Halil Zeki Tonbul

Comparison of 4- and 8-h dialysis sessions in thrice-weekly in-centre haemodialysis A prospective, case-controlled study

BACKGROUNDnLonger dialysis sessions may improve outcome in haemodialysis (HD) patients. We compared the clinical and laboratory outcomes of 8- and 4-h thrice-weekly HD.nnnMETHODSnTwo-hundred and forty-seven HD patients who agreed to participate in a thrice-weekly 8-h in-centre nocturnal HD (NHD) treatment and 247 age-, sex-, diabetes status- and HD duration-matched control cases to 4-h conventional HD (CHD) were enrolled in this prospective controlled study. Echocardiography and psychometric measurements were performed at baseline and at the 12th month. The primary outcome was 1-year overall mortality.nnnRESULTSnOverall mortality rates were 1.77 (NHD) and 6.23 (CHD) per 100 patient-years (P = 0.01) during a mean 11.3 ± 4.7 months of follow-up. NHD treatment was associated with a 72% risk reduction for overall mortality compared to the CHD treatment (hazard ratio = 0.28, 95% confidence interval 0.09-0.85, P = 0.02). Hospitalization rate was lower in the NHD arm. Post-HD body weight and serum albumin levels increased in the NHD group. Use of antihypertensive medications and erythropoietin declined in the NHD group. In the NHD group, left atrium and left ventricular end-diastolic diameters decreased and left ventricular mass index regressed. Both use of phosphate binders and serum phosphate level decreased in the NHD group. Cognitive functions improved in the NHD group, and quality of life scores deteriorated in the CHD group.nnnCONCLUSIONSnEight-hour thrice-weekly in-centre NHD provides morbidity and possibly mortality benefits compared to conventional 4-h HD.

The Relationship Between Neutrophil-to-Lymphocyte Ratio and Inflammation in End-Stage Renal Disease Patients

Abstract Background: Patients with end-stage renal disease (ESRD) have elevated serum levels of inflammatory mediators including C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and interleukin (IL)-6. Systemic inflammation was found to be correlated with coronary artery disease (CAD) in this population. Neutrophil-to-lymphocyte ratio (NLR) was introduced as a potential marker to determine inflammation in cardiac and non-cardiac disorders. Data regarding NLR and its association with inflammation are lacking. We aimed to determine the relationship between NLR and inflammation in ESRD patients. Material and methods: This was a cross-sectional study involving 61 ESRD patients (25 females and 36 males; mean age: 48.3 ± 14.5 years) receiving peritoneal dialysis (PD) or hemodialysis (HD) for ≥6 months in the Dialysis Unit of Selcuk University. NLR, CRP, TNF-α, and IL-6 levels were measured. Results: NLR, serum CRP, IL-6, and TNF-α levels were significantly higher in PD patients when compared with HD patients. ESRD patients with NLR ≥ 3.5 had significantly higher TNF-α levels when compared with patients with NLR < 3.5. In the bivariate correlation analysis, NLR was positively correlated with TNF-α in this population. Conclusions: Simple calculation of NLR can predict inflammation in ESRD patients.

Sertraline treatment is associated with an improvement in depression and health-related quality of life in chronic peritoneal dialysis patients

ObjectivesThere is scarce data about effects of treatment of clinical depression in peritoneal dialysis (PD) population. We aimed to determine prevalence of depression, its association with health-related quality of life (HRQoL) and effects of sertraline treatment in PD patients.Materials and methodsWe included 124 PD patients who had been on PD at least for 6xa0months. Short Form of Medical Outcomes Study was used to evaluate HRQoL. Depression was screened by Beck Depression Inventory (BDI). Patients with a BDI score ≥17 were deemed to have depression and were referred to a psychiatrist for evaluation via Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) of diagnosis of clinical depression. About 25 patients diagnosed with clinical depression agreed to receive antidepressant treatment (Sertraline hydrochloride, 50xa0mg/day) for a 12-week period. After the treatment, biochemical analyses and questionnaires were repeated.ResultsThirty-two patients (25.8%) had depression. BDI score of patients were lower compared to those without depressive symptoms (23xa0±xa06.7 and 9.8xa0±xa03.0, respectively Pxa0<xa00.001). Physical component scale (PCS) and mental component scale (MCS) domains of HRQoL were significantly decreased in patients with depression than in patients without depression (Pxa0<xa00.001 for PCS and MCS). In bivariate analysis the BDI score was correlated inversely with the PCS and MCS (Pxa0<xa00.001). Sertraline treatment improved BDI score of patients with depression (Pxa0<xa00.001). HRQoL parameters also improved. No adverse effects requiring drug cessation was seen in the study group.ConclusionsTreatment of depression with sertraline is associated with improvement of the HRQoL and symptoms related to depression.

Health‐related qualıty of lıfe, sleep qualıty, and depressıon in peritoneal dialysis and hemodıalysıs patıents

Health‐related quality of life (HRQoL) and sleep quality (SQ) were impaired in patients with end‐stage renal disease (ESRD). The impairment of both HRQoL and SQ and being in a depressive mood were found to be associated with increased morbidity and mortality in dialysis patients. We aimed to investigate the association between SQ, HRQoL, and depression, and to define independent predictors of SQ and depression in peritoneal dialysis (PD) and hemodialysis (HD) patients. Ninety HD patients (41 females, 49 males with mean age 50u2009±u200915.7 years) and 64 PD patients (27 females, 37 males with mean age 52.4u2009±u200915.3 years) receiving renal replacement therapy for at least 3 months were screened for the assessment of SQ, HRQoL, and depression in this cross‐sectional study. A modified postsleep inventory, Short Form of Medical Outcomes Study (SF‐36) and Beck depression inventory (BDI) were applied to all patients for evaluating SQ, HRQoL, and depression, respectively. HD and PD patients had similar total SQ scores. Physical and mental component scale of HRQoL were found to be significantly higher in HD patients (pu2009<u20090.001). PD patients were found to be much more in depressive mood when compared with HD patients (pu2009<u20090.001). Independent predictors of depression in patients were mental component scale of HRQoL, gender (being female), and dialysis modality (being PD patient). Physical component scale was also found to be an independent predictor of SQ. This study showed that despite similar SQ scores between two groups, HD patients had better HRQoL and less depression than PD patients.

Epicardial Adipose Tissue and Coronary Artery Calcification in Diabetic and Nondiabetic End-Stage Renal Disease Patients

Background/aims: Atherosclerosis, coronary artery calcification, diabetes mellitus, inflammation, endothelial dysfunction, and left ventricular hypertrophy are the most commonly encountered risk factors in the pathogenesis of cardiovascular disease in end-stage renal disease (ESRD) patients. Epicardial adipose tissue (EAT) is the true visceral fat depot of the heart. The relationship between coronary artery disease (CAD) and EAT was shown in healthy subjects and patients with high risk of CAD. To date, there is not enough data about EAT in diabetic and nondiabetic ESRD patients. Therefore, we aimed to investigate the EAT and coronary artery calcification score (CACS) in diabetic and nondiabetic ESRD patients and healthy subjects. Methods: Sixty ESRD patients (17 diabetic, 43 nondiabetic ESRD patients) and 20 healthy subjects were enrolled in the study. EAT and CACS were performed by a 64-slice multidetector computed tomography scanner. Results: There were no differences in age, gender, body mass index, predialysis systolic and diastolic blood pressure levels, biochemical parameters including serum low-density lipoprotein and high-density lipoprotein cholesterol, triglycerides, and C-reactive protein between healthy subjects, diabetic, and nondiabetic ESRD patients. Total CACSs and EAT measurements were significantly higher in diabetic ESRD patients when compared with nondiabetic ESRD patients and healthy subjects. There was statistically significant relationship between EAT and CACS in ESRD patients (p < 0.0001, r = 0.48). Conclusion: In conclusion, we found a significant increase in terms of EAT and CACS in diabetic ESRD patients when compared with nondiabetic ESRD patients and healthy subjects.

Efficacy and Tolerability of Intravenous Paricalcitol in Calcitriol-Resistant Hemodialysis Patients with Secondary Hyperparathyroidism: 12-Month Prospective Study

Rationale/objectives: Data are limited regarding the use of paricalcitol in calcitriol-resistant patients with secondary hyperparathyroidism (SHPT). We aimed to evaluate the effects of paricalcitol in calcitriol-resistant hemodialysis patients with SHPT. Methods: This is a 12-month, open-label, prospective study. Forty patients with calcitriol-resistant and/or calcitriol-intolerant SHPT were included. After a washout period, all patients converted to paricalcitol with a 1:3 conversion ratio. Serum calcium and phosphorus were monitored monthly, while serum intact parathyroid hormone (iPTH) once in every 3 months. Paricalcitol dose was reduced or discontinued in case of hypercalcemia and/or hyperphosphatemia. Pre- and posttreatment electrolyte and iPTH values were compared with Student’s t-test and Wilcoxon signed-rank test, respectively. Main findings: Forty patients completed the study. Mean initiation dose of paricalcitol was 23 ± 7 μg/week. Mean serum calcium was 8.9 ± 0.8 mg/dL at baseline and 9.4 ± 0.7 mg/dL at study end (p = 0.07). Mean monthly serum phosphorus levels stayed stable. Paricalcitol was effective in reducing iPTH levels when compared with pretreatment values (747.9 ± 497.2 pg/mL, 307.3 ± 417.1 pg/mL, respectively; p < 0.001). Thirty-two patients had to discontinue intravenous (IV) paricalcitol at some time during their treatment. Main reasons for discontinuation were as follows: hyperphosphatemia (58%), hypercalcemia (25%), and iPTH < 150 pg/mL (17%). Principle conclusions: Paricalcitol was found to be effective in reducing iPTH levels in calcitriol-resistant patients with SHPT despite relatively frequent drug discontinuation rates.

Peri-aortic fat tissue and malnutrition–inflammation–atherosclerosis/calcification syndrome in end-stage renal disease patients

PurposeThoracic peri-aortic fat tissue (PFT) is considered as a metabolically active organ in atherosclerosis. Malnutrition, inflammation and atherosclerosis/calcification (MIAC) are the most commonly encountered risk factors of cardiovascular disease in end-stage renal disease (ESRD) patients. Calcification of the aorta was found to be an important cardiovascular risk marker predicting future events, morbidity and mortality in this population. We aimed to investigate the relationship between PFT, MIAC syndrome and thoracic aortic calcification (TAC) in ESRD patients.MethodsSeventy-nine ESRD patients receiving hemodialysis (HD) or peritoneal dialysis (PD) and 20 control subjects were enrolled in this cross-sectional study. PFT and TAC were assessed using a 64-MDCT scanner. Patients with serum albumin <3.5xa0g/dL were defined as patients with malnutrition; those with serum C-reactive protein level >10xa0mg/L had inflammation, and those with coronary artery calcification score (CACS) >10 had atherosclerosis/calcification.ResultsTAC and PFT were significantly higher in ESRD patients compared with control subjects. There was a statistically significant relationship between PFT and TAC in ESRD patients (rxa0=xa00.458, pxa0<xa00.0001). PFT was found to be significantly increased when the MIAC components increased. PFT was positively associated with age, BMI, uric acid, hemoglobin and CAC. The multivariate analysis revealed that age and uric acid were independent predictors of increased PFT. Twenty-four (30.4xa0%) patients had none, 30 (37.9xa0%) had one component, 17 (21.5xa0%) had two components, and 8 (10.2xa0%) had all MIAC components. PFT was highest among patients having all three components (28.6xa0cm3) and lowest among those who do not have the MIAC syndrome (8.54xa0cm3). TAC was highest among patients having all three components (179.2 HU) and lowest among those who do not have the MIAC syndrome (0 HU).ConclusionsWe found a relationship between PFT and MIAC syndrome in ESRD patients.

Cost of Paid Transplantation Abroad: Possible Donor-Origin Early Multiple Myeloma in a Renal Transplant Recipient Treated Using Bortezomib

The incidence of cancer is greater in transplant recipients compared with the general population. Posttransplantation lymphoproliferative disorder (PTLD) is the second most common cancer in these patients. Non-Hodgkin lymphoma is most commonly observed, and multiple myeloma (PTLD-MM) accounts for less than 4% of PTLDs. Most reported PTLD-MM is of recipient origin, and to date, few cases of donor-origin PTLD-MM have been reported. Bortezomib is a protease inhibitor that has been used successfully to treat multiple myeloma. Herein, we describe the case of a patient in whom multiple myeloma developed shortly after paid living-unrelated renal transplantation performed abroad (in Egypt). The patient had no apparent risk factors for PTLD-MM. Thus, it was supposed that PTLD-MM was of donor origin, considering its early development, lack of recipient risk factors, and no available donor medical status. To our knowledge, this report is the first to describe the use of bortezomib in this setting. Although bortezomib plus dexamethasone therapy resulted in hematologic remission, the patient remained dialysis-dependent.

PERI-AORTIC FAT TISSUE THICKNESS IN PERITONEAL DIALYSIS PATIENTS

♦ Background: Thoracic peri-aortic fat tissue (PFT) and epicardial adipose tissue (EAT) are metabolically active visceral fat deposits surrounding the thoracic aorta and the heart, respectively. Various studies have demonstrated a positive predictive value of both PFT and EAT for coronary artery disease in the general population. In the present study, we aimed to investigate PFT thickness and the independent predictors of PFT in peritoneal dialysis (PD) patients. ♦ Methods: Our cross-sectional study enrolled 35 PD patients (10 women, 25 men) and 30 age-and-sex-matched healthy subjects (15 women, 15 men). We measured PFT, thoracic artery calcification (TAC), EAT, and coronary artery calcification (CAC) by electrocardiogram-gated 64-multi-detector computed tomography. ♦ Results: The measured PFT, EAT, CAC, and TAC were significantly higher in the PD group than in the healthy subjects (p < 0.05 each). In the PD group, PFT and TAC were significantly correlated (r = 0.33, p = 0.007). Also, PFT measurements were positively correlated with EAT and total CAC in the PD and the control group alike (r = 0.58, p = 0.001 and r = 0.54, p = 0.01 respectively). A stepwise linear regression analysis revealed that age, duration of hypertension, and being a PD patient were independent predictors of PFT. ♦ Conclusions: Measured PFT was higher in PD patients than in healthy subjects and, in the PD population, was also shown to be related to calcification scores and EAT.

Frequency and outcome of patients with acute renal failure have more causes than one in etiology

In literature, there was little data about frequency and outcomeof ARF with two or more causes in etiology. Therefore, the aim of this studywas to search this issue. This series included 339 patients with ARF from Jan 1,1987 to Jan 1,1999.Fourty-six (30 males) of all patients (13.5%) had two or more causes in etiologyof ARF. Of these patients, causes were prerenal and renal in 26 (56%), prerenal,renal and postrenal in 12 (26%), renal and postrenal in 4 (9%), and prerenaland postrenal in 4 (9%). The most frequent cause is diarrhea and vomitingin prerenal, gentamycin usage in renal and prostat hypertrophy in postrenal.Of these patients, there was oliguria in 32 (70%), anuria in 8 (17%) and non-oliguriain 6 (13%). Treatment modalities of patients was only medical in 19 (41%),dialysis in addition to medical therapy in 27 (59%). In spite of treatment,5 (10.8) of patients with two or more causes in etiology died. Causes of deathwere uremic coma in 2, cardiac disorders in 2 and septic shock in 1. Three(11.2%) of other patients with one cause died. Mortality rates were not different(χ2: 0.0298, p> 0.5). Cortical necrosis was diagnosed in one patient with multiplee etiologyand 2 of other patients. Finally, frequency of ARF with two or more etiologic causes was 13.5%,and most frequent causes were hypovolemia and nephrotoxic drugs. Outcome ofthese patients was similar to other patients with one cause.