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.

Cost of paid transplantation abroad: possible donor-origin early multiple myeloma in a renal transplant recipient treated using bortezomib.

The incidence of cancer is greater in transplant recipients compared with the general population. Posttransplantation lymphoproliferative disorder (PTLD) is the second most common cancer in these patients. Non-Hodgkin lymphoma is most commonly observed, and multiple myeloma (PTLD-MM) accounts for less than 4% of PTLDs. Most reported PTLD-MM is of recipient origin, and to date, few cases of donor-origin PTLD-MM have been reported. Bortezomib is a protease inhibitor that has been used successfully to treat multiple myeloma. Herein, we describe the case of a patient in whom multiple myeloma developed shortly after paid living-unrelated renal transplantation performed abroad (in Egypt). The patient had no apparent risk factors for PTLD-MM. Thus, it was supposed that PTLD-MM was of donor origin, considering its early development, lack of recipient risk factors, and no available donor medical status. To our knowledge, this report is the first to describe the use of bortezomib in this setting. Although bortezomib plus dexamethasone therapy resulted in hematologic remission, the patient remained dialysis-dependent.

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.

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.

Frequency and outcome of patients with acute renal failure have more causes than one in etiology.

In literature, there was little data about frequency and outcome of ARF with two or more causes in etiology. Therefore, the aim of this study was to search this issue. This series included 339 patients with ARF from Jan 1,1987 to Jan 1,1999. Fourty-six (30 males) of all patients (13.5%) had two or more causes in etiology of ARF. Of these patients, causes were prerenal and renal in 26 (56%), prerenal, renal and postrenal in 12 (26%), renal and postrenal in 4 (9%), and prerenal and postrenal in 4 (9%). The most frequent cause is diarrhea and vomiting in prerenal, gentamycin usage in renal and prostate hypertrophy in postrenal. Of these patients, there was oliguria in 32 (70%), anuria in 8 (17%) and non-oliguria in 6 (13%). Treatment modalities of patients was only medical in 19 (41%), dialysis in addition to medical therapy in 27 (59%). In spite of treatment, 5 (10.8) of patients with two or more causes in etiology died. Causes of death were uremic coma in 2, cardiac disorders in 2 and septic shock in 1. Three (11.2%) of other patients with one cause died. Mortality rates were not different (chi2: 0.0298, p > 0.5). Cortical necrosis was diagnosed in one patient with multiple etiology and 2 of other patients. Finally, frequency of ARF with two or more etiologic causes was 13.5%, and most frequent causes were hypovolemia and nephrotoxic drugs. Outcome of these patients was similar to other patients with one cause.

Outcome of pregnancies with HELLP syndrome complicated by acute renal failure (1989-1999).

HELLP syndrome, a syndrome of hemolysis, elevated liver enzymes and low platelets may occur in pregnancy with pre-eclampsia/eclampsia, and its a significant complication is acute renal failure (ARF). The aim of study was to determine frequency and outcome of HELLP syndrome complicated by ARF. Thirty-nine patients with pregnancy-related ARF were treated between Jan 1, 1989 and Jan 1, 1999. In these patients, the most frequent causes were HELLP syndrome (n = 14; 36%), postpartum hemorrhage (n = 10; 26%), pre-eclampsia/eclampsia (n = 6; 15%) and abruptio placenta (n = 4; 10%). Seven of the patients with HELLP syndrome had impairment of consciousness during hospitalization. Of these patients, coma in 5, stupor in 1, confusion in 1 were diagnosed. Twelve of the patients with HELLP syndrome and 14 of the other patients were treated by dialysis. Mann-Whitney U test and chi2 test(corrected by Yates and Fisher exact) were used for statistical analysis. Although serious clinical findings, with supportive treatment, 12 patients with HELLP syndrome and 21 other patients were fully recovered. One patient both with and without HELLP syndrome could not recovered due to diffuse cortical necrosis. Moreover, one patient with HELLP syndrome and 3 other patients were died. Mortality rate of the patients with HELLP syndrome was not found different from those of the other patients (p = 0.544). The causes of death were cerebral hemorrhage in patient with HELLP syndrome and disseminated intravascular coagulation (n = 1), cerebral emboli (n = 1), adult respiratory distress syndrome (n = 1). Fetal death occurred in 4 patients with HELLP syndrome (28.5%) and 7 other patients (28%), and rates were similar (p > 0.5). Finally, HELLP syndrome was the most frequent cause leading to ARF in pregnancy and their prognosis was not different from those of the other patients.

Changes in frequency and etiology of acute renal failure in pregnancy (1980-1997).

In recent years, the incidence of acute renal failure (ARF) in pregnancy has decreased in developed countries. This cause of this decline has been reported to be liberalized abortion laws and improved prenatal care. The aim of this study was to determine if the incidence and etiology of ARE in pregnancy in our population had undergone similar changes. Between January 1, 1980 and January 1 1997 the number of the patients with ARF was 487. In 74 (15%) of these patients, the etiology of ARF was associated with pregnancy. The frequency of ARF in pregnancy was 17.4% between January 1980 and August 1985, 15.4% between September 1985 and November 1989, 13.5% between December 1989 and January 1997. The differences between the frequencies were not statistically significant (p > 0.5). In the present series, the various disorders leading to ARF in pregnancy were abortion (30%), HELP syndrome and pre-eclampsia (14%), pre-eclampsia or eclampsia (12%), postpartum hemorrhage (15%), fetal death (12%), abruption placentae (6%) and placentae previa (1%).

The importance of serum transferrin receptor level in the diagnosis of functional iron deficiency due to recombinant human erythropoietin treatment in haemodialysis patients.

In haemodialysis (HD) patients, functional iron deficiency frequently appears due to recombinant human erythropoietin (r-HuEPO) treatment. However, the diagnosis of iron deficiency is not always easy in such patients. Recent studies have shown that the serum transferrin receptor (s-TfR) level is a sensitive, quantitative measure of tissue iron deficiency. In this study, we examined the changes in s-TfR levels in patients with iron deficiency anaemia due to r-HuEPO treatment. We compared s-TfR levels of 24 patients with i.v. administered r-HuEPO (50-70 U/kg/dose) at the end of each dialysis session (three times a week) and diagnosed as having iron deficiency anaemia by routine laboratory methods (ferritin <50 microg/l and transferrin saturation <16%) with s-TfR levels of 32 patients not receiving r-HuEPO and without iron deficiency anaemia. Also, 40 healthy volunteer subjects were included in the study as a control group. Serum ferritin and transferrin receptor levels were measured with ELISAs using monoclonal reagents. There were no differences between the two groups with and without iron deficiency anaemia with respect to mean age, body weight, haemodialysis duration, haemoglobin and serum creatinine levels (p>0.05). For s-TfR levels, while no difference was present between the control and the non-iron deficiency groups (p>0.05), the iron deficiency group had higher s-TfR values than those of both the control and non-iron deficiency groups (p<0.001). Besides, there was an inverse correlation between haemoglobin and s-TfR levels in patients with iron deficiency anaemia (r = -0.85, p<0.0001). We conclude that the measurement of s-TfR levels may be useful in the diagnosis of functional iron deficiency in haemodialysis patients receiving r-HuEPO.