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.

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.

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.

[AUTONOMIC DYSREFLEXIA].

Autonomic dysreflexia (AD) is a syndrome that occurs in patients with high spinal cord lesion. It is caused by activation of sympathetic nervous system by a noxious stimulus below the level of injury, usually consisting of distention and/or irritation of the bladder or constipation. Sympathetic system activation leads to blood pressure elevation because compensatory mechanisms cannot properly regulate blood pressure due to the spinal cord lesions. The most important manifestation of AD is arterial hypertension because of the possible cerebrovascular and cardiovascular complications, including death. Initial treatment consists of recognition of the symptoms and resolution of the cause. In patients with high blood pressure antihypertensive therapy is initiated (with nifedipine, captopril and nitroglycerin). Prevention is also a very important task, with the goal of influencing all possible triggers of this condition, specially micturition and colon disorders. One of the most important tasks is educating patients, their caregivers and health professionals about AD.

[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.

[THE FIRST CROATIAN GUIDELINES FOR DIAGNOSIS, TREATMENT AND FOLLOW-UP OF PERSONS WITH PREMATURE EJACULATION].

Premature ejaculation (PE) is a sexual disorder with high prevalence, defined by three characteristics: short intravaginal ejaculation latency time, poor control over delaying ejaculation and personal and/or partner distress. The diagnosis is reached by a thorough and comprehensive history taking, which should include presence/absence of other ­co-morbid conditions (e.g. erectile dysfunction, anxiety), and assessing the type of PE (primary, secondary, variable, subjective). It is important to counsel the patient (and, if possible, the partner) about this condition and treatment options. The first line of treatment is selective serotonin reuptake inhibitors (dapoxetine, which is the only drug with an official label for this indication, paroxetine, sertraline, fluoxetine, citalopram, escitalopram). The first line of treatment also includes psychological/sexological treatment methods, such as behavioural methods (stop-start and squeeze techniques), and new functional sexological treatment. The choice of the method depends on the type of PE and on the patient preference. The second line of treatment are clomipramine and local anaesthetics, and the third line is tramadol.

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.

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.

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.

[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.

Case report: Challenging kidney transplantation in an adolescent patient with tetralogy of Fallot.

Tetralogy of Fallot is the most common cyanotic congenital heart disease. This severe disorder of cardiac physiology can impair renal function and lead to the development of cardiorenal syndrome and eventually to end-stage renal disease. Kidney transplantation may be the best option for renal replacement treatment in patients with tetralogy of Fallot, but only after correcting cardiac abnormalities and optimizing cardiac functions, all of which require a multidisciplinary approach. We report the first case of kidney transplantation in an adolescent patient with tetralogy of Fallot. Our findings confirms that kidney transplantation is a valuable treatment option in selected congenital heart disease cases.

[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.

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.

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.