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Background: Carpal tunnel syndrome (CTS) is the most common complication of dialysis-related amyloidosis (DRA) developing in patients on long-term dialysis therapy. The aim of this study was to evaluate the incidence of CTS and identify factors influencing the development of CTS in patients on maintenance hemodialysis, as well as results of its surgical treatment., Material/methods: The study included 386 patients, among whom CTS was diagnosed in 40 patients (10.4%) on the basis of signs and physical symptoms, as well as by nerve conduction. The group of patients with CTS and the group of patients without CTS were compared according to age (mean 54.50 vs. 56.48 years) and duration of dialysis treatment. Initial analysis of CTS incidence by sex, presence of anti-HCV antibodies, and location of arterio-venous fistula (AV fistula) was undertaken., Results: Duration of dialysis treatment was the statistically significant risk factor for the development of CTS (16.05 vs. 4.51 years; p<0.0001). Among patients treated for a long period on hemodialysis (20-30 years), 100% required surgical release procedures, while 66.66% of those treated for 15-19 years, 42.1% of those treated for 10-14 years, and 1.6% of those treated for less than 10 years. CTS was diagnosed more often in anti-HCV-positive patients as compared with anti-HCV-negative patients (47.5 vs. 6.9%; p<0.0001). No significant differences were found when comparing CTS incidence by sex or between the development of CTS requiring surgical release intervention and location of the AV fistula., Conclusions: Surgical release procedure of the carpal tunnel gave good treatment results in patients with CTS.

Familial lecithin-cholesterol acyltransferase (LCAT) deficiency (FLD) is a rare genetic disorder of lipid metabolism, characterised by low plasma HDL cholesterol, proteinuria, haemolytic anaemia and corneal opacities. Usually renal disease progresses during the third decade of life to renal failure; however the pathogenesis of renal disease is not well understood. In this study we describe treatment of renal disease in two siblings with FLD. The proband WX at the age of 31 years presented proteinuria and ankle oedema during her third pregnancy. Diagnosis of FLD was based on a renal biopsy with characteristic serpiginous fibrillar deposits under electron microscopy, markedly decreased HDL cholesterol, esterified cholesterol levels and LCAT activity, confirmed by molecular analysis. After 3 years her proteinuria increased and she received an ACE inhibitor to which she responded well. During further increases of proteinuria she additionally received methylprednisolone and her proteinuria decreased. This long-term observation indicates the efficacy of corticosteroids and renin-angiotensin-aldosterone system blockers in the treatment of proteinuria in patients with FLD. The results suggest the role of inflammatory processes as well as dyslipidemia in the pathogenesis of glomerular disorders in LCAT-deficient patients.

Fibroblast growth factor-23 (FGF-23) is a phosphatonine of important value in maintenance of mineral homeostasis. In the 1st part of this review dealing with FGF-23 its composition, mode of action, and regulatory mechanisms of its secretion were described. In the 2nd part of this work, regulatory activity in the calcium-phosphate homeostasis in different stages of chronic kidney disease (CKD) with special attention to increased synthesis of FGF-23 in the course of declined glomerular filtration rate were elucidated. The FGF-23 concentration in dialyzed patients, subjects after parathyroidectomy and patients after kidney transplantation were characterized. The relationship between FGF-23 serum concentaration and cardiovascular morbidity and mortality will be presented in the 3rd part of this review.

The very high cardiovascular mortality and morbidity in hemodialyzed patients (HD) is strongly associated with cardiovascular calcification. The aim of the study was to find the predictors of mortality in HD patients during 5-years observation period. The study group was composed of 64 patients (35 F, 29 M) aged 25-75 years (mean 48.9) hemodialyzed three times a week for 12-275 months (mean 77.8). The levels of hemoglobin, total protein, albumin, Ca, P, Ca x P, iPTH, cholesterol, triglycerides, fibrinogen, insulin, homocysteine, leptin, procalcitonin, CRP, IL-6, TGF-beta, PDGF were assessed and all patients underwent Calcium Score (CS) of coronary arteries (CACS) calculation using MSCT and B-mode ultrasound of carotid arteries for intima-media thickness (CCA-IMT), as well as echocardiographic assessment with LVMI calculation and heart valves evaluation at the start of observation. The self-elaborated Cumulative Calcification Index (CCl) was calculated as a sum of CACS Index according to Rumberger et al. (CS<10-0, 10400 - 3 points); number of calcified plaques in carotid arteries (0-0, 1 - 1, 2 - 2, 3 and more - 3 points) and the number of calcified heart valves. At the start of the study the median value of CCl was 4 and interquartile range 4. Only 2 (3%) patients were free of any type of cardiovascular calcification (CCl =0), 15 (23%) patients had minimal calcification (CCl 1 to 2 points), 33 (52%) average (2 - 6 points) and 14 (22%) patients had severe calcification (CCl>6). 21 (32,8%) patients died during observation period. Patients who died were older (56.9 vs. 45.3 yrs.) and had higher CS at the start (1275 vs. 356), higher CCA-IMT (0.948 vs. 0.687 mm) and CCl (6.15 vs. 3.63) values. Those patients had also higher CRP (0.645 vs. 0.245 mg/dl) and IL-6 (10.16 vs. 4.15 pg/ml) levels (p<0.05). LVMI and mean: hemoglobin, total protein, albumin, Ca, P, Ca x P, iPTH, cholesterol, triglycerides, fibrinogen, insulin, homocysteine, leptin, procalcitonin, TGF-beta as well as PDGF levels did not differ between the groups. In logistic regression model (p<0.00002), among tested parameters only CCl was an independent and statistically significant factor of mortality with OR=1.82 per every point of CCl (p<0.0003). Cardiovascular calcification expressed as CCl confirmed to be a strong predictor of mortality in HD patients.

Fibroblast growth factor-23 (FGF-23) discovered in the last years, produced by osteocytes and osteoblast is hormone that lowers plasma phosphate level due to inhibition of renal tubule phosphate reabsorption (phosphaturic effect). It diminishes gut absorption of phosphate as a result of lowered kidney 1alpha-hydroxylase activity and respective decreased active vitamin D1,25(OH)2D synthesis. FGF-23 acts in the presence of the co-receptor Klotho protein which stabilizes its binding with receptor. The pathological states that are associated with increased FGF-23 synthesis in normal renal function lead to hypophosphatemia, while its deficiency may lead to severe hyperphosphatemia. The increased FGF-23 synthesis in patients with chronic kidney disease (CKD) allow to maintain phosphate concentration in spite of severe kidney dysfunction. This problem will be discussed in the II-nd part of this review.

In the 1st part of this review dealing with FGF-23 its composition, mode of action, and regulatory mechanisms of its secretion were described. In the 2nd part of this review, regulatory activity in the calcium-phosphate homeo-stasis in different stages of chronic kidney disease (CKD) including dialyzed patients, subjects after parathyreoidectomy and patients after kidney transplantation were characterized. The aim of this part was to analyze the relationship between FGF-23 and left ventricular hypertrophy, vascular calcification and increased morbidity and mortality in patients with CKD. The current knowledge on FGF-23 has lead to suspect that in the nearest future it may serve as sensitive marker of early calcium-phosphate disturbances in patients with CKD.

Pauci-immune glomerulonephritis, i.e., with no evidence of immune deposits in the blood vessel, is the most prevalent form of rapidly progressive glomerulonephritis (RPGN). In the pathogenesis of pauci-immune renal disease inflammation of blood vessels in the presence of circulating anti-neutrophil cytoplasm antibodies (ANCA) takes place. However the lack of ANCA (about 5-30% of patients) does not exclude pauci-immune vasculitis. The patients without circulating ANCA might have fewer extrarenal symptoms than those who are ANCA-positive. We describe a case of a 40-year old women with ANCA-negative renal limited pauci-immune small-vessel vasculitis with rapidly decreasing kidney function. She was ineffectively treated with plasmapheresis combined with a puls of cyclophosphamide (i.v.) and 3 pulses of methyloprednisolone (i.v.). The patient progressed to end-stage renal disease and should be treated with renal replacement therapy. In differential diagnosis we excluded other causes of pauci-immune vasculitis (Churg-Strauss syndrome, Wegener's granulomatosis), vasculitis with immune complexes deposition (systemic lupus erythematosus, Schoenlein-Henoch purpura, post-infection RPGN), Goodpasture disease, haemolytic-uremic syndrome (HUS), disseminated intravascular coagulation (DIC) and Wilson's disease.

Cardiac diseases are associated independently with a deterioration of renal function and worsening of existing kidney diseases. On the other hand chronic kidney disease is an independent risk factor for increased cardiovascular morbidity and mortality. Cardiorenal syndromes are disorders of the heart and kidneys whereby acute or long-term dysfunction of one organ may induce acute or chronic dysfunction of the other. In these review paper we focused on the pathophysiology and treatment options of five subtypes of the cardiorenal syndrome.

Along with dialysis therapy evolvement and its widespread availability, highly economically developed countries have shown a tendency to initiate dialysis therapy earlier. In the light of available data, this does not seem to be a tendency worth recommending. The key to improvement of quality of life and patient survival in chronic kidney disease (CKD) are: prophylactic measures of CKD, quicker diagnosis of kidney disease and early patient referral to the nephrologist. These measures permit for the delay of initiation of renal replacement therapy. When it becomes mandatory to start therapy, preemptive renal transplantation should be the choice especially for patients having a living related donor. When it is impossible start dialysis therapy based on peritoneal dialysis or hemodialysis.

Unlabelled: The type of vascular access is an important determinant of complications in the dialysis population. The aim of the study was to evaluate types of hemodialysis vascular access at hemodialysis start, in the course of treatment and complications during a one year observation period. The study group consisted of 213 patients [126 (59%) males; 87 (41%) females] treated for 54 months (range from 2 to 384 months) by maintenance hemodialysis at the Nephrology Department of the University Hospital. Mean age of the patients equaled 57.4 years and ranged from 21 to 91 years. The observation period began on June 1st, 2009 and finished on May 31st, 2010. At the start of the dialysis therapy - 99 (46.5%) patients had arterio-venous fistula (AVF), 81 (38.0%) temporary catheters (TC), and 33 (15.5%) permanent catheters (PC). At the beginning of the one-year observation period, 161 (75.6%) of the patients were treated using an AVF, 37 (17.4%) using a CP, 11 (5.1%) CT, and 4 (1.9%) using an artificial graft (AVG). At the end of the one year observation period - 179 (84%) patients were dialyzed using AVF, while 30 (14.1%) patients on PC, and 4 (1.9%) using a AVG. Statistically significant differences in possessing AVF were noted between start of renal replacement therapy and the start and finish of the one year observation period (p < 0.0001), as well as beginning and finish of the observation period (p < 0.002). During the observation period - 37 (20.7%) patients with an AVF required intervention due to complications associated with vascular access; where 4 from 11 (36.4%) patients in this group had AVF located on the arm and 33 from 150 (22.0%) on the forearm. The most common complications associated with AVF were thrombosis (23 = 14.3%), narrowing of the fistula (9 = 5.6%), too high output flow (HOF) 2 = 1.2% and the steal syndrome (SS) 3 (1.9%). Infectious complications were noted in 4 from 37 patients with PC (10.8%), and significantly less with AVF-4 from 161 (2.5%) (p < 0.0001). AVG infection occurred in 2 (50%) individuals of this group., Conclusions: AVF created using patients' own vessels of the forearm is characterized with decreased risk of complications in comparison to fistulas made of artificial materials or permanent catheters. However, fistula thrombosis of the AVF is still the most common complication requiring surgical intervention.

PTLD is a very severe, life threatening complication after organ transplantation. A 17 years old female patient with kidney transplanted (KTx) 7th months ago on immunosuppression therapy: Tacrolimus (TAC), Cell Cept (MMF), Encorton (Enc) was described. She was admitted to the hospital due to: fever, abdominal pain, diarrhea and enlarged cervical and inguinal lymph nodes on palpation. Histopathological diagnosis revealed monomorphic PTLD; diffuse large B cell lymphoma, immunoblastic. Treatment of PTLD was started immediatly after the final diagnosis. MMF was stopped, dose of TAC was reduced (blood level 3-4 ng/ ml), Enc were continued. Anti-CD20 antibodies (Rituximab) were administered. After 7 days of treatment the patient developed signs of diffuse peritonitis. In the course of surgery, perforation in six sites of the small intestine and sigmoid colon were discovered. The Hartman's surgery was performed (sigmoidectomy) with formation of temporary sigmoideostomy. Resected parts of intestine and sigmoid colon were infiltrated by immnunoblasts and revealed diffuse necrosis - the same process was seen in lymph nodes. After the wounds healed, Rituksymab was continued (8 doses) and chemotherapy was started - CHOP - 6 cycles every month. Eight months after surgery, full remission was obtained, TAC was change to rapamycine (RAP) and closure of sigmoideostomy was performed. At present, almost 10 years after first symptoms of PTLD, the patient remains in full remission of the disease.

Unlabelled: Infectious complications associated with vascular access are a well known cause of increased morbidity and mortality in hemodialysis patients. The aim of the study was to evaluate the incidence of hemodialysis vascular access infections and patients survival in the group of maintenance hemodialysis patients during a one year observation period. The study group consisted of 213 patients (126 male, 87 female; aged 57.4 +/- 14.9 years being on renal replacement therapy for 54 months; range: 2 to 384 months) treated by maintenance hemodialysis at the Nephrology Department of the University Hospital. From the study group 181 patients (84.9%) had created arterio-venous fistulas (AVF); 28 (13.2%) permanent central venous catheters (CVC) implanted and 4 (1.9%) arterio-venous grafts (AVG). Vascular access infectious complications were monitored during a one year observation period. Infections of CVC were observed in 4 (14.3%) of the patients with CVC; 4 (2.2%) of patients with AVF and 2 (50%) of AVG. In the group of patients with signs of AVF infection the following pathogens were found: S. epidermidis 50%, S. aureus 25% and negative culture in 25%. The common pathogens in the group of patients with AVG were as follows: S. aureus and S. hemoliticus. Patients that had infections of implanted CVCin 75% were found to have Gram-positive bacteria (50% S. aureus, 25% S. coagulazo-negative), while 25% had Gram-negative infections (E. coli). In the analyzed period 30 deaths (14.1%) were noted; 23 (12.7%) in patients with AVF and 7 (25%) with CVC. Mortality due to cardio-vascular events in dialyzed patients using permanent catheters came to 43%; death due to catheter infections 14%. In the group of patients with AVF from 23 deaths 83% were of cardio-vascular origin, and 4% due to infections. No deaths were occurred during the observation period in the group of patients with AVG. One should note that only 4 patients with AVG during the study period were evaluated., Conclusions: 1. Types of vascular access has some influence on infectious complications and survival in the group of hemodialized patients. 2. High rate of CVC infections and associated increased mortality and better patients outcome with AVF, indicate that fistula should be constructed in all cases where it is possible.

Renal failure is a common complication in the course of multiple myeloma (MM). It is being observed in 20-40% of patients at the moment of disease diagnosis and in 10-36% of the cases dialysis treatment is required. Kidney damage is mainly caused by the toxic effect of monoclonal light chains, also known as Bence-Jones proteins produced by the pathological plasma cells. Light chains coaggregate with Tamm-Horsfall glycoprotein leading to casts formation in the distal nephron (cast nephropathy). Additional factors causing renal damage in MM may be dehydration, hypercalcemia, hyperuricemia as well as drug nephrotoxicity. We have described a 49 year-old woman diagnosed with IgA multiple myeloma at IIIB advance stage according to Durie and Salmona classification. The disease course was complicated by renal failure. Myeloma treatment (cyclophosphamide + talidomid + dexamethasone) was initiated simultaneously with hemodialysis therapy. Treatment with this was successful even though disease course was very severe and required longer-term hemodialysotherapy. Complete hematological remission was obtained and after 17 months of renal replacement therapy--hemodialysis treatment was ceased due to improvement of renal function. The presented case confirms the necessity of dialysis therapy initiation in every case of acute renal failure in the course of multiple myeloma--even when symptoms indicates an advanced stage of the disease. Initiation of dialysis therapy allows to initiate and continue the effective multiple myeloma treatment. This is the chance for recovery of renal function to such a level that dialysis treatment could be ceased, even after many months of dialysis therapy.

Unlabelled: HCV and HGV were recognized as highly prevalent in maintenance dialysis population and variable from country to country and unit to unit. The introduction of serologic tests, for detecting antibodies to HCV (anti-HCV) and HGV (anti-HGV) antigens, has facilitated the study of the epidemiology as well as clinical significance of HCV and HGV infections in patients on maintenance dialysis. The implementation of molecular biology techniques (polymerase chain reaction) for detecting HCV and HGV viremia (HCV-RNA, HGV-RNA) facilitate diagnosis and transmission routes of the infection. The aim of the study was to evaluate the coincidence of HCV and HGV infections in dialysis population and relationship between current and overcome infections and markers of liver damage. The study was performed in the group of 215 patients aged 26-81 years (mean 53.2) on 3 x week maintenance hemodialysis from 33 to 301 months (mean 101.8 months) in the Department of Nephrology, University Hospital, Cracow. Anti-HCV and anti-HGV antibodies were determined based on immunoenzymatic, IIIrd generation, methods. HCV-RNA and HGV-RNA were estimated using polymerase chain reaction (PCR). The anti-HCV antibodies were present (+) in 40 (18.6%) of patients. From the group of patients with anti-HCV (+) antibodies 42.5% were also HCV-RNA (+) whereas from the patients with anti-HCV (-) antibodies 10.4% were HCV-RNA (+). Anti-HGV antibodies tested in the group of 93 patients: 32 anti-HCV (+) and 61 anti-HCV (-) were positive in 20 (62.5%) and 22 (36.1%) patients, respectively. In the group of patients with anti-HGV (+) antibodies HGV-RNA (+) were detected in 63.6%. Anti-HCV (+) and anti-HGV (+) patients were dialysed longer as compared with negative ones: 144.5 vs. 83.5 months, p < 0.001 and 119 vs. 96.4 months, p-NS, respectively., Conclusions: 1. The prevalence of HCV and HGV infections in the dialysis population is very high. 2. The coincidence of HCV and HGV infections is frequent. 3. Our results showed that even anti-HCV (-) and anti-HGV (-) patients carry the risk of viral infection due to detected HCV-RNA and HGV-RNA in some patients.

Unlabelled: Carpal tunnel syndrome (CTS) is the most frequent neuropathy observed in maintenance haemodialysis patients. In spite of the established diagnostic guidelines and many different methods of nerve conduction testing, sometimes difficult to distinguish very advanced CTS (absent median motor and sensory responses) from uremic neuropathy. In the last few years the 2LI-DML test has been accepted as a reliable method for the diagnosis for very advanced stage of CTS. The aim of this study was to evaluate the usefulness of nerve conduction testing based on the interlatency difference (2LI-DML) between the second lumbrical (2L) and second dorsal interosseous (21) muscles in the diagnosis of severe forms of carpal tunnel syndrome in long-term hemodialysis patients with superimposed polyneuropathy. From the group of 40 patients with CTS the 2LI-DML test was used in five cases of long-term hemodialysis with severe damage of the median nerves (absent median motor and sensory responses) and with forearm arteriovenous fistulas and concomitant uremic polyneuropathy. The presence of forearm arteriovenous fistulas makes needle electrode test impossible to apply. The performed 2LI-DML test allowed for a confirmation of clinical diagnosis of CTS in all the patients. A mean difference of motor latency between the second lumbrical and the second interosseous muscles was significantly prolonged and amounted to 10.91+2.36 ms., Conclusions: The 2LI-DML test is the only test that may be used to diagnose CTS in patients with severe damage of the median nerves and with forearm arterio-venous fistulas and superimposed polyneuropathy. The test is fast, simple to perform and well-tolerated by such patients.

Unlabelled: The aim of the study was to investigate the incidence of comorbidities and performed surgical procedures in the group of patients with different stages of chronic kidney diseases (CKD). 1183 patients aged between 17 and 98 years with creatinine level > 120 micromol/I and/or creatinine clearance < 90 ml/min/1.73m2 were analyzed. In the studied group 31.3% of patients had diagnosed ischaemic heart disease, 25.2% diabetes, 64.5% arterial hypertension, 10.6% overcome myocardial infarction, 6.7% atrial fibrillation, 9.8% cardiac failure, 7.7% urolithiasis, 26.6% obesity (BMI > 30) and 10.6% were post nephrectomy. Patients with performed surgical procedures in the past constituted 22.8%. With the usage of statistical analysis, we attempted to find connections between GFR calculated based on the abbreviated MDRD formula, Cockcroft-Gault formula and 24h urine collection and potential risk factors for every method separately; later noted correlations were evaluated. Statistically significant correlations were found between GFR and BMI, occurence of atrial fibrillation, myocardial infarction, chronic cardiac failure, urolithiasis, ischaemic heart disease, obesity, female sex, previous coronary artery bypass graft, hypertension and previous surgical procedures., Conclusions: 1. Comorbidities are frequent in patients with CKD and 22.8% of them had performed in the past one or more surgical procedures. 2. There is a relationship between GFR values and cardiovascular complications.

Pure red-cell aplasia (PRCA) is a serious, life threatening rare condition of multifactorial causes manifested as severe anemia with absence of erythroid precursors in the bone marrow. PRCA may be a consequence of antibody production against applied recombinant human erythropoietin (EPO). The first description of PRCA in the course of EPO therapy was performed in a patient receiving subcutaneously Eprex and in the next years after therapy with other erythropoiesis stimulating agents like erythropoietin beta, omega or darbepoetin. In the paper we describe epidemiology and diagnostic criteria of PRCA. The current treatment possibilities of this complication were described with special attention dedicated to different immunosuppressive agents and effectiveness of kidney transplantation with subsequent immunosuppression.

Hemodialyzed patients with increased risk of bleeding can be dialyzed according to a method of limited anticoagulant use including saline flush technique, regional citrate anticoagulation, regional heparinization or use of membranes with low thrombogenic properties. Methods that limit anticoagulation use are not completely effective, increase work load for the dialysis team and create a risk of complications. The aim of the study was to evaluate the clinical usefulness of Nephral ST dialyzers with poli-acrylonitrile membranes treated with polyethylenimine binding heparin in hemodialyzed patients with increased risk of bleeding. In 12 patients with increased bleeding risk, 121 hemodialyzed sessions were performed utilizing Nephral ST dialyzers. Heparin was not administered during the procedure. Degree of clotting of the dialyzer and the venous drip chamber was evaluated using a 4-degree visual scale. Platelet count, partial activation time of thromboplastine (APTT), thrombin time (TT), antithrombin III, as well as d-dimer concentrations were measured before dialysis and after 15, 120 and 240 minutes of procedure. No complications of massive clotting necessitating premature termination of dialysis was noted. In most sessions trace or small clotting was observed in the dialyzers and drip chambers. No significant differences in platelet count and AT III levels were measured. Increased TT and APTT after 15 minutes of dialysis were observed, which was probably due to release of small amounts of dialyzer membrane heparin. After 120 and 240 minutes these values returned to normal ranges. These observations along with increased d-dimers after 240 minutes suggested an increased risk of clotting during evaluated sessions. Application of Nephral ST dialyzers permits for heparin-free dialysis procedure in patients with increased risk of bleeding.

Background: Continuous increase in the number of patients with end-stage renal disease demands early detection of chronic kidney disease (CKD). The aim of the present study was to diagnose CKD in its earliest stages in a randomly selected population using a diagnostic algorithm developed by the working group., Methods: An algorithm for the diagnostic procedure was created to identify patients with CKD requiring further nephrological care. Randomly chosen adult inhabitants of a city with a population of 60,000 were invited to participate in this study. Screening procedures included a microalbuminuria dipstick test accompanied by blood pressure measurement and medical questionnaire. In further diagnosis of CKD, estimated glomerular filtration rate (eGFR), albumin concentration in urine, urinalysis and ultrasound examination were used according to the algorithm. Multivariate logistic regression was performed to identify associations between participants' characteristics and albuminuria., Results: Out of 9,700 invited subjects, 2,471 individuals participated in the PolNef study. Albuminuria was detected in 15.6% of the investigated population using the dipstick test and thereafter confirmed in 11.9% by the turbidimetric method. The modeling of multivariate logistic regression indicated the following independent predictors of albuminuria: male sex, diabetes, nocturia and hypertension. For people without diabetes and without hypertension, nocturia independently predicted detection of albuminuria. 481 people received a consultation with a nephrologist, and 96% of them were recognized as having CKD. At least 9% of patients with CKD had eGFR by MDRD <60 ml/min/1.73 m(2). Six persons were referred for further treatment because of newly diagnosed kidney tumor., Conclusions: CKD in early stages occurs frequently in the studied population. The proposed diagnostic algorithm seems to be a powerful tool to identify subjects at risk of CKD. The role of nocturia as an independent predictor of albuminuria, both in the general population and in people without diabetes or hypertension, should be further examined., (2008 S. Karger AG, Basel.)

Acute kidney injury (AKI) is a multifactorial disease syndrome affecting usually patients in severe states negatively influencing present and long-term prognosis. Between many factors influencing long-term prognosis urine volume at the time of AKI incidence may be a factor that determines the future fate of patients and explains the necessity of its monitoring. The aim of the study was to evaluate the coexistence between present urine volume at the time of AKI and long-term follow-up of 127 patients with AKI treated in our department. It was shown that sustained urine output during the course of AKI incidence significantly influenced long-term prognosis and was a positive factor. Additionally, 300 ml/24 hours urine volume limit as a border of oligoanuria was satisfactory discriminant.

Along with increasing mean age of dialyzed patients one begins to ask whether old age may be a factor influencing the decision concerning dialysis treatment. We are presenting a case concerning female patient that initiated hemodialysis at the age 99 and continued treatment for the following 18 months. After this observation period, the medical team agreed that the decision to initiate dialysis therapy in this patient positively influenced her quality of life in regard to her daily needs. The presented case proves that rationing access to dialysis treatment in regard to age would not have been appropriate.

Glomerular filtration rate (GFR) estimation is very important for evaluation of kidney function. Its calculation is based upon a 24 hour urine collection and serum creatinine concentration values or on the basis of developed for this purpose numerous formulas with special attention dedicated to the abbreviated MDRD formula and Cockcroft-Gault formulas for adults and Schwartz et al. and Counahan et al. formulas for children. Future expectations are related to GFR estimation based on serum cystatin C concentration and formulas specially developed for this cause. The aim of the study was the comparative analysis of GFR results based on Filler's and Lapage's, Grubb's et al. and Schwartz's et al. formulas and reference values obtained in 93 patients after measuring iohexol concentration after its single injection. Significant differences between the results obtained from employed formulas for high, as well as for low values of GFR were shown, respectively. Serial calculations were performed allowing to finding out a new prescription for GFR calculation. A new formula for GFR calculation based on cystatin C concentration: GFR = -7.28+82.29 x C(-1) was proposed.

The influence of some selected pharmacological compounds on the structure of human erythrocytes (red blood cells, RBCs) has been studied by means of an atomic force microscopy (AFM). The imaging has been done both in the air environment on the fixed cells, and in the liquid (physiological conditions). It was shown that RBCs are very sensitive to osmotic changes in the solution. Increased NaCl concentration in the solution to a value higher than 0.9% leads to the characteristic changes of the erythrocyte from a discoid-like shape to a very irregular one, the so-called "echinocyte", with a lot of ledges. After exposition on nifedipin the modification of the erythrocyte surface morphology was observed. Based on the contact and non-contact AFMs study the consecutive stages of RBCs surface modification were observed. Scanning electron microscopy pictures of erythrocytes were presented for comparison.

The aim of the study was to compare three methods of GFR estimation as simplified MDRD formula, Cockcroft-Gault formula and 24 hour urine collection used in evaluation of kidney function. The study was conducted at the outpatient clinic and enclosed 1183 patients aged between 17 and 98 years (mean 64.7) with creatinine level >120 micromol/l and/or creatinine clearance <90 ml/min/1.73 m2, described in detail in part I. After calculation we obtained different mean GFR values adequately to the method: 38.4 +/- 15.13 ml/min/1.73 m2 (simplified MDRD formula), 44.51 +/- 20.59 ml/min/1.73 m2 (Cockcroft-Gault formula) and 45.63 +/- 25.55 ml/min/1.73 m2 (24-h urine collection). Results of the GFR assessment were different according to the applied method of calculation. The smallest data dispersion was observed in GFR values calculated based on abbreviated MDRD formula and the highest when obtained based on to the 24-hour urine collection. The GFR values obtained based on 24 hour urine collection showed positive correlations with BMI (p<0.01), hemoglobine (p<0.01), hematocrite (p<0.01), diastolic blood pressure (p=0.01), albumin (p=0.041), iron (p=0.03), AIAT activity (p=0.01), and negative with age (p<0.01), phosphate (p<0.01), alkaline phosphatase activity (p=0.039), parathormone (p=0.03), potassium (p<0.01) and magnesium (p<0.01). In the group of patients with GFR values below 30 ml/min in comparison with patients with GFR values above 30 ml/min, in all three methods of GFR estimation it was shown significantly higher values of phosphate, potassium, age, and lower hemoglobin, hematocrite. It was shown also in the group with GFR below 30 ml/min values estimated based on Cockcroft-Gault formula and 24 hour urine collection significantly lower BMI.

Background: Low-molecular-weight proteins (LMWPs) are substances of molecular weights 10-35 kDa, which accumulate in plasma of patients with end-stage renal disease (ESRD) due to the abolishment of plasma renal filtration. LMWPs are considered as a separate group of uremic toxins., Aim: The influence of hemodialysis (HD) on the release of some LMWPs from leukocytes was assessed by comparing levels of serum pancreatic-type alkaline RNase and leukocyte-type acid RNase as well as polymorphonuclear (PMN) elastase., Methods: The mentioned proteins were assayed in 58 ESRD patients on HD prior and after the dialysis session and compared with the results obtained from 36 healthy subjects. The levels of elastase and acid and alkaline RNase were correlated with HD parameters, residual diuresis, predialysis concentrations of serum creatinine, urea and albumin as well as pre- and postdialysis granulocyte count., Results: Changes in PMN elastase produced by the dialysis session positively correlate with changes in acid RNase levels (r = 0.3650; p = 0.0061), while there is no such correlation for alkaline RNase. There is a negative correlation between pre- and postdialysis differences in levels of acid and alkaline RNases (r = -0.3542; p = 0.008), indicating that HD induces liberation of a factor suppressing alkaline RNase. Levels of acid and alkaline RNase negatively correlate with residual diuresis, indicating its significance in control of LMWP accumulation (r = -0.3970; p = 0.0025; r = -0.2596; p = 0.0533, respectively)., Conclusions: Dialysis treatment causes an increase in both acid leukocyte-type and alkaline pancreatic-type RNase activity in plasma. Dialysis-related increases in acid RNase activity correlate with the respective changes in PMN elastase, which suggests that leukocyte activation during dialysis contributes to an increase in plasma LMWPs., (Copyright 2009 S. Karger AG, Basel.)

During the last years the incidence of chronic kidney disease (CKD) is permanently increasing and has become a global social and economical problem in the world as well as in Poland. The aim of the study was the retrospective analysis of medical records of patients with renal failure under supervision at the outpatient clinic, Department of Nephrology, University Hospital in Cracow. The study population enclosed 1183 patients (640 men and 543 women) aged between 17 and 98 years (mean 64.7) with creatinine concentration >120 micromol/l and/or creatinine clearance <90 ml/min/1.73 m2. Hemoglobin, iron, creatinine, urea, sodium, potasium, calcium, phosphate, magnesium, PTH, uric acid, albumin, total protein, bilirubin, glucose, total cholesterol, LDL and HDL cholesterol, triglicerydes concentration and values of hematocrite, MCV, HbA1, as well as alkaline phosphatase, AspAT, AIAT activity were estimated based on standard laboratory methods. Creatinine clearances were evaluated based on 3 different methods: simplified MDRD formula, Cockcroft-Gault formula and 24-h urine collection. Mean creatinine concentration in the studied population was 172.8 micromol/l (1.95 mg/dl). Hypertension was diagnosed in 65% of patients. In spite of treatment, more than half of the patients (51.9%) have increased systolic blood pressure and above 1/3 (35%) increased diastolic blood pressure. Mean hemoglobin concentration was 13.02 g/dl; more than 12% of patients had decreased hemoglobin below 11 g/dl. Mean values of parameters discovering calcium-phosphate metabolism were: calcium--2.33 mmol/l, phosphate--1.23 mmol/l and parathormon--169.3 pg/ml. Increased value of total serum cholesterol level was noted more than half of the patients (56.5%). Significant positive correlations were found between GFR calculated based on Cockcroft-Gault formula and BMI, hemoglobin, hematocrite, serum iron, diastolic blood pressure, total and LDL serum cholesterol, triglicerydes level, as well as AIAT activity and % values of HbA1c and negative with age, serum potassium, phosphorus, PTH and uric acid.

The most characteristic finding in non-typhoid salmonella (NTS) infection is acute food related outbreaks of gastroenteritis, which is usually benign and self-limiting. However, more serious extraintestinal findings, such as bacteraemia and focal infections localized to any organ may appear. The objective of this paper is to describe the most important characteristic of the extraintestinal infections due to NTS serotypes observed in University Hospital, in Cracow between January 2000 and December 2006. To do so, we reviewed the clinical presentations, risk groups, complications and outcomes of in-patients, in which extraintestinal non-typhoid Salmonella serotypes were isolated, applying a clinomicrobiological protocol. Out of 30 patients with either bacteraemias (n = 22) or focal salmonella infections (n = 8), 12 had malignancies, 17 had immune dysfunction state, 9 had gastrointestinal disorders and 8 had chronic heart, pulmonary or kidney disease. Four of these patients (13%) who had hematological malignancies (2), renal transplantation (1) and pulmonary disease (1) died. Regarding the clinical picture, primary bacteraemia and focal infections occurred with similar frequency (33.3% and 26.7%, respectively); the remaining were bacteraemias secondary to gastroenteritis. The incidence rate (mean 0.30/1000 hospital admission/year) increased steadily from 0.19/1000 to 0.32/1000 hospital admission during the study period. From 30 Salmonella isolates from extraintestinal samples collected, only four isolates were resistant to ampicillin, ciprofloxacin or trimethoprim-sulfamethoxazole. This finding indicate that multidrug resistance does not represent a serious problem among NTS serotypes collected from the our medical center as monitored over a period of 7 years. Given this presentation, clinicians need to have a high index of suspicion and to consider preemptive therapy, especially in elderly patients who are likely to develop severe immunosuppression following interventions.

Relapsing polychondritis is a rare autoimmune disease, which is due to sporadic occurrence, unexplained etiology and wide range of symptoms resulting in the difficulties in diagnosis. Recurrent inflammation leads to destruction of cartilaginous tissues, such as ear, nasal septum, larynx, trachea and bronchi, peripheral joints and vertebral structures. Blood vessels, the central nervous system, eyes, and the urinary tract can be involved as well. Clinical course of relapsing polychondritis is often modified by co-existing systemic diseases and remains misdiagnosed. In case of inappropriate or delayed treatment, serious and life-thretening complications may develop. In this article we present the most characteristic clinical features of the disease, differential diagnosis, focusing on current approaches to treatment.

Hepatitis C virus (HCV) infection is a global health problem, common worldwide, leading to acute and chronic hepatitis and its consequences of hepatocirrhosis and hepatocellular carcinoma. Patients on hemodialysis belong to the high-risk group of HCV infection. The prevalence of HCV infection in dialysis patients ranges from 4% to more than 70% in some countries. The main reasons for such a high incidence of infections are a high prevalence of HCV infection in the general population, lack of standard infection precautions and effective vaccination, inadequate disinfection procedures of dialysis machines and other medical equipment, as well as spread of infection from patient to patient, especially in dialytic centers with a high percentage of infected patients. The diagnostic procedures useful in the evaluation of HCV infection are detection of anti-HCV antibodies, identification of HCV RNA, counts of virus copies, and identification of its genome. From the 6 major genotypes and multiple subtypes of the HCV, genotypes 1a and 1b are the most common in Europe and Japan, and 1b is responsible for more severe liver disease and aggressive course leading to liver fibrosis. Antiviral therapy of HCV+ dialysis patients with interferon-alpha (INF-alpha) gives slightly better results than in the general population, but is poorly tolerated and associated with side effects. Although ribavirin in not recommended for dialysis patients, the addition of small doses of this compound to pegylated INF is discussed, especially for patients in whom previous infection treatment failed.

We investigated the relations between selenium status (SeS) parameters, indexes of nutrition, erythropoiesis, and uremic toxemia, serum electrolytes, and other biochemical markers in end-stage renal disease (ESRD) patients, as no multivariate statistical analysis concerning all of these parameters was performed so far. SeS was evaluated by plasma Se concentration (plSe) and glutathione peroxidase (plGSHPx) activity in 69 uremic patients treated with hemodialysis (HD) and 40 healthy controls. The hierarchical multivariate partial least squares model (PLS2) was employed to establish data structure and correlations between parameters investigated. plSe and plGSHPx activity were significantly lower in patients when compared with controls (p=0.000). plSe was positively associated with indexes of erythropoiesis and nutritional status, as well as serum electrolytes and parameters of uremic toxemia. plGSHPx was inversely dependent on the pair of parameters: intact parathyroid hormone (iPTH) and aluminum plasma concentration (Al). We conclude that (1) ESRD strongly decreases selenium status and (2) the PLS2 approach revealed the existence of significant interactions among plSe, plGSHPx, and selected biochemical parameters or groups of such parameters; some of these associations need further studies to be clarified.

Previous clinical data suggested that with a tacrolimus-based regimen adjunctive immunosuppressives may be withdrawn after an initial treatment period. This study investigated the early discontinuation of mycophenolate mofetil (MMF) from a standard triple regimen. Patients were randomized either to receive a continued tacrolimus/MMF/steroids triple regimen (control group) or to reduce and then stop the MMF dose (MMF stop group). Both groups received identical daily tacrolimus and corticosteroid doses. The initial MMF dose was 1 g/day in both arms, but in the MMF stop group the dose was reduced to 0.5 g/day from week 7 to week 12 and then stopped. The intent-to-treat population consisted of 74 (control) and 78 (MMF stop) patients. MMF was tapered off as planned in 82.9% of the patients in the MMF stop arm. The 6-month incidence of biopsy-proven acute rejection was similar in both arms (21.6% control, 16.7% MMF stop). Graft loss occurred in 5.4% (control) and 3.8% (MMF stop) of the patients. MMF could be safely discontinued from a tacrolimus-based triple therapy early after transplantation without any rebound in efficacy during the 6-month follow-up period. (Name of registry: ClinicalStudyResults.org, number: FG-02-CEE-01, date: 9 June 2006).

Unlabelled: The aim of the study was to assess severity of injury of the peripheral nervous system of chronic renal failure patients on continuous ambulatory peritoneal dialysis (CAPD) or on maintenance hemodialysis (HD) diagnosed based on the electrophysiological testing as well as to establish the effect of adequate dialysis dose on peripheral nerve functioning. The study was performed in 53 patients (21 males, 32 females) on CAPD for mean 16.9 +/- 14.4 months and 68 patients (46 males, 22 females) on HD for mean 47.5 +/- 46.5 months. Both groups were age matched (48.9 +/- 12.4 vs. 50.6 +/- 11.9 yrs; p= NS). Patients with co-existing diseases that could lead to disturbances in nerve conduction were excluded from the study group., Methods: Electrophysiological testing was performed using Medelec Shaphire 2ME equipment. Nerve conductivity testing was performed in motor and sensory fibres of right ulnar nerve, motor fibres of right fibular nerve and left tibial nerve as well as in sensory fibres of right calf nerve. In the sensory nerves there were assessed: amplitude of the evoked sensory response, latency of the response and conduction velocity. In the motor nerves there were analyzed amplitude of the compound muscle action potential, latency of the evoked response, F-wave minimal latency and conduction velocity. Polyneuropathy was diagnosed if abnormal results obtained in electrophysiological examination were found in at least two out of four tested nerves. To assess dialysis adequacy in the CAPD group weekly Kt/V (wKt/ V) and weekly creatinine clearance (WCrCI) were used and in the HD patients the following indices were measured: Kt/V, PRU, TAC and TAD., Results: Polyneuropathy diagnosed based on the above described criteria, was found in 59 (86.8%) HD patients and in 41 (77.4%) CAPD patients (p= NS). The results of motor conductivity testing showed significantly longer distal latency in HD patients in comparison to the CAPD patients in fibular nerve (4.9 +/- 0.9 vs. 4.5 +/- 0.8 ms; p< 0.05) and F-wave latency in ulnar nerve (29.3 +/- 3.1 vs. 27.3 +/- 2.5 ms; p< 0.05), in fibular nerve (52.4 +/- 6.4 vs. 48.5 +/- 7.94 ms; p< 0.05), in tibial nerve (54.8 +/- 7.8 vs. 50.6 +/- 7.12 ms; p< 0.05) and also significantly lower conduction velocity in ulnar nerve (51.9 +/- 5.9 vs. 55.6 +/- 6.99 m/s; p< 0.05), in fibular nerve (41.2 +/- 5.9 vs. 44.5 +/- 5.5 m/s; p< 0.05), in tibial nerve (40.1 +/- 5.81 vs. 42.7 +/- 4.6 m/s; p< 0.05). Mean value of sensory response amplitude evoked in ulnar nerve was significantly higher in the CAPD treated patients than in HD patients (21.2 +/- 14.8 vs. 15.1 +/- 11.4 microV; p< 0.05) and distal latency in calf nerve was significantly shorter (2.1 +/- 1.0 vs. 2.4 +/- 0.6 ms; p< 0.05). Analysing the effect of dialysis on peripheral nerve functioning in the group of CAPD patients a statistically significant relationship between the severity of peripheral nerve injury and WCrCl was demonstrated. Mean value of WCrCl in patients without features of neuropathy was significantly higher (83.3 +/- 28.98 l/week/ 1.73m2) in comparison with those with diagnosed polyneuropathy (59.9 +/- 15.9 l/week/1.73m2) (p< 0.01). Analyzing effect of WCrCl on conduction velocity in the tested nerves there was demonstrated that in patients with WCrCl value at least 60 l/week/1.73m2, mean velocity values were higher, and the statistically significant difference was found for sensory (p< 0.05) and motor (p< 0.01) fibers of ulnar nerve. Mean value of residual renal clearance in the CAPD treated patients without features of sensory and motor nerve injury was significantly higher (2.9 +/- 1.8 ml/min) when compared to the patients with diagnosed polyneuropathy (1.4 +/- 1.3 ml/min) (p= 0.006). In the hemodialyzed group no statistically significant relationship was found between conduction velocity in the tested nerves and indices of dialysis efficiency (Kt/V, PRU) as well as degree of exposure to uremic toxemia described by TAC and TAD., Conclusions: Polyneuropathy is a common complication in patients with chronic renal failure independently of a kind of the therapy. Well preserved residual renal function in CAPD patients plays an important role in improving effectiveness of the dialytic treatment, in consequence influencing preservation of proper peripheral nerve function.

An accurate evaluation of water content in the body of hemodialyzed patients seems to be an important problem in chronic dialysotherapy. Acute intradialytic hypotension observed in 20-33% of hemodialysis patients is a very common complication of this kind of renal replacement therapy. The study was performed in 40 uremic patients, treated with hemodialysis at the Nephrology Clinic of the University Hospital in Cracow. In every patient, 3 model dialysis sessions were carried out. Total fluid removal was the same during every hemodialysis. The first model hemodialysis (HD1) was performed with constant dialysate sodium concentration (140 mmol/L), the second (HD2) with linear and the third (HD3) with expotential decrease of dialysate sodium concentration (from 144 to 136 mmol/L). Every hemodialysis was also monitored continuously with Crit-Line 2 R system (In-Line Diagnostics, Riverdale, UT). Before and after the first model hemodialysis (HD1), ultrasound examination of abdominal cavity was performed. The measurement of inferior vena cava diameter (mm), circumference (mm), area (mm2), at hepatic veins orifice-level, on expiration was performed. The fluid removal during the first model hemodialysis resulted in significant reduction of the vena cava inferior diameter, circumference and area, measured with ultrasound on expiration. The statistically significant lower fall of blood volume after the first and second hour of the second model hemodialysis session (HD2) was observed when compared to the first hemodialysis (HD1) - p<0.05 was observed. The statistically significant lower frequency of hypotension during the second hemo-dialysis session (HD2) as compared to HD1 (chi2=5.25 p<0.05). Differences among HD1 and HD3 and HD2 and HD3 did not reach statistical significance. The monitoring of hemodialysis with the Crit-Line instrument permits for optimalization of dry weight of dialyzed patients and allows reaching higher ultrafiltration rates during dialysis without hypotensive episodes. The changes in the blood volume, approximately 5% per one hour of dialysis session are an optimal value for these patients.

Hepatitis B is a serious epidemiological problem in uremic patients treated with renal replacement therapy. A high proportion of hemodialyzed patients do not respond to the standard method of intramuscular (i.m.) hepatitis B vaccination. Low-dose intradermal (i.d.) inoculations and supplementary i.m. injections have been reported to improve the responsiveness in formerly non responding uremic patients. We applied a inoculation schedule of 10 microg Engerix B i.d. in 49 pts and i.m. (control group) in 13 pts once a week during 12 consecutive weeks in order to compare the effectiveness of the various ways of immunization in maintenance dialyzed patients not responding to standard vaccination. Serum anti-HBs antibody level, as well as biochemical and immunological parameters were examined. Already one month after initiation of the cycle, 57.1% of patients in the i.d. group responded by achieving the minimum protective anti-HBs antibody level (>10 IU/I.); while 14.3% reached full adequate anti-HBs antibody level (>100 IU/I.). After the full therapy period, anti-HBs antibody level >100 IU/I. was achieved in 42.9% of the patients, while a total of 81.7% of patients reached the anti-HBs antibody level >10 IU/I. In 18.4% of patients no response was observed. Surprisingly similar results were achieved in the i.m. group. Twelve months after termination of the inoculation cycle we noted decrease of anti-HBs antibody level; the values >100 IU/ I. was observed only in 18.4% of the study group, while 87.8% reached a titre >10 IU/I. We found a relationship between the effectiveness of immunization and RBC count, total serum protein and albumin levels and GGTP activity. Mitogen stimulation indexes in both groups were 4-5 times lower in comparison to reference values in the general population. In the study group that did not respond to vaccination, mitogen stimulation indexes were 2 times lower as compared to the group characterized as having a good response. In conclusion, the route of injection seems to be less important than the frequency and number of doses of the vaccine. Anemia and malnutrition may be responsible for the worse response to vaccination against hepatitis B virus.

Calcium-phosphate disorders and vascular calcification are highly prevalent in patients with diabetes mellitus and nephropathy. The aim of the study was to compare the prevalence and advancement of vascular calcification in patients with end-stage diabetic nephropathy on peritoneal dialysis and diabetic patients with chronic renal disease stages 2-4. The study group included 31 patients with type 2 diabetes and diabetic nephropathy divided into 2 groups: 12 patients (aged 50-74 years: mean 58.6+/-8.8) undergoing peritoneal dialysis and 19 patients (aged 46-82 years; mean 65.8+/-9.7) with chronic kidney disease stages 2-4 (GFR range 24-78 ml/min/1.73 m2). Coronary artery calcification score, was assessed using multi-slice computed tomography. Coronary artery calcification score did not differ significantly between groups (CaSc values 1085.2 vs 452.4 AgU; NS). The patients undergoing peritoneal dialysis showed significantly higher levels of parathyroid hormone (658.2 vs. 74.3 pg/ml; p=0.001), fibrinogen (5.82 vs. 3.89 g/l; p<0.0001) and alkaline phosphatase (330.9 vs. 168.0 U/l; p=0.001). Despite more advanced abnormalities in calcium-phosphate balance parameters and more active inflammation in peritoneal dialysis subjects we failed to demonstrate any statistically significant difference in coronary artery calcification score between patients with diabetic nephropathy on peritoneal dialysis and those with chronic kidney disease stages 2-4.

The occurrence of DIH is 15-30 or even 50% of dialysis sessions. There are three clinical patterns of DIH: acute, recurrent and chronic. Intradialytic hypotension essentially augments mortality due to hypoperfusion and concomitant damage of many vital organs, as well as due to chronic overhydration and inability to reach proper dry weight. The main causes of dialysis induced hypotension are age hypovolemia (rapid ultrafiltration), and coexisting decreases: autonomic neuropathy, cardiovascular diseases, diabetes. Therapeutic strategies include: patient education and perfect supervision by dialysis staff dialysis procedure-related methods (extension of dialysis duration, low dialysate temperature, sodium and ultrafiltration profiling and usage of biofeedback technique) and pharmacological treatment (e.g. midodrine, caffeine, vasopressin analogues). Proper treatment includes usage of invasive or cardiosurgical methods of heart failure which is a common reason of hypotension in the dialyzed population. Dialysis-induced hypotension is a very important, multifactorial clinical problem in dialysotherapy. Its incidence increases because of the growing number of elderly and diabetic patients in the dialyzed population.

Glomerulonephritis is one of the diseases leading to chronic renal failure and need of renal replacement therapy. Changes in extraglomerular compartments, especially in the interstitium, are thought to play a major role in progression. However, the exact relationships between renal interstitium, tubules and vessels and their prognostic impact are less well understood. The material consisted of 111 biopsies with primary glomerulonephritis. Normal renal tissue from surgically removed kidneys served as controls. Relative interstitial volume (RIV), its variability, volume of interstitial infiltrate, cross-sectional tubular area were measured with the point-counting method. A number of vascular parameters were also measured. The assessed interstitial and tubular parameters were strongly correlated to creatinine level. The strongest correlation was seen for RIV, also on multiple regression. In patients with renal failure, increased RIV, more pronounced vascular lesions and interstitial infiltrates were seen. Survival analysis showed that interstitial expansion is the most important factor leading to renal failure. Tubulointerstitial and vascular factors are interrelated and linked to renal function. RIV has strongest impact on renal function and survival, even taking into account other factors.

Malnutrition is a frequent complication among patients on chronic peritoneal dialysis and early recognition of malnutrition can be a key factor in successful treatment. The aim of the study was to assess the nutritional status of patients on peritoneal dialysis and to search for the relationships between activation of non-specific inflammatory process and progression of malnutrition. The study group included 60 patients (age 50.4+/-14 years) on peritoneal dialysis for 17.6+/-20 months. Fourty-six patients completed the entire 24-month observation period. Nutritional status was assessed using SGA scale, anthropometric measures, bioimpendance, and several biochemical parameters. Inflammatory markers included: IL-6, TNFalpha, fibrinogen and CRP. Severe malnutrition was observed in the range between 8.4% (5 subjects, group C in SGA scale) to 11.7% (7 subjects, BMI <20 kg/m2) of patients. The nutritional status of the entire cohort was constant over 2 years of observation (based on SGA scale), although the mean albumin level decreased significantly after 24 months of observation (from 39.55+/-3.5 to 37.63+/-3.7 g/l; p<0.01). The mean concentrations of CRP (4.8 and 5.25 mg/l), IL-6 (3.45 and 6.8 pg/ml) and leptin (22.95 and 22.2 ng/ml) were above reference ranges both at the initial and final assessment. Moreover, the concentration of IL-6 significantly increased (p<0.001) after 24 months of observation. Patients treated with PD are frequently affected by malnutrition. Our results indicate a strong association between nutritional indices and markers of inflammation.

Atherosclerosis and calcifications in the cardio-vascular system are the most frequent causes of increased morbidity and mortality in patients with end-stage renal disease treated with hemodialyses. The aim of this study was to estimate the atherosclerosis progression and presence of calcifications in the circulatory system in patients treated with hemodialyses using, non-invasive imaging diagnostic techniques and to search for the relationships between these changes and microinflammation and oxidative stress during two years. The study was performed in 73 patients (36 female and 37 male), aged 25 to 75 years (mean -49.5), treated with hemodialyses, 3 times/week for 12 to 275 months (mean -73.8). In each patient before starting hemodialysis levels of: ox-LDL, Lp (a), procalcitonin, IL-1beta, IL-6, CRP, TGFbeta, TNFalpha, PDGF, AOPP and MPO were determined. Presence of artery calcifications was detected by Multi-Row Spiral Computed Tomography (MSCT) and expressed as coronary artery calcification score (CACS). Ultrasonography was used to evaluate CCA-IMT. During the study CACS increased significantly after 12 and 24 months (p < 0.00001) as compare with baseline. After 12 months, CACS increase significantly correlated with procalcitonin level (r = 0.30 p = 0.01) and after 24 months with CRP (r = 0.46; p = 0.0002) and IL-6 (r = 0.36; p = 0.005). Independent factor of coronary artery calcification progression after 24 months of observation was only CRP (beta = 0.569). CCA-IMT increased during the study and this increase was statistically significant (p < 0.00001). CCA-IMT increase correlated with CACS growth after 12 (r = 0.36; p = 0.003) and 24 months (r = 0.39; p = 0.002). After 12 months significant relationship was noted with procalcitonin (r = 0.29; p = 0.022). After 24 months CCA-IMT correlated with AOPP (r = -0.30; p = 0.017). The independent factor of CCA-IMT progression after 24 months of observation was only CACS (delta CACS beta = 0.49). From the performed study, we can conclude that exacerbation of atherosclerosis and calcification in the circulatory system of patients treated with maintenance hemodialyses depends on microinflammation and oxidative stress. Reasonable tools for diagnostic algorithm estimation of atherosclerosis advancement in this group of patients are non-invasive, visual diagnostic techniques such as MSCT and ultrasonography.

The term glomerulonephritis encompass a heterogeneous group of diseases; these are a important cause of end stage renal disease. Although several evidence exist, that the main prognostic factors are extraglomerular lesions, no quantitative assessment is usually done. In nephropathological practice a semiquantitative approach is preferred. However, most of work on extraglomerular lesions significance was done with quantitative methods. The aim of the study was to compare the effects of quantitative and semiquantitative assessment of extraglomerular lesions in glomerulonephritis. The material consisted of 120 renal biopsies. On inspection, percentage of sclerosed glomeruli, degree of interstitial fibrosis, degree of interstitial infiltration, degree of tubular atrophy were and degree of mesangial matrix expansion assessed. For quantitative measurements AnalySIS 3.0 pro image analysis system was used. Relative interstitial volume, volume of interstitial infiltrate, with their variability--ross sectional areas of proximal and distal tubules were assessed by point counting method. Relative interstitial volume was significantly correlated to percentage of sclerosed glomeruli (R = 0.33 p < 0.001), degree of tubular atrophy (gamma = 0.57 p < 0.00001), degree interstitial fibrosis (gamma = 0.31 p < 0.0002) and mesangial matrix expansion (gamma = 0.24 p < 0.001). Semiquantitative and quantitative assessment of interstitial infiltrate was significantly correlated as well (gamma = 0.81 p < 0.001). Semiquantitatively assessed degree of tubular atrophy showed significant relation to total proximal tubular area (gamma = -0.30 p = 0,004). Percentage of sclerosed glomeruli was significantly correlated to creatinine level (R = 0.24 p = 0.03), but not to urea level (R = 0.09, NS). Semiquantitatively assessed degree of interstitial fibrosis showed only marginal correlation to creatinine level (gamma = 0.18 NS), however degree of interstitial infiltration was significantly correlated to creatinine (gamma = 0.34 p = 0.002) and urea level (gamma = 0.22 p = 0.06). Degree of tubular atrophy was significantly correlated to creatinine (gamma = 0.43 p < 0.001) and urea level (gamma = 0.28 p = 0.015). Relative interstitial volume was the very most important correlate of creatinine (R = 0.47 p < 0.0001) and urea level (R = 0.30 p < 0.01). In conclusion, it was confirmed, that the strongest correlate of renal function is relative interstitial volume. Some, but not all of semiquantitative parameters are also significantly correlated to kidney function.

Unlabelled: Chronic inflammation is a widely accepted pathophysiologic factor of development and progression of atherosclerosis. One of the most important consequences of atherosclerosis is accelerated arterial stiffness. The impact of chronic inflammation on arterial stiffness was not analyzed up to now in patients with end-stage renal disease treated with peritoneal dialysis (PD). The aim of the study was to evaluate the possible relationship between aortic pulse wave velocity (AoPWV), considered useful tool of aortic stiffness assessment and blood pressure parameters, anthropometric characteristics, pro-inflammatory cytokines and acute phase reactants in patients treated with PD. MATERIAL AND METHOSA: The study was performed in the group of 43 patients (19 F 24 M) with ESRD, in the mean age of 50.6 +/- 13.4 years and on dialysis for the mean period of 21.9 +/- 20.7 months. Pulse wave velocity was assessed using two pressure transducers placed on common carotid and femoral artery, connected with automatic processor. In all patients Tumor Necrosis Factor alpha (TNF alpha), interleukin 6 (IL-6), C- reactive protein and fibrinogen were assayed as 'markers of inflammation'. Blood pressure was also measured in the standardized conditions. Mean AoPWV equaled 10.7 +/- 2.1 m/s. Significant correlations were found between AoPWV, age, body weight and BMI. AoPWV was associated with systolic blood pressure, mean arterial pressure and pulse pressure., Results: Significant correlations between AoPWV and serum IL-6 were shown, whereas association with CRP was close to statistical significance (p= 0,053). Associations between AoPWV, age and systolic blood pressure were also confirmed by multiple regression analysis., Conclusion: Chronic, uremia-dependent inflammation may be one of the factors influencing aortic stiffness in patients treated with PD.

Calcium-phosphate balance abnormalities, present in chronic renal failure since its early stages, are responsible for their negative impact on bones and cardiovascular system which increases patients morbidity and mortality. Phosphate retention, the strong stimulator of PTH secretion, plays the main role in calcium-phosphate disturbances. The present paper reviews clinical experience with currently available phosphate binders and therapeutic strategies used in the treatment of secondary hyperparathyroidism. Special attention was paid to the new group of drugs namely calcimimetics, with emphasis on the first registered drug from this group cinacalcet. Mechanism of its' action, influence of the drug on calcium-phosphate balance parameters, safety profile, as well as the most frequent adverse effects are discussed in the present review.

Chronic inflammation is an inherent feature of chronic renal failure. Successful renal transplantation (RTx) is the only known renal replacement therapy sufficient to reverse most of the metabolic disturbances of chronic uremia, although still some of these abnormalities may be present or even new problems may occur (mostly as the side effects of immunosuppressive drugs). The aim of this study was to evaluate the level of inflammation in 20 patients (9 F, 11 M, aged mean 44.0 +/- 11.8 years) with well-preserved renal function 36 months after kidney transplantation, using serum levels of selected cytokines (IL-6, IL-18, TNFalpha and soluble receptor for TNF - sTNFRII), acute phase proteins (CRP, fetuin A) and hepatocyte growth factor (HGF). Procalcitonin was also assessed as the sensitive indicator of active infection. Obtained results were compared with the control group of healthy subjects in a respective age. Serum levels of IL-6, TNF-R and IL-18 were significantly higher, and HGF and fetuin A--significantly lower in patients vs. controls (p < 0.05 for all differences). Significant negative correlations were noted between glomerular filtration rate (GFR) and serum TNF, sTNFRII and IL-18 in RTx patients, whereas strong positive relationship between GFR and fetuin A was observed. Serum creatinine correlated with IL-6, IL-18, TNFalpha, sTNFRII and hsCRP levels and serum urea-with TNFalpha, sTNFRII, IL-6 and IL-18. Significant negative associations were also noticed between serum fetuin A and most of the tested inflammatory markers: sTNFRII (r = -0.77; p = 0.0005), IL-6 (r = -0.63; p = 0.009), hsCRP (r = -0.62; p = 0.009) and IL-18 (r = -0.60; p = 0.01). Obtained results permit us to conclude that the increased activity of inflammation can still be noticed in RTx patients 36 months after successful engraftment. This process is inversely associated with the level of kidney function. The role of fetuin A as the 'negative' acute phase protein was also demonstrated in this group of patients.

Pure red cell aplasia (PRCA) emerged recently as the potentially life-threatening condition secondary to anti-Epo antibodies. Vast majority of cases were reported from Western European countries and were secondary to subcutaneous injections of Epoietin alpha. Here we describe possibly for the first time in the literature the case of PRCA from Poland or even Central and Eastern Europe in patient treated exclusively with Epoietin beta from multi-dose vial. In the last section of the paper the current epidemiological, diagnostic and therapeutic aspect of PRCA were discussed.

Acute renal failure is a sudden clinical condition caused by loss of renal ability to maintain homeostasis. Despite significant advances in renal replacement therapy--the mortality rate in ARF patients is still very high--ranging from 20% to 50%. Differential diagnostics, especially between acute prerenal and intrinsic acute renal failure is an extremly important stage in patient evaluation process. In the article--the authors present a short and concise profile of novel, more and less promising for future diagnostic ARF biomarkers: neutrophil gelatinase associated lipocalin (NGAL), sodium/hydrogen exchanger isoform 3 (NHE3), human kidney injury molecule-1 (hKIM-1), interleukin 6 (IL-6), interleukin 8 (IL-8), interleukin 18 (IL-18), urinary cysteine-rich protein (Cyr 61), urinary glutathione-S-transferase (GST), cystatin C, spermidine/spermine N-acetyl transferase (SSAT) and actin) which are recently either in the animal model research stage or during preliminary clinical studies. Extension of research and wideninig of knowledge about the discussed novel, early markers of ARF--would permit for quicker introduction of specifically guided therapy and might improve the prognosis of ARF patients in the near future.

Rapid and dynamic increase of the number of patients that need different forms of renal replacement therapy can be noticed in the developed countries. This increase is associated with increased number of patients with 'diseases of modern civilization', such as diabetes and hypertension, which lead to kidney complications (e.g. diabetic and hypertensive nephropathy). Improved long-term care (especially diabetic and cardiologic) allows these patients to survive longer and to reach the stage of end-stage renal disease. This leads to increasing age and morbidity of patients treated with dialysis. In many cases, due to extremely advanced level of co-morbidity patients on dialysis are exposed to extreme level of suffering and unacceptably low quality of life. Persistent continuing of renal replacement therapy under such circumstances (with no hope for recovery or improvement) raises also some economical issues, especially in the context of permanent crisis and shortage of resources in health systems of most countries in the world. In this review the current practice concerning withdrawal or withholding of renal replacement therapy as well as some legal and ethical issues of this practice are discussed.

Liver and kidney are essential organs for maintaining metabolic balance because of their detoxificational, excretory and regulatory functions. Liver insufficiency, especially alcohol-induced hepatocirrhosis with ascites may cause functional, potentially reversible kidney failure known as hepatorenal syndrome (HRS). Hepato-renal syndrome is the reason for 8-30% cases of acute kidney failure in cirrhotic patients. It is also an independent risk factor of mortality in this group of patients. There are two types of HRS with different dynamics of clinical course and different prognosis for long term survival of patients. The only efficient treatment for HRS is transplantation of liver or it's right lobe from a living donor. Transplantation removes unbeneficial effects of liver failure and also in most cases restores proper kidney function. The other methods of treatment concentrate to improve and retain kidney function as long as possible and simultaneously to reduce mortality in patients awaiting for liver transplantation. Some of them are: administration of intravenous albumin, diuretics and arterial vasoconstrictors or correction of portal hypertension with a trans-jugular intrahepatic portacaval shunt (TIPS). In patients qualified to liver transplantation renal replacement therapy should also be undertaken. The newest supporting extracorporeal technique for liver insufficiency with/or without HRS is albumin dialysis with MARS of Prometheus devices.

Background: Accelerated atherosclerosis and vascular calcifications increase cardiovascular morbidity and mortality in patients on dialysis. Common carotid artery (CCA) intima-media thickness (IMT) is considered useful for imaging atherosclerosis non-invasively. Since chronic inflammation may accelerate atherosclerosis in end-stage renal disease patients, the aim of this 1 year study was to assess changes in CCA-IMT in stable peritoneal dialysis (PD) patients, and to search for possible associations between these changes and selected cytokines, acute phase proteins and other risk factors of atherosclerosis., Methods: Of the original cohort of 61 stable patients on PD-28 female, 33 male; mean age 50.4+/-13.6 years; dialyse for a median of 17.5 months at inclusion (range 1-96 months)-47 patients survived the 1 year period on PD. CCA-IMT was assessed at baseline and after 12 months. Pro-inflammatory cytokines (IL-6, TNFalpha), acute phase proteins (CRP, fibrinogen), calcium-phosphate balance and lipid profile were assessed at baseline and after 6 and 12 months. Anthropometric parameters (age, weight, BMI, waist-to-hip ratio) were measured at baseline., Results: The mean CCA-IMT at baseline, 0.66+/- 0.19 mm, increased by a mean of 0.098+/-0.17 to 0.76+/-0.21 mm (P<0.001) in 1 year. In 14 patients (29.8%) at least one plaque was found in the CCAs examined. At the end of follow-up: 28 patients (59.6%) had increases in CCA-IMT (from 0.63+/-0.2 to 0.83+/- 0.21 mm; P = 0.03), and 19 (40.4%) remained stable or even showed slight, but non-significant, decreases of CCA-IMT (from 0.72+/-0.17 to 0.66+/-0.17 mm, P = NS). The 'progressors' had significantly higher initial BMI (P<0.05), and mean concentrations of calcium (P = 0.005), IL-6 (P = 0.05), TNFalpha (P = 0.05), CRP (P = 0.005) and lower HDL-cholesterol than 'non-progressors'. In univariate analysis, DeltaCCA-IMT correlated positively with age (R = 0.32, P = 0.03), BMI (R = 0.29, P = 0.05) and mean concentrations of CRP (R = 0.37, P = 0.01), TNFalpha (0.52, P = 0.0002), but inversely with HDL-cholesterol (R = -0.37, P = 0.01). In multiple regression analysis, however, only age appeared to be independently associated with increase in CCA-IMT (beta = 0.37, P<0.01; R(2) for the model 0.14)., Conclusions: Our results suggest a possible role of non-specific inflammation in the progression of atherosclerosis in patients treated with PD, in addition to age.

Malnutrition of maintenance hemodialysis patients is a serious clinical problem, strongly and negatively affecting their outcome. However, very few studies are available concerning assessment of nutritional state and its predisposing factors in the Polish hemodialysed patient population. Included were 103 patients: 49 man and 54 woman (aged 48.57 years), on maintenance hemodialysis for an average of 71.46 +/- 64.3 months. They were subjected to anthropometry, SGA scale and biochemical evaluation. Simultaneously we calculated dialysis adequacy indicators. Then we compared obtained results with anthropometrical and biochemical norms and results obtained from the group of 29 healthy volunteers. Hemodialysed patients have been significantly underweight (62.51 vs. 73.55 kg in controls). Muscle mass loss dominated: AMA/50 centile AMA in the patients vs. controls have been 75.75 vs. 99.3%. Analysing body weight after dialysis to standard body weight (obtained from anthropometric data) ratio of 5.8% of patients were severely malnourished, 60.2% moderately malnourished. Analysing the patient study group 8.4% had albumin < 35 g/l and 33.3% prealbumin < 0.3 g/l. Only 34% achieved 10-12 points in the SGA scale. Normalized pcr < 1.2 g/kg/day was obtained in 54.4% patients. In the elderly we observed malnutrition more frequently than in the younger population. When pcr increases, also LBM and albumin level in blood increases. The patients who had metabolic acidosis revealed higher pcr and lower albumin. We did not find any relationship between Kt/V and AMA, LBM or albumin. The patients, who were underdialysed revealed lower prealbumin levels.