Volume 9 issue Suppl. 1

Transcription

EDITORIAL BOARD
EDITOR-IN-CHIEF
Goce Spasovski, Skopje
ASSOCIATE EDITORS
Mustafa Arici, Ankara
Nada Dimkovic, Belgrade
Dimitrios Goumenos, Patra
Nikolina Basic-Jukic, Zagreb
DEPUTY EDITORS
Adrian Covic, Iasi
Veselin Nenov, Varna
EMERITUS EDITORS
Dimitar Nenov, Varna
Momir Polenakovic, Skopje
Ljubica Djukanovic, Belgrade
Charalambos Stathakis, Athens
Ali Basci, Izmir
EDITORIAL BOARD
Adalbert Schiller, Timisoara
Aydin Turkmen, Istanbul
Alketa Koroshi, Tirana
Amira Peco Antic, Belgrade
Biljana Stojmirovic, Belgrade
Boriana Kiperova, Sofija
Cengiz Utas, Kayseri
Daniela Monova, Sofia
Dimitrios Memmos, Thessaloniki
Dimitris Tsakiris, Thessaloniki
Ekrem Erek, Istanbul
Evgueniy Vazelov, Sofija
Fehmi Akcicek, Izmir
Fevzi Ersoy, Antalya
Georgios Vergoulas, Thessaloniki
Gordana Peruncic-Pekovic, Belgrade
Gultekin Suleymanlar, Antalya
Halima Resic, Sarajevo
Igor Mitic, Novi Sad
Jadranka Buturovic-Ponikvar, Ljubljana
Jelka Masin Spasovska, Skopje
John Boletis, Athens
Kamil Serdengecti, Istanbul
Kenan Ates, Ankara
Katica Zafirovska, Skopje
Ladislava Grcevska, Skopje
Liliana Garneata, Bucharest
Kostas Siamopoulos, Ioannina
Marko Malovrh, Ljubljana
Milan Radovic, Belgrade
Myftar Barbullushi, Tirana
Olivera Stojceva Taneva, Skopje
Petar Kes, Zagreb
Rade Naumovic, Belgrade
Rafael Ponikvar, Ljubljana
Sanja Simic-Ogrizovic, Belgrade
Sanjin Racki, Rijeka
Serhan Tuglular, Istanbul
Sevgi Mir, Izmir
Tekin Akpolat, Samsun
Velibor Tasic, Skopje
Vidosava Nesic, Belgrade
Vidojko Djordjevic, Nis
Visnja Lezaic, Belgrade
Vladislav Stefanovic, Nis
Mahmut Ilker Yilmaz, Ankara
The content of this supplement is prepared according to the selection made by the
scientific committee!
10th BANTAO CONGRESS ORGANIZERS
President:
D. Tsakiris, Thessaloniki
Honorary President:
Ch. Stathakis, Athens
Vice President:
K. Sombolos, Thessaloniki
Secretary:
I. Boletis, Athens
Deputy Secretary:
P. Kiriklidou, Thessaloniki
Treasurer:
E. Sarris, Athens
BOARDS
BANTAO BOARD
President:
A. Basci, Izmir
Secretary General:
C. Utas, Kayseri
President-Elect:
D. Tsakiris, Thessaloniki
BJ Editor-in-chief:
G. Spasovski, Skopje
Members:
L. Djukanovic, Belgrade
D. Nenov, Varna
V. Nesic, Belgrade
M. Polenakovic, Skopje
Honorary Members: H. Klinkmann, Rostock
J. Vienken, Bad Homburg
E.J. Dorhout Mees, Vorden
BOARD OF THE HELLENIC SOCIETY OF NEPHROLOGY
President:
C. Iatrou, Athens
Vice President:
P. Passadakis, Alexandroupolis
Secretary:
D. Goumenos, Patras
Treasurer:
E. Sarris, Athens
Members:
G. Bamihas, Thessaloniki
K. Fourtounas, Patras
G. Visvardis, Thessaloniki
COMMITTEES
LOCAL ORGANIZING COMMITTEE
A. Aggelou, Thessaloniki
E. Kokolina, Thessaloniki
E. Mitsopoulos, Thessaloniki
F. Christidou, Thessaloniki
E. Manou, Thessaloniki
D. Oikonomidou, Thessaloniki
A. Kelesidis, Veria
I. Minasidis, Thessaloniki
A. Sioulis, Thessaloniki
SCIENTIFIC COMMITTEE
Chairmen: K.C. Siamopoulos, Ioannina / V. Vargemezis, Alexandroupolis
Members:
N. Afentakis, Athens
I. Kyriazis, Chios
K. Serdengecti, Istanbul
F. Akcicek, Izmir
V. Liakopoulos, Thessaloniki
A. Sikole, Skopje
M. Barbullushi, Tirana
M. Malovrh, Ljubljana
D. Stamatiadis, Serres
N. Dimkovic, Belgrade
K. Mavromati dis, Komotini
V. Stefanovic, Nis
F. Ersoy, Antalya
V. Nenov, Varna
G. Suleymanlar, Antalya
M. Gafencu, Timisoara
N. Nikolopoulou, Athens
N. Theresca, Tirana
L. Garneata, Bucharest
V. Orthopoulos, Athens
E. Thodis, Alexandroupolis
E. Giannatos, Argostoli
I. Papadakis, Athens
E. Vazelov, Sofia
P. Gusbeth-Tatomir, Iasi
A. Papagianni, Thessaloniki
S. Ziakka, Athens
B. Kiperova, Sofia
M. Pappas, Ioannina
N. Zoumbaridis, Edessa
A. Koroshi, Tirana
M. Radovic, Belgrade
N. Kotsadamis, Veria
H. Resic, Sarajevo
PAPER SELECTION COMMITTEE
Chairman: N. Papagalanis, Athens
Deputy Chairman: N. Kaperonis, Athens
Supported by:
ERA-EDTA CME COURSE
“VASCULITIDES”
Endorsed by:
Under the auspices of:
INTERNATIONAL SOCIETY
OF NEPHROLOGY
HELLENIC SOCIETY
OF NEPHROLOGY
10th BANTAO CONGRESS
ORAL PRESENTATIONS
10th BANTAO Congress
Oral Presentations
OP 01
OP 02
PARAOXONASE AND RENIN-ANGIOTENSIN SYSTEM
GENE POLYMORPHISMS IN CARDIORENAL DISEASE
CYTOKINE GENE POLYMORPHISMS AND
PROGRESSION OF CARDIORENAL DISEASE
2
1
I. Bouba, 2 C. Bountouri, 1 E. Dounousi, 3 V. Kiatou,
I. Georgiou, 1 S. Chatzidakis, 3 N. Kotzadamis,
4
D. Tsakiris, 1 K.C. Siamopoulos
1
Department of Nephrology, University Hospital of
Ioannina, Greece
2
Laboratory of Human Reproductive Genetics, Medical
School University of Ioannina, Greece
3
Department of Nephrology General Hospital of Veria,
Greece
4
Department of Nephrology, General Hosptial
"Papageorgiou" of Thessaloniki, Greece
C. Bountouri, 2 I. Bouba, 1 E. Dounousi, 3 A. Papagianni,
V. Kiatou, 2 I. Georgiou, 4 A. Kelesidis, 5 D. Tsakiris,
1
K.C. Siamopoulos
1
Ioannina, Greece
2
Laboratory of Human Reproductive Genetics, Medical
School University of Ioannina, Greece
3
Department of Nephrology, "Hippokration" Hospital of
Thessaloniki, Greece
4
Department of Nephrology, General Hsopital of Veria,
Greece
5
Department of Nephrology, General Hospital
Background. Inflammation, atherosclerosis and oxidative
stress are established risk factors for the progression of
chronic kidney disease (CKD) and increased cardiovascular
(CV) disease (CVD) in these patients. Paraoxonases (PONs)
and renin-angiotensin system (RAS) gene polymorphisms
have been implicated as potential genetic risk factors for
the progression of CKD and CV events in uremic patients.
The aim of this study was to investigate the putative role
of gene polymorphisms of PON1 (L55M, Q192R), PON2
(S311C), Angiotensinogen (M235T), Angiotensin II type 1
receptor (A1166C) and Angiotensin-Converting Enzyme
(ACE ID) on the progression of CKD and CV complications
[left ventricular hypertrophy (LVH), events of ischemic
heart/cevebrovascular/peripheral vascular disease)] in
these patients. Methods. Two hundred twenty nine CKD
outpatients (52% men, 31% diabetics) of stages 1-4 with
mean age of 65±12 years were prospectively followed up
to 3 years or until entering dialysis. One hundred fifty eight
(77%) patients had LVH, while 42% had previous CV
event. During follow-up KDOQI target therapeutic levels for
hypertension and dyslipidemia were achieved in more than
50%. Genotype analysis was performed with real-time PCR
by using Taq Man Genotyping Assays. At baseline and
annually thereafter estimated GRF (eGFR-ml/min, MDRD)
was assessed (mean baseline MDRD=52±28 ml/min).
Patients were clustered according to changes of eGFR in 2
groups (group 1= stable or loss eGFR <2 ml/min/year,
group 2= loss eGFR >2 ml/min/year). Left ventricular
mass index (LVMI) was calculated at baseline and at the
end of the follow up period. Patients were divided in 2
groups based on whether they had LVH at recruitment or
presented during study. During follow-up, 37 (18%) major
CV events were recorded and 23 patients started dialysis.
Results. Regarding genotype distributions the study
population was in Hardy-Weinberg equilibrium. Patients
carrying the R allele of PON1 Q192R polymorphism showed
significantly
increased
LVMI
levels
(p=0.003)
at
recruitment.
The
genotype
distribution
of
the
polymorphisms studied did not show any association with
the rate of the progression of CKD neither with starting
dialysis. Moreover, they did not demonstrate any
association with CV events during follow-up. Conclusion.
PON1 Q192R gene polymorphism had an impact on LVMI
levels in CKD predialysis patients. The present study did
not
provide
further
evidence
that
the
studied
polymorphisms play a role on the progression of CKD and
of CVD in predialysis patients, implicating that no genetic
factors may prevail over genetics in the progression of
cardiorenal disease.
Background. Inflammation and atherosclerosis have been
recognized as risk factors for the progression of chronic
kidney disease (CKD) and increased cardiovascular (CV)
mortality in these patients. Cytokine gene polymorphisms
have been implicated as potential genetic risk factors for
the progression of CKD and CV events in uremic patients.
The aim of the study was to investigate the putative role of
gene polymorphisms of ICAM-1 (K469E), TNFa (G/A-238,
G/A-308) and VEGF (C/T-460) genes on the progression of
CKD, on occurrence/deterioration of left ventricular
hypertrophy (LVH) and on major CV events (ischemic
heart/cevebrovascular/peripheral vascular disease) in non
dialysis CKD patients. Methods. Two hundred twenty nine
consecutive CKD outpatients (52% men, 31% diabetics) of
stages 1-5 with mean age of 65±12 years were
prospectively followed up to 3 years or until entering
dialysis. One hundred fifty eight (77%) of them had LVH
while 42% had experienced a previous CV event. Genotype
analysis was performed with real-time PCR by using Taq
Man Genotyping Assays. Serum levels of ICAM-1 (sICAM1), TNFa (sTNFa) and VEGF were assessed at recruitment
by using ELISA. At baseline and then annually estimated
GRF (eGFR-ml/min, MDRD) was assessed (mean baseline
eGFR=52±28 ml/min). Patients were clustered according
to changes of eGFR in two groups (group 1=stable or loss
GFR <2 ml/min/year, group 2=loss GFR >2 ml/min/year).
Left ventricular mass index (LVMI) was calculated at
baseline and at the end of the follow up period. Patients
were divided in two groups based on whether they had LVH
at the beginning or occurred during study. During followup, 37 (18%) major CV events were recorded and 23
patients started dialysis. Results. Regarding genotype
distributions the study population was in Hardy-Weinberg
equilibrium. At baseline, sTNFa level correlated negatively
with MDRD and positively with LVMI (p<0.001 and p<0.01
respectively). Regarding sICAM-1 levels, patients carrying
the E469 allele of ICAM-1 K469E polymorphism showed
significantly increased levels (p<0.05). The genotype
distribution of the polymorphisms studied did not show any
significant association with the rate of the progression of
CKD neither with starting dialysis. Moreover, they did not
demonstrate any association with the occurrence of CV
events and deterioration of LVH in these patients.
Conclusion. K469E polymorphism of ICAM-1 gene had an
impact on sICAM-1 levels in CKD predialysis patients. The
present study did not provide further evidence that the
studied polymorphisms play a role on the progression of
CKD and deterioration of CV disease in uremic patients.
2
4
1
Oral Presentations
OP 03
OP 04
INCREASED CIRCULATING LEVELS OF VEGF-A AS
INDEPENDENT CORRELATE OF PROTEINURIA IN
EARLY STAGES OF CHRONIC KIDNEY DISEASE
CIRCULATING MATRIX GELATINASES (MMP-2 AND 9) IN ATHEROSCLEROSIS OF PATIENTS WITH EARLY
STAGES OF TYPE 2 DIABETIC NEPHROPATHY
G.G. Dimas, 2 T.J. Tegos, 1 F.S. Iliadis, 3 K.J. Makedou,
T.P. Didaggelos, 2 C.G. Pitsalidis, 2 A.I. Chatziapostolou,
3
A.D. Makedou, 2 S.J. Baloyannis, 1 D.M. Grekas
1
1st Propaedeutic Medical Department, “AHEPA” University
Hospital, Aristotle University of Thessaloniki, Greece
2
1st Neurology Medical Department, “AHEPA” University
3
2nd Pediatric Department, Lipids Research Laboratory,
“AHEPA” University Hospital, Aristotle University of
1
1
G.G.Dimas, 2 T.J.Tegos, 1 F.S.Iliadis, 3 K.G.Makedou,
T.P.Didaggelos, 2 C.G.Pitsalidis, 2 A.I.Chatziapostolou,
3
A.D.Makedou, 2 S.J.Baloyannis, 1 D.M.Grekas
1
1st Propaedeutic Medical Department, “AHEPA” University
2
1st Neurology Medical Department, “AHEPA” University
3
2nd Propaedeutic Medical Department, “AHEPA” University
1
1
Background. Matrix gelatinases (MMP-2 and -9) are the
major enjymes that degrade collagen-IV (col-IV), which is
the main component of the vessels’ BM and have been
implicated in chronic kidney disease (CKD) and
cardiovascular disease (CVD). MMPs have also been
involved in the progression of proteinuria. The mechanisms
underlying this process have not yet been completely
elucidated. Diabetic nephropathy (DN) represents the
leading cause of end-stage renal disease. However, to date
there is no data about the correlation between serum
levels of MMP-2 and -9, proteinuria and atherosclerosis in
patients with early stages of type 2 DN. The aim of this
study was to determine serum levels of MMP-2 and -9 and
their potential correlation with the atherosclerotic markers
and albuminuria in early of type 2 DN. Methods. CKD
patients of stages I and II (n: 20) with type 2 DN and
normo-, micro-, and macro-albuminuria without renal
dysfunction were included. As controls, there were two
groups, patients with diabetes type 2 without CKD (n=6)
and healthy individuals (n=6). Clearance of creatinine
(Clcr) and albumin excretion were examined in the 24h
urine. MMP-2 and -9 levels were measured by an ELISA
method. Intima media thickness (IMT) of carotid and
femoral arteries and the presence of atherosclerotic plaque
were determined by a high resolution ultrasonography.
Statistical analysis was performed with the use of a SPSS17 version system. Statistically significant was defined as
p<0,05 and all values were mean ±SD. Results. The levels
of MMP-2 were significantly higher in patients than in the
control groups (p<0,036). The levels of MMP-9 were also
significantly higher in patients than in controls (p<0,004).
The mean levels of MMP-9 in DN were 615ng/ml±228,74 vs
366±119 in diabetes type 2 and 265±105,5 in healthy
individuals (p<0,004, multivariate analysis). Clcr and
albumin excretion levels were statistically different
between patients and controls (p<0,001), as well as in all
four groups (p<0,001). MMP-2 and MMP-9 levels indicated
a positive strong correlation with albuminuria in patients as
opposed to controls (p<0,05) but no significant evidence in
any of the groups, due to the insufficient number of
patients. Further, MMP-2 levels were independent correlate
of IMT (p<0,01) and MMP-9 levels were independent
correlate of atherosclerotic plaque (p<0,01). Conclusion.
This study suggests that serum levels of MMP-2 and MMP-9
were found to be independent risk factors of
atherosclerosis as well as of albuminuria in early stages of
type 2 diabetic nephropathy.
Background. Albuminuria is considered to be one of the
most important agents for the onset and progression of
renal dysfunction in diabetic nephropathy (DN) and more
recently, it has also been implicated in cardiovascular
disease (CVD) and peripheral vascular disease. Recent
evidence suggests that renal vascular changes contribute
to progressive renal disease and that alteration of vascular
endothelial growth factor (VEGF) might play an important
role in modulating microvascular loss of macrovascular
remodeling in the kidney, as well as in the vessels.
Whether VEGF is detrimental in early stages of DN or other
renal conditions is not yet clearly answered. It remains
controversial the mechanism by which VEGF works in the
kidney, as well as in the vessels in the early stages of DN
and CKD. The aim of the present study was to investigate
the serum levels of VEGF-A and its potential role in
atherosclerosis and albumimuria of early stages of DN and
CKD. Methods. CKD patients (n=31) of stages 1 and 2
with type 2 DN (n=20) and chronic glomerulonephritis,
(CG, n=11) were included. As controls, there were two
groups, patients with diabetes type 2 without CKD (n=6)
and healthy individuals (n=6). Clearance of creatinine
(Clcr) and albumin excretion were examined in the 24h
urine. VEGF-A levels were measured by an ELISA method.
Intima media thickness of carotid and femoral arteries and
atheromatic plaque were evaluated by a high resolution
ultrasonography. Statistical analysis was performed with
the use of a SPSS system. Results. There was a notable
difference between VEGF levels in any of the groups, but
not enough statistically significant evidence to support a
claim of a relationship, probably due to the fact that the
sample size was rather limited. It should be noted that DN
group had the largest and highest mean level of VEGF
(475,8237,5 in DN vs 262,9121,8 in healthy). There
was a statistically significant correlation between levels of
VEGF and the micro-albuminuria group especially in CG
patients (p<0,002). VEGF levels were an independent
correlate of atheromatic plaque (p<0,05). Conclusion.
Our study suggests that serum levels of VEGF-A might
present an independent risk factor of atherosclerosis and
proteinuria, at least in the early stages, to the progression
of CKD.
2
Oral Presentations
OP 05
OP 06
PREDICTORS FOR THE SURVIVAL OF PATIENTS IN
RENAL REPLACEMENT THERAPY
RISK FACTORS OF NONTUNNELED NONCUFFED
HEMODIALYSIS CATHETER MALFUNCTION
1
V. Gerasimovska, A. Oncevski,
B. Gerasimovska-Kitanovska, A. Sikole
University Clinic of Nephrology, Medical Faculty, Skopje
University of Skopje, FYR of Macedonia
V. D. Raikou, 1 N. Tentolouris, 2 E. Chaviaras,
C. Skalioti, 1 N. Katsilambros, 2 J. N. Boletis
1
1st Department of Medicine - Propaedaetic, School of
Medicine, University of Athens, General Hospital “LAΪKO”,
Athens, Greece
2
Department of Nephrology and Transplantation, General
Hospital “LAΪKO”, Athens, Greece
2
Background. The use of noncuffed, nontunneled central
venous catheters is a widely accepted method of gaining
temporary vascular access for hemodialysis (HD).
Malfunction and catheter-related infection (CRI) are the
main factors limiting catheter survival. Methods. We
followed up prospectively 539 hemodialysis catheters(HC)
divided in 4 groups. Gr. A-364 femoral catheters (FC) and
Gr.B- 8 subclavian catheters (SC) in hospitalized pts; Gr.C137 femoral catheters (FaC) and Gr.D- 30 subclavian
catheters (SaC) in ambulatory pts. Catheters were
removed when no longer required (permanent VA was
performed)
or
significant
complications
occurred
(malfunction or infection). Cox regression model,
univariant and multivariable analysis were conducted to
examine association of hospital/ambulatory placed HC with
sex, comorbidity of diabetes/malignancy, number of
previous catheters, number of previous thrombosed AVF,
catheters swab (positive/negative),microbiological analysis
of
catheter
tip
(positive/negative),
blood
culture
(positive/negative) as a risk factors. Results. Duration of
HC were 6-199days (mediana 45 d) with cumulative total
of 11 818 days. Mostly of the FC in Gr.A were electively
removed - 320 (88%); for malfunction 26 (7,1%), and for
suspected
CRI-18(4,9%).Infection
rate
was-1,52
episodes/1000 catheter days.In Gr. B all SC were electively
removed . In Gr. C electively removed were 130 (95%);
for malfunction 5(3,6%); suspected CRI-2(1,4%).Infection
rate for Gr.C was 0,81 episodes/1000catheter days. Gr.D –
29 SaC were electively removed and only one with CRI.
Kaplan-Meier curve of survival show significant statistical
difference between 60 and 80 catheter days of survival
between groupA and C (log-rank test p=0,00001). We
analysed risk factors for catheter survival in groups with
Cox regression model and we found that for Gr.A risk
factors
were:
age
(<51/>51)
(p=0,0007)
sex
(p=0,002905) and diabetes mellitus (p=0,008).For Gr. C
risk factors was hospital/ambulatory placed catheters
(p=0,006).Univariate analysis do not reveal significant risk
factors in all groups. With multivariant analysis we found
this risk factors: gr.A- sex (p=0,002905) and blood culture
(p=0,006883); gr.C- number of previous thrombosed AVF
(p=0,049508) and comorbidity of diabetes/malignancy
(p=0,009928). The infection and malfunction free survival
time was not affected by other analyzed risk factors.
Conclusions. We concluded that most of the HC were
removed because of provided permanenet vascular access
and not due to complication. Femoral catheters can be
inserted ambulatory and can remain in place for a long
time, without complication, with permanent care of a
specially educated vascular access team. Recognizing and
knowing the risk factors that are associated with infection
and
malfunction
of
the
catheters
can
prevent
complications.
Background. Patients in the end stage of renal failure
present increased morbitity and mortality due mainly to
cardiovascular disease.Our aim was to study predictors of
survival in correlation to treatment modalities and
transplantation
in
patients
on
permanent
renal
replacement therapy. Methods. We studied 96 dialyzed
patients, 62 males and 34 females, on mean age
62,1±14,27 years old. The treatment modalities which were
applied were: regular haemodialysis (HD, n=34),
predilution haemodiafiltration (HDF, n=42) and peritoneal
dialysis (PD, n=20).The mean follow up was 5.5 years and
in the end of this time we examined the death and
transplantation events.Then, we studied the survival in
comparison to renal replacement modalities, as well as
comparatibly the survival between the survived dialyzed
patients and the patients after renal transplantation.We
built a cox-regression analysis to examine the common
factors that predict mortality of these patients. Results.
During the follow up period, 26 deaths were noted (a ratio
of
27.1%),
and
10
patients
underwent
renal
transplantation (a ratio of 10.4%).The mean survival was
5.45 years for the patients on HDF, 5.42 years for the
patients on HD and 4.6 years for PD patients (HDF and HD
vs PD, Log Rank test =35.086, p<0.001).We did not
observed significant difference in survival between lived
dialyzed patients and renal transplanted patients
(p=NS).In the cox-regression analysis, we found that heart
insufficiency (p=0.001), treatment modality (p=0.001) and
sex (male vs female p=0.02) act as significant predictors
for the survival of our patients.However, the age and the
duration of renal replacement therapy were not found to
influence significantly the survival of studied patients
(p=NS). Conclusion. The patients on peritoneal dialysis
presented worse survival than the patients on HDF or HD
during a follow up of 5.5 years, although the cardiovascular
disease was found very important predictor for the survival
of the dialyzed patients with an additional deterioration for
the male patients.
3
Oral Presentations
OP 07
OP 08
CATHETER-RELATED BLOODSTREAM
INFECTION IN PATIENTS WITH
PERMANENT HEMODIALYSIS CATHETERS
EPIDEMIOLOGY OF RENAL REPLACEMENT THERAPY
IN ALBANIA
1
A.Strakosha, 1 N. Pasko, 2 T. Dedej, 1 S. Kodra, 1 A. Idrizi,
M. Barbullushi, 1 N. Thereska
1
Nephrology Unit, University Hospital Center "Mother
Tereza" of Tirana, Albania
2
Clinical laboratory unit, University Hospital Center
"Mother Tereza" of Tirana, Albania
1
V. Gerasimovska, A. Oncevski,
B. Gerasimovska-Kitanovska, A. Sikole
University Clinic of Nephrology, Medical Faculty, Skopje
University of Skopje, R. Macedonia
Background. Tunneled cuffed haemodialysis catheters
(TCC) are used for long term vascular access in a small
proportions of patients. Catheter-related bloodsteram
infection (CRBI) is a frequent complication among
hemodialysis (HD) patients (pts) using TCC. Methods.
During the 3 year study period we analysed a group of 123
pts receving chronic HD via 181 TCC. Duration time of TCC
were 9500-10 500 days. TCC were divided in 3 groups:
Group 1 - tunneled femoral catheters (TFC) - 103 (77
pts);Group 2 - tunneled jugular catheters (TJC) - 41 (24
pts); Group 3 - tunneled subclavian catheters (TSC)- 37
(22 pts). All pts with TCC were monitored for infection and
data recorded for each patient included: clinical signs of
infection (high temperature, chills.. conected with HD),
episodes of CRBI, blood culture from catheter and
peripheral vein when we had a suspicion of infection,
antibiotic therapy and clinical outcomes. Results. In Group
1(TFC) - 21 catheters had 41 episodes of CRBI and they
were successfully treated with antibiotics (systemically and
antibiotic "lock" therapy) and unsuccessful in 6 cases
(5,8%). Microbiologically in 4 of this 6 cases we isolated
Staphylococcus aureus, in 2 cases Staphylococcus
coagulasa negative and 2 cases Enterococcus +
Pseudomonas together. Infective rate in this group was 4,1
infective episodes/1000 catheter days. Group 2 (TJC) - 7
catheters had 30 episodes of CRBI successfully treated
with antibiotics (systemically and antibiotic "lock" therapy)
and unsuccessful in 4 cases (9,7%). Microbiologically we
isolated in 3 cases Staphylococcus aureus, and in 1 case
Acinetobacter + Enterococcuss. Infective rate in this group
was 2,8 infective episodes/1000 catheter days. Group 3
(TSC)- 14 catheters had 32 episodes of CRBI successfully
treated with antibiotics and unsuccessful in only 1 case
(2,7%).Microbiologically
we
isolated
Staphylococcus
aureus. Infective rate in this group was 3,6 infective
episodes/1000 catheter days. Most often isolated
microorganism was Staphylococcus coagulasa negative and
much less Staphylococcus aureus and Enterococuss. The
initial AB regimens were Vancomycin/Cefotaxim or
Ciprofloxacin systemically and "locked" into TCC. Antibiotic
therapy was statistically significant for catheters survival in
group 3 -TSC (log rank test=0,06) and using multivariant
analysis, only in this group we found that positive blood
culture (p=0,0008295) has prognostic value as a risk
factor for free survival time for TCC. Conclusion. We
concluded that use of AB therapy was sensitive to
causative bacteria and was effective and successfull
tretment modality in eradicating CRBI and this will reduce
catheter replacement in some cases.
Background. Chronic kidney disease (CKD) has become
the leading cause of mortality in Albania associated with an
increasing health cost. During the last decade Albania has
undergone under deep political and economic changes. An
enormous support of the nephrology community by central
authorities has resulted in gradual increasing number of
patients treated with renal replacement therapies (RRT)
(hemodialysis,
peritoneal
dialysis
and
renal
transplantation), though not in equally manner. This study
is the first report of the National Registry of CKD in Albania
that aims to present the incidence and the prevalence of
patients treated for end stage-renal disease (ESRD).
Methods. This is a multicenter, cross-sectional study.
From January 2007, all patients belonging to the
participating centers were included in the analysis, after
having given their informed consent. Clinical data were
collected using the SIGANA software. Results. There were
a total of 592 patients [368 (62.2%) M and 224 (37.8%)
F] treated for end stage-renal disease, with a total
prevalence of 126.5 pmp. Four hundred four (68.2%)
patients were treated with hemodialysis (HD), 51 (8.6%)
with peritoneal dialysis (PD) and 137 (23.1%) with renal
transplantation. The total prevalence for HD and PD was 92
pmp. The prevalence of transplanted patients was 31.3
pmp. The increase in the number of patients treated with
renal replacement therapies (RRT) during the last decade
correlated very closely with the increase in healthcare
spending per person. Most renal transplantations have
been performed in Turkey (45.2%), less in Greece
(22.0%), Albania (18.2%), Italy (8.4%), Pakistan(3,2%),
Austria(2,1%) and Hungary (0.5%). Most recipients
received the transplanted kidney from a living donor [131
(95.6%)], only 6 (4.3%) from a cadaveric donor. Among
living donors 86.7% were consanguineous, and 13.3%
were not. Since the first renal transplantation in Albania
performed on 2008, it has been an impressive increase in
the number of renal transplant procedures. Conclusion.
The nephrology reality in Albania is still expanding, but
certainly inadequate to the real needs of the population.
The model based on national electronic registry is perhaps
the best suited to systematic, longitudinal surveillance of
chronic disease. Based on this surveillance program it
should be possible to adopt future national disease
prevention strategies.
4
Oral Presentations
OP 09
OP 10
THE DEVELOPMENT OF A CONTINOUS AMBULATORY
PERITONEAL DIALYSIS PROGRAM IN ALBANIA
SYSTEMIC AND INTRAPERITONEAL
PROINFLAMMATORY CYTOKINES PROFILES IN
PATIENTS ON CAPD
1
M. Rroji (Molla), 1 S. Seferi, 1 M. Barbullushi, 2 E. Petrela,
N.Thereska
1
Department of Nephrology-Dialysis-Transplantation,
University Hospital Center "Mother Teresa" of Tirana,
Albania
2
Department of Statistic, University Hospital Center
"Mother Teresa” of Tirana, Albania
1
D. Maksic, S. Vasilijic, M. Colic, D. Pilcevic, D. Bokonjic
1
Clinic of Nephrology, Military Medical Academy, Belgrade,
Serbia
2
Institute for Medical Research, Military Medical Academy,
Belgrade, Serbia
3
National Center for Poisoning Control, Military Medical
Academy, Belgrade, Serbia
Background. The management of end-stage renal disease
(ESRD) poses major challenges to the health care system
of any country. Albania is a country with about 3.5 million
inhabitans where the incidence of CKD is about 118/million
per year. We started with CAPD at 2004 but expansion of it
was less rapid than HD during the last years. Penetration
of Peritoneal Dialysis (PD) in Albania is estimated at 9.8%
and is comparable with the other countries of the region.
Methods. To analyze the status of CAPD in Albania,
technical survival, patient outcome, complications and to
evaluate their contributing factors we studied records of
CAPD patients treated in our Hospital from the time we
started, February 2004 till April 2011 who had more than 3
months in CAPD. Results. 91 patients, males 55%, mean
age 51.42±13.51 years; 68% older than 51years old with
mean time in therapy 26.47±12.35 months were
registered in in PD program. 44% of the pts lived in rural
and 49% had low education. The causes of ESRD were
typical for a developing country, with glomerulonephritis
still the most prevalent cause. 23 % of the patients were
diabetic, but analysis according to Log Rank (Mantel-Cox)
showed that neither of the diagnoses nor gender didn’t
have significant impact in survival (p=0,352); (p=0,342)
respectively. 57% of the presented pts in PD were late
referrals with significant lower GFR than early referrals
2.7±0.9ml/min vs GFR 6.5 ±. 1.4(p=0.02). Peritonitis was
the most frequent serious complication of CAPD with a
major influence on the number of patients switching from
CAPD to haemodialysis but its incidence decreased
significantly after 2008 when we began to use double bag
system 30% vs 16%.There were 34 episodes of
peritonitis,3 tunnel,4 exit site infections, 6 catheter
displacement,2 catheter leakage,2 sclerotisants peritonitis
and 3 ultrafiltration failure. Obstruction of the catheters
followed by hernias were the most frequent noninfection
complications. Polycystic kidney disease was the only
factor associated with higher rate of hernia p=(0.005).
54% of the dropped out pts had passed to HD and in only
28% of the pts peritonitis was the cause of mortality.
Conclusion. In Albania, CAPD is relatively new treatment.
It is organized as part of integrated care model of RRT.
While outcomes in terms of complications rates have
improved considerably our goal is to increase penetration
of PD in a near future.
Background.The cross-sectional study included 44 CAPD
patients (27M and 17 F, average age 57.12±16.66), of
whom 21 patients were on the standard solutions ( Stay •
safe, A.N.D.Y.Disc) for peritoneal dialysis and 23 on the
biocompatible solutions (Gambrosol bio trio, Stay •Safe
balance). Average dialysis treatment period was 3.59±2.67
years. Methods. In all CAPD patients dialysed longer than
6 months levels of IL-1β, TNFα and IL-6 in the serum and
dialysis effluent were analysed in the phase without acute
infection-related complications (CAPD peritonitis, infection
of the catheter exit-site, other acute infections). Control
group included 20 patients with the CRF (stage IV and V)
whose serum levels of the examined cytokines were also
determined. Levels of the inflammatory cytokines were
measured by commercial specific ELISA kits (BioSource,
Camarillo, California, USA). Statistical analysis of the
obtained results was performed by commercial statistics PC
software (Stat for Windows, R.4.5, USA). Results. The
serum IL-1 and IL-6 levels were not statistically
significantly different in patients on CAPD, irrespective of
the type of the used dialysis solutions and in the control
group of patients with CRF. The serum TNFα levels, unlike
IL-1β and IL-6, were statistically significantly higher in
patients on CAPD in comparison with the control group of
patients (13.20±3.23 v.s. 5.59±4.54 , p < 0.001, Mann
Whitney test). The serum and effluent IL-1β levels in
patients on CAPD within one and longer than one year of
dialysis did not significantly differ, but the effluent IL-6
levels were significantly higher than in the serum of both
groups of patients, that is, effluent IL-6 levels in CAPD
patients dialysed more than one year was significantly
higher in comparison with those in patients dialysed within
a year. Both serum and intraperitoneal (IP) levels of the
examined cytokines did not significantly differ in patients
on the standard and biocompatible solutions, regardless of
the present trend toward decrease of IP IL-6 levels in
patients on biocompatible solutions. Residual renal funcion
(RRF) and number of CAPD peritonitis did not have any
important impact upon the serum and IP levels of the
examined citokynes. Conclusion. Elevated serum TNFα
levels and significant local IL-6 production in our CAPD
patients indirectly confirm importance of peritoneal dialysis
(PD) in amplification of the chronic inflammation
substantialy dependent on the duration of dialysis
treatment.
5
Oral Presentations
OP 11
OP 12
DEFECTS OF THE RED BLOOD CELL MEMBRANE AS A
POSSIBLE RISK FACTOR OR DIAGNOSTIC MARKER
FOR THE DECREASED RED BLOOD CELL LIFESPAN IN
HEMOADIALYSIS PATIENTS
DIALYSIS PATIENTS WITH METABOLIC SYNDROME
NEED LESS RHUEPO FOR SIMILAR HEMOGLOBIN
LEVELS
M. Erkmen Uyar, E. Tutal, Z. Bal, N. Ahmed, S. Sezer
Department of Nephrology, Baskent University Hospital,
Turkey
1
D. Stamopoulos, 2 E. Grapsa, 1 E. Manios, 1 V. Gogola,
3,4
N. Bakirtzi
1
Institute of Materials Science, National Center for
Scientific Research “Demokritos”, Athens, Greece
2
Renal Unit, Athens General Hospital “Aretaieion”, Athens,
Greece
3
Renal Unit, Athens General Hospital “Alexandra”, Athens,
Greece
4
Department of Nephrology, Athens General Hospital “G.
Gennimatas”, Athens, Greece
Background. The metabolic syndrome (MS) associates
metabolic abnormalities such as insulin resistance,
dyslipidemia, abdominal obesity and hypertension. Visceral
fat mass is associated with metabolic syndrome and
atherosclerosis. We investigated the effects of body
compositions and metabolic syndrome on anemia
parameters and rHuEPO requirements in maintenance
hemodialysis (MHD) patients. Methods. Body composition
(body mass index and bioimpedance analysis) and
laboratory data were obtained from 110 MHD patients (39
female; aged 53,8±13,5 years). Body compositions were
analyzed by using the Body Composition Analyzer (Tanita
BC-420MA). Metabolic syndrome was identified according
to ATP-III criterias. The malnutrition-inflammation score
was used to evaluate the malnutrition-inflammation
complex syndrome. Last 6 months monthly anemia
parameters,
hemoglobin
albumin,
CRP,
calcium,
phosphorus,
parathormone
levels
and
rHuEPO
requirements were retrospectively analyzed. Results.
Patients with metabolic syndrome seem to reach target Hb
levels (11g/dL, more frequently to the (10-12g/dl, 66.3%
vs 84.8%, p:.03). Metabolic syndrome patients also
needed lower rHuEPO for reaching similar hemoglobin
levels compared to patients without metabolic syndrome
(2679.3 ± 1936.1 vs 3702.5 ± 2213.0 u/kg, p:.02).
Patients with metabolic syndrome also had significantly
higher fat mass, visceral fat mass; and lower MIS than in
patients without MS (p:.0001, .0001, .01 respectively). In
regression analysis, bone mass and BMR were the major
determinants of rHuEPO requirement for the whole group
(p:,01 and p:,05 respectively). In patients with MS bone
mass (p:,01) and in patients without MS BMR and CRP
levels (p:,0001 and p:,008 respectively) were the major
determinants of rHuEPO requirement. Conclusion. Our
results indicate that MS might be an advantage for
reaching higher Hb levels with lower rHuEPO dosages.
Background. Impaired production of erythropoietin and
iron deficiency are two important factors contributing to
chronic anemia in hemodialysis patients (HDp). Another
factor relates to the decreased lifespan of red blood cells
(RBCs) observed in HDp. Methods. Atomic force
microscopy (AFM) is employed to survey the membrane of
intact RBCs (iRBCs) of seven HDp in comparison to healthy
donors (hd). Representative AFM images are shown in
Figures 1(a)-1(c) for an HDp iRBC. Panel (a) shows the
whole iRBC, panel (b) focuses on part of the membrane
(dotted rectangle in panel (a)) and panel (c) shows the
reconstructed side view of panel (b) where the intracellular
(ics) and extracellular (ecs) space is discerned. Results.
The iRBCs membrane of the HDp is crowded with extended
defects that are mainly circular, thus called orifices (Figure
1(b)). These orifices extend through the membrane (Figure
1(c)) and exhibit a statistically significant relative increase
of order 54±12 % for the HDp when compared to hd. A
correlation between the orifices index, Ror, defined as
orifices per iRBC, and urea concentration, [Ur] is evidenced
by the results shown in Figure 2 for the hd (normal [Ur]),
HDp:A (subgroup A of HDp with relatively low [Ur]) and
HDp:B (subgroup B of HDp with relatively high [Ur])
groups. Conclusion. These results give evidence that the
membrane of iRBCs of HDp is structurally degraded in
comparison to hd. The correlation between the orifices
index, Ror and urea concentration, [Ur] suggests that the
uremic milieu is the underlying cause, possibly resulting in
the decrease of the RBCs lifespan observed in HDp. In this
context, the introduced index, Ror could be a key risk
factor or useful diagnostic marker for the evaluation of
both HD adequacy and anemia management. More
experiments are needed to discriminate the two cases.
6
Oral Presentations
OP 13
OP 14
A PROSPECTIVE STUDY IN A SINGLE CENTER IN
ALBANIA. PREVALENCE AND RISK FACTOR OF POSTTRANSPLANT ANEMIA
CORONARY ARTERY CALCIFICATION: COMPARISON
BETWEEN RENAL TRANSPLANT RECIPIENTS AND
CHRONIC KIDNEY DISEASE PATIENTS
1
1,2
A. Strakosha, 2 T. Dedej, 1 S. Mumajesi, 1 V. Cadri,
F. Riza, 3 A. Dedej, 1 N. Thereska
1
2
Clinical laboratory unit, University Hospital Center
"Mother Tereza" of Tirana, Albania
3
American Hospital, Tirana, Albania
S. Simic-Ogrizovic, 5 V. Dopsaj, 5 N. Bogavac-Stanojevic,
M. Vuckovic, 4 V.Giga, 1,2 V.Lezaic
1
Clinic of Nephrology, Clinical Center Serbia, Belgrade,
Serbia
2
School of Medicine, University of Belgrade, Belgrade, Serbia
3
Institute for Radiology, Clinical Center Serbia, Belgrade,
Serbia
4
Clinic of Cardiology, Clinical Centar Serbia, Belgrade, Serbia
5
Institute of Medical Biochemistry, Faculty of Pharmacy,
Belgrade, Serbia
3
3
Background.
Anemia
is
common
after
renal
transplantation but its true incidence is not well known as
it various according to the criteria used in its definition.
The purpose of the present study was to investigate the
evolution of post transplant anemia during the first three
years after renal transplantation, its treatment and
possible risk factor. Methods. 150 renal transplant
recipients with a functioning graft at 12 months were
included in the study.75% (112 patients) were on
cyclosporine and 25% (37 patients) on tacrolimus
treatment. Anemia was defined following the WHO criteria:
Hemoglobin (Hb) concentration <13 gr/dl in man and Hb
<12 gr/dl in women. Results. The Hb concentration
increased from 10.5 gr/dl at 1 month to 13 gr/dl at 12
months and 13.5gr/dl to 36 months. The prevalence of
post transplant anemia decreased from 88% at 1 month to
29% at 12 months and to 20% to 36 months. There were
no differences in age, gender, dialysis treatment before
transplant, incidence of acute rejection, delayed graft
function and immunosuppressant therapy between anemic
and non-anemic recipients. At 12 months only 20% of
recipients were on treatment with erythropoietin
stimulating agent (ESA). At 36 months anemia post
transplant was associated with higher serum creatinine and
lower serum albumin levels. Conclusion. Anemia post
renal transplantation defined according to WHO criteria is
common and its incidence remained stable between 12 and
36 months. Variables associated with anemia were graft
function at 12 months and graft function and malnutrition
at 36 months.
Background. Even if the kidney transplantation (Tx)
provides cardiac and renal benefits, kidney function still
remains poorer than that of healthy persons, and renal Tx
recipients have up to ten times the rate of cardiac death as
the general population. The aims of the study were to
evaluate the prevalence of coronary artery calcification
(CAC) in stable renal Tx recipients as well as age and gender
matched chronic kidney disease (CKD) patients in stage 2-5
not requiring dialysis; to assess possible demographic and
laboratory risk factors (promoters and inhibitors of
calcifications) associated with CAC and to single out possible
predictors of patients’ mortality after 30 months follow up.
Methods. The study involved 97 pts: 49 Tx recipients (31
males, aged 41.9 ± 10.6 years, previous CKD and/or dialysis
(D) duration 143 (97-206) months and Tx duration 9.56 ±
5.27 years, GFR 39.6± 15.0 ml/min/1.73m2 ) and 48 CKD
pts (25 males, aged 38.2 ± 15.5 years, CKD duration 24
(12-33) months, GFR 30.8± 22.3 ml/min/1.73m2). CAC
score was evaluated using MSCT and the final score is
expressed in modified Agatston units. Results. The
prevalence of pts with a CAC score > 100 was 31% for all
examined patients, but 43.8 % in the Tx group and 16.7%
for CKD pts (p<0.001). Renal Tx pts with CAC were
significantly older and had longer CKD and /or D duration
than Tx patients without CAC. CKD patients with CAC were
older, had longer CKD duration, as well higher
homocysteinemia but lower serum albumin and fetuin A
levels. The AUC was calculated to assess the accuracy of the
examined parameters in diagnosing a CAC score > 100 in
CKD patients. Only fetuin A and albumin had acceptable
discriminative ability for detecting CAC presence. In renal Tx
recipients no parameter had significant discriminative ability
for detecting CAC. During the observational period (30
months) 30 patients began dialysis, and 6 pts died.
Independent predictors of mortality using the multivariate
analysis were age, serum amyloid A (SAA) and CAC score.
Conclusion. The prevalence of CAC in renal Tx pts is
relatively high and definitely linked with age and CKD and/or
D duration. In CKD pts the prevalence was less with age and
CKD duration, while the negative acute phase markers, SAA
and fetuin A levels were associated with CAC. Along with age
and serum amyloid A, CAC score was a predictor of patient
death.
7
Oral Presentations
OP 15
OP 16
OUTCOME OF CONVERSION FROM CALCINEURINE
INHIBITORS TO SIROLIMUS IN RENAL ALLOGRAFT
RECIPIENTS WITH STABILE RENAL FAILURE GRADE
III AND PROTEINURIA BELOW 500 MG IN PERIOD
MORBIDITY AND MORTALITY OF HEMODIALYSIS
PATIENTS (IN THE WAITING LIST) ELIGIBLE FOR
CADAVERIC RENAL TRANSPLANTATION
A. Tsiantoulas, E. Liakou, D. Ekonomidou, C. Dimitriadis,
A.-M. Belechri, G. Efstratiadis, D. Memmos
Nephrology Department Aristotle University, Hippokration
General Hospital Thessaloniki
1
L. Ignjatovic, 1 N. Vavic, 1 V. Rabrenovic, 2 A. Tomic,
1
Z. Kovacevic, 1 D. Jovanovic, 1 D. Maksic
1
Clinic of nephrology, Medical Military Academy, Belgrade,
Serbia
2
Clinic of vascular surgery, Medical Military Academy,
Belgrade, Serbia
Background. The increase of the prevalent hemodialysis
patient population and the relative shortage of kidney
transplants prolong the waiting time for a cadaveric renal
transplantation. This prolonged exposure to hemodialysisassociated cardiovascular morbidity eventually renders a
considerable amount of these patients ineligible candidates
for transplantation. The aim of this study was to evaluate
the morbidity and mortality of eligible cadaveric kidney
transplant recipients on hemodialysis. Methods. We
evaluated 505 incident ESRD patients (mean±SD age 61.5
± 15.6 years) that were started on thrice weekly
hemodialysis during 18 years (Jan 1992- Jan 2010) and
excluded those who died in the first 3 months and those
with a follow up <12 months. Among those, 166 patients
(mean age 48.1 ± 13.2 years) fulfilled eligibility criteria for
a cadaveric kidney transplantation (age<65 years, with no
evidence of active infection, neoplastic or advanced
cardiovascular disease). 33/166(20%) patients (mean age
39.5 ±12.8 years) were transplanted; 13 from a living
donor, after a mean period of 24 ± 21 months on dialysis,
and 20 from a cadaveric donor after a mean period of 62
±38.2 (range 12-180) months. Results. The 133 nontransplanted patients (mean age 49.3 ± 12.5 years)
continued on hemodialysis for a mean follow up period of
79 ± 52 months, during which 48% of them died. KaplanMeier-estimated five year survival was 57% and ten year
survival was 24%. Relative risk for death for patients on
the waiting list was 5.0 (CI 1.7-15.15) Almost 10%
(13/133) of these patients had a history of cardiovascular
disease (coronary artery disease: CAD, cardiac arrhythmias
or peripheral arterial disease: PAD) upon starting
hemodialysis. The 5 year prevalence of CAD was 57%, of
myocardial infarction 41.8%, of PAD 44.9% and that of
arrhythmias 43.9%. The ten year prevalence was 57.5%,
47.5%, 50% and 50%, respectively. Moreover, after ten
years, 26(16%) of the patients were diagnosed with
neoplastic disease and 43 (24.2%) had episodes of severe
systemic bacterial (endocarditis, osteomyelitis, etc) or viral
(mainly HCV seroconversion) infections, and 17.8%
underwent parathyroidectomy. Conclusions. In Greece,
the mean waiting time on the cadaveric kidney transplant
list was more than 5 years. During that time, 43% of the
transplant candidates on hemodialysis had died. Morbidity
is high and is mainly attributed to cardiovascular,
infectious and neoplastic disease.
Background. Tremendous breakthrough in solid organ
transplantation was made with introduction of calcineurine
inhibitors. In the same time they are potentially
nephrotoxic drugs in the patients with transplanted
kidneys. The aim of this study was to evaluate the
outcome of conversion from calcineurine inhibitors to less
toxic sirolimus in renal allograft recipients with renal failure
grade III and proteinuria below 500 mg. Methods. In the
period 2003-2010 24 patients (6f/18m), mean age
41±12,2 years, on triple immunosuppressive therapy:
steroids, antiproliferative drug and calcineurine inhibitors
were switched from calcineurine inhibitors to sirolimus and
followed 64±13 months. During the regular outpatients
controls we followed graft function through serum
creatinine and GFR calculated with Cockcroft-Gault
equation, proteinuria and lipidemia. Results. 30. days
after conversion patients insignificantly increased GFR
(from 48,9±16 to 65,6±23.5ml/min), proteinuria (from
379±232 to 1051±1920 mg) and triglyceridemia (from
2,63±1,1
to
4,8±1,74
mmol/l)
and
significantly
hypercholesterolemia
(from
4,8±1,5
to
7,63±0,84
mmol/l). After 21±11 months 15 patients ceased sirolimus
therapy due to: reconversion to calcineurine inhibitors (10
pts) and double immunosuppressive therapy (3 patients),
return to hemodialysis (1 patient) and death (1 patient).
Nine patients, are still on sirolimus therapy. In that period
they significantly improved graft function (GFR from
53,2±12,.7 to 69±15 ml/min), insignificantly increased
proteinuria (from 265±239 to 530,6±416,7 mg) and
lipidemia (cholesterol from 4,71±0,98 to 5,61±1,6 and
triglycerides from 2,04±1,18 to 2,1±0,72 mmol/l). Ten
patients were re-converted from sirolimus to calcineurine
inhibitors due to abrupt increment of proteinuria (from
298±232 to 1639±1200 mg - 7 patients), rapid growth of
multiple de novo formed ovarian cysts (2 patients) and
operative treatment of persisted hematoma (1 patient).
From re-conversion to the end of follow up they were
stabile and significantly improved proteinuria (from
1639±1642 to 529±300 mg) but insignificantly decreased
GFR (from 56,10±28,09 to 47±21 ml/min). Conclusion.
Patients who didn’t experience abrupt onset of proteinuria
had the greatest benefit of conversion from calcineurine
inhibitors to sirolimus. Those with subnephrotic proteinuria,
after reconvertsion to calcineurine inhibitors decreased
proteinuria below 1 g, but also slowly and progressively
decreased GFR.
8
Oral Presentations
OP 17
OP 18
ASSOCIATION BETWEEN RED BLOOD CELL PROTEIN
MARKERS AND MICROALBUMINURIA IN PATIENTS
WITH DIABETIC NEPHROPATHY
PERI-AORTIC FAT TISSUE AND MIAC SYNDROME IN
ESRD PATIENTS
1
1
K. Turkmen, 2 O. Ozbek, 3 I. Guney, 3 L. Altintepe,
H. Zeki Tonbul
1
Department of Nephrology, Meram School of Medicine,
Selcuk University, Konya, Turkey
2
Department of Radiology, Meram School of Medicine,
3
Department of Nephrology, Meram Research and Training
Hospital, Konya, Turkey
2
1
G. Perunicic-Pekovic, Z. Rasic-Milutinovic,
A. Nikolic-Kokic, 4 M. Nikolic
1
Department of Nephrology, University Hospital Zemun,
Belgrade, Serbia
2
Department of Endocrinology, University Hospital Zemun,
Belgrade, Serbia
3
Department of Physiology, Institute of Biological
Research, Belgrade, Serbia
4
Department of Biochemistry, Faculty of Chemistry,
University of Belgrade, Serbia
3
Background. Thoracic peri-aortic fat tissue (PFT) was
considered as a metabolically active organ that has a
pathogenic role in the genesis of atherosclerosis.
Malnutrition,
inflammation,
atherosclerosis/calcification
(MIAC), and endothelial dysfunction are the most
commonly encountered risk factors of cardiovascular
disease in ESRD patients. We aimed to investigate the
relationship between PFT and MIAC syndrome in ESRD
patients. Methods. 79 ESRD patients (30 females, 49
males) receiving PD or HD and 20 healthy control subjects
enrolled in this cross-sectional study. PFT and thoracic
aortic aortic calcification (TAC) were performed by a 64MDCT scanner. Patients with albumin<3.5 mg/dL was
defined as patients with malnutrition; hs-CRP level >10
ng/dL
had
inflammation;
TAC
>10
had
atheroscleosis/calcification. The demographic, clinic and
laboratory features of the ESRD patients and healthy
subjects were shown in table 1. Results. TAC and PFT
were significantly higher in ESRD patients compared with
healthy subjects (p=0.03, p=0.049, respectively). There
was a statistically significant relationship between PFT and
TAC in ESRD patients (r=0.458, p<0.0001). PFT was found
to be significantly increased when the MIAC components
increased. PFT was positively correlated with age, BMI, uric
acid, TAC, presence of hypertension and MIAC. Advanced
age and TAC were found to be independent predictors of
increased PFT. Conclusion. We found a relationship
between PFT and MIAC syndrome in ESRD patients.
Background. Diabetes mellitus (DM) is chronic metabolic
disease
characterized
by
varying
or
persistent
hyperglycemia, attributed to the decreased production of
insulin or improper utilization of glucose. Diabetic
nephropathy is a micro vascular complication occurring in
people
with
DM,
characterized
by
albuminuria,
hypertension,
and
progressive
renal
insufficiency.
Microalbuminuria is a risk factor for atherosclerotic
vascular disease and predicts cardiovascular disease
mortality and renal failure in diabetic and non-diabetic
populations. Being a metabolic disorder, DM affects the
functioning of the red blood cells (RBCs) through
interaction
with
its
membrane
and
intracellular
constituents. The increasing number of diabetes patients in
the developing world emphasizes the need of precise
detection of changes in blood cells. Methods. This study
examined the associations of RBC proteins (activities of
antioxidant enzymes, the level of glycated haemoglobin,
the level of oxidized haemoglobin, and RBC membrane
proteins profile) with microalbuminuria in persons at high
risk of renal and cardiovascular disease. A ratio of about
0.03 to 0.30 mg/g of albumin to creatinine in the urine is
considered positive for microalbuminuria. Fasting venous
blood samples were collected from 40 subjects of whom 20
were healthy individuals and 20 had type 2 diabetes (for
more than 5 years) with nephropathy. Diabetes status was
determined according to the World Health Organization
criteria. Results. After adjustment for age, gender, body
mass index, smoking status, plasma lipid profile and blood
pressure, microalbuminuria was associated (p<0.01) with
significantly lower CuZn-superoxide dismutase (SOD1)
activity, but with significantly higher RBC concentrations of
glycated as well as oxidized haemoglobin compared with
controls. Significant associations of microalbuminuria with
RBC membrane proteins profile and activities of catalase
and the RBC antioxidant defense system relating to
glutathione were absent. Conclusion. The data are
consistent with the view that oxidative stress (antioxidantprooxidant imbalance) could play a crucial role in the
development and progression of diabetic nephropathy.
9
Oral Presentations
OP 19
OP 20
ADVANCED GLYCATION END-PRODUCTS (AGES) AND
LONG-DISTANCE RUN
THE IMPACT OF MEMBRANE PERMEABILITY AND
QUALITY OF DIALYSATE ON CARDIOVASCULAR
OUTCOMES IN HEMODIALYSIS PATIENTS
1,2
M. Mydlik, 1 K. Derzsiova, 3 K. Sebekova
IVth Internal Clinic, University Hospital of L. Pasteur,
Kosice, Slovak Republic
2
Institute of Experimental Medicine, Medical School, P.J.
Safarik University, Kosice, Slovak Republic
3
Institute of Molecular Biomedicine, Medical School,
Comenius University, Bratislava, Slovak Republic
1
G. Asci, 1 M. Ozkahya, 1 H. Toz, 1 S. Duman, 1 F. Kircelli,
E. Sevinc Ok, 2 M. Cirit, 3 S. Bayraktaroglu, 1 S. Sipahi,
1
H. Dheir, 1 D. Bozkurt, 4 S. Erten, 1 A. Basci, 1 E. Ok
1
Division of Nephrology, Ege University, Turkey
2
Division of Nephrology, Ataturk Research and Training
Hospital, Turkey
3
Department of Radiology, Ege University, Turkey
4
Division of Nephrology, Bozyaka Research and Training
Hospital, Turkey
1
1
Background. AGEs may be formed exogenously by
heating (e.g., cooking), or endogenously through normal
metabolism and aging. Under certain pathologic conditions
(e.g., oxidative stress), AGEs formation can be increased
beyond normal levels. The aim of the study was to
investigate AGEs and essential renal function parameters
(ERFP) before, immediately after and 2 days after both
runs. Methods. Thirteen well trained runners (mean age:
47.8±11 yr) during 16.3-kilometre long-distance run and 9
well trained runners (mean age 42.9±9 yr) during 9.5-km
run were investigated. ERFP were investigated in all
runners using standard biochemical methods, plasma
AGEs, advanced oxidation protein product (AOPP) by
spectrofluorometric methods and malondialdehyde (MDA)
using spectrophotometric method. Results. Body weight in
runners decreased in average of 1.7±0.4 kg after 16.3-km
run and of 1.2±0.5 kg after 9.5-km run. Blood pressure
decreased after 16.3-km run and 9.5-km run (from
14.5±1.6/9.5±0.9 to 12±2.0 kPa, p<0.01;resp. from
16.9±1.9/10.1±1.0 to 15.5±2.4/9.1±1.6 kPa, p>0.05).
Total proteinuria was 0.45±0.31 g/L after 16.3-km run and
0.46± 0.29 g/L after 9.5-km run. Serum urea and
creatinine significantly increased after both runs (urea:
from 6.05±1.8 to 6.84 ± 2.1 mmol/L, p<0.01 resp. from
5.6±0.8 to 6.2±1.1 mmol/L, p<0.05; creatinine: from
84.0±12.3 to 118.7±17.5 µmol/L, p<0.01, resp.
74.7±10.2 to 95.9±13.5 µmol/L, p<0.05). Estimated
glomerular filtration rate (eGFR) MDRD significantly
decreased after both runs (16.3-km: from 1.65±0.4 to
1.08±0.3 ml/s; resp. 9.5-km: 1.63±0.3 to 1.18±0.2 ml/s,
p<0.01). Fraction excretion of Na (FE-Na) non-significantly
decreased after both runs and of K (FE-K) significantly
increased after 16.3-km run (from 12.8±3 to 17.6±4%,
p<0.01) and non-significantly increased after 9.5-km run
(from 10.7±2 to 13.2±3 %, p>0.05). No significant
changes in plasma AGEs and AOPP were found (AGEs: from
283.8±64.6 to 292.5±90.1 AU resp. 177.8±86 to
286.7±71.9 AU, p>0.05; AOPP: 159.9±100.4 to
133.9±65.7 resp. from 151.7±58.7 to 106.6±21.8 µmol/L,
p>0.05) after both runs. Plasma MDA significantly
decreased after both runs (from 3.7±1.1 to 3.2±0.9
µmol/L, p<0.01; resp. from 4.5±1.5 to 3.6±1.2 µmol/L,
p<0.05). Conclusion. AGEs and AOPP in runners were in
our reference ranges, no significant changes during the
both runs were observed. Parameter of the oxidation
stress, plasma MDA, significantly decreased after runs,
more significantly after 16.3-km run. Renal function
abnormalities in runners were caused by dehydratation,
protein catabolism, rhabdomyolysis and others. These
renal functional changes were not present or parameters
not significantly differed from initial values two days after
both runs.
Background. The effect of high-flux dialyser (HF) use on
survival is controversial, while the effect of ultrapure
dialysate (UD) use has never been investigated. Methods.
In this prospective, randomized, controlled trial we
examined the impact of membrane flux and dialysate
quality on cardiovascular (CV) outcomes along with CV
surrogate markers (coronary artery calcification-CAC,
carotid artery intima-media thickness-IMT). We randomly
assigned 704 prevalent hemodialysis (HD) patients in a 1:1
ratio to either HF or low-flux (LF) dialyser and either UD or
standard dialysate (SD) groups by 2x2 factorial design.
Follow-up period was 4 years. Primary outcome was
composite of fatal and non-fatal CV events. Results.
Despite trend favoring HF and UD, fatal and nonfatal CV
event-free survival was not different between HF and LF
arms and between UD and SD arms, as well as overall and
CV survival and progression of CAC and carotid artery IMT.
In patients with arterio-venous (AV) fistula (n=576),
composite CV event-free survival was higher in HF group
compared to LF (p=0.02). In adjusted models, HF use was
associated with a 39% risk reduction for composite CV
events (95% CI; 0.38-0.97, p=0.03). Also, both overall
and CV survival was better in HF arm. Composite CV
event-free survival was higher in UD group than SD arm
among patients with HD duration longer than 3 years at
randomization (n=399) (adjusted HR 0.55, 95% CI 0.310.97, p=0.04). CRP levels and CAC progression within 4
years were lower in UD group compared to SD group.
Combined treatment with HF and UD had best overall
survival rate in patients with AV fistula (Figure).
Conclusion. Use of HF membrane improves survival
among patients with AV fistula and UD offers better
outcomes in patients with longer HD duration. Combination
of HF and UD provides greatest survival.
10
Oral Presentations
OP 21
OP 22
ASYMMETRIC-DIMETHYLARGININE AS PREDICTOR
OF MORTALITY, NOT INFLAMMATORY MARKER IN
PATIENTS ON DIALYSIS
ASSOCIATIONS OF SEX HORMONES AND ARTERIAL
STIFFNESS IN FEMALE HEMODIALYSIS PATIENTS
1
1,2
3
J. Kyriazis, 2 K. Stylianou, 3 I. Tzanakis, 2 M. Tzanakakis, 1
G. Lamprinoudis,
1
E. Asmanis, 2 E. Daphnis
1
Nephrology Department , General Hospital of Chios,
Chios, Greece
2
Nephrology Department, University Hospital of Heraklion,
Crete, Greece
3
Nephrology Department , General Hospital of Chania,
Crete, Greece
4
T. Cvetkovic, R. Pavlovic, A. Ignjatovic,
V. Djordjevic, 1 R. Velickovic-Radovanovic, 1 P. Vlahovic,
1
Z. Dimitrijevic
1
Clinic of nephrology, Clinical centre Nis, Serbia
2
Institute of biochemistry, University of Nis, Faculty of
Medicine, Serbia
3
Research Centre for Biomedicine, University of Nis,
Faculty of Medicine, Serbia
4
Department of Medical Statistics, University of Nis,
1
Background.
Arterial
stiffness is
an established
independent
predictor
of
adverse
outcomes
in
cardiovascular disease (CVD), particularly in uremic
patients. However, the way sex hormones impact on
arterial stiffening in hemodialysis (HD) patients remains
largely unknown. Here, we examined the influence of sex
hormones on pulse wave velocity (PWV), a reliable
measure of arterial stiffness, in female HD patients.
Methods. Sixty-two HD women (mean age of 65±13
years), not using any hormonal therapy, were studied. In
each of them, PWV measurements were performed by the
Pulse Trace 6000 system (MicroMedical Ltd, Kent, UK).
After PWV and blood pressure measurements, arterial
blood samples were drawn for estradiol (E2), progesterone
(Pro), testosterone (Te), follicle stimulating hormone
(FSH), luteinizing hormone (LH) and prolactin (PRL)
determinations. Univariate and multivariate regression
analysis were used to determine the factors influencing
PWV (table 1). Results. PWV was not associated with Pro,
Te and LH. On the contrary, PWV correlated positively with
E2 and PRL and inversely with FSH. The direct association
of PWV with E and PRL persisted even after adjustment for
other well-known determinants of PWV, such as age and
SBP. Conclusion. Our results clearly indicated that E2 and
PRL, independently of each other, could adversely affect
arterial stiffness in HD women Thus, the enhanced
progression of arterial stiffening in uremia could be further
substantially accelerated by high endogenous E2 and PRL
levels. Prevention or correction of the hyperprolactinemic
states and avoiding estrogen hormonal therapy during the
postmenopausal years may have beneficial effects on
vascular function, and, thus, may improve the
cardiovascular risk profile in women on HD.
Background. Asymmetric dimethylarginine (ADMA) and Creactive protein (CRP) are important risk factors for
endothelial dysfunction and mortality in the end stage
renal diseases (ESRD) population. C-reactive protein
(CRP), a marker of systemic inflammation and an
independent predictor of cardiovascular mortality in the
general population, and asymmetric dimethylarginine
(ADMA), an endogenous inhibitor of NO synthase, are
important risk factors for cardiovascular disease and
mortality in the ESRD population. Increased CRP levels
have been described in hemodialysis probably due to
concomitant diseases, recurrent infections and chronic
dialytic therapy. ADMA accumulation in the ESRD
population is a consequence of reduced renal excretion and
impaired enzymatic degradation and is related to the
progression of atherosclerosis. Both CRP and ADMA have
been shown to be associated with increases in the
incidence and progression of atherosclerotic lesions in
carotid arteries. Moreover, elevated plasma level of ADMA
in patients with ESRD found to be a strong predictor for
future cardiovascular events and renal injury progression
as well. Methods. In this prospective follow-up study, 82
patients (58 males and 24 females) on hemodialysis were
included. Plasma concentration of ADMA was measured by
the high-performance liquid chromatography (HPLC). Creactive
protein
(CRP)
was
measured
using
immunonephelometric assays. After the initial assessments
patients were followed up during the fourteen months. The
relationships between ADMA, CRP and all-cause mortality
and cardiovascular outcomes were investigated by
univariate and multiple Cox regression analyses. Hazard
ratio (HR) and confidence interval (95% CI) are presented
per 1-SD change in ADMA levels. Results. Elevated plasma
CRP levels were positively correlated with plasma urea
levels in HD patients. This finding suggests that uremia
itself might be associated with elevated inflammation which
may contribute to the development and progression of
atherosclerosis. Unadjusted hazard ratio showed that the
strongest predictor of all-cause mortality among tested
parameters is ADMA (HR 1.39 (1.01-1.91) p=0.043). CRP
is also shown as an independent predictor (HR 1.024
(1.009-1.1.040) p=0.001). When Cox regression model is
adjusted for age, sex and smoking than ADMA has become
the only predictor of all-cause mortality (HR 1.76 (1.0023.11) p=0.049). Conclusion. CRP and ADMA may be
emerging as important risk factors for atherosclerosis in
dialysis patients. Reduced NO elaboration secondary to
accumulation of ADMA and elevated inflammation may be
important pathogenic factors for endothelial dysfunction in
dialysis treatment strategies. Our data shows that ADMA is
independent and a better marker of all-cause and
cardiovascular mortality than CRP.
11
RAPID FIRE PRESENTATIONS
12
Rapid Fire Presentations
RFP 01
RFP 02
MODIFIABLE RISK FACTORS AND PROGRESSION OF
CARDIORENAL DISEASE
ENDOTHELIAL DYSFUNCTION, VOLUME OVERLOAD
AND AGEING ARE POSSIBLE MECHANISMS OF
HYPERTENSION AND LEFT VENTRICULAR
HYPERTROPHY IN CHRONIC KIDNEY DISEASE
1
E. Dounousi, 2 V. Kiatou, 1 K. Pappas, 1 X. Zikou,
G. Spanos, 1 E. Pappas, 1 O. Balafa, 1 A. Tatsioni,
1
D. Karasavvidou, 2 N. Kotzadamis, 3 D. Tsakiris,
1
K.C. Siamopoulos
1
1
4
1
3
Department of Nephrology, University Hospital of Ioannina,
Greece
2
Department of Nephrology, General Hospital of Veria, Greece
3
Department of Nephrology, General Hospital "Papageorgiou"
of Thessaloniki, Greece
8
K. Ioannou, 2 E. Dounousi, 3 A. Kelesidis,
I. Tsouchnikas, 5 S. Papakonstantinou, 6 K. Pappas,
N. Kotzadamis, 7 V. Vargemezis, 2 K. Siamopoulos,
D. Tsakiris
1
Department of Nephrology, Nicosia General Hospital, Cyprus
Department of Nephrology, University of Ioannina, Greece
3
Department of Nephrology, Veria General Hospital, Greece
4
Department of Nephrology, Hippokration Hospital of
5
Department of Nephrology, Nephrology Institute, Athens,
Greece
6
Department of Cardiology, University of Ioannina, Greece
7
Department of Nephrology, University of Thrace, Greece
8
Department of Nephrology, Papageorgiou General Hospital,
2
Background. Hypertension, dyslipidemia, secondary
hyperparathyroidism and severe anemia have been
recognized as modifiable risk factors contributing to the
progression of chronic kidney disease (CKD). The same
factors along with CKD are responsible for the high
prevalence of cardiovascular (CV) disease in these
patients. The aim of this prospective study was to assess
the effect of therapeutic intervention on modifiable risk
factors, progression of CKD and changes of left ventricular
mass index (LVMI), an established surrogate CV marker.
Methods. Two hundred twenty five consecutive CKD
outpatients of stages 1-4 (52% men, 31% diabetics) with
mean age of 65±12 years were followed up for 3 years or
until entering dialysis. At the end of the study 141
patients remained (23 started on dialysis, 10 died and the
rest voluntary drop out). At baseline and then annually
the following parameters were assessed: estimated GRF
(eGFR-ml/min, MDRD), systolic and diastolic blood
pressure (SBP, DBP), Hb, serum cholesterol (Chol), LDL,
triglycerides (TG), serum albumin (sAlb), PTH, Ca++xPO3-4
and treatment with antihypertensives and statins. LVMI
was calculated at baseline and at the end of the study.
Therapeutic target levels were set according to NKF
KDOQI guidelines. Results. SBP and DBP targets were
achieved in 50% and 62% of patients respectively and
independently from CKD stage and the existence of
diabetes mellitus or not. During study, within target were
96%-97% and 97%-99% of patients regarding Hb and
sAlb respectively. All three lipid parameters improved
significantly (Chol: x2=17.6, p=0.001, TG: x2=7.9
p=0.045, LDL: x2=52 p<0.001). Conversely, PTH
increased beyond therapeutic target levels in CKD stages
3 and 4 (x2= 43.8, p<0.001). MDRD level showed a minor
but significant reduction in patients that completed the
follow up (from 52.8 to 51.4, p<0.001). Significant higher
percentage of patients were started on diuretics and
statins (p=0.002, p<0.001, respectively). LVMI levels
showed a significant negative correlation with MDRD at
recruitment and at the end (p<0.001, p=0.005). For
patients that completed the follow up, there was no
significant increase of mean LVMI independently of CKD
stage. Multiple regression analysis showed that sex and
age were significantly associated with change of LVMI
levels, while sAlb (p=0.06), LDL (p=0.06), smoking
(p=0.08) and diuretics (p=0.09) had marginal influence.
Conclusion. Holistic therapeutic intervention minimized
loss of renal function in CKD patients. Although, control of
modifiable risk factors generally improved, amelioration of
LVMI did not prove feasible.
Background. Left ventricular hypertrophy (LVH) is a
common finding in chronic kidney disease (CKD) and
etiology is multifactorial. Hypertension (HT) is considered
as
one
major
contributing
parameter.
Similarly,
hypertension’s etiology in CKD is multifactorial. Aim of this
study was to investigate the mechanisms of both
hypertension and LVH in CKD. Methods. 221 patients from
CKD stages 1-4 (52%men), with mean age 65±12, from
the Outpatients Clinics of 3 hospitals were enrolled. 202
patients
underwent
echocardiographic
study.
The
distribution of these patients in CKD stage 1, 2, 3 and 4
were 13,6%, 26,7%, 37,1% and 22,6% respectively. In
one third, primary renal disease was unknown, while
diabetic nephropathy and hypertensive nephrosclerosis
accounted for 14.9% and 15.8% of cases respectively.
Patients were considered hypertensives if they had a
history of hypertension or if in the absence of known
history, BP was >140/90mmHg in two recordings.
Results. 92% of patients in total were hypertensives with
no significant differences between CKD stages. Less than
half (47.8%) achieved satisfactory BP control. Among
hypertensives, 70.7% had systolic HT, 5.6% diastolic HT
and 23.6% mixed HT. Most patients needed 2-3
medications, while 18% of patients needed four or more
medications for BP control. Eventhough, there was an
increase in the number of antihypertensives used along
with CKD progression (p=0.018), there was still increase in
both systolic BP (SBP) (p=0.046) and mainly pulse
pressure (PP) (p=0.000). Left ventricular mass index
(LVMI) increased along with declining eGFR, independent
of sex or the presence of diabetes. Both SBP and PP
positively correlated to the LVMI increase, but not as
independent predictors. Ageing (p=0,000) and declining
eGFR (p=0,000) were proved to be more significant and
independent predictors for both SBP and PP and for the
LVMI increase. Additionally, declining eGFR correlated to an
increase
in
parameters
that
suggest
endothelial
dysfunction, such as vascular cell adhesion molecule-1
(VCAM-1) (p=0,000), fibrinogen (p=0,000) and urine
albumin excretion (p=0,013) and to NT-proBNP levels
(p=0,003) which reflect volume status. These parameters
also correlated positively to SBP and PP levels and LVMI
increase. Conclusion. Hypertension is a constant finding
in CKD, aggravating along with disease progression despite
the increase in antihypertensive medication. It contributes
to the LVMI increase, but not as independent predictor.
Ageing but also declining kidney function through
endothelial dysfunction and volume overload mechanisms
could explain both the observed BP and LVMI increase in
CKD.
13
RFP 03
RFP 04
IMMUNOSUPPRESSION TREATMENT IN IGA
NEPHROPATHY MAY ACT THROUGH MODIFYING
LOCAL PRODUCTION OR ACTIVATION OF MULTIPLE
CYTOKINES
TREATMENT OF IGA NEPHROPATHY BASED ON THE
SEVERITY OF CLINICAL AND HISTOLOGICAL
FEATURES
1
1
1
1
P. Kalliakmani, 1 M. Gerolymos, 1 D. Komninakis,
E. Savvidaki, 1 E. Papachristou, 2 L. Nakopoulou,
1
D.S. Goumenos
1
Department of Internal Medicine-Nephrology, University
Hospital of Patras, Greece
2
Department of Pathology, Medical School, University of
Athens
1
1
M. Stangou, A. Papagianni, C. Bantis, C. Pliakos,
M. Spartalis, 2 A. Pantzaki, 1 G. Efstratiadis, 1 D. Memmos
1
Department of Nephrology, Aristotle University of
Thessaloniki, Hippokration General Hospital, Thessaloniki,
Greece
2
Department of Pathology, Hippokration General Hospital,
1
Background. IgA nephropathy is the most common
primary glomerulonephritis in the developed countries.
Several regimens have been used for treatment. The
purpose of this study is to estimate the clinical course of
patients with IgA nephropathy treated with different
regimens according to the severity of the disease.
Methods. Fifty patients (M/F: 39/11), 49.7±14 years old
with baseline serum creatinine 1.3±0.7mg/dl and
proteinuria 3.2±4.8g/24h, were included in the study. The
choice of therapeutic regimen was based on the severity
of clinical and histological involvement. Patients with
normal renal function, proteinuria <1g/24h and mild
mesangial proliferation received no treatment (Group A,
n= 6). Patients with normal or slightly impaired renal
function, proteinuria >1g/24h, mild to moderate
mesangial proliferation and tubulointerstitial inflammation
received angiotensin converting enzyme inhibitors (ACEi)
and corticosteroids (Group B, n=23). Patients with normal
or impaired renal function, proteinuria >3g/24h, moderate
to severe mesangial proliferation, crescents and severe
tubulointerstitial
involvement
received
ACEi
with
corticosteroids and other immunosuppressive drugs
(Group C, n=18). Patients with normal renal function and
heavy proteinuria (>3g/24h) received cyclosporine
(n=10), those with impaired renal function and crescents
in more than 20% of the glomeruli cyclophosphamide
(n=3) and the rest azathioprine (n=5). Patients with
serum creatinine >2.5mg/dl, severe glomerulosclerosis
and
tubulointerstitial
fibrosis
received
no
immunosuppressive drugs (Group D, n=3). All patients
were regularly followed-up for 5 years. The clinical course
was estimated using the end points of doubling of baseline
serum creatinine and end stage renal disease (ESRD).
Results. None of patients from group A showed
deterioration of renal function. Doubling of baseline serum
creatinine was observed in 2 patients from group B
(8.9%), 5 from group C (27.8%) and 2 from group D
(67.7%). ESRD was observed in 1 patient from group B
(4.4%), 4 from group C (22.2%) and 2 from group D
(67.7%). Reduction of proteinuria to <1g/24h was
observed in all patients of group B (100%) and in15 from
group C (83.3%). Relapse of proteinuria was observed in
3 patients from group B (13%) and in 3 out of 10 patients
treated by cyclosporin from group C (30%). Side-effects
related to steroids or to other immunosuppressive drugs
were observed in 3 of 41 patients (7.3%). Conclusion.
The choice of therapeutic regimen for treatment of
patients with IgA nephropathy should be based on the
severity of clinical and histological involvement in order to
achieve the maximun beneficial effect with the less
adverse reactions.
Background. Cytokines produced within the kidney in
IgAN seem to introduce inflammation and lead to fibrosis.
Immunosuppression treatment may reduce production or
activity of these cytokines. Methods. Oxford classification
system was applied for the evaluation of histology in 53
IgAN patients [M/F 35/18 age 40.5yrs (17-65)], and renal
biopsies were classified as MEST score (Mesangial
hypercellularity, Endocapillary hypercellularity, Segmental
glomerulosclerosis, Tubular atrophy) 1, 2, and 3. First
morning urine samples, collected at day of renal biopsy,
were used to detect IL-1beta, IL-2, IL-4, IL-5, IL-6, IL-7,
IL-8, IL-10, IL-12, IL-13, IL-17, INF-gama, G-CSF, GMCSF, MCP-1, MIP1b, TNFa by a multiplex cytokine assay.
Eighteen patients were treated with steroids±azathiopine,
while 35/53 had only conservative treatment. Follow up
was 5.5 (1-12years). Results. Serum creatinine at time
of diagnosis correlated with MEST score (p=0.007) and
urinary excretion of IL-2 (p=0.01) and IL-12 (0.04). In
patients who did not have any specific treatment, serum
creatinine at the end of follow up had positive correlation
with MEST score (p=0.006), IL-1b (p=0.007), IL-2
(p=0.01), IL-6 (p=0.02), IL-10 (p=0.04), IL-12 (p=0.01)
and MCP-1 (p=0.03) urinary levels. In patients treated
with steroids+aza, the only parameters correlated
significantly with serum creatinine at the end of follow up
were IL-1b and IL-6 urinary excretion (p=0.01 and
p=0.03 respectively). Conclusion. In conclusion several
cytokines are excreted in the urine of patients with IgAN,
and their levels predict outcome of renal function.
Treatment with steroids+aza may have a beneficial effect
in renal function outcome, and this is probably due to the
alleviation of urinary cytokine excretion.
14
RFP 05
RFP 06
THE ROLE OF MOLECULAR GENETICS IN
DIAGNOSING FAMILIAL HEMATURIA(S)
HEMOGLOBIN VARIABILITY AND ERYTHROPOIETIN
RESPONSIVENESS IN BALKAN NEPHROPATHY AND
OTHER KIDNEY DISEASES
1
C. Deltas, 2 A. Pierides, 1 K. Voskarides
Molecular Medicine Research Center, University of
Cyprus, Nicosia, Cyprus
2
Department of Nephrology, Hippocrateon Hospital,
Nicosia, Cyprus
1
L. Lukic, 2 N. Petkovic, 1 D. Mitrovic, 1 S. Kovacevic,
M. Stanisic, 1 S. Pelemis, 1 J. Tesic, 1 S. Vakicic,
3
L. Djukanovic
1
International Dialysis Center Bijeljina, Bosnia and
Herzegovina
2
Fresenius Medical Care Center, Samac, Bosnia and
Herzegovina
3
School of Medicine, University of Belgrade, Serbia
1
1
Background. Familial microscopic hematuria (MH) of
glomerular origin represents a heterogeneous group of
monogenic conditions, involving several genes, some of
which remain unknown. Recent advances have increased
our understanding and our ability to use molecular
genetics for diagnosing such patients, enabling us to
study their clinical characteristics over time. Methods.
Three collagen IV genes, COL4A3, COL4A4 and COL4A5
explain the autosomal and X-linked forms of Alport
Syndrome (AS), and a subset of Thin Basement
Membrane Nephropathy (TBMN). Results. A number of
X-linked AS patients follow a milder course reminiscent of
that of patients with heterozygous COL4A3/COL4A4
mutations and TBMN, while at the same time a significant
subset of patients with TBMN and familial MH progress to
chronic kidney disease (CKD) or end-stage kidney disease
(ESKD). A mutation in CFHR5, a member of the
complement factor H family of genes that regulate
complement activation, was recently shown to cause
isolated C3 glomerulopathy, presenting with MH in
childhood and demonstrating a significant risk for
CKD/ESKD after 40–yo. Conclusion. Through these
results molecular genetics emerges as a powerful tool for
a definite diagnosis when all the above conditions enter
the differential diagnosis, while in many at-risk related
family members, a molecular diagnosis may obviate the
need for another renal biopsy.
Background. Balkan endemic nephropathy (BEN)
patients maintained with hemodialysis (HD) have more
severe anemia than patients with other kidney diseases.
Treatment with recombinant human erythropoietin
(rHuEPO) enabled correction of hemoglobin (Hb) level of
HD patients including those with BEN. The studies on BEN
patients’ responsiveness to rHuEpo therapy are scarce. In
the present prospective study Hb variability and rHuEpo
response variability in HD patients with BEN and other
kidney diseases was compared. Methods. The 6-month
prospective study involved 294 patients (166 males, 65.9
± 12.2 years) on regular HD in two centers situated in
BEN foci. Out of them 183 had BEN and 111 other kidney
diseases and all of them were treated with rHuEpo for
more than one year. Treatment with rHuEpo was carried
out according to European guidelines for the management
of anemia. The intraindividual Hb variability over time was
quantified by the coefficient of variation (CV%) calculated
from the Hb values measured monthly as the ratio of the
SD to the mean. To evaluate the dose-response effect of
rHuEpo therapy erythropoietin resistance index (ERI) was
calculated as the weekly weight-adjusted dose of rHuEpo
divided by Hb level. Results. BEN patients were
significantly older (71 ± 7.2 yrs) than non-BEN ones (58
± 15 yrs) and their s-urea and s-creatinine levels were
significantly lower, but Kt/V index differed insignificantly
between these two groups. Mean Hb level in 6-month
period was 105.9 ± 15.0 g/L in BEN and 109.3 ± 11.0 g/L
in non-BEN patients (p: 0.039) and mean rHuEpo dose
was 63.8 ± 27.6 U/kg/week and 51.1 ± 36.2 U/kg/week
in the same groups (p: 0.041). Mean CV of Hb in BEN and
non-BEN patients differed insignificantly (6.4 ± 3.3 vs. 6.2
± 2.9%), but mean ERI differed significantly (0.64 ± 0.31
U/kg/week/gHb vs. 0.49 ± 0.38 U/kg/week/gHb; p:
0.0003) between two groups. Significant correlation was
found between ERI and Kt/V. Conclusion. BEN patients
required higher rHuEpo dose for maintaining target Hb
level than non-BEN patients. Consequently ERI of BEN
patients was significantly higher than in non-BEN ones,
while Hb variability over time differed insignificantly
between these two groups.
15
RFP 07
ASSESSING THE REAL LIFE CLINICAL PRACTICE
DATA OF THE MANAGEMENT OF RENAL ANAEMIA
PATIENTS IN DIALYSIS, TREATED WITH
ERYTHROPOIESIS STIMULATING AGENTS
Gen.Hospital “Papageorgiou” Thessaloniki, 2University
Hospital Alexandroupoli, 3Gen.Hospital Volou, 4Gen.Hospital
“Papanikolaou” Thessaloniki, 5Gen.Hospital “St.George”
Chania, 6University Hospital of Ioannina, 7Gen.Hospital
“Ippokratio” Athens, 8Gen.Hospital “G.Hatzikosta” Ioannina,
9
Gen.Hospital “St.Panteleimon” Nikaia Piraeus, 10Gen.Hospital
“St.Barbara” Athens, 11Gen.Hospital “Korgialenio-Mpenakio”
Athens, 12Gen.Hospital “Tzanio” Piraeus
1
K.C. Siamopoulos
on behalf of the ESA08 Group*
Background. Anaemia is one of the major complications
in chronic kidney disease (CKD) patients on hemodialysis.
Treatment of renal anaemia with Erythropoiesis
Stimulating Agents (ESAs) is very well established,
however, is often observed to be associated with recurrent
fluctuations in hemoglobin levels. The aim of this study
was to assess the hemoglobin (Hb) stability and the
biochemical outcome in a cohort of patients in dialysis
treated
with
ESAs.
Methods.
This
multicentre,
prospective, observational study recorded data from the
real life clinical practice of the renal anaemia treatment
with ESAs, in patients on hemodialysis (n=200, 69%
CERA, 22% darbepoetin alfa, 9% epoetin). Adult renal
anaemia patients, on hemodialysis for at least 12 weeks,
with Hb levels >11 g/dL, entered a 12-month observation
period. A homogeneous cohort of 154 patients (74%
CERA, 26% darbepoetin alfa) was evaluated for this
period. For the analysis of collected data, epidemiologic
methods were applied. Results. The demographic and
clinical characteristics were well balanced between the two
treatment groups. 93% of patients, exhibited an Hb
fluctuation ≥1.5 g/dL, at least once during the study
period. Patients on CERA showed higher, although non
statistically significant, probability than darbepoetin alfa in
achieving Hb stability for 3 months. The tendency of
association was more pronounced in the OR adjusted for
ferritin and diabetes [OR=2.41 (0.95-6.07)]. Comparing
the two treatment groups, in regard to ferritin and TSAT%
levels over time, a significant difference was shown for
ferritin patterns (P=0.01), with darbepoetin alfa group
showing consistently higher ferritin levels vs CERA group,
while TSAT% levels patterns were similar in both groups
(Figure). Conclusion. Recurrent fluctuations of the
hemoglobin levels are extremely common between
dialysis patients, treated with erythropoiesis stimulating
agents. Nevertheless, there is a tendency for CERA to
perform better than darbepoetin alfa in maintaining stable
Hb levels. Patients treated with darbepoetin alfa seem to
need more iron supplementation in order to maintain
adequate TSAT% levels.
*ESA08 Group:
1
D.Tsakiris, 1D.Papadopoulou, 1G.Visvardis, 1Ε.Mitsopoulos,
1
P.Kyriklidou, 1Ε.Manou, 2V.Vargemezis, 2P.Pasadakis,
2
S.Panagoutsos, 2Ε.Mourvati, 2Κ.Kantartzi, 3C.Syrgkanis,
3
G.Koutroumpas, 4Κ.Sombolos, 4G.Bamichas, 5Ι.Tzanakis,
6
Κ.C.Siamopoulos, 6X.Zikou, 6S.Kountouris, 6Ε.Dounousi,
6
Α.Tatsioni, 7Ι.Papadakis, 7Ι.Kakavas, 7D.Petras, 8Μ.Pappas,
8
Ε.Kokkolou, 9C.Iatrou, 9Ι.Makryniotou, 10Ε.Sarris,
10
Κ.Salpiggidis, 11Ν.Papagalanis, 11C.Kourvelou,
12
G.Papadakis, 12Κ.Ntaitzikis
16
RFP 08
RFP 09
LIVING UNRELATED DONOR KIDNEY
TRANSPLANTATION - CHELANGES AND DILEMAS
EVALUATION OF PERIPHERAL ARTERIAL DISEASE
IN HEMODIALYSIS PATIENTS WITH ANKLEBRACHIAL INDEX
D. Jovanovic, L. Ignjatovic, A. Jovanovic, Z. Kovacevic
Department of nephrology, Medical Military Academy,
Belgrade, Serbia
1
E. Likaj, 2 G. Caco, 1 A. Idrizi, 1 S. Seferi, 1 M. Rroji,
A. Duraku, 1 M. Barbullushi, 2 E. Kapedani, 1 N.Thereska
1
Service of Nephrology, Dialysis, Transplantation,
University Hospital Center "Mother Tereza" of Tirana,
Albania
2
Service of Cardiovascular Disease University Hospital
Center "Mother Tereza" of Tirana, Albania
1
Background. There are three options for treatment of
end stage renal desease: hemodialysis, peritoneal dialysis
and kidney transplantation. State legislation permits
transplantations from deceased, living related and living
unrelated –but emotionaly related donors (LURD). In
order to increase number of kidney transplantations we
started with transplant program from LURD. The aim of
this work is to stress out the posibility for increment
number of transplanted kidneys, keeping in mind
permanently increasing gep between number of retrived
kideys and waiting list. Results. fromRf21.05 1996.g. to
the end od 2010. we pereformed 17 trasnplantaios from
LURD. Stabile kidney allograft function is noticed in
almous all transplanted patients (12 years in the first, 8 in
second, 7 in third, 5 in fourth, 4 in fift and sixt patient,
and 2 years in the rest of transplanted patients). One
recipeient who got graft across blood group barrier died in
second post transplant year due to serious infective
complications. Serum creatinine in all donors are in
normal range. Conclusion. Transplantations from LURD
had the same survival and outcome as transplantations
from
living
realted
donors.
They
contributionte
significantelly to kidney transplant program. Very
important in these situations is psychosocial evaluation in
order to exclude mental illnes, trading and different
preassures for organ donation. For generrous act of organ
donation all LURD should receve some permanent
gratitude.
Background. Peripheral arterial disease as important part
of cardiovascular disease is very common in uremic
patients and determinant for their long-term outcome.
PAD in these patients may present in the form of
occlusions or mediacalcinosis of the arteries of the legs.
Different means have been used to assess the prevalence
of these conditions, including questionnaires for leg pain,
history of previous diagnosis or interventions for
peripheral arterial disease or physical examination of
arterial foot pulses. Ankle-brachial pressure index (ABI) is
a very effective and reliable mean to assess arterial
integrity in the legs. We present our investigation for leg
arterial occlusions and/or mediacalcinosis of a random
sample of patients of our dialysis centre using ABI.
Method. Systolic pressures were measured in 100
consecutive hemodialysis (HD) patients on anterior and
posterior artery in the ankle on both feet using a hand
held Doppler device and ABI was calculated for each
artery. ABI < 0.9 is accepted as evidence for arterial
occlusions and ABI > 1.3 as evidence for mediacalcinosis.
Information from clinical recording was gathered for age,
years of diagnosis of chronic kidney disease (CKD), years
in HD, blood pressure lowering treatment and calcium,
phosphorus, calcium x phosphorus production and iPTH
levels. Results. Arterial occlusions of at least one leg
artery were detected in 36% of the patients while
mediacalcinosis in 69% of them. Occlusions were more
frequent in women while mediacalcinosis prevailed in
men. Prevalence of arterial damage was correlated with
the time since CKD was diagnosed and the time lasting of
dialysis. The prevalence doubled after 10 years of CRD
and 2.5 years of HD. No correlation resulted between both
types of arterial damages and the time since in CKD or
HD. No correlations were found between prevalence of the
lesions and age or calcium, phosphorus and iPTH levels.
17
RFP 10
RFP 11
PERI-AORTIC FAT TISSUE THICKNESS PREDICTS
CORONARY ARTERY AND THORACIC AORTIC
CALCIFICATION IN PD PATIENTS
ROUTINE ASSESSMENT OF DEPRESSION IN
CHRONIC KIDNEY DISEASE PATIENTS WITHOUT
THE INVOLVEMENT OF MENTAL HEALTH
PROFESSIONALS: A TWO STAGE APPROACH
1
K. Turkmen, 2 O. Ozbek, 3 M. Kayrak, 1 H. Zeki Tonbul
2
3
Department of Cardiology, Meram School of Medicine,
1
M. Ikonomou, 2 P. Skapinakis, 3 M. Eleftheriadou,
E. Kyroglou, 4 A. Chardalias, 4 I. Bakavos, 5 M. Sygelakis,
1
A. Banioti, 1 R. Kalaitzidis, 6 K. Asimakopoulos,
3
D. Tsakiris, 4 D. Goumenos, 1 K.C. Siamopoulos
1
Ioannina, Greece
2
Department of Psychiatry, University Hospital of
Ioannina, Greece
3
4
Department of Nephrology, University Hospital of Patra,
Greece
5
Department of Psychiatry, General Hospital
6
Department of Psychiatry, Unviersity Hospital of Patra,
Greece
1
3
Background. Epicardial adipose tissue (EAT) and thoracic
peri-aortic fat tissue (PFT), are metabollically active
visceral fat depot surrounding the heart and thoracic
aorta, respectively. The relationship between coronary
artery disease (CAD), EAT and PFT was shown in CAD
patients. The coronary artery calcification score (CACS) in
patients with ESRD reflects the severity atherosclerotic
vascular disease and predicts the cardiovascular events.
In this study we aimed to investigate the relationship
between PFT, EAT, CACS and TAC in PD patients.
Methods. Thirthy-five PD patients (F/M:10/25) and 30
healthy subjects (F/M:15/15) enrolled in this crosssectional study. PFT, TAC, EAT and CACS were performed
by a 64-MDCT scanner. Results. PFT, EAT, CACS and TAC
measurements were significantly higher in PD patients
compared with healthy subjects ( p=0.02, p=0.003,
p=0.02, 0.04, respectively). There was a statistically
significant relationship between EAT and CACS (p=0.007,
r=0.339) and PFT and TAC in PD patients (p=0.007,
r=0.448). Conclusion. In conclusion, we found a
relationship between PFT, EAT, TAC and total CACS in PD
patients.
Background. The impAleact of depression in the
morbidity, mortality and quality of life of patients with
chronic kidney disease (CKD) is well described. Screening
tools for depression, such as the brief self-completed
PHQ-9 have been successfully validated in this group of
patients. However, the decision to treat or not to treat is
usually taken by a mental health professional after a
patient has screened as positive. The aim of the current
study was to examine the feasibility of using a two-stage
approach for diagnosing depression in CKD patients, using
both the PHQ-9 as a screening tool (first stage) and a
more detailed fully structured computerized psychiatric
interview administered, by the primary nurse without the
need for a formal psychiatric assessment (second stage).
Methods. We assessed 190 patients with CKD (64%
male, 48% on hemodialysis -HD, 20% on peritoneal
dialysis -PD, 10% kidney transplanted -Tx patients and
22% in CDK stages 1-4). All patients completed the PHQ9 and the computerized version of the revised Clinical
Interview Schedule (CIS-R), a fully structured psychiatric
interview designed to be used by lay interviewers. The
interview was administered by the primary nurse using a
laptop computer. We calculated the sensitivity, specificity,
positive predictive value for various cut-offs of the PHQ-9,
using the diagnosis of depression according to the CIS-R
as the gold-standard. Results. A diagnosis of depression
(ICD-10 criteria) was made in 3% of the total sample (5%
on the subgroup of patients on HD, p=0.19). The ROC
curve showed high predictive accuracy of the PHQ-9 (area
under the curve: 0.942, 95% confidence interval: 0.901 –
0.984). The optimal cut-off value for the PHQ-9 was 10 or
greater for a depressive diagnosis with a sensitivity of
82% and a specificity of 93%, a positive predictive value
of 18% and a negative predictive value of 100%.
Conclusion. A two-stage procedure of assessing
depression using the PHQ-9 at a cut-off of 10 or greater
followed by a more detailed computerized psychiatric
interview administered by the primary nurse might be
feasible in CKD patients. This procedure could facilitate
the treatment of depression by the nephrology team
without the need for a formal assessment by a
psychiatrist. This possibility should be further investigated
in randomized controlled trials.
18
RFP 12
RFP 13
PSYCHOLOGICAL SYMPTOM PROFILES IN CHRONIC
KIDNEY DISEASE PATIENTS AND THE GENERAL
POPULATION
SUBJECTIVE GLOBAL ASSESSMENT AND PATIENT
RELATED QUALITY OF LIFE
1
2
P. Skapinakis, 1 M. Ikonomou, 3 E. Kyroglou,
3
P. Kyriklidou, 4 P. Hondrogiannis, 5 M. Sygkelakis,
5
C. Varvara, 1 O. Balafa, 2 V. Mavreas, 3 D. Tsakiris,
4
D. Goumenos, 1 K.C. Siamopoulos
1
Department of Nephrology, University Hospital of Ioannina,
Greece
2
Department of Psychiatry, University Hospital of Ioannina,
Greece
3
4
Department of Nephrology, University Hospital of Patra,
Greece
5
Department of Psychiatry, General Hospital "Papageorgiou"
of Thessaloniki, Greece
Background.
Mental
health
problems,
especially
depression, are prevalent among chronic kidney disease
(CKD) patients. Much of the previous research has
centered on screening tools for identifying depression.
However, other mental health problems have largely been
neglected despite the fact that mental health issues are
associated with a worse quality of life. The aim of this
study was to describe the prevalence and associations of a
broad range of psychological symptoms in CKD patients
and to compare these with a general population sample
using the same methodology. Methods. We assessed 190
patients with CKD (64% male, 48% on hemodialysis -HD,
20% on peritoneal dialysis, 10% kidney transplanted
patients and 22% in CKD stages 1-4). We used the
computerized version of the revised Clinical Interview
Schedule (CIS-R) to assess the presence of 14
psychological symptoms and 6 psychiatric disorders using
operationally
defined
diagnostic
algorithms.
A
representative sample of the general population of our
country consisting of 4198 participants was used to
compare the results. Results. In all CKD patients the most
prevalent symptoms were sleep problems (31%), fatigue
(24%), generalized anxiety / worry (18%), anxiety / worry
about the physical health (17%), depressive mood (14%),
depressive ideation (12%), irritability (11%) and somatic
anxiety (10%). Women were more likely to show fatigue
(32% vs. 20% in male, p<0.05) while men showed a trend
to report more sleep problems (34% vs. 24%, p=0.11).
Patients on HD were significantly more likely to have a
higher psychiatric morbidity (p<0.05) compared to other
CKD patients. Prevalence of major depression in CKD
patients was 3% with no gender differences. Compared to
the general population, CKD patients did not show a higher
psychiatric morbidity (at least one psychiatric disorder was
reported by 13% of women with CKD vs. 13% of the
general population and 7% of men with CKD vs. 8% of
men in the general population). However, differences in
the symptom profile were noted. Conclusion. Individual
psychological symptoms are quite prevalent in CKD
patients, especially sleep problems in men and fatigue in
women. Contrary to what was expected, formal psychiatric
diagnoses do not differ significantly from the general
population, probably due to coping and adaptation
mechanisms. These findings show that a more dimensional
approach in screening and assessing for psychological
symptoms in CKD patients might offer advantages over the
categorical approach of using diagnostic categories.
19
P. Malindretos, 1 P. Makri, 1 G. Koutroubas, 1 G. Zagotsis,
N. Anagnostou, 2 E. Togousidis, 1 C. Syrganis
1
Nephrology Department, "Achillopoulion" General
Hospital, Volos, Greece
2
Department of Biochemistry, "Achillopoulion" General
1
Background. In patients suffering from chronic kidney
disease (CKD) and especially in end stage renal (ESRD)
patients, nutritional status is known to be affected.
Moreover, nutritional status is a known determinant of
survival in these patients. Additionally, health related
quality of life (HRQOL) is both affected and related with
survival in CKD and ESRD patients. A generally accepted
instrument to assess nutritional status is represented by
subjective global assessment (SGA). Kidney disease
quality of life questionnaire (validated and culturally
adapted) is similarly used to estimate HRQOL in ESRD
patients. The following study will provide preliminary data
regarding possible correlation between subjective global
assessment of nutritional status and health related quality
of life in ESRD patients. Methods. HRQOL questionnaire
was administered to 106 prevalent hemodialysis patients.
Seventy five patients responded (70.7%). In these
patients SGA was also estimated and demographic and
laboratory data were drawn from their medical files.
Results. According to SGA, patients were divided in 3
groups: A-category SGA - well nourished (60 patients –
80%), B-category SGA – moderately malnourished (12
patients – 16%) and C-category SGA – severely
malnourished (3 patients – 4%). Well nourished patients
tended to be younger (mean age in years: 61.4 ±13.1 vs.
65.0 ±12.8 and 67.1 ±9.1) and received dialysis for a
shorter period (median in months: 39.6 vs. 60.7 and
118.5), these differences were not proven to be
statistically significant though. Well nourished patients
scored better in the Pain component summary of the
HRQOL questionnaire (69.1 ±30.6 vs. 55.4 ±25.3 and
33.3 ±27.7; p=0.046), as well as in Physical Functioning
component summary (48.8 ±29.1 vs. 31.7 ±30.5 and
22.5 ±23.7; p=0.04). Both Kidney Disease component
summary and Overall Health Rating were found to be
negatively correlated with age (cc=-0.229 p=0.048 and
cc=-0.220 p=0.05 respectively) and time on dialysis (cc=0.256 p=0.027 and cc=-0.344 p=0.002 respectively).
Additionally, serum albumin was found to be positively
correlated with Work Status (cc= 0.318 p=0.006), with
Physical Functioning (cc= 0.225 p=0.052), with Role
Physical (cc= 0.357 p=0.002), and Physical Component
Summary
(cc=
0.258
p=0.026).
Conclusion.
Deteriorated nutritional status as it is reflected by SGA is
correlated with health related quality of life in end stage
renal disease patients receiving hemodialysis.
RFP 14
RFP 15
PHASE-CONTRAST EXAMINATION OF URINE
SAMPLES AS A DIAGNOSTIC TOOL IN OUT-CLINIC
PATIENTS WITH HEMATURIA
CAN IMMUNOHISTOCHEMISTRY BE HELPFUL IN
REVEALING THE ORIGIN OF MYOFIBROBLASTS IN
RENAL FIBROSIS?
1
1
E. Koliousi, 2 D. Kalogeras, 3 P. Katsarou, 4 G. Dimos
Private office of Nephrology and Hypertension, Greece
2
Private office of Urology, Greece
3
Private office of Cardiology, Greece
4
Private office of Internal Medicine, Greece
F. Bob, 1 G. Gluhovschi, 2 D. Herman, 1 L. Petrica,
A. Schiller, 1 S. Velciov, 1 G. Bozdog, 1 C. Gluhovschi,
1
F. Gadalean, 2 E. Potencz
1
Nephrology, County Hospital, University of Medicine
Timisoara, Romania
2
Pathology, County Hospital, University of Medicine
Timisoara, Romania
1
1
Background. Microscopic urine examination with phasecontrast (p.c.) is an important diagnostic tool in the
evaluation of hematuria. When the number of
acanthocytes is > 5% or the number of dysmorphic
erythrocytes is > 80% of the total amount of erythrocytes
then hematuria is most likely of glomerular origin, what is
a strong evidence to perform a kidney biopsy. Our aim
was to present our experience from p.c. urine examination
of out-clinic patients in a private office of nephrology.
Methods. In the last 5 years in a total number of 807
patients, 100 p.c. generally of second morning urine, were
performed in 92 patients with hematuria, 5 of them with
macroscopic hematuria. Nine patients were under 14
years old, 44% of the adults were women. In 65% of the
patients a complete urological control had been performed
before they were referred to the nephrologist. About 10%
of the patients had visited the office of their own because
of hematuria, 15% were referred to the office by
colleagues of other specialty, 15% of the adults and all
the children had been referred particularly for the
performance of the p.c. examination. Results. In 18
patients hematuria was of glomerular origin (4 patients
had dysmorphic erythrocytes > 80% & acanthocytes <
5%, 8 patients had dysmorphic erythrocytes < 80% &
acanthocytes > 5% and 6 patients had dysmorphic
erythrocytes > 80% & acanthocytes > 5%). In 14 patients
a kidney biopsy was performed. Nine of them had
concomitant proteinuria. In 7 patients biopsy revealed
IgA-Nephropathy, 2 patients had IgM-Nephropathy, one
patient had Mesangioproliferative Glomerulonephritis
without Immune fluorescence, 2 patients had focalsegmental glomerulosclerosis, one had vasculitis and in
one biopsy no special alterations were found. Three
children had hematuria of glomerular origin and biopsy
revealed IgA-Nephropathy in 2 and IgM-Nephropathy in
one child. 3 Children had hypercalciuria. Eleven patients
with dysmorphic erythrocytes < 80% and crystals
presented hypercalciuria, one patient hyperoxaluria and
one patient with dysmorphic erythrocytes < 80% had
urine bladder neoplasm. He was referred to the urologist
after performing the p.c. which had also revealed a great
amount of deep layer uroepithelial cells. Conclusion. As
findings of the p.c. examination correlated well with
biopsy results and clinical status of the patients we
conclude that, p.c. is an easy to perform, cheap, relatively
quick, harmless examination, while it provides so much
information, that it is an obligatory tool in the diagnostic
workout of hematuria in every nephrologist’s practice
Background. Myofibroblasts are responsible for scar
formation in fibrotic kidney diseases, and therefore
understanding their origin is of great importance. In vitro
studies show that in response to injury tubular epithelial
cells undergo epithelial-to-mesenchymal transition (EMT).
Other possible origins, as recently described in vivo, could
be represented by endothelial cells through, endothelialto-mesenchymal transition, or interstitial pericytes. In
order to assess the role played by tubular epithelial cells
(TEC) and interstitial vascular endothelial cells (VEC) in
human glomerulonephritis, we studied the expression of
markers of activated fibroblasts (alpha smooth muscle
actin-SMA and vimentin-Vim) and of the transforming
growth factor β (TGF), at the level of these cells.
Methods. We studied retrospectively 41 renal biopsies
from
patients
with
primary
and
secondary
glomerulonephritis [M-24p,F-17p,mean age 45.5±12.9y].
Immunohistochemistry
using
monoclonal
antibodies
(SMA,Vim, TGFβ) was assessed using a semiquantitative
score, that was correlated with biological and histological
data (quantified using a scoring system in order to assess
active-inflammatory
and
chronicsclerotic/fibrotic
lesions). Results. The presence of SMA and Vim as
markers of myofibroblasts was found in TECs and VECs.
VEC Vim expression showed indirect correlations with
interstitial infiltrate(R=-0.32;p=0.023), activity index
(R=-0.33;p=0.02),
interstitial
fibrosis
(R=0.34;p=0.017), chronicity index(R=-0.33;p=0.023). VEC
TGF correlated with the activity index(R=0.27;p=0.04).
TEC Vim expression correlated with interstitial Vim
expression,
(R=0.38;p=0.008),
interstitial
infiltrate
(R=0.31;p=0.027), interstitial fibrosis (R=0.25;p=0.042),
GFR(R=-0.35;p=0.016), SMA(R=-0.42;p=0.015), and
TGF (R=0.25;p=0.046). Conclusion. The study reflects
the complexity of the involvement of both TECs and VECs
in fibrosis, but could not reveal their role as progenitors of
myofibroblasts.
20
RFP 16
RFP 17
LOWER RETICULOCYTE THAN ERYTHROCYTE
HEMOGLOBIN CONTENT MAY BE PREDICTIVE OF
RECENT DEVELOPMENT OF IRON DEFICIENCY
PARENTERAL NUTRITIONAL INTERVENTION IS
IMPORTANT IN MALNUTRITION HEMODIALYSIS
PATIENTS
1
B. Knap, M. Madronic, J. Buturovic Ponikvar, R. Ponikvar,
A. F. Bren
Department Of Nephrology, University Clinical Center
Ljubljana, Slovenia
M. Tsiatsiou, 1 E. Mitsopoulos, 1 P. Kyriklidou,
E. Manou, 1 V. Kousoula, 1 I. Minasidis, 2 I. Thodis,
2
V. Vargemezis, 1 D. Tsakiris
1
Department of Nephrology, Papageorgiou General
Hospital, Thessaloniki, Greece
2
Department of Nephrology, Medical School, Democritus
University of Thrace, Alexandroupolis, Greece
1
Backround. Malnutrition is an important cause of
morbidity and mortality in patients with end-stage renal
disease. Especially patients on hemodialysis with cancer,
some chronic diseases or severe infection are often
anorectic. In some of these patients classical eternal
nutrition therapy is impossible. The aim of the observation
was to evaluate if parenteral nutrition (Aminomel Nepro)
could improve the nutritional status in these severe
undernourished hemodialysis patients. Methods. In the
university clinical centre for dialysis Ljubljana (single
centre study)(200 patients) 30 % of malnutrition patients
was found. Usually eternal nutrition is a good choice of
therapy. Only in nine patients parenteral nutritional
intervention was necessary. Classical parameters such as
SGA (subjective global assessment), body weight, BMI
(body mas index) and routine biochemical parameters for
the evaluation of nutritional status were observed before
and after parenteral intradialytic intervention. The
duration of intravenously nutritional interventions with
Aminomel Nepro 500ml was six weeks during every
dialysis procedures (three times per week). Infusions of
Aminomel Nepro were started after the beginning of each
dialysis session and patients received 125ml infusion per
hour without side effects. Three patients had another
severe cause of malnutrition (cancer, chronic diseases,
severe infection). Results. The SGA value improved in
three patients, at one patient it was stable and in five
patients the SGA values decreased. Body weights were
stable for 4 patients while five patients had a decreased
body weight. Serum values of proteins were increased
after nutritional intervention at 5 patients, two patients
had stable values and only two had decreased values. The
results of the serum albumin values were similar.
Conclusion. Parenteral intervention with infusion during
dialysis is the last chance of helping severe
undernourished patients where eternal nutrition is
impossible. Our results are optimistic, especially the effect
of Aminomel Nepro infusion on protein and albumin values
in those malnutrition patients. Therapy of the basic illness
is also very important for improving the nutritional status
as well as increasing the surviving possibility.
Backround. Reticulocytes develop and mature in the red
bone marrow and then circulate for about a day in the
blood stream before developing into mature erythrocytes.
Mean cellular reticulocyte volume (MCVr), reticulocyte
hemoglobin concentration (CHMr) and their derivative
reticulocyte hemoglobin content (CHr) have been used to
describe reticulcytes in analogy to mature erythrocyte
parameters
of
cell
volume
(MCV),
hemoglobin
concentration (CHCM) and hemoglobin content (CH). The
aim of this study was to evaluate the relationship between
erythrocyte and reticulocyte indices in a population of
hemodialysis
patients.
Methods.
Erytrocyte
and
reticulocyte indices, along with serum ferritin, transferrin
saturation (Tsat), soluble transferrin receptor (sTfR) and
C-reactive protein (CRP) were measured in 99
hemodialysis
patients
on
stable
maintenance
erythropoietin dose. Results. Among the 99 patients
studied CH, CHr, MCV and MCVr values were distributed
approximately normally. The mean CHr of 32.4pg
exceeded the mean CH of 30.4pg, with a ratio of CHr / CH
equal to 1.06. The two values were closely correlated
(r=0.87). The normal relationship of CHr being greater
than CH was inverted in 12 (12.1%) patients. Compared
to patients with CHr > CH, patients with the inverted ratio
(CHr < CH) had lower mean CHr, 29.9 ± 2.2pg versus
32.7 ± 3.01pg, and higher mean sTfR, (3.1 ± 1.05mg/L
versus 2.1 ± 0.98mg/L, p=0.001), whereas the mean
values for haemoglobin, CH, ferritin and TSat were not
significantly different between the two groups. Both lower
mean CHr and higher mean sTfR support the suggestion
that the inverted ratio of CHr < CH may indicate recent
development of iron deficiency. The mean MCVr of 109.5fL
was 16% higher than the mean MCV of 93.8fL in the
entire population and the two values were closely
correlated (r = 0.87) as expected. Conclusion. The
relationship of erythrocyte and reticulocyte indices HD
patients is relevant to the respective relationship observed
in the general population. A value for CHr that is lower
than CH may indicate recent development of iron
deficiency.
21
RFP 18
RFP 19
EFFECT OF HAEMODIALYSIS ON FIBROBLAST
GROWTH FACTOR-23 LEVELS
LIPID PROFILE AND EFFICACY OF THERAPEUTIC
APPROACH AMONG PATIENTS ON HEMODIALYSIS
A. Papagianni, E. Kasimatis, E. Stavrinou, C. Pliakos,
M. Spartalis, C. Dimitriadis, A-M. Belechri, P. Giamalis,
G. Efstratiadis, D. Memmos
University Department of Nephrology, Hippokration
General Hospital, Thessaloniki Greece
1
Background. Recent evidence suggests that fibroblast
growth factor-23 (FGF-23), a novel biomarker of
disordered bone and mineral metabolism in chronic kidney
disease, is markedly elevated in haemodialysis (HD)
patients and is associated with vascular calcifications and
the increased mortality rate observed in this patient
population. However, the probable effect of haemodialysis
(HD) treatment on FGF-23 levels have not been
elucidated. The aim of the present study was to
investigate the probable effect of dialysis modality on
FGF-23 levels. Methods. Fifty-eight patients (31 male,
mean age 64±14 years, mean HD duration 93±71
months) entered the study. Diabetics, patients with
parathyroidectomy
and
patients
receiving
oral
anticoagulants
were
excluded.
Dialysate
calcium
concentration was 1.5 mmol/L in >90% of the cases.
None of the patients was receiving active vitamin D.
Twenty-three patients (39.6%) were receiving treatment
for secondary hyperparathyroidism with paricalcitol and/or
cinacalcet. Thirty-five patients were dialyzed with a lowflux polysulfone (ULF18 Nikkiso) membrane (LF group)
and 23 were on on-line haemodiafiltration (FDX Nikkiso)
(HDF group). Blood samples were taken before and at the
end of a routine mid week pre-dialysis session. Intact
FGF-23 levels were measured by ELISA (human intact
FGF-23, immutopics Inc, San Clemente CA, USA) in
plasma EDTA. Results. Compared with HDF patients, LF
patients were relatively older (60±14 vs 65±15 years,
p<0.5) and had lower serum phosphate levels (5.4±1.3 vs
4.4±1.0 mg/dl, p<0.05) and calcium x phosphate
products (46.3±10.2 vs 39.6±10.2 mg2/dl2, p<0.05).
Calcium and iPTH values did not differ significantly
between the groups as well as Kt/V. In addition, duration
of HD and the other clinical and laboratory parameters
were not also different in the two groups, Calcium,
phosphate, calcium x phosphate products and iPTH were
significantly correlated with pre-dialysis plasma FGF-23
levels both in LF (p=0.005, p=0.0007, p=0.0005 and
p=0.02 respectively) and HDF group (p=0.04, p=0.003,
p=0.0004 and p=0.006 respectively) Pre-dialysis FGF-23
tended to be higher in LF compared with HDF patients but
the difference did not reach statistical significance
(415±380 vs 347±252 ng/ml). Plasma FGF-23 at the end
of dialysis session, compared with pre-dialysis levels were
increased in LF patients (504±390 vs 415±380 ng/ml,
p<0.05) but significantly decreased in HDF patients
(225±170 vs 347±252 ng/ml, p=0.002). Conclusion.
On-line haemodiafiltration results in a significant decrease
in FGF-23 levels in contrast with conventional low-flux
haemodialysis that is associated with an increase. The
underlying mechanisms and the clinical implications of the
above findings are currently under investigation.
Background. Lipid abnormalities are one of the main
causes of atherosclerosis .They are most commonly
observed among patients on hemodialysis (HD). The aim
of this study was lipid profile testing and the efficacy of
therapeutic approach among these patients. Methods. A
total of 106 patients (32 women and 74 men, aged 66 ±
14 years) on chronic HD were studied. The lipidemic
profile (total cholesterol, LDL-cholesterol, triglycerides)
and the lipidemic therapy have been recorded within two
years follow up. Results. A total of 64 patients (60% of
the study population) were on antilipidemic therapy
(statins or omega 3). Cholesterol levels were within
normal levels for the majority (80% ) of the patients and
only 20 persons (20%) had cholesterol levels up to 240
mg/dl .The mean value of total cholesterol levels in
patients on antilipidemic therapy was 174.5±44.4 at
initiation of the study and 165.1±34.6 at two –year follow
up (p=0.05).Among patients on therapy, only 37 (57.8%)
responded. The mean value of triglyceride at starting was
168mg/dl (range 86-432) and at the end 167mg/dl range
(59-709) (p=0.92). Half of the patients (53%) on therapy
have been responded. LDL Cholesterol levels were lower
than 130 mg/dl for the majority of the patients (83.3%)
at starting the therapy and for the 94% at the end. Low
levels of HDL –Chol (<35mg/dl) were found for the 64%
of the patients. Conclusion. Patients on HD despite their
lipidemic disorders may have a good lipidemic control
under an appropriate chronic antilipidemic therapy.
1
1
2
22
E. Deda, 1 C. Pipili, 1 P. Tseke, 1 K. Pandelias,
P. Korfiatis, 2 Z. Tegou, 1 H.Tzanatos, 1 E. Grapsa
Aretaieion University Hospital, Athens, Greece
Dialysis Unit Specimed, Loutraki, Greece
POSTER PRESENTATIONS
23
Poster Presentations
PP 001
PP 002
EFFECT OF AV FISTULA ON CARDIAC HORMONES IN
CKD PATIENTS
EFFECT OF AV FISTULA ON DOPPLER
ECHOCARDIOGRAPHY PARAMETERS IN
PREDIALYSIS, HEMODIALYSIS AND RENAL
TRANSPLANTATION PATIENTS
C. Kampouris, I. Roudenko, M. Karamouzis,
A. Hatzibaloglou, C. Pliakos, D. Grekas
Renal Unit of Central Clinic, Propedeftiki Pathologiki
University Hospital “AHEPA”, Thessaloniki, Greece
C. Kampouris, A. Hatzibaloglou, M. Karamouzis,
C. Pliakos, P. Malindretos, I. Roudenko, D. Grekas
Renal Unit of Central Clinic, Propedeftiki Pathologiki
University Hospital “AHEPA”, Thessaloniki, Greece
Background. Cardiac failure is present in CKD patients
which are induced even more by the endothelial and
cardiac hormones. Purpose: To investigate the possible
role of the creation and closure of AVF on the release of
cardiac and endothelial hormones in CKD patients.
Methods. Three groups of patients were included in the
study: Fourteen renal transplanted patients underwent
fistula closure(C); 21 predialysis patients(Α) and 34
hemodialysis patients (Β) were all evaluated before,
one month, three months and six months after the
surgical intervention calculating the hormones NO,
VEGF, ANP, PRA , ALD , ET-1. Results. The levels of
ALD was significantly higher in group A (t =-2.09,
p=.049), and B (t=3.33, p =.002) from three months.In
group C lower (t =2.25, p =.043) after six months. ANP
in group A was significantly higher in third and sixth
month (t =-2.30, p= .032), (t = -3.17, p = .005). In
group B (t = -5.12, p =.000) from month one. In group
C from month one reduction (t =3.39, p =.005) and 6
months (t= 5.77, p =.000). For VEGF elevation from
month one in group A (t =-2.52, p=.020) and B (t =6.99, p =.000).Group C reduction from the first month
(t =3.74, p =.002). For ET-1 and group A elevation from
the third month (t =-4.44, p =.000). In group B
elevation from first month (t=-7.19, p=.000). Group C
reduction from month one (t =4.17, p =.000). Elevation
of NO in six months (t =-2.93, p =.008) in group A. In
group B from month one (t =-2.62, p =.013). In group
C reduction of NO from month one (t =2.53, p =.024).In
group A and B elevation of Renin from month one (t =7.21, p =.000) and (t =-3.96 p=.000). In group C from
month one reduction (t=4.87, p =.000). Conclusion.
We have clear elevation of the calculated parameters in
groups A & B and reduction in group C after the creation
/ ligation of AVF.
Background. Creation of arteriovenous fistula may
increase left ventricular hypertrophy, while fistula
closure may lead to its regression. Methods. Fourteen
renal transplanted patients underwent fistula closure; 21
predialysis patients and 34 patients who initiated
hemodialysis within the last 5 months, were all
evaluated before, after one month, after three months
and six months after the surgical intervention
respectively, with the use of Doppler echocardiography.
Results. Left posterior ventricular wall, showed a slight
increase in predialysis (11.4 mm ±2.1 vs 12.5 mm
±1.7) and dialysis patients (11.4 mm ±2.4 vs 12.1 mm
±1.9), while a significant reduction (p<0.01) was
observed in transplanted patients (11.5 mm ±2.2 vs 9.6
mm ±1.5). Intervetricular septum showed an increase
both in predialysis (10.1 mm ±2.6 vs 11.8 mm ±1.5)
and dialysis patients (11.1 mm ±2.3 vs 12.2 mm ±2.4),
while a slight decrease was found in transplanted
patients (9.8 mm ±1.5 vs 9.6 mm ±1.5); this difference
between fistula formation and fistula closure was proven
statistically significant (p<0.04). End diastolic diameter
showed significant decrease (p<0.001) in all groups
(53.4 mm ±5.0 vs 48.1 mm ±9.2; 50.9 mm ±5.1 vs
46.3 mm ±6.6 and 49.3 mm ±4.6 vs 48.1 mm ±7.7
respectively). Left ventricular ejection fraction showed
significantly higher values in the transplanted group
both before (68.9 % ±7.6 vs 67.3 % ±5.7 and 64.0 %
±10.5), as well as after six months (68.2 % ±6.0 vs
64.5 % ±5.7 and 62.1 % ±6.5). Conclusion. Changes
in doppler echocardiography findings, reflecting changes
in cardiac structure after six months of follow up,
deteriorated both in predialysis and dialysis patients
after fistula creation, but were proven beneficial after
fistula closure in renal transplanted patients.
24
PP 003
PP 004
RENAL TRANSPLANTATION OF GREEK PATIENTS:
TRANSPLANTATION ABROAD VERSUS EVOLUTION
OF THE NATIONAL PROGRAM
IGA NEPHROPATHY IN RENAL ALLOGRAFT: REPORT
OF 10 CASES
1
1
1
1
H.Gakiopoulou, 1 G.Liapis, 2 E.Theodoropoulou,
E.Chaviaras, 2 G.Vlachopanos, 2 G.Zavvos, 1 E.Patsouris,
2
J.N.Boletis
1
1st Department of Pathology, School of Medicine,
University of Athens, Greece
2
Renal Transplantation Unit, General Hospital "Laiko",
Athens, Greece
1
2
A.Gompou, S.Marinaki, G.Toka, I.Bokos,
A.Iniotaki, 1 G.Zavvos, 1 J.N.Boletis
1
Renal Transplantation Unit, General Hospital "Laiko",
Athens, Greece
2
Department of Immunology, General Hospital
"G.Gennimatas", Athens, Greece
2
Background. The purpose of the study was to present
the registry of the Greek patients that underwent renal
transplantation (RTx) abroad and are under regular
follow up at our Hospital. Methods. From 1975 to 2009
1853 RTx were performed in our hospital while another
303 RTx recipients, 16,35% of the total of kidney / and
kidney- pancreas, were transplanted abroad. From these
patients 12 died, 45 lost their graft, 37 lost the follow up
and 209 continue to be under regular follow up.
Results. The 303 RTx were divided in time periods,
based on the characteristics of our national program
development: 1975-1990, 1991-2000 and 2001-2009.
In total, 179 RTx were from deceased donors (DD), 43
from living related (LRD) and 81 from living unrelated
donors (LUD). From 1975 to 1990 the number of RTx
was 80 (47 DD, 16LRD, 17 LUD). From 1991 to 2000
there were 108 RTx (73 DD, 17 LRD, 18 LUD) showing
an increase by 26% and from 2001-2009 another 115
RTx (59 DD, 10 LRD, 46 LUD) were performed with an
increase by 6%. The last period, transplantation from
living donors was increased in comparison to the other
two periods (49% versus 40.7% and 32.5%,
respectively). The following table presents the RTx
depending on the country that was held and the time
period. Conclusion. In conclusion, Greek pts continue
undergoing RTx abroad, even though the increasing
number showed a trend towards decrease at the last
decade. At the same period an increased number of RTx
from LUD originated from countries of “transplantation
tourism” was registered.
Background. IgA nephropathy in renal transplants
represents in most cases recurrence of the primary
disease and less commonly de novo disease. IgA
nephropathy recurrence is reported with a frequency of
37% to 60% increasing over time. We present 10 cases
of renal transplant IgA nephropathy in relation to
clinicopathological parameters. Methods. Ten renal
transplant biopsies were investigated by means of light
microscopy using conventional histochemical and
immunohistochemical
stains
and
under
immunofluorescence microscopy by which a diagnosis of
IgA nephropathy was made. Results. Patients’ mean
age was 42.5 years and the male /female ratio was 8/2.
Mean time from renal transplantation to diagnosis of
recurrence was 47.33 months (13 – 78months). The
primary disease was unknown in 7 patients while 2
patients had a history of IgA nephropathy and 1 patient
had a history of Henoch-Shonlein purpura. All patients
developed glomerular hematuria which was the main
indication for biopsy in 6 patients. In one , the main
indication was the sudden onset of proteinuria while in
two, it was the deterioration of renal function. The latter
demonstrated focal segmental glomerular necroses
reminiscent - in one of them – of the lesions described
in the native renal biopsy. In two cases with stable renal
function the presence of interstitial inflammation and
mild tubulitis created a differential diagnostic problem
with subclinical borderline acute rejection. Conclusion.
Performance of immunofluorescence in renal transplant
biopsies reveals cases of IgA nephropathy in certain
patients with unknown primary disease. Although in
most cases, the presence of IgA deposits does not seem
to influence renal function, some patients does exhibit
renal dysfunction related to IgA nephropathy and
possibly to the severity of the disease in the native
kidneys.
25
PP 005
PP 006
MULTITARGET IMMUNOSUPRESSIVE THERAPY AND
FOLLOW UP PROTOCOL BIOPSIES IN PATIENTS
WITH SLE AND RAPIDLY PROGRESSIVE
GLOMERULONEPHRITIS
COMPLICATIONS OF DIABETES MELLITUS IN
DIALYSIS UNIT
S. Stanoevska-Grankova, H. Saltanovska,
S.B. Kostadinoska
J.Z.O. Zelezara, Dialysis, Skopje, R. Macedonia
1
S.Marinaki, 1 K.Kolovou, 2 H.Gakiopoulou,
M.Chaviaras, 1 C.Skalioti, 1 J.N.Boletis
1
Nephrology Department, General Hospital "Laiko",
Athens, Greece
2
Pathology Department, University of Athens, Greece
1
Background. DM is one of the leading cause of ESRD in
the upcoming world. So far, we decided to show
complications of DM in dialysis unit. Methods. In the
study 28 pts were included, from witch male=11 and
female=17, age from 31 to 65.DM was discovered about
17 years before starting dialysis regime. They were on
dialysis for about 5 years.20 pts were on long lasting
insulin TH (Mixtard-Novonordisk) and 8 were on oral
hypoglucemic drugs, all prescribed by endocrinilogyst
and depending of glucemic status. Ehorenogram was
performed in all patients: it showed enlarged kidneys
with micronodular strukture of parenhima,leads from
transformed glomerli. Corticomedular index was 0.ECG:
showed St depresion, sings of coronay Sy. Dialysis was
performed via AVF in 25pts and via subclavia catheter in
3pts on Bicarbonat modul 3x4 times weekly. (GambroLund Sweden) Results. All of the evaluated group
showed
with
micro
and
macroangipathic
complications,same of what severe.8pts developed
HTA,5pts developed retinopathy,3 pts developed
diabetic food,3 pts developed CMP,3pts developed
AIM,and 3 developed appolplectio cerebri.During
interdialysis perion 2pts developed ketoacidosis and the
condition was so far treted.Pts with severe hypoglycemic
epizods
were
put
no
solutions
with
5%
DextrosaHypoglucemic episodes dyring dialysis were
coupled with 30% Glucosa, depending on glucemic
status.All of the pts showed Anaemic Sy and
dislipidemia.They were all on therapy with human
erythropoethin (Recormon-Hoffman la Roche) in doses
of 6000 I.E. weekly. and statins TH for dislipedemia.
Conclusion. In spite the fact that all of the patients
were switch to long lasting insulin early and they have
regular dialysis tretmant they developed complications,
some of what were severe.
Background. Aim of the study was to assess the course
and efficacy of aggressive immunosuppressive therapy
in a subgroup of SLE patients with rapidly progressive
glomerulonephritis (RPGN). Methods. In a series of 195
patients with SLE nephritis from 2000-2009, 5 (2.4%)
had RPGN.There were 3 men and 2 women, age 21-54
years with SLE nephritis class III and IV (ISN/RPS 2003)
with crescents in >50% of the glomeruli (range 5077%), high activity index (13-20), active urinary
sediment and mean proteinuria of 3-13g/24h. Results.
They had impaired renal function with calculated eGFR
(Cockrofft
-Gault
formula)
17-55ml/min,
low
complement levels (C3 31-81mg/dl and C4 3-8.6mg/dl
respectively) and high antids-DNA levels (16-100 iu/ml).
All
patients
received
aggressive
induction
immunosuppressive treatment with 3 pulses of
methylprednizolone (0.5-1g/d) and iv Cyclophosphamide
(0.5-1g/m2) monthly for at least 6 months in
conjunction with 6-8 courses of immunoadsorption (23lt, plasmaflo+immusorba filters) and 2 doses of 1g of
the anti-CD20 mAbRituximab. As maintenance, they
received MPA’s (2.5-3g of MMF or its equivalent of MPS)
and low dose steroids. Follow up was 13-24 months.
Patients were closely monitored with serology, renal
parameters and either repeat protocol biopsies or by
indication. Protocol biopsies were performed in 4/5
patients after 18 months of therapy. From the 3rd
month of induction therapy, there was a substantial
improvement in renal function with an eGFR of 2475ml/min. At the end of follow up there was a
remarkable clinical response in 4/5 patients with an
eGFR 85-120ml/min, negative urine sediment and a
decrease of proteinuria to 0.15-1.4g/24h. The patient,
who remained with eGFR at 30ml/min and 1.8g/24h
proteinuria at the end of follow up, was the oldest
(54years), with a high chronicity index of 8/12 at first
biopsy. One indication biopsy was performed at month
12 in one patient because of persistent nephrotic
syndrome. After adding cyclosporine to low dose MPA
and methylprednisolone of 4mg/d, she also had
complete remission at the end of follow up.There were
no infections or other serious adverse events. Despite
the remarkable response with complete remission in 4/5
patients and the almost complete absence of activity in
the repeat, protocol biopsies, there was an increase in
chronicity. Conclusion. It is concluded that immediate
initiation of multitarget immunosuppressive therapy is
mandatory for the patients with the most aggressive
form of SLE nephritis and it is tolerated very well.
However, despite remarkable clinical improvement and
no disease activity, in the protocol biopsies residual
chronic damage is increased.
26
PP 007
ACUTE RENAL FAILURE IN INTENSIVE CARE
PATIENTS: EPIDEMIOLOGY, TREATMENT AND
OUTCOME: 9 YEARS PROSPECTIVE STUDY
PP 008
1
1
2
2
THE PRESENCE OF ACUTE RENAL FAILURE IN
ADULT PATIENTS WITH MINIMAL CHANGE
DISEASE. WHAT DIFFERENCE DOES IT MAKE?
P. Kyriklidou, 1 N. Anagnostou, 1 P. Pateinakis,
K. Arvaniti, 2 A. Kalakonas, 1 E. Manou, 1 I. Minasidis,
2
D. Matamis, 1 D. Tsakiris
1
Nephrology Department, “Papageorgiou” General
2
Intensive Care Unit, “Papageorgiou” General Hospital,
E. Liakou, 1 M. Stangou, 1 D. Ekonomidou, 1 P. Giamalis,
A. Pantzaki, 1 P. Pateinakis, 1 G. Efstratiadis,
1
D. Memmos
1
Thessaloniki, “Hippokration” General Hospital,
2
Department of Pathology, “Hippokration” General
Background. Acute Renal Injury (ARI) is common
among Intensive Care Unit (ICU) patients and has been
related to high mortality. The aim of this study was to
define epidemiology, clinical assessment and outcome of
Greek ICU patients with ARI. Methods. Over a period of
9 years (2000-2009), we analyzed 3387 patients
admitted in an ICU with a catchment area of over 2.5
million population. ARI was defined as: serum creatinine
> 1.2mg/dl or diuresis < 500ml/24h (or <180/8h) or
the need for dialysis. Demographic data, APACHE and
SAPS score, cause of admission and duration of
hospitalization in ICU, hemodynamic status, 24h urine
output, mechanical ventilation, need for dialysis,
laboratory and blood gas analysis data were collected
and their association with mortality and outcome was
tested. Results. ARI was diagnosed in 200 of 3387 ICU
(5.9%) patients. 146/200 o (73%) had ARI on
admission. There were 100/200 [50%] male, and the
average age was 68 years (range 50-75). The APACHE
II and SAPS mean score values were 20.4 +/-6.4 and
53+/-18.2 respectively. 125/200 patients [62.5%] had
serum creatinine value > 1.8 mg/dl, pH<7.3 95/200
[47.5%], HCO3<20 100/200 [50%], Ht <35% 144/200
[72%]. 155/200 of the patients [76%] were treated with
administration of inotropes/vasoactive drugs. 168/200
[84%] needed mechanical ventilation. 138/200 [69%]
of the patients maintained diuresis <500ml/24h, 73/200
[36.5%] required hemodialysis (HD) from whom 38/73
[52.05%] died. The ICU combined mortality was
100/200 [50%]. 12% of the ARI ICU survivors
developed ESRD with need for chronic dialysis. In
multivariate analysis death in ICU patients with ARI was
significantly associated with SAPS [OR 1.039; 95% CI:
1.018-1.061, p=0.00], the use of inotropes/vasoactive
drugs [OR 2.533, 95% CI:1.137-5.644, p=0.023] and
pH<7.30 [OR 2.632, 95% CI: 1.359-5.097, p=0.01].
Conclusion. ARI in a Greek ICU was associated with
high mortality. SAPS score on admission, the use of
inotropic drugs and severe acidosis were the most
predictive variables of the patient’s outcome.
Background. Acute renal failure (ARF) can be
manifested in patients with Minimal change disease
(MCD) at diagnosis or during the course of the disease.
In the present study we tried to determine parameters
that potentially participate in the development of ARF
and also evaluated the role of ARF in short and long
term outcome of MCD. Methods. Clinical and
histological findings at time of presentation were
retrospectively studied in adult MCD patients with ARF
and compared to those in MCD patients with normal
renal function. Renal function and degree of proteinuria
were also estimated at the end of follow up, 4,2 (18)yrs. ARF was defined as a ≥50% increase in serum
creatinine. Results. During the period 2000-2009, ARF
was diagnosed in 12 of the 50 patients with MCD (24%).
Main difference at presentation between patients with or
without ARF was serum albumin levels, 1.7 ± 0.4 vs. 2.2
± 0.4g/24hr, p=0.03, respectively. Severity of histology
was similar in two groups of patients. However, the
degree of tubulointerstitial infiltration, tubular atrophy
and arteriosclerosis were significantly increased in ARF
patients with severe deterioration of renal function
(Screat>2.5mg/dl), compared to patients with less
severe ARF (Screat≤2.5mg/dl) (0.7±0.7 vs. 0, p=0.02,
0.3±0.5 vs. 0 p=0.05 and 0.8±1.1 vs. 0 p=0.05
respectively).
Furthermore,
the
presence
of
tubulointerstitial infiltration and tubular atrophy were
the main predictors of renal function outcome at the end
of the study (Final Screat 5.6±5 vs. 1±0.3mg/dl,
p=0.03 and 6.8±5 vs. 1.1±0.2mg/dl, p=0.01
respectively). Five of ARF patients (41.6%) had frequent
relapses and 2/12 (16.6%) developed ESRD and
commenced on hemodialysis. Conclusion. ARF is not a
rare complication of MCD; predisposing factors remain
unknown. The presence of tubular atrophy and
tubuloiterstitial inflammation in MCD may be the main
predictors of renal function deterioration.
27
PP 009
PP 010
HISTOLOGY AND URINARY LEVELS OF EPIDERMAL
GROWTH FACTOR MAY PREDICT RESPONSE TO
IMMUNOSUPRESSIVE TREATMENT OF IDIOPATHIC
FOCAL SEGMENTAL GLOMERULOSCLEROSISS
THE SIGNIFICANCE OF DONOR KIDNEY BIOPSIES
IN MAKING A DECISION FOR THE USE OF ORGANS
IN TRANSPLANTATION
1
1
1
G. Liapis, 1 H. Gakiopoulou, 2 M. Darema,
C. Melexopoulou, 2 P. Kaisidis, 3 G. Zavvos, 2 J. Boletis
1
1st Department of Pathology, University of Athens,
“Laiko” General Hospital, Athens, Greece
2
Nephrology Department, “Laiko” General Hospital,
Athens, Greece
3
Surgery Department, “Laiko” General Hospital, Athens,
Greece
1
2
M. Spartalis, M. Stangou, C. Pliakos,
D. Oikonomidou, 2 A. Pantzaki, 1 E. Rizopoulou,
1
G. Efstratiadis, 1 D. Memmos
1
Thessaloniki, “Hippokration” General Hospital,
2
Department of Pathology, “Hippokration” General
1
Background. Our aim is to determine the significance
of donor kidney biopsies in making a decision for the use
of organs in transplantation. For this purpose, a cohort
of 16 kidney biopsies (10 Deceased and 6 Living donor
biopsies) was examined, including 2 wedge biopsies and
14 needle biopsies, from 11 females and 5 males.
Material and Methods. Hematoxyline/Eosine stained
slides, along with histochemical stains (PAS, Silver,
Masson) from all 16 cases were used for the evaluation
of
different
histological
parameters,
such
as
glomerulosclerosis, interstitial fibrosis, arteriosclerosis,
acute tubular injury and presence of glomerular
capillaries red blood cell congestion or thrombi. All cases
met the adequacy criteria proposed by others, including
at least 10 glomeruli in paraffin-fixed sections and
branches from arcuate arteries. Results. The median
age of patients was 60 years old. The mean glomeruli
number per biopsy was 21 for needle biopsies and 50 for
wedge biopsies. Only 2/16 (13%) cases, all derived from
Deceased donors, demonstrated moderate tubular
atrophy/interstitial fibrosis (>25% of the tissue) in
association with moderate glomerulosclerosis (>20%
global glomerulosclerosis), while all the others exhibited
only mild glomerulosclerosis and mild interstitial fibrosis.
9/10 (90%) cases derived from Deceased donors
showed moderate or severe arteriosclerosis. By contrast
only 1 case showed significant arteriosclerosis in Living
donors group (1/6, 17%, p<0.05). In Deceased donor
biopsies there was also acute tubular injury as expected,
while three biopsies from Deceased donors showed
glomerular capillaries red blood cell congestion or a few
glomerular thrombi. All the kidneys from our study
group were successfully transplanted. Conclusion. Our
findings indicate that the role of donor biopsy is not to
identify reasons to discard organs. Furthermore, we
showed that histology as a solely factor, usually can not
be applied to make a decision for the use of the organs
in transplantation.
Background.
Idiopathic
Focal
Segmental
Glomerusclerosis
(FGGS),
a
relatively
common
glomerular disease may present with a wide range of
clinical and pathologic features and runs an
unpredictable course, frequently leading to end stage
renal disease, in spite of immunosuppressive treatment.
The aim of this study was to determinate factors
correlated with the treatment response, prognosis and
outcome of the disease. Methods. The presentation and
outcome of biopsy proven idiopathic FSGS were
retrospectively analyzed in 105 adults, M/F: 61/44,
Mage 43.3 (14-79) years. Clinical and histological
findings and urinary levels of epidermal growth factor
(EGF) were estimated at day of renal biopsy and results
were correlated to disease outcome and response to
treatment. Results. Serum creatinine at the beginning
(Scr1) was 1.81.1mg/dl and Ualb1 3.52.5g/24hr.
Parameters correlated with Scr1 were: patients' age
(r=0.2, p=0.04), percentage of global sclerosis (r=0.5,
p<0.0001), degree of tubular atrophy (r=0.4, p=0.001)
and degree of tubulointerstitial (TIN) inflammation
(r=0.04, p<0.0001). Patients response to initial
treatment depended upon degree of renal function at
diagnosis (p=0.003), EGF urinary levels (p=0.02),
percentage of global sclerosis (p=0.01) and tubular
atrophy (p=0.01). At the end of follow up
(68.440.5months), Ualb2 was 1.21.1g/24hr and Scr2
was 5.24.3mg/dl, 29/105 patients (27.6%) reached end
stage renal disease. The patients who initially responded
to treatment were more likely to have a better final
outcome in proteinuria (p=0.01) and renal function
(p<0.0001). One-way ANOVA test was performed to
estimate significance of factors correlated with
complete, partial remission or no response to treatment.
Age (p=0.04), Scr1 (p=0.001), EGF urinary levels,
(p=0.004), percentage of global sclerosis (p=0.001),
severity of tubular atrophy (p=0.002) and degree of TIN
inflammatory infiltration (p=0.02) were all significant
parameters correlated with final outcome. Conclusion.
EGF urinary excretion, global sclerosis and severity of
TIN lesions are the main parameters that predict renal
function outcome and response to treatmentt in
idiopathic FSGS.
28
PP 011
PP 012
LOW SERUM TESTOSTERONE LEVELS ARE
ASSOCIATED WITH INCREASED RISK OF
MORTALITY IN HAEMODIALYSIS MEN
SEROEPIDEMIOLOGY OF COXIELLA BURNETII IN
END-STAGE RENAL DISEASE (ESRD) PATIENTS
M. Pape, K. Mandraveli, S. Dionysopoulou, C.Kanonidou,
E. Diza
Laboratory of Infectious Diseases, “AHEPA” University
Hospital of Thessaloniki, Thessaloniki, Greece
1
E. Mitsopoulos, 1 M. Tsiatsiou, 1 E. Ginikopoulou,
1
I. Minasidis, 1 V. Kousoula, 1 M. Tsikeloudi, 1 E. Manou,
2
A. Giannakou, 2 A. Pavlitou, 1 D. Tsakiris
1
Department of Nephrology, “Papageorgiou” General
2
Department of Immunology, “Papageorgiou” General
Background. Q fever is not easily diagnosed, especially
when it presents with nonspecific symptoms, such as
fever. Since immunocompromised patients are a
potential risk group of infection, the aim of this study
was to determine the seroprevalence of Coxiella burnetii
among ESRD patients. Methods. Between 2006 and
2010, antibodies to C. burnetii were determined using
an immunofluorescent test (Focus, kit) in 73
hemodialysis patients (41 men, 32 women, mean age
58+/-5yr). The epidemiologic study included sex, age,
contact with animals, symptoms associated with Q
fever. Results. Of the 73 ESRD patients, 16 (21%) were
seropositive for C. burnetii IgG phase I antibodies. Titers
1/64, 1/128, 1/256 were found in 13% (10/73), 2%
(2/73), ~1% respectively. Noone of both study groups
reported animal exposure before serologic test was
performed. No symptoms or signs were present during
the study period. The seropositivity in the healthy
population in Northern Greece as shown in previously
published data reveals statistically significant differences
with ESRD patients. Conclusion. Our data indicate that
C.
burnetii
infection
is
common
among
immunocompromised patients. Therefore, Coxiella
burnetii should be considered in the differential
diagnosis of opportunistic infections in ESRD patients
and the epidemiological factors involved should be
further identified.
Background. In the general population, an inverse
association between testosterone concentrations and
mortality has been observed. The available data on
haemodialysis (HD) patients regarding the influence of
serum testosterone on mortality are very limited. The
aim of the present study was to evaluate a possible link
between testosterone levels and all-cause mortality in
HD patients. Methods. We used data from a single HD
unit of adults from 1 September 2005 through 31
December 2010. Serum total testosterone levels were
available in a subsample of 82 chronic HD men who
were included in this analysis. Proportional hazards
regression was used to compute hazard ratios. Survival
was determined from the day of testosterone
measurement, with a mean follow-up period of 42±22
months. Results. Mean age of the patients was 60±13
years with a mean body mass index (BMI) of 25±4
kg/m2. Mean testosterone levels were 35±20 ng/ml.
During the follow-up period 32 patients (39.5%) died.
The mean concentrations of testosterone were 29±13
ng/ml among participants who died and 39±23 ng/ml
among participants who survived (P = 0.033) After
adjustment for age, HD vintage, diabetes mellitus,
serum albumin, BMI, haemoglobulin (Hb) and serum
creatinine the Cox proportional hazards model showed
that patients with low testosterone levels had an
increased mortality by all causes [hazard ratio (HR)
0.965, 95% confidence interval (CI): 0.938 to 0.994, P
= 0.017]. The adjusted HR of diabetes mellitus was
3.672 (95% CI: 1.337 to 10.088, P = 0.012) and of
creatinine values was 0.827 (95% CI: 0.691 to 0.989, P
= 0.038). The HR did not vary by age (P = 0.927), BMI
(P=0.452), albumin levels (P = 0.141), Hb (P = 0.846)
and HD vintage (P = 0.401). Conclusion. Among men
treated with HD, low serum testosterone concentrations
are inversely associated with all-cause mortality.
29
PP 013
PP 014
BACTEREMIA IN HEMODIALYSED PATIENTS
DEPRESSION IN END-STAGE RENAL DISEASE
PATIENTS TREATED BY HEMODIALYSIS: AN UPHILL
BATTLE
1
M. Kostaki, 1 D.Georgakopoulou, 1 N.Nikolaidis,
S.Bristogiannis, 1 M.Ralli, 2 P.Triantos, 2 E.KaranikolaPavlaki, 2 A.Anagnostopoulou, 1 G.Bristogiannis
1
Dialysis Unit, Kalamata General Hospital, Kalamata,
Greece
2
Microbiology laboratory, Kalamata General Hospital,
Kalamata, Greece
1
E. Chelioti, S. Pavlopoulou, S. Mamali, I. Lorentzaki,
S. Mikros, M. Sotiraki, G. Papadakis
General Hospital of Piraeus “Tzaneio”, Piraeus, Greece
Background. Depression is well established as a
prevalent mental problem for people with end-stage
renal disease (ESRD) on replacement therapy and is a
risk factor for morbidity and mortality. The overlap
between symptoms of chronic illness and those of
depression make for a particularly challenging diagnosis
in this illness. Current estimates suggest a 20 to 30%
prevalence of depression that meets diagnostic criteria
in this population. The aim of the study was to identify
the rates of depression symptoms in a cohort of
haemodialysis (HD) patients of 3 Renal Units in the area
of Piraeus. Methods. A sample of 126 (76 males/ 50
females, mean age 66±13 years , mean period on
dialysis 52±68 months, mean kt/v1,4±0,18, undergoing
on dialysis three times per week) randomly selected
hemodialysis patients were evaluated using an adjusted
method based on the Beck-Depression Inventory (BDI)
and the Center for Epidimiological studies-Depression
Scale (CES-D). The score was a 0 to 60 for the levels of
depression. A part of HD patients had been prescribed
psychiatric medication by their physician. Results. The
analysis of collected data showed that 58% (73/126) of
patients were found to have mild-moderate depression,
32% (40/126) moderate-severe depression and only
10% (13/126) of patients had a diagnosis of dysthymia.
The mean score was 16.7±5 in women and 15.6±4.8 in
men. There was not found statistician difference in the
score between women and men (p=0.252). Out of the
total of 126 HD patients, 41(33%) were receiving
psychiatric medication, with the percent of medication
prescription to be 4 times higher in women (RR=2,375,
95%Cl: 1.41-3.98). Conclusion. Our results showed
that the majority of HD patients met criteria for
depression. Also, there is a tendency to prescribe
psychiatric medications to women due to their temper to
depression. Finally, studies of interventions designed to
reduce levels of depressive affect in ESRD patients are
urgently needed.
Background. The aim of this study is to record the
frequency, the etiologic factors, and the course of
bacteremia in patients undergoing hemodialysis, as well
as the characteristics of the responsible microorganisms.
Methods. Our study included 135 patients (74 men, 61
women) with a mean age of 68.1±14.8 years (range 1994), who underwent chronic hemodialysis for a mean
period of 72.2±63.7 months (range 1-368). We
analyzed the bacteremia episodes that occurred during a
period of 60 months (4,315 patients-months). Results.
We recorded 44 bacteremia episodes in 30 patients (13
men-43.3% and 17 women-56,7%) with a mean
incidence of 1.02episodes/100patients-months. Twenty
seven episodes (61.4%) occurred in patients over 65
years. Seventeen patients (56.7%) were known for
diabetes mellitus. In the majority of cases (38 out of 44
-86.4%), the infection was related to the vascular
access for hemodialysis (VARS). A different etiology was
found only in 6 cases (13.6%): cholangitis (2),
prostatitis (1), shin ulcer (2), diabetic leg (1). Twenty
seven out of forty four patients (61%) had an
intravascular
catheter
(jugular-24,
subclavian-1,
femoral-2), 8 (18%) an AV fistula and the rest an AV
graft. Gram-positive microorganisms were isolated in a
total of 33 blood cultures. In all of them except one
there was a VARS. The most frequently isolated
microorganisms were Staphylococcus aureus and
coangulase-negative Staphylococcus, present in 28 out
of 44 samples (63.6%). Escherichia coli was found in 7
out of 44 samples (15,9%). In 8 cases the intravascular
catheter had to be removed and the bacterium isolated
from the culture of its end (in 7 out of 8 cases) was the
one identified in the patient’s blood culture. All patients
received an anti-staphylococcal agent (vancomycin or
teicoplanin) and an aminoglycoside (netilimicin),
occasionally
associated
to
a
3rd
generation
cephalosporin. Afterwards, if necessary, the treatment
was modified according to the antibiogram. The outcome
was successful in the majority of the cases (41 out of
44-93.2%). Three patients from the VARS group who
were contaminated by S.aureus and S.epidemidis died.
Conclusion.
Bacteremia
is
frequent
among
hemodialysed patients and constitutes an important
cause of death. Hemodialysis vascular access and
especially intravascular catheters is the major
predisposing factor. The treatment should start
immediately and be focused in the most commonly
isolated microorganisms, such as Staphylococcous and
gram-negative bacteria.
30
PP 015
PP 016
OUR EXPIRIENCE WITH NON-INFECTIOUS
COMPLICATIONS IN PEDIATRIC PERITONEAL
DIALYSIS IN R. MACEDONIA
EPIDEMIOLOGICAL STUDY RELATED TO OXIDATIVE
STRESS IN END STAGE RENAL DISEASE
1
P. Dejanov, 2 B. Dejanova
Clinic of Nephrology, Clinical Center Skopje, FYROM
2
Institute of Physiology, Medical Faculty, University of
Skopje, R. Macedonia
1
E. Sahpazova, D. Kuzmanovska, M. Petrovski,
R. Simeonov
1
University Pediatric Clinic
2
Clinic of Pediatric Surgery
University of Skopje, R. Macedonia
Background. End stage renal disease (ESRD) has a
number of complications due to hemodialysis (HD)
session,
lipid
impairment,
infection,
hemostasis
disturbances, etc. Oxidative stress (OS) as a condition of
free radicals (FR) overproduction without appropriate
antioxidative defense may increase and accelerate
numerous disease consequences. The aim of this study
was to examine OS in ESRD patients concerning age,
gender, HD duration, type of used HD membrane and
primary renal disease. Methods. A number of 79 ESRD
patients were divided regarding: the age - <30 years old
(n=22); 31-50 years old (n=29); and >51 years old
(n=28); gender - male (n=49) and female (n=30), HD
year duration - <5 (n=30); 5-10 (n=24); >10 years
(n=25); HD membranes - hemophane (n=30),
polymetilmetacrylate (n=15) and polysulphone (n=34);
the primary renal disease - glomerulonephritis (n=21),
pyelonephritis (n=12), hypertension condition (n=9),
polycystic renal disease (n=7), diabetes mellitus (n=6),
unknown (n=23). Results. The increasing of LP value
was age related from 3.8+/-0.4 mmol/l in young group,
to 4.83+/-1.2 mmol/l in middle aged group and in old
group, 4.99+/-1.7mmol/l (p<0.01). No significant
differences were found related to gender of ESRD
patients, but the longest HD duration showed highest LP
level, 5.1+/-1.4 mmol/l (p<0.05). For hemophan used
membrane LP level showed higher value of 5.36+/-1.98
mmol/l than for polymetilmetacrylate one, 5.02+/-1.25
mmol/l and polysulphone one, 4.52 +/-1.22 mmol/l
(p<0.05). Regarding primary renal disease diabetes
mellitus showed the highest value of 4.8+/-1.65 mmol/l
(p<0.05). Conclusion. Due to our results we may
conclude that patient age, HD duration, different types
of HD membranes and the type of primary renal disease
may influence on patient conditions according to OS
increase. These findings represent possible factors that
may accelerate the morbidity and the mortality of the
ESRD patients.
Background. Peritoneal dialysis (PD) is known to be
associated
with
infectious
and
non-infectious
complications. Non-infectious complications are usually
less common as compared with infectious Methods. In
this retrospective study we examined the incidence of
various non-infectious complications in pediatric patients
who underwent PD treatment. Results. We analyzed 25
children (10 girls and 15 boys, mean age 10.25±4.20
years) on PD in the period between January 1996 and
May 2011. Results. The cause of ESRD was uropathy in
11 children (44%), chronic glomerular disease in 6
children (24%) and others in 8 children (32%). The
mean duration of PD was 36.2±27.16 months (range 4115 months). 16 children received CAPD and nine
received automated PD. The incidence of non-infectious
complications was as follows: hernias in 20%, catheter
dysfunction in 36%, dialysate leak in 8%, cardiovascular
problem in 20%, cuff extrusion in 12% and ileus in 4%.
Catheter block and hernias were more prevalent then
other complications and were diagnosed with a median
duration after catheter insertion of 28.89±25.36 and
22.67±15.14 days, respectively. More than half of
hernias were inquinal and all were bilateral. Surgical
intervention and catheter replacement were required in
16 episodes to resolve technique failures. During followup period 4 patients (16%) died because cardiovascular
problems, and dialysate leak in 2 children (8%) was the
main cause for transferred to HD. Conclusion.
Prevention,
early
recognition,
and
appropriate
management of these complications are important
because of associated patient morbidity and technique
failure.
31
PP 017
PP 018
SEROEPIDEMIOLOGY OF COXIELLA BURNETII IN
END-STAGE RENAL DISEASE (ESRD) PATIENTS
THYROID HORMONE PROFILE IN PATIENTS WITH
END STAGE RENAL DISEASE FROM NORTHERN
GREECE
M. Pape, K. Mandraveli, S. Dionysopoulou, E. Diza
Laboratory of Infectious Diseases, “AHEPA” University
M. Pape, C. Kanonidou, M. Karamouzis
Department of Biochemistry, “AHEPA” University Hospital
of Thessaloniki, Thessaloniki, Greece
Background. Q fever is not easily diagnosed, especially
when it presents with nonspecific symptoms, such as
fever. Since immunocompromised patients are a
potential risk group of infection, the aim of this study
was to determine the seroprevalence of Coxiella burnetii
among ESRD patients. Methods. Between 2006 and
2010, antibodies to C. burnetii were determined using
an immunofluorescent test (Focus, kit) in 73
hemodialysis patients (41 men, 32 women, mean age
58+/-5yr). The epidemiologic study included sex, age,
contact with animals, symptoms associated with Q
fever. Results. Of the 73 ESRD patients, 16 (21%) were
seropositive for C. burnetii IgG phase I antibodies. Titers
1/64, 1/128, 1/256 were found in 13% (10/73), 2%
(2/73), ~1% respectively. Noone of both study groups
reported animal exposure before serologic test was
performed. No symptoms or signs were present during
the study period. The seropositivity in the healthy
population in Northern Greece as shown in previously
published data reveals statistically significant differences
with ESRD patients. Conclusion. Our data indicate that
C.
burnetii
infection
is
common
among
immunocompromised patients. Therefore, Coxiella
burnetii should be considered in the differential
diagnosis of opportunistic infections in ESRD patients
and the epidemiological factors involved should be
further identified.
Background. Thyroid abnormalities are common in
patients with end stage renal disease (ESRD) on
hemodialysis, although signs and symptoms are rarely
suggestive and often confused. The aim of this study
was to investigate the prevalence of thyroid dysfunction
in patients with ESRD on hemodialysis. Methods. 130
patients with ESRD (78 men / 53 women) and median
age 63,5 ± 7,8 were included. At the time of the study
all patients were clinically euthyroid and noone had a
history of recent infection or other illness or received
any medication that could affect thyroid function. Serum
samples were obtained before the first dialysis of the
week and serum levels of TSH, FT3 and FT4 were
measured
(Roche,
Modular
E170).
Subclinical
hyperthyroidism was defined when TSH was abnormal
low (<0,27 µIU/ml) and FT3 (3,1-6,8 pmol/lit) and FT4
(12-22,0
pmol/lit)
were
present
at
normal
levels. Subclinical hyporthyroidism was defined when
TSH was abnormal high (>4,20 µIU/ml) and FT3 and
FT4 were present at normal levels. Results. Subclinical
hyperthyroidism was detected in 6/130 (4,6%) patients
[4/78 men (5,1%) and 3/53 women (5,6%)]. Subclinical
hypothyroidism was detected in 12/130 (9,2%) patients
[3/78 men (3,8%) and 9/53 women (p<0,05) (16,9%)].
Hyperthyroidism was not detected and only 2/53 (3,7%)
women presented with hypothyroidism. Conclusion.
Thyroid abnormalities were not unsual in patients with
ESRD. Therefore serum levels of TSH, FT3 and FT4
should be considered in the evaluation of every ESRD
patient.
32
PP 019
PP 020
INTERVENTIONAL NEPHROLOGY: PLACEMENT OF
TUNNELLED CENTRAL LINE UNDER ULTRASOUND
GUIDANCE IN ‘REAL TIME’
INTERVENTIONAL NEPHROLOGY: NATIVE AND
TRANSPLANT KIDNEY BIOPSY UNDER
ULTRASOUND GUIDANCE IN ‘REAL TIME’.
1,2
1,2
1
1
2
I. Griveas, 2 J.O. Nwosu
401 Military Hospital of Athens, Greece
'Queen Elizabeth' University Hospital of Birmingham,UK
2
Backround. Tunnelled cuffed central venous catheters
may be required where formation or maturation of
fistula is awaited, not possible for medical or personal
reasons or when other routes of access have failed. Aim
of this study is to introduce the technique of placement
of tunnelled central lines under ultrasound guidance in
‘real time’. Methods. After obtaining consent we define
anatomy of the posterior and anterior triangles with
head fully rotated to left for right internal jugular vein
approach and right if left approach and make our choice
depending on patient. We pick our spot at the apex, mid
or base of triangle depending on vein accessibility. Next
step is to inject lignocaine to skin, tissues as safely close
of the vein as possible. We make sure tip of our needle
is in view at all times, using ultrasound guidance in ‘real
time’. Under these conditions vein is approached and
punctured with introducer and aspirate. Our intention is
to avoid artery. Then we introduce guide wire. After that
we create space in the soft tissues around the
guidewire, in order to make dilatation much more
convenient. We peek the spot and create the tunnell,
following local anesthesia. After that we dilate the vein,
action achieved with gentle downwards and inwards
rotating action. Gently remove of the guide wire is our
next step and very quickly we introduce the catheter
and remove the dilator. We check if the catheter is
working. We lock then the line to specified volume with
heparin and apply sutures to secure it. Results. The
whole procedure is straightforward and can be
performed in the procedure room by nephrologists in
less than an hour. They can be used immediately when
inserted and the patients by-pass the pathway of the
operation theatre. Conclusion. The procedure of
inserting permanent tunnelled central lines under
ultrasound guidance in ‘real time’ is safe, quick,
completely organized and performed from nephrologists,
who know better than anyone the special needs of
patients with end stage renal disease.
I. Griveas, 2 J.O.Nwosu
'Queen Elizabeth' University Hospital of Birmingham, UK
Backround. ‘Core’ procedures, such as percutaneous
renal (native and transplant) biopsies have traditionally
been performed by nephrologists but increasingly are
perfomed by other specialists. Aim of this study is to
introduce the ‘real time’ ultrasound kidney biopsy
technique. Methods. It is essential to define anatomical
landmarks. Using the ultrasound we localise the kidney
and with the transverse location identify the lower pole.
With the ultrasound guidance all the marks are made.
Then, local anaesthesia is offered. With the help of the
ultrasound in ‘real time’, spinal needle infiltration is
taken place, lower pole of the kidney is identified
(observe movement of the needle with respiration) and
the actual depth is assessed. Next step is ultrasound
guided deployment of biopsy gun, incision to lower pole,
impale kidney by a few mm, try to avoid medulla and
then release the gun. Tissue is hopefully obtained. In
transplant kidney biopsy, with the definition of
anatomical landmarks, spot is peaked. With the help of
the ultrasound, transplant kidney is located and be
evaluated to exclude other obvious significant
pathology. Definite location of point of biopsy (usually
upper pole, except otherwise) is decided. Then, local
anaesthesia is offered. Next step is ultrasound guided
spinal needle deep tissue infiltration, location of renal
cortex and assessment of the depth. Note that
movement of the needle with the respiration is absent in
the transplant kidney. Using the ultrasound in ‘real
time’, tip of the biopsy gun is located in renal cortex,
then pierce to a few mm at an angle to the horizontal
and release gun appropriately. Tissue is hopefully
obtained. Results. The above procedure is generally
safe and not significantly time consuming. With regard
to renal biopsies only nephrologists can make real-time
decisions about adequacy of sample size. This technique
is readily mastered, requiring training with the help of
an experienced nephrologist using inexpensive portable
ultrasound devices. Conclusion. Given the rapid growth
in nephrologist-performed ultrasound guidance, it is
evident that this is being perceived as a valuable
technique to teach fellows.
33
PP 021
PP 022
INTERVENTIONAL NEPHROLOGY: PERITONEAL
DIALYSIS CATHETER INSERTION WITH
PERITONEOSCOPIC TECHNIQUE.
ASSOCIATION BETWEEN NEPHROLITHIASIS,
HYPERTENSION AND BODY WEIGHT
1
1,2
V. Bajrami, 2 A. Idrizi, 2 M. Barbullushi, 1 S. Beqiri,
E. Roshi
1
Diagnostic Center Ikeda, Tirana, Albania
2
Service of Nephrology, UHC Mother Teresa, Tirana,
Albania
3
Department of Public Health, UHC Mother Teresa,
Tirana, Albania
3
1
I. Griveas, J.O. Nwosu
2
'Queen Elizabeth', University Hospital of Birmingham,
UK
1
Backround. Traditionally the placement of a peritoneal
dialysis (PD) catheter in a patient with end-stage renal
disease has been accomplished by a surgeon using
general anesthesia. Aim of this study is describe the
peritoneoscopic technique by interventional nephrologist
using local anesthesia. Methods. For peritoneoscopic
insertion, the entire abdomen is prepped and draped in
sterile fashion. Anatomical landmarks then defined and
marked. A small skin incision (2-3 cm) is made over the
desired location inder local anesthesia. Dissection is
carried down to deep tissues. The anterior rectus sheath
is exposed and transverse incision is made. Trochar with
quill (spiral sheath) guide deployed trough rectus
incision to peritoneal space. The procedure must be
done carefully to avoid bowel perforation. Approximately
600-700 mils of normal saline and then 600-1000 cc of
air are infused through an air filter. At this point
peritoneoscopy is performed. We may have close look,
avoid bowel and identify potential space. Then, we
remove surrounding sheath from quill quide and after
that laparoscope and inner metal cylinder are removed
carefully. After dilating rectus sheath we insert catheter
with customised stylet. We deep cuff manipulated
beyond anterior rectus sheath into muscle. We gently
remove stylet and confirm spontaneous flow. A safe
approach is to ensure correct burial of deep cuff, inspect
catheter, rectus incision and surrounding tissues and
secure the deep cuff into the rectus muscle using and
absorbable suture at the anterior rectus sheath. The
superficial cuff is implanted into the subcutaneous tissue
and an exit site to right or left lateral is created through
a tunnell. Then we confirm flow from the catheter and
the skin is closed. The patient may go home the same
day 4 hours later provided he is fine and abdomen is
unremarkable. Results. The above procedure is quite
safe, giving the ability to visualize intraperitoneal
structures in the catheter placement. It reduces costs
and bypassing the mortality risk associated with local
anesthesia.
Conclusion.
When
performed
by
nephrologist the PD catheter insertion can be
accomplished swiftly and dialysis therapy initiated in a
timely manner.
Background. Hypertension and obesity are social
diseases with important epidemiological similarities to
nephrolithiasis. We aim to define the association
between nephrolithiasis, hypertension and body weight
in our patients. Methods. We included 30 patients with
nephrolithiasis from October 2010 to March 2011. The
patients
underwent
renal
ultrasonography,
plan
abdominal X-ray, metabolic evaluation of blood and
urine. Results. The mean age of our patients was
51.4±5.7 years. 56% of patients were men and 44%
were women. Twenty one patients (70%) have
eliminated kidney stones which were evaluated with
spectral analysis. The stones were composed primarily
of urate (48%) and calcium oxalate (38%), and other
compounds 14%. 60% of patients were hypertensive
and 56% had increased body mass index (BMI) (more
than 25 kg/m2). Ten patients (33%) have diabetes
mellitus.
Conclusion.
The
association
between
nephrolithiasis, hypertension and body weight is
important in our patients. We think dietary habits are
important contributor factors to this association. Both
hypertension and kidney stones might be addressed
through lifestyle modification to prevent weight gain.
34
PP 023
PP 024
ASSOCIATION OF LUPUS NEPHRITIS AND CROHN'S
DISEASE
COMPARISON OF ANGIOTENSIN CONVERTING
ENZYME INHIBITORS AND ANGIOTENSIN IIRECEPTOR BLOCKERS EFFICACY IN CONTROLLING
MICROALBUMINURIA OF DIABETIC NEPHROPATHY
1
E. Ktona, 2 M. Barbullushi, 2 M. Rroji, 2 A. Idrizi
Diagnostic Center Ikeda, Tirana, Albania
2
Service of Nephrology, UHC Mother Teresa, Tirana,
Albania
1
1
Y. Themeli, 1 V. Bajrami, 1 E. Ktona, 2 M. Barbullushi,
F. Agaci, 2 A. Idrizi
1
Service of Internal Medicine, Diagnostic Center Ikeda,
Tirana, Albania
2
Service of Nephrology, UHC “Mother Teresa”, Tirana,
Albania
3
Service of Internal Medicine, Hospital “Hygeia”, Tirana,
Albania
3
Background. Systemic lupus erythematosus and
Crohn's disease have been described in a rare
association. The immunological background of both
diseases may explain the mechanism of this rare
association. Case report. A 50 years-old woman was
diagnosed with Chrohn's disease in May 2007 according
to gastrointestinal symptoms such diarrhoea, abdominal
pain, weight loss, vomiting, malaise, low grade fever,
and confirmed by barium studies, colonoscopy, and
biopsy. Four years leater, when she was successfully
treated with oral corticosteroids and aminosalicylates
(mesalazine) she developed disabling arthritis, malar
rash, oral ulcers, hypertension, hematuria, proteinuria ,
pancitopenia, hypocomplementemia, anti-ANA, antidsDNA and anti-Ro (SS-A) antibodies positive, and
negative anti-histone antibodies. Based on all these
facts, the diagnosis of systemic lupus erythematosus
(SLE), complicated with lupus nephritis was done. A
pulse therapy of methylprednisolone for 3 days and
cyclophosphamide was started, and very good results
are achieved using cyclophosphamide 1gr/month and
0.5 mg/kg corticosteroids. Conclusion. Despite the
rarity of such combination (Crohn’s disease with SLE),
patients with Crohn’s disease who develop such clinical
findings might need evaluation for SLE.
Background. Diabetes mellitus (DM) remains the
leading cause of end stage renal disease. Angiotensin
converting enzyme inhibitors (ACE-I) and angiotensin IIreceptor blockers (ARB) are shown to have beneficial
effect in reducing microalbuminuria of diabetic
nephropathy. Our aim was to compare the effects of
ACE-I and ARB on microalbuminuria in persons with type
2 of DM. Methods. In a prospective and randomized
study were included 70 patients with type 2 of DM with
microalbuminuria (mean age 45±15 years, 40% males
and 60% females). Patients with type 1 of DM, overt
proteinuria, history of hypertension, history of coronary
heart disease and non diabetic renal disease were
excluded from the study. They were divided into two
groups of 35 each in a double blind fashion. The patients
of group A received ACE-I (enalapril 5 mg/day) while the
patients of group B received ARB (losartan 50 mg/day).
Albuminuria in 24 hours urine was tested by the radio
immuno-assay method at the start of the study and at
the end of 3 months of treatment with ACE-I and ARB.
Baseline mean values and 3 months values were
compared for all the variables investigated and the
difference was compared between the two drugs.
Results. Age, sex, height, weight and body mass index
had no influence on the outcome. Seven patients had
progression of proteinuria despite treatment: 5 of them
were from enalapril group (4 females and 1 male) and 2
males of the losartan group. The study shows that
losartan had better reduction in systolic blood pressure,
as compared to the reduction seen with enalapril,
though not significant difference was seen in the
reduction of diastolic blood pressure. Despite this
difference on blood pressure, both the drugs have
shown reduction in microalbuminuria. At the end of 3
months treatment, the mean reduction of 24 hours urine
microalbuminuria in enalapril group was 26.74 mg as
compared to 32.18 mg in the losartan group (p= 0.27).
Conclusion. There isn’t significant difference in
microalbuminuria reduction between two groups. The
study
shows
that
ACE-I
and
ARB
reduce
microalbuminuria and decrease the progression to
albuminuria even in normotensive patients.
35
PP 025
PP 026
ROLE OF DIURETCS AND GLYCOSYLATED
HEMOGLOBIN IN THE PREDICTION OF FUTURE
DIABETES RISK
RET-HE: A USEFUL MARKER IN THE ASSESSMENT
OF IRON STATUS IN PATIENTS WITH END-STAGE
CHRONIC KIDNEY DISEASE
E. Chelioti, S. Mikros, M. Sotiraki, A. Georgiou, T. Fragou,
M. Tsilivigou, G. Papadakis
Deptartment of Nephrology and Renal Unit, General
Hospital of Piraeus "Tzaneio", Athens, Greece
C. Kanonidou, S. Prodromidou, A. Nikolaidou, E. Diza
Hematology Laboratory, Department of Clinical
Microbiology, “AHEPA” University Hospital, Thessaloniki,
Greece
Background.
Evidence
has
suggested
that
hypokalaemia induced by diuretics increases the risk for
diabetes mellitus (DM) in hypertensive individuals.
However, no prospective study has investigated the
association between diuretics and the development of
type 2 diabetes in patients with chronic kidney disease
(CKD) and clearance creatinine(CLCr) <60ml/min. This
study aimed to evaluate the role of diuretics and
glycosylated hemoglobin (HbA1c) for future diabetes risk
in non diabetic patients with CKD and CLCr<60ml/min.
Method. We reviewed 135 patients (52,2% men, mean
age 70±12years) with no history of diabetes, use of
antihypertensives included diuretics and CKD with a
CLCr<60ml/min, over a 6-months period in Outpatient
Clinic. The patients who were received diuretics had a
dose range 40-80mg.Laboratory parameters were
evaluated for HbA1c and serum creatinine. The CKD was
identified using the MDRD equation. The statistical
analysis was done using the pearson’s correlation and
chi-square test. Results. Of 135 non-diabetics,
49(36,3%) take diuretics and 9 (18,4%) have HbA1c
>6,5%. Of 135 non-diabetics, 32 (23,7%) have CKD
with CLCr<60ml/min. 15(46,9%) of these patients are
on diuretics and 12 (37,5%) are not. Of the 15 patients
on diuretics, 9(60%) have HbA1c<6,5%. Non-diabetic
patients with CKD who take diuretics will have low
HbA1c (<6,5%) with p=0,036. Although, there is a
negatively statistical significant correlation (r=-0,552)
between diuretics and HbA1c levels (p=0,016).
Conclusion. These results suggest that both diuretics
and HbA1c should not be considered as a means to
identify patients with CKD at high risk of developing
type 2diabetes. Contrary, diuretics contribute to lower
HbA1c levels in patients with CKD.
Backround. The evaluation of iron status in patients
with chronic kidney disease is crucial as it provides
prerequisite information for deciding recombinant
human erythropoietin treatment. As there are cases
(e.g. inflammation) when the traditional biochemical
markers for the estimation of iron deficiency seem to be
inadequate, the introduction of more reliable tools
remains
a
laboratory
challenge.
Reticulocyte
hemoglobulin equivalent (RET-He) is a new parameter
provided by modern automated hematologic analysers
as a component of complete blood count. It provides an
indirect measure of iron availability for new red blood
cell production and it is considered an indicator of irondeficient erythropoiesis. Our aim was to investigate the
levels of RET-He in patients with chronic kidney disease,
its correlation with red blood cell indices and to examine
whether it can be used as a useful marker in the
assessment of iron status. Methods. A total of 31
patients (males/females:16/15) under hemodialysis
referred to the dialysis unit of our hospital were studied.
Data were centrally analysed after extraction from a
computerized database. Iron stores were defined as
deficient as per the guidelines of NKF / DOQI. For the
determination of RET-He and red blood cell indices flow
cell hematology XE-5000 Sysmex analyser (ROCHE) was
used. Results. The mean RET-He value was 28,33±4,04
pg. Levels below the reference range were determined
in 18/31 (58%) patients. RET-He levels were positively
correlated with mean corpuscular volume-MCV (r=0,55,
p=0,001), mean corpuscular hemoglobin-MCH (r=0,68,
p=0,000)
and
mean
corpuscular
hemoglobin
concentration-MCHC (r= 0,49, p=0,005). The examined
index was strongly and inversely related to red blood
cell distribution width-RDW (r= -0,45, p= 0,01).
Conclusion. RET-He levels in patients undergoing
hemodialysis treatment were found to be lower than
that of the normal population. RET-He was well
correlated with conventional whole blood indices of iron
deficiency. The potential utility of this simple, easily
measurable and low-cost laboratory test as a reliable
marker of iron status in chronic kidney disease patients
should not be underestimated.
36
PP 027
PP 028
IGA NECROTIC VASCULITIS ASSOCIATED WITH
EXACERBATION OF PSORIASIS VULGARIS IN TWO
PATIENTS. CLINICAL PRESENTATION AND
OUTCOME
THE INFLUENCE OF HEMODIALYSIS ON NOVEL
ELECTROCARDIOGRAPHIC INDEXES OF ARRYTHMIC
RISC IN PATIENTS WITH END-STAGE RENAL
DISEASE
1
2
1
2
M. Androulaki, 1 A. Andricos, 1 A. Saganas,
G. Sferopoulos, 1 E. Kokolou, 1 M. Pappas, 2 E. Ioakim
1
Nephrology Department, General Hospital of Ioannina
"G.Hatzikosta", Greece
2
Pathology Department, General Hospital of Ioannina
"G.Hatzikosta", Greece
1
2
K. Kalantzi, 1 A. Vlachopanou, 2 P. Korantzopoulos,
A. Bechlioulis, 1 C. Gouva
General Hospital Arta, Greece
University of Ioannina, Greece
Background. End-stage renal disease is associated with
considerable cardiovascular morbidity and mortality.
Cardiac arrest and arrhythmias are responsible for a
significant number of cardiac deaths in hemodialysis
(HD) patients while the dialysis process may have
arrhythmogenic potential. We sought to examine the
effect of HD on conventional electrocardiographic
parameters as well as on novel indexes of repolarization,
given that increased spatial dispersion of repolarization
is related to malignant ventricular arrhythmias.
Methods. Chronic HD patients who were not receiving
QT-prolonging drugs were studied. We carefully
recorded
demographic,
clinical,
and
laboratory
characteristics as well as several ECG indexes before
and after the HD session. Specifically, we calculated the
QTc interval, the QRS duration, the QRS dispersion, the
T peak-to-end (Tpe) interval, and the Tpe/QT ratio.
Comparisons of ECG indexes were performed by nonparametric tests. Results. The study population
consisted of 66 chronic HD patients (mean age:
68.9±11.8 years, 39 males). There were 17 patients
(25.7%) with established coronary artery disease and
15 (22.7%) with diabetes. QRS duration, QRS
dispersion, and QTc interval did not change significantly
after the HD process. However, the Tpe interval and the
Tpe/QT ratio increased significantly (80 [65-90] ms vs.
85 [77.5-100] ms; p=0.03, and 0.21 [0.18-0.24] vs.
0.25 [0.21-0.28]; p=0.05, respectively). Multiple
regression analysis revealed that potassium and calcium
level alterations are independently associated with these
ECG changes. No significant arrhythmias were observed
during the HD sessions. Conclusion. The HD process
increases
the
ventricular
spatial
dispersion
of
repolarization and therefore may increase the
arrhythmic risk, especially in the long term. Whether
indexes of repolarization and dispersion of repolarization
at baseline, or after HD have a prognostic value with
regard to future untoward events remains to be
elucidated.
Background. Association between psoriasis vulgaris
and nephrotic syndrome has been early described.
Glomerular involvement in such patients represents
different types of glomerulonephritis, most frequently
IgA and membranous nephropathy, and only a few
cases of focal segmental glomeroulosclerosis. Methods.
we report two cases of crescending glomerulonephritis in
patients with coexisted psoriasis withought arthritis
which had synchronous exacerbation of the psoriatic
skin lesions. Case no 1: 45 years old male with a 15
year medical history of plaque psoriasis, was referred to
our clinic due to anouria from 24 hours and metabolic
acidosis, due to rapid acceleration of kidney injury. He
reported generalization of the skin lesions the last 4
weeks, so that by the time of his refer almost the entire
skin surface area was covered by psoriatic plaques. Two
months earlier, he had had routine check up with his
biochemical parameters within the normal range. Due to
persistent anouria of two weeks duration, he underwent
transdermal renal biopsy which revealed necrotic
vasculitis with IgA deposits within the mesangium, along
with acute tubulointersticial necrosis. Case no2: 42
years female with a ten years history of mild cutaneous
psoriasis was referred to our clinic due to macroscopic
hematouria, rapid deterioration of kidney function,
edema and nephrotic range proteinouria. She reported
exacerbation of the psoriatic skin lesions the last 2
months. Renal biopsy revealed necrotic vasculitis with
cellular crescent formation and IgA deposits within the
mesangium. Results. both patients were treated with
oral cyclophosphamide along with cortisone therapy of
at least 6 months duration. Concervative therapy
included azathioprine for 12 months. 4 years and seven
months later respectively, our patients are in clinical
remission with an estimated GFR of 95 and 98 ml/min.
Conclusion. The mesangial nephropathy with IgA
deposits
usually
presenting
with
subnephrotic
proteinouria, is the most frequent glomeroulonephritis
reported in association with psoriasis. All the cases of
crescending glomeroulonephritis in patients with
psoriasis that are retrieved in the literature, reveal as
culprit either the use of certain antipsoriasic drugs such
as anti TNF agents, or the progression of the disease to
psoriatic arthropathy. As far as our research in the
literature revealed, these are the first cases reported,
that
associate
psoriasis
and
crescending
glomeroulonephritis.
37
PP 029
PP 030
EFFECT OF HEMODIALYSIS ON ARTERIAL
STIFFNESS AND WAVE REFLECTIONS IN ENDSTAGE RENAL DISEASE PATIENTS
CKD-EPI EQUATION ACCURACY IN PREDICTING
PERITONEAL DIALYSIS-DELIVERED CREATININE
CLEARANCE
P.I. Georgianos, P.A. Sarafidis, P. Nikolaidis,
A.N. Lasaridis
Section of Nephrology and Hypertension, 1st Department
of Medicine, “AHEPA” University Hospital, Thessaloniki,
Greece
1
V. Filiopoulos, 1 I. Koutis, 1 L. Takouli, 1 D. Arvanitis,
K. Panagiotopoulos, 1 D. Vlassopoulos
1
Nephrology Department, “Amalia Fleming” General
Hospital, Athens, Greece
2
Biochemical Department, “Amalia Fleming” General
2
Background. Vascular system in end-stage renal
disease
(ESRD)
patients
undergoes
remodeling
characterized by accelerated arterial stiffening. Previous
studies that evaluated the effect of hemodialysis on
large artery elasticity gave contradictory results. Aim of
this study was to investigate the effect of hemodialysis
on arterial stiffness and wave reflections in ESRD
patients on maintenance hemodialysis. Methods. A total
of 51 stable patients, being on a 3-time per week
hemodialysis schedule for at least 3 months were
evaluated in the first and second dialysis session of the
week. Arterial stiffness was assessed by measuring
pulse wave velocity (PWV) in the carotid-femoral and
carotid-radial arterial segments, using a Sphygmocor
system. Heart rate-adjusted augmentation index
(AIx(75)) was estimated as a measure of wave
reflections by performing radial artery applanation
tonometry. All measurements were performed 30΄
before and 30΄ after the completion of both dialysis
sessions. Results. Hemodialysis significantly reduced
systolic blood pressure (SBP) and pulse pressure (PP) at
the level of brachial artery as well as at the level of
central aorta. AIx(75) was significantly reduced in the
first and second dialysis session of the week (27.5±1.2
vs 21.0±1.5, P<0.001 and 24.7±1.2 vs 20.5±1.5,
P<0.001 respectively). In contrast to wave reflections,
aortic and brachial PWV remained unchanged between
the beginning and the end of both dialysis sessions
(9.6±0.3 vs 9.7±0.4, P=0.739 and 9.5±0.3 vs 9.4±0.3,
P=0.830 for aortic PWV and 7.6±0.2 vs 7.8±0.2,
P=0.566 and 7.4±0.2 vs 7.7±0.2, P=0.521 for radial
PWV respectively). Changes in AIx(75) during dialysis
sessions exhibited significant associations with changes
in brachial and central aortic PP (r=0.385, P<0.01 and
r=0.494, P<0.001 for the first dialysis session of the
week and r=0.235, P<0.05 and r=0.333, P<0.05 for the
mid-week dialysis session respectively). Conclusion.
The present study shows that hemodialysis reduces
wave reflections from the periphery, without affecting
elastic properties of large arteries. This dissociation
between the effect of hemodialysis on AIx(75) and PWV
may reflect a differential impact of hemodialysis on
micro- and macrocirculation.
Background. Measuring total (residual renal plus
peritoneal) creatinine clearance (CrCl) with 24-hour
urine and dialysate collections is recommended for
Peritoneal Dialysis (PD) adequacy evaluation. However,
prediction equations applied in this instance could
simplify the approach. Cockroft-Gault and MDRD four
(MDRD-4) and six (MDRD-6) variables equations have
been tested in this setting, with variable accuracy. The
Chronic Kidney Disease Epidemiology Collaboration
(CKD-EPI) equation is currently considered to be
substantially more sensitive than the established
equations for kidney function estimation and should
replace them for routine clinical use. However, its
performance in the estimation of peritoneal adequacy
has not been studied. The aim of this study was to
determine whether CKD-EPI equation would predict
measured total CrCl in PD patients with greater accuracy
than the established prediction equations. Methods. A
group of 23 consecutive PD patients, male/female: 5/18,
median age: 66 (32-91) years, median time on PD 32
(2-126) months, were enrolled in the study. All were
treated by Automated PD. Sixteen out of twenty-three
had residual renal function. Primary renal disease was
Diabetic Nephropathy in 6, Chronic Glomerulonephritis
in 5, Nephrosclerosis in 3, Cystic Kidney Disease in 1,
IgA Nephropathy in 1, Amyloidosis in 1, Reflux
Nephropathy in 1, Interstitial Nephropathy in 1 and
unknown Nephropathy in 4. CrCl was determined from
24-hour dialysate and urine collections and also
estimated by Cockcroft-Gault, MDRD (4 and 6) and
CKD-EPI equations. Results. CKD-EPI and MDRD-6
estimation results were similar to CrCl measured by 24hour dialysate and urine collection (9.01±3.9 and
9.54±2.98 vs 8.63±3.73 ml/min/1.73m2, P=0.49 and
0.09, respectively). Additionally, neither the presence
nor the volume of residual urine affected the accuracy of
the prediction. In contrast, Cockcroft-Gault and MDRD-4
equations were not accurately predictive of the
measured CrCl and differed significantly from the latter.
Conclusions. CKD-EPI equation could be used with
accuracy for estimating creatinine clearance in PD
patients. Subsequently, PD efficiency could be evaluated
with reasonable precision. Only MDRD-6 showed similar
accuracy
whereas
MDRD-4
and
Cockcroft-Gault
equations were found to be inappropriate in this setting.
38
PP 031
PP 032
ENZYME REPLACEMENT THERAPY WITH
AGALSIDASE ALFA IN A KIDNEY TRANSPLANT
PATIENTS WITH FABRY DISEASE: RESULTS AFTER
3.5 YEARS OF TREATMENT
LONG TERM EFFECT OF ONLINE
HEMODIAFILTRATION (HDF-OL) ON Β2
MICROGLOBULIN (Β2 M) METABOLISM IN
DIALYSIS PATIENTS
1
1
F. Christidou, 1 A. Aggelou, 1 K. Michalaki, 2 G. Miserlis,
T. Bishiniotis
1
Renal Unit, General Hospital of Chalkidiki, Greece
2
Transplantation Clinic, Hippocratio General Hospital of
D. Lazarou, 1 D. Hadjiyannakos, 1 M. Sonikian, 1 I. Pani,
P. Fraginea, 1 D. Vlassopoulos
1
Department of Nephrology, “Amalia Fleming” General
2
Department of Hematology, “Amalia Fleming” General
1
2
Background. Fabry disease results in kidney damage
and leads to progressive impairment of renal function in
almost all male patients and in a significant proportion
of females. The life expectancy is reduced and the major
causes of death include cardiac death, stroke and the
consequences of end stage renal disease. Fabry
nephropathy does not recur in the allograft and
transplanted Fabry patients appear to have better
overall outcome than those maintained on dialysis. The
availability of enzyme replacement therapy (ERT) since
2001 has led to major expectations with regard to
improvement of clinical symptoms and disease burden in
patients with Fabry disease. We present the safety and
efficacy of enzyme replacement therapy (ERT) in a
kidney transplant recipient with Fabry disease.
Methods. Our patient had been on dialysis for 5 years
when
Fabry
disease
documented
and
Fabry
myocardiopathy was diagnosed. One month later he
received a cadaveric renal transplant and re-established
normal renal function. Immediately after transplantation
he began ERT with Agalsidase alfa, 0.2 mg/kg of body
weight every 2 weeks by intravenous infusion and was
monitored
biochemically,
clinically,
electrocardiographically and echocardiographically for
three and a half years. Results. The patient had
biochemical,
clinical/functional,
and
morphologic
response to ERT. Extremity pain resolved within 2
months. Echocardiographic findings included: diminished
left ventricular mass, normalization of left ventricular
dimensions and improvement in systolic and diastolic
left ventricular function. Further improvement of cardiac
function was documented by echocardiography during
the last six months of ERT. A year ago he suffered an
ischemic peripheral vascular event, which was
successfully managed with a bypass operation. Renal
function was preserved until the end of the study
without
any
significant
variation
of
the
immunosuppressive regimens. Mean serum creatinine
ranged from 0.96 mg/dl at the first month after
transplantation to 0.88 mg/dl after 3.5 years of ERT,
and mean creatinine clearance remained around 61.2
ml/min. Proteinuria is stable and less than 100 mg/d
until now. No treatment-related adverse event or
intolerance was noticed. Conclusion. 1. Although Fabry
patients after renal transplantation represent a group of
patients with specific co morbidities possibly affecting
the outcome and efficacy of ERT, agalsidase alfa seems
to be safe in transplant patients. 2. Further open-label
extension studies are needed to establish the long-term
protective effect of ERT on the preservation of kidney
function and the improvement of cardiac parameters in
Fabry patients after transplantation.
Background. Hemodiafiltration is evaluated as the most
biocompatible and efficient method of dialysis for β2 M
removal, with fewer complications and better survival.
We evaluated changes in β2 M levels and inflammation
markers, C-Reactive Protein (CRP) and serum albumin,
after 12 months on HDF-OL versus classic hemodialysis
(HD). Methods. Measurements of β2 M, parathyroid
hormone-PTH, Urea Reduction Ratio-URR, single pool
Kt/V, albumin-Alb, alkaline phosphatase-ALP and CRP in
a group of 8 HDF-OL patients (group A), M/F 7/1, aged
64 years (38-82), on high efficiency, high flux,
polysulphones dialysis membranes with surfaces 1,9 m
(1,7-2,1), sterilized by steam or gamma radiation with
substitution fluid volumes of 23,5 l (20,5-27),produced
by ultrapure dialysis solution subjected to cold
sterilization procedure (two hyperfilters). Dialysis
duration was 4,5 hours (4-5), blood flow at 350 ml/min
and dialysate at 700 ml/min. Results, obtained at the
beginning and the end of the 12 months follow up, were
compared to those of a group of 11 HD patients (group
B), M/F 5/6, aged 68 years (38-77), on polysulfone
membrane classic hemodialysis of 4,5 hours (4-5)
duration. Results. The two groups differed significantly
only in time (months) on HD : (A) 270 (154-345) vs (B)
66 (17-249), p<0,001 and PTH levels at the beginning
of the observation period (A) 182 136 pg/ml vs (B) 333
215 pg/ml p<0,03, since 2/8 of A had been
parathyroidectomized compared to none in B. β2 M
levels diminished significantly in A from 33,05 5,08 mg/l
to 28,46 3,32 mg/l, p=0,01 and serum ALB rose from
3,36 0,16 g/dl to 3,88 0,29 g/dl, p=0, 01) while in B, β2
M increased from 41,36 19 mg/l to 53,27 15,11 g/l,
p=0,004) making a significant difference (p<0,001)
between the two groups by the end of the study. CRP
also rose significantly in B from 5,9 2,1 IU/l to 24,6 42,9
IU/l, p<0,002. No correlation of β2 M, serum ALB or CRP
to the other evaluated factors was found in any group.
Conclusions. Classic hemodialysis with biocompatible
membranes induced a rise in β2 M levels and CRP. HDFOL diminished β2 M burden and exerted a significant
positive effect on serum ALB in our patients.
39
PP 033
PP 034
ADRENAL INSUFFICIENCY AS THE PRESENTING
FEATURE IN A PATIENT WITH LUNG CANCER
MINERAL METABOLISM PARAMETERS IN PATIENTS
WITH END-STAGE CHRONIC KIDNEY DISEASE:
EXPERIENCE FROM A TERTIARY HOSPITAL LAB
G. Zagotsis, P. Malindretos, M. Markou, G. Koutroubas,
P. Makri, D. Kapsalas, C. Syrganis
Achillopouleion General Hospital, Volos, Greece
C. Kanonidou, M. Pape, D. Tarpagkos, S. Spiroglou,
G. Sidiras, M. Karamouzis
Laboratory of Biochemistry, “AHEPA” University Hospital,
Aristotle University of Thessaloniki, Thessaloniki, Greece
Background. Although metastatic infiltration of the
adrenal glands is a common finding in lung carcinomas,
adrenal insufficiency is rarely diagnosed. We present a
case of adrenal insufficiency due to bilateral adrenal
metastases as the presenting manifestation of lung
cancer. Case report. A 65-year old man was admitted
to our hospital due to altered mental status, weakness
and vomiting during last week. He had a history of
smoking and alcohol abuse for the last 45 years. During
the last four months he complained for anorexia and
loss of weight of about 10 Kg. Physical examination
revealed severe dehydration, blood pressure of 100/60
mmHg, bradycardia (50 bpm), crackles in the left lung
and
hyperpirmented
skin.
Laboratory
tests
demonstrated hyponatremia (127 meq/L), hyperkalemia
(8.6 meq/L), hypoglycemia (60 mg/dL), mild metabolic
acidosis (pH = 7.25) and a rise in serum urea (144
mg/dL) and serum creatinine levels (2.9 mg/dL). Chest
and abdominal CT scan revealed cancer of the left lung
and large bilateral adrenal metastases. We performed a
high dose cosyntropin stimulation test. The serum
cortisol level was 35 nmol/L before the intramuscular
administration of cosyntropin (250 mcg) and 31 nmol/L
60 minutes after the administration. These results
established the diagnosis of adrenal insufficiency. We
initiated replacement therapy with glucocorticoids and
the patient improved within a few days. Discussion.
Metastatic infiltration of the adrenal glands is a common
finding in lymphomas and adenocarcinomas of breast,
lung, stomach, esophagus, kidney and colon. During the
initial diagnosis of lung cancer, adrenal metastases, if
observed, are usually unilateral without clinical
significance. In this patient, bilateral adrenal metastases
were present at the time of initial diagnosis, being
responsible for clinical evident adrenal insufficiency.
There are only a few reports of adrenal insufficiency
being the presenting manifestation of underlying lung
cancer. In order to confirm the diagnosis of adrenal
insufficiency, we performed the high dose cosyntropin
stimulation test. Serum cortisol levels were determined
both before and 1 hour after the intramuscular
administration of consytropin (250 mcg), which is a
synthetic analog of corticotropin (ACTH). Conclusion.
Values of serum cortisol lower than 440 nmol/L before
and one hour after the injection indicate clinically
important adrenal insufficiency.
Background.
The
development
of
secondary
hyperparathyroidism is a common complication in the
course of chronic kidney disease (CKD). As the elevated
levels of serum calcium (Ca), phosphorus (P) and intact
parathyroid hormone (iPTH) have been associated with
increased cardiovascular morbidity and mortality, the
control of these imbalances is critical. The aim of the
study was to examine the status of these markers in
end-stage CKD patients. Methods. A total of 100
patients with end-stage CKD (males/females: 63/27,
mean age: 59,2 years) under hemodialysis (n=66) and
under peritoneal dialysis (n=33), referred to the dialysis
unit of our hospital were studied. Data were centrally
analysed after extraction from a computerized database.
In each patient the average of three values of serum Ca,
P and iPTH obtained in a three-month period was
calculated. Serum Ca and P were measured by standard
techniques
and
iPTH
was
determined
by
electrochemiluminescence immunoassay with Elecsys
Μodular
E170
analyser
(ROCHE).
The
target
concentrations of mineral metabolism parameters are
specified by the National Kidney Foundation guidelines.
Results. Mean levels of serum Ca, P and iPTH for both
groups of patients are presented in Table 1. Patients
under
hemodialysis
had
significantly
higher
P
concentrations and CaxP levels when compared to those
under peritoneal dialysis. 46% of the participants (36%
under hemodialysis, 10% in peritoneal dialysis) had
serum P >5,5 mg/dl and 35% (25% under hemodialysis
and 10% in peritoneal dialysis) had CaxP levels >55
mg2/dl2. iPTH levels above the target concentrations
(16,5-33,0 pmol/l) were determined in 30% of the study
population (25% and 5% respectively). Only 19% of the
patients achieved combined targets for all these
parameters.
Conclusion.
Despite
treatment,
a
significant number of patients, especially hemodialysis
ones, fails to meet the targets indicated by clinical
practice guidelines. The control of mineral metabolism
and iPTH secretion in CKD remains a therapeutic
challenge.
40
PP 035
PP 036
A SUCCESSFUL AUTOLOGOUS ARTERIOVENOUS
FISTULA IN TYPE I DIABETES MELLITUS PATIENT
UNDERGOING HEMODIALYSIS
SUCCESSFUL PREGNANCY IN A WOMAN WITH END
STAGE RENAL DISEASE ON HEMODIALYSIS
1
C. Pipili, 1E. Grapsa, 2G. Triantaphylis, 2A. Koutsovasili,
P. Sorvinou, 2 E. Poirazlar, 3 D. Kiosses, 2 G.
Xatzigeorgiou
1
Department of Nephrology, “Aretaieion” University
Hospital Athens, Greece
2
Department of Nephrology, Athens Bioclinic, Athens,
Greece
3
Department of Obstetrics, “Alexandra” Hospital, Athens,
Greece
2
S. Mumajesi, A. Idrizi, N. Pasko, S. Seferi, M. Rroji, E.
Bolleku, N. Thereska
Service of Nephrology, University Hospital Center “Mother
Teresa”, Tirana, Albania
Background. Diabetes mellitus is an increasingly
common cause of end stage renal failure (ESRF) and the
establishment of adequate permanent vascular access
for dialysis is a major cause of morbidity and mortality
in these patients. Arteriovenous fistula (AVF) is the best
access for haemodialysis for these patients, but it is also
one of the most complication and one of the main
causes of hospitalization. Case report. We describe a
diabetic patient who has performed many AVF,
prosthetic graft which have failed, and recently has done
an autologous AVF. A 22- year old girl with ESRF
secondary to type I diabetes mellitus began
haemodialysis 6 years ago. She first undergo to
peritoneal dialysis which failed due to bacterial
peritonitis. Throughout this period, usual accesses were
used, such as femoral venous catheters and AVF in the
upper and lower limbs. As polytetrafluoroethylene
(PTFE) grafts for the construction of a new AVF is
preferred to be used in cases of failure of the
autogenous
AVF,
the
patient
underwent
the
reconstruction of an AVF between the right axillary
artery and the dexter axillary vein. The AVF was
maturated
one
month
later,
and
she
began
haemodialysis with this new fistula. Conclusion. It has
passed 3 months from the new created fistula and there
is no complication such as infection, cardiac insufficiency
or swelling.
Background. Dialysis women of childbearing age, even
with reduced fertility and at high risk of complications,
should not be discouraged from pregnancy. It is
presented an unplanned but successful pregnancy of a
dialysis -dependent woman, emphasizing pre and post
pregnancy management Case Report. This 35 year-old
woman on maintenance hemodialysis (HD) for 4 years,
due to glomerulonephritis, reported amenorrhea and
had a positive pregnancy test. Her dialysis schedule was
changed to 6 days a week (for a total of 24 hours
weekly), maintaining her blood urea level at 90 mg/dl
and reducing her intradialytic weight gain to
approximately 1 kg. A high flux dialyzer with volume
control ultrafiltration, a dialysate flow fixed at 500
ml/min and a blood flow between 250 and 300ml/min
were used. All medications were discontinued, apart
from darbopoetin. During the HD session the patient’s
blood pressure (BP) and her dry weight were monitored
carefully. Her BP was ranged from 110-130/50-70
mmHg without any antihypertensive therapy over the
course of pregnancy. Dry weight was gradually
increased and she gained a total of 13 kilograms. On the
22nd gestational week the patient complained of mild
prolonged hypogastric pain. The diagnosis of cervical
insufficiency (cervical dilation of 4cm) was made. To
avoid premature labor, progresterone caps (300mg/day)
and bed rest were recommended, while a cervical
cerclage was placed. On the 33rd gestational week the
patient presented uterine bleeding, due to premature
rupture of membranes so caesarian section was
performed. Perioperatively she was hemodynamically
stable and did not require any blood transfusion. She
delivered a male neonate, weighing 2.1 kg with Apgar
scores of 5 and 7. Following delivery, HD schedule, BP
and dry weight were under tight control and after one
year she returned to her non pregnant-dry weight.
Because of small amount of milk bromocriptine mesilate
(2.5 mg twice a day for 2 weeks) was started for
lactation suppression One year after the delively mother
and infant remain Conclusion. Pregnancy in women on
HD represents a potential, challenging and demanding
situation. With the increasing and shared experience,
better policies will be drawn.
41
PP 037
PP 038
VITAMIN D STATUS IN STONE FORMERS
A CASE OF MESANGIOPROLIFERATIVE
GLOMERULOPATHY AND AUTOIMMUNE
CHOLANGIOPATHY
C. Pipili, C. Dimitriadis, N. Sekercioglu, D. D. Oreopoulos
University of Toronto and University Health Network,
Toronto, Canada
1
G. Aperis, 1 C. Paliouras, 1 E. Tsampikaki, 2 M. Stambori,
S. Karatapanis, 1 N. Karvouniaris, 1 P. Alivanis
1
Department of Nephrology, General Hospital of Rhodes,
Rhodes, Greece
2
1st Department of Internal Medicine, General Hospital of
Rhodes, Rhodes, Greece
2
Background. Data regarding the prevalence of 25
hydroxyvitamin D [25(OH)D] insufficiency in patients
with nephrolithiasis, and the effects of Vitamin D (VitD)
supplementation on parathyroid hormone (PTH) are few
and conflicting. The present study was designed to
examine the prevalence of VitD insufficiency and
deficiency in kidney stone formers and to determine the
correlation of VitD levels with other parameters of stone
formation. Methods. Two hundred thirty six stone
formers [mostly men (63.5%) with mean age of 50.3 ±
13.6 years] of Mediterranean origin were enrolled in the
study. VitD insufficiency defined as 25(OH)D levels
below 50 nmol/L and VitD deficiency as 25(OH)D levels
below
30
nmol/L.
Patients
with
primary
hyperparathyroidism (defined as ionized calcium values
corrected with pH >1.35 mmol/L and PTH >7.5 pmol/L)
[3.8% (9/236)] were excluded. Results. 35.1%
(80/227) of subjects presented VitD insufficiency and
19.4% (44/227) VitD deficiency. High PTH levels (PTH >
7.5 pmol/L) with normal serum (total and ionized)
calcium values exhibited 24.7% (56/227) of subjects.
Hypercalciuria (urinary calcium >7.5 mM/day) and
hypocitraturia (urinary citrate <1.6 mM/day) were
noticed in 21% (47/227) and 22% (50/227) of stone
formers respectively. Hyperoxaluria (urine calcium> 490
mM/day in male, >320 mM/day in women) was present
in 55% of stone formers, being pronounced mostly in
women
[37.4%
(85/227)]
than
in
men
[17.5%)(40/227)]. Prevalent stone composition was
calcium oxalate [80.4% (78/97)] and uric acid [16.45%
(16/97)]. Using t-test to assess the significance of any
differences between stone formers with low and normal
VitD (37.9±9.8 vs 74.9±21.6 p=0.0001), stone formers
with VitD insufficiency presented higher PTH levels
(7.11±4.35 vs 5.43 ±2.55 p=0.0017). Predictor of low
25(OH)D level was PTH (r=0.989 r2=0.977 p<0.001).
Stone formers with hypercalciuria had higher 25(OH)D
values (72.26 ± 4.21 vs 59.29 ± 1.76, p=0.0013)
compared to stone formers with urine calcium within
normal ranges. Conclusion. VitD insufficiency is
encountered in more than one third of stone formers
and that it may contribute to the development of
secondary hyperparathyroidismin these patients. Further
studies are needed in order to better define the
consequences of VitD insufficiency and to evaluate the
impact of the therapeutic interventions in this cohort.
Background.
We
describe
a
rare
case
of
mesangioproliferative
glomerulopathy,
autoimmune
cholangiopathy and Hashimoto’s thyreoiditis. Methods.
A 57-year old female was admitted in the Nephrology
Department for the investigation of proteinuria (1869
mg/24h). She had a history of arterial hypertension,
increased cholestatic enzymes for the last 2 years and
Hashimoto’s thyroiditis. On clinical examination liver was
palpable 2-3 cm below the right costal margin.
Laboratory tests revealed mild anemia and leukocytosis,
mildly increased cholestatic enzymes (γ-GT=87 IU/L,
ALP=149 IU/L) while aminotransferases and bilirubin
were both normal. Her renal function tests were within
normal range, while ESR and CRP were slightly elevated.
Although immunoglobulins were normal, autoimmune
screen revealed increased ANA (1:320), and anti-ASMA
(1:160). Anti-LKM (1:160) titers and anti-AMA
antibodies were weakly positive (1:20). Anti-ΤPO were
496.5 IU/mL. Hepatitis B and C screen were both
negative. Results. The patient underwent renal and
liver biopsy. Renal biopsy revealed segmental mesangial
hyperplasia, increased matrix and IgM deposits (+/++)
on immunofluorescence. Liver biopsy revealed small,
fibrinous widening in 3 out of 4 portal spaces with
lymphocytic infiltration in one of them. Liver
parenchyma had a small degree of steatosis, centrilobar
and periportal peri-sinusoidal fibrosis. The above picture
set the diagnosis of autoimmune cholangiopathy. We
initiated ursodeoxycholic acid at 15 mg/kg of body
weight and ramipril 5 mg orally daily. Two years after
initiation of treatment, cholestatic enzymes are normal
and there is a partial remission of the proteinuria (<1
gr/24h). Conclusion. To our knowledge, this is the first
case
of
IgM
mesangiocapillary
glomerulopathy,
autoimmune cholangiopathy and Hashimoto’s thyroiditis
ever reported. In the literature, IgA nephropathy with
autoimmune cholangiopathy and Hashimoto’s thyroiditis
has been described once. Our patient responded to
treatment with ursodeoxycholic acid and blood pressure
control with an ACE-I.
42
PP 039
PP 040
CINACALCET IN RENAL TRANSPLANT RECIPIENTS
WITH HYPERPARATHYROIDISM AND/OR
HYPERCALCEMIA
REFRACTORY FABRY’S ASSOCIATED PROTEINURIA
RESPONDING TO DOUBLE DOSE OF A-AGALSIDASE
ALFA
M. Papasotiriou, M. Vardoulaki, G. Voliotis, E. Savvidaki,
P. Kalliakmani, E. Papachristou, D.S. Goumenos
Department of Internal Medicine–Nephrology, University
Hospital of Patras Transplantation Center, Patras,
Greece
C. Paliouras, G. Aperis, E. Tsampikaki, N. Karvouniaris,
P. Alivanis
Rhodes, Greece
Background. We present a cardiac variant of Fabry’s
disease with proteinuria refractory to conventional doses
of a-agalsidase A that responded in double dosing of the
enzyme. Μethods. A 42-year old male with a history of
Fabry’s disease diagnosed with renal biopsy, cardiac
echo, as well as low alfa-galactosidase A activity in the
blood presented with proteinuria 1 g/24 hours. He
received initially enzyme replacement therapy with
agalsidase alfa (Replagal®, Shire HGT Inc.) at the
conventional dose of 0.2 mg/kg every other week during
a 45 min infusion. In his regular follow-up there was no
change in his proteinuria as well as the cardiac and brain
findings on echo and MRI respectively in the next
seventeen months. However, at 20 months of treatment
proteinuria was deteriorated (2.5 gr/24 h) without any
other obvious causes. Thus, the dose was increased at
0.4 mg/kg intravenously every other week. Results.
Two months after dose change proteinuria was
decreased to 1.7 g/24 h and at 7 months was stabilized
at approximately 1.1 g/24 h. In order to confirm that
the improvement was due to the doubling of enzyme’s
dose, we recommenced the conventional dose. One
month later the 24 hour protein was again increased to
2.9 g/24 h. Hence, we doubled the dose and the patient
several months later has stable proteinuria at the initial
levels. Similar findings were noted regarding the cardiac
abnormalities with concomitant increase of left
ventricular mass which promptly relieved with the dose
doubling. Conclusion. It is known that in Fabry’s
disease the control of proteinuria delays the progression
of renal damage and constitutes an important target of
treatment. Although double-dosing is not supported by
the literature, it should be considered in selected cases
when conventional doses are not effective. However,
more studies are required in order to become a common
practice.
Background. Secondary hyperparathyroidism (HPT) is
a common complication of chronic renal disease that
usually regresses automatically after successful kidney
transplantation. However in 30% of patients, HPT may
persist
after
transplantation.
Administration
of
calcimimetics (cinacalcet) has contributed significantly to
the treatment of HPT in patients with end stage renal
disease. However, the role of calcimimetics in the
treatment of HPT and/or hypercalcaemia after
transplantation remains under investigation. In this
study we assessed the safety and effectiveness of
cinacalcet in renal transplant recipients with HPT and/or
hypercalcemia. Methods. Thirty three patients (23
males and 10 females) with a mean age of 48 ± 9.8
years were studied. All patients had persistent
hypercalcemia and/or HPT at least six months posttransplantation. Intact parathormone ( iPTH) values
adjusted for the degree of renal function were
normalized at six months post transplantation while
hypercalcemia was considered when serum calcium (Ca)
concentration exceeded 10.5 mg/dl. All patients received
cinacalcet at an initial dose of 30 mg daily. Ca and iPTH
values were assessed after the first month of treatment
and every 2 months for a follow up period of 30 months.
Renal function was also estimated and serum phosphate
(P), alkaline phosphatase, 24h urinary calcium
excretion, albuminuria and bone density (measured by
DEXA) were also estimated before and after treatment.
Results. All patients showed reduction of iPTH levels 6
months after renal transplantation and before the
initiation of cinacalcet (from 580 to 291 pg/ml,
p=0.0068). The administration of cinacalcet was
followed by further reduction of iPTH values 1 month
later (from 291 to 183 pg/ml, p=0.01) and this
reduction was maintained for the whole follow up period.
Serum Ca concentration was also reduced 1 month after
cinacalcet administration (from 10.8 to 9.89 mg/dl,
p<0.0001) and remained within normal limits during
follow up. P levels showed a slight but not significant
increase (from 2.74 to 2.95 mg/dl, p=ns). No significant
change was observed in bone density according to the
DEXA scan before and after treatment with cinacalcet. A
slight but not significant reduction of albumiuria was
also observed. Furthermore, urinary calcium excretion
remained within normal values, 6 months after initiation
of treatment and renal function remained stable.
Conclusion.
Cinacalcet
administration
in
renal
transplant recipients with persistent hyperparathyroidism and/or hypercalcemia is shown to be a safe and
effective therapeutic intervention.
43
PP 041
PP 042
A CASE WITH EOSINOPHILIC PERITONITIS
TREATED WITH HIGH-DOSE CORTICOSTEROIDS
SURVIVAL TIME, MORTALITY AND CAUSES OF
TRANSITION FROM PERITONEAL DIALYSIS (PD) TO
HEMODIALYSIS (HD). A SINGLE CENTER
EXPERIENCE
C. Paliouras, G. Aperis, E. Tsampikaki, N. Karvouniaris,
P. Alivanis
Greece
K. Xanthopoulou, D. Makridis, V. Kiatou, P. Spiropoulos,
A. Kelesidis, N. Kotzadamis,
General Hospital of Veria, Veria, Greece
Background. We present a rare case of eosinophilic
peritonitis in a patient undergoing automated peritoneal
dialysis. Methods. An 80-year old male with a history of
chronic, refractory arterial hypertension, heart failure,
and prostate hypertrophy presented to our clinic with
end stage renal disease due to hypertensive
nephrosclerosis and initiated automated peritoneal
dialysis. Four months later, in his regular check up he
was afebrile with stable body weight, BP 145/80 mmHg,
and heart rate 52/min. On clinical examination there
was no skin rash or bronchospasm. Apart from a soft
systolic aortic murmur the rest of the clinical
examination
was
normal.
Blood
tests
showed
leucocytosis (WBC=12710/mm3), and eosinophilia
(28.3%, absolute number 3600/mm3), and IgE was
elevated as well (171 IU/ml, n.v.<150 IU/mL).
Furthermore, there was a mild hypoalbuminemia
(3.3gr/dl) and CRP was normal (1.43mg/dl). Peritoneal
fluid was turbid and the fluid cell count was 1500
cells/mm3. On Wright’s stain the cells were 80%
eosinophils. Peritoneal fluid culture was negative for
bacteria, and fungi. Finally, blood cultures were
negative.
Results.
We
initiated
levocetirizine
hydrochloride 5 mg daily orally. On Day 4 there was no
response [blood eosinophils 2860/mm3 (20.6%)], while
the peritoneal cell count was 280/mm3. At ten days
blood eosinophils were still high [2630/mm3 (18.5%)],
and peritoneal fluid cell count was increased
(1200/mm3)]. We discontinued levocetirizine and
initiated intravenous pulse methylprednisolone 125 mg
for 3 days, followed by oral methylprednisolone at 16
mg on alternative days. Two days after treatment
changes, blood and peritoneal fluid eosinophils were
both decreased [60/mm3 (0.3%) and 80/mm3
respectively]. Conclusion. Eosinophilic peritonitis is
defined as the eosinophilic predominance in the
peritoneal fluid with absolute numbers >100/mm3 or >
10% of the WBC when the eosinophils are >40/mm3. It
is considered an allergic reaction to the plastic catheter,
the peritoneal solution, the sterilization process or from
air insertion. Usually occurs in the first 6 months after
initiation of peritoneal dialysis. Fungal peritonitis must
be excluded as well as other conditions associated with
eosinophilia
(allergies,
parasitic
infestations,
vasculitides). It has favorable prognosis-usually self
limited. Treatment is needed when abdominal pain,
catheter malfunction or low blood albumin is present
and consists of antihistamines, intraperitoneal or
systemic glucocorticoids.
Backround. PD utilization for renal replacement is less
popular and the frequency of PD termination is higher
compared with HD. The aim of this study was to
examine the reasons affecting the duration of PD
therapy. Methods. We reviewed medical records of 237
patients (51.9% men, 45.3 % diabetics, mean age at
initiation of PD 65,76±12,9 years old), followed in our
PD unit during the last decade. We recorded all the
principal causes of death and the reasons of PD
termination and related them with various risk factors.
Statistical analyses were done with SPSS 16.0 Results.
52 patients dropped out of PD and 138 died, with
29,5%, 23,2% and 15,1% of end points taking place
within the first, second and third year respectively. The
mean patient survival was 44,9 months SE 2,72. The
most frequent cause of death was cardiovascular
disease, followed by cerebrovascular disease (Table).
The incidence of cardiovascular disease was stable and
high throughout the first years of therapy. Infections
were more frequent in diabetic patients (p<0,05).
Mortality due to cachexia was high, even during the first
year of treatment. Patient survival was negatively
influenced by the age at initiation of PD (RR1,037,
95%Cl 1,018-1,056) and DM (RR1,4, 95%Cl 0,9971,965). Of the fifty-two patients who dropped out of PD,
28 did so during the first two years, eight during the
third and 16 later. The most frequent cause was fungal
peritonitis (18 cases), followed by recurrent peritonitis
(8 cases) and peritonitis of other causes. There were 6
patients who had surgical diseases necessitating PD
termination. Loss of ultrafiltration led to HD 5 patients
and there were just 5 transplantations. Three patients
had peritoneal fluid leak and two changed method due
to psychological burnout. Older age appeared to have an
effect on staying in PD (RR0,957, 95%Cl 0,932-0,983).
Conclusion. Cardiovascular disease was the most
frequent cause of death in PD. Peritonitis, and specially
fungal, was the leading cause of transition to HD. Older
age and diabetes are negative prognostic factors for
survival of PD patients. The mean duration of overall
survival of PD patients was close to four years.
44
PP 043
PP 044
MICROBIOLOGY OF EXIT-SITE INFECTIONS (ESI’S)
AND RELATION WITH PERITONITIS IN
PERITONEAL DIALYSIS (PD) PATIENTS. A SINGLE
CENTER EXPERIENCE
THE EFFECT OF IMMUNOSUPPRESSION ON CD4+T
CELLS OF STABLE RENAL TRANSPLANT RECIPIENTS
1
A.Vittoraki, 2 M. Darema, 1 M. Apostolaki, 2 K. Kolovou,
T. Karatzas, 1 A.Iniotaki, 2 J. Boletis
1
National Tissue Typing Center, General Hospital of
Athens “G.Gennimatas”, Greece
2
Transplantation Unit, General Hospital of Athens
“Laiko”, Greece
2
K. Xanthopoulou, D. Makridis, P. Spiropoulos, V. Kiatou,
C. Chatziaslanidou, A. Kelesidis, N. Kotzadamis
General Hospital of Veria, Veria, Greece
Backround. ESI’s remain an important cause of
morbidity in PD patients in view of their association with
tunnel infections and peritonitis. The aim of the study
was to examine the incidence and type of ESI’s and their
impact on peritonitis rates and PD technique failure.
Methods. We reviewed medical records of 75 patients
on PD during the period of 2007-2011 (40 men, 33 with
diabetes, mean age at start of PD 65,5±15,3 years,
mean PD duration 32,2±25,7 months, CAPD 66 and APD
9 patients). ESI’s were identified according to
international peritoneal dialysis scoring system based on
clinical appearance. Results of swab cultures were
recorded at that time and on follow up. Positive cultures
in the absence of clinical infection were characterized as
colonization. Results. 122 positive cultures were
recorded in 55 patients (Table). 29 patients had a single
positive culture, while five patients had more than 4
infections with different microbes. 47,2% of the positive
cultures were seen during the first year of treatment.
Seventeen recurrent infections were observed, most
frequently due to S.Aureus and Pseudomonas. Clinical
signs of infection were found in 63 cases (51,6%). The
most frequent microbes were S.Aureus, S.Epidermitis,
Pseudomonas. All symptomatic patients received
treatment. Out of these, six patients developed tunnel
infection, which led to the removal of the catheter and
three patients lost PD permanently. The total peritonitis
rate was 0,53 per patient-year, but just nine cases of
peritonitis were associated with ESI (most frequently
due to S.Aureus, and the rest due to Pseudomonas,
Providencia, S.Simulans, S.Epidermitis). We did not find
any association between the peritonitis and ESI’s rate
per patient. The incidence of ESI’s was not associated
with diabetes, age or duration of PD. APD did not seem
to decrease the incidence of ESI’s. Conclusion. The
association of ESI’s with peritonitis is not frequent. ESI’s
can potentially lead to loss of PD as a method of renal
replacement. Peritonitis rates are not influenced by the
incidence of ESI’s per patient. Microbes of the normal
skin flora can cause serious morbidity due to the
presence of peritoneal catheter.
Background. Even though maintenance of effective
immunosuppression is crucial for renal transplantation
(RTx) success, a parameter to determine the efficacy of
the immunosuppressive therapy is still missed. The aim
of this study was to evaluate the immune status in RTx
recipients (RTRs) by estimating of the levels of
intracellular ATP (iATP) in CD4+T-cells. Methods. CD4+
T cell-mediated functional immunity was defined in renal
transplant recipients (RTR) by estimating intracellular
ATP (iATP) levels using the Cylex Immuknow assay as
means of determining levels of drug-mediated
immunosuppression. iATP was evaluated in 656 RTRs
with stable graft function and in 200 healthy blood
donors (NC). Blood samples (n=1,095) were collected at
various times post-Tx over a two-year period and iATP
levels (ng/mL) measured in CD4+ T cells following
stimulation with phytohemagglutinin (PHA). Results
were compared to parameters pre and post
transplantation and with different immunosuppressive
protocols. Results. Although RTRs exhibited lower iATP
levels compared to NC (P<0.001), there was extensive
overlapping between the groups(72.2% and 75%
respectively) at the moderate immune response zone
(iATP=226-524 ng/mL). CD4+T-cell levels were found
negatively correlated with patient age (P<0.001) and
time on dialysis (P=0.007) and positively correlated with
time post-Tx (P<0.001). Patients who received Fk506
had lower iATP as compared to those on CsA (p=0.012).
iATP levels identified patients with different immune
response levels but were not correlated with infection or
rejection. Conclusion. It seems that this method cannot
be used for monitoring of immunosuppression posttransplantation but could be informative for the efficacy
of immunosuppressive drugs or protocols.
45
PP 045
PP 046
ADRENOCORTICOTROPIC HORMONE THERAPY IN
THREE RESISTANT CASES OF IDIOPATHIC
MEMBRANOUS NEPHROPATHY: EFFICACY AND
ADVERSE REACTIONS
EFFICACY AND SAFETY OF TOTAL DOSE LOW
MOLECULE WEIGHT IRON DEXTRANE INFUSION IN
PREDIALYSIS PATIENTS
D. Missiou, M. Dardamanis
Renal Unit and Nephrology Department, General Hospital
of Preveza, Greece
E.E. Politis, D.A. Moutzouris, D. Bakoulis, T. Apostolou,
N. Nikolopoulou
Department of Nephrology, General Hospital of Athens
"EVANGELISMOS", Greece
Background. Chronic Kidney Disease anemia is
managed with administration of epoietin, providing
sufficiency of iron storage. Often, mere replacement of
iron insufficiency in predialysis patients restores Ht/Hb
in desirable levels, without administration of epoietin.
The aim of the present study was to estimate the
efficacy of and potential adverse events stemming from
total dose infusion low molecule iron dextrane in
predialysis patients of the Outpatient Nephrology
Department
presenting
iron
deficiency,
whether
suffering from anemia or not. Methods. 49 patients (15
male, 34 females) aged 73.60 ± 10.04 ( ±SD)- were
studied. Patients were suffering from Chronic Kidney
Disease of various seriousness, mainly stage III – IV; as
for the cause of the disease, the diagnosis was mainly
clinical while very few underwent kidney biopsy. In
addition, 28% of the sample was diagnosed with
diabetes mellitus while 32% with renovascular disease.
Ferritin rates of <200 mg/dl and transferin saturation of
<20% were considered to represent iron deficiency
which was estimated using an algorithm. Patients were
administered 1000 mg low molecule iron dextrane in 1 L
NaCl 0.9% within 10 hours after preceding sensitivity
test, independently of the deficiency level. Potential side
effects were recorded to prevent a possible allergy
shock. Subsequently, the same laboratory tests were
repeated each month. Results. A significant increase of
Ht 37.76 ± 3.59 vs 32.56 ± 2.91 ( ±SD, t=9.27,
p<0.001) and Hb 12.33 ± 1.18 vs 10.59 ± 1.04( ±SD,
t=1.45, p<0.001) was observed, along with an increase
in TSAT 26.21% ± 5.61% vs 16.94% ± 3.27%( ±SD,
t=2.96, p<0.001) and ferritin levels 297.48 ± 130.13 vs
56.42 ± 68.08( ±SD, t=2.32, p<0.001). Patients
presented symptoms of chest pain (n=2), chest and loin
pain (n=2) and flashing, pruritus and erythema (n=2);
one of those patients also showed dyspnoea and
pharynx burning sensation and he was administered
with methylprednizolone 125 mg. All of them were
released at the same day. A month later, all of them
were feeling better. Conclusion. Results showed that
filling of iron storage improves anemia resulting in either
decreased need for epoietin or in delaying its
administration, thus decreasing the total cost. The risk
of serious allergic reaction is practically impossible. The
potentially administered bolus quantity is large enough
to sufficiently cover the patient’s needs in the long term.
In cases where filling ferrum.
Background. Treatment of idiopathic membranous
nephropathy (IMN) remains controversial. However, in
high risk patients (ie patients with sustained nephrotic
range proteinuria and/or impaired renal function)
treatment depends on immunosuppressive agents and
corticosteroids. 9% of them will exhibit serious
complications. Several researchers have reported good
results
and
few
adverse
reactions
using
adrenocorticotropic hormone (ACTH). We present our
experience in the treatment of 3 resistant cases of IMN
with ACTH. Methods. We enrolled 3 patients, 42, 53
and 68 years old, with biopsy-proven IMN and nephrotic
range
proteinuria.
Previous
immunosuppressive
regimens included cyclophosphamide and prednisolone
or cyclosporine and prednisolone. The third patient did
not respond on either of the aforementioned regimens.
Recurrence has been observed on the first and the
second patient after a period of partial remission. There
was a wash out period of 6 months without specific
immunosuppressive medication for each patient. 1 mg
of tetracosactide (a synthetic analogue of ACTH) has
been given intramuscularly 2 times per week for 8
months. Follow up time lasted 12 months. Results. the
first patient showed partial remission (24h urine protein:
3.6g → 2g) after 3 months and complete remission after
8 months. He exhibited impaired fasting plasma glucose
and cushingoid face. The oral glucose tolerance test was
normal. The second patient had partial remission (24h
urine protein: 4.8g → 1.85g) after 2 months. She is
currently in partial remission and has no adverse
reactions, despite her history of diabetes melitus. The
third patient did not respond to treatment and presented
newly uncontrolled blood pressure, weight gain and
cushingoid face. GFR remained stable in all 3 patients.
Conclusion. ACTH has showed benefit in achieving
remission in 2 of our patients. The patient who did not
respond has a very persistent proteinuria. Several
immunosuppressive regimens have been tried with no
success. The adverse reactions were not insignificant,
but no patient had to stop the drug. Concisely, ACTH
seems to be a potential alternative choice for the
treatment of IMN, but larger, randomized studies are
necessary in order to clarify its effectiveness, optimal
dose and incidence of adverse reactions.
46
PP 047
PP 048
THE USE OF MULTIFREQUENCY BIOIMPEDANCE
ANALYSIS IN ASSESSING DRY WEIGHT AND BODY
COMPOSITION IN HEMODIALYSIS PATIENTS
IMPLEMENTATION OF NKF-K/DOQI CLINICAL
PRACTICE GUIDELINES IN A POPULATION OF
PATIENS ON CHRONIC HAEMODIALYSIS
V. Liakopoulos, O. Nikitidou, A. Ptinopoulou, K. Leivaditis,
A. Michalaki, G. Antoniadi, N. Savvidis, P. Nikolaidis
Hemodialysis Unit, 1st Department of Internal Medicine,
“AHEPA” Hospital, Medical School, Aristotle University of
Thessaloniki
M. Balios, B. Galanaki, K. Stergiou, K. Traianou,
M. Kalientzidou, F. Papoulidou, A. Ouzouni, F. Miari,
K. Kalaitzidis
Department of Nephrology, General Hospital Kavala,
Greece
Background. At present, the determination of dry
weight in patients on hemodialysis (HD) is largely made
empirically by trial and error and is based on the clinical
judgment of dialysis doctors. Bioimpedance analysis
(BIA) is an objective technique for determining dry
weight and it also provides useful data on body
composition. Whole-body bioimpedance spectroscopy or
multifrequency BIA (50 frequencies, 5-100 kHz) has
been recently validated and proven a very reliable
technique for independently determining extracellular
and intracellular water. The aim of this study was to
assess volume status of HD patients by multifrequency
BIA and detect possible differences between the
clinically prescribed dry weight and the euvolemic status
as assessed by BIA. Methods. Body Composition
Monitoring (BSM; Fresenius Medical Care, Bad Homburg,
Germany) was performed in 19 stable hemodialysis
patients (11 males, with mean age 48.7±17.5 years)
without relative contraindication before and 30 minutes
after a single midweek HD session. Overhydration was
defined as an overhydration to extracellular water
(ECW) ratio of >0.15. Results. The clinically determined
dry weight was 71±13 kg and the mean pre-HD weight
gain was 2.8±1.6 kg. The overhydration calculated by
BCM was 2.25±1.54 L pre-HD and 0.14±1.6 L post-HD
(p<0.0001). There was no difference in the euvolemic
weight assessed by BCM and the patients’ dry weight.
Pre-HD 9 patients were overhydrated and only 2 of them
remained overhydrated post-HD. Relative overhydration
(overhydration/ECW ratio) was 0.12±0.08 pre-HD and
0.008±0.11 post-HD (p<0.0001). Total Body Water,
Extracellular Water and Intracellular Water were
35.9±7.3 L vs. 33.6±7.2 L (p<0.0001), 17.5±3.1 L vs.
15.2±2.8 L (p<0.0001) and 18.5±4.3 L vs. 18.4±4.6 L
(p=ns) pre- and post-HD respectively. Lean Tissue Mass
was 37.3±10.1 kg, Fat Body Mass 24.9±8.3 kg and
Body Cell Mass 20.2±6.8 kg without any significant
changes pre- and post-HD. Conclusion. Multifrequency
BIA is a simple, non-invasive and trustworthy technique
that could be helpful in assessing volume status and
body composition of HD patients. However, clinical
judgment remains the easiest and most important tool
in assessing dry weight with reliable results.
Background. The purpose of the present study was to
evaluate the application of those guidelines on clinical
practices and on the achievement of bone disease,
anemia and haemodialysis adequacy. Methods. Data
were collected retrospectively from 72 stable patients
(men:45, 62.5%), mean age (66.4 ± 10.5), diabetics
(20.8%), mean haemodialysis duration (83 ± 61
months) during the last two years. The following
variables were calculated and recorded: the mean of all
monthly measurements of serum Ca, P, Ca×P, intact
parathyroid hormone (i-PTH), haemoglobin (Hb), urea
reduction rate (URR), dialysis adequacy (KT/V), serum
K, serum albumin and blood pressure alterations during
haemodialysis session. Results. K/DOQI targets for Ca,
P, Ca×P, i- PTH, Hb, URR, were met by: 69.4%, 61.1%,
81.9%, 37.5%, 54.2%, 69.4%, respectively. There was
not any significant difference between patients under/
over 65 years old, men vs women, diabetics vs no
diabetics, concerning the above mentioned targets,
according t-test. The compliance of patients to the
dietary restriction concerning K consumption (
predialysis K<5.5meq/l) was 58.3%. Discussion. The
K/DOQI Clinical Practice Guidelines for bone metabolism
and disease in chronic renal disease were published in
October 2003, but assessment of the results obtained
from the application of those guidelines, is essential for
evaluating their true applicability and the consequences
of its application. Instead of using novel therapies
(including calcimimetics, paricalcitol, etc) only the
35.5% of the patients achieved i- PTH target. This could
be
explained
as
a
result
of
superimposed
hyperphosphataemia and hypercalcaemia in 30.6% of
them. 20.8% of the patients had also hemoglobin levels
above 12g% due possibly to administration of higher
recombinant human erythropoietin doses .The results of
the present study indicate that a large proportion of our
patients stayed outside the proposed targets, which
points to the need for more effective therape utic
options.
47
PP 049
PP 050
DERMATOLOGICAL PROBLEMS IN HAEMODIALYSIS
PATIENTS ON MAINTENANCE HEMODIALYSIS
DO NOT FORGET EXTRAPULMONARY
TUBERCULOSIS IN HEMODIALYSIS PATIENTS
1
E. Likaj, S. Seferi, M. Rroji, A. Duraku, M. Kasa,
S. Mumajesi, M. Barbullushi, N. Thereska
Department of Nephrology–HaemodialysisTransplantation, University Hospital Center “Mother
E. Likaj, 2 A. Bano, 1 S. Seferi, 1 M. Rroji, 1 A. Duraku,
S. Mumajesi, 1 A. Idrizi, 1 M. Barbullushi, 1 N. Thereska
1
Department of Nephrology–HaemodialysisTransplantation, University Hospital Center “Mother
2
Service of Dermatology, Lezha Hospital Center, Albania
1
Background. An enlarged left supraclavicular lymph
node (Virchow-Troisier`s) usually evokes the diagnosis
of a metastatic abdominal cancer, a node in the superolateral part of the breast accompanied by a axillar lymph
node a breast cancer. We present here a rare case of a
hemodialysis
patient
with
this
picture
of
symptomatology that did not result cancer but only
extrapulmonary tuberculosis and resolved totally with
the specific therapy. Case. A 32-year old female, patient
on maintenance hemodialysis for 11 years from kidney
stones was admitted to the hospital for left
supraclavicular tender swelling, cervical lymph nodes, a
breast node in the superolateral part accompanied with
an axillar lymph node. She also complanied of
arthralgia, anorexia and fatigue. Admission laboratory
data didn`t reveal something special but the abdomenthoracic computerized tomography confirmed the
presence of small multiple calcified lymph nodes in the
mediastinum, left and right supraclavicular, paraaortal,
iliac bifurcation, lienal hilus, hepatic hilus. Excisional
biopsy of the cervical lymph node and breast node was
performed and after light microscopy examination,
auramine staining and polymerase chain reaction assay
all resulted in tuberculous lymphadenopathy and
tubercular granuloma. Resolution of symptomatology
and disappearing of all lymph nodes came after specific
therapy was completed for 6 months. Conclusion.
Tuberculosis is not a rare infection among hemodialysis
patients arising the ranges of 8-10% and often is
extrapulmonary (64- 92% of cases) but the non-specific
and insidious symptomatology and the localization of the
enlarged lymph nodes may be confounding, evoking
cancers. Histological and microbiological examinations
are useful for establishing the diagnosis then giving the
appropriate treatment.
Background. Chronic renal failure is nearly a common
problem nowadays and haemodialysis is taking a wider
place in renal replacement therapies. Nearly all patients
with ESRD have at least one dermatological disorder and
a great part of them presents an array of cutaneous
manifestations, which can affect the patient`s quality of
life. Newer changes are being described since the advent
of haemodialysis which prolongs the life expectancy,
giving time for this changes to manifest. We must be
aware to diagnose, reassure, educate patients and offer
appropriate therapies. AIM : The aim of the study was to
evaluate the prevalence of dermatological problems
among haemodialysis patients Methods. One hundred
patients with ESRD on maintenance haemodialysis were
examined for cutaneous changes. Results. Seventy-five
per cent patients complained of some skin disorders
however on examination all of them had at least one
skin lesion attributable to CKD. The most prevalent
finding was xerosis ( 58%) followed by pruritus (51%),
hiperpigmetation (46%), pallor (20%), fungal (15%),
bacterial (13%), viral (11 %) infections of the skin,
dermatitis( 10 %), varicous arterio-venous fistulas
(8%), purpura (3%). The nail changes included
onychomycosis 10%, Mees`line (4%),Muehrcke`s line(
3%), Beau`s line (2%), onycholysis (1%), Hair changes
included sparse body hair (20%), lusterless hair (17%),
sparse scalp hair (12%).Oral changes included
xerostomia (15%), uremic breath (10%),ulcerative
stomatitis (2%),angular cheilitis (1%). Conclusion. CRF
is associated with a complex array of cutaneous
manifestations caused either by the disease itself or by
treatment. The commonest are xerosis and pruritus and
the early recognition can relieve suffering and decrease
morbidity treating them the right way.
48
PP 051
PP 052
SUCCESSFUL TREATMENT OF VALACYCLOVIR
NEUROTOXICITY WITH INTENSIVE PERITONEAL
DIALYSIS
THE INFLUENCE OF RISK FACTORS ON DIABETIC
NEPHROPATHY AND RETINOPATHY IN TYPE 2
DIABETES MELLITUS Y
1
1
C. Pipili, 2 E. Kostis, 1 K. Pandelias, 1 E. Deda,
P. Korfiatis, 2 P. Tsiamalos, 1 H. Tzanatos, 1 E. Grapsa
1
“Aretaieion University” Hospital Athens, Greece
2
Therapeutic Department, University of Athens,
“Alexandra” Hospital, Athens, Greece
Y. Themeli, 1 V. Bajrami, 1 E. Petani, 2 B. Kambo,
A. Idrizi, 3 M. Barbullushi, 2 F. Agaci, 1 E. Ktona
1
Service of Internal Medicine, Diagnostic Center "IkedaEuromedica", Tirana, Albania
2
Service of Internal medicine, "Hygeia" Hospital, Tirana,
Albania
3
Service of Nephrology, University Hospital
Center"Mother Teresa", Tirana, Albania
1
3
Background. Valacyclovir consists an effective oral
agent for therapy of herpes virus infection. Its
pharmacokinetics are altered in renal insufficiency, so it
needs dose adjustment to avoid neurotoxicity.
Conventional hemodialysis is the method of choice for
severe valacyclovir adverse effects. We describe the
case of a patient on continuous ambulatory peritoneal
dialysis (CAPD) who recovered from severe valacyclovir
neurotoxicity treated with intensive CAPD. Case report.
A 72-year-old woman with a 5-year history on CAPD for
end-stage renal disease due to nephrosclerosis referred
to a dermatologist with complain of a painful, unilateral
vesicular eruption displaced on her back and right leg.
She was diagnosed with herpes virus infection and oral
valacyclovir 1000 mg thrice /day (dosage without renal
adjustment) was prescribed. After two days under
valacyclovir treatment, she presented with altered level
of consciousness, dysphasia, ataxia, numbness and
optical hallucinations. She was hospitalized with the
presumptive diagnosis of herpes virus encephalitis or
valacyclovir neurotoxicity. Examination of cerebrospinal
fluid ruled out central nervous system infection, brain
magnetic resonance imaging was unremarkable and
valacyclovir
was
discontinued.
Concurrently
her
peritoneal dialysis prescription was increased, from four
to six exchanges per day. Patient was without residual
renal function. After 2 days of hospitalization her mental
status improved and after 5 days the neurological
symptoms have been totally disappeared. The rash
started erasing and only topical antiviral treatment was
applied. Conclusion. Intensive peritoneal dialysis
resulted in amelioration of serious mental symptoms in a
patient on end-stage renal disease with valacyclovir
intoxication; without the need of conventional
hemodialysis treatment.
Background. Several risk factors such as poor glycemic
control, dyslipidemia, hypertension, obesity and smoking
act synergistically to develop nephropathy and
retinopathy in patients with type 2 diabetes mellitus
(T2DM).
Since
progression
to
microvascular
complications is likely to occur in a significant proportion
of type 2 diabetic patients, the role of these risk factors
needs to be further explored. The aim of the study was
to analyze the association between a variety of baseline
risk
factors
and
occurrence
of
microvascular
complications at follow-up in T2DM patients. Methods.
A prospective, observational study was conducted at a
hospital and two diagnostic centers in Tirana. 130
patients with T2DM, aged ≥ 20 years were enrolled in
the study. Exclusion criteria were type 1 diabetes
mellitus, diabetic nephropathy and/or retinopathy at
baseline. Inclusion criteria were normal urinary albumin
levels and absence of retinopathy (as assessed by
funduscopy) at baseline. The clinical end-point was a
urinary albumin excretion (UAE) level >30 mg/24 h
and/or the presence of retinopathy after three years. A
Student’s t test for unpaired samples was used to
compare mean levels with standard deviations (SD), and
a Chi-square to compare proportions. Results. Fifty two
patients (40% of total cases) developed microvascular
complications at follow-up, from which 30 patients
developed nephropathy and 22 developed retinopathy.
Twenty
six
of
them
developed
both
retinopathy(predominantly
maculopathy)
and
nephropathy. No different features were seen between
the groups with retinopathy or nephropathy only, and
those with both retinopathy and nephropathy. Cases
with microvascular complications were predominantly
male, tended to be older, to have a longer mean
diabetes duration, to be taking more insulin, to receive
less frequently oral hypoglycemic agents, to have higher
hypertension rates and C-reactive protein (CRP) levels
>3 mg/L. In the logistic regression analyses of baseline
risk
factors
for
development
of
microvascular
complications at follow up, the main independent risk
factors were UAE > 12 mg/24 h, CRP > 3 mg/L and
hypertension. Conclusion. Increased baseline UAE rate,
male sex, presence of retinopathy, increased serum
cholesterol levels, HbA1c concentration and age are risk
factors for the development of incipient or overt diabetic
nephropathy. Presence of hypertension is an exceedingly
strong independent risk factor for development of
nephropathy and/or retinopathy. Diabetic maculopathy
is closely associated with diabetic nephropathy and with
several atherosclerotic risk factors, suggesting that
these factors could have a significant role in the
pathogenesis of maculopathy.
49
PP 053
PP 054
TREATMENT OF SECONDARY
HYPERPARATHYROIDISM AND DISLIPIDEMIA IN
HEMODIALYSIS PATIENTS
A RARE CASE OF PERITONITIS DUE TO
OCHROBACTRUM ANTHROPI IN A CONTINOUS
AMPULATORY PERITONEAL DIALYSIS PATIENT
D. P.Karasavvidou, T. Fountoglou, A. Tsirmani,
S. Lambropoulos, C. Katsinas
“Mpodosakio” General Hospital, Ptolemaida, Greece
A. Kourouklaris, A. Panagidou, K. Ioannou, I. Savva,
P. Georgiou, M. Zavros
Department of Nephrology, Nicosia General Hospital,
Gyprus
Background. Secondary hyperparathyroidism (SHPT) is
a common problem among patients with end-stage
kidney disease on hemodialysis (HD) and may
contribute to abnormalities of lipid metabolism.
Amelioration of SHPT has been reported to mitigate also
dyslipidaemia .The study objectives were to compare the
efficacy of treatment with calcitriol versus paricalcitol i.v
on SHPT and also their impact on lipid levels. Methods.
Twenty-six patients with a serum intact PTH (iPTH) >
150 pmol/L were recruited in the study and they
received either i.v. calcitriol (0.01mcg) (14 patients) or
i.v. paricalcitol (0.04 ug/kg)(12patients) during every
haemodialysis session. The dosage were adjusted
according to the evidence. Results. Patients’ median
age was 62 years (38-75) and there were 8 men
(34.5%). From the totallity of the patients only 6
patients had iPTH >300 pg/ml. Median iPTH was 113.15
(21 -563) pg/ml. Correction of anemia was according to
K/DOQI guidelines (mean Ht:35.89±3.42, mean
Hb:11.22±7.62). Hemodialysis adequacy according to
the Urea Reduction Ratio was 72.5±7.62. Patients were
receiving the following medications: 14 (31.8%) patients
were receiving calcitriol, 12 (27.3%) paricalcitol, 2
(9.5%) calcium carbonate, 15 (71.4%) sevelamer, 5
(23.8%) lanthanum carbonate and 12 (63.8%) statins,5
(23.8) fibrates. Paricalcitol group showed a higher
reduction of iPTH compared to calcitriol group (mean
iPTH:205±87 vs 269±102 pg/ml)(p=0.001). In this
group serum phosphorus increased compared to
calcitriol group but without anystatistical significance.
Serum calcium and CaxPo4 product also showed no
significant differences between the two groups (Ca:
9±1.04 vs 8.9±0.7 mg/dl, Po4-: 5.4±1.04 vs 4.8±1.45
mg/dl ,Ca x Po4- product :50%±11.4 vs 44%±12.23 )
On the other hand calcitriol group had a better lipid
profile compared with paricalcitriol group (TCHOLtotal:155.±31. vs 173.±29mg/dl TGL:122.±3 vs
122.±3mg/dl, HDL-CHOL:46±10 vs 46±910mg/dl,
p=0.05, p=0.001, p=0.05 respectively). Six patients
from the calcitriol group and 6 patients from the
paricalcitol group were in combination with statins.
Combination of calcitriol and statins had a better impact
in dyslipidemia compared to combination paricalcitol
with statins (TCHOL-total: 191±24 vs 171±29.5 mg/dl,
TGL 214±78.7 vs 141±44.6 mg/dl, HDL-C:43±19.9 vs
52±12mg/dl, p=0.05, p=0.001, p.0.05). Conclusion.
Paricalcitol had a better effect on reducing iPTH levels
compared with calcitriol. No significant changes in serum
calcium, phosphorus, or Ca x Po4- product were noticed.
However, calcitriol treatment may have a positive effect
on HD patients’ dyslipidemia.
Background. Peritonitis is one of the most common
complications in peritoneal dialysis (PD) patients and
remains the primary reason for treatment failure. We
present a rare case of peritonitis due to Ochrobactrum
Anthropi in an otherwise immunocomponent patient.
Case report. A 84-year-old female continuous
ambulatory peritoneal dialysis (CAPD) patient, presented
with cloudy peritoneal effluent and abdominal
tenderness. Because of ESRD of unknown etiology she
started CAPD, through a Tenckoff catheter, three
months before admission. She was afebrile with no
systemic signs. The tunnel and exit site of the catheter
were normal. White blood cell count in peritoneal
effluent was 660/mm3 (81% neutrophils).Once culture
was obtained, empiric antibiotic therapy was initiated
with intraperitoneal Ceftazidime 1gr divided in 4 doses
in each exchange and Vancomycin 1gr on day 1 and 5,
according to our center protocol, with good response.
Culture result showed Streptococus salivarius and
Ceftazidime was discontinued. Seven days later,
abdominal pain and cloudy effluent recurred. There was
also fever, nausea and rebound tenderness. White blood
cell count in peritoneal effluent was 3000/mm3 (77%
neutrophils) and culture isolated Ochrobactum Anthropi.
Intra-abdominal pathology was excluded and a new
regimen of intraperitoneal Amicacin 500mg every
72hours and intravenous Tygecycline 100mg stat and
50mg twice daily was started according to the
antibiogram. Because of little clinical improvement and
sustained leukocytosis, three weeks after admission, the
peritoneal catheter had to be removed. The patient
switched from PD to hemodialysis (HD).Intravenous
tygecycline was continued for an additional 7 days
.There was no bacterial growth from the removed
catheter. Conclusion. According to the current
bobliography this is the fifth case of Ochrobactrum
Anthropi peritonitis reported so far and the first reported
in Cyprus. Ochrobactrum Anthropi is a nonfermenting
aerobic, mobile, oxidase and urease positive, gram
negative bacillus. It is considered an opportunistic
pathogen of low virulence and an early colonizer of
indwelling catheters. In up to two third of cases, it is
necessary to remove the catheter in order to control
infection.
The
patient
had
significant
clinical
improvement since then.
50
PP 055
PP 056
CYSTINURIA IN A FAMILY OVER TWO
GENERATIONS
ASSESSMENT OF MICROCIRCULATION FOR
HEMODIALYSIS EFFICIENCY EVALUATION
1
1
N. Ristoska Bojkovska, 2 K. Popovska-Jankovic,
Z. Gucev, 2 G. Efremov, 2 D.Plaseska-Karanfilska,
1
V. Tasic
1
University Children’s Hospital, Skopje, Macedonia
2
Research Center for Genetic Engineering and
Biotechnology, Macedonian Academy of Science and Arts
Skopje, R. Macedonia
C. Pipili, 1 E. Grapsa, 2 E. Tripodaki, 2 C. Manetos,
M. Kravari, 2 M. Parisi, 2 S. Kokkoris, 3 S. Ioannidou,
2
S. Nanas
1
Department of Nephrology, Aretaieion University
2
1st Critical Care Department, University of Athens,
Greece,
3
Department of Biochemistry, Evangelismos Hospital,
Athens, Greece
1
2
Background. Cystinuria is an autosomal recessive
disorder that is characterized by an impaired tubular
transport of cystine and dibasic aminoacids, resulting in
cystine urolithiasis. The transport of these amino acids is
mediated by the rBAT/b0,+AT transporter, the subunits
of which are encoded by the genes SLC3A1, located on
chromosome 2p16.3-21, and SLC7A9, located on
chromosome 19q12-13.1. Case report. In this work we
present a family in which cystinuria was manifested in
two generation. The index case is a female, aged 9
years when she was diagnosed with a kidney stone and
underwent surgery. Nitroprusside test was positive and
urinary excretion of cystine was high (127.5 mM/M
creatinine, normal 0.6-20.0 mM/M creatinine). The
family screening revealed that two siblings (sister and
brother) had positive nitroprusside test and increased
urinary excretion of cystine. The mother had history of
surgery for nephrolithiasis, had positive nitroprusside
test and increased urinary excretion of cystine. The
mutational analysis of the SLC3A1 gene revealed that
the index case and the mother were compound
heterozygote (T216M/M467T), while the female and the
male siblings were homozygote for M467T mutation. The
father was heterozygote for M467T mutation. The ethnic
origin of the patients is Egyptian. Conclusion. To the
best of our knowledge this is the first report of cystinuria
occurring over two generations.
Background. Augmentation of hemodialysis (HD)
parameters such as blood, dialysis fluid flow rate and
dialyzer surface area are efforts made to increase
efficiency
of
dialysis
process.
However,
some
investigators believe that microcirculation plays a key
role in the hemodialysis process. The aim of this study
was to correlate microcirculatory alterations, as
assessed by Near Infrared Spectroscopy (NIRS), with
dialysis adequacy. Methods. Chronic HD patients
underwent NIRS evaluation before and at the end of one
mid-week dialysis session. Tissue oxygen saturation
(StO2, %), defined as the percentage of hemoglobin
saturation in the microvasculature compartments, was
measured with a probe placed on the thenar muscle. A
3-min brachial vascular occlusion technique was applied
to evaluate microcirculation. Measurements included
StO2%, oxygen consumption rate (OCR %/min, as the
first degree slope of the desaturation of hemoglobin),
recovery slope (RS%/min, as the first degree slope of
the resaturation of hemoglobin after the release of the
cuff, and reactive hyperemia was estimated as the area
(units/min) under the StO2% curve above baseline
values. HD parameters (filter, duration and adequacy),
medical treatment, etiology of Chronic Kidney Disease
and comorbities were also recorded. The percent change
of parameters was estimated by subtraction of
predialysis from post dialysis measurement values
divided with predialysis values and multiplied by 100.
Results. Measurements were performed in 19 HD pts
(13 males, mean age 47±12 years, kt/V: 1.2±4, Ηt:
38±3,3 %) on HD for 4.5±3 years, before and after one
HD session. The percent change of StO2 correlated with
HD adequacy (r=0.487, p=0.048). A small number of
patients receiving on line hemodiafiltration presented
better predialysis recovery slope than patients receiving
conventional HD (63.82±34.87 vs. 13.52 ±14.07,
p=0.001). The one way ANOVA model indicated that the
erythropoietin kind was related to the percent change of
oxygen consumption rate (p=0.038) and recovery slope
(p<0.001). Conclusion. Dialysis affects peripheral
microcirculation of HD patients as assessed by NIRS and
NIRS occlusion technique seems to predict the HD
efficiency. Further studies are needed to evaluate the
effect of HD in the microcirculation of these patients and
the possible contribution of NIRS to the assessment of a
subset of patients who will benefit more from different
strategies of dialysis. *Acute effect of hemodialysis on
microcirculation
assessed
by
near
–infrared
spectroscopy XLXII ERA-EDTA Congress.
51
PP 057
PP 058
DO BLOOD VISCOSITY VALUES INFLUENCE THE
OCCURANCE OF MICROANGIOPATHY OR ITS
EVOLUTION IN PATIENTS WITH TYPE 2 DIABETES
MELLITUS AND CHRONIC RENAL DISEASE?
THE ASSOCIATION OF ELEVATED SERUM FERRITIN
LEVELS AND THE RISK OF MICROANGIOPATHY IN
PATIENTS WITH TYPE 2 DIABETES MELLITUS AND
CHRONIC RENAL DISEASE
1
1
R. Papadopoulos, 2 E. Kanonidou, 3 C. Kanonidou,
A. Michalopoulos, 1 A. Papagianni,
1
A.Kelesidis, 2 L. Papazisis, 1 N. Kotzadamis
1
Department of Nephrology, General Hospital of Veria,
Veria, Greece
2
Department of Ophthalmology, General Hospital of
Veria, Veria, Greece
3
Postgraduate student, Aristotle University of
Thessaloniki, Thessaloniki, Greece
R. Papadopoulos, 2 E. Kanonidou, 3 C.Kanonidou,
A.Michalopoulos, 1 A. Papagianni, 1 A. Kelesidis,
2
L. Papazisis, 1 N. Kotzadamis
1
Veria, Greece
2
3
Backround. To comparatively evaluate the factors
affecting blood viscosity in patients with diabetes and
chronic renal disease, with and without accompanying
defects of diabetic retinopathy. Methods. 53 patients
with diabetes mellitus (34 male and 19 female) with an
average age of 70.45 years (SD 8.21) participated in the
study. All were suffering from chronic renal disease. 31
of these had no lesions (group I) and 22 had lesions of
diabetic
retinopathy
(group
II)
during
fundus
examination. All patients had a mean duration of
diabetes 9 years (SD 4.67). The study compared the
following factors in both groups of patients: Ht (%), GLU
(mg / dl), HbA1c (%), Tchol (mg / dl), Trig (mg / dl),
HDL (mg / dl), LDL ( mg / dl). Results. The results of
hematological and biochemical tests as compared to
groups I and II were as follows: Ht 38.80 vs 37.53
(p=0.254), GLU 148.5 vs 159 (p=0.395), HbA1c 9.08 vs
7.2 (p=0.368), Tchol 171 vs 157 (p=0.255), Trig 195 vs
154 (p=0.298), HDL 42.44 vs 42.31 (p=0.973), LDL
89.11 vs 76.71 (p=0.236). Mean GFR was calculated for
both groups using the MDRD formula. Mean GFR was
51,48 ml/min/1,73m² (SD 16,73) for group I and 40,34
ml/min/1,73 m² (SD 21,25) for group II (p<0,05). No
significant correlation was observed between the blood
viscosity values and the severity of retinopathy.
Conclusion. There was no significant difference in
patients with diabetes and chronic renal disease
regarding the factors that affect blood viscosity between
those who had diabetic retinopathy lesions and those
who did not have lesions. It seems that the levels of
blood viscosity parameters in diabetic patients may not
remarkably influence the evolution of microangiopathy
related to diabetic retinopathy.
Backround. To comparatively evaluate the levels of
serum ferritin in diabetic patients with and without
diabetic retinopathy lesions and concomitant renal
disease. Methods. 53 patients (34 male and 19 female)
with a mean age of 70.45 years (SD 8.21) participated
in the study. All suffered from type 2 diabetes mellitus
and had chronic renal disease (CRD). 31 had no lesions
(group I) and 22 had lesions of diabetic retinopathy
(group II) during fundus examination. The mean
duration of diabetes was 9 years (SD 4.67). 21 healthy
controls (11 male and 10 female) with a mean age of
71.28 years (SD 3.37) also participated in the study
(group III). The serum ferritin levels were measured in
the three groups and were comparatively evaluated.
Results. The mean serum ferritin values in group I was
146.69 mg / L, in group II 131.9 mg / L and in the
group III 48.59 mg / L. There was a significant
difference in the values of serum ferritin between the
diabetic patients with and without diabetic retinopathy
lesions and the healthy controls (p=0.010 and p=0.006
respectively), while no significant difference in the
values between the two groups of diabetic patients was
found (p=0.704). Mean GFR was calculated for both
groups using the MDRD formula. Mean GFR was 51,48
ml/min/1,73m² (SD 16,73) for group I and 40,34
ml/min/1,73 m² (SD 21,25) for group II (p<0,05).
Moreover, there was no significant correlation between
ferritin values and the values of HbA1c in both groups of
diabetic patients (p=0.365 and p=0.941 respectively).
Conclusion. The results show that the levels of iron in
diabetic patients with CRD may play a role in the
occurrence of microangiopathy or its evolution.
1
1
52
PP 059
PP 060
THE EFFECT OF HAEMATOCRIT, GLYCEMIC AND
LIPID PROFILE ON THE APPEARANCE OF LESIONS
OF DIABETIC RETINOPATHY AND NEPHROPATHY
IN PATIENTS WITH DIABETES MELLITUS TYPE 2
DIABETIC RETINOPATHY AND NEPHROPATHY: TO
EVALUATE THE ASSOCIATION BETWEEN THE TWO
MOST DREADED COMPLICATIONS OF DIABETES IN
PATIENTS WITH DIABETES MELLITUS TYPE 2
1
1
R. Papadopoulos, 2 E. Kanonidou, 3 C. Kanonidou,
A. Michalopoulos, 1 A. Papagianni, 1 A. Kelesidis,
2
L. Papazisis, 1 N. Kotzadamis
1
Veria, Greece
2
3
R. Papadopoulos, 2 E. Kanonidou, 2 I. Chatziralli,
C. Kanonidou, 1 A. Michalopoulos, 1 A. Papagianni,
1
A. Kelesidis, 2 L. Papazisis, 1 N. Kotzadamis
1
Veria, Greece
2
3
Backround. To comparatively evaluate the values of
haematocric and of the parameters comprising the
matabolic and glycemic profile in patients with diabetes
mellitus, chronic renal disease and defects of diabetic
retinopathy compared to normal controls. Methods. 22
patients with diabetes mellitus (15 male and 7 female)
with an average age of 68.81 years (SD 7.08)
participated in the study. All patients had a mean
duration of diabetes 13 years (SD 5.69) and suffered
from chronic renal disease. 12 of these had lesions of
non-proliferative diabetic retinopathy (6 mild, 3
moderate and 3 severe) and 10 had lesions of
proliferative
diabetic
retinopathy
during
fundus
examination. 16 healthy controls (8 male and 8 female)
with an average age of 61.28 years (SD 3.37) also
participated in the study. The study compared the
following factors between diabetic and healthy
participants: Ht (%), GLU (mg / dl), HbA1c (%), Tchol
(mg / dl), Trig (mg / dl), HDL (mg / dl), LDL (mg / dl).
Results. The results of hematological and biochemical
examinations between diabetic patients and healthy
controls were as follows: Ht 37 vs 40.64 (p = 0.002),
GLU 159.9 vs 90.3 (p <0.0001), HbA1c 9 vs 4.68 (p
<0.0001), Tchol 171 vs 157 (p = 0.21), Trig 154.13 vs
95 (p = 0.008), HDL 42.31 vs 56.625 (p <0.0001), LDL
95.37 vs 80.2 (p = 0.05) Mean GFR was calculated for
both groups using the MDRD formula. Mean GFR was
40,34 ml/min/1,73 m² (SD 21,25) for the diabetic
patients. Conclusion. There were significant differences
found in factors affecting blood viscosity in patients with
diabetes mellitus, chronic renal disease and diabetic
retinopathy lesions compared to healthy controls. The
increased prices of factors related to blood viscosity may
play an additional and important role in the appearance
of lesions of diabetic retinopathy and nephropathy.
Backround. Diabetes mellitus has microvascular
complications, such as retinopathy and nephropathy.
Our purpose was to assess the prevalence of diabetic
retinopathy and its relationship with nephropathy in
patients with diabetes mellitus type 2 and chronic renal
disease. Methods. Participants in our study were 53
patients (34 male and 19 female) with diabetes mellitus
type 2 and chronic renal disease, mean age 70,45 years
old (SD 8.21). 31 of these had no lesions (group I) and
22 had lesions of diabetic retinopathy (GroupII) during
fundus examination. All patients were referred to the
Department of Ophthalmology of our hospital and
underwent dilated fundoscopy, so as to evaluate the
presence of diabetic retinopathy and its grade. In
addition to this, the stage of chronic renal disease and
GFR were recorded and statistically analyzed. Results.
88,7% of our patients suffered from hypertension and
79,2% presented arteriosclerosis of fundus vessels.
58,5% of the patients had no signs of diabetic
retinopathy (group I), while 54,5% of group II (12
patients) had non-proliferative and 45,5% (10 patients)
proliferative diabetic retinopathy. Mean GFR was
calculated for both groups using the MDRD formula.
Mean GFR was 51,48 ml/min/1,73m² (SD 16,73) for
group I and 40,34 ml/min/1,73 m² (SD 21,15) for group
II, (p<0,05). Lower estimated GFR was associated with
greater eye pathology (p<0.05). Conclusion. The
prevalence of diabetic retinopathy was 22,7% for the
non-proliferative and 18,8% for the proliferative one.
There was a positive association between diabetic
retinopathy and nephropathy.
1
3
53
PP 061
PP 062
BONE MINERAL DENSITY EVALUATION IN
HEMODIALYSIS PATIENTS AND ASSOCIATION
WITH VASCULAR CALCIFICATION
SERUM CREATININE (< 2 MGR/DL) SENSITIVITY IS
NOT ADEQUATE TO PREDICT ADVERSE OUTCOMES
FOLLOWING VERY SEVERE PERIPHERAL VASCULAR
SURGERY
K.N.Adamidis, T.D.Oikonomaki, G.E.Metaxatos,
T.K.Apostolou, C.T.Christodoulidou, K.P.Psounis,
N.I.Nikolopoulou
Department of Nephrology, “Evangelismos” General
Hospital of Athens, Greece
1,2,4
D. Koumoutsea, 3 V. Tsiligiris, 1,4 S. Kalakonas,
E. Chouliaras, 1,2 I. Griveas, 2 A. Galinas,
1,4
A. Salapata, 3,4 I. Angelakas, 2 G. Stavgianoudakis,
2
K. Karamitsos
1
Department of Critical Care Medicine (ICU) 401 General
Military Hospital of Athens, Greece
2
Department of Nephrology (Renal Medicine) 401
General Military Hospital of Athens, Greece
3
Department of Vascular Surgery 401 General Military
4
Departments of Anaesthesiology and Critical Care
Medicine (ICU), Hygeia Hospital, Athens, Greece
1,4
Background. In patients on hemodialysis (HD)
disturbances of mineral metabolism are common and
reduced Bone Mineral Density (BMD) may result from
the combined effects of age-related factors and renal
osteodystrophy (RO). There are evidence suggesting
that factors involved in RO may also be important in the
pathogenesis of vascular calcification and further
cardiovascular complications among HD patients. The
purpose of this study is to evaluate the BMD in HD
patients, and determine any correlation with the
laboratory parameters of bone mineral metabolism and
the vascular calcification. Methods. A cross-sectional
study was conducted in our unit for 17 HD patients (5
females, 12 males) of age range from 28 to 75 years
(mean, 53,9 ±15,8 years) who had been hemodialyzed
3 times a week for 11 to 222 months (mean, 63 ± 53
months). To evaluate BMD all patients underwent a
Dual-Energy X-ray Absorptiometry (DEXA). Coronary
artery calcification (CAC) was evaluated with a Multislice
Spiral Coronary Computed Tomography (MSCT) using
the Agatston technique for calcium scoring (CS).
Calcium (Ca), phosphate (P), calcium-phosphate product
(Ca x P), alkaline phosphatase (ALP) and iPTH were
measured. Pearson correlation test was applied between
those parameters, and when it was necessary univariate
analysis of variance by SPSS 15.0. Results. The
prevalence of abnormal values of BMD (t-score <-1) was
94%, while 53% had t-score<-2.5. BMD was strongly
correlated with age (p<0.017). Important correlation
was identified between Femoral Wards region BMD and
CS (p=0.023). Although it was not statistically
significant, there was a correlation between Femoral
Neck and Troch t-score and CS (p=0.053). Applicating a
glm model, with univariate analysis of variance, it was
revealed that there is a statistical important influence of
the (Ca x P) and the intake of vitamin D, that not acts
independently, over the Τ-score of L1. Conclusion. Low
BMD is prevalent in HD patients and highly associated
with age. The correlation between Femoral BMD and CS
could probably indicate a more extensive use of DEXA,
as an alternative method, which could lead us to an
early detection of vascular calcification. Moreover, Vit-D
analogues seem, when their use is needed, to improve
Lumbar BMD.
Background. Preoperative serum creatinine (sCr) levels
of more than 2,0 mgr/dl have generally been known as
an independent risk factor for postoperative mortality
and morbidity following cardiac and very severe
peripheral vascular surgery. Renal consultants declare
that glomerular filtration rate (GFR) rather than sCr has
been demonstrated to be the best predictor of adverse
postoperative outcomes. The aim of this study was to
investigate any potential relationship between sCr< 2
mgr/dl patients with decreased GFR and adverse
postoperative outcomes. Methods. Subjects were all
patients who had predominantly undergone very severe
peripheral vascular surgery (no: 237) during a longlasting period of 3,5 years with sCr< 2 mgr/dl and no
history of dialysis. GFR (ml / min per 1,73m2) was
calculated by the Modification of Diet in Renal Disease
Study Equation (M.D.R.D. - G.F.R. Calculator) and
subjects were separated into groups of GFR normal (>
90), GFR mild (60-90), GFR moderate (30-60) and GFR
severe (< 30) (ml/min/1,73m2). Results. The following
variables were found to be significantly associated with
decreased GFR (p< 0,05): increased age, female
gender, hypertension and high EuroSCORE. Decreased
GFR across all categories was associated with increased
mortality [(OR: 1,62, 3,74, 18,24) (95% CI)], prolonged
ventilation time [(OR: 1,34, 3,41, 3,85) (95% CI)] and
acute postoperative renal failure (ARF) [(OR: 2,55,
9,65) (95% CI)] for mild and moderate groups only.
Conclusion. Established surgical risk algorithms for
cardiac and severe peripheral vascular operations which
include only dichotomized sCr levels < 2 mgr/dl may
miss a very critical section of the population. The GFR is
the best predictor of adverse outcomes following very
severe peripheral vascular surgery especially among
high risk populations such as older patients, females,
hypertensive patients and those patients with high
EuroSCORE defined risk profile. Widespread use of the
GFR seems to be justified as well as necessary for those
patients that may not be apparent with preoperative sCr
levels < 2 mgr/dl.
54
PP 063
PP 064
HIV SEROPOSITIVE PATIENTS WITH ESRD- A 6YEAR STUDY
OCURRENCE AND OUTCOME OF AKI IN ICU
PATIENTS ACCORDING TO RIFLE CRITERIA
J.G. Droulias, G.E. Metaxatos, C.T. Christodoulidou,
V.K.Margelos, T.K. Apostolou, N.I. Nikolopoulou
Department of Nephrology, “Evangelismos” General
1
A. Gjyzari, 1 N. Thereska, 1 M. Barbullushi, 1 A. Koroshi,
S. Kodra, 1 A. Idrizi, 1 A. Strakosha, 2 E. Petrela
1
Department of Nephrology, University Hospital Center
“Mother Teresa”, Tirana, Albania
2
Epidemiology, University Hospital Center “Mother
1
Background. HIV infection in patients with end stage
renal disease(ESRD) is a world major health issue which
has growing incidence in Greece and across the world.
Although there are guidelines for the evaluation of these
patients, we have no clear evidence about their
treatment options Methods. Six cases of HIV
seropositive patients with End Stage Renal Disease
(ESRD) are presented that were hospitalized,enrolled in
and followed renal replacement therapy in our
Nephrology Department for interval from 6 months up to
6 years. Under this opportunity we reviewed the
management of these patients. Results. We reviewed
six patients (five males, one female) aged 36-59 years
old. The first case was a 59-year old man, homosexual,
HIV seropositive by 15 years, he was on haemodialysis
sessions (HD) for 6 months and he died by septic shock
The second case was a 54-year old man, bisexual, HIV
seropositive by 10 years ,he was on haemodialysis
sessions (HD) for 11 months and he died by myocardial
infarction The third case was a 45-year old man,
homosexual, HIV seropositive by 20 years, he was on
CAPD for 32 months and then on HD until today with no
remarkable problems. The fourth case was a 45-year old
man, homosexual, HIV seropositive by 20 years,
receiving chronically antiretroviral therapy by 10 years,
he was on HD for 33 months and then he received
kidney graft by 3 years with follow-up to our
Department until today in good clinical condition. The
fifth case was a 36-year old man homosexual, HIV
seropositive by 10 years, who received kidney graft by 5
years and was on antiretroviral therapy before the
transplantation. Today he is in good clinical condition.
The sixth case was a 63-year woman, sailor’s wife, HIV
seropositive of unknown duration who died on her first
HD session probably by heart arrest Conclusion. Three
of them died (one by infection, the others two by
cardiovascular disease), two are on transplantation and
one on HD. All three are living well with no serious
problems. Maybe the reason is the improvement of renal
replacement
therapies
combined
with
chronic
antiretroviral therapy received by these patients. This
hypothesis is required further research to be confirmed.
Background. Aim of this study was to evaluate
ocurrence and outcome of acute kidney injury (AKI) in
the intensive care unit (ICU) patients based on RIFLE
criteria. Methods. 93 adult patients treated in a medical
surgical ICU, in a tertiary hospital centre during 2007
were reviewed retrospectively. Patients who stayed
more than 24 hours were included. AKI was classified
according to maximum RIFLE criteria using both serum
creatinine and urine output. Baseline serum creatinine
was estimated using the Modification of Diet in Renal
Disease equation (assuming average baseline GFR of 75
ml/min per 1.73 m2) Transplanted and chronic dialysis
patients before admission to the ICU were excluded.
Results. 53 (57%) patients reached RIFLE criteria for
AKI. They were classified as Risk 11 (11,8%), Injury 15
(16,1%), and Failure 27 (29%). AKI patients were aged,
median [IQR] 68 (60-76) versus non AKI patients 55
(31-73); p=0,008. SOFA score increased from non AKI
median [IQR] 2 (1-3), Risk 6 (5-9), Injury 7 (6-10),
Failure 11 (9-13) p<0,001. Mechanical ventilation was
used in 65,4% of AKI patients. Sepsis was the most
common cause of AKI 20 (37,7%) patients. Oliguria was
in 18 (33,9%) AKI patients. Mortality increased from
non AKI 4 (10%), Risk 7 (63,6%), Injury 10 (66,7%),
Failure 21 (77,8%), p<0,001. Three patients were
treated with intermittent haemodialysis. Recovery
according to RIFLE criteria was complete in 14 (25%)
AKI patients: Risk 5 (45,5%), Injury 5 (33,3%), Failure
2 (7,4%). p=0,004. Cox regression analysis for 30 day
ICU stay was significant p=0,001. Risk OR 95,0% CI 4,6
(1,3-15,9), p=0,015; Injury OR 95,0% CI 7,3 (2,223,7), p=0,001; Failure OR 95,0% CI 6,6 (2,2-19,3),
p=0,001 Conclusion. High ocurrence of AKI in ICU
patients is associated with worse outcome according
RIFLE criteria. Early detection and prevention of AKI
may help improve outcome in ICU patients. Key-words:
Acute kidney injury, incidence, intensive care unit,
mortality, RIFLE criteria.
55
PP 065
PP 066
DOUBLE FILTRATION PLASMAPHERESIS FOR THE
TREATMENT OF FIBRATE INDUCED
RHABDOMYOLYSIS IN SEVERE RENAL FAILURE
COMPARATIVE STUDY OF DIFFERENT IRON
INDICES IN HAEMODIALYSIS PATIENTS
1
M. Tsiatsiou, 1 E. Mitsopoulos, 1 E. Intzevidou,
O. Kougioumtzidou, 1 G. Visvardis, 1 D. Papadopoulou,
2
P. Passadakis, 2 V. Vargemezis, 1 D. Tsakiris
1
Department of Nephrology, “Papageorgiou” General
2
Department of Nephrology, Medical School, Democritus
University of Thrace, Alexandroupolis, Greece
1
K. Ioannou, I. Savva, A. Panagidou, A. Kourouklaris,
I. Athanasiou, K. Demetriou, C. Patsias, M. Zavros
Cyprus
Background. In a minority of patients, fibrates can
cause serious adverse effects with rhabdomyolysis
followed by acute renal failure being the most life
threatening one. Bezafibrate’s clearance in renal failure
is severely decreased, since its elimination is primary
renal. In serum it is highly protein bound which makes
its removal with common dialysis methods almost
impossible. Aim of the study was to investigate whether
plasmapheresis could contribute to bezafibrate clearance
and rhabdomyolysis improvement. Methods. We
describe a 66 year old female patient on peritoneal
dialysis who was admitted with a three day history of
generalised severe myalgia, muscle weakness, dark
urine and a decrease in urine output from 1500 to
250ml/24h. Five days ago, she was switched from
Fluvastatin to Bezafibrate 200mg twice daily due to
significant hypertriglyceridemia (550mg/dl). Since
bezafibrate is highly protein bound in serum, we
considered plasmapheresis as the most suitable method
for both drug and myoglobulin removal. Double filtration
plasmapheresis (DFP), 1.5 plasma volume per session
with albumin replacement, for 4 consecutive days was
performed and one on-line HDF session. Results. On
admission, creatine kinase (CK) levels were 13008 U/L,
which rapidly increased to 27940 and 49810 U/L, 12 and
24 hours later. Symptoms improved soon after the first
DFP treatment, while CK levels stopped rising and
started to decrease with the second DFP session (Figure
1) suggesting amelioration of myotoxicity, probably due
to bezafibrate clearance. This was not the case with the
on-line HDF therapy, since CK levels continued to rise.
On day 5, femoral catheter was removed and the patient
was restarted on peritoneal dialysis and discharged. One
week later the patient remained in good condition, all
biochemical parameters returned within normal limits
and urine output and residual renal function returned to
previous levels. Conclusion. We propose DFP as a safe,
fast and drastic method in severe cases of fibrate
induced rhabdomyolysis with acute or acute on chronic
renal failure, since DFP can remove both myoglobulin
and the protein bound fibrate and thus cease fibrate’s
toxic effects on muscle tissue, improve patient’s
symptoms
and
ensure
residual
renal
function
preservation.
Bacgkround. Iron deficiency constitutes a significant
cause of anemia in hemodialysis patients and is
evaluated by the use of hematological and biochemical
indices. The study was aimed to estimate the diagnostic
value of conventional iron indices, ferritin and transferrin
saturation (Tsat), in comparison to alternative indices:
percentage of hypochromic erythrocytes (Hypo%),
erythrocyte hemoglobin content (CHr) and concentration
(CHCMr), concentration of soluble transferrin receptor
(sTfR) in serum and sTfr index (sRfR/log(ferritin)).
Methods. 98 stable-state hemodialyis patients (52
men) were included in this study. All patients were on
stable rHuEPO maintenance dose and had no
transfusions or per os / parenteral iron administration
for at least 2 months. Their mean age was 65 years and
the mean duration of hemodialysis was 62 months.
Detailed medical history and routine analysis, along with
all the above iron indices (ferritin, Tsat, HYPO%, CHr,
CHCMr, sTfR and sTfR/log(ferritin)) were reported at
baseline. Each patient received 1000mg iron sucrose
intravenously, distributed among 10 consecutive dialysis
treatments. A response to intravenous iron was defined
as an increase in hemoglobin value equal or greater
than 10% from baseline values, detected at least in two
recordings, during two months following the end of iron
loading. Results. Twenty nine patients responded to
iron loading and were considered iron deficient. Receiver
operating characteristic (ROC) curve analysis showed
that the test with the largest area under the curve
(AUC)
was
CHCMr,
followed
by
the
ratio
sTfR/log(ferritin), sTfR, HYPO%, ferritin, CHr, Tsat.
These tests had a predictive value to detect iron
deficiency, and this was the case also with values of CHr
increase at the end of the first week. However, although
the AUC in the ROC analysis was significantly different
from 0.5, the combined sensitivity and specificity of
these markers to diagnose iron depletion was <80% at
any cutoff value. Conclusion. The tests CHCMr, CHr,
sTfR, sTfR/log(ferritin), HYPO% were superior to
conventional iron indices ferritin and/or Tsat, in the
assessment of iron deficient hemodialysis patients.
However, no index at any cutoff value provided
combined sensitivity and specificity >80%.
56
PP 067
PP 068
TRENDS IN HIGH BLOOD PRESSURE AMONG
ADOLESCENTS
MEMBRANE EXPRESSION OF TOLL-LIKE (TLR)
RECEPTORS AND INTACELLULAR CYTOKINE
SYNTESIS IN PATIENTS WITH CHRONIC KIDNEY
DISEASE AND DIABETIC NEPHROPATHY
1
D. Athanasopoulos, 2 E. Chelioti, 1 E. Garopoulou,
M. Sotiraki, 2 T. Fragou, 2 A. Georgiou, 2 M. Tsilivigou,
2
G. Papadakis
1
“Vouvaleio” General Hospital of Kalymnos, Kalymnos,
Greece
2
Department of Nephrology and Renal Unit, “Tzaneio”
General Hospital of Piraeus, Athens, Greece
2
1
X. Zikou, 2 K. Rousouli, 2 C. Tellis, 2 A. Tselepis,
K.C. Siamopoulos
1
Ioannina, Greece
2
Laboratory of Biochemistry, Department of Chemistry,
University of Ioannina, Greece
1
Background. High blood pressure(HBP) is an
established risk factors for cardiovascular disease and
premature mortality. Of particular note, some studies
show that increased blood pressure levels during
childhood strongly predict hypertension in young
adulthood. All the above support that both screening of
adolescents for HBP and recognition of risk factors could
give us the opportunity for early prevention and
intervention in order to reduce the long term
complications of hypertension. There are few published
studies detailing temporal trends in blood pressure(BP)
in Greece and consequently there are not standardized
BP data for Greek children and adolescents.
Underdiagnosis of HBP is of greater concern in rural
setting because the access to physician may be difficult.
Primary objective of the study is to estimate the
prevalence of HBP in adolescents from a remote Greek
island and to reveal which factors are associated with
increased blood pressure. Methods. It was carried out a
cross sectional study. Eligible subjects for this study
were adolescents aged between 13 to 15 years from a
high school of the island of Kalymnos, a remote Greek
island. Somatometrics and BP were measured at the
school environment. A questionnaire was administered
divided in three sections. First section concerned with
adolescents' habits, the second with parental habits and
somatometrics and the last section was a brief dietary
history. HBP was defined according to simplified
abnormal blood pressure screening table based on the
fourth report of National High Blood Pressure Education
Program Working Group on High Blood Pressure in
Children and Adolescents. Nutritional status was defined
according to International Obesity Task Force. Statistical
analysis was performed using univariable and
multivariable logistic regression analysis. Results.
Participants were 215 adolescents(106 boys and 109
girls). 60 subjects were classified as adolescents with
HBP(27.9%). In the univariable analysis of the increased
blood pressure with the studied factors statistically
significant factors associated positively with increased
blood pressure were the male gender, the overweight
and the maternal obesity. In multivariable analysis as
independent factors associated with increased blood
pressure remained the male gender, the overweight and
the maternal obesity(p<0.001, p<0.01 and p=0.01).
Conclusion. A great number of adolescents had
increased blood pressure. As independents factors for
this were the male gender, the overweight and the
maternal obesity. Confirmation of the trends observed in
the current study is needed. Additionally, factors that
have resulted in HBP among children and adolescents in
Greek need to be identified.
Background. Inflammation plays an important role in
the pathogenesis of chronic kidney disease (CKD). Tolllike receptors (TLRs) are a family of pattern recognition
receptors that participate in the regulation of immune
function and inflammatory responses of certain
pathological conditions. We previously showed that CKD
patients and especially patients with diabetic type 2
nephropathy have increased expression of TLR2 and
TLR4 in peripheral blood monocytes. In the present
study we investigated the membrane expression of TLR2
and TLR4 on monocytes as well as the intracellular
cytokine synthesis in CKD nondiabetic and diabetic
patients. Methods. In this pilot, cross-sectional study,
56 CKD patients of stages 1-5 were included with a
mean eGFR – MDRD of 36.7±22 ml/min/1.73 m2.
Patients were divided in two groups, pending on having
or not diabetic nephropathy. Group 1, included 37 CKD
patients, (25 men, 12 women, mean age 66.4±12.5
years) not having diabetes mellitus. Group 2 included 19
CKD patients (14 men, 5 women, mean age 69.3±9.0
years) with diabetic nephropathy. Both groups were
compared with 21 age matched controls, (control
group). Patients receiving statins, or having cancer or
autoimmune disease or have been hospitalized recently
for infectious diseases, were excluded from the study.
Membrane expression of TLR2 and TLR4 was determined
by staining with anti-CD282PE and anti-CD284PE
antibody respectively, and analysis of mean fluorescence
intensity (MFI) was performed by flow cytometry. In
addition, we studied the intracellular cytokine (IL-6 and
IL-1b) synthesis in 10 patients of each group, before
and after stimulation with lipopolysaccharide (LPS),
labeled with anti-CD14 antibody. Results. Patients of
group 1 exhibited increased membrane expression only
of TLR2 in monocytes compared with the control group
(MFI: 136±36 versus 116±21, p<0.02). Patients of
group 2 presented increased membrane expression of
both TLR2 and TLR4 compared with the control group
(MFI: 148±40 and 61±28 versus 116±21 and 39±10,
p<0.003 and p<0.001, respectively) and increased
expression of TLR4 compared with group 1 (MFI: 61±28
versus 46±19, p<0.02). Both the stimulated and
unstimulated intracellular monocyte cytokine levels were
reduced in the studied groups compared to control and
there were no statistically significant differences
between the two CKD groups. Conclusion. CKD patients
and patients with diabetic nephropathy are characterized
by increased expression of TLRs, on monocytes, that
may contribute to their increased inflammatory state.
The reduced levels of cytokines in both groups indicate
impaired signal transduction, possibly due to CKD.
57
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PP 070
IMPACT OF RISK FACTORS ON ARTERIAL
STIFFNESS IN NON DIALYSIS CKD PATIENTS.
RESULTS OF 12 MONTHS FOLLOW UP
ASSOCIATED OF X-LINKED ICHTHYOSIS,
KALLMANN SYNDROME AND NEPHROTIC
SYNDROME
D. Karasavvidou, R. Kalaitzidis, G. Spanos, K. Pappas,
E. Pappas, S. Kountouris, A. Tatsioni, K.C. Siamopoulos
Department of Nephrology, Unviersity Hospital of
Ioannina, Greece
1
M. Barbullushi, 1 A. Idrizi, 1 E. Likaj, 2 A. Laku,
M. Kasa, 1 X. Xhaferri, 1 M. Rroji, 1 S. Seferi,
1
N. Spahia, 1 N. Thereska
1
Sercive of Nephrology, University Hospital Center
2
Service of Biomolecular Genetic, University Hospital
Center “Mother Teresa”, Tirana, Albania
1
Background. Aortic pulse wave velocity (PWV) is a
predictor of mortality in patients with chronic kidney
disease (CKD). However, the precise risk factors for
arterial stiffening remain unclear and studies related to
changes in PWV in response to antihypertensive
treatment are limited. The aim of the present study was
to assess the correlation of changes in PWV with
traditional parameters of cardiovascular risk factors, as
well as, the changes in PWV in response to
antihypertensive treatment for a period of 12 months in
49 non-dialysis dependent CKD patients. Methods.
Arterial stiffness was evaluated by PWV measurement
between carotid femoral arteries in baseline and at the
end of the study. Demographic characteristics, blood
pressure levels, drug administration and other clinical
and laboratory parameters before, during follow up and
the end of the study, were also recorded. Results.
Patients' mean age was 64±13 years and there were 34
(45.2%) men. There were no statistical significant
differences between mean peripheral systolic/diastolic
blood pressure levels (147.5±20.1/78±11, 138.5±20,
77.12±10.24 mmHg) at the onset and the end of the
study. Regarding the use of antihypertensive drugs:
39.7% of the patients were receiving ACE inhibitors,
17.8% ARBs, 41.1% CCBs, 57.6% b-blockers, 6.8%
central blockers and 21.6% were in diuretics. The vast
majority of the patients were in combination of
antihypertensive agents. Nineteen (38.78%) patients
developed an increase of mean PWV (3.31±2.72), 18
showed a decrease of mean PWV (3.33±3.37) and in 7
patients PWV remained stable. Patients with diabetes
(n=15) compared to non-diabetics (n=23) revealed an
increase of PWV (10.79±3.64 vs. 8.24±2.45, p=0.001).
These statistically significant different values were also
evident at the beginning of the study. Factors with a
negative impact on arterial stiffness at latest follow-up
was: increased body mass index (BMI >29 kg/m²,
p<0.005), history of cardiovascular disease (NYHA >2,
p<0.05), male sex, (p<0.05), smoking (p<0.05),
increased serum fibrinogen (>350 mg /dl, p<0.05), and
severe CKD (eGFR-MDRD <15 ml/min, p<0.05).
Administration of rennin-angiotensin-aldosterone system
(RAAS) blockers either alone or in combination (with
CCBs or diuretics) compared to patients not receiving
these drugs, had a positive impact and resulted in a
decrease of PWV (8.4±3.15 vs. 10.01±3.10, p<0.005).
Conclusion. The evolution of arterial stiffness in CKD
patients depends on various modifiable and nonmodifiable factors. Antihypertensive treatment with
RAAS blockers alone or in combination with other agents
improves arterial stiffness.
Background. X linked ichthyosis (XLI) is a relatively
common disease, affecting approximately 1 in 6000
males worldwide, with no geographic or racial variations,
that affects 1 in 2000 to 1 in 6000 males (1). The
frequency of XLI was estimated to be approximately
1.98 cases per 10.000 males, which is similar to
estimates from other European surveys. Males are
affected overwhelmingly; however, a few female
heterozygotes have been reported (2). XLI occurs at
birth or in early infancy. The major symptoms of X
linked ichthyosis include scaling of the skin, particularly
on the neck, trunk, and lower extremities. The extensor
surfaces are typically the most severely affected areas.
X linked ichthyosis may be associated with other
contiguous gene syndromes such as Kallmann
syndrome,
showing
gonadal
dysfunctions.
The
association of X linked ichthyosis with nephrotic
syndrome is prescribed till now only in pediatric age,
while their association together with Kallmann syndrome
in adults we haven’t seen previously reported in the
English-language literature. Case report. We report an
adult patient with nephrotic syndrome, XLI and Kallman
syndrome. His brother and maternal uncle showed the
clinical picture of congenital ichthyosis, hypogonadism,
hyposmia. Investigations revealed proteinuria 5 g/day,
serum albumin 2 g/l, cholesterol 360 mg/dl, triglycerides
300 mg/dl. Kidney function tests were normal. Blood
pressure was 150/90 mmHg. Hepatitis B surface antigen
(HbsAg), anti-HCV antibodies and antinuclear antibody
were negative. On physical examination, the patient had
dry, thickened and scaly skin. The lesions that consisted
in large polygonal dark brown scales were symmetrical
and affected anterior and posterior surfaces of the upper
and lower extremities, scalp, and trunk. The patient had
no involvement of the flexure areas, palms, or soles. On
further clinical examination, the patient was found to
have hypogonadism and anosmia. Ultrasonography
showed both kidneys with enhanced echogenicity,
longitudinal diameter near normal and a diminishing
cortico-medullary
differentation.
Opthalmological
examination showed keratitis due to ectropion. The
kidney biopsy was performed and revealed minimal
change glomerulonephritis.The patient was diagnosed as
nephrotic syndrome with X linked ichthyosis with
Kallman syndrome and the therapy with prednisolone
per os at 1 mg/kg/day was started. Despite
immunosuppressive therapy, no clinical response was
achieved. He reached end-stage renal failure in one year
and finally underwent in hemodialysis. The association of
nephrotic syndrome with ichthyosis has been described
in only 2 cases in the literature. Conclusion. This was
the first case describing nephrotic syndrome in
association with XLI.
58
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RENAL TRANSPLANT IN AN ADULT WITH ELLIS VAN
CREVELD SYNDROME
PLASMA SEROTONIN EFFECT ON BONE TURNOVER IN
1
T. Eleftheriadis, G. Antoniadi, V. Liakopoulos,
I. Stefanidis
Nephrology, University Hospital of Larissa, Medical
School, University of Thessaly, Greece
M. Barbullushi, 1 A. Idrizi, 2 A. Laku, 1 E. Likaj,
M. Kasa, 1 N. Thereska
1
Service of Nephrology, University Hospital Center
2
Service of Biomolecular Genetic, University Hospital
1
Background. Serotonin receptors are present in
osteoblasts and osteoclasts and many experimental
studies showed that peripheral serotonin affects bone
metabolism. In the present study the effect of plasma
serotonin on bone metabolism was evaluated in
hemodialysis (HD) patients. Methods. 24 HD patients
(11 diabetics) and 22 healthy volunteers enrolled into
the study. Serotonin was assessed in platelet free
plasma, whereas the markers of osteoblastic activity NMID osteocalcin (OCN) and total procollagen type-1
amino-terminal propeptide (P1NP) as well as the marker
of osteoclastic activity beta-isomerized C-terminal crosslinked peptide of collagen type I (β-CTx) were measured
in serum. Serum intact parathyroid hormone (iPTH) was
also assessed. Results. Serotonin did not differ
significantly between HD patients and healthy
volunteers. All evaluated markers of bone metabolism
and iPTH were much higher in HD patients. Serotonin
was positively related to all evaluated markers of bone
metabolism in HD patients, and independently of iPTH.
Serotonin was negatively related to the patients’ age.
Serotonin, OCN, P1NP and β-CTx were much lower in
diabetic HD patients. Conclusion. Serotonin increases
both bone formation and bone resorption in HD patients.
The negative relation of serotonin to patients’ age as
well as its lower levels in diabetic HD patients indicate
that low plasma serotonin may contribute to the higher
incidence
of
low-turnover
bone
disease
that
characterizes old and diabetic HD patients.
Background. Ellis van Creveld (EVC) syndrome is an
autosomal
skeletal
dysplasia
characterized
by
disproportionate short stature with acromesomelic
shortness of the limbs, postaxial polydactyly, and
dysplastic nails and teeth. Cardinal features of the
syndrome are disproportionate small stature with
increasing severity from the proximal to distal portions
of the limbs, shortening of the middle and distal
phalanges, polydactyly affecting hands usual bilateral,
and occasionally, the feet and hidrotic ectodermal
dysplasia mainly affecting the nails, hair and teeth.
Congenital cardiac defects, most commonly a defect of
primary atrial septation producing a common atrium,
occur in 60% of affected individuals. The presence of
congenital heart disease may support the diagnosis of
the EVC syndrome and appears to be the main
determinant of longevity. Several inconstant additional
clinical findings are strabismus, epi- and hypospadias,
cryptorchidism, and thoracic wall and pulmonary
malformations. Renal abnormalities are found in rare
cases with agenesis, dysplasia, megaureter and
nephrocalcinosis. Case report. We report a patient who
was diagnosed with EVC syndrome at birth. On physical
examination, the short stature of the patient was
evident
with
disproportionate,
irregularly
short
extremities, genu valgum, narrow thorax, short and
wide hands, dystrophic to friable nails, cutaneous
syndactyly of second and third toes bilaterally. The
examination of the right hand and the left foot revealed
the scars because of the surgical excision of the extra
fingers before the first year of life. He also had short
upper lip bound by frenula to alveolar ridge and dental
abnormalities; partial anodontia, small teeth, enamel
hypoplasia, gingival abnormalities in the level of inferior
incisives. In cardiac auscultation a systolic cardiac
murmur was noted. Echocardiography revealed a mild
tricuspidal regurgitation. There were small cysts at the
cortico-medullary junction on kidneys’ ultrasound.
Nephronophthisis has been occasionally reported in
patients with ATD, and rarely in patients with EVC
syndrome. He developed hypertension at age 15 and
gradually progressive renal failure, requiring renal
replacement therapy in 25 years old, initially
hemodialysis and than a successful renal transplantation
from his mother. Only few cases are reported in
literature with EVC syndrome and renal failure requiring
renal transplantation in childhood age. Conclusion. So
we think that this case is the first described in the
literature with EVC syndrome survived till the adult age
who has developed renal failure and requiring a renal
transplantation. Since EVC syndrome is a multi-systemic
disorder it can be managed by a multidisciplinary team
of physicians.
59
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PP 074
PLASMA INDOLEAMINE 2,3-DIOXYGENASE
CONCENTRATION IS INCREASED IN
HEMODIALYSIS PATIENTS AND IS FURTHER
INCREASED IN HEMODIALYSIS PATIENTS WITH
CORONARY HEART DISEASE
SERUM 25-HYDROXY-VITAMIN D HAS ANTIINFLAMMATORY PROPERTIES AND MAY SUPPRESS
OSTEOCLASTIC ACTIVITY IN HD PATIENTS
I. Stefanidis
I. Stefanidis
Background. In hemodialysis (HD) patients 25hydroxy-vitamin D (25(OH)D3) conversion to the active
1,25-dihydroxy-vitamin D by the kidneys is very
limited.The expression of both vitamin D receptor (VDR)
and 1α-hydroxylase in cells of the immune system and
in both osteoblasts and osteoclasts makes possible that
25(OH)D3 could play an important role in both
inflammation and bone metabolism acting in a autocrine
and/or paracrine way in these patients. Methods. 33
HD patients not under VDR agonist treatment were
enrolled into the study. 25(OH)D3, the markers of
inflammation C-reactive protein (CRP) and interleukin-6
(IL-6), the two major proteins that control osteoclastic
activity, the receptor activator of nuclear factor-κB
ligand (RANKL) and the osteoprotegerin (OPG), as well
as intact parathyroid hormone (iPTH) were assessed in
the serum by immunoassays. Results. Regarding
inflammation, 25(OH)D3 was negatively related to both
CRP and IL-6. Regarding bone metabolism, 25(OH)D3
was positively related to OPG but negatively to RANKL.
The last could be the result of iPTH suppression by
25(OH)D3, since 25(OH)D3 was negatively related to
iPTH, which in turn was positively related to RANKL.
Conclusion. Serum 25-hydroxy-vitamin D has antiinflammatory properties and may suppress osteoclastic
activity in HD patients.
Background. Coronary heart disease (CHD) is the
leading cause of death in hemodialysis (HD) patients.
Inflammation
contributes
to
atherosclerosis
development in this population. Indoleamine 2,3dioxygenase (IDO), an enzyme with immunomodultory
properties, was evaluated in HD patients with or without
CHD. Methods. Sixty-six HD patients, 22 of them with
CHD confirmed with coronary angiography and 24
healthy volunteers enrolled into the study. Plasma IDO
was assessed by means of ELISA. Interleukine-6 (IL-6)
and C-reactive protein (CRP) were also measured in the
serum. Results. Compared to healthy volunteers, HD
patients
had
significantly
higher
plasma
IDO
concentration (medians 8.04 ng/ml vs. 48.9 ng/ml).
Serum IL-6 and CRP were also significantly increased in
HD patients. HD patients with CHD had significantly
increased IDO compared to HD patients without CHD
(medians 74.5 ng/ml vs. 38.6 ng/ml). Neither IL-6 nor
CRP differed between the last two groups. Conclusion.
IDO concentration is increased in HD patients and is
further increased in HD patients with CHD. It remains to
be elucidated if increased IDO plays a direct role in
atherosclerosis development or if it has an indirect role
by curtailing chronic inflammation or both.
60
PP 075
PP 076
ASSOCIATIONS BETWEEN SEX HORMONES AND
PREVALENT CARDIOVASCULAR DISEASE IN MALE
NEUTROPHIL GELATINASE-ASSOCIATED
LIPOCALIN (NGAL) AS A BIOMARKER OF ACUTE
KIDNEY INJURY IN PATIENTS WITH MORBID
OBESITY UNDERGOING BARIATRIC SURGERY
1
J. Kyriazis, 2 K. Stylianou, 3 I. Tzanakis,
G. Kokologiannakis, 1 E. Asmanis, 1 G. Lamprinoudis,
2
E. Daphnis
1
Department of Nephrology, General Hospital of Chios,
Chios, Greece
2
Heraklion, Crete, Greece
3
Department of Nephrology, General Hospital of Chania,
Crete, Greece
2
1
M. Koukoulaki, 2 C. Spyropoulos, 1 P. Hondrogiannis,
E. Papachristou, 1 E. Mitsi, 1 I. Savvidaki,
1
P. Kalliakmani, 2 F. Kalfarentzos, 1 D. S. Goumenos
1
Department of Internal Medicine – Nephrology,
University Hospital of Patras, Greece
2
Department of Surgery, University Hospital of Patras,
Greece
1
Background.
Acute
kidney
injury
in
patients
undergoing major surgery increases significantly
morbidity and mortality. Urinary biomarkers could
contribute to early diagnosis of acute kidney injury (AKI)
and
subsequently
effective
management.
NGAL
(neutrophil gelatinase-associated lipocalin) has been
identified as a biomarker of AKI and purpose of this
study was to evaluate NGAL as a predictive marker of
AKI in patients with clinically severe obesity (BMI: >50)
undergoing biliopancreatic diversion surgery. Methods.
We studied 23 patients (male/female: 12/11), aged 39
± 9 years old suffering from clinically severe obesity
(ΒΜΙ: 55.8 ± 3.0) who underwent biliopancreatic
bypass. NGAL was measured using chemiluminescent
microparticle immuoassay in three urine samples from
each patient collected prior to surgery (first sample), 26 hours post surgical operation (second sample) and the
first postoperative day (third sample). NGAL was
evaluated as a marker to predict AKI based on renal
function during postoperative period. Results. Renal
function evaluated using serum creatinine that was
0.91± 0.26 mg/dl prior to surgery, 0.87 ± 0.31 mg/dl
immediately post surgery and 0.92 ± 0.62 mg/dl the
fifth postoperative day. Three sequential urine NGAL
measurements were 21.8 ng/mL (range 4.2-125.1), 3.9
ng/mL (range 0-314.8) and 13.5 ng/mL (range 0.6369.1) respectively. AKI during the immediate
postoperative period was observed in two patients
(2/23), of whom one required renal replacement therapy
with hemodialysis. Urine NGAL in these patients were
34, 314.8 και 359.3 ng/mL for the first patient and 5.2,
3.9 and 369.1 ng/mL for the second patient.
Conclusion. Urine NGAL in patients with clinically
severe obesity, who are treated surgically, is a potential
biomarker of early detection of AKI. The small number
of patients who developed postoperative AKI does not
provide sufficient data to extract conclusions and further
evaluation
is
necessary
in
order
to
make
recommendations for NGAL predictive value in patients
undergoing bariatric surgery.
Background. The leading cause of death in patients
with end-stage renal disease (ESRD) is cardiovascular
disease (CVD). However, data regarding the role of sex
hormones in the pathogenesis in CVD in the
hemodialysis (HD) setting are lacking. In this crosssectional study, we examined the contribution of sex
hormones to the increased CVD risk occurring in male
HD patients. Methods. One-hundred and eleven HD
men (mean age of 65±12years) were studied. In each
patient, demographic, risk factor, and prevalent CVD
data were obtained. CVD was defined by myocardial
infarction, angina, percutaneous coronary intervention
and coronary artery bypass surgery, stroke, transient
ischemic attack, claudication, therapeutic interventions
(revascularization and amputation) and artery stenosis
>60% in imaging studies. Logistic regression analysis
(Table 1) were used to determine the factors impacting
on the accelerated rate of CVD in the HD men, including,
testosterone (Te), estradiol (E2), follicle stimulating
hormone (FSH), luteinizing hormone (LH) and prolactin
(PRL). Results. Prevalent CVD was detected in 63
(56.8%) patients. In crude analysis, among sex
hormones, Te and PRL were directly associated with
prevalent CVD. In multivariate analysis, higher levels of
E2 and LH and lower levels of Te were associated with
higher risk of CVD, irrespective of other conventional
CVD risk factors. Conclusion. These results suggest
important associations between sex hormones with both
clinical and subclinical manifestations of CVD in HD men.
Specifically, our findings confirm the population- based
positive and negative association of CVD with E2 and Te,
respectively, and indicate, for first time, that LH may be
a robust predictive index of adverse cardiovascular
outcomes in ESRD.
61
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DOES RENIN INHIBITOR ALISKIREN KEEP ITS
ANTIPROTEINURIC EFFECT ON AN EVERY OTHER
DAY ADMINISTRATION?
AMBULATORY BLOOD PRESSURE MONITORING IN
MICROALBUMINURIC NORMOTENSIVE TYPE 2
DIABETIC
G. Spanos, R. Kalaitzidis, K. Pappas, D. Karasavvidou,
E. Evangelou, K.C. Siamopoulos
Ioannina, Greece
E. Nelaj, M. Gjata, A. Gjika, M. Tase
Internal Medicine, University Hospital Center, Tirane,
Albania
Background. Albuminuria has been shown to predict
cardiovascular disease in populations with diabetes
mellitus. The aim of this study was to assess the mean
pressure values and the circadian rhythm of blood
pressure
during
its
ambulatory
monitoring
in
normotensive diabetic patients, dividing them according
to the presence of microalbuminuria. Methods. The
study group comprised of 77 type 2 diabetic patients.
Their mean age was 56.5±6.7 years, and the mean
duration of their disease was 8 years. For
microalbuminuria, spot urine samples were collected in
the early morning and microalbuminuria was defined as,
a urinary albumin excretion between 30 and 300 mg/g.
These
patients,also
underwent
determination
of
ambulatory blood pressure monitoring. Results. 19
(24.6%) patients were microalbuminuric. Ambulatory
blood pressure monitoring in the microalbuminuric
patients had higher mean pressure values, mainly the
systolic pressure, during sleep as compared with that in
the
normoalbuminuric
patients
(120.1±8.3
vs
110.8±7.1 mmHg; p=0.007). The pressure load was
higher in the microalbuminuric individuals, mainly the
systolic pressure load during wakefulness [6.3 (2.945.9) vs 1.6 (0-16%); p=0.001]. This was the variable
that better correlated with the urinary excretion of
albumin (rS=0.61; p<0.001). Systolic pressure load
>50% and diastolic pressure load > 30% during sleep
was associated with microalbuminuria (p=0.008). The
pressure drop during sleep did not differ between the
groups. Conclusion. Microalbuminuric normotensive
type 2 diabetic patients show greater mean pressure
value and pressure load during ambulatory blood
pressure monitoring, and these variables correlate with
urinary excretion of albumin.
Background. Renin inhibitor aliskiren shows kidneyprotective and antihypertensive activity similar or better
than other renin-angiotensin-aldosteron system (RAAS)
blockers. Furthermore, it has been suggested that the
drug has a long half-life (exceeding 40 hours), provides
smoothly sustained 24-h blood pressure (BP) control
and maintains a BP lowering effect following a missed
dose. In this pilot study we investigated the
renoprotective and antihypertensive effect of every
other day administration of the drug, either as
monotherapy
or
in
combination
with
other
antihypertensive agents. Methods. Seven hypertensive
patients
with
proteinuria
(5
patients)
or
microalbuminuria (2 patients), not treated with RAAS
blockers, were studied. Initially all patients received
aliskiren 150mg once daily (od) and then titrated to 300
mg od, if blood pressure (BP) was not well-controlled
(BP measurements ≥140/90 mmHg). In patients who
remained hypertensive diltiazem and nebivolol was
added according to the evidence. Those patients who
completed a 6-month treatment period program were
switched to every other day administration of aliskiren
300 mg for an additional period of 6 months without
changing the administration frequency of the other
agents. Office BP measurements were monitored every
4 weeks while 24h and 48h ambulatory BP
measurements
(ABPM),
as
well
as
laboratory
measurements were performed at baseline, month 6
and month 12, respectively. Results. All patients
completed the total treatment period. There was
statistical significant difference in office systolic BP
between baseline and month 6 and month 12 [median
144/83mmHg,
130/79mmHg
(p=0,028)
and
130/84mmHg
(p=0,042),
respectively).
The
administration of aliskiren resulted in a median
reduction of urine protein/creatinine ratio (uPCR) of
0,25mg/g (p=0.018). On the every other day protocol,
the reduction was evident but without any statistical
significant difference (median 0.19mg/g, p=0.09). The
overall 24 and 48h systolic/diastolic ABPM (month 6 and
12) has non-statistical significant difference (median
127/78 mmHg and 133/81 mmHg, respectively).
However, at the end of the 12-month period there was
better systolic BP control on the first 24 hours (the day
that aliskiren was taken), than on the second half of the
48h-ABPM (median 124/78 mmHg and 134/78 mmHg,
respectively, p=0.018). Conclusion. In terms of
reducing albuminuria, every other day administration of
aliskiren appears to be effective with a tendency to be
significant.
Furthermore,
aliskiren
provides
less
adequate blood pressure control on the every other day
administration protocol, despite the long half-life of the
drug.
62
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LEFT VENTRICULAR HYPERTROPHY AND DIABETIC
NEPHROPATHY; FACTORS THAT INFLUENCING THIS
RELATIONSHIP
PLASMA LEVELS OF D-DIMERS ARE ASSOCIATED
WITH SHORT-TERM MORTALITY IN DIALYSIS
PATIENTS
E. Nelaj, M. Gjata, A. Gjika, M. Tase
Internal Medicine, University Hospital Center, Tirane,
Albania
S. Spaia, A. Martika, A. Evangelou, S. Kellidou,
N. Askepidis
Department of Renal, Panagia Branch - General Hospital
“Ag.Pavlos”, Thessaloniki, Greece
Background. The prevalence of left ventricular
hypertrophy (LVH) is high among patients with chronic
kidney disease (CKD) and associated with a lower
cardiac functional status, particularly in patients with
diabetes mellitus (DM). The aim of the study was to
estimate prevalence of LVH and to define factors
influencing to development of LVH in patients with
diabetic nephropathy (DN). Methods. 65 patients with
type 2 DM were studied - 22 males, 43 females, mean
age 53.7 17.4. 21 patients had normal renal function
with mean hemoglobin (Hb) 13.7 2.0 g/dl, 44 patients
had chronic renal failure (CRF) with decreased mean
GFR 46.7 23.7 ml/min/1.73 m2/ and Hb 11.8 2.4 g/dl
(p<0.05). Glomerular filtration rate (GFR) was
calculated using the Cockcroft-Gault formula. Anemia
was defined as hemoglobin (Hb) < 13 g/dl in men and <
12 g/dl for women by the definition of World Health
Organization. 62 patients had arterial hypertension.
Patients on dialysis were not included. Results. LVH
(left ventricular mass index (LVMI) > 134 g/m2 for men
and > 110 g/m2 for women) was found in 50 DN
patients (77.6%). At GFR < 30 ml/min/1.73 m2 the
prevalence of LVH was 100%. Concentric hypertrophy of
left ventricular (LV) was found in 51% patients,
eccentric LV hypertrophy in 26.5% patients, 14.3%
patients had concentric remodeling of LV, 8.2% - were
with normal geometry of LV. The LVMI is significantly
associated with older age (R=0.43, p<0.01), Hb (R= 0.44, p<0.05), GFR (R= - 0.29, p<0.05). Independent
factors affecting on development of LVH in patients with
DN by multiple logistic regression analysis were Hb level
and value of systolic blood pressure (p=0.0003).
Conclusion. We conclude that prevalence of LVH was
higher in patients with type 2 diabetes, with impaired
renal function. Anemia and systolic blood pressure were
independent factors influencing on development of LVH
in patients with DN.
Background.
D-dimers
(DD)
represent
fibrin
degradation products which are released during local or
systemic activation of the coagulation mechanism. Ddimer testing is widely used for the work-up of patients
suspected of deep vein thrombosis or pulmonary
embolism. Thrombosis and inflammation are involved in
the pathogenesis of acute cardiovascular events (CVD).
In a case control study, plasma DD levels were found to
be strongly and independently correlated to the
prevalence of CVD in HD patients, while higher levels of
DD, were significantly associated with higher all-cause
short term mortality, in a prospective cohort of 377
patients with peripheral arterial disease. Methods. We
prospectively studied 73 dialysis patients, mean age
71.5±11 years and mean duration on dialysis 70± 60
months. We recorded on a bimonthly basis, vascular
access’ complications and the use of double lumen
catheter, cardiovascular events, inflammation indices,
and DD, along with routine laboratory workup. Mean
follow up was 26 months (3-36). Results. Twenty
patients (27%) died during the observation period. Mean
follow-up was 18±11 months for those who died vs
29±10 months for the survivors (p<0,001). Those who
died had higher entry levels of DD (1336±1367 vs 579±
840, p<0<0.05) and mean plasma DD levels
(1167±1044 vs 551±540ng/ml p<0.05). Number of
clinically evident inflammation episodes was similar and
oddly enough number of cardiovascular events
(including thromboses of arteriovenous access) were
higher in the survivor group (0.74±1.2 vs 0.1±0.45,
p<0.005). Plasma levels of DD at the entry as well as
mean values of DD were significantly correlated to
mortality and inflammation, and negatively with the
period of follow up. (p<0.05). At the entry, 22 patients
with central double lumen catheters for dialysis access
had significantly higher levels of DD and CRP and lower
levels of URR. Survival was better in patients with native
vascular access. Levels of CRP or any other biochemical
parameter did not correlate to mortality Conclusion.
Biomarkers such as d dimers studied in this cohort could
be useful for predicting short-term mortality where other
more easily measured traditional risk factors can not
provide such information.
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ADYNAMIC BONE DISEASE IN KOSOVAR
NON-TRAUMATIC FRACTURES OF ACETABULUM
AND ILIAC BONE DUE TO HYPOCALCEMIC
SEIZURES
Y. Elezi, B. Rugova, A. Hasani, E. Elezi, S. Elezi,
I. Rudhani, B. Zylfiu
Department of Nephrology, Internal Medicine Clinic,
Univerity of Prishtina, Kosovo
P. Makri, P. Malindretos, G. Koutroubas, G. Zagotsis,
C. Syrganis
Department of Nephrology, "Achillopoulion" General
Background. Aplastic or adynamic bone disease (ABD)
was described in the early 1980s. ABD is characterized
by low bone turnover without osteoid accumulation. ABD
is being increasingly recognized as the most common in
hemodialysis patients (HD), particularly in peritoneal
dialysis patients. ABD is associated with a very low
capacity of bone to incorporate calcium in the bone
compartment and inability to handle an extra calcium
load. The aim of the study was to interrogate the
prevalence and the clinical and laboratory characteristics
of ABD patients in Kosovo. Methods. From 700 patients
with chronic hemodialysis treatment currently treated in
Kosovo, in our study we included 118 patients (16.8%)
with ABD. Females were 40% of patents. Mean age was
58 ± 4 years. All patients were treated three times per
week for 4 hours with Ca + + concentration in dialysis
solution on 1.75 mmol/l or 1.25 mmol/l, also every
month the laboratory analysis was performed for Ca++,
alkaline phosphatasis, CRP, total proteins, albumins,
cholesterol, and triglycerides. Parathyroid hormone
(TPH) is used every 6 month. In ABD patients with
clinical symptoms plain radiography was performed for
detection of calcification in abdominal aorta and pelvic
arteries. Results. Most prevalent clinical symptoms
were strong pain in the lower extremities and in the
lumbosacrale area and pronounced itching of skin. Ca x
PO(4) product was elevated in 56% of patients,
hypercalciemia ( > 2,6 mmol/l) was present in 72% of
patents, law PTH level (< 100 pg/l) was present in all
studied patients and vascular calcifications was present
in 54% of patients. Conclusion. This is the first study
conducted in Kosovo on ABD and it demonstrates high
prevalence of this disease. The etiology of ABD is
complex involving many risk factors, therefore we
promote using additional diagnostic methods and
measures to reveal more comprehensively the extend of
ABD in Kosovo, like bone biopsy, application of dialysis
solutions with 1.25mmol/l concentration of Ca, adequate
dialysis and the use non-calcium phosphate binders.
Case report. A 57 years-old female from Asia (China)
was admitted to our hospital claiming weakness, nausea
and anorexia for the past 6 months. The patient
reported continuous use of Chinese herbs for the past
10 years. There were no other contributory findings
from the personal and family history. Her blood pressure
levels were 120/70mmHg, with a heart rate of 68bpm
and her body temperature was 36.6oC. Laboratory test
exams revealed severe hypocalcemia (corrected plasma
calcium=
4.4
mg/dl),
anemia
(Hct=13.1%,
Hb=4.5gr/dl)
and
elevated
serum
creatinine
(Cr=8.0mg/dl). Arterial blood gases showed pH: 7.37,
pCO2: 20, pO2: 111 and HCO-3: 11.6. The ultrasound
examination revealed a significantly reduced size of both
kidneys; therefore, it was considered that renal biopsy
would not confer any additional information. Oliguria
(urine output 100ml per day) and uremic symptoms led
to initiation of hemodialysis. She was also administrated
calcium carbonate per os (6 gr/24h) and intravenous
calcium gluconate (0.5mg/Kg/h/day). Four days later,
the patient experienced a generalized tonic-clonic
seizure without a traumatic fall during seizure. The
following day, started to complain of soreness in the
right hip with restriction of motion on both active and
passive movements. Both x-rays and CT-scan of the
pelvis revealed a non-displaced fracture of the anterior
column of the acetabulum and the iliac bone, with a
concomitant impaction fracture of the femoral head.
These were treated conservatively. Discussion. In the
present case, seizures appeared after 4 hemodialysis
sessions. By that time both BUN (Urea=155 – Urea after
4 sessions=88) and sodium levels (139-142) were not
drastically reduced and dialysis sessions duration was
short (1h and 30 min in average), with a reduced QB
and a small dialyzer. Thus disequilibrium syndrome is
highly unlikely. Her blood pressure levels were 120/70
mmHg and the patient had never experienced any
episode of transient hypotension during dialysis
sessions. The patient magnesium levels within normal
limits and she was not receiving any erythropoeitin
stimulating agent or any other drug that might have
been incriminated. Epileptic seizures might cause non
traumatic fractures in 0.3 % of the cases1. Conclusion.
Seizure-induced fractures due to metabolic reasons are
a
very
uncommon
phenomenon.
Furthermore,
hypocalcemic seizures are even less frequently
incriminated as the causing agent of non-traumatic
seizures. Moreover, acetabulum fracture is highly rare
and may lead to fatal pelvic hemorrhage.
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ASSESSMENT OF THE RESPONSE TO INTRAVENOUS
(IV) BOLUS OF FERRUM CARBOXYMALTOSE (FCM)
IN PATIENTS (PTS) WITH CHRONIC KIDNEY
DISEASE STAGE III/IV (CKD III/IV)
SECONDARY HYPERPARATHYROIDISM IN
CONTINUOUS RENAL REPLACEMENT THERAPY
PATIENTS AND TREATMENT WITH CINACALCET
1
1
1
1
R. Zortcheva, 1 V. Ikonomov, 1 I. Teodorova,
D. Paskalev, 2 K. Hristozov
1
Clinic of Nephrology Dialysis and Toxicology, "St.
Marina" University Hospital, Medical University of Varna,
Bulgaria
2
Clinic of endocrinology, "St. Marina" University Hospital,
Medical University of Varna, Bulgaria
1
1
A. Drakou, D. Bafas, D. Bacharaki, P. Gounari,
N. Christoforides, 1 D. Vlahakos
1
Department of Nephrology, “Attikon” University
2
Volos General Hospital, Greece
2
Background. Renal anemia is associated with increased
M&M, decreased QOL, and substantial health care costs.
Iron (Fe) deficiency is seen in up to 65% of pts with
CKD III/IV and Fe replacement with or without
erythropoiesis-stimulating agents is often used to
correct renal anemia. Even iron replacement alone can
improve clinical condition and survival in such pts. Our
goal was to examine the clinical, demographic and
labarotory markers that may predict correction of
anemia after IV bolus of 1gr FCM in Fe-deficient pts with
CKDIII/IV (Ferritin < 100 ng/ml and transferrin
saturation (TSAT) < 20%). Methods. This was a
prospective study including 30 Fe-deficient pts with
CKD- III (50%) and -IV (50%) recruited from the
Outpatient Renal Clinic at ATTIKON University Hospital
from June to Dec 2010. Pts received a bolus of 1g FCM
and followed by the same nephrologist (A.D.) for 6
weeks. Exclusion criteria included elevated CRP, collagen
diseases,
malignancies,
transfusion
or
active
hemorrhage were. Data are reported as mean +/- SEM.
P<0.05 was considered statistically significant. Results.
Response to Fe bolus was defined as increment in Hb >
1 gr/dl within 6 weeks. Pts were divided in 2 groups,
non-responders (n=14) and responders (n=16). As
shown in Table 1 responders and non-responders did not
differ significantly in baseline clinical and demographic
characteristics, such as age, gender, co-morbid
conditions and medications that may influence
erythropoiesis, such as erythropoietin injections (EPO)
and ACE inhibitors or AII receptor blockers (ACEI/ARB).
As shown in Table 2, no differences in renal function or
severity of Fe deficiency were seen at baseline between
the two groups. However, at the end of the study
responders had utilized iron to correct anemia, whereas
non-responders failed to augment erythropoiesis despite
abundance of hematinic factors, such as B12, folic acid,
ferritin and TSAT. Creatinine, eGFR and hsCRP were
similar between the two groups. Side effects and
adverse reactions were not reported both after IV bolus
of FMC or during follow up Conclusion. No prediction as
to whether patients with CKD III/IV will respond to IV
FMC administration could be made based on the usual
demographic, clinical or laboratory parameters known to
influence erythropoiesis. Research is warranted to
identify mechanisms that preclude iron utilization or
suppress bone marrow in non-responders.
Background. The secondary hyperparathyroidism leads
to increased total and cardiovascular morbidity and
mortality, disability and worsening of the quality of life
of continuous renal replacement therapy (CRRT)
patients. In recent years nephrologists have been
disposing of calcimimetics - very expensive but very
effective - a new serious step in secondary
hyperparathyroidism treatment. The aims of the study
were:1.To monitor the reduction of iPTH during
treatment with cinacalcet 2. To determine the treatment
duration necessary for reaching iPTH target levels 3.To
examine the continuance of this effect after treatment
discontinuation. Methods. CRRT patients included in the
study: 26 - 11 male and 15 female, aged 26-70 years.
Study duration-32 weeks. In all CRRT patients the levels
of calcium were in the referent range at the moment of
starting the treatment. iPTH, Са and Р levels were
monitored at weeks 2, 3, 4, 6, 10, 14, 20 and 28-32
after
starting
the
treatment.
Methods:
Parathormone(pg/ml) in serum - hemiluminiscent;
Calcium and phosphate (mlmol/L) in serum- standard
Beckman-Coulter kits. Results. We found a high levels
of iPTH in 86 of the 101 tested CRRT patients (85.15%)
and 26 of them were treated with cinacalcet. iPTH
reached the target levels during the first 32 weeks in 13
CRRT patients treated with cinacalcet. The time for
reaching the target levels of PTH probably does not
strongly depend upon its initial levels, but the shortest
time is for the patients with the lowest starting iPTH
levels. Reaching targets, iPTH remains within these
ranges without treatment for different periods of time according to our results from 2 to 30 weeks. Eight CRRT
patients showed a slow decrease of iPTH, but still did not
reach the target range. Treatment with cinacalcet had
no effect in a small group of CRRT patients. Using
ultrasonography of the parathyroid glands we diagnosed
parathyroid adenomas. Conclusion. 1. The treatment
with cinacalcet should start as soon as possible in order
to obtain better results. 2.Having in mind the duration of
the beneficial effect after treatment discontinuation,
iPTH should be tested every 4 weeks after treatment
with cinacalcet is discontinued because of reaching
targets. 3. Patients whose levels of iPTH are higher than
1000 pg/ml should undergo ultrasonography of the
parathyroid glands to exclude parathyroid adenomas
requiring surgery.
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WERNICKE'S ENCEPHALOPATHY IN
HEMODIALYSIS; A CASE OF A NON-ALCOHOLIC
DIABETIC PATIENT
SIDE EFFECTS OF SYSTEMIC CYCLOSPORINE IN
PATIENTS UNDERGOING CORNEA
TRANSPLANTATION
D. Bafas, D. Bacharaki, A. Drakou, D. Vlahakos
Department of Nephrology, “Attikon” University Hospital,
Athens, Greece
1
S. Inal, 2 A. Yozgat, 3 E. Yuksel, 3 F. Akata, 1 G. Guz
Department of Nephrology, Faculty of Medicine, Gazi
University Hospital, Ankara, Turkey
2
Department of Internal Medicine, Faculty of Medicine,
Gazi University Hospital, Ankara, Turkey
3
Department of Ophthalmology, Faculty of Medicine,
Gazi University Hospital, Ankara, Turkey
1
Background. Wernicke's encephalopathy (WE) is a
dangerous neurological disorder caused by deficiency of
vitamin B1 (thiamine). The effect has been observed in
patients under hemodialysis because of loss of the
soluble vitamin B1 during dialysis, and because of
inadequate dietary intake of these patients. Case
report. A 62-year-old male patient with diabetic
nephropathy treated with insulin and under dialysis for 6
months, former alcoholic, bearing colostomy, was
admitted to our hospital due to dysarthria, gait
disturbance and severe truncal ataxia without weakness.
After an emergency CT Brain which excluded
hemorrhagic stroke, the initial neurological assessment
was that of an ischemic stroke in the cerebellum. The
patient was given IV D5W due to his inability to obtain
food. The patient's neurological deficit declined rapidly,
he became disoriented, stimulant, presenting also
ofthalmoplegia and gaze direction nystagmus. A Brain
Magnetic Resonance Imaging (MRI) was performed and
disclosed abnormalities suggestive of WE. We therefore
interrupted the glucose and granted thiamine originally
500 mg iv, then 200 mg p.os. The thiamine supply
diminished these symptoms soon after, but he did not
become fully asymptomatic. A second MRI two weeks
after, confirmed his clinical improvement with its
findings and set the diagnosis. Conclusion. WE is a lifethreatening disease, and 'early detection, early cure' is
important
for recovering without
sequelae
.In
malnourished patients under hemodialysis presenting
with the characteristic clinical triad of the disease
(encephalopathy, ataxia, ofthalmoplegia) we should
consider WE and address promptly and aggressively
high doses of B1.
Background. Cyclosporine A (CsA) is a potent T cell
regulatory agent that has been utilized extensively in
organ transplantation. Despite the excellent graft and
patient survival seen in the modern immunosuppressive
era, CNI nephrotoxicity is stil a major problem. Our aim
was to investigate the systemic side effects of oral CsA
usage in a population with normal renal functions, with
indication of high risk cornea transplantation. Methods.
Patients undergoing cornea transplantation and using
systemic CsA alone were evaluated. Exclusion criteria
were as fallows: uncontrolled hypertension, serum
creatinine levels > 1.3 mg/dl, present uncontrolled
infections and previous treatment with CsA. A total of 30
patients were found eligible and included in the study.
Their clinical features and laboratory parameters were
recorded at the beginning and at the second visit.
Results. 9 of the patients were female and 21 were
male. Mean age of the patients was 52.1±15.5 years.
Patients were given oral CsA approximately 2-3 mg/kg
daily, in divided doses and mean dosage was calculated
as 211.7±36.4 mg. Mean plasma levels of CsA was
C0:195.7±88.2 C2: 628.3±279.8 ng/ml. Mean time
interval between the two visits was 7.6±5.3 months.
The most significant adverse effect during the study was
hypertension, which occurred in seven patients (%23.3),
about 70% of whom finally required anti-hypertensive
agents. Renal dysfunction occurred in two patients, and
CsA was discontinued in one of them, while this was
ameliorated by the reduction of the CsA dosage in the
other patient. In three patients one positive proteinuria
was detected in dipstick test. Other adverse effects
included fatigue, gingival hyperplasia, and mild
hirsutism
in
one
patient
each.
Hepatotoxicity,
neurological or hematological side efects were not seen
and all of the adverse effects were reversible through
dose reduction or discontinuation. Serum levels of lipids,
glucose and uric acid were also found significantly higher
after CsA treatment. Conclusion. One of the
impediments to the wider use of CsA as an
immunosuppressive agent is the view that CsA has a
high rate of side effects. However according to our
results, just one patient discontinued CsA because of
toxicity and most of the side effects were tolerable.
Nevertheless serious treatment limiting side effects were
mostly seen at the elderly patients (>65 years).
Therefore we are suggesting that CsA may not be a
good choice for many older patients, and that such
patients should be carefully monitored after a decision
to use CsA.
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FIBROMYALGIA AND NON DIPPER BLOOD
PRESSURE PROFILE
AN ACUTE RENAL FAILURE FROM MUSHROOMS
POISONING, CASE REPORT
1
M. Vasiu, JF.Benitez-Macias, D.Garcia-Gil, FM.BrunRomero, S.Nogue-Xarau, P.Seizer, B.Prayon, E.Grone,
K.Mussig, S.Trabulus, MR.Altiparmak, T.Ferenc,
B.Lukasiewicz, J.Ciecwierz, E.Kowalczyk,
1
Dialysis Center, Elbasan Hospital Center,Albania
2
Servicio de urgencias.Hospital Universitario Puerto
real.Cadiz.Espana
3
Medizinische Universitatsklinik Tubingen,Abteilung fur
Kardiologie und Kreislauferkrankungen
4
Department of Nephrology,Instanbul Research and
Training Hospital,Instanbul,Turkey
5
Uniwersytet Medyczny,Lodz
S. Inal, 2 E. Erkol Inal, 3 G. Tuna Ozturk, 1 K. Onec,
Y. Erten, 1 G. Guz
1
Department of Nephrology, Faculty of Medicine, Gazi
University Hospital, Ankara, Turkey
2
Department of Physical Medicine and Rehabilitation,
Nafiz Korez Sincan State Hospital, Ankara, Turkey
3
Department of Physical Medicine and Rehabilitation,
Nigde State Hospital Nigde, Turkey
1
Background. Fibromyalgia (FM) syndrome is a chronic,
debilitating disorder characterized by widespread
nonarticular musculoskeletal pain. The role of autonomic
nervous system dysfunction have been reported in
patients with FM. ‘Nondippers’ are individuals with
absence of anticipated nocturnal decrease in blood
pressure and increased incidence of target organ
damage. We aimed to investigate the frequency of non
dipper blood pressure profile among the fibromyalgia
patients, via 24-hour ambulatory blood pressure
monitoring. Methods. 75 normotensive women with
fibromyalgia that had been diagnosed at physical
medicine outpatient units of Sincan State Hospital
between May 2010 and December 2010, were evaluated
and 67 of these patients without reverse dipping and
masked hypertension were included in the study. 38 out
of 40 normotensive age-matched healthy women who
attended for a routine internal medicine outpatient visit,
were included in the control group. As the fibromyalgia
group patients with reverse dipping and masked
hypertension were excluded. Results. ‘Dippers’ were
defined as individuals whose night-time blood pressures
dropped more than 10% compared with their daytime
blood pressures. Likewise a patient whose night time
blood pressures dropped less than 10% was defined as
‘non-dipper’ and one whose night time blood pressures
were greater than the day time values was defined as
‘reverse dipper’. The number of dipper individuals
according to SBP (systolic blood pressure) and DBP
(diastolic blood pressure) measurements were 23/67
(34,3%) and 39/67 (58.2%) in the fibromyalgia group;
and 25/38 (65,8%) and 30/38 (78,9%)in the control
group, respectively. The differences between two groups
were significant for both parameters (p:0.002 and
0.031, respectively). Likewise the differences between
the mean systolic and diastolic dipping ratios (night/day
ratio) in term of mmHg were also significant (p:0.01 and
0.004, respectively). Conclusion. These data suggest
that nondipper blood pressure patern is likely more
frequent in women with fibromyalgia then in healthy
women. Currently, the pathogenesis of nondipper
hypertension remains largely unclear, but it can be
suggested that this diminished dipping ratios may be
due to an abnormal cronobiology. This abnormal
cronobiology may also contribute to sleep disturbance
and fatigue. Additionally autonomic nervous system
abnormalities
like
decreased
microcirculatory
vasoconstriction, diminished heart rate variability and
orthostatic hypotension etc. are often observed in
patients with fibromyalgia. When the adverse effects of
nondipper blood pressure profile is taken into
consideration, the importance of accurate diagnosis and
treatment of fibromyalgia and sleep disturbances due to
fibromyalgia becomes more clear.
Background. The collection and the consumption of
wild mushrooms by individuals with no mycological
knowledge and their accidental ingestion are responsible
for poisonings. In the majority of cases the symptoms
are weakness. Mortality is usually related to the
development of potentially fatal liver necrosis after
consumptions of the fungus Amanita Phalloides and
others which contain amatoxins. The treatment is based
on support measures but no specific treatment exist, but
dialysis is a good way for the removal of toxins and help
reins and liver to be regenerated where it is possible.
May be a liver transplation will be helpful. Case report.
In our case it is not known the type of mushroom which
poisoned but from the clinic features we deduct that it
must be Amanita because it is found in our climatic
conditions and it populates the zone where lived the
patient. Amanita phalloides is the most dangerous,
poisonous mushroom species in our climatic conditions.
We suspected also for Amanita Phalloide because of its
relatively prolonged latency period (8-24) from
mushroom ingestion. This was a case of mushroom
poisoning which was developed ARF but not hepatic
failure. We treated with symptomatically medication and
Hemodialysis treatment with good results. But there are
other similar cases where we have failed. Conclusion.
The people must pay attention on ingesting mushrooms
specially if they find them personally and have no
knowledge about fungus.
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THE EFFECT OF DIETARY SODIUM RESTRICTION ON
HYPERTENSION IN PERITONEAL DIALYSIS
PATIENTS
ANALYSIS OF PARAMETERS RELATED TO CARDIAC
ARRHYTMIAS IN HEMODIALYSIS PATIENTS
M. Stanojevic, M. Stosovic, Z. Dokic, S. Simic-Ogrizovic,
D. Jovanovic, N. Jovanovic, B. Stojimirovic
Clinic of Nephrology, Clinical Center of Serbia, Serbia
1
S. Inal, 1 Y. Erten, 2 G. Akbulut, 1 K. Onec,
2
N. Acar Tek, 2 N. Sanlıer
1
Department of Nephrology, Gazi University, Faculty of
Medicine, Ankara, Turkey
2
Department of Nutrition and Dietetics, Gazi University
Faculty of Health Sciences, Ankara, Turkey
Background. Cardiac arrhythmias are found in 75% of
hemodialysis patients if Holter monitoring is used. Left
ventricular hypertrophy, ischemic heart disease and
congestive heart failure together with hypotension
during dialysis and digitalis usage participate in their
genesis. Estimate prevalence of cardiac arrhythmias and
factors related to them which could participate in their
origin. Methods. This retrospective study involved 41
patients (28 men) average age 55.8(10.9) years and
dialysis vintage 125.9(54.2) months. They were
separated in two groups - patients with arrhythmias and
others. Statistical significance was tested using Chisquare and Fisher exact tests Results. Prevalence of
cardiac arrhythmias was 53.3%. Left ventricular
hypertrophy and dilatation was found in 9,1%, ischemic
heart disease in 22.7%, while cardiac arrhythmias, left
ventricular hypertrophy and ischemic heart disease
together were found in 36,4% of patients. Cardiac
arrhythmias were associated with left ventricular
hypertrophy and dilatation and ischemic heart disease in
36.4% of patients. They appeared during dialysis in
18.2% and between dialysis in 86.4% patients. They
appeared from time to time in 86.4% patients and
permanent absolute arrhythmia was found in 13.6% of
patients. All types of arrhythmias were found including
disturbance of conduction. A half of patients needed
permanent medication, 31.8% of patients used
medication from time to time and 18.2% of patients did
not use therapy. Hemoglobin level was significantly
lower in patients where cardiac arrhythmias were
associated with left ventricular hypertrophy and
dilatation and/or ischemic heart disease. Among groups
of patients divided by severity of arrhythmias statistical
significant difference were found in older patients with
systolic dysfunction and congestive heart failure.
Conclusion. In order to prevent cardiac arrhythmias it
is necessary to diagnose and cure left ventricular
hypertrophy and ischemic heart disease, avoiding
electrolyte changes, anemia and dialysis hypotension.
Medial therapy depends on the type of arrhythmia.
Background. Hypertension is common problem in
patients on peritoneal dialysis (PD) therapy which is
responsible for increased cardiovascular morbidity and
mortality. It is accepted that fluid and salt balance have
an important role in the success of PD therapy and there
is also growing evidence that PD patients are often
volume expanded and have high blood pressures (BP).
We aimed to investigate the effect of strong dietary salt
restriction on the control of BP levels and the total
sodium removal in patients on PD. Methods. 50
clinically stable patients that were undergoing PD
therapy for more than six months and who did not have
peritonitis during the last three months were included.
In the study period one patient died and one had renal
transplantation; so 48 patients were included to the final
evaluation. All patients were consulted by a renal
dietitian for dietary recommendations that included a
restricted salt (<4 g/day) intake. 31 of them completed
the monthly dietitian visits and the rest, 17 patients,
denied to be on such a strict diet. At the beginning and
at the third month of follow-up, clinical findings were
recorded, urinary sodium removal (USR) and peritoneal
sodium
removal
(PSR)
were
calculated
and
bioimpedance analysis (BIA) was performed. Results.
48 PD patients (24 female, 24 male) mean age: 47.2
years, mean duration of PD treatment: 47.4 months and
percentage of diabetics: 21% (10/48) were included in
the study. Group A consisted of 31 patients those were
closely followed with a strong dietary salt restriction and
the other 17 patients were accepted as Group B. Sex,
age, body mass index were not statistically different
among the two groups, For group B, there was not a
significant differance between the first and last visits in
term of BP levels and number of antihypertensive
medications. However in Group A, although the
reduction of TSR did not reach statistical significance,
SBP, DBP, TBW and serum sodium concentrations
decreased significantly at the end of the last visit.
Conclusion. The association between salt intake and
hypertension has been shown in PD patients. Our study
has shown that even a little reduction in daily dietary
sodium intake can cause significant reduction in BP
levels without increasing antihypertensive medications.
In order to decrease cardiovascular morbidity and
mortality associated with hypervolemia, maintenance of
reduction of salt intake should be one of the main goals
in patients with PD therapy.
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THE IMPACT OF ANEMIA PREVALENCE ON
PROGRESSION OF RENAL FUNCTION IN EARLY
STAGES OF DIABETIC NEPHROPATHY
INITIAL EXPERIENCE WITH CINACALCET IN
HEMODIALYSIS PATIENTS WITH VERY SEVERE
HYPERPARATHYROIDISM
M. Gjata, E. Nelaj, Z. Gjergji, V. Duraj, L. Collaku,
M. Tase
Department of Internal Medicine and Hypertension,
University Hospital Center “Mother Teresa”, Tirana,
Albania
S. Seferi, M. Rroji, M. Barbullushi, E. Likaj, S. Mumajesi,
N. Thereska
Department of Nephrology- Dialysis- Transplantation,
Albania
Background. It is becoming increasingly clear that
anemia occurs at a high frequency early in the course of
diabetic renal disease, even before GFR is severely
reduced. The aim of the study is to determinate the
prevalence of anemia in early stage of diabetic
nephropathy (chronic kidney disease stage II) and to
evaluate its impact in progression of renal function.
Methods. The study interested 30 patients presenting
diabetic nephropathy (stage II CKD) and 30 non diabetic
renal patients in the same stage of CDK. The follow up
period was 6 months. All the patients were evaluated for
renal function, HbA1C hemoglobin level, lipid profile and
microalbuminuria at the study begin and after 6 months.
Results. 38% of the patients presented anemia at the
study begin. The presence of anemia was higher in the
first group, 26%, compared with the second group,
12%. The decline in GRF was higher in the first group 5,
1 ml/min/6 months compared with the second group 3,
5 ml/min/6 months. (p < 0, 05). Conclusions. The
prevalence of anemia was higher in diabetic renal
patients compared with non diabetic renal patients in
the same stage of chronic kidney disease. Anemia has
negative impacts on the progression of chronic renal
failure in diabetic renal patients.
Background. Excessive serum level of parathyroid
hormone have been reported to increase the mortality
risk in patients undergoing hemodialysis. We report our
initial experience with cinacalcet a relatively new drug
that reduces intact parathyroid hormone (iPTH). The aim
of the study was to evaluate efficacy of cinacalcet on a
small group of hemodialysis patients with persistent
very high serum level of iPTH, refractory of previous
treatment with vitamin D and phosphate binders.
Methods. Eight hemodialysis patients with uncontrolled
secondary
hyperparathyroidism,
despite
standard
therapy with calcium, phosphate binders, and active
vitamin D sterols, were treated in this 16-week study
with single daily oral doses of cinacalcet up to 60 mg.
We were not able to titrate the dose upper this level
because of limited resources (cinacalcet is not
reimbursed in our country). Results. Six patients were
male, time on dialysis treatment was 81 ± 33 months,
mean age 41 ± 11 years old. The iPTH at baseline was
1868 ± 429 pg/ml. Addition of cinacalcet was associated
with an overall 59 % reduction in mean iPTH (769 ± 481
pg/ml). In four patients who had baseline iPTH < 1500
pg/ml the level fell at the range recommended by
KDIGO (< 500 pg/ml). Only one patient ( iPTH at
baseline 2350 pg/ml, and 118 months on dialysis
treatment) failed to have an adequate response to
cinacalcet
therapy,
probably
by
tertiary
hyperparathyroidism or insufficient dose of cinacalcet. In
three other patients serum level of iPTH was reduced
more than 50% of the baseline level avoiding the
indication for parathyroidectomy. There was a tendency
without a significant difference toward lower serum PO4
(6.4 ± 0.7 to 6.2 ± 0.5 mg/dl, p=0.11 ), serum calcium
(9.9 ± 0.5 to 9.5± 0.9mg/dl, p=0.62) and CaxPO4
product (63.3 ± 1.3 to 58.8 ± 1.8 mg2/dl2, p=0.57). 2
patients experienced gastrointestinal symptoms at the
start of therapy without requiring discontinuation of
cinacalcet. Conclusion. Although at limited doses,
addition of cinacalcet to standard therapy improved
medical treatment of very severe hyperparathyroidism
in hemodialysis patients, achievement of KDIGO targets
for iPTH, and reduced indication for parathyroidectomy.
69
PP 093
PP 094
MICROALBUMINURIA AND GLOMERULAR
FILTRATION CORRELATION IN HYPERTENSIVE
PATIENTS
THE ROLE OF ANEMIA ON PROGRESSION OF RENAL
FUNCTION IN EARLY STAGES OF DIABETIC
NEPHROPATHY
M. Gjata, V. Duraj, Z. Gjergji, E. Sadiku, E. Nelaj,
M. Tase
Albania
M. Gjata, E. Nelaj, V. Duraj, E. Sadiku, L. Collaku,
M. Tase
Albania
Background. Changes in renal function related to
essential hypertension are associated with an elevated
cardiovascular morbidity and mortality. Indices of
altered renal function (e.g., microalbuminuria, increased
serum creatinine concentrations, decrease in estimated
creatinine clearance or GFR, and overt proteinuria) are
independent predictors of cardiovascular morbidity and
mortality. The present study was aimed to investigate
correlation between mikroalbuminuria and estimated
glomerular filtration rate (moderate decrease <60, mild
decreased 60–90 and normal>90 ml/min) in patients
with essential hypertension. Methods. The study
interested
65
hypertensive
patients,
under
antihypertensive treatment. The mean age of patients
was 59, 5years. The patients were divided in three
groups according to the renal function, namely 20 with
normal function, 22 presented stage II of CDK and 23 in
stage III of CDK. Microalbuminuria (MA) was defined as
abnormal urinary excretion of albumin between 30 and
300 mg/d. Results. In a multiple logistic regression
analysis MA was significantly associated with a decrease
of renal function, older age, male gender, and systolic
blood pressure and left ventricular hypertrophy. The
patients with normal renal function presented lower MA
and not significant correlation between MA and age,
systolic blood pressure, left ventricular hypertrophy.
Conclusion. Microalbuminuria correlated with the
decrease of renal function, older age, male gender,
blood systolic pressure and left ventricular hypertrophy
in patients presenting essential hypertension.
Background. It is becoming increasingly clear that
anemia occurs at a high frequency early in the course of
diabetic renal disease, even before GFR is severely
reduced. The aim of the study is to determinate the
prevalence of anemia in early stage of diabetic
nephropathy (chronic kidney disease stage II) and to
evaluate its impact in progression of renal function.
Methods. The study interested 30 patients presenting
diabetic nephropathy (stage II CKD) and 30 non diabetic
renal patients in the same stage of CDK. The follow up
period was 6 months. All the patients were evaluated for
renal function, HbA1C hemoglobin level, lipid profile and
microalbuminuria at the study begin and after 6 months.
Results. 38% of the patients presented anemia at the
study begin. The presence of anemia was higher in the
first group, 26%, compared with the second group,
12%. The decline in GRF was higher in the first group 5,
1 ml/min/6 months compared with the second group 3,
5 ml/min/6 months. (p < 0, 05). Conclusion. The
prevalence of anemia was higher in diabetic renal
patients compared with non diabetic renal patients in
the same stage of chronic kidney disease. Anemia has
negative impacts on the progression of chronic renal
failure in diabetic renal patients.
70
PP 095
PP 096
LEFT VENTRICULAR HYPERTROPHY AND
PLASMATIC URIC ACID CORRELATIONS IN
CHRONIC KIDNEY DISEASE PATIENTS PRESENTING
HYPERTENSION
PREVALENCE OF KIDNEY DISEASE IN RHEUMATOID
ARTHRITIS
1
V. Duraj, 2 M. Gjata, 1 A. Zotaj, 2 L. Collaku, 1 A. Tafaj
Department of Rheumatology, University Hospital
2
Albania
1
M. Gjata, Z. Gjergji, V. Duraj, E. Nelaj, J. Klosi, M. Tase
Albania
Background. Several studies on the general population
have suggested an association between uric acid level
and cardiovascular outcomes. Other studies also have
shown an association of uric acid level with established
cardiovascular risk factors as hypertension and diabetes.
Hyperuricemia is highly prevalent in patients with
chronic kidney disease (CKD). The evaluation of
correlation between serum uric acid level and left
ventricular hypertrophy in patients with essential
hypertension and chronic kidney disease. Methods. 57
patients with stage III of essential hypertension and
chronic kidney disease were studied. All patients were
examined for serum uric acid concentration. Patients
were divided in 2 groups based on the presence of
hyperuricemia, defined as serum uric acid level greater
than 9 mg/dL or lower than 8 mg/dL. Left ventricular
abnormalities have been determined by bidimensional
echocardiography. The left ventricular mass index
(LVMI) has been evaluated according to the method of
Devereux and Reichek Results. A positive correlation
was observed between uric acid level (UA) and LVMI. (r
= 0.412, p < 0, 05). The study evidenced that patients,
which presented uric acid levels > 9 mg /dl show
significant differences in left ventricular hypertrophy
degree and systolic left ventricular functions compared
with patients which presented uric acid levels < 8 mg/dl
Conclusion. The results show that elevated UA serum
levels are associated with left ventricular hypertrophy
and worsening of systolic left ventricular function in
patients presenting chronic hypertensive disease and
CKD.
Background. Previous reports have indicated that the
incidence of renal disease in patients with rheumatoid
arthritis (RA) is considerable. Renal involvement in RA is
clinically meaningful because it worsens the course of
primary disease and increases mortality. The aim of the
study to investigate the prevalence of kidney disease in
patients with rheumatoid arthritis Methods. In the
study were involved 100 patients, which was diagnosed
with rheumatoid arthritis, the age of patients varied
from 45-70 years old (65 women and 35men ).At the
moment of the presentation, the patients were
subjected to all laboratory examinations Result. Serum
creatinina was normal in 75% of the 100 patients and
25 % was renal kidney disease (stage II 60%, stage III
25%, stage IV 15% and stage V 0 %.) Proteinuria in
35% and hematuria were observed in 20% of them.
Leucocyturia in 18% of the patients.Combined
proteinuria and haematuria was observed in 15 of the
patients. Anemia was presented in 84% of the patients
Conclusion. We found that kidney disease was highly
prevalent in our RA patients. Serum creatinina is not
sufficient to estimate renal function in patients with
rheumatoid arthritis. In patients with kidney disease at
high risk for drug toxicity, dosage should be adapted to
renal function.
71
PP 097
PP 098
MAGNESIUM INTRADIALYTIC KINETICS IN
PATIENTS RECEIVING CALCIUM-MAGNESIUMCONTAINING PHOSPHATE BINDERS
ENCAPSULATING PERITONEAL SCLEROSIS WITH
EARLY DIAGNOSIS AND FAVORABLE OUTCOME IN
EXCLUSIVE HEMODIALYSIS TREATMENT
1
1
M. Sonikian, 1 D. Lazarou, 2 I. Skarakis, 3 T. Daskalou,
C. Chiotis, 1 D. Vlassopoulos
1
2
Chemistry, Kapodistriakon University of Athens, Athens,
Greece
3
Department of Biochemistry, “Amalia Fleming” General
M. Sonikian, 1 I. Pani, 1 D. Lazarou, 2 L. Khaldi,
A. Dounavis, 4 S. Lafoyanni, 1 D. Vlassopoulos
1
2
Department of Pathology, “Amalia Fleming” General
3
Department of Surgery, “Amalia Fleming” General
4
Department of Radiology, “Amalia Fleming” General
3
3
Background. A combination of calcium acetate and
magnesium carbonate, containing 110 and 60 milligrams
of elemental calcium and magnesium respectively, is
used as a new, cost effective phosphate binder
(Osvaren®) in hemodialysis patients. Methods. In
order to estimate hypermagnesaemia risk, magnesium
kinetics was investigated during dialysis session. Ten
patients were studied, aged 61(38-80) years, on
standard HD with low flux polysulfone membranes,
dialyzed thrice weekly since 88(14-257 months), with a
dialysate Mg concentration of 1mEq/l(1,25mg/dl). Group
A (GrA) included 5 patients receiving Osvaren® since 3
months, in doses of 440(330-660)mg of elemental
calcium and 240(180-360)mg of elemental magnesium.
Group B (GrB) included 5 patients treated with calciumaluminum-magnesium-free binders. Blood samples were
collected from “arterial lines” of the extracorporeal
circuit as well as sixty milliliters of dialysis fluid (D) at
the effluent dialyser port at baseline, at the end and
every hour of the sessions. Paired ‘‘arterial’’ and
“venous” blood samples were drawn simultaneously at
two hours. Results. There was no difference between
groups in Kt/V and predialysis serum (S) phosphate(P),
corrected for albumin calcium(cCa), sodium(Na),
potassium(K), total protein(Prot), albumin(Alb). Predialysis(T0), two hour-(T2) and post-dialysis(T4) SMg
were higher in GrA compared with GrB (2,3±0,3 vs
1,8±0,4mg/dl-p=0,02, 2,03±0,09 vs 1,6±0,4mg/dlp=0,01, 2,19±0,3mg/dl vs 1,8±0,08mg/dl respectively).
There was a marginal T2-SMg decrease only in GrA
(2,3±0,3 to 2,03±0,9mg/dl-p=0,05). No significant
change in T2-SMg was observed at the dialyser outflow
site or in T4-SMg in either group. ScCa increased
significantly only at the end of session in both groups
(8,9±0,75 to 10,5±0,3-p=0,03 and 8,6±1 to 10,6±1,2
mg/dl-p=0,03 respectively). Intradialytic DMg did not
show any significant changes in either group but in GrA
the T2-DMg was marginally higher than that in GrB
(1,4±0,2 vs 1,2±0,2mg/dl-p=0,05). No difference was
observed between groups in values of Mg extraction
coefficient (GrA:0,7±0,08, GrB:0,8±0,2-p=NS) and Mg
transmembrane
clearance
(GrA:424,8±52,2ml/min,
GrB:476,6±136,1ml/min-P=NS).
Intradialytic
Mg
balance was negative in both groups and especially in
GrA
(-381,4±197,5
vs
-88,2±221,8mg-P=0,05).
Significant correlations of Mg loss in D were found with
HD session duration (R=0,92), SMg (R=0,79) and SP
(R=0,74). In conclusion, compared with patients treated
with
calcium-aluminum-magnesium-free
binders,
patients under Osvaren® had higher SMg during the
entire HD session, a marginal T2-SMg decrease, a
marginal T2-DMg increase and a greater negative
intradialytic Mg balance. Conclusion. Our findings
indicate that treatment with Osvaren® is safe under
conventional dialysate Mg concentrations, with no risk of
Mg positive intradialytic balance.
Background. Encapsulated peritoneal sclerosis is a rare
condition of a poorly understood pathogenesis, with
recognized risk factors involved, such as medications,
surgical
interventions,
systematic
diseases
and
malignancies. In end-stage kidney disease it has been
associated
with
chronic
peritoneal
dialysis.
In
hemodialysis patients never treated by peritoneal
dialysis two cases of encapsulated peritoneal sclerosis
have been reported with a long-standing ascites of
“nephrogenic” and cirrhotic origin respectively and bowel
obstructive signs. Case report. We studied the case of
a 59-year-old male patient treated exclusively by
hemodialysis, who developed a massive ascites 4
months after a laborious laparoscopic cholecystectomy
with bile and blood spillage into the peritoneum and use
of oxidized regenerated cellulose for hemostasis.
Laparoscopic exploration and histology supported the
early diagnosis of the first case of “pre-encapsulated
peritoneal sclerosis” with parietal peritoneum and spleen
involvement. The patient was successfully treated for 12
months with prednisone and tamoxifen. Oxidized
regenerated cellulose is a biomaterial that prevents
intra-abdominal adhesion formation but it may result in
de novo adhesions via increasing in vitro the expression
of transforming growth factor-beta1 in mesothelial cells
and type I collagen in mesothelial cells and normal
peritoneal fibroblasts. Therefore, oxidized regenerated
cellulose
use
combined
with
intraoperative
complications, the 10-year cholelithiasis and cholecysitis
and the low-grade chronic inflammation existing in HD
patients, could lead to a peritoneal irritation resulting to
fibrous
membrane
formation.
Conclusion.
In
conclusion, clinical suspicion, laparoscopy and histology
lead to an early diagnosis of the disease prior to
evolution to the severe and possibly fatal stage of
encapsulated peritoneal sclerosis, and to a favorable
outcome under prednisone and tamoxifen. Oxidized
regenerated cellulose could be included among possible
pathogenetic factors of peritoneal sclerosis.
72
PP 099
PP 100
LONG TERM OUTCOMES OF PATIENTS WITH
IDIOPATHIC MEMBRANOUS GLOMERULOPATHY
AFTER B CELL DEPLETION
HEMOGLOBIN VARIABILITY IN HEMODIALYSIS
PATIENTS COMPARING FOUR DIFFERENT
ERYTHROPOIETIN STIMULATING AGENTS
(ERYTHROPOEITIN-A, ERYTHROPOEITIN-B,
DARBEPOETIN AND CERA)
1
S. Lionaki, 1 S. Marinaki, 2 L. Nakopoulou, 1 C. Skalioti,
A. Iniotaki, 2 P. Sfikakis, 4 K. C. Siamopoulos,
1
J. Boletis
1
Nephrology & Transplantation center, “Laiko” Hospital,
Athens, Greece
2
Department of Internal Medicine, University of Athens,
Athens, Greece
3
Histocompatibility Center, “Gennimatas” Hospital,
Athens, Greece
4
Department of Nephrology, University of Ioannina,
Greece
3
S. Ziakka, D. Poulikakos, A. Koutsovasili,
A. Zagorianakos, A. Sgantzos, V. Kolovos, D. Nastou,
G. Ntatsis, N. Kaperonis, N. Papagalanis
Hellenic Red Cross Hospital "Korgialenio-Benakio",
Greece
Background. Hemoglobin variability of hemoglobin
(Hb) is associated with increased mortality and
morbidity in hemodialysis patients. The aim of this study
was to estimate the efficacy and variability of
hemoglobin (estimated as mean value of SD) by
comparing four different erythropoietin factors in
hemodialysis patients. Methods. Thirty hemodialysis
patients (9F, 21M) aged 58±23,5 (34-83) years,
received four different erythropoietin stimulating agents
(ESA). The period of exposure in each ESA was three
months and EPO-a, EPO-b, Darbepoetin and CERA were
used in random sequence. The Hb levels were measured
every week and the Hb target-levels were predefined at
11-12,5 gr/dl. The necessary erythropoietin dose
adjustments were done with 25% increase or decrease
from the last dose and the waiting time before the next
change was 3 weeks for EPO-a and EPO-b and 4 weeks
for Darbepoetin and CERA. In all patients ferritin levels
were >150 ng/ml (256,27±129,13ng/ml) during the
study and patients who suffered from infection,
neoplasia, uncontrolled secondary hyperparathyroidism
(mean value PTH of patients: 166,9±122,02pg/ml),
bleeding or other causes of anemia and access problems
were excluded. Results. In all patients, the level and
variability of Hb were similar in all ESA’s (mean value
and SD of Hb in EPO-a: 11,44±0,648gr/dl, EPO-b: 11,38
± 0,548 gr/dl, Darbepoetin: 11,59±0,668 gr/dl and
CERA: 11,52±0,657 gr/dl, p>0,05) without statistical
significance. The frequency of variability of Hb was
different for every patient. The frequency of changes of
erythropoietin dose was different for every patient and
ESA in according with its pharmacokinetics. Conclusion.
The results of this study indicate that all ESAs are
effective and cause the same answer in the level and
variability of Hb. The frequency of Hb variability depends
on the patient per se and the frequency of changes of
erythropoietin-dose correlated with the kind of ESA and
its pharmacokinetics.
Background. To evaluate the therapeutic benefit of
temporary depletion of B lymphocytes in patients with
idiopathic Membranous Glomerulopathy (MGN) in long
term, and search for predictors of response. Methods.
We included patients with biopsy proven MGN in the
absence of secondary causes. Estimated glomerular
filtration rate should be above 30 ml/min/1.73m2, and
24-hour proteinuria 3g/day or more. Patients who had
been treated with cyclosporine or cytotoxic agents
during the previous year were excluded. Rituximab was
administered intravenously, once weekly, for 4
consecutive weeks. Partial remission was defined as a
>50% decrease in proteinuria with absolute proteinuria
<3g/d, while complete remission was defined as a
>50% decrease in proteinuria and an absolute protein
excretion< 0.3 g/day. Results. Twelve patients were
entered, (4 females/8 males) with a mean age of 51.3
years. No major adverse effects were observed. During
a median follow up time of 48 months, 11/12 (91.6%)
patients achieved remission [7/12, 58.3% complete
remission and 4/12 (33.3%) partial remission], while 1
patient didn’t not respond to therapy. Twelve months
post therapy 68.8% (p=0.003) of cases had achieved
partial and 28.4% complete remission. Measurements of
lymphocytes’ subpopulations were not significantly
altered beyond B cell depletion. B cell infiltrates
captured per mm3 of renal tissue in the diagnostic
biopsy did not correlate with subsequent response.
Conclusion. Depletion of B cells in idiopathic MGN was
well tolerated and resulted in significant and long lasting
response rates in a small series of 12 patients.
73
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PP 102
THE RELATIONSHIP BETWEEN EPICARDIAL
ADIPOSE TISSUE AND MIAC SYNDROME IN ESRD
PATIENTS
THE OUTCOME OF PATIENTS OF DIALYSIS CENTER
IN ELBASAN, ALBANIA
M. Vasiu
Dialysis Center, Elbasan Hospital Center, Albania
1
K. Turkmen, 2 H. Kayikcioglu, 3 O. Ozbek, 1 Y. Solak,
4
M. Kayrak, 3 C. Samur, 1 M. Anil, 1 H. Zeki Tonbul
1
2
Department of Internal Medicine, Meram School of
Medicine, Selcuk University, Konya, Turkey
3
4
Department of Cardiology, Meram School of Medicine,
Background. Chronic renal disease is the progressive
decline of GFR and the failure of kidney to eliminate
metabolic products and others. The outcome of CKD to
end-stage is accompanied with complication of other
systems and organs that overload the clinical situation
of the patient. The number of renal patients is grown up
through the years and also the number of dialitic
patients is grown up too. There are many problems and
complications which appears during dialysis where these
and those of CKD has both a great role in the of chronic
kidney disease decurse, and in the mortality and
morbidity. The purpose of this study is to make present
evidently the problems or complications which appear
among the patients who received renal replacement
therapy as HD at Dialysis Center in Elbasan Hospital
Center. Make present these complications will help us
during our time work on patient outcome, and in the
introduction to the new schemes of medication for every
one of the evident problems decreasing the mortality.
Methods. The study is prospective, observative and its
lies on a year. The patients are divided into age group
and time durations of dialysis group. The problems are
presented and specified as they appear during HD time,
the underling diseases are qualified and also with the
number of patients which have every specific disease
that due to CKD. The specific cases are introduced. The
main interest of this study is to show the concrete and
real problems of dialitic patient in this Hospital Center
dispersed into age group and to focus the middle age of
patients who receive HD. Results. The presentation of
clinic problems during HD and the number of patients
with every one of these problems. To monitorate the
patients. During the depistation we take into
consideration the underline diagnosis, disease duration
since the beginning of it until to the depistation.
Concomitant diseases and their outcomes, the
complications during the HD time, before and after it.
We consider too the vascular access, its function or not
(fistulae), the problems which link with it, or at catheter
cases their outcomes too, their complications such as
(coagulation, pressure, infection). Conclusion. We take
in consideration the HB levels, the erythropoietin
treatment, the follow up of secondary anemia, the level
of under nutrition, the BMI influence in the outcome of
these patients.
Background. Malnutrition, inflammation, atherosclerosis /calcification (MIAC), and endothelial dysfunction
are the most commonly encountered risk factors in the
pathogenesis of cardiovascular disease in ESRD patients.
Epicardial adipose tissue (EAT), is the true visceral fat
depot of the heart. The relationship between CAD and
EAT was shown in patients with high risk of coronary
artery disease. In this study we aimed to investigate the
relationship between EAT and MIAC syndrome in ESRD
patients. Methods. Eighty ESRD patients (F/M:31/49)
and 27 healthy subjects (F/M:13/14) enrolled in this
cross-sectional study. EAT and CACS were performed by
a 64-MDCT scanner. Patients with serum albumin<3.5
mg/dL was defined as patients with malnutrition; serum
CRP level >10 ng/dL (normal range, 0–5 ng/dL) had
inflammation;
CACS
>10
had
atheroscleosis
/calcification. The demographic, clinic and laboratory
features of the ESRD patients and healthy subjects were
shown in table 1. Results. Total CACS and EAT
measurements were significantly higher in ESRD
patients when compared with healthy subjects (p=0.01,
p=0.02, respectively). There was statistically significant
relationship between EAT and CACS in ESRD patients
(p<0.0001, r=0.48). EAT meaurements were higher in
PD patients than HD patients. Twenty-four of the
patients had none, 31 had one component, 17 had two
components and 9 had all of the MIAC components. EAT
was found to be significantly increased when the
presence of MIAC components increased (p=0.003
between all groups). EAT was positively corraleted with
age, BMI, and presence of MIAC. These parameters
were also found as independent predictors of increased
EAT. Conclusion. In conclusion, we found a relationship
between EAT and components of MIAC syndrome in
ESRD patients.
74
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FIXED DOSES OF SEVELAMER HYDROCLORIDE VS
CALCIUM CARBONATE FOR REDUCTION OF SERUM
PHOSPHORUS IN HEMODIALYSIS PATIENTS
ARE LOW DOSES OF SEVELAMER SIMILARLY
EFFECTIVE AS CONVENTIONAL DOSES IN
HEMODIALYSIS PATIENTS?
N. Zeneli, A. Duraku, N. Thereska
Department of Nephrolgy- Dialysis- Transplantation,
University Hospital Center "Mother Teresa", Tirana,
Albania
A. Duraku, N. Zeneli, N. Thereska
Department of Nephrolgy- Dialysis- Transplantation,
Albania
Background. More than a half of dialysis patients have
serum phosphorus above the target recommended by
KDOQI. Elevated serum phosphorus is associated with
increased morbidity and mortality in dialysis patients.
The aim of the study was to compare the efficacy of
fixed doses of sevelamer hydrocloride and calcium
carbonate in reduction of serum phosphorus in our
hemodialysis (HD) patients. Methods. We performed an
open- label, randomized, crossover study to evaluate
the efficacy of sevelamer hydrochloride and calcium
carbonate in controlling hyperphosphatemia in HD
patients. Patients with iPTH ≥ 700 pg/ml were excluded
because of limited response to phosphate binders in
severe hyperparathyroidism. After a 2 weeks phosphate
binder washout period twenty seven patients with serum
phosphorus level ≥ 6.0 mg/day were randomized to
receive 3200 to 4000 mg/day sevelamer (800mg
tablets: 1x2x1tb and after the first week 1x2x2 tb, 2tb
with main meals and 1tb with the lighter meal) or 2000
to 2500 mg/day calcium carbonate (500mg tablets:
1x2x1tb and after the first week 1x2x2 tb) for 4 weeks.
After a second washout period of 2 weeks patients
switched to the alternate binder for 4 other weeks. All
the patients were dialyzed on 1.5 mmol/l dialysate
calcium concentration during the study period. Vitamin
D dosage was not changed during the study period.
Results. Twenty six patients completed both phases,
one patient completed calcium phase and moved to
another center during the sevelamer phase. The serum
phosphorus at baseline was 7.3 ± 1.6 mg/dl. At the end
of the study there was a similar decrease of serum
phosphorus level in both sevelamer ( - 1.2 ± 0.3 mg/dl)
and calcium carbonate ( -1.4 ± 0.4 mg/dl) groups p=
0.12. The occurrence of adverse events was similar 15%
in sevelamer group and 11.5% in calcium group. There
was a 0.2 mg/dl decrease of the adjusted serum calcium
during sevelamer treatment, while there was a 0.3
mg/dl increase of it during the treatment with calcium
carbonate. Hypercalcemia, defined as a serum calcium ≥
11.0 mg/dl, occurred in 4% of patients during 8-weeks
of sevelamer treatment and 22% of patients during 8weeks of calcium carbonate treatment (p<0.05)
Conclusion. This study demonstrates that fixed doses
of sevelamer were as effective as fixed doses of calcium
carbonate in controlling hyperphosphatemia, without
any increase in the incidence of hypercalcemia as it was
seen with calcium carbonate.
Background. Inadequate phosphorus control is
associated with increased morbidity and mortality in
hemodialysis patients. Sevelamer would be a good
alternative in this group of patients in effort to reduce
the level of phosphorus and not increase the burden of
calcium. The high price of sevelamer for our health
budget prompted us to evaluate the role of prescribing a
low dose of sevelamer. At the time when this study was
conducted the amount of sevelamer was supported by
hospital given that the sevelamer is not reimbursed in
our country. Methods. To determine whether low doses
of sevelamer (1600 to 2400 mg/day) are as effective as
conventional doses (4000 mg/day) in control of serum
level of phosphorus in hemodialysis patients we
conducted an open label randomized (2:1) study. We
have excluded the patients who have previously used
sevelamer. Use of vitamin D analogs and other
phosphate binders was not restricted. Forty- two
patients with serum level of phosphorus ≥ 6 mg/dl were
recruited. Twenty eight were randomized to the low
dose treatment group (1600 to 2400 mg/day) and
fourteen to the conventional group (4000 mg/day).
Follow- up continued for 2 months. Results. The mean
age of the patients was 42 ± 15 years old and the mean
baseline serum phosphorus level was 6.8 ± 1.4 mg/dl.
There were no significant differences in demographic,
clinical or laboratory characteristics between the two
groups at baseline. Adherence to sevelamer treatment
was 86% in the conventional- dose group and 89% in
the low-dose group. The incidence of adverse events
was the same 7% in both groups. After 2 months of
treatment the serum phosphorus declined significantly in
conventional group, but not in low-dose group –1.9
mg/dl P = 0.04, and –0.6 mg/dl P = 0.31, respectively.
Regarding to the achievement of KDOQI goal for serum
phosphorus the percentage was 57% in conventional
group and 28.5% in low dose group with no significant
difference P = 0.13. The lack of significance probably is
due to the small number of patients. Conclusion. Low
doses of sevelamer hydrocloride are not equally
effective as conventional doses in control of serum
phosphorus in dialysis patients in our study . A further
analysis is needed to evaluate cost- efficiency of lowdose sevelamer treatment and conventional dosing in
control of serum phosphorus levels in hemodialysis
patients.
75
PP 105
PP 106
IS KIDNEY BIOPSY REASONABLE IN PATIENTS
WITH DIABETES MELLITUS
SERUM CYSTATIN C AS A MARKER OF INITIAL
DETERIORATION OF RENAL FUNCTION
1
1
1
1
N. Dobreva, 1 A. Rapondjieva, 1 S. Ilieva, 2 T. Todorov
Internal Medicine Ward- Nephrology Division, Tokuda
Hospital Sofia, Bulgaria
2
Department of Pathology, University Hospital
Alexandrovska, Bulgaria
A. Rapondjieva, 1 N. Dobreva, 1 S. Ilieva, 2 V. Koleva
Department of Internal Medicine, Tokuda Hospital Sofia,
Bulgaria
2
Clinical Laboratory, Tokuda Hospital, Sofia, Bulgaria
Background. Serum creatinine is widely used in clinical
practice to identify patients with an impaired renal
function. However moderately reduced glomerular
filtration rate may be missed by this conventional
parameter. Creatinine clearance is a more sensitive
marker of reduced renal function than serum creatinine.
Nevertheless, there are many clinical conditions where
estimation of creatinine clearance is very difficult.
Recently, serum cystatin C has been suggested as a new
marker of renal function independent of sex or muscle
mass. It is not clear if it has some advantages to serum
creatinine in detection of early deterioration of renal
function. The aim of this study was to validate the
hypothesis that serum cystatin C is a sensitive marker of
initial deterioration of renal function including cases in
creatinine “blind” zone. Methods. we investigated
simultaneously serum cystatin C, serum creatinine and
standard creatinine clearance in 134 patients / m 65, f
69, mean age 50 ± 16 years/. Sensitivity and specificity
of elevated serum cystatin C for detecting renal failure /
reduced creatinine clearance / are calculated. Results.
We found high levels of serum creatinine / ≥ 133
µmol/L/ in 36 pts / 26,86%/ and all of them had high
levels of cystatin C / ≥ 95 mg/L/. Reduced creatinine
clearance / ≤ 80 ml/min/1,73m2/ but normal serum
creatinine we found in 32 patients /23,88%/ and 29 of
them /21,64%/ had high levels of serum cystatin C.
Normal renal function assessed by creatinine clearance
but elevated serum cystatin C were found in 34 patients
/25,3%/. Thirty two patients had normal levels of
creatinine clearance and serum cystatin C /23,88%/.
Only 3 patients /2,2%/ had reduced creatinine clearance
but normal cystatin C. Sensitivity of serum cystatin C as
a marker of impaired renal function is 95% / SE 2,6%,
CI 90 – 100% / but specificity is 48% / SE 6,1%, CI 42
– 54% /. There is a positive correlation between serum
cystatin C and age / r=0,2; p<0,05/, but not with sex,
weight, height or BMI. Conclusion. serum cystatin C is
a useful marker with high sensitivity to identify initial
impairment of renal function. It could be a valuable tool
in patients in difficult clinical conditions where
estimation of creatinine clearance is not possible.
Background. Diabetes mellitus is one of the major
causes of ESRD. Due to the high frequency of diabetic
nephropathy, renal biopsy is rarely considered in
patients with Diabetes mellitus and renal manifestation.
Is it reasonable? The aim of the study is to analyze
morphological findings and clinical data in patients with
Diabetes mellitus in Tokuda Hospital Sofia during a 4year period- from March, 2007 to March, 2011.
Methods. Forty two patients were included (25 males
and 17 females), mean age 50+16,08 years. All of them
had at least one of the following clinical indications for
renal biopsy- nephrotic syndrome, presence of
proteinuria, pathological urinary sediment, arterial
hypertension, renal insufficiency. Biopsy samples were
processed
by
standard
histological
and
immunofluorescent techniques. In 1 patient an
electronic microscopy was performed. Clinical and
laboratory data were analyzed. Results. According to
morphological findings, patients were divided into 2
groups: first- with diabetic nephropathy (16 out of 42
patients- 38,1%) and second- with glomerulonephritis
and diabetes mellitus (26 out of 42 patients- 61,9%).
Morphological diagnosis in the second group were as
follows: FSGS – 8 patients (19 %); Mesangiocapillary
glomerulonephritis- 1 patient (2,38%); Membranous
nephropathy- 3 (7,14%), as in one of them diagnosis
has
been
proven
by
electronic
microscopy;
mesangioproliferative glomerulonephritis- 2 patients
(4,76%);
Crescent
glomerulonephritis
in
ANCAassociated vasculitis- 2 patients (4,76%); Tubulointerstitial nephritis – 4 (9,5%); Minimal change disease
– 3 (7,14%); Fibrillary nephropathy- 1 (2,38%);
Hypertensive nephropathy- 2 (4,76%). There is a
significant difference between the two groups regarding
the duration of the diabetes, treatment modality, a
presence of diabetic retinopathy and neuropathy. In
spite of this, their presence does not exclude a
concomitant glomerulopathy in patients with Diabetes
mellitus. Conclusion. High frequency of combination of
Diabetes mellitus with other glomerulopathies makes
renal biopsy reasonable in all diabetic patients,
especially in cases with nephrotic syndrome, lack of
diabetic retinopathy and other vascular and neurological
complications, presence of arterial hypertension and
urinary findings, excluding pyelonephritis.
76
PP 107
PP 108
EFFECTS OF AN ANGIOTENSIN-CONVERTING
ENZYME INHIBITOR ON RESIDUAL RENAL
FUNCTION IN PATIENTS TREATED WITH
PERITONEAL DIALYSIS.
EVALUATION OF PERIODONTAL STATUS IN
PATIENTS UNDERGOING PERITONEAL DIALYSIS OR
HEMODIALYSIS
1
M. Rroji, 1 S. Seferi, 2 E. Petrela, 1 M. Barbullushi,
N. Spahia, 1 E. Likaj, 1 N. Thereska
1
Albania
2
Department of Statistic, University Hospital Center
"Mother Teresa", Tirana, Albania
1
M. Rroji (Molla), S. Seferi, N. Spahia, E. Likaj,
M. Barbullushi, N. Thereska
Albania
Background. Residual renal function (RRF) is one of the
most powerful predictors of outcome in peritoneal
dialysis (PD) patients. Unfortunately, RRF declines
during treatment on PD, albeit at a lower rate than on
classic hemodialysis (HD). Several clinical studies have
shown
that
RAS
inhibitors
offers
significant
renoprotection in both diabetic and non-diabetic
nephropathy and slows glomerular filtration rate (GFR)
decline over time and progression to end-stage renal
disease (ESRD). Few trials had showed a positive effect
of ACE-i inhibitors on residual glomerular filtration rate
(rGFR) in peritoneal dialysis (PD) patients. Method. The
aim of this study is to evaluate the use ACE-I (Ramipril
5 mg; Enalapril 20 mg ) and its effect on declining of
residual renal function in CAPD patients We examined
42 pts on CAPD from 3 months to 1 years after the start
of dialysis therapy. Patients were randomly assigned to
Ramipril 5mg; Enalapril 20 mg (n = 25; age, 58.84 +/10.01 years; 12 men, 15 women) or a control group (n
= 17; age, 48.88 +/-15.27 years; 10 men,7 women).
Conventional antihypertensive treatment was continued
in all patients to achieve the target BP in both groups of
130/80 mm Hg or less. Results. Over 12 months,
average residual GFR declined by 1.38+/-0.56 mL/min
per 1.73 m2 in the ACE-i group versus 2.78+/-0.78
mL/min per 1.73 m2 in the control group (P = 0.02).
The difference between the average changes in residual
GFR in the ACE-i and control groups from baseline to 12
months was 1.4 mL/min per 1.73 m2 . The pts in the
treated group used more more antihypertensive
medications 2.33+/-0.61 vs 0.93+/-0.82. At 12 months,
1 patients in the group and 4 pts in the control group
developed anuria. The rates of death from any cause,
duration of hospitalization, and cardiovascular events
did not differ significantly between groups. Conclusion.
The angiotensin-converting enzyme inhibitor may reduce
the rate of decline of residual renal function in patients
with end-stage renal failure treated with peritoneal
dialysis although the size of the study was small and had
a limited ability to exclude effects of potential
confounding factors.
Background. Periodontitis contributes to generalized
inflammation and development of systemic diseases,
including atherosclerosis and cardiovascular disease.
The aim of our study was to investigate the prevalence
of periodontal pathology among patients who were
receiving chronic outpatient hemodialysis and peritoneal
dialysis treatment. Methods. 93 patients (63 on HD,
mean age, 49.3 ± 10.9 years, average duration of
dialysis 49.7 ± 39.4 months; 30 pts on CAPD, mean age
51.2 ± 16.1 years, average duration of dialysis 26.1
±18.9 months were enrolled in the study. Periodontal
examination was carried out by a single professional
stomatologist and the measurements were recorded
according to WHO recommendations. A periodontitis
case was defined as > 60% of sites with attachment
level ≥4 mm. Binary logistic regression was used to
determine the association between periodontitis and two
measures of systemic inflammation, low serum albumin
(defined as <3.5 mg/dl) and high C-reactive protein
(defined as >5.0 mg/dl). Results. There was no
significant difference between the prevalence of
periodontal disease in pts on HD or PD therapy (54% vs
47%). Fifty of all subjects (54.2%) were diagnosed as
periodontitis cases. The average number of teeth was
20.08 (SD 6.12). Plaque index score, gingival index
score, papillary bleeding index, loss of Clinical
attachment level, and Community Periodontal Index
were 2.11 ± 2.26; 1.31 ± 1.0; 2.05 ± 1,35 mm; 5.12 ±
1,23mm and 1.61± 1.11 respectively. Periodontitis
cases reported being uncomfortable when eating or
swallowing. 91.2% of them were sensitive to hot or
cold; 93,8% had a worse sense of taste and 87,5% had
painful aching in the mouth. It was seen an association
between presence periodontitis disease and low serum
albumin (OD=4,93, CI95%: 1,298-14,866, p =0,017).
Significant difference was found between the group with
or no periodontis for alb, PTH, GI, PBI, CAL, CPI
(p=0.32); (p=0.24); (p<0,001); (p<0,001); (p<0,001)
respectively. Conclusion. The results of the study
showed that periodontal disease is prevalent, severe and
under recognized in dialysis patients. Periodontitis was
associated with low serum albumin level but we didn’t
found a positive correlation with CRP. This finding is
probably due to uncomfortable eating. Althought highly
prevalent it doesn’t seems to be a great source of
inflammation in end-stage renal disease patient on
dialysis therapy. The significant higher value of PTH in
group with periodontis support the idea that secondary
hyperparathyroidism may be is a possible cause of
increased gingival inflammation and possible alveolar
bone loss in dialysis patients.
77
PP 109
PP 110
APPLICATION OF METOXYPOLYETHYLENE GLYCOLEPOETIN BETA IN THE TREATMENT OF ANEMIC
SYNDROME IN HAEMODIALYSIS PATIENTS
VITAMINE D LEVELS IN CKD PATIENTS WITH AND
WITHOUT METABOLIC SYNDROME
1
1
1
1
A. Kitsos, 1 E. Dounousi, 1 R. Kalaitzidis, 1 K. Katopodis,
A. Challa, 1 K.C. Siamopoulos
1
Ioannina, Greece
2
Pediatric Research Laboratory, Child Health
Department, University of Ioannina, Greece
2
R. Penkov, P. Angelov, M. Hrincheva, Z. Ramsheva,
Dialysis Treatment Unit, Military Medical Academy,
Bulgaria
2
Central Clinical Laboratory, Military Medical Academy,
Bulgaria
2
Background. This study aims at establishing the
possibility for supporting and monitoring optimal
hemoglobin levels in the application of erythropoesis
activator with long release. Methods. We have achieved
correction of the anemic syndrome in haemodialysis
patients, as follows: 1. Via applying, three times weekly,
erythropoesis stimulating agents – erythropoietin alpha
or beta, in six patients – group I; 2. Via substituting
treatment, intravenously, with iron medication, utilizing
metoxypolyethylene glycol-epoetin beta, as supportive
treatment, in six patients – group II. The monitoring of
the clinical results has been performed by measuring the
erythropoetin serum levels, every three months, as well
as, via routine clinical laboratory tests. Results. We
have applied erythropoetin α, three times weekly,
average 6 000 МЕ, and metoxypolyethylene glycolepoetin beta once monthly, for a period of twelve
months. We have applied ready-to-use syringes of 100
and 200 µg/ml. We have continued the treatment with
iron medication, intravenously. There have been treated
twelve patients- 4 /four/ women and 8 /eight/ men. We
have monitored the hematological indications as serum
createnin, iron, iron-binding capacity, arterial pressure.
The indications stand for statistically significant positive
effect in the patients in group II. There have been
recorded no changes in the values of the arterial
pressure, therefore, the anti-hypertensive therapy has
not been adjusted. No changes in the thrombocytes and
leucocytes values recorded, neither. There have been
recorded no side effects from the therapy. Conclusion.
Metoxypolyethylene glycol-epoetin β is an erythropoesis
stimulating agent, which allows for transition from
application of short-release erythropoietin, three times
weekly,
directly
to
supportive
treatment
with
erythropoesis activator with long-release – once
monthly.
Background. Vitamin D metabolism plays a central role
in calcium and phosphate homeostasis in patients with
chronic kidney disease (CKD). The calcitriol levels seem
to decline progressively as the kidney disease advances
and many factors can inhibit the production and the
actions of calcitriol. Accumulating data correlates CKD
and vitamin D with metabolic syndrome (MS). Each one
of the components of MS had been associated with
increased risk of CKD and patients with MS had 2.6-fold
increased odds of CKD. Recent evidence focus on noncalcemic functions of vitamin D in MS related conditions,
as
obesity,
insulin
resistance,
diabetes
and
hypertension. In addition, a higher incidence of
hypovitaminosis D is observed in patients with MS. In
the present study, we investigated the association
between vitamin D metabolites and MS in patients with
CKD. Methods. We recruited 110 patients from the CKD
outpatient clinic (52% men,) with a mean age of 63.5
years (range 25-88), and a mean eGFR (MDRD) of 54.3
ml/min. Eighty-six (78%) of them also had MS (group
1), using the NCEP/ATP III criteria, while 24 CKD
patients (22%) did not develop a MS (group 2). Fasting
25 hydroxyvitamin D [25(OH)D], 1.25-dihydroxyvitamin
D [1.25 (OH)2D], insulin and other laboratory
parameters were measured in all patients. Results.
Regarding the eGFR levels there was no statistical
significant difference between the two groups. We found
a significant positive correlation between both 25(OH) D
and 1.25 (OH)2 D and eGFR (r=0.25-p=0.08 and
r=0.38-p<0.001 respectively). Serum concentrations of
both 25(OH) D and 1.25 (OH)2 D were lower in patients
with moderate and severe CKD (eGFR <60 ml/min,
p=0.002 and p<0.001, respectively). Serum 25(OH) D
concentrations were lower in group 1 (p<0.001) and the
prevalence of MS was higher among patients with
25(OH) D <20 mg/dl (91%) and lower in patients with
25(OH) D >32 mg/dl (62.5%). Finally, in the total
studied population serum levels decreased with the
increasing
BMI
(r=-0.28,
p=0.02)
and
waist
circumference (r=-0.24, p=0.01). Conclusion. CKD-MS
patients have lower 25(OH) D levels than CKD without
MS patients. However, no differences regarding the 1.25
(OH)2 D levels were found.
1
78
PP 111
PP 112
ANTIBIOTIC RESISTANCE OF STAPHYLOCOCCAL
INFECTIONS OF CENTRAL VENOUS CATHETERS IN
HEMODIALYSIS PATIENTS: A SINGLE CENTRE 3YEARS EXPERIENCE
EARLY DETECTION OF MINERAL-METABOLIC
ABNORMALITIES AND PREVENTION MBD-CKD AND
CARDIOVASCULAR COMPLICATIONS
1
R. Jelacic, 2 L. Bacvanski, 1 L. Lucic -Dragic, 1 M. Vukoje
Department of Internal, HD unit, General Hospital,
Serbia
2
Biocemical Laboratory, General Hospital, Serbia
C. Bantis, N. M. Kouri, G. Bamichas, E. Tsandekidou,
A. Rizos, M. Kachrimanidou, K. Sombolos, T. Natse
Department of Nephrology, “Papanikolaou” General
1
Background. We used regular laboratory parameters
(Ca,PO4, alcaline phosphatas, albumins, urea , creatinin,
acid-base status, GFR, iPTH, hemoglobin, glicemia) with
clinical examination of the patient in order to evaluate
how routine monitoring in the outpatient caretaking of
patients with various primary kidney diseases can
contribute to early detection of initially hormonal,
metabolic and clinically defect of mineral metabolic
disorders and organ damage in chronic kidney disease
(CKD). Methods. In the 12 months (2009-2010), we
followed 28 patients – 13 male and 15 female, aged
between 30 and 68 years. Primary renal disease –
Glomerulonephritis - on 5 patientss, Hypertension
caused nephropathy – 4 patients, Diabetes mellitus – 10
patients, Nephropathy undefined – 5 patients, APKD – 1
patient and Pyelonephritis – 3 patients. The degree of
renal failure was estimated by the MDRD formula, which
found that the GFR over 60 ml/ min - 0 pts, and of 3059 ml / min -7 pts of 10-29 ml / min -16 pts less than
10 ml / min - 5 pts. Results. We found iPTH between
50-150 pm/ml - 3pts, 151-300 pm/ml - 11 pts, 301500pm/ml -7 pts; 501-800pm/ml -5 pts; more than
800pm/ml - 2pts It was noted that the value of iPTH did
not correlate with the degree of CKD, the patients
associated with DM do not have high values of iPTH, the
findings in control for a period of 6 months has no
important increase in iPTH values in relation to the
progression of CKD leading to ESRD /6 pts /. Phosphate
less than 1.0 mmol / l is only 5 pts, from 1.1 to 1.50
mmol / l has 8 pts, and greater than 1.50 mmol / l -15
pts. / 15 of 28 patients have phosphates out of range of
desirable values./ Calcium greater than 2.2 mmol / l,
with 24 of 28 pts / 85,5. % / and less than 2.1 mmol / 4
-14,5.9% pts. Question is - does the application of
Calcium phosphate binders, and Vitamin D3 perhaps
indirectly or directly contribe to the early risk of
calcification in the small vessels. Conclusion. Insistence
on an early correction of dietary regimes in terms of
reduction of phosphate intake and recent changes
calcium free phosphate binders, application of
Calcimimetics and vitamin D analogs in early stages
CKD, can be of real interest in the timely prevention of
progression of metabolic bone disease in CKD and
cardiovascular problems.
Background. Despite all efforts a considerable number
of patients dialyses through central vein catheters
(CVCs). Infections of CVCs remain an important cause of
morbidity and mortality in this patient group, with
staphylococcus being the major causative organism.
Methods. We reviewed n=123 positive cultures taken
from patients on hemodialysis carrying tunnelled or nontunnelled CVCs in the last 3 years in our centre.
Analysed were cultures of the tips of removed catheters
as well as blood cultures taken through the dialysis
catheters. Resistance to antibiotics used in daily clinical
practice against CVC infections was evaluated. Results.
Staphylococcal strains were isolated in 95 cases
(77.2%). Bacteria less frequently isolated were:
Pseudomonas aeruginosa (5.7 %), Acinetobacter
baumanii
(2.4%),
Proteus
mirabilis
(2.4%),
Enterococcus spp (2.4) ect. S. aureus as found in only 5
patients. S. epidermidis was the most common species
isolated (77 cases). Other coagulase negative species
were: S. hominis (n=6), S. hemolyticus (n=3), S. capitis
(n=2), S. warneri (n=1) and S. saprophyticus (n=1).
The resistance of the isolated staphylococcal strains to
commonly used antibiotics is demonstrated in the table
below. No case of methicillin resistant S. aureus (MRSA)
was detected. Conclusion. Staphyloccus spp remains
the major cause of CVC infections. Resistance to fusidic
acid, oxacillin, mupirocin and gentamicin is very
common. Cases of resistance to vancomycin or the
newer antistapholococcal agents teicoplanin, linezolid
and daptomycin are still rare.
79
PP 113
PP 114
MODIFIED PET WITH TEMPORARY DRAINAGE IN
CLINICAL ROUTINE PRACTICE: ANY USE?
CORONARY ARTERY DISEASE AFTER KIDNEY
TRANSPLANTATION
X. Zikou, O. Balafa, M. Ikonomou, E. Pappas, A. Banioti,
K.C. Siamopoulos
Ioannina, Greece
1
S. Vodopivec, 1 I. Mitic, 1 T. Djurdjevic-Mirkovic,
D. Bozic, 1 L. Petrovic, 1 T. Ilic, 1 V. Sakac, 2 M. Kovac
1
Clinical Center of Vojvodina, Nephrology and
immunology Clinic, Novi Sad, Serbia
2
Institute for cardiovascular diseases sremska Kamenica,
Serbia
1
Background. PET, as described by Twardowski- is the
most widely used test for studying the characteristics of
the peritoneal membrane. However, it can give no
information for water transport, especially free water
transport (FWT) and Na sieving. Mini PET has been
developed for this purpose but it cannot reveal
information for solute transport. Modified PET with
temporary dialysate drainage at one hour can combines
the information from both classical PET and mini-PET. To
use modified PET as routine test in our unit and confirm
its importance for our clinical practice. Methods. A 4hour PET using 3.86% glucose solution was performed.
After one hour (time of maximum Na sieving) we
performed temporary drainage of the dialysate. After
weigh measurement and dialysate sampling for sodium
estimation the dialysate was re-instilled. At 4 hour,
measurement
of
creatinine,
glucose
and
total
ultrafiltration (UF) was done. D/PNa 60 min (sodium
dialysate/sodium serum at 60 min), DipNa (sodium
dialysate 60 min - sodium dialysate 0 min) and
ultrafiltration at 60 min (UF60) were calculated. FWT at
60 min was calculated according to LaMilla method.
Patients with ultrafiltration failure (UF <400 ml) were
compared to patients without ultrafiltration failure.
Results. Test was carried out in 33 patients with mean
value of PD duration of 33.4 (1-115 months). Patients
with ultrafiltration failure had statistically significant
lower FWT and higher D/P Na60 min (Table).
Conclusion. Modified PET with temporary drainage is an
easy way to access the kinetics of solutes and water in
PD patients. This information can help us advance the
prescription of PD, especially in patients with
ultrafiltration failure.
Background. The researches of prevalence of coronary
artery disease in renal transplant recipients show five
times higher frequency than data from Framingham
Study patients of similar sex and age. The risk factors
are: pre transplanted cardiovascular disease, arterial
hypertension, graft disfunction, immunosupressive
regimen, diabetes, hiperlipidemia, smoking etc. The aim
of the study is to evaluate the prevalence of myocardial
infarction in renal transplant patients, and all precipitant
factors of the illness. Methods. This is a retrospective
analysis wich includes two periods of transplanatation in
our Center. The first period is from 1986 -1998 (116
patients) and the second is from 2000 - 2010 (96
patients). Multiple factors wich might be of influence
were analysed, such as: demografic data, aetiology of
underlying
disease,
immunosupressive
regime,
hypertension, hiperlipidemia, diabetes, smoking and low
physical activity. Echocardiography parameters, 24 h
blood pressure monitoring, vascular alterations of the
fundus of the eye and body mass index have also been
investigated. Results. The first period is characterised
with high prevalence of myocardial infarction (12%) and
consecutive death outcome (64,28%) of patients. The
second period is caracterised with low incidence of
myocardial infarction (2, 08%) and good prognosis.
Cardiovascular risk factors have been analysed, and it is
concluded that bad kidney function, male sex, higher
arterial tension, and higher blood holesterol and
smoking cigarettes; therefore, they are known as the
most important risk factors. Conclusion. The factors of
infulence in lowering prevalence of myocardial infarction
and cardiac death after kidney transplantation in the
past decade are: better menagement of chronic renal
failure,
better
dyalisis
procedure,
intensive
antihypertensive, antilipemic therapy and better
compliance.
80
PP 115
PP 116
EFFECT ON DIALYSIS ADEQUACY OF AN
INTRADIALYTIC EXERCISE PROGRAM IN ENDSTAGE RENAL DISEASE PATIENTS RECEIVING
MAINTENANCE HEMODIALYSIS
A COMPARISON OF TWO METHODS OF VASCULAR
ACCESS FLOW MEASUREMENT IN HEMODIALYSIS
PATIENTS
1
1
1
K. Leivaditis, 1 S. Panagoutsos, 1 K. Kantartzi,
V. Devetzis, 1 P. Passadakis, 2 M. Lazaridis,
1
V. Vargemezis
1
Department of Nephrology, Democritus University of
Thrace, University General Hospital of Alexandroupolis,
Greece
2
Department of Vascular Surgery, Democritus University
of Thrace, University General Hospital of Alexandroupolis,
Greece
1
1
D. Sivridis, S. Panagoutsos, K. Kantartzi,
M. Theodoridis, 2 I. Fatouros, 1 E. Thodis,
1
V. Vargemezis
1
Greece
2
Department of Physical Education & Sport Science,
Democritus University of Thrace, Greece
1
Background. Review of literature to assess the effect
on dialysis adequacy of an intradialytic exercise program
in hemodialysis patients did not yield a clear positive
relationship. A few studies showed increase in dialysis
efficacy but others did not. Among those with beneficial
affect the mean possible mechanism considered the
reduction of solute rebound due to increased blood flow
in the skeletal muscles during exercise. The purpose of
the study was to find out if an 24-week exercise
program during dialysis in end-stage renal disease
patients could increase solute removal and thereby the
efficiency
of
hemodialysis.
Methods.
Fifteen
hemodialysis patients were randomized into an exercise
group (n=7) and a control group (n=8).The exercise
programme consisted of cycle ergometry aerobic
exercise 3 times per week for 10-30 min between the
first and second hour of the 4hours dialysis session.
Exercise gradually increased by 2-4 minutes each week
maintaining 50%-70% maximal heart rate (HR) in each
period. Plasma concentrations of urea, creatinine,
potassium and phosphorus were measured pre-, 60΄,
90΄min. and post- dialysis. Dialysis efficacy was
measured using «R», where R= post-x/pre-x (where x
parameter: urea, creatinine, potassium, phosphorus)
The «R» index calculated pre- and post dialysis session
for each parameter but also for the 60΄ and 90΄min
measures, correspondently which was the time including
the exercise. Results. In exercise group there was no
significant difference in R between baseline and period
low,
moderate
and
high
intensity
exercise
correspondently (table). There was not also significant
difference in R between exercise group and control
group in each period of exercise correspondently.
Conclusion. These results suggest that short duration
exercise training of low- to- moderate intensity during
dialysis, seems to have no significant effect on solute
removal as well as on dialysis adequacy.
Background. Vascular access survival is a crucial issue
associated with morbidity and mortality of patients
undergoing permanent hemodialysis. Postoperative
vascular access surveillance seems to prolong access
patency and to improve the quality of patients’ life.
Blood flow measurement is a reliable method of vascular
access surveillance according to KDOQI guidelines. We
compare two methods of arteriovenous dialysis grafts
flow measurement: a) the optodilution method (Delta-H)
using the CRITLINE III device and b) color Doppler
ultrasonography. Methods. Α total of 124 access blood
flow measurements were performed with both methods
in
29
patients
undergoing
hemodialysis
via
arteriovenous polytetetrafthoroethylene (PTFE) grafts.
Optodilution method with CRITLINE III device is based
on continuous hematocrit measurement during the
hemodialysis session with the aid of a sensor adjusted to
the arterial side (inlet) of the dialyzer. Color Doppler
flow measurement depends on estimation of the graft
lumen diameter (cross sectional area) and mean blood
flow velocity by spectral Doppler. Volume blood flow in
PTFE grafts was estimated to be 1144±519 ml/min and
837±280 ml/min by optodilutional method and color
Doppler ultrasound, respectively. Results. A statistically
significant
difference
was
documented
between
measurements with the two methods as far as blood
flow was concerned (p<0.001) but with a weak
correlation of values (Spearman correlation coefficient
r=0.615, p<0.001). For optodilution method, the Area
Under the Curve (AUC) was 0.631(0.533-0.723),
p=0.043 and cut-off value was 765ml/min. The
sensitivity was 50% and the specificity 73.6%. For
Doppler ultrasonography the AUC was 0.704 (0.6150.783), p=0.0002, cut-off value was 700ml/min,
sensitivity
was
72.7%
and
specificity
73.3%.
Conclusion. The optodilution method tends to
overestimate blood volume flow and is less sensitive
compared to Doppler ultrasonography. Besides blood
flow measurement, the latter method offers the
possibility of direct graft imaging and depiction of
stenoses or any other abnormalities that affect vascular
access patency and survival.
81
PP 117
PP 118
DOES BEGINNING OF HEMODIALYSIS TREATMENT
HAVE ANY INFLUENCE ON ENDOTHELIUM
FUNCTION, ANEMIA AND INFLAMMATION?
LINK BETWEEN CREATININE CLEARANCE AND BMODE ULTRASONOGRAPHIC ASSESSMENT OF
CAROTID ARTERY PLAQUE COMPOSITION
T. Jemcov, S. Simic-Ogrizovic, M. Radovic
Clinic of Nephrology, Clinical Center of Serbia, Belgrade,
Serbia
1
T. Jemcov, 2 I. Koncar, 1 M. Kravljaca, 3 M. Golubovic,
S. Simic-Ogrizovic, 2 L. Davidovic
1
Serbia
2
Clinic of Vascular and Endovascular surgery, Clinical
Center of Serbia, Belgrade, Serbia
3
Center for Medical Biochemistry, Clinical Center of
Serbia, Belgrade, Serbia
1
Background. Chronic kidney disease (CKD), especially
end stage renal disease (ESRD), is strongly associated
with the occurrence of cardiovascular disease. It is
supposed that endothelial dysfunction is the first step in
the accelerated atherogenesis and there is evidence that
decreased GFR is associated with endothelial dysfunction
as well as inflammatory activity. Aim of the present
study was to examine hemodialysis treatment effects on
endothelial function, inflammatory parameters and
anemia after 12 months of starting chronic hemodialysis
therapy. Methods. Prospective, observational, single
centre study was undertaken in 24 incident HD patients
(pts), 12 male, age (50,75±15,46). Measurements of
flow mediated dilatation (FMD) of brachial artery, intima
media thickness (IMT) of common carotid artery (ACC)
and the presence of calcification (CCF) and stenosis as
well as biochemical parametars :hemoglobin (Hb),
calcium (Ca), phosphorus (PO4), sedimentation (SE),
fibrinogen (Fb), albumin (Alb), C-reactive protein (CRP)
were performed before and 12 months after initiation of
hemodialyses therapy. Student- T test for dependent
samples was used to test difference in each variables in
both groups. Spearman correlation was used to test the
existence of significant correlation between measured
parameters. Results. Hb level raised from 94.36±10.82
g/l before and 110.12±10.34g/l after 12months as well
as Ca level :2.02±0.29mmol/l vs 2.29±016mmol/l and
Alb : 34.15± 8.12 vs 38.85 vs 4.42, although SE, Fib
and CRP decreased (tab.1). All this changes were
significant (p<0.05). FMD was improved after 12
months (3.2±2.91% vs 4.42±5.68%) but not significant
(p>0.05). Significant positive correlation was found
between IMT and age (r=0.433); arterial CCF and IMT
(r=0.564); arterial CCF and age (r=0.381). Product
CaxPO4 was correlated significantly but inversely with
IMT (r=-3.35).Conclusion. Incident HD patients have
anemia, hypocalcemia and inflammation. Beginning of
hemodialysis treatment is followed with correction of
anemia and hypocalcemia, inflammation reduction and
improvement in endothelial function.
Background. In chronic kidney disease (CKD) patients,
reduced GFR is associated with a high prevalence of
cardiovascular disease (CVD) risk factors and a higher
prevalence of CVD surrogates such as carotid arteries
intima-media thickness and carotid artery plaques
(CAP). In CKD patients atherosclerotic lesions are
frequently calcified, as opposed to fibroatheromatous,
and have increased media thickness compared to lesions
in general population. The aim of present study was to
assess the prevalence of patients with different CKD
stage 1 to 5 (K-DOQI classification) with carotid vascular
calcifications (CVC) in CAP by high-resolution B-mode
ultrasonography and possible association with traditional
(age, gender, hypertension, lipids, smoking) and
nontraditional (anemia, markers of inflammation and
both divalent ions) CVD risk factors. Methods.
Ultrasound characteristics of carotid plaques and
presence of high acoustic shadow that means CVC in
223 patients (male 122, age 65,88±8,86) in different
CKD stages and with significant carotid artery stenosis
were investigated. Results. The prevalence of CKD
patients with CVC in CAP was 48,43%. CVC significantly
positive correlates only with cholesterol (p=0,018) and
serume creatinine level (p=0,02). Variance analysis for
both depends variable (CKD stages and CVC) show
significant association with hypertension, serum
albumin, cholesterol, sedimentation rate, hs-CRP and
hemoglobin. There were no significant correlation
between both divalent ions (calcium and phosphor)
serum concentration with CVC. Conclusion. Results of
the present study demonstrated that impaired renal
function followed with increase serum creatinine and
cholesterol serum level significantly affects plaque
composition in patients with present carotid artery
stenosis.
Also,
CKD
progression
followed
with
inflammation, malnutrition and anemia, makes suitable
milieu for development of carotid vascular calcifications.
Enhanced calcification and reduced collagenous plaque
may lead to plaque instability and rupture. Further
investigations should be perform to identify in CKD
patients as early as possible pathogenetic mechanism
and possible prevention of accelerated atherosclerosis.
82
PP 119
PP 120
VEIN DISTENSIBILITY INFLUENCES PRIMARY AVF
OUTCOME
FLOW-DEPENDENT DISTAL RENAL TUBULAR
PROTON [H+] SECRETION: A UNIQUE CASE OF
PSEUDO-DISTAL RENAL TUBULAR ACIDOSIS
(PSEUDO-DRTA)
1
T. Jemcov, 2 I. Kuzmanovic, 2 I. Koncar, 2 M. Dragas,
N. Ilic, 1 M. Radovic
1
Serbia
2
Clinic for Vascular and Endovascular Surgery, Clinical
Center of Serbia, Belgrade, Serbia
2
1,2
M. C. Prikis, 2 A. S. Segal
University of Cyprus, Nicosia, Cyprus
2
Department of Nephrology and Hypertension, Fletcher
Allen Health Care, University of Vermont, Burlington, USA
1
Background. Well maturated native arteriovenous
fistula (AVF) is of great importance to efficient
hemodialyses
treatment.
Preoperative
Duplex
sonography (DS) is of great help in increasing the
percentage of successful AVFs and is recommended as a
mandatory
preoperative
noninvasive
diagnostic
procedure by European Best Practice Guidelines (EBPG).
Aim of the present study was to evaluate whether and
which morphological and functional factors influence the
outcome of primary native AVFs. Methods. Prospective,
observational study (preliminary data) on 58 patients
(pts), 34 male, age 59,07±14,1 who were prepared for
the beginning of chronic renal replacement therapy
(RRT). DS examination before the AVF creation were
performed in all pts. Examined parametars were feeding
artery internal diameter (IDA), resistance index (RI),
flow mediated dilatation (FMD) of brachial artery,
internal diameter of the vein (IDV), vein distensibility
(VD) – difference in vein diameter before and after
proximal vein compression (PVC), as well as the flow
measurement of the created AVF 0 and 28 day after
creation. Patients were divided into two groups,
depending on the outcome of AVF. Group A with
successful AVFs (Flow>600ml/min and vein diameter
≥5mm) and group B with failed AVFs. Results. The
primary patency rate (successfully constructed AVFs) of
the native AVFs was 72.4% (42/58). There was no
statistically significant differences in the tested
parameters in both groups, except in VD (0,68 vs 0,47
p<0,01).In group A, analyzed data shows significant
correlations (p<0.05) between: IDA and RI (r= -0,31);
IDA and AVF flow 0 day (r=0,36); IDV and VD (r=0,34);
IDV and BMI (r=0,41); IDV and HTA (r=-0,47) and IDV
with RI (r=-0,48). In group B: RI with FMD (r=-0,47).
Conclusion. VD is a significant parameter of the
positive outcome of primary AVF construction. Its
measurement is necessary and should become a
mandatory step in the preoperative DS mapping.
Background. Distal renal tubular acidosis (RTA) is
caused by inadequate proton secretion by intercalated
cells along the collecting duct, either due to a defective
proton pump, a permeability defect resulting in protons
leaking back into the cells and an unfavorable electrical
gradient for H+ secretion. The two most important
diagnostic
observations
in
distal
RTA
are
an
inappropriately elevated urine pH (>5.5) despite the
presence of metabolic acidosis, and a positive urine anion
gap. Case report. We report a 26 year old quadriplegic
man with a history of chronic respiratory acidosis
(baseline blood gases pH 7.41, pCO264mmHg,
tCO242mEq/L),
who
presented
with
hypercapnic
respiratory failure and acidemia due to both acute
respiratory and non-anion gap metabolic acidosis
(pH7.12, pCO274mmHg, tCO226mEq/L). Renal function
was normal (serum creatinine 0.4mg/dl). The patient was
admitted to the intensive care unit and was intubated.
Prior to presentation the patient had taken a thirty-two
hour car ride in hot weather mostly in an immobile
position, resulting in profuse sweating, minimal access to
fluids and severe volume depletion. At that point, arterial
blood gases showed pH7.21, pCO251mmHg, and tCO2
22mEq/L, serum electrolytes were [Na]134mEq/L,
[K]3.8mEq/L, [Cl]107mEq/L, [tCO2]24mEq/L, anion gap
3 and urine net charge of -91, urine pH 6.04.
Discussion. This patient’s presentation initially suggests
that distal tubular acidification ability is impaired and
distal renal tubular acidosis is present, supported by the
alkaline pH despite low serum pH as well as the mild
hypokalemia and the normal anion gap. However, the
very negative urine net charge suggests that his distal
tubular acidification ability is intact and proton secretion
is occurring. Our hypothesis is that in order to
compensate for this chronic respiratory acidosis, his
distal tubular acidification ability had been chronically
maximized possibly by high aldosterone levels and
upregulation of the vacuolar H+-ATPase pump on the
luminal membrane of the α-intercalated cells. This led to
his dependence on distal sodium reabsorption as means
of creating a favorable electronegative gradient for
further proton secretion. Therefore, when he developed
acute respiratory acidosis in combination with severe
volume depletion, the decrease in tubular flow resulted in
inadequate distal tubular delivery of sodium and chloride
leading to sudden inadequate capacity to secrete
protons. Conclusion. We propose that when the patient
became volume depleted, he lost the ability to the
maximally secrete protons because the capacity of his
distal nephron to secrete protons was significantly
abrogated. We characterize this presentation as a unique
case of pseudo-RTA.
83
PP 121
PP 122
FACTORS ASSOCIATED WITH ERYTHROPOIETIN
RESPONSIVENESS IN HEMODIALYSIS PATIENTS
CATHETER-RELATED RIGHT ATRIAL THROMBI IN
DIALYSIS PATIENTS. PRESENTATION, PROGNOSIS,
AND MANAGEMENT
1
N. Petkovic, 2 V. Lezaic, 3 B. Miljkovic, 1 S. Pivasevic,
A. Bozic, 3 K. Vucicevic, 2 M. Stosovic, 2 S. Simic
Ogrizovic, 2 L. Djukanovic
1
Fresenius Medical Care Center, Samac, R. Srpska, BiH
2
3
Faculty of Pharmacy, University of Belgrade, Serbia
1
1
A. Stavroulopoulos, 1 V. Aresti, 2 C. Zounis
Department of Nephrology, “IASIO” Hospital-General
Clinic of Kallithea, Athens, Greece
2
Department of Cardiology, “IASIO” Hospital-General
Clinic of Kallithea, Athens, Greece
1
Background.
Recombinant
human
erythropoietin
(rHuEPO) has revolutionized treatment of anemia in
hemodialysis (HD) patients (pts). However, great
variability of individual pts hemoglobin (Hb) level over
the time, and Hb variability among different pts remains
an important problem. Aim of the study was to analyze
intra- and inter-patient Hb variability and to assess
pharmacokinetic (PK) characteristics of rHuEPO.
Methods. The prospective 12-month study involved 48
pts, aged 67.5±13 years, dialyzed for 43.9±31.7
months and treated with rHuEpo for more than one
year. The intra-individual Hb variability over time was
quantified by the coefficient of variation (CV%)
calculated as the ratio of the standard deviation (SD) to
the mean Hb value. To evaluate the dose-response
effect of rHuEpo therapy erythropoietin resistance index
(ERI) was calculated as the weekly weight-adjusted
dose of rHuEpo divided by Hb level. In 10 patients
pharmacokinetics of rHuEpo was examined after
subcutaneous administration of 75U/kg of rHuEpo.
Predose blood sample and 7-9 postdose samples were
taken. For PK analysis the predose plasma level of
endogenous erythropoietin was subtracted from all
postdose
levels
of
rHuEpo
for
each
pt.
Noncompartmental PK analysis using Kinetica software
was performed in order to calculate relevant
parameters. Results. During one year follow up period
individual Hb level varied between 87-149g/L and
rHuEpo dose between 22-297U/kg/week. CV of Hb in
particular pts ranged between 2.37-16.14% and mean
ERI between 0.29-2.54U/kg/week/gHb. Multiple linear
regression analysis found age, Kt/V and serum albumin
associated with ERI. PK analysis showed that maximum
plasma levels ranged between 20.6-141.7mU/mL
(56.87±34.91mU/mL) and drug exposure to Epo, based
on the partial area under the curve (AUC0→72) between
0.86-5.63Uh/mL (2.14±1.4Uh/mL) being the highest in
pts with the highest ERI. Mean Epo half-life was
33.38±20.94h,
and
its
mean
residence
time
55.49±31.74h, whereas clearance and volume of
distribution were 2.22±1.19L/h and 101.83±44.94L,
respectively. Conclusion. In long-term HD pts’ age,
Kt/V and serum albumin are associated with rHuEpo
hyporesponsiveness. Great variability observed in PK
parameters may be a potential cause of variable
response to the rHuEPo. Our further research will aim in
finding the factors that contribute to PK rHuEpo
variability, and correlate it with PK drug profile.
Background. Catheter-related right atrial thrombus
(CRAT) is a potentially fatal complication in dialysis
patients and the optimal management is controversial.
Aims of our study were to identify prognostic factors of
mortality and to compare treatment options, after
encountering the dilemma while managing a patient in
our hospital. Methods. We conducted a retrospective
analysis of all reported cases of CRAT in dialysis
patients, in English-language literature, in which therapy
and outcome data were available. Results. As of
December 2010, we identified 71 cases of CRAT in
dialysis patients (including our). CRAT was reported with
all types of haemodialysis catheter and complications
(pulmonary emboli, endocarditis or other cardiac
complications, shock) occurred in 42.3% (30/71) of the
cases. Overall mortality was 18.3% (13/71). Survivors
were younger, were dialysed for a shorter period, had
less complications, had the catheter removed or
exchanged, and were more likely to have received
treatment. Bacteraemia alone was not associated with
mortality. In binary logistic regression analysis,
advanced age, not removal of the catheter and presence
of complications were independently and significantly
associated with mortality. Nine patients received no
treatment, except from catheter removal and antibiotics,
four of them died. Systemic thrombolysis was
administered in eight patients, but was successful only
in two with pulmonary embolism, the remaining required
further treatment. Finally, 37 patients received
anticoagulation
and
23
underwent
surgical
thrombectomy (one percutaneous intravascular removal
of the thrombus). Mortality was 16.2% (6/37) and 13%
(3/23), respectively, P=1. Patients who underwent
surgery were younger and had larger thrombus.
Regarding presence of various complications, no
treatment choice was superior over the other. Regarding
thrombus’ size there was no difference in mortality
between the anticoagulation and the thrombectomy
groups. However, five of the six patients who had a
thrombus ³60 mm underwent surgery and all survived.
Conclusion. CRAT is associated with a high mortality
rate in dialysis patients, especially if accompanied with
complications and the catheter is not removed.
Thrombolysis has a poor success rate. Surgical
thrombectomy is not superior to anticoagulation,
however maybe considered in those patients with a
thrombus ³60 mm, or if other treatments fail. In case of
contraindication to anticoagulation and surgery, simple
catheter removal, is an option especially in the absence
of complications. Alternatively, percoutaneous removal
of the thrombus may be performed by experienced
personnel. Nevertheless, the small number of patients
and the design of the current study do not permit for
strict guidelines.
84
PP 123
PP 124
RELATIONSHIP BETWEEN DIABETIC NEPHROPATHY
AND STRUCTURAL CHANGES IN ARTERIES
SERUM MG2+ AND ABDOMINAL AORTA
CALCIFICATIONS IN HEMODIALYSIS PATIENTS
E. Nelaj, M. Gjata, M. Tase
Internal Medicine, University Hospital Center "Mother
Teresa", Tirana, Albania
1
G. Koutroubas, 1 G. Zagotsis, 2 E. Voutsinas,
P. Malindretos, 1 P. Makri, 2 I. Siomos, 1 C. Syrganis
1
Department of Nephrology, General Hospital of Volos
"Achillopoulion", Greece
2
Department of Radiology, General Hospital of Volos
"Achillopoulion", Greece
1
Background. The association between nephropathy,
particularly
microalbuminuria,
and
cardiovascular
disease,
is
becoming
increasingly
apparent.
Atherosclerotic process is a combination of fatty
degeneration (atherosis) and of vessel stiffening
(sclerosis) of the arterial wall. The aim of the study was
to assess relationship between diabetic nephropathy and
structural changes in arteries, such as carotid intima –
media thickness (IMT). Methods. We selected 80 adults
with type 2 diabetes. 47 were women and 33 were men,
mean age 51±14. They were divided into three groups
based on albuminuria status: Group I = no albuminuria
(<30 mg albumin/g creatinine), numbers of patients 27;
Group II = microalbuminuria (30 to 300 mg/g) numbers
of patients 26; and Group III = macroalbuminuria
(>300 mg/g) numbers of patients 27. Albuminuria was
measured by collection of fasting random urine
specimen on arrival to the clinic, usually in the morning.
The IMT was measured by a B-mode ultrasound, 10 MHz
transducer. Each group was evaluated for body mass
index (BMI), glycosylated hemoglobin (HbA1C), lipid
profile, blood pressure. Results. Systolic blood pressure
in the II-group was 143.3±15.2mmHg and significantly
higher (p<0.01) than in the I-group (132.5
±18.1mmHg) and III-group (139.8±18.9mmHg). No
significant differences in age, smoking and kind of
antihypertensive agent used were found between three
groups. IMT level in the II-group was 1.28±0.35mm and
significantly higher than in the I and III group
(1.09±0.28mm; 1.19±0.44mm, respectively). There
were no significant differences in HbA1C, lipid or serum
creatinine between three groups. Conclusion. The
carotid IMT was significantly higher in the patients with
microalbuminuria and so, the last one is associated with
structural changes in arteries.
Background. The past few years, serum Mg2+ has been
correlated with vascular calcifications, cardiovascular
disease and mortality in hemodialysis patients. The aim of
this study was to determine the correlation between serum
Mg2+ and abdominal aorta calcifications in hemodialysis
patients. Methods. Eighty one hemodialysis patients of
our renal unit participated in the study. Their mean age
was 64.2±14.1 years and the median time on dialysis was
76.7 months (from 9 to 233 months). The mean value of
monthly follow-up for the last 12 months was calculated for
serum Mg2+, normalized Ca2+, phosphate, CaxP product,
alkaline phosphatase, intact PTH, Kt/V, total cholesterol,
triglycerides, HDL, LDL and albumin. Abdominal aorta
calcifications (AAC) were evaluated in lateral plain X-ray of
lumbar spine. The severity of the anterior and posterior
aortic calcification was graded individually on a 0–3 scale
for each lumbar segment for the first four lumbar
vertebras. Statistical analysis was performed using
Pearson’s και Spearman’s correlations and multiple
regression analysis. Results. Median value of calcification
score was 8 (25%-75% percentiles 2-17). The mean
values for serum Mg2+, normalized Ca2+, phosphate,
CaxP product were Mg:2.6±0.3mg/dl, Ca:9.3±0.4mg/dl,
P:5.5±1.2mg/dl, CaxP: 50.9±11.9 mg2/dl2 respectively
and median value of iPTH was 264.5pg/ml. In univariate
analysis serum Mg2+ was found to be correlated with age
(cc=-0.301 p=0.006), with CRP (cc=0.425 p<0.001),
phosphate (cc=0.242 p=0.032) and CaxP product
(cc=0.312 p=0.005), while there was no significant
correlation with AAC score, time on dialysis, normalized
Ca2+, iPTH, albumin and Kt/V. In univariate analysis AAC
score was found to be correlated with age (cc=0.473
p<0.001), with CRP (cc=0.237 p=0.033), with presence of
diabetes mellitus (cc=0.309, p=0.005), with presence of
coronary disease (cc=0.638, p<0.001) and triglycerides
(cc=-0.418, p<0.001). In multivariate analysis AAC score
was found to be correlated with age (B=0.123, p=0.018,
95%CI=0.022–0.225), with presence of diabetes mellitus
(B=3.622, p=0.007, 95%CI=1.012–6.233), with presence
of coronary disease (B=7.182, p<0.001, 95%CI=4.541–
9.822), with CRP (B=0.292, p=0.013, 95%CI=0.65–5.19),
with triglycerides (B=-0.018, p=0.037, 95%CI=-0.036–0.001) and there was no significant correlation with time
on dialysis, normalized Ca2+, phosphate, CaxP product,
alkaline
phosphatase,
iPTH,
Kt/V
and
albumin.
Conclusion. AAC was found to be correlated with serum
Mg2+ only when adjusted for CRP. Serum Mg2+ of these
hemodialysis patients was correlated with abdominal aorta
calcifications, as were evaluated with plain X-ray of lumbar
spine, only after adjusted for CRP. AAC were also
correlated with age, with presence of diabetes mellitus,
coronary disease and serum triglycerides.
85
PP 125
PP 126
NEFROLOGY REFERRAL BUT NOT GLOMERULAR
FILTRATION RATE PREDICTS SURVIVAL IN
HEMODYALISIS PATIENTS: A 5 YEARS
PROSPECTIVE OBSERVATIONAL STUDY
MARGINAL ZONE LYMPHOMA WITH CONCURRENT
MEMBRANOPROLIFERATIVE
GLOMERULONEPHRITIS WITH IGMK DEPOSITS IN
AN ANTI-HCV POSITIVE PATIENT: THE RENAL
BIOPSY AS A POWERFUL DIAGNOSTIC VALUE
G. Selim, O. Stojceva - Taneva, L. Tozija, N. Stojcev,
S. Gelev, P. Dzekova, L. Trajcevska, S. Pavleska, M.
Popov, A. Sikole
University Clinic of Nephrology, University “Sts. Cyril and
Methodius” Skopje, R. Macedonia
1
E. Chelioti, 1 S. Mikros, 1 E. Chrisanthopoulou,
M. Sotiraki, 1 T. Fragou, 2 L. Nakopoulou,
2
G. Papadakis
1
Department of Nephrology and Renal Unit, General
Hospital of Piraeus “Tzaneio”, Athens, Greece
2
1st Laboratory of Pathology, Athens University Medical
School, Athens, Greece
1
Background. The objective of the study was to
estimate the eventual influence of nephrology referral
upon the relationship of timing of dialysis initiation and
survival in haemodialysis (HD) patients. Methods. We
studied the data of a total of 208 patients who started
HD treatment in our department from 1996 to 2006
(mean age at start of HD 50.55±15.03 years). The time
intervals between the first evaluation by a nephrologist
and the date of the first HD were categorized as early
(ER>12 months) or late (LR<12months) referral. We
defined the initiation of dialysis as early start (E-start) if
the estimated glomerular filtration rate (GFR calculated
with the use of the Cockcroft–Gault equation) was ≥7.5
mL/min/1.73m² or late start (L-start) if GFR was <7.5
mL/min/1.73 m2. Patients were classified into four
groups according to nephrology referral and GFR (ER
with E-start and L-start; LR with E-start and L-start). We
evaluated the effects of nephrology referral and GFR at
start on HD on all-cause mortality after long-term
follow-up on HD. Results. Among the 208 patients
analysed, 32.7% started HD in the ER group and 67.3%
in the LR group. At the start of HD, ER and LR patients
with L-start had significantly higher levels of urea and
creatinine than ER and LR patients with E-start. The 24h
urine output was significantly higher in ER with E-start,
albumin and ejection fraction were significantly lower in
LR with E-start. HD duration (in months) was
significantly longer in ER and LR with L-start
(100.48±75.50 and 95.10±51.51), compared to ER and
LR with E-start (79.74±64.17 and 67.27±51.46;
p=0.016). During a follow-up, 45 of 103 patients in the
E-start group (43.7%) and 50 of 105 in the L-start
group (47.6%) died, without a significant difference in
survival between the groups (log rank, p=0.567). But,
regarding nephrology referral, 20 of 68 patients in ER
(29.45%) and 75 of 140 patients in LR (53.6%) died,
with significantly lower survival in LR group (log rank,
p=0.0005). The survival rate by Kaplan-Meier analysis
in the four groups showed a significantly lower mortality
only in ER with L-start group (χ2 =11.78, p=0.008),
whereas no significant difference was seen in mortality
between the other three groups (ER with E-start, LR
with E-start and LR with L-start). Conclusion. This
study showed that nephrology referral above 12 months
and late start of dialysis (GFR<7.5 mL/min/1.73 m2)
was associated with a reduced risk of mortality.
Background.
The
presence
of
nephrotic-range
proteinuria and severe renal impairment in the context
of a chronic inflammatory state like hepatitis C infection
is usually attributed to secondary Membranoproliferative
Glomerulonephritis (MPGN) and concomitant type II
cryoglobulinemia, although reports of other types of
renal implication appear occasionally. In these cases the
pattern of glomerular basement membrane IgM deposits
is rarely observed. On the other hand, renal implication
in the course of lymphoproliferative disorders has been
recognized and reported sporadically. In these cases,
glomerular injury is usually the direct effect of renal
parenchymal infiltration by lymphoid cells originating
from remote loci. In a recent study of 18 patients with
concomitant lymphoproliferative disorder and renal
injury, it was the renal disorder that predominated
clinically and the lymphoid tissue neoplasm was
diagnosed after a renal biopsy. Methods. A 50-year-old
male with a history of alcohol and IV drug abuse,
chronic HCV infection presented in a uremic state that
necessitated the urgent initiation of dialysis treatment.
Considering the history of the patient and after
excluding and treating all other causes of renal function
deterioration, our initial diagnostic approach pointed
towards a HCV-related renal offence in the context of
cryoglobulinemia. However, the rapid decline of renal
function,
the
hypoalbuminemia,
anemia,
thrombocytopenia, the signs of glomerular involvement
(urine red blood cells = 40 – 60/HPF, 24-hour urine
proteins = 3.06g) and the absence of radiologic signs of
end stage renal disease (normal sized kidneys with high
echogenicity) suggested the performance of a kidney
biopsy. Results. The renal biopsy findings were
consistent with the initial suspicion, except the dominant
monoclonal IgMκ glomerular basement membrane
deposits and the abundance of strongly IgM-positive
lymphoid cells infiltrating the interstitium. Subsequent
imaging exploration revealed hepatosplenomegaly
without any clinical or radiological sign of lymph node
involvement. The hematological workup of the patient
and the immunophenotype was consistent with the
lymphoplasmacytic
lymphoma
–
marginal
zone
lymphoma spectrum of small B cell lymphomas with
plasmacytic differentiation. Conclusion. The evolution
of the patient and the subsequent emergence of MPGN
secondary
to
IgMκ
deposits
and
monoclonal
gammopathy by B-cell lymphoproliferative disorder as
marginal zone lymphoma is a rare diagnosis. Similar
cases should arouse the level of suspicion to all
clinicians and emphasize on the value of renal biopsy as
a powerful diagnostic means when appropriate.
86
PP 127
PP 128
A NOVEL PROGNOSTIC MODEL FOR PREECLAMPSIA
EXCESSIVE HAIR GROWTH IN A FEMALE KIDNEY
TRANSPLANT RECIPIENT. A RARE CASE OF AN
OVARIAN SEROUS CYSTADENOMA
B. Gerasimovska-Kitanovska, K. Zafirovska,
S. Bogdanovska, L. Lozance
University Department of Nephrology, Skopje, FYROM
1
M. C. Prikis, 2 V. Zeniou, 2 M. K. Picolos
Transplantation Unit, Nicosia General Hospital,
University of Cyprus, Nicosia, Cyprus
2
Endocrinology Clinic, Lakatamia, Cyprus
1
Background. The aim of this study is to provide provide
prediction of preeclampsia through a novel integrated
prognostic model. Methods. A total of 120 gravid
patients, referred to the University Department of
Nephrology in Skopje for preexisting or newly
discovered hypertension in pregnancy were followed in
the period 2008-2010. data on risk factors were
obtained at the first control at the Department. At every
control, biochemical and biophysical parameters were
followed: 24 hour blood pressure monitoring, D-dimers
and in 32nd gestation week, an analysis of the
resistance index of the Doppler of umbilical artery.
Outcome was defined as a group with and a group
without preeclampsia. The integrated prognostic model
was calculated by the method of determination of apriori
and aposteriori risk. Statistical analyses were made by
the use of the SPSS 13.0 software. Results. The
examined population, was divided after delivery into 2
groups: a group with preeclampsia (N=51), and a group
without preeclampsia (N=69). The integrated prognostic
model comprised three steps: first, determination of
apriori risk. From the risk factors that were significant at
the univariant analysis, by the use of multivariant
logistic regression, the following were determined as
predictors of preeclampsia- age above 35 years and use
of dual antihypertensive therapy (p=0,09 and p=0,032
respectively). The logistic regression is the basis of
determination of the apriori risk of preeclampsia, which
equals 3,95%. The second step in the model was logistic
regression of biochemical parameters and determination
of the likelihood ratio for preeclampsia, that equal
LR+=1,8 for the first, LR+=2 for the second and
LR+=2,2 for the third trimester. The third step was
determination of the log MoM for the 24 hour blood
pressure analysis and D-dimers, entered into logistic
regression, and equalling LR+=1,3 for the first
trimester, LR+=2,1 for the second trimester and
LR+=2,3 for the third trimester. The aposteriori risk was
obtained by multiplication of apriori risk by likelihood
ratios. Thus, aposteriori risks for the first trimester were
9,2 for the second trimester 16,6 and for the third
trimester 19,9. The aposteriori model was able to detect
preeclampsia correctly by 90% in the second trimester.
Conclusion. The integrated prognostic model offers
possibilities for an apriori and aposteriori assessment of
risk, thus correctly detecting 90% of patients with
preeclampsia from the second trimester of pregnancy.
Background. Immunosuppressive medications, such as
calcineurin inhibitors and/or glucocorticoids, widely used
in
multiple
regimens
for
maintenance
immunosuppression in transplantation, very frequently
cause the appearance of excessive hair growth, a
condition called hypertrichosis. However, excessive hair
growth in the post transplant period can occasionally
have
a
different
underlying
cause.
Therefore,
hypertrichosis must be carefully distinguished from
hirsutism, a different form of excessive hair growth.
Hirsutism is defined medically as excessive terminal hair
that appears in a male pattern (i.e., sexual hair) in
women. Although hirsutism is often regarded as a purely
cosmetic problem, it can result from an increased
androgen level or oversensitivity of the hair follicle to
androgens. In postmenopausal women, hirsutism is
often seen due to autonomic or gonadotrophin driven
androgen producing ovarian tumors. Case report. In
this report, we present a 62-year old postmenopausal
woman with stable kidney function after kidney
transplantation, who presented with hoarsness and
excessive hair growth on the chest, back, face,
abdomen, and lower extremities. Her medications
included tacrolimus, mycophenolic acid and prednisone
Testosterone levels were elevated (10.40 nmol/L),
prolactin and DHEA-S plasma levels were lower than
normal, and FSH and LH levels were normal. Initially,
pelvic ultrasound examination and later computerized
tomography revealed a large well outline cystic lesion of
approximately 13 x 10 cm in the center of the small
pelvis causing compression and displacement of the
urinary bladder and the bowel. Serum tumor marker
(CA-125) was normal (3.0 IU/ml). Histology revealed a
left ovarian serous cystadenoma with no signs of
malignancy. Postoperatively, progressive regression of
the hirsutism was noted with normalization of the
hormonal levels. Conclusion. We conclude that
excessive hair growth in the female kidney transplant
recipient on calcineurin inhibitors and glucocorticoids,
should not be simply attributed to hypertrichosis due to
these medications. On the contrary, thorough history
taking and physical examination may distinguish
between hypertrichosis and hirsutism leading to the
correct diagnosis and treatment.
87
PP 129
PP 130
THE IMPORTANCE OF ARTERIOVENOUS
HEMODIALYSIS GRAFTS SURVEILLANCE BY
REGULAR MEASUREMENTS OF BLOOD FLOW
BIOCOMPATIBILITY CHARACTERISTICS AMONG
THE NEWER HEMODIALYSIS MODALITIES - A
RANDOMIZED PROSPECTIVE CROSSOVER STUDY
1
1
K. Kantartzi, 1 S. Panagoutsos, 2 C. Tsigalou,
E. Mourvati, 1 V. Devetzis, 1 P. Passadakis,
1
V. Vargemezis
1
Greece
2
Biochemistry Laboratory, University Hospital of
Alexandroupolis, Greece
K. Leivaditis, 1 S. Panagoutsos, 1 E. Mourvati,
A. Roumeliotis, 1 V. Devetzis, 2 M. Lazaridis,
1
V. Vargemezis
1
Greece
2
Department of Vascular Surgery, Democritus University
of Thrace, University General Hospital of Alexandroupolis,
Greece
1
1
Background. During hemodialysis (HD) session, the
overproduction of inflammatory and endothelial cell
markers has been implicated in the bioincombatibility of
the modality. This production has been linked to the
activation of mononuclear cells of the peripheral blood,
as a result of their contact with the hemodialysis
materials (membrane, dialysate, and replacement
solution). The aim of this study was to evaluate the
changes in serum levels of proinflammatory markers,
among different hemodialysis methods: convective HD,
on line hemodiafiltration (OHDF), and hemodiafiltration
with prepared bags (HDF) using the same hemodialysis
membrane. Methods. Twenty four (24) patients (5
females and 19 males), aged 62±13 years old,
undergoing chronic HD treatment for 31±23 months,
were recruited and randomized for a year cross over
study. Trimesters bicarbonate dialysis sessions of 240
minutes, three times a week, had been scheduled for
each one of the three different modalities HD, OHDF,
HDF. All the modalities were conducted with polysulfone
membranes and ultrapure dialysis fluid, while samples
were drawn at the end of each treatment period. The
serum levels of interleukins IL-1β, IL-6, IL-10, TNFa, hsCRP and the soluble adhesion molecules sICAM-1,
sVCAM-1, E-Selectin and L-Selectin were compared
among modalities. Results. All the evaluated factors
were significant elevated, except for IL-10 and TNF-a,
that were significantly reduced after a 4-hour session,
independent of the modality used. (Table 1) Also no
statistical significant difference was revealed for the
values between the three hemodialysis methods. (Table
2) Conclusion. These results indicate that among the
different HD modalities, the online production and use of
the replacement solution during online hemodiafiltration,
does not negatively affect the biocombatibility cha
racteristics, favoring its clinical use.
Background.
Despite
the
fact
that
regular
postoperative
vascular
access
surveillance
is
recommended by current guidelines, it is not yet
established in daily clinical practice. This is mostly
because the results from studies about various methods
of vascular access monitoring are conflicting. The aim of
the present study is to evaluate the surveillance of
arteriovenous hemodialysis grafts function by regular
measurement of blood flow. Methods. Thirty six
polytetrafthoroethylene
(PTFE)
grafts
from
29
hemodialysis patients were prospectively assessed by
measurement of blood volume flow every three months.
Two different methods of flow measurement were
applied-the optodilution method with the use of the
CRITLINE III device (Delta-H method) and the colour
Doppler ultrasound method. Measurements from both
methods were comparatively evaluated. Blood flow from
thrombosed or strenosed grafts was compared to that
from well functioning grafts. Primary and cumulative
survival was estimated by Kaplan-Meier analysis.
Results. Eleven grafts out of 36 were thrombosed
during the study period. Stenosis was detected in 7
grafts and they were timely referred for surgical repair
or percutaneous transluminal angioplasty. One and twoyear primary graft survival were 78% and 47%
respectively. One and two year cumulative survival were
83% and 63% respectively. Blood flow from stenosed or
thrombosed grafts was significantly lower compared to
well functioning grafts. (831 ± 234 vs 1429 ± 693
ml/min, p = 0,017 for optodilution method and 664 ±
240 vs 990 ± 236 ml/min, p < 0,001 for Doppler
ultrasound
method).
Conclusion.
Blood
flow
measurement by colour Doppler ultrasound is associated
with good one and two- year primary and cumulative
graft survival. It is also very useful in early detection
and correction of graft dysfunction.
88
PP 131
PP 132
COIL EMBOLIZATION OF A RENAL ARTERY
ANEURYSM
NOCTURNAL NATRIURESIS IN RELATION TO THE
CIRCADIAN PHENOTYPE OF ARTERIAL BLOOD
PRESSURE
1
P. Kriki, 2 V. Souftas, 1 A. Roumeliotis, 1 T. Bounta,
E. Thodis, 1 P. Passadakis, 1 V. Vargemezis
1
Greece
2
Department of Radiology and Medical Imaging,
Democritus University of Thrace, University General
Hospital of Alexandroupolis, Greece
1
1
G. Ntatsis, 1 A. Zagorianakos, 2 D. Poulikakos,
S. Ziakka, 1 N. Kaperonis, 1 V. Kolovos, 3 A. Kalafati,
3
G.Mitsiou, 1 A. Sgantzos, 1 N. Papagalanis
1
Department of Nephrology, Red Cross Hospital
"Korgialenio-Benakio", Athens, Greece
2
Renal and Transplantation “St George” Hospital,
London, UK
3
Department of Biochemistry, Red Cross Hospital
"Korgialenio-Benakio", Athens, Greece
1
Background. Since there is an increase in the
abdominal imaging in the patients’ evaluation, the
incidence of renal artery aneurysms is likely to increase.
Several surgical and percutaneous methods have been
proposed for the management of such aneurysms,
although clear indications for each therapeutic procedure
to repair the aneurysms are lacking. Case report. We
herein report a case of coil embolization of a right renal
artery aneurysm that was noted during the evaluation
for arterial hypertension on computed tomography (CT),
in a 24-year-old patient. The CT angiography of the
abdominal aorta and abdominal arteries revealed an
aneurysm of the anterior superior right renal segmental
artery. The patient underwent a full work up and other
causes of secondary hypertension were excluded. At the
time that hypertension was diagnosed he was prescribed
on angiotensin receptor inhibitor with adequate control
of his Blood Pressure. A CE-MR angiography revealed a
12mm x 10mm right renal artery aneurysm arising from
the bifurcation of the right renal artery. A 64- channel
MDCT angiography followed, which suggested that the
aneurysm was possibly arising from the superior
segment of the renal artery. The patient denied any
complaints of abdominal or back pain as well as any
change in urinary habits. Besides no variation was
observed in the patient’s renal function (serum levels
Crea=0.8mg%, urea=46mg%, Clcr=118ml/min/1.72m2.
A diagnostic intra artery selective angiography and coil
embolization of the aneurysm was performed. Five
electrolytic detachable platinum coils were proceeded
through a microcatheter into the central section of the
aneurysm, so no occlusion of the segmental artery
occurred The patient remained stable during and after
the procedure. He was prescribed on antiplatelet drugs
for 2 weeks only. Coil embolization was successfully
completed. Reduction in blood pressure and a no further
requirement for antihypertensive medications has been
well documented. At follow-up one month and six
months later, Doppler duplex ultrasound revealed no
arterial obstruction. Moreover the patient had retained
normal blood pressure. A new CE-MRA is going to be
performed one year after the procedure. Considerable
controversy surrounds the management of the real rare
renal artery aneurysms and neither the proper
technique, nor the indication for intervention, has been
established. Conclusion. Treatment decision should be
based upon patient age, gender and symptoms and the
experience of the center. Recently percutaneous
techniques for the embolization of aneurysms have been
well described, while their clinical and angiographic
success rates, are high and early data are encouraging.
Background. It is well known that the nondipping of
blood pressure (BP) is associated with the disorder of
the circadian rhythm of sodium excretion and an
increase in nocturnal natriuresis. It has been assumed
that this is due to an adaptive mobilization of the
mechanism of pressure natriuresis during the night
because of the diminished ability of natriuresis during
the day. However, until today, this hypothesis has not
been directly tested. Apart from this, there are
indications that a circadian regulation of the renal
tubular transport systems exists, which in turn could
primarily modify the natriuretic ability independently of
the systemic BP and of sodium which is handled by the
kidney. The aim of this study is to identify the predictors
of nocturnal natriuresis and to explore the hypothesis
that the ability of nocturnal natriuresis differs primarily
in relation to the circadian phenotype of BP. Methods.
The circadian rhythm of BP and sodium excretion,
respectively, were measured in three consecutive daily
intervals, two daytime and one nighttime, in 40 patients
(23 dippers) with proteinuric non-diabetic renal disease
and mild hypertension whose daily intake of food (and
sodium) occurred exclusively during the second daytime
interval. This specific study design allowed the
distinction between nocturnal sodium excretion and
nocturnal sodium load, the latter of which is defined as
the quantity of sodium which remains in the body during
the start of the nocturnal interval (daily sodium intake
minus the sodium excretion during the second daytime
interval), and the calculation of the effectiveness of
nocturnal natriuresis. Results. The nocturnal sodium
load was increased in nondippers vs. dippers (95.1±32.7
vs. 60.4±32.8 mmol Na, p=0.002) and the difference
remained significant after adjustment for the daily
sodium intake (p<0.0005). The rate of nocturnal
natriuresis, after adjustment for the nocturnal sodium
load and nighttime blood pressure, is significantly
greater in nondippers vs. dippers (7.1 as opposed to 4.5
mmol Na/h, p<0.0005). During the nighttime, the
nondippers as opposed to the dippers, excreted a
greater
percentage
of
nocturnal
sodium
load
(66.1±9.2% vs. 42.5±12.2%, p<0.0005), and had a
three times greater nocturnal natriuresis gain (2.2±1.0
vs. 0.8±0.5, p<0.0005). In general linear models
analysis, the nocturnal sodium load and BP,
respectively, did not exert a significant effect on these
differences. Conclusion. In conclusion, these findings
suggest that additional factors besides the nocturnal
sodium quantity and volume and the nighttime BP are
responsible for the increased nocturnal natriuresis in
nondippers vs. dippers.
89
PP 133
PP 134
ASCITES IN HEMODIALYSIS PATIENTS – FOUR
CASE STUDY
AUTONOMIC DYSFUNCTION IN PREDIALYSIS AND
H. Resić, F. Mašnić, N. Kukavica
Clinic for Hemodialysis, Clinical Center University of
Sarajevo, Bosnia and Herzegovina
1
G. B. Perunicic-Pekovic, 1 S. Pljesa,
Z. Rasic-Milutinovic, 1 L. Komadina, 1 H. Heydari,
1
V. Djurkovic, 1 R. Markovic, 1 N. Zec, 1 L. Lambic,
3
B. Milovanovic
1
Department of Nephrology, University Hospital Zemun,
Serbia
2
Department of Endocrinology, University Hospital
Zemun, Serbia
3
Department of Cardiology, University Hospital
Bezaniska Kosa, Serbia
2
Background.
Ascites
indicates
a
pathological
accumulation of fluid in the abdominal cavity and the
most frequent complications of liver cirrhosis. Ascites
occurs when the amount of lymph formed in the
abdominal cavity exceeds the resorptive ability of the
lymphatic system. Dialysis or nephrogenic ascites is a
clinical diagnosis defined as refractory ascites in patients
with end-stage renal disease, and presents a complex
diagnostic problem with poorly understood etiology and
pathophysiology. The appearance of fluid in the
abdominal cavity can be detected by physical
examination, ultrasound and CT abdomen, after which it
is paracentesis, ascites fluid and analyzed biochemically
and microbiologically. Diagnosis of ascites must be
established by excluding other causes. Patients often
have moderate to massive ascites, associated with
cachexia. Morbidity and possible mortality of this
complex problem are significant. Evaluation of four
cases of hemodialysis patients present with signs of
dialysis ascites. Case reports. We present three men
and one woman, mean age 48.75 years and average
duration of hemodialysis of 72 months, who are on
chronic hemodialysis three times a week and who have
clinically verified ascites. The study included four
patients, three males (75%) and one female (25%) who
were on chronic hemodialysis therapy, at the Clinic for
Hemodialysis, Clinical Centre University of Sarajevo and
who have clinically verified ascites. Primary renal
disease
in
our
four
patients
was
chronic
glomerulonephritis of unknown etiology. As comorbidity
in two patients there are signs of congestive heart
failure. One patient had hepatitis C infection and
clinically verified compensated cirrhosis. None of the
patients had signs of peripheral edema. All patients
underwent abdominal paracentesis of ascites in several
occasions. Patients were followed-up for four years. One
patient had 18 paracentesis in almost two years; one
had 8 paracentesis from 2009. One female patient
included in the study had in total five paracentesis from
2008, and one patient with mental retardation had only
one in 2010. Ascites fluid was analyzed biochemically
and microbiologically, in the search for primary cause of
ascites formation. Patients had intensified hemodialysis
therapy, with albumin and plasma compensation,
together with reduced intake of fluid and salt. One of the
four patients included in the study, had no clinical signs
of ascites for 35 months. Conclusion. 5% of dialysis
patients have so-called dialysis ascites of unknown
etiology, as was shown in our study.
Background. Autonomic dysfunction (AD) in patients
with renal insufficiency is one of the components of
uremic neuropathy. AD can complicate uremia and
promote sudden death. In this cross-sectional study, we
investigated the effect of hemodialysis treatment on
uremic autonomic dysfunction with time-domain and
frequency-domain heart variability. Methods. Fourteen
predialysis patients were the first investigated
group.Second group was eig hteen haemodialysis
patients who had been on regular hemodialysis
treatment were selected from our unit. The exclusion
criteria was diabetes mellitus. The mean time spent on
hemodialysis was 34 ± 26 month. Blood concentrations
of urea, creatinine, lipids parameters, C-reactive protein
(CRP) were examined of laboratory parameters and the
adequacy of hemodialysis by Kt/V,as an index of
fractional urea clearance was investigated. Standard
cardiovascular reflex tests were performed. Power
spectral analysis was used to investigate R-R interval
variability and was calculated through both, time domain
SDNN, rMSSD and frequence domain analysis, very low
frequency power (VLF), low frequency power (LF), high
frequency power (HF) and LF/HF power. Results.
Cardiovascular tests have shown the prevalence of
parasympathetic dysfunction (all three tests were
positive- Valsalva test, Deep breathing test and Heart
rate response to tilt), without significant difference for
sympathetic response (hand grip test and head-up tilt
test). In time-domain analysis, significant increases in
all parameters were observed in hemodialysis patients
(p<0.01). In frequency-domain analysis, low frequency
and high frequency spectral power were found to be
significantly
increased
in
hemodialysis
patients
(p=0.005), but the LF/HF ratio was not different from
predialysis period. Conclusion. It was concluded that
autonomic dysfunction in hemodialysis patients is
reversible and hemodialysis reverses the sympathetic
and parasympathetic autonomic dysfunction.
90
PP 135
PP 136
VITAMIN D SERUM LEVELS IN PATIENTS ON
HEMODIALYSIS AND AFTER KIDNEY
TRANSPLANTATION
RETROSPECTIVE ANALYSIS OF HAEMODIALYSIS
POPULATION AND DIALYSIS POLICY 2003-2010:
SINGLE CENTRE EXPERIENCE
P. Giamalis, C. Dimitriadis, D. Ekonomidou, C. Pliakos,
I. Stavrinou, A. Belechri, G. Efstratiadis, D. Memmos
Department of Nephrology, Aristotle University,
“Hippokration” General Hospital Thessaloniki, Greece
J. Popovic, N. Dimkovic, Z. Djuric, G. Popovic,
T. Djordjevic, T. Damjanovic, D. Jovanovic
Department of Nephrology, Zvezdara University Medical
Centre, Belgrade, Serbia
Background. Vitamin D deficiency is frequently
recorded in the general population and has been
associated with increased risk of bone fractures, cancer
and autoimmune disorders. Observational studies
suggest that vitamin D deficiency or insufficiency
(25OHVitD serum levels <20ng/ml or between 20 to 30
ng/ml respectively are even more prevalent in chronic
kidney disease patients and therefore regular screening
and oral or intravenous supplementation has been
proposed. However, vitamin D testing is not routinely
implemented worldwide or in Greece. Aim of the study
was to estimate serum vitamin D levels in patients (pts)
on hemodialysis (HD) or with kidney transplantation
(KT), living in Northern Greece and assess the
prevalence of vitamin D insufficiency and deficiency.
Methods. 99 HD pts and 45 KT pts were enrolled in the
study. Serum levels of 25(OH)VitD and 1,25(OH)2VitD
were measured using IRMA(Biosource, Diachel) and
were correlated with serum levels of calcium,
phosphorus, and intact parathyroid hormone (iPTH). The
first two were measured on a biochemical analyzer,
while parathyroid hormone was measured with IRMA
(Immunotech, Marseille, France). Results. Mean age
was 64 and 45 years, for HD and KT patients
respectively, while glomerular filtration rate was 59 ±14
ml/min for KT pts. In HD pts, serum levels of
25(OH)VitD were 14.4 ±9.9 ng/ml, 1,25(OH)2VitD
2.8±3.1 pg/ml, calcium 9.0±0.6 mg/dl, phosphorus
5.5±1.5 mg/dl and iPTH 307±276 pg/ml. 95% of pts
had deficiency (<30 ng/ml) and 77% had insufficiency
of 25(OH)VitD, while all pts had 1,25(OH)2VitD
deficiency (< 20pg/ml). In KT pts, serum levels of
25(OH)VitD were 35.5±20.2 ng/ml, 1,25(OH)2VitD
33.1±14.7 pg/ml, calcium 9.7±0.6 mg/dl, phosphorus
3.3±0.7 mg/dl, iPTH 84±78 pg/ml. 45% of KT pts had
25(OH)VitD deficiency and 13% had insufficiency, while
18% had 1,25(OH)2VitD deficiency. 28/99 (28%) of HD
pts and 20/45 (44%) of KT pts were treated with active
Vitamin D compounds or paricalcitol. There was an
inverse correlation between 25(OH)VitD serum levels
and patient age and phosphorus levels in HD pts, but
not in KT pts. Conclusion. Vitamin D deficiency is
prevalent in the majority of pts on hemodialysis, but is
also encountered in a large proportion of patients with
kidney transplantation.
Background. The steady increment of age in prevalent
and new patients starting RRT worldwide is well
demonstrated. ESRD due to diabetes is also rising,
reaching a plateau in developed countries. Elderly
patients and diabetics have increasing number of comorbidities. We aimed to assess possible differences in
characteristics of our incident and prevalent HD
patients; implementation of advances in HD technology
and individualization of dialysis procedures in order to
improve patient outcomes and quality of life. Methods.
Retrospective study of our HD population (2003-2010)
was conducted. Statistical analysis was performed using
t-test and chi-square test. Results. Age of prevalent
patients increased significantly. The mean age of new
ones varied from 57 to 61.5 years, population >65
ranging from 34.4% to 48.8%. Results are presented in
Table 1. Together with the gradual rise in diabetic
prevalent and incident patients as well as in the ones
with vascular disease, we registered increased use of
vascular grafts (AVG) and permanent vascular catheters
(PVC). AVG or PVC were the first vascular access in
7.3% of patients initiating HD after 2005. Even so,
mortality rate decreased due to individualized
treatment. We adjusted dialysers and concentrates,
applied blood temperature and blood volume control,
sodium and ultrafiltration profile and prolongation of HD
sessions to 18h weekly according to patients' need. Also,
hemodiafiltration and ESA use increased and anti-HCV+
prevalence decreased. The main causes of death were
cardiovascular,
malignancies,
infections
and
cerebrovascular. Malignancy mortality rate rose from
10.5% (2003-2006) to 16.4% (2007-2010); 24.3% of
deceased were diabetics, 23.2% initiated HD with a prior
diagnosis of myocardial infarction, CVI, peripheral
vascular disease. The longest HD vintage was in
deceased 2009 and 2010 (119.3 and 88.1 months
respectively) and oldest were the ones that died in
2010. Conclusion. Data obtained revealed unfavorable
changes in characteristics of HD population (increase in
both age and diabetic patients, numerous comorbidities). Mortality rate decreased despite the rise in
malignancy-specific
mortality
and
increased
cardiovascular and peripheral vascular morbidity prior to
HD. Implementation of efficient HD technology and
individualization of treatment helped to improve both
quantity and quality of life.
91
PP 137
PP 138
HEMODIALYSIS POPULATION DIFFERENCE IN
NUTRITIONAL STATUS AFTER 23 YEARS
WHAT ARE THE MOST FREQUENT CAUSES OF
PERITONITIS IN CAPD PATIENTS: SIX YEAR STUDY
1
1,2
1
1,2
Background. In our hemodialysis center almost all
population of patients were changed after 23 years. In
1988 anthropometric measures were done for the first
time in our center. Acetate dialysis and cuprophane
membrane were used in majority of patients but
erythropoietin-stimulated agents (ESA) were deficient in
that time. In order to find out how advent of high flux
synthetic membrane, bicarbonate dialysis, ESA and
possibly many other factors influenced on nutritional
status of the patients these results were compared with
anthropometric parameters in present time. Methods.
In 1988 total of 98 patients (50 men, average age 52
years, HD vintage median 23 months) and in 2011 total
of 108 patients (51 men, average age 54 years, HD
vintage
mediane
101
moths)
were
examined.
Anthropometric measurements from 1988 (dry body
weight, body mass index, midarm circumference,
midarm muscle circumference, percentage of body fat)
and laboratory parameters (hemoglobin, albumin) were
compared
with
parameters
from
2011.
All
anthropometric measurements were preformed by the
same investigator. T – test for independent samples
were done. Results. In 1988, men had significantly
lower anthropometric measurements comparing to men
in 2011 but not significantly lower serum albumin
concentration. Contrary, there is no significant
difference
in
anthropometric
parameters
and
albuminemia between women in 1988 and in 2011.
Hemoglobinemia was significantly higher in all HD
patients from 2011 compared to all patients from 1988
as it was expected and it was related to ESA.
Conclusion. In present time, men had better nutrition
status but the women not, compared to 1988.god.
Unfortunately, according that majority parameters were
unavailable in 1988, we are not able to completely
understand these differences.
Background. Peritonitis still remains one of the most
serious complications in patients on continuous
ambulatory peritoneal dialysis (CAPD) treatment.
Therefore, the aim of the present study was to analyze
the causes and outcome of peritonitis in CAPD patients
during six-year period. Methods. Two hundred fifty four
patients (149 males, aged between 22 and 83, mean
60.1 ± 12.9 years), treated with CAPD between 3 and
145 (28.1±23.2) months were analyzed. Diagnosis of
peritonitis was made based on the number of white
blood cells and culture from the first peritoneal dialysis
fluid, as well as signs of inflammation, e.g. number of
white blood cells, ESR, levels of fibrinogen and CRP.
Results. During six-year period 149 (58,7%) patients
had 362 peritonitis episodes which means one episode
per 19.7 patient’s months. During the analyzed period
65 exit site infections were found in 35 CAPD patients.
All patients had positive inflammatory signs and
pathological number of white blood cells in dialysis
effluent. The most common causes of peritonitis in our
CAPD patients were Staphylococcus spp (125) and
sterile peritonitis (86), followed by Enterococcus and
Pseudomonas (23), Staphylococcus aureus (20) and
Klebsiella (17). The most common causes of exit site
infections were Staphylococcus spp and Staphylococcus
aureus (15), Pseudomonas (13) and Candida (9). After
antibiotic therapy based on culture of peritoneal effluent
313 (86.5%) patients recovered and continued CAPD
treatment, 22 (6.1%) patients started hemodialysis
treatment and 27 (7.4%) patients died. Conclusion.
Accordingly, we can conclude that our CAPD patients
had one peritonitis per 19.7 patient’s months, that the
most common cause of peritonitis was Staphylococcus
spp and for exit site infections were Staphylococcus spp
and Staphylococcus aureus and that 86.5% of CAPD
patients recovered after this serious complication and
continued CAPD treatment.
M. Stosovic, 1 M. Stanojevic, 1 S. Pejanovic,
S. Simic-Ogrizovic, 1 D. Jovanovic, 2 N. Vasiljevic,
1
R. Naumovic
1
Serbia
2
Institute of Hygiene and Medical Ecology, University
School of Medicine, Belgrade, Serbia
D. Jovanovic, 2 M. Stosovic, 2 N. Jovanovic, 2 Z. Dokic,
R. Naumovic
1
School of Medicine, University of Belgrade, Belgrade,
Serbia
2
Clinic of Nephrology, Clinical Center of Serbia,
Belgrade, Serbia
92
PP 139
PP 140
PRIMARY AVF-OBJECTIVES AND HOW TO ACHIEVE
THEM
PREVALENCE OF RISK FACTORS FOR CHRONIC
KIDNEY DISEASE IN BALKAN ENDEMIC
NEPHROPATHY FOCI
1
T. Jemcov, 1 M. Milinkovic, 2 I. Kuzmanovic, 2 M. Dragas,
N. Jakovljevic, 2 I. Koncar, 2 N. Ilic, 2 L. Davidovic
1
Clinic of Nephrology, Clinical Center of Serbia, Serbia
2
Clinic for vascular and endovascular surgery, Clinical
Center of Serbia, Serbia
2
1
1
5
1
2
3
Background. Hemodialysis is one of the methods for
renal replacement therapy, which achieves a partial
correction of homeostatic disorders which are due to
renal insufficiency. Condition for effective hemodialysis
is the existence of adequate access to the systemic
circulation-vascular access. Vascular access are divided
into: 1. native arteriovenous fistula (AVF), 2.
arteriovenous grafts (AVG), 3. tunnelised catheters (TC)
and 4. short-term catheters (BC). Compared to other
types of vascular access AVF have many advantages:
reduced risk of infection, thrombosis, greater blood flow,
resulting in greater effectiveness of hemodialysis, longer
life, lower maintenance costs, and avoidance of
complications, placement and use of central venous
catheters. Objectives of our study were to evaluate the
frequency of native AVF in the Department of
Nephrology, Clinical Center of Serbia, and assessment of
CDU examination effectivness before creating vascular
access. Methods. We analyzed the number and type of
vascular access created in the Department of
Nephrology in the period since January 2003. until
January 2011. Results In 2003. we created a total of 21
vascular access without preoperative CDU examination.
Total
6
(28.5%)
vascular
access
required
reinterventions.
Number
of
reintervention
was
significantly reduced in 2004, when each vascular access
preceded, both clinical and CDU examination (a total of
62 vascular access, 14.5% for reintervention) - p =
0.29. In 2003, we created 38 AVF (88%), in 2004. 99
(86%), 2005. 76 (91%), 2006. (81%), 2007. 73 (81%),
2008. 56 (85%), 2009. 62 (87%) and in 2010. 81
(81%) native AVF. Since 2004. in each patient
preoperative
period
implied
CDU
examination.
Conclusion. The introduction of the CDU examination
as a mandatory part of the preoperative diagnosis
significantly increases the percentage of successfully
created vascular access. This approach also led to a high
percentage of native AVF in the Department of
Nephrology, compared to other types of vascular access,
and this was in accordance with the European
recommendations and guidance for vascular access
(EBPG) and NFK-K/DOQI guidance for vascular access.
4
5
S. Ristic, 2 L. Lukic, 3 Z. Maksimovic, 3 S. Maric,
M. Kovacevic, 1 D. Trifunovic, 4 D. Pavlovic, 1 V. Maric,
L. Djukanovic
Foca Medical Faculty, University of East Sarajevo
International Dialysis Center, Bijeljina
Bijeljina Health Center
Foca Clinical Center, R. Srpska, Bosnia and Herzegovina
School of Medicine, University of Belgrade
Background. Recent screening surveys in Balkan
endemic nephropathy (BEN) villages indicated that, in
addition to a family burden for BEN, several other risk
factors for CKD were highly prevalent. The present study
was undertaken with the aim to find out the prevalence
of the most frequent risks factors for CKD in adult
inhabitants of three endemic villages of the municipality
of Bijeljina, BiH, as well as the frequency of urinary
abnormalities depending on the presence of risk factors.
Methods. The survey started with an interview with
special attention to personal history of kidney disease,
hypertension and diabetes and family history of BEN. In
addition, blood pressure was measured and urine was
analyzed using urine dipstick test for proteinuria,
hematuria and glycosuria. Results. The study involved
1625 (739 males, aged 51 ± 16 years) inhabitants from
three endemic villages (Bijeljina, BiH). The examined
subjects were allocated in one of the five groups
according to the presence of risk factors: 319 subjects
(19.6%) with positive family history for BEN, 585 (36%)
with hypertension, 604 (37.2%) above 60 years, 146
(9%) with diabetes and 566 (34.8%) with none of these
risk factors. Proteinuria was present in 6.2-7.1% of the
subjects with risk factors for CKD but in only 3.4% of
those without risk factors (p<0.05). No significant
differences among the groups were found in the
frequency of hematuria but glucosuria was the most
frequent in patients with diabetes. The frequency of
urinary abnormalities increased with the number of risk
factors. Multivariate logistic regression analysis found
systolic blood pressure and BEN in brother/sister as
significant independent variables associated with
proteinuria, but female gender and a history of kidney
disease with hematuria. Conclusion. In addition to a
family burden for BEN, other risk factors for CKD were
highly prevalent in the endemic villages of the Bijeljina
municipality. The frequency of proteinuria was higher in
at risk groups than in the group without risk factors and
increased with the number of risk factors.
93
PP 141
PP 142
DISTURBANCES OF PHOSPHATE METABOLISM –
HIGH CONTRIBUTION OF CARDIOVASCULAR RISK
FACTORS
SALT INTAKE AND HYPERVOLEMIAIN THE
DEVELOPEMENT OF HYPERTENSION IN
PERITONEAL DIALYSIS PATIENTS
1,2
1
M. Stoian, 3 B. Stoian, 1,2 V. Stoica
Carol Davila University of Medicine, Bucharest,
Romania
2
Cantacuzino Hospital, Bucharest, Romania
3
Polimed Apaca Medical Center, Bucharest, Romania
S. Inal, 1 Y. Erten, 2 G. Akbulut, 1 K. Onec, 2 N. Acar
Tek, 2 G. Sahin, 2 N. Sanlıer
1
Department of Nephrology, Gazi University Faculty of
Medicine, Ankara, Turkey
2
Department of Nutrition and Dietetics, Gazi University
Faculty of Health Sciences, Ankara, Turkey
1
Background. Metabolic syndrome represents a cluster
of cardiovascular risk factors that has become a public
health problem of epidemic proportions. It was proposed
that disturbances in phosphate metabolism may
represent a key feature of metabolic syndrome, with a
high contribution of cardiovascular risk factors. The aim
of the study is to investigate the relationship between
phosphate levels and the presence of the characteristics
of metabolic syndrome, as well as the mechanisms that
may responsable for reduced phosphate levels in
patients with metabolic syndrome. Methods. Two
hundred subjects are enrolled in the study: one hundred
with metabolic syndrome and one hundred whithout this
syndrome. Biochemical parameters of the metabolic
syndrome study populations were compared with
healthy population study. Results. Patients with
metabolic
syndrome
showed
significantly
lower
phosphate(46%) and magnesium levels compared with
controls( 22,7%) (p<0.001).Because fractional excretion
of phosphate was similar in both groups,we think that
hypophosphatemia in patients with metabolic syndrome
can be attribuited to decreased dietary intake, as well as
internal redistribution of this element. Lower magnesium
hyperinsulimemia-induced renal magnesium wasting
also may be a contributory factor. Conclusion. Patients
with metabolic syndrome show significantly lower
phosphate and magnesium concentrations compared
with individuals who do not fulfill criteria for diagnosis of
this syndrome. This reduction is likely to be attributed to
reduced dietary intake and internal redistribution of
phosphate and is more pronounced as the number of
components of metabolic syndrome increases.
Background. Fluid and salt balance have a major role
in the success of peritoneal dialysis (PD) therapy. The
combination of volume overload and hypertension (HT)
is an important factor in the development of
cardiovascular disease, the leading cause of death in PD
patients. Although PD has some hemodynamic
advantages, there is growing evidence that PD patients
are often volume expanded and have higher blood
pressure (BP) levels. In the present study, we aimed to
investigate the role of fluid balance and salt intake in BP
control in our PD patients. Methods. 37 patients that
were undergoing PD, for more than six months and
having complete data for three consecutive months were
included. Patients were divided into two groups based
on their BP in the last three months: Hypertensives
(patients whose mean BP levels were over 140/90
mmHg, persistently or even once or twice) and
Normotensives (patients whose BP did not meet the
criteria of HT in the three consecutive months).
Bioelectrical impedance analysis (BIA) was performed
after patients emptied their dialysis solutions. Estimation
of extracellular water (ECW), intracellular water (ICW)
and total body water (TBW) could be acquired. ECW was
normalized to patients’ height in meters (N-ECW).
Urinary sodium removal (USR) and peritoneal sodium
removal (PSR) values were calculated. Total sodium
removal (TSR) was the sum of USR and PSR. Results. A
total of 37 patients (18 female, 19 male) were included
in the study with a mean age of 46.4 years, 73% of the
total population had hypertension and 14 % of them
were diabetics. There were 20 and 17 patients in the
HTs and NTs groups respectively. Gender distribution,
age, time on PD and BMI were similiar betwen two
groups. Total sodium load, body weight, TSR, ECW, NECW and TBW values were all significantly higher in
hypertensive group. ICW, TFR and percentage of
extraneal users were also higher in hypertensives,
however the differances did not reach statistical
significance. Conclusion. Acording to our results, fluid
overload seems to be closely associated with
development of HT in PD patients. Additionaly, we
showed that hypertensive patients were more
hypervolemic, despite a higher fluid and sodium removal
as compared with normo-tensive patients. Increasing
fluid and salt removal by peritoneal ultrafiltration results
in increased finacial burden and also cause to numerous
clinical problems. Therefore restricting fluid and salt
intake is an alternative and safer strategy to maintain
good fluid balance.
94
PP 143
PP 144
CYTOMEGALOVIRUS INFECTION IN RENAL
TRANSPLANT RECIPIENTS
THE ROLE OF PLASMAPHERESIS PERFORMED IN
HEMODIALYSIS UNIT FOR THE TREATMENT OF
ANTI NEUTROPHILIC CYTOPLASMIC ANTIBODY
ASSOCIATED SYSTEMIC VASCULITIDES
A. Strakosha, N. Pasko, F. Riza, S. Kodra, N. Thereska
1
Z. Aydin, 1 M. Gursu, 1 S. Karadag, 1 S. Uzun, 1 E. Tatli,
A. Sumnu, 1 S. Ozturk, 2 R. Kazancioglu
1
Department of Nephrology, Haseki Training and
Research Hospital, Istanbul, Turkey
2
Department of Nephrology, Bezmialem Vakif University,
Istanbul, Turkey
1
Background. Cytomegalovirus (CMV) is one of the most
important infections in renal transplant recipients. The
IgG anti-CMV antibodies in the plasma are present in
more than two-thirds of donors and recipients prior to
transplantation. The impact of CMV infection on kidney
graft survival was examined in a prospective, single
center study of almost 42 patients who did receive CMV
prophylaxis. Methods. A prospective study of
cytomegalovirus infection was carried out on 42 renal
transplant recipients managed at Transplant Center in
University Hospital center in Tirana. Renal transplant
recipients
were
systematically
screened
for
cytomegalovirus infection and the findings correlated
with the clinical course. Results. 42 renal transplant
recipients were followed from 2004 to 2011. Mean age
of renal recipients was 35.2 ± 5.3 years old. Fifteen
patients
showed
evidence
of
infection
with
cytomegalovirus uncomplicated by bacterial infections
with the following viral titers: 5% in 3 patients, 10% in
5 patients, 15% in 5 patients and 20% in 2 patients.
The longer hemodialysis period previous transplantation
correlated with the viral titers. Patients without viral
infections were usually asymptomatic. In contrast, the
onset of viral infections were almost always
accompanied
by
a
significant
clinical
illness
characterized by fever, leukopenia, and low graft
function. Compared to those without CMV, CMV disease
was associated with a relative risk of overall kidney
dysfunction of 2.5 Conclusion. The cytomegalovirus
infection is a frequent complication after renal
transplantation and is associated with less favorable
prognosis for renal graft.
Background. Anti neutrophilic cytoplasmic antibody
(ANCA) positivity is seen in some systemic necrotizing
vasculitides. Wegener’s granulomatosis (WG) and
microscopic polyangiitis (MPA) are among ANCA
associated systemic vasculitides (AASV). Mortality is
very high when renal failure is together with alveolar
hemorrhage. Role of plasmapheresis in treatment of
these diseases has been studied retrospectively.
Methods. Twelve patients with AASV who had
plasmapheresis
together
with
immunosuppressive
medications have been involved. Primary diseases,
immunosuppressive
protocols,
number
of
plasmapheresis sessions, amount of plasma that has
been exchanged, urea-creatinine levels before and after
treatment, pulmonary findings, need for hemodialysis
and outcome of patients were recorded. Results. The
mean age of patients was 52.9±18.2 years. WG was
diagnosed in 7(58.3%) and MPA in 5(41.7%) patients.
All
patients
had
pulse
cyclophosphamide
and
methylprednisolone followed by maintenance doses and
plasmapheresis. Seven patients had hemodialysis at the
beginning and hemodialysis need continued in 3
patients. Partial and complete remission was seen in
6(50%) and 3(25%) patients, respectively. Pulmonary
finding regressed in all. Conclusion. End-stage renal
disease develops generally in AASVs due to rapidly
progressive
glomerulonephritis
causing
severe
irreversible glomerular damage. Mortality rate rises to
50% in case of renal failure with diffuse alveolar
hemorrhage. So, pulse immunosuppressive treatment
with plasmapheresis may be life-saving as shown in our
study.
95
PP 145
PP 146
24 HOUR AMBULATORY BLOOD PRESSURE
MONITORING IN DIABETIC PATIENTS WITH
CHRONIC RENAL DISEASE
CHRONIC KIDNEY DISEASE (CKD) AND THE NEED
FOR NEPHROLOGICAL CARE IN PATIENTS WITH
ACUTE MYOCARDIAL INFARCTION (AMI)
N. Pasko, A. Strakosha, S. Mumajesi, E. Kaculini,
N. Thereska
1
N. Spahia, 1 M. Rroji, 1 S. Seferi, 1 A. Idrizi, 1 A. Duraku,
I. Pendavinji, 1 N.Thereska
1
Department of Nephrology, University Hospital Center
2
Nephrology Service, Korca regional Hospital, Albania
2
Background. As clinic blood pressure measurements do
not present values throughout the day, it is well
established that ambulatory blood pressure monitoring
(ABPM) is particularly useful in detecting white coat,
masked hypertension and control the goal of
antihypertensive therapy. Diabetes is one of the leading
causes of chronic renal disease. Diabetic nephropathy is
most likely to occur in patients who have worse glycemic
control or high blood pressure. The data have shown
that hypertension is an important risk factor for adverse
cardiovascular and renal outcomes in diabetic patients.
Aim The goal of this study was to evaluate the role of 24
hour ambulatory blood pressure monitoring in
evaluating blood pressure targets in patients with
diabetic nephropathy. Methods. 81 patients hospitalized
at our center with diabetic nephropathy and chronic
renal disease stage III and IV were included in the
study, of whom 58.5% were male. The following data
were recording: ambulatory blood pressure, clinic blood
pressure, glomerular filtration rate, proteinuria and
demographic details. 24-h ABPM was performed using
Cardioline BPOne OPCB System. The device was
installed in the morning period and it was drop out after
24 hours. The patients should keep their regular
activities and make a report describing the hours of each
activity. The device was programmed to perform four
measures per hour during the day and two
measurements during the night. Average systolic and
diastolic pressure during diurnal, nocturnal and 24 hours
period was established. Non-dipping was defined as a
daytime systolic blood pressure (SBP)–nighttime SBP
ratio higher than 0.90. Results. The mean age of
patients was male 45±5.3 and female 51.3±8.4. Mean
day time and nighttime were 138/92 ± 4.2 and 125/85
± 3.5 respectively. 65% of patients were determined as
non-dippers. Non-dipping was significantly associated
with a higher incidence of diastolic dysfunction,
increased risk of total morbidity and end-stage renal
disease. There was a significant difference between the
clinic SBP and ABPM. After ABPM performed, 32.5% of
patients started a new medication in order to achieve
better control of hypertension. All patients presented an
abnormal albuminuria. Conclusion. 24 hour ABPM is an
important tool for risk evaluation of patients with
diabetic nephropathy, but it still remains underused in
our clinic practice. Ambulatory blood pressure
monitoring remains the only method to evaluate the
white coat hypertension, assess the drug-resistant
hypertension and achievement of the goal values of
blood pressure in patients with diabetic nephropathy.
Background. Increased cardiovascular morbidity and
mortality in pts with CKD has been evidenced by many
epidemiological studies in the last years. Those studies
found that , CKD being a cause of HTA, LVH and anemia,
is also a risk factor for development of arteriosclerosis
and atheromatosis of arteries including the coronary
artheries. The aim of the study was to evaluate the
presence of CKD in patients diagnosed with acute
myocardial infarction and the need for nephrological
follow-up of these patients. Methods. In this study we
evaluated 92 pts,( mean age 64 +/- 12 years), 69(75%)
male, diagnosed (in cardiology department at our
hospital) with acute myocardial infarction(AMI) during
Jan.2011- April 2011 period. For each patient detailed
anamnesis
concerning
co-morbidities
(diabetes,
hypertension, dislipidemia, cardiovascular and kidney
diseases) was taken. GFR was calculated by MDRD
formula. Patients diagnosed with CKD were consulted by
a nephrologist during admission or referred to
nephrologist after discharge. Results. CKD was
diagnosed in 53 (58.6%) of patients with AMI. GFR<60
mL/min/1.73m2 was found in 27 patients (18 males;
50.9% of CKD pts, 29% of total pts )mean age 69 +/12 years. GFR< 30 mL/min/1.73m2 was found in 5
patients, (3 males;9.4 % of CKD pts, 5.4% of total pts
)mean age 66 +/- 14 years. The most frequent comorbidities, documented prior to the event of AMI, in
the group of CKD stage 3 & 4 were type II DM in 8
patients, HTA in 6 patients, obesity in 1 patient, prior
ischemic stroke in 1 patient. Nephrological care prior to
AMI was documented only in 1 patient. Conclusion. The
incidence of CKD in the AMI patients is not negligible
and the increased awareness of nephrologists &
cardiologists can provide a better medical service to this
patient’s population.
96
PP 147
PP 148
PREVALENCE OF THE METABOLIC SYNDROME IN
HEMODIALYSIS
AN OPTIMAL MIX OF DIALYSIS MODALITIES
1,2
M. Stoian, 3 B. Stoian, 1,2 V. Stoica
Romania
2
3
1
Z.Gjergji, 2 M.Gjergji, 3 M.Gjata, 4 A.Bulo, 3 M.Tase,
5
N.Thereska, 5 M.Barbullushi
¹
Department of Nefrology and Hemodialysis, Hospital
Center “Dr. Xh. Kongoli” Elbasan, Albania
2
Department of Physic Education, University “A.
Xhuvani”, Elbasan, Albania
3
Service of Internal Medicine and Hypertension,
Albania
4
Bio-chemichal Service, University Hospital Center
5
Service of Nephrology, University Hospital Center
1
Background. Renal professionalists cannot solve the
dialysis dilemma of epidemic growth and high costs, but
we do have an obligation to seek the best ways to treat
more patients with the highest quality therapies, for the
lowest level of public expenditure. Review report. In
some developing countries the least expensive dialysis
modalities is used. Most Western European nations
predominately utilize HD, especially if there is a private
or mixed public and private dialysis system. Because
modality mix is an important determinant of costs may
impact on patient outcomes and quality of life, there is
an urgent need to better define the optimum modality
distribution. It is possible that this will vary between and
within countries, depending upon population density,
demographics and other factors. In many countries, the
economic perspective and interests of patients,
physicians, facilities industry and society are different,
and may actually be in conflict. Sensible solutions will
seek to align these interests and incentives in order to
foster the evolution of a cost effective, balanced system
that allows patients informed choice amongst the
various dialysis modalities, and witch encourages, but
does not force, suitable patients to select a less
expensive, home based therapy. Conclusion. Early
referral to a nephrologist has been shown to impact
upon modality selection in precisely this way.
Background. To investigate the prevalence of the MS
and the specific patient characteristics in a cohort of
hemodialysis patients. Methods. 60 stable patients on
maintenance hemodialysis (33 male/27 female with a
mean time on dialysis of 57.19 ± 47.16 months) were
studied for 12 months. Results. The prevalence of the
MS is high (58%) during the first year on dialysis and
gradually declines (44.8% from 2-5 years and 29.7% for
>5 years). In total 35/60 patients had MS (58%);16/35
were men (46.3%) and 19/35 women (52.7%). The
prevalence of MS in males was 46.3% and 52.7% in
females, while the most frequent combination of risk
factors in MS patients was high blood pressure-high
waist circumference-high levels of serum triglycerides
(36.58%). Serum triglycerides >150 mg/dL is the most
frequent component of the MS both in well-nourished
patients and according to the duration of dialysis
(58.53% for 0-5 years and 19.51% for >5 years on
dialysis). MS patients had a better nutritional status and
were on dialysis for less time than their non-MS (NMS)
counterparts. Actual or anamnestic cardiovascular
events and infections did not differ between the 2
groups. Conclusion. Our study provides new data
concerning the prevalence of the MS and the specific
patient characteristics in a hemodialysis population. The
prevalence of MS in hemodialysis patients is high (58%)
and seems to reflect a state of good nutrition compared
to patients without the MS. Furthermore, the MS is more
common in the first years of dialysis (42.46±34.29
months) than later on (67.25±52.15 months) probably
reflecting the long term consequences of the
hemodialysis treatment. Our results also indicate that
although patients in the MS group were well-nourished
and for a shorter time on dialysis, they were not
protected from cardiovascular disease and infections.
Our study provides new data concerning both the
prevalence of the MS and a variety of patient
characteristics in a hemodialysis population. Further
research and a larger number of patients are required in
order to clarify the precise role of this syndrome in
patients on MHD.
97
PP 149
PP 150
AN ELDERLY MAN WITH CONFUSION,
HYPERCALCAEMIA AND ACUTE RENAL FAILURECASE REPORT
INCIDENCE AND CHARACTERISTICS RESTLESS
LEGS SYNDROME IN HEMODIALYSIS PATIENTS
1
1,2
3
R. Stolic, 2 S. Milenkovic, 2 S. Radosavljevic, 2 S. Ilic,
S. Sovtic, 1 G. Subaric-Gorgieva
1
School of Medicine, Pristina/K.Mitrovica, University of
Pristina, Kosovska Mitrovica, Serbia
2
Health Center, Kosovska Mitrovica, Serbia
1,2
1
M. Stoian, B. Stoian,
V. Stoica
Romania
2
3
1
Background. Restless legs syndrome is a serious
problem in patients on hemodialysis. The study
determines prevalence and characteristics of restless
legs syndrome in hemodialysis patients. Methods. The
research was organized as a cross-section study,
patients who were treated for chronic hemodialysis. In
all patients was determined demographic structure,
anthropometric and clinical caracteristics (body mass
index, smoking, alcohol consumption, existence of
insomnia and residual diuresis, urea kinetic model,
presence of diabetes mellitus and cardiovascular
disease). Restless legs symptoms were determined
based on the criteria adopted by the International
Restless Legs Syndrome Group. Patients were divided
into groups with restless legs syndrome and a group of
patients without restless legs syndrome. Biochemical
analysis were determined at the start of dialysis in the
middle of the week. Results. Of total tested patients,
restless legs syndrome was found in 62% of patients.
Group of patients who have restless legs syndrome is
older (63.5 ± 10.6 vs. 53 ± 13.35 years) than patients
without this syndrome, difference between the groups
was statistically significant (p = 0.006). Statistically
significant difference between the two groups of patients
with and without restless legs syndrome has been
achieved in relation to the concentration of serum iron
(p = 0.018) and the degree of elimination of urea (p =
0.03). Conclusion. Patients who have restless legs
syndrome are older, have lower concentrations of serum
iron and lower the adequacy of hemodialysis. The
incidence of restless legs syndrome in the population of
our patients was 62%.
Background. myeloma, hyperparathyroidism, bone
metastases and humoral hypercalcaemia of malignancy.
Other less common causes include sarcoidosis, Addison
s disease, drugs. Case report. A 71-year-old man
presented with a 6-month history of lethargy, nausea,
10 kg weight loss and short term memory loss. He is
currently under the urologists for prostatic adenoma.
Physical examination revealed an elderly gentleman with
pulse rate 60/min and blood pressure 160/100 mmHg
and no other abnormalities findings than an irregular,
enlarged prostate gland. A chest X-ray was normal.
Biological examination showed anemia, raised urea and
serum creatinine and hypercalcaemia. A renal
ultrasound was normal; urinalysis revealed blood
2+,protein +,glucose +, few white cells and some
granularcasts. A renal biopsy showed foci of lymphocitic
tubulitis and a mild mononuclear interstitial infiltrate;
focal peri-tubular interstitial calcification; several
discrete
non-necrotizing
epithelioid
granulomata
comprised of epitheliod macrophages and Langerhanstype giant cells.A histological diagnosis was made for
acute or chronic granulomatosis interstitial nephritis with
nephrocalcinosis. A CT scan of his chest was performed:
calcified mediastinal lymph nodes between the aorta and
the
trachea,
intra-pulmonary
nodules
scattered
throughout the upper and lower lobes without any
apparent perivascular or peri- septal association. The
scan findings were consistent with sarcoidosis. A serum
ACE level was abnormal. A clinical diagnosis of
sarcoidosis was made and patient comonced 40 mg
prednisone /day orally. Upon the treatment the patient s
condition rapidly improved. Conclusion. Sarcoidosis
should be considered as a potential diagnosis in any
patient with hypercalcaemia and acute renal failure, and
a biopsy performed if other obvious causes such
myeloma, carcinoma with secondary metastases and
primary hyperparathyroidism have been excluded.
98
PP 151
PP 152
RENAL CELL CARCINOMA WITH COEXISTENT RENAL
ARTERY STENOSIS: A CASE REPORT
DIABETIC NEPHROPATHY AND CHRONIC RENAL
FAILURE - THE VALUE OF RESISTANCE INDEX (RI)
IN PROGRESSION
1
N. Karpuz, 1 M. Tunc, 2 A. Tepeler, 2 A. Armagan,
R. Kazancioglu, 2 S. Onol, 1 R. Erkoc
1
Department of Nephrology, Faculty of Medicine,
Bezmialem Vakif University, Istanbul, Turkey
2
Department of Urology, Faculty of Medicine, Bezmialem
Vakif University, Istanbul, Turkey
1
M. Milovanceva Popovska, L. Grcevska, V. Ristovska,
V. Nikolov, A. Sikole
Clinic of Nephrology, Clinical Center, University “Ss Cyril
and Methodius”, Skopje
Background.
Intrarenal
resistive
index
(RI)
demonstrates changes of renal vascular resistance and
determines
evolution
in
patients
with
diabetic
nephropathy and chronic renal failure. Methods.
Intrarenal
RI
values
were
achieved
from
intraparenchimal arteries; values > 0.68 is considered
pathologic. The study was longitudinal. Clinical
parameters and renal function were evaluated at
baseline and after 3, 6, 9, 12, 15, 18, 21 and 24
months. 70 patients with diabetic nephropathy were
divided based on their intrarenal RI: group 1 had values
of ≥0.68, group 2 had values <0.68. A group of 30
healthy volunteers, matched for age, sex and body mass
index, was used as control. Results. Intrarenal RI value
≥0.68 had 64.3%, at baseline; 50% of them had a
decline in renal function after 9 months and 64% after
24 months. In patients with intrarenal RI values <0.68,
34% had a decline in renal function after 24 months. In
multivariate regression analysis, proteinuria, higher
baseline Ccr and RI were independent predictors of
declining renal function. RI values were significantly
affected by mean blood pressure, Delta CCr and
proteinuria. The relationship between the RI values and
CCr (Delta CCr) showed a negative correlation
coefficient of r=-0.630 (P<0.01). There was no
relationship between CCr and age and RI and age in
diabetic patients. Conclusion. The RI can be used as a
non-invasive, easily available parameter of the evolution
in patients with advanced clinical diabetic nephropathy.
An intrarenal RI value of ≥70 identifies diabetic patients
at risk for progressive renal disease.
Background. Renal cell carcinoma (RCC) is an
uncommon cancer, accounting for only 3% of cell
malignancies. Renal artery disease (RAD) coexisting in
patients with RCC is an even more infrequent clinical
presentation that may pose unique and challenging
management issues. Here we present a case of RCC
with contralateral RAD. Case report. A 69-year-old
male patient presented with fatigue and headache. Past
medical history consisted of hypertension and diabetic
nephropathy. Physical examination revealed a blood
pressure of 240/140 mmHg and was otherwise normal.
His creatinine and GFR were 2.52 mg/dl and 30.3
ml/min, respectively. In urinary ultrasound examination
a solid mass in right kidney was detected. Abdomen MRI
demostrated a 57x53 mm solid mass with an exophitic
growing pattern at the lower pole of right kidney which
was diagnosed as RCC. Renal MRI angiography showed
left renal artery stenosis and Tc 99m DTPA demostrated
that bilateral perfusion of the kidneys was low.
Cardiologists implanted a stent for left renal artery
stenosis.
Following
this
intervention,
partial
nephrectomy of the left kidney was performed. After the
operation, we didn’t detect any complications and the
patient was discharged. Three months later, his
creatinine is still 2 mg/dl and his blood pressure is under
control and he continues his follow-up in the Nephrology
department.
Conclusion.
In
patients
with
atherosclerotic RAD and RCC affecting opposite kidneys.
Renal artery stent placement may be an alternative
treatment in selected cases. The nephron-sparing
surgery
combined
with
selected
renal
artery
reconstruction can yield gratifying results in this
complex patient population.
99
PP 153
PP 154
COMPARATIVE STUDY BETWEEN RESTLESS LEGS
SYNDROME IN PREDIALYSIS AND DIALYSIS
PATIENTS
PLASMA EXCHANGE–OUR EXPIRIENCE IN NEW
MILLENIUM
G. Strazmester Majstorovic, D. Bozic, D. Celic, B. Milic,
V. Knezevic, I. Mitic
Clinic for Nephrology and Clinical Immunology, Clinical
Center of Vojvodina Novi Sad, Novi Sad, Vojvodina,
Serbia
1
B. Deliyska, 1 H. Shivarov, 2 N. Nenchev, V. Lazarov,
1
V. Shurliev, 1 V. Vasilev,1 I. Kaludina, 2 D. Trifonova,
2
I. Sredkov
1
University Hospital "Queen Giovanna-ISUL", Sofia,
Bulgaria
2
University Hospital "Ivan Rilski", Sofia, Bulgaria
Background. Plasma exchange (TPE, plasmapheresis)
is a therapeutic, extracorporal blood purification
technique. It is designed for the removal of large
molecular weight substances from the plasma, like
pathogenic
autoantibodies,
immune
complexes,
cryoglobulins, myeloma paraproteins etc. The aim of this
study is to determ the safety of the TPE procedures.
Methods. Since the year of 2000., 487 procedures, on
138 patients (pts) were done on our clinic. All the
procedures were done on the Haemonetics machine (on
Haemonetics MCS+ since the begining of 2008.year),
with citrat solution, as anticoagulant. Among 138 pts,
45,65% were man and 54,35% women. Patiens were 18
to 76 years old (average 48,85years). Results.
Peripheral vein was used as a vascular access in 71,25%
of the procedures, dual-lumen catheter in 26,90%
(v.subclavia/v.jugularis 25,67%, v.femoralis 1,23%),
Hickman catheter in 0,72%, and arterio-venous fistula in
1,45% of the procedures. Plasmapheresis was used as a
therapeutic procedure in 32 different diseases and
syndromes. Some of the most frequent indications were:
vasculitis in 18,12% pts, myeloma multiplex in 15,94%
pts, Sy Moskowich in 10,87% pts, polyradiculoneurits in
7,25% pts, SLE in 5,80% pts, Myastenia gravis in
3,62% pts, Polyneuropathia and crioglobulinemia in
2,90% pts and Sy antiphospholipidum, preparation for
the transplantation, rejection of transplantes kidney and
Sy Sjogren in 2,17% pts. One to 13 procedures were
done per patient (average 3,52). Per treatment, 100 to
3841 ml (average 1864,68ml) of plasma were removed.
Per patient, 335 to 25542ml (average 6544,35ml) of
plasma were removed. Since 2000. to 2008. year, all
the procedures were done in a citrate/blood range 1:10.
From 2008. year till today, procedures were done with
citrate/blood range of 1:10 in 68,18%, 1:11 in 12,12%
and 1:12 in 19,70% of procedures. Complications
appeared in 4,93% procedures, with 12,32% pts. They
included: collapses in 1,23%, urticarial reaction to
supstitutional plasma 1,03%, hypotension in 0,82%,
paresthesias due to citrate induced hypocalcaemia
0,82% pts, breaking of the used vein 0,62%, Grand mall
epileptic seizure and abdominal pain in 0,20%. Only
3,70% of the procedures had to be terminated earlier,
2,26% due to complications and another 1,44% of the
procedures because of inadequate vascular access.
Conclusion. Plasmapheresis is an effective therapeutic
procedure, used in a combination with medicament
treatment. It has very wade range of indications in
many medical fields. Plasma exchange is a safe
procedure, with a small percentage of complications and
even smaller of procedures that had to be
discontinuated because of them.
Background. Restless legs syndrome (RLS) is a
movement disorder wherein sensory motor symptoms
are observed in the limbs mainly during sleep and quiet
wakefulness. The aim of the study was to compare RLS
in dialysis (HD) and predialysis patients with chronic
kidney failure (CKF). Methods. In the study were
included 61 patients - 24 predialysis and 37 dialysis
patients. RLS was measured using IRLSSG's RLS
Questionnaire (RLSQ) with 10 questions. According to
the score from RLSQ the severity of the syndrome was
divided as: none (0 points), mild (1-10 points),
moderate (11- 20 points), sever (21-30 points) and very
severe (31 - 40 points). Data collected included also
age, gender, duration of renal failure and hypertension,
hemogram, serum creatinin, serum electrolites, iron and
total iron-binding capacity. Results. In predialysis
patients serum creatinine was lower than in dialysis
group.(283,6±94 µmol/l and 713±142 µmol/l). Duration
of the CKF was longer in the dialysis group (68,16±11
months vs. 51,96±12 months). The level of serum
phosphate in dialysis patients was higher-1,93±0,4
mmol/l compared with non-dialysis patients (1,26±0,3
mmol/l). The hemoglobin was higher in predialysis
patients (resp. 114,7±15,2 g/l and 101,76±16g/l),
(р<0,05). Serum iron levels in dialysi group were lower9,96±1,8 µmol/l and their total iron-binding capacity
was 38,5±9,6 µmol/l. The score from RLSQ for
predialysis patients was 15,1 and 15,8-for dialysis
patients. RLS absent in 18,9 % from dialysis and in
12,5% from predialysis patients. The syndrome was
more often in men in predialysis stage and in women on
dialysis. More patients from first group were with mild
severity, while in dialysis group more of them were with
moderate RLS. There was no correlation between clinical
and laboratory data and the severity of the syndrome.
Patients from the two groups with lower iron level were
with more severe RLS. One patient from first group was
with phosphate level> 2 mmol/l and was with severe
RLS (27 points). Eleven dialysis patients were with
serum phosphates > 2 mmol/l and had moderate mean
score (15,9 points). We conclude that more patients in
predialysis and dialysis stage have RLS. Conclusion. In
predialysis patients it is often with mild while in HD
patients it is with moderate severity RLS does not
correlate with clinical and laboratory data but the
patients with iron defficiency has higher severity of the
syndrome. Optimal care of patients with renal failure
should include particular attention to the diagnosis and
management of RLS.
100
PP 155
PP 156
CLASS IV-S VERSUS CLASS IV-G LUPUS NEPHRITIS
LUPUS NEPHRITIS AND GOUTY ARTHRITIS
1
1
1
1
D. Monova, 2 S. Monov, 3 T. Todorov
Department of Internal Diseases, Medical Institute,
Sofia, Bulgaria
2
Department of Rheumatology, Medical University,
Sofia, Bulgaria
3
Department of Pathoanathomy, Medical University,
Sofia, Bulgaria
D. Monova, 2 S. Monov
Department of Internal Diseases, Medical Institute,
Bulgaria
2
Department of Rheumatology, Medical UniversitySofia, Bulgaria
Background. Hyperuricaemia and gout are extremely
uncommon in healthy young women. Since patients with
systemic lupus erythematosus (SLE) are predominantly
young and female, gout would be expected to be rarely
associated with SLE. The presentation of gout in SLE
may be modified or suppressed by anti-inflammatory
therapy and may be misinterpreted as SLE arthritis. The
aim of this study is to examine the frequency of gouty
arthritis and hyperuricaemia in patients with lupus
nephritis (LN) and elucidate the clinical factors that
predispose to this occurrence. Methods. 231 patients
(210 female, 21 male) with biopsy proven LN, were
enrolled in this study. Renal histopathology was
classified according to the ISN/RPS criteria for nephritis
in SLE. Results. 67 patients were hyperuricaemic,
defined as uric acid level greater than 0,46 mmol/l for
female and greather 0,48 mmol/l for male. The average
age of the hyperuricaemic patients (35,34 ± 9,98 yrs)
was comparable to the normouricaemic group
(32,76±9,74 yrs), but substantially younger then LN
patients with gout (39,27±7,41 yrs). Elevation of serum
creatinine was not a prominent feature in the
hyperuricaemic pts, being present in only 12 patients.
The patients with hyperuricaemia and gout tender to be
more frequently male than hyperuricaemic patients. The
most (83,58 %) of the hyperuricaemic patients were on
corticosteroid (CS) therapy, although CS therapy was
nearly as frequent in the normouricaemic patients
(86,09 %). 14 of 16 patients were on prednisone (mean
dose 12 mg/day) for their SLE at the time the attack of
gout occurred. CS treatment did not prevent their acute
gouty episodes, although in 10 patients acute gout
occurred during a period of CS tapering. Analysis of
synovial fluid and tophi from LN patients with acute
synovitis (16 patients) showed microcrystalline uric acid
in 15 patients, calcium pyrophosphate dehydrate - in 5
patients, hydroxyapatite crystals – in 4 patients.
Synovial fluid showed a mildly inflammatory fluid with
reduced viscosity, poor mucin clot and leucocytes up to
9,1 x 109/l. Lupus activity at the time of the first gout
attack was low. Conclusion. Gouty arthritis is
uncommon in SLE. It occurs primarily in patients with
long-standing SLE and nephritis. Worsening renal
function usually preceded G attacks, but SLE disease
activity was minimal. Crystal-induced arthritis should be
included in the differential diagnosis of a LN patient
presenting with acute inflammatory arthritis because the
long-term treatment of the two conditions differs
substantially.
Background. The new ISN/RPS classification of lupus
nephritis divides diffuse proliferative lupus nephritis into
two subcategories with predominantly segmental
proliferative lesions (class IV-S) and those with
predominantly global proliferative lesions (class IV-G).
This study explores the validity of this distinction and
possible differences in pathogenesis between the two
types of lesions. Methods. A retrospective analysis of
biopsy-proven cohort of 231 patients with lupus
nephritis using ISN/RPS classification was performed.
Clinical data were available on all patients selected.
Results. The prevalence of Class IV lupus nephritis was
27,27 %. Of patients with class IV, 41 had class IV-S
and 22 had class IV-G. The mean age was 33,87±10,39
years. The serum creatinine levels (185,2±138,7 µmol/l
vs 114,0±64,14 µmol/l), proteinuria (5,54±4,69 g/24 h
vs 3,22±2,26 g/24 h) and diastolic blood pressures
(104,12±10,45 mmHg vs 96,42±13,12 mmHg) were
significantly greater in the IV G group, but haemoglobin
was significant lower (102,8±13,64 g/l vs 115,9±12,48
g/l). Duration of systemic lupus erythematosus were
similar in the 2 groups (mean 45,73±22,13 months).
Histologically
combined
lesions
with
segmental
endocapillary proliferation and fibrinoid necrosis were
more frequent in the IV-S class lupus nephritis. The
percentage of glomeruli with cellular crescents also was
greater in the IV-S group (28,24 % vs 23,88 %), but
the difference was not significant. No significant
difference was detected in outcomes in the two groups
after follow ups of 145,2±76,87 months. Conclusion.
There are definite clinical and morphologic differences
between class IV-S and IV-G lesions. Data suggest that
class IV-G lesions behave as an immune complex
disease, however, in class IV-S lesions, the presence of
proportionally greater glomerular fibrinoid necroses
suggest that these lesions may have a different
pathogenesis.
101
PP 157
PP 158
POLYMORPHISMS OF ANGIOTESIN CONVERTING
ENZYME AND MATRIX METALLOPROTEINASE 3
GENES IN HAEMODIALYSIS PATIENTS –
ASSOCIATION WITH CARDIOVASCULAR AND
CEREBROVASCULAR DISEASE
CYCLOSPORINE A IN THE TREATMENT OF
NEPHROTIC SYNDROME
1
G. Strazmester Majstorovic, 2 M. Majic, 1 T. Ilic,
B. Milic, 1 D. Celic, 1 I. Mitic
1
Clinic for nephrology and clinical immunology, Clinical
center Vojvodina-Novi Sad, Serbia
2
Emergency center, Clinical center of Vojvodina-Novi
Sad, Serbia
1
1
J. Tosic, 1 Z. Djuric, 1 J. Popovic, 2 I. Buzadzic,
I. Pejin- Grubisa, 2 N. Barjaktarevic, 1 N. Dimkovic
1
Clinical Department for Renal Deseases, Zvezdara
University Medical Center, Serbia
2
Department of Human Genetics and Prenatal
Diagnostics, Serbia
2
Background. Cyclosporine A (CysA) has well known
antiproteinuric effect. It inhibits proliferation of the
helper T cells, through the inhibition of interleukin 2
synthesis. As there are no lymphocines from T cells,
inflammation is reduced. Through the changes in
intrarenal hemodynamics and reduction of glomerular
filtration CysA reduces proteinuria, too. Recommended
daily dose of CysA in the treatment of nephrotic
syndrome is 3-5 mg/kg. Serum levels of CysA should be
around 100 ng/ml. The aim of this study is to evaluate
the efficacy of the cyclosporine A in the treatment of
nephrotic syndrome. Methods. There were 30 patients
(pts) with nephrotic syndrome, included in the study
(56,67% men, 43,33% women). They were 21 to 69
years old (average 44,63 years). With 86,67% pts
nephrotic syndrome was the manifestation of the
primary glomerulonephritis (GN) (membranous GN
23,33%,
membranoproliferative
GN
26,67%,
mesangioprolifeative GN 26,67%, minimal change GN
10%), and with 13,33% pts was the manifestation of
lupus nephritis. Results. Average duration of the
disease before introduction of CysA in the treatment was
7,3 years. All the patients were treated before CysA,
with steroids or one to three medicaments more.
Patients were checked regularly, clinical status and
laboratory test, including the serum levels of CysA with
dose adjusting. After one year of treatment 86,67% pts
developed remission of nephrotic syndrome (46,67%
complete, 40% partial) and 13,33% pts had no
favorable effect. After one year of treatment, 30% pts
had proteinuria in subnephrotic range, and 53,33% pts
less than 1g/day. Proteinuria stayed at nephrotic range,
but with significant decrease, in 3,33% pts. Treatment
had no effect on proteinuria in 13,33% pts. At the
beginning 73,33% pts had normal renal function and
others first or second degree of chronic renal failure
(CRF). One year after, 70% pts still had no CRF,
creatinine levels decreased in 3,33% pts, and 10%
stayed at the same range. One patient (3,33% pts)
developed first stage CRF, 13,33% pts progressed to
second stage CRF. After one year of treatment favorable
effect was seen on the levels of: serum proteins in
86,67% pts, erythrocyte sedimentation in 80% pts, C
reactive protein in 93,33% pts, triglycerides in 86,67%
pts and cholesterol in 50% pts. No statistically
significant increase in creatinine level was seen during
the treatment, as the complication. Conclusion. Only
one patient (3,33%) developed hypertension, which was
easy to treat. Cyclosporine A showed good efficacy in
the treatment of nephrotic syndrome.
Background. Atherosclerotic lesions in haemodialysis
patients are the major concern and many risk factors
are proposed to be involved into pathogenesis. Apart
from traditional and non-traditional risk factors, genetic
susceptibility may be of importance including reninangiotensin system (RAS) and matrix metalloproteinase
3 (MMP 3) polymorphism. The aim of this study was to
analyse RAS and MMP 3 polymorphism in our group of
haemodialysis patients and to correlate the findings with
cardiovascular morbidity. Methods. The study included
196 patients on regular haemodialysis, three time per
week on polysulphone membrane for more than six
months. Genetic analysis was performed by using
polymerase chain reaction – restriction fragment lenght
polymorphism method (PCR-RFLP). Results. Out of 196
patients 73% had 5A/6A, 21,4% had 5A/5A and 5,6%
had 6A/6A MMP 3 genotype, 55% had I/D, 35% had
D/D and 10% had I/I ACE genotype. It was shown that
patients with D allele genotype experienced significantly
higher incidence of cerebrovascular accidents (CVA,
p=0,05).Patients who had 5A/6A genotype, experienced
five times higher incidence of left ventricular
hypertrophy if this genotype was associated with D
allele. Individual haplotypes of MMP 3 and ACE genes
showed no statistically significant association with
incidence of coronary disease, hypertension and
peripheral vascular disease. Conclusion. The presence
of the D allele of ACE gene is associated with
cerebrovascular disease and incidence of left ventricular
hypertrophy, in those with 5A/6A MMP 3 genotype. The
MMP 3 5A/6A and ACE I/D polymorphisms do not appear
to influence coronary disease, hypertension and
peripheral vascular disease apart from CVA.
102
PP 159
PP 160
THE LEVEL OF Β2 MIKROGLOBULIN AND ONE YEAR
MORTALITY AMONG HAEMODIALYSIS PATIENTS
HYPERTENSION, CARDIOVASCULAR DISEASES,
AND ACUTE RESPIRATORY DISTRESS SYNDROME
WITH MULTIPLE ORGAN SYSTEM FAILURE: FLIP
SIDES OF A COIN FOR ACUTE KIDNEY INJURY
OUTCOME
1
S. Bajcetic, 2 I. Jaglicic, 2 O. Savic, 1 J. Popovic,
N. Dimkovic
1
Clinical Department for Nephrology and Dialysis,
Zvezdara University Medical Center
2
Institute for blood transfusion, Belgrade, Serbia
1
1,2
M. Radovic, 1 J. Pavlovic, 1 A. Bontic
Serbia
2
University of Belgrade, School of Medicine, Belgrade,
Serbia
1
Background. Accumulation of beta-2 mikroglobulin
(β2MG) among patients with ESRD is a parameter of
good dialysis and indicator of mortality. It is still unclear
if particular membrane and/or dialysis technique offers
better clearance of this molecule. The aim of the study
was to correlate pre- and post-dialysis level of β2MG in
patients on low-, high flux membrane and HDF and the
correlate the results with one-year mortality (Mt).
Methods. The values of β2 MG were performed
before/after HD on imunonefelometry, BM100, Dade
Behring Marburg GmbH, USA with N Latex β2 MG
reagents (Dade Behring). Normal range of β2 MG in
serum 0,7-2,8 mg/L. Results. There were 206 patients,
(mean age 61+11.7, male 56,8% HD vintage
6.86+4.96) divided into groups: one with high-flux
membranes (HF, 64.5%; age 57.6+9.9, HD vintage
7.5+4.8,) and another with low-flux membranes (LF,
35.5%
age
65.8+12.9,
HD
vintage
5.5+5.0).
Haemodiafiltration (HDF) was performed among 18.4%
patients. The mean β2MG before HD was 40.9+22.0 and
after HD 27.3+19.3 (overall); 39.5+21.7 before HD and
19.2+10.7 after HD (HF group); 43.9+22.6 before HD
and 42.6+22.8 after HD (LF group) and 35.5+22.4
before, and 15.7+15.21 after HD (HDF). The lowest
values of β2MG before HD were among patients younger
then 40 yrs. (26.3+23.6). In 4/133 patients (3%) from
HF group and 37/73 (50,7%) patients from LF group
post-dialysis β2MG was higher than pre-dialysis β2MG
(p<0,001). Paradoxally, the value of β2MG before HD
was higher among patients on longer HD then in
patients on shorter HD (3x5h vs. 3x4h weekly,
53.05+28.3 vs.39.8+20.9), but that group was with
longer HD vintage (10.2+6.3 vs. 6.5+4.7 years). One
year Mt was 14.1%: 9,7% in HF group, and 21,9% in LF
group, p<0,05. Patients who died were older, with
longer HD vintage, higher CRP, PTH and higher values of
β2 MG after HD. Conclusion. The values of beta2MG
were very high in all patients on HD (from 3,6-110mg/L)
regardless of membrane type and dialysis technique.
The age had the highest influence on pre-dialysis
beta2MG values, as compared with value of CRP,
albumin or residual renal function. HF membranes and
HDF reduced pre-dialysis beta2MG more efficiently than
LF membranes. Although higher Mt was registered
among patients on LF membranes with higher postdialysis β2MG, additional contributing factors could not
be excluded.
Background. Paradigm about binomial acute kidney
injury (AKI) outcome has been recently challenged.
Unlike mortality risk, factors which influence lack of
complete recovery were not fully elucidated. AIM: The
aim of study was to compare impact of comorbidities
and complications on either deadly outcome or
incomplete
AKI
stage
3
recovery.
Methods.
Retrospective, observational, single centre study was
undertaken in 825 patients (mean age 50.3±15.8, 604
male), treated by hemodialysis because AKI stage 3.
Patients were assigned to one out of 4 groups according
to in-hospital outcome: 1= no AKI recovery and death
(44.7%), 2= AKI recovery but death (1.1%), 3=
incomplete AKI recovery and survival (5.2%), 4=
complete recovery and survival (49%, p < 0.001).
Individual severity score (ISS), age (ANOVA and post
test analysis) and frequencies of comorbidities and
complications (Kruskal – Wallis) were compared
between groups. Results. Patients in group 1 were
older than in group 4 (p<0.001). ISS was significantly
higher in group 1 than in other groups (p<0.001).
Significantly greater frequencies of hypertension and
cardiovascular diseases (p < 0.001) were found in
groups 1 and 3 than other groups. Sepsis (p = 0.038),
ARDS (p < 0.001) and MOSF (p < 0.001) were more
frequent in group 1 than group 4, and MOSF was more
frequent in group 1 than group 3 (p < 0.001).
Hypertension (OR 2.716 CI 1.198 – 6.19, p=0.0179)
and ischaemia (OR 6.49, CI 1.98 – 21.3, p=0.002),
without obstruction (OR 4.72, CI 1.92 – 11.58, p =
0.044) or nephrotoxines (OR 6.49, CI 1.98 – 21.29, p =
0.02) were significantly related with ARF non recovery in
survivors. Neoplasia (OR 1.625, CI 1.01 – 2.61, p =
0.045) and cardiovascular diseases (OR 2.43, CI 1.48 –
3.97, p< 0.001) were related with lethal outcome in
comparison to survivors. In Cox regression model (p =
0.011) hypertension significantly influenced incomplete
AKI recovery (OR 4.66, CI 1.95 – 11.12, p=0.01). Lethal
outcome was associated with greater risk for patients
with cardiovascular (OR 1.67, CI 1.19 -2.32, p = 0.003)
or hepatic (OR 1.52, CI 1.056 – 2.17, p = 0.024)
comorbidities, and ARDS as a complication (OR 2.23, CI
1.37 – 3.67, p = 0.01). Conclusion. Cardiovascular
diseases are the most important comorbidity for lethal
outcome and hypertension for incomplete recovery of
AKI stage 3. Respiratory failure and MOSF are related
with lethal outcome in AKI stage 3 patients.
103
PP 161
PP 162
HEALTH RELATED QUALITY OF LIFE AND
TREATMENT EFFICACY, TEN YEARS LATER
FACTORS THAT INFLUENCED INCOMPLETE
RECOVERY OF ACUTE KIDNEY INJURY (AKI)
1,2
1
S. Simic-Ogrizovic, 1 M.Kravljaca, 1 T.Jemcov,
S.Pejanovic, 1,2 M.Radovic, 1 M.Stososvic
1
Serbia
2
J. Pavlovic, 1,2 M. Radovic
Serbia
2
University of Belgrade, School of Medicine, Belgrade,
Serbia
Background. Advances in the treatment of end-stage
renal
disease
(ESRD)
patients
contributed
to
improvement of their survival, but their health-related
quality of life (HrQoL) was still much lower than for the
general population. Therefore, improvement of HrQoL is
one of the main goals of ESRD patient treatment. The
aim of the study was to examine the influence of
improved treatment of hemodialysis (HD) patients on
their HrQoL and to assess the predictive value of HrQoL
dimensions on patient outcome. Methods. The
prospective cohort study involved 102 HD patients and
their clinical and laboratory parameters and HD
adequacy indices were followed from 2001 to 2011.
HrQoL was measured using KDQOL-SF Version 1.3 in
2001, 2004, 2007 and 2011. Results. During a tenyears period, quality of HD and anemia treatment
improved and resulted in significant increase of mean
Kt/V (1.2 – 1.48) and hemoglobin levels (86.5 -111.8
g/L). During a first six-year period, all four HrQoL
dimensions (physical- PH, mental health- MH, kidney
disease target issues-KDI and patient satisfaction-PS)
maintained unchanged. In next 4 year 2007-2011, Kt/V
and Hb were unchanged but all four HrQoL dimensions
improved moreover PH and KDI significantly. Mortality
rate decreased from 18.6% to 7.14% per year. Age was
associated positively, but kidney disease target issue
score associated negatively with patient death.
Conclusion. Improved HD adequacy and anemia
treatment in HD patients were followed with
maintenance of all four HrQoL dimensions unchanged
over six years but in next four years all four dimensions
improved.
Background. Substantial number of patients does not
recover renal function completely after AKI. Factors
which influence lack of complete recovery have not been
fully elucidated. AIM: The aim of study was to compare
whether presence of comorbidities, such as diabetes,
hypertension (HTN), cardiovascular disease (CVD), liver
disease, chronic obstructive lung diseases, preexisting
kidney disease, with major AKI cause (surgical, medical,
obstructive, ischaemia, toxin induced, hemorrhagic fever
with renal syndrome - HFRS) had influence on
incomplete AKI recovery. Methods. Retrospective,
observational, single centre study was undertaken in
772 (mean age 49.6±15.8 years, 562 male) patients
who needed hemodialysis (HD) for AKI treatment.
Patients were assigned to one out of 4 groups according
to ARF in-hospital outcome: 1 = no AKI recovery and
death (N =356, 46.2%), 2 = AKI recovery but death
(N=60, 7.8%), 3 = incomplete AKI recovery and
survival (N=51, 6.6%), 4 = complete recovery and
survival (N=303, 39.4%). Individual severity score
(ISS), age (ANOVA and post test analysis), duration of
treatment to the endpoint (Kruskal-Wallis) and
frequencies of comorbidities (X2 test) were compared
among groups. Logistic regression and Cox proportion
hazard model were calculated. Results. Patients in
group 1 were older than in groups 2 and 4 (p<0.01,
borderline than group 3: p = 0.053). ISS was
significantly higher in group 1 than in other groups
(p<0.001). Group 3 had the longest duration of hospital
treatment (p<0.001). Group 3 shown significantly
greater frequency of both HTN (X2 6.349, p=0.012) and
CVD (X2 6.498, p=0.011) with surgical cause of ARF, as
well as CVD and preexisting renal disease (X2 6.253,
p=0.044). Presence of HTN (OR 2.96 CI 1.08 – 8.05,
p=0.039) and HFRS (OR 4.42, CI 1.02 – 19.1, p=0.047)
were significantly related with AKI non recovery in
survivors. Cox regression model shown significant
influence of male gender (OR 3.66, CI 1.46 – 9.21,
p=0.006) and HTN (OR 4.43, CI 1.33 – 14.71, p=0.015)
on incomplete ARF recovery. Conclusion. Incidence of
incomplete ARF recovery was 6.6%. Incomplete
recovery of renal function was less likely in patients with
AKI superimposed on HTN, patients with CVD
comorbidity and patients without HFRS.
1
1
104
PP 163
PP 164
VASCULAR ENDOTHELIAL GROWTH FACTOR AND
PERITONEAL SOLUTE TRANSPORT RATE IN
COMPARATIVE STUDY OF OCCUPATIONAL
BURNOUT SYNDROME AMONG DOCTORS AND
NURSES IN NEPHROLOGY AND DIALYSIS CLINICS
1
1
N. Jovanovic, 1 B. Stojimirovic, 1 D. Jovanovic,
A. Bontic, 2 S. Zunic, 3 R. Obradovic
1
Clinic of nephrology, Clinical center of Serbia, Belgrade,
Serbia
2
Institute of pathophysiology, School of medicine,
University of Belgrade, Belgrade, Serbia
3
Institute of biochemistry, Clinical center of Serbia,
Belgrade, Serbia
B. Deliyska, 1 V. Lazarov, 2 N. Nenchev, 1 S. Krivoshiev,
R. Robeva, 3 Z. Pavlova
1
Med. University, University Hospital Queen Giovanna,
Bulgaria
2
Med. University, University Hospital "St.Ivan Rilski ",
Bulgaria
3
Med. University, Faculty of public health, Bulgaria
1
2
Background. It is well known that due to long working
hours and stressful working conditions, doctors
experience burnout more often than other professional
groups. Burnout is a syndrome of emotional exhaustion,
depersonalization and a sense of low personal
accomplishment that leads to decreased effectiveness at
work. The aim of this study was to analyse and to
compare BS in doctors and nurses in nephrology and
dialysis units. Population and methods. Methods. The
Maslach Burnout Inventory (MBI) questionnaire is a 22item questionnaire, generally considered as the ‘gold
standard’ measure for burnout.The scale of MBI rate
from 0-never to 6 points-always. MBI has 3 domains of
burnout: emotional exhaustion included 9 questions,
depersonalization-5
questions
and
personal
accomplishment-9 questions. It was voluntarily and
anonymously applied to 64 persons-36 doctors and 28
nurses from 2 nephrology and 2 dialysis clinics in 2
university hospitals in Sofia. We records also sex, age,
duration of all professional occupation and it the unit
Results. Mean score for all persons was 55,05±12,3,
for dialysis clinics (DC) it was 53,8±11,8 and for
nephrology clinics (NC) it was 56,6±12,9. The doctors
from DC had score 52,1±11,4 and from NC-59,4±9,9
(p<0,01). There was not significant differences in the
score between nurses in DC and NC (resp. 54,5±11 and
53,4±13). Nurses in DC had higher score that the
doctors (resp. 54,5±11 and 52,1±11,4) while the
doctors from NC were with higher score than the nurses
(resp.59,4±9,9 and 53,4±13). Emotional exhaustion,
depersonalization and personal accomplishment were
higher in doctors in NC. There were no correlations
between BS with age, gender and duration of
occupation. Conclusion. We conclude that the staff of
nephrology and dialysis clinic have moderate burnout
syndrome. Doctors in nephrology clinics have higher
score of emotional exhaustion, depersonalization and
personal accomplishment.
Background. Peritoneal solute transport rate (PSTR) is
measured by dialysate-to-plasma (D/P) ratios of low
molecular weight solutes. High PSTR reflects either a
large effective peritoneal surface area or increased
permeability of the peritoneal vasculature. Vascular
endothelial growth factor (VEGF) is the prototypical
cytokine associated with angiogenesis in many disease
processes throughout the body. The aim of the study
was to evaluate the possible influence of serum and
peritoneal effluent concentrations of VEGF on peritoneal
small-solute transport rate in continuous ambulatory
peritoneal dialysis (CAPD) patients (pts). Methods. We
examined 39 pts mean age 54 years (range 28-68
years), 27 male and 12 female, being 11 patients
affected by diabetes mellitus type I and 9 patients by
diabetes mellitus type II, 13 pts older than 65 years. Pts
were on CAPD treatment with conventional 40 mmol/l
lactate dialysis solution, pH 5.3-5.5 containing 1,36 to
2,27% dextrose as appropriate, and 8 of the pts
performed an overnight icodextrine based dwell. Pts
performed four or five 2 to 2,5 l. exchanges daily for
seven days a week with no dry period. Fasting blood
samples taken for analyses of VEGF were centrifuged at
40 C at 1000g for 15-30 minutes and frozen at -700 C.
Peritoneal effluent was collected from a timed overnight
(8 hours) dwell using a 1,36% glucose solution.
Approximately 20 ml of overnight drain fluid was
collected for storage at -70 0 C. The samples were
filtered prior to assay. An ELISA method was used for
the measurement of plasma and effluent VEGF
concentration. The peritoneal equilibration test (PET)
was performed according to the method described by
Twardowsky. Results. The pts performed adequate
dialysis with Ccr 58,34±13,78 l/week and Kt/V
1,89±0,34. The RRF was 18,4±12 l/week. VEGF
concentration in serum was 188,5±69,4 ng/ml. VEGF
concentration in dialysate effluent was 30,5±16,7
ng/ml. There was no significant correlation between
concentration of VEGF in serum and in dialysate effluent
and peritoneal small-solute transport rate in our group
of pts. Conclusion. Significant variability was seen in
PD
effluent
concentration
of
VEGF
and
low
concentrations of VEGF in PD effluent were found in our
patients. Prospective studies on higher number of pts
are needed to assess the role of VEGF in chronic
peritoneal dialysis treatment and to define factors
influencing its concentration in serum and effluent on
chronic PD treatment.
105
PP 165
PP 166
CYTOMEGALOVIRUS INFECTION, OUR
EXPERIENCES AND ANALYSIS IN RENAL
TRANSPLATATION
HYPERTENSION AND SMOKING IN ELDERLY
D. Tasic
Clinic of Nephrology, Clinical center Nis, Serbia
K. Obrencevic, M. Radojevic, J. Tadic-Pilcevic,
Z. Kovacevic, D. Pilcevic, V. Rabrenovic, M. Mijuskovic,
Z. Cukic
Clinic for Nephrology, Military Medical Academy, Serbia
Background. Isolated systolic hypertension is more
comon in old patients. Risk factors as obesity, smoking,
diabetes, smoking habits also contribute isolated systolic
hypertension and exact prevalence is unknown. Aim of
investigation is to determinate prevalence and
characteristics of resistant hypertension among persons
older than 60 years. Methods: We stratified participants
into 2 groups based on smoking habits. National
guidance for arterial hypertension was used for High
Blood Pressure classification stage. Finally, we modeled
a stepwise multiple regression analysis to determine
predictors of cardiovascular responce. Results. There
were 44 participants (23 men and 21 women) with
hypertension mean age 67±7.83 years, mean BMI
30.28±5.12kg/m², mean body weight 84.73±13.57kg,
mean GFR 68.50±32.56 µmol/L/1.73m². Conclusion.
Smoking significantly affects the systolic arterial
pressure - 0.305 (p<0.05) and pulse pressure - 0.301
(p<0.05). Detecton of patients with risk factors and
hypertension ables timely application of adequate
therapy strategy and provide blood pressure control.
Background. Cytomegalovirus (CMV) infections is one
of the most important pathogens in renal transplant
patients. CMV disease has been associated with the two
most common causes of late graft loss: cardiovascular
disease and chronic rejection. It has shifted from being
overtly to insidiously lethal.Prophylactic and preemptive
therapy of CMV infection are effective for the
management of CMV postrenal transplantation in the
short term. Methods. We analyzed all patients
undergoing kidney transplatation at the Military Medical
Academy Belgrade (descriptive retrospective study)
between january 2006. and january 2011..The diagnosis
of CMV disease was performed by serology ( ELISA),
pp65 antigenemia determination or qunatification of
CMV-PCR (polymerase chain reaction) in peripheral
blood. Patients who received 3 month of prophylaxis
with valganciclovir followed by monitoring of CMV
DNAemia by polymerase chain reaction (PCR) every
month during 3 additional month. Prophylaxis included
acyclovir in 11 patients (8.9%), ganciclovir in 88
patients (71%), valganciclovir in 25 patients (20.1%).
Patients with low risk for CMV infection ( donor
negative/ recipient negative / D-/R-/ ) we treated with
acyclovir; patients with middle or high risk for CMV
infection we treated with ganciclovir (D-/ R+, D+/ R+)
and patients with high risk for CMV infection treated
with valganciclovir ( D+/ R-, and patients who received
anti-thymocyte globulin (ATG) or basiliximab for
induction or tretmant of rejection). Results. CMV
serology was positive in 112 donors (90%) and in 115
recipients (93%). Among the recipients who suffered
from CMV disease (N=11), three lost the graft and one
died. Early infection and early disease were significantly
more frequent (p< 0.05) in positive donor- negative
recipient cases ( D+/ R-), and patients who received
ATG or basiliximab for induction or treatment of
rejection .Early or late CMV infection was associated
with increased graft loss from any cause. Conclusion.
CMV has been associated with both atherosclerosis and
chronic rejection, and the two most common causes of
late graft loss are cardiovascular death and chronic
rejection (chronic allograft nephropathy). The primary
limitation of our analyzed patients was cost of medicines
for treated CMV, because of the that we treated with
valganciclovir at prophylactic therapy only patients who
received ATG or basiliximab and patients with high risk
for CMV infection.
PP 167
ANALYSIS OF CARDIOVASCULAR MORTALITY IN
1
D. Petrovic, 2 B. Stojimirovic
CC Kragujevac, Clinic of Urology and Nephrology,
Kragujevac, Serbia
2
CC of Serbia, Clinic of Nephrology, Belgrade, Serbia
1
Background. Cardiovascular diseases are the leading
cause of death in hemodialysis (HD) patients. The
annual cardiovascular mortality rate in these patients is
9%, with left ventricular (LV) hypertrophy, ischemic
heart disease and heart failure being the most prevalent
causes of death. The aim of this study was to determine
the cardiovascular mortality rate and estimate the
influence of risk factors on cardiovascular mortality in
HD patients. Methods. A total of 115 patients
undergoing HD for at least 6 months were investigated.
Initially a cross-sectional study was performed, followed
by a two-year follow-up study. Beside standard
biochemical parameters, C-reactive protein (CRP),
homocysteine,
cardiac
troponins
(cTn)
and
echocardiographic parametes of LV morphology and
function (LV mass index, LV fractional shortening, LV
ejection fraction) were determined. Results were
analyzed with Cox regression analysis, Kaplan-Meier and
Log-Rank tests. Results. The average one-year
mortality cardiovascular rate was 8.51%. Multivariate
Cox regression analysis identified increased CRP, cTn T
and I, and LV mass index as independent risk factors for
cardiovascular mortality. Patients with cTnT > 0.10
ng/mL and CRP > 10 mg/L had significantly higher
cardiovascular mortality risk (p < 0.01) then patients
with cTnT > 0.10 ng/mL and CRP ≤ 10 mg/L and those
with cTnT ≤ 0.10 ng/mL and CRP ≤ 10 mg/L (p < 0.01).
Conclusion. HD patients with high cTnT and CRP have
higher cardiovascular mortality risk.
106
PP 168
PP 169
ASSOCIATION BETWEEN KIDNEY INJURY
MOLECULE-1 (KIM-1) EXPRESSION IN TISSUE
WITH TUBULOINTERSTITIAL INFLAMMATION AND
FIBROSIS IN PATIENTS WITH DIFFERENT KIDNEY
DISEASES
TUBULOINTERSTITIAL NEPHRITIS AND
HYPOKALEMIC TETRAPARESIS IN PRIMARY
SJOGRENS SYNDROME
T. Ilic, G. Strazmester Majstorovic, I. Mitic, B. Milic,
D. Celic, T. Djurdjevic-Mirkovic, L. Petrovic, D. Bozic,
M. Popovic, M. Sibalic Simin
Clinic of Nephrology and clinical Immunology, Clinical
Center of Vojvodina, Novi Sad, Serbia
1,2
S. Simic-Ogrizovic, 3 S.Bojic, 2,4 G.Basta Jovanovic,
R.Naumovic
1
Serbia
2
3
Clinical Hospital Center B.Kosa, Belgrade, Serbia
4
Institute of pathology, Serbia
1,2
Background. Primary Sjogrens Syndrome presenting as
acute tetraparesis is rare. Case report. We present a
patient in whose case, 12 years after establishing
diagnosis of Primary Sjogrens Syndrome we have
recognized the
development
of
tubulointerstitial
nephritis which leads to renal tubular acidosis and
hypokalemia. Patient was under regular immunologist
control
and
immunosupresive
treatment
(corticosteroides and antimalarian drugs). A few days
before hospitalization patient had history of muscle pain
and progressive weakness of all four limbs. When
reviewed at the emergency, the patient could not move
extremitates and her head. Preliminary examination
showed severe hypokalemia with metabolic acidosis.
Patient was treated with KCl infusion and intravenous
soda bicarbonate was started after sera K achives value
> 3,5 mmol/l . Also we used tiazide diuretics treatment.
Upon this treatment we noticed significant improvement
in laboratory findings as well as clinical status of the
patient. Conclusion. Percutan renal biopsy was done
and showed chronical tubulointerstitial nephritis on
patohistology. Immunofluorescence showed focal tubular
basement membrane deposits of IgG and C3.
Background. Kidney injury molecule-1 (KIM-1),
transmembrane tubular protein, is the trademark of
almost all proteinuric, toxic and ischemic kidney
diseases.
Recent
data
reveled
its
possible
pathophysiological role in modulating tubular damage
and repair. The aim of this study was to examine
projected association between tissue KIM-1 expression
with tubulointerstitial (TIN) inflammation and fibrosis in
different kidney disease. Sixty one patients, pts (28
males, 34.15 ±12.23 years old) with different kidney
biopsy indications were included in the study. Methods.
Tissue
KIM-1
expression
was
determine
immunohistochemicaly
(kit,
R&D
Systems
Inc,
Minneapolis, MN, USA) and KIM-1 staining was scored
semi-quantitatively by estimating the percentage of
cortical tubules expressing KIM-1 per field. TIN
inflammatory and TIN fibrosis per field were scored 0-4.
Results. Pathohystological analisys revealed MCGN in 3
pts, MzPGN in 9 pts, IgA GN in 6 pts, MGN in 7 pts,
MPGN in 7 pts, FSGS in 11 pts, SLE LN type IV in 10 pts,
RPGN in 4 pts and vasculitis in 4 pts. Results revealed
significantly postitive correlation between KIM-1 tissue
expression with TIN inflammatory activity (r= 0.457)
and TIN fibrosis (r=0.358). Conclusion. KIM-1 tissue
expression correlated significantly with TIN feathures
and furher study should be perform in order to evaluate
the KIM -1 tissue expression in kidney function and
proteinuria prediction at time, 6 months and one yeras
after kidney biopsy in diffrent kidney disease.
107
PP 170
INFERIOR VENA CAVA PARAMETERS IN THE
CLINICAL VOLUME ASSESSMENT IN HEMODIALYSIS
PATIENTS
PP 171
1
1
NINE MONTHS PROSPECTIVE STUDY: LOW
CALCIUM HD-SOLUTION FOR PATIENTS WITH LOW
IPTH
V. Djurkovic, 2 L. Suric Lambic, 3 R. Markovic
Clinical Hospital Center “Zemun”, Department of
Nephrology, Haemodialysis unit, Belgrade, Serbia
2
3
E. Hadzibulic, 1 F. Birdozlic, 2 M. Savin
Department of Nephrology and Haemodialysis, Medical
Center of Novi Pazar, Serbia
2
Nephrology Clinic, Clinical Canter of Serbia, University
Belgrade School of Medicine, Serbia
1
1
Background. Adynamic bone disease (ABD) in HDpatients with low iPTH is serious therapeutic problem.
Prospective study on 51 HD-patients was conducted to
evaluate the effect of 9 months regular HD-procedure
with low calcium (Ca) HD-solution (HDfl) of 1.25 or
1.5mmol/l for the patients who developed disorders of
Ca
and
phosphate
(P)
turnover
with
low
iPTH<150ngr/ml following HD-regimen with standard
HDfl-Ca=1.75mmol/l for 1-120 months. Based on low
initial iPTH two groups were defined; group-1:11
patients with iPTH<50ngr/ml (34.4+-8.9);sCa=2.27+0.21mmol/l;Ca*P=3.3+-1.2 submitted to very low HDflCa=1.25mmol/l; and group-2: 23 patients with
50>iPTH<150ngr/ml
(85.9+-26.3);
sCa=2.16+0.2mmol/l;Ca*P=3.3+-0.8 submitted to low HDflCa=1.5mmol/l. They were compared with control group3: 9 patients with 150>iPTH<300ngr/ml (198.6+-30.9)
converted from HDfl-Ca=1.75mmol/l to the regimen
with low HDfl-Ca=1.5mmol/l; and group-4: 8 patients
with
hyper-iPTH>300ngr/ml
(543.6+-193.9)
continuously on HDfl-Ca=1.75mmol/l. Primary endpoints of the study were iPTH>50ngr/ml and
iPTH>150ngr/ml after 9 months HD treatment with low
HDfl-Ca combined with reduced peroral CaCO3<=2gr
daily and alfaD3<=0.25ngr every 3rd day in patients
with initial iPTH<150ngr/ml. GLM test for repeated
measures and Bonferroni test were applied for data
analysis. Four groups had similar distribution of gender
(28M,22F), age (50.8+-13.4yrs), HD-time and underline
kidney
disease
(14
glomerulonephritis,15
nephroangiosclerosis,11
diabetic
nephropathy,11
tubulointerstitial-nephtitis including 8 ADPKD). sCa
gradually increased in groups-1 and -2 for 9
months(p=0.04), significant improvement commenced
after 4th months of treatment. Initial hyper-P was
detected in 6/34 patients with low iPTH (1 of group-1
and 5 of group-2), while P>=2mmol/l had one patient
(9%) of group-1 and 3 (13%) of group-2 after 9
months. Parallel iPTH increase was noted in groups 1
and 2 (p9mo vs.0=0.04), two patients of group-1
(18%),
and
8
of
group-2
(35%)
reached
iPTH>150ngr/ml at 9thmonth. In group-1 iPTH
significantly increased during first 3 months and 6-9th
month, while in group-2 continuous increase of iPTH
commenced later, at 3rd month (p3mo vs.0=0.033)
when the dosage of CaCO3 was significantly reduced
(p3mo vs.later=0.012). Two patients of group-1 (18%)
and one of group-2 (4%) did not respond to treatment
(iPTH9thmo<50ngr/ml). In group-3 iPTH remained in
range
150-300ngr/ml,
in
group-4
hyper-iPTH
>300ngr/ml persisted. Conclusion. 9-months HDprocedure with low Ca dialysis solution may induce
significant increase of low iPTH that may prevent ABD.
Background. Control of hydration and volume state in
patients on hemodialysis (HD) has an important clinical
significance. Many patients remain in a state of
unrecognized hypervolemia for a longer period of time.
Accurate estimation of the volume and determining dry
body weight (DBW) remains a significant clinical
problem which is why it needs to be objective to check
in hemodialysis patients without clinically manifest signs
of hypervolemia, the ultrasonography parameters of the
inferior vena cava (VCI), and determine whether the
correction of DBW is needed. Methods. 20 patients on
HD, with moderate hypertension with clinical and X-ray
examination not showing signs hypervolemia, an
ultrasound measurement of VCI before and 2 h after HD
was done. DBW is reduced during the next month, and
the above mentioned measurements were then
repeated. Statistical analysis of data showed the
following results: Results. DBW was reduced in average
of 3.77 kg during the month and was 70.31 ± 12.8 (I
measurement) and 66.54 ± 11.84 (II measurement)
(p> 0.05). The values of the parameters of VCI to the
first and second measurements ( I and II ), before and 2
h after dialysis are shown in the table below. Legend:
VCIi - the diameter of VCI in inspiratory, VCIe - the
diameter of VCI in expiratory, CI% - collapsing index of
VCI Conclusion. Measurements of VCI diameter in the
inspiratory and expiratory flow as well as calculated
collapsing index at the beginning of studies have shown
that our patients had hypervolemia. After reduction of
DBW, statistically significant changes in the parameters
of VCI were obtained. Also, changes in certain
parameters of VCI (primarily VCI diameter at expiration)
in the second measurement were more generous than
the same changes in the first measurement, which
indicates the relieve of patients from the excessive
volume by DBW reduction procedure. The parameters of
VCI appeared to be more sensitive in assessing volume
status in HD patients than clinical examination,
especially in state of clinically not manifested
hypervolemia. As well as in our patients who have no
clinical side effects after the reduction of the DBW.
108
PP 172
PP 173
THE RENAL ARTERY STENOSIS DIAGNOSIS
ASPECTS
ACUTE INTERMITTENT PORPHYRIA - DIAGNOSTIC
PROBLEM IN NEPHROLOGICAL PRACTICE, WITH A
CASE REPORT
1
R. Motoc, 2 C. Motoc, 3 M. Laszlo, I. Tilea, 4 M. Borda
Medical Clinic 3, University Of Medicine And Pharmacy,
Targu Mures, Romania
2
Medical Clinic 3, Emergency County Hospital, Targu
Mures, Romania
3
SCM Procardia, Targu Mures, Romania
4
Cardiovascular Reabilitation Hospital, Cluj, Romania
1
Z. Cukic, N. Vavic, M. Mijuskovic, V. Rabrenovic,
Z. Kovacevic, D. Pilcevic, J. Tadic Pilcevic, D. Savic,
M. Petrovic
Military Medical Academy, Belgrade, Serbia
Background. Acute intermittent porphyria (AIP) is a
rare disease with potentially serious consequences,
which is caused by mutations porphobilinogen
deaminase enzyme, essential in the biosynthesis of
heme. Diagnosis of AIP is not difficult to make, if we
think of this disease and application of appropriate
diagnostic procedures. The main difficulty lies in the
diversity of its clinical were done, which often point to
the wrong choice of diagnostic procedures and
therapeutic measures, which make the potentially lifethreatening patients. Case report. Thirty year old
female was admitted to the Nephrology Clinic Military
Medical Academy with simptoms and signs that indicate
acute pyelonephritis (weakness, fatigue, pain in the left
lumbal region, constipation, red colored urine).
Symptoms appear preceded increased physical activity,
longer absence of bowel movements, insomnia and
mental distress. As there was no clinical and laboratory
confirmation of disease on which the suspected, and
because
of
existing
severe
hyponatremia
and
hypochloremia, suspected to be a female patient comes
to acute intermittent porphyria attack, which proved
positive findings of the porphyrin from the 24-hour urine
porphobilinogen and delta-aminolevulinic acid with
morning urine sample. Of the infusion of hypertone
glucose solution, adjusting electrolyte abnormalities, and
other symptomatic therapy, after four days of treatment
achieved complete recovery of patient. Conclusion. In
this way, is conveniently ended the first serious episode
of her illness, with the further course and outcome,
unfortunately, uncertain.
Background. Guiding the screening for renovascular
disease implies identifying the prediction factors
associated with this pathology and its relation to other
vascular diseases (coronary, carotid, peripheral). Our
aim was the rapid and accurate diagnosis of renal artery
stenosis with the aid of duplex mode Doppler
ultrasonography, that provides functional information
revealing
hemodynamicaly
significant
stenosis.
Methods. We included 122 patient with hypertension
admitted to hospital and with a follow-up between 2000
and 2010. Using duplex mode Doppler ultrasonography
we measured a series of parameters (maximum systolic
speed, resistivity indexes) in the renal artery and
interlobar arteries. The 122 patients included in the
study were included in 2 groups according to the
maximum systolic speed (Max speed >1.8m/s is
characteristic for hemodinamicaly significant renal artery
stenosis) and resistivity index lower then 0.6.
Angiographic examination was used to confirm the
presence of the stenosis and its severity. Statistic
analysis was performed using the SPSS for Windows
statistics program. Results. We found patients without
stenosis 86 representing (70.49%), and with stenosis 36
patients (29.51%). The average blood pressure was
higher in the group with stenosis (194mmHg) vs. the
group without stenosis (160mmHg), with the value of
p<0.001. A larger proportion of patients required 3
antihypertensive drugs in the group with the stenosis
31(86.11%) vs. 49(56.98%)in the group without
stenosis, the value of p=0.002. Coronary disease was
found in 21(58.33%) of the patients with stenosis and in
17(19.77%) in those without stenosis (p=0.001). We
found a correlation (p=0.001) between acute pulmonary
edema and renal artery stenosis, particularly in bilateral
stenosis. In the group with stenosis 20 patients
(55.56%) had peripheral arteriopathy versus 21 patients
(24.42%) in the group without stenosis (p=0.001).
Cerebrovascular disease was significantly more frequent
(p=0.004) in the group with stenosis 15 patients
(41.67%) versus no stenosis 15 patients (17.44%).
Conclusion. Coronary disease, peripheral arteriopathy,
cerebrovascular disease and acute pulmonary edema
have a much higher frequency in the group with
stenosis. In the group with stenosis, blood pressure
values were significantly higher and required more often
over 3 antihypertensives. The angiographic examination
confirms that Doppler vascular ultasonography is an
efficient, relatively cheap and reproducible examination
in the diagnosis of renal artery stenosis. Maximum
systolic speed and resistivity index are indicators of the
hemodynamic severity and therefore of the prognosis of
renal artery stenosis. The evaluation of these markers
beside the diagnosis provides information about the
prognosis of the renal revascularization.
109
PP 174
PP 175
RELATIONSHIP BETWEEN VITAMIN D ANALOGS
AND LEFT VENTRICULAR MASS INDEX IN STAGE 5
CHRONIC KIDNEY DISEASE PATIENTS
ARTERIAL HYPOTENSION IS MOST COMMON ACUTE
COMPLICATION DURING HEMODIALYSIS
Z. Cukic, Z. Kovacevic, M. Mijuskovic, D. Jovanovic,
B. Terzic, D. Savic, J. Tadic Pilcevic, D. Pilcevic, L.
Ignjatovic, V. Rabrenovic
Military Medical Academy, Belgrade, Serbia
S. Sezer, E. Tutal, Z. Bal, M. Erkmen Uyar, F. Nurhan
Ozdemir Acar
Turkey
Background. Arterial hypotension is most common
complication during hemodialysis. Dialysis arterial
hypotension is defined as systolic blood pressure lower
than 100 mmHg, or a drop in systolic pressure over 40
mmHg and diastolic over 20 mmHg during 15 minutes,
with the appearance of symptoms: vertigo, dizziness,
cramps, fatigue, etc. Incidence of dialysis hypotension is
10-30% of hemodialysis treatment and 20-50% of
patients on hemodialysis. High-risk group of patients are
those with diabetic nephropathy, cardiovascular disease,
poor nutritional status, neuropathy, anemia and elderly
patients. The goal of the study is to determine the
incidence of dialysis-induced hypotension compared to
other acute complications in our hemodialysis unit, the
frequency of certain symptoms of dialysis hypotension,
the most common period of occurrence of hypotension
during hemodialysis, the structure of patients with
dialysis hypotension in relation to sex, age, duration of
hemodialysis treatment, nutritional status, average
interdialytic increase in body mass, the distribution of
patients in particular risk groups and impact on the
effectiveness of hemodialysis treatment. Methods. The
study included all patients in the treatment of repeated
regular hemodialysis in our center during the one year,
divided into three groups with normal (MAP 85-115
mmHg), low blood pressure (MAP below 84 mmHg) and
high blood pressure (MAP over 116 mmHg) before
dialysis treatment. Results. The study determined that
dialysis hypotension manifests in approximately 17% of
patients and 12% of all hemodialysis procedures, mainly
during the third hour of hemodialysis procedures. The
remaining acute complications of hemodialysis were not
represented more than 6% of hemodialysis procedures.
The most of patients with dialysis hypotension were
from a group with low blood pressure before dialysis
(43%) and in group with hypertension (38%), nearly
equal male and female, middle aged and elderly (43%
over 45 years and 38% of elderly than 62 years) and
with poor nutritional status (average BMI 19.3).
Conclusion. In all patients there was an large
interdialytic weight gain (more than 5% of dry body
weight), of which 52% had moderate anemia, 41% left
ventricular hypertrophy, 19% diabetes mellitus and 14%
of ischemic heart disease. Kt/V index was more than 1.2
(average 1.33) in all patients.
Background. Secondary hyperparathyroidism (SHPT) is
a common complication of chronic kidney disease (CKD).
In CKD, left ventricular hypertrophy (LVH) is frequent
and is associated with increased cardiovascular
morbidity and mortality. Vitamin D receptor (VDR)
activation reduces LVH progression in animal models.
The aim of this study was to evaluate the effects of oral
and intravenous paricalcitol treatment on left ventricular
mass index (LVMI) in long-term hemodialysis (HD) and
peritoneal dialysis (PD) patients. Methods. This is a
randomized,
6-months
prospective
study
with
intravenous paricalcitol or calcitriol treatment in subjects
with stage 5 CKD. Results. 54 subjects (27 paricalcitol,
27 calcitriol group) were included. Paricalcitol group (8
female, age; 47.5 ±11.3 yrs) received 0.04 mcg/kg to
0.1 mcg/kg intravenous paricalcitol 3 times per week
(n=27) while calcitriol group (16 female, age; 53.6 ±
11.8 yrs) received 1-2 mcg 3 times/week intravenous
calcitriol for 6 months. Demographic and clinical (blood
pressure, interdialytic weight gain) characteristics and
including the laboratory data (calcium, phosphorus,
alkaline phosphatase, hemoglobine and CRP) of patient
group were similar. Lessen the days of VDR activator
therapy were 330 patient days in parikalcitol group and
450 patient days in calcitriol group (p:0,01). In
paricalcitol group, mean PTH values in 1st and 6th
month were 879.8±311.9 pg/ml and 621.2±297.8
pg/ml. In calcitriol group, mean PTH values in 1st and
6th month were 889.6±580.0 pg/ml and 814.2±652.4
pg/ml (p<0.05). Echocardiographic evaluations were
performed by same cardilogist at the beginning and 6th
month of study. LVMI was calculated by Devereux's
formula. We found that in calcitriol group left ventricular
mass index significantly increased during follow-up
period (133.7±26.0 g/m2 vs. 147.32±32.6 g/m2) (p:
.04) while there was no significant change in paricalcitol
group. End-study LVMI of calcitriol group was also
higher compared to paricalcitol group while basal values
were similar (132.2±42 g/m2 vs. 147.32±32.6 g/m2)
(p: .03). Conclusions. Decreasing the secondary
hyperparathyroidism with VDR analogs there may also
be a difference in the risk of cardiovascular mortality by
decreasing
LVMI.
Treatment
sustainability
with
paricalcitol is significantly better than calcitriol.
Keywords: dialysis, paricalcitol, left ventricular mass
index.
110
PP 176
PP 177
INFLUENCE OF RESIDUAL DIURESIS AND
EXCRETION OF SODIUM ON BLOOD PRESSURE IN
VOLUME AND NUTRITIONAL STATUS EVALUATED
BY BIOIMPEDANCE AFFECTED BY BODY POSITION
IN HEALTHY POPULATION
A. Bontic, M. Lausevic, N. Jovanovic, M. Milinkovic,
J. Pavlovic, M. Kravljaca, D. Jovanovic, V. Nesic
Clinic for Nephrology, Belgrade, Serbia
1
2
1
2
3
Background. Blood pressure in peritoneal dialysis (PD)
patients may be related to hypervolemia, preservation
of residual renal function, clirens of vasoactive
substances, patients cooperation or to administration of
erythropoietin. The aim of the study is to compare
influence of residual diuresis (RD) and excretion of
sodium on blood pressure control in PD patients.
Methods. The study is retrospective analysis of 30
patients who are divided in 3 subgroups by volume of
RD and ultrafiltration (UF). In the first were 12 patients
with RD<500 ml/day (40%), in the second 7 patients
with RD between 500 and 1000 ml/day (23.3%) and in
the third 11 patients with RD>1000 ml/day (36.7%).
Results. By increased RD volume linear trend of blood
pressure was decreasing with statistical significant
coefficient of linear correlation with sistolic pressure
(R2=0,7106), diastolic pressure (R2=0,7106) and mean
arterial pressure - MAP (R2=0,8467). In the first
subgroup correlation RD with UF, totally excretion of
sodium and blood pressure was inverse. Higher sistolic
pressure had statistical significant correlation with less
loss of sodium in dialysate, urine and totally (urine and
dialysate). Diastolic pressure and MAP had statistical
significant correlation with less loss of sodium in
dialysate. In the second subgroup correlation RD with
UF, diastolic pressure and loss of sodium in dialysate
and totally loss was inverse. Small RD volumes in these
interval were correalate with higher UF rate, higher
diastolic pressure and higher totally excretion of sodiu,
but without statistical signification. In the third subgroup
correlation RD with UF, loss of sodium in dialysate and
totally was inverse, but without statistical signification.
Conclusion. We can conclude that RD and excretion of
sodium have important role in better blood pressure
control in PD patients no metter of RD volume. Totally
excretion of sodium has positive influence on better
blood pressure control no metter of RD volume and
inverse.
4
E. Hur, 2 M. Ozisik, 2 C. Ural, 2 D. Bozkurt, 2 F. Akcicek,
A. Basci, 3 G. Suleymanlar, 4 K. Ates, 2 S. Duman
Karaelmas University, Turkey
Ege University, Turkey
Akdeniz University, Turkey
Ankara University, Turkey
Background. Body composition analysis is useful for
assessing hydration, nutritional status and predicting
clinical outcomes. Composition is altered in chronic
kidney disease patients because of protein energy
malnutrition, altered micronutrient status, and variable
fluid homeostasis. Bioimpedance analysis (BIA) is a
simple, cheap, and noninvasive tool for monitoring body
composition. We aimed to find out if body position has
an effect on the BIA results. Method. Characteristics
including age, gender, height and weight were recorded.
Hydration and nutritional status measured by BCM while
the same person lying down and standing positions with
the same electrodes. Results. 201 healthy populations
from various regions in Turkey, 61% (n: 123) male,
mean age was 46,3±12 years (range of 18-76) of age,
participated in this crossectional study. Conclusion.
During bioimpedance measurements, lying and standing
positions could affect the results of hydration even
nutritional parameters in healthy population. Protocols
should be re evaluated inorder to get more accurate
results in bioimpedance measurements.
111
PP 178
PP 179
IDENTIFICATION OF DEPRESSION AND SOCIAL
BEHAVIORS PROBLEMS IN PATIENTS MAINTAINED
ON HEMODIALYSIS
COMPLICATIONS IN PATIENTS WITH
TRANSPLANTED KIDNEY WHO WERE PREVIOUSLY
TREATED BY PERITONEAL DIALYSIS: OUR 15
YEARS EXPERIENCE (1996-2011)
1
S. Mumajesi, 1 J. Caja, 1 N. Pasko, 1 A. Strakosha,
E. Likaj, 1 S. Seferi, 1 M. Rroji, 2 E. Emrullaj,
1
N. Thereska
1
Department of Nephrology –HemodialysisTransplantation, University Hospital Center “Mother
2
Polyclinic Medical Center, Tirana, Albania
1
V. Rabrenovic, Z. Kovacevic, L. Ignjatovic, D. Jovanovic,
N. Vavic, M. Radojevic, M. Petrovic, M. Mijuskovic,
D.Pilcevic, J. Tadic Pilcevic
Clininic of Nephrology Military Medical Academy,
Belgrade, Serbia
Background. Patients with Tx kidney who were
previously treated by PD represent a group of pts being
much less exposed to hepatitis virus, with milder form of
anemia developed but with a higher percentage of
occurrence of complications and infections. The aim of
this study is to provide a review of complications and
renal function in patients with Tx kidney who were
previously treated by PD. Methods. Retrospective
analysis conducted in the period jan1996 – jan2011,
with the monit. period of 2-144 months (aver. 41,39
mth). Out of 324 kidney Tx. performed, 40 (12,3 %)
were done in PD pts (18 female, 22 mail pts, average
age of 33,35±5,2 yrs). Results. The main disease
causing renal insufficiency was GN in 24 (62,5%) pts,
DM in 8 (20%), juv. nephronophthisis in 2 (5%),while
VUR, kidney hypoplasia,Sy GoodPasture, SLE and
policyst. kidney were registered in 5 separate cases. 5
(12,5%) Tx from deceased donors and 35 (87,5%)
living donor kidney Tx were performed. The
immunosuppressive Th. was quadrupled in 22 (54%) pts
and trippled in 18 (45%). We observed the graft
survival, early and ch. complications and the renal
function : s/creatinine and Cl.Creatinine. Thrombosis of
renal artery and early loss of graft occured in 6 (15%)
pts. mainly with DM. As far as the early complications
are concerned, we registered bleeding in 5 (12,5%) pts,
hematoma on the surgical injury site in 4 (10%) pts
and, lymphocele in 5 (12,5%) pts. Delayed graft
function occured in 5 (12,5%) pts, acute rejection in 10
(25%) pts. There wasn’t any case of peritonitis
identified. As for the chronic complications, there were 7
(17,5%) cases of ch.rejection with 4 (10%) loss of graft.
4 (10%) pts was with uretyera stenosis. We registrated
7 (17,5%) bacterial infections,9(22,5%) cases of
reactiv.of CMV inf and in 1 case Herpes Zoster inf. The
reccurence of disease occured in 3 (7,5%), and 2 pts
loss of graft. The stable medium volume of s/creatinine
was 129,62 ±10,3umol/l in the early stage and 146,86
±12,1umol/l in the end of the monit.period. The medium
volume of Cl.creatinine was 63,26±6,5ml/min at the
early ph. of monit. period and 64,78±6,2ml/min in the
end). This study has shown that more frequent surgical
(vascular) complications occure in patients with diabetes
mellitus. Conclusion. There wasn’t any case of
peritonitis identified most probably because the
peritoneal catheter was removed during the Tx. The
largest number of pts was with stable graft function.
Background. Depression and social behavior problems
are very common among patients undergoing
hemodialysis. It is known nowadays that behavior
problems have a significant impact on morbidity and
mortality of these patients. For that reason is very
important to diagnose these disorders at first steps in
order to provide the appropriate therapies to those
patients. The aim of the study was to evaluate the
prevalence of depression and social behaviors problems
among hemodialysis patients at our center. Methods.
One hundred and twenty patients with ESRD on
hemodialysis maintenance were examined. Patients
were 18 year and older, and were over one month on
hemodialysis. We used three different methods to
evaluate depression and social behavior problems to our
hemodialysis patients: The Beck Depression Inventory
(BDI) test, Perception of Illness Effects scale, and the
Multidimensional Scale of Perceived Social Support
(PSSS). Results. Approximately more than half of the
sample manifested depression and anxiety symptoms at
clinically relevant levels from the BDI, from PSSS ,80%
of patients confirmed that the source of support is their
family scored maximally that indicate high levels of
perceived support. And from the Perception Illness
Effects Scale, 45% of patients think negatively that
there is little that can be done to improve their illness
and 90% of them thinks that their illness has major
consequences on their life. These thoughts match 100%
with BDI. Conclusion. In our centre depression and
social behavior problems are commonly present, and the
tests used for this study were very useful for screening
these patients. A greater attention by the medical stuff
and social workers it is needed for this group of patients.
We must work to increase motivation and selfish, but
not only through psychologists, but also by family and
loving people. The doctor (social workers or
psychologist) should play a very important role in the
life of these patients.
112
PP 180
PP 181
HEMOGLOBIN LEVEL FLUCTUATION ASSOCIATED
WITH DIFFERENT ERYTHROPOIESIS STIMULATING
AGENTS IN HEMODIALYSIS PATIENT
EPIDEMIOLOGY OF BALKAN ENDEMIC
NEPHROPATHY IN JABLANIC AREA
1
S. Glogovac, 2 V. Djordjevic
Clinical of Nephrology and Hemodialysis, Medical Centre
Leskovac, Clinical Centre Nis, Serbia
Z. Dimitrijevic, T. Cvetkovic, G. Paunovic, S. Ljubenovic,
K. Paunovic, M. Stojanovic, V. Djordjevic
Clinic of Nephrology and Hemodialysis, Clinical Center
Nis, Serbia
Background. Balkan endemic nephropathy (BEN) is
chronic family type of kidney disease, mostly leading to
progressive deterioration of kidney parenchyma up to
the appearance of chronic kidney insufficiency. Over the
last 30 years there have not been clear facts about the
frequency of this disease, nor the participation of this
disease in relation to the other basic causes of terminal
chronic kidney insufficiency common in the all region.
The objective/aim is following the frequency of the
appearance and length of surviving of BEN and other
kidney diseases (OKD) in Jablanica Region in longer time
period. Methods. This study took into account 614
patients who are treated with chronic dialysis for longer
than 90 days in the Center for hemodialysis of General
Hospital in Leskovac. The examination was done in the
period 1980-2009. The results are shown in a table form
and graphically in absolute values and with the rate per
100 000 people. Results. In Jablanica Region, in the
period from 1980 to 2009 on chronic programme HD in
Leskovac there were 614 patients from who 102
(16.64%) had BEN and 512(83.36%) OKD. The age of
the group of the BEN patients was 47-75 (Xsr=58,18;
SD=26,87), while OKD moved from 16 to 81 (Xsr=
51,21; SD=24,95). Regarding gender in the first group
it was equal (51 males, 51 females) and in the second
that was 324 males and 188 females (1,72:1).
Approximate annual step of incidence with hemodialysis
patients in Jablanica Region is 8,02 for BEN and was
1.33 for OKD 6.69. Approximate annual rate of incidence
of BEN in endemic settlements in regarded periods was
37,53 while in non endemic settlements of Jablanica
Region was 0,04. The incidence rate OKD (6,74) was
higher in non-endemic settlements in relation to
endemic (5,47). Linear trend of BEN incidence in
regarded
period
was
in
statistical
fall
(y=0.2127x+6.6966; r2=0.8529), and for OKD in
significant increase (y=0.4245x+10.487; r2=0.3857).
There has not been any significant difference (p=0.736)
between surviving of the patients with BEN and
surviving of OKD patients. Conclusion. Explanation of
HD incidence fall -patients with BEN in Jablanica Region
in the period from 1980-2009 should be searched in real
fall of BEN incidence, better terrain -outdoor type of
nephrological work, in - time diagnosis, better
conservatory treatment of the patients in early and
starting phase of BEN, better water supply
Background. Hemoglobin (Hb) fluctuation is a
commonly occurring phenomenon in haemodialysis (HD)
patients receiving erythropoietin-stimulating agents
(ESA) and is associated with increased mortality. This
variability is related to intercurrent illness, infections,
iron supplementation, bleeding, hospitalizations, ESA
dosing changes. The purpose of this study was to
describe the frequencies and the characteristics of Hb
fluctuation in HD patients treated with different type of
ESA agents. Methods. Data were analyzed for 94
patients on maintenance HD at our unit between
January 2009 and December 2010 who were using
darbepoetin alfa (n=24), epoetin beta (n=28), epoetin
alfa (n=23) and epoetin zeta (n=19). Enrolled patients
were treated with ESA and oral iron ≥6 months before
study period. Hemoglobin was measured monthly and
Hb cycling (cycles with amplitude >1.5 g/dL and
duration >8 weeks) and excursions (a half of Hb cycle)
were analyzed. Results. None of the ESA treated
patients had hemoglobin levels stable within the target
range over a one-year period. The mean number of Hb
excursions for all patients, regardless of ESA type was
1.6±1.5
times/year/person.
Multivariate
analysis
showed that the clinical factors associated with
variability were changes in ESA dose (relative risk [RR]:
2.26; 95% confidence interval [CI]: 1.1–8.1; P < .05)
and elevated CRP (RR: 1.88; 95% CI: 1.19–2.01; P <
.05). The mean duration of hemoglobin excursions was
9.6 +/- 4.1 weeks in darboetin alfa patients, 10.4 +/3.2, 11.2 +/- 4.5, and 10.9 +/- 5.9 in epoetin beta, alfa
and zeta treated patients respectively. Hemoglobin
cycling in patients receiving epoetin alfa had greater
frequency (1.71+/-0.75 vs. 1.22+/-0.88 times/year,
p<0.05) and amplitude (2.48+/-1.16 vs. 1.98+/-1.48
g/dL, p<0.05), than that in patients receiving darboetin
alfa. The variance of hemoglobin in patients receiving
epoetin beta (0.67+/-0.31 g/dL) was smaller than that
in patients receiving darbepoetin alfa (1.19+/-0.68 g/dL,
p<0.05), epoetin alfa (1.18+/-0.56 g/dL, p<0.05) and
epoetin zeta (1.21+/-0.51 g/dL, p<0.05). Conclusion.
Hemoglobin fluctuation is a common occurrence in ESA
treated hemodialysis patients and depend on type of
ESA used. There was greater fluctuation in hemoglobin
levels in patients receiving epoetin alfa and zeta
compared with darbepoetin alfa and epoetin beta. Dose
changes and inflammatory status are the determining
factors of variability. Effects of drug-related factors such
as differences in pharmacokinetics and bioavailability
warrant further investigations.
113
PP 182
PP 183
DRUG INTERACTION BETWEEN TACROLIMUS AND
ERTAPENEME IN RENAL TRANSPLANT RECIPIENTS
ACUTE RENAL FAILURE IN AN INTENSIVE CARE
UNIT: CLASSIFICATION ACCORDING TO THE AKIN
AND RIFLE SYSTEMS
1
F. Bora, 2 I. Aliosmanoglu, 1 H. Kocak, 3 F. Gunseren,
A. Dinckan, 1 B. Uslu, 1 O. Akin, 1 F. Ersoy,
1
G. Yakupoglu, 1 G. Suleymanlar
1
Department of Nephrology, Faculty of Medicine,
Akdeniz University, Turkey
2
Faculty of General Surgery, Dicle University,
Diyarbakır, Turkey
3
Infectious Disease and Clinical Microbiology
Department, Akdeniz University Medical Faculty,
Antalya, Turkey
4
Department of Transplantation Center, Akdeniz
University, Antalya, Turkey
4
1
R. Erdem Er, 2 Y. Erten, 2 G. Ulusal Okyay,
M. Turkoglu, 3 G. Aygencel
1
Department of Internal Medicine, Gazi University
Hospital, Turkey
2
Division of Nephrology, Department of Internal
Medicine, Gazi University Hospital, Turkey
3
Division of Critical Care Medicine, Department of
Internal Medicine, Gazi University Hospital, Turkey
3
Background. Acute renal failure (ARF) in intensive care
unit (ICU) patients is related with a considerably
increased mortality. AKIN and RIFLE classification
systems are recently introduced for the identification of
ARF cases. Superiority of these classification methods to
each other is not clearly demonstrated up to date. Aims:
We sought to determine the incidence and risk factors
for ARF in ICU patients according to the RIFLE and AKIN
systems and to demonstrate the effect of ARF
development over the mortality and morbidity.
Methods. Three hundred and ninty six patients were
analysed retrospectively. During hospitalization period,
development of ARF were noted according to the AKIN
and RIFLE systems. The laboratory findings on
admission to ICU, APACHE II, Glaskow and SOFA scores
were evaluated. Results. 204 of 396 patients (51.5%)
were male, and mean age was 62±19. 218 patients
(55.1%) have developed ARF according to the RIFLE
system. In subgroups of risk, injury, and failure, 44
(11.1%), 68 (17.2%), and 106 (26.8 %) patients were
recorded consecutively. Mortality rates of the ICU
patients with ARF was higher than those without ARF.
The independent predictors of ARF development
determined by RIFLE classification were higher APACHE
II and SOFA scores (p<0.01 for both), lower Glaskow
coma score (p<0.01), longer ICU stay (p<0.05),
concomittant hypertension (p<0.01), low bicarbonate
and pH values (p<0.05). 182 of 396 patients (46%)
were diagnosed with ARF using AKIN classification. In
subgroups of stage I, Stage II and stage III; 79 (19.9
%), 13 (13.3%) and 90 (22.7%) patients were recorded
consecutively. Mortality rates of the ICU patients with
ARF was higher than those without ARF. The
independent predictors of ARF development determined
by AKIN classification were higher APACHE II and SOFA
scores
(p<0.05),
longer
ICU
stay
(p<0.01),
concomittant hypertension (p<0.05), and low pH value
(p<0.05). Both systems were identified as predictor of
the in-hospital mortality (p<0.01); whereas only AKIN
system was also found to be the determinant of the ICU
mortality (p<0.05). Conclusion. In ICU patients,
development of ARF was related to the increased
mortality with both of the classification systems. The
risk factors for ARF development were shown to be
similar in both. AKIN system was found to be the
determinant of ICU and in-hospital mortality; whereas
RIFLE system was found to be only predictor of inhospital mortality.
Background. It is well known that calcineurin inhibitors
used organ transplantation may interact many drugs
such as ketaconozole and rifampicine via cytochrome p450 system inhibition or stimulation. The knowledge of
which drugs use may cause the alteration of calcineurine
inhibitors concentration is an important because of the
fact that calcineurine inhibitors have narrow therepeutic
range. Methods. Herein, we report that ertapenem use
due to urinary tract infection (UTI) in 13 renal transplant
(RTX) patients decreases tacrolimus dose to acheive
target serum tacrolimus concentration. We evalauted
laboratuary and clinical data of 13 RTX patients
maintained on tacrolimus based immunosupression who
received i.v ertapenem due to UTI retrospectivelly.
Results. It was found that the mean dose of tacrolimus
decrased from 0.079 mg/kg to 0.043 mg/kg during the
the treatment of UTI in RTX patients (p<0.005). This is
the first report that ertapenem administration in RTX
patients may decrease serum tacrolimus concentration.
Conclusion. Therefore, during the administration of
ertapeneme in RTX patients maintained on tacrolimus
based
immunossupresssion
should
be
closely
monitorised for tacrolimus dose adjusment.
114
Background. The prevalence of vascular access
aneurysm (VAA) and pseudoaneurysm (VAPA) differs
between clinical reports and data about risk factors for
their development are insufficient. It is known that
Matrix metalloproteinases (MMPs) are upregulated in the
walls of aneurysms and seem important in patogenesis
of aortic aneurysm formation. Also, degradation of
elastin and collagen mediated by angiotensin II, TGF-β
has been described to influence aneurysm formation.
The aim of this single-centre study is to evaluate the
possible role of MMP-3 and ACE gene polymorphysm in
patogenesis of VAA and VAPA. Methods. We examined
vascular access and MMP3 and ACE gene polymorphysm
in 184 patients on regular hemodialysis: 151 with AVF,
27 with AVG and 6 with permanent vascular catheter
(excluded from further analysis). Patients with
VAA/VAPA were classified into 3 groups according to the
scoring system (length, cm + width, cm): Group I (score
<5), Group II (score 5-10), Group III (score >10).
VAA/VAPA were correlated with patients’ MMP3 gene
polymorphysm (6A/6A, 5A/6A, 5A/5A) and with ACE
gene polymorphysm (I/I, I/D, D/D). Results.
Aneurismal/pseudoaneurismal changes of vascular
access were detected in 93 (52%) out of 178 patients.
Majority of patients had one (30.1%) and two (52%)
aneurysms; other had three (12.8%) and even four
aneurysms (5.1%). There was no significant difference
in MMP3 and ACE gene polymorphysm in patients with
and w/o VAA/VAPA (p>0.05) (table 1 and 2). Also, there
was no significant difference between Group I, II and III
(p>0.05) (table 3 and 4). Conclusion. In our group of
pateints there is high percent of VAA/VAPA, but there is
no influence of MMP3 and ACE gene polymorphysm in
their appearence and size. Further studies with more
patients should be done to confirm our findings.
PP 184
MALIGNANT TUMORS AFTER KIDNEY
TRANSPLANTATION
N. Vavic, M. Radojevic, L. Ignjatovic, Z. Kovacevic,
V. Rabrenovic, D. Jovanovic
Military Medical Academy, Nephrology Clinic, Belgrade,
Serbia
Background. Patients (pc) with transplanted(TX)
kidneys have a higher incidence of malignant tumors
(Tu). We analyze the frequency, type, the outcome of
Tu in kidney Tx pc in our Center from 1996 to 2011 year
(y). Results. malignant Tu diagnosed in 8 pc (2.8% of
Tx pc), 5 w and 3 m, average age 44 y (26 to 56 y). Tu
appeared 5.2 y after TX (1 month to 11 years). All pc
received
steroids,
calcineurin
inhibitors
and
antimetabolites after TX. 5 of 8 pc received
antythimocite globulin. Following tumors were find:
carcinoma (Ca) of the skin (1), colon (2), vulva (1),
thyroid gland (1), transition cell carcinoma (TCC) of
native urothelium (2), acute leukemia (AL)(1). In 7 pc
Tu is removed surgically, but in 4 pc Tu was recurred
and reoperated ( Ca of skin, vulva and 2 pc with TCC).
In one pc (AL) chemotherapy applied, in 2 pc (Ca of
colon and thyroid) adjuvant radiotherapy applied as
well. 4 pc converted to rapamycin after Dg of Tu, with
small doses of steroids. . In follow-up period (1-9 y, an
average of 3,1 y) 2 pc died, one after 3 months (AL),
second after 16 months (TCC). 5 pc have functional
kidney graft and 1 pc is on the dialysis. There were no
acute rejection after converting and/or minimizing IS
therapy. In 5 pc there no signs of local or remote Tu ,
while in pc with TCC Tu recurred locally after 3 months
and is now in inoperative stadium. Conclusion.
malignant Tu can occur early after kidney TX and early
screening for malignancy is necessary. In Tu with a
lower degree of malignancy, minimizing and the tailoring
of IS therapy may preserve graft function, but keeping
in mind that some pc may have bad clinical course (TCC
in our pc).
PP 185
IS THERE ANY ROLE OF MATRIX
METALLOPROTEINASE 3 (MMP3) AND
ANGIOTENSINCOVERTING ENZYME (ACE) GENE
POLYMORPHYSM IN PATOGENESIS OF VASCULAR
ACCESS ANEURYSM/PSEUDOANEURYSM?
1
A. Jankovic, 1 J. Tosic, 2 I. Buzadzic, 1 T. Damjanovic,
Z. Djuric, 1 S. Bajcetic, 1 J. Popovic, 2 N. Barjaktarovic,
1
N. Dimkovic
1
Department for renal diseases with dialysis, University
Medical Center Zvezdara, Serbia
2
Department for citogenetic, University Medical Center
Zvezdara, Serbia
1
115
PP 186
PP 187
NIH PROTOCOL IN THE TREATMENT OF NEPHROTIC
SYNDROME
SURGICAL EXPERIENCE AND COMPLICATIONS OF
CATHETER IMPLANTATION FOR PERITONEAL
DIALYSIS – A SINGLE CENTRE EXPERIENCE
G. Strazmester Majstorovic, T. Ilic, D. Bozic, D. Celic,
B. Milic, I. Mitic
Clinic for nephrology and clinical immunology, Clinical
center of Vojvodina-Novi Sad, Serbia
1
D. Pilcevic, 2 M. Mitrovic, 1 D. Maksic, 3 Z. Paunic,
M. Petrovic, 1 J. Tadic Pilcevic, 1 V. Rabrenovic,
1
N. Vavic, 1 Z. Kovacevic, 1 L. Ignjatovic
1
Nephrology department, Military Medical Academy,
Belgrade, Serbia
2
Abdominal Surgery Department, Military Medical
Academy, Belgrade, Serbia
3
Fresenius Haemodialisys Centre, Belgrade, Serbia
1
Background. Cyclophosphamide (CYP) is a golden
standard for the treatment of lupus nephritis.
Effectivenes of CYP in the treatment of primary
glomerulonephritides varies among the autors. The aim
of study is to evaluate the efficacy and safety of
cyclophosphamide in treatment of nephrotic syndrome.
Methods. There were 48 patients (pts) with nephrotic
syndrome included in the study (47,92% men, 52,08%
women). Patients had 18-75 years (average 42) at the
beginning. Primary glomerulonephritis had 52,08%pts
(mostly
membranoprolifferative)
and
47,92%pts
secondary glomerulonephritis (lupus nephritis 31,25%,
vasculitis 16,67%). Results. Patients were treated due
to NIH protocol. Patients received 500-1100mg per
pulse (average 861,36mg) with cumulative dose 2,623,15g (average 10,81g). They received 2 to 19 pulses
of CYP (average 10,8). Patients were checked regularly,
with check points at the beginning, after 6 months, at
the end, and 6 months after the end of the treatment.
At the end of the treatment 68,75%pts developed
remission (complete 25%, partial 43.75%), 20,83%pts
had no favorable effect and 10,42% died. At the end of
the follow-up 69,77% of the remaining patients were in
remission (complete 46,51%, partial 23,26%), 6,98%
developed relapses of the disease. Patients who had no
favorable effect of CYP, had no good effect on the
changed therapy either. At the end of the therapy
favorable effect on renal function was seen in 77,08%
pts (76,74% at the end of follow-up). At the end of the
therapy 20,83%pts doubled they basal creatinin level.
Average proteinuria levels dropped from basal 7,37g to
1,7g at the end, with 87,5%pts with favorable effect
(82,05%pts at the end of follow-up). Before CYP,
58,33% had microhematuria, with only 25% after the
treatment. Favorable effect on serum protein levels was
seen in 70,83%pts at the end of the treatment
(86,05%pts at the end of follow-up). Average
erythrocyte sedimentation at first hour fell from 71mm
to 37mm at the end of treatment (27mm at the end of
follow-up). Favorable effect was seen on 70,83%pts
(81,36%pts at the end of follow-up). Average fibrinogen
levels fell from 4,74g/l to 3,13g/l at the end of
treatment (3,55g/l at the end of follow-up). Favorable
effect was seen on 85,42%pts (86,05%pts at the end of
follow-up). Complications occurred in 58,33%pts
(serious in 31.25%pts). Infections occurred in
52,08%pts (serious in 12,5%pts), sepsis in 2,08%pts,
leucopenia
in
10,42%pts,
thrombocytopenia
in
12,5%pts. Malignant tumor occurred in 2,08%pts.
12,5%pts died during the treatment. Conclusion.
Cyclophosphamide is effective and relatively safe in the
treatment of glomerulonephritis.
Background. The aim of this paper is to present our
results in the placement of catheters for PD during the
past two years. Methods. Between 01.01.2008.31.12.2010.g. we had 49 surgical procedures in 43
patients / 28 males and 15 females / treatment program
for CAPD. Of this number of operations, 32 were a PD
catheter placement / Tenckhoffov catheters with swan
neck /, 8 were extraction of PD catheters, 6
repositioning, and three times we were doing
simultaneous PD catheter replacement. We used
standard surgical technique -35 procedures/ 81.40% /
et laparoscopic technique - 8 reposition the PD catheter
(18.60). In all patients was followed protocol antibiotic
prophylaxis. Results. Extracted from 8 PD catheter, in 2
/ 25% / patient reason was because of refractory CAPD
peritonitis, fungal peritonitis in 1 / 12.5% / patient,
exhaustion of the peritoneal membrane with the inability
to achieve adequacy of CAPD in 2 patient / 25% /,
mechanical complications in 1 / 12.5% / patient and
kidney transplant was performed in 2 patients / 25% /.
Eight laparoscopic repositioning were done because of
malposition - in 6 cases /75% / and omentisation PD
catheter - 2 cases / 25% /. Of perioperative
complications, the most common was the bleeding-in 4 /
8.16% / patient which were treated by revision of the
weld. Two / 4.08% / patient had a wound infectionoutput places. Total one-year survival of PD catheter
was 89.86%. Conclusion. The standard surgical
techniques is leading the way placement of PD catheters
in our center. Refractory CAPD peritonitis are the leading
reason for the extraction of PD catheters.
116
PP 188
PP 189
CLINICAL OUTCOME IN PATIENTS WITH
COMMUNITY ACQUIRED ACUTE KIDNEY INJURY
(CA-AKI) – USE OF RIFLE CLASSIFICATION
LONG-TERM PERITONEAL DIALYSIS-A CASE
REPORT
1
D. Pilcevic, 1 D. Maksic, 2 Z. Paunic, 1 M. Petrovic,
J. Tadic Pilcevic, 1 Z. Kovacevic, 1 N. Vavic,
1
V. Rabrenovic, 1 L.Ignjatovic, 1 M. Mijuskovic
1
Department of Nephrology, Military Medical Academy,
Belgrade, Serbia
2
Fresenius Haemodialisys Centre, Belgrade, Serbia
1
L. Tozija, I. Nikolov, S. Gjulsen, D. Petronijevic
Department of Nephrology, University Clinic of
Nephrology, R. Macedonia
Background. Acute kidney injury (AKI) is a serious
syndrome with an uncertain follow up and often with a
fatal outcome (mortality rate 20-80%). The RIFLE and
AKIN initiatives have provided a unifying definition for
AKI and it has been also shown that RIFLE classification
can improve the possibility of prediction, robustness and
clinical relevance in patients with AKI. Methods. We
analysed the clinical outcome in 112 patients (pts) with
CA-AKI. We excluded dialysis pts, those with malignancy
and with pre-existing chronic kidney disease (CKD) or
prior kidney transplantation. Results. In total, 68 pts
were analysed and their clinical and laboratory
parameters were followed as well as outcome risk
factors (RF). RIFLE criteria were implied on the day of
admission, with retrospective analysis of previously
prospectively collected data. Pts median age was
45.51±18.08 years, 69 (61.6%) were male. 40 (35.7%)
pts had 1, 29 (25.4%) pts had 2 and 8 (7.1%) pts had 4
comorbid diseases. Univariate statistical analysis
determined 27 risk factors implicated in pts outcome.
Creatinine (s) and urine output (UO) as RF had no
statistical significance on outcome. According to RIFLE
criteria, pts were classified in AKI stage 1 (Risk) in 1
(0.9%) pts, AKI stage 2 (Injury) in 4 (3.6%) pts and
AKI stage 3 (Failure) in 76 (67.9%) pts. Mortality rate in
stage 3 pts was 18 (16.82%). After 4 weeks of
treatment, we found that 31 (27.7%) pts where in AKI
stage 4 (Lost) with a mortality rate of 7 (6.5%).
Univariate analysis of four RF like creatinine(s), age
(years), UO and APACHE 2 in stage 3 and 4 of RIFLE, in
correlation with mortality, were significant only with UO.
We found also that pts who died, had significantly lower
baseline levels of Creatinine(s) (p=0.028) and UO
(0.017) than those alive at 4 weeks. Higher APACHE 2
score was associated with higher mortality in this
population. Kaplan-Meyer surviving courve showed that
pts on RIFLE stage 3 were with significantly longer
surviving in period of 4 weeks compared to pts on stage
4. Most of our pts with CA-AKI at admission were in
stage 3 and 4 of RIFLE classification. Urinary output but
not serum creatinine levels were implicated in pts
survival rate. Conclusion. The study supports use of
RIFLE as an optimal classification system to stage CAAKI severity, still there is perhaps a need for use of
other new parameters in this type of AKI.
Background. Female patient, 61 year old, the
treatment program of the peritoneal dialysis back l3
years. Terminal renal failure occurred 19 years ago,
underlying disease chronic glomerulonephritis. Case
report. She was six years on chronic haemodialysis
treatment initially, due to exhaustion of vascular access
modality translated to peritoneal dialysis. The first two
years she was treated with CAPD, when she translated
into the CCPD treatment program. She had four
episodes of peritonitis. The average ultrafiltration around
12ooml / 800 - 1600ml /, without residual diuresis, Kt /
V 2.3. Anemic syndrome is well-regulated intermittent
application of recombinant EPO- Hgb 115. Nutritition
status is satisfactory- BMI 23.11 kg/m2, alb 38,
transferin 37, creatinine 787µmol/l, Hol 6.64. PTH 26
pmol / l. For the long term survival on peritoneal dialysis
the most important concern is a good selection of
patients. Conclusion. A favorable predictive factors are
female sex, younger age, the gracious constitution,
diabetes mellitus absance and preserved urine output.
117
PP 190
PP 191
RENAL INVOLVEMENT IN PATIENT WITH LATE
DIAGNOSED SJGREN SYNDROME ASSOCIATED
WITH LYMPHOPROLIFERATIVE DISORDER
EPIDEMIOLOGICAL STUDY ON THE FREQUENCY OF
ARTERIAL HYPERTENSION IN PERSONS IN ACTIVE
AGE
1
1
2
1
I. Nikolov, 1 Z. Petronijevic, 1 K. Cakalaroski,
S. Kostadinova-Kunovska, 2 G. Petrusevska, 1 L. Tozija
1
University Clinic of Nephrology, Medical Faculty, Skopje,
FYROM
2
University Clinic of Pathology, Medical Faculty, Skopje,
FYROM
P. Angelov, 2 B. Kiperova
Department of Dialysis, Higher Military Medical
Academy, Serbia
2
Department of Nephrology, University Hospital
“Lozenetz”, Serbia
Background. The relation between arterial hypertension,
obesity, diabetes and cardio-vascular diseases, including
renal vascular disease, is well known. The objective of
the present study was to determine the frequency of
arterial hypertension in persons in active age. Methods.
Arterial pressure measurement was done by taking
random measurements in outpatient conditions in
workers from the same company. The arterial pressure of
1215 persons was measured: 820 male /67,5%/ and 395
female /32,5%/. Нigh blood pressure > 140/90 was
found in 344 persons (28,3 %): 257 male and 87 female.
Results. The percentage of persons with high blood
pressure of both sexes was increasing with age. In
65,4% of the total number of hypertensive persons high
blood pressure was not treated and 1/3 out of them had
diastolic pressure over 110 mm Hg. 119 persons /34,6%/
were on antihypertensive treatment. Nevertheless,
diastolic pressure more than 110 mmHg was measured in
42 patients under treatment (35.29 %). This study
showed that only in 77 (22,4%) out of 344 hypertensive
persons blood pressure was successfully controlled and
267 out of 1215 persons having problematic hyperension
were treated inadequately or not treated at all.
Conclusion. Arterial hypertension in people in working
age is a serious medical and social problem. The
significant number of inadequately treated patients rises
again and again the problem about the adequate and
competent medical care.
Background. Sjögren’s syndrome (SS) is the second
most common autoimmune disease affecting mainly
middle-aged women. The true prevalence of SS is
unknown but is estimated to affect 1–3% of the adult
female population. Both tubular and glomerular damage
have been described in SS, although glomerular disease
is rare. The aim of this report is to present a case of
severe interstitial nephritis with proteinuria in late
diagnosed primary Sjogren’s syndrome (pSS), aiming to
suggest recommendations for treatment. Methods. We
describe a rare case of primary SS (pSS) in a 76-yearold woman presenting with hypokalaemic cardiac
arrhythmia, chronic renal failure due to severe tubular
and glomerular affection. Results. The patient had been
diagnosed as having pSS on the basis of dry eyes, dry
mouth, weight loss, arthralgia, parotid glad tumefaction,
positive SSA and positive Schrimer’s test. She was
referred to nephrology department for further
evaluation. Clinical presentation at admission was
cardiac arrhythmia with acute over chronic renal failure
with intermediate range of proteinuria. Patient had more
than ten years a hypertension as a medical comorbidity.
We performed renal biopsy and found global
glomerulosclerosis, with mild tubule interstitial nephritis
accompanied with interstitial fibrosis and atherosclerotic
changes. Imunohystochemical tissue analysis showed
multifocal lymphocytic infiltrate. MDRD at point of renal
biopsy
was
5.01
ml/min.
A
treatment
with
corticosteroids (1mg/kg/day) was started. Patient was
set to dialysis treatment and preparation for chronic
dialysis program was initiated. Few weeks later she
broke her hip and femur fracture was confirmed. Bone
mineral density revealed osteopenia of the hip and
normal density of spine. Vitamin D levels were low,
supporting the diagnosis of osteomalacia. Conclusion.
The kidney may be a target of the disease in pSS.
Although, overt renal disease is rare, latent involvement
has been reported in up to one-third of patients. Further
studies and successful cases are required to determine
indications for and dosages of immunosuppressive
treatment in patients with renal involvement of pSS.
118
PP 192
PP 193
PLASMA EXCHANGE AS ADJUNCTIV THERAPY IN
ANCA ASSOCIATED VASCULITIS WITH SEVERE
RENAL INVOLVEMENT
FREQUENCY OF GASTROINTESTINAL SYMPTOMS IN
PATIENTS AFTER KIDNEY TRANSPLANTATION
1
M. Milinkovic, 1,2 A. Kezic, 1 S. Jovicic-Pavlovic,
C. Tulic, 2,3 A. Vuksanovic, 3 C. Topuzovic,
2,3
D. Milutinovic, 2,3 O. Durutovic, 1 D. Radivojevic,
1,2
V. Lezaic, 1, 2 R. Naumovic
1
Belgrade, Serbia
2
Faculty of Medicine, University of Belgrade, Belgrade,
Serbia
3
Clinic of urology, Clinical Center of Serbia, Belgrade,
Serbia
2,3
I. Nikolov, Z. Petronijevic, G. Selim, K. Cakalaroski,
L. Tozija
Department of Nephrology, University Clinic of
Nephrology, FYROM
Background. Systemic vasculitis associated with
autoantibodies to neutrophil cytoplasmic antigens
(ANCA) is the most frequent cause of rapidly progressive
glomerulonephritis. Renal failure at presentation carries
an increased risk for chronic kidney disease (CKD) and
death despite immunosuppressive therapy. Early and
accurate diagnosis and aggressive treatment are
essential to optimizing outcomes while avoiding
unnecessary immunosuppressive therapy. Methods.
This study investigated the role of plasma exchange in
the achievement of renal recovery in patients who
presented a serum creatinine 500 mol/L. We present
here three patients treated in ICU at University Clinic of
Nephrology in Skopje, with confirmed diagnosis of ANCA
vasculitis associated with respiratory symptoms and a
renal affection manifested as glomerulonephritis.
Results. All patients had diagnosis of ANCA associated
vasculitis confirmed by renal biopsy and serum
creatinine >500 mol/L. Initial hospital admission was
marked by serious respiratory symptoms with
development of important deterioration of renal function
as well as anemia and hypoproteinemia. Dialysis
treatment was introduced as well as immunosuppressive
therapy with prednisolone and cyclophosphamide by
EUVAS recommendations. Plasma exchange was also
introduced in at least 9 sessions per patient. This
together with immunosuppressive therapy resulted in a
disappearance of signs and symptoms of systemic
inflammation and in an important improvement of
respiratory symptoms and moderate improvement of
kidney function. Patients were discontinued from dialysis
and at a point of 3 months after hospital admission all
patients were dialysis independent. Conclusion. In
patients with clinically and histologicaly confirmed ANCA
associated vasculitis, plasma exchange together with
recommended immunosuppressive therapy can increase
the rate of renal recovery and should be considered as
an effective adjunctive modality of treatment.
Background. Mycophenolic acid (MPA) selectively
inhibits lymphocyte proliferation and function and
represents the basis of current immunosuppressive
protocols after kidney transplantation. The most
common side effects of MPA therapy are gastrointestinal
symptoms (GIS), mainly diarrhea. The aim was to
compare the incidence of GIS depending on the applied
immunosuppressive protocol based on MPA. Methods.
In this study, we prospectively followed kidney
transplant recipients who received first allograft, during
2010, with respect occurence of GIS (nausea, vomiting
and diarrhea) and compared them to the historical
group of patients transplanted in 2009. The study
included 87 patients: 41 transplanted in 2009, age
39.95 ± 11.17, treated according to protocol: ATG
9mg/kg, followed by 3mg/kg for 4 days, Tacrolimus
0.3mg/kg, MMF 2 x 500 mg to 2 x 750 mg and
corticosteroids (Group 1), and 46 patients transplanted
in 2010, age 44.56 ± 9.86, treated according to
protocol: ATG 9mg/kg, followed by 3mg/kg, Tacrolimus
0.15mg/kg, MPA: MMF 2 x 1g (38 patients) or MPS 2 x
720 mg (8 patients) and corticosteroids (Group 2).
Doses of corticosteroids and Tacrolimus in Group 2 were
half those in Group 1, while doses of MPA were higher.
Results. In 2009, 15 (36.6%) patients had diarrhea
lasting up to 10 days, out of which 5 had concomitant
nausea. In 2010, 10 (21.7%) patients had diarrhea
lasting up to 8 days-6 were treated with MMF, 4 with
MPS. There was no statistical significance between the
results of Group 1 and 2. Conclusion. The number of
patients with diarrhea during 2010. was lower in
comparsion to 2009. Based on our results, we can
conclude that diarrhea was not associated with the form
nor the dose of the medicine, but the main ingredient of
the drug (MPA).
119
PP 194
PP 195
HYPOALBUMINAEMIA AS SURVIVAL RISK IN
PERITONEAL DIALYSIS PATIENTS DIVIDED IN TWO
SUBGROUPS: DIABETICS AND NONDIABETICS
DETERMINATION OF C-REACTIVE PROTEIN, SERUM
AMYLOID A AND ASYMMETRIC DIMETHYLARGININE
LEVELS IN PATIENTS ON HEMODIALYSIS
A. Bontic, M. Lausevic, N. Jovanovic, M. Milinkovic,
J. Pavlovic, M. Kravljaca, D. Jovanovic, V. Nesic
Clinic for Nephrology, Belgrade, Serbia
1
N. Stefanovic, 2,3 T. Cvetkovic, 2 R. VelickovicRadovanovic, 2 V. Djordjevic, 2 N. Sladojevic,
4
A. Ignjatovic, 1 S. Zivanovic, 1 R. Pavlovic
1
Research Centre for Biomedicine, University of Nis,
2
Clinic of Nephrology, Clinical centre Nis, Serbia
3
Institute of Biochemistry, University of Nis, Faculty of
Medicine, Serbia
4
Department of Medical Statistics, University of Nis,
Background.
Cause
of
hypoalbuminemia
is
multifactorial, associated with malnutrition, lack of
appetite due to absorption of glucose from the dialysate,
increased loss of albumine by dialyzate, the presence of
systemic
diseases,
inflammatory
processes
and
comorbid conditions, which is significantly associated
with blood pressure values, nutritional status and
mortality. The aim of the study is to examine the
hypoalbuminemia as a survival factor in 2 groups of
patients on peritoneal dialysis (PD) - in diabetics and
nondiabetics. Methods. The study is retrospective
analysis of 55 patients who are divided in 2 subgroups –
diabetics and nondiabetics. When we analyze the
structure and activities covered by treated patients
compared to diabetes mellitus (DM), there were 20
(36.4%) nondiabetic patients, while 35 (63.6%) patients
had diabetes. Results. There are significant differences
in the value of the loss of albumin in dialysate and urine
for 24 h in relation to the disease at the start of the
study, ANOVA F = 10.79, p<0,0001, significantly
greater loss of albumin in dialysate and urine for 24 h in
patients with DM. The most common is the death rate
among patients with lower albumin of 25g / l, in
diabetics and with accompanying comorbidities, χ2=
6.370, p <0,041, while the lowest incidence of death
among patients with albumin of 35 g / l and more.
Statistically significant difference in the amount of the
BMI groups in relation to albumin at the start of F =
5.047, p <0,01, where BMI was lowest in patients with
DM and albumin less than 25g / l. Values of nPCR was
significantly higher in patients with Alb less than 25g / l
at the beginning, F = 0.577, p = 0.565, compared to the
amount of nPCR after 6 months of research, p <0,04 .
Values of CRP and fibrinogen were significantly different
in patients with DM and albumin to 25 g / l in the control
measurement after 6 months - significantly higher after
6 months, F = 9.597, p<0,011. Conclusion. The
hospitalizations and episodes of peritonitis are more
frequent in dialysis patients, but without significance.
We can conclude that hypoalbuminemia is more
expressed in patients with diabetes in accordance with
the loss of dialysis and urine, and to play an important
role in survival, nutrition status of patients and quality
of life.
Background. Chronic inflammation is associated
condition in patients on hemodialysis. The causes of
inflammation are complex and include factors dependent
and independent of dialysis. The level of inflammation is
follow up by positive acute phase reactants such as Creactive protein (CRP) and serum amyloid A (SAA). Creactive protein (CRP), a marker of systemic
inflammation and an independent predictor of
cardiovascular mortality in the general population, is
important risk factors for cardiovascular disease and
mortality in the end stage renal disease population. SAA
is one of the most sensitive low-molecular-weight acutephase proteins, produced primarily by the liver as a
result of tissue injury, infection, or inflammation.
Asymmetric dimethylarginine (ADMA), an endogenous
inhibitor of nitric oxide synthase, is formed by
methylation of arginine residues in proteins and released
after proteolysis. ADMA is not only a uremic toxin, but
also a strong marker of endothelial dysfunction and
atherosclerosis and a stronger independent predictor of
all-cause mortality and cardiovascular outcome in
patients with chronic renal failure than some traditional
risk factors The aim of this study was to determine
whether SAA or ADMA are more sensitive indicator of
inflammation than CRP in hemodialysis patients.
Methods. The research involved 83 patients on regular
hemodialysis and control group of 29 subjects. All
patients were further divided to those who have a
current inflammation (39 patients) (with CRP>5mg/L)
and a group of 42 patients with CRP<5mg/L. CRP was
measured by immunoturbidimetric assay, and SAA was
determined
immunonephelometry.
ADMA
was
determined on plasma by extraction and HPLC assay.
Results. Concentration of CRP, SAA and ADMA were
statistically significantly higher than control group
(p<0,001). It was found that values of SAA and ADMA
were significantly elevated in patients with inflammation
compared to group of patients without inflammation
(p<0,001) and control group (p<0,001). We found a
positive correlation between SAA level and serum CRP
levels. Conclusion. CRP and ADMA may be emerging as
important risk factors for atherosclerosis in dialysis
patients. Serum amyloid A isn't more sensitive marker
of inflammation compared to C-reactive protein.
120
PP 196
PP 197
CYTOMEGALOVIRUS INFECTION IN RENAL
TRANSPLANT RECIPIENTS: ONE CENTER
EXPERIENCE
BODY COMPOSITION ANALYSIS İN PERITONEAL
DIALYSIS AND HEMODIALYSIS PATIENTS
Z. Bal, M. Erkmen Uyar, N. Ahmed, E. Tutal, S. Sezer
Turkey
1
Z. Bal, 1 M. Erkmen Uyar, 1 E. Tutal, 2 E. Erdogan,
1
T. Colak, 3 M. Haberal
1
Turkey
2
Department of Internal Medicine, Baskent University
Hospital, Turkey
3
Department of General Surgery, Baskent University
Hospital, Turkey
Background. Bioelectrical impedance assessment (BIA)
is a simple, noninvasive method of assessing body
composition. Dialysis modality and selection of buffer
type in terms of lactate or bicarbonate may be an
impact on body composition. The aim of our study was
to compare body compositions of peritoneal dialysis (PD)
and hemodialysis (HD) patients. Methods. This study
included 42 PD and 110 HD patients. PD group included
40.4% female, age; 47.9 ±9.0 years while HD group
included 35.4%female, age; 48.2±11.2 years. Duration
of dialysis in both groups were similar (9.54 years vs.
9.59 years) and 4% of HD patients and %5 of PD
patients were diabetic. For BIA, we used a Body
Composition
Analyzer
(Tanita
BC-420MA).
Measurements were done for weight, height, total body
water (TBW), fat mass (FM), muscle mass, bone mass,
basal metabolic rate (BMR), visceral fat rate, body mass
index (BMI) and degree of obesity. Results. Groups
were similar in means of demographic characteristics,
albumin and CRP levels. The BMI and degree of obesity
(BMI>30 kg/m2) were significantly higher in PD patients
than HD group[25.8±4.7 kg/m2 vs. 23.4±4.9 kg/m2
(p:.01);
17.3±21.5%
vs.
6.7±22.4%
(p:.006),
respectively]. Muscle mass and bone mass were
significantly higher in the PD group than HD group
[48.2±8.4 kg vs. 44.1±8.3 kg (p:.005); 2.6±0.4 kg vs.
2.3±0.4 kg (p:.005), respectively]. Among PD patients,
visceral fat rate, BMI and degree of obesity were higher
in patients using bicarbonate/lactate buffered PD
solution (Physioneal; Baxter) compared to patients using
lactate buffered conventional PD solution (Dianeal;
Baxter) [8.03±5.2 vs. 4.68±2.5 (p:.02); 27.0±5 kg/m2
vs. 23.7±3.5 kg/m2 (p:.02) and 23±22.7% vs.
8.06±16.2%
(p:.02),
respectively].
Conclusion.
Despite of increased obesity rates and BMI in PD
patients, these patients also tend to have increased
muscle and bone masses which is possibly a sign of
better nutritionl status. We suggest that for suitable
end-stage renal failure patients PD might be the first
option and choice of PD solution could influence the
metabolic status of the patients. Keywords: BIA,
dialysis.
Background. Cytomegalovirus (CMV) , the most
common opportunistic viral infection that causes
morbidity, graft loss and mortality among renal
recipients. The aim of this study was to evaluate the
impact of cytomegalovirus infection on allograft function
and survival. Methods. This retrospective study
included 58 renal transplantation recipients who had at
least 1 year (between January 2009 and December 2009
) regular posttransplant follow-up in our center. Donor
and recipient were evaluated for anti-CMV antibody
during the pretransplantation evaluation. Patients whose
quantative CMV polymerase chain reactions (PCR) were
positive were assigned to the study group (n=29). The
control group (n=29) was statistically similar to study
group in means of demographic, clinical, basal
laboratory
findings
and
posttransplant
immunosuppressive regimes. Valganciclovir was given
for prophylaxis therapy to all recipients after
transplantation for 3 months. Results. The mean age of
the recipients in both groups were 37.9±11.8 years and
39.0 ±11.8 years, respectively. All donors and recipients
were negative for CMV IgM and were positive for CMV
IgG. Serum creatinine levels, urine leukcyte counts and
CRP levels were significantly higher in study group (p:
0.0001, p: 0.05 and p: 0.0001 respectively). There was
a negative correlation between lymphocyte count and
CMV viral load (p: 0.05; r: -0.348). We observed that
frequency of acute rejection was significantly higher in
study group [n: 17 (77.3%) vs. n: 12 (33.3%), p:
0.001]. In follow up period, graft loss due to any cause
was significantly higher in study group [n: 11 (42.3%)
vs. n: 2 (6.9%), p: 0.002]. Conclusion. Despite of
using valganciclovir prophylaxis, CMV infection is still a
risk factor for clinical acute rejection and graft loss in
kidney recipients. After transplantation, increased serum
creatinine levels and lymphopenia together might
denote a CMV infection. Keywords: CMV, renal
trasplantation.
121
PP 198
PP 199
THE RELATIONSHIP BETWEEN BODY COMPOSITION
ANALYSIS AND RHUEPO REQUIREMENT IN
WHAT IS THE RISK FACTORS FOR ARTERIOVENOUS
FISTULA THROMBOSIS IN HEMODIALYSIS
PATIENTS; IS THE PLATELET COUNT IMPORTANT?
E.Tutal, M. Erkmen Uyar, S. Sezer, Z. Bal
Turkey
1
R. Ozelsancak, 1 D. Torun, 2 L. Oguzkurt,
H. Micozkadioglu, 1 A. Zumrutdal, 3 F. Nurhan Ozdemir,
4
M. Haberal
1
Department of Nephrology, Baskent University Faculty
of Medicine Adana Medical and Research Center, Turkey
2
Department of Radiology, Baskent University Faculty of
Medicine Adana Medical and Research Center, Turkey
3
of Medicine Ankara Medical and Research Center, Turkey
4
Department of General Surgery, Baskent University
Faculty of Medicine Ankara Medical and Research
Center, Turkey
1
Background.
Patients
undergoing
maintenance
hemodialysis (MHD) often suffer from malnutrition, a
condition that results in increased morbidity and
mortality, as a result of poor appetite, various
comorbidities and dietary restrictions. Malnutrition is a
well-known risk factor influencing survival in MHD
patients and is reported to correlate with poor outcome,
including a decreased quality of life, refractory anemia,
and significantly greater rates of hospitalization. Our aim
in the present study was to validate the use of
bioimpedance analysis (BIA) in MHD patients for the
assesment of the relationship between body composition
and anemia and epoetin (rHuEPO) dose requirements.
Methods. Body composition of 110 MHD patients (39
female; aged 53,8±13,5 years) was measured using the
Body Composition Analyzer (TanitaBC-420MA). Last 6
months monthly anemia parameters, hemoglobin
albumin, CRP, calcium, phosphorus, parathormone
levels and rHuEPO requirements were retrospectively
recorded. Results. Patients with Hb <10 g/dl had lower
muscle mass (p:,0001), bone mass (p:,05), visceral fat
mass (p:,005) and basal metabolic rate (BMR) (p:,03)
compared to patients with Hb levels 10 g/dl or higher.
Total rHuEPO requirements were negatively correlated
with muscle mass (r:-,367, p:), bone mass (r:-,368),
BMR (r:-,388), fat mass (r:-,202), visceral fat mass (r:,214) and BMI (r:-,275). Serum CRP levels and MIS
were positively correlated with rHuEPO requirements
(r:0,208 vs. r:0,256, respectively). In regression
analysis, CRP and bone mass were the major
determinants of rHuEPO requirement (p:,02 and p:,0001
respectively). When we analyzed the study group
according to Hb variability under rHuEPO treatment, we
found that patients with low-stable (<10g/dl) Hb levels
had lower muscle mass (p:,04), bone mass (p:,005),
BMR (p:,005) and higher CRP levels (p:,005) compared
to patients with high-stable (>11g/dl) Hb levels.
Conclusion. Our results suggest that decrased muscle,
bone mass, BMR, BMI and visceral fat mass might
reflect malnutrition. Nutritional status is closely related
with Hb levels and total rHuEPO requirements.
Anthropometric measurements might be useful to
evaluate the MHD patients’ nutritional status.
Background. The aim of this study was to investigate
factors associated with arteriovenous fistula thrombosis.
Methods. Clinical data from the last 5 years on 212
maintenance hemodialysis patients were reviewed
retrospectively. This patient group was comprised of 110
men, 102 women, with a mean age of 52 ± 16 years
and the mean duration of hemodialysis was 62.3 ± 30.1
months. Results. Fistulography was performed on 116
patients (M/F: 49/67), thrombosis was observed in 65
patients (56%) and stenosis was observed in all
remaining patients. The frequency of hypertension (p =
0.02), LDL cholesterol (p = 0.016), total cholesterol (p
= 0.000), triglyceride levels (p = 0.001) and platelet
counts (p = 0.004) were higher in patients with
arteriovenous fistula thrombosis than in patients with
patent arteriovenous fistula. Conclusion. Presence of
hypertension, lipid profile and higher platelet count is
associated with arteriovenous fistula thrombosis.
122
PP 200
PP 201
THE EFFECT OF MAGNETIC RESONANCE IMAGING
AND COMPUTERIZED TOMOGRAPHY ON URINARY
NEUTROPHIL GELATINASE ASSOCİATED LIPOCALIN
LEVELS
COMPLICATION OF HUS IN CHILDREN
1
M. Gafencu, 1 G. Doros, 2 O. Limoncu, 2 I. Oprescu,
A. Botiz
1 rd
3 Pediatric clinic, Emergency Children Hospital “L.
Turcanu”, Timisoara, Romania
2
“Gr. Alexandrescu” Emergency Children Hospital,
Bucharest, Romania
1
1
R. Ozelsancak, 1 D. Torun, 1 A. Zumrutdal, 2 N. Sezgin,
I. Yildiz, 1 E. Erken, 1 H. Micozkadioglu, 3 T. Yildirim
1
of Medicine Adana Medical and Research Center, Turkey
2
Department of Biochemistry, Baskent University
Faculty of Medicine Adana Medical and Research Center,
Turkey
3
Department of Radiology, Baskent University Faculty of
Medicine Adana Medical and Research Center, Turkey
1
Background. Hemolytic uremic syndrome (HUS) is
characterized by the triad of hemolytic anemia with
fragmented erythrocytes, thrombocytopenia and acute
renal failure. HUS is known as the most common cause
of acute renal failure in previously healthy children. The
underlying
histological
lesion
is
thrombotic
microangiopathy. Our aim is to focus and present some
complications in our HUS cases in children. Methods.
We studied complications from the 33 cases of HUS
treated between 1999-2009 in Department of Dialysis of
“Gr. Alexandrescu” Emergency Children Hospital Bucharest and 12 cases from the 3rd Pediatric clinic
from Emergency Children Hospital “L. Turcanu” –
Timisoara. Results. In the absence of a proven specific
therapy the treatment is intensive supportive care and
dialysis, which was performed in majority of cases.
Peritoneal dialysis was the preferred method 60,6% for
infants in Bucharest. The neurological complications
dominated, but cerebral hemorrhage was the major
factor of severity. Mortality rate was 21,2% in the first
cohort and 25% (3 cases) in the second. Conclusion.
High mortality rate was associated with small age,
sepsis, and cerebral hemorrhage. The precocity of
diagnosis and forceful intensive care in HUS lead to a
better survival rate in HUS. The major interest is moving
to the long term prognosis of complicated HUS and we
recommend closely monitoring renal function.
Background. Gadolinium based contrast agents are
recommended to replace iodinated contrast media in
patients at risk for acute kidney injury. Several
biomarkers are being evaluated for early diagnosis of
acute kidney injury and Neutrophil gelatinase associated
lipocalin (NGAL) is one of the promising markers. The
aim of our study is to compare urinary NGAL levels in
patients undergoing CT or MRI. Methods. Per group
included 20 patients with normal renal function. Patients
with diabetes, malignancy or infection were excluded.
Blood samples were drawn before and 2-48 h after
procedure. Urine samples were collected before and 2 h
after the procedure for urinary creatinine and NGAL
measurements. Levels of urinary NGAL before and after
the procedure were compared. Results. Urinary NGAL
levels did not significantly change 2 h after compared to
baseline value at CT (36,79 ± 28,74 vs 33.31 ± 27.33 p
= 0,61) and at MRI (27.50 ± 35.19 vs 23.19 ± 23.85 p
= 0,33), but there was a tendency to decrease. Contrast
induced nephropathy, defined as a 50% increase in
serum creatinine from baseline, occurred in one patient
in the CT group. Creatinine levels at 48 h were higher
compared to baseline in CT group, but did not increase
as 50%. The serum creatinine did not significantly
change at any time point in the other patients.
Conclusion. Gadolinium or iodinated contrast agents
did not significantly change urinary NGAL levels when
used intravenously in patients with normal renal
function.
123
PP 202
PP 203
CAPD PERITONITIS: OUR EXPERIENCES IN
DIAGNOSIS, TREATMENT AND OUTCOMES IN
YEARS 1999 – 2008
SOCIAL SUPPORT DECREASES THE INCIDENCE OF
DEPRESSION IN HEMODIALYSIS PATIENTS WHILE
SPECIAL CARE SHOULD BE GIVEN TO THEIR
PRIMARY CAREGIVERS
A. Trost Rupnik, D. Klancic, S. Saksida, M. Martinuc
Bergoc
Department of Nephrology and Dialysis, General Hospital
of Nova Gorica, Slovenia
S. Sezer, M. Erkmen Uyar, Z. Bal, E. Tutal, F. Nurhan
Ozdemir Acar
Turkey
Background. Peritonitis is a frequent complication of
continuous ambulatory peritoneal dialysis (CAPD) and
the most common cause of CAPD failure. It is associated
with catheter loss, adhesions, increased protein loss,
return to hemodialysis (HD) and considerable morbidity.
Most episodes are caused by contamination of the
dialysis tubing or extension of catheter exit site or
tunnel infections. An accurate diagnosis of CAPD
peritonitis is based on both clinical and laboratory
findings. All episodes of CAPD peritonitis are potentially
serious. It is usually caused by a single pathogen, often
by a gram-positive (G+) coccus originating from the
normal flora of the patient’s skin (in more than 50%
coagulase-negative
and
coagulase-positive
Staphylococcus species). Gram-negative (G-) organisms
most frequently associated with CAPD peritonitis are
Escerichia coli and Pseudomonas aeruginosa. Methods.
In this retrospective study we included all patients, who
were treated for CAPD peritonitis between the years
1999
and
2008.
We
report
the
causative
microorganisms, antibiotic therapy and the outcome.
Results. In that period of ten years we treated 17
patients for 39 episodes of CAPD peritonitis (13 males
and 4 females). We recorded on average 2,3 episodes
per patient, max. 6, min. 1. Staphylococcus spp. was
the causative agent in 13 cases (33%), 6 episodes
(6,5%) were caused by G- organisms. Other episodes
were caused by different G+ microorganisms. All of
them were treated with cefamezine and gentamicin. We
treated them on average for 10,4 days (max. 16 days,
min. 1 day). 30 patients (77%) were healed. 3 of them
(8%) died and 5 of them (13%) were returned to HD. 3
patients among those three who died and five ones who
were returned to HD (1 in the first group and two in the
second one), underwent a complication with fungal
peritonitis. They were additionally treated with
fluconazole. The other two patients among those three
who died, had a Pseudomonas aeruginosa-caused
peritonitis (G-). Three patients, who were returned to
HD, had a S. aureus- (2 of them) and Corynebacterium
spp.- (1 of them) caused peritonitis. There is no data
about the outcome of one patient. Conclusion.
Bacterial peritonitis is a frequent complication of CAPD,
effectively treated with cefamezine and gentamicin,
specially when gram-positive organisms are the
causative agent. We had less success in treating fungal
peritonitises: in all three cases of peritonitis CAPD failed
as renal replacement therapy (one patient died and two
of them were returned to hemodialysis).
Background. Depression is a major factor that affects
life quality and some clinical factors in patients recieving
maintenance hemodialysis (MHD). Low transplantation
rates and being in transplantation waiting list for
prolonged duration might also affect psychological status
of MHD patients. In this study we aimed to analyze
effects of social support, family structure, living
conditions and economical status of patients and
primary caregivers on depression scores. Methods. 141
MHD patients (54 female, aged; 53.6 ± 14.2 yrs) were
included. We used Beck Depression Inventory (BDI) for
depression scoring. All study data was collected by face
to face interview with patients and primary caregivers.
Results. Ninety patients (%63,8) had BDI scores up to
16 with minimal to mild depressive symptoms. Number
of patients with moderate to severe depressive
symptoms were 51 (%35,3) with BDI scores up to 45.
Primary caregivers were %55 depressive with mild to
severe BDI scores. BDI score was positively correlated
with number of children under guardianship (p:.01,
r:.218), primary caregivers’ BDI score (p:.0001, r:.526).
Monthly income was negatively correlated with both
patients’ and primary caregivers’ BDI score (p:.005, r:.278, -.345 respectively). Patients who are being taken
care primarily by their children had significantly higher
BDI scores compared to patients living with other
relatives (p:.05). Single living and unemployed patients
were also more depressive compared to patients living
with their relatives or employed ones respectively
(p:.005). Number of previous transplantations and
duration being in transplantation waiting list did not
have any significant influence on BDI scores. Being
economically and socially self-sufficient lowers the
depression rates in transplantation waiting MHD
patients. Also living with relatives decreases depression
scores in dialysis patients while increased number of
children under guardianship or being under care of
children seems to have a negative impact on depression.
Conclusion. Primary caregivers and relatives also need
social and physchological support as much as MHD
patients.
124
PP 204
ADYNAMIC BONE DISEASE - RISK FACTORS
1
S. Pejanovic, 3 J. Marinkovic, 1 V. Lezaic, 1 M. Stosovic,
S. Simic-Ogrizovic, 1 T. Jemcov, 1 M. Radovic,
2
S. Ignjatovic, 2 M. Dajak
1
Belgrade, Serbia
2
Institute of Biochemistry, Clinical Center of Serbia,
Belgrade, Serbia
3
Institute of Social Medicine, Statistics and Health
Research, School of Medicine, Belgrade, Serbia
1
Background. Over the last 20 years prevalence of
adynamic bone disease (ABD) in chronic kidney disease
(CKD) patients has increased, and now represents very
frequent type of bone lesion. This study was conducted
to evaluate clinical risks factors for ABD after avoiding of
calcium and vitamin D load as advised by K/DOQI
guideline. Methods. In this cross sectional study 108
patients (age 54.1±12.4 years, range 25-79, 53.7 %
males, 6.5% diabetics) on regular hemodialysis
(96.5±69.5 months, range 8 to 329 months) were
evaluated. The following variables were analyzed:
biochemical parameters of bone mineral metabolism
(Ca, PO4,
bone alkaline phosphatase-BAP, intact
parathormon-iPTH), hemodialysis data (Kt/V, urat,
calcium dialysate-dCa), data on nutrition (serum
albumin, cholesterol, body mass index-BMI), iron status,
type of phosphate binders, vitamin D treatment,
simultaneous intake of calcium based phosphate
binders+vitamin D or calcium based phosphate
binders+vitamin D+high dCa and history of peritoneal
dialysis, diabetes mellitus, renal transplantation,
parathyroidectomy. ABD was diagnosed by a iPTH< 150
pg/ml and BAP< 27 U/L. Logistic regression analysis was
used to identify independent covariates for ABD and
ROC to assessed cut-off values for identified variables.
Results. The prevalence of ABD was 47.2 %. ABD
patients in comparasion to the patients with both iPTH >
150 pg/mL and BAP >27 U/L (25% of patients) had
significantly lower Kt/V (1.36+0.24 vs. 1.49+ 0.25,
p=0.05), serum iron (10.58+3.92 umol/L vs 14.85+8.58
umol/L,
p=0.005)
and
transferin
saturation
(24.77+8.93% vs 31.79+12.78%, p=0.008). As an
independent covariate for BAP <27 U/L lower Kt/V was
derived. As an independent covariates for iPTH <150
pg/mL there were deriveted lower PO4, lower transferin
saturation, daily aluminium hydroxyd dose. Cut-off
values for determined covariates are as follows: Kt/V
<1.52, PO4 <1.72 mmol/L, transferin saturation <32
%, and daily doses of aluminium hydroxyd >0.27 g.
Conclusion. Our data show that Kt/V lower than 1.52,
PO4 lower than 1.72 mmol/ L, transferin saturation
lower than 32 % and daily doses of aluminium hydroxid
higher than 0.27g were assossiated with ABD diagnosis.
Avoiding Ca and vitamin D load might have resulted in
ABD risk factors change.
125
INDEX
A
Acar Tek, N.
Adamidis, K.N.
Agaci, F.
Aggelou, A.
Ahmed, N.
Akata, F.
Akbulut, G.
Akcicek, F.
Akin, O.
Aliosmanoglu, I.
Alivanis, P.
Altintepe, L.
Altiparmak, MR.
Anagnostopoulou, A.
Anagnostou, N.
Andricos, A.
Androulaki, M.
Angelakas, I.
Angelov, P.
Anil, M.
Antoniadi, G.
Aperis, G.
Apostolaki, M.
Apostolou, T.
Aresti, V.
Armagan, A.
Arvaniti, K.
Arvanitis, D.
Asci, G.
Asimakopoulos, K.
Askepidis, N.
Asmanis, E.
Ates, K.
Athanasopoulos, D.
Aydin, Z.
Aygencel, G.
PP 089, PP 142
PP 061
PP 024, PP 052
PP 031
OP 12, PP 197
PP 086
PP 089, PP 142
PP 177
PP 182
PP 182
PP 038, PP 040,
PP 041
OP 18
PP 088
PP 013
RFP 13, PP 007
PP 027
PP 027
PP 062
PP 109, PP 191
PP 101
PP 047, PP 072,
PP 073, PP 074
PP 038, PP 040,
PP 041
PP 044
PP 045, PP 061,
PP 063
PP 122
PP 151
PP 007
PP 030
OP 20
RFP 11
PP 080
OP 22, PP 075
PP 177
PP 067
PP 144
PP 183
PP 112
PP 083, PP 085
PP 159, PP 185
PP 022, PP 024,
PP 052
Bakavos, I.
Bakirtzi , N.
Bakoulis, D.
Bal, Z.
RFP 11
OP 11
PP 045
OP 12, PP 174,
PP 196, PP 197,
PP 198, PP 203
Balafa, O.
RFP 01, RFP 12,
PP 113
Balios, M.
Baloyannis, S.J.
Bamichas, G.
Banioti, A.
Bano, A.
Bantis, C.
Barbullushi, M.
PP 048
OP 03, OP04
PP 111
RFP 11, PP 113
PP 049
RFP 03, PP 110
OP 08, OP 09,
RPF 09, PP 022,
PP 023, PP 024,
PP 049, PP 050,
PP 052, PP 064,
PP 070, PP 071,
PP 092, PP 103,
PP 104, PP 107,
PP 108, PP 147
Barjaktarovic, N.
Basci, A.
Basta Jovanovic, G.
Bayraktaroglu, S.
Bechlioulis, A.
Belechri, A.-M.
PP 157, PP 185
OP 20, PP 177
PP 168
OP 20
PP 028
OP 16, RFP 18,
PP 065, PP 135
PP 088
PP 022
PP 171
PP 031
RFP 15
OP 14
PP 127
PP 168
OP 10
PP 003
Benitez-Macias, J. F.
Beqiri, S.
Birdozlic, F.
Bishiniotis, T.
Bob, F.
Bogavac-Stanojevic, N.
Bogdanovska, S.
Bojic, S.
Bokonjic, D.
Bokos, I.
B
Bacharaki, D.
Bacvanski, L.
Bafas, D.
Bajcetic, S.
Bajrami, V.
PP 083, PP 085
127
Boletis, J. N.
PP 003, PP 004,
PP 005, PP 010,
PP 044, PP 099
Boletis, N.
Bolleku, E.
Bontic, A.
OP 05
PP 035
PP 160, PP 163,
PP 176, PP 194
PP 182
PP 172
PP 201
OP 01, OP 02
PP 131
OP 01, OP 02
RFP 15
PP 121
PP 114, PP 154,
PP 169, PP 186
OP 20, PP 177
RFP 17
PP 013
PP 013
PP 088
PP 147
RFP 17
PP 157, PP 185
Bora, F.
Borda, M.
Botiz, A.
Bouba, I.
Bounta, T.
Bountouri, C.
Bozdog, G.
Bozic, A.
Bozic, D.
Bozkurt, D.
Bren, A. F.
Bristogiannis, G.
Bristogiannis, S.
Brun-Romero, F. M.
Bulo, A.
Buturovic Ponikvar, J.
Buzadzic, I.
Christoforides, N.
Ciecwierz, J.
Cirit, M.
Colak, T.
Colic, M.
Collaku, L.
Cukic, Z.
Cvetkovic, T.
D
C
Caco, G.
Cadri, V.
Caja, J.
Cakalaroski, K.
Celic, D.
RFP 09
OP 13
PP 178
PP 190, PP 192
PP 154, PP 158,
PP 169, PP 186
Challa, A.
Chardalias, A.
Chatziapostolou, A. I.
Chatziaslanidou, C.
Chatzidakis, S.
Chatziralli, I.
Chaviaras, E.
Chaviaras, M.
Chelioti, E.
PP 110
RFP 11
OP 03, OP04
PP 043
OP 01
PP 060
OP 05, PP 004
PP 005
PP 014, PP 025,
PP 067, PP 126
Chiotis, C.
Chouliaras, E.
Chrisanthopoulou, E.
Christidou, F.
Christodoulidou, C. T.
PP 097
PP 062
PP 126
PP 031
PP 061, PP 063
PP 083
PP 088
OP 20
PP 196
OP 10
PP 091, PP 094,
PP 096
PP 165, PP 173,
PP 175
OP 21, PP 180,
PP 195
128
Dajak, M.
Damjanovic, T.
Daphnis, E.
Dardamanis, M.
Darema, M.
Daskalou, T.
Davidovic, L.
Deda, E.
Dedej, A.
Dedej, T.
Dejanov, P.
Dejanova, B.
Deliyska, B.
Deltas, C.
Derzsiova, K.
Devetzis, V.
PP 204
PP 136, PP 185
OP 22, PP 075
PP 046
PP 010, PP 044
PP 097
PP 118, PP 139
RFP 19, PP 051
OP 13
OP 08, OP13
PP 016
PP 016
PP 153, PP 164
RFP 05
OP 19
PP 116, PP 129,
PP 130
Dheir, H.
Didaggelos, T. P.
Dimas, G. G.
Dimitriadis, C.
OP 20
OP 03, OP04
OP 03, OP04
OP 16, RFP 18,
PP 037, PP 065,
PP 135
Dimitrijevic, Z.
Dimkovic, N.
OP 21, PP 180
PP 136, PP 157,
PP 159, PP 185
Dimos, G.
Dinckan, A.
Dionysopoulou, S.
Diza, E.
RFP 14
PP 182
PP 012, PP 017
PP 012, PP 017,
PP 026
Djordjevic, T.
Djordjevic, V.
PP 136
OP 21, PP 180,
PP 181, PP 195
Djukanovic, L.
Djurdjevic-Mirkovic, T.
Djuric, Z.
Djurkovic, V.
Dobreva, N.
Dokic, Z.
Dopsaj, V.
Doros, G.
Dounavis, A.
Dounousi, E.
Dragas, M.
Drakou, A.
Droulias, J. G.
Duman, S.
Duraj, V.
Duraku, A.
Durutovic, O.
Dzekova, P.
RFP 06, PP 121,
PP 140
PP 114, PP 169
PP 136, PP 157,
PP 185
PP 134, PP 170
PP 105, PP 106
PP 090, PP 138
OP 14
PP 201
PP 098
OP 01, OP 02,
RFP 01, RFP 02,
PP 110
Erkoc, R.
Erkol Inal, E.
Ersoy, F.
Erten, S.
Erten, Y.
Evangelou, A.
Evangelou, E.
F
Fatouros, I.
Ferenc, T.
Filiopoulos, V.
Fountoglou, T.
Fraginea, P.
Fragou, T.
PP 119, PP 139
PP 083, PP 085
PP 063
OP 20, PP 177
PP 091, PP 093,
PP 094, PP 095,
PP 096
Gadalean, F.
Gafencu, M.
Gakiopoulou, H.
Galanaki, B.
Galinas, A.
Garcia-Gil, D.
Garopoulou, E.
Gelev, S.
Georgakopoulou, D.
Georgianos, P.I.
Georgiou, A.
Georgiou, I.
Georgiou, P.
Gerasimovska, V.
Gerasimovska-Kitanovska, B.
PP 193
PP 125
E
PP 055
OP 16, RFP 03,
RFP 18, PP 008,
PP 009, PP 065,
PP 135
Ekonomidou, D.
OP 16, PP 008,
PP 065, PP 135
PP 072, PP 073,
PP 074
Eleftheriadis, T.
Eleftheriadou, M.
Elezi, E.
Elezi, S.
Elezi, Y.
Emrullaj, E.
Erdem Er, R.
Erdogan, E.
Erken, E.
Erkmen Uyar, M.
PP 115
PP 088
PP 030
PP 053
PP 032
PP 025, PP 067,
PP 126
G
RFP 09, PP 049,
PP 050, PP 103,
PP 104, PP 146
Efremov, G.
Efstratiadis, G.
PP 151
PP 087
PP 182
OP 20
PP 087, PP 089,
PP 142, PP 183
PP 080
PP 077
Gerolymos, M.
Giamalis, P.
RFP 11
PP 081
PP 081
PP 081
PP 178
PP 183
PP 196
PP 200
OP 12, PP 174,
PP 196, PP 197,
PP 198, PP 203
Giannakou, A.
Giga, V.
Ginikopoulou, E.
Gjata, M.
Gjergji, M.
129
RFP 15
PP 201
PP 004, PP 005,
PP 010
PP 048
PP 062
PP 088
PP 067
PP 125
PP 013
PP 029
PP 025, PP 067
OP 01, OP 02
PP 054
OP 06, OP 07
OP 06, OP 07,
PP 127
RFP 04
RFP 18, PP 008,
PP 065, PP 135
PP 011
OP 14
PP 011
PP 078, PP 079,
PP 091, PP 093,
PP 094, PP 095,
PP 096, PP 123,
PP 147
PP 147
Gjergji, Z.
PP 091, PP 093,
PP 095, PP 147
PP 078, PP 079
PP 188
PP 064
PP 181
RFP 15
RFP 15
OP 11
PP 118
PP 003
RFP 04, RFP 11,
RFP 12, PP 039,
PP 076
Idrizi, A.
OP 08, RPF 09,
PP 022, PP 023,
PP 024, PP 035,
PP 049, PP 052,
PP 064, PP 070,
PP 071, PP 146
Ignjatovic, A.
OP 21, PP 179,
PP 195
OP 15, RFP 08,
PP 175, PP 184,
PP 187, PP 189
Gounari, P.
Gouva, C.
Grapsa, E.
PP 083
PP 028
OP 11, RFP 19,
PP 036, PP 051,
PP 056
Ikonomov, V.
Iliadis, F.S.
Ilic, N.
Ilic, S.
Ilic, T.
Grcevska, L.
Grekas, D.M.
PP 152
OP 03, OP04, PP
001, PP 002
PP 019, PP 020,
PP 021, PP 062
PP 088
PP 055
OP 18
PP 182
PP 144
PP 086, PP 087
Gjika, A.
Gjulsen, S.
Gjyzari, A.
Glogovac, S.
Gluhovschi, C.
Gluhovschi, G.
Gogola, V.
Golubovic, M.
Gompou, A.
Goumenos, D.
Griveas, I.
Grone, E.
Gucev, Z.
Guney, I.
Gunseren, F.
Gursu, M.
Guz, G.
Ignjatovic, L.
Ignjatovic, S.
Ikonomou, M.
Ilieva, S.
Inal, S.
Iniotaki, A.
Intzevidou, E.
Ioakim, E.
Ioannidou, S.
Ioannou, K.
PP 204
RFP 11, RFP 12,
PP 113
PP 084
OP 03, OP04
PP 119, PP 139
PP 150
PP 114, PP 158,
PP 169, PP 186
PP 105, PP 106
PP 086, PP 087,
PP 089, PP 142
PP 003, PP 044,
PP 099
PP 066
PP 027
PP 056
RFP 02, PP 054
J
H
Haberal, M.
Hadjiyannakos, D.
Hadzibulic, E.
Hasani, A.
Hatzibaloglou, A.
Herman, D.
Heydari, H.
Hondrogiannis, P.
Hrincheva, M.
Hristozov, K.
Hur, E.
PP 196, PP 199
PP 032
PP 171
PP 081
PP 001, PP 002
RFP 15
PP 134
RFP 12, PP 076
PP 109
PP 084
PP 177
I
130
Jaglicic, I.
Jakovljevic, N.
Jankovic, A.
Jelacic, R.
Jemcov, T.
PP 159
PP 139
PP 185
PP 112
PP 117, PP 118,
PP 119, 139, PP
161, PP 204
Jovanovic, A.
Jovanovic, D.
RFP 08
OP 15, RFP 08,
PP 090, PP 136,
PP 137, PP 138,
PP 163, PP 175,
PP 176, PP 179,
PP 184, PP 194
Jovanovic, N.
PP 090, PP 138,
PP 163, PP 176,
PP 194
Jovicic-Pavlovic, S.
PP 193
K
Kachrimanidou, M.
Kaculini, E.
Kaisidis, P.
Kalafati, A.
Kalaitzidis, K.
Kalaitzidis, R.
Kalakonas, A.
Kalakonas, S.
Kalantzi, K.
Kalfarentzos, F.
Kalientzidou, M.
Kalliakmani, P.
Kalogeras, D.
Kaludina, I.
Kambo, B.
Kampouris, C.
Kanonidou, C.
Kanonidou, E.
Kantartzi, K.
Kapedani, E.
Kaperonis, N.
Kapsalas, D.
Karadag, S.
Karamitsos, K.
Karamouzis, M.
Karanikola-Pavlaki, E.
Karasavvidou, D.
Karatapanis, S.
Karatzas, T.
Karpuz, N.
Karvouniaris, N.
PP 111
PP 145
PP 010
PP 132
PP 048
RFP 11, PP 069,
PP 077, PP 110
PP 007
PP 062
PP 028
PP 076
PP 048
RFP 04, PP 039,
PP 076
RFP 14
PP 153
PP 052
PP 001, PP 002
PP 012, PP 018,
PP 026, PP 034,
PP 057, PP 058,
PP 059, PP 060
PP 057, PP 058,
PP 059, PP 060
PP 115, PP 116,
PP 130
RFP 09
PP 100, PP 132
PP 033
PP 144
PP 062
PP 001, PP 002,
PP 018, PP 034
PP 013
RFP 01, PP 053,
PP 069, PP 077
PP 038
PP 044
PP 151
PP 038, PP 040,
PP 041
Kasa, M.
PP 050, PP 070,
PP 071
Kasimatis, E.
Katopodis, K.
RFP 18
PP 110
Katsarou, P.
Katsilambros, N.
Katsinas, C.
Kayikcioglu, H.
Kayrak, M.
Kazancioglu, R.
Kelesidis, A.
RFP 14
OP 05
PP 053
PP 101
RFP 10, PP 101
PP 144, PP 151
OP 02, RFP 02,
PP 042, PP 043,
PP 057, PP 058,
PP 059, PP 060
Kellidou, S.
Kezic, A.
Khaldi, L.
Kiatou, V.
PP 080
PP 193
PP 098
OP 01, OP 02,
RFP 01, PP 042,
PP 043
Kiosses, D.
Kiperova, B.
Kircelli, F.
Kitsos, A.
Klancic, D.
Klosi, J.
Knap, B.
Knezevic, V.
Kocak, H.
Kodra, S.
PP 036
PP 191
OP 20
PP 110
PP 202
PP 095
RFP 17
PP 154
PP 182
OP 08, PP 064,
PP 143
PP 056
PP 075
PP 027
PP 106
RFP 14
PP 100, PP 132
PP 005, PP 044
PP 134
RFP 04
PP 118, PP 119,
PP 139
PP 028
RFP 19, PP 051
PP 064
PP 006
PP 190
PP 013
PP 051
Kokkoris, S.
Kokologiannakis, G.
Kokolou, E.
Koleva, V.
Koliousi, E.
Kolovos, V.
Kolovou, K.
Komadina, L.
Komninakis, D.
Koncar, I.
Korantzopoulos, P.
Korfiatis, P.
Koroshi, A.
Kostadinoska, S.B.
Kostadinova-Kunovska, S.
Kostaki, M.
Kostis, E.
131
Kotzadamis, N.
Kougioumtzidou, O.
Koukoulaki, M.
Koumoutsea, D.
Kountouris, S.
Kouri, N. M.
Kourouklaris, A.
Kousoula, V.
Koutis, I.
Koutroubas, G.
Koutsovasili, A.
Kovac, M.
Kovacevic, M.
Kovacevic, S.
Kovacevic, Z.
Kowalczyk, E.
Kravari, M.
Kravljaca, M.
Kriki, P.
Krivoshiev, S.
Ktona, E.
Kukavica, N.
Kuzmanovic, I.
Kuzmanovska, D.
Kyriazis, J.
Kyriklidou, P.
Kyroglou, E.
OP 01, RFP 01,
RFP 02, PP 042,
PP 043, PP 057,
PP 058, PP 059,
PP 060
Lausevic, M.
Lazaridis, M.
Lazarou, D.
Lazarov, V.
Leivaditis, K.
PP 066
PP 076
PP 062
PP 069
PP 111
PP 054
RFP 16, PP 011
PP 030
RFP 13, PP 033,
PP 082, PP 124
PP 036, PP 100
PP 114
PP 140
RFP 06
OP 15, RFP 08,
PP 165, PP 173,
PP 175, PP 179,
PP 184, PP 187,
PP 189
Lezaic, V.
Liakopoulos, V.
Liakou, E.
Liapis, G.
Likaj, E.
Limoncu, O.
Lionaki, S.
Ljubenovic, S.
Lorentzaki, I.
Lozance, L.
Lucic -Dragic, L.
Lukasiewicz, B.
Lukic, L.
PP 088
PP 056
PP 118, PP 161,
PP 176, PP 194
PP 131
PP 164
PP 023, PP 024,
PP 052
PP 201
PP 099
PP 180
PP 014
PP 127
PP 112
PP 088
RFP 06, PP 140
M
Madronic, M.
Majic, M.
Makedou, A.D.
Makedou, K.J.
Makri, P.
PP 133
PP 119, PP 139
PP 015
OP 22, PP 075
RFP 12, RFP 16,
PP 007
RFP 11, RFP 12
Makridis, D.
Maksic, D.
Maksimovic, Z.
Malindretos, P.
L
Lafoyanni, S.
Laku, A.
Lambic, L.
Lambropoulos, S.
Lamprinoudis, G.
Lasaridis, A.N.
Laszlo, M.
PP 176, PP 194
PP 116, PP 129
PP 032, PP 097,
PP 098
PP 153, PP 164
PP 047, PP 116,
PP 129
OP 14, PP 121,
PP 193, PP 204
PP 047, PP 072,
PP 073, PP 074
OP 16, PP 008
PP 004, PP 010
RFP 09, PP 049,
PP 050, PP 070,
PP 071, PP 092,
PP 103, PP 104,
PP 107, PP 108,
PP 178
PP 098
PP 070, PP 071
PP 134
PP 053
OP 22, PP 075
PP 029
PP 172
Mamali, S.
Mandraveli, K.
Manetos, C.
Manios, E.
Manou, E.
132
RFP 17
PP 158
OP 03, OP04
OP 03, OP04
RFP 13, PP 033,
PP 082, PP 124
PP 042, PP 043
OP 10, OP 15,
PP 187, PP 189
PP 140
RFP 13, PP 002,
PP 033, PP 082,
PP 124
PP 014
PP 012, PP 017
PP 056
OP 11
RFP 16, PP 007,
PP 011
Margelos, V. K.
Maric, S.
Maric, V.
Marinaki, S.
Marinkovic, J.
Markou, M.
Markovic, R.
Martika, A.
Martinuc Bergoc, M.
Masnic, F.
Matamis, D.
Mavreas, V.
Melexopoulou, C.
Memmos, D.
Metaxatos, G. E.
Miari, F.
Michalaki, A.
Michalaki, K.
Michalopoulos, A.
Micozkadioglu, H.
Mijuskovic, M.
Mikros, S.
Milenkovic, S.
Milic, B.
Milinkovic, M.
Miljkovic, B.
Milovanceva Popovska, M.
Milovanovic, B.
Milutinovic, D.
Minasidis, I.
Miserlis, G.
Missiou, D.
Mitic, I.
Mitrovic, D.
Mitrovic, M.
Mitsi, E.
PP 063
PP 140
PP 140
PP 003, PP 005,
PP 099
PP 204
PP 033
PP 134, PP 170
PP 080
PP 202
PP 133
PP 007
RFP 12
PP 010
OP 16, RFP 03,
RFP 18, PP 008,
PP 009, PP 065,
PP 135
Mitsiou, G.
Mitsopoulos, E.
Monov, S.
Monova, D.
Motoc, C.
Motoc, R.
Mourvati, E.
Moutzouris, D. A.
Mumajesi, S.
PP 132
RFP 16, PP 011,
PP 066
PP 155, PP 156
PP 155, PP 156
PP 172
PP 172
PP 129, PP 130
PP 045
OP 13, PP 035,
PP 049, PP 050,
PP 092, PP 103,
PP 104, PP 145,
PP 178
Mussig, K.
Mydlik, M.
PP 088
OP 19
N
PP 061, PP 063
PP 048
PP 047
PP 031
PP 057, PP 058,
PP 059, PP 060
PP 199, PP 200
PP 165, PP 173,
PP 175, PP 179,
PP 189
Nakopoulou, L.
Nanas, S.
Nastou, D.
Natse, T.
Naumovic, R.
Nelaj, E.
PP 014, PP 025,
PP 126
PP 150
PP 154, PP 158,
PP 169, PP 186
PP 139, PP 176,
PP 193, PP 194
Nenchev, N.
Nesic, V.
Nikitidou, O.
Nikolaidis, N.
Nikolaidis, P.
Nikolaidou, A.
Nikolic, M.
Nikolic-Kokic, A.
Nikolopoulou, N.
PP 121
PP 152
PP 134
PP 193
RFP 16, PP 007,
PP 011
PP 031
PP 046
PP 114, PP 154,
PP 158, PP 169,
PP 186
Nikolov, I.
Nikolov, V.
Nogue-Xarau, S.
Ntatsis, G.
Nurhan Ozdemir Acar, F.
RFP 06
PP 187
PP 076
Nwosu, J. O.
133
RFP 04, PP 099,
PP 126
PP 056
PP 100
PP 111
PP 137, PP 138,
PP 168, PP 193
PP 078, PP 079,
PP 091, PP 093,
PP 094, PP 095,
PP 123
PP 153, PP 164
PP 176, PP 194
PP 047
PP 013
PP 029, PP 047
PP 026
OP 17
OP 17
PP 045, PP 061,
PP 063
PP 188, PP 190,
PP 192
PP 152
PP 088
PP 100, PP 132
PP 174, PP 199,
PP 203
PP 019, PP 020,
PP 021
Pape, M.
O
Obradovic, R.
Obrencevic, K.
Oguzkurt, L.
Oikonomaki, T. D.
Oikonomidou, D.
Ok, E.
Oncevski, A.
Onec, K.
Onol, S.
Oprescu, I.
Oreopoulos, D.D.
Ouzouni, A.
Ozbek, O.
Ozelsancak, R.
Ozisik, M.
Ozkahya, M.
Ozturk, S.
PP 163
PP 165
PP 199
PP 061
PP 009
OP 20
OP 06, OP 07
PP 087, PP 089,
PP 142
PP 151
PP 201
PP 037
PP 048
OP 18, RFP 10,
PP 101
PP 199, PP 200
PP 177
OP 20
PP 144
Papoulidou, F.
Pappas, E.
Pappas, K.
Pappas, M.
Parisi, M.
Paskalev, D.
Pasko, N.
Passadakis, P.
Pateinakis, P.
Patsouris, E.
Paunic, Z.
Paunovic, G.
Paunovic, K.
Pavleska, S.
Pavlitou, A.
Pavlopoulou, S.
Pavlova, Z.
Pavlovic, D.
Pavlovic, J.
P
Paliouras, C.
Panagidou, A.
Panagiotopoulos, K.
Panagoutsos, S.
Pandelias, K.
Pani, I.
Pantzaki, A.
Papachristou, E.
Papadakis, G.
Papadopoulos, R.
Papadopoulou, D.
Papagalanis, N.
Papagianni, A.
Papakonstantinou, S.
Papasotiriou, M.
Papazisis, L.
PP 038, PP 040,
PP 041
PP 054
PP 030
PP 115, PP 116,
PP 129, PP 130
RFP 19, PP 051
PP 032, PP 098
RFP 03, PP 008,
PP 009
Pavlovic, R.
Pejanovic, S.
Pejin-Grubisa, I.
Pelemis, S.
Pendavinji, I.
Penkov, R.
Perunicic-Pekovic, G. B.
Petani, E.
Petkovic, N.
Petrela, E.
RFP 04, PP 039,
PP 076
PP 014, PP 025,
PP 067, PP 126
PP 057, PP 058,
PP 059, PP 060
PP 066
PP 100, PP 132
OP 02, RFP 03,
RFP 18, PP 057,
PP 058, PP 059,
PP 060
Petrica, L.
Petronijevic, D.
Petronijevic, Z.
Petrovic, D.
Petrovic, L.
Petrovic, M.
RFP 02
PP 039
PP 057, PP 058,
PP 059, PP 060
Petrovski, M.
Petrusevska, G.
Picolos, M. K.
134
PP 012, PP 017,
PP 018, PP 034
PP 048
RFP 01, PP 069,
PP 113
RFP 01, RFP 02,
PP 069, PP 077
PP 027
PP 056
PP 084
OP 08, PP 035,
PP 143, PP 145,
PP 178
PP 066, PP 116,
PP 130, PP 131
PP 007, PP 008
PP 004
PP 187, PP 189
PP 180
PP 180
PP 125
PP 011
PP 014
PP 164
PP 140
PP 160, PP 162,
PP 176, PP 194
OP 21, PP 195
PP 137, PP 161,
PP 204
PP 157
RFP 06
PP 146
PP 109
OP 17, PP 134
PP 052
RFP 06, PP 121
OP 09, PP 064,
PP 108
RFP 15
PP 188
PP 190, PP 192
PP 167
PP 114, PP 169
PP 173, PP 179,
PP 187, PP 189
PP 015
PP 190
PP 128
Pierides, A.
Pilcevic, D.
RFP 05
OP 10, PP 165,
PP 173, PP 175,
PP 179, PP 187,
PP 189
Pipili, C.
RFP 19, PP 036,
PP 037, PP 051,
PP 056
Pitsalidis, C.G.
Pivasevic, S.
Plaseska-Karanfilska, D.
Pliakos, C.
OP 03, OP04
PP 121
PP 055
RFP 03, RFP 18,
PP 001, PP 002,
PP 009, PP 065,
PP 135
Pljesa, S.
Poirazlar, E.
Politis, E.E.
Ponikvar, R.
Popov, M.
Popovic, G.
Popovic, J.
PP 134
PP 036
PP 045
RFP 17
PP 125
PP 136
PP 136, PP 157,
PP 159, PP 185
PP 169
PP 055
RFP 15
PP 100, PP 132
PP 088
PP 120, PP 128
PP 026
PP 061
PP 047
Popovic, M.
Popovska-Jankovic, K.
Potencz, E.
Poulikakos, D.
Prayon, B.
Prikis, M. C.
Prodromidou, S.
Psounis, K. P.
Ptinopoulou, A.
OP 15, PP 165,
PP 173, PP 175,
PP 179, PP 184,
PP 187, PP 189
Radivojevic, D.
Radojevic, M.
PP 193
PP 165, PP 179,
PP 184
PP 150
PP 117, PP 119,
PP 160, PP 161,
PP 162, PP 204
Radosavljevic, S.
Radovic, M.
Raikou, V. D.
Ralli, M.
Ramsheva, Z.
PP 105, PP 106
OP 17, PP 134
PP 133
PP 140
PP 055
PP 152
OP 13, PP 143
PP 009
PP 111
PP 164
PP 022
PP 001, PP 002
PP 129, PP 131
PP 068
OP 09, RPF 09,
PP 023, PP 035,
PP 049, PP 050,
PP 070, PP 092,
PP 103, PP 104,
PP 107, PP 108,
PP 146, PP 178
Rudhani, I.
Rugova, B.
PP 081
PP 081
S
Sadiku, E.
Saganas, A.
Sahin, G.
Sahpazova, E.
Sakac, V.
Saksida, S.
Salapata, A.
Saltanovska, H.
Samur, C.
Sanlıer, N.
Sarafidis, P.A.
Savic, D.
Savic, O.
Savin, M.
Savva, I.
Savvidaki, E.
Savvidaki, I.
Savvidis, N.
Schiller, A.
Sebekova, K.
R
Rabrenovic, V.
Rapondjieva, A.
Rasic-Milutinovic, Z.
Resic, H.
Ristic, S.
Ristoska Bojkovska, N.
Ristovska, V.
Riza, F.
Rizopoulou, E.
Rizos, A.
Robeva, R.
Roshi, E.
Roudenko, I.
Roumeliotis, A.
Rousouli, K.
Rroji (Molla), M.
OP 05
PP 013
PP 109
135
PP 093, PP 094
PP 027
PP 142
PP 015
PP 114
PP 202
PP 062
PP 006
PP 101
PP 089, PP 142
PP 029
PP 173, PP 175
PP 159
PP 171
PP 054
RFP 04, PP 039
PP 076
PP 047
RFP 15
OP 19
Seferi, S.
Segal, A. S.
Seizer, P.
Sekercioglu, N.
Selim, G.
Sevinc Ok, E.
Sezer, S.
Sezgin, N.
Sferopoulos, G.
Sfikakis, P.
Sgantzos, A.
Shivarov, H.
Shurliev, V.
Siamopoulos, K.C.
OP 09, RPF 09,
PP 035, PP 049,
PP 050, PP 070,
PP 092, PP 103,
PP 104, PP 107,
PP 108, PP 146,
PP 178
Sonikian, M.
Sorvinou, P.
Sotiraki, M.
Souftas, V.
Sovtic, S.
Spahia, N.
PP 120
PP 088
PP 037
PP 125, PP 192
OP 20
OP 12, PP 174,
PP 197, PP 198,
PP 203
Spaia, S.
Spanos, G.
Spartalis, M.
Spiroglou, S.
Spiropoulos, P.
Spyropoulos, C.
Sredkov, I.
Stambori, M.
Stamopoulos, D.
Stangou, M.
PP 200
PP 027
PP 099
PP 100, PP 132
PP 153
PP 153
OP 01, OP 02,
RFP 01, RFP 02,
RFP 07, RFP 11,
RFP 12, PP 068,
PP 069, PP 077,
PP 099, PP 110,
PP 113
Sibalic Simin, M.
Sidiras, G.
Sikole, A.
PP 169
PP 034
OP 06, OP 07,
PP 125, PP 152
Simeonov, R.
Simic-Ogrizovic, S.
PP 015
OP 14, PP 090,
PP 117, PP 118,
PP 121, PP 137,
PP 161, PP 168,
PP 204
Siomos, I.
Sipahi, S.
Sivridis, D.
Skalioti, C.
PP 124
OP 20
PP 115
OP 05, PP 005,
PP 099
Skapinakis, P.
Skarakis, I.
Sladojevic, N.
Solak, Y.
Sombolos, K.
RFP 11, RFP 12
PP 097
PP 195
PP 101
PP 111
Stanisic, M.
Stanoevska-Grankova, S.
Stanojevic, M.
Stavgianoudakis, G.
Stavrinou, E.
Stavrinou, I.
Stavroulopoulos, A.
Stefanidis, I.
Stefanovic, N.
Stergiou, K.
Stoian, B.
PP 195
PP 048
PP 141, PP 148,
PP 149
Stoian, M.
PP 141, PP 148,
PP 149
PP 141, PP 148,
PP 149
PP 180
PP 125
PP 125
PP 090, PP 163,
PP 167
Stoica, V.
Stojanovic, M.
Stojcev, N.
Stojceva - Taneva, O.
Stojimirovic, B.
Stolic, R.
Stosovic, M.
136
PP 032, PP 097,
PP 098
PP 036
PP 014, PP 025,
PP 067, PP 126
PP 131
PP 150
PP 070, PP 107,
PP 108, PP 146
PP 080
RFP 01, PP 069,
PP 077
RFP 03, RFP 18,
PP 009
PP 034
PP 042, PP 043
PP 076
PP 153
PP 038
OP 11
RFP 03, PP 008,
PP 009
RFP 06
PP 006
PP 090, PP 137
PP 062
RFP 18
PP 065, PP 135
PP 122
PP 072, PP 073,
PP 074
PP 150
PP 090, PP 121,
PP 137, PP 138,
PP 161, PP 204
Strakosha, A.
OP 08, OP13, PP
064, PP 143, PP
145, PP 178
Strazmester Majstorovic, G.
PP 154, PP 158,
PP 169, PP 186
OP 22, PP 075
PP 150
PP 177, PP 182
PP 144
PP 170
RFP 11, RFP 12
RFP 13, PP 033,
PP 082, PP 124
Stylianou, K.
Subaric-Gorgieva, G.
Suleymanlar, G.
Sumnu, A.
Suric Lambic, L.
Sygelakis, M.
Syrganis, C.
T
Tadic Pilcevic, J.
PP 165, PP 173,
PP 175, PP 179,
PP 187, PP 189
Tafaj, A.
Takouli, L.
Tarpagkos, D.
Tase, M.
PP 096
PP 030
PP 034
PP 078, PP 079,
PP 091, PP 093,
PP 094, PP 095,
PP 123, PP 147
Tasic, D.
Tasic, V.
Tatli, E.
Tatsioni, A.
Tegos, T. J.
Tegou, Z.
Tellis, C.
Tentolouris, N.
Teodorova, I.
Tepeler, A.
Terzic, B.
Tesic, J.
Themeli, Y.
Theodoridis, M.
Theodoropoulou, E.
Thereska, N.
OP 08, OP 09,
OP 13, RPF 09,
PP 035, PP 049,
PP 050, PP 064,
PP 070, PP 071,
PP 092, PP 103,
PP 104, PP 107,
PP 108, PP 143,
PP 145, PP 146,
PP 147, PP 178
Thodis, E.
Thodis, I.
Tilea, I.
Todorov, T.
Togousidis, E.
Toka, G.
Tomic, A.
Topuzovic, C.
Torun, D.
Tosic, J.
Toz, H.
Tozija, L.
PP 115, PP 131
RFP 16
PP 172
PP 105, PP 155
RFP 13
PP 003
OP 15
PP 193
PP 199, PP 200
PP 157, PP 185
OP 20
PP 125, PP 188,
PP 190, PP 192
PP 088
PP 048
PP 125
PP 036
PP 013
PP 153
PP 140
PP 056
PP 202
OP 01, OP 02,
RFP 01, RFP 02,
RFP 11, RFP 12,
RFP 16, PP 007,
PP 011, PP 066
Trabulus, S.
Traianou, K.
Trajcevska, L.
Triantaphylis, G.
Triantos, P.
Trifonova, D.
Trifunovic, D.
Tripodaki, E.
Trost Rupnik, A.
Tsakiris, D.
PP 166
PP 055
PP 144
RFP 01, PP 069
OP 03, OP04
RFP 19
PP 068
OP 05
PP 084
PP 151
PP 175
RFP 06
PP 024, PP 052
PP 115
PP 004
Tsampikaki, E.
Tsandekidou, E.
Tseke, P.
Tselepis, A.
Tsiamalos, P.
Tsiantoulas, A.
Tsiatsiou, M.
Tsigalou, C.
Tsikeloudi, M.
Tsiligiris, V.
137
PP 038, PP 040,
PP 041
PP 111
RFP 19
PP 068
PP 051
OP 16
RFP 16, PP 011,
PP 066
PP 130
PP 011
PP 062
Tsilivigou, M.
Tsirmani, A.
Tsouchnikas, I.
Tulic, C.
Tuna Ozturk, G.
Tunc, M.
Turkmen, K.
Turkoglu, M.
Tutal, E.
Tzanakakis, M.
Tzanakis, I.
Tzanatos, H.
PP 025, PP 067
PP 053
RFP 02
PP 193
PP 087
PP 151
OP 18, RFP 10,
PP 101
PP 183
OP 12, PP 174,
PP 196, PP 197,
PP 198, PP 203
Vodopivec, S.
Voliotis, G.
Voskarides, K.
Voutsinas, E.
Vucicevic, A.
Vuckovic, M.
Vukoje, M.
Vuksanovic, A.
PP 114
PP 039
RFP 05
PP 124
PP 121
OP 14
PP 112
PP 193
X
Xanthopoulou, K.
Xatzigeorgiou, G.
Xhaferri, X.
OP 22
OP 22, PP 075
RFP 19, PP 051
PP 042, PP 043
PP 036
PP 070
Y
U
Ulusal Okyay, G.
Ural, C.
Uslu, B.
Uzun, S.
Yakupoglu, G.
Yildirim, T.
Yildiz, I.
Yozgat, A.
Yuksel, E.
PP 183
PP 177
PP 182
PP 144
PP 182
PP 200
PP 200
PP 086
PP 086
Z
V
Vakicic, S.
Vardoulaki, M.
Vargemezis, V.
Zafirovska, K.
Zagorianakos, A.
Zagotsis, G.
RFP 06
PP 039
RFP 02, RFP 16,
PP 066, PP 115,
PP 116, PP 129,
PP 130, PP 131
Zavros, M.
Zavvos, G.
Varvara, C.
Vasilev, V.
Vasilijic, S.
Vasiljevic, N.
Vasiu, M.
Vavic, N.
RFP 12
PP 153
OP 10
PP 137
PP 088, PP 102
OP 15, PP 173,
PP 179, PP 184,
PP 187, PP 189
Zec, N.
Zeki Tonbul, H.
Velciov, S.
Velickovic-Radovanovic, R.
Visvardis, G.
Vittoraki, A.
Vlachopanos, G.
Vlachopanou, A.
Vlahakos, D.
Vlahovic, P.
Vlassopoulos, D.
RFP 15
OP 21, PP 195
PP 066
PP 044
PP 004
PP 028
PP 083, PP 085
OP 21
PP 030, PP 032,
PP 097, PP 098
Zivanovic, S.
Zortcheva, R.
Zotaj, A.
Zounis, C.
Zumrutdal, A.
Zunic, S.
Zylfiu, B.
Zeneli, N.
Zeniou, V.
Ziakka, S.
Zikou, X.
138
PP 127
PP 100, PP 132
RFP 13, PP 033,
PP 082, PP 124
PP 054
PP 003, PP 004,
PP 010
PP 134
OP 18, RFP 10,
PP 101
PP 103, PP 104
PP 128
PP 100, PP 132
RFP 01, PP 068,
PP 113
PP 195
PP 084
PP 096
PP 122
PP 199, PP 200
PP 163
PP 081
Notes
Notes
140

Volume 9 issue Suppl. 1

Transcription

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