Seyhun Kursat

Increased Incidence of Tuberculosis in Chronic Hemodialysis Patients

We encountered 9 cases of tuberculosis out of our 157 chronic HD patients in 36 months. Four pulmonary, 4 lymph nodal and one isolated dermal involvement were detected. Therapy was commenced without waiting for absolute cultural or pathologic diagnosis because of the high index of clinical suspicion. All cases except one recovered completely. Among associated conditions, peptic ulcer disease, anti-HCV positivity, and diabetes mellitus were noted, though the last two did not reach statistical significance. Prompt institution of the specific therapy and close supervision of the cases during treatment enabled us to obtain a cure in all cases except one and to discern adverse drug effects immediately and to make appropriate changes in the therapy. Thus, no morbidity due to the disease itself or drugs was observed.

Relationship between the Degree of Malnutrition and Echocardiographic Parameters in Hemodialysis Patients

Background: The aim of this study is to investigate the relationship between the degree of malnutrition and inadequate volume control evidenced by echocardiography. Methods: In this study 72 chronic hemodialysis patients were investigated in a cross-sectional manner. The malnutrition score was calculated using Subjective Global Assessment. M-mode echocardiography was performed in all patients. Results: The highest malnutrition score (23.2 ± 1.5 points) and lowest vena cava inferior collapse index (35 ± 2%) were observed in the eccentric left ventricular hypertrophy group. The malnutrition index was found to be in positive relationship with the left atrium diameter and index, left ventricular mass and index, and left ventricular end-diastolic diameter. On the other hand, a negative correlation was detected with the vena cava inferior collapse index. When all parameters that were found to be related to malnutrition were assessed by multivariate analyses, a statistically significant relation was found between the left ventricular end-diastolic diameter and the malnutrition index. Conclusion: The results of our study show that the progressive worsening of the nutritional status follows a parallel course along with the deterioration in the echocardiographic parameters concerning hypervolemia. This in turn suggests that increasing degrees of malnutrition are associated with more profound derangements in the volume status. Volume excess might be a mechanism explaning the increased mortality and morbidity caused by malnutrition in hemodialysis patients. Owing to its cross-sectional design, this study cannot provide unequivocal evidence regarding the cause and effect relationship between volume overload and malnutrition in hemodialysis patients.

Relationship between epicardial adipose tissue, inflammation and volume markers in hemodialysis and transplant patients.

Cardiovascular (CV) diseases are still the most important cause of morbidity and mortality in both patients receiving hemodialysis (HD) treatment and individuals with renal transplantation (Rtx). Measurement of epicardial adipose tissue (EAT) thickness is an easily applied, cheap, and useful recent method predicting increased CV risk. We aimed to compare EAT changes in HD and Rtx patients and the association between EAT and inflammatory and CV volume markers in both groups. A total of 124 patients: 45 Rtx, 43 HD patients and 36 healthy controls were enrolled in the study. Laboratory parameters and inflammatory markers (interleukin‐6 [IL‐6] and high sensitive C‐reactive protein [Hs‐CRP]) were evaluated from venous blood samples after an overnight fast. EAT thickness was measured with transthoracic echocardiography. The levels of Hs‐CRP, IL‐6, systolic and diastolic blood pressures, left atrial (LA) diameter, left atrial index (LAI), left ventricular mass (LVM) and LVM index (LVMI) were significantly higher in the HD patients than in the other groups. EAT was positively correlated with age, body mass index (BMI), time on dialysis, serum creatinine, total cholesterol, Low density lipoprotein‐cholesterol, and LVM in Rtx group and positively correlated with age, BMI, duration of dialysis, Hs‐CRP, IL‐6, LAI and LVMI and inversely correlated with inferior vena cava collapse index (IVC‐CI) in HD group. EAT thickness of RTx patients (whose previous HD duration was similar to those in HD group) are similar to the healthy population and significantly thinner than patients on HD.

Bone mineral density and biochemical markers of bone metabolism in predialysis patients with chronic kidney disease

The aim of the study was to evaluate the usefulness of serum bone turnover markers (BTM) and bone mineral density (BMD) determined by dual-energy X-ray absorptiometry (DEXA) in predialysis patients with chronic kidney disease (CKD). We enrolled 83 patients with CKD, 41 (49.4%) males, 42 (50.6%) females, with mean estimated glomerular filtration rate (eGFR) 23.90±12 (range=6.0–56.0). BMD of the lumbar spine (LS) (anteroposterior, L2 through L4), femoral neck (FN) and femoral trochanter (FT) were measured by DEXA. Biochemical BTM, including calcium (Ca), phosphorus (P), intact parathyroid hormone (PTH), serum specific alkaline phosphatase (serum AP), bone-specific AP (BSAP), plasma bicarbonate and 25-hydroxy-vitamin D (25hD) were used for the prediction of BMD loss. T score results of LS and FN were worse than FT. BMD levels were lower in females than in males (all p<0.05). According to different BMD T score levels, patients with age ≥65 years and patients in menopause were significantly more osteopenic (p=0.026) and there was no relation between different BMD T scores and presence of diabetes (p=0.654). A positive correlation was identified between the BMD of FN T-Z scores (r=0.270, p=0.029, r=0.306, p=0.012), FT T-Z scores (r=0.220, p=0.076, r:0.250, p=0.043) and serum HCO3, while the correlation with serum alkaline phosphatase (AP) and BSAP was considered to be negative. No statistically significant association was found between BMD of all the measured skeletal sites and eGFR. Loss of BMD was identified mostly in females over ≥65 years of age and after menopause. Higher serum levels of BSAP and AP can be determined in the advanced stages of renal failure and they reflect fracture risk of the femur, but not spine. Measurements of BMD by DEXA are useful to demonstrate bone loss, but not technical enough to distinguish the quantity of bone loss between different stages of CKD.

Effects of nutritional parameters on nocturnal blood pressure in patients undergoing hemodialysis

Abstract Background: Malnutrition is a common problem in uremic patients. It is unclear whether there is an association between the degree of malnutrition and 24-h ambulatory blood pressure patterns in patients undergoing hemodialysis. In the present study, we observed the relationship between the degree of malnutrition and deterioration of the rhythm of diurnal blood pressure, which are both risk factors for cardiovascular morbidity--mortality and associated with hypervolemia. Method: We observed 148 patients undergoing hemodialysis in the Nephrology Department of Celal Bayar University Hospital. All cases were assessed for body weight alterations, dietary food intake, gastrointestinal symptoms, loss of subcutaneous fat and muscle tissue, presence and severity of comorbidities, functional capacity (subjective global assessment), and anthropometric indices. Ambulatory blood pressure measurements were performed for all cases on the day between the two hemodialysis sessions. Results: We found that the circadian blood pressure rhythm deteriorated in patients with a high-malnutrition score, and that malnutrition was more common and severe in those subjects with the non-dipper and reverse-dipper blood pressure patterns. Malnutrition score was positively correlated with the nighttime systolic and nighttime mean blood pressures and mean 24-h arterial blood pressure (all p ≤ 0.01). We identified a positive correlation between malnutrition score and the reduction in serum albumin and anthropometric indices. Conclusion: This is the first study to demonstrate an association between malnutrition and deterioration in the circadian blood pressure rhythm in a hemodialysis population. Nutritional disturbance is associated with an increase in night-time blood pressure. Low serum albumin levels and hypervolemia may contribute this situation.

Relationship of insulin resistance in chronic haemodialysis patients with inflammatory indicators, malnutrition, echocardiographic parameters and 24 hour ambulatory blood pressure monitoring

Abstract Objective. The relationship between malnutrition, echocardiographic parameters, 24 h ambulatory blood pressure (ABP) parameters and decreased insulin sensitivity index (ISI-S) in chronic haemodialysis patients was investigated. Material and methods. ISI-S and inflammatory indicators were measured. The nutritional state was assessed by malnutrition score. Echocardiography and 24 h ABP were performed 1 day before the second haemodialysis session of the week. Results. ISI-S was inversely correlated with the night-time mean blood pressure (BP)/day-time mean BP ratio (p = 0.021) and malnutrition score (p < 0.01). High-sensitivity C-reactive protein, night-time mean BP/day-time mean BP and vena cava collapse index were independent risk factors affecting ISI-S (p < 0.001; β = 0.412, p = 0.025; β = –0.204, p < 0.001; β = –0.465). Conclusions. The decrease in ISI-S along with the hypervolaemia suggests that volume overload is a contributory factor in the pathogenesis of insulin resistance in patients with chronic renal failure. This study indicates that, in addition to the traditional cardiovascular risk factors in these patients, insulin resistance can be regarded as a risk factor, but not an independent one, mainly a reflection of the underlying culprit, hypervolaemia.

Functional bowel disorders and associated risk factors in hemodialysis patients in Turkey

BACKGROUND/AIMS Functional bowel disorders (FBDs) impair the quality of life in patients with end-stage renal disease (ESRD). The aim of our study was to determine the prevalence and distribution of the subtypes of FBDs in hemodialysis (HD) patients. MATERIALS AND METHODS This prospective, cross-sectional study included 80 patients who received HD for more than 3 months (patient group) and 80 healthy controls (control group). FBDs were diagnosed according to the Rome II diagnostic criteria by excluding organic pathologies. RESULTS Forty-six (57.5%) patients were males, and their average age was 62.13±12.92 (23-90) years. The mean duration of dialysis was 57.48±59.23 (3-312) months, and the mean Kt/V (K: dialyzer clearance of urea, t: dialysis time, V: volume of distrubition of urea) value was 1.53±0.31. The rate of FBDs was significantly higher in the patient group than in the control group (p=0.01). In total, 7.5% of the patients had irritable bowel syndrome, 3.8% had functional bloating, and 16.3% had functional constipation. FBDs were significantly higher in women (p=0.004). While there was no statistically significant difference between patients with and those without FBDs in terms of the presence of additional diseases, smoking, alcohol use, educational level, marital status, and resi- dential areas (p>0.05), serum phosphorus (P) levels were significantly higher in the patients with FBDs (p=0.03). CONCLUSION FBDs and their functional constipation subtype are more common in HD patients than in the healthy population in Turkey. FBDs are most frequently observed in females and housewives with high serum P levels.

The relationship between malnutrition subgroups and volume parameters in pre-dialysis patients

There are two types of malnutrition in patients with chronic renal failure (CRF); type 1 and type 2. The aim of this study was to investigate the relationship between malnutrition and inflammation and also the relationship between malnutrition and volume status. Ninety-four pre-dialysis CRF patients were included in the study. Nutritional status of the patients was calculated using the subjective global assessment. Scores of 1-5 were given according to the severity of the symptoms and physical examination findings. Serum inflammation markers [high-sensitive C-reactive protein (hs-CRP), interleukin-1β, interleukin-6 and tumor necrosis factor-alfa] and nutrition parameters (albumin, pre-albumin, transferrin, fetuin-A, insulin like growth factor-1 and insulin-like growth factor-binding protein-3)] were measured in all the patients. Serum N-terminal pro-brain natriuretic peptide levels and echocardiography were performed to evaluate the volume status of the patients. The mean age of the patients was 59.6±13.3 years, the mean malnutrition score was 17.2±6.01, the mean and the median of hs-CRP levels were 18.5±40.7 and 5.6 mg/L, respectively, the mean albumin level was 3.46±0.48 and the mean creatinine clearance was 23.7±13.5 mL/min. A positive correlation between malnutrition scores with inflammation and volume parameters was found in the bivariate and multivariate analysis. In the multiple regression analysis, volume parameters proved to be the most important factors influencing malnutrition scores. Thus, the elimination of volume excess would ameliorate both inflammation and malnutrition. This hypothesis needs to be supported or proved with prospective studies.

Hypervolemia–malnutrition in renal failure: Is there a relationship?

Background: Malnutrition is very common in chronic kidney disease patients and it starts from predialytic stage. The purpose of our project is to investigate the relationship between volume and malnutrition. Materials and method: A total of 109 chronic kidney disease patients were included in the study. Three groups have been created in patients according to their subjective global assessment (SGA) and malnutrition situation; SGA A: well feed group, SGA B: mild to moderate malnutrition, SGA C: severe malnutrition. Anthropometric measurements of all patients have been made (Body mass index, mid arm circumference, mid arm muscle circumference, triceps skinfold thickness, biceps skinfold thickness). Albumin, total chlosterol, triglyceride, serum amino acid leves have evaluated in blood samples of all patients. 24 hour ambulatory blood pressure monitoring was made for all patients. Results: According to results average age of patients was 59.92 year and average GFR was 23.56 mL/min. 22.01 percent of patients was evaluated as SGA A and 77.98 percent of patients was evaluated as SGA B and C. We found negative correlation between albumin, body mass index, mid arm circumference, mid arm muscle circumference, triceps skinfold thickness measurements and SGA scores. At the same time a positive correlation was found between NTSBP (Night time systolic blood pressure) and SGA scores. Discussion: Malnutrition and hypervolemia are significant cardiovascular risk factors for chronic kidney disease patients. In this study we examine the relationship between malnutrition and hypervolemia in predialysis patients. This study was cross sectional and only ambulatory blood pressure measuring used as a volume parameter so cause and effect relationship between hypervolemia-malnutrition should not be inferred. This study should be taken into consideration because it’s the first study that examines the relationship between ambulatory blood pressure and malnutrition in prediyalisis patients. Also our data shows statistically significant relationship between amino acid levels and blood pressure parameters and this study is the first reported data in this topic.

Correlation of the Volume Control Parameters With Health Related Quality of Life in Renal Transplant Patients

INTRODUCTION Transplantation is the most effective treatment strategy for end-stage renal failure. We aimed to investigate the correlation of volume control parameters with health-related quality of life (HRQoL) in renal transplantation patients during the pre- and post-transplantation periods. MATERIAL AND METHODS Seventy-seven patients who underwent renal transplantation from deceased donors between January 2011 and January 2013 were included in the study. The biochemical markers, complete blood count, and creatinine levels were measured during pretransplantation and at post-transplantation month 6. The Turkish version of the Short Form 36 (SF-36) health survey questionnaire was used for the assessment of HRQoL. Blood pressure (BP) and echocardiographic measurements were used to evaluate the volume status. RESULTS Significant improvements were achieved in all echocardiographic measurements, biochemical parameters except Ca(++), and SF-36 questionnaire domain scores (DSs) except vitality in the post-transplantation period. Systolic BP (SBP), the left atrium index, vena cava inferior collapsibility index (VCCI), and diastolic BP were associated with vitality (P = .02, .03, .05, and .04, respectively); SBP was associated with social functioning (P < .01) and role emotional (P < .01); and left ventricular mass index was associated with mental health (P = .05) DSs during the pretransplantation period. In the post-transplantation period, VCCI, left ventricular mass index, and SBP were associated with general health (P = .02, .05, and .05, respectively); VCCI and SBP were also associated with mental health (P = .05 and .01, respectively); and left atrium index was associated with role emotional (P = .05) DSs. CONCLUSION Concomitant improvement in the volemic status may contribute to improvements in HRQoL after renal transplantation.