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Citrates share both metabolic and excretory role. Through Krebs-cycle conversion they stimulate blood alkalization with biochemical-hormonal effects depending from the accompanying cation. The excretory function covers inhibition of calcium oxalate (COM) and uric acid (UA) aggregation in urine, reduction of calciuria. Citriaturia depends on acid-base equilibrium, diet, accompanying diseases and their treatment. Hypocitriaturia is defined as excretion of less than 320 mg/24h. It is found in tubular acidosis t.1, in 76-87% cases of calcium stones, in 40% of UA stone disease, in 30% cases of kidney stones with osteopenia. Potassium citrate (K3Cit) reduces urinary COM saturation, has good citriaturic effect. K3Cit increases effectiveness of thiazide treatment of calcium stone disease with osteopenia. In metabolic syndrome COM and UA saturation raise much more than cytriaturia. A metabolic acidosis in t.2 diabetes (DM2) induces hypocytriaturia and raises a risk of UA stone disease. Growing-up body mass index reduces citriaturic effect of K3Cit. In DM2 K3Cit reduces stone morbidity, reverses negative base equilibrium and increases insulin sensitivity. High K3Cit doses increase general lumbar bone mass and reduce bone resorption activity. In chronic interstitial nephropathies K3Cit slow down GFR decline.///Slow releasing formulas of K3Cit and other citrates in accordance to precise indications should be elements of therapeutic regimen of calcium (i.e.: COM) or UA stone diseases, metabolic syndrome, osteopenia and chronic (interstitial) nephropathies. Profits are limited by the hydration status of patient and his/her motivation to long lasting treatment. The interdisciplinary usefulness of K3Cit may improve cost/effect ratio of treatment. [ABSTRACT FROM AUTHOR]

Diabetics with stage V chronic kidney disease (CKD) on hemodialysis (HD) are considered as "difficult patients", because of problems with creation of the vascular access. There is controversy regarding the results and recommendations for preparation of the vascular access in these patients. The aim of this retrospective study was to evaluate the results of creating different types of arteriovenous fistula (AVFs) in consecutive series of patients starting dialysis treatment. The analysis was performed in 741 patients (385 females and 356 males), average age 61.4±7 years, who started dialysis treatment in our department between January 2005 and December 2012. Native AVFs were created in all patients. No patients received an AVF requiring synthetic graft material. The number of patients with diabetic nephropathy was 166 (22.4%). Among them, 30 (18%) had type 1 diabetes and 136 (82%) type 2. In this group the occurrence of calcification in the forearm artery was estimated on the basis of physical examination, Allan's test, Doppler ultrasound and forearm X-ray. In a subgroup of patients with atherosclerotic changes in the arterial system the frequency of failed AVFs was analyzed. These results were compared with the group without diabetes. The number of procedures necessary for successfu AVF creation and type of access was counted in both groups. The assessment of the procedure frequency and AVF location in diabetic and in non-diabetic patients was made by χ² test with Yates correction. In the group of 166 patients with diabetes, in 100 cases (60%) atherosclerotic changes in forearm arteries were observed. In a subgroup of 30 patients with type 1 diabetes atherosclerosis was observed in 17 adults (57%). In this subgroup creation of a suitable forearm AVF in the first procedure in 9 patients was possible and in the other 8 cases the atherosclerotic changes necessitated repeated procedures and were an important obstacle to create the AVF. In the subgroup of 136 patients with type 2 diabetes, atherosclerosis in the forearm artery was observed in 83 cases (61%). In this subgroup the creation of a native AVF was possible in 40 patients during the first procedure and in 43 cases additional intervention was needed, but only in 8 cases was atherosclerosis the cause of fistula failure. Generally, among 166 patients only in 16 cases (10%) did atherosclerosis present an important obstacle for AVF creation, but the number of necessary procedures to create one functioning AVF was significantly greater in this population (2 v 2.7, p=0.0001). A functioning AVF in patients with diabetes was found significantly frequently in the arm localization in comparison to non-diabetic patients (4.3 v 2%, p=0.0478). Atherosclerotic changes in forearm arteries in diabetic patients appear in 60% of hemodialysis patients and make it difficult to create an AVF only in 10% of diabetic patients, but it is possible to create a native AVF in 90% of diabetic patients, although this requires more procedures. In patients with diabetes, AVF in the wrist region should be preferred.

Vascular access is one of the most important problems of hemodialysis therapy. It is known that an arteriovenous fisutla provides the best vascular access, but its creation is not always possible. Other solutions, such as the insertion of a central venous catheter, are then required. Adequate protection of such catheters by interdialytic fill with locking solution affects the frequency of hemodialysis-related complications. The most widespread catheter locking solution is heparin. Sodium citrate is being used more frequent recently. Available data indicate that hemorrhage is 11.9 times more frequent if the catheter locking solution is 5000 IU/ml heparin than if 4% sodium citrate or 1000 IU/ml heparin is used. Other data indicate that the frequency of infection is statistically decreased when 30% sodium citrate is used to fill the catheter instead of 5000 IU/ml heparin. Analogous data on 46.7% sodium citrate are not consistent. It seems that the use of 4% sodium citrate instead of 5000 IU/ml heparin does not decrease the frequency of infections. Numerous studies indicate that sodium citrate at various concentrations exerts a positive influence on catheter function. However, not all data are in accord. The spill of sodium citrate from the catheter to the systemic circulation is connected with a risk of adverse events. It may be dangerous if the citrate concentration is 46.7%. However, adequate filling of the catheter should prevent such events. Available data indicate that filling of the catheter with a solution of citrate of a concentration of no more than 30% should be safe. Data on 46.7% citrate are not conclusive, so precautions should be taken.

Peritoneal dialysis is an alternative to hemodialysis in the treatment of patients with end-stage renal disease. Long-term use of peritoneal dialysis is limited by progressive alterations in the peritoneal membrane. The pathological changes in the peritoneum are due to the exposure to traditional nonphysiological peritoneal dialysis fluids that have low pH, high glucose and glucose degradation product content, and high molarity. Repeated episodes of bacterial peritonitis are another cause of peritoneal membrane damage. The characteristic features of peritoneal alterations include peritoneal fibrosis and morphologic changes in the peritoneal microvasculature with the accumulation of extracellular matrix in the submesothelial area and loss of mesothelial cells.These changes in the peritoneal membrane cause ultrafiltration failure and loss of dialysis efficacy. The pathogenesis of the peritoneal membrane damage is very complicated and understanding the processes involved in these alterations will be crucial in improving treatment with peritoneal dialysis. Some points of view on fibrosis of peritoneal membrane in patients undergoing peritoneal dialysis are presented here.

A sedentary lifestyle is one of the main causes of low physical capacity and an independent risk factor for death in patients with end-stage renal disease (ESRD) undergoing hemodialysis (HD). The physical capacity of ESRD patients is 60% of an age-matched population with normal kidney function. Although muscular dysfunction is of crucial significance in low physical capacity, its etiology is more complex. The influence of uremic toxins, vitamin D3 deficiency, hyperparathyroidism, anemia, insulin resistance, androgen deficiency, mitochondrial dysfunction, malnutrition, inflammation, and cachexia are all taken into consideration. Physical rehabilitation improves physical proficiency, the performance of daily activities, and quality of life. In this review possible methods of rehabilitation and their advantages, disadvantages, and possible complications are presented.