This case demonstrates the importance of rapid diagnostics and aggressive and prolonged treatment of Acinetobacter pitti PD-associated acute peritonitis in order to avoid dropout and lethal outcomes.
Rhizobium radiobacter is an uncommon opportunistic pathogen commonly found in soil. To date, only a few cases have reported R. radiobacter as a cause of PD-related peritonitis. Our patient developed R. radiobacter peritonitis after gardening, presenting with cloudy dialysate without pain or febrility. The infection was successfully treated with cefepime. However, it relapsed one month later, ultimately leading to catheter removal. Physicians must remain vigilant for this rare pathogen despite the much more common causes of peritonitis. Education of patients about the connection between Rhizobium radiobacter, soil exposure, and non-sterile conditions is crucial for prevention of relapses and avoiding the need for catheter removal.
Rhabdomyolysis is a common cause of acute renal failure. It represents a peripheral muscle damage with myoglobinuria and electrolyte disturbances with or without volume changes and renal injury. We present a 47-years-old male patient with traumatic subdural he- matoma who developed acute renal failure after two grand mal seizures. After alkalization, hydration and diuretic treatment renal failure subsided and the patient underwent successful evacuation of hematoma. We discuss the pathogenic mechanisms of development of acute renal injury in rhabdomyolysis.
Introduction. Diabetes, hypertension, or genetic predispositions often cause chronic kidney disease (CKD), which is characterized by a persistent decline in renal function. As CKD develops through five stages, i.e. from a moderate impairment to an end-stage renal failure, a prompt treatment becomes critical. Kidney transplantation is frequently the recommended treatment for individuals with end-stage renal disease, since it provides a better long-term survival and quality of life compared to dialysis. Despite breakthroughs in transplantation and immunology, complications continue to pose substantial hurdles. Case report. This case report details the clinical progression of a 55-year-old male patient who underwent a living donor kidney transplant. Serious complications with the kidney graft, such as renal vein rupture and hematoma, necessitated rapid revision and a graft im- plantation during surgery. The patient had hemodynamic instability, requiring hemodialysis and inotropic support. Despite many challenges, we explanted the graft and the routine monitoring revealed no cytotoxic HLA antibodies. Unexpectedly, the patient restored his kidney function, which ultimately led to his release into a stable condition. The discussion underscores the critical importance of a holistic and multidisciplinary approach in kidney transplantation. Preoperative optimization and careful intra-operative management are key factors for risks reduction, while regional anesthesia plays a significant role in enhancing patient comfort and outcomes. The paper further highlights the complex, multifactorial nature of post-transplant complications. Conclusion. This paper reinforces the need for a com- prehensive, multidisciplinary approach to kidney trans- plantation, with particular attention to the unique im- portance of living donor grafts, ultimately leading to enhanced patient survival and quality of life.
Introduction. Benign prostatic hyperplasia/Benign prostatic obstruction (BPH/BPO) and chronic kidney disease (CKD) are two important public health problems in elderly men, with a huge medical and social impact on rapidly aging population globally. Clinical studies have proven obstruction of the lower urinary tract, secondary to BPO as a cause of a decreased renal fun- ction and CKD development. Conversely, the reverse process of the lower urinary tract obstruction relieve should be improving the renal function. The aim of this study is to evaluate the possibility of simultaneous improvement in renal function with transurethral prostate surgery for treatment of BPO. Methods. A randomized, study (1:1) initiated in July 2022 at the University clinic for urology in Skopje, Republic of N Macedonia, was conducted on 40 patients with BPO to compare the efficacy and safety of the two endourological transurethral surgical methods for BPO treatment: in our country the recently introduced Tm:YAG laser transurethral vaporesection of the prostate (ThuVARP) and the traditional and well-established method of transurethral resection of the prostate (TURP) by using high-frequency electric current (TURP). For evaluation two types of indicators were used, BPO related and renal function (RF) related indicators. The BPO related indicators (International Prostate Symptom Score-IPSS, maximum flow rate- Qmax, prostate volume-V, and post-void residual urine volume-PVR) were assessed preoperatively and reassessed at 6 months postoperatively. RF related indicators (serum potassium, serum creatinine, and estimated glomerular filtration rate (eGFR) evaluated with the 2021 Creatinine equation (CKD-EPI) were also assessed preoperatively and reassessed after 7-10 days, postoperatively. By comparing the pre and postoperative values within each surgical group, conclusions were drawn about the possible effect of BPO surgery on renal function improvement. Other risk factors for CKD like diabetes, hypertension, smoking, obesity, dyslipidemia and metabolic syndrome were not considered in this study. Results. Significant improvements were observed postoperatively in all BPO related indicators in both surgical groups. In the ThuVARP group, Qmax increased from 6.06 ± 2.1 to 16.59 ± 6.2 ml/s (p=0.00) and IPSS, prostate V and PVR decreased from 25 ± 1.9 to 3.56 ± 5 (p=0.00); 61.4 ± 33.4 to 26.2 ± 11.9 ml (p=00); and 142.8 ± 79.1 to 7.97 ± 11ml (p=0.00); and ml (p=0.00), respectively. In the TURP group, Qmax increased from 7.96 ± 3.5 to 18.14 ± 6.6 ml/s (p=0.00); and IPSS, prostate V and PVR decreased from 22.89 ± 4.4 to 6.68 ± 5 (p=0.00); 61.5 ± 16.2 to 21.13 ± 14.4 ml (p=0.00); and 128.9 ± 86.1 to 23.45 ± 47.2 ml (p=0.00), respectively. RF related indicators also presented significant improvements postoperatively. In the ThuVARP group, serum potassium and serum creatinine decreased from 4.44 ± 0.5 to 4.17 ± 0.4 mmol/l (p=0.019) and 86.77 ± 23.2 to 78.84 ± 19.3 (p=0.029), respectively and eGFR increased from 83.26 ± 18.3 to 88.63 ± 88.63 ± 15 ml/min/1.73m2 (p=0.049). In the TURP group, serum potassium and serum creatinine decreased from 4.32 ± 0.3 to 4.13 ± 0.5 mmol/L (p=0041); and 78.59 ± 12.3 to 73.44 ± 12 nmol/L (p=0.004), respectively and eGFR, increased from 89.05 ± 11.8 to 93.65 ± 10.70 ml/min/1.73m2 (p=0.0028). Conclusion. Our findings suggest that prostate surgery with consecutive relief of the lower urinary tract obstruction, regardless of the chosen method (ThuVARP or TURP) may improve the renal function and be potentially benefitial in CKD patients.
A healthy urinary tract is not a sterile environment but is inhabited by diverse microorganisms that change according to environmental factors and the patient's condition. Elderly patients are predisposed to urinary tract infections and asymptomatic bacteriuria, and distinguishing between these two conditions is challenging. They are specific in several issues: the pathogenesis of infection and causative agents, diagnostic procedures, applied therapy, and preventive measures. Proper interpretation of symptoms, sampling of materials for analysis, and interpretation of results are of great importance. Correct procedures allow sparing patients from unnecessary treatment and complications of antibiotic therapy, as well as reducing bacterial resistance.
Introduction. Prostate cancer, the second most common cancer in males globally, frequently requires radical prostatectomy. Laparoscopic radical prostatectomy, a common approach, has uncertainties regarding pain reduction. This study investigates ultrasonography-guided erector spinae plane block for pain management in laparoscopic radical prostatectomy. Methods. This one-year prospective study involved 50 American Society of Anesthesiology classification I- III male patients (age 40-78) undergoing laparoscopic radical prostatectomy. An ultrasonography-guided erector spinae plane block was performed before surgery after induction of anesthesia. Postoperatively, pain was assessed using a numerical rating scale. Postoperative nausea and vomiting were evaluated using a verbal descriptive scale. Total time for block performance, anesthesia and surgery time, and any complications was noted as well. Results. The study demonstrated that erector spine block improved pain management in laparoscopic radical prostatectomy patients. At different times after surgery, numerical rating scale scores, rescue analgesia needs, postoperative nausea and vomiting scores were reduced with no adverse effects on the kidney function. Conclusion. This evaluation supports the beneficial role of ultrasonography-guided erector spine block in enhancing pain control during laparoscopic radical prostatectomy preventing any acute or chronic kidney injury.
Introduction. Antibodies to human leukocyte antigens (HLA) are one of the major immune barriers to successful organ transplantation. In addition to complementdependent cytotoxicity (CDC) assay as a standard method for the HLA antibodies detection, more sensitive solid-phase assays like Luminex were introduced. The aim of this study was to define mean fluorescence intensity (MFI) cutoff values of HLA Class I antibodies detected by Luminex from those detected by CDC given the possibility to use only Luminex assay in HLA antibody screening. Methods. This is a retrospective analysis of the HLA antibody screening results of patients on a kidney transplant waiting list, performed at the Tissue Typing Laboratory, Clinical Hospital Center Rijeka, Croatia, from January 2012 to July 2019. The study included 1,665 sera tested in parallel by CDC and Luminex techniques. Results. Almost half sera contained HLA antibodies (47.9%), significantly more detected by the Luminex than a CDC method. Antibodies against HLA-A and HLA-B molecules had higher MFI values, relative to the HLA-C antibodies, as well as antibodies detected by Luminex and CDC than those detected by Luminex alone. A cutoff MFI≥9,204 for Luminex detected HLA Class I antibodies correlated with positivity in the CDC assay. Besides MFI, several factors need to be taken into consideration in interpreting test results to identify unacceptable antigen mismatch. Conclusion. The results of this analysis suggest that the current features of the Luminex technique provide the most benefit in the HLA antibody scre.
AbstractIntroduction. Monitoring of graft function by creatinine concentrations in serum and calculated glomerular filtration rate (GFR) is recommended after kidney transplantation. KDIGO recommendations on the treatment of transplant patients advocate usage of one of the existing mathematical equations based on serum creatinine. We compared clinical application of three equations based on serum creatinine in monitoring the function of transplanted kidney. Methods. A total number of 55 adult patients who received their first renal allograft from living donors at our transplant center in between 2011-2014 were included into the study. Renal allograft GFR was estimated by the Cockroft-Gault, Nankivell and MDRD formula, and correlated with clinical parameters of donors and recipients. Results. The mean age of recipients was 35.7±9.5 (range 16-58), and the mean age of donors was 55.5±9.0 (34- 77) years. Out of this group of 55 transplant patients, 50(90.91%) were on hemodialysis (HD) prior to transplantation. HD treatment was shorter than 24 months in 37(74%) transplant patients. The calculated GFR with MDRD equation showed the highest mean value at 6 and 12 months (68.46±21.5; 68.39±24.6, respectively) and the lowest at 48 months (42.79±12.9). According to the Cockroft&Gault equation GFR was the highest at 12 months (88.91±24.9) and the lowest at 48 months (66.53±18.1 ml/min). The highest mean level (80.53±17.7) of the calculated GFR with the Nankivell equation was obtained at 12 months and the lowest (67.81±16.7 ml/min) at 48 months. The values of Pearson’s correlation coefficient between the calculated GFR and the MDRD at 2 years after transplantation according to donor’s age of r=-0.3224, correlation between GFR and the Cockfroft & Gault at 6 and 12 months and donor’s age (r=-0.2735 and r=-0.2818), and correlation between GFR and the Nankivell at 2 years and donor’s age of r=-0.2681, suggested a conclusion that calculated GFR was lower in recipients who had an older donors. Conclusion. Our analysis showed difference in the calculated GFR with different equations at the same time points. Using one mathematical equation during the total post-transplantation period would be a recommended method in order to eliminate the discrepancy in determining the stage of kidney failure.
Abstract A 21-year-old female patient with abdominal pain, vomiting and constipation was admitted to the hospital with the possible diagnosis of diabetic ketoacidosis. Due to increased abdominal pain and constipation the patient underwent a surgery with the diagnosis of ileus. However, no pathological findings were found in the abdominal organs apart from serous fluid in the abdominal cavity. The patient became hypertensive, tachycardic and had an episode of seizures postoperatively. Neurological manifestations with unexplained abdominal pain indicated a diagnosis of acute intermittent porphyria (AIP). Acute intermittent porphyria diagnosis is based on elevated urinary δ-aminolevulinic acid (ALA) and porphobilinogen (PBG) levels as well as hydroxymethylbilane synthase (HMBS) IVS13-2 A>G heterozygous mutation. Familial Mediterranean Fever (FMF) gene mutations were not confirmed. Porphyria should be considered in the differential diagnosis of patients with recurrent abdominal pain, neurological symptoms and lack of FMF gene polymorphism.
Abstract Studies have documented independent contribution of sympathetic activation to the cardiovascular disease continuum. Hypertension is one of the leading modifiable factors. Most if not all the benefit of antihypertensive treatment depends on blood pressure lowering, regardless how it is obtained. Resistant hypertension is defined as blood pressure that remains uncontrolled in spite of the concurrent use of three antihypertensive drugs of different classes. Ideally, one of the three drugs should be a diuretic, and all drugs should be prescribed at optimal dose amounts. Poor adherence to antihypertensive therapy, undiscovered secondary causes (e.g. obstructive sleep apnea, primary aldosteronism, renal artery stenosis), and lifestyle factors (e.g. obesity, excessive sodium intake, heavy alcohol intake, various drug interactions) are the most common causes of resistant hypertension. Cardio(reno)vascular morbidity and mortality are significantly higher in resistant hypertensive than in general hypertensive population, as such patients are typically presented with a long-standing history of poorly controlled hypertension. Early diagnosis and treatment is needed to avoid further end-organ damage to prevent cardiorenovascular remodeling. Treatment strategy includes lifestyle changes, adding a mineralocorticoid receptor antagonist, treatment adherence in cardiovascular prevention and, in case of failure to control blood pressure, renal sympathetic denervation or baroreceptor activation therapy. The comparative outcomes in resistant hypertension deserve better understanding. In this review, the most current approaches to resistant hypertension and cardiovascular risk based on the available literature evidence will be discussed.
AbstractIntroduction. Contrast-induced-nephropathy (CIN) is a common complication during angiography that may lead to long-term complications. This study was conducted to investigate the effect of melatonin administration on prevention of CIN in patients who underwent coronary angiography with intra-arterial contrast agents. Method. This is single-blind randomized clinical trial that was performed over 100 patients with indication for coronary angiography. Patients are randomly assigned to two equal groups. All patients in the 12 hours before and 12 hours after the procedure, were received adequate intravenous hydration with normal saline and for the intervention group in addition to hydration, the day before angiography and immediately after angiography 3 mg melatonin was administered. For all patients, serum level of creatinine (Cr), blood urea nitrogen (BUN) and glomerular filtration rate (GFR) before and 48 hours after the procedure were measured. Data were analyzed using SPSS 18 software. Results. Totally 100 participants with the mean age of 64.0±8.2 years were enrolled (63% male). There was no significant difference between intervention and control groups in baseline and demographic characteristics (P> 0.05). Although the mean serum Cr and BUN level increased in both groups, but the mean Cr, BUN and GFR before and after coronary angiography was not statistically significant. Based on the definition of CIN in the current study, 3(6%) patients from intervention group and 2(4%) patients from control group were affected by CIN (P = 0.243). Conclusion. It is likely that, melatonin administration has no significant effect on prevention of CIN following coronary angiography.
Abstract First renal transplantation in Montenegro was performed on September 25th, 2012. Since then, 32 transplantations have been performed. Only one was from deceased donor, the remaining were from living donors. 40.4% of all patients with end-stage renal disease currently live with the functioning renal allograft (190 patients on dialysis, 129 transplanted patients). There are 32 patients on the waiting list. Further efforts will be focused on development of the deceased donor program and introduction of the AB0 incompatible renal transplantations.
AbstractIntroduction. None of the classification systems in immunoglobulin A (IgA) nephropathy has been widely agreed or implemented by clinicians or pathologists. In order to meet this need, "Oxford Classification System", which is highly reproducible and predictive for clinical course, was developed in 2009. In the present study, we investigated clinical and pathological characteristics of patients with IgA nephropathy based on current classification and the predictivity of crescent presence on prognosis. Methods. The study comprised 40 patients with diagnosis of primary IgA nephropathy on renal biopsy. The biopsy findings and follow-up parameters of patients were retrospectively re-evaluated. Pathological findings were examined based on the Oxford classification system. The presence of crescent formation in the specimens was noted. Results. The presence of crescent formation was predictive of poor prognosis regarding the glomerular filtration rate (eGFR), the level of proteinuria, and mean arterial pressure (MAP). Conclusion: Considering the importance of crescent formation in prediction of the clinical course and need for immunosuppressive therapy, it is suggested that crescent presence can be included in this classification system.
Abstract Amiodarone is a potent inhibitor of CYP3A4 and can increase serum concentrations of drugs that are substrates of this enzyme system. Immunosuppressive drugs are also metabolized through the cytochrome metabolic pathway what may lead to important drug-drug interactions. A 60-year-old female received her second allograft from the deceased donor and was treated with tacrolimus, mycophenolate mofetil and steroids. Amiodarone was introduced for treatment of paroxysmal atrial fibrillation four days after the transplantation. One month after the discharge she was readmitted to hospital for evaluation of the creeping creatinine. Biopsy showed borderline acute rejection. She received 3 boluses of 6- methilprednisolone but creatinine continued to rise. Repeated biopsy was without signs of rejection with mild interstitial fibrosis/tubular atrophy, mild global glomerulosclerosis and moderate arterial sclerosis. However, tubular vacuolization was prominent. After careful revision of her therapy we decided to replace amiodarone with sotalol. One week later her creatinine fell from 350 to 220 μmol/l and remained stable. This case illustrates possible amiodarone nephrotoxicity in a renal transplant recipient. We suggest that patients who need amiodarone in combination with tacrolimus be closely monitored by both cardiologists and nephrologists, with frequent determinations of tacrolimus trough levels and serum creatinine measurements.
Abstract Propionibacterium acnes is a gram-positive human skin commensal that is involved in the pathogenesis of acne and prefers anaerobic growth conditions. It has been considered as a low virulence pathogen in different clinical conditions. We present the case of acute peritonitis caused by Propionibacterium acnes in a peritoneal dialysis patient.
Abstract Introduction. Bone disease is a chronic complication of chronic kidney disease and major clinical problem in hemodialysis (HD) patients. The aim of our study was to assess the influence of treatment longevity on biochemical parameters of mineral and bone metabolism in HD patients, and to identify the most important parameters. Methods. The research was observational and retrospective, involved 70 patients, mean age 58.69±12.54, divided into groups in respect to the duration of dialysis treatment (Group I-5 years, Group II-5-10 years and Group III-over 10 years). Results. Serum phosphorus was increased, but the values tend to increase along with dialysis duration - (Group I: 1.93±0.45; Group II: 1.97±0.50; Group III: 2.01±0.37; p>0,05). Calcium values were also not significantly increased based on the duration of treatment [Group I: 2.3 (2.2-2.41); Group II: 2.46 (2.15-2.6), Group III: 2.35 (2.10-2.52)]. Dialysis and PTH correlated positively in the first group of patients (Rho=0.470, p=0.013). The values of calcium and alkaline phosphatase correlated positively in all patients (Rho=0.351, p=0.003). PTH was significantly higher in the second and third compared to the first group (p=0.009 and p=0.038, respectively), and there was no significant difference between the second and the third group. Interestingly, parathyroidectomized patients had higher PTH values compared to those without parathyroidectomy (557 vs. 359 pg/ml). Conclusion. The most reliable marker for clinical monitoring of bone disease in dialysis patients is PTH. The values of calcium and phosphorus are highly variable and not reliable parameters for bone disease follow-up.
Abstract Introduction. Extracellular sodium (Na+) concentration is maintained within a tight physiological range due to hormonal control, that mainly modulates thirst, Na+ and water renal excretion. Extra-renal regulation of Na+ and water homeostasis is only partially understood. Recently it has been debated whether the osmotically inactive Na+ storage is fixed or variable. Methods. In the present study, fourteen End-Stage Renal Disease (ESRD) patients treated by chronic hemodialysis underwent by accident to a sharp increase in plasmatic calcium (Ca+2) levels due to the failure of the water control system, leading to the so-called hard water syndrome. The levels of plasmatic Ca+2 after 1 hr of hemodialysis were correlated with urea, Na+, potassium (K+) and creatinine levels. Eleven ESRD patients treated with hemodialysis under similar conditions were used as controls. Results. The hard water syndrome resulted in hypercalcemia, while mean plasma levels of Na+, K+ and urea were not different compared to controls. Plasma creatinine levels were slightly but significantly higher that control. A correlation analysis on the measured variables has showed a positive correlation between plasma Ca+2 and Na+ levels (Pearson=0.428, p=0.032), and the absence of any correlation with K+, creatinine and urea concentration. Conclusions. Our study suggests that acute changes in plasmatic Ca+2 levels may affect Na+ concentration in the absence of renal function; it is possible that hypercalcemia may trigger Na+ release from the osmotically inactive storage. These data further support previous observations on the interplay of sodium and calcium at extrarenal sites.
