Oktay Oymak

The long‐term effects of arteriovenous fistula creation on the development of pulmonary hypertension in hemodialysis patients

The aim of this prospective study was to evaluate long‐term effects of arteriovenous fistula (AVF) on the development of pulmonary arterial hypertension (PAH) and the relationship between blood flow rate of AVF and pulmonary artery pressure (PAP) in the patients with end‐stage renal disease (ESRD). This prospective study was performed in 20 patients with ESRD. Before an AVF was surgically created for hemodialysis, the patients were evaluated by echocardiography. Then, an AVF was surgically created in all patients. After mean 23.50 ± 2.25 months, the second evaluation was performed by echocardiography. Also, the blood flow rate of AVF was measured at the second echocardiographic evaluation. Pulmonary arterial hypertension was defined as a systolic PAP above 35 mmHg at rest. Mean age of 20 patients with ESRD was 55.05 ± 13.64 years; 11 of 20 patients were males. Pulmonary arterial hypertension was detected in 6 (30%) patients before AVF creation and in 4 (20%) patients after AVF creation. Systolic PAP value was meaningfully lower after AVF creation than before AVF creation (29.95 ± 10.26 mmHg vs. 35.35 ± 7.86 mmHg, respectively, P: 0.047). However, there was no significant difference between 2 time periods in terms of presence of PAH (P>0.05). Pulmonary artery pressure did not correlate with blood flow rate of AVF and duration after AVF creation (P>0.05). In hemodialysis patients, a surgically created AVF has no significant effect on the development of PAH within a long‐term period. Similarly, blood flow rate of AVF also did not affect remarkably systolic PAP within the long‐term period.

Role of neutrophil/lymphocyte ratio in prediction of disease progression in patients with stage–4 chronic kidney disease

BACKGROUND Chronic kidney disease (CKD) tends to progress to end-stage renal disease without any intervention. Neutrophil/lymphocyte (N/L) ratio may be indicative of an underlying inflammatory state. We aimed to investigate the role of N/L ratio for prediction of progression to dialysis in patients with stage 4 CKD. METHODS We included 105 patients with stage 4 CKD in the study. All patients were followed up from the first admission to dialysis. N/L ratio was measured during follow-up. Patients were divided into two groups as baseline N/L (N/Lb) ratio < 3 and N/Lb ratio =3 and rapid progression was defined as > 5 mL/minute/year loss of creatinine clearance and slow progression as < 5 mL/minute/year. RESULTS Patients with N/L ratio =3 demonstrated high progression rate compared to patients who had N/L ratio <3 (2.6 ± 1.6 and 5.4 ± 3.3, P<.001). hs-CRP levels were higher in patients who had rapid progression (5.6 ± 3.0 and 20.2 ± 10.6, P<.001). The sensitivity and specificity of N/Lb were 79% and 69%, respectively, when the cutoff level was accepted as N/L ratio =3 for determining rapid progression. Furthermore, patients with a high N/Lb ratio had worse prognosis and significantly faster progression to the dialysis compared with those with a low N/L ratio. CONCLUSION Our results suggest that N/L ratio may predict the progression rate of stage 4 chronic kidney disease to dialysis. It is an easily accessible and useful marker for monitoring CKD patients in clinical practice.

IMPACT OF ARTERIAL STIFFNESS ON ADVERSE CARDIOVASCULAR OUTCOMES AND MORTALITY IN PERITONEAL DIALYSIS PATIENTS

♦ Background: Cardiovascular (CV) disease is a major cause of morbidity and mortality in patients with end-stage renal disease. In recent years, arterial stiffness has taken on great importance in the pathophysiology of CV diseases. The independent predictive value of arterial stiffness for CV events and for all-cause and CV mortality has been demonstrated in the general population and in hemodialysis patients. Our aim in this study was to determine the relationship of arterial stiffness with mortality and fatal and nonfatal CV events in peritoneal dialysis (PD) patients. ♦ Methods: In this prospective observational cohort study with 2 years of follow-up, we studied a cohort of 156 PD patients with a mean follow-up of 19.2 ± 6.4 months. At baseline, echocardiography and standard clinical and biochemical analyses were performed in all patients and in 28 healthy subjects. Aortic stiffness index beta (ASIβ, a surrogate marker of arterial stiffness) was calculated as follows: ♦ Results: During the follow-up period, 25 of the patients (16.0%) died, and 10 of those deaths had CV causes. Nonfatal CV events occurred in 15 patients. The median ASIβ was greater in PD patients than in control subjects (4.2 vs. 3.5; interquartile range: 3.2 – 5.5 vs. 2.5 – 4.8; p = 0.028]. In the fully adjusted multivariate Cox regression analysis (co-variates: age, sex, albumin, hemoglobin, diabetes mellitus, comorbid CV disease, left ventricular mass index, residual glomerular filtration rate, dialysate-to-plasma ratio of creatinine, Kt/V urea, left ventricular ejection fraction, duration of dialysis, smoking), ASIβ independently predicted fatal and nonfatal CV events (hazard ratio: 1.239; 95% confidence interval: 1.103 to 1.392), but not all-cause mortality. ♦ Conclusions: Our results provide the first direct evidence that arterial stiffness is an independent risk predictor of adverse CV outcome in PD patients.

Brucella Peritonitis in a Patient on Continuous Ambulatory Peritoneal Dialysis with Acute Brucellosis

Peritonitis is an uncommon complication of brucellosis. Brucella peritonitis in chronic ambulatory peritoneal dialysis (CAPD) patients has not been reported before. A male patient is presented with peritonitis caused by Brucella melitensis who was on CAPD. The source of infection was thought to be unpasteurized, unsalted cheese eaten a month before the onset of symptoms. At the beginning, antibiotic therapy with doxycyline and rifampicin led to a rapid clinical improvement, with disappearance of the organism in the peritoneal fluid. However, peritonitis relapsed after discontinuation of antimicrobial therapy. Successful management required a combination of medical therapy and removal of the Tenckhoff catheter.

Endothelial Nitric Oxide Synthase Gene Expression Is Associated with Hypertension in Autosomal Dominant Polycystic Kidney Disease

Background/Aims: Early occurrence of hypertension is the prominent feature of autosomal dominant polycystic kidney disease (ADPKD). The role of angiotensin-converting enzyme (ACE) gene polymorphism and endothelial nitric oxide synthase (eNOS) gene polymorphism in the clinical course of ADPKD is not well understood. However, data about the expression of these genes are lacking. Thus, we aimed to investigate the polymorphisms and expressions of both the ACE and eNOS genes that affect hypertension in ADPKD. Methods: Whole blood samples were obtained from all participants. ACE and eNOS gene polymorphisms and their expressions were analyzed in 78 ADPKD patients and 30 controls. Gene expressions were assessed by quantitative real-time PCR. Twenty-four-hour blood pressure monitoring was performed for the diagnosis of hypertension in all study participants. Results:eNOS expression and the estimated glomerular filtration rate were found to be significantly higher in ADPKD patients without hypertension than in those with hypertension. Each unit of increase in eNOS expression led to a 0.88-fold decrease (95% CI: 0.80-0.96) in the risk of hypertension in multiple logistic regression analysis. Conclusions:eNOS gene expression is independently predictive of hypertension in the ADPKD population. This study showed, for the first time, a novel link between eNOS gene expression and hypertension in ADPKD.

MAGNETIC RESONANCE IMAGING DIAGNOSIS OF RIGHT ATRIAL SEPTIC THROMBUS CAUSED BY SUBCLAVIAN CATHETER IN A HEMODIALYSIS PATIENT

Dr. Yunus Erdem, Hacettepe Hastanesi, Nefroloji Bölümü, TR-06100 Ankara (Turkey) Dear Sir, Subclavian catheters are widely used in end-stage renal failure patients for hemodialysis. Thrombosis of the thoracic veins and right atrium and infection are well-known complications of subclavian catheters with increased morbidity and mortality. Phlebog-raphy, echocardiography, computerized tomography, and magnetic resonance imaging (MRI) are used to detect thrombosis of the thoracic veins and right atrium due to central venous catheters [ 1 ]. We present a hemodialysis patient with septic thrombus in vena cava superior extending into right atrium caused by subclavian catheter which was diagnosed by MRI while echocardiography revealed no pathology. A 40-year-old woman with end-stage renal failure of unknown origin, who had been on hemodialysis program for 24 months was admitted to the hospital because of malfunctioning arteriovenous fistula. A femoral arte-riovenous fistula was created and regular hemodialysis program was continued via a double lumen subclavian catheter while awaiting the maturation of her fistula. Catheter was removed 2 weeks after and a new one was inserted at the same side. She was hospitalized because of fever 3 weeks later. Her physical examination was unremarkable except fever. Her urine sediment was normal. The catheter was removed and gram stain of catheter’s tip revealed grampositive cocci. Vancomycin plus rifampicin was begun. Blood cultures revealed methicillin-resistant Staphylococcus aureus which was sensitive to vancomycin. Urine culture remained sterile. Fever continued despite this regimen and serial chest X-rays documented progressive bilateral patchy infiltration of the lungs. Echocardiography was performed with presumptive diagnosis of right-sided endocarditis which did not reveal any pathology. MRI was performed and thrombus in the superior vena cava extending into the right atrium was shown (fig. 1). Septic thrombus in the lumen of the superior vena cava extending into right atrium was removed by surgical excision and the fever subsided. Thrombosis due to central venous catheters is a very common problem and up to 73% of thoracic catheters may cause thrombosis after 14 days [2], Right atrial septic thrombi due to central

Reversible Neutropenia and Thrombocytopenia during Famotidine Treatment

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Effect of extracorporeal shock wave lithotripsy on glomerular and tubular functions

To evaluate the early and late effects of extracorporeal shock wave lithotripsy on renal function, we prospectively designed a controlled study using a Direx lithotriptor. Twenty-five patients with renal stones and 16 healthy volunteers as the control group were included in the study. Blood and urine samples were collected before and after 24 hours, seven days and 8 months in the patient group. White blood cell count, serum levels of haemoglobin, urea, creatinine, SGOT, SGPT, AP, and LDH were determined. 24-hour urine specimens were collected to be tested for volume, excretion of creatinine, albumin, N-acetyl-β-glucosaminidase, γ-glutamyltransferase and β-2-microglobulin. There were statistically significant increments in the secretion of urinary enzymes and albumin in the early period after ESWL, no longer lasting 8 months after the procedure. At 8 months one patient, was hypertensive as judged by the diastolic pressure above 95 mm Hg. The results of this study showed that, although there was a transient glomerular and tubular damage after extracorporeal shock wave lithotripsy, the procedure seems safe and causes no permanent deterioration in renal function.

Hemodialysis does not impair ventricular functions over 2 years.

We aimed to evaluate the long‐term effect of hemodialysis (HD) treatment on left and right ventricular (LV and RV) functions in patients with end‐stage renal disease. The study population consisted of 22 patients with newly diagnosed end‐stage renal disease. Before an arteriovenous fistula was surgically created for HD, the patients were evaluated by echocardiography for systolic and diastolic functions. After the first HD session (mean 24.22 ± 2.14 months), the second echocardiographic evaluations were performed. Left ventricular and RV functions before and after long‐term HD treatment were compared. The mean age was 55 ± 13 years and 10 (45%) of the patients were female. After long‐term HD treatment, the isovolumic relaxation time was significantly decreased; however, the peak early (E) and late (A) diastolic mitral inflow velocities, E/A ratio, and deceleration time of E wave were not significantly different from the baseline measurements. Also, there was no significantly change in the early diastolic velocity (Ea) of the lateral mitral anulus and the E/Ea ratio. Pulmonary vein peak diastolic velocity, peak atrial reversal velocity, and peak atrial reversal velocity duration remained almost unchanged even though the pulmonary vein peak systolic velocity and the pulmonary vein peak systolic velocity/pulmonary vein peak diastolic velocity ratio were significantly lower after long‐term HD treatment. In addition, LV systolic functions, LV diameters, LV mass index, left atrium size, and RV diastolic functions were not statistically different after long‐term HD treatment. The myocardium is exposed to hemodynamic, metabolic, and neuro‐humoral abnormalities during HD treatment; however, the long‐term effects of HD on ventricular functions are not clearly known. The present study showed that the long‐term effects of HD on LV and RV functions were insignificant in patients with end‐stage renal disease. We have demonstrated that the LV and RV functions did not change significantly after long‐term HD treatment. We suggest that this result may be due to regulated blood pressure levels of the patients, treatment of anemia and other metabolic disorders during the HD period and the prevention of weight gain and hypervolemia.

Peritoneal Dialysis-Related Peritonitis Caused by Vancomycin-Resistant Enterococcus faecium

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