88 research outputs found
The effect of pretransplant dialysis modality on the outcome of renal transplantation
No full textUvod: Kronična bubrežna bolest je globalna bolest koja prvenstveno zahvada stariju populaciju te predstavlja veliki financijski trošak za svaki zdravstveni sustav. Liječenje kronične bubrežne bolesti se provodi putem dijalize ili transplantacijom bubrega. Cilj istraživanja je vidjeti povezanost tipa dijalize prije transplantacije na ishod transplantacije bubrega. Ispitanici i metode: U ovu retrospektivnu studiju su uključeni svi primatelji bubrega, odnosno pankreasa i bubrega, u razdoblju od 2007. do 2013. godine u KB Merkur, Zagreb.
Rezultati: U istraživanje je uključeno 280 bolesnika (106 muškaraca i 174 žene). Od ukupnog broja transplantacija je učinjeno 229 transplantacija bubrega te 51 simultana transplantacija bubrega i gušterače. Prije transplantacije vedina bolesnika je bila na HD (207) dok ih je 63 bilo na PD. Prema Kaplan Meier krivulji preživljenja petogodišnje preživljenje svih bolesnika iznosi 82.9 % dok preživljenje grafta iznosi 78.5%. U odnosu na tip dijalize prije transplantacije nije bilo statistički značajne razlike u preživljenju bolesnika (p=.09), preživljenju bubrega (p=.19) te u preživljenju grafta cenzuriranom za smrt bolesnika (p=.16). Incidencija svih infekcija u prva tri mjeseca nakon transplantacije je iznosila 58.9% od čega su urinarne infekcije činile gotovo 50% svih infekcija. U odnosu na tip dijalize prije transplantacije nije bilo statistički značajne razlike u incidenciji infekcija. Iako je u univarijatnoj analizi tip dijalize prije transplantacije bio jedan od čimbenika koji su utjecali na vrijednost glomerularne filtracije isto se izgubio u multivarijatnoj analizi gdje su samo dob primatelja i darivatelja ostale statistički značajne varijable koje utječu na funkciju bubrega 6 i 12 mjeseci nakon transplantacije. Prosječna cijena transplantacije bubrega je iznosila 85.85±41.67 tisuda kuna, dok je za SPKT iznosila 111.84±89.20 tisuda kuna (p= .02). Nije bilo statistički značajne razlike u cijeni transplantacije u odnosu na tip dijalize prije transplantacije. Odgođena funkcija grafta, smrt bolesnika, vrsta transplantacije te preživljenje grafta cenzuriranog za smrt bolesnika su statistički značajne varijable povezane s cijenom transplantacije.
Zaključak: Vrsta dijalize prije transplantacije ne utječe na preživljenje bolesnika i grafta, pojavnost infekcija i vrijednost glomerularne filtracije nakon transplantacije te na cijenu same transplantacije. Peritonejska dijaliza je jeftinija od hemodijalize te je manje financijsko opteredenje za javnozdravstveni sustav. Zbog toga se PD treba promovirati u metodu prvog odabira, kada je u pitanju liječenje dijalizom, u svih bolesnika koji nemaju kontraindikaciju za njezino provođenje.Introduction: Chronic renal disease is a global disease that primarily affects the elderly population and represents a major financial expense for all healthcare systems. Chronic renal disease is treated by dialysis or kidney transplantation. The goal of the research is to discover the connection between the type of dialysis before the transplantation and the outcome of the kidney transplantation.
Test subjects and methods: This retrospective study includes all kidney recipients or pancreas and kidney recipients in the period from 2007. to 2013. at the University Hospital Merkur, Zagreb.
Results: The research included 280 patients (106 male and 174 female). Of the total number of transplantations, there were 229 kidney transplantations and 51 simultaneous kidney and pancreas transplantations. Before the transplantation most of the patients were on HD (207), while 63 of them were on PD. According to the Kaplan-Meier survival curve, the five year survival of all the patients is 82.9 % while the graft survival is 78.5%). Considering the type of dialysis before the transplantation, there was no statistically significant differences in the survival of the patients (p=.09), kidney survival (p=.19), and graft survival censored for death of the patient (p=.16). The incidence of all infections in the first three months after transplantation was 58.9%, and 50% of all the infections were urinary infections. Considering the type of dialysis before transplantation, there were no statistically significant differences in the incidence of infections. Even though the type of dialysis before the transplantation was one of the factors that affected the value of glomerular filtration in the univariate analysis, it was lost in the multivariate analysis, where only the ages of the recipient and the donor remained as statistically significant variables that affect the function of the kidneys 6 and 12 months after the transplantation. The average price of a kidney transplantation was HRK 85.85±41.67 thousand, and for SPKT it was HRK 111.84±89.20 thousand (p= .02). There was no statistically significant difference in the price of the transplantation considering the type of dialysis before the transplantation. Delayed graft function, death of the patient, type of transplantation, and graft survival censored for death of the patient are statistically significant variables connected to the price of the transplantation. Conclusion: The type of dialysis before transplantation does not affect the survival of the patient and the graft, the incidence of infections, the value of glomerular filtration after the transplantation, or the price of the transplantation itself. That is why PD should be promoted as the first choice method for dialysis treatment of all the patients that do not have contraindications for its use
The impact of delayed graft function on progression of chronic histological changes in transplanted kidney
No full textUvod: Odgođena funkcija presatka (OFP) mainfestacija je akutne bubrežne ozljede koja nastaje kao poslijedica
ishemijsko reperfuzijskog oštećenja. Obično je definirana kao potreba za dijalizom u prvih
7 dana nakon transplantacije. Cilj ovog istraživanja bio je analizirati povezanost OFP-a s
progresijom fibroze u transplantiranom bubregu.
Metode i materijali: Istraživanje je bilo retrospektivno. Uključeno je 163 konsekutivna bolesnika kod kojih je učinjena
transplantacija u našem centru od 2007. do 2014. godine. Isključeni su bili bolesnici kod
kojih nisu učinjene protokolarane biopsije, 0 dan i 12 mjeseci nakon transplantacije te oni s
neadekvatnim uzorcima. Primarna mjera ishoda bila je progresija kroničnih histoloških promjena
u transplantiranom bubregu u prvoj godini nakon transplantacije. Kao surogat marker kronične
ozljede presatka koristili smo složeni kronični histološki skor (SKS) i pojedinačne histološke
skorove ci i ct. Složeni kronični skor (SKS) sastojao se od zbroja pojedinačnih kroničnih skorova
prema Banff klasifikaciji, ci+ct+cv+ah (vrijednost skora od 0 do 12). Analizirali smo promjenu (Δ)
SKS-a u skupini sa i bez odgođene funkcije presatka (OFP) i promjenu (Δ) pojedinačnih skorova
u ovisnosti o OFP-u. Dodatno smo analizirali povezanost OFP-a s preživljenjem presatka i
bolesnika uključenih u našu skupinu.
Rezultati: Ukupno je bilo 60 bolesnika s OFP-om (36.8 %). Prosječno vrijeme praćenja bilo je 1665 ± 590 dana. SKS
je bio statistički značajno viši u svim biopsijama nakon 12 mjeseci (1.92 ± 2.16 u 0 biopsijama
vs. 3.56 ± 2.93 u biopsijama nakon 12 mjeseci, p<0.001). U univarijatnoj analizi OFP je bila
povezana sa SKS-om i njegovom promjenom (Δ). U multivarijatnoj analizi OFP nije bila povezana
sa SKS-om na 12 mjeseci (p=0.417), ali je bila povezana s promjenom SKS-a (Δ) (p=0.012). U
multivarijatnoj analizi OFP nije bila povezana s ci i ct na 12 mjeseci, niti s njihovom promjenom
(Δ). Preživljenje presatka i bolesnika bilo je podjednako u obje skupine, neovisno o OFP-u.
Zaključak: Kronična ozljeda presatka mjerena složenim kroničnim histološkim skorom, kao i pojedinačnim
kroničnim skorovima ci i ct samo se umjereno povećava u prvoj godini nakon transplantacije.
Čini se da OFP nije neovisni čimbenik rizika koji dovodi do progresije patohistoloških promjena
u presatku.Background and objectives: Delayed graft function (DGF) is a manifestation of acute kidney injury resulting from ischemia-reperfusion
injury. It has usually been defined as the need for dialysis within 7 days after transplantation.
Aim of our study was to evaluate effect of delayed graft function on the progression of fybrosis
in transplanted kidney after deceased donor kidney or kidney pancreas transplantation.
Methods and materials: Our study was retrospective. We included 163 consecutive patients transplanted in our center from 2007
to 2014. Kidney graft only, and kidney pancreas transplanted patients were included. Patients
without paired biopsies (day 0 and 12 moths postransplant) were excluded. The primary
outcome was the one year progression of chronic histology changes based on protocol biopses
performed on the day of transplantation and at 12 months postransplant. We used composite
chronic histological score as a marker of chronic allograft injury, and separate chronic scores
ci and ct. The composit score is a sum of Banff chronic scores ci,ct,ah and cv (therefore, score
value range 0–12). We analysed the distribution of the change (Δ score) in the composite score
between group of patients with and without delayed graft function on paired biopsies, and
distribution of change for separate scores. We also analysed impact of DGF on graft survival and
graft function in our cohort of patients.
Results: There were 60 patients with DGF (36.8%) in our cohort. Follow up was 1665 ± 590 days. Chronic
composite histological score were statisticaly significantly higher in all biopsies at 12 months
after transplantation (1.92 ± 2.16 at 0 biopsies vs. 3.56 ± 2.93 at 12 months biopses, p<0.001).
In univariate analysis DGF was correlated with composite chronic histological score and with
the change of the score (Δ). In a multivariate analysis DGF was not correlated with composite
chronic histological score at 12 months (p=0.417) but it was correlated with change of the score
(Δ) (p=0.012). DGF was not correlated with ci and ct at 12 months, and it was also not correlated
with change of ci and ct score (Δ). Graft and patient survival was similar in both groups.
Conclusion: Chronic allograft injury, as measured by a composite score and separate scores, ci and ct increased only
mildly in the first post-transplant year. Delayed graft function does not seem to be a major drive
of a chronic allograft injury during first post-transplant year
Chronic kidney disease afther liver transplantation - risk factor and etiology
No full textUvod: Kroniĉna bubreţna bolest (KBB) znaĉajna je komplikacija transplantacije jetre (TJ), koja utjeĉe na morbiditet i mortalitet bolesnika nakon transplantacije. Stoga je vaţno identificirati i modificirati faktore rizika koji negativno utjeĉu na bubreţnu funkciju. Hipoteza disertacije bila je da je KBB ĉesta nakon TJ i da je vodeći uzroĉni ĉimbenik nefrotoksiĉnost kalcineurinskih inhibitora. Ciljevi ovog rada bili su odrediti incidenciju novonastale KBB, identificirati faktore rizike, istraţiti kliniĉki tijek, te odrediti etiologiju novonastale KBB kod bolesnika nakon TJ.
Metode: Analizirano je 197 bolesnika kojima je u KB Merkur transplantirana jetra u razdoblju od 2005. do 2010. godine, koji nisu imali KBB prije TJ. KBB nakon TJ definirana je procijenjenom glomerularnom filtracijom (eGFR) <60 ml/min/1,73 m2 u trajanju od najmanje 3 mjeseca, koristeći Modification in Renal Disease (MDRD) formulu.
Rezultati: Većina bolesnika (50,3%) transplantirana je zbog alkoholne bolesti jetre. Veliĉina eGFR prije TJ pozitivno je korelirala s veliĉinom pada eGFR nakon TJ, tako da su veći pad doţivjeli bolesnici s višom eGFR prije transplantacije. Prosjeĉna eGFR svih bolesnika pogoršala se nakon transplantacije. Kumulativna incidencija novonastale KBB nakon TJ iznosila je 54,5% nakon 12 mj., 58,9% nakon 24 mj., 63,6 % nakon 36 mj. i 69,7%.nakon 48 mj. Multivarijatna analiza pokazala je da su neovisni ĉimbenici rizika za razvoj KBB nakon TJ: starija dob bolesnika, infekcija virusom hepatitisa C, stupanj bubreţne funkcije prije TJ i stupanj bubreţne funkcije u 1. mj. nakon TJ. Patohistološkom analizom 33 bioptiĉka uzorka bubrega bolesnika s KBB nakon TJ, više od polovice bolesnika (57,5%) imalo je kalcineurinsku (CNI) nefrotoksiĉnost, 24,2% primarnu bolest glomerula, a 15,2% hipertenzivnu nefropatiju. Kod bolesnika s KBB općenito, kao ni kod bolesnika s CNI nefrotoksiĉnošću nije naĊena korelacija izmeĊu eGFR i stupnja intersticijske fibroze i tubularne atrofije (IF/TA).
Zakljuĉak: KBB je ĉesta nakon TJ, a CNI nefrotoksiĉnost je njezin vodeći uzrok. S obzirom na izostanak korelacije izmeĊu IF/TA i eGFR, znaĉajna komponenta bubreţne disfunkcije je funkcionalna (vjerojatno vazokonstrikcijski uĉinak CNI). Duţim razdobljem praćenja moţe se oĉekivati daljnje povećanje uĉestalosti uznapredovalih stadija KBB nakon TJ, odnosno potreba za bubreţnim nadomjesnim lijeĉenjem u znaĉajnog broja bolesnika. Biopsija bubrega je nezamjenjivi alat u rasvjetljavanju etiologije KBB nakon TJ. Potrebno ju je rano uvrstiti u dijagnostiĉke algoritme bubreţne disfunkcije nakon TJ, jer se time omogućuje etiološka terapija, dok još kroniĉne histološke promjene u bubrezima nisu uznapredovale. S obzirom na CNI nefrotoksiĉnost kao vodeći uzrok KBB nakon TJ, potrebno je evaluirati imunosupresivne protokole s niţom ekspozicijom CNI-a.Background: Chronic kidney disease (CKD) is a significant complication after liver transplantation (LT) which affects patients’ survival. Therefore it is important to identify and influence risk factors that negatively affect kidney function. Hypothesis of the thesis is that CKD is frequent after LT and that calcineurin inhibitors (CNIs) are the major leading cause. The goals of this study were to determine incidence of newly developed CKD, to identify the risk factors, to investigate clinical course and to determine the etiology of CKD after LT.
Methods: Hundred and ninety seven liver recipients without preexisting CKD transplanted in KB Merkur between 2005. and 2010. were analyzed. CKD after LT was defined as decreased estimated glomerular filtration rate (eGFR) <60 ml/min/1,73m2 for at least three consecutive months using Modification in Renal Disease (MDRD) formula.
Results: Majority of recipients (50,3%) were transplanted due to alcoholic liver cirrhosis. The level of eGFR before LT correlated positively with the eGFR decline after LT, where the decline was more pronounced in patients with higher eGFR prior to LT. The mean eGFR of all recipients significantly deteriorated after LT. Cumulative incidence of newly developed CKD for 12, 24, 36 and 48 months after LT was 54,5%, 58,9%, 63,6 % and 69,7%, respectively. A multivariate Cox regression analysis revealed that overall risk of CKD development was associated with old age of recipients, hepatitis C virus infection, the level of kidney function before LT and the level of kidney function at 1 month after LT. Pathohistological analysis of 33 kidney samples revealed in majority of patients (57,5%) CNI nephrotoxicity, in 24,2% primary glomerular disease and in 15,2% hypertensive nephropathy. No correlation was established between the eGFR and the stage of interstitial fibrosis and tubular atrophy (IF/TA) in all patients with CKD, as well as patients with CNI nephrotoxicity.
Conclusion: CKD is frequent after LT, and CNI nephrotoxicity is its leading cause. Considering the lack of correlation between eGFR and IF/TA, a significant component of kidney dysfunction is functional (possible vasoconstrictive effect of CNI). With prolonged observation, it is likely to expect the increased incidence of advanced stages of CKD after LT and the application of renal replacement therapies in significant number of patients. Kidney biopsy is an irreplaceable diagnostic method for determining the etiology of CKD after LT. It should be considered in the early phase of diagnostic algorithm for the kidney dysfunction to enable proper etiological therapy before the development of irreversible histological changes in kidneys. Considering CNIs nephrotoxicity as the major leading cause of CKD after LT, it is necessary to evaluate immunosuppressive protocols with lower CNI exposition
The effect of pretransplant dialysis modality on the outcome of renal transplantation
No full textUvod: Kronična bubrežna bolest je globalna bolest koja prvenstveno zahvada stariju populaciju te predstavlja veliki financijski trošak za svaki zdravstveni sustav. Liječenje kronične bubrežne bolesti se provodi putem dijalize ili transplantacijom bubrega. Cilj istraživanja je vidjeti povezanost tipa dijalize prije transplantacije na ishod transplantacije bubrega. Ispitanici i metode: U ovu retrospektivnu studiju su uključeni svi primatelji bubrega, odnosno pankreasa i bubrega, u razdoblju od 2007. do 2013. godine u KB Merkur, Zagreb.
Rezultati: U istraživanje je uključeno 280 bolesnika (106 muškaraca i 174 žene). Od ukupnog broja transplantacija je učinjeno 229 transplantacija bubrega te 51 simultana transplantacija bubrega i gušterače. Prije transplantacije vedina bolesnika je bila na HD (207) dok ih je 63 bilo na PD. Prema Kaplan Meier krivulji preživljenja petogodišnje preživljenje svih bolesnika iznosi 82.9 % dok preživljenje grafta iznosi 78.5%. U odnosu na tip dijalize prije transplantacije nije bilo statistički značajne razlike u preživljenju bolesnika (p=.09), preživljenju bubrega (p=.19) te u preživljenju grafta cenzuriranom za smrt bolesnika (p=.16). Incidencija svih infekcija u prva tri mjeseca nakon transplantacije je iznosila 58.9% od čega su urinarne infekcije činile gotovo 50% svih infekcija. U odnosu na tip dijalize prije transplantacije nije bilo statistički značajne razlike u incidenciji infekcija. Iako je u univarijatnoj analizi tip dijalize prije transplantacije bio jedan od čimbenika koji su utjecali na vrijednost glomerularne filtracije isto se izgubio u multivarijatnoj analizi gdje su samo dob primatelja i darivatelja ostale statistički značajne varijable koje utječu na funkciju bubrega 6 i 12 mjeseci nakon transplantacije. Prosječna cijena transplantacije bubrega je iznosila 85.85±41.67 tisuda kuna, dok je za SPKT iznosila 111.84±89.20 tisuda kuna (p= .02). Nije bilo statistički značajne razlike u cijeni transplantacije u odnosu na tip dijalize prije transplantacije. Odgođena funkcija grafta, smrt bolesnika, vrsta transplantacije te preživljenje grafta cenzuriranog za smrt bolesnika su statistički značajne varijable povezane s cijenom transplantacije.
Zaključak: Vrsta dijalize prije transplantacije ne utječe na preživljenje bolesnika i grafta, pojavnost infekcija i vrijednost glomerularne filtracije nakon transplantacije te na cijenu same transplantacije. Peritonejska dijaliza je jeftinija od hemodijalize te je manje financijsko opteredenje za javnozdravstveni sustav. Zbog toga se PD treba promovirati u metodu prvog odabira, kada je u pitanju liječenje dijalizom, u svih bolesnika koji nemaju kontraindikaciju za njezino provođenje.Introduction: Chronic renal disease is a global disease that primarily affects the elderly population and represents a major financial expense for all healthcare systems. Chronic renal disease is treated by dialysis or kidney transplantation. The goal of the research is to discover the connection between the type of dialysis before the transplantation and the outcome of the kidney transplantation.
Test subjects and methods: This retrospective study includes all kidney recipients or pancreas and kidney recipients in the period from 2007. to 2013. at the University Hospital Merkur, Zagreb.
Results: The research included 280 patients (106 male and 174 female). Of the total number of transplantations, there were 229 kidney transplantations and 51 simultaneous kidney and pancreas transplantations. Before the transplantation most of the patients were on HD (207), while 63 of them were on PD. According to the Kaplan-Meier survival curve, the five year survival of all the patients is 82.9 % while the graft survival is 78.5%). Considering the type of dialysis before the transplantation, there was no statistically significant differences in the survival of the patients (p=.09), kidney survival (p=.19), and graft survival censored for death of the patient (p=.16). The incidence of all infections in the first three months after transplantation was 58.9%, and 50% of all the infections were urinary infections. Considering the type of dialysis before transplantation, there were no statistically significant differences in the incidence of infections. Even though the type of dialysis before the transplantation was one of the factors that affected the value of glomerular filtration in the univariate analysis, it was lost in the multivariate analysis, where only the ages of the recipient and the donor remained as statistically significant variables that affect the function of the kidneys 6 and 12 months after the transplantation. The average price of a kidney transplantation was HRK 85.85±41.67 thousand, and for SPKT it was HRK 111.84±89.20 thousand (p= .02). There was no statistically significant difference in the price of the transplantation considering the type of dialysis before the transplantation. Delayed graft function, death of the patient, type of transplantation, and graft survival censored for death of the patient are statistically significant variables connected to the price of the transplantation. Conclusion: The type of dialysis before transplantation does not affect the survival of the patient and the graft, the incidence of infections, the value of glomerular filtration after the transplantation, or the price of the transplantation itself. That is why PD should be promoted as the first choice method for dialysis treatment of all the patients that do not have contraindications for its use
Chronic kidney disease afther liver transplantation - risk factor and etiology
No full textUvod: Kroniĉna bubreţna bolest (KBB) znaĉajna je komplikacija transplantacije jetre (TJ), koja utjeĉe na morbiditet i mortalitet bolesnika nakon transplantacije. Stoga je vaţno identificirati i modificirati faktore rizika koji negativno utjeĉu na bubreţnu funkciju. Hipoteza disertacije bila je da je KBB ĉesta nakon TJ i da je vodeći uzroĉni ĉimbenik nefrotoksiĉnost kalcineurinskih inhibitora. Ciljevi ovog rada bili su odrediti incidenciju novonastale KBB, identificirati faktore rizike, istraţiti kliniĉki tijek, te odrediti etiologiju novonastale KBB kod bolesnika nakon TJ.
Metode: Analizirano je 197 bolesnika kojima je u KB Merkur transplantirana jetra u razdoblju od 2005. do 2010. godine, koji nisu imali KBB prije TJ. KBB nakon TJ definirana je procijenjenom glomerularnom filtracijom (eGFR) <60 ml/min/1,73 m2 u trajanju od najmanje 3 mjeseca, koristeći Modification in Renal Disease (MDRD) formulu.
Rezultati: Većina bolesnika (50,3%) transplantirana je zbog alkoholne bolesti jetre. Veliĉina eGFR prije TJ pozitivno je korelirala s veliĉinom pada eGFR nakon TJ, tako da su veći pad doţivjeli bolesnici s višom eGFR prije transplantacije. Prosjeĉna eGFR svih bolesnika pogoršala se nakon transplantacije. Kumulativna incidencija novonastale KBB nakon TJ iznosila je 54,5% nakon 12 mj., 58,9% nakon 24 mj., 63,6 % nakon 36 mj. i 69,7%.nakon 48 mj. Multivarijatna analiza pokazala je da su neovisni ĉimbenici rizika za razvoj KBB nakon TJ: starija dob bolesnika, infekcija virusom hepatitisa C, stupanj bubreţne funkcije prije TJ i stupanj bubreţne funkcije u 1. mj. nakon TJ. Patohistološkom analizom 33 bioptiĉka uzorka bubrega bolesnika s KBB nakon TJ, više od polovice bolesnika (57,5%) imalo je kalcineurinsku (CNI) nefrotoksiĉnost, 24,2% primarnu bolest glomerula, a 15,2% hipertenzivnu nefropatiju. Kod bolesnika s KBB općenito, kao ni kod bolesnika s CNI nefrotoksiĉnošću nije naĊena korelacija izmeĊu eGFR i stupnja intersticijske fibroze i tubularne atrofije (IF/TA).
Zakljuĉak: KBB je ĉesta nakon TJ, a CNI nefrotoksiĉnost je njezin vodeći uzrok. S obzirom na izostanak korelacije izmeĊu IF/TA i eGFR, znaĉajna komponenta bubreţne disfunkcije je funkcionalna (vjerojatno vazokonstrikcijski uĉinak CNI). Duţim razdobljem praćenja moţe se oĉekivati daljnje povećanje uĉestalosti uznapredovalih stadija KBB nakon TJ, odnosno potreba za bubreţnim nadomjesnim lijeĉenjem u znaĉajnog broja bolesnika. Biopsija bubrega je nezamjenjivi alat u rasvjetljavanju etiologije KBB nakon TJ. Potrebno ju je rano uvrstiti u dijagnostiĉke algoritme bubreţne disfunkcije nakon TJ, jer se time omogućuje etiološka terapija, dok još kroniĉne histološke promjene u bubrezima nisu uznapredovale. S obzirom na CNI nefrotoksiĉnost kao vodeći uzrok KBB nakon TJ, potrebno je evaluirati imunosupresivne protokole s niţom ekspozicijom CNI-a.Background: Chronic kidney disease (CKD) is a significant complication after liver transplantation (LT) which affects patients’ survival. Therefore it is important to identify and influence risk factors that negatively affect kidney function. Hypothesis of the thesis is that CKD is frequent after LT and that calcineurin inhibitors (CNIs) are the major leading cause. The goals of this study were to determine incidence of newly developed CKD, to identify the risk factors, to investigate clinical course and to determine the etiology of CKD after LT.
Methods: Hundred and ninety seven liver recipients without preexisting CKD transplanted in KB Merkur between 2005. and 2010. were analyzed. CKD after LT was defined as decreased estimated glomerular filtration rate (eGFR) <60 ml/min/1,73m2 for at least three consecutive months using Modification in Renal Disease (MDRD) formula.
Results: Majority of recipients (50,3%) were transplanted due to alcoholic liver cirrhosis. The level of eGFR before LT correlated positively with the eGFR decline after LT, where the decline was more pronounced in patients with higher eGFR prior to LT. The mean eGFR of all recipients significantly deteriorated after LT. Cumulative incidence of newly developed CKD for 12, 24, 36 and 48 months after LT was 54,5%, 58,9%, 63,6 % and 69,7%, respectively. A multivariate Cox regression analysis revealed that overall risk of CKD development was associated with old age of recipients, hepatitis C virus infection, the level of kidney function before LT and the level of kidney function at 1 month after LT. Pathohistological analysis of 33 kidney samples revealed in majority of patients (57,5%) CNI nephrotoxicity, in 24,2% primary glomerular disease and in 15,2% hypertensive nephropathy. No correlation was established between the eGFR and the stage of interstitial fibrosis and tubular atrophy (IF/TA) in all patients with CKD, as well as patients with CNI nephrotoxicity.
Conclusion: CKD is frequent after LT, and CNI nephrotoxicity is its leading cause. Considering the lack of correlation between eGFR and IF/TA, a significant component of kidney dysfunction is functional (possible vasoconstrictive effect of CNI). With prolonged observation, it is likely to expect the increased incidence of advanced stages of CKD after LT and the application of renal replacement therapies in significant number of patients. Kidney biopsy is an irreplaceable diagnostic method for determining the etiology of CKD after LT. It should be considered in the early phase of diagnostic algorithm for the kidney dysfunction to enable proper etiological therapy before the development of irreversible histological changes in kidneys. Considering CNIs nephrotoxicity as the major leading cause of CKD after LT, it is necessary to evaluate immunosuppressive protocols with lower CNI exposition
The effect of pretransplant dialysis modality on the outcome of renal transplantation
No full textUvod: Kronična bubrežna bolest je globalna bolest koja prvenstveno zahvada stariju populaciju te predstavlja veliki financijski trošak za svaki zdravstveni sustav. Liječenje kronične bubrežne bolesti se provodi putem dijalize ili transplantacijom bubrega. Cilj istraživanja je vidjeti povezanost tipa dijalize prije transplantacije na ishod transplantacije bubrega. Ispitanici i metode: U ovu retrospektivnu studiju su uključeni svi primatelji bubrega, odnosno pankreasa i bubrega, u razdoblju od 2007. do 2013. godine u KB Merkur, Zagreb.
Rezultati: U istraživanje je uključeno 280 bolesnika (106 muškaraca i 174 žene). Od ukupnog broja transplantacija je učinjeno 229 transplantacija bubrega te 51 simultana transplantacija bubrega i gušterače. Prije transplantacije vedina bolesnika je bila na HD (207) dok ih je 63 bilo na PD. Prema Kaplan Meier krivulji preživljenja petogodišnje preživljenje svih bolesnika iznosi 82.9 % dok preživljenje grafta iznosi 78.5%. U odnosu na tip dijalize prije transplantacije nije bilo statistički značajne razlike u preživljenju bolesnika (p=.09), preživljenju bubrega (p=.19) te u preživljenju grafta cenzuriranom za smrt bolesnika (p=.16). Incidencija svih infekcija u prva tri mjeseca nakon transplantacije je iznosila 58.9% od čega su urinarne infekcije činile gotovo 50% svih infekcija. U odnosu na tip dijalize prije transplantacije nije bilo statistički značajne razlike u incidenciji infekcija. Iako je u univarijatnoj analizi tip dijalize prije transplantacije bio jedan od čimbenika koji su utjecali na vrijednost glomerularne filtracije isto se izgubio u multivarijatnoj analizi gdje su samo dob primatelja i darivatelja ostale statistički značajne varijable koje utječu na funkciju bubrega 6 i 12 mjeseci nakon transplantacije. Prosječna cijena transplantacije bubrega je iznosila 85.85±41.67 tisuda kuna, dok je za SPKT iznosila 111.84±89.20 tisuda kuna (p= .02). Nije bilo statistički značajne razlike u cijeni transplantacije u odnosu na tip dijalize prije transplantacije. Odgođena funkcija grafta, smrt bolesnika, vrsta transplantacije te preživljenje grafta cenzuriranog za smrt bolesnika su statistički značajne varijable povezane s cijenom transplantacije.
Zaključak: Vrsta dijalize prije transplantacije ne utječe na preživljenje bolesnika i grafta, pojavnost infekcija i vrijednost glomerularne filtracije nakon transplantacije te na cijenu same transplantacije. Peritonejska dijaliza je jeftinija od hemodijalize te je manje financijsko opteredenje za javnozdravstveni sustav. Zbog toga se PD treba promovirati u metodu prvog odabira, kada je u pitanju liječenje dijalizom, u svih bolesnika koji nemaju kontraindikaciju za njezino provođenje.Introduction: Chronic renal disease is a global disease that primarily affects the elderly population and represents a major financial expense for all healthcare systems. Chronic renal disease is treated by dialysis or kidney transplantation. The goal of the research is to discover the connection between the type of dialysis before the transplantation and the outcome of the kidney transplantation.
Test subjects and methods: This retrospective study includes all kidney recipients or pancreas and kidney recipients in the period from 2007. to 2013. at the University Hospital Merkur, Zagreb.
Results: The research included 280 patients (106 male and 174 female). Of the total number of transplantations, there were 229 kidney transplantations and 51 simultaneous kidney and pancreas transplantations. Before the transplantation most of the patients were on HD (207), while 63 of them were on PD. According to the Kaplan-Meier survival curve, the five year survival of all the patients is 82.9 % while the graft survival is 78.5%). Considering the type of dialysis before the transplantation, there was no statistically significant differences in the survival of the patients (p=.09), kidney survival (p=.19), and graft survival censored for death of the patient (p=.16). The incidence of all infections in the first three months after transplantation was 58.9%, and 50% of all the infections were urinary infections. Considering the type of dialysis before transplantation, there were no statistically significant differences in the incidence of infections. Even though the type of dialysis before the transplantation was one of the factors that affected the value of glomerular filtration in the univariate analysis, it was lost in the multivariate analysis, where only the ages of the recipient and the donor remained as statistically significant variables that affect the function of the kidneys 6 and 12 months after the transplantation. The average price of a kidney transplantation was HRK 85.85±41.67 thousand, and for SPKT it was HRK 111.84±89.20 thousand (p= .02). There was no statistically significant difference in the price of the transplantation considering the type of dialysis before the transplantation. Delayed graft function, death of the patient, type of transplantation, and graft survival censored for death of the patient are statistically significant variables connected to the price of the transplantation. Conclusion: The type of dialysis before transplantation does not affect the survival of the patient and the graft, the incidence of infections, the value of glomerular filtration after the transplantation, or the price of the transplantation itself. That is why PD should be promoted as the first choice method for dialysis treatment of all the patients that do not have contraindications for its use
Association of chronic kidney disease with periprocedural myocardial injury after elective stent implantation
No full textCilj istraživanja: Koronarna bolest je vodeći uzrok smrtnosti bolesnika s kroničnom bubrežnom bolesti (CKD). Bolesnici s CKD, podvrgnuti perkutanoj koronarnoj intervenciji (PCI), imaju veći rizik razvoja kardiovaskularnih komplikacija u odnosu na bolesnike s očuvanom bubrežnom funkcijom. Cilj ovog istraživanja je odrediti incidenciju i intenzitet periproceduralne ozljede miokarda (PMI) nakon elektivne PCI u ovisnosti o CKD. Nacrt studije Ova prospektivna studija je uključila 344 bolesnika sa stabilnom koronarnom bolesti koji su podvrgnuti elektivnoj PCI u Kliničkoj bolnici Merkur u Zagrebu, u vremenskom periodu od ožujka 2012. do lipnja 2015. godine. Ispitanici i metode Svi ispitanici su imali stabilnu koronarnu bolest. Isključujući kriteriji su bili: dob ispod 18 godina, akutno zatajenje bubrežne funkcije, akutni koronarni sindrom, okluzija postraničnog ogranka, kronična totalna okluzija, višežilno stentiranje i kontraindikacija za primjenu dvojne antiagregacijske terapije. Ispitanici su podijeljeni u dvije skupine: kontrolna skupina s očuvanom bubrežnom funkcijom i ispitivana skupina s CKD koja je dalje podijeljena u četiri podskupine ovisno o stadiju bubrežne bolesti. Serumska koncentracija troponina I (cTnI), C reaktivnog proteina i kreatinina je određena bazalno te 8 i 16 sati nakon PCI. Periproceduralni porast cTnI iznad gornje referentne serumske vrijednosti definira PMI, a razlika postproceduralne i bazalne vrijednosti cTnI definira intenzitet ozljede. Rezultati Nije bilo statistički značajne razlike u incidenciji PMI 8 i 16 sati nakon PCI između kontrolne i ispitivane skupine bolesnika. Isto tako nije bilo statistički značajne razlike u incidenciji PMI, 8 i 16 sati nakon PCI između kontrolne skupine i pojedinih podskupina bolesnika s CKD. Nismo uočili statistički značajnu razliku u intenzitetu PMI 8 i 16 sati nakon PCI između kontrolne i ispitivane skupine niti smo uočili statistički značajnu razliku u intenzitetu ozljede između kontrolne skupine i pojedinih podskupina bolesnika s CKD. Multivarijantna analiza je pokazala da su angina pectoris CCS stadij IV, ugradnja BMS-a i ACEI-i u terapiji neovisni prediktori razvoja PMI, dok je arterijska hipertenzija ostala neovisan protektivni čimbenika razvoja PMI. Zaključak: Niti jedan stupanj CKD nije bio povezan s većom incidencijom odnosno s većim intezitetom ozljede miokarda tijekom elektivne PCI. Svakako su neophodne prospektivne i randomizirane kliničke studije koje će istražiti sigurnost i učinkovitost perkutane revaskularizacije miokarda u ovoj populaciji bolesnika kao i optimalni izbor stenta i optimalni izbor preproceduralne terapije koja ima za svrhu prevenciju periproceduralne ozljede miokarda.Objectives Coronary artery disease (CAD) is the leading cause of mortality in patients with chronic kidney disease (CKD). Patients with CKD who undergo coronary revascularization may have more ischemic events than patients without CKD. The aim of this study was to determine the incidence and intensity of periprocedural myocardial injury (PMI) after elective stent implantation among patients with and without CKD. Study Design In a single center prospective cohort study, we enrolled 344 consecutive patients who underwent an elective PCI at Merkur University Hospital, Zagreb, Croatia, in a period of 39 months between March 2012 and June 2015. Patients and Methods All patients had stable angina pectoris, or documented inducible myocardial ischemia. Criteria for inclusion were successful PCI procedure and an optimal final result. The exclusion criteria were: age less than 18, acute coronary syndrome, acute kidney injury, multivessel stenting in a single procedure, major (>1,5 mm) side branch occlusion, chronic total occlusion and contraindication to the use dual antiplatelet therapy. Patients were divided into two groups: control group with estimated glomerular filtration rate (eGFR) > 90 ml/min/1,73m² and the CKD group with eGFR 90 ml/min/1.73m2) and the CKD group (< 90 ml/min/1.73m2) both 8 and 16 hours after PCI. When the CKD patients were further subdivided according to their CKD stage, there was again no difference in the intensity or incidence of PMI compared to the control group. Further analyses of our data showed angina pectoris CCS IV, bare metal stent (BMS) implantation and treatment with angiotensin-converting enzyme inhibitors (ACEI) as independent predictors of PMI. Furthermore presence of hypertension was inversely related to the occurrence of PMI. Conclusion: We found no association between PMI occurrence and the presence of CKD. Furthermore, CKD burden (i.e. stratification of patients according to the CKD stage) was also not associated with higher PMI incidence or PMI intensity. Further analyses showed other factors that could potentially influence the occurrence of PMI
Vascular access for hemodialysis
No full textHemodijaliza je postupak izvantjelesnog odstranjivanja tvari koje se nakupljaju u organizmu zbog privremenog ili trajnog gubitka ekskretorne funkcije bubrega. U pacijenata koji imaju indikaciju za započinjanje liječenja hemodijalizom, mogući krvožilni pristupi su: arteriovenska fistula, arteriovenski graft te trajni ili privremeni centralni venski kateter. Krvožilni bi pristup, idealno, za učinkovitu hemodijalizu trebao osigurati dostatan protok krvi za isporuku adekvatne doze hemodijalize te imati dug vijek korištenja uz nisku učestalost komplikacija. Unatoč relativno visokoj incidenciji primarnog izostanka funkcije, arteriovenska fistula predstavlja krvožilni pristup izbora jer je udružena s najduljim preživljenjem pristupa i bolesnika, nižim morbiditetom i mortalitetom bolesnika, najmanjom učestalosti komplikacija te najnižim troškovima liječenja. Arteriovenski graft predstavlja krvožilni pristup izbora u bolesnika kod kojih nije moguće kreirati arteriovensku fistulu. Centralni venski kateteri koriste se za brzu uspostavu adekvatnog krvožilnog pristupa kad je indicirana hitna hemodijaliza, za vrijeme sazrijevanja arteriovenske fistule i u pacijenata kojima su iscrpljeni svi ostali krvožilni pristupi. Najbolje preživljenje imaju bolesnici koji se dijaliziraju putem arteriovenske fistule. Osim krvožilnog pristupa, na preživljenje bolesnika utječu i brojna pridružena stanja i bolesti. Budući da su arteriovenski graft i trajni dijalizni kateter udruženi s višestruko većim rizikom od pobola i smrtnosti u odnosu na arteriovensku fistulu, nije sasvim jasno proizlazi li rizik za preživljenje bolesnika od samih krvožilnih pristupa ili od pridruženih stanja i bolesti.Hemodialysis is a method of extracorporeal removal of substances that accumulate in the body due to temporary or permanent loss of renal excretory function. In patients who have an indication for initiation of hemodialysis treatment, possible vascular accesses are: arteriovenous fistula, arteriovenous graft and non-tunnelled and tunelled dialysis catheters. For effective hemodialysis, vascular access should provide sufficient blood flow to deliver adequate dialysis dose and should have a long survival and low incidence of complications. Despite the relatively high incidence of the primary loss of function, arteriovenous fistula is the vascular access of choice because it is associated with the longest vascular access survival, the longest patient survival, lower morbidity and mortality of patients, the lowest complication rates and the lowest costs of treatment. Arteriovenous graft is the vascular access of choice in patients in whom arteriovenous fistula can not be created. Dialysis catheters are used for the rapid establishment of an adequate vascular access when an urgent hemodialysis is indicated, during the maturation of arteriovenous fistulas and in patients who have exhausted all other vascular accesses. The best survival is achieved by patients who are dialyzed using arteriovenous fistula. Since many comorbidities affect survival of dialysis patients, it is unclear whether the risk for the survival of patients arises from vascular access type or from associated conditions and diseases that are more often present in patients who are dialyzed through arteriovenous graft and catheter
Polyomavirus nephropathy following kidney transplantation
No full textUvod:
Imunosupresivno (IS) liječenje predstavlja rizik za oportunitističke infekcije u bolesnika s
transplantiranim bubregom. Poliomavirusna nefropatija uzrokovana BK virusom (BK virusna
nefropatija;BKVAN) kao infektivna komplikacija jedan je od značajnijih uzroka gubitka
presađenog bubrega. Cilj istraživanja bio je utvrditi klinički tijek BKVAN i ishod presatka te
osjetljivost i specifičnost citologije urina i lančane reakcije polimerazom (PCR) u dijagnostici
BKVAN.
Metode:
Provedeno je retrospektivno istraživanje na 16 bolesnika s BKVAN i 32 kontrolna bolesnika s
presađenim bubregom, bubregom i gušteračom te bubregom i jetrom. IS terapija se sastojala
od takrolimusa, mikofenolat mofetila (MMF) i steroida u 35 pacijenata, od takrolimusa i
MMF u 10, ciklosporina, MMF i steroida u 2 bolesnika, dok je jedan bolesnik primao
takrolimus, azatioprin i steroide. BKVAN je liječena visokom dozom intravenskih
imunoglobulina i/ili smanjenjem IS.
Rezultati:
Medijan vremena od transplantacije do PHD BKVAN bio je 366 (130-3065) dana. Citološki
nalaz decoy stanica u vrijeme PHD bio je pozitivan u 73.3% bolesnika s BKVAN te u 10.71%
ispitanika iz kontrolne skupine.Osjetljivost citološkog nalaza decoy stanica u urinu iznosila je
73.33% a specifičnost 89.29%. PCR za BKV DNA u plazmi bio je pozitivan u 100%
bolesnika s BKVAN i 22.22% ispitanika iz kontrolne skupine. Osjetljivost PCR testa za
BKVAN bila je 100%, a specifičnost PCR za BKVAN iznosila je 77.78%. Nakon
postavljanja PHD BKVAN ispitanici su imali medijan praćenja od 311 (32-1898) dana. Jedan
je bolesnik u tom razdoblju umro, a dvoje je izgubilo presadak. Ukupno petogodišnje
preživljenje presatka nakon postavljanja dijagnoze bilo je 65.3%. Petogodišnje preživljenje
bubrega u kontrolnoj skupini bilo je 90.6% (u usporedbi s BKVAN p=0.44, log-rank test).
Pronađena je značajna statistička razlika između promatranih skupina u vrijednosti serumskog
kreatinina 1 mjesec prije PHD (175.38}50.78 s BKVAN, 132.75}49.43 bez BKVAN, p<
0.025), u vrijeme PHD (202.13}68.51 s BKVAN, 140.09}56.14 bez BKVAN, p<0.005) i 3
mjeseca nakon PHD (221.29}108.67 s BKVAN, 134}80.43 bez BKVAN, p<0.025).
Zaključak:
BKVAN je važna infektivna komplikacija transplantacije bubrega, koja uz odgovarajući
postupak u velikom postotku bolesnika ne mora dovesti do gubitka bubrežnog presatka. PCR
za BKV DNA u plazmi i citologija urina predstavljaju važne testove probira bolesnika s
rizikom za BKVAN.Introduction:
Immunosuppressive therapy poses risks for increased incidence of opportunistic infections in
patients with a transplanted kidney. Being an infective complication, BK virus nephropathy
(BKVAN) is one of the leading causes of renal transplant loss. The aim of this study was to
determine the clinical course and the outcome of the graft, as well as the sensitivity and
specificity of urine cytology and polymerase chain reaction (PCR) in BKVAN diagnostics.
Methods:
A retrospective case-control study was conducted in a cohort of 48 patients with a kidney,
kidney-pancreas, and kidney-liver transplant, 16 of whom had been pathohistologically
(PHD) diagnosed with BK polyomarivus nephropathy. Immunosuppressive therapy consisted
of tacrolimus, mycrophenolate mofetil (MMF) and steroids in 35 patients, of tacrolimus and
MMF in 10 patients, and of cyclosporine, MMF and steroids in 2 patients, while one patient
was treated with tacrolimus, azathioprine and steroids. BKVAN was treated with a high dose
of intravenous immunoglobulins and/or immunosuppression reduction.
Results:
Median time between transplantation and PHD of BKVAN was 366 (130-3065) days.
Cytology test results for decoy cells at the time of PHD were positive in 73.3% of patients
with BKVAN and in 10.71% of patients from the control group of kidney transplant
recipients. PCR for BKV-DNA in plasma was positive in100%of patients with BKVAN and
in 22.22% of patients from the control group. Sensitivity of positive PCR for BKV-DNA in
plasma was 100% and specificity was 77.78%. Urine cytology for decoy cells had a
sensitivity of 73.3% and a specificity of 89.29% for BK nephropathy. Median time of patient
follow-up after the PHD of BKVAN was 311 (32-1898) days. One of the patients died during
that period, and two lost the renal graft. Overall 5-yeargraft survival rate following diagnosis
was 65.3 %, while it was 90.6% in the control group (p=0.44, log-rank test). A significant
statistical difference between the studied groups was found in serum creatinine values
measured 1 month before the PHD (202.13±68.51 with BKVAN, 140.09±56.14 without
BKVAN,p<0.025), at the time of the PHD (202.13±68.51 with BKVAN, 140.09±56.14
without BKVAN, p<0.005), and 3 months after the PHD (221.29±108.67 with BKVAN,
134±80.43 without BKVAN, p<0.025).
Conclusion:
BKVAN is an important post-kidney transplant infective complication which, if properly
treated, in a large percentage of patients will not necessarily result in transplant loss. Urine
cytology and PCR for BKV-DNA in plasma are valuable screening tests for patients at risk of
BKVAN
Kidney Biopsy Types, Complications and Outcomes- Our Experience
No full textBackground: Kidney biopsy is frequently performed in our centre as an outpatient
procedure. The aim of this study was to evaluate the safety of biopsy in the outpatient
setting. -----
Methods: We analysed kidney biopsies performed from March 2013 to February 2017.
725 biopsies performed in the outpatient setting were identified: There were 592
transplant and 133 native biopsies including 3 solitary kidney biopsies. All were
performed under ultrasound guidance using a 16G or 18G needle, with freehand
technique. In all patients with eGFR<30ml/min/1.73m2 desmopressin was administered.
Patients were observed for 6h before discharge, with a CBC and urine test after 4h.
Major complications were haemorrhage requiring therapeutic intervention or
transfusion. Minor complications were significant reduction in Hb levels (>10%),
without need for transfusion or intervention and macrohaematuria. -----
Results: There were 506 (69.8%) male patients. Average age was 50.3 ±12.7 yrs.
Indications for native kidney biopsy included nephrotic syndrome (39.8%), nephritic
syndrome (42.9%), follow-up biopsy (15.8%), and other (1.5%). There were no major
complications. A decline in Hb was observed in 72% of pts. Average Hb decline was
4.2±6.3 g/L. In 10.1% pts there was >10% reduction in Hb level, with no evident
bleeding, including by ultrasonography. In 2.5% of patients macrohaematuria was
present. In a multivariate analysis male gender, lower eGFR, higher prebiopsy Hb and
native kidney biopsy were predictive for Hb decline. No therapeutic interventions were
required. -----
Conclusion: We found that kidney biopsy performed in an outpatient setting in select
patients is only rarely associated with adverse events and is a safe procedure. It remains
a possibility in low-risk patients. In other patients it should be done in the hospital
setting due to possibly serious complications
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