Urothelial cancer in patients with Endemic Balkan Nephropathy (EN) after renal transplantation.

GOAL: Analysis of the incidence of urothelial cancer and outcome of treatment in patients with Endemic Balkan Nephropathy (EN) after renal transplantation. METHODS: From January 1985 until October 2006, 550 kidney transplantations (389 cadaveric) and 5 combined kidney and pancreas transplantations were performed in University Hospital Center Rijeka. In only 6 (1.1%) of 555 transplant recipients, EN was diagnosed as the original kidney disease, based on medical history, clinical findings, and laboratory results, but without pathohistologic verification. All patients with EN received the first renal transplant from a cadaver. Patients' mean age at transplantation was 50.3 +/-15.9 yrs, five patients (83.3%) were male. The incidence of malignant tumors in all 555 transplant recipients was analyzed, with an emphasis on the incidence of urothelial cancer and outcome of treatment in the group of patients with EN. RESULTS: During posttransplant follow-up period, malignancy was diagnosed in 27 (4.9%) out of 555 transplant recipients. Skin cancer was diagnosed in 7 patients (1.3%), followed by cancer of the urinary tract in 6 patients (1.1%) and breast cancer in 3 patients (0.5%). In 3 of 6 patients with EN, urothelial cancer was diagnosed, resulting in the death in two patients. In the third patient, urothelial cancer showed a high affinity for recurrence, and besides the strong reduction of immunosuppressive therapy, repeated surgical treatment was needed. CONCLUSIONS: Patients with EN show a high incidence of urothelial cancer after renal transplantation. A thorough nephro-urological evaluation is needed before transplantation, and a careful follow-up is required afterward to ensure an early diagnosis of malignancy. Preventive nephroureterectomy is recommended.

Cardiovascular risk factors and diseases strongly predict hemodialysis treatment outcome in maintenance hemodialysis patients.

AIM: To identify independent predictors of hemodialysis treatment outcome among major cardiovascular risk factors and pre-existent cardiovascular diseases in maintenance hemodialysis patients with the end-stage renal disease. METHODS: A total of 144 prevalent patients on maintenance hemodialysis at Rijeka University Hospital between 1998 and 2003 were included in the prospective clinical study. Pre-existent cardiovascular risk factors and diseases were identified, as well as their relation to hemodialysis treatment outcome. Primary outcome measure was death, and secondary outcome measure was the length of time from the beginning of patient's hemodialysis treatment to the end of follow-up, ie, end of the study or patient's death. The independent variables on hemodialysis treatment outcome were identified with the multiple linear regressions. RESULTS: Cardiovascular diseases were the major cause of death in 40 (60.6%) patients. Acute myocardial infarction in 15 (22.7%) patients was the major single cause of death. Among risk factors, hyperglycemia (P<0.001), low delivered dialysis dose (P<0.001), use of semi-synthetic dialysis membrane (P<0.001), and anemia (P=0.041) were independent predictors of hemodialysis treatment outcome. Hypertensive heart disease (P<0.001), ischemic heart disease (P<0.001), and dilated cardiomyopathy (P=0.016) were independent predictors of the hemodialysis treatment outcome. CONCLUSIONS: Cardiovascular diseases were the leading cause of death in hemodialysis patients. There was also high prevalence of cardiovascular risk factors and pre-existent cardiovascular diseases. Several of them were independent predictors of the hemodialysis treatment outcome.

Assessment of hemodialysis adequacy by ionic dialysance: comparison to standard method of urea removal.

BACKGROUND: The hemodialysis adequacy is one of the most important issues influencing the survival of patients on maintenance hemodialysis (HD). Assessment of measuring the delivered dialysis dose using clearance x time/volume (Kt/V) index requires multiple blood sampling. New methods for assessment of dialysis dose based on ionic dialysance (ID) have been suggested. Online conductivity monitoring (using sodium flux as a surrogate for urea) allows the repeated noninvasive measurement of Kt/V on each HD treatment. In this study we have compared this method with the standard method of estimating Kt/V. METHODS: We studied 24 established HD patients over a 4 week time period. Patients were dialyzed using Fresenius 4008S dialysis monitors, equipped with modules to measure ID. Data were manually collected and analyzed using the appropriate statistical software. Urea removal (UR) was measured once a week by a two-pool calculation, estimating an eKt/V. RESULTS: The Kt/V measured by ID highly correlated with the one derived from the measurement of the UR (r=0.8959, p< 0.0001). The ID underestimated UR by the mean of 6%. The ID varied greatly within individual patients with a median of 1.29 +/- 0.22. If the eKt/V > or = 1.2 is considered adequate, 33% of the patients would have been inadequately dialyzed. The mean HD duration to achieve an adequate dialysis was 4 hours and 47 minutes with high interpatient variability. CONCLUSION: The ID seems to be an easily obtained measure of the delivered dialysis dose, correlating well with standard UR method. Substantial individual variations imply that repeated measures (ideally for all treatments) are necessary to obtain a real answer to the mean treatment dose being delivered to the patients.

[Development of peritoneal dialysis at Rijeka Clinical Hospital Center]. / Razvoj peritonejske dijalize u Klinickom bolnickom centru Rijeka.

The dialysis population is steadily rising as a consequence of the growing incidence of terminal renal failure patients and lack of organs for transplantation. Peritoneal dialysis (PD) has become an established form of renal replacement therapy. The development of new methods, techniques, PD fluids and catheters has significantly lowered the incidence of complications and increased the use of PD throughout the world. The development of PD at Rijeka University Hospital Center, the incidence of PD patients, their underlying renal disease leading to terminal renal failure, demographic characteristics of patients, complications of treatment, and causes of discontinuation of PD treatment are described. At Rijeka University Hospital Center, PD was introduced in 1963 in patients with acute renal failure (ARF), and in 1965 in patients with chronic renal failure (CRF). Until June 2002, 149 patients were treated, 71 with ARF and 78 with CRF. Continuous peritoneal dialysis was introduced at our hospital in 1978. An increasing number of patients on continuous ambulatory peritoneal dialysis (CAPD), altogether 35, was noticed in 1999. Automated peritoneal dialysis (APD) was introduced in January 2001. Five patients were treated with this method until June 2002. The most common underlying renal diseases in patients treated from January 1999 until June 2002 were diabetic nephropathy in 13 (37.1%) and glomerulonephritis in 11 (31.4%) patients, mean age 55.5 years, range 31-75 years, both sexes equally present. The leading cause of complications were infections and the main cause of death was cardiovascular disease. Five (14.3%) patients received kidney transplants which have been functioning well in all of them. Because of the high incidence of complications during the seventies, intermittent peritoneal dialysis (IPD) was used only occasionally. A significant increase in the number of patients on CAPD was observed in 1999. By the end of 2001 almost ten percent of patients receiving dialytic treatment were on CAPD. The most common complications were peritoneal catheter exit site infection and peritonitis, which caused referral to HD treatment in four (11.4%) and death in two (5.7%) patients with impossible vascular access. The knowledge and availability of different renal replacement therapies allow the choice and application of the most appropriate treatment option in individual patients with terminal renal failure. In comparison to HD, PD improves the quality of patient's life and decreases mortality in the first years of treatment. Patients with cardiovascular disease and diabetes, whose incidence is steadily rising, have a higher incidence of complications on hemodialysis treatment. In these patients PD is preferred, especially if used as the first dialytic treatment modality. PD has also provided a means of managing patients with no possibility for vascular access for HD treatment. Infective and mechanical complications are the main obstacles during PD treatment. Adequate facilities, equipment, educated and well-trained medical personnel and appropriate selection and thorough education of patients are necessary for a successful PD program.

[Value of urinary sediment cytology in evaluation of acute tubular necrosis after kidney transplantation]. / Vrijednost citologije sedimenta mokrace u evaluaciji akutne tubularne nekroze nakon transplantacije bubrega.

AIM: The aim of the study was to assess the clinical value of urinary sediment cytology (USC) by use of phase-contrast microscopy in the evaluation of acute tubular necrosis (ATN) during the early period after kidney transplantation. The study was performed at the Cytology Laboratory, Department of Nephrology and Dialysis, Clinical Hospital Center Rijeka, Croatia. PATIENTS AND METHODS: Patients included 141 kidney recipients, 99 male and 42 female, mean age 40 +/- 13 (range 8-72) years, who had received kidney allograft during the period of ten years, and who were treated at the University Department of Internal Medicine, Rijeka Clinical Hospital Center. The majority of patients (76%) had received cadaveric kidneys. Urinary sediment was analyzed for the presence of renal tubular cells, isomorphic erythrocytes, lymphocytes, casts and debris. Renal tubular cells on USC were recognized as the most constant sign of ATN. The presence of lymphocytes should arise suspicion of rejection. MAIN OUTCOME MEASURES: A typical cytologic profile of acute tubular lesion consists of tubular cells, isomorphic erythrocytes, casts, cellular and/or amorphic debris. RESULTS: USC by use of phase contrast microscopy is confirmed as a method of a very high sensitivity (82%) and specificity (93%) in the evaluation of ATN in transplanted kidney patients during early post-transplantation period. In situations of coexistence of several causes of allograft dysfunction, "mixed" cytologic pictures were frequently created, from which it is difficult or almost impossible to identify the actual cause of kidney dysfunction. In these cases, the final judgment should be made solely by histologic evaluation, which still represents the gold standard in the evaluation of kidney allograft dysfunction. CONCLUSION: Serial USC, when thoroughly examined using phase-contrast microscopy, is a simple, noninvasive, fast, easily repeatable and inexpensive diagnostic method of high sensitivity and specificity in the evaluation of ATN during the early phase after kidney transplantation.

[Clinical use of phase-contrast microscopy in the differential diagnosis of microhematuria]. / Klinicka primjena mikroskopije s faznim kontrastom u diferencijalnoj dijagnostici mikrohematurije.

AIM: To evaluate phase-contrast microscopy in differential diagnosis of asymptomatic microhematuria in patients with asymptomatic microhematuria during the 1993-2000 period. PATIENTS AND METHODS: The study was performed at the Laboratory of Cytology, Department of Nephrology and Dialysis, Rijeka University Hospital Center, Rijeka, Croatia, and included 526 patients with asymptomatic hematuria referred from Urology Department. MAIN OUTCOME MEASURES: Presence of red blood cells (RBC), other cell types, other elements, and detritus. According to size and shape, RBCs were classified into 2 main categories: dysmorphic and isomorphic RBCs. The presence of > 80% of dysmorphic RBCs was recognized as glomerular hematuria. Isomorphic cell predominance was classified as postglomerular hematuria, and equal presence of both types was considered as mixed hematuria. RESULTS: Glomerular hematuria was found in 238 (45.2%), postglomerular hematuria in 181 (34.4%) and mixed hematuria in 22 (4.2%) patients. Additional diagnostic procedures in patients with glomerular hematuria included renal biopsy. In 89% of those patients glomerular disease was found. CONCLUSION: Phase-contrast microscopy is a simple, noninvasive and reliable diagnostic procedure in nephrology practice.

[Evaluation and selection of candidates for renal transplantation at the Clinical Hospital Center in Rijeka]. / Ispitivanje i odabir kandidata za transplantaciju bubrega u Klinickom bolnickom centru Rijeka.

On December 31, 2001, 2486 patients with terminal renal failure received dialysis treatment in Croatia. Only one third of the patients are registered on the national waiting list for cadaveric kidney transplant. In most of the others, transplantation is impossible because of comorbidity. This is mainly due to the steadily growing age of the dialytic population and therefore a higher incidence of cardiovascular disease and diabetes. Still, evaluation of the potential recipients of cadaveric kidney transplant, registered on the waiting list, often reveals contraindications for transplantation. The aim of this study was to determine the incidence and type of contraindications in transplant candidates, found during immediate preoperative evaluation. Analysis of these data should help in determining how contraindications can be early detected and prevented. Before registering onto the national waiting list transplant candidates need to be thoroughly investigated including detailed history, physical examination, routine diagnostic procedures and additional examinations, if needed, to exclude or evaluate the possibly existing contraindications for transplantation. During the period from January 1997 until June 2002, 145 potential recipients from the national waiting list were referred to the Rijeka University Hospital Center and evaluated for kidney transplantation. Eighty-eight patients underwent transplantation. Preoperative evaluation revealed contraindications for transplantation in 52 (35.9%) candidates. Twenty-two (15.2%) patients had a positive cross-match with donor lymphocytes, 6 (4.1%) patients refused transplantation, and in 24 (16.6%) patients serious comorbidity was the reason for not being accepted for transplantation and for their withdrawal from the national waiting list. Comorbidity was mainly due to cardiovascular disease (12 patients--8.3%) and infection (8 patients--5.5%). These data show a high incidence of contraindications found during the immediate preoperative evaluation of potential kidney recipients. It was the case in more than one third of patients. During the evaluation of potential candidates for kidney transplantation special attention should be addressed to the presence of cardiovascular morbidity and infection. Peripheral vascular occlusive disease, cardiac status and/or cerebrovascular disease should be evaluated. Measures used to treat or reduce the development of complications include an optimal control of blood pressure, serum phosphate, hyperparathyroidism, dyslipidemia, and renal anemia. The sites of infection must be treated and eradicated, because immunosuppressive treatment is a threat to the transplant recipient's life. The second most common cause of refusal of potential candidates was a positive cross-match with donor lymphocytes. Sensitization to human leukocyte antigens can be prevented by the avoiding of blood transfusions and use of erythopoietin in treating renal anemia. To minimize the morbidity and mortality, the potential kidney recipients should undergo rigorous selection and thorough evaluation before including them into the waiting list for kidney transplantation. Afterwards, regular examinations are obligatory to reveal contraindications, proceed to medical interventions and treat concomitant diseases in time, which can influence the patient's survival. In case that contraindications for transplantation arise, the patient must be temporarily or definitely removed from the waiting list.