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Objectives: Our country Croatia is among the global leaders regarding deceased donation rates, yet we are facing organ shortage and concurrently a sharp decline in our acceptance rates for kidney offers. To reevaluate our organ acceptance policy, we retrospectively analyzed the factors that influenced the posttransplant outcomes of kidneys from elderly deceased donors at our center during a 20-year period and the changes to our organ acceptance criteria during Eurotransplant membership. Materials and Methods: We studied all kidney transplants from donors ≥60 years old during the two 5-year episodes of Eurotransplant membership from 2007 to 2017 (period II and period III) and compared those data to data from the decade before Eurotransplant membership (period I, 1997-2007). Differences in acceptance rates and reasons for the decline of kidney offers between the two 5-year periods of Eurotransplant membership were analyzed. Results: In period I, 14.1% of all kidney allografts were obtained from donors ≥60 years old; in period II and period III the rates were nearly 2-fold higher (27.0% and 25.7%,respectively; P = .007 and P = .008). During the first 5-year period of Eurotransplant membership (period II), we accepted significantly more grafts from marginal donors with a higher number of human leukocyte antigen mismatches compared with period I. Consequently, the 3-month survival rate of kidneys from donors ≥60 years old dropped from 91.1% to as low as 74.2% (P = .034). After application of morestringent human leukocyte antigen matching, especially in human leukocyte antigen DR, and morestringent donor acceptance criteria in period III, graft survival improved to 91.1%. Conclusions: Our experience indicates that careful selection of kidneys from elderly deceased donors and allocation to human leukocyte antigen-matched recipients is important to improve transplant outcomes.

Procjenjuje se da u Europi oko 10 % odraslih osoba (75 milijuna) ima početni stupanj kronične bubrežne bolesti. Kod velikog broja pacijenata bubrežna bolest otkrije se tek u uznapredovalom stupnju, često praćenom komplikacijama i drugim bolestima koje uvelike umanjuju kvalitetu pacijentova života te povećavaju smrtnost i troškove liječenja. Učestalost primjene pojedinih metoda nadomjesnog bubrežnog liječenja razlikuje se između europskih država, no sveobuhvatni podaci o učinku tih metoda manjkavi su ili nedostupni. Projekt EU-a EDITH ima za cilj istražiti čimbenike koji utječu na odabir metoda nadomjesnog bubrežnog liječenja u državama Europske unije (EU) te analizirati ishode liječenja i troškove za svaku od pojedinih metoda, kako bi se mogao usporediti njihov učinak na pacijente i zdravstvene sustave. Praćenje zdravstvenog stanja primatelja presatka i ishoda transplantacije kao najučinkovitije metode nadomjesnog bubrežnog liječenja planira se provesti uspostavom nacionalnih i zajedničkog Europskog registra. Za pouzdanu procjenu rizika povezanog s darovanjem bubrega potrebno je dugoročno i sveobuhvatno praćenje zdravstvenog stanja (živih) darovatelja bubrežnog presatka kroz jedinstveni registar na (nacionalnoj) i europskoj razini. Sveobuhvatna analiza i usporedba učinka pojedinih metoda nadomjesnog bubrežnog liječenja, u pogledu uspješnosti odnosno ishoda, kao i troškova liječenja, preduvjet su za kreiranje učinkovitih strategija i održivih javno-zdravstvenih politika na nacionalnoj i/ili razini EU-a. Očekuje se da će rezultati ovog projekta dati snažan poticaj široj stručnoj zajednici, nadležnim tijelima i pacijentima za zajedničko djelovanje u cilju unapređenja preventivnih mjera te ujednačavanja dostupnosti optimalnih modaliteta liječenja bubrežnih pacijenata na razini EU-a., In Europe, early stages of chronic kidney disease (CKD) are present in nearly 10% of adult persons (75 million). In most of the patients, however, CKD is discovered at an advanced stage, often leading to complications and comorbidity with a strong impact on the quality of life, and an increase in mortality and higher treatment costs. Large variations in practice regarding the frequency of different modalities of renal replacement treatment (RRT) in European countries have been noticed, however comprehensive data on treatment outcomes are often incomplete or missing. The aim of the EDITH EU project is to investigate the factors influencing RRT modality choice in EU Member States and analyse outcomes and treatment costs, to compare the impact of different modalities on patients and healthcare systems. Development of national and common European registries for the long-term follow-up of living kidney donors and kidney recipients will be enhanced and piloted to ensure safeguard and a more accurate assessment of the risks associated with organ donation and transplantation. A comprehensive analysis and comparison of the impact of various RRT methods, measured by outcomes and treatment costs, are the key preconditions for creation of efficient strategies and public-health policies on a national and/or EU level. It is expected that the results will provide a strong stimulus to the professional community, competent authorities and patients’ joint efforts in implementation of effective strategies and sustained funding models for prevention of kidney disease and optimisation of its treatment in the EU member states.

Imunosni sustav obuhvaća imunost koju čini nespecifični (prirođeni) imunosni odgovor i specifičnu (stečenu) imunost koja se adaptivno razvija protiv stranih antigena. Presađivanje alogeničnog AB0-podudarnog bubrega prvenstveno stimulira specifičan imunosni odgovor usmjeren na peptidne antigene koji se predočavaju na donorskim stanicama u okviru molekula kodiranih glavnim sustavom tkivne podudarnosti MHC. Imunosni odgovor započinje prepoznavanjem antigena od strane limfocita T, pri čemu je neophodno međudjelovanje T-staničnog receptora s peptidnim antigenima predočenim od antigen-predočnih stanica i kostimulacijskog receptora s ligandom na antigen-predočnim stanicama. Oba signala su neophodna za ulazak limfocita T u stanični ciklus, a nakon toga se unutarstaničnim prijenosom signala aktiviraju geni za proizvodnju i lučenje citokina. Aktivirani limfociti T, koji migriraju do presatka gdje induciraju akutni upalni odgovor, djeluju izravno citotoksično i potpomažu proizvodnju protutijela od strane limfocita B te odgovore odgođenog tipa preosjetljivosti inducirane makrofagima. Čimbenici ovisni i neovisni o aloantigenu pridonose efektorskim mehanizmima koji uzrokuju reakciju odbacivanja presatka. Značajan napredak na područjima imunobiologije i imunogenetike omogućio je sigurnije i uspješnije liječenje transplantacijom organa. Izuzetno je važno rano otkrivanje i sprječavanje reakcije odbacivanja presatka. Uz primjenu suvremenih imunosupresivnih lijekova rijetko se javlja teška reakcija odbacivanja posredovana limfocitima T. Najčešći uzrok gubitka funkcije presatka je kronična reakcija odbacivanja posredovana protutijelima koja su usmjerena na HLA antigene darovatelja. U radu prikazujemo mehanizme nastanka reakcije odbacivanja presatka posredovane stanicama i protutijelima, mjesta djelovanja imunosupresivnih lijekova te razvoj novijih strategija liječenja s ciljem daljnjeg poboljšanja preživljenja pacijenata i presatka., The immune system comprises the nonspecific (natural) immune response and the specific (aquired) immunity that has adaptively developed against foreign antigens. AB0-compatible kidney allotransplantation primarily stimulates a specific immune response against peptide antigens presented on donor cells by major histocompatibility complex (MHC) encoded molecules. The immune response begins with alloantigen recognition by T lymphocytes, i.e. the T-cell receptor interaction with peptide antigens presented by antigen-presenting cells, and the costimulatory receptor interaction with its ligand on the antigen-presenting cell. Both signals are necessary for T lymphocytes to enter the cell cycle, then intracellular signalling leads to the activation of genes and secretion of cytokines. Activated T lymphocytes migrate to the allograft where they induce an acute inflammatory response. They act directly cytotoxic and provide help to B lymphocytes for antibody production, and for delayed-type hypersensitivity responses induced by macrophages. Alloantigen-dependent and independent factors contribute to effector mechanisms which lead to allograft rejection. Remarkable advances in the field of immunobiology and immunogenetics have enhanced the safety and improved outcome after kidney transplantation. It is very important to early detect and prevent allograft rejection. With currently available immunosuppressive drugs, severe T-cell mediated rejection has become a rare event. The most common cause of graft failure is chronic rejection mediated by antibodies directed against donor HLA antigens. Herein, we review the mechanisms of cell- and antibody-mediated rejection, site of action of immunosuppressive drugs and recent development of treatment strategies aiming at further improvement of patient and graft survival.

Contains fulltext : 226016.pdf (Publisher’s version ) (Closed access) In several deceased donor kidney allocation systems, organs from elderly donors are allocated primarily to elderly recipients. The Eurotransplant Senior Program (ESP) was implemented in 1999, and since then, especially in Europe, the use of organs from elderly donors has steadily increased. The proportion of ≥60-year-old donors reported to the Collaborative Transplant Study (CTS) by European centers has doubled, from 21% in 2000-2001 to 42% in 2016-2017. Therefore, in the era of organ shortage it is a matter of debate whether kidney organs from elderly donors should only be allocated to elderly recipients or whether

Background: Peritoneal dialysis (PD) catheter placement is usually performed using general or local anesthesia. We present our PD catheter placement experience using an ultrasound-guided transversus abdominis plane (TAP) block, which is a regional anesthesia technique. Methods: In this study, we analyzed 33 patients from our center with ESRD who underwent PD catheter placement using a TAP block between June 2011 and April 2014. Results: The TAP block was successful for 29/33 (87.9%) patients. Four patients (12.1%) had pain at the incision site and required general anesthesia. There were no anesthesia-, surgery- or catheter-related complications. Conclusion: ESRD patients have a substantial number of comorbidities that can be negatively influenced by general anesthesia. Because regional anesthesia has no systemic effect, this procedure could be recommended for this group of patients. A TAP block is an effective, safe method and can be used as the principal anesthesia technique for PD catheter placement.

Peritoneal dialysis (PD) is an established method for renal replacement therapy in patients with end-stage renal disease (ESRD). Transversus abdominis plane (TAP) block is a regional anesthesia technique, since recently used for PD catheter placement. The main aim of this study was to evaluate the efficacy of PD catheter placement using ultrasound-guided TAP block. We studied 43 ESRD patients from our center that underwent PD catheter placement under TAP block between June 2011 and December 2014. TAP block was successful in 38 (91.4%) of 43 patients. The remaining five (8.6%) patients required general anesthesia. All procedures were performed without complications. ESRD patients have a substantially greater number of comorbid conditions compared to general population, many of which are adversely influenced by general anesthesia. Opposite to general anesthesia, regional anesthesia has no systemic effect and using this technique may prove beneficial in this group of patients. In conclusion, TAP block is an effective method for PD catheter placement and should be especially considered in ESRD patients with major comorbidities., Peritonejska dijaliza (PD) je učinkovita metoda nadomjesne terapije bubrežne funkcije u bolesnika koji se nalaze u terminalnom stadiju bubrežnog zatajenja (ESRD). Transversus abdominis plane (TAP) blok spada u regionalnu anesteziju i nedavno se počeo primjenjivati i i kod implantacija katetera za PD. Cilj ove studije bio je procijeniti učinkovitost postavljanja katetera za PD uz pomoć ultrazvučno vođenoga TAP bloka. Analizirali smo 43 bolesnika s ESRD iz našega centra u kojih je postavljen kateter za PD uz pomoć TAP bloka između lipnja 2011. i prosinca 2014. godine. TAP blok bio je uspješan u 38 (91,4%) od 43 bolesnika. U ostalih pet bolesnika bilo je potrebno primijeniti i opću anesteziju. Svi zahvati su prošli bez komplikacija. Bolesnici s ESRD imaju značajan i uvećan broj popratnih bolesti u odnosu na opću populaciju, od kojih se mnoge mogu pogoršati djelovanjem opće anestezije. Za razliku od opće anestezije, regionalna anestezija nema sistemskog učinka te uporaba ove tehnike može biti korisna u ove skupine bolesnika. Zaključno, TAP blok je učinkovita metoda kod postavljanja katetera za PD, pogotovo u bolesnika s ESRD koji imaju brojne popratne bolesti.

We presented an extremely severe case of tuberous sclerosis complex (TSC) in a female patient with recurring, life-threatening bleeding complications related to renal angi-omyolipomas. Massive intratumoral hemorrhage required surgical removal of both angiomyolipomatous kidneys and kidney transplantation. During the follow-up period, the patient developed severe metrorrhagia that eventually led to hysterectomy and salpingo-oophorectomy. Bleeding from the operative sites caused the loss of the first kid- ney transplant received from the mother, and immediate hemorrhagic shock led to the loss of the second, cadaveric kidney allograft. The third kidney transplant had a successful outcome. Pathological analysis of all tissue specimens showed TSC-associated lesions and deformed blood vessels in the surgically removed organs. Molecular genetic analysis of TSC1 and TSC2 in the DNA of peripheral leukocytes identified a novel TSC2 c.3599G>C (p.R1200P) variant. Functional assessment confirmed the likely pathogenicity of the TSC2 c.3599G>C (p.R1200P) variant. To the best of our knowledge, this is the first report of the c.3599G>C (p.R1200P) variant in exon 29 of the TSC2 gene related to a severe clinical course and multiple kidney transplants in a patient with TSC

Cilj: Adultna policistična bolest bubrega je najčešća nasljedna bolest bubrega.Tijekom godina dolazi do povećanja cisti, smanjenja funkcionalne nefronske mase i kompresije uvećanih bubrega na okolne strukture. U ovom radu prikazujemo pacijenticu s policističnom bolesti bubrega, kod koje se nakon presađivanja bubrega razvila tromboza donje šuplje vene. Prikaz pacijenta: Tri mjeseca nakon transplantacije kadaveričnoga bubrega u lijevu ilijačnu jamu 67-godišnja pacijentica hospitalizirana je zbog otoka desne noge. Kliničkim i ultrazvučnim pregledom ustanovljena je duboka venska tromboza desne noge i uvedena je terapija heparinom. S obzirom na to da nije dolazilo do poboljšanja, učinjen je pregled kompjutoriziranom tomografijom kojim je potvrđena duboka venska tromboza desne noge, ilijačnih vena desno i parcijalna tromboza distalnog dijela donje šuplje vene. Nalazi radiološke obrade ukazali su na pritisak desnog policističnog bubrega na donju šuplju venu te smo, zbog sprječavanja kompletnog venskog zastoja na razini donje šuplje vene, učinili nefrektomiju policističnog bubrega. Poslijeoperacijski tijek bio je uredan, otok noge se smanjio i funkcija bubrežnog presatka je ostala stabilna. Rasprava i zaključak: U pacijenata s velikim policističnim bubrezima kompresija donje šuplje vene može dovesti i do njezine tromboze. Indicirana je pravovremena nefrektomija., Aim: Autosomal dominant polycystic kidney disease is the most common renal hereditary disease. During many years renal cysts become larger, the functional nephron mass decreases and enlarged kidneys compress the surrounding structures. We present the case of a patient with polycystic kidney disease and inferior vena cava thrombosis after kidney transplantation. Case report: Three months after kidney transplantation into the left iliac fossa, the 67 year-old woman was admitted to our hospital due to swelling oft the right leg. Clinical and ultrasound examination revealed deep vein thrombosis of right leg and therapy with heparine was introduced. Since there was no improvement, a computerized tomography examination was performed that confirmed deep vein thrombosis of the right leg, thrombosis of iliac veins on the right side and partial thrombosis of the distal part of the inferior vena cava. As radiologic imaging revealed compression of the right polycystic kidney onto the inferior vena cava, we performed nephrectomy of the polycystic kidney to prevent complete thrombosis. The postoperative course was uneventful, with a regression of the right leg edema and stable graft function. Discussion and conclusion: In patients with large polycystic kidneys, compression of the inferior vena cava may lead to its thrombosis. A nephrectomy should be performed in time.

During the past ten years, the efforts to improve and organize the national transplantation system in Croatia have resulted in a steadily growing donor rate, which reached its highest level in 2011, with 33.6 utilized donors per million population (p.m.p.). Nowadays, Croatia is one of the leading countries in the world according to deceased donation and transplantation rates. Between 2008 and 2011, the waiting list for kidney transplantation decreased by 37.2% (from 430 to 270 persons waiting for a transplant) and the median waiting time decreased from 46 to 24 months. The Croatian model has been internationally recognized as successful and there are plans for its implementation in other countries. We analyzed the key factors that contributed to the development of this successful model for organ donation and transplantation. These are primarily the appointment of hospital and national transplant coordinators, implementation of a new financial model with donor hospital reimbursement, public awareness campaign, international cooperation, adoption of new legislation, and implementation of a donor quality assurance program. The selection of key factors is based on the authors' opinions ; we are open for further discussion and propose systematic research into the issue.

Highlights • Pretransplant DSA have a deleterious impact on graft survival only in the presence of high pretransplant serum levels of sCD30. • The majority of patients with pretransplant DSA might be transplanted safely without special pretreatment measures. Kidney transplantation in the presence of donor-specific HLA antibodies (DSA) is associated with a high failure rate due to antibody-mediated rejection. Many centers avoid transplantations if DSA are present. Others perform such transplantations after removal of DSA by apheresis under potent immunosuppression. We provide strong evidence that DSA positive recipients reject their grafts at a high rate only if the immune activation marker sCD30 is also high, suggesting that T-cell help from an activated immune system is necessary for pretransplant DSA to exert a deleterious effect on the graft. High-risk patients with DSA and sCD30 may benefit from special treatment measures. The presence of DSA alone may not be deleterious., Background It is an unresolved issue why some kidney transplant recipients with pretransplant donor-specific HLA antibodies (DSA) show a high transplant failure rate, whereas in other patients DSA do not harm the graft. We investigated whether help from preactivated T-cells might be necessary for DSA to exert a deleterious effect. Methods The impact of pretransplant DSA and immune activation marker soluble CD30 (sCD30) on 3-year graft survival was analyzed in 385 presensitized kidney transplant recipients. Findings A deleterious influence of pretransplant DSA on graft survival was evident only in patients who were positive for the immune activation marker sCD30. In the absence of sCD30 positivity, 3-year graft survival was virtually identical in patients with or without DSA (83.1 ± 3.9% and 84.3 ± 2.8%, P = 0.81). A strikingly lower 3-year graft survival rate of 62.1 ± 6.4% was observed in patients who were both sCD30 and DSA positive (HR 2.92, P

Cilj: Prikaz timskog pristupa u liječenju pacijenata s malfunkcijom arteriovenske (AV) fistule za hemodijalizu i rezultata kliničkog praćenja u prvih šest mjeseci. Ispitanici i metode: Deset pacijenata s malfunkcijom AV fistule prezentirano je multidisciplinarnom timu koji obuhvaća nefrologa, radiologa i urologa. Kliničke manifestacije bile su nedostatan protok krvi i/ili visoki venski otpor na hemodijalizi, zgrušavanje krvi u izvantjelesnom krvotoku, duže krvarenje nakon punkcije, bolovi u ruci, otok ruke ili nesazrijevanje AV fistule. U svih pacijenata učinjen je angiografski pregled s neposrednim endovaskularnim zahvatom, ako je bio indiciran, i hemodijalizom. Rezultati: Angiografski pregled pokazao je različitost patologije arterijskog i venskog segmenta. U većine pacijenata klinički ishod je bio uspješan uz dobar protok krvi na postupcima hemodijalize koji su bili urednog tijeka. Zaključak: Iako je broj ispitanika relativno malen, postigli smo značajan klinički uspjeh kao rezultat uspješne suradnje članova multidisciplinarnog tima., Aim: To present team approach in resolving arteriovenous (AV) fistula malfunction in patients on chronic hemodialysis and our results during the six months follow-up. Patients and methods: Ten patients with AV fistula malfunction were presented to our multidisciplinary team, that includes a nephrologist, radiolgist and urologist. Clinical manifestations were inadequate blood flow rate and / or high venous pressure during dialysis, blood clotting in the extracorporal circuit, longer bleeding after puncture, pain in the arm, arm sweeling or non-maturation of AV fistula. In all patients fistulography was performed with immediate endovascular therapy and dialysis, if applicable. Results: Fistulography showed a variety of pathological findings in arterial and venous segments. In the majority of patients the clinical outcome was successful, allowing a much higher blood flow rate and successful dialytic treatment. Conclusions: Although the patient group was small, we observed significant clinical benefits as a result of close team-work between different specialities.

The association of donor-specific HLA antibodies (DSA) with kidney graft failure has been addressed previously ; however, the majority of studies were based on small numbers of patients with graft failure. We investigated 83 patients with failed kidney transplants for a possible association of de novo development and persistence or loss of pre-existing DSA with graft failure. Single Antigen Bead assay-detected DSA and non-DSA antibodies were compared between patients with graft loss and matched controls with functioning grafts. The incidence of weak de novo DSA or non-DSA at a mean fluorescence intensity of 500 or higher was higher in the graft loss than in the nonrejector group (76% vs 40%, P < 0.001). Because of the low number of patients developing de novo DSA, the DSA results did not reach statistical significance (only 22% of patients with graft loss developed de novo DSA). However, at all cutoffs, there was a significantly higher rate of graft loss in patients with de novo non-DSA. The incidence of strong pretransplant DSA that persist after transplantation was higher in the graft loss group (10% vs 1%, P = 0.034). When C1q-binding ability in sera of rejectors and nonrejectors with posttransplant de novo or persistent DSA was compared, none of the nonrejectors demonstrated C1q positivity, whereas 43% of patients with graft loss showed C1q-positive antibodies, although not necessarily donor-specific (P < 0.001). Our data show that the posttransplant presence of persisting or de novo HLA antibodies, especially if C1q binding, is associated with graft loss, even if the antibodies are not specific for mismatched donor HLA.

Background: There is a need for methods that would enable monitoring of the effects of immunosuppression on the recipient's immune system to avoid rejection, immunodeficiency related complications and non-immune toxicities of the drugs used in therapy. Methods: This prospective trial included thirty patients who underwent renal transplantation in our center. All patients received an interleukin-2 receptor (IL-2R) antagonist in combination with mycophenolate, corticosteroid and calcineurin inhibitor. During the first six weeks after transplantation, the anti-CD3-stimulated proliferative response of peripheral blood T lymphocytes (PBTL) was studied by cell cycle analysis. The proportion of PBTL in different phases of the cell cycle and expression of IL- 2R were determined by flow-cytometry. Results: As an effect of quadruple immunosuppressive therapy including IL-2R antagonists, cell cycle analysis showed an incremental decrease in the proliferative response of PBTL during the first six weeks after renal transplantation. A sudden drop in the proportion of IL-2R-positive cells was observed immediately after the first dose of the IL-2R antagonist and a significant antiproliferative effect on PBTL after the second dose. In vitro, IL-2R antagonists showed a dose-dependent inhibition of the anti-CD3 stimulated proliferation of PBTL of healthy blood donors. Conclusions: Cell-cycle analysis of the immune reactivity of renal allograft recipients may represent a valuable tool for the immunological posttransplant follow-up and optimization of the immunosuppressive therapy.

Liječenje bolesnika s terminalnim kroničnim bubrežnim zatajenjem dijalizom povezano je s kraćim očekivanim trajanjem života i smanjenu kvalitetu u odnosu na opću populaciju. Cilj rada bio je prikazati bolesnika na nadomjesnom liječenju hemodijalizom koji se dijalizira više od 38 godina. Naš bolesnik je 1974. godine, u 28. godini života, započeo liječenje redovitom hemodijalizom zbog terminalnog kroničnog bubrežnog zatajenja uzrokovanog glomerulonefritisom. Prije početka liječenja konstruirana mu je arterio-venska fistula, koja je bila funkcionalna punih 30 godina. Kada je započeo liječenje hemodijalizom dijalizirao se na Killovim dijalizatorima i prve dijalize trajale su po 12 sati dva puta tjedno. Posljednjih petnaest godina je na hemodijafiltraciji. U dva navrat bio je podvrgnut transplantaciji bubrega, ali je transplantat funkcionirao prvi puta mjesec dana, a kod druge transplantacije svega četiri dana. Godine 1983. učinjena mu je paratireidektomija. Tegobe s lokomotornim aparatom javile su se prije 15 godina u vidu bolova i zakočenosti. Godine 2002. zadobio je patološki prijelom kuka od tada je u kolicima. Zbog bolova koristi analgetike, sedative uključujući i opijate. Posljednja komplikacija koju je bolesnik imao je perforacija crijeva, koja je uspješno kirurški sanirana. Liječenje dijalizom može značajno produljiti trajanje života i poboljšati kvalitetu života, ponekad daleko više od očekivanog u toj grupi bolesnika., Background and aim: the mortality of chronic kidney disease patients is very high. Patients on chronic renal replacement therapy are also et very high mortality risk. Nevertheless, by the advance in renal replacement therapy the surveillance of these patients could be long with reasonable quality of life. the present a patient on renal replacement therapy for more than 38 years. case history: our patient was born in 1946. twenty years later acute glomerulonephritis was diagnosed and he was treated with corticosteroid therapy for four years. despite treatment his renal function deteriorated and haemodialysis was started in 1974. at that time, the haemodialysis regime was 12 hours two time per week and kill dialyzer were used. bicarbonate dialysis was introduced in 1984. Last 15 years our patient is on the hemodiafiltration. the treatment by erythropoietin was started in 1993. during this 38 years, he received two cadaveric kidney transplants. the first transplantation was in december 1974 in our hospital. Few days after transplantation he get rejection and transplant kidney never functioned. after one month he get thrombosis of the graft and transplantectomy was performed. the second cadaveric transplantation was performed abroad in 1985. transplant kidney functioned only four days and fifth days urgent transplantectomy was performed. after these experience our patient decline any new kidney transplantation. first arteriovenous fistula was created at the time of start haemodialysis and was functional for 30 years. first arteriovenous graft was created after 30 years on the left forearm few years later on the left upper arm. Last graft has been in good function for six years. the last two years he has a central venous catheter. a subtotal parathyroidectomy was performed in 1983. after parathyroidectomy parathyroid hormone values were between 30 to 55 pmol/L, and the values of serum calcium and serum phosphate were in reference values . Last 15 years he had bone pain and before 10 years he had patlogical hip fracture. due to vascular disease he often had skin ulcers and infections, particularly on the both hands.very often he was treated by analgetics, sedatives, including opiates. Last severe complications was a bowel perforation, successfully treated by surgical intervention . social history: our patient graduated on the university. He is married and had one child. He has worked in the profession for several years. He was founder of association for dialysis and kidney transplant patients. Last twenty years he and colleagues conducted a private centre for haemodialysis. it was the first private centre in the country. conclusion: dialysis treatment sometimes can significantly prolong life, i.e. far more than expected in this group of patients and can offer appreciable quality of life.

Za većinu bolesnika presađivanje bubrega najbolje je nadomjesno liječenje kod bubrežnog zatajenja, no ono je često povezano s razvojem komplikacija. Vodeći uzroci završnog zatajivanja bubrega (šećerna bolest, arterijska hipertenzija i ateroskleroza), starenje dijalitičke populacije te širenje kriterija za prihvaćanje sve većeg broja primatelja i darivatelja organa značajno povećavaju morbiditet. U prvoj godini nakon presađivanja bubrega najčešći su uzroci gubitka presatka akutno odbacivanje, arterijska tromboza, primarna afunkcija presatka i smrt, dok se nakon prve godine najviše presadaka gubi zbog smrti bolesnika s funkcionirajućim presatkom te kronične nefropatije presatka. Prema podacima našeg centra (KBC Rijeka), tijekom proteklog 25-godišnjeg razdoblja srčanožilne bolesti su uzrokovale smrt u 44,8 % primatelja, infekcije u 20,1 % i zloćudni tumori u 8,4 % slučajeva, s time da u 17,5 % primatelja nije bio poznat uzrok smrti. U ovom radu opisane su najčešće komplikacije nakon presađivanja bubrega, načini njihovog otkrivanja i liječenja. Reakcija odbacivanja presatka zauzima značajno mjesto među uzrocima kronične nefropatije i gubitka funkcije presatka. Akutna reakcija odbacivanja uz današnje imunosupresivno liječenje javlja se u manje od 15 % bolesnika i većinom ima asimptomatski tijek, a porast koncentracije serumskog kreatinina je kasni i nespecifični pokazatelj. Radi ranog otkrivanja reakcije odbacivanja te drugih uzroka oštećenja presatka ispituju se metode imunosnog praćenja koje, pored određivanja protutijela usmjerenih protiv stanica presatka i biljega stanične aktivacije, uključuju prikazivanje gena te određivanje bjelančevina i metabolita u krvi, mokraći i bioptatu presatka. Ove metode mogle bi omogućiti individualizaciju imunosupresivnog liječenja i pravodobno liječenje komplikacija, a time i poboljšanje rezultata liječenja presađivanjem bubrega., Renal transplantation is the best replacement therapy for renal failure in most patients, but it is often associated with development of complications. The leading causes of end-stage renal failure (diabetes mellitus, arterial hypertension and atherosclerosis), aging of the population undergoing dialysis and widening of the acceptance criterias for both recipients and donors, significantly increase morbidity. During the first year after transplantation, most grafts are lost due to acute rejection, arterial thrombosis, primary graft non-function and death. After the first year, most grafts are lost due to death from other causes, but with a functioning graft, and chronic allograft nephropathy. According to the data collected in our institution during the last twenty-five years, cardiovascular diseases caused death in 44.8 % recipients, infection in 20.1 % and malignant tumors in 8.4 %, while in 17.5 % of cases, the cause of death was unknown. This paper addresses the etiology of the most common complications after renal transplantation. Acute allograft rejection is a significant cause of chronic nephropathy and graft loss. With available immunosuppressive treatments, it occurs in less than 15 % of patients, it is frequently asymptomatic and a rise in serum creatinine is a late and nonspecific marker. For early diagnosis of rejection and causes of graft damage, several methods of immune monitoring are investigated, including not only the determination of antibodies against the allograft and markers of cell activation, but also gene profiling and determination of proteins and metabolites in blood, urine and biopsy specimens. These methods could allow individualised immunosuppressive treatments and timely treatment of complications, leading to an improvement of results after renal transplantation.

Cilj: Analizirati broj bolesnika koji su započeli liječenje hemodijalizom u KBC-u Rijeka od 1966. do 2009. godine, njihovu dob i uzrok terminalnog bubrežnog zatajenja (TBZ). Metode: Retrospektivna opservacijska studija. Analizirali smo podatke iz medicinske dokumentacije. Rezultati: Liječenje hemodijalizom od 1966. do 2009. godine započelo je 1.336 bolesnika (813 muškaraca, 523 žene). Prvih pet godina liječenje hemodijalizom započinjalo je dva do pet novih bolesnika godišnje. Do 1985. godine broj novih bolesnika na liječenju hemodijalizom bio je 10 do 19 godišnje. Od 1986. do 1990. godine broj novih bolesnika iznosio je od 25 do 42 godišnje. Devedesetih godina broj novih bolesnika i dalje se povećavao (40 do 50 bolesnika godišnje). Od 2000. do 2007. godine novih bolesnika bio je od 50 do 60. Najveći broj novih bolesnika bio je 2005. godine (63 bolesnika). Prosječna životna dob bolesnika koji su započeli liječenje hemodijalizom 1966. godine iznosila je 29,5 godina. Tijekom godina bila je u stalnom porastu, da bi posljednjih godina dostigla skoro 70 godina. Sve je veći udio starijih bolesnika od 65 godina; 2005. godine oni su činili 65 % novih bolesnika. Posljednjih deset godina vodeći uzroci TBZ bila su dijabetička nefropatija i nefroskleroza, dok su to ranije bili glomerulonefritis i pijelonefritis. Zaključak: Broj novih bolesnika povećavao se do 2005. godine. Prosječna životna dob novih bolesnika u stalnom je porastu. Danas veliki udio čine bolesnici stariji od 65 godina. Vodeći uzroci TBZ posljednjih godina su dijabetička nefropatija i žilne bolesti bubrega., Aim. To analyze the incidence of hemodialysis, patient’s age and causes of endstage renal disease (ESRD) in the University Hospital Center Rijeka from 1966 to 2009. Methods. Retrospective, observation study of the patient’s medical records. Results. In the period from 1966 to 2009 hemodialysis was started in 1336 patients (813 men and 523 women). Until 1970, the number of new patients was from two to five. From 1971 till 1985 the number of new patients on hemodialysis year was from 10 to 19. From 1986 till 1990 the number of new patients was in the range of 25 and 42 per year. During nineties, the number of new dialysis patients was still growing up to 50 patients per year. From 2000 to 2007 the number of new patients was 50 to 60 per year. The largest number of new patients was in 2005 (63 patients). The mean age of the patients who started hemodialysis in 1966 was 29.5 years. Over the years mean age was growing steadily up to 70 years recorded in 2009. The proportion of elderly patients over 65 years increased by years and in 2005 their percentage reached 65 among new patients on hemodialysis. In last ten years, the leading cause of ESRD was diabetic nephropathy followed by nephrosclerosis. Earlier causes of ESRD were glomerulonephritis and pyelonephritis. Conclusion. The incidence of new patients increased until 2005. The mean age of new patients increased every year. Today, the largest proportion of patients are older than 65 years. The leading causes of ESRD today are diabetic nephropathy and nephrosclerosis.

Bubrežni presadak se u pravilu dobiva od genski neidentičnog darivatelja organa, što pobuđuje imunosni sustav primatelja na razvoj transplantacijske reakcije. Ova reakcija usmjerena je prvenstveno na strane MHC molekule, ali i na druge nepodudarne jake i slabe tkivne antigene. Intenzitet imunosnog odgovora određuju čimbenici darivatelja, prvenstveno izražaj nepodudarnih HLA antigena i prisustvo antigen predočnih stanica u presatku, dok je među čimbenicima primatelja najvažnija ranija senzibilizacija i razvoj protutijela na AB0 i HLA antigene. U ovom radu opisane su suvremene spoznaje o kliničkim značajkama i temeljnim imunosnim mehanizmima transplantacijske reakcije, koje čine osnovu za provođenje imunosupresivnog liječenja kod presađivanja bubrega., Renal transplants are usually received from geneically non-identical donors, which induces the recipient’s immune system to develop a transplantation reaction. This reaction is primarily directed against foreign MHC molecules, but also to other incompatible strong and weak tissue antigens. The intensity of the immune response depends on donor-dependent factors, primarily the expression of incompatible HLA antigens and the presence of antigen presenting cells in the allograft. Among recipient’s factors, the most important is an earlier sensitation and development of antibodies against AB0 and HLA antigens. In this paper we summarize the recent knowledge on clinical features and basic immune mechanisms of the transplantation reaction, which represents the basis for imunosuppressive treatment for renal transplantation.

Peritonejska dijaliza (PD) postala je dobro afi rmirana metoda integriranog liječenja završnog stupnja bubrežnog zatajenja. Ona ima prednost kao prva metoda dijaliti čkog liječenja jer se u usporedbi s hemodijalizom dulje održava ostatna bubrežna funkcija, čime se značajno poboljšava kvaliteta života i preživljavanje bolesnika. PD je neophodna kod male djece i bolesnika sa srčanožilnim komplikacijama, kao što su dijabeti čari i starije osobe. U ovom radu prikazani su važni klinički aspekti , prednosti i komplikacije liječenja PD. Usavršavanje tehnologije i uvođenje biokompati bilnih otopina za PD, te individualizacija dijaliti čkog liječenja značajno smanjuju morbiditet i mortalitet bolesnika sa završnim stupnjem bubrežnog zatajenja., Peritoneal dialysis (PD) is a well-established method for the integrated care of end-stage renal disease. It is advantageous to start with PD as the fi rst dialyti c method, because it preserves residual renal functi on bett er than hemodialysis (HD) which leads to a signifi cant improvement in the quality of life and pati ent survival. PD is necessary for small children and pati ents with cardiovascular complicati ons, as are diabeti cs and the elderly. This paper addresses important clinical aspects, advantages and complicati ons of PD treatment. Improvement of technology, introducti on of biocompati ble soluti ons for PD, and individualisati on of dialyti c treatment signifi cantly reduce morbidity and mortality in pati ents with end-stage renal failure.

Oko 30 % bolesnika s terminalnim stadijem kroničnog bubrežnog zatajenja (TBZ) koji se liječe dijalizom nalazi se na listi čekanja za transplantaciju bubrega od umrle osobe u Hrvatskoj. U većine ostalih bolesnika postoje kontraindikacije za transplantaciju. Glavni je uzrok sve starija životna dob bolesnika i zbog toga veća učestalost kardiovaskularnih bolesti, kao i šećerne bolesti. Prije uvrštavanja na listu čekanja, bolesnike s TBZ potrebno je opsežno i temeljito obraditi. Potrebno je liječiti prateće bolesti koje mogu utjecati na preživljavanje transplantata i preživljavanje bolesnika. Nakon uvrštavanja bolesnika na listu čekanja obavezno je ponovno učiniti pretrage i u slučaju pojave kontraindikacije za transplantaciju privremeno ili trajno brisati bolesnika s liste čekanja., Only one third of those patients with end-stage renal disease (ESRD) who received dialysis treatment in Croatia are registered on the waiting list for a cadaveric kidney transplant. For majority of patients transplantation is not possible because of various contraindications. The main reason is a steadily growing age and therefore higher incidence of cardiovascular disease and diabetes. Before including patients in the waiting list, potential kidney transplant recipients should undergo a rigorous selection and evaluation. It is necessary to treat concomitant diseases which can influence patient’s and transplant’s survival. After including patients on waiting list, it is obligatory to evaluate them and look for potential contraindications. In that case they have to be temporarily or permanently removed from the waiting list.