Beril Akman

Adherence, depression and quality of life in patients on a renal transplantation waiting list

To study nonadherence, and its relationship with depression and quality of life (QOL) in patients on a cadaveric renal transplantation waiting list (RTWL). In 86 RTWL patients (56 men/30 women), there were 49 nonadherent patients (age, 46.8 ± 21.8 years) and 37 adherent patients (age, 42.8 ± 12.1 years). Clinical nonadherence was defined as skipping or shortening dialysis sessions, interdialytic weight gain (IDWG) of >5.7% body weight, a predialysis potassium level of >6 mEq/l and a predialysis phosphate level of >7.5 mg/dl. For each study subject, marital status, level of education duration of dialysis, prior renal transplantation, IDWG, predialysis blood urea nitrogen (BUN) value and creatinine, potassium, phosphate levels were recorded as were scores from the short form‐36 and Beck depression inventory (BDI). A high IDWG (33.7% of the subjects) was the most common nonadherence pattern noted. Age, sex, marital status, duration of dialysis, prior transplantation, comorbid conditions the predialysis BUN values, the levels of creatinine, potassium, and phosphate were not significantly different between the two groups (P > 0.05). The level of education was higher in adherent group (P = 0.018). QOL and BDI scores were negatively correlated (P = 0.001, r = −0.561). Nonadherent patients had lower QOL (P = 0.04) and higher depression scores (P = 0.01) than did adherent patients. Of the depressed patients, 77.8% had a comorbid condition. Nonadherence was only associated with BDI scores (OR, 2.146; CI, 2.052–2.350; P = 0.002). In dialysis patients, close monitoring of adherence, early diagnosis of depression, and the treatment of disease may further enhance QOL during the waiting period for a cadaveric renal transplant.

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.

AMYLOID GOITER IN FAMILIAL MEDITERRANEAN FEVER (FMF): A CLINICOPATHOLOGIC STUDY OF 10 CASES

FMF Amyloidosis is an important etiological factor of end stage renal disease (ESRD) in Mediterranean Countries. Apart from major target organs as cardiovascular, respiratory and gastrointestinal system, endocrine organs can also be involved. We planned to investigate the thyroid involvement in our amyloidosis group. The aim of this study was to determine clinical characteristics of amyloid goiter in FMF patients and the abnormalities of thyroid function, as well as to identify pathologic characteristics. Twenty-two hemodialysis patients (mean age 34.1 ±14 years, range 17–68) whose ESRD secondary to FMF amyloidosis were evaluated with physical examination, serum levels of thyroid hormones, ultrasound examination of thyroid glands, thyroid syntigraphic studies. Goiter was found in 10 patients (4 male, 6 female) having enlarged neck mass (mean age 35 ± 14 years, range 23–64). The serum levels of thyroid hormones and TSH were normal in 4 patients. Other four cases had euthyroid sick syndrome. Only one patient developed tender enlarged neck mass with subacute thyroiditis symptoms and one had primary hyperthyroidism. Ultrasound examination showed; hypoecoic nodules in 6 patients diffuse multinodular enlargement in 4 patients. Thyroid syntigraphic studies revealed hypoactive nodules in 7 patients and hyperactive nodules in 3 patients. After the laboratory tests were completed, in 10 patients diagnosis were made with fine needle aspiration biopsy. Of 10 patients 5 underwent subtotal thyroidectomy. Immunohistochemical evaluation demonstrated the presence of amyloid AA immunoreactivity in all cases. In conclusion fine needle aspiration from the thyroid when enlarged is useful in the diagnosis of suspected amyloidosis, especially since it is a safe, easily performed procedure. With the help of amyloid goiter diagnosis the patients prognosis on hemodialysis and with renal transplantation can be predicted. Amyloid goiter must be searched in hemodialysis patients especially in Mediterranean Countries.

BRONCHIECTASIS-RELATED AMYLOIDOSIS AS A CAUSE OF CHRONIC RENAL FAILURE

Bronchiectasis is defined as acquired and permanent abnormal dilation and destruction of the bronchial walls. Secondary amyloidosis is a disorder characterized by the deposition of amyloid A (AA) in multiple organs and tissues in the body. End-stage renal disease (ESRD) secondary to bronchiectasis-related amyloidosis has only been mentioned in case reports. Little is known about the complications of bronchiectasis-related amyloidosis and the outcomes in patients who develop ESRD due to amyloid deposition in the kidneys. The aim of this study was to identify the clinical characteristics of this patient group, and to report the outcomes of these cases relative to bronchiechtasis type. We assessed the records of 40 patients with AA-type amyloid nephropathy and ESRD who were on hemodialysis (HD) at Baskent University Hospital between 1997 and 2000. The diagnosis of amyloidosis was based on histopathological findings in kidney, rectum, bone marrow, lymph node, thyroid, bladder, liver, and stomach biopsies. Bronchiectasis was diagnosed on the basis of history and findings on physical examination, chest X-ray, and thoracic high-resolution computerized tomography (HRCT). The patients’ records were retrospectively evaluated for cause of secondary amyloidosis, and cases with causes other than bronchiectasis were excluded. Secondary amyloidosis due to bronchiectasis and recurrent pulmonary infection was identified in 40% (16 patients) of the 40 patients. For each of these 16 cases, we recorded patient age, duration of bronchiectasis, duration of HD, amount of lung involvement, and biopsy site(s). The means for age, duration of bronchiectasis, and duration of HD in the 16 patients were 50.6 ± 13.5 years, 22.18 ± 12.02 years (range, 6–42 years), and 30.81 ± 36.94 months (range, 4–144 months), respectively. The most common biopsy site was the rectum (n = 8). Thoracic HRCT revealed cystic bronchiectasis in 8 cases (50%). Four of these 8 patients (25% of the group of 16) died from sepsis within 3-year follow-up period. Two of the four patients who died had bilateral cystic bronchiectasis, and the other two had unilateral cystic bronchiectasis. In the other eight patients in the group, thoracic HRCT showed chronic fibrotic changes in the pulmonary parenchyma and minimal traction bronchiectasis. Four of these patients exhibited apical fibrosis and bronchiectasis (25% of the group of 16), and these radiological findings were considered sequelae of previous tuberculosis infections. In conclusion, chronic respiratory infections and associated bronchiectasis remain a serious problem in Turkey due to insufficient prevention, diagnosis, and treatment. It is important that patients with progressive cystic and diffuse bronchiectasis be followed carefully, as they may develop amyloidosis and ESRD in time. Also, the clinical course in patients with cystic bronchiectasis may be worse than that in other types of bronchiectasis due to complicating pulmonary infections.

Renin-Angiotensin System Polymorphisms: A Risk Factor for Progression to End-Stage Renal Disease in Vesicoureteral Reflux Patients

Aim. Renin-angiotensin system (RAS) gene mutations have been implicated as a risk factor for the presence and progression of renal disease in vesicoureteral reflux (VUR). However, the results are contradictory, and the effects of RAS polymorphisms in VUR patients with end-stage renal disease (ESRD) have not been defined yet. This study was designed to evaluate the angiotensin-converting enzyme insertion/deletion (ACE-I/D), angiotensinogen (AGT) M235T, and angiotensin II receptor type 1 (ATR1) A1166C and type 2 (ATR2) C3123A gene polymorphisms as risk factors for progression to ESRD in patients with VUR. Methods. ACE-I/D, AGT-M235T, ATR1-A1166C, and ATR2-C3123A were identified in 161 ESRD patients (52 female, 109 male; 77 renal transplant, 84 dialysis; age: 34.4 ± 11.2 years). VUR was the ESRD etiology in 40 patients. Genetic polymorphisms of the ACE gene I/D, AGT gene M235T, ATR1 gene A1166C, and ATR2 gene C3123A were identified in all of the patients. Results. We detected no linkage between genetic polymorphisms of ATR1-, ATR2-, AGT-, and VUR-related ESRD. When ACE gene was considered, VUR(+) patients had 63.6% DD, 36.4% ID, and no II alleles, whereas VUR(−) patients had 48.6% DD, 43.2% ID, and 8.1% II alleles. Conclusion. A striking feature of VUR-related ESRD patients was the absence of II alleles, so the DD genotype may be accepted as a genetic susceptibility factor for progression to ESRD in VUR 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