Introduction: Based on the statistics the population in Bosnia and Herzegovina is getting older. In 2013 the average life span for women was 73.6 years and 68.1 for men. The chronic hemodialysis program is mainly reserved for elderly patients with high mortality risk. The most common cause of hemodialysis mortality relates to cardiovascular diseases (60.2%), regardless of frequent innovations and improvement of hemodialysis procedures. The aim of the study: was to determine the mortality rate by age groups with comments on the presence of non-traditional predictors (anemia, hypoalbuminemia, CRP, vascular access and PTH) in dialysis patients in the follow-up period of 36 months. Methods: The study included all patients undergoing chronic hemodialysis treatment at the Clinic of Hemodialysis of the Clinical Center University of Sarajevo (CCUS). Results: Out of a total number of hemodialysis patients (n=232), the specific mortality rate in patients under 65 years of age was 16.8%, and 50.5% in patients over 65 years of age. According to the age groups the mortality rate in elderly patients is as follows: from 65 to 74 years (45.1%), from 75 to 84 years (55.0%), over ≥85 years (75.0%). The most frequent vascular access in patients under and above 65 is arteriovenous fistula (79.6% and 62.1 %), temporary hemodialysis catheter (11.7% and 43.8 %) and long-term hemodialysis catheter (8.8% and 4.2 %). In the age group under 65 years of age the temporary hemodialysis catheter is significantly and more frequently used in diseased patients in respect to survivors (34.8% vs. 7.0%) [χ2(2)=15.769, p=0.001]. Diseased patients from the age group over 65 had a significantly lower mean value of haemoglobin in blood (M=100.9±17.5 g/L) in respect to survivors (M=109.2±17.1)[t(93)=2.339; p=0.021], lower mean value of albumin in blood (Me=32.0; IQR=29.0 do 35.0) in respect to survivors (Me=34.0; IQR=32.0 to 38.0) [U=762.5; p=0.006], and higher mean value of CRP in blood (Me=19.3 mg/L; IQR=6.6 to 52.0) in respect to survivors (Me=7.8; IQR=4.0 to 16.7) [U=773.5; p=0.008]. Diseased patients belonging to the age group over 65 had lower mean value of PTH, but without statistical significance (p>0.05). Conclusion: older age, temporary vascular access, anaemia and hypoalbuminemia are strong predictors of mortality in hemodialysis patients. Old age does not present contraindication for hemodialysis treatment, and treatment of terminal renal illness should not be abandoned.

Introduction: Increased levels of C-Reactive Protein are found in 30-60% on hemodialysis patients and it is closely associated with the progression of atherosclerosis, cardiovascular morbidity and mortality. Non enzymatic antioxidants are antioxidants which primarily retain potentially dangerous ions of iron and copper in their inactive form and thereby prevent its participation in the production of free radicals. Aim: The aim of the study was to examine the relationship of CRP and non enzymatic antioxidants (albumin, ferritin, uric acid and bilirubin) i.e. examine the importance of CRP as a serum biomarker in assessing the condition of inflammation and its relationship to antioxidant protection in patients on hemodialysis. Methods: The study was cross-sectional, clinical, comparative and descriptive. The study involved 100 patients (non diabetic) on chronic hemodialysis. The control group consisted of 50 subjects without subjective and objective indicators of chronic renal disease. In all patients, the concentration of CRP as well as concentrations of non enzymatic antioxidants were determined. Results: In the group of hemodialysis patients 60% were men and 40% women. The average age of hemodialysis patients was 54.13 ± 11.8 years and the average age of the control group 41.72 ± 9.8 years. The average duration of hemodialysis treatment was 91.42 ± 76.2 months. In the group of hemodialysis patients statistically significant, negative linear correlation was determined between the concentration of CRP in and albumin concentration (rho = -0.251, p = 0.012) as well as negative, statistics insignificant, linear correlation between serum CRP and the concentration of uric acid (r = -0.077, p = 0.448). Furthermore, the positive, linear correlation was determined between serum CRP and ferritin (r = 0.159, p = 0.114) and positive linear correlation between CRP and total serum bilirubin (r = 0.121, p = 0.230). In the control group was determined a statistically significant, positive, linear correlation between serum CRP and uric acid concentration (rho = 0.438, p = 0.001) and statistically significant, positive, linear correlation between serum CRP and total serum bilirubin (rho = 0.510, p = 0.0001) A statistically significant, negative linear correlation was determined between CRP and albumin concentration (rho= -0.393, p = 0.005) as well as statistically significant, negative linear correlation between serum CRP and ferritin control group (rho = -0.391, p = 0.005). Conclusion: Elevated CRP level is a strong and independent predictor of low levels of serum albumin, which indicates that the hypoalbuminemia in hemodialysis patients could be more due to inflammation than malnutrition. There was no statistically significant correlation between CRP and other non enzymatic antioxidants (uric acid, ferritin, bilirubin), which shows that indicators of antioxidant defense in hemodialysis patients must be individually measured to determine their actual stocks and activity.

Abstract Introduction. BNP plasma levels are significantly increased in heart failure and have an excellent negative predictive value for left ventricular dysfunction. Measurement of BNP level is useful for “screening” in high-risk populations. It is suitable for detection of left ventricular hypertrophy (LVH) and/or dysfunction and risk assessment in the sub-acute phase of acute myocardial infarction in hypertensive patients. The aim of our study was to find whether BNP may correlate with the left ventricular systolic function, i.e. its echocardiographic parameters in chronic kidney disease (CKD) patients. Methods. In a prospective study performed at the Department of Nephrology and Clinic for hemodialysis at the Clinical Center in Sarajevo we followed-up 80 patients stratified in three separate groups according to CKD stage (Stage III, IV and V) for two years, regardless of their cardiovascular symptoms. We analyzed levels of BNP before and after diuretic therapy or hemodialysis and echocardiographic characteristics of the left ventricle. Results. There was a strong negative correlation between BNP values and the size of the EF before (rho=−0.692, p<0.0001) and after diuretic therapy (rho=−0.683, p<0.0001) for patients in CKD stage III, stage IV (rho=−0.314, p>0.05) and after diuretic therapy (rho=−495, p<0.05) Similarly, a negative correlation was found for BNP and EF values before (rho=−0.432, p<0.05) and after hemodialysis (rho=−0.556, p<0.01) for stage V CKD. Conclusions. Our study confirmed that the value of BNP in CKD patients may represent a measure of left ventricular systolic function with a strong negative correlation with ejection fraction. BNP measurement is a reliable parameter for further follow-up and prognosis in patients with established left ventricular dysfunction, acute coronary syndrome and for estimation of the left ventricular dysfunction.

Kronicna bubrežna bolest (HBB) je važan javno-zdravstveni problem (1). Prema definiciji KDIGO (Kidney Disease: Improving Global Outcomes) HBB je definirana kao strukturno ili funkcionalno ostecenje bubrega, koje traje >3 mjeseca, s posljedicama za zdravlje i klasificirana je na osnovi uzroka, kategorije glomerularne filtracije i kategorije albuminurije (2). HBB ima nekoliko stadija, a posljednji, terminalni stadij ili end-stage of renal disease (ESRD) odgovara uremiji s glomerularnom filtracijom 90 dana se također povecala i u 2011. godini iznosila 123,1 (3). Također, i u drugim zemljama koje vode renalni registar, zabilježen je porast incidencije i prevalencije pacijenata s ESRD. U svijetu je, u odnosu na modalitet tretmana zamjene bubrežne funkcije u razdoblju 2001.-2010. godina, bila najzastupljenija HD (68,5-69,2 %), zatim transplantacija bubrega (22,5-23,1 %), te peritonejska dijaliza (8,3-8,5 %) (4). U Bosni i Hercegovini u razdoblju 2006.-2011., HD je najucestalija metoda zamjene bubrežne funkcije s ucestaloscu UCINAK INTRADIJALIZNOG PROGRAMA VJEŽBANJA NA KVALITETU ŽIVOTA I FIZICKE MOGUCNOSTI U HEMODIJALIZIRANIH PACIJENATA

AIM To determine the effect of a 16-week intradialytic exercise program consisting of 30 minutes of exercise during the first two hours of dialysis with three times a week frequency, on the quality of life (QoL), level of depression/anxiety and physical perfor- mance in hemodialysis (HD) patients. METHODS The clinical, longitudinal, prospective study with one-group repeated measures design was conducted during a 16-week period. A convenience sample of 52 HD patients, who had been on HD for a minimum of 6 months, were included. QoL, level of depression and anxiety (questionnaires: SF-36, Back Depression Inventory (BDI) and Back Anxiety Inventory (BAI)) and physical performance (modifying Visual Analogue Scale (VAS) and Manual Muscle Testing (MMT)) were assessed at baseline and after 4-month exercise program. RESULTS The following scales of SF-36 questionnaire were improved after 16-week exercise program: role functioning/emotional (P=0.01 8), energy/fatigue (P = 0.002) and social functi- oning (P = 0.030). Level of depression and anxiety were significantly decreased in males (P = 0.007 and P = 0.022, respectively) and females (P = 0.001 and P = 0.000, respectively). VAS scale and MMT were significantly increased in males (P = 0.000 and P = 0.001, respectively) and females (P = 0.01 9 and P = 0.001, respectively) after 16-week exercise program. CONCLUSION Exercise program improves some aspects of QoL and physical performance, and decreases the level of depression and anxiety in HD patients.

INTRODUCTION Central venous catheters in hemodialysis patients can be used as vascular access for hemodialysis. At our clinic, our doctors use temporary and tunneled catheters for hemodialysis treatment. The presence of the catheter, increases the risk of bacteremia in hemodialysis patients. Risk factors are nasal colonization with Staphylococcus aureus, prolonged use of catheters, previous bacteremia, anover dose of iron, low hemoglobin, low albumins, diabetes mellitus, and surgical procedures. The aim of this study was prevention of catheter sepsis and timely disclosures of existing and effective cures. PATIENTS AND METHODS Thirty-eight patients with tunnelled catheters as vascular access for hemodialysis were included into the study. The study was conducted between January 1, 2011 and January 3, 2012. Outof 38 patients, 60% (23) were male and 40% (15) were female, while the average age was 67.48 +/- 13.9 years. The duration of hemodialysis treatment was 108.9 +/- 16.54 months. RESULTS Over the study period, 9 patients developed bacteriemia associated with the use of catheter as a vascular approach. The incidence of infection in our study was 3.5 cases per 1000 catheter days. Two patients (5.2%) developed an infection in the first three months after the day of catheter placement, and the remaining 6 (15.8%) patients after one year of the use of catheter as a vascular approach. Regarding the causes of infection, in 3 (33%) patients these were gram-positive pathogens, in 5 (56%) patients gram-negative pathogens, and in one (11%) patient it was polimicrobe flora. According to the protocol and pending the outcome of susceptibility testing (antibiogram), all the patients were prescribed with antibiotic treatment therapy. In 7 (75%) patients tunnelled catheter was removed and replaced with temporary catheters for hemodialysis treatment. In 2 (25%) patients, was antibiotic-lock solution was injected into the catheter. There were no significant differences (p<0.05) in age, duration of dialysis treatment, hemoglobin levels, iron, transferrin saturation, ferritin and albumin in patients without infection and those who developed an infection. Only one patient has had a nasal colonization with Staphylococcus aureus. One patient developed severe thrombocytopenia, followed by sepsis anda lethal outcome due to heavy gastrointestinal bleeding. CONCLUSION tunneled venous catheter is the increasingly common vascular access with the hemodialytic patients, but it is also a common cause of infection. Proper care and use of catheters, making the unique protocols of care and treatment algorithm occupy a significant place in each hemodialysis center. Our goal is to prevent the catheter sepsis, and to promptly detect the existing and a fast treatment of the same.

INTRODUCTION Hepatitis C virus infection (HCV) is an important cause of morbidity and mortality in patients with end-stage renal disease (ESRD). PATIENTS AND METHODS In this prospective, observational study, 205 patients, 37 (18%) of them with chronic HCV infection, were followed up for a one-year period at Department of Hemodialysis, Sarajevo Clinical Center, University of Sarajevo. The following parameters were analyzed: dialysis duration, sex, PCR RNA, HCV genotypes and biochemical parameters. Thirteen anti-HCV PCR RNA positive patients were treated with pegylated interferon alpha (Pegasys, Hoffman-La Roche). The goal of therapy was to reach sustained virologic response. The presence of anti-HCV antibodies in serum was detected by enzyme linked immunosorbent assay (ELISA). RESULTS Of 37 anti-HCV positive patients, there were 20 (54%) males and 17 (45.9%) females with the mean hemodialysis duration of 143.67 +/- 57.64 months and mean age of 54.45 +/- 8.93 years. Of 37 anti-HCV positive patients, 30 (81.08%) patients were HCV RNA PCR positive. Among HCV RNA PCR positive patients, two had up to twofold elevated ALT values, one had twofold elevated AST values, and one had sixfold elevated GGT values. Thirteen RNA PCR positive patients were treated with pegylated interferon alfa for 48 weeks. Only one patient had genotype 1 virus. Upon therapy completion, only three patients were negative by PCR RNA (genotype 1b, 23.07%) at six months and yearly follow ups remained PCR negative. CONCLUSION Sustained virologic response was achieved in three study patients. Monitoring guidelines for infection control, isolation of seropositive patients, and strict hygienic preventive measures can prevent HCV seroconversion in hemodialysis patients.

AIMS We examined effects of treatment with 1-thyroxin on glucose regulation in patients with subclinical hypothyroidism. METHODS The study included 100 patients, ages 51.75 +/- 13.23 years, BMI = 27.97 +/- 4.52 kg/m2, with SH (TSH > 4.2 mU/L and with normal level of T3 and T4). Laboratory evaluation included serum free T3, free T4, TSH, thyroid antibodies, TGL, insulin, C-peptide and glucose during OGTT, HbA1c, CRP and level of lipids. Percentile, average and correlation analysis have been utilized in statistical analysis. Twelve patients with SH had GI and 38 patients had DM. All patients were treated with low dose of 1-thyroxin (25-50 ug) and high physical activity. RESULTS After 6 months treatment with 1-thyroxin, patients had normal or limited TSH (5.85 +/- 0.92 vs. 3.54 +/- 0.55 mU/L), level of fasting insulin (114.64 +/- 24.11 vs. 96.44 +/- 17.26 pmol/l) significantly decreased, HbA1c (6.74 +/- 1.01 vs. 6.26 +/- 1.12) decreased as well. The level of CRP significantly decreased as well (2.27 +/- 0.8 vs. 3.32 +/- 1.1 mg/l). The changes were and in level of total cholesterol (5.39 +/- 0.57 vs. 6.10 +/- 0.67 mmol/l), triglyceride levels (1.69 +/- 0.37 vs. 2.22 +/- 0.49 mmol/l), HDL cholesterol (1.16 +/- 0.14 vs. 1.03 +/- 0.15 mmol/l) and LDL cholesterol (3.79 +/- 0.64 vs. 4.37 +/- 0.77 mmol/l). The correlation between TSH and HbA1c was positive and significant (r = 0.46). CONCLUSION The normalization of TSH resulted in decrease of level of fasting insulin, fasting and postprandial glucose, CRP and lipids. Higher CRP associated with fasting hyperinsulinemia before insulin resistance has been evidenced in most patients with SH. These data support an important role of treatment of SH in support of glucose regulation.

Goal: To investigate the correlation between TSH and HbA1c in the treatment of L-thyroxine in the process of glycemic control in patients with subclinical hypothyroidism. Patients and methods: The sample consisted of 100 patients, mean age 51.75±3.23 years, BMI=27.97±4.52 kg/m2, with SH (TSH>4.2 mU/L and normal serum T3 and T4). Laboratory diagnosis included the determination of free T3, free T4, thyroid antibodies, Tg, insulin, C-peptide and glucose during the OGTT, HbA1c, CRP and lipid levels. 20 patients with SH had prediabetes and 38 patients had DM. All patients were treated with low doses of L-thyroxine (25-50ug) and all were physically active. Results: After 6 months of treatment with L-thyroxine, the patients had normal or decreased TSH (5.85±0.92 vs. 3.54±0.55 mU/L), insulin levels (114.64±24.11 vs. 96.44±17.26 pmol/L) significantly reduced HbA1c (6.74±1.01 vs. 6.26±1.12) is reduced. Conclusion: The correlation between TSH and HbA1c was positive and significant (r=0.46). This indicates a significant effect of treatment with L-thyroxine on glycemic control in patients with subclinical hypothyroidism.

INTRODUCTION Cardiovascular diseases are one of the main causes of morbidity and mortality in dialysis patients. High incidence of cardiovascular diseases in patients with chronic kidney disease (CKD) can not soley be explained by traditional risk factors. Several studies have confirmed association between vascular calcification and increased mortality. MATERIALS AND METHODS This study included total of 44 patients on chronic hemodialysis program, 18 women and 26 men, with average age of 50.66 +/- 11.62 years and average duration of treatment of 100.25=52.83 months. We analyzed socio-demographic parameters and standard laboratory findings. X-ray of hand and pelvis was obtained from each patient along with echocardiography and carotid ultrasound imaging. To estimate the level of vascular calcifications on the X-rays, we used the simple vascular score (sVC). RESULTS Using noninvasive methods, we found vascular calcifications in 26 (59%) patients. In 22 (45%) patients, vascular calcifications were found in X-rays. Four (9%) patients with vascular calcifications lacked any abnormality on X-rays but had calcified plaques on carotid arteries or hart valves. In the group of patients that had vascular calcifications, 3 (14%) patients had sVC score of 2,2 (9%) had score of 3,7 (32%) had score of 4,4 (18%) had score of 6, and 6 (27%) had sVC score of 8. Comparing the group of patients with and without vascular calcifications, we found statistically significant age difference (p<0.05) as well as difference in the duration of hemodialysis (p<0.05). There were no other significant differences found between the two groups. There is a statistically significant correlation between sVC score and level of calcium (p<0.09) and iPTH (p<0.05). Using regression model for increase of sVC score, we found significant correlation with duration of hemodialysis (p<0.05). CONCLUSION Existence of vascular calcifications represents warning sign of increased cardiovascular risk. Simple vascular score is an easy method for assessing that risk. In our study, increased frequency of vascular calcifications was directly correlated with older age and length of hemodialysis. Standard X-rays, echocardiography and ultrasound imaging can be used in screening of vascular calcifications. Among these methods, X-ray has advantage because it is widely available and easy to interpret.

AIM To evaluate frequency of CVD in dialysis population, in relationship to patients with and without diabetes, and their most common treatment. PATIENTS AND METHODS This retrospective study included 187 patients, 106 males and 81 females, divided in two groups, diabetics and non-diabetics, treated by chronic hemodialysis. Patients' analyses included: anamnesis, ECG, chest X-rays, echocardiogram, laboratory examinations for calcium (Ca), phosphorus (P), parathormone (PTH), cholesterol (chol), triglicerids (TG), C-reactive protein (CRP), hemoglobin (Hb) and uric acid. In addition, we analyzed groups of drugs used by patients as prescribed by cardiologists. RESULTS Average age was 58.0 years, most of them between 51 and 60. Average hemodialysis length was 4 years. Primary kidney diseases were pyelonephritis and glomerulonephritis. 19,78% of patients had diabetes. 165 patients (88,23%) had one or more cardiovascular diseases. 110 patients (58,2%) had hypertension, most of them used ACE inhibitors. Using test of multiple correlation, statistically significant correlations, among others, were shown between BMI and Ca, uric acid and P, albumin and PTH in diabetics, at the statistical significance level at p < 0.05. CONCLUSION Cardiovascular diseases are the most common comorbidity and cause of mortality in hemodialysis population. There was no statistical significance in age, however there is a statistical difference in the dialysis duration variable, but in some biochemical laboratory parameters there was some difference. ACE inhibitors were most commonly used in the treatment of hypertension and systolic dysfunction, alone or with beta-blockers.