Ekrem Erek

International Differences in Dialysis Mortality Reflect Background General Population Atherosclerotic Cardiovascular Mortality

Existing national, racial, and ethnic differences in dialysis patient mortality rates largely are unexplained. This study aimed to test the hypothesis that mortality rates related to atherosclerotic cardiovascular disease (ASCVD) in dialysis populations (DP) and in the background general populations (GP) are correlated. In a cross-sectional, multinational study, all-cause and ASCVD mortality rates were compared between GP and DP using the most recent data from the World Health Organization mortality database (67 countries; 1,571,852,000 population) and from national renal registries (26 countries; 623,900 population). Across GP of 67 countries (14,082,146 deaths), all-cause mortality rates (median 8.88 per 1000 population; range 1.93 to 15.40) were strongly related to ASCVD mortality rates (median 3.21; range 0.53 to 8.69), with Eastern European countries clustering in the upper and Southeast and East Asian countries in the lower rate ranges. Across DP (103,432 deaths), mortality rates from all causes (median 166.20; range 54.47 to 268.80) and from ASCVD (median 63.39 per 1000 population; range 21.52 to 162.40) were higher and strongly correlated. ASCVD mortality rates in DP and in the GP were significantly correlated; the relationship became even stronger after adjustment for age (R(2) = 0.56, P < 0.0001). A substantial portion of the variability in mortality rates that were observed across DP worldwide is attributable to the variability in background ASCVD mortality rates in the respective GP. Genetic and environmental factors may underlie these differences.

Diarrhoea following renal transplantation

In this study, we retrospectively evaluated all attacks of diarrhoea in our renal transplant recipients that came to our medical attention between 1985 and 2000. Also, the clinical features of patients with diarrhoea were compared with the features of recipients without diarrhoea. We diagnosed 41 attacks of diarrhoea in 39 (12.6%) of 308 renal transplant recipients during this time period. An aetiology was detected in 33 (80.5%) of all diarrhoeal episodes and in seven (17.1%) of those the specific agent was diagnosed with the help of stool microscopy. The most frequent causes of diarrhoeal attacks were infectious agents (41.5%) and drugs (34%). Six (14.6%) episodes of diarrhoea were chronic and six were nosocomial. About two‐thirds of diarrhoea developed within the late post‐transplant period (>6 months). When recipients with diarrhoea were compared with those without diarrhoea, it was seen that diarrhoeal patients had significantly higher creatinine and significantly lower albumin levels when compared with the latter group (p < 0.05). Also, the frequency of antibiotic usage was significantly higher in diarrhoeal patients than in the control group (p < 0.05). Four (10.2%) patients with diarrhoea died despite institution of the appropriate therapy. Two of these deaths were primarily related to diarrhoea and the aetiological agent was Clostridium difficile in both these cases. During the 15‐yr study period, 3.6% of all deaths and 5.1% of infection‐related deaths in transplant recipients were secondary to diarrhoea. As a result, we observed that infections and drugs were the most frequent causes for diarrhoea in our series of renal transplant recipients. Also, diarrhoea was an important cause of mortality in this patient population.

Features of Chronic Hemodialysis Practice after the Marmara Earthquake

After disasters, treatment of chronic hemodialysis (HD) patients is problematic because of logistic and medical reasons. This study analyzes features of HD practice in the regions affected by the Marmara earthquake that struck northwestern Turkey in August 1999. Questionnaires asking about HD infrastructure, medical/social problems of chronic dialysis patients, and the fate of dialysis personnel after the disaster were sent to dialysis units located in the affected region. Data gathered from eight HD centers that responded to questionnaires were then analyzed. The number of HD centers and machines were 12 and 124, respectively, before the earthquake. The number of weekly HD sessions in the analyzed eight centers declined from 1093 before the disaster to 520, 616, and 729 1 wk, 1 mo, and 3 mo after the earthquake, respectively. In the effective seven centers, the number of HD personnel was 112 before the earthquake, which dropped to 86 and 94 1 and 3 mo after the disaster, respectively. Overall, there were 439 patients in the analyzed eight centers before the disaster, whereas data were provided on 356 (212 were male; mean age, 47.6 +/- 15.1 yr) dialysis patients. Six patients died, and seven were seriously and 28 mildly injured by the direct effects of trauma. The percentage of patients who received once-weekly dialysis increased from 2.3 to 7.2% within the first week, with a return to lower figures (4.1 and 2.8%) 1 and 3 mo afterward. Despite a decrease in the number of HD sessions, interdialytic weight gain decreased 1 wk after the disaster and BP measurements did not change significantly before and after the earthquake. A total of 301 and 31 patients left their dialysis centers, temporarily and permanently. After catastrophic earthquakes, despite a decrease in the number of HD sessions, patients comply with disaster conditions, likely by strictly following dietary and fluid restrictions.

Treatment Modalities and Outcome of the Renal Victims of the Marmara Earthquake

Background/Aims: Treatment of renal problems during natural catastrophes is highly complicated both for medical and logistic reasons. The therapeutic interventions applied to and the outcome of 639 victims with acute renal problems during the catastrophic Marmara earthquake have been the subject of this study. Methods: Questionnaires regarding information about 63 clinical and laboratory variables were sent to 35 reference hospitals that treated the victims. Information considering therapeutic interventions and outcome obtained through these questionnaires was submitted to analysis. Results: At least one form of renal replacement therapy was administered to 477 (74.6%) of the 639 victims. Of these, 437, 11, and 4 were treated solely by intermittent hemodialysis, continuous renal replacement therapy, and peritoneal dialysis, respectively; 25 victims needed more than one dialysis modality. In total, 5,137 hemodialysis sessions were performed. Also, 2,981, 2,837 and 2,594 units of blood, fresh frozen plasma, and human albumin were administered, respectively. Transfusion of these products was usually associated with higher rates of dialysis needs and mortality. Ninety-seven patients (15.2%) died. The mortality rate of dialyzed victims was higher as compared to nondialyzed ones (17.2 vs. 9.3%, p = 0.015). Conclusions: Massive amounts of dialysis treatment as well as blood and blood product transfusions can be necessary in the treatment of catastrophic earthquake victims with nephrological problems. Despite the potential risk of a high mortality, in the case of appropriate and energetic medical interventions, reasonable final outcomes can be achieved.

Lessons learned from the catastrophic Marmara earthquake: factors influencing the final outcome of renal victims.

BACKGROUND During catastrophic earthquakes, crush syndrome is the second most frequent cause of death after the direct impact of trauma. The Marmara earthquake, which struck Northwestern Turkey in August 1999, was characterized by 639 crush syndrome victims with acute renal problems. The factors influencing their final outcome have been the subject of this study. PATIENTS/METHODS Within the first week of the disaster questionnaires asking about 63 clinical and laboratory variables were sent to 35 reference hospitals that treated the victims. Information obtained by means of these questionnaires, including the factors with a potential influence on outcome, was submitted to analysis. RESULTS Overall mortality rate was 15.2%. In univariate analysis, nonsurvivors were older (p = 0.048); the highest mortality rates were observed among the victims coming from the closest cities to the reference hospitals. Admission within the first 3 days of the disaster (p = 0.016), with oliguria (p = 0.042), lower figures for blood pressure (p < 0.001), platelets (p = 0.004) and serum albumin (p = 0.005) were associated with mortality. Also, higher body temperature (p = 0.013) and serum potassium (p < 0.001) as well as suffering from thoracic or abdominal traumas, extremity amputations and medical complications other than renal failure (for all 4: p < 0.0001) in addition to need of dialysis support (p = 0.015) and mechanical ventilation (p < 0.0001) indicated higher risk of death. In the multivariate analysis, age (p = 0.030, OR = 1.02), presence of disseminated intravascular coagulation (p = 0.001, OR = 4.49), abdominal trauma (p = 0.012, OR = 4.05) and amputations (p = 0.010, OR = 2.81) were predictors of mortality. Dialyzed patients were characterized by higher mortality rates than nondialyzed victims (17.2% versus 9.3%, p = 0.015). CONCLUSION Outcome of the renal victims of catastrophic earthquakes is influenced by the type of trauma, comorbid events and complications observed during the clinical course as well as epidemiological features such as age, distance to reference hospitals and time lapse between disaster and admission to reference hospitals.

Mycobacterium tuberculosis infections after renal transplantation.

The incidence of tuberculosis was found to be 5.8% (16/274) in 274 kidney graft recipients in our centre between 1986 and 1998. The kidney recipients were evaluated retrospectively. A total of 51 recipients received isoniazid prophylaxis for 6 months. The prevalence of tuberculosis was found similar (6% vs. 8.8%, p=0.15) between recipients with prophylaxis and no prophylaxis. Eight patients were recipients of cadaveric donor kidneys and 8 were recipients of living donor kidneys. Lungs were the most frequently affected site, as in the normal population. M. tuberculosis grew in 7 patients. In 5 patients, M. tuberculosis was also detected on direct microscopy and polymerase chain reaction. In 4 patients, diagnosis was made on clinical grounds and later confirmed by positive response to therapy. In 8 patients, invasive procedures were performed for diagnosis. Five patients had miliary tuberculosis at the time of diagnosis. In 3 patients dissemination occurred during follow-up. Nine patients responded to anti-tuberculous therapy while still preserving their graft function, 1 patient rejected the graft while under treatment and returned to haemodialysis. Five patients (31%) died. Since the risk of dissemination of tuberculosis is high in these patients, anti-tuberculous therapy should be started whenever clinical findings suggestive of tuberculosis are present, even in the absence of any microbiological and/or histological evidence.The incidence of tuberculosis was found to be 5.8% (16/274) in 274 kidney graft recipients in our centre between 1986 and 1998. The kidney recipients were evaluated retrospectively. A total of 51 recipients received isoniazid prophylaxis for 6 months. The prevalence of tuberculosis was found similar (6% vs. 8.8%, p = 0.15) between recipients with prophylaxis and no prophylaxis. Eight patients were recipients of cadaveric donor kidneys and 8 were recipients of living donor kidneys. Lungs were the most frequently affected site, as in the normal population. M. tuberculosis grew in 7 patients. In 5 patients, M. tuberculosis was also detected on direct microscopy and polymerase chain reaction. In 4 patients, diagnosis was made on clinical grounds and later confirmed by positive response to therapy. In 8 patients, invasive procedures were performed for diagnosis. Five patients had miliary tuberculosis at the time of diagnosis. In 3 patients dissemination occurred during follow-up. Nine patients responded to anti-tuberculous therapy while still preserving their graft function, 1 patient rejected the graft while under treatment and returned to haemodialysis. Five patients (31%) died. Since the risk of dissemination of tuberculosis is high in these patients, anti-tuberculous therapy should be started whenever clinical findings suggestive of tuberculosis are present, even in the absence of any microbiological and/or histological evidence.

Renoprotective effects of valsartan and enalapril in STZ-induced diabetes in rats

Effects of the angiotensin II type 1 (AT1) receptor antagonist valsartan and the angiotensin-converting enzyme (ACE) inhibitor enalapril were studied in streptozotocine (STZ)-induced diabetes in rats on the basis of microalbuminuria (Ma) and renal morphology. Five groups of Wistar rats were used, one group was the non-diabetic control, one group consisted of untreated STZ-diabetics and 3 groups of STZ-diabetics were treated with either enalapril and/or valsartan for 30 days. Blood glucose (BG) and Ma levels, body and kidney weight and glomerular size were measured. Immunohistochemical staining with an anti-transforming growth factor-beta1 (TGF-beta1) antibody was performed as well. In STZ-diabetics, BG and Ma levels were significantly increased when compared with the non-diabetic group. Although Ma levels in the valsartan-treated group was found to be higher than those in the non-diabetics group after 15 days of treatment, in all treated diabetic groups Ma levels were significantly decreased as compared with STZ-diabetics at the end of the experiment. Thickening of the glomerular and tubular basement membranes, increased mesangial matrix and glomerular size were found in the untreated diabetic group. All these changes were less in the treated groups. A significant increase in TGF-beta1 immunoreactivity was found in glomeruli of untreated STZ-diabetics as compared with non-diabetics. Again, TGF-beta1 expression was decreased in the treated groups as compared with untreated STZ-diabetics. We conclude that valsartan and enalapril have renoprotective effects in diabetic nephropathy. A combined therapy has an advantage because lower dosages of these drugs can be used. Their beneficial effects are related to a blockade of the renin-angiotensin system (RAS) and a decrease in TGF-beta1 expression in glomeruli.

Cost of renal replacement therapy in Turkey.

Background and Results:  By the end 2000, 22 224 patients were on renal replacement therapy (RRT) in Turkey. We investigated the cost of RRT in three medical faculties and one private dialysis centre. Yearly expenses were US

Systemic Fungal Infections after Renal Transplantation

22 759 for haemodialysis (HD), US

The effect of renal transplantation on pulmonary function

22 350 for continuous ambulatory peritoneal dialysis (CAPD), and US