[An overview of the results of renal transplantation in the Czech Republic]. / Piehled výsledku transplantací ledvin v Ceské republice.

Renal (kidney) transplantation is now a routine and the most successful form of renal replacement therapy. There is a long tradition of renal transplantation in the Czech Republic, The first was performed as early as 1961 in Hradec Kralove, and the programme as such was launched in 1966 with the first successful transplantation at the Institute of Experimental Surgery (later Institute for Clinical and Experimental Medicine, Prague). At present, transplantations are being performed at 7 transplantation centres (IKEM Prague, Centre for Cardiovascular and Transplantation Surgery Brno, Faculty Hospitals Hradec Kralove, Plzen, Olomouc and Ostrava and Faculty Hospital Motol for children). From the programme launch until the end of 2010, 8,761 renal transplantations were performed, 364 in 2010 alone. One-year patient and cadaver renal allograft survival, transplanted in the CR between 2000 and 2009, is around 95% and 92%, respectively, and 5-year survival is 87% and 81%, respectively. As of 31st December 2009, a total of 3,771 patients lived with functional renal allograft in the Czech Republic and the proportion of patients with irreversible renal failure treated with transplantation has recently been around 40%.

[Monitoring the important mycotoxin biomarkers (ochratoxin A, aflatoxin M1) in the Czech population]. / Stav sledováni významných biomarkeru mykotoxinu (ochratoxinu A, aflatoxinu M1) u populace v Ceské republice.

BACKGROUND: In among mycotoxins, secondary metabolites of toxinogenic moulds, ochratoxin A and aflatoxins occupy a prominent place. These mycotoxins have been--as etiologic agents-- associated with a wide numbers of acute and chronic human diseases including mycotoxicoses like Balkan endemic nephropathy or liver cancer. While the risk of acute toxic effects of ochratoxin A and aflatoxin B1 is usually considered to be minimal in the Czech Republic, the situation is different as far as the risk of the late toxic effects (particularly carcinogenic), which result from a single or repeated intake of low doses of these mycotoxins from foodstuffs is concerned. METHODS AND RESULTS: The presence of ochratoxin A and aflatoxins in human environment has been monitored within the program "Monitoring the health state of the population". As for ochratoxin A, 2206 samples of blood serum were investigated, 2077 (94 %) of them turned out to be positive (with levels > or = 0.1 microg x l(-1)), the average was 0.28 microg x l(-1), the median was 0.2 microg x (l(-1), and the percentile (90%) was 0.5 microg x l(-1). The ochratoxin A levels ranged from 0.1 to 13.7 microg x l(-1) of sera. The presence of ochratoxin A was also analyzed in 30 samples of human kidneys; 12 samples were positive (with levels > or = 0.1 microg l(-2), the average was 0.07 microg x kg(-1), the median was 0,05 microg x kg(-1). As for aflatoxins, in 1997-1998 the presence of aflatoxin M1 was investigated in 205 samples of human urine; 118 samples (58%) were positive (with levels >125 pg x l(-1) of urine). CONCLUSIONS: When calculated to a concentration of creatinine in urine, the average was 391 pg x g(-1), the median was 127 pg x g(-1), and the percentile (90%) was 585 pg x g(-1). The aflatoxin M1 levels ranged from 19 to 19 219 pg x g(-1) of creatinine.

[The latest trends in the treatment peritonitis of the patients on peritoneal dialysis]. / Soucasné trendy v lécbe peritonitid u nemocných lécených peritoneální dialýzou.

Peritonitis is still one of the major complications ambulatory peritoneal dialysis (CAPD). The initial empiric therapy for peritonitis should be effective against most grampositive organisms as well as gramnegative organisms. Intraperitoneal administration antibiotics has the advantage of a high concentration of the antibiotics at the site of infection. The treatment should provide broad coverage of all organisms, without side-effects or risk for the patient and should not provoke the emergence of resistant germs. The present guidelines of the ad hoc advisory committee are of great value in this regard. The ISPD guidelines for treatment of peritonitis recommended an empirical therapy based on the association of a first-generation cephalosporin with an aminoglycoside or ceftazidime.

[The results of kidney transplantation from very young paediatric cadaveric donors to adult recipients in Czech Republic in the years 1994-2001 (retrospective study of the Czech transplant centres)]. / Výsledky transplantací ledvin od malých detských kadaverózních dárcu dospelým príjemcum v Ceské republice v letech 1994-2001 (Retrospektivní studie ceských transplantacních center).

The results of kidney transplantation from very young paediatric cadaveric donors up to five years, which were transplanted to adult recipients, are evaluated in the first retrospective study of all Czech transplantcentres. In general, 42 of these transplantations were carried out during 1994-2001. In 28 cases single kidney was transplanted, in 14 cases en bloc graft of both children kidneys was transplanted. The reasons of kidney failure by recipients are usual (in 42.9% glomerulonephritis). An average age of the donors was 34.7 months (median 39 months). An average age of the recipients during transplantation was 42.6 years (median 43.5 years). All the kidneys were placed into retroperitoneum. As long as only single kidney was transplanted, the rules, already propagated by Salvatiera in 1970, were respected. At the transplantation of en bloc graft, Kinne's method with possible vessels elongation of the graft and with uretero-uretero anastomoses (in so called Ostrava modification) was used. The higher occurrence of the primary graft non-function (as 50% losses of all grafts) was confirmed in the study. Its reason was an acute thrombosis of vessels or rotation of graft stem. One-, three- and five-years patients and grafts survival were 97.6-90.5-90.5% and 76.2-73.8-73.8% actually. Patients survival are very good while grafts survival are average, momentarily a bit worse than national data published by the Czech Transplant Society, which determines one-, three- and five-years grafts survival with 90.3-82.9-75.5% and 79.1-71.1-65% actually. The kidney transplantation from paediatric cadaveric donors to adult recipients is acceptable under present allocated criteria, in case that some principles are kept. The study confirms the international experiences about rather higher incidence of surgical complications and primary graft non-function. In conclusion, some general references for reduction of complications, as well as for improvement of these transplantation results are introduced.

[Comparison of 2 methods of diagnosis of changes in transplanted kidneys in the early postoperative period: biopsy vs dynamic scintigraphy of the graft]. / Srovnání dvou metod v diagnostice zmen transplantované ledviny v casném pooperacním období: biopsie versus dynamická scintigrafie stepu.

Renal transplantation is at present a standard therapeutic method in chronic renal insufficiency. For a favourable development of the graft some investigated criteria are of basic importance: basic diagnosis which led to renal failure, period of dialyzation treatment, high standard collection and perfusion and early diagnosis of the rejection episode. Non-invasive diagnostic methods of the rejection episode are always indirect and correlate with histologically confirmed rejection, depending on the period of transplantation in 10-90% patients. Indirect diagnosis is based in particular on a rise of the creatinemia, decline of glomerular filtration, fluid retention variations of blood pressure and increase of the Doppler assessed index of resistance (IR) in the peripheral veins of the graft [1]. For many years the role of nuclear diagnostics are tested. The disadvantage of direct diagnosis--biopsy--is increased haemorrhage and loss of the graft [1, 2, 3, 4]. The greatest problem is the differentiation of acute (cellular) rejection as compared with acute tubular necrosis during the initial days after transplantation. The authors describe their experience with 81 biopsies in the course of 3 years in patients during the first 10 days after transplantation, comparison with dynamic scintigraphy of the graft. Their attention is focused on the technique and risks of renal biopsy.

[Prevalence of viral hepatitis G infection in hemodialysis patients and coinfection with viral hepatitis B and C]. / Prevalence infekce virem hepatitidy G u hemodialyzovaných pacientu a její koinfekce s viry hepatitid B a C.

The group of infectious agents causing viral hepatitis was extended by another virus the detection of which was published in 1995. This virus is described as virus of hepatitis G (HGV) or GBV-C virus and is included among RNA viruses family Flaviviridae. Detection of HGV is based on reverse transcription with subsequent amplification of the viral nucleic acid by means of a polymerase chain reaction. The authors examined sera of 82 chronically haemodialyzed patients incl. 22 (26.8%) HGV RNA positive ones, whereby coinfection with HBV was proved in 3 specimens (13%). In 6 HGV RNA positive samples anti-HCV positivity was found (27%), incl. one sample where HCV RNA positivity was proved (4.5%). Raised transaminase activity was found only in three patients with HGV RNA positivity (13.6%). From the presented results ensues that haemodialyzed patients are a high risk group for HGV infection.

The dialysis of Ochratoxin A (OTA).

Standard dialysis did not result in a decrease of the OTA level in the blood serum of patients regularly treated by dialysis. Therefore, we examined the effect of dialysis on both OTA bound to the blood plasma proteins and free OTA. We carried out an in vivo experiment to determine OTA levels in the serum of patients in the terminal stage of chronic renal insufficiency (CHRI) before and after dialysis and also in the dialysate in which we did not find OTA. OTA bound to blood plasma proteins did not penetrate the dialysis membrane. In contrast, free OTA during an in vitro experiment with the identical dialyzer (as during the in vivo experiment), easily penetrated the same dialysis membrane.

[Calciphylaxis in a patient on long-term dialysis]. / Kalcifylaxe u dlouhodobe dialyzované nemocné.

Calciphylaxis is a special form of soft tissue calcification (in particular blood vessels), affecting specially patients with chronic renal insufficiency and associated secondary hyperparathyroidism. Most severely affected are small arteries with a diameter of 0.2-0.5 mm at the interface of the corium and subcutaneous layer. Calcification of the vascular media with subsequent narrowing of the lumen causes ischaemic changes manifested by the development of painful reddish-violet spots on the skin with necrosis and ulcerations. The authors describe the case of a 73-year-old diabetic female patient with regular dialyzation treatment. The patient developed reddish-violet spots on the lower extremities shortly before admission to hospital. At the site of the spots rapidly progressing necroses developed. The cause of these ischaemic changes were calciphylactic changes confirmed on post-mortem examination and by histological examination.

[Subacute thrombosis of the abdominal aorta with suprarenal involvement and successful treatment with pharmacomechanical fibrinolysis]. / Subakutní trombóza brisní aorty suprarenálne zasahující, úspesne lécená farmakomechanickou fibrinolýzou.

In a 43-year-old patient with Ebstein's anomaly and a history of acute myocardial infarction by means of duplex ultrasonography and aortography the diagnosis of thrombotic occlusion of the a aorta was established, starting above the insertion of the renal arteries and reaching as far as the bifurcation of the aorta and the common iliac arteries. In the clinical picture dominated complete anuria with uraemia and marked hyperkaliaemia as a result of ischaemic affection of the extremities due to thrombosis of the aorta; at the onset of hospitalization also left ventricular failure with hyperhydration and later also signs of the hyperviscous syndrome. The latter developed after repeated haemofiltrations which led to a rise of the originally high haemoglobin and haemotocrit values a result of a righ-left shunt in Ebstein's anomaly. After improvement of the clinical condition local fibrinolytic treatment of the aortal thrombosis with urokinase (total dose 2,160,000 u. administered within 24 hours) was provided. The thrombus with a total length of 13.5 cm was dissolved except for a residual portion of 10 mm located in the area of insertion of the right renal artery. After dissolution of the thrombus it proved possible to restore the blood flow into the left kidney a and lower extremities, but not into the right kidney because of the residual thrombus. Seventy-two hours after terminated fibrinolysis - and after 31 days of anuria - the diuresis was restored and after a polyuric stage normalization of mineral, urea levels was restored and the creatinine value was slightly above the upper normal range. Concurrently with fibrinolytic therapy angioplasty of the aorta was carried out and a stent was placed on the left iliac artery. The clinical condition of the patient was improving, the patient started to mount stairs. Death occurred suddenly and the cause was cardiac failure due to very serious congenital heart disease.

Kinetics of phenols in body fluid compartments during hemodialysis.

On the basis of direct quantification of hemodialysis (HD), the kinetics of phenols (Ph) were followed in 13 patients on regular HD treatment. The average plasma levels of Ph before and after HD were 627 +/- 109 mumol/L and 416 +/- 81 mumol/L, respectively. The total amount of Ph removed during 5-h HD was 7,481 +/- 1,894 mumol. For calculation of the generation rate (G), a new formula has been derived not requiring knowledge of the corresponding volume of distribution. The G of Ph was 2.9 +/- 0.7 mumol/min on average. The mean dialysis clearance (K) of Ph was 48.2 +/- 10.2 ml/min.

[Changes in amino acids in a regular dialysis program]. / Aktuální zmeny aminokyselin v pravidelném dialyzacním programu.

BACKGROUND: Dialyzed patients are chronically in a state of negative nitrogen balance, and amino acids, their building stones, are also significantly affected by dialysis. The purpose of the present investigation was to assess whether they should be supplied, how frequently and for how long and how they are influenced by the usual diet of patients. METHODS AND RESULTS: The examination was made in a group of 13 patients included in a regular haemodialysis programme. Their mean age was 53.2 +/- 12.4 years, they were dialyzed for an average period of 55 months, maximum 163 months. The patients were dialyzed three times per week for four hours, bicarbonate dialysate was used. The patients' diet was not modified in any way. A total of 52 haemodialysis were examined: losses of alpha-amino nitrogen were monitored as well as changes of serum concentrations of different amino acids. Their mean losses were 119 +/- 54.69 mmol/4 h: this corresponds to 10.5 +/- 4.8 mg amino acids. The dialysis clearance was on average 122.7 +/- 63.2 ml/min. This value did not differ significantly from the dialysis clearance of urea, but it was significantly higher than creatinine clearance (p < 0.05). During dialysis a significant drop (p < 0.001) of the plasma concentration of amino nitrogen occurred, however, the changes of serum concentrations of amino acids differed. A significant drop was recorded in serum concentrations of histamine, lysine, cysteine, methionine, tyrosine, glycine, asparagine, citrullin, glutamine, taurine. Before the beginning of dialysis the values of valine, lysine, threonine, serine, alanine and asparagine were lower than corresponds to the reference interval in healthy subjects. CONCLUSIONS: Changes of serum concentrations of individual amino acids are significantly influenced not only by their losses into the dialysate but also by their shift from cells into the extracellular fluid and by resorption from the digestive tract during protein intake in the course of dialysis. An adequate supply of high quality protein can compensate for these losses. Investigation of serum concentration of individual amino acids does not record their kinetic changes but can give an idea on the effectiveness of the dietary regime.

[Determination of urea distribution space on the basis of hemodialysis quantification]. / Stanovení distribucního prostoru mocoviny na podklade kvantifikace hemodialýzy.

By using direct dialysis quantification--DDQ--in 124 haemodialyses made in 14 patients the authors assessed the urea output in mmol in the dialyzation fluid collected after every dialysis. The evaluation of total body fluids, which accounts roughly for 60% of the total body weight, was replaced by a calculated distribution space of urea (Vu) according to the Du/Ppre--Ppost formula. This equation was modified with regard to the degree of ultrafiltration and urea formation. The authors found a 5% difference between the values of the modified Vu equation and total body fluids corresponding to 60% of the body weight.

[Poisoning with a high dose of amitriptyline in a 9-year-old girl]. / Otrava devítileté dívky vysokou dávkou amitriptylinu.

In the submitted case-history the authors publish the case of successful treatment of a 9-year-old girl whose life was at risk after intoxication with a large dose of amitriptyline. Concurrently they deal with the social background of emotional disorders and some peculiar features in this girl with suicidal behaviour; attention is also drawn to specific features of the psychopathological picture of psychiatric child morbidity.

[Hemorrhage into the digestive tract as a cause of death in patients after kidney transplantation]. / Krvácení do zazívacího traktu jako prícina úmrtí u nemocných po transplantaci ledvin.

The authors investigated the prevalence, cause and possible prevention of haemorrhage into the gastrointestinal tract in 218 patients after transplantation of the kidney (TK). 1. Haemorrhage into the gastrointestinal tract after TK occurred in 32 patients incl. 53.1% who died. In the total mortality after TK haemorrhage into the gastrointestinal tract account for 15.7%. 2. The danger of haemorrhage into the gastrointestinal tract is increased in particular: in the early postoperative period (within one month after transplantation of the kidney), during acute rejection with declining function of the graft, in infectious complications, after graftectomy, in preexisting peptic ulcers. 3. The most frequent cause of haemorrhage were duodenal ulcers. The authors elaborated a system of preventive provisions which involve: a) medicamentous prophylaxis by administration of H2 blockers and antacids not only at the time of transplantation of the kidney and during the early postoperative period but also when there is an increased risk, b) detailed gastroenterological examination before transplantation of the kidney, c) in case of relapsing peptic ulceration in the case-history or haemorrhage into the gastrointestinal tract, subject patients on the waiting list for transplantation of the kidneys during the dialyzation period to proximal gastric vagotomy, or so-called highly selective vagotomy.

[Complications of subclavian and femoral cannulas]. / Komplikace podklíckových a femorálních kanyl.

In the course of 15 years in the author's department some 15,000 cannulas were inserted into the subclavian or femoral vein. This number included cca 2300 cannulas inserted to dialyzed patients. 213 patients (inl. 28 dialyzed) died with the inserted cannula. In these patients the incidence of complications was evaluated. A parietal thrombosis was the most frequent complication and was recorded in 119 cases, i.e. in 56% (in non-dialyzed in 57% and in dialyzed in 50%). In two non-dialyzed patients it was the cause of embolization into the lungs. In the incidence of complications there is no significant difference in dialyzed and non-dialyzed patients. For completeness the authors present a preliminary calculation per approximate number of inserted cannulas during this period. From the total number of 15,000 inserted cannulas fatal complications occurred in 0.06% (in dialyzed in 0.13% and non-dialyzed in 0.047%).

[Early acute tubulointerstitial nephropathy in transplanted kidneys]. / Casná akutní tubulointersticiální nefropatie transplantované ledviny.

The authors investigated in a group of 124 patients the effect of acute tubular nephropathy and rejection on the period of functional persistence of transplanted kidneys. Transplants which developed tubulointerstitial nephropathy during the first two weeks after transplantation of the kidney had significantly lower cumulative indexes of survival for as long as the second year after transplantation. Grafts which were rejected during the first two weeks after transplantation had a significantly lower cumulative survival index only during the first and second year. The statistical significance was always tested in comparison with grafts where the postoperative course was uneventful. It is better to evaluate the functional prognosis of transplanted kidneys from the maximal achieved glomerular filtration after a load; it did not matter whether tubulointerstitial nephropathy or rejection was involved.

[Bone metabolism in patients after kidney transplantation]. / Kostní metabolismus u nemocných po transplantaci ledviny.

The bone metabolism was evaluated in 20 patients after successful transplantation of the kidneys. In case of a functional graft within 22 months after transplantation of the kidneys complete regression of histological signs of secondary hyperparathyroidism was found, i.e. of fibrous osteodystrophy with a decline of the osteoclastic absorption and in 50% of the patients bone histology revealed osteomalacia. On the X-ray of the skeleton in 65% signs of osteoporosis were found, incl. 10% where the results were in discrepancy with the histological finding. The normal plasma calcium level before and after transplantation of the kidney was not affected. Other basic indicators of bone metabolism--phosphates, alkaline phosphatase, the bone isoenzyme of alkaline phosphatase and parathormone attained normal levels within 22 months after transplantation. Bone fluorides remain elevated also after 22 months following successful transplantation of the kidneys, although significantly less than before.