Prevalence of chronic kidney disease and its risk factors among family practice patients in Lithuania

BACKGROUND

Early detection of chronic kidney disease (CKD) by the first line is essential. In many countries, serum creatinine measurements are reimbursed in home practice. In Lithuania however, until recently they were not. Therefore, the aim of this study was to assess the prevalence of risk factors of CKD in primary care patients, to evaluate the awareness of family practitioners and, finally, to investigate renal function parameters in patients at risk.

METHODS

We reviewed the charts of adult patients (n = 4,082) from four home practices in Kaunas and identified patients at increased risk for CKD (severe arterial hypertension, diabetes, cardiovascular disease (CVD), other causes of kidney damage). We noted age and gender in all patients, and renal function measurements performed over the preceding 24 months in the patients at risk. In the second part, we assessed nephrological status (history, clinical characteristics, serum creatinine, dipstick urinalysis and microalbuminuria, estimated glomerular filtration rate (eGFR) by the abbreviated MDRD formula) for those at risk who were referred by their family practitioners.

RESULTS

In total, 458 (11.2%) patients had risk factors for CKD. Severe arterial hypertension was found in 62.6% of these patients, diabetes in 20.9%, CVD in 6.2% and 34.5% had a history of kidney damage. Kidney tests had been performed by family practioner in 59% of these patients. Only 30.3% of these patients were referred to the nephrologist and an additional 20.1% came after receiving an invitation letter. eGFR < 60 ml/min/1.73 m2 was found in 42.9% of these patients, 23.4% had microalbuminuria and 7.8% overt proteinuria. Optimal blood pressure control (< 130/85 mmHg) was achieved in a minority (10.4%). 79.7% had abnormal BMI, 39% used no ACEI/ARB, and 16% were smokers. Kidney dysfunction was associated with a higher prevalence of microalbuminuria and a lower use of ACEI/ ARB.

CONCLUSIONS

Risk factors for CKD were present in 11% of the patients in this primary care cohort. Kidney dysfunction was found in almost half of the patients at risk. However, awareness of this problem by family practitioners was low.

[Focal segmental glomerulosclerosis: prognosis of chronic renal failure]

We analyzed 19 patients with focal segmental glomerulosclerosis (FSGS): 11 males and 8 females (mean age 38.3 yrs. (SD 16.4), who were under observation for 39.4 months (SD 17.2). At the moment of renal biopsy 73.7% of patients had arterial hypertension, 52.6%--nephrotic proteinuria, 36.9%--chronic renal failure. Global glomerulosclerosis was present in 14 biopsies (73.7%), and intersticial fibrosis--in 13 biopsies (68.4%). The results of analysis showed multiple risk factors for progression of renal failure: initial renal failure (p=0.005), proteinuria (> or =3 g/l) (p=0.005), expressed glomerulosclerosis (p=0.005) and expressed interstitial fibrosis (p=0.034). Focal segmental glomerulosclerosis were found to have a relatively bad long-term prognosis--the renal survival rate in 5 years was 77.8%. Kaplan-Meier survival analysis showed that expressed glomerulosclerosis was risk factor (logrank p=0.016, Breslov p=0.043) associated with end-stage renal disease in 5 years.

[Relationship between lethality of hemodialysis patients, erythropoietin dosage for renal anemia treatment and hemodialysis quality]

In December of 1999 and 2000 we visited all hemodialysis centers of Lithuania and collected data about all hemodialysis patients, using special questionnaires. The aim of the study was to evaluate the relationship between lethality of hemodialysis patients, erythropoietin dosage for renal anemia treatment and hemodialysis quality. The patients with higher Kt/V, higher levels of iron and albumin, normal levels of phosphorus and parathyroid hormone (PTH) requested lower doses of erythropoietin (analysis of the patients who were on hemodialysis in 2000 more than 6 months). So, we can conclude that adequate hemodialysis procedure and good management of hemodialysis patient are leading to the decrease request of erythropoietin doses for anemia treatment. We compared two groups of patients in order to examine relationship between hemodialysis quality and lethality of hemodialysis patients. We selected incident patients registered in December of 1999 and we divided these patients in December of 2000 in two groups: a) 175 patients, who continued hemodialysis treatment and b) 41 patients, who died in 2000. The results revealed, that dead patients were elder, their duration of weekly hemodialysis was shorter, Hb concentration lower, they had worse nutritional status (blood albumin level was lower). Lethality was associated with underlying diseases such as diabetes, hypertensive nephropathy and renal amyloidosis.

[The indications of renal biopsies and spectrum of renal diseases in five nephrological centers of Lithuania (a five-year study)]

A retrospective study of 316 patients, who underwent renal biopsy, during the period of 1995-1999 in five nephrological centers of Lithuania. All renal biopsy materials were investigated in the State Center of Pathology. Male:female ratio was 204:112, the mean age 41.4 (SD 16.7) yrs., range 15-80. The main indications for renal biopsy were nephrotic syndrome (29.1%), hematuria and nonnephrotic proteinuria (27.8%). The leading type of kidney damage was primary glomerulonephritis--194 (69.3%), which was 2.4 times more frequent in males than in females. The dominant types of primary glomerulonephritis were IgA nephropathy--30.4%, membranoproliferative glomerulonephritis--26.8%, membranous nephropathy--10.3% and focal segmental glomerulosclerosis--9.8%. Renal amyloidosis was found even in 8.6% of all renal biopsies.

[Dynamics of diabetic nephropathy and other complications of type I diabetes mellitus in the period of 1996-2002 (data from 2 Kaunas outpatient polyclinics)]

Kidney involvement in diabetes mellitus has negative impact on the outcomes of disease. Strong relationship between progressive diabetic kidney disease and the development of other diabetic complications was found by many investigators. In order to evaluate the dynamics of diabetic nephropathy in type I diabetes mellitus during 6-year period and its relationship with other diabetes mellitus complications and control of glycemia and hypertension, in 2002 we reviewed ambulatory case records of patients, who were followed by endocrinologists and who were investigated by us in 1996. During 6-year period, 5.1% from 156 pts. died and all of them had diabetic nephropathy; 26.9% of pts. moved to general practitioners and never visited endocrinologists again. Only 105 pts. remained under follow-up by endocrinologists. Their mean age 37.6+/-1.3 yrs. Out of all patients, 54% were males and 46% females. Mean diabetes mellitus duration was 19.5+/-0.9 yrs. Control of glycaemia was poor and insufficient in 2/3 of pts. HbA(1C) wasn't checked in 68.9% of pts. Control of arterial hypertension became better, but not sufficiently. During 6-year period persistent proteinuria developed in 12.1% of pts., who had no or transient proteinuria <0.5 g/l in 1996. Persistent proteinuria developed 19.9+/-1.8 yrs. after the diabetes mellitus onset and correlated with hypertension and renal insufficiency. Higher level of proteinuria was associated with worse control of glycemia. Progression of diabetic retinopathy and neuropathy over 6 yrs. were more expressed than in diabetic nephropathy. On average retinopathy developed after 14+/-1.8 yrs. after the diabetes mellitus onset, neuropathy--17.8+/-2.2 yrs., renal failure--21.1+/-2.8 yrs., heart failure--22.9+/-1.9 yrs. and arterial hypertension--12.1+/-1.3 yrs. The prevalence and time of incipient diabetic nephropathy appearance remained unknown because the test for microalbuminuria was not available in the primary health care centres.

[Prognosis of chronic renal failure in patients with membranous nephropathy]

Two hundred eighty patients underwent renal biopsy during the period of 1995-1999 in five nephrological centers of Lithuania. All renal biopsies materials were examined in the State Center of Pathology. In 20 patients (7.1%) membranous nephropathy was found. The main clinical presentation at the moment of renal biopsy were nephrotic syndrome (55%) and arterial hypertension (55%). Glomerulosclerosis was found in 30% of patients, interstitial fibrosis--in 40% of patients. The results of analysis showed multiple risk factors for renal failure progression: initial renal failure (p=0.000), systolic and diastolic hypertension (p=0.009 and p=0.009), proteinuria (=1 g/l, =3 g/l) (p=0.026). Membranous nephropathy was found to have a relatively good long-term prognosis - the renal survival rate in 5 years was 84.2%. Kaplan-Meier survival analysis showed that initial renal failure was risk factor (logrank p=0.018, Breslov p=0.032) associated with development of end-stage renal disease in 5 years.

[Clinical and laboratory features and prognostic implications in myeloma with and without renal impairment]

Presenting clinical and laboratory features, prognostic implications and survival in 124 multiple myeloma patients were reviewed in a retrospective study based on hospital records. The median age was 65 years. Out of all patients, 2.42% were younger than 40 years and 62.9% were 60 years and older. The main presenting clinical features were bone pain (70.16%), fatigue (31.45%), recurrent infections (9.68%) and weight loss (0.3%). Renal failure was present in 35.48% of patients. The higher means of ionised calcium, uric acid, erythrocyte sedimentation rate, M protein were correlated with the higher mean of serum creatinine. The acturial survival of myeloma patients without renal failure at 1 and 2 years was 95.08% and 89.23% respectively, while acturial survival of myeloma patients with renal failure at 1 and 2 years was 82.5% and 73.35% respectively (p<0.01). One-year survival in myeloma patients maintained on chronic hemodialysis was 68.75% while it is reported as 90.91% for myeloma patients not on dialysis (p<0.006).

[Parallels in development of hemodialysis service and kidney transplantations in Lithuania during 1996-2005]

The aim of our study was to evaluate the changes in hemodialysis service, main demographic characteristics of hemodialysis patients in Lithuania during 1996-2005, and their correlation with the number of recipients on the kidney waiting list. During the study period, we annually visited all hemodialysis centers in Lithuania and collected data about all hemodialysis patients. There was a sharp increase in the number of hemodialysis centers (from 17 to 43), hemodialysis stations (from 25 to 100 per million population, P<0.001), hemodialysis patients (from 60 to 312 per million population, P<0.001), and new hemodialysis patients (from 54.3 to 95 per million population, P<0.01). The mean age of hemodialysis patients increased from 47.2+/-16.1 years in 1996 to 58.8+/-15.6 years in 2005 (P<0.001). Hemodialysis population became older. The percentage of patients aged more than 60 years increased from 22.8% to 53.2% (P<0.001) and aged more than 70 years from 5.4% to 24.4% (P<0.001). The frequency of chronic glomerulonephritis as underlying disease of end-stage renal disease decreased from 54.5% in 1996 to 21.1% in 2005 (P<0.001). There was an increase in the percentage of patients in whom end-stage renal disease was caused by diabetic (from 7.1% to 19.2%, P<0.01) and hypertensive nephropathies (from 3.1% to 13.9%, P<0.05) and chronic pyelonephritis (from 11.2% to 17.9%, P<0.01). The percentage of recipients on the kidney waiting list decreased from 71.4% in 1996 to 21.1% in 2005. In summary, during the last 9 years, hemodialysis service in Lithuania significantly expanded. The number of hemodialysis patients was continuously rising with predominance of diabetic, hypertensive, and elderly patients. Diabetic nephropathy, chronic glomerulonephritis, and pyelonephritis were the main underlying diseases of end-stage renal disease in hemodialysis patients in 2005. The percentage of recipients on the kidney waiting list decreased probably because of the rise in the number of elderly patients and patients with diabetes mellitus in Lithuanian hemodialysis population.

[Reactivation of cytomegalovirus infection after kidney transplantation in Kaunas University of Medicine Hospital during the period of 2000-2006]

Cytomegalovirus infection has been associated with increased morbidity and mortality after transplantation and with diminished graft survival. After transplantation, more than 75% of solid organ transplant patients are newly infected with cytomegalovirus, or latent cytomegalovirus infection may be reactivated. The objective of our study was to evaluate reactivation rate of cytomegalovirus infection after kidney transplantation in Kaunas University of Medicine Hospital and its relation to anticytomegalovirus prophylaxis. A retrospective review of all kidney transplants performed between May 2000 and December 2006 was conducted. We analyzed the prevalence of cytomegalovirus in the groups of donors and recipients, and risk categories were defined for cytomegalovirus infection/disease in transplant patients. During this period, a total of 93 transplantations were performed in 56 men (60.2%) and 37 women (39.8%). The mean age of recipients was 41.04+/-12.74 years. There were 33 (68.7%) men and 15 (31.3%) women in the group of donors; their mean age was 39.49+/-14.81 years. Patients at high risk for the development of cytomegalovirus infection/disease were defined as those who had donor-positive/recipient-negative serostatus (D+/R-), and they made up 5.4% of all patients. Intermediate-risk patients with cytomegalovirus infection (D+/R+ and D-/R+) accounted for 73.1% and 15.1% of all recipients, respectively; 6.4% of patients were at low risk (D-/R-). Anti-cytomegalovirus prophylaxis with i/v ganciclovir was given during the period of hospitalization in all cases, except when there was a D-/R- combination, or when the transplant was removed in the early period after transplantation. The reactivation of cytomegalovirus infection was observed in 23 patients (24.7%). We have observed 41 episodes of cytomegalovirus infection, but during this period, no patient developed cytomegalovirus disease that might cause lethal outcome.

[The level of endotoxins in hemodialysis water and dialysate]

Hemodialysis is a process when the blood of patients contacts with dialysate through a semipermeable membrane. Water used for dialysis is not sterile. Microorganisms cannot pass through the membrane pores, but bacterial endotoxins can diffuse to the blood of patients. Several acute and long-term complications (pyrogenic reactions, silent chronic inflammation, malnutrition) in dialysis patients might be associated with dialysate contamination. The aim of this study was to determine the level of endotoxins in hemodialysis water and dialysate in several hemodialysis centers of different Lithuanian cities.

MATERIAL AND METHODS

Material was dialysis water (n=6) and dialysate (n=14) from six hemodialysis centers in three different cities of Lithuania. Bacterial endotoxin levels were measured using a sensitive Limulus Amebocyte Lysate (LAL) assay.

RESULTS AND CONCLUSIONS

The level of endotoxins was less than 0.25 endotoxin unit (EU)/mL in all hemodialysis water (n=6) and dialysate (n=14) samples. One sample of water (16.7%) and two of dialysate (14.3%) had the level of endotoxins above 0.03 EU/mL. Therefore, the level of endotoxins in hemodialysis water and dialysate in studied Lithuanian hemodialysis centers (n=6) complied with the recommendations of the European Pharmacopoeia and the ERA-EDTA best practice guidelines for conventional dialysis modalities. The level of endotoxins in dialysate of five Lithuanian hemodialysis centers complied with the recommendations of the ERA-EDTA best practice guidelines for ultrapure dialysate.

[The prevalence of major risk factors for chronic kidney disease among patients in primary health care centers]

The aim of the study was to investigate the prevalence for high-risk factors for chronic kidney disease among patients in primary health care centers and to assess diagnostic strategy carried out by family doctors.

RESULTS

We analyzed case records (n=4082) of patients aged more than 18 years in four family doctor's practices of Kaunas city. The ratio of female to male was 1.4:1. The major risk factors for chronic kidney disease (severe hypertension, diabetes, kidney diseases, and severe ischemic diseases) were identified in 458 patients: 287 (62.66%) women and 171 (37.34%) men. It accounted for 11.2% of all patients. They were significantly older as compared to all patients (66.96+/-14.34 vs. 49.86+/-18.54 years, P<0.0001). The most common risk factors were as follows: hypertension (62.66%), primary kidney diseases (33.84%), diabetes (20.96%), and complicated ischemic disease (6.11%). Of the 458 patients, 366 (79.9%) had one and the remaining patients had several risk factors. During the last 24 months, family doctor evaluated kidney function and urinanalysis in 24.4% and 53.6% of patients with high-risk factors, respectively. While examining these patients (n=91), it was determined that even in 54.95% of them, glomerular filtration rate was lower than 60 mL/min/1.73 m2.

CONCLUSIONS

The major risk factors for chronic kidney disease were identified in 11.2% of patients from primary health care centers. Most of them were older than 75 years. The most common risk factor was arterial hypertension. The assessment of kidney function in these patients by family doctor was insufficient. A thorough examination of the patients with major risk factors revealed chronic kidney insufficiency in half of them.

[Prevalence of antibodies to hantavirus among hemodialysis patients with end-stage renal failure in Kaunas and its district]

The objective of this study was to investigate the prevalence of antibodies to hantaviruses among hemodialysis patients with end-stage renal failure in Kaunas and its district.

MATERIAL AND METHODS

Serums of 218 patients from four dialysis centers of Kaunas district were tested by using the immunoglobulin G antibody-capture enzyme-linked immunosorbent assay (ELISA). The reactivity of ELISA-positive sera was proven in Western blot tests using various hantavirus recombinant nucleocapsid proteins. The yeast-expressed nucleocapsid proteins were used for testing.

RESULTS

Antibodies against Dobrava/Hantaan and Puumala hantaviruses were found in 16 patients (seroprevalence 7.4%). Most of the sera were positive for Dobrava hantavirus (81%). The ratio of males to females was 1.2:1. Seroprevalence was significantly higher in older patients.

CONCLUSIONS

Results indicate that antibodies to two hantaviruses (Dobrava/Hantaan virus and Puumala virus) are prevalent among hemodialysis patients in Kaunas district with approximately the same seroprevalence as in neighboring countries.

[Quality of life and depression in renal transplant patients]

The objective of this study was to examine the factors affecting quality of life in renal transplant patients and to evaluate the association between depression and quality of life.

MATERIAL AND METHODS

A study was carried out in 61 renal transplant patients. Health-related quality of life was evaluated using the Medical Outcomes Study 36-item Short Form (SF-36) questionnaire. Depression was measured using the Beck's Depression Inventory (BDI).

RESULTS

Twenty percent of the subjects had a BDI score higher than 15. The BDI score correlated inversely with these quality-of-life domains: physical functioning (r=-0.691, P<0.001), limitations in physical activities because of physical problems (r=-0.428, P=0.001), bodily pain (r=-0.662, P<0.001), and limitations in usual role activities because of emotional problems (r=-0.319, P<0.001). The BDI score also correlated with age (r=0.44, P<0.001) and serum creatinine level (r=0.453, P<0.001). Subjects with BDI score higher than 15 were significantly older (51.40+/-11.35 years vs. 42.64+/-10.89 years, P<0.05), they had higher serum creatinine levels (215.7+/-82.63 micromol/L vs. 153.2+/-50.6 micromol/L, P<0.05), lower bodily pain score (39.7+/-21.44 vs. 72.32+/-19.0, P<0.001), and lower score in limitations in usual role activities because of emotional problem (36.6+/-33.23 vs. 67.36+/-37.83, P<0.05).

CONCLUSIONS

Depression was associated with a lower quality of life in four domains. Patients with depression were older and had a worse graft function.

[Comparison of methods for evaluating renal function (Data of Kaunas University of Medicine Hospital in 2006)]

Cockcroft-Gault formula and Modification of Diet in Renal Disease (MDRD) equation are widely used as indirect estimates of renal function. The precision and reliability of these formulas regarding kidney function are still discussed. The aim of our study was to evaluate glomerular filtration rate by different methods and compare the results. Data on patients in whom renal function was evaluated at the Clinic of Nephrology of Kaunas University of Medicine Hospital in 2006 are presented in this article. Glomerular filtration rate was assessed based on 24-hour endogenous creatinine clearance and calculated using three formulas: Cockcroft-Gault, abbreviated MDRD, and complete MDRD. Blood serum creatinine level was measured by the standardized Jaffe assay. Glomerular filtration rate was examined in 125 patients. Their mean age was 58.07+/-18.962 years. The mean endogenous creatinine clearance was 31.1287+/-31.14 783 mL/min. The mean glomerular filtration rate calculated by Cockcroft-Gault formula was 34.1220+/-29.02 967 mL/min, by abbreviated MDRD formula was 29.8212+/-25.83 866 mL/min/1.73 m2, and by complete MDRD formula was 28.6884+/-24.99 353 mL/min/1.73 m2. There was no statistically significant difference in mean glomerular filtration rates estimated using all methods in the evaluation of kidney function. When the reliability of formulas was analyzed depending on each stage of chronic kidney disease, it was found that Cockcroft-Gault and MDRD formulas, in contrast to endogenous creatinine clearance, did not precisely reflect kidney function in stages 1 and 2 of chronic kidney disease. Estimates by Cockcroft-Gault and MDRD formulas correctly showed decreased kidney function in stages 3 and 4 of chronic kidney disease. Formulas were not reliable, in contrast to endogenous creatinine clearance, when patients were in end-stage chronic kidney disease. CONCLUSIONS. Cockcroft-Gault and MDRD formulas are best for the evaluation of moderate degree of renal insufficiency, and in early stage of chronic kidney disease, underestimation of glomerular filtration rate is possible by using formulas. Estimates of glomerular filtration rate based on formulas are higher as compared to endogenous creatinine clearance measurements in end-stage chronic kidney disease.

[Evaluation of bone mineral density and its importance for hemodialysis patients]

The aim of the study was to determine the changes in bone mineral density in hemodialysis patients and to evaluate their correlation with disorders of calcium-phosphate metabolism.

PATIENTS AND METHODS

Data of 82 patients on chronic hemodialysis were analyzed. The patient group consisted of 40 (48.8%) men and 42 (51.2%) women. Clinical and laboratory data were collected from medical records. Bone mineral density was measured by ultrasound (Sahara Hologic densitometer) in the heel area.

RESULTS

The mean age of the patients was 60.13+/-16.02 years. Mean T score was 1.7+/-1.19, mean Z score was 1.076+/-1.2, and mean bone mineral density was 0.393+/-0.0 g/cm2. Women had significantly lower bone mineral density than men (0.361 g/cm2 and 0.425 g/cm2, respectively; P=0.006). Normal bone mineral density, when T score was -1 and more, was observed only in 23 (28%) patients. More than one-third (n=37, 45.1%) of patients were classified as osteopenic (T score between -2.5 and -1) and 22 (26.8%) patients as osteoporotic (T score less than -2.5). Patients with normal bone mineral density were significantly younger than those with decreased bone mineral density (54.7+/-15.48 years vs. 58.76+/-15.76 years and 68.09+/-14.5 years, respectively; P<0.05). Laboratory parameters reflecting calcium-phosphate metabolism did not differ between the groups. A statistically significant correlation was observed between T score, bone mineral density and age (-0.328, P=0.03 and -0.301, P=0.007, respectively), body weight (0.27, P=0.014 and 0.339, P=0.002, respectively), and level of parathyroid hormone (-0.322, P=0.003 and -0.286, P=0.01, respectively).

CONCLUSIONS

In our study, bone mineral density lower than normal was observed in more than half of hemodialysis patients. Low bone mineral density in hemodialysis patients correlated with age, gender, lower body weight, and higher level of parathyroid hormone.

[Survival of hemodialysis patients in Lithuania (data from all hemodialysis centers in the 1998-2005 cohort)]

BACKGROUND

There is no any official renal registry in Lithuania, so in order to know the exact demographic statistics of patients on hemodialysis, we started to collect data since 1996. The aim of the study was to estimate the survival rate of hemodialysis patients and its dynamics, to compare survival in different groups of sex, age, primary renal disease, and to compare to survival of dialysis patients in Europe.

MATERIAL AND METHODS

We analyzed the data of all patients who started hemodialysis in Lithuania between January 1, 1998, and December 31, 2005. The information was obtained from medical documentation. The total survival rate was estimated using the Kaplan-Maier method.

RESULTS

During the study period, 2418 patients started hemodialysis (51.7% of males, 48.3% of females). Their mean age at the beginning of treatment was 56.19+/-16.12 years. Death occurred in 792 patients. The main cause of death was cardiovascular events, accounting for 32.3%. The total survival rate of hemodialysis patients in Lithuania at 1 year was 79.97%; at 2 years, 69.18%; at 5 years, 49.97%; at 7 years, 38.3%. Males lived longer than females (log rank P<0.05), but the mean age of females was greater, and survival rate adjusted for age did not differ between the groups. The highest survival rate was in the youngest group (0-19 years old), the lowest - in patients older than 75 years. Diabetic patients lived shorter than nondiabetic patients (log rank P<0.00001). Although patients who start hemodialysis have become older and their survival has been improving, in the 1998-2002 cohort survival was lower as compared to overall survival of patients on dialysis in European countries participating in ERA-EDTA registry.

CONCLUSION

Survival of hemodialysis patients in Lithuania in the 1998-2005 cohort depended on age and primary renal disease and despite aging of population on hemodialysis has been improving.

Membranoproliferative glomerulonephritis is still the most frequent glomerulonephritis in Lithuania

BACKGROUND

In Lithuania renal biopsies (RB) have become routine since 1995. Our study attempted to analyze RB for 5 years in Lithuania.

METHODS

We analyzed data of adult patients who underwent native kidney biopsies in 6 renal units in the period between 1995 - 1999. It accounted for 62.5% of all kidney biopsies, done throughout Lithuania. All biopsy specimens were examined by the same pathologist using light- and immunofluorescence microscopy.

RESULTS

A total of 316 renal biopsies was analyzed; males : females 1.8 : 1. The mean age was 41.4 +/- 16.7 years. The most common indications for biopsy was nephrotic syndrome (29.1%) and urinary abnormalities (27.8%). After exclusion of inadequate biopsies in the remaining 280 RB, primary glomerulonephritis (GN) accounted for 68.7% and secondary GN for 19.5%. The most frequent forms of primary GN were membranoproliferative GN and immunoglobulin A nephropathy (17.9% and 15.4%, respectively), followed by membranous nephropathy (7.1%) and focal segmental glomerulosclerosis (6.8%).

CONCLUSIONS

The main indication for renal biopsy in Lithuania was nephrotic syndrome, which was followed by isolated urinary abnormalities. The leading type of kidney damage was primary glomerulonephritis, which was 2.4 times more frequent in males than in females. The most frequent form of primary glomerulonephritis was membranoproliferative GN, with dominance in males. Immunoglobulin A nephropathy was the second form of primary GN according to the frequency.

Hospitalization in hemodialysis patients in one region of Lithuania

INTRODUCTION AND METHODS

The objective of our study was to evaluate hospitalization rates in hemodialysis patients in the region of Kaunas, the second largest city in Lithuania. We analysed ambulatory case records of 187 ESRD patients dialysed in all 7 hemodialysis centers in the Kaunas region over the year 2002.

RESULTS

During the year 2002 the unadjusted hospitalization rate over a 1 year period in all dialysed patients (the prevalent patients, n=187) was 1.4 hospitalizations per patient year at risk. There were 17.5 hospital days per patient year at risk, the mean length of one hospitalization being 12.5 days. The most frequent causes of hospitalization were cardiovascular diseases (25%), infections (22%), and access related complications (10%). Of the 187 patients, 55 started hemodialysis in the year 2002 (incident patients). The comparison of prevalent patients with incident patients revealed a higher hospitalization rate in the incident patients (unadjusted hospitalization rate was 1.9 hospitalizations per patient year at risk). The length of hospitalization (29.1 hospital days per patient year at risk) and the mean length of one hospitalization (15.1 days) were longer in the incident patients than the prevalent patients. In the year 2002, the National Sickness Fund paid $361 per year for hospitalizations of one hemodialysis patient and $10,800 per year for the dialysis procedures of one hemodialysis patient.

CONCLUSIONS

The hospitalization rate in Lithuania for patients undergoing hemodialysis is similar to that of other European countries while hospitalization costs are lower.

[Changes of control of disorders of calcium and phosphorus metabolism in Lithuanian hemodialysis centers 1996-2003]

The aim of the study was to evaluate the changes of the rate of disorders of calcium and phosphorus metabolism and their control in patients on hemodialysis (HD) in Lithuania in 1996-2003. Every December during this period we visited all HD centers of Lithuania and collected data on calcium-phosphorus metabolism in HD patients. 51.8% of HD patients in 1999 and 44.6% in 2003 had hyperphosphatemia (>1.8 mmol/l) (p<0.05). The mean phosphate concentration was 1.82+/-0.56 mmol/l in 2003 (p<0.05, comparing with 1.95+/-0.72 mmol/l in 1999 and 1.9+/-0.72 mmol/l in 2001). 7.1% of HD patients had hypocalcemia in 2003 and 7.8% hypercalcemia. Serum parathyroid hormone level was investigated only in 27.3% of HD patients in 1999 and 84.8% in 2003 (p<0.05). Use of alfacalcidol significantly decreased from 77.5% in 1998 to 29.4% in 2003, when the evaluation of serum parathyroid hormone increased (r=-0.911, p=0.03). Serum parathyroid hormone level was not analyzed for 59.8% of patients who used alfacalcidol and 59.4% of them had hyperphosphatemia in 1999 (6.3% and 32.9% in 2003, respectively; p<0.05). 10.7% of these patients had hypercalcemia in 2003. In summary, the correction of disorders of calcium and phosphorus metabolism in HD patients was insufficient but ameliorative. Monitoring of serum parathyroid hormone increased significantly during 1997-2003. The percentage of the precarious use of alfacalcidol decreased significantly when the evaluation of serum parathyroid hormone level became regular.

[The beginning of kidney transplantation in Kaunas (results of Kaunas University of Medicine Hospital 2000-2004)]

During the last year 57 cadaver kidney transplantations were performed in Lithuania, 23 of them in Kaunas. The first transplantation of cadaver kidney at Kaunas University of Medicine Hospital was performed in May 2000. The purpose of the study was to analyze the results of kidney transplantations performed at Kaunas University of Medicine Hospital between May 2000 and December 2004 and to evaluate the most frequent early and late complications after transplantation and survival of the kidney transplant. During this period a total of 51 cadaver kidney transplantations were done. The mean age of patients was 38.37+/-12.45 years. 90.2% of cadaver kidneys were taken from the optimal kidney donors. The most common early complications after kidney transplantation were infections of the urinary tract (33.3%) and on the late period of kidney transplantation complications of the immunosuppressive treatment (40%) (cytomegalovirus infection, agranulocytosis). Acute rejections were in 13.7 proc. of patients. Kidney transplant survival rate at 1 and 3 years after cadaver kidney transplantation was 85%. Mortality of transplant patients was 2%.

[Early risk factors for secondary hyperparathyroidism in hemodialysis patients]

The aim of the study was to identify risk factors for secondary hyperparathyroidism at the start and during the first year of hemodialysis. Retrospective analysis of medical records of all patients with end-stage renal disease, dialyzed at the hemodialysis center of Kaunas University of Medicine Hospital on December 2004, was performed. Biochemical data at the start, during the first year and at the end of follow-up (December 2004) were analyzed. At the start of hemodialysis elevated level of parathyroid hormone (PTH) was observed in 46 of 69 patients (67.6%), at the end of the first year in 27 of 69 patients (39.1%). In 22 of 46 patients (47.8%), who started hemodialysis with elevated PTH levels, the level of PTH decreased to <22 pmol/l after 1 year. In comparison with patients who maintained elevated PTH levels, they showed lower levels of PTH at the start of hemodialysis. Levels of serum calcium and phosphate at the start of hemodialysis did not differ between groups. At the end of the first year patients in whom levels of PTH decreased had higher serum calcium concentration as compared with those who maintained levels of PTH > or =22 pmol/l. A multivariate analysis revealed that levels of PTH and alkaline phosphatase after one year of hemodialysis were associated with increased risk for secondary hyperparathyroidism on the follow up.

CONCLUSIONS

Control of calcium-phosphate metabolism in the pre-dialysis period is not sufficient. Symptoms of secondary hyperparathyroidism were diagnosed in more than a half of patients starting hemodialysis. Levels of PTH and alkaline phosphatase at the end of the first year are early risk factors for secondary hyperparathyroidism on the follow-up.

[Sleep disorders and quality of life in patients on hemodialysis]

The objective of this study was to determine the rate of sleep disorders in patients on hemodialysis and to evaluate the association between quality of sleep and quality of life in these patients.

METHODS

A total of 81 hemodialysis patients were enrolled in the study. Quality of sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI): higher scores indicate worse sleep quality. Health-related quality of life was evaluated using the Medical Outcomes Study 36-item Short Form (SF-36) questionnaire.

RESULTS

In the present study 54 dialysis patients (66.7%) were "poor sleepers" (PSQI>5). The SF-36 mental component summary (PCS) and physical component summary (MCS) correlated with the global PSQI score (PCS, r=-0.463, p<0.001; MCS, r=-0.426, p<0.001), age (PCS, r=-0.330, p=0.003; MCS, r=-0.381, p<0.001), hemoglobin (PCS, r=0.289, p=0.009; MCS, r=0.301, p=0.006), comorbidity (PCS, r=-0.286, p=0.01; MCS, r=-0.283, p=0.011). Dialysis patients with global PSQI< or =5 ("good sleepers") had higher SF-36 PCS and MCS scores (PCS, 51.15+/-17.2 vs. 34.72+/-16.58, p<0.001; MCS, 59.52+/-17.43 vs. 41.92+/-18.34, p<0.001) and higher hemoglobin levels (102.74+/-12.34 g/l vs. 95.67+/-10.57 g/l, p=0.009) compared with "poor sleepers" (PSQI>5).

CONCLUSIONS

In the present study two-thirds of dialysis patients (66.7%) were "poor sleepers". Lower hemoglobin levels correlated with worse quality of sleep and quality of life. We hypothesize that correction of anemia may improve quality of life in patients on hemodialysis. Poor sleep is associated with lower quality of life in hemodialysis patients.