Trends in kidney transplantation rate across Europe: Study from the ERA Registry

BACKGROUND

The aim of this study was to identify trends in total, deceased donor and living donor kidney transplantation (KT) rates in European countries.

METHODS

The European Renal Association (ERA) Registry and the Global Observatory on Donation and Transplantation (GODT) databases were used to obtain the number of KTs in individual European countries between 2010 and 2018. General population counts were obtained from Eurostat or the national bureaus of statistics. The KT rate per million population (pmp) and the average annual percentage change (APC) were calculated.

RESULTS

The total KT rate in the 40 participating countries increased with 1.9% annually (95% confidence interval (CI): 1.5, 2.2) from 29.6 pmp in 2010 to 34.7 pmp in 2018, reflecting an increase of 3.4 pmp in the deceased donor KT rate (from 21.6 pmp to 25.0 pmp, APC: 1.9% [95%CI: 1.3, 2.4]) and of 1.5 pmp in the living donor KT rate (from 8.1 pmp to 9.6 pmp, APC: 1.6% [95%CI: 1.0, 2.3]). The trends in KT rate varied widely across European countries. An East-West gradient was observed for deceased donor KT rate with Western European countries performing more KTs. In addition, most countries performed less living donor KTs. In 2018, Spain had the highest deceased donor KT rate (64.6 pmp) and Turkey the highest living donor KT rate (37.0 pmp).

CONCLUSIONS

The total KT rate increased due to a rise in the KT rate from deceased donors and to a lesser extent from living donors, with large differences between individual European countries.

The ERA Registry Annual Report 2019: summary and age comparisons

Background

Data on renal replacement therapy (RRT) for end-stage renal disease were collected by the European Renal Association (ERA) Registry via national and regional renal registries in Europe and countries bordering the Mediterranean Sea. This article provides a summary of the 2019 ERA Registry Annual Report, including data from 34 countries and additional age comparisons.

Methods

Individual patient data for 2019 were provided by 35 registries and aggregated data by 17 registries. Using these data, the incidence and prevalence of RRT, the kidney transplantation activity and the survival probabilities were calculated.

Results

In 2019, a general population of 680.8 million people was covered by the ERA Registry. Overall, the incidence of RRT was 132 per million population (p.m.p.). Of these patients, 62% were men, 54% were ≥65 years of age and 21% had diabetes mellitus as primary renal disease (PRD), and 84% had haemodialysis (HD), 11% had peritoneal dialysis (PD) and 5% had pre-emptive kidney transplantation as an initial treatment modality. The overall prevalence of RRT on 31 December 2019 was 893 p.m.p., with 58% of patients on HD, 5% on PD and 37% living with a kidney transplant. The overall kidney transplant rate was 35 p.m.p. and 29% of the kidney grafts were from a living donor. The unadjusted 5-year survival probability was 42.3% for patients commencing dialysis, 86.6% for recipients of deceased donor grafts and 94.4% for recipients of living donor grafts in the period 2010–14. When comparing age categories, there were substantial differences in the distribution of PRD, treatment modality and kidney donor type, and in the survival probabilities.

The ERA-EDTA Registry Annual Report 2018: a summary

Background

The European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) Registry collects data on kidney replacement therapy (KRT) via national and regional renal registries in Europe and countries bordering the Mediterranean Sea. This article summarizes the 2018 ERA-EDTA Registry Annual Report, and describes the epidemiology of KRT for kidney failure in 34 countries.

Methods

Individual patient data on patients undergoing KRT in 2018 were provided by 34 national or regional renal registries and aggregated data by 17 registries. The incidence and prevalence of KRT, the kidney transplantation activity and the survival probabilities of these patients were calculated.

Results

In 2018, the ERA-EDTA Registry covered a general population of 636 million people. Overall, the incidence of KRT for kidney failure was 129 per million population (p.m.p.), 62% of patients were men, 51% were ≥65 years of age and 20% had diabetes mellitus as cause of kidney failure. Treatment modality at the onset of KRT was haemodialysis (HD) for 84%, peritoneal dialysis (PD) for 11% and pre-emptive kidney transplantation for 5% of patients. On 31 December 2018, the prevalence of KRT was 897 p.m.p., with 57% of patients on HD, 5% on PD and 38% living with a kidney transplant. The transplant rate in 2018 was 35 p.m.p.: 68% received a kidney from a deceased donor, 30% from a living donor and for 2% the donor source was unknown. For patients commencing dialysis during 2009-13, the unadjusted 5-year survival probability was 42.6%. For patients receiving a kidney transplant within this period, the unadjusted 5-year survival probability was 86.6% for recipients of deceased donor grafts and 93.9% for recipients of living donor grafts.

Leptin is associated with disease activity but not with anthropometric indices in rheumatoid arthritis patients

INTRODUCTION

Leptin is a cytokine-like hormone which has a complex role in inflammation. However, the importance of leptin in the pathogenesis of rheumatoid arthritis (RA) is far from being fully elucidated. The aim of the study was to determine serum leptin levels in RA patients and to evaluate whether there is an association between disease activity, anthropometric indices and leptin levels.

MATERIAL AND METHODS

This hypothesis-generating study included 55 RA patients and 25 matched healthy subjects. The serum leptin concentration was determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Median serum leptin level in RA patients of 27.4 ng/ml (14.5-54.9 ng/ml) was statistically significantly higher (p = 0.03) compared with the median leptin value of 16.3 ng/ml (9.6-38.8 ng/ml) determined in healthy controls. The serum leptin level in the high disease activity group was significantly higher (p < 0.0005) than that in the low disease activity group and in healthy controls. A significant difference (p = 0.001) in serum leptin level was also found when the high disease activity group was compared with the moderate disease activity group. In the RA group a statistically significant positive correlation (rho = 0.390; p = 0.003) was observed between serum leptin level and disease activity score (DAS28).

CONCLUSIONS

The present results show that serum leptin levels are increased and significantly associated with disease activity in patients with RA and may have a valuable role in the inflammatory reactions and pathogenesis of RA.

[[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.

Renal replacement therapy in Europe: a summary of the 2013 ERA-EDTA Registry Annual Report with a focus on diabetes mellitus

Background

This article provides a summary of the 2013 European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report (available at http://www.era-edta-reg.org), with a focus on patients with diabetes mellitus (DM) as the cause of end-stage renal disease (ESRD).

Methods

In 2015, the ERA-EDTA Registry received data on renal replacement therapy (RRT) for ESRD from 49 national or regional renal registries in 34 countries in Europe and bordering the Mediterranean Sea. Individual patient data were provided by 31 registries, while 18 registries provided aggregated data. The total population covered by the participating registries comprised 650 million people.

Results

In total, 72 933 patients started RRT for ESRD within the countries and regions reporting to the ERA-EDTA Registry, resulting in an overall incidence of 112 per million population (pmp). The overall prevalence on 31 December 2013 was 738 pmp (n = 478 990). Patients with DM as the cause of ESRD comprised 24% of the incident RRT patients (26 pmp) and 17% of the prevalent RRT patients (122 pmp). When compared with the USA, the incidence of patients starting RRT pmp secondary to DM in Europe was five times lower and the incidence of RRT due to other causes of ESRD was two times lower. Overall, 19 426 kidney transplants were performed (30 pmp). The 5-year adjusted survival for all RRT patients was 60.9% [95% confidence interval (CI) 60.5–61.3] and 50.6% (95% CI 49.9–51.2) for patients with DM as the cause of ESRD.

Renal replacement therapy in Europe: a summary of the 2012 ERA-EDTA Registry Annual Report

BACKGROUND

This article summarizes the 2012 European Renal Association-European Dialysis and Transplant Association Registry Annual Report (available at www.era-edta-reg.org) with a specific focus on older patients (defined as ≥65 years).

METHODS

Data provided by 45 national or regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. Individual patient level data were received from 31 renal registries, whereas 14 renal registries contributed data in an aggregated form. The incidence, prevalence and survival probabilities of patients with end-stage renal disease (ESRD) receiving renal replacement therapy (RRT) and renal transplantation rates for 2012 are presented.

RESULTS

In 2012, the overall unadjusted incidence rate of patients with ESRD receiving RRT was 109.6 per million population (pmp) (n = 69 035), ranging from 219.9 pmp in Portugal to 24.2 pmp in Montenegro. The proportion of incident patients ≥75 years varied from 15 to 44% between countries. The overall unadjusted prevalence on 31 December 2012 was 716.7 pmp (n = 451 270), ranging from 1670.2 pmp in Portugal to 146.7 pmp in the Ukraine. The proportion of prevalent patients ≥75 years varied from 11 to 32% between countries. The overall renal transplantation rate in 2012 was 28.3 pmp (n = 15 673), with the highest rate seen in the Spanish region of Catalonia. The proportion of patients ≥65 years receiving a transplant ranged from 0 to 35%. Five-year adjusted survival for all RRT patients was 59.7% (95% confidence interval, CI: 59.3-60.0) which fell to 39.3% (95% CI: 38.7-39.9) in patients 65-74 years and 21.3% (95% CI: 20.8-21.9) in patients ≥75 years.

Cutaneous silent period in the assessment of small nerve fibers in patients on hemodialysis

AIM

In hemodialysis patients renal disease may cause an impairment of central and peripheral nervous system. In most cases of the peripheral nervous system polyneuropathy is reported. The aim of this study was to evaluate the function of small A-delta nerve fibres, whose function is often overlooked.

METHODS

The function of large diameter nerve fibers was performed by standard routine neurophysiological examination. Cutaneous silent period (CSP) was elicited by single electrical stimulations at the tip of digit II by the bipolar electrodes. The superficial electrodes were placed on the muscle belly of m. abductor pollicis brevis. The onset latency (L1) was recorded at the beginning of voluntary muscle activity suppression, the late latency (L2) at the start of new muscle activity. The difference between two latencies indicates the duration of CSP.

RESULTS

The study included 38 consecutive patients (male/female - 21/17, median age 56.6±10.9 years) treated with hemodialysis (one month to 30 years) and 35 healthy subjects (male/female 23/17, age 47.4±10.1 years). The results of the conduction study demonstrated a significant prolongation of F-waves of the median and ulnar nerves, decreased motor and sensory velocities of both nervesin patients on hemodialysis (p less than 0.001). In patients with A-V fistulas a significant prolongation of the onset CSP latency L1 was obtained (p less than 0.001), whereas duration of CSP was not changed.

CONCLUSION

In hemodialysis patients the significant impairment of small nerve fibers was recorded. The evaluation of small nerve fibers contributes to the assessment of the whole peripheral nerve function.

[The effect of intradialytic exercise program on the quality of life and physical performance in hemodialysis patients]

AIM

To determine the effect of a 16-week intradialytic exercise program consisting of 30 minutes of exercise during the first two hours of dialysis with three times a week frequency, on the quality of life (QoL), level of depression/anxiety and physical perfor- mance in hemodialysis (HD) patients.

METHODS

The clinical, longitudinal, prospective study with one-group repeated measures design was conducted during a 16-week period. A convenience sample of 52 HD patients, who had been on HD for a minimum of 6 months, were included. QoL, level of depression and anxiety (questionnaires: SF-36, Back Depression Inventory (BDI) and Back Anxiety Inventory (BAI)) and physical performance (modifying Visual Analogue Scale (VAS) and Manual Muscle Testing (MMT)) were assessed at baseline and after 4-month exercise program.

RESULTS

The following scales of SF-36 questionnaire were improved after 16-week exercise program: role functioning/emotional (P=0.01 8), energy/fatigue (P = 0.002) and social functi- oning (P = 0.030). Level of depression and anxiety were significantly decreased in males (P = 0.007 and P = 0.022, respectively) and females (P = 0.001 and P = 0.000, respectively). VAS scale and MMT were significantly increased in males (P = 0.000 and P = 0.001, respectively) and females (P = 0.01 9 and P = 0.001, respectively) after 16-week exercise program.

CONCLUSION

Exercise program improves some aspects of QoL and physical performance, and decreases the level of depression and anxiety in HD patients.

Renal replacement therapy in Europe: a summary of the 2011 ERA-EDTA Registry Annual Report

Background

This article provides a summary of the 2011 ERA–EDTA Registry Annual Report (available at www.era-edta-reg.org).

Methods

Data on renal replacement therapy (RRT) for end-stage renal disease (ESRD) from national and regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. From 27 registries, individual patient data were received, whereas 17 registries contributed data in aggregated form. We present the incidence and prevalence of RRT, and renal transplant rates in 2011. In addition, survival probabilities and expected remaining lifetimes were calculated for those registries providing individual patient data.

Results

The overall unadjusted incidence rate of RRT in 2011 among all registries reporting to the ERA–EDTA Registry was 117 per million population (pmp) (n = 71.631). Incidence rates varied from 24 pmp in Ukraine to 238 pmp in Turkey. The overall unadjusted prevalence of RRT for ESRD on 31 December 2011 was 692 pmp (n = 425 824). The highest prevalence was reported by Portugal (1662 pmp) and the lowest by Ukraine (131 pmp). Among all registries, a total of 22 814 renal transplantations were performed (37 pmp). The highest overall transplant rate was reported from Spain, Cantabria (81 pmp), whereas the highest rate of living donor transplants was reported from Turkey (39 pmp). For patients who started RRT between 2002 and 2006, the unadjusted 5-year patient survival on RRT was 46.8% [95% confidence interval (CI) 46.6–47.0], and on dialysis 39.3% (95% CI 39.2–39.4). The unadjusted 5-year patient survival after the first renal transplantation performed between 2002 and 2006 was 86.7% (95% CI 86.2–87.2) for kidneys from deceased donors and 94.3% (95% CI 93.6–95.0) for kidneys from living donors.

[Tunneled catheter infections in patients on hemodialysis--one center experience]

INTRODUCTION

Central venous catheters in hemodialysis patients can be used as vascular access for hemodialysis. At our clinic, our doctors use temporary and tunneled catheters for hemodialysis treatment. The presence of the catheter, increases the risk of bacteremia in hemodialysis patients. Risk factors are nasal colonization with Staphylococcus aureus, prolonged use of catheters, previous bacteremia, anover dose of iron, low hemoglobin, low albumins, diabetes mellitus, and surgical procedures. The aim of this study was prevention of catheter sepsis and timely disclosures of existing and effective cures.

PATIENTS AND METHODS

Thirty-eight patients with tunnelled catheters as vascular access for hemodialysis were included into the study. The study was conducted between January 1, 2011 and January 3, 2012. Outof 38 patients, 60% (23) were male and 40% (15) were female, while the average age was 67.48 +/- 13.9 years. The duration of hemodialysis treatment was 108.9 +/- 16.54 months.

RESULTS

Over the study period, 9 patients developed bacteriemia associated with the use of catheter as a vascular approach. The incidence of infection in our study was 3.5 cases per 1000 catheter days. Two patients (5.2%) developed an infection in the first three months after the day of catheter placement, and the remaining 6 (15.8%) patients after one year of the use of catheter as a vascular approach. Regarding the causes of infection, in 3 (33%) patients these were gram-positive pathogens, in 5 (56%) patients gram-negative pathogens, and in one (11%) patient it was polimicrobe flora. According to the protocol and pending the outcome of susceptibility testing (antibiogram), all the patients were prescribed with antibiotic treatment therapy. In 7 (75%) patients tunnelled catheter was removed and replaced with temporary catheters for hemodialysis treatment. In 2 (25%) patients, was antibiotic-lock solution was injected into the catheter. There were no significant differences (p<0.05) in age, duration of dialysis treatment, hemoglobin levels, iron, transferrin saturation, ferritin and albumin in patients without infection and those who developed an infection. Only one patient has had a nasal colonization with Staphylococcus aureus. One patient developed severe thrombocytopenia, followed by sepsis anda lethal outcome due to heavy gastrointestinal bleeding.

CONCLUSION

tunneled venous catheter is the increasingly common vascular access with the hemodialytic patients, but it is also a common cause of infection. Proper care and use of catheters, making the unique protocols of care and treatment algorithm occupy a significant place in each hemodialysis center. Our goal is to prevent the catheter sepsis, and to promptly detect the existing and a fast treatment of the same.

[Prevention and treatment of hepatitis C infected patients on hemodialysis]

INTRODUCTION

Hepatitis C virus infection (HCV) is an important cause of morbidity and mortality in patients with end-stage renal disease (ESRD).

PATIENTS AND METHODS

In this prospective, observational study, 205 patients, 37 (18%) of them with chronic HCV infection, were followed up for a one-year period at Department of Hemodialysis, Sarajevo Clinical Center, University of Sarajevo. The following parameters were analyzed: dialysis duration, sex, PCR RNA, HCV genotypes and biochemical parameters. Thirteen anti-HCV PCR RNA positive patients were treated with pegylated interferon alpha (Pegasys, Hoffman-La Roche). The goal of therapy was to reach sustained virologic response. The presence of anti-HCV antibodies in serum was detected by enzyme linked immunosorbent assay (ELISA).

RESULTS

Of 37 anti-HCV positive patients, there were 20 (54%) males and 17 (45.9%) females with the mean hemodialysis duration of 143.67 +/- 57.64 months and mean age of 54.45 +/- 8.93 years. Of 37 anti-HCV positive patients, 30 (81.08%) patients were HCV RNA PCR positive. Among HCV RNA PCR positive patients, two had up to twofold elevated ALT values, one had twofold elevated AST values, and one had sixfold elevated GGT values. Thirteen RNA PCR positive patients were treated with pegylated interferon alfa for 48 weeks. Only one patient had genotype 1 virus. Upon therapy completion, only three patients were negative by PCR RNA (genotype 1b, 23.07%) at six months and yearly follow ups remained PCR negative.

CONCLUSION

Sustained virologic response was achieved in three study patients. Monitoring guidelines for infection control, isolation of seropositive patients, and strict hygienic preventive measures can prevent HCV seroconversion in hemodialysis patients.

[New vaccination protocol against hepatitis B for hemodialysis patients--a single-centre experience]

Patients with end stage renal disease (ESRD) have a reduced response to vaccination against hepatitis B infection. The aim of the study has been to determine the adequacy of immune response with new protocol of vaccination against hepatitis B infection.

PATIENTS AND METHODS

The study included incident hemodialysis patients since 2008 until 2011 at the Clinic of Hemodialysis of the Clinical Center of the University of Sarajevo. We started the new vaccination protocol in September 2009. New protocol implied vaccination six month before starting renal replacement therapy (RRT) and "ic" (intracutaneously) application vaccine vs. "sc" (subcutaneously) application. Vaccination was carried out for over 12 months. The follow up period lasted from 2009 to 2011.

RESULTS

The study included 64 patients, men were represented with 57,81% (37), and 42,19% women (27), who were divided in two groups. The first group included patients from the period from 2008 to 2009, who have been vaccinated under the old vaccination protocol, while the second group included patients with the new protocol from September 2009 to 2011. The first group had 28 patients, mean age of patients was 55,17 +/- 11.84 and mean duration of hemodialysis was 24,65 +/- 5,32 months. The second group had 36 patients, mean age of patients was 62,79 +/- 15,88 years, and mean duration of hemodialysis was 22,16 +/- 24,53 month. Neither group of patient has been previously vaccinated, nor these had positive in serum antiHBs before vaccination in second group. Five patients received a booster dose of vaccine, after which 4 showed adequate responses to anti HbS. In the first group of patients, out of total of 28 patients, 15 patients did not respond response with the adequate anti-HbS titer at the end of vaccination. In the second group of patients, out of 36 patients 31 of them responded to the vaccination with the new protocol, which was statistically significant (p<0,005). The total percentage of patients with adequate titer of antiHBs after vaccination towards a new protocol was 97.43% and the percentage of patients who required booster dose of vaccines was 12.82%.

CONCLUSION

Vaccination of patients in ESRD,six months before renal replacement therapy and intradermal application of vaccine vs. subcutaneously, improved immune response of our patients.

[Non invasive evaluation of vascular calcifications in patients on hemodyalisis]

INTRODUCTION

Cardiovascular diseases are one of the main causes of morbidity and mortality in dialysis patients. High incidence of cardiovascular diseases in patients with chronic kidney disease (CKD) can not soley be explained by traditional risk factors. Several studies have confirmed association between vascular calcification and increased mortality.

MATERIALS AND METHODS

This study included total of 44 patients on chronic hemodialysis program, 18 women and 26 men, with average age of 50.66 +/- 11.62 years and average duration of treatment of 100.25=52.83 months. We analyzed socio-demographic parameters and standard laboratory findings. X-ray of hand and pelvis was obtained from each patient along with echocardiography and carotid ultrasound imaging. To estimate the level of vascular calcifications on the X-rays, we used the simple vascular score (sVC).

RESULTS

Using noninvasive methods, we found vascular calcifications in 26 (59%) patients. In 22 (45%) patients, vascular calcifications were found in X-rays. Four (9%) patients with vascular calcifications lacked any abnormality on X-rays but had calcified plaques on carotid arteries or hart valves. In the group of patients that had vascular calcifications, 3 (14%) patients had sVC score of 2,2 (9%) had score of 3,7 (32%) had score of 4,4 (18%) had score of 6, and 6 (27%) had sVC score of 8. Comparing the group of patients with and without vascular calcifications, we found statistically significant age difference (p<0.05) as well as difference in the duration of hemodialysis (p<0.05). There were no other significant differences found between the two groups. There is a statistically significant correlation between sVC score and level of calcium (p<0.09) and iPTH (p<0.05). Using regression model for increase of sVC score, we found significant correlation with duration of hemodialysis (p<0.05).

CONCLUSION

Existence of vascular calcifications represents warning sign of increased cardiovascular risk. Simple vascular score is an easy method for assessing that risk. In our study, increased frequency of vascular calcifications was directly correlated with older age and length of hemodialysis. Standard X-rays, echocardiography and ultrasound imaging can be used in screening of vascular calcifications. Among these methods, X-ray has advantage because it is widely available and easy to interpret.

Evaluation and treatment of cardiovascular diseases in patients on hemodialysis--single center experience

AIM

To evaluate frequency of CVD in dialysis population, in relationship to patients with and without diabetes, and their most common treatment.

PATIENTS AND METHODS

This retrospective study included 187 patients, 106 males and 81 females, divided in two groups, diabetics and non-diabetics, treated by chronic hemodialysis. Patients' analyses included: anamnesis, ECG, chest X-rays, echocardiogram, laboratory examinations for calcium (Ca), phosphorus (P), parathormone (PTH), cholesterol (chol), triglicerids (TG), C-reactive protein (CRP), hemoglobin (Hb) and uric acid. In addition, we analyzed groups of drugs used by patients as prescribed by cardiologists.

RESULTS

Average age was 58.0 years, most of them between 51 and 60. Average hemodialysis length was 4 years. Primary kidney diseases were pyelonephritis and glomerulonephritis. 19,78% of patients had diabetes. 165 patients (88,23%) had one or more cardiovascular diseases. 110 patients (58,2%) had hypertension, most of them used ACE inhibitors. Using test of multiple correlation, statistically significant correlations, among others, were shown between BMI and Ca, uric acid and P, albumin and PTH in diabetics, at the statistical significance level at p < 0.05.

CONCLUSION

Cardiovascular diseases are the most common comorbidity and cause of mortality in hemodialysis population. There was no statistical significance in age, however there is a statistical difference in the dialysis duration variable, but in some biochemical laboratory parameters there was some difference. ACE inhibitors were most commonly used in the treatment of hypertension and systolic dysfunction, alone or with beta-blockers.

Methylenetetrahydrofolate Reductase gene polymorphism in patients receiving hemodialysis

Methylenetetrahydrofolate Reductase (MTHFR) is key enzyme in metabolism of homocysteine. Homozygotes for mutation (TT genotype) have hyperhomocysteinemia, risk factor for atherosclerosis development. The aim of the study was to find out distribution of genotype frequencies of C677T MTHFR among patients on maintenance hemodialysis. Possible association of alleles and genotypes of C677T polymorphism of the MTHFR gene with age of onset, duration of dialysis and cause of kidney failure was studied also. Cross-sectional study includes 80 patients from Clinic of Hemodialysis KUCS in Sarajevo. In order to perform genotyping, isolated DNA was analyzed by RFLP-PCR and gel-electrophoresis. From total of 80 patients, 42.5% (n=24) were female, 57.5% (n=46) were male, mean age 54.59+/-1.78 years and duration of dialysis 79.92+/-6.32 months. Genotype distribution was: CC 51.2% (n=41), CT 37.5% (n=30) and TT 11.2% (n=9). Patients with wild-type genotype have longer duration of dialysis in month (87.1 +/- 63.93) comparing to TT genotype patients (67.06 +/- 39.3), with no statistical significance. T allele frequency was significantly higher in group of vascular and congenital cause of kidney failure (Pearson X2 =6.049, P<0.05) comparing to inflammation etiology group. Genotype distribution results are within the results other studies in Europe. Obtained results indicate that C677T polymorphism is not associated with onset, duration and cause of kidney failure in our hemodialysis population. There is an association of T allele of the MTHFR gene and vascular and congenital cause kidney failure.

Trends in Renal Replacement Therapy in Bosnia and Herzegovina 2002-2008

Renal Registry (RR) of Bosnia and Herzegovina was established in 2002, with aim to follow up the trends of Renal Replacement Therapy in Bosnia and Herzegovina. The prevalence of Renal Replacement Therapy (RRT) in Bosnia and Herzegovina is rising steadily. One reason for this is an increasing number of patients starting RRT. The aim is to present the epidemiology and treatment of all aspects of RRT in Bosnia and Herzegovina in period 2002-2008. Centre-related and patient-related questionnaires were sent to all 25 dialysis centres in Bosnia and Herzegovina. The demographic data, prevalence and incidence, type of renal replacement therapy, cause of ESRD, erythropoietin administration, cause of death, and type of vascular access were obtained from the questionnaires. Collected data were analysed using SPSS statistics. The number of patients treated by Renal Replacement Therapy (RRT) increased steadily from 1,531 patients in 2002 to the 2,206 at the 2008 (43%). The prevalence has increased from 399 pmp in 2002 to 696 pmp. in 2008. Incidence (new patients) in 2002 was 110 pmp and incidence rate in 2008 was 163, and there were 249 new patients (day 1). The mean age for new patients increased from 60 years in 2002 to 63.5 years in 2008 and the population over 75 years rate from 8.79% to 11.3%. Most ESRD patients in Bosnia and Herzegovina are undergoing intermittent hemodialysis (92%), while some patients (8%) are treated by peritoneal dialysis and transplantation. The most significant cause of ESRD in 2008 was chronic glomerulonephritis (421 patients, 19.2%), followed by pyelonephritis (414 patients, 18.9%), BEN (14.7%) and Diabetes mellitus (12.2%). Hepatitis B and C virus infections had 397 (16.3%) patients, out of them 22 had both type of infections and 98 patients had B type infection. Only 10.5% of patients were tested on MRSA and 3 patients were positive on MRSA. There were no HIV-positive patients on RRT. The most common type of vascular access was AV fistula in 85% patients, AV graft 2% and catheters in 13%. Out of hemodialysis patients, 85.7% received ESA almost s.c. The median weekly dose was 4,000 UI. Cardiovascular diseases were the leading cause of death, gross mortality rate of dialysis patients being 13.01% in 2008. The need for RRT in Bosnia and Herzegovina is increasing and the number of patients increased by 43% since 2002. Hemodialysis is still the most common modality of treatment (92%), while proportion of PD and transplantation is slowly increasing. The preventive measures are necessary to prevent ESRD and also to decrease the number of patients on dialysis.

Different effects of low weight molecular heparin and unfractioned heparin on lipid profile and coagulation at haemodialysis patients

Each haemodialysis treatment requires the application of anticoagulation medicines, which will prevent coagulation in extracorporal blood circulation. In this study we try to determine the quality of admitted anticoagulant and his effect on lipid profile on hemodialysis patients after twelve months. We were applying standard heparin and low weight molecular heparin (LWMH). During our study we was analyzed effect of anticoagulant therapy on lipid profile of hemodialysis patients. In that parameters was included triglycerides, cholesterol, lipoprotein fractions, complete blood count, Hgb, HCT; All of these parameters was analyzed in correlation with duration of hemodialysis treatment, sex and age of the patients. Our research was carried out as a prospective study, for the period of 12 months. In the study were included 60 patients (34M/26F), who were on chronic hemodialysis program. All patients were divided into two groups. The first group of patients was included 27 patients (15M/12F) who were treated with standard heparin. The second group was included 33 patients (19M/14F) treated with LWMH (enoxaparin). The average length of hemodialysis was 4.15 +/- 0.52 years. Each patient had a protocol in which is marked parameters such as flushing dialysator, creating fibrin-ring in vein and arterial dropper and the time it takes to stop the bleeding. In the results the average age amounted to 58.54 +/- 2.24 years. The average value of cholesterol in the blood was 5.38 +/- 2.26. Values of HDL-cholesterol in patients treated with LWMH were significantly lower (P<or=0.05) in the treated group compared to standard heparin. There were no significant statistical differences between both groups in relation to the level of LDL cholesterol in the blood. (p ns). LWMH had a better effect on the irrigation system and dialysator on both sex equally, compared with standard heparin. LWMH is in the female dialysis population has led to improvements in lipid profile. After the first six months of study in male patients treated with standard heparin in relation to the female part of the observed patients was significantly better anticoagulation effect in the first half of the study (1.85 +/- 0.05 compared to 2.09 +/- 0.10) (P<or=0.001). Average rating blood clots were statistically significant for standard heparin (p<or=0,001) with 1,86 at the beginning the value is fell to 1.41, while for LWMH with 1.85 at the beginning of the study amounted to 1.52 grade average. (P<or=0.05). The results of our study show that LWMH had a better rinsing effect of dialysis systems and dialysator in both sex equally, compared to standard unfractioned heparin. When the male part of the respondents in the first six months of standard heparin had a better evaluation of blood clots than women in the same group, and also better than the group on enoxaparin for both gender. LWMH in female dialysis population has led to improved lipid profiles. Patients treated with standard heparin had a statistically significant reduction in the rate of blood clots than patients who received enoxaparin (LWMH). Such differences were minimal, which can be interpreted by the fact that LWMH still derivative of the standard heparin.

Depression in hemodialysis patients

Depression is the most frequent psychological complication of haemodialysis (HD) patients (pts) and has been associated with impaired Quality of Life (QoL). The aim of our study was to investigate the prevalence of depression in HD pts in relation to sociodemographic factors and the relationship between depression and QoL. 200 pts from Clinic for haemodialysis in Sarajevo, B&H were participating in the study. Mean age was 57.26+/-13.78 years and mean HD duration was 64.26+/-58.18 months. From the test material we applied BDI and SF-36. 51% of our pts have shown depression (BDI>11) in various degrees (30%-mild depression, 8.5%-moderate depression and 12.5%-severe depression). As we could expect, the most emphasized symptoms of depression were somatic symptoms. 55.5% of pts have shown QoL lower then average. Sociodemographic data such as gender, marital status and HD duration did not influence significantly on pt's QoL and occurrence of depression (p>0.05). As the age of the pts increased, level of depression increased too and QoL significantly decreased (p<0.05). Employed pts have shown significantly better QoL and lower level of depression in relation to unemployed pts (p<0.05). As the educational level of pts increased, QoL increased too and level of depression significantly decreased (p<0.05). Pts in 1st HD shift were significantly more depressed and have significantly worse mental health in compare to pts in 3rd HD shift (p<0.05). Our results showed a high prevalence of depressive symptoms among the study group that was linked to trend of poor QoL.

Risk factors for development of cardiovascular complications in patients with chronic renal disease and diabetic nephropathy

INTRODUCTION

Cardiovascular diseases are the most frequent causes of morbidity and mortality in patients with chronic renal disease. The aim of our paper is to evaluate the risk factors of cardiovascular complications in patients with various stages of chronic renal disease (CRD), with or without diabetes mellitus (DM).

PATIENTS AND METHODS

The study included 98 patients with different stages of the CRD, with creatinine clearance <60 ml/min/1.73m2, and laboratory parameters monitored: homocysteine, BNP, cholesterol, LDL, HDL, HbA1c, Body Mass Index (BMI). First group comprised 49 patients with DM, age 50-82 years, M 28/F 21. Second group comprised 49 patients without DM, age 35-80 years, M 18/F 31. The IMT (intima media thickness) was measured by B-mode ultrasonography, and all patients had echocardiography examination done by 2D Doppler ultrasonography.

RESULTS

The IMT values in diabetic patients had statistically significant positive correlation with homocysteine values of r=0.9393, p<0.034, and cholesterol r=0.289, p<0.05, compared to non-diabetics. A significant negative correlation was found between the ejection fraction (EF) and BMI in both groups, more prominent in non-diabetics r=0.289, p<0.044 (diabetics r=0.162, p>0.05). 47.4% of diabetics had arteriosclerotic changes on carotid arteries, 8.5% had stenosis of ACC, and 22.0% had rhythm abnormalities on ECG. A positive correlation between IMT and BMI was found in diabetics, but was not statistically significant r=0.111, p>0.05. In the diabetics group a significantly higher (p<0.05) values of BNP, HbA1c, proteinuria, BMI, and cholesterol were found, and significantly lowered EF (p<0.0001).

CONCLUSION

Risk factors for cardiovascular complications in patients with DM are various, and the most pronounced significance was found in the values of homocysteine, BNP and cholesterol.

Plasma levels of brain natriuretic peptides and cardiac troponin in hemodialysis patients

Patients with End-Stage Renal Disease (ESRD) are at high risk of death as a result of the cardiovascular disease (CVD), which cannot be explained by the conventional risk factors only. Haemodialysis patients frequently have elevated serum concentrations of the cardiac troponins T, specific markers of myocardial injury. Plasma levels of brain natriuretic peptide (BNP) are elevated in fluid volume overload and heart failure, and decreased during dialysis. Currently, LV hypertrophy and LV dysfunction are considered the strongest predictors of cardiovascular mortality in dialysis population, and the synthesis of cardiac natriuretic peptides is high in the presence of alterations in the left ventricular (LV) mass and function. The aim of this study was to investigate the factors associated with the increased serum levels of BNP and CTN in haemodialysis patients, and their impact on cardiovascular morbidity. In this cross-sectional study we included 30 patients with ESRD, without coronary symptoms, who were subjected to regular dialysis treatment three times a week for the duration of four hours. Heart failure was defined as an ejection fraction (EF) of < 35%, and dyspnoea associated with either elevated jugular pressure or interstitial oedema evidenced in chest X-ray. All patients were in sinus rhythm at the time of the study. Twenty-five patients were on erythropoietin treatment. Blood samples were taken before and after the dialysis session. Our study included 30 patients (17 males, 13 females). The average age was 53,8 years (total range 31-74) divided into two groups: euvolemic and hypervolemic. The average dialysis time was 70,3+/-46,95 months. All haemodialysis patients had excessively high levels of BNP 2196,66+/-4553,86 ng/cm3. Plasma cTnT was found to be increased in 33,3% of patients. Patients with hypervolemia had significantly higher cTnT levels (0,0577+/-0,0436), as compared to the euvolemic patients 0,0184+/-0,0259 p<0,05. The elevated cTnT significantly correlated with the level of BNP (p<0,01), while average post-dialysis BNP was not significantly lower (1698,06+/-3499,15; R=0,191; p-ns.) as compared to the pre-dialysis BNP (1839,13+/-3691,55; R=432; p<0,01). The pre-dialysis cTnT was lower (0,0315+/-0,0372) as compared to the post-dialysis cTnT (average 0,0399). Euvolemic patients had BMI 24,28+/-3,15, as compared to the hypervolemic patients BMI 25,71+/-4,20 (p-n.s.). Increased BNP was not in correlation with older age (R-0,271 p-ns.) and duration of dialysis (R-0,198). The hematocrit level increases significantly during haemodialysis (39,9%; p<0,05). Patients with higher BNP and cTnT have significantly higher indexed left ventricular mass, as compared to the patients with normal ventricular function. Our study shows that 33,3% of asymptomatic patients on haemodialysis have elevated cTnT while all patients have elevated BNP. Measuring the plasma concentration of brain natriuretic hormones may be useful for identification of the dialysis patients with LVH.

Polymorphism in Methylentetrahydrofolate Reductase Gene: Important Role in Diseases

It has been recognized that some people have a genetic variant which leads to elevated levels of homocysteine and impairs ability to process folate. This condition was recognized as independent risk factor of coronary heart disease. Recently, connection between this termolabile mutation of the methylenetetrahydrofolate reductase and numerous conditions and diseases has been established. Aim of this review is to draw attention to this interesting area in medicine. Additionally, well defined study about presence and frequency of gene polymorphism in our region will provide proper diagnosis and achieve possible delay of development of diseases with vitamin supplementation.

[Evaluation of clinical presentation and prognosis of tuberculosis in patients undergoing hemodialysis]

INTRODUCTION

Patients with chronic renal failure treated with hemodialysis represent a high risk group for the development of tuberculosis (TB) in comparison to general population.

AIM

The aim of the study was to evaluate clinical presentation, biochemical parameters and outcome of tuberculosis in patients attending the Center for Hemodialysis, Sarajevo University Clinical Center.

PATIENTS AND METHODS

The study conducted during the 2000-2005 period included four patients with tuberculosis that were already treated with chronic hemodialysis. Three of these four patients had pulmonary type and one had extrapulmonary type (bone type) of tuberculosis diagnosed by bone biopsy. Miliary TB diagnosis was verified with radiographic lung imaging and appropriate bacteriologic and biochemistry tests.

RESULTS

The mean age of the study patients was 66.5 +/- 59.6 years and mean hemodialysis duration 6.7 +/- 4.5 years. During the study period, we diagnosed four cases of active tuberculosis in 200 patients receiving hemodialysis therapy (2%). Tuberculin test was performed in all four patients and was negative. Clinical presentation was predominated by inappetence, feebleness and elevated body temperature. Biochemical tests revealed anemia (Htc 0.25 +/- 0.15), hypoalbuminemia (36.0 +/- 28.5) and extremely raised sedimentation raste (86 +/- 30). Increased transaminases were present in two of four patients; the culture of Mycobacterium tuberculosis was found in patients with pulmonary type of TB. Radiographic tests revealed miliary changes in two patients and pleural effusion in one patient. All patients were administered tuberculostatic drugs and six-month treatment resulted in full recovery.

CONCLUSION

Negative PPD test does not exclude the occurrence of TB in hemodialysis patients and the existence of pulmonary infiltrate and pleural effusion on radiographic chest images suggests the presence of the TB.

[Mechanism of therapy effects by botulinum neurotoxin]

Botulinum neurotoxin (BoNT) is produced by Clostridium botulinum as a complex of proteins containing the neurotoxin itself and other nontoxic proteins. Activation of the neurotoxin occurs upon proteolytic cleavage into the heavy and light chains. This di-chain moiety is essential for neurotoxin and each chain is playing a unique role; the heavy chain mediates neurospecifics cell binding and entry, whereas the light chain, a protease, catalyzes the cleavage and inactivation of neuronal proteins that mediate neurotransmitter release. There are seven BoNT serotypes (A,B,CI,D,E,F, and G), all of which inhibit acetylcholine release, though their intracellular target proteins, the characteristics of their actions, and their potencies vary substantially. BoNT type A has been the most widely studied and applied serotype for therapeutic purposes. It has been a mainstay in the treatment of cervical dystonia, blepharospasm, and hemifacial spasm for years. BoNT has more recently emerged as an increasingly important therapeutic option in the clinical management of a broad array of conditions, including other focal dystonias, spasticity, cerebral palsy, equinovarus, gastrointestinal (GI) and urogenital disorders, hypersecretory disorders, facial lines due to hyperfunctional facial muscles and recently, musculoskeletal pain disorders and headache.

[Prevalence of MRSA infections in patients on hemodialysis]

INTRODUCTION

The prevalence of MRSA (Methicillin Resistant Staphylococcus Aureus) in haemodialysis patients has increased dramatically during recent years. The aim of our study is to determine the prevalence of MRSA colonization among haemodialysis patients and medical staff.

MATERIAL AND METHODS

This prospective study included 235 patients undergoing haemodialysis therapy and 60 medical staff members, in the Center for Haemodialysis Sarajevo. Nasal and throat samples were taken (identification of MRSA was performed using standard microbiological methods). A total of 474 nasal and throat cultures from patients' samples and 120 cultures from medical staff samples were obtained.

RESULTS AND DISCUSSION

The total number of sampled patients was 235 and colonies were found in 36 of the samples (15.3%). Among medical staff nasal carriage rate of MRSA was 11.6% (7/60). The mean age of haemodialysis patients with MRSA was 52.94:1:5.3. The patients aged between 55 and 64 had the highest prevalence of MRSA (11/36, 30.55%). Those aged 45-54 had the next highest prevalence of nasal carriage (10/36, 27.77%). Patients aged 65 years had middle prevalence of MRSA (6/36, 8.33%). Patients aged 25-34 had the lowest prevalence of nasal carriage. We did not have possibilities to isolate MRSA positive dialysis patients, and we used intensive antibacterial prophylaxis. We treated our patients with mupirocin ointment (three times a day for 5-14 days) and gained decolonization in 34 patients (94.4%). In the treatment period, positive medical staff did not come to work.

CONCLUSION

The overall prevalence of MRSA colonization in our dialysis patients was higher (15.3%). Implementation of adequate strategies for prevention of MRSA with application of mupirocin among carriers, reduced prevalence of MRSA in our dialysis units.

[The correlation between psychic disorders and demographic features in hemodialysis patients]

INTRODUCTION

Recent studies show that psychological status of HD patients has been changed in terms of an increased score of the called neurotic triad: hypochondria, depression and hysteria. The aim of this study was to evaluate the correlation between the development of psychopathological tendencies in HD patients and the demographic features such as: gender, age, marital status, education level, employment status and HD duration.

MATERIAL AND METHODS

There were 56 patients on HD. Depending on registered psychopathological tendencies, we compared patients according to the mentioned demographical characteristics. We applied MMPI 201. Previously, all patients were psychologically examined by explorative interview regarding demographical data and the pre-dialysis psychological status. To compare categorical variations, we use 6 multivariant analysis of variance. A p value of <0.5 was considered to be statistically significant.

RESULTS

The overall profile of psychopathological tendencies of HD patients indicates increase of scores on neurotic triad. Female patients showed significantly higher level of psychosteny than male patients (FPt=4.86, p<0.05): singles showed significantly higher scores on some psychotic subscales--paranoia, schizophrenia, mania--in relation to the group of married patients (FPa=7.21, FSc=6.84, FMa=5.35, p<0.05): patients with only primary school have significantly more expressive paranoia in relation to patients with university education (FPa=3.80, p<0.05); unemployed patients have significantly more expressed paranoia and tendencies to emphasize pathology in relation to employed patients (FF=5.13, FPa=5.94, p<0.05).

CONCLUSION

Depression could be taken as a a primary psychiatric complication associated with life on haemodialysis. Gender, marital status, education level and employment status significantly influence the differences in occurrences of psychopathological tendencies in HD patients.

[Hypertension treatment in patients on hemodialysis]

Prevalence of arterial hypertension increases with the advancement of chronic renal failure (CRF). In terminal stage of CRF arterial hypertension is present in 80-90% of patients. Cardiovascular and cerebrovascular diseases are the most frequent cause of death in patients on hemodialysis. Cardiovascular mortality rate is three to twenty times higher in patients on hemodialysis compared to general population. In the beginning of the treatment with hemodialysis blood pressure lowers in certain number of patients who had used three, four or more blood pressure lowering medications during the pre-dialysis period.

[Neuropathic pain]

Neuropathic pain is result of damage or dysfunction of periphery or central nervous system. There is no adequate adaptation and produce suffering without biological helpfulness. The aim of treatment of patient with neuropathic pain is soothing of pain and suffering and prevention of further development of pathological process. Periphery mechanisms of neuropathic pain include hyperexcitability of cell membrane and periphery sensibilization. Central mechanism includes central sensibilization, central reorganization of alphabeta fibers and loss of inhibition mechanisms. The main symptoms of neuropathic pain are described as lancinating, stabbing, or shooting pain. Hyperalgesia and allodynia are special kind of neuropathic pain that is provoked by mechanic or thermal stimuli. Mononeuropathy, plexopathy, radiculopathy, and myelopathy, lesions of thymus, cortex or brain stem are real cause of neuropathic pain. In the treatment of neuropathic pain drug such as opioid, nonsteroid antirheumatics, analgetics, tricyclic antidepressant and antiepileptic are used. The most successful treatment is with antiepileptic drugs of second generation. Carbamazepin was the drug of choice till ten years ago. Since then the leader position in treatment has belong to gabapentin in dose from 900-2400 mg daily. Currently the new drug is tested, antiepileptic pregabaline. The first experiences are promising.

[Central venous catheters for haemodialysis and optimal blood flow]

INTRODUCTION

Central venous catheters (CVC) have become and indispensable form of haemodialysis access and represent, in our centre, about 8,58 % of the permanent vascular access with a total number of more than 957 venous catheters in the past 8 years. We used double-lumen catheters.

METHODS

The aim of this study was to identify the factors of the catheter dysfunction. We studied prospectively 23 chronic haemodialysed patients with CVC, 14 men and 9 women 63 +/- 14 (51-83), treated with haemodialysis for 3.7 +/- 4 (1-9) years. Catheters were inserted by percutaneous Seldinger techniques in right internal jugular vein. We studied the localization of the catheter tip: superior vena cava, right atrium, the blood pressure before and after haemodialysis, the interdialytic weight gain, and number of symptomatic episodes during 13 last dialysis (one month). The patients were divided into two groups: group I with usual adequate catheter function (n=17) and group II with frequent dysfunction (n=6).

RESULTS

In group I the catheters tip was in the right atrium, and in group II in the vena cava superior. Blood pressure was not different between the two groups. We found no correlation between central venous pressure, blood pressure, interdialytic weight gain and symptomatic hypotension, but there was a higher frequency of hypotension in the hypovolemic patients.

CONCLUSIONS

Optimal hemodynamic conditions will be provided by a catheters tip in the rights atrium and a central venous pressure over 5 mmHg, which can be provided with vascular filling or dry body weight.

[Renal osteodystrophy: diagnostic-therapeutic approach]

Disturbances in mineral and bone metabolism are common in patients with chronic kidney disease (CKD). Patients with CKD almost always develop secondary hyperplasia of the parathyroid glands, resulting in elevated blood levels of parathyroid hormone (PTH). The processes causing disordered mineral metabolism and bone disease have their onset in the early stages of CKD, continue throughout the course of progressive loss of kidney function and may be influenced beneficially or adversely by various therapeutic approaches used. It is should be emphasized that the care of CKD patients with bone disease requires frequent assessment of the various parameters (levels of calcium, phosphorus, vitamin D, PTH) and frequent evaluation of the therapies.

[Balkan endemic nephropathy in Bosnia and Herzegovina--renal registry report]

INTRODUCTION

Balkan Endemic Nephropathy (BEN) is still dominant cause of the end stage renal disease (ESRD) in North-Eastern Bosnia. The aim of this paper was to analyze the patients with BEN diagnosis on chronic dialysis treatment in Bosnia and Herzegovina.

METHODS

In this study we used data from individual questionnaires which we collected for Renal Registry. Individual questionnaires include: sex, age, place of birth and address, primary renal disease, data of the first dialysis treatment, type of dialysis, kidney transplantation, co-morbid diseases, erythropoietin therapy and outcome. For patients with BEN diagnosis we gathered additional data: history of urothelial tumor and family history of similar kidney diseases and renal replacement therapy. We compared these data with data about others dialysis patients in Bosnia and Herzegovina.

STATISTICAL ANALYSIS

descriptive statistical analysis.

RESULTS

Prevalence of the chronic dialysis patients in Bosnia and Herzegovina in 2003 was 474 pmp, 70 pmp for patients with BEN and 54 pmp for patients with diabetic nephropathy. In North-Eastern Bosnia prevalence of chronic dialysis patients was 844 and of patients with BEN 520 pmp. Incidence of the new chronic dialysis patients in Bosnia and Herzegovina in 2003 was 113 pmp, 11 pmp for BEN, and 19 pmp for diabetic nephropathy. Mortality of the chronic dialysis patients in Bosnia and Herzegovina in 2003 was 11.24 %, and mortality of the BEN patients 10.75 %.

CONCLUSION

From the total number of the chronic dialysis patients in Bosnia and Herzegovina 14.7 % are BEN patients and 11.3 % are patients with diabetes. BEN is still big medical and social problem in Bosnia and Herzegovina, especially in the North-Eastern Bosnia. There are certain indicators that the incidence of the BEN patients is in decrease such as decreased difference between the prevalence of the patients with BEN and diabetic nephropathy; as well as increase of average age of patients with BEN.

[Predictors of AV fistula adequacy in haemodialysed patients]

INTRODUCTION

Vascular access failure remains a significant problem in haemodialysis. Complications of dialysis access represent major cause of morbidity in dialysis patients. The aim of our study was to correlate the AV-fistula adequacy with clinical and demographic factors.

MATERIAL AND METHODS

The survey encompassed 40 patients followed up in one-year period. AV-fistula adequacy was graded if the blood flow rate was higher or equal to 300 ml/ min. AV-fistula adequacy was correlated with clinical and demographic factors. Following data were gathered: age, gender, diabetic status, body mass index (BMI), serum parathyroid hormone (PTH), and serum albumin.

RESULTS

The study included 40 patients (25 males and 15 females), average age of 46.3 +/- 12.65 years and haemodialysis duration of 3.16 +/- 2.39 years. 40% of AV-fistulas were created in patients older then 65 years. Diabetes was present in 30% of patients. 45% of patients were overweighed (BMI > or = 27 kg/m2). The mean concentration of intact PTH was 418.867 +/- 320.44. Serum PTH was higher then 500 pg/mol in 35% of patients. The mean serum albumin concentration was 40.129 +/- 3.509 g/l. AV-fistula adequacy was lower in older patients (age > or = 65) then in younger patients (age < 65). The difference in AV fistula adequacy between patients with BMI > or = 27 kg/m2 was statistically highly significant (p < 0.001). Lower overweighed patients had better AV-fistula adequacy. Serum albumin, as well as the PTH level did not influence AV-fistula adequacy, while age and BMI significantly correlated with AV-fistula adequacy.

CONCLUSION

Predictors of AV-fistula malfunction in our dialysis population were age, diabetes and overweight, while other clinical and demographical factors did not influence AV-fistula adequacy.

[Effect of high flux on lipid profile in haemodialysed patients]

INTRODUCTION

Patients suffering from chronic kidney failure and patients on haemodialysis are characterized with numerous biochemical abnormalities, including hyperlipidemia. Hyperlipidemia is one of the risk factors that contribute to increased incidence of cardiovascular diseases among haemodialysed patients. The aim of our paper is to evaluate high flux effect in patients on haemodialysis.

MATERIAL AND METHODS

49 patients receiving dialysis treatment were included in this study (28 males and 21 females). 28 patients were on high flux (13M/15F) and 21 on low flux (8M/13F). All of them were followed up for one year. Lipid profile included testing of cholesterol, T6, VLDL, LDL, HDL, HDLC and atenogenic index.

RESULTS

Mean age of our dialysed population (N=49) is 56.8+/-10.1 years and mean dialysis duration is 3.7+/-1.26 years. Mean cholesterol level in patients on high flux was 5.42+/-1.26 at the beginning of the study. Female patients (N=15) showed significant decrease of cholesterol level (5.80+/-1.20), which after one year was 5.11+/-1.28, p<0.05. In 21 patients on low flux cholesterol was in normal range (4.72+/-0.94). Triglyceride (T6) level was significantly higher in female (3.13+/-1.33) on low flux than in males (2.35+/-1.25). Female patients have also shown a significant decrease of T6 level (2.31+/-1.33) at the end of the study. In 21 patients on low flux, mean values of T6 were 2.24+/-1.18 and there was no significant T6 decrease (2.51+/-1.20). HDL fraction of lipoproteins was lowered in both groups (0.188+/-0.074); HDL normalized in high flux group (0.2863+/-0.2394). Atenogenic index was significantly higher in low flux group (3.247+/-2.025) compared to high flux group.

CONCLUSION

Our dialyzed population showed an improvement of T6 level in patients that were on high flux. Female patients showed significant improvement in comparison to patients receiving conventional dialysis treatment. The mechanism responsible for different lipid profiles in dialyzed patients, with special emphasis on gender, should be explored further.

[Prevention of hepatitis C at Center for Haemodialisys of Clinical Centre of University of Sarajevo]

GOAL

The patients with the chronical programm for haemodialisys have the higher risk from getting ill virus hepatitis C in the realtion to the rest population.

AIM OF THE WORK

Was the evaluation of the prevalence and incidence of hepatitis C at the Center for Haemodialisys CCU Sarajevo and the effect of the prevalentive measures on the incidence of the serum conversion of hepatitis C, in the period from 2002 till 2004 year.

MATERIAL AND METHOD

By the examening is comprehended 155 patients aged 54,58 +/- 14,797 years, with the aproximative length of the haemodialisys 58,9 +/- 53,9 months. Patients at the chronic programm of the bicarbonite haemodialisys taree times per week, and antibodies on the hepatitis C were determined III generation. Also was determined PCR.

RESULTS

During the periiod of examination the dialized population was increased also 2002 year the prevalence of hepatitis C was 23,87% (37/155), in 2003 year 29,29% (46/157) and 2004 year the pregalence amounted 26,28% (46/175). Incidence of hepatitis C was significantly decreased in the course of the period of followup and in 2002 year was 16,21%, in 2003 year 13,04%, that in 2004 year would amount 4,34%, that is only in two patients occurred the serum conversion on hepatitis C.

CONCLUSION

By applying of the corresponding protocoles and their strict realization (desinfection of the hands, wearing of gloves, apparatus desinfection) and separation of the dialyzed monitors for anti HCV positive and anti HCV negative patients dicreased significantly the hepatitis C incidence in our dialyzed population. The strict application of the preventive measures can completely prevent the speading occurrence of hepatitis C on haemodialisys.

[Clinical characteristics of pruritus in hemodialysis patients]

AIM

Aim of the research was to analyze clinical characteristics and most important risk factors of uremic pruritus.

PATIENTS AND METHODS

A total of 151 patients on chronic hemodialysis (CHD) during at least 12 months were analyzed. Thorough history was taken for pruritus, its presence and localization, sleep disorder and neuropathic symptoms. On physical examination, attention was focused on the skin. Laboratory tests includes blood cells count, serum urea, creatinine, electrolytes, aminotransferases, alkaline phosphatase and proteins. The dose of dialysis was followed by Kt/V. On statistical analysis, t-test and chi2 test were used.

RESULTS

Pruritus was present in 85 (56%) patients, 41 women and 44 men, mean age 53.56+/-13.36 (26-81) years, mean time on CHD 78.36+/-55.02 (12-268) months. There were 66 (44%) patients without pruritus, 32 women and 34 men, mean age 50.35+/-13.76 (22-73) years, on CHD for 58.64+/-50.40 (12-187) months. Although the patients with pruritus were somewhat older and longer on CHD, there was no significant difference either in sex structure or distribution according to primary renal disease. In the group with pruritus there were significantly more anuric patients (43 vs. 22) (p<0.01). The patients with pruritus had a higher rate of sleep disorder (NS), calcium deposits in soft tissues and blood vessels (NS) and clinical neuropathy (p<0.01). Skin changes were found in almost all patients with pruritus (93%), which differed significantly from the patients without pruritus (48%) (p<0.005). The mean value of Kt/V was 1.23+/-0.35 in patients with pruritus, and 1.34+/-0.41 in those without pruritus (NS). Kt/V higher than 1.4 was significantly less frequently recorded in patients with pruritus than in those without pruritus (55%) (p<0.005). The red cell and white cells count, serum hemoglobin, calcium, phosphorus and their products, aminotransferases, bilirubin, alkaline phosphatase and proteins were approximately the same in both groups of patients.

CONCLUSION

The loss of residual renal diuresis, Kt/V below 1.4, presence of calcium deposits and neuropathy were the most common risk factors for the extent of uremic pruritus in our CHD patients.

[Effect of erythropoietin on gonadotropic hormones and sexual function in patients on hemodialysis]

INTRODUCTION

Correction of anemia in haemodialysed patients by recombinant human erythropoetin (R-Hu Epo) has been reported to improve sexual functions and hormonal disturbances. The purpose of this study was to evaluate how levels of sexual hormones and sexual function differ before and during a 12 month R-Hu Epo therapy.

MATERIALS AND METHODS

Thirty six male patients, mean age 47.5 +/- 12.78 and thirty six female patients, mean age 53.0 +/- 10.14, were included in this study. All patients were dialyzed 3 times per week with haemodialysis mean duration of 4.56 +/- 3.84 years. In order to evaluate sexual activities, the questionnaire was presented to all patients. The levels of prolactin, testosterone, FSH, LH were measured at the beginning of the study and every forth month during the study.

RESULTS

During twelve month therapy with Epo, serum hemoglobin significantly increased from 96.0 +/- 13.3 g/dl to 104.0 +/- 17.2 g/dl (p < 0.005), and hematocrit value rose from 0.284 +/- 0.046% to 0.308 +/- 0.052% (p < 0.05). Prolactin was not significantly decreased: at the beginning of the study was 540.3 +/- 302.2 and at the end 537.4 +/- 297.1 microIU/ml. Testosterone concentrations were in normal range in male patients (18.26 +/- 8.61 microIU/ml). There was significant difference in value of LH in female patients which increased from 57.68 +/- 62.58 to 73.79 +/- 68.52 IU/L. Improvement of sexual function was remarkable in female patients. In male patients sexual desire, frequency of sexual intercourse was strengthen after R-Hu epo therapy.

CONCLUSION

Better sexual functions in our patients after treatment with R-Hu Epo did not correlate with hormonal disturbances except changes of LH that increased at the end of the therapy.

[Prevalence and incidence of hepatitis C seroconversion in patients on hemodialysis]

INTRODUCTION

Patients on hemodialysis belong to a high risk group of patients that are exposed to viral hepatitis. The aim of the study was to evaluate the prevalence and incidence of HCV infection seroconversion in this high risk group of patients.

PATIENTS AND METHODS

Patients were followed up from January 1997 until January 2002. During this five-year period, the dialysis population increased. There were 99 patients (58 m/41 f) in January 1997, 43 of them seropositive. Out of 186 patients recorded in January 2002, 44 had anti-HCV antibodies. The following parameters were recorded: sex, age, hemodialysis duration, number of blood transfusions, and hepatitis markers. HCV antibodies were determined by third--generation ELISA method (Behring).

RESULTS

The study included 164 patients (75 f/92 m), mean age 47.2 +/- 4.2 years, and mean hemodialysis duration 6.2 +/- 4.2 years. In January 1997, HCV antibodies were detected in 43/99 patients with a prevalence of 43.51%. During five-year follow-up, the highest prevalence of hepatitis C was 44% in 1998, with an extremely high incidence of 40% (8 patients became seropositive). In the first three years of the follow-up, the number of blood transfusions and duration of hemodialysis were the main risk factors for HCV transmission. The mean length of hemodialysis of seropositive patients was 6.92 +/- 4.23 in seropositive patients and 2.44 +/- 1.82 in seronegative patients (p < 0.001). Anti-HCV positive patients received significantly more blood transfusions (8.2 +/- 4.36) as compared to seronegative patients. Upon the introduction of preventive measures in 2000 and 2001, which included strict disinfection of monitors and working surfaces, connecting anti-HCV positive and anti-HCV negative patients to different machines, and use of erythropoietin, the incidence rate decreased, and in January 2002, it was 11% with a prevalence of 25%.

CONCLUSION

HCV infection is frequent among hemodialysis patients. The number of blood transfusions and duration of hemodialysis as well as sharing the same dialysis machines were the main risk factors of transmission of HCV infection. The use of erythropoietin and preventive measures, along with the use of appropriate protocols and separation of HCV positive from HCV negative patients led to a decrease in the prevalence and incidence of hepatitis C in our hemodialysis population.

[Antiepileptic agents in the treatment of symptomatic epileptic seizures during and after cerebrovascular insult (CVI)]

The epileptic seizures occur as the consequence of THE cerebrovascular insult. The morphologic changes at the brain after cerebrovascular insult are responsible for its occurrence. The pathophysioloogic basis of the late epileptic manifestations (after the second week after CVI) are the epyleptic activities of the morphological brain changes which behave according to the type of the "epileptogene focus". The epileptic seizures which occur during CVI are the result of the moleculary changes which occur in ischemia as the primary, and in haemohagia as secondary ones. The aim of our paper is to see the therapeutic aspects of the early and late epileptic seizures during and after cerebrovascular insult. In the course of the retrospective processed treatment of the patients at our clinic, and in the ten years period (01.01.1989-31.12.1998), we treated 7001 patients with the various types and subtypes of CVI. The incidence of the epileptic seizure moved from 0.65% (1994) till 3.14% (1998). In our sample we had 111 patients with late epileptic seizures, and 56 patients with early epileptic seizures. The early epileptic seizures in most cases were treated by Diazemap intravenously, while in the group of the patients with late seizures, most frequently we applied Fenobarbiton, and later diazepam intravenously. After the seizures and admission at the Clinic and in the future treatment most often we recommended and gave diazemap, phenobarbiton and karabo zepine. The therapeutic effects of the applied therapy were statistically significant. It is significant that there were more patients of the applied therapy statistically significantly. It is significant that there were more patients had no later seizures or of whose the seizures were more rarely (Hi2 = 14.209, n = 2, p < 0.01). On the basis of our research we can conclude that the therapeutic principle of the symptomatic epileptic seizures during and after cerebrovascular insult is the principle of the MONOTHERAPY. On the basis of our material we came to the conclusion that kabazepin optimally antiepileptic for this group of symptomatic epileptic seizures.

[Effect of erythropoietin on thyroid function in patients on hemodialysis]

INTRODUCTION

Chronical renal insufficiency is followed by many endocrinological abnormalities which pathogenesis isn't still enough clarified. The hormone level of thyroid gland is often abnormal. It is well known that use of erythropoietin leeds to an improvement of the various endocrine disorders. The aim of this paper was to evaluate the erythropoetin impact on the thyroid function in patients on haemodialysis.

MATERIALS AND METHODS

This study included patients that were on chronical haemodialysis treatment 4 hours 3 times a week. Acetate or bicarbonate were used as buffers. 32 out of totally 74 patients, received erythropoietin (40-50 IU/kg/HD), and 42 patients did not. FT3, FT4, TSH were taken right before haemodialysis as were albumins, total proteins and hematocrit. FT3 and FT4 were determined by fluorimmunnoassay method, and TSH by immunoradiometric assay (IRMA) method.

RESULTS

Our survey included 74 clinically crithroid patients, 37 males and 37 females, average age 49.3 +/- 12.3 and duration of the haemodialysis 4.34 +/- 2.846. Thyroid Stimulation Hormone (TSH) was high in 10.8% of patients (8/74), FT3 was low in 38% of patients (28/74), and FT4 in 25% of our patients (18/24). The hormone level of the thyroid gland was similar in both groups, so there was no statistically important difference between them. FT3 in group with erythropoietin was 5.21 +/- 0.93, FT4--12.18 +/- 4.84, TSM -2.02 +/- 1.46 mlU/K, while in group without erythropoetin (non-erythropoietin group) references were FT3-4.81 +/- 0.87, FT4-12.49 +/- 1.98 TSH 2.31 +/- 2.08. No significant correlation was found between Hct, albumin, protein and T3, T4 and TSH in group that received erythropoietin, although there was correction of anemia.

CONCLUSION

Our results imply that patients on haemodialysis usually have asymptomatic abnormalities of thyroid gland. The use of erythropoietin did not improve their hormonal status, although correction of anemia was gained.

[Remission of nephrotic syndrome in patients treated with corticosteroids and other immunosuppressive agents]

INTRODUCTION

Glomerular diseases are hybrid group, mostly immunologically related kidney diseases where pathologic changes start in glomerules, but afterwards within their further process they grasp the other kidney structures. The most common clinical manifestation of the primary glomerulonephritis in the adults is nephrotic syndrome. Therefore, this elaboration aims are to estimate the therapy effect onto the different pathohistologic forms of the primary nephrotic syndrome.

MATERIAL AND METHODS

Study has been conducted on 41 patients having the primary nephrotic syndrome, prior having normal kidney function. Different pathohistological forms of NS were verified by percutaneous kidney biopsy. Depending on the pathohistological finding the different therapeutic protocoles were applied. Each of the monitored patients were treated by giving steroids at least six weeks dosing them 2 mg/kg/bw/48 h, but not higher then 130 mg/48 h. In the cases of the patients having the given therapy, it did not lead them to the nephrotic syndrome remission, cyclophosphamid was induced in the dosage of 1.5-2.0 mg/kg/bw/48 h. According to the therapy reaction the patients were divided in three groups: the patients with the complete remission, with partial remission and the patients resistant to the treatment.

THE RESULTS

41 patients have been observed, 28 male and 13 female, aged between 16-69, average 32.3 years old. All patients had normal kidney function, and diseases duration from the moment of the pathohistomorphologic diagnosis had been lasting 0-2 years, from average 6.4 months. According to pathohistological diagnosis the patients were divided into four groups: a) "minimal changes" MCNS (n -11), b) focal--segmental glomerulosclerosis FSGS (n - 10) c) membraneous glomerulonephritis MGN (n-9) d) membranoproliferative MPGN (n-10). The best therapy effect had been resulted within the group with MCNS having 82% cases with the complete remission, while the group with MCNS had reacted the most adversely, 45% were resistant onto the therapy. 18 patients of the total 41 had the complete remission, 14 partial remission, and 9 of them were without remission.

CONCLUSION

The patient having the minimal changes had the best response onto the steroids therapy, while the patients having the expressive proliferative changes did not respond with the complete remission.

[Echocardiographic changes in patients with chronic renal insufficiency on hemodialysis]

Cardiovascular diseases cause death in 40% patients on the chronic haemodialysis program. Our aim was to assess the heart changes in these patients by echocardiography. We have tested 40 patients, but 34 of them accomplished criteria for this study. There were 19 (55.88%) females and 15 (44.12%) males. The average age was 44 years and average duration of haemodialysis treatment was 4.72 years. The research was made with ultrasound device TOSHIBA SSH 65 A SONOLAYER and transducers 3.5 and 2.75 MHz. Twenty patients (58.82%) have had pathological echocardiogram. Ten patients (29.42%) have had conditionally normal echocardiogram while four patients (11.76%) have had completely normal echocardiogram. In patients with pathological echocardiogram, some of the left ventricle hypertrophy forms dominated. Echocardiography is a useful method in morphologic and functional cardiac assessment at the last stage renal disease patients on the chronic haemodialysis program. Using the aforementioned method we are able to select the patients who need intensive cardiac care.