Evaluation of salivary parameters and dental status in adult hemodialysis patients.

AIMS: Caries is a multifactor disease, and impaired stimulated salivary flow rate and buffering capacity are the best-known risk factors. The salivary flow rate, pH, buffering capacity and DMFT (decayed, missing and filled teeth) index of adult hemodialysis patients were compared with those of healthy controls. MATERIAL AND METHODS: Seventy-two (34 F, 38 M, mean age: 45.05 +/- 14.15 years) hemodialysis patients and 50 (26 F, 24 M, mean age: 43.92 +/- 18.80 years) control saliva were collected after prestimulation and expressed as ml/min. Salivary pH and buffering capacity were measured (Ericsson method). The dental examinations were performed according to WHO criteria and DMFT index was calculated. Statistical analysis was performed with Student t-test and Pearson correlation test. RESULTS: The patients' mean salivary flow rate was 0.69 +/- 0.31 ml/min, pH, 8.15 +/- 0.72, buffering capacity, 6.83 +/- 0.71 and DMFT index was 11.91 +/- 8.73. The salivary flow rate was less than the controls (p <0.001), but salivary pH and buffering capacity were higher (both p < 0.001). There was no difference in DMFT index between groups (p > 0.05). There was no significantly negative correlation between DMFT index and stimulated salivary flow rate, pH but there was a positive correlation with buffering capacity (r = 0.286, p < 0.05) in the patients. Moreover, there was no significantly positive correlation between stimulated salivary flow rate and pH buffering capacity in these patients. CONCLUSIONS: Salivary flow rate of hemodialysis patients was less than the hyposalivary limit. Salivary pH and buffering capacity were both above the reference values, but DMFT index of hemodialysis patients did not differ from that of controls. However, caries and related dental infections may lead to serious problems in infection-prone hemodialysis patients, so these patients should have regular dental examinations and careful treatments.

Outcome of living unrelated (commercial) renal transplantation.

BACKGROUND: Due to inadequate cadaveric and living related organ supply, many end-stage renal disease patients go to Third World countries for commercial transplantation, although the high risk of complications is well established and ethical arguments debate this practice. METHODS: The midterm outcome of 115 patients who had been commercially transplanted in various countries and admitted to our center for post-transplant care and follow-up between 1992 and 1999 was retrospectively analyzed. Data considering the transplantation practice and post-transplant course were collected from the patient files. Outcome of these patients was compared with those with a living related transplant performed at our center. RESULTS: The patients (91 male and 24 female; mean age of 42 +/- 12 years) were transplanted in India (N = 106), Iraq (N = 7), and Iran (N = 2). The mean follow-up period was 64.5 +/- 23.9 months. Post-transplant course was complicated by numerous surgical and/or medical complications, and many of the latter were unconventional infections caused by malaria, invasive fungal infections, and pneumonia due to various opportunistic pathogens. Overall, 52 patients still have functioning allografts, while 22 lost their grafts, 20 died, and 21 were lost to follow-up. Graft survival rates at two, five, and seven years were 84, 66, and 53%, respectively, for the study group, while it was 86, 78, and 73% for living related transplantations performed at our center (P = 0.036). Patient survival rates for the same periods were 90, 80, and 74% for the study group and 90, 85, and 80% for the living related transplantations (P = 0.53). CONCLUSIONS: Besides the ongoing ethical debate, commercial transplantation carries a high risk of unconventional complications, and despite that the patient survival rate is comparable, graft survival is worse than conventional living related transplantations at the midterm.

The outcome of patients presenting with crush syndrome after the Marmara earthquake.

In this study, we evaluated the clinical and laboratory data of the patients presenting after the Marmara earthquake. Crush syndrome was diagnosed in 60 patients (30 M, 30 F, mean age: 31.3+/-13.8 years). They were buried under the rubble for a mean period of 12.3+/-15.1 hours. On admission, 27 patients were oligoanuric and the mean serum creatinine, creatinine phosphokinase and potassium levels were 4.4+/-3.2 mg/dl, 18453.1+/-24527.2 IU/L, and 4.9+/-1.7 mEq/L, respectively. The most frequent site of trauma was the lower extremity. Dialysis treatment was initiated in 40 patients (19 M, 21 F; mean age: 32.7+/-13.0 years). Mean number of hemodialysis sessions/patient was 8.9+/-6.8. Nine (23%) patients among the dialyzed and 4 (20%) among the non-dialyzed died leading to an overall mortality of 21.6%. This low mortality rate suggests that the death rate from acute renal failure due to crush syndrome could be decreased by extensive follow-up.

Clinical outcomes of renal cholesterol crystal embolization.

Cholesterol crystal embolization is an increasingly recognized disease, presenting with a wide clinical spectrum, usually occurring in elderly men who undergo an angiographic procedure or vascular surgery. We report three patients who developed systemic cholesterol embolic disease and varying degrees of renal failure after angiographic interventions of the coronaries.

The prognostic importance of severity and type of post-transplant proteinuria.

Proteinuria, developing after renal transplantation may influence allograft and patient outcomes. This study aimed to investigate the effect of proteinuria on patient and allograft survival. Among 514 patients, 56 (11%) patients with good allograft function and proteinuria were evaluated retrospectively. Patients with proteinuria were classified as group P (20 patients with permanent proteinuria, Male/Female: 16/4) and group T (36 patients with temporary proteinuria, M/F: 29/7) according to the type of proteinuria. Also, considering the amount of proteinuria, patients were classified as group M (32 patients with massive proteinuria, M/F: 29/3) and group NM (24 patients with non-massive proteinuria, M/F: 16/8). The mean time interval between transplantation and appearance of proteinuria was 23.7 months (range 0-121 months) and no difference was found between groups. Two- and 5-yr allograft survival rates were found to be 85 and 80% in group M, and 95 and 82% in group NM. respectively (p = 0.24). In terms of type of proteinuria, 2- and 5-yr allograft survival rates were found to be 70 and 58% in group P and 92 and 87% in group T, respectively. The difference between groups P and T was found to be statistically significant (p = 0.02). Most (85%) of the patients with permanent proteinuria also had massive proteinuria. In conclusion, we found a significant relation between type and severity of proteinuria. The type of post-transplant proteinuria had a stronger effect on allograft outcome than the severity of proteinuria.

Helicobacter pylori antibodies in hemodialysis patients and renal transplant recipients.

In this cross-sectional, controlled study, Helicobacter pylori (H. pylori) infection, a probable factor in the development of gastrointestinal problems, was investigated in dialysis patients and renal transplant recipients. Forty-seven dialysis patients (22 male, 25 female, mean age of 36.6 +/- 15 yr (range 18-83 yr)), 57 renal transplant recipients (39 male, 18 female, mean age of 36.8 +/- 10 yr (range 19-60 yr)) and 55 healthy individuals (34 male, 21 female, mean age of 33.4 +/- 9.6 yr (range 21-58 yr)) were included and no significant difference was found in the study groups. The mean time spent on dialysis in the hemodialysis group was 32.5 +/- 27.7 months (range 1-100 months). H. pylori antibodies were detected in 22 of 57 (38.6%) patients in the transplantation group, 31 of 47 (65.9%) patients in the dialysis group and 39 of 55 (72.5%) in the control group. No correlation was found between H. pylori infection and age, sex, primary disease, frequency of dialysis, duration and type of transplantation and the immunosuppressive therapy. However, patients with H. pylori antibodies spent a shorter time on dialysis compared to patients without the antibodies (26.6 +/- 23.5 vs 44.1 +/- 32.1 months, p = 0.038). The frequency of H. pylori infection in the transplantation group was significantly lower than the control and dialysis groups (p < 0.01). This finding may be explained on the basis of decreased humoral antibody response to H. pylori infection, secondary to immunosuppressive therapy rather than decreased incidence of infection in the transplantation group. Finally, we concluded that the value of the serological test for diagnosis of H. pylori infection should be interpreted cautiously in these patient groups.

Transplantation in renal amyloidosis.

In this report, the results of renal transplantation in patients with renal amyloidosis were retrospectively analysed and compared with the control group. Fifteen (3.04%) of the 493 renal transplant recipients whom were followed up in Istanbul School of Medicine transplant outpatient clinic, between 1983 and 1997, were included in the study. The etiology of amyloidosis was familial Mediterranean fever in all patients. The mean follow-up period was 38.3 +/- 31.8 (range 7-65) months. Twelve of the patients were male and 3 female with the mean age 34.13 +/- 10.87 (range 21-60) years. Seven patients had living related, 4 living-unrelated and 4 cadaveric donors. Five patients were lost because of different complications: Three patients died from cardiac amyloidosis all with well functioning grafts, 2, 3 and 36 months after the operation. Sepsis and cardiovascular failure was the probable cause of death in 1 patient who also had chronic rejection. Another one patient with chronic rejection died from hepatic failure. Acute rejection developed in 2 patients. Renal functions of these patients improved by anti-rejection therapies. Chronic rejection developed in 3 patients. In the control group, acute rejection and chronic rejection were diagnosed in 5 and 1 patients, retrospectively. While 1 patients returned to hemodialysis in control group, the others are alive with satisfactory graft function. There was no death in control group. The 5-yr graft and patient survival rates in amyloidosis and the control groups were 75, 77, 95 and 100%, respectively. It was concluded that although transplantation is not a contraindication for the treatment of end stage renal failure in patients with renal amyloidosis, it carries high risk of cardiac complications in the postoperative period. Detailed preoperative cardiovascular evaluations are mandatory in these patients and this intervention should improve the prognosis by excluding the patients who have already been complicated with this problem.

Improvement of uremic autonomic dysfunction after renal transplantation: a heart rate variability study.

Autonomic dysfunction in hemodialysis patients is one of the components of uremic neuropathy. In this prospective study, we investigated the effect of renal transplantation on uremic autonomic dysfunction with long-term time-domain and frequency-domain heart rate variability. Fourteen hemodialysis patients (10 male, 4 female; mean age 33 +/- 11 (range 16-50) years) were examined before and at the early after transplantation period (mean 4.6 +/- 1.5 (range 3-7. 5) months). The mean time spent on hemodialysis was 16.7 +/- 15.6 (range 6-65) months. In time-domain analysis, significant increases in all parameters except pNN50 (SD, SDANN, SDNN, rMSSD) were observed after renal transplantation (p < 0.01). In frequency-domain analysis, low-frequency (LF) (0.04-0.15 Hz) and high-frequency (HF) (0.15-0.40 Hz) spectral power were found to be significantly increased after renal transplantation (4.54 +/- 1.04 vs. 12.58 +/- 8. 69 for LF (p = 0.005), 2.80 +/- 1.0 vs. 6.50 +/- 3.55 for HF (p = 0. 005)), but the LF/HF ratio was not different from a pretransplant period (1.71 +/- 0.349 vs. 1.85 +/- 0.49, p = 0.26). It was concluded that autonomic dysfunction in hemodialysis patients is reversible and renal transplantation reverses the sympathetic and parasympathetic autonomic dysfunction simultaneously and at a relatively early stage.

Effects of zinc supplementation on the immune system and on antibody response to multivalent influenza vaccine in hemodialysis patients.

The depression of the immune system in chronic uremia is a well-known phenomenon but the role of serum zinc (Zn) levels on both cell-mediated and humoral immunity is still controversial. The aim of this study was to investigate the effect of Zn supplementation on the immune system and on antibody response to multivalent influenza vaccine (MIV) in hemodialysis patients (HP). Twenty-six HP and 11 healthy subjects (HS) were vaccinated with MIV. Hemodialysis patients were randomly divided into two groups. Group I (13 HP) was supplemented with 120 mg ZnSO4 after each dialysis session. Group II (13 HP) and Group III (11 HS) were given placebo. In all cases, the serum Zn levels, CD3, CD4, CD8, CD19, HLA-DR+ cell percentages, CD4/CD8 ratio and CD3+ HLA-DR+ cell percentages were determined before and 30 days after vaccination. Antibody levels to subgroups of MIV were also measured. All the baseline parameters studied were not statistically different between Group I and II. However, there was a significant difference between the basal parameters of Group III and the other two groups, except for CD3 and CD4 cell percentages. Serum Zn, CD19 cell percentage and antibody levels to MIV subgroups were significantly increased in Group I at the end of the first month of the study (p<0.01, p<0.05, p<0.001, p<0.001, and p<0.01, respectively), but the other parameters showed no significant changes. The only significant change observed in Groups II and III was an increase in antibody levels to MIV subgroups one month after vaccination. Antibody levels to MIV subgroups, were not statistically different between Groups I and II, but in Group III they were strikingly higher than those of HP (p<0.001). These results led us to conclude that Zn supplementation could not restore the immune parameters and enhance antibody response to MIV in HP.

Tuberculosis after renal transplantation: experience of one Turkish centre.

BACKGROUND: In this study, renal transplant recipients with tuberculosis of different organs, were retrospectively analysed with respect to prevalence, outcome and drug toxicity. PATIENTS AND METHODS: In 520 patients, 22 (4.2%) tuberculosis of various organs was diagnosed. The time interval between transplantation and diagnosis of tuberculosis was 44.4 +/- 33.5 (range 3-111) months. In 18 (82%) of the patients, tuberculosis was detected after the first year of transplantation. The most common form was pleuro/pulmonary tuberculosis (54%), and other localizations included jejunum, liver, bone, and urogenital tract. RESULTS: Sixteen of the 22 patients responded favourably to the treatment and maintain excellent allograft function, whereas six patients (27.2%) died. Toxic hepatitis was seen in four (18%) patients, and one case was complicated with acute hepatocellular failure due to isoniazide (INH). However, of the 23 patients at risk of tuberculosis who had had INH prophylaxis for 1 year, neither tuberculosis, nor hepatotoxicity was observed. CONCLUSION: Tuberculosis is a common infection of renal transplant recipients in developing countries. The peak incidence is after the first year of transplantation and mortality is considerable. Hepatoxicity is a considerable risk of treatment, possibly as a result of additive toxic effects of immunosuppressive drugs.

Heart rate variability in patients with secondary amyloidosis.

Heart rate variability (HRV) is increasingly being used to evaluate the function of the autonomic nervous system. Although autonomic dysfunction has been described in primary amyloidosis patients, this has not been established for patients with secondary amyloidosis. This study examines the autonomic function of 23 biopsy-proven secondary amyloidosis patients (10 male, 13 female) and compares it with 19 healthy (8 male, 11 female) sex- and age-matched controls (Group III), using frequency- and time-domain HRV analysis. The study group was further divided according to renal function; Group I (14 nonuremic patients with serum creatinine level < 1.4 mg/dl) and Group II (9 uremic patients with serum creatinine level > 1.4 mg/dl). In time domain analysis, standard deviation and mean of the standard deviation of all normal R to R intervals, and standard deviation of the average normal R to R interval were significantly lower in Groups I and II as compared to Group III. In frequency domain analysis, low frequency power (LF), representing sympathetic function, was significantly lower in Groups I and II as compared to Group III, but high frequency power (HF), representing parasympathetic function, and the LF/HF ratio, as an index of sympathovagal balance, were not different among the groups. In conclusion, in patients with secondary amyloidosis, sympathetic components of heart rate variables decreased before the onset of uremia and the change became more prominent with the appearance of uremia despite not reaching statistical significance.

Posttransplant malaria.

The frequency and clinical characteristics of plasmodium infection were reported in 420 renal transplant recipients who were followed in the Transplantation Unit and Out-Patient Clinic of the Medical School of Istanbul. Plasmodium infection was diagnosed in eleven (9 male, 2 female) of the 420 patients (2.6%). Ten of the patients were transplanted in India, and one in our institution. The mean duration between the transplantation and the diagnosis of malaria was 21.7 + 44.4 days in patients who were transplanted in India. All of the patients were taking triple immunosuppressive drugs (CsA, AZA, PRED). Plasmodium falciparum was diagnosed in 6 patients, P vivax in 1 patient and P malariae in 1 patient. Also mixed infection with P falciparum and P malariae was diagnosed in 3 patients. After definite diagnosis, the patients were hospitalized. Chloroquine phosphate plus primaquine phosphate was administered for P vivax infection, whereas chloroquine phosphate alone was given for P falciparum and P malariae infection as a first line antimalarial therapy. As a result of therapy, infection improved clinically and the plasmodia disappeared rapidly from the thick blood film in 10 of the patients. Severe hemolysis and acute renal failure developed in one patient, who improved after hemodialysis therapy and exchange transfusions. It was concluded that malaria is quite a frequent infection of transplant recipients who get their allografts from donors living in high-risk areas, and all transplant recipients having this kind of transplantations should be suspected and examined for malaria. This may help to diagnose and treat the complication in the early period, thus resulting in an improved prognosis for this potentially life-threatening complication of the posttransplant period.

Automated sulfur hexafluoride washout functional residual capacity measurement system for any mode of mechanical ventilation as well as spontaneous respiration.

A new sulfur hexafluoride (SF6) washout functional residual capacity (FRC) measurement system has been developed which will work with any mode of mechanical ventilation, as well as with spontaneous respiration. This system was evaluated in three different human studies. In the first two studies, the accuracy of the system was compared with He dilution and body plethysmography in 12 spontaneously breathing normal volunteers and in 12 spontaneously breathing chronic obstructive pulmonary disease (COPD) patients. In the third study, the reproducibility and efficacy of using the system in the ICU was tested in 12 adult respiratory distress syndrome (ARDS) patients who were mechanically ventilated with PEEP. In the normal volunteers, there was no significant difference between the three measurement techniques. In the COPD group, there was an overall significant difference between measurement techniques (F[2,28] = 17.18, p less than .0001) and the rank of the magnitude of the FRC measurements from lowest to highest was SF6 washout, He dilution, and body plethysmography. There was a significant difference in accuracy between the COPD and normal volunteer groups (F[2,28] = 12.24, p less than .0002). There were a total of 1,227 FRC measurements made on the 12 ARDS patients. The number of FRC measurements per patient was 102 +/- 13 (SEM). The "stable" periods were 14 +/- 2 h long and ranged from 60 min to 63.5 h. The reproducibility for all 12 patients was 188 +/- 17 ml or 11.7 +/- 0.7%. This automated SF6 washout system should make routine FRC measurements in patients who are being mechanically ventilated simple and easy to do.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictors of perioperative mortality, morbidity and late quality of life in coronary bypass surgery.

Between January 1, 1977 and January 1, 1988, 220 patients over 70 years of age underwent coronary artery bypass surgery (CABG). Patients undergoing combined procedures, e.g. CABG and valve surgery, were not included. 39% of the patients were emergencies or urgent cases. Hospital mortality (less than 30 days after surgery or in hospital) was 7.7%. Mean hospital stay was 13.9 days. Postoperative morbidity consisted mainly of infections (n = 51), peri-operative infarction (n = 35), bleeding (n = 13), and renal failure (n = 13). 72% of the patients were in NYHA functional class I at the time of follow-up (mean 3.66 years postoperatively). Many factors were analysed as possible indicators for mortality, morbidity and postoperative functional class. Mortality was only related to the presence of pre-operative hypertension (P = 0.038), previous infarction (P = 0.056) and severity of coronary disease (P = 0.0458). Morbidity was weakly related to emergency procedures, previous infarction and severity of coronary artery disease (P less than 0.05). For postoperative functional class, no specific predictors were found.

Progressive coronary vasoconstriction during 25 hours of myocardial preservation in vitro impairs functional capacity following preservation.

We have developed perfusion techniques for preserving rat hearts for 25 h and have quantified haemodynamic function after preservation to establish the relation between coronary vascular resistance during preservation and the quality of postpreservation pump function. Thirteen rat hearts underwent hypothermic (8 degrees C), low-pressure (15 mmHg) perfusion with an hyperosmotic (385 mOsm/l) crystalloid preservation buffer for 25 h. During this period, the coronary flow rate decreased from 1.12 +/- 0.28 ml/min to 0.87 +/- 0.12 ml/min (+/- SD). Following the preservation period, the quality of pump function was tested in the isolated working heart model. At a fixed value of left atrial pressure (15 mmHg), the afterload was increased stepwise (5 mmHg) from 45 mmHg to 70 mmHg, making use of a Starling resistor in series with an air compliance. Each afterload step was maintained for 5 min to obtain stable readings of cardiac output and coronary flow. These measurements were compared with those from a control group of 10 rat hearts undergoing the same test protocol for haemodynamic function without previous preservation. The 13 hearts which underwent 25 h preservation had subnormal haemodynamic function: cardiac output was 50% +/- 4% compared to 10 control hearts. If preserved hearts were divided into two groups based on coronary vascular resistance measured at the end of the preservation period lower than 18 mmHg.min per ml (group 1), and higher than or equal to 18 mmHg.min per ml (group 2), it appeared that the haemodynamic function of group 2 hearts was about half that of group 1 hearts.(ABSTRACT TRUNCATED AT 250 WORDS)