OSTEOPROTEGERIN AS AN EARLY SIGN OF CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER.

Chronic kidney disease (CKD) is among the most significant health problems, with the associated cardiovascular disease and bone metabolism disorders being the leading cause of morbidity and mortality in these patients. The aim of the study was to determine markers of bone turnover in patient sera (phosphates, calcium, alkaline phosphatase, parathyroid hormone and osteoprotegerin (OPG)) in all stages of kidney failure including kidney transplant recipients. We also wanted to determine whether dialysis vintage affects recovery of bone markers one year after transplantation. There were 164 study patients, whereas 30 healthy individuals served as a control group. Serum OPG progressively increased with decline of the glomerular filtration rate. The highest OPG concentration was recorded in dialysis group. We observed a statistically significant OPG increase in stage 2 CKD. In kidney transplant group, there was positive correlation between OPG and dialysis vintage. We also found that serum OPG was lower in patients treated with dialysis for less than 4 years prior to transplantation. We confirmed that CKD-mineral and bone disorder began in stage 3 CKD with parathyroid hormone and OPG elevation, and a statistically significant OPG increase in stage 2 CKD might be an early sign of CKD-mineral and bone disorder. Dialysis vintage longer than 4 years is associated with more significant disturbances in mineral and bone metabolism.

DIFFERENT APPROACHES TO MANAGING UROLITHIASIS IN KIDNEY TRANSPLANT PATIENTS - A CASE REPORT.

Urolithiasis is a rare urologic complication after kidney transplantation, and its diagnosis and treatment can be challenging for clinicians. In our 52-year-old male patient, graft hydronephrosis was found six months after transplantation. The patient had recurrent urinary tract infections followed by macrohematuria and an increase in creatinine levels. Computerized tomography revealed a 13-mm diameter stone in the ureter of the transplanted kidney as the cause of obstruction. Percutaneous nephrostomy was placed in the graft to solve the obstruction. Initial endoscopic treatment with a retrograde approach failed. An antegrade approach through a previously placed nephrostomy was not successful either. By a repeated retrograde approach, laser lithotripsy was performed successfully. The patient has been monitored for six months and has stable graft function without hydronephrosis or stones. As in our patient's case, the diagnosis and treatment of urolithiasis in kidney transplant patients is challenging, and minimally invasive procedures are the treatment of choice.

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.

THE ROLE OF LYMPHADENECTOMY IN PROSTATE CANCER PATIENTS.

Prostate cancer is one of the most important men's health issues in developed countries. For patients with prostate cancer a preoperative staging of the disease must be made. Involvement of lymph nodes could be assessed using imaging methods (CT or/and MRI), however, newer methods also exist (PET/CT, PSMA PET/CT). For some patients during radical prostatectomy a pelvic lymphadenectomy is recommended. Pelvic lymphadenectomy is indicated in intermediate- and high-risk group patients and with increased probability of lymph node invasion. The most used prediction tools for preoperative assessment of lymph nodes are Briganti and MSKCC nomograms and Partin tables. Pelvic lymphadenectomy can include different lymph nodes group, but extended lymphadenectomy is the recommended procedure. In 1-20% of patients, the lymph node invasion is present. Pelvic lymphadenectomy is primarily a diagnostic and staging method, and in minority of patients with positive lymph nodes it can be a curative method, too. In other patients with positive lymph nodes adjuvant therapy (radiotherapy and androgen deprivation therapy) can be beneficial.

[MINI-PERCUTANEOUS NEPHROLITHOTRIPSY ­ OUR FIRST EXPERIENCE]. / MINIPERKUTANA NEFROLITOTRIPSIJA ­ NASA PRVA ISKUSTVA.

Urolithiasis is a significant problem in the developed countries due to the increased number of patients with stones. Just a few decades ago open surgery was the only surgical treatment which is today, in most cases, replaced with minimally-invasive methods. One of these new methods is mini-percutaneous nephrolihotripsy. We present four patients in whom mini-percutaneous nephrolithotripsy was performed. In all patients the stone was located in the renal pelvis. In three patients the stone was in the native kidney and in one in the transplanted kidney. In all patients laser lithotripsy was successfully performed. On the control x-ray the residual fragments were not found in any patients. Mini-percutaneous nephrolithotripsy is a minimally-invasive method which is successfull in the treatment of nephfrolithiasis in native and transplanted kidneys.

10-year survival of a patient with metastatic prostate cancer: Case report and literature review.

Prostate cancer is the most common malignancy in men. The 5-year relative survival for all stages combined is 98.8%. Patients diagnosed with metastatic prostate cancer have median survival from 2 to 3 years. We describe a case of 64-year old man who clinically presented with inguinal lymphadenopathy. Because of elevated PSA levels biopsy of prostate was done and adenocarcinoma was diagnosed. Biopsy of inguinal lymph nodes confirmed the diagnosis of prostate cancer. Hormonal treatment was started and at the most recent follow-up, 10 years later, the patient is asymptomatic with no clinical signs of disseminated disease.

Prostate volume and urinary discomforts in elderly.

Occasional doubts about the real effect of the prostate volume on the urinary discomforts that elderly have been experiencing required additional assessment of these parameters. The aim of this study was to re-evaluate relationship between the urinary discomforts of the elderly and the prostate volume in comparison with age. Results of the group of 79 patients observed within one-year period were analyzed. In assessing their urinary discomforts the International Prostate Symptom Score (IPSS) was calculated, the ultrasound prostate volumetry was performed, and both of these parameters where compared with age. Statistical analysis of the results confirmed significant positive correlation between the prostate volume and age, positive correlation between IPSS and age, as well as between prostate volume and IPSS.

The effect of 5alpha-reductase inhibition with finasteride and dutasteride on bone mineral density in older men with benign prostatic hyperplasia.

Testosterone is converted to dihyrotestosterone by two isoenzymes of 5alpha-reductase. Finasteride and dutasteride are 5alpha-reductase inhibitors commonly used in the treatment of benign prostatic hyperplasia. We compared indices of bone mineral density in 50 men treated with finasteride, 50 men treated with dutasteride and 50 men as control. Bone mineral density of spine and hip were measured using dual energy X-ray absorptiometry. Bone formation was assessed by measuring serum osteocalcin and bone resorptionby measuring serum C-terminal telopeptide of collagen type 1. In addition serum total testosteron and estradiol were determined. The dutasteride group had significantly higher mean bone min- eral density, mean bone mineral content, mean T score, mean Z score at femoral neck and mean total hip Z score than control. Mean total testosterone and estradiol levels were higher in the dutasteride group. There were no significant dif- ferences between the groups in lumbar spine bone density parameters or bone turnover markers. Our results provide evidence that long-term 5alpha-reductase suppression does not adversely affect bone mineral density. Dutasteride therapy could have beneficial effect on bone density.

The role of negative pressure wound therapy in patients with kidney transplantation.

Kidney transplantation is the best treatment modality for patients with end-stage renal disease. Wound healing is impaired in these patients, and factors such as immunosuppression, older age and comorbidities have a negative impact on wound healing. Recently, negative pressure wound therapy has become an important wound management technique. We present two patients with wound healing issues in the early posttransplant period. In both patients, an imrnunosup- pressive treatment was administered, which included tacrolimus, mycophenolate mophetil and high-dose corticosteroids with anti-IL-2 induction therapy. Postoperatively, the wounds became inflamed with dehiscence. Negative pressure wound therapy was successfully applied to aid the wound healing. The treatment duration period was two weeks for one patient and three weeks for the other. After the treatment period, the wounds were significantly improved and were closed. After the secondary wound closures, the posttransplant course was uneventful in both patients. Presently, one and three years after the transplantations, both patients have well functioning kidneys. According to our limited experience, negative pressure wound therapy is a feasible and effective dehiscence wound treatment following kidney transplantation.

Surgical treatment of kidney cancer in elderly.

The aim of this study was to analyze our patients over the age of 70 suffering from kidney cancer that had undergone surgical treatment. During the 2000-2012 period 634 patients with kidney cancer were treated, 197 of whom were over the age of 70. In this group there were 117 (59.4%) men and 80 (40.6%) women. In most of these patients (156 patients--79.2%) the clear cell type of renal carcinoma was diagnosed. According to TNM classification the dominant stages were Tlb in 62 patients (31.8%) and T1a in 48 patients (24.6%). The most common grade was G2 (73 patients--37%). Radical nephrectomy was performed in 103 (52.3%) patients, simple nephrectomy in 86patients (43.7%), enucleation of the tumor and resection of the kidney in 6 (3.1%) patients, while in 2 patients the tumor was inoperable. Early postoperative compli cations developed in 21 (10.8%) patients. They included complications in distant organs in 11 (5.6%) patients and surgical complications in 10 (5.4%) patients. Five patients (2.6%) died during early postoperative period. Surgery is recommended treatment for elderly patients with kidney cancer with complications comparable with those in younger patients.

Treatment of hardware infection after osteosynthesis of lower leg using negative pressure wound therapy and transforming powder dressing.

Fractures of the distal part of the lower leg are more common in everyday practice and traumatology. In young and active patients these injuries are mainly caused by high energy trauma. They are treated with external fixator in first step, and in second step, after sanation of the soft tissue, with open reduction and internal fixation (ORIF). It is very safe and effective method of treatment. Treatment of the infections that occur in the early postoperative period after open reduction and internal fixation represents a great problem and challenge for surgeons. It is widely accepted that the presence of deep infection can't be cured in the presence of hardware. However, removal of hardware in the presence of unhealed fractures significantly complicates sanation of infection and fracture itself We have decided to present a 35-years-old patient with a hardware infection with present chronic wound with hardware exposed eight months after the first operation and six months after second operation. The wound measured one centimeter in diameter with cell detritus and bad granulations tissue inside the wound. Hardwre was exposed in the depth of the wound.The secretion was minimal. Negative Pressure Wound Therapy (NPWT) was applicated after debridemet and lavage performed in ambulatory conditions. The starting therapy was continuously -125 mm Hg of vacuum. After five days of NPWT the defect was partially filled with granula- tion tissue. For another five days we continue with NPWT with the same values of-125 mm Hg pressure but in the inter- mitent mode. After that period we used transforming powder dressing for covering and protection of the wound with was filled with granulation tissue. Five days later, wound was completely healed with epithelisation. After four months of patient follow-up, we found the wound is completely repaired. The patient denies pain and has continued orderly flow of fracture healing, with no signs of infection.

[Use of new materials in the treatment of chronic post-traumatic wounds]. / Primjena novih materijala u lijecenju kronicnih posttraumatskih rana.

Postoperative infection and the presence of osteosynthetic material in human body pose a major problem for patients and operators. Previously, it was considered that osteosynthetic material must be removed, and only then the expected full infection recovery could occur. However, removal of osteosynthetic material in unhealed fractures complicates bone fracture healing, as well as infection recovery. Nowadays, it is indicated to place an external bone fixator and in case of soft tissue recovery access to reosteosynthesis. The negative pressure wound therapy has brought new opportunities for treatment of this type of infections without the need of osteosynthetic material removal. Direct and indirect effects of negative pressure wound therapy create optimal healing conditions. Local use of new materials, transforming powder (Altrazeal) and topical hemoglobin spray (Granulox), provide and improve physiological conditions for appropriate and safe healing.

[Orthotopic kidney transplantation--a case report]. / Ortotopna transplantacija bubrega--prikaz bolesnika.

Kidney transplantation is the treatment of choice in patients with end-stage renal disease. Heterotopic kidney transplantation is the most common technique used. Some patients with severe vascular pathology of iliac vessels or retained iliac fossae after previous transplantations are no more candidates for heterotopic kidney transplantation. In these patients, the orthotopic kidney transplantation represents an appropriate alternative. We present a patient with end-stage renal disease and severe atherosclerosis of iliac vessels which preclude heterotopic transplantation. In our patient a successful orthotopic kidney transplantation was done.

[Use of negative pressure therapy in the treatment of primary infected traumatic wounds of the foot caused by high energy impact]. / Uporaba terapije negativnim tlakom u lijecenju primarno inficiranih traumatskih rana stopala uzrokovanih ozljedivanjem visokom energijom.

Foot injuries caused by firearms and high pressure washing machines are not common, but due to high energy can be very destructive and contaminated with microorganisms. Due to the anatomical specificity of the foot, injures of the specific structure such as blood vessels, nerves and tendon-ligament apparatus are frequent. Soft tissue defect is often present. Functional and aesthetic recovery of the foot is a challenge for the surgeon. Direct and indirect effect of the negative pressure therapy helps in wound healing and provides good preparation for definitive surgical management of wounds.

[A role of negative pressure therapy in the treatment of surgical wound infection after intramedullary osteosynthesis in pertrochanteric femoral fracture]. / Uloga terapije negativnim tlakom u lijecenju infekcije kirurske rane nakon intramedularne osteosinteze pertrohanternog prijeloma bedrene kosti.

Fractures of the proximal femur are specific to older adults. Today, life expectancy for men and women is increasing, so one can expect an increased number of hip fractures. Elderly people suffer from associated diseases that may compromise the biological potential in healing of surgical wounds. On the other hand, there is an increased number of microorganisms resistant to antimicrobial drugs, so an increased number of postoperative infections can be expected. With conventional treatment methods of postoperative infections where the osteo-synthetic material is present in tissue, negative pressure therapy is gradually taking an increasingly important role in the treatment of these conditions. Because of its simple application in hospital or outpatient setting and good comfort with no pain for the patient, negative pressure therapy contributes significantly to healing of the wounds without removing osteosynthetic material from the wound.

[Kidney transplantation--a successful story started 110 years ago]. / Transplantacija bubrega--110-godisnja uspjesna prica.

Organ transplantation is one of the most important medical achievement of the 20th century. Emerich Ullmann performed on March 7th 1902, in the Vienna, the first successful kidney transplantation. It was an autotransplantation in a dog, with a transposition of a kidney in the neck region. Graft function persisted over the next five days. Only the few months later Alexis Carrel performed in Lyon another succcessful kidney autotransplantation in a dog. Carrel was interested in the vascular anastomosis improvement. He developed the triangulation technique of vessel anastomosis and so called Carrel patch. Since then both techniques have become a standard in kidney transplantation. Carrel was awarded with Nobel Prize in Physiology and Medicine in 1912 for his innovatory work in the field of transplantation and vascular surgery. These experimental transplantations preceded kidney transplantation in the humans which has become a routine operative procedure.

[Retrograde balloon dilatation as a minimally invasive treatment for ureteral stricture]. / Retrogradna balonska dilatacija kao minimalno invazivni oblik lijecenja stenoze uretera.

Ureteral stricture is not a common urologic condition. Balloon dilatation represents one of the least invasive methods for treatment of ureteral strictures. We retrospectively analysed 24 patients with ureteral strictures treated with retrograde balloon dilatation in our department. The etiology of stricture was iatrogenic in 11 (45.8%) patients, post-TBC in one (4.2%), congenital in one (4.2%), retroperitoneal fibrosis in one (4.2%) and unknown in 10 (41.6%) patients. Twelve (50%) patients had a stricture of pelvic, 9 (37.5%) lumbar, and 3 (12.5%) of terminal ureter. In all patients retrograde balloon dilatation has been performed. Only complication related to the procedure was febrility in 4 patients (16.7%). Restrictures were noted in 12 (50%) patients, who consequently have been treated surgically, or had to be stented. Retrograde balloon dilatation, as a safe and relatively effective treatment, is proposed as the first choice in patients with short ureteral strictures.

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.

Primary testicular necrotizing vasculitis clinically presented as neoplasm of the testicle: a case report.

We present a case of necrotizing vasculitis with the testicle as the isolated affected organ. A 25-year-old man, pretreated for epididymo-orchitis, presented with a presumed testicular neoplasm. Radical orchiectomy was performed and diagnosis of necrotizing vasculitis was established. In the absence of any other sign of systemic disease, the diagnosis of isolated necrotizing vasculitis of the testis was confirmed. Two years after the operation, the patient showed no symptoms of systemic disease.