Z. Arat

Renal transplantation offers a better survival in HCV-infected ESRD patients

Abstract:  The presence of hepatitis C virus (HCV) infection has been found to adversely affect the morbidity and mortality rates in the dialysis population. Renal transplantation is a treatment option after a careful pre‐transplant evaluation. We designed this study to find the impact of HCV infection on patient survival, co‐morbidity and allograft survival in a selected group of hemodialysis (HD) and transplant population. We retrospectively analyzed 116 renal transplant patients (94 HCV‐negative, 22 HCV‐positive) and 136 HD patients (106 HCV‐negative, 30 HCV‐positive) who had renal transplantation or underwent dialysis before 1996. The HCV‐infected patients were evaluated by liver biopsy for the absence of advanced liver disease before transplantation. There was no clinical or laboratory decompensation of liver disease in transplant and dialysis patient groups. The overall 5‐yr survival rates were 85.2% for renal transplant recipients and 74.5% for those on HD. The comparison results revealed a significant difference between HCV‐infected patients with and without transplantation. The 3‐yr renal allograft survival rates were comparable in HCV‐positive and ‐negative patients, but the risk of chronic allograft nephropathy (CAN) and graft failure were higher at the fifth year in HCV‐positive patients. In conclusion, renal transplantation should the preferred therapy in HCV‐infected dialysis patients as it improves the survival rates. The presence of HCV infection increases the CAN rate and the influence on allograft survival is evident at the fifth year of assessment.

THE ASSOCIATION OF INTERDIALYTIC WEIGHT GAIN WITH NUTRITIONAL PARAMETERS AND MORTALITY RISK IN HEMODIALYSIS PATIENTS

High interdialytic weight gain (IDWG) is considered as an indicator of noncompliance but could also be interpreted as an index of appetite. This study was designed to investigate the relationship IDWG with malnutrition and mortality risk in hemodialysis (HD) patients through a follow-up of 24 months. We divided HD patients into two groups according to their IDWG as Group I (IDWG<3% of dry weight/day) (27 patients; age 46.8 ± 21.1 years; HD duration: 28.3 ± 39.5 months) and Group II (IDWG ≥ 3% of dry weight/day) (41 patients; age 40.9 ± 11.3 years; HD duration: 54.7 ± 38.7 months). We investigated malnutrition through biochemical analysis (albumin, prealbumin, total cholesterol, creatinine, predialysis potassium and phosphorus levels), normalized protein catabolic rate (nPCR), anthropometric measurements. On initial assessment, group I had significantly lower predialysis creatinine, prealbumin and potassium levels than Group II (p<0.0001, p<0.01 and p<0.001, respectively). At the 24th month, there were significantly lower creatinine, prealbumin, potassium and phosphorus levels in the low-IDWG group. Group I had significantly lower nPCR, body weight, body mass index and triceps skinfold thickness during the follow-up. Over the 24 months, 13 (48.1%) Group I patients and nine (21.9%) Group II patients exhibited loss of dry weight (p<0.02). According to the survival curves prognosis was significantly poorer for Group I than Group II (2-year survival 74.0% and 92.6%, p<0.03). Group I individuals with low albumin levels had the worst survival rate (57.1%). In conclusion there is a strong association of IDWG with nutritional parameters in HD patients. Our study draws attention for a possible risk of developing malnutrition in a HD patient with low IDWG.

Diagnostic pitfalls in the evaluation of fine needle aspiration cytology of the thyroid: correlation with histopathology in 260 cases

Objectives:  Fine needle aspiration cytology (FNAC) of the thyroid is a non‐invasive, cost‐effective screening procedure that is valuable for distinguishing neoplastic lesions from non‐neoplastic nodules. The aim of this study was to determine the diagnostic accuracy of FNACs performed at our institution by correlating FNAC results with histopathological diagnoses.

Predictors for quality of life in continuous ambulatory peritoneal dialysis patients

Aim:  Peritoneal dialysis patients have diminished quality of life scores compared with healthy subjects. Measures of quality of life have been reported to have a significant predictive value for patient survival and hospitalization in peritoneal dialysis patients. The purpose of this study is to determine the clinical, biochemical and psychological predictors for the quality of life in continuous ambulatory peritoneal dialysis (CAPD) patients.

Triad of Malnutrition, Inflammation, and Atherosclerosis in Hemodialysis Patients

Background/Aim: As chronic inflammation underlies both atherosclerosis and malnutrition, a possible link between these factors has been suggested in hemodialysis (HD) patients. We designed this study to compare nutritional indices and inflammatory parameters of HD patients with demonstrated atherosclerosis (group I) and HD patients without (group II). Methods: We included 59 and 57 patients in groups I and II, respectively. The patient groups were matched for the risk factors for atherosclerosis such as age, gender, smoking habits, hypertension, and HD duration. The nutritional status of the patients was evaluated according to laboratory parameters, normalized protein catabolic rate, anthropometric measurements, and subjective global assessment. Results: Laboratory parameters (albumin, prealbumin, total cholesterol, phosphorus, creatinine), normalized protein catabolic rate, and triceps skinfold thickness revealed a significant decline in the nutritional status of the patients with atherosclerosis. We found that the patients with atherosclerosis had significantly higher C-reactive protein, ferritin, and fibrinogen levels when we compared the patient groups for acute-phase reactants. When we assessed malnutrition as being in category B/C (B = mild to moderately malnourished, C = severely malnourished) according to subjective global assessment and inflammation on the basis of a C-reactive protein level ≧10 mg/l, among patients with atherosclerosis, there was a significantly higher proportion of them having malnutrition and inflammation. Additionally, the proportion of patients without any evidence of malnutrition and inflammation was significantly lower in group I than in group II. Conclusion: Our study gives evidence for the possible triad of malnutrition, inflammation, and atherosclerosis in HD patients.

Percutaneous Sonographic Guidance for TIPS in Budd-Chiari Syndrome : Direct Simultaneous Puncture of the Portal Vein and Inferior Vena Cava

OBJECTIVE Budd-Chiari syndrome (BCS) is a clinical condition characterized by hepatic venous outflow obstruction. A transjugular intrahepatic portosystemic shunt (TIPS) is an effective means of decompressing the portal system in patients unresponsive to traditional medical therapy. TIPS may be difficult in patients with BCS owing to the presence of hepatic venous occlusive disease. We present our experience using direct percutaneous simultaneous puncture of the portal vein and the inferior vena cava to place a TIPS in patients with BCS. MATERIALS AND METHODS Between September 2003 and October 2006, percutaneous sonographically guided TIPS was performed on 11 patients (five women and a girl, four men and a boy; age range, 6-43 years). Indications for the TIPS procedure were intractable ascites in nine patients and intractable ascites and variceal bleeding in two patients. RESULTS Technical success was achieved in all patients. The mean portosystemic pressure gradient was reduced from 23.5 to 9.8 mm Hg. The cumulative rate of primary patency was 60% at 1 year. Nine revisions were performed in five patients. In nine of the 11 patients, ascites resolved completely, and in two patients, it was relieved. CONCLUSION Excellent technical and clinical success can be achieved with percutaneous sonographically guided direct simultaneous puncture of the portal vein and inferior vena cava in patients with BCS.

Post-transplant C-reactive protein monitoring can predict chronic allograft nephropathy

Abstract:  Chronic allograft nephropathy (CAN) is a major problem after renal transplantation and chronic inflammation can be one of its promoters. C‐reactive protein (CRP) is an important marker of inflammation and atherosclerosis. We retrospectively analyzed the predictive role of serum CRP levels on the development of CAN and graft failure. One hundred and twenty‐five renal transplant patients were randomly included into the study. Serum CRP levels were measured at pre‐transplant period, first month after transplantation and at yearly intervals throughout follow‐up. CAN was diagnosed in 40.8% of patients and 82.4% of them had graft failure in 60.9 ± 36.7 months. There was no difference at pre‐transplant CRP levels of patients with and without CAN, but the first month CRP levels were higher in those who experienced CAN. The initial 3‐yr mean CRP levels were higher, but not statistically different between the patients with and without CAN. The simultaneously detected CRP levels when CAN were diagnosed was significantly higher in those with CAN. High post‐transplant CRP levels at the first month and at the diagnosis of CAN significantly influenced the allograft failure according to the regression analysis. CRP monitoring gives important information about the risk for CAN and graft failure. Therefore, CRP levels should be included in the follow‐up data after renal transplantation.

Early Assessment of Renal Resistance Index and Long-Term Renal Function in Renal Transplant Recipients

Background. The effect of the intrarenal arterial resistance index (RI) on long-term renal functions is not well known. We examined the predictive value of intrarenal RI on long-term allograft outcomes. Methods. We retrospectively investigated 121 stable renal transplant recipients, followed for a mean of 63.21 ± 19.9 months after renal transplant. Patients with complications during the first six months after transplant were not included. Color Doppler ultrasonography was done to calculate the intrarenal RI within the first four weeks after transplant. Results. Older recipient age, high pulse pressure, active smoking, and proteinuria were associated with a higher intrarenal RI. Multivariate analyses revealed that renal RI and donor age were independent predictors of allograft outcome. Kaplan-Meier estimates of cumulative graft survival were significantly worse in patients who had an RI of 0.7 or more than they were in patients who had an RI of less than 0.7 (p = .005). Development of chronic allograft nephropathy (CAN) was significantly higher in patients who had an RI of 0.7 or more (p = .02). Conclusions. Renal RI determined within the first month after renal transplant predicts long-term allograft function and development of CAN in renal transplant recipients.

A Six-Year Follow-Up After Interferon-Alpha Monotherapy for Chronic Hepatitis C Infection in Hemodialysis Patients

Interferon‐alpha (IFN) has been accepted as an effective treatment for chronic hepatitis C virus (HCV) infection in hemodialysis (HD) patients. We prospectively assess the long‐term clinical, biochemical, and virological effects of interferon in the treatment of HD patients with chronic HCV infection. This study was performed in 20 HCV‐RNA‐positive HD patients with evidence of chronic hepatitis on liver biopsy. The patients received IFN administered after HD sessions in doses ranging from 3 to 6 million units for 6 to 12 months. The patients were followed up for a period of 6 years with determinations of serial alanine aminotransferase (ALT) levels and serum HCV‐RNA. At the time of the final follow‐up, the patients had no cirrhosis or hepatocellular carcinoma. Among the nonresponder group, only 1 patient died due to sudden cardiac death. Sustained normal serum ALT levels occurred in 9 (45%) of the patients. Nine patients had variable ALT levels, and 2 patients had persistently elevated ALT levels. Eight (40%) patients were continuously HCV‐RNA negative, whereas 12 patients (60%) had variable HCV‐RNA results at the end of the 6‐year follow‐up. These findings show that the long‐term clinical, biochemical, and virological response to interferon monotherapy is good in HD patients with HCV infection.

Malnutrition inflammation score is associated with coronary artery disease in hepatitis C virus-infected hemodialysis patients

Objective:Hepatitis C virus (HCV) infection exerts diverse effects on atherogenesis. We investigated whether malnutrition inflammation score (MIS) is associated with the presence of coronary artery disease (CAD) in anti-HCV-positive hemodialysis (HD) patients.Subjects/Methods:Twenty-two anti-HCV-positive HD patients with CAD and 61 anti-HCV-positive HD patients without CAD (as controls) were included. Data were obtained from hospital records, patients were evaluated for risk factors for CAD. The same physician performed MIS evaluation.Results:MIS of anti-HCV-positive HD patients with CAD were significantly higher than patients without CAD (8.8±4.0 vs 6.5±2.6, P=0.02). In patients with CAD, basal (P=0.002) and peak C-reactive protein (P=0.03) and serum ferritin (P=0.01) concentrations were higher, serum albumin concentrations (P=0.003) were lower than those patients without CAD. MIS was positively correlated with age (r=+0.359, P=0.001) and viral load (r=+0.629, P<0.0001). In univariate logistic regression analysis, advanced age (odds ratios (OR)=1.093, confidence interval (CI): 1.039–1.150, P=0.001), hypertension (OR=3.143, CI: 1.084–9.116, P=0.035), diabetes mellitus (OR=5.344, CI: 1.343–21.269, P=0.017), low triglyceride (OR=0.992, CI: 0.984–0.999, P=0.026) and high MIS (OR=1.259, CI: 1.066–1.488, P=0.007) were associated with the presence of CAD. Multivariate logistic regression analysis identified age (OR=1.090, CI: 1.007–1.179, P=0.033) and MIS as the factors associated with the presence of CAD (OR=1.232, CI: 1.004–1.511, P=0.04).Conclusions:MIS may be associated with CAD in anti-HCV-positive HD patients.