it is associated with peptic ulcer disease ( pud ) , gastric / duodenal erosions , gastric adenocarcinoma , and gastric lymphoma both in healthy population and patients with uremia . 
 

studies have shown that pud is more prevalent in h.pylori positive hemodialysis patients than the general population .
furthermore , these patients are more prone to gastrointestinal bleeding , partially because of the fragility of gastric mucosa and inevitable use of anticoagulant therapy during hemodialysis .
therefore , h.pylori treatment is an important issue in this group of patients . 
 
 on the other hand , patients with uremia , especially those with end - stage renal disease ( esrd ) have some degrees of immune system dysfunction .
consequently , the eradication of h.pylori may be more difficult in such patients , because antibiotic resistance is the most common cause of failure to eradicate h.pylori . 
 

hybrid regimen is a novel treatment including a proton pump inhibitor ( ppi ) + amoxicillin during the first 7 days , followed by quadruple regimen of a ppi + amoxicillin + clarithromycin + metronidazole / tinidazole for the second 7 days .
also , a recent review article considering h.pylori eradication regimens in west asia has reported hybrid regimen as an ideal regimen for first line h.pylori therapy in this geographic region . however , to the best of our knowledge , no study has assessed the effects of hybrid regimen for h.pylori eradication in patients with uremia .
therefore , we designed a study to compare the effects of hybrid therapy with standard triple therapy in hemodialysis patients . 


 from december 2013 to january 2014 , forty hemodialysis patients with nave h.pylori infection entered the study .
h.pylori infection had been confirmed by both rapid urease test ( rut , shim anzy , tehran , iran ) and fecal h.pylori antigen test ( dahelwit 93 , germany ) .
the reasons for gastrointestinal evaluation were long - standing dyspepsia , iron deficiency anemia , or being candidate for renal transplantation . before starting the protocol ,
the exclusion criteria were age less than 18 years or above 85 years , any chronic disease that would hinder follow - up ( such as liver failure , heart failure , chronic pulmonary disease , or history of malignancy ) , history of allergic reactions to any of the medications used in this study , history of gastric or esophageal surgery , using antibiotics during the previous week , pregnancy , or breastfeeding . 
 

twenty patients received hybrid regimen including : pantoprazole 40 mg + amoxicillin 500 mg both twice a day during the first 7 days , followed by pantoprazole 40 mg + amoxicillin 500 mg + clarithromycin 500 mg + tinidazole 500 mg , all twice a day , for the second 7 days .
the remaining 20 patients received standard triple therapy including : pantoprazole 40 mg , clarithromycin 500 mg , and amoxicillin 500 mg , all twice a day for 14 days . 
 

the patients were advised to call the doctor in case of any severe side effects .
after treatment , all patients were visited and were asked about the number of remained medications ( if any ) .
compliance to treatment was considered excellent if the patient took more than 90% of the medications , good in case of taking 70 - 90% of the drugs and poor , if the patient used less than 70% of the prescribed medications . 
 

h.pylori eradication was assessed by fecal h.pylori antigen test ( dahelwit 93 , germany ) 8 weeks after the treatment . in order to calculate intention to treat eradication rates , all the patients who entered the study
but in order to calculate per - protocol eradication rates , only data of those who completed the entire protocol with more than 90% compliance to treatment were analyzed . 
 

demographic data including age , sex , history of gastrointestinal bleeding , endoscopic findings , the reasons for gastrointestinal evaluation , and the need for h.pylori eradication did not show statistically significant difference between the two groups ( table 1 ) .
the indications for h.pylori eradication were : being candidate for renal transplantation , dyspepsia , or gastroduodenal ulcer or erosions . 
 

gib : gastrointestinal bleeding 
 
 six patients in the triple therapy group ( 30% ) reported mild adverse effects ( four cases of metallic taste and two cases of malaise ) .
also , two patients who received hybrid regimen ( 10% ) complained of mild metallic taste ( p<0.05 ) .
however , compliance to treatment was excellent in all patients and no one interrupted treatment because of adverse effects of the treatment . 
 
 according to both intention to treat and per - protocol analyses , h.pylori eradication rates were 100% ( 95% ci : 100 ) in those who received hybrid regimen and 70% ( 95% ci : 69.41 70.89 ) in those who were treated by standard triple therapy ( p=0.02 , figure 1 ) 
  method of follow - up & treatment efficacy

 our study showed that hybrid regimen could eradicate h.pylori in 100% of patients , but the eradication rate achieved by standard triple therapy was disappointing .
furthermore , the rates of side - effects of treatment were significantly lower in those who received hybrid regimen . however , both regimens were well tolerated and no one interrupted the treatment because of the adverse effects of the prescribed drugs . 
 
 if we consider h.pylori as an infectious disease , the ideal regimen would be the one that can eradicate h.pylori in more than 95% of the cases .
most of previous studies could not achieve optimal eradication rates in hemodialysis patients . 
 
 comparing the results of our study with previous reports ,
this is in concordance with most previous studies . according to a recent study performed by makhlough and colleagues ,
49 hemodialysis patients were randomized to receive either 14-day clarithromycin - containing triple therapy or sequential regimen .
h.pylori eradication rates were 76.2% and 87.5% by per - protocol analysis , respectively . according to another study by wang and co - workers on 40 hemodialysis patients , 7-day omeprazole - amoxicillin - clarithromycin(oac ) regimen
in addition , tsukada and colleagues reported 82.1% eradication rate using the same regimen for 39 hemodialysis patients .
sezer and others showed a high eradication rate ( 94.1% ) in 17 hemodialysis dependent patients using 14-day oac regimen .
however , itatsu and colleagues reported low eradication rate ( 72.7% ) among 11 hemodialysis patients who had received 7-day lansoprazole - amoxicillin - clarithromycin . on the other hand
, chang studied the effects of low - dose oac on 33 hemodialysis patients and reported an eradication rate of 83.4% by per - protocol analysis . 
 
 on the other hand
however , to the best of our knowledge , all related studies have been performed on patients without uremia and no study has been performed on patients with uremia . according to a study performed by de francesco and coleagues on patients without uremia , hybrid therapy could achieve 82.7% eradication rate by intention to treat analysis . also , oh and co - workers reported 81.1% and 85.9% eradication rates by hybrid therapy according to intention to treat and per - protocol analyses , respectively .
zullo and others evaluated the effects of concomitant , sequential and hybrid therapies on 270 patients with non - ulcer dyspepsia .
the eradication rates achieved by hybrid therapy were 80% and 85.7% according to intention to treat and per - protocol analyses , respectively .
sardarian and colleagues also performed a study to compare the effects of hybrid therapy versus sequential therapy for h.pylori eradication .
the eradication rates achieved by hybrid therapy were 89.5% and 92.9% by intention to treat and per - protocol analyses , respectively . in the mentioned study ,
it has been shown that chronic renal failure , either prior to renal transplantation or in patients on hemodialysis , is a predisposing factor for gastroduodenal mucosal lesions .
also patients with uremia are more prone to complications of pud than the general population .
furthermore , some studies have reported higher resistance rates to antibiotics in patients with uremia than the general population . therefore , introducing an h.pylori eradication regimen with ideal eradication rates seems to be important in this group of patients and our study reported excellent h.pylori eradication rate by hybrid regimen . 
 

one of the main limitations was small number of patients that is because of evaluating a special group of patients ( hemodialysis patients ) .
however , the strong point of the present study was to evaluate the effects of hybrid regimen in patients with uremia , because to the best of our knowledge , no study has been performed to evaluate the effects of hybrid therapy in hemodialysis patients 
 
 in conclusion , hybrid regimen could achieve ideal h.pylori eradication rate with low rate of side - effects and excellent compliance to treatment .
 background 
 the prevalence of peptic ulcer disease in hemodialysis patients is more than the general population . 
 they are also more prone to complications including upper gastrointestinal bleeding . 
 the aim of this study was to compare the efficacy of 14 days hybrid regimen with 14 days triple therapy for   helicobacter pylori ( h. pylori ) eradication in hemodialysis patients . 
 
 methods 
 forty hemodialysis patients with nave h.pylori infection were randomized to receive either hybrid regimen ( pantoprazole 40 mg + amoxicillin 500 mg , both twice a day during the first 7 days , followed by pantoprazole 40 mg + amoxicillin 500 mg + clarithromycin 500 mg + tinidazole 500 mg , all twice a day , for the second 7 days , or standard triple therapy including pantoprazole 40 mg , clarithromycin 500 mg , and amoxicillin 500 mg , all twice a day for 14 days . 
 h.pylori eradication was assessed by fecal h.pylori antigen test 8 weeks after the treatment . 
 
 results 
 all the patients completed the study . according to both intention to treat and per - protocol analyses , h.pylori eradication rates were 100% ( 95% confidence interval ( ci ) : 100 ) in those who received hybrid therapy and 70% ( 95% ci : 69.4  70.8 ) in those who were treated by standard triple therapy ( p=0.02 ) . 
 severe adverse effects were not reported by any patient ; however , mild adverse effects were more frequent in those who received standard triple therapy ( p<0.05 ) . 

 
 conclusion 

 hybrid regimen could achieve ideal h.pylori eradication rates with low rates of adverse effects . 
 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
ACKNOWLEDGEMENT
CONFLICT OF INTEREST