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Introduction: More frequent and/or longer hemodialysis (HD) has been associated with improvements in numerous clinical outcomes in patients on dialysis. Home HD (HHD), which allows more frequent and/or longer dialysis with lower cost and flexibility in treatment planning, is not widely used worldwide. Although, retrospective studies have indicated better survival with HHD, this issue remains controversial. In this multicenter study, we compared thrice-weekly extended HHD with in-center conventional HD (ICHD) in a large patient population with a long-term follow-up. Methods: We matched 349 patients starting HHD between 2010 and 2014 with 1047 concurrent patients on ICHD by using propensity scores. Patients were followed-up with from their respective baseline until September 30, 2018. The primary outcome was overall survival. Secondary outcomes were technique survival; hospitalization; and changes in clinical, laboratory, and medication parameters. Results: The mean duration of dialysis session was 418 ± 54 minutes in HHD and 242 ± 10 minutes in patients on ICHD. All-cause mortality rate was 3.76 and 6.27 per 100 patient-years in the HHD and the ICHD groups, respectively. In the intention-to-treat analysis, HHD was associated with a 40% lower risk for all-cause mortality than ICHD (hazard ratio [HR] = 0.60; 95% confidence interval [CI] 0.45 to 0.80; P < 0.001). In HHD, the 5-year technical survival was 86.5%. HHD treatment provided better phosphate and blood pressure (BP) control, improvements in nutrition and inflammation, and reduction in hospitalization days and medication requirement. Conclusion: These results indicate that extended HHD is associated with higher survival and better outcomes compared to ICHD.

Erişkin Böbrek Nakli Hastalarında Uzun Etkili Takrolimus Kullanımı, Uzun Dönem Böbrek Ve Hasta Sağkalımı Üzerine Etkisi, Tek Merkez Deneyimi AMAÇ : Takrolimus organ nakli hastalarında kullanılan en önemli immun supresif ajanlardan biridir. Uzun etkili takrolimus preparatının polifarmasiyi azaltması ve takrolimus kan düzeyini daha stabil tuttuğuna dair bilgiler bulunmaktadır. Biz de organ nakli ünitemizde uzun etkili takrolimusa geçilen ve en az 1 yıl takip edilen böbrek nakli hastalarında renal fonksiyon değişimi ve hasta sürvisine etkisini araştırmayı amaçladık. MATERYEL METOT : Tek merkezli retrospektif gözlemsel çalışmamızda ünitemizde böbrek nakli yapılan 934 hasta dosyası tarandı. Tarama sonrasında takrolimusdan uzun salınımlı takrolimusa konversiyon yapılan veya uzun salınımlı takrolimusa denovo başlanan en az 1 yıl süre ile takip edilen 45 hasta çalışmaya dahil edildi. Hastaların demografik verileriyle beraber, değişim anı kreatinleri, değişim sonrası takip süreleri , son kreatinin değerleri ve hasta sürvileri değerlendirildi. Delta kreatinin düzeyi hastanın son kreatininden hastanın değişim anı kreatinin seviyesinin çıkarılması ile hesaplandı . SONUÇLAR : Çalışmaya alınan 45 hastanın ortalama yaşı 47,7 ± 13,6 yıl (miminimu 19 – max 70 ) idi. Hastaların 29’u (%64,4) erkek, 16’sı (%35) kadın idi. Hastaların 5’i (%11,1) 65 yaş üzeriydi. Hastaların primer böbrek hastalıkları değerlendirildiğinde 5’i (%11,1) diyabetik böbrek hastalığı , 5’ i primer glomerulonefrit (%11,1) ; 4 ü (%8,9) hipertansif nefroskleroz ; 4’ü otozomak dominant polikistik böbrek hastalığı , 5’i obstrüktif nefropatiye bağlı böbrek yetmezliği idi. 10’u (%22,2) diğer sebeplere bağlı ve 12 hastanın da (%26,7) primer böbrek hastalığı bilinmiyordu. Hastaların 3 ü (%6,7) ikinci transplantasyondu. Konversiyon öncesi 39 hasta (%86) tacrolimus + Mikofenolat Mofetil/Mikofenolat sodyum (MMF/MYF) + prednizolon kullanmakta iken 3 hasta (%6,7) Takrolimus +Azatiopurin + perdnizolon kullanmaktaydı. 2 hasta (%4,4) Takrolimus + Everolimus + prednizolon, 1 hasta ise (%2,2) Takrolimus + MMF kullanmaktaydı. Hastaların 8 tanesine (%17,8) uzun etkili takrolimusu denovo olarak pretransplant -3. günde başlanmış. 2 hastada da (%4,4) posttransplant 1. haftada uzun etkili takrolimusa dönüşüm yapılmıştır. Geriye kalan 35 hastanın 29 u takrolimus kan düzeyi değişkenliği sebebiyle, 3 hasta polifarmasi sebebiyle, 3 hasta da viral enfeksiyon süresindeki takrolimus değişkenliği nedeniyle uzun etkili takrolimusa değişim yapılmıştır. Hastaların değişim anı kreatinin ortalaması 1,23 ± 0,34 mg/dl (min 0,60 , max 1,90 ) idi. Değişime kadar geçen süre ortancası 39 (IQR 22-77 ,min 3 ay , max 190 ay) idi. Değişim sonrası hastaları takip süreleri ortalama 44,8 ±14,6 ay (min 14 , max 74 ay ) idi. Hastaların son takip kreatinin ortalamları 1,48 ± 0,49 mg/dl ( min 0,7, max 3,7 idi ) . Hastaların delta kreatinin ortancaları 0,10 (IQR -0,05 – 0,40 mg/dl idi) . Hastalardan 2 tanesinde (% 4,4) takipte DSA (Donör spesifik antikor) gelişip, antikor aracılı rejeksiyon gelişti. Takip edilen 45 hastanın 5 i ( %11,1) ex olmuş iken 40 hastanın takibi ünitemizde halen devam etmektedir. Ex olan hastaların 3 ü (%60) 65 yaş üzeri, 2 si 65 yaş altındaydı. Yaşlı hastalarda mortalide oranı daha yüksekti ( p

Background: We investigated the efficacy, safety and tolerability of once-monthly administration of C.E.R.A. in erythropoiesis stimulating agents (ESAs) naive predialysis patients with CKD for anemia treatment Study Design: Single arm, open label study. Methods: A total of 75 patients (mean (SD) age was 52.8 (16.4) years, 76.0% were female) were included in this study conducted between 12 August 2008 and 30 October 2009 in 9 centers across Turkey. The mean change in Hb concentration (g/dL) between baseline (week 0) and the efficacy evaluation period (EEP) was the primary efficacy parameter evaluated in three consecutive periods including a dose titration period (DTP; with initial 1.2 μg/kg dose of C.E.R.A., subcutaneously, 28 weeks), EEP (8 weeks) and a long-term safety period (16 weeks). Results: Our analysis revealed an improvement in Hb levels from baseline value of 9.4 (0.4) g/dL to time adjusted average level of 11.4 (0.7) g/dL in EEP in the per protocol (PP) population and from 9.3 (0.5) g/dL to 11.1 (1.0) g/dL in intent-to-treat (ITT) population. Mean (SD) change in Hb levels from baseline to EEP was 2.0 (0.7) g/dl in the PP population (primary endpoint) and 1.7 (1.1) g/dL in the ITT population. The percentage of patients whose Hb concentrations remained within the target range of 10.0-12.0 g/dL throughout the EEP was 43.9% (95% CI: 28.5-60.3%) in the PP population and 38.7% (95% CI: 27.6% to 50.6%) in the ITP population. A total of 206 adverse events (AE) were reported in 77.0% of patients with hypertension (20%) as the most frequent AE. Conclusion: Once-monthly subcutaneous C.E.R.A. administration is effective and safe in the treatment of anemia in pre-dialysis patients with CKD, who are not currently treated with ESAs.

This scoping review prepared by endocrinology and nephrology experts aimed to address the significance of finerenone, as a novel therapeutic option, in diabetic kidney disease (DKD), based on the biological prospect of cardiorenal benefit due to non-steroidal mineralocorticoid receptor antagonist (MRA) properties, and the recent evidence from the finerenone phase 3 program clinical trials. The importance of finerenone in slowing DKD progression was critically reviewed in relation to the role of MR overactivation in the pathogenesis of cardiorenal disease and unmet needs in the current practice patterns. The efficacy and safety outcomes of finerenone phase III study program including FIDELIO-DKD, FIGARO-DKD and FIDELITY were presented. Specifically, perspectives on inclusion of patients with preserved estimated glomerular filtration rate (eGFR) or high albuminuria, concomitant use of sodium-glucose co-transporter-2 inhibitor (SGLT2i) or glucagon-like peptide 1 receptor agonist (GLP-1 RA), baseline glycated hemoglobin (HbA1c) level and insulin treatment, clinically meaningful heart failure outcomes and treatment-induced hyperkalemia were addressed. Finerenone has emerged as a new therapeutic agent that slows DKD progression, reduces albuminuria and risk of cardiovascular complications, regardless of the baseline HbA1c levels and concomitant treatments (SGLT2i, GLP-1 RA, or insulin) and with a favorable benefit-risk profile. The evolving data on the benefit of SGLT2is and non-steroidal MRAs in slowing or reducing cardiorenal risk seem to provide the opportunity to use these pillars of therapy in the management of DKD, after a long-period of treatment scarcity in this field. Along with recognition of the albuminuria as a powerful marker to detect those patients at high risk of cardiorenal disease, these important developments would likely to impact standard-of-care options in the setting of DKD.

Background: We aimed to study the characteristics of peritoneal dialysis (PD) patients with Coronavirus disease-19 (COVID-19), determine the short-term mortality and other medical complications, and delineate the factors associated with COVID-19 outcome. Methods: In this multicenter national study, we included PD patients with confirmed COVID-19 from 27 centers. The baseline demographic, clinical, laboratory, and radiological data and outcomes at the end of the first month were recorded. Results: We enrolled 142 COVID-19 patients (median age:52 years). 58.2% of patients had mild disease at diagnosis. Lung involvement was detected in 60.8% of patients. 83 (58.4%) patients were hospitalized, 31 (21.8%) patients were admitted to intensive care unit and 24 needed mechanical ventilation. 15 (10.5%) patients were switched to hemodialysis and hemodiafiltration was performed for four (2.8%) patients. Persisting pulmonary symptoms (n=27), lower respiratory system infection (n=12), rehospitalization for any reason (n=24), malnutrition (n=6), hypervolemia (n=13), peritonitis (n=7), ultrafiltration failure (n=7) and in PD modality change (n=8) were reported in survivors. 26 patients (18.31%) died in the first month of diagnosis. The non-survivor group was older, comorbidities were more prevalent. Fever, dyspnea, cough, serious-vital disease at presentation, bilateral pulmonary involvement, and pleural effusion were more frequent among non-survivors. Age (OR:1.102; 95%CI: 1.032-1.117; p: 0.004), moderate-severe clinical disease at presentation (OR:26.825; 95%CI: 4.578-157.172; p

Abstract Background We aimed to present the demographic characteristics, clinical presentation, and outcomes of our multicenter cohort of adult KTx recipients with COVID-19. Methods We conducted a multicenter, retrospective study using data of patients hospitalized for COVID-19 collected from 34 centers in Turkey. Demographic characteristics, clinical findings, laboratory parameters (hemogram, CRP, AST, ALT, LDH, and ferritin) at admission and follow-up, and treatment strategies were reviewed. Predictors of poor clinical outcomes were analyzed. The primary outcomes were in-hospital mortality and the need for ICU admission. The secondary outcome was composite in-hospital mortality and/or ICU admission. Results One hundred nine patients (male/female: 63/46, mean age: 48.4 ± 12.4 years) were included in the study. Acute kidney injury (AKI) developed in 46 (42.2%) patients, and 4 (3.7%) of the patients required renal replacement therapy (RRT). A total of 22 (20.2%) patients were admitted in the ICU, and 19 (17.4%) patients required invasive mechanical ventilation. 14 (12.8%) of the patients died. Patients who were admitted in the ICU were significantly older (age over 60 years) (38.1% vs 14.9%, p = 0.016). 23 (21.1%) patients reached to composite outcome and these patients were significantly older (age over 60 years) (39.1% vs. 13.9%; p = 0.004), and had lower serum albumin (3.4 g/dl [2.9–3.8] vs. 3.8 g/dl [3.5–4.1], p = 0.002), higher serum ferritin (679 μg/L [184–2260] vs. 331 μg/L [128–839], p = 0.048), and lower lymphocyte counts (700/μl [460–950] vs. 860 /μl [545–1385], p = 0.018). Multivariable analysis identified presence of ischemic heart disease and initial serum creatinine levels as independent risk factors for mortality, whereas age over 60 years and initial serum creatinine levels were independently associated with ICU admission. On analysis for predicting secondary outcome, age above 60 and initial lymphocyte count were found to be independent variables in multivariable analysis. Conclusion Over the age of 60, ischemic heart disease, lymphopenia, poor graft function were independent risk factors for severe COVID-19 in this patient group. Whereas presence of ischemic heart disease and poor graft function were independently associated with mortality.

Abstract Background Maintenance hemodialysis (MHD) patients are at increased risk for coronavirus disease 2019 (COVID-19). The aim of this study was to describe clinical, laboratory, and radiologic characteristics and determinants of mortality in a large group of MHD patients hospitalized for COVID-19. Methods This multicenter, retrospective, observational study collected data from 47 nephrology clinics in Turkey. Baseline clinical, laboratory and radiological characteristics, and COVID-19 treatments during hospitalization, need for intensive care and mechanical ventilation were recorded. The main study outcome was in-hospital mortality and the determinants were analyzed by Cox regression survival analysis. Results Of 567 MHD patients, 93 (16.3%) patients died, 134 (23.6%) patients admitted to intensive care unit (ICU) and 91 of the ones in ICU (67.9%) needed mechanical ventilation. Patients who died were older (median age, 66 [57–74] vs. 63 [52–71] years, p = 0.019), had more congestive heart failure (34.9% versus 20.7%, p = 0.004) and chronic obstructive pulmonary disease (23.6% versus 12.7%, p = 0.008) compared to the discharged patients. Most patients (89.6%) had radiological manifestations compatible with COVID-19 pulmonary involvement. Median platelet (166 × 103 per mm3 versus 192 × 103 per mm3, p = 0.011) and lymphocyte (800 per mm3 versus 1000 per mm3, p

Endothelial progenitor cells (EPC) are bone marrow derived or tissue-resident cells that play major roles in the maintenance of vascular integrity and repair of endothelial damage. Although EPCs may be capable of directly engrafting and regenerating the endothelium, the most important effects of EPCs seem to be depended on paracrine effects. In recent studies, specific microvesicles and mRNAs have been found to mediate the pro-angiogenic and regenerative effects of EPCs on endothelium. EPC counts have important prognostic implications in cardiovascular diseases (CVD). Uremia and inflammation are associated with lower EPC counts which probably contribute to increased CVD risks in patients with chronic kidney disease. Beneficial effects of the EPC therapies have been shown in studies performed on different models of CVD and kidney diseases such as acute and chronic kidney diseases and glomerulonephritis. However, lack of a clear definition and specific marker of EPCs is the most important problem causing difficulties in interpretation of the results of the studies investigating EPCs.

Abstract Background Hemodialysis (HD) patients have increased risk of cardiovascular disease (CVD). Impaired stem cell health and adipocytokine metabolism may play important roles in the complex pathophysiological mechanisms of CVD in this patient population. We aimed to investigate the relationships between CD133+ cell counts, adipocytokines and parameters of endothelial dysfunction and atherosclerosis in HD patients. Methods In 58 chronic HD patients (male/female:28/30, mean age:58 ± 14 years), serum levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), leptin, adiponectin and resistin were measured by ELISA. Left ventricular mass index (LVMI), carotid intima-media thickness (CIMT), flow-mediated dilatation (FMD) of the brachial artery were measured. CD133+ cells were counted by flow cytometry (BD FACSCalibur-BD Bioscience,CA). Results CD133+ cell counts were inversely associated with FMD (r = −0.39, p = 0.007) and positively correlated with serum resistin (r = 0.45, p

Due to organ shortage and difficulties for availability of cadaveric donors, living donor transplantation is an important choice for having allograft. Live donor surgery is elective and easier to organize prior to starting dialysis thereby permitting preemptive transplantation as compared to cadaveric transplantation. Because of superior results with living kidney transplantation, efforts including the usage of “Medically complex living donors” are made to increase the availability of organs for donation. The term “Complex living donor” is probably preferred for all suboptimal donors where decision-making is a problem due to lack of sound medical data or consensus guidelines. Donors with advanced age, obesity, asymptomatic microhematuria, proteinuria, hypertension, renal stone disease, history of malignancy and with chronic viral infections consist of this complex living donors. This medical complex living donors requires careful evaluation for future renal risk. In this review we would like to present the major issues in the evaluation process of medically complex living kidney donor.

Background. In previous studies, the oral and dental health statuses were compared in hemodialysis (HD) and peritoneal dialysis (PD) patients without taking into account the effect of educational levels on oral health. Hence we aimed to make a comparison of these parameters based upon the subjects educational levels. Patients and Methods. 76 PD (33 males, 43 females-mean age: 44±12 years) and 100 HD (56 males, 44 females-mean age: 46±14 years) patients were included. The number of decayed, missing and filled teeth were detected, DMFT index was calculated and plaque index (PI) values were assessed. Results. Significantly higher numbers of filled teeth (P