Research focus: The role of peritoneal dialysis (PD) in the management of acute kidney injury (AKI) is not well defined, although it remains frequently used, especially in lowresource settings. A review was performed to ascertain its suitability as the “first choice” in AKI patient treatment and to compare PD with extracorporeal blood purification (EBP), such as hemodialysis (HD). Research methods used: Design, setting, participants, and measurements of MEDLINE, CINAHL, and Central Register of Controlled Trials were searched. The review selected eligible adult population studies on PD in the setting of AKI. Results/findings of the research: This paper suggests that PD should be consid‐ ered as a valuable method for AKI since it offers several advantages over HD, such as technical simplicity, no extracorporeal circuit, and no bleeding risk. It offers good cardiovascular tolerance and less cardiovascular instability, thus reducing kidney aggression by ischemia and hydroelectrolytic imbalance. Main conclusions and recommendations: Finally, not only in developing countries but also in developed countries, PD is relatively simple and inexpensive and is more widely used. Various techniques of PD have been developed, and these have been adapted for use in AKI. There is currently no evidence to suggest significant differences in mortality between PD and HD in AKI. There is a need for further good-quality evidence in this impor‐ tant area.

The r enal damage is an emerging complication of excess weight.  Aim of this study was to determine the occurrence of chronic kidney disease (CKD) in subjects depending on their weight and the influence of body mass index (BMI) on glomerular filtration (GF) rate decline in outpatients with hypertension and/or diabetes mellitus type 2. Methods: This observational, cross sectional, pilot study included 200 adult patients suffering from hypertension and/or diabetes mellitus type 2 from March 2012. to March 2013. in the Institute for Occupational Medicine of Canton Sarajevo. Renal function was evaluated by using MDRD equation and measurement of microalbuminuria and proteinuria in 24 - hour urine, using nefelometric method at the Institute of Clinical Biochemistry of the University Clinical Center in Sarajevo K/DOQI classification  was used to define the stages of CKD. Results: Of the total 200 patients (62.5% male; mean age of 52.46 ± 8.2 years) most of them had a BMI of 25 - 30 (n=99; 49.5%). Most patients with a body mass index above 30 suffered from hypertension associated with diabetes mellitus type 2 (n=23; 34.3%,  p<0.05). The average values of BMI were statistically higher in men than in women (29.16±4.4 vs. 27.76±3.7). Early CKD was found in 118 patients (59.0%), mostly those with a BMI above 30 (63.8%). Conclusion: Early detection of CKD in primary care should definitely be a priority, especially in high - risk patients. It is also necessary to increase work on the prevention of obesity in order to prevent disease progression.

Research focus: The role of peritoneal dialysis (PD) in the management of acute kidney injury (AKI) is not well defined, although it remains frequently used, especially in lowresource settings. A review was performed to ascertain its suitability as the “first choice” in AKI patient treatment and to compare PD with extracorporeal blood purification (EBP), such as hemodialysis (HD). Research methods used: Design, setting, participants, and measurements of MEDLINE, CINAHL, and Central Register of Controlled Trials were searched. The review selected eligible adult population studies on PD in the setting of AKI. Results/findings of the research: This paper suggests that PD should be consid‐ ered as a valuable method for AKI since it offers several advantages over HD, such as technical simplicity, no extracorporeal circuit, and no bleeding risk. It offers good cardiovascular tolerance and less cardiovascular instability, thus reducing kidney aggression by ischemia and hydroelectrolytic imbalance. Main conclusions and recommendations: Finally, not only in developing countries but also in developed countries, PD is relatively simple and inexpensive and is more widely used. Various techniques of PD have been developed, and these have been adapted for use in AKI. There is currently no evidence to suggest significant differences in mortality between PD and HD in AKI. There is a need for further good-quality evidence in this impor‐ tant area.

Background: Methicillin resistant Staphylococcus aureus (MRSA) is responsible for a wide spectrum of nosocomial and community associated infections worldwide. The aim of this study was to analyze MRSA strains from the general population in Canton Sarajevo, B&H. Methods: Our investigation including either phenotypic and genotypic markers such as antimicrobial resistance, pulsed-field gel electrophoresis (PFGE), SCC typing, and Panton-Valentine leukocidin (PVL) detection. Results: Antimicrobial susceptibility: all MRSA isolates were resistant to the β-lactam antibiotics tested, and all isolates were susceptible trimethoprim sulphamethoxazole, rifampicin, fusidic acid, linezolid and vancomycin. Sixty-eight per cent of the MRSA isolates were resistant to erythromycin, 5% to clindamycin, 5% to gentamicin and 4% to ciprofloxacin. After the PFGE analysis, the isolates were grouped into five similarity groups: A-E. The largest number of isolates belonged to one of two groups: C: 60 (60%) and D: 27 (27%). In both groups C and D, SCCmec type IV was predominant (60% and 88, 8%, respectively). A total of 24% of the isolates had positive expression of PVL genes, while 76% showed a statistically significantly greater negative expression of PVL genes. Conclusion: SCCmec type IV, together with the susceptibility profile and PFGE grouping, is considered to be typical of CA-MRSA

Aim: Identification of risk factors for adverse outcome in acute kidney injury (AKI) provides the knowledge necessary to make important medical decisions. Sepsis, as the most important cause of AKI, deserves special attention in evaluating AKI prognosis. The present study aimed to identify risk factors for renal function non-recovery and in-hospital death in AKI patients. Additionally, we evaluate baseline characteristics and clinical outcomes of patients with septic AKI compared to patients with non-septic AKI. Methods: This prospective study included one hundred hospitalized patients diagnosed with AKI. Baseline physiological and laboratory parameters, as well as renal function outcome and in-hospital death of AKI patients, were evaluated. Results: Patients with septic AKI had significantly higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (p<0.001), erythrocyte sedimentation rate (ESR) (p<0.001) and white cell counts (p=0.017), higher levels of ferritin (p<0.001), C-reactive protein (CRP) and fibrinogen (p<0.001) as well as significantly lower serum albumin values (p<0.01) compared to patients with non-septic AKI. Risk factors for adverse renal outcome were increased APACHE II score (p<0.01) and ESR (p<0.05), higher values of CRP (p<0.01) and serum ferritin (p<0.05), as well as hypoalbuminemia (p<0.01). By multivariate analysis, APACHE II score was the independent risk factor for non-recovery of renal function (95% CI 0.788-0.956, p꞊0.004) and in-hospital mortality (95% CI 1.057-9.075, p꞊0.039), while sepsis (95% CI 0.128-0.967, p=0.043) was predictive of renal function non-recovery in AKI patients. Conclusion: Acute-phase reactants, APACHE II score, and sepsis are useful in predicting the adverse clinical outcome in AKI patients.

Introduction: Data regarding prognostic factors of post-discharge mortality and adverse renal function outcome in acute kidney injury (AKI) hospital survivors are scarce and controversial. Objectives: We aimed to identify predictors of post-discharge mortality and adverse renal function outcome in AKI hospital survivors. Patients and Methods: The study group consisted of 84 AKI hospital survivors admitted to the tertiary medical center during 2-year period. Baseline clinical parameters, with renal outcome 3 months after discharge and 6-month mortality were evaluated. According survival and renal function outcome, patients were divided into two groups. Results: Patients who did not recover renal function were statistically significantly older (P < 0.007) with higher Charlson comorbidity index (CCI) score (P < 0.000) and more likely to have anuria and oliguria (P = 0.008) compared to those with recovery. Deceased AKI patients were statistically significantly older (P < 0.000), with higher CCI score (P < 0.000), greater prevalence of sepsis (P =0.004), higher levels of C-reactive protein (CRP) (P < 0.017) and ferritin (P < 0.051) and lower concentrations of albumin (P<0.01) compared to survivors. By multivariate analysis, independent predictors of adverse renal outcome were female gender (P =0.033), increasing CCI (P =0.000), presence of pre-existing chronic kidney disease (P =0.000) and diabetes mellitus (P =0.019) as well as acute decompensated heart failure (ADHF) (P =0.032), while protective factor for renal function outcome was higher urine output (P =0.009). Independent predictors of post-discharge mortality were female gender (P =0.04), higher CCI score (P =0.001) and sepsis (P =0.034). Conclusion: Female AKI hospital survivors with increasing burden of comorbidities, diagnosis of sepsis and ADHF seem to be at high-risk for poor post-discharge outcome.

The most common influenza A (H1N1)-associated complications are pulmonary, but other organ systems, such as kidneys and nervous system can be affected too. There are no sufficient data about the development of acute kidney injury (AKI) related to A (H1N1) infection. Neurological complications, especially encephalitis with or without seizures, have been documented among pediatric patients, but data of influenza A (H1N1) related focal neurological deficits in adults are scarce. Here we describe a previously fit 46-year-old male patient with influenza A (H1N1) infection presenting with multi-organ failure (acute respiratory distress syndrome and AKI) accompanied by muscular and unusual neurological complications. We found hypoglossal nerve paralysis and unilateral peroneal nerve paralysis in the course of the influenza A (H1N1) infection, but with no permanent neurological sequelae. Renal function was fully recovered one month after patient’s discharge. Keywords : influenza A (H1N1), pulmonary complications, acute kidney injury, hypoglossal nerve paralysis

Objective was to assess whether the concentration of malondialdehyde (MDA) as a marker of lipid peroxidation and serum concentration of matrix metalloproteinase-9 (MMP-9) are involved in the process of atherosclerosis in chronic kidney disease (CKD) patients nondialysis-dependent and those on peritoneal dialysis (PD), both with signs of cardiometabolic syndrome (CMS). Thirty CKD and 22 PD patients were included in a study. All observed patients were divided into three subgroups depending on the degree of atherosclerotic changes in the carotid arteries (CA). Severity of atherosclerotic changes in the CA was evaluated by ultrasonography. We confirmed significantly lower level of serum MDA throughout all the stages of atherosclerosis in PD patients compared with observed CKD patients (P < 0.05) and increased serum concentration of MDA and MMP-9 with the progression of severity atherosclerotic changes in both groups of patients. The multiple regression analysis revealed that MDA and MMP-9 are significant predictors of changes in IMT-CA CKD patients (P < 0.05) and plaque score on CA in these patients (P < 0.05). The results suggest that MDA and MMP-9 could be mediators of CKD-related vascular remodeling in CMS.

Background/Aims: Residual renal function (RRF) has been shown to influence survival of peritoneal dialysis (PD) patients. This study examined the relations between RRF and left ventricular hypertrophy (LVH) before switching on dialysis treatment and observed during 18 months on PD treatment. Methods: A prospective longitudinal study was performed in 50 non-anuric (defined as >200 mL urine output in a 24-hour period) PD patients. Echocardiography, RRF and other known risk factors for the increase of LV mass index (LVMi) were determined at study baseline and the end of follow-up. Results: There was 78% patients with LVH in end-stage renal disease (ESRD) baseline and 60% at the end of follow-up. RRF at the start of the study showed no significant difference between patients with normal and increased LVMi, as well as in daily collection of urine. After 18 months, patients with decreased LVMi had better RRF, lower CRP and better Kt/V compared to patients with increased LVMi (p < 0.001). Patients with better preserved RRF not only had significantly higher total Kt/V, but were less anemic and hypoproteinemic and lesser presence of LVH. Conclusions: PD in non-anuric ESRD patients the first 18 months has a positive effect on the preservation of RRF and partial regression of left ventricular remodeling.

Introduction: Starting from the point that the chronic kidney disease (CKD) is chronic, inflammatory and hypercoagulable state characterized by an increase in procoagulant and inflammatory markers high cardiovascular morbidity and mortality in these patients could be explained. Aim: The aim of the research was to monitor inflammatory markers and procoagulants in various stages of kidney disease (stage 1-4). Materials and Methods: The research included 120 subjects older than 18 years with CKD stages 1-4 examined and monitored in Clinic of Nephrology, University Clinical Centre Sarajevo over a period of 24 months. The research included determining the following laboratory parameters: serum creatinine, serum albumin, C-reactive protein, leukocytes in the blood, plasma fibrinogen, D-dimer, antithrombin III, coagulation factors VII (FC VII) and coagulation factor VIII (FC VIII). Results: With the progression of kidney disease (CKD stages 1-4), there was a significant increase of inflammatory and procoagulant markers: CRP, fibrinogen and coagulation factor VIII, and an increase in the average values of leukocytes and a reduction in the value of antithrombin III, but without statistical significance. Also, there were no significant differences in the values of D-dimer and coagulation factor VII. Conclusion: The progression of kidney disease is significantly associated with inflammation, which could in the future be useful in prognostic and therapeutic purposes. Connection of CKD with inflammation and proven connection of inflammation with cardiovascular risk indicates the potential value of some biomarkers, which could in the future identify as predictors of outcome and could have the benefit in the early diagnosis and treatment of cardiovascular disease in CKD.

Abstract Background: Cardiac valve calcification (CVC) and left ventricular (LV) alterations are frequent complication in end-stage renal disease (ESRD). We determined the prevalence of CVC and LV hypertrophy (LVH) in ESRD patients before renal replacement therapy and 12 months after peritoneal dialysis (PD). Methods: A prospective longitudinal of 50 incident PD patients was studied. Demographic and clinical data were recorded and blood assayed at baseline and after 1-year of follow-up. CVC and LVH were evaluated by M-mode two-dimensional echocardiography. Results: CVC of the mitral and aortic valves and of both valves were noted in 30, 18 and 10% of patients, respectively. After 12 months of PD regimen, 20% patients had aortic, 24% mitral and 8% had calcification of both valves. After one year of PD, LVH was 62 and 36% in patients with and without CVC, respectively (p < 0.05). Endothelin-1 is an independent predictor of CVC at the baseline, while nitric oxide is inversely an independent predictor at the end of follow-up. Conclusions: CVC is associated with LVH in PD patients. These findings identified a potential role for monitored markers to be incorporated into therapeutic strategies aimed at detection and treatment of cardiovascular complications and prevention strategies.

The endothelial cell layer is responsible for molecular traffic between the blood and surrounding tissue, and endothelial integrity plays a pivotal role in many aspects of vascular function. Cardiovascular disease (CVD) is the main cause of death in patients with chronic kidney disease (CKD) and its incidence and severity increase in direct proportion with kidney function decline. Non-traditional risk factors for CVDs, including endothelial dysfunction (ED), are highly prevalent in this population and play an important role in cardiovascular (CV) events. ED is the first step in the development of atherosclerosis and its severity has prognostic value for CV events. Several risk markers have been associated with ED. Reduced bioavailability of nitric oxide plays a central role, linking kidney disease to ED, atherosclerosis, and CV events. Inflammation, loss of residual renal function, and insulin resistance are closely related to ED in CKD. ED may be followed by structural damage and remodelling that can precipitate both bleeding and thrombotic events. The endothelium plays a main role in vascular tone and metabolic pathways. ED is the first, yet potentially reversible step in the development of atherosclerosis and its severity has prognostic value for CV events. Therefore, evaluation of ED may have major clinical diagnostic and therapeutic implications. In patients with CKD, many risk factors are strongly interrelated and play a major role in the initiation and progression of vascular complications that lead to the high mortality rate due to CVD.

Aim: The objective of this study was to evaluate prognostic impact of clinical factors on outcome of renal function in septic and non-septic acute kidney injury (AKI) patients. Methods: The prospective, observational, clinical study was performed at Nephrology Clinic and Clinic for Infectious Diseases, University Clinical Centre Sarajevo. One hundred patients with diagnosis of AKI were enrolled in the study, and divided into two groups: septic and non-septic AKI patients. Clinical parameters included causes and type of AKI, pre-existing comorbidities and different treatment modalities. Patients were followed up until discharge or death. Renal function outcome was defined by creatinine clearance values at discharge. Results: Septic AKI patients had significantly longer hospital stay (p=0.03), significantly worse renal function outcome (p<0.001), and higher burden of comorbidities (70.6% vs. 60.6%), compared to non-septic patients. Septic AKI patients were almost three times less likely to receive renal replacement therapy (8.8% vs. 24.4%) and they had significant delay in initiation of dialysis (p=0.03). By multivariate analysis, sepsis (95% CI 0.128-0.967, p=0.043) and hypertension (95% CI 0.114-0.788, p=0.015) were independent predictors of adverse renal function outcome in AKI patients. Postrenal type of AKI was independent predictor of renal function recovery in non-septic AKI patients (95% CI 1.174-92.264, p=0.035), while Failure, as third class of AKI, was independent predictor of non-recovered renal function only in septic AKI patients (95% CI 0.026 to 0.868, p=0.034). Conclusion: Septic AKI patients are clinically distinct compared to non-septic AKI patients with different prognostic factors and poorer renal function outcome.

Background: Hypertension (HT) and renal anaemia (RA) are well-established markers of cardiovascular risk in patients with chronic kidney disease (CKD). They appear to be the stimuli for left ventricular hypertrophy (LVH), who significantly participates in cardiac complications in uremic patients. Hypertension is extremely common after kidney transplantation (KTx) and it has been observed in up to 75% of patients. The prevalence of post-renal transplant anaemia (PTA) is variable (up to 30%) and several factors such as graft function contribute towards its pathophysiology. Aim: The aim of this study was to analyze the impact of blood pressure and anaemia on LV remodelling in first year after transplantation comparing echocardiographic findings before and twelve months after transplantation had done. Methods: In five years retrospective-prospective study we followed up 30 patients with renal allograft in first post-transplant year. During the study values of systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), blood hemoglobin (Hgb), serum creatinine and creatinine clearance were monitored monthly. Results: Before transplantation (Tx) 86% of patients had HT, and RA was confirmed in all patients. Normal echocardiographic findings had 33% of patients and 67% of patients had echocardiographic sings of LVH. Before renal transplantation group with LVH had statistically higher the mean values of blood pressure (MBP) (p=0.053) compared to group with diastolic (LVDDF) (p=0.0047) and systolic-diastolic dysfunction (LVSDDF) (p=0.0046). The values of SBP and DBP positively correlated with LV mass index (LVMI) in the group of patients with LVH (p=0.0007 and p=0.0142). The values of Hgb was statistically higher in group with normal LV mass index compared to LVH (p=0.019), with negative correlation between LVMI and values of Hgb in the patients group with LV hypertrophy (p=0.009). After the first year of transplantation, 63% of patients showed normal LV mass index and 37% remained with echocardiographic findings of the LVH. The values of SBP and values of Hgb in both groups, as well as values of DBP in group of LVH were statistically different in compare with data before transplantation (p<0.05). The positive echocardiographic remodelling of LV significantly correlated with the increase of Hgb values (p=0.05), but without significant correlation with the decrease of the mean SBP and DBP. Conclusion: These results confirmed that positive echocardiographic remodelling of left ventricle after successful renal transplantation is complex process depended on many risk factors and elimination of uremia- related factors is a priority.