The Longitudinal Evolution of Post-COVID-19 Outcomes Among Hemodialysis Patients in Turkey.

Introduction: Hemodialysis (HD) patients have increased risk for short-term adverse outcomes of COVID-19. However, complications and survival at the post-COVID-19 period have not been published extensively. Methods: We conducted a national, multicenter observational study that included adult maintenance HD patients recovered from confirmed COVID-19. A control HD group without COVID-19 was selected from patients in the same center. We investigated the characteristics and outcomes in the follow-up of HD patients and compare them with the non-COVID-19 group. Results: A total of 1223 patients (635 patients in COVID-19 group, 588 patients in non-COVID-19 group) from 47 centers were included in the study. The patients' baseline and HD characteristics were almost similar. The 28th-day mortality and mortality between 28th day and 90th day were higher in the COVID-19 group than non-COVID-19 group (19 [3.0%] patients vs. none [0%]; 15 [2.4%] patients vs. 4 [0.7%] patients, respectively). The presence of respiratory symptoms, rehospitalization, need for home oxygen therapy, lower respiratory tract infection, and arteriovenous (AV) fistula thrombosis was significantly higher in the COVID-19 group in both the first 28 days and between 28 and 90 days. In the multivariable analysis, age (odds ratio [OR] [95% CI]: 1.029 [1.004-1.056]), group (COVID-19 group vs. non-COVID-19 group) (OR [95% CI]: 7.258 [2.538-20.751]), and vascular access type (tunneled catheter/AV fistula) (OR [95% CI]: 2.512 [1.249-5.051]) were found as independent parameters related to 90-day mortality. Conclusion: In the post-COVID-19 period, maintenance HD patients who have had COVID-19 have increased rehospitalization, respiratory problems, vascular access problems, and high mortality compared with the non-COVID-19 HD patients.

Serum seladin-1 levels in diabetes mellitus and Alzheimer's disease patients.

BACKGROUND: Diabetes mellitus (DM) has been shown to increase the risk of Alzheimer's disease (AD). Downregulation of selective Alzheimer's disease indicator-1 (seladin-1) occurs in the cerebral regions affected by AD. However, inconsistent results have been reported for the relationship between seladin-1 levels and AD. The effect of DM on serum seladin-1 levels in AD is unknown. The present study is aimed to investigate serum seladin-1 levels in diabetic and non-diabetic patients with AD. METHODS: Forty-six patients with AD and 25 healthy volunteers over 65 years of age were included in this study. The patients were divided into three groups-those with AD only, those with DM and AD, and control groups. Demographic characteristics and serum seladin-1 levels were compared among the groups. RESULTS: There was no statistically significant difference in seladin-1 levels in the AD only group compared to the control group (p = 0.376). However, seladin-1 levels were significantly lower in the DM and AD group compared to the AD only and control groups (p = 0.002, p = 0.001; respectively). Negative correlations were present between seladin-1 and fasting glucose, postprandial glucose, HbA1c, and insulin (p < 0.05; all). CONCLUSION: Decreased serum seladin-1 values in the presence of DM and inverse correlations with diabetic parameters in patients with AD, together with a non-significant difference from the control group, suggests that seladin-1 may be altered only in the presence of DM in patients with AD. Lower serum seladin-1 levels may also play a role in the pathogenesis of AD in patients with DM.

The effect of dietary salt restriction on hypertension in peritoneal dialysis patients.

BACKGROUND/AIM: To investigate the effect of dietary salt restriction on blood pressure levels, total sodium removal, and hydration status of peritoneal dialysis (PD) patients. MATERIALS AND METHODS: Thirty-one stable PD patients who consulted a renal dietitian monthly for dietary recommendations, including restricted salt intake <5 g/day, and education about hypertension and hypervolemia were included in this study. Baseline and third month clinical and laboratory findings, bioelectrical impedance analysis results, and urinary and peritoneal sodium removal values were recorded. RESULTS: The mean age of the patients was 47.6 years and the mean time on PD was 39.6 months. The mean total sodium removal decreased slightly from 139.4 ± 69.1 to 136.2 ± 64.8 mmol/day (P > 0.05) for the whole sample, and from 164.3 ± 70.9 to 154.2 ± 72.3 mmol/day (P > 0.05) for the hypertensive subgroup (n: 17). Systolic blood pressure (from 134.3 ± 20.1 to 127.2 ± 19.5 mmHg, P: 0.01), diastolic blood pressure (from 83.2 ± 12.0 to 77.4 ± 10.5 mmHg, P: 0.01) and total body water (from 39.2 ± 10.9 to 38.3 ± 9.3 L, P: 0.04) decreased significantly. CONCLUSION: We demonstrated that even a little reduction in daily dietary sodium intake caused significant decreases in blood pressure levels and fluid overload.

Fibromyalgia and nondipper circadian blood pressure variability.

BACKGROUND AND OBJECTIVES: Aberrant circadian rhythm with persistent nocturnal sympathetic hyperactivity has pointed out malfunctioning autonomic nervous system in fibromyalgia (FM) patients. This is a common pathogenesis shared also by patients with nondipping blood pressure (BP) pattern. Therefore, we aimed to investigate the frequency of nondipping BP pattern in normotensive women with newly diagnosed FM compared with healthy women. METHODS: Sixty-seven normotensive women with new diagnosis of FM and 38 age-matched healthy volunteer women were recruited into the study. All subjects underwent 24-hour ambulatory BP monitoring on a usual working day. Individuals were defined as "dippers" if their nocturnal BP values decreased by more than 10% compared with daytime values; defined as "nondippers" in case of a decline less than 10%. Serum creatinine, fasting blood glucose, cholesterol levels, albumin, and thyroid-stimulating hormone levels were assessed. RESULTS: Ambulatory measurements showed significantly higher diastolic BP values in patients with FM for both average of 24-hour recordings. Patients with FM had significantly lower systolic (9.1 ± 3.9 vs 11.5 ± 4.9, P = 0.010) and diastolic dipping ratios (12.3 ± 6.1 vs 16.1 ± 6.4, P = 0.004). The number of nondippers in the FM group was significantly higher than that of controls for both systolic (66% vs 34%, P = 0.002) and diastolic BP measurements (42% vs 21%, P=0.031). Patients with FM were 3.68 times more likely to be systolic nondipper and 2.69 times more likely to be diastolic nondipper. CONCLUSIONS: We have demonstrated a significant relationship between FM and nondipping BP pattern, and we suggest that nondipping profile, which has been closely associated with cardiovascular morbidity, may appear as an additional risk factor in patients with FM.

Left ventricular hypertrophy and blood pressure control in automated and continuous ambulatory peritoneal dialysis patients.

Hypertension, non-dipper blood pressure (BP) pattern and decrease in daily urine output have been associated with left ventricular hypertrophy (LVH) in peritoneal dialysis (PD) patients. However, there is lack of data regarding the impact of different PD regimens on these factors. We aimed to investigate the impact of circadian rhythm of BP on LVH in end-stage renal disease patients using automated peritoneal dialysis (APD) or continuous ambulatory peritoneal dialysis (CAPD) modalities. Twenty APD (7 men, 13 women) and 28 CAPD (16 men, 12 women) patients were included into the study. 24-h ambulatory blood pressure monitoring (ABPM) and transthoracic echocardiography besides routine blood examinations were performed. Two groups were compared with each other for ABPM measurements, BP loads, dipping patterns, left ventricular mass index (LVMI) and daily urine output. Mean systolic and diastolic BP measurements, BP loads, LVMI, residual renal function (RRF) and percentage of non-dippers were found to be similar for the two groups. There were positive correlations of LVMI with BP measurements and BP loads. LVMI was found to be significantly higher in diastolic non-dippers compared to dippers (140.4 ± 35.3 vs 114.5 ± 29.7, respectively, P = 0.02). RRF and BP were found to be independent predictors of LVMI. Non-dipping BP pattern was a frequent finding among all PD patients without an inter-group difference. Additionally, higher BP measurements, decrease in daily urine output and non-dipper diastolic BP pattern were associated with LVMI. In order to avoid LVH, besides correction of anemia and volume control, circadian BP variability and diastolic dipping should also be taken into consideration in PD patients.

Association between bioimpedance analysis parameters and left ventricular hypertrophy in peritoneal dialysis patients.

PURPOSE: Chronic volume overload, hypertension and left ventricular hypertrophy are major risk factors contributing to the high mortality rate in peritoneal dialysis (PD) patients. In this study, we aimed to determine the impact of blood pressure measurements and volume status determined by bioelectrical impedance analysis (BIA) measurements over left ventricular hypertrophy (LVH) in PD patients. METHODS: Thirty-one prevalent PD patients were enrolled. Patients with a documented cardiovascular disease and uncontrolled hypertension were excluded. BIA and transthoracic echocardiography were performed in all patients All measurements were taken with the empty abdominal cavity. Routine laboratory parameters were also assessed in all patients. Extracellular water (ECW) in liters and ECW/total body water (TBW) ratio were used for determining volume status. RESULTS: Mean age of the patients was 43.9 ± 15.4 years, and mean PD duration was 39.5 ± 29.6 months. Mean ECW/TBW ratio was 44.3 %. Left ventricular mass index (LVMI) was 134.3 ± 34.9 g/m(2). Fifty-eight percent of patients had LVH. Mean LVMI was negatively correlated with daily urine volume (r -0.568, p 0.001) and weekly Kt/V (r -0.393, p 0.029); positively correlated with daily ultrafiltration (r +0.585, p 0.001) and office systolic (r +0.500, p 0.004) and diastolic (r +0.459, p 0.009) blood pressures. In linear regression analysis, daily urine volume (B -0.426, p 0.002) mean diastolic blood pressure (B 0.550, p <0.001), ECW/TBW ratio (B 0.313, p 0.02) and waist circumference (B 0.304, p 0.016) were independent risk factors for LVH. CONCLUSIONS: We want to underline that, besides maintaining residual renal function, strict blood pressure control, particularly diastolic blood pressure, and avoiding hypervolemia and abdominal obesity should be main clinical goals in follow-up of PD patients in order to prevent LVH progression.

Novel inflammatory marker in dialysis patients: YKL-40.

YKL-40 has been introduced as a marker of inflammation in different clinical situations. The association between YKL-40 and inflammation in chronic renal failure patients has not been researched currently. The objectives of this study were to establish serum YKL-40 concentrations in dialysis patients with chronic renal failure compared to healthy subjects and to explore its relationships with a proinflammatory cytokine, interleukine-6 (IL-6) and an acute phase mediator, high sensitivity C-reactive protein (hs-CRP). The study population included hemodialysis patients (N = 43; mean age of 40.9 ± 14.5), peritoneal dialysis patients (N = 38; mean age of 45.8 ± 13.7) and healthy subjects (N = 37; mean age of 45.5 ± 10.6). Serum concentrations of YKL-40, IL-6, hs-CRP and routine laboratory measures were evaluated. Compared to the healthy subjects, hemodialysis and peritoneal dialysis patients had higher concentrations of YKL-40, IL-6, hs-CRP, as well as lower concentrations of hemoglobin, serum albumin and high density lipoprotein-cholesterol (P < 0.001). YKL-40 concentrations were positively correlated with serum creatinine (P < 0.001, r = 0.495), IL-6 (P < 0.001, r = 0.306), hs-CRP (P = 0.001, r = 0.306) levels and inversely correlated with hemoglobin (P = 0.002, r = -0.285), serum albumin (P < 0.001, r = -0.355) and high density lipoprotein-cholesterol (P = 0.001, r = -0.306). In multivariate regression analysis YKL-40 was associated with creatinine, serum albumin and hs-CRP concentrations after adjustments with covariates. Dialysis patients with chronic renal failure have elevated serum YKL-40 concentrations. Associations with standard inflammatory parameters suggest that YKL-40 might be a novel inflammatory marker in this population.

Neutrophil to lymphocyte ratio in evaluation of inflammation in patients with chronic kidney disease.

AIM: The current data have proven the pivotal role of inflammation in the development of atherosclerosis and cardiovascular diseases in patients with chronic kidney disease (CKD). Neutrophil to lymphocyte (N/L) ratio has increasingly been reported as a measure of systemic inflammation. This study assessed N/L ratio and investigated its associations with standard inflammatory biomarkers in different stages of CKD patients. MATERIAL AND METHODS: This cross-sectional study included 30 predialysis, 40 hemodialysis, 35 peritoneal dialysis patients, and 30 healthy subjects. N/L ratio and important clinical and laboratory parameters were registered. Multivariate regression analyses were carried out to investigate the relations of N/L ratio. RESULTS: N/L ratio was significantly higher in each patient group compared to the healthy subjects (for all, p < 0.001). It was positively correlated with interleukin-6 (IL-6) (r = 0.393, p < 0.001) and high-sensitivity C-reactive protein (hs-CRP) (r = 0.264, p = 0.002) levels and negatively correlated with hemoglobin (r = -0.271, p = 0.001), serum albumin (r = -0.400, p < 0.001), and high-density lipoprotein (HDL) cholesterol levels (r = -0.302, p < 0.001). In CKD patients with hypertension (HT), higher N/L ratio was detected when compared to those without HT (p = 0.006). Having CKD, the presence of HT, serum albumin, HDL-cholesterol, IL-6, and hs-CRP levels were found to be independent predictors of the ratio after adjusting for significant covariates (p < 0.001). CONCLUSION: An easy and inexpensive laboratory measure of N/L ratio might provide significant information regarding inflammation in CKD including predialysis and dialysis patients.

Daily dietary energy and macronutrient intake and anthropometric measurements of the peritoneal dialysis patients.

INTRODUCTION: This study was planned to investigate the relation between dietary macronutrient status and anthropometric measurements in peritoneal dialysis (PD) patients. MATERIALS AND METHODS: A total of 28 clinically stable patients were enrolled in this study. All patients were taken a dietary therapy according to the guidelines of the American Journal of Kidney Foundation for 12 weeks. The anthropometric measurements were taken by bioelectrical impedance analyzer. The daily macronutrient intakes of the patients were calculated by the food consumption records. RESULTS: The mean age was 48.3 ± 13.10 years [56.3 ± 7.41 years for males (n = 14) and 40.3 ± 12.84 years for females (n = 14)]. There were significant changes in fat percentage (%), total body water (TBW; %, L), extracellular water (ECW; %, L), basal metabolic rate over body weight (BMR/BW), and body fat mass index (BMFI) in males (p < 0.05), but there was no change in females (p > 0.05). The daily dietary energy and protein intakes were under the recommended level in the study period. CONCLUSION: Patients undergoing PD frequently have low intakes of protein and energy. It is recommended that individuals undergoing PD periodically maintain 3-day dietary records followed by dietary interviews conducted by a dietitian.

The effects of iron on FGF23-mediated Ca-P metabolism in CKD patients.

BACKGROUND: Fibroblast growth factor 23 (FGF23) is an important counterregulatory hormone for phosphate homeostasis. Since it has been reported that iron administration induces hypophosphatemic osteomalacia by triggering FGF23 synthesis, we hypothesized that iron administration might lead to a further increase in FGF23, resulting in alterations to Ca-P metabolism in a stage 5 CKD population. METHODS: This cross-sectional study was performed in a single center, and involved 73 hemodialysis patients (47.7 ± 15.74 years old, 68.5% men), 29 peritoneal dialysis patients (44.55 ± 15.05 years old, 62.1% men), and 55 healthy (43.57 ± 14.36 years old, 55.6% men) subjects. The dialysis group was subcategorized according to iron therapy administration into users and nonusers. RESULTS: The median iFGF23 level was significantly higher in the dialysis population than in the healthy controls [88.050 (25.2-1038.3) pg/ml versus 46.95 (2.4-356) pg/ml (p < 0.001)]. In the dialysis population, a significantly lower median iFGF23 level was observed in iron therapy users than in nonusers [87.6 (25.2-1038.3) versus 119 (51.6-1031); respectively, p = 0.045]. A significant negative association between iron administration and iFGF23 level was revealed by both univariate (r = -0.237, p = 0.016) and multivariate (ß = -0.221, p = 0.032) analysis. No association was found between iFGF23 and serum ferritin and iron levels. Also, there was no association between iron therapy and serum phosphate level. CONCLUSION: In contrast to what is seen for the general population, this study showed that there was a negative relationship between iron administration and serum iFGF23 level in a dialysis population. We can therefore conclude that if high levels of FGF23 are harmful, iron therapy may have a beneficial effect on bone metabolism by reducing FGF23 levels in a dialysis population.

Contribution of high flux membranes to the therapy of uremia-associated dyslipidemia.

Cardiovascular diseases are the leading causes of mortality in hemodialysis patients. Uremia induced hypertriglyceridemia; increased levels of lipoprotein remnants and low high-density lipoprotein are the main features of cardiovascular risk factors. Also, elevated oxidative stress and inflammation are the main contributors of endothelial dysfunction. Even statin based interventional trials failed to improve mortality in dialysis patients, and different treatment options have been proved to be useful. We aimed to evaluate the effect of dialyzer type on uremia-associated dyslipidemia and endothelial dysfunction. In total 312 patients were enrolled. The initial and 6(th) month blood samples were obtained from the non-arteriovenous fistula arm on the day before the first hemodialysis session of the week. Flow mediated dilatation of the patients was measured from the same arm before obtaining the blood samples. Patients were on hemodialysis therapy for 76.43 ± 52.7 months. According to their dialyzer type, there has been a statistically significant improvement noted in terms of total cholesterol, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol and triglyceride levels. The flow mediated dilatation of the patients are measured as 4.3 ± 0.5 and 4.4 ± 0.4 in baseline measurements of the low flux and high flux groups, respectively. Sixth month values of the patients were measured as 4.34 ± 0.4 and 4.62 ± 0.6. The improvement in low flux groups was not statistically significant but in the high flux group the endothelial dysfunction was significantly improved. Our results show that high-flux dialyzers improved dyslipidemia and endothelial dysfunction in hemodialysis patients. These findings provide a new insight on the selection of high efflux in hemodialysis.

Remission of de novo membranous nephropathy in a kidney allograft recipient: a case report.

Membranous nephropathy (MN), one of the most frequent causes of nephrotic syndrome in native kidneys, is also a common glomerular pathology in transplanted kidneys(Davison AM, Johnston PA. Allograft membranous nephropathy, Nephrol Dial Transplant, 1992;7(Suppl. 1):114-118. Specific treatment modalities have not been described for this population. However, renal transplanted patients presented with MN could have spontaneous remission as those with idiopathic MN. Here, we report a kidney allograft recipient diagnosed with de novo MN in early phases of posttransplantation period having a clinical remission over months.

Diffuse amyloid deposition in thyroid gland: a cause for concern in familial Mediterranean fever.

Thyroid gland is among the many organs that could be infiltrated in systemic amyloidosis. However, diffuse infiltration of the thyroid gland secondary to systemic amyloidosis associated with Familial Mediterranean fever (FMF) is rare. Here, we present a 49-year-old woman diagnosed with FMF and systemic amyloidosis, who had a large goiter and multiple nodules that developed slowly through the years and was complicated by tracheal compression symptoms and a mild thyroid dysfunction. Multiple fine needle aspiration biopsies of the nodules and the thyroid parenchyma revealed amyloid deposits. We would like to point out that amyloidosis may have a significant impact on the thyroid gland and fine needle aspiration biopsy is a valuable tool for diagnosis.

Salt intake and hypervolemia in the development of hypertension in peritoneal dialysis patients.

Peritoneal dialysis (PD) patients are often volume-expanded and have higher-than-normal blood pressure (BP) levels. In the present study, we aimed to investigate the role of fluid balance and salt intake for BP control in our PD patients. The study included 37 patients undergoing PD and having complete data for 3 consecutive months. Patients were allocated to one of two groups based on measured BP in the preceding 3 months: hypertensive patients (BP > 140/90 mmHg) and normotensive patients (did not meet the hypertensive BP criteria). Volume status was evaluated by bioimpedance analysis. The 37 patients (18 women, 19 men) had a mean age of 46.4 years. The hypertensive and normotensive groups included 17 and 20 patients respectively. Sex, age, and time on PD were similar between the groups. Weight (77.3 +/- 20.3 kg vs. 64.5 +/- 9.8 kg, p < 0.05), total sodium load (2649.2 +/- 621.9 mmol vs. 2272.4 +/- 511.9 mmol, p < 0.05), daily total sodium removal (160.5 +/- 74.4 mmol vs. 112.1 +/- 48.0 mmol, p < 0.05), extracellular water (19.4 +/- 4.3 L vs. 16.4 +/- 3.5 L, p < 0.05), and normalized extracellular water (11.6 +/- 1.9 L vs. 10.1 +/- 1.8 L, p < 0.05) were all significantly higher in the hypertensive group. Despite higher fluid and sodium removal, hypertensive patients were more hypervolemic than normotensive patients. Increasing fluid and salt removal by peritoneal ultrafiltration results in an increased financial burden and also causes serious clinical problems. Restricting fluid and salt intake is an alternative and safer strategy to maintain good fluid balance.

Mycophenolate mofetil treatment of crescentic Henoch-Schönlein nephritis with IgA depositions.

Mycophenolate mofetil (MMF) is considered to be a promising therapeutic agent in primary glomerulonephritis but there are no data on the use of MMF in Henoch-Schönlein nephritis (HSN). Herein we report the first adult crescentic HSN patient in whom long-term complete remission was achieved after MMF therapy.

Cavernous sinus syndrome caused by metastatic colon carcinoma.

Cranial metastasis has been reported as infrequent during colon cancers and usually occurs in the late stages with liver and/or lung metastasis. Metastasis to cavernous sinus is even rarer and only reported as case reports in the literature. In patients with cavernous sinus metastasis, the most common primary sites are the breast, lung, and genitourinary carcinomas, if head and neck tumors are excluded. A 34-year-old man underwent a right hemicolectomy for a mucinous adenocarcinoma of the right colon 14 months before presentation. Because metastatic implants on the omentum were detected during the operation, combination chemotherapy was begun. After 5 months of the last cycle of the chemotherapy, his left eyelid began to droop, left eye movements became limited, and he began experiencing numbness of his right forehead and cheek. Clinical and radiologic findings were discussed. Despite antiedematous treatment and radiation therapy, he did not experience marked improvement of his symptoms. He could not be given chemotherapy and died 2.5 months after the first symptom of cavernous sinus metastasis. Primary colon adenocarcinoma with cavernous sinus metastasis is very rare. It was hypothesized that the paravertebral plexus of Batson could permit the spread of tumor cells from pelvis toward the cranium. This could explain the metastases from pelvis to the cavernous sinus, such as in our case. Prognosis for the patients with cavernous sinus metastasis seems to be poor, and this might be the harbinger of rapid progression with widespread disease.