Thyroid functions on hemodialyzed patients

Abnormalities in thyroid function tests are frequently encountered in uremic patients. Disturbance in endothelial dysfunction and inflammatory processes are common in individuals with chronic renal failure. This may predispose to accelerated atherosclerosis with all its complications. The study was performed to investigate relationship between thyroid function and markers of endothelium damage and inflammation in patients with regular hemodialysis [HID]. The study was performed on 50 patients with end stage renal diseases [ESRD] on regular ND for at least 10 months. All patients and control were subjected to complete history and clinical examination and measurements of thyroid function tests, marker of inflammation [CRP], marker of endothelial damage, [intracellular adhesion molecules [ICAM]], in addition to renal function, CBC, lipid profile, total protein and serum albumin. Out of 50 patients under hemodialysis, had cardiovascular events. The following parameters were significantly higher in patients under HD than control; blood urea [p < 0.001], serum creatinine [P <0.001], CRP [p <0.001], ICAM [p <0.001] and triglycerides [P <0.01]. The following parameters were significantly lower in patients under HD than controls; serum albumin [p < 0.001], FT3 [p <0.01, but still within the normal range] and hemoglobin [p < 0.01]. Using multiple regression analysis serum FT3 negatively correlated with, duration of RD [r=-0.830, p < 0.001], albumin [r=-0.770, p <0.001], CRP [r=-0.840, p < 0.001], ICAM [r=-0.500, p < 0.01], triglycerides [r=-0.540, p <0.01], and total protein [r=-0.520, P <0.01]. Logistic regression analysis and after adjusted for age, sex, BMI, hypertension, FT3 levels were independently related to CRP [OR 206, 95% CI 1.6-5.4, P < 0.001], followed by duration of dialysis [OR 2.58, 95% CI 1.7-5.2, P <0.001], lastly serum albumin [OR 2.32, 95% CI 1.6-3.9, p <0.001]. Interestingly, and serum albumin were significantly lower, while CRP and duration of dialysis were significantly higher in patients with vascular complications than the rest of patients [P < 0.01]. We can conclude that thyroid dysfunction in HID patients related to inflammation, duration of dialysis, malnutrition and to a lesser extent endothelial dysfunction. All these factors lead to accelerated atherosclerosis and cardiovascular complications and a clinical significance of these findings merits further studies

C-reactive protein an D-dimer as a prognostic factors of ischemic stroke

Inflammatory processes have a fundamental role of atherosclerotic lesion and increased risk of vascular disease especially cerebral ischemia. The study was performed to assess the prognostic influence of inflammatory markers, C - reactive protein [CRP] and D-dimer on outcome of ischemic stroke. The study includes 100 patients with first-ever ischemic stroke. The study was performed at Al-Azhar University Hospitals from May 2005 to January 2006, followed by one-year follow up. All patients were suspected to complete history and clinical examinations, CT or MRI in the first day and one week latter. CRP and D-dimer were measured within the first 24 hours of ischemic stroke. In addition to routine investigations such as; fasting and post prandial blood sugar, lipid profile, CBC, ECG, echocardiography and body mass index [BMI]. The primary end-point was either, death of any causes [vascular or non-vascular] or any non-fatal vascular events [transient ischemic attack, recurrent stroke, unstable angina, acute myocardial infarction or peripheral ischemia]. Multiple logistic regression analysis was used to evaluate the association between end-point and risk factors of stroke. The incidence of diabetes, hypertension, hypercholesterolemia and obesity were significantly higher in patients than control [p < 0.01] and in patients with fatal and non-fatal vascular events than those survival free vascular events [p <0.01]. Serum levels of CRP and D-dimer were significantly higher in patients with first-ever stroke than control [p <0.001] and in patients with fatal and non-fatal vascular events than those survival free vascular events [p < 0.01]. Kaplan-Meier analysis showed an increased incidence of new vascular events during follow-up with increased levels of CRP especially in high tertiles [64%] compared to intermediate [29%] and low tertiles [18.5%], [OR 9.1, CI 3.9-18.4; p <0.001]. Also Kaplan-Meier analysis showed an increased incidence of new vascular events during follow-up with increased levels of D-dimer especially in high tertiles [44.4%] compared to intermediate [34%] and low tertiles [30%], [OR 1.95, CI 0.95-2.1; p <0.01]. However, logistic regression analysis between, risk factors and outcome during 1-year follow-up proved that CRP is the most risk factor predictive for recurrent vascular events independent to other risk factors for stroke [OR 2.57, CI 1.34-5.10; p <0.001]. We can conclude that increased serum levels of CRP are related with a worse outcome in patients with first-ever stroke more than D-dimer independent to other risk factors of ischemic stroke. Therefore, addition of CRP to standard initial screening will generate an improved method for identifying persons at high risk of future vascular events

Left ventricular functions in patients with thyroid disorders

Cardiac functions in patients with different thyroid disorders are not well studied. The study was addressed to study cardiac dysfunctions especially in subclinical thyroid disorders by a new specific and sensitive imaging, pulsed wave tissue Doppler imaging [PWTDI], which is able to precisely assess the ventricular wall motion. In addition to N-terminal pro-brain natriuretic peptide [N-terminal proBNP]. A new neurohormone, which is a specific and sensitive marker for early detection of left ventricular dysfunctions. We studied 40 patients [29 females and 11 males] with hypothyroidism, 20 of them with overt hypothyroidism [group I], the other 20 patients with subclinical hypothyroidism [group II]. Forty patients [27 females and 13 males] with thyrotoxicosis, 20 of them with overt hyperthyroidism [group III], the other 20 patients with subclinical hyperthyroidism [group IV]. In addition to 20 euthyroid, subjects with age and sex matched [14 females and 6 male] as controls [group V]. The study was performed at Al-Azhar University Hospitals from January 2006 to March 2007. All partners were subjected to full clinical examinations to assess thyroid and left ventricular function, measurements of thyroid profile [FT3, FT4 and TSH] and N-terminal proBNP. All subjects underwent to PWTDI to accurately quantify the global and regional left ventricular function at the posterior septal wall. Left ventricular diastolic dysfunction in the form of impairment of both diastolic relaxation [decreased Ea] and compliance to ventricular filling [decrease Ea / Aa ratio]. LV systolic dysfunction in the form of impaired systolic ejection [decrease Sa]. PWTDI indices show a significant impairment of systolic ejection in all studied groups [P < 0.01] for overt and P< 0.05 for subclinical hypo and hyperfunction] and a delay in diastolic relaxation in overt hypothyroidism [P < 0.01], even those with subclinical hypothyroidism, [P < 0.05] but not impaired in hyperthyroid groups. PWTDI indices showed LV impairment early and significantly than when we used standard 2-D echocardiograms [EF% impaired only in patients with overt thyroid disorders] especially in subclinical groups. In subclinical hypothyroidism LV dysfunction was detected in two patients [10%], using standard 2-D echocardiograms vs. 14 patients [70%], using PWTDI, Sa [P < 0.01] and in 16 patients [80%], using Ea / Aa ratio [P < 0.01] and significantly correlated with FT3, FT4, TSH and N-terminal proBNP. In subclinical hyperthyroidism LV dysfunction was detected in two patients [10%], using standard 2-D echocardiograms vs. 8 patients [40%], using PWTDI, Sa [P < 0.01] and no patients [0%], using Ea / Aa ratio. N-terminal proBNP is highly sensitive and specific with a good positive and negative predicted value for early detection and diagnosis of LV dysfunction especially in subclinical groups and significantly correlated with thyroid profile and PWTDI indices. Left ventricular dysfunction is common in patients with different thyroid disorders even in patients with subclinical thyroid disorders. PWTDI and measurement of N-terminal proBNP are sensitive techniques that allow detection of LV dysfunction, not only in patients with overt thyroid disorders, but also in patients with subclinical thyroid disorders

Study of some endogenous factors and hormones contributing in the pathogenesis of ketosis in obese versus lean type 2 diabetes mellitus

Diabetic Ketoacidosis [DKA], resulting from severe insulin deficiency, accounts for most hospitalization in type 1 DM. However, the frequency, distinguishing features and pathogenesis of this syndrome in type 2 DM remain to be defined. The study was performed to evaluate the role of some endogenous factors and hormones contributing in the vulnerability of some type 2 DM that developed DKA easily than other. The study was conducted on 80 known type 2 diabetic patients [45 males and 35 females], 48 of them were obese body mass index [BMI] > 30 kg/m[2], admitted to Al-Azhar University Hospitals [emergency department] with manifestations of DKA [group I] from July 2003 to January 2005, and 20 type 2 diabetic patients of the same duration of DM, without history of DKA, [group II] with age and sex matched [12 males and 8 females], 10 of them were obese, as controls. After complete clinical examination and routine laboratory investigations, which confirm the diagnosis of DKA, the following investigations were studied; serum glucagon, C-peptide, glutamic acid decarboxylase antibody [GAD-ab], and C-peptide / glucagon ratio, random blood sugar [RBS], renal and liver function tests, arterial blood gases [bicarbonate and pH], serum electrolyte [sodium, potassium and chloride], lipid profile, CBC, complete urine analysis with special attention to level of ketone bodies Serum levels of glucagon, RBS and urine ketone were significantly higher in-group I than group II, while serum levels of C-peptide, C-peptide / glucagon ratio, sodium, potassium, and bicarbonate were significantly lower in-group I than group II. On the other hand no significant differences in the age, sex, disease duration, GAD abs, lipid profile, blood pH and serum chloride between group I and II. In patients with DKA, the age, disease duration, C-peptide, glucagon and C-peptide / glucagon ratio were significantly lower in lean than obese parents [p<0.05] for all. While serum levels of GAD-abs were significantly higher in lean than obese patients [p<0.05]. Interestingly in patients without DKA, serum levels of C-peptide were significantly lower [p<0.05], while serum levels of GAD-abs were significantly higher in lean than obese patients [p<0.05] and no significant changes in other parameters between them. On the other hand C-peptide correlated negatively with glucagon [r=-650] and GAD abs [r=-684], while serum glucagon correlated positively with GAD-abs [r=644]. It could be concluded that the pathogenesis of ketosis in type 2 diabetes is triggered mainly by deficient endogenous insulin in lean patients [had a criteria of type 1 diabetes such as; younger age of onset of DKA short duration of disease, elevated GAD-abs and low C-peptide / glucagon ratio but still classified as type 2diabetes] and relative increase glucagon level activity in obese patietrts. However, the C-peptide / glucagon ratio is the main denominator or determinant factor for ketosis in type 2 diabetes mellitus

Proteinuria as a risk factor for stroke in type 2 diabetes mellitus

The study was designed to assess the relation between proteinuria and stroke in patients with type 2 diabetes mellitus. The study was conducted on two groups; Group I included 60 patients with type 2 DM with ischemic stroke, group II included 60 patients with type 2 DM without stroke. Both groups were matched by age, sex, body mass index and duration of diabetes. The study was performed at Al-Azhar University Hospitals from May 2005 to January 2006. The patients were evaluated clinically using Glasgow Coma Scale [GCS] for comatose patients and Canadian Neurological Scale [CNS] for conscious patients. Routine laboratory investigations as well as 24 hours urine protein were measured for both groups. CT scans were performed to all patients of group I within two days and after one week from the onset of stroke to determined site, depth and size of infarction. Systolic and diastolic blood pressures, prevalence of smoking and 24 hours proteinuria were significantly higher in group I than group II. On the other hand no significant changes were found on duration of DM, fasting and postprandial blood sugar, total cholesterol, LDL cholesterol, triglycerides, HbAlc, age and gender between two groups. In group I 38 patients were found to have proteinuria 38/60 [63%] versus 16 patients 16/60 [26.7%] had proteinuria in-group II, which was statistically significant. HDL-cholesterol only was significantly lower in-patients with proteinuria than those without proteinuria in-group I [p<0.01]. On the other hand no significant correlations were found between proteinuria and severity of strokes and CT findings. In multivariate logistic regression analysis, the ORs and 95% CLs for the variables identified as risk factors for stroke were as follow; SBP [OR 14.5, 95% CL 2.5-13.9], DBP [OR 13.1, 95% CL 2.4-15.9], proteinuria [OR 7.6, 95% CL 2.5-22.9], HDL cholesterol [OR 5.5,95% CL 2.1-23.5] and smoking [OR 4.89, 95% CL 1. 7-22.3]. Our results give evidence that proteinuria is an independent risk factor for ischemic stroke in patients with type 2 DM. Further support from additional prospective studies is recommended to confirm these findings

Assessment of thyroid function and autoantibody in type 2 diabetes mellitus

The associations between type 1 diabetes mellitus [DM] and autoimmune thyroid disease and other autoimmune diseases have long been recognized. However, these associations in type 2 DM are not certain. The study was performed to assess the thyroid function and autoimmune thyroiditis by detection of thyroglobulin antibodies [TG-ab] and thyroid peroxidase antibodies [TPO-ab] in type 2 diabetes mellitus. The study included 50 patients with type 2 diabetes over 10 years duration and 20 control subjects. The study was performed at Al-Azhar University Hospitals for control or management of diabetic complications. Patients with non-thyroidal illness or drug therapy, which known to affect thyroid functions were excluded from the study. The subjects of this study were submitted to the following: complete history and clinical examination, BMI, blood sugar, lipid profile, thyroid function test [FT3, FT4, and TSH], HbAlc and thyroid autoantibodies [Tg-ab and TPO-ab]. Twenty-six patients out of 50 having abnormal levels of TSH, 6 of them below the normal reference range, while the other 18 patients with elevated TSH levels. Patients with elevated TSH had significantly lowered serum FT3, FT4 and elevated levels of TPO-ab, TG-ab, HbAlc, disease duration and BMI when compared to those with normal TSH [p<0.01, for all]. Patients with decreased levels of TSH had significantly elevated levels of FT3, FT4, HbAlc and BMI when compared to those with normal TSH [p<0.01], but no significant changes were found in serum levels of autoantibodies. Interestingly the incidence of abnormal thyroid function and elevated thyroid auto-antibodies were significantly higher in patients treated by insulin [70%] versus those treated by oral hypoglycemic drugs [30%], [p<0.01]. Twenty two patients out of 50 [44%] had elevated TPO-ab levels, 13 of them have TSH abnormality, 12 of these 13 patients have subclinical hypothyroidism and one has subclinical hyperthyroidism. 25 patients of 50 [50%], have increased level of TG-ab, 18 of them have abnormal TSH values, 16 out of these 18 have subclinical hypothyroidism and two patients have subclinical hyperthyroidism. Serum level of TSH only was significantly higher in females than males [p<0.05]. Serum levels of autoantibodies were correlated positively with serum levels of TSH, BMI, HbAlc, disease duration and insulin therapy and correlated negatively with FT3 and FT4. Type 2 diabetes may be associated with alteration in thyroid function especially subclinical hypothyroidism that is not fully explained by the mere presence of antithyroid antibodies

Role of adhesion molecules in the pathogenes of chronic obstructive pulmonary disease

Interaction between cell adhesion molecules and their ligands are an important step of inflammatory processes and may have direct relevance to the pathology of airway inflammation in patients with COPD. To determine the possible role of adhesion molecules in increased airway inflammation in subjects with COPD. Serum levels of adhesion molecules [ICAM-1, VCAM-1 and P-Selectin] were measured in 30 patients with COPD and in 20 healthy controls, as well as in broncho-alveolar lavage [BAL] obtained from both groups [patients and controls]. In addition, pulmonary function tests [ventilatory function FEV [1], FVC, and FEV [1]/ FVC], E.C.G. and echocardiography for all studied subjects were studied. Serum adhesion molecules were significantly higher in patients than controls, p < 0.01 [in the serum as well as in BAL]. Smoking significantly increases expression of adhesion molecules in patients and controls in the serum as well as in BAL [p < 0.01]. The degree of airway obstruction was significantly higher in smoker versus non-smoker and correlated significantly with serum levels of adhesion molecules [r = 0.520, 0.560 and 0.500] for serum ICAM 1, VCAM 1 and P-selectin respectively. Increased airway inflammation and obstruction in patients with COPD is associated with an increased expression of adhesion molecules in the serum as well as in BAL, especially in smokers, where they may reflect the degree of ongoing airway inflammation in patients with COPD

Effect of daily hemodialysis of uremic peripheral neuropathy

Objective and aim of the work: uremic syndrome is characterized by overall deterioration of biochemical and physiological functions in parallel with progression of renal failure. Uremic polyneuropathy represent a well- known complication of end-stage renal failure [ESRF] caused by major neurotoxins accumulating in uremia, such as urea, creatinine, uric acid, middle molecules and others. The study was performed to study the effect of daily hemodialysis on uremic polyneuropathy and improving the patients clinically and biochemically. The cases of this study were patients under regular hemodialysis in the Nephrology Unit, Medical Department, Al-Azhar University and Naser City Hospitals from October 2004 to Mayo 2005. Material and methods: the cases of this study were patients under regular hemodialysis in the Nephrology Unit, Medical Department, Al-Azhar University and Nasr City Hospitals. The patients classified into 2 groups: group 1 comprised 10 patients with ESRF under thrice-weekly hemodialysis for less than 3 years; group ii comprised 10 patiepts with ESRF under thrice-weekly hemodialysis for less than 3 years who shift to daily hemodialysis except Fridays for 6 months; and 10 healthy normal volunteers of matching age and sex were the control group. Complete clinical and laboratory instigation were performed with nerve conduction velocity [sensory] and distal latency [motor] for median, ulnar and common peroneal nerves. K [t/v] to assess the adequacy of hemodialysis. paraethesia showed significant differences after 6 months of daily dialysis [p < 0.001], while other neurological symptoms and signs showed no significant differences in both groups after 6 months of dialysis. Sensory and motor nerve conduction study was significantly impaired in the median, ulnar and common peroneal in both groups when compared to controls [p < 0.001]. Nerve conduction velocities [sensory] were significantly improved in three nerves after 6 months of daily dialysis [p < 0.01], on the other hand no significant improvement was noticed after 6 months of thrice-weekly dialysis. Distal motor latency [motor] showed no significant improvement in three nerves in both groups after 6 months of dialysis. K [t/v] value was not significantly improved after 6 months of daily dialysis [3.2 vs. 3.1, p = 0.521]. from our study we speculated that the protocol of daily hemodialysis is feasible in routine hospital practice being well tolerated by patients and having a low incidence of complications compared to the standard protocol. Further works are required to study the effect of daily home dialysis on the different clinical, biochemical and psychological aspects of dialysis patients as well as the economic aspects of the daily regimen hemodialysis