Aim: Familial Mediterranean Fever (FMF) is a recurrent, self-limiting autosomal recessive disease. It is characterized by fever, peritonitis, pleuritis, arthritis, and erysipelas-like erythema. Mutations in the MEFV gene alter the structure of the pyrin protein, leading to the clinical manifestation of the disease. In our study, we aimed to evaluate the prevalence and clinical findings of MEFV gene mutations in the Marmara region

Material and Methods: Mutations in the MEFV gene were identified in 482 patients through DNA sequence analysis in a retrospective study.

Results: The most frequently detected mutation was the R202Q heterozygous mutation (135 patients, 25%). Other mutations were detected at the following frequencies: E148Q in 28% (135 patients), M680I in 2.48% (12 patients), R761H in 1.86% (9 patients), and M694V in 1.86% (9 patients). The most frequently detected homozygous mutation, however, was R202Q (22 patients, 4,56%).

Discussion: Here, we present the distribution of MEFV mutations and the frequency of clinical findings in 482 patients residing in Kocaeli province who were first diagnosed with FMF. The most frequently detected mutation in our study, R202Q, may be a contributing cause of the disease in FMF patients.

Keywords: Mefv Mutations, Fmf, R202q

Introduction

Familial Mediterranean Fever (FMF) is a genetic disorder inherited in an autosomal recessive manner (OMIM:249100). It is caused by mutations in the MEFV gene (OMIM:608107) located on chromosome 16p13. The FMF is characterized by acute recurrent self-limiting episodes of fever, peritonitis, pleuritis, arthritis, and erysipelas-like erythema. Despite its prevalence in the Mediterranean region, FMF is also frequently observed among Turkish, Armenian, Arab, and Jewish communities. The Tel-Hashomer criteria, recommended by Livneh, are used for diagnosing FMF[1- 4].
FMF primarily manifests as abdominal pain; fever and arthritis are also frequent symptoms [5]. FMF may be misdiagnosed due to nonspecific clinical and laboratory manifestations; for example, sometimes it can mimic the symptoms of appendicitis. During FMF attacks, erythrocyte sedimentation rate (ESR), C-reactive protein, fibrinogen, and serum amyloid A (SAA) values often increase. Elevated SAA levels can lead to renal amyloidosis and chronic renal failure as long-term complications. Colchicine is used in treatment to prevent FMF attacks and to protect patients from long-term side effects [6].
To date, about 385 MEFV variants have been listed as mutations and polymorphisms in the Infevers database (https ://infevers.umai-montpellier.fr). Pathogenic mutations that cause FMF are generally located in exons 2, 3, 5, and 10. The most prevalent FMF-causing mutations identified in the population include M694V, M680I, V726A, M694I on exon 10, and E148Q on exon 2 [7, 8]. The MEFV gene exhibits other variants like A744S, R761H, I692del, E167D, and T267I. Additionally, there are five variants, namely K695R, E148Q, P369S, F479L, and I591T, which are classified as having unknown significance. The M694V mutation is the most common and pathogenic mutation in the Mediterranean region. Individuals with the M694V homozygous mutation exhibit symptoms that begin at an earlier age and are more severe. In addition, they are more prone to developing arthritis and amyloidosis [9, 10].
Due to the immigration from different parts of the country, the Marmara region has a diverse social structure. However, we believe that the number of FMF patients and their proportion within the population are high. In this study, we examined the MEFV gene mutation profile and its corresponding clinical findings.

Material and Methods

A retrospective analysis was conducted on 480 patients who presented to the Department of Medical Genetics at Kocaeli Derince Training and Research Hospital between 2016 and 2019 with a preliminary diagnosis of FMF. The MEFV gene mutation results and clinical findings of the patients were examined.
DNA isolation was performed according to the manufacturer’s instructions (QIAamp DNA blood Maxi kit, Qiagen, Hilden, Germany). MEFV exons 2, 3, 5, and 10 were examined using DNA sequencing analysis . Separate PCR was performed for each exon, and nucleotide changes were detected using the Applied Biosystems 3500 Series (Thermo Fisher Scientific).
The study was conducted retrospectively, informed consent was not obtained from the participants.

Ethical Approval

This study was approved by the Ethics Committee of Kocaeli Derince Training and Research Hospital Ethical Board (Date: 2019-03-09, No: 2019/39).

Results

The study included a total of 482 patients, with 272 being female (56.4%) and 210 being male (43.6%), aged between 1 and 81 years. The mean age of patients was 24.41 ± 17.95 years. Of the 482 patients, 216 (44.8%) were in the pediatric group (<18 years) and 266 (55.2%) were in the adult group (≥18 years). The most common complaint in 70% of the study population was abdominal pain. Arthritis was reported as the second most common complaint, with a rate of 63.3%. The most common symptoms reported by the patients included fever in 50.8%, constipation in 29%, chest pain in 20%, gastroenteritis in 19%, erysipelas-like erythema in 9.5%, operated appendicitis in 8.5%, oral aphthosis in 8%, chronic renal failure (CRF) in 4%, pericarditis in 2%, and nausea in 1.2% .
MEFV mutation results detected in patients are classified in Table 1. Out of 482 patients, 6.19% (30 patients) were found to have a homozygous mutation, 46.5% (225 patients) had a heterozygous mutation, 29.5% (141 patients) had a compound heterozygous mutation, and 16.83% (82 patients) had a complex allele mutation.
The frequency of MEFV mutation is presented in Table 1,2 and 3. The most frequently detected mutation was the R202Q heterozygous mutation (135 patients, 25%). The frequencies of other detected mutations were as follows: E148Q in 28% (135 patients), M680I in 2.48% (12 patients), R761H in 1.86% (9 patients), and M694V in 1.86% (9 patients). However, the most frequently detected homozygous mutation was determined to be R202Q (22 patients, 4.56%). The frequencies of other homozygous mutations detected were as follows: V726A (4 patients, 4.56%), M680I (2 patients, 0.41%), M694V (1 patient, 0.2%), and E148Q (1 patient, 0.2%).
M694V/R202Q, the most common compound heterozygous allele, was observed in 19.29% of 93 patients. Other frequently detected compound heterozygous mutations were R202Q/V726A (8 patients, 1.65%), R202Q/E148Q (7 patients, 1.45%), V726A/M680I (5 patients, 1.03%), and P369S/R408Q (4 patients, 0.82%).
The most common complex allele is M694V heterozygous/R202Q homozygous, found in 2.68% (23 patients). Other identified complex alleles were M694V heterozygous/R202Q heterozygous/E148Q heterozygous (10 patients, 2.07%), M694V homozygous/R202Q homozygous (10 patients, 2.07%), M694V heterozygous/R202Q heterozygous/V726A heterozygous (9 patients, 1.86%), and M694V heterozygous/R202Q heterozygous/M680I heterozygous (8 patients, 1.65%).

Discussion

FMF is the most common autoinflammatory disease, clinically characterized by self-limiting inflammatory attacks. MEFV mutations primarily affect people in the Mediterranean region, particularly Arabs, Armenians, Turks, and Jews. According to the studies conducted in Turkey, the prevalence of FMF disease is 1:1000, and the carrier frequency is much higher, at a rate of 1:3 to 1:10. Studies have reported that FMF is commonly observed in the Turkish population worldwide [1- 3].
MEFV gene variant analyses are frequently used in daily practice to support clinical diagnosis. Around 20-30% of individuals with FMF have either no variant or only one variant in the MEFV gene [9, 11]. The most common mutations in Turkey are M694V, M680I, V726A, and E148Q, which are also prevalent among Arabs, Armenians, and Jews. The predominant mutations among Arabs are V726A, M680I, and M694V. While in Armenians, they are M694V, M680I, and V726A. In Egypt, the prevalent mutations are E148Q, M694I, and V726A. However, M694V and E148Q are more common among North African Jews, and E148Q, V726A are more common among Ashkenazi Jews [1, 2, 12, 13]. In a large study conducted on Turkish society, Dundar et al. identified 88 different variants in 27,504 patients; the most frequently detected variants were M694V (29.47%), E148Q (18.27%), R202Q (17.90%), M680I (10.61%), and V726A (10.14%) [8]. Bilge et al. reported in their study, which included 1,719 patients, that the most frequently detected variants were M694V (44.5%), M680I (12.3%), V726A (9.2%), and E148Q (1%) [14].
Nevertheless, in some studies, the frequency of detected variants varies significantly. In a study conducted on the Turkish population, Arpacı et al. reported that the most frequently observed variants in the analysis of 2,639 patients were R202Q (19.55%), E148Q (7.05%), M694V (6.51%), V726A (2.61%), and M680I (2%) [7]. In a study conducted by Celep et al., the most frequently detected variant was reported to be R202Q (50.1%) [16]. Similarly, in our study, the most frequently detected mutation was the R202Q heterozygous mutation (135 patients, 25%). However, the most frequently detected homozygous mutation was R202Q (22 patients, 4.56%).
The most common symptoms of FMF are abdominal pain, fever, arthritis, arthralgia, and erysipelas-like erythema. In their study involving 2838 FMF patients, Tunca et al. evaluated the clinical findings and reported that the most common clinical finding was abdominal pain [1]. In their investigation, Kalem et al. reported that the most prevalent symptom was abdominal pain, followed by fever [16]. In our study, the most common complaint in 70% of the patients was abdominal pain. Arthritis was the second most prevalent complaint, with a prevalence of 63.3%. Fever was observed in in 50.8% of our patients.

Conclusion

R202Q, which we still report as a polymorphism in our findings, is frequently detected in patients with FMF clinical symptoms. Similar to many other studies, the present study found that the R202Q variant was most frequently detected in patients diagnosed with FMF. To further understand the clinical impact of the R202Q variant, it must be evaluated in larger patient populations.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and Human Rights Statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.

Funding: None

Conflict of Interest

The authors declare that there is no conflict of interest.

References

1. Tunca M, Akar S, Onen F, Ozdogan H, Kasapcopur O, Yalcinkaya F, et al. Familial Mediterranean fever (FMF) in Turkey: results of a nationwide multicenter study. Medicine (Baltimore). 2005;84(1):1–11.
2. Yilmaz E, Ozen S, Balci B, Duzova A, Topaloglu R, Besbas N, et al. Mutation frequency of Familial Mediterranean Fever and evidence for a high carrier rate in the Turkish population. Eur J Hum Genet. 2001;9(7):553-5.
3. Ben-Chetrit E, Touitou I. Familial Mediterranean fever in the world. Arthritis Rheum. 2009;61(10):1447-53.
4. Kilic A, Varkal MA, Durmus MS, Yildiz I, Yıldırım ZNY, Oguz F, et al. Relationship between clinical findings and genetic mutations in patients with familial Mediterranean fever. Pediatr Rheumatol. 2015;13(2015):59.
5. Barut K, Sahin S, Adrovic A, Sinoplu AD, Yucel G, Pamuk G, et al. Familial Mediterranean fever in childhood: a single‑center experience. Rheumatol Int. 2018;38(1):67–74.
6. Lachmann H, Sengul B, Yavuzsen T, Booth D, Booth S, Bybee A, et al. Clinical and subclinical inflammation in patients with familial Mediterranean fever and in heterozygous carriers of MEFV mutations. Rheumatology (Oxford). 2006;45(6):746-50.
7. Arpacı A, Serdar Doğan S, Erdoğan HF, El Ç, Cura SE. Presentation of a new mutation in FMF and evaluating the frequency of distribution of the MEFV gene mutation in our region with clinical findings. Mol Biol Rep. 2021;48(3):2025–2033.
8. Dundar M, Fahrioglu U, Yildiz SH, Gungor B, Temel SG, Akın H, et al. Clinical and molecular evaluation of MEFV gene variants in the Turkish population: A study by the National Genetics Consortium. Funct Integr Genomics. 2022;22(3):291–315.
9. Ozdogan H, Ugurlu S. Familial Mediterranean fever. Presse Med. 2019(1 Pt 2);48: e61–e76.
10. Ozen S, Batu ED. The myths we believed in familial mediterranean fever: what have we learned in the past years? Semin Immunopathol. 2015;37(4):363–9.
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13. Mansour AR, El-Shayeb A, El Habachi N, Khodair MA, Elwazzan D, Abdeen N, et al. Molecular patterns of MEFV gene mutations in Egyptian patients with Familial Mediterranean Fever: a retrospective cohort study. Int J Inflam. 2019;2019:2578760.
14. Bilge NŞY, Sarı I, Solmaz D, Şenel S, Emmungil H, Kılıc L, et al. The distribution of MEFV mutations in Turkish FMF patients: multicenter study representing results of Anatolia. Turk J Med Sci. 2019;49(2):472-477.
15. Celep G, Durmaz ZH , Erdogan Y, Akpinar S, Kaya SA, Guckan R. The Spectrum of MEFV Gene Mutations and Genotypes in the Middle Northern Region of Turkey. Eurasian J Med. 2019;51(3):252-6.
16. Kalem H, Tetik BK, Tabel Y, Selçuk EB, Elmas AT. Evaluation of Genotypic and Phenotypic Characteristics of Children with Familial Mediterranean Fever in Eastern Turkey. Turk J Nephrol. 2019;28(1):68-74.

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Nejmiye Akkus, Yelda Dagcıoglu. MEFV Gene Mutation Frequency And Clinical Findings: A Single Center Experience. Ann Clin Anal Med 2024;15(10):690-693

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Aim: Hemodialysis (HD) patients may experience many symptoms, such as fatigue, muscle cramps, headaches, and decreased sexual desire, with the severity of these symptoms varying individually. This study aimed to evaluate the frequency and severity of symptoms in HD patients using the dialysis symptom index (DSI), which provides an assessment of non-fatal physical and emotional symptoms that negatively affect quality of life.

Material and Methods: Patients aged 18 years and over who received hemodialysis treatment for at least three months at the hemodialysis unit of Giresun Training and Research Hospital, who agreed to participate in the study and signed the consent form, and who were conscious and had no communication problems were included in the study. Data were collected using a face-to-face interview method and the Dialysis Symptom Index.

Results: Of the 97 patients included in the study, 53 were male, 44 were female, and the mean age was 58 years. There was a statistically significant difference in DSI scores between male and female patients. Female patients complained of physical and emotional symptoms more often than male patients. The most common and most severe symptom described by the patients, according to DSI, was feeling tired/decreased energy (90.7%) and decreased interest in sexual intercourse (92.8%). More than half of the patients in the study complained of muscle cramps (62.9%), numbness and tingling in the feet (54.6%), feeling sad (73.2%) and dry skin (72.2%).

Discussion: Symptoms of patients receiving HD treatment should be monitored at regular intervals, and the awareness of health professionals providing care to this patient group should be increased.

Keywords: Hemodialysis, Dialysis Symptom Index, Physical and Emotional Symptoms

Introduction

Chronic renal failure (CRF) is a significant health problem with increasing prevalence worldwide, including in Turkey. According to the 2022 reports of the Turkish Society of Nephrology, there are a total of 13,725 patients receiving renal replacement therapy for end-stage renal failure (ESRF) in Turkey, and 10,287 of these patients receive hemodialysis (HD) treatment [1]. The mortality rate in the HD patient population is as high as 24% per year and which is higher than that of many cancers [2]. The growing population of dialysis patients has increased interest in improving palliative care.
Many symptoms, such as fatigue, muscle cramps, headaches, and decreased sexual desire, may occur in HD patients, and the severity of these symptoms varies individually. Although the physical and emotional symptoms in this population are similar to those of many cancer patients, they are not as well recognized in cancer patients [3]. The aging of hemodialysis patients in the last decade has also changed the symptom profile of this patient group [4]. Healthcare professionals are often unaware of many symptoms experienced by HD patients. Inadequate understanding of symptoms leads to insufficient treatment [2, 5]. The use of tools such as the Dialysis Symptom Index (DSI), which enables the evaluation of non-fatal physical and emotional symptoms that negatively affect the quality of life in HD patients, can increase awareness and improve palliative care.
This study was conducted to determine the most common and most distressing physical and emotional symptoms in patients receiving HD treatment in our unit and to determine whether any biochemical and demographic factors affect these symptoms.

Material and Methods

Patients aged 18 years and over who received hemodialysis treatment for at least three months in the Hemodialysis Unit of Giresun Training and Research Hospital, who agreed to participate in the study, signed the consent form, were conscious and did not have any communication problems were included in the study. A total of 97 patients who met these criteria were interviewed by the researcher during the dialysis session and completed the DSI form, which consists of 30 items. Responses were obtained using a 5-point Likert scale. Symptoms experienced in the last week were recorded as ‘0 = none, 1 = a little, 2 = sometimes, 3 = very little, 4 = very much’. Demographic data and biochemical parameters were recorded from patient files.

Statistical Analysis

Excel 2013 (Microsoft, WA, USA), XLSTAT 2021 (Addinsoft, New York, USA), and GraphPad Prism 9.0.1 (GraphPad Software, San Diego, CA) were used for statistical analysis. The conformity of continuous variables to a normal distribution was investigated using Shapiro-Wilk tests. Gaussian variables were expressed as mean ± standard deviation (SD), and non-gaussian variables were expressed as median (25th percentile – 75th percentile).

Ethical Approval

This study was approved by the Ordu University Clinical Research Ethics Committee (Date: 2022-02-25, No: 44).

Results

Of the 97 patients included in the study, 53 were male and 44 were female, with a mean age of 58 years. Approximately 30% of the patients had coronary artery disease (CAD), and 19% had cerebrovascular disease (CVD) as comorbidities. Fifty-three percent of the patients were smokers, and 37% were alcohol users. The mean Dialysis Symptom Index (DSI) score was 31.8 ± 12.8. There was a statistically significant difference in DSI scores between male and female patients. Female patients complained of physical and emotional symptoms more than male patients (29.2 ± 11.5 vs. 35.0 ± 13.7, p = 0.026, respectively). Patients with CAD had statistically significantly higher DSI scores than those without CAD (35.9±12.4, 29.7±12.7, p= 0.030, respectively). Although the DSI scores of hemodialysis patients with LVH were higher, the difference was not statistically significant (34.1 ± 14.0 vs. 31.0 ± 12.7, p = 0.396, respectively). Clinical and demographic data of the patients included in the study are presented in Table 1. The most common and most severe symptoms described by patients according to the DSI was feeling tired/decreased energy (90.7%) and decreased interest in sexual intercourse (92.8%). More than half of the patients in the study complained of muscle cramps (62.9%), numbness and tingling in the feet (54.6%), feeling sad (73.2%), and dry skin (72.2%). The distribution of symptoms experienced by the patients according to the DSI is presented in Table 2. The mean hemoglobin and albumin levels were 11.6 ± 2.0 g/dL and 38.9 ± 4.3 g/L, respectively. The mean calcium, inorganic phosphate, and magnesium levels were 8.4 ± 0.65, 4.41 ± 1.11, and 2.34 ± 0.37 mg/dL, respectively. The mean levels of C-reactive protein (CRP), one of the inflammatory markers, were 5.97 (2.33-14.25) mg/dL, and ferritin levels were 826 (476-1276) ng/dL. When vitamin levels were analyzed, the folate level was 4.28 (3.07-6.99) µg/L and vitamin b12 level was 402 (331-569) ng/L. The biochemical data of the study group are presented in Table 3.

Discussion

End-stage renal failure causes many symptoms, most notably cardiovascular disease, and is accompanied by various comorbidities, including the psychological impact of undergoing hemodialysis three times a week. Developments such as the increase in the dialysis patient population, the aging of this population, and increased use of erythroid stimulating agents (ESAs) in treatment will ensure that the physical and emotional symptoms of this patient group are more recognized, and their care is improved by using the DSI [2].
In this study, the most severe and frequent symptoms experienced by HD patients were fatigue/decreased energy (90.7%) and decreased interest in sexual intercourse (92.8%). Similar to our study, Yurtsever S. et al. found that the rate of experiencing fatigue in HD patients was 92.5% [6]. In another study by Steven D et al., fatigue/decrease energy was found in 69% of HD patients [5]. Decreased interest in sexual intercourse, one of the most common and most severe symptoms experienced by HD patients, was found at a very high rate of 92.8% in our study. Decreased interest in sexual intercourse in HD patients was found to be 23.5% in the study by Mi-Kyoung et al. and 36% in the study by Steven D. et al., with frequencies quite different from our study [3, 7]. It is known that sexual desire is largely related to age. The difference in results between studies might be related to age, gender, and cultural differences.
In our study, feeling sad was found to be among the most frequent and severe symptoms experienced by patients, with a high rate of 73.2%. In other studies, conducted in HD patients, 20%-42.8% of patients reported feeling sad [3, 5, 7]. In our study, skin dryness was described by 72.2% of the patients, whereas it was found to be 72% in the study by Steven D. et al. and 63% in the study by Mi-Kyoung et al. [5, 7]. Although the pathophysiology of muscle cramps in HD patients is not fully understood, it has been reported that 33-78% of patients receiving dialysis treatment complain of muscle cramps [8, 9, 10]. In our study, muscle cramps were among the most common and severe symptoms experienced by patients (62.9%). Muscle cramps are encountered more frequently in patients with high interdialytic weight gain and significant fluid withdrawal during dialysis. Since this may vary depending on individual factors such as fluid intake habits and dietary non-compliance, we believe that differences between these studies may be due to these factors. Feeling anxious was recorded as one of the symptoms experienced frequently and severely experienced by 69.1% of the patients. In the study by Mi-Kyoung et al., 59.6% of the patients reported feeling anxious, whereas in another study conducted in HD patients, this rate was recorded at 28% [5, 7]. In our study, more than half of the patients reported numbness or tingling in the feet, dry mouth, irritability, and difficulty falling asleep.
When the demographic data of the patients who participated in the study were evaluated, a statistically significant difference was found in DSI scores between male and female patients. Women receiving HD treatment experience physical and emotional symptoms more frequently and more severely than men (35.0 ± 13.7, 29.2 ± 11.5, p = 0.026, respectively). Similar to our study, other studies conducted in HD patients have also shown that women experience more frequent and severe symptoms than men [11]. We believe that this might be attributed to the fact that women continue their duties in social life and are less likely to receive social support compared to men.
Studies have shown that the symptoms of chronic dialysis patients are more stable than those of oncology patients [12]. A group of multiple related symptoms is referred to as a symptom cluster. Various studies have shown that many simultaneous symptoms occur in clusters in chronic diseases. Although there are differences in symptom clusters across studies, emotional, uremic, skin, and gastrointestinal symptom clusters are the most widely accepted classifications in the HD patient group. Although symptom clusters are more stable in dialysis patients, there is still variability. Similar to the study by Marques Shek Nam et al., in our study found that fatigue/lack of energy, numbness or tingling sensation in the feet, and muscle cramps symptoms included in the uremic symptom cluster, were the most common symptoms. Similarly, decreased interest in sexual desire in the gastrointestinal symptom cluster, feeling sad in the emotional symptom cluster, and dry skin in the skin symptom cluster were identified as the most commonly suffered symptoms [13]. Emotional symptoms, which are known to be common in dialysis patients, have been reported to be present in one out of every three patients. Psychological symptoms were evaluated in two studies on symptom clusters [14, 15]. Psychological symptoms in HD patients, as in other individuals in society, can lead to negative impacts in daily life. Evaluating emotional symptoms and referring patients to the appropriate specialist is expected to contribute to their well-being.
The presence of comorbid diseases in the majority of HD patients is well known. In our study, a statistically significant difference was found between the frequency and severity of symptoms in HD patients with and without coronary artery disease (CAD) (35.9 ± 12.4 vs. 29.7 ± 12.7, p = 0.030, respectively). This was thought to be due to the increased incidence of symptoms, such as hypotension and dizziness, in patients with CAD as maintaining hemodynamic stability during dialysis is more challenging in these patients. Although DSI scores were higher in patients with cerebrovascular disease (CVD) compared to those without CVD, they did not reach statistical significance (34.1 ± 14.0 vs. 31.0 p = 0.396).

Conclusion

In our study, we found that the most common and severe symptoms experienced by HD patients were fatigue/decreased energy and decreased interest in sexual intercourse. Physical symptoms such as muscle cramps, dry mouth, and dry skin, and emotional symptoms such as anxiety and sadness, were experienced by more than half of the patients. The symptom burden of this patient group can be determined by using the validated DSI to identify the non-fatal symptoms of HD patients. This approach has the potential to improve the quality of life for patients by increasing the awareness of healthcare professionals serving HD patients.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and Human Rights Statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.

Funding: None

Conflict of Interest

The authors declare that there is no conflict of interest.

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Ozdem Kavraz Tomar, Tülin Akagün, Murat Usta, Süleyman Baylan. Assessment of symptom frequency and severity in hemodialysis patients using the dialysis symptom index (DSI); A single center experience. Ann Clin Anal Med 2024;15(10):708-712

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