NEFROPATIJA POVEZANA S VARFARINOM – PRIKAZ BOLESNIKA NA TEMELJU BIOPSIJE BUBREGA I PREGLED LITERATURE

Warfarin-related nephropathy (WRN) is a recently recognized condition in patients with chronic kidney disease (CKD). WRN is clinically detected as an episode of unexplained acute kidney injury (AKI). It is defined as a serum creatinine (sCR) increase >0.3 mg/dL (26.5 μmol/L) within one week of an international normalized ratio (INR) measurement >3.0 in a patient treated with warfarin without clinical evidence of hemorrhage. Therefore, warfarin therapy can result in AKI by causing glomerular hemorrhage and renal tubular obstruction by red blood cell casts. WRN appears to accelerate the rate of CKD progression and increase the risk of death in susceptible patients. We report on renal biopsy in a patient on warfarin therapy with unexplained AKI and hematuria associated with increased INR. We would like to stress the necessity of an interdisciplinary approach to patients on warfarin therapy.Nefropatija povezana s varfarinom (WRN) je odnedavno prepoznato stanje u bolesnika s kroničnom bolešću bubrega (KBB). WRN je klinički prepoznata kao epizoda neobjašnjivog akutnog oštećenja bubrega (AOB). Definira se kao povećanje kreatinina u serumu (sCR) >0,3 mg/dL (26,5 micromol/L) unutar tjedna INR mjerenja >3,0 u bolesnika liječenog varfarinom bez klinički utvrđenog krvarenja. Zbog toga terapija varfarinom može dovesti do AOB uzrokujući glomerularno krvarenje i opstrukciju bubrežnih tubula odljevnim cilindrima eritrocita. Čini se da WRN ubrzava napredovanje KBB i u osjetljivih bolesnika povećava rizik od smrtnog ishoda.Izvješćujemo o biopsiji bubrega u bolesnika na terapiji varfarinom s neobjašnjivim AOB i hematurijom povezanom s povećanim INR. Namjera nam je naglasiti potrebu interdisciplinarnog pristupa bolesnicima na terapiji varfarinom

Dyslipidemia in patients with chronic kidney disease: etiology and management

Abstract: Patients with chronic kidney disease (CKD), including those with end-stage renal disease, treated with dialysis, or renal transplant recipients have an increased risk for cardiovascular disease (CVD) morbidity and mortality. Dyslipidemia, often present in this patient population, is an important risk factor for CVD development. Specific quantitative and qualitative changes are seen at different stages of renal impairment and are associated with the degree of glomerular filtration rate declining. Patients with non-dialysis-dependent CKD have low high-density lipoproteins (HDL), normal or low total cholesterol (TC) and low-density lipoprotein (LDL) cholesterol, increased triglycerides as well as increased apolipoprotein B (apoB), lipoprotein(a) (Lp (a)), intermediate- and very-low-density lipoprotein (IDL, VLDL; “remnant particles”), and small dense LDL particles. In patients with nephrotic syndrome lipid profile is more atherogenic with increased TC, LDL, and triglycerides. Lipid profile in hemodialysis (HD) patients is usually similar to that in non-dialysis-dependent CKD patients. Patients on peritoneal dialysis (PD) have more altered dyslipidemia compared to HD patients, which is more atherogenic in nature. These differences may be attributed to PD per se but may also be associated with the selection of dialytic modality. In renal transplant recipients, TC, LDL, VLDL, and triglycerides are elevated, whereas HDL is significantly reduced. Many factors can influence post-transplant dyslipidemia including immunosuppressive agents. This patient population is obviously at high risk; hence, prompt diagnosis and management are required to improve their clinical outcomes. Various studies have shown statins to be effective in the cardiovascular risk reduction in patients with mild-to-moderate CKD as well as in renal transplant recipients. However, according to recent clinical randomized controlled trials (4D, A Study to Evaluate the Use of Rosuvastatin in Subjects on Regular Dialysis: an Assessment of Survival and Cardiovascular Events, and Study of Heart and Renal protection), these beneficial effects are uncertain in dialyzed patients. Therefore, further research for the most suitable treatment options is neede

Bone mineral densitometry in patients on hemodialysis: difference between genders and what to measure

Introduction: Chronic kidney disease (CKD) and osteoporosis are important health problems. There is an interrelationship between osteoporosis and CKD. Bone densitometry is the “gold” standard in the diagnosis of osteoporosis. Unfortunately, there are some problems with the interpretation of bone densitometry in CKD patients. The goal of this study was to determine bone mineral density (BMD) in CKD patients, to assess the difference between genders and different sites of bone densitometry correlation between BMD and laboratory parameters, and to assess the most optimal measuring site. Methods: We studied 134 hemodialysis (HD) patients (62 females, 72 males). The mean age was 56.4 ± 12.4 years and the mean duration of HD was 54.4 ± 60 months. BMD of the lumbar spine (posterior–anterior projection and lateral projection), hip (femoral neck, trochanter, intertrochanter, total femur, the Ward's Triangle), and forearm (ultradistal (UD), middistal (MID), distal third portion, and total forearm) was measured using dual X-ray absorptiometry (DXA) (Hologic Delphi apparatus). Values were expressed as BMD, T-score, and Z-score. Results: Females had lower values of BMD in all measurement points. There were no significant differences in T- and Z-scores of forearm between males and females. Age was in a positive correlation with lumbar spine BMD in males and females. There was a negative correlation with neck and forearm BMD in both groups. Serum parathyroid hormone (PTH) was also in negative correlation with hip and forearm BMD in both groups. The best correlation of BMD in different sites was between forearm and neck. Conclusion: BMD data in CKD patients should be interpreted with caution and appendicular skeletal sites should be included in the evaluation

Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in the Early Period after Kidney Transplantation

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

BODY MASS PATTERNS DURING COVID-19 PANDEMIC IN PATIENTS WITH STABLE KIDNEY TRANSPLANT FUNCTION

Nakon transplantacije bubrega u velikog broja bolesnika dolazi do značajnog porasta tjelesne mase. Pandemija COVID-19 koja se javila kod nas početkom 2020. godine promijenila je dotadašnji način života i navike svih stanovnika uključujući i bolesnike s transplantatom. Cilj rada bio je ispitati kretanje tjelesne mase (TM) u bolesnika sa stabilnom funkcijom bubrežnog transplantata. Istraživanje je bilo retrospektivno. U ispitivanje je bilo uključeno 35 bolesnika (19 muškaraca, 16 žena). Prosječna životna dob na početku praćenja bila je 60,7 ± 11,5 godina, a prosječno vrijeme proteklo od transplantacije bubrega 9,3 ± 7,1 godina. Podatci su se analizirali u razdoblju od 18 mjeseci, od početka pandremije COVID-19 (od siječnja 2020. do 30. 06. 2021.) Referentno razdoblje od 18 mjeseci podijeljeno je u tri intervala u trajanju od 6 mjeseci. Analizirani podatci sakupljeni su na početku te nakon šest, 12 i 18 mjeseci. U svih ispitanika pratili smo: TM, izračunali indeks tjelesne mase (ITM), laboratorijske parametre i krvni tlak (KT). Od laboratorijskih parametara pratili smo: ureju, kreatinin, kolesterol i trigliceride. Uz to pratila se antihipertenzivna terapija i terapija hipolipemicima. Svi ispitanici u imunosupresivnom protokolu imali su kortikosteroide, a 91,4 % ispitanika bilo je na trojnoj imunosupresivnoj terapiji. Tijekom ispitivanog razdoblja došlo je do značajnog porasta TM i ITM ((P=0,007; P=0,03). U žena tijekom ispitivanog razdoblja nije bilo statistički značajnog porasta TM u odnosu na početnu vrijednost nakon šest, 12 i 18 mjeseci. U muškaraca je došlo do značajnog porasta TM nakon 12 i 18 mjeseci od ispitivanog razdoblja (P=0,01; P=0,04). Nije bilo statistički značajnih promjena u vrijednostima serumske ureje, kreatinina, kolesterola i triglicerida. Nije bilo statističke značajne razlike u prosječnim vrijednostima sistoličkog i dijastoličkog KT. Na početku istraživanja prosječan broj antihipertenziva po bolesniku je bio 2,17, a nakon 18 mjeseci trajanja pandemije prosječan broj antihipertenziva je narastao na 2,54; radilo s o statistički značajnoj razlici (P=0,002). Analizom prema spolu, u muškarca i u žena broj antihipertenziva u terapiji tijekom ispitivanog razdoblja se statistički značajno povećao (P=0,01; P=0,04). Nije bilo značajne razlike u uzimanju hipolipemika. Dobiveni rezultati pokazuju da je promjena životnih navika u bolesnika sa stabilnom funkcijom bubrežnog transplantata zbog pandemije COVID-19 uzrokovala porast TM uz značajno povećanje uzimanja antihipertenzivne terapije.After kidney transplant, a large number of patients gain weight. The COVID-19 pandemic, which occurred in our country in early 2020, changed the way of life and habits of all residents, including transplant patients. The aim of this study was to examine body mass (BM) patterns in patients with stable renal transplant function. The study was retrospective and included 35 patients (19 male and 16 female), mean age 60.7±11.5 years and mean time elapsed from kidney transplantation 9.3±7.1 years. Data were analyzed for 18-month period, from the beginning of the COVID-19 pandemic (from January 2020 to June 30, 2021). The reference period of 18 months was divided into three intervals of 6 months, and the data used were taken at the beginning and after 6, 12 and 18 months. In all subjects, we monitored BM, calculated body mass index (BMI), laboratory parameters and blood pressure (BP). Laboratory data included urea, creatinine, cholesterol and triglycerides. In addition, antihypertensive therapy and hypolipidemic therapy were followed. All subjects had corticosteroids in the immunosuppressive protocol, and 91.4% of them were on triple immunosuppressive therapy. There was a signifi cant increase in BM and BMI (p=0.007 and p=0.03, respectively) during the study period. There was no statistically signifi cant increase in BM compared to baseline BM in females. In men, there was a signifi cant increase in BM after 12 and 18 months (p=0.01 and p=0.04, respectively). There were no statistically signifi cant differences in serum urea, creatinine, cholesterol, and triglyceride levels during the follow-up period. There was no statistically signifi cant difference in the mean systolic and diastolic BP values. At the beginning of the study, the mean number of antihypertensives per patient was 2.17 and after 18 months of the pandemic the mean number of antihypertensives increased to 2.54, yielding a statistically signifi cant difference (p=0.002). The number of antihypertensives in therapy increased statistically signifi cantly during the study period in males and females (p=0.01 and p=0.04, respectively). There was no signifi cant difference in the use of hypolipidemic therapy. The results obtained show that the change in life habits due to the COVID-19 pandemic in patients with stable kidney transplant function caused an increase in BM and signifi cantly increased the use of antihypertensive therapy

Nutritional Risk Screening in Hospitalized and Haemodialysis Patients

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

Chronic kidney disease mineral bone disorder

Chronic kidney disease – mineral bone disease (CKD-MBD) is a syndrome defined as a systemic mineral metabolic disorder associated with CKD. The term renal osteodystrophy, as a part of CKD-MBD, indicates a pathomorphological concept of bone lesions. High morbidity and mortality of CKD patients is a consequence of CKD-MBD. The pathogenesis of this syndrome is not completely understood, but undoubtedly the development of mineral and bone disorder begins in the earliest stages of CKD. The diagnosis is made by non-invasive methods (biochemistry, x-ray, ultrasound, etc.) and bone biopsy as an invasive method. In addition to new drugs, e.g. non-calcium phosphate binders, vitamin D analogs, calcimimetics, prevention and treatment is still a major challenge for the nephrologist. In this article we will briefly discuss the pathophysiology, diagnosis, prevention and treatment of CKD-MBD