[[GUIDELINES FOR THE PREVENTION, MONITORING AND THERAPY OF CHRONIC KIDNEY DISEASE-METABOLIC BONE DISEASE IN PATIENTS WITH CHRONIC KIDNEY DISEASE].]

Chronic kidney disease (CKD) is a systemic disease with numerous complications associated with increased morbidity and mortality. Chronic kidney disease-metabolic bone disease (CKD-MBD) starts at early stages of CKD with phosphorus accumulation and consequent initiation of numerous events that result with the development of secondary hyperparathyroidism with changes on bones and extraskeletal tissues. The most important and clinically most relevant consequences of CKD-MBD are vascular calcifications which contribute to cardiovascular mortality. Patients with the increased risk for the development of CKD-MBD should be recognized and treated. Prevention is the most important therapeutic option. The first step should be nutritional counseling with vitamin supplementation if necessary and correction of mineral status. Progression of CKD requires more intensive medicamentous treatment with the additional correction of metabolic acidosis and anemia. Renal replacement therapy should be timely initiated, with the adequate dose of dislaysis. Ideally, preemptive renal transplantion should be offered in individuals without contraindication for immunosuppressive therapy.

The novella about diabetic nephropathy.

Diabetic nephropathy is a common complication in patients with diabetes mellitus and one of the major reasons for renal replacement therapy in Croatia, Europe and the United States. It is characterized by proteinuria, decline in glomerular filtration, hypertension, and high risk of cardiovascular morbidity and mortality. Deterioration of renal function in diabetic nephropathy develops through five clinical stages characterized by the respective histologic description. Genetic susceptibility, hyperglycemia, high blood pressure and duration of diabetes mellitus definitely play a role in the pathogenetic sequence. Early diagnosis, appropriate patient follow up and treatment are essential to improve the outcomes. Interdisciplinary approach and close collaboration of nephrologists and diabetologists are essential for timely detection of disease progression. Tight glycemic control under the supervision of diabetologists, screening of patients, and once a year report of albuminuria and glomerular filtration allow for detection of renal damage in the early stages and timely referral to a nephrologist. The points of interest given in this overview are description of clinical staging in relation to pathologic classification, repetition of basic causal features, and brief analysis of treatment.

Bone fragility fractures in hemodialysis patients: Croatian surveys.

Disturbances of bone mineral metabolism are common complications of chronic kidney disease with bone fractures as one of the most important consequences. The aim of this study was to estimate prevalence of bone fractures among Croatian hemodialysis patients and to determine the possible fracture risk. The study was carried out in 767 hemodialysis patients from nine Croatian hemodialysis centers. Demographic, laboratory and bone fracture data were collected from medical records as well as therapy with vitamin D analogs. Fragility fractures were defined according to the World Health Organization definition. In 31 patient a total of 36 fractures were recorded. The prevalence of patients with bone fractures was 4.0%. The mean age of patients with fractures was 68.6 years. There were 9 male and 22 female patients with frac- tures. The mean hemodialysis duration was 63.3 months. Among all fractures the most common were hip fractures (39%) followed by forearm fractures (22%). This is the first study regarding epidemiology of bone fractures in Croatian hemodialysis patients. The prevalence of patients with bone fractures in our group of hemodialysis patients is high. Fractures were more frequent among women and older patients, patients who have been longer on dialysis and in patients with higher concentration of PTH.

Vein diameter after intraoperative dilatation with vessel probes as a predictor of success of hemodialysis arteriovenous fistulas.

BACKGROUND: Vascular access is "the life line" for patients on chronic hemodialysis. The autogenous arteriovenous fistula provides the best access to the circulation because of low complication rate, long-term use, and lower cost, compared to arteriovenous graft and central venous catheter. The primary objective of this prospective study was to investigate the predictive value of vein diameter after intraoperative dilatation with vessel probes on hemodialysis fistula maturation. MATERIAL AND METHODS: Ninety-three fistulas were performed by a single surgeon from February 1, 2006 to January 31, 2009. Intraoperative vein dilatation with vessel probes was attempted in all fistulas. Measurements of the feeding artery diameter, vein diameter and the increased vein diameter after intraoperative dilatation were performed and immediate failure, early patency, early failure, primary patency, and fistula survival outcomes were recorded during 48-month follow-up. RESULTS: Early failure occurred in 20% of fistulas and 70% matured sufficiently for cannulation. Variables with significant impact on the failure to mature by univariate analysis were: body-mass index (P=0.041), artery diameter (P<0.001), vein diameter (P=0.004), and vein diameter after dilatation (P=0.002). However, but multivariate analysis showed that only body-mass index (P=0.038), artery diameter (P=0.001), and the diameter of the vein after dilatation (P=0.018) significantly affected maturation. In a group of 56 (60%) patients with vein diameter before dilatation ≤ 2 mm, among vessel characteristics found by multivariate analysis, only vein diameter after dilatation (P=0.004) significantly affected function. CONCLUSIONS: Artery diameter and vein diameter after intraoperative dilatation with vessel probes were the main predictors of fistula function.

[How to prevent protein-energy wasting in patients with chronic kidney disease--position statement of the Croatian Society of Nephrology, Dialysis and Transplantation]. / Kako prevenirati i lijeciti proteinsko-energetsku pothranjenost u bolesnika s kronicnom bolescu bubrega--osvrt hrvatskog drustva za nefrologiju, dijalizu i transplantaciju na preporuke medunarodnog drustva za prehranu bubreznih bolesnika.

Protein-energy wasting (PEW) is a frequent problem in patients with end-stage renal disease, which is associated with adverse outcome. Risk factors for development of PEW in dialysis patients include anorexia, limitations in food intake due to problems with mineral metabolism (hyperphosphatemia, hyperkalemia). Prevention of PEW in dialysis population demands different therapeutic measures to correct abnormalities and to prevent loss of energy and proteins. Therapeutic approach should be individualized based on the specific problems of each patient in order to correct metabolic problems and to optimize food intake. In patients with inability to maintain nutritional status with standard oral feeding, other measures which include oral nutrition supplements and intradialytic parenteral feeding should be applied. Anabolic steroids, growth hormone and adequate oral nutritional supplements, together with physical activity may prevent further catabolism and correct abnormalities. Appetite stimulators, antiinflammatory interventions and anabolic drugs seem promising; however, their efficacy should be investigated in future clinical trials.

[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.

Renal replacement therapy in cardiology wards: changing trends in a transitional country.

The leading causes of death in patients with chronic kidney disease (CKD) are cardiovascular diseases, regardless of the stage of disease or method of renal replacement therapy. On the other hand, CKD is a major risk factor for cardiovascular complications after acute myocardial infarction, as well as for adverse outcome in patients with chronic heart failure. In the present study we prospectively followed-up nephrological interventions in cardiology wards in order to determine changes in indications, treatment possibilities and outcome of patients. All patients treated at cardiology ward of the Clinical Hospital Centre Zagreb and requiring renal replacement therapy from January 2003 to December 2009 were included in the investigation. Cardiology hospital unit (intensive care or regular hospital cardiology ward), age, gender, Sepsis-related Organ Failure Assessment (SOFA) score, indication for dialysis, primary diagnosis, vascular access, methods of treatment, number of treatments, prescribed and delivered dose of dialysis and outcome were recorded. Patients were followed up until death during hospitalization or discharge from the hospital. From January 2003 to December 2009, 251 patients had been hospitalized at different cardiology wards and required renal replacement therapy. Mean age was 64.95 years (range 22 to 97 years), and there were 27.8% female patients. 52.9% of patients were hospitalized in the coronary intensive care unit. SOFA score had increased during the observed period from average 6.5 in 2003 to 13.45 in 2009. Specific knowledge with close collaboration between nephrologists and cardiologists is needed to achieve optimal outcome in this complex condition.

[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.

[Adhesiolysis and partial resection of terminal ileum in a patient with kidney transplantation and severe sclerosing peritonitis]. / Adhezioliza i parcijalna resekcija terminalnog ileuma u bolesnice s transplantiranim bubregom i teskim sklerozirajucim peritonitisom.

A 21-year-old female patient was diagnosed with horseshoe kidney at the age of 10. She had been treated with peritoneal dialysis from 2005 to 2009, when she received kidney from a deceased donor. The posttransplant course was complicated by development of Pseudomonas aeruginosa and Candida sepsis. Reduced immunosuppression resulted in acute rejection, which demanded graphtectomy 2 months after transplantation. She restarted peritoneal dialysis for additional 2 years. In March 2011, she received her second transplant with excellent function. Nine months after the transplantation, she developed ascites, with early satiety and vomiting. MSCT revealed severe encapsulating sclerosing peritonitis. Her overall condition deteriorated, so she underwent adhesiolysis with resection of incarcerated terminal ileum. Due to acute allograft rejection, urgent graphtectomy was performed. Currently, she is receiving everolimus and dialysis successfully, with excellent overall status.

[Post-transplant erythrocytosis]. / Eritrocitoza nakon transplantacije bubrega.

Post-transplant erythrocytosis is defined as an increase in hematocrit above 55%. It occurs in 10%-15% of renal transplant recipients, most commonly from 8 to 24 months after transplantation. Twenty-five percent of patients experience spontaneous remission within 2 years, while 75% develop symptoms and signs of hyperviscosity (headache, hypertension, plethora). The etiology is multifactorial and includes erythropoietin, renin-angiotensin system (RAS) and IGF-1 as the main factors. RAS inhibition with either ACE inhibitors or angiotensin receptor blockers is efficient therapy which decreases hematocrit in 90% of patients within 2 to 6 weeks, thus decreasing the incidence of fatal complications (like pulmonary embolism and stroke).

[Association between viral infections and post-transplant malignancies in renal transplant recipients]. / Povezanost virusnih bolesti i tumora nakon transplantacije bubrega.

Immunosuppressive treatment is associated with an increased incidence of different malignant diseases. The etiology of posttransplant malignancies is multifactorial and includes decreased immune response to different viral infections, inappropriate removal of damaged cells, and impaired ability to repair DNA. EBV, HHV-8, Merkel cell virus, hepatitis B virus, hepatitis C virus and BK virus are all considered to be involved in the etiology of post-transplant malignancies. CMV has been considered as a potential causative factor in the development of colon cancer. However, current knowledge is mainly based on case reports. Further studies are needed to establish the causative role of different viruses in the etiology and pathogenesis of different malignant diseases in renal transplant population.

[Treatment of renal anemia with iron in hemodialysis patients in General Hospital Bjelovar]. / Lijecenje anemije kronicne bubrezne bolesti zeljezom u bolesnika na kronicnom programu hemodijalize.

Renal anemia is caused by a lack of erythropoietin and iron, and is associated with increased morbidity and mortality in patients with chronic kidney disease. Iron deficiency is more common than previously thought. Diagnosis of absolute and relative iron deficiency is difficult because of the lack of an ideal diagnostic method. Adequate supplementation of iron in patients with renal anemia at a certain percentage of patients corrects anemia, while the other reduces the required doses of erythropoesis stimulating agents (ESAs), which can reduce treatment costs. In Department of Dialysis of General Hospital Bjelovar we carried out a retrospective study about treating renal anemia with iron during 36 months in 67 patients on chronic hemodialysis program in a period from 2007. to 2010. Our goal was to see if we adequately treat renal anemia with iron and to show the connection between the level of hemoglobin (Hb), ferritin and transferrin saturation (TSAT). The average value of ferritin in the 36 months follow-up was 196.8mcg/l, TSAT 24.16%, 107.8 g Hb/l. We conclude that the elevation of ferritin and TSAT correlates with the increase of Hb values in patients with renal anemia. Ferritin and TSAT values in our center are above the minimum criteria recommended by guidelines, but not within the target values for the treated population.

[Treatment of renal anemia in hemodialysis patients in General Hospital Bjelovar from 2007 to 2010]. / Lijecenje anemije kronicne bubrezne bolesti u bolesnika na programu kronicne dijalize u OB Bjelovar u razdoblju od 2007. do 2010. godine.

Renal anemia is complication of chronic kidney disease. It is caused by crythropoietin deficency and is associated with adverse outcomes in CKD patients. Renal anemia should be treated with erythropoesis-stimulating agents (ESAs), supplementary iron, adequate dialysis, and if necessary with red blood cells transfusions. The main problem of treatment is how to determine target hemoglobin value and keep it within the constant range. Current guidelines recommend target hemoglobin level 110 - 120 g/l, but optimal value need to be adjusted for every patient individualy keeping in mind primary kidney disease, age, gender and comorbidities. In Department of Dialysis of General Hospital Bjelovar we carried out a retrospective study about treating renal anemia in 67 patients on chronic hemodialysis program during 36 months in a period from 2007. til 2010. We monitored hemoglobin, feritin, saturation of transferin (TSAT), dose of LSE, number of change in dosage and number of transfusion. Mean hemoglobin level was 107.8 g/l, feritin level 196.8 mcg/l, TSAT 24.16%, weekly dose of ESAs 5951.9 IU. in 53.7% patiens dose was changed 11 - 20 times during that period, and 34% of patiens was treated with at least 1 dose of transfusion of red blood cells. We conclude that better iron supplementation and moderately higher doses of FSAs correlate with higher hemoglobin value, and hemoglobin variations is still big problem in renal anemia treatment.

Are lipoprotein disturbances in chronic hemodialyzed patients only renal failure related?

Chronically hemodialyzed (HD) patients frequently suffer from quantitative and even more often qualitative serum lipids disorders. Mostly they have increased triglycerides and VLDL-cholesterol, slightly increased or normal total and LDL-cholesterol and decreased HDL-cholesterol concentrations. The study compared lipid profile between two groups of chronic HD patients coming from regionally distinct areas, the continental and the maritime one. The aim was to examine the hypothetic influence of their different dietary habits on lipid profile. The study included 72 patients from continental region (39 men) and 50 from maritime part of the country (30 men). Patients suffering from diabetes mellitus, hypothyroidism, liver disease, alcoholics as well as sevelamer treated patients were not included. Prior to a HD session the patients were determined fasting total cholesterol, triglycerides, HDL- and LDL-cholesterol, total proteins, albumins and C-reactive protein serum concentrations. All patients were undergoing bicarbonate hemodialysis with polysulphone dialysers of low permeability. The continental group of patients were somewhat older, undergoing HD for longer period of time, of lower height, greater weight, greater body mass index, higher total (4.70 +/- 0.91:4.42 +/- 1.02 mmol/L), and LDL-cholesterol (2.78 +/- 0.74:2.66 +/- 0.75 mmol/L) concentrations, while lower triglycerides (1.72 +/- 0.84:1.81 +/- 0.83 mmol/L) and HDL-cholesterol (1.13 +/- 0.42:1.16 +/- 0.54 mmol/L). However all the differences were without statistical significance. Chi-square test showed that the continental group of patients consumed more often pork, bacon, smoked and cured meats, margarine, butter, walnuts, almonds, garlic, cream and full-fat cheese than fish. They prepare food more often with lard and sunflower oil. Almost every fourth continental patient received statins, while only every 25th in the maritime group of patients. There were not any statistically significant Chi-square values for differences in frequencies of patients with total cholesterol greater than 5.2 mmol/L, triglycerides above 1.6 mmol/L, HDL-cholesterol less than 1.1 mmol/L, LDL-cholesterol greater than 2.6 mmol/L, obesity and malnutrition between the two groups. Based on the results of this study we have concluded that diet has significant influence on lipid profile of HD patients. Even though the continental and the maritime groups of patients differed significantly in diet, they were similar in plasmatic lipoprotein concentrations. However, this similarity was ascribed only to statin treatment, which was more frequent in the continental group of patients. The influence of ESRD and HD as a method of renal replacement therapy on lipid profile was not more dominant than diet.

[Treatment anaemia of chronic kidney disease in predialysis patients (stage 1-4)]. / Lijecenje anemije u bolesnika s kronicnom bubreznom bolesti koji jos nisu na dijalizi (stadiji 1.-4.).

Anemia is the most frequent haematological problem of chronic kidney disease (CKD). It begins in early stage of CKD and worsens with disease progression, affecting nearly all of predialysis patients. It is usually asymptomatic, therefore is underdiagnosed and undertreated. Anemia of CKD is predominantly a result of abnormal erythropoietin (EPO) production and iron deficiency. Renal anemia is associated with an increased risk of ischemic heart disease, left ventricular hypertrophy, chronic heart failure and higher cardiovascular morbidity and mortality. Patients et risk for CKD should be more often monitored for early detection of anemia so they could start with treatment on time. Recent studies show that erythropoeisis-stimulating agents (ESAs) are effective in predialysis especially if used with antihypertensive agents and statin. Correcting anemia in early stage kidney disease may delay progression to end-stage kidney disease (ESRD) and prolong time to start dialysis. Improved cardiac function in those patients reduce morbidity and mortality risk and improve quality of life (QoL) in patients with CKD.

[The treatment of hyperhomocysteinemia in patients on dialysis: folic acid or the high-flow polysulphonic membrane?]. / Lijecenje hiperhomocisteinemije u dijaliziranih bolesnika: folna kiselina ili visokoprotocna membrana?

AIM: The aim of the study was to determine the effects of high-flow and low-flow hemodialysis (HD), with simultaneous treatment with folic acid and vitamin B12, on total homocysteine (tHcy) concentration in plasma of dialyzed patients. METHODS: The planned clinical observation included 46 patients of both sexes, aged 21-82, treated with bicarbonate dialysis for a mean of 4.7 years. The patients were divided into group A, subsequently dialyzed by use of high-flow polysulphonic membrane (AN 69ST, Nephral 300), and group B that continued to be dialyzed by use of low-flow diacetate membrane (Diacepal 14 and 16). The subjects in both groups received 30 mg of folic acid at the end of each dialysis (3 times a week), and 500 g of vitamin B12 at the end of every other dialysis. The method of stable isotopic dilution mass spectrometry was used to measure tHcy. Folic acid was determined by the test based on ion capture technology. Vitamin B12 was determined by MEIA. RESULTS: An increase in the concentration of tHcy was observed in 39/46 (85%) patients with a mean concentration of 24.76 +/- 11.04 micromol/L. The mean concentration of folic acid and vitamin B12 was within the normal limits. In the group dialyzed by high-flow dialyzer, the values of tHcy and folic acid decreased (18.74 +/- 2.95 micromol/L and 13.90 +/- 6.78 pmol/L) after hemodialysis, which was significant compared to the initial value (p<0.01 and p<0.05, respectively). At four weeks of treatment, tHcy concentration before HD showed a significant decrease both in the group dialyzed by high-flow dialyzer (15.10 +/- 4.26 mmol/L, p<0.01) and in the group dialyzed by low-flow dialyzer (12.54 +/- 3.87 micromol/L, p<0.01) compared to the measure before HD and before the treatment. There was no statistically significant difference (z -0.40, p>0.68) in the percentage of tHcy change between the group treated by high-flow dialyzer and the group treated by low-flow dialyzer in the measurements before HD and before the treatment with folic acid and vitamin B12, and after the treatment. DISCUSSION: There is a literature report on the concentration increase by 26 micromol/L, which is very similar to our result. The absence of long-term effect on predialysis concentration of tHcy in HD by high-flow membrane has also been described, because the decrease of tHcy is mantained until the uremic toxins, enzyme inhibitors that are necessary for the process of remethylation of Hcy, accumulated again. During high-flow HD, the folic acid concentration decreased by 23.05% on an average, consistent with other literature reports. Some reports support our observation that the dosage of folic acid required for tHcy decrease is 15-30 mg, and that the dosage higher than 60 mg does not significantly decrease tHcy concentration. Our study confirmed the reported observations that treatment with folic acid and vitamin B12 rather than high-flow dialyzer contributes to tHcy decrease. CONCLUSION: The study confirmed the high prevalence of hyperhomocysteinemia in patients on dialysis. The treatment with folic acid and vitamin B12 results in a significant decrease of tHcy. After individual HD by high-flow dialyzer, there is a significant, but temporary decrease of tHcy concentration in plasma. There is no significant difference in the efficiency on pre-dialysis tHcy concentration between the high-flow and low-flow dialyzer membrane. Because of the atherogenic effect of hyperhomocysteinemia, the treatment with folic acid and vitamin B12 should be accepted as an options to lower the risk factors for the rapid atherosclerosis in patients on dialysis, thus reducing the occurrence and fatality of cardiovascular diseases.

[Characteristics of hyperhomocysteinemia in dialysis patients]. / Obiljezja hiperhomocisteinemije u bolesnika koji su lijeceni hemodijalizom.

AIM: The aim of the study was to determine the prevalence of hyperhomocysteinemia and its relationship with other cardiovascular risk factors in dialysis patients. METHODS: Blood pressure and biochemical indicators (creatinine, urea, total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides) were determined by standard methods in 46 dialysis patients. Homocysteine (Hcy) was determined by the method of stable isotopic dilution mass spectrometry. ECHO of the heart was used for the parameters necessary for calculation of the left ventricular mass index. Left ventricular hypertrophy was defined as a left ventricular mass index higher than 109 +/- 20 g/m2 for males and higher than 89 +/- 15 g/m2 for females. Delivered dosage of dialysis (Kt/V) was calculated by Daugirdas formula. RESULTS: Arterial hypertension was present in 72% and left ventricular hypertrophy in 82% of study subjects. An increased concentration of total homocysteine (tHcy) (mean 24.76 +/- 11.04 micromol/L) was observed in 85% of subjects. Dyslipemia was manifested by increased concentration of tChol in 22%, elevated values of LDL Chol in 26%, decreased concentration of HDL Chol in 50%, and hypertriglyceridemia in 46% of study subjects. There was no statistically significant correlation of plasma tHcy concentration with age (p > 0.5), creatinine (p > 0.2), time on dialysis (p > 0.9), dosage of dialysis (p > 0.78) and left ventricular mass index (p > 0.19). DISCUSSION: Numerous studies have shown that mild to moderate elevation of plasma tHcy concentration (tHcy 15-30 micrtomol/L, and 30-100 micromol/L) occurs in 5%-7% of the general population and in 85%-90% of dialysis patients. In our study, hyperhomocysteinemia was present in 85% of patients. Increased tHcy concentration in plasma of uremic patients is one of non-traditional atherosclerosis risk factors, acting synergestically with traditional risk factors for cardiovascular diseases in uremic patients. In patients on hemodialysis, dyslipidemia is generally characterized by increased concentrations of LDL cholesterol and triglycerides, and a decreased concentration of HDL cholesterol, as also confirmed by our study. In 43.5% of patients, inadequate dosage of dialysis is the consequence of insufficient function of the A-V fistula and lack of patient cooperation. Left ventricular hypertrophy is an independent risk factor for cardiovascular disease, while hypertension is one of its main causes. Literature data indicate that elevated arterial pressure and Hcy affect the degree of cardiac hypertrophy independently, and that Hcy is in direct correlation with heart failure for which decreased diastolic function is not responsible. Some 57%-93% of hemodialysis patients have left ventricular hypertrophy. In our study, left ventricular hypertrophy was observed in 81% of patients, of which 86% had arterial hypertension. CONCLUSION: The study has confirmed hyperhomocysteinemia in as many as 85% of patients. There was no positive correlation of Hcy concentration with patient age, time on dialysis, serum creatinine, adequacy of dialysis, left ventricular mass index. Cardiovascular diseases are common in dialyzed patients with hyperhomocysteinemia, suggesting a causal relationship since Hcy is an independent atherosclerosis risk factor. However, additional studies in a large number of subjects will hopefully provide more comprehensive answers.

[The impact of glucose absorbed from dialysis solution on body weight gain in peritoneal dialysis treated patients]. / Utjecaj glukoze apsorbirane iz dijalizata na tjelesnu tezinu peritonejskom dijali lijecenih bolesnika.

A proportion of peritoneal dialysis (PD) patients experience substantial body weight (BW) gain with time. It is caused by fat tissue accumulation or fluid retention. It is believed that fat tissue accumulates due to caloric contribution of glucose absorbed from dialysis solution or to the mitochondrial fat regulatory uncoupling protein (UCP) gene polymorphism. This study examined BW fluctuations in 40 patients (24 females, 16 males), treated by PD at least 36 months (initial mean age 54.50+/-9.00 years, mean BW 68.00+/-8.50 kg and mean height 164.00+/-8.50 cm), relation of the BW fluctuation and caloric contribution of glucose absorbed from dialysis solution and characteristics of the patients with BW gain. Initial BW increased after 6, 12, 24 and 36 months by 5.90+/-3.50 kg, 7.90+/-4.90 kg, 9.50+/-5.00 and 11.00+/-5.00 kg, or for 8.68, 11.62, 13.97 and 16.18% of the initial value, respectively. After the first 6 and 12 months 38 patients gained weight, 39 after 24 and all 40 patients after 36 months. There was not significant correlation between BW gain and caloric contribution of glucose absorbed from dialysis solution. Female patients had initially lower BW, but for the first 12 months period significantly increased BW more than males, and not for the other observed periods. High transporters (patients with higher transport, higher transmission of glucose from peritoneal solution into the blood, and urea and creatinine in the opposite direction, with rapid decrement of osmolality gradient between dialysate and blood that is necessary for excessive fluid elimination), had lower initial BW and, although without statistical significance, only within the first period increased BW more than low transporters. In conclusion, with time BW gain was found in all the PD dialysis patients, it was not related to caloric contribution of glucose absorbed from dialysis solution, and women and high transporters increased BW weight more than men and low transporters in the first year of treatment. The BW gain is at least in part caused by fluid retention.

[Left ventricular hypertrophy in patient on dialysis]. / Hipertrofija lijeve klijetke u bolesnika na dijalizi.

Left ventricular hypertrophy (LVH) is a significant factor for higher mortality caused by cardiovascular diseases, which are the main cause of death (45%) in hemodialysis patients. In this study we analyzed the link between hypertension nad anemia, which are the main risk factors for the occurrence of LVH. The study included 40 patients (20 M and 20 F, age 20-80 years) who were treated with chronic dialysis. Using the method of transthoracic echocardiography, in M-mode, 38 patients underwent measurement of the thickness of intraventricular septum and posterior wall of the left ventricle at the end of diastole. LVH was expressed through the left ventricle mass index (LVMI) > 131 g/m2 for male and > 100 g/m2 for female. The efficiency of dialysis was calculated with the standard formula (Kt/V1,2). The patients on erythropoietin therapy received medium maintenance dose of 4000 units per week. Blood pressure and hemoglobin data were included in the calculations. A statistically higher rate of hypertension was found in males (M 17/20, F 10/20, p = 0.04), and of myocardial hypertrophy in females (M 7/20, F 17/20, p = 0.004). Overall patient data analysis showed LMVI to be statistically significantly higher (p = 0.0004) in hypertensive patients, and so were the values of systolic and diastolic pressure (p = 0.0006) in spite of applied medication. Hemoglobin was significantly higher (p = 0.04) in LVH patients. A significant positive correlation was found between LVMI and arterial pressure (p = 0.006), and negative between LVMI and hemoglobin concentration (p = 0.03). There was no statistically significant correlation between LVMI and age, interdialytic fluid intake and Kt/V. These results indicate that among patients on chronic dialysis treatment, LVH is more frequent in those with hypertension. The higher hemoglobin concentration found in patients with LVH was probably due to the relatively small number of patients. It is necessary to reduce the effect of risk factors for LVH by using better therapeutic options, thus to decrease the mortality in dialysis patients.