Search

Unlabelled: CKD patients present deficient elimination of potassium. Ambulatory treatment with hypotensors, mainly angiotensin-renin system inhibitors, can be associated in these patients with potassium retention and risk of hyperkalemia. In pre-dialysis stage-5 CKD patients, the use of medication accompanied by hyperkalemia increases risks of developing it. Using diuretics like spironolactone also increases this risk. Serum potassium can also increase in case of inappropriate consumption of potassium-rich food (bananas). Since ambulatory care does not always rigorously control hyperkalemia in CKD patients we consider it is useful to screen patients when they are referred to dialysis services. The screening can reflect the management of ambulatory CKD patients under treatment with ACE-I and ARB hypotensors. We remark that beta-blockers are attributed a (limited) role in increasing the values of serum K., Material and Method: We studied a group of 477 stage-5 CKD patients referred for dialysis to The Dialysis Centre of the Emergency County Hospital Timişoara. The average age of the patients was 57.41 +/- 14.26 years. 260 were males and 217 females. All were stage-5 CKD with GFR < 15 mL/min/1.73 m2, with a group average value of eGFR of 5.72 +/- 2.81 mL/min/1.73m2. Our investigations showed hypokalemia in 14 patients (2.93%). Hyperkalemia was found in 179 patients. Of these, 124 had mild hyperkalemia (5.5-6.4 mEq/L), 45 patients had medium hyperkalemia (6.5-7.5 mEq/L) and 10 (2.09%) had severe hyperkalemia (K > 7.5 mEq/L)., Discussion: Hyperkalemia was more frequent in patients who had been treated with blockers of the renin-angiotensin system than in patients who had used other hypotensors or who had not needed hypotensors and had not taken diuretics. Severe hyperkalemia (K > 7.5 mEq/L) was present both in patients treated with blockers of the renin-angiotensin system and in those treated with other hypotensors and in 1 case without hypotensor or diuretic treatment. 2 cases treated with blockers of the renin-angiotensin-aldosterone system with severe hyperpotassemia associated antialdosteronic diuretics, cumulating hyperpotassemic effects. Diuretic treatments with loop diuretics influenced the values of serum K of most patients. Hyperkalemia represents an important problem in nephrology because of the risks it induces in the treatment ofpre-dialysis CKD patients and it requires attentive monitoring.

We consider that re-assessment of the vascular status is necessary, even mandatory, in patients with CKD when initiating dialysis because of two reasons:--assessment of vascular remodelling is important for establishing the artery-venous fistula as it can supply appreciative data on its success and duration;--vascular remodelling plays an important part in cardio-vascular pathology of patients dialysed, with the required consecutive prophylactic measures. In chronic kidney disease, calcium deposits at extra-skeletal level also affect the vessels, determining calcifications of both the vascular intima and media. Atherosclerosis and arteriosclerosis are present in patients with CKD and they contribute to diminishing the elasticity of the artery wall by vascular remodelling. Vascular remodelling determines thickening of the artery wall, respectively of the thickness of the arterial intima-media. Thus, arteries lose their elasticity, and the wall of the arterial tree wall turns stiff. Arterial stiffness is a process that precedes the development-proper of atherosclerosis, determined by cumulative exposure to various risk factors. Atherosclerosis is a focal process, in which indemne areas alternate with areas with atheroma plaques at intima level, and arteriosclerosis is a diffuse process located at the level of the arterial media. Non-invasive assessment of arterial stiffness can be achieved by analyzing pulse wave velocity and the augmentation index. We studied a group of 35 patients with chronic kidney insufficiency, CKD, stage 5, with an average age of 52.03 +/- 17.36 years, of whom 15 (43%) were females and 20 (57%) were males. The investigated parameters presented the following average values: PWV = 16.7 +/- 1.27 m/s; IMT = 1.63 +/- 0.18 mm; Aix = 36.14 +/- 9.98%; AAI = 0.78 +/- 0.2. The assessment of vascular stiffness in chronically dialysed patients offers better appreciation of vascular stiffness. Knowing the amplitude of the vascular remodelling process is of special importance for deciding the place and modality of performing the vascular access with regard to replacing the kidney function and to preventing cardiovascular events in dialysed patients.

Hypotheses explaining pathogenesis of secondary hyperparathyroidism (SH) in late and severe CKD as a unique entity called Sagliker syndrome (SS) are still unclear. This international study contains 60 patients from Turkey, India, Malaysia, China, Romania, Egypt, Tunisia, Taiwan, Mexico, Algeria, Poland, Russia, and Iran. We examined patients and first degree relatives for cytogenetic chromosomal abnormalities, calcium sensing receptor (Ca SR) genes in exons 2 and 3 abnormalities and GNAS1 genes mutations in exons 1, 4, 5, 7, 10, 13. Our syndrome could be a new syndrome in between SH, CKD, and hereditary bone dystrophies. We could not find chromosomal abnormalities in cytogenetics and on Ca SR gene exons 2 and 3. Interestingly, we did find promising missense mutations on the GNAS1 gene exons 1, 4, 10, 4. We finally thought that those catastrophic bone diseases were severe SH and its late treatments due to monetary deficiencies and iatrogenic mistreatments not started as early as possible. This was a sine qua non humanity task. Those brand new striking GNAS1 genes missense mutations have to be considered from now on for the genesis of SS., (Copyright © 2012 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: It is known that secondary hyperparathyroidism (SH) and particularly skeletal changes is a severe condition in chronic kidney disease (CKD). Sagliker syndrome (SS) is a very prominent feature in CKD including uglifying human face appearances, short stature, extremely severe maxillary and mandibulary changes, soft tissues in the mouth, teeth-dental abnormalities, finger tip changes and severe psychological problems., Methods: In the last 8 years we have confronted 36 extremely incredible SS cases in CKD by performing an international study in Turkey, India, Malaysia, Romania and Egypt., Results: In addition to the uglifying human face appearance, we found extremely severe X-ray and tomographical, pantomographical, histo-pathological changes in the head and whole body. Finally, we compared previous face pictures with recent ones. Just a few years earlier they had been pretty and good-looking young boys and girls. By investigating their history, we understood they had not received proper therapy and were in the late-irreversible period., Conclusion: SS is a serious and severe complication of CKD. Late and improper treatment leads to abnormalities throughout skeleton particularly in the skull and face. Changes particularly in children and teens become irreversible-disastrous for appearance and psychological health. Appropriate treatment must begin as early as possible in specialized centers. It is possible that SS patients may survive long-term with dialysis, but with all those particular changes could anyone claim this type of life would continue in an acceptable way without extending their height, correcting all the changes in the skull and face, remodeling new faces and most particularly convincing the patients to deal with all those tragi-dramatic psychological problems?

Objective: It is known that skeletal changes due to secondary hyperparathyroidism (SH) can be severe in chronic kidney disease (CKD). Recently described Sagliker syndrome (SS) is a very striking and prominent feature of SH in CKD, including an uglifying appearance to the face, short stature, extremely severe maxillary and mandibulary changes, soft tissue in the mouth, teeth/dental abnormalities, fingertip changes, knee and scapula deformities, hearing abnormalities, and neurological and, more important, severe psychological problems., Design, Setting, Patients: In the past 8 years, we have encountered 40 cases of SS in SH and CKD by performing an international study in Turkey, India, Romania, Egypt, Maleysia, Tunis, and China., Results: The medical history of these patients showed that they did not receive proper therapy. Changes, particularly in children and teenagers, become irreversible, which was disastrous for the patients both aesthetically and psychologically., Conclusion: Treatment must begin early and be the appropriate treatment given in centers with sophisticated skills. Otherwise, the inability to correct all the changes in the skull and face, to remodel a new face, to extending the height, and, most important, to convince the patients to face the dramatic psychological problems can be catastrophic for those patients.

Diabetic nephropathy is a major microangiopathic complication of diabetes mellitus. Its features are represented by: proteinuria and renal function decrease. The etiology of proteinuria in diabetic patients is assessed in this study. The study was performed on 30 patients with diabetes mellitus (11 type 1, 19 type 2) and proteinuria (19 males and 11 females), at the mean age of 42.1+/-7.72 years. Renal biopsies were done with Vim-Silverman needle, using hematoxylin-eosin and PAS staining. Diabetic retinopathy was found in 26 patients (86.66%). The values of proteinuria were: 0.62+/-0.07 g/24 hours in 4 (13.33%), 2.41+/-1.26 g/24 hours in 10 (33.33%) and 4.68+/-2.11 g/24 hours in 16 patients (53.33%). 18 patients presented elevated blood pressure (170.11+/-6.25/97.12+/-4.44 mmHg). Reduced creatinine clearance (48.01+/-7.25 ml/min) was found in 7 patients (23.33%). Histological analysis showed: diffuse diabetic glomerular lesions in 14 patients (46.66%), nodular diabetic glomerular lesions associated with diffuse glomerular lesions in 12 patients (40%) and membranous glomerulonephritis, without diabetic lesions in 4 patients (13.33%). Appearance of proteinuria in diabetic patients is not synonymous with diabetic nephropathy, requiring further investigations. including renal biopsy.

Background: Hepatitis C virus (HCV) infection rates are still high in hemodialysis (HD) centers in developing countries. Standard interferon (IFN) monotherapy is associated with good results in HCV-positive patients (more than 30% rate of sustained virological response) but with poor tolerance. Pegylated interferon (PEG-IFN) is better tolerated and has a more sustained antiviral effect in the general population. There have been no large trials to date with PEG-IFN in hemodialysis populations., Methods: We report the largest series to date of HCV+ HD patients (n=78) treated with PEG-IFN alfa -2a 135 microg s.c. weekly monotherapy. The primary outcomes were (a) efficacy - assessed by the viral response at 12, 48 weeks and 6 months after completion of therapy, and (b) rate of serious adverse events., Results: In 48/78 (61.5%) patients an early (12 weeks) viral response was obtained. Viral end-of-treatment response (ETR) was evaluated in the 21 patients (26.9%) who reached week 48 on therapy: only 15 subjects (19.2% of the initial population) had undetectable HCV-RNA levels. In these 15 patients, a sustained viral response (SVR) was recorded in 11 - i.e. 14.1% of the initial intention-to-treat (ITT) population. A high prevalence of noncompliance (32%) and of adverse events (83%) was recorded; minor adverse effects (flu-like syndrome, mild-to-moderate thrombocytopenia, leukopenia and anemia) responded to symptomatic therapy or dose reduction, but often caused lack of compliance. The incidence rate of serious adverse events was 0.19/patient-year (median time to event 20.5 weeks), and incidence of deaths was 0.11/patient-year., Conclusions: In dialysis patients, PEG-IFN alfa -2a is poorly tolerated and associated with a high number of serious adverse events, causing a significant lack of compliance/discontinuation of therapy. In this largest HCV-positive hemodialysis population survey, we report a low sustained viral response in an ITT analysis, compared with previously published historical data using non-PEG-IFN, a low compliance rate and an unsatisfactory overall safety profile, not supporting the superiority of PEG-IFN monotherapy.

Background: Currently, less frequent than once-weekly subcutaneous epoetin administration regimens were shown to be equally effective and safe as once-weekly schedules in stable predialysis and peritoneal dialysis patients. Bioequivalency of once-every-2-weeks and once-weekly subcutaneous administration of the same total dose of epoetin beta for the maintenance phase of anemia treatment in stable iron-replete long-term hemodialysis patients therefore was investigated prospectively., Methods: Two hundred seven stable selected hemodialysis patients without diabetes, acute illness, significant inflammation, malnutrition or hyperparathyroidism administered once-weekly subcutaneous epoetin beta and preserving stable hemoglobin levels between 10 and 12 g/dL (100 and 120 g/L; difference between maximum and minimum of 3 subsequent levels

Aim: To evaluate the response to pegylated-interferon alpha 2a in chronic hepatitis C patients on chronic haemodialysis., Methods: Ten patients with chronic C hepatitis were enrolled in this study. All had increased aminotransferases for more than 6 mo, positive antiHCV antibodies and positive PCR HCV-RNA. We administrated Peg-Interferon alpha 2a 180 microg/wk for 48 wk. After 12 wk of treatment we evaluated the biochemical and early virological response (EVR). At the end of the treatment we evaluated the biochemical response and 24 wk after the end of the treatment we evaluated the sustained virological response (SVR). We monitored the side-effects during the treatment., Results: Two patients dropped out in the first 12 wk of treatment and 2 after the first 12 wk of treatment. After 12 wk of treatment, 7 out of 8 patients had biochemical response and EVR and 1 had biochemical response but persistent viremia. We had to reduce the dose of pegylated-interferon to 135 mug/wk in 2 cases. Three out of 6 (50%) patients had SVR 24 wk after the end of the treatment. Intention-to-treat analysis showed that 3 out of 10 patients (30%) had SVR. Side-effects occurred in most of the patients (flu-like syndrome, thrombocytopenia or leucopoenia), but they did not impose the discontinuation of treatment., Conclusion: After 12 wk of treatment with Peg-Interferon alpha 2a (40 ku) in patients on chronic haemodialysis with chronic C hepatitis, EVR was obtained in 87.5% (7/8) of the cases. SVR was achieved in 50% of the cases (3/6 patients) that finished the 48 wk of treatment.

Unlabelled: INTRODUCTION. This report describes the current status of nephrology and renal replacement therapy (RRT) in Romania, a country with previously limited facilities, highlighting national changes in the European context., Methods: Trends in RRT development were analysed in 2003, on a national basis, using the same questionnaires as in previous surveys (1991, 1995). Survival data and prognostic risk factors were calculated retrospectively from a large representative sample of 2284 patients starting RRT between January 1, 1995 and December 31, 2001 (44% of the total RRT population investigated)., Results: In 2003, RRT incidence [128 per million population (p.m.p.)] and prevalence (250 p.m.p.) were six and five times higher, respectively, than in 1995. The annual rate of increase in the stock of RRT patients (11%) was supported mainly by an exponential development of the continuous ambulatory peritoneal dialysis (CAPD) population (+600%), while the haemodialysis (HD) growth rate was stable (+33%) and renal transplantation made a marginal contribution. Renal care infrastructure followed the same trend: nephrology departments (+100%) and nephrologists (+205%). The characteristics of RRT incident patients changed accordingly to current European epidemiology (increasing age and prevalence of diabetes and nephroangiosclerosis). The estimated overall survival of RRT patients in Romania was 90.6% at 1 year [confidence interval (CI) 89.4-91.8] and 62.2% at 5 years (CI 59.4-65.0). Patients' survival was negatively influenced (Cox regression analysis) by age >65 years (P < 0.001), lack of pre-dialysis monitoring by a nephrologist [P = 0.01, hazards ratio (HR) = 0.8], severe anaemia, lack of erythropoetin treatment (P < 0.001, HR = 0.6), and co-morbidity, e.g. cardiovascular diseases (P < 0.001, HR = 1.8) and diabetes mellitus (P < 0.001, HR = 2.2)., Conclusions: Although the rate of increase in RRT patient stock in 1996-2003 in Romania was the highest in Europe, the prevalence remained below the European mean. As CAPD had the greatest expansion, followed by HD, an effective transplantation programme must be set up to overcome the imbalance. The quality of RRT appears to be good and survival was similar to that in other registries. Further evolution implies strategies of prevention, based on national surveys, supported by the Romanian Renal Registry.

The aim of the study was to evaluate the response to Pegylated Interferon alpha2a (40 kDa) in patients on chronic haemodialysis with chronic C hepatitis. 10 patients were enrolled in this study (4 males and 6 females). All had increased aminotransferases, anti HCV antibodies and PCR HCV-RNA positive. We administrated Peg-Interferon alpha2a 180 microg/week for 48 weeks. One patient was excluded from the study because of lack of compliance. We had to stop the treatment in one patient due to complications after surgery. After 12 weeks of treatment we evaluated the biochemical and virological response. We continued with Peg-Interferon until 48 weeks. Six patients finished the treatment. After 12 weeks of treatment with Peg-Interferon alpha 2a (40 kDa) in patients on chronic haemodialysis with chronic C hepatitis, the virological response (HCV-RNA absent by PCR) was obtained in 87.5% (7/8) of the cases. All patients who finished the 48 weeks of treatment had normal transaminases (biochemical response) (6/6). We had to reduce the dose of Peg-Interferon in only 2 cases. Even if side-effects occurred in most of the patients (flu-like syndrome, thrombocytopenia or leucopenia) they did not impose the discontinuation of treatment. The sustained response will be established by determining PCR RNA-HCV 6 months after the end of the treatment.

Rifampicin re-administration may cause immunologically mediated acute tubulo-interstitial injury. Retrospectively, 170 consecutive cases with acute renal failure (ARF) following re-treatment with rifampicin (71% males, 29% females, age 21 to 68 years) were analysed, which accounted for 12% of all ARF patients treated by two large dialysis referral centres in Romania, Timisoara and Iasi, between 1974-2001 and 1988-2001, respectively. The most frequent clinical features of rifampicin-induced ARF were: Anuria, gastro-intestinal (abdominal pain, nausea, vomiting and diarrhoea) and "flu-like" symptoms. Urine analysis revealed sterile leucocyturia in 54%, proteinuria in 31%, haematuria in 26% and haemoglobinuria in 7% of cases. Haemolytic anaemia was frequent, found in 66% of the patients; half of these had Hct values of < 30%, thrombocytopenia and also more severe renal damage (a longer anuric phase and a slower recovery of the renal function), thus suggesting a severe multi-target autoimmune aggression. The association of hepatic injury--not explained by prior hepatic disease, B or C hepatitis virus infection or history of alcohol abuse--was encountered in 17% of the cases, without a significant influence on the renal and the general outcome. The outcome of rifampicin-induced ARF is generally favourable, with complete recovery of the renal function within 30 days in 52% of the cases and within 90 days in 92% of the cases. The mortality rate was 3.5%, compared to 21% for the overall ARF population treated during the same period (p < 0.05).

This retrospective study was performed on 92 patients diagnosed with acute renal failure (ARF) post discontinuous rifampicin treatment, admitted between 1974-2000, in Hemodialysis Center of 1st Timisoara Clinical County Hospital. The passage from the continuous treatment (7/7) to discontinuous RMP treatment triggered the ARF in 77 patients and the restart of the treatment after one year or more of treatment arrest, lead to ARF in 15 cases. The ARF symptomatology appeared in the first 12 hrs of treatment resumption in 14.13% cases and in 85.87% after 38.5 +/- 8.2 hrs. The most frequent symptoms were lumbar pain in 76.08%, nausea and vomiting in 60.86%, abdominal pain (52.17% of cases) flu-like (fever, chills, myalgia), jaundice, diarrhea, hypotension, confusion and hypertension in only 7.6% of cases. In 94.56% of cases renal symptoms appeared in normal kidneys. The renal injury evolution was favorable, with significant improvements after 20 days in serum and urine biological parameters. The antibodies anti-RMP were present in serum 55.43% of patients, in 80.39% of them, the presence of antibodies was related to high values of gamma-globulins. In 33.69% of patients sterile leukocyturia, considered a marker of interstitial nephritis, was present. The most frequent associated ARF complications were the hemolytic anemia emphasized by high levels of unconjugated bilirubin and positive Coombs' test in 93.3% of patients, and liver injuries, present in 41.69% of cases. Thrombocytopenia was registered in 27.7% of cases, infections in 28.6%, gastrointestinal complications in 11.95%, and cardiovascular complications in 9.78% of cases, these severe forms leading to the death of patients. The ARF post discontinuous rifampicin treatment presents a favorable evolution even when it is associated with other organ or systems complications. The ARF and associated complications are due to the specific immune system activation by rifampicin, and by direct toxic effects of rifampicin at tissues level.

A group of 37 hemodialyzed patients with chronic renal failure were investigated within a period of 6 months to 9 years. Of these patients five presented quantitatively significant bacteriuria noncorrelated with the causal nephropathy. Of the 9 patients with urologic past history two presented urinary infection. Urinary bacterial immunofluorescence was constantly positive in all the cases in which bacteriuria was significant and, at least in one determination when the germ count was below 10,000/ml. This finding was also supported by the increase of gammaglobulinemia and of the circulating immune complexes in all the cases investigated as well as of the B lymphocytes in one third of cases. Fifty percent of the patients presented T lymphocytopenia with excess of suppressor lymphocytes and deficit of the helper ones. It can, therefore be assumed that in patients with chronic renal failure nondialyzable antigens persist in the renal parenchyma where they stimulate anticorpogenesis but at a low level owing to some immune disturbances present in such patients.

Six observations are presented of patients receiving intermitent rifampicin treatment (900 mg twice weekly) that developed acute renal failure during treatment (4 cases) or when treatment was taken up again, after an interruption of 6 months (2 cases). Following anuria of 4--14 days and nitrogen retention between 248 and 521 mg, the evolution was favourable. Clinical, biological and immunological data (anti-rifampicin antibodies were detected in 1/8 and 1/16 in 3 cases) suggest the immune origin of this type of renal accidents.

The causes of failure in surgical arteriovenous anastomoses are discussed with reference to 60 operations performed on 52 patients suffering from chronic renal insufficiency in the uremic stage. The various technical variants applied are shown, as well as the early and late complications and the order in which reinterventions were performed. The work concludes with an original mathematical study of the blood output in the three fistula variants practiced by the authors, designed to supply evidence of their functional value.