Determinants of non-diabetic kidney diseases in type 2 diabetic patients: Twenty years of single center experience.

BACKGROUND: Diabetic nephropathy is one of the most common complications associated with diabetes. However, non-diabetic kidney disease has been reported in patients with type 2 diabetes at varying incidence rates. The objective of our study is to investigate the occurrence, clinicopathological characteristics, and inflammatory markers linked to diabetic and non-diabetic nephropathy (NDN) in patients with type 2 diabetes mellitus (DM). Additionally, we aimed to explore the possibility of identifying non-diabetic pathology using different biopsy indications. MATERIALS AND METHODS: A total of 159 patients with type 2 DM who underwent renal biopsy at a tertiary care nephrology clinic between January 2000 and January 2022 were enrolled in the study. We collected comprehensive data, including patient demographics, co-morbidities, diabetes duration, renal biopsy indications and results, serological markers, renal function, diabetic retinopathy (DRP), full blood count, blood biochemistry, urinalysis, and inflammatory markers. Patients were categorized based on their biopsy indications, and their biopsy results were classified into three groups: isolated NDN, isolated diabetic nephropathy (DN), and mixed nephropathy with concurrent NDN. We evaluated the relationship between biopsy indications and accompanying pathologies and statistically assessed the likelihood of each biopsy indication detecting non-diabetic renal pathology. Additionally, differences in other data, including demographic and laboratory results and medical histories, among the three groups were investigated. RESULTS: The most frequent indication of renal biopsy was atypical presentations of nephrotic syndrome or nephrotic range proteinuria (ANS/ANP) in 25.1% of patients. Other indications included unexplained renal failure (URF) in 22.6%, atypical presentations of non-nephrotic range proteinuria (ANNP) in 18.2%, acute kidney injury or rapidly progressive kidney dysfunction (AKI/RPKD) in 16.9%, microscopic hematuria in 15.7%, URF with ANNP in 11.3%, and severe nephrotic range proteinuria (SNP) in 9.4%. Renal biopsy revealed isolated NDN in 64.8%, DN in 25.1%, and mixed nephropathy in 10.1% of patients. Primary glomerular diseases were the main non-diabetic renal pathology, predominantly focal segmental glomerulosclerosis (FSGS) (36.4%) followed by MN (10.6%) and IgA nephropathy (7.5%). In comparison with the isolated DN and mixed nephropathy groups, patients in the isolated NDN group had significantly shorter diabetes duration, fewer DRP, as well as lower serum creatinine and neutrophil-to-lymphocyte ratio (NLR). Multivariate logistic regression analysis revealed that presence of hematuria (OR 4.40; 95% CI 1.34 - 14.46, p = 0.014), acute nephrotic range proteinuria (OR 11.93; 95% CI 1.56 - 90.77, p = 0.017), and AKI/APKD (OR 41.08; 95% CI 3.40 - 495.39, p = 0.003) were strong predictors of NDN. Lower NLR (OR 0.77; 95% CI 0.60 - 0.98, p = 0.035), shorter duration of diabetes (OR 0.90; 95% CI 0.84 - 0.97, p = 0.010), and absence of DRP (OR 0.35; 95% CI 0.12 - 0.98, p = 0.046) were also found to be independent indicators of NDN. Receiver operating characteristic curve (ROC) analysis revealed a cut-off value of ≤ 3.01 for NLR (sensitivity of 63.1%, specificity of 63.5%) with regards to predicting non-diabetic renal pathology (p = 0.006). CONCLUSION: Renal biopsy findings in patients with type 2 DM highlight that the prevalence of NDN may be higher than assumed, as presented mainly in the form of primary glomerular disease. The presence of AKI/RPKD, hematuria, and ANS/ANP serves as a reliable indicator of non-diabetic renal pathology. In more ambiguous situations, factors such as a shorter duration of diabetes, absence of DRP, and a lower NLR value may assist clinicians in biopsy decision.

Immunosuppressive treatment results in patients with primary IgA nephropathy in Turkiye; the data from TSN-GOLD working group.

BACKGROUND: Immunoglobulin A (IgA) nephropathy (IgAN) treatment consists of maximal supportive care and, for high-risk individuals, immunosuppressive treatment (IST). There are conflicting results regarding IST. Therefore, we aimed to investigate IST results among IgAN patients in Turkiye. METHOD: The data of 1656 IgAN patients in the Primary Glomerular Diseases Study of the Turkish Society of Nephrology Glomerular Diseases Study Group were analyzed. A total of 408 primary IgAN patients treated with IST (65.4% male, mean age 38.4 ± 12.5 years, follow-up 30 (3-218) months) were included and divided into two groups according to treatment protocols (isolated corticosteroid [CS] 70.6% and combined IST 29.4%). Treatment responses, associated factors were analyzed. RESULTS: Remission (66.7% partial, 33.7% complete) was achieved in 74.7% of patients. Baseline systolic blood pressure, mean arterial pressure, and proteinuria levels were lower in responsives. Remission was achieved at significantly higher rates in the CS group (78% vs. 66.7%, p = 0.016). Partial remission was the prominent remission type. The remission rate was significantly higher among patients with segmental sclerosis compared to those without (60.4% vs. 49%, p = 0.047). In the multivariate analysis, MEST-C S1 (HR 1.43, 95% CI 1.08-1.89, p = 0.013), MEST-C T1 (HR 0.68, 95% CI 0.51-0.91, p = 0.008) and combined IST (HR 0.66, 95% CI 0.49-0.91, p = 0.009) were found to be significant regarding remission. CONCLUSION: CS can significantly improve remission in high-risk Turkish IgAN patients, despite the reliance on non-quantitative endpoints for favorable renal outcomes. Key predictors of remission include baseline proteinuria and specific histological markers. It is crucial to carefully weigh the risks and benefits of immunosuppressive therapy for these patients.

Peritoneal dialysis related non-infectious complications: A single-center experience over 20 years.

OBJECTIVES: Non-infectious complications of peritoneal dialysis (NICPD) are common and could be an important cause of technical failure, especially in the early period of peritoneal dialysis (PD) initiation. NICPD are also center- and provider-dependent. This study aimed to investigate the frequency, etiology, and associated outcomes of NICPD in a single center over a period of 20 years. MATERIALS AND METHODS: Data were retrospectively collected in 262 patients who were initiated on PD between April 2001 and April 2021. Inclusion criteria were age 18 years or older and a minimum follow-up period of 3 months. Patients were grouped according to the reason of NICPD: catheter-related, increased intra-abdominal pressure-related, metabolic, and other complications. RESULTS: There were 142 females and 120 males in the study, with a mean age of 44 ± 16.9 years. The mean time on PD was 52.6 ± 40 months. During the follow-up period, 185 (71%) patients experienced 382 NICPD episodes. 26 patients (9.9%) were switched to maintenance hemodialysis (HD) due to NICPD. Outflow failure was the most common NICPD (n = 97). It was also the most common reason for catheter revision (n = 23) and PD discontinuation (n = 12). Catheter intervention was required in 32 patients (12.2%). Prior HD treatment and male gender were independent risk factors for NICPD and catheter-related complications (OR 2.076; p = 0.037; OR: 1.797, p = 0.042, respectively). Early-start PD was associated with a lower risk for NICPD development (OR: 0.393, p = 0.013). CONCLUSION: In this select cohort of PD patients, we found that NICPD are common and outflow failure is the most common cause of NICPD. NICPD are associated with major complications requiring catheter removal or transfer to in-center HD. Early recognition and appropriate management of NICPD are essential to prolonging time on PD in end-stage renal disease patients.

Clinical and pathologic features of primary membranous nephropathy in Turkey: a multicenter study by the Turkish Society of Nephrology Glomerular Diseases Working Group.

BACKGROUND: We aimed to evaluate the features of primary membranous nephropathy (MNP) in Turkish people. METHODS: This is a retrospective analysis of patients with biopsy-proven primary MNP. We obtained the data collected between 2009 and 2019 in the primary glomerulonephritis registry of the Turkish Society of Nephrology Glomerular Diseases Study Group (TSN-GOLD). Patients with a secondary cause for MNP were excluded. Clinical, demographic, laboratory, and histopathological findings were analyzed. RESULTS: A total of 995 patients with primary MNP were included in the analyses. Males constituted the majority (58.8%). The mean age was 48.4 ± 13.9 years. The most common presentation was the presence of nephrotic syndrome (81.7%) and sub nephrotic proteinuria (10.3%). Microscopic hematuria was detected in one-third of patients. The median estimated glomerular filtration rate (eGFR) was 100.6 mL/min/1.73 m2 (IQR, 75.4-116.3), and median proteinuria was 6000 mg/d (IQR, 3656-9457). Serum C3 and C4 complement levels were decreased in 3.7 and 1.7% of patients, respectively. Twenty-four (2.4%) patients had glomerular crescents in their kidney biopsy samples. Basal membrane thickening was detected in 93.8% of cases under light microscopy. Mesangial proliferation and interstitial inflammation were evident in 32.8 and 55.9% of the patients, respectively. The most commonly detected depositions were IgG (93%), C3 complement (68.8%), and kappa and lambda immunoglobulin light chains (70%). Although renal functions were normal at presentation, vascular, interstitial, and glomerular findings were more prominent on biopsy in hypertensive patients. No significant effect of BMI on biopsy findings was observed. CONCLUSIONS: Despite some atypical findings, the main features of primary MNP in Turkey were similar to the published literature. This is the largest MNP study to date conducted in Turkish people.

Comparison of Circulating Levels of Uremic Toxins in Hemodialysis Patients Treated with Medium Cut-Off Membranes and High-Flux Membranes: Theranova in Sisli Hamidiye Etfal (THE SHE) Randomized Control Study.

INTRODUCTION: Removal of uremic toxins is a main objective of hemodialysis; however, whether high-flux and medium cut-off (MCO) membranes differ as regards removal of middle and large uremic toxins is not clear. OBJECTIVE: To compare medium cut-off and high-flux dialyzers as regards their intra- and interdialysis effect on circulating levels of middle and large uremic toxins and serum albumin. METHODS: Fifty-two patients were randomized to have hemodialysis with either 3 months of high-flux dialyzer followed by 3 months of MCO or vice versa. Blood samples were taken before and after dialysis at the first and last sessions of each dialyzer for analyses of middle and large uremic toxins including inflammatory mediators and vascular endothelial growth factor (VEGF), and serum albumin. RESULTS: Reduction rates were higher, and postdialysis levels of ß-2 microglobulin, free kappa and lambda light chains, and myoglobulin were lower at the first and last sessions with MCO dialyzers compared to high-flux dialyzers (p < 0.05 for all). Last session predialysis levels of ß-2 microglobulin, free kappa light chain, and free lambda light chain were lower than first session predialysis levels in MCO dialyzers as compared to high-flux dialyzers (p < 0.05 for all). Last session levels of interleukin-6, interleukin-10, interleukin-17, and interferon-gamma did not differ between dialyzers (p > 0.05 for all). VEGF level was lower in the MCO group compared to the high-flux group (p = 0.043). Last session level of serum albumin with MCO dialyzers was lower than that with high-flux dialyzers (3.62 [3.45-3.88] vs. 3.78 [3.58-4.02] g/L) (p = 0.04) and 6.7% lower (p < 0.001) than at the first session of MCO dialyzers. CONCLUSION: The decline in circulating levels of several middle and large uremic toxins including VEGF following hemodialysis was more pronounced when using MCO membranes as compared to high-flux membranes while their effect on inflammatory molecules was similar.

Epidemiological features of primary glomerular disease in Turkey: a multicenter study by the Turkish Society of Nephrology Glomerular Diseases Working Group.

BACKGROUND: The largest data on the epidemiology of primary glomerular diseases (PGDs) are obtained from the databases of countries or centers. Here, we present the extended results of the Primary Glomerular Diseases Study of the Turkish Society of Nephrology Glomerular Diseases (TSN-GOLD) Working Group. METHODS: Data of patients who underwent renal biopsy and received the diagnosis of PGD were recorded in the database prepared for the study. A total of 4399 patients from 47 centers were evaluated between May 2009 and May 2019. The data obtained at the time of kidney biopsy were analyzed. After the exclusion of patients without light microscopy and immunofluorescence microscopy findings, a total of 3875 patients were included in the study. RESULTS: The mean age was 41.5 ± 14.9 years. 1690 patients were female (43.6%) and 2185 (56.3%) were male. Nephrotic syndrome was the most common biopsy indication (51.7%). This was followed by asymptomatic urinary abnormalities (18.3%) and nephritic syndrome (17.8%). The most common PGD was IgA nephropathy (25.7%) followed by membranous nephropathy (25.6%) and focal segmental glomerulosclerosis (21.9%). The mean total number of glomeruli per biopsy was 17 ± 10. The mean baseline systolic blood pressure was 130 ± 20 mmHg and diastolic blood pressure was 81 ± 12 mmHg. The median proteinuria, serum creatinine, estimated GFR, and mean albumin values were 3300 (IQR: 1467-6307) mg/day, 1.0 (IQR: 0.7-1.6) mg/dL, 82.9 (IQR: 47.0-113.0) mL/min and 3.2 ± 0.9 g/dL, respectively. CONCLUSIONS: The distribution of PGDs in Turkey has become similar to that in other European countries. IgA nephropathy diagnosed via renal biopsy has become more prevalent compared to membranous nephropathy.

The predictive value of malnutrition - inflammation score on 1-year mortality in Turkish maintenance hemodialysis patients.

OBJECTIVE: The aim of this study was to evaluate the predictive value of malnutrition-inflammation score (MIS) on short-term mortality and to identify the best cut-off point in the Turkish maintenance hemodialysis (MHD) population. METHODS: A total of 100 patients on MHD were included in this prospective single-center study. Demographic, anthropometric, and biochemical data were obtained from all patients. The study population was followed up as a 12-month prospective cohort to evaluate mortality as the primary outcome. RESULTS: Median (IQR) age and HD vintage of 100 patients (M/F: 52/48) were 53 (39.5 - 67) years and 53.5 (11 - 104.7) months, respectively. Deceased patients (n = 7) had significantly older age (years) (50 (38.5 - 63.5) vs. 70 (62 - 82), respectively, p = 0.001), lower spKt/V (1.60 (1.40 - 1.79) vs. 1.35 (0.90 - 1.50), respectively, p = 0.002), lower triceps skinfold thickness (14 (10 - 19) vs. 9 (7 - 11), respectively, p = 0.021) and higher MIS (5 (4 - 7) vs. 10 (7 - 11), respectively, p = 0.013). In the ROC analysis, we found that the optimal cut-off value of MIS for predicting death was 6.5 with 85.7% sensitivity and 62.4% specificity (positive and negative predictive values were 0.6951 and 0.8136, respectively). Advanced age, low spKt/V, and high MIS were found to be predictors of mortality in multivariate logistic regression analysis. The 1-year mortality rate was significantly higher in MIS > 6.5 group compared to the MIS ≤ 6.5 group (14,3% (6/41) vs. 1.6% (1/59), respectively). Compared to MIS ≤ 6.5 group, 1 year survival time of the patients with MIS > 6.5 was found to be significantly lower (47.8 ± 0.16 vs. 43.6 ± 1.63 weeks, respectively, p (log-rank) = 0.012). CONCLUSION: MIS is a robust and independent predictor of short-term mortality in MHD patients. Patients with MIS > 6.5 had a significant risk, and additional risk factors associated with short-term mortality were advanced age and low spKt/V.

Neutrophil-to-lymphocyte ratio and platelet-tolymphocyte ratio in evaluation of inflammation in end-stage renal disease.

OBJECTIVE: To evaluate the relationship between neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and inflammation in end-stage renal disease (ESRD) patients on maintenance hemodialysis (HD). METHODS: 100 ESRD patients on maintenance HD (mean ± SD age: 52.3 ± 1.7 years, 52% were males) were included in this cross-sectional study. Data on patient demographics, dry weight, body mass index, duration of HD (months), etiology of ESRD, delivered dose of dialysis (spKt/V), complete blood count, blood biochemistry and inflammatory markers including hs-CRP (mg/L), TNF-α (pg/mL), NLR, and PLR were recorded in all patients and compared in patients with hs-CRP levels of ≤ 3 mg/L vs. > 3 mg/L. other study parameters were also recorded. RESULTS: Compared to patients with lower hs-CRP levels, patients with hs-CRP levels of > 3 mg/L had significantly higher values for NLR (3.7 ± 0.2 vs. 2.7 ± 0.2, p < 0.01) and PLR (150.7 ± 6.9 vs. 111.8 ± 7.0, p < 0.001). Both NLR and PLR were positively correlated with hs-CRP (r = 0.333, p = 0.01 and r = 0.262, p = 0.001, respectively) and negatively correlated with transferrin saturation (%) (r = -0.418, p = 0.001 and r = -0.309, p = 0.002, respectively). CONCLUSION: Our findings in a cohort of ESRD patients on maintenance HD revealed higher values for NLR and PLR in patients with higher levels of inflammation along with a significant positive correlation of both NLR and PLR with hs-CRP levels. Being a simple, relatively inexpensive and universally available method, whether or not calculation of NLR and PLR offers a plausible strategy in the evaluation of inflammation in ESRD patients in the clinical practice should be addressed in larger scale randomized and controlled studies.

Clinical Validation of a Peritoneal Dialysis Prescription Model in the PatientOnLine Software.

Peritoneal transport characteristics and residual renal function require regular control and subsequent adjustment of the peritoneal dialysis (PD) prescription. Prescription models shall facilitate the prediction of the outcome of such adaptations for a given patient. In the present study, the prescription model implemented in the PatientOnLine software was validated in patients requiring a prescription change. This multicenter, international prospective cohort study with the aim to validate a PD prescription model included patients treated with continuous ambulatory peritoneal dialysis. Patients were examined with the peritoneal function test (PFT) to determine the outcome of their current prescription and the necessity for a prescription change. For these patients, a new prescription was modeled using the PatientOnLine software (Fresenius Medical Care, Bad Homburg, Germany). Two to four weeks after implementation of the new PD regimen, a second PFT was performed. The validation of the prescription model included 54 patients. Predicted and measured peritoneal Kt/V were 1.52 ± 0.31 and 1.66 ± 0.35, and total (peritoneal + renal) Kt/V values were 1.96 ± 0.48 and 2.06 ± 0.44, respectively. Predicted and measured peritoneal creatinine clearances were 42.9 ± 8.6 and 43.0 ± 8.8 L/1.73 m(2)/week and total creatinine clearances were 65.3 ± 26.0 and 63.3 ± 21.8 L/1.73 m(2) /week, respectively. The analysis revealed a Pearson's correlation coefficient for peritoneal Kt/V of 0.911 and Lin's concordance coefficient of 0.829. The value of both coefficients was 0.853 for peritoneal creatinine clearance. Predicted and measured daily net ultrafiltration was 0.77 ± 0.49 and 1.16 ± 0.63 L/24 h, respectively. Pearson's correlation and Lin's concordance coefficient were 0.518 and 0.402, respectively. Predicted and measured peritoneal glucose absorption was 125.8 ± 38.8 and 79.9 ± 30.7 g/24 h, respectively, and Pearson's correlation and Lin's concordance coefficient were 0.914 and 0.477, respectively. With good predictability of peritoneal Kt/V and creatinine clearance, the present model provides support for individual dialysis prescription in clinical practice. Peritoneal glucose absorption and ultrafiltration are less predictable and are likely to be influenced by additional clinical factors to be taken into consideration.

Serum uric acid levels and inflammatory markers with respect to dipping status: A retrospective analysis of hypertensive patients with or without chronic kidney disease.

BACKGROUND: The aim of this study was to evaluate serum uric acid levels, inflammatory markers [C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR)] and mean platelet volume (MPV) among hypertensive patients with or without chronic kidney disease (CKD) with respect to dipping status. METHODS: A total of 432 hypertensive patients with (n = 340) or without (n = 92) CKD who had ambulatory blood pressure monitoring recordings were included. Correlation of serum uric acid levels with inflammatory markers (CRP, PLR, NLR) was evaluated as was the logistic regression analysis for determinants of nondipper pattern. RESULTS: Nondipper pattern was noted in 65.2% and 79.7% of non-CKD and CKD patients, respectively. Multivariate logistic regression analysis revealed that only serum uric acid (OR, 2.69; 95% CI, 1.60 to 4.52; p = 0.000), MPV (OR, 1.81; 95% CI, 1.30 to 2.53; p = 0.000), PLR (OR, 0.98; 95% CI, 0.97 to 0.99; p = 0.000), and serum albumin (OR, 0.42; 95% CI, 0.19 to 0.93; p = 0.031) were significant determinants of nondipper pattern in the overall study population. CONCLUSION: In conclusion, our findings revealed higher prevalence of nondipper pattern in hypertensive patients with than without CKD and significantly higher levels for uric acid, CRP, MPV, PLR, and NLR among nondipper than dipper hypertensive patients with CKD. High levels for uric acid and MPV and lower levels for PLR and serum albumin were noted as significant determinants of nondipper pattern among hypertensive patients.

Test of the recommended dialysis dose on one-year mortality of nondiabetic maintenance hemodialysis patients; observations from a single dialysis unit.

BACKGROUND: The optimal delivered dialysis dose has been of a great interest for the last three decades, though a clear cut point has not been reached yet. We aimed to evaluate the relationship between one-year mortality and the delivered dialysis dose, which was recommended by Kidney Disease Outcomes Quality Initiative (KDOQI), in our maintenance hemodialysis (MHD) patients. METHODS: This was a single center, prospective observational study with one year of follow-up. Patients with extremes of age, BMI, residual renal function, diabetes mellitus, severe infection malignancy, and recent hospitalization within the last three months were excluded. Demographic, anthropometric, laboratory, and outcome data (mortality as the primary) were prospectively collected. Patients were classified into two groups according to baseline spKt/V levels; group 1 (n = 20): spKt/V ≤ 1.4, group 2 (n = 60): spKt/V > 1.4. RESULTS: Median (IQR) age and hemodialysis vintage of all patients (M/F: 41/39) were 49.5 (29) years and 60 (94) months, respectively. Both groups had similar characteristics, with the exception of significantly higher BMI (24 vs. 21.7, p = 0.012), serum creatinine and uric acids, and lower spKt/V (1.30 vs. 1.71, p < 0.001) in group 1. Overall death occurred in seven (8.75%) patients (5 from group 1 and 2 from group 2). Patients in group 1 had significantly higher one-year mortality rate and shorter survival time (25% vs. 3.3%, p = 0.003 and 43.9 vs. 47.3 weeks, p = 0.003, respectively). CONCLUSIONS: Higher spKt/V (>1.4) was associated with a lower one-year mortality in this small cohort of patients.

Elevated serum leptin levels are associated with good nutritional status in non-obese chronic hemodialysis patients.

OBJECTIVE: Leptin is a hormone and a proinflammatory cytokine secreted from adipocytes, which functions to suppress appetite in healthy persons. Serum leptin levels are significantly elevated in patients with end-stage renal disease (ESRD) primarily due to decreased clearance by the kidneys The consequence of hyperleptinemia in ESRD is not fully understood. We aimed to investigate the association between serum leptin levels and nutrition/inflammation status in non-obese chronic hemodialysis (HD) patients. METHODS: 65 chronic, anuric, nonobese (body mass index (BMI) < 25 kg/m2) HD patients were included in this cross-sectional study. Demographic, anthropometric, and biochemical data were obtained from all patients to determine nutrition and inflammation status. Patients were classified into the 3 groups according to serum leptin levels; group 1 (low leptin, n = 9), group 2 (normal leptin, n = 31), and group 3 (high leptin, n = 25). RESULTS: Mean age and duration on dialysis of 65 patients (male/female: 34/31) were 51.6 ± 17.8 years and 78.0 ± 67.9 months, respectively. Serum leptin levels increased with older age, female gender, higher BMI and triceps skinfold thickness. Elevated serum leptin levels were significantly associated with good nutritional status parameters, such as higher albumin (p = 0.001), prealbumin (p = 0.033), total iron binding capacity (p = 0.045), total cholesterol (p = 0.041), and lower malnutrition inflammation score (MIS) (p = 0.002). Serum leptin levels remained a negative correlation with MIS after adjustments made for BMI. No correlation was established between leptin and inflammation parameters including ferritin, highly sensitive C-reactive protein (hs-CRP), and tumor necorsis factor alpha (TNF-α). CONCLUSION: Elevated serum leptin levels seem to be associated with good nutritional status. However, there was no correlation between leptin and inflammatory status.

Relationship between relative interdialytic weight gain and serum leptin levels, nutrition, and inflammation in chronic hemodialysis patients.

INTRODUCTION: Excessive relative interdialytic weight gain (RIDWG, %) is an important risk factor for long-term adverse cardiovascular outcomes in chronic hemodialysis (HD) patients. On the other hand, it may also be an index of good appetite and nutritional status. We aimed to assess the relationship between RIDWG and appetite, nutrition, inflammation parameters of chronic HD patients. METHODS: 100 chronic anuric HD patients were enrolled in this prospective study between January 2013 and January 2014. Patients with hospitalization, major surgery, obvious infectious/inflammatory disease, end-stage liver disease, malignancies, and malabsorption syndromes were excluded. Patients were divided into 3 groups according to their RIDWG levels; group 1 = RIDWG < 3%, group 2 = RIDWG: 3 - 5%, and group 3 = RIDWG > 5%. RESULTS: Group 3 patients were younger (p = 0.011) and had a lower body mass index (BMI) (p = 0.014). Nutrition and inflammation parameters including malnutrition inflammation score (MIS), serum albumin, prealbumin, triceps skinfold thickness, hs-CRP, and TNF-α ere not significantly different between the groups. Leptin and leptin/BMI ratio were significantly lower in group 3 (p = 0.001). RIDWG was negatively correlated with age (p = 0.001, r = -0.371), BMI (p = 0.001, r = -0.372), leptin (p = 0.001, r = -0.369), leptin/BMI (p = 0.001, r = -0.369). After adjustment for BMI in linear regression analyis, leptin/BMI remained significantly correlated with RIDWG (p = 0.024). CONCLUSION: This study revealed that RIDWG was associated with younger age, lower BMI and dry weight, and lower serum leptin levels. More detailed studies are needed to validate and dissect the mechanisms of these findings.

Familial Mediterranean Fever is associated with abnormal ventricular repolarization indices.

BACKGROUND: Cardiac arrhythmias can be a part of cardiovascular involvement in some rheumatic diseases, but data about familial Mediterranean fever (FMF) are conflicting. AIM: To search for abnormalities in ventricular repolarization indices in FMF patients. PATIENTS AND METHODS: Seventy seven FMF patients and 30 age/gender comparable healthy controls were included. All patients were attack free and subjects with disease or drugs that are known to alter cardiac electrophysiology were excluded. Electrocardiographic data were obtained and analyzed. RESULTS: Twelve FMF patients had amyloidosis. QT and QTc intervals were within the normal ranges and similar between FMF patients and healthy controls. QT dispersion, peak to end interval of T wave (Tpe), Tpe/QT and Tpe/QTc ratios were significantly higher in FMF patients than in healthy controls. Patients with amyloidosis had significantly higher QT dispersion, Tpe, Tpe/QT and Tpe/QTc than their counterparts without FMF. Levels of proteinuria were moderately correlated with QT dispersion, Tpe, Tpe/QT and Tpe/QTc. CONCLUSIONS: FMF patients may have an increased risk for arrhythmias.

Outcome of 121 patients with renal amyloid a amyloidosis.

BACKGROUND: Amyloid A (AA) amyloidosis is a multisystem, progressive and fatal disease. Renal involvement occurs early in the course of AA. We aimed to investigate the etiology, clinical and laboratory features, and outcome of patients with biopsy-proven renal AA amyloidosis. MATERIALS AND METHODS: A total of 121 patients (male/female: 84/37, mean age 42.6 ± 14.4 years) were analyzed retrospectively between January of 2001 and May of 2013. Demographic, clinical and laboratory features and outcomes data were obtained from follow-up charts. RESULTS: Familial Mediterranean fever (37.2%) and tuberculosis (24.8%) were the most frequent causes of amyloidosis. Mean serum creatinine and proteinuria at diagnosis were 2.3 ± 2.1 mg/dL and 6.7 ± 5.3 g/day, respectively. Sixty-eight (56.2%) patients were started dialysis treatment during the follow-up period. Mean duration of renal survival was 64.7 ± 6.3 months. Age, serum creatinine and albumin levels were found as predictors of end-stage renal disease. Fifty patients (%41.3) died during the follow-up period. The mean survival of patients was 88.7 ± 7.8 months (median: 63 ± 13.9). 1, 2 and 5 years survival rates of patients were 80.7%, 68.2% and 51.3%, respectively. Older age, male gender, lower levels of body mass index, estimated glomerular filtration rate, serum albumin, calcium, and higher levels of phosphor, intact parathyroid hormone and proteinuria were associated with a higher mortality. Higher serum creatinine, lower albumin, dialysis requirement and short time to dialysis were predictors of mortality. CONCLUSION: The outcome of patients with AA amyloidosis and renal involvement is poor, particularly in those who had massive proteinuria, severe hypoalbuminemia and dialysis requirement at the outset.

Cyclosporin A therapy on idiopathic thrombotic thrombocytopenic purpura in the relapse setting: two case reports and a review of the literature.

BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disease, characterized by microangiopathic hemolytic anemia, thrombocytopenia, fever, neurologic disturbances, and renal failure. Plasma therapy has dramatically improved prognosis of TTP, whereas recurrent acute episodes still occur in approximately 40% of patients. Moreover, patients with acquired ADAMTS13 deficiency, which is a significant factor for relapse, may require additional immunosuppressive treatment to get a durable remission. STUDY DESIGN AND METHODS: We hereby report two patients with a history of relapsed idiopathic TTP, who both received cyclosporin A (CSA) as a prophylactic manner after the remission was achieved. We also discuss the efficacy of CSA in patients with relapsed idiopathic TTP with a review of the published literature. RESULTS: Under CSA therapy, both patients maintained their clinical remission state, and the ADAMTS13 levels were normalized. CONCLUSION: To conclude, CSA therapy may be useful for the prevention of relapsed idiopathic TTP in patients with a history of frequent relapses.

Renal involvement in AA amyloidosis: clinical outcomes and survival.

BACKGROUND: The natural history of AA amyloidosis is typically progressive, leading to multiple organ failure and death. We analyzed the etiology as well as clinical and laboratory features of patients with biopsy-proven AA amyloidosis and evaluated the ultimate outcome. METHODS: Seventy-three patients (24 female; mean age 41.85±15.89 years) were analyzed retrospectively. Demographic, clinical and laboratory features were studied and the outcome was assessed. RESULTS: Familial Mediterranean Fever and tuberculosis were the most frequent causes of amyloidosis. Mean serum creatinine and proteinuria at diagnosis were 4.65±4.89 mg/dl and 8.04±6.09 g/day, respectively; and stage I, II, III, IV and V renal disease were present in 19.2%, 13.7%, 16.4%, 11%, and 39.7% of the patients, respectively. ESRD developed in 16 patients during the follow-up period. All of the ESRD patients started a dialysis programme. Thirty patients (41%) died during the follow-up period; median patient survival was 35.9±6.12 months. Old age, tuberculosis etiology, advanced renal disease and low serum albumin levels were associated with a worse prognosis. Serum albumin was a predictor of mortality in logistic regression analysis. CONCLUSION: The ultimate outcome of the patients with AA amyloidosis is poor, possibly due to the late referral to the nephrology clinics. Early referral may be helpful to improve prognosis.

Clinical outcomes and mortality in peritoneal dialysis patients: a 10-year retrospective analysis in a single center.

AIM: To evaluate the clinical outcome, identify predictors of patient and technique survival in our peritoneal dialysis (PD) patients in the western region of Turkey. METHODS: We included all patients who initiated therapy between 2001 and 2010. Socio-demographic characteristics such as who helped to administer the PD as well as conditions under which PD was chosen by patients were investigated from patients' files. Hemodialysis (HD) history and duration, additional systemic diseases, and end-stage renal disease etiologies of all patients were recorded. Clinical data such as blood pressure, amount of ultrafiltration, and laboratory parameters were evaluated before initiation of PD and during the last monitoring period. Infectious complications and their incidences were investigated. Patient and technique survival were investigated for every patient. RESULTS: 322 patients started PD treatment during the study period. 23 patients were excluded. Data from the remaining 299 patients (167 female, mean follow-up time 38.5 ± 26.8 months, mean age 44.7 ± 15.9 years) were evaluated retrospectively. It was determined that 87.3% of the patients made their PD exchanges without help from anyone. 79.9% of patients chose PD as their personal preference. 48 patients had HD history before PD. Peritonitis incidences and catheter exit site/tunnel infection attacks were 27 ± 23 and 32.3 ± 24.9 patient-months, respectively. During the follow-up period, 199 patients (80 patients transferred to HD, 78 patients died and, 41 patients had transplantation) were withdrawn from PD. The most frequent causes of death were cardiovascular events and peritonitis and/or sepsis, whereas most frequent causes of transfer to HD were peritonitis and/or sepsis. Mean survival time was 49.9 ± 2.6 months. The estimation of survival rate was 85.2%, 66.5% and 45.3% at 1, 3, and 5 years, respectively. Preference for PD (RR: 4.77, p < 0.001), presence of HD history (RR: 2.08, p = 0.04), presence of diabetes mellitus (RR: 2.13, p = 0.01), low pretreatment serum albumin (RR: 0.32, p < 0.001), and low serum parathormone levels at last visit (RR: 0.99, p = 0.04) were predictors of mortality. Mean technique survival duration was 48.5 ± 2.4 months. The estimation of technique survival by Kaplan-Meier analyses was 92%, 67% and 43% at 1, 3, and 5 years, respectively. Technique survival was associated with preference for PD (RR: 0.45, p < 0.001), presence of diabetes mellitus (RR: 1.92, p = 0.003), and pretreatment serum albumin levels (RR: 0.58, p = 0.003). CONCLUSION: Patient survival in the presented institute is similar to that reported in Western countries. Compulsory choice of PD, presence of HD history, presence of diabetes, low pretreatment serum albuminm, and low serum parathormone levels at last visit were the strongest predictors of death. Risk factors for technique failure were compulsory choice of PD, presence of diabetes, low pretreatment serum albumin.

FGF-23 associated with the progression of coronary artery calcification in hemodialysis patients.

BACKGROUND: Disordered mineral metabolism is implicated in the pathogenesis of vascular calcification in hemodialysis (HD) patients. Fibroblast growth factor 23 (FGF-23) is the main regulator of phosphate metabolism. In this prospective study, we aimed to investigate the association of serum FGF-23 with progression of coronary artery calcification in HD patients. METHODS: Seventy-four HD patients (36 male/38 female, mean age: 52 ± 14 years) were included. Serum FGF-23 levels were measured by ELISA. Coronary artery calcification score (CACS) was measured twice with one year interval. Patients were grouped as progressive (PG) (36 patients-48%) and non-progressive (NPG). RESULTS: Age, serum phosphorus, baseline and first year CACS were found to be significantly higher in the PG compared to NPG group. Serum FGF-23 levels were significantly higher in PG [155 (80-468) vs 147 (82-234), p = 0.04]. Patients were divided into two groups according to baseline CACS (low group, CACS ≤ 30; high group, CACS > 30). Serum FGF-23 levels were significantly correlated with the progression of CACS (ΔCACS) in the low baseline CACS group (r = 0.51, p = 0.006), but this association was not found in high baseline CACS group (r = 0.11, p = 0.44). In logistic regression analysis for predicting the PG patients; serum FGF-23, phosphorus levels and baseline CACS were retained as significant factors in the model. CONCLUSIONS: Serum FGF-23 was found to be related to progression of CACS independent of serum phosphorus levels. FGF-23 may play a major role in the progression of vascular calcification especially at the early stages of calcification process in HD patients.

Is There a Relationship Between Epicardial Adipose Tissue, Inflammatory Markers, and the Severity of COVID-19 Pneumonia?

Objectives: Epicardial adipose tissue (EAT) is a type of visceral adipose tissue with pro-inflammatory properties. We sought to examine the relationship between the EAT volume and attenuation measured on non-contrast chest computed tomography (CT), inflammation markers, and the severity of COVID-19 pneumonia. Methods: One hundred and twenty-five patients who are over 18 years old who applied to our hospital and were found to have COVID-19 polymerase chain reaction (+) on nasopharyngeal swab sample and COVID-19 pneumonia on chest CT were included in the study. At admission, C-reactive protein (CRP), procalcitonin, fibrinogen, leukocytes, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lactate dehydrogenase (LDH), ferritin, and d-dimer were evaluated. EAT volume and attenuation were measured on chest CT. Patients who were hospitalized and discharged from the ward were categorized as Group 1, whereas patients who required intensive care admission and/or died were classified as Group 2. The primary endpoint of our study was defined as death, hospitalization in the intensive care unit, and discharge. The relationship between disease severity and EAT and other inflammatory markers was investigated. Results: One hundred and six individuals were in Group 1 and 19 patients were in Group 2. Of the 125 individuals, 46 were women and 79 were men. The mean age was 58.5±15.9 years. Group 2 patients were older. Regarding measurements of the EAT volume and attenuation; there was no statistically significant difference between the groups determined. The patients in Group 2 had statistically substantially higher values for urea, creatinine, LDH, d-dimer, troponin T, procalcitonin, CRP, and neutrophil/lymphocyte ratio in their laboratory tests. When compared to patients in Group 1, patients in Group 2 had statistically significantly lower albumin values (p<0.001). In obese patients, EAT volume was statistically significantly higher and EAT attenuation was found to be lower. Conclusion: In our study, no relationship was found between critical COVID-19 disease and EAT volume and attenuation, which is an indicator of EAT inflammation. Inflammatory markers from routine laboratory tests can be used to predict critical COVID-19 disease. No relationship was found between obesity and critical COVID-19 disease.