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Medical societies have a social responsibility to disseminate knowledge and inform health authorities on threats to public health posed by various diseases. Advocacy for health protection programmes and for medical research funding is now embedded into the missions of most scientific societies. To promote kidney research funding in Europe, the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA), rather than acting as an individual society advocating for the fight against kidney disease, has actively helped to create an alliance of national associations centred on kidney diseases, the European Kidney Health Alliance (EKHA), and joined the Biomedical Alliance (BMA). The ERA-EDTA is fully committed to supporting its working groups (WGs) and consortia of its members to allow them to produce valuable kidney research. The framing and formalization of projects, and the regulatory issues related to submission to the European Commission, are complex. To help WGs to gain expert advice from agencies with specific know-how, the ERA-EDTA has adopted a competitive approach. The best research projects proposed by WGs and consortia of other European investigators will receive seed funding to cover the costs of consultancy by expert agencies. Via its broader platforms, the EKHA and the BMA, the ERA-EDTA will strive towards broader recognition of kidney disease and related clusters of non-communicable diseases, by European and national agencies, as major threats to the qualities of life of their populations and their economies.

The determination of blood flow rate (BFR) is a useful tool for assessing the function of arteriovenous fistula (AVF).Eighty patients with a newly created radio cephalic AVF were analyzed. Hemodynamics and morphological characteristics of the blood vessels were assessed by Doppler ultrasound.The mean age of patients was 59.9 ± 13.5 years. A successful rate of AVF maturation was 62.5% at 8 weeks. Six adjusted models of multivariate analysis showed that BFR at Day 1 was a predictor for AVF maturation both at 4 weeks (p 0.001) and 8 weeks (p 0.001). Receiver operating characteristic analysis showed an optimal cut-off point for BFR at Day 1 of 395 ml/min for successful maturation at 4 weeks (sensitivity 0.714, specificity 0.889) and 344 ml/min for successful maturation at 8 weeks (sensitivity 0.860, specificity 0.867).BFR at Day 1 is a powerful predictor for successful AVF maturation at 4 and 8 weeks.

Neurocognitive disorders are frequent among chronic kidney disease (CKD) patients. Identifying and characterizing cognitive impairment (CI) can help to assess the ability of adherence to CKD risk reduction strategy, identify potentially reversible causes of cognitive decline, modify pharmacotherapy, educate the patient and caregiver and provide appropriate patient and caregiver support. Numerous factors are associated with the development and progression of CI in CKD patients and various conditions can influence the results of cognitive assessment in these patients. Here we review clinical warning signs that should lead to cognitive screening; conditions frequent in CKD at risk to interfere with cognitive testing or performance, including specificities of cognitive assessment in dialysis patients or after kidney transplantation; and available tests for screening and observed cognitive patterns in CKD patients., Graphical Abstract Graphical abstract

BACKGROUND AND AIMS Doppler Ultrasound (DUS) is a superior tool for the assessment of arteriovenous fistula (AVF) functionality. The aim of the study was to determine the association between morphological and haemodynamic characteristics of the blood vessels with AVF maturation. METHOD The study was prospective that analysed 80 patients with chronic kidney disease (CKD) stage 4/5 and CKD stage 5 on haemodialysis (CKD5D) with newly created radio cephalic AVF. Haemodynamics and morphological evaluation of blood vessels by DUS was performed in all patients. The diameter of the cephalic vein, radial and brachial artery was measured: before creation, on the first day (24-h after creation) and at 4 weeks. The blood flow (BF) rate of AVF was calculated by DUS on day 1, at 4 and 8 weeks. The successful maturation of AVF was defined with BF ≥ 600 mL/min. RESULTS The mean age of the patients was 59.9 ± 13.5 years, of which 46 (57.50%) were males. Successful AVF maturation at 4 weeks was 43.75% and 62.5% at 8 weeks. The results of six adjusted models in multivariate analyses showed BF rate on day 1 was a predictor for AVF maturation at 4 (P CONCLUSION Our study showed that BF rate of AVF on day 1 was a predictor for AVF maturation at 4 and 8 weeks. The diameter of blood vessels and male gender were statistically associated with AVF maturation.

Background: A new medium cut-off (MCO) membranes has been designed to achieve better removal capacities for middle and large middle molecules in hemodialysis (HD) treatment. Aim: The aim of this study was to evaluate the removal efficacy of Theranova® in standard HD in comparison with standard high-flux HD. Methods: Four HD patients (M/F 1/4) were included in 12-week observational pilot study in HD with Theranova® 400 and Theranova® 500 dialyzers. Each patient was assessed 4 times, T0 with high-flux dialyzers, T1 at 1 month, T2 at second month, and T3 at third month, by measuring pre- and post-HD samples of urea, Cr, β2-microglobilin (β2M), myoglobin, albumin, free light chains kappa (FLC-k), and free light chains lambda (FLC-λ). Results: The data showed a higher average removal rate for all the uremic toxins with Theranova® dialyzers for β2M, myoglobin, FLC-k, and FLC-λ (62.7, 56.9, 63.5, and 54.6%, respectively) during the 3 months. Albumin retention was observed and did not change between T0 and T3 (p = 0.379). Conclusion: Compared to high-flux membranes, MCO membranes show greater permeability for middle molecules in midterm report.

The Macedonian Society for Nephrology, Dialysis, Transplantation and Artificial Organs (MSNDTAO) was established on September 1, 1992 in order to stimulate the development of nephrology and to unite experts from all professions interested in the research and treatment of kidney patients. Momir H. Polenakovic was elected President of MSNDTAO. The First congress of MSNTAO was held in Ohrid from October, 7 to 10, 1993 in hotel “Desaret” under the auspices of the first President of R. Macedonia, Kiro Gligorov. During the Congress, the Balkan Cities Association of Nephrology, Dialysis, Transplantation and Artificial Organs (BANTAO) was formed on October 9, 1993. The idea of cooperation with the Department of Nephrology from the Ege University, Izmir, R. Turkey was promoted. Some of the presented papers were published in the Proceedings “Nephrology ’93” as a supplement to the Macedonian medical review. The “Doctrine for performing nephrological activity in the Republic of Macedonia” was also promoted. The Second congress of MSNDTAO was held in Struga, R. Macedonia from September, 6 to 10, 1997 together with the Second BANTAO Congress. Selected papers were printed in the Macedonian Medical Review. The Third congress of MSNDTAO was held from May, 30 to June 2, 2001 in Skopje, at the Macedonian Academy of Sciences and Arts (MASA). Proceedings of papers was also published. In 2011 M. H. Polenakovic was elected Honorary President of MSNDTAO for life, and Goce Spasovski was elected the current President of MSNDTAO. The Fourth congress of MSNDTAO was held in Ohrid from June, 21 to 24, 2012 together with the Fourth Meeting of the South-Eastern European Pediatric Nephrology Working Group (SEEPNWG). The Fifth congress of MSNDTAO was held from June, 9 to 12, 2016 in Skopje, at MASA together with the 6th Southeastern European Pediatric Nephrology Working Group (SEPNWG) Meeting and IPNA (International Pediatric Nephrology Association) Teaching Course. The VIII Macedonian-Croatian Nephrology Days were also held during the Congress. The Sixth congress of MSNDTAO was held from September, 26 to 29, 2019 along with the 15th BANTAO Congress, in Skopje, at MASA. The Congress also marked the 80th anniversary of the birth of M. H. Polenakovic. Apart from the participants from R. Macedonia, the congress was attended by renowned nephrologists from Europe and the world. A novelty of the last congresses was the organization of 9 CME (Continuing Medical Education) courses with famous lecturers. CME courses supported by the ERA-EDTA and / or the ISN were as follows: 2005 - Ohrid (BANTAO), 2006 - Skopje (MSNDTAO), 2009 - Skopje (MSNDTAO), 2010 - Skopje (ERA-EDTA - ESAO), 2011 Skopje (ERA-EDTA - EUTox group), 2012 - Ohrid (MSNDTAO), 2014 -Skopje (MSNDTAO), 2016 - Skopje (MSNDTAO), 2018 - Skopje (MSNDTAO - ERA-EDTA & ISN), 2019 - Skopje (BANTAO - ISN & ERA-EDTA). In addition to the congresses, MSNDTAO has held meetings with nephrological associations from the neighboring countries as Croatia, Serbia, Albania and Kosovo. The congresses of MSNDTAO contributed to the introduction and education of doctors in the diagnosis and treatment of kidney patients. They were a strong stimulus for the development of nephrology in R. Macedonia and beyond.

A bone biopsy of the anterior iliac crest is the gold standard for the evaluation of bone disease in chronic kidney disease (CKD). The bone histomorphometric analysis consists of a detailed description of bone histology, including skeletal remodeling, bone mineralization, and bone microarchitecture. Like many histopathological diagnostic classifications (e.g. Banff), bone histomorphometry is based on a semi-quantitative assessment, utilizing both quantitative cutoffs of key parameters and a qualitative interpretation by an experienced physician.

Prof. Dr. Dimitar T. Hrisoho was born on June 11, 1924 in Bitola, R. Macedonia. He died in Struga on September 22, 1986, and was buried in Skopje. He completed primary and secondary education in Bitola. He graduated from the Medical Faculty in Belgrade in 1951 as one of the best students of his generation (average grade of 9.75). In 1953 he was employed at the Internal Clinic of the Medical Faculty in Skopje, where in 1955 he passed the specialist exam in internal medicine. He successfully defended his habilitation “Polyarthritis chronica evolutiva” and his doctoral dissertation “Clinical features of Vitina nephropathy”. The doctoral dissertation indicates that Vitina nephropathy is a new site of the Balkan Endemic Nephropathy entity and that more genetic testing of patients were needed. Based on numerous clinical and scientific researches published in over 200 papers, he was elected a Full Professor of internal medicine at the Medical Faculty of the Ss. Cyril and Methodius University in Skopje in 1971. In 1970, he formed the nephrology section of the Macedonian Medical Association (MMA), which grew into the nephrology Association of MMA. Through the Association, the education of the medical staff from the field of nephrology was performed. He also set up a bio-cybernetics association. He achieved his vision and desire to transfer and apply the achievements of modern nephrology in the diagnosis and treatment of kidney patients in Macedonia at the Clinic of Nephrology of the Medical Faculty in Skopje, which was the first specialized institution established for examination and treatment of kidney patients in the former Yugoslavia and the Balkans. The Clinic educated nephrological staff and examined and treated kidney patients with new methods and drugs that positively affected the development of nephrology as a subspecialty of the internal medicine. D. Hrisoho was actively involved in the introduction of new methods for examination of kidney patients, as well as in the treatment of patients with acute and chronic renal insufficiency with dialysis since 1965. He also participated in the first two kidney transplantations from living donors performed in 1977. He wrote a chapter on “kidney examination”, printed in the book of Prof. A. J. Ignjatovski “Fundamentals of Internal Propedeutics” Part III, published by “Prosvetno delo”, 1963, in Skopje. This is the first text to investigate a patient with kidney disease published in a textbook in R. Macedonia. In 1984 he published the textbook “Clinical Nephrology” printed by the University of the Ss. Cyril and Methodius University in Skopje. Prof. D. Hrisoho organized the First Scientific Meeting of Yugoslav Nephrologists with international participation, from 26 to 28 September 1977, in Struga, R. Macedonia. The meeting was attended by prominent nephrologists from the former Yugoslavia, the Balkans, Europe and the United States, among them: J.S. Cameron from UK, J.L. Funck-Brentano from France, M. Burg and P. Ivanovich from the USA, R. Kluthe from Germany and A. Puchlev from Bulgaria. The scientific meeting was the largest nephrology event until then organized in the former Yugoslavia. The meeting provided an exchange of experiences with world-renowned nephrologists. D. Hrisoho presented the paper Artificial intelligence in nephrology. The author tried to apply bio-cybernetics in nephrology. Prof. D. Hrisoho was Vice Dean of the Medical Faculty in Skopje in the period 1963-1965 and Vice Rector of the University of the Ss. Cyril and Methodius University in Skopje in the period 1974-1975. Prof. Hrisoho was also active in socio-political organizations. For his medical, educational and scientific activities he received several awards and recognitions in the country and abroad. Thus, the work of Prof. D. Hrisoho was permanently embedded in the nephrology of R. Macedonia.

The Balkan Cities Association of Nephrology, Dialysis, Transplantation and Artificial Organs (BANTAO) was established in Ohrid, Republic of Macedonia on October 9, 1993 during the First Congress of the Macedonian Society of Nephrology, Dialysis, Transplantation and Artificial Organs (MSNDTAO). The idea of the founders was that such Society would have a clear impact on several aspects of practice and research in nephrology and artificial organs in the Balkans, firstly, by increasing its international visibility and potential collaborative work, and recognition by international organizations. Secondly, such a society would facilitate the exchange of experience and knowledge between experts in our area. In addition, it would be a very positive symbolic act showing that collaborative work for the betterment of life is possible and desirable in our area and that coming together will bear better fruits at the human and cultural levels. It will also send a very clear signal to the outside world that the Balkans can be a place of collaboration and mutual understanding. Several international bodies such as the International Society of Artificial Organs and the International Faculty of Artificial Organs have signaled their interest in and support for the creation of such a society. Despite the turbulent times in the Balkan Peninsula, the First BANTAO Congress was held in Varna from September 22 to 24, 1995, which was an impressive event. F. Valderrabano, Chairman of the EDTA–ERA registry reported on that event with a lot of sympathy in the paper entitled “Nephrologists of the Balkan countries meet across political frontiers and war fronts – an example to politicians. The foundation of and the Second Congress of BANTAO were also well accepted by the colleagues nephrologists from Russia. The Second Congress was held on September 6-10, 1997 in Struga, the Third BANTAO Congress was held on September 18-20, 1998 in Belgrade, the Fourth Congress of BANTAO was held in Izmir on November 14-16, 1999, the Fifth Congress of BANTAO was held in Thessaloniki on September 30 – October 3, 2001, the 6th BANTAO Congress was held in Varna, on October 6-9, 2003, the 7th BANTAO Congress was held in Ohrid, on September 8-11, 2005, the 8th BANTAO Congress was held in Belgrade, on September 16-19, 2007, the 9th BANTAO Congress was held in Antalya, November 18-22, 2009, the 10th BANTAO Congress was held in Chalkidiki, October 13-15, 2011, the 11th BANTAO Congress was held from 26 to 29 September 2013 in Timisoara on the 20th Anniversary of the foundation of BANTAO, the 12th BANTAO Congress was held on October 15-18, 2015 in Opatija, the 13th BANTAO Congress was held on 4-8 October, 2017 in Sarajevo, the 14th BANTAO Congress was held on September 20-23, 2018, in Budva and the 15th BANTAO Congress was held in Skopje, 26-29 September 2019. Another milestone in the life of BANTAO was the appearance of the BANTAO journal in 2003, which has been published biannually since then. In the past 17 years there have been 33 editions of the journal and seven supplements reporting BANTAO congresses. The editors of the journal past and present are: 2003–2005 (Dimitar Nenov); 2005–2009 (Ali Basci); 2009–(Goce Spasovski). Up to date, more than 400 papers have been published. The BANTAO journal is registered on EBSCO, DOAJ, SCOPUS, and has become a strong ‘glue’ among nephrologists from the Balkan cities. The BANTAO congresses and the BANTAO journal have succeeded in elevating nephrology knowledge and thus increased the standards of nephrology patient care throughout the Balkans. Standing above the divisive forces of politics, language and war, BANTAO gives a living example that collaboration and humility are feasible in times of maddening destruction, and are transformative.

Neuropeptide Y (NPY) is a 36-amino-acid peptide member of a family also including peptide YY and pancreatic polypeptide, which are all ligands to Gi/Go coupled receptors. NPY regulates several fundamental biologic functions including appetite/satiety, sex and reproduction, learning and memory, cardiovascular and renal function and immune functions. The mesenteric circulation is a major source of NPY in the blood in man and this peptide is considered a key regulator of gut-brain cross talk. A progressive increase in circulating NPY accompanies the progression of chronic kidney disease (CKD) toward kidney failure and NPY robustly predicts cardiovascular events in this population. Furthermore, NPY is suspected as a possible player in accelerated cognitive function decline and dementia in patients with CKD and in dialysis patients. In theory, interfering with the NPY system has relevant potential for the treatment of diverse diseases from cardiovascular and renal diseases to diseases of the central nervous system. Pharmaceutical formulations for effective drug delivery and cost, as well as the complexity of diseases potentially addressable by NPY/NPY antagonists, have been a problem until now. This in part explains the slow progress of knowledge about the NPY system in the clinical arena. There is now renewed research interest in the NPY system in psychopharmacology and in pharmacology in general and new studies and a new breed of clinical trials may eventually bring the expected benefits in human health with drugs interfering with this system. Funding Agencies|COST Action CA19127-Cognitive Decline in Nephro-Neurology: European Cooperative Target (CONNECT)

Background Kidney transplantation is the best treatment option for end-stage kidney disease but is still associated with long-term graft failure. In this study, we evaluated the application of urinary proteomics to identify grafts with high failure risk before initial decline of estimated glomerular filtration rate (eGFR) with irreversible graft changes. Methods Fifty-two living donor kidney transplant recipients (KTR) with 8-year follow-up were enrolled. All patients underwent clinical examination and had a routine laboratory screening at 3, 6, 12, 24, 36, 48 and 96 months post-transplantation, including creatinine, urea, albumin and 24-h proteinuria. Graft function was estimated according to Nankivell. Urine samples at Month 24 were analysed by capillary electrophoresis coupled mass spectrometry followed by classification with the chronic kidney disease classifier CKD273. Results CKD273 showed significant correlation with serum creatinine at every time point and moderate inverse correlation for the slope in glomerular filtration rates by Nankivell (r = −0.29, P = 0.05). Receiver operating characteristics analysis for graft loss and death within the next 6 years after proteomic analysis resulted in an area under curve value of 0.89 for CKD273 being superior to 0.67 for Nankivell eGFR. Stratification into CKD273-positive and -negative patient groups revealed a hazard ratio of 16.5 for prevalence of graft loss in case of CKD273 positivity. Conclusions Using a representative KTR cohort with 8-year follow-up, we could demonstrate significant value of CKD273 for risk stratification of graft loss. This study provides the conceptual basis for further evaluation of CKD273 as a prognostic tool for long-term graft function risk stratification by large prospective clinical trials.

The aim of the study is to review recent studies on the management of acute and chronic hyponatremia.In acute symptomatic hyponatremia, bolus infusion of hypertonic saline improves hyponatremia and neurological status more quickly than continuous infusion. In chronic hyponatremia, newly identified predictors of nonresponse to fluid restriction include a high urine osmolality (500 mOsm/kg) and high urine sodium (133 mmol/l). Vasopressin-receptor antagonists effectively raise the serum sodium concentration in patients with euvolemic or hypervolemic hyponatremia but have a risk of overcorrection, even at low doses. Several observational studies now support the use of urea for a more gradual correction of hyponatremia without a risk of overcorrection. Recently identified risk factors for overcorrection include lower serum sodium at presentation, polydipsia, hypovolemia, and early urine output during treatment. Specific treatments with potential efficacy are the use of intravenous albumin for hyponatremia because of liver cirrhosis, and fludrocortisone for hyponatremia in tuberculous meningitis.The recent data will help to further optimize and personalize the management of patients with acute and chronic hyponatremia. However, most data are still observational and retrospective. Therefore, the field is in need of prospective studies comparing interventions for chronic hyponatremia and focusing on patient-relevant outcomes.

World Kidney Day (WKD) is a global campaign to raise awareness of the importance of our kidneys to overall health and to reduce the frequency and impact of kidney disease and associated health problems worldwide. Kidney disease is a non-communicable disease (NCD) and currently affects around 850 million people worldwide. One in ten adults has chronic kidney disease (CKD). The global burden of CKD is increasing, and is projected to become the 5th most common cause of years of life lost globally by 2040. CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume 2–3% of the annual healthcare budget in high-income countries. Crucially, kidney disease can be prevented and progression to end-stage kidney disease can be delayed with appropriate access to basic diagnostics and early treatment. This year World Kidney Day continues to raise awareness of the increasing burden of kidney diseases worldwide and to strive for kidney health for everyone, everywhere. During the pandemic with COVID 19 patients kidneys are also damaged, apart from the respiratory tract and other organs. It can lead to an increase in acute renal failure and consequent chronic kidney insufficiency, as well as number of deaths. Therefore, it is important to evaluate the renal function in each patient with COVID 19 virus. In the Republic of North Macedonia from 2006 to present day nephrologists and other medical personnel devoted to the early diagnosis, prevention and treatment of renal disease have participated in the activities of the World Kidney Day. These activities were supported by the Macedonian Society of Nephrology, Dialysis, Transplantation and Artificial Organs, the Department of Nephrology at the Medical Faculty, the Macedonian Academy of Sciences and Arts, the Government of the Republic of North Macedonia, non-governmental nephrology organizations (NEFRON) and the media. There were lectures and presentation devoted to the various theme of the WKD, publications in journals, as well as activities for examination of the renal function of patients in the medical centers. The activities during the WKD contributed to the improvement of the nephrological protection of the citizens of the Republic of N. Macedonia.

Chronic renal failure; Dialysis; Kidney transplantation Insuficiència renal crònica; Diàlisi; Trasplantament de ronyó Insuficiencia renal crónica; Diálisis; Trasplante de riñón Chronic kidney disease (CKD) is a major health problem because of its high prevalence, associated complications and high treatment costs. Several aspects of CKD differ significantly in the Eastern European nephrology community compared with Western Europe because of different geographic, socio-economic, infrastructure, cultural and educational features. The two most frequent aetiologies of CKD, DM and hypertension, and many other predisposing factors, are more frequent in the Eastern region, resulting in more prevalent CKD Stages 3–5. Interventions may minimize the potential drawbacks of the high prevalence of CKD in Eastern Europe, which include several options at various stages of the disease, such as raising public, medical personnel and healthcare authorities awareness; early detection by screening high-risk populations; preventing progression and CKD-related complications by training health professionals and patients; promoting transplantation or home dialysis as the preferred modality; disseminating and implementing guidelines and guided therapy and encouraging/supporting country-specific observational research as well as international collaborative projects. Specific ways to significantly impact CKD-related problems in every region of Europe through education, science and networking are collaboration with non-nephrology European societies who have a common interest in CKD and its associated complications, representation through an advisory role within nephrology via national nephrology societies, contributing to the training of local nephrologists and stimulating patient-oriented research. The latter is mandatory to identify country-specific kidney disease–related priorities. Active involvement of patients in this research via collaboration with the European Kidney Patient Federation or national patient federations is imperative to ensure that projects reflect specific patient needs. The treatment of kidney failure is costly, therefore financial support from governments is essential to ensure that all patients receive appropriate treatment. This imposes a major burden on the economy. According to the World Bank, only 74% of governments in Eastern and Central Europe provide full support for KRT [7]. Funding of treatment in earlier stages of CKD is even more problematic because of the high number of patients and because the diagnosis may not be made in a timely manner. Although no objective data are available, it is very likely that public funding at earlier stages of CKD is less common or, at least, less comprehensive than reimbursement of KRT.

BACKGROUND: Excess mortality is defined as mortality above what would be expected based on the non-crisis mortality rate in the population of interest. AIM: In this study, we aimed to access weather the coronavirus disease (COVID)-19 pandemic had impact on the in-hospital mortality during the first 6 months of the year and compare it with the data from the previous years. METHODS: A retroprospective study was conducted at the University Clinic of Nephrology Skopje, Republic of Macedonia. In-hospital mortality rates were calculated for the first half of the year (01.01–30.06) from 2015 until 2020, as monthly number of dead patients divided by the number of non-elective hospitalized patents in the same period. The excess mortality rate (p-score) was calculated as ratio or percentage of excess deaths relative to expected average deaths: (Observed mortality rate–expected average death rate)/expected average death rate *100%. RESULTS: The expected (average) overall death mortality rate for the period 2015–2019 was 8.9% and for 2020 was 15.3%. The calculated overall excess mortality in 2020 was 72% (pscore 0.72). CONCLUSION: In this pragmatic study, we have provided clear evidence of high excess mortality at our nephrology clinic during the 1st months of the COVID-19 pandemic. The delayed referral of patients due to the patient and health care system-related factors might partially explain the excess mortality during pandemic crises. Further analysis is needed to estimate unrecognized probable COVID-19 deaths.

An arteriovenous fistula (AVF) remains the best choice of vascular access (VA) for hemodialysis (HD). The aim of the study was to determine the factors associated with the achievement of adequate blood flow (BF) of AVFs at the 4th week after creation. Created AVFs in 63 patients with chronic kidney disease (CKD) stage 4/5 and CKD stage 5 on hemodialysis (CKD5D) were analyzed in a prospective study. Doppler ultrasound (DUS) was used for measuring the diameter of the radial artery, the brachial artery and the cephalic vein before AVF creation. The BF of AVF was calculated by DUS at the 4th week after creation and adequate BF was defined as ≥ 600 mL/min. The average age of patients was 61.31 ± 12.9 years. An adequate BF of AVF at the 4th week after creation was achieved in 43.54% of patients. The BF of AVF measured in male patients was significantly higher compared to the BF of AVF obtained in females (576.03 mL/min vs 375.12 mL/min, P = 0.004). The diameter of the blood vessels with achieved adequate BF was significantly larger compared to the diameter of the blood vessels without adequate BF (radial artery: 2.45 mm vs 2.03 mm, P = 0.000; brachial artery: 4.78 mm vs 4.06 mm, P = 0.001 and cephalic vein: 3.12 mm vs 2.83 mm P = 0.018). The gender and the diameter of the blood vessels before AVF creation were significantly associated with achievement of adequate BF of AVF at the 4th week of creation.

Background and Aims HLA compatibility between donor and recipient is an important factor that influences graft outcomes after kidney transplantation. Increasing number of class I (HLA-AB) and class II (HLA-DR) mismatches are associated with an increased risk of acute rejection and graft loss. Recent developments have increased our understanding of the structural basis of HLA antigenicity and may allow accurate evaluation of the immunogenic potential of broad antigen HLA mismatches. The immunogenicity of HLA antigens is determined by continuous and discontinuous short sequences of amino acids that form the antibody-accessible regions within each HLA allele known as epitopes. HLAMatchmaker, a computer algorithm that calculates the number of epitope mismatches between donors and recipients by considering each HLA allele as a combination of distinct epitopes known as triplets (continuous amino acid sequences) or eplets (closely located contiguous amino acid sequences). Method A total number of 55 adult patients with LDKT were included in the study. The inclusion criteria: first transplantation of one organ - kidney, use of living donor related or unrelated, emotionally related (spouses) donor. Data concerning donor - sex, age of the donor, type of donation (related or unrelated donor), and data concerning the recipients: sex, age, hemodialysis vintage, underlying disease, type of immunosuppressive therapy, were analyzed. The number of eplet HLA mismatches for each recipient and donor pair at HLA class I (HLA-AB) and class II (HLA-DR) loci was calculated using HLAMatchmaker (Version 1.2) Results In our study we have included 55 patients. 44 patients have related and 11 have unrelated donors. From the group of related donors 31 patients were haploidentycal, with 3 HLA miss match, in the group of unrelated donors-recipients 5 of them have 6 miss match. According HLA MM triplets Class 1 + 2 < or> 20 we have devided 2 groups, but no statistical difference on the graft function was observed in the follow up period. Three acute rejections were reported in the group of patients with HLA miss match triplets Class 1 + 2> 20. Conclusion An increasing number of epitope HLA mismatches is associated with an increased risk of acute rejection. Triplet HLA mismatches may provide better risk stratification for acute rejection and graft survival among those who are otherwise classified as low immunological risk at the broad antigen level.

Background and Aims An arteriovenous fistula (AVF) remains the best choice of vascular access (VA) for hemodialysis (HD). The aim of our study was determination of factors associated with achieved adequate blood flow (BF) of AVF during 4-th week after creation Method : Created AVF in 63 patients with chronic kidney disease (CKD) stage 4, 5 and 5-HD were analyzed in the prospective single center study, from January 2019 to October 2019. Preoperative mapping of blood vessels by Doppler ultrasound (DUS) on the forearm was performed in all patients. All patients were undergoing surgical creation of new forearm AVF (radio-cephalic) by one doctor. The DUS was used for measuring the diameter size of artery radialis, artery brachialis and vein cephalica before creation of AVF and again on 1-st day, 2-nd and 4-th week after AVF creation. In addition the BF of AVF was also measured by DUS on 1-st day, 2-nd and 4-th week after AVF creation. The adequate BF of AVF for hemodialysis treatment was defined as ≥ 600 ml/min. Patient gender and age, hemodialysis vintage, diameter size of artery radialis, artery brachialis and vein cephalica before creation of AVF were analyzed as factors that were affecting the achieved BF of AVF during 4-th week after creation. Results : The average age of patients was 61.31 ± 12.9 years. From all patients, 60.31% (38/63) were men. The adequate BF of AVF (≥600 ml/min) during 4-th week after creation was achieved in 43.54% (27/63) of created AVFs. The blood flow of AVF measured in male gender was significantly higher compared to the blood flow of AVF measured in female gender (576.03 ml/min vs 375.12 ml/min, p=0.004). The age of the patients and hemodialysis vintage were not significantly associated with achieved adequate BF of AVF during 4-th week after creation of AVF. The adequate BF of AVF was achieved in blood vessels with bigger diameter size. The diameter size of the blood vessels with achieved adequate BF was significantly higher compared to the diameter size of the blood vessels without adequate BF (artery radialis : 2.45 mm vs 2.03 mm, p=0.000; artery brachialis: 4.78 mm vs 4.06 mm, p=0.001 and vein cephalica: 3.12 mm vs 2.83 mm, p=0.018). Conclusion The gender and the diameter size of artery radialis, artery brachialis and vein cephalica before creation of AVF were significantly associated with achieved adequate BF of AVF (≥600 ml/min) during 4-th week after creation of AVF.

Background and Aims The life expectancy in dialysis patients depends on patients’ age and comorbidities. Frailty in elderly patients is a state of impaired homeostasis with loss of physiologic reserve and a consequent impaired responses to dialysis burden. In this study we assessed the impact of age, comorbidities and frailty on dialysis patients’ survival. Method The study enrolled 162 prevalent patients on chronic hemodialysis with mean dialysis vintage of 100 months, 55% were women and 21 % had diabetes. Patients were divided into three groups by the Khan Comorbidity index score, highest score was considered worse. Frailty was assessed by presence of 3 or more symptoms (unintentional weight loss, feeling exhausted, weak grip strength, slow walking speed and low physical activity) and expressed as absolute number. Estimates of five years life expectancy were assessed by Kaplan Meier survival log-rank test and Cox regression hazard model. Results There were 26 (16%) with lowest score, 85 (52%) with medium score and worst highest score in 51 (31%). During the 5 years of follow up 69(43%) patients died of all-cause mortality. There were no deaths in the group with lowest score and mortality rates in the intermediate and worse score group increased by double (0; 30%; 69%, respectively). Significantly higher mean life expectancy was found in lower Khan Score groups: 60mo; 48.40 ± 18.51; 32.44 ± 22.06, log-rank: p < 0.012. Patients that scored worse had four folds higher risk for death HR 4.2 (95% CI: 2.72 – 6.36), p=0.0001. In the multivariate model Khan Score was a more powerful predictor of mortality than frailty in elderly, with HR 3.2 (95% CI: 2.88 – 5.41), p=0.0001. Conclusion Comorbidities and age outperforms frailty burden as a predictor of mortality in dialysis patients.

Background and Aims After the first year following kidney transplantation approximately 3-5% of grafts fail each consecutive year. Many factors have impact on the graft function and only a few may be modifiable. Monitoring of the graft function by serum creatinine concentrations and estimated glomerular filtration rate (eGFR) are recommended methods for evaluation. The aim of the study was to assess the decline of graft function defined by change in the annual eGFR slope and factors that might affect it. Method A total number of 55 adult patients with living donor kidney transplant (LDKT) were included in the study. The inclusion criteria were: first transplantation of one organ - kidney, use of living donor related or unrelated (emotionally related - spouses) donor. Clinical and biochemical variables, serum creatinine, BUN, protein status, 24 hours proteinuria and body weight were analyzed at 12, 24, 36 and 48 months after transplantation. The Nankivell equation for estimating glomerular filtration rate was used to calculate the slope of renal function over time (1 to 4 years post-transplantayion) by linear regression analysis. Results Out of 55 kidney transplant recipients 18 (33.3%) were female. The majority of transplants had good function (eGFRNankivell ≥ 60 ml/min) at 1 year. The average GFR at 12 months was 67.81±16.7 mL/min/1.73 m2 with majority of patients at stage 2 of chronic kidney disease classification. Thirty eight patients had eGFR slope 5ml/min/year). Only 5 patients (∼ 9%) have graft failure during the period of follow up of 48 months. The average slope decline calculated with linear regression analysis was -3.42 ± 3.2 mL/min/year (range -12.38 – 3.29 ) (slope ± standard error). Proteinuria was predictive for worsening of the graft function. Rapid progressors have been associated with a higher proteinuria at 24 and 48 months: 0.35 ± 0.39 g/24h, median 0.24 (range 0.11 – 0.43 g/24h) and 0.49 ± 0.59 g/24h, median 0.31 (range 0.14 – 0.48 g/24h), (p=0.044 and p=0.021, respectively). Younger patients have more rapid eGFR slope decline (slope (-7.81 ± 2.12 vs. -2.40 ± 1.3, mL/min/year, p=0,0001). The mean recipient age in the group with stabile eGFR slope was 37.59± 8.7, and in the group with rapid progression was 29.1 ± 8.6 years (p=0.0046). Conclusion Proteinuria after kidney transplantation has been identified as a risk factor associated with poor graft survival. Younger renal transplant recipients are associated with more rapid decline of the graft function that could be partially explained with their more potent immune response

Background and Aims Kidney size has been found to be correlated with anthropometric features and is different among different ethnicities. In this study, we used ultrasonography for measurement of kidney volumes in healthy individuals and evaluated the relationships with body height, age and gender. Method We conducted a cross-sectional observational study and evaluated 108 healthy individuals whose serum creatinine level was within reference range. Patients’ medical clinical and laboratory records were reviewed. Age, gender and height were recorded. Pearson correlation coefficients were used to evaluate the strength of association between ultrasonographic parameters with each other and with other parameters, and were expressed as r2. Variations in left and right renal dimensions between various age groups were compared using a one-way analysis of variance, followed by a post-hoc Tukey's test. Results Subjects’ age ranged from 16 to 84 years and the mean age was over 50 years. There was an equal distribution among genders. Strong and positive correlations were seen for the measured length, parenchyma thickness and also for both total and parenchymal volumes with subjects’ height for both kidneys. The strongest correlations were observed for the left and right kidney length and also for the right kidney parenchymal volume (r=0.536, p=0.001; r=0.469, p=0.001; r=0.44, p=0.001). On the opposite, most of the relations with age were negative, but week and insignificant. When we divided the study subjects into three age groups and compared them for the height, there was no significant difference among them. Regarding the parenchymal and total kidney volumes of both kidneys, the different age groups showed similar findings in the ultrasonographic measurements. The mean calculated volumes were slightly declining with age and showed the largest values in the first group of patients under 30 years and lowest values in patients over 70 years old. Ultrasonographic measurements were also compared among the two genders. Both (men and women) showed similar age (53.55 ± 18.22 vs. 50.79 ± 18.13 p= 0.430, respectively). As for the height, men were significantly taller than women (1.734 ± 0.007 vs.1.637 ± 0.005, p= 0.001). The kidney length, volume and parenchymal volumes of both kidneys were significantly larger in men. Conclusion Renal length and volume are strongly correlated with body height. This relation must be considered in clinical decisions on further investigations regarding kidney disease progression.

Background and Aims Non-compliant dialysis patients are at increased risk of mortality. Compliance depends on patient demographics, educational level and income. Family support and marital status might also influence the patients compliance, as well as the quality of life. Missed/shortened dialysis sessions, adherence to prescribed medications, excessive phosphate serum values and interdialytic weigh gain, smoking and adherence to medical investigations provide indicators of non-compliance. Aim: To assess the impact of family support on different compliance indicators in the dialysis patients. Method In this observational study 134 dialysis patients were scored for different indicators of compliance from 0-2 and summary scores of compliance were assessed. Clinical and laboratory data were obtained from the previous two years. Patients with mean IDWGs >4.5% of body weight (BW) and/or phosphorous level above 1.6 mmol/L were scored with 1, patients with IDWG/BW more than 5.7% and/or 2.0 for mean phosphorous level were scored with 2. Summary scores of non-compliance were also assessed. Patients were scored for quality of life with SF-36 questionnaire. Patients non-adherence was analysed for predictors in multivariate analysis. Results Estimated rates of noncompliance varied: Medical investigations 63%, phosphorous 33, IDWG 22, therapy 14%, HD treatment 9%. When the complete dietary fluid, medications and treatment regimen were studied noncompliance rate was 73%, and when adherence to medical investigations was added the rate rose up to 87%. Patients with family support above median level (≥25) were significantly more often men (0.049), with diabetes (p=0.014), lower socioeconomic status (0.001) and married (0.003). The quality of life scores were significantly worse in the low family supported patients (56.73±26.15 vs 39.23±24.05, p=0.0001). They also scored worse in overall non-compliance scores 2.04±1.71 vs 2.97±2.06, p= 0.007). In the multivariate analysis the non-compliance was predicted most powerfully in patients with younger age, low social status and lower family support (β=-0.202, p=0.023, β=0.220, p=0.036, β=-0.175, p=0.019, respectively). Conclusion Family support is crucial for dialysis patients adherence to treatment and Quality of life. Efforts should be done to recognize the patients real needs and adequately help those confronting dialysis burden and improve their quality of life.

Chronic kidney disease is defined as a decrease in renal function or evidence of kidney injury for >3 months. This represents an oversimplification that may confuse physicians. Thus kidney function is equated to glomerular filtration rate, which represents one of multiple kidney functions. Some potentially more important renal functions are lost earlier, such as the production for the anti-ageing factor Klotho. Overall, these changes modify the emergent properties of the body, altering the relationships between different organs and systems, in a manner that is difficult to predict the response to interventions based on normal physiology concepts, as there is a novel steady state of interorgan relations. In this regard we now discuss the impact of CKD on heart failure; osteomuscular and joint pain and bone fragility and fractures; and osteosarcopaenia as seen by a cardiologist, a rheumatologist and a geriatrician. ispartof: CLINICAL KIDNEY JOURNAL vol:14 issue:4 pages:1077-1087 ispartof: location:England status: published

In the period from 26th until 29th of September 2019, the 15th BANTAO Congress (Balkan Cities Association of Nephrology, Dialysis, Transplantation and Artificial Organs) in conjunction with the 6th Congress of the Macedonian Society of Nephrology, Dialysis, Transplantation and Artificial Organs (MSNDTAO) was held in Skopje, Republic of North Macedonia, hosted by the Macedonian Academy of Sciences and Arts (MASA). MSNDTAO was created in 1992 and the First Congress of the MSNDTAO was held on 9th October 1993 in Ohrid when, also, the Balkan Association of Nephrology, Dialysis, Transplantation and Artificial Organs (BANTAO) was established, as the only professional association of this kind in the Balkans and Southern Europe. Since then, MSNDTAO has been very active in education and collaboration with BANTAO, the European Renal Association (ERA-EDTA) and the International Society of Nephrology (ISN). The 15th BANTAO and the 6th MSNDTAO Congress were highly professional events in honor of the 80th anniversary of Academician Momir Polenakovic from the Republic of North Macedonia, one of the founders of BANTAO and MSNDTAO, who was unselfishly dedicated to the education and guidance for many generations of young doctors in this region. This year’s Congress was endorsed by the ERA-EDTA, and supported by the ISN. On the first day of the Congress, a European Renal Best Practice (ERBP) session was held, in which the Chair of the ERBP Working Group, Prof. Dr. Jonathan Fox gave a comprehensive insight of the purpose and aims of ERBP, the methods used for their achievement, and an overview of the recently produced and guidelines in development. The second day was organized in four sessions: Clinical nephrology and renal registries; CKD Diagnosis, comorbidities and treatment; Kidney transplantation and Acute and chronic renal failure management. On the third congress day, the ISN CME Course with ERA-EDTA endorsement was held. The course was entitled “Possibility of diagnosis and treatment of the CKD progression and complications/Possibility of diagnosis and treatment of the CKD progression – current perspective” and was chaired by Prof. Dr. Caskey Fergus and Prof. Dr. Serhan Tuglular. On the last Congress day, before the official closure and the best wishes from the President of the Congress, Prof. Dr. Goce Spasovski, a session about CKD and the renal replacement therapy complications was held. This event was of an exceptional importance for the region, considering the charred international achievements and the most up-to-date methods used in the Nephrology field, bringing out continuous quality improvement in the treatment of patients with renal diseases.

Secondary hyperparathyroidism (SHPT) is common among patients with end-stage renal disease (ESRD). SHPT is associated with high-turnover bone disease, interstitial and vascular calcifications, cardiovascular morbidity and mortality. The pharmacological management of SHPT has progressed in recent years. The introduction of targeted therapies, such as selective vitamin D receptors activators and calcium-sensing receptor modulators, offers an increased opportunity to adequately control elevated parathyroid hormone (PTH), especially in patients with chronic kidney disease under dialysis treatment. Calcimimetic medications such as cinacalcet negatively feedback on the parathyroid glands and do not have the consequences of calcium augmentation. However, there are no randomised, prospective data that demonstrate improved quality of life, improvement in anemia, reduction in phosphate binders, reduction in use of vitamin D analogs, or reduction in mortality. Literature supports cinacalcet therapy to improve patient outcomes, especially with regard to vascular calcifications and presumably the very lethal condition of calciphylaxis. However, cinacalcet is administered orally and has been associated with gastrointestinal intolerance along with hypocalcemia. In addition, poor adherence has been observed among dialysis patients self-administering oral cinacalcet. On the other hand, successful surgical parathyroidectomy (sPTX) can yield a dramatic reduction in PTH level and clinical symptoms. The advanced pharmacological treatments of SHPT often obviate parathyroidectomy; however, some researchers have reported that sPTX may be more cost-effective than cinacalcet in some patients with ESRD and suffering uncontrolled SHPT.

Considering high cardiovascular (CV) risk in chronic kidney disease (CKD), the aim of this cross-sectional study was to assess the association between carotid intima-media thickness (IMT) and fibroblast growth factor (FGF) 23 as important players in CV pathophysiology. Eighty-seven patients with mean estimated glomerular filtration rate 40.1 mL/min per 1.73 m2 were involved. FGF23 and IMT were elevated from early stages of CKD. Mean IMT value was 1.10 ± 0.20 mm, being significantly elevated starting from early CKD, showing no correlation with FGF23 (r = −0.01, P = −0.91). Unlike the FGF23 level that followed worsening of kidney function, IMT was increasing only in the initial CKD stages, with no further increase from CKD stage 3 on. Although we found no direct association between current use of vitamin D and statin therapy, this may be associated with the sustained reference values of lipid and vitamin D status under treatment that further preclude worsening of IMT in patients with advanced CKD.

BACKGROUND: Elderly population (≥ 65) are more prone to develop acute kidney injury (AKI) compared to younger, also elderly with AKI have an increased requirement for dialysis treatment and an elevated risk of short-term and long-term mortality.AIM: The objectives of this study were to examine the effect of treatment of short-term outcomes and mortality in elderly patients with AKI.MATERIAL AND METHODS: Seventy elderly AKI patients, that filled one of the criteria of AKI definition and had hospitalization over 24 hours, were enrolled in the study.RESULTS: The median age of patients was 74.28 ± 6.64, with mean CCI (Charlson Comorbidity Index) score of 6.94 ± 1.94. The majority of patients (70%) were classified at stage 3 of AKIN, 20% of patients were classified at stage 2 and 10% at stage 1. In the groups of patients with death outcome, the chronic cardiomyopathy was more frequently present (p = 0.034). Regarding treatment, 58.6% of the AKI patients underwent hemodialysis while 41.4% received conservative treatment. Mortality rate was 52.8%, out of which 28.6% was in-hospital mortality, while in 24.3% of patients death occurred in the follow-up period of 90 days.CONCLUSION: In our study, short- term survival is not related to different treatment options. Applied treatment in elderly patients with AKI should be assessed by measuring the long term outcome.

Atherosclerosis is frequently present in patients with chronic kidney disease (CKD) treated with dialysis. We evaluated the association between residual renal function (RRF), phosphate level, inflammation and other risk factors in carotid modeling as a marker of early atherosclerosis in peritoneal dialysis (PD) compared with hemodialysis (HD) patients. We studied 39 stable PD and 53 HD patients on renal replacement therapy (RRT) for 3 to 36 months duration. B-mode ultrasonography was used to determine carotid artery intima media thickness (CIMT). We classified patients with atherosclerosis if they have CIMT >10 mm and or presence of plaque. Out of our total dialysis population studied of 92 patients, 16.3% were diabetics and 57.6% were on hemodialysis. Expectedly, PD patients had a higher RRF (P

Introduction. Monitoring of graft function by creatinine concentrations in serum and calculated glomerular filtration rate (GFR) is recommended after kidney transplantation. KDIGO recommendations on the treatment of transplant patients advocate usage of one of the existing mathematical equations based on serum creatinine. We compared clinical application of three equations based on serum creatinine in monitoring the function of transplanted kidney. Methods. A total number of 55 adult patients who received their first renal allograft from living donors at our transplant center in between 2011-2014 were included into the study. Renal allograft GFR was estimated by the Cockroft-Gault, Nankivell and MDRD formula, and correlated with clinical parameters of donors and recipients. Results. The mean age of recipients was 35.7±9.5 (range 16-58), and the mean age of donors was 55.5±9.0 (34- 77) years. Out of this group of 55 transplant patients, 50(90.91%) were on hemodialysis (HD) prior to transplantation. HD treatment was shorter than 24 months in 37(74%) transplant patients. The calculated GFR with MDRD equation showed the highest mean value at 6 and 12 months (68.46±21.5; 68.39±24.6, respectively) and the lowest at 48 months (42.79±12.9). According to the Cockroft&Gault equation GFR was the highest at 12 months (88.91±24.9) and the lowest at 48 months (66.53±18.1 ml/min). The highest mean level (80.53±17.7) of the calculated GFR with the Nankivell equation was obtained at 12 months and the lowest (67.81±16.7 ml/min) at 48 months. The values of Pearson’s correlation coefficient between the calculated GFR and the MDRD at 2 years after transplantation according to donor’s age of r=-0.3224, correlation between GFR and the Cockfroft & Gault at 6 and 12 months and donor’s age (r=-0.2735 and r=-0.2818), and correlation between GFR and the Nankivell at 2 years and donor’s age of r=-0.2681, suggested a conclusion that calculated GFR was lower in recipients who had an older donors. Conclusion. Our analysis showed difference in the calculated GFR with different equations at the same time points. Using one mathematical equation during the total post-transplantation period would be a recommended method in order to eliminate the discrepancy in determining the stage of kidney failure.

Introduction. Bone disease is a chronic complication of chronic kidney disease and major clinical problem in hemodialysis (HD) patients. The aim of our study was to assess the influence of treatment longevity on biochemical parameters of mineral and bone metabolism in HD patients, and to identify the most important parameters. Methods. The research was observational and retrospective, involved 70 patients, mean age 58.69±12.54, divided into groups in respect to the duration of dialysis treatment (Group I-5 years, Group II-5-10 years and Group III-over 10 years). Results. Serum phosphorus was increased, but the values tend to increase along with dialysis duration - (Group I: 1.93±0.45; Group II: 1.97±0.50; Group III: 2.01±0.37; p>0,05). Calcium values were also not significantly increased based on the duration of treatment [Group I: 2.3 (2.2-2.41); Group II: 2.46 (2.15-2.6), Group III: 2.35 (2.10-2.52)]. Dialysis and PTH correlated positively in the first group of patients (Rho=0.470, p=0.013). The values of calcium and alkaline phosphatase correlated positively in all patients (Rho=0.351, p=0.003). PTH was significantly higher in the second and third compared to the first group (p=0.009 and p=0.038, respectively), and there was no significant difference between the second and the third group. Interestingly, parathyroidectomized patients had higher PTH values compared to those without parathyroidectomy (557 vs. 359 pg/ml). Conclusion. The most reliable marker for clinical monitoring of bone disease in dialysis patients is PTH. The values of calcium and phosphorus are highly variable and not reliable parameters for bone disease follow-up.

Evidence-based cinical practice guidelines improve delivery of uniform care to patients with and at risk of developing kidney disease, thereby reducing disease burden and improving outcomes. These guidelines are not well-integrated into care delivery systems in most low- and middle-income countries (LMICs). The KDIGO Controversies Conference on Implementation Strategies in LMIC reviewed the current state of knowledge in order to define a road map to improve the implementation of guideline-based kidney care in LMICs. An international group of multidisciplinary experts in nephrology, epidemiology, health economics, implementation science, health systems, policy, and research identified key issues related to guideline implementation. The issues examined included the current kidney disease burden in the context of health systems in LMIC, arguments for developing policies to implement guideline-based care, innovations to improve kidney care, and the process of guideline adaptation to suit local needs. This executive summary serves as a resource to guide future work, including a pathway for adapting existing guidelines in different geographical regions.

In January 2019, the ERA-EDTA surveyed nephrologists with questions on kidney care and kidney research designed to explore comprehension of the impact of alterations to organization of renal care and of advancements in technology and knowledge of kidney disease. Eight hundred and twenty-five ERA-EDTA members, ∼13% of the whole ERA-EDTA membership, replied to an ad hoc questionnaire. More than half of the respondents argued that kidney centres will be increasingly owned by large dialysis providers, nearly a quarter of respondents felt that many medical aspects of dialysis will be increasingly overseen by non-nephrologists and a quarter (24%) also believed that the care and long-term follow-up of kidney transplant patients will be increasingly under the responsibility of transplant physicians caring for patients with any organ transplant. Nearly half of the participants (45%, n = 367) use fully electronic clinical files integrating the clinical ward, the outpatient clinics, the haemodialysis and peritoneal dialysis units, as well as transplantation. Smartphone-based self-management programmes for the care of chronic kidney disease (CKD) patients are scarcely applied (only 11% of surveyed nephrologists), but a substantial proportion of respondents (74%) are eager to know more about the potential usefulness of these apps. Finally, European nephrologists expressed a cautious optimism about the application of omic sciences to nephrology and on wearable and implantable kidneys, but their expectations for the medium term are limited.

Chronic kidney disease (CKD) is now seen as a systemic disease involving also the central nervous system [1], but the link between the kidney and different organ systems and disease went unnoticed for a long time. The king of Poland, Stephen Bathory (1533-86), suffered from CKD due to polycystic kidney disease and depression [2]. Similarly, Wolfgang Amadeus Mozart was also thought to have had CKD [3] and depression [4]. A list of 'Famous People Who Have Died from Kidney Disease' [5] includes many who suffered from both CKD and depression or other signs of mental illness. Is this a coincidence or actually evidence of a link between kidney disease and brain dysfunction? This is not merely an academic question because all forms of mental illness can seriously impair an individual's quality of life, and are frequently associated with progression of diseases and premature mortality, so it is worth the effort of trying to answer it. Europe and much of the industrialized countries are experiencing growing numbers of patients with CKD within their ageing populations [6]. CKD is complex and potentially fatal: (i) all organs are affected, sooner or later; (ii) the balance of plasma volume, electrolytes, acid-base and minerals, metabolites, hormones and proteins is disturbed; and (iii) patients often need a multidisciplinary team approach managing complex comorbidities, drug regimens and special diets. Although the prognosis of patients with CKD remains poor, their increasing life expectancy has shifted medical attention from life-threatening emergencies to long-term complications and sequelae, and how to improve quality of life [7]. Indeed, kidney failure has detrimental effects on health-related quality of life (HRQoL), reaching levels similar to those seen in patients with metastatic cancer [8]. This might be due to psychological factors, both kidney disease and cancer being chronic diseases with a bad prognosis. However, although the effect of CKD on quality of life is more evident in advanced stages (stage G4P) and in older patients [9, 10], a large study has shown a significant decrease in HRQoL as early as CKD stage G2 [11]. Notably, neurological and cognitive impairments [12], and depression [13] are among the most debilitating consequences of CKD contributing to the significantly reduced HRQoL [14].

Background The impact of serum uric acid (UA) on morbidity and mortality in hemodialysis (HD) patients is quite controversial in relation to the general population. The aim of this study was to evaluate the association of serum UA with both mortality and left ventricular hypertrophy (LVH) in HD patients. Methods This longitudinal study enrolled 225 prevalent HD patients who were classified into three groups according to their follow-up-averaged UA (FA-UA) levels: low FA-UA (FA-UA 450 µmol/L). Echocardiography was performed on a nondialysis day and the presence of LVH was defined based on a left ventricular mass index (LVMI) >131 and >100 g/m2 for men and women, respectively. The patients were followed during a 60-month period. Results The mean FA-UA level was 425 ± 59 µmol/L (range 294–620). There was a consistent association of higher FA-UA with better nutritional status (higher body mass index, normalized protein catabolic rate, creatinine, albumin and phosphorus), higher hemoglobin, but lower C-reactive protein and LVMI. During the 5-year follow-up, 81 patients died (36%) and the main causes of death were cardiovascular (CV) related (70%). When compared with the reference group, the hazard ratio for all-cause mortality was 1.75 [95% confidence interval (CI) 1.02–2.98; P = 0.041] in the low FA-UA group, but there was no significant association with the high FA-UA group. In contrast, FA-UA did not show an association with CV mortality neither with the lower nor with the high FA-UA group. The unadjusted odds ratio (OR) of LVH risk in the low FA-UA compared with the reference FA-UA group was 3.11 (95% CI 1.38–7.05; P = 0.006), and after adjustment for age, gender, diabetes and CV disease, ORs for LVH persisted significantly only in the low FA-UA group [OR 2.82 (95% CI 1.16–6.88,); P = 0.002]. Conclusions Low serum UA is a mortality risk factor and is associated with LVH in HD patients. These results are in contrast with the association of UA in the general population and should be the subject of further research.

BACKGROUND: Renal biopsy performed in native and transplant kidneys is generally considered a safe procedure. AIM: In this study, we evaluated renal biopsy complications and risk factors in one nephrology facility. MATERIAL AND METHODS: We conducted a three-year retrospective study on patients who underwent renal biopsy between January 2014 and December 2016. Strict written biopsy protocol was followed. Clinical and laboratory data were obtained from medical charts. Complications were categorised as minor and major, according to the need for intervention. Minor complications included macrohematuria and/or hematoma that did not require intervention. Major complications included hematuria or hematoma with fall of hematocrit that required a blood transfusion, surgery or caused death. A binary logistic regression model was used to analyse the possible factors associated with complications after the biopsy. RESULTS: We analysed 345 biopsies; samples were taken from patients aged from 15-81 years, of whom 61% were men. A total of 21 (6%) patients developed a complication, 4.4% minor and 1.7% major complications. There were no nephrectomy or death due to biopsy intervention. Overweight patients, as well as those with higher creatinine, lower hemoglobin, higher blood pressure and biopsy due to AKI had higher chances to develop complications (p = 0.037, p = 0.023, p = 0.032, p = 0.002, p = 0.002, respectively). The patients’ age, gender, kidney dimension, number of passes and uninterrupted aspirin therapy were not found as significant predictors of complications. In the multivariate logistic model, body weight (OR = 1.031, 95%CI = 1.002-1.062), lower hemoglobin (OR = 0.973, 95%CI = 0.951–0.996) and hypertension (OR = 1.025, 95%CI = 1.007-1.044) increased the risk of complications in biopsied patients. CONCLUSION: Renal biopsy is a safe procedure with a low risk of complications when strict biopsy protocol is observed. Correction of anaemia and blood pressure is to be considered before the biopsy.

The strengths and the limitations of research activities currently present in Europe are explored in order to outline how to proceed in the near future. Epidemiological and clinical research and public policy in Europe are generally considered to be comprehensive and successful, and the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) is playing a key role in the field of nephrology research. The Nephrology and Public Policy Committee (NPPC) aims to improve the current situation and translation into public policy by planning eight research topics to be supported in the coming 5 years by ERA-EDTA.

Description of problems and possible solutions

The exclusion of chronic kidney disease (CKD) patients from clinical trials—particularly cardiovascular trials—remains a long-standing, unsolved problem, which prevents the optimization of clinical care in these patients. The situation recalls the insufficient recruitment of women in cardiovascular trials until the 1980s, a problem that was only resolved following regulatory interventions. Regulatory agencies are in a unique position to promote recruitment of CKD patients in clinical trials. The main stakeholders, namely patients’ associations and scientific societies, should make major lobbying efforts to persuade these agencies that the issue is an absolute public health priority.

In the last two decades a great progress was observed in understanding of podocytes, their specific structure and function identifying many specific podocyte proteins, such as nephrin and podocalyxin. Podocytes form the final barrier to plasma proteins leakage. Nephrin as a main component of the filtration diaphragm forms a physical barrier while podocalyxin as sialoglycoprotein forms an electrostatic barrier. Podocyte damage, i.e. podocytopathies and their loss through urine-podocyturia, are crucial in pathogenesis and progression of nephropathies with proteinuria as main clinical manifestation. In podocytopathies, nephrin and podocalyxin appear in the urine before proteinuria and microalbuminuria which were previously considered as earliest markers of nephropathies. Nephrinuria and podocalyxuria indicate damage of the podocytes on glomerular level and/or presence of apoptotic and necrotic podocytes in urine. These urinary markers are also important in early diagnosis of secondary nephropathies such as diabetic, lupus and hypertensive nephropathy as the most common causes of end-stage renal failure (ESRF). These markers are also important in the prediction of preeclampsia, which is the most common complication in pregnancy. In this review we elaborate in dept the main structural and functional features of podocytes and their specific proteins, nephrin and podocalyxin, summarizing the recent literature data on their importance in the early diagnosis of the most common secondary nephropathies.

Introduction. Assessment of renal function is a crucial component of donor evaluation. The higher measured donor GFR is independently associated with a better allograft outcomes in living donor kidney transplantation (LDKT). Monitoring graft function and estimation of GFR is a recommended method for patients’ follow-up in posttransplantation period. The aim of our study was to investigate the correlation of directly measured GFR of donated kidney with estimated GFR through creatininebased formulas and to detect impact factors on the graft function at 12 months posttransplantation. Methods. Fifty LDKT patients (related and nonrelated donors) with stable renal function in a period of 12 months after transplantation were included in our study. The mean recipient age was 30.7±9.6 years, and donor age 55.45±9.41 years. The mean directly measured donated kidney GFR was 47.61±5.72 ml/min. Graft function was estimated at 3, 6 and 12 months by 3 formulas: Cockcroft- Gault (C-G), MDRD 6 variables and Nankivell. Direct correlation of estimated with measured radiolabeled 99mTc DTPA GFR was performed. Various impact factors such as donor age, dialysis vintage and different calcineurin inhibitors as a part of immunosupression were evaluated. Results. Estimated GFR at 12 months with MDRD, Cockroft Gault, and Nankivell formulas was 72.65±22.6, 94.25±36.42, and 81.78±17.89 ml/min, respectively. The highest estimated GFR was obtained with C-G formula at all three time points. The estimated allograft GFR did not correlate with directly measured GFR of donated kidney. Donor age well correlated with the graft function at 12 months. Allografts from standard criteria donors-SCD (60 years). The highest GFR was estimated with C-G equation (106.08±39.26 ml/min), while GFR estimated with Nankivell was 86.86±15.30 ml/min, and with MDRD 79.67±20.28 ml/min, presenting patients in stage 2 of chronic kidney disease. Duration of hemodialysis treatment under 24 months showed better graft function estimated by C-G at 12 months (102.23±38.86 ml/min), compared to that above 24 months of HD (77.84±18.11 ml/ min). Different type of calcineurin inhibitors did not influence on the graft function at any time point. Conclusion. Creatinine-based formulas for estimation of the graft function did not correlate with directly measured function of the donated kidney with radiolabeled isotopes, nor between each other. Hence, the monitoring of the graft function should be done by a single formula in the posttransplantation period. Expectedly, a better graft function was observed in young donors (standard criteria) and in patients with shorter hemodialysis treatment.

Background: This study investigated in a North American patient population the longer-term treatment effects of the phosphate binder, colestilan, in patients with CKD Stage 5D and hyperphosphataemia. Methods: One hundred and sixteen CKD Stage 5D patients with hyperphosphataemia were entered into a multi-centre, open-label study where they received flexible dose colestilan (6-15 g/day) to maintain serum phosphorus levels between 3.5 and 5.5 mg/dl. The primary endpoint was safety, assessed by treatment-emergent adverse events. Efficacy was assessed by changes in serum phosphorus, mineral metabolism, lipids, HbA1c, uric acid and bone markers. Results: Serum phosphorus was significantly reduced by 1.18 mg/dl (p < 0.001), from 6.99 mg/dl at baseline to 5.80 mg/dl at week 52. LDL-cholesterol was also significantly reduced as well as uric acid. Significant change was observed only for one bone marker - PINP. Most adverse events were of mild or moderate intensity. Nausea (22.4%), vomiting (21.6%), and diarrhoea (19.8%) were most commonly reported. Conclusions: Long-term flexible dosing with colestilan reduces serum phosphorus and demonstrates an acceptable safety and tolerability profile.

Introduction. Nowadays, obesity has emerged as one of the most independent risk factors for chronic kidney disease (CKD) in both economically developed and undeveloped countries. The number of patients requiring dialysis as a consequence of obesity-related renal diseases, such as diabetes mellitus and hypertension, is increasing worldwide. Moreover, obesity has been shown to favorize the risk of cardiovascular diseases (CVD) with premature death due to CKD and/or end-stage renal disease (ESRD). The aim of the study was to investigate the association between obesity [e.g. body mass index (BMI)], kidney function [e.g. glomerular filtration rate (GFR)] and renal anemia in CKD patients. Methods. Retrospectively, data from the register of 315 pre-dialysis patients with different stages of CKD not on erythropoiesis stimulation agents (ESAs) during the period between 1 Jan 2013-30 June 2013 were used to assess the association between the degree of CKD impairment with the degree of obesity and anemia. The stage and/or progression of CKD was calculated by GFR, while the degree of obesity by the body mass index (BMI). CKD was defined as a glomerular filtration rate (GFR) 2. Data analysis was performed by means of the simple Microsoft excel program. Results. Within the study population of 315 CKD patients, 123 were males with mean age of 63.4±1.33 years and 192 females of 57.3±1.2 years. The GFR reduced with the increased BMI in both genders, and majority of patients (n=243) were in CKD stage 3, with a mean GFR of 44.5 ml/min/1.73 m2. The BMI values in female patients with first and second degree of obesity negatively correlated with GFR (r=−0.46, p2) had a positive correlation between the decreased renal function and reduced Hb levels. Conclusions. Our study provided an unconditional evidence not only for the presence of an association between the degree of obesity (BMI) and the degree of renal function impairment (GFR), but also an association between the higher BMI and the higher degree of kidney anemia seen in women with second degree of obesity. Further larger scale trials and interventional studies are required to see the effect of body weight reduction on renal function and especially anemia.