Ayse Bilgic

Predictors for quality of life in continuous ambulatory peritoneal dialysis patients

Aim:  Peritoneal dialysis patients have diminished quality of life scores compared with healthy subjects. Measures of quality of life have been reported to have a significant predictive value for patient survival and hospitalization in peritoneal dialysis patients. The purpose of this study is to determine the clinical, biochemical and psychological predictors for the quality of life in continuous ambulatory peritoneal dialysis (CAPD) patients.

Effect of supportive extracorporeal treatment in liver transplantation recipients and advanced liver failure patients

Recently, continuous venovenous hemodiafiltration (CVVHDF) and plasmapheresis (PF) were suggested as supportive therapy options in combination with standard treatment in advanced liver failure. The aim of this study was to analyze the effects of supportive extracorporeal treatment (SET) in a group of patients with advanced hepatic failure. A total of 25 patients (7 women, 18 men; mean age, 39.3±15.4 years; 13 were transplant recipients [6 women, 7 men; mean age, 37.7±16.9 years]) were included. All patients were in hepatic coma and receiving standard coma and liver failure management when they received SET. Number of SET sessions; levels of serum blood urea nitrogen, creatinine, albumin, calcium, phosphorus, ammonia, alanine and aspartate aminotransferase, and total/conjugated bilirubin; and prothrombin times (PTT) before and after SET were recorded retrospectively. 7.7±7.9 SET sessions were performed. Thirteen liver transplant recipients required SET for an average of 9.7±8.3 days after transplantation. Serum ammonia and bilirubin levels were lower after termination of supportive therapy when compared with initial levels (p<0.0001 and p<0.005 respectively). During follow‐up, hepatic encephalopathy and liver failure resolved in 11 patients, while 14 patients (7 transplant recipients) died. There was no significant difference between patients in either group except that PTT was shorter in patients who survived (p<0.01). Further analyses revealed that in surviving patients, ammonia clearance was higher (p<0.01). In patients with advanced liver failure, or liver transplants, CVVHDF and/or PF could be supportive options combined with standard treatment.

Regular Lactulose Use Is Associated with Lower Peritonitis Rates: an Observational Study

change technique. Contamination and even infection of the peritoneal fluid of female CAPD patients caused by retrograde menstruation have been described (4). In the cases we report here, the recovery of these micro-organisms from the vaginal swab sample during episodes of peritoneal infection suggests a possible ascending contamination of the peritoneum from the genital tract, favored by sexual activity or menstruation. Retrograde flow of infection with peritoneal spread is well known in cases of salpingitis. The presence of RBCs in peritoneal effluent is often observed in peritonitis arising from a gynecological source, although absent in our patients. Even the micro-organisms isolated were unusual. In Case 1 we reported the development of Streptococcus agalactiae, a gram-positive group B β-hemolytic streptococcus. The gastrointestinal tract is the most common site of spreading of this facultative member of the normal flora of the female genital tract. It typically induces serious infections in pregnant women and newborns. Only a few cases of S. agalactiae peritonitis in PD have been reported in the literature (5,6) and, as a rule, they have a very severe course. This micro-organism was isolated from both peritoneal fluid and vaginal swab during episodes of peritonitis with negative blood cultures. Infection was precipitated by menstruation and perhaps retrograde passage of infected material. A curative laparoscopic tubal ligation was performed without more than a brief interruption of CAPD. In Case 2, with recurrent CAPD peritonitis the peritoneal fluid was culture negative by conventional bacteriological and fungal cultures. Ureaplasma urealyticum was identified with special media for culture. This organism colonizes the genital tract of 75% of women and 45% of sexually active men. It has been implicated in non-gonococcal urethritis as well as salpingitis and pelvic inflammatory disease (7). Doxycycline is highly active against Ureaplasma and should be the treatment of choice; ciprofloxacin has only moderate activity. This is the second documented report of Ureaplasma peritonitis (8). The peritonitis in this patient was precipitated by sexual activity: for this reason, unusual organisms such as U. urealyticum should be considered in a female with recurrent “culture negative” peritonitis, especially when symptoms are precipitated by menstruation or sexual activity.

Low Total Plasma Homocysteine Level in Relation to Malnutrition, Inflammation, and Outcome in Hemodialysis Patients

OBJECTIVE We examined the association between nutritional status and total plasma homocysteine (tHcy) level, cardiovascular disease (CVD), and mortality in hemodialysis (HD) patients. DESIGN This prospective study consisted of 124 HD patients. A number of baseline parameters were measured, including tHcy level and laboratory markers of nutrition and inflammation. A CVD history and a malnutrition-inflammation score (MIS) were determined in all patients. The follow-up period was 2 years. RESULTS Forty-nine patients (39.8%) had a history of CVD. During follow-up, 11 (8.8%) deaths occurred, and of these 7 deaths were attributable to CVD. A low tHcy level and an increased MIS were associated with CVD and mortality. The rates of CVD and mortality were also higher in the lowest tHcy level tertiles. In addition, tHcy level was positively correlated with albumin and creatinine, and was negatively correlated with C-reactive protein, MIS, and comorbidity. The survival rates in Kaplan-Meier survival analysis tests were significantly lower in patients with the highest MIS (log rank, 22.3; P < .001). Patients with higher tHcy levels had significantly longer survival rates (log rank, 9.7; P = .007). CONCLUSIONS Because of the strong association of tHcy levels with malnutrition- inflammation, the presence of these factors should be considered when tHcy is evaluated as a risk factor of outcomes in HD patients.

Effect of protein‐energy malnutrition on erythropoietin requirement in maintenance hemodialysis patients

Possible interactions between inflammatory and nutritional markers and their impact on recombinant human erythropoietin (rHuEPO) hyporesponsiveness are not well understood. We investigated the role of nutritional status in rHuEPO requirement in maintenance hemodialysis (MHD) patients without evidence of inflammation. This cross‐sectional study included 88 MHD patients. The associations between required rHuEPO dose and malnutrition‐inflammation score (MIS) and several laboratory values known to be related to nutrition and/or inflammation were analyzed. Anthropometric measures including body mass index, triceps skinfold thickness, and midarm circumferences were also measured. Twenty‐three patients with serum C‐reactive protein levels >10 mg/L were excluded from the analysis. The remaining 65 patients (male/female, 41/24; age 49.1±11.4 years; dialysis duration 99.7±63.0 months) were studied. These patients had moderate malnutrition and the average MIS was 7.4 (range 3–17). The average weekly dose of administered rHuEPO was 69.1±63.1 U/kg. Malnutrition‐inflammation score had a positive correlation with the serum concentration of tumor necrosis factor‐α, whereas it had a negative correlation with anthropometric measures, total iron‐binding capacity, prealbumin, phosphorus, creatinine, and triglyceride. According to Pearsons correlation analysis, significant relationships of increased MIS with increased required rHuEPO dose and rHuEPO responsiveness index (EPO divided by hematocrit) were observed (p=0.008, r=−0.326; p=0.017, r=−0.306, respectively). Recombinant human erythropoietin dose requirement is correlated with MIS and adverse nutritional status in MHD patients without evidence of inflammation. Further research should focus on reversing the undergoing microinflammation for a better outcome in dialysis patients.

The influence of hepatitis C infection activity on oxidative stress markers and erythropoietin requirement in hemodialysis patients.

We sought to expose the possible effect of hepatitis C virus (HCV) infection on oxidative stress indicators, nutritional status, and erythropoietin (rHuEPO) requirements in maintenance hemodialysis (MHD) patients. A total of 111 MHD patients (69 males, 42 females; mean age 51.3 +/- 13.0 years; MHD duration 78.5 +/- 52.1 months) and 46 healthy controls were enrolled in the study. We excluded patients with hepatitis B infection or malignancy. Indicators for oxidative status were studied in plasma samples obtained at the beginning of a clinically stable MHD session. Measurements were performed for plasma superoxide dismutase, glutathione peroxidase (antioxidative agents), and malonyldialdehyde (MDA; oxidative agent) by spectrophotometric methods. All patients were analyzed for the presence of anti-HCV; positive patients were also evaluated for the presence of HCV RNA. MHD patients were divided into three groups according to HCV infection status: group I (anti-HCV-positive, HCV-RNA-negative; n = 22); group II (anti-HCV-positive, HCV-RNA-positive; n = 22), and group III (anti-HCV-negative; n = 67). According to the analyses, MHD patients showed higher plasma oxidative stress indicators and lower antioxidative indicator levels compared to controls (P < .0001). MHD patients also displayed lower albumin and higher C-reactive protein (CRP) levels compared to controls (P < .0001). Antioxidant levels were decreased significantly from group I to III (P < .0001). MDA levels significantly increased from group I to III (P < 0.01). HCV-RNA-positive patients showed lowest albumin and highest CRP levels and rHuEPO requirements. Although alanine transferase (ALT) levels were in the normal range, group II patients had significantly higher ALT levels than the other groups (P < .01). In conclusion, we observed negative effects of active HCV infection on oxidative stress and rHuEPO requirements. In contrast, we detected that clinically inactive HCV infection was associated with reduced oxidative stress and rHuEPO requirements compared with active HCV infection and HCV-negative patients.

Mortality risk factors in chronic renal failure patients after coronary artery bypass grafting

Perioperative risk during coronary artery bypass grafting (CABG) is high in patients with chronic renal disease. We aimed to determine postoperative two-year mortality and identify the preoperative risk factors of mortality during CABG surgery in hemodialysis (HD)-dependent and HD-non-dependent CRF patients. We included 102 CRF patients who underwent CABG in Baskent University Hospital between 2000 and 2005. There were 47 patients with CRF undergoing HD (Group I) and 55 CRF patients without dialysis requirement (Group II). We retrospectively retrieved demographic variables; clinical, operative, and echocardiographic data; and biochemical parameters at the time of the operation and six months postoperation. Postoperative HD requirement in Group II patients and infectious complications were recorded. In the second postoperative year, mortality rate was 27.7% in group I and 16.4% in group II (p > .05). When preoperative risk factors evaluated by univariate Cox analysis, only age (RR = 1.06, p = .04) was a significant determinant of survival in Group I patients. Among the operative and postoperative risk factors of mortality such as duration of operation, numbers of coronary vessel bypass, HD requirement, and infection were investigated in Group I and II patients. Rate of infectious complication (including mediastinitis) was found to be a major determinant of mortality by multivariate Cox analyses in both group I (RR = 4.42, p ≤ .05) and group II (RR = 9.39, p ≤ .05). HD dependency did not increase mortality if the patients are younger and were electively prepared for CABG surgery. High infection rates have increased the postoperative mortality and hospitalization in CRF patients. Early diagnosis of infections in CRF patients is important for early recovery, shorter hospitalization, and lower mortality after CABG operation

Soluble Endothelial Protein C Receptor: Influence on Arteriovenous Fistula Thrombosis Development in Hemodialysis Patients

Background/Aims: Arteriovenous fistulae (AVF) thrombosis is a common cause of morbidity in hemodialysis (HD) patients. Increased soluble endothelial protein C receptor (sEPCR) levels have been associated with increased risk of venous thrombosis. We aimed to investigate the possible effects of sEPCR levels on the development of AVF thrombosis in adult HD patients. Methods: 60 HD patients and 22 healthy controls were included. Patients were followed for 18 months and were divided into two groups according to AVF thrombosis development: group 1 (with thrombosis) and group 2 (without thrombosis). Also, patients classified into tertiles according to plasma sEPCR levels: lowest, intermediate, and highest. Groups were analyzed for any relationship between sEPCR levels and development of AVF thrombosis. Results: Mean plasma sEPCR levels were significantly higher in HD patients than they were in controls. Group 1 patients had significantly higher sEPCR levels compared with group 2 patients. Patients’ groups were similar regarding other possible risk factors for AVF thromboses. The rate of AVF thrombosis development was significantly higher in the highest sEPCR tertile. Conclusion: This is the first study to analyze sEPCR levels in HD patients. Our findings demonstrate a relationship between plasma sEPCR levels and development of AVF thromboses.