Rumeyza Kazancioglu

Risk factors for chronic kidney disease: an update

Chronic kidney disease has become a serious public health issue. There are currently over 1.4 million patients receiving renal replacement therapy worldwide. One way to reduce the economic burden of chronic kidney disease would be early intervention. In order to achieve this, we should be able to identify individuals with increased risk of renal disease. An individuals genetic and phenotypic make-up puts him/her at risk for kidney disease. Factors such as race, gender, age, and family history are highly important. For instance, being of African-American decent, older age, low birth weight and family history of kidney disease are considered to be strong risk factors for chronic kidney disease. Moreover, smoking, obesity, hypertension, and diabetes mellitus can also lead to kidney disease. An uncontrolled diabetic and/or hypertensive patient can easily and quickly progress to an end-stage kidney disease patient. Exposure to heavy metals, excessive alcohol consumption, smoking, and the use of analgesic medications also constitute risks. Experiencing acute kidney injury, a history of cardiovascular disease, hyperlipidemia, metabolic syndrome, hepatitis C virus, HIV infection, and malignancy are further risk factors. Determination of serum creatinine levels and urinalysis in patients with chronic kidney disease risk will usually be sufficient for initial screening.

The effect of calcineurin inhibitors on endothelial function in renal transplant recipients.

Abstract:  Endothelial dysfunction is of vital importance, as it may cause ischemia and dysfunction in various organs. Despite, this problem has been well documented in patients with end‐stage renal disease (ESRD), there is not enough data considering this issue following renal transplantation. One of the potential causes of endothelial dysfunction in renal transplant recipients may be administration of calcineurin inhibitors. The aim of this study is to evaluate the effects of two different calcineurin inhibitors [cyclosporin A (CsA) and tacrolimus (FK506)] on endothelial function in renal transplant patients. Forty‐four renal transplant recipients [22 on FK506 (group I) and 22 on CsA (group II)] were studied. Endothelial functions of the brachial artery were evaluated by using high resolution vascular ultrasound. Endothelium‐dependent and ‐independent vasodilations were assessed by establishing reactive hyperemia and using sublingual nitroglycerine (NTG), respectively. Results are presented as percentage change from baseline values. Significant endothelial dysfunction was noted in renal transplant patients treated with CsA. While endothelium‐dependent vasodilation was 12.1 ± 5.1% in group I and it was 6.5 ± 3.7% in group II (p < 0.001). The increase in brachial artery diameter after sublingual NTG was 20.1 ± 6.3 and 12.7 ± 5.6% in groups I and II, respectively. This indicates that the endothelium‐dependent and ‐independent vasodilation of the patients on FK506 is better preserved than the patients on CsA therapy. Besides, blood flow volume (BFV) increase was 51.2 ± 39.4 and 43.9 ± 24.3%, in groups I and II, respectively, in reactive hyperemia period (p > 0.05). Post‐transplant course of renal transplant recipients is complicated by endothelial dysfunction. This problem is more prominent in patients on CsA therapy, which can predispose these patients to more frequent cardiac complications.

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.

Immunization of renal transplant recipients with pneumococcal polysaccharide vaccine

Background: Streptococcus pneumoniae, a common pathogen leading to pneumonia, is a cause of morbidity and mortality in immunosuppressed patients. Vaccination against this agent can be recommended for immunosuppressed patients, including those with chronic renal failure, nephrotic syndrome and renal transplant recipients; however, a diminished immune response and loss of protective antibodies have been observed.Patients and methods: In our prospective study, the efficacy and side effects of polyvalent pneumococcal vaccination were investigated in renal transplant recipients. A total of 21 patients (6 female, 15 male) with well‐functioning renal allografts, who had transplant surgery at least 2 months before, were included in the study. The patients were stratified according to the immunosuppressive protocol and 8 received double, while 13 received triple, immunosuppresive agents. After obtaining basal serum samples, all cases were vaccinated with the 0.5 mL intramuscular administration of polyvalent polysaccharide pneumococcal vaccine (Pneumo 23 Pasteur–Merieux, lot No: K 1131).Results: Following a mean of 6 wk in all patients and also a mean of 12 wk in 12 patients, serum samples were again obtained to measure pneumococcal antibodies. Antibody titers following 6 and 12 wk of vaccination were significantly higher, as compared with basal values in all patients, except one. These titers did not show any statistically significant difference between double and triple therapies. There was no significant difference between the 12th and 6th wk postvaccination antibody titers. No systemic or local adverse effects were observed.Conclusion: Pneumococcal vaccination is safe and effective in patients with well‐functioning renal allografts, at least in the short term. This vaccination policy may be useful for preventing invasive pneumococcal disease in immunosuppressed patients.

Stimulated Salivary Flow Rate in Chronic Hemodialysis Patients

Background: Reduced salivary flow has been reported in patients undergoing hemodialysis (HD) treatment. Our aim was to investigate the most important factors associated with stimulated salivary flow rate (ssfr) in chronic HD patients. Methods: Fifty HD patients (27 F, 23 M, mean age 46. 7 ± 13.2 years) were divided into two groups according to the duration of HD treatment as those receiving HD therapy less than or equal to (group I) or those more than (group II) 24 months. Fasting blood samples were obtained to determine hepatitis B and C serology, and biochemical and hematological parameters before a HD session. After prestimulation with a standard weight paraffin wax, stimulated saliva was collected in the HD patients and control group (23 F, 25 M, mean age 45.7 ± 19.1 years) and the flow rate was expressed as ml/min. Results: Both HD groups consisted of 25 patients. There was no significant difference between the two HD groups other than serum alkaline phosphatase (ALP) levels and presence of HCV. The ssfr was decreased than controls in both groups (0.8 ± 0.6 and 0.7 ± 0.4, respectively, vs. 1.5 ± 0.5 ml/min) and it did not correlate with any parameter. Smoking had a positive effect on ssfr in all groups. Conclusion: Although the salivary flow rate decreased significantly in chronic HD patients, the duration of therapy displayed no effect on the salivary changes in HD patients, but smoking increased ssfr.

Evaluation of periodontal parameters in patients undergoing peritoneal dialysis or hemodialysis

OBJECTIVE To analyze and compare periodontal parameters in chronic renal failure (CRF) patients undergoing peritoneal dialysis (PD) therapy with a group of patients on hemodialysis (HD) treatment and healthy controls (C). PARTICIPANTS Seventy-five PD patients (mean age: 44 +/- 12 years) were matched with 41 HD patients (mean age: 46 +/- 15 years) and 61 C (mean age: 46 +/- 18 years). METHODS Plaque (PI) and calculus (CSI) accumulation and gingival bleeding (GI) were recorded with the appropriate indices. Periodontal condition was assessed using the probing pocket depth (PPD). One-way anova test, Pearson chi-squared test, Mann-Whitney U-test and Kruskal-Wallis test were performed to compare PD patients with HD patients and healthy C. RESULTS Plaque Index values were significantly higher (P < 0.001) in the PD and HD groups than the C group. GI values were significantly higher (P < 0.01) in the HD group than the PD group. Finally, CSI values in the PD and HD groups were also significantly higher (P < 0.001) than the C group. CONCLUSIONS Chronic renal failure patients on PD treatment are more susceptible to periodontal diseases like HD patients. Thus, it is very important to maintain an optimal oral hygiene level. Further studies on periodontal parameters of only PD patients are needed to get more information on the oral health status of this patient group.

The changes in serum leptin, body fat mass and insulin resistance after renal transplantation

Abstract: Background:  In this prospective‐controlled study, we aimed to investigate the effect of changes in insulin resistance and anthropometrical parameters on serum leptin levels (SLL) after renal transplantation (Tx).

The effect of sleep apnea syndrome on the development of diabetic nephropathy in patients with type 2 diabetes

AIMS Type 2 diabetes mellitus and obstructive sleep apnea syndrome (OSAS) are serious comorbidities. Effects of OSAS on diabetic microvascular complications are ongoing research subjects. We evaluated the incidence of OSAS in Type 2 diabetes mellitus patients with nephropathy and with no renal involvement. METHODS A total of 52 people with diabetes were enrolled in this study. Patients body mass indices were calculated and fasting glucose, glycosylated hemoglobin, urea, creatinine, total lipid profile, and urinary albumin excretion were evaluated. Full polysomnography was used to detect sleep disorders. RESULTS Baseline characteristics and laboratory results of the patients were similar. Meeting criteria for OSAS was detected in 35 of the 54 patients (67.3%). 25 patients (48%) had mild, six patients (11.5%) had moderate, and four patients (7.7%) had severe sleep disorders. There was no significant relationship between respiratory obstructive parameters and microalbuminuria (R=0.91, p=0.362). Substantial correlation was detected between lower values of serum triglyceride levels and lower respiratory indices (R=0.299, p=0.031). CONCLUSIONS In type 2 diabetes accompanying OSAS affects glucose regulation but its effect on nephropathy development is currently a subject of research.

Changes in endothelial function before and after renal transplantation

Endothelial dysfunction is an early key event in the development of atherosclerotic cardiovascular disease observed in chronic renal failure patients. The role of renal transplantation (RTx) on endothelial dysfunction is still unclear. The aim of this study was to evaluate the endothelial function of chronic renal failure patients before RTx (while they were on hemodialysis, HD), and after RTx (at the 6th and 12th months) by a noninvasive method, brachial arterial ultrasound. A total of 22 (17 male, mean age: 33.9 ± 11.6 years) RTx recipients were enrolled in the study. Endothelium‐dependent vasodilation (EDD) was assessed by establishing reactive hyperemia. EDD prior to transplantation was significantly lower when compared with EDD measured at the 6th and 12th months after RTx (EDD pretransplantation: 6 ± 3.7%, EDD at the 6th month of RTx: 8.3 ± 2.3% and EDD at the 12th month of RTx: 12.1 ± 3.6%, P < 0.001). When the EDD values measured at the 6th and 12th months of RTx were compared, measurements of the 12th month were found significantly higher than those of the 6th month (P < 0.001). Our results also showed that RTx has provided improvement in endothelial function by eliminating the uremic environment although not in the early post‐RTx period.

Role of Plasmapheresis Performed in Hemodialysis Units for the Treatment of Anti‐Neutrophilic Cytoplasmic Antibody‐Associated Systemic Vasculitides

Anti‐neutrophilic cytoplasmic antibody (ANCA) positivity is seen in some systemic necrotizing vasculitides. Wegeners granulomatosis and microscopic polyangiitis are among the ANCA‐associated systemic vasculitides (AASV) and mortality is very high when renal failure occurs together with alveolar hemorrhage. The role of plasmapheresis in the treatment of these diseases has been studied retrospectively. Twelve patients with AASV who had plasmapheresis together with immunosuppressive medications have been involved. Primary diseases, immunosuppressive protocols, the number of plasmapheresis sessions, the amount of plasma that has been exchanged, urea and creatinine levels before and after treatment, pulmonary findings, the need for hemodialysis, and the outcome of patients were recorded. The mean age of patients was 52.9 ± 18.2 years. Wegeners granulomatosis was diagnosed in seven (58.3%) and microscopic polyangiitis in five (41.7%) patients. All patients had pulse cyclophosphamide and methylprednisolone followed by maintenance doses and plasmapheresis. Seven patients had hemodialysis at the beginning, and hemodialysis needed to be continued in three patients. Partial and complete remission was seen in 6 (50%) and 3 (25%) patients, respectively, and pulmonary findings regressed in all patients. End‐stage renal disease develops generally in AASV due to rapidly progressive glomerulonephritis causing severe irreversible glomerular damage. The mortality rate rises to 50% in cases of renal failure with diffuse alveolar hemorrhage; therefore, pulse immunosuppressive treatment with plasmapheresis may be life‐saving, as shown in our study.