TREATMENT WITH PEGYLATED INTERFERON BEFORE TRANSPLANTATION IMPROVES POSTTRANSPLANT OUTCOME IN DIALYSIS PATIENTS INFECTED WITH HCV

Uvod: Dijalizni bolesnici infi cirani HCV kandidati su za transplantacijsko liječenje, no dugoročno preživljenje ovih bolesnika i transplantiranog bubrega lošije je no u neinfi ciranih bolesnika. Primarni cilj ovog rada je usporedba jednogodišnjeg i trogodišnjeg preživljenja transplantata i bolesnika koji su u predtransplantacijskom razdoblju liječeni pegiliranim interferonom alfa 2 a (PEG-INF) (PEG DA skupina) i onih kod kojih ovo liječenje nije provedeno (PEG NE skupina). Sekundarni cilj je praćenje posttransplantacijskih komplikacija i to odgođene funkcije transplantata, odbacivanja transplantata, uroloških komplikacija (infekcije rane, urinom, limfokela, krvarenja), učestalost virusnih infekcija (infekcije polioma virusima -BK virusom, JS virusom, citomegalovirusom - CMV, te varicela-zoster virusom - VZV), te pojavnost neoplazmi. Bolesnici i metode: Retrospektivna analiza učinjena je pregledom medicinske dokumentacije 28 bolesnika s kroničnom HCV infekcijom koji su liječeni transplantacijom bubrega u KBC Zagreb (2007.-2010.). Devet od 28 bolesnika liječeno je pegiliranim interferonom alfa 2a (PEG-INF)-135 ug s.c. tjedno tijekom 48 tjedana, jednu do četiri godine prije transplantacije. Prosječna životna dob u trenutku transplantacije bila je 48,8 (17-61) godina, prosječno liječenje dijalizom 14 (5-23) godina. Šest od devet bolesnika liječenih PEG-INF postigli su SVR te su bili HCV RNA negativni, a kod troje bolesnika nije postignut SVR. U svih bolesnika učinjena je kadaverična transplantacija bubrega, imunosupresivni protokol uključivao je indukciju basiliksimabom ili daclizumabom, inhibitor kalcineurina (ciklosporin ili tacrolimus), mikofenolat mofetil i steroide. Rezultati: Trogodišnje preživljenje transplantata iznosilo je 78 % u PEG NE skupini, 88 % u PEG DA skupini, preživljenje bolesnika 89 % u PEG NE skupini, a 100 % u PEG DA skupini. Posttransplantacijske komplikacije bile su rjeđe u PEG DA skupini. Odgođena funkcija transplantiranog bubrega zabilježena je u 44,4 % bolesnika u PEG DA skupini, a u PEG NE skupini u 57,8 %. Akutno odbacivanje transplantiranog bubrega imalo je ukupno 25 % naših bolesnika, 31,58 % u skupini PEG NE, a značajno manje - 11,11 % u skupini PEG DA; samo jedan bolesnik u PEG DA skupini (11,1 %) imao je akutno odbacivanje transplantata, naprama 6 bolesnika (32 %) u PEG NE skupini. Virusne infekcije bile su nešto učestalije u PEG NE skupini. Nije zabilježena značajnija razlika u učestalosti infekcije polioma virusima BK/JS (26,3 %/33,3 %) i infekcije VZV (10,5 %/11,1 %), dok je CMV infekcija bila manje učestala u PEG DA skupini (22 % naprama 42,1 %). Zabilježen je samo jedan malignom i to planocelularni karcinom kože u bolesnika PEG DA skupine. Zaključak: Kod dijaliziranih bolesnika s kroničnom HCV infekcijom potrebno je provesti liječenje pegiliranim interferonom ili DAA lijekovima prije transplantacije bubrega, jer se eradikacijom HCV smanjuje rizik, a poboljšava transplantacijski ishod. Naši rezultati pokazuju da je uspješno liječenje HCV infekcije pegiliranim interferonom reduciralo rizik akutnog odbacivanja transplantiranog bubrega.Introduction: Dialysis patients with hepatitis C virus (HCV) infection are candidates for transplantation, but long-term patient and graft survival is less favorable than in non-infected patients. The primary objective of this study was to compare three-year graft and patient survival in patients treated with pegylated interferon alfa 2 (PEG-IFN) before transplantation (PEG YES group) and patients without specifi c anti-HCV treatment (PEG NO group). The secondary target was tracking of the following post-transplant complications: delayed graft function, graft rejection, urologic complications (wound infection, urinoma, lymphocele, bleeding), viral infections (polyoma BK/JC virus infection, varicella-zoster (VZV) infection, cytomegalovirus (CMV) infection), and incidence of neoplasia. Subjects and Methods: A retrospective analysis was done by reviewing medical charts of 28 patients with chronic HCV infection that received renal allograft at Zagreb UHC (2007-2010). Nine of 28 patients received 135 μg of PEG-IFN 2a weekly for 48 weeks, 1-4 years before transplantation. The mean age at the time of transplantation was 48.8 (17-61) years, dialysis vintage 14 (5-23) years. Six (66.7%) patients achieved sustained virological response (SVR) and were HCV-RNA negative before transplantation, while three patients did not achieve SVR. All patients received kidney allograft from deceased donors, immunosuppressive protocol included basiliximab or daclizumab, calcineurin inhibitor cyclosporine or tacrolimus, mycophenolate mofetil, and steroids. Results: Three-year graft survival was 78% in the PEG NO group and 88% in the PEG YES group, with patient survival of 89% and 100%, respectively.Post-transplant complications were less frequent in the PEG YES group. Delayed graft function was observed in 44.4%, while in the PEG NO group it occurred in 57.8%. Acute rejection was recorded in 25% of our patients, 31.58% in the PEG NO group and signifi cantly less (11.11%) in the PEG YES group; only one (11.1 %) patient treated with PEG-IFN developed acute allograft rejection, as opposed to six (32%) patients in the PEG NO group. Viral infections were more frequent in the PEG NO group; there was no difference in polyoma BK/JC virus infection (26.3%/33.3%) and VZV infection (10.5%/11.1%), but CMV infection was less common in the PEG YES group (42.1 %/22.2%). Only one case of malignancy (squamous cell carcinoma) was observed in a patient from the PEG YES group. Conclusion: HCV positive patients should be treated with pegylated interferon before transplantation in order to eradicate HCV, thus eliminating one of the risk factors for adverse outcome after transplantation. Our results demonstrated that treatment with pegylated interferon reduced the risk of acute allograft rejection after kidney transplantation

INFECTIONS DURING THE FIRST POSTTRANSPLANT YEAR – EXPERIENCE AT ŠIBENIK GENERAL HOSPITAL

Infektivne komplikacije su veliki rizik za primatelje bubrega i odgovorne su za značajan morbiditet i mortalitet, u prvom redu zbog posttransplantacijske imunosupresije. Cilj rada bio je prikazati učestalost i vrstu infektivnih komplikacija u primatelja bubrega tijekom prve godine nakon transplantacije. Retrospektivn smo analizirali dijagnostiku i liječenje infektivnih komplikacija u primatelja bubrega koji su bili u skrbi Nefrološkog odjela Opće bolnice Šibenik u razdoblju 2004.–2012. godine. Bilježena je pojavnost infekcija mokraćnog sustava (asimptomatske bakterijurije, akutnog pijelonefritisa, urosepse), donjeg dišnog sustava (pneumonije), infekcija citomegalovirusom, poliomavirusima (BK virus, JC virus), Epstein-Barrovim virusom (EBV) i varicela zoster virusom (VZV). Učestalost i vrstu infektivnih komplikacija promatrali smo s obzirom na jednogodišnje i trogodišnje preživljenje presatka i primatelja. Posebno smo se osvrnuli na ishod bolesnika s transplantatom s kroničnom infekcijom HCV-om. Rezultate smo obradili deskriptivnom statistikom. U promatranom razdoblju praćeno je 36 bolesnika s transplantatom od kojih 22 muškarca i 14 žena, životne dobi u trenutku transplantacije 19–73 godine. Najčešća infektivna komplikacija u 25 (69 %) bolesnika bila je infekcija mokraćnog sustava od kojih je 17 (68 %) imalo jedan ili više recidiva. Najčešći klinički oblik bio je akutni pijelonefritis (14/25), a najčešći uzročnici E. coli i Klebsiella pneumoniae (u po 12/25 slučajeva) od čega se u 4/12 slučajeva radilo o soju koji luči beta-laktamaze proširenog spektra. Pneumonija je registrirana u 4 (11 %) bolesnika s transplantatom od kojih jedna uzrokovana CMV-om, dok su ostale bile bakterijske etiologije. Infekcija CMV-om i BK virusom javila se u po 6 (17 %) bolesnika, dok je infekciju VZV-om razvilo 4 (11 %) bolesnika. U jednog bolesnika s meningoencefalitisom dokazana je infekcija EBV-om; isti je bolesnik osim uroinfekcije imao pneumonitis uzrokovan CMV-om te akutno odbacivanje transplantiranog organa. Trogodišnje preživljenje presatka iznosilo je 100 % u bolesnika bez infekcije mokraćnog sustava, a 96 % u bolesnika s infekcijom u prvoj godini nakon transplantacije.Aim: The aim of this study was to assess the frequency and type of infective complications in kidney recipients during the first year after transplantation. Patients and Methods: We retrospectively analyzed data on the diagnosis and treatment of infective complications in 36 patients transplanted from 2004 until September 2012 (22 men and 14 women), age at the time of transplantation 19-73 years. We recorded the incidence of urinary tract infections, clinical variants (asymptomatic bacteriuria, acute pyelonephritis, sepsis) and etiology, i.e. causes, pneumonia, viral infections and cytomegalovirus infections (CMV) (with special reference to the use or no use of prophylactic valganciclovir), polyoma virus infection, BKV, JC, Epstein-Barr virus, and herpes zoster virus. Results: The most common infective complication, uroinfection, was recorded in 69% of patients, of which 68% had one or more relapses. The most common clinical form of the infection was acute tubulointerstitial nephritis, caused by Klebsiella pneumoniae (of which 4 cases of ESBL Klebsiella pneumoniae). Pneumonia occurred in 4 transplant patients, one CMV pneumonia, other of bacterial origin. CMV infection and BKV occurred in 17% and herpes zoster infection in 11% of patients. One patient was diagnosed with EBV meningoencephalitis. One-year graft survival was 100% in patients without urinary tract infections in the first year after transplantation (31% of all patients) and 96% in patients with infections (69% of all patients).Three-year graft survival rate was 100% in patients without infection and 96% in patients with infections in the first year after transplantation. One- and three-year graft survival in patients with chronic hepatitis C was 100%. It was a small group of patients (5/36, 14%); the incidence of urinary tract infections amounted to 60%, and of CMV and BK virus to 20%

Hepatitis G virus (HGV) infection in chronic haemodialysis patients in the County of Šibenik and Knin

Hepatitis G virus (HGV) i GB virus tipa C (GBV-C) danas se smatraju varijantama istog RNA virusa i svrstani su u porodicu Flaviviridae. Obzirom da se HGV prvenstveno prenosi parenteralnim putem, uočena je njegova učestalija pojava među dijaliziranim bolesnicima. Cilj ovog rada bio je istražiti pojavnost infekcije HGV-om u bolesnika s kroničnim zatajenjem bubrega liječenih kroničnom hemodijalizom u Jedinici za dijalizu Opće bolnice Šibenik te razmotriti značenje infekcije HGV-om u tih bolesnika. Od 79 bolesnika koji su u razdoblju od kolovoza 2004. do lipnja 2005. godine dijalizirani u ovoj bolnici, prospektivno je tijekom devet mjeseci praćeno 16 bolesnika koji su zadovoljavali uvjete za uključenje na listu čekanja za kadaveričnu transplantaciju bubrega. Infekcija HGV-om utvrđena je metodom lančane reakcija polimeraze u 6/16 ispitanika među kojima niti u jednog nije potvrđena koinfekcija HBV-om, dok je u jednog potvrđena koinfekcija HCV-om. Povišene vrijednosti aminotransferaza nađene su u 2/6 HGV-pozitivna bolesnika, od kojih je jedan bio koinficiran HCV-om. Vrijeme provedeno na hemodijalizi znatno pridonosi povećanju rizika akviriranja infekcije HGV-om. Međutim, višekratno liječenje krvnim pripravcima, koje se u literaturi spominje kao glavni čimbenik rizika za akviriranje infekcije HGV-om, nije utvrđeno kao značajan čimbenik rizika u naših ispitanika.Hepatitis G virus (HGV) and GB virus type C (GBV-C) are today considered variants of the same RNA virus that belong to the Flaviviridae family. Since HGV is primarily transmitted parenterally, its high prevalence has been recorded among dialyzed patients. The aim of this paper was to investigate the prevalence of HGV infection in patients with chronic renal failure undergoing chronic haemodialysis at the Dialysis Unit of the General Hospital Šibenik and to determine the significance of HGV infection in these patients. Out of 79 patients dialyzed in this Unit during the observed period (August, 2004 – June, 2005), we prospectively followed 16 patients that met inclusion criteria for cadaveric kidney transplant waiting list. HGV infection was detected by polymerase chain reaction (PCR) method in 6/16 examinees, non of whom had a HBV coinfection confirmed, only HCV coinfection in one patient. Elevated aminotransferases were found in two HGV-positive patients, of whom one was coinfected with HCV. The time spent on haemodialyis significantly increases the risk for activating HGV infection. However, multiple treatments with blood products, described in literature as the main risk factor for activating HGV infection, were not determined as a significant risk factor in our examinees

NUTRITIVNI ZBROJ (CONTROLLING NUTRITIONAL STATUS - CONUT) MOŽE PREDVIDJETI PREŽIVLJENJE BOLESNIKA NA HEMODIJALIZI

Malnutrition causes substantial morbidity in maintenance hemodialysis (HD) patients. The Controlling Nutritional Status (CONUT) has emerged as a simple and an easily obtainable tool to comprehensively assess nutrition as it consists of serum albumin levels, absolute lymphocyte counts, and total cholesterol levels. The CONUT has been shown to predict overall survival (OS) in peritoneal dialysis patients. This study investigated whether CONUT might also predict OS in maintenance HD patients. Clinical and laboratory data were retrospectively collected. Survival time was calculated from the fi rst HD until death or last follow-up; survival analyses were performed using the methods of Kaplan-Meier and Cox regression analysis. Eighty-nine patients were included; mean age was 65.76 years (±14), 35 (39.3%) were female, and the mean CONUT was 3. Higher CONUT score correlated with lower low-density liproprotein, higher serum creatinine, higher serum C-reactive protein and higher neutrophil-to-lymphocyte ratio, as well as with a higher incidence of nephrotic proteinuria (p<0.050 for all analyses). Univariately, patients with higher CONUT (≥5) had an inferior OS (median 54 vs. 112 months, HR 2.27; p=0.013). In the Cox regression analysis, higher CONUT remained independently associated with inferior OS (HR 9.50; p=0.002) when adjusted to age, sex, diabetes mellitus and nephrotic proteinuria. Therefore, the CONUT score might identify HD patients at an increased risk of death; however, future studies are needed to elucidate whether CONUT score might be able to guide nutritional support in HD patients.Pothranjenost uzrokuje značajan pobol i smrtnost bolesnika na hemodijalizi (HD). Controlling Nutritional Status (CONUT) je jednostavan nutritivni zbroj koji cjelovito procjenjuje uhranjenost, a sastoji se od serumske koncentracije albumina, apsolutnog broja limfocita i koncentracije serumskog kolesterola. Ova unicentrična retrospektivna studija analizirala je prediktivnu sposobnost zbroja CONUT da procijeni preživljenje bolesnika na HD. Ukupno preživljenje mjereno je kao vrijeme od prve HD do smrti ili posljednjeg pregleda bolesnika, a krivulje preživljenja uspoređene su Kaplan-Meirovom metodom, dok je Coxova regresijska metoda primijenjena u multivarijatnim analizama. Uključeno je 89 bolesnika, od toga 35 (39,3 %) žena; srednja dob bila je 65,76 godina (±14). Srednji zbroj CONUT bio je 3. Viši zbroj CONUT korelirao je s nižim koncentracijama serumskog lipoproteina niske gustoće, višim serumskim kreatininom, višim serumskim C-reaktivnim proteinom i višim omjerom neutrofi la/limfocita, kao i s većom učestalošću nefrotske proteinurije (p<0,050 za sve analize). U univarijatnoj analizi je viši zbroj CONUT (≥5) bio povezan s lošijim preživljenjem (medijan 54 prema 112 mjeseci, HR 2,27; p=0,013). U multivarijatnoj Coxovoj regresijskoj analizi je viši CONUT ostao nezavisno povezan s lošijim preživljenjem (HR 9,50; p=0,002) kada je bio ispravljen za dob, spol, šećernu bolest i nefrotsku proteinuriju. Zaključno, zbroj CONUT može identifi cirati bolesnike na HD s povišenim rizikom od smrti. Potrebne su dodatna istraživanja kako bi se analizirala sposobnost zbroja CONUT da usmjeri nutritivnu potporu u bolesnika na HD

Expression of BMP-2 in vascular endothelial cells of recipient may predict delayed graft function after renal transplantation

BACKGROUND/AIMS: Delayed graft function (DGF) is associated with adverse outcomes after renal transplantation. Bone morphogenetic protein-2 (BMP-2) is involved in both endothelial function and immunological events. We compared expression of BMP-2 in epigastric artery of renal transplant recipients with immediate graft function (IGF) and DGF. ----- METHODS: 79 patients were included in this prospective study. Patients were divided in IGF group (64 patients) and DGF group (15 patients). BMP-2 expression in intima media (BMP2m) and endothelium (BMP2e) of epigastric artery was assessed by immunohistochemistry. ----- RESULTS: Lower intensity of BMP2e staining was recorded in DGF compared to IGF. In DGF patients, 93% had no expression of BMP2e and 7% had 1st grade expression, compared to 45% and 41% in IGF group, respectively (P=0.001) (P<0.001 for no expression and P = 0.015 for 1st grade expression). Patients who had BMP2e staining positive had lower odds for DGF (OR 0.059 [0.007, 0.477]) and this remained significant even after adjustment for donor and recipient variables, cold ischemia time, and immunological matching (OR 0.038 [0.003, 0.492]). ----- CONCLUSIONS: Our results demonstrate that BMP-2 expression in endothelial cells of epigastric arteries may predict development of DGF

Preporuke za prevenciju infekcije humanim papilomavirusima (HPV) u primatelja bubrežnog presatka Hrvatskog društva za nefrologiju, dijalizu i transplantaciju

Zaraza humanim papilomavirusom (HPV) učestala je u populaciji te ukoliko imunosni sustav ne uspije uništiti virus, perzistirajuća infekcija visokorizičnim onkogenim tipovima HPV-a povećava rizik razvoja karcinoma. Iako ne postoji specifično liječenje, zaraza HPV-om može se spriječiti cijepljenjem. Bolesnici s presađenim bubregom imaju veći rizik za perzistentnu infekciju HPV-om i razvoj komplikacija zbog cjeloživotne imunosupresije u odnosu na opću populaciju. Sukladno preporukama brojnih stručnih društava donosimo hrvatske preporuke za cijepljenje protiv zaraze HPV-om u primatelja bubrežnog presatka

Guidelines for the prevention of pneumococcal diseases by vaccination in patients with chronic renal disease

S obzirom na zabilježene slučajeve invazivne pneumokokne bolesti u bolesnika s kroničnom bubrežnom bolesti uznapredovala stadija, Upravni odbor Hrvatskog društva za nefrologiju, dijalizu i transplantaciju (HDNDT) Hrvatskoga liječničkog zbora donio je u svibnju 2017. godine odluku o izradi Preporuka/Smjernica za prevenciju pneumokoknih bolesti cijepljenjem u bolesnika s kroničnom bubrežnom bolesti. Preporuke/Smjernice temelje se na relevantnoj medicinskoj literaturi: smjernicama Europskog društva za kliničku mikrobiologiju i zarazne bolesti i Svjetskog udruženja za zarazne bolesti i imunosne poremećaje te na Programu imunizacije, seroprofilakse i kemoprofilakse za posebne skupine stanovništva Hrvatskog zavoda za javno zdravstvo. U njihovoj su izradi sudjelovali nefrolozi, infektolozi i epidemiolozi. U Republici Hrvatskoj dostupne su dvije vrste pneumokoknog cjepiva koje se mogu primijeniti u odraslih: konjugirano cjepivo PCV13 i polisaharidno cjepivo PPSV23. U Preporukama/Smjernicama navedena je detaljna shema cijepljenja koje se preporučuje provesti u bolesnika s kroničnom bubrežnom bolesti koji bubrežnu funkciju nadomještaju hemodijalizom, peritonealnom dijalizom, kandidati su za transplantacijsko liječenje ili su transplantirani i imaju jedan ili više komorbiditeta (šećernu bolest, kroničnu plućnu bolest, kroničnu srčanožilnu bolest, kroničnu uznapredovalu jetrenu bolest, kronični bubrežni bolesnici sa solidnim ili hematološkim tumorima te splenektomirani).Considering the reported cases of invasive pneumococcal disease in advanced chronic kidney disease patients, in May 2017 the Steering Board of the Croatian Society of Nephrology, Dialysis and Transplantation (CSNDT) of the Croatian Medical Association issued a decision on the preparation of Guidelines for the prevention of pneumococcal diseases in patients with chronic kidney disease. The Guidelines are based on relevant medical literature, Guidelines of the European Society of Clinical Microbiology and Infectious Diseases, the World Association for Infectious Diseases and Immunological Disorders, and the Program for immunization, seroprophylaxis and chemoprophylaxis for special population groups of the Croatian Institute of Public Health. Nephrologists, infectologists and epidemiologists were involved in their development. There are two types of pneumococcal vaccine available in Croatia that can be used for adults, conjugated vaccine PCV13 and polysaccharide vaccine PPSV23. The Guidelines include planning and implementation of vaccination in chronic kidney disease patients who replace kidney function with hemodialysis, peritoneal dialysis, renal transplant, or are candidates for treatment by transplantation, having one or more comorbidities: diabetes mellitus, chronic pulmonary disease, chronic cardiovascular disease, chronic advanced liver disease, chronic kidney disease with solid or hematological tumors, and splenectomy

Guidelines for the prevention of pneumococcal diseases by vaccination in patients with chronic renal disease

S obzirom na zabilježene slučajeve invazivne pneumokokne bolesti u bolesnika s kroničnom bubrežnom bolesti uznapredovala stadija, Upravni odbor Hrvatskog društva za nefrologiju, dijalizu i transplantaciju (HDNDT) Hrvatskoga liječničkog zbora donio je u svibnju 2017. godine odluku o izradi Preporuka/Smjernica za prevenciju pneumokoknih bolesti cijepljenjem u bolesnika s kroničnom bubrežnom bolesti. Preporuke/Smjernice temelje se na relevantnoj medicinskoj literaturi: smjernicama Europskog društva za kliničku mikrobiologiju i zarazne bolesti i Svjetskog udruženja za zarazne bolesti i imunosne poremećaje te na Programu imunizacije, seroprofilakse i kemoprofilakse za posebne skupine stanovništva Hrvatskog zavoda za javno zdravstvo. U njihovoj su izradi sudjelovali nefrolozi, infektolozi i epidemiolozi. U Republici Hrvatskoj dostupne su dvije vrste pneumokoknog cjepiva koje se mogu primijeniti u odraslih: konjugirano cjepivo PCV13 i polisaharidno cjepivo PPSV23. U Preporukama/Smjernicama navedena je detaljna shema cijepljenja koje se preporučuje provesti u bolesnika s kroničnom bubrežnom bolesti koji bubrežnu funkciju nadomještaju hemodijalizom, peritonealnom dijalizom, kandidati su za transplantacijsko liječenje ili su transplantirani i imaju jedan ili više komorbiditeta (šećernu bolest, kroničnu plućnu bolest, kroničnu srčanožilnu bolest, kroničnu uznapredovalu jetrenu bolest, kronični bubrežni bolesnici sa solidnim ili hematološkim tumorima te splenektomirani).Considering the reported cases of invasive pneumococcal disease in advanced chronic kidney disease patients, in May 2017 the Steering Board of the Croatian Society of Nephrology, Dialysis and Transplantation (CSNDT) of the Croatian Medical Association issued a decision on the preparation of Guidelines for the prevention of pneumococcal diseases in patients with chronic kidney disease. The Guidelines are based on relevant medical literature, Guidelines of the European Society of Clinical Microbiology and Infectious Diseases, the World Association for Infectious Diseases and Immunological Disorders, and the Program for immunization, seroprophylaxis and chemoprophylaxis for special population groups of the Croatian Institute of Public Health. Nephrologists, infectologists and epidemiologists were involved in their development. There are two types of pneumococcal vaccine available in Croatia that can be used for adults, conjugated vaccine PCV13 and polysaccharide vaccine PPSV23. The Guidelines include planning and implementation of vaccination in chronic kidney disease patients who replace kidney function with hemodialysis, peritoneal dialysis, renal transplant, or are candidates for treatment by transplantation, having one or more comorbidities: diabetes mellitus, chronic pulmonary disease, chronic cardiovascular disease, chronic advanced liver disease, chronic kidney disease with solid or hematological tumors, and splenectomy

Guidelines for the prevention of pneumococcal diseases by vaccination in patients with chronic renal disease

S obzirom na zabilježene slučajeve invazivne pneumokokne bolesti u bolesnika s kroničnom bubrežnom bolesti uznapredovala stadija, Upravni odbor Hrvatskog društva za nefrologiju, dijalizu i transplantaciju (HDNDT) Hrvatskoga liječničkog zbora donio je u svibnju 2017. godine odluku o izradi Preporuka/Smjernica za prevenciju pneumokoknih bolesti cijepljenjem u bolesnika s kroničnom bubrežnom bolesti. Preporuke/Smjernice temelje se na relevantnoj medicinskoj literaturi: smjernicama Europskog društva za kliničku mikrobiologiju i zarazne bolesti i Svjetskog udruženja za zarazne bolesti i imunosne poremećaje te na Programu imunizacije, seroprofilakse i kemoprofilakse za posebne skupine stanovništva Hrvatskog zavoda za javno zdravstvo. U njihovoj su izradi sudjelovali nefrolozi, infektolozi i epidemiolozi. U Republici Hrvatskoj dostupne su dvije vrste pneumokoknog cjepiva koje se mogu primijeniti u odraslih: konjugirano cjepivo PCV13 i polisaharidno cjepivo PPSV23. U Preporukama/Smjernicama navedena je detaljna shema cijepljenja koje se preporučuje provesti u bolesnika s kroničnom bubrežnom bolesti koji bubrežnu funkciju nadomještaju hemodijalizom, peritonealnom dijalizom, kandidati su za transplantacijsko liječenje ili su transplantirani i imaju jedan ili više komorbiditeta (šećernu bolest, kroničnu plućnu bolest, kroničnu srčanožilnu bolest, kroničnu uznapredovalu jetrenu bolest, kronični bubrežni bolesnici sa solidnim ili hematološkim tumorima te splenektomirani).Considering the reported cases of invasive pneumococcal disease in advanced chronic kidney disease patients, in May 2017 the Steering Board of the Croatian Society of Nephrology, Dialysis and Transplantation (CSNDT) of the Croatian Medical Association issued a decision on the preparation of Guidelines for the prevention of pneumococcal diseases in patients with chronic kidney disease. The Guidelines are based on relevant medical literature, Guidelines of the European Society of Clinical Microbiology and Infectious Diseases, the World Association for Infectious Diseases and Immunological Disorders, and the Program for immunization, seroprophylaxis and chemoprophylaxis for special population groups of the Croatian Institute of Public Health. Nephrologists, infectologists and epidemiologists were involved in their development. There are two types of pneumococcal vaccine available in Croatia that can be used for adults, conjugated vaccine PCV13 and polysaccharide vaccine PPSV23. The Guidelines include planning and implementation of vaccination in chronic kidney disease patients who replace kidney function with hemodialysis, peritoneal dialysis, renal transplant, or are candidates for treatment by transplantation, having one or more comorbidities: diabetes mellitus, chronic pulmonary disease, chronic cardiovascular disease, chronic advanced liver disease, chronic kidney disease with solid or hematological tumors, and splenectomy

OUTCOME OF RENAL TRANSPLANTATION IN PATIENTS WITH CHRONIC VIRUS HEPATITIS

Cilj rada bio je pokazati rezultate liječenja transplantacijom bubrega bolesnika s terminalnim zatajenjem funkcije bubrega liječenih dijalizom s kroničnim C/B virusnim hepatitisom. Retrospektivno smo analizirali rezultate transplantacijskog liječenja tih bolesnika od 1985. do 2009. godine u KBC-u Zagreb: funkciju i preživljenje transplantiranog bubrega, preživljenje bolesnika, jetrenu funkciju, te komplikacije transplantacijskog liječenja: epizode akutnog odbacivanja, pojavnost dijabetesa melitusa, te proteinurije. Analizirali smo podatke transplantacijskog liječenja 91 bolesnika, od toga 50 muškaraca i 41 žene, prosječne dobi 40,9 godina, prethodno liječenih dijalizom 7,8 godina, a prosječno praćenje nakon transplantacije iznosilo je 7,3 godine. Najčešće dijagnoze koje su dovele do kroničnog zatajenja funkcije bubrega bile su: kronični glomerulonefritis, refluks nefropatija, tubulointersticijski nefritis, hipoplazija/aplazija bubrega i policistična bolest bubrega. 59,5% bolesnika imalo je dobru funkciju transplantiranog bubrega (serumski kreatinin do 200 umol/L). Jednogodišnje preživljenje transplantiranog bubrega iznosilo je 93%, 5-godišnje 64%, 10-godišnje 39%. Jednogodišnje preživljenje bolesnika iznosilo je 98%, 5-godišnje 72%, 10-godišnje 42%. Uredne vrijednosti jetrenih enzima (AST, ALT) imalo je 61% bolesnika, dok su povišene vrijednosti zabilježene u 39% bolesnika. Epizode akutnog odbacivanja transplantiranog bubrega imalo je 56% bolesnika. Proteinurija je zabilježena u 27% bolesnika, dijabetes melitus u 18%, dok je povišene vrijednosti arterijskog tlaka imalo 66% bolesnika. Bolesnici s kroničnim virusnim C/B hepatitisom liječeni transplantacijom bubrega imali su lošije preživljenje transplantata, bolesnika, lošiju funkciju transplantata no bolesnici bez kroničnog virusnog hepatitisa. Razlozi su veća učestalost epizoda akutnog odbacivanja transplantiranog organa, a prema podacima iz literature i veća učestalost infekcija (bakterijske infekcije, sepse), češće i dulje hospitalizacije, veća učestalost malignih bolesti, te češća kronična alograft nefropatija. Najčešći uzroci smrti bili su kardiovaskularne i cerebrovaskularne bolesti, te jetrena ciroza.The objective is to present results of renal transplantation in patients with end-stage renal disease and chronic virus C/B hepatitis. We retrospectively reviewed outcome of transplantation in patients having received renal allograft from 1985 to 2009 at Zagreb University Hospital Center: graft function, graft and patient survival, hepatic function, and complications of transplantation, i.e. episodes of acute rejection, manifestation of diabetes mellitus, and proteinuria. There were 91 patients, 50 men and 41 women, mean age 40.9. Patients were previously treated with dialysis for 7.8 years, with the mean follow-up after transplantation of 7.3 years. The most frequent diagnoses of end-stage renal disease were chronic glomerulonephritis, reflux nephropathy, tubulointerstitial nephritis, renal hypoplasia/aplasia, and polycystic renal disease. Good graft function (creatinine 200 μmol/L) was recorded in 59.5% of patients. One-year, 5-year and 10-year graft survival was 93%, 64% and 39%, and 1-year, 5-year and 10- year patient survival after transplantation was 98%, 72% and 42%, respectively. Normal values of liver chemistry (AST, ALT) were found in 59.5% and elevated values in 40.5% of patients. Episodes of acute rejection occurred in 56% of patients. Proteinuria was recorded in 27%, diabetes mellitus in 18% and elevated blood pressure in 66% of patients. Patients with chronic C/B virus hepatitis having undergone renal transplantation had worse graft function and worse graft and patient survival than patients without chronic hepatitis. The most common causes of death were cardiovascular diseases, cerebrovascular diseases and cirrhosis hepatitis