The relationship between 25-hydroxyvitamin D levels and ambulatory arterial stiffness index in newly diagnosed and never-treated hypertensive patients.

OBJECTIVES: Vitamin D insufficiency has been shown to be associated with cardiac dysfunctions, such as cardiac hypertrophy and hypertension, in animal studies. Arterial stiffness is a prognostic marker for cardiovascular disease. Previous studies have demonstrated that 25-hydroxyvitamin D [25(OH)D] levels were negatively correlated with arterial stiffness index. The aim of this study was to investigate the relationship between 25(OH)D levels and arterial stiffness, which is evaluated using an ambulatory arterial stiffness index (AASI), in patients who have untreated and newly diagnosed essential hypertension. DESIGN: A total of 123 consecutive patients with newly diagnosed and untreated essential hypertension were included. Patients were divided into two groups according to their 25(OH)D levels. Vitamin D insufficiency was defined by 25(OH)D levels less than 20 ng/ml. All patients were referred for ambulatory blood pressure monitoring. The regression slope of diastolic and systolic blood pressure was computed for each individual on the basis of ambulatory blood pressure readings. AASI was described as one minus the respective regression slope. RESULTS: The mean AASI was significantly higher in patients with 25(OH)D levels less than 20 as compared with patients with 25(OH)D levels greater than or equal to 20 (0.50±0.20 vs. 0.34±0.17, P<0.001). In Pearson's correlation analysis, AASI had a significantly strong negative correlation with vitamin D levels (r=-0.385, P<0.001). In multivariate linear regression analysis, vitamin D levels were found to be significantly and independently associated with AASI (ß=-0.317, P=0.035). CONCLUSION: Arterial stiffness measured by AASI in newly diagnosed and untreated patients with essential hypertension were significantly related to vitamin D levels.

Galectin-3 as a new biomarker of diastolic dysfunction in hemodialysis patients.

BACKGROUND: Galectin-3 (gal-3) is an emerging prognostic biomarker in heart failure (HF). Clinical and experimental studies suggest that gal-3 is an important mediator of HF. Here we aimed to examine the relationship between gal-3 and diastolic dysfunction in patients undergoing maintenance hemodialysis (HD). METHODS: We examined the relationship between plasma gal-3 levels and left ventricular diastolic function. Plasma gal-3 was measured in 87 subjects with chronic HD and in 45 healthy controls using biochemical evaluations. Conventional echocardiography and pulsed tissue Doppler assessment were performed in all patients. Left ventricular diastolic dysfunction (LVDD) was defined as E' < 8 cm/s. The E/E' ratio was used as the main determinant of LVDD grade. RESULTS: The mean gal-3 concentrations were: 16.05 ng/ml (13.89-19.75) in healthy controls; 14.54 ng/ml (10.85-17.65) in HD patients with normal diastolic function; and 23.30 ng/ml (20.12-26.87) in HD patients with LVDD (p < 0.01). Plasma gal-3 levels correlated with E/E' (r = 0.933, p < 0.01), left atrial volume index (r = 0.713, p < 0.01), and E' (r = -0.685, p < 0.01). ROC analysis showed that the best gal-3 cut-off point for the diagnosis of LVDD was 20.12 ng/ml with a sensitivity of 67.6 % and specificity of 84.6 % (AUC = 0.803). CONCLUSION: We suggest that gal-3 may be a promising biomarker for the detection of LVDD in HD patients.

Daytime sleepiness and quality of life in peritoneal dialysis patients.

We aimed to compare automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) therapy with regard to patients' excessive daytime sleepiness (EDS) and quality of life (QOL). EDS was assessed with the Epworth Sleepiness Scale (ESS) and QOL with the Medical Outcomes Study 36-Item Short Form (SF-36) health survey. We included 59 patients (CAPD/APD, 30/29; male/female, 33/26; age, 45.3±15.8 years; dialysis duration, 42.0±33.6 months). The CAPD and APD groups were similar with respect to factors that affected sleep quality (age, sex, duration of PD), smoking, alcohol intake, socioeconomic status, body mass index, comorbid disease, and various laboratory parameters. Although one patient (3.3%) treated with CAPD and four patients (13.8%) treated with APD experienced EDS, there was no significant differences in ESS scores between the CAPD and APD patients. There was no difference in the SF-36 total and subscale scores when APD patients were compared with CAPD patients. The independent predictors of ESS were the serum albumin level (ß= -2.04, P<0.01), total SF-36 score (ß= 0.08, P=0.02), social functioning score (ß= -2.47, P=0.01), and role-emotional subscale score (ß= -1.12, P=0.05). The incidence of EDS was slightly higher in APD patients, but it did not negatively affect daily activities or QOL.

Predictors for quality of life in continuous ambulatory peritoneal dialysis patients.

AIM: Peritoneal dialysis patients have diminished quality of life scores compared with healthy subjects. Measures of quality of life have been reported to have a significant predictive value for patient survival and hospitalization in peritoneal dialysis patients. The purpose of this study is to determine the clinical, biochemical and psychological predictors for the quality of life in continuous ambulatory peritoneal dialysis (CAPD) patients. METHODS: This cross-sectional study included 60 CAPD patients (male/female 33/27; age 45.5 +/- 15.7 years, CAPD duration 43.4 +/- 32.7 months). Pittsburg Sleep Quality Index was used for assessing sleep quality. We evaluated each patient's depressive symptoms with Beck Depression Inventory (BDI). Quality of life parameters were assessed by the self-administered SF-36 generic health survey questionnaire. In all patients, demographic variables, personality traits and habits, Charlson Comorbidity Index, clinical and laboratory parameters were recorded and analysed. RESULTS: A Pearson bivariate correlation analysis revealed that total quality of life score was negatively correlated with Pittsburg Sleep Quality Index (-0.533, P < 0.0001), BDI (-0.642, P < 0.0001) scores, C-reactive protein (-0.588, P = 0.001), and positively correlated with blood urea nitrogen (0.336, P = 0.02) and albumin (0.351, P = 0.01). BDI scores (beta = -0.505, P = 0.001) and the serum albumin levels (beta = 0.324, P = 0.009) were the significant independent predictors of quality of life. CONCLUSION: Poor sleep quality, presence of depression, higher C-reactive protein and lower albumin levels are associated with poorer quality of life. In order to improve life quality in CAPD patients, quality of sleep, depression and nutritional status should be serially evaluated and given appropriate treatment when required.

Low total plasma homocysteine level in relation to malnutrition, inflammation, and outcome in hemodialysis patients.

OBJECTIVE: We examined the association between nutritional status and total plasma homocysteine (tHcy) level, cardiovascular disease (CVD), and mortality in hemodialysis (HD) patients. DESIGN: This prospective study consisted of 124 HD patients. A number of baseline parameters were measured, including tHcy level and laboratory markers of nutrition and inflammation. A CVD history and a malnutrition-inflammation score (MIS) were determined in all patients. The follow-up period was 2 years. RESULTS: Forty-nine patients (39.8%) had a history of CVD. During follow-up, 11 (8.8%) deaths occurred, and of these 7 deaths were attributable to CVD. A low tHcy level and an increased MIS were associated with CVD and mortality. The rates of CVD and mortality were also higher in the lowest tHcy level tertiles. In addition, tHcy level was positively correlated with albumin and creatinine, and was negatively correlated with C-reactive protein, MIS, and comorbidity. The survival rates in Kaplan-Meier survival analysis tests were significantly lower in patients with the highest MIS (log rank, 22.3; P < .001). Patients with higher tHcy levels had significantly longer survival rates (log rank, 9.7; P = .007). CONCLUSIONS: Because of the strong association of tHcy levels with malnutrition- inflammation, the presence of these factors should be considered when tHcy is evaluated as a risk factor of outcomes in HD patients.

Nutritional status and depression, sleep disorder, and quality of life in hemodialysis patients.

OBJECTIVE: The malnutrition-inflammation score (MIS) is a scoring system that measures malnutrition and inflammation. We sought to explore its associations with depression, sleep disturbance, and quality of life. DESIGN: This was a cross-sectional study. SETTING: This study took place at the Baskent University Outpatient Hemodialysis Unit (Ankara, Turkey). PATIENTS: We enrolled 67 hemodialysis patients (male/female, 34/33; age, 47.7 +/- 11.4 years [mean +/- SD]; hemodialysis duration, 103.7 +/- 59.1 months [mean +/- SD]). INTERVENTION: We retrospectively recorded patients' monthly clinical and laboratory findings from the previous 6 months. The same physician calculated MIS scores. We interviewed all patients, and each completed a Beck Depression Inventory (BDI) assessment. We used the Pittsburgh Sleep Quality Index (PSQI) to assess quality of sleep, and the Medical Outcomes Study 36-item short form (SF-36) questionnaire to evaluate health-related quality of life. MAIN OUTCOME MEASURES: The main outcome measures involved the univariate and multivariate relationships of the MIS with BDI, PSQI, and SF-36. RESULTS: Patients with PSQI scores of < or = 5 ("good sleepers") had lower MIS scores than did poor sleepers (6.8 +/- 2.5 vs. 8.8 +/- 3.2, P < .05). Patients with moderate-to-severe depression (BDI score > or = 19) had higher MIS scores (9.0 +/- 3.2 vs. 6.5 +/- 2.5, P = .005) and higher PSQI scores (7.6 +/- 2.1 vs. 4.7 +/- 1.8, P = .001), compared with patients with BDI scores < 19. Increased MIS scores were correlated with increased comorbidity (P = .01) and poor SF-36 scores (P = .009). CONCLUSION: Increased MIS is significantly associated with the presence of depression, sleep disorders, and poor quality of life. This close relationship may help establish the MIS as an important determinant of the increased morbidity and mortality of hemodialysis patients.

Mortality risk factors in chronic renal failure patients after coronary artery bypass grafting.

Perioperative risk during coronary artery bypass grafting (CABG) is high in patients with chronic renal disease. We aimed to determine postoperative two-year mortality and identify the preoperative risk factors of mortality during CABG surgery in hemodialysis (HD)-dependent and HD-non-dependent CRF patients. We included 102 CRF patients who underwent CABG in Baskent University Hospital between 2000 and 2005. There were 47 patients with CRF undergoing HD (Group I) and 55 CRF patients without dialysis requirement (Group II). We retrospectively retrieved demographic variables; clinical, operative, and echocardiographic data; and biochemical parameters at the time of the operation and six months postoperation. Postoperative HD requirement in Group II patients and infectious complications were recorded. In the second postoperative year, mortality rate was 27.7% in group I and 16.4% in group II (p > .05). When preoperative risk factors evaluated by univariate Cox analysis, only age (RR = 1.06, p = .04) was a significant determinant of survival in Group I patients. Among the operative and postoperative risk factors of mortality such as duration of operation, numbers of coronary vessel bypass, HD requirement, and infection were investigated in Group I and II patients. Rate of infectious complication (including mediastinitis) was found to be a major determinant of mortality by multivariate Cox analyses in both group I (RR = 4.42, p

Soluble endothelial protein C receptor: influence on arteriovenous fistula thrombosis development in hemodialysis patients.

BACKGROUND/AIMS: Arteriovenous fistulae (AVF) thrombosis is a common cause of morbidity in hemodialysis (HD) patients. Increased soluble endothelial protein C receptor (sEPCR) levels have been associated with increased risk of venous thrombosis. We aimed to investigate the possible effects of sEPCR levels on the development of AVF thrombosis in adult HD patients. METHODS: 60 HD patients and 22 healthy controls were included. Patients were followed for 18 months and were divided into two groups according to AVF thrombosis development: group 1 (with thrombosis) and group 2 (without thrombosis). Also, patients classified into tertiles according to plasma sEPCR levels: lowest, intermediate, and highest. Groups were analyzed for any relationship between sEPCR levels and development of AVF thrombosis. RESULTS: Mean plasma sEPCR levels were significantly higher in HD patients than they were in controls. Group 1 patients had significantly higher sEPCR levels compared with group 2 patients. Patients' groups were similar regarding other possible risk factors for AVF thromboses. The rate of AVF thrombosis development was significantly higher in the highest sEPCR tertile. CONCLUSION: This is the first study to analyze sEPCR levels in HD patients. Our findings demonstrate a relationship between plasma sEPCR levels and development of AVF thromboses.

Effect of protein-energy malnutrition on erythropoietin requirement in maintenance hemodialysis patients.

Possible interactions between inflammatory and nutritional markers and their impact on recombinant human erythropoietin (rHuEPO) hyporesponsiveness are not well understood. We investigated the role of nutritional status in rHuEPO requirement in maintenance hemodialysis (MHD) patients without evidence of inflammation. This cross-sectional study included 88 MHD patients. The associations between required rHuEPO dose and malnutrition-inflammation score (MIS) and several laboratory values known to be related to nutrition and/or inflammation were analyzed. Anthropometric measures including body mass index, triceps skinfold thickness, and midarm circumferences were also measured. Twenty-three patients with serum C-reactive protein levels >10 mg/L were excluded from the analysis. The remaining 65 patients (male/female, 41/24; age 49.1+/-11.4 years; dialysis duration 99.7+/-63.0 months) were studied. These patients had moderate malnutrition and the average MIS was 7.4 (range 3-17). The average weekly dose of administered rHuEPO was 69.1+/-63.1 U/kg. Malnutrition-inflammation score had a positive correlation with the serum concentration of tumor necrosis factor-alpha, whereas it had a negative correlation with anthropometric measures, total iron-binding capacity, prealbumin, phosphorus, creatinine, and triglyceride. According to Pearson's correlation analysis, significant relationships of increased MIS with increased required rHuEPO dose and rHuEPO responsiveness index (EPO divided by hematocrit) were observed (p=0.008, r=-0.326; p=0.017, r=-0.306, respectively). Recombinant human erythropoietin dose requirement is correlated with MIS and adverse nutritional status in MHD patients without evidence of inflammation. Further research should focus on reversing the undergoing microinflammation for a better outcome in dialysis patients.

Effect of supportive extracorporeal treatment in liver transplantation recipients and advanced liver failure patients.

Recently, continuous venovenous hemodiafiltration (CVVHDF) and plasmapheresis (PF) were suggested as supportive therapy options in combination with standard treatment in advanced liver failure. The aim of this study was to analyze the effects of supportive extracorporeal treatment (SET) in a group of patients with advanced hepatic failure. A total of 25 patients (7 women, 18 men; mean age, 39.3+/-15.4 years; 13 were transplant recipients [6 women, 7 men; mean age, 37.7+/-16.9 years]) were included. All patients were in hepatic coma and receiving standard coma and liver failure management when they received SET. Number of SET sessions; levels of serum blood urea nitrogen, creatinine, albumin, calcium, phosphorus, ammonia, alanine and aspartate aminotransferase, and total/conjugated bilirubin; and prothrombin times (PTT) before and after SET were recorded retrospectively. 7.7+/-7.9 SET sessions were performed. Thirteen liver transplant recipients required SET for an average of 9.7+/-8.3 days after transplantation. Serum ammonia and bilirubin levels were lower after termination of supportive therapy when compared with initial levels (p<0.0001 and p<0.005 respectively). During follow-up, hepatic encephalopathy and liver failure resolved in 11 patients, while 14 patients (7 transplant recipients) died. There was no significant difference between patients in either group except that PTT was shorter in patients who survived (p<0.01). Further analyses revealed that in surviving patients, ammonia clearance was higher (p<0.01). In patients with advanced liver failure, or liver transplants, CVVHDF and/or PF could be supportive options combined with standard treatment.

Clinical outcome after transfer from peritoneal dialysis to hemodialysis.

Guidelines for the clinical care and management of intra-abdominal complications in patients transferred from peritoneal dialysis (PD) to hemodialysis (HD) are not well established. In this study, we analyzed the indications for transfer, presence of abdominal complications, and clinical outcome on HD of 26 patients who were followed up between 1996 and 2004. Laboratory and radiology data for the patients (computerized tomographic and ultrasonographic examinations performed during the transfer and annually thereafter) were collected retrospectively. The indications for transfer from PD to HD were peritonitis (19%), mechanical problems (39%), and ultrafiltration failure (42%). At the time of transfer, 11 patients had no intra-abdominal complications, 8 had intra-abdominal loculated fluid collection, and 7 had intra-abdominal free fluid. One year after transfer, intra-abdominal fluid collection was observed in 6 patients, 3 of whom received percutaneous drainage. Patients who had intra-abdominal complications at the time of transfer exhibited significantly lower albumin (p < 0.01), higher levels of C-reactive protein (p < 0.02), and erythropoietin resistance at the time of transfer (p < 0.0001). During the first year after transfer, we observed a tendency toward an increase in albumin and a decrease in C-reactive protein level in the group that had complications, and yet nutritional interventions were still necessary in that group. A high ratio of intra-abdominal problems, which have adverse nutritional and inflammatory impacts, are seen after patients are transferred from peritoneal dialysis.

Isolated Brucella peritonitis in a CAPD patient.

Peritonitis is the most common complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Brucellosis is a rare cause of bacterial peritonitis. Only 1 case was reported of a patient with brucella peritonitis during CAPD therapy. In that case, CAPD peritonitis was accompanied by acute brucellosis. We present the case of a patient with isolated brucella peritonitis receiving CAPD therapy without systemic manifestations of brucellosis who works as a farmer. Results of a serum agglutination test and blood cultures were negative; however, the patient's peritoneal fluid agglutination titer was 1:160 and samples inoculated into BACTEC (Becton Dickinson, NJ) bottles yielded Brucella melitensis. Because we were unable to isolate the organism in blood samples, transmission seems to be the result of direct inoculation, rather than hematogenous spreading. Therefore, our patient represents the first case of isolated brucella peritonitis during CAPD therapy. Successful treatment was obtained by using a treatment regimen of rifampin and doxycycline.

Adding ultrasound in the management of soft tissue disorders of the shoulder: a randomized placebo-controlled trial.

BACKGROUND AND PURPOSE: There is still a lack of evidence about the beneficial effects of ultrasound (US) intervention for the management of soft tissue problems. Thus, this study was designed to assess the effectiveness of US over a placebo intervention when added to other physical therapy interventions and exercise in the management of shoulder disorders. SUBJECTS AND METHODS: Forty patients who were diagnosed by ultrasonography or magnetic resonance imaging to have a periarticular soft tissue disorder of the shoulder were randomly assigned to either a group that received true US (n=20; mean time since onset of pain=8.7 months, SD=8.8, range=1-36) or a group that received sham US (n=20; mean time since onset of pain=8.1 months, SD=10.8, range=1-42). Besides true or sham US (10 minutes), superficial heat (10 minutes), electrical stimulation (15 minutes), and an exercise program (15-30 minutes) were administered to both groups 5 days each week for 3 weeks. RESULTS: Subjects showed within-group improvements in pain, range of motion, Shoulder Disability Questionnaire scores, and Health Assessment Questionnaire scores with the intervention, but the differences did not reach significance when compared between the groups. DISCUSSION AND CONCLUSION: The results suggest that true US, compared with sham US, brings no further benefit when applied in addition to other physical therapy interventions in the management of soft tissue disorders of the shoulder.