Nutritional state alters the association between free triiodothyronine levels and mortality in hemodialysis patients

BACKGROUND

Serum free triiodothyronine (fT3) level is suggested to be a risk factor for mortality in unselected dialysis patients. We investigated the prognostic value of serum fT3 levels and also low-T3 syndrome on overall survival in a large cohort of hemodialysis (HD) patients with normal thyroid-stimulating hormone levels.

METHODS

A total of 669 prevalent HD patients were enrolled in the study. Serum fT3 level was measured by enzyme immune assay in frozen sera samples at the time of enrollment. Overall mortality was assessed during 48 months of follow-up.

RESULTS

Baseline fT3 was 1.47 ± 0.43 (0.01-2.98) pg/ml, and low-T3 syndrome was present in 71.7% of the cases. During a mean follow-up of 34 ± 16 months, 165 (24.7%) patients died. fT3 level was a strong predictor for mortality in crude and adjusted Cox models including albumin or high-sensitivity C-reactive protein (hs-CRP). Further adjustment for both albumin and hs-CRP made the impact of fT3 on mortality disappear. The presence of low-T3 syndrome was associated with mortality in only the unadjusted model.

CONCLUSIONS

Low-T3 syndrome is a frequent finding among HD patients, but it does not predict outcome. However, serum fT3 level is a strong and inverse mortality predictor, in part explained by its underlying association with nutritional state and inflammation.

Risk factors and consequences of post-transplant diabetes mellitus

BACKGROUND

The aim of this study is to investigate the clinical course as well as risk factors and prognosis of post-transplant diabetes mellitus (PTDM).

METHODS

Five hundred fifty-five kidney transplant recipients were retrospectively evaluated. PTDM was defined as fasting blood glucose ≥140 mg/dL on at least two consecutive measurements or requirement of oral antidiabetic drug or insulin. Patients with PTDM were divided into subgroups according to time of onset (early; <90 d vs. late, ≥90 d) and duration of diabetes (transient, <90 d vs. sustained ≥90 d).

RESULTS

The frequency of PTDM was 18.3%. In multivariate analysis age (p < 0.001), hepatitis C virus (HCV) infection (p < 0.05) and tacrolimus use (p < 0.001) were independent risk factors. Among 220 HCV+ patients, liver biopsy was performed in 158, the histological grade (3.3 ± 2.8 vs. 4.4 ± 3.1) and stage (0.9 ± 1.1 vs. 1.4 ± 1.2) were significantly more severe in patients with PTDM than in non-diabetics. Incidence of PTDM in patients with severe fibrosis was 46.7%; 19.2% in nil or mild fibrosis (p < 0.05). Patient and graft survival were significantly worse, and cardiovascular events and life-threatening infection episodes were more frequent in PTDM. Half of the patients had early PTDM, while 30.3% of patients with PTDM showed transient nature. Five- and 10-yr death censored graft survival rates were worse in transient subgroup compared with sustained patients with diabetes (log rank 0.025) whereas there was no difference in outcome between early and late subgroups.

CONCLUSIONS

Age, tacrolimus, and HCV are independent risk factors for PTDM. PTDM has a negative impact on both patient and graft survival, irrespective of the time of onset and duration of diabetes.

Bioimpedance spectroscopy for the detection of hypervolemia in peritoneal dialysis patients

A practical, inexpensive, and reliable method is needed for the assessment of volume status in peritoneal dialysis (PD) patients. In the present study, we investigated the efficiency of bioimpedance spectroscopy (BIS) for detection of hypervolemia. The study enrolled 79 prevalent PD patients (mean age: 47 +/- 14 years; PD duration: 30 +/- 17 months; 55% men; 19% with diabetes) from a single center. Echocardiography and body composition analysis using the BIS technique [50 frequencies (Body Composition Monitor: Fresenius Medical Care, Bad Homburg, Germany)] were performed. Overhydration (OH) and extracellular water (ECW) in liters and OH/ECW ratio were used as volume indices. The mean left ventricular (LV) mass index was 117 +/- 37 g/m2, and 46% of patients had LV hypertrophy (LVH). Mean OH and OH/ECW ratio were 1.3 +/- 1.7 L and 7.6% +/- 9.3% respectively The OH/ ECW ratio correlated with LV mass index (r = 0.237, p < 0.036) and with left atrium index (r = 0.354, p < 0.001). Compared with patients not having LVH, patients with LVH had higher OH values (1.79 +/- 1.82 L vs 0.93 +/- 1.62 L, p = 0.003). In linear regression analysis, the OH/ECW ratio was an independent risk factor for LVH (t = 2.558, p = 0.01). In PD patients, BIS is a reliable method for evaluating volume status. The OH/ECW measured by BIS is a major determinant of LV mass. Control of hypervolemia and blood pressure is associated with better cardiac condition.

The link between bone and coronary calcifications in CKD-5 patients on haemodialysis

BACKGROUND

Vascular calcifications are frequent in Stage 5 chronic kidney disease (CKD-5) patients receiving haemodialysis. The current study was designed to evaluate the associations between bone turnover/volume and coronary artery calcifications (CAC).

METHODS

In 207 CKD-5 patients, bone biopsies, multislice computed tomography of the coronary arteries and blood drawings for relevant biochemical parameters were done. The large number of CKD-5 patients enrolled allowed separate evaluation of patients with CAC versus patients without CAC and adjustment for traditional and non-traditional risk factors for CAC.

RESULTS

When all patients were analysed, associations were found between CAC and bone turnover, bone volume, age, gender and dialysis vintage. When only patients with CAC were included, there was a U-shaped relationship between CAC and bone turnover, whilst the association with bone volume was lost. In these patients, the relationship of CAC with age, gender and dialysis vintage remained.

CONCLUSIONS

Beyond the non-modifiable risk factors of age, gender and dialysis vintage, these data show that bone abnormalities of renal osteodystrophy amenable to treatment should be considered in the management of patients with CAC.

Endogenous testosterone and mortality in male hemodialysis patients: is it the result of aging?

BACKGROUND AND OBJECTIVES

Low serum testosterone levels in hemodialysis (HD) patients have recently been associated with cardiovascular risk factors and increased mortality. To confirm this observation, we investigated the predictive role of serum total testosterone levels on mortality in a large group of male HD patients from Turkey.

DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS

A total of 420 prevalent male HD patients were sampled in March 2005 and followed up for all-cause mortality. Serum total testosterone levels were measured by ELISA at baseline and studied in relation to mortality and cardiovascular risk profile.

RESULTS

Mean testosterone level was 8.69 ± 4.10 (0.17 to 27.40) nmol/L. A large proportion of patients (66%) had testosterone deficiency (<10 nmol/L). In univariate analysis, serum testosterone levels were positively correlated with creatinine and inversely correlated with age, body mass index, and lipid parameters. During an average follow-up of 32 months, 104 (24.8%) patients died. The overall survival rate was significantly lower in patients within the low testosterone tertile (<6.8 nmol/L) compared with those within the high tertile (>10.1 nmol/L; 64 versus 81%; P = 0.004). A 1-nmol/L increase in serum testosterone level was associated with a 7% decrease in overall mortality (hazard ratio 0.93; 95% confidence interval 0.89 to 0.98; P = 0.01); however, this association was dependent on age and other risk factors in adjusted Cox regression analyses.

CONCLUSIONS

Testosterone deficiency is common in male HD patients. Although testosterone levels, per se, predicted mortality in this population, this association was largely dependent on age.

Left atrial volume predicts mortality in low-risk dialysis population on long-term low-salt diet

BACKGROUND

Echocardiography provides insight to the management of end-stage renal disease (ESRD) and might be valuable in assessing the prognosis. We evaluated the predictive value of echocardiography along with clinical findings in a low-risk hemodialysis (HD) population who had been treated with strict salt restriction strategy for blood pressure control.

METHODS

Study population consisted of a cohort of 555 ESRD patients from 8 HD centers where the same strict volume control strategy applied for blood pressure control. Clinical findings and echocardiography were examined as predictors of mortality for a mean follow-up period of 3 years (29.6 +/- 11.6 months).

RESULTS

During the follow-up, 89 patients (16%) died. Left atrium (LA) volume index was the only independent echocardiographic predictor of mortality (hazard ratio 1.025, 95% CI 1.001-1.050, P = .042). The other predictors of mortality were age, pulse pressure, diabetes mellitus, and high-sensitivity C-reactive protein. However, when we added interdialytic weight gain (IDWG) ratio to the Cox model, it also appeared as an independent predictor of mortality, whereas LA volume index no longer was.

CONCLUSIONS

Increased LA volume index emerged as the only independent echocardiographic determinant of mortality in low-risk dialysis patients treated by strict volume control. Close relationship with IDWG ratio indicates the intermittent stretching of atrium between dialysis sessions leading to atrial remodeling. This index is not the result of a single factor such as age, hypervolemia, or left ventricular hypertrophy but reflects the combination of these contributing causes. Therefore, it might be considered as an overall echocardiographic sign of mortality in ESRD.

The influence of dialysate calcium on progression of arterial stiffness in peritoneal dialysis patients

BACKGROUND

One of the origins of cardiovascular disease in dialysis patients is arterial stiffness. The aim of our study was to assess the relationship between the calcium content of peritoneal dialysis (PD) solution and arterial stiffness.

PATIENTS AND METHODS

We enrolled into the study 49 PD patients who had been treated with the same PD solution for the preceding 6 months. The calcium content of the PD solution was 1.25 mmol/L in 34 patients (low-Ca group) and 1.75 mmol/L in 15 patients (high-Ca group). Study patients were followed for 6 months on the same PD prescription. Arterial stiffness was assessed by measurement of augmentation index (AI) and brachial pulse wave velocity (PWV) at baseline and at month 6 (SphygmoCor: Atcor Medical, West Ryde, NSW, Australia). Demographic data were recorded from patient charts.

RESULTS

Mean age of the whole group was 51 +/- 11 years, prevalence of diabetes was 14%, duration of PD was 43 +/- 30 months, percentage of women was 45%, and percentage of patients using a cycler was 33%. We observed no differences between groups with regard to those variables or creatinine clearance, residual renal function, Ca, phosphorus, parathormone, C-reactive protein, lipid parameters, and use of phosphate binder with or without Ca content. Mean arterial pressure was higher in the high-Ca group, but the difference was not statistically significant (100 +/- 22 mmHg vs 88 +/- 18 mmHg, p = 0.06). At baseline, AI was significantly higher in the high-Ca group than in the low-Ca group (27% +/- 10% vs 21% +/- 9%, p < 0.05). Measurements of PWV were not different between the groups (8.4 +/- 1.1 m/s vs 8.5 +/- 1.7 m/s). Measurement of arterial stiffness parameters at month 6 revealed that PWV had increased in the high-Ca group (to 9.6 +/- 2.3 m/s from 8.4 +/- 1.1 m/s, p < 0.05), but had not changed in the low-Ca group (to 8.2 +/- 1.9 m/s from 8.5 +/- 1.7 m/s). The AI did not change in either group.

CONCLUSIONS

These data suggest that Ca exposure through PD solution plays a role in the progression of arterial stiffness, which may be related to increased vascular calcification.

The Influence of Dialysate Calcium on Progression of Arterial Stiffness in Peritoneal Dialysis Patients

Background

One of the origins of cardiovascular disease in dialysis patients is arterial stiffness. The aim of our study was to assess the relationship between the calcium content of peritoneal dialysis (PD) solution and arterial stiffness.

Patients and Methods

We enrolled into the study 49 PD patients who had been treated with the same PD solution for the preceding 6 months. The calcium content of the PD solution was 1.25 mmol/L in 34 patients (low-Ca group) and 1.75 mmol/L in 15 patients (high-Ca group). Study patients were followed for 6 months on the same PD prescription. Arterial stiffness was assessed by measurement of augmentation index (AI) and brachial pulse wave velocity (PWV) at baseline and at month 6 (SphygmoCor: Atcor Medical, West Ryde, NSW, Australia). Demographic data were recorded from patient charts.

Results

Mean age of the whole group was 51 ± 11 years, prevalence of diabetes was 14%, duration of PD was 43 ± 30 months, percentage of women was 45%, and percentage of patients using a cycler was 33%. We observed no differences between groups with regard to those variables or creatinine clearance, residual renal function, Ca, phosphorus, parathormone, C-reactive protein, lipid parameters, and use of phosphate binder with or without Ca content. Mean arterial pressure was higher in the high-Ca group, but the difference was not statistically significant (100 ± 22 mmHg vs 88 ± 18 mmHg, p = 0.06). At baseline, AI was significantly higher in the high-Ca group than in the low-Ca group (27% ± 10% vs 21% ± 9%, p < 0.05). Measurements of PWV were not different between the groups (8.4 ± 1.1 m/s vs 8.5 ± 1.7 m/s). Measurement of arterial stiffness parameters at month 6 revealed that PWV had increased in the high-Ca group (to 9.6 ± 2.3 m/s from 8.4 ± 1.1 m/s, p < 0.05), but had not changed in the low-Ca group (to 8.2 ± 1.9 m/s from 8.5 ± 1.7 m/s). The AI did not change in either group.

Conclusions

These data suggest that Ca exposure through PD solution plays a role in the progression of arterial stiffness, which may be related to increased vascular calcification.

Interdialytic blood pressure obtained by ambulatory blood pressure measurement and left ventricular structure in hypertensive hemodialysis patients

Unlike in subjects with normal renal function, the relationship between hypertension and cardiovascular morbidity and mortality in dialysis patients is still being debated. In order to clarify this issue, we performed 44-hour ambulatory blood pressure measurements (ABPM) during the interdialytic period in a group of 164 hypertensive patients, the blood pressure (BP) control based on conventional antihypertensive strategy previously, on chronic hemodialysis treatment in the Mediterranean region of Turkey. These results were then compared with their echocardiographic data. This is a cross-sectional analysis. The mean ABPM during 44 hours was close to the manually measured predialysis value, but there was a gradual increase in the ABPM values in the interdialytic period. When divided into a group with mild or no left ventricular hypertrophy (LVH) (45 patients) and severe LVH (119 patients), the latter had significantly higher BP levels in all separate periods, while the difference in predialysis BP was not significant. Patients with severe LVH had larger left atrium and left ventricular diameters, and consumed more antihypertensive drugs. Systolic BP during the night before dialysis showed the strongest relation to LVH, but interdialytic weight gain was also independently related to LVH. Yet, 56% of the patients with systolic BP <135 had severe LVH. There is not only an association between BP and presence of LVH, but it is shown that volume expansion is also an important independent determinant of LVH. This may explain the difficulty in identifying hypertension as a cardiac risk factor in these patients.

Carbamylated low-density lipoprotein induces proliferation and increases adhesion molecule expression of human coronary artery smooth muscle cells

AIM

Presence of accelerated atherosclerosis in dialysis patients cannot be entirely explained by conventional risk factors. Exposure to urea, which is elevated in patients with kidney disease, leads to the carbamylation of proteins. We investigated the effects of carbamylated low-density lipoprotein (cLDL) on human coronary artery vascular smooth muscle cells (VSMC).

METHODS

Native LDL (nLDL) was carbamylated with potassium cyanate. Cells were incubated with different concentrations of cLDL carbamylated at different time points. Cytotoxicity, apoptosis, proliferation (bromodeoxyuridine incorporation), expression of adhesion molecules and extracellular matrix protein synthesis were studied.

RESULTS

Carbamylated low-density lipoprotein exposure leads to morphological alterations and presence of cellular debris. Neither nLDL nor cLDL caused apoptosis. Lactate dehydrogenase (LDH) release was not different between groups. Carbamylated low-density lipoprotein led to a striking proliferation in VSMC compared to nLDL. Carbamylated low-density lipoprotein significantly increased intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 expression compared to the control. The effects of cLDL on proliferation and adhesion molecule expression were dose-dependent and correlated with the degree of low-density lipoprotein carbamylation. cLDL had no effect on extracellular matrix protein synthesis.

CONCLUSION

The results support the hypothesis that cLDL may contribute to the pathogenesis of atherosclerosis in uraemic patients.

Efficacy and safety of enteric-coated mycophenolate sodium in de novo and maintenance renal transplant patients

Enteric-coated mycophenolate sodium (ECMPS) has been developed as an alternative agent to mycophenolate mofetil (MMF), with the aim to provide reduction in gastrointestinal side effects. This open-label, single-arm, two-center prospective study sought to investigate the efficacy and safety of ECMPS used in combination with steroid and cyclosporine (CyA) in de novo and maintenance renal transplant patients with 12 months' follow-up. Twenty-one patients were recruited (mean age, 39 +/- 8 years) into the de novo group. Of these patients, 66% were male and 76.2% underwent living related kidney donation. The induction immunosuppression was ATG in 10 and basiliximab in 6 patients. At 12 months' posttransplantation, there was no graft or patient loss and two (10%) acute rejection episodes. None of the patients in this group discontinued the study medication due to drug-induced adverse events. One patient was excluded from the study because of recurrent oxalosis. Serum creatinine (SCr) levels at 3, 6, and 12 months after renal transplant were 1.30 +/- 0.3, 1.40 +/- 0.3, and 1.40 +/- 0.3 mg/dL, respectively. The maintenance group included 20 patients. Time posttransplantation (mean +/- SD) was 27 +/- 25 months. All patients in this group had been on maintenance azathioprine or MMF in combination with steroid and CyA. These patients were switched to ECMPS. They mean age was 36 +/- 8 years. Sixty-six percent of the patients were male and 57% received living donor kidneys. Acute rejection was nil, whereas two patients lost their grafts owing to chronic rejection in this group. Three patients were excluded from the study, one to discontinuation of the drug because of intractable diarrhea, the second to loss to follow-up, and the last case due to withdrawal of informed consent. Leukopenia was not observed in this group. The SCr levels prior to and at 3, 6, and 12 months after conversion to ECMPS were 1.80 +/- 1.0, 1.95 +/- 1.5, 1.50 +/- 0.8, and 1.60 +/- 0.8 mg/dL, respectively. This is the first phase IV study with ECMPS in the Turkish population. Renal function was preserved in both groups. Only 2.5% of patients were excluded because of side effects. Use of ECMPS in combination with prednisolone and CyA is an effective and safe therapeutic choice for both de novo and maintenance renal transplant patients.

Management of small bowel volvulus in a patient with simultaneous pancreas-kidney transplantation (SPKT): a case report

There are several surgical complications which can occur following simultaneous pancreas-kidney transplantation (SPKT). Although intestinal obstruction is known to be a common complication after any type of abdominal surgery, the occurrence of small bowel volvulus, which is one of the rare causes of intestinal obstruction, following SPKT has not been published before. A 24-year-old woman suffering from type I diabetes mellitus with complications of nephropathy resulting in end stage renal disease (ESRD), neuropathy and retinopathy underwent SPKT. On the postoperative month 5, she was brought to the emergency service due to abdominal distention with mild abdominal pain. After laboratory research and diagnostic radiological tests had been carried out, she underwent exploratory laparotomy to determine the pathology for acute abdominal symptoms. Intra-operative observation revealed the presence of an almost totally ischemic small bowel which had occurred due to clockwise rotation of the mesentery. Initially, simple derotation was performed to avoid intestinal resection because of her risky condition, particularly for short bowel syndrome, and subsequent intestinal response was favorable. Thus, surgical treatment was successfully employed to solve the problem without any resection procedure. The patient's postoperative follow-up was uneventful and she was discharged from hospital on postoperative day 7. According to our clinical viewpoint, this study emphasizes that if there is even just a suspicion of acute abdominal problem in a patient with SPKT, surgical intervention should be promptly performed to avoid any irreversible result and to achieve a positive outcome.

Long-term survival rates in haemodialysis patients treated with strict volume control

METHODS

We analysed the survival of 218 patients (132 male, 86 female, age 48 +/- 15 years) who were treated in our dialysis units since we adopted the strategy of strict volume control without antihypertensive drugs. The mean observation period was 47 +/- 34 (6-140) months. Follow-up was ended because of death (57 patients), transfer to another center (35 patients), continous ambulatory peritoneal dialysis (CAPD) (15 patients) or transplantation (23 patients), while 88 were still under our treatment at the time of writing.

RESULTS

Blood pressure (BP) decreased from a mean of 150 +/- 31/89 +/- 16 at the start to 121 +/- 14/75 +/- 8 mmHg at the end of observation (P < 0.001). Only nine patients needed a drug (enalapril) to reach this goal. Cardiothoracic index (CTI) dropped from 0.50 +/- 0.06 to 0.46 +/- 0.05 (P < 0.001). Interdialytic weight gain decreased from 1440 +/- 360 to 930 +/- 240 g/day (P < 0.001). Mortality rate was 68, 2 per 1000 patient-years, better than in most published series. There was a striking influence of age, but also of CTI and systolic BP on survival rate. Patients with CTI > or = 0.48 showed mortality 3.8 times higher than CTI < 0.48 (log rank P < 0.001). Consequently, the mean CTI of the deceased patients was much higher (0.50) than the average of the group (0.46) while their mean BP (123 +/- 16/75 +/- 9 mmHg) was not significantly different from the other patients. We found no increased mortality at low-normal pressure levels (systolic BP between 100 and 130 mmHg), but mortality was increased in small groups of patients whose pressures were lower or higher than these values. Thus, the curve, relating mortality to blood pressure was shifted markedly to the left.

CONCLUSIONS

These results strongly suggest that the strategy of 'volume control', also when applied with conventional dialysis times, normalizes BP and increases survival of dialysis patients. Cardiomegaly, as evidenced on the chest X-ray despite normal BP, had a strong negative influence on survival. The large majority of the patients had low-normal BP after long periods of treatment and showed the lowest mortality, favouring the view that target BP should be lower than advised by most authors.

High-dose immunoglobulin therapy in renal transplant recipients with hemophagocytic histiocytic syndrome

BACKGROUND

Hemophagocytic histiocytic syndrome (HHS) generally occurs in immunocompromised patients and often has a rapidly fatal course. HHS may be cured by treatment of the underlying disorder, especially when it is triggered by an infection. If no cause has been found, no therapy is known and outcome is poor. The aim of this study was to investigate the clinical course and response to intravenous immunoglobulin treatment in renal transplant patients diagnosed with HHS.

METHODS

Thirteen patients who were diagnosed with HHS between 1995 and 2003 were retrospectively assessed. The mean age of HHS patients was 38.6 +/- 10 years (5 women, 8 men).

RESULTS

Median time to onset of symptoms after renal transplantation was 15.1 +/- 12.1 months (range 0.5-30 months). The first 2 patients in whom no etiologic factor was found were seen before 1998 and died due to multiorgan failure. HHS was related to an infectious etiology in 6 of 13 patients: tuberculosis (n=3), cytomegalovirus (CMV) infection (n=2), Escherichia coli (E. coli)-associated septicemia (n=1), but HHS was cured by antimicrobial therapy in only 2 of them (1 with tuberculosis, the other with E. coli-associated septicemia). After June 1998, high-dose immunoglobulin (IVIg) therapy was used in 6 patients. HHS was related to an infectious etiology in 2 patients unresponsive to antimicrobial treatment, and of unknown etiology in 4 patients. All of them completely recovered. Before 1998, 2 patients unresponsive to antimicrobial therapy (1 with tuberculosis, the other with CMV) died. They were not given IVIg.

CONCLUSIONS

We concluded that when HHS does not respond to treatment of the underlying infection, or is of unknown etiology in immunocompromised patients, high-dose IVIg therapy should be administered.

Volume control associated with better cardiac function in long-term peritoneal dialysis patients

BACKGROUND

This study was undertaken to investigate the effect of long-term blood pressure (BP) reduction, achieved with salt restriction and strict volume control, on frequency and regression of left ventricular hypertrophy (LVH) in long-term peritoneal dialysis (PD) patients.

METHODS

56 patients who had been treated for more than 2 years under our care were enrolled. After echocardiographic (Echo) evaluation, 46 patients were included in the follow-up study. In our unit, we aim to keep patients' BP below 130/85 mmHg and cardiothoracic index below 0.50. To reach these targets, moderate salt restriction is advised, and if necessary, hypertonic PD solutions are used. Echo was performed at the beginning of the study (after a mean period of 36 months on PD) and at the end of the prospective follow-up period (24 months later).

RESULTS

At the time of the first Echo, LVH was detected in only 8 (21%) patients. Residual urine volume was significantly decreased compared to data taken when they first started PD (658 +/- 795 vs 236 +/- 307 mL/day). Mean left ventricular mass index (LVMI) was 107 +/- 26.5 g/m2. LVMI was significantly decreased at the end of the follow-up in patients who had LVH at baseline. No LVH developed in patients who had normal LVMI at baseline.

CONCLUSION

Our results indicate that control of hypertension is possible when extracellular fluid volume is kept under control using hypertonic PD solutions in case of recruitment in addition to salt restriction in long-term PD patients. Sustained normovolemia is associated with low incidence and regression of LVH.

Skin diseases in Turkish renal transplant recipients

BACKGROUND

Organ transplant recipients are predisposed to a variety of cutaneous complications due to immunosuppressive therapy. We aimed to determine the prevalence and the clinical spectrum of skin diseases in renal transplant recipients (RTRs).

METHODS

One hundred and eleven RTRs were examined at the Renal Transplantation Center in Ege University Hospital between October 1999 and October 2001. The effects of age, gender and duration time after transplantation on cutaneous manifestations were evaluated and the dermatologic manifestations in RTRs were compared with findings in a control group consisting of 100 patients. The t-test, chi2 test and Fisher's exact test were used for statistical analysis.

RESULTS

Seventy-five patients (66.4%) had an infection of the skin, 66 patients (58.4%) had drug-related manifestations, and 11 patients (9.7%) had premalignant or malignant skin lesions. Human papilloma virus (HPV) infections were the most common skin lesions. There was no significant relation between age and gender and the incidence of skin diseases in RTRs. The incidence of HPV infections, tinea versicolor and premalignant and malignant lesions increased with the duration of immunosuppression. The incidence of infectious skin diseases, especially HPV infections and tinea versicolor, was higher in the study group than in the control group.

CONCLUSIONS

In this study, we observed that cutaneous lesions, especially those caused by infectious diseases, had a higher frequency in RTRs. The findings emphasize the importance of regular dermatological screening in these patients, which can provide early diagnosis and a better quality of life for RTRs.

Tuberculosis in renal transplant recipients on various immunosuppressive regimens

BACKGROUND

Mycophenolate mofetil (MMF) and tacrolimus (TAC) are more potent than conventional immunosuppressive drugs, i.e. azathioprine, cyclosporin and prednisolone, and may be associated with an increase in the incidence of infections in the post-transplantation (post-tx) period. The aim of this study was to determine if the use of either or both of MMF and TAC for immunosuppression in renal transplant recipients increases the prevalence or modifies the clinical presentation of tuberculosis (TB), when compared with conventional therapy.

METHODS

The medical records of 443 adult patients who received a kidney transplant between 1994 and 2002 were reviewed retrospectively. Comparisons were made between patients who had conventional immunosuppressive treatments (cyclosporin, azathioprine and prednisolone) or an alternative regimen (including MMF, TAC or both).

RESULTS

We found 20 patients (4.5%) to have post-tx TB. There were 13 cases of TB (age 38.9+/-10.6 years) among 328 patients who received conventional immunosuppressants (group I) (4.0%) and seven cases (age 24.2+/-7.4 years) among 115 (6.1%) who received an alternative immunosuppressive regimen (group II) (P>0.05). The patients in group II were younger than the patients in group I (P = 0.002). A significantly higher number of patients in group II developed TB within the first 6 months post-tx (P = 0.042). However, there was no significant difference between the two groups regarding clinical and radiographic presentations or outcomes.

CONCLUSIONS

Immunosuppression with TAC or MMF is associated with the development of TB earlier in the post-tx period and in younger patients.

Impact of volume control on left ventricular hypertrophy in dialysis patients

BACKGROUND

Left ventricular hypertrophy (LVH), which strongly predicts cardiac mortality, is seen in more than 60% of end-stage renal disease patients. The aim of this study was to prospectively investigate the effect of salt restriction and strict volume control on blood pressure and LVH.

METHOD

Nineteen hypertensive patients on chronic hemodialysis (HD) treatment (age 52 +/- 17 years, 7 women) were included in the study. Treatment consisted of 12-h HD per week, during which as much ultrafiltration (UF) was applied as possible without an excessive blood pressure (BP) drop. Special attention was given to dietary salt restriction. Predialysis mean BP (MBP), body weight (BW), cardio-thoracic index (CTI) and echocardiographic results were recorded at baseline and after 6 and 12 months.

RESULTS

All patients reached acceptable BP (< 140/90 mmHg) within three months (10-75 days) with our strict volume control strategy. Mean pre-dialysis BP was 127 +/- 17/78 +/- 9 mm Hg at baseline, 120 +/- 9/75 +/- 6 mm Hg at the 6th month and 118 +/- 11/73 +/- 5 mm Hgat the 12th month. The incidence of symptomatic hypotension gradually decreased from a mean of 22% to 11% and 7%, respectively during follow-up. Left ventricular mass index decreased from 164 +/- 64 to 112 +/- 36 g/m2. CTI, left atrial, left ventricular systolic and diastolic diameters significantly decreased in all patients. Inter-dialytic weight gain was 930 +/- 70 g/day in the follow-up period. Hematocrit did not significantly differ at the first, second and last visits.

CONCLUSION

Normal BP and improvement of cardiac structure, in particular a reduction of LVH could be reached in all our patients by intensifying salt restriction and UF.

The efficiency of fractionated parenteral iron treatment in CAPD patients

Some chronic renal failure patients respond poorly to recombinant human erythropoietin (rHuEPO). In continuous ambulatory peritoneal dialysis (CAPD) patients, such a poor response may indicate inadequate dialysis or low body iron stores. To correct iron deficiency, once-a-week intravenous iron supplementation is recommended. However, hemodialysis patients receive iron supplements three times a week. This study was designed to compare the efficacy of iron supplementation between once-weekly and twice-weekly regimens. In both groups, rHuEPO doses were similar. Seventeen CAPD patients were studied. All had hemoglobin levels less than 10 g/dL. Ten patients were given 100 mg intravenous iron once weekly, and 7 were given 50 mg intravenous iron twice weekly until a total iron dose of 600 mg was achieved (stage I). The patients were crossed over to receive another 600 mg iron (stage II). Hematocrit increased significantly in patients receiving twice-a-week iron supplementation (+3.8% and 6%) compared to those receiving once-a-week iron supplementation (+1.3% and 1.4%) during stages I and II. The ferritin levels were not different between the groups. In conclusion, rHuEPO is more effective when administered with intravenous iron.