A low serum free triiodothyronine level is associated with epicardial adipose tissue in peritoneal dialysis patients

AIM

Cardiovascular disease is a major cause of mortality in dialysis patients. Epicardial adipose tissue (EAT) has been proposed as a cardiovascular risk marker in this population. Subclinical hypothyroidism and low free triiodothyronine (fT3) levels are associated with EAT in patients without chronic renal failure. The aim of this study was to investigate the relationship between EAT and low free T3 levels in peritoneal dialysis (PD) patients.

METHODS

A total of 125 prevalent PD patients were enrolled in this cross-sectional study. The epicardial fat thickness (EFT) was measured by echocardiography, and the endothelial function was assessed by flow mediated dilatation (FMD). Thyroid function tests were performed by an enzyme immunoassay.

RESULTS

The mean age of the patients was 51 ± 13, and the time on PD was 36 months. The mean EFT was 6.7 ± 2.9 mm. The EFT correlated positively with the patient age, systolic blood pressure (BP), mean BP, high sensitivity C-reactive protein (hs-CRP) level and body mass index (BMI), and negatively with the fT3 level and FMD. The median fT3 value was 2.53, and patients were divided according to their serum fT3 values (within the normal range and below the reference level). Compared with patients in the low fT3 group, the subjects in the normal fT3 group had higher serum albumin levels and FMD, but a lower BMI, plasma fasting glucose level, EFT, TSH level, hs-CRP level, low density lipoprotein (LDL) cholesterol level and mean BP in office measurements, and both the diastolic BP and mean BP by ambulatory blood pressure measurement. A multivariate linear regression analysis showed that the EFT was predicted by the hs-CRP and fT3 levels.

CONCLUSION

Low free T3 levels are associated with the epicardial fat thickness in PD patients. Further studies are needed to evaluate the pathogenesis and to support these findings.

An ignored cause of inflammation in patients undergoing continuous ambulatory peritoneal dialysis: periodontal problems

AIM

We aimed to assess whether there is a significant relation between periodontal health status and inflammation in uremic patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and also to reveal the efficiency of periodontal treatment in patients with various degrees of periodontal problems.

PATIENTS AND METHODS

Overall, 68 patients undergoing CAPD were included in the study. Clinical indices and measurements were obtained at baseline and panoramic radiographies were used for the diagnosis. According to the baseline values, patients were stratified into four groups according to the severity of periodontal problems as follows: healthy/gingivitis, slight-to-moderate, and severe periodontitis. A control examination was performed 3 months after the periodontal treatment for only 43 patients. Clinical and laboratory parameters before and after treatment were compared.

RESULTS

The frequency of periodontal disease was found to be high in uremic patients on CAPD. The frequency and severity of periodontitis was also found to be significantly (p < 0.01) higher in patients with high sensitive C-reactive protein levels and longer duration of peritoneal dialysis (p < 0.01). In addition, the periodontitis rate was found to be higher in patients with cardiovascular disease (p < 0.05) and diabetes mellitus (p < 0.01).

CONCLUSION

A meticulous periodontal examination should be a routine part of management of the uremic patients on CAPD because periodontal disease could be one of the hidden sources of unexplained inflammatory status.

Mean platelet volume and its relation with arterial stiffness in patients with normotensive polycystic kidney disease

BACKGROUND

Autosomal-dominant polycystic kidney disease (ADPKD) demonstrates cardiovascular manifestations, such as hypertension, myocardial infarction, and increased carotid intimae-media thickness. These complications are the main cause of morbidity and mortality in patients with ADPKD. Platelet activation and arterial stiffness are important manifestations that independently predict cardiovascular events. In the present study, we aimed to investigate the relation between arterial stiffness, mean platelet volume (MPV), and highly sensitive C-reactive protein (hs-CRP) in patients with normotensive polycystic kidney disease.

METHODS

We included 30 normotensive subjects with ADPKD with an estimated glomerular filtration rate (eGFR) of 60 mL or more per minute per 1.73 m, 30 normotensive subjects with ADPKD with eGFR from 30 to 60 mL/min per 1.73 m, and 30 healthy controls in our study. Pulse wave velocity (PWV), eGFR, spot urine protein-creatinine ratio, MPV, and hs-CRP levels were measured in all participants. In addition, transthoracic echocardiography and ambulatory blood pressure monitoring were performed.

RESULTS

Age, sex, biochemical markers, eGFR, hemoglobin level, and platelet count were similar in the ADPKD subjects and the controls. There were significant differences in MPV (9.8 ± 0.7, 8.7 ± 0.8, and 8.0 ± 0.5 femtolitre; P < 0.001) and hs-CRP (6.8 ± 3.0, 5.3 ± 2.7, and 2.6 ± 0.52 mg/L; P < 0.001) in the groups. Additionally, PWV values were increased from healthy subjects to ADPKD patients who have decreased eGFR (5.5 ± 1.1, 8.8 ± 1.6, and 10.8 ± 1.2 m/s; P for trend <0.001). There were significant positive correlations between PWV and MPV (r = 0.401; P = 0.002) and hs-CRP (r = 0.343; P = 0.007) in the patients with ADPKD. Additionally, PWV was independently predicted by MPV (β = 0.286; P = 0.007), proteinuria (β = 0.255; P = 0.001), eGFR (β = -0.479; P < 0.001), and hs-CRP (β = 0.379; P < 0.001) in the patients with ADPKD. In addition, eGFR, as a sign of severity of disease, was independently predicted by MPV (β = -0.325; P = 0.003), PWV (β = -0.471; P < 0.001), and hs-CRP (β = -0.269; P = 0.008).

CONCLUSIONS

Our findings suggest that MPV and hs-CRP levels are associated with increased arterial stiffness in patients with early-stage ADPKD and those with late-stage ADPKD. Also, MPV and hs-CRP were independently associated with the severity of ADPKD.

The association between arterial stiffness and fluid status in peritoneal dialysis patients

OBJECTIVES

In this study our aim was to evaluate the relationship between degree of fluid status and arterial stiffness measured by pulse wave velocity (PWV) in peritoneal dialysis (PD) patients. Fluid status was determined by different methods including fluid overload measured by bioimpedance (Body Composition Monitor, BCM), calf normalized resistivity (CNR), plasma N-terminal fragment of B-type natriuretic peptide (NT-proBNP) and extracellular to intracellular water ratio (ECW/ICW).

METHODS

Sixty PD patients were evaluated. They were stratified into normo- and hypervolemic groups according to their fluid overload (FO). CNR was calculated from resistance at 5 kHz using calf bioimpedance spectroscopy. Arterial stiffness was assessed by PWV. Additionally, all patients underwent transthoracic echocardiography and had levels of NT-proBNP measured.

RESULTS

PWV was higher in the hypervolemic compared to normovolemic patients (9.99 ± 2.4 m/sec vs 7.48 ± 2.3 m/sec, p < 0.001). Hypervolemic patients had higher NT-proBNP levels (3065 ± 981 pg/mL vs 1095 ± 502 pg/mL, p < 0.001), a higher ratio of ECW/ICW; (0.93 ± 0.11 vs 0.81 ± 0.08, p < 0.001) and lower CNR (13.7 ± 2.4 vs 16.0 ± 3.3 W m(3)/kg(*)10(-2), p = 0.005). NT-pro BNP level, ECW/ICW ratio, relative FO, and left ventricular (LV) mass index were positively and CNR negatively correlated with PWV. Relative FO and CNR independently predicted PWV in multivariate analysis adjusted for age, duration of PD, body mass index and mean arterial pressure.

CONCLUSIONS

Arterial stiffness is increased in fluid-overloaded PD patients. Our results indicated that fluid status is an independent predictor of PWV.

Comparison of chemotherapy and hematopoietic stem cell transplantation pre and postterm DMFT scores: a preliminary study

AIMS

Chemotherapy is frequently used as a conditioning regimen to destroy malignant marrow cells before transplantation. Xerostomia, dysphagia, altered taste perception, mucositis, soft-tissue ulceration, and infection are common adverse oral effects of chemotherapy. The study was aimed to compare decayed, missing, filled teeth (DMFT) scores before and after hematopoietic stem cell transplantation (HSCT) and chemotherapy.

MATERIALS AND METHODS

Thirty-six patients undergoing HSCT were included in the study. A pre-HSCT dental treatment protocol was implemented that consisted of restoration of all active carious lesions, treatment of periodontal infections, and extraction of all teeth with advanced periodontal disease. Upon completion of dental treatment, the importance of rigorous and effective oral hygiene was reemphasized, and patients were recalled 6 months later. DMFT scores were calculated prior to the initiation of HSCT treatment and 6 months after transplantation.

STATISTICAL ANALYSIS USED

Regression analysis was used to evaluate the effects of HSCT and chemotherapy on DMFT scores.

RESULTS

Wilcoxon T test showed a statistically significant difference in DMFT scores before and after HSCT ( P < 0.001).

CONCLUSIONS

DMFT scores were found to increase after chemotherapy and HSCT, suggesting that the risk of infection is higher among HSCT patients when compared to other individuals. The results emphasize the need for dental examinations as an integral part of examination and treatment planning for patients undergoing HSCT and chemotherapy.

Does body mass index affect survival and technique failure in patients undergoing peritoneal dialysis?

OBJECTIVE

To investigate effect of body mass index (BMI) on survival and technique failure in patients undergoing peritoneal dialysis (PD).

METHODS

In this retrospective study three hundred ninety-two consecutive patients undergoing peritoneal dialysis from September 1995 to January 2013 were included. Median PD duration was 53 (range: 4-189) months. Clinical outcomes were mortality and technique failure. Technique failure was defined as transfer to hemodialysis (HD) due to peritonitis, ultrafiltration failure, inadequate dialysis, exit-site and/or tunnel infection, and mechanical problems. Deaths within 3 months after transferring to HD were accepted as PD-related mortalities. The patient and technique survival rates were estimated using the Kaplan-Meier method. Mortality risks were analyzed using the multivariate Cox regression model in which we included (in a backward-wald manner) all the significant variables from the univariate analysis.

RESULTS

There were 164 (41.8%) deaths. Forty-six (11.7%) patients underwent renal transplantation whereas 132 (33.7%) patients were transferred to HD. The multivariate Cox regression analysis found that the patient survival rates were significantly associated with age, BMI, baseline serum creatinine and albumin levels, and total Kt/Vurea. All variables as potential risk factors for the patient survival were also assessed for technique survival in univariate analysis and technique survival rates were significantly associated only with BMI (p: 0.015).

CONCLUSION

BMI was associated with unfavorable patient survival in PD patients.

A link between the intrarenal renin angiotensin system and hypertension in autosomal dominant polycystic kidney disease

BACKGROUND/AIMS

Early onset of hypertension and its consequences account for the great majority of deaths in patients with autosomal dominant polycystic kidney disease (ADPKD). Renin-angiotensin system (RAS) components have been shown in ADPKD kidneys independent of systemic RAS. Thus, we examined the urinary angiotensinogen (UAGT) levels as a biomarker of intrarenal RAS status in ADPKD patients with/without hypertension and healthy subjects.

METHODS

Eighty-four ADPKD patients (43 with hypertension and 41 without hypertension) and 40 healthy controls were studied cross-sectionally. Patients with glomerular filtration rate <60 ml/min were excluded from the study. Hypertension was diagnosed with ambulatory blood pressure monitoring. Urinary and plasma concentration of angiotensinogen, spot urine microprotein and creatinine (UCre) levels were recorded for each participant.

RESULTS

UAGT/UCre levels were higher in hypertensive ADPKD patients (23.7 ± 8.4) compared with normotensive ADPKD patients (16.6 ± 5.2) and healthy controls (6.9 ± 3.3; p < 0.001). In univariate analysis, UAGT correlated with systolic blood pressure, diastolic blood pressure (DBP) and proteinuria. The independence of these correlations was analyzed in a regression model, and UAGT was shown to be significantly predicted by proteinuria and DBP.

CONCLUSION

Intrarenal RAS activation which is monitored by UAGT levels clinically may be a harbinger of hypertension and kidney disease in ADPKD patients.

Serum uric acid levels and endothelial dysfunction in patients with autosomal dominant polycystic kidney disease

BACKGROUND/AIMS

Patients with autosomal dominant polycystic kidney disease (ADPKD) exhibit endothelial dysfunction (ED) despite normal levels of renal function. Hyperuricemia occurs in these patients and has been postulated to affect ED through the generation of oxidative stress. We therefore investigated the prevalence of ED and its association with serum uric acid levels in early-stage ADPKD.

METHODS

A cross-sectional design was used for the assessment of prevalent patients with early-stage (normal renal function) ADPKD (n = 91) from two academic medical centers. ED was assessed using ischemia-induced forearm flow-mediated vasodilation (FMD). Serum uric acid levels were evaluated using an Olympus AU2700 autoanalyzer.

RESULTS

ADPKD patients with higher serum uric acid levels had a higher asymmetric dimethylarginine (ADMA) level (1.19 ± 0.2 vs. 1.47 ± 0.3, p < 0.001) and lower FMD rates (8.1 ± 1.3 vs. 6.8 ± 0.7, p < 0.001). In multiple regression analysis for predictors of cohort FMD, uric acid (β = -0.32, p < 0.001), ADMA (β = -0.36, p < 0.001), high-sensitivity C reactive protein (CRP; β = -0.32, p < 0.001) and estimated glomerular filtration rate (eGFR; β = 0.33, p < 0.001) all predicted FMD.

CONCLUSIONS

In early-stage ADPKD patients, uric acid levels, serum ADMA and eGFR all independently predict ED in a similar manner. Future studies are needed to investigate the causes of elevated serum uric acid, ADMA and CRP in these patients.

Growth hormone deficiency due to sports-related head trauma is associated with impaired cognitive performance in amateur boxers and kickboxers as revealed by P300 auditory event-related potentials

OBJECTIVES

It has been recently reported that boxing and kickboxing may cause pituitary dysfunction, GH deficiency in particular. The strong link between poor cognitive performance and GH deficiency due to causes other than head trauma and the improvement of cognitive function after GH replacement therapy have been previously shown. P300 auditory event-related potential (ERP) measure is widely used to evaluate cognitive performance. In this study, we investigated the relation between the GH-IGF-I axis and cognitive performance in boxers and kickboxers.

DESIGN AND PATIENTS

Forty-one actively competing or retired male boxers (n: 27) and kickboxers (n: 14) with a mean age of 29·04 ± 9·30 year and 14 age- and education-matched healthy male controls were included in the study. For neuropsychological tests, the mini-mental state examination (MMSE) and Quality of Life Assessment of GH Deficiency in Adults (QoL-AGHDA) questionnaires were administered. Moreover, cognitive performance was evaluated according to P300 ERPs.

RESULTS

Nine of 41 (21·9%) athletes had GH deficiency. P300 amplitudes were lower at all electrode sites in the GH-deficient group than in controls, and the differences were statistically significant at Fz and Oz electrode sites (P < 0·05). When GH-deficient athletes were compared with GH-sufficient athletes, the P300 amplitudes were lower at all electrode sites in the GH-deficient group; these differences were statistically significant at Fz, Pz and Cz electrode sites (P < 0·05). In all athletes, there were significant negative correlations between IGF-I levels vs P300 latencies, and there were significant positive correlations between IGF-I levels vs P300 amplitudes (P < 0·05).

CONCLUSION

This study provides the first electrophysiological evidence for the close relation between the P300 ERPs and the GH-IGF-I axis in boxers and kickboxers.

Microalbuminuria is associated with high prevalence of anemia in renal transplant recipients

BACKGROUND AND AIM

Prevalence of anemia is higher in diabetic patients with microalbuminuria than those with normoalbuminuria despite the absence of significant renal impairment. The aim of this study was to investigate whether there was a relationship between microalbuminuria and anemia in renal transplant recipients (RTRs).

PATIENTS AND METHOD

Twenty-eight RTRs with microalbuminuria and 21 control RTRs with normoalbuminuria were classified based on urinary albumin creatinine ratios (UACR) of 0.03-0.3 versus <0.03, respectively. Anemia was defined as a hemoglobin level <13 g/dL for men and <12 g/dL for women.

RESULTS

Anemia was observed in 13 (46.4%) microalbuminuric and 4 (19%) normoalbuminuric patients (P = 0.044). Hemoglobin level was significantly lower in the microalbuminuric than the normoalbuminuric group (13.3 ± 1.3 g/dL vs 14.4 ± 1.9 g/dL, respectively; P = .018). Although creatinine clearance was significantly higher among the normoalbuminuric group (84 ± 30 mL/min vs 65 ± 22 mL/min, respectively; P = .017), mean creatinine clearance in microalbuminuric group was >60 mL/min, the threshold value for anemia due to erythropoietin (EPO) deficiency. In contrast, there was no significant difference between the 2 groups for age, gender, donor source, and transplant duration.

CONCLUSION

Anemia was frequent among RTRs displaying microalbuminuria, which may reflect EPO deficiency due to the tubulointerstitial injury of chronic allograft nephropathy. The EPO deficiency may begin before significant deterioration in excretory function of the kidney.

The role of platelet activation in determining response to therapy in patients with primary nephrotic syndrome

To test the role of platelet activation in the prognosis of nephrotic syndrome (NS), we evaluated the mean platelet volume (MPV) in patients with NS undergoing treatment. In this prospective, multicenter clinical study 156 patients with primary NS under treatment were assigned and followed for one year. Patients were divided into three groups for complete remission, partial remission, and resistance. Biochemical parameters, estimated glomerular filtration rate, proteinuria level, and MPV levels were compared at baseline and 12 months after treatment. MPV, proteinuria, total cholesterol, triglyceride, LDL cholesterol, HDL cholesterol, total protein, albumin, and hs-CRP levels significantly decreased in partial and complete remission group after 12 months compared to the baseline (p < 0.05). However, MPV levels significantly increased and only LDL cholesterol significantly decreased in the resistance group (p < 0.05). Univariate analyses demonstrated that ΔMPV was significantly associated with Δproteinuria (r = 0.41, p < 0.001), Δhs-CRP (r = 0.39, p < 0.001), and ΔAlbumin (r = -0.30, p < 0.001). We found that ΔAlbumin (β = -0.33, p < 0.001), ΔTotal cholesterol (β = -0.20, p = 0.011), and Δhs-CRP (β = 0.19, p = 0.018) were statistically significant predictors of the Δproteinuria in multiple regression analysis. In subjects with primary NS, MPV is associated with the prognosis or the disease. This study provides the background for longer trials and the role of platelet activation in NS.

Role of Grape Seed Extract on Methotrexate Induced Oxidative Stress in Rat Liver

The efficacy of methotrexate (MTX), a widely used cytotoxic chemotherapeutic agent, is often limited by its severe hepatotoxicity. Regarding the mechanisms of these adverse effects, several hypotheses have been put forward, among which oxidative stress is noticeable. The present study was undertaken to determine whether grape seed extract (GSE), a new natural free radical scavenger, could ameliorate the MTX-induced oxidative injury in the rat liver. The animals were divided into 3 groups. Each group consisted of 12 animals. MTX-GSE group: rats were given GSE (100mg/kg body weight) orally for 15 days, and a single dose of MTX (20mg/kg, intraperitoneally) was added on the 10th day. MTX group: these received placebo distilled water (orally) instead of GSE for 15 days and the same MTX protocol applied to this group on the 10th day. Control group: rats were given distilled water (orally) through 15 days and physiological saline (intraperitoneally) instead of MTX was administered on the 10th day in a similar manner. On the 16th day, liver tissue samples were obtained under deep anaesthesia. The level of malondialdehyde (MDA), an end product of lipid peroxidation, and the activities of süperoxide dismutase (SOD) and catalase (CAT), two important endogenous antioxidants, were evaluated in the tissue homogenates. MTX administration increased the MDA level and decreased the SOD and CAT activities in the liver homogenates ( p < 0.001), while these alterations were significantly reversed by GSE treatment ( p < 0.001). MTX led to significantly reduced whole blood count parameters ( p < 0.05). When GSE was supplemented, no significant changes in blood count parameters were noted. It appears that GSE protects the rat liver and inhibits methotrexate-induced oxidative stress. These data indicate that GSE may be of therapeutic benefit when used with MTX.

Levofloxacin-induced delirium: is it a dangerous drug in patients with renal dysfunction?

The central nervous system (CNS) toxicity of fluoroquinolones is well known but usually occurs benign. In the literature, there are a few number of severe CNS toxicity cases related to fluoroquinolones. Levofloxacin is a third-generation fluorinated quinolone antibiotic, is the active levo stereoisomer of ofloxacin, and has one of the most favorable adverse reaction profiles. We describe a case of delirium associated with levofloxacin in a 55-year-old man who was hospitalized in our medical clinic for pneumonia.