Multiorgan Toxicity from Dual Checkpoint Inhibitor Therapy, Resulting in a Complete Response-A Case Report.

Immunotherapy treatment with checkpoint inhibitors (ICIs) has led to a breakthrough in the treatment of oncological diseases. Despite its clinical effectiveness, this treatment differs from others, such as cytotoxic chemotherapy, in that it causes immune-related adverse events. This type of toxicity can affect any organ or organ system of the body. We present a literature review and a rare clinical case from our clinical practice, in which a patient with metastatic clear cell renal carcinoma was treated with a single dose of dual checkpoint blockade (cytotoxic T-lymphocyte-4 (CTLA-4) and programmed death-1 (PD-1)) and simultaneously diagnosed with colitis, hepatitis, and nephritis. After early immunosuppressive treatment with the glucocorticoids, complete organ function recovery was achieved. The follow-up revealed a sustained complete response lasting more than a year.

The Influence of Tacrolimus Exposure and Metabolism on the Outcomes of Kidney Transplants.

Tacrolimus (TAC) has a narrow therapeutic window and patient-specific pharmacokinetic variability. In our study, we analyzed the association between TAC exposure, metabolism, and kidney graft outcomes (function, rejection, and histological lesions). TAC trough (C0), coefficient of variation (TAC CV), concentration/dose ratio (C/D), and biomarkers related to kidney injury molecule-1 (KIM-1) and neutrophil gelatinase lipocalin (NGAL) were analyzed. We examined 174 patients who were subjected to a triple immunosuppressive regimen and underwent kidney transplantation between 2017 and 2022. Surveillance biopsies were performed at the time of kidney implantation and at three and twelve months after transplantation. We classified patients based on their Tac C/D ratios, classifying them as fast (C/D ratio < 1.05 ng/mL × 1/mg) or slow (C/D ratio ≥ 1.05 ng/mL × 1/mg) metabolizers. TAC exposure/metabolism did not significantly correlate with interstitial fibrosis/tubular atrophy (IF/TA) progression during the first year after kidney transplantation. TAC CV third tertile was associated with a higher chronicity score at one-year biopsy. TAC C/D ratio at three months and Tac C0 at six months were associated with rejection during the first year after transplantation. A fast TAC metabolism at six months was associated with reduced kidney graft function one year (OR: 2.141, 95% CI: 1.044-4.389, p = 0.038) and two years after transplantation (OR: 4.654, 95% CI: 1.197-18.097, p = 0.026), and TAC CV was associated with reduced eGFR at three years. uNGAL correlated with IF/TA and chronicity scores at three months and negatively correlated with TAC C0 and C/D at three months and one year. Conclusion: Calculating the C/D ratio at three and six months after transplantation may help to identify patients at risk of suffering acute rejection and deterioration of graft function.

Immune Response after Anti-SARS-CoV-2 mRNA Vaccination in Relation to Cellular Immunity, Vitamin D and Comorbidities in Hemodialysis Patients.

In the global threat of SARS-CoV-2, individuals undergoing maintenance dialysis represent a vulnerable population with an increased risk of severe COVID-19 outcomes. Therefore, immunization against SARS-CoV-2 is an essential component of healthcare strategy for these patients. Existing data indicate that they tend to exhibit a reduced immune response to vaccines compared to the general population. Our study aimed to assess both humoral and cellular immune responses following two doses of an anti-SARS-CoV-2 mRNA vaccine, an ability to maintain adequate antibody titers over time, and potential relations with vitamin D, comorbidities and other factors in hemodialysis patients based on a single center experience. A total of 41/45 patients (91.1%) responded to the second dose of the anti-SARS-CoV-2 mRNA vaccine. The titer of anti-SARS-CoV-2 IgG class antibodies and levels of T cells three to four weeks after vaccination were lower in dialysis patients than in healthy controls. Antibodies titer in dialysis patients had a positive correlation with B lymphocytes and was related to cardiovascular diseases. The level of CD4+ cells had a negative correlation with hemodialysis vintage, as did the vitamin D level with post-vaccination seroconversion and decline in anti-SARS-CoV-2 antibodies titer during six months after vaccination. Hemodialysis patients had decreased amounts of CD4+ and CD8+ cells and lower levels of anti-SARS-CoV-2 antibodies than healthy controls. Therefore, chronic hemodialysis could lead to diminished cellular immunity and humoral immune response to the anti-SARS-CoV-2 mRNA vaccination and reduced protection from COVID-19. Comorbidity in cardiovascular diseases was associated with a lower level of specific anti-SARS-CoV-2 antibody titer. Vitamin D may be important in maintaining stable levels of anti-SARS-CoV-2 antibodies, while the duration of dialysis treatment could be one of the factors decreasing anti-SARS-CoV-2 antibody titer and determining lower CD4+ cell counts.

Deceased Kidney Donor Biomarkers: Relationship between Delayed Kidney Function and Graft Function Three Years after Transplantation.

With an increasing number of marginal donors, additional methods for the evaluation of cadaveric kidney quality are required. This study aimed to evaluate pretransplant deceased donor serum (s) and urine (u) biomarkers, including neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), interleukin-18, and C-X-C motif chemokine 10 (CXCL10) for predicting early and late graft function. In total, 43 deceased kidney donors and 76 corresponding recipients were enrolled. Delayed graft function (DGF) occurred in 27.6% of cases. sIL-18, sKIM-1, uNGAL, and uKIM-1 were predictors of DGF. A model incorporating sIL-18, uKIM-1, and clinical factors was developed to predict DGF (AUROC 0.863). Univariate analysis showed a negative association between uKIM and graft eGFR at 6, 12, 24, and 36 months, but this was not confirmed in the multivariate analysis. In conclusion, we report a superior performance of donor biomarkers for predicting DGF and later graft function over serum creatinine. Higher levels of donor sIL-18 and uKIM in conjunction with expanded-criteria donors and longer cold ischemia times predicted DGF. With no renal tubular damage in zero-time donor biopsies, higher pretransplant urine and serum NGAL levels were associated with better allograft function one year after transplantation, and sNGAL with graft function three years after transplantation.

The Impact of the Emotional Disposition of Healthcare Workers on the Expression of Adverse Events after Primary Vaccination against SARS-CoV-2.

Background and Objectives: Vaccination is one means of SARS-CoV-2 prevention and control. However, despite the effectiveness of vaccination, adverse reactions continue to require vigilance and monitoring. The researchers emphasize the possibility that some of the reported side effects may be psychological in origin. Based on this hypothesis, the main goal of this study was to evaluate the emotional dispositions of healthcare workers who experienced emotions before vaccination and adverse reactions after vaccination. Materials and Methods: This study was conducted between February and May 2021 in the Kaunas Clinics of the University of Health Sciences. A total of 2117 employees of the clinic departments who were vaccinated with two doses of the Pfizer-BioNTech vaccine participated in this study. Statistical analysis was performed on the data using IBM SPSS Statistics®. Results: Most participants (74.5%) experienced systemic (including local) adverse events; 16.5% experienced only local adverse events, and 9.1% experienced no adverse events. The frequency of systemic (including local) adverse events reduced with increasing age (p < 0.05). The main emotions that participants experienced before vaccination were anxiety (37.88%) and happiness (39.02%). Systemic (including local) adverse events occurred 1.26 times more frequently in women than men (77.44% vs. 61.6%, p < 0.05), while local adverse events occurred 1.4 times more often in male participants than in female participants (21.39% vs. 15.27%, p < 0.05). Among the respondents who did not experience adverse events, the most common emotion felt was happiness (25.5%), and most of the participants who experienced systemic (including local) adverse events felt anxiety (42.6%). Conclusions: The information about vaccination and potential adverse events should be targeted at younger persons. It is recommended that women, more than men, should receive professional counseling from psychologists or psychotherapists. The public dissemination of positive messages about the benefits and safety of vaccines prior to a vaccination campaign may alleviate the tension or anxiety felt regarding potential adverse events. Healthcare specialists-both those who work directly with vaccines and those who do not-should maintain a positive psychological attitude towards vaccination, as this can increase patient satisfaction with the benefits of vaccines.

The Role of Pre- and Post-Transplant Hydration Status in Kidney Graft Recovery and One-Year Function.

Background and Objectives: Early improvements to graft function are crucial for good outcomes in kidney transplantation (kTx). Various factors can influence early graft function. This study aimed to evaluate the pre- and post-transplant hydration statuses of kTx recipients using bioimpedance analysis (BIA) and lung ultrasonography (LUS) and to investigate the hydration status' relationship with the function of the transplanted kidney during the first year after transplantation. Materials and Methods: This observational prospective cohort study included deceased kidney recipients transplanted in the Hospital of the Lithuanian University of Health Sciences between September 2016 and January 2023. BIA and LUS were performed before transplantation, on days 3 and 7, and at discharge. Data on recipient and donor clinical characteristics were collected. Graft function was evaluated according to the serum creatinine reduction ratio and the need for dialysis. Hydration status was evaluated by calculating B-lines (BL) on LUS and the ratio of extracellular/total body water on BIA. Results: Ninety-eight kTx recipients were included in the study. Patients with immediate graft function (IGF) were compared to those with slow or delayed graft function (SGF + DGF). Recipients in the SGF + DGF group had a higher sum of BL on LUS before transplantation. After transplantation in early postoperative follow-up, both groups showed hyperhydration as determined by BIA and LUS. After one year, recipients with no BL before transplantation had better graft function than those with BL. Logistic regression analysis showed that having more than one BL in LUS was associated with a 2.5 times higher risk of SGF or DGF after transplantation. Conclusions: This study found that lung congestion detected by LUS before kTx was associated with slower graft recovery and worse kidney function after 1 year. Meanwhile, the hyperhydration status detected by BIA analysis did not correlate with the function of the transplanted kidney.

Prevalence of COVID-19 in Kidney Transplant Patients in Relation to Their Immune Status after Repeated Anti-SARS-CoV-2 Vaccination.

The prospective study was conducted to evaluate the prevalence of COVID-19 in kidney transplant patients in relation to their immune status after three doses of the BNT162b2 (Pfizer-BioNTech) vaccine during one post-pandemic year based on the experience of one center-Hospital of Lithuanian University of Health Sciences. Thirty-three patients were invited for a follow-up visit 3 to 6 weeks after anti-SARS-CoV-2 vaccination and were obliged to report having COVID-19 during the one-year post-pandemic period. Forty-two percent of patients developed antibody response against SARS-CoV-2 after the third dose of the vaccine. The number of COVID-19 cases during the post-pandemic period did not differ significantly between seropositive and seronegative patients. However, only seronegative patients were hospitalized due to COVID-19. The anti-SARS-CoV-2 antibody titer in seropositive patients correlated with a relative number of CD3+ cells (R = 0.685, p = 0.029). The CD8+/CD38+ ratio in this group increased 2-fold after the anti-SARS-CoV-2 vaccination. Higher antibody response to the COVID-19 vaccine was associated with better kidney function. The anti-SARS-CoV-2 antibody titer relation with the components of cellular immunity (CD3+ cells and CD8+/CD38+ ratio) shows a role of both chains during the response to the anti-SARS-CoV-2 vaccine in kidney transplant patients.

Challenges to an Individualized Approach Toward Batterers Intervention Programs in the Context of Coordinated Community Response to the Intimate Partner Violence in Lithuania.

Purpose: Although batterers' intervention programs (BIPs) constitute an important part of the coordinated response to intimate partner violence (IPV) and contribute to increasing the perpetrators' accountability and keeping victims safe, the effectiveness of these programs is still debated. Only recently has the focus of these debates shifted away from researching outcomes by measuring overall program effectiveness toward specific qualities of interventions across program models that may be effective for the distinct client (Babcock et al., Clinical Psychology Review, 23(8), 1023-1053, 2004; Zarling et al., Psychology of Violence, 9(3), 257-266, 2019). The discussion on the practical implementation of BIPs was supplemented by various significant concepts emerging from new empirical findings, such as differential treatment, motivational interviewing, and effective facilitator-client alliances (Hamel et al., Partner Abuse, 11(4), 387-414, 2020; Holtrop et al., Journal of Interpersonal Violence, 32(8), 1267-1290, 2017). This paper aimed to address some of the abovementioned concepts by identifying challenges that arise during the implementation of BIPs in Lithuania. Methods: Using qualitative data from semi-structured interviews and focus group discussions with BIPs facilitators, BIPs attendees, and various stakeholders, the paper discusses how to contribute to more effective BIPs outcomes. Results: According to this study, the process of implementing BIPs in Lithuania should be systematized by incorporating existing instruments, such as motivational interviewing, risk-based assessment, and differential treatment, evidence-based programs focused on different theoretical approaches, and forms of implementation. Conclusion: The study found that the consistency and integrity of the entire BIP implementation process should be prioritized, and institutional cooperation in Lithuania needs to be improved to achieve a successful coordinated response to intimate partner violence.

Adverse Events and Immunogenicity of mRNA-Based COVID-19 Vaccine among Healthcare Workers: A Single-Centre Experience.

Background and Objectives: The safety and effectiveness of vaccines are among the key priorities in COVID-19 pandemic management. Moreover, evidence-based data regarding vaccine safety and immunogenicity can play an important role in building the trust of the community regarding vaccination. The aim of this study was to investigate the safety and immunogenicity of Pfizer-BioNTech vaccine among healthcare workers in one hospital, 21 days after first dose. Materials and Methods: This study was conducted in the Hospital of the Lithuanian University of Health Sciences between February and March 2021. Hospital employees who arrived to receive the second dose of the Pfizer-BioNTech vaccine 21 days after the first one were invited to participate in the study: they were asked to complete an anonymous adverse events questionnaire and were offered a SARS-CoV-2 IgG/IgM rapid test. The study was performed at a single point, 21 days after the first dose of the vaccine. Results: Data of 4181 vaccine recipients were analysed. The first vaccine dose was associated with a 53.6% incidence of adverse events, mainly local reactions. Adverse events occurred more frequently in younger participants and women. Moderate adverse events were experienced by 1.4% of the vaccine recipients; 6.2% were incapacitated. Of the 3439 participants who performed a rapid IgG test, 94.5% were positive for IgG antibodies after the first vaccine dose. Seroconversion rates were lower in participants older than 47 years. Conclusions: Despite 1.4% moderate adverse events, no safety concerns or anaphylaxis were identified. The Pfizer-BioNTech vaccine induced an immune response in the overwhelming majority of recipients after a single dose. Younger participants experienced adverse events and were positive for IgG antibodies more frequently than older counterparts. It is important to mention that this study specifically considered short-term safety and reactions following vaccination and that long-term adverse effects were not investigated in the study. Thus, future research into both long-term adverse reactions and immune system programming is essential.

Immune Response after SARS-CoV-2 Vaccination in Kidney Transplant Patients.

Background and Objectives: The prospective study was conducted to evaluate humoral and cellular immune responses after two doses of BNT162b2 (Pfizer-BioNTech) vaccine and possible relation with other factors (medication, etc.) in kidney transplant patients. Materials and Methods: Out of 167 vaccinated patients, 136 agreed to a follow-up visit three to six weeks after vaccination. Results: Only 39 patients (29%) developed antibody response against SARS-CoV-2 (≥35.2 binding antibody units (BAU)/mL) after full vaccination. Multivariate binary logistic regression analysis showed that predictive factors for good antibody response to the COVID-19 vaccine were better kidney function, higher hemoglobin level, and no use of mycophenolate mofetil for immunosuppression. For seropositive kidney transplant patients there was a significant negative correlation between anti-SARS-CoV-2 antibody titer and CD4/CD8 ratio (Spearman's correlation coefficient -0.4, p = 0.02), percentage of CD19+ cells (r = -0.37, p = 0.02), and a positive correlation with percentage of CD8+ cells (r = 0.4, p = 0.01). There was an increase of total leucocyte count after vaccination in the total studied population, and in the group of responders. Conclusions: Only one third of kidney transplant patients develop sufficient antibody responses after full COVID-19 vaccination with Pfizer-BioNTech. Better kidney function, higher hemoglobin level, and no use of mycophenolate mofetil for immunosuppression increases the adequacy of response. The antibody titers correlated positively with relative number of CD8+ cells and negatively with CD4/CD8 ratio in responders.

Assessment of Fluid Status by Bioimpedance Analysis and Central Venous Pressure Measurement and Their Association with the Outcomes of Severe Acute Kidney Injury.

Background and Objectives: Fluid disbalance is associated with adverse outcomes in critically ill patients with acute kidney injury (AKI). In this study, we intended to assess fluid status using bioimpedance analysis (BIA) and central venous pressure (CVP) measurement and to evaluate the association between hyperhydration and hypervolemia with the outcomes of severe AKI. Materials and Methods: A prospective study was conducted in the Hospital of the Lithuanian University of Health Sciences Kauno Klinikos. Forty-seven patients treated at the Intensive Care Unit (ICU) with severe AKI and a need for renal replacement therapy (RRT) were examined. The hydration level was evaluated according to the ratio of extracellular water to total body water (ECW/TBW) of bioimpedance analysis and volemia was measured according to CVP. All of the patients were tested before the first hemodialysis (HD) procedure. Hyperhydration was defined as ECW/TBW > 0.39 and hypervolemia as CVP > 12 cm H2O. Results: According to bioimpedance analysis, 72.3% (n = 34) of patients were hyperhydrated. According to CVP, only 51.1% (n = 24) of the patients were hypervolemic. Interestingly, 69.6% of hypovolemic/normovolemic patients were also hyperhydrated. Of all study patients, 57.4% (n = 27) died, in 29.8% (n = 14) the kidney function improved, and in 12.8% (n = 6) the demand for RRT remained after in-patient treatment. A tendency of higher mortality in hyperhydrated patients was observed, but no association between hypervolemia and outcomes of severe AKI was established. Conclusions: Three-fourths of the patients with severe AKI were hyperhydrated based on bioimpedance analysis. However, according to CVP, only half of these patients were hypervolemic. A tendency of higher mortality in hyperhydrated patients was observed.

Molecular Characterization and Seroprevalence of Hepatitis E Virus in Inflammatory Bowel Disease Patients and Solid Organ Transplant Recipients.

Seroprevalence rates and molecular characterization of hepatitis E virus (HEV) prevalent in the Lithuanian human population has not yet been evaluated. Immunosuppressed individuals have been recognized as a risk group for chronic hepatitis due to HEV genotype 3 (HEV-3) infections. The objectives of the present study were to determine prevalence rates of anti-HEV antibodies among inflammatory bowel disease (IBD) patients and solid organ transplant (SOT) recipients, to isolate and characterize HEV strain present in the Lithuanian human population, and to investigate its capacity to infect non-human primate (MARC-145 and Vero), swine (PK-15) and murine (Neuro-2a) cells in vitro. In the present study, the significant difference of anti-HEV IgG prevalence between healthy (3.0% (95% CI 0-6.3)) and immunosuppressed individuals (12.0% [95% CI 8.1-15.9]) was described. Moreover, our findings showed that anti-HEV IgG seropositivity can be significantly predicted by increasing age (OR = 1.032, p < 0.01), diagnosis of IBD (OR = 4.541, p < 0.01) and reception of SOT (OR = 4.042, <0.05). Locally isolated HEV strain clustered within genotype 3i subtype of genotype 3 and was capable of infecting MARC-145 cells. This study demonstrates higher HEV seroprevalence in the risk group compared to healthy control individuals without confidence interval overlap. The high level of genetic homology between human and animal strains in Lithuania and the capacity of locally isolated strains to infect cells of non-human origin suggests its potential for zoonotic transmission.

Child-Friendly Legal Aid and Individual Assessment of Children in Conflict with the Law: Building the Basis for Effective Participation.

This article focuses on the importance of the right to effective participation of children in conflict with the law in criminal (youth justice) proceedings. In particular, it explores two procedural aspects which are closely related to the right to child-friendly legal aid and the role of individual assessment. The authors claim that qualitatively identifying the needs of the child (through the instrument of individual assessment) and establishing a relationship of trust with a specifically trained legal aid lawyer is critical in raising the child's status to that of an active participant in the proceedings and ensuring that the best interests of the child are observed. The authors also suggest that such an initial encounter within the justice system forms an attitude (of either confidence or rejection) of the child towards public institutions and, accordingly, directly affects the effectiveness of further interventions. To support their position, the authors of the paper bring several examples from the comparative research carried out in two European projects, noting, regretfully, that the initial interventions often suffer from formal implementation and lack a systemic approach.

Analyses of AUC(0-12) and C0 Compliances within Therapeutic Ranges in Kidney Recipients Receiving Cyclosporine or Tacrolimus.

The AUC (area under the concentration time curve) is considered the pharmacokinetic exposure parameter best associated with clinical effects. Unfortunately, no prospective studies of clinical outcomes have been conducted in adult transplant recipients to investigate properly the potential benefits of AUC(0-12) monitoring compared to the C0-guided therapy. The aim of the present study was to compare two methods, C0 (through level) and AUC(0-12) (area under the concentration time curve), for assessing cyclosporine and tacrolimus concentrations. The study included 340 kidney recipients. The AUC(0-12) was estimated using a Bayesian estimator and a three-point limited sampling strategy. Therapeutic drug monitoring of tacrolimus performed by using AUC(0-12) and C0 showed that tacrolimus in most cases is overdosed when considering C0, while determination of the AUC(0-12) showed that tacrolimus is effectively dosed for 27.8-40.0% of patients receiving only tacrolimus and for 25.0-31.9% of patients receiving tacrolimus with MMF (mycophenolate mofetil). In the 1-5 years post-transplantation group, 10% higher CsA (cyclosporine) dose was observed, which was proportionate with a 10% higher AUC(0-12) exposure value. This indicates good compatibility of the dosage and the AUC(0-12) method. The Bland-Altman plot demonstrated that C0 and AUC(0-12) might be interchangeable methods, while the ROC (receiver operating characteristic) curve analysis of the C0/AUC(0-12) ratio in the tacrolimus-receiving patient group demonstrated reliable performance to predict IFTA (interstitial fibrosis and tubular atrophy) after kidney transplantation, with an ROC curve of 0.660 (95% confidence interval (CI): 0.576-0.736), p < 0.01. Moreover, AUC(0-12) and C0 of tacrolimus depend on concomitant medication and adjustment of the therapeutic range for AUC(0-12) might influence the results.

In comparative perspective: The effects of incarceration abroad on penal subjectivity among prisoners in Lithuania.

This article looks at how global flows of people and policies affect penal subjectivity among prisoners in Lithuania. Those who had previously been incarcerated abroad perceive their punishment in Lithuania's reforming penal system in comparative terms. We find that international prison experience may either diminish or increase the sense of the severity of the current punishment. Respondents often felt more comfortable in a familiar culture of punishment in Lithuania that emphasizes autonomy and communality. Moreover, internationalized prisoners perceive prison reform emulating West European models as a threat to this culture and are able to articulate comparative critiques of this reform and contest its effects.

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.

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.

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.