Nilgun Aysuna

The influence of low dialysate sodium and glucose concentration on volume distributions in body compartments after haemodialysis: a bioimpedance analysis study

BACKGROUND Despite the developments in haemodialysis, there are still some difficulties in maintaining the haemodynamic stability. Bioimpedance analysis (BIA) has been proposed for the estimation of dry weight in haemodialysis patients. We aimed to investigate the effects of dialysate sodium and glucose contents on volume distribution in body compartments after haemodialysis by using BIA, a sensitive and reliable method. METHODS Seventeen chronic haemodialysis patients [11 males, 6 females, mean age: 36.9 (18-64) years] were included in the study. Patients were evaluated in three periods. The patients (period 1-P1) underwent haemodialysis with dialysate of 200 mg/dL glucose and 140 mmol/dL sodium for 4.5 h in the middle session of the first week. At the beginning and the end of the session, haematocrit, vital parameters (blood pressure, pulse), ultrafiltrated volume, plasma osmolarity and plasma renin activity were recorded. Also multi-frequency bioelectric impedance analyses (Bodystat Quadscan 4000) were applied to all patients at 5, 50, 100 and 200 kHz, including the impedance index (Z200/Z5). In the second midweek session the same procedure was repeated with same glucose concentration and 135 mmol/dL sodium including dialysate (period 2-P2), and in the third week, it was performed with a dialysate that included 140 mmol/dL sodium and no glucose (period 3-P3). RESULTS The change of the ratio of the intracellular volume to total body weight (ICV/TBW) at the beginning and the end of the session was same in all periods. However, there were significant differences in the change (after/before session) ratio for the extracellular volume/total body weight (ECV/TBW) in P2 compared to other periods (P values for P1-P2: <0.001 and P2-P3: 0.007). Likewise, the same was observed in the changes of impedance (P values for P1-P2: 0.08, P1-P3: 0.44 and P2-P3: 0.063). There was a significant increase of hypotensive events in P2 against the other periods (P = 0.001). CONCLUSION Decreasing dialysate sodium concentration results in important haemodynamic changes but the lack of glucose in dialysate does not result in any changes in haemodynamic and inflammatory parameters. The changes in bioimpedance parameters are parallel to haemodynamic changes in the haemodialysis patients.

Effect of Educational Level on Oral Health in Peritoneal and Hemodialysis Patients

Background. In previous studies, the oral and dental health statuses were compared in hemodialysis (HD) and peritoneal dialysis (PD) patients without taking into account the effect of educational levels on oral health. Hence we aimed to make a comparison of these parameters based upon the subjects educational levels. Patients and Methods. 76 PD (33 males, 43 females-mean age: 44 ± 12 years) and 100 HD (56 males, 44 females-mean age: 46 ± 14 years) patients were included. The number of decayed, missing and filled teeth were detected, DMFT index was calculated and plaque index (PI) values were assessed. Results. Significantly higher numbers of filled teeth (P < .001) and lower PI values (P < .01) in the PD group were detected with higher educational levels, whereas no significance was detected in the HD group. Higher DMFT index values were assessed in the lower educated and high school levels in PD than HD patients (P < .05). Higher numbers of filled teeth (P < .05) were detected in the secondary school level in PD patients. This difference was even more significant in the high school level (P < .001). Conclusion. We assume that PD patients, who were found to be in a higher educational level, are more caring for their oral health as compared to HD patients.

Outcomes of Acute Renal Failure Patients Requiring Intermittent Hemodialysis

The published studies on the prognosis of patients requiring intermittent hemodialysis (IHD) are scarce and have some conflicts. In this study, we retrospectively analyzed our data on ARF patients who were treated with IHD. A total of 192 (female: 85, 44.3%; male: 107, 55.7%) patients were included in the study. The mean age was 56.3 ± 17.1 years. In all, 48.9% of the patients were older than 60 years. The mean number of IHD sessions was 7.8 ± 8.0 per patient; 12.4% was due to prerenal causes, 76.8% was due to intrarenal causes, and 10.8% was due to postrenal causes. The leading indication of the IHD was uremic symptoms (46.8%). With the exclusion of hypertension, 72.4% of the patients had at least one systemic comorbidity. After treatment, 75.5% of the patients recovered, in contrast to 9.4% of patients who were transferred to chronic renal replacement programs and 15.1% who died during IHD period. Pre-dialytic serum creatinine (p = 0.003) and albumin levels (p = 0.016), total IHD session number per patient (p = 0.003), and age (p = 0.034) were the parameters that were related to high mortality in statistical analysis. Mortality was higher if the leading indication of IHD was biochemical disturbances (p = 0.013). Diabetes mellitus did not influence mortality. Consequently, predialytic serum creatinine and albumin levels may be very important predictors of mortality. Patients in high-risk groups (older age, female sex, and low pre-dialytic creatinine and albumin levels) should be considered to be treated with slow continuous renal replacement methods.

Effects of pyridoxine-HCl therapy on serum aminotransferase levels in haemodialysis patients.

To the Editor: Vitamin B6 deficiency can cause metabolic, immunological, haematological, endocrinological and dermatological disorders in patients with chronic renal failure. The optimal dosage of vitamin B6 supplementation is not certain in patients undergoing haemodialysis. Although some authors advise high dosages such as 300 mg/day, some do not advise any supplement. 1–4 Different dosages of vitamin B6 are suggested probably because factors related to uraemia may affect therapeutic response. We analysed preand post-haemodialysis serum aspartate aminotransferase (AST) levels before and after the vitamin B6 replacement therapy. Twenty-seven haemodialysis (thrice weekly for 4 h) patients (16 women, mean age: 36.6 ± 12.8 years) were enrolled in the present study. All vitamin supplements were stopped 1 week before enrolment and no other vitamins except vitamin B6 were used during the study. Serum samples were collected before and after haemodialysis in all patients. Dialysis regimens and ultrafiltration were identical before and after treatment in all patients. Serum blood urea nitrogen, creatinine, uric acid, electrolytes and AST levels were analysed in serum samples. All patients were treated with 250 mg/day pyridoxine-HCl (B6 vitamin – B6 Vigen tablet 250 mg) for 1 month. All biochemical tests were reanalysed at the end of treatment. Analyses were performed with a Technicon SMA 12/60 autoanalyser (NY, USA). Statistical analyses were performed by paired t -test. Biochemical results are shown in Table 1. There was a statistically significant difference between preversus post-haemodialysis serum AST levels both before and after treatment. Pre-haemodialysis serum AST levels were no different before versus after treatment; yet post-haemodialysis levels were different before versus after treatment. Aspartate aminotransferase has two isomeric forms in serum; active holoand inactive apoenzyme. Apoenzyme stimulation occurs after lysine forms an aldimine bound with pyridoxal 5 ′ phosphate (PLP) of epsilon amino groups. Biochemical assays analysing serum AST levels reflect this active reaction. 1 In uraemic patients, cyanate anion is an accumulated toxin that inhibits apoenzyme stimulation by carbamylation of lysine aminoacid. 2,5 Nutritional deficiency, impaired intestinal absorption and transportation, clearance by dialysis 3 and increased natural clearance 4 cause vitamin B6 deficiency in haemodialysis patients. There is no consensus about the dosage of vitamin B6 supplementation. This discrepancy may be related to variable serum levels of uraemic toxins. In the present study post-dialysis, but not pre-dialysis serum AST levels, which reflect vitamin B6 effects, were statistically different before versus after treatment. These results suggest that removal of uraemic toxins rather than vitamin supplementation is primarily responsible for AST elevation. High dosages of vitamin B6 may overcome these toxic effects.

Hyperbaric-oxygen treatment: An adjunctive therapy in acute renal failure due to crush injury

Objective: Major seismic events leave their survivors trapped under the rubble leading to extensive muscle damage and its devastating sequale of hemodynamic and metabolic disturbances and acute renal failure. Hypoxemia aggravated during each hemodialysis (HD) session is important in acute renal failure patients with massive tissue injury. We retrospectively analyzed the adjunctive role of hyperbaric-oxygen (HBO) therapy in patients treated with HD for acute renal failure due to crush injury in terms of dialysis duration. Patients and Methods: 16 patients admitted after the 1999 Marmara earthquake to Istanbul Faculty of Medicine were treated with HBO. Only 8 (2 M, 6 F, mean age: 24.8 + 7.3 years) of them had required HD treatment. 29 (16 M, 13 F, mean age: 34.6 + 12.9 years) crush syndrome patients treated with HD but not with HBO were taken as controls and the clinical and laboratory data of the two groups were compared. Results: The mean duration time under the rubble for the HBO group was 9.4 + 3.2 hours. Mainly lower extremity fasciotomies were performed at 15.6 + 14.8 hours after extrication. There were no amputations in this group. There were three amputations in the control group. The mean number of HD sessions was 9.2 + 6.7/patient for 10.9 + 9.6 days until renal functions recovered and the patients had 27.4 + 15.6 HBO sessions until the recovery of their lesions. There were no correlations between the number of HBO sessions and any laboratory parameter nor the number of HD sessions. There was no statistical difference in the need for HD between the HBO and control group. Conclusions: Our results could not demonstrate a significant effect of HBO treatment in terms of HD duration; however, the valuable contribution of the HBO treatment was to increase the salvage of crushed limbs.