Capacity for the management of kidney failure in the International Society of Nephrology Eastern and Central Europe region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA).

Delivery of care for kidney failure (KF) globally has a significant disparity; even in some countries, it means end of life for the person. The International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) tries to address gaps in KF care and standardize global nephrology care. From the third iteration of the ISN-GKHA, we present data for countries in the ISN Eastern and Central Europe region. The median prevalences of chronic kidney disease (12.8%) and treated KF (873.5 pmp) were higher than the global rates, respectively. Hemodialysis was the most preferred modality for KF in adults, whereas kidney replacement therapy was more balanced in children. Although most of the countries in the region had lower-middle-income and upper-middle-income levels, health expenditures for kidney health care were almost generally covered publicly. Nephrologists were responsible for the medical kidney care of people with KF in all countries. There was adequate infrastructure to provide all kinds of treatment for kidney care in the region. Regional characteristics such as high levels of obesity, smoking, and Balkan nephropathy as an endemic disease coupled with a shortage of workforce and finance continued to affect kidney care in the region negatively. By making organizational and legislative arrangements, partnerships with national authorities and societies may accelerate the improvement of kidney health care in the region.

OSTEOPROTEGERIN AS AN EARLY SIGN OF CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER.

Chronic kidney disease (CKD) is among the most significant health problems, with the associated cardiovascular disease and bone metabolism disorders being the leading cause of morbidity and mortality in these patients. The aim of the study was to determine markers of bone turnover in patient sera (phosphates, calcium, alkaline phosphatase, parathyroid hormone and osteoprotegerin (OPG)) in all stages of kidney failure including kidney transplant recipients. We also wanted to determine whether dialysis vintage affects recovery of bone markers one year after transplantation. There were 164 study patients, whereas 30 healthy individuals served as a control group. Serum OPG progressively increased with decline of the glomerular filtration rate. The highest OPG concentration was recorded in dialysis group. We observed a statistically significant OPG increase in stage 2 CKD. In kidney transplant group, there was positive correlation between OPG and dialysis vintage. We also found that serum OPG was lower in patients treated with dialysis for less than 4 years prior to transplantation. We confirmed that CKD-mineral and bone disorder began in stage 3 CKD with parathyroid hormone and OPG elevation, and a statistically significant OPG increase in stage 2 CKD might be an early sign of CKD-mineral and bone disorder. Dialysis vintage longer than 4 years is associated with more significant disturbances in mineral and bone metabolism.

Case Report: Synchronous Removal and Implantation of Peritoneal Dialysis Catheter Using Bilateral Transversus Abdominis Plane Block.

Background: Peritoneal dialysis (PD) surgery include PD catheter insertion and removal. Both procedures require the use of anesthesia. The end-stage renal disease (ESRD) patients usually have severe comorbidities. The general anesthesia, because of its negative systemic effect, should be omitted in this vulnerable group of the patients. Transversus abdominis plane (TAP) block as a newer method of regional anesthesia is a technique without systemic effect and recently started to be used in ESRD patients for PD catheter placement and/or removal. Here we report a patient in whom we for the first time simultaneously removed and implanted a PD catheter by using a bilateral transversus abdominis plane block. Case Presentation: The patient was an 80-year-old man who was admitted for removal of malfunctioned PD catheter. Since the patient opted for staying on PD simultaneous implantation of catheter was planned. Because of his age and significant comorbidities, general anesthesia was avoided and bilateral TAP block become our option. In the same anesthesia, using bilateral TAP block, the old PD catheter was removed and a new one was implanted. Until now the patient is on regular PD without any complications. Conclusion: The TAP block could be used as a primary anesthetic technique in ESRD patients for PD surgery even for synchronous removal and implantation of PD catheter.

Peritoneal Dialysis Catheter Surgery using Transversus Abdominis Plane Block.

BACKGROUND: Peritoneal dialysis (PD) catheter surgery can be performed using regional anesthesia. We present our PD catheter placement and extraction experience using ultrasound-guided transversus abdominis plane (TAP) block. METHODS: In the present study, we analyzed 74 patients from our center with end-stage renal disease (ESRD) who underwent PD catheter placement (60 patients) and removal (14 patients) using a TAP block between June 2011 and December 2015. RESULTS: The TAP block was successful for 55/60 (91.7%) patients (insertion) and 13/14 (92.9%) patients (extraction). Other patients had pain at the incision site and required general anesthesia. There were no anesthesia-, surgery- or PD catheter-related complications. CONCLUSION: The TAP block is a safe and effective technique not only for high-risk ESRD patients but for all patients undergoing PD catheter placement or extraction.

Severe bleeding complications and multiple kidney transplants in a patient with tuberous sclerosis complex caused by a novel TSC2 missense variant.

We presented an extremely severe case of tuberous sclerosis complex (TSC) in a female patient with recurring, life-threatening bleeding complications related to renal angiomyolipomas. Massive intratumoral hemorrhage required surgical removal of both angiomyolipomatous kidneys and kidney transplantation. During the follow-up period, the patient developed severe metrorrhagia that eventually led to hysterectomy and salpingo-oophorectomy. Bleeding from the operative sites caused the loss of the first kidney transplant received from the mother, and immediate hemorrhagic shock led to the loss of the second, cadaveric kidney allograft. The third kidney transplant had a successful outcome. Pathological analysis of all tissue specimens showed TSC-associated lesions and deformed blood vessels in the surgically removed organs. Molecular genetic analysis of TSC1 and TSC2 in the DNA of peripheral leukocytes identified a novel TSC2 c.3599G>C (p.R1200P) variant. Functional assessment confirmed the likely pathogenicity of the TSC2 c.3599G>C (p.R1200P) variant. To the best of our knowledge, this is the first report of the c.3599G>C (p.R1200P) variant in exon 29 of the TSC2 gene related to a severe clinical course and multiple kidney transplants in a patient with TSC.

Treatment of Kidney Stone in a Kidney-Transplanted Patient with Mini-Percutaneous Laser Lithotripsy: A Case Report.

We report a case of a kidney-transplanted patient with urolithiasis treated with mini-percutaneous laser lithotripsy. The patient presented with renal dysfunction and graft hydronephrosis. Diagnostic procedures revealed ureterolithiasis as a cause of obstruction, and percutaneous nephrostomy was inserted as a temporary solution. Before surgery, the stone migrated to the renal pelvis. Mini-percutaneous laser lithotripsy was successfully performed, and during surgery, all stone fragments were removed. Six months after successful treatment, the patient has good functioning and stone-free graft.

Peritoneal Dialysis Catheter Placement Using an Ultrasound-Guided Transversus Abdominis Plane Block.

BACKGROUND: Peritoneal dialysis (PD) catheter placement is usually performed using general or local anesthesia. We present our PD catheter placement experience using an ultrasound-guided transversus abdominis plane (TAP) block, which is a regional anesthesia technique. METHODS: In this study, we analyzed 33 patients from our center with ESRD who underwent PD catheter placement using a TAP block between June 2011 and April 2014. RESULTS: The TAP block was successful for 29/33 (87.9%) patients. Four patients (12.1%) had pain at the incision site and required general anesthesia. There were no anesthesia-, surgery- or catheter-related complications. CONCLUSION: ESRD patients have a substantial number of comorbidities that can be negatively influenced by general anesthesia. Because regional anesthesia has no systemic effect, this procedure could be recommended for this group of patients. A TAP block is an effective, safe method and can be used as the principal anesthesia technique for PD catheter placement.

Nonalcoholic fatty liver disease and the renin-angiotensin system blockers in the patients with chronic kidney disease.

BACKGROUND: Recent data suggest that the renin-angiotensin-aldosteron system (RAAS) may be of importance in the pathogenesis of nonalcoholic fatty liver disease (NAFLD). We were interested to investigate whether the therapy with RAAS blockers in patients with different stages of chronic kidney disease (CKD) has any effect on steatosis and fibrosis grade; NAFLD documented by transient elastography (TE) (Fibroscan(®)-CAP). METHODS: Of 191 patients with various stages of CKD there were 61 patients with CKD grade III and IV, 62 patients with end-stage renal disease treated with chronic hemodialysis and 68 renal transplant recipients. Liver stiffness was selected as the parameter to quantify liver fibrosis. Furthermore, the Controlled Attenuation Parameter (CAP) was used to detect and quantify liver steatosis with the help of TE. RESULTS: CKD patients (p = 0.005) and CKD-NAFLD patients (p = 0.0005) with angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARBs) had statistically significant lower degree of liver stiffness in comparison to those without these medications (p = 0.005). Also, we were interested to explore is there any difference in fibrosis and steatosis grade due to use of ACE-I or ARBs. We did not find statistically significant differences between those two subgroups of patients with respect to liver steatosis/fibrosis. CONCLUSION: Based on our results, RAAS blockers could be an attractive option for the management of NAFLD. We believe that TE provides the opportunity of noninvasive screening of NAFLD in CKD patients. In further prospective analysis, we believe that by using TE as noninvasive method we could investigate are ACE-I/ARBs really effective medications for the treatment of NAFLD in CKD patients.

Nonalcoholic fatty liver disease (NAFLD) proven by transient elastography in patients with coronary heart disease.

BACKGROUND/AIM: The relationship between nonalcoholic fatty liver disease (NAFLD) and coronary heart disease (CHD) is poorly understood. In the present study, we aimed to assess the frequency of NAFLD in CHD patients by using a new diagnostic tool: transient elastography (TE; Fibroscan(®)-CAP). Clarification of the present study may help to provide a new noninvasive tool for the assessment of NAFLD in this specific population of patients and may be of clinical importance in planning preventive strategies in high-risk patients. PATIENTS AND METHODS: A total of 75 patients with proven CHD were enrolled. Liver stiffness was used to assess liver fibrosis, and controlled attenuation parameter (CAP) was used to detect and quantify liver steatosis by using Fibroscan(®) (Echosens, Paris, France). By CAP being implemented on TE, both liver steatosis and fibrosis can be evaluated simultaneously. RESULTS: Of the 75 patients, 45 (60 %) had CAP > 238 dBm(-1) and, by definition, NAFLD. Among the patients with NAFLD, 24 (53.3 %) had, in addition, liver stiffness > 7 kPa. Analyzing the influence of the degree of liver steatosis (expressed by CAP values) on the degree of CHD (defined by single or multiple vessels involved), we found that patients with multiple vessels involved had higher CAP values (p = 0.002). Furthermore, we noticed that significantly more patients with multiple vessels involved had liver stiffness > 7 kPa (p < 0.0001) indicating the more severe form of NAFLD in those patients. CONCLUSION: The main finding of our study is that TE provides the opportunity of noninvasive screening for NAFLD in CHD patients, as it is a quick, simple, reliable, and repeatable method and more cost-effective than liver biopsy.

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.

[Evaluation of viral hepatitis in solid organ transplantation]. / Evaluacija virusnih hepatitisa u transplantaciji solidnih organa.

Renal transplantation has significantly improved survival of patients with end-stage renal disease (ESRD). Transplantation is the best treatment in this population of patients. Despite the introduction of various preventive measures, viral hepatitis, i.e. hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, are still a major problem because they are common in patients on renal replacement therapy as well as in allograft recipients. They are a significant cause of morbidity and mortality in this patient population. In recent years, hepatitis E virus (HEV) infection has been added as an emergent cause of chronic hepatitis in solid organ transplantation, mainly in renal and liver allograft recipients. Most studies show higher mortality in renal transplant recipients (RTRs) infected with HBV, compared with RTRs without HBV infection, although this topic is still under debate. Furthermore, HCV infection in RTRs is associated with a significant reduction in patient and graft survival due to liver disease and septic complications related to cirrhosis and immunosuppressive therapy. The immunosuppressive therapy prescribed after transplantation modifies the natural history of chronic HCV infection. Given the high prevalence of HCV and HBV infections in RTRs, a growing incidence of hepatocellular carcinoma and the possible contribution of immunosuppression might be expected in these patients. Therefore, after renal transplantation, early screening with abdominal ultrasound (every 3 months in cirrhotic patients and every 6-12 months in non-cirrhotic RTRs) is necessary when the risk factors such as HBV and HCV are present. The European Association for the Study of the Liver (EASL) recommends that all HbsAg-positive patients who are candidates for solid organ transplantation should be treated with nucleoside analogs. The KDIGO guidelines recommend that all HbsAg-positive RTRs receive prophylaxis with tenofovir, entecavir or lamivudine; however, tenofovir and entecavir are preferable to lamivudin. Viral suppression by inhibiting necro-inflammation may result in reduced fibrosis, thereby improving transplant survival. Active HCV infection in a dialysis patient requires evaluation of liver fibrosis. Antiviral therapy should be given to all HCV-infected dialysis patients in order to achieve a sustained virologic response (SVR) not only to avoid subsequent hepatic deterioration but also to limit the risks of HCV-related posttransplant de novo glomerulonephritis. Systematic vaccination of all HbsAg-negative patients is the best preventive treatment of HBV infection. HbsAg positive donors are only used occasionally, whereas the use of hepatitis B core antibody (HbcAb)+, HbsAg negative donors is more common but remains somewhat controversial. The presence of antibody to HCV is indicative of HCV infection because antibody to HCV appears in peripheral blood within two months of HCV exposure. However, it is important to emphasize that detection of antibody to HCV by serologic screening of the donor is not predictive of HCV transmission. Approximately 50% of patients positive for antibody to HCV have detectable hepatitis C viremia by PCR analysis of peripheral blood. Therefore, all organ donors with PCR analysis positive for HCV will transmit HCV to RTRs. On the other hand, the risk of transmission from an organ donor with negative PCR analysis is unclear. Another problem in the evaluation of the potential donors of solid organs is the fact that antibody testing by enzyme-linked immunosorbent assays (ELISAs) will not detect recent infections. The use of nucleid acid testing (NAT) could be useful because it involves amplification of viral gene products and thus is not dependent on antibody formation. Therefore, by using this method the period between the infection and detectability, which is known as the window period, could be reduced. However, this method is expensive and time consuming.

[Guidelines for diagnosis, therapy and follow up of Anderson-Fabry disease]. / Smjernice za dijagnostiku, lijecenje i pracenje Anderson-Fabryjeve bolesti.

Fabry disease (Anderson-Fabry disease) is one of the most common lysosomal storage diseases (after Gaucher disease) caused by deficient activity of the α-galactosidase A (α-Gal A) enzyme, which leads to progressive accumulation of globotriaosylceramide in various cells, predominantly in endothelium and vascular smooth muscles, with multisystem clinical manifestations. Estimates of the incidence range from one per 40,000 to 60,000 in males, and 1:117,000 in the general population. Pain is usually the first symptom and is present in 60%-80% of affected children, as well as gastrointestinal disturbances, ophthalmologic abnormalities and hearing loss. Renal failure, hypertrophic cardiomyopathy, or stroke as the presenting symptom may also be found even as isolated symptoms of the disease. Life expectancy is reduced by approximately 20 years in males and 10-15 years in females, therefore enzyme replacement therapy should be introduced in patients of any age and either sex, who meet treatment criteria for Anderson-Fabry disease.

Guidelines for diagnosis, therapy and follow up of Anderson-Fabry disease.

Fabry disease (Anderson-Fabry disease) is one of the most common lysosomal storage diseases (after Gaucher disease) caused by deficient activity of the alpha-galactosidase A (alpha-Gal A) enzyme, which leads to progressive accumulation of globotriaosylceramide in various cells, predominantly in endothelium and vascular smooth muscles, with multisystem clinical manifestations. Estimates of the incidence range from one per 40,000 to 60,000 in males, and 1:117,000 in the general population. Pain is usually the first symptom and is present in 60%-80% of affected children, as well as gastrointestinal disturbances, ophthalmologic abnormalities and hearing loss. Renal failure, hypertrophic cardiomyopathy, or stroke as the presenting symptom may also be found even as isolated symptoms of the disease. Life expectancy is reduced by approximately 20 years in males and 10-15 years in females, therefore enzyme replacement therapy should be introduced in patients of any age and either sex, who meet treatment criteria for Anderson-Fabry disease.

[Kidney transplantation--a successful story started 110 years ago]. / Transplantacija bubrega--110-godisnja uspjesna prica.

Organ transplantation is one of the most important medical achievement of the 20th century. Emerich Ullmann performed on March 7th 1902, in the Vienna, the first successful kidney transplantation. It was an autotransplantation in a dog, with a transposition of a kidney in the neck region. Graft function persisted over the next five days. Only the few months later Alexis Carrel performed in Lyon another succcessful kidney autotransplantation in a dog. Carrel was interested in the vascular anastomosis improvement. He developed the triangulation technique of vessel anastomosis and so called Carrel patch. Since then both techniques have become a standard in kidney transplantation. Carrel was awarded with Nobel Prize in Physiology and Medicine in 1912 for his innovatory work in the field of transplantation and vascular surgery. These experimental transplantations preceded kidney transplantation in the humans which has become a routine operative procedure.

[The role of core decompression for the treatment of femoral head avascular necrosis in renal transplant recipients]. / Lijecenje asepticne nekroze glavice femura u bolesnika s bubreznim transplantatom metodom dekompresije.

Avascular bone necrosis is a relatively rare but significant complication in renal transplant recipients because it causes progressive pain and invalidity. It can be the consequence of the action of numerous causative factors, but it is mostly connected to corticosteroid treatment.The underlying pathophysiologic mechanism is a diminished blood flow to the bone leading to necrosis and bone destruction. During the past 25-years period, 570 renal transplantations and five combined kidney and pancreas transplantations were performed in our centre. A part of the patients was lost to follow-up due to the separation of Croatia from the former Republic of Yugoslavia. After transplantation, we revealed aseptic necrosis of the femoral head in five female patients. All patients had a history of treatment with pulse doses of corticosteroids. At transplantation the average age of the patients was 52.2 yrs (range 46 to 62 yrs), and dialytic treatment before transplantation lasted in average 9.2 yrs (range 2.5 to 21.2 yrs). The period between renal transplantation and the development of clinical signs of avascular bone necrosis lasted in average 1.2 yrs (range 0.3 to 2.3 yrs). We will demonstrate our 62-year old female patient with terminal renal failure caused by post-streptococcal glomerulonephritis, who was treated with peritoneal dialysis 2.5 years before renal transplantation. Twenty months before renal transplantation the patient received pulse doses of corticosteroids, together with immunoglobulins and plasmapheresis, for the treatment of an acute polyradiculoneuritis Guillaine Barré. After transplantation a standard immunosuppressive protocol was applied which included tacrolimus, mycophenolate mofetil, corticosteroids and induction with basiliximab. Four months after transplantation the patient started to feel pain in the right hip after longer standing, in addition to the earlier long-lasting problems caused by bilateral coxarthrosis. The pelvic radiograph showed subchondral radiolucencies in the lateral part of the head circumference spreading into the proximal part of the neck of the right femur, which indicated the presence of aseptic necrosis, but these changes could have also been caused by coxarthrosis. Unexpectedly, magnetic resonance imaging (MRI) did not reveal changes characteristic for avascular bone necrosis. Due to the progressively worsening of pain and the radiographic finding, the patient was submitted to decompression surgery of the femoral head. The surgical procedure was performed under diascopic guidance (C-arm) which allowed the correct positioning of a Kuerschner wire. A cannulated drill (diameter 4.0 mm) was placed over the wire and we performed two drillings of the spongiosis of the femoral head through to the subchondral area. Postoperatively, the patient was soon verticalized and advised to walk with crooks during a period of six weeks. This time is necessary to allow the mineralisation and strengthening of the bone which is now better vascularised. The patient recovered well and had no more pain. In renal transplant recipients it is most important to raise suspicion and verify the presence of avascular bone necrosis early, because timely bone decompression surgery can eliminate pain and cure the patient or it can prevent or delay bone destruction. When clinical signs of avascular bone necrosis arise and radiographic or standard MRI findings are negative, additional investigations (i.e. SPECT or MRI with contrast) should be performed to confirm or exclude the diagnosis. In latter phases of the disease, surgical decompression of the femoral head cannot lead to permanent amelioration, and it is inevitable to perform more invasive surgical procedures like "resurfacing" or bone grafting in younger patients, or the implantation of total hip endoprotheses.

[Opatija study: observation of hemodialysis patients and titration of CERA dose just switched from another erythropoiesis stimulating agent]. / Istrazivanje OPATIJA: Promatranje hemodijaliziranih bolesnika i titriranje doze lijeka CERA na koji su bolesnici prebaceni s drugih lijekova koji stimuliraju eritropoezu.

INTRODUCTION: Anemia is a well-documented consequence of chronic kidney disease, its frequency increases with the progression of renal failure and occurs in up to 95% of patients with end stage renal disease (ESRD). Erythropoietin stimulating agents (ESAs) have become the standard of care in the treatment of renal anemia. The use of methoxy polyethylene glycol-epoetin beta, continuous erythropoietin receptor activator, represents an important benefit in clinical practice. AIM: The aim of the OPATIJA study was to compare the efficacy and safety of maintaining hemoglobin levels in dialysis patients and to assess its variability in a parallel-group design. Patients were randomly assigned to receive methoxy polyethylene glycolepoetin beta once monthly in "normal" dose conversion according to the label of record or "low" or "alternative" dose conversion widely spread according to previous ESA doses. SUBJECTS AND METHODS: A total of 79 patients were included in the study. The patients who had undergone continuous maintenance intravenous ESA therapy were divided into two parallel groups: group 1 including 36 patients directly switched to CERA according to the manufacturer recommended dosage; and group 2 including 43 patients that were switched by using "low" or "alternative" dose conversion widely spread according to previous ESA doses. During the 18-month period, each patient's anemia parameters, i.e. hemoglobin level, serum iron concentration, TSAT and ferritin, were monitored at intervals not longer than two months. According to hemoglobin levels, the dosage of CERA was adjusted if needed along with iron supplementation. RESULTS: At the end of the study, the two groups consisted of 51 patients: 26 of those treated with the recommended dose of CERA and 25 treated with the alternative dose. In the normal conversion group, the mean hemoglobin level during the course of the study was 104.41 g/L with the mean monthly dose of 104.33 mcg CERA. In the alternative conversion group, the mean hemoglobin level during the course of the study was 105.33 g/L with the mean monthly dose'of 113.08 mcg CERA. In the alternative conversion group, 33% of patients had Hb levels in the tight recommended range of 110-120 g/L. In 30% of patients, Hb levels were 100-110 g/L, in 29% less than 100 g/L, and in 8% more than 120 g/L. The mean Hb levels at the beginning and the end of the study did not differ significantly, except for the patient group with Hb levels >120 g/L, where 7% of patients with recommended dosing and none of the patients from the alternative dosing group had such levels (P=0.017). Hemoglobin variability higher than 10 and 20 g/L was recorded in both groups, but less frequently in the alternative CERA dosing group. CONCLUSION: Both treatments with the recommended and alternative conversion dosing achieved and maintained target hemoglobin level. Study results confirmed the need of individualized approach in the treatment of anemia in ESRD patients receiving hemodialysis, resulting in less potentially harmful hemoglobin variability.

Defense mechanisms in alcohol dependent patients with oral and oropharinegal cancer.

The effects of psychological factors in alcoholics with malignant tumor of the oral cavity and oropharynx are scarcely explored. The aim of the research was to examine early family relations and investigate differences in the use of defense mechanisms in alcohol dependent patients suffering from malignant tumor of the oral cavity and oropharynx compared to alcohol dependent persons without malignant tumors and healthy controls. The research included 51 alcohol dependent patients treated for malignant tumor of the oral cavity and oropharynx at the University Hospital Center Rijeka from 2005 to 2009. The control groups corresponded to the experimental group in age, sex and education level. The research used a general demographic questionnaire, the Mini International Neuropsychiatric Interview and the Revised Questionnaire of Life Style and Defense Mechanisms. The research groups showed significant differences in difficult childhood (p < 0.001) including abuse (p = 0.004). The alcohol dependent persons suffering from malignant tumors of the oral cavity and oropharynx significantly less frequently used primitive defense mechanisms of regression (p = 0.004) and displacement (p = 0.013) compared to alcoholics without malignant tumors who significantly more often used neurotic defense mechanisms - compensation (p = 0.005) and intellectualization (p < 0.001). The earliest emotional experiences and quality of family relations affect the development of defense mechanisms. These are the psychological factors in the development of oropharyngeal cancer in alcohol addicts.

[Role of renal anemia in progression of chronic kidney disease]. / Bubrezna anemija: cimbenik rizika u nastanku kronicnog bubreznog zatajenja.

Anemia is common in the patients with chronic kidney disease (CKD). It usually appears in stage 4, but it is not rare even in stage 3 of the CKD. It is mandatory to evaluate the patients with signs of CKD on the presence of renal anemia. Early anemia treatment, both in the stages 3 and 4, is associated with less cardiovascular events and better quality of life of this patient population. Treatment of renal anemia is possible with all erythropoiesis stimulating agents (ESAs). Newer formulations may cause less hemoglobin variations and prolonged treatment interval. There are some evidences about beneficial treatment of renal anemia causing slower progression of CKD, but we need further controlled, randomized clinical trials to prove these observations.

Predictive parameters of gestational diabetes mellitus.

Gestational diabetes mellitus is a carbohydrate intolerance recognized in pregnancy. The objective of this study was to determine the prevalence of gestational diabetes mellitus (GDM) of all deliveries at the University Hospital Rijeka, Croatia (34 997 deliveries over 10-year period) using 2-hour 75 g oral glucose tolerant test and to evaluate the impact of GDM on neonatal outcomes and mother's health. Gestational diabetes was diagnosed in 55 of 128 pregnant women with suspected glucose intolerance. Logistic regression analysis was used to examine the relationship between fasting plasma glucose, age, family history, body mass index, maternal weight gain, neonatal weight, neonatal head diameter and Apgar score in the gestational diabetes group and in the non-diabetes group. The results indicate that fasting plasma glucose greater than 7.0 mmol/L and maternal overweight are strong predictors for GDM and macrosomia. There was no difference in the mode of delivery, and vitality and metabolic complications among the infants of all analyzed mothers. We concluded that to prevent GDM as well as to reduce the rate of macrosomic infants good glycemic control should be initiated as soon as possible. The 2-hour 75 g OGTT is worth enough to evaluate GDM. Women should be counseled and encouraged to lose weight before or at the beginning of the conception period.

Urothelial cancer in patients with Endemic Balkan Nephropathy (EN) after renal transplantation.

GOAL: Analysis of the incidence of urothelial cancer and outcome of treatment in patients with Endemic Balkan Nephropathy (EN) after renal transplantation. METHODS: From January 1985 until October 2006, 550 kidney transplantations (389 cadaveric) and 5 combined kidney and pancreas transplantations were performed in University Hospital Center Rijeka. In only 6 (1.1%) of 555 transplant recipients, EN was diagnosed as the original kidney disease, based on medical history, clinical findings, and laboratory results, but without pathohistologic verification. All patients with EN received the first renal transplant from a cadaver. Patients' mean age at transplantation was 50.3 +/-15.9 yrs, five patients (83.3%) were male. The incidence of malignant tumors in all 555 transplant recipients was analyzed, with an emphasis on the incidence of urothelial cancer and outcome of treatment in the group of patients with EN. RESULTS: During posttransplant follow-up period, malignancy was diagnosed in 27 (4.9%) out of 555 transplant recipients. Skin cancer was diagnosed in 7 patients (1.3%), followed by cancer of the urinary tract in 6 patients (1.1%) and breast cancer in 3 patients (0.5%). In 3 of 6 patients with EN, urothelial cancer was diagnosed, resulting in the death in two patients. In the third patient, urothelial cancer showed a high affinity for recurrence, and besides the strong reduction of immunosuppressive therapy, repeated surgical treatment was needed. CONCLUSIONS: Patients with EN show a high incidence of urothelial cancer after renal transplantation. A thorough nephro-urological evaluation is needed before transplantation, and a careful follow-up is required afterward to ensure an early diagnosis of malignancy. Preventive nephroureterectomy is recommended.