Cihan Altin

Pulmonary Hypertension in Patients With End-Stage Renal Disease Undergoing Renal Transplantation

INTRODUCTION Pulmonary hypertension (PHT) has been reported to occur in a considerable proportion of patients with end-stage renal disease (ESRD). It is a progressive condition of the pulmonary circulation that poses prognostic importance. In this study, we sought to investigate the prevalence and the predictors of PHT among ESRD patients undergoing renal transplantation. PATIENTS AND METHODS We retrospectively evaluated the records, clinical and demographic data as well as laboratory results of 500 adult patients who underwent renal transplantation at our institution. A comprehensive Doppler echocardiographic examination was performed in all patients as part of the preoperative assessment. Systolic pulmonary artery pressure (SPAP) was calculated using Bernoulli equation; a value of >30 mm Hg was accepted as PHT. RESULTS The mean age of the study population was 31.6 +/- 10.2 years. The mean duration of dialysis was 40 months; 432 patients (86.4%) were on hemodialysis (HD) and 68 (13.6%) on peritoneal dialysis (PD). PHT was detected in 85 (17%) patients with a mean SPAP of 46.7 +/- 8.7 mm Hg (range = 35-75 mm Hg). The mean age, sex, and laboratory variables were similar between patients with versus without PHT (P > .05 for all). The mean duration of dialysis therapy was longer in the PHT group than those subjects with normal SPAP (50.8 vs 38.5 months; P = .008). Concerning the type of dialysis, the ratio of patients having PHT was higher in the HD compared with the PD group (18.8% vs 5.9%; P = .008). The prevalence of chronic obstructive pulmonary artery disease, asthma, smoking, hypertension, and diabetes mellitus did not differ between patients with versus without PHT (P > .05 for all). CONCLUSION The findings of this study revealed that PHT was a common clinical condition among patients with ESRD evaluated for renal transplantation. The time on renal replacement therapy particularly HD as the treatment was associated with greater prevalences. Since it may be of prognostic importance in patients undergoing renal transplantation, a careful preoperative assessment including a comprehensive Doppler echocardiographic examination is needed to identify PHT.

Impaired coronary flow reserve in patients with metabolic syndrome

BACKGROUND Metabolic syndrome (MetS) is a strong predictor of cardiovascular events. Coronary flow reserve (CFR), as determined by transthoracic echocardiography, is an indicator of microvascular function. In this study, we sought to determine whether CFR is impaired in patients with MetS without clinical coronary heart disease. METHODS Thirty-three patients with MetS (mean age, 67+/-8 years) and 35 age- and sex-matched controls were studied prospectively. Transthoracic two-dimensional and Doppler echocardiography was performed on all patients. Baseline and hyperemic (after dipyridamole infusion) coronary flow rates were measured using pulsed Doppler echocardiography. CFR was calculated as the ratio of hyperemic to baseline diastolic peak velocities. RESULTS There was no difference with regard to baseline systolic and diastolic coronary flow rates in patients with MetS compared with control subjects (19.9+/-3.1cm/s vs. 19.7+/-2.9cm/s, P>.05; and 27.7+/-4.2cm/s vs. 27.1+/-3.6cm/s, P>.05, respectively). Hyperemic diastolic flow and CFR were significantly lower in patients with MetS than in controls (61.7+/-9.4cm/s vs. 70.2+/-9.2cm/s, P<.0001; and 2.2+/-0.5 vs. 2.6+/-0.4, P=.001, respectively). In a logistic regression analysis that included age, sex, body mass index, hypertension, and dyslipidemia and MetS, MetS was the only predictor of a CFR<2.5 (P=.007, OR=6.1, 95% CI: 1.6-23.3). CONCLUSION In conclusion, CFR is impaired in patients with MetS suggesting that coronary microvascular dysfunction, an early finding of atherosclerosis, is present in this patient population. Metabolic syndrome is associated with a CFR<2.5.

Coronary anatomy, anatomic variations and anomalies: a retrospective coronary angiography study.

INTRODUCTION The incidence of coronary artery anomalies (CAAs) varies from 0.2% to 8.4%. Knowledge of such anatomical variations is important as coronary procedures are regularly performed these days. We aimed to find the coronary dominance pattern, intermediate artery (IMA) frequency and CAA incidence in our clinic, and compare them to those in the literature. METHODS The medical reports of 5,548 patients who had undergone coronary angiography (CAG) between 2005 and 2009 were retrospectively investigated. Dominance pattern and presence of IMA and CAA were recorded. CAAs were described using two different classifications: Angelini and Khatamis classification, and a new modified classification that was derived from Angelini and Khatamis classification. Some procedural details and clinical features of the patients with CAA were also investigated. RESULTS Coronary dominance pattern was: 81.6% right coronary artery, 12.2% circumflex artery and 6.2% co-dominant. IMA was present in 613 (11.0%) patients. The incidences of overall anomaly were 2.7% and 1.4%, according to the different classifications. Absent left main coronary artery, which was the most common anomaly in the present study, was found in 51 (0.9%) patients. Incidences of myocardial bridge, coronary arteriovenous fistulae and aneurysms were 1.1%, 0.2% and 0.3%, respectively. CONCLUSION CAAs are generally asymptomatic, isolated lesions. Some may lead to anginal symptoms, myocardial infarction or sudden death. We found that CAA was associated with increased radiation and contrast exposure in patients who underwent CAG. This risk could be reduced if appropriate catheters were designed and training programmes on ostial cannulation were developed.

Assessment of Subclinical Atherosclerosis by Carotid Intima-Media Thickness and Epicardial Adipose Tissue Thickness in Prediabetes.

Impaired fasting glucose (IFG) and impaired glucose intolerance (IGT) are predictors of cardiovascular disease (CVD). We tested the hypothesis that epicardial fat thickness (EFT) and carotid intima–media thickness (cIMT), as markers of early atherosclerosis, are increased in patients with prediabetes. We prospectively enrolled 246 patients (162 with prediabetes and 84 controls). Prediabetes was defined according to American Diabetes Association criteria, and patients were divided into 3 groups: group 1—IFG, group 2—IGT, and group 3—IFG + IGT. Both cIMT and EFT were significantly greater in patients with prediabetes compared with controls (0.81 ± 0.20 mm vs 0.68 ± 0.16 mm, P < .001 and 7.0 ± 2.0 mm vs 5.6 ± 1.6 mm, P < .001, respectively). This difference was mainly attributed to patients with IGT. Age, waist circumference, and 2-hour glucose independently predicted cIMT, while 2-hour glucose was the only independent predictor of EFT in multivariate analysis among other relevant parameters for cIMT and EFT. The cIMT and EFT (measured noninvasively) could be useful indicators of CVD risk in these patients. In order to prove this hypothesis, long-term prospective studies with greater patient numbers are required.

Assessment of epicardial adipose tissue and carotid/femoral intima media thickness in insulin resistance

BACKGROUND Metabolic syndrome is a combination of multiple cardiovascular (CV) risk factors including insulin resistance (IR). Carotid, femoral intima media thickness (IMT), and epicardial fat thickness (EFT) are considered as novel cardiometabolic risk factors. We aimed to test the hypothesis that carotid, femoral IMT, and EFT are increased in patients with IR. METHODS We enrolled consecutively and prospectively 113 patients with IR. Then we collected data from an age- and sex-matched control group of 112 individuals without IR. Homeostasis model assessment (HOMA) index value >2.5 was accepted as IR. Patients with diabetes mellitus, CV diseases, systolic heart failure, chronic liver or renal diseases were excluded. On B-mode duplex ultrasound the mean IMT at the far wall of both left and right common carotid/femoral arteries were measured manually. EFT was measured on the free wall of the right ventricle at end-diastole from the parasternal long-axis views by standard transthoracic 2D echocardiography. RESULTS Both carotid IMT and EFT were significantly higher in patients with IR compared to controls (0.80±0.21mm vs 0.60±0.21mm; p<0.001 and 7.34±1.96mm vs 5.22±1.75mm; p<0.001, respectively). However, there were no significant differences in femoral IMT between the groups (0.74±0.20 vs 0.69±0.17; p=0.062). In multivariate linear regression analysis age (β=0.223, p=0.010), 2-h blood glucose (β=0.198, p=0.021), and IR (β=0.369, p<0.001) were independent predictors of EFT. On the other hand age (β=0.363, p<0.001) and IR (β=0.321, p<0.001) were independent predictors of carotid IMT. CONCLUSIONS Patients with IR have increased carotid IMT and EFT, but not femoral IMT. This apparent incoherence may be due to the involvement of carotid arteries prior to femoral arteries in patients with IR.

The Prevalence and Types of Cardiovascular Dısease in Patıents With End-Stage Renal Dısease Undergoing Renal Transplantation

BACKGROUND Cardiovascular disease (CVD) is the most common cause of death in patients with end-stage renal disease (ESRD) as well as in renal transplant recipients (RTR). In this study we sought to evaluate the prevalence and the types of CVD in patients with ESRD undergoing renal transplantation. PATIENTS AND METHODS The data of 500 consecutive patients with ESRD undergoing renal transplantation were evaluated retrospectively. Demographic findings, clinical variables, and laboratory results including invasive and noninvasive cardiologic tests were recorded. RESULTS The mean age of patients was 31.6 ± 10.2 years, of whom 133 (26.6%) were female. The prevalence of major atherosclerotic risk was as follows: hypertension 62.2%, diabetes mellitus 3.4%, smoking 26.4%, dyslipidemia 13.2%, and family history of atherosclerosis 9.8%. Treadmill exercise test was performed on 139 subjects, and myocardial perfusion scintigraphy on 73. Coronary artery disease was identified in 16 of 42 cases (38.1%) who had undergone angiography. Eight patients underwent percutaneous coronary intervention, and coronary bypass surgery was performed on 4 cases prior to renal transplantation. On echocardiographic examination mean ejection fraction was 51.9 ± 7.1%, and wall motion abnormality was detected in 15% of cases. The most prevalent valvular disease was mitral regurgitation (45.8%) followed by tricuspid regurgitation (30.6%). CONCLUSION The findings of this study indicate that CVD and atherosclerotic risk factors are common in patients with ESRD undergoing renal transplantion. With regard to the prognostic significance, pretransplantation identification of these conditions is of paramount importance. As a result, improved detection of occult CV disorders results in the possiblity of improved outcomes following renal transplantation.

Renal transplant improves pulmonary hypertension in patients with end stage renal disease

BackgroundPulmonary hypertension (PH) is present in a significant proportion of patients with end stage renal disease (ESRD) and is of prognostic importance. Data on the effect of renal transplant on PH is very limited. In this study, the aim was to examine the effect of renal transplant on systolic pulmonary artery pressure (SPAP) determined by Doppler echocardiography.MethodsAnalysis was performed on the records of 500 consecutive patients who underwent renal transplant at our center between the years 1999 to 2008. The prevalence of PH in the preoperative assessment period was established. Patients were diagnosed as having PH when measured SPAP values were > 35 mm Hg.ResultsPulmonary hypertension was detected in 85 of the 500 (17%) patients under pre-transplant evaluation. At post-transplant follow up Doppler echocardiographic examination was performed on 50 of the 85 patients. After exclusion of 8 cases (1 due to massive pulmonary thromboemboli; 7 due to graft failure requiring dialysis therapy) analyses were performed on 42 patients who had undergone both pre- and post-transplant echocardiographic examination. Mean SPAP at pre-transplant evaluation was 45.9 ± 8.8 mm Hg and in 6 (14.3%) cases SPAP was above 50 mm Hg.Compared to pre-transplant values, a significant decrease was observed in mean SPAP values in an average of 53 months of postoperative follow up (41.8 ± 7.4 mm Hg vs. 45.9 ± 8.8 mm Hg, p < 0.0001).ConclusionThese findings indicate that patients with ESRD accompanied by PH may benefit from renal transplant. Further research is required for more concrete conclusions to be drawn on this subject.RiassuntoRazionaleL’ipertensione polmonare (PH) è presente in una quota rilevante di pazienti con grave insufficienza renale ed ha rilevanza prognostica. Dati sugli effetti del trapianto renale sulla PH sono molto limitatı. Scopo di questo studio era valutare gli effetti del trapianto renale sulla pressione arteriosa polmonare sistolica (SPAP) stimata con l’ecocardiografia Doppler.MetodiAnalisi retrospettiva dei dati di 500 pazienti consecutivi sottoposti a trapianto renale presso il nostro centro tra il 1999 ed il 2008. È stata individuata la prevalenza di PH nel periodo di valutazione pre-trapianto, definita come valore di SPAP > 35 mm Hg.RisultatiUna ipertensione polmonare è stata diagnosticata in 85 (17%) dei 500 pazienti sottoposti a valutazione pre-trapianto. Al follow up post-trapianto 50 degli 85 pazienti sono stati sottoposti ad una ecocardiografia Doppler. Dopo avere escluso 8 casi (1 per tromboembolia polmonare massiva, 7 per fallimento del trapianto che ha reso necessario proseguire con la dialisi) l’analisi è stata effettuata sui 42 pazienti di cui erano disponibili i dati pre- e post-trapianto. Il valore medio della SPAP alla valutazione pre-trapianto era 45,9 ± 8,8 mm Hg e in 6 (14,3%) casi la SPAP era oltre 50 mm Hg. Dopo trapianto si è osservata una riduzione significativa dei valori medi di SPAP nei 53 mesi di media del follow up post-trapianto (41,8 ± 7,4 mm Hg vs 45,9 ± 8,8 mm Hg, p < 0,0001).ConclusioniI nostri dati indicano che i pazienti con PH associata a ESRD possono trarre beneficio dal trapianto di rene, ma ulteriori studi saranno necessari per trarre conclusioni più certe su questo tema.

Investigation of the relationship between asthma and subclinical atherosclerosis by carotid/femoral intima media and epicardial fat thickness measurement

ABSTRACT Objective: Since asthma and atherosclerosis may share similar pathophysiological mechanism, this study is planned to investigate whether epicardial fat thickness (EFT), carotid and femoral intima media thicknesses, which are markers of subclinical atherosclerosis, are increased in patients with asthma. Methods: The study was designed as a cross-sectional study. A total of 154 participants (83 patients with asthma and 71 healthy volunteers) were enrolled into the study. Epicardial fat, carotid, and femoral intima media thicknesses were measured and recorded in both groups. The statistical difference between the two groups was examined. Results: Both carotid and femoral intima media thicknesses were significantly higher in patients with asthma compared to control group (5.52 ± 0.4 mm−1 vs. 5.36 ± 0.4 mm−1; p = 0.038 and 5.64 ± 0.4 mm−1 vs. 5.46 ± 0.5 mm−1; p = 0.036, respectively). However, there was not a significant difference in EFT between the groups [5.9 mm (5.3–6.6; IQR = 1.3) vs. 5.6 mm (4.7–6.5; IQR = 1.8); p = 0.1]. On comparison of control group and asthma subgroups (mild, moderate, and severe), there was a statistically significant difference among these four groups in terms of carotid and femoral intima media thicknesses (p = 0.002 and p < 0.001, respectively). Subgroup analyses showed that this difference was mainly due to patients with severe asthma. Conclusions: Carotid and femoral intima media thicknesses in asthmatic patients were found to be increased compared to the normal population. As a result, the risk of subclinical atherosclerosis in asthmatic patients may be high.

Cortical membranectomy in chronic subdural hematoma: Report of two cases

Different surgical procedures have been used in the management of chronic subdural hematoma (CSDH). Nowadays treatment with burr hole is more preferable than craniotomy in most clinics. We present two cases of CSDH, which caused neurological deficits. In both cases cortical membranectomy was performed following craniotomy. After this procedure, significant improvement was observed in patients neurological deficits. We recommend that craniotomy and subtotal membranectomy may be a more adequate choice in such cases. This report underlined that craniotomy is still an acceptable, safe, efficient and even a better procedure in selected patients with CSDH.

A novel oral anticoagulant, dabigatran, in acute renal infarction.

Acute renal infarction (ARI), which is a rare cause of flank pain, results from interruption in the blood supply of renal tissue. The severity of its clinic depends on the width of the affected part of the kidney. It is often impossible to find the underlying cause (1, 2). Thromboembolic states related to cardiac diseases, such as atrial fibrillation, rheumatic mitral stenosis, endocarditis, and left ventricular wall aneurysms, are the major causes, whereas occlusion of the renal artery following endovascular aortic or renal intervention, renovascular diseases, malignant hypertension, paradoxical cardiac emboli associated with atrial septal defects, polyarteritis nodosa, and cocaine have also been reported as rare causes in the etiology (3-5). In the literature, the incidence of ARI lies within a range of 0.007%-1.4% (1-5). Herein, we present a patient with ARI and its treatment with a novel oral anticoagulant, dabigatran.