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Renal osteodistrophy is one of the most common complications of chronic renal failure and one of the risk factors of increased mortality among chronic haemodialysis patients. Aim of the study was to evaluate frequency of renal osteodistrophy in our dialysis population and to identify demographic, clinical and laboratory parameters associated with poor phosphorus and PTH control. Research included 100 patients on chronic haemodialysis program three times weekly for four hours with programmed ultrafiltration. Average age was 52,6 years and there were 55 males and 45 females in total, with average haemodialysis length of six years. Average calcium value was 2,19±0,190 mmol/L, 10% of patients had hypercalcaemia Ca>2,4 mmol/L. 58 patients (60,5%) involved in study had hyperphosphataemia and calcium-phosphorus product >4,4 mmol2/L2. Secondary hyperparathyroidism was found in 64 patients (64%), respectively to PTH>300 pg/ml. There was no significant correlation between patients' age, haemodialysis length, levels of PTH and phosphorus in tested dialysis population. Parathyreoidectomy was performed in 10 patients (16%), with significant lowering of PTH (959,7 pg/ml vs. 163,3 pg/ml). Conclusions: Our study has shown poorly controlled levels of phosphate in blood. In our dialysis population 60,5% of patients had P04 >1,8 mmol/L and 49% of the patients had calcium-phosphorus product >4,4 mmol2/L2, with the levels of PTH>300pg/ml. In 10% of our patients parathireidectomya was done because of SHP. Results show the need for intensive education of patients in restricting phosphorus intake as a preventive measure in reducing bone diseases in patients on haemodialysis. Multidisciplinary approach in treating secondary hyperparathyroidism includes doctor, nurse, dietitian, patient and his/her family, because renal osteodistrophy relates to increased morbidity and mortality of haemodialysis patients. [ABSTRACT FROM AUTHOR]

In BiH, brucellosis (a disease that is transmitted from animals to people in a group of zoonoses) has become endemic disease. Epidemic has not yet been published, although in the past ten years in the constantly growing number of applicants cases. Nearly a thousand patients were reported in 2008. Brucellosis in hemodialysis is described sporadically. We will show the case in our clinic patient who was infected with brucellosis in 2008. In the period June / July 2008 after positive hemocultures series patient was hospitalized at the Clinic for Infectious Diseases due to septicemia and persistant symptoms in the form of malaise, general weakness, arthritis, subfebrility and loss of weight during the last three months. During the first HD treatment of febrile to 39 C, the first series hemoculture was done. B.mellitensis was isolated during the first hemolcultures. On the Clinic for Infectious Diseases the patient was examined and treated according to the protocol of treatment of brucellosis, with some modified therapy for haemodialysis patients.After conducted therapy culturally negative, not febrile patient was dismissed with recommendations for monthly control , laboratory findings and echography of gluteal region, after gluteal abscessus incurred due to the antibiotic therapy applied intramuscularly. [ABSTRACT FROM AUTHOR]

The aim of this paper is to give a cross section through the etiology, type of seizures and outcome of epileptic seizures at the Neurology Clinic, Clinical Center University of Sarajevo. The material for our paper comprised 49 patients with the epileptic status, treated at the Clinic from January 1 1997 until October 21, 2004. A specially designed questionnaire with all relevant parameters was used. There were 13105 patients in total who were treated at the Clinic during this period. 0.38% had epileptic status. There were 20 males (mean age 47 years), 25 females (mean age 53.83% years). The majority of patients were over 60. Etiologically, the majority of symptomatologic seizures happened after stroke (42.3%). This group included significantly more females. 60% of patients had partial seizures with or without generalization. The most frequently used medication to resolve epileptic status was diazepam (58%). In fourteen patients (28.75%) the epileptic status ended lethally; 46.63% recovered. [ABSTRACT FROM AUTHOR]

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.

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.

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.

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.

Unlabelled: 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.

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.

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.

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.

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.

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.

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.