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The Role of Prolidase Activity in the Diagnosis of Uremic Bone Disease

The derangements in bone metabolism in patients with chronic renal failure (CRF) are summarized as uremic bone disease (UBD). In this study, we planned to determine the serum prolidase to compare it with the other biochemical markers. This study was performed on 44 patients (19 females, 25 males, mean age = 56.8 ± 15.6 years) with end-stage renal disease (ESRD). The patients were divided into three groups according to serum bone alkaline phosphatase (bAP) levels. The patients whose bAP was ≥77 U/L were accepted as having high-turnover UBD (n = 18), the patients whose bAP was ≤50 U/L were accepted as having low-turnover UBD (n = 14), and the patients whose bAP levels were between these two values were accepted as having bone disease with normal turnover (n = 12). The serum prolidase levels did not increase in patients with ESRD. There were no significant differences between the serum prolidase levels of patients according to types of the UBD (p > 0.05). Kidney is the most prolidase-rich tissue of the human body. The serum prolidase activity is low in all patients with ESRD, irrespective of the type of UBD. Therefore, we concluded that prolidase had no value in the diagnosis of UBD.

Relationship between P-Wave Dispersion and Effective Hemodialysis in Chronic Hemodialysis Patients

Objective: To investigate whether or not P-wave dispersion (PWD) can be used as a good indicator of effective hemodialysis. Subjects andMethods: The study included 35 patients (20 males, 15 females, mean age 61 ± 10 years) who regularly received hemodialysis treatment for chronic renal failure. Following hemodialysis, the patients whose hemodynamic parameters were preserved and who reached dry body weight were included. Twelve-lead resting electrocardiogram (ECG) at a speed of 25–50 mm/s, the value of total body fluid (TBF) and bioelectric impedance using bipedal bioelectric impedance equipment were obtained before and immediately after hemodialysis. Blood samples were also taken for the assessment of blood electrolytes, urea and creatinine. PWD was defined as the difference between the maximum and minimum P-wave duration calculated on a standard 12-lead ECG before and after dialysis. Results: The following parameters were obtained before and after hemodialysis: blood pressure 132 ± 21 vs. 130 ± 10 mm Hg (p > 0.05), TBF 33.9 ± 6 vs. 32 ± 5.6 liters (p = 0.001), impedance 499 ± 110 vs. 596 ± 136 Ω (p = 0.001), P-max 103.1 ± 8.9 vs. 106.3 ± 12.7 ms (p > 0.05), P-min 70.2 ± 11 vs. 72.5 ± 7.9 ms (p > 0.05), PWD 32.2 ± 11.9 vs. 33.8 ± 13.4 ms (p > 0.05). Although statistically significant decreases were observed in urea and creatinine levels after hemodialysis, no such changes were observed in blood electrolytes. Conclusion: The P-max and PWD did not change significantly after hemodialysis, hence these two parameters can be used as an indicator of effective hemodialysis.

A rare complication of idiopathic membranous nephropathy: crescentic transformation.

Introduction. In this study, the cause of rapidly deteriorating renal functions in a follow-up period of a 65-year-old female patient, who applied with nephrotic syndrome findings and diagnosed as membranous nephropathy, is presented. Case report. A 65-year-old patient with findings of nephrotic syndrome had normal kidney size and serum complement level, and was negative for autoantibodies and viral serology. In histopathologic examination, 20 glomeruli were consistent with membranous glomerulonephritis. The patient, evaluated for idiopathic membranous nephropathy, was followed-up monthly with supportive treatment. In the second month of follow-up, a re-evaluation of the patient due to nausea and urine discoloration revealed 144 mg/dL urea, 6.3 mg/dL creatinine, and 2.5 g/dL albumin. Urine sediment revealed dysmorphic erythrocytes and granular silenders. Renal re-biopsy was done. Of 11 glomeruli, three global sclerosis and eight crescentic glomeruli with fibrosis and scarce cellular component were seen. The case was accepted as crescentic glomerulonephritis, a rare complication of idiopathic MN. Before the treatment, antiGBM, pANCA, cANCA, and ANA were negative. Pulse metil prednisolone and pulse cyclophosphamide treatment protocol was administered. Hemodialysis was needed nine times. At the end of first month of the treatment, hemodialysis was no longer needed. Conclusion. Due to a risk of spontaneous remission up to 30% of membranous nephropathy, there is no consensus on specific treatment applicable to all cases. However, crescentic GN should be investigated immediately when sudden and rapid deterioration of renal functions appeared.

Correlation between hypervolemia, left ventricular hypertrophy and fibroblast growth factor 23 in hemodialysis patients.

Abstract Introduction: Left ventricular hypertrophy (LVH) is a significant risk factor for cardiovascular complications in hemodialysis (HD) patients. Hypervolemia has been accepted as an independent risk factor for progressive LVH in HD patients. Additionally, high FGF23 levels have been a significant predictor of cardiovascular mortality and morbidity in chronic kidney disease and HD patients. The aim of our study is to investigate the correlation among LVH, interdialytic volume increase and FGF-23 in the patients on a chronic hemodialysis program. Design and methods: A total of 97 chronic hemodialysis patients (64.43 ± 11.28 years old, M/F:47/50) were included in the study. Human FGF-23 ELISA kit was used for FGF-23 analysis of predialysis blood samples. Echocardiographic evaluation was performed in all of the patients after dialysis. Left Ventricular Mass Index (LVMI) was calculated by using the Devereux Formula. We collected the following data: LVMI, FGF-23 levels, interdialytic fluid gain, blood pressure changes, and the other biochemical and clinical parameters. Results: Mean LVMI of the patients was 184.41 ± 48.62 g/m2. LVMI of the patients with daily urine output >250 mL was found significantly lower. Statistically significant positive correlation was found between predialysis systolic blood pressure, predialysis diastolic blood pressure, predialysis mean arterial blood pressure and LVMI measurements (p < 0.01). Mean interdialytic volume excess was correlated with LVMI measurements of the patients (r = 0.459; p < 0.01). Increased FGF-23 levels (159.79 ± 134.99 ng/L) predicted increased LVMI measurements of the patients (r = 0.322; p < 0.01). In addition, FGF-23 levels were also increased as the interdialytic fluid volume increased (r = 0.326; p < 0.05). A positive correlation was also found between FGF-23 levels and interventricular septum thickness (r = 0.238; p < 0.05). Predialysis mean arterial blood pressure, predialysis volume overload and presence of diabetes were determined to be independent risk factors on LVMI on multivariate regression analysis. Conclusion: Our study showed that interdialytic volume overload increased both LVMI and FGF-23 values. We can consider that interdialytic volume control exerts positive effects on increased FGF-23 levels which predict the negative cardiovascular outcomes.

The Influence of the Amount of Ultrafiltration in Chronic Hemodialysis on P Wave Dispersion

Objective. Paroxysmal atrial fibrillation (AF) observed in patients undergoing chronic hemodialysis program with higher rates is an important morbidity and mortality cause that negatively influences the hemodynamics and leads to thromboembolic complications. It is known that P wave dispersion (PWD) facilitating the development of paroxysmal atrial fibrillation is increasing during intradialytic process. This study researched the influence of various amounts of ultrafiltration that applied in the various hemodialysis sessions in the same patient cohort on PWD. Materials and Methods. 25 patients in a chronic hemodialysis program undergoing four hours bicarbonate hemodialysis three times a week were included in the study. The patient cohort was divided into four groups regarding the amount of ultrafiltration (UF) performed during a four-hour standard hemodialysis session as following: UF up to 1 liter, UF of 1–2 liters, UF of 2–3 liters, and UF of 3–4 liters. Notes were kept until each patient had been included once into each group regarding the amount of ultrafiltration performed parallel to intradialytic weight gain in different hemodialysis session. A 12-lead ECG was taken from the patients immediately before the hemodialysis and within 20 minutes after completion of the session, and maximum P wave duration (Pmax), minimum P wave duration (Pmin) and PWD values (i.e., the difference between Pmax and Pmin) were measured. The inter-group data was assessed with a one-way ANOVA, and the within-group assessments were performed with paired samples test. Mann Whitney U test was used for the evaluations performed according to the presence of diabetes. Findings. The mean age of 25 patients (15 male and 10 female) was 62.7 ± 20.2 (range: 21–89). PWD after UF was decreased significantly in group 1 (56.12 ± 15.26 vs. 46.60 ± 18.45 ms, p = 0.018) and were increased in groups with UF more than 1 liter: group 2 (39.68 ± 21.26 vs. 47.12 ± 21.20 ms, p = 0.020), group 3 (41.60 ± 23.99 vs. 65.92 ± 31.04 ms, p = 0.001), and group 4 (17.52 ± 14.67 vs. 26.80 ± 15.52 ms, p = 0.007). Furthermore, while PWD before UF was significantly higher in a diabetic group compared to a nondiabetic group (68.85 ± 10.44 vs. 51.16 ± 14.06 ms, p = 0.007), it was seen that PWD difference had disappeared after UF application (57.14 ± 17.99 vs. 42.50 ± 17.40 ms, p = 0.065). Conclusion. UF application of more than 1 liter during hemodialysis session increases the PWD value significantly. Hypervolemia exceeding 1 liter between two dialysis sessions should be avoided in all patient groups, especially in diabetics, and an effective UF planning should be arranged because of a decrease in PWD values with UF observed in diabetics.

Objective analysis of voice changes in a hemodialysis session and its correlation with ultrafiltration

Abstract Introduction: The aim of the study is to analyze the voice changes occurring during a hemodialysis session objectively and to investigate the statistical correlation between voice changes and ultrafiltration, blood pressure, dry weight and the other variables of the patients. Materials and methods: A total of 169 patients were included in the study. Electronic voice recordings of the patients were performed with the aim of making objective voice analysis before and after dialysis. Fundamental frequency measurements occurring at the level of the larynx (Fo) and harmonic-to-noise ratio (HNR) were measured from these voice recordings. Results: When the voice recordings obtained from 169 hemodialysis patients before and after dialysis were investigated, it was observed that a significant increase occurred in the Fo (from 164.52 ± 43.36 Hz to 193.19 ± 47.08 Hz, p < 0.01). When the change in HNR was investigated, a significant reduction was determined in the post-dialysis measurements (4.6 ± 3.23 dB) compared to the pre-dialysis measurements (16.10 ± 4.06 dB, p < 0.01). Mean 2.49 ± 0.83 L of ultrafiltration was performed and a significant reduction was observed in post-session body weights of the patients (p < 0.01). There was a highly statistical significance between the measurements of post-dialysis Fo and post-dialysis body weights. A highly significant correlation was determined between the amount of ultrafiltration performed and a significant increase observed in Fo before and after dialysis. Also a significant correlation was determined between the reduction in the mean post-session blood pressures and the reduction in the HNRs. Conclusion: Objective voice analysis is suggesting that it can be a simple and applicable method that can be used to determine the dry weight.

Urinary Glycosaminoglycan Levels as a Marker of Renal Amyloidosis in Patients with Familial Mediterranean Fever

Introduction and aim. Familial Mediterranean Fever (FMF) is an autosomal recessive disease with a defect in the pyrine gene and is manifested with short attacks of inflammatory serositis, fever, and erysipelas-like skin lesions. Secondary amyloidosis is the most serious complication of the disease, in which extracellular deposits of amyloid (an amorphous and eosinophilic protein) are seen in tissues. Glycosaminoglycans are mucopolysaccharide molecules that take place in amyloid deposits with fibrillar links to amyloid. They form glycoproteins by linking to proteins, and their free forms are excreted in the urine in the form of polysaccharides. The aims of this study were to evaluate if the urinary levels of glycosaminoglycans have a predictive value in the diagnosis of amyloidosis secondary to FMF and if these levels are affected by treatment with colchicine. Materials and methods. The study included 55 volunteer patients (age range: 18–36 years) with FMF (15 with amyloidosis) of the same socio-economic circumstances without other concomitant inflammatory, malignant, or chronic diseases, along with 20 healthy subjects as control. Urinary glycosaminoglycan levels were determined twice, once when the patients were on medication and once after they have stopped treatment for two weeks. Results. Initial mean urinary GAG levels were significantly lower in amyloidosis patients. Mean urinary GAG levels determined two weeks after the cessation of colchicine was also significantly lower than controls in both amyloidosis and non-amyloidosis FMF patients. Likewise, in patients with a disease duration longer than ten years, urinary GAG levels were also lower than those with a disease duration of less than three years. Conclusion. Urinary GAG level can have a predictive value for amyloidosis in patients with FMF, and it can also be used as a non-invasive marker for screening the effects of colchicine on fibrillogenesis as well as for the follow-up of the patients.