Introduction: Acute kidney injury is characterized by a rapid loss of renal excretory function with the increase of nitrogen compounds in the blood and with different outcome. Objective: Since descriptions of the risk factors and sequelae of acute kidney injury (AKI) remain relatively limited, the objective of this study was to determine etiology and clinical characteristics of AKI, as well as risk factors for adverse outcome of renal function and death in AKI patients. Methods: We retrospectively studied a cohort of 84 adult AKI patients admitted to Nephrology Clinic in University Clinical Centre Sarajevo during period 2012-2014. Demographic, laboratory and clinical parameters were retrieved. The in-hospital and 6 months mortality were recorded. Renal function outcome was defined 3 months following discharge. Results: Majority of patients were older (median age 73.5 years) with great severity of AKI (Stage III in 78.5% of cases) and high burden of comorbidities (mean Charlson comorbidity index, CCI score 6.4±3.05). The most common causes of AKI were acute interstitial nephritis (16.7%), heart failure (15.5%), gastroenterocolitis (13.1%), and sepsis (12%). Renal function recovery was recorded in 48.8% of patients, with prevalence of 10.7% of intrahospital mortality and 37.3% of 6 months mortality. Risk factors for poor outcome of renal function and mortality in AKI patients were increasing age and higher CCI score, while protective factor was higher diuresis. Sepsis proved to be risk factor for death.

Aims: Cardiovascular alterations contribute to a high mortality rate in patients with end-stage renal disease (ESRD). The aims of the present study are to evaluate left ventricular (LV) function and common carotid artery (CCA) parameters and to determine risk factors associated with these changes in patients undergoing peritoneal dialysis (PD). Methods: This longitudinal prospective study was conducted in 50 ESRD patients in whom PD had been initiated and who were observed for 18 months after the commencement of dialysis treatment, with echocardiography and CCA ultrasound parameter evaluation. Results: LV hypertrophy was observed in 78% of patients at baseline and in 60% after 18 months of PD treatment. LV systolic and diastolic function was found to be significantly better after 18 months of PD treatment. Examining predictors of LV systolic function, it was found that total cholesterol was an independent positive predictor and endothelin-1 (ET-1) an independent negative predictor of LV systolic function after 18 months of treatment with PD (p < 0.001). Independent negative predictors of diastolic LV function were hemoglobin and type 2 diabetes mellitus, and daily collection of urine was an independent positive predictor (p < 0.001). Female gender was an independent negative predictor of CCA intima-media thickness, whereas body mass index, ET-1 and C-reactive protein were independent positive predictors (p < 0.001). Conclusions: The results suggest several novel modifiable mechanisms related to the short-term effects of dialysis that are potentially implicated in the development of uremic cardiomyopathy.

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.

Objectives: Atherosclerosis is a significant cause of morbidity and mortality in peritoneal dialysis patients. The aim of this study was to measure the intima-media thickness (IMT) and peak systolic velocity (PSV) values on common carotid arteries (CCA) and to assess relationship between CCA parameters and serum nitric oxide (NO) level, traditional and uremic specific risk factors in patients treated with continuous ambulatory peritoneal dialysis (CAPD) with and without type 2 diabetes mellitus (DM2). Methods: Study included 38 patients on CAPD, (mean age 51.32 } 18.03 y) (44.7% DM2 and 55.3% non-DM2 patients). CCAIMT and PSV were determined by B-mode ultrasound and serum NO level was measured by ELISA. Results: Serum NO level in DM2 patients was significantly higher compared to non-DM2 patients (7.09 vs. 5.15 μmol/L). Vascular calcification was found in 94.1% DM2 patients and in 33.3% non-DM2 patients. There were no CCA hemodynamic flow blockages in 11.8% DM2 patients. Mid-significant hemodynamic blockage was present in 47.1% and very significant in 41.2% DM2 patients. Significant correlation was found between serum NO level and age (r=0.63), diabetes (r=0.74), IMT value (r=0.72) and number of atherosclerotic plaques (r=0.78). There was an independent association between serum NO and low-density lipoprotein level (β=3.09;p=0.04). Conclusion: Our results suggest significant association between serum NO level and morphological and functional changes of CCA in uremic patients on peritoneal dialysis, especially in patients with type 2 DM. Key words: peritoneal dialysis, nitric oxide, intima media thickness, common carotid artery, atherosclerosis, diabetes mellitus type 2

Left ventricular (LV) structure and function abnormalities are frequent in patients with chronic uraemia; these disorders increase the risk of cardiovascular (CV) and overall morbidity and mortality in the predialysed population, during dialysis treatment, and in renal transplant recipients. Since the first description of the association between chronic kidney disease (CKD) and heart disease, many epidemiological studies have confirmed and extended this finding. The risk of cardiovascular disease (CVD) is notably increased in patients with CKD. When adjusted for traditional CV risk factors, impaired kidney function increases the risk of CVD 2 to 4-fold. CVD is frequently underdiagnosed and undertreated in patients with CKD. This review will attempt to summarise current knowledge of the prevalence and pathophysiological mechanisms of LV disease in chronic uraemia, and to discuss useful medical strategies in this population.

Abstract Background: Left ventricular hypertrophy is the most common structural cardiac alteration in chronic dialysis patients. The aim of this study was to determine the possible association of endotelin-1 (ET-1) and nitric oxide (NO) with parameters of echocardiography in order to assess their participation in left ventricular (LV) remodeling in patients on peritoneal dialysis (PD). Methods: This prospective longitudinal study included 40 PD patients. Serum levels of ET-1 and NO baseline and after 12 months of PD treatment were measured and compared with echocardiography parameters done at the same time of PD treatment. Linear regression analysis was used to detect independent correlations of variables. Results: Mean ET-1 serum concentration decreased significantly after 12 months of PD treatment compared to baseline values (p < 0.01). NO serum concentration increased significantly 12 months after treatment compared to baseline values (p < 0.01). Left ventricular hypertrophy (LVH) was observed in 72.5% of patients at baseline with significant reduction in LV mass index after 12 months of PD treatment (p < 0.001). On linear regression analysis serum concentration of ET-1 was independent predictors of LV mass index, as well as NO at the end of observed period. Conclusions: According to our data ET-1 and NO are independently related to the process of left ventricular remodeling in PD patients

Objectives: The purpose of this study was to determine endothelin (ET)-1 and nitric oxide (NO) serum concentration levels at baseline and after 1 year of peritoneal dialysis (PD) treatment. A further aim was to evaluate the association between ET-1 and NO with parameters of echocardiography and the common carotid artery (CCA) ultrasound, and to assess their impact on cardiovascular remodeling. We also aimed to evaluate the influence of dialysis adequacy and residual renal function (RRF) on cardiovascular remodeling. Methods: This study included 40 PD patients in whom we measured serum ET-1 and NO concentrations, echocardiography and CCA ultrasound parameters. Results: ET-1 decreased and NO serum concentration levels increased (p < 0.01) after 12 months of PD treatment compared to baseline values. Left ventricular (LV) hypertrophy was observed in 77.5% of patients at baseline with significant reduction in LV mass index (LVMI), CCA intima media thickness (IMT) and plaque score after 12 months of PD treatment (p < 0.001). The dialysis adequacy and RRF were significantly associated with LVMI and CCA IMT after 12 months on PD. Conclusion: In our study, ET-1 significantly decreased while NO increased during PD treatment and both were independently related to the cardiovascular remodeling parameters in PD patients.

Diabetes mellitus (DM) is the leading cause of the end-stage renal disease (ESRD). Vascular diseases are the most common cause of morbidity and mortality in the chronic kidney disease. The aim of this study was to analyze the impact of peritoneal dialysis (PD) treatment on morphologic and hemodynamic vascular parameters of carotid arteries in diabetic type 2 and nondiabetic patients with ESRD during the period of one year after the start of PD treatment using ultrasonography of carotid arteries and their relation on uremia and PD inherent factors. Mean intima-media thickness, plaque score, peak systolic velocity, end-diastolic velocity, and carotid diameter significantly decreased 12 months after PD treatment start in both groups. Significant reduction in median serum endothelin-1 concentration after 12 months on PD treatment was observed in the group of patients with DM (7.6–5.9 pg/mL) and also in group of patients without DM (3.6–3.3 pg/mL). Also median nitric oxide concentration significantly increased after 12 months on PD compared to baseline levels both in patients with DM (25.0–34.3 μmol/L) as was observed in patients without DM (49.6–56.5 μmol/L). PD treatment, with the regulation of these vasoactive molecules and other vascular risk factors, significantly contributes to vascular remodeling, especially in DM patients.

We present the case of a 67-year-old female patient with microscopic polyangiitis presented with polyneuropathy of lower extremities and rapidly progressive glomerulonephritis. Disease had started as a pain and weakening of muscular strength first in the left and than in the right leg. Electromiography has shown that a mainly dominant neurological affection was paresis of peroneal nerve in both lower extremities. In laboratory examination the titer of anti-myeloperoxidase anti-neutrophilic cytoplasmic antibodies (p-ANCA) was elevated. Due to renal involvement presented as a microscopic haematuria and decreasing of renal function, patient undergone kidney biopsy. It confirmed the immune vasculitis microscopic polyangiitis type with ANCA-associated glomerulonephritis. This is one of rare case of microscopic polyangiitis without lung simptomatology, first presented with asymmetrical polineuropathy of lower extremities. The patient was treated with methylprednisolone and cyclophosphamide in dosis adjusted to the level of disease severity and the renal function (methylprednisolone 1 mg/kg of body weight for two months with gradually tapering to the minimum effective dose and cyclophosphamide 1 mg/kg of body weight). This treatment lead to the partial remission of disease. In maintenance therapy azathioprin was introduced instead of cyclophosphamide.

Endothelial dysfunction is associated with diabetic micro- and macroangiopathy as well as with the decline in creatinine clearance. It has been suggested that endothelial dysfunction presents in patients (pts) on continuous ambulatory peritoneal dialysis (CAPD). The objective of this study was to examine the plasma biomarkers of endothelial dysfunction and their association with IMT of carotid arteries in diabetic and non-diabetic patients on CAPD. This study included 37 CAPD pts (25 with type II diabetes and 12 non-diabetic pts) mean age 59.2 years ± 2.48. Plasma von Willebrand factor (vWF) activity, serum albumin, glucose, total cholesterol, triglycerides and lipoprotein (a) levels, as well as serum level of homocysteine, parathyroid hormone (PTH) in plasma and microalbuminuria was determined. Ultrasound examination of carotid arteries was performed in all patients by measured bilateral intima-media thickness of carotid artery (CIMT). Mean IMT value was significantly higher in type 2 DM patients (0.86 ± 0.04 mm) compared to non-diabetic patients (0.52 ± 0.06 mm) on peritoneal dialysis (p<0.0001). There was also a significant difference in lipids /triglycerides and Lp (a)/, procoagulation (fibrinogen, von Wilebrand factor, factor VIII) and inflammatory markers (CRP) level between type 2 DM and non-diabetic CAPD patients. A stepwise multiple regression analysis revealed that log triglycerides and factor VIII were independent factors for the IMT. The results of this research impose that diabetic type 2 CAPD patients have developed systemic alteration of endothelial function and higher risk of cardiovascular complications compared to non-diabetic CAPD patients.

Cardiovascular diseases (CVD) are a major cause of morbidity and leading cause of mortality in almost 50% of patients (pts) with chronic kidney disease (CKD), including kidney transplant recipients. Left ventricular hypertrophy (LVH) is the most common structural alteration and powerful risk factor for cardiovascular complications in the uremic patients. The aim of this study is to analyze predictors of the left ventricular remodelling in the first year after kidney transplantation based on comparison of echocardiographic findings, which had been done before and twelve months after transplantation. In five years retrospective study, we followed up 30 kidney transplant patients in the first post-transplant year. All patients data - blood pressure, BMI, ECG, blood haemoglobin, serum protein, calcium, phosphorus, product of calcium and phosphorus, the values of parathyroid hormone, serum creatinine and creatinine clearance were recorded just before kidney transplantation and in one month interval after transplantation in the first post-transplant year. Echocardiographic examination was done before transplantation and one year after kidney transplantation. Before transplantation, 33% of patients had normal echocardiographic finding and 67% of patients had echocardiographic signs of left ventricular hypertrophy. After first post-transplant year, 63% of patients showed normal echocardiographic finding of LV, while 37% of patients remained with LV hypertrophy. Diastolic dysfunction of LV until the end of study had been reduced in 40% of pts compared to 70% pts at the beginning of the study. The positive echocardiographic remodelling of LV significantly correlated with rising values of haemoglobin (p<0.05), creatinine clearance (p=0.039) and with the reduction of the serum creatinine values (p=0.047), as well as values of parathyroid hormone (p=0.022). These results confirmed positive relationship between echocardiographic remodelling of left ventricular hypertrophy and elimination uraemia-related risk factors after successful renal transplantation.

Accelerated atherosclerosis and vascular calcification, with oxidative stress, endothelial dysfunction, and other factors causing the arterial stiffness, increases cardiovascular morbidity and mortality in patients on peritoneal dialysis. The aim of this paper is to assess changes in intima media thickness (IMT) at common carotid arteries (CCA) in patients with stable continuous ambulatory peritoneal dialysis (PD) and examine the relationship of these changes and other risk factors on the occurrence of atherosclerosis. The study was conducted on 35 stable PD patients (25 type 2 diabetic patients), aged 58.6 +/- 10.6 years. CCA-IMT was assessed using ultrasound B-mode technique, bilaterally. Other risk factors for the occurrence of atherosclerosis were monitored through regular laboratory control. One atheromatous plaque was found in 19 patients (54.3%). Among 25 type 2 diabetic patients, vascular calcifications were found in 80% patients. In all PD patients, CCA-IMT is 0.77 +/- 0.23, in PD patients with vascular calcifications CCA-IMT is 1.05 +/- 0.2 mm, while in group without vascular calcifications the value of this parameter is 0.56 +/- 0.09 (p<0.01 ). Significant differences were found between PD patients with and without vascular calcifications on CCA in patients age (p<0.001), as well as values of systolic blood pressure (p=0.001), serum phosphorus (p=0.017), product calcium and phosphorus (p=0.021), CRP (p=0.039), triglycerides (p<0.05) and lipoprotein (a) values (p=0.044). Our results suggest an important determination of common carotid arteries intima media thickness and its relation to other risk factors for the occurrence and progression of atherosclerosis in patients undergoing peritoneal dialysis.

The aim of this study was to analyze the importance of the peritoneal equilibration test (PET) in evaluation of the peritoneal membrane transport status in patients treated with continuous ambulatory peritoneal dialysis (CAPD). The study included 30 adult continuous ambulatory peritoneal dialysis (CAPD) patients, 16 male and 14 female, mean age 61 +/- 16.5 years with a prescription of four exchanges of 2 litres (L) per day, who underwent peritoneal equilibration test (PET). Eleven of patients were diabetics. A modified PET was performed during a 4 hours dwell using 4.25% glucose dialysis solution. The dialysate/ plasma ratio of creatinine (D/P) at the end of the procedure, and the dialysate 240 min/ initial dialysate ratio of glucose (D/Do) were calculated and used as parameter of solute transport. With the test, categorization of patients was possible into high (H), high-average (HA), low average (LA), and low (L) transporters. In multivariate analysis age, gender, time on dialysis, comorbid diseases, diabetes mellitus (DM), serum albumin, were considered as independent factors influencing the PET. Among 30 patients 5 (16.7%) were classified as H transporters, 6 (20%) as HA, and 19 (63.3%) as LA. There were no patients in low category. Creatinine D/P at 4 hours was not different DM and non-DM patients. There were significant differences in gender, comorbid disease, serum albumin, D4/Do glucose and volume drained in 4 hours. The high transporter group had higher proportion of man (p<0.05), higher proportion of patients with comorbid diseases, lower serum albumin concentration (p<0.001), lower D4/Do glucose (p<0.001), and lower drained volume (p<0.001). The PET was en easy, inexpensive, reliable test to assess peritoneal transport type and it also provided information about peritoneal clearance of solutes and ultrafiltration. Peritoneal transport type classification was recognized not only as aid for prescription, but also as a prognostic index.

Lupus nephritis (LN) is an immune inflammation of kidneys caused by systemic lupus erythematosus (SLE), a chronic inflammatory disease that affects the body's immune system. Aim of this study was to analyze clinical manifestation and treatment results of patients with LN. Forty one patients with clinical signs of LN were included in the study. Mean age of patients was 31.9+/-12.1 years in the moment of first diagnosis of LN, with female-male ratio 8:1. Renal disease was pathohistologically (PTH) verified in 53.7% of patients (4 pts with class III, 17 pts with class IV, one pt with class V of lupus nephrites). Patients with high nephrotic proteinuria were treated with pulse dose of methylprednisolone and pulse doses of cyclophosphamide (CYC) in induction therapy. Corticosteroid and CYC were continued according to treatment protocol. The other group of LN patients with lower nephrotic proteinuria was treated with mycophenolate mofetil (MMF) in induction therapy at a dose of 2x1 g/day for six months, and than in maintenance 2x0.5 g/day. The patients with non-nephrotic proteinuria and normal renal function were treated with oral prednisolone 0.75-1 mg/kg/day in a single morning dose, and then gradually reduced to the dose of maintenance. The mean time of patient's follow-up was 10.9+/-4.1 years. Partial renal remission was accomplished in 29.2% pts, and complete remission in 60.9% pts for period of 17.2+/-13.3 months from the beginning of the treatment. Duration of complete renal remission was 30.1+/-19.1 months. During the period of follow-up, 29.3% pts developed at least one nephritic flare and were treated again. These results confirmed that the aggressive form of lupus nephritis should be treated associating cyclophosphamide with corticosteroids therapeutical regiment. MMF is a new promising immunosuppressive drug for a treatment of this serious disease.

The metabolic syndrome (MS) is a multi-factorial disorder which includes a main risk factors associated with the development of cardiovascular, neurologic, renal and endocrine diseases, especially type 2 diabetes. This study has been conducted to estimate the prevalence of the MS in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and its association with cardiovascular morbidity. The study included 37 patients (25 type 2 diabetic patients and 12 non-diabetic patients), who had been on peritoneal dialysis for > 3 months. At the beginning of CAPD treatment (baseline) and at the end of follow-up, we measured: body mass index (BMI), blood pressure, fasting blood glucose, triglycerides and high-density lipoprotein cholesterol (HDLC) and defined the prevalence of the MS using the modified National Cholesterol Education Program (NCEP; Adult Treatment Panel III) for peritoneal dialysis patients. The overall prevalence of the MS was 89.2%. The metabolic syndrome was estimated in all (100%) type 2 diabetic patients (vs. 60% patients on the beginning of CAPD treatment). In non-diabetic peritoneal patients, the MS was estimated in 50% cases, according to 33.3% at the beginning CAPD treatment. Development of the MS was significantly higher in the type 2 diabetic patients in compared with non-diabetic patients until the end of follow-up examination (p=0.0005). The prevalence of LVH in type 2 diabetic patients with the MS was significantly higher (p=0.002) than in non-diabetic peritoneal patients with the MS. We didn't found statistical significantly difference in the prevalence of ischemic heart disease between this two category of peritoneal dialysis patients (p=0.076). The results indicate that the metabolic syndrome is presented in high percentage in peritoneal dialysis patients, and it's also important risk factor of high cardiovascular morbidity rate in these patients, especially in type 2 diabetic patients.