Turkiye Klinikleri Journal of Internal Medicine

.: ORIGINAL RESEARCH
The Effects of Socio-Economic Status and Medical Treatments on Mortality in Long Term Peritonal Dialysis Patients: Retrospective Cross-Sectional Research
Sosyoekonomik Durumun ve Tıbbi Tedavinin Uzun Dönemde Periton Diyaliz Hastalarında Mortalite Üzerine Etkisi: Retrospektif Kesitsel Araştırma
Refika BÜBERCİa, Semahat KARAHİSAR ŞİRALİa, Murat DURANAYa
aClinic of Nephrology, Ankara Training and Research Hospital, Ankara, Türkiye
Turkiye Klinikleri J Intern Med. 2023;8(1):25-34
doi: 10.5336/intermed.2022-92907
Article Language: EN
Full Text
ABSTRACT
Objective: Despite technical advances in peritoneal dialysis (PD), mortality rates are still very high. Factors affecting mortality have been the aim of many studies. However, there are not enough studies investigating the effects of socio-economic status (SES) and medical treatments on mortality. The aim of our study is to investigate the long-term effects of SES and medical treatments on mortality in PD patients. Material and Methods: The study included 145 patients. Demographic characteristics, laboratory data, and medical treatments were recorded. Three main variables play a role in the SES indices. These variables are education, income level and occupation. These variables were questioned in PD patients. Cox regression analysis was used to determine the factors affecting mortality. Results: The mean age of the patients was 57.51±15.73 years, and 14% had a low income level. After 3.8±3.6 years of follow-up, 27.6% of the patients had died. The income level was lower, the tendency to infection was higher in the non-survivor group. There was no difference between survivor and non-survivor group in terms of gender, age, marital status, PD duration. Factors affecting mortality were low income [hazard ratio (HR): 2.272, 95% confidence interval (CI): 1.12-4.812, p=0.001], using high peritoneal dialysate glucose concentration solution, and low use of phosphorusbinding drugs and calcitriol (HR: 2.812, 95% CI: 1.160-6.818 and HR: 3.632, 95% CI: 1.665-7.291, p=0.001, respectively). Conclusion: Low income level in PD patients increases mortality by creating a tendency to infections. Lack of volume control and malnutrition are other factors affecting mortality.

Keywords: Hypervolemia; malnutrition; mortality; peritoneal dialysis; socio-economic status
ÖZET
Amaç: Periton diyalizinde teknik gelişmelere rağmen mortalite oranları hâlâ yüksektir. Mortaliteyi etkileyen faktörler birçok çalışmanın amacı olmuştur. Ancak sosyoekonomik düzeylerin (SED) ve tıbbi tedavinin mortalite üzerine etkisi ile ilgili yeteri kadar araştırma yapılmamıştır. Bu çalışmanın amacı, SED ve tıbbi tedavinin uzun dönemde periton diyaliz hastalarında mortalite üzerine etkisini araştırmaktır. Gereç ve Yöntemler: Çalışmaya 145 hasta alındı. Demografik özellikler, tıbbi tedaviler ve laboratuvar verileri kaydedildi. SED endekslerinde 3 ana değişken rol oynamaktadır. Bu değişkenler eğitim, gelir düzeyi ve meslektir. Bu değişkenler, periton diyaliz hastalarında tek tek sorgulandı. Mortaliteyi etkileyen faktörlerin tespiti için Cox regresyon analizinden yararlanıldı. Bulgular: Hastaların yaş ortalaması 57,51±15,73 yıl olup, %14'ü düşük gelir düzeyine sahipti. Hastaların %27,6'sı 3,8±3,6 yıllık takip sonrası öldü. Yaşamayan hasta grubunda gelir düzeyi daha düşük ve enfeksiyona eğilim daha fazlaydı. Yaşayan ve yaşamayan hasta gruplar arasında yaş, cinsiyet, medeni durum ve periton diyaliz süresi açısından anlamlı bir fark yoktu. Mortaliteyi etkileyen faktörler ise düşük gelir düzeyi 'tehlike oranı [hazard ratio (HR)]: 2,272, %95 güven aralığı [confidence interval (CI)]: 1,12-4,812, p=0,001', yüksek glukoz konsantrasyonlu periton diyaliz solüsyonu kullanma, fosfor bağlayıcı ajan ve kalsitriol kullanımının az olmasıydı (sırasıyla HR: 2,812, %95 CI: 1,160-6,818 ve HR: 3,632, %95 CI: 1,665-7,291, p=0,001). Sonuç: Periton diyaliz hastalarında düşük gelir düzeyine sahip olmak, enfeksiyona eğilim yaratarak mortaliteyi etkilemektedir. Volüm durumunu yeteri kadar kontrol altına alamama ve malnütrisyon mortaliteyi etkileyen diğer faktörlerdir.

Anahtar Kelimeler: Hipervolemi; malnütrisyon; mortalite; periton diyalizi; sosyoekonomik düzey
REFERENCES:
  1. United States Renal Data System [Internet]. [Cited: 10 Agust 2022]. 2022 Annual Data Report. Available from: [Link] 
  2. Song MK, Lin FC, Gilet CA, Arnold RM, Bridgman JC, Ward SE. Patient perspectives on informed decision-making surrounding dialysis initiation. Nephrol Dial Transplant. 2013;28(11):2815-23. [Crossref]  [PubMed]  [PMC] 
  3. Grace BS, Clayton P, Cass A, McDonald SP. Socio-economic status and incidence of renal replacement therapy: a registry study of Australian patients. Nephrol Dial Transplant. 2012;27(11):4173-80. [Crossref]  [PubMed] 
  4. Grace BS, Clayton PA, Gray NA, McDonald SP. Socioeconomic differences in the uptake of home dialysis. Clin J Am Soc Nephrol. 2014;9(5):929-35. [Crossref]  [PubMed]  [PMC] 
  5. Ward FL, O'Kelly P, Donohue F, O'Haiseadha C, Haase T, Pratschke J, et al. The influence of socioeconomic status on patient survival on chronic dialysis. Hemodial Int. 2015;19(4):601-8. [Crossref]  [PubMed] 
  6. Plantinga LC. Socio-economic impact in CKD. Nephrol Ther. 2013;9(1):1-7. [Crossref]  [PubMed] 
  7. Vart P, Gansevoort RT, Joosten MM, Bültmann U, Reijneveld SA. Socioeconomic disparities in chronic kidney disease: a systematic review and meta-analysis. Am J Prev Med. 2015;48(5):580-92. [Crossref]  [PubMed] 
  8. Braveman PA, Cubbin C, Egerter S, Chideya S, Marchi KS, Metzler M, et al. Socioeconomic status in health research: one size does not fit all. JAMA. 2005;294(22):2879-88. [Crossref]  [PubMed] 
  9. Shavers VL. Measurement of socioeconomic status in health disparities research. J Natl Med Assoc. 2007;99(9):1013-23. [PubMed]  [PMC] 
  10. Tao S, Zeng X, Liu J, Fu P. Socioeconomic status and mortality among dialysis patients: a systematic review and meta-analysis. Int Urol Nephrol. 2019;51(3):509-18. [Crossref]  [PubMed] 
  11. Sandhu GS, Khattak M, Rout P, Williams ME, Gautam S, Baird B, et al. Social Adaptability Index: application and outcomes in a dialysis population. Nephrol Dial Transplant. 2011;26(8):2667-74. [Crossref]  [PubMed] 
  12. Porche DJ. Poverty and Men's Health. Am J Mens Health. 2007;1(4):241. [Crossref]  [PubMed] 
  13. Ahrenfeldt LJ, Pedersen JK, Thinggaard M, Christensen K, Lindahl-Jacobsen R. Sex differences in health and mortality by income and income changes. J Epidemiol Community Health. 2020;74(3):225-31. [Crossref]  [PubMed]  [PMC] 
  14. Chen X, Mao G, Leng SX. Frailty syndrome: an overview. Clin Interv Aging. 2014;9:433-41. [Crossref]  [PubMed]  [PMC] 
  15. Nitta K, Hanafusa N, Tsuchiya K. Role of frailty on outcomes of dialysis patients. Contrib Nephrol. 2018;195:102-9. [Crossref]  [PubMed] 
  16. Sy J, McCulloch CE, Johansen KL. Depressive symptoms, frailty, and mortality among dialysis patients. Hemodial Int. 2019;23(2):239-46. [Crossref]  [PubMed]  [PMC] 
  17. Kamijo Y, Kanda E, Ishibashi Y, Yoshida M. Sarcopenia and frailty in PD: impact on mortality, malnutrition, and inflammation. Perit Dial Int. 2018;38(6):447-54. [Crossref]  [PubMed] 
  18. Zhang Q, Ma Y, Lin F, Zhao J, Xiong J. Frailty and mortality among patients with chronic kidney disease and end-stage renal disease: a systematic review and meta-analysis. Int Urol Nephrol. 2020;52(2):363-70. [Crossref]  [PubMed] 
  19. Holmes C, Mujais S. Glucose sparing in peritoneal dialysis: implications and metrics. Kidney Int Suppl. 2006;(103):S104-9. [Crossref]  [PubMed] 
  20. Liu J, Rosner MH. Lipid abnormalities associated with end-stage renal disease. Semin Dial. 2006;19(1):32-40. [Crossref]  [PubMed] 
  21. Rasić S, Hadzović-Dzuvo A, Rebić D, Uncanin S, Hadzić A, Mujaković A, et al. The metabolic syndrome in patients on peritoneal dialysis: prevalence and influence on cardiovascular morbidity. Bosn J Basic Med Sci. 2010;10 Suppl 1(Suppl 1):S3-7. [Crossref]  [PubMed]  [PMC] 
  22. Hyun SH, Choi JY, Cho JH, Park SH, Kim CD, Kim YL. Assessment of fluid and nutritional status using multifrequency bioelectrical impedance analysis in peritoneal dialysis patients. Blood Purif. 2014;37(2):152-62. [Crossref]  [PubMed] 
  23. Kim YL, Biesen WV. Fluid Overload in Peritoneal Dialysis Patients. Semin Nephrol. 2017;37(1):43-53. [Crossref]  [PubMed] 
  24. Paniagua R, Ventura MD, Avila-Díaz M, Hinojosa-Heredia H, Méndez-Durán A, Cueto-Manzano A, et al. NT-proBNP, fluid volume overload and dialysis modality are independent predictors of mortality in ESRD patients. Nephrol Dial Transplant. 2010;25(2):551-7. [Crossref]  [PubMed] 
  25. Hogas S, Ardeleanu S, Segall L, Serban DN, Serban IL, Hogas M, et al. Changes in arterial stiffness following dialysis in relation to overhydration and to endothelial function. Int Urol Nephrol. 2012;44(3):897-905. [Crossref]  [PubMed] 
  26. Guo Q, Lin J, Li J, Yi C, Mao H, Yang X, et al. The effect of fluid overload on clinical outcome in southern Chinese patients undergoing continuous ambulatory peritoneal dialysis. Perit Dial Int. 2015;35(7):691-702. [Crossref]  [PubMed]  [PMC] 
  27. Demirci MS, Demirci C, Ozdogan O, Kircelli F, Akcicek F, Basci A, et al. Relations between malnutrition-inflammation-atherosclerosis and volume status. The usefulness of bioimpedance analysis in peritoneal dialysis patients. Nephrol Dial Transplant. 2011;26(5):1708-16. [Crossref]  [PubMed] 
  28. Cheng LT, Tang W, Wang T. Strong association between volume status and nutritional status in peritoneal dialysis patients. Am J Kidney Dis. 2005;45(5):891-902. [Crossref]  [PubMed] 
  29. Konings CJ, Kooman JP, Schonck M, Struijk DG, Gladziwa U, Hoorntje SJ, et al. Fluid status in CAPD patients is related to peritoneal transport and residual renal function: evidence from a longitudinal study. Nephrol Dial Transplant. 2003;18(4):797-803. [Crossref]  [PubMed] 
  30. Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD. Malnutrition-inflammation complex syndrome in dialysis patients: causes and consequences. Am J Kidney Dis. 2003;42(5):864-81. [Crossref]  [PubMed] 
  31. Haarhaus M, Evenepoel P; European Renal Osteodystrophy (EUROD) workgroup; Chronic Kidney Disease Mineral and Bone Disorder (CKD-MBD) working group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA). Differentiating the causes of adynamic bone in advanced chronic kidney disease informs osteoporosis treatment. Kidney Int. 2021;100(3):546-58. [Crossref]  [PubMed] 
  32. Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG, Chertow GM. Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol. 2004;15(8):2208-18. [Crossref]  [PubMed] 
  33. Adragao T, Pires A, Lucas C, Birne R, Magalhaes L, Gonçalves M, et al. A simple vascular calcification score predicts cardiovascular risk in haemodialysis patients. Nephrol Dial Transplant. 2004;19(6):1480-8. [Crossref]  [PubMed] 
  34. Naves-Díaz M, Passlick-Deetjen J, Guinsburg A, Marelli C, Fernández-Martín JL, Rodríguez-Puyol D, et al. Calcium, phosphorus, PTH and death rates in a large sample of dialysis patients from Latin America. The CORES Study. Nephrol Dial Transplant. 2011;26(6):1938-47. [Crossref]  [PubMed] 
  35. Floege J, Kim J, Ireland E, Chazot C, Drueke T, de Francisco A, et al; ARO Investigators. Serum iPTH, calcium and phosphate, and the risk of mortality in a European haemodialysis population. Nephrol Dial Transplant. 2011;26(6):1948-55. [Crossref]  [PubMed]  [PMC] 

.: Up To Date



Login



Contact


Ortadoğu Reklam Tanıtım Yayıncılık Turizm Eğitim İnşaat Sanayi ve Ticaret A.Ş.

.: Address

Turkocagi Caddesi No:30 06520 Balgat / ANKARA
Phone: +90 312 286 56 56
Fax: +90 312 220 04 70
E-mail: info@turkiyeklinikleri.com

.: Manuscript Editing Department

Phone: +90 312 286 56 56/ 2
E-mail: yaziisleri@turkiyeklinikleri.com

.: English Language Redaction

Phone: +90 312 286 56 56/ 145
E-mail: tkyayindestek@turkiyeklinikleri.com

.: Marketing Sales-Project Department

Phone: +90 312 286 56 56/ 142
E-mail: reklam@turkiyeklinikleri.com

.: Subscription and Public Relations Department

Phone: +90 312 286 56 56/ 118
E-mail: abone@turkiyeklinikleri.com

.: Customer Services

Phone: +90 312 286 56 56/ 118
E-mail: satisdestek@turkiyeklinikleri.com

1. TERMS OF USE

1.1. To use the web pages with http://www.turkiyeklinikleri.com domain name or the websites reached through the sub domain names attached to the domain name (They will be collectively referred as "SITE"), please read the conditions below. If you do not accept these terms, please cease to use the "SITE." "SITE" owner reserves the right to change the information on the website, forms, contents, the "SITE," "SITE" terms of use anytime they want.

1.2. The owner of the "SITE" is Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. (From now on it is going to be referred as "Turkiye Klinikleri", shortly) and it resides at Turkocagi cad. No:30, 06520 Balgat Ankara. The services in the "SITE" are provided by "Turkiye Klinikleri."

1.3. Anyone accessing the "SITE" with or without a fee whether they are a natural person or a legal identity is considered to agree these terms of use. In this contract hereby, "Turkiye Klinikleri" may change the stated terms anytime. These changes will be published in the "SITE" periodically and they will be valid when they are published. Any natural person or legal identity benefiting from and reaching to the "SITE" are considered to be agreed to any change on hereby contract terms done by "Turkiye Klinikleri."

1.4. The "Terms of Use" hereby is published in the website with the last change on March 30th 2014 and the "SITE" is activated by enabling the access to everyone. The "Terms of Use" hereby is also a part of the any "USER Contract" was and/or will be done with the users using "Turkiye Klinikleri" services with or without a fee an inseparable.

2. DEFINITIONS

2.1. "SITE": A website offering different kind of services and context with a certain frame determined by "Turkiye Klinikleri" and it is accessible on-line on http://www.turkiyeklinikleri.com domain name and/or subdomains connected to the domain name.

2.2. USER: A natural person or a legal identity accessing to the "SITE" through online settings.

2.3. LINK: A link enabling to access to another website through the "SITE", the files, the context or through another website to the "SITE", the files and the context.

2.4. CONTEXT: Any visual, literary and auditory images published in the "Turkiye Klinikleri", "SITE" and/or any website or any accessible information, file, picture, number/figures, price, etc.

2.5. "USER CONTRACT": An electronically signed contract between a natural or a legal identity benefiting from special services "Turkiye Klinikleri" will provide and "Turkiye Klinikleri".

3. SCOPE OF THE SERVICES

3.1. "Turkiye Klinikleri" is completely free to determine the scope and quality of the services via the "SITE".

3.2. To benefit the services of "Turkiye Klinikleri" "SITE", the "USER" must deliver the features that will be specified by "Turkiye Klinikleri". "Turkiye Klinikleri" may change this necessity any time single-sided.

3.3. Not for a limited number, the services "Turkiye Klinikleri" will provide through the "SITE" for a certain price or for free are;

- Providing scientific articles, books and informative publications for health industry.

- Providing structural, statistical and editorial support to article preparation stage for scientific journals.

4. GENERAL PROVISIONS

4.1. "Turkiye Klinikleri" is completely free to determine which of the services and contents provided in the "SITE" will be charged.

4.2. People benefiting from the services provided by "Turkiye Klinikleri" and using the website can use the "SITE" only according to the law and only for personal reasons. Users have the criminal and civil liability for every process and action they take in the "SITE". Every USER agrees, declares and undertakes that they will not proceed by any function or action infringement of rights of "Turkiye Klinikleri"s and/or other third parties', they are the exclusive right holder on usage, processing, storage, made public and revealing any written, visual or auditory information reported to Turkiye Klinikleri" and/or "SITE" to the third parties. "USER" agrees and undertakes that s/he will not duplicate, copy, distribute, process, the pictures, text, visual and auditory images, video clips, files, databases, catalogs and lists within the "SITE", s/he will not be using these actions or with other ways to compete with "Turkiye Klinikleri", directly or indirectly.

4.3. The services provided and the context published within the "SITE" by third parties is not under the responsibility of "Turkiye Klinikleri", institutions collaborated with "Turkiye Klinikleri", "Turkiye Klinikleri" employee and directors, "Turkiye Klinikleri" authorized salespeople. Commitment to accuracy and legality of the published information, context, visual and auditory images provided by any third party are under the full responsibility of the third party. "Turkiye Klinikleri" does not promise and guarantee the safety, accuracy and legality of the services and context provided by a third party.

4.4. "USER"s cannot act against "Turkiye Klinikleri", other "USER"s and third parties by using the "SITE". "Turkiye Klinikleri" has no direct and/or indirect responsibility for any damage a third party suffered or will suffer regarding "USER"s actions on the "SITE" against the rules of the hereby "Terms of Use" and the law.

4.5. "USER"s accept and undertake that the information and context they provided to the "SITE" are accurate and legal. "Turkiye Klinikleri" is not liable and responsible for promising and guaranteeing the verification of the information and context transmitted to "Turkiye Klinikleri" by the "USER"s, or uploaded, changed and provided through the "SITE" by them and whether these information are safe, accurate and legal.

4.6. "USER"s agree and undertake that they will not perform any action leading to unfair competition, weakening the personal and commercial credit of "Turkiye Klinikleri" and a third party,  encroaching and attacking on personal rights within the "SITE" in accordance with the Turkish Commercial Code Law.

4.7. "Turkiye Klinikleri" reserves the right to change the services and the context within the "SITE"  anytime. "Turkiye Klinikleri" may use this right without any notification and timelessly. "USER"s have to make the changes and/or corrections "Turkiye Klinikleri" required immediately. Any changes and/or corrections that are required by "Turkiye Klinikleri", may be made by "Turkiye Klinikleri" when needed. Any harm, criminal and civil liability resulted or will result from changes and/or corrections required by "Turkiye Klinikleri" and were not made on time by the "USER"s belongs completely to the users.

4.8. "Turkiye Klinikleri" may give links through the "SITE" to other websites and/or "CONTEXT"s and/or folders that are outside of their control and owned and run by third parties. These links are provided for ease of reference only and do not hold qualification for support the respective web SITE or the admin or declaration or guarantee for the information inside. "Turkiye Klinikleri" does not hold any responsibility over the web-sites connected through the links on the "SITE", folders and context, the services or products on the websites provided through these links or their context.

4.9. "Turkiye Klinikleri" may use the information provided to them by the "USERS" through the "SITE" in line with the terms of the "PRIVACY POLICY" and "USER CONTRACT". It may process the information or classify and save them on a database. "Turkiye Klinikleri" may also use the USER's or visitor's identity, address, e-mail address, phone number, IP number, which sections of the "SITE" they visited, domain type, browser type, date and time information to provide statistical evaluation and customized services.

5. PROPRIETARY RIGHTS

5.1. The information accessed through this "SITE" or provided by the users legally and all the elements (including but not limited to design, text, image, html code and other codes) of the "SITE" (all of them will be called as studies tied to "Turkiye Klinikleri"s copyrights) belongs to "Turkiye Klinikleri". Users do not have the right to resell, process, share, distribute, display or give someone permission to access or to use the "Turkiye Klinikleri" services, "Turkiye Klinikleri" information and the products under copyright protection by "Turkiye Klinikleri". Within hereby "Terms of Use" unless explicitly permitted by "Turkiye Klinikleri" nobody can reproduce, process, distribute or produce or prepare any study from those under "Turkiye Klinikleri" copyright protection.

5.2. Within hereby "Terms of Use", "Turkiye Klinikleri" reserves the rights for "Turkiye Klinikleri" services, "Turkiye Klinikleri" information, the products associated with "Turkiye Klinikleri" copyrights, "Turkiye Klinikleri" trademarks, "Turkiye Klinikleri" trade looks or its all rights for other entity and information it has through this website unless it is explicitly authorized by "Turkiye Klinikleri".

6. CHANGES IN THE TERMS OF USE

"Turkiye Klinikleri" in its sole discretion may change the hereby "Terms of Use" anytime announcing within the "SITE". The changed terms of the hereby "Terms of Use" will become valid when they are announced. Hereby "Terms of Use" cannot be changed by unilateral declarations of users.

7. FORCE MAJEURE

"Turkiye Klinikleri" is not responsible for executing late or never of this hereby "Terms of Use", privacy policy and "USER Contract" in any situation legally taken into account as force majeure. Being late or failure of performance or non-defaulting of this and similar cases like this will not be the case from the viewpoint of "Turkiye Klinikleri", and "Turkiye Klinikleri" will not have any damage liability for these situations. "Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. Also, force majeure situations include but not limited to natural disasters, rebellion, war, strike, communication problems, infrastructure and internet failure, power cut and bad weather conditions.

8. LAW AND AUTHORISATION TO FOLLOW

Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com