Serdar Kahvecioglu

Effect of Fluid Management Guided by Bioimpedance Spectroscopy on Cardiovascular Parameters in Hemodialysis Patients: A Randomized Controlled Trial

BACKGROUND Fluid overload is the main determinant of hypertension and left ventricular hypertrophy in hemodialysis patients. However, assessment of fluid overload can be difficult in clinical practice. We investigated whether objective measurement of fluid overload with bioimpedance spectroscopy is helpful in optimizing fluid status. STUDY DESIGN Prospective, randomized, and controlled study. SETTING & PARTICIPANTS 156 hemodialysis patients from 2 centers were randomly assigned to 2 groups. INTERVENTION Dry weight was assessed by routine clinical practice and fluid overload was assessed by bioimpedance spectroscopy in both groups. In the intervention group (n = 78), fluid overload information was provided to treating physicians and used to adjust fluid removal during dialysis. In the control group (n = 78), fluid overload information was not provided to treating physicians and fluid removal during dialysis was adjusted according to usual clinical practice. OUTCOMES The primary outcome was regression of left ventricular mass index during a 1-year follow-up. Improvement in blood pressure and left atrial volume were the main secondary outcomes. Changes in arterial stiffness parameters were additional outcomes. MEASUREMENTS Fluid overload was assessed twice monthly in the intervention group and every 3 months in the control group before the mid- or end-week hemodialysis session. Echocardiography, 48-hour ambulatory blood pressure measurement, and pulse wave analysis were performed at baseline and 12 months. RESULTS Baseline fluid overload parameters in the intervention and control groups were 1.45 ± 1.11 (SD) and 1.44 ± 1.12 L, respectively (P = 0.7). Time-averaged fluid overload values significantly decreased in the intervention group (mean difference, -0.5 ± 0.8 L), but not in the control group (mean difference, 0.1 ± 1.2 L), and the mean difference between groups was -0.5 L (95% CI, -0.8 to -0.2; P = 0.001). Left ventricular mass index regressed from 131 ± 36 to 116 ± 29 g/m(2) (P < 0.001) in the intervention group, but not in the control group (121 ± 35 to 120 ± 30 g/m(2); P = 0.9); mean difference between groups was -10.2 g/m(2) (95% CI, -19.2 to -1.17 g/m(2); P = 0.04). In addition, values for left atrial volume index, blood pressure, and arterial stiffness parameters decreased in the intervention group, but not in the control group. LIMITATIONS Ambulatory blood pressure data were not available for all patients. CONCLUSIONS Assessment of fluid overload with bioimpedance spectroscopy provides better management of fluid status, leading to regression of left ventricular mass index, decrease in blood pressure, and improvement in arterial stiffness.

Clinical Value of the Malnutrition-Inflammation- Atherosclerosis Syndrome for Long-Term Prediction of Cardiovascular Mortality in Patients with End- Stage Renal Disease: A 5-Year Prospective Study

Background/Aim: Mortality resulting from cardiovascular disease in patients with end-stage renal disease (ESRD) is high. In this study we sought to investigate the clinical value of the malnutrition-inflammation-atherosclerosis (MIA) syndrome for long-term prediction of cardiovascular mortality in patients treated with ESRD. Methods: A total of 42 ESRD patients on hemodialysis were enrolled. Inflammatory markers and nutritional parameters were determined. Carotid atherosclerosis was investigated by ultrasonographically evaluated carotid intima-media thickness (cIMT). Mortality was evaluated at a 5-year follow-up. Results: No correlation was evident between nutritional markers and inflammatory indexes. cIMT was inversely correlated with predialysis serum albumin. In the overall population of 42 patients, 11 (26.2%) died of cardiovascular causes during follow-up. Kaplan-Meier survival curves indicate that cIMT (≧0.9 mm), C-reactive protein (CRP) (>1 mg/dl), and serum albumin (<3.5 g/dl) predict cardiovascular death in patients with ESRD. Conclusions: We have demonstrated that cIMT, CRP and serum albumin predict long-term mortality in ERSD patients. Our study suggests that further investigation of the MIA syndrome will provide insights into the susceptibility to CVD in this patient group.

Effect of fluvastatin on serum prohepcidin levels in patients with end-stage renal disease

OBJECTIVES Anemia, low-grade inflammation and/or alterations in lipid metabolism are common findings in individuals with end-stage renal disease (ESRD) despite advances in dialysis treatment. Hepcidin, a key regulator of iron metabolism, may play an important role in the interdependence of inflammation and anemia in ESRD patients. Statins may reduce cardiovascular events in dialysis patients and have pleiotropic effects in addition to lowering total and low-density lipoprotein (LDL)-cholesterol. DESIGN AND METHODS Because there is a paucity of data on the effect of statins on serum prohepcidin levels in dialysis patients, this 8-week study was conducted to test the effect of fluvastatin (80 mg/day, n=22) compared with placebo (n=18) on circulating serum prohepcidin, a prohormone of hepcidin, and high-sensitive C-reactive protein (hs-CRP) in dyslipidemic ESRD patients with renal anemia. RESULTS Fluvastatin treatment decreased total cholesterol (P<0.05), LDL-cholesterol (P<0.01), hs-CRP (P<0.05) and serum prohepcidin levels (P<0.05) significantly. CONCLUSION Our pilot data suggest that short-term statin treatment may exert a beneficial effect on serum prohepcidin levels in ESRD patients. The potential clinical benefits of statins on renal anemia need to be confirmed and expanded with an appropriately powered long-term study.

Calcineurin inhibitors and post-transplant weight gain.

Aim:  Excessive weight gain that leads to obesity is quite common after kidney transplantation. This is often attributed to immunosuppression. The aim of this retrospective study was to assess the effect of calcineurin inhibitors on post‐transplant weight gain.

Aldosterone Blockage in Proliferative Glomerulonephritis Prevents Not Only Fibrosis, but Proliferation as Well

Studies performed recently have determined that aldosterone has not only a major role in electrolyte and water balance and K excretion, but it also modulates myofibroblast growth in the heart and blood vessels and causes fibrosis. This study investigated the effects of aldosterone blockers in rats with anti-thy 1.1 nephritis, both on proliferation and fibrosis, by comparing it to an angiotensin receptor inhibitor valsartan. Rats with anti-thy 1.1 nephritis were randomly allocated to one of the three following groups of treatment: the control group (group 1); those treated with the aldosterone receptor blocker spironolactone (group 2); and those treated with the ATRB valsartan (group 3). On day 7, the parameters of glomerular fibrosis [transforming growth factor beta, TGF staining areas %], proliferation (Ki-67), and renal damage scores were determined. The TGF-β and Ki-67 levels of control group were significantly more than the other two groups (p<0.01). The TGF staining areas percentages were significantly decreased compared to control group. The artery, glomerular, and renal injury scores evaluated between the groups were found to be significantly decreased compared to control group. In line with previous studies, this study found that in anti–thy 1.1 mesangioproliferative glomerulonephritis, aldosterone blockage affected proliferation and fibrosis.

Evaluation of relationship between sexual functions, depression and quality of life in patients with chronic kidney disease at predialysis stage

Abstract Aim: The relation of chronic kidney disease (CKD) with metabolic, psychiatric and endocrinologic disorder is well-known. Depressive mood and sexual dysfunction are frequently observed as renal functions deteriorate. We aimed to analyze the relationship of sexual dysfunction, depressive mood and life quality in patients with CKD at predialysis stage. Patients and methods: Fifty-three patients; 27 female and 26 male with CKD who had estimated glomerular filtration rate (eGFR) between 15 and 90 mL/min and followed up in the Nephrology Department, Bursa Sevket Yılmaz Education and Research Hospital, were enrolled. Age- and sex-matched 20 female and 20 male healthy control subjects were assigned to the control group. Detailed medical and sexual history was obtained by using Female Sexual Function Index (FSFI), Erectile Function International Evaluation Form (IEFF), Short form (SF) 36 Form and Beck Depression Questionnaire (BDI). Biochemical and hormonal parameters including urea, creatinine, uric acid, sedimentation rate, c-reactive protein, total testosterone, DHEA-S, FSH, LH, TSH, estradiol and prolactin were analyzed. Findings: Depression was observed in 12 male (46%) and 14 female (51%) patients. The frequency of depression among male patients and control subjects was similar, however, significantly higher in female patients than female controls (p = 0.036). Physical function score, physical role score and pain score in SF 36 of entire patients were significantly lower than controls (p = 0.0001, 0.0001, 0.001, respectively). The frequency of depression was similar between patients and controls (p > 0.05). When SF 36 tests of male and female patients were compared, general health status, vitality and mental health status were significantly better in male patients (p = 0.005, 0.016, 0.035, respectively). SF 36 scores of female patients were significantly lower than female controls (p = 0.0001). The frequency of erectile dysfunction (ED) was similar between male patients (84%) and controls (75%) (p = 0.62). On the other hand, sexual dysfunction was significantly higher in female patients when compared to female controls (92% vs. 30%; p = 0.0001). Conclusion: We showed that sexual dysfunction and depression are more frequent among female patients with CKD at predialysis stage; however, it does not have significant impact on life quality. When life quality of female and male patients was compared, general health status, vitality and mental health status of female patients were poorer. We failed to demonstrate a relationship between sexual dysfunction and sex hormone level.

Spontaneous perirenal hematoma with AA amyloidosis in a hemodialysis patient after unilateral nephrectomy

Secondary amyloidosis presents with a variety of systemic symptoms or signs. Amyloid diseases can be associated with potentially life-threatening hemorrhage. Although bleeding manifestations are common in amyloidosis, renal bleeding is rare and generally due to trauma, cyst and malignancy. For the first time we present a ureamic patient who was diagnosed with AA amyloidosis after unilateral nephrectomy because of spontaneous perirenal hematoma.

Paraoxonase Activity in Glomerulonephritic Patients

Background. Cardiovascular disease is the most common cause of morbidity and mortality in patients with chronic renal failure. Glomerulonephritic patients have an increased risk for cardiovascular disease, but its etiology is unclear. It is known that an increase in oxidizability of apolipoprotein B-containing lipoproteins has a key role in the initiation of atherosclerosis, and paraoxonase enzyme activity particularly has a preventive role against atherosclerosis. The aim of the present study was to evaluate the oxidizability of apolipoprotein B-containing lipoproteins, serum, and urinary paraoxonase/arylesterase activities in glomerulonephritis patients who had normal lipid parameters and creatinine levels. Methods. Thirty-two patients with glomerulonephritis and 22 healthy controls were included in this study. A total of 32 patients (including nine with membranous GN, eight with immunoglobulin A nephropathy, eight with mesangial proliferative GN, five with focal-segmental glomerulosclerosis, one with diffuse proliferative GN, and one with minimal chance disease having biopsy proven GN) were enrolled into the study. We compared serum and urinary paraoxonase, arylesterase, serum lipids, urea, creatinine, hemoglobin, total protein and albumin values between groups. Results. Serum urea, creatinine, total protein, albumin, uric acid, hemoglobin, and lipid parameters were similar in the glomerulonephritis and control groups (p > 0.05). PON1 activity was significantly lower in GN group than controls, but there was no statistically significant difference on arylesterase activity between groups. Oxidizability of apolipoprotein B-containing lipoproteins was significantly higher in GN group than controls. Conclusion. Our study shows that the findings of normal serum levels of creatinine, lipids, and proteins increased the oxidizability of apolipoprotein B-containing lipoproteins, and any decrease in PON1 activity in patients diagnosed with GN should be considered important. Hence, the immediate commencement of preventive as well as curative treatment in other to avoid the risk of cardiovascular and renal problems would be a correct approach.

Evaluation of serum Spondin 2 levels in the different stages of Type 2 diabetic nephropathy

We aimed to determine whether serum SPON2 is a useful biomarker in the detection of Diabetic Nephropathy (DN) and to compare serum SPON2 levels with 24‐hour urinary albumin excretion rate (UAER) in patients with DN at different stages.

Synchronous carcinomas of stomach and bladder together with AA amyloidosis (Case Report)

SUMMARY:  Although the association and causality between chronic inflammatory states and systemic AA amyloidosis have been well established, the evidence linking solid malignancies to reactive AA amyloidosis is scarce. Here, a case of diagnosed AA amyloidosis associated with synchronous carcinomas of stomach and bladder complicated with nephrotic syndrome and renal failure is reported.