POTHRANJENOST BOLESNIKA NA DIJALIZI

Many factors contribute to morbidity and mortality in patients with end-stage renal disease, one of these being malnutrition. Eating disorders are inevitable in patients with uremia. A common associated factor is inflammation with hypoalbuminemia and decrease in serum proteins. In the present study, data on 33 (38.37%) female and 53 (61.63%) male patients were assessed with standard statistical analysis including the R-test for normality. The assessment method used was the Malnutrition Inflammation Score (MIS) composed of 10 components. The mean patient age was 67.28±12, range 32-86 years. The mean duration of hemodialysis (HD) was 48.94±47.57, range 3-224 months. The MIS has three categories: (A) well nourished; (B) mild malnutrition; and (C) severe malnutrition. At the beginning of the study, results were as follows: (A) 6.98%; (B) 51.16%; and (C) 41.86%. The respective figures recorded after 6 months were as follows: (A) 10.47%; (B) 25.58%; and (C) 63.95%. During the study, 53.49% of patients had a MIS of 7 or more, 6.97% of patients passed away, and 3.49% underwent transplantation. The mean MIS was 20.3±1.63 in the deceased, 3±2.6 in the transplanted, and 7.98±5.7 in the rest of patients. Patients having undergone HD for at least 3 months and aged at least 18 years were included in the analysis. The objective of the study was to determine the rate of malnutrition among HD patients and to compare the results recorded in our center with other HD centers around the world. Furthermore, our aim was to compare MIS with mortality rate. We repeated MIS after 6 and 12 months to find out whether there would be a decrease in the rate of malnutrition among patients, since additional nutritional support was introduced after detection of the state. According to our study results, there is strong correlation of malnutrition, hospitalization and mortality.Poznato je da teške bolesti uzrokuju gubitak apetita, tjelesne težine i malnutriciju. Uremija je teška bolest i čest pratilac pothranjenosti. Uzroci tome su višestruki: ograničen unos bjelančevina, gubitak bjelančevina uz još očuvanu diurezu. Sama hemodijaliza potiče katabolizam proteina i eliminira neke hranjive tvari te djeluje proupalno. U Centru za kroničnu hemodijalizu svih ispitanika liječenih najmanje 3 mjeseca i starijih od 18 godina napravili smo presječnu analizu. Željeli smo vidjeti kolika je zastupljenost pothranjenosti i u kojoj je korelaciji sa svjetskim podatcima te koliki je utjecaj visine ispitivanog zbira na smrtnost. Ponavljanjem testa nakon 6 i 12 mjeseci očekivali smo smanjenje stupnja pothranjenosti s obzirom na nutricionističku potporu nakon otkrivanja stanja, a na osnovi kojeg se podizala svijest o tom problemu kod bolesnika, obitelji i osoblja, naročito iz područja prehrane i tjelesne aktivnosti. U analiziranim podatcima na prvi pogled došli smo do poražavajućih rezultata u smislu porasta pothranjenosti u prvih 6 mjeseci. Daljnja analiza je pokazala da je pothranjenost bila uglavnom uzrokovana komorbiditetom povezanim s malignitetom te visokom dobi. Logično je da je uočena velika razlika u Malnutrition Inflammation Score (MIS) između umrlih i transplantiranih bolesnika. Kod umrlih bolesnika zbir MIS je bio 20,3±1,63, kod transplantiranih 3±2,6, a kod svih ostalih 7,98±5,7. Ne smijemo zaboraviti da se prema nekim autorima u literaturi navodi učestalost pothranjenosti kod bolesnika na dijalizi od 70% i više

POSEBNOST DIJALIZE u STARIH I VRLO STARIH BOLESNIKA – DILEME

The global increase in the proportion of older population contributes to the increasing number of patients with renal insufficiency. This disorder particularly involves the old (age 70-75) and very old (over 80) population groups. The number of comorbidities is increasing and life expectancy reduced with aging. Cross-sectional analysis of ten-year survival showed a rate of 33.9% in patients treated at the Hemodialysis Center, 23.81% in transplanted patients and 19.35% in dialyzed patients. In patients having started hemodialysis (HD) at the age of ≥70, the mean survival was 20.27±18.62 months, in those that died 15.54±17.35 months, and in survivors 30.29±17.85 months. Among HD treated patients, 35% survived for up to one year, 18% for two years and 8% for ≥3 years. Karnofsky index was below 50% in all patients that survived, while the Malnutrition Inflammation Score and Subjective Global Assessment indicated malnutrition. In Croatia, the number of HD patients is constantly increasing as the result of population aging, better, accessible and equal health care that prolongs life span, easier access to substitution methods, more accesses to the vascular system, development of the national transplant network and good immunosuppressive therapy. All this provides biological, economic and normative space for replacement therapy. Old age, comorbidities and poor nutritional status influence high mortality, poor functional status and impaired quality of life. Survival results correspond to reports in the literature.U svijetu je ubrzan porast broja starijih bolesnika koji trebaju liječenje dijalizom. Ti se izvještaji poklapaju iz raznih zemalja. Problemi koje nosi starija dob su višestruki. Različiti su stavovi za stratifikaciju dobnih granica. Bilo kako bilo, dobne granice su produžene i porast starije populacije sa svim pratećim komorbiditetima je neizbježan. Kronična bubrežna bolest ima puno veću incidenciju u među starom negoli među mlađom populacijom i u stalnom je porastu u svijetu bilo kao bolest, komorbiditet ili posljedica raznih stanja. Ova činjenica nameće pitanja fiziologije i patofiziologije starenja i promjena u glomerularnoj filtraciji (GF). Ima li jasnih stavova o normalnim laboratorijskim vrijednostima prilagođenim dobnoj granici? U kojem stupnju je GF fiziološka varijanta za konkretnu dob? Produžava li liječenje hemodijalizom životni vijek vrlo starih osoba? Odgovori nisu uvijek precizni. Stara populacija često je izložena odlukama liječnika, obitelji ili skrbnika mimo svoje želje, bilo zbog nedostatka komunikacije ili zbog nepoznavanja postupaka. Procedure mogu na bolesnika ostaviti psihičke i fizičke posljedice (patnje), bez obzira na to što su sve napravljene profesionalno, oni često kažu “da sam znao što me čeka, ne bih pristao”. Zbog toga je nužno poštivati odluku bolesnika. Analizom vlastitih podataka vidljiva je prisutnost veoma stare populacije s velikim brojem pridruženih komorbiditeta te visokim stupnjem pothranjenosti (MIS) i Karnofskyjeva skora. U Centru je više od 49,23% populacije starije od 70 godina, s velikom zastupljenošću privremenog ili trajnog centralnog venskog katetera kao pristupa za dijalizu (42,35%). Najviše preživjelih do 1, 2 i 3 godine bilo je u skupini od 76-80 godina, a u skupini starijih od 80 godina nitko nije preživio 4 ili 5 godina. Kod preživjelih bolesnika visoke dobi sposobnost za samostalno funkcioniranje je veoma mala. Karnofskyjev zbir za preživjele 6 mjeseci i više bio je u prosjeku 50%

TRANSPLANTATION AND RETRANSPLANTATION – IMPACT ON EMOTIONAL STATE

U svom kliničkom radu često smo se susretali s emocionalnim poteškoćama bolesnika s transplantom. Najčešće su to tjeskoba, teškoće integriranja novoprimljenog organa kao vlastitog, osjećaj krivnje, poteškoće povezane s osobnim doživljajem sebe. Mnoge studije, unatoč često prisutnim emocionalnim poteškoćama, opisuju poboljšanje kvalitete života kod bolesnika s transplantatom. Međutim, kvaliteta života ponovno se pogoršava u slučaju odbacivanja transplantata. U takvim situacijama pojavljuje se osjećaj nemira, gubitka kontrole nad vlastitim životom, osjećaj promašenosti, ideje bezizlaznosti i bezperspektivnosti. U složenim emocionalnim proživljavanjima vrlo je važno psihološki ojačati zdrave snage bolesnikove ličnosti čime se postiže bolja suradljivost liječenja općenito.In our clinical practice, we are often faced with emotional difficulties of transplanted patients. Most are due to anxiety, difficulty in integrating newly recruited organ as its own, feeling of guilt, and difficulties with personal experience of self. Despite common presence of emotional difficulties, many studies describe improvement in the quality of life of transplant patients. However, the quality of life is deteriorating again in case of transplant rejection. In such situations, restlessness develops along with losing control over their own lives, a sense of failure, hopelessness and lack of prosperity ideas. Complex emotional experiencing is very important in strengthening the patient’s psychological health and personality, thus achieving better treatment compliance in general

TRANSPLANTATION AND RETRANSPLANTATION – IMPACT ON EMOTIONAL STATE

U svom kliničkom radu često smo se susretali s emocionalnim poteškoćama bolesnika s transplantom. Najčešće su to tjeskoba, teškoće integriranja novoprimljenog organa kao vlastitog, osjećaj krivnje, poteškoće povezane s osobnim doživljajem sebe. Mnoge studije, unatoč često prisutnim emocionalnim poteškoćama, opisuju poboljšanje kvalitete života kod bolesnika s transplantatom. Međutim, kvaliteta života ponovno se pogoršava u slučaju odbacivanja transplantata. U takvim situacijama pojavljuje se osjećaj nemira, gubitka kontrole nad vlastitim životom, osjećaj promašenosti, ideje bezizlaznosti i bezperspektivnosti. U složenim emocionalnim proživljavanjima vrlo je važno psihološki ojačati zdrave snage bolesnikove ličnosti čime se postiže bolja suradljivost liječenja općenito.In our clinical practice, we are often faced with emotional difficulties of transplanted patients. Most are due to anxiety, difficulty in integrating newly recruited organ as its own, feeling of guilt, and difficulties with personal experience of self. Despite common presence of emotional difficulties, many studies describe improvement in the quality of life of transplant patients. However, the quality of life is deteriorating again in case of transplant rejection. In such situations, restlessness develops along with losing control over their own lives, a sense of failure, hopelessness and lack of prosperity ideas. Complex emotional experiencing is very important in strengthening the patient’s psychological health and personality, thus achieving better treatment compliance in general