We report on 10 patients with acute renal involvement in Hantaan virus infection observed at the Department of Nephrology, Faculty of Medicine, Skopje, Republic of Macedonia, during a period of 3 years (October 1987-July 1990). Eight patients were male and 2 were female, aged 37.5 +/- 4.8 years. The diagnosis of Hantaan virus infection was proven by an indirect immunofluorescent and ELISA test with a significant increase of the titer after a week to ranges from 1:512 to 1:2,048. Percutaneous renal biopsy was performed in 3 cases using standard procedures for optical and immunofluorescent microscopy. Fever, weakness, headache, conjunctival injection, hematuria, and lumbar pain were clinical features all patients had in common. Complete anuria was noted in 7 out of 10 and oliguria in the other 3 of the 10 cases with serum levels of creatinine 967 +/- 152.6 mumol/L. Other following laboratory findings were leukocytosis in 10 out of 10 patients, with neutrophylia, and reduction of serum sodium and potassium in 8 out of 10, and a decrease in serum complement C3 in 3 out of 10 patients. Percutaneous renal biopsy confirmed interstitionephritis in 2 out of 3 biopsied patients and acute diffuse proliferative glomerulonephritis in the third. Interstitial mononuclear infiltration with dominant T cells proven with monoclonal antisera (direct immunoperoxidase method) was present in all 3 cases. The outcome of the disease was good in 8 of the 10 patients with a development of polyuric phase and complete recovery of renal function later. One patient with interstitial lesions on biopsy developed chronic renal failure, and the other with a concomitant brucellosis died during the polyuric phase of the disease.

Eight thousand eight hundred and forty nine different vascular hemodialysis accesses were performed in the period from 1976 until 1999 at the Department of Nephrology, Skopje: 3,114 native arterial-venous fistula (AVF), 715 arterial-venous shunts (AVS), 4,964 temporary or permanent catheters (4,411/88.86% femoral, 410/8.26% subclavian, 143/2.88% jugular) and 56 PTFE vascular grafts. Femoral catheterization (4,312/86.86%) is the favoured solution if a temporary vascular dialysis access is taken into consideration. The most popular chronic dialysis angio-access in our country is native AVF (90.5% of 3,440 permanent dialytic vascular accesses). The tunneled subcutaneously positioned catheters as a permanent dialytic angio-access were present in 270 cases (7.9%): 99 in femoral veins (our original method), 123 in subclavian veins and 48 catheters in jugular veins. The synthetic vascular grafts-PTFE (polytetrafluoro-ethylene) represent only 1.6% of all dialysis angio-accesses. The number of preventive AVFs created in patients with preterminal end-stage renal disease eventually increased; from 14% in the eighties, 20.8% after 10 years and 31.50% in 1999. Most of the preventive AVFs are done in outpatients 71.8% in 1999. This year 44.4% of all chronic vascular access were created in the same way. We prefer femoral catheters for both temporary and permanent access because our results show that femoral catheterization has a lower rate of early complications when compared to the subclavian catheterization group; the rate of late complications (thrombosis, stenosis, infections) is lower or the same; infections in femoral catheterizations are less frequent, compared to subclavian and jugular ones. Our contributions in the field of vascular access surgery are the three original methods which are constantly used at the Department: 1. Combination of temporary (AVS) and permanent vascular access (AVF) using the same blood vessels, performed in one surgical act; 2. Tunneled femoral catheter as a permanent vascular access for hemodialysis (2 types: on the abdominal wall and on the infrainguinal region - thigh); 3. Reduction of hyper-flow in AVF without the operation of "banding", with ligation of the artery before arteriovenous anastomosis.

1,019 adult patients with terminal renal failure were treated with dialysis (D) in the first part of the year 2000 in the Republic of Macedonia. 1,010 patients (99%) were treated with chronic intermittent (maintenance) hemodialysis (HD) while nine patients (1%) were on continuous ambulatory peritoneal dialysis (CAPD). For the children, a special peritoneal dialysis program was developed; 509 patients per million of the population (PMP) were on dialysis. The Republic of Macedonia is, therefore, among those central and eastern European countries with a higher PMP number in the treatment of end-stage renal disease, following Croatia, the Czech Republic and Slovenia. The patients were treated at 18 Centers in a network of HD Centers at a distance of 30-50 km. from their place of residence in order to facilitate their access to treatment and to work. All patients who have had symptoms indicating need for treatment with D were accepted for treatment. The government payed all the expenses of the treatment and the salaries of the staff. 56% were male and 44% were female patients. The youngest patient was aged 9 and the oldest was 82 years old. There has been an increase in the age of the patients on D as well as an increase in their number. In 1993 we had 727 patients being treated with D, and now we have 1,019 with a constant increase in the number of patients with ESRD and a need for D and renal transplantation. Mortality per year at the different Centers ranged from 8-19% in 1999 and the average is 12%. Glomerulonephritis (GN)--both primary and secondary--is the main cause of renal failure (RF) in some Centers up to 45%. Tubulo-interstitial disease follows GN. ADPKD patients constitute 9.4% with a difference among the Centers of 3-29%, and diabetic nephropathy is found in 10%, 5-15% in different Centers. 11-61% of patients have an unknown etiology. 352 patients are on treatment with human recombinant erythropoietin (rhuEPO) - in some Centers up to 60%. The mode of application was subcutaneous and the initial dose is 20 U/kg body weight and the mean maintenance dose of EPO per patient weekly is 4,000 U. The Cimino-Brescia arteriovenous fistula is being applied as a standard vascular access. The survival rate of our patients treated with maintenance HD at 5 years was 58%. CAPD and particularly renal transplantation are to be further developed as alternative methods in treating terminal renal failure.

Background: Hemodialysis as an efficient therapy for advanced CKD is the most used treatment modality all over the world. Even though primary AVF is widely accepted as a best permanent vascular access in hemodialysis patients, up to 60% of all fistulas fail to mature. The pathogenesis of early fistula failure is not very well understood. Many general and local factors are involved: patient's age, sex, primary renal disease, small vessel's diameter, presence of accessory veins, prior venipunctures, surgical skill, genetics, etc. Histological investigations have confirmed the neointimal venous hyperplasia as a major pathological finding in stenotic lesions of AVF failure, due to local inflammation, oxidative stress and migration and proliferation of myofibroblasts, fibroblasts and endothelial cells. Materials and methods: A total of 89 patients with stadium 4-5 of CKD are involved in the study. A typical radio-cephalic AVF is created in all patients. Part of the fistula vein was taken for histological, immunohistochemical (Vimentin, TGF  and KI67) and morphometric analysis. Appriopriate statistical method was applied. Results: Up to 80% of the patients showed some degree of endothelial changes at the time of creation of AVF, among them 19 pts with substantial intimal hyperplasia, 51 with medial hypertrophy and 19 pts with normal histology. Almost two thirds of the patients did not have expression of TGF. More than 95% had some expression of Vimentin. None of the patients had expression of the marker KI 67. Conclusion: Medial hypertrophy is predominant preexisting pathohistological lesion prior the AVF creation, despite the presence of neointimal hyperplasia. The absence of TGF expression in majority of our patients could suggest that inflammation and oxidative stress are developing later, after vascular access surgery. The dominant cells within the stenosis in the veins are myofibroblasts. Their increased presence maybe a reason why some patients are prone to developing venous endothelial changes as a results of exaggerated vascular endothelial response to the effect of uremia, hypertension and other insults.

Femoral catheterization is fast and simple and associated with a low risk of complications. Those which occur can usually be managed easily. Femoral catheters are usually kept in place for a short period of a few days. We, instead, used femoral catheters (FC) as a temporary vascular access for a longer period of time (until the permanent vascular access matured) in inpatients and in outpatients on regular ambulatory hemodialysis who had a problem with their permanent access. We analyzed 59 patients with end-stage renal disease treated with hemodialysis (HD), divided into two groups. Of the group that started with hemodialysis (group I), only 16 patients were hospitalized during the maturation of native arterio-venous fistula (AVF). Duration time of the catheters was 15-47 days (average 32 days). The second group (group II) comprised 43 patients going on regular ambulatory hemodialysis who were discharged from hospital with femoral catheters. Duration time of catheters in this group was 13-183 days (average 44.2 days). Catheters were removed when AVF matured, or if a significant complication occured. We took blood culture from peripheral vein (BCP) and from catheter (BCC) on removal of the catheter, or when we suspected infection. Catheter tips (CT) were also sent for microbiological analysis. We monitored the clinical signs of infection. We compared microbiological results of BCP, BCC and CT from the two groups using chi-square test and we did not find any significant difference among the three types of findings (p<0.05). The FC was removed from one patient only from group II because of suspicion of catheter-related infection. Two pts were treated with antibiotics (AB) systemically and locally (AB was 'locked' in the catheter) because of febricity. When the catheters were removed the microbiological findings were sterile. We concluded that FC can be used without any problem for a longer period of time for ambulatory HD, with the provision of permanent care from a team specially trained for vascular access.