Factors influencing renal graft survival: 7-Year experience of a single center.

BACKGROUND AND OBJECTIVE: The demand for kidney transplants exceeds the existing supply. This leads to a recently growing interest of research in the area of factors that could prolong graft long-term outcomes and survival. In Lithuania, approximately 90% of kidney transplantations are from deceased donors. Donor organs are received and shared only inside the country territory in Lithuania; therefore, donor data is accurate and precise. This study was performed to present particularities of kidney transplantation data in Lithuania and to identify the effect of donor and recipient factors and histologic findings on renal graft outcomes. The aim of this study was to identify the effect of donor and recipient factors and histologic findings on renal graft outcomes. MATERIALS AND METHODS: We analyzed the influence of deceased donor and recipient factors and histological findings on the graft function in 186 renal transplant patients. Graft survival was estimated within the first year after transplantation. RESULTS: The donors and recipients were older in worse eGFR group 1 year after transplantation. Dissimilarity of degree of glomerulosclerosis (GS), interstitial fibrosis (IF) and arteriolar hyalinosis (AH) were significant in inferior and superior renal function groups (GS >20% 11.4 vs. 0%, P=0.017; IF 9.3 vs. 0%, P=0.034; AH 69 vs. 26.2%, P<0.001). Nine independent variables were significantly associated with a worse renal transplant function 1 year posttransplantation: AH (OR=6.287, P<0.001), an episode of urinary tract infection (OR=2.769, P=0.020), acute graft rejection (OR=3.605, P=0.037), expanded criteria (OR=4.987, P=0.001), female gender donors (OR=3.00, P=0.014), cerebrovascular disease caused donor brain death (OR=5.00, P=0.001), donor's age (OR=1.07, P<0.001), and recipient's age (OR=1.047, P=0.022). Worse renal graft survival 1 year posttransplantation was associated with a delayed graft function and a higher level of glomerulosclerosis in time-zero biopsy. CONCLUSIONS: Donor factors, such as age, female gender, brain death of cerebrovascular cause and expanded criteria donor status had a significant negative impact on the renal graft function 1 year after transplantation. Recipients' age, urinary tract infection and acute graft rejection episodes after transplantation were associated with a worse kidney function 1 year after transplantation. Lower 1-year graft survival was related to a delayed graft function (DGF) and a higher degree of glomerulosclerosis.

Mortality prediction in patients with acute kidney injury requiring renal replacement therapy after cardiac surgery.

BACKGROUND AND OBJECTIVE: Acute kidney injury (AKI) is a common and potentially serious postoperative complication after cardiac surgery, and it remains a cause of major morbidity and mortality. The aim of our study was to assess the prognostic illness severity score and to estimate the significant risk factors for poor outcome of patients with AKI requiring renal replacement therapy (RRT) after cardiac surgery. MATERIALS AND METHODS: We retrospectively analyzed data of adult (>18 years) patients (n=111) who underwent open heart surgery and had developed AKI with need for RRT. Prognostic illness severity scores were calculated and perioperative risk factors of lethal outcome were assessed at the RRT initiation time. We defined three illness severity scores: Acute Physiology and Chronic Health Evaluation (APACHE II) as a general score, Sequential Organ Failure Assessment (SOFA) as an organ failure score, and Liano score as a kidney-specific disease severity score. Logistic regression was also used for the multivariate analysis of mortality risk factors. RESULTS: Hospital mortality was 76.5%. More than 7% of patients remained dialysis-dependent after their discharge from the hospital. The prognostic abilities of the scores were assessed for their discriminatory power. The area under the receiver-operating characteristic (ROC) curve of SOFA score was 0.719 (95% CI, 0.598-0.841), of Liano was 0.661 (95% CI, 0.535-0.787) and 0.668 (95% CI, 0.550-0.785) of APACHE II scores. From 16 variables analyzed for model selection, we reached a final logistic regression model, which demonstrated four variables significantly associated with patients' mortality. Glasgow coma score<14 points (OR=3.304; 95% CI, 1.130-9.662; P=0.003), mean arterial blood pressure (MAP)<63.5mmHg (OR=3.872; 95% CI, 1.011-13.616; P=0.035), serum creatinine>108.5µmol/L (OR=0.347; 95% CI, 0.123-0.998; P=0.046) and platelet count<115×109/L (OR=3.731; 95% CI, 1.259-11.054; P=0.018) were independent risk factors for poor patient outcome. CONCLUSIONS: Our study demonstrated that SOFA score estimation is the most accurate to predict the fatal outcome in patients with AKI requiring RRT after cardiac surgery. Lethal patient outcome is related to Glasgow coma score, mean arterial blood pressure, preoperative serum creatinine and postoperative platelet count.

Hepcidin serum levels and resistance to recombinant human erythropoietin therapy in hemodialysis patients.

OBJECTIVE: The aim of this study was to analyze the factors that are associated with the response to erythropoiesis-stimulating agents (ESAs) and its association with hospitalization and mortality rates; to evaluate the serum hepcidin level and its associations with iron profile, inflammatory markers, ESA responsiveness, and mortality; and to determine independent factors affecting ERI and hepcidin. MATERIALS AND METHODS: To evaluate a dose-response effect of ESAs we used the erythropoietin resistance index (ERI). Patients were stratified in two groups: nonresponders and responders (ERI>15, n=20, and ERI ≤15U/kg/week/g per 100mL, n=153, respectively). Hematological data, hepcidin levels, iron parameters, inflammatory markers, hospitalization and mortality rates were compared between the groups. Multiple regression analysis was used to determine independent factors affecting ERI and hepcidin. RESULTS: C-reactive protein (CRP) (ß=0.078, P=0.007), albumin (ß=-0.436, P=0.004), body mass index (ß=-0.374, P<0.001), and hospitalization rate per year (ß=3.017, P<0.001) were found to be significant determinants of ERI in maintenance hemodialysis (MHD) patients. Inadequate dialysis was associated with higher ERI. Patients with concomitant oncological diseases had higher ERI (31.2±12.4 vs 9.7±8.1U/kg/week/g per 100mL, P=0.002). The hepcidin level was 158.51±162.57 and 120.65±67.28ng/mL in nonresponders and responders, respectively (P=0.33). Hepcidin correlated directly with ERI, dose of ESAs, ferritin and inversely with Hb, transferrin saturation, and albumin. ERI (ß=4.869, P=0.002) and ferritin (ß=0.242, P=0.003) were found to be significant determinants of hepcidin in MHD patients. The hospitalization rate per year was 2.35±1.8 and 1.04±1.04 in nonresponders and responders, respectively (P=0.011). The mean length of one hospitalization was 25.12±21.26 and 10.82±17.25 days, respectively (P=0.012). Death occurred in 30% of the patients from the responders' group and in 50% from the nonresponders' group (P=0.289). The mean hepcidin concentration of patients who died was 141.9±129.62ng/mL and who survived, 132.98±109.27ng/mL (P=0.797). CONCLUSIONS: CRP, albumin, BMI, and hospitalization rate per year were found to be significant determinants of ERI in MHD patients. Inadequate dialysis was associated with higher epoetin requirements. There were no difference in patient mortality by ERI, but a significant difference in hospitalization rates and mean length of one hospitalization was revealed. A significant positive relation between hepcidin and ERI was revealed. ERI and ferritin were found to be significant determinants of hepcidin in MHD patients. Hepcidin was not related to mortality.

Association between vascular calcification assessed by simple radiography and non-fatal cardiovascular events in hemodialysis patients.

BACKGROUND: Vascular calcification (VC) is one of the factors associated with cardiovascular mortality in hemodialysis (HD) patients. Recommendations concerning screening for VC differ. Possible ability to prevent and reversibility of VC are major subjects on debate whether screening for VC could improve outcomes of renal patients. The objective of the study was to evaluate the significance of simple vascular calcification score (SVCS) based on plane radiographic films and to test its association with non-fatal cardiovascular events in patients on chronic HD. METHODS: A study population consisted of 95 prevalent HD patients in the HD unit of Hospital of Lithuanian University of Health sciences Kaunas Clinics. Clinical data and laboratory tests information were collected from medical records. SVCS was evaluated as it is described by Adragao et al. After measurement of VC, HD patients were observed for novel non-fatal cardiovascular events. RESULTS: Patients were divided into two groups: SVCS≥3 (57 patients [60%]) and <3 (38 patients [40%]). The Kaplan-Meier survival curves show a significant difference in non-fatal cardiovascular events in the group with SVCS≥3 vs. <3 group (26.3% vs. 7.8%; log rank 5,49; P=0.018). Multivariate Cox regression analysis confirmed a negative impact of VC, hyperphosphatemia, and lower ejection fraction on cardiovascular events. No statistically significant differences were observed comparing parameters of Ca-P metabolism disorders between groups with different SVCS. On separate analysis, the presence of VC in hands was also associated with higher rate of novel cardiovascular events (score 0 goup-5 events [10.6%] vs. score≥1 group-13 events [27%], log rank P=0.035). CONCLUSION: VC assessed by simple and inexpensive radiological method was an independent predictor of novel non-fatal cardiovascular events in HD patients.

Changes of etiology, incidence and outcomes of severe acute kidney injury during a 12-year period (2001-2012) in large university hospital.

BACKGROUND: Despite improvement in the quality of critical care, the incidence and mortality of acute kidney injury (AKI) continues to rise. The aim of our study was to analyze the changes during a 12-year period in etiology, incidence and outcomes of severe AKI, which required dialysis, in a large single centre. METHODS: We performed retrospective analysis of all the patients (n=3215) with severe AKI hospitalized and dialysed in the hospital of Lithuanian university of health sciences Kauno Klinikos (HLUHS KK) during the period of 2001-2012. RESULTS: During a 12-year period, the incidence of severe AKI increased from 154 to 597 cases/p.m.p. The mean age of the patients increased from 58.2±19.2 years in 2001 to 65.7±17 years in 2012 (P<0.001). The number of men (n=2012; 62.6%) was significantly higher than that of women (n=1201; 37.4%; P<0.001). The causes of severe AKI were renal (n=1128; 35.1%), prerenal (n=642; 20%), obstructive (n=310; 9.6%) and in 12.7% of the patients-multifactorial. Overall, the most frequent cause of AKI was acute tubular necrosis (n=1069; 33.2%). The renal replacement therapy (RRT) was discontinued due to improved kidney function in 45.3% of cases. 8.1% of the patients remained dialysis dependent. The mortality rate was 44%. CONCLUSIONS: During a 12-year period, the number of the patients with severe AKI increased three times with the predominance of men and elderly people. There was an observed increase in multifactorial causes of severe AKI; however, ATN remained dominant over the decade. The mortality rate remained high, almost half of the patients died, less than 10% remained dialysis dependent, the rest had the improvement of renal function.

Nationwide renal biopsy data in Lithuania 1994-2012.

BACKGROUND: Our aim was to evaluate the incidence of biopsy-proven kidney diseases in Lithuania and to compare their changes in three different time intervals. All Lithuanian kidney biopsies were performed in the National Center of Pathology, enabling analysis at the national level. METHODS: The native kidney biopsy data were reviewed, and incidence of renal disorders and patient demographics were compared during three time intervals: 1994-1999, 2000-2006, and 2007-2012. RESULTS: A total of 5,368 kidney biopsies were performed, including 3,640 native kidney and 1,728 kidney transplant biopsies; 59.5% (2,165) of the native kidney biopsies were classified as primary glomerulopathies. The most common entity was IgA nephropathy (737; 34.0%), followed by focal segmental glomerulosclerosis (285; 13.2%) and membranoproliferative glomerulonephritis (256; 11.8%). Prominent decrease in incidence of membranoproliferative glomerulonephritis (16.8 to 8.7% from the first to third time interval) and increase in (mainly, pauci-immune) crescentic glomerulonephritis (6.2 to 15.3%) were noted over the study period. In a subgroup of 427 pediatric native kidney biopsies, IgAN accounted for 24.9% of biopsies. The incidence of MCNS increased dramatically from the first to third time interval (6.3 to 25.4%), while the number of MPGN increased in the second time interval (from 7.2 to 8.9%) but decreased in the third one (to 4.4%). CONCLUSIONS: Decrease in relative incidence of membranoproliferative glomerulonephritis, most likely, reflects improvement in socioeconomic conditions, while relative increase in crescentic glomerulonephritis is interpreted as improved diagnostics of the disease.

Renal anemia control in Lithuania: influence of local conditions and local guidelines.

Erythropoietin stimulating agents had a long haul in Lithuania--we had no epoetin till 1994 and there was no intravenous iron in 2001-2004. The aim of this study was to assess the changes of renal anemia control in hemodialysis patients from early independence of Lithuania till nowadays and to evaluate the link of anemia with hospitalization rates and survival and hemoglobin variability in association with mortality. In December of each year since 1996 all hemodialysis centers have been visited and data has been collected using special questionnaires. The history of renal anemia control in Lithuania was complicated; however, a significant improvement was achieved: 54.7% of hemodialysis patients reached the target hemoglobin; all patients have a possibility of treatment with epoetin and intravenous iron. The involuntary experiment with an intravenous iron occurred in Lithuania because of economic reasons and confirmed the significant role of intravenous iron in the management of renal anemia. Hemoglobin below 100 g/L was associated with a 2.5-fold increase in relative risk of death and 1.7-fold increase in relative risk of hospitalization in Lithuanian hemodialysis patients. Although hemoglobin variability was common in Lithuanian hemodialysis patients, we did not find the association between hemoglobin variability and all-cause mortality in our study.

Prevalence of chronic kidney disease and its risk factors among family practice patients in Lithuania.

BACKGROUND: Early detection of chronic kidney disease (CKD) by the first line is essential. In many countries, serum creatinine measurements are reimbursed in home practice. In Lithuania however, until recently they were not. Therefore, the aim of this study was to assess the prevalence of risk factors of CKD in primary care patients, to evaluate the awareness of family practitioners and, finally, to investigate renal function parameters in patients at risk. METHODS: We reviewed the charts of adult patients (n = 4,082) from four home practices in Kaunas and identified patients at increased risk for CKD (severe arterial hypertension, diabetes, cardiovascular disease (CVD), other causes of kidney damage). We noted age and gender in all patients, and renal function measurements performed over the preceding 24 months in the patients at risk. In the second part, we assessed nephrological status (history, clinical characteristics, serum creatinine, dipstick urinalysis and microalbuminuria, estimated glomerular filtration rate (eGFR) by the abbreviated MDRD formula) for those at risk who were referred by their family practitioners. RESULTS: In total, 458 (11.2%) patients had risk factors for CKD. Severe arterial hypertension was found in 62.6% of these patients, diabetes in 20.9%, CVD in 6.2% and 34.5% had a history of kidney damage. Kidney tests had been performed by family practioner in 59% of these patients. Only 30.3% of these patients were referred to the nephrologist and an additional 20.1% came after receiving an invitation letter. eGFR < 60 ml/min/1.73 m2 was found in 42.9% of these patients, 23.4% had microalbuminuria and 7.8% overt proteinuria. Optimal blood pressure control (< 130/85 mmHg) was achieved in a minority (10.4%). 79.7% had abnormal BMI, 39% used no ACEI/ARB, and 16% were smokers. Kidney dysfunction was associated with a higher prevalence of microalbuminuria and a lower use of ACEI/ ARB. CONCLUSIONS: Risk factors for CKD were present in 11% of the patients in this primary care cohort. Kidney dysfunction was found in almost half of the patients at risk. However, awareness of this problem by family practitioners was low.

Adherence to treatment and hospitalization risk in hemodialysis patients.

BACKGROUND: The aim of this study was to evaluate whether adherence to treatment is associated with hospitalization risk in hemodialysis patients. METHODS: We completed a cohort analysis of risk factors during 1 census month (November) and 1 year of follow-up during 5 consecutive years (2002-2006) in all end-stage renal disease patients hemodialyzed in the Kaunas region. During the census month, we collected data on noncompliance defined as (i) skipping of a hemodialysis (HD) session, (ii) shortening of 1 or more HD sessions, (iii) presence of hyperkalemia, (iv) presence of hyperphosphatemia, or (v) interdialytic weight gain (IDWG). In addition, data on age, sex, disability status, comorbidities, anemia control, malnutrition and inflammation, calcium-phosphorus metabolism and hospitalization rate were collected. Relative risk of hospitalization was estimated using Cox regression evaluating time to first hospitalization. RESULTS: We analyzed 559 patients for a total of 1,163 patient-years during the 5 years of the study. On multivariate analysis, adjusting for ischemic heart disease, diabetes mellitus, higher number of comorbid conditions, higher systolic blood pressure before dialysis, worse disability status, lower hemoglobin, albumin and urea before dialysis, the relative risk for hospitalization increased by 1.1 for every additional percentage point of IDWG and by 1.19 with each 1 mmol/L rise of serum phosphorus level. Skipping or shortening of hemodialysis sessions and serum potassium level were not associated with hospitalization. CONCLUSIONS: Higher IDWG and higher serum levels of phosphorus independently increased the relative risk of hospitalizations in hemodialysis patients. With skipped and shortened dialysis sessions, higher serum potassium level was not associated with hospitalization risk.

History of renal replacement therapy in Baltic countries.

The history of renal replacement therapy (RRT) in the 3 Baltic countries can be divided into 2 periods: the Soviet period (1944-1991) with strict central regulation and isolation from Western countries, and the period of independence (1991 to the present). Between 1963 and 1967, hemodialysis was used in cases of acute kidney injury and later in chronic renal failure, but only for patients suitable for kidney transplantation. The first renal transplant was performed in 1968, in Tartu, Estonia, and shortly thereafter, in Lithuania and Latvia. During the period of independence, development of RRT has been extremely rapid, and now this field of the health system has no major differences from that in other developed countries.

Impact of hemodialysis dose and frequency on survival of patients on chronic hemodialysis in Lithuania during 1998-2005.

INTRODUCTION: The question of the targets of dialysis dosing remains controversial since the beginning of the long-term dialysis treatment era. It is still uncertain if higher dialysis dose is better. The aim of our study was to investigate issues of dialysis dose in Lithuania during the period of 1998-2005 and to determine associations between hemodialysis dose and survival of patients on chronic hemodialysis. MATERIAL AND METHODS: We analyzed data of all patients who started hemodialysis due to end-stage renal disease in Lithuania between January 1, 1998, and December 31, 2005. The information about hemodialysis frequency, duration, and adequacy (according to Kt/V) was obtained from medical documentation. The overall survival rate was estimated using the Kaplan-Meier method. Survival comparisons were made using the log-rank or Breslow tests. Univariate Cox proportional hazards analysis was used to select variables significantly associated with the risk of death; then these variables were included in multivariate Cox proportional hazards models. RESULTS: During the study period, from 2428 patients who started chronic hemodialysis, 58.5% of patients started hemodialysis three times a week. More than one-third (36.2%) of patients were dialyzed twice weekly, and 5.3% of patients started hemodialysis once weekly. Survival analysis revealed that patients dialyzed less than three times per week survived shorter than patients receiving a higher dialysis dose. Duration of HD session of ≤8 hours per week was an independent risk factor for mortality. A higher mean Kt/V was associated with better survival of patients on chronic hemodialysis. CONCLUSIONS: Dialysis frequency and weekly duration of HD sessions were dependent on HD accessibility in Lithuania during the period of 1998-2005. Better survival of patients on chronic hemodialysis was associated with a higher hemodialysis dose.

The association between health-related quality of life and mortality among hemodialysis patients.

INTRODUCTION: Mortality rates for patients undergoing maintenance hemodialysis remain high. Published data regarding association between health-related quality of life (HRQOL) and mortality among hemodialysis patients are inconsistent. Very few data are published on the change in HRQOL over time as a predictor of mortality. The aim of this study was to assess whether HRQOL and change of it over time could be considered an independent predictor of mortality in hemodialysis patients. MATERIAL AND METHODS: This prospective observational study enrolled 183 patients undergoing maintenance hemodialysis. HRQOL was measured annually 2004-2008 using a generic Short Form 36 questionnaire. Physical component summary (PSC) and mental component summary (MSC) scores were calculated. The change of the patient's HRQOL over time was calculated as a difference between SF-36 scores of the first and the last HRQOL measurements. RESULTS: The median follow-up was 48 months (range, 1-72 months). Cutoff values for HRQOL predicting mortality for PSC score was ≥35 and for MSC score was ≥45. In the model adjusted for age, sex, dialysis months, creatinine, albumin and hemoglobin levels, mortality risk decreased by 0.96 (95% CI, 0.95-0.99) for 1-point increase in the baseline PSC score and decreased by 0.97 (95% CI, 0.95-0.98) for 1-point increase in the baseline MSC score. A 1-point decline in the PSC score (relative risk, 1.11; 95% CI, 1.008-1.221) and MSC score (relative risk, 1.07; 95% CI, 1.002-1.149) over the period of follow-up were associated with a significant additional increase in mortality. CONCLUSIONS: Both baseline HRQOL and decline of HRQOL are independent predictors of mortality in hemodialysis patients.

Ten-year experience of kidney transplantation at the Hospital of Kaunas University of Medicine: demography, complications, graft and patient survival.

UNLABELLED: During 10 years, 163 cadaveric kidney transplantations were performed at the Hospital of Kaunas University of Medicine. The aim of this study was to analyze the first 10-year experience in kidney transplantation and to evaluate the most frequent early and late complications after transplantation, graft and patient survival, and impact of delayed graft function on graft survival. MATERIAL AND METHODS: A total of 159 patients were included into the study. Graft and patient survival was calculated at 1, 3, and 5 years after transplantation using the Kaplan-Meier method; graft function was also analyzed. RESULTS: Fifty-three patients (33.3%) in the early period and 72 (55.4%) in the late period had at least one episode of urinary tract infection. Less than half (47.2%) of patients had complications related to immunosuppressive treatment, mostly cytomegalovirus infection, in the late period. The risk of CMV reactivation was 3.98 times higher among recipients who received prophylaxis only with intravenous ganciclovir as compared to patients who received valganciclovir after a brief course of ganciclovir (OR, 3.98; 95% CI, 1.48-8.19; P=0.003). Delayed graft function was observed in 53 cases (33.3%); 37 (23.3%) grafts were lost. Graft and patient survival at 1, 3, and 5 years after transplantation was 85%, 82%, and 71% and 97%, 94%, and 94%, respectively. Graft survival at 1, 3, and 5 years was worse among patients with delayed graft function as compared to patients with good graft function (69%, 69%, 50% vs. 93%, 86%, 84%, respectively; P<0.05). CONCLUSIONS: Urinary tract infection was the most frequent complication after kidney transplantation. Reactivation of cytomegalovirus infection was present only in a quarter of our patients. The administration of valganciclovir was associated with a significantly lower incidence of CMV infection/disease. Graft and patient survival was sufficiently good. Delayed graft function was an independent risk factor for worse graft survival.

Risk factors for cardiovascular hospitalization in hemodialysis patients.

UNLABELLED: The aim of this study was to evaluate the risk factors for cardiovascular hospitalization in hemodialysis patients. MATERIALS AND METHODS: A cross-sectional cohort analysis of risk factors during one census month (November) and one-year follow-up for cardiovascular hospitalization rates during 5 consecutive years (2002-2006) in all end-stage renal disease patients hemodialyzed in Kaunas region was carried out. During the census month, we collected data on patient's age and sex, disability status, comorbidities, anemia control, malnutrition and inflammation, calcium-phosphorus metabolism, and patient's compliance with prescribed medications. We analyzed 559 patients during 1163 patient-years of observation. Patients were considered as new patients every year (1520 cases). Kaplan-Meier method and Cox regression analysis were used to evaluate time to first hospitalization. RESULTS: The mean number of cardiovascular hospitalizations was 0.31 per patient-year at risk, the total days of cardiovascular hospitalizations per patient-year at risk were 3.93, and the mean length of one hospitalization was 13.2±12.9 days. Cardiovascular diseases were the most frequent cause of hospitalization (25% of all hospitalizations). The relative risk of cardiovascular hospitalization increased by 1.03 for every year of age, by 1.7 for worse disability status, by 1.4 for nonadherence to medications, by 1.1 for every additional medication prescribed to the patient. Cardiovascular hospitalization risk was decreased by 0.99 with a 1-g/L rise in hemoglobin level. CONCLUSIONS: Older age, worse disability status, patient's noncompliance with medications, and higher number of medications used were associated with a higher risk for cardiovascular hospitalization. Higher hemoglobin level was associated with a lower risk for cardiovascular hospitalization.

The level of endotoxins in hemodialysis water and dialysate in Lithuanian hemodialysis centers.

The composition and quality of the dialysis fluid play an important role in the modulation of dialysis-related complications. During hemodialysis, patient's blood has a contact with dialysate through a semipermeable membrane. Bacterial endotoxins can pass through the membrane pores into the patient's blood and cause a silent chronic microinflammation. The aim of this study was to determine the level of endotoxins in hemodialysis water and dialysate in Lithuanian hemodialysis centers. Dialysis water (n=50) and dialysate (n=50) were collected from 91% (n=50) of all hemodialysis centers. The presence of bacterial endotoxins was evaluated using a sensitive Limulus amebocyte lysate test, which detects intact lipopolysaccharides. The level of endotoxins was lower than 0.25 EU/mL in 43 (86%) dialysis water samples and in 46 (92%) dialysate samples, and complied with the recommendations of the European Pharmacopoeia and the European Best Practice Guidelines for pure dialysis fluid. The dialysate of 39 (78%) Lithuanian hemodialysis centers complied with the definition of an ultrapure dialysis fluid. The water and dialysate were of insufficient quality in 14% and in 8% of Lithuanian hemodialysis centers, respectively, and this could be improved by the establishment of routine investigation of endotoxins.

Vascular access for hemodialysis: creation, functioning, and complications (data of the Hospital of Kaunas University of Medicine).

BACKGROUND: There are no data about arteriovenous fistulas (AVF) formation, survival, and complications rate in patients with end-stage renal failure in Lithuania. MATERIAL AND METHODS: We analyzed the data of patients (N=272) with end-stage renal failure, dialyzed at the Hospital of Kaunas University of Medicine from January 1, 2000, until March 30, 2010, and identified 368 cases of AVF creation. The patients were divided into two groups: group 1 included the patients with an AVF that functioned for <15 months (n=138) and group 2 included patients with an AVF that functioned for ≥15 months (n=171). RESULTS AND CONCLUSIONS: Less than half (47%) of the patients started planned hemodialysis and 51% of the patients started hemodialysis urgently. The mean time of AVF functioning was 15.43±8.67 months. Age, gender, the kidney disease, and time of AVF maturation had no influence on AVF functioning time. AVFs of the patients who started planned hemodialysis functioned longer as compared to AVFs of the patients who started hemodialysis urgently (P<0.05). Hospitalization time of the patients who started hemodialysis urgently was longer as compared that of the patients who had a matured AVF (37.63±20.55 days vs. 16.54±9.43 days). The first vascular access had better survival than repeated access. AVF survival in patients with ischemic brain vascular disease was worse than in patients without this comorbidity.

[Frequency, etiology, and outcomes of acute renal failure (data of Kaunas University of Medicine Hospital in 1995-2006)]. / Uminio inkstu nepakankamumo daznis, priezastys ir baigtys (Kauno medicinos universiteto kliniku 1995-2006 metu duomenys).

The aim of this study was to determine the frequency, etiology, and outcomes of acute renal failure. We retrospectively collected data on all patients (n=1653) who received renal replacement therapy for acute renal failure at the Kaunas University of Medicine Hospital during 1995-2006. The number of patients with acute renal failure increased nine times during the 11-year period. The mean age of patients was 59.76+/-17.52 years and increased from 44.97+/-17.1 years in 1995 to 62.84+/-16.49 years in 2006. The most common causes of acute renal failure were renal (n=646, 39%), prerenal (n=380, 23%), and obstructive (n=145, 9%). The renal replacement therapy was discontinued because of recovery of renal function in 49.9% of cases. The overall hospital mortality rate was 45.1%. Renal function did not recover in 6.7% of patients. The mortality rate over the 11-year period varied from 37.8 to 57.5%. The highest mortality rate was in the neurosurgical (62.3%) and cardiac surgical (61.8%) intensive care units. High mortality rate (more than 50%) was in the groups of patients with acute renal failure that was caused by hepatorenal syndrome, shock, sepsis, and reduced cardiac output.

[Acute renal failure in patients with alcoholic surrogate intoxication]. / Uminis inkstu nepakankamumas apsinuodijus alkoholio surogatais.

Intoxications with alcoholic surrogates are still frequent in Lithuania. The aim of this study was to evaluate the frequency, course, and effectiveness of treatment and outcomes of acute renal failure in patients with alcoholic surrogate intoxication. We have analyzed the case histories of 94 patients with alcoholic surrogate poisoning. Patients were treated in the Clinic of Nephrology, Kaunas University of Medicine Hospital, during 1997-2006. Fifty-three cases of poisoning with unspecified ethanolic surrogates, which did not provoke acute renal failure, were identified, and we did not analyze them in detail. Forty-one cases of intoxication with nonethanolic surrogates were identified, and acute renal failure developed in 34 patients. In 31 of the 41 patients, hemodialysis was started for toxin removal. Among eight patients in whom treatment was started within 12 hours of intoxication, seven (87.5%) patients had no acute renal failure. In the 23 remaining patients, treatment was started later than 12 hours after intoxication, and acute renal failure was diagnosed in all of them. Three patients died within 48 hours after hospitalization because of severe intoxication. CONCLUSION. Acute renal failure developed in 82.9% of patients poisoned with nonethanolic surrogates. In such cases, when hemodialysis for toxin removal was started up to 12 h after poisoning, acute renal failure developed significantly rarely.

[The prevalence of major risk factors for chronic kidney disease among patients in primary health care centers]. / Letines inkstu ligos didziuju rizikos veiksniu paplitimas tarp pirmines sveikatos prieziuros centru pacientu.

UNLABELLED: The aim of the study was to investigate the prevalence for high-risk factors for chronic kidney disease among patients in primary health care centers and to assess diagnostic strategy carried out by family doctors. RESULTS: We analyzed case records (n=4082) of patients aged more than 18 years in four family doctor's practices of Kaunas city. The ratio of female to male was 1.4:1. The major risk factors for chronic kidney disease (severe hypertension, diabetes, kidney diseases, and severe ischemic diseases) were identified in 458 patients: 287 (62.66%) women and 171 (37.34%) men. It accounted for 11.2% of all patients. They were significantly older as compared to all patients (66.96+/-14.34 vs. 49.86+/-18.54 years, P<0.0001). The most common risk factors were as follows: hypertension (62.66%), primary kidney diseases (33.84%), diabetes (20.96%), and complicated ischemic disease (6.11%). Of the 458 patients, 366 (79.9%) had one and the remaining patients had several risk factors. During the last 24 months, family doctor evaluated kidney function and urinanalysis in 24.4% and 53.6% of patients with high-risk factors, respectively. While examining these patients (n=91), it was determined that even in 54.95% of them, glomerular filtration rate was lower than 60 mL/min/1.73 m2. CONCLUSIONS: The major risk factors for chronic kidney disease were identified in 11.2% of patients from primary health care centers. Most of them were older than 75 years. The most common risk factor was arterial hypertension. The assessment of kidney function in these patients by family doctor was insufficient. A thorough examination of the patients with major risk factors revealed chronic kidney insufficiency in half of them.

[Changes in hemodialysis adequacy in Lithuania during 1999-2005]. / Hemodializes proceduros kokybes pokyciai Lietuvoje 1999-2005 m.

Despite the improvement of hemodialysis technique, mortality of chronic hemodialysis patients remains quite high. It considerably depends on dialysis adequacy. The aim of the study was to evaluate the adequacy of hemodialysis procedure and its changes in Lithuania during 1999-2005. Between 1999 and 2005 in December, all hemodialysis centers in Lithuania were annually visited, and data on the type of hemodialysis, duration of hemodialysis (hours per week), single-pool Kt/V were collected from all hemodialysis patients. The percentage of patients on bicarbonate hemodialysis sharply increased from 57.9% in 1999 to 100% in 2001 (P<0.001), and the duration of hemodialysis procedure increased (67.3% of hemodialysis patients were dialyzed 12 and more hours per week in 2005 vs. 41.3% in 1999, P<0.001). The percentage of patients who were dialyzed three times per week increased from 51% in 1999 to 77% in 2005 (P<0.001). The mean Kt/V was 0.81+/-0.53 in 1999, but it increased to 1.21+/-0.27 in 2005 (P<0.001). More than half (54%) of all hemodialysis patients in 2005 had Kt/V > or =1.2 vs. more than one-third (36%) in 1999 (P<0.001). The mean Kt/V of patients who were on dialysis three times per week was 1.25+/-0.6; two times per week, 1.30+/-0.8; and one time per week, 1.27+/-0.26 in 2003. In 2005, the results were 1.21+/-0.27, 1.22+/-0.26, and 1.16+/-0.29, respectively (P>0.05). CONCLUSIONS. 1. The improvement of the quality of hemodialysis was observed in Lithuania during 1999-2005: a) from 2001, patients received only bicarbonate hemodialysis; b) weekly duration of hemodialysis increased; c) Kt/V improved. 2. Despite the improvement of hemodialysis quality, it is not optimal yet and is associated with insufficient duration of hemodialysis.