F. Nurhan Özdemir

THE ASSOCIATION OF INTERDIALYTIC WEIGHT GAIN WITH NUTRITIONAL PARAMETERS AND MORTALITY RISK IN HEMODIALYSIS PATIENTS

High interdialytic weight gain (IDWG) is considered as an indicator of noncompliance but could also be interpreted as an index of appetite. This study was designed to investigate the relationship IDWG with malnutrition and mortality risk in hemodialysis (HD) patients through a follow-up of 24 months. We divided HD patients into two groups according to their IDWG as Group I (IDWG<3% of dry weight/day) (27 patients; age 46.8 ± 21.1 years; HD duration: 28.3 ± 39.5 months) and Group II (IDWG ≥ 3% of dry weight/day) (41 patients; age 40.9 ± 11.3 years; HD duration: 54.7 ± 38.7 months). We investigated malnutrition through biochemical analysis (albumin, prealbumin, total cholesterol, creatinine, predialysis potassium and phosphorus levels), normalized protein catabolic rate (nPCR), anthropometric measurements. On initial assessment, group I had significantly lower predialysis creatinine, prealbumin and potassium levels than Group II (p<0.0001, p<0.01 and p<0.001, respectively). At the 24th month, there were significantly lower creatinine, prealbumin, potassium and phosphorus levels in the low-IDWG group. Group I had significantly lower nPCR, body weight, body mass index and triceps skinfold thickness during the follow-up. Over the 24 months, 13 (48.1%) Group I patients and nine (21.9%) Group II patients exhibited loss of dry weight (p<0.02). According to the survival curves prognosis was significantly poorer for Group I than Group II (2-year survival 74.0% and 92.6%, p<0.03). Group I individuals with low albumin levels had the worst survival rate (57.1%). In conclusion there is a strong association of IDWG with nutritional parameters in HD patients. Our study draws attention for a possible risk of developing malnutrition in a HD patient with low IDWG.

Acute Renal Failure and Mortality After Open-Heart Surgery in Infants

Acute renal failure (ARF) is a major complication in infants who undergo cardiac surgery. The aim of this investigation was to identify possible risk factors for ARF and mortality in this patients group. Out of 64 patients, 21 (32.8%) cases developed acute renal failure and overall mortality rate was 25%. The mortality rate was higher in the infants who developed ARF than those who did not (66.7% and 4.7%, respectively, p < 0.05). Also, ARF was positively correlated with mortality (r:0.70, p < 0.0001). The nonsurvivors had lower mean serum albumin than did the survivors (p < 0.05), and serum albumin level was negatively correlated with mortality (r = − 0.34, p < 0.05). For the patients with serum albumin level < 3.5 g/dL, the unadjusted odds ratio for mortality was 4.3 (CI 95%:1.05 − 17.86). Total bypass time and aorta clamping time were significantly longer in the nonsurvivor group than in the survivor group (p < 0.05 for both). In conclusion, the significant risk factors for mortality in these patients were development of ARF, low serum albumin level, and long total bypass and aorta clamping times, which may be predictive of poor prognosis.

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.

Triad of Malnutrition, Inflammation, and Atherosclerosis in Hemodialysis Patients

Background/Aim: As chronic inflammation underlies both atherosclerosis and malnutrition, a possible link between these factors has been suggested in hemodialysis (HD) patients. We designed this study to compare nutritional indices and inflammatory parameters of HD patients with demonstrated atherosclerosis (group I) and HD patients without (group II). Methods: We included 59 and 57 patients in groups I and II, respectively. The patient groups were matched for the risk factors for atherosclerosis such as age, gender, smoking habits, hypertension, and HD duration. The nutritional status of the patients was evaluated according to laboratory parameters, normalized protein catabolic rate, anthropometric measurements, and subjective global assessment. Results: Laboratory parameters (albumin, prealbumin, total cholesterol, phosphorus, creatinine), normalized protein catabolic rate, and triceps skinfold thickness revealed a significant decline in the nutritional status of the patients with atherosclerosis. We found that the patients with atherosclerosis had significantly higher C-reactive protein, ferritin, and fibrinogen levels when we compared the patient groups for acute-phase reactants. When we assessed malnutrition as being in category B/C (B = mild to moderately malnourished, C = severely malnourished) according to subjective global assessment and inflammation on the basis of a C-reactive protein level ≧10 mg/l, among patients with atherosclerosis, there was a significantly higher proportion of them having malnutrition and inflammation. Additionally, the proportion of patients without any evidence of malnutrition and inflammation was significantly lower in group I than in group II. Conclusion: Our study gives evidence for the possible triad of malnutrition, inflammation, and atherosclerosis in HD patients.

Cardiac troponin I and beta 2 microglobulin as risk factors for early-onset atherosclerosis in patients on haemodialysis.

Aim:  To investigate the associations of different risk factors with carotid artery intima‐media thickness (C‐IMT) in non‐diabetic haemodialysis (HD) patients who had no clinical evidence of atherosclerosis.

Vascular Endothelial Growth Factor Expression and Cyclosporine Toxicity in Renal Allograft Rejection

The aim of this study was to evaluate the influence of vascular endothelial growth factor (VEGF) on renal function and on development of interstitial fibrosis (IF) in renal allografts. Tubular and interstitial expressions of VEGF and TNF‐α, and density of macrophages in the interstitium were examined in 92 patients with nonrejected kidneys, acute rejection (AR), chronic allograft nephropathy (CAN), borderline changes (BC) and acute cyclosporin A (CsA) toxicity. Follow‐up biopsy specimens from patients with AR and BC were evaluated for development of IF. A significant difference in tubular and interstitial VEGF expressions was found between patients with AR, BC, CAN and CsA toxicity (p < 0.001). Macrophage infiltration was positively correlated with VEGF and TNF‐α expressions (p < 0.001). VEGF expression increased with increasing expression of TNF‐α (p < 0.001). Renal function in first 6 months after initial biopsy was better in patients with marked tubular VEGF expression (p < 0.01); however, in follow‐up, development of IF and graft loss was found earlier in these patients (p < 0.01 and p < 0.05, respectively). Increased renal VEGF expression has protective properties immediately following renal allograft but allows for increased risk of early IF, and therefore poor graft outcome in the long term.

Pulmonary Function in Uremic Patients on Long‐term Hemodialysis

Twenty patients with end‐stage renal failure who were on maintenance hemodialysis (HD) underwent pulmonary function testing (PFT) before and shortly after an HD session. On pre‐HD PFT, the mean values of all parameters except residual volume (RV) were in the normal range. Mean RV was high (152.9%), and mean diffusing capacity of the lung for carbon monoxide (DLCO) was high‐normal (110.4%). The pre‐HD static inspiratory (PImax) and expiratory pressures (PEmax) were much lower than normal (67.4% and 36.3%, respectively). After the HD session, repeat PFT revealed a small increase in expiratory flow rates, and a significant drop in PImax. There was a strong correlation between PImax and PEmax (r = 0.567, p < 0.01) at the pre‐ and post‐HD stages, indicating that common mechanism(s) are responsible for impairment of both inspiratory and expiratory muscle strength. The well‐preserved DLCO was thought to be due to the use of biocompatible dialyzer membranes. Chronic vascular congestion might be the other explanation of high DLCO.

Risk factors for candidemia with non-albicans Candida spp. in intensive care unit patients with end-stage renal disease on chronic hemodialysis

BACKGROUND/PURPOSE The objective of this study was to describe factors associated with bloodstream infections (BSIs) with non-albicans Candida species (NAC), compared with Candida albicans BSIs, and antifungal susceptibility patterns in adult intensive care unit (ICU) patients with chronic renal failure undergoing hemodialysis. To the best of our knowledge, this is the first study to report the potential factors for NAC candidemia in ICU patients with end-stage renal disease on chronic hemodialysis. METHODS This prospective, observational, multicenter study was conducted in the two centers of Baskent University between January 2007 and July 2010. All adult patients excluding patients with neutropenia, malignancy, glucocorticoid treatment or AIDS, were included. RESULTS Sixty cases (58.8%) of candidemia were due to C. albicans and 42 (41.2%) to NAC. Multivariate regression analysis revealed that the presence of a central venous catheter was the only risk factor independently associated with BSI due to NAC (p=0.046, odds ratio: 5.90, 95% confidence interval: 1.032-33.717). Mortality was more frequent in those with NAC than C. albicans BSIs (64.3% vs. 55%), but the difference was not significant (p=0.067). Except for two Candida glabrata strains, which were dose-dependently fluconazole susceptible, all Candida species were susceptible to fluconazole, caspofungin, voriconazole and amphotericin B. CONCLUSION Central venous catheterization was the only factor significantly associated with BSI due to NAC in ICU patients with end-stage renal disease.

Low Total Plasma Homocysteine Level in Relation to Malnutrition, Inflammation, and Outcome in Hemodialysis Patients

OBJECTIVE We examined the association between nutritional status and total plasma homocysteine (tHcy) level, cardiovascular disease (CVD), and mortality in hemodialysis (HD) patients. DESIGN This prospective study consisted of 124 HD patients. A number of baseline parameters were measured, including tHcy level and laboratory markers of nutrition and inflammation. A CVD history and a malnutrition-inflammation score (MIS) were determined in all patients. The follow-up period was 2 years. RESULTS Forty-nine patients (39.8%) had a history of CVD. During follow-up, 11 (8.8%) deaths occurred, and of these 7 deaths were attributable to CVD. A low tHcy level and an increased MIS were associated with CVD and mortality. The rates of CVD and mortality were also higher in the lowest tHcy level tertiles. In addition, tHcy level was positively correlated with albumin and creatinine, and was negatively correlated with C-reactive protein, MIS, and comorbidity. The survival rates in Kaplan-Meier survival analysis tests were significantly lower in patients with the highest MIS (log rank, 22.3; P < .001). Patients with higher tHcy levels had significantly longer survival rates (log rank, 9.7; P = .007). CONCLUSIONS Because of the strong association of tHcy levels with malnutrition- inflammation, the presence of these factors should be considered when tHcy is evaluated as a risk factor of outcomes in HD patients.

Value of testis biopsy in the diagnosis of systemic amyloidosis

OBJECTIVES To evaluate testis biopsy as a diagnostic tool in systemic amyloidosis, to assess how amyloidosis affects testicular tissue, and to examine the relationship between testicular amyloidosis and infertility. METHODS Testicular biopsies from 72 patients with confirmed systemic amyloidosis were examined for amyloid deposition after Congo red and crystal violet staining. A rectal biopsy was also done in each case, and the results were compared with the testicular biopsy findings. RESULTS Testicular amyloid deposition was detected in 62 (86.1%) of 72 patients. Fifty-one (85%) of 60 patients with secondary amyloidosis, 11 (91.7%) of 12 patients with primary amyloidosis, and 28 (87.5%) of 32 patients with familial Mediterranean fever showed amyloid deposition in the testis. Rectal biopsies were positive in 40 cases (55.6%). Only 4 of the 62 patients with testicular amyloid showed normal spermatogenesis. The remaining 58 exhibited abnormal spermatogenesis, and 77.7% of patients had seconder infertility. Of 62 patients with positive testis biopsies, 30 had serum creatinine levels less than 1.5 mg/dL, and 29 patients with testicular amyloid manifested nephrotic syndrome. CONCLUSIONS The testis biopsy is a valuable and more sensitive method than rectal biopsy for diagnosing systemic amyloidosis. The results also showed that testicular amyloidosis causes infertility at a higher rate than expected.