Prevalence, clinical characteristics, and predictors of peripheral arterial disease in hemodialysis patients: a cross-sectional study.

BACKGROUND: Peripheral arterial disease (PAD) is common in patients with end-stage renal disease on hemodialysis, but is frequently underdiagnosed. The risk factors for PAD are well known within the general population, but they differ somewhat in hemodialysis patients. This study aimed to determine the prevalence of PAD and its risk factors in patients on hemodialysis. METHODS: This cross-sectional study included 156 hemodialysis patients. Comorbidities and laboratory parameters were analyzed. Following clinical examinations, the ankle-brachial index was measured in all patients. PAD was diagnosed based on the clinical findings, ankle-brachial index < 0.9, and PAD symptoms. RESULTS: PAD was present in 55 of 156 (35.3%; 95% CI, 27.7-42.8%) patients. The patients with PAD were significantly older (67 ± 10 years vs. 62 ± 11 years, p = 0.014), more likely to have diabetes mellitus (p = 0.022), and anemia (p = 0.042), and had significantly lower serum albumin (p = 0.005), total cholesterol (p = 0.024), and iron (p = 0.004) levels, higher glucose (p = 0.002) and C-reactive protein (p < 0.001) levels, and lower dialysis adequacies (p = 0.040) than the patients without PAD. Multivariate analysis showed higher C-reactive protein level (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.00-1.06; p = 0.030), vascular access by Hickman catheter (OR, 4.66; 95% CI, 1.03-21.0; p = 0.045), and symptoms of PAD (OR, 5.20; 95% CI, 2.60-10.4; p < 0.001) as independent factors associated with PAD in hemodialysis patients. CONCLUSION: The prevalence of PAD was high among patients with end-stage renal disease on hemodialysis. Symptoms of PAD, higher C-reactive protein levels, and Hickman vascular access were independent predictors of PAD in patients on hemodialysis.

Respiratory Muscle Strength and Exercise Performance in Cystic Fibrosis-A Cross Sectional Study.

Introduction: Decreased respiratory muscle strength in patients with cystic fibrosis (CF) may cause progressive exercise intolerance during cardiopulmonary exercise testing (CPET), and may contribute to the development of chronic respiratory insufficiency. The aim of this study is to evaluate exercise tolerance during CPET of children and adults with clinically stable CF who exhibit different respiratory muscle strength. Methods: Sixty-nine clinically stable CF subjects aged 8-33 years underwent spirometry, body plethysmography, CPET, and respiratory muscle strength measurement. Respiratory muscle strength was measured using maximal inspiratory pressures (Pimax) and maximal expiratory pressures (Pemax). Participants were stratified into three groups according to Pimax values:below normal (≤80% predicted), normal (81-100% predicted), and above normal (>100% predicted). A similar stratification of participants was made according to Pemax values. The oxygen consumption on peak load (VO2peak) was expressed relative to BM (VO2peak/kg), relative to BM raised by the exponent of 0.67 (VO2peak/kg0.67) and as log-linear adjustment of VO2peak (VO2peak/kg-alo). Results: Participants with low Pemax values had a lower mean maximum load per kilogram/predicted (Wmax; p = 0.001) VO2peak/kg (p = 0.006), VO2peak/kg0.67 (p = 0.038) and VO2peak/kg-alo (p = 0.001). There were no significant differences in exercise tolerance parameters with regard to Pimax values. Stepwise multiple linear regressions confirmed that Pemax (B = 24.88, ß = 0.48, p < 0.001) was the most powerful predictor of Wmax. There were no statistically significant differences in age, lung function parameters, exacerbation score, or respiratory muscle strength according to gender. Conclusions: In subjects with clinically stable CF, expiratory muscle strength is associated with a decrease in exercise performance during CPET and can predict exercise intolerance. Increase in expiratory muscle strength by patient specific rehabilitation protocols would result in improvement of exercise tolerance.

Bridging the gap between informatics and medicine upon medical school entry: Implementing a course on the Applicative Use of ICT.

Education is undergoing profound changes due to permanent technological innovations. This paper reports the results of a pilot study aimed at developing, implementing and evaluating the course, "Applicative Use of Information and Communication Technologies (ICT) in Medicine," upon medical school entry. The Faculty of Medicine, University of Belgrade, introduced a curriculum reform in 2014 that included the implementation of the course, "Applicative Use of ICT in Medicine" for first year medical students. The course was designed using a blended learning format to introduce the concepts of Web-based learning environments. Data regarding student knowledge, use and attitudes towards ICT were prospectively collected for the classes of 2015/16 and 2016/17. The teaching approach was supported by multimedia didactic materials using Moodle LMS. The overall quality of the course was also assessed. The five level Likert scale was used to measure attitudes related to ICT. In total, 1110 students were assessed upon medical school entry. A small number of students (19%) had previous experience with e-learning. Students were largely in agreement that informatics is needed in medical education, and that it is also useful for doctors (4.1±1.0 and 4.1±0.9, respectively). Ability in informatics and use of the Internet in education in the adjusted multivariate regression model were significantly associated with positive student attitudes toward ICT. More than 80% of students stated that they had learned to evaluate medical information and would use the Internet to search medical literature as an additional source for education. The majority of students (77%) agreed that a blended learning approach facilitates access to learning materials and enables time independent learning (72%). Implementing the blended learning course, "Applicative Use of ICT in Medicine," may bridge the gap between medicine and informatics upon medical school entry. Students displayed positive attitudes towards using ICT and gained adequate skills necessary to function effectively in an information-rich environment.

Factors affecting the patency of arteriovenous fistulas for hemodialysis: Single center experience.

INTRODUCTION: Arteriovenous fistulas (AVFs) are the preferred form vascular access for hemodialysis (HD), as they have a low rate of complications and durable function. The aim of our investigation was to analyze the factors that might influence the function of AVFs. METHODS: Data were taken from the computerized patient record system in the Clinic of Urology and Nephrology, Clinical Center, Kragujevac, Serbia, for a 2-year period. We analyzed patients who had requested re-creation of AVFs as a secondary procedure. During this period 112 patients, 73 (65%) men and 39 (35%) women, had AVF thromboses. All relevant clinical and laboratory parameters that could affect the function and survival of AVF were evaluated. FINDINGS: In univariate logistic regression analysis, statistically significant predictors influencing the duration of the fistula were magnesium (P < 0.001), triglycerides (P = 0.041), smoking (P = 0.001), antiplatelet therapy (P < 0.001), and type of HD (bicarbonate vs. hemodiafiltration) (P < 0.001). In the multiple logistic regression model, high concentrations of magnesium (B = 7.434; P < 0.001) and antiplatelet therapy (B - 1.042; P = 0.04) were significantly associated with the length of AVF function. DISCUSSION: After successful establishment of an AVF, there is a compelling need to maintain fistula patency. Factors that affect functioning of the AVFs are presently under intense scrutiny. According to our results, some clinical factors may determine long term fistula duration, such as concentration of the magnesium and antiplatelet therapy.

Cannulation Technique and Arteriovenous Fistula Survival in Older Adult Patients on Hemodialysis.

Cannulation technique has the potential to impact arteriovenous fistula (AVF) function. The aim of this research was to determine the impact of cannulation technique on the length of the functioning AVFs in older adult patients on hemodialysis. The study included 110 participants with fistula thrombosis who had used area technique or rope ladder technique. Biochemical parameters, gender, demographic, and clinical variables were determined. Patients who used the area cannulation technique differed significantly from patients using the rope ladder technique with regard to duration of hemodialysis (p < 0.001), outcome of the AVF revision (p = 0.045), and positioning of the anastomosis (p = 0.013). The group that used the area cannulation technique had a longer duration of hemodialysis, proximal anastomoses, and more successful revisions of AVFs.

Encouraging employees to report verbal violence in primary health care in Serbia: A cross-sectional study.

INTRODUCTION: Workplace violence is a serious and multidimensional problem that adversely affects professional and personal lives of employees. The aim of this study was to assess the prevalence and characteristics of verbal violence as a part of psychological violence among employees in primary health care in Belgrade, and to identify contributing factors of verbal violence in the workplace. METHODS: In this cross-sectional study, the final analysis included 1526 employees, using multi-stage sampling. Data were collected using the questionnaire Workplace Violence in the Health Sector Country Case Studies Research, developed by ILO/ICN/WHO/PSI. Descriptive statistics and logistic regression analysis were used to analyse the data. The general response rate was 86.8% (1526/1757). RESULTS: It was found that 47.8% of the participants were subjected to verbal violence. The main source of verbal violence was patient/client, 55.6% of employees did not report the incident. Among those who did not report the incident, 74.9% believed that reporting violence was useless. The interaction with patients (OR, 1.45; 95% CI, 1.02-2.06) and work between 6pm and 7am (OR, 1.27; 95% CI, 1.01-1.60) were significant contributing factors of verbal violence. CONCLUSION: The results are indicative of a high prevalence of verbal violence against employees in primary health centres, which could have undesirable consequences. Conducting a better organizational measure and encouraging employees to report workplace violence could reduce the prevalence of verbal violence.

Correlation between nonalcoholic fatty liver and cardiovascular disease in elderly hemodialysis patients.

PURPOSE: The number of elderly patients with end-stage kidney disease is on the rise. Nonalcoholic fatty liver disease (NAFLD) is characterized by parenchymal fat accumulation in patients without information about alcohol abuse. The aim of our study was to determine correlation between NAFLD and cardiovascular diseases in elderly hemodialysis patients. METHODS: The examination was organized as observational and cross-sectional study in elderly patients on hemodialysis. An abdominal ultrasound examination was made in order to define NAFLD. Intima-media thickness of the carotid arteries was quantified by Doppler ultrasound. Biochemical parameters, gender, anthropometric characteristics, duration, adequacy of hemodialysis, blood pressure, smoking and cardiovascular disease were determined. Respondents were divided into a group with NAFLD (37/72 patients, 51 %) and group without NAFLD (35/72 patients, 49 %). RESULTS: Patients with NAFLD have significantly more cardiovascular disease (p = 0.017) as well as significantly higher values of intima-media thickness of the carotid arteries (p = 0.03) in correlation with patients without NAFLD. Patients without NAFLD have a statistically lower triglyceride (p = 0.04), aspartate aminotransferase (p = 0.006), alanine aminotransferase (p = 0.013) and gamma-glutamyl transpeptidase (p = 0.029) compared to patients with NAFLD. Patients with cardiovascular disease have a higher risk of NAFLD; likewise, patients with NAFLD have a three times higher chance for developing cardiovascular diseases (OR 3.01). CONCLUSION: Elderly patients on hemodialysis with cardiovascular disease have a higher risk of NAFLD; likewise, patients with NAFLD have a three times higher chance for developing cardiovascular diseases.

Improving Education in Medical Statistics: Implementing a Blended Learning Model in the Existing Curriculum.

BACKGROUND: Although recent studies report on the benefits of blended learning in improving medical student education, there is still no empirical evidence on the relative effectiveness of blended over traditional learning approaches in medical statistics. We implemented blended along with on-site (i.e. face-to-face) learning to further assess the potential value of web-based learning in medical statistics. METHODS: This was a prospective study conducted with third year medical undergraduate students attending the Faculty of Medicine, University of Belgrade, who passed (440 of 545) the final exam of the obligatory introductory statistics course during 2013-14. Student statistics achievements were stratified based on the two methods of education delivery: blended learning and on-site learning. Blended learning included a combination of face-to-face and distance learning methodologies integrated into a single course. RESULTS: Mean exam scores for the blended learning student group were higher than for the on-site student group for both final statistics score (89.36±6.60 vs. 86.06±8.48; p = 0.001) and knowledge test score (7.88±1.30 vs. 7.51±1.36; p = 0.023) with a medium effect size. There were no differences in sex or study duration between the groups. Current grade point average (GPA) was higher in the blended group. In a multivariable regression model, current GPA and knowledge test scores were associated with the final statistics score after adjusting for study duration and learning modality (p<0.001). CONCLUSION: This study provides empirical evidence to support educator decisions to implement different learning environments for teaching medical statistics to undergraduate medical students. Blended and on-site training formats led to similar knowledge acquisition; however, students with higher GPA preferred the technology assisted learning format. Implementation of blended learning approaches can be considered an attractive, cost-effective, and efficient alternative to traditional classroom training in medical statistics.

Is low magnesium a clue to arteriovenous fistula complications in hemodialysis?

PURPOSE: Magnesium insufficiency is a pro-atherogenic factor involved in endothelial dysfunction, atherosclerosis, and vascular calcification. Our aim was to examine the role of magnesium in the development of arteriovenous fistula complications in hemodialysis. METHODS: This was a retrospective clinical investigation of data from 88 patients who were divided into two groups: those with and without arteriovenous fistula complications. We examined the influence of sex, demographics, and clinical and laboratory parameters. The existence of fistula stenosis was determined by measuring Doppler flow, while B-mode ultrasound was used to detect plaques and evaluate the carotid artery intima-media thickness. RESULTS: Patients with arteriovenous fistula complications had significantly higher leukocyte counts (p = 0.03), platelet counts (p = 0.03), phosphate concentrations (p = 0.044), and alkaline phosphatase concentrations (p = 0.04). Patients without complications had significantly greater blood flow through the arteriovenous fistula (p < 0.0005), higher magnesium concentrations (p = 0.004), and a lower carotid artery intima-media thickness (p = 0.037). The magnesium level was inversely correlated with leukocyte (p = 0.028) and platelet (p = 0.016) counts. The magnesium concentration was significantly lower in patients with carotid artery plaques (p = 0.03). Multiple linear regression, using magnesium as the dependent variable in patients with arteriovenous fistula complications, indicated statistically significant correlations with platelet (p = 0.005) and leukocyte (p = 0.027) counts and carotid plaques (p = 0.045). CONCLUSIONS: Hypomagnesemia is a significant pro-atherogenic factor and an important predictor of arteriovenous fistula complications.

Does workplace violence exist in primary health care? Evidence from Serbia.

BACKGROUND: Violence in the workplace is a serious social and public health problem. The objective of this study was to estimate the prevalence of workplace violence and to identify potential predictors of workplace violence at Serbian Primary Health Care (PHC) centres. METHODS: A cross-sectional study was conducted between October 2012 and July 2013. The sample consisted of medical and non-medical staff employed at PHC centres in Belgrade, Serbia. Among 1757 currently presented at work, 1526 returned the questionnaires. The data were collected by questionnaire Workplace Violence in the Health Sector-Country Case Studies, developed by the ILO/ICN/WHO/PSI. Binary logistic regression was conducted to assess the association between exposure to workplace violence and sociodemographic and work-related characteristics. RESULTS: The prevalence of workplace violence, was 803 (52.6%), with 147 (18.3%), exposed to physical violence. Multiple logistic regression models indicated that the following work-related characteristics were positive associated of workplace violence with working between 18:00 and 07:00 h [odds ratio (OR): 1.37, 95% confidence interval (CI): 1.08-1.73], nurses as a professional group (OR: 1.91, 95% CI: 1.16-3.17), working with preschool children (OR: 0.56, 95% CI: 0.34-0.91). There was negative association of workplace violence with encouragement to report violence (OR: 0.61, 95% CI: 0.49-0.76) and the number of staff in the same work setting (OR: 0.73, 95% CI: 0.56-0.96). CONCLUSIONS: More than half of employees in Belgrade PHC centres were exposed to different types of workplace violence. There is a need for interventions to protect health workers and provide safer workplace environments.

Predictive parameters of survival in hemodialysis patients with restless leg syndrome.

Restless leg syndrome (RLS) affects the quality of life and survival in patients on hemodialysis (HD). The aim of this study was to determine the characteristics and survival parameters in patients on HD with RLS. This study was a non-randomized clinical study involving 204 patients on HD, of whom 71 were female and 133 were male. Symptoms of RLS were defined as positive responses to four questions comprising the criteria of RLS. We recorded the outcome of treatment, biochemical analyses, demographic, sexual, anthropometric and clinical characteristics in all study patients. Patients with RLS who completed the study had a significantly higher body mass index and lower intima-media thickness and flow through the arteriovenous fistula. Among patients with RLS who died, there were more smokers as well as higher incidences of cardiovascular disease and diabetes mellitus. Among patients with RLS who survived, there were a greater number of patients with preserved diuresis and receiving erythropoietin therapy. Patients who completed the study had significantly higher levels of hemoglobin, creatinine, serum iron and transferrin saturation. Diabetes mellitus (B = 1.802; P = 0.002) and low Kt/V (B = -5.218; P = 0.001) were major predictive parameters for survival.

Predictive value of serum myeloperoxidase activity for thrombosis of arteriovenous fistulas.

Myeloperoxidase is a proinflammatory protein that appears as a result of increased oxidative stress. It plays an important role in the promotion and progression of atherosclerosis. The aim of this study was to determine the importance of MPO as a predictive parameter for thrombosis of arteriovenous fistula (AVF). The study involved monitoring patients with AVFs for hemodialysis over a period of 2 years. There were 41 patients, 19 (46%) men and 22 (54%) women, with mean age of 65 ± 12.7 years. Routine laboratory analyses were carried out in all respondents, including determination of MPO concentration. Gender, demographic and anthropometrical characteristics, smoking, alcohol consumption, as well as the presence of diabetic nephropathy, as an etiological factor of kidney disease, were recorded. The group of patients who developed initial thrombosis of the AVFs had significantly different values for leukocytes (8.5 ± 3.8 vs. 7.3 ± 2.1, P = 0.024), erythrocytes (2.8 ± 0.27 vs. 3.2 ± 0.65; P = 0.019), hemoglobin (88.5 ± 81 vs. 99.1 ± 6.02; P = 0.041), and myeloperoxidase (19.3 ± 4.67 vs. 11.1 ± 4.43; P = 0.007) when compared with the group without fistula thrombosis. Diabetic nephropathy (P = 0.02) characterized the group of patients with thrombosis of the fistula. Diabetic nephropathy (B = 2.53, P = 0.049) and MPO (B = 0.03, P = 0.029) were statistically significant predictors of fistula thrombosis. In our study, MPO and diabetic nephropathy were predictors of thrombosis of the AVF.

Arteriovenous fistulas and digital hypoperfusion ischemic syndrome in patients on hemodialysis.

AIM: To determine survival parameters as well as characteristics of patients with this syndrome. METHODS: The investigation was conducted over a period of eight years, as a prospective, non-randomized, clinical study which included 204 patients, treated by chronic hemodialysis. Most patients received hemodialysis 12 h per week. As vascular access for hemodialysis all subjects had an arteriovenous fistulae. Based on surveys the respondents were divided into groups of patients with and without digital hypoperfusion ischemic syndrome. Gender, demographic and anthropometric characteristics, together with comorbidity and certain habits, were recorded. During this period 34.8% patients died. RESULTS: Patients with digital hypoperfusion ischemic syndrome were older than those without ischemia (P = 0.01). Hemodialysis treatment lasted significantly longer in the patients with digital hypoperfusion ischemic syndrome (P = 0.02). The incidence of cardiovascular disease (P < 0.001) and diabetes mellitus (P = 0.01), as well as blood flow through the arteriovenous fistula (P = 0.036), were higher in patients with digital hypoperfusion ischemic syndrome. Statistically significant differences also existed in relation to oxygen saturation (P = 0.04). Predictive parameters of survival for patients with digital hypoperfusion ischemic syndrome were: adequacy of hemodialysis (B = -3.604, P < 0.001), hypertension (B = -0.920, P = 0.018), smoking (B = -0.901, P = 0.049), diabetes mellitus (B = 1.227, P = 0.005), erythropoietin therapy (B = 1.274, P = 0.002) and hemodiafiltration (B = -1.242, P = 0.033). Kaplan-Meier survival analysis indicated that subjects with and without digital hypoperfusion ischemic syndrome differed regarding the length of survival (P < 0.001), i.e., patients with confirmed digital hypoperfusion ischemic syndrome died earlier. CONCLUSION: Survival was significantly longer in the patients without digital hypoperfusion ischemic syndrome.

Validation of the chronic liver disease questionnaire in Serbian patients.

AIM: To translate into Serbian and to investigate the validity of the cross-culturally adapted the chronic liver disease questionnaire (CLDQ). METHODS: The questionnaire was validated in 103 consecutive CLD patients treated between October 2009 and October 2010 at the Clinic for Gastroenterology, Clinical Centre of Serbia, Belgrade (Serbia). Exclusion criteria were: age < 18 years, psychiatric disorders, acute complications of CLD (acute liver failure, variceal bleeding, and spontaneous bacterial peritonitis), hepatic encephalopathy (grade > 2) and liver transplantation. Evaluation of the CLDQ was done based on the following parameters: (1) acceptance is shown by the proportion of missing items; (2) internal reliabilities were assessed for multiple item scales by using Cronbach alpha coefficient; and (3) in order to assess whether the allocation of items in the domain corresponds to their distribution in the original questionnaire (construction validity), an exploratory factor analysis was conducted. Discriminatory validity was determined by comparing the corresponding CLDQ score/sub-score in patients with different severity of the diseases. RESULTS: The Serbian version of CLDQ questionnaire completed 98% patients. Proportion of missing items was 0.06%. The total time needed to fill the questionnaire was ranged from 8 to 15 min. Assistance in completing the questionnaire required 4.8% patients, while 2.9% needed help in reading, and 1.9% involved writing assistance. The mean age of the selected patients was 53.8 ± 12.9 years and 54.4% were men. Average CLDQ score was 4.62 ± 1.11. Cronbach's alpha for the whole scale was 0.93. Reliability for all domains was above 0.70, except for the domain "Activity" (0.49). The exploratory factor analysis model revealed 6 factors with eigenvalue of greater than 1, explaining 69.7% of cumulative variance. The majority of the items (66%) in the Serbian version of the CLDQ presented the highest loading weight in the domain assigned by the CLDQ developers: "Fatigue" (5/5), "Emotional function" (6/8), "Worry" (5/5), "Abdominal symptoms" (0/3), "Activity" (0/3), "Systemic symptoms" (3/5). The scales "Fatigue" and "Worry" fully corresponded to the original. The factor analysis also revealed that the factors "Activity" and "Abdominal symptoms" could not be replicated, and two new domains "Sleep" and "Nutrition" were established. Analysis of the CLDQ score/sub-score distribution according to disease severity demonstrated that patients without cirrhosis had lower total CLDQ score (4.86 ± 1.05) than those with cirrhosis Child's C (4.31 ± 0.97). Statistically significant difference was detected for the domains "Abdominal symptoms" [F (3) = 5.818, P = 0.001] and "Fatigue" [F (3) = 3.39, P = 0.021]. Post hoc analysis revealed that patients with liver cirrhosis Child's C had significantly lower sub-score "Abdominal symptoms" than patients without cirrhosis or liver cirrhosis Child's A or B. For domain "Fatigue", patients with cirrhosis Child's C had significantly lower score, than non-cirrhotic patients. CONCLUSION: The Serbian version of CLDQ is well accepted and represents a valid and reliable instrument in Serbian sample of CLD patients.

Correlation of mortality and location of arteriovenous fistula in hemodialysis patients.

PURPOSE: Since the type of vascular access is very important and a significant risk factor for mortality in patients on hemodialysis, the aim of our study was to determine the impact of AVF positioning on the mortality of our patients. METHODS: The survey was organized as a prospective, clinical and non-randomized study of 538 surgical interventions on 323 patients, which indicates that a large number of patients had more than one fistula. Among these patients, 120 subjects (81 (67.5%) men and 39 (32.5%) women) died during the study period. We analyzed the demographic structure, the site location and type of anastomosis for the arteriovenous fistula, artery and vein lumen and presence of instillation catheters, as well as measuring flow through the fistula and arterial blood pressure. Biochemical parameters thought to have a significant impact on survival were obtained from routine monthly analyses. RESULTS: In patients in whom infection was the cause of death, termino-terminal anastomosis was more frequently present (p=0.035). Variables that were statistically significant predictors of death were elderly individuals (Beta 0.033, p<0.001); patients whose diastolic blood pressure was low (Beta -0.028, p<0.001); and the position of the arteriovenous fistula (distal Beta -0.737, p=0.001; proximal Beta -0.581, p=0.008). Patients with a cubital fistula (p=0.001) had a significantly shorter Kaplan-Meier survival curve. CONCLUSIONS: End-to-end artery and vein connection was a significantly more common form of anastomosis in patients who died as a result of infection. Important parameters of mortality in our study were the position of the arteriovenous fistula, age, and the diastolic component of arterial blood pressure.

Impact of metabolic syndrome and malnutrition on mortality in chronic hemodialysis patients.

OBJECTIVE: Metabolic abnormalities contribute to increases in the mortality rate of patients on hemodialysis. Here, we estimate the importance and influence of metabolic syndrome and malnutrition on mortality rate. DESIGN: This was a follow-up study. METHODS: We examined the demographic characteristics of time on dialysis, body mass index, indications for hospitalization, treatment outcomes, and biochemical parameters over a 4-year period. RESULTS: Whereas 31.7% of patients had metabolic syndrome, 26.7% showed evidence of malnutrition. More than two thirds of the malnourished patients died. Many patients (46%) with malnutrition were hospitalized because of problems with vascular access, whereas hospitalization of half of the examined patients with metabolic syndrome was attributable to cardiovascular disorders. Differences between groups in the parameters of anemia, total proteins, albumin, and low-density lipoprotein cholesterol also occurred, with the lowest values in malnourished patients. Glycemia, total cholesterol, and fibrinogen were significantly higher in patients with metabolic syndrome, whereas those with malnutrition had a markedly higher concentration of C-reactive protein. The mean survival was 24 months with metabolic syndrome and 17.5 months with malnutrition, which was significantly shorter. CONCLUSIONS: More than half of the examined patients had metabolic abnormalities. Patients with malnutrition had a lower rate of survival compared with those who had metabolic syndrome. Two thirds of our malnourished patients died, and the total rate of mortality in the examined sample was 38%.

Influence of the level of renal insufficiency on endoscopic changes in the upper gastrointestinal tract.

AIM: Lesions of the gastrointestinal tract are frequent finding in uremic patients but their actual nature is not completely clear. The aim of this study was to detect any correlation between endoscopic lesions of patients with different levels of renal insufficiency. METHODS: This prospective study involved 244 cases, with dyspeptic difficulties including 124 patients in different stages of renal insufficiency, and a control group of 120 patients with normal renal function. Upper esophagogastroscopy was performed in all patients because of the appearance of dyspeptic difficulties. Helicobacter pylori infection was detected by the urease test. RESULTS: H. pylori infection (P=0.009), gastric erosions (P=0.019), gastric ulcer (P=0.002), and duodenal ulcer (P<0.001) were more common in the control group of patients. Significant negative correlations were found between the level of renal insufficiency and H. pylori infection (Kendall's tau=-0.346; P=0.003), stomach erosions (Kendall's tau=-0.272; P=0.019), stomach ulcer (Kendall's tau=-0.347; P=0.003), and duodenal ulcer (Kendall's tau=-0.531; P<0.001). CONCLUSIONS: In patients with end stage renal disease, endoscopic lesions of the gastrointestinal tract are detected less frequently in relation to patients without kidney disease.

The influence of atherosclerosis and plasma D-dimer concentration in patients with a functioning arteriovenous fistula for maintenance hemodialysis.

OBJECTIVE: The aim of this study was to deduce the influence of atherosclerosis and plasma D-dimer concentration on the functioning of arteriovenous fistulae for hemodialysis. METHODS: The study was organized as a prospective and non-randomized investigation in the "Kragujevac" Clinical Center. The 81 examined patients, 49 (60.5%) males and 32 (39.5%) females, were divided into a group (n = 36) requiring several attempts to create arteriovenous fistulae for hemodialysis and a group (n = 45) with no complications of arteriovenous fistulae for hemodialysis. The demographic structure, etiology of renal disease, biochemical parameters and concentration of D-dimer were analyzed at the beginning of the study and 1 year later, as well as the existence of tissue calcification and Duplex ultrasound parameters of the carotid artery. RESULTS: The patients with arteriovenous fistulae complications were significantly older (58.4 +/- 12.9 vs. 52.3 +/- 11.6 years; P = 0.026). High venous pressure (98.6 +/- 29.98 vs. 80 +/- 33.57 mmHg; P = 0.005) and soft-tissue calcification (P = 0.03) were correlated with the occurrence of arteriovenous fistula complications. The greatest risk for failure of fistula was within the first month after creation of the anastomosis (failure rate was 0.235). The hemoglobin concentration (89 +/- 14.0 vs. 96.6 +/- 17.7 g/l; P = 0.048) was lower, and concentration of D-dimer at the end of the study was higher (219.56 +/- 193.05 vs. 332.03 +/- 149.48; P = 0.012) in patients with vascular access complications. By Cox regression analysis, the concentration of fibrin D-dimer at the end of the study was shown to be a significant predictor of fistula survival (beta = 0.002; P = 0.006). CONCLUSIONS: Complications of arteriovenous fistulae were more often recorded in older patients. The greatest risk for fistula functioning was within the first month after creation of the anastomosis. Vein pressure and anemia were important indicators of arteriovenous fistula complications. D-dimer was a significant marker of arteriovenous fistula thrombosis.