Neslihan Seyrek

Is there any relationship between serum levels of interleukin-10 and atherosclerosis in hemodialysis patients?

Objective. Cardiovascular complications due to atherosclerosis (AS) are the major cause of mortality in hemodialysis (HD) patients. Inflammation may play an important role in the development of AS. Several studies have demonstrated an association between AS and acute-phase proteins and cytokines in the general population and in HD patients. Interleukin-10 (IL-10) is an anti-inflammatory cytokine. The aim of this study was to compare serum levels of inflammatory and anti-inflammatory indicators in HD patients according to the presence or absence of AS. Material and methods. A total of 33 HD patients were studied. AS was defined as the presence of plaques as detected by Doppler ultrasonography. The patients were subgrouped according to the presence or absence of plaques. Serum levels of IL-1, -2, -6 and -10, C-reactive protein (CRP) and tumor necrosis factor-α (TNF-α) were measured. Risk factors for AS, such as age, gender, hypertension, hyperlipidemia and duration of HD, were also evaluated. Results. Patients with AS had significantly higher high sensitivity (hs)-CRP and lower IL-10 levels. Blood pressure was also elevated in patients with AS. There was an inverse correlation between CRP and IL-10 levels in patients with AS. Conclusion. Patients with AS undergoing HD had low serum levels of the anti-inflammatory cytokine IL-10 and high serum levels of hs-CRP. These results may suggest that limitation of the anti-inflammatory response in atherosclerotic uremic patients is a triggering or contributory factor for AS.

Which Parameter Is More Influential on the Development of Arteriosclerosis in Hemodialysis Patients

Arteriosclerosis is characterized by stiffening of arteries. The incremental elastic modulus (Einc) measurement is a good marker of arterial wall stiffness. Metabolic, inflammatory and hemodynamic alterations cause structural changes and vascular complications in end stage renal disease. The aim of the present study was to evaluate the factors that may affect the development of arteriosclerosis by measurement of Einc in hemodialysis (HD) patients. Thirty-two patients (16 men; 16 female) on chronic HD with a mean age of 42.2 ± 19.3 (range: 15–80) were included in the study. The carotid Einc was measured to determine arteriosclerosis by high-resolution echo-tracking system (Acuson Aspen, Acuson Corp., Mountain View, California, USA). Einc measurement was calculated from transcutaneous measurements of common carotid arterial (CCA) internal diameter and wall thickness and carotid pulse pressure. Common carotid compliance and distensibility were determined from changes in carotid artery diameter during systole and simultaneously measured carotid pulse pressure. Common carotid artery stuffiness (Einc) was influenced by age, systolic blood pressure (SBP), pulse pressure (PP), calcium (Ca) and alkaline phosphatase (ALP). The distensibility of CCA was correlated with age, SBP, diastolic blood pressure (DBP), PP, Ca, ALP, and parathormone (PTH). The inflammatory parameter, hs-CRP, was increased with Einc. The mean Einc measurement was found significantly increased in patient receiving vitamin D. In conclusion, the stiffening of carotid artery in HD patients is related not only to hemodynamic changes (increased SBP, PP) but also to metabolic (increased Ca) and to inflammation (increased hs-CRP). Carotid Einc is accepted independent risk factor for cardiovascular mortality. Because of the positive correlation between Einc and serum Ca, vitamin D and Ca containing phosphorus (P) binders should be used carefully.

Heart Rate Variability, Left Ventricular Functions, and Cardiac Autonomic Neuropathy in Patients Undergoing Chronic Hemodialysis

Objective. Autonomic neuropathy and impairment of left ventricular functions (LVF) have been frequently encountered in chronic renal failure (CRF). The aim of the present study was to evaluate the relationship of cardiac autonomic modulation impairments, as assessed by means of heart rate variability (HRV), with clinical characteristics, and left ventricular function in the patients with CRF undergoing hemodialysis (HD). Methods. Twenty control subjects (Group I) and 22 comparable by age and gender patients with CRF undergoing hemodialysis (Group II) were enrolled in the study. After routine clinical and biochemical evaluations, electrocardiography, and 2 Dimensional, M Mode echocardiography were performed in all participants. Frequency domain HRV analysis was studied by using Kardiosis System. The powers (P1 and P2) and the central frequencies (F1 and F2) of low and of high frequency spectral bands were recorded. Results. End systolic (ESV) and end diastolic volumes (EDV) were significantly higher in Group II (59.3 ± 21.1 mL vs. 34.0 ± 14.3 mL and 131.5 ± 37.3 mL vs. 96.9 ± 18.9 mL, p<0.01, p<0.05, respectively) when compared to those of Group I. Ejection fraction (EF) and fractional shortening (FS) were significantly lower in Group II than in control subjects (52.3 ± 2.4% vs. 63.7 ± 10.1% and 0.29 ± 0.01 vs. 0.34 ± 0.07, p<0.001, p<0.05, respectively). P1 and P2 were decreased in Group II than in Group I (136.2 ± 173.9 m s2 vs. 911.0 ± 685.5 and 96.5 ± 149.6 vs. 499.7 ± 679.5, p<0.001, p<0.01, respectively). Significant correlations were found between high frequency spectral power and dialysis duration (DD), ESV, EDV, EF, FS (r = 0.52 p<0.01, r = 0.68 p<0.001, r = 0.65 p<0.002, r = 0.66 p<0.02, and r = 0.69 p<0.01). Conclusion. As a result, the dependence of cardiac autonomic neuropathy on the disease duration and degree of left ventricular function impairment was shown in the patients undergoing chronic hemodialysis.

Severe acute renal failure due to tubulointerstitial nephritis, pancreatitis, and hyperthyroidism in a patient during rifampicin therapy

It is well known that rifampicin can cause nephrotoxicity. Rifampicin-related pancreatitis and hyperthyroidism are rarely reported in the same patient in the presence of tubulointerstitial nephritis. Reported herein is the medical management of a patient with hemolytic anemia, acute renal failure, pancreatitis, and hyperthyroidism during with rifampicin therapy. A 50-year-old man was admitted to the hospital owing to abdominal colic and acute renal failure. He was treated with 2 courses of tetracycline-rifampicin for brucellosis 3 weeks and 4 months prior to admission. Physical examination showed blood pressure of 130/70 mm Hg, pulmonary crackles, and edema. Laboratory findings are detailed in the case report. Findings of abdominal ultrasonography suggested edematose pancreatitis and thyroid ultrasonography showed several solid nodules. Renal biopsy showed tubu-lointerstitial nephritis. Although rifampicin-related tubulointerstitial nephritis and acute renal failure are not uncommon during rifampicin therapy, the convergence of hyperthyroidism, pancreatitis, tubulointerstitial nephritis, and acute renal failure rarely presents in the same patient. Although pancreatitis, tubulointerstitial nephritis, and acute renal failure were ameliorated with corticoid therapy within 2 months, hyperthyroidism continued and required antithyroid therapy. In conclusion, rifampicin may trigger hyperthyroidism in patients with goiter.

Prevalence of Cholelithiasis in Patients with End-Stage Renal Disease

S. Paydaş, MD, Department of Nephrology, Çukurova University Medical Faculty, TR-01330 Adana (Turkey) Dear Sir, The prevalence of cholelithiasis (CL) differs with age, sex, obesity, diet, infections, and concomitant diseases like diabetes mellitus, hemolytic anemias, and chronic hepatic failure [1]. Geographic regions, ethnic origin, race, and socioeconomic factors have also their effects on the prevalence of CL [1-3]. Today, it has been accepted that ultraso-nography is superior to oral cholecystogra-phy for detecting gallstones. We studied the prevalence of CL by ultrasonography and its relationship to serum lipids in patients with end-stage renal disease. One-hundred patients, aged between 15-80 years, were included in the study. After the physical examinations and the histories, the patients with end-stage renal disease (creatinine clearance < 10 ml/min) were examined for hematocrit, white blood, cell count, blood urea nitrogen, serum glucose, aspartate, and alanine aminotransferases, uric acid, bilirubin, alkaline phosphatase, total lipid, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides. All patients were asymptomatic in terms of a gallbladder disease. Echoic intraluminal, mobile masses with acoustic shadows were regarded as gallstones. Our study group did not include alcoholics. The results are expressed as mean values ± SEM, and the SPSS program package was used for statistical analysis. The mean age of the patients was 47.72 ± 17.33 (range 15-80) years, and out of the 100 patients, 56 were male and 44 female. Thirty-five patients were undergoing hemodialysis, and 65 patients were outpatients with a creatinine clearance < 10ml/ min. The causes of the renal failure were hypertensive nephrosclerosis (n = 33), tubulointerstitial nephritis (n = 28), chronic glo-merulonephritis (n = 12), diabetes mellitus (n = 17), autosomal dominant polycystic kidney disease (n = 6), and renal amyloidosis (n = 4). One of the patients underwent chole-cystectomy. CL was seen in 8% of all patients, in 5.8% (1/17) of the diabetics, in 8.4% (7/83) of the nondiabetics, and in 5.7% (2/35) of the hemodialysis patients. The prevalence of CL was 6.6% in males and 10.8% in females (table 1). The prevalence of CL changes in different countries. In the USA it is 20% for females and 10% for males among the age group 55-60 years [1]. The known highest incidence is reported for American Indians. Similarly high rates are reported from western Europe [4]. The prevalence we found in patients with chronic renal disease was 8%. In a study performed in our region (n =

Oxidative-antioxidative system in peripartum acute renal failure and preeclampsia-eclampsia.

Background: Preeclampsia‐eclampsia and acute renal failure in peripartum women can be the cause of mortality and morbidity. There are many different reports about oxidative–antioxidative systems in preeclampsia‐eclampsia. Until now, products of activated oxidative–antioxidative systems were not evaluated in peripartum women with acute renal failure. In this study, our aim was to evaluate the oxidative–antioxidative systems in peripartum women with acute renal failure and/or preeclampsia‐eclampsia. Methods: The study groups consisted of 17 peripartum women (first week of delivery) with acute renal failure (G I), 11 preeclamptic (G II), 11 healthy pregnancy (≥ 30 weeks of pregnancy) (G III), and 11 healthy women (G IV) aged between 18–38 years. Superoxide dismutase (SOD), glutathione peroxidase (GSHPx) in erythrocytes, and plasma malondialdehyde (MDA) levels were measured in all groups. SOD, GSHPx, and MDA levels were also measured at the onset of acute renal failure (G IA), regression of renal dysfunction (G IB) and recovery of renal functions (G IC). Results: MDA levels were 11.95 ± 4.25, 9.22 ± 3.62, 5.10 ± 3.65, 3.40 ± 1.27, 4.91 ± 2.06, 4.24 ± 1.67 mmol/mL in G IA, G IB, G IC, G II, G III, and G IV, respectively. SOD activity in erythrocyte were 3269.23 ± 1437.83, 2641.35 ± 1411.13, 2056.35 ± 1143.11, 924 ± 160.04, 1057.91 ± 257.03, 861.63 ± 243.28 Ug/Hb in G IA, G IB, G IC, G II, G III, and G IV, respectively. GSHPx activity in erythrocyte was 70.17 ± 23.52, 58.27 ± 23.75, 45.44 ± 17.60, 24.48 ± 6.77, 26.28 ± 7.27, 32.95 ± 8.24 Ug/Hb in G IA, G IB, G IC, G II, G III, and G IV, respectively. MDA levels and activities of SOD, GSHPx in erythrocytes were highest in GIA The values of MDA, SOD, and GSH‐Px in G IA, G IB, and G IC were significantly different from each other and decreased while regaining of renal functions. Preeclampsia‐eclampsia or normal pregnancy did not cause elevation of plasma MDA levels and GSHPx, SOD in erythrocyte. Conclusion: Although SOD and GSHPx in erythrocytes and plasma MDA level were found to be similar in healthy women, pregnant women, and preeclamptic women; SOD, GSHPx, and MDA increased at the beginning and decreased during recovery of renal functions in peripartum women with acute renal failure.

Long-term comparative results of C0 and C2 monitoring of CyA in renal transplanted patients

The purpose of this study was to evaluate the effects of CyA monitoring using Co monitoring (fasting level after 12 h from last dose), and C2 monitoring (2 h after morning dose) on renal functions, lipid levels, CyA levels, and daily dosages of CyA in renal transplanted patients in the posttransplant period from the first month to the 36th month. In our center between 1992–2003, 37 of the 54 renal transplanted patients were treated with CyA, prednisolone, and mycophenolate mofetil or azathioprine. The mean age was 32.36 ± 10.32 and 35.00 ± 10.23 (p = 0.39) in Co (M/F: 18/7) and in C2 (9/3), respectively. Cadaveric donor (d), living related d, and living unrelated d were in four patients (p), 17 p and four p in Co, and two p, seven p, and three p in C2, respectively (p = 0.79). Chronic allograft nephropathy (CAN) developed in 13 p (52%) and one p (8.3%) in Co and in C2, respectively (p = 0.013). Creatinine clearance values were 72.31 ± 23.10 mL/min and 78.73 ± 22.42 mL/min (p:0.621) at first month, 64.97 ± 22.58 mL/min and 78.00 ± 19.90 mL/min (p:0.065) at sixth month, 56.50 ± 19.62 mL/min and 76.62 ± 21.06 mL/min (p:0.006) at 12th month, 50.28 ± 24.79 mL/min and 80.87 ± 18.24 mL/min (p< 0.001) at 24th month, and 55.15 ± 19.21 mL/min and 86.65 ± 14.97 mL/min (p:0.004) at 36th month in C0 and C2, respectively. The mean daily dosages of CyA were 354.35 ± 122.63 and 266.67 ± 64.95 mg/d (p:0.031) at first month, 277.17 ± 77.94 and 250.00 ± 73.31 mg/d (p:0.228) at sixth month, 247.92 ± 58.48 and 211.36 ± 62.61 mg/d (p:0.09) at 12th month, 232.95 ± 56.90 and 170.45 ± 41.56 mg/d (p:0.003) at 24th month, and 240.63 ± 52.34 and 153.57 ± 46.61 mg/d (p:0.002) at 36th month in C0 and C2, respectively. In C2, systolic and diastolic blood pressure, uric acid, total cholesterol (C), LDL-C, and triglyceride levels were lower than those monitored with C0. In C2, HDL-C levels were also higher than those monitored with C0. None of these patients returned to dialysis or died in this period. In conclusion, during the first 36 months with monitoring C2, preservation of renal function, control of blood pressure serum lipids and uric acid were better than those with monitoring C0. In addition, daily dose of CyA was lower in C2 method and, at the same time, this effect of C2 can be accepted as cost effective.

Other glomerular pathologies in three patients with diabetes mellitus.

Diabetic nephropathy is the common cause of end stage renal disease in diabetes mellitus. But other glomerular pathologies have been also described in diabetic patients. We described 3 cases with diabetes mellitus and other glomerular diseases. Case I: A 59‐year‐old male patient with type 2 diabetes mellitus for 4 years was evaluated for generalized edema. Physical examination showed pretibial edema and no diabetic retinopathy. The cause of nephrotic syndrome was membranoproliferative glomerulonephritis. Conservative therapy could not control the severe proteinuria and renal dysfunction. With corticosteroid and cyclophosphamide therapy partial remission was obtained. Case II: A 46‐year‐old diabetic woman was evaluated for severe proteinuria. Diabetic retinopathy was not found on her funduscopic examination. Mesangioproliferative glomerulonephritis was found on renal biopsy. Proteinuria did not regress with conservative therapy and corticosteroid and cyclophosphamide. Case III: A 48‐year‐old male patient with diabetes mellitus type 2 for 2 years was admitted to the hospital because of nephrotic syndrome and weakness. At another hospital his diagnosis with biopsy showed minimal change disease. He was treated with corticosteroid since 3 months. His renal biopsy was re‐evaluated and found amyloid deposition but not diabetic nephropathy or minimal change disease. In diabetic patients, nondiabetic nephropathy is not uncommon and it was reported as common as about 30%. In addition to therapy for diabetes mellitus these patients can need specific therapy.

Report of a renal transplanted patient with fibroadenoma occurring in a short time

The incidence of breast cancer in renal transplant patients is similar to that of general population. But fibroadenomas may be seen as a result of exposure to cyclosporine (CyA). Herein we report the case of a 32-year-old woman who received a renal transplant and had a breast fibroadenoma. She had been prescribed CyA, azathioprine, and steroids for 4 years. At the end of the first year a palpable mass had been detected in her right breast; the pathologic diagnosis was fibroadenoma. At the 4th year after transplantation, immunosuppressive treatment was switched to CyA and mycopholate mofetil (MMF) because of an increased serum creatinine level. Two years later seven breast nodes from both breasts were detected by ultrasonography. Totally excision was performed revealing a histopathologic diagnosis of fibroademata as before. In this case, the combination of CyA and MMF administration seemed to cause an increase in the number of nodules in a short time. The cause of fibroadenomas may be related to drug-induced secretion of proliferative or anti-apoptotic cytokines.

The Prevalence and Clinical Features of Tuberculous Peritonitis in CAPD Patients in Turkey, Report of Ten Cases from Multi-centers

Objective. To determine the rate, risk factors and outcome of Tuberculous Peritonitis (TBP) in patients treated with continuous ambulatory peritoneal dialysis (CAPD) in our units. Design. Retrospectively, we reviewed the medical data of all CAPD patients from 12 centers for TBP, covering the period between 1986 and 12 2002. Setting. All patients were from 12 renal clinics at tertiary-care university hospitals. Results. Ten cases of TBP were identified among the CAPD patients in our centers. There were five male and five female patients with a mean age of 37.2 years. None of the patients had tuberculosis history, 6 patients had predominance of PNL. One patient had coincidental bacterial peritonitis. Two patients were successfully treated without the removal of the Tenckhoff catheter. Conclusion. TBP in CAPD patients is a very rare complication. In contrast to predominance of lymphocytes in nonuremic patients with tuberculous peritonitis, CAPD patients with tuberculous peritonitis may have predominance of PNL on examination of the peritoneal fluid. Since TBP has high morbidity and mortality, early diagnosis and treatment of disease are extremely important for improving outcome.