Nurhan Bilen

Neutrophil-Lymphocyte Ratio Is Significantly Decreased in Preemptive Renal Transplant Patients

AIM Cardiovascular diseases and infections are the leading two causes of morbidity and mortality in end-stage renal disease (ESRD) patients. Kidney transplantation is the preferred method for renal replacement owing to better survival. There are reports of irreversibly damaged immune system in dialysis patients, which did not return to normal even after kidney transplantation. The neutrophil-lymphocyte ratio (NLR) is an easily applicable method for evaluation of inflammation. We hypothesized that preemptive kidney transplantation can improve inflammatory state compared with nonpreemptive recipients. To test our hypothesis, we retrospectively investigated pretransplant and posttransplant NLR and C-reactive protein (CRP) levels of ESRD patients and compared them with values in healthy controls. MATERIALS AND METHODS We retrospectively analyzed NLR, CRP, and other hematologic parameters of ESRD patients who were transplanted between January 2005 and January 2014 on the day of transplantation and at the end of first year. We grouped the patients as preemptive and nonpreemptive ones. We excluded patients with coronary artery disease, obesity, hypotension, hyperthyroidism, uncontrolled diabetes mellitus, hematologic or solid organ cancers, and active documented infection at any evaluation period. RESULTS We included 137 ESRD patient and 34 healthy control individual in our study. Of the 137 ESRD patients, 52 (38%) were transplanted preemptively. Of the patients, 85 were already on either hemodialysis or peritoneal dialysis therapy at the time of transplantation. The white blood cell count value of the patient and control group (7246.72 ± 1460.26 and 76661.76 ± 1286.29, respectively; P = .43), NLR of the control group was significantly lower than patient group (1.98 ± 0.94 and 3.47 ± 2.33, respectively; P = .007). The NLR of the preemptive group was decreased substantially at the end of first year posttransplantation, the NLR of the preemptive group was significantly lower than the nonpreemptive group (3.08 ± 1.32 and 3.71 ± 2.33; P = .01). CONCLUSIONS We showed that all ESRD patients had an increased inflammation rate according to CRP and NLR when compared with healthy controls. We also found that improvement of inflammatory state in preemptive patients is significantly better than nonpreemptive patients at the end of first year evaluation.

High-Grade Inflammation in Renal Failure Patients, According to Mean Platelet Volume, Improves at the End of Two Years After Transplantation

BACKGROUND Chronic kidney disease (CKD) is a worldwide disorder which is characterized by the presence of systemic low-grade inflammation. There is also acquired immune deficiency in this patient group which is clinically present with increased incidence of severe infections, poor response to vaccination, and increased risk of virus-associated cancers. Renal transplantation is one of the renal replacement modalities that restore renal functions. Mean platelet volume (MPV) is emerging as a marker of inflammation in many clinical conditions. In this study we aimed to disclose the improvement of paired immune response of ESRF patients after renal transplantation even though they are under immunosuppressive therapy. METHODS We retrospectively investigated C-reactive protein, MPV, platelets (PLT), and other hematologic parameters on the day of transplantation and at the end of the 1st and 2nd years after transplantation of 58 preemptive and 112 nonpreemptive renal transplant patients. We compared them with a healthy control group. RESULTS The MPV of the control group was 8.00 ± 0.73. The mean MPV of transplant patients before transplantation and at the end of the 1st and 2nd years after transplantation were 7.66 ± 1.01, 8.06 ± 0.97, and 8.20 ± 0.84, respectively. The initial MPV of the patient group was statistically significantly lower than the control group (P = .04). There was a statistically significant increase of MPV after transplantation. At the end of the 2nd year the difference of MPV between the patient and control groups was gone. CONCLUSIONS We detected that CKD patients had a decreased MPV compared with normal individuals and that it normalized at the end of the 2nd year after renal transplantation. We speculated that the decreased MPV in CKD patients is related to increased inflammation and uremic toxins owing to uremia which was improved after renal transplantation.

Efficacy and Tolerability of Weekly Docetaxel, Cisplatin, and 5-Fluorouracil for Locally Advanced or Metastatic Gastric Cancer Patients with ECOG Performance Scores of 1 and 2

BACKGROUND Docetaxel, cisplatin, 5-fluorouracil (DCF) given every three weeks is an effective, but palliative regimen and significantly toxic especially in patients who have a low performance score. Here, we aimed to evaluate the efficacy and tolerability of a weekly formulation of DCF in locally advanced and metastatic gastric cancer patients. MATERIALS AND METHODS 64 gastric cancer patients (13 locally advanced and 51 metastatic) whose ECOG (Eastern Cooperative Oncology Group) performance status (PS) was 1-2 and who were treated with at least two cycles of weekly DCF protocol as first-line treatment were included retrospectively. The weekly DCF protocol included 25mg/m2 docetaxel, 25mg/m2 cisplatin, and 24 hours infusion of 750mg/m2 5-fluorouracil, repeated every week. Disease and patient characteristics, prognostic factors, treatment response, grade 3-4 toxicity related to treatment, progression free survival (PFS) and overall survival (OS) were evaluated. RESULTS Of the patients, 41 were male and 23 were female; the median age was 63 (29-82) years. Forty-one patients were ECOG-1 and 23 were ECOG-2. Of the total, 81.2% received at least three cycles of chemotherapy. Partial response was observed in 28.1% and stabilization in 29.7%. Overall, the disease was controlled in 57.8% whereas progression was noted in 42.2%. The median time to progression was 4 months (95%CI, 2.8-5.2 months) and median overall survival was 12 months (95%CI, 9.2-14.8 months). The evaluation of patients for grade 3-4 toxicity revealed that 10.9% had anemia, 7.8% had thrombocytopenia and 10.9% had neutropenia. Non-hematologic toxicity included renal toxicity (7.8%) and thrombosis (1.6%). CONCLUSIONS In patients with locally advanced or metastatic gastric cancer who were not candidates for DCF administered every-3-weeks, a weekly formulation of DCF demonstrated modest activity with minimal hematologic toxicity, suggesting that weekly DCF is a reasonable treatment option for such patients.

The Frequency of Complications and the Etiology of Disease in Patients with Liver Cirrhosis in Erzurum

OBJECTIVE This study included 100 patients diagnosed with liver cirrhosis who presented at Atatürk University Faculty of Medicine Gastroenterology clinic and polyclinic. MATERIALS AND METHODS The etiology of liver cirrhosis and the incidence of its complications have been investigated. RESULTS The etiological classification of liver cirrhosis in our patients was as follows: 47 hepatitis B virus hepatitis, 11 hepatitis C virus hepatitis, 5 HBV+HDV hepatitis, 4 Budd Chiari syndrome, 2 chronic alcohol abuse, 2 ischemic heart disease, 1 autoimmune hepatitis, 1 sclerosing cholangitis, 1 hydatid cyst. In 26 patients we could not find any etiological condition. These patients were called cryptogenic cirrhosis patients.When we examined the complications of liver cirrhosis, it appeared that there were ascites in 83 patient. In 56 patients, esophageal variceal bleeding occurred. There was spontaneous bacterial peritonitis in 42 patients. Hepatorenal syndrome occurred in 26 patients. Finally, in 3 patients we detected hepatorenal syndrome. CONCLUSION The most common causes in the etiology of liver cirrhosis are viral, especially HBV. Many of the patients were in decompensated phase when diagnosed. We found that there was a close relation between the frequency of complications and mortality in liver cirrhosis.

Rasagiline-Induced Hypoglycemia

Address for Correspondence: Yusuf Bilen MD, Atatürk University Faculty of Medicine, Department of Hematology, Erzurum, Turkey E-mail: bilenyusuf@hotmail.com Received: 19/04/2015 Accepted: 04/10/2015 Dear Editor, Hypoglycemia that results from an absolute or relative decline in blood sugar is a clinical condition with various manifestations and mortality rate up to 11-27% (1). Rasagiline is a second generation irreversible monoamine oxidase B (MAO-B) inhibitor which is indicated for the treatment of Parkinson’s disease (2). We aimed to present a patient with Parkinson’s disease who developed hypoglycemia due to rasagiline use. The case is unique in the literature, because she had no concomitant diseases or medication usage. A 42-year-old female patient presented to the outpatient clinic with the complaints of dizziness, weakness, fatigue, nervousness, tension, cold sweating, and hunger sensation over the past year. She was having the diagnosis of Parkinson’s disease for years and was using rasagiline 0.5 mg/day. The patient was alert, oriented, and cooperative. On physical examination, the skin was cold and moist. Rhythmic heartbeats and tachycardia (105/minute) were observed. Laboratory tests revealed the followings: WBC: 4600/ mL hemoglobin: 11.8 g/dL hematocrit: 35.2% platelet: 342x106/ mL, mean corpuscular volume: 79 fL, urea: 79 mg/dL, glucose: 55 mg/dL (measurement was repeated two times, the results were in accordance with the previous ones) calcium: 8.8 mg/dL, creatinine: 0.6 mg/dL, K: 4.6 mmol/L, sodium: 135 mmol/dL, total protein: 7.6 g/dL, cortisol: 8.9 mcg/dL, and prolactin: 6.9 ng/mL. Hypoglycemia was observed at admission (blood glucose level: 55 mg/dL). The patient was awake and conscious, she received 20 grams oral carbohydrate as a first intervention in the outpatient clinic and, then, she was hospitalized. Hypoglycemia symptoms were improved after oral carbohydrate. The patient was evaluated for possible causes of hypoglycemia and the following results were obtained: Adrenocorticotropic hormone: 23.4 ng/mL, cortisol 12.02 mcg/dL (repeated), ferritin: 24 mg/dL, free T4: 1.04 ng/dL thyroid-stimulating hormone: 0.696 m IU/l, 25-hydroxy vitamin D: 21.4 ng/mL, insulin-like growth factor-1: 102 ng/mL, insulin: <2 mIU/mL, C-peptide: 0.583 ng/mL, and growth hormone: 0.741 ng/mL. The patient had mild iron-deficiency anemia. According to the examination and laboratory and imaging studies, any pathology other than hypoglycemia due to rasagiline medication for Parkinson’s disease was not detected. The symptoms related to hypoglycemia were not detected after discontinuation of rasagiline. Parkinsonism treatment was organized by the department of neurology. A diet program was created. During outpatient follow-up, we did not detect any sign and symptom of hypoglycemia for two months, thus, follow-up for hypoglycemia was terminated. Rasagiline is a selective MAO-B inhibitor. It is used in Parkinson’s disease either as monotherapy or in combination with levodopa. Rasagiline treatment may come with some adverse effects, such as gastrointestinal symptoms, hypotension, sleep disorders, headache, anxiety, and edema. There have been post-marketing information obtained, the use range in the about 166.000 Parkinson’s disease patients with estimated 399.120 patient/ year usage across the world a serious adverse effect did not reported until the date 2010 (3). However, accompanying possible hypoglycemic effects of selegiline, which is also a selective MAO-B inhibitor, have been reported in animal and human studies (4). According to Food and Drug Administration reports of the adverse effects related to rasagiline therapy, until December 2013, only two out of 1.380 patients have been reported to have hypoglycemia due to rasagiline use. These two patients were over the age of 60, the both patients had systemic diseases other than Parkinson’s disease such as type 2 diabetes mellitus, hypertension, and rheumatoid arthritis (5). As these features were present in both patients, rasagiline was not the possible cause of hypoglycemia. Our patient did not have any accompanying systemic disease and drug use; symptoms and signs of hypoglycemia improved after cessation of rasagiline therapy. Any other possible cause of hypoglycemia was not detected. When all these facts were considered, rasagiline was found to be the sole factor inducing hypoglycemia in our patient. This case is unique in the literature. Atatürk University Faculty of Medicine, Department of Internal Medicine, Erzurum, Turkey *Erzurum Research and Training Hospital, Clinic of Endocrinology, Erzurum, Turkey **Atatürk University Faculty of Medicine, Department of Hematology, Erzurum, Turkey Nurhan Bilen, Ayşe Çarlıoğlu*, Yusuf Bilen** Rasagiline-Induced Hypoglycemia Rasajiline Bağlı Hipoglisemi DOI: 10.4274/tjem.3129