Rezzan Ataman

Bone mineral density and its correlation with clinical and laboratory factors in chronic peritoneal dialysis patients

The aim of this study was to assess the clinical and laboratory correlations of bone mineral density (BMD) measurements among a large population of patients on chronic peritoneal dialysis (PD). This cross-sectional, multicenter study was carried out in 292 PD patients with a mean age of 56 ± 16 years and mean duration of PD 3.1 ± 2.1 years. Altogether, 129 female and 163 male patients from 24 centers in Canada, Greece, and Turkey were included in the study. BMD findings, obtained by dual-energy X-ray absorptiometry (DEXA) and some other major clinical and laboratory indices of bone mineral deposition as well as uremic osteodystrophy were investigated. In the 292 patients included in the study, the mean lumbar spine T-score was −1.04 ± 1.68, the lumbar spine Z-score was −0.31 ± 1.68, the femoral neck T-score was −1.38 ± 1.39, and the femoral neck Z score was −0.66 ± 1.23. According to the WHO criteria based on lumbar spine T-scores, 19.2% of 292 patients were osteoporotic, 36.3% had osteopenia, and 44.4% had lumbar spine T-scores within the normal range. In the femoral neck area, the prevalence of osteoporosis was slightly higher (26%). The prevalence of osteoporosis was 23.3% in female patients and 16.6% in male patients with no statistically significant difference between the sexes. Agreements of lumbar spine and femoral neck T-scores for the diagnosis of osteoporosis were 66.7% and 27.3% and 83.3% for osteopenia and normal BMD values, respectively. Among the clinical and laboratory parameters we investigated in this study, the body mass index (BMI) (P < 0.001), daily urine output, and urea clearance time × dialysis time/volume (Kt/V) (P < 0.05) were statistically significantly positive and Ca × PO4 had a negative correlation (P < 0.05) with the lumbar spine T scores. Femoral neck T scores were also positively correlated with BMI, daily urine output, and KT/V; and they were negatively correlated with age. Intact parathyroid hormone levels did not correlate with any of the BMD parameters. Femoral neck Z scores were correlated with BMI (P < 0.001), and ionized calcium (P < 0.05) positively and negatively with age, total alkaline phosphatase (P < 0.05), and Ca × P (P < 0.01). The overall prevalence of fractures since the initiation of PD was 10%. Our results indicated that, considering their DEXA-based BMD values, 55% of chronic PD patients have subnormal bone mass—19% within the osteoporotic range and 36% within the osteopenic range. Our findings also indicate that low body weight is the most important risk factor for osteoporosis in chronic PD patients. An insufficient dialysis dose (expressed as KT/V) and older age may also be important risk factors for osteoporosis of PD patients.

Diarrhoea following renal transplantation

In this study, we retrospectively evaluated all attacks of diarrhoea in our renal transplant recipients that came to our medical attention between 1985 and 2000. Also, the clinical features of patients with diarrhoea were compared with the features of recipients without diarrhoea. We diagnosed 41 attacks of diarrhoea in 39 (12.6%) of 308 renal transplant recipients during this time period. An aetiology was detected in 33 (80.5%) of all diarrhoeal episodes and in seven (17.1%) of those the specific agent was diagnosed with the help of stool microscopy. The most frequent causes of diarrhoeal attacks were infectious agents (41.5%) and drugs (34%). Six (14.6%) episodes of diarrhoea were chronic and six were nosocomial. About two‐thirds of diarrhoea developed within the late post‐transplant period (>6 months). When recipients with diarrhoea were compared with those without diarrhoea, it was seen that diarrhoeal patients had significantly higher creatinine and significantly lower albumin levels when compared with the latter group (p < 0.05). Also, the frequency of antibiotic usage was significantly higher in diarrhoeal patients than in the control group (p < 0.05). Four (10.2%) patients with diarrhoea died despite institution of the appropriate therapy. Two of these deaths were primarily related to diarrhoea and the aetiological agent was Clostridium difficile in both these cases. During the 15‐yr study period, 3.6% of all deaths and 5.1% of infection‐related deaths in transplant recipients were secondary to diarrhoea. As a result, we observed that infections and drugs were the most frequent causes for diarrhoea in our series of renal transplant recipients. Also, diarrhoea was an important cause of mortality in this patient population.

Mycobacterium tuberculosis infections after renal transplantation.

The incidence of tuberculosis was found to be 5.8% (16/274) in 274 kidney graft recipients in our centre between 1986 and 1998. The kidney recipients were evaluated retrospectively. A total of 51 recipients received isoniazid prophylaxis for 6 months. The prevalence of tuberculosis was found similar (6% vs. 8.8%, p=0.15) between recipients with prophylaxis and no prophylaxis. Eight patients were recipients of cadaveric donor kidneys and 8 were recipients of living donor kidneys. Lungs were the most frequently affected site, as in the normal population. M. tuberculosis grew in 7 patients. In 5 patients, M. tuberculosis was also detected on direct microscopy and polymerase chain reaction. In 4 patients, diagnosis was made on clinical grounds and later confirmed by positive response to therapy. In 8 patients, invasive procedures were performed for diagnosis. Five patients had miliary tuberculosis at the time of diagnosis. In 3 patients dissemination occurred during follow-up. Nine patients responded to anti-tuberculous therapy while still preserving their graft function, 1 patient rejected the graft while under treatment and returned to haemodialysis. Five patients (31%) died. Since the risk of dissemination of tuberculosis is high in these patients, anti-tuberculous therapy should be started whenever clinical findings suggestive of tuberculosis are present, even in the absence of any microbiological and/or histological evidence.The incidence of tuberculosis was found to be 5.8% (16/274) in 274 kidney graft recipients in our centre between 1986 and 1998. The kidney recipients were evaluated retrospectively. A total of 51 recipients received isoniazid prophylaxis for 6 months. The prevalence of tuberculosis was found similar (6% vs. 8.8%, p = 0.15) between recipients with prophylaxis and no prophylaxis. Eight patients were recipients of cadaveric donor kidneys and 8 were recipients of living donor kidneys. Lungs were the most frequently affected site, as in the normal population. M. tuberculosis grew in 7 patients. In 5 patients, M. tuberculosis was also detected on direct microscopy and polymerase chain reaction. In 4 patients, diagnosis was made on clinical grounds and later confirmed by positive response to therapy. In 8 patients, invasive procedures were performed for diagnosis. Five patients had miliary tuberculosis at the time of diagnosis. In 3 patients dissemination occurred during follow-up. Nine patients responded to anti-tuberculous therapy while still preserving their graft function, 1 patient rejected the graft while under treatment and returned to haemodialysis. Five patients (31%) died. Since the risk of dissemination of tuberculosis is high in these patients, anti-tuberculous therapy should be started whenever clinical findings suggestive of tuberculosis are present, even in the absence of any microbiological and/or histological evidence.

Cost of renal replacement therapy in Turkey.

Background and Results:  By the end 2000, 22 224 patients were on renal replacement therapy (RRT) in Turkey. We investigated the cost of RRT in three medical faculties and one private dialysis centre. Yearly expenses were US

Systemic Fungal Infections after Renal Transplantation

22 759 for haemodialysis (HD), US

The effect of renal transplantation on pulmonary function

22 350 for continuous ambulatory peritoneal dialysis (CAPD), and US

Progression of coronary artery calcification in renal transplant recipients

23 393 and US

Phosphorus control in peritoneal dialysis patients

10 028, respectively, for the first and second years of transplantation (Tx). In the first year, renal Tx was significantly more expensive than CAPD. However, after the first year of renal transplantation, Tx became significantly more economical than both CAPD and HD. The sum of all yearly RRT expenses for the country was US

Coronary artery calcification and coronary ischaemia in renal transplant recipients

488 958 709, which corresponds to nearly 5.5% of Turkeys total health expenditure.

Hypercalcemia and Hyperparathyroidism after Renal Transplantation

In a retrospective evaluation, the incidence of systemic fungal infections (SFIs) in 296 kidney graft recipients admitted to our center between 1986 and 1999 was found to be 4%. Eighteen percent of 28 recipients transplanted in India and 8% of 12 recipients transplanted in Russia developed SFI. In contrast, SFI was encountered in only 2% of recipients transplanted at our center. The median time of diagnosis of SFI was 5 months after transplantation. The lungs and central nervous system were the most frequently affected sites. The most common etiologic agent was Aspergillus fumigatus (n =7) but Candida spp. (n = 1), Rhizopus spp. (n = 1) and Cryptococcus neoformans (n = 1) were also encountered. In 2 patients, 2 different pathogens were isolated at the same time: A. fumigatus and Rhizopus spp. in 1 patient and Candida spp. and A. fumigatus in another. In order to determine predisposing factors for SFI, patients admitted immediately before and after those with SFI were used as controls: long-term hospitalization, long-term antibiotic use and post-transplant diabetes mellitus were found to be predisposing factors. Eight patients were treated with antifungal drugs and a good response to liposomal amphotericin B therapy was obtained in 3/5. Nine patients (75%) with SFI died. As SFIs are associated with a high mortality rate in renal transplant recipients, antifungal therapy, especially with liposomal amphotericin B, should be started whenever fungal infection is suspected, even before the results of microbiologic and/or histologic examinations are known.