Neval Duman

Relationship of ambulatory blood pressure monitoring data to echocardiographic findings in haemodialysis patients

BACKGROUND The present study was performed to assess the value of ambulatory blood pressure monitoring (ABPM) in determining the adequacy of blood pressure (BP) control, and its relationship to echocardiographic findings in haemodialysis (HD) patients. METHODS We studied 40 non-diabetic adult patients who had been on regular HD treatment for a median duration of 43 months. Twenty-four-hour ABPM was performed using a non-invasive ABP monitor (Pressurescan, ERKA). Casual BP (cBP) was defined as the average of two measurements obtained at two HD sessions, one preceding and one following the ABP recordings, and was calculated for both the predialysis and postdialysis phases. Two-dimensional and M-mode echocardiography were performed in each patient to determine interventricular septal thickness (IVS), left ventricular posterior wall thickness (LVPW), left ventricular fractional shortening (FS), and left ventricular mass index (LVMI). RESULTS According to average 24-h BP levels, 50% of the patients had systolic hypertension (HT) (> 139 mmHg), and 72.5% had diastolic HT (> 87 mmHg), while only 25% had been diagnosed as HT by cBP measurements (P < 0.01 and P < 0.0001 respectively). Diurnal variation in BP was not present in about 80% of the patients. Echocardiography was normal in only four patients (10%). LVMI and LV wall thickness were correlated to ABPM data better than to cBP measurements. Using stepwise linear regression analysis, LVMI and IVS were positively correlated with systolic BP load (P < 0.0001 and P = 0.0001 respectively), and LVPW was positively correlated with night-time systolic BP level (P < 0.001). CONCLUSIONS ABPM is necessary to assess the adequacy of BP control, and is well correlated to end-organ damage of HT in HD patients.

RECOGNITION OF NEUROCOGNITIVE DYSFUNCTION IN CHRONIC HEMODIALYSIS PATIENTS

We sought to determine the prevalence, recognition, and consequences of mental impairment among chronic hemodialysis patients. We administered the Mini Mental Status Exam (MMSE), a brief validated method for assessing cognitive mental status that is commonly used by clinicians, to 84 patients from our dialysis units. To determine the clinical implications of mental impairment, we obtained Kt/V, albumin, protein catabolic rate, blood pressure, and hematocrit values. We found that 21% of subjects had mild mental impairment (MMSE 18 to 23) and that 11% had moderate-severe mental impairment (MMSE 0 to 17). We found no relationship between MMSE score and years on dialysis, Kt/V value, hematocrit value, or erythropoietin use. On univariate analysis, MMSE score was associated with albumin, protein catabolic rate, inter-dialytic weight gain, number of co-morbid conditions, number of hospitalizations. Outcomes on univariate analysis were further analyzed by multivariate analysis. There was an independent relationship between decrement in MMSE score and lower protein catabolic rate and increased hospitalization number and number of co-morbid conditions. Based on our findings, we recommend that clinicians routinely screen hemodialysis patients for mental impairment and target impaired patients for interventions to improve mental status and associated adverse outcomes.

Renal Doppler ultrasonographic findings in earthquake victims with crush injury.

In the Marmara earthquake, which occurred on August 17, 1999, 639 people had renal complications, and 477 needed hemodialysis treatment because of acute renal failure due to crush injury. Our objective was to use Doppler ultrasonography as a noninvasive procedure to provide renal hemodynamic information.

PREVALENCE OF CRYPTOSPORIDIUM INFECTION IN HEMODIALYSIS PATIENTS

The prevalence of Cryptosporidium infection in patients who are on chronic hemodialysis due to end-stage renal failure is investigated and compared with the incidence in the healthy population. Stool specimens of 74 adult hemodialysis patients treated on an outpatient basis and 50 healthy individuals are examined for Cryptosporidium oocysts by using the modified acid-fast method. While 20.27% (15/74) of patients in the dialysis group had Cryptosporidium oocysts in their stools, none (0/50) of the controls had such an infection (p < 0.001). Ten of 15 patients who had Cryptosporidium oocysts in their stool specimens were asymptomatic and the remaining 5 had diarrhea. Four of these 5 diarrheic patients had Cryptosporidium oocysts in their stools and 1 had both Cryptosporidium oocysts and Giardia trophozoites. Since hemodialysis patients with chronic renal failure are candidates for renal transplantation, general preventive measures against infection must be taken and these patients must be screened for their carrier state before transplantation.

Demographic and Clinical Characteristics of Patients with Autosomal Dominant Polycystic Kidney Disease: A Multicenter Experience

Aim: Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease. It accounts for 5–10% of patients with end-stage renal disease (ESRD). The aim of this multicenter study was to investigate the demographic and clinical characteristics of patients with ADPKD. Methods: 1,139 patients with ADPKD who were followed up at 12 different centers were recruited for this study. The investigated demographic and clinical characteristics were gender, age, smoking history, educational status, the existence of hypertension, hematuria, urinary tract infection, urinary tract stones and renal replacement therapy. Patients were considered as hypertensive if they were taking antihypertensive medications or if they had blood pressure (BP) of 140/90 mm Hg or greater. If the patients were currently on antihypertensive drugs, the classes of these agents were noted. Results: 548 male and 591 female patients were included and the mean age at initial diagnosis was 37.1 ± 16.3 years. 20.3% were current smokers whereas 15% were ex-smokers. The mean systolic and diastolic BPs were 136.1 ± 29.8 and 84.9 ± 17.8 mm Hg, respectively. 63.7% used antihypertensive drugs and 73.1% of those used renin-angiotensin system blockers. 11.8% had ESRD, of which 75.8% were treated with hemodialysis. Conclusion: This study showed that hypertension is the most common (72.6%) clinical finding in ADPKD patients in Turkey and renin-angiotensin system blockers are widely used.

Intravascular volume dependency of left ventricular mass calculation by two-dimensional guided M-mode echocardiography

BACKGROUND Increased left ventricular mass (LVM) is an independent risk factor for cardiovascular morbidity and mortality, and may be used for risk stratification. Two-dimensional echocardiography, the most commonly used technique for estimation of LVM, uses the third power of the left ventricular internal diameter (LVID) for the calculation. OBJECTIVES To determine whether a decrease in intravascular volume after dialysis may cause inaccurate estimation of LVM by echocardiography. METHODS Thirty-eight patients undergoing hemodialysis due to chronic renal failure constituted the study group (14 women [37%] and 24 men [63%], mean age +/- SD 38.7+/-10.9 years). LVID, and interventricular and posterior wall thicknesses were measured by two-dimensionally guided M-mode echocardiography. Stroke volume and cardiac output were calculated using left ventricular outflow tract diameter and the pulsed-wave Doppler time-velocity integral obtained from left ventricular outflow tract. LVM was calculated by using Devereuxs formula, and was indexed for body surface area and height. All echocardiographic parameters were measured or calculated before and after dialysis (on the same day), and then compared. RESULTS There were no significant changes in wall thickness; however, LVID, LVM, the LVM/body surface index and the LVM/height index significantly decreased after dialysis (P<0.001 for each parameter). There was a significant correlation between the change in LVID and the change in LVM (P<0.001, r=0.59). Stroke volume and cardiac output also decreased significantly after hemodialysis (P<0.001 for each parameter). CONCLUSIONS Intravascular volume-dependent change in LVID causes inaccurate estimation of LVM, so volume status should be kept in mind, especially in serial assessment of LVM.

General or Disease Specific Questionnaire? A Comparative Study in Hemodialysis Patients

Objective. Today questionnaires developed to assess important outcome measures such as health-related quality of life are widely used. In this study we evaluated the construct validity of the Nottingham Health Profile (NHP) and the reliability of its Turkish version in hemodialysis patients. Methods. In a sample of patients on renal dialysis (n = 94) the quality of life is measured by the NHP. The validity of this questionnaire is evaluated by using the Kidney Disease Questionnaire (KDQ) in the same patient group. The NHP is administered twice to each patient, at dialysis intervals two weeks apart. Results. NHP scores at both administrations are similar in both assessments. Pearsons correlation coefficients range from 0.61 to 0.84. Cronbachs alpha coefficients for the NHP sections range between 0.64 and 0.79. The alpha coefficients for three of the NHP scales (energy, sleep and social isolation) are well below 0.7. In the KDQ the mean values obtained for the five dimensions are: 4.2 ± 1.5 for physical symptoms, 4.8 ± 1.7 for fatigue, 4.9 ± 1.9 for depression, 4.2 ± 1.2 for relationship with others, and 4.8 ± 1.5 for frustration. In general the correlation between the dimensions of the NHP and KDQ is good and the correlation coefficients varies from 0.18 to 0.73. Clinical validity is assessed by examining the correlation between the results obtained for the two questionnaires (components of the NHP and KDQ) and hemoglobin level, number of the co-morbid conditions and educational level. Conclusions. The NHP is shown to have construct validity when used in patients with end-stage renal disease (ESRD) in Turkey. The application of the NHP in patients with ESRD is easy, fast and the questions are not difficult to understand. The multiple-degree scoring in the KDQ causes a complexity in answering. The correlation between the dimensions of the NHP and KDQ is good. Our results show better correlations between disease specific questionnaires and clinical parameters.

A comparison between percutaneous and surgical placement techniques of permanent peritoneal dialysis catheters.

Dr. Kenan Ateş, Başçavuş sokak 19/10, Seyranbağlari, TR-06660 Ankara (Turkey) Table 1. Complication rates and catheter longevity following percutaneous or surgical catheter placement techniques Dear Sir, Continuous ambulatory peritoneal dialysis (CAPD) has been established as an effective treatment of end-stage renal disease. The key to successful CAPD is permanent and safe access to the peritoneal cavity. Several implantation techniques for the peritoneal dialysis catheter, such as percutaneous, open surgical and laparoscopic procedures, have been described [1-4]. The type of catheter implantation technique may influence the success of the CAPD procedure [2, 5]. Some studies have suggested that the percutaneous placement technique has caused more catheter-related complications than the surgical procedure [6, 7]. However, the optimal approach to the implantation technique of the catheter is still a matter of debate. In this study, we carried out a retrospective analysis of all peritoneal dialysis catheters inserted by both percutaneous and surgical techniques, and compared complication rates and catheter survival. A total of 284 patients with end-stage renal disease, 171 males and 113 females, were maintained on CAPD between March 1985 and December 1994. The mean age was 45.8 ± 13.6 years (15-76 years). In 219 cases catheters were placed percutaneously using the Tenckhoff Trocar technique, and in 65 cases catheters were placed surgically under general or spinal anaesthesia. Peritoneal dialysis was started between the 4th and 5 th days after placements using a 1-litre dial-ysate volume. The incidence of peritonitis, exit-site/tunnel infection, drainage failure and other mechanical complications, such as cuff extrusion, dialysate leak, hernia, abdominal or genital edema, and the longevity of catheter were compared using Student’s t test, χ2 test or life table analysis as appropriate. Age, sex, etiology of renal failure and catheter design were similar between both groups. The incidence of peritonitis and exit-site/tunnel infections were not significantly different between the 2 groups. Also, early and late drainage failure, and other mechanical complications were

Urinary angiotensinogen, related factors and clinical implications in normotensive autosomal dominant polycystic kidney disease patients

Abstract Background: Although several lines of evidence suggest that renin angiotensin system (RAS) proteins are synthesized by cyst epithelium and dilated tubules, role of intrarenal RAS in the progression of otozomal dominant polycystic kidney disease (ADPKD) is not well known. We aimed to study the levels and clinical correlations of urinary angiotensinogen (UAGT) in normotensive ADPKD patients compared with age- and sex-matched healthy subjects. Methods: The study included 20 normotensive ADPKD patients (F/M: 11/9) and 20 age and sex matched healthy controls (F/M: 9/11). Diagnosis of ADPKD was made based on Ravine criteria. Twenty-four hours ambulatory blood pressure monitoring (ABPM) was performed. Serum concentrations of creatinine, Na, K, uric acid, and urinary concentrations of Na, K, uric acid, creatinine, protein and albumin were measured. UAGT were measured via commercially available ELISA kit. Results: ADPKD patients had higher urinary albumin:creatinine ratio (UAIb/UCrea) than healthy controls (p < 0.01). UAGT/UCrea levels significantly positively correlated with urinary protein: creatinine ratio (UPro/UCrea) (r = 0.785, p = 0.01), and UAIb/UCrea (r = 0.681, p = 0.01) in normotensive ADPKD patients. Conclusion: This pilot study demonstrates that UAGT levels tend to be elevated and are correlated with proteinuria and albuminuria in normotensive ADPKD patients during relatively early stages of the disease.

Comparison of Aminophylline and Insulin Infusions in Treatment of Hyperkalemia in Patients with End-Stage Renal Disease

Kenan Ateş, MD, Başçavuş Sokak 19/10, 06660 Seyranbaǧlari, Ankara (Turkey) Table 1. Mean plasma potassium levels before and after aminophylline (group A) or insulin (group B) infusions in hyperkalemic patients Group A Group B P > * p < 0.001 vs. before treatment; ** p < 0.0001 vs. before treatment. Dear Sir, Hyperkalemia is a frequent encountered problem in patients with chronic renal failure (CRF). The principal cause of hyperkalemia is reduced renal potassium excretion, but the extrarenal potassium homeostasis may also be impaired [1]. Besides dialysis, it can be treated effectively with intravenous administration of insulin and glucose. Beta-adrenergic agonists that facilitate intracellu-lar potassium uptake may be a cause of hypokalemia [2]. Several studies have reported a decrease in plasma potassium levels in uremic patients treated with salbutamol, a ß2-adrenergic agonist [3-5]. In this study, we examined effectiveness of aminophylline, a methylxanthine derivative, in the treatment of hyperkalemia in patients with CRF. Forty-five patients with CRF whose plasma potassium level was higher than 6 mEq/1 were included in the study. None of these patients was taking digitalis, ß-blockers, insulin or ßadrenergic agonist, and was known to have asthma, diabetes mellitus or heart disease. Twenty-five patients, 15 male and 10 female, were treated with 480 mg aminophylline in 100 ml of 0.9% NaCl solution administered intravenously over a period of 30 min (group A). Twenty patients, 12 male and 8 female, were treated with 10 units of regular insulin in 100 ml of 30% dextrose solution infused over a period of 30 min (group B). Immediately before, and 60, 180 and 360 min after the infusions, blood pressure, heart rate, plasma potassium, sodium, glucose and creatinine levels were measured. Results are expressed as mean ± SD.