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The leading causes of death in patients with chronic kidney disease (CKD) are cardiovascular diseases, regardless of the stage of disease or method of renal replacement therapy. On the other hand, CKD is a major risk factor for cardiovascular complications after acute myocardial infarction, as well as for adverse outcome in patients with chronic heart failure. In the present study we prospectively followed-up nephrological interventions in cardiology wards in order to determine changes in indications, treatment possibilities and outcome of patients. All patients treated at cardiology ward of the Clinical Hospital Centre Zagreb and requiring renal replacement therapy from January 2003 to December 2009 were included in the investigation. Cardiology hospital unit (intensive care or regular hospital cardiology ward), age, gender, Sepsis-related Organ Failure Assessment (SOFA) score, indication for dialysis, primary diagnosis, vascular access, methods of treatment, number of treatments, prescribed and delivered dose of dialysis and outcome were recorded. Patients were followed up until death during hospitalization or discharge from the hospital. From January 2003 to December 2009, 251 patients had been hospitalized at different cardiology wards and required renal replacement therapy. Mean age was 64.95 years (range 22 to 97 years), and there were 27.8% female patients. 52.9% of patients were hospitalized in the coronary intensive care unit. SOFA score had increased during the observed period from average 6.5 in 2003 to 13.45 in 2009. Specific knowledge with close collaboration between nephrologists and cardiologists is needed to achieve optimal outcome in this complex condition.

Prikazano je prospektivno, neintervencijsko, opservacijsko praćenje učinkovitosti i podnošljivosti eritropoetina beta (NeoRecormon®) u liječenju anemije u bolesnika s kroničnom bubrežnom bolesti (KBB) koji još nisu podvrgnuti nadomjestnom bubrežnom liječenju u Hrvatskoj. U studiji ML20474 uključeno je ukupno 368 bolesnika u 3 do 5. stadiju KBB s anemijom u kojih je bilo indicirana primjena lijekova koji stimuliraju eritropoezu (LSE). Svi su bolesnici primili eritropoetin beta (Neorecormon) supkutano u dozi od 4000 do 6000 IU jednom tjedno u razdoblju do korekcije anemije ili porasta Hb za 10 g/L a potom jednom tjedno u reduciranoj dozi od 50% u odnosu na početnu. Bolesnici su praćeni u razdoblju od 3 do maksimalno 52 mjeseca, prosječno 13.6 (Std.dev.10,36) mjeseci. Većina bolesnika bili su muškarci (55,3%), dob preko 51 godina (81,3%). Medijan vrijednosti razine hemoglobina iznosio je 93.5 g/L na početku studije a nakon 12 mjeseci 104,23 g/L. Nije bilo statistički značajne razlike u razini Hb ovisno o uzroku osnovne bubrežne bolesti i dobi bolesnika. Na kraju praćenja većina je bolesnika navela bolje podnošenje napora, bolje spavanje i manju razdražljivost. Nuspojave primjene terapije eritropoetinom beta nismo uočili. Rezultati pokazuju da je primjena učinkovita i sigurna u liječenju anemije u bolesnika s KBB koji nisu započeli liječenje nadomještanjem bubrežne funkcije., We performed observational multicenter study on CKD patients in stage 3-5, with renal anemia. Key inclusion criteria were: haemoglobin level > 6.0 g/dL, age >18 years and written inform consent. Exclusion criteria were dialysis and transplanted patients and haemoglobin level > 12.0 g/dL. Study was performed from 2006.-2012. and 368 patients were included. All patients received Erythropoietin beta (Neorecormon®; Roche, Basel, Switzerland) subcutaneously in dose of 4000-6000 IU every week during the correction phase of anemia treatment or once weekly 2000-4000IU during the maintenance treatment. Iron supplementation was administrated orally in >80% patients in order to achieve serum ferritin 200-500 μg/L. From 368 patients on beginning, 246 were followed and statistically analyzed (M:F=136/110). Mean duration study period was 13.6 (Std.dev.10.36) months (max 52 months). Patients were mainly men (55.3%), age >51 years (81.3%). The median of Hb level at baseline was 9.35 g/dL and after 12 months 10.4 g/dL respectively. After 12 months, most of patients had Hb range 10.0 g/dL to 11.0 g/dL. There were no statistically significant differences between Hb in groups of patients stratified according to the primary kidney disease and age, and between sex: mean level of Hb in M at the end of study was 10.27 g/dl and in F 10.58 g/dl (p=0.051). Baseline eGFR (Cocroft Gault) values were 16.31 (range form 4.1-62.6) vs. 16.71 (range from 4.9-43.8) mL/min after 12 months. The majority of patients had reported better exercise tolerance and sleep. 47.7% of patients have started after predialysis education with dialysis and in 2 patients preemptive transplantation was performed. The results of this multicenter observational study in Croatia suggest that the use of erythropoietin beta is effective and safe in correction of anemia in pre-dialysis CKD patients.

Disturbances of bone mineral metabolism are common complications of chronic kidney disease with bone fractures as one of the most important consequences. The aim of this study was to estimate prevalence of bone fractures among Croatian hemodialysis patients and to determine the possible fracture risk. The study was carried out in 767 hemodialysis patients from nine Croatian hemodialysis centers. Demographic, laboratory and bone fracture data were collected from medical records as well as therapy with vitamin D analogs. Fragility fractures were defi ned according to the World Health Organization defi nition. In 31 patient a total of 36 fractures were recorded. The prevalence of patients with bone fractures was 4.0%. The mean age of patients with fractures was 68.6 years. There were 9 male and 22 female patients with fractures. The mean hemodialysis duration was 63.3 months. Among all fractures the most common were hip fractures (39%) followed by forearm fractures (22%). This is the fi rst study regarding epidemiology of bone fractures in Croatian hemodialysis patients. The prevalence of patients with bone fractures in our group of hemodialysis patients is high. Fractures were more frequent among women and older patients, patients who have been longer on dialysis and in patients with higher concentration of PTH.

Renal anemia is the result of chronic kidney disease (CKD) and deteriorates with disease progression. Anemia may be the first sign of kidney disease. In all patients with anemia and CKD, diagnostic evaluation is required. Prior to diagnosing renal anemia, it is necessary to eliminate the other possible causes. Direct correlation between the concentration of hemoglobin and the stage of renal failure is well known. Early development of anemia is common in diabetic patients. Correction of anemia may slow the progression of CKD. Anemia is an independent risk factor for developing cardiovascular disease in patients with CKD. Treatment of anemia in patients with CKD is based on current guidelines. Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) group has produced comprehensive clinical practice guidelines for the management of anemia in CKD patients and ERBP (European Renal Best Practice) group its position statement and comments on the KDIGO guidelines. The Croatian Society of Nephrology, Dialysis and Transplantation (HDNDT) has already published its own guidelines based on the recommendations and positive experience of European and international professional societies, as well as on own experience. The latest version of Croatian guidelines was published in 2008. Since then, on the basis of research and clinical practice, there have been numerous changes in the modern understanding of the treatment of anemia in CKD. Consequently, HDNDT hereby publishes a review of the recent recommendations of international professional societies, expressing the attitude about treating anemia in CKD as a basis for new guidelines tailored to the present time.

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.

Diabetic nephropathy is a common complication in patients with diabetes mellitus and one of the major reasons for renal replacement therapy in Croatia, Europe and the United States. It is characterized by proteinuria, decline in glomerular filtration, hypertension, and high risk of cardiovascular morbidity and mortality. Deterioration of renal function in diabetic nephropathy develops through five clinical stages characterized by the respective histologic description. Genetic susceptibility, hyperglycemia, high blood pressure and duration of diabetes mellitus definitely play a role in the pathogenetic sequence. Early diagnosis, appropriate patient follow up and treatment are essential to improve the outcomes. Interdisciplinary approach and close collaboration of nephrologists and diabetologists are essential for timely detection of disease progression. Tight glycemic control under the supervision of diabetologists, screening of patients, and once a year report of albuminuria and glomerular filtration allow for detection of renal damage in the early stages and timely referral to a nephrologist. The points of interest given in this overview are description of clinical staging in relation to pathologic classification, repetition of basic causal features, and brief analysis of treatment., Dijabetička nefropatija je najčešća komplikacija u bolesnika sa šećernom bolešću tip 2 i jedan je od najčešćih razloga za nadomještavanje bubrežne funkcije u Hrvatskoj, Europi i Sjedinjenim Američkim Državama. Obilježena je proteinurijom, smanjenjem glomerularne filtracije te visokim srčano-žilnim pobolom i smrtnošću. Oštećenje bubrežne funkcije u dijabetičkoj se nefropatiji razvija kroz pet kliničkih stadija s pripadajućim patohistološkim značajkama. U patogenetskom slijedu neosporna je uloga genetske predispozicije, hiperglikemije, arterijske hipertenzije i trajanja šećerne bolesti. Interdisciplinarni pristup i bliska suradnja nefrologa i dijabetologa neophodni su za pravodobno otkrivanje i napredovanje bolesti, a time i za poboljšanje ishoda bolesnika. Kontrola glikemije, probir bolesnika te jedanput godišnje određivanje albuminurije i glomerularne filtracije omogućava otkrivanje bubrežnog oštećenja u ranoj fazi i pravodobno upućivanje nefrologu. U ovome su radu prikazani klinički stadiji bolesti u korelaciji s patohistološkom klasifikacijom, ponovljene su osnove patogeneze i pristupa liječenju.

BACKGROUND: Vascular access is "the life line" for patients on chronic hemodialysis. The autogenous arteriovenous fistula provides the best access to the circulation because of low complication rate, long-term use, and lower cost, compared to arteriovenous graft and central venous catheter. The primary objective of this prospective study was to investigate the predictive value of vein diameter after intraoperative dilatation with vessel probes on hemodialysis fistula maturation. ----- MATERIAL AND METHODS: Ninety-three fistulas were performed by a single surgeon from February 1, 2006 to January 31, 2009. Intraoperative vein dilatation with vessel probes was attempted in all fistulas. Measurements of the feeding artery diameter, vein diameter and the increased vein diameter after intraoperative dilatation were performed and immediate failure, early patency, early failure, primary patency, and fistula survival outcomes were recorded during 48-month follow-up. ----- RESULTS: Early failure occurred in 20% of fistulas and 70% matured sufficiently for cannulation. Variables with significant impact on the failure to mature by univariate analysis were: body-mass index (P=0.041), artery diameter (P

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

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

Uporaba imunosupresijskih lijekova povezuje se s povećanom učestalosti različitih zloćudnih bolesti. Etiologija posttransplantacijskih zloćudnih bolesti je multifaktorska te uključuje i oslabljen imunološki odgovor na različite virusne infekcije, neodgovarajuće uklanjanje oštećenih stanica, kao i oslabljenu mogućnost popravka lomova DNK. Među viruse koji se povezuju s pojavom tumora nakon transplantacije bubrega ubrajaju see EBV, HHV-8, virus Merkelovih stanica, virusi hepatitisa B i C, te BK virus. CMV se povezuje s karcinomom debelog crijeva. Dosadašnje se spoznaje uglavnom temelje na pojedinačnim slučajevima opisanima u literaturi. Potrebna su daljnja istraživanja kojima bi se potvrdila povezanost virusnih infekcija s razvojem tumora nakon transplantacije bubrega., Immunosuppressive treatment is associated with an increased incidence of different malignant diseases. The etiology of posttransplant malignancies is multifactorial and includes decreased immune response to different viral infections, inappropriate removal of damaged cells, and impaired ability to repair DNA. EBV, HHV-8, Merkel cell virus, hepatitis B virus, hepatitis C virus and BK virus are all considered to be involved in the etiology of post-transplant malignancies. CMV has been considered as a potential causative factor in the development of colon cancer. However, current knowledge is mainly based on case reports. Further studies are needed to establish the causative role of different viruses in the etiology and pathogenesis of different malignant diseases in renal transplant population.

Hyperhomocysteinemia is an independent risk factor for cardiac, cerebral and peripheral vascular disease as well as for venous thromboembolic disease. Its clinical relevance appears to approach the known, traditional risk factors such as hypercholesterolemia, diabetes mellitus, hypertension, and cigarette smoking. The benefit of homocysteine concentration reduction has been demonstrated in cardiovascular disease. The recommended drug dosage varies among clinical studies, depending on the etiology of hyperhomocysteinemia and on homocysteine and folic acid concentrations in patient serum; however, there is general consensus that folic acid and vitamin B12 are first line treatment. In addition, measurement of homocysteine concentration is advised in patient groups at risk, with an increased daily dietary vitamin intake in these patients., Hiperhomocisteinemija je neovisan čimbenik rizika za bolesti krvnih žila srca, mozga, periferije i tromboembolijske bolesti vena. Po važnosti se približila dosadašnjim tradicionalnim čimbenicima rizika: hiperkolesterolemiji, šećernoj bolesti, hipertenziji i pušenju. Dokazana je korist sniženja koncentracije homocisteina u srčanožilnim bolestima. Zaključci kliničkih pokusa se razilaze u preporuci o dozi lijeka, ovisno o etiologiji hiperhomocisteinemije te koncentraciji homocisteina i folne kiseline u serumu bolesnika, no svi se slažu da je davanje folne kiseline i vitamina B12 osnova liječenja. Uz to se preporuča mjerenje koncentracije homocisteina u rizičnim skupinama bolesnika i savjetuje pojačan dnevni unos vitamina hranom u ovih bolesnika.