Urea rebound - some disadvantages of urea kinetic modeling

PURPOSE: The objectives of the present study are to determine the average urea rebound by examining the urea concentrations immediately after completion of hemodialysis (HD) and comparing these results to urea concentrations taken 30 min after the procedure (equilibrated values), to assess how the delivered dialysis dose changes when URR and Kt/V are calculated using each of these two values and to evaluate the significance of these differences and the reliability of the indicators in use.MATERIAL AND METHODS: The study covered 30 end-stage renal failure (ESRF) patients, 16 males and 14 females on chronic HD at a mean age of 43.90±10.63 years and average duration of dialysis treatment of 6.90±3.75 years. Average urea values were calculated for each patient using data from three consecutive monthly examinations taken immediately and 30 min after HD in order to determine the mean urea rebound percentage.RESULTS: Mean urea values in samples taken immediately and 30 min after HD showed statistically significant differences (p<0.05). Equilibrating urea concentration led to an average increase of 17.7% at the 30 min after HD. There was a statistically significant difference (p<0.05) between the calculated single pool Kt/V (1.23±0.11) and equilibrated Kt/V (1.17±0.18) as well as concerning mean URR values calculated by using non-equilibrated and equilibrated post dialysis urea (65.3±1.18% and 6.67±2.4%, respectively).CONCLUSION: Calculation of URR and single pool model of Kt/V for assessment of dialysis adequacy in ESRF patients on chronic HD results in overestimation of the delivered dialysis dose. These values differ statistically significantly from those when accounting for urea rebound. URR and Kt/Vsp indicators do not possess the necessary reliability as means to evaluate the delivered dialysis dose.Scripta Scientifica Medica 2013; 45(1): 71-74

Role of therapeutic plasma exchange in the complex treatment of severe kidney diseases

PURPOSE: The strongest effect of therapeutic plasma exchange (TPE) is achieved in diseases with immune and autoimmune genesis, hyperviscous conditions and intoxications of various origins. The aims of the study were to assess the long-term effect of TPE in the complex therapy of severe renal diseases and to highlight therapeutic strategies necessary to achieve good clinical results.MATERIAL AND METHODS: During the period 1980-2010, TPE was carried out in the form of a complex treatment of 87 patients with immune nephropathies and 44 patients with malignant myeloma. The primary diseases were the following: chronic glomerulonephritis - 42, lupus nephropathy - 31, Henoch-Schonlein nephritis - 8, Wegener granulomatosis ± four and Goodpasture syndrome - two patients. The diagnosis was confirmed after a puncture kidney biopsy in 72 (82.8%) patients with immune nephropathies. TPE was performed using centrifugal or filtration methods.RESULTS: The patients with immune nephropathies underwent between 5 and 7 consecutive plasma exchanges daily or every two days. A three consecutive days of corticosteroid pulse therapy was initiated after last procedure followed by conventional immunosuppressive therapy. After serial TPE a significant decrease in anti-GMB antibodies and circulating immune complexes was detected. Continuous clinical and paraclinical remission was achieved in 62.7% of the patients who received the combined treatment.CONCLUSION: TPE has a beneficial effect after being included in the complex treatment of patients with severe immune nephropathies. The immunomodulation contributes to the successful management of severe ongoing autoimmune processes. In patients with hyperviscosity, `supporting` TPE every 2 or 3 months is required to lower the increased viscosity, to prevent thromboembolic complications, and to slow-down nephropathy progression.Scripta Scientifica Medica 2013; 45(1): 66-70

Study of Hemodialysis Patients` Compliance for the Performed Treatment. Do the Patients Adhere to Physician`s Guidelines?

The patients with chronic renal failure (CRF) on chronic haemodialysis (CHD) should strictly adhere to the prescribed therapeutic regimens and physician`s guidelines. Otherwise the results from this long-lasting treatment are often unfavourable. The aim of the present study was to reveal the opinion of CRF patients on CHD about their attitude towards their continuous treatment. Forty patients, 21 males and 19 females, at the mean age of 50,48±14,90 years and a mean duration of CHD of 5,82±4,11 years were examined. They filled-in anonymous questionnaire containing 26 items devoted to their observation of the necessary therapeutic and dietary regimens. The longer CHD duration influenced negatively on patient`s compliance. However, such patients tended to observe more strictly the time for haemodialysis prescribed by the physician. Patient`s compliance depended on the educational level, too. Therefore, an extraordinarily important physician`s task was the provision to the patients of adequate information about their disease and its treatment

A clinical case of a patient with subclinical hypothyroidism and newly diagnosed diabetes mellitus and arterial hypertension

Захарният диабет и хипотиреоидизмът са двете най-често срещани ендокринни нарушения, който при съчетанието си при един и същи пациент биха могли да протекат с различен ход от колкото изолирано. Инсулинът и тиреоидните хормони са тясно свързани в клетъчния метаболизъм и техния ексцес или дефицит взаимно се повлияват. Познаването на връзките между тях е полезно в клиничната практика за скрининга и управлението на тези заболявания. Добре известно е, че хормоналните отклонения при една ендокринна жлеза могат да повлияят функцията и на другите жлези. Така например, хипотиреоидизма и хипертиреоидизма променят стойностите на кръвната захар и трябва да се имат предвид при интерпретацията на лабораторните резултати. От друга стана наличието на захарен диабет, особенно автоимунната форма, става често причина да се търси асоциирано автоимунно заболяване като тиреоид на Хашимото. Представяме клиничен случай на пациентка с хипертонична криза, без известнa до този момент артериална хипертония, която става повод да се диагностицират редици други заболявания, като тиреоидна дисфункция и захарен диабет. Представяме подхода при диагнозата, оценката на таргетните увреди и избора на терапия в светлината последните съвременните ръководства.Diabetes mellitus and hypothyroidism are the most common endocrine disorders and when concomitant in the same patient can change the course of each conditions in a rather different way than when running their course on their own. Both hormones - insulin and the thyroid hormone, act on cell metabolism and the excess or insufficient secretion of any of them affects the function of the other. In clinical practice, it is very useful to be familiar with the interaction between these two hormones for better screening and management of the diseases. It is well known that a single hormone dysfunction can change other hormone activity. It is the situation in hyper- or hypothyroidism, both influence blood glucose level and that should be taken into account when biochemistry is analyzed. On the other hand, diagnosing diabetes mellitus, especially the autoimmune form of the disease, directs our attention toward searching for another autoimmune disorder like Hashimoto thyroiditis. Here, we present a clinical case of a female patient with hypertensive crises with unestablished arterial hypertension, in whom additional concomitant disorders - thyroid dysfunction and diabetes mellitus, were diagnosed simultaneously. We discuss the approach to the diagnosis and target organ evaluation, as well as the management of the diseases in the light of the newest guidelines

The challenge to manage a patient with advanced heart failure and necrotizing vasculitis - a clinical case

Пациентите с напреднала сърдечна недостатъчност много често имат и придружаващи заболявания, които повлияват и ограничават избора на лечение както за сърдечната недостатъчност, така и за придружаващото заболяване. Предствяме мъж, на 64години, с механична клапна протеза на аортно място, с високостепенна трикуспидална регургитация и високостепенна пулмонална хипертония, с тотална сърдечна недостатъчност, захарен диабет, периферна артериална болест и некротизиращ васкулит. Лечението, което бе предприето е напълно съобразено с препоръките за лечение на сърдечна недостатъчност на Европейското дружество по Кардиология от 2016 год., както и съвременните препоръки за лечение на захарен диабет и васкулити.Patients with advanced heart failure are patients with a lot of comorbidities that have important influence on the options of treatment - both for heart failure and the concomitant diseases. Here we present a 64-year-old man with mechanical aortic valve prosthesis, severe tricuspid regurgitation, severe pulmonary hypertension and total heart failure, diabetes mellitus type 2, peripheral artery disease and necrotizing vasculitis. The management of heart failure is according to the guidelines for the treatment of patients with heart failure of the European Society of Cardiology 2016; the treatment of the diabetes mellitus and the necrotizing vasculitis is also in accordance with the latest recommendations

Insulinoma

Introduction: Insulinoma is a rare endocrine pancreatic tumor that is derived from beta cells and produces insulin. Clinically it presents with hypoglycemia, weakness, blurred vision, palpitation, and unconsciousness resulting from endogenous hyperinsulinism.Materials and Methods: A 47-year-old man presented to the Internal Medicine Department with hypoglycemia (1.1 mmol/l), weakness, loss of appetite for a few days, blurred vision and a loss of consciousness. His past medical history included chronic pangastritis, chronic colitis, hypoglycemia (1.6,…2.3 mmol/l), severe weight loss in the past 5 years and episodes of unconsciousness on several occasions.The hematology and biochemistry tests were normal except for the low blood glucose level (2.6 mmol/l). A fasting test was performed and the levels of insulin and blood glucose were measured at the same time, giving the ratio > 3.5 which speaks in favour of an inappropriate insulin secretion. In order to localise the tumor, an MRI of the abdomen and CT - enterography were performed, both of which showed pathological induration of the wall of jejunum. For a more precise diagnosis an octreoscan is to be performed.The patient was treated with glucose, diazoxide, hydrochlorothiazide and prepared for surgical intervention.Results: The differential diagnoses include insulinoma, noninsulinoma pancreatogenic hypoglycemia syndrome (NIPHS), gastrinoma and VIPomas. Elevated insulin level, hypoglycemia and failure of endogenous insulin suppression by hypoglycemia are the hallmark of an insulinoma and disprove other diagnoses.Conclusion: Most insulinomas are benign tumors and have a good prognosis.Treatment in the long-term consists of complete resection of the tumor

Secondary adrenal insufficiency in a patient with Hashimoto thyroiditis and multiple comorbidities

Introduction: While Addison`s disease may be thought of when considering autoimmune polyglandular syndrome in patients with Hashimoto Thyroiditis, secondary adrenal insufficiency is an even rarer finding. The diagnosis is further complicated by nonspecific signs and symptoms, such as hyponatraemia or fatigue, that may be attributed to other comorbidities, like heart failure.Materials and methods: A 63-year-old male patient presented with complaints of generalized weakness, weight loss (body mass index 15), lack of appetite and nausea. His medical history was extensive, including Hashimoto thyroiditis and advanced left-sided heart failure with pacemaker placement due to Sick Sinus Syndrome and hypertension stage III, amongst other diagnoses.Results: Initial examinations revealed hypoglycaemia (2.2 mmol/L) and hyponatraemia (118 mEq/L), with no other relevant abnormalities. Once adrenal insufficiency was considered, serum cortisol (46.98 nmol/L) and adrenocorticotropic hormone (7.13 pg/mL) were both found decreased. Synacthen test results were 91.32 nmol/L - 0 min, 281.09 nmol/L - 30 min, 390.3 nmol/L - 60 min, and urine cortisol was 552 mcg/24h. The remaining pituitary hormones were in normal range. Computed tomography (as magnetic resonance was contraindicated) failed to determine the cause and no hypothalamopituitary pathology was observed, although the possibility of a microadenoma could not be excluded. Therapy with methylprednisolone was instituted successfully.Conclusion: The pathophysiology of secondary adrenal insufficiency in this patient was most likely autoimmune. This case report represents an unusual diagnosis, which additionally highlights the various possible effects of adrenocorticotropic hormone deficiency and the complexity of the clinical picture that may be seen in patients with multiple autoimmune endocrine disorders and comorbidities

50 години Катедра „Социална медицина и организация на здравеопазването`

22 Май 201