study documents the value of ultrasonographic elastography as an effective non-invasive screening method for the diagnosis of NAFLD.

[Efficacy and safety of CERA in anemia correction in predialysis patients--Croatian experience]. / Ucinkovitost i sigurnost primjene CERA u lijecenju anemije u predijaliznih bolesnika--hrvatsko iskustvo.

AIM: To evaluate efficacy and safety of CERA (continuous erythropoietin receptor activator) administration for correcting anemia in the patients with chronic kidney disease (CKD), not on dialysis. METHODS: We performed observational study on 27 CKD patients in stage 4 or 5 with renal anemia requiring use of erythropoiesis-stimulating agents (ESA). All patients received CERA (Mircera; Roche, Basel, Switzerland) subcutaneously in dose of 0.6 microg per kg every two weeks during the correction phase of anemia treatment or once monthly during the maintenance treatment. Dose of CERA was modified according to manufacturer instructions. Iron supplementation was administrated orally or intravenously in order to achieve serum ferritin 200-500 microg/L. Patients were followed up to 1 year (from 3-12 months). Response criteria for CERA were Hb increase >10 g/L above baseline or Hb > or = 110 g/L. RESULTS: Hb statistically significant (p < 0.05), increased during the observation period. The median at baseline was 94 g/L and after 6 months and one year were 108 g/L and 114.5 g/L respectively. Furthermore, the range of the lowest and highest values of Hb gradually decreased indicating less Hb fluctuation. After one year, all patients had Hb range 100 g/L to 120 g/L. There were no statistically significant differences between Hb between groups of patients stratified according to the primary kidney disease and age. During the study period two patients died due to myocardial infarction, probably not associated with CERA administration according to observed Hb levels (103 and 110 g/L). Only registered side effect was slight increase in arterial pressure, controlled with antihypertensive drugs. The majority of patients had reported better exercise tolerance and sleep and less irritability. CONCLUSION: The results of this observational study suggest that the use of CERA is effective and safe and leads to a successful correction of anemia in CKD patients who have not yet started renal replacement therapy.

[Long term survival patient on hemodialysis--case report]. / Dugogodisnje prezivljavanje bolesnikana lijecenju hemodijalizom--prikaz slucaja.

BACKGROUND AND AIM: The mortality of chronic kidney disease patients is very high. Patients on chronic renal replacement therapy are also et very high mortality risk. Nevertheless, by the advance in renal replacement therapy the surveillance of these patients could be long with reasonable quality of life. The present a patient on renal replacement therapy for more than 38 years. CASE HISTORY: Our patient was born in 1946. Twenty years later acute glomerulonephritis was diagnosed and he was treated with corticosteroid therapy for four years. Despite treatment his renal function deteriorated and haemodialysis was started in 1974. At that time, the haemodialysis regime was 12 hours two time per week and Kill dialyzer were used. Bicarbonate dialysis was introduced in 1984. Last 15 years our patient is on the hemodiafiltration. The treatment by erythropoietin was started in 1993. During this 38 years, he received two cadaveric kidney transplants. The first transplantation was in December 1974 in our hospital. Few days after transplantation he get rejection and transplant kidney never functioned. After one month he get thrombosis of the graft and transplantectomy was performed. The second cadaveric transplantation was performed abroad in 1985. Transplant kidney functioned only four days and fifth days urgent transplantectomy was performed. After these experience our patient decline any new kidney transplantation. First arteriovenous fistula was created at the time of start haemodialysis and was functional for 30 years. First arteriovenous graft was created after 30 years on the left forearm few years later on the left upper arm. Last graft has been in good function for six years. The last two years he has a central venous catheter. A subtotal parathyroidectomy was performed in 1983. After parathyroidectomy parathyroid hormone values were between 30 to 55 pmol/L, and the values of serum calcium and serum phosphate were in reference values. Last 15 years he had bone pain and before 10 years he had patlogical hip fracture. Due to vascular disease he often had skin ulcers and infections, particularly on the both hands. Very often he was treated by analgetics, sedatives, including opiates. Last severe complications was a bowel perforation, successfully treated by surgical intervention. SOCIAL HISTORY: Our patient graduated on the university. He is married and had one child. He has worked in the profession for several years. He was founder of association for dialysis and kidney transplant patients. Last twenty years he and colleagues conducted a private centre for haemodialysis. It was the first private centre in the country. CONCLUSION: Dialysis treatment sometimes can significantly prolong life, i.e. far more than expected in this group of patients and can offer appreciable quality of life.

[Clinical relevance of anemia treatment in patients with chronic kidney disease]. / Klinicko znacenje lijecenja anemije u bolesnika s kronicnom bubreznom bolesti.

INTRODUCTION: In the last ten years or so, there has been a steady increase in the number of patients with chronic kidney disease and those with end-stage renal failure who require some form of renal replacement therapy. Anemia is a well-known consequence of chronic kidney disease; its prevalence increases with the progression of renal failure and occurs in up to 95% of patients in the final stages of chronic kidney disease. In recent years, the greatest advance in the treatment of renal anemia has been made by the introduction of erythropoietin preparations, the application of which has significantly improved the patients' quality of life. The aim of this study was to analyze whether the treatment of renal anemia in chronic kidney disease patients not treated by dialysis affects the outcome of their treatment, reduces the incidence of cardiovascular diseases, delays the need of dialysis, reduces morbidity and mortality, and reduces the incidence of adverse cardiovascular events. SUBJECTS AND METHODS: The study included patients with chronic kidney disease presenting for regular outpatient follow up at Department of Nephrology and Dialysis, Rijeka University Hospital Center. Patients were divided into two groups. Group 1 included patients whose renal anemia was treated with erythropoietin and group 2 patients whose anemia of chronic kidney disease was treated in any other way, regardless of the reason for the exclusion of erythropoietin. Each group included 31 patients with chronic kidney disease. During two years, each patient's laboratory parameters of chronic renal disease and renal anemia treatment were monitored at intervals not longer than six months. In addition, each patient's number of hospitalizations was recorded, taking into account the cause of hospitalization and the number of days spent in hospital. RESULTS: During the two-year period, 62 patients with chronic kidney disease were analyzed (31 patients in the groups receiving and not receiving erythropoietin each). The mean age was 66 +/- 13.5 in the group receiving erythropoietin and 68 +/- 13.6 in the group not receiving erythropoietin. There were 70% of men and 30% of women in the former group, and 53% of men and 47% of women in the latter group. Examination for comorbid conditions (diabetes, hypertension, hyperlipoproteinemia and previous stroke) revealed no statistically significant differences between the two groups of patients. There were no statistically significant differences in changes of biochemical parameters (Fe, ferritin, CRP, albumin, calcium, phosphorus) between the two groups of patients during the two-year period either. There was no statistically significant between group-difference in the glomerular filtration rate after two years, but a tendency of slower progression of renal failure was observed in patients having received erythropoietin as compared to those who did not receive erythropoietin. Moreover, the number of hospitalizations due to adverse cardiovascular events was statistically significantly lower in patients that received erythropoietin, while there was no statistically significant difference in the total number of hospitalizations, hospitalizations for other indications (infection, bleeding, and worsening of renal failure), or total number of days spent in hospital, regardless of indication. CONCLUSION: The number of patients with chronic kidney disease and those with end-stage renal failure requiring renal replacement therapy is increasing. Renal anemia, which occurs as a consequence of chronic kidney disease, is associated with increased morbidity and mortality, and with a reduced quality of life in these patients. Consequently, it is necessary to recognize this condition and apply appropriate treatment early in order to prolong life and improve the quality of life of patients with chronic kidney disease.

Dominant-negative FADD rescues the in vivo fitness of a cytomegalovirus lacking an antiapoptotic viral gene.

Genes that inhibit apoptosis have been described for many DNA viruses. Herpesviruses often contain even more than one gene to control cell death. Apoptosis inhibition by viral genes is postulated to contribute to viral fitness, although a formal proof is pending. To address this question, we studied the mouse cytomegalovirus (MCMV) protein M36, which binds to caspase-8 and blocks death receptor-induced apoptosis. The growth of MCMV recombinants lacking M36 (DeltaM36) was attenuated in vitro and in vivo. In vitro, caspase inhibition by zVAD-fmk blocked apoptosis in DeltaM36-infected macrophages and rescued the growth of the mutant. In vivo, DeltaM36 infection foci in liver tissue contained significantly more apoptotic hepatocytes and Kupffer cells than did revertant virus foci, and apoptosis occurred during the early phase of virus replication prior to virion assembly. To further delineate the mode of M36 function, we replaced the M36 gene with a dominant-negative FADD (FADD(DN)) in an MCMV recombinant. FADD(DN) was expressed in cells infected with the recombinant and blocked the death-receptor pathway, replacing the antiapoptotic function of M36. Most importantly, FADD(DN) rescued DeltaM36 virus replication, both in vitro and in vivo. These findings have identified the biological role of M36 and define apoptosis inhibition as a key determinant of viral fitness.

Targeted deletion of regions rich in immune-evasive genes from the cytomegalovirus genome as a novel vaccine strategy.

Human cytomegalovirus (CMV), a ubiquitous human pathogen, is a leading cause of congenital infections and represents a serious health risk for the immunosuppressed patient. A vaccine against CMV is currently not available. CMV is characterized by its large genome and by multiple genes modulating the immunity of the host, which cluster predominantly at genome termini. Here, we tested whether the deletion of gene blocks rich in immunomodulatory genes could be used as a novel concept in the generation of immunogenic but avirulent, herpesvirus vaccines. To generate an experimental CMV vaccine, we selectively deleted 32 genes from the mouse cytomegalovirus (MCMV) genome. The resulting mutant grew to titers similar to that of wild-type MCMV in vitro. In vivo, the mutant was 10,000-fold attenuated and well tolerated, even by highly susceptible mice deficient for B, T, and NK cells or for the interferon type I receptor. Equally relevant for safety concerns, immune suppression did not lead to the mutant's reactivation from latency. Immunization with the replication-competent mutant, but not with inactivated virus, resulted in protective immunity, which increased over time. Vaccination induced MCMV-specific antibodies and a strong T-cell response. We propose that a targeted and rational approach can improve future herpesvirus vaccines and vaccine vectors.

Cmv4, a new locus linked to the NK cell gene complex, controls innate resistance to cytomegalovirus in wild-derived mice.

CMV can cause life-threatening disease in immunodeficient hosts. Experimental infection in mice has revealed that the genetically determined natural resistance to murine CMV (MCMV) may be mediated either by direct recognition between the NK receptor Ly49H and the pathogen-encoded glycoprotein m157 or by epistatic interaction between Ly49P and the host MHC H-2D(k). Using stocks of wild-derived inbred mice as a source of genetic diversity, we found that PWK/Pas (PWK) mice were naturally resistant to MCMV. Depletion of NK cells subverted the resistance. Analysis of backcrosses to susceptible BALB/c mice revealed that the phenotype was controlled by a major dominant locus effect linked to the NK gene complex. Haplotype analysis of 41 polymorphic markers in the Ly49h region suggested that PWK mice may share a common ancestral origin with C57BL/6 mice; in the latter, MCMV resistance is dependent on Ly49H-m157 interactions. Nevertheless, PWK mice retained viral resistance against m157-defective mutant MCMV. These results demonstrate the presence of yet another NK cell-dependent viral resistance mechanism, named Cmv4, which most likely encodes for a new NK activating receptor. Identification of Cmv4 will expand our understanding of the specificity of the innate recognition of infection by NK cells.

Novel functions of tyrosine kinase 2 in the antiviral defense against murine cytomegalovirus.

We have recently reported that tyrosine kinase 2 (Tyk2)-deficient mice have a selective defect in the in vivo defense against certain viruses. In our current study we show that Tyk2 is essential for the defense against murine CMV (MCMV). In vivo challenges with MCMV revealed impaired clearance of virus from organs and decreased survival of mice in the absence of Tyk2. Our in vitro studies demonstrate that MCMV replicates to dramatically higher titers in Tyk2-deficient macrophages compared with wild-type cells. We show an essential role of type I IFN (IFN-alphabeta) in the control of MCMV replication, with a prominent role of IFN-beta. MCMV infection leads to the activation of STAT1 and STAT2 in an IFN-alphabeta receptor 1-dependent manner. Consistent with the role of Tyk2 in IFN-alphabeta signaling, activation of STAT1 and STAT2 is reduced in Tyk2-deficient cells. However, lack of Tyk2 results in impaired MCMV-mediated gene induction of only a subset of MCMV-induced IFN-alphabeta-responsive genes. Taken together, our data demonstrate a requirement for Tyk2 in the in vitro and in vivo antiviral defense against MCMV infection. In addition to the established role of Tyk2 as an amplifier of Jak/Stat signaling upon IFN-alphabeta stimulation, we provide evidence for a novel role of Tyk2 as a modifier of host responses.