Treatment of acute kidney injury in elderly people

Starenjem dolazi do degenerativnih promjena u bubregu koje povećavaju rizik od akutnog bubrežnog zatajenja (ABZ). Stariji od 80 godina su 5 puta skloniji razviti ABZ od mlađe populacije (Pascual J, Liano F 2009). U starijih od 65 godina postoji 28% manja vjerojatnost za oporavak bubrežne funkcije nakon epizode ABZ (Schmitt i sur. 2008). Općenito je zabilježen porast incidencije ABZ kao i prosječne dobi pacijenata s pojavom epizode ABZ (Turney JH i sur. 1990)( Baraldi A i sur. 1998). Većina starijih pacijenata s ABZ imaju istovremeno disfunkciju i drugih organskih sustava što povećava mortalitet ove skupine. Takvim pacijentima je često potrebna kontinuirana metoda dijalize koja donekle oponaša funkciju zdravog bubrega. Cilj ovog rada bio je istražiti odnos primjene različitih metoda dijalize i ishoda liječenja u pacijenata ≥65 godina s ABZ bez prethodne dijagnoze kroničnog bubrežnog zatajenja (KBZ) liječenog dijalizom te usporediti razultate s mlađom dobnom skupinom (18-64 godina) akutno dijaliziranih pacijenata, također bez prethodne dijagnoze KBZ. Iz BISa i Centralnog arhiva prikupljeni su podaci o dobi, dijagnozama i ishodima liječenja za akutno dijalizirane pacijente bez prethodne dijagnoze KBZ u razdoblju 2009.- 2013. godine (uključujući i 2013. g.). Iz obrazaca dijalize su prikupljeni podaci o vrsti i trajanju dijalize te komplikacijama i antikoagulantnoj terapiji. Skupinu ≥65 godina činilo je 121 pacijenata (61%) i 77 pacijenata dobi 18-64 g. (39%). U starijoj dobnoj skupini umrlo je 64 (53%), a u mlađoj dobnoj skupini 35 pacijenata (45%) (p=0.31). 125 umrlih su bili muškarci (63%), a 73 žene (37%) (p=0.88). Najmanji udio umrlih po metodi bio je kod IHD (2.2%), a najveći kod CVVHDF (21.7%) što se pripisuje dijelom broju dijaliza tim metodama i općem stanju pacijenta (p=0.007, V=0.145). Najveća učestalost komplikacija je bila kod trajanja dijalize >48 sati (54.7%) (p<0.001, V=0.267). CVVH metoda je imala najveću učestalost komplikacija (68.5%), dok IHD najmanju (13.0 %).People >80 yrs are 5 times more prone to developing AKI than the younger population due to ageing of the kidney (Pascual J, Liano 2009). In people ≥65 yrs there is 28% less chance of kidney function recovery after an AKI episode (Schmitt et al. 2008). An increased incidence of AKI has been recorded as well as an increase in the average age of patients with AKI (Turney JH i sur. 1990)( Baraldi A i sur. 1998). The majority of older patients with AKI have a previous dysfunction in other organ systems which increases the risk of AKI. These patients benefit from CRRT which somewhat imitates the function of a healthy kidney. The aim of this study was to determine the relationship between various dialysis methods and outcomes in patients ≥65 yrs of age with AKI without a pre-existing chronic renal insufficiency (CRI) previously treated with dialysis and to compare the findings with the younger age (18-64 yrs) group with AKI. The data for age, diagnosis and tretament outcomes in patients with AKI (without previous CRI) were gathered from the Central hospital archive and the Hospital informatic system for the period 2009 - 2013 (including year 2013). Information about complications, anticoagulation therapy, duration and type of dialysis was acquired from the dialysis forms. There were 121 patients (61%) in the group aged ≥65 yrs and 77 patients (39%) in group aged 18-64 yrs. 64 patients (53%) died in the older age group and 35 patients (45%) in the younger age group (p=0.31). 125 male (63%) and 73 female (37%) patients died (p=0.88). The least proportion of deaths was in IHD group (2.2%) and the biggest was in CVVHDF group (21.7%) which can partially be attributed to the amount of patients in each group and patient's health status at the moment (p=0.007, V=0.145). The biggest proportion of complications was in dialysis lenght >48 hrs (54.7%) (p<0.001, V=0.267). The biggest proportion of complications was in the CVVH group (68.5%) while the IHD group had the least proportion (13.0%)

Treatment of acute kidney injury in elderly people

Starenjem dolazi do degenerativnih promjena u bubregu koje povećavaju rizik od akutnog bubrežnog zatajenja (ABZ). Stariji od 80 godina su 5 puta skloniji razviti ABZ od mlađe populacije (Pascual J, Liano F 2009). U starijih od 65 godina postoji 28% manja vjerojatnost za oporavak bubrežne funkcije nakon epizode ABZ (Schmitt i sur. 2008). Općenito je zabilježen porast incidencije ABZ kao i prosječne dobi pacijenata s pojavom epizode ABZ (Turney JH i sur. 1990)( Baraldi A i sur. 1998). Većina starijih pacijenata s ABZ imaju istovremeno disfunkciju i drugih organskih sustava što povećava mortalitet ove skupine. Takvim pacijentima je često potrebna kontinuirana metoda dijalize koja donekle oponaša funkciju zdravog bubrega. Cilj ovog rada bio je istražiti odnos primjene različitih metoda dijalize i ishoda liječenja u pacijenata ≥65 godina s ABZ bez prethodne dijagnoze kroničnog bubrežnog zatajenja (KBZ) liječenog dijalizom te usporediti razultate s mlađom dobnom skupinom (18-64 godina) akutno dijaliziranih pacijenata, također bez prethodne dijagnoze KBZ. Iz BISa i Centralnog arhiva prikupljeni su podaci o dobi, dijagnozama i ishodima liječenja za akutno dijalizirane pacijente bez prethodne dijagnoze KBZ u razdoblju 2009.- 2013. godine (uključujući i 2013. g.). Iz obrazaca dijalize su prikupljeni podaci o vrsti i trajanju dijalize te komplikacijama i antikoagulantnoj terapiji. Skupinu ≥65 godina činilo je 121 pacijenata (61%) i 77 pacijenata dobi 18-64 g. (39%). U starijoj dobnoj skupini umrlo je 64 (53%), a u mlađoj dobnoj skupini 35 pacijenata (45%) (p=0.31). 125 umrlih su bili muškarci (63%), a 73 žene (37%) (p=0.88). Najmanji udio umrlih po metodi bio je kod IHD (2.2%), a najveći kod CVVHDF (21.7%) što se pripisuje dijelom broju dijaliza tim metodama i općem stanju pacijenta (p=0.007, V=0.145). Najveća učestalost komplikacija je bila kod trajanja dijalize >48 sati (54.7%) (p<0.001, V=0.267). CVVH metoda je imala najveću učestalost komplikacija (68.5%), dok IHD najmanju (13.0 %).People >80 yrs are 5 times more prone to developing AKI than the younger population due to ageing of the kidney (Pascual J, Liano 2009). In people ≥65 yrs there is 28% less chance of kidney function recovery after an AKI episode (Schmitt et al. 2008). An increased incidence of AKI has been recorded as well as an increase in the average age of patients with AKI (Turney JH i sur. 1990)( Baraldi A i sur. 1998). The majority of older patients with AKI have a previous dysfunction in other organ systems which increases the risk of AKI. These patients benefit from CRRT which somewhat imitates the function of a healthy kidney. The aim of this study was to determine the relationship between various dialysis methods and outcomes in patients ≥65 yrs of age with AKI without a pre-existing chronic renal insufficiency (CRI) previously treated with dialysis and to compare the findings with the younger age (18-64 yrs) group with AKI. The data for age, diagnosis and tretament outcomes in patients with AKI (without previous CRI) were gathered from the Central hospital archive and the Hospital informatic system for the period 2009 - 2013 (including year 2013). Information about complications, anticoagulation therapy, duration and type of dialysis was acquired from the dialysis forms. There were 121 patients (61%) in the group aged ≥65 yrs and 77 patients (39%) in group aged 18-64 yrs. 64 patients (53%) died in the older age group and 35 patients (45%) in the younger age group (p=0.31). 125 male (63%) and 73 female (37%) patients died (p=0.88). The least proportion of deaths was in IHD group (2.2%) and the biggest was in CVVHDF group (21.7%) which can partially be attributed to the amount of patients in each group and patient's health status at the moment (p=0.007, V=0.145). The biggest proportion of complications was in dialysis lenght >48 hrs (54.7%) (p<0.001, V=0.267). The biggest proportion of complications was in the CVVH group (68.5%) while the IHD group had the least proportion (13.0%)

ISHOD TRANSPLANTACIJE BUBREGA KOD BOLESNIKA S LUPUSNIM NEFRITISOM – ISKUSTVO JEDNOG CENTRA I PREGLED LITERATURE

Aims: Kidney transplantation (KT) is the treatment of choice for end-stage kidney disease in patients with systemic lupus erythematosus (SLE). Still, these patients tend to fare worse than other patient groups with chronic kidney failure. The main aim of this retrospective observational study was to evaluate the outcomes of KT in patients with SLE. Methods: Data were obtained from medical records and charts. Results: From February 2007, a total of 12 SLE patients, average age 37 (18-56) years, underwent deceased donor KT at our Center. Comorbidities were primarily cardiovascular. At the time of KT, 91.7% of patients showed no signs of SLE activity. Immunological matching was favorable and all allografts showed satisfactory initial function. Median graft survival for the whole patient population was 41 (0-93) months. In 66.7% of patients with stable graft function, median survival was 61 (22-93) months, in three patients longer than fi ve years. One patient died 4 months after the transplantation from neurologic complications, whereas 25% of allografts were lost in the early post-transplant period, in 0-5 months after KT. Our patient outcomes showed no clear correlation between age, previous KT or number of comorbidities. Episodes of acute rejection or recurrent lupus nephritis brought a higher risk of poor outcome. Conclusion: While there still are many unanswered questions relating to the management of this immunologically very sensitive group of patients, forming a multidisciplinary transplantation team would enable pre-transplant evaluation of SLE patients with possible risk assessment and adjustment of follow up strategy to achieve an optimal survival outcome.Uvod i ciljevi: Transplantacija bubrega metoda je izbora u liječenju završnog stadija kronične bubrežne bolesti u bolesnika s lupusnim glomerulonefritisom (LN). Ipak, u usporedbi s drugim bolesnicima ova skupina unatoč napretku u liječenju i dalje pokazuje lošiji ishod. Glavni cilj ovog istraživanja bio je usporediti ishode našeg Centra s ishodima drugih studija te raspraviti nove mogućnosti u praćenju i liječenju ove skupine pacijenata. Ispitanici i metode: Svi istraživani parametri prikupljeni su iz dostupne medicinske dokumentacije. Rezultati: 12 bolesnika sa SLE, prosječne dobi 37 (18-56) godina, učinjena je transplantacija u našem Centru od veljače 2007. godine. Svi su bolesnici bili primatelji presatka kadaveričnog darivatelja. Najčešći komorbiditeti bile su kardiovaskularne bolesti. U vrijeme transplantacije 91,7% bolesnika bilo je u potpunoj serološkoj i kliničkoj remisiji osnovne bolesti. Stupanj tkivne podudarnosti bio je zadovoljavajući, a uspostavljanje bubrežne funkcije promptno u svih ispitanika. Prosječno vrijeme preživljenja presatka iznosilo je 41 (0-93) mjesec. Kod 66,7% bolesnika sa stabilnom bubrežnom funkcijom, to je vrijeme iznosilo 61 (22-93) mjesec, za tri je presatka zabilježeno preživljenje dulje od 5 godina. Tri su bolesnika graftektomirana (25%), dok je u jedne olesnice zabilježen smrtni ishod. Gubitak presadaka nastupio je u ranom posttransplantacijskom razdoblju – od 0 do 5 mjeseci nakon transplantacije. Zaključak: Iako postoje brojna neistražena i neodgovorena pitanja vezana uz zbrinjavanje ove imunološki vrlo osjetljive i zahtjevne skupine bolesnika, pažljiva skrb prije i nakon transplantacije te uska suradnja nefrologa i imunologa omogućavaju dobar ishod uz značajno povećanje kvalitete života

KIDNEY TRANSPLANTATION IN PATIENTS WITH FOCAL SEGMENTAL GLOMERULOSCLEROSIS

Uvod i ciljevi: Povratak fokalne segmentalne glomerularne skleroze (FSGS) u presadak i dalje ostaje važna prepreka u postizanju dugoročno zadovoljavajućih rezultata transplantacije bubrega. Glavni cilj istraživanja bio je procijeniti ishode bolesnika praćenih u našem Centru te raspraviti nove mogućnosti u liječenju ove skupine bolesnika. Ispitanici i etode: U istraživanje su uključeni svi bolesnici (n=30; 33,3% muškaraca) s dijagnozom FSGS vlastitih bubrega, liječeni transplantacijom u razdoblju od listopada 2007. i listopada 2013. Svi istraživani parametri prikupljeni su iz dostupne medicinske dokumentacije. Rezultati: 29 bolesnika imalo je nekolabirajuću FSGS (ncFSGS), dok je u jednog bolesnika ustanovljena kolabirajuća varijanta bolesti (cFSGS). Kadaverični presadak primilo je 96,7 % bolesnika. Ukupno preživljenje bolesnika tijekom praćenja iznosilo je 90 %. Osamdeset posto bolesnika imalo je zadovoljavajuću funkciju presatka uz medijan preživljenja 49,15 (0,5-84) mjeseci. Incidencija povratka bolesti u presadak bila je 20 % (6/30), a 3 presatka su promptno izgubila svoju funkciju zbog cFSGS. Skupina bolesnika sa cFSGS varijantom izražavala je višu proteinuriju značajno ranije u posttransplantacijskom razdoblju (P <0,05), što se u konačnici odrazilo težom kliničkom slikom i ranim gubitkom presatka (3-6 mjeseci nakon transplantacije). Terapijskim izmjenama plazme uspješno su liječena dva bolesnika s ncFSGS, dok dva bolesnika s cFSGS varijantom nisu odgovorila na terapiju (50 %-tni odgovor na terapiju). Zaključak: Iako je rizik za povratak FSGS u presadak visok, transplantacija bubrega i dalje je zlatni standard u liječenju bolesnika s FSGS. Neophodno je bez odgađanja učiniti biopsiju presatka u svih bolesnika s razvojem proteinurije kako bi se na vrijeme započela specifi čna terapija i poboljšao ishod.Aims: Posttransplant recurrence of FSGS remains an obstacle towards satisfactory long-term kidney allograft survival. We aimed to evaluate the outcomes of kidney transplantation (KTx) in patients with FSGS treated at our Center and discuss available management options for improved outcomes in this group of patients. Patients and Methods: All patients (n=30; 33.3% male) with histological evidence of FSGS on a native kidney biopsy transplanted during the period between October 2007 and October 2013 were analyzed. Data were obtained from the medical records and charts. Results: 29 patients had a non-collapsing FSGS (ncFSGS), while one had collapsing FSGS (cFSGS). 96.7% of patients received deceased donor kidney allograft. Overall patient survival was 90% during the follow-up period. 80% of patients had satisfactory allograft function, with median allograft survival of 49.15 (range, 0.5-84) months. The incidence of recurrence was 20% (6/30), with 3 allografts lost rapidly due to cFSGS. cFSGS group had higher urine protein excretion earlier in the posttransplant period (P < 0.05), which resulted with more severe clinical presentation and early allograft loss (3-6 months posttransplant). Therapeutic plasma exchange (TPE) was successfully employed in 2 patients with ncFSGS, while 2 patients in the cFSGS group did not respond to treatment (response rate 50%). Conclusion: Although an increased risk of recurrence exists, KTx remains the treatment of choice for patients with FSGS. Immediate allograft biopsy should be performed in all patients developing proteinuria and prompt therapy should be started in order to achieve better outcomes

Metabolička acidoza - zanemarujemo li je nakon transplatacije bubrega?

Despite prolonged survival and better quality of life as compared to dialysis, kidney transplantation frequently presents with a complex set of medical issues that require intensive management to protect graft function. Metabolic acidosis has an impact on several metabolic complications such as mineral and muscle metabolism, nutritional status and anemia. It may also have an effect on graft function, possibly through the stimulation of adaptive mechanisms aimed at maintaining acid-base homeostasis. We investigated current practice in the evaluation of metabolic acidosis at one of the largest transplant centers in the Eurotransplant region. Adult renal transplant recipients having received allograft from January 2011 to August 2012 were included in the investigation. We recorded the frequency of measuring the parameters of venous blood gas analysis, as well as creatinine and urea levels, creatinine clearance, proteinuria, calcium, phosphate and potassium blood levels, body mass index and the time spent on dialysis prior to kidney transplantation. Out of 203 patients who had received renal allograft at our institution during the observed period, 191 (124 males and 67 females, age range from 18 to 77 years) were enrolled in the study. Of these, only 92 (48.167%) patients had parameters of venous blood gas analysis measured at some time after kidney transplantation. Acid-base status was determined more often in males (77 males vs. 22 females, p=0.001). Patients with pH/blood gas analysis performed were found to have significantly higher creatinine and urea levels and significantly lower creatinine clearance (p<0.001 both). Serum calcium levels were also significantly lower in this group of patients (p<0.001). Metabolic acidosis is a very important clinical issue that needs to be monitored in every transplant recipient. Its effects on graft function, nutritional status, anemia and bone mass are complex but can be successfully managed. Our study showed metabolic acidosis to be linked with significantly higher creatinine and urea levels, decreased creatinine clearance and lower calcium levels. Nevertheless, metabolic acidosis still stays a highly underestimated problem among nephrologists dealing with transplant recipients. We suggest regular determination of the acid-base status in renal transplant recipients.Metabolička acidoza je česta komplikacija vezana uz progresivan gubitak bubrežne funkcije. Njezin utjecaj na status uhranjenosti, razvoj anemije, koštanu masu i funkciju presađenog bubrega je vrlo složen, ali se može učinkovito spriječiti. Istražili smo koliko se određivanju i praćenju acidobaznog statusa (ABS) posvećuje pozornosti u jednom od najvećih transplantacijskih centara unutar organizacije Eurotransplant. U istraživanje su uključeni svi odrasli primatelji bubrega u razdoblju od siječnja 2011. do kolovoza 2012. godine. Tijekom promatranog razdoblja transplantirano je 203 bolesnika, a 191 bolesnik uključen je u istraživanje (124 muškarca i 67 žena, raspona dobi od 18 do 77 godina). Statistička analiza pokazala je da je u poslijetransplantacijskom razdoblju ABS bio određen samo u 92 (48,167%) bolesnika. ABS je češće određivan muškarcima (p=0,001). Bolesnici s određivanim ABS imali su značajno više vrijednosti kreatinina i ureje (p<0,001), kao i značajno niži klirens kreatinina (p<0,001). Ova skupina bolesnika imala je i značajno niže serumske koncentracije kalcija (p<0,001). Metabolička acidoza je važno kliničko pitanje koje je potrebno pažljivo razmotriti kod svakog primatelja bubrega. Naše istraživanje pokazalo je da je metabolička acidoza povezana sa značajno višim vrijednostima kreatinina i ureje, smanjenim klirensom kreatinina i nižim vrijednostima kalcija. Unatoč tome, metabolička acidoza ostaje uvelike zanemaren problem kod ove skupine bolesnika. Preporučamo redovito praćenje acidobaznog statusa svih bolesnika s presađenim bubregom

Melanomas in renal transplant recipients: a single-centre study

Skin cancers are the most common malignancies in renal transplantrecipients, with squamous-cell and basal-cell cancers accounting for the majorityof all skin cancer cases. Melanoma is relatively rare in this group of patients.From 1973 to May 2017, out of 1889 patients who received allografts at our institution,4 developed melanoma. After the mean follow-up of 11.5 months, 2patients died and 2 are still alive with functioning allografts. Malignancies werelocalized in the legs in both female patients, and in the neck and head in 1 malepatient each. Compared to the general population of Croatia, renal transplantrecipients from our cohort have 6.85 times higher risk for development of melanoma.Regular screenings and patient education are mandatory, especially inMediterranean countries.</p

Prevalence of incidental chronic kidney disease and patient characteristics - results of the EH-UH 2 study and the ENAH project

Introduction: Chronic kidney disease (CKD) is an independent risk factor for cardiovascular (CV) disease and premature deaths. The worldwide prevalence of CKD in 2017 in the general population is 9.1%. In this paper our primary aim was to present preliminary data on incidental, i.e., newly discov- ered CKD and the overall prevalence of CKD in the adult population in Croatia. Secondary aim was to compare these data with the data of the CKD prevalence of the adult population from the rural part of Croatia (results of the ENAH study). Materials and Methods: This cross-sectional observational study included random, representative sample of general adults in Croatia, 781 subjects who were part of the large cohort from the EH-UH 2 study. The eGFR was calculated by creatinine-based CKD EPI equation. Albuminuria was determined from the albumin to creatinine ratio in urine (ACR) in 691 subjects. Results: The overall prevalence of CKD in Croatia was 12.7%, of which 9.5% were newly discovered CKD, and only 3.2% were subjects with previously known CKD. According to the albuminuria level, 30.7% of the adult population belonged to the group with a moderate risk of CKD progression, and 7% had a high risk, while 2.5% of the study subjects had a very high risk. Predictors for newly discov- ered CKD are older age, higher urate and potassium, antihypertensive therapy, angina pectoris, atrial fibrillation, lower hemoglobin level. Conclusions: These results continue in a pilot project of the Croatian Kidney Society and the Croatian Hypertension League on the implementation of an action plan to detect new kidney disease in the general population in real life, in a collaboration of primary care physicians and nephrologists

Prevalence of incidental chronic kidney disease and patient characteristics - results of the EH-UH 2 study and the ENAH project

Introduction: Chronic kidney disease (CKD) is an independent risk factor for cardiovascular (CV) disease and premature deaths. The worldwide prevalence of CKD in 2017 in the general population is 9.1%. In this paper our primary aim was to present preliminary data on incidental, i.e., newly discov- ered CKD and the overall prevalence of CKD in the adult population in Croatia. Secondary aim was to compare these data with the data of the CKD prevalence of the adult population from the rural part of Croatia (results of the ENAH study). Materials and Methods: This cross-sectional observational study included random, representative sample of general adults in Croatia, 781 subjects who were part of the large cohort from the EH-UH 2 study. The eGFR was calculated by creatinine-based CKD EPI equation. Albuminuria was determined from the albumin to creatinine ratio in urine (ACR) in 691 subjects. Results: The overall prevalence of CKD in Croatia was 12.7%, of which 9.5% were newly discovered CKD, and only 3.2% were subjects with previously known CKD. According to the albuminuria level, 30.7% of the adult population belonged to the group with a moderate risk of CKD progression, and 7% had a high risk, while 2.5% of the study subjects had a very high risk. Predictors for newly discov- ered CKD are older age, higher urate and potassium, antihypertensive therapy, angina pectoris, atrial fibrillation, lower hemoglobin level. Conclusions: These results continue in a pilot project of the Croatian Kidney Society and the Croatian Hypertension League on the implementation of an action plan to detect new kidney disease in the general population in real life, in a collaboration of primary care physicians and nephrologists

Trends, Characteristic, and Outcomes of Preterm Infants Who Received Postnatal Corticosteroid: A Cohort Study from 7 High-Income Countries

INTRODUCTION Our objective was to evaluate the temporal trend of systemic postnatal steroid (PNS) receipt in infants of 24-28 weeks' gestational age, identify characteristics associated with PNS receipt, and correlate PNS receipt with the incidence of bronchopulmonary dysplasia (BPD) and BPD/death from an international cohort included in the iNeo network. METHODS We conducted a retrospective study using data from 2010 to 2018 from seven international networks participating in iNeo (Canada, Finland, Israel, Japan, Spain, Sweden, and Switzerland). Neonates of 24 and 28 weeks' gestational age who survived 7 days and who received PNS were included. We assessed temporal trend of rates of systemic PNS receipt and BPD/death. RESULTS A total of 47,401 neonates were included. The mean (SD) gestational age was 26.4 (1.3) weeks and birth weight was 915 (238) g. The PNS receipt rate was 21% (12-28% across networks) and increased over the years (18% in 2010 to 26% in 2018; p &lt; 0.01). The BPD rate was 39% (28-44% across networks) and remained unchanged over the years (35.2% in 2010 to 35.0% in 2018). Lower gestation, male sex, small for gestational age status, and presence of persistent ductus arteriosus (PDA) were associated with higher rates of PNS receipt, BPD, and BPD/death. CONCLUSION The use of PNS in extremely preterm neonates increased, but there was no correlation between increased use and the BPD rate. Research is needed to determine the optimal timing, dose, and indication for PNS use in preterm neonates