Taner Camsari

Nationwide and Long-Term Survey of Primary Glomerulonephritis in Japan as Observed in 1,850 Biopsied Cases

Primary chronic glomerulonephritis is the most common cause of end-stage renal failure in Japan. The incidence in dialysis patients in Japan is about four times higher than in the United States for reason which are unclear. We conducted a nationwide survey on the natural history and treatment of primary glomerulonephritis under a program project from the Ministry of Health and Welfare of Japan entitled ‘Progressive Chronic Renal Disease’. We analyzed patient characteristics, disease onset, clinical data, and histological findings in 1,850 patients with primary glomerulonephritis from 53 institutions in 1985 who underwent renal biopsy at least 5 years ago, and the follow-up study was carried out 8 years after registration. The incidence of diffuse-mesangial proliferative glomerulonephritis is 41.9%, that of minor glomerular abnormalities 17.5%, and that of focal-mesangial proliferative glomerulonephritis 13.0%. Of 1,045 biopsy specimens that were examined by immunofluorescence microscopy, 47.4% showed IgA nephropathy. Half of all cases with primary chronic glomerulonephritis were asymptomatic and were detected on routine health examination. The survival rates at 20 years from the apparent onset or earliest known renal abnormality are: focal glomerular sclerosis 49%, membranoproliferative glomerulonephritis 58%, diffuse-mesangial proliferative glomerulonephritis 66%, focal-proliferative glomerulonephritis 81%, membranous nephropathy 82%, minor glomerular abnormalities 94%, and IgA nephropathy 61%. In conclusion, a high incidence of IgA nephropathy and a better renal survival of membranous nephropathy are the features of primary chronic glomerulonephritis in Japan. This high incidence of IgA nephropathy together with its poor prognosis is probably the reason for the increased incidence of primary chronic glomerulonephritis in dialysis patients in Japan. In addition, the importance of routine health examination including urinalysis is demonstrated.

A population-based survey of Chronic REnal Disease In Turkey—the CREDIT study

Background. Chronic kidney disease (CKD) is a growing health problem worldwide that leads to end-stage kidney failure and cardiovascular complications. We aimed to determine the prevalence of CKD in Turkey, and to evaluate relationships between CKD and cardiovascular risk factors in a population-based survey. Methods. Medical data were collected through home visits and interviews. Serum creatinine, blood glucose, total cholesterol, triglycerides, HDL, LDL and uric acid were determined from 12-h fasting blood samples, and spot urine tests were performed for subjects who gave consent to laboratory evaluation. Results. A total of 10 872 participants were included in the study. The final analysis was performed on 10 748 subjects (mean age 40.5 ± 16.3 years; 55.7% women) and excluded 124 pregnant women. A low glomerular filtration rate (GFR) (< 60 mL/min/1.73 m2) was present in 5.2% of the subjects who were evaluated for GFR, while microalbuminuria and macroalbuminuria were observed in 10.2% and 2% of the subjects, respectively. The presence of CKD was assessed in subjects who gave consent for urinary albumin excretion measurement (n = 8765). The overall prevalence of CKD was 15.7%; it was higher in women than men (18.4% vs. 12.8%, P < 0.001) and increased with increasing age of the subjects. The prevalence of hypertension (32.7% in the general population), diabetes (12.7%), dyslipidaemia (76.3%), obesity (20.1%) and metabolic syndrome (31.3%) was significantly higher in subjects with CKD than subjects without CKD (P < 0.001 for all). Conclusions. The prevalence of CKD in Turkey is 15.7%. Cardiovascular risk factors were significantly more prevalent in CKD patients.

The Comparison of Antibody Response to Influenza Vaccination in Continuous Ambulatory Peritoneal Dialysis, Hemodialysis and Renal Transplantation Patients

Background : The immune system in renal transplant (Tx), Continuous Ambulatory Peritoneal Dialysis (CAPD) and hemodialysis (HD) patients have been suppressed and antibody response to vaccination is weaker than that of the normal population. Additionally immune response to vaccination also differs from each other in aforementioned three groups resulting from different levels immunosuppression. In the present study, detection of antibody response to influenza vaccine as an indicator of the level of immunity in Tx, CAPD and HD patients was aimed Patients and methods : Forty-eight patients (17 Tx, 16 CAPD and 15 HD) and 10 healthy adults, as a control group were enrolled into the study. Purified, split-virus, commercial trivalent influenza vaccine (VAXIGRIP ® --Pasteur Merieux Connaught, single dose of 0.5 r ml into the deltoid muscle) containing 15 r 7 g of each hemagglutinin of A/Johannesburg/82/96 (H 1 N 1 ), A/Nachang/933/95 (H 3 N 2 ) and B/Harbin/07/94 (B) strains were administered to all subjects. Serum samples were collected before and 1 month after vaccination to determine antibody titers. Hemagglutination-inhibition test (HI) was applied for determination of antibody response. The antibody response against each strain was measured separately. In addition to measurement of antibody response, increments in antibody titer (n-fold increase in titer), proportion of patients with protective antibody levels and seroconversion levels were taken into account. Wilcoxon paired 2 test and Mann-Whitney U test were applied for statistical analysis. p r < r 0.05 was accepted as significance level. Results : Significant increases in antibody titers for all three antigens were observed in the study groups after vaccination ( p r = r 0.001). However, the increase in titer of H 3 N 2 was lower in Tx, CAPD and HD patients than that of the control group (1.0-2.0 vs 5.00) ( p r = r 0.01). The proportion of protective antibody titers and seroconvertions were increased after vaccination in all subjects. Proportions of patients with protective antibody titers after vaccination were lower in Tx, CAPD and HD groups in comparison to control group. Conclusion : Although antibody titers in Tx, CAPD and HD patients presented significant increases after vaccination, the proportions of patients with protective antibody titers were lower in comparison to control group. Tx, CAPD and HD patients should be vaccinated every year to be able avoid potential morbidity and mortality of the influenza infection. Trial of high dose vaccination protocols may be useful to increase the proportion of patients with protective antibody levels.

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.

Urinary Stone Disease in Diabetes Mellitus

Objective: Diabetes mellitus (DM) and urinary stone disease (USD) are common diseases in the community. The prevalence of USD has not previously been studied in DM patients. Material and Methods: We evaluated 286 diabetics and 111 age-matched controls by means of direct urinary system X-ray, ultrasonography and/or intravenous pyelography. We also examined the history, risk factors and clinical aspects of USD in DM patients. Results: The prevalence of USD (21% vs 8%; p r < r 0.05) and the rate of recurrence (2.1 r - r 2.2 vs 1.3 r - r 0.5 stones/case; p r < r 0.05) were higher in the diabetics compared to the controls. Family history and male gender were significant risk factors for the development of USD in the DM patients. Increased daily total fluid consumption was not preventive for USD in the DM patients, and the type of fluid consumed did not have an impact on the risk of USD. Alcohol consumption was a significant risk factor for the development USD in the DM patients (odds ratio 3.68; 95% confidence interval 1.29-10.45; p r < r 0.05). Crystaluria (10% vs 1%; p r < r 0.05) and positive urine culture (8% vs 1%; p r < r 0.05) were also more prominent in the diabetics compared to the controls. Conclusions: The results of this study suggest that DM is a risk factor for the development USD.

Lipid Peroxidation and Antioxidant Activity in Chronic Haemodialysis Patients Treated with Recombinant Human Erythropoietin

In anaemia of chronic renal failure, the most important factor in the shortened erythrocyte survival may be lipid peroxidation of the cell membrane. Defective antioxidant activity may increase this damage. Although recombinant human erythropoietin (r-HuEPO) can effectively correct anaemia in chronic haemodialysis patients, its actions on lipid peroxidation and antioxidant activity are not clear. These actions were investigated in 13 patients undergoing chronic haemodialysis. Antioxidant activity, including red blood cell superoxide dismutase and total glutathione peroxidase levels and the lipid peroxidation product malondialdehyde, were measured before and 3 months after initiation of r-HuEPO treatment, using heparinized venous whole blood for cell and plasma determinations. Age-matched healthy volunteers were controls. Significantly higher levels of superoxide dismutase and total glutathione peroxidase were found in the patients than in the controls (p < 0.01). Plasma malondialdehyde levels were not affected by r-HuEPO. The results are explained by erythropoiesis and cellular haemoglobin synthesis due to r-HuEPO, followed by increase of circulating young red cells. The membranes of these young cells contain more antioxidant enzymes than the others. Despite r-HuEPO treatment, plasma malondialdehyde levels in haemodialysis patients may be higher than normal because of the uraemic milieu and the chronic haemodialysis.

Efficacy and safety of sildenafil for treating erectile dysfunction in patients on dialysis

Objective  To assess the efficacy of sildenafil for erectile dysfunction (ED) in patients on haemodialysis (HD) or peritoneal dialysis (PD), as men with end‐stage renal disease (ESRD) often have sexual dysfunction (up to 82% among those on chronic dialysis).

Phosphorus control in peritoneal dialysis patients

Hyperphosphatemia is independently associated with an increased risk of death among dialysis patients. In this study, we have assessed the status of phosphate control and its clinical and laboratory associations in a large international group of patients on chronic peritoneal dialysis (PD) treatment. This cross-sectional multicenter study was carried out in 24 centers in three different countries (Canada, Greece, and Turkey) among 530 PD patients (235 women, 295 men) with a mean+/-s.d. age of 55+/-16 years and mean duration of PD of 33+/-25 months. Serum calcium (Ca(2+)), ionized Ca(2+), phosphate, intact parathyroid hormone (iPTH), 25-hydroxy vitamin D(3), 1,25-dihydroxy vitamin D(3), total alkaline phosphatase, and bone alkaline phosphatase concentrations were investigated, along with adequacy parameters such as Kt/V, weekly creatinine clearance, and daily urine output. Mean Kt/V was 2.3+/-0.65, weekly creatinine clearance 78.5+/-76.6 l, and daily urine output 550+/-603 ml day(-1). Fifty-five percent of patients had a urine volume of <400 ml day(-1). Mean serum phosphorus level was 4.9+/-1.3 mg per 100 ml, serum Ca(2+) 9.4+/-1.07 mg per 100 ml, iPTH 267+/-356 pg ml(-1), ionized Ca(2+) 1.08+/-0.32 mg per 100 ml, calcium phosphorus (Ca x P) product 39+/-19 mg(2)dl(-2), 25(OH)D(3) 8.3+/-9.3 ng ml(-1), 1,25(OH)(2)D(3) 9.7+/-6.7 pg ml(-1), total alkaline phosphatase 170+/-178 U l(-1), and bone alkaline phosphatase 71+/-108 U l(-1). While 14% of patients were hypophosphatemic, with a serum phosphorus level lower than 3.5 mg per 100 ml, most patients (307 patients, 58%) had a serum phosphate level between 3.5 and 5.5 mg per 100 ml. Serum phosphorus level was 5.5 mg per 100 ml or greater in 28% (149) of patients. Serum Ca(2+) level was > or =9.5 mg per 100 ml in 250 patients (49%), between 8.5 and 9.5 mg per 100 ml in 214 patients (40%), and lower than 8.5 mg per 100 ml in 66 patients (12%). Ca x P product was >55 mg(2)dl(-2) in 136 patients (26%) and lower than 55 mg(2)dl(-2) in 394 patients (74%). Serum phosphorus levels were positively correlated with serum albumin (P<0.027) and iPTH (P=0.001), and negatively correlated with age (P<0.033). Serum phosphorus was also statistically different (P = 0.013) in the older age group (>65 years) compared to younger patients; mean levels were 5.1+/-1.4 and 4.5+/-1.1 mg per 100 ml, respectively, in the two groups. In our study, among 530 PD patients, accepted uremic-normal limits of serum phosphorus control was achieved in 58%, Ca x P in 73%, serum Ca(2+) in 53%, and iPTH levels in 24% of subjects. Our results show that chronic PD, when combined with dietary measures and use of phosphate binders, is associated with satisfactory serum phosphorus control in the majority of patients.

Prevalence, awareness, treatment and control of hypertension in adults with chronic kidney disease in Turkey: results from the CREDIT study.

Background: In the Chronic REnal Disease In Turkey -CREDIT Study, a large populationbased study on 10,748 adults, the prevalence of chronic kidney disease (CKD) and relationship between CKD and other cardiovascular risk factors had been studied. Methods: This report presents the results of CREDIT study on the prevalence, awareness, treatment, and control of hypertension among CKD patients. Results: The prevalence and awareness of hypertension in CREDIT population was 32.7% and 48.6%, respectively. Of the patients with hypertension, 31.5.% were under treatment, and 16.4% had hypertension under control. Prevalence of CKD was 25.3% in patients with hypertension. Among CKD patients (15.7% of the CREDIT study population), 56.3% had hypertension. The prevalence of hypertension was 34.8% at stage 1, 79.8% at stage 3, and 92.3% at stage 5 CKD. Only 13.4% of patients with CKD have optimal blood pressure. Among CKD patients, 61.9% were aware of hypertension, and 44.2% were under treatment. Overall control rate of hypertension in subjects with CKD was 16.3% with the lowest rate at stage 1 (12.3%) and highest rate at stage 4 (40%). The control rate increased to 28.8% for CKD patients under treatment for hypertension. Conclusion: As a conclusion, hypertension is highly prevalent in subjects with CKD in Turkey with suboptimal awareness, treatment, and control rates. Appropriate health strategies should be implicated to improve prevention, early diagnosis, and treatment of hypertension, which is one of the leading causes of CKD.

Effects of N-acetylcysteine on radiocontrast nephropathy in rats

Objective. N-acetylcysteine (NAC) has yielded some promising results recently in the prevention of radiocontrast nephropathy (RCN). In this study, the structural and functional effects of NAC on RCN were analyzed. Material and methods. Twenty-eight Wistar rats were randomized into four groups, as follows: Group 1, controls; Group 2, contrast; Group 3, contrast + NAC; and Group 4, NAC. All rats were deprived of water for 24 h and then contrast medium (ioxoglate; 10 ml/kg) was administered to Groups 2 and 3. NAC (50 mg/kg) was introduced enterally to Groups 3 and 4 at a dose of 50 mg/kg in 0.5 ml of distilled water, in four sequential doses 12 h apart, starting after 12 h of water deprivation. After 4 days, rats were sacrificed. Creatinine clearance was calculated. The malondialdehyde (MDA) level was quantified in tissue samples. Slides stained with hematoxylin–eosin and periodic acid–Schiff were examined by means of light microscopy. Each tubular cross-section from all images was scored as either mild (preserved brush border, no necrosis), moderate (loss of brush border, no necrosis) or severe (loss of brush border accompanied by necrosis) and the frequencies of these lesion severities were compared. Results. Mean baseline serum creatinine levels and creatinine clearances were similar in all groups. Mean serum creatinine level increased significantly only in Group 2 (0.6±0.1 vs 0.7±0.2 mg/dl; p<0.05). Tissue MDA levels were similar in all groups. Moderate (13.8%±1.5% vs 42%±1.4%; p<0.05) and severe (0% vs 40%±2.1%; p<0.05) lesions were significantly more frequent in Group 2 compared to Group 1. The frequency of severe lesions in Group 3 was found to be halved compared to that in Group 1 (40%±2.1% vs 20.2%±0.86%; p<0.05). Conclusion. NAC protects the kidneys following exposure to contrast medium as it decreased the severity of tubular lesions in rats.