M. Emin Yilmaz

The effect of venlafaxine HCl on painful peripheral diabetic neuropathy in patients with type 2 diabetes mellitus

OBJECTIVE The objective of this study was to evaluate the efficacy of venlafaxine HCl in the symptomatic treatment of painful peripheral diabetic neuropathy (PPDN) among patients with type 2 diabetes mellitus (DM). DESIGN This study was designed as a prospective, randomized, and controlled trial. SETTING This study was conducted at the Dicle University Medical Faculty (Diyarbakir, Turkey). PATIENTS Sixty type 2 DM outpatients (47 females and 13 males) with PPDN who had a minimum visual analog scale (VAS) score of 40 mm were enrolled in this study. INTERVENTIONS Patients randomized to the treatment group (n=30) received venlafaxine HCl, whereas those randomized to the control group (n=30) received a combination of vitamins B(1)and B(6) tablets. MEASURES Severity of pain was measured by VAS, Short-Form McGill Pain Questionnaire, and numerical analog scale scores at admission and at the second, fourth, and eighth weeks of the study. Polyneuropathy was supported by electromyelography. OUTCOME In the treatment group, severity of pain was measured as 70.0+/-13.0 in the VAS, as 24.9+/-6.2 in the Short-Form McGill Pain Questionnaire, and as 7.2+/-1.1 in the numerical analog scale. In the control group, it was measured as 73.0+/-8.0 in the VAS, as 26.8+/-6.2 in the Short-Form McGill Pain Questionnaire, and as 7.4+/-0.8 in the numerical analog scale (P>.05). RESULTS The most common form of PPDN was distal symmetrical sensorimotor polyneuropathy in both groups (46.8% vs. 50.0%). At the end of the study, there was a significant difference in severity of pain between the groups. In the treatment group, scores were 8.5+/-5.2 and 3.1+/-1.6 in the Short-Form McGill Pain Questionnaire and numerical analog scale, respectively; in the control group, these were 20.5+/-7.0 and 5.5+/-1.6, respectively (P<.001). CONCLUSIONS Venlafaxine HCl is a safe and well-tolerable analgesic drug in the symptomatic treatment of PPDN; however, it has minimal adverse effects. It showed its efficacy markedly in the second week of therapy.

Periodontitis is an important and occult source of inflammation in hemodialysis patients.

Aim: To evaluate the association between C-reactive protein (CRP) levels and the periodontal status of hemodialysis (HD) patients. Methods: 41 HD patients on rHuEPO therapy were enrolled in the study. Hematologic and biochemical parameters and CRP levels were recorded. The plaque index, gingival index, probing pocket depth and periodontal disease index were used to identify periodontal disease. The patients were divided into 2 groups: group 1 (n = 21), high CRP, and group 2 (n = 20), normal CRP. Results: After periodontal therapy, while the mean CRP level and erythrocyte sedimentation rate declined from 30.46 to 10.36 (p = 0.001) and from 93.4 to 35.8 mg/l (p = 0.001), respectively, the hemoglobin level increased from 9.4 to 10.6 g/dl (p = 0.009) and hematocrit level from 28.2 to 32.0% (p = 0.008) in group 1. Conclusion: Periodontitis is an important and occult source of chronic inflammation and increases the CRP levels in HD patients. Periodontitis can cause hyporesponsiveness to rHuEPO treatment and decrease the hemoglobin levels.

The prevalence of insulin resistance in nondiabetic nonobese patients with chronic kidney disease.

This study was undertaken to evaluate the prevalence of insulin resistance (IR) and associated factors in nondiabetic, nonobese patients with chronic kidney disease (CKD) who had not yet received dialysis therapy. A group of 89 consecutive patients (42 male, 47 female) who were hospitalized in the Nephrology Clinic at Dicle University, had recently been diagnosed with CKD, and had not yet been treated with dialysis were enrolled in the study, as was a control group of 30 healthy volunteers. Diabetic and obese patients were excluded. IR was determined by the homeostasis model assessment of IR (HOMA-IR) formula. Blood samples were taken after an overnight fasting period to establish serum glucose, insulin, C-peptide, albumin, lipid profile, hematocrit, bicarbonate, and intact parathormone (iPTH) levels. The mean age of patients was 48.7±19.7 y (men, 49.5±21.5 y; women, 48.1 ±18.0 y); other mean values were as follows: glucose, 98.4±20.6 mg/dL; insulin, 16.7±16.2 μU/mL; HOMA-IR, 5.46±1.14; hemoglobin (Hgb), 8.7±1.6 g/dL; calcium-phosphorus product (Ca × P), 52.2± 16.2 mg2/dL2; iPTH, 377.7±258.1 pg/mL, and bicarbonate (HCO3]), 16.6± 5.3 mEq/L. HOMA-IR was significantly higher in patients with stage 4 CKD than in controls (P < .001); serum levels of urea, creatinine clearance (CrCl), C-reactive protein (CRP), albumin, total cholesterol, high-density lipoprotein cholesterol (HDL-C), Hgb, HCO3, Ca × P, and iPTH were found to be associated with HOMA-IR when a comparison was made with the control group. According to correlation analyses of possible risk factors in patients with IR, positive correlations with age, body mass index, CRP, Ca × P product, and iPTH, and negative correlations with albumin, CrCl, Hgb, and HDL-C were found. A high percentage of IR was found, and this percentage increased as glomerular filtration rate decreased in patients with stage 4 CKD. In addition, a correlation was found between IR and parameters such as age, body mass index, CRP, Ca × P, iPTH, albumin, CrCl, Hgb, and HDL-C.

Parameters of oxidative stress and echocardiographic indexes in patients on dialysis therapy

Aim: Quantity of oxidative stress (OS) is enhanced in every stage of chronic renal failure (CRF). OS and its effects on echocardiographic indexes in patients on hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) were evaluated. Materials and methods: Thirty-nine patients on CAPD, 32 patients on HD, and 30 healthy individuals with similar demographic features were included. Patients with diabetes mellitus and chronic inflammatory diseases were excluded. Blood samples were collected to examine hematological and biochemical parameters and levels of malonyldialdehyde (MDA), glutathione peroxidase (GSH-px), and superoxide dismutase (SOD) after a 12-hour fasting period in the middle of dialysis week. OS parameters were compared with ejection fraction (EF), interventricular septum diameter (IVSd), left ventricular posterior wall diameter (LVPWd), and left atrium diameter (LAd) determined in M-mod echocardiographic examination. Results: No significant difference was observed between MDA and GSH-px levels of patients and control group; however, SOD levels of patients group were significantly lower (p < 0.0001). SOD levels of patients on HD were lower than that of patients on CAPD (p = 0.039). Negative correlation was detected between MDA and EF (r = −0.380, p = 0.001); SOD has negative correlation with systolic blood pressure (r = −0.265, p = 0.011), diastolic blood pressure (r = −0.230, p = 0.028), phosphorus (r = −0.327, p = 0.001), intact parathyroid hormone (iPTH) (r = −0.259, p = 0.013), C-reactive protein (CRP) (r = −0.235, p = 0.024), fibrinogen (r = −0.342, p = 0.001), and total cholesterol (r = −0.249, p = 0.017); and positive correlation with hemoglobin (r = 0.414, p < 0.001) and albumin (r = 0.367, p < 0.001). MDA was independently related with age (β = −0.258, p = 0.035), male gender (β = −0.312, p = 0.004), and EF (β = −0.461, p < 0.001). No correlation was determined between antioxidants and cardiac indexes. Conclusion: SOD levels decreased significantly especially in patients on HD, and it was observed that lower levels of SOD would lead to OS in patients on HD and CAPD when compared to healthy individuals; MDA levels were independently influenced from EF.

Seroprevalence of Hepatitis B and C Viruses in Patients with Chronic Kidney Disease in the Predialysis Stage at a University Hospital in Turkey

Background: Hepatitis B (HBV) and C (HCV) viruses are the most common viruses that cause viral infections among the hemodialysis patients. Objectives: To assess the prevalence of HBV and HCV in predialytic chronic kidney disease (CKD) patients. Design: A cross-sectional study. Subjects: 171 consecutive predialytic CKD patients. Measurements: Third-generation micro-ELISA assay was used for hepatitis B surface antigen (HBsAg), antibody to hepatitis B core (anti-HBc) and surface antibody (anti-HBs), secretory form of hepatitis B envelop antigen (HBeAg), antibody to secretory form of hepatitis B envelop antigen (anti-HBe), and ELISA for antibody to hepatitis C virus (anti-HCV). Results: The main causes of CKD were 29.8% diabetic nephropathy, 19.9% chronic glomerulonephritis, 16.3% hypertensive nephrosclerosis, 14.0% unknown, 5.3% amyloidosis, 4.7% autosomal-dominant polycystic kidney disease, 4.1% chronic tubuluointerstitial nephritis, 3.5% malignancies, 1.7% benign prostatic hypertrophy, 0.6% Alport syndrome. The seroprevalence of hepatitis was: HBsAg 10.5%, anti-HBc 36.8%, anti-HBs 28.7%, HBeAg 5.3%, anti-HBe 32.7%, anti-HCV 7% and HBsAg+anti-HCV 0.6%. Conclusions: The seroprevalence of HBsAg and anti-HCV among predialytic CKD patients was similar to our patients in hemodialysis program.

Relationship Between Bone Mineral Density and Biochemical Markers of Bone Turnover in Hemodialysis Patients

End-stage renal disease is closely associated with changes in bone and mineral metabolism. In recent times, osteoporosis has become important among hemodialysis (HD) patients. In this study, the investigators sought to evaluate the relationship between bone mineral density (BMD) and biochemical markers of bone turnover among HD patients. A total of 70 uremic patients on a maintenance HD program for at least 1 y were enrolled in the study. All patients were treated with conventional bicarbonated HD for 5 h through the use of low-flux hollow-fiber dialyzers. Bone densitometry was measured by dual energy x-ray absorptiometry in the lumbar spine (LS) and the femoral neck (FN). BMD was classified according to World Health Organization criteria on the basis of BMD T scores. Biochemical bone turnover markers such as calcium, phosphorus, ionized calcium, intact parathyroid hormone, alkaline phosphatase, plasma bicarbonate, blood pH, serum albumin, and hematocrit levels were measured before the HD session in the morning. Male patients (n=37; 52.9%; mean age, 46.2±17.0 y) were assigned to a single study group, and female patients (n=33; 47.1 %; mean age, 44.0±13.1 y) to another. Mean duration of HD treatment was 33.7±28.5 mo in females and 33.0±26.0 mo in males. Among all patients, BMD T scores in the osteopenia/osteoporosis range were observed at the LS in 58 patients (82.8%) and at the FN in 45 patients (64.3%). According to BMD measurements in FN T score, 10% of patients (n=7) were osteoporotic, 54.3% (n=38), osteopenic, and 35.7% (n=25), normal. On the other hand, in LS T score, the results were 47.1% (n=33) osteoporotic, 35.7% (n=25), osteopenic, and 17.1% (n=12), normal. No statistically significant association was found in osteopenia/osteoporosis between sexes according to FN and LS T score (P=.542, P=.267, respectively). No significant relationship was noted between BMD and biochemical markers of bone turnover. A positive correlation was found between FN T scores of BMD and age (r=.413, P=.000). BMD T scores within the range of scores for osteopenia/osteoporosis were observed in 78.5% of patients at the LS and in 58.5% of patients at the FN. The investigators concluded that no correlation could be found between markers of bone turnover and bone mass measurements in both skeletal regions. LS T score results were worse than FN T score results. Elevated alkaline phosphastase levels combined with high intact parathyroid hormone levels are predictive of renal osteodystrophy but not of adynamic bone disease/osteoporosis.

The Evaluation of Effects of Demographic Features, Biochemical Parameters, and Cytokines on Clinical Outcomes in Patients with Acute Renal Failure

Aim. To evaluate the effects of cytokines, biochemical parameters and demographic features on clinical outcomes of acute renal failure (ARF). Patients and Methods. 59 patients with acute renal failure (28 men, 31 women) were enrolled to the study. Cytokines, biochemical parameters, and complete blood count were measured. Patients were divided into two groups: as survivors (group 1, n = 46) and nonsurvivors (group 2, n = 13). Results. Mean age of patients were 52.3 ± 17.9 years. 46 patients survived (77.9%) and 13 patients died (22.1%). There was a statistically significant relationship between IL-2R, IL-6, and TNF-α levels and mortality rates (p = 0.004, p = 0.016, p = 0.020, respectively) and between TC levels and mortality rates (p = 0.041). In multivariable logistic regression analysis, the effects of proinflammatory cytokines (IL-1β, IL-2R, IL-6, TNFα, CRP, and ESR) on the clinical outcomes in ARF was observed to be statistically significant (r = 0.341, p = 0.005). Conclusion. We realized that in totally demographic features (male gender, advanced age, poor nutritional status), biochemical parameters (TC, albumin, and hemoglobin) and cytokine levels (IL-2R, IL-6, TNF-α), CRP and ESR may be predictive factors for mortality in patients with ARF.

Prophylactic intranasal mupirocin ointment in the treatment of peritonitis in continuous ambulatory peritoneal dialysis patients.

This study was undertaken to evaluate the effectiveness of prophylactic intranasal mupirocin for peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD). A total of 49 patients undergoing CAPD for at least 6 mo were followed for 1 year. A nasal smear was obtained from each patient at the beginning and end of the study. Intranasal mupirocin ointment was administered to the nares twice daily for 5 d every 4 wk in the mupirocin group. The frequency ofStaphylococcus aureus nasal carriage was similar in both groups at the beginning, andS aureus was eradicated in 56.5% of patients in the mupirocin group; 29% of patients in the control group had negative nasal smear culture findings atthe end of the study. Peritonitis episodes occurred at rates of 4.3% in the mupirocin group and 4.1% in the control group (P > .05). Prophylactic administration of intranasal mupirocin ointment was ineffective in reducing episodes of peritonitis.

The impact of diabetes mellitus on peritoneal dialysis: the Turkey Multicenter Clinic Study

Abstract Purpose: It is well established that diabetic peritoneal dialysis (PD) patients have a higher mortality rate than the other PD population. This study was designed to determine the overall predictors of survival and compared mortality and morbidity between diabetic and non-diabetic Turkish PD patients. Methods: We conducted a multicenter retrospective study with 915 PD patients [217 had diabetes mellitus (DM)]. Serum albumin, PTH, HbA1c, co-morbid diseases, dialysis adequacy (Kt/V), and peritoneal transport characteristics as well as peritonitis episodes and ultrafiltration failure during the follow-up period were recorded. Results: DM patients were older and had more co-morbidities than non-DM patients. Peritonitis rates were higher in DM patients (one episode per 35.9 patient months) compared to non-DM patients (one episode per 41.5 patient months) (p < 0.001). On Kaplan–Meier analysis, patient survival was significantly lower in DM patients with the 2-, 3- and 5-year patient survival rates of 90.8%, 87.8% and 78.2% in non-diabetics and 80.9%, 70.4% and 61.2% in diabetics, respectively. On Cox regression analysis, DM (HR 1.5, p = 0.022), age (HR 1.03, p < 0.001), baseline serum albumin (HR 0.39, p < 0.001), heart failure (HR 0.038, p = 0.038), peripheral artery disease (HR 1.83, p = 0.025) and amputation (HR 4.1, p = 0.009) at baseline were significant predictors of overall mortality. Conclusions: Patient survival is lower in diabetic compared to non-diabetic patients on PD. Peritonitis rates were also higher in diabetic PD patients. DM, older age, albumin level and cardiovascular co-morbidities are predictors of mortality

A Rare Cause of Secondary Amyloidosis: Common Variable Immunodeficiency Disease

The common variable immunodeficiency disease (CVID) is the most common symptomatic primary antibody deficiency. It is the most frequently observed cause of panhypogammaglobulinemia in adults. Here, we present a case of systemic amyloidosis that developed secondary to the common variable immunodeficiency disease causing recurrent infections in a young female patient. A 24-year-old female patient, who was under treatment at the gynecology and obstetrics clinic for pelvic inflammatory disease, was referred to our clinic when she was observed to have swellings in her legs, hands, and face. She had proteinuria at a rate of 3.5 gr/day, and her serum albumin was 1.5 gr/dl. The levels of immunoglobulins are IgG: 138 mg/dl, IgA: 22,6 mg/dl, and IgM: 16,8 mg/dl. The renal USG revealed that the kidneys were observed to be enlarged. Since the patient had recurrent infections, hypogammaglobulinemia, nephrotic range proteinuria, and enlarged kidneys in the renal USG, she was thought to have type AA amyloidosis and therefore underwent a renal biopsy. The kidney biopsy revealed amyloid (+). So the patient was diagnosed with AA type of amyloidosis secondary to common variable immunodeficiency disease. A treatment regimen (an ACE inhibitor and a statin) with monthly administration of intravenous immunoglobulin was started.