Petar Kes

Complications of therapeutic plasma exchange: experience with 4857 treatments.

Abstract:  Plasma exchange (PE) is a technique of extracorporeal blood purification which removes large molecular weight substances from plasma. The Department of Dialysis, Zagreb University Hospital Centers database, which includes data on 509 patients, or 4857 PE treatments, was retrospectively analyzed to test the safety of PE. A total of 231 adverse reactions were recorded (4.75% of treatments). The most common complications were paresthesias (2.7%), hematoma at the puncture site (2.4%), clotting (1.7%), mild to moderate allergic reactions (urticaria; 1.6%) and bleeding (0.06%). True anaphylactoid reactions were recorded in five procedures. The incidence of severe, potentially life‐threatening adverse reactions was 0.12%. The prophylactic use of calcium and potassium was responsible for a low incidence of electrolyte disturbances. There was no lethal outcome associated with PE. When carried out by experienced staff, PE is a relatively safe procedure. The use of fresh frozen plasma is associated with a higher rate of adverse reactions.

Acute renal failure complicating severe acute pancreatitis.

The records of 563 patients admitted to the hospital with diagnosis of acute pancreatitis have been studied retrospectively. The aim of the study was to investigate the prevalence of acute renal failure (ARF) in these patients, and to evaluate the most important risk factors for ARF development and mortality. The prevalence of ARF in studied population was 14%, but only 3.8% of ARF patients with acute pancreatitis had isolated renal failure. Other patients had additional failure of other organ systems, 68.4% of whom had multiorgan failure (MOF) before the onset of ARF. In only 8.9% of ARF patients was the renal system the first organ system to fail. Patients with ARF were significantly older, had more preexisting chronic diseases (including chronic renal failure), usually had MOF, and local pancreatic complications relative these in the group with normal renal function. The development of ARF was directly influenced by severity of acute pancreatitis. The mortality rate in ARF patients was 74.7%, compared to an 7.4% mortality of patients with acute pancreatitis and normal renal function. Preexisting chronic disease, the presence of MOF and their number, local pancreatic complications, and older age of the patients increased mortality in ARF patients. The prognosis of patients with oliguric ARF requiring renal replacement therapy was extremely poor, indicating the importance of prevention of ARF in the patients with acute pancreatitis.

Consensus statement on screening, diagnosis, classification and treatment of endemic (Balkan) nephropathy

Currently used diagnostic criteria in different endemic (Balkan) nephropathy (EN) centers involve different combinations of parameters, various cut-off values and many of them are not in agreement with proposed international guidelines. Leaders of EN centers began to address these problems at scientific meetings, and this paper is the outgrowth of those discussions. The main aim is to provide recommendations for clinical work on current knowledge and expertise. This document is developed for use by general physicians, nephrologists, urologist, public health experts and epidemiologist, and it is hoped that it will be adopted by responsible institutions in countries harboring EN. National medical providers should cover costs of screening and diagnostic procedures and treatment of EN patients with or without upper urothelial cancers.

Efficacy of Interferon-α in the Treatment of Chronic Hepatitis C in Dialysis Patients: Two Therapeutic Protocols Compared

Background: Data on the efficacy of particular therapeutic protocols of interferon-α (IFN-α) treatment for chronic hepatitis C in patients on hemodialysis (HD) vary. Aim: To compare the efficacy of two different therapeutic protocols for HD patients. Patients and Methods: 15 hepatitis C virus (HCV)-positive patients on chronic HD at two dialysis centers: 8 patients treated with IFN-α 3 × 3 MU/week s.c. for 6 months (group A), and 7 patients treated with IFN-α 3 × 5 MU/week for 3 months, then 1 × 5 MU/week for another 3 months (group B). End of treatment response (ETR) and sustained virologic response (SVR) were evaluated by HCV-RNA determination. There was no statistically significant difference between the two patient groups according to age, sex, duration of HD and HCV infection. Results: ETR was 87.5% (7/8) in group A and 28.5% (2/7) in group B, being statistically significant (p < 0.05). Although better SVR [50% (4/8) vs. 28.5% (2/7)] and lower drop-out rate [0% (0/8) vs. 28.5% (2/7)] were achieved in group A compared to group B, these differences did not reach statistical significance (p > 0.05). Conclusion: Therapy with IFN-α 3 × 3 MU/week s.c. for 6 months seems to be more appropriate for treatment of hepatitis C in HD patients, mostly due to better tolerability, i.e. lower drop-out rate. These differences could be attributed to different pharmacokinetic properties of the particular therapy protocol.

Cytokines and growth factors in mostly atherosclerotic patients on hemodialysis determined by biochip array technology.

Abstract Background: The lifespan of patients with chronic renal failure (CRF) is reduced, and coronary artery disease is the leading cause of morbidity and mortality in these patients. The progression of atherosclerosis is accelerated and angiogenesis is impaired in CRF. Risk factors that could contribute to further understanding of vascular pathology include markers of inflammation and growth factors. The purpose of this study was to determine the levels of cytokines (IL-2, IL4, IL-6, IL-8, IL-10, IL-1α, IL-1β), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), interferon-γ (IFNγ), tumor necrosis factor-α (TNFα) and monocyte chemotactic protein-1 (MCP-1) in patients on chronic hemodialysis (HD; n=75), and to compare values with those of control subjects (n=113). Methods: Evidence® biochip array analyzer was used for quantification of plasma concentrations in samples. Results: Significant differences were found between the control subjects and HD patients. IL-2 (p<0.001), IL-4 (p<0.001) and EGF (p<0.001) levels were higher in controls than in HD patients, while IL-6 (p<0.001), IL-8 (p=0.081), IL-10 (p=0.008), TNFα (p<0.001), IL-1β (p<0.001) and MCP-1 (p<0.001) levels were higher in HD patients. We also found IL-2 (p=0.015) and IL-1α (p=0.035) levels to be significantly higher in males than females, while IL-4 (p=0.025) and IL-1β (p=0.049) levels were significantly higher in females. Among HD patients, IL-2 levels were higher in patients under the age of 50 years (p<0.048). It was also higher in female than in male patients (p<0.035) and in patients on HD for more than 10 years (p<0.009). IL-6 levels were higher in patients over the age of 50 years (p<0.047). Patients with previous glomerulonephritis had the highest level of IL-6 compared to patients with previous pyelonephritis and diabetes mellitus (p<0.063). IL-6 levels were higher in patients with concomitant hepatitis C virus (HCV) infection (p<0.036) and in patients with developed atherosclerosis (p<0.003). IL-8 levels were higher in patients over the age of 50 years (p<0.003) and in the group with previous glomerulonephritis (p<0.031). IL-10 levels were higher in the group with developed atherosclerosis (p<0.045). EGF was the highest in the group of patients with previous diabetes mellitus compared to pyelonephritis and glomerulonephritis groups (p<0.073). TNFα levels were higher in the patient population on HD for more than 10 years (p<0.032) and in the concomitant HCV group (p<0.073). IL-1β levels were higher in the HCV group (p<0.088). Conclusions: Plasma concentrations of some cytokines and growth factors could serve as useful diagnostic and prognostic parameters for patients with CRF on HD. Clin Chem Lab Med 2007;45:1347–52.

Influence of Long-Term Dialysis Treatment on Operative Complications After Renal Transplantation

BACKGROUND We sought to assess the influence of long-term dialysis treatment on operative complications after kidney transplantation. METHODS We identified and prospectively followed 2 groups of patients who underwent renal transplantation: group I were on dialysis <5 years and group II, >15 years. We compared the groups regarding mismatches, residual diuresis, operative and medical complications, as well as duration of hospitalization after transplantation. RESULTS Groups I and II included 36 and 24 patients with 33.3% and 45.8% female of mean ages at transplantation of 49 (range, 9-73) and 45 (range, 27-56) years, respectively. Group I contained 9 seniors and 4 subjects <18 years. There were no significant differences in mean donor age, number of marginal donors, mismatches, postoperative bleeding, wound infections, urine leakage, or duration of hospitalization. However, the number of postoperative lymphoceles was significantly higher in group II: 5 (20.8%) versus 1 (2.7%) (P = .01). Graftectomy was performed in 2 group II patients including 1 primary graft nonfunction, and another for recurrent focal segmental glomerulosclerosis. CONCLUSION Our results suggested that the duration of dialysis treatment was not a significant factor for postoperative complications and prolonged hospital stay, except for an increased risk of lymphocele formation.

Pegylated interferon for treatment of chronic hepatitis C in hemodialysis patients in Croatia

Background and Aims: Hepatitis C virus (HCV) infection is a frequent complication among long-term dialysis patients. The aim of the present study was to evaluate the efficacy and side effects of pegylated interferon-α2a (PEG-IFN-α2a) treatment in hemodialysis patients. Methods: We retrospectively reviewed charts of 16 HCV-RNA-positive hemodialysis patients. Results: There were 11 male and 5 female patients treated with dialysis for 6–28 years. Twelve patients had HCV genotype 1b, 2 patients had 3a, and 1 patient had genotype 2a. Although only 10 out of 16 patients completed 48 weeks of treatment, early virological response and end-of-treatment virological response were achieved in 9 and 13 patients, respectively. Sustained virological response was recorded in 9 patients. The most common side effect was anemia. A flu-like syndrome was documented in 6, myalgia in 4, and arthralgia in 5 patients. Rectorrhagia, endocarditis and severe cough were recorded in 1 patient each. Nine patients received a renal transplant, and all 6 responders remained HCV-RNA-negative. Conclusions: PEG-IFN-α2a has limited efficacy in dialysis patients. A significant proportion of patients discontinued treatment because of side effects. Additional studies with long-term follow-up are needed to determine the optimal treatment of HCV infection in the dialysis population.

First documented case of successful kidney transplantation from a donor with acute renal failure treated with dialysis

There is a widening gap between the needs and possibilities of kidney transplantation. In order to solve the problem of organ shortage, the selection criteria for kidney donors have been less stringent over the last years. Favorable outcome of renal transplantation from deceased donors with acute renal failure requiring dialysis may have an important role in expanding the pool of donors. We present the case of two renal transplantations from a polytraumatized 20-years old donor with acute renal failure requiring dialysis. One recipient established good diuresis from the first post-transplant day and did not require hemodialysis. The second recipient had delayed graft function and was treated with 8 hemodialysis sessions. The patient was discharged with good diuresis and normal serum creatinine. After two years of follow-up, both recipients have normal graft function. According to our experience, kidneys from deceased young donors with acute renal failure requiring dialysis may be transplanted, in order to decrease the number of patients on transplantation waiting lists.

Anti-citrullinated protein antibody and rheumatoid factor in patients with end-stage renal disease

Abstract Background: Patients with end-stage renal disease (ESRD) and on hemodialysis (HD) are at increased risk for developing rheumatoid arthritis (RA), as a result of defective immunity. Our aim was to examine if ESRD and the length of HD treatment impact the clinical utility of antibodies to cyclic citrullinated peptides (anti-CCP) and rheumatoid factor (RF) as diagnostic tools for RA. Methods: We included 94 subjects in our study: 37 healthy volunteers and 57 patients with ESRD who had been undergoing HD for 1–12 years, and without confirmed RA. In order to test our hypothesis, we measured and correlated anti-CCP and RF as laboratory markers of RA. Results: Our study showed that there is no significant difference between values for anti-CCP (p=0.11) and RF (p=0.98) in control subjects as well as in patients undergoing HD, regardless of the length of time that patients had been undergoing HD treatment. Conclusions: Our study indicates that HD does not impair the specificity of anti-CCP and RF for RA in patients where the disease has not yet developed. Future prospective studies may show whether there is any use in determinating RF, and especially anti-CCP, as early predictors of RA in patients with ESRD who are at greater risk of developing this condition. Clin Chem Lab Med 2009;47:959–62.

Influence of Renal Functional Mass on the Catabolism of Endogenous Gastrin in Humans

The influences of renal function and mass on the catabolism of serum gastrin were studied in 27 patients with hypertension caused by unilateral parenchymal renal disease (77.8%), renal artery stenosis (11.1%) and essential hypertension (11.1%). Blood for gastrin analysis was taken by catheterization from the aorta, inferior vena cava, renal veins and cubital vein. Separate renal functions were measured using radioisotope methods and the renal mass was also calculated. Significant differences (p < 0.001) in serum gastrin concentration between the aorta (29.5 +/- 6.7 pmol/l), inferior vena cava (23.4 +/- 5.8 pmol/l) and cubital vein (19.4 +/- 4.5 pmol/l) were found. Extrarenal gastrin extraction amounted to 12.5% and was considerably lower than renal gastrin extraction (20.5%). There was a significant positive correlation between renal gastrin extraction and renal blood flow or renal functional mass. Kidneys have an important, but not exclusive, role in the catabolism of endogenous gastrin in humans. In the catabolism of some, or at least some molecular forms of, gastrin, the capillary systems of extrarenal tissues have an important role.