DiaTransplant hrvatski simpozij o nadomještanju bubrežne funkcije s meðunarodnim sudjelovanjem Opatija, Hrvatska listopada 2018.

Transcription

1 Knjiga sažetaka Abstract book DiaTransplant hrvatski simpozij o nadomještanju bubrežne funkcije s meðunarodnim sudjelovanjem Opatija, Hrvatska listopada th 7 Croatian Symposium on Renal Replacement Therapy with International Participation Opatija, Croatia October 11-14,

2 Knjiga sažetaka Abstract book Legenda oznaka (Legend): IS Pozvani predavači (Invited speakers) U Usmeno izlaganje (Oral presentation) P E-poster (E-poster) D Dijaliza (Dialysis) T Transplantacija (Transplantation) O Ostalo (Other) S Studenti (Students) RN Medicinske sestre/tehničari (Renal Nurses)

3 IS-1 ASISTIRANA PERITONEJSKA DIJALIZA Dragan Klarić Opća bolnica Zadar U zadnje vrijeme dolazi do značajnog pada nadomještanja bubrežne funkcije peritonejskom dijalizom (PD) u svijetu i u Hrvatskoj. Neadekvatna komunikacija i nedostatak informacija o mogućnostima dovodi do akutne supstitucije bubrežne funkcije bez jasnog razumijevanja pacijenta o metodama koje se primijenjuju. Nadalje, needucirani i nestimulirani članovi obitelji i skrbnici te potencijalni asistenti često zaziru od takve metode. Razvoj asistirane peritonejske dijalize može imati zavidan cost-effectiv učinak na ukupni zdravstveni budžet. Tko su potencijalni pomoćnici-asistenti? Asistencija podrazumijeva jedan od oblika pomoći pacijentu koj se liječi PD metodom. Ona može bitit kompletna, parcijalna, povremena ili trajna, bilo da se radi o ručnoj izmjeni dijaliznih otopina ili da se radi o automatiziranoj peritonejskoj dijalizi (apd) pomoću aparata. Asistenti mogu biti članovi obitelji, supružnici, roditelji, plaćeni njegovatelji ili djelatinci ustanova (rehabilitacijski centri ili starački domovi,udomiteljske djelatnosti). Ponekad Centar za dijalizu može u određenom modalitetu liječenja PD-om preuzeti kompletnu brigu o nadomiještanju bubrežne funkcije apd-om. Današnji model liječenja PD-om u Hrvatskoj u pojedinim centrima ima visoki stupanj asistencije u svakodnevnom radu. Nažalost, mi još uvijek nemamo medicinsku sestu- asistenta koja djeluje u kući bolesnika, što je slučaj u nekim zemljana EU i svijeta. Najčešće potrebe za asistencijom. Starost sama po sebi nosi nejasnoće oko PD metode, strah od nepoznatog, nerazumijevanje tekstualnih poruka, slabovidnost, kognitivne disfunkcije, demenciju, psihičke poremećaje, što sve može biti prepreka za samo porovođenje postupaka. Ishodi pacijenata. Bez obzira na dob, brojne komorbiditete, ishodi pacijenata liječenih PD-om prema izvorima nisu lošiji, naprotiv, bilo da se radilo o ukupnoj smrtnosti ili komplikacijama metode. Ponekad ova metoda može biti i uvjet samog pacijenta za pristanak na liječenje. Dodatna pozitivna iskustva su u općem funkcioniranju i boljoj kvaliteti života bolesnika u poznatoj okolini. Zaključak. Bez obzira na upornost stalnog ponavljanja, PD metoda je zapostavljena, kao i asistirani modeli liječenja. Adekvatnim pristupom i boljom organizacijom modaliteti asistirane peritonejske dijalize mogli bi biti elegantniji način liječenja u kući bolesnika ili njegovom trajnom mjestu boravka te imati i financijski benefit. Asistencija kod PD programa ne bi trebala biti problem kao što nije niti prepreka za samostalni život čovjeka. 2

4 IS-2 Epidemiology of CKD GFR measurement Halima Resić, Fahrudin Mašnić Clinic for Hemodialysis, Clinical Center University of Sarajevo Bosnia and Herzegovina Chronic kidney disease (CKD) is a global public health problem. KDIGO 2012 recommends CKD classification based on: cause, GFR category, and albuminuria category. CKD, as defined by KDIGO 2012 (The Kidney Disease: Improving Global Outcomes) represents abnormalities of kidney structure or function present for >3 months with implications for health or the presence of glomerular filtration rate (GFR) <60 ml/ min/1.73 m2 (GFR categories 3a to 5). These abnormalities include: albuminuria >30 mg/g of creatinine, urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging, or history of kidney transplantation. The prevalence of end-stage renal disease (ESRD) is increasing worldwide. This increase may also be due, among other reasons, in improved survival from non-renal diseases (particularly cardiovascular diseases). But, ESRD incidence seems to be largely stabilized from 2000's according to the last USRDS report. The overall prevalence of CKD increased significantly in the U.S. adult population between 1999 and Since , the overall prevalence of stages 3 4 CKD has mostly stabilized in the last decade. These data have been parallel to some international studies, like the data from the nationally representative Health Survey for England (HSE) random samples, which show no increase in prevalence of CKD (defined there as egfr <60 ml/min/1.73m2) from 2003 to Other international studies, mostly meta-analyses, underlie up to 15 percent higher CKD prevalence rates in low- and middle-income countries than in high-income countries. Frequency of kidney disease dramatically increases after the age of 60. Due to number of reasons, CKD has been largely unrecognised. In Europe, 1 in 10 adults has some degree of kidney disease. Patients with chronic kidney disease have three times higher cardiovascular risk. GFR formulas have been developed to help physicians quickly and easily estimate GFR (egfr). Most widely used formulas are CKD Epidemiology Collaboration (CKD-EPI) equations and the Modification of Diet in Renal Disease (MDRD). Albuminuria increases risk of progression of CKD, mortality risk and ESRD, independent of egfr. Therefore, albuminuria staging has recently been added into CKD classification. Decreased GFR is mostly seen in the older population, which may indicate that these persons are classified as having kidney disease, despite having stable kidney function. Labelling elderly patients with CKD (those with microalbuminuria or those with an egfr between 45-60mls/min) has no meaningful effect on patient management and outcomes. This may implicate creating more age and gender-specific egfr values to create accurate definition of CKD than KDIGO definitions. What do we want from a diagnostic/classification system identify risk or clinical decision aid to improve outcomes. 3

5 IS-3 Liječenje dijabetičara sa KBB, novosti u inzulinskoj terapiji Sanja Klobučar Majanović Klinički bolnički centar Rijeka Šećerna bolest je globalna epidemija suvremenog društva. Unatoč neospornim iskoracima u farmakoterapiji još uvijek značajan broj bolesnika ne postiže zadane ciljeve glukoregulacije. Poseban izazov predstavlja liječenje dijabetičara s pridruženom kroničnom bubrežnom bolesti (KBB). Epidemiološki podaci ukazuju da oko 20-30% oboljelih od šećerne bolesti ima i pridruženo oštećenje bubrežne funkcije. Kombinacija dijabetesa i KBB višestruko povećava kardiovaskularni rizik i smrtnost ove skupine bolesnika. Smanjenjem GFR dolazi do promjena u signalnom putu inzulina i transportu glukoze, a nakupljanjem uremičnih toksina i krajnjih produkata metabolizma glukoze dolazi do povećanja inzulinske rezistencije. U bolesnika s KBB mogu biti promijenjeni različiti aspekti farmakokinetike antihiperglikemika što povećava rizik od nastanka nuspojava, prvenstveno hipoglikemija. Kako bi se održala učinkovitost, a izbjegle nuspojave često je potrebno smanjiti dozu lijeka, produžiti interval uzimanja, a primjenu nekih i obustaviti, ovisno o stupnju zatajenja bubrežne funkcije. Dobrom glukoregulacijom može se usporiti progresija KBB stoga se u ovih bolesnika često vrlo rano pribjegava prelasku na inzulinsku terapiju. Nove generacije bazalnih inzulina kao što su glargin U300 i inzulin degludek imaju ravnomjerniji profil djelovanja i manji rizik hipoglikemija u usporedbi sa starijim generacijama inzulina što ih čini poželjnim terapijskim opcijama u dijabetičara s KBB. Njihova dodatna prednost sadržana je u fleksibilnom načinu primjene. Pored kontrole glikemije od izuzetne je važnosti sveobuhvatni pristup oboljelom uključujući i kontrolu krvnog tlaka, lipida i tjelesne težine s ciljem smanjenja kardiovaskularnog rizika. 4

6 IS-4 Overview of anemia treatment in CKD Ingrid Prkačin, Marko Martinović, Josip Hrabar, Inga Mandac Rogulj University Hospital Merkur, Zagreb, Croatia INTRODUCTION Erythropoiesis-stimulating agents (ESAs) administered either subcutaneously (sc.) or intravenously (iv.), along with iv. or oral iron therapy, are currently the cornerstones for treating anemia in patients with chronic kidney disease (CKD). The risks associated with ESAs, including an increased risk of death and CV events, highlight the need for additional therapies like inhibitors of hypoxia-inducible factor prolylhydroxylases (HIF PHs). Multiple factors are involved in the pathogenesis of anaemia in CKD: iron deficiency, inadequate production of erythropoietin (Epo), hepcidin and hypoxia-inducible factors (HIFs). Patients with CKD are prone to iron deficiency (absolute and functional). AIM To compare the efficacy and safety profile of oral and intravenous iron with erythropoietin for the treatment of iron deficiency anemia in non-dialysis patients (ND-CKD). MATERIALS AND METHODS 43 Adult CKD patients with the confirmed diagnosis of iron deficiency anemia (A) at University Hospital Merkur. Exclusion criteria were history of secondary hyperparathyroidismus, gastrointestinal bleeding, inflammation (hs CRP>5mg/l), drugs (cyclophosphamide, mycophenolate mofetil, angiotensinconverting inhibitors or angiotensin receptor blockers), or tromboebolism, malignancy (myeloma) or uncontrolled resistant hypertension. Patients were divided into two groups. In the group-a (20 pts), intravenous iron sucrose or ferric carboxymaltose in doses of 1000mg was given. In the group-b (23 pts), oral daily intake of iron (ferrous fumarate 350 mg) was given. Erythropoietin beta subcutaneously in dose of IU every week during the correction phase of anemia treatment was given. Iron supplementation was administrated in order to achieve serum ferritin mg/l. Hemoglobin (Hb) was checked at beginning and at the time of 12 months for both groups. Paired sample t-test were applied for comparison of results. RESULTS AND CONCLUSION Mean level of iron on beginning in M/F was 9.7/7.9± 0.28/0.31 and after 12 months 10.7/8.94± 0.27/0.43 umol/l. In the treatment groups mean Hb level was in A 9.19 ± 0.84 g/dl and in B 9.72 ± 0.95 g/dl, respectively. Mean increase in Hb was in A ± 0.97 g/dl and in B ± 1.22 g/dl at 12 months, respectively. There were no statistically significant differences between increase of Hb in groups of patients. Parenteral or oral iron in combination with Epo are effective treatment of anemia in ND CKD patients if other factors are considered. In future we will have new drugs like hepcidin antagonists, HIF and ferroportin stabilizers in order to delay CKD progression. This alternate therapeutic approach in future may avoid the overshoots and fluctuations in Hb levels seen with currently injectable ESAs and provide a steady and controlled rise in Hb concentration. 5

7 IS-5 TRANSPLANTACIJA BUBREGA U STARIJIH OSOBA Lidija Orlić Zavod za nefrologiju, dijalizu i transplantaciju bubrega, KBC Rijeka U zadnjem stoljeću došlo je do značajnog prosječnog produženja ljudskog životnog vijeka i ono danas iznosi preko 70 pa čak i 80 godina u razvijenim zemljama, uz udio starijih od preko 20% stanovništva te predviđanjima za dva do tri desetljeća i više od 30% stanovništva razvijenih zemalja. Broj bolesnika s kroničnom bubrežnom bolesti (KBB) je također u stalnom porastu, a veliki udio među njima su stariji bolesnici. Prema podacima velikih registara stariji bolesnici čine više od 50%u bolesnika s KBB koji započinju nadomjesno liječenje. Znamo da je transplantacija bubrega najbolja metoda nadomjesnog bubrežnog liječenja i da pruža najveće produljenje života kao i najbolju kvalitetu života. Ova metoda nadomjesnog liječenja sve se više provodi i u grupi starijih bolesnika, pa čak je moguća i u starijih od 80 godina. Do prije dvadeset godina primjenjivala se gotovo sporadično u starijih bolesnika, dok zadnjih desetljeća raste udio starijih bolesnika s transplantiranim bubregom. Prema podacima iz literature iz različitih zemalja, oni otprilike čine oko 10% od ukupno transplantiranih bolesnika. U KBC Rijeka prva transplantacija bolesnika starijeg od 60 godina učinjena je još davne godine. Zadnjih godina u našem Centru udio novih transplantiranih bolesnika starijih od 65 godina se kreće između 20-30% od ukupnog broja transplantiranih. Sigurno je da su stariji bolesnici s KBB podložni više pratećim bolestima i to prvenstveno uključuje kardiovaskularne bolesti, maligne bolesti i infekcije. Zbog toga je kod ove grupe bolesnika potrebna detaljna prijetransplantacijska obrada, po potrebi adekvatno liječenje i dobra procjena za stavljanje na listu čekanja. U odnosu na dijalizu, pa čak i u bolesnika koji su na listi čekanja, transplantacija bubrega u starijih bolesnika se pokazala kao metoda koja značajno produljuje život i kvalitetu života. Transplantacija od živog donora je moguća i u ovoj grupi bolesnika i u odnosu na transplantaciju od umrlog donora pokazala bolje rezultate u preživljavanju kao bolesnika tako i transplantata. Akutna odbacivanja presatka u starijih bolesnika su rjeđa, ali je viši broj infekcija u odnosu na mlađe skupine. Zbog toga je važna optimalizacija imunosupresivnog protokola koja je zahtjevna zbog promjena u farmakokinetici lijekova u starijih. Ona se mijenja zbog promjena u apsorpciji, bioraspoloživosti, promjena u metabolizmu jetre i smanjenoj bubrežnoj funkciji. Također treba obratiti pozornost i na moguće interreakcije između imunosupresiva i drugih lijekova. Odabir imunosupresiva ne razlikuje se od njihove primjene u mlađih bolesnika, a najčešće se temelji na iskustvu liječnika. Zaključno, životna dob nije kontaraindikacija za transplantaciju bubrega. Ona se pokazala kao optimalna metoda nadomjesnog liječenja i u skupini starijih bolesnika, kojima značajno produljuje trajanje života, ali zbog svoje specifičnosti zahtjeva dodatni oprez, znanje i iskustvo liječnika. 6

8 IS-6 Expanded hemodialysis (HDx) a novel technology meet clinical needs Sanjin Rački 1, Dragan Ljutić 2, Dragan Klarić 3, Karmela Altabas 4, Marija Kadović 5, Antonela Đerek 2, Ante Šegić 3, Marica Prša 4, Bosiljka Devčić 1 1 University Hospital Center Rijeka, 2 University Hospital Center Split, 3 General Hospital Zadar, 4 University Hospital Sestre milosrdnice Zagreb, 5 Agmar d.o.o. Zagreb INTRODUCTION End-stage renal disease (ESRD) is a challenging health problem worldwide. Hemodialysis patients mainly undergo low-flux hemodialysis (LF-HD), high-flux hemodialysis (HF-HD), or hemodiafiltration (HDF). The middle and large molecules clearance is quite insufficient as regards HF-HD, HDF, and online HDF. This can lead to increased incidence of cardiovascular complications, development of chronic inflammatory state and incidence of clinically important infections. An unsatisfactory prognosis has led to improved dialysis technology and materials; both protein-leaking membranes and high cut-off membranes increase the clearance of uremic toxin, but in clinical application they may induce albumin loss. To enhance the removal of uremic toxins and increase membrane permeability, a high retention onset (HRO) membrane with larger pore size and HRO, once defined as medium cut-off, has been developed in the past few years (Theranova, Gambro-Baxter). Such a membrane enables leakage of larger size molecules including albumin. The dialysis using HRO membranes has recently been proposed as expanded hemodialysis (HDx). Theoretically, HDx could promote the removal of more toxin solutes retained in the blood of ESRD patients and improve the outcomes of dialysis. MATERIALS AND METHODS Validation of Theranova membrane in Croatia has been performed in 4 Croatian dialysis centers with approval of ethical committees (University Hospital Center Rijeka, University Hospital Center Split, General Hospital Zadar and University Hospital Sestre milosrdnice, Zagreb). A total of 14 patients were included and 11 patients has concluded validation through protocol with all data. All patients gave written informed consent for validation. The duration of study was 12 weeks with 36 consecutive dialysis sessions. All patients included were treated previously with hemodiafiltration procedure using synthetic high-flux dialysis membrane for at least 6 months. Laboratory data were collected (urea, creatinine, hemoglobin, phosphates, myoglobine, total proteins, albumin, serum transferrin saturation and additionally, beta 2 microglobulin and lambda (λ) light chains). RESULTS AND CONCLUSION The reduction of urea of 13% and sustained creatinine concentration approved low-flux capacity of membrane. Reduction of myoglobine (12,8%), beta 2 microglobulin (13%) and λ-light chains (5,5%) with sustained albumin concentration (2% increase) approved a high retention onset capacity of membrane Theranova and capacity to perform expanded hemodialysis procedure (HDx) without significant albumin loss. However, randomized controlled trials are required to evaluate the long-term efficacy of HDx procedures. 7

9 U-D1 Čimbenici rizika oboljenja srčanožilnoga sustava kod bolesnika na kontinuiranoj ambulatornoj peritonejskoj dijalizi Damir Rebić, Aida Hamzić-Mehmedbašić, Vedad Herenda, Edina Hasanagić, Amira Srna Klinika za nefrologiju KCU Sarajevo Bolesti srčanožilnoga sustava su vodeći uzrok smrtnosti u bolesnika u terminalnom bubrežnom zatajenju (TBZ). Cilj rada je bio evaluirati funkcionalno-morfološke karakteristike lijeve srčane klijetke i karotidnih krvnih žila (CA) u bolesnika sa TBZ prije početka dijaliznog liječenja, i tijekom sljedećih 18 mjeseci obavljanja kontinuirane ambulatorne peritonejske dijalize (CAPD) u cilju ispitivanja udjela tradicionalnih, za uremiju vezanih i čimbenika rizika specifičnih za PD. U prospektivnom, longitudinalnom istraživanju obuhvaćeno je 50 CAPD bolesnika, praćenih kroz jednoipolgodišnji period od momenta uključivanja na dijalizni tretman i nakon 18 mjeseci dijaliznog liječenja. Hipertrofija lijeve srčane klijetke (HLK) je zastupljena kod bolesnika sa TBZ prije početka dijaliznog tretmana u 78% ispitanika, a nakon 18 mjeseci PD tretmana 60%. Aterosklerotske promjene na CA u bolesnika prije početka dijalizne terapije su zabilježene u 44%, a nakon 18 mjeseci PD tretmana kod 26% ispitanika. Neovisni čimbenici rizika razvoja HLK nakon 18 mjeseci PD sa signifikantnom pozitivnom udruženošću su lipoproteini male gustoće, troponin i C reaktivni protein (CRP), dok je inverzni odnos sa HLK pokazala ostatna bubrežna funkcija i dušični oksid (NO). Razina NO u serumu bolesnika je značajno porasla tijekom 18 mjeseci praćenja (p<0.001), dok je razina endotelina-1 (ET-1) u serumu u istom periodu signifikantno pala (p<0.001). Neovisni prediktori debljine intime medije (IMT CCA) kod PD bolesnika su bili homocistein, CRP, lipoprotein male gustoće, lipoprotein(a), produkt CaxP, ET-1 i proteinurija. Teški oblik ateroskleroze CA u CAPD bolesnika je udružen sa povećanom koncentracijom ET-1, CRP-a i B-tipa natriuretskog peptida. Bolesnici sa HLK i aterosklerotskim promjenama na CA su imali slabiju adekvatnost dijalize, dok su transportna obilježja potrbušnice u najvećem broju bila u rangu umjereno visokih i visokih transportera. Prisutnost srčanožilnog preoblikovanja u TBZ naglašava značaj identificiranja i modificiranja srčanožilnih čimbenika rizika, prisutnih u visokom postotku kod bolesnika u TBZ, kao i tijekom dijalizne terapije. 8

10 U-D2 PROGNOSTIC BIOMARKERS OF DIALYSIS AND MORTALITY IN ACUTE HEART FAILURE AND/OR ACUTE CORONARY SYNDROME Aida Hamzić-Mehmedbašić, Damir Rebić, Amina Valjevac, Vedad Herenda Klinika za nefrologiju, KCU Sarajevo INTRODUCTION Although many predictive tools have already been developed in the past, efforts are still proceeding to identify reliable biomarker to predict the prognosis of the patients with acute heart failure (AHF) and acute coronary syndrome (ACS). This study aimed to investigate the role of biomarkers of heart failure (plasma B-type natriuretic peptide-bnp) and renal injury (serum cystatin C, serum and urinary interleukin-18-il-18) in the prediction of 6-month mortality and the postdischarge need for renal replacement therapy (RRT) in patients with AHF and/or ACS. MATERIALS AND METHODS We performed an observational prospective study in the coronary intensive care unit of the Clinical Center University of Sarajevo. In patients diagnosed with AHF and/or ACS, baseline clinical parameters, cardiac and renal biomarkers were determined. The primary outcome was hospital mortality. The secondary composite outcome was the postdischarge need for RRT and/or 6-month mortality. RESULTS AND CONCLUSION The study group consisted of 120 ACS and/or AHF hospital survivors. Of this study cohort, 5.8% patients underwent and continued RRT after discharge. The 6-month mortality was 20%. Multiple Cox logistic regression hazard analysis revealed that plasma BNP (p=0.046), urinary IL-18 (p=0.021), Acute Physiology and Chronic Health Evaluation (APACHE) II score (p=0.002), and left ventricular diastolic dysfunction (p=0,045) were independent prognostic factors of adverse composite outcome (need for RRT and/or 6-month mortality). Using plasma BNP cutoff value of pg/ml showed 66.7% sensitivity and 70.8% specificity (area under curve AUC 0.76, p<0.001) for predicting dialysis and/or death, while ROC curve for urine IL-18 produced an AUC of 0.7 (p<0.001) with sensitivity of 66.7% and specificity of 67.7% for the cutoff point of 29.1 pg/ml. Conclusion: Our results showed that plasma BNP and urinary IL-18 are significant prognostic biomarkers of the postdischarge need for dialysis and/or death in patients with acute cardiac events (AHF and/or ACS). 9

11 U-D3 ETELKALCETID U LIJEČENJU SEKUNDARNOG HIPERPARATIREOIDIZMA, NAŠA PRVA ISKUSTVA Draško Pavlović, Boris Kudumija, Sonja Dits, Ivančica Hršak Poliklinika za internu medicinu i dijalizu B. Braun Avitum Sekundarni hiperparatireoidizam (SHPT) je jedna od najčešćih komplikacija u kroničnoj bubrežnoj bolesti i uzrok mnogobrojnih drugih, posebno kardiovaskularnih komplikacija. Nažalost liječenje nije uvijek uspješno. U kliničku praksu nedavno je uveden kalcimimetik 2. generacije, etelkalcetid, koji je je agonist i alosterički modulator kalcijskih receptora. U jednog bolesnika, 41 g., na hemodijalizi (HD) 6 g, te dvije bolesnice u dobi od 67 i 60 g., na HD 7, odnosno 2 g. započeli smo liječenje etelkalcetidom u dozi od 2,5 mg odnosno 5 mg, intravenski na kraju HD. PTH na početku th. je bio 197 pmol/l, alkalna fosfataza (AP) 515 I/U Ca 2,21 i P 1,47 mmol/l. u bolesnica PTH je bio 104 odnosno 98,2 pomol/l, Ca 2,2 odnosno 2,37 a P 1,43 i 1,97 mmol/l, AP 117 i 129 I/U. Dvoje bolesnika je bilo na HDF sa koncnetracijom Ca u otopini 1,75 mmol/l a jedna bolesnica na hemodijalizi i koncentracijom Ca 1,5 mmol/l. Tjedno smo kontrolirali koncentraciju Ca, mjesečno PTH, AP, Ca i P, te bilježili eventualne nuspojave. Prema indikaciji u bolesnika smo korigirali dozu vezača fosfata U bolesnika smo zbog asimptomatske hipokalcemije (Ca 1,95 mmol/l) smanjili dozu etelkalcetida na 2,5 mg. Nakon četiri tjedna u tog bolesnika PTH je bio 293 pmol/l AP 547 I/U Ca 1,98 i P 1,03 mmol/l. U jedne bolesnice nakon četiri tjedna PTH je bio 24,8 pmol/l, AP 123 I/U Ca 2,07 i P 1,73 mmol/l, u druge bolesnice 35,8 pmol/l, Ca 2,3 i P 1, 55 pmol/l., AP 110 I/U. U dvije bolesnice je nakon 4 tjedna koncentracija PTH bila značajno manja, dok je u bolesnika koncentracija PTH porasla, najvjerojatnije jer smo smanjili dozu lijeka. Naši prvi rezultati pokazuju kako liječenje etelkalcetidom biti učinkovito. Rezultati liječenja većeg broja bolesnika i dulje vrijeme će pokazati prednosti ili moguće nedostatke etelkalcetida. 10

12 U-D4 VASCULAR ACCESS FOR HEMODIALYSIS IN REPUBLIC OF MACEDONIA Petar Dejanov, Vesna Gerasimovska, Vladimir Pusevski, Nikola Gjorgjievski Clinic of Nephrology, Medical Faculty Skopje INTRODUCTION The aim of the study was to describe the creation of unusual VA for HD in patients with limited options that may be a matter of choice to safe and prolong the patient s life. MATERIALS AND METHODS We had performed VA at our Department for VA, Clinic of Nephrology, Skopje in a period of 40 years ( ): 9309 as permanent VA, 7968 AV fistula (85.6%) and 1341 (14,4%) tunnelled catheters (TC) (femoral, subclavian and jugular). Due to some complications, v.azygos (n=1) was enlarged which gave an opportunity to be used as unusual VA for HD; v.saphena magna and a. femoralis superficialis anastomosis (n=2); a. femoralis was cannulated until patients were prepared for continuous ambulatory peritoneal dialysis (n=4). RESULTS AND CONCLUSION We have cannulated v.azygos during cardiosurgery performed thrombectomy to right atrium and bypass from v.innominate to right atrium with Dacron graft 8mm and catheter Tesio insertion in v.innominate to right atrium. In 2 other patients we avoid using upper VA due to stenosis at innominate veins and performed v.saphena magna and a. femoralis superficialis anastomosis. One patient was with occlusion of right and left axilar vein and occlusion of both femoral veins. We had to perform HD sessions using catheters in a.femoralis in a period of 45 days until patients were prepared for continuous ambulatory peritoneal dialysis. Unusual VA for HD may be used as a last life saving procedure in chronic renal failure patients in whom conventional access failed. Such approach may be of choice as it provides sustainable VA for HD. 11

13 U-D5 CORRELATION OF NUTRITIONAL STATUS MARKERS WITH ARTERIAL STIFNESS IN MAINENTANCE HEMODIALYSIS PATIENTS - A PILOT STUDY Josipa Radić 1, Tanja Ilić Begović 1, Leida Tandara 1, Darko Modun 2 1 University Hospital Centre Split 2 University of Split School of Medicine INTRODUCTION Arterial stiffening in dialysis patients is of multifactorial origin. The aim of this study was to examine correlation of nutritional status markers with arterial stifness in haemodialysis (HD) patients. MATERIALS AND METHODS A selected population of 16 HD patients (10 men and 6 women) were included. Records of radial pulse waveforms were conducted on the right radial artery using HEM-9000AI (Omron Healthcare Co Ltd.). The nutritional status was evaluated measuring serum albumin and prealbumin and calculating body mass index (BMI) and malnutrition inflammation score (MIS) for each patients. Also, serum high sensitive C- reactive protein (hscrp) was measured. Assessment of peripheral arterial stiffness was conducted by method of aplanation tonometry. AIx obtained directly from the radial pulse waveform simplifies the measurement procedure and provides equivalent information as aortic AIx used in other studies. RESULTS AND CONCLUSION Patients were divided in two groups according BMI value. Our results showed that those HD patients with BMI = 23 (N=5) 72 (( ) vs. 91 (86-98), p= But, those patients with BMI < 23 also have statistically higher level of albumin (p=0.009), prealbumin (p=0.001) and statistically significantly lower value of hscrp (p=0.003). Therefore, MIS significantly correlated with AIx (r=0.660 p=0.005). The result suggested that BMI might not be a good marker for nutritional status in HD patients due to fluid overload. Better marker of nutritional status is prealbumin. Our results suggested that those patients with lower BMI had statistically higher level of other (better) nutritional parameters (albumin and prealbumin) and lower level of inflammation (lower hscrp). Also, those patients have lower arterial stiffness, suggesting that higher BMI (as reflection of fluid overload) and higher MIS (as reflection of worse nutritional status) might be a risk factors for arterial stiffness in this population. 12

14 U-D6 Utjecaj terapijskih vježbi i elektromišićne stimulacije (ES) na funkcionalnu sposobnost donjih ekstremiteta u bolesnika na kroničnoj hemodijalizi Petra Kovačević, Karmela Altabas, Simeon Grazio, Karla Kovačević, Siniša Šefer KBC Sestre milosrdnice Najčešći uzrok kroničnog zatajenja bubrega je šećerna bolest tipa II (33%) te vaskularna bolest (24%). Obzirom na teško kronično stanje te proteinsko energetsku pothranjenost u tih bolesnika dolazi do smanjenja mišićne mase. Slaba fizička aktivnost dovodi do pogoršanja u kardiovaskularnom sustavu, što utječe na povećanje mortaliteta bolesnika. Posljedično teškom kroničnom stanju bolesnici na hemodijalizi imaju oslabljene funkcionalne sposobnosti, pogotovo pokretljivost, zbog čega imaju veći rizik od padova U istraživanju je sudjelovalo 35 odraslih bolesnika (17 žena, 18 muškaraca) u dobi od 41 do 89 godina koji su na kroničnom programu hemodijalize u Zavodu za nefrologiju i dijalizu Kliničkog bolničkog centra Sestre milosrdnice. Fizioterapeut je inicijalno proveo s ispitanicima funkcionalne testove za ispitivanje donjih ekstremiteta (30s-sit-to-stand test, timed-up and go test), nakon čega je započet program terapijskih vježbi s otporom i elektrostimulacije m.kvadricepsa u trajanju od 3 mjeseca, tijekom procesa hemodijalize, 3 puta tjedno. Nakon 3 mjeseca ponovljeni su funkcionalni testovi. 25 bolesnika je završilo ispitivanje (12 žena u dobi od godina; 13 muškaraca u dobi od godina). Najčešći razlozi prekidanja programa su bili transplantacija bubrega, neka druga unaprijed dogovorena operacija ili opći umor. Jedna bolesnica je preminula uslijed komplikacija terminalne faze maligne diseminirane bolesti. Nakon tri mjeseca provođenja terapijskih vježbi i elektrostimulacije m. kvadricepsa timed-upandgo test je pokazao statistički značajno bolje rezultate u odnosu na istovjetan test učinjen prije intervencije (T test, p ) s 9,8 na 8,5. 30s-sit-to-stand test se nakon tri mjeseca provođenja programa statistički značajno popravio s 11,9 na 14,7( T test, p<0,001). Ovim istraživanjem potvrdio se pozitivan učinak terapijskih vježbi i elektromišićne stimulacije provedenih tijekom procesa hemodijalize na funkcionalnu sposobnost donjih ekstremiteta. To znači da bismo ove vježbe mogli preporučiti bolesnicima na kroničnoj hemodijalizi, što bi posljedično imalo utjecaj na poboljšanje pokretljivosti, a uz to bi se mogao smanjiti i rizik od padova. 13

15 U-O1 VITAMIN D AND CARDIOVASCULAR COMPLICATION IN CHRONIC KIDNEY DISEASE Vedad Herenda, Damir Rebić, Aida Hamzić-Mehmedbašić, Elnur Tahirović Klinika za KV bolesti, KCU Sarajevo INTRODUCTION The development of cardiovascular disease in the population of chronic kidney patients (CKD) is of multifactorial genesis. Hypovitaminosis D can lead to various cardiovascular complications. It s treatment could improve survival od CKD patients. The aims of the study were to determine the level of vitamin D in the serum as well as cardiac status at different stages of chronic kidney disease. Also, aims were to assess link between serum level of vitamin D and echocardiographic changes in the left ventricle. MATERIALS AND METHODS Prospective cross-sectional study was conducted at the Clinic of Nephrology CCU Sarajevo. The study included 120 patients in different stages of chronic renal disease and 30 healthy volunteers, who represented the control group. All patients were clinically assesed. Serum level of vitamin D, phosphorus, and markers of inflammation were obtained. The laboratory findings were complemented with echocardiography. RESULTS AND CONCLUSION CKD is a state of prolonged inflammation. There was a significant correlation between vitamin D levels and markers of inflammation (p<0.001), suggesting that the anti-inflammatory role of vitamin D. The correlation was established between vitamin deficiency D and the appearance of the left ventricle hypertrophy (p <0.01). According to the results of this study vitamin D was significant independent predictor of the development of concentric hypertrophy (p = 0.039). Significant independent predictors of cardiovascular disease in CKD were phosphorus serum levels and chronic kidney disease (p <0.05). Conclusion. Low levels of vitamin D were of significant predictive value in the formation of concentric hypertrophy of the left ventricle. Vitamin D has multiple extrasceletal functions, through which indirectly influence on cardiovascular status. 14

16 U-O2 FIBROMUSCULAR DYSPALSIA (FMD ) - CASE REPORT Danilo Radunović, Živka Dika, Ivana Abramović, Dražen Perkov, Bojan Jelaković Clinical Hospital Center Zagreb INTRODUCTION Fibromuscular dysplasia (FMD) is a segmental, non-inflammatory, non atherosclerotic disorder of the musculature of arterial walls, leading to stenosis of small and medium-sized arteries. Etiology is unknown; estimated incidence in the general population is 2% to 3%. Renal arteries are mostly affected (bilateral involvement in 39% to 64%) but FMD changes of cerebral and/or carotid arteries were found in 15% of cases. MATERIALS AND METHODS Case report. RESULTS AND CONCLUSION Female patient, 40 years, smoker, normal BMI. In 2006, at age of 27, hypertension was verified during the second pregnancy (no edema, no proteinuria). In 2011 she was admitted to our department after hypertensive emergency (BP 220/140 mmhg). Bilateral renal artery stenosis was diagnosed. Digital subtraction angiography (DSA) revealed left renal artery (RA): the ring of FMD with non-significant (20% lumen) stenosis; the right RA: hemodynamically significant stenosis- the type of medial fibroplasia. The patient was treated with percutaneous transluminal renal angioplasty (PTRA) of the left RA. After intervention hers BP was controlled with trandolapril 0.5 mg, amlodipine 10 mg and nebivolol 2.5 mg and kidney function was normal. In 2012 she was admitted to the hospitalized again after hypertensive emergency and neurological symptoms (headache, disorientation) - subarachnoid hemorrhage + aneurism of the right ACI, aphasia of the right PCA were verified on CT. Embolization of the right ACI was performed. Later on in 2013 she was treated three more times with "coiling" due to recurrent aneurysms in the basin of right ACI and its branches, BP was normal. In 2016 BP became uncontrolled (24h ABPM 157/94 mmhg) without neurological symptom. DSA verified the restenosis of the right RA ("string of pearls") plus recidive of aneurysm at right ACI. She was treated with balloon dilatation (RA) and stent-embolizatin (ACI) after which the BP was controlled (nebivolol 2.5 mg, amlodipine 5 mg) with normal kidney function. 15

17 U-O3 ENDEMSKA NEFROPATIJA -NAK- U HRVATSKOM ŽARIŠTU NEKAD I SADA; POSTOJI LI UOPĆE HRVATSKO ENDEMSKO ŽARIŠTE Ninoslav Leko 1, Nikolina Bukal 1, Zvonimir Bosnić 1, Marijana Kovačević 1, Nino Leko 2, Bojan Jelaković 3 1 OB "Dr. Josip Benčević" Slavonski Brod, 2 Stomatološki fakultet Sveučilišta u Zagrebu, 3 Klinički bolnički centar Zagreb Cilj rada je usporediti osnovne epidemiološke podatke u hrvatskom žarištu u periodu te : broj novih bolesnika koji započinju hemodijalizu radi NAK, spol, dob, hipertenziju, broj tumora gornjeg urinarnog trakta/uuc/ te vidjeti da li se tijekom 25 godina broj oboljelih od NAK smanjuje. Retrospektivna studija stanovnika 14 sela tzv hrvatskog endemskog žarišta koji započinju hemodijalizu od do 2017.godine te koji imaju UUC iz medicinske dokumentacije Opće Bolnice \"Dr. Josip Benčević\" u Slavonskom Brodu. Od godine 153 bolesnika započinju HD, od toga 58 s NAK (39,7%). Prosječna dob na početku HD za muškarce je 66.2, a za žene 63.8 godina. Od godine 118 bolesnika započinje HD, od toga 16 s NAK (13.7%). Prosječna dob muškaraca je 72.5, a žena 73.3godine. U zadnjih 10 godina nema novih bolesnika na HD iz 8 od 14 sela. Spol bolesnika s NAK i ostalih bolesnika na početku HD se ne razlikuje, muškaraca je 51%, a žena 49% u grupi bolesnika koji ne boluju od NAK, a u bolesnika koji boluju od NAK je 52% muškaraca i 48% žena. Hipertenzija je bez statistički značajne razlike. U zadnjih 10 godina iz 8 /14 sela nema UUC. U 5 sela zadnjih 10 godina nema bolesnika na HD niti UUCnisu više endemska sela. 3 sela imaju nove bolesnike na HD i novodijagnosticirane UUC. ZAKLJUČAK: Značajno je smanjen broj novih bolesnika na HD u periodu u usporedbi sa (13.9%:37.9%). Bolesnici koji započinju dijalizu znatno su stariji u periodu Nema novih bolesnika na HD iz 8/14. U 5 sela nema novih bolesnika na HD niti UUC, a samo 3 sela imaju nove bolesnike s UUC te na HD. Endemsko žarište se smanjilo te prema ovome ima samo 3 sela te možemo govoriti o paradigmi da se endemsko žariste gasi. 16

18 U-O4 Plazmafereza kod trombotske trombocitopenične purpure Dragan Klarić, Petra Grbić Pavlović, Dario Nakić, Danijela Santini- Dušević, Lada Gilić Šipicki Opća bolnica Zadar Trombotska trombocitopenična purpura (TTP) je kliničko-patološki sindrom karakteriziran mikroangiopatskom hemolitičkom anemijom, trombocitopenijom, akutnom renalnom insuficijencijom (ARI). Cilj je upozoriti da su trombotske mikroangiopatije rijetke bolesti, koje se često previde u dijagnostici. Poremećaj može biti nasljedni i stečeni uz ostale sekundarne uzroke (hipertenzija, lijekovi, trudnoća). Nasljedni kao posljedica mutacije gena za ADAMTS 13 koji služi razgradnji multimera von Willenbrandtovog faktora. Stečene varijante bolesti, inače češće, posljedica su defekta spomenutog faktora, vjerojatno uz stvaranje protutjela na ADAMTS 13. Prikaz bolesnice od 18 godina sa kliničkom slikom ARI, bolovima u trbuhu, hemolitičkom anemijom i trombocitopenijom. Lab nalazi kod prijema: E 3.60, Hb 113g/l, Trc 14, urea 18.4, kreatinin 154, bilirubin 64, Ast 63, Alt 12, LDH 1567, K4.0, CRP 31.4, APTV 80, fibrinogen 3.6, u urinu ++E, ++proteina, u razmazu periferne krvi nešto shistocita. Inicijalno je započeto specifično liječenje terapijskom izmjenom plazme(ptx) tijekom 3 uzastopna dana (zamjena 1.5 volumena plazme) te potom sa 1 volumenom kroz 3 dana i metilprednizolonom u dozi 1mg/kg na dan. Na primijenjenu terapiju 3. dan hospitalizacije dolazi do oporavka laboratorijskih nalaza uz poboljšanje općeg stanja bolesnice. Po završetku tretmana PTX 7. dana lab: E 3.62, Hb 109 g/l, Trc 267, urea 5.3, kreatinin 83, bilirubin 20, K4.8, PV 1.13, INR 0.95, APTV 22. Kod bolesnice smo na osnovi kliničke slike i laboratorijskih nalaza započeli sa PTX zbog temeljite sumnje na TTP a nakon isključene akutne infekcije, te se na temelju kliničkog i laboratorijskog odgovora na terapiju ipak najvjerojatnije radilo o stečenoj varijanti TTP-a. Trombotske mikroangiopatije se zbog različitosti kliničke slike često previde u dijagnostici. PTX je temelj liječenja, te je smrtnost prije uvođenja iste bila 90 %,te u današnjim uvjetima ne smije biti izostavljena. Kod svake nejasne hemolitičke anemije, trombocitopenije uz ARI dijagnostički postupak je potrebno usmjeriti na dokaze hemolize, isključiti akutne infekcije te početi sa PTX-om. 17

19 U-T1 Spontaneous clearance of hepatitis C infection in renal transplant recipients Nikolina Bašić-Jukić, Vesna Furić-Čunko KBC Zagreb INTRODUCTION Spontaneous recovery from chronic HCV infection is rare. Possible factors affecting this phenomenon may include HCV genotype, virus heterogeneity, the impact of viral proteins on the immune system and host factors (the interleukin genotypes, HLA alleles, and factors affecting the T lymphocyte response). The aim of this study was to determine the rate of spontaneous clearance of HCV in renal transplant cohort and factors which predict spontaneous clearance. MATERIALS AND METHODS This retrospective single-centre study was carried out in 1980 renal transplant patients treated at University hospital centre Zagreb. Patients with HCV infection were identified and screened for viral replication. RESULTS AND CONCLUSION 135 patients were diagnosed with chronic HCV infection (12 had hepatitis B (HBV) coinfection). Out of this number, 7 patients (5 male) spontaneously cleared HCV infection. All of them had genotype 1b, and more frequently received induction with basiliximab than patients with persistant infection (71% vs. 33%, p=0.08), but not with antithymocyte globulin. There was no statistically significant difference regarding the complications. Patients with spontaneous clearance less frequently had elevated liver chemistries (14 vs 29%, p=0.67), and lower mortality (14% vs. 34%, respectively, p=0.43), but were significantly younger (median 36 (range 34-60) vs. 58,5 (48-64) years; p=0.02) than patients with persistant infection. Unregular determination of HCV RNA (both qvalitative and quantitative) disabled analysis of timing of HCV clearance. In conclusion, in our cohort of renal transplant recipients younger age was associated with spontaneous clearance of the HCV infection. 18

20 U-T2 GASTROINTERSTINAL TUMORS IN KIDNEY TRANSPLANT RECIPIENTS Danilo Radunović, Vesna Furić Čunko, Ivana Jurić, Lea Katalinić, Ines Mesar, Vladimir Prelević, Ljubica Bubić Filipi, Nikolina Bašić Jukić Clinical Hospital Center Zagreb INTRODUCTION The development of new immunosuppressive agents has provided long-term survival for transplant recipients, thereby increasing the risk of de novo malignancies. While de novo post-transplant lymphoproliferative diseases and skin cancer have been shown to have an increased incidence in longterm survival, the association with gastrointestinal (GI) cancer is controversial.. MATERIALS AND METHODS Data about kidney transplant recipients with de novo GI tumors. RESULTS AND CONCLUSION Gastrointestinal tumors were diagnosed in 14 out of 1990 patients in the period of 45 years. Ten patients (71,4%) were male. Average age at the time of diagnosis of GI tumors was 58,7 years. Average time after kidney transplantation until the diagnosis was 12 (range 1 to 27) years. In 5 patients (35,7%) colorectal carcinoma was diagnosed; in 3 patients (21,4%) pancreatic adenocarcinoma, in 2 patients (14,2%) cholangiocarcinoma, in 1 patient (7,1%) papillary adenocarcinoma of the stomach, in 2 patients (14,2%) carcinoid tumor of appendix and in one patient (7,1%) GIST (gastrointestinal stromal tumor) of the stomach and small intestine. Immunosuppressive regimen after kidney transplantation consisted of CIN inhibitors (cyclosporine in 8 patients 57,1%, tacrolimus in 6 patients 42,9%), mycophenolate mofetil and steroid; all patient afterwards were converted to mtor inhibitors. Specific oncologic treatment was conducted in 8 patient (57,1%). Survival rate was was 42,8%. Graft survival rate over the same time was 85,7% (12 patients); 2 patients lost graft function. One of 14 patients had CMV reactivation early after kidney transplantation (in the first trimester after kidney tx); the same patient developed carcinoid tumor of appendix. GISTs occurring in the kidney recipient are rarely described in the literature. We suggest a closer follow-up for de novo GI cancer in renal transplant recipients in order to avoid delayed diagnosis and complications. Some investigations suggest a closer follow up for de novo GI cancers in renal transplants with early CMV reactivation. 19

21 U-T3 MAKING KIDNEY TRANSPLANTATION MORE AVAILABLE IS THERE ROOM FOR IMPROVEMENT? Vesna Furić Čunko, Nikolina Bašić Jukić KBC Zagreb INTRODUCTION Kidney transplantation is the preferred method of renal replacement therapy in patients with end stage renal disease. Several indexes are used for calculating organ quality. The Kidney Donor Risk Index (KDRI) combines a variety of donor factors to expresses the relative risk of kidney graft failure for a given donor compared to the median kidney donor from last year. The KDPI is a remapping of the KDRI onto a cumulative percentage scale. In order to make kidney transplantation more available to our patients we have analyzed the causes of refusal of organs by our Center. Here we present the KDPI profile of kidneys that were declined by our Center in the first 6 months of MATERIALS AND METHODS The KDPI and KDRI were calculated for all kidneys that have been declined by our Center in the first 6 months of Data on Remuzzi scores for organs where preimplantation biopsy was performed and the reason of refusal was analyzed. RESULTS AND CONCLUSION In the first 6 months of a total of 37 kidneys have been declined, most of which had a KDPI greater than 81%. In 26% of refused organs, KDPI was in a range between 40 and 80%, and in this group 37% of organs were declined by recipients. We believe that there is room for improvement in the practice of our Center. Namely, patients should have better education in order not to decline organs that have good quality potential. Preimplantation biopsy should be used more often in marginal donors. Knowing that organs with a KDPI of 80%, have an expected 5 year graft survival of 70.4% these organs should be considered for Senior program recipients. 20

22 U-T4 UČESTALOST MALIGNOMA NAKON TRANSPLANTACIJE U BOLESNIKA S TRANSPLANTIRANIM BUBREGOM U SPLITSKO-DALMATINSKOJ ŽUPANIJI Josipa Radić 1, Željka Čuljak 2 1 Zavod za nefrologiju i dijalizu, KBC Split 2 Zavod za hitnu medicinu Splitsko - dalmatinske županije Maligne bolesti nakon transplantacije solidnih organa glavni su uzrok smrti u bolesnika s transplantiranim organima diljem svijeta. Stoga je cilj navedenog istraživanja bio istražiti učestalost malignoma u bolesnika s transplantiranim bubregom u Splitsko-dalmatinskoj županiji sa posebnim osvrtom na malignome kože. U istraživanje su uključena 213 bolesnika s transplantiranim bubregom u dobi od 61 (52-67) godine, 124 (58,2%) muškaraca i 89 (41.8%) žena. Za svakog ispitanika zabilježeni su podaci (anamnestički te uvidom u medicinsku dokumentaciju) o dobi, spolu, vremenu proteklom od transplantacije bubrega, vrsta i broj malignoma u obitelji, te vrsti i broju malignoma prije i nakon TX bubrega. Od ukupnog broja ispitanika 32 (15%) ispitanika su naveli malignome u obitelji, 16 (7,5%) ispitanika je imalo malignom prije TX, dok je 34 (16%) ispitanika imalo malignu bolest nakon TX bubrega. Analizirajući učestalost pojedinih malignoma nakon TX rezultati ukazuju kako je 17 (8%) ispitanika je imalo malignome kože, slijede malignomi urogenitalnog sustava 8 (3.8%), malignomi gastrointestinalnog sustava 3 (1,4%), malignomi štitnjače 2 (0,9%), malignomi dojke 1 (0,5%) te ostale dijagnoze su bile navedene kod 3 (1,4%), bolesnika sa transplantiranim bubregom. Nadalje, 9 (4,2%) ispitanika je imalo planocelularni, a 8 (3,8%) ispitanika bazocelularni karcinom kože. Vrijeme proteklo od TX bubrega bilo je statistički značajno kraće u skupini ispitanika sa malignomima nakon TX bubrega (p=0,002). Učestalost malignoma nakon TX je viša nego li u ranije opisanoj literaturi, a malignomi kože su najučestaliji kao što je i od ranije poznato. S obzirom na utjecaj malignoma na preživljenje bolesnika nakon TX bubrega potrebno je redovito provoditi probir na maligne bolesti prije TX bubrega te u ranom poslijetransplantacijskom praćenju uz individualizaciju imunosupresivne terapije te bolesnike savjetovati o zaštiti kože s obzirom na klimatsko okruženje u kojem obitavaju. 21

23 U-T5 EN-BLOC TRANSPLANTACIJA BUBREGA Josip Španjol 1, Romano Oguić 1, Kristian Krpina 1, Antun Gršković 1, Dražen Rahelić 1, Nino Rubinić 1, Mauro Materljan 1, Lidija Orlić 2, Ivan Bubić 2, Dean Markić 1 1 Klinika za urologiju, KBC Rijeka 2 Zavod za nefrologiju, dijalizu i transplantaciju bubrega, KBC Rijeka Standardna transplantacijska tehnika pretpostavlja implantaciju jednog bubrega u ilijačnu jamu uz anastomoziranje renalnih krvnih žila na ilijakalne krvne žile. U veoma mladih donora ili onih s malenom masom neophodno je en-bloc eksplantirati oba bubrega zajedno s pripadajućim dijelom aorte i donje šuplje vene koje se zatim anastomoziraju na ilijakalne krvne žile. Prikazati ćemo en-bloc transplantaciju bubrega koja je po prvi puta u Republici Hrvatskoj učinjena u našem centru. Prezentirati ćemo 2 bolesnice u kojih je učinjena en-bloc transplantacija dječjih bubrega. Prva transplantacija je učinjena u prosincu godine, a druga u listopadu godine na Klinici za urologiju, KBC Rijeka. Oba bubrega su dobivena putem Eurotransplanta. U prve bolesnice prihvatili smo en-bloc izvađene dječje bubrege stare samo 24 dana. Transplantacija je učinjena u desnu ilijačnu jamu. Postoperativno je došlo do razvoja arterijske i venske tromboze te je učinjena transplantektomija (deseti dan po transplantaciji). U druge bolesnice darivatelj en-bloc izvađenih bubrega bilo je 12-mjesečno dijete. Bubrezi su transplantirani u desnu ilijačnu jamu. Postoperacijski tijek je bio bez komplikacija. Devet mjeseci nakon transplantacije bubrežna funkcija druge bolesnice je normalna. Transplantacija dječjih bubrega je zbog manjih vaskularnih struktura zahtjevnija u odnosu na adultni bubreg. Zbog manjeg promjera krvnih žila povećan je broj vaskularnih komplikacija i to u najranijem poslijeoperacijskom razdoblju. Po literaturi se preživljenje i grafta i pacijenata ne razlikuje od standardne populacije. 22

24 U-T6 ARTERIOVENSKA FISTULA U POSLIJETRANSPLANTACIJSKOM RAZDOBLJU Dean Markić 1, Kristian Krpina 1, Antun Gršković 1, Dražen Rahelić 1, Nino Rubinić 1, Mauro Materljan 1, Ivan Vukelić 1, Lidija Orlić 2, Josip Španjol 1 1 Klinika za urologiju, KBC Rijeka 2 Zavod za nefrologiju, dijalizu i transplantaciju bubrega, KBC Rijeka Modaliteti nadomještanja bubrežne funkcije su hemodijaliza, peritonejska dijaliza i transplantacija bubrega. Transplantacija bubrega je najučinkovitiji oblik liječenja, ali na nju treba pričekati određeno vrijeme te je hemodijalizno liječenje najzastupljenije. Ono se najčešće provodi putem arteriovenske (AV) fistule. Nakon uspješne transplantacije AV fistula više nije potrebna. Prikazati ćemo funkcionalnost AV fistule u bolesnike u kojih je učinjena transplantacija bubrega. Retrospektivno smo analizirali bolesnike koji su transplantirani na Klinici za urologiju, KBC Rijeka između i godine. Iz tog trogodišnjeg razdoblja izdvojili smo i analizirali bolesnike koji su se dijalizirali putem AV fistule. U trogodišnjem razdoblju učinili smo ukupno 88 transplantacija bubrega. Ukupno je 49/88 (55,7%) bolesnika koristilo AV fistulu prije uspješne transplantacije bubrega. Godinu dana nakon uspješne transplantacije AV fistula je bila funkcionalna u 37 (75,5%) bolesnika. Razlozi nefunkcionalnosti unutar prve godine po transplantaciji bili su: spontana tromboza (9 bolesnika-18,3%) te smrtni ishod s funkcionirajućom AV fistulom (3 bolesnika-6,1%). Tijekom daljnjeg praćenja u 4 (8,2%) bolesnika fistula je kirurški zatvorena. Većina naših pacijenata prije transplantacije bubrega bila je na hemodijalitičkom liječenju. Nakon uspješne transplantacije u većine bolesnika AV fistula ostaje funkcionalna. U bolesnika u kojih je nastupila neka od komplikacija vezanih uz AV fistulu (pojačani protok, razvoj aneurizme) pristupa se kirurškom zatvaranju AV fistule. 23