Evaluation of Code Blue Notifications and Their Results: A University Hospital Example.

OBJECTIVE: Code blue is one of the important practices for preventing mortality and morbidity and increasing the quality of care in hospitals. The aim of this study was to evaluate the blue code notifications and their results, emphasise their importance, and determine the effectiveness and deficiencies of the application. METHODS: In this study, all code blue notification forms recorded between January 1 and December 31, 2019, were examined retrospectively. RESULTS: It was determined that code blue calls were made for 108 cases, including 61 females and 47 males, and the mean age of the patients was 56.47 ± 20.73. The accuracy rate of the code blue calls was determined as 42.6%, and 57.4% of them were made during non-working hours. Also, 15.2% of the correct code blue calls were made from dialysis and radiology units. The mean time for the teams to reach the scene was 2.83 ± 1.30 minutes, and the mean time to respond to correctly made code blue calls was 33.97 ± 17.95 minutes. It was found that 15.7% of the patients in correctly made code blue calls were exitus after the intervention. CONCLUSION: Early diagnosis of cardiac or respiratory arrest cases and quick and correct intervention are very important in achieving patient and employee safety. For this reason, it is necessary to continuously evaluate code blue practices, educate the staff, and organise improvement activities constantly.

C allele in transforming growth factor-ß1 rs1800471 gene polymorphisms might indicate a protective feature in encapsulating peritoneal sclerosis development.

INTRODUCTION: Peritoneal fibrosis may progress in peritoneal dialysis (PD) patients to a fatal clinical condition called encapsulating peritoneal sclerosis (EPS). Transforming growth factor (TGF)-ß plays a pivotal role in the pathogenesis of peritoneal fibrosis. We aimed to investigate the association among polymorphisms in the gene encoding TGF-ß1, which were -509C/T (rs1800469), +869T/C (rs1982073), and +915G/C (rs1800471) in EPS patients. METHODS: A total of 16 PD patients who were clinically and radiologically diagnosed with EPS were enrolled and 22 age- and gender-matched PD patients were selected as the non-EPS group. RESULTS: G allele frequency at the rs1800471 gene polymorphism was significantly higher in the EPS group than non-EPS group (p = 0.005). Interestingly, the non-EPS group patients had CC or CG polymorphisms. CONCLUSION: C allele in TGF-ß1 rs1800471 gene polymorphisms might indicate a protective feature in EPS development. Knowing the presence of polymorphism may be effective in selecting renal replacement therapy in patients.

Serum uromodulin levels, MR imaging findings, and their relationship with eGFR-based CKD staging in ADPKD patients.

PURPOSE: Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease that may progress to end-stage renal disease, characterized by increased kidney volume due to cystic formations. In this study, we aimed to investigate the relationship between serum uromodulin levels, total kidney volume and estimated glomerular filtration rate (eGFR) in patients with ADPKD. METHODS: This study included a total of 54 ADPKD patients and 18 healthy volunteers (control group). Total kidney volumes were calculated through magnetic resonance images using ellipsoid method. Serum uromodulin measurements were measured using an ELISA method. RESULTS: Serum uromodulin levels were lower in patients compared with the control group (2.47 ± 0.16 vs 2.6 ± 0.28, p = 0.021). There was no significant difference in uromodulin values among the patients in chronic kidney disease (CKD) stages 1-2, 3 and 4-5. TKV measurements of CKD stage 4-5 patients were significantly higher than the stage 1-2 patients (p = 0.015). A negative correlation was observed between TKV and eGFR (r = - 0.433, p = 0.001). A positive correlation was observed between uromodulin and eGFR (r = 0.274, p = 0.02). When the serum levels of uromodulin and the level of eGFR were evaluated using simple linear regression analysis, R2 value was found to be 0.075, suggesting that 7.5% change in serum uromodulin values corresponds with the change in eGFR value. CONCLUSION: These findings are consistent with previous studies that reported that serum uromodulin may be a good biomarker for demonstrating renal function in the early stages of CKD, before eGFR levels deteriorate. Serum uromodulin level may be useful in demonstrating renal functions in the follow-up of individuals with ADPKD.

Is Skin Tag Associated with Diabetic Macro and Microangiopathy?

INTRODUCTION: Although skin tag is associated with diabetes mellitus, no data in the literature show that the presence of skin tag is associated with diabetic macro and microangiopathy. The purpose of this study was to investigate the frequency of hypertension, dyslipidemia, obesity, macro and micro angiopathy in type 2 diabetic patients with and without skin tag. MATERIAL AND METHODS: We evaluated 99 (40 female and 59 male) type 2 diabetic patients. All patients were evaluated for blood pressure, body mass index, lipids, HbA1c, macroangiopathy (peripheral vascular disease, cerebrovascular disease and coronary heart disease), microangiopathy (neuropathy, nephropathy, retinopathy) and skin tag. RESULTS: Age, HbA1c and body mass index were 65.0 ± 14.2 years, 8.1 ± 2.0% and 30.5 ± 6.4 kg/m2, respectively. The frequency of skin tags 53.5%, dyslipidemia 68.7%, hypertension 69.7%, obesity 39.4%, macroangiopathy 61.6% (peripheral vascular disease 12.1%, cerebrovascular disease 16.2%, and coronary heart disease 49.5%), microangiopathy 63.6% (neuropathy 21.2%, nephropathy 38.4%, retinopathy 38.4%) were detected. Higher body mass index (p = 0.04) and frequency of obesity (p = 0.03) were detected in patients with skin tag than without skin tag. Age (p = 0.8), gender (p = 0.6), HbA1c (p = 0.4) and the presence of dyslipidemia (p = 0.4), hypertension (p = 0.6), macroangiopathy (p = 0.2), and microangiopathy (p = 0.9) were not different in patients with and without skin tag. CONCLUSION: We conclude that presence of skin tag is merely related to obesity and may not be strongly associated with macro- and microangiopathy in type 2 diabetic individuals. Further studies with large patient population are required to elucidate the association between the presence of skin tag and diabetic angiopathy.

Sexual Dysfunction Is Associated with Depression and Anxiety in Patients with Predialytic Chronic Kidney Disease.

OBJECTIVE: We aimed to determine the prevalence of sexual dysfunction and clarify the relationship between sexual dysfunction and depressive mood state, drugs, and disease activities in patients with predialytic chronic kidney disease (CKD). MATERIALS AND METHODS: In total, 150 patients with CKD who had an estimated glomerular filtration rate of 15-60 mL/min were included; 65 healthy controls were selected. A detailed medical and sexual medical history was taken from individuals in the control and patient groups by applying the Golombok-Rust Inventory of Sexual Satisfaction and Hospital Anxiety and Depression Scale. RESULTS: Sexual frequency (p=0.027), impotence (p<0.001), and premature ejaculation scores (p<0.001) in male patients and sexual frequency (p=0.004), communication (p=0.004),, satisfaction (p<0.001), avoidance (p=0.008), orgasmic dysfunction (p<0.001), sensuality (p=0.002), and total sexual dysfunction scores (p<0.001) in female patients with CKD were found to be higher compared with the control group. In female patients, the depression scores of patients with stage 3 CKD were found to be higher than those of patients with stage 4 CKD (p=0.028). The avoidance scores of male patients with depression (p=0.006) were high. In contrast, the communication score of female patients with depression was high (p=0.004). It has been detected that the factors that affect the sexual dysfunction score of patients with CKD in males are age (p=0.006), hypertension (p=0.008), anxiety (p=0.003), and depression (p=0.002) and those in female patients are age (p=0.034), anxiety (p<0.001), and depression (p=0.001). CONCLUSION: Patients with predialytic CKD substantially have sexual dysfunction. The most important factors that affect sexual dysfunction are age, hypertension, anxiety, and depression.

Eculizumab experience in an adult patient with atypical hemolytic uremic syndrome.

Atypical hemolytic-uremic syndrome is a disease characterized by nonimmune hemolytic anemia, thrombocytopenia, and renal failure. In this study, we present a case of a patient with atypical hemolytic-uremic syndrome treated successfully with eculizumab. A 20-year-old female was admitted with clinical signs of atypical hemolytic syndrome. The laboratory findings were as follows: hemoglobin 9.2 g/dL, platelet count 18 × 103/µL, creatinine 4.69 mg/dL, schistocytes were in peripheral blood smear, lactate dehydrogenase 2080 U/L, and emergency plasmapheresis procedure with fresh frozen plasma were initiated. The patient was anuric within 12 h of her admittance. ADAMTS13 activity was normal. Her mother's cousin developed acute rejection immediately after receiving a renal transplant and died two months later. As she did not respond to the treatment and considering her family history, eculizumab was initiated which resulted in platelet counts starting to rise on day 5, and the patient no longer needed dialysis after 22 days.

High serum soluble CD200 levels in patients with autosomal dominant polycystic kidney disease.

CD200 is a novel immune-effective molecule, existing in a cell membrane-bound form, as well as in a soluble form in serum, which performs to modulate inflammatory and acquired immune responses. Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the development of large renal cysts and progressive loss of renal function. As defects in cell cycle arrest and apoptosis of renal tubular epithelial cells occur in ADPKD, we asked whether serum soluble CD200 might underlie and effect on ADPKD. Serum soluble CD200 levels were measured in 44 patients with ADPKD and 24 healthy volunteers. Concentrations of soluble CD200 in the serum samples were quantified using an ELISA kit. The mean serum soluble CD200 levels were higher in patients with ADPKD than in the control group (71.4±29.2 and 21.4±5.6 pg/mL, p<0.001). Positive correlation was detected between serum soluble CD200 levels and glomerular filtration rate (r=0.772, p<0.001), and serum albumin level (r=0.466, p=0.001). Negative correlation was detected between serum soluble CD200 levels and serum creatinine levels (r=-0.761, p<0.001), and C reactive protein levels (r=-0.364, p=0.015). In the ADPKD patients group, serum soluble CD200 levels were lower in patients with stage 5 chronic kidney disease (CKD) than in patients with stages 1-2 (p<0.001), 3 (p=0.005) and 4 CKD (p=0.006). Serum soluble CD200 levels were similar in patients with stages 1-2, 3, and 4 CKD (p>0.05). Our results show that patients with ADPKD have activated soluble CD200 levels which were related to renal function and inflammation.

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

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

Autosomal Dominant Polycystic Disease is Associated with Depressed Levels of Soluble Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is characterized by multiple, large renal cysts and impaired kidney function. Although the reason for the development of kidney cysts is unknown, ADPKD is associated with cell cycle arrest and abundant apoptosis of renal tubular epithelial cells. AIMS: We asked whether serum-soluble TNF-related apoptosis-inducing ligand (sTRAIL) might underlie ADPKD. STUDY DESIGN: Case-control study. METHODS: Serum sTRAIL levels were measured in 44 patients with ADPKD and 18 healthy volunteers. The human soluble TRAIL/Apo2L ELISA kit was used for the in vitro quantitative determination of sTRAIL in serum samples. RESULTS: Mean serum sTRAIL levels were lower in patients with ADPKD as compared to the control group (446.9±103.1 and 875.9±349.6 pg/mL, p<0.001). Serum sTRAIL levels did not differ among stages of renal failure in patients with ADPKD. There was no correlation between serum sTRAIL levels and estimated glomerular filtration rate in patients with ADPKD (p>0.05). CONCLUSION: Our results show that ADPKD patients have depressed sTRAIL levels, indicating apoptosis unrelated to the stage of chronic renal failure.

Soluble Klotho and fibroblast growth factor 23 levels in diabetic nephropathy with different stages of albuminuria.

The relationship between soluble Klotho (s-Klotho) levels, fibroblast growth factor 23 (FGF23) levels, and albuminuria in patients with diabetic chronic kidney disease (CKD) remains unclear. A total of 109 patients with type 2 diabetes (mean age 61.63±9.77 years), at the outpatient clinic of the Antalya Research and Training Hospital Nephrology Unit between January and June 2014, as well as 32 healthy controls (mean age 49.53±7.32 years) were enrolled for this cross-sectional study. Patients were classified into three groups according to their urinary albumin creatinine ratio (UACR), normoalbuminuria (UACR<30 mg/g), microalbuminuria (UACR 30-300 mg/g), and macroalbuminuria (UACR>300 mg/g). The blood was analyzed for FGF23, s-Klotho, parathyroid hormone (PTH), P, Ca, creatinine, and 25-hydroxyvitamin D3 (25hD) levels. Creatinine, s-Klotho, FGF23, and PTH levels were significantly higher and 25hD levels were significantly lower in the patient group than in the healthy controls (p<0.001). Between the groups according to UACR, 1-way analysis of variance revealed statistically significant differences for creatinine (p<0.001), 25hD (p<0.001), PTH (p=0.002), Ca (p=0.002), and albumin levels (p<0.001). A statistically significant positive correlation was found between s-Klotho and FGF23 (r=0.768; p=0.001), and between FGF23 levels and UACR (r=0.768; p=0.001). In conclusion, the results of the present study suggest that s-Klotho levels are significantly elevated in patients with diabetes and s-Klotho levels decreased with increasing albumin excretion in our patients despite a reduction in estimated glomerular filtration rate.

Decrease of Urotensin II activity can impact on the volume status in predialysis chronic kidney disease.

Urotensin II (U-II) was thought to be one of the mediators of primary renal sodium retention due to effects on renal sodium excretion. For this purpose, the relationship between U-II and overhydration was investigated. A total of 107 patients were enrolled in the study. According to body compositor monitor analysis, fluid overload up to 1.1 L, was considered normohydration. Patients were divided according to hydration status; overhydrate (n = 42) and normohydrate (n = 65) were studied in both groups. Pulse waveform velocity propagation for arterial stiffness and blood pressure analysis and echocardiographic left ventricular and left atrial indices were performed with known fluid overload-related parameters. U-II levels were measured by using Human ELISA kit. In overhydrated group, U-II levels were significantly lower. All parameters (blood pressure, arterial stiffness parameters, echocardiographic data, age, gender, diabetes, U-II, hemoglobin) correlated with overhydration, were determined by linear regression model (method = enter), when considered together, U-II was found to be an independent predictor from other conventional overhydration-related parameters. Male sex, left ventricular mass index, left atrial volume index, hemoglobin value were found to be independent predictors for overhydration. Considering the association of low U-II levels with adverse cardiovascular events and its role in sodium retention, we think that low U-II levels can be accepted as a potential therapeutic target in patients with hypervolemic cardio-renal syndrome.

Serum prolactin and macroprolactin levels in diabetic nephropathy.

OBJECTIVE: Three molecular forms of prolactin with molecular weights of 23 (monomeric), 50 - 60 and > 100 kDA (macroprolactin) have been defined. Prolactin levels have been shown to be reduced in especially poorly controlled diabetes mellitus and the prevalence of macroprolactinemia in diabetic patients has been higher than the non-diabetic population. PATIENTS AND METHODS: A total 234 Type 2 diabetic patients with different nephropathy stage was included in the study. Serum prolactin levels were analyzed by the Electrochemiluminescense method. Following polyethylene glycol (PEG) precipitation, recovery less than or equal to 40% was taken as evidence that a significant level of macroprolactin was present in the serum. RESULTS: Hyperprolactinemia and macroprolactinemia were detected in 40 (17%) and 13 (5.5%) patients, respectively. Macroprolactinemia was detected 13 of 40 patients with hyperprolactinemia (32.5%). Increased prolactin and macroprolactin levels in patients with moderate and severe renal failure (Stage 3, 4, and 5) according to the U.S. NKF-DOQI classification (p < 0.001). Prolactin and macroprolactin levels were not increased in patients with normoalbuminuria, microalbuminuria and macroalbuminuria (p > 0.05). Serum creatinine levels correleted positively with both prolactin (r = 0.51, p < 0.001) and macroprolactin levels (r = 0.43, p < 0.001). On the other hand, glomerular filtration rate correlated negatively with both prolactin (r = -0.54, p < 0.001) and macroprolactin levels (r = -0.44, p < 0.001). Albuminuria significantly related with neither prolactin nor macroprolactin levels (p > 0.05). CONCLUSION: In the present study, we found that not only serum prolactin but also serum macroprolactin levels increased especially in moderate to severe renal failure which was due to decreased glomerular filtration and renal parenchymal function resulting in an increased amount of monomeric prolactin and macroprolactin in the circulation in patients with Type 2 diabetes mellitus.

Good response to HBsAg vaccine in dialysis patients is associated with high CD4+/CD8+ ratio.

OBJECTIVE: Chronic renal failure is accompanied by various abnormalities of innate and acquired, cellular and humoral immunity. We aimed to investigate whether positive Candida skin test results, CD4+ and CD8+, before the first dose of vaccination could be a predictor for antibody response to hepatitis B vaccination and the relation of these parameters with hepatitis B antibody levels 1 month after the last dose of vaccination. MATERIALS AND METHODS: The present study was carried out in 57 dialysis patients. All patients received recombinant hepatitis B vaccine (40 µg) given intramuscularly in the deltoid muscle in a four-dose schedule at 0, 1, 2, and 6 months. Candida skin test and lymphocyte subsets (CD4+ and CD8+) were determined before the first dose of vaccination and 1 month after the fourth inoculation of hepatitis B vaccine. RESULTS: Ten patients (17.5%) were non-responders (HBsAb < 10 IU/L), while 47 patients (82.5%) were responders (HBsAb ≥ 10 IU/L). However, 29 patients (50.9%) were weak responders (HBsAb:10-100 IU/L), 18 patients (31.6%) good responders (HBsAb > 100 IU/L), which was determined 1 month after the fourth dose of vaccination. Thirty-nine patients (68.4%) and 44 patients (77.2%) were anergic to Candida skin test before the first dose and 1 month after fourth inoculation of hepatitis B vaccine, respectively. There was no relationship between Candida skin test and response to hepatitis B vaccination. Mean age was lower, and CD4+/CD8+ ratio measured both before and after vaccination was higher in good responders compared with that of weak responders and that of non-responders. Females were better responders than males. CONCLUSION: High skin test anergy rate and low seroconversion rate after hepatitis B vaccination are important problems in patients on dialysis. Females, younger patients, and patients with higher CD4+/CD8+ ratio have better HBsAb antibody response to hepatitis B vaccination.

The effect of quinapril treatment on insulin resistance, leptin and high sensitive C-reactive protein in hypertensive patients.

The aim of the study was to evaluate the effect of quinapril on HOMA-IR, high sensitive C-reactive protein and leptin. Total 54 hypertensive and 24 control subjects were included in this study. Blood pressure, leptin, high sensitive C-reactive protein, and HOMA-IR were determined at baseline and after 3 months quinapril treatment. After treatment with quinapril HOMA-IR (p = 0.04), high sensitive C-reactive protein (p = 0.027), and leptin (p = 0.046) were decreased in hypertensive patients. Quinapril may be used as a therapy for improving blood pressure as well as the insulin resistant, hyperleptinemic, and low-grade inflammatory state in hypertension.

Relationship between thyroid volume and iodine, leptin, and adiponectin in obese women before and after weight loss.

OBJECTIVE: To investigate whether or not reduction of thyroid volume during weight loss is related to adipocytokines and urinary iodine excretion in obese women. SUBJECTS AND METHODS: 98 obese and 31 non-obese women consecutively admitted to the endocrinology and metabolism outpatient clinic of the School of Medicine, Akdeniz University were included in the study. Thyroid volume, thyroid function tests, leptin and adiponectin levels, and urinary iodine excretion were measured at baseline and six months after treatment for obesity. RESULTS: Thyroid volume increased in obese women (p = 0.048). After adjustment for body mass index, there were no significant differences in plasma leptin and serum adiponectin levels between obese and non-obese women (p > 0.05). Thyroid volume correlated positively with body mass index (r = 0.48, p = 0.04), leptin (r = 0.1, p = 0.03), and thyroid-stimulating hormone (r = 0.43, p = 0.001) levels, while there was a negative correlation between thyroid volume and urinary iodine (r = -0.38, p = 0.04) and urinary iodine/creatinine ratio (r = -0.25, p = 0.045) in obese women. Changes in body mass index (p = 0.022) and leptin levels (p = 0.039) were the only factors that significantly affected the change of thyroid volume during weight loss. CONCLUSION: Iodine status may play an important role in increased thyroid volume in obese women; however, iodine status did not seem to exert a significant influence on the changes in thyroid volume. On the other hand, changes in both body mass index and plasma leptin levels seemed to be important for changes in thyroid volume.

Normal pregnancy and healthy child after continued exposure to gliclazide and ramipril during pregnancy.

OBJECTIVE: To report a case of exposure to gliclazide and ramipril during pregnancy in a patient with diabetes mellitus and hypertension. CASE SUMMARY: A 42-year-old female with type 2 diabetes mellitus and hypertension who had been taking gliclazide 30 mg/day and ramipril 10 mg/day for 2 years was admitted in the 16th week of gestation. The following week, gliclazide and ramipril were discontinued and methyldopa 500 mg 4 times daily and intensive insulin therapy were instituted. Blood glucose concentrations and blood pressure remained within acceptable levels throughout the pregnancy. The patient gave birth to a healthy child (3200 g) by cesarean section after completing an uneventful gestation period. DISCUSSION: Oral antidiabetic drug use in pregnancy is not recommended secondary to known effects on the fetus such as congenital abnormalities, fetal hyperinsulinemia, macrosomia, and neonatal hypoglycemia. Although this infant had no abnormalities after being exposed to gliclazide and ramipril during the first 16 weeks of gestation, this case is not an unconditionally acceptable indication for safety of these medications in pregnancy. Angiotensin-converting enzyme inhibitors increase fetal risks and therefore should not be used during pregnancy, according to data from animals and humans. There are few data available on use of sulfonylureas; thus, their use should also be avoided during pregnancy. CONCLUSIONS: Although the normal pregnancy outcome in our patient does not indicate that use of gliclazide and ramipril is safe during gestation, these data contribute to limited information regarding human exposure to these drugs.