Nurhan Ozdemir

Interferon therapy in haemodialysis patients with acute hepatitis C virus infection and factors that predict response to treatment

In view of the high rate of chronicity of acute hepatitis C and the low efficacy of interferon (IFN) treatment in advanced liver disease, it may be beneficial to treat patients during the acute phase of the infection. Here we assessed the effects of variable‐dose IFNα‐2b treatment in haemodialysis patients with acute hepatitis C virus (HCV) infection, and identified factors that may predict response to this therapy. The study population included 67 patients, but 14 were excluded due to side‐effects or because they were lost to follow‐up. Seventeen patients who received no specific treatment were used as controls (Group 1). Sixteen and 20 patients received low‐(3 MU) and high‐dose (6–10 MU) IFNα‐2b three times weekly for 3 months (Groups 2 and 3, respectively). Virological end‐of‐treatment response (ETR) was observed in 1 (5.6%), 13 (56.5%), and 17 (65.4%) patients in Groups 1, 2, and 3, respectively, and virological sustained response (SR) was observed in 1 (5.6%), 6 (26.1%), and 13 (50%) patients in the three groups. The rates of virological ETR and SR in the treated groups were significantly higher than those of the control group (P < 0.01 for all comparisons). In multivariate logistic regression analysis, single stranded confirmational polymorphysm (SSCP) band number (P=0.02) was the only factor that was significantly associated with virological SR. In conclusion, IFN‐α treatment initiated during the acute phase of HCV infection is associated with a higher rate of virological ETR and SR. This study suggested that quasispecies heterogeneity has predictive value with regard to virological SR.

Treatment Modalities and Outcome of the Renal Victims of the Marmara Earthquake

Background/Aims: Treatment of renal problems during natural catastrophes is highly complicated both for medical and logistic reasons. The therapeutic interventions applied to and the outcome of 639 victims with acute renal problems during the catastrophic Marmara earthquake have been the subject of this study. Methods: Questionnaires regarding information about 63 clinical and laboratory variables were sent to 35 reference hospitals that treated the victims. Information considering therapeutic interventions and outcome obtained through these questionnaires was submitted to analysis. Results: At least one form of renal replacement therapy was administered to 477 (74.6%) of the 639 victims. Of these, 437, 11, and 4 were treated solely by intermittent hemodialysis, continuous renal replacement therapy, and peritoneal dialysis, respectively; 25 victims needed more than one dialysis modality. In total, 5,137 hemodialysis sessions were performed. Also, 2,981, 2,837 and 2,594 units of blood, fresh frozen plasma, and human albumin were administered, respectively. Transfusion of these products was usually associated with higher rates of dialysis needs and mortality. Ninety-seven patients (15.2%) died. The mortality rate of dialyzed victims was higher as compared to nondialyzed ones (17.2 vs. 9.3%, p = 0.015). Conclusions: Massive amounts of dialysis treatment as well as blood and blood product transfusions can be necessary in the treatment of catastrophic earthquake victims with nephrological problems. Despite the potential risk of a high mortality, in the case of appropriate and energetic medical interventions, reasonable final outcomes can be achieved.

Infectious complications after mass disasters: the Marmara earthquake experience.

The Marmara earthquake occurred on 17 August 1999. There were 639 renal victims, of whom 477 needed some form of renal replacement therapy. Although several medical complications have been reported in the literature, there has been no detailed description of infectious complications in patients with crush syndrome after earthquakes. Data from 35 hospitals considering clinical and laboratory findings, as well as infectious complications and the results of microbiological examinations, were analysed. 223 out of 639 (34.9%) patients had infectious complications, which comprised the most frequent medical problem in the renal victims. The patients who suffered from infections had a higher mortality rate than those who did not (p=0.03). Sepsis and wound infection were the main presentation of the infectious complications. 121 (18.9%) patients suffered from sepsis; the mortality rate was higher in these patients (27.3%) than in victims who did not suffer from sepsis (12.4%, p<0.0001). In a multivariate model, sepsis was associated with increased mortality (p=0.0002, odds ratio 2.45, 95% confidence interval 1.52–3.96). 53 (8.2%) and 41 (6.4%) patients had wound and pulmonary infections, respectively. Most of the infections were nosocomial in origin and caused by Gram-negative aerobic bacteria and Staphylococcus spp. Infectious complications are common in renal victims of catastrophic earthquakes and are associated with increased mortality when complicated by sepsis.

Prevalence and Predictors of Arrhythmia in End Stage Renal Disease Patients on Hemodialysis

Background. Sudden death is common in end-stage renal disease (ESRD). Cardiac arrhythmia is observed frequently in patients with ESRD and is thought to be responsible for this high rate of sudden death. This study investigated the prevalence and the predictors of arrhythmia in patients on maintenance dialysis. Methods. Ninety-four patients on hemodialysis program were enrolled in the study. Routine laboratory results were noted. Arrhythmia, periods of silent ischemia, and heart-rate variability analyses were obtained from 24-hour Holter monitor recordings. Corrected QT (QTc) dispersion was calculated from 12-lead surface EKG. Echocardiographic and tissue Doppler examinations were performed on interdialytic days as well. Ventricular arrhythmia was classified according to Lown classification; classes 3 and above were accepted as complex ventricular arrhythmia (CVA). Results. The mean age was 52.5±13.2 years; 44 (46.8%) were women. Ventricular premature contractions were detected in 80 (85.1%) patients, of whom 35 (37.2%) were classified as complex ventricular arrhythmia (CVA). Coronary artery disease, hypertension, and QTc dispersion appeared as independent factors predictive of CVA development. Atrial premature contractions (APC) were detected in 53 patients (56.4%) and supraventricular arrhythmia in 15 (16%) patients; all were identified as atrial fibrillation. Duration of dialysis therapy was found as an independent predictor of APC. Conclusion. Arrhythmia is frequently observed in ESRD patients receiving hemodialysis and may be responsible for the high rate of sudden mortality. Hypertension, CAD, and QTc dispersion are independent predictors of CVA, and duration of dialysis therapy is an independent factor affecting APC development in these patients.

DISTRIBUTION OF HCV GENOTYPES IN PATIENTS WITH END-STAGE RENAL DISEASE ACCORDING TO TYPE OF DIALYSIS TREATMENT

The objective of this study was to investigate the effects of types of dialysis treatments on hepatitis C virus infection and the epidemiologic properties of hepatitis C virus (HCV) infection at three Baskent University hospitals, in Ankara, Adana, and Izmir, Turkey, in 655, 326, and 118 patients with end-stage renal disease, respectively. One hundred thirty patients with HCV viremia among 271 patients with end-stage renal disease seropositive for HCV were included in this cross-sectional study. HCV RNA-positive patients were classified according to the renal replacement therapies (hemodialysis or continuous ambulatory peritoneal dialysis), and viral load, transaminase levels, and distribution of genotypes were compared between these subgroups. In the continuous ambulatory peritoneal dialysis group, 26 of 165 patients (16%) were serum anti-HCV positive, and 11 of 26 patients (42%) were serum HCV RNA positive. Twenty-six percent of the patients undergoing hemodialysis were anti-HCV positive, and 49% were HCV RNA positive. The prevalence of genotype 1b was 68% and 73% for patients in the continuous ambulatory peritoneal dialysis and hemodialysis groups, respectively. No significant differences were found between the genotype 1b and the non-1b groups or between different dialysis types with regard to age and sex and serum aspartate transaminase, alanine aminotransferase, and HCV RNA levels. We conclude that HCV seropositivity may differ between different types of dialysis treatments, although viral load and genotypes may be similar in persons with end-stage renal disease and those without.

Is low blood magnesium level associated with hemodialysis headache

Objective.—The aim of this study was to evaluate the prevalence, demographic, clinical features, and possible risk factors for hemodialysis headache (HDH).

Gastroesophageal reflux disease in chronic renal failure patients with upper GI symptoms: multivariate analysis of pathogenetic factors.

OBJECTIVE:The association between gastroesophageal reflux disease and end-stage renal disease remains unclear. We aimed to assess the prevalence of gastroesophageal reflux disease and also to identify possible pathogenetic factors in the development of reflux in symptomatic end-stage renal disease patients.METHODS:The study involved 42 end-stage renal disease patients with upper GI symptoms (group I) and 46 age- and sex-matched controls who did not have renal disease but had the same symptoms (group II). Endoscopy, endoscopic biopsies, and 24-h esophageal pH studies were used to diagnose gastroesophageal reflux disease. Subjects were also investigated for Helicobacter pylori gastritis and GI amyloidosis.RESULTS:The prevalences of gastroesophageal reflux disease in the two groups were similar (81% vs 84.8%, p = 0.423). The prevalence of H. pylori infection was significantly lower in group I than in group II (38.1% vs 67.4%, p = 0.01). There were 11 cases of GI amyloidosis in group I. Multivariate logistic regression analysis in group I showed that GI amyloidosis (OR = 7.28, 95% CI = 1.13–46.93), chronic ambulatory peritoneal dialysis treatment (OR = 5.54, 95% CI = 1.01–30.43), and absence of H. pylori infection (OR = 3.75, 95% CI = 1.01–13.9) were significantly associated with reflux esophagitis.CONCLUSIONS:Upper GI symptoms are important in predicting gastroesophageal reflux disease in end-stage renal disease patients. Chronic ambulatory peritoneal dialysis, GI amyloidosis, and absence of H. pylori infection seem to be risk factors for the development of gastroesophageal reflux disease in end-stage renal disease patients.

Lamivudine in renal transplant candidates with chronic hepatitis B infection

CHRONIC hepatitis B virus (HBV) is one of the most common and serious infectious diseases throughout the world, currently affecting 400 million persons globally. Although the incidence of chronic HBV infection among patients on hemodialysis has declined, the illness remains an important problem in renal transplant recipients. HBV infection is a frequent and major risk factor for acute and chronic liver disease, causing increased morbidity and mortality both before and after transplantation. Treatment of HBV in kidney recipients is difficult but probably necessary to reduce morbidity and mortality. Interferon has been associated with an increased incidence of rejection and limited success. Recent reports have noted promising results with the antiviral agent lamivudine, a pyrimidine nucleoside analogue. Lamivudine therapy significantly decreases serum HBV-DNA levels and improves the histologic findings, reduces serum aminotransferase levels, and slows progression to cirrhosis in patients with chronic HBV. In renal transplant patients with recurrent hepatitis B, it stabilizes liver enzymes and decreases HBV replication. Our aim in this study was to assess the efficacy and safety of lamivudine in renal transplant candidates with replicative HBV.

Comparison of the non-invasive methods estimating dry weight in hemodialysis patients.

Background. The treatment of deranged water homeostasis of hemodialysis (HD) patients needs focusing on an accurate assessment of dry weight (DW). However, the correct estimation of postdialysis DW is still a problem. Echocardiography of inferior caval vein diameter (ICVD) was recently considered as a reliable technique to estimate DWs of HD patients, whereas conductivity measurements and biochemical parameters remain controversial. In this study, we aimed to compare the noninvasive methods estimating DW in HD patients. Methods. We enrolled 60 patients: 30 hypervolemic (HV) (12 M, 18 F, with a mean age of 41.9 ± 13.6 years, mean HD duration of 38 ± 45 months) and 30 normovolemic (NV) patients (19 M, 11 F, with a mean age of 42.2 ± 14 years, mean HD duration of 62 ± 51.5 months) according to clinical sign and symptoms as well as the findings on chest x-ray. Furthermore, the DWs of patients were evaluated in post-HD period in terms of echocardiography parameters [ICVD and collapse index (CI) determined by Cheriex], plasma ANP (pANP) levels (RIA), and total body water (TBW) by bioelectrical impedance (BEI). Results. Forty-one of 60 patients had hypervolemic findings (68%) and 19 patients had normovolemia (32%) according to echocardiography parameters. Determination of “hypervolemia” by clinical acumen and pANP levels were not reliable, especially negative predictive values were lower as follows: sensitivity, specificity, positive predictive value, negative predictive values of clinical acumen and pANP levels: 63%, 69%, 87%, 50%, and 67%, 59%, 79%, 43%, respectively. TBW established by BEI did not correlate with ICVD and CI after HD (p > 0.05). The TBW of HV group according to echocardiography parameters was greater than NV group, but the difference was not statistically significant (27.4 ± 6.6 kg versus 26.4 ± 5.8 kg, respectively, p > 0.05). However, there was not any difference in the divided BSA values (1.58 ± 0.2 kg/m2 versus 1.60 ± 0.2 kg/m2, respectively, p > 0.05). Hypertension was seen in 37 (90%) of the echocardiographically hypervolemic patients, and the blood pressure was kept under control by previously given medication in only 7 (19%) patients. After the dry weight of the patients was corrected echocardiographically to normal limits, the blood pressure of 31 patients (86%) was normalized without antihypertensive treatment, but only in 6 patients remained the necessity of antihypertensive treatment. In addition, in 8 of 11 normotensive patients using antihypertensive drugs, assessment of their clinical and radiological findings showed normovolemia but ICVD > 11.5 mm/m2; however, the need for antihypertensive drugs disappeared when the ICVD reduced to 8–11.5/m2. Conclusions. Clinical and radiological assessment, pANP levels, and TBW established by BEI appeared to be less valuable in interpreting DWs of HD patients. In accordance with the literature, echocardiography findings have proven to be reliable, and they are important noninvasive tools that can establish an effective and rational antihypertensive treatment.

Fulminant liver failure secondary to mushroom poisoning in children: Importance of early referral to a liver transplantation unit

Abstract:  Patients poisoned with toxic mushrooms have a spectrum of clinical presentations ranging from gastrointestinal symptoms to fulminant liver failure, and outcomes range from complete recovery to the need for liver transplantation. We reviewed the clinical presentation, course, outcome and management of four children poisoned with mushrooms who developed fulminant liver failure. Although one patient survived, two children died and one underwent living related liver transplantation. Early referral to specialized centers for treatment and for liver transplantation is emphasized.