Cardiovascular risk assessment prior to kidney transplantation.

OBJECTIVES: The objective was to find out risk factors indicating the patients directly to selective coronarography (SCG) to avoid unnecessary non-invasive testing and in their absence to asses low cardiovascular risk and faster inclusion on the waiting list. BACKGROUND: Cardiovascular diseases (CVD) are the most frequent cause of death in dialysed patients. The aim of our retrospective analysis was to identify risk factors for coronary artery disease (CAD) before kidney transplantation (KTx). METHODS: Our retrospective analysis consisted of 55 dialysed patients (46 males, 9 females, p < 0.0001), undergoing SCG before KTx. We divided the patients according to SCG results (negative, n = 40, positive finding, n = 15). RESULTS: We confirmed a significantly lower incidence of diabetic nephropathy (p = 0.0484), ischaemic heart disease (p = 0.0174) and CAD (p = 0.0001) in patients without percutaneous coronary intervention (PCI; negative finding). Haemodynamically significant coronary stenosis correlated with the occurrence of stroke in a patient's history (p = 0.0104). We identified predictors for performing PCI (positive result): type 2 diabetes mellitus (DM) (p = 0.0472), high-density lipoprotein cholesterol ≤ 1.03 mmol/l (p = 0.0359), total calcium level ≤ 2 mmol/l (p = 0.0309), phosphate level ≥ 1.45 mmol/l (OR 0.2034; p = 0.0351). CONCLUSION: In our analysis, patients with DM and poorly managed chronic kidney disease/mineral bone disease were the riskiest subset of the patients with a positive SCG finding (Tab. 4, Fig. 2, Ref. 30). Text in PDF www.elis.sk Keywords: kidney transplantation, coronary artery disease, selective coronarography, cardiovascular risk.

The role of proteinuria, paricalcitol and vitamin D in the development of post-transplant diabetes mellitus.

INTRODUCTION: Post-transplant diabetes mellitus (PTDM) occurs most frequently during the first year after transplantation. We focused on parameters of calcium-phosphate metabolism and proteinuria as possible new risk factors for PTDM after kidney transplantation. MATERIALS AND METHODS: We have prospectively identified risk factors for post-transplant diabetes mellitus with follow-up of 12 months in a set of 167 patients after kidney transplantation. Patients with diabetes mellitus type 1 and type 2 as well as patients using ciclosporin A or mTOR inhibitor have been excluded from the monitoring. From the perspective of immunosuppression it was a homogeneous set of patients. RESULTS: We identified the following independent risk factors for PTDM in our set: average proteinuria > 0.300 g/24 h (HR 3.0785, (95 % CI 1.6946-5.5927), p=0.0002), level of vitamin D<20 ng/ml (HR 5.4517, (95 % CI 2.3167-11.8209), p1.45 mmol/l (HR0.0821, (95 % CI0.0042-1.5920), p=0.0439). The lowest occurrence of PTDM and proteinuria was recorded in patients whose treatment included paricalcitol (p<0.0001) and these patients had at the same time the highest level of vitamin D (p<0.0001). CONCLUSION: Deficit of vitamin D, proteinuria and hyperphosphatemia have been independent risk factors for the development of PTDM in our set. We identified the usage of paricalcitol as protective factor with regard to the PTDM development (Tab. 6, Fig. 4, Ref. 29).

The detection of early myocardial changes in asymptomatic diabetic individuals by 99mTc - Myoview gated-SPET and heart rate variability measurement.

AIMS: Incidence of early myocardial changes in asymptomatic diabetic individuals is not clearly documented. In the present study, we examined diabetic patients without a history of cardiovascular disease with negative treadmill test and no signs of systolic dysfunction for presence of cardiac autonomic neuropathy established by measurement of heart rate variability (HRV) and (99m)Tc - Myoview gated-SPET. MATERIALS AND METHODS: 47 type I and type II diabetic patients were subjected to prospective study including echocardiography and HRV measurement using the combination of Ewing´s testing and spectral analysis. Subsequently, patients underwent treadmill test and stress myocardial perfusion scintigraphy. Additionally, vascular and metabolic parameters were collected. RESULTS: Treadmill test was negative in all patients. Diastolic dysfunction was found in 10 % of T1DM and 11 % of T2DM patients by echocardiography, whereas none of the patients had systolic dysfunction. SPET confirmed hypoperfusion in 35 % T1DM (p=0.01) and in 60 % T2DM (p=0.001). Diagnosis of cardiac autonomic neuropathy based on Ewing´s testing and HRV examination was established in 60 % of T1DM patients (p=0.001) and 77 % of T2DM patients (p=0.001). In T1DM group, significant association was found between cardiac autonomic neuropathy (CAN) and frequency of hypoglycaemia (p=0.04). No such correlations were found in patients with T2DM. CONCLUSION: The results of the present study show high incidence of myocardial hypoperfusion and cardiac autonomic neuropathy among asymptomatic diabetic patients, whereas the standard diagnostic approaches including treadmill test and echocardiography failed to show any changes. Therefore, we conclude that diabetic heart disease remains underdiagnosed by standard approaches, but could be detected in asymptomatic patients by more sensitive methods, such as HRV measurement and myocardial scintigraphy (Tab. 2, Fig. 2, Ref. 26).

[The arrhytmias in patients with diabetes mellitus]. / Poruchy srdcového rytmu u pacientov s diabetes mellitus.

Cardiovascular disorders are the most common reason of morbidity and mortality worldwide. The prevalence of diabetes mellitus, which is strongly associated with cardiac and cerebrovascular events, is increasing during the last decades. Based on the results of clinical studies we summarize in the review article the risk factors and patomechanisms connecting diabetes mellitus to incidence of arrhythmias and sudden cardiac death. The paper analyzes influence of diabetes mellitus on atrial fibrillation and arrhythmogenic effect of antidiabetic drugs.

[Prevalence of diabetic retinopathy and distal symmetrical diabetic polyneuropathy, and glomerular filtration screening upon the diagnosis of type 2 diabetes mellitus - a cohort study]. / Prevalencia diabetickej retinopatie, distálnej symetrickej diabetickej polyneuropatie a screening glomerulárnej filtrácie v case dia-gnózy diabetes mellitus 2. typu -  kohortná stúdia.

The prospective cohort study analyzes the prevalence of microvascular complications at the time of dia-gnosis type 2 diabetes (DM 2). We were monitoring 200 outpatients (117 men and 83 women, aged from 30 to 92 years) with newly diagnosed and previously untreated type 2 diabetes mellitus during the period of August 2007 -  August 2011 accidentally sending GP or internists. Prevalence of diabetic retinopathy in men was 0.85% and in women 1.2%. The prevalence of diabetic distal symetric polyneuropathy in men was 53% and in women 62%. The median of glomerular filtration based on a simplified MDRD 4 equation (according to the study Modification of Diet in Renal Disease) was 1.27 ± 0.6 ml/ s/ 1.73 m2 for men and 1.05 ± 0.32 ml/ s/ 1.73 m2 for women. At baseline, 16.6% of men and 46.2% of women enrolled in our cohort study had glomerular filtration rate < 1 ml/ s/ 1.73 m2.

[Syncope as first and only sign of left atrial myxoma]. / Synkopa ako prvý a jediný príznak myxómu lavej predsiene.

Myxoma is the most frequent primary heart tumor. It is localised in the left atrium in majority of cases, but each of heart chambers may be affected. Left atrial myxoma becomes symptomatic in case it leads into mitral valve obstruction, systemic embolisation or it manifests with unspecific systemic symptoms. Echocardiography is a golden standard of myxoma diagnostics. We present a case of 61-years old woman patient in whom exercise induced syncope was the first and only sign of far gone left atrial myxoma with left ventricle inflow tract obstruction, leading to mitral pseudostenosis.

[Indicators of inflammation in patients with coronary atherosclerosis - role of usCRP in diagnosis and disease progression prediction]. / Indikátory zápalu u pacientov s koronárnou aterosklerózou - úloha usCRP v diagnostike a predikcii prognózy ochorenia.

Atherosclerosis is being nowadays defined as chronic subclinical inflammatory disease. Recently published clinical and laboratory studies have shown that subclinical inflammation represents main role in initiation of creation, in progress and destabilization of atherosclerotic plaque. Screening including traditional cardiovascular risk factors fails in identification in more than 50% of individuals with later development of acute coronary syndrome. According to above mentioned reason indicators are being searched for, which would be usable to monitor the activity of atherosclerotic process. According to role of subclinical inflammatory process in pathogenesis of atherosclerosis, the determination of C-reactive protein using ultrasensitive method is being showed as perspective marker. Ultrasensitive C-reactive protein represents a strong, independent predictor of future cardiovascular events in apparently heal-thy individuals and has also prognostic utility in patients with acute coronary syndromes. Predictive capacity of C-reactive protein determination is independent of traditional risk factors and offers prognostic advantage as opposed to determination of lipids alone. The paper provides a review of currently available knowledge of possibilities for utilization of C-reactive protein laboratory assessment, as the main representative of acute phase proteins, in monitoring of creation and severity of coronary atherosclerosis, in possibilities of the disease prognosis determination and prediction of its acute complications, and also in prediction of prognosis in patient with already existing acute complication.

[The value of ECG assessment in pulmonary embolism diagnostics]. / Význam hodnotenia EKG v diagnostike plúcnej embólie.

Acute pulmonary embolism is one of the most frequent and risky cardiovascular diseases. Despite accessability of different examinig methods and rich clinical experience, pulmonary embolism is demanding disease especially in diagnostics. The reason might be in clinical picture, that is not typical everytime and leads to incorrect choice of diagnostic methods, that delay the disease assessment. Regarding this, precise evaluation of every each symptom and basal, resp. supplemental examinations is important step to rapid and right assessment of this diagnose.

[Paraneoplastic hypoglyacemia]. / Paraneoplastická hypoglykémia -  popis prípadu a prehlad problematiky.

Paraneoplastic hypoglyacemia (PH) is a relatively rare phenomenon, which may be caused by insulinomas or nonislet cell tumours (NICT). Both types are among the major "fasting" hypoglyacemia as opposed to reactive postprandial hypoglyacemia. The most common group of nonislet cell tumours causing hypoaglycemia are large mesenchymal tumours, which account for over 50 % of all neoplasms associated with hypoglyacemia. Neuroglycopenic symptoms in patients with NICT may be present for months or years before the actual diagnosis of the underlying disease. Differentiation and correct diagnosis of this type of disease leads to significant improvement in the quality of life of these patients.

[Hyponatremia - carbamazepine medication complications]. / Hyponatrémia - komplikácia liecby karbamazepínom.

Hyponatremia can be defined like the low sodium concentration, lower that 135 mmol/l. It becomes really serious when the concentration is lower than 120 mmol/l. The most frequent causes of hyponatremia are: the extrarenal loss (GIT, skin, bleeding, sequestration), the renal loss (diuretics, nephritis with the salt loss, osmotical diuresis, the Addison disease), hypothyroidism, the lack of glucocorticoids, emotional stress, pain, pseudohyponatremia (incorrect taking, dyslipoproteinemia). There is fatigue, exhaustion, headache and vertigoes dominating in the clinical record file. By the deficit increasing a patient becomes delirious, comatose even with the shock development. It is necessary to separate sufficient supply of sodium from much more often reason, which is loss of sodium which can be caused by: excessive sweating, vomitting with the metabolical alkalosis development, diarrhoea with the metabolical acidosis development, renal losses (a phase of renal failure). Treatment of hyponatremia: intensive treatment starts at the level of plasmatic concentration of sodium under 120 mmol/l or when neurological symptoms of brain oedema are present. In the therapy it is necessary to avoid fast infusions of hypertonic saline solutions (3-5% NaCl solutions) because of the danger of the development of serious CNS complications (intracranial bleeding, etc.). It is recommended to adjust the plasmatic concentration of sodium up to 120 mmol/l during the first four hours and a subsequent correction should not be higher than 2 mmol per an hour. Treatment of the basic illness is very important. We present 2 case histories: a 74-year old female patient and a 69-year old female patient both with the hyponatremia caused by taking of carbamazepine. We want to inform and warn about not only a well known side effect during long-term treatment but about hyponatremia that arose within 48 hours after the start of taking medicine as well.

[Morbus Ormond (idiopatic retroperitoneal fibrosis)]. / Ormondova choroba (idiopatická retroperitoneálna fibróza).

Idiopathic retroperitoneal fibrosis (IRF) is a rare condition characterized by the development of fibrotic tissue around the abdominal aorta and iliac arteries and often involves structures as ureters and the inferior vena cava. The age at onset of signs and symptoms is between 40-60 years, males predominane over females. In most cases the clinical manifestation is presented as compressive syndrom of ureters, therefore the first known cases were described by urologists. In this report we present the case of 37-years old male examinated for persistent fever about 38 degrees C and high inflammatory activity in spite of empiric antibiotic therapy. Positron emission tomography (PET) showed locality of high metabolic activity of fluorodeoxyglucose with maximum paraaortal left. Microscopic examination of extracted mass showed presence of fibrous and inflammatory components. With clinical presentation, imaging and histological findings we made out the diagnosis of idiopathic retroperitoneal fibrosis--morbus Ormond.

Kidney transplantation as a treatment of choice for AA amyloidosis due to periodic fever syndrome.

Renal AA amyloidosis is the most serious complication of periodic fever syndrome, which, inadequate suppression, due to persistent inflammation, leads to nephrotic syndrome and renal failure over several years. In most cases, periodic fever syndromes begin to manifest clinically in early childhood. Occurrence in adulthood is considered rare and is associated with a poorer clinical course. Kidney transplantation (KT) is an effective and safe treatment for end-stage chronic kidney disease (CKD) based on AA amyloidosis. In this paper, we present cases of two patients after deceased donor KT, who have been diagnosed with adult periodic fever syndrome. In the first one, diagnosis and treatment began in advanced stage of CKD and therefore underwent KT with compensated disease, while in the second patient, the disease manifested and diagnosed in the post-KT period. Timely initiation of treatment ensured protection of the graft from amyloid deposition.

Cancer-associated thrombosis - treatment and prevention with direct oral factor Xa inhibitors.

BACKGROUND: Venous thromboembolism (VTE) is a frequent cause of morbidity and mortality in patients with cancer. Moreover, management of VTE is frequently connected with complications, namely risk of recurrent VTE and bleeding. Low molecular weight heparins (LMWH) therapy administrated for 3-6 months is currently considered a standard for the treatment of cancer-associated VTE (CA-VTE). Direct oral factor Xa inhibitors (FXaI) apixaban, edoxaban and rivaroxaban have emerged as a new possibility for long-term antithrombotic therapy for VTE. These agents expose several advantages in individuals with cancer, and might overcome several disadvantages connected with LMWH therapy. PURPOSE: First clinical studies with oral FXaI for the treatment of CA-VTE with very promising results were recently published. The article summarizes current data regarding the use of oral FXaI in the treatment of CA-VTE.

Hypoglycemia unawareness.

Hypoglycemia unawareness can occur in diabetic as well as nondiabetic individuals. A single causative mechanism for its occurrence is not yet apparent. It is likely to be multifactorial but current evidence favors a major role for some type of CNS adaptation. Certainly in some instances, classic autonomic neuropathy could be a contributory factor in patients with longstanding diabetes. Most, if not all, individuals with this condition have reduced plasma epinephrine and/or norepinephrine responses during mild hypoglycemia. Although it may be difficult to distinguish between mere reductions in the magnitude of a response and a true alteration in the threshold to initiate that response, four studies (44, 59, 65, 86) have provided evidence for an increase in the threshold (greater hypoglycemia required) for activation of counterregulatory hormone secretion associated with reduced awareness of hypoglycemia; in one study (44), diabetic patients had developed abnormalities with improved glycemic control after intensive insulin therapy; in another study (59), diabetic patients had recurrent hypoglycemia but did not differ in glycemic control (as assessed by glycosylated hemoglobin values) from subjects aware of hypoglycemia. In the two other studies, patients with impaired counterregulatory hormone responses and hypoglycemia unawareness had lower glycosylated hemoglobin levels than the other patients (65, 86). Altered tissue sensitivity to catecholamines seems unlikely to provide a primary explanation since not all symptoms are adrenergic and since, as mentioned earlier, most patients with this condition have reduced or delayed catecholamine responses to hypoglycemia, which in themselves could explain reduced awareness of hypoglycemia. Furthermore, patients with diabetic autonomic neuropathy have been reported to have increased sensitivity to catecholamines (143). One frequent observation, dating back to the early descriptions of hypoglycemia unawareness (17-19), is that patients with this condition have had frequent episodes of hypoglycemia. Although it is easy to envision how reduced warning symptoms could result in development of severe hypoglycemia, it is quite possible that frequent episodes of hypoglycemia themselves might initiate the process. For example, as depicted in Fig. 4, episodes of mild hypoglycemia occurring in insulinoma patients, diabetic patients undergoing intensive insulin therapy, or patients with longstanding diabetes complicated by autonomic neuropathy and impaired glucagon secretion could lead to CNS adaptation.(ABSTRACT TRUNCATED AT 400 WORDS)

[Hypoglycaemia]. / Hypoglykémia.

Hypoglycaemia is a serious, frequent and recurrent complication of treatment of diabetes mellitus which may become a direct danger to the patient's life. In clinical practice, it is best defined descriptively as Whipple's triad involving the presence of typical clinical symptoms of hypoglycaemia, low plasma glucose concentration and the disappearance of symptoms of hypoglycaemia after the administration of glucose. The overview article focuses, in more detail, on the issues of definition of hypoglycaemia based on the optimal threshold value ofglycaemia, classification ofhypoglycaemia based on its causes, rate of occurrence and factors provoking hypoglycaemia in patients with type 1 and 2 diabetes mellitus, as well as modern diagnosis and treatment of hypoglycaemic states.

Interaction between glucose and free fatty acid metabolism in human skeletal muscle.

The mechanism by which FFA metabolism inhibits intracellular insulin-mediated muscle glucose metabolism in normal humans is unknown. We used the leg balance technique with muscle biopsies to determine how experimental maintenance of FFA during hyperinsulinemia alters muscle glucose uptake, oxidation, glycolysis, storage, pyruvate dehydrogenase (PDH), or glycogen synthase (GS). 10 healthy volunteers had two euglycemic insulin clamp experiments. On one occasion, FFA were maintained by lipid emulsion infusion; on the other, FFA were allowed to fall. Leg FFA uptake was monitored with [9,10-3H]-palmitate. Maintenance of FFA during hyperinsulinemia decreased muscle glucose uptake (1.57 +/- 0.31 vs 2.44 +/- 0.39 mumol/min per 100 ml tissue, P < 0.01), leg respiratory quotient (0.86 +/- 0.02 vs 0.93 +/- 0.02, P < 0.05), contribution of glucose to leg oxygen consumption (53 +/- 6 vs 76 +/- 8%, P < 0.05), and PDH activity (0.328 +/- 0.053 vs 0.662 +/- 0.176 nmol/min per mg, P < 0.05). Leg lactate balance was increased. The greatest effect of FFA replacement was reduced muscle glucose storage (0.36 +/- 0.20 vs 1.24 +/- 0.25 mumol/min per 100 ml, P < 0.01), accompanied by decreased GS fractional velocity (0.129 +/- 0.26 vs 0.169 +/- 0.033, P < 0.01). These results confirm in human skeletal muscle the existence of competition between glucose and FFA as oxidative fuels, mediated by suppression of PDH. Maintenance of FFA levels during hyperinsulinemia most strikingly inhibited leg muscle glucose storage, accompanied by decreased GS activity.

Metabolic syndrome and new onset diabetes after kidney transplantation.

AIMS: The metabolic syndrome developed after kidney transplantation is the result of several factors which are identical with the risk factors in normal population, however, also some factors typical for the transplanted patients-especially the effects of immunosuppressive therapy. MATERIAL AND METHODS: In the groupof 268 patients after kidney transplantation, which had no type 1 or type 2 diabetes mellitus before transplantation, we identified patients with metabolic syndrome(based on IDF criteria), 12 months from the kidney transplantation. In all patients, we recorded the following parameters: age at the time of transplantation, type of immunosuppression, waist measure, the value of triacylglycerols, the value of HDL cholesterol, presence of arterial hypertension, andthe value of glycaemia in fasting state (or presence of diabetes mellitus). The groupof patients was divided into the control group and the group of patients with metabolic syndrome. RESULTS: The average age of patients was 46.1±11.6years. The control group included 149 patients (55.6%),and we identified the metabolicsyndromein 119patients (44.4%). The patients with metabolicsyndrome were significantly older (P<0.0001), had significantly larger waist (both the entiregroup and the males andfemales) P<0.0001.The femaleswith metabolic syndrome had significantly lower value of HDL-cholesterol (P=0.0013), and significantly higher number of patients with metabolic syndrome had hyperglycaemia in fasting state or diabetes mellitus (P=0.0006). CONCLUSION: By controlling the weight and waist, we may identify the risk patients for development of metabolic syndrome after kidney transplantation.

Flow Cytometry Panel-Reactive Antibody Screening of Anti-HLA Antibodies in the Waiting List Significantly Reduces the Occurrence of Acute Rejection After Kidney Transplantation.

INTRODUCTION: The presence of preformed HLA-reactive antibodies in recipient serum before transplantation has long been recognized as a prominent risk factor for a generally worse graft outcome. Screening and identification of HLA antibodies can be used to stratify patients into high- and low-risk categories. MATERIALS AND METHODS: We determined patients' anti-HLA antibodies using flow cytometry panel-reactive antibody (flowPRA) screening, specifying more than 5% after positive screening. According to the results of the screening test, patients were allocated to the induction immunosuppressive protocol according to the actual immunologic risk. RESULTS: In the group of 78 patients, screening with flowPRA of anti-HLA antibodies was done twice a year. Patients were divided into 2 groups of immunologic risk (low or medium), and we chose the induction immunosuppressive protocol according to the risk. Stratification of the risk was correct, because the only predictor for development of acute rejection in the monitored period of 12 months was delayed graft function (odds ratio 33.2501; 95% confidence interval 10.0095-110.4508; P < .0001). The occurrence of acute rejection upon implementing the screening was reduced in our transplant center from 44% to 19% (P < .0001). No difference was recorded in the 12-month survival of grafts and patients according to the applied induction immunosuppressive protocol. CONCLUSION: We confirmed significantly reduced occurrence of acute rejection in the follow-up period of 12 months by using individualized induction according to flowPRA screening of anti-HLA antibodies. FlowPRA screening represents a suitable alternative for screening and specification of anti-HLA antibodies in case the Luminex methodology is unavailable.

Starting insulin therapy in type 2 diabetes: twice-daily biphasic insulin Aspart 30 plus metformin versus once-daily insulin glargine plus glimepiride.

AIM: To compare the efficacy and safety of two analog insulins as starting regimens in insulin-naïve Type 2 diabetes patients. METHODS: In this randomized, open-label parallel study, twice-daily biphasic insulin aspart 30 (30% soluble and 70% protaminated insulin aspart; BIAsp 30) plus metformin (met) was compared with once-daily insulin glargine (glarg) plus glimepiride (glim) in 255 insulin-naïve patients (131 male; mean+/-SD age, 61.2+/-9.1 years). Mean baseline HbA (1c) (+/-SD) was 9.2+/-1.4% and 8.9+/-1.3% for BIAsp 30 plus met ( N=128) and glarg plus glim ( N=127), respectively ( P=0.0747). Primary endpoint was the difference in absolute change in HbA (1c) between groups after 26 weeks of treatment. RESULTS: HbA (1c) change was significantly greater in the BIAsp 30 plus met group than the glarg plus glim group (between-group difference: -0.5% (95% CI: -0.8; -0.2); P=0.0002). Mean prandial plasma glucose increment was significantly lower for BIAsp 30 plus met compared with glarg plus glim: 1.4+/-1.4 mmol/l vs. 2.2+/-1.8 mmol/l; P=0.0002. During the maintenance phase (weeks 6-26), one major hypoglycemic episode occurred in each group; 20.3% and 9% of patients experienced minor hypoglycemic episodes in the BIAsp 30 plus met and glarg plus glim groups, respectively ( P=0.0124). At end-of-trial, mean daily insulin doses were 0.40 U/kg BIAsp 30 and 0.39 U/kg glarg. Glarg plus glim-treated patients experienced significant weight gain of 1.5 kg (95% CI: 0.84; 2.19; P<0.0001). Weight change with BIAsp 30 plus met of +0.7 kg was not statistically significant (95% CI: -0.07; 1.42; P=0.0762). CONCLUSIONS: Starting insulin in Type 2 diabetes patients with twice-daily BIAsp 30 plus met can reduce HbA (1c) and mean prandial plasma glucose increment to a greater extent than once-daily glarg plus glim.

[Chronic renal disease and gravidity--case study]. / Chronické ochorenie obliciek a gravidita: kazuistika.

Uremia, the result of renal failure, is a serious clinical problem. Rising azotemia during gravidity significantly increases perinatal morbidity and mortality. This study presents the case of 34 years old patient with 27-year medical history of diabetes mellitus type 1 with diabetic nephropathy and chronic renal insufficiency. The patient got pregnant in the stage of preterminal renal failure. During the first trimester, she showed hypertension and proteinuria. In her 25th week of pregnancy, she was hospitalized with progressive proteinuria, almost uncontrollable hypertension and increased azotemia. Intensive conservative therapy led to a slight decrease of azotemia and proteinuria levels which, however, remained high. In fact, we considered using elimination methods several times. Due to severe hypoxia of the foetus, the gravidity was terminated by section at 30 weeks. After the parturition, the newborn had to be resuscitated. In the first days, the newborn showed increased azotemia which decreased spontaneously after several days. In a month after the termination of gravidity, N-substances increased again and the patient was enrolled in the chronic dialysis programme.