Effect of hemoglobin variability on mortality and some cardiovascular parameters in hemodialysis patients

BACKGROUND AND OBJECTIVES

Most hemodialysis patients show hemoglobin fluctuations between low-normal and high levels. This hemoglobin variability may cause left ventricle hypertrophy and may increase mortality as well. Recently, many studies were designed to evaluate the effect of hemoglobin variability on mortality but results were conflicting. We aimed to investigate the effect of hemoglobin variability on mortality and some cardiovascular parameters in hemodialysis population.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

Hundred and seventy-five prevalent hemodialysis patients classified into three hemoglobin variability groups according to their hemoglobin levels throughout 24 month observation period: Low-Normal, Low-High, Normal-High. Groups were compared in terms of laboratory, demographical data and mortality rates, initial and the end of 24 month echocardiographic data. Initial and last echocardiographic data were compared within groups in terms of left ventricle mass index increase.

RESULTS

Mortality rates and cardiovascular risk factors such as coronary heart disease, diabetes mellitus and hypertension that may affect mortality were same between three groups. There was no significant difference between three groups in terms of echocardiographic and laboratory parameters. Only Low-High group showed significant increase on left ventricle mass index when initial and last echocardiographic parameters were compared.

CONCLUSIONS

Consistent with previous studies, we found that most of the patients exhibited hemoglobin variability and our study is consistent with some of the studies that did not find any relationship between hemoglobin variability and mortality. Firstly, in this study based on objective data, it was shown that hemoglobin variability has adverse effect on left ventricle geometry independent from anemia.

Prevalence of and factors affecting pulmonary hypertension in hemodialysis patients

BACKGROUND

Pulmonary hypertension (PH) has been reported to be high among end-stage renal disease (ESRD) patients.

OBJECTIVES

The aim of this study was to investigate the role of arteriovenous fistula (AVF) flow in the pathogenesis of PH and the prevalence of PH in patients with chronic renal failure (CRF) and to suggest other possible etiologic factors.

METHODS

The prevalence of PH was prospectively estimated by Doppler echocardiography in 116 ESRD patients on regular hemodialysis (HD). Laboratory and clinical variables were compared between patients with and without PH (groups 1 and 2, respectively). PH was defined as systolic pulmonary artery pressure (SPAP) over 30 mm Hg. Patients with PH underwent further evaluation by 2 pulmonologists. AVF flow was measured by Doppler ultrasonography. Blood tests including arterial blood gases, hemoglobin, serum calcium, phosphorus and parathyroid hormone were determined.

RESULTS

PH was found in 25 (21.6%) patients (group 1) with an SPAP of 37.9 ± 2.8 mm Hg. Mean AVF flow was increased (1,554 ± 207.60 ml/min) in group 1. Left ventricular ejection fraction (LVEF) was significantly different between the 2 groups (55.3 ± 11.5 and 64.4 ± 40, respectively; p < 0.05). Neither significant primary lung disease nor parenchymal lesions were detected in group 1. PH showed a significant difference for cigarette smoking (p < 0.05). In group 1 the prevalence of cigarette smoking was higher. The main etiology of CRF was diabetes mellitus with a ratio of 44% in group 1.

CONCLUSION

Our study demonstrated a surprisingly high prevalence of PH among patients receiving long-term HD. PH was related to high AVF flow, low LVEF and cigarette smoking. AVF flow and cigarette smoking are important correctable causes of PH. Early detection is important in order to avoid the serious consequences.

Efficacy and tolerability of pegylated-interferon alpha-2a in hemodialysis patients with chronic hepatitis C

BACKGROUND AND AIM

Hepatitis C virus (HCV) is prevalent in hemodialysis (HD) patients. These patients experience more side-effects with antiviral treatment. The aim of the present study was to evaluate the efficacy and tolerability of pegylated interferon (PEG-IFN) alpha-2a in chronic hemodialysis patients with chronic hepatitis C.

METHODS

Twenty-five patients were included into the study. All of the patients were interferon naive, anti-HCV antibodies positive and polymerase chain reaction HCV-RNA positive. Twelve of the patients received PEG-IFN alpha-2a at a dose of 135 microg weekly for 48 weeks (Group 1). The remaining 13 patients who received no specific treatment were used as controls (Group 2). The patients were prospectively followed up for a period of 18 months. Biochemical and virological responses were evaluated at the end of the study period (end-of-treatment response) and 6 months after the completion of therapy (sustained response).

RESULTS

Virological end-of-treatment response was observed in 10 patients (83.4%) in Group 1 and one patient (7.7%) in Group 2 (P < 0.001). Sustained virological response was observed in nine patients (75%) in Group 1 and one patient (7.7%) in Group 2 (P < 0.001). Alanine aminotransferase (ALT) levels were initially increased in seven patients in Group 1 and normalized in five of these patients at the end of the treatment and sustained biochemical response was 71.4%. In contrast, ALT levels in Group 2 were initially high in five patients and normalized in two of them (40%) at the end of the 48 weeks. Even if most of the patients experienced several side-effects (anemia 75%, fatigue 58.3%, thrombocytopenia 33.3% and leukopenia 33.3%), they did not impose the discontinuation of the treatment.

CONCLUSION

The present study showed that PEG-IFN alpha-2a for 48 weeks is efficacious and well tolerated in hemodialysis patients with HCV.

Sagliker syndrome: uglifying human face appearance in late and severe secondary hyperparathyroidism in chronic renal failure

Almost every patient with chronic renal failure (CRF) eventually develops secondary hyperparathyroidism (SH) unless they are treated with proper and novel medications in advanced medical centers by skilled medical personnel. Every kind of bone abnormality including skull deformities has been described in detail by almost every concerned researcher and textbook, but descriptions of this phenomenon are limited in the medical literature to the years from 1973 to 1977. To our knowledge, extensive data regarding uglifying human face appearances have not been defined so far in the literature. We are therefore making this addition to the clinical nephrology field by accumulating such data. After we found 2 consecutive peculiar and unique patients with uglifying human face appearances in 2000, we attempted to inform and draw attention to this new entity to all hemodialysis (HD) centers in Turkey, as well as in other developing countries around the world to collect data on this phenomenon. Accordingly, we visited dialysis centers and patients' houses to collect detailed information, including medical clinical histories, physical examinations, laboratory data, biographies, current medications, and so forth. We found 25 patients who had CRF, SH, short stature, extremely severe skull changes, maxillary and mandibular bone changes, teeth/dental abnormalities, and soft and innocuous tumoral tissues in the mouth (hence, uglifying the appearance of the face), fingertip changes, severe psychologic problems, and depression. It appears that patients with CRF may have a new syndrome of bone deformities that have long been neglected, ignored, and forgotten since the mid-1970s when they were first described. This is vital and critical information for the clinical status of patients who suffered from the syndrome that we have named Sagliker syndrome (SS), and we believe there are many more patients in the world who are suffering from it.

Impression cytology changes and corneoconjunctival calcification in patients with chronic renal failure

OBJECTIVE

To evaluate the relationship between corneoconjunctival calcification and conjunctival squamous metaplasia in patients with chronic renal failure (CRP).

STUDY DESIGN

We studied impression cytology in 45 CRF patients on regular hemodialysis and 30 age- and sex-matched controls. Specimens were obtainedfrom the temporal bulbar conjunctiva using cellulose acetate filter paper. The samples were fixed in a mixture of 70% ethyl alcohol, 37% formaldehyde and glacial acetic acid and then stained with a combination of periodic acid- Schiff and Gill's modified Papanicolaou stain and graded by a masked observer. Corneoconjunctival calcification was graded by the Porter-Crombie classification.

RESULTS

Of 45 study patients, 4 (9%) disclosed grade 0, 23 (51%) grade 1, 14 (31%) grade 2 and 4 grade 3 (9%) impression cytology changes. There was a statistically significant difference between the patient and control groups (p < 0.001). Calcium deposits were more frequent and extensive in CRF patients than in controls (p = 0.01). There was no correlation between impression cytology and calcium deposit grades (p = 0.128). However the presence of conjunctival inflammation correlated with the existence of extensive squamous metaplasia (p < 0.001).

CONCLUSION

The severity of conjunctival changes in CRF patients on regular hemodialysis are not related to calcium deposition but to acute conjunctival inflammation.