Ekrem Dogan

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.

Tuberculin Skin Test Results and the Booster Phenomenon in Two-Step Tuberculin Skin Testing in Hemodialysis Patients

Patients with chronic renal failure are at increased risk for tuberculosis (TB). Centers for Disease Control and Prevention (CDC) have recommended annual skin testing for TB, with tuberculin-purified protein derivative (PPD), in patients with chronic renal failure. Uremia alters the macrophage function, which can lead to anergy for skin tests. The aim of this prospective study was to determine the prevalence of positive tuberculin skin test (TST) and the booster effect of TST in hemodialysis patients living in a relatively underdeveloped portion of the country. Material and Methods. Patients were recruited from Van (Yuzuncu Yil University Hospital, Yuksek Ihtisas Hospital) and the Mus State Hospital). At the time of this study, a total of 143 patients were under hemodialysis treatment in these hemodialysis centers, and among them, 124 were included in the study. Informed consent was obtained before inclusion in the study. A positive PPD was an induration of >10 mm in response to five tuberculin units of PPD (RT23-Tween 80), at 72 h. TST-negative patients received a booster TST 10 days later, ~ 10 cm away from the previous intracutaneous injection. The test dose could not be increased due to unavailability of this kind of preparation. The test was performed and interpreted in the same way. Skin testing was performed in June and December 2003. Patients with known active TB are not included in the study. Testing was not done in hospitalized patients to rule out effects of other disease states. Results. Mean age of the patients was 45.3 ± 16 (range 13–82) years. All patients were on HD treatment twice (n: 14) or three times (n: 110) weekly. Duration of dialysis before TST was 30 ± 17 (12–84) months. With the first test (n: 14), 11.3% of the patients showed a positive reaction; the second test added (n: 15) 12.1% more TST-positive patients, reaching a total of (n: 29) 23.4% of the patients with a positive TST. The mean induration of the positive TST was 16 ± 4 mm in the first test and 15 ± 3 mm in the second. Five (17.2%) of the patients with positive PPD and two of the patients (2.1%) with negative PPD results subsequently developed active TB within 12 months. Conclusion. We found a significant booster effect in our hemodialysis patients using TST-2. Repeat PPD test with the same dosage could detect positive patients more than twofold higher. Among positive PPD patients, TB incidence is considerably high.

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.

Nonketotic hyperosmolar coma in a patient with type 1 diabetes-related diabetic nephropathy: Case report

Nonketotic hyperosmolar coma (NHC) is characterized by severe hyperglycemia; absence of, or only slight ketosis; nonketotic acidosis; severe dehydration; depressed sensorium or frank coma; and various neurologic signs. This condition is uncommon in type 1 diabetes. Because of little or no osmotic diuresis in patients with diabetic nephropathy, increases in plasma osmolality and therefore the likelihood of neurologic symptoms are limited. A 20-year-old male patient with type 1 diabetes with chronic kidney disease on conservative treatment (glomerular filtration rate [GFR], 18 mL/dk) presented with acute nonketotic hyperosmolar syndrome. The patient was admitted presenting with thirst, fatigue, and drowsiness. Blood biochemistry levels were urea 87 mg/dL, creatinine 5.09 mg/dL, glucose 830 mg/dL, glycosylated hemoglobin (HbA1c) 8%, C peptide < 0.3 ng/mL, sodium 131 mmol/L, chloride 93 mmol/L, potassium 5.2 mmol/L, and calculated serum osmolality 385 mOsm/kg. The presumptive diagnosis on admission was nonketotic hyperosmolar syndrome precipitated by urinary infection. This is the first case report of hyperosmolar coma in a patient with type 1 diabetes with chronic kidney disease.

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

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Effect of hormone replacement therapy on CD4+ and CD8+ numbers, CD4+/CD8+ ratio, and immunoglobulin levels in hemodialysis patients.

Uremia induces a suppression of the immune status. A large clinical literature suggests that estradiol (E2) plays a critical role in immune function. A large proportion of women hemodialysis patients faced early menopause and inadequate estrogen levels. The aim of the present study is to evaluate the effect of hormone replacement therapy on immune function in terms of CD4+ numbers (inducer/helper T cells), CD8+ numbers (cytotoxic/suppressor T cells), CD4+/CD8+ ratio, and IgG, IgM, IgA levels in woman hemodialysis patients. In our study, 15 female hemodialysis patients (median age 32.6 range 24–45) were treated with triphasic estrogen/progesterone preparation (estradiol 2 mg for 10 days, and afterwards estradiol 2 mg + norethisterone 1 mg for another 10 days, and at the end estradiol 1 mg for 6 days) for 6 months. CD4+ numbers, CD8+ numbers, and IgG, IgA, and IgM levels were determined before and after HRT. The “paired-samples T” test was used for statistical analysis of pretreatment and posttreatment values. A significant increase was observed for CD4+ numbers (582 ± 435 versus 637 ± 445, p = 0.04) and CD4+/CD8+ ratio (1.4 ± 0.16 to 2.4 ± 0.3, p < 0.01) after hormone replacement therapy (HRT). Serum immunoglobulin levels were not changed significantly. In conclusion, in postmenopausal hemodialysis patients, HRT significantly increased CD4+ numbers and CD4+/CD8+ ratio, but no effect was observed in IgM, IgG, and IgA levels. Long-term clinical effects of HRT on immune system should be investigated in dialysis patients with further studies.

The Effect of Colchicine on the Peritoneal Membrane

Peritoneal dialysis (PD) is a treatment modality for patients with renal failure. Peritoneal fibrosis is one of the most serious complications after long-term continuous ambulatory peritoneal dialysis (CAPD). Histological studies in both humans and animals show that chronic peritoneal dialysis results in fibrosis of the peritoneal membrane. In our study, we investigated the effect of colchicine on peritoneal alterations induced by hypertonic PD solution in rats. Sprague-Dawley rats intraperitoneally received saline (control group) once daily, for 28 days, or 3.86% glucose (PDF group), or 3.86% glucose plus colchicine (colchicine group). Animals from each group were sacrificed after 28 days with anesthetized ketamine (60 mg/kg BW). For the PD fluid assessment, 1 h before the sacrifice of animals, 10 mL PD fluid of 2.27% glucose was given, and this fluid was obtained after the sacrifice. The levels of transforming endothelial growth factor β (TGF-β), tumor necrosis factor α (TNF-α) and albumin were investigated both in the peritoneal dialysate and blood, and the levels of malondialdehyde (MDA) were investigated only in peritoneal dialysate. The peritoneal membrane was evaluated histologically by light microscopy. When groups were compared in terms of body weight change, the colchicine group significantly lost weight compared to controls and PDF group (−4.7% ± 4.5, 3.5% ± 7.2, 3.0% ± 1.3, respectively, p = 0.018). Also, the blood albumin level was significantly lower for these in the colchicine group compared to those in the PDF group (2.7 ± 0.35 versus 3.2 ± 0.3 g/dL, respectively, p = 0.048). The blood TGF-β level was significantly lower in the control group, and no difference was observed between the PDF and colchicine groups (294.4 ± 67.5 versus 787.4 ± 237.4 versus 615.3 ± 235.1 pg/mL, respectively, p = 0.004). The mesothelial thickness found in groups was as follows: control group 102 ± 18.9 µm, PDF group 128.33 ± 33.1 µm, colchicine group 117 ± 35.6 µm (p = 0.34). In conclusion, a rat model for peritoneal dialysis associated peritoneal derangement without fibrosis could be induced. Colchicine could not prevent peritoneal derangement in this model.

Contrast-enhanced CT and MRI findings of atypical hepatic Echinococcus alveolaris infestation

Diagnosis of liver infestation by Echinococcus alveolaris (EA) is based on serological and radiological findings. In this report, we present a 15-year-old girl with atypical hepatic EA infestation showing central punctate calcifications and contrast enhancement on the portal and late phases of CT and MRI. CT showed a hypodense mass involving more than half of the liver with prominent central calcifications. MRI revealed hypointense signal of the infiltrative mass on both T1- and T2-weighted images. Contrast enhancement is a unique finding in hepatic EA infestation that may cause difficulties with diagnosis. MRI may provide invaluable information in the diagnosis of EA infestation of the liver, either by disclosing the infiltrative pattern of infestation without significant effect to vascular structures, or by the signal characteristics.