Rhabdomyolysis is a clinical syndrome characterized by necrosis of skeletal/striated muscle tissue and the release of intracellular elements into circulation, dominated by markedly elevated creatine kinase (CK) levels, myoglobinuria, and muscle weakness. Among the drugs that cause rhabdomyolysis, statins are most well-known, but many other drugs and their interactions can also trigger it. Polypharmacy nowadays represents a significant clinical challenge, especially in elderly patients and those with chronic illnesses. Combination of multiple drugs can lead to serious adverse effects. This paper presents a case in which the interaction between statins, ezetimibe, cyclosporine and clarithromycin led to the development of clinically significant rhabdomyolysis. Caution when prescribing medications, regular therapy reviews, and the use of available interaction-checking tools are key to preventing such adverse events.

Chronic kidney disease is increasingly recognised as a systemic disorder with important neurological consequences, including cognitive impairment. However, the field remains challenging because CKD-related cognitive decline involves diverse uremic toxins, overlapping vascular, inflammatory, metabolic, endothelial, and neurodegenerative pathways, inconsistent cognitive screening practices, and no unified treatment strategy. Within this context, the kidney-brain axis provides a useful framework for integrating renal dysfunction, toxin retention, systemic inflammation, blood-brain barrier disruption, and cognitive vulnerability. Of these mechanisms, uremic neurotoxicity offers a biologically credible connection between compromised renal clearance and cerebral dysfunction. Retained solutes such as indoxyl sulfate, p-cresyl sulfate, indole-3-acetic acid, trimethylamine-N-oxide, urea, guanidino compounds, lanthionine, quinolinic acid, and homocysteine may induce endothelial injury, oxidative stress, neuroinflammation, mitochondrial dysfunction, excitotoxicity, and glial activation. Although these pathways are supported by experimental and translational studies, direct causal evidence in humans remains limited, and most clinical data should currently be interpreted as associative rather than definitive proof of causality. These processes converge on neuronal and synaptic vulnerability and may elucidate the distinctive cognitive profile associated with chronic kidney disease, particularly deficits in attention, processing speed, and executive function. This review summarizes the most recent evidence on the epidemiology and clinical phenotype of cognitive impairment in chronic kidney disease. It also discusses the molecular and cellular mechanisms of uremic neurotoxicity and examines new biomarkers of the kidney-brain axis, including neurofilament light chain, glial fibrillary acidic protein, brain-derived neurotrophic factor, tight junction proteins, and uremic toxins. However, these biomarkers remain insufficiently validated for routine clinical use, as their interpretation is complicated by reduced renal clearance, systemic inflammation, comorbid vascular disease, methodological heterogeneity, and the lack of longitudinal studies linking biomarker changes to cognitive outcomes. Therapeutic strategies targeting uremic toxins remain compelling from a mechanistic standpoint, but they are not yet fully developed in clinical practice. Subsequent research ought to amalgamate toxin profiling, cognitive phenotyping, neuroimaging, endothelial and inflammatory biomarkers, alongside patient-centered outcomes. Integrating cognitive assessment into nephrology care may enhance risk stratification, collaborative decision-making, and personalised management for patients with chronic kidney disease.

Introduction: Melanoma often metastasizes to the liver, leading to significant morbidity and mortality. Liver injury can also occur due to hepatitis caused by immunotherapy used in the treatment of melanoma. Case Presentation: This case report presents a 38-year-old male diagnosed with advanced melanoma who experienced acute liver failure (ALF) initially thought to be a side effect of immunotherapy. Despite following aggressive supportive care as per the latest guidelines, the patient’s condition deteriorated rapidly. It was discovered that the patient had liver metastases. As the tumor had a positive BRAF mutation, we opted for invasive treatment with therapeutic plasma exchange to restore liver function and create the conditions for initiating treatment with BRAF/MEK inhibitors. After the use of a liver support device, the liver function was resolved, and a BRAF/MEK inhibitor was introduced. After 2 months of targeted therapy, a favorable effect and good melanoma control are observed. Conclusion: The report underscores the complexity of managing melanoma with liver metastasis and the urgent need for advancements in treatment modalities ALF in oncology patients. We suggest that invasive treatment methods, such as liver support system devices, should be considered in well-selected oncology patients, even in advanced stages of disease.

This report describes data collected by the Croatian Registry of Renal Biopsies (CRRB) for the period of 5 years. The aim of this study is to report the relative frequency of nephropathies according to gender, age, clinical presentation, and renal function at the time of renal biopsy based on the histologic diagnosis. Ten centers (90%) provided the data for 1732 native kidney biopsies during the period 2019-2023. We assessed the anthropometric data, data on kidney function(eGFR), 24-hour proteinuria, hematuria, serum albumin level, arterial hypertension, histological diagnosis, and complications after renal biopsy. Examined group consisted of 58% males, median age 55 y (18–93 y) and 42% women, median age 56 y (18–87 y). Biopsy rate of 86, 6 p.m.p./year was relatively constant through the 5-year period except for pandemic years 2020 and 2021 when it was reduced by half. Males had a more impaired renal function at the time of renal biopsy (eGFR 53.1 vs 60 ml/min/1.73 m2P < 0.001), nephrotic syndrome (24-hour proteinuria 4.9 vs 3.8 g/dU P < 0.001), and hypertension (139/83 vs 133/81 mmHg P < 0.001). The most prevalent clinical presentations were urinary abnormalities e.g. asymptomatic proteinuria and hematuria (32.9%) and nephrotic syndrome (28.3%) Among all biopsy cases, primary glomerular diseases were the most prevalent histology group (45.2%); IgA nephropathy (IgAN) being most frequent (39.5.1%), followed by focal segmental glomerulosclerosis (FSGS) (27.6%) and membranous nephropathy (MN) (19.1%). Secondary glomerular diseases were diagnosed in 33.1% of cases. Within secondary glomerular diseases, pauci-immune glomerulonephritis (PIGN) was most often found (28.8%), followed by lupus nephritis 19.3% and diabetic nephropathy 16.3%. During the observed period IgAN was the most prevalent disease 16.5% except for the year 2020. when PIGN was most prevalent reflecting the indications for biopsy during COVID pandemic. Incidence of IgAN decreased from 2.5 to 2.2/per 100 000 population during the 5 year period while FSGS increased 1.4–2.1/per 100 000 population. Among secondary causes we observe increase in incidence of diabetic nephropathy by 25% and decrease of vascular causes by 22%. The most common disease in patients presented with nephrotic proteinuria was minimal change disease (MCD) (78%) and membranous nephropathy 75% in those presented with urinary abnormalities thin membrane disease (55%) and lupus nephritis (53%) and in nephritic syndrome acute tubulointerstitial nephritis (25%) and acute tubular injury (23%). Patients with DN had the highest blood pressure levels (147/82 mmHg) at the time of kidney biopsy. Patients older than 65 years had higher sCr (263 vs 183 μmol/l) and proteinuria (4.79 vs 4.29 g/dU). Most prevalent diagnosis in older group was PIGN. There were no significant differences in any parameters between continental and Mediterranean part of Croatia. The frequency of severe complications ( symptomatic hematoma, blood transfusion or gross hematuria) was 6%. CRRB provides representative data of the epidemiology of biopsy proven renal disease in Croatia. Availability of these data will be a valuable source to nephrologists to stimulate further research and comparison with other national registries.

Kidney disease is an increasing global health problem involving about 10% of the global population. Increasing prevalence of diabetes, hypertension and obesity are likely to increase kidney disease prevalence with serious implications for quality of life, survival and health care costs. Early detection is the key strategy to prevent kidney disease. Primary care practitioners (PCP) are crucial in early identification and management of patients with CKD. The aim of this study is to report first results of Early detection program of CKD in Croatia, obtained through new, digital interactive tool “Chronic Kidney Disease Preventive Panel”. Croatian Society of Nephrology, Dialysis and Transplantation and Association of Croatian Family Physicians launched “Chronic Kidney Disease Preventive Panel”—an interactive, innovative, digital tool for detecting, monitoring and standardizing comprehensive care of patients with CKD on PCP level through interactive interface depending on the degree of renal disfunction according to the latest KDIGO guidelines. The panel has been implemented in electronic health charts of 2300 family medicine practices with intention to facilitate screening of CKD in high risk populations (diabetic, hypertensive and obese population). The CKD Preventive Panel collects anthropometric data, gender, age, medical history, blood pressure values, serum creatinine (sCr), eGFR, albumin/creatinine ratio (ACR) and calculate staging and risk of progression of kidney disease according to KDIGO guidelines for management of CKD. results are shown for the first 6 months of using the CKD Preventive Panel (May 2024–October 2024). During observed period 10 497 records were obtained, 44% males and 56% women. The number of screened patients varied from month to month between 1400–2300 per month. Most patients were screened in first three stages of CKD, G1 26.6%, G2 41.1% and G3a 16.7 %. Of all enrolled patients blood pressure values were recorded in 78% patients, sCr and eGFR 83% and ACR in only 20%. Of all screened patients 93.6% had hypertension, 44.4% had diabetes and 21.4% were obese. Average blood pressure values increased with declining renal function in G1 130/77 mmHg to 154/98 mmHg in G5 stage. Average eGFR for the whole group was 75.1 ml/min/1.73 m2 and average ACR 2.8 mg/mmol. 32.3% of patients had eGFR <60 ml/min/1.73 and 41.8% of patients had ACR > 3mg/mmol. According to KDIGO guidelines, CKD Preventive Panel instructed PCPs to continue following up 94% of screened patients and 6% were referred to nephrologist. Kidney disease were classified as newly diagnosed CKD in 29.8% of patients. This is the first organized program for early detection of CKD in Croatia. The response from PCPs exceeded expectations in number of screened patients, which we attribute to the simplicity and instructiveness of the Panel, which has enabled PCPs to deal with kidney patients using uniform guidelines more easily and quickly, thus reducing their workload. CKD Panel already showed some shortcomings in care of CKD patients like low usage of ACR in diagnosing kidney disease. However, we expect that true value of CKD Panel has yet to be demonstrated in monitoring the outcome of patients with CKD who were screened and treated with new drugs expecting to reduce progression of the disease and decreasing the complications of CKD.

Background/Objectives: The interplay between thyroid function and kidney graft function following kidney transplantation remains incompletely understood. Thyroid disorders are more prevalent in kidney transplant recipients than in the general population and are associated with poorer outcomes. Methods: This prospective, single-center study was designed to estimate thyroid function (thyroid-stimulating hormone (TSH), triiodothyronine (T3), free triiodothyronine (FT3), thyroxine (T4), free thyroxine (FT4), as well as anti-thyroid peroxidase antibody (anti-TPO), anti-thyroglobulin antibody (anti-Tg), and thyroid-stimulating immunoglobulin (TSI)) and its influence on kidney graft function among a cohort of 23 kidney transplant recipients during a follow-up period of 12 months. Results: Significantly increased levels of T4 and T3 were observed 12 months post-transplantation, with FT3 levels increasing significantly after 6 months. The prevalence of immeasurably low anti-Tg antibodies rose during follow-up. Initially, 8% of patients showed positive TSI, which turned negative for all after 6 months. A statistically significant correlation was found between the initial TSH and the estimated glomerular filtration rate (eGFR) value 6 months after transplantation (p = 0.023). The graft function was stable. Proteinuria was statistically significantly lower 12 months after transplantation. Conclusions: Identifying additional risk factors, understanding their impact on kidney graft function, and recognizing cardiovascular comorbidities could enhance patient care. Notably, this study marks the first prospective investigation into thyroid function after kidney transplantation in Croatia, contributing valuable insights to the global understanding of this complex interplay.

Abstract Background and Aims SGLT2 inhibitors, namely dapagliflozin, proved to slow progression of kidney disease in randomized clinical trials. Our aim was to assess real world efficacy of dapagliflozin on proteinuria level in primary glomerulopathies (GN). Method adult patients with biopsy proven glomerulonephritis from all university hospitals in Croatia who started dapagliflozin as a standard of care were enrolled. Data were analyzed if patients had at least six months of follow up. None of the patients were on immunosuppression. Data are shown as N (%) or median with interquartile range (IQR) and accompanied p levels. Results Overall 118 patients, predominantly male 84 (71.8%) of average age of 52 years (min–max 20–76), were enrolled. Most of the patients had IgA nephropathy (IgAN) (N = 55;46.6%), followed by membranous nephropathy (N = 27;22.9%), FSGS (N = 19;16.1%), membranoproliferative GN (N = 8;6.8%), Alport syndrome (N = 8;6.8%). 95.8% of patients were on ACE inhibitors or angiotensin receptor blockers and 10.7% were on mineralocorticoid receptor inhibitors and RAAS blockage was not significantly upscaled during follow up. During the median follow up of 12.2 (7.5-18.6) months, proteinuria was significantly reduced from 1139 (534–2265) to 701 (305-1543) mg/dU; p &lt; 0.001. When divided by glomerulonephritis type, statistically significant reduction of proteinuria was observed in patients with IgAN and Alport syndrome, while trend of reduction of proteinuria was observed in all types of GN. There was a slight reduction in eGFR levels (54 (43-78) vs. 52 (39–73) ml/min/1,73 m²; p &lt; 0.001) and rise in creatinine values (122 (89–149) vs. 128 (91–159) μmol/l; p &lt; 0.001). There was a significant reduction in systolic (130 (120-140) vs.125 (115-134) mmHg; p &lt; 0.001) and diastolic blood pressure (80 (75-90) vs. 80 (70-85) mmHg; p &lt; 0.001). Reduction of uric acid level was noticed (377 (313–460) vs.343 (294–422); p &lt; 0.001), while there was no effect on LDL levels (2.6 (2.12–3.53) vs.2.3 (1.9–3.30); p = 0.073). Dapagliflozin was well tolerated, one patient discontinued the therapy due to intolerance, one due to urinary infection and two due to relapse of GN which needed immunosuppressive therapy. One patient was excluded from analysis due to non-adherence. Conclusion SGLT2 inhibitor dapagliflozin has significant effect on reduction of proteinuria in patients with primary glomerulonephritis. Our data support a growing body of evidence that SGLT2 inhibitors should be used as a standard of care in patients with glomerular kidney diseases, especially IgAN. Future research should address earlier use of SGLT2 inhibitors during the treatment of glomerulonephritis alongside immunosuppressive therapy as well as look into the effect of SGLT2 inhibitors on mesangial cells.

BACKGROUND:The interplay between peritoneal dialysis (PD), residual kidney function (RKF), and thyroid function remains poorly understood, with limited prospective studies comparing thyroid function in PD versus hemodialysis (HD) patients. METHODS:This prospective single-center study assessed thyroid function in 18 PD patients over a 24-month follow-up period at the Department of Nephrology, Dialysis, and Kidney Transplantation, UHC Rijeka, Croatia. Data were compared to 24 concurrently treated HD patients. RESULTS:Initially, some PD patients exhibited elevated TSH levels, which normalized during follow-up despite longer dialysis duration. Compared to HD patients, PD patients demonstrated significantly higher T4 concentrations at baseline and higher FT4 concentrations at 12 and 24 months. Furthermore, FT3 levels were significantly higher in PD patients at baseline and at both 12 and 24 months, with T3 levels also within the reference interval after the beginning of the study. Additionally, a positive association was observed between T4 levels and 24-h diuresis after 12 months in PD patients. CONCLUSION:Recognizing additional risk factors and potential impacts on RKF and cardiovascular comorbidities in dialysis patients can enhance patient care, influence dialysis modality selection, and guide ongoing patient monitoring. Thorough evaluation of thyroid function in PD and HD patients is essential for optimizing clinical outcomes and overall well-being. This study contributes to understanding the complex interplay between thyroid function, RKF, and dialysis modality, emphasizing the need for further research to inform comprehensive patient care strategies.

Tetralogy of Fallot is the most common cyanotic congenital heart disease. This severe disorder of cardiac physiology can impair renal function and lead to the development of cardiorenal syndrome and eventually to end-stage renal disease. Kidney transplantation may be the best option for renal replacement treatment in patients with tetralogy of Fallot, but only after correcting cardiac abnormalities and optimizing cardiac functions, all of which require a multidisciplinary approach. We report the first case of kidney transplantation in an adolescent patient with tetralogy of Fallot. Our findings confirms that kidney transplantation is a valuable treatment option in selected congenital heart disease cases.

Background: This report describes data collected by the Croatian Registry of Renal Biopsies (CRRB) for the year 2019. Patients and methods: nine centers (82%) provided data for 255 native kidney biopsies. We assessed the anthropometric data, data on serum creatinine concentration (sCr), 24 h proteinuria, haematuria, serum albumin level, arterial hypertension, histological diagnosis, and complications after renal biopsy. Results: examined group consisted of 58% males, median age 58 y (18-80 y) and 42% women, median age 57 y (20-86 y). Males had a more impaired renal function at the time of renal biopsy, nephrotic syndrome, and hypertension. The most prevalent clinical presentation were urinary abnormalities (34.9%). Among all biopsy cases, primary glomerular diseases were the most often found histology group (41.5%), and IgA nephropathy was the most frequent diagnosis(47.1%). Among secondary glomerular diseases, pauci-immune glomerulonephritis (PIGN) was most often found (30.9%). The highest proteinuria was observed in minimal change disease and diabetic nephropathy (DN). The highest sCR values were found in membranoproliferative glomerulonephritis (MPGN) and necrotizing vasculitis. Patients with MPGN and DN had the highest blood pressure levels. Conclusion: CRRB provides important data on the epidemiology of biopsy-proven kidney diseases from the whole territory of Croatia

COVID-19 infection in patients treated in dialysis centers is a particular challenge given that there is a significantly increased risk of transmitting the infection to medical staff, other staff of the institution, other patients, and family members of the patients. The purpose of our work is to share our experiences in the implementation of preventive and epidemiological measures with reference to patients on a chronic outpatient hemodialysis program. Nurses play an important role in education and caring for the dialysis patient.

A well balanced, time-restricted diet with 50% more vegetables and restriction of red meat can delay the progression of kidney damage. This paper suggests that such diet changes can also have an immunoregulatory role, with adding pre/probiotics. There were two groups of patients (20M/28F; age 67±9 years, estimated glomerular filtration rate 42,1±12 ml/min/1.73m2): group A practiced a modified diet that consisted of certain nutritional changes (50% more vegetable intake, reduction of red meat to twice per week), time-restricted eating (8 hours), and taking probiotics. Group B was also taking probiotics; however, their nutrition included no restrictions on red meat intake, they ate fewer vegetables, and there was no time-restricted eating. After 3 months, therapy from Group A − a balanced, time-restricted diet plus probiotics, resulted in weight loss (from 113±13 to 110±18 kg), body mass index decrease (from 36.4±5.1 to 34±5 kg/m2), decrease in waist circumference (from 119±11 to 115±10 cm), as well as lower hsC-reactive protein by 8% (group A) and 5% (group B). The values of kidney function measurements after 3 months were 45,3±11 ml/min/1.73m² in group A, while in group B, those were 42,4±10 ml/min/1.73m² (p<0.05). This study shows a positive correlation between the daily consumption of probiotics and decreased progression of chronic kidney disease.

Introduction: primary membranous nephropathy (pMN) is glomerulopathy caused in the majority of cases by autoantibodies to Phospholipase-A2 receptors (PLA2R-AB). This study aimed to evaluate the clinical course and outcomes of the patients with pMN regarding PLA2R-AB status. Patients and methods: 32 patients (21 males, 11 females) with renal biopsy-proven pMN were included in the study. PLA2R-AB (ELI SA method) and outcomes (defined according to KDIGO) were evaluated after 21 and 64 months of follow-up in 28 patients. Results: 19 patients had positive PLA2R-AB (>20 RU /ml) (59.3%), with median titer of 97 (21-1418 RU /ml). The rate of remission in low PLA2R-AB titer group (< 200 RU /ml) after 21 months was significantly higher than in high PLA2R-AB group (> 200 RU /ml) (90% vs. 50%, p=0.045), and after 64 months the difference was not significant (80% vs. 50%, p=0.210). The relapse rate after 64 months was higher in the high PLA2R-AB group (87% vs. 63%). Multivariant linear regression found serum creatinine (ß=0.682, p<0.001) and PLA2R-AB (ß=0.527, p<0.001) as significant predictors for kidney function at the end of follow-up. Conclusion: higher titers of PLA2R-AB are related to worse kidney function outcome, higher 24-hour proteinuria, and a higher number of relapses in patients with pMN.

Background. This article presents a summary of the 2017 Annual Report of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry and describes the epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in 37 countries. Methods. The ERA-EDTA Registry received individual patient data on patients undergoing RRT for ESRD in 2017 from 32 national or regional renal registries and aggregated data from 21 registries. The incidence and prevalence of RRT, kidney transplantation activity and survival probabilities of these patients were calculated. Results. In 2017, the ERA-EDTA Registry covered a general population of 694 million people. The incidence of RRT for ESRD was 127 per million population (pmp), ranging from 37 pmp in Ukraine to 252 pmp in Greece. A total of 62% of patients were men, 52% were >= 65 years of age and 23% had diabetes mellitus as the primary renal disease. The treatment modality at the onset of RRT was haemodialysis for 85% of patients. On 31 December 2017, the prevalence of RRT was 854 pmp, ranging from 210 pmp in Ukraine to 1965 pmp in Portugal. The transplant rate in 2017 was 33 pmp, ranging from 3 pmp in Ukraine to 103 pmp in the Spanish region of Catalonia. For patients commencing RRT during 2008-12, the unadjusted 5-year patient survival probability for all RRT modalities combined was 50.8%.