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Background: Vascular calcifications (VC) are increasingly prevalent in patients with chronic kidney disease. This study aimed to assess the incidence of iliac artery calcifications in kidney transplant (KT) patients and explore the relationship between iliac VC burden measured by pelvic calcification score (PCS) and renal transplant outcomes. Methods: This prospective study involved 79 KT recipients. VC quantification, using a pre-transplant computed tomography (CT) scan, was performed by assessing calcifications in the common and external iliac arteries bilaterally, resulting in an overall PCS ranging from 0 (no calcifications) to 44 (extensive calcifications). Based on PCS values, patients were divided into three equal-sized groups: PCS Group 1 (PCS 0-4), PCS Group 2 (PCS 5-19), and PCS Group 3 (PCS > 19). Post-transplant outcomes tracked for at least 1 year were patient and graft survival, graft function (urea, creatinine, MAG-3 clearance), and incidence of MACE during the first post-transplant year. Results: Calcifications were present in at least one arterial segment in 61 patients (77.2%). One-year patient survival was 95%, and one-year graft survival was 92.4%. Patients in PCS Group 3 had significantly lower one-year patient and graft survival compared to those in PCS Group 1 and 2 ( p = 0.006 and p = 0.008, respectively). MACE and renal function indicators 1-year post-transplant were similar across all PCS groups. Conclusions: Our study demonstrated that a significant majority of KT recipients exhibited iliac VC during pre-transplant CT assessments. Patients in PCS Group 3 exhibited significantly lower one-year patient and graft survival rates compared to those in PCS Groups 1 and 2, indicating that this subgroup may require more intensive post-transplant monitoring and management.

Tetralogy of Fallot is the most common cyanotic congenital heart disease. This severe disorder of cardiac physiology can impair renal function and lead to the development of cardiorenal syndrome and eventually to end-stage renal disease. Kidney transplantation may be the best option for renal replacement treatment in patients with tetralogy of Fallot, but only after correcting cardiac abnormalities and optimizing cardiac functions, all of which require a multidisciplinary approach. We report the first case of kidney transplantation in an adolescent patient with tetralogy of Fallot. Our findings confirms that kidney transplantation is a valuable treatment option in selected congenital heart disease cases., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Jakšić, Barbalić, Orlić, Župan, Vujičić, Gršković, Ćelić, Chinchella, Čače, Flajšman-Raspor, Bubić, Španjol and Markić.)

Background/Objectives: The interplay between thyroid function and kidney graft function following kidney transplantation remains incompletely understood. Thyroid disorders are more prevalent in kidney transplant recipients than in the general population and are associated with poorer outcomes. Methods: This prospective, single-center study was designed to estimate thyroid function (thyroid-stimulating hormone (TSH), triiodothyronine (T3), free triiodothyronine (FT3), thyroxine (T4), free thyroxine (FT4), as well as anti-thyroid peroxidase antibody (anti-TPO), anti-thyroglobulin antibody (anti-Tg), and thyroid-stimulating immunoglobulin (TSI)) and its influence on kidney graft function among a cohort of 23 kidney transplant recipients during a follow-up period of 12 months. Results: Significantly increased levels of T4 and T3 were observed 12 months post-transplantation, with FT3 levels increasing significantly after 6 months. The prevalence of immeasurably low anti-Tg antibodies rose during follow-up. Initially, 8% of patients showed positive TSI, which turned negative for all after 6 months. A statistically significant correlation was found between the initial TSH and the estimated glomerular filtration rate (eGFR) value 6 months after transplantation ( p = 0.023). The graft function was stable. Proteinuria was statistically significantly lower 12 months after transplantation. Conclusions: Identifying additional risk factors, understanding their impact on kidney graft function, and recognizing cardiovascular comorbidities could enhance patient care. Notably, this study marks the first prospective investigation into thyroid function after kidney transplantation in Croatia, contributing valuable insights to the global understanding of this complex interplay.

Objectives: Computerized tomography (CT) is the most accurate method for evaluating pelvic calcifications, which are of utmost importance for planning kidney transplantation (KT). The aim of our study was to evaluate the incidence and distribution of iliac artery calcifications and correlate the novel pelvic calcification score (PCS) with cardiovascular risk factors and graft and overall survival in KT patients., Methods: We retrospectively included 118 KT patients operated at our institution with pretransplant pelvic CT. Calcification morphology, circumference and length of both common and external iliac arteries were independently scored by two uroradiologists. PCS was calculated as the total score sum of all three calcification features in all vessels. PCS correlation with graft and patient survival was performed., Results: Calcification in at least one vascular segment was found in 79% of patients. PCS was significantly higher in male patients ( p = 0.006), patients over 55 years ( p < 0.001), and patients on haemodialysis ( p = 0.016). Patients with a PCS >3 had significantly shorter graft and overall survival rates ( p = 0.041 and p = 0.039, respectively)., Conclusions: The extent of iliac artery calcification in KT recipients quantified by PCS on pretransplant CT correlates with graft and overall patient survival. A PCS over three was associated with worse clinical outcomes and could become a possible prognostic factor., Advances in Knowledge: Our novel PCS is a robust method for quantifying iliac artery calcification burden. Since higher a PCS correlates with worse patient and graft survival, PCS has the potential to become a prognostic factor in kidney transplant patients.

Objectives: Our country Croatia is among the global leaders regarding deceased donation rates, yet we are facing organ shortage and concurrently a sharp decline in our acceptance rates for kidney offers. To reevaluate our organ acceptance policy, we retrospectively analyzed the factors that influenced the posttransplant outcomes of kidneys from elderly deceased donors at our center during a 20-year period and the changes to our organ acceptance criteria during Eurotransplant membership., Materials and Methods: We studied all kidney transplants from donors ≥60 years old during the two 5-year episodes of Eurotransplant membership from 2007 to 2017 (period II and period III) and compared those data to data from the decade before Eurotransplant membership (period I, 1997-2007). Differences in acceptance rates and reasons for the decline of kidney offers between the two 5-year periods of Eurotransplant membership were analyzed., Results: In period I, 14.1% of all kidney allografts were obtained from donors ≥60 years old; in period II and period III the rates were nearly 2-fold higher (27.0% and 25.7%, respectively; P = .007 and P = .008). During the first 5-year period of Eurotransplant membership (period II), we accepted significantly more grafts from marginal donors with a higher number of human leukocyte antigen mismatches compared with period I. Consequently, the 3-month survival rate of kidneys from donors ≥60 years old dropped from 91.1% to as low as 74.2% (P = .034). After application of morestringent human leukocyte antigen matching, especially in human leukocyte antigen DR, and morestringent donor acceptance criteria in period III, graft survival improved to 91.1%., Conclusions: Our experience indicates that careful selection of kidneys from elderly deceased donors and allocation to human leukocyte antigen-matched recipients is important to improve transplant outcomes.

With the increasing incidence of obesity and metabolic syndrome the incidence of nonalcoholic fatty liver ­disease (NAFLD) is increasing as well. These patients have a significant risk of progression to the end-stage liver disease, but also these patients are at increased risk of developing hepatocellular carcinoma. In recent years there is a growing ­number of publications that support the idea that NAFLD is not just a disease that is limited to the liver, but is associated with a number of extrahepatic manifestations. For example, NAFLD increases the risk of type 2 diabetes mellitus, cardiovascular diseases and chronic kidney disease. Consequently NAFLD has become a growing public health problem. A number of sub-specialists as well as primary care physicians should be aware of these potential extrahepatic associations, given the availability of numerous methods for screening in clinical practice. The above approach is important in order to recognize potentially modifiable events in the early stages, and thus manage them and at least prevent the progression of certain diseases.

XNonalcoholic fatty liver disease (NAFLD) has become a common cause of elevated liver tests. The association between fatty liver and metabolic syndrome (MS) is well documented and widely accepted. Cirrhosis due to nonalcoholic steatohepatitis (NASH) is currently the second most common indication for liver transplant with increasing incidence. Gastroenterologists/hepathologists and primary care physicians have more questions than answers regarding the NAFLD. The most common questions are which NAFLD patients have a risk of progression to NASH, fibrosis, cirrhosis and hepa- tocellular carcinoma, and which patients with NAFLD have a need for liver biopsy. In addition, a number of non-invasive diagnostic methods in the approach to the patient with NAFLD are investigated. How to approach these patients in routine clinical practice, is more of an art than a science at this time. In this article we will try to provide more recent recommenda- tions of how to approach the patients with NAFLD.

We report a case of a kidney-transplanted patient with urolithiasis treated with mini-percutaneous laser lithotripsy. The patient presented with renal dysfunction and graft hydronephrosis. Diagnostic procedures revealed ureterolithiasis as a cause of obstruction, and percutaneous nephrostomy was inserted as a temporary solution. Before surgery, the stone migrated to the renal pelvis. Mini-percutaneous laser lithotripsy was successfully performed, and during surgery, all stone fragments were removed. Six months after successful treatment, the patient has good functioning and stone-free graft.

Voiding dysfunction is frequently seen in the early posttransplant period. Among other causes, this condition can arise due to bladder outlet obstruction. Primary bladder neck obstruction (PBNO) is a possible but very rare cause of bladder outlet obstruction. We present the case of a 52-year-old woman who, after kidney transplantation, presented with PBNO. The diagnosis was established based on symptoms, uroflowmetry, and multichannel urodynamics with electromyography. The transurethral incision of the bladder neck was made at the 5- and 7-o'clock position. After the operation, the maximal flow rate was significantly increased, and postvoid residual urine was decreased compared to the preoperative findings. The patient was followed for 5 years, and her voiding improvement is persistent. This is the first reported case of PBNO treated with a transurethral incision of the bladder neck in a posttransplantation female patient.

Introduction: Acute renal failure (ARF) is a serious complication that occurs in 5%-18% of hospitalized patients and in up to 30% of patients admitted to Intensive Care Unit. The hospital mortality rate of patients with ARF is between 28% and 90%. The incidence of ARF is proportional to patient age. Therefore, despite all improvements in modern medicine, the annual incidence of ARF has not changed over the two past decades. The aim of our study was to analyze the incidence and causes of ARF in our Center during the five-year period, to analyze the characteristics of patients and their comorbid conditions, variations in laboratory parameters during hospitalization, and therapy administered. Also, we analyzed the outcome and length of hospitalization., Subjects and Methods: During the five-year period (from January 2008 till December 2012), we analyzed 316 patients treated for ARF at Department of Nephrology and Dialysis, Rijeka University Hospital Center. Data were obtained by searching medical records. ARF was defined according to the KDIGO recommendations: increase in serum creatinine (sCR) > 26 μmol/L within 48 h, or increase in sCR by 1.5 times compared to the reference values, which is known or assumed to have appeared within a week of hospitalization, or diuresis < 0.5 mL/kg/h for ≥ 6 hours., Results: Out of 316 ARF patients analyzed, 57 were hospitalized at our Department in 2008 (50.9% of men and 49.1% of women), 56 in 2009 (39.3% of men and 60.7% of women), 66 in 2010 (55.3% of men and 44.7% of women) and 76 in 2011 (55.3% of men and 44.7% of women). In 2012, we analyzed 61 ARF patients (42.6% of men and 53.4% of women). There were no statistically significant age and gender differences, although we noticed an increasing tendency in the number of elderly patients hospitalized for ARF. Furthermore, analyzing the frequency of patient arrival from home, nursing home or transfer from other departments we recorded an increase in the arrival of patients from nursing homes during the study period. Analysis of the proportion of patients hospitalized for ARF in our Department in relation to the total number of hospitalized patients revealed that ARF was the cause of hospitalization in 8.2%-9.9% of all patients. There was no significant change in the number of patients hospitalized for ARF during the period observed. Analyzing the frequency of hospitalization due to ARF by months, we noticed that the largest number of patients were hospitalized during summer months (from June to September). The most common form of ARF was prerenal (56.1%-67.9%). The largest number of patients were treated by parenteral rehydration and antibiotics (52.6%-71.4%). Renal replacement therapy was performed in 12.5%- 21.1% of all patients. The mortality rate throughout the period of observation ranged from 21.2%-30.4%. Furthermore, complete recovery of renal function was achieved in 30.5%-40.4% of all patients. The mean length of hospital stay ranged from 11.8 to 15.1 days., Conclusion: Acute renal failure is a significant cause of hospitalization, especially in elderly patients. Therefore, early identification along with appropriate and early treatment of patients with ARF is needed to improve survival and recovery of renal function in these patients.

Introduction: It is well established that nutritional status is an important factor affecting the outcome and recovery from disease or injury. Assessment of nutritional status is an integral part of care for patients with chronic kidney disease, especially for those treated with dialysis procedures. According to available literature, 18%-80% of patients on dialysis have some form of nutritional deficiency. Furthermore, in patients treated with dialysis procedures there is a rule called 'reverse epidemiology', according which patients with better nutritional status have better survival rate. Therefore, nutritional assessment should detect malnutrition and rate the overall nutritional status of each patient through clinical data categories: medical history, physical examination, nutrition physical examination, psychosocial history, demographics, physical activity, and current medical/surgical issues. Consequently, the main aim of our study was to analyze the nutritional status of our patients treated with hemodialysis procedures. Another aim was to analyze the applicability of measuring skinfold by caliper as a method of nutritional status assessment., Subjects and Methods: During a six-month period, we analyzed 129 patients (57.4% of men and 42.6% of women), mean age 68.1 ± 12.4 years, treated with hemodialysis procedures (24.8% of patients were treated with online hemodiafiltration and 75.2% with standard, conventional hemodialysis) as the method of choice of renal replacement therapy (RRT) for more than 6 months. All patients were dialyzed three times a week for four hours on biocompatible synthetic membranes. The patients treated with online hemodiafiltration were dialyzed on high-flux helixone membranes, while those treated with standard, conventional hemodialysis were dialyzed on polysulfone membranes and helixone low-flux membranes. The mean time of RRT was 71.2 ± 56.7 months. During the study period, in each patient we followed medical history, and clinical and laboratory parameters of nutritional status at 3 and 6 months. To assess the nutritional status, we used dry weight (DW), body mass index (BMI), skinfold caliper measurement (result is correlated with total body fat, FAT), and common laboratory indicators of nutritional status (serum albumin and cholesterol). RE- SULTS: Analyzing the efficiency of skinfold thickness measurement with caliper, we found that the FAT obtained by caliper showed a statistically significant positive correlation with clinical indicators of nutritional status, and with BMI (r = 0.364, p < 0.0001), DW (r = 0.206, p = 0.005) and volume of muscle circumference (r = 0.399, p < 0.0001). Also, FAT showed statistically significant positive correlation with laboratory indicators of nutritional status, including serum albumin (r = 0.299, p = 0.01) and cholesterol (r = 0.225, p = 0.002). There was no statistically significant correlation between the duration of RRT and FAT (p = NS)., Conclusion: In clinical practice, as well as for regular evaluation of nutritional status, it is important that the method we used proved efficient, precise, relatively fast and posing less economic burden. From our experience, the measurement of skinfold with caliper is an applicable, relatively quick and inexpensive method for regular assessment of nutritional status in patients treated with hemodialysis proce- dures. Therefore, all patients treated with RRT should undergo nutritional screening and expert help should be available from dietitians or nutritional support teams in order to identify this problem properly in its early stage and to reduce its high prevalence.

Renal transplantation has significantly improved survival of patients with end-stage renal disease (ESRD). Transplantation is the best treatment in this population of patients. Despite the introduction of various preventive measures, viral hepatitis, i.e. hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, are still a major problem because they are common in patients on renal replacement therapy as well as in allograft recipients. They are a significant cause of morbidity and mortality in this patient population. In recent years, hepatitis E virus (HEV) infection has been added as an emergent cause of chronic hepatitis in solid organ transplantation, mainly in renal and liver allograft recipients. Most studies show higher mortality in renal transplant recipients (RTRs) infected with HBV, compared with RTRs without HBV infection, although this topic is still under debate. Furthermore, HCV infection in RTRs is associated with a significant reduction in patient and graft survival due to liver disease and septic complications related to cirrhosis and immunosuppressive therapy. The immunosuppressive therapy prescribed after transplantation modifies the natural history of chronic HCV infection. Given the high prevalence of HCV and HBV infections in RTRs, a growing incidence of hepatocellular carcinoma and the possible contribution of immunosuppression might be expected in these patients. Therefore, after renal transplantation, early screening with abdominal ultrasound (every 3 months in cirrhotic patients and every 6-12 months in non-cirrhotic RTRs) is necessary when the risk factors such as HBV and HCV are present. The European Association for the Study of the Liver (EASL) recommends that all HbsAg-positive patients who are candidates for solid organ transplantation should be treated with nucleoside analogs. The KDIGO guidelines recommend that all HbsAg-positive RTRs receive prophylaxis with tenofovir, entecavir or lamivudine; however, tenofovir and entecavir are preferable to lamivudin. Viral suppression by inhibiting necro-inflammation may result in reduced fibrosis, thereby improving transplant survival. Active HCV infection in a dialysis patient requires evaluation of liver fibrosis. Antiviral therapy should be given to all HCV-infected dialysis patients in order to achieve a sustained virologic response (SVR) not only to avoid subsequent hepatic deterioration but also to limit the risks of HCV-related posttransplant de novo glomerulonephritis. Systematic vaccination of all HbsAg-negative patients is the best preventive treatment of HBV infection. HbsAg positive donors are only used occasionally, whereas the use of hepatitis B core antibody (HbcAb)+, HbsAg negative donors is more common but remains somewhat controversial. The presence of antibody to HCV is indicative of HCV infection because antibody to HCV appears in peripheral blood within two months of HCV exposure. However, it is important to emphasize that detection of antibody to HCV by serologic screening of the donor is not predictive of HCV transmission. Approximately 50% of patients positive for antibody to HCV have detectable hepatitis C viremia by PCR analysis of peripheral blood. Therefore, all organ donors with PCR analysis positive for HCV will transmit HCV to RTRs. On the other hand, the risk of transmission from an organ donor with negative PCR analysis is unclear. Another problem in the evaluation of the potential donors of solid organs is the fact that antibody testing by enzyme-linked immunosorbent assays (ELISAs) will not detect recent infections. The use of nucleid acid testing (NAT) could be useful because it involves amplification of viral gene products and thus is not dependent on antibody formation. Therefore, by using this method the period between the infection and detectability, which is known as the window period, could be reduced. However, this method is expensive and time consuming.

Protein-energy wasting (PEW) is a frequent problem in patients with end-stage renal disease, which is associated with adverse outcome. Risk factors for development of PEW in dialysis patients include anorexia, limitations in food intake due to problems with mineral metabolism (hyperphosphatemia, hyperkalemia). Prevention of PEW in dialysis population demands different therapeutic measures to correct abnormalities and to prevent loss of energy and proteins. Therapeutic approach should be individualized based on the specific problems of each patient in order to correct metabolic problems and to optimize food intake. In patients with inability to maintain nutritional status with standard oral feeding, other measures which include oral nutrition supplements and intradialytic parenteral feeding should be applied. Anabolic steroids, growth hormone and adequate oral nutritional supplements, together with physical activity may prevent further catabolism and correct abnormalities. Appetite stimulators, antiinflammatory interventions and anabolic drugs seem promising; however, their efficacy should be investigated in future clinical trials.

Aim: To describe the experience of the Department of Nephrology and Dialysis, University Hospital Rijeka, Croatia, in the treatment of patients with acute humoral rejection (AHR) of kidney transplant by using high dose of intravenous immunoglobulin (IVIG) alone and as a first line treatment., Methods: Eight kidney transplant recipients in whom the AHR appeared at different time after the transplantation were reported. At the time of transplantation cross-match in all patients was negative for both T and B cells. At the time of presentation, all patients had signs of renal allograft dysfunction and the rejection was proven by biopsy of the kidney transplant with positive C4d-staining and histopathological evidence of antibody-mediated injury. Early rejection was considered within 180 days after the transplantation and the late one 180 days after the transplantation. In two cases plasmapheresis (PAF) with albumin as replacement fluid was performed. Plasma exchange was done with a 35 mL/kg/body weight volume exchange with albumin for six times., Results: Acute humoral rejection was classified as early in three patients and in five as late one. In two patients PAF had been performed as the first line treatment. After the completion of PAF, recuperation of severe graft dysfunction was incomplete and in addition IVIG (as a single dose of 2.0 g/kg) was administered to these patients. In six patients IVIG as a single dose of 2.0 g/kg was applied as the first line treatment., Conclusion: Usage of high dose IVIG in the treatment of the acute humoral rejection is efficient, safe and relatively well tolerated.

The role of renin-angiotensin system inhibitors (ACE-inhibitors) or angiotensin receptor blockers (ARB) in the renal transplant recipients (RTRs) is incompletely defined and according to the current guidelines they should be initiated after six months post-transplantation. The aim of the present paper is to evaluate the efficiency and safety of early (within six months post-transplantation) versus late (after six months post-transplantation) initiation of ACE-inhibitors or ARB in RTRs. The study group compromised of 108 RTRs (50 male and 58 female) who received a kidney transplant. Beside other prescribed antihypertensive drugs all of them took and ACE inhibitors or ARB in order to achieve blood pressure control. For this analysis purpose, recipients were stratified into two groups according to the time of ACE inhibitors/ARB initiation into early (within six months post-transplantation) and late (after six months after transplantation) group. For each patient haemoglobin, serum creatinine and potassium levels were analyzed at the beginning of ACE inhibitors/ARB introduction and at the end of the first, third, sixth and twelfth month. In the 54 (50%) of the 108 patients ACE inhibitors/ARB were initiated within six months post-transplantation and in 49 (90.7%) of them within three months (in 29 patients within one month; in 13 within two months; in 7 within 3 months) post-transplantation. In additional 54 (50%) patients ACE inhibitors/ARB were initiated, but after six months post-transplantation. There was no statistically significant difference between the two groups related to age or gender and due to the duration of dialysis treatment before the transplantation. Analyzing the haemoglobin, creatinine and potassium serum levels after initiation of therapy with ACE inhibitors/ARB trough observed period we did not found any statistically significant difference in all measured parameters between the two groups of patients and also within the same group of patients. Therefore, according to experience from our Institution early initiation of ACE inhibitors or ARB appears to be safe in carefully selected recipients with relatively good early graft function.

Hypertension is a common finding in end-stage renal disease patients with the prevalence between 20 to 85%. Although the etiology of arterial hypertension (AH) in this patient group is multifactorial, sodium and volume excess leading to extracellular volume overload are one of the most important and potentially adjustable causes. Control of volume status can either normalize the blood pressure (BP) or make the AH easier to control in the great majority of dialysis patients. Heavy reliance is placed on the dialysis procedure to gradually remove fluid over a period of days to weeks until a stable dry weight is achieved. Numerous attempts have been made to utilize alternative methods to more accurately assessment of dry weight, and the newest and most interesting method is multifrequency bioelectrical impedance spectroscopy (BIS). In this prospective study we used BIS in 65 haemodialysis (HD) patients in order to detect those with volume-dependent hypertension and to further investigate the role of dry weight management in BP control. Dry weight was corrected at the beginning, and after 1, and 3 months. Final data were collected after six months. Our data showed that assessment of fluid overload using BIS provides better management of fluid status and BP control in the patients on maintenance HD, and that dry weight correction can lead to significantly better control of volume-dependent hypertension in this patient group.

Background and Aim: The mortality of chronic kidney disease patients is very high. Patients on chronic renal replacement therapy are also et very high mortality risk. Nevertheless, by the advance in renal replacement therapy the surveillance of these patients could be long with reasonable quality of life. The present a patient on renal replacement therapy for more than 38 years., Case History: Our patient was born in 1946. Twenty years later acute glomerulonephritis was diagnosed and he was treated with corticosteroid therapy for four years. Despite treatment his renal function deteriorated and haemodialysis was started in 1974. At that time, the haemodialysis regime was 12 hours two time per week and Kill dialyzer were used. Bicarbonate dialysis was introduced in 1984. Last 15 years our patient is on the hemodiafiltration. The treatment by erythropoietin was started in 1993. During this 38 years, he received two cadaveric kidney transplants. The first transplantation was in December 1974 in our hospital. Few days after transplantation he get rejection and transplant kidney never functioned. After one month he get thrombosis of the graft and transplantectomy was performed. The second cadaveric transplantation was performed abroad in 1985. Transplant kidney functioned only four days and fifth days urgent transplantectomy was performed. After these experience our patient decline any new kidney transplantation. First arteriovenous fistula was created at the time of start haemodialysis and was functional for 30 years. First arteriovenous graft was created after 30 years on the left forearm few years later on the left upper arm. Last graft has been in good function for six years. The last two years he has a central venous catheter. A subtotal parathyroidectomy was performed in 1983. After parathyroidectomy parathyroid hormone values were between 30 to 55 pmol/L, and the values of serum calcium and serum phosphate were in reference values. Last 15 years he had bone pain and before 10 years he had patlogical hip fracture. Due to vascular disease he often had skin ulcers and infections, particularly on the both hands. Very often he was treated by analgetics, sedatives, including opiates. Last severe complications was a bowel perforation, successfully treated by surgical intervention., Social History: Our patient graduated on the university. He is married and had one child. He has worked in the profession for several years. He was founder of association for dialysis and kidney transplant patients. Last twenty years he and colleagues conducted a private centre for haemodialysis. It was the first private centre in the country., Conclusion: Dialysis treatment sometimes can significantly prolong life, i.e. far more than expected in this group of patients and can offer appreciable quality of life.

Avascular bone necrosis is a relatively rare but significant complication in renal transplant recipients because it causes progressive pain and invalidity. It can be the consequence of the action of numerous causative factors, but it is mostly connected to corticosteroid treatment.The underlying pathophysiologic mechanism is a diminished blood flow to the bone leading to necrosis and bone destruction. During the past 25-years period, 570 renal transplantations and five combined kidney and pancreas transplantations were performed in our centre. A part of the patients was lost to follow-up due to the separation of Croatia from the former Republic of Yugoslavia. After transplantation, we revealed aseptic necrosis of the femoral head in five female patients. All patients had a history of treatment with pulse doses of corticosteroids. At transplantation the average age of the patients was 52.2 yrs (range 46 to 62 yrs), and dialytic treatment before transplantation lasted in average 9.2 yrs (range 2.5 to 21.2 yrs). The period between renal transplantation and the development of clinical signs of avascular bone necrosis lasted in average 1.2 yrs (range 0.3 to 2.3 yrs). We will demonstrate our 62-year old female patient with terminal renal failure caused by post-streptococcal glomerulonephritis, who was treated with peritoneal dialysis 2.5 years before renal transplantation. Twenty months before renal transplantation the patient received pulse doses of corticosteroids, together with immunoglobulins and plasmapheresis, for the treatment of an acute polyradiculoneuritis Guillaine Barré. After transplantation a standard immunosuppressive protocol was applied which included tacrolimus, mycophenolate mofetil, corticosteroids and induction with basiliximab. Four months after transplantation the patient started to feel pain in the right hip after longer standing, in addition to the earlier long-lasting problems caused by bilateral coxarthrosis. The pelvic radiograph showed subchondral radiolucencies in the lateral part of the head circumference spreading into the proximal part of the neck of the right femur, which indicated the presence of aseptic necrosis, but these changes could have also been caused by coxarthrosis. Unexpectedly, magnetic resonance imaging (MRI) did not reveal changes characteristic for avascular bone necrosis. Due to the progressively worsening of pain and the radiographic finding, the patient was submitted to decompression surgery of the femoral head. The surgical procedure was performed under diascopic guidance (C-arm) which allowed the correct positioning of a Kuerschner wire. A cannulated drill (diameter 4.0 mm) was placed over the wire and we performed two drillings of the spongiosis of the femoral head through to the subchondral area. Postoperatively, the patient was soon verticalized and advised to walk with crooks during a period of six weeks. This time is necessary to allow the mineralisation and strengthening of the bone which is now better vascularised. The patient recovered well and had no more pain. In renal transplant recipients it is most important to raise suspicion and verify the presence of avascular bone necrosis early, because timely bone decompression surgery can eliminate pain and cure the patient or it can prevent or delay bone destruction. When clinical signs of avascular bone necrosis arise and radiographic or standard MRI findings are negative, additional investigations (i.e. SPECT or MRI with contrast) should be performed to confirm or exclude the diagnosis. In latter phases of the disease, surgical decompression of the femoral head cannot lead to permanent amelioration, and it is inevitable to perform more invasive surgical procedures like "resurfacing" or bone grafting in younger patients, or the implantation of total hip endoprotheses.

Introduction: Advancements in immunosuppressive treatment of renal transplant recipients have significantly increased the graft and patient survival and significantly lowered the incidence of rejection crises. Efforts to increase long term patient and graft survival are directed to the prevention and treatment of cardiovascular diseases because they are the leading cause of mortality in these patients. Traditional risk factors for the development of cardiovascular diseases (e.g., arterial hypertension, posttransplant diabetes mellitus and metabolic lipid disorder) are up to fifty times more frequent among renal transplant recipients than in the general population. The goal of this study was to analyze the prevalence of the above mentioned metabolic disorders in renal transplant recipients, to analyze the impact of immunosuppressive therapy on the manifestation of these mentioned metabolic disorders, and to analyze the antihypertensive therapy applied., Subjects and Methods: We analyzed 53 patients that underwent renal transplantation at Rijeka University Hospital Center during a two-year follow-up. Glomerulonephritis was the primary kidney disease in 14 (29.6%), polycystic kidney disease in 10 (18.87%), interstitial nephritis in 7 (13.21%), nephroangiosclerosis in 5 (18.5%), diabetic nephropathy in 4 (7.55%) and other diseases in 13 (24.53%) patients., Results: The study included 53 patients (58.5% male), mean age 49.8 +/- 11.3 (range 27-72) years and mean dialysis treatment before transplantation 56.0 +/- 41.9 months. All patients received triple immunosuppressive therapy including a calcineurin inhibitor/MMF/corticosteroids and induction with IL-2 receptor blocker (daclizumab or basiliximab). Thirty-three (62%) patients were treated with tacrolimus and 20 (38%) with cyclosporine. The mean creatinine value was 144.92 +/- 46.49. Eighteen (34%) patients had creatinine lower than 120 mmol/L and 35 (66%) patients had a level higher than 120 mmol/L. After transplantation, 49 (92.5%) patients were treated for arterial hypertension (arterial hypertension was defined as systolic blood pressure greater than 140 mm Hg and diastolic pressure greater than 90 mm Hg or the routine use of antihypertensive therapy). Patients receiving cyclosporine had a significantly higher incidence of arterial hypertension as compared with patients on tacrolimus (P=0.025). Among patients with serum creatinine level higher than 120 mmol/L, 32 (65.3%) patients had hypertension, 9 (17%) achieved target blood pressure (<130/80 mm Hg), 8 (16.32%) were treated with one drug, 24 (48.98%) with two drugs, 15 (30.61%) with three drugs and 2 (4.09%) with more than three antihypertensives. Only four patients did not take any antihypertensive medication. The most often used antihypertensive drugs were calcium channel blockers (40.4% of patients), beta-blockers (26.6%), and RAS inhibitors (9.2% of patients received ACE inhibitors and 16.5% ARB). In 6 (11.3%) patients, posttransplant diabetes mellitus developed and 21 (39.62%) patients were treated for metabolic lipid disorder., Conclusion: In order to identify patients at a higher risk of developing cardiovascular disease with time, it is essential that kidney transplant recipients undergo regular follow up of graft function, blood pressure, and metabolic parameters. Good graft function is important to improve the quality of life and decrease mortality of renal transplant recipients.

Aims: Renal arterial pseudoaneurysm is a rare complication of renal transplantation that often causes a graft loss. A recent successful outcome of the operative treatment and a reappearance of a pseudoaneurysm and a possibility of watchful followup of pseudoaneurysm encouraged us to present our modest experience with pseudoaneurysm after renal transplant., Material and Methods: In our series of 843 renal transplants performed during 37 years vascular complications were observed in 57 (6.76%) patients. Pseudoaneurysm occurred in three patients (0.35%). The first pseudoaneurysm was found in 1973. A 23-year-old male patient received a double renal artery kidney from HLA identical brother. The upper renal artery was anastomosed by an end-to-end way with the internal iliac artery, and and the lower renal artery by end-to-side way to the external iliac artery. Five weeks after transplant an arteriography was performed because of the bruits heard over the transplant. A 15 x 10-mm pseudoaneurysm was revealed on the end-to-end anastomosis between internal iliac and upper renal artery. Six weeks after transplant a renal arterial resection and an end-to-side anastomosis between renal artery and common iliac artery was performed. The 38-year-old male patient received his second transplant from a 17-year-old female donor dead after craniocerebral trauma in December 2004. Two renal arteries were anastomosed separately with external iliac artery using aortic patches. Two and half moths after transplant he was admitted for an increase of creatinine level and hypertension. Color Doppler, dynamic scintigraphy and an angiography revealed a 20 x 1,3 mm aneurysmatic formation at the anastomosis of upper renal artery. The flow in the belonging part of the transplant was reduced. At surgical intervention a saphenous vein graft between internal iliac artery and renal artery was performed. Ischemia time was 15 min. The pseudoaneurysm was removed. A hole on external iliac artery was closed with a saphenal patch. The 38-year-old female patient received her second transplant in January 2005 from cadaver. There were 3 arteries. The upper polar arterywas first anastomosed to principal renal artery Then both arteries were anastomosed to external iliac artery termino-laterally., Results: In the first patient a lesion of the ureteral anastomosis caused an infection, thrombosis of lower artery and a graft loss 4 months and half after transplant. The second patient was admitted urgently 3.5 months after the repair of his pseudoaneurysm because of the pain in the pelvic region. He was working that day during several hours in sitting position on his terrace. Immediate examination with color Doppler revealed a large 6 x 7-cm pseudoaneurysm medially of the transplant. An arteriography demonstrated a pseudoaneurysm with a blood leakage most likely at the site of the closure of external iliac artery with a saphenal vein patch. The arteriography showed a slower and diminished blood flow in the lower part of the transplant. At intervention the pseudoaneurysm was removed. The external iliac artery was considerably damaged and replaced with Goretex prostesis 6 mm. Unfortunately the transplant lower artery could not be saved. A microbiological examination of pseudoaneurysm in both patients was negative. In the third case we chose a watchful follow-up. Last Doppler controls show reduction of psudoaneurysm., Discussion and Conclusions: The development of a pseudoaneurysm of a transplant artery is very rare complication. Since actually ultrasonography is routinely used, a pseudoaneurysm can be easily detected. Color Doppler allows a differential diagnosis from hematoma, urinoma and lymphocele. Unfortunately a pseudoaneurysm after renal transplant often causes a loss of the transplant. The first patient had successful resection of a pseudoaneurysm, but the transplant was lost because of infection. The other patient had a subsequent pseudoaneurysm after the repair of the first. Unfortunately its repair caused an exclusion of the lower part of the kidney, but the residual renal function is satisfactory. In the third patient we chose a follow-up aware that each intervention could cause a graft loss.

Malnutrition is an independent risk factor impacting on higher complications and increased length of hospital stay and costs. The aim of this study was to determine the prevalence of nutritional risk among patients on regular haemodialysis (HD) (Group I, N = 105) and among the patients at Gastroenterology, Endocrinology, Hematology and Clinical Immunology (Group II, N = 652). Cross-sectional nutritional evaluation was done using Nottingham Hospital Screening Tool (NS). The prevalence of nutritional risk was 9% in Group I and 21% in Group II (p = 0.0002). We found statistically significant larger quantity of malnourished patients among acute internistic patients than among chronic from the same Group II. Malnutrition among patients on HD didn't differ statistically to chronic internistic patients. We didn't found a significantly higher percentage of nutritional risk among elderly patients (65 years and more). Correlation between body mass index (BMI) and NS was significant, but weak (r = -0.32). We can conclude that the prevalence of nutritional risk among HD patients was lower than we had expected. It seems that the screening tool we used is not sensitive enough for HD patients and needs further investigations.

Goal: Analysis of the incidence of urothelial cancer and outcome of treatment in patients with Endemic Balkan Nephropathy (EN) after renal transplantation., Methods: From January 1985 until October 2006, 550 kidney transplantations (389 cadaveric) and 5 combined kidney and pancreas transplantations were performed in University Hospital Center Rijeka. In only 6 (1.1%) of 555 transplant recipients, EN was diagnosed as the original kidney disease, based on medical history, clinical findings, and laboratory results, but without pathohistologic verification. All patients with EN received the first renal transplant from a cadaver. Patients' mean age at transplantation was 50.3 +/-15.9 yrs, five patients (83.3%) were male. The incidence of malignant tumors in all 555 transplant recipients was analyzed, with an emphasis on the incidence of urothelial cancer and outcome of treatment in the group of patients with EN., Results: During posttransplant follow-up period, malignancy was diagnosed in 27 (4.9%) out of 555 transplant recipients. Skin cancer was diagnosed in 7 patients (1.3%), followed by cancer of the urinary tract in 6 patients (1.1%) and breast cancer in 3 patients (0.5%). In 3 of 6 patients with EN, urothelial cancer was diagnosed, resulting in the death in two patients. In the third patient, urothelial cancer showed a high affinity for recurrence, and besides the strong reduction of immunosuppressive therapy, repeated surgical treatment was needed., Conclusions: Patients with EN show a high incidence of urothelial cancer after renal transplantation. A thorough nephro-urological evaluation is needed before transplantation, and a careful follow-up is required afterward to ensure an early diagnosis of malignancy. Preventive nephroureterectomy is recommended.

Hypertension frequently occurs in patients with renal transplant. The aim of the present study was to determine the incidence, time of occurrence and hypertension severity following transplantation. A total of 78 patients (37 women and 41 men) mean age 49.9 +/- 12 years were included in the study. The post-transplant period amounted from 6 to 168 months. Prior to transplantation, hypertension was registered in 14 patients (17.9%). Following transplantation hypertension was registered in 59 (75.6%). During the first post-transplant year hypertension occurred in 79% of patients, while in the period of one to three years in 13.5% and in 6.7% of patients with transplant performed three or more years earlier. Hypertension responsive to only one drug was found in 22%, and to two or more drugs in 25% of patients. The satisfactory blood pressure values were obtained in 78% of patients. The study reveals that hypertension in the majority of renal transplant patients develops during the first post-transplant year.

Unlabelled: Today, the elderly are a fast growing population. Ever more patients aged > or = 65 are starting dialysis treatment. It is understood the they are a special and more sensitive group, due to their age and comorbid diseases. The aim of the study was to analyze the correlation of albumin, hemoglobin, cholesterol concentration and comorbid diseases at the beginning of treatment on the survival of patients aged > or = 65 years., Patients and Methods: Sixty-one patients starting hemodialysis (31 male and 30 female) were followed-up between January 1, 1995 and December 31, 1999. There survival was monitored until June 30, 2002. Study patients were divided in four groups according to years of survival: group 1--patients who died during the first year of treatment; group 2--patients who died in the second year of treatment; group 3--patients still alive in the third year up the fifth year of treatment; group 4--patients with >5-year survival. Group 1 had 17 patients (9 male and 8 female), mean age 71.4 +/- 4.3 years; group 2 15 patients (7 male and 8 female), mean age 71.2 +/- 3.9 years; group 3 25 patients (13 male and 12 female), mean age 70.3 +/- 4.4 years; group 4 four patients (two male and two female), mean age 71.0 +/- 5.0 years. There was no significant age difference among the groups. All patients received regular hemodialysis for 4 hours, three times per week. Cellulose diacetate membranes and bicarbonate dialysate were used in all patients., Results: The mean albumin value (g/L) at the beginning of dialysis was 31.9 +/- 5.9* in group 1, 35.3 +/- 6.4 in group 2, 38.1 +/- 6.6 in group 3, 41.8 +/- 6.7* in group 4 (p=0.017). The mean hemoglobin (g/L) value at the beginning of dialysis was 81.1 +/-14.3* in group 1, 85.7 +/- 20.5 in group 2, 86.4 +/- 14.5 in group 3, and 97.2 +/- 6.2* in group 4 (p=0.021). The mean cholesterol value (mmol/L) at the beginning of dialysis was 4.7 +/-1.1* in group 1, 5.1 +/- 1.8 in group 2, 5.2 +/- 1.5 in group 3, and 5.1 +/- 0.7* in group 4 (p=0.072). The greatest number of comorbid diseases were recorded in patients surviving for one year (4.6 +/- 1.2) and lowest in those surviving for more than five years (1.5 +/- 0.6) (p=0.001). In group 1, 70.6% of patients had five and more comorbid diseases. In group 2, 3 and 4, there were no statistically significant changes in albumin, cholesterol and hemoglobin concentrations during the first six months. Cardiac and cerebrovascular diseases were the most common cause of death., Discussion and Conclusion: Accordingly, shorter survival of elderly patients on hemodialysis correlated with lower albumin and hemoglobin values at the beginning of treatment. Also, patients with shorter survival rates had lower cholesterol values, however, without statistically significant differences. During the six month period there was no significant albumin increase in study patients. Shorter survival was associated with higher comorbidity. It is concluded that patients having appropriate albumin, hemoglobin and cholesterol values on starting dialysis therapy have better prognosis.

Chronic hemodialysis treatment in the world started in 1960. At that time, due to technical development and construction of arteriovenous shunt for repeated blood access for dialysis, it was possible to treat uremia. At the Department of Surgery, Rijeka Clinical Hospital, former Dr. Zdravko Kucić Hospital, first hemodialysis was performed in 1962, whereas regular chronic dialysis treatment started in 1966. On September 20, 1966, the first hemodialysis was done in a patient with chronic uremia. A week later, the next patient was admitted for therapy. The aim of the study was to analyze demographic and other data of all patients who started dialysis in the period between 1966 and 2001. There were 910 patients, 555 (60.9%) male and 355 (39.1%) female. In the first year, only two patients were treated with hemodialysis. Until 1970, the number of new patients was 4 or 5. From 1971 till 1984 between 10 and 19 new patients started dialysis every year, and from 1985 till 1990 their number ranged from 23 to 34 per year. Further increase in the number of treated patients was recorded in 1990 when 42 patients were dialyzed. In the following years until 2001 the figures were between 40 and 58, and in 2001 55 new patients were treated. In 1966, the mean age of patients undergoing this therapy was 29.5 years, and with time it increased to 40 in 1978. From 1989 on, the mean age rose to 50, and from 1998 to 60. In 2001, the mean patient age was 63.2 years. The primary renal diseases that led to uremia in the study population were glomerulonephritis (GN) in 256 (28.1%), pyelonephritis (PN) in 165 (18.1%), diabetes mellitus (DM) in 161 (17.7%), nephrosclerosis in 111 (12.2%), uremia after transplanted kidney rejection in 47 (5.2%), polycystosis in 40 (4.4%), lupus nephritis in 12 (1.3%), other causes in 89 (9.7%), and unknown cause in 24 (2.6%) patients. The distribution of primary renal disease during the observed period was as follows: from 1966 till 1979 the cause of uremia was GN in 88 (62%), PN in 30 (21.1%), DM in only 1, polycystosis in 3, post-transplant uremia in 7, lupus in 3, and other causes in 7 patients. From 1980 to 1989, GN was the cause of uremia in 67 (31.6%), PN in 45 (21.2%), DM in 22 (10.4%), nephrosclerosis in 26 (12.3%), polycystosis in 11 (5.2%), post-transplantation uremia in 12 (5.7%), lupus nephritis in 8 (3.8%), other causes in 17 (7.9%) and unknown cause in 3 (1.9%) patients. During the 1990-2001 period, GN was recorded in only 101 (18%), PN in 90 (16.2%), DM in 138 (24.9%), nephrosclerosis in 82 (14.7%), polycystosis in 26 (4.7%), post-transplantation uremia in 28 (5.0%), lupus nephritis in 6 (1.1%), other causes in 65 (11.7%) and unknown cause in 20 (3.6%) patients. The mortality was caused by cardiac disease in 50.4%, cerebrovascular disease in 14.8%, infectious disease in 13.2%, malignancy in 7.5%, high potassium in 5.1%, gastrointestinal disease in 3.5%, other vascular diseases in 1.6%, cachexia in 1.3%, loss of blood access in 0.8%, other reasons in 1.1% and unknown reasons in 0.5% of patients. The results clearly indicate that the number of new patients grew and the mean patient age increased every year. Diabetes mellitus was the leading cause of uremia while GN and PN were less common. The main causes of death were cardiovascular diseases.

Unlabelled: Acute renal failure (ARF) is an unusual and severe complication which may occur in patients following cardiac surgery. The incidence of ARF is from 1% to 15% (according to some authors up to 40%). The ARF, occurring in the postoperative period and requiring dialysis is an important risk factor for early mortality, while the overall mortality due to this complication is as high as 40% (40% to 90%)., Aim: The aim of this study was to assess the incidence of ARF in patients undergoing cardiac surgery at our hospital from January 1, 2001 to June 1, 2002 and to compare it with the data obtained at the same institution and published 17 years ago., Methods: A total of 290 patients undergoing cardiac surgery were analyzed, 71 (24.5%) female and 219 (75.5%) male, mean age 61.1 (range 17-81) years. Exclusion criteria were death within a few hours of surgery and need of chronic hemodialysis prior to surgery. ARF was defined as doubling of serum creatinine (sCr) concentration with preoperative sCr concentration below 130 micromol/L, or sCr increase by 100 or more micromol/L after cardiac surgery. Age, sex, type of surgery, preoperative sCr and preoperative risk factors (hypertension, diabetes mellitus, hyperproteinemia, pulmonary disease, peripheral vascular disease, central vascular disease) as well as complications occurring during the operation and their influence on ARF were analyzed. The incidence of ARF, therapy and mortality were also analyzed., Results: Ischemic cardiac disease was present in 236 (81%) and valvular disease in 41 (14%), ventricular or atrial septal defect in 6 (2%), thoracic aortic aneurysm in 3 (1%), patent ductus arteriosus in 2 (0.7%) patients, and pericardial tumor and penetrant pericardial injury in 1 (0.36%) patient each. Arterial hypertension was present in 199 (68.6%), hyperlipoproteinemia in 194 (66.8%), diabetes mellitus in 76 (26.2%), cardiac arrhythmias in 39 (13.45%), cerebrovascular diseases in 32 (11.0%) previous, renal diseases in 25 (8.6%), chronic obstructive lung disease in 23 (7.9%) patients, peripheral vascular disease by 19 (6.6%) patients, thyroid disease by 8 (3.1%), and malignant disease in 5 (7.1%) patients. Renal function according to sCr was as follows: <79 micromol/L in 90 (31.0%), 80 to 99 micromol/L in 124 (42.7%), and 100-129 micromol/L in 58 (20%), 130-159 in 10 (3.4%), and >160 micromol/L in 4 (1.4%) patients. ARF developed in 8 (2.1%) patients who had undergone cardiac surgery. Among them, only one (0.3%) patient needed dialysis treatment (hemodialysis and continuous venovenous hemofiltration). There were no differences in sex distribution between the patients who developed ARF and those who did not. The patients who developed ARF were older, mean age 65.7 years. Most of the patients with ARF suffered from hypertension, diabetes mellitus and hyperlipoproteinemia. Seventy-five percent of patients who developed ARF had some kind of "surgical" complications: postoperative bleeding with developing hemorrhagic shock, myocardial infarction during the operation, or acute abdomen after the operation., Conclusion: The incidence of ARF in patients undergoing cardiac surgery was low (2.1%). The incidence of severe ARF (which must be treated with dialysis) was 0.3%. We compared the data obtained at our hospital with those obtained 17 years ago and found a reduction in the incidence of severe ARF after cardiac surgery (0.3% vs. 4%).

The quality of life is considerably impaired in patients on regular hemodialysis has been changed. It is difficult to determine it because there are no general definitions or measuring instruments. There are objective and subjective components of the quality of life, one among them being occupational ability. During the progression of chronic renal disease (CRD) to terminal renal failure (TRF) physical activity of the patients becomes poorer. In this stage, their physical activity is by 40-60% below the value expected for the same healthy age cohort. The intention of this analysis was to determine occupational ability in patients on regular hemodialysis. The analysis included 161 patients on hemodialysis, 78 (48.5%) female and 83 (51.5%) male, mean age 61.2 +/- 13.1 years, and mean time on hemodialysis was 54 +/- 71.9 months. All patients filled-out a self-administered questionnaire on schooling and occupational ability. The cause of TRF was glomerulonephritis in 45 (26.8%), diabetes mellitus in 42 (26.3%), nephrosclerosis in 26 (16.1%), and pyelonephritis in 12 (7.4%) patients. Age distribution was as follows: 0-19 years 1 patient, 20-44 years 14 (8.7%); 45-64 years 64 (39.8%) and 65 years 82 (50.9%) patients. Educational structure: elementary school 65 (40.4%), secondary school 79 (49.1%), college 10 (6.2%), and university 6 (3.7%) patients. Occupational structure: retired 123 (76.4%), housekeeper 20 (12.4%), never employed 4 (2.5%), employed 10 (6.2%), unemployed 2 (1.2%), 1 child and 1 student. Among employed patients there were 7 men and 3 women. Their educational level was as follow: elementary school 1 patient, secondary school 8 patients, college 1 patient. At the beginning of hemodialysis their occupational status was: full-time employment 30 (18.6%) patients, part-time employment 1 patient, longer time on sick-leave payment (3.1%), retired 95 (59%), pupils and students 3, unemployed 2, and 1 child did not attended school. Time interval between the beginning of hemodialysis and retirement was: less than 1 year work 13 (36.1%) patients, 1-2 year work 6 (16.7%), three year work 2 patients, more than 8 year work 2 patients, and 10 year work only 3 patients, for 14, 18 and 26 years each. Two patients lost their job for employer bankruptcy. The judgment of patients regarding their occupational ability was as follows: out of 161 patients, 23 (14.3%) felt fit for work, 12 on full-time and 11 on part-time basis. Occupationally incapable were 46.6% of patients, and 63 felt unable to take care of another person. Some kind of additional activity, like working in garden or taking care of children was reported by 26 patients. The aforementioned results showed that 22.4% of the patients were occupationally active at the time of starting hemodialysis. Many patients were retired after hemodialysis had started. Only 6.2% of hemodialysis patients were occupationally active although 14.3% felt occupationally capable. The main reasons for such a low level of employment were advanced age, diminished physical activity due to the disease, and difficulties associated with the socioeconomic situation in the country.

On December 31, 2001, 2486 patients with terminal renal failure received dialysis treatment in Croatia. Only one third of the patients are registered on the national waiting list for cadaveric kidney transplant. In most of the others, transplantation is impossible because of comorbidity. This is mainly due to the steadily growing age of the dialytic population and therefore a higher incidence of cardiovascular disease and diabetes. Still, evaluation of the potential recipients of cadaveric kidney transplant, registered on the waiting list, often reveals contraindications for transplantation. The aim of this study was to determine the incidence and type of contraindications in transplant candidates, found during immediate preoperative evaluation. Analysis of these data should help in determining how contraindications can be early detected and prevented. Before registering onto the national waiting list transplant candidates need to be thoroughly investigated including detailed history, physical examination, routine diagnostic procedures and additional examinations, if needed, to exclude or evaluate the possibly existing contraindications for transplantation. During the period from January 1997 until June 2002, 145 potential recipients from the national waiting list were referred to the Rijeka University Hospital Center and evaluated for kidney transplantation. Eighty-eight patients underwent transplantation. Preoperative evaluation revealed contraindications for transplantation in 52 (35.9%) candidates. Twenty-two (15.2%) patients had a positive cross-match with donor lymphocytes, 6 (4.1%) patients refused transplantation, and in 24 (16.6%) patients serious comorbidity was the reason for not being accepted for transplantation and for their withdrawal from the national waiting list. Comorbidity was mainly due to cardiovascular disease (12 patients--8.3%) and infection (8 patients--5.5%). These data show a high incidence of contraindications found during the immediate preoperative evaluation of potential kidney recipients. It was the case in more than one third of patients. During the evaluation of potential candidates for kidney transplantation special attention should be addressed to the presence of cardiovascular morbidity and infection. Peripheral vascular occlusive disease, cardiac status and/or cerebrovascular disease should be evaluated. Measures used to treat or reduce the development of complications include an optimal control of blood pressure, serum phosphate, hyperparathyroidism, dyslipidemia, and renal anemia. The sites of infection must be treated and eradicated, because immunosuppressive treatment is a threat to the transplant recipient's life. The second most common cause of refusal of potential candidates was a positive cross-match with donor lymphocytes. Sensitization to human leukocyte antigens can be prevented by the avoiding of blood transfusions and use of erythopoietin in treating renal anemia. To minimize the morbidity and mortality, the potential kidney recipients should undergo rigorous selection and thorough evaluation before including them into the waiting list for kidney transplantation. Afterwards, regular examinations are obligatory to reveal contraindications, proceed to medical interventions and treat concomitant diseases in time, which can influence the patient's survival. In case that contraindications for transplantation arise, the patient must be temporarily or definitely removed from the waiting list.

Introduction: Cytomegalovirus (CMV) infection is the most common infectious complication after organ transplantation. Serology is useful only for detecting previous CMV infection. Dissatisfied with serologic follow-up after kidney transplantation, three years ago we introduced detection of CMV antigenemia by an immunocytochemical method using a monoclonal antibody specific for the pp65 CMV matrix protein. This test allows for quantification of positive leukocytes. The purpose of this paper is to present our three-year experience., Patients and Methods: From May 1999 till May 2002 CMV antigenemia was examined in 76 patients: 55 patients submitted to kidney transplantation during the study period, and 21 patients previously. Antigenemia became positive at 25.68 +/- 15.51 days after transplantation. These 76 patients were divided into three groups according to the number of positive cells per 200,000 leukocytes: < 5 (group I), 6-20 (group II) and > 20 (group III). The groups consisted of 23, 20 and 11 patients, respectively. The percentage of patients treated by ganciclovir was 4.34%, 15% and 100%, respectively. In group I only one patient received ganciclovir because of geographic indication, in group II three patients because of septicemia, thrombopenia and leukopenia and previous miliary tuberculosis., Results: One patient from group III with steroid diabetes died from pneumonia with abscess formation three days from admission. In another two patients, interstitial pneumonia and abscess of the arm developed. Five patients had an acute rejection episode each and were treated by high doses of methylprednisolone. Five patients had elevated temperature, transaminases were elevated in five patients, and neutropenia with or without thrombopenia was found in six patients. One patient had recurrent CMV disease and lymphocele. Two patients had preemptive treatment by ganciclovir based on positive CMV antigenemia., Discussion: Various centers differ according to the approach to treatment of CMV infection, ranging from prophylaxis to deferred treatment for CMV disease. Determination of pp65 CMV antigenemia allowed us a safe follow-up of patients after kidney transplantation. Compared with previous serologic follow-up antigenemia is a considerable progress. We did not use CMV prophylaxis because it is more expensive and can cause resistance to ganciclovir. A promising novel drug valganciclovir will allow for good prophylaxis owing to its better absorption from the gut. Based on our three-year experience, optimal cut-off for antigenemia has been set at 20 positive cells per 200,000 leukocytes. The existence of symptoms or changes in the level of leukocytes, platelets or transaminases goes in favor of treatment decision., Conclusion: Cytomegalovirus pp65 antigenemia is a reliable tool in the follow-up of patients after kidney transplantation. Patients with primary CMV infection, those with rejection episode and threshold of 20 positive cells require preemptive treatment with ganciclovir. The measurement of pp65 CMV antigenemia has clinical, analytical and cost-effective advantages. Intensive monitoring for CMV infection allows for quick and specific detection of active CMV infection. This approach avoids resistance to ganciclovir. The method is simple and specific without expensive equipment. Avoidance of unnecessary prophylaxis adds to its cost-effectiveness.

Metabolic bone disease is one of the most frequent complications of chronic renal failure. Numerous disorders leading to the metabolic bone disease can be reversed by successful renal transplantation. However, in some patients, in spite of satisfactory renal function, some disorders may persist for months after successful transplantation, e.g. increased parathyroid hormone secretion. Besides, drugs used in immunossuppressive therapy may cause metabolic bone disease or reduction of of bone mass. Therefore, significant loss of mass takes place in the majority of patients during the first six months. Among drugs used in the prevention of bone disease after transplantation of solid organs the most important role have biphosphonates and vitamin D, i.e. calcitriol.