Stages Of Renal Insufficiency Research Articles

#2534 Classification of patients with acute kidney damage on the base of blood pressure value as a risk factor using a neural network

Abstract Background and Aims In acute kidney damage, the monitoring of hemodynamic status is best achieved by determining the blood pressure value. It is considered that the values of diastolic blood pressure in young and healthy people are constant from the aorta to the periphery, and the values of systolic and pulse pressure increase from the periphery to the aorta. The frequency of hypertension correlates with the presence of a cardiovascular precipitating risk factor in acute kidney injury, hypertension is also a modifying risk factor in the second and third stages of acute kidney injury, while the presence of hypotension on admission can be a clinical indicator of its cause. In patients with acute kidney damage and in patients with sepsis, the mechanism of autoregulation of mean arterial pressure, which is affected by stroke volume and heart rate, is not effective. The aim of the paper is to examine the classification of hospitalized patients with acute kidney injury based on blood pressure as a risk factor. Method The study included 86 patients over 18 years of age of both sexes (39 men 45.3% and 47 women 54.7%) with an average age of 66.85 ± 15.30 years who were diagnosed with acute kidney injury on admission to hospital treatment. Patients were divided into groups according to the stages of renal insufficiency. The study was designed as a cross-sectional comparative study. The assessment of the existence of acute kidney damage, as well as the determination of the stage of the disease, was based on the diagnostic criteria proposed by the K/DIGO expert group for acute kidney damage. The study did not include patients who had disease progression after acute kidney failure and were treated with dialysis for more than three months. Basic clinical, biochemical and hemodynamic parameters were determined in all subjects at the beginning of treatment, except for the analysis of nitrogen status, which was determined both before and at the end of treatment. During the formation of the neural network (pattern recognition Mat Lab), the parameters of systolic arterial pressure, diastolic arterial pressure normalized by min-max normalization to values from 0 to 1 were included. The data were randomly distributed into three categories: 80% for training, 10% for test, 10% for validation, which means that the parameters of 68 patients were used for training, 9 patients for validation and another 9 patients for the test. The number of input parameters is 33 to 39, while the number of output parameters is 2 in relation to treatment. Formed neural networks with different included blood pressure parameters, structures of 25 neurons in the hidden layer, with 55 and 15 epochs and with accuracy of 97.7% and 90.7% of patient classification. Results Our results show that 40.3% of patients in the third stage of acute kidney injury have hypertension. The lowest average values of systolic (108.44 ± 22.81 mmHg) and diastolic (65.56 ± 15.29 mmHg) blood pressure were experienced by patients in the first stage of acute kidney damage, and the lowest values of mean arterial pressure existed in the second stage of acute kidney damage (68.20 ± 44.96 mmHg) .Statistically significant risk factors for the development of the third stage of acute kidney damage in the multivariate analysis were patients older than 65 years, and mean arterial pressure values less than 65 mmHg. The confusion matrices showed that the classifiers adapted to the minimum and maximum values of systolic, diastolic and mean arterial blood pressure are well adapted and achieve satisfactory accuracy with 97.7% and 90.7%. Conclusion By comparing blood pressure parameters in hospitalized patients in relation to the stage of acute kidney damage, no statistically significant deviations were found. Univariate logistic regression analysis showed that age over 65 was a significant independent risk factor for stage three acute kidney injury, while the multivariate model showed that risk factors for the development of stage three acute kidney injury were patients same age and middle arterial blood pressure less than 65 mmHg. Satisfactory accuracy of formed neural networks when classifying patients during validation training and test was also demonstrated.

Mechanisms of renal damage in patients with new coronavirus infection (literature review)

One in four people in the world currently has kidney problems to varying degrees. It is known that the new coronavirus infection (COVID-19) is primarily a respiratory disease, but the kidneys are the target organ. Coronavirus is tropic to renal tissue due to the presence in the organ of the angiotensin converting enzyme type 2 and transmembrane serine protease 2, which are considered the target of this virus. The presence of any stage of renal insufficiency is an independent adverse risk factor for coronavirus infection and results in high hospitalization rates in hospitals and a mortality rate. Kidney damage is caused by a variety of pathogenetic mechanisms: direct cytopathic effect of the virus on their structure (in the kidney body - podocytes, mesangial cells, in the vascular glomerulus - endothelium of capillaries, in the proximal tubules - epithelial cells); cytokine storm; damage to the renin-angiotensin-aldosterone system; immunothrombosis. In many patients with confirmed coronavirus infection, significant changes in urine analysis (hematuria, proteinuria) and an increase in serum creatinine levels have been observed in the laboratory since the first days of the disease. One of the main risk factors for mortality is the development of acute renal injury. More research is needed on the exact effects of SARS-CoV-2 on the kidneys. Understanding the main pathogenetic pathways of kidney damage in COVID-19 is necessary for the development of strategies and the development of effective treatment methods.

Prescription of DOACs in Patients with Atrial Fibrillation at Different Stages of Renal Insufficiency.

Atrial fibrillation (AF) and renal insufficiency often coexist and are increasingly prevalent with advancing age. Both the risk of thromboembolic events and bleeding propensity are higher in patients with AF and impaired renal function versus those with good renal health. Direct oral anticoagulants (DOACs) are being increasingly preferred over vitamin K antagonists (VKAs) in the treatment of patients with AF and impaired renal function as VKAs may accelerate progression of chronic kidney disease. DOACs, however, are eliminated by the kidneys to varying degrees, and their dosages must be adapted in accordance with renal function. Since creatinine clearance (CrCl) monitoring is recommended in patients with AF receiving DOAC therapy, CrCl must be routinely monitored in patients at the start and during the course of anticoagulation to avoid deviation from Summary of Product Characteristics dosage specifications. This review article provides an overview of current knowledge on the selection and dose of DOACs including apixaban, dabigatran, edoxaban and rivaroxaban in AF patients at different stages of renal insufficiency, with a special focus on elderly patients with comorbidities and receiving multiple medications. The groups discussed in this review include patients with varying levels of CrCl including hyperfiltration or CrCl > 90ml/min, CrCl < 90-50ml/min, CrCl < 50-30ml/min, CrCl < 30-15ml/min and end-stage renal disease or on dialysis.

Multimorbidity in nephrotic syndrome.

Nephrotic syndrome (NS) is characterized by high proteinuria (over 3,5g/24 hrs), hypalbuminaemia, general edemas and hypercoagulation. Beside of primary glomerulonephritides this is found in secundary glomerulopaties eg. diabetes, systemic inflammatory diseases, oncology, damage by drugs and poisoning, by alergy, serious infections and in children from hereditary reasons. The most frequent reason for NS in adults patiens is diabetes and diabetes with nephropathy represents almost 40% of dialysed patiens. From this point of view, there is great interest focusing on gliflozins (SGLT2 inhibitors) with positive nephroprotecive effect. It leads do increasing of glycosuria with concomitant natriuresis and osmotic diuresis. The effect is proportional to glomerulal filtration, but the effect on natriuresis stay in all stages of renal insufficiency.

ACTUALITIES IN THE MANAGEMENT OF SECONDARY HYPERPARATHYROIDISM DUE TO CHRONIC KIDNEY DISEASE IN CHILDREN.

Pediatric chronic kidney disease (CKD) has a substantial global impact because is associated with notable morbidity. Secondary hyperparathyroidism (SPHT) frequently emerges as a complication in the early stages of renal insufficiency, it is an adaptive response to uphold mineral balance. It is a component of the chronic kidney disease-mineral and bone disorder (CKD-MBD). The development of SHPT in CKD involves multiple factors and it is important to understand them in order to properly manage it, starting with early diagnosis and continuing with proper treatment. In children with CKD and SHPT, the difficulty in case management is due to non-adherence to proper diet which makes it difficult for the pediatric nephrologist to manage the case. In this review we want to focus on new data regarding this CKD complication.

Importance of Bio-electrical Impedance for Measurement of Body Fluid Status in Chronic Kidney Disease Patients on Maintenance Haemodialysis: A Narrative Review

Assessing the precise body water status in patients with renal disorders is crucial for their health. It has been reported that chronic fluid overload is present even in the early stages of renal insufficiency. If volume overload in a patient with chronic renal failure is not controlled, serious problems such as pulmonary oedema, cardiac remodelling, and diastolic heart failure can develop. Bioelectrical Impedance Analysis (BIA) has emerged as one of the most useful tools, although randomised clinical studies are lacking to support its universal use. Early management of hydration may improve clinical outcomes, as it allows for personalised dialysis prescriptions and nutritional support. BIA practice is utilised as non invasive health monitoring for Body Composition (BC). BIA is a practical and inexpensive method. Moreover, BIA parameters estimated for disease prognosis analysis have been found to be reasonably predictable for both patient status and healthcare. Additionally, BIA is a simple, accurate, portable, quick, easy, and low-cost method. In patients with End-stage Renal Disease (ESRD) undergoing maintenance Haemodialysis (HD) treatment, excessive fluid volume is considered a risk factor for death. Furthermore, fluid elimination to achieve Dry Weight (DW) is a crucial component of HD treatment for ESRD patients. DW is an important concept related to patients undergoing HD. Conventional methods seem to be time-consuming and operator-dependent. BIA is a new and simple method that has been reported to accurately estimate DW. Estimating the dry weight of HD patients is a challenging task. Many tools are available, but not every HD centre has access to them. Several strategies have been used to develop a more standardised method of assessing dry weight in HD patients. The Bio-impedance Spectroscopy (BIS) device has been validated against gold standard methods of volume assessment. Body composition monitoring appears to be a helpful diagnostic tool that reasonably complements existing clinical methods in assessing the DW of HD patients. BIS identifies Fluid Overload (FO) as a virtual "Over Hydration (OH)" compartment, which is calculated from the difference between the measured extracellular volume and the predicted values based on a fixed hydration of lean and adipose tissue mass.

Effectiveness of antiviral treatment of patients with chronic hepatitis C GT 1b depending on the presence of comorbid chronic renal insufficiency

Aim. The aim of the work was to analyze the effectiveness of antiviral therapy (3D mode) in patients with chronic hepatitis C (CHC) GT1 in clinical practice, depending on the presence of comorbid chronic renal insufficiency stage V, who receiving hemodialysis. Materials and methods. 101 patients with CHC GT1 who received antiviral therapy (AVT) according to the scheme OBV/PTV/r + DSV ± RBV (3D-mode) during 12 weeks were included in the study. All patients with CHC were divided into two groups depending on the presence of comorbid chronic renal insufficiency (CRI): 92 patients who did not have accompanying CRI and 9 patients with comorbid CRI stage V who received program hemodialysis. Results. The effectiveness of antiviral therapy in patients with CHC GT1 according to the OBV/PTV/r + DSV ± RBV scheme in clinical practice was high in terms of the achievement of 12 weeks sustained virologic response (SVR 12) SVR 12 (94.1 %). The frequency of achieving SVR 12 in CHC patients without concomitant CRI was 94.6 %, and with of comorbid CRI stage V (hemodialysis) – 88.9 % and had not statistically significant differences (P &gt; 0.05). Treatment according to the 3D-mode was accompanied with stable normalization of ALT activity in 86.0 % of patients with CHC, and the frequency of it is achievement did not depend on the presence of comorbid CRI stage V (100.0 % vs. 85.2 % in patients without the specified concomitant pathology, P &gt; 0.05). Conclusions. The effectiveness of antiviral therapy in patients with CHC GT1 according to the OBV/PTV/r + DSV ± RBV scheme in clinical practice is high in terms of the achievement of SVR 12 (94.1 %) and does not depend in the presence of comorbid CRI stage V in the patient (94.6 % vs. 88.9 %, P &gt; 0.05). The severity of liver fibrosis does not affect the effectiveness of AVT in patients with CHC GT1 in the presence of comorbid CRI stage V and without this comorbid condition.

The Elevation of Pancreatic Enzymes in Serum and Their Distribution at Different Stages of Renal Insufficiency Among Diabetic Patients Attending Goba Referral Hospital.

IntroductionAcute pancreatitis is auto-cell destruction that is manifested by increased leakage of amylase and lipase into circulation. During pancreatitis, the activity of serum amylase and lipase is elevated three times above the upper limit of the normal range. This elevation was observed in both prediabetic and diabetic patients. Severe acute pancreatitis can result in acute kidney injury and other multi-organ dysfunction, which is one of the reasons for death.ObjectiveThis study aimed to evaluate the elevation of serum amylase and lipase and their distribution at different stages of renal insufficiency among diabetic patients.MethodsThis study included 286 diabetic patients (36 type 1 and 250 type 2), and data were collected from May 1 to June 30, 2019. The study design used was an institution-based cross-sectional study. A face-to-face interview was used to collect data, and serum creatinine, amylase, and lipase levels were measured using a chemistry analyzer. For data entry and statistical analysis, respectively, Epidata software version 3.02 and SPSS version 21 were used.ResultsThe mean serum amylase among diabetic patients suffering from G3b and G4 was 106.79 IU/L ± 118.18 IU/L and 104.85 ± 90.42 IU/L, respectively. Their mean serum lipase activity was 105.07 IU/L ± 127.54 IU/L and 106.98 IU/L ± 88.35 IU/L, respectively. Serum lipase activity was elevated above the normal range and three times above the upper limit of the normal range with a magnitude of 11.2% and 4.2%, respectively. Similarly, 9.1% and 0.7% of diabetic patients had increased serum amylase above the normal range and three-fold above the normal range, respectively.ConclusionAs glomerular filtration decreases, particularly in moderate-to-severe chronic kidney disease, serum amylase and lipase activity rise above the upper limit.

A Pilot Observational Study Assessing Long-Term Changes in Clinical Parameters, Functional Capacity and Fall Risk of Patients With Chronic Renal Disease Scheduled for Hemodialysis.

BackgroundPatients with end-stage renal disease are known to be particularly frail, and the cause is still widely seen as being directly related to specific factors in renal replacement therapy. However, a closer examination of the transitional phase from predialysis to long-term hemodialysis leads to controversial explanations, considering that the frailty process is already well-described in the early stages of renal insufficiency. This study aims to describe longitudinally and multifactorially changes in the period extending from the decision to start the replacement therapy through to the end of 2 years of hemodialysis. We hypothesized that frailty is pre-existent in the predialysis phase and does not worsen with the beginning of the replacement therapy. Between 2015 and 2018 we recruited 25 patients (72.3 ± 5.7 years old) in a predialysis program, with the expectation that replacement therapy would begin within the coming few months.MethodsThe patients underwent a baseline visit before starting hemodialysis, with 4 follow-up visits in the first 2 years of treatment. Health status, physical performance, cognitive functioning, hematology parameters, and adverse events were monitored during the study period.ResultsAt baseline, our sample had a high variability with patients ranging from extremely frail to very fit. In the 14 participants that did not drop out of the study, out of 32 clinical and functional measures, a statistically significant worsening was only observed in the Short Physical Performance Battery (SPPB) score (p < 0.01, F = 8.50) and the number of comorbidities (p = 0.01, F = 3.94). A careful analysis, however, reveals a quite stable situation in the first year of replacement therapy, for both frail and fit participants and a deterioration in the second year that in frail participants could lead to death.ConclusionOur results should stimulate a reassessment about the role of a predialysis program in reducing complications during the transitional phase, but also about frailty prevention programs once hemodialysis has begun, for both frail and fit patients, to maintain satisfactory health status.

Long-term safety of Gadofosveset in clinical practice

PurposeThe purpose of this study was to systematically search for long-term complications, including Nephrogenic Systemic Fibrosis (NSF), in patients who were previously administered the gadolinium-based contrast agent Gadofosveset at our institute. Materials and methodsAll patients who were administered Gadofosveset at our institute between 2006 and 2009 were identified in our Radiological Information System (RIS). Clinical data such as cause of death during follow-up, and dermatological or nephrological diseases were systematically searched for in electronic patient records (EPR). ResultsDuring 2006–2009, Gadofosveset was administered a total of 67 times to 62 patients. One patient was unavailable for follow-up. The remaining 61 patients were followed up for up to 14 (median 12) years based on RIS and EPR data.There were 13 deaths among the 61 patients, all assessed as unrelated to Gadofosveset administration. No dermatological or renal disease suggestive of NSF, or potentially related to Gadofosveset administration, was found.At the time of examination, six patients were diagnosed with various stages of renal insufficiency, three of whom were on hemodialysis. Another three patients were diagnosed with renal insufficiency during the follow-up period, but none of these diagnoses were suspected to be related to the administration of Gadofosveset. ConclusionsBased on the results of this retrospective safety analysis of up to 14 years following 1–2 exposures, we conclude that Gadofosveset in clinical practice is safe in the long-term.

Extended erythrocyte and reticulocyte parameters in the diagnosis of iron deficiency in hemodialysis patients

Objective: Iron deficiency (ID) is a frequent complication in end stage renal insufficiency. These patients have to be diagnosed and treated to reduce the prevalence of anemia. Functional iron deficiency (FID) is a situation that can disrupt biochemical iron tests and mask an eventual association with ID. In this study, we tried to prove the ability of extended parameters of red cells and reticulocytes to diagnose ID without being influenced by FID. Design and methods: 164 chronic hemodialysis patients (CHP) in end stage renal disease were enrolled. Research parameters of red cells and reticulocytes determined on ADVIA 2120i were studied in the diagnosis of ID associated or not with chronic inflammation. Results: Parameters such as corpuscular hemoglobin of mature red cells (CHm), corpuscular hemoglobin of reticulocytes (CHr), cellular concentration of hemoglobin in mature red cells (CHCMm), cellular concentration of hemoglobin in reticulocytes (CHCMr) and percentage of microcytic and hypochromic red cells (HYMI) showed a high sensitivity to diagnose ID. However, the distinction of combined iron deficiency (CID) from other entities was not possible with all parameters. In chronic inflammatory states, the decrease of CHm, CHCMm and CHCMr with the rise of percentage hypochromic mature red cells (HYPOm) and reticulocytes (HYPOr) is in favor of CID. So, determination of inflammatory state is needed to complete research parameters of blood count in CHP. Conclusion: Extended erythrocyte and reticulocyte parameters can be useful to check iron status in CHP.

Safety and Performance Outcomes of a Self-Expanding Transcatheter Aortic Heart Valve: The BIOVALVE Trials

ObjectivesThe aim of this study was to assess the safety and performance of a newly introduced transfemoral self-expanding supra-annular transcatheter heart valve. BackgroundTranscatheter aortic valve replacement has become an established procedure, and newer transcatheter heart valves aim to supplement the current armamentarium. MethodsBIOVALVE-I is a prospective, single-center feasibility study enrolling 13 high-risk patients with severe aortic stenosis, and BIOVALVE-II is a multicenter pilot study enrolling a further 55 patients under the same protocol. ResultsPatients’ mean age was 82.4 ± 5.3 years, 57.4% had concomitant coronary artery disease, 50.0% had renal insufficiency stage ≥3, 32.4% had diabetes mellitus, 29.4% had current anemia, 19.1% had chronic obstructive pulmonary disease, 19.1% were frail, and 17.6% had prior cerebrovascular events. The primary endpoint, early safety according to the Valve Academic Research Consortium-2 guidelines, was observed in 13 patients (19.1%). One patient (1.5%) died through 30 days of a noncardiac cause, and 4 patients (7.8%) died through 180 days. Disabling stroke occurred at 30 days in 1 patient (1.5%) and at 180 days in 2 patients (3.2%). New permanent pacemakers up to 30 days were implanted in 9 patients (13.4%). Two patients (3.8%) had moderate or severe paravalvular leakage at 30 days and 4 (9.1%) at 6 months, mean effective orifice area was 2.0 ± 0.4 cm2 and 1.9 ± 0.5 cm2, and mean gradient was 6.4 mm Hg at 30 days and 6 months. ConclusionsClinical outcomes with the Biovalve self-expanding transcatheter heart valve were similar to those seen in other first-in-human studies with first-generation devices for severe aortic stenosis.

Safety of gadoterate meglumine in over 1600 children included in the prospective observational SECURE study.

BackgroundTo date, few data on the safety profile of gadoterate meglumine in pediatric patients are available.PurposeTo assess the safety profile of gadoterate meglumine in routine practice, to detect any case of nephrogenic systemic fibrosis (NSF) suspicion and to collect efficacy data.Material and MethodsThe pediatric population of the observational SECURE study comprised 1631 patients scheduled for contrast-enhanced magnetic resonance imaging (MRI) with gadoterate meglumine (dose: 0.1 mmol/kg). Risk factors, MRI types and immediate adverse events (AEs) were systematically recorded. Patients with moderate to severe renal impairment were followed up for at least 3 months for detection of any NSF suspicion. Efficacy was assessed by the on-site radiologist in terms of image quality and ability to come to diagnosis.ResultsThe population included 106 children (6.5%) aged <2 years, 815 (50.0%) aged 2 to <12 years and 710 (43.5%) aged 12 to <18 years, with a mean (± SD) age of 10.2 (± 4.9) years. Central nervous system exploration was the most frequent MRI type (80.4%) and main risk factors were any stage of renal insufficiency (9.8%) and allergies (5.2%). Only one AE (vomiting) that was deemed doubtfully related to gadoterate meglumine was observed. No suspicions of NSF were reported. Good to very good image quality was obtained for 98.4% of pediatric patients and diagnosis was established in 99.6% of cases.ConclusionThis study confirmed the good safety profile of gadoterate meglumine in routine practice in a large pediatric population. The study is registered on https://clinicaltrials.gov/ with the identifier NCT01523873.

Renal insufficiency among urban populations in Bangladesh: A decade of laboratory-based observations.

ObjectiveThe objective of this study was to describe the age and sex-specific prevalence of renal insufficiency, and observe its trends over a decade at an urban Bangladesh setup.MethodThis was a cross-sectional study, in which we observed the Estimated Glomerular Filtration Rate (eGFR) of 218,888 adults, aged ≥19 years, who had submitted their blood specimen to the Clinical Biochemistry Laboratory of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) during the years 2006–2015. We applied CKD-EPI definition in estimating eGFR using their age-and sex-specific serum creatinine concentrations. Based on the eGFR, we classified the population into five stages of renal insufficiency (stage-1 to stage-5), at age intervals of five-years. Data were analysed using the Linear Regression and Multinomial Logistic Regression models.ResultsFemales constituted 43% (n = 94,931) of the study population; and 34% (n = 42,576) of the males and 31% (n = 29,830) of the females had their serum creatinine concentrations above the upper limit of the laboratory reference cut-off. The overall prevalence of stage-2 to stage-5 renal insufficiency were 24% (n = 52,126), 17% (n = 38,539), 8% (n = 16,504) and 6% (n = 12,665) respectively; the prevalence were 23% (n = 1,890), 19% (n = 1,579), 9% (n = 769) and 9% (n = 770) respectively in 2006, and 24% (n = 10,062), 17% (n = 6,903), 6% (n = 2,537) and 5% (n = 1,924) respectively in 2015. The prevalence was higher among the females. At least 2% of the adults, younger than <44 years, had stage-4 and stage-5 in 2015. The age-adjusted eGFR was significantly lower among the post-menopausal females (aged ≥46 y) compared to the same age group males (64.08±10.83 vs. 66.83±10.41 mL/min/1.73 m2; p<0.001). Compared to 2006, the number of individuals with renal insufficiency (stage 2 and above) had increased at least two times, irrespective of age, in 2015. A single year of increase in the age was significantly associated with 1.32 unit reductions in the eGFR; and the reductions were higher for females who also had higher odds of renal insufficiency stages-2 and beyond.ConclusionThis study observed high prevalence of stage-2 to stage-5 renal insufficiency in Bangladeshi populations, irrespective of age, and especially among the females.

Evaluation of histological dynamics, kidney function and diabetes in liver transplant patients after antiviral treatment with direct-acting antivirals: Therapy of HCV-recurrence.

Direct-acting antivirals allow efficient and safe treatment of hepatitis C (HCV) before and after liver transplantation (LT). However, the impact of sofosbuvir on the graft, diabetes, and on kidney function is not answered yet. Primary endpoint of this analysis was the evaluation of kidney function after antiviral treatment (AVT). Secondary endpoints were the assessment of extrahepatic manifestation of HCV-infection by diabetes mellitus and the histopathological changes in terms of inflammation, content of fat, and fibrosis stage. From 2014 to 4/2015, 100 patients with HCV-recurrence after LT were successfully treated with AVT. Ninety-eight received a sofosbuvir-based regimen. Indication was based on genotype, transplant fibrosis stage, and urgency. Biopsies were evaluated before and after treatment. Renal function and diabetes were assessed before, during, and after AVT. All patients achieved sustained virological response. A significant improvement of inflammation (P=0.001) and fibrosis stage (P=0.031) were observed. Significantly less insulin was required in 32 patients with diabetes (P<0.001) to keep Hb1Ac unchanged after AVT. Kidney function was stable during, 12weeks after and 48weeks after antiviral therapy. Stages of renal insufficiency were comparable before and after AVT. Successful sofosbuvir-based AVT leads to a variety of positive development in transplant patients including a significant improvement of inflammation, fat content and fibrosis, a significant decrease in daily insulin dose and no significant impairment of kidney function.

Clinical value of contrast-enhanced ultrasonography in evaluating renal cortical perfusion in elderly diabetic patients

Objective To investigate the clinical value of contrast-enhanced ultrasonography(CEUS)in evaluating renal cortical perfusion in elderly diabetic patients. Methods A retrospective cross-sectional study was conducted.A total of 70 diabetic patients with chronic renal insufficiency stage 1 to 5 were enrolled.The glomerular filtration rate(GFR)was estimated according to the creatinine level.Based on GFR, patients were divided into a mild-to-moderate chronic kidney disease(CKD)group(n=42, CKD stage 1 to 3)and a severe CKD group(n=28, CKD stage 4 to 5). All patients underwent CEUS for the assessment of renal perfusion and renal dynamic imaging for the assessment of GFR.QLAB analysis software was used to obtain the time-intensity curve(TIC)and related parameters including area under the curve(AUC), the ascending slope(A), the derived peak intensity(DPI)and the time to peak(TTP). The differences in renal perfusion parameters were compared between the two groups.Pearson correlation test was used to assess the correlation between the quantitative parameters of renal cortical perfusion and GFR. Results There was no significant difference in age, gender, history of hypertension, basal blood glucose level, systolic or diastolic blood pressure between the two groups(all P>0.05). CEUS findings revealed high renal cortical blood perfusion in the mild-to-moderate group.There were significant differences in quantitative perfusion parameters including AUC, DPI, A and TTP between the two groups.Pearson correlation test indicated that TTP and A were significantly correlated with GFR in both groups(r=-0.456 and -0.693, 0.432 and -0.529, all P 0.05). Conclusions Diabetic patients with mild-to-moderate CKD have high renal cortical blood perfusion.CEUS findings can indirectly reflect renal function.The perfusion parameters A and TTP have good correlations with GFR.CEUS can be used as a safe and effective method to evaluate renal function, especially in patients with severe renal insufficiency, but more studies are needed to verify the results. Key words: Ultrasonography, inter ventional; Kidney cortex; Renal circulation

ACE Inhibitors and ARB in Chronic Kidney Disease: What Has to Be Considered

Proteinuric kidney disease, especially in the early and middle stages of renal insufficiency, may be favorably affected by ACE-I/ARB. The progression of renal insufficiency is thereby slowed down and dialysis obligation occurs later or can even be avoided. This effect is independent of the underlying glomerular kidney disease. In the advanced stage of renal insufficiency, the benefit of ACE-I/ARB cannot yet be conclusively assessed. The interruption of ACE-I/ARB therapy may possibly contribute to a certain recovery of renal function and delay the onset of dialysis a little. However, studies are still pending and the benefits of ACE-I/ARB for the heart and blood vessels, especially at this stage of renal insufficiency, should not be overlooked.Patients with proteinuria benefit from ACE-I/ARB not only in terms of renal stabilization. A cardio-protective effect by reduction of proteinuria and a delay of progression is proven. On the other hand, the protective effect of ACE-I/ARB that can be detected directly on the heart and blood vessels should not be disregarded. Thus, even if chronic renal insufficiency no longer benefits directly from ACE-I/ARB therapy, cardiac protection may still be of great importance to the chronic kidney patient.

Hepatic Production of Fibroblast Growth Factor 23 in Autosomal Dominant Polycystic Kidney Disease.

The bone-derived hormone fibroblast growth factor (FGF) 23 controls phosphate homeostasis and urinary phosphate excretion. FGF23 plasma levels increase in the early stage of renal insufficiency to prevent hyperphosphatemia. Recent evidence suggests that this increase has effects on cardiac and immune cells that compromise patients' health. Patients with autosomal dominant polycystic kidney disease (ADPKD) have been reported to have higher FGF23 concentrations than other patients with similar renal function. The significance of this finding has remained unknown. Analyzing the FGF23 plasma levels in 434 patients with ADPKD and 355 control subjects with a measured glomerular filtration rate (mGFR) between 60 and 120 mL/min per 1.73 m2, we confirmed that patients with ADPKD had higher FGF23 plasma concentrations than controls. Remarkably, this difference did not translate into renal phosphate leakage. Using different assays for FGF23, we found that this discrepancy was explained by a predominant increase in the cleaved C-terminal fragment of FGF23, which lacks phosphaturic activity. We found that FGF23 plasma concentration independently correlated with the severity of cystic liver disease in ADPKD. We observed that, in contrast to control liver tissues, the cystic liver from patients with ADPKD markedly expressed FGF23 messenger RNA and protein. In line with this finding, the surgical reduction of polycystic liver mass was associated with a decrease in FGF23 plasma levels independently of any modification in mGFR, phosphate, or iron status. Our findings demonstrate that severely polycystic livers produce FGF23 and increase levels of circulating FGF23 in patients with ADPKD.

Dijabetesna nefropatija

Diabetes mellitus is one of the most prevalent chronical non-communicable diseases and is a huge public health problem. Diabetic nephropathy is a microvascular complication of both insulin dependant and insulin independent diabetes mellitus and is characterized by persistent proteinuria, accompanied by hypertension and retinopathy, but without urinary tract infection, other kidney disease or heart failure. According to the newest Annual report on dialysis treatment and transplant surgery in Serbia for the year 2015, hypertension and diabetic nephropathy were the most common causes of terminal renal failure (51.5%); the percentage of new diabetic patients was 22.6%. About 2/3 of all patients diagnosed with manifested diabetic nephropathy die of cardiovascular disease even before their kidney disease progresses to the final stage of renal insufficiency. Risk factors for the development of diabetic nephropathy are: gender, age, genetic factors, hyperglicemia, hypertension, dyslipidemia, hypoprotein nutrition and smoking. Diabetic nephropathy shall not develop if there is no hyperglicemia, regardless of genetic predisposition and all other risk factors. The phases of development of diabetic nephropathy are: glomerular hyperfiltration, latent phase, mycroalbuminuria, macroalbuminuria, chronic kidney disease development. The most important measures of prevention for diabetic nephropathy are: maintenance of glicemia and HbA1C < 7.0% as close as possible to the recommended target level ranges, blood pressure reduction and maintenance at the target range of 130/80, blocking the renin angiotensin aldosterone system, stopping smoking, avoiding nephrotoxic agents - NSAID, aminoglycoside antibiotics, radiocontrast media; treatment of hyperlipidemia, physical activity, weight reduction in overweight patients. The Steno 2 study emphasised the importance of a multifactorial approach to the prevention of proteinuria. It is expected that new drugs, that will affect certain growth factors, AGEs or reactive oxygen radicals, vasoactive factors which include endothelial receptor blockers, shall be efficient in the prevention of diabetic nephropathy.

Eight Leads at One Stroke: Lead Extraction with the Excimer Laser

Introduction: A 67-year-old woman presented with a device-associated endocarditis (Staph. aureus) post implantation of a DDD-ICD and an Optimizer system. She was totally pacemaker dependent, an suffered from chronic heart failure (NYHA III-IV) due to ischemic cardiomyopathy (LVEF= 15%). Further diagnosis were an Oxygen therapy at home, coronary three-vessel disease, status post CABG 1996 and post MitraClip intervention, and a chronic renal insufficiency stage IV.