Abstract Total thyroidectomy is complicated by hypoparathyroidism in 1-3% of patients. Hypoparathyroidism is treated with oral calcium and vitamin-D supplements. Everyday use of calcium and vitamin D can lead sometimes to hypercalcemia. Ingestion of large amounts of calcium and absorbable alkali that cause hypercalcemia, various degrees of renal failure, and metabolic alkalosis, can be associated with a diagnosis of calcium-alkali syndrome. This syndrome was first identified as milkalkali syndrome, after treatment of peptic ulcer disease with milk and alkali which was widely adopted at the beginning of the 20th century. With the introduction of histamine-2 blockers and proton pump inhibitors, the occurrence of milk-alkali syndrome became rare; however, it has emerged recently as calcium-alkali syndrome because of the wide availability and increasing use of calcium carbonate, mostly for osteoporosis prevention. We present a female patient with hypoparathyroidism who presented with hypercalcemia and alkalosis as a result of treatment with calcium carbonate, vitamin D and thiazide diuretic. The patient was treated successfully by discontinuation of the above drugs, intravenous fluid administration and enhancement of calcium renal excretion. Hypercalcemia presenting as calcium-alkali syndrome is a diagnosis that requires a high index of suspicion in order to quickly identify the disorder and initiate appropriate therapy. It is important for clinicians to keep the syndrome on their list of differential diagnosis.

Abstract Introduction. Proteinuria after renal transplantation increases the risk of graft failure and mortality. The aim of the study was to determine the prevalence and causes of proteinuria in kidney transplant recipients. Methods. All kidney transplant recipients followed up in our clinic were included in the study. As a center protocol 24-hour urine collections were used to quantify protein excretion with 3-month intervals posttransplantation during the first year, and yearly thereafter. The etiology of chronic kidney disease and demographic characteristics of the study group were obtained from outpatient records. Data regarding the immunosuppressive regimens used, 24-hour proteinuria levels and creatinine clearences, new-onset hypertension, new-onset diabetes mellitus, rejection episodes, infections like cytomegalovirus (CMV) and polyoma (BK), and biopsy findings were noted. Results. A total of 260 kidney transplant recipients (97 females, mean age 42.3±12.3 years) were evaluated. Median follow-up period was 36 months; 137 of all transplantations were from living donors. Mean age of donors was 42.7±15 years and 133 were female. Proteinuria with protein excretion ≥300 mg/d was present in 35.4% of patients. The most common cause of biopsy-proven proteinuria was transplant-specific conditions (acute rejection, and borderline changes). Conclusion. The prevalence of proteinuria was 35.4%. The transplant-specific diagnoses were the most likely causes. Even in nonnephrotic ranges it was associated with decreased graft survival.

Abstract In the last two decades a great progress was observed in understanding of podocytes, their specific structure and function identifying many specific podocyte proteins, such as nephrin and podocalyxin. Podocytes form the final barrier to plasma proteins leakage. Nephrin as a main component of the filtration diaphragm forms a physical barrier while podocalyxin as sialoglycoprotein forms an electrostatic barrier. Podocyte damage, i.e. podocytopathies and their loss through urine-podocyturia, are crucial in pathogenesis and progression of nephropathies with proteinuria as main clinical manifestation. In podocytopathies, nephrin and podocalyxin appear in the urine before proteinuria and microalbuminuria which were previously considered as earliest markers of nephropathies. Nephrinuria and podocalyxuria indicate damage of the podocytes on glomerular level and/or presence of apoptotic and necrotic podocytes in urine. These urinary markers are also important in early diagnosis of secondary nephropathies such as diabetic, lupus and hypertensive nephropathy as the most common causes of end-stage renal failure (ESRF). These markers are also important in the prediction of preeclampsia, which is the most common complication in pregnancy. In this review we elaborate in dept the main structural and functional features of podocytes and their specific proteins, nephrin and podocalyxin, summarizing the recent literature data on their importance in the early diagnosis of the most common secondary nephropathies.

Abstract Introduction.Residual diuresis (RD) is an important predictor of mortality and cardiovascular (CV) deaths in peritoneal dialysis (PD) patients, and contributes more to overall survival compared to PD clearance. In this study we investigated the correlation between RD and CV outcomes in PD patients.Methods.A total of 190 PD patients from 13 dialysis centers, a national representation, were included in this analysis. Biomarkers of anemia, nutritional status [malnutrition inflammation score (MIS), subjective global assessment (SGA), serum albumin, anthropometric measurements including body mass index (BMI)], dialysis dose (Kt/V) and laboratory measurements were determined. RD was estimated using the volume of daily urine.Results.There were 78(41.05 %) females and 112 (58.95 %) males; aged 57.35±14.41 years, on PD for 24.96±24.43 months. Fifty-six patients had diabetes type II (44 as primary kidney disease). The mean RD was 1170±673.6 ml (range 0-3000 mL). Statistically significant correlations between RD and BMI, hip circumference, time on PD, Kt/V, MIS, SGA, erythrocytes (E), Hemoglobin (Hb), PTH, and serum albumin were observed.Conclusions.We demonstrated a significant correlation between RD and MIS score, SGA, anthropometry and albumin. Every effort should be invested to maintain RD for as long as possible to achieve optimal treatment results and to decrease CV mortality in PD population.

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Abstract Introduction. Patients on hemodialysis (HD) are proven to have impaired Health Related Quality of Life (HRQoL) compared to the general population. Recovery from the hemodialysis session is a permanent problem among majority of patients receiving HD treatment. A partial explanation may be the osmotic imbalance between different compartments of the body due to the fluid and electrolyte movement across the cell membrane which is a part of the HD process itself. The aim of our study was to see whether the length of recovery time (RT) is associated with different clinically relevant variables and dialysis treatment features in our HD population. Methods. We performed a cross-sectional study on patients receiving trice weekly HD in a single hemodialysis center. The recovery time was defined by posing a single question "How long does it take you to recover after a hemodialysis session?" and was calculated in hours (up to 2, 2-6, 6-12, and 12-24 hours) / minutes. Various demographic and clinical characteristics were analyzed for association with the RT. Results. The mean RT was 364.62±339.24 minutes. From all of the analyzed variables a significant statistical correlation was obtained with the level of albumin, urea, interdialytic weight gain (IDWG), protein catabolic rate (PCR), body mass index (BMI) and the level of hemoglobin (p<0.05 for all parameters). The longest mean RT had patients with hypertension and glomerulonephritis as a primary cause of ESRD and the shortest, patients with an adult dominant polycystic kidney disease. With the multiple regression analysis a significant correlation was obtained only for the level of hemoglobin (Hb) with a coefficient for partial regression analysis - 0.2635. The t-test showed that the influence of the level of hemoglobin on recovery time in patients was statistically significant (p = 0.039). Conclusions. RT in our study was associated with IDWG, albumin, urea, BMI, and PCR, while the level of hemoglobin was also shown to have a significant impact on the RT and on patients’ overall health status. Hence, we could conclude that maintaining Hb levels in dialysis patients within reference values among the other benefits, may improve the recovery time and HRQoL of our patients.

Abstract Granulomatosis polyangiitis (Wegener's granulomatosis) is an ANCA-associated necrotising vasculitis. The disease involves upper respiratory tract, the lungs and kidneys but central nervous system (CNS) involvement is 1-5%. A 40-year-old male patient was admitted to the hospital with joint pain, rash, aphthous lesions. The skin biopsy from the lesion showed leukocytoclastic vasculitis. The patient had c-ANCA positive and was diagnosed granulomatosis polyangiitis. He was treated with a pulse steroid and cyclophosphamide. Before the 5th session of therapy, the patient developed hemoptysis and hematuria. Thorax CT (computarized tomography) showed a diffuse alveolar hemorrhage and hence plasmapheresis and IVIG (intravenous immunoglobulin) were added to the treatment. Two days after IVIG, the patient developed globe vesical, headache and respiratory arrest. MR (magnetic resonance) showed CNS involvement. The patient was treated with a pulse steroid, but did not respond to therapy and died after 5 months since establishing the diagnosis. More studies are needed to identify effective treatment and course of disease for patients with central nervous system involvement.

Abstract Streptococcus salivarius is a Gram-positive bacteria that may cause infections like endocarditis and meningitis. However, it has not been reported as a causative agent of peritonitis in peritoneal dialysis patients. In this paper we present a rare case of peritonitis with Streptococcus salivarius admitted to our Clinic with abdominal pain, who had been on peritoneal dialysis treatment for 19 months. Streptococus salivarius was cultured from the effluent, sensitive to ampicillin and penicillin G. Patient was discharged completely cured. Peritonitis is the most important clinical issue that occurs in patients treated with peritoneal dialysis, and every effort should be invested to determine the causative agent while even rare bacteria as Streptococcus salivarius may be found.

Abstract Recently, the presence of left ventricular clefts has been identified frequently with the advancement of cardiac imaging modalities such as cardiac magnetic resonance imaging and computed tomography. Here we report a rare case of left ventricular cleft that was incidentally diagnosed with the ECG changes that imitated the presence of LMCA stenosis and diagnosed by transthoracic echocardiography in a patient with autosomal dominant polycytic kidney disease.

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