Pleiotropic and Renoprotective Effects of Erythropoietin Beta on Experimental Diabetic Nephropathy Model.

BACKGROUND: This study aimed at investigating the possible protective effect of erythropoietin beta on experimental diabetic nephropathy (DN) model in rats. METHODS: Sprague Dawley rats (n = 32) were allocated into 4 equal groups of 8 each, the control (Group C), diabetes (Group D), erythropoietin beta (Group E), and erythropoietin beta treated DN (Group E + D) groups. Streptozocin (65 mg/kg) was used to induce diabetes in 10-week old rats. Erythropoietin beta was given intraperitoneally at a dose of 500 IU/kg/3 days of a week for 12 weeks. Renal function parameters, intrarenal levels and activities of oxidative stress biomarkers, serum inflammatory parameters and kidney histology were determined. RESULTS: Group E + D had lower mean albumin-to-creatinine ratio (p < 0.001) as well as higher creatinine clearance (p = 0.035) than the diabetic rats (Group D). Intrarenal malondialdehyde levels were significantly lower (p = 0.004); glutathione (GSH) levels (p = 0.003), GSH peroxidase (p = 0.004) and superoxide dismutase (p < 0.005) activities of renal tissue were significantly higher in Group E + D than in Group D. The mean serum levels of interleukin-4 (p < 0.005), interleukin 1 beta (p = 0.012), interferon gamma (p = 0.018) and tumor necrosis factor alpha (p < 0.005) were significantly lower; serum levels of monocyte chemoattractant protein 1 (p = 0.018) was significantly higher in Group E + D when compared to Group D. The mean scores of tubulointerstitial inflammation (p = 0.004), tubular injury (p = 0.013) and interstitial fibrosis (p = 0.003) were also lower in Group E + D when compared to Group D. CONCLUSION: Our data seem to suggest a potential role of erythropoietin beta for reducing the progression of DN in an experimental rat model. This protective effect is, in part, attributable to the suppression of the inflammatory response and oxidative damage.

Prevalence, associated factors and impact on mortality of chronic kidney disease in nursing home residents: A single-center experience.

AIM: We carried out the present study to determine the prevalence, associated comorbidities and impact on mortality of chronic kidney disease (CKD) in nursing home residents. METHODS: This was an 8-year prospective single-center, longitudinal cohort study consisting of 612 patients living in a nursing home from 2005-2013. The glomerular filtration rate (GFR) was estimated from a prediction equation, the Chronic Kidney Disease Epidemiology Collaboration equation, based on the serum creatinine concentration, age, race, sex and body size. The demographic and clinical characteristics of the residents were collected. RESULTS: CKD, defined as abnormalities of kidney structure or function, present for >3 months, with implications for health, was present in 197 (39.9%) residents. Specifically, 109 (21.5%) residents had an estimated GFR of 45-59 mL/min, and 64 (12.6%) had an estimated GFR of 30-44 mL/min. Multivariate logistic regression identified older age (OR 0.97, 95% CI 0.95-0.99), female sex (OR 2.99, 95% CI 1.99-4.49) and hypertension (OR 1.55, 95%, CI 1.00-2.40) as the only independent predictors of CKD. After a follow up of 8 years, 208 (41.1%) of the 506 residents died. Of these residents, 104 (52.8%) had CKD and 104 (33.4%) did not have CKD. The Kaplan-Meier survival curves showed that residents with CKD had a significantly higher mortality than those without CKD. CONCLUSION: CKD is prevalent in nursing home residents. A decline in renal function is associated with cardiovascular disease and mortality. Early recognition of CKD might improve drug dosage, renal management and outcomes in this particular group of patients.

Effects of paricalcitol and aliskiren combination therapy on experimental diabetic nephropathy model in rats.

BACKGROUND/AIMS: The aim of the present study was to investigate the effect of combination of aliskiren with paricalcitol on experimental diabetic nephropathy (DN) model in rats. METHODS: Forty male Sprague Dawley rats were divided into 5 groups of 8 rats each, namely the control (Group C), diabetes (Group D), aliskiren (Group A), paricalcitol (Group P), and aliskiren plus paricalcitol (Group A+P) groups. Aliskiren was given by oral-gavage at a dose of 50 mg/kg/day once daily for 12 weeks. Paricalcitol was given by intraperitoneally at a dose of 0,4 µg/kg/three day of week for 12 weeks. Renal function parameters, oxidative stress biomarkers, mRNA expression of renin-angiotensin system parameters and kidney histology were determined. RESULTS: Group A+P had lower mean albümin-to-creatinine ratio (ACR) (p=0.004) as well as higher creatinine clearance (CCr) (p<0.005) than the diabetic rats (Group D). Combination therapy significantly increased CCr (Group A+P vs. Group A, p<0.005; Group A+P vs. Group P, p=0.022) and reduced ACR (Group A+P vs. Group A, p=0.018; Group A+P vs. Group P, p<0.005) when compared to monotherapy. Serum malondialdehyde levels were significantly lower (p=0.004); glutathion levels (p=0.003), glutathion peroxidase (p=0.004) and superoxide dismutase (p<0.005) activities were significantly higher in group A+P than in group D. The mean scores of mRNA expression of renin (p<0.005), angiotensin II (p=0.012) and angiotensin type 1 receptor (p=0.018) in group A+P were significantly lower. Although combination therapy showed no additional effect on oxidative system, renin-angiotensin system and renal histology, aliskiren plus paricalcitol significantly decreased interstitial fibrosis volume when compared to monotherapy (Group A+P vs. Group A, p<0.005; Group A+P vs. Group P, p=0.002). CONCLUSION: Our data seem to suggest a potential role of aliskiren plus paricalcitol acting synergystically for reducing the progression of diabetic nephropathy in an experimental rat model.

[Saccharomyces cerevisiae fungemia in an elderly patient following probiotic treatment]. / Probiyotik tedavisinden sonra yasli bir hastada gelisen Saccharomyces cerevisiae fungemisi.

Saccharomyces cerevisiae, known as baker's yeast, is also used as a probiotic agent to treat gastroenteritis by modulating the endogenous flora and immune system. However, since there have been increasing reports of fungemia due to S.cerevisiae and its subspecies S.boulardii, it is recommended that probiotics should be cautiously used in immunosuppressed patients, people with underlying diseases and low-birth weight babies. To emphasize this phenomenon, in this report, a case of S.cerevisiae fungemia developed in a patient given probiotic treatment for antibiotic-associated diarrhea, was presented. An 88-year-old female patient was admitted to our hospital with left hip pain, hypotension, and confusion. Her medical history included hypertension, chronic renal failure, left knee replacement surgery, and recurrent urinary tract infections due to neurogenic bladder. She was transferred to the intensive care unit with the diagnosis of urosepsis. After obtaining blood and urine samples for culture, empirical meropenem (2 x 500 mg) and linezolid (1 x 600 mg) treatment were administered. A central venous catheter (CVC) was inserted and after one day of inotropic support, her hemodynamic parameters were stabilized. The urine culture obtained on admission yielded extended-spectrum beta-lactamase-producing Klebsiella pneumoniae and Escherichia coli. Urine culture was repeated after three days and no bacteria were isolated. On the 4th day of admission she developed diarrhea. Toxin A/B tests for Clostridium difficile were negative. To relieve diarrhea, S.boulardii (Reflor 250 mg capsules, Sanofi Aventis, Turkey) was administered twice a day, without opening capsules. Two days later, her C-reactive protein (CRP) level increased from 23.2 mg/L to 100 mg/L without fever. Her blood culture taken from the CVC yielded S.cerevisiae. Linezolid and meropenem therapies were stopped on the 13th and 14th days, respectively, while prophylactic fluconazole therapy was replaced with caspofungin 1 x 50 mg on the fifth day. After seven days of therapy CRP and serum creatinine levels decreased to 9.1 mg/L and 1.2 mg/dl, respectively; and she was discharged from the hospital with improvement. The probiotic capsules were used unopen, thus, it was proposed that S.cerevisiae fungemia originated from translocation from the intestinal mucosa. Since it was not possible to investigate the molecular genetics of the strain isolated from the blood culture and the strain present in the probiotic, a definite conclusion about the origin of the strain could not be reached. It was thought that old age and underlying disease of the patient were the related predisposing factors for S.cerevisiae fungemia. This case emphasized that clinicians should be cautious in case of probiotic application even though in encapsulated form, even in immunocompetent patients with a history of long-term hospital stay and use of broad-spectrum antimicrobials since there may be a risk of S.cerevisiae fungemia development.

Home and ambulatory blood pressure monitoring: when? who?

Blood pressure measurement in the diagnosis and management of hypertension, including the technique required for ambulatory blood pressure monitoring and home blood pressure monitoring, will be reviewed in this article. Home and ambulatory measurements are widely used, both to confirm the diagnosis and to improve adherence to therapy. The major advantage of out-of-office blood pressure monitoring is that it provides a large number of blood pressure measurements away from the medical environment, which represents a more reliable assessment of actual blood pressure than office blood pressure. The advantage of ambulatory blood pressure monitoring is its unique ability to measure nocturnal blood pressure. Although not fully validated in large-scale clinical trials, ambulatory blood pressure monitoring appears to correlate best with prognosis. Ambulatory blood pressure monitoring and home blood pressure monitoring provide somewhat different information on the subject's blood pressure status, and the two methods should thus be regarded as complementary, rather than competitive or alternative.

A Single-Centre Study of Acute Cardiorenal Syndrome: Incidence, Risk Factors and Consequences.

OBJECTIVE: Cardiac and kidney diseases are common, and the impact of acute kidney injury (AKI) on patient outcome is well known. We aimed to investigate the incidence of acute cardiorenal syndrome (CRS) and the risk factors and outcomes associated with the disease. METHODS: We conducted a retrospective cohort study comprising 289 patients with acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF), examining the incidence of AKI defined according to the Acute Kidney Injury Network (AKIN) classification, the factors contributing to AKI, and the impact of AKI on in-hospital mortality and hospital re-admission. RESULTS: Of 71 patients with AKI, 36 (50.7%) had ACS and 35 (49%) had ADHF. Overall in-hospital mortality was 5.5% (n = 16). Multivariate logistic regression identified the following independent predictors of AKI in male patients with ACS: previous myocardial infarction at age >65 years (OR 5.967, 95% CI 1.16-30.47, p = 0.03), chronic kidney disease (OR 3.72, 95% CI 1.31-16.61, p = 0.01), and decreased hemoglobin levels (OR 0.684, 95% CI 0.53-0.88, p = 0.03). No variable was identified as an independent risk factor in ADHF patients. Kaplan-Meier survival curves indicated that patients with ACS plus AKI had significantly higher in-hospital mortality (log rank = 0.007). CONCLUSION: Acute CRS (type 1 CRS) is more frequent in patients with ADHF and can be considered multifactorial. Although CRS is less frequent in ACS patients, it is associated with longer hospital stay and with higher in-hospital mortality. The heart-kidney interaction should be managed collaboratively between cardiologists and nephrologists to increase our knowledge and enhance clinical approaches.

Paraoxonase 1 polymorphisms in patients with primary glomerulonephritis: a single-center study in Turkey.

INTRODUCTION: Human paraoxonase 1 (PON1) is an enzyme related with high-density lipoprotein cholesterol. The link between genetic polymorphisms of PON1 and hyperlipidemia and increased lipid oxidation may explain these complications in the course of glomerular diseases. In this study, we aimed to investigate PON1 192 and PON1 55 polymorphisms in patients with primary glomerulonephritis and healthy individuals. MATERIALS AND METHODS: Eighty-six patients with biopsy-proven primary glomerulonephritis and 50 healthy controls were included in the study. Clinical characteristics, lipid profile, paraoxonase activity, and PON1 genotypes (PON1 192 and PON1 55) of all of the participants were studied. RESULTS: Histopathological diagnoses of the patients were membranoproliferative glomerulonephritis (53.5%), focal segmental glomerulosclerosis (33.7%), and membranous nephropathy (12.8%). The patients had lower PON1 activity levels than the healthy controls. No differences were observed in PON1 192 genotypes between the two groups. However, the controls were more likely to carry PON1 55 LM genotype (odds ratio, 4.10; 95% confidence interval, 1.96 to 8.61; P < .001) and M allele (odds ratio, 3.0; 95% confidence interval, 1.45 to 6.19; P = .003) compared to the patients with primary glomerulonephritis. There was a marked elevation in the frequency of PON1 55 LL genotype in the patients compared to the controls (odds ratio, 0.33; 95% confidence interval, 0.16 to 0.68; P = .003). CONCLUSIONS: This preliminary study shows that the LL genotype might be a risk factor for the development of primary glomerulonephritis and the M allele might be a protective factor against its progression.

Risk factors for acute kidney injury after hip fracture surgery in the elderly individuals.

OBJECTIVE: We aimed to evaluate possible risk factors associated with acute kidney injury (AKI) after hip fracture surgery in the elderly individuals. DESIGN: Level II diagnostic study, evidence obtained from prospective cohort study from 1 center with level 2, and 3 patients. PATIENTS: A total of 165 patients (>65 years) with femoral neck fracture were enrolled in this prospective study between 2007 and 2010. Two patients were dropped for inadequate laboratory follow-up data. Patients with kidney failure or renal replacement therapy (RRT) history or AKI at admission were excluded. INTERVENTION: Nephrology consultation was obtained from all patients at admission. All patients had undergone bipolar cemented hip arthroplasty that was performed by the same surgical team in all patients within 24 hours of fracture and admission under the same protocol. MAIN OUTCOME MEASUREMENTS: Serum creatinine (SCr), urine output, and complete blood counts were evaluated at baseline and daily basis thereafter. The AKI was defined based on Acute Kidney Injury Network classification. Hospital charges were converted from Turkish Liras to US dollars and rounded. RESULTS: Among 163 patients, AKI occurred in 25 (15.3%) patients, all within the first 48 postoperative hours. Three (1.8%) patients required RRT. Baseline SCr levels were restored within 4.84 ± 1.34 days on average (3-8 days). No patient required RRT after discharge. The mean hospital stay was 3 days (2-6 days) longer and the hospital charge was 2500 US$ higher for the patients with AKI. After multivariable adjustment, only lower estimated glomerular filtration rate levels (odds ratio 0.945, 95%confidence interval 0.92-0.96) emerged as an independent predictor for AKI. CONCLUSION: The AKI represents a frequent complication after hip fracture surgery associated with longer hospital stay and higher treatment costs with increased morbidity. Our results show baseline renal function is an independent predictor of AKI.

Frequency of cardiovascular risk factors and metabolic syndrome in patients with chronic kidney disease.

OBJECTIVE: Metabolic syndrome is a clustering of cardio-metabolic risk factors. Cardiovascular disease is the main cause of morbidity and mortality in end-stage renal disease. The aim of this study was to elucidate the frequency of traditional and novel cardiovascular and metabolic syndrome risk factors in patients with chronic kidney disease. Identification of these risk factors will allow for precautions to be taken earlier to prevent cardiovascular diseases and metabolic syndrome in chronic kidney disease patients. METHODS: A total of 214 patients (91 females, 123 males, mean age 56.1 ± 14.4 years) with chronic kidney disease who were followed in the Nephrology Department of Istanbul Goztepe Training and Research Hospital were included in the study. Anthropometric and biochemical measurements for cardiovascular risk factors and metabolic syndrome parameters were recorded. Glomerular filtration rates (GFR) were estimated using the Cockroft Gault formula. Metabolic syndrome was defined according to International Diabetes Federation criteria. RESULTS: Thirty-seven percent of patients with chronic renal failure were found to have three or more major cardiovascular risk factors. Seventy percent of patients were found to have metabolic syndrome. The mean numbers of major cardiovascular risk factors and metabolic syndrome parameters in patients with different GFR stages were: 1.8 ± 1.0, 2.6 ± 1.2 (GFR <15 mL/min per 1.73 m(2), n = 102); 2.4 ± 1.0, 3.0 ± 1.0 (GFR 15-29 mL/min per 1.73 m(2), n = 51 ); 2.5 ± 1.1, 3.3 ± 1.0 (GFR 30-59 mL/min per 1.73 m(2), n = 39); 2.4 ± 1.1, 3.5 ± 0.7 (GFR 60-89 mL/min per 1.73 m(2), n = 22), respectively (P = .001). CONCLUSION: Although the frequency of cardiovascular risk factors and metabolic syndrome were high in patients with chronic kidney disease, they were negatively correlated with the stage of renal failure.

Assessment of female sexual function and quality of life in predialysis, peritoneal dialysis, hemodialysis, and renal transplant patients.

INTRODUCTION: Chronic renal failure (CRF) and renal replacement treatments have a negative effect on sexual function and quality of life (QoL). The literature on female sexual dysfunction (FSD) in patients with CRF is limited. The aim of this study is to compare the sexual function and QoL in predialysis (PreD), dialysis, and transplant patients. MATERIALS AND METHODS: A total of 106 women including 21 PreD, 45 dialysis, 20 renal transplantation (Tx), and 20 control patients were enrolled in the study. The Female Sexual Function Index (FSFI) and SF-36 scales were used to assess all patients, and demographic and clinical variables were documented. The FSFI and QoL scale scores were compared among the groups. RESULTS: The rates of FSD were 50, 81, 66.7, 75, and 50% in the control, PreD, peritoneal dialysis (PD), hemodialysis (HD) and Tx patients respectively. Total FSFI scores for desire, arousal and orgasm scores in the PreD group were significantly lower than those in Tx and control patients (P < 0.05). Physical components of QoL in CRF patients were significantly worse than in the control group (P < 0.0001). On logistic regression analysis, age, glucose and creatinine were significantly associated with FSD. CONCLUSION: This preliminary study documented that Tx is the most effective way to retain good sexual function in women, and a diagnosis of FSD should be made routinely in CRF patients.

The effect of dialytic modalities on clinical outcomes in ESRD patients with familial Mediterranean fever.

BACKGROUND: Familial Mediterranean fever (FMF) is an autosomal recessive disease seen primarily in Sephardic Jews, Turks, and Armenians. The disease manifests as recurrent attacks of fever and serositis. The most important complication of FMF is the development of renal failure due to AA type amyloidosis. There has not been extensive experience with renal replacement therapy in FMF amyloidosis. Nevertheless, there may be a concern about the possibility of higher rates of morbidity and mortality in amyloidotic patients maintained on chronic hemodialysis. Moreover, there is not enough experience regarding patients on chronic peritoneal dialysis. As a result, the best treatment modality of end-stage renal disease (ESRD) in these circumstances still remains unclear. This study aimed to compare the effect of hemodialysis and peritoneal dialysis modalities on clinical outcomes in ESRD patients associated with FMF amyloidosis. METHODS: Forty FMF patients with ESRD due to amyloidosis were retrospectively analyzed. All 40 patients were on renal replacement therapy, 20 on hemodialysis (HD), 20 on peritoneal dialysis (PD). Peritoneal solute transport rates, weekly mean creatinine clearance, and daily mean ultrafiltration (UF) of the patients on chronic peritoneal dialysis were evaluated. Weekly dialysis durations, dialysis membrane properties, Kt/V values, interdialytic weight gains, and frequency of hypotension during dialysis were evaluated on hemodialysis patients. All of the patients were examined according to their demographic characteristics, laboratory results, duration time on dialysis, erythropoietin requirements, frequencies of infectious complications requiring hospitalization, and the two renal replacement modalities mentioned above were compared in terms of these parameters. RESULTS: Serum albumin levels of the patients with FMF amyloidosis who were maintained on peritoneal dialysis treatment were lower (2.87 vs 3.45) and the frequency of infections of the same group was higher (4.2 vs 0.5) than the patients with ESRD secondary to other diseases in the CAPD group. CONCLUSIONS: This retrospective analysis showed that peritoneal dialysis may have some disadvantages in amyloidotic patients. Due to the high frequency of hypoalbuminemia and infectious complications seen in this group, peritoneal dialysis is widely accepted as an alternative choice of treatment when hemodialysis is not appropriate.

Mycophenolate mofetil treatment for therapy-resistant glomerulopathies.

BACKGROUND: The management of steroid-resistant glomerulopathies remains a clinical problem. In this trial, we report a clinical observation of 43 patients treated with mycophenolate mofetil (MMF) for steroid-resistant glomerulopathies. METHODS: All patients underwent renal biopsies, and immunofluorescence and light microscopy examinations were conducted in all cases. All patients had been treated with prednisone at a dose of 1 mg/kg per day for at least 8 weeks. Of the 43 patients, 16 were treated with cyclophosphamide and five were treated with cyclosporine A before MMF started. The primary study outcomes were the change in the urinary protein excretion, serum creatinine, comparing the levels at the start of MMF treatment with those at the end of the MMF treatment period. Changes in renal function were also estimated with Modification of Diet in Renal Failure calculation. Wilcoxon signed-ranks test was used as appropriate to compare data from the start with data at the end of the treatment period. RESULTS: The primary glomerular diseases represented included membranoproliferative glomerulonephritis in 23.2%, membranous glomerulonephritis in 18.6%, IgA nephropathy in 13.9%, focal segmental glomerulosclerosis in 9.3%, lupus nephritis (systemic lupus erythematosus) in 25.6% and pauci-immune glomerulopathy in 9.3% of patients. The mean follow-up time was 28.9+/-12 months. Before MMF treatment, 16 patients (37%) had nephrotic range proteinuria and 11 (26%) had renal insufficiency. The urinary protein before MMF treatment was 3.3+/-2.6 g/dL (0.6-9.6) and decreased significantly to 0.87+/-1.1 g/dL (0-5.5) at the end of the MMF treatment period (P=0.02). During treatment, complete remission was seen in 27 patients, partial remission in 10 patients and MMF failure in six patients. The serum creatinine level decreased significantly from 1.29+/-0.55 mg/dL (0.6-3.0) to 1.14+/-0.38 mg/dL (0.5-2.4) post MMF therapy (P=0.046). Using the four-variable Modification of Diet in Renal Failure formula, the glomerular filtration rate increased from 71.5+/-28 mL/min per 1.73 m2 to 78.1+/-27 mL/min per 1.73 m2 (P=0.021). Renal insufficiency resolved in seven of the 11 (63.6%) patients with renal insufficiency initially, two with membranoproliferative glomerulonephritis, two with membranous glomerulonephritis, one with focal segmental glomerulosclerosis, four with pauci-immune glomerulopathy, two with systemic lupus erythematosus nephritis, and in two patients de novo renal insufficiency developed. CONCLUSION: In general, MMF was well tolerated, and most of the patients achieved remission and improvement of renal functions. MMF treatment appeared to offer benefits to problematic patients refractory to conventional therapies for glomerulopathies.

Association of FMF-related (MEFV) point mutations with secondary and FMF amyloidosis.

BACKGROUND: Familial Mediterranean fever (FMF) is the major cause of AA amyloidosis in Turkey. M694V mutation in MEFV gene was suggested to be associated with severe clinical features and amyloidosis of FMF. METHODS: In this study, the frequencies of three FMF-related MEFV mutations (M694V, M680I and V726A) were investigated in FMF patients with (AA-FMF, n = 37) and without amyloidosis (non-AA-FMF, n = 35), in patients with secondary amyloidosis related to non-FMF inflammatory conditions (S-AA, n = 19) and in a non-inflammatory control group (n = 185) by molecular genetic studies using polymerase chain reaction with the ARMS (amplification refractory mutation system) method. RESULTS: Both AA and non-AA-FMF patients had significantly higher MEFV mutations compared to non-inflammatory controls (81 and 62.7% respectively vs. 4.2%, p = 0.0001). AA-FMF patients carried significantly more MEFV mutations than non-AA-FMF patients (p = 0.01). M694V was the most common mutation in both FMF groups (63.5 vs. 51.4%), however allele frequency (p = 0.17) and the number of homozygous patients for this mutation did not differ between the groups (p = 0.77). Although lower compared to FMF patients, S-AA patients also had a significantly higher incidence of MEFV mutations than non-inflammatory controls (21 vs. 4.2%) (p = 0.0002). M694V was the only MEFV mutation in this group. CONCLUSION: MEFV mutations are found to be increased both in FMF and non-FMF associated secondary amyloidosis in our study; however, no clear association between M694V and amyloidosis is observed, except in the non-FMF group. Our results suggest that MEVF mutations may also serve as a severity marker for other inflammatory conditions.

Clinical characteristics of patients developing ARF due to sepsis/systemic inflammatory response syndrome: results of a prospective study.

BACKGROUND: Acute renal failure (ARF) in patients with sepsis provokes high mortality and financial cost. In this prospective study, we collected characteristics of patients in the intensive care unit (ICU) who developed sepsis/systemic inflammatory response syndrome (SIRS) to analyze differences between those who subsequently did or did not develop ARF. METHODS: All patients admitted to the ICU of the University Hospital Gent, Belgium, between January 1, 2001, and December 31, 2001, who developed sepsis/SIRS were included if they had a serum creatinine level less than 2 mg/dL (<177 micromol/L). RESULTS: Of 2,442 patients admitted to the ICU, 257 patients developed sepsis/SIRS. Of those, 29 patients (11%) developed ARF. In a univariate analysis, age, central venous pressure (CVP), and serum creatinine and blood urea nitrogen levels were greater (P = 0.003, P = 0.006, P < 0.001, and P < 0.001, respectively), whereas mean arterial and diastolic blood pressures, 24-hour urinary output, arterial pH, bicarbonate level, thrombocyte count, albumin level, and prothrombin time were lower (P = 0.05, P = 0.004, P = 0.005, P = 0.03, P = 0.009, P = 0.037, P = 0.05, and P = 0.006, respectively) in the ARF group. Prevalence of diabetes, sex, and need for ventilation were not different between the ARF and no-ARF groups, but in the ARF group, diuretic use, vasopressor use, and presence of primary hepatic failure were more prevalent (P = 0.001 for each). In a multivariate analysis, age, serum creatinine level, CVP, and presence of liver failure significantly contributed to a logistic regression model for ARF. CONCLUSION: Several parameters already were disturbed at the first day of SIRS/sepsis in patients who later developed ARF. Older age, elevated serum creatinine level despite elevated CVP, and presence of hepatic failure are predictive for ARF in septic patients.

Renal replacement therapies in the aftermath of the catastrophic Marmara earthquake.

BACKGROUND: Renal replacement therapy is of vital importance in the treatment of crush syndrome victims, who are frequently encountered after catastrophic earthquakes. The Marmara earthquake, which struck Northwestern Turkey in August 1999, was characterized by 477 victims who needed dialysis. METHOD: Within the first week of the disaster, questionnaires containing 63 clinical and laboratory variables were sent to 35 reference hospitals that treated the victims. Information considering the features of dialyses obtained through these questionnaires was submitted to analysis. RESULTS: Overall, 639 casualties with renal complications were registered, 477 of whom (mean age 32.3 +/- 13.7 years, 269 male) needed dialysis. Among these, 452 were treated by a single dialysis modality (437 intermittent hemodialysis, 11 continuous renal replacement therapy and 4 peritoneal dialysis), while 25 victims needed more than one type of dialysis. In total, 5137 hemodialysis sessions were performed (mean 11.1 +/- 8.0 sessions per patient) and mean duration of hemodialysis support was 13.4 +/- 9.0 days; this duration was shorter in the non-survivors (7.0 +/- 8.7 vs. 10.0 +/- 9.8 days, P = 0.005). Thirty-four victims who underwent continuous renal replacement therapy had higher mortality rates (41.2 vs. 13.7%, P < 0.0001). Only eight victims were treated by peritoneal dialysis, four of whom also required hemodialysis or continuous renal replacement therapy. The mortality rate in the dialyzed victims was 17.2%, a significantly higher figure compared to the mortality rate of the non-dialyzed patients with renal problems (9.3%; P = 0.015). CONCLUSION: Substantial amounts of dialysis support may be necessary for treating the victims of mass disasters complicated with crush syndrome. Dialyzed patients are characterized by higher rates of morbidity and mortality.

Acute renal failure due to crush syndrome during Marmara earthquake.

During the earthquake in Marmara, Turkey (August 17, 1999), 87 of 476 victims (18.3%) admitted to Marmara University Hospital (Istanbul, Turkey) experienced renal failure caused by crush injuries. Fifty-nine patients (68%; 40 men, 19 women) required renal replacement therapy (RRT), whereas 28 patients (32%; 20 men, 16 women) recovered renal function under conservative treatment. The aim of the present study is to compare clinical and laboratory data from patients with crush syndrome who needed RRT with those who could be maintained on conservative medical treatment. Data for demographic, clinical, and laboratory findings of patients who had renal problems were collected retrospectively and analyzed. The proportion of men was significantly greater (68% versus 42%; P < 0.05), and time spent under the rubble was significantly shorter (9.4 +/- 6.9 versus 19.1 +/- 22.5 hours; P < 0.05) among patients who required RRT compared with those who recovered under conservative treatment. Patients who required RRT had significantly less urine output in the first 24 hours, underwent more fasciotomies, and needed more blood and fresh frozen plasma transfusions (P < 0.05). Blood urea nitrogen, creatinine, potassium, creatine kinase, and aspartate aminotransferase levels were significantly greater compared with patients managed conservatively both on admission and for the mean of values obtained during the first 2 weeks (P < 0.05). Furthermore, fasciotomies were the most powerful predictors of a later need for RRT. In a similar disaster in the future, these factors should be taken into consideration for priority in referral to medical centers with dialysis facilities.