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ABSTRACT: WNT 4 is a secreted glycoprotein that is critical for nephrogenesis during mesenchymal to epithelial transformation. Lately there are some experimental modles witch confirm a role of Wnt 4 during regeneration process in acute renal failure. On the other hand there are some evidence that Wnt 4 plays important role in renal fibrosis during experimental renal injury in rats that provide tubuloinerstitial fibrosis. When will Wnt 4 have a protective role or when will induce fibrosis still is not known and therefore futher studies will be necessary to gain a more precise understanding.
Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 10/2012; 66 Suppl 2:56-8.
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Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 10/2012; 66 Suppl 2:1-3.
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ABSTRACT: The balance and quality of different renal replacement treatment modalities used in the elderly with end-stage renal disease vary between countries depending on economic resources, distribution of renal units, number of specialists, and patterns of reimbursement of both hospitals and physicians. Elderly patients with end-stage renal disease need detailed assessment of medical, psychological, motor, and social factors in order to choose an appropriate renal replacement treatment option. Presence or absence of significant comorbidity is much more important than the chronological age. The choice between hemodialysis and continuous ambulatory peritoneal dialysis is largely dependant on preferences of the local team and the patient. Patients with adequate cardiovascular systems are generally considered to be more suitable for hemodialysis. Hemoglobin should be optimized (Hb between 100 and 120 g/L) in all patients. Poor cardiac status and/or angina will require assessment, medical treatment, and, if necessary, surgical treatment or angioplasty. Transplantation should be considered in all reasonably fit and carefully selected patients older than 65 or even 70 years. Only the permanent shortage of suitable kidneys limits our ability to treat all those who could benefit from this type of treatment. Renal transplant recipients may benefit in terms of both survival and quality of life even if older than 70 years and beyond. Immunosuppressive therapy in elderly patients should be moderate.
Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 10/2012; 66 Suppl 2:22-36.
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ABSTRACT: Heparin-induced thrombocytopenia type II (HIT) is a clinicopathologic syndrome in which one or more clinical events are temporally related to heparin administration and caused by HIT antibodies. There are at least five different types of clinical events that are associated with HIT: thrombocytopenia; thrombosis; skin necrosis at heparin injection site, venous limb gangrene; and an acute systemic reaction that occurs 5-30 min after intravenous bolus of heparin. HIT typically presents 5-14 days after initiation of heparin therapy, later onset is unusual. Heparin is a routine anticoagulant in hemodialysis but administration is different than in surgical and other medical population. Doses are lower and administered every other day, yet hemodialysis patients receive heparin for years. Relationship between dialysis vintage and HIT-antibody positivity has been analyzed in two studies. In national survey of HIT in hemodialysis population of the United Kingdom mean time between starting hemodialysis and development of HIT was 61 days (5-390 days). Japanese authors also found greatest incidence of HIT antibody positivity in patients who were on hemodialysis for less than 1 year, none of patients on hemodialysis for more than 10 years was HIT-antibody positive. We present a case of 70-years old female who developed HIT after 24 years of hemodialysis and exposure to heparin. First 22 years she was receiving unfractionated heparin for anticoagulation during hemodialysis sessions. Afterwards her therapy was changed to low molecular weight heparin. Last 12 years she has tunneled cuffed catheter which was also filled with unfractionated heparin. She had a history of severe renal osteodistrophy and severe aortal valve stenosis, hypothyreosis, thrombosis of both subclavian veins and partial colon resection due to mesenterial artery thrombosis. Her thrombocyte count was low, but despite extensive work-up which included HIT antibody detection, no cause could be identified. She started complaining of flushing, dyspnea and chest pain that developed several minutes after start of hemodialysis and stopped spontaneously during or after hemodialysis. Symptoms were attributed to her heart disease and she was hospitalized for cardiac reevaluation. Thrombosis of right superficial and commune femoral vein was diagnosed as well as further worsening of thrombocytopenia. HIT antibodies were assessed again and they were positive. Anticoagulation during hemodialysis was changed to fondaparinux and catheter filling to citrate. Afterwards symptoms during hemodialysis disappeared and thrombocyte count recovered. HIT type II is a rare but potentially fatal syndrome that can develop years after start of heparin therapy. To our knowledge, this is the patient with longest hemodialysis vintage and newly diagnosed HIT. This is also the first case of patient on hemodialysis that developed HIT in Croatia published to date.
Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 10/2012; 66 Suppl 2:68-71.
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Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 07/2012; 66(3):151-2.
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ABSTRACT: Renal transplantation is the method of choice for renal replacement therapy in the majority of patients. Immunosuppressive drugs may increase the risk of developing malignancies. We present a case of a patient having undergone different renal replacement methods over 25 years. He had good graft function at 12 years of transplantation. Development of spontaneous retroperitoneal hematoma caused by rupture of the native kidney oncocytoma was complicated with sepsis and deterioration of graft function. We emphasize the importance of regular ultrasonography follow-up of native kidney, which is challenging because of fibrous changes.
Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 07/2012; 66(3):251-3.
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ABSTRACT: Renal failure is a rare complication of hereditary coagulopathies. However, when it occurs, it rapidly progresses to a stage that requires replacement of renal function. Major problems include the choice of dialysis method, prevention of complications and supplementation of deficient factor. In hemodialysis, it is challenging to prevent system clotting and avoid bleeding. We present a case of polytraumatized male patient with hemophilia A, who developed compartment syndrome with acute renal failure. Continuous venovenous hemodialysis (CWHD) improved his condition and he recovered his kidney function. However, over the next few days he developed severe sepsis with deterioration of renal function. CWHDF (hemodiafiltration) was restarted. Several large hematomas were found in the abdominal cavity and in the inguinal region, one of them inducing compartment syndrome with leg necrosis. The patient died from cardiorespiratory arrest.
Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 07/2012; 66(3):247-50.
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ABSTRACT: Aging is a natural process that occurs in all tissues and organs resulting in a decreasing functional capacity. Aging of the population results in an increased number of elderly patients who require replacement of renal function. Renal transplantation is the method of choice for this group of patients if they have no contraindications for immunosuppressive therapy. The lack of donors is the main obstacle for renal transplantation. However, the use of organs from elderly donors for transplantation in elderly recipients is an appropriate method of renal replacement therapy in this group of patients.
Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 07/2012; 66(3):203-6.
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ABSTRACT: A 21-year-old female patient was diagnosed with horseshoe kidney at the age of 10. She had been treated with peritoneal dialysis from 2005 to 2009, when she received kidney from a deceased donor. The posttransplant course was complicated by development of Pseudomonas aeruginosa and Candida sepsis. Reduced immunosuppression resulted in acute rejection, which demanded graphtectomy 2 months after transplantation. She restarted peritoneal dialysis for additional 2 years. In March 2011, she received her second transplant with excellent function. Nine months after the transplantation, she developed ascites, with early satiety and vomiting. MSCT revealed severe encapsulating sclerosing peritonitis. Her overall condition deteriorated, so she underwent adhesiolysis with resection of incarcerated terminal ileum. Due to acute allograft rejection, urgent graphtectomy was performed. Currently, she is receiving everolimus and dialysis successfully, with excellent overall status.
Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 07/2012; 66(3):243-6.
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ABSTRACT: Bone morphogenetic proteins (BMPs) are a large group of growth factors. More than 20 members of BMP family have been identified to date. Based on their structural and functional properties, BMPs can be divided into 4 subgroups: BMP 2/4, BMP 5/6/7/8a/8b, BMP 9/10 and BMP 12/13/14. Each BMP has a unique structural feature that differentiates it from all other family members. BMPs take part in different stages of kidney development. For example, BMP-2 inhibits branching morphogenesis in ureteric buds; BMP-4 is expressed in metanephritic mesenchyme along the Wolff canal before kidney development, its expression is also found in the mesenchyme surrounding the ureteric bud before the invasion of the mesenchymal cells in the ureteric stem and induction completion; BMP-7 is the only bone morphogenetic protein that is crucial in kidney development. BMP family members are also included in maintaining normal kidney structure and function. Experimental models have shown that BMP-7 prevents ischemia/reperfusion damage. Expression of BMP-7 is reduced in the samples of kidney tissue with diabetic nephropathy. Also, BMP-7 mRNA is reduced in clear cell kidney carcinomas, indicating its protective effects in maintaining normal kidney structure and function. Bone morphogenetic proteins are some of the key players in regulating normal kidney development, but their role also extends into maintaining normal kidney structure and function.
Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 07/2012; 66(3):207-13.
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ABSTRACT: Therapeutic plasma exchange (TPE) is a well-established therapeutic procedure commonly used in many neurologic immune-mediated disorders. It is thought that the beneficial effects of TPE occur through elimination of pathognomonic autoantibodies, immune complexes, inflammatory mediators, complement components and cytokines, which play a crucial role in many kinds of neurologic autoimmune disease. In various neurologic disorders, randomized controlled studies have demonstrated the efficacy of TPE (e.g., in acute inflammatory demyelinating polyneuropathy (Guillain-Barré syndrome), chronic inflammatory demyelinating polyradiculoneuropathy, myasthenia gravis and paraproteinemic polyneuropathies). For these disorders, TPE is accepted as first-line therapy, either as a primary standalone treatment or in conjunction with other modes of treatment. Although widely used, the potential benefit of TPE in the treatment of acute disseminated encephalomyelitis, chronic focal encephalitis (Rasmussen's encephalitis), Lambert-Eaton myasthenic syndrome, multiple sclerosis and neuromyelitis optica (Devic's disease) is less clear. For these disorders, TPE is accepted as second-line therapy, either as a standalone treatment or in conjunction with other modes of treatment.
Acta clinica Croatica 03/2012; 51(1):137-53. · 0.25 Impact Factor
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ABSTRACT: A 68-year-old Caucasian woman was admitted to the Department for construction of vascular access for dialysis after thrombosis of arteriovenous fistula. Temporary dialysis catheter was inserted in the left internal jugular vein while she had permanent pacemaker implanted on the right thoracic side. The patient signalized pain in the left breast. Postprocedural chest x-ray revealed that the catheter was malpositioned in the right internal mammary vein. The catheter was immediately pulled out and temporary catheter was inserted in the left femoral vein. Malposition of central venous catheter into small tributaries of central vein is a rare complication which can be hazardous and needs to be quickly recognized.
Acta clinica Croatica 12/2011; 50(4):623-6. · 0.25 Impact Factor
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ABSTRACT: Varicella zoster virus reactivation often occurs in the setting of impaired immunity, which is generally present in patients with end-stage renal disease (ESRD). Therapy for variceIla zoster virus infection is well established. However, it is often been forgotten that acyclovir dosage should be adjusted to renal function. We point to the problem encountered in clinical practice when ESRD patient presents with cutaneous herpes zoster and neurological symptoms. Clinical findings alone may prove inadequate to determine whether neurological deficit is caused by infection of the central nervous system or is a consequence of acyclovir induced neurotoxicity.
Acta clinica Croatica 12/2011; 50(4):549-52. · 0.25 Impact Factor
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ABSTRACT: Patients with chronic kidney disease (CKD) and specially end-stage renal disease (ESRD) have markedly advanced vascular disease when compared to the general population. In particular, several authors have reported more severe atherosclerotic disease of the carotid arteries among ESRD patients than in subjects with normal renal function. This accelerated disease of the cerebral vasculature could increase the risk of ischemic stroke in these patients. Additionally, ESRD is associated with hypertension, a bleeding diathesis, and the routine administration of heparin during hemodialysis, which could increase the risk of hemorrhagic stroke. Dialytic support, including both hemodialysis (HD) and peritoneal dialysis, have been shown to be risk factors for stroke. No studies have assessed stroke risk in renal transplant recipients. Although there are some epidemiologic data for stroke in patients with CKD, there are fewer data for stroke treatment in patients with CKD. In primary and secondary prevention of stroke even in the CKD patients, it has been well established that improved outcomes occur by correcting reversible risk factors, including treating hypertension, secondary hyperparathyroidisam, anemia, dyslipidemia, coagulation abnormalities, malnutrition, inflammation, controlling diabetes, and cardiac disease.
Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 10/2011; 65 Suppl 3:67-77.
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ABSTRACT: The link between the kidney and hypertension has been considered a villain-victim relationship because of the potential two-way causality between high blood pressure (BP) and chronic kidney disease (CKD). Arterial hypertension (AH) per se, but also together with diabetes mellitus, is the most important cause of CKD and end-stage renal disease (ESRD) in the developed world. Pathophysiologicaly, the increment in systemic BP leads to the rise in glomerular pressure. Glomerular hypertension results in glomerular capillary wall stretch, endothelial damage and a rise in protein glomerular filtration. These processes, in turn, cause changes of mesangial and proximal tubular cells, ultimately resulting in the replacement of functional by non-functional connective tissue and the development of fibrosis. One of the most important factors in the progression of CKD is activation of the renin-angiotensin system (RAS). Its effect is not only elevated BP, but also the promotion of cell proliferation, inflammation and matrix accumulation. The terms that clinicians use to identify renal damage associated with hypertension are nephrosclerosis, benign nephrosclerosis, hypertensive kidney disease, or nephroangiosclerosis. Many studies, first in experimental animals and later in humans, have shown that the lowering of BP (and proteinuria) is associated with a slower progression of CKD. It seems that angiotensin-converting enzyme inhibitors (ACEI's) are more renoprotective than other antihypertensives (the protection beyond the antihypertensive effect), although some studies have also confirmed a comparatively beneficial effect of non-dihydropiridine calcium channel blockers (CCBs) and angiotensin II receptor blockers (ARBs). Moreover, it seems that a combination of antihypertensives (e.g. ACEI, CCB, and ARB) has a more effective action than either of the drugs alone. The effects depend first on the degree of BP reduction. The strict BP control has been considered the basis of therapy for slowing renal deterioration.
Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 10/2011; 65 Suppl 3:78-84.
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ABSTRACT: Cardiovascular diseases and cardiac complications are the major causes of death in patients with chronic kidney disease (CKD). Recently, even a modest degree of impaired kidney function (i.e. low estimated glomerular filtration rate or albuminuria) has been recognized as a powerful cardiovascular risk factor, with a predictive value comparable to that of the classical cardiovascular risk factors. The risk of acute myocardial infarction, angina pectoris, or pulmonary edema associated with left ventricular failure is as high as 10% per year, and the incidence of sudden cardiac death, congestive heart failure. ischemic heart disease, and complex ventricular arrhythmias has been reported to be 9%, 10%, 17% to 31%, and 18%, respectively. Recently, cardiology and nephrology experts proposed that evaluation of renal function should be part of the work-up of patients with cardiovascular disease. All patients with kidney disease should be screened for evidence of cardiovascular disease. Patients with CKD need to be managed from cardiological diseases like the other patients from general population (including percutaneous coronary interventions, and cardiovascular surgery procedures). Some risks of treatment, such as bleeding and technical complications, are certainly more frequent in renal patients, but, overall, cardiologists should treat renal patients with the same vigor as nonrenal patients. There is very important to exchange ideas and informations between cardiologists and nephrologists. It is time to make departmental barriers more permeable and to motivate cardiologists to think more renal' and nephrologists to think more "cardial".
Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 10/2011; 65 Suppl 3:85-9.
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ABSTRACT: The aim of the study was to assess the incidence and etiology of repeated bladder outlet obstruction (BOO) after kidney transplantation and to analyze the results of transurethral incision of the prostate/transurethral resection of the prostate (TUIP/TURP) in the early period after kidney transplantation. The study included 24 male patients having undergone renal transplantation and early transurethral surgery for BOO in our institution between 2005 and 2011. TUIP or TURP was performed depending on the etiology of BOO. The indications for transurethral surgery were repeated urinary retention despite therapeutic attempts with alpha-receptor antagonists, or repeated residual urine with renal transplant dysfunction and/or consequent urinary tract infection. Preoperative assessment included past medical history, clinical examination, PSA, volume of residual urine estimated with ultrasound, and urinary culture. Among 345 male patients having undergone renal transplantation, repeated BOO was noted in 24 patients. TUIP was performed in 19 and TURP in five patients. The mean age of our patients was 52 (range, 33-73) years and the mean time on dialysis 7.43 years (range, 4 months to 25 years). The procedure was performed on the mean of day 16 (range, 14-29) after transplantation and urethral catheter was removed on the mean of day 3.3 (range, 2-9) after the procedure. The etiology of BOO was bladder neck contracture in nine and benign prostatic hyperplasia in 15 patients. In all patients, surgical procedures were performed without any complication. Restoration of urinary bladder function was complete in all patients. In conclusion, early transurethral treatment of repeated BOO is a safe procedure with excellent results following renal transplantation.
Acta clinica Croatica 09/2011; 50(3):381-4. · 0.25 Impact Factor
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ABSTRACT: Health-related quality of life (HRQoL) among hemodialysis (HD) patients recently became a nephrologist's focus of interest. HRQoL is an important predictor of outcome in HD patients and need to be regularly assessed. The aim of the present study was to compare the HRQoL of chronic HD patients with general population and to analyze influencing sociodemographic and clinical factors. We included 255 prevalent HD patients from four dialysis centers. HRQoL was measured with The Medical Outcomes Study Short Form 36 Health Survey Questionnaire (SF-36). This data were compared with control group (N = 132) from the general Croatian population. Comparisons of SF-36 scale scores of HD patients regarding demographic and clinical factors (age, gender, education level, dialysis vintage and diabetes) were also performed and analyzed with a multivariate regression analysis. HRQoL in prevalent HD patients was relatively low (mean Physical Component Summary, PCS = 33.7, mean Mental Component Summary, MCS = 43.0) and was lower compared to the control group from the general population in all HRQoL domains, PCS and MCS scores. Almost 53% of the HD patients had the critical score PCS < 43 + MCS < 51 as the predictor of death and hospitalization. Better HRQoL was revealed in the patients < 65 years old, males, patients with higher educational level and in the patients on maintenance HD less than one year. Age was the only statistically significant predictor of PCS and MCS. Developments of HD technology, treatment of comorbidities, continuous patients' education, social and psychological support and use of other renal replacement modalities, especially kidney transplantation, may improve the HRQoL in these patients.
Collegium antropologicum 09/2011; 35(3):687-93. · 0.61 Impact Factor
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ABSTRACT: The principal iron storage protein is ferritin, which is primarily present in cytoplasm. The most common cause of hyperferritinemia is iron overload, which is either primary or secondary. Hyperferritinemia is commonly found in patients with chronic kidney disease regardless of their hemoglobin level and is often considered to be related to chronic inflammatory status as well as malnutrition and neoplasias. We present a case of a kidney transplant patient that developed severe hyperferritinemia associated with liver dysfunction. In our patient, high hyperferritinemia was detected a year after transplantation, when she had no signs of inflammation. Malignancies, chronic viral hepatitis, and chronic inflammatory disease were also excluded as the causes of hyperferritinemia. Since high serum ferritin levels were combined with increased transferrin saturation and mildly elevated plasma iron concentrations, we presume that the most probable cause of hyperferritinemia in our patient was iron overload.
Acta clinica Croatica 06/2011; 50(2):245-8. · 0.25 Impact Factor
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ABSTRACT: The major targets of novel immunosuppressive protocols are decreased toxicity and improved graft and patient survival. Over the last decade, several drugs have been demonstrated to have potential beneficial effect in transplantation. Most of these agents are currently in phase II or III of clinical studies.
Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 01/2011; 65(4):361-4.
