Patients with chronic kidney disease (CKD), including those with end-stage renal disease, treated with dialysis, or renal transplant recipients have an increased risk for cardiovascular disease (CVD) morbidity and mortality. Dyslipidemia, often present in this patient population, is an important risk factor for CVD development. Specific quantitative and qualitative changes are seen at different stages of renal impairment and are associated with the degree of glomerular filtration rate declining. Patients with non-dialysis-dependent CKD have low high-density lipoproteins (HDL), normal or low total cholesterol (TC) and low-density lipoprotein (LDL) cholesterol, increased triglycerides as well as increased apolipoprotein B (apoB), lipoprotein(a) (Lp (a)), intermediate-and very-low-density lipoprotein (IDL, VLDL; "remnant particles"), and small dense LDL particles. In patients with nephrotic syndrome lipid profile is more atherogenic with increased TC, LDL, and triglycerides. Lipid profile in hemodialysis (HD) patients is usually similar to that in non-dialysis-dependent CKD patients. Patients on peritoneal dialysis (PD) have more altered dyslipidemia compared to HD patients, which is more atherogenic in nature. These differences may be attributed to PD per se but may also be associated with the selection of dialytic modality. In renal transplant recipients, TC, LDL, VLDL, and triglycerides are elevated, whereas HDL is significantly reduced. Many factors can influence post-transplant dyslipidemia including immunosuppressive agents. This patient population is obviously at high risk; hence, prompt diagnosis and management are required to improve their clinical outcomes. Various studies have shown statins to be effective in the cardiovascular risk reduction in patients with mild-to-moderate CKD as well as in renal transplant recipients. However, according to recent clinical randomized controlled trials (4D, A Study to Evaluate the Use of Rosuvastatin in Subjects on Regular Dialysis: an Assessment of Survival and Cardiovascular Events, and Study of Heart and Renal protection), these beneficial effects are uncertain in dialyzed patients. Therefore, further research for the most suitable treatment options is needed.

Nealkoholna masna bolest jetre (engl. nonalcoholic fatty liver disease; NAFLD) najcesca je kronicna bolest jetre danas. Jedna je od manifestacija

Nonalcoholic fatty liver disease (NAFLD) has become a common cause of elevated liver tests. The association between fatty liver and metabolic syndrome (MS) is well documented and widely accepted. Cirrhosis due to nonalcoholic steatohepatitis (NASH) is currently the second most common indication for liver transplant with increasing incidence. Gastroenterologists/hepathologists and primary care physicians have more questions than answers regarding the NAFLD. The most common questions are which NAFLD patients have a risk of progression to NASH, fi brosis, cirrhosis and hepatocellular carcinoma, and which patients with NAFLD have a need for liver biopsy. In addition, a number of non-invasive diagnostic methods in the approach to the patient with NAFLD are investigated. How to approach these patients in routine clinical practice, is more of an art than a science at this time. In this article we will try to provide more recent recommendations of how to approach the patients with NAFLD

AIM: Our aim was to investigate the correlation between Controlled Attenuation Parameter (CAP) and liver stiffness measurements (LSM) values obtained by FibroScan® as measurements of liver steatosis/fibrosis and red blood cell distribution width (RWD) values in patients with one or more components of metabolic syndrome (MS). MATERIALS AND METHODS: In this prospective study we have analyzed 360 patients between April 2014 and October 2015. The HIS, FIB-4 and BARD scores as well as CAP and LSM were obtained to asses liver steatosis and fibrosis. RESULTS: RDW showed significant positive correlation with age, presence of diabetes, hypertension and MS, waist circumference, CRP and uric acid as well as with LSM, HIS and BARD scores as indicators of fibrosis (all p 13.4%), had statistically significantly higher incidence of diabetes, hypertension, MS, higher values of waist circumference. CRP, uric acid, as well as CAP, LSM and FIB-4 and BARD scores in comparison to the patients with lower RDW (≤13.4%) values. In multivariate analysis, RDW continued to be statistically significant and an independent predictor of elevated LSM (OR = 1.88, 95%CI: 1.0226-3.4774, p =0.04) CONCLUSION: RDW, is an inexpensive, non-invasive parameter that can be used for assessment of liver steatosis/fibrosis in NAFLD patients, especially in those with MS. Our results give a possibility that RDW in combination with FibroScan®-CAP or in combination with some other noninvasive markers could identify patients with NAFLD that have a risk for progression of liver disease.

The aim of the present study was to investigate whether patients with inflammatory bowel disease (IBD) have some degree of renal involvement. Furthermore, we investigated whether this connection is related to active bowel disease. In this cross-sectional study, 50 patients diagnosed with IBD, mean age 47.1±16.5 years, were recruited from September 2012 to September 2013. The diagnosis of IBD was based on clinical history, endoscopic, histological and radiological findings. Disease activity was assessed using the UC activity index (UCAI) for ulcerative colitis (UC) and Crohn’s disease activity index (CDAI) for Crohn’s disease (CD). There were 38% of UC patients and 62% of CD patients. The prevalence of abnormal albuminuria in UC and CD patients was 21.1% and 29%, respectively. There was a high negative correlation between duration of bowel disease and 24-h albuminuria in UC patients, as well as a high correlation between albumin-creatinine ratio (ACR) and UCAI score in UC patients, but these correlations were not statistically significant, probably due to the small number of UC patients. On the other hand, estimated glomerular filtration rate (eGFR) showed negative correlation with disease activity in CD patients (r=-0.569; p=0.05), while there was no statistically significant correlation between active UC and eGFR (r=0.343; p=NS). In conclusion, abnormal albuminuria is quite frequent in patients with IBD. It seems that patients with IBD have some degree of glomerular damage, mainly those with CD. Collaborative, prospective studies conducted by gastroenterologists and nephrologists are needed to investigate this association.

Cilj naseg istraživanja bio je utvrditi utjecaj kronicne HCV infekcije na preživljene bolesnika s bubrežnim transplantatom kao i preživljenje samog bubrežnog transplantata. Ispitanici i metode: Retrospektivnom analizom analizirali smo 492 bolesnika u razdoblju od 1990. do 2013.godine koji su bili transplantirani u KBC Rijeka. Od 492 analizirana bolesnika, 471 bolesnik prosjecne životne dobi 50, 2±14 godina bio je HCV negativan. S druge strane, 21 bolesnik prosjecne životne dobi 49±8 godina bio je HCV pozitivan. Rezultati: Nije bilo statisticki znacajne razlike u ucestalosti kriza odbacivanja između HCV pozitivnih i HCV negativnih bolesnika (p=0, 749). Također, nije bilo statisticki znacajne razlike u funkciji bubrežnog transplantata nakon prve (p=0, 798), druge (p=0, 651) i pete (p=0, 651) godine od transplantacije između HCV pozitivnih i HCV negativnih bolesnika. Nismo dokazali statisticki znacajnu razliku u uzrocima gubitka bubrežnog transplantata između dvije skupine bolesnika. Analizirajuci preživljenje bolesnika nakon petogodisnjeg pracenja, nismo pronasli statisticki znacajnu razliku u petogodisnjem preživljenju između HCV pozitivnih i HCV negativnih bolesnika. (p=0, 081). Zakljucak: Prema dobivenim rezultatima HCV infekcija nema utjecaja na funkciju bubrežnog transplantata. Također, HCV infekcija nema utjecaja na preživljene kako bolesnika, tako i bubrežnog transplantata

Prema važecem preporukama opca profilaksa citomegalovirusne (CMV) infekcije uputna je kod bolesnika kojima je transplantiran bubreg. Cilj nase studije bio je analizirati ucestalost CMV viremije/bolesti kod bolesnika koji su primili CMV profilaksu u odnosu na bolesnike koji nisu primili CMV profilaksu. Retrospektivnom analizom analizirali smo 521 bolesnika prosjecne životne dobi 48, 9±13, 6 godina u razdoblju od 01.01.1990 do 31.12.2014. Od 521 analizirana bolesnika, 426 bolesnika nije primilo CMV profilaksu, a 95 bolesnika primilo je CMV profilaksu peroralnim valganciklovirom tijekom tri do sest mjeseci nakon transplantacije. Bolesnici koji su primili CMV profilaksu imali su znacajnu nižu ucestalost CMV bolesti u usporedbi s bolesnicima koji nisu primali profilaksu (2, 1% vs. 8, 7% ; p=0, 046). Bolesnici koji su primali CMV profilaksu imali su nižu ucestalost CMV viremije u odnosu na bolesnike koji nisu primali CMV profilaksu, ali ova razlika nije bila statisticki znacajna (3, 2% vs. 9, 4% ; p=0, 073). Bolesnici koji su primili CMV profilaksu imali su niže vrijednosti kreatinina nakon prve postoperativne godine, ali niti ova razlika nije bila statisticki znacajna (131, 1±66, 4 vs.145, 6±88, 5 ; p=0, 173). Veci udio bolesnika koji nisu primili CMV profilaksu izgubio je bubrežni transplantata nakon prve godine poslije transplantacije u odnosu na udio bolesnika koji je primio CMV profilaksu, ali ta razlika također nije bila statisticki znacajna. U grupi bolesnika koja je primila profilaksu najcesci razlozi za gubitka transplantata bili su krize odbacivanja i kirurske komplikacije, a u grupi bolesnika koja nije primila profilaksu najcesci uzroci bili su kronicna nefropatija transplantata i kirurske komplikacije. Profilakticka primjena valganciklovira ucinkovita je u prevenciji CMV infekcije nakon transplantacije bubrega.

XNonalcoholic fatty liver disease (NAFLD) has become a common cause of elevated liver tests. The association between fatty liver and metabolic syndrome (MS) is well documented and widely accepted. Cirrhosis due to nonalcoholic steatohepatitis (NASH) is currently the second most common indication for liver transplant with increasing incidence. Gastroenterologists/hepathologists and primary care physicians have more questions than answers regarding the NAFLD. The most common questions are which NAFLD patients have a risk of progression to NASH, fibrosis, cirrhosis and hepa- tocellular carcinoma, and which patients with NAFLD have a need for liver biopsy. In addition, a number of non-invasive diagnostic methods in the approach to the patient with NAFLD are investigated. How to approach these patients in routine clinical practice, is more of an art than a science at this time. In this article we will try to provide more recent recommenda- tions of how to approach the patients with NAFLD.

Proton pump inhibitors (PPI) are the drugs that have brought a revolution as a treatment of choice for various conditions associated with increased secretion of gastric acid; peptic ulcers, gastroesophageal reflux disease, functional dyspepsia. Although PPIs are widely prescribed and generally safe drugs, recently increased attention was focused on the potential adverse effects of these drugs. Given the increasing number of patients receiving PPI’s, long-term potential adverse effects of this class of drugs are gaining increasing attention. However, most of recent investigations raise the possibility that elderly and malnourished patients have a higher risk for these side effects.

Prema važecem preporukama opca profilaksa citomegalovirusne (CMV) infekcije uputna je kod bolesnika kojima je transplantiran bubreg. Cilj nase studije bio je analizirati ucestalost CMV viremije/bolesti kod bolesnika koji su primili CMV profilaksu u odnosu na bolesnike koji nisu primili CMV profilaksu. Retrospektivnom analizom analizirali smo 521 bolesnika prosjecne životne dobi 48, 9±13, 6 godina u razdoblju od 01.01.1990 do 31.12.2014. Od 521 analizirana bolesnika, 426 bolesnika nije primilo CMV profilaksu, a 95 bolesnika primilo je CMV profilaksu peroralnim valganciklovirom tijekom tri do sest mjeseci nakon transplantacije. Bolesnici koji su primili CMV profilaksu imali su znacajnu nižu ucestalost CMV bolesti u usporedbi s bolesnicima koji nisu primali profilaksu (2, 1% vs. 8, 7% ; p=0, 046). Bolesnici koji su primali CMV profilaksu imali su nižu ucestalost CMV viremije u odnosu na bolesnike koji nisu primali CMV profilaksu, ali ova razlika nije bila statisticki znacajna (3, 2% vs. 9, 4% ; p=0, 073). Bolesnici koji su primili CMV profilaksu imali su niže vrijednosti kreatinina nakon prve postoperativne godine, ali niti ova razlika nije bila statisticki znacajna (131, 1±66, 4 vs.145, 6±88, 5 ; p=0, 173). Veci udio bolesnika koji nisu primili CMV profilaksu izgubio je bubrežni transplantata nakon prve godine poslije transplantacije u odnosu na udio bolesnika koji je primio CMV profilaksu, ali ta razlika također nije bila statisticki znacajna. U grupi bolesnika koja je primila profilaksu najcesci razlozi za gubitka transplantata bili su krize odbacivanja i kirurske komplikacije, a u grupi bolesnika koja nije primila profilaksu najcesci uzroci bili su kronicna nefropatija transplantata i kirurske komplikacije. Profilakticka primjena valganciklovira ucinkovita je u prevenciji CMV infekcije nakon transplantacije bubrega.

With the increasing incidence of obesity and metabolic syndrome the incidence of nonalcoholic fatty liver ­disease (NAFLD) is increasing as well. These patients have a significant risk of progression to the end-stage liver disease, but also these patients are at increased risk of developing hepatocellular carcinoma. In recent years there is a growing ­number of publications that support the idea that NAFLD is not just a disease that is limited to the liver, but is associated with a number of extrahepatic manifestations. For example, NAFLD increases the risk of type 2 diabetes mellitus, cardiovascular diseases and chronic kidney disease. Consequently NAFLD has become a growing public health problem. A number of sub-specialists as well as primary care physicians should be aware of these potential extrahepatic associations, given the availability of numerous methods for screening in clinical practice. The above approach is important in order to recognize potentially modifiable events in the early stages, and thus manage them and at least prevent the progression of certain diseases.

INTRODUCTION: Gastrointestinal adverse events are common in renal transplant recipients, with one of the most frequent being diarrhea. Celiac disease (CD) is a frequent chronic autoimmune disease. Patients with CD may present to specialists other than gastroenterologists with the diverse clinical manifestations. CASE REPORT: Here we report case of a 56-year-old patient referred to our center because of diarrhea, who had a kidney transplant since 2007. Since transplantation, he had no acute rejection crisis or infections. But, during the last three years he was hospitalized at our Department for several times due to diarrhea, weight losses and worsening of the kidney function. There were no signs of infections or malignant. In May 2010, a patients was admitted to our department after one more episode of diarrhea and weight loss that had occurred during the past 14 days. During that hospitalizations screening evaluations for infection etiologies of diarrhea was unremarkable. Anti-tTG antibodies were within normal range. He had disturbances of consciousness and hallucinations. A brain CT scan was without any abnormalities. An upper endoscopy with multiple duodenal biopsies was performed. Histological findings were compatible with a coeliac disease. According to the Marshal Classification grade 3A. The patient was advised to follow gluten free diet and was started on an enteral and parenteral nutrition because of malnutrition. The patient responded well. Continued further ambulatory monitoring by a nephrologist and gastroenterologist was advised. CONCLUSION: We would like to stress the necessity of an interdisciplinary approach to patients with CD as well as many other conditions.

Nealkoholna masna bolest jetre (NAFLD, nonalcoholic fatty liver disease) najcesca je kronicna bolest jetre danas. Jedna je od manifestacija metabolickog sindroma, uz dijabetes, inzulinsku rezistenciju, debljinu, hiperlipidemiju i hipertenziju. NAFLD je klinicki sindrom koji obuvaca jednostavnu steatozu, nealkoholni steatohepatitis, fibrozu i cirozu jetre, te hepatocelularni karcinom. Za sada ne postoji optimalna terapija nealkoholne masne bolesti jetre, lijecenje se temelji na promjeni nacina života, dijeti i tjelesnoj aktivnosti. Lijekovi za smanjenje inzulinske rezistencije, vitamini E i D te blokatori renin-angiotenzin-aldosteron sustava pokazuju obecavajuce rezultate u pristupu bolesniku s NAFLD-om, ali njihova dugorocna ucinkovitost i sigurnost primjene jos uvijek nije znanstveno utemeljena.

INTRODUCTION: It remains controversial whether hepatitis C infection (HCV) alters log-term patients and renal graft survival. Our aim was to analyze the effects of HCV infection on patients and graft survival. METHODS: We retrospectively examined the 23-year (1990-2013) data of 471 renal transplant recipients (RTRs) mean age 50.2±14 years who were anti-HCV negative and 21 RTRs mean age 49±8 years who were anti-HCV positive at the time of transplantation. We compared graft and patients survival rates and causes of death and graft failure in HCV-positive and HCV-negative RTRs. RESULTS: There was no statistically significant difference between the two groups related to age or gender and due to the duration of dialysis treatment before the transplantation The mean posttransplant follow-up of 471 HCV negative RTRs was 61.1±59.3 months and for 21 HCV positive RTRs was 75.3±44.3 months (p=NS).There was no significant difference due to acute rejection crisis during the first-year of follow up (p=NS). The mean values of serum creatinine didn’t showed any significant differences after one-year, two-years and five-years of follow-up between the HCV negative RTRs and HCV positive RTRs (p=NS). In the HCV positive RTRs the main reason for graft loss was a chronic allograft nephropathy (CAN) (42.9%) and acute rejection crisis (42.9%). On the other hand, CAN was the cause of graft loss in the 44.1% of HCV negative RTRs, while acute rejection was the cause of graft loss in the 22% of RTRs that were anti-HCV negative. There were no significant differences in the patients survival between the HCV positive RTRs and HCV negative groups of our renal transplant recipients (38.1% vs. 22.9% ; p=NS). CONCLUSION: According to our experience, patients and graft survival were not affected by HCV infection. Anti-HCV positively should not preclude chronic renal failure patients from renal transplantation.

AIM: The aim of the present study was to investigate whether patients with inflammatory bowel disease (IBD) have some degree of renal involvement. Furthermore, we were investigated whether this connection is related to active bowel disease. METHODS: In this cross-sectional study 50 patients mean age 47.1±16.5 years with a diagnosis of IBD were recruited from September 2012 to September 2013. The diagnosis of IBD was based on clinical history, endoscopic, histological and radiological findings. Disease activity was assessed using Mayo score for ulcerative colitis (UC), and CDAI for Crohn’s disease (CD) as well. There were and 38% patients with UC and 62% patients with CD. For this analysis purpose, patients were stratified according the disease (CD vs UC) and according to the disease activity (active IBD vs inactive IBD). RESULTS: The prevalence of abnormal proteinuria in UC and CD patients was 21.1% and 29% respectively. Proteinuria wasn't associated with IBD activity. Also, it wasn't associated with disease duration. On the other hand, eGFR showed negative correlation with disease activity in CD patients (r=-0.569 ; p=0.05), while there was no statistically significant correlation between active UC and eGFR (r=0.343 ; p=NS). CONCLUSION: Abnormal proteinuria is quite frequent in patients with IBD. It is not associated with disease activity. Furthermore, it seems that patients with IBD have some degree of glomerular damage, mainly those with CD. Further, larger and prospective studies that will investigated this association are needed.

UVOD: Dijareja je jedna od najcescih komplikacija od strane gastrointestinalnog sustava nakon transplantacije. Osim cinjenice da je dijareja neugodna i iscrpljujuca za samog bolesnika, ona može dovesti do mrsavljenja, porasta parametara bubrežne funkcije odnosno pogorsanja funkcije bubrežnog presatka uslijed dehidracije i neadekvatne koncentracije imunosupresiva. Time može dovesti do gubitka presatka. Egzokrina pankreasna insuficijencija (EPI) posljedica je brojnih bolesti gusterace, te ekstrapankreasnih bolesti, ali nastaje i zbog promjena anatomskih odnosa nakon resekcija pankreasa i kirurskih zahvata na crijevima i želucu. Egzokrini i endokrini dijelovi gusterace povezani su anatomski i fizioloski, te patoloski proces jedne funkcionalne cjeline može utjecati na drugu i obrnuto. Cesto je EPI udružena s dijabetesom, bilo da se radi o tipu 1 ovisnom o inzulinu ili tipu 2 dijabetesa neovisnom o inzulinu. Osnovna klinicka posljedica EPI je maldigestija i malapsorpcija. Prikazujemo slucaj bolesnice s bubrežnim presatkom i presatkom pankreasa, koja je izgubila presadak pankreasa, a potom i bubrežni presadak. PRIKAZ SLUCAJA: Radi se o 32-godisnjoj bolesnici koja boluje od secerne bolesti tip I te joj je 2009. godine ucinjena simultana transplantacija bubrega i gusterace. U ranom posttransplantacijskom periodu doslo je do gubitka presatka gusterace uslijed akutnog pankreatitisa. Od transplantacije ima ucestale proljeve, zbog cega je visekratno lijecena u drugoj ustanovi. Ucinjenom ekstenzivnom obradom nije utvrđen infektivni uzrok. Od 11.10.-11.12.2013. ponovno je hospitalizirana u drugoj ustanovi. Tada ucinjena biopsija presatka ukazala je na akutno odbacivanje posredovano stanicama, a na ucinjenom CT-abdomena utvrđeno je formiranje pseudociste transplantirane gusterace. Zbog pogorsanja funkcije presatka u zavrsni stadij bubrežnog zatajenja ponovno je zapoceto lijecenje hemodijalizom dana 9.12. 2013. Dana 23.12.2013. bolesnica je zbog ponovnih proljeva primljena na Zavod za nefrologiju, dijalizu i transplantaciju, KBC Rijeka. Iz uzetih uzoraka krvi (iz periferije i oba kraka centralnog venskog katetera) te stolice nije izoliran infektivni uzrocnik. Zbog sumnje na egzokrinu insuficjenciju gusterace, uvedena je peroralna supstitucijska terapija enzimima gusterace. Po primijenjenoj terapiji, prati se klinicko poboljsanje stanja uz normalizaciju broja stolica. ZAKLJUCAK: Opisani slucaj ukazuje na cinjenicu da u bolesnika nositelja bubrežnog presatka koji boluje i od secerne bolesti i koji ima proljeve treba misliti i o egzokrinoj insuficjenciji gusterace. Navedeno je važno, jer ucestali proljevi kao sto je vidljivo iz prikaza nase bolesnice mogu dovesti i do gubitka presatka uslijed smanjenje apsorpicije imunosupresiva. Prepoznavanje i adekvatno lijecenje EPI bitno utjece na smanjenje najcescih simptoma, te smanjenje morbiditeta i mortaliteta.