Detection of myocardial ischemia in diabetic patients: the limitations of myocardial perfusion imaging.

In the study of 286 patients with suspected coronary artery disease and recent exercise single photon emission computed tomography (SPECT) test, we performed coronary angiography with coronary fractional flow reserve (FFR) measurement and tested the differences between diabetic (103) and non-diabetic (183) patients in ischemia detection by this two methods. The diabetic patients had a higher prevalence of hypertension, higher BMI and cholesterol levels, as well as longer duration of hospitalization than non-diabetic patients. There was no difference found between groups according to the exercise SPECT test, but, there were significantly more negative results in the non-diabetic group than in the diabetic group according to the FFR test, also, the percentage of stenosis was higher in diabetic patients. The concordance between the two methods was found, it was fair in diabetic patients (kappa = 0.25, 95% C.I. 0.06-0.45) and moderate in non-diabetic patients (kappa = 0.49, 95% C.I. 0.36-0.62).

Acute renal failure due to pericardial tamponade in a 60-year-old male patient.

Acute renal failure (ARF) is still a considerable factor in hospital morbidity and mortality. This clinical condition occurs in up to 25% of critically ill patients. Mortality in these patients varies widely depending on the cause. ARF in the context of a large pericardial effusion and pericardial tamponade has not often been reported. This paper presents a case of life-threatening pericardial tamponade and a consecutive rapid onset of ARF. Successful treatment with pericardiocentesis was performed, which was followed by restitution of renal function.

Influence of the type and degree of left ventricular hypertrophy on the prevalence of ventricular arrhythmias in patients with hypertensive heart disease.

PURPOSE: To investigate the correlation between the prevalence of ventricular arrhythmias (VA) and the type and degree of left ventricular hypertrophy (LVH) in hypertensive patients using exercise testing and Holter monitoring. PATIENTS AND METHODS: A total of 192 patients (87 men and 105 women) without coronary disease were divided into three groups according to type of LVH (concentric, eccentric, and asymmetric) and three subgroups in relation to the degree of hypertrophy (mild, moderate, and severe). In all subjects blood pressure was measured, electrocardiographic and echocardiographic data obtained and the prevalence of VA determined by Holter monitoring and bicycle ergometry. RESULTS: The most frequent LVH type was the concentric (63%), followed by eccentric (28%) and asymmetric (9%). Severe LVH was found in 10% of patients. Complex VA during Holter monitoring were identified in > 40% of patients. During the stress test this percentage increased by additional 7.4%. There was no statistically significant difference between groups in frequency of simple (p = 0.757) and complex (p = 0.657, p = 0.819, p = 0.617, for polytopic, pairs and ventricular tachycardia, respectively) VA. Increased prevalence of VA was found for the moderate and severe degree in all types. In the concentric type the difference was statistically significant for simple VA (p = 0.042). CONCLUSION: : There was no correlation between type of LVH and prevalence of VA. The severity of hypertrophy contributes more to a greater prevalence of VA than the LVH pattern. The combination of severe degree and concentric type carries the greatest cardiovascular risk.

Comparison of survival between diabetic and non-diabetic patients on maintenance hemodialysis: a single-centre experience.

We analyzed survival rates of 144 prevalent patients on maintenance hemodialysis from 1998 to 2003 at the Department of Nephrology and Dialysis, Rijeka University Hospital, Rijeka, Croatia, and evaluated risk factors predicting their survival. Included were only end-stage renal disease (ESRD) patients on maintenance hemodialysis treatment dialysed more than 6 months before entering the study and who were clinically stable. The patients were randomised in two groups according to the presence or absence of diabetic nephropathy as the cause of ESRD and followed-up. The patient's death as outcome measure was recorded. The survival rates were estimated by the Kaplan-Meier method. The major causes of death were cardiovascular disease in 40 (60.6%) patients. An acute myocardial infarction in 15 (22.7%) patients was the major single cause of death. We found a significantly lower survival of diabetic patients than non-diabetic patients (P=0.0013). The most important predictors of death among diabetic patients on maintenance hemodialysis were hyperglycaemia (P<0.001), ischemic heart disease (P=0.004), hypercholesterolemia (P=0.013), and low delivered dialysis dose (P=0.013). The survival of diabetic patients undergoing hemodialysis was much worse than survival of non-diabetic patients. The cardiovascular disease remained the major cause of death in both groups. Early detection of pre-existing cardiovascular risk factors and diseases, and treatment of infections leading to sepsis, are of great importance, as they may influence the survival rates. Intensive management of diabetic patients is essential.

C-reactive protein is a strong predictor of mortality in hemodialysis patients.

BACKGROUND: To establish the baseline cutoff value of C-reactive protein (CRP) that would predict increased overall and cardiovascular mortality in patients with end-stage renal disease (ESRD). METHODS: A cohort of 270 prevalent hemodialysis patients treated at Rijeka University Hospital was eligible for the study. Monthly CRP measurements were performed for three consecutive months. Only the patients with CRP values varying <20% were included (n=256). During the follow-up, 24 patients were transplanted and therefore excluded from the analysis. The CRP cutoff point of 6.2 mg/L was established by Receiver Operating Characteristic curve. The patients were divided into four groups according to their CRP values. Group 1 included 80 (34.5%) patients with CRP <3.0 mg/L, group 2 included 23 (9.9%) patients with CRP 3.0-6.1 mg/L, group 3 consisted of 18 (7.7%) patients with CRP 6.2-10.0 mg/L, and group 4 included 111 (47.9%) patients with CRP >10.0 mg/L. The survival was evaluated by Kaplan-Meier curve. RESULTS: During the two-year follow-up, 59 patients died. The major cause of death was cardiovascular disease (64%). Significantly higher overall and cardiovascular mortality was observed in group 3 when compared with groups 1 and 2 (chi2=11.97; P < 0.001) and in group 4 when compared with groups 1 and 2 (chi2=14.40; P<0.001). Compared with survivors, non-survivors had a higher median CRP value (19.0 [1.5-99.7] mg/L vs. 2.3 [0.1-49.1] mg/L, respectively; P<0.001). CONCLUSION: Serum concentration of CRP above 6.2 mg/L is a strong predictor of overall and cardiovascular mortality in patients with ESRD.

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.

Characteristics of blood-pressure control in treated hypertensive patients in Croatia.

The aim of our study was to investigate blood pressure (BP) control and different factors with possible influence on BP control in Croatian hypertensive patients. In this cross-sectional investigation, a representative sample of target populations (primary care physicians and patients) from different parts of Croatia was included according to the study protocol. During December 2003 and January 2004, we included, according to correctly completed questionnaires, 141 physicians and 814 hypertensive patients. A controlled BP (BP < 140/90 mmHg) in this hypertensive population treated with antihypertensive drugs was in 23% of patients. The analysis of BP control according to risk factors showed that significantly related with higher levels of systolic or diastolic BP were the age (poorer systolic BP control in patients older than 60 years), left ventricular hypertrophy, changes of the eye retina, smoking and diabetes mellitus. Furthermore, patients from towns closer to the hospital, from urban centers, with higher education and employed had significantly lower average BP. According to our results of hypertension control in Croatia, there is a need and a possibility for the improvement of the quality of hypertension care. The relationship between demographic and cardiovascular risk factors with poor BP control should be taken into account when treating patients.

Permanent left atrial electromechanical dissociation after conversion of atrial fibrillation in a patient with interatrial block.

In a 52-year-old woman, pharmacological conversion to sinus rhythm was achieved after 31 days of atrial fibrillation. In spite of permanent sinus rhythm, even 7 months after the conversion, no mechanical left atrial activity was restored, although right atrium showed normal contractility.

[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.