Cevat Topal

Effects of late referral to a nephrologist in patients with chronic renal failure

Background:  We lack information about the role of late diagnosis of end‐stage renal disease (ESRD), late nephrological referral and its impact on biochemical variables and first hospitalization in East Anatolia, Turkey.

Tuberculosis in dialysis patients, single centre experience from an endemic area.

Because of immunity defect, patients with end‐stage renal disease are at increased risk of developing infections, tuberculosis (TB) in particular. The incidence of TB is higher in dialysis patients than in general population. We retrospectively reviewed the charts of dialysis patients with TB in our facility. A total of 287 dialysis patients (153 male, 134 female, 223 haemodialysis (HD), 64 continuous ambulatory peritoneal dialysis (CAPD) patients, mean age 46 ± 15) were reviewed from October 1997 to January 2002. TB developed in 30 patients (17 male, 13 female, 24 HD and six CAPD). Thirteen patients with TB presented with fever of unknown origin (FUO) and four of them subsequently developed military lesions on chest X‐ray. Nine patients had pulmonary TB (four with pleural effusions), five patients had TB lymphadenits, two patients had TB peritonitis and one patient had vertebral TB. TB was presented mostly as FUO among dialysis patients in a region under poor socio‐economic conditions. In such areas with endemic TB, dialysis patients who present with FUO should be carefully evaluated for the presence of TB, and test therapy for TB should be performed in otherwise unexplained FUO.

Nephropathy and retinopathy in type 2 diabetic patients living at moderately high altitude and sea level.

Background: High-altitude-induced hypoxia results in various diseases, such as chronic mountain sickness and high altitude retinal edema, and may affect severity and incidence of some cardiovascular diseases. In order to evaluate the effects of moderately high altitude on diabetic nephropathy and retinopathy, a cross-sectional study was planned. Material Method: Long-term type II diabetic residents of sea level (n = 75, 38 male, 37 female, mean age 51.9 ± 10.5 in Trabzon and Zonguldak cities) and moderately high altitude (h = 1,727 m, n = 73, 28 male, 45 female, mean age 48.3 ± 12.1, Van city) were compared. Results: No difference was observed in terms of age, gender, diabetes duration, body mass index, smoking, systolic, diastolic, and mean arterial blood pressure values, serum glucose levels, cholesterol, high-density lipoprotein (HDL)-cholesterol, low-density lipoprotein (LDL)-cholesterol, hemoglobin, HbA1C, hypertension control, or blood pressure medications and retinopathy incidence. Mean 24 h protein excretion (210.0 ± 139.9, 127.8 ± 112.1 mg; P = 0.00), proteinuria prevalence (57.5% versus 33.3%, p = 0.003), and serum creatinine levels (1.04 ± 0.22 versus 0.84 ± 0.21, p = 0.00) were significantly higher in the highlanders, glomerular filtration rate (GFR) was significantly lower in sea level (SL) patients (90.9 ± 26.5 versus 83 ± 21.1, p = 0.05). Conclusion: Tendency to diabetic nephropathy as indicated by higher proteinuria and creatinine levels is increased among type 2 diabetic patients living at moderately high altitude. Prospective studies are needed to confirm these findings.

Effect of valsartan on erythropoietin and hemoglobin levels in stage III‐IV chronic kidney disease patients

Angiotensin‐converting enzyme inhibitors (ACEIs) were accepted as a potential cause of inadequate epoetin response in chronic kidney disease (CKD) patients. We aimed to determine the effects of valsartan, an angiotensin receptor blocker (ARB), on serum ertyhropoietin levels and on certain biochemical and haematological parameters in hypertensive CKD patients. Twenty‐two stage III‐IV CKD patients (mean age; 56.8 ± 8.9 years, 12 male 10 female) were included in the study. Before initiating the treatment, current anti‐hypertensive treatments (if any) were discontinued, and blood samples were collected after a washout period of 3 weeks. Valsartan 80 mg/day was started, and additional anti‐hypertensive agents were given according to study protocol if needed. One way Anova and paired t‐tests were used for statistical comparisons. Serum blood urea nitrogen (BUN), creatinine, uric acid, potassium, haemoglobin and erythropoietin values were measured, and glomerular filtration rates were calculated before and 3, 6 and 90 days after valsartan treatment, a significant reduction in EPO level was observed at 3rd (19.6 ± 24.0 vs. 13.8 ± 8.5, p = 0.010), 6th (12.1 ± 7.6, p = 0.009), and 90th days (8.3 ± 5.4, p = 0.007). When pre‐treatment values were compared with 90th day results, no significant change was observed in terms of hgb, htc, serum BUN, creatinine, uric acid, potassium, and GFR values. In conclusion, valsartan, an ARB, did not decrease haemoglobin levels in stage III‐IV CKD patients despite significant reduction in serum ertyhropoietin levels, so ARBs may be preferred to ACEIs in CKD patients when indicated.

Effect of Indapamide on Urinary Calcium Excretion in Patients with and without Urinary Stone Disease

BACKGROUND: Indapamide is an antihypertensive agent similar to thiazides, but with some different effects. Thiazide and thiazide-like diuretics are useful in preventing recurrent urinary stone formation due to their hypocalciuric effects. OBJECTIVE: To determine the hypocalciuric and other effects on certain laboratory parameters of indapamide 1.5 mg in different patient groups. METHODS: Four groups of patients recruited from urology and nephrology outpatient departments were experiencing non-hypercalciuric urinary stone disease (group 1), idiopathic hypercalciuria (group 2), urinary stone disease with hypercalciuria (group 3), and essential hypertension (group 4). In all patients, fasting serum uric acid, calcium, sodium, potassium, cholesterol, triglyceride, parathyroid hormone (PTH) values, and morning second-spot urine calcium and creatinine levels were assessed before and 8 weeks after treatment with indapamide. RESULTS: Urinary calcium excretion was reduced significantly in all groups: group 1 from 0.10 ± 0.02 to 0.07 ± 0.03 (mean ± SD; 30% reduction; p < 0.001), group 2 from 0.30 ± 0.15 to 0.15 ± 0.10 (50% reduction; p < 0.001), group 3 from 0.35 ± 0.15 to 0.20 ± 0.10 (43% reduction; p < 0.001), and group 4 from 0.10 ± 0.03 to 0.08 ± 0.02 (20% reduction; p < 0.0010). These results should be interpreted with caution since no control group was included in this study. Mean serum uric acid and triglyceride levels were significantly increased, and mean PTH and potassium levels and diastolic and systolic blood pressure were significantly decreased in all groups. Few temporary adverse effects, such as dizziness and fatigue, were noticed and none of them caused discontinuation of treatment. CONCLUSIONS: Indapamide 1.5 mg/day is effective in decreasing calciuria in patients with non-hypercalciuric urinary stone disease, idiopathic hypercalciuria, urinary stone disease with hypercalciuria, and essential hypertension. This could be achieved with few adverse effects similar to those of thiazides and indapamide 2.5 mg. Indapamide decreased the PTH levels in all groups. Long-term clinical benefits of these effects should be evaluated prospectively with further randomized studies.

Diurnal rhythm of urinary calcium excretion in adults.

Twenty-four-hour urinary calcium excretion is normally the equivalent of daily calcium intake, and varies between 200–300 mg/dL with a calcium/creatinine ratio of 0.07–0.15. In this study, we aimed to investigate the diurnal rhythm of calcium excretion in healthy individual. Forty subjects (30 male, 10 female) were involved into the study. The spot urine samples were taken at 08:00, 14:00, and 22:00 together with a 24-hour collection. Mean spot urinary calcium levels at 08:00, 14:00, and 22:00 were 12.39 ± 8.19, 12.97 ± 8.37, and 16.95 ± 10.39 mg/dL, with calcium/creatinine ratios of 0.104 ± 5.26l, 0.119 ± 7.85, and 0.133 ± 8.17, respectively. Twenty-four-hour urinary calcium excretion was 12.74 ± 7.31 mg/dL with a calcium/creatinine ratio of 0.111 ± 5.41. The values at 08:00, 14:00, and of 24-hour collection were statistically similar (p > 0.05), but the nighttime values were significantly elevated (p < 0.05). In conclusion, calcium excretion is increased at night, and urinary calcium measurements should be interpreted accordingly.

Mycophenolate Mofetil Use in Hepatitis B Associated—Membranous and Membranoproliferative Glomerulonephritis Induces Viral Replication:

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Simultaneous Occurrence of Papillary Intrafollicular and Microcarcinomas with Bilateral Medullary Microcarcinoma of the Thyroid in a Patient with Multiple Endocrine Neoplasia Type 2A: Report of a Case

Abstract.We report the case of a simultaneous occurrence of papillary intrafollicular and microcarcinomas with bilateral medullary microcarcinoma of the thyroid in a patient with multiple endocrine neoplasia type 2A. The concurrent presence of two thyroid carcinomas is rare. The simultaneous occurrence of two different tumors in the same thyroid each being multifocal and smaller than 1 cm in diameter has not been previously reported in the literature. Furthermore, we define the first case of intrafollicular papillary thyroid carcinoma (carcinoma in situ).

The thrombotic events in polycythemia vera patients may be related to increased oxidative stress.

Objective: This study was designed to compare the oxidative stress parameters of patients with polycythemia vera (PV) to those of healthy volunteers and to investigate the probable relationship between vascular events and parameters of oxidative status such as total oxidative status (TOS), total antioxidant status, oxidative stress index (OSI) and malondialdehyde (MDA) in PV patients. Material and Methods: Thirty-five PV patients (20 males and 15 females) and 20 healthy volunteers (11 males and 9 females) were enrolled. The oxidative status parameters of the patients were measured by spectrophotometric analyses at the time of diagnosis and at 6 months after treatment which consisted of phlebotomy and 100 mg/day acetyl salicylic acid with or without hydroxyurea for the high- and low-risk disease group, respectively. These parameters were compared both to healthy controls and to each other, in order to obtain the values before and after treatment. In addition, during diagnosis, the oxidative status parameters of patients with PV and a history of a vascular event were compared with those of patients with no history of a vascular event. Results: The TOS, OSI and MDA values were significantly higher in the patients than in the control group at the time of diagnosis. At 6 months after phlebotomy and 100 mg/day acetyl salicylic acid therapy, the TOS, OSI and MDA values were significantly lower in the patients when compared to the pretreatment values. The TOS and OSI levels were notably higher in the patients with a vascular-event history than in those without this history. Conclusion: Oxidative stress parameters were increased in PV patients.

Effect of glucose concentration on peritoneal inflammatory cytokines in continuous ambulatory peritoneal dialysis patients

OBJECTIVE: It is known that glucose concentrations of peritoneal dialysis solutions are detrimental to the peritoneal membrane. In order to determine the effect of glucose concentration on cytokine levels of peritoneal fluid of continuous ambulatory peritoneal dialysis (CAPD) patients, a cross-sectional study was performed. METHODS: Nine non-diabetic CAPD patients participated in two 8-h dwell sessions of overnight exchanges in consecutive days, with 1.36% and 3.86% glucose containing peritoneal dialysis solutions (Baxter-Eczacibas). Peritoneal dialysis fluid tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 levels were measured. RESULTS: TNF-alpha levels after 1.36% and 3.86% glucose used dwells were 23+/-14 pg/ml and 28+/-4 pg/ml, respectively (p=0.78). The IL-6 levels were 106+/-57 pg/ml and 115+/-63 pg/ml (p=0.81), respectively. CONCLUSION: In our in vivo study we found that the glucose concentration of the conventional lactate-based CAPD solution has no effect on basal IL-6 and TNF-alpha levels of peritoneal fluid. Further in vivo studies with non-lactate-based CAPD solutions are needed in order to determine the effect of glucose concentration per se on cytokine release.