C allele in transforming growth factor-β1 rs1800471 gene polymorphisms might indicate a protective feature in encapsulating peritoneal sclerosis development

INTRODUCTION

Peritoneal fibrosis may progress in peritoneal dialysis (PD) patients to a fatal clinical condition called encapsulating peritoneal sclerosis (EPS). Transforming growth factor (TGF)-β plays a pivotal role in the pathogenesis of peritoneal fibrosis. We aimed to investigate the association among polymorphisms in the gene encoding TGF-β1, which were -509C/T (rs1800469), +869T/C (rs1982073), and +915G/C (rs1800471) in EPS patients.

METHODS

A total of 16 PD patients who were clinically and radiologically diagnosed with EPS were enrolled and 22 age- and gender-matched PD patients were selected as the non-EPS group.

RESULTS

G allele frequency at the rs1800471 gene polymorphism was significantly higher in the EPS group than non-EPS group (p = 0.005). Interestingly, the non-EPS group patients had CC or CG polymorphisms.

CONCLUSION

C allele in TGF-β1 rs1800471 gene polymorphisms might indicate a protective feature in EPS development. Knowing the presence of polymorphism may be effective in selecting renal replacement therapy in patients.

High serum soluble α-Klotho levels in patients with autosomal dominant polycystic kidney disease

This study aims to determine fibroblast growth factor-23 and soluble α-Klotho levels in patients with autosomal dominant polycystic kidney disease. A total of 76 patients with autosomal dominant polycystic kidney disease and 32 healthy volunteers were included in the study. Serum fibroblast growth factor-23 and soluble α-Klotho levels were measured with ELISA kits. Parathyroid hormone, phosphate, calcium, creatinine, 25-hydroxyvitamin D3 levels, urinary protein to creatinine ratio and estimated glomerular filtration rate were also measured or calculated. Patients with autosomal dominant polycystic kidney disease had significantly higher serum parathyroid hormone (p<0.001), fibroblast growth factor-23 (p<0.001), soluble α-Klotho levels (p=0.001) and lower serum 25-hydroxyvitamin D3 levels (p<0.001) as compared with healthy volunteers. Serum fibroblast growth factor-23, soluble α-Klotho and 25-hydroxyvitamin D3 levels were similar in all five chronic kidney disease stages of autosomal dominant polycystic kidney disease (p>0.05). Fibroblast growth factor-23 (r=−0.251, p=0.034) and soluble α-Klotho levels (r=−0.251, p=0.034) were found to be negatively correlated with estimated glomerular filtration rate. This study shows increased fibroblast growth factor-23 levels in patients with autosomal dominant polycystic kidney disease which is in harmony with the general trend in patients with chronic kidney disease of other aetiologies, but, unlike them, also a significant increase in serum soluble α-Klotho levels in patients with autosomal dominant polycystic kidney disease suggesting an aberrant production or a decreased clearance of α-Klotho molecule. Considering the unique increases in erythropoietin levels due to erythropoietin production in renal cysts, we assume, patients with autosomal dominant polycystic kidney disease may potentially have different soluble α-Klotho production/clearance characteristics than the patients with other parenchymal renal diseases.

Relationship between carotid artery intima-media thickness and brachial artery flow-mediated dilation in peritoneal dialysis patients

BACKGROUND AND AIM

Carotid artery intima-media thickness (CIMT) and brachial artery flow-mediated dilation percentage (FMD%) are two commonly used parameters for detecting subclinical atherosclerosis. However, studies investigating the relationship between CIMT and brachial artery FMD% in different populations have produced conflicting results. The aim of this study was to determine the relationship between CIMT and brachial artery FMD% in patients on peritoneal dialysis (PD) METHODS: Fifty-two PD patients without known cardiovascular disease and 30 age-gender matched controls were included in the study. Endothelial function was determined using ultrasonography (US) to measure the FMD of the brachial artery, and this parameter was expressed as the percentage change from the baseline diameter of the brachial artery (FMD%). We also measured CIMT by US and analysed the relationship between CIMT and brachial FMD%.

RESULTS

The CIMT was significantly higher in patients than in the control group (0.84 +/- 0.08 vs. 0.75 +/- 0.06 mm, P < 0.01), whereas brachial artery FMD% was lower in patients than in the controls (8.2 +/- 5.0 vs. 11.7 +/- 5.5%, P < 0.01). There was no significant correlation between CIMT and FMD% (r = -0.004, P = 0.94).

CONCLUSION

Although PD patients are known to be characterized by an impaired flow-mediated vasodilatation of brachial artery and increased in CIMT, we did not find a significant correlation between FMD% and CIMT in our PD patient cohort. One possible explanation for our results is that each method measures a different aspect and stage of atherosclerosis.

Severe vitamin D deficiency in chronic renal failure patients on peritoneal dialysis

The aim of this study was to evaluate the prevalence of vitamin D deficiency in chronic renal failure (CRF) patients on peritoneal dialysis (PD) and to correlate the findings with various demographic and renal osteodystrophy markers.

METHOD

This cross-sectional, multicenter study was carried out in 273 PD patients with a mean age of 61.7 +/- 10.9 years and mean duration of PD 3.3 +/- 2.2 years. It included 123 female and 150 male patients from 20 centers in Greece and Turkey, countries that are on the same latitude, namely, 36-42 degrees north. We measured 25(OH)D3 and 1.25(OH)2D3 levels and some other clinical and laboratory indices of bone mineral metabolism.

RESULTS

Of these 273 patients 92% (251 patients) had vitamin D deficiency i.e. serum 25(OH)D3 levels less than 15 ng/ml, 119 (43.6%) had severe vitamin D deficiency i.e., serum 25(OH)D3 levels, less than 5 ng/ml, 132 (48.4%) had moderate vitamin D deficiency i.e., serum 25(OH)D3 levels, 5-15 ng/ml, 12 (4.4%) vitamin D insufficiency i.e., serum 25(OH)D3 levels 15 - 30 ng/ml and only 10 (3.6%) had adequate vitamin D stores. We found no correlation between 25(OH)D3 levels and PTH, serum albumin, bone alkaline phosphatase, P, and Ca x P. In multiple regression analyses, the independent predictors of 25(OH)D3 were age, presence of diabetes (DM-CRF), levels of serum calcium and serum 1.25(OH)2D3.

CONCLUSION

We found a high prevalence (92%) of vitamin D deficiency in these 273 PD patients, nearly one half of whom had severe vitamin D deficiency. Vitamin D deficiency is more common in DM-CRF patients than in non-DM-CRF patients. Our findings suggest that these patients should be considered for vitamin D supplementation.

Tacrolimus plus low-dose mycophenolate mofetil in renal transplant recipients: better 2-year graft and patient survival than with a higher mycophenolate mofetil dose

OBJECTIVES

Mycophenolate mofetil (MMF) has become more widely prescribed in recent years, but its adverse effects on the gastrointestinal system and bone marrow restrict its use in certain settings. The aim of this study was to compare the demographic features and clinical data for 173 renal transplant recipients who received tacrolimus (TAC) plus 1 g/d MMF (group I, n = 112) versus TAC plus 2 g/d MMF (group II, n = 61 patients) over a 2-year period. Each patient received similar TAC doses.

METHODS

We compared demographic data and clinical data for each case: acute rejection (AR) episodes, chronic rejection (CR) episodes, death, graft loss, development of posttransplantation diabetes mellitus (PTDM), and posttransplantation hypertension rates.

RESULTS

Demographic features were similar. There were also no significant differences between groups I and II with respect to number of AR episodes (17/112 vs 12/61, respectively), number of CR episodes (4/112 vs 1/61, respectively), PTDM, and hypertension rate (P > .05). Kaplan-Meier survival analysis revealed 2-year graft survival rates of 94% in group I versus 83% in group II. The corresponding 2-year patient survival rates were 100% in group I versus 91% in group II. The graft survival and patient survival rates in group I were significantly higher than those in group II (log-rank 0.005 and 0.001, respectively).

CONCLUSIONS

The 2-year graft and patient survival rates for the renal transplant recipients in this study suggest that the combination of a full TAC dose with 1 g/d MMF is a better choice than 2 g/d MMF.

Bone mineral density and its correlation with clinical and laboratory factors in chronic peritoneal dialysis patients

The aim of this study was to assess the clinical and laboratory correlations of bone mineral density (BMD) measurements among a large population of patients on chronic peritoneal dialysis (PD). This cross-sectional, multicenter study was carried out in 292 PD patients with a mean age of 56 +/- 16 years and mean duration of PD 3.1 +/- 2.1 years. Altogether, 129 female and 163 male patients from 24 centers in Canada, Greece, and Turkey were included in the study. BMD findings, obtained by dual-energy X-ray absorptiometry (DEXA) and some other major clinical and laboratory indices of bone mineral deposition as well as uremic osteodystrophy were investigated. In the 292 patients included in the study, the mean lumbar spine T-score was -1.04 +/- 1.68, the lumbar spine Z-score was -0.31 +/- 1.68, the femoral neck T-score was -1.38 +/- 1.39, and the femoral neck Z score was -0.66 +/- 1.23. According to the WHO criteria based on lumbar spine T-scores, 19.2% of 292 patients were osteoporotic, 36.3% had osteopenia, and 44.4% had lumbar spine T-scores within the normal range. In the femoral neck area, the prevalence of osteoporosis was slightly higher (26%). The prevalence of osteoporosis was 23.3% in female patients and 16.6% in male patients with no statistically significant difference between the sexes. Agreements of lumbar spine and femoral neck T-scores for the diagnosis of osteoporosis were 66.7% and 27.3% and 83.3% for osteopenia and normal BMD values, respectively. Among the clinical and laboratory parameters we investigated in this study, the body mass index (BMI) (P < 0.001), daily urine output, and urea clearance time x dialysis time/volume (Kt/V) (P < 0.05) were statistically significantly positive and Ca x PO(4) had a negative correlation (P < 0.05) with the lumbar spine T scores. Femoral neck T scores were also positively correlated with BMI, daily urine output, and KT/V; and they were negatively correlated with age. Intact parathyroid hormone levels did not correlate with any of the BMD parameters. Femoral neck Z scores were correlated with BMI (P < 0.001), and ionized calcium (P < 0.05) positively and negatively with age, total alkaline phosphatase (P < 0.05), and Ca x P (P < 0.01). The overall prevalence of fractures since the initiation of PD was 10%. Our results indicated that, considering their DEXA-based BMD values, 55% of chronic PD patients have subnormal bone mass-19% within the osteoporotic range and 36% within the osteopenic range. Our findings also indicate that low body weight is the most important risk factor for osteoporosis in chronic PD patients. An insufficient dialysis dose (expressed as KT/V) and older age may also be important risk factors for osteoporosis of PD patients.

Sirolimus as Primary Immunosuppression Agent in Kidney Transplant Recipients: Akdeniz University Experience

OBJECTIVES

Recently usage of sirolimus as the primary immunosuppressant is widening among kidney transplant recipients. We reviewed the clinical follow-up of patients transplanted at our center using sirolimus protocols.

METHODS

Sirolimus including primary immunosuppressive treatment protocols were begun in February 2002. Among the 21 patients (15 men, six women) who received sirolimus, six patients were prescribed sirolimus + prednisolone; seven, sirolimus + mycophenolate mofetil + prednisolone; and eight, sirolimus + cyclosporine + prednisolone. The mean age of the patients was 32.9 +/- 7.3 years and the mean posttransplantation follow-up, 13.2 +/- 4.5 months.

RESULTS

Three patients experienced acute rejection episodes, which were treated successfully with steroids. None of the patients had either hematologic or wound healing problems. Lymphoceles developed in eight patients. Serum creatinine level was 1.4 +/- 0.5 mg/dL at 12 months. There was a serious increase in serum cholesterol and triglyceride levels starting from the first month posttransplant (total cholesterol levels pretransplant and at 1 month, respectively: 159.3 +/- 29.5 and 255.7 +/- 52.3 mg/dL, P = .0001; triglycerides pretransplant and at 1 month, respectively: 146.9 +/- 89.5 and 215.1 +/- 102.5 mg/dL, P = .001). Despite routine antihyperlipemic treatment those high levels were maintained for 12 months.

CONCLUSIONS

We achieved 100% graft and patient survival rates for 1 year among patients who were using sirolimus. But the most important role in defining the morbidity and mortality in this group of patients is cardiovascular events; for this reason the abnormalities in the lipid profile must be taken seriously.

The role of the transplant coordinator on tissue donation in Turkey

While solid organs represent the dramatic and lifesaving aspect of donation after death, the transplantation of tissues from donors after death is a much larger-scale activity that benefits enormous numbers of patients, usually in a life-enhancing rather than a lifesaving manner. Some types of tissue transplantation, such as heart valve and cornea transplantation, have been established for many decades and are reasonably well understood by health professionals and the public. Many other types of tissue donation, such as bone, skin, tendons, etc, are much less well known but nonetheless result in beneficial treatment for large numbers of patients. Skin is used to prevent fluid loss and infection following a major burn; bone is used to improve the clinical success of a range of orthopedic operations, such as joint replacements, spinal fusions, and reconstructions following trauma or tumor. In the United States more than 20,000 donors provided cadaveric tissue in 1999, compared to 6,000 in 1994. We ask all families of brain-dead donors for consent for tissue donation. Between January 1, 1999, and January 3, 2003, we had 58 actual cadaveric donors, procuring three skins, 15 tendons, six bones, 13 heart valves, and 40 corneas. We performed three skin, 40 tendon, and three bone transplants as well as storing other tissues. One donor can give health to 50 different recipients. In general, the argument runs for a transplant coordinator "if you can do it, then you must." We can save lives and present a better quality of life with solid organ and tissue donation.

The solution to organ shortage in Turkey: trained transplant coordinators

The organ shortage is a social, psychological, ethical, moral, and probably legal and political problem of the 21st century. It must be solved as soon as possible to save lives; transplant coordinators are important cornerstones in this effort. The first transplant coordinator training course was organized in May, 2002, including 27 participants from different hospitals, but unfortunately only 13 were able to work as transplant coordinators in their hospitals after the course. After the course, the number of cadaveric donors in Turkey increased 12%, compared to 2001. Currently, only 14 hospitals have transplant coordinators and 12 of them are transplant centers. There is no transplant coordinator at 10 transplant centers. Only two nontransplant centers have a transplant coordinator. Eightyeight percent of donors are procured from hospitals with a transplant coordinator. According to data from the Transplantation Society meeting held in Rome, August 2000, there should be 1675 donors in Turkey, but we had only 100 for 2002 and 49 in 1999. Transplant coordinators are essential to organize donation, seeking to achieve the maximum for potential generating capacity (60 brain-dead pmp). So we need approximately 200 (3/pmp) trained transplant coordinators in Turkey but we presently have only 15% of this number.

Impact of chronic renal failure and peritoneal dialysis fluids on advanced glycation end product and iNOS levels in penile tissue: an experimental study

OBJECTIVES

To investigate the impact of chronic renal failure (CRF) on advanced glycation end product and inducible nitric oxide synthase (iNOS) in penile tissue, we examined the advanced glycation end product 5-hydroxy methyl furfural (5-HMF) content and iNOS expression in rats in which uremia had been produced by greater than 85% nephrectomy. In addition, the contribution of peritoneal dialysis (PD) fluids to the elevation of penile tissue 5-HMF levels and iNOS staining scores has been investigated.

METHODS

Adult male Wistar rats, aged between 10 and 12 weeks and weighing 200 to 330 g, were divided into five groups that each included 6 animals. The first group served as a control group. In the second group, CRF was induced and a peritoneal catheter was implanted, but PD was not performed. In group 3, CRF was induced and PD was performed using dialysis fluids containing 1.36% glucose and icodextrin. In group 4, CRF was also induced and PD was performed using 3.86% glucose and icodextrin. Finally, in group 5, without CRF, an indwelling catheter was implanted, and the PD procedure was performed using dialysis fluids containing 3.86% glucose and icodextrin.

RESULTS

The elevation in 5-HMF levels and iNOS staining scores in penile tissue from groups 2, 3, 4, and 5 was significant compared with group 1 (P <0.05). The elevation in 5-HMF levels and iNOS staining scores was also significant between groups 2 and 3, 2 and 4, 3 and 4, 3 and 5, and 4 and 5 (P <0.05). Moreover, the correlation between the 5-HMF levels and iNOS staining scores was statistically significant (r = 0.525, P = 0.003).

CONCLUSIONS

In the present experimental study, we found that 5-HMF levels and iNOS staining scores were significantly elevated in rat penile tissue in which uremia had been produced compared with the groups without CRF. Additionally, PD fluids containing glucose had an effect on the elevation of penile tissue 5-HMF levels and iNOS staining scores.

[Is seat belt sign a predictor for physicians in management of trauma patients in emergency settings?]

Seat belt sign (SBS) is frequently seen as a clinical finding in motor vehicle accidents. The purpose of this study is to determine the diagnostic value of SBS. All adult patients presenting with an history of motor vehicle accident to a tertiary care university hospital emergency department was included in this prospective, observational study covered the time period between July 01, 1999 and February 01, 2000. 213 patients were included in this study; 135 (63.4%) were male, and 76 patients (35.7%) were seat-belted. SBS was seen on 27 (35.5%) belted patients. Fourteen of seat-belted had rib fractures nine of those patients with rib fractures were found to have SBS. There was a statistically significant difference between the patient groups with or without SBS in rib fractures (p = 0.0128) While no significant differences were detected between groups regarding the frequency of intra-cranial, intra-thoracic, intra-abdominal and extremity injuries three of four patients who had sternum and clavicular fractures took place in SBS(+) group (p = 0.090). The presence of SBS in trauma patients may create a high index of suspicion for thoracic injuries, especially for rib fractures. It is widely accepted that any delay in the diagnosis may increase morbidity and mortality following thoracic injuries. Further studies are needed to investigate the possible role of SBS in the prediction of the severity of injuries following thoracic trauma.

[The role of computed tomography for minor head injury]

Head trauma is a major health problem which affects young people, especially young males and also causes serious economic losses. Although major head injuries are cause greater morbidity and mortality, minor head injuries are more common presentations to emergency departments. In this study our goal is to determine the prevalence of CT usage in minor, adult head injury patients and determine clinical variables for the use of head CT scans. In our study we retrospectively examined 230 adult head injury patients who were presented to the Dokuz Eylül University Medical School Hospital Emergency Department. We recorded age, gender, symptoms of nausea, vomiting, headache, alcohol use, physical examination findings, history of loss of consciousness prior to presentation, concurrent injuries, and Glasgow Coma Scale (GCS) scores. Head CT ordering and abnormal findings were correlated with the above clinical variables. We ascertained that all variables affected the ordering of CT scans except age, gender and alcohol use. The prevalence of abnormal head CT in all patients were 21.7%. We found that GCS is only one clinical variability of which statistically significant relationship to acquaint abnormal CT findings.

Chemical peritonitis associated with high dialysate acetaldehyde concentrations

BACKGROUND

During the standard heat sterilization process of lactate-buffered peritoneal dialysis (PD) solutions, glucose degrades to form compounds called glucose degradation products such as acetaldehyde, formaldehyde, or glyoxal. Despite evidence that these products may be responsible for some in vitro cytotoxic effects induced by commercially available PD fluids, data on their acute or chronic effects on the human peritoneum is scarce.

SUBJECTS AND METHODS

This case presentation is based on an observation of 21 aseptic peritonitis cases of unknown aetiology. All cases appeared within one month in a university hospital PD unit that had a peritonitis rate of 1 episode/26 patient months and 55 active patients on CAPD. Acetaldehyde level in the bags was assayed by gas chromatography.

RESULTS

Twenty-one patients presented with signs of peritonitis including cloudy dialysate and abdominal tenderness with additional abdominal pain in 11 patients and vomiting in one. In all cases, cultures and Gram stains were negative for micro-organisms. Fever was not observed in any patient. Average dialysate white blood cell count was 1795/mm(3). All patients were free of intraperitoneal medication when symptoms appeared. Patients were using PD solutions from a newly established domestic production plant. Apparently all patients with symptoms of peritonitis used bags with the same lot number and the solution in the bags appeared to be darker in colour than that in bags with other lot numbers. Chemical analysis of the unused PD solution samples revealed acetaldehyde levels of 17-20 p.p. m. in bags containing darker solution, which is very high compared with the usual acetaldehyde level of 6 p.p.m. in heat-sterilized PD solutions.

CONCLUSIONS

Based on the above findings, we hypothesize that higher levels of acetaldehyde and possibly other glucose degradation products may have been an aetiological factor in these 21 cases of chemical peritonitis. Our observation suggests that acetaldehyde, in concentrations 3-4 times higher than the usual level in commercially available PD solutions, may induce acute sterile peritonitis in CAPD patients.

Effect of cefodizime on peritoneal mononuclear- and polymorphonuclear-cell chemotaxis

In this study, a third-generation cephalosporin with proposed immunomodulatory properties, cefodizime, was investigated to see if it has any effect on the chemotactic activity of human peritoneal monocyte and polymorphonuclear cell populations ex vivo. Ten continuous ambulatory peritoneal dialysis patients with peritonitis were entered in the study. Monocytes and polymorphonuclear cells were isolated from the patients' peritoneal effluent prior to initiation of any antibiotic therapy. Chemotaxis was measured by the Boyden chamber method before and after 2-hour incubation with cefodizime (200 mg/2L). Following 2-hour incubation with 200 mg/2L cefodizime, monocyte chemotaxis was increased from 36.8 +/- 5.6 microns to 50.2 +/- 6.6 microns (P = 0.0005). A similar increase was observed in polymorphonuclear cells from 42.0 +/- 8.8 microns to 48.7 +/- 10.3 microns (P = 0.02). We conclude that cefodizime acts as a priming agent on peritoneal polymorphonuclear cells, particularly on monocytes, and increases their chemotactic movements.

Computerized tomography with and without intraperitoneal contrast for determination of intraabdominal fluid distribution and diagnosis of complications in peritoneal dialysis patients

Seven computed tomography scans and 19 computed tomograph peritoneography (CTP) studies performed in 20 peritoneal dialysis patients were analyzed retrospectively as to their diagnostic usefulness in peritoneal dialysis related complications. Computed tomographic peritoneography was found to be superior to computed tomography scans in localizing small leak sites. In seven of nine patients with clinically diagnosed dialysate leakage, computed tomographic peritoneography supported the clinical diagnosis and localized the leak site in six patients. All patients with a conspicuous leak site and/or with leaks through hernias had to have surgical treatment. Computed tomographic peritoneography failed to reveal a leak or identify a fluid tract in patients with intermittent, small leaks. Those leaks responded easily to a dialysis regimen with diminished intraabdominal pressure. Normal intraperitoneal fluid distribution was based on 17 studies after intraperitoneal infusion of 2,000 ml of peritoneal dialysis solution in patients without intraabdominal organomegaly and/or any clinical suspicion of fluid maldistribution, with average peritoneal transport characteristics. As appraised in the supine position, approximate fluid contents in the intraperitoneal spaces were pelvis, 30-55%; paracolic gutter, 15-30%; perisplenic and perihepatic, 10-20% each, and lesser sac, 1-3%. Severe fluid maldistribution on computed tomography peritoneography, particularly a small fluid volume in the pelvic space, is a poor prognostic sign as to the feasibility of peritoneal dialysis; neither of our two patients with no fluid in the pelvic space could be maintained on peritoneal dialysis, while patients with no fluid in the lesser sac, perihepatic and perisplenic spaces could be maintained on peritoneal dialysis. No fluid was seen in the peritoneal cavity after drainage in the vertical position.(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence for the histamine-mediated myotropic effect of angiotensin II in the rabbit aorta

Histamine H1-receptor antagonist mepyramine and H2-receptor antagonist metiamide, respectively diminished and potentiated angiotensin II(A II)-induced myotropic responses in the rabbit aortic strips. The responses of the octapeptide were also inhibited in the presence of histidine decarboxylase inhibitor, 2-hydroxy-5-carbomethoxybenzoxyamine and restored when subcontractile quantities of histamine are added to the inhibitor-containing medium. Inhibition of histamine degradation by aminoguanidine potentiates A II's responses. These results are taken as evidences indicating A II-induced histamine synthesis in the test preparation.