Serum asymmetric-dimethylarginine, apelin and NT-pro BNP levels in dialysis patients.

BACKGROUND: The relationships among serum Apelin, Asymmetric- dimethylarginine (ADMA), N-terminal probrain natriureticpeptide (NT-proBNP) levels, and blood pressures in dialysis patients are not well known. MATERIALS AND METHODS: Age and sex matched 30 hemodialysis (HD), 30 peritoneal dialysis (PD) patients, and 20 healthy controls were recruited. Serum apelin-36, ADMA, NT-proBNP levels, and blood pressures of both patients and healthy controls were measured and compared. RESULTS: Serum ADMA and Apelin levels in HD patients were significantly higher than in PD patients. In multiple regression analyses the predictors of higher serum apelin levels were higher BMI, higher ADMA and lower systolic blood pressure. The predictors of serum ADMA levels were being on HD. The predictors of serum NT-proBNP levels were lower serum albumin and higher systolic blood pressure. CONCLUSION: Being on HD is a predictor of high ADMA levels. HD might be less effective on ADMA removal than PD. It seems that higher serum apelin levels related with lower sytolic blood pressure levels, whereas higher NT-proBNP levels related with higher sytolic blood pressure levels indicating potential roles as independent prognostic factors for systolic hypertension in dialysis patients.

Vascular calcification is not related to serum fetuin-A and osteopontin levels in hemodialysis patients.

INTRODUCTION: Vascular calcification (VC) in hemodialysis (HD) patients is a sign of severe cardiovascular disease and can predict cardiovascular outcomes. Fetuin-A and osteopontin (OPN) inhibit VC. Serum fetuin-A levels are lower in patients with end-stage kidney disease (ESKD) and in those who are on chronic HD therapy. However, there are limited data concerning OPN in patients who are on dialysis. The aim of our study was to determine VC in HD patients, the relationship between VC and 25-OH-vitamin D, fetuin-A, and OPN levels, and independent predictors of VC. MATERIALS AND METHODS: Ninety-three patients with ESKD on HD therapy were recruited. Among these patients, 44 were male and 49 were female. The patient group was compared with a group of 20 healthy controls of similar age and sex. A plain radiograph of the hand was taken using a mammography machine for the evaluation of VC. Serum fetuin-A, OPN, and 25-OH-vitamin D levels of both patients and controls were measured. RESULTS: VC was detected in 45 (48.4%) HD patients. When patients were compared with healthy controls, fetuin-A levels (p < 0.029) were significantly lower in patients, whereas OPN (p < 0.000) and VC (p < 0.002) were significantly higher in the patient group. Age [odds ratio (OR) 1.036], the presence of diabetes mellitus (DM) (OR 17.527), and high parathyroid hormone (PTH) levels (OR 1.002) were independent predictors of VC in a logistic regression model including the following factors: age, the presence of DM, HD duration, and serum albumin, phosphate, PTH, 25-OH-vitamin D, fetuin-A, OPN, and calcium levels. No significant correlation was found between patients with VC and patients without VC in terms of fetuin-A, OPN, and 25-OH-vitamin D levels. CONCLUSIONS: VC is a frequent sign in patients undergoing HD and is not related to serum fetuin-A and osteopontin levels. Age, the presence of DM, and high PTH levels were independent predictors of VC in patients undergoing HD. Further studies are warranted to understand the mechanism underlying and the factors contributing to VC.

Outcomes of Kidney Transplantations From the Same Deceased Donor to Two Different Recipients: A Single-Center Experience.

BACKGROUND: Kidney transplantation is the best treatment method for end-stage renal disease. Technically, left kidney transplantation is easier than right kidney, and the complication rates in the right are higher than the left kidney. We performed 28 kidney transplantations from 14 deceased donors between November 2010 and May 2016. Our aim was to share our outcomes and experiences about these 28 patients. METHODS: We performed 182 kidney transplantations between November 2010 and May 2016. Fifty-four kidney transplantations were performed from deceased donors. Thirty-two of these were performed from 16 of the same donors. These 32 recipients' data were collected and retrospectively analyzed. We excluded the transplantations from two same-donors to their four recipients in this study. The remaining 28 recipients were included in the study. RESULTS: The left and right kidney recipients' numbers were equal (14:14). The left kidney:right kidney rate was 11:3 in the first kidney transplantation recipient group; in the second kidney transplantation recipient group, the rate was 3:11. The difference was statistically significant (P = .002). We found no statistical differences for sex, mean age, and body mass index of recipients, total ischemic time of grafts, hospitalization times, creatinine levels at discharge time, and current ratio of postoperative complications of recipients (P > .05). CONCLUSIONS: There were no differences in the left or the right kidneys or in the first and the second kidney transplantations during the long follow-up period.

Identifying the determinants of microalbuminuria in obese patients in primary care units: the effects of blood pressure, random plasma glucose and other risk factors.

OBJECTIVE: The objective of this study is to evaluate the demographic characteristics, blood pressure and blood glucose and the other related factors that affect the microalbuminuria levels in the obese patients aged 40 and above who applied to the primary care for medical evaluation. MATERIALS AND METHODS: The population of the research, which was a cross-sectional type, comprised obese patients aged 40 and above who had applied to the community health centers in the center of Malatya. A total of 422 obese patients consisting of 116 males and 306 females were included in the research. The anthropometric measurements of the participants were determined, their blood pressures and their random blood glucoses were evaluated, as well. A microalbuminuria measurement was performed in the urine samples taken from the patients using "Nycocard Reader II" device. FINDINGS: The incidence of microalbuminuria in patients was found as 31.5%, whereas the incidence of macroalbuminuria was 6.6%. The incidence of microalbuminuria in female patients was 32.7%, while it was 28.4% in male patients; on the other hand, the incidence of macroalbuminuria in female patients was found as 6.8%, whereas this percentage was determined as 7.8 in male patients (p > 0.05). The probability of the incidence of microalbuminuria increased 2.8 times more in those with the diastolic blood pressure of 90 mmHg and above when compared to those without it (GA: 1.79-4.56), whereas the incidence increased 3.2 times more in those with the random blood glucose of 200 mg/l and above (GA: 1.32-7.84) (p < 0.001). In our study, among the variables predicting the microalbuminuria in obese patients; the cutoff values of the diastolic and systolic blood pressures, the waist circumference were found as >85 mmHg; >130 mmHg; >141 mg/dl, respectively, in male patients and found as >85 mmHg, >114 cm, and 109 cm, respectively, in female patients. The sensitivity and specificity of the tests indicating the cutoff values showed significance (p < 0.05). There was no statistically significant relevance between the microalbumin levels of the obese patients via the anthropometric criteria, except for their waist circumference (p > 0.05). RESULT: In this study, the blood pressure and blood glucose levels of the patients along with their waist circumference that indicated a central obesity were specified as the determinants of microalbuminuria. While the obese patients are being evaluated in terms of proteinuria, the cutoff values of these variables can be taken into consideration.

HLA-A, -B, -DRB1 allele and haplotype frequencies and comparison with blood group antigens in dialysis patients in the East Anatolia region of Turkey.

AIM: The first aim of that study was to investigate HLA class I and class II allele and haplotype frequencies in renal dialysis patients who live in East Anatolia in Turkey. Our second aim was to investigate whether there was a relationship between ABO and D blood group antigens and HLA alleles and haplotypes for the study group. MATERIALS AND METHODS: HLA class I and II polymorphisms in 408 renal dialysis patients were studied using sequence-specific primers (SSP) and sequence-specific oligonucleotides (SSO). Blood group antigens were detected by agglutination methods on microplates. RESULTS: A total of 16 HLA-A, 34 HLA-B, and 15 HLA-DRB1 alleles were identified. The most frequent HLA-A alleles were HLA-A*02, HLA-A*24, and HLA-A*11. The most frequent HLA-B alleles were HLA-B*35, HLA-B*51, and HLA-B*44. In case of HLA-DRB1; HLA-DRB1*11, HLA-DRB1*04, and HLA-DRB1*13 were first 3 alleles with higher frequency, in order. In the combination of those 3 alleles, the most frequent HLA-A-B-DRB1 haplotypes were HLA-A*02-B*51-DRB1*11, HLA-A*11-B*35-DRB1*11, A*24-B*35-DRB1*11. The frequency of ABO, D blood group antigens were observed as 0.168 for A Rh(+), 0.019 for A Rh(-), 0.057 for B Rh(+), 0.013 for B Rh(-), 0.123 for O Rh(+), 0.014 for O Rh(-), 0.018 for AB Rh(+), and 0.001 for AB Rh(-). While A Rh(+) samples with HLA-A*02 and HLA-DRB1*11 had the highest frequencies (0.067 and 0.088, respectively), O Rh(+) samples with HLA-B*51 had the highest frequency (0.06). CONCLUSION: According to haplotype frequencies HLA-A*02-B*51-DRB1*11 is also found at higher frequencies in Bulgarian and Armenian populations. In case of HLA-associated diseases, the east Anatolian population could be susceptible to myastenia gravis, Behçet's disease, and systemic sclerosis due to the high frequencies of HLA-A*24, HLA-B*51, and HLA-DRB1*11 respectively. We did not observe a correlation between blood group antigens and HLA alleles or haplotypes in renal dialysis patients.

A kidney transplant center's initial experiences in eastern Turkey.

OBJECTIVES: Kidney transplantation is the best treatment method associated with improved quality of life and better survival for patients with end-stage renal disease. We started performing kidney transplantations in November 2010. We have performed 19 kidney transplantations so far. Fourteen of these were from living donors and five from deceased donors. Here, we present our initial experiences with 14 kidney transplant recipients from living donor kidney transplantations. MATERIALS AND METHODS: All recipients and their donors underwent detailed clinical history and examination. Recipients and their donors were followed in the transplant clinic during hospitalization. RESULTS: The male-to-female ratio was 11:3 in recipients. The mean age of recipients was 27.8 years (range 4-58 years). The number of the related, emotionally related, and unrelated transplantations were 9, 3, 2, respectively. The mean warm ischemic time was 95.7 seconds (range 52-168 seconds). Urine output started immediately after vascular anastomosis in all. The mean time of discharge from hospital was postoperative day 8 (range 4-18 days). The mean flow up was 125 days (range 18-210 days). Graft survival was 100% in this period, but one patient died from sepsis after 56 days. No kidney was lost from rejection, technical causes, infection, or recurrent disease. CONCLUSION: If transplant centers are as equipped and experienced as ours, kidney transplant programs should be started immediately so that they can reduce the number of the patients in waiting list for kidney transplantation.

Vitamin D and muscle strength, functional ability and balance in peritoneal dialysis patients with vitamin D deficiency.

25(OH)D deficiency has been associated with significantly worse physical performance in individuals with normal renal function. We examined the physical function, muscle strength and balance in age- and gender-matched 25 Stage 3 - 4 CKD patients and 47 Stage 5 CKD patients on peritoneal dialysis (PD) with vitamin D deficiency by objective methods and evaluated the effect of vitamin D replacement on physical performance tests: the "timed up and go" (TUG) test, gait velocity test, timed chair stand test, stair climb test, dynamic balance tests (TUG test, dynamic postural stability test), static balance test (functional reach test) and muscle strength in these two groups. At baseline 25(OH)D in the Stage 3 - 4 CKD patients and patients on PD were 6.9 ± 3.5 ng/ ml (17.2 ± 8.7 nmol/l) and 5.7 ± 3.3 ng/ml (14.2 ± 8.2 nmol/l), respectively (p > 0.05). Mean (± SD) 25(OH)D in Stage 3 - 4 CKD patients and those on PD were 52.0 ± 40.9 ng/ml (129.7 ± 102.2 nmol/l) and 41.9 ± 21, ng/ml (104,5 ± 52,6 nmol/l) respectively after vitamin D replacement (p > 0.05). When both Stage 3 - 4 CKD and dialysis patients became vitamin D-sufficient after vitamin D replacement, they took a significantly shorter time to complete the TUG test, gait velocity test, the timed chair stand test and stair climb test. Results of physical performance tests, static and dynamic balance tests and isometric strength tests improved in both groups after the treatment (p < 0.05). In conclusion, our results show that vitamin D supplementation improves muscle strength, functional ability and balance in both CKD and dialysis patients.

Treatment of hyper-IgG4 disease with sequential corticosteroids and tamoxifen - case report and review of the literature.

We report a patient with multifocal fibrosclerosis presenting as sialadenitis, hepatic fibrosis, and retroperitoneal fibrosis with renal failure. His medical management consisted of prednisone (4 months at 40 mg daily, then tapered down to 5 mg daily for another 14 months) and 18 months of tamoxifen. He responded clinically and radiographically to this regimen, and remains in clinical remission 10 months after discontinuing medical therapy. Subsequent histologic examination of submandibular gland tissue revealed strong staining for IgG4-positive plasma cells. To our knowledge, this is the first case of confirmed multifocal hyper-IgG4 disease to be successfully treated with sequential corticosteroids and tamoxifen.

Vascular complications of the lower extremities in diabetic patients on peritoneal dialysis.

BACKGROUND: Diabetic patients with end-stage renal disease (ESRD) are at high risk for developing foot complications and few have studied this complication in the diabetic patients treated with peritoneal dialysis (PD). The purpose of this study was to examine peripheral vascular disease (PVD) in diabetic patients with ESRD, who are being treated with PD, and to identify those factors that may contribute to its development. PATIENTS: We reviewed retrospectively the charts of 71 diabetic patients who started PD between January 1999 and January 2006, inclusive, and recorded their demographic data, their treatment regimens, their complications and the results of biochemical investigation(s) at the beginning and throughout their follow-up period. All patients were under the care of a chiropodist who examined them at regular intervals and more often when needed. We divided the patients into two groups with respect to the presence of complications in the lower extremities, such as ulcers, open wounds, osteomyelitis, necrotizing or gangrenous lesions, and amputations, intermittent claudication and/or the presence on an imaging examination of changes in the leg vessels consistent with vascular disease. RESULTS: 33 of the 71 patients had some type of a foot lesion. There were 8 amputations in the course of 176 patient-years (2 double amputations), or 1 amputation per 30 PD patient-years. Those patients with foot complications were treated more frequently with CCPD (p<0.05), more often had peripheral neuropathy (p<0.002), as well as coronary artery disease (p<0.044). They had lower serum albumin (p<0.005), significantly higher serum phosphorus (p<0.047) and they received higher doses of erythropoietin (p<0.042). There was no statistically significant difference between the groups regarding sex, age at initiation of PD, type of diabetes, use of insulin, levels of HbA(1c), body mass index (BMI), presence of retinopathy, cerebral vascular disease, hyperlipidemia, smoking, rate of transplantation, rate of drop-out from PD, time-averaged Kt/V, creatinine clearance, serum calcium, Ca x P and intact PTH. In a multiple logistics regression model, only peripheral neuropathy and hypoalbuminemia were independently associated with the development of lower-extremity complications (p<0.0066 and p <0.026, respectively). One-, two- and three-year cumulative survival of the whole group was 91.5%, 78.8% and 69%, respectively. Patients with foot lesions had a lower survival than those without. Interestingly though, those patients, who had had an amputation, survived as long as those patients, who did not have foot complications at all. CONCLUSION: In conclusion, compared to reports in the literature, our diabetic patients on PD had a lower rate of foot complications and amputation probably because of early intervention by our chiropodist. This fact stresses the need for constant and expert monitoring of the condition of the diabetic patient's feet, especially in those with low serum albumin and peripheral neuropathy.

Reverse epidemiology in peritoneal dialysis patients: the Canadian experience and review of the literature.

High Body Mass Index (BMI) has been associated with improved survival of End-Stage Renal Disease (ESRD) patients on chronic hemodialysis (HD); however, studies on the relationship of BMI with survival in Peritoneal Dialysis (PD) patients have yielded conflicting results. The purpose of this study was to evaluate the impact of BMI on survival of Canadian ESRD patients on PD, correcting for their age, sex, race, diabetes mellitus, and arterial hypertension. In an intent to treat study, we reviewed data of the Canadian Organ Replacement Register (CORR), of incident patients, starting PD between 1994 and 1998 and followed up from their initial PD treatment to the end of 2003. Patients were censored at loss to follow up, transplantation, and the end of the observation period. Cox regression (multivariate) analysis was performed and adjustments were made for age, gender, race, primary renal disease and BMI. During these years, 4054 patients commenced PD, 1742 (43%) of them were females and 1471 (36.3%) were diabetics. The majority were Caucasians (n=3058, 75.4%); 120 (3%) belonged to the First Nations, 137 (3.4%) were black, and the rest (739 pts-18.2%) belonged to various other ethnicities. Based on quartiles of the BMI distribution, 1130 patients (28%) had a BMI < 18.5 kg/m(2); 1163 (28.7%), 18.5-24.9 kg/m(2); 1214 (30%), 25-29.9 kg/m(2); 547 (13.5%) > 30 kg/m(2). Intent to treat Cox regression analysis showed that being underweight was a strong risk factor for death. Specifically, a BMI less than 18.5 was associated with a death hazard ratio (HR) 1.3, (CI: 1.1-1.6). On the contrary, BMI > 30 was not associated with worse survival than those with normal BMI (HR = 1.009, CI = 0.89-1.14). High-BMI patients should not be discouraged from PD just because of their size.

A dilemma: prophylaxis for pulmonary embolism after surgical or invasive interventions for hemodialysis.

AIM: This study was designed to investigate if it needs to do prophylaxis for pulmonary embolism in the patients treated with different kinds of dialysis or not, and if it is, to find a proper method for prophylaxis. METHODS: Ten numbers of patients with central venous catheters (CVC group), 13 numbers of patients with arteriovenous fistula (AVF group) were enrolled in this study. Eleven patients treated with peritoneal dialysis (PD group) were utilized as a control group. Clinical and laboratory examinations to exclude pulmonary embolism were carried out in both AVF and PD groups at the onset and after three months. Same examinations were performed in CVC group at the onset and after 3 weeks (mean: 21 days). Examinations to exclude pulmonary embolism consist of medical history, clinical examinations, d-dimer measures, chest x-ray, respiratory function tests, blood gas analyses, ventilation-perfusion scintigraphies. RESULTS: Neither clinical nor laboratory findings in any stages reflected any suspicion for pulmonary embolism. None of the patients in any groups was admitted with pulmonary embolism in any period of follow-up. There was not any statistically difference between the outcomes of all first examinations and of all second ones (P>0.005). Neither obvious nor subclinical pulmonary embolism was detected in any case. None of the patients had deep venous thrombosis in any stage of follow-up. CONCLUSIONS: Conventional techniques of haemodialysis do not lead to pulmonary embolism unless deep venous thrombosis due to any intervention occurs in the patients. Thus, prophylactic anticoagulant usage to prevent pulmonary embolism is not necessary in haemodialysis patients. To shorten the length of stay of central venous catheters is the most important factors for pulmonary embolism prophylaxis in haemodialysis patients.

Severe vitamin D deficiency in chronic renal failure patients on peritoneal dialysis.

UNLABELLED: The aim of this study was to evaluate the prevalence of vitamin D deficiency in chronic renal failure (CRF) patients on peritoneal dialysis (PD) and to correlate the findings with various demographic and renal osteodystrophy markers. METHOD: This cross-sectional, multicenter study was carried out in 273 PD patients with a mean age of 61.7 +/- 10.9 years and mean duration of PD 3.3 +/- 2.2 years. It included 123 female and 150 male patients from 20 centers in Greece and Turkey, countries that are on the same latitude, namely, 36-42 degrees north. We measured 25(OH)D3 and 1.25(OH)2D3 levels and some other clinical and laboratory indices of bone mineral metabolism. RESULTS: Of these 273 patients 92% (251 patients) had vitamin D deficiency i.e. serum 25(OH)D3 levels less than 15 ng/ml, 119 (43.6%) had severe vitamin D deficiency i.e., serum 25(OH)D3 levels, less than 5 ng/ml, 132 (48.4%) had moderate vitamin D deficiency i.e., serum 25(OH)D3 levels, 5-15 ng/ml, 12 (4.4%) vitamin D insufficiency i.e., serum 25(OH)D3 levels 15 - 30 ng/ml and only 10 (3.6%) had adequate vitamin D stores. We found no correlation between 25(OH)D3 levels and PTH, serum albumin, bone alkaline phosphatase, P, and Ca x P. In multiple regression analyses, the independent predictors of 25(OH)D3 were age, presence of diabetes (DM-CRF), levels of serum calcium and serum 1.25(OH)2D3. CONCLUSION: We found a high prevalence (92%) of vitamin D deficiency in these 273 PD patients, nearly one half of whom had severe vitamin D deficiency. Vitamin D deficiency is more common in DM-CRF patients than in non-DM-CRF patients. Our findings suggest that these patients should be considered for vitamin D supplementation.

Maxillary brown tumor and uremic leontiasis ossea in a patient with chronic renal insufficiency.

Findings of renal osteodystrophy in cranial bones are not uncommon and include osteomalacia, osteosclerosis, erosion of the cortical bone, brown tumors and resorption of the lamina dura. However, massive thickening of the cranial vault and facial bones, called uremic leontiasis ossea, have been reported very rare. In the present article, we describe the case of an uncooperative female patient with a brown tumor, involving the left maxillary sinus and massive thickening of the cranial vault and facial bones, secondary to severe secondary hyperparathyroidism during 8 years of regular hemodialysis treatment.

Case report. Candida lusitaniae peritonitis in a patient on continuous ambulatory peritoneal dialysis.

We report a case of Candida lusitania peritonitis in continuous ambulatory peritoneal dialysis. Since fluconazole therapy was not successful in this patient, the peritoneal catheter was removed and antifungal therapy continued, and the patient was then converted to haemodialysis. This treatment protocol was successful. We suggest that early peritoneal catheter removal should be considered in such cases.

Continuous ambulatory peritoneal dialysis.

PURPOSE: To assess complications of continuous ambulatory peritoneal dialysis (CAPD) in uremic patients with and without clinical symptoms by CT peritoneography. MATERIAL AND METHODS: A total of 64 patients with end-stage renal disease and on continuous CAPD were investigated. Twenty-eight had some clinical symptoms, which might be related to the complications of CAPD. Thirty-six patients had no complaints or symptoms due to the dialysis treatment. RESULTS: CT peritoneography revealed various complications including hernias (50%), dialysate leakage (46%), localized fluid collection (4%) and peritoneal adhesions (4%) in the patients who had clinical symptoms that might be related to the dialysis treatment. Moreover, similar complications were found in the asymptomatic patients at a lower rate: hernia (3%), dialysate leakage (17%), peritoneal adhesions (3%) and abdominal wall laxity (3%). Complication detection rate by CT peritoneography was 68% (n=19) in the symptomatic patients and 22% (n=8) in the asymptomatic patients. The number of complications found in each group was significant. CONCLUSION: CT peritoneography was an effective modality in detecting complications from CAPD in patients with and without clinical symptoms.

Horner's syndrome secondary to internal jugular catheterization.

We present three cases of people who developed Horner's syndrome following repeated attempts for catheterization of the internal jugular vein for hemodialysis. Any other neurologic finding or evidence of mass lesions in the neck or pulmonary apex could not be determined. Horner's syndrome should be considered a possible complication of percutaneous internal jugular vein catheterization for hemodialysis.

Improvement of thyroid hormone profile and thyrotrophin (TSH) surge alterations in hemodialysis patients on erythropoietin treatment.

BACKGROUND, MATERIAL AND METHODS: This study was performed in 20 patients with end-stage chronic renal failure (CRF) and 10 healthy volunteers. All of the patients were on regular hemodialysis treatment (RHD), 10 of whom were on recombinant human erythropoietin (rHuEPO) therapy. Hematocrit levels of the patients with CRF on rHuEPO were between 0.30 to 0.33 and not on rHuEPO were below 0.24. Baseline serum T3, T4, fT3, fT4 and TSH levels were measured and TRH stimulation test was performed in patients and control subjects. Serum TSH levels were measured hourly during the afternoon (2 to 5 p.m.) and at night (10 p.m. to 2 a.m.) to determine the nocturnal rhythm of TSH. RESULTS: The mean T3 in rHuEPO, not rHuEPO and control groups were 98.01 +/- 5.54, 70.55 +/- 7.09, 98.29 +/- 4.2 ng/dl; T4 6.47 +/- 0.68, 6.39 +/- 0.59, 8.35 +/- 0.46 ng/dl; fT3 2.24 +/- 0.19, 1.52 +/- 0.24, 2.29 +/- 0.17 pg/ml and fT4 0.88 +/- 0. 14, 0.75 +/- 0.14, 0.97 +/- 0.10 ng/dl, respectively. These values were significantly lower in patients not on rHuEPO compared to controls (p < 0.05). In patients on rHuEPO only T4 values were lower than in the controls (p < 0.05). In patients not on rHuEPO the T3, and fT3 were significantly lower than the values of patients on rHuEPO treatment (p < 0.05). Normal in 8 (80%), blunted in 1 (10%), no TSH response in 1 (10%) to TRH stimulation were obtained in rHuEPO group. TSH response was normal in 1 (10%), and delayed in 9 (90%) patients not on rHuEPO. The circadian nocturnal rhythm of TSH was abnormal in 8 (80%) patients not on rHuEPO, in 2 (20%) patients on rHuEPO. As a result, CRF and RHD distorts the circadian TSH rhythm and substantially change the thyroid hormone profile probably by affecting hypothalamic-pituitary-thyroid axis. Distortion of the circadian rhythm of TSH and TSH response to TRH points to a defect at the level of hypothalamus and pituitary gland. CONCLUSION: rHuEPO treatment has some beneficial effects on hypothalamo-pituitary-thyroid axis in the patients on RHD.