Background: Noninvasive ventilation (NIV) is a cornerstone treatment for hypercapnic respiratory failure in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to evaluate the impact of selected comorbidities on the effectiveness of NIV in these patients, and to compare clinical characteristics and outcomes between continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) modalities.Materials and methods: This prospective, randomized, single-center study included 80 patients with hypercapnic respiratory failure due to COPD, randomized 1:1 to CPAP or BiPAP. Demographic and clinical data, comorbidities, vital signs, and arterial blood gas parameters were recorded at admission and during NIV. The primary outcome was pCO₂ reduction at the end of treatment compared with baseline.Results: Arterial hypertension significantly enhanced pCO₂ reduction with CPAP, but not with BiPAP. Systolic and mean arterial pressure independently predicted the magnitude of pCO₂ reduction, regardless of NIV modality. Patients treated with BiPAP more frequently had decompensated cor pulmonale and severe pulmonary hypertension, while pneumonia was more common in the CPAP group. NIV modality itself was not an independent predictor of pCO₂ reduction.Conclusion: Systemic hemodynamic status and arterial hypertension influence NIV effectiveness in hypercapnic COPD. The cardiovascular status should be considered alongside respiratory parameters when selecting the NIV strategy.

AIM Lung ultrasound (LUS) can be used for an assessment of volume overload in patients with end-stage kidney disease (ESKD) and those undergoing dialysis. The aim of this study was to analyse whether the initial use of LUS in evaluating volume status could benefit patients by optimizing haemodialysis treatment and improving their clinical status. METHODS The study included 50 haemodialysis patients in stage V of ESKD with the diagnosis of ischaemic heart failure with reduced (HFrEF) or midrange ejection fraction (HFmrEF). The assessment of volume status was verified solely by LUS (along with the analysis of B lines as measures of volume status). The specified laboratory parameters were performed initially, after three, and after six months. RESULTS The number of B-lines on LUS were decreased during the six-month follow-up compared to baseline, indicating a reduction in volume overload due to the LUS-guided protocol. Statistically significant differences were observed in the average creatinine (p=0.001) and parathormone (PTH) (p=0.003) levels over the six-month monitoring period. Significant differences were also noted in triglyceride (p=0.000) and potassium (p=0.02) levels. No significant differences were found in the values of other monitored parameters. CONCLUSION In haemodialysis patients diagnosed with heart failure, LUS can aid the achievement of a more efficient volume reduction by decreasing B-lines, which are indicative of congestion. Our study also demonstrated beneficial effects of LUS on potassium and parathormone levels.

Introduction: Calciphylaxis (calcific uremic arteriolopathy), is a condition primarily observed in patients with end-stage renal disease (ESRD). Aim: To increase clinical awareness of calciphylaxis and to consider it a differential diagnosis in the presence of atypical skin nodules or ulcers occurring in patients with chronic kidney disease (CKD), especially in patients on hemodialysis and non-hemodialysis patients with the background of diabetes mellitus and secondary hyperparathyroidism. Case Report: We present the case of a 77-year-old woman with CKD and diabetes mellitus as well as severely painful, firm, indurated plaques on the lower extremities. The plaques progressed to involve larger areas with associated local ulceration and necrosis. Laboratory testing revealed hyperparathyroidism and incisional skin biopsy confirmed calciphylaxis. Conclusion: Each single CKD patient with diabetes mellitus and signs of secondary hyperparathyroidism with extremely painful ischemic cutaneous lesions or painful subcutaneous nodules without skin changes, although at times, pain may precede the development of the lesions, is a candidate for skin biopsy. Calciphylaxis is a rare but serious kidney complication. Keywords: calciphylaxis, chronic kidney disease, prognosis, treatment.

The aim of the study was to elucidate predictors associated with the initial choice of vascular access (VA) type. The secondary aim was to determine the initial VA's median utilization time and the factors governing it. This prospective cohort study included 387 hemodialysis (HD) patients admitted to the Clinic for Hemodialysis, Clinical Center University of Sarajevo, in consecutive order between January 2006 and December 2016. We selected the primary predictors for the initial VA type using a random forest algorithm. We further quantified factors governing the initial choice of VA: temporary catheters (TC), compared to arteriovenous fistula (AVF), using multivariate logistic regression. Finally, we used log-rank and Cox regression models to estimate the median time on each initial VA and find predictors governing it. Of the 387 patients, 265 (68,5%) used TC at dialysis initiation and 122 (31,5 %) AVF. Predictors of the TC's vs. AVF's initial use were older age (OR=1.02, CI=1.0, 1.03, p=0.03) and primary cause of CKD, particularly diabetes, compared to all other causes of kidney disease (CKD). Median time on initial AVF was 57.0 months (95%CI =36.9, 64.1), and on initial TC 4.99 months (95%CI =2.69, 8.48). Younger age (HR=.98,95%CI=.97, .99, p=.01), male sex (HR=1.51, 95%CI=1.05, 2.19, p=.03), and hypertension (HR=1.63, 95%CI=1.13,2.36, p=.01) predicted median time on initial TC, while older age (HR for patients>70years = 1.86, 95%CI=1.09, 3.17, p=.02), and diabetes (HR=1.97, 95%CI=1.19, 3.24, p=.01), predicted median time on initial AVF. These results point to late VA referrals and delays in transitioning to permanent VA.

Goal

Introduction: Transthyretin amyloid cardiomyopathy (ATTR-CM) can be diagnosed in the absen-ce of histology with typical echocardiographic fi ndings and skeletal scintigraphy showing grade 2 or 3 myocardial tracer uptake, when clonal plasma cell dyscrasia is excluded. Aim: To present a patient diagnosed with ATTR-CM, who was hospitalized with clinical signs of congestive heart failure. Case Report: An 84-year-old man was hospitalized with clinical signs of heart failure. Echocardiography showed concentric left ventricular hypertrophy (LVH) with reduced systolic function, along with impaired LV global longitudinal strain (GLS) with apical sparing (-9.9%). Serum and urine protein electrophoresis with immunofi xation were obtained and were negative for plasma cell dyscrasia. Bone scintigraphy showed similar radiotracer uptake in the myocar-dium and ribs (Perugini grade 2). The diagnosis of ATTR-CM was confi rmed. Conclusion: ATTR-CM is an underdiagnosed condition and should be suspected in patients with heart failure and unexplained LVH.

Some of the conditions which occur in maintenance hemodialysis (MHD) patients with a high incidence resulting in a decline in their quality of life, include malnutrition, renal osteodystrophy, refractory hypertension and chronic systemic inflammation. In developing countries, due to the low level of economic development, low-flux dialysis is the main means of extracorporeal blood purification therapy. But it can hardly remove the middle and large molecule uremic toxins and protein-bound toxins; as a result, the patients suffer from long-term complications and poor quality of life. In this study, we attempted to investigate whether the combination of maintenance hemodialysis (MHD) with hemoperfusion (HP) could improve the clearance rate of middle and large molecule uremic toxins so as to improve their uremic complications. A total of 54 patients, who underwent routine hemodialysis, were assessed in this study. Those patients were randomly divided into two groups: Group 1 (27 patients) received combined treatment of HD with hemoperfusion (HP) in this regimen: HD 2 times a week with HD+HP once a week two times in a row, then after two weeks, and afterwards once a month as a maintenance treatment. Group 2 (27 patients) was only undergoing maintenance HD 3 times a week. The clinical and laboratory properties of both groups were followed up for 18 months, whereas the primary outcomes included normal clinical data, high sensitive C-reactive protein (hsCRP), immunoreactive parathyroid hormone (iPTH), phosphorus (P04), calcium (Ca), albumin, iron (Fe), total iron binding capacity (TIBC), hemoglobin, Epo doses and types of hypertensive drugs. At the end of the 18-month observation, the serum concentration of albumin, P04, hsCRP, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were lower with Group 1 than with Group 2 (p<0.05). Whereas, higher levels of iPTH were noticed in group 1, but when the laboratory and clinical data are analysed of the group 1 alone a statistically significant lower values after the observational period are noticed especially in the serum values of iPTH (p<0.05), P04 (p<0.001), CRP (p<0.011), SBP and DBP (p<0.05). HD+HP was superior to HD in regularly eliminating middle and large molecule uremic toxins accumulated in the body which is mostly shown through reducing the values of iPTH and hsCRP. These findings suggest a potential role for HD+HP in the treatment of inflammation and renal osteodystrophy as well, because lowering these values of iPTH leads to a normalization of other minerals which is expected and therefore leads to a stabilization of this long-term uremic complications, which can improve the overall general condition of the MHD patient.