Glucose pump test can be used to measure blood flow rate of native arteriovenous fistula in chronic hemodialysis.

PURPOSE: In chronic hemodialysis patients, the low flow of vascular access may leads to inadequate dialysis, increased rate of hospitalization, morbidity, and mortality. It was found that surveillance should be performed for native arteriovenous (AV) should not be performed for AV graft in various studies. However, surveillance was done in graft AV fistulas in most studies. Doppler ultrasonography (US) was suggested for surveillance of AV fistulas by the last vascular access guideline of National Kidney Foundation Disease Outcomes Quality Initiative (NKF KDOQI). The aim of study is to determine whether glucose pump test (GPT) is used for surveillance of native AV fistulas by using Doppler US as reference. METHODS: In 93 chronic hemodialysis patients with native AV fistula, blood flow rates were measured by Doppler US and GPT. For GPT, glucose was infused to 16 mL/min by pump and was measured at basal before the infusion and 11 s after the start of the infusion by glucometer. Doppler US was done by an expert radiologist. Used statistical tests were Mann-Whitney U test, Friedman test, regression analysis, and multiple regression analysis. RESULTS: Median values of blood flow rates measured by GPT (707 mL/min) and by Doppler US (700 mL/min) were not different (Z = 0.414, P = 0.678). Results of GPT and Doppler US measurements were positive correlate by regression analysis. The mean GPT value of diabetic patients (n = 39; 908 mL/min) was similar to that of nondiabetic patients (n = 54; 751 mL/min; Z = 1.31, P = 0.188). GPT values measured at three different dialysis session did not differ from each other that by Friedman test (F = 0.92, P = 0.39). This showed that GPT was stable and reliable. CONCLUSIONS: Glucose pump test can be used to measure blood flow rate of native AV fistula. GPT is an accurate and reliable test.

Peri-aortic fat tissue and malnutrition-inflammation-atherosclerosis/calcification syndrome in end-stage renal disease patients.

PURPOSE: Thoracic peri-aortic fat tissue (PFT) is considered as a metabolically active organ in atherosclerosis. Malnutrition, inflammation and atherosclerosis/calcification (MIAC) are the most commonly encountered risk factors of cardiovascular disease in end-stage renal disease (ESRD) patients. Calcification of the aorta was found to be an important cardiovascular risk marker predicting future events, morbidity and mortality in this population. We aimed to investigate the relationship between PFT, MIAC syndrome and thoracic aortic calcification (TAC) in ESRD patients. METHODS: Seventy-nine ESRD patients receiving hemodialysis (HD) or peritoneal dialysis (PD) and 20 control subjects were enrolled in this cross-sectional study. PFT and TAC were assessed using a 64-MDCT scanner. Patients with serum albumin <3.5 g/dL were defined as patients with malnutrition; those with serum C-reactive protein level >10 mg/L had inflammation, and those with coronary artery calcification score (CACS) >10 had atherosclerosis/calcification. RESULTS: TAC and PFT were significantly higher in ESRD patients compared with control subjects. There was a statistically significant relationship between PFT and TAC in ESRD patients (r = 0.458, p < 0.0001). PFT was found to be significantly increased when the MIAC components increased. PFT was positively associated with age, BMI, uric acid, hemoglobin and CAC. The multivariate analysis revealed that age and uric acid were independent predictors of increased PFT. Twenty-four (30.4 %) patients had none, 30 (37.9 %) had one component, 17 (21.5 %) had two components, and 8 (10.2 %) had all MIAC components. PFT was highest among patients having all three components (28.6 cm(3)) and lowest among those who do not have the MIAC syndrome (8.54 cm(3)). TAC was highest among patients having all three components (179.2 HU) and lowest among those who do not have the MIAC syndrome (0 HU). CONCLUSIONS: We found a relationship between PFT and MIAC syndrome in ESRD patients.

Treatment with antidepressive drugs improved quality of life in chronic hemodialysis patients.

BACKGROUND: Despite some improvements in dialysis therapies, depression still remains an important problem in chronic hemodialysis (HD) patients. In this study, we aimed to investigate the association of depression and its treatment with quality of life (QOL) in HD patients. PATIENTS AND METHODS: 97 HD patients (52 male, 45 female, mean age 55 +/- 16 years) were enrolled. All patients had been dialyzed for more than 6 months. In order to evaluate QOL of the patients, a short form of Medical Outcomes Study (SF-36) was used. Depression was assessed by using Beck Depression Inventory (BDI). Patients who had BDI score > or = 15 were diagnosed as to have depression. Patients with depression received antidepressive treatment (sertralin HCl, 50 mg/day) for an 8-week period. After 8-week antidepressive treatment, all biochemical analysis, SF-36 and BDI were performed again. RESULTS: 40 patients (20 male, 20 female, mean age 56 +/- 14 years) had depression. All parameters related to QOL were significantly decreased in patients with depression as compared to patients without depression. Severity of depression was correlated with QOL parameters. After 8 weeks of treatment, as parallel to changes in BDI, QOL parameters improved in patients with depression. CONCLUSION: Decrease in QOL, associated with depression and antidepressive treatment, improves QOL in HD patients. Hemodialysis patients should be followed-up closely for presence of depression. Treatment of depression with antidepressive drug regimen would lead to relieve the symptoms related to depression and improvement of QOL in these patients. Antidepressive treatment should be required more often than we prescribe in routine clinical practice now.

Lower erythropoietin and iron supplementation are required in hemodialysis patients with hepatitis C virus infection.

BACKGROUND: Chronic hepatitis C virus (HCV) infection is a common infectious agent in chronic hemodialysis (HD) patients. In this prospective case-control study, we aimed to investigate the influence of chronic HCV infection on erythropoietin (EPO) and iron requirement in HD patients. PATIENTS AND METHODS: 49 HD patients (24 male, 25 female, mean age 47 +/- 15 years) were included. The mean time spent on dialysis was 39 +/- 38 months, and follow-up time was 1 year for this study. Biochemical analyses and complete blood counts together with iron status of the patients (transferrin saturation and serum ferritin levels) were measured monthly. Highly sensitive C-reactive protein (hs-CRP) levels were measured within 3-month intervals. Endogenous EPO levels were measured by enzyme-linked immunoassay 2 weeks after cessation of EPO treatment. RESULTS: Eleven of the HD patients (22%) were anti-HCV(+). There was no difference in age, sex, time on dialysis, distribution of primary renal diseases, predialytic BUN, Kt/V, albumin and i-PTH levels between HCV(+) and (-) patients. Anti-HCV-positive patients required significantly lower weekly doses of EPO (87 +/- 25 IU/kg vs 129 +/- 11 IU/kg, p = 0.042) and iron (16.8 +/- 12.2 mg vs 32.6 +/- 16.1 mg, p = 0.02) replacement than anti-HCV(-) group; hs-CRP levels were similar between study groups. Serum endogenous EPO levels were significantly higher in HCV(+) patients than HCV(-) HD patients (9.43 +/- 6.47 mU/ml vs 3.59 +/- 2.08 mU/ml, p = 0.008). CONCLUSION: Anti-HCV(+) HD patients had higher serum EPO levels and required less EPO and iron replacement as compared to anti-HCV(-) patients. Because of the changes in iron metabolism, iron treatment should be carefully administered in HD patients with HCV.

Assessment of acute renal failure patients treated in our nephrology clinic between 1996 and 2002.

Acute renal failure (ARF) is a cause of high morbidity and mortality associated with long hospital stay, and expensive treatment. The initial approach to patients with ARF should be focused on preventing future injury to the kidney. Two hundred eighty-three ARF patients, treated from January 1996 to June 2002, were retrospectively investigated for their etiology, clinic features, and laboratory characteristics, as well as treatment results and mortality rate. The mean age was 52.3 +/- 18.7 years. Patients with hospital-acquired ARF comprised 38.8% of the sample. Renal causes (60%) were responsible for most ARF patients. They were medical (63.95%), surgical (23.67%), and obstetric (12.4%) causes. Twenty-five percent of patients with ARF had multiple etiologies. Hemolysis elevated liver enzymes low platelets (HELLP) syndrome was seen in the most of the obstetric-related ARF cases. Signs of hypervolemia were present in approximately 50% of the cases. Oliguric patients comprised 59.7% of the sample, and the mean time to oliguria was 5.2 +/- 4.1 days. The necessity of dialysis was greater in oliguric patients (42.6%) and the ratio of complete/partial improvement (82.2%) was greater among non-oligoanuric patients. However, there was no significant difference between mortality rates. Irreversible renal insufficiency did not develop in the non-oliguric cases. Also, 7.4% of ARF patients died, with the main causes being infection (31.8%) and cardiovascular events (27.2%). Medical problems are important in the etiology of ARF as well as obstetric cases. The mortality rate was low in our cases, a situation that may be explained by medical causes being of importance in the etiology. We are of the opinion that early referral of patients to a nephrologist and following treatment in the nephrology clinic may positively affect the outcome.

Ambulatory blood pressure monitoring in haemodialysis and continuous ambulatory peritoneal dialysis (CAPD) patients.

The aim of this study was to compare the results of the 44-h ambulatory blood pressure monitoring (ABPM) data between haemodialysis (HDp) and CAPD patients and to investigate the relation of circadian rhythm in blood pressure (BP) with development of left ventricular hypertrophy. Twenty-two HDp (11 male, 11 female, mean age: 50 +/- 17 years) and 24 CAPDp (11 male, 13 female, mean age: 47 +/- 15 years) were included. Echocardiographic measurements and ABPM were performed in all study groups. ABPM of the first and second days were analysed separately and compared with CAPDp. Left ventricular hypertrophy was detected in 17 of the 22 HDp (77%) and 17 of the 24 CAPDp (71%). There was no significant differences between HD and CAPDp in respect to 44-h, daytime and night-time systolic and diastolic BP values. Although the course of BP in CAPDp was stable during the 44-h period, systolic and diastolic BP levels on the second day were significantly higher than those of on the first day in HDp (P < 0.001 for both). Daytime systolic and diastolic BP levels on the first day in HD group were recorded lower than those of the CAPD group. On the second day, night-time BP readings (both systolic and diastolic BP) were measured significantly higher in the HD group compared with the CAPD group. Twenty-one of the 24 (88%) CAPD patients were dippers, whereas only four of the 22 (18%) HDp were dippers (P < 0.001). Dipper patients had significantly lower left ventricular mass index (LVMI) than non-dipper patients (131 +/- 29 g/m(2) vs 153 +/- 40 g/m(2), P = 0.03). In 44-h ABPM, there were no differences in daytime and night-time systolic and diastolic blood pressures between HD and CAPD patients. Non-dipper patients had increased LVMI as compared with dipper patients. Abnormalities in circadian rhythm of the blood pressure might be one of the implicated factors for development of left ventricular hypertrophy.

Erectile dysfunction and the effects of sildenafil treatment in patients on haemodialysis and continuous ambulatory peritoneal dialysis.

BACKGROUND: Sexual dysfunction, including erectile dysfunction, is common in patients with uraemia. Despite successful treatment of male sexual dysfunction with sildenafil in non-uraemic population, its efficacy in dialysis patients is unknown. PATIENTS AND METHODS: In this study, 35 male HD patients (mean age 48+/-12 years) and 15 male CAPD patients (mean age 44+/-12 years) were included. In the baseline period, haemoglobin, serum urea, and albumin, Kt/V, several hormonal parameters, Beck depression scale, and penile Doppler blood flow, (peak systolic velocity after intracavernous papaverine administration) were measured. The international index of erectile function (IIEF) form was used to evaluate erectile dysfunction. Sildenafil was given to patients with erectile dysfunction at a dose of 50-100 mg/day twice a week. RESULTS: The percentage of erectile dysfunction was similar between patients on HD (71%) and those on CAPD (80%). Patients with erectile dysfunction were significantly older and had lower free-testosterone serum levels and penile blood flow than those without. In linear regression analysis for baseline IIEF score, penile blood flow was the only independent variable associated with erectile dysfunction. IIEF score increased to a similar extent after sildenafil treatment in both HD patients (from 8.10+/-5.54 to 21.70+/-9.61, P<0.001) and CAPD patients (from 9.90+/-3.87 to 21.60+/-10.18, P=0.011). Changes in IIEF scores after sildenafil treatment were associated with baseline penile blood flow as an independent variable by linear regression analysis. Adverse events observed during sildenafil treatment were dyspepsia in two patients and headache in one patient. CONCLUSION: The rate of erectile dysfunction is high in dialysis patients. Penile blood flow is the most important factor for predicting both the development of erectile dysfunction and the response to sildenafil therapy in such patients. Oral sildenafil is an effective, reliable, well-tolerated treatment for uraemic patients with erectile dysfunction.