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Sekundarni hiperparatireoidizam (SHPT) česta je komplikacija u bolesnika na hemodijalizi, međutim u nekih bolesnika mogu biti prisutne relativno niske koncentracije parathormona (PTH), tj. relativni hipoparatireoidizam (RhPT). Cilj rada je ispitati povezanost pojave RhPT s kliničkim i laboratorijskim obilježjima bolesnika te s lijekovima koje uzimaju. Bolesnici i metode: Proveli smo opservacijsko presječno istraživanje u bolesnika na hemodijalizi u tri centra. Uključeno je 199 bolesnika (127 muškaraca, 72 žene) prosječne dobi 66 godina i srednjeg trajanja hemodijalize 5,7 godina. Bolesnicima su određeni sljedeći parametri: dob, spol, šećerna bolest (DM), trajanje hemodijalize, vrsta lijekova koje uzimaju te laboratorijski parametri: Ca, P, PTH, albumin, alkalna fosfataza. RhPT je defi niran kao koncentracija PTH < 21,6 pmol/L. Rezultati: RhPT je bio statistički značajno povezan sa starijom dobi (prosječne dobi 70,5 prema 65,1 godina, p=0,026), šećernom bolesti (DM) (p=0,042), neuzimanjem vezača fosfata u terapiji (p=0,001), neuzimanjem aktivatora receptora vitamina D (aVDR) (p, Although secondary hyperparathyroidism (SHPT) is a common complication in hemodialysis patients, in some patients the concentration of parathyroid hormone (PTH) is relatively low, which can be defi ned as relative hypoparathyroidism (RhPT). The aim of this study was to examine the association of the occurrence of RhPT with clinical and laboratory characteristics of patients and their medication. Patients and methods: We conducted an observational cross-sectional study in hemodialysis patients at three centers. Altogether 199 patients were included. There were 127 men and 72 women, mean age 66 years and mean duration of hemodialysis 5.7 years. The following parameters were determined: age, sex, diabetes (DM), duration of hemodialysis, drugs, and laboratory parameters (Ca, P, PTH, albumin, alkaline phosphatase). RhPT was defi ned as PTH concentration

Anti-glomerular basement membrane (anti-GBM) disease is an acute and life-threatening systemic autoimmune disorder. The coexistence of circulating anti-neutrophil cytoplasmic antibodies (ANCA) and anti-GBM disease, the so-called double-positive disease (DPD), is exceptionally rare. We report a unique case of DPD manifesting as pulmonary-renal syndrome (PRS) in a 46-year-old woman who first presented with clinical and radiological suspicion of pneumonia. Chest computed tomography scan later revealed bilateral alveolar hemorrhage. Kidney biopsy showed necrotizing crescentic (100% glomeruli) glomerulonephritis. On immunofluorescence microscopy, glomeruli were global linear positive for IgG, confirming anti-GBM disease. Double positivity was detected for circulating anti-myeloperoxidase ANCA (p-ANCA) and anti-GBM antibodies. Acute renal failure evolved rapidly. Therapeutic plasma exchange (TPE) and hemodialysis (HD) were initiated early in combination with intravenous pulse corticosteroid therapy followed by oral methylprednisolone and cyclophosphamide. Pulmonary hemorrhage resolved, but renal function could not be preserved. The patient remains HD dependent. This case report highlights that pulmonary symptomatology may be the leading clinical presentation of PRS, with initially normal renal function at DPD onset. Early recognition and diagnosis are therefore crucial to timely clinical intervention. The role of prompt kidney biopsy and initiation of TPE and HD in PRS must not be underestimated., Bolest protiv glomerularne bazalne membrane (anti-GBM) je akutna i po život opasna sistemska autoimuna bolest. Pojava cirkulirajućih antitijela na citoplazmu granulocita (engl. anti-neutrophil cytoplasmic antibody, ANCA) u bolesnika sa anti-GBM glomerulonefritisom, tako zvana dvostruko pozitivna bolest (engl. double-positive disease, DPD), je vrlo rijetka. Prikazujemo 46 godišnju bolesnicu u koje je prvo klinički i radiološki postavljena sumnja na upalu pluća, a koja se kasnije manifestirala sa pulmo-renalnim sindromom (PRS) odnosno DPD. Kompjutorskom tomografijom pluća dokazano je alveolarno krvarenje. Biopsijom bubrega dokazan je nekrotizirajući glomerulonefritis (100 % glomerula). Imunoflorescencija je pokazala pozitivne linearne IgG depozite, što odgovara anti-GBM glomerulonefritisu. U bolesnice su dokazana antitijela na mijeloperoksidazu p-ANCA i antitijela na glomerularnu bazalnu membranu. Liječena je terapijskom izmjenom plazme (engl. therapeutic plasma exchange, TPE), hemodijalizom te kombinacijom parenteralne pulsne terapije kortikosteroidima, kasnije oralnom primjenom metilprednisolona i ciklofosfamida. Došlo je do regresije krvarenja u plućima ali se bubrežna funkcija nije oporavila, zbog čega smo nastavili s redovitim hemodijalizama. Ovaj prikaz bolesnice pokazuje kako u DPD, plućna simptomatologija može biti vodeći simptom PRS sa urednom bubrežnom funkcijom u početku. Rano prepoznavanja i dijagnoza su značajni za pravovremeni početak liječenja. Potrebno je naglasiti značaj rane biopsije bubrega, ranog početka TPE te po potrebi i nadomještanje bubrežne funkcije hemodijalizom.

Cilj rada bio je odrediti status vitamina D u bolesnika s terminalnom kroničnom bubrežnom bolešću liječenih kroničnom hemodijalizom (KBB-5-HD) i povezanost s osnovnim kliničkim i laboratorijskim parametrima. Bolesnici i metode: Presječno opservacijsko retrospektivno istraživanje provedeno je u bolesnika liječenih u Poliklinici za internu medicinu i dijalizu B. Braun Avitum. Bolesnicima je određena koncentracija 25OH-vitamina D (25(OH)D) u serumu, praćeni su dob i spol bolesnika, dužina liječenja na hemodijalizi, postojanje šećerne bolesti, koncentracija PTH, Ca, P, albumina i C-reaktivni protein (CRP) u serumu te oblik vitamina D primijenjen u liječenju. Na osnovi koncentracije 25(OH)-D bolesnici su klasifi cirani u tri skupine: defi cijencija (75nmol/L). Značajnost razlike među skupinama testirana je t-testom i jednosmjernim ANOVA testom za kontinuirane varijable i χ2-testom za kategorijske varijable, a postavljena razina značajnosti bila je p50nmol/ L), oni s 25(OH)D, The aim of this study was to determine vitamin D status in patients with end-stage kidney disease (ESKD) treated with chronic hemodialysis and its relationship with basic clinical and laboratory parameters in these patients. The cross-sectional observational retrospective study was carried out in patients treated at B. Braun Avitum Internal Medicine and Dialysis Polylinic. Serum 25OH-vitamin D (25(OH)D) was determined; other parameters included were age and gender, length of hemodialysis treatment, fi nding of diabetes mellitus, serum concentrations of parathyroid hormone (PTH), calcium, phosphate, albumin and C-reactive protein (CRP). Based on 25(OH)D serum concentrations, patients were classifi ed into 3 groups as follows: defi ciency (75 nmol/L). Between group differences were analyzed with t-test and one-way ANOVA for continuous variables, and χ2-test for categorical variables. The level of statistical signifi cance was set at p50 nmol/L) showed that those with defi ciency had higher PTH (40.78 vs. 28.42 pmol/L, p=0.003), higher phosphate (1.72 vs. 1.53 mmol/L, p=0.039), lower CRP (18.9 vs. 26.7 mg/L, p=0.019) and more often diabetes (29/65 vs. 16/69, p=0.011). These results showed a high prevalence of vitamin D defi ciency and insuffi ciency in patients with ESKD despite supplementation and treatment. Additional randomized and prospective studies are necessary to determine optimal treatment regimen, as well as its effects on morbidity and mortality.

Upravni odbor Hrvatskoga društva za hipertenziju na svojoj elektroničkoj sjednici održanoj 12. prosinca 2018. raspravljao je o opaženom povećanom riziku za nastanak nemelanomskih karcinoma kože povezanom s liječenjem hidroklorotiazidom i pripremio sljedeće mišljenje. Zaključci 1. Rizik od nemelanomskoga karcinoma kože i usnica veći je u bolesnika liječenih hidroklorotiazidom nego što je u osoba koje nisu liječene ovim lijekom. Rizik se povećava s duljinom trajanja liječenja, tj. s kumulativnom dozom. 2. Mehanizam karcinogenosti hidroklorotiazida temelji se na fotosenzitivnosti. UV zračenje dovodi do disocijacije kloridnoga dijela molekule lijeka, čime se stvara pretpostavka za sintezu slobodnih radikala kisika i posljedično oštećenje molekule DNK. 3. Korist od primjene hidroklorotiazida veća je od rizika. 4. Omjer koristi i rizika napose je veći u starijih i teže bolesnih osoba. 5. Bolesnik mora biti informiran o postojećem riziku. 6. Bolesnik mora biti informiran o postojećoj alternativnoj terapiji koja je na raspolaganju u Hrvatskoj. 7. Svaki liječnik mora u svakoga pojedinog bolesnika procijeniti omjer koristi i rizika te nakon razgovora s bolesnikom odlučiti nastavlja li terapiju hidroklorotiazidom ili se odlučuje za postojeću alternativu. 8. Svim bolesnicima, a napose bolesnicima koji su liječeni hidroklorotiazidom, treba preporučiti uporabu adekvatne fotoprotekcije i redovito provjeravanja pojave ili promjena na koži.

Cilj je bio istražiti prognostička svojstva sindroma niskog trijodtironina, proteinsko energetske pothranjenosti i kronične upale te drugih poznatih rizičnih čimbenika sa smrtnošću prevalentnih dijaliznih bolesnika.

AIM: The analysis aims to determine relationship between BMD assessed by T and Z score and mortality risk in hemodialysis (HD) patients. Furthermore, it explores which skeletal sites are most suitable for predicting mortality rate. METHODS: Present study has analyzed the survival of 102 patients who had been treated with chronic HD according to the bone mineral density (BMD). RESULT: Patients who had T score ≤ 2.5 at mid part of forearm, at ultradistal and proximal part of forearm, suffered from a higher death risk than those T score was ≥ -2.5. But besides that, there has not been found any statistically significant association between losses of bone mass at other measuring points – lumbar spine (antero-posterior orientation from L1-L4) and hip (neck, trochanter, intertrochanter, total and Ward's triangle) – and mortality risk. Moreover, the examination has been interested in exploring a relationship between Z score in different skeletal regions and mortality risk. It has been found that patients who had Z score ≤ -1 at all three parts of forearm had a great mortality risk. Also, it is worth to mention that Z score noted at all three parts of forearm was more apparent predictor of mortality, compared to T-score in the same skeletal regions. CONCLUSION: This empirical analysis showed that BMD assessed should be obtained at forearm, due to a good predictability quality of this skeletal site, when it comes to mortality of HD patients. What is second, data concerning bone density should be reported as Z-scores.

Introduction Control of serum phosphate is important for patients on hemodialysis. The aim of the study was to determine if education based on phosphorus-reducing techniques in food preparation and thermal processing, and accordingly prepared and applied diets, will lead to better outcomes than a standard education program to improve phosphate control in patients on hemodialysis. Methods Forty-seven patients on hemodialysis were divided between an intervention and a control group. All subjects received training about nutrition for hemodialysis patients by trained dietitian. In addition, subjects in the intervention group received additional training in phosphorus-reducing techniques in food preparation and received two hospital meals prepared using suggested cooking methods to reduce the phosphate content of food during dialysis treatment. Serum phosphate, serum albumin, and anthropometric parameters were measured, while nPCR was calculated, at the baseline and during the 1-year study. Findings No differences in serum phosphate levels were observed between intervention (1.68 mmol/L [1.48-2.03]) and control group (1.88 mmol/L [1.57-2.2]) at baseline (P = 0.130). Although not statistically significant between groups the mean reduction was more apparent in the intervention group (-0.3 mmol/L (-0.4 to 0.1) vs. -0.2 (-0.5 to 0.1)), and lead to significantly reduction of phosphate binder therapy. During the study, the nPCR and anthropometric status of the patients did not change significantly. Discussion Providing additional education to hemodialysis patients on the specific cooking methods and accordingly prepared meals may decrease serum phosphate levels without significantly affecting nutritional status which may be useful in helping to prevent and treat hyperphosphatemia.

Uvod: Prijašnje studije pokazale su da je preostala bubrežna funkcija važniji pokazatelj preživljenja, morbiditeta i kvalitete života pacijenata nego propisana, odnosno dobivena dijaliza. Cilj ove studije bio je istražiti koji klinički i laboratorijski parametri su povezani s preostalom diurezom. Pacijenti i metode: Analizirali smo 206 pacijenata (120 muških) na kroničnoj hemodijalizi (HD), srednje dobi 67, 8 ± 13, 2 godina. Prosječna duljina trajanja nadomjesne bubrežne terapije bila je 56, 6 ± 66, 4 mjeseci. Rezultati: Nismo utvrdili niti jednu značajnu povezanost između preostale diureze te dobi, spola i prisutnosti arterijske hipertenzije, odnosno koronarne bolesti srca. Unutar proučenih laboratorijskih testova samo su serumski kalij (r = -0, 143 ; p = 0, 05) i serumski kreatinin (r = 0, 181 ; p = 0, 01) pokazali značaju korelaciju s preostalom diurezom. Nadalje, duljina trajanja hemodijalize (r = -0, 339 ; p < 0, 0001), prisutnost šećerne bolesti (-0, 173 ; p = 0, 02), tjedni porast tjelesne mase između hemodijaliza (r = -0, 185 ; p = 0, 01) te hipotenzivne krize tijekom HD (r = -0, 188 ; p = 0, 009) pokazali su značajno negativnu korelaciju s preostalom bubrežnom funkcijom. S druge strane, kardiotorakalni indeks (r = 0, 217 ; p = 0, 01), uporaba diuretika (r = 0, 326 ; p < 0, 0001), dnevna doza diuretika (r = 0, 276 ; p = 0, 0001), uporaba ACE-I/ARB-ova (r = 0, 148 ; p = 0, 04), blokatora kalcijevih kanala (r = 0, 152 ; p = 0, 03), sistolički tlak prije (r = 0, 148 ; p = 0, 04) i nakon HD (r = 0, 263 ; p = 0, 0002), dijastolički tlak prije početka HD (r = 0, 149 ; p = 0, 04) te poslije (r = 0, 244 ; p = 0, 0007) pokazali su značajnu pozitivnu korelaciju s preostalom bubrežnom funkcijom. Zaključak: Upotreba diuretika, ACE-I/ARB-ova, blokatora kalcijevih kanala, tjedni porast tjelesne mase između hemodijaliza, sistolički i dijastolički tlak prije HD te posebno sistolički i dijastolički tlak poslije HD pokazali su značajnu povezanost s očuvanom bubrežnom funkcijom.

Arterijska je hipertenzija glavni neovisni čimbenik rizika za kardiovaskularni pobol i smrtnost. Prevalencija hipertenzije u većini zemalja pokazuje tendenciju rasta. Unatoč dostupnosti svih razreda antihipertenziva, kontrola liječenih hipertoničara nije zadovoljavajuća, za što postoji niz razloga i objašnjenja. Jedan od razloga jest i jaz između smjernica koje se temelje na činjenicama te mogućnostima njihova provođenja u stvarnome životu, što kao posljedicu ima lošu kontrolu hipertenzije i velik broj prijevremenih kardiovaskularnih događaja i smrti. Prvi korak u zbrinjavanju hipertoničara jest racionalna dijagnostika, što znači da pri tako masovnoj kroničnoj bolesti nepotrebnim pretragama ne povećavamo troškove, a s druge strane da pristupom na najmanju mjeru smanjimo propuste. Svrha je ovih smjernica za dijagnosticiranje arterijske hipertenzije da budu praktične i korisne u svakodnevnome radu. U njima je naglasak na konkretnim postupcima i podatcima s točno navedenim graničnim vrijednostima. Budući da je cilj smjernica ne samo usmjeriti i olakšati razmišljanja u svakodnevnome kliničkome radu nego i educirati, uz postupnike podsjećamo na neka temeljna znanja. U smjernicama ima nekoliko posve novih elemenata (upute o frekvenciji srca, mjesto i uloga mjerenja centralnoga arterijskoga tlaka i brzine pulsnoga vala, procjena bubrežne funkcije, zatim informatička tehnologija, tj. telemonitoriranje, primjena aplikacija za „pametne mobitele“). Na kraju smjernica uvršteno je nekoliko dodataka koji mogu biti korisni u svakodnevnome kliničkome radu, kao što su npr. upitnici za sindrom apneje u snu, upitnik o erektilnoj i seksualnoj disfunkciji, upitnik o kognitivnoj disfunkciji i drugi. U ovim smo smjernicama željeli biti praktični, precizni i realni s obzirom na mogućnosti koje nam pruža sredina u kojoj živimo. Svrha je bila na jednome mjestu obuhvatiti i prikazati što više konkretnih postupaka i podataka koji će biti korisni u radu, tako da liječnik ne mora gubiti vrijeme tražeći podatke bilo u samim smjernicama bilo u literaturi.

Chronic kidney disease (CKD) is a systemic disease with numerous complications associated with increased morbidity and mortality. Chronic kidney disease-metabolic bone disease (CKD-MBD) starts at early stages of CKD with phosphorus accumulation and consequent initiation of numerous events that result with the development of secondary hyperparathyroidism with changes on bones and extraskeletal tissues. The most important and clinically most relevant consequences of CKD-MBD are vascular calcifications which contribute to cardiovascular mortality. Patients with the increased risk for the development of CKD-MBD should be recognized and treated. Prevention is the most important therapeutic option. The first step should be nutritional counseling with vitamin supplementation if necessary and correction of mineral status. Progression of CKD requires more intensive medicamentous treatment with the additional correction of metabolic acidosis and anemia. Renal replacement therapy should be timely initiated, with the adequate dose of dislaysis. Ideally, preemptive renal transplantion should be offered in individuals without contraindication for immunosuppressive therapy.

Kronična bubrežna bolest (KBB) sistemska je bolest povezana s nizom komplikacija koje naposljetku dovode do povećanog pobolijevanja i smrtnosti bolesnika. Poremećaj koštano-mineralnog metabolizma (CKD-MBD) počinje u ranim stadijima KBB-a nakupljanjem fosfora u organizmu s posljedičnim pokretanjem niza zbivanja koja rezultiraju razvojem sekundarnog hiperparatiroidizma s promjenama na kostima i izvankoštanim tkivima. Najvažnija i klinički najbitnija posljedica CKD-MBD-a jesu vaskularne kalcifikacije koje pridonose povećanju smrtnosti od srčano-krvožilnih bolesti. Potrebno je prepoznati bolesnike s povećanim rizikom od razvoja CKD-MBD-a i terapijski intervenirati. Prevencija je najbolji ­pristup zbrinjavanju bolesnika. Prvi korak u liječenju jest nutritivno savjetovanje uz nadoknadu vitamina i ispravljanje poremećaja minerala. Napredovanjem KBB-a prema završnom stadiju povećava se potreba za medikamentnom terapijom. Istodobno treba liječiti i ostale probleme poput anemije i acidoze. Potrebno je pravodobno započeti s nadomještanjem bubrežne funkcije uz osiguranje odgovarajuće doze dijalize. Idealno je omogućiti preemptivnu transplantaciju u bolesnika koji nemaju kontraindikacija za primjenu imunosupresijske terapije., Chronic kidney disease (CKD) is a systemic disease with numerous complications associated with increased morbidity and mortality. Chronic kidney disease-metabolic bone disease (CKD-MBD) starts at early stages of CKD with phosphorus accumulation and consequent initiation of numerous events that result with the development of secondary ­hyperparathyroidism with changes on bones and extraskeletal tissues. The most important and clinically most relevant consequences of CKD-MBD are vascular calcifications which contribute to cardiovascular mortality. Patients with the ­increased risk for the development of CKD-MBD should be recognized and treated. Prevention is the most important therapeutic option. The first step should be nutritional counseling with vitamin supplementation if necessary and correction of mineral status. Progression of CKD requires more intensive medicamentous treatment with the additional correction of metabolic acidosis and anemia. Renal replacement therapy should be timely initiated, with the adequate dose of dialysis. Ideally, preemptive renal transplantation should be offered in individuals without contraindications for immunosuppressive therapy

Smjernice za prevenciju, praćenje i liječenje koštano-mineralnog metabolizma u bolesnika s kroničnom bubrežnom bolesti

Calcific uremic arteriolopathy or alciphylaxis is a malignant form of calcification of small arteries and arterioles, usually present in patients with chronic kidney disease and dialysis therapy. It causes high mortality. Histological distinctive feature are calcium deposits lining vascular intima. Calcification of medial muscle layer, inflammation and necrosis of subcutaneous adipose tissue are frequent. The disease begins with painful violaceous mottling, resembling livedo reticularis. Ths skin lesion progresses to ulcers and eschars, sometimes it becomes very vulnerable to secondary infection which can often develop into fatal sepsis. Our first patient with proximal form of calciphylaxis dies in repeated sepsis. The second patient with the distal form of calciphylaxis was treated successfully. The decisive moment was the use of calcimimetic. A multiinterventional strategy is likely to be more effective than any single therapy. It is necessary to regulate metabolism of calcium phosphate and secondary hyperparathyroidism. Effectiveness has been demonstrated using calcimimetics, sodium thiosulfate, oxygen therapy, careful application of biphosphonates and surgical procedures. Warfarin withdrawal is urgently recommended and subsequent vitamin K supplementation is appropriate. The control of infection is critically important and the use of carbonylated hemoglobin in the stage without infections could accelerate the wound healing.

BACKGROUND: Recent observations have associated low magnesium (Mg) levels with increased risk of cardiovascular (CVD) morbidity and mortality in hemodialysis (HD) patients. There have been some small studies of hypomagnesemia due to use of proton-pump inhibitors (PPIs). Since patients with end-stage renal disease have little to no kidney Mg loss to affect serum Mg concentration, HD patients are an interesting population in whom to study the relationship between PPI use and serum Mg levels. METHODS: A total of HD 418 patients were screened for inclusion, with 159 excluded due to either incomplete medical data, use of Mg-based phosphate binders or other Mg-based medications or presence of chronic increased GI losses. Among 259 patients included in the study, 160 patients were on PPIs, and median time on the PPIs was 25.2±20 months. There was no significant difference in dialysate Mg concentrations between the PPIs-users and non- users (0.6±0.1vs.0.6±0.1 ; p=0.750). RESULTS: The most common prescribed PPIs was pantoprazole (67.5%). There were no significant differences between the two groups in age, presence of diabetes, duration of HD, or mean values for calcium, phosphorus, albumin or iPTH. Pre-and postdialysis systolic and diastolic blood pressures were also not different between the two groups, as well as diuretic use (29.4%vs.34.3 ; p=0.483). Serum Mg levels were significantly lower among PPI users vs. non-users (0.96vs.1.02 mmol/L, p=0.028). The daily PPIs dose almost reached the significant correlation with low Mg levels (r=0.138 ; p=0.080). The duration of PPIs use (r=0.128 ; p=0.142) wasn´t significantly associated with Mg levels. Although, PPI users had higher rate of adverse CVD events during the one year of follow-up in comparison to non- users, that difference wasn’t statistically significant (17.5%vs.11.1% ; p=0.110). CONCLUSION: Among HD patients, PPI users have lower serum Mg levels as compared with non- users. This observational investigation indicate the need for interventional studies to confirm a cause-effect relationship between hypomagnesemia, PPI use and adverse CVD outcomes in HD patients.

BACKGROUND/AIM: Outcome studies suggest that residual renal function (RRF) is a more important determinant of patient survival, morbidity, and quality of life than the prescribed or achieved dialysis dose. The aim of this analysis was to investigate which clinical and laboratory parameters are associated with residual diuresis. METHODS: We analysed 418 (242 male) chronic haemodialysis (HD) patients mean age 67.7 ±13.1 years from five dialyses centres. The mean duration of renal replacement therapy (RRT) was 55.9 ±64 months, while the most commons etiologies of chronic kidney disease were arterial hypertension (30%) and chronic glomerulonephritis (24%). Of 417 analysed patients, 147 (35%) were anuric, while 256 of them had daily urine output of less than 500 ml per day. RESULTS: We didn’t find any significant correlation among residual diuresis and gender, systolic blood pressure (SKT) before the start of HD treatment, as well as SKT at the end of HD procedures and patients dry weight (p=NS). Among investigated laboratory tests (haemoglobin, urea, serum creatinine, potassium, sodium and albumins, as well as C-reactive protein), only serum potassium (r= -0.179 ; p=0.0003) and serum creatinine (r= -0.203 ; p

AIM: The aim of present analysis was to determine the relationship between BMD assessed by T and Z score and mortality risk in hemodialysis (HD) patients. Also we were explore which skeletal sites are the best in predicting mortality rate. METHODS: In the present study we have analyzed the survival of 102 patients that were treated with chronic HD according to the bone mineral density (BMD). RESULTS: Patients who had T score ≤ 2.5 at mid part of forearm, at ultradistal and proximal part of forearm had a higher risk for death than those patients who had T score ≥ -2.5 On the other hand, we didn’t find any statistically significant association between losses of bone mass at other measuring points ; lumbar spine (antero-posterior orientation from L1-L4) and hip (neck, trochanter, intertrochanter, total and Ward\'s triangle) and mortality risk. Next we were interested to explore the relationship between Z score in different skeletal regions and mortality risk. We have founded that patients who had Z score ≤ - 1 at all three parts of forearm had a great mortality risk. Also, Z score obtained at all three parts of forearm was an even better predictor of mortality in comparison to T-score in the same skeletal regions. CONCLUSION: Based at our experience, BMD assessed should be obtained at forearm because this skeletal site is a good predictor of mortality in HD patients. Furthermore, data about bone dnsity should be reported as Z-scores.

Kronična bubrežna bolest (KBB) je globalni javno zdravstveni problem. Koštana bolest i poremećaj mineralnog metabolizma česti su u KBB. Značaj fosfora u patogenezi koštane bolesti odnosno sekundarnog hiperparatireoidizma dobro je poznat. Postoje brojni dokazi kako je hiperfosfatemija predskazatelj povećane smrtnosti u KBB, odnono kako je hieprfosfatemija novi rizični čimbenik kalcifikacije krvnih žila, hipertrofije lijeve klijteke i progresije kronične bubrežne bolesti. Prevencija i liječenje hiperfosfatemije u KBB je veliki stručni izazov. Novi vezači fosfata pružaju nove i bolje mogućnosti liječenja.

For more than 50 years, renal osteodystrophy has been known as one of the most common complications of chronic kidney disease. Mineral metabolism disorder develops at the early stages of kidney failure. Hyperphosphataemia, hypocalcaemia and vitamin D deficiency are the most important factors. Mineral metabolism disorder leads not only to the development of bone disease, but also to even more important pathological changes – calcifications of blood vessels. Therefore, renal osteodystrophy is considered a part of the syndrome called chronic kidney disease–mineral bone disorder. In all patients with glomerular filtration rate

Peritonejska dijaliza (PD) je metoda izbora kod bolesnika u kojih je otežano kreiranje krvožilnog pristupa za hemodijalizu. Tridesetosmogodišnja bolesnica javila se u našu Ustanovu u fazi terminalnog bubrežnog zatajenja nepoznate geneze zbog kreiranja AV fistule. Zbog preboljelog moždanog udara 1993. godine, bolesnici je zaostala desnostrana hemipareza s kontrakturom šake i epilepsija. Učinjenom obradom dijagnosticirali smo lupus nefritis s fosfolipidnim sindromom, okluziju trunkusa brahiocefalikusa, zajedničkih karotidnih arterija, te lijeve arterije subklavije. Također smo dokazali glutensku enteropatiju i značajnu anemiju. Kreiranje AV fistule na ruci nije bilo moguće, kao niti asistirana peritonijska dijaliza, a zbog desnostrane hemipareze i kontrakture desne šake bila je upitna mogućnost samostalnog provođenja peritonejskih izmjena. Unatoč tom hendikepu bolesnica je, uz jaku motivaciju, uspjela samostalno savladati tehniku peritonejske dijalize. Iako je procijenjeno da ima visok operativni rizik, zahvat postavljanja peritonejskog katetera je prošao bez komplikacija. Zbog komorbiditeta, u prvom redu zbog značajnih stenoza i okluzija arterija luka aorte, odustalo se od transplantacije bubrega. Bolesnica već petnaest mjeseci samostalno provodi peritonejsku dijalizu bez infektivnih komplikacija, osjeća se dobro, zadovoljna je kvalitetom života, sekvele kronične bubrežne bolesti zadovoljavajuće su kontrolirane, sustavni eritemski lupus je, uz malu dozu kortikosteroida, u fazi mirovanja, pothranjenost je korigirana, ali je i dalje prisutna hipoalbuminemija.

UVOD I CILJ. Temeljem preporuka ERA-EDTA o primjeni sintetskih visoko protočnih membrana, u Poliklinici BBraun Avitum Zagreb, smo kod 117 bolesnika liječenih hemodijalizom, u travnju 2011. započeli primjenjivati dijalizatore nove generacije Xevonta. Kod 2/3 bolesnika korišteni su dijalizatori visoko protočnih membrana. Cilj opservacijske studije je prosudba razlike učinkovitosti nove generacije filtera u odnosu prema niskoprotočnim dijalizatorima Diacap koji se korišteni u razdoblju prije zamjene. Sekundarni cilj je bio opažanje nuspojava nove generacije dijalizatora koje bi zahtijevale zamjenu istog. Poseban naglasak je stavljen na uočavanje znakova i nuspojava nepodnošljivosti dijalizatora. METODE. U 117 bolesnika prosječne životne 66, 2 godine bilo je 64% muškaraca i 36% žena. Prosječno vrijeme nadomjesnog liječenja bubrega iznosilo je 5, 6 godina. Nastojali smo osnovne parametre postupka HD ujednačiti nakon primjene Xevonta filtera: protok krvi, protok dijalizata, postupak antikoagulacije. Ključna razlika se dogodila povećanjem KUF-a kod 2/3 bolesnika te povećanjem površine dijalizne membrane kod 1/5 bolesnika. Nakon 6 tjedana primjene novih dijalizatora, usporedili smo pokazatelje učinkovitosti klirensa malih molekula: eKt/V, serumsku koncentraciju P te pokazatelj klirensa srednje velikih molekula: β2 mikroglobulin. Usporedba koncentracija serumskog albumina prije i poslije novih dijalizatora predstavlja indirektno stupanj selektivnosti propuštanja visoko protočnih membrana te stanje upalnih procesa ispitanika. T-testom neovisnih uzoraka mjerena je statistička značajnost razlika eKt/V-a, P i albumina. Wilcoxon testom parnih uzoraka mjerena je razlika koncentracija β2M. REZULTATI. Srednja vrijednost eKt/Va prve grupe podataka bila je 1, 30±0, 24, a druge grupe 1, 42±0, 25 (P

Study aims were oo survey bone mineral disturbances in the hemodialysis (HD) population in Europe and current clinical practice in Europe for the prevention, diagnosis and treatment of secondary hyperparathyroidism (SHPT) in HD patients. First, to estimate the prevalence of Kidney Disease Outcomes Quality Initiative (K/DOQI) guideline achievement in a representative sample of European hemodialysis subjects. As part of this objective, we will investigate the prevalence of achievement by type of dialysis, type of center and time on dialysis (less than or greater than 1 year). Among new dialysis subjects (less than 1 year), we will evaluate prevalence of K/DOQI target achievement until the end of the study. The study will run for 3 years. Second, to estimate the association of bone mineral markers (parathyroid hormone [PTH], calcium [Ca], serum phosphorus [P] and calcium phosphate product [CaxP]) classified by achievement of K/DOQI targets with mortality and overall cardiovascular hospitalization. Third, to characterize the longitudinal changes in bone mineral markers. As part of this objective, we will describe the patterns and predictors of bone mineral markers and achievement, with K/DOQI targets, using repeated measurements on individuals over time. First, To estimate the association of bone mineral markers (PTH, Ca, P and CaxP) classified by achievement of K/DOQI targets with specific cardiovascular outcomes, parathyroidectomy, manifest bone disease (including incidence of symptomatic bone fractures), hospitalizations and vascular access. Second, to evaluate the additional value of albumin and hemoglobin levels in conjunction with bone mineral markers in the prediction of mortality and clinical events.

Koštana bolest i poremećaj mineralnog metabolizma u kroničnoj bubrežnoj bolesti

U uvodniku se predstavljaju i detaljno objašnjavaju smjernice Europskog društva za hipertenziju i Europskog kardiološkog društva (ESH/ESC) za dijagnosticiranje i liječenje arterijske hipertenzije prilagođeno uvjetima i organizaciji zdrastvene službe u Hrvatskoj. Smjernice imaju temeljnu svrhu pridonošenja kvalitetnijoj kontroli hipertoničara u Hrvatskoj. Ovaj dokument službeni je stav stručnih društava i institucija koje su sudjelovale u njegovoj izradi.

Vitamin D therapy is important in the management of secondary hyperparathyroidism (SHPT). The effects of calcitriol and its an-alogs on PTH secretion and parathyroid gland hyperplasia have been well established. Several studies have also demonstrated the effect on bone metabolism. Besides its selective effect on vitamin D receptor, it seems that paricalcitol has a different effect on bone cells The aim of the study was to assess the short-term effect of paricalcitol on bone metabolism in hemodialysis patients with secondary hyperparathyroidism by using biochemical markers of bone formation and resorption. Seven hemodialysis patients (PTH > 300 pg/ml) were treated with paricalcitol. The dose of par-icalcitol was 5 meg 3 times per week. At the start of therapy and 3 months later serum total procollagen 1 N-propeptide (P1NP) and osteocalcin (OC) as bone formation markers, and beta-cross laps (Beta-CTX) as a bone resorption marker, were determined by the electrochemoluminescence immunoassay. PTH was deter-mined by radioimmunometric assay. All patients underwent hemodialysis treatment for 4 hours 3 times per week. Dialysate calcium concentration was 1.5mmol/L ; sevelamer hydrochloride was used as a phosphate binder. After 3 months of treatment, a significant reduction, of PTH (average 68%) was observed. At the same time, the average reduction of OC was 26%, P1NP 41%, and Beta-CTX 51%. The results indicate the reduction of bone turn-over, i.e. bone formation, and a bit more bone resorption. The reduction of Beta-CTX was the closest to the reduction of PTH. We need to confirm these results on larger group of patients and for a longer follow up period.

Nedostatak vitamina D u osoba sa kroničnom bubrežnom bolesti

Vitamin D ima ključnu ulogu u mineralnom metabolizmu i očuvanju zdravlja kostiju. Međutim danas znamo da vitamin D ima važnu ulogu i u monogim drugim procesima, a ne samo u mineralnom metabolizmu.

Sekundarni hiperparatireoidizam je najčešća komplikacija u bolesnika na kroničnoj hemodijalizi. Posljedice sekundarnog hiperparatireoidizma su koštana bolest ali i patološke kalcifikacije kao i povećani morbiditet i mortalitet dijalitičkih bolesnika. Prosječna dob bolesnika koji danas počinju hemodijalizu je 65 godina. U toj dobi i osobe s urednom bubrežnom funkcijom često imaju koštane promjene u vidu gubitka koštane mase. Cilj ispitivanja bio je ispitati učestalost i stupanj sekundarnog hiperparatireoidzma u starijih bolesnika na hemodijalizi. U ispitivanje je bilo uključeno 64 bolesnika, 25 starijih od 65 g. ( prosječna dob 73.6± ; ; ; ; 5.4 godine) i 39 mladih od 65 g ( prosječna dob 52.2± ; ; ; ; 12.4 godine). Stariji bolesnici su bili na hemodijalizi 4.5± ; ; ; ; 3.3, a mladi 9.4± ; ; ; ; 13.4 godina. U svih bolesnika smo odredili parathormon (PTH) u serumu RIA metodom, te biokemijske pokazatelje koštane pregradnje: prokolagen I N-terminalnog propeptida (P1NP), beta-crosslaps ( C) i osteocalcin (OC) elektrokemiluminiscentnom metodom na analizatoru Elecsvs 2010 (Roche). Prosječna vrijednost PTH u starijih bolesnika bila je 252.07± ; ; ; ; 207.9 pg/ml, P1NP 328.4± ; ; ; ; 88.3 ng/ml, C 245.4± ; ; ; ; 128.3 ng/ml i OC 234.2± ; ; ; ; 74.2 ng/ml. U mladih bolesnika prosječna vrijednost PTH je bila 400.7± ; ; ; ; 399.4 pg/ml, a P1NP324.3± ; ; ; ; 128.4 ng/ml, C 298.6± ; ; ; ; 98.4 ng/ml, i OC 398.6± ; ; ; ; 196.3 ng/ml. U mladih bolesnika, koji su bili dulje na hemodijalizi, vrijednosti parathormona su bile više kao i biokemijski pokazatelji koštane pregradnje. Iako nema statistički značajne razlike, što je najvjerojatnije posljedica malog broja ispitanika, u mladih osoba svi nalazi upućuju na ubrzanu pregradnju kosti kao posljedicu sekundarnog hiperparatireoidizma. U starijih bolesnika sekundarni hiperparatireoidizam je manje izražen, a pregradnja kosti je sporija. Nalaz je u skladu sa poznatom činjenicom češće pojave adinamične lezije kosti u starijih dijalitičkih boelsnika što zahtjeva poseban terapijski pristup. Sigurno da za donošenje konačnih zaključaka treba provesti ispitivanje na većem broju ispitanika i nadopuniti sa mjerenjem gustoće koštane mase.

Results From The Initial Cross-Sectional Analysis Of The Cosmo-Baselina Population.