аЯрЁБс>ўџ 23ўџџџ1џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџмЅhWр eоJй`оG\j\jj\j\j\j\j\4t]t]t]t]t]t] ~].t]м_VЌ]Ќ]Ќ]Ќ]Ќ]Ќ]Ќ]Ќ]7^9^9^9^%^^А_АО_2`XŠ`Oм_j\Ќ]&'Ќ]Ќ]Ќ]Ќ]м_Ќ]j\j\Ќ]Ќ]Ќ]Ќ]Ќ]Ќ]j\Ќ]j\Ќ]7^Р)юJeсМž\Pю\†j\j\j\j\Ќ]7^Ќ]‹Ќ] Revised text ETIOLOGY AND OUTCOME OF ACUTE RENAL FAILURE SECONDARY TO WAR RELATED TRAUMA AND INFECTIOUS DISEASE IN CROATIA Gašparovic Vladimir (1), MD PhD, Radonic Radovan (1), MD, Gjurašin Mirko (1), MD PhD, Gašparovic Hrvoje (2), MD, Ivanovic Dragutin (1), MD, Merkler Marijan (1), MD, Jelic Ivan (2), MD PhD 1 Department of Internal Medicine, University Hospital Rebro, University of Zagreb, School of Medicine 2 Department of Surgery, University Hospital Rebro, University of Zagreb, School of Medicine ABSTRACT The aim of our study was to explore the etiology and the outcome of ARF during the war in Croatia. Out of the 2132 patients admitted to our hospital between April 1990 and November 1992 due to war related trauma, 11 (0,5%) developed ARF. We believe that the development of ARF in these patients was secondary to an overwhelming septic process. Most of our patients suffered from multiple organ failure. The outcome of ARF in these conditions is very grave. Out of the 11 patients suffering from ARF due to war related trauma only 4 had recovered (63,6% had died). We attribute the lethal outcome to the progression of the septic process. Patients who developed ARF due to infectious diseases unrelated to trauma had a different prognosis. ARF caused by the Hantan virus ran a benign course, in both its oliguric and nonoliguric form. Patients who developed ARF as a complication of leptospirosis, also, had a good prognosis. Although ARF is usually of a multifactorial genesis, our study aimed to emphasize the importance of disseminated septic processes as a cause of ARF. Key words: acute renal failure, war, multiple organ failure INTRODUCTION Acute renal failure (ARF) is a clinical syndrome frequently observed in the war (1,2,3). A significant shift in the structure of patients managed at our Center for Acute Haemodialysis has been seen after the onset of the war in Croatia. Two groups of patients were analyzed in this study. Patients initially treated at the Department of Surgery for their war related injuries constituted the first group. The second group was made of patients in whom ARF was secondary to an infectious disease. The renal lesion in these patients was caused either by hemorrhagic fever or by leptospirosis. The frequent contact of soldiers and civilians with animals, primarily small rodents, as well as the usage of contaminated water has resulted in a higher incidence of the previously mentioned infectious diseases. PATIENTS AND METHODS This study was based upon data collected at the Department of Surgery and the Division of Emergency Internal Medicine, Department of Medicine, University Hospital Rebro, Zagreb. ARF was defined as a compromitation of the renal function with a subsequent increase in the creatinine level (>400 mmol/L), and/or an increase in the potassium concentration (>6 mmol/L). ARF was defined independently of the urine output. Patients treated at the Department of Surgery were admitted to our hospital after their wounds were primarily managed at the military setting. Some of them were treated at local hospitals before they were admitted to our institution. The concentrations of CPK and LDH were monitored, and their elevated values could have contributed to the deterioration of the renal function. The highest levels of these enzymes were recorded at the time of admission, while the onset of ARF was usually noticed during the second week of their hospitalization. Every patient received a central venous catheter on arrival, by the means of which, CVP was constantly monitored. Due to a prompt fluid substitution instituted before the patients were admitted to our hospital, only one of them had a lowered CVP. Those patients whose haemoglobin values were below normal, received intravenous blood transfusions. Following the development of ARF haemodialysis was performed on a daily basis via a double-lumen catheter inserted into the jugular, subclavian or femoral vein. Haemodialysis was performed in those patients whose creatinine value exceeded 500 mmol/L. Patients with a potassium serum concentration greater or equal to 6 mmol/L were, also, scheduled for haemodialysis. The condition of our patients at the time of their arrival was assessed by their APACHE II score. We have found that the surgical patients (19,1) had a higher mean value of the APACHE II score than the medical ones (14,2). This could explain the lower survival rates of the surgical patients. Patients who developed ARF as a complication of an infectious disease unrelated to trauma (medical group), were treated at the Department of Emergency Medicine. RESULTS A total of 20 patients with ARF secondary to war related trauma and infectious disease were treated at the Center for Acute Haemodialysis between April, 1990 and November, 1992. All of our subjects were males. Most of them were Croatian soldiers. One patient was a member of the UNPROFOR, and two were civilians. The age of our patients ranged from 21 to 44 years (mean: 29,3 years). 11 of our patients developed ARF following an initial traumatic event. Over the above mentioned period of time 2132 patients were treated at the Department of Surgery due to war related injuries. Thus, we conclude that the incidence of ARF in this population is 0,51%. Seven of these patients died (lethality equaled 63,6%). None of our subjects suffered from direct trauma to the kidney, and this etiologic factor was excluded as being responsible for the development of ARF in any of our patients. Of the 9 patients with ARF secondary to an infectious disease, 7 suffered from hemorrhagic fever, while two were diagnosed as having leptospirosis. Table 1 summarizes the results. Table 1. In the group of patients in whom military combat trauma was the initial event, the most common cause of ARF was sepsis. Severe hemorrhagic shock due to extensive injuries was responsible for the development of an acute renal insufficiency in only one patient. We explain this with a prompt and adequate fluid substitution at the primary military setting. In this group of patients the outcome was an unfavorable one. In the second group of patients ARF was a complication of an infectious disease unrelated with trauma. Two of these patients had leptospirosis, while the other seven were suspected of having hemorrhagic fever. The clinically diagnosed hemorrhagic fever was serologically confirmed in two patients. Of the remaining five, one had died following a fulminant course of the disease, before a positive titre on the causative agent could have been obtained. An additional confirmation of the clinical suspicion was sought in the pathoanatomical findings. Serologic results are shown in Table 1. Discussion A significant shift in the structure of the patients treated at our Center for Acute Haemodialysis has been observed after the onset of the war in Croatia. The war devastation with its terrible consequences in Croatia, resembled those previously described by various authors (4,5,6). Human sufferings, annihilation of appropriate housing facilities and hospitals, resulted in a change in both the morbidity and the mortality of our population (7). The activities of our Center for haemodialysis before the war were similar to those practiced in institutions parallel to our own, but those functions were redefined by the war (8,9,10,11). Earlier reports state that war related ARF frequently occurred as a consequence of inadequate fluid suplementation (12,13,14). Before the war, ARF in our setting was usually a complication of politrauma, such as is seen in traffic accidents. After the war had begun the Department of Surgery was confronted with multiple war related injuries, mostly of the abdomen and chest. The condition of some of these patients was complicated with the development of an impairment in the renal function. In one of our patients hypotension following severe hemorrhagic shock was the cause of ARF. The importance of prompt fluid supplementation in these circumstances cannot be overestimated. The development of ARF in all other patients suffering from war related trauma, was due to sepsis. We acknowledge the fact that there are many factors involved in the development of ARF, but we believe that the septic process was primarily responsible for its occurrence in the traumatized group of patients (with the exception of the one patient suffering from hypovolaemia). Patients suffering from a Pseudomonas infection were treated with Imipenem. Staphyloccocal infections were treated with Vancomycin. Only those subjects suffering from widespread candidiasis were treated with the nephrotoxic Amphotericin. We have retrospectively evaluated the case histories of these patients, and found that all of them had manifested symptoms of a compromised renal function before this therapy was instituted. Aminoglyosides were administered to some of our patients, and the nephrotoxicity of these drugs probably contributed to the development of ARF. It is impossible to estimate how great a role they played in the deterioration of the renal function. However, the serum concentration of gentamicin was monitored, and it was always within the therapeutic range. We did not control the serum concentrations of amikacin and netilmycin because these tests were not available at our institution. During the same period of time we have observed an increased incidence of ARF induced by infectious diseases (15,16,17,18,19,20). The patients with ARF secondary to war related trauma and sepsis, had a different prognosis than the patients in whom ARF was a complication of an infectious disease. Sepsis is a frequent cause of ARF (21). ARF in patients with numerous war injuries was a component of multiple organ failure, usually resulting from sepsis caused by a resistant strain of microorganisms (Pseudomonas, Staphyloccocus Aureus, Acinetobacter) and fungi. Other organs were monitored. In the surgical group of patients respiratory insufficiency was observed before the compromitation of other organ functions. This was manifested by a prolonged, postoperative artificial ventilation. Some of our patients developed liver failure with consequent coagulation disturbances at approximately the same time as their renal function began to deteriorate. It is our opinion that both of these events are secondary to sepsis. Seven out of 11 patients in the surgical group of patients died. The outcome of nonoliguric ARF was not better than that of oliguric ARF, as was previously reported (22). The incidence of leptospirosis and hemorrhagic fever during the war in Croatia, according to the epidemiological data, was significantly higher than in the pre-war period (23). All patients with hemorrhagic fever and leptospirosis were soldiers who fought in marshes and other damp areas. The prognosis of patients with ARF induced by leptospirosis and hemorrhagic fever was good when compared with traumatized group of patients. In the former group, one out of nine patients died, but concomitant pancreatis could have been responsible for it. We believe that a modified antigenic structure of the virus responsible for the clinical syndrome of hemorrhagic fever, could explain the negative serologic findings in the four patients with a clinical picture suggesting hemorrhagic fever. However during the past two years we have treated severe forms of hemorrhagic fever with predominant pulmonary symptoms and a very serious prognosis (24). Our experience demonstrates that timely volume substitution plays a major role in the prevention of the hypovolemic form of ARF. In the surgical group of patients ARF was usually a component of MOF. It is important to recognize that the preservation or the restitution of the renal function is only one of our goals in the treatment of MOF. The recovery of the renal function does not guarantee a good outcome, if the function of other organs is irreversibly damaged (as was the case in one of our patients). Control over the septic process remains of paramount significance. In the treatment of ARF secondary to war related trauma and infectious disease haemodialysis remains an important procedure. A patient can die with ARF, but should not die from ARF. References 1. Better, OS: The crush syndrome revisited (1940-1990) Nephron 55:97,1990 2. Bywaters EGL, Beall D: Crush injuries with impairment of renal function. Br. Med J i: 427,1941 3. Turney JH, Marshall DH, Brownjohn AM, Ellis CM, Parsons FM: The Evolution of Acute Renal Failure. l956-1988. Quarterly Journal of Medicine 273:82,l990 4. Lordon RE, Burton JR. Post-traumatic renal failure in military persnnel in Southeast Asia: experience at Clarc USAF hospital, Republic of the Philippines. Am J Med. 53:137,1972 5. Ascherio A, Chase R, Cote T, Dehaes G, Hoskins E, Laouej J, Passey M, Qaderi S., Shuqaidef S., Smith MC, Zaidi S: Efect of the gulf war on infant and child mortality in Iraq. N Engl J Med, 237-931,1992 6. Bellamy RF, Maningas PA, Vayer JS: Epidemiology of Trauma: Military Experience. Ann Emerg Med. 15:138,1986 7. Acheson D: Croatia: Broken hospitals, unbroken workers. The Lancet.340:843, 1992 8. Ga{parovi} V, Labar B, Puljevi} D, Skodlar J, Bogdani} V, Ivanovi} D: Elimination of antibodies by plasma exchange in ABO incompatible bone marrow transplantation, Bone Marrow Transp. 4(3):109,1989 9. Ga{parovi} V, Labar B, Puljevi} D, Skodlar J, Bogdani} V, Ivanovi} D: The incidency of acute renal failure by heart transplantation inm Croatia, First Congress of transplantation in developing countries, Singapore, 1992 10. Leurs PB, Mulder AW, Fiers HA, Hoorntje SJ: Acute renal failure after cardiovascular surgery. Current concepts in patophysiology, prevention and treatment. Europ Heart J. 10(H):3, l989 11. Ga{parovi} V, Planinc D, Sutli} @, Bio~ina, B, Sokoli} J, Gjura{in M: Acute renal failure in heart transplant recipients. Lije~ Vjesn, 115:152, 1993 12. Levinsky NG. Pathophysiology of acute renal failure. N Eng J Med. 296:1453, 1977 13. Myers BD, Moran M. Hemodinamycally mediated acute renal failure. N. Eng J Med.3314:97, 1986 14. Maningas PA, Bellamy RF: Hypertonic Sodium Chlorides Solutions for the Prehospital Management of Traumatic Hemorrhagic Shock: A Possible Improvement in the Standard of Care? Ann Emerg Med. 15:1411,1986 15. Ryner B.L, Willeox P.A., Pasceo M.D. Acute Renal Failure in Community-Acquired Bacteraemia. Nephron. 54:32, 1990 16. Cosgriff T. M. Mechanisms of disease in Hantanvirus infection: pathophysiology of hemorrhagic fever with renal syndrome. Rev Infect Dis. 13(1):97,1991 17. Gartner L, Emmerich P., Schmitz H. Hantavirusinfektionen als Ursache von akute Nierenversagen. Dtsch. med. Wshr. 113:937, 1988 18. Seguro AC, Lomar AV, Rocha AS: Acute Renal Failure of Leptospirosis: Nonoliguric and Hypokalemic Forms. Nephron, 55:146, 1990 19. Bruno Ph, Harisson H, Brown J, Tanner W: The protean manifestation of hemorrhagic fever with renal syndrome. Ann Int Med. 113:385,1990 20. Frost L, Pedersen R.S., Hansen H.E. Prognosis in septicemia complicated by acute renal failure requiring dialysis. Scand. J Urol Nephrol, 25(4):307,1990 21. Anderson RJ, Linac SL, Berns AS, Henrich WL, Miller TR, Gabow PA, Schrier RW: Nonoliguric acute renal failure, N Engl J Med, 296-1134, 1977 22. Bor~i} B: Izvje{}e o stanju i radu u zdravstvu republike Hrvatske u 1992, Hrvatski zavod za javno zdravstvo, Zagreb, 131, 1993 23. Ga{parovi} V, Radoni} R, Gjura{in M, Ivanovi} D, Kvarantan M, Husar J. Acute renal failure in the war in Croatia. Nephrol Dialys Transpl, 10:1261, 1995 24. Ivanovi} D, Radoni} R, Ga{parovi} V, Merkler M, Gjura{in M. Pulmonary involvement a new pattern of the severe clinical picture in patients with haemorrhagic fever with renal syndrome?, 9th European Congress on Intensive Care Medicine, Monduzzi Ed. 655-658,1996 Table 1. Patients with acute renal failure conected with the war in Croatia ________________________________________________________________________________________________________________________ Pts. Age Diagnosis and causative agents Apache II ARF HD Outeome _________________________________________________________________________________________________________________________ K.D. 21 War injury and sepsis (St.aureus, Serratia, E. Coli, Clostr.tetani biformantas, Acinetobacter) 21 Olig 14 died M.M. 30 War injury and sepsis (Candida, Klebsiella pn. Pseudomonas, Bacilus sp.) 25 Olig 11 died D.M. 21 War injury and sepsis (Pseudomonas, Enterobacter) 19 Olig 11 died S.Ш. 21 War injury, hemorrhagic shock, intraop. arest 18 Neolig 0 died Z.S. 44 War injury and sepsis (Enterobacter, Acinotobacter) 18 Olig 12 died D.I. 30 War injury and sepsis (St. aur., Acinotob, sp. E. Coli, Enterobact) 20 Olig 16 recovered Z.M. 42 War injury and sepsis (Enterobacter, St. aures) 19 Olig 4 recovered K.M. 30 War inury and sepsis (Pseudomonas, Enterobacter) 16 Neolig 0 recovered A.S. 30 War injury and sepsis (Pseudomonas) 18 Olig 16 died M.M. 24 War injury and sepsis (Acinetobacer) 16 Olig 11 died P.V. 32 War injury and sepsis (Staph.aureus, Morgnella morgani, Candida alb) 20 Olig 0 recovered S.D. 21 Febris hemorrhagica (IF:Haantan virus 1:16, Plitvice virus 1:15) 8 Olig 0 recovered Z.V. 40 Febris hemorrhagica (Pathological finding) 34 Olig 1 died J.M. 21 Febris hemorrhagica (IF:Haantan virus (76118) 1:16, Plitvice virus 1:16) 9 Olig 4 recovered H.D. 28 Febris hemorrhagica (Without serologic confirmation) 12 Neolig 0 recovered R. D. 24 Febris hemorrhagica (without serologic confirmation) 12 Neolig 4 recovered B.M. 43 Leptospirosis (L.sejroe 1:400, L.saxkoebing 1:500) 14 Olig 13 recovered V.I. 24 Leptospirosi (L.sejroe 1:500, L. icterohaemorrhagica 1:500) 18 Olig 0 recovered M.T. 25 Febris hemorrhagica (with serological confirmation) 10 Olig 0 recovered G.M. 35 Febris hemorrhagica (with serological confirmation) 11 Olig 0 recovered _________________________________________________________________________________________________________________________ Єа/Ѕр=ІЇЈ Љ ЊЂЄт=Ѕв/І Ї ЈЉЊЋЄа/Ѕр=ІЇЈ Љ Њ‚Ъ_ ž 3YAZAŽJ‘J“JоJ(K§њ§і§і§ђюъюђшu]c]c]c]cUc c‚ƒ„…†‡CDEFGHIJKLMNOPQRSTUМ !"+,ќќїєїќђђђђэќќќќќќќќќќќќќќќќќќќќќќќќќќќќќќќааа*,ЊЪ_ ` a b ž Ÿ   Ё Ѓ Є Ѕ В Г з и й к я № ё Є Ѕ ~GHIJRSд]^~‰Š+xyz…ћћћћћћћћћћћћћћћћћћћћћћћћјјјћћћћћћћћћћћћћћћћћа,…†‡К'=(х(f,0S2 3 3 3 3 33333333333333333(3)3u3v3и3й3t4u4)5*5ј5љ5ћћёћћћыћћћшшшшшшшшшшшшшшшшшшшцццццццццццца№ Zvа)љ5g6h6М6Н6‡7ˆ7h8i8&9'9С9Т9::y:z:H;I;О;П;[<\<п<р<b=c=ю=я=>Ž>? ?Ѓ?Є?@@A@KALAMANAOAPAQARASAўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўћћћћћћћћ-SATAUAVAWAXAYAZAЈA!BiBуBфB[CПCD[DЌDEpEЭEFTFСF(GpGпG>HŸHљH\IИIJŽJJJ‘J’J“J”J•J–J—J˜J§§§§§§љљљљљљљљљљљљљљљљљљљљљїљљљљљёљљїї§§§§§PўhPў+˜J™JšJ›JœJJžJŸJ JЁJЂJЃJЄJЅJІJЇJЈJЉJЊJЋJЌJ­JЎJЏJАJБJВJГJДJЕJЖJЗJИJЙJКJЛJМJНJОJПJРJСJТJУJФJХJ§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§§-ХJЦJЧJШJЩJЪJЫJЬJЭJЮJЯJаJбJвJгJдJеJжJзJиJйJкJлJмJнJоJ§§§§§§§§§§§§§§§§§§§§§§§§§K@ёџNormala "A@ђџЁ"Default Paragraph FontZ>GоGоJџџџџѕJџџџџKџџџџ !џџ!џџ!џџ џџ џџ џџ џџ џџ џџ џџ !џџ !џџ  џџ Ђ ~f)07R>Z>GОGоGrЅ­a  (K&,…љ5SA˜JХJоJ'()*+,-‹xC:\WINWORD\ARF-CRO.DOCxxA:\ARF-CRO.DOCxxC:\WINWORD\ARF-CRO.DOCTSKA:\ARF-CRO.DOCVladimir GašparovicC:\Biocompatible\ARF-CRO.DOCџ@OKIPAGE 4wLPT1:VHSD4W12OKIPAGE 4wOKIPAGE 4w Dl ќџOKIPAGE 4wџџџџOKIPAGE 4w Dl ќџOKIPAGE 4wџџџџ€Y>Y>Y>Y>VTimes New Roman Symbol &ArialюTimes New Roman CE Dutch"ˆаhL &lЬЦkЬЦ>­e B; ƒ~ $O'ACUTE RENAL FAILURE DUE TO WAR INJURIESxVladimir Gašparovicc\ClientProtocolsTransportLoad4авdгв0ввввXгвTгвHгв@гв0гвTгвncacn_ip_tcp34280ncacn_spx135ncacn_nb_nbepmapper%d.%d.%d.%dncadg_ipxncadg_ip_udpncacn_nb_xnsncacn_nb_ipxncacn_nb_tcpncacn_at_dspRPCSSInitSecurity  !"#$%&'()*+,-./0ўџџџ§џџџ5ўџџџ=ўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџRoot EntryZ>’џџџџџџџџ РFє\šНаЛР)юJeсМ4€WordDocumentpюўXXpХР!џџџџй` CompObjю@@џџџџџџџџџџџџџџџџџџpjSummaryInformation(џџџџџџџџрўџџџ ўџџџ ўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџўџ џџџџ РFMicrosoft Word Document MSWordDocWord.Document.6є9ВqаЯрЁБсўџр…ŸђљOhЋ‘+'Гй0А˜ амшє ,8 ` l x „˜ Јт(ACUTE RENAL FAILURE DUE TO WAR INJURIESxC№NormalOVladimir Gašparovic62eMicrosoft Word fDocumentSummaryInformation8џџџџџџџџџџџџ єџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџўџеЭеœ.“—+,љЎ0ФHP\dl t| „тdiЖ~ (ACUTE RENAL FAILURE DUE TO WAR INJURIESаєќ˜ TDlЄTѕќЬ TЁThЁT4ЁTœЁTаЁTЂTd*D8ЂTlЂTМЄT\\DEFAULT ЂTШњќџџџџџџџџџџџџџџџџ<ЃTpЃTџџџџpCDџџџџ”EDдЂTЃTџџџџ№Dџџџџи&DШњќџџџџџџџџџџџџџџџџШњќџџџџџџџџџџџџџџџџ#§ЄЃTРРэРёРщРѕРиЃT(СXаQаP7‚or Windows 95@N<ю;@м eсМ@Х]bžЛ@HŸ1eсМ e B;аЯрЁБс>ўџ ўџеЭеœ.“—+,љЎ0ФHP\dl t| „тdiЖ~ (ACUTE RENAL FAILURE DUE TO WAR INJURIESаЯрЁБсџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџ