[Survival of hemodialysis patients aged 65 years and more: correlation of albumin, hemoglobin, cholesterol concentration and comorbid diseases]. / Prezivljavanje na hemodijalizi bolesnika starijih od 65 godina: povezanost koncentracije albumina, hemoglobina, kolesterola i pratecih bolesti.

UNLABELLED: Today, the elderly are a fast growing population. Ever more patients aged > or = 65 are starting dialysis treatment. It is understood the they are a special and more sensitive group, due to their age and comorbid diseases. The aim of the study was to analyze the correlation of albumin, hemoglobin, cholesterol concentration and comorbid diseases at the beginning of treatment on the survival of patients aged > or = 65 years. PATIENTS AND METHODS: Sixty-one patients starting hemodialysis (31 male and 30 female) were followed-up between January 1, 1995 and December 31, 1999. There survival was monitored until June 30, 2002. Study patients were divided in four groups according to years of survival: group 1--patients who died during the first year of treatment; group 2--patients who died in the second year of treatment; group 3--patients still alive in the third year up the fifth year of treatment; group 4--patients with >5-year survival. Group 1 had 17 patients (9 male and 8 female), mean age 71.4 +/- 4.3 years; group 2 15 patients (7 male and 8 female), mean age 71.2 +/- 3.9 years; group 3 25 patients (13 male and 12 female), mean age 70.3 +/- 4.4 years; group 4 four patients (two male and two female), mean age 71.0 +/- 5.0 years. There was no significant age difference among the groups. All patients received regular hemodialysis for 4 hours, three times per week. Cellulose diacetate membranes and bicarbonate dialysate were used in all patients. RESULTS: The mean albumin value (g/L) at the beginning of dialysis was 31.9 +/- 5.9* in group 1, 35.3 +/- 6.4 in group 2, 38.1 +/- 6.6 in group 3, 41.8 +/- 6.7* in group 4 (p=0.017). The mean hemoglobin (g/L) value at the beginning of dialysis was 81.1 +/-14.3* in group 1, 85.7 +/- 20.5 in group 2, 86.4 +/- 14.5 in group 3, and 97.2 +/- 6.2* in group 4 (p=0.021). The mean cholesterol value (mmol/L) at the beginning of dialysis was 4.7 +/-1.1* in group 1, 5.1 +/- 1.8 in group 2, 5.2 +/- 1.5 in group 3, and 5.1 +/- 0.7* in group 4 (p=0.072). The greatest number of comorbid diseases were recorded in patients surviving for one year (4.6 +/- 1.2) and lowest in those surviving for more than five years (1.5 +/- 0.6) (p=0.001). In group 1, 70.6% of patients had five and more comorbid diseases. In group 2, 3 and 4, there were no statistically significant changes in albumin, cholesterol and hemoglobin concentrations during the first six months. Cardiac and cerebrovascular diseases were the most common cause of death. DISCUSSION AND CONCLUSION: Accordingly, shorter survival of elderly patients on hemodialysis correlated with lower albumin and hemoglobin values at the beginning of treatment. Also, patients with shorter survival rates had lower cholesterol values, however, without statistically significant differences. During the six month period there was no significant albumin increase in study patients. Shorter survival was associated with higher comorbidity. It is concluded that patients having appropriate albumin, hemoglobin and cholesterol values on starting dialysis therapy have better prognosis.

[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.

[Work capacity in patients on hemodialysis]. / Radna sposobnost bolesnika na hemodijalizi.

The quality of life is considerably impaired in patients on regular hemodialysis has been changed. It is difficult to determine it because there are no general definitions or measuring instruments. There are objective and subjective components of the quality of life, one among them being occupational ability. During the progression of chronic renal disease (CRD) to terminal renal failure (TRF) physical activity of the patients becomes poorer. In this stage, their physical activity is by 40-60% below the value expected for the same healthy age cohort. The intention of this analysis was to determine occupational ability in patients on regular hemodialysis. The analysis included 161 patients on hemodialysis, 78 (48.5%) female and 83 (51.5%) male, mean age 61.2 +/- 13.1 years, and mean time on hemodialysis was 54 +/- 71.9 months. All patients filled-out a self-administered questionnaire on schooling and occupational ability. The cause of TRF was glomerulonephritis in 45 (26.8%), diabetes mellitus in 42 (26.3%), nephrosclerosis in 26 (16.1%), and pyelonephritis in 12 (7.4%) patients. Age distribution was as follows: 0-19 years 1 patient, 20-44 years 14 (8.7%); 45-64 years 64 (39.8%) and 65 years 82 (50.9%) patients. Educational structure: elementary school 65 (40.4%), secondary school 79 (49.1%), college 10 (6.2%), and university 6 (3.7%) patients. Occupational structure: retired 123 (76.4%), housekeeper 20 (12.4%), never employed 4 (2.5%), employed 10 (6.2%), unemployed 2 (1.2%), 1 child and 1 student. Among employed patients there were 7 men and 3 women. Their educational level was as follow: elementary school 1 patient, secondary school 8 patients, college 1 patient. At the beginning of hemodialysis their occupational status was: full-time employment 30 (18.6%) patients, part-time employment 1 patient, longer time on sick-leave payment (3.1%), retired 95 (59%), pupils and students 3, unemployed 2, and 1 child did not attended school. Time interval between the beginning of hemodialysis and retirement was: less than 1 year work 13 (36.1%) patients, 1-2 year work 6 (16.7%), three year work 2 patients, more than 8 year work 2 patients, and 10 year work only 3 patients, for 14, 18 and 26 years each. Two patients lost their job for employer bankruptcy. The judgment of patients regarding their occupational ability was as follows: out of 161 patients, 23 (14.3%) felt fit for work, 12 on full-time and 11 on part-time basis. Occupationally incapable were 46.6% of patients, and 63 felt unable to take care of another person. Some kind of additional activity, like working in garden or taking care of children was reported by 26 patients. The aforementioned results showed that 22.4% of the patients were occupationally active at the time of starting hemodialysis. Many patients were retired after hemodialysis had started. Only 6.2% of hemodialysis patients were occupationally active although 14.3% felt occupationally capable. The main reasons for such a low level of employment were advanced age, diminished physical activity due to the disease, and difficulties associated with the socioeconomic situation in the country.

[Incidence of chronic renal failure during 35 years at the Rijeka Clinical Hospital Center]. / Incidencija kronicnog bubreznog zatajenja tijekom 35 godina u Klinickom Bolnickom Centru Rijeka.

Chronic hemodialysis treatment in the world started in 1960. At that time, due to technical development and construction of arteriovenous shunt for repeated blood access for dialysis, it was possible to treat uremia. At the Department of Surgery, Rijeka Clinical Hospital, former Dr. Zdravko Kucic Hospital, first hemodialysis was performed in 1962, whereas regular chronic dialysis treatment started in 1966. On September 20, 1966, the first hemodialysis was done in a patient with chronic uremia. A week later, the next patient was admitted for therapy. The aim of the study was to analyze demographic and other data of all patients who started dialysis in the period between 1966 and 2001. There were 910 patients, 555 (60.9%) male and 355 (39.1%) female. In the first year, only two patients were treated with hemodialysis. Until 1970, the number of new patients was 4 or 5. From 1971 till 1984 between 10 and 19 new patients started dialysis every year, and from 1985 till 1990 their number ranged from 23 to 34 per year. Further increase in the number of treated patients was recorded in 1990 when 42 patients were dialyzed. In the following years until 2001 the figures were between 40 and 58, and in 2001 55 new patients were treated. In 1966, the mean age of patients undergoing this therapy was 29.5 years, and with time it increased to 40 in 1978. From 1989 on, the mean age rose to 50, and from 1998 to 60. In 2001, the mean patient age was 63.2 years. The primary renal diseases that led to uremia in the study population were glomerulonephritis (GN) in 256 (28.1%), pyelonephritis (PN) in 165 (18.1%), diabetes mellitus (DM) in 161 (17.7%), nephrosclerosis in 111 (12.2%), uremia after transplanted kidney rejection in 47 (5.2%), polycystosis in 40 (4.4%), lupus nephritis in 12 (1.3%), other causes in 89 (9.7%), and unknown cause in 24 (2.6%) patients. The distribution of primary renal disease during the observed period was as follows: from 1966 till 1979 the cause of uremia was GN in 88 (62%), PN in 30 (21.1%), DM in only 1, polycystosis in 3, post-transplant uremia in 7, lupus in 3, and other causes in 7 patients. From 1980 to 1989, GN was the cause of uremia in 67 (31.6%), PN in 45 (21.2%), DM in 22 (10.4%), nephrosclerosis in 26 (12.3%), polycystosis in 11 (5.2%), post-transplantation uremia in 12 (5.7%), lupus nephritis in 8 (3.8%), other causes in 17 (7.9%) and unknown cause in 3 (1.9%) patients. During the 1990-2001 period, GN was recorded in only 101 (18%), PN in 90 (16.2%), DM in 138 (24.9%), nephrosclerosis in 82 (14.7%), polycystosis in 26 (4.7%), post-transplantation uremia in 28 (5.0%), lupus nephritis in 6 (1.1%), other causes in 65 (11.7%) and unknown cause in 20 (3.6%) patients. The mortality was caused by cardiac disease in 50.4%, cerebrovascular disease in 14.8%, infectious disease in 13.2%, malignancy in 7.5%, high potassium in 5.1%, gastrointestinal disease in 3.5%, other vascular diseases in 1.6%, cachexia in 1.3%, loss of blood access in 0.8%, other reasons in 1.1% and unknown reasons in 0.5% of patients. The results clearly indicate that the number of new patients grew and the mean patient age increased every year. Diabetes mellitus was the leading cause of uremia while GN and PN were less common. The main causes of death were cardiovascular diseases.

[Acute renal failure in patients undergoing cardiac surgery]. / Akutno zatajenje bubrega u bolesnika podvrgnutih kardiokirurskom zahvatu.

UNLABELLED: Acute renal failure (ARF) is an unusual and severe complication which may occur in patients following cardiac surgery. The incidence of ARF is from 1% to 15% (according to some authors up to 40%). The ARF, occurring in the postoperative period and requiring dialysis is an important risk factor for early mortality, while the overall mortality due to this complication is as high as 40% (40% to 90%). AIM: The aim of this study was to assess the incidence of ARF in patients undergoing cardiac surgery at our hospital from January 1, 2001 to June 1, 2002 and to compare it with the data obtained at the same institution and published 17 years ago. METHODS: A total of 290 patients undergoing cardiac surgery were analyzed, 71 (24.5%) female and 219 (75.5%) male, mean age 61.1 (range 17-81) years. Exclusion criteria were death within a few hours of surgery and need of chronic hemodialysis prior to surgery. ARF was defined as doubling of serum creatinine (sCr) concentration with preoperative sCr concentration below 130 micromol/L, or sCr increase by 100 or more micromol/L after cardiac surgery. Age, sex, type of surgery, preoperative sCr and preoperative risk factors (hypertension, diabetes mellitus, hyperproteinemia, pulmonary disease, peripheral vascular disease, central vascular disease) as well as complications occurring during the operation and their influence on ARF were analyzed. The incidence of ARF, therapy and mortality were also analyzed. RESULTS: Ischemic cardiac disease was present in 236 (81%) and valvular disease in 41 (14%), ventricular or atrial septal defect in 6 (2%), thoracic aortic aneurysm in 3 (1%), patent ductus arteriosus in 2 (0.7%) patients, and pericardial tumor and penetrant pericardial injury in 1 (0.36%) patient each. Arterial hypertension was present in 199 (68.6%), hyperlipoproteinemia in 194 (66.8%), diabetes mellitus in 76 (26.2%), cardiac arrhythmias in 39 (13.45%), cerebrovascular diseases in 32 (11.0%) previous, renal diseases in 25 (8.6%), chronic obstructive lung disease in 23 (7.9%) patients, peripheral vascular disease by 19 (6.6%) patients, thyroid disease by 8 (3.1%), and malignant disease in 5 (7.1%) patients. Renal function according to sCr was as follows: <79 micromol/L in 90 (31.0%), 80 to 99 micromol/L in 124 (42.7%), and 100-129 micromol/L in 58 (20%), 130-159 in 10 (3.4%), and >160 micromol/L in 4 (1.4%) patients. ARF developed in 8 (2.1%) patients who had undergone cardiac surgery. Among them, only one (0.3%) patient needed dialysis treatment (hemodialysis and continuous venovenous hemofiltration). There were no differences in sex distribution between the patients who developed ARF and those who did not. The patients who developed ARF were older, mean age 65.7 years. Most of the patients with ARF suffered from hypertension, diabetes mellitus and hyperlipoproteinemia. Seventy-five percent of patients who developed ARF had some kind of "surgical" complications: postoperative bleeding with developing hemorrhagic shock, myocardial infarction during the operation, or acute abdomen after the operation. CONCLUSION: The incidence of ARF in patients undergoing cardiac surgery was low (2.1%). The incidence of severe ARF (which must be treated with dialysis) was 0.3%. We compared the data obtained at our hospital with those obtained 17 years ago and found a reduction in the incidence of severe ARF after cardiac surgery (0.3% vs. 4%).

[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.