Ibrahim Guney

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.

Quality of Life in Male Hemodialysis Patients

Background: Health-related quality of life (QOL) is affected in hemodialysis patients (HD). A number of factors such as age, anemia, and comorbidity had been implicated in decreased QOL. Erectile dysfunction (ED) is a frequent and potentially treatable complication in HD patients. In this cross-sectional study, we aimed to evaluate the possible relation between the QOL and ED in HD patients. Patients and Methods: Among the 511 chronic HD patients dialyzed in 11 outpatient HD centers, 148 male patients (mean age: 46 ± 9 years) were included. The mean time on dialysis was 41 ± 35 months (range: 3–203 months). Biochemical parameters such as BUN, creatinine, hemoglobin, serum albumin and Kt/V were measured. The QOL of the patients were measured with the short form of Medical Outcomes Study (SF-36), physical component scores (PCS) and mental component scores (MCS) were calculated. The ED was evaluated by the International Index of Erectile Function (IIEF). Results: One hundred and four of the 148 patients (70%) had ED. Hemoglobin levels were correlated with PCS (r = 0.197, p = 0.02) and MCS (r = 0.20, p = 0.019). Patients with ED had lower scores in nearly all the components related to PCS and MCS as compared to patients without ED. IIEF score was correlated with PCS (r = 0.369, p < 0.001) and MCS (r = 0.308, p < 0.001). In linear regression analysis, IIEF score and hemoglobin levels were the independent variables that predicted both PCM and MCS. Conclusion: ED, a frequent complication in HD patients, was related to QOL together with anemia. Successful treatment of ED and anemia may lead to improvement in QOL in HD patients.

Physical disability, psychological status, and health-related quality of life in older hemodialysis patients and age-matched controls

We aimed at comparing the elderly adults and normal subjects with regard to their disability, psychological status, and quality of life (QOL). One hundred and twenty‐five dialysis patients and 61 controls were recruited in the study. Depression and anxiety symptoms of the patients were evaluated with the Psychological Symptom Screening List (SCL 90‐R). For evaluating the disability, the Rivermead mobility index (RMI) was utilized. For evaluating the QOL, we used the short form‐36 (SF‐36) scale. The Rivermead mobility index of the patients (9.6±3.4) was found. When compared with controls, dialysis patients had higher levels of disability (p=0.0001). Depression and anxiety symptom scores of these patients were also significantly higher than that of the controls (p<0.05). There was a correlation between the disability and depression symptom scores (r: 0.171, p=0.037). Both physical and mental capacity scores of the dialysis patients were lower than those of the controls (p<0.05 and p<0.05) QOL scores for elderly hemodialysis patients were found to be lower. Their disability was higher, making them dependable on others during their daily lives. Specific exercise programs should be developed for these patients. Even the smallest effort in this regard will result in improvements in physical functioning while bringing them significant benefits.

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 50 ± 15.7 years) and 64 PD patients (27 females, 37 males with mean age 52.4 ± 15.3 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 (p < 0.001). PD patients were found to be much more in depressive mood when compared with HD patients (p < 0.001). 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.

Antifibrotic Effects of Aldosterone Receptor Blocker (Spironolactone) in Patients with Chronic Kidney Disease

Aims. Proteinuria and transforming growth factor β (TGF-β) are parameters that can lead to glomerulosclerosis and tubulointerstitial fibrosis. All components of the renin-angiotensin-aldosterone system (RAAS) activate the TGF-β. Aldosterone may not be inhibited with angiotensin-converting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers (ARBs) due to aldosterone escape. We aimed to evaluate the effect of spironolactone on parameters leading to fibrosis. Methods. This prospective study included 30 non-diabetic chronic kidney disease (CKD) patients treated with ACEIs and/or ARBs. The patients were divided into two groups that are similar in terms of demographic parameters. 25 mg of spironolactone was added to group 1 (n = 15) for six months, though it was not administered to group 2 (n = 15). Creatinine (U-Cr), protein (U-Prot), and TGF-β1 (U- TGF-β1) were measured in spot urine sample in the beginning of study and six months later. Results. Twenty-four patients completed the study. There were no significant changes in mean blood pressure, glomerular filtration rate, creatinine, albumin, and plasma aldosterone concentrations during the observation period in either group. U-Prot/U-Cr (mg/mg Cr) was reduced from 2.43 ± 4.85 at baseline to 1.66 ± 3.51 at sixth month (p = 0.003) in group 1. In addition, U-TGF-β1/U-Cr (ng/mg Cr) was also reduced from 22.50 ± 6.65 at baseline to 17.78 ± 10.94 at sixth month (p = 0.041) in the same group. U-TGF-β1/U-Cr and U-Prot/U-Cr ratios after the sixth month were not found significant compared with baseline values in group 2. Conclusion. Spironolactone reduced both proteinuria and urinary TGF-β1 excretion in CKD patients. We consider that spironolactone would be beneficial to prevent progression of renal fibrosis in CKD.

Sleep quality, depression, and quality of life in elderly hemodialysis patients.

Objective Both the incidence and the prevalence of end-stage renal disease (ESRD) in elderly patients are increasing worldwide. Elderly ESRD patients have been found to be more prone to depression than the general population. There are many studies that have addressed the relationship between sleep quality (SQ), depression, and health related quality of life (HRQoL) in ESRD patients, but previous studies have not confirmed the association in elderly hemodialysis (HD) patients. Therefore, the aim of the present study was to demonstrate this relationship in elderly HD patients. Patients and methods Sixty-three elderly HD patients (32 females and 31 males aged between 65 and 89 years) were included in this cross-sectional study. A modified Post-Sleep Inventory (PSI), the Medical Outcomes Study 36-item short form health survey, and the Beck Depression Inventory (BDI) were applied. Results The prevalence of poor sleepers (those with a PSI total sleep score [PSI-4 score] of 4 or higher) was 71% (45/63), and the prevalence of depression was 25% (16/63). Of the 45 poor sleepers, 15 had depression, defined as a BDI score of 17 or higher. Poor sleepers had a significantly higher rate of diabetes mellitus (P = 0.03), significantly higher total BDI scores, and lower Physical Component Scale scores (ie, lower HRQoL) than good sleepers. The PSI-4 score correlated negatively with Physical Component Scale (r = −0.500, P < 0.001) and Mental Component Scale scores (r = −0.527, P < 0.001) and it correlated positively with the BDI score (r = 0.606, P < 0.001). In multivariate analysis, independent variables of PSI-4 score were BDI score (beta value [β] = 0.350, P < 0.001), Mental Component Scale score (β = −0.291, P < 0.001), and age (β = 0.114, P = 0.035). Conclusion Poor SQ is a very common issue and is associated with both depression and lower HRQoL in elderly HD patients.

Malnutrition-Inflammation-Atherosclerosis (MIA) Syndrome Components in Hemodialysis and Peritoneal Dialysis Patients

Background. Malnutrition, inflammation, and atherosclerosis (MIA syndrome) are common in end-stage renal disease (ESRD) patients. Each component of MIA syndrome is the predictor of outcomes in ESRD patients. In this cross-sectional study, we aimed to compare both dialysis modalities for MIA syndrome components. Material and Methods. Thirty hemodialysis (HD) (mean age 44 ± 11 years, 14 male and 16 female, mean time on dialysis: 31.0 ± 19.0 months) and 30 continuous ambulatory peritoneal dialysis (CAPD) patients (41 ± 9 years, 12 male and 18 female, mean time on dialysis: 25.5 ± 21.5 months) were included. In order to determine malnutrition in ESRD patients, serum albumin level and anthropometric measurements were used. For inflammation, serum C-reactive protein level, erythrocyte sedimentation rate, and fibrinogen levels were measured. Mean-carotid artery intima media thickness (m-CIMT), presence of carotid plaque and serum homocysteine level were used to determine atherosclerosis. Results. Five CAPD patients (16%) and one HD patient (3%) was hypoalbuminemic. HD and CAPD groups were similar for inflammation. Mean-CIMT and serum homocysteine level were higher in HD patients than CAPD patients. There was a positive correlation between homocysteine and m-CIMT. Conclusion. Before choosing renal replacement therapy, malnutrition, inflammation, and atherosclerosis parameters must be investigated in ESRD patients. Hemodialysis seems to be more advantageous for malnutrition components than CAPD. Both dialysis modalities seem to be similar for inflammation, and CAPD modality has superiority for atherosclerosis. Before choosing the type of renal replacement therapy, assessment of MIA syndrome components could be useful for individualization of the decision on which dialytic modality is appropriate in ESRD patients.

Sleep Quality and Depression in Peritoneal Dialysis Patients

Background. Sleep quality (SQ) is a significant problem in peritoneal dialysis (PD) patients, yet the underlying factors are not well known. In addition, depression and impaired quality of life (QOL) are main problems in PD patients. We measured the SQ and investigated the effect of depression, QOL, and some other factors on SQ in PD patients. Methods. Data were collected from 124 PD patients (59 male, 65 female) in our center. Demographic data and laboratory values were analyzed. All patients were asked to complete the Pittsburgh Sleep Quality Index (PSQI), Beck Depression Index (BDI), and SF-36. Results. Mean age of the patients was 52.6 ± 14.3 year. The prevalence of poor SQ was 43.5%, defined as global PSQI score >5. The prevalence of depression was 25.8%, defined as BDI scores >17. The poor sleepers had higher BDI scores, poor QOL, older age, and lower duration of PD compared to the good sleepers. There was not a difference in hemoglobin, albumin, C-reactive protein, Kt/V, urea, creatinine, lipid parameters, gender, marital status, cigarette smoking, mode of PD, and comorbidity between poor and good sleepers. The global PSQI score was correlated negatively with both PCS and MCS (r = −0.414, r = −0.392, respectively; p < 0.001) and correlated positively with BDI scores and age (r = 0.422, p < 0.001 and r = 0.213, p = 0.018, respectively). In multivariate analysis, only BDI scores were found to be factors that could predict the patients being poor sleepers. Conclusion. Poor SQ is a significant problem in PD patients, and we found an association with depression, QOL, and age. Regular assessment and management of SQ may be important especially with PD patients who are depressive and elderly to increase QOL.

Early and intensive fluid replacement prevents acute renal failure in the crush cases associated with spontaneous collapse of an apartment in Konya.

Background. Crush syndrome developing as a result of earthquake and other natural disasters has been investigated from many angles to date. Data are scarce, however, on cases associated with the spontaneous crash of buildings. This study presents the results on seven rhabdomyolysis patients treated in our clinics out of nine casualties who were rescued from the rubble of Zümrüt apartment after the building collapsed suddenly and spontaneously. Methods. As a result of the sudden, spontaneous collapse of the 10-floor Zümrüt apartment in Konya at 20:15 hours on February 2, 2004, 92 out of a total of 121 persons who were inside the building lost their lives, and 29 casualties were rescued from the rubble. Nine hospitalized patients had crush syndrome, and a prophylactic mannitol-bicarbonate cocktail was started in all at admission. Results. The time they remained entrapped under the rubble was 11.1 ± 7.3 (5–24 hours) on average. The highest CPK level of the patients was 79049 ± 75374 u/L (17478–223600 u/L), observed on the median day 1.7 ± 1.1 (days 1–4) following the incident. ARF developed in only two cases (28.6%) owing to the prophylactic mannitol-bicarbonate cocktail administered to prevent ARF, and because of hyperpotassemia, hemodialysis (HD) treatment was administered to these patients. One patient required two sessions of HD, and another required four. In both patients who received HD treatment, the level of potassium was in excess of 7 mEq/L. A total of eight fasciotomies were performed on five (71.4%) of the seven patients with crush syndrome. Five of the fasciotomies (62.5%) were performed on two of our patients who required HD treatment. None of our patients with crush syndrome developed permanent kidney damage, and no mortality occurred. Conclusion. It was deduced that rapid fluid therapy accompanied by the prophylactic administration of mannitol-bicarbonate are largely effective in preventing the development of ARF in cases with crush syndrome resulting from disasters.

Urinary tuberculosis: ten years' experience.

In this study of 26 patients, clinical features diagnosed as urinary tuberculosis in our nephrology and urology clinics between 1993 and 2002 were investigated retrospectively. Fifteen patients (52%) were male, and mean age was 43.5 (18–71). Twenty percent of the patients were asymptomatic. Frequency-dysuria (46%), flank pain (33%), and macroscopic hematuria (12%) were presenting symptoms. Physical examination was not diagnostically helpful in most patients. Hematuria and/or pyuria were detected in 80% of the patients. Eleven patients had positive urine cultures of Mycobacterium tuberculosis (42%), and 7 patients had positive smears (25%). Definitive diagnosis of urinary tuberculosis was established microbiologically in 15 patients (58%) and histopathologically in 11 patients (42%). Tuberculin skin test was positive in 60% of the patients. Eight patients had an abnormal chest roentgenogram. Hydronephrosis (majority bilateral) in 11 patients (42%), contracted bladder in 9 patients (34.6%), and renal calcification in 6 patients (23%) were detected. Two patients also had genital tuberculosis (epididymoorchitis). Although only medical treatment was applied in 13 patients for 9 months, in the rest of the patients medical therapy plus surgical intervention was carried out. End-stage renal failure developed in one patient who died on hemodialysis. Renal functions had decreased moderately in two other patients. In conclusion, the diagnosis of urinary tuberculosis was able to be established after the obstructive complications and functional losses were developed in a fair number of cases. Surgical treatment was carried out in half the patients. Urinary tuberculosis should be taken into consideration because early diagnosis and treatment is very important for the presenting of irreversible sequelae.