Capacity for the management of kidney failure in the International Society of Nephrology Eastern and Central Europe region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA).

Delivery of care for kidney failure (KF) globally has a significant disparity; even in some countries, it means end of life for the person. The International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) tries to address gaps in KF care and standardize global nephrology care. From the third iteration of the ISN-GKHA, we present data for countries in the ISN Eastern and Central Europe region. The median prevalences of chronic kidney disease (12.8%) and treated KF (873.5 pmp) were higher than the global rates, respectively. Hemodialysis was the most preferred modality for KF in adults, whereas kidney replacement therapy was more balanced in children. Although most of the countries in the region had lower-middle-income and upper-middle-income levels, health expenditures for kidney health care were almost generally covered publicly. Nephrologists were responsible for the medical kidney care of people with KF in all countries. There was adequate infrastructure to provide all kinds of treatment for kidney care in the region. Regional characteristics such as high levels of obesity, smoking, and Balkan nephropathy as an endemic disease coupled with a shortage of workforce and finance continued to affect kidney care in the region negatively. By making organizational and legislative arrangements, partnerships with national authorities and societies may accelerate the improvement of kidney health care in the region.

A CT-based pelvic calcification score in kidney transplant patients is a possible predictor of graft and overall survival.

OBJECTIVES: Computerized tomography (CT) is the most accurate method for evaluating pelvic calcifications, which are of utmost importance for planning kidney transplantation (KT). The aim of our study was to evaluate the incidence and distribution of iliac artery calcifications and correlate the novel pelvic calcification score (PCS) with cardiovascular risk factors and graft and overall survival in KT patients. METHODS: We retrospectively included 118 KT patients operated at our institution with pretransplant pelvic CT. Calcification morphology, circumference and length of both common and external iliac arteries were independently scored by two uroradiologists. PCS was calculated as the total score sum of all three calcification features in all vessels. PCS correlation with graft and patient survival was performed. RESULTS: Calcification in at least one vascular segment was found in 79% of patients. PCS was significantly higher in male patients (p = 0.006), patients over 55 years (p < 0.001), and patients on haemodialysis (p = 0.016). Patients with a PCS >3 had significantly shorter graft and overall survival rates (p = 0.041 and p = 0.039, respectively). CONCLUSIONS: The extent of iliac artery calcification in KT recipients quantified by PCS on pretransplant CT correlates with graft and overall patient survival. A PCS over three was associated with worse clinical outcomes and could become a possible prognostic factor. ADVANCES IN KNOWLEDGE: Our novel PCS is a robust method for quantifying iliac artery calcification burden. Since higher a PCS correlates with worse patient and graft survival, PCS has the potential to become a prognostic factor in kidney transplant patients.

Case Report: Synchronous Removal and Implantation of Peritoneal Dialysis Catheter Using Bilateral Transversus Abdominis Plane Block.

Background: Peritoneal dialysis (PD) surgery include PD catheter insertion and removal. Both procedures require the use of anesthesia. The end-stage renal disease (ESRD) patients usually have severe comorbidities. The general anesthesia, because of its negative systemic effect, should be omitted in this vulnerable group of the patients. Transversus abdominis plane (TAP) block as a newer method of regional anesthesia is a technique without systemic effect and recently started to be used in ESRD patients for PD catheter placement and/or removal. Here we report a patient in whom we for the first time simultaneously removed and implanted a PD catheter by using a bilateral transversus abdominis plane block. Case Presentation: The patient was an 80-year-old man who was admitted for removal of malfunctioned PD catheter. Since the patient opted for staying on PD simultaneous implantation of catheter was planned. Because of his age and significant comorbidities, general anesthesia was avoided and bilateral TAP block become our option. In the same anesthesia, using bilateral TAP block, the old PD catheter was removed and a new one was implanted. Until now the patient is on regular PD without any complications. Conclusion: The TAP block could be used as a primary anesthetic technique in ESRD patients for PD surgery even for synchronous removal and implantation of PD catheter.

Kidney Transplants from Elderly Donors: The Experience of a Reference Center in Croatia.

OBJECTIVES: Our country Croatia is among the global leaders regarding deceased donation rates, yet we are facing organ shortage and concurrently a sharp decline in our acceptance rates for kidney offers. To reevaluate our organ acceptance policy, we retrospectively analyzed the factors that influenced the posttransplant outcomes of kidneys from elderly deceased donors at our center during a 20-year period and the changes to our organ acceptance criteria during Eurotransplant membership. MATERIALS AND METHODS: We studied all kidney transplants from donors ≥60 years old during the two 5-year episodes of Eurotransplant membership from 2007 to 2017 (period II and period III) and compared those data to data from the decade before Eurotransplant membership (period I, 1997-2007). Differences in acceptance rates and reasons for the decline of kidney offers between the two 5-year periods of Eurotransplant membership were analyzed. RESULTS: In period I, 14.1% of all kidney allografts were obtained from donors ≥60 years old; in period II and period III the rates were nearly 2-fold higher (27.0% and 25.7%, respectively; P = .007 and P = .008). During the first 5-year period of Eurotransplant membership (period II), we accepted significantly more grafts from marginal donors with a higher number of human leukocyte antigen mismatches compared with period I. Consequently, the 3-month survival rate of kidneys from donors ≥60 years old dropped from 91.1% to as low as 74.2% (P = .034). After application of morestringent human leukocyte antigen matching, especially in human leukocyte antigen DR, and morestringent donor acceptance criteria in period III, graft survival improved to 91.1%. CONCLUSIONS: Our experience indicates that careful selection of kidneys from elderly deceased donors and allocation to human leukocyte antigen-matched recipients is important to improve transplant outcomes.

Hospitalization and death after recovery from acute COVID-19 among renal transplant recipients.

INTRODUCTION: Data on post-COVID-19 in renal transplant recipients (RTR) is scarce. We investigated the rate of hospitalizations, reasons for hospital admission, and mortality rate among RTR who survived acute COVID-19. METHODS: A multi-center retrospective observational cohort study measured hospital admission and death to 180 days after acute SARS-CoV-2 infection in 308 adult patients. RESULTS: The median age was 57 years, 64.9% were male. All patients had at least one comorbidity, and 26.3% had diabetes. Data on post-COVID-19 course was available for 267 patients, and 49 of them (15.9%) required hospital treatment after recovery from the acute infection. The most common indications included pneumonia (24.5%) and renal allograft dysfunction (22.4%), 7 (14.3%) had sepsis and 5 (10.2%) had thrombotic events. A median duration of the hospital stay was 12 days. Six patients (2.2%) died due to multiorgan failure, respiratory insufficiency or urosepsis. The strongest predictor for hospitalization after acute COVID-19 was hospitalization for acute SARS-CoV-2 infection, while better allograft function decreased the probability of hospitalization. CONCLUSION: Delayed consequences of acute COVID-19 are highly prevalent and the health care systems should be prepared to respond to the needs of RTR suffering from post-COVID-19 complications.

THE BEGINNINGS OF KIDNEY TRANSPLANTATION IN SOUTH-EAST EUROPE.

Organ transplantation is one of the most important medical achievements of the 20th century. Kidney transplantation is the most efficient method of renal replacement therapy. The first successful kidney transplantation in human was performed in 1954 in Boston, USA. In former Yugoslavia, the first kidney transplantation was performed on April 16, 1970 in Ljubljana, Slovenia, and second one on January 30, 1971 in Rijeka, Croatia. In both cases, the mother donated kidney to the son. In the article, we describe the prerequisite conditions for this operation, the characteristics of first patients, and the impact of transplantation program on the development of the hospitals and medical schools.

Comparison of clinical assessment and multifrequency bioimpedance analysis as methods of estimating volume status in peritoneal dialysis patients - A single-center experience
.

INTRODUCTION: Clinical assessment (CA) is frequently used for the evaluation of volume status in peritoneal dialysis (PD) patients despite its subjectivity. Multiple-frequency bioelectrical impedance analysis (MF-BIA) is objective, accurate, and quick, proving to be a promising technique for measuring volume status. The aim of this study was to assess volume status in PD patients using CA and MF-BIA and to compare results. MATERIALS AND METHODS: Incident PD patients were prospectively analyzed between January 1, 2014, and January 1, 2016, at the Clinical Hospital Center of -Rijeka, Croatia. Volume status measurements were performed once a month for 6 consecutive months. The presence of symptoms and signs associated with hyper- or hypovolemia were detected by CA. Euvolemia was defined as a symptom-free state or up to 2 symptoms maximum. Patients lacking up to 1.2 L of volume or with up to 1.2 L in excess were considered euvolemic, as measured by MF-BIA. RESULTS: A total of 45 PD patients were analyzed; 51% were men, 27% were diabetic, the mean age was 52 ± 26 years, and PD duration was 11.5 ± 6.5 months. In comparison to MF-BIA, CA showed a significant difference in detected hypervolemia between baseline and follow-up (p = 0.708 vs. p = 0.01, respectively) and among all measurements (p < 0.01). Contrary to CA, volume status measured by MF-BIA correlated significantly with systolic and diastolic blood pressure (R = 0.29; p ≤ 0.01 and R = 0.26; p ≤ 0.01, respectively). CA showed low sensitivity (0.24) and high specificity (0.92) in detecting hypervolemia. CONCLUSION: MF-BIA is an effective, objective, and safe method for assessing volume status in PD patients. Longitudinal monitoring of body composition changes - including hydration state - leading to adequate therapeutic intervention is a promising and potential application of MF-BIA along with CA.

Kidney transplantation using a colon pouch (Mainz pouch III): a case report.

Kidney transplantation is the most efficient method of renal replacement therapy. When this method is performed, native urinary bladder is the preferred urinary reservoir. However, in some patients with an anatomically and functionally abnormal lower urinary tract, the urinary bladder cannot be used for transplantation. In these patients, urinary diversion should be performed before kidney transplantation. We present a case of a 32-year-old male patient with orthotopic kidney transplantation performed using a colon pouch (Mainz-pouch III). He was born with severe anomalies including sacral agenesis, anorectal atresia, and hypospadias, which were corrected during childhood. Neurogenic bladder with severe vesicoureteral reflux led to end-stage renal disease. This dysfunctional bladder was unsuitable for kidney transplantation, and a staged approach for future transplantation was chosen. The first step was the creation of urinary diversion. Due to a short appendix, we created a continent, colon pouch (Mainz pouch III). Two years later, orthotopic kidney transplantation was performed using a right cadaveric kidney. The renal vessels were anastomosed to the aorta and inferior vena cava and the pyelon to the native ureter. Four years after transplantation, the patient has stable renal function without any complications. This is the first documented case of using Mainz-pouch III as a reliable option for kidney transplantation in selected patients.

Anemia Is Correlated with Malnutrition and Inflammation in Croatian Peritoneal Dialysis Patients: A Multicenter Nationwide Study.

Malnutrition, inflammation, and anemia are common in peritoneal dialysis (PD) patients. In this study, correlations between Malnutrition Inflammation Score (MIS), laboratory and anthropometric parameters, and anemia indices in Croatian PD patients were analyzed. One hundred and one PD patients (males/females 54/47, age 58.71 ± 14.68 years, mean PD duration 21.82 ± 21.71 months) were included. Clinical, laboratory, and anthropometric parameters were measured. Statistically significant correlations between MIS and erythropoietin weekly dose per kg of body weight (ESA weekly dose), hemoglobin (Hb), and erythrocytes were found (r = 0.439, p < 0.001; r = -0.032, p < 0.001; r = -0.435, p < 0.001), respectively. Also, statistically significant correlations were found between MIS and mean corpuscular volume (r = 0.344, p < 0.001), iron (r = -0.229, p = 0.021), and total iron binding capacity (TIBC) (r = -0.362, p < 0.001), respectively. Furthermore, statistically significant correlations between ESA weekly dose and serum albumin level and body mass index (BMI) were found (r = -0.272, p = 0.006; r = -0.269, p = 0.006), respectively. When we divided PD patients into 2 groups according Hb level (Hb ≥ 110 [N = 60, 59.41 %]) and Hb < 110 [N = 41, 40.59%]), statistically significant differences were found in MIS score (3.02 ± 2.54 vs 4.54 ± 3.54, p = 0.014), C-reactive protein (CRP) (3.52 ± 6.36 vs 7.85 ± 7.96, p = 0.005), and serum albumin level (44.22 ± 8.54 vs 39.94 ± 8.56, p = 0.003), respectively. Our findings suggest that anemia is correlated with malnutrition and inflammation in Croatian PD patients. Further studies are needed to assess whether modulating inflammatory or nutritional processes can improve anemia management in PD patients.

Peritoneal Dialysis Catheter Surgery using Transversus Abdominis Plane Block.

BACKGROUND: Peritoneal dialysis (PD) catheter surgery can be performed using regional anesthesia. We present our PD catheter placement and extraction experience using ultrasound-guided transversus abdominis plane (TAP) block. METHODS: In the present study, we analyzed 74 patients from our center with end-stage renal disease (ESRD) who underwent PD catheter placement (60 patients) and removal (14 patients) using a TAP block between June 2011 and December 2015. RESULTS: The TAP block was successful for 55/60 (91.7%) patients (insertion) and 13/14 (92.9%) patients (extraction). Other patients had pain at the incision site and required general anesthesia. There were no anesthesia-, surgery- or PD catheter-related complications. CONCLUSION: The TAP block is a safe and effective technique not only for high-risk ESRD patients but for all patients undergoing PD catheter placement or extraction.

Severe bleeding complications and multiple kidney transplants in a patient with tuberous sclerosis complex caused by a novel TSC2 missense variant.

We presented an extremely severe case of tuberous sclerosis complex (TSC) in a female patient with recurring, life-threatening bleeding complications related to renal angiomyolipomas. Massive intratumoral hemorrhage required surgical removal of both angiomyolipomatous kidneys and kidney transplantation. During the follow-up period, the patient developed severe metrorrhagia that eventually led to hysterectomy and salpingo-oophorectomy. Bleeding from the operative sites caused the loss of the first kidney transplant received from the mother, and immediate hemorrhagic shock led to the loss of the second, cadaveric kidney allograft. The third kidney transplant had a successful outcome. Pathological analysis of all tissue specimens showed TSC-associated lesions and deformed blood vessels in the surgically removed organs. Molecular genetic analysis of TSC1 and TSC2 in the DNA of peripheral leukocytes identified a novel TSC2 c.3599G>C (p.R1200P) variant. Functional assessment confirmed the likely pathogenicity of the TSC2 c.3599G>C (p.R1200P) variant. To the best of our knowledge, this is the first report of the c.3599G>C (p.R1200P) variant in exon 29 of the TSC2 gene related to a severe clinical course and multiple kidney transplants in a patient with TSC.

Treatment of Kidney Stone in a Kidney-Transplanted Patient with Mini-Percutaneous Laser Lithotripsy: A Case Report.

We report a case of a kidney-transplanted patient with urolithiasis treated with mini-percutaneous laser lithotripsy. The patient presented with renal dysfunction and graft hydronephrosis. Diagnostic procedures revealed ureterolithiasis as a cause of obstruction, and percutaneous nephrostomy was inserted as a temporary solution. Before surgery, the stone migrated to the renal pelvis. Mini-percutaneous laser lithotripsy was successfully performed, and during surgery, all stone fragments were removed. Six months after successful treatment, the patient has good functioning and stone-free graft.

Soluble intracellular adhesion molecule-1 and omentin-1 as potential biomarkers of subclinical atherosclerosis in hemodialysis patients.

PURPOSE: Atherosclerotic cardiovascular complications represent significant cause of mortality in hemodialysis (HD) patients. The aims of this study were to: (a) investigate association of sICAM-1, sVCAM-1, omentin-1 and other non-traditional risk factors with subclinical atherosclerosis; (b) examine the diagnostic value of these specific markers in the early detection of subclinical atherosclerosis; and (c) examine their role as predictors of mortality in group of patients with subclinical atherosclerosis on regular HD. MATERIALS AND METHODS: Starting from November 2011, a cohort of 210 HD patients participated in this 3-year follow-up study. The subjects were divided into three groups according to the presence of atherosclerosis. Atherosclerotic disease was assessed by measuring carotid intima-media thickness (IMT). Samplings were withdrawn at baseline and thereafter every 12 months until the end of follow-up. RESULTS: IMT showed weak correlation with sICAM-1 (r = 0.39, P = 0.001), sVCAM-1 (r = 0.27, P = 0.015) and omentin-1 (r = -0.25, P = 0.020), and also omentin-1 showed good correlation with parameters of systolic and diastolic function (r = 0.52, P = 0.001 and r = 0.51, P = 0.001). Multivariate analysis showed that sICAM-1 and sVCAM-1 concentrations were a strong independent correlate of IMT (P = 0.031 and P = 0.010, respectively). The Cox proportional analysis showed that sICAM-1 and omentin-1 concentrations were strong predictors of cardiovascular death (HR 1.85, CI 1.18-2.32, P = 0.021 and HR 4.14, CI 1.38-12.1, P = 0.004, respectively) and that serial measurements of these markers predict IMT progression (HR 1.98, 95 % CI 1.21-2.38, P < 0.002 and HR 2.91, 95 % CI 1.57-4.72, P < 0.001, respectively). CONCLUSIONS: Our study demonstrated that sICAM-1 and omentin-1 levels are strong predictors of cardiovascular death in HD patients with subclinical atherosclerosis.

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

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

Nonalcoholic Fatty Liver Disease (NAFLD)-A New Cardiovascular Risk Factor in Peritoneal Dialysis Patients.

UNLABELLED: ♦ BACKGROUND: Recent investigations indicated that nonalcoholic fatty liver disease (NAFLD), a hepatic component of metabolic syndrome (MS), is associated with an increased risk of cardiovascular disease (CVD). Accordingly, we were interested in exploring the frequency of NAFLD in peritoneal dialysis (PD) patients and analyzing factors in PD patients associated with NAFLD occurrence. In addition, we were interested in investigating whether NAFLD is associated with higher CVD risk in our PD patients. ♦ METHODS: In the present cross-sectional study, we analyzed 58 PD patients. The controlled attenuation parameter (CAP) was used to detect and quantify liver steatosis with the help of transient elastography (TE) (FibroScan, Echosense SA, Paris, France). A carotid ultrasound was performed in all patients to measure carotid intimae media thickness (IMT) and plaque as surrogate measures of increased CVD risk, and we investigated their association with NAFLD. ♦ RESULTS: Nonalcoholic fatty liver disease was present in 74.1% of PD patients. Peritoneal dialysis/nonalcoholic fatty liver disease patients had statistically greater daily (136.5 ± 62.6 vs 93.6 ± 36.1; p = 0.02) and monthly (4,095.3 ± 1,877.7 vs 2,806.6 ± 1,083.2; p = 0.02) glucose load in comparison to the non-NAFLD/PD patients. In the next step, we were interested in analyzing what demographic and clinical characteristics in our PD patients are associated with a higher NAFLD occurrence. Presence of diabetes mellitus (DM), arterial hypertension (AH), dyslipidemia, body mass index > 25 kg/m(2), and daily glucose load > 100 g were associated with NAFLD occurrence. Peritoneal dialysis patients with NAFLD showed more carotid atherosclerosis than PD patients without NAFLD. In addition, CAP values (as indicator of liver steatosis) showed strong positive association with IMT (r = 0.801; p < 0.0001). Nonalcoholic fatty liver disease was a strong predictor of carotid atherosclerosis in PD patients. ♦ CONCLUSION: Nonalcoholic fatty liver disease is highly prevalent in PD patients. Peritoneal dialysis patients with NAFLD are at high risk of atherosclerosis. Assessment of NAFLD in PD patients may be helpful for CVD risk stratification.

Serum omentin-1 levels as a possible risk factor of mortality in patients with diabetes on haemodialysis.

AIM: The main cause of mortality in haemodialysis (HD) patients is cardiovascular disease. Serum omentin-1 level was found to be associated with cardio-metabolic disorders. The aim of this study was to examine the role of omentin-1 as a predictor of mortality in a group of diabetes positive HD patients. METHODS: A total of 120 prevalent HD patients were included in the study from December 2012 to May 2014. Patients were divided into two groups according to the presence or absence of diabetes. Venous blood samples were taken at months 0 and 18 following an overnight fast (prior to a midweek HD session). Serum omentin-1 level was assessed by enzyme-linked immunosorbent assay. RESULTS: A total of 84 HD patients were analysed at the end of an 18-month follow-up. Omentin-1 levels of HD patients with diabetes were found to be lower than of HD patients without diabetes (9.1±5.8 ng/mL vs. 11.4±4.1 ng/mL, respectively; P=0.015) at the end of follow-up. Omentin-1 levels of survived patients with diabetes were found to be higher than of nonsurvived patients with diabetes (16.5±10.1 ng/mL vs. 12.9±5.3 ng/mL, respectively; P=0.045). During follow-up, 36 patients (30%) died, of whom 25 had diabetes (34%). CONCLUSIONS: Serum omentin-1 levels were significantly lower in HD patients with diabetes. A decrease in omentin-1 levels could be an independent mortality risk factor in this patient group. Further investigation in a greater number of patients is needed.

Peritoneal Dialysis Catheter Placement Using an Ultrasound-Guided Transversus Abdominis Plane Block.

BACKGROUND: Peritoneal dialysis (PD) catheter placement is usually performed using general or local anesthesia. We present our PD catheter placement experience using an ultrasound-guided transversus abdominis plane (TAP) block, which is a regional anesthesia technique. METHODS: In this study, we analyzed 33 patients from our center with ESRD who underwent PD catheter placement using a TAP block between June 2011 and April 2014. RESULTS: The TAP block was successful for 29/33 (87.9%) patients. Four patients (12.1%) had pain at the incision site and required general anesthesia. There were no anesthesia-, surgery- or catheter-related complications. CONCLUSION: ESRD patients have a substantial number of comorbidities that can be negatively influenced by general anesthesia. Because regional anesthesia has no systemic effect, this procedure could be recommended for this group of patients. A TAP block is an effective, safe method and can be used as the principal anesthesia technique for PD catheter placement.

Usefulness of liver test and controlled attenuation parameter in detection of nonalcoholic fatty liver disease in patients with chronic renal failure and coronary heart disease.

BACKGROUND: In recent years, nonalcoholic fatty liver disease (NAFLD) was recognized as an important factor in chronic kidney disease (CKD) pathogenesis. The concentrations of serum aminotransferases in both chronic dialysis and chronic renal failure (CRF) patients most commonly fall within the lower end of the range of normal values. The aim of the present study was to investigate the usefulness of four liver tests and four biological scores in detection of NAFLD in comparison with transient elastography (TE) findings in different groups of patients. METHODS: The study was cross-sectional analysis collected data from a single tertiary care center. Of 202 patents there were 52 patients with CKD, 50 patients with end-stage renal disease (ESRD) treated with haemodialysis (HD), 50 renal transplant recipients (RTRs) and 50 patients with proven coronary heart disease (CHD). Fifty sex- and age-matched individuals without NAFLD and with normal liver and kidney function tests served as controls. With the help of TE (FibroScan®, Echosense SA, Paris, France), liver stiffness was selected as the parameter to quantify liver fibrosis and Controlled Attenuation Parameter (CAP) was used to detect and quantify liver steatosis. RESULTS: According to the CAP findings 76.9 %CKD patients, 82 %HD patients, 74 %RTRs and 69.1 % CHD patients had CAP > 238 dB.m(-1) and thus by definition NAFLD. We have found that ALT, AST and GGT levels were positively correlated with CAP values while ALT and AST showed positive correlation with liver stiffness acquired with TE only in CHD patients. According to TE findings APRI (AUC 0.796) and FIB-4 (AUC 0.790) scores were correlated with the presence of fibrosis, while HIS score was correlated with the presence of steatosis (AUC 0.867) only in CHD patients. CONCLUSION: Liver tests and biological scores are not useful for NAFLD detection in CRF patients. TE with CAP provides the opportunity of noninvasive screening for NAFLD as well as liver fibrosis in patients with CRF.

[Croatian guidelines for screening, prevention and treatment of protein-energy wasting in chronic kidney disease patients]. / Preporuke za pracenje, prevenciju i lijecenje proteinsko-energijske pothranjenosti u bolesnika s kronicnom bubrezom bolesti.

There is a high incidence of cardiovascular morbidity and mortality among patients with chronic kidney disease (CKD) and malnutrition is a powerful predictor of cardiovascular morbidity and mortality in this population of patients. A multitude of factors related to CKD and renal replacement therapy can affect the nutritional status of CKD patients and lead to the development of malnutrition. In patients with CKD, protein energy wasting (PEW) is a condition that is distinct from undernutrition and is associated with inflammation, increased resting energy expenditure, low serum levels of albumin and prealbumin, sarcopenia, weight loss and poor clinical outcomes. Nutritional and metabolic derangements are implicated for the development of PEW in CKD and leading to the development of chronic catabolic state with muscle and fat loss. Prevention is the best way in treating PEW. Appropriate management of CKD patients at risk for PEW requires a comprehensive combination of strategies to diminish protein and energy depletion, and to institute therapies that will avoid further losses. The mainstay of nutritional treatment in MHD patients is nutritional counselling and provision of an adequate amount of protein and energy, using oral supplementation as needed. Intradialytic parenteral nutrition and total enteral nutrition should be attempted in CKD patients who cannot use the gastrointestinal tract efficiently. Other strategies such as anemia correction, treatment of secondary hyperparathyroidism and acidosis, delivering adequate dialysis dose can be considered as complementary therapies in CKD patients. Multidisciplinary work of nephrologists, gastroenterologist and dietician is needed to achieve best therapeutic goals in treating CKD patients with PEW.