Zvonimir Puretić

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.

Treatment of Steroid Unresponsive Relapse With Plasma Exchange in Aggressive Multiple Sclerosis

The options for treating steroid unresponsive relapses in relapsing remitting multiple sclerosis (RRMS) are modest. We present a small series of patients with an aggressive course of RRMS whose steroid unresponsive relapses were treated with plasma exchange. In the period from January 2007 until February 2009 we identified four patients with steroid unresponsive relapses. All recorded relapses were treated with methylprednisolone, either with 500 mg for 5 days or 1000 mg for 3 days. If there was no improvement, patients were given five cycles of plasma exchange. If there was no recovery after the initial five cycles, five more were administered. Each patients clinical status was monitored using the extended disability status scale. The median time from symptom onset until starting plasma exchange was 30 days (23–45 days). For four relapses, five cycles of plasma exchange were given with marked recovery in one, moderate in two, and mild in one case. In one patient, after five cycles there was no recovery, so five more cycles were administered, after which a moderate recovery ensued. This study further supports the efficacy of plasma exchange in the treatment of steroid unresponsive relapses in aggressive RRMS.

The life-threatening hemodialysis catheter heparin lock caused bleeding in a child after peritoneal catheter removal

Hemodialysis catheter patency is regularly maintained by high-concentration heparin filling, according to manufacturers recommendation. Surprisingly, there are only few reports on serious bleeding complications in children on dialysis. A case of serious, life-threatening hemorrhage in a child after tunneled peritoneal catheter removal because of hemodialysis catheter heparin lock flushing is described. Discussion of the literature data is presented. Further investigations are needed to develop the guidelines for pediatric dialysis catheter care, including the optimal concentration for heparin lock as the possible heparin alternatives, but until that moment, previously suggested guidelines to prevent hemorrhagic complications in dialyzed children should be emphasized.

Bone density in renal transplant recipients and in patients with chronic kidney disease: a follow-up study in children and adolescents.

AIMS Disturbances in mineral and bone metabolism are common in patients with chronic kidney disease. The purpose of this follow-up study was to compare the change of bone mineral density in patients with chronic kidney disease to those who have received the renal transplant. METHODS The study included 47 children and adolescents: 16 with mild to moderate kidney disease, 14 on dialysis and 17 patients with renal transplant. At the baseline and follow-up visits, regular biochemistry, anthropometry and bone mineral density were measured. To minimize the effect of skeletal size, bone mineral apparent density (BMAD; g/cm3) was calculated. RESULTS The mean height was below one standard deviation from reference values in patients on dialysis and in those with renal transplant. After correction for age, baseline and follow-up BMAD did not differ significantly between patients after transplantation and those with chronic kidney disease. The increase of BMAD between two measurements (mean period 16.0 +/- 4.4 months) was not significantly higher in patients with kidney transplant compared to those with chronic kidney disease. The significant predictors of BMAD were PTH in patients with chronic kidney disease and duration of steroid therapy in patients with renal transplant. CONCLUSIONS The results showed that bone density in children and adolescents, even several years after kidney transplantation, did not significantly change over time comparing to patients with chronic kidney disease. Hyperparathyroidism and steroid therapy were the most important risk factors for the slow increase of bone density.

Croatian Recommendations for Dialysis of HIV-Positive Patients

Abstract Human immunodeficiency virus (HIV) infection may be associated with renal impairment since about 0.4% of all HIV-positive patients develop end-stage renal disease. The share of patients with HIV infection in hemodialysis centers throughout the world ranges from 0.3% to as high as 38%. In Croatia, renal replacement therapy was needed by 1% of all the HIV-positive patients from 1985 until the end of 2014. Healthcare professionals (HP) should be aware of the risks of occupational exposure to blood-borne infections in their daily work. Performing dialysis in HIV-positive patients increases the risk of exposure to HIV during the extracorporeal circulation of the infected blood. However, post-exposure prophylaxis (PEP) with effective antiretroviral drugs significantly reduces the risk of infection after occupational exposure. On behalf of the Croatian Society of Nephrology, Dialysis and Transplantation, the authors of this paper have proposed recommendations for the management of HIVpositive patients on dialysis, which aim to prevent the transmission of HIV among patients and HPs. The important recommendations include the following: 1. when the need arises, it is necessary to provide HIV-positive patients with dialysis in the vicinity of their place of residence. 2. HIV-positive patients should be dialyzed with a separate hemodialysis machine in an isolated area. Alternatively, they can be dialyzed in an area for the hemodialysis of HCV-positive and/or HBVpositive patients. 3. Specialized and trained personnel should be provided during the hemodialysis procedure, together with strict compliance with the standard precautions for the prevention of blood-borne infections. 4. There should be a good and prompt cooperation with the National Referral Center for HIV infection.

The role of noninherited HLA haplotypes in inducing donor-specific hyporesponsiveness

The ultimate goal of clinical transplantation is the induction of donor-specific unresponsiveness to MHC antigens without the impairment of host defense mechanisms. One possible route to a tolerance assay my be through a better understanding of mechanisms involved. Recent study have suggested that exposure of the fetus and newborn to noninherited maternal HLA antigens has a life-long effect on allograft recognition that could influence tolerance of organ grafts.