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Neurocognitive disorders are frequent among chronic kidney disease (CKD) patients. Identifying and characterizing cognitive impairment (CI) can help to assess the ability of adherence to CKD risk reduction strategy, identify potentially reversible causes of cognitive decline, modify pharmacotherapy, educate the patient and caregiver and provide appropriate patient and caregiver support. Numerous factors are associated with the development and progression of CI in CKD patients and various conditions can influence the results of cognitive assessment in these patients. Here we review clinical warning signs that should lead to cognitive screening; conditions frequent in CKD at risk to interfere with cognitive testing or performance, including specificities of cognitive assessment in dialysis patients or after kidney transplantation; and available tests for screening and observed cognitive patterns in CKD patients., Graphical Abstract Graphical abstract

Background: Controversy surrounds which factors are important for predicting early mortality after dialysis initiation (DI). We investigated associations of predialysis course and circumstances affecting planning and execution of DI with mortality following DI. Methods: Among 1580 patients participating in the Peridialysis study, a prospective study of causes and timing of DI, features of predialysis course, clinical and biochemical data at DI, incidence of unplanned suboptimal DI, contraindications to peritoneal dialysis (PD) or hemodialysis (HD), and modality preference, actual choice, and cause of modality choice were registered. Patients were followed for 12 months or until transplantation.Results: First-year mortality was 20.2%. In addition to age and comorbid factors, independent factors predicting death were: clinical contraindications to PD or HD, a rapidly falling eGFR before DI, suboptimal DI, acidosis, high C-reactive protein, signs of overhydration (pulmonary stasis) and cerebral symptoms at DI while eGFR at DI was not. Among 1061 (67.2%) patients who could select dialysis modality based on personal choice, 654 (61.6%) chose PD, 368 (34.7%) center HD and 39 (3.7%) home HD. The 12-months survival did not differ significantly between patients receiving PD and in-center HD.Conclusions: First-year mortality in incident dialysis patients was associated with high age, comorbidity, worsening of kidney failure and clinical symptoms, acidosis, inflammation, and suboptimal DI while eGFR at DI and dialysis modality did not appear as predictors. These findings support the view that choice of dialysis modality among patients who are able to make an informed decision can be based on patient preference.

16 p.-3 fig.-5 tab., Seroprevalence rates and molecular characterization of hepatitis E virus (HEV) prevalent in the Lithuanian human population has not yet been evaluated. Immunosuppressed individuals have been recognized as a risk group for chronic hepatitis due to HEV genotype 3 (HEV-3) infections. The objectives of the present study were to determine prevalence rates of anti-HEV antibodies among inflammatory bowel disease (IBD) patients and solid organ transplant (SOT) recipients, to isolate and characterize HEV strain present in the Lithuanian human population, and to investigate its capacity to infect non-human primate (MARC-145 and Vero), swine (PK-15) and murine (Neuro-2a) cells in vitro. In the present study, the significant difference of anti-HEV IgG prevalence between healthy (3.0% (95% CI 0–6.3)) and immunosuppressed individuals (12.0% [95% CI 8.1–15.9]) was described. Moreover, our findings showed that anti-HEV IgG seropositivity can be significantly predicted by increasing age (OR = 1.032, p < 0.01), diagnosis of IBD (OR = 4.541, p < 0.01) and reception of SOT (OR = 4.042, This research was partly funded by the Lithuanian University of Health Sciences Science Foundation (LSMUSF), grant number 119-05 and COST Action CA15116 ASF-STOP, supported by COST (European Cooperation in Science and Technology).

Background and objectives: Vascular calcification (VC) is one of the factors associated with mortality in hemodialysis (HD) patients. The purpose of the study was to assess associations between prevalent VC and disturbances of calcium-phosphate metabolism as well as changes in vitamin D (25(OH)D), FGF 23 and MGP levels and to evaluate the possible impact of VC and changes of these biomarkers on survival in HD patients. Methods: The study population consisted of 81 prevalent patients in the hemodialysis unit of Hospital of Lithuanian University of Health Sciences Kaunas Clinics. A simple vascular calcification score (SVCS) was evaluated as it is described by Adragao et al. 25(OH)D (nmol/L), FGF 23 (ng/L) and MGP (ng/mL) were measured and analysed. Results: Patients were divided into two groups: SVCS Conclusion: VC in HD patients is highly influenced by age and presence of diabetes and associated with higher risk of death. No significant association was found between MGP and FGF 23 and VC as well as between these two biomarkers and risk of death. Lower 25(OH)D levels were associated with mortality in this dialysis patients cohort.

Vascular calcification (VC) is one of the factors associated with cardiovascular mortality in hemodialysis (HD) patients. Recommendations concerning screening for VC differ. Possible ability to prevent and reversibility of VC are major subjects on debate whether screening for VC could improve outcomes of renal patients. The objective of the study was to evaluate the significance of simple vascular calcification score (SVCS) based on plane radiographic films and to test its association with non-fatal cardiovascular events in patients on chronic HD.A study population consisted of 95 prevalent HD patients in the HD unit of Hospital of Lithuanian University of Health sciences Kaunas Clinics. Clinical data and laboratory tests information were collected from medical records. SVCS was evaluated as it is described by Adragao et al. After measurement of VC, HD patients were observed for novel non-fatal cardiovascular events.Patients were divided into two groups: SVCS≥3 (57 patients [60%]) and3 (38 patients [40%]). The Kaplan-Meier survival curves show a significant difference in non-fatal cardiovascular events in the group with SVCS≥3 vs.3 group (26.3% vs. 7.8%; log rank 5,49; P=0.018). Multivariate Cox regression analysis confirmed a negative impact of VC, hyperphosphatemia, and lower ejection fraction on cardiovascular events. No statistically significant differences were observed comparing parameters of Ca-P metabolism disorders between groups with different SVCS. On separate analysis, the presence of VC in hands was also associated with higher rate of novel cardiovascular events (score 0 goup-5 events [10.6%] vs. score≥1 group-13 events [27%], log rank P=0.035).VC assessed by simple and inexpensive radiological method was an independent predictor of novel non-fatal cardiovascular events in HD patients.

Background Despite early referral of uraemic patients to nephrological care, suboptimal dialysis initiation (SDI) remains a common problem associated with increased morbimortality. We hypothesized that SDI is related to pre-dialysis care. Methods In the ‘Peridialysis’ study, time and reasons for dialysis initiation (DI), clinical and biochemical data and centre characteristics were registered during the pre- and peri-dialytic period for 1583 end-stage kidney disease patients starting dialysis over a 3-year period at 15 nephrology departments in the Nordic and Baltic countries to identify factors associated with SDI. Results SDI occurred in 42%. Risk factors for SDI were late referral, cachexia, comorbidity (particularly cardiovascular), hypoalbuminaemia and rapid uraemia progression. Patients with polycystic renal disease had a lower incidence of SDI. High urea and C-reactive protein levels, acidosis and other electrolyte disorders were markers of SDI, independently of estimated glomerular filtration rate (eGFR). SDI patients had higher eGFR than non-SDI patients during the pre-dialysis period, but lower eGFR at DI. eGFR as such did not predict SDI. Patients with comorbidities had higher eGFR at DI. Centre practice and policy did not associate with the incidence of SDI. Conclusions SDI occurred in 42% of all DIs. SDI was associated with hypoalbuminaemia, comorbidity and rate of eGFR loss, but not with the degree of renal failure as assessed by eGFR.

Despite improvement in the quality of critical care, the incidence and mortality of acute kidney injury (AKI) continues to rise. The aim of our study was to analyze the changes during a 12-year period in etiology, incidence and outcomes of severe AKI, which required dialysis, in a large single centre.We performed retrospective analysis of all the patients (n=3215) with severe AKI hospitalized and dialysed in the hospital of Lithuanian university of health sciences Kauno Klinikos (HLUHS KK) during the period of 2001-2012.During a 12-year period, the incidence of severe AKI increased from 154 to 597 cases/p.m.p. The mean age of the patients increased from 58.2±19.2 years in 2001 to 65.7±17 years in 2012 (P0.001). The number of men (n=2012; 62.6%) was significantly higher than that of women (n=1201; 37.4%; P0.001). The causes of severe AKI were renal (n=1128; 35.1%), prerenal (n=642; 20%), obstructive (n=310; 9.6%) and in 12.7% of the patients-multifactorial. Overall, the most frequent cause of AKI was acute tubular necrosis (n=1069; 33.2%). The renal replacement therapy (RRT) was discontinued due to improved kidney function in 45.3% of cases. 8.1% of the patients remained dialysis dependent. The mortality rate was 44%.During a 12-year period, the number of the patients with severe AKI increased three times with the predominance of men and elderly people. There was an observed increase in multifactorial causes of severe AKI; however, ATN remained dominant over the decade. The mortality rate remained high, almost half of the patients died, less than 10% remained dialysis dependent, the rest had the improvement of renal function.

Background & Aim Acute kidney injury (AKI) is a life-threatening postoperative complication, affecting 10-30% of treated patients and characterized by the damage to the proximal tubular cells, thereby markedly impairing renal function.1,2,3 15% of patients develop chronic kidney disease (CKD) and fibrosis, eventually managed by hemodialysis and kidney transplantation.4 Mesenchymal stem cells have been shown to possess anti-inflammatory and immunomodulatory properties and be able to aid in tissue repair.5 A link between AKI and CKD has been established and the optimal treatment approach to reduce the high unmet medical need and an economical burden is still being researched.6 Placenta-derived mesenchymal stem cells (PSCs) may be a viable approach to treat AKI and prevent subsequent CKD development. Methods, Results & Conclusion M.: PSCs have been isolated using GMP grade materials, cultivated for three weeks and characterized by yield, viability, flow cytometry and potency in vitro. Wistar rats (8-12 wk) underwent preclinical ischemia-reperfusion injury (IRI). Two experimental groups received treatment. Experimental group (Index) received 3 × 105 of PSCs in the corticomedullar region of each kidney. Control group (Control) received PBS vehicle solution. Survival analysis was carried out till day 7. Urine and blood serum samples were collected on day 0, 3 and 7 and analysed for urine volume/24hrs., protein, creatinine, urea, Na+ and K+. Histological kidney analysis on days 3 and 7 for evaluation of tubular necrosis. R. PSCs had a consistent yield, viability, MSCs markers expression and suppressed proliferation of T cells. Survival rate improved – 100% (Index) vs. 75% (Control). Serum urea and K+ was reduced in index group on day 7 (p Serum creatinine was 1.9 and 1.6 times lower in index group on days 3 and 7, respectively. Na+ was similarly lower after 7 days after PSCs injection. Extensive acute tubular necrosis (ATN) with broad coagulative tubular epithelial necrosis was evident after 3 days in the Control group. Variable extent of ATN without significant coagulative necrosis was observed after 3 and 7 days of Index group. C. Placental derived stem cells have the potential to prevent initial kidney fibrosis cascade through ameliorating initial kidney damage and improving kidney function. A superior 100% survival rate of treated animal group exhibits the potential of characterised PSCs to be used in a larger scale preclinical tumorigenicity and toxicity studies and subsequent clinical first-in-human studies.

Our aim was to evaluate the incidence of biopsy-proven kidney diseases in Lithuania and to compare their changes in three different time intervals. All Lithuanian kidney biopsies were performed in the National Center of Pathology, enabling analysis at the national level. The native kidney biopsy data were reviewed, and incidence of renal disorders and patient demographics were compared during three time intervals: 1994–1999, 2000–2006, and 2007–2012. A total of 5,368 kidney biopsies were performed, including 3,640 native kidney and 1,728 kidney transplant biopsies; 59.5 % (2,165) of the native kidney biopsies were classified as primary glomerulopathies. The most common entity was IgA nephropathy (737; 34.0 %), followed by focal segmental glomerulosclerosis (285; 13.2 %) and membranoproliferative glomerulonephritis (256; 11.8 %). Prominent decrease in incidence of membranoproliferative glomerulonephritis (16.8 to 8.7 % from the first to third time interval) and increase in (mainly, pauci-immune) crescentic glomerulonephritis (6.2 to 15.3 %) were noted over the study period. In a subgroup of 427 pediatric native kidney biopsies, IgAN accounted for 24.9 % of biopsies. The incidence of MCNS increased dramatically from the first to third time interval (6.3 to 25.4 %), while the number of MPGN increased in the second time interval (from 7.2 to 8.9 %) but decreased in the third one (to 4.4 %). Decrease in relative incidence of membranoproliferative glomerulonephritis, most likely, reflects improvement in socioeconomic conditions, while relative increase in crescentic glomerulonephritis is interpreted as improved diagnostics of the disease.

Electrolytes play an essential role in the regulation of the heart, and the electrocardiogram (ECG) can be a useful instrument for detecting metabolic disturbances. Hyperkalaemia, usually clinically silent, is a medical condition known for higher serum potassium levels and it is one of the causes of sudden cardiac deaths in chronic kidney disease patients. In order to develop a unobtrusive method capable of monitoring potassium changes remotely, our study investigated which ECG parameters are sensitive to fluctuations during the interdialytic period. Specifically, we evaluated 14 morphological and 5 model-based ECG features. Results show that T wave features: right slope, the ratio of the right slope and T wave peak amplitude, and lognormal fitting parameters show statistically significant differences if evaluated before and after haemodialysis.

Background In Lithuania renal biopsies (RB) have become routine since 1995. Our study attempted to analyze RB for 5 years in Lithuania. Methods We analyzed data of adult patients who underwent native kidney biopsies in 6 renal units in the period between 1995 - 1999. It accounted for 62.5% of all kidney biopsies, done throughout Lithuania. All biopsy specimens were examined by the same pathologist using light- and immunofluorescence microscopy. Results A total of 316 renal biopsies was analyzed; males : females 1.8 : 1. The mean age was 41.4 +/- 16.7 years. The most common indications for biopsy was nephrotic syndrome (29.1%) and urinary abnormalities (27.8%). After exclusion of inadequate biopsies in the remaining 280 RB, primary glomerulonephritis (GN) accounted for 68.7% and secondary GN for 19.5%. The most frequent forms of primary GN were membranoproliferative GN and immunoglobulin A nephropathy (17.9% and 15.4%, respectively), followed by membranous nephropathy (7.1%) and focal segmental glomerulosclerosis (6.8%). Conclusions The main indication for renal biopsy in Lithuania was nephrotic syndrome, which was followed by isolated urinary abnormalities. The leading type of kidney damage was primary glomerulonephritis, which was 2.4 times more frequent in males than in females. The most frequent form of primary glomerulonephritis was membranoproliferative GN, with dominance in males. Immunoglobulin A nephropathy was the second form of primary GN according to the frequency.

The history of renal replacement therapy (RRT) in the 3 Baltic countries can be divided into 2 periods: the Soviet period (1944-1991) with strict central regulation and isolation from Western countries, and the period of independence (1991 to the present). Between 1963 and 1967, hemodialysis was used in cases of acute kidney injury and later in chronic renal failure, but only for patients suitable for kidney transplantation. The first renal transplant was performed in 1968, in Tartu, Estonia, and shortly thereafter, in Lithuania and Latvia. During the period of independence, development of RRT has been extremely rapid, and now this field of the health system has no major differences from that in other developed countries.

Erythropoietin stimulating agents had a long haul in Lithuania—we had no epoetin till 1994 and there was no intravenous iron in 2001–2004. The aim of this study was to assess the changes of renal anemia control in hemodialysis patients from early independence of Lithuania till nowadays and to evaluate the link of anemia with hospitalization rates and survival and hemoglobin variability in association with mortality. In December of each year since 1996 all hemodialysis centers have been visited and data has been collected using special questionnaires. The history of renal anemia control in Lithuania was complicated; however, a significant improvement was achieved: 54.7% of hemodialysis patients reached the target hemoglobin; all patients have a possibility of treatment with epoetin and intravenous iron. The involuntary experiment with an intravenous iron occurred in Lithuania because of economic reasons and confirmed the significant role of intravenous iron in the management of renal anemia. Hemoglobin below 100 g/L was associated with a 2.5-fold increase in relative risk of death and 1.7-fold increase in relative risk of hospitalization in Lithuanian hemodialysis patients. Although hemoglobin variability was common in Lithuanian hemodialysis patients, we did not find the association between hemoglobin variability and all-cause mortality in our study.

Background: The aim of this study was to evaluate whether adherence to treatment is associated with hospitalization risk in hemodialysis patients. Methods: We completed a cohort analysis of risk fac- tors during 1 census month (November) and 1 year of follow-up during 5 consecutive years (2002-2006) in all end-stage renal disease patients hemodialyzed in the Kaunas region. During the census month, we collected data on noncompliance defined as (i) skipping of a he- modialysis (HD) session, (ii) shortening of 1 or more HD sessions, (iii) presence of hyperkalemia, (iv) presence of hyperphosphatemia, or (v) interdialytic weight gain (IDWG). In addition, data on age, sex, disability status, comorbidities, anemia control, malnutrition and inflam- mation, calcium-phosphorus metabolism and hospita- lization rate were collected. Relative risk of hospitali- zation was estimated using Cox regression evaluating time to first hospitalization. Results: We analyzed 559 patients for a total of 1,163 patient-years during the 5 years of the study. On multi- variate analysis, adjusting for ischemic heart disease, diabetes mellitus, higher number of comorbid condi- tions, higher systolic blood pressure before dialysis, worse disability status, lower hemoglobin, albumin and urea before dialysis, the relative risk for hospitali- zation increased by 1.1 for every additional percentage point of IDWG and by 1.19 with each 1 mmol/L rise of serum phosphorus level. Skipping or shortening of he- modialysis sessions and serum potassium level were not associated with hospitalization. Conclusions: Higher IDWG and higher serum levels of phosphorus independently increased the relative risk of hospitalizations in hemodialysis patients. With skipped and shortened dialysis sessions, higher serum potas- sium level was not associated with hospitalization risk.