Laparoscopic Findings of Peritoneal Dialysis Catheter Malfunction and Management Outcomes

Objective

Peritoneal dialysis catheter malfunction is a common complication forcing conversion to hemodialysis. The purpose of this study was to evaluate laparoscopic findings of catheter malfunction and to establish a relationship between those findings and the outcomes of procedures performed.

Design

Retrospective study.

Setting

A tertiary referral center.

Patients

40 consecutive patients with stage 5 chronic kidney disease underwent 46 laparoscopic correction procedures for the treatment of peritoneal dialysis catheter malfunction between November 1994 and August 2004.

Main Outcome Measures

Laparoscopic findings of catheter malfunction, procedures performed, catheter survival, and recurrent cases were evaluated.

Results

There were 28 tip migrations in 40 patients; 16 were without adhesions and 10 were associated with omental adhesions. Reposition and adhesiolysis were the most frequent procedures performed. Malfunction recurred in 12 patients and 5 of them underwent 6 secondary laparoscopic procedures. Estimated mean catheter survival was 19.9 ± 3.32 months (%95 confidence interval 13.43 – 26.46).

Conclusions

The most frequent laparoscopic finding was catheter tip migration, with or without adhesions. Laparoscopic repositioning and adhesiolysis without omentectomy are simple and effective procedures that can prolong catheter survival, even in recurrent malfunctions.

Tissue Doppler Echocardiography and Myocardial Performance Index in Patients with Scleroderma

In this study, left and right ventricular functions were examined echocardiographically in 22 patients with scleroderma and 22 healthy volunteers. Conventional and tissue Doppler echocardiography and myocardial performance indexes were used as measures of right and left ventricular global functions. Mitral early diastolic E wave deceleration time, isovolumetric contraction time and left ventricular myocardial performance index and peak tricuspid A wave velocity were significantly higher in the scleroderma group compared with the control group. Mitral and tricuspid E/A ratios were significantly lower in patients with scleroderma. In addition, mitral annular and tricuspid annular isovolumetric relaxation times and the tricuspid E/E' ratio were significantly increased in scleroderma patients compared with the control group. In conclusion, in scleroderma patients the global left ventricular functions were depressed and diastolic function abnormalities were seen in both right and left ventricles. In addition, longitudinal muscle functions of the ventricles were depressed in scleroderma patients, as shown by tissue Doppler imaging parameters.

Ki-67 proliferation index in renal biopsy samples of patients with systemic lupus erythematosus and its correlation with clinical findings

INTRODUCTION

Systemic lupus erythematosus is an autoimmune disease that may affect almost all organ systems. Renal involvement is the most significant prognostic factor. Renal biopsy findings play an important role in treatment decision. Ki-67 is a monoclonal antibody that is only found in proliferative cells. This study aimed to investigate the proliferative activity in renal biopsy specimens of patients with lupus nephritis using the Ki-67 monoclonal antibody, and to compare the proliferative index between different subgroups of patients.

MATERIALS AND METHODS

Renal biopsy specimens of 29 patients with systemic lupus erythematosus were retrospectively evaluated. Type of lupus nephritis and activity and chronicity indexes were determined. Ki-67 immunostaining was performed. For each patient, 1000 cells were counted and the number of Ki-67 positive cells was determined. The Ki-67 activity index was compared between different subgroups of lupus nephritis and correlated with systemic lupus erythematosus disease activity index, serum creatinine, proteinuria, anticardiolipin antibodies, and complement levels.

RESULTS

A positive correlation between Ki-67 proliferation index, serum creatinine levels, and systemic lupus erythematosus disease activity index were found. Although conventional activity indexes were low, in 3 of 9 patients with class II lupus nephritis, Ki-67 proliferation indexes were high, indicating proliferation.

CONCLUSIONS

Ki-67 can be used as a proliferation marker in renal biopsy specimens for patients diagnosed with systemic lupus erythematosus.

Interleukin-2 gene polymorphism in Turkish patients with Behçet's disease and its association with ocular involvement

Behçet's disease (BD) is a chronic immune-mediated systemic disease, characterized by oral and genital lesions and ocular inflammation. Several cytokine genes may play crucial roles in host susceptibility to BD, because the cytokine production capacity varies among individuals and depends on the cytokine gene polymorphisms. The association of the interleukin (IL)-2 gene polymorphisms with the susceptibility to BD was investigated in this study. DNA samples were obtained from a Turkish population of 97 patients with BD and 76 healthy control subjects. Polymorphisms of IL-2 gene at position -330 and +166 were determined using the polymerase chain reaction with sequence-specific primers. In the patients with BD, there was a significantly increased frequency of IL-2 -330 GT genotype. Interestingly, we demonstrated that the frequencies of IL-2 -330 GT and IL-2 + 166 GG genotypes were increased in BD patients with ocular involvement, whilst IL-2 -330 TT genotype was significantly decreased. Also, analysis of allele frequency demonstrated that the presence of G allele at position +166 of IL-2 seems to be a risk factor for ocular involvement. These results reveal that IL-2 -330 GT genotype may be a susceptibility factor for BD, whereas IL-2 -330 TT genotype seems to display a protective association with BD. Additionally, IL-2 gene polymorphisms might be associated with ocular involvement in BD.

The time course of gastric methotrexate intolerance in patients with rheumatoid arthritis and psoriatic arthritis

OBJECTIVES

This study aimed to evaluate the incidence and the time course of methotrexate (MTX)-associated gastric intolerance in patients with rheumatoid arthritis and psoriatic arthritis.

METHODS

Four hundred twenty subjects undergoing MTX treatment for rheumatoid arthritis (n = 346) and psoriatic arthritis (n = 74) were retrospectively assessed. The incidence and time course of gastric MTX intolerance resulting in treatment discontinuation were investigated. In addition, the relations between gastric intolerance and patient characteristics, including gender, age, diagnosis, and rheumatoid factor (RF) positivity, were examined.

RESULTS

Overall, oral MTX discontinuation rate due to gastric intolerance was 28.6 %. The time to discontinuation for oral MTX was 8.1 ± 11.5 months on average, with more than half of the discontinuations occurring within the first three months of treatment. Discontinuation was not associated with gender, age, diagnosis, or RF positivity. More than half of the patients that switched to a parenteral treatment regimen (52.6 %, 20/38) could tolerate the agent.

CONCLUSIONS

Gastric MTX intolerance usually develops within the first year of treatment and presents a major obstacle to long-term treatment retention in patients with rheumatologic disease. However, parenteral MTX appears to be a good alternative for patients intolerant of oral MTX.

Tumor necrosis factor-alpha antagonist therapy-induced psoriasis in Turkey: analysis of 514 patients

OBJECTIVES

New adverse events are being reported with the increased use of anti-tumor necrosis factor (TNF) α therapy. We studied cases of anti-TNFα-induced psoriasis observed in our pool of 514 patients receiving anti-TNFα treatment in Turkey.

METHODS

Three rheumatoid arthritis patients and 3 ankylosing spondylitis patients with anti-TNFα-induced psoriasis were included in the study. All patients were examined by a dermatologist, and 3 patients underwent skin biopsy.

RESULTS

None of the 6 patients had preexisting psoriasis or a familial history of psoriasis. The earliest and latest occurrences of psoriatic lesions were at the 6th week and 44th month of anti-TNFα therapy, respectively. Psoriasis was severe and refractory in two patients (requiring systemic treatment), while it presented as mild in four patients. Anti-TNFα therapy was totally withdrawn in case 1. In case 2, the treatment was halted for 3 months then switched to another TNFα blocker, and case 3 was switched to another anti-TNFα treatment. The treatment was sustained in the other 3 patients (cases 4, 5, and 6).

CONCLUSIONS

TNFα blockers are very effective agents in the treatment of psoriasis, but it is interesting that the same molecules can, paradoxically, induce psoriasis. The occurrence of anti-TNFα-induced psoriasis in six out of 514 patients suggests that the incidence of this adverse reaction is, in fact, as not low as presumed in the literature. In some cases, a severe course of psoriasis may limit the use of these agents.

Paraoxonase Activity in Glomerulonephritic Patients

BACKGROUND

Cardiovascular disease is the most common cause of morbidity and mortality in patients with chronic renal failure. Glomerulonephritic patients have an increased risk for cardiovascular disease, but its etiology is unclear. It is known that an increase in oxidizability of apolipoprotein B-containing lipoproteins has a key role in the initiation of atherosclerosis, and paraoxonase enzyme activity particularly has a preventive role against atherosclerosis. The aim of the present study was to evaluate the oxidizability of apolipoprotein B-containing lipoproteins, serum, and urinary paraoxonase/arylesterase activities in glomerulonephritis patients who had normal lipid parameters and creatinine levels.

METHODS

Thirty-two patients with glomerulonephritis and 22 healthy controls were included in this study. A total of 32 patients (including nine with membranous GN, eight with immunoglobulin A nephropathy, eight with mesangial proliferative GN, five with focal-segmental glomerulosclerosis, one with diffuse proliferative GN, and one with minimal chance disease having biopsy proven GN) were enrolled into the study. We compared serum and urinary paraoxonase, arylesterase, serum lipids, urea, creatinine, hemoglobin, total protein and albumin values between groups.

RESULTS

Serum urea, creatinine, total protein, albumin, uric acid, hemoglobin, and lipid parameters were similar in the glomerulonephritis and control groups (p > 0.05). PON1 activity was significantly lower in GN group than controls, but there was no statistically significant difference on arylesterase activity between groups. Oxidizability of apolipoprotein B-containing lipoproteins was significantly higher in GN group than controls.

CONCLUSION

Our study shows that the findings of normal serum levels of creatinine, lipids, and proteins increased the oxidizability of apolipoprotein B-containing lipoproteins, and any decrease in PON1 activity in patients diagnosed with GN should be considered important. Hence, the immediate commencement of preventive as well as curative treatment in other to avoid the risk of cardiovascular and renal problems would be a correct approach.

Cytokine gene polymorphisms in Behçet's disease and their association with clinical and laboratory findings

The association of the cytokine gene polymorphisms with the development of Behçet's Disease (BD) was investigated in this study. DNA samples were obtained from a Turkish population of 97 unrelated patients with BD, and 127 unrelated healthy control subjects.All genotyping (IL-6, IL10, IFN-gamma, TGF-Beta1 and TNF-alpha) experiments were performed using sequence-specific primers PCR. The frequency of TGF-Beta1 codon 25 GG genotype was found significantly lower in BD patients compared to healthy control subjects. The IL-10 -1082 GA genotype was more frequent whereas the AA genotype was less common in the BD group compared to the control group. The association between clinial findings and cytokine gene polymorphisms was further investigated in the patients with BD. The frequency of IFN-gamma AA genotype was lower in the patients with genital ulcer. Additionally, it was found that the frequency of IL-6 -174 GG genotype was lower in the patients with Pathergy positivity. These results suggest that TGF-Beta1 and IL-10 gene polymorphisms may affect host susceptibility to BD. Also, to confirm the biological significance of our results, further studies should be performed on other population groups and in large number of cases.

Efficacy of a self-management program for osteoporotic subjects

OBJECTIVE

This study is based on whether the self-management program choices For Better Bone Health is effective to promote behavioral strategies for improving bone health, life quality, pain perception, physical function, and balance in osteoporotic subjects.

DESIGN

In this single-blind, randomized controlled study, a total of 50 sedentary women with postmenopausal and idiopathic osteoporosis were selected from the outpatients of Atatürk Balneotherapy and Rehabilitation Center according to their physical activity level and T scores of dual-energy x-ray absorptiometry as the inclusion criteria. Fifty sedentary women with BMD T scores of -2.5 or lower were randomized into two groups (self-management group: group 1; and control group: group 2) and enrolled in a 6-mo study. Participants attended self-management class once a week for 5 wks. Evaluations were done at baseline, at the end of the fifth week, and at the sixth month. Pain-intensity evaluation by Visual Analogue Scale (VAS), life-quality assessments by SF-36, balance testing by Sensitized Romberg Test (SRT), and functional assessment by Timed Sit to Stand test (TSS) and a simple questionnaire were the outcome measures.

RESULTS

When the groups were compared by change scores and percentages of change, improvements observed in pain intensity by VAS (P < 0.001), SF-36 Physical Function (P < 0.001), SF-36 Physical Role Limitations (P < 0.001), SF-36 Social Function (P < 0.001), SF-36 Mental Health (P < 0.001), SF-36 Vitality (P < 0.01), SF-36 Pain (P < 0.001), SF-36 General Health Perceptions (P < 0.05), SF-36 Emotional Role Limitations (P < 0.01), SRT eyes open (P < 0.001), SRT eyes closed (P < 0.001), and TSS (P < 0.001) were determined to be superior in group 1 at the end of the sixth month. Seventy-four percent of patients in group 1 engaged in regular physical activities, and 92% of them declared that they understood the purpose and benefits of medications and dietary calcium intake. Fifty-seven percent of them formed personal plans for preventing traumas, whereas 8% of the subjects in group 2 experienced new falls but no fractures.

CONCLUSION

It is determined that the self-management class led to improvements in functional, balance, and life-quality outcomes and to reductions in pain perception.

Arterial elasticity measurement in renal transplant recipients

Arterial distensibility is reduced in chronic kidney disease (CKD) and after kidney transplantation. Pulse counter analysis provides an assessment of compliance or elasticity of the large conduit arteries (C1) and small arteries (C2). Decreased compliance has been shown to be predictive of primary coronary events in CKD patients. The aim of the present study was to compare elasticity measurements in hemodialysis (HD) patients, renal transplant recipients (RTR), and healthy subjects whose coronary angiographies were without lesion. Twenty-three RTRs, 18 HD patients, and 20 healthy subjects were included in the study. Pulse wave analysis was used to determine large and small vessel compliances. The C1 and C2 levels were significantly lower in HD patients compared with recipients and healthy subjects. Recipients showed lower C2 level compared with healthy subjects. There was no difference in C1 and C2 measurements between recipients receiving tacrolimus versus cyclosporine. Transplantation improves large and to some extend small artery elasticities in CKD patients.

Comparison of higher dose of losartan treatment with losartan plus carvedilol and losartan plus ramipril in patients with glomerulonephritis and proteinuria

BACKGROUND

Proteinuria may cause a worsening of accompanying renal disease or even lead to glomerulosclerosis. There is no data about the effect of carvedilol on patients with proteinuric (>0.5 g/day) glomerulonephritis. This study aimed to compare the effects of carvedilol with ramipril and losartan in patients with proteinuric glomerulonephritis.

METHODS

Twenty-one glomerulonephritis patients were followed for 12 months. Patients were divided into three groups. All patients were treated with losartan 50 mg once daily for two weeks. After two weeks (baseline), patients were given additional medications: 50 mg losartan, 5 mg ramipril, and 25 mg carvedilol were given additionally to the patients in groups 1, 2, and 3 respectively.

RESULTS

Baseline mean proteinuria values of patients in groups 1, 2 and 3 were 1.6 +/- 1.1 g/day, 2.1 +/- 1.3 g/day, and 1.4 +/- 1.2 g/day, respectively. These values decreased to 0.5 +/- 0.7 g/day, 0.6 +/- 0.7 g/day, and 0.9 +/- 0.9 g/day, respectively, at the end of the 12th month. These results were statistically significant only in group 1 (p = 0.04). The rational variation of proteinuria between the first and 12th month of losartan, ramipril, and carvedilol were -61%, -62%, and -27%, respectively. The decreases in blood pressures between baseline and the first, sixth, and twelfth-month measurements were significant in all groups.

CONCLUSIONS

Thee results showed that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (AT1ras) provide marked decreases in proteinuria, making their use indisputable in patients with glomerulonephritis. Carvedilol was not found to be as effective as ACEIs and AT1ras in decreasing proteinuria and preserving renal function.

Laser Acupuncture in Knee Osteoarthritis: A Double-Blind, Randomized Controlled Study

OBJECTIVE

The purpose of this study was to investigate the effects and minimum effective dose of laser acupuncture in knee osteoarthritis (KOA), and to determine if it is superior to placebo treatment (sham) in the evaluation of clinical-functional outcome and quality of life.

METHODS

In this randomized, placebo-controlled study, patients with grade 2 and 3 primary KOA were selected. Group I (n = 27) received 904-nm low-level laser irradiation with 10 mW/cm(2) power density, 4 mW output power, 0.4 cm(2) spot size, 0.48 J dose per session, and 120-sec treatment time on the medial side of the knee to the acupuncture point Sp9. Group II (n = 25) received placebo-laser therapy at the same place on the same point. Patients in both of the groups had treatment 5 days per week (total duration of therapy was 10 days) and 20 min per day. The study was comprised of a 2-week (10-session) intervention. Participants were evaluated before treatment (baseline), after treatment (2nd week), and at the 12th week. In this double-blind study, a blind examiner carried out all outcome assessments. The main outcome measures were as follows: pain on movement (pVAS), 50-foot walking time (50 foot w), knee circumference (KC), medial tenderness score (MTS), Western Ontario and McMaster Universities osteoarthritis index (WOMAC), and Nottingham Health Profile (NHP).

RESULTS

Statistically significant improvement was observed in PVAS, 50 foot w, and KC in group 1. In Group II, statistically significant improvement was observed in PVAS, 50 foot w, and WOMAC. When groups were compared with each other, the improvement observed in KC was superior in Group I at the 2(nd) week (p = 0.005).

CONCLUSION

Laser acupuncture was found to be effective only in reducing periarticular swelling when compared with placebo laser.

The effect of balneotherapy on patients with ankylosing spondylitis

OBJECTIVE

To compare the effect of balneotherapy on physical activity and quality of life as well as the symptoms of pain and stiffness with exercise alone in ankylosing spondylitis (AS) patients.

METHODS

A total of 60 patients who had a diagnosis of AS according to the modified New York criteria were included in the study. The patients were randomly assigned to two groups. In Group I (n = 30) the patients received balneotherapy in a therapeutic pool for 30 min once a day for 3 weeks. All patients received instructions on the exercise programme, which they were requested to repeat once a day for 30 min during the study. The patients in this group continued the same exercise programme after the end of the balneotherapy protocol to complete a course of 6 months. In Group II the patients were given the same exercise protocol but did not receive balneotherapy. Patients were evaluated before the start of the study and at 3 weeks and 24 weeks. Evaluation parameters were daily and night pain, morning stiffness, the patient's global evaluation and the physician's global evaluation (according to a scoring system of 1 to 5), the Bath Ankylosing Spondilitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Dougados Functional Index (DFI), tragus-wall distance, chest expansion, modified Shober test (MST), fingertip-fibula head distance, and Nottingham Health Profile (NHP).

RESULTS

Evaluations were completed in 54 patients in the two groups. Comparison of the groups showed significantly superior results for Group I for parameters of BASDAI, NHP total, pain, physical activity, tiredness and sleep score, patient's global evaluation and the physician's global evaluation at 3 weeks, but only for the parameters of patient's global evaluation and MST at 24 weeks.

CONCLUSION

Balneotherapy has a supplementary effect on improvement in disease activity and functional parameters in AS patients immediately after the treatment period. However, in the light of our medium-term evaluation results, we suggest that further research is needed to assess the role of balneotherapy applied for longer durations in AS patients.

Effect of indomethacin and selective cyclooxygenase-2 inhibitors on proteinuria and renal function in patients with AA type renal amyloidosis

AIMS

Because the cardiovascular system (CVS) side-effects of cyclooxygenase-2 (COX-2) selective inhibitors have recently been questioned, we aimed to compare the renal and haemodynamic effects of cyclooxygenase selective (celecoxib and rofecoxib) and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) (indomethacin) in patients with renal amyloidosis secondary to rheumatological diseases who required anti-inflammatory agents and are taking maximum tolerable dose of angiotensin-converting enzyme inhibitors.

METHODS

The present study was performed on 11 patients with stable proteinuria who were diagnosed as AA amyloidosis secondary to rheumatological diseases confirmed by renal biopsies. The study had three consecutive stages (celecoxib 200 mg/day; indomethacin 100 mg/day; rofecoxib 25 mg/day.) Each was given for 4 weeks and a wash-out phase of 3 weeks was allowed between consecutive stages.

RESULTS

Although the decrease of proteinuria in the celecoxib period was higher than in the rofecoxib and indomethacin periods, the difference was not statistically significant. No statistically significant differences were found between serum urea, creatinine, creatinine clearance and urinary sodium excretion.

CONCLUSION

In this study, no differences were found between indomethacin and the two selective COX-2 inhibitors in respect to proteinuria and renal functions in 11 patients with renal amyloidosis secondary to rheumatological diseases with varying degrees of proteinuria. Routine doses of NSAIDs brought no additional benefit to the ACE inhibitor use in terms of proteinuria and renal functions. The use of selective COX-2 inhibitors should be limited to their anti-inflammatory and analgesic effects in this population.

A modified yoga-based exercise program in hemodialysis patients: a randomized controlled study

AIM

To evaluate the effects of a yoga-based exercise program on pain, fatigue, sleep disturbance, and biochemical markers in hemodialysis patients.

MATERIALS AND METHODS

In 2004 a randomized controlled trial was carried out in the outpatient hemodialysis unit of the Nephrology Department, Uludag University Faculty of Medicine. Clinically stable hemodialysis patients (n=37) were included and followed in two groups: the modified yoga-based exercise group (n=19) and the control group (n=18). Yoga-based exercises were done in groups for 30 min/day twice a week for 3 months. All of the patients in the yoga and control groups were given an active range of motion exercises to do for 10 min at home. The main outcome measures were pain intensity (measured by the visual analogue scale, VAS), fatigue (VAS), sleep disturbance (VAS), and grip strength (mmHg); biochemical variables-- urea, creatinine, calcium, alkaline phosphatase, phosphorus, cholesterol, HDL-cholesterol, triglyceride, erythrocyte, hematocrit--were evaluated.

RESULTS

After a 12-week intervention, significant improvements were seen in the variables: pain -37%, fatigue -55%, sleep disturbance -25%, grip strength +15%, urea -29%, creatinine -14%, alkaline phosphatase -15%, cholesterol -15%, erythrocyte +11%, and hematocrit count +13%; no side-effects were seen. Improvement of the variables in the yoga-based exercise program was found to be superior to that in the control group for all the variables except calcium, phosphorus, HDL-cholesterol and triglyceride levels.

CONCLUSION

A simplified yoga-based rehabilitation program is a complementary, safe and effective clinical treatment modality in patients with end-stage renal disease.

Balneotherapy and tap water therapy in the treatment of knee osteoarthritis

To investigate if spa water is superior to tap water (TW) in relieving the symptoms of pain, joint motion, life quality in knee osteoarthritis (KOA) patients. In this randomized placebo-controlled trial, 52 patients with KOA were followed in two groups. In group I (n = 27), patients were treated in the pool full of spa water at 37 degrees C for 20 min a day, 5 days a week, for a period of 2 weeks. In group II (n = 25), the same protocol was used but spa water was replaced by TW heated to 37 degrees C. Patients in both groups were given a home-based standardized exercise program. Evaluation parameters were pain (pVAS), tenderness score (TS), 50-ft walking duration, quadriceps muscle strength (QMS), active flexion degree (AFD), WOMAC OA index, and Nottingham Health Profile (NHP). The first evaluation was done after the informed consent was obtained. Second and third evaluations were done at the 2nd and 12th week. PVAS, 50-ft walking duration, AFD, TS, WOMAC, and NHP variables improved in group I. Same variables except QMS improved also in group II. Comparison of the groups just after treatment showed that only pVAS (P = 0.015), NHP pain score (P = 0.020), and TS (P = 0.002) differed significantly in favor of group I at the 2nd or 12th week. Both of the thermal treatment modalities were found to be effective in the management of the clinical symptoms and quality of life in KOA patients. However, pain and tenderness improved statistically better with balneotherapy. There were no significant differences between the groups for the other variables.

Laparoscopic findings of peritoneal dialysis catheter malfunction and management outcomes

OBJECTIVE

Peritoneal dialysis catheter malfunction is a common complication forcing conversion to hemodialysis. The purpose of this study was to evaluate laparoscopic findings of catheter malfunction and to establish a relationship between those findings and the outcomes of procedures performed.

DESIGN

Retrospective study.

SETTING

A tertiary referral center.

PATIENTS

40 consecutive patients with stage 5 chronic kidney disease underwent 46 laparoscopic correction procedures for the treatment of peritoneal dialysis catheter malfunction between November 1994 and August 2004.

MAIN OUTCOME MEASURES

Laparoscopic findings of catheter malfunction, procedures performed, catheter survival, and recurrent cases were evaluated.

RESULTS

There were 28 tip migrations in 40 patients; 16 were without adhesions and 10 were associated with omental adhesions. Reposition and adhesiolysis were the most frequent procedures performed. Malfunction recurred in 12 patients and 5 of them underwent 6 secondary laparoscopic procedures. Estimated mean catheter survival was 19.9 +/-3.32 months (%95 confidence interval 13.43 - 26.46).

CONCLUSIONS

The most frequent laparoscopic finding was catheter tip migration, with or without adhesions. Laparoscopic repositioning and adhesiolysis without omentectomy are simple and effective procedures that can prolong catheter survival, even in recurrent malfunctions.

Hand involvement in Behçet's disease

AIMS

To study the clinical hand findings in Behçet's disease (BD) and to observe scintigraphic changes of these areas.

METHODS

Fifty-seven randomly selected BD patients and the patients in the control group (N=40) were evaluated by two blind rheumatologists. The hands were examined for the presence of pain, tenderness, swelling, effusion, erythema, warmth, range of motion and limitation of motion, deformities and muscle atrophy. Then scintigraphic examination of the hands was performed. Control hand scintigrams were obtained from 40 age- and sex-matched patients and were examined by the same two observers.

RESULTS

Thirty-two of the 57 patients (56.1%) showed Behçet's clinical hand findings. Terminal phalangeal pulp atrophy was observed in 17 (29.81%), rheumatoid-like hand findings were observed in 16 (28.1%), dorsal interosseos atrophy was observed in 12 (20.05%) and erythema over the digits was observed in 12 (20.05%). Twenty-four patients (42.1%) had scintigraphic involvement. The disease duration was observed to be an important factor for hand findings (P=0.040) and scintigraphic involvement (P=0.011).

CONCLUSION

High prevalence of hand involvement in BD and its relationship with disease duration is demonstrated. Hand involvement tends to be overlooked and careful examination is required in the evaluation of BD. The scintigraphic involvement detected in hands requires special consideration, too.

Efficacy of sildenafil in male dialysis patients with erectile dysfunction unresponsive to erythropoietin and/or testosterone treatments

The aim of this study was to evaluate the effects of recombinant human erythropoietin (Epo), testosterone (T) or a combination of them in the treatment of erectile dysfunction (ED) in hemodialysis patients, as well as the efficacy of sildenafil in patients unresponsive to combination treatment. A total of 23 patients with ED were divided into two groups. The international index of erectile function (IIEF) was used to evaluate ED and treatment response. Patients received Epo or T treatments for 12 weeks. Later on both groups received combination treatment for another 12 weeks. Although IIEF scores increased significantly in both groups after the combination treatment, the score changes were similar. After combination treatment, 16 patients still having IIEF score <26 were given sildenafil treatment in combination with Epo while T was discontinued. Although the IIEF scores increased significantly in all patients (17.4%), only eight of them attained an IIEF score of > or =26. The baseline IIEF scores of the patients with satisfactory response to the sildenafil treatment were higher than those with unsatisfactory response. The patients with a score of > or =22 responded better to the treatment. Although Epo and/or T therapies could partially improve ED in male dialysis patients besides correcting renal anemia and hypogonadism, sildenafil treatment could improve ED in unresponsive patients. Especially, those with higher baseline IIEF scores benefited more.

High prevalence of irritable bowel syndrome and upper gastrointestinal symptoms in patients with chronic renal failure

BACKGROUND

Gastrointestinal symptoms and psychiatric disorders are common among patients with chronic renal failure since uremia affects all systems as well as the gastrointestinal tract. Irritable bowel syndrome (IBS) is a frequent functional disorder worldwide. We aimed to evaluate the frequency of IBS and upper gastrointestinal symptoms in patients with chronic renal failure (CRF). The relationships between IBS, sex and additional psychiatric disorders in the same patient group were determined and results were compared with controls.

METHODS

Ninety-three hemodialysis (HD) and 35 peritoneal dialysis (PD) patients and 51 healthy volunteers were enrolled in this cross-sectional study. They completed the questionnaires that were later evaluated to determine the frequency of IBS in HD, PD and control groups; the frequency of depression and anxiety in these three groups and their relationship to sex. Symptoms of upper gastrointestinal system and their relation to sex were also investigated in all groups.

RESULTS

In this study, we have demonstrated that prevalence of IBS in patients with chronic renal failure on hemodialysis or peritoneal dialysis is higher than the controls though the type of dialysis does not seem to influence the IBS prevalence itself. Epigastric pain was more prevalent in HD patients than PD patients.

CONCLUSIONS

The present study suggests that though IBS is common in patients with CRF, it is generally underestimated. Type of dialysis does not seem to change the clinical picture much. Accompanying mood disorders must also be taken into consideration.

A renal transplant recipient with pulmonary tuberculosis and visceral leishmaniasis: review of superimposed infections and therapy approaches

Visceral leishmaniasis (VL) is an acute or subacute disease that is almost invariably fatal if untreated. It is a rare disease in renal transplant recipients and frequently reported together with other infectious agents. A 39-year-old renal transplant patient was admitted to hospital for elective coronary surgery. In the post-operative period, he developed spiking fever and non-productive cough and his general condition deteriorated. While he was taking medication for non-specific pneumonia, a cavitary lesion occurred in his lung, and he had the diagnosis of pulmonary tuberculosis and antituberculous treatment was started. Despite treatment, his fever continued. As the patient developed pancytopenia and splenomegaly, a bone marrow aspiration was done. Evaluation of bone marrow aspirate indicated Leishmania parasites. He was successfully treated with a more intensive liposomal amphotericin (L-AmB). Complete cure was achieved during follow-up period of 10 months without clinical relapse. In the existence of fever and long-standing pancytopenia, VL should be suspected although the patient had another proved infection and did not live or visit an endemic area. L-AmB usage can be safely preferred for treatment of selected renal transplant recipients with VL as first-line therapy.

Prevalence of transfusion transmitted virus infection and its effect on renal graft survival in renal transplant recipients

OBJECTIVE

Little is known about the prevalence of transfusion transmitted virus (TTV) infection in renal transplant recipients (RTxs) and its effects on allograft survival. We investigated the prevalence of TTV and its effects on liver injury and graft survival in RTxs.

MATERIAL AND METHODS

The study was performed in 33 consecutive RTxs (8 females, 25 males) and 100 blood donors (35 females, 65 males). A nested polymerase chain reaction was used to detect TTV DNA in serum. Serum creatinine and alanine aminotransferase (ALT) levels and 24-h protein excretion were determined in both TTV-positive and-negative patients. The total number of blood transfusions, the duration of hemodialysis and the total duration after transplantation were recorded in RTxs. In addition, hepatitis B surface antigen (HbsAg), anti-hepatitis C virus (HCV) and hepatitis G virus DNA antibodies were determined in all patients.

RESULTS

TTV DNA was detected in 51.5% of RTxs and in 7% of the control group and this difference was statistically significant (p < 0.01). In the RTx group, 64.7% of TTV-positive and 56.2% of TTV-negative patients had undergone a previous blood transfusion. However, the blood transfusion replacement rate, total duration of dialysis therapy and posttransplant period did not differ between these two groups. Five (15.1%) patients in the RTx group had abnormal liver function tests (ALT >40 IU/l). Of these patients, 2 were anti-HCV-positive, 1 was HBsAg-positive and anti-HCV- plus TTV DNA-positive and the serologic tests of the remaining 2 patients were all negative. Among the TTV-positive patients, 2 (11.7%) were anti-HCV-positive, 1 (5.8%) was HBsAg-positive and 3 (17.6%) were HGV DNA-positive. The baseline serum creatinine levels did not differ significantly between the TTV-positive and-negative patients, being 1.5 +/- 0.6 and 1.4 +/- 0.6 mg/dl, respectively ( p > 0.05). Two of the TTV-positive patients and 1 of the TTV-negative patients had proteinuria. A 1-year follow-up of TTV-positive and-negative patients demonstrated neither acute nor chronic graft rejection.

CONCLUSION

In RTxs, TTV infection was more prevalent than in the normal population. In our patients the virus did not have an important effect on renal graft rejection and did not cause liver injury. However, the question of whether TTV infection may affect graft survival requires further long-term investigation in larger groups.

Long-term effects of losartan on proteinuria and renal function in patients with renal amyloidosis

OBJECTIVE

To investigate the effect of the angiotensin II receptor antagonist losartan on proteinuria in secondary amyloidosis cases.

MATERIAL AND METHODS

Sixteen patients with renal biopsy-proven AA amyloidosis with proteinuria were included in the study. All the patients had received colchicine treatment for at least 18 months. The patients were divided into two groups with similar age and gender distributions. Eight patients were given losartan at a dose of 50 mg/day for 12 months and the other 8 patients served as controls. Mean arterial blood pressure, proteinuria, serum albumin level and renal function were determined at the initiation of the study and after 1 and 12 months.

RESULTS

There were no significant differences in proteinuria, serum albumin level, renal function or mean arterial blood pressure at the initiation of the study. In the losartan group daily proteinuria decreased significantly from 5.2 +/- 0.7 g at the initiation of the study to 3.9 +/- 1.2 g at 1 month and 3.6 +/- 0.8 g at 12 months, while in the control group it changed from 4.6 +/- 1.0 g to 4.7 +/- 1.0 g and 6.1 +/- 1.2 g, respectively. The increment at 12 months was significant. After 12 months of treatment with losartan, proteinuria was significantly lower in comparison to the degree of proteinuria in the control group. Serum albumin level increased significantly in the losartan group but was unchanged in the control group. In the control group, creatinine clearance showed a significant decrease. There was no significant difference in mean arterial blood pressure measurements, serum creatinine levels, total protein, albumin and creatinine clearance levels between the two groups.

CONCLUSIONS

Losartan seemed to prevent an increase in proteinuria without altering the creatinine clearance level in patients with amyloidosis type AA during a 12-month period. This indicates that losartan may be used to decrease proteinuria in this patient group. However, our results are only preliminary and need to be confirmed by larger studies.

Survival analysis of the factors affecting in mortality in injured patients requiring dialysis due to acute renal failure during the Marmara earthquake: survivors vs non-survivors

BACKGROUND

We reviewed medical records of dialyzed patients admitted to our hospital after the Marmara earthquake and evaluated the factors affecting mortality in survivors and non-survivors according to the survival times.

PATIENTS AND METHODS

Crush syndrome (CS) was diagnosed in 110 patients. Dialysis treatment was initiated in 60 patients; 21 of all died. The patients were divided into 2 groups which consisted of 39 survivors (Group A, 25 male, 14 female, mean age: 31 +/- 2.2 years) and 21 non-survivors (Group B, 9 male, 12 female, mean age: 27 +/- 3.0 years). Victims treated by any form of renal replacement therapy, including daily or intermittant hemodialysis and/or continuous venovenous hemodiafiltration. Clinical and laboratory findings were recorded regularly. Statistical analysis was performed with Kaplan-Meier method, log rank test and Cox regression analysis for the survival functions.

RESULTS

APACHE II scores were 13.5 +/- 0.5 for Group A and 13 +/- 0.9 for Group B. Dialysis support was started to patients in Group A in a mean period of 2.8 +/- 0.2 days and in Group B in a mean period of 3.7 +/- 0.6 days after the earthquake (p > 0.05). The most frequent site of trauma was lower extremity (61.5%) and upper + lower extremities (23%) in Group A, and lower extremity (38.1%) and trunk + lower extremity (23.8%) in Group B. The frequencies of abdominal trauma, pelvic fracture and thoracic trauma in Group B were 23.8%, 19% and 14.2%, respectively. Multiple trauma was more frequent in Group B than in Group A (42.8% vs 2.5%). The rates of fasciotomy, amputation and surgery were similar in both groups. The frequency of sepsis was higher in non-survivors. In our center, the overall mortality rate was 8%, mortality rate in CS was 21% and in dialyzed patients it was 35%. Mortality was mainly associated with sepsis. Survival periods (52.3 +/- 4.0 days) in Group A were longer than in Group B (17.3 +/- 2.5 days). With Cox regression analysis, the parameters such as systolic hypotension on admission, female gender, high serum peak creatine kinase (> 20,000 U/l) and multiple trauma including thoracic and abdominal regions, were factors increasing risk of mortality.

CONCLUSION

As a result, sepsis, multiple trauma and severe crush injury were the main factors increasing mortality risk in dialyzed injuries after the earthquake.

Efficacy of losartan in patients with primary focal segmental glomerulosclerosis resistant to immunosuppressive treatment

OBJECTIVES

Angiotensin II may play an important role in the progression of renal disease. Currently, angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor antagonists are commonly used for renoprotection. To our knowledge, there is no study investigating this effect of angiotensin II receptor antagonists in patients with primary focal segmental glomerulosclerosis (FSGS) in the literature. The aim of this study was to evaluate the effects of losartan on proteinuria and renal function in patients with FSGS refractory to immunosuppressive treatment.

DESIGN

Twenty-three normotensive patients with FSGS proven through renal biopsy were included in the study. Thirteen of them, five men and eight women, were given losartan in a dose of 50 mg day(-1) during 12 months, and 10, four men and six women, were in the control group. Mean arterial blood pressure (MAP), 24-h urine protein excretion, serum total protein and albumin levels were determined just before the start of treatment as well as after 1, 6 and 12 months of the study. In addition, serum creatinine, creatinine clearance (CrCl), cholesterol and triglyceride levels were determined at the beginning and end of the study.

RESULTS

Age, gender and baseline levels of proteinuria, serum albumin, total protein, creatinine, CrCl and MAPs were similar in the two groups. Nephrotic range of proteinuria was present in five of 13 patients (38.4%) in the losartan group and in four of 10 patients (40%) in the control group. In the losartan group, 24-h proteinuria had decreased from 3.6 +/- 0.5 g to 2.3 +/- 0.5 g after 1 month, to 2.4 +/- 0.7 g after 6 months and to 1.9 +/- 0.7 g after 12 months. In the control group, a significant increase in proteinuria compared with the baseline value was noticed after 12 months. Proteinuria levels were significantly higher in the control group than in the losartan group after 6 and 12 months. Whilst total protein and albumin levels increased in the losartan group, they did not change significantly in the control group. The total protein levels after 6 and 12 months, and albumin levels after 6 months were significantly higher in the losartan group than in the control group. No significant change was observed between the baseline and the 12-month creatinine and CrCl levels of the groups when intra- and inter-group comparisons were made. Furthermore, serum cholesterol levels of the losartan group were reduced significantly. The changes in MAP values did not reach significant levels in either of the groups. There was no correlation between the percentage changes in MAP and in proteinuria of the losartan group after 12 months.

CONCLUSIONS

Angiotensin II receptor antagonists may be an alternative therapy in FSGS patients who are resistant to immunosuppressive therapy.

Angiotensin-II receptor antagonist losartan reduces microalbuminuria in hypertensive renal transplant recipients

In recent years, it has been demonstrated that losartan lowers macroproteinuria in diabetic or non-diabetic renal transplant recipients (RTx) similar to angiotensin converting enzyme (ACE) inhibitors. Microalbuminuria (MAU) may reflect subclinical hyperfiltration damage of the glomerulus. It could be a marker of kidney dysfunction in renal transplantation. The aim of the study was to assess the efficacy of losartan in hypertensive RTx with MAU. This study was conducted in 17 (M/F: 4/13) stable RTx. No change was made in the medical treatment of the patients. All cases received 50 mg/day losartan therapy for 12 wk. Renal functions and MAU were determined 12 and 6 wk and just before the treatment as well as sixth and twelfth week of the treatment in all patients. Losartan satisfactorily lowered systemic blood pressure. A significant reduction in MAU was observed from 103 +/- 53 microg/min at the beginning to 59 +/- 25 microg/min in the sixth week and 47 +/- 24 microg/min in the twelfth week (p=0.0007 and 0.0005, respectively). From the sixth week of the treatment, the therapy significantly decreased hemoglobin, hematocrit and erythrocyte levels but did not change mean leukocyte and platelet counts, urea, creatinine levels and creatinine clearances. No serious side-effect was observed during the study. In conclusion, we found that losartan decreased MAU in hypertensive RTx. For that reason, it might be considered as the first choise antihypertensive agent for the renoprotection in selected patients.

Free choline and phospholipid-bound choline concentrations in serum and dialysate during peritoneal dialysis in children and adults

OBJECTIVES

This study tested whether continuous ambulatory peritoneal dialysis (CAPD) changes free or phospholipid-bound choline concentrations in serum or peritoneal dialysis fluid of patients with end stage renal disease (ESRD).

DESIGN AND METHODS

Serum and dialysate choline and phospholipid-bound choline were measured before, during and after 6 h CAPD.

RESULTS

Serum choline concentrations were higher in patients with ESRD compared with age-matched controls. CAPD lowered serum choline concentrations significantly although it did not influence phospholipid-bound choline. Choline accumulated in the dialysate, reaching 28.4 +/- 2.7 microM in children and 18.2 +/- 1.4 microM in adults, during six hours CAPD; phospholipid-bound choline increased to 22.9 +/- 2.5 microM and 10.8 +/- 1.4 microM in children and adults, respectively. The total daily loss of choline into the dialysate was 181 +/- 20 micromoles in children and 260 +/- 18 micromoles in adults.

CONCLUSION

CAPD causes a substantial loss of choline into peritoneal dialysates and reduces serum choline concentrations significantly.

Changes of plasma free choline and choline-containing compounds' concentrations and choline loss during hemodialysis in ESRD patients

OBJECTIVES

This study was undertaken to determine the changes in plasma free choline and choline-containing compounds in end stage renal disease (ESRD) and to determine if they were lost into the dialysate during hemodialysis.

DESIGN AND METHODS

Plasma and dialysate free choline, phosphocholine and phospholipid-, phosphatidylcholine-, sphingomyelin-bound choline were measured before, during and after hemodialysis.

RESULTS

Plasma free and bound choline concentrations (mean +/- standard error of the mean) were 12.9 +/- 0.6 and 2697 +/- 57 microM or 37.3 +/- 0.9 and 2792 +/- 98 microM in controls or in ESRD patients, respectively. Free choline concentrations were correlated (r = 0.598; p < 0.001) with the time the patients were subjected to hemodialysis. Plasma free choline and phosphocholine concentrations are decreased by a total of -8.1 +/- 0.6 micromol/L and -88 +/- 8 micromol/L, respectively; phospholipid-, phosphatidylcholine- and sphingomyelin-bound choline are increased, during hemodialysis. Patients lost about 350 micromoles of choline into the dialysate during hemodialysis.

CONCLUSION

Plasma free choline concentrations are elevated in ESRD, and a considerable amount of choline is lost into the hemodialysate.

A family with IgA nephropathy and hereditary lymphoedema praecox

Immunoglobulin A (IgA) nephropathy is the most common primary glomerulonephritis worldwide. The pathogenesis is still unknown and treatment has not yet been established. Rarely it can be associated with other disorders. Its association with hereditary lymphoedema is not reported before. We report four patients, a 60-year-old father, his two sons and his daughter, with hereditary lymphoedema. The family had nine members and in four of them lymphoedema was evident. The other members had neither lymphoedema nor IgA nephropathy. This is the first report of IgA nephropathy in association with hereditary lymphoedema.

Clinical investigation of methotrexate in the treatment of ankylosing spondylitis

OBJECTIVES

To investigate the efficacy and possible side effects of Methotrexate (MTX) treatment in patients with ankylosing spondylitis.

METHODS

A total of 51 patients with a diagnosis of AS according to NewYork criteria were randomly distributed into 2 groups. In Group I (n = 25) only Naproxen (1000 mg/day) and in Group II (n = 26) oral MTX (7.5 mg/week) combined with Naproxen were given for 12 months. The patients were evaluated at 3, 6, and 12 months after the start of the treatment according to a number of clinical parameters using objective and subjective variables. Data were analysed using ki-square and Mann-Whitney U tests.

RESULTS AND CONCLUSIONS

The comparison of the values using the percent changes and difference scores with respect to pretreatment values showed significant improvement in the "global evaluation of the physician" in Group II compared to Group I while no other parameter was found to be significantly different between the two groups. Those results have led us to conclude that a combination of MTX with Naproxen did not prove to be superior to Naproxen-alone treatment in terms of statistical significance. Further trials with MTX employing larger doses and different patient populations, mainly comprised of peripheral arthritis are necessary for delineation of the role of MTX in AS treatment.