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Transplantacija bubrega značajno poboljšava kvalitetu, ali i očekivano trajanje života bolesnika. Veliki nesrazmjer između broja dostupnih i potrebnih organa produljuje vrijeme čekanja na transplantaciju. Visoka smrtnost u populaciji bolesnika na hemodijalizi uz prihvatljive ishode transplantacije bubrega od darovatelja po proširenim kriterijima rezultirali su sve češćim transplantacijama organa od starijih darovatelja. Prikazujemo slučaj transplantacije bubrega 83-godišnjeg darovatelja primatelju starom 72 godine. Odgovarajuća priprema darovatelja nakon moždane smrti u jedinici intenzivnog liječenja, preimplantacijska biopsija i kratko vrijeme hladne ishemije bili su ključ za procjenu prihvaćanja organa za transplantaciju i rezultirali su primarnom funkcijom presatka. Primatelj starije životne dobi bez značajnijih pridruženih bolesti, kratko liječenje dijalizom uz odgovarajuće postoperativno praćenje bolesnika i imunosupresivne terapije rezultirali su brzim oporavkom bolesnika bez intraoperativnih i ranih postoperativnih komplikacija te kratkim trajanjem hospitalizacije., Kidney transplantation ensures not only the improvement of the patient’s quality of life but also extends life expectancy. A significant disproportion between the numbers of available and needed organs for transplantation has led to prolonged wait time for a kidney transplant. Since mortality rates for hemodialysis patients are manifold higher when compared to general population of the same age, organs from older donors are increasingly being accepted. We report the case of kidney transplantation in a 72-year-old recipient who received kidney from an 83-year-old deceased donor. Proper care of deceased donor in the intensive care unit, preimplantation biopsy and short cold ischemia time were crucial for organ acceptance and resulted in immediate graft function. Adequately prepared older recipient, with short period on hemodialysis, appropriate postoperative monitoring and immunosuppressive therapy resulted in quick recovery of the patient, without intraoperative or early postoperative complications, and a short inpatient stay.

Breast cancer is the most common neoplasm and the fi fth cause of death among females. The etiology and pathogenesis of this malignancy are multifactorial. The occurrence of neoplasms in solid organ recipients treated with immunosuppressive drugs is 2 to 3 times higher than in the general population. Females with kidney transplants are also in the at-risk population. The aim of this article is to review recent literature on immunosuppression and the effect it has on breast cancer prevalence in kidney transplant recipients; to discuss the proposed pathologic mechanisms of breast cancer owing to concurrent immunosuppressive treatments; and to review breast cancer screening recommendations for kidney transplant recipients. To attain relevant literature, we conducted literature search using PubMed databases, see PRISMA Diagram (Figure 1). The following MeSH Terms were used in the search: “breast cancer”; “risk factors”; “cancer screening”; “kidney transplantation”; "immunosuppression”; and “cancer”. We reviewed a total of 409 articles after having applied exclusion criteria. These articles included randomized controlled trials, reviews, and systematic reviews. Importantly, we also utilized references from other review/primary research articles to attain additional relevant information previously not captured from our initial research. Breast cancer is the third leading malignant cause of death in Croatia, preceding lung and colorectal carcinoma. Generally, breast cancer develops due to a combination of hormonal, genetic and age-related factors. However, a signifi cant risk factor and critical motif in carcinogenesis is immunosuppression. Carcinogenic environmental factors, disturbed function of the immune system due to chronic use of immunosuppressive drugs, and genetic make-up infl uence the process of carcinogenesis in transplant patients. Immunosuppression reduces immunosurveillance that predisposes patients to increased viral oncogenesis and general carcinogenesis causing cancer to be the second most frequent cause of death in post-kidney transplant patients. Particularly, kidney transplant recipients are prone to carcinogenesis due to lifelong immunosuppressive regimens. Importantly, differences in cancer risk depend on the kidney recipient's cancer type. Certain malignancies, such as breast cancer, are not affected by immunosuppression as their relative risk is comparable to that of the general population. Due to the limited number of articles addressing post-transplant breast cancer (PTBC), we present here a comprehensive review of the topic, current understanding of its pathophysiology, and the role of screening in its diagnosis, treatment and overall management. The risk of developing PTBC in kidney transplant recipients is not increased when compared to the general population. It appears that the development of breast cancer in kidney transplant recipients is unrelated to transplantation immunosuppressive regimen and is mostly associated with aging and independent risk factors that can lead by themselves to kidney transplantation such as diabetes mellitus. Due to screening programs, PTBC is usually diagnosed early. However, if PTBC is diagnosed in advanced grades, it is associated with signifi cantly increased mortality risk. Therefore, it is recommended that patients be screened periodically compared to their age- and gender-matched counterparts from the general population. Notably, this is an area of ongoing research and requires further investigation. Due to the rarity of PTBC and scarce resources on the topic, most guidelines are extrapolated from the general population and are not corresponding to the minimal risk of developing PTBC. Similarly, treatment guidelines are inferred from the general population and do not account for the particular considerations in these patients such as graft survival, graft rejection, nephrotoxic chemotherapeutic drugs, and concurrent administration of immunosuppression. It is worth mentioning that the heterogeneity of results discussed in our review is perhaps due to differing immunosuppressive regimens, type of organ transplantation, concomitant comorbidities, length of follow-up, and screening protocols used. To draw clear guidelines tailored for this population, further investigation into the mechanisms of disease is warranted, with prolonged follow-up time in patients on differing immunosuppressive regimens to allow for subsequent comparison., Rak dojke najčešća je novotvorina i peti uzrok smrti žena. Etiologija i patogeneza ovoga zloćudnog tumora su multifaktorske. Pojava neoplazma u primatelja solidnih organa liječenih imunosupresivnim lijekovima je 2 do 3 puta veća nego u općoj populaciji. U rizičnoj populaciji su i žene s presađenim bubregom. Cilj ovoga pregleda literature je istražiti povezanost pojavnosti karcinoma dojke u primatelja bubrežnog presatka i imunosupresivnih režima, opisati njihovu ulogu u tom procesu te istražiti trenutne preporuke probira za rano otkrivanje karcinoma dojke u toj populaciji. Kako bismo pristupili potrebnoj literaturi koristili smo bazu podataka PubMed-a. MeSH pojmovi uporabljeni za pretragu baze literature su bili: “breast cancer”; “risk factors”; “cancer screening”; “kidney transplantation”; “immunosuppression” i “cancer”. Nakon primjene kriterija isključenja ukupno je pregledano 409 članaka. Članci su uključivali randomizirana kontrolna istraživanja, preglede i sustavne preglede literature. Uporabljene su i reference s drugih pregleda literature kako bi se pribavile dodatne relevantne informacije koje potencijalno nisu bile dohvaćene pri inicijalnoj pretrazi. Karcinom dojke najdijagnosticiraniji je karcinom i ujedno peti vodeći uzrok smrti žena u svijetu. Karcinom dojke je na trećem mjestu liste malignih uzročnika smrti, odmah iza karcinoma pluća i kolorektalnog karcinoma. Karcinom dojke je uzrokovan kombinacijom hormonskih i genetskih čimbenika te čimbenika vezanih uz starenje. Značajan čimbenik procesa kancerogeneze je imunosupresija, što potvrđuje dva do tri puta češća pojavnost malignih bolesti u populaciji primatelja transplantiranih organa. Kronična imunosupresivna terapija, okolišni čimbenici (izlaganje sunčevu zračenju) i genetički zapisi pojedinaca utječu na proces razvoja malignih bolesti u primatelja transplantiranih organa. Imunosupresivni lijekovi smanjuju imuni nadzor, što pospješuje proces virusne onkogeneze te opće karcinogeneze. Primatelji bubrežnog presatka skloniji su razvoju karcinoma upravo zbog doživotne imunosupresivne terapije pa je karcinom drugi uzročnik smrtnosti kod te populacije. Od iznimne važnosti je spomenuti da razlike u procijenjenom riziku razvoja karcinoma ovise upravo o vrsti karcinoma. Pokazalo se da imunosupresija ne utječe na određene maligne bolesti poput karcinoma dojke, jer je njihov relativni rizik usporediv s onim u općoj populaciji. Zbog ograničenog broja radova koji se bave tematikom karcinoma dojke nakon transplantacije bubrega ovom prigodom predstavljamo sveobuhvatan pregled dosadašnje literature, trenutnog razumijevanja patofi ziologije bolesti, uloge probira u- njenoj dijagnozi i liječenju. Opsežnim pregledom literature došli smo do zaključka da rizik razvoja karcinoma dojke nakon transplantacije u primatelja bubrežnog presatka nije povećan u usporedbi s općom populacijom. Iz pregledanih radova proizlazi zaključak da razvoj karcinoma dojke u primatelja bubrežnog presatka nije povezan s post-transplantacijskim imunosupresivnim režimom te je uglavnom povezan sa starenjem i neovisnim čimbenicima rizika koji sami po sebi mogu dovesti do transplantacije bubrega, kao što je dijabetes melitus. Zbog programa probira za rano otkrivanje karcinoma post-transplantacijski karcinom dojke obično se dijagnosticira rano. Međutim, ako ga se dijagnosticira u uznapredovalim stadijima povezan je sa značajno lošijim ishodom i povećanom razinom smrtnosti u usporedbi s općom populacijom. Preporuka je da se probir bolesnika provodi zajedno s općom populacijom koja odgovara dobi i spolu bolesnika s presatkom, uz naglasak na individualni pristup svakom bolesniku. Iznimno je važno napomenuti da je ovo područje medicine koje zahtijeva daljnje istraživanje. Zbog rijetkosti post-transplantacijskog karcinoma dojke i oskudnih resursa na tu tematiku većina smjernica ekstrapolirana je iz opće populacije i ne odgovara minimalnom riziku od razvoja te bolesti. Slično tome, smjernice za liječenje izvedene su iz podataka opće populacije i ne uzimaju u obzir posebna razmatranja kod populacije pacijenata s bubrežnim presatkom kao: održavanje funkcionalnog presatka, odbacivanje presatka, nefrotoksične kemoterapijske lijekove i istodobnu primjenu imunosupresivnih lijekova. Potrebno je spomenuti da je heterogenost rezultata o kojima se raspravlja u našem pregledu literature posljedica različitih vrsta imunosupresivnih režima, transplantiranih organa, pridruženih bolesti, duljine praćenja bolesnika i programa probira. Kako bi se defi nirale jasne smjernice prilagođene ovoj populaciji, potrebno je daljnje istraživanje mehanizama nastanka bolesti, uz produljeno vrijeme praćenja pacijenata na različitim imunosupresivnim režimima kako bi se omogućila naknadna usporedba.

Delirium can manifest as a neurological complication after COVID-19 in immunocompromised patients. To date, several reports have described delirium associated with SARS-COV-2 infection in older patients. Herein we present a case of a younger adult with a kidney transplant, who became disoriented, confused, and restless after acute COVID-19 and was admitted to the psychiatric ward for delirium management. He recovered and had a stable allograft function in follow-up., Delirij se može manifestirati kao neurološka komplikacija nakon COVID-19 kod imunokompromitiranih bolesnika. Do danas je u nekoliko istraživanja opisan delirij u starijih osoba nakon infekcije COVID-19. Prikazali smo mlađeg bolesnika s presatkom bubrega koji je nakon preboljene infekcije SARS-CoV-2 postao dezorijentiran, zbunjen, nemiran i agresivan te je primljen na psihijatrijski odjel zbog liječenja delirija. Stanje bolesnika se postupno popravilo, a funkcija presatka bubrega ostala je stabilna.

Anemija kronične bubrežne bolesti (KBB) je multifaktorska i uključuje poremećaj željeza (apsolutni ili funkcionalni manjak), nedostatnu proizvodnju eritropoietina, gubitak krvi, stanje kronične infl amacije s povišenim hepcidinom i čimbenike vezane uz prisutno kronično stanje hipoksije (hypoxia-inducible factor, HIF). Temelj današnjeg liječenja anemije KBB čini primjena eritropoietina uz liječenje preparatima željeza, no više razine hemoglobina (Hb >130 g/L) povezane su s povišenim rizikom neželjenih kardiovaskularnih i cerebrovaskularnih događaja, trombozama vaskularnih pristupa kao i činjenici progresije u završni stadij KBB-a i ukupne smrtnosti. Liječenje anemije u bolesnika s KBB temelji se na postojećim smjernicama KDIGO (Kidney Disease: Improving Global Outcomes) iz 2012. godine. Hrvatske smjernice za liječenje anemije KBB-a objavljene su 2014. godine. Od tada do danas, temeljem brojnih istraživanja i kliničkom praksom došlo je do novih izmjena u suvremenom shvaćanju liječenja anemije KBB-a. Hipoksija-inducibilni faktori-inhibitori domene prolil hidroksilaze (HIF-PHI) nova su klasa oralno primijenjenih lijekova za liječenje anemije KBB-a, aktivirajući put osjetljivosti na razinu kisika HIF-a. Dokazana je njihova učinkovitost u prekliničkim i kliničkim studijama u korekciji i održavanju razine Hb u predijaliznih/dijaliznih bolesnika smanjujući razinu hepcidina i modulirajući metabolizam željeza, a smatra se da imaju i učinke izvan eritropoeze. Slijedom navedenog, ptikazujemo osvrt i preporuke za liječenje anemije KBB-a prilagođene trenutnim spoznajama 2021. godine., Multiple factors are involved in the pathogenesis of anemia in chronic kidney disease (CKD), including iron defi ciency, inadequate production of erythropoietin (Epo), hepcidin, and hypoxia-inducible factors (HIFs). Renal anemia is the result of CKD and deteriorates with disease progression. Erythropoiesis-stimulating agents administered either subcutaneously (sc.) or intravenously (iv.), along with iron therapy, are currently the cornerstones for treating anemia, but higher hemoglobin (Hb >130 g/L) increases the risk of cardiovascular and cerebrovascular events, vascular access thrombosis, progression to end-stage renal disease, and overall mortality. Treatment of anemia in patients with CKD is based on current guidelines. The latest version of Croatian guidelines for anemia was published in 2014. Since then, on the basis of research and clinical practice, there have been numerous changes in modern understanding the treatment of anemia in CKD. Hypoxia-inducible factor-prolyl hydroxylase domain inhibitors (HIF-PHIs) are a new class of orally administered drugs for the treatment of anemia in CKD. HIF-PHIs activate the HIF oxygen-sensing pathway and are effi cacious in correcting and maintaining Hb, reduce hepcidin and modulate iron metabolism, and are predicted to have effects beyond erythropoiesis. Consequently, we hereby publish a review on the recent recommendations for treating anemia in CKD 2021.

Infections are a common complication arising after kidney transplantation with a high rate of morbidity and mortality. Since the beginning of the COVID-19 pandemic, it has been reported that the kidney transplant recipient population have the worst outcome and highest rate of mortality. The pandemic greatly influences the management of chronic kidney failure and transplantation programs. This review describes clinical presentation and risk factors linked to COVID-19, the management and outcomes, COVID-19 vaccination in kidney transplant recipients, and the impact of COVID-19 on renal transplantation programs., Infekcije su česta komplikacija nakon transplantacije bubrega. Povezane su s visokom stopom pobola i smrtnosti. Od samog početka pandemije COVID-19 uočeno je da bolesnici s transplantiranim bubregom imaju lošije ishode i višu stopu smrtnosti u usporedbi s općom populacijom. Pandemija COVID-19 je značajno utjecala na zbrinjavanje bolesnika sa završnim stadijem kronične bubrežne bolesti i na transplantacijske programe. Prikazujemo klinički nastup, čimbenike rizika, liječenje i ishode COVID-19 u populaciji bolesnika s transplantiranim bubregom, kao i utjecaj pandemije na transplantacijske programe.

Kidney transplantation is the treatment of choice for patients with end-stage renal disease. However, it took years and numerous attempts to achieve success, for the kidney to function well and for the patient to survive after the transplantation. Following this breakthrough made by Murray in 1954, the introduction of immunosuppressive therapy and tissue typing has significantly improved this program. Today we have new challenges in maintaining or improving a kidney transplant program, one of which is COVID- 19 infection. This review presents the history and current status of kidney transplantation, emphasizing the Croatian Kidney Transplant Program.

Background Everolimus permits reduced calcineurin inhibitor (CNI) exposure, but the efficacy and safety outcomes of this treatment after kidney transplant require confirmation.Methods In a multicenter noninferiority trial, we randomized 2037 de novo kidney transplant recipients to receive, in combination with induction therapy and corticosteroids, everolimus with reduced-exposure CNI (everolimus arm) or mycophenolic acid (MPA) with standard-exposure CNI (MPA arm). The primary end point was treated biopsy-proven acute rejection or eGFR Results In the intent-to-treat population (everolimus n=1022, MPA n=1015), the primary end point incidence was 48.2% (493) with everolimus and 45.1% (457) with MPA (difference 3.2%; 95% confidence interval, -1.3% to 7.6%). Similar between-treatment differences in incidence were observed in the subgroups of patients who received tacrolimus or cyclosporine. Treated biopsy-proven acute rejection, graft loss, or death at post-transplant month 12 occurred in 14.9% and 12.5% of patients treated with everolimus and MPA, respectively (difference 2.3%; 95% confidence interval, -1.7% to 6.4%). De novo donor-specific antibody incidence at 12 months and antibody-mediated rejection rate did not differ between arms. Cytomegalovirus (3.6% versus 13.3%) and BK virus infections (4.3% versus 8.0%) were less frequent in the everolimus arm than in the MPA arm. Overall, 23.0% and 11.9% of patients treated with everolimus and MPA, respectively, discontinued the study drug because of adverse events.Conclusions In kidney transplant recipients at mild-to-moderate immunologic risk, everolimus was non-inferior to MPA for a binary composite end point assessing immunosuppressive efficacy and preservation of graft function.

Background. The safety profiles of standard therapy versus everolimus with reduced-exposure calcineurin inhibitor (CNI) therapy using contemporary protocols in de novo kidney transplant recipients have not been compared in detail. Methods. TRANSFORM was a randomized, international trial in which de novo kidney transplant patients were randomized to everolimus with reduced-exposure CNI (N = 1014) or mycophenolic acid (MPA) with standard-exposure CNI (N = 1012), both with induction and corticosteroids. Results. Within the safety population (everolimus 1014, MPA 1012), adverse events with a suspected relation to study drug occurred in 62.9% versus 59.2% of patients given everolimus or MPA, respectively (P = 0.085). Hyperlipidemia, interstitial lung disease, peripheral edema, proteinuria, stomatitis/mouth ulceration, thrombocytopenia, and wound healing complications were more frequent with everolimus, whereas diarrhea, nausea, vomiting, leukopenia, tremor, and insomnia were more frequent in the MPA group. The incidence of viral infections (17.2% versus 29.2%; P < 0.001), cytomegalovirus (CMV) infections (8.1% versus 20.1%; P < 0.001), CMV syndrome (13.6% versus 23.0%, P = 0.044), and BK virus (BKV) infections (4.3% versus 8.0%, P < 0.001) were less frequent with everolimus. CMV infection was less common with everolimus versus MPA after adjusting for prophylaxis therapy in the D+/R− subgroup (P < 0.001). Study drug was discontinued more frequently due to rejection or impaired healing with everolimus, and more often due to BKV infection or BKV nephropathy with MPA. Conclusions. De novo everolimus with reduced-exposure CNI yielded a comparable incidence, though a distinctly different pattern, of adverse events versus current standard of care. Both regimens are safe and effective, yet their distinct profiles may enable tailoring for individual kidney transplant recipients

Zbog razvoja visoko aktivne antiretroviralne terapije (HAART) produljen je životni vijek HIV pozitivnih bolesnika zbog čega im raste rizik razvoja kroničnih bolesti među kojima je i kronična bubrežna bolest. Terapijske opcije za nadomještanje bubrežne funkcije uključuju peritonejsku dijalizu, hemodijalizu i transplantaciju bubrega. HIV infekcija je dugo bila apsolutna kontraindikacija za transplantaciju bubrega zbog bojazni od primjene imunosupresijske terapije. Danas se, zbog napretka na području antiretroviralne terapije i zbog boljeg razumijevanja farmakoloških interakcija između HAART i imunosupresije, uspješno provodi. Mi smo do sada u KBC-u Zagreb uspješno proveli transplantaciju bubrega u dva HIV pozitivna bolesnika., With development of highly active antiretroviral therapy (HAART), HIV positive patients have longer life expectancy and therefore a higher risk of developing chronic diseases such as chronic kidney disease. HIV associated nephropathy is one of the most common causes of end stage renal failure in HIV positive patients. Therapy choices for renal replacement therapy for those patients are peritoneal dialysis, hemodialysis and kidney transplantation. HIV infection was considered as absolute contraindication for transplantation due to fear from consequences of immunosuppression. Today, with HAART and better understanding in pharmacology, interactions between HAART and immunosuppression, kidney transplantation is an option in HIV positive patients. Two cases of deceased-donor kidney transplantation in HIV positive patients were performed at the Zagreb University Hospital Centre.

Transplantacija bubrega je najbolja metoda nadomještanja bubrežne funkcije za sve bolesnike sa završnim stadijem kronične bubrežne bolesti koji nemaju kontraindikacije za operativni zahvat i za primjenu imunosupresijske terapije (1). Republika Hrvatska je jedna od vodećih zemalja svijeta po broju darovatelja organa, ali i po broju transplantacija bubrega na milijun stanovnika. To je rezultat dugogodišnjih napora svih subjekata uključenih u proces donacije i transplantacije organa uz snažnu podršku medija, crkve i opće populacije.

The aim of the current study was to determine whether plasmapheresis in combination with chemotherapy could significantly remove free light chains (FLC) in multiple myeloma (MM) patients with acute kidney injury (AKI) and therefore improve renal recovery and patient survival. During the study period, 29 patients with MM and AKI presented to our unit and were treated with two different therapy modalities (plasmapheresis with chemotherapy or bortezomib). At the end of treatment, a significant decrease of FLCs was present in the group treated with plasmapheresis compared to the bortezomib group. Patients treated with plasmapheresis had similar survival compared to patients treated with bortezomib. There was a significantly higher decrease of FLCs and longer survival in patients treated with three or more plasmapheresis sessions than in patients treated with two plasmapheresis sessions. Plasmapheresis therapy still remains a useful and effective method in the treatment of AKI in MM patients. Plasmapheresis significantly reduces FLCs compared to bortezomib especially with higher number of plasma exchange sessions but it must be combined with other chemotherapy agents in order to prolong renal recovery and therefore patient survival.

Compliance is a major obstacle to achieving phosphorus control in the majority of patients with end-stage renal disease. We investigated self-reported medication adherence and its correlation with serum phosphate levels and nutritional status in hemodialysis patients. A total of 417 patients from Croatia, Montenegro and Bosnia and Herzegovina, mean age 63.82 (range, 21-92) years, were included in the study. There were 55.1% of male patients with the mean dialysis vintage of 68.67 (range, 3-456) months. A signifi cant positive correlation was found between self-reported adherence and serum phosphorus (0.192), and negative correlation with hemoglobin, prealbumin, albumin, Kt/V and residual diuresis (-0.187, -0.227, -0.100, 0.192, and -0.106, respectively). On the other hand, the number of pills taken daily correlated signifi cantly with residual diuresis, serum prealbumin, serum glucose, triglycerides, ferritin and ultrafi ltration volume (0.241, 0.154, 0.158, 0.112, 0.201 and 0.125, respectively). In conclusion, self-reported medication adherence correlates with serum phosphate levels, residual diuresis and nutritional status in hemodialysis patients., Suradljivost je glavna prepreka kontroli fosfora u većine bolesnika sa završnim stadijem kronične bubrežne bolesti. Istražili smo povezanost suradljivosti s uzimanjem lijekova, procijenjene od strane samih bolesnika, s koncentracijom fosfora u serumu i statusom uhranjenosti bolesnika na hemodijalizi. U istraživanje je uključeno 417 bolesnika iz Hrvatske, Crne Gore i Bosne i Hercegovine. Prosječna dob bila je 63,82 godine (raspon, 21-92), 55,1 % ih je bilo muškog spola, prosječno liječenih dijalizom 68,67 (raspon, 3-456) mjeseci. Nađena je statistički značajna pozitivna korelacija između suradljivosti i serumskog fosfora (0,192), a negativna s prealbuminom, albuminom, Kt/V i ostatnom diurezom (redom, -0,187, -0,227, -0,100, 0,192 i -0,106). S druge strane, broj dnevno unesenih tableta je statistički značajno korelirao s ostatnom diurezom, serumskim prealbuminom, glukozom, trigliceridima, feritinom i volumenom ultrafi ltracije (redom, 0,241, 0,154, 0,158, 0,112, 0,201 i 0,125). Zaključno, samoprocijenjena suradljivost bolesnika korelira sa serumskim fosforom, ostatnom diurezom i statusom uhranjenosti bolesnika na hemodijalizi.

Continuous veno-venous hemofiltration (CVVH) could modulate the inflammatory response by removal of circulating cytokines and therefore improve cardiac function in patients with heart failure (HF). We hypothesized that patients with developed cardiorenal syndrome and treated with CVVH have lower risk for mortality than other patients treated with slow continuous ultrafiltration (SCUF). This was a prospective, longitudinal follow-up study for 24 months duration. In total, 120 patients were recruited from the intensive care units. Only patients with cardiorenal syndrome type 1 and 2 were enrolled. 54 CVVH and 23 SCUF patients survived. Mean survival time was longer in CVVH group with cardiomyopathy than in the SCUF group. When we compared patients with cardiomyopathy and hourly urine output

transplantacija bubrega

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.

Kronična bubrežna bolest (KBB) sistemska je bolest povezana s nizom komplikacija koje naposljetku dovode do povećanog pobolijevanja i smrtnosti bolesnika. Poremećaj koštano-mineralnog metabolizma (CKD-MBD) počinje u ranim stadijima KBB-a nakupljanjem fosfora u organizmu s posljedičnim pokretanjem niza zbivanja koja rezultiraju razvojem sekundarnog hiperparatiroidizma s promjenama na kostima i izvankoštanim tkivima. Najvažnija i klinički najbitnija posljedica CKD-MBD-a jesu vaskularne kalcifikacije koje pridonose povećanju smrtnosti od srčano-krvožilnih bolesti. Potrebno je prepoznati bolesnike s povećanim rizikom od razvoja CKD-MBD-a i terapijski intervenirati. Prevencija je najbolji ­pristup zbrinjavanju bolesnika. Prvi korak u liječenju jest nutritivno savjetovanje uz nadoknadu vitamina i ispravljanje poremećaja minerala. Napredovanjem KBB-a prema završnom stadiju povećava se potreba za medikamentnom terapijom. Istodobno treba liječiti i ostale probleme poput anemije i acidoze. Potrebno je pravodobno započeti s nadomještanjem bubrežne funkcije uz osiguranje odgovarajuće doze dijalize. Idealno je omogućiti preemptivnu transplantaciju u bolesnika koji nemaju kontraindikacija za primjenu imunosupresijske terapije., 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 dialysis. Ideally, preemptive renal transplantation should be offered in individuals without contraindications for immunosuppressive therapy

There is a high incidence of cardiovascular morbidity and mortality among patients with chronic kidney disease (CKD) and malnutrition is a powerful predictor of cardiovascular morbidity and mortality in this population of patients. A multitude of factors related to CKD and renal replacement therapy can affect the nutritional status of CKD patients and lead to the development of malnutrition. In patients with CKD, protein energy wasting (PEW) is a condition that is distinct from undernutrition and is associated with inflammation, increased resting energy expenditure, low serum levels of albumin and prealbumin, sarcopenia, weight loss and poor clinical outcomes. Nutritional and metabolic derangements are implicated for the development of PEW in CKD and leading to the development of chronic catabolic state with muscle and fat loss. Prevention is the best way in treating PEW. Appropriate management of CKD patients at risk for PEW requires a comprehensive combination of strategies to diminish protein and energy depletion, and to institute therapies that will avoid further losses. The mainstay of nutritional treatment in MHD patients is nutritional counselling and provision of an adequate amount of protein and energy, using oral supplementation as needed. Intradialytic parenteral nutrition and total enteral nutrition should be attempted in CKD patients who cannot use the gastrointestinal tract efficiently. Other strategies such as anemia correction, treatment of secondary hyperparathyroidism and acidosis, delivering adequate dialysis dose can be considered as complementary therapies in CKD patients. Multidisciplinary work of nephrologists, gastroenterologist and dietician is needed to achieve best therapeutic goals in treating CKD patients with PEW.

There is a high incidence of cardiovascular morbidity and mortality among patients with chronic kidney disease (CKD) and malnutrition is a powerful predictor of cardiovascular morbidity and mortality in this population of patients. A multitude of factors related to CKD and renal replacement therapy can affect the nutritional status of CKD patients and lead to the development of malnutrition. In patients with CKD, protein energy wasting (PEW) is a condition that is distinct from undernutrition and is associated with inflammation, increased resting energy expenditure, low serum levels of albumin and prealbumin, sarcopenia, weight loss and poor clinical outcomes. Nutritional and metabolic derangements are implicated for the development of PEW in CKD and leading to the development of chronic catabolic state with muscle and fat loss. Prevention is the best way in treating PEW. Appropriate management of CKD patients at risk for PEW requires a comprehensive combination of strategies to diminish protein and energy depletion, and to institute therapies that will avoid further losses. The mainstay of nutritional treatment in MHD patients is nutritional counselling and provision of an adequate amount of protein and energy, using oral supplementation as needed. Intradialytic parenteral nutrition and total enteral nutrition should be attempted in CKD patients who cannot use the gastrointestinal tract efficiently. Other strategies such as anemia correction, treatment of secondary hyperparathyroidism and acidosis, delivering adequate dialysis dose can be considered as complementary therapies in CKD patients. Multidisciplinary work of nephrologists, gastroenterologist and dietician is needed to achieve best therapeutic goals in treating CKD patients with PEW., Bolesnici s kroničnom bubrežnom bolesti imaju visoku stopu pobolijevanja i smrtnosti od srčano-žilnih bolesti kojoj u velikoj mjeri pridonosi i pothranjenost. Razvoju pothranjenosti pridonosi niz čimbenika rizika povezanih sa samom bubrežnom bolesti, ali i s nadomještanjem bubrežne funkcije dijalizom. Proteinsko-energijsku pothranjenost (PEP) potrebno je razlikovati od samog pojma pothranjenosti. Povezana je s upalom, trošenjem energijskih zaliha u mirovanju, niskim serumskim vrijednostima albumina i prealbumina, gubitkom mišićne mase s gubitkom tjelesne mase ili bez gubitka tjelesne mase te lošim kliničkim ishodom. Uključuje prehrambene i metaboličke poremećaje koji se javljaju u bolesnika s kroničnom bubrežnom bolešću, a dovode do razvoja stanja kroničnog katabolizma te gubitka mišićnog i masnog tkiva. Može biti prisutna i u adipoznih bolesnika, što se rijetko prepoznaje. Prevencija je najbolji pristup zbrinjavanju bolesnika. Potrebno je prepoznati bolesnike s povećanim rizikom od razvoja PEP-a i terapijski intervenirati. Prvi su koraci u liječenju nutritivno savjetovanje i promjene prehrambenih navika obavezno vodeći računa o unosu kuhinjske soli. Primjena enteralnih pripravaka sljedeći je korak u postizanju terapijskih nutritivnih ciljeva, nakon čega slijedi i intradijalitička parenteralna prehrana te u konačnici totalna parenteralna prehrana. Osim nutritivnih aspekata liječenja, nužno je istodobno liječiti i ostale probleme poput anemije, sekundarnog hiperparatiroidizma i acidoze uz osiguravanje odgovarajuće doze dijalize. Postizanje terapijskih ciljeva zahtijeva multidisciplinarni pristup, pri čemu se optimalni rezultati postižu suradnjom nefrologa, gastroenterologa i nutricionista.

Lupus nephritis (LN) is a severe complication of systemic lupus erythematosus (SLE), associated with high morbidity and mortality. Up to 60% of SLE patients develop LN, and despite novel and potent therapeutic regimens, 5 to 22% develop end-stage renal disease within 15 years of diagnosis. While LN primarily affects younger individuals, it is important to choose optimal method of renal replacement therapy for those who develop end-stage renal disease. Numerous studies were carried out trying to solve problems of treatment of patients with LN. Increased risk of infections, disease recurrence in renal allograft, undefined criteria for follow-up of disease activity after transplantation, as well as higher inci- dence of rejection episodes and thrombotic events are well known risks which have postponed and restricted access to transplantation for patients with LN for long-time. However, numerous studies have demonstrated similar long-term survival in patients treated with haemodialysis or peritoneal dialysis, with clear superiority of renal transplantation regarding the prolonged survival and better quality of life for SLE patients. Many questions are still waiting for answers. Close cooperation between nephrologists and immunologists provides the best treatment for SLE patients with end-stage renal disease.

Peritonejska dijaliza je jednostavna metoda nadomještanja bubrežne funkcije koja je i financijski isplativija u usporedbi sa hemodijalizom. Brojna istraživanja pokazala su njenu učinkovitost u održavanju ostatne bubrežne funkcije, odgađanju nastupa uremijskih komplikacija i očuvanju acidobazne ravnoteže, ali i bolji posttransplantacijski ishod u bolesnika liječenih tom metodom. Unatoč tome peritonejska dijaliza se još uvijek nije izborila za mjesto koje zaslužuje u liječenju završnog stadija kronične bubrežne bolesti. Metabolička acidoza je česta komplikacija vezana uz progresivan gubitak bubrežne funkcije. Njezin utjecaj na koštanu i mišićnu masu, razvitak anemije, ostatnu bubrežnu funkciju kao i funkciju presađenog bubrega vrlo je složen, ali se može učinkovito spriječiti. Glavni cilj našeg istraživanja bio je utvrditi učinkovitost peritonejske dijalize u održavanju acidobazne ravnotežće. U istraživanje je uključeno 28 bolesnika liječenih metodom peritonejske dijalize. Prosječno vrijeme liječenja iznosilo je 32, 39+/-43, 43 mjeseci. Kod svih su bolesnika korištene otopine puferirane isključivo dodatkom laktata. U potpunosti uredan acidobazni status imalo je 73, 07% bolesnika, a 11, 54% bilo je u stanju blage metaboličke acidoze. Blaga metabolička alkaloza zabilježena je kod identičnog udjela bolesnika. U jednog je bolesnika utvrđeno postojanje mješovitog poremećaja, alkaloze s respiratornim i metaboličkom komponentom. Ovim smo radom pokazali da se acidobazna ravnoteža u bolesnika liječenih metodom peritonejske dijalize zaista može uspješno održavati čak i primjenom isključivo laktatompuferiranih otopina koje su nizom istraživanja proglašavane inferiornijima u odnosu na bikarbonate. Uz dobru edukaciju i pažljivu primjenu metode, te temeljitu i čestu evaluaciju ovoj skupini se itekako omogućuje kvalitetno kontinuirano nadomještanje bubrežne funkcije uz dobru kvalitetu života.

Bubrežna anemija nastaje kao posljedica kronične bolesti bubrega (KBB), a pogoršava se s napredovanjem bolesti. Anemija može biti prvi znak bolesti bubrega. Sve bolesnike s KBB i anemijom potrebno je dijagnostički obraditi čime se može otkloniti druge uzroke bolesti. Dokazana je direktna povezanost koncentracije hemoglobina i stadija zatajenja bubrežne funkcije, a ranija pojava anemije učestalija je u dijabetičara. Rano liječenje anemije moglo bi usporiti napredovanje KBB. Anemija je neovisan činitelj rizika za razvoj srčano-žilnih bolesti u bolesnika s KBB. Liječenje anemije u bolesnika s KBB temelji se na smjernicama. Nedavno je skupina KDIGO (Kidney Disease: Improving Global Outcomes) objavila nove smjernice za liječenje anemije u KBB, a skupina ERBP (European Renal Best Practice) osvrt na te smjernice. Hrvatsko društvo za nefrologiju, dijalizu i transplantaciju (HDNDT) već godinama objavljuje vlastite smjernice koje se temelje na preporukama i pozitivnim iskustvima europskih i svjetskih stručnih društava, kao i na vlastitim iskustvima. Posljednja inačica hrvatskih smjernica objavljena je 2008. godine. Od tada do danas, temeljem brojnih istraživanja i kliničke prakse, došlo je do brojnih izmjena u suvremenom shvaćanju liječenja anemije u KBB. Slijedom navedenog, HDNDT objavljuje osvrt na posljednje preporuke međunarodnih stručnih društava, izražava svoj stav za liječenje anemije u KBB kao osnovu za nove smjernice prilagođene sadašnjem trenutku., Renal anemia is the result of chronic kidney disease (CKD) and deteriorates with disease progression. Anemia may be the first sign of kidney disease. In all patients with anemia and CKD, diagnostic evaluation is required. Prior to diagnosing renal anemia, it is necessary to eliminate the other possible causes. Direct correlation between the concentration of hemoglobin and the stage of renal failure is well known. Early development of anemia is common in diabetic patients. Correction of anemia may slow the progression of CKD. Anemia is an independent risk factor for developing cardiovascular disease in patients with CKD. Treatment of anemia in patients with CKD is based on current guidelines. Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) group has produced comprehensive clinical practice guidelines for the management of anemia in CKD patients and ERBP (European Renal Best Practice) group its position statement and comments on the KDIGO guidelines. The Croatian Society of Nephrology, Dialysis and Transplantation (HDNDT) has already published its own guidelines based on the recommendations and positive experience of European and international professional societies, as well as on own experience. The latest version of Croatian guidelines was published in 2008. Since then, on the basis of research and clinical practice, there have been numerous changes in the modern understanding of the treatment of anemia in CKD. Consequently, HDNDT hereby publishes a review of the recent recommendations of international professional societies, expressing the attitude about treating anemia in CKD as a basis for new guidelines tailored to the present time.

Zahvaćanje bubrega teška je komplikacija sistemskog eritemskog lupusa, praćena visokim pobolijevanjem i smrtnošću. Do razvoja lupusnog nefritisa dolazi u do 60% oboljelih, a unatoč primjeni novih i potentnijih terapijskih protokola u 5 do 22% ove specifične populacije razvije se završni stadij kronične bubrežne bolesti unutar 15 godina od postavljanja dijagnoze. Kako je SLE ponajprije vezan uz mlađu životnu dob, izuzetno je važno odabrati optimalan modalitet nadomještanja bubrežne funkcije. Brojne su studije provedene ne bi li se odgovorilo na kontroverzna pitanja vezana uz ovu specifičnu populaciju. Veća sklonost infekcijama, rizik od povratka osnovne bolesti u presadak, nedefinirani kriteriji praćenja aktivnosti bolesti nakon transplantacije te veća učestalost epizoda odbacivanja i trombotskih događaja rizični su čimbenici zbog kojih se ovoj skupini dugo vremena onemogućavalo liječenje transplantacijom. Rezultati studija nedvojbeno pokazuju da je dugoročno preživljenje podjednako u liječenih hemodijalizom i peritonealnom dijalizom, no transplantacija bubrega nametnula se kao mnogo bolja metoda koja omogućava dulje preživljenje i veću kvalitetu života, umanjujući istodobno aktivnost samog SLE-a. Iako postoje brojna neistražena i neodgovorena pitanja vezana uz zbrinjavanje ove imunosno vrlo osjetljive i zahtjevne skupine bolesnika, pažljiva skrb prije i nakon transplantacije te uska suradnja nefrologa i imunologa omogućavaju dobar ishod uz znatno povećanje kvalitete života

Proteinsko-energetska pothranjenost (PEP) se često nalazi u bolesnika s kroničnom bubrežnom bolešću (KBB) i povezana je s lošim kliničkim ishodima u osoba na nadomjesnoj bubrežnoj terapiji. Čitav niz različitih čimbenika utječe na nutricijski i metabolički status bolesnika s KBB uključujući anoreksiju, gadljivost prema hrani, značajna ograničenja u prehrani zbog problema s metabolizmom fosfora ili kalija. Održavanje odgovarajućeg statusa uhranjenosti bolesnika s KBB zahtijeva različite terapijske mjere s ciljem ispravljanja poremećaja te sprječavanje gubitka proteina i energije. Potrebno je individualno pristupiti svakom bolesniku, optimizirati unos prehrambenih tvari hranom, ispraviti metaboličke poremećaje poput acidoze i sistemne upale. Izuzetno je važno osigurati odgovarajuću dozu dijalize. Nadomjesna primjena prehrambenih tvari oralno, enteralno ili parenteralno daje se u slučaju nemogućnosti održavanja nutritivnog statusa peroralnim unosom standardnih obroka. Primjena anaboličkih steroida, hormona rasta i fizičke aktivnosti u kombinaciji s nadomjesnim prehrambenim pripravcima ili bez njih mogu poboljšati proteinske zalihe i predstavljaju mogući dodatni pristup liječenju PEP. Stimulatori apetita, protuupalne intervencije i noviji anabolički pripravci pojavljuju se kao novi oblici liječenja. Njihov učinak još treba potvrditi u daljnjim istraživanjima., Protein-energy wasting (PEW) is a frequent problem in patients with end-stage renal disease, which is associated with adverse outcome. Risk factors for development of PEW in dialysis patients include anorexia, limitations in food intake due to problems with mineral metabolism (hyperphosphatemia, hyperkalemia). Prevention of PEW in dialysis population demands different therapeutic measures to correct abnormalities and to prevent loss of energy and proteins. Therapeutic approach should be individualized based on the specific problems of each patient in order to correct metabolic problems and to optimize food intake. In patients with inability to maintain nutritional status with standard oral feeding, other measures which include oral nutrition supplements and intradialytic parenteral feeding should be applied. Anabolic steroids, growth hormone and adequate oral nutritional supplements, together with physical activity may prevent further catabolism and correct abnormalities. Appetite stimulators, antiinflammatory interventions and anabolic drugs seem promising; however, their efficacy should be investigated in future clinical trials.

The exact etiology of the conflicting hemostatic disorder in the advanced stage of chronic renal disease, i.e. prothrombotic versus bleeding tendency, is not completely understood. Abnormal platelet function in patients with renal failure is not caused by high concentrations of urea, although the presence of fibrinogen fragments may prevent binding of normal fibrinogen and formation of platelet aggregates. Hemostatic abnormalities in end-stage kidney disease may be affected, to some extent, by the choice of renal replacement therapy. Patients on hemodialysis have an increased risk of thrombotic events, primarily due to the release of thromboxane A2 and adenosine diphosphate into the circulation, as well as platelet degranulation. Some activation of platelets occurs due to the exposure of blood to the roller pump segment, but microbubbles may also play a role. Renal transplantation is the treatment of choice for patients with end-stage renal disease. Immunosuppressive therapy is associated with an increased risk of thromboembolic complications. Additional research is required to identify the potential benefits of different immunosuppressive therapies in relation to platelet aggregation, keeping in mind the long term need for immunosuppression in renal transplant patients., Točna etiologija proturječnih hemostatskih poremećaja u terminalnom stadiju bubrežne bolesti, tj. tromboze i sklonosti krvarenju, nije u potpunosti razjašnjena. Poremećena funkcija trombocita u bolesnika s bubrežnim zatajenjem nije uzrokovana povišenom koncentracijom ureje, premda prisutnost fragmenata fibrinogena može spriječiti vezivanje normalnog fibrinogena, odnosno stvaranje agregata tromobocita. Na poremećaj hemostaze kod bolesnika s bubrežnim zatajenjem može utjecati i izbor nadomjesnog bubrežnog liječenja. Bolesnici na hemodijalizi imaju povećani rizik tromboze prvenstveno zbog oslobađanja tromboksana A2 i ADP -a u cirkulaciju, kao i zbog degranulacije trombocita. U stanovitoj mjeri trombociti se aktiviraju i prolaskom krvi kroz sustav crpki, dok moguću ulogu imaju i mikromjehurići. Transplantacija bubrega je metoda izbora u liječenju bolesnika s bubrežnim zatajenjem. Imunosupresivna terapija je povezana s povećanim rizikom razvoja trombembolijskih komplikacija. Imajući u vidu dugotrajnu potrebu za imunosupresivnim liječenjem kod bolesnika s transplantiranim bubregom potrebna su daljnja istraživanja radi utvrđivanja mogućeg povoljnog učinka različitih imunosupresiva u odnosu na agregaciju trombocita.

As an N-methyl-D-aspartate antagonist, magnesium sulfate has analgesic properties and reduces noxious input during surgery. The aim of the study was to determine the effect of preemptive intravenous low-dose magnesium sulfate on early postoperative pain after laparoscopic cholecystectomy. In this prospective, randomized study, 60 ASA I-II patients undergoing elective laparoscopic cholecystectomy were assigned to three groups (n=20 each). After anesthesia induction, prior to surgical incision, patients received magnesium sulfate 5.0 mg/kg (group A), magnesium sulfate 7.5 mg/kg (group B) or saline intravenously (group C). General anesthesia was performed with the same drugs in all three groups. Postoperative pain intensities at rest, according to the visual analog scale (VAS 0-10), were evaluated at 1, 3, 6, 9 and 24 hours after surgery. According to the VAS scores, patients intravenously received metamizol 2.5 g (VAS 3-4), diclofenac 75 mg (VAS 5-7) or tramadol 1 mg/kg (VAS 8-10). VAS scores at 1 hour postoperatively were significantly lower in groups A (4.7±1.7 ; p

Prisutnost antitijela na ljudske leukocitne antigene (Human Leukocyte Antigens – HLA) je značajan terapijski izazov u transplantaciji organa. Senzibiliziranost (Panel Reactive Antibody – PRA >10%) primatelja transplantiranog srca povezana je s nastankom niza kliničkih sindroma koji utječu na kratkotrajno, a moguće i na dugotrajno preživljenje bolesnika. Prikazujemo slučaj modulacije imunog sustava u pripremi za transplantaciju srca visoko senzibilizirane bolesnice. Prema našem saznanju, to je prvi slučaj provedene terapije desenzibilizacije u transplantaciji solidnih organa na području Republike Hrvatske. Bolesnici je zbog dekompenzirane primarne dilatativne kardiomiopatije ugrađen sustav za potporu lijeve klijetke kako bi preživjela do transplantacije srca. Obradom za listu za transplantaciju dijagnosticirana je gljivična pneumonija i visoki stupanj senzibilizacije na HLA (PRA 97%). Protokol desenzibilizacije uključivao je mikofenolatmofetil, takrolimus, terapijske plazmafereze i imunoglobuline uz ranije uključenu antifungalnu terapiju. Navedenim smo postupkom smanjili PRA na svega 6%. Nažalost, tijekom sljedećih nekoliko tjedana nije nađen odgovarajući davatelj, te je bolesnica umrla zbog multiorganskog zatajenja. Izbjegavanje nastanka alosenzibilizacije ranom transplantacijom, izbjegavanjem transfuzija, upotrebom koncentrata eritrocita sa smanjenim brojem leukocita izuzetno je važno kod potencijalnih primatelja transplantiranih organa kako bi se smanjilo vrijeme čekanja na adekvatan organ, mogućnost razvoja brojnih komplikacija i smanjilo smrtnost bolesnika., The presence of human leukocyte antigen (HLA) poses a significant therapeutic challenge in solid organ transplantation. Sensitized patients (panel reactive antibody, PRA >10%) receiving a heart transplant are at an increased risk of developing several clinical syndromes that influence short-term, and possibly also long-term patient survival. We present a case of immune system modulation in a highly sensitized patient awaiting heart transplantation. To our knowledge, this is the first case of desensitization therapy in solid organ transplantation done in Croatia. The patient with decompensated primary dilated cardiomyopathy received left ventricular assist device as a bridge to heart transplantation. Pre-transplantation evaluation revealed the presence of fungal pneumonia and high sensitization to HLA antibodies (PRA 97%). Desensitization protocol consisted of mycophenolate mofetil, tacrolimus, intravenous immune globulin and preoperative plasmapheresis along with previously initiated antifungal therapy. We withheld the application of rituximab until after resolution of pneumonia, but our protocol lowered PRA to 6% even without it. Unfortunately, during the next several weeks, a suitable donor was not found and our patient died form multiorgan failure. Avoidance of allosensitization by early referral to transplantation center, early transplantation, and avoidance of transfusions are very important when treating a potential transplant recipient. In this way, waiting time to ransplantation, development of posttransplantation complications and mortality are reduced.

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.

Posttransplantacijska eritrocitoza se definira kao povišenje hematokrita iznad 51%, a javlja se u 8-15% bolesnika nakon transplantacije bubrega. Bolest se najčešće javlja između 8 i 24 mjeseca od transplantacije. U četvrtine bolesnika dolazi do spontane remisije bolesti tijekom 2 godine, dok se u ostalih 75% bolesnika javljaju simptomi zbog hiperviskoznosti krvi (glavobolje, hipertenzija, pletora). Etiologija je multifaktorska, a kao glavne čimbenike uključuje eritropoetin, sustav renin-angiotenzin (RAS) i IGF-1. Inhibicija RAS sustava bilo ACE inhibitorima ili antagonistima angiotenzin I receptora učinkovita je terapija u više od 90% bolesnika i dovodi do sniženja hematokrita unutar 2-6 tjedana smanjujući incidenciju komplikacija (cerebrovaskularni inzult, plućna ambolija), koje bez terapije dovode u 1-2% bolesnika do smrtnog ishoda., Post-transplant erythrocytosis is defined as an increase in hematocrit above 55%. It occurs in 10%-15% of renal transplant recipients, most commonly from 8 to 24 months after transplantation. Twenty-five percent of patients experience spontaneous remission within 2 years, while 75% develop symptoms and signs of hyperviscosity (headache, hypertension, plethora). The etiology is multifactorial and includes erythropoietin, renin-angiotensin system (RAS) and IGF-1 as the main factors. RAS inhibition with either ACE inhibitors or angiotensin receptor blockers is efficient therapy which decreases hematocrit in 90% of patients within 2 to 6 weeks, thus decreasing the incidence of fatal complications (like pulmonary embolism and stroke).

We report a case of a complete, ectopic blind-ending ureteral duplication in a 26-year-old man who presented with the symptoms of an acute urinary tract infection for the first time. Since anamnestic data and clinical examination indicated a complicated urinary infection he was referred for further examination. On the left side, the imaging studies revealed a normal ureter draining the lower pole of the kidney and a blind-ending ureter with ectopia in the seminal vesicle. The patient recovered completely following surgical removal of the blind-ending ureter.