Avascular Necrosis in Renal Transplant Patients.

OBJECTIVES: Kidney transplant recipients are at increased risk for avascular necrosis due to steroid use and accompanying comorbidities. Concerning risk factors, uncertainty still exists. We evaluated the clinical characteristics and risk factors of avascular necrosis in kidney transplant recipients. MATERIALS AND METHODS: Symptomatic avascular necrosis was found by magnetic resonance imaging in 33 of 360 kidney transplant patients between 2005 and 2021. The patients' clinical characteristics, biochemical testing, and medications were evaluated. RESULTS: We found the frequency of avascular necrosis to be 9.7% during the follow-up period. If the total steroid dosage used was more than 4 g in the first 3 months, the risk of developing avascular necrosis increased 4.08 times, and the presence of cytomegalovirus disease increased the risk by 4.03 times. Avascular necrosis was observed bilaterally in 60.6% of cases and at the femoral head in 66.7%. The frequency of avascular necrosis was highest in the first and second years posttransplant. CONCLUSIONS: We found that avascular necrosis appears most frequently in the first 2 years after kidney transplant and the most important risk factors are cumulative steroid dose and cytomegalovirus disease. In the follow-up of kidney transplant patients, it is important to use low-dose steroid doses if possible. Of note, preventing the development of cytomegalovirus disease by screening and prophylaxis for cytomegalovirus is also important in reducing the development of avascular necrosis.

Management of pericatheter dialysate leaks using hemostatic agents.

Continuous ambulatory peritoneal dialysis (CAPD) is one of the treatment modalities used in end-stage renal disease. The most common cause of failure is catheter-related complications. Dialysate leak represents a major noninfectious complication of PD. Here, we aimed to present the results of patients who had pericatheter dialysate leak following PD catheterization and who were administered a hemostatic agent (HaemoCer Plus, BioCer, Germany) around the catheter and the tunneled segment under the subcutaneous tissue under local anesthesia. We performed a local procedure on six patients in total. No major complications developed in any of the patients at postoperative follow-up. Five patients started to receive PD uneventfully within postoperative 3 days with no dialysate leak. We believe that this practice is effective in the management of peritoneal dialysate leak. The hemostatic agents administered in the present study can manage dialysate leak and ensure safe use of the catheter.

Blood pressure, inflammation, and quality of life in patients treated with different renal replacement therapies.

Our aim was to determine the relationship between the modality of renal replacement therapy and inflammation markers, BP control, and quality of life (QoL). Sixteen hemodialysis, 17 peritoneal dialysis patients, and 27 kidney transplant receivers (KTr) have been included in this study. Short Form-36 (SF-36) for the evaluation of QoL and ambulatory BP monitoring were performed on the same day. Erythrocyte sedimentation rate, CRP, IL-6, and IL-10 were measured. While the mean IL-10, IL-6, and CRP levels were the highest in the dialysis groups, there were no significantly differences any parameters for all groups. QoL was better in the KTr almost as in healthy controls but worse in the dialysis patients. It should be taken into account that hypertension may occur at night even if the daytime BP is normal in KTr.

Comparison of erectile function in patients with end-stage renal disease receiving haemodialysis and kidney transplantation.

To investigate the frequency and risk factors of ED in haemodialysis patients (HDps) and kidney transplantation (KTx) recipients (KTxRs). HDps and KTxRs between the ages of 18-65 were compared in terms of ED. IEFF-15 (International Index of Erectile Function) score was used to evaluation of ED. Fifty-seven male HDps and 52 male KTxRs with a mean age of 45.6 ± 10.4 years were included in our study. DM, CAD, hyperlipidaemia, smoking and beta blocker use were higher HDps (p = 0.037, p < 0.001, p = 0.001, p = 0.001 and p = 0.031 respectively). There was no ED in five (8.8%) HDps and 27(51.9%) KTxRx. Severity of ED was significantly higher in HDps (p < 0.001). In multiple logistic regression analysis, KTx was found the most relevant associated factor with ED. KTxRs had decreased risk for ED (OR = 0.09, 95% CI 0.02-0.30, p < 0.001). ED is significantly more common in HDps than KTxRs. Known risk factors for ED, HT, DM, CAD, HL, smoking, obesity and beta-blocker use were not related to ED in the HDps and KTxRs, and the KTx was positively effective for ED in patients undergoing renal replacement therapy.

Primary glomerulonephritis in diabetic patients.

BACKGROUND: Primary glomerulonephritis (PGN) has a significant part in non-diabetic kidney disease (NDKD) in diabetes mellitus (DM) patients. In our study, we compared the clinical, demographic and laboratory features of patients with biopsy-proven diabetic nephropathy (DN) and PGN with type 2 DM. METHODS: In our retrospective study, type 2 DM patients who underwent kidney biopsy between 2011 and 2019 were included. Demographic, clinical and laboratory characteristics of DN and PGN patients were compared. RESULTS: Seventy patients with a mean age of 55.7 ± 9.4 and 43 (61.4%) males were included. About 38 (54.3%) of the patients had DN and 32 (45.7%) had PGN. In the PGN, membranous GN (20, 62.5%) was most common. In DN patients, diabetes duration was longer; complications such as retinopathy, neuropathy, hypertension, coronary artery disease, heart failure were more frequent. At the time of renal biopsy, blood sugar, HbA1C, blood pressure, serum albumin and proteinuria values were similar in two groups. The pathological damage findings of kidney biopsy in DN patients were more severe. In the first year after kidney biopsy decrease in eGFR was higher in DN patients, whereas eGFR did not change in PGN patients. CONCLUSION: In a diabetic patient, fasting blood sugar, hbA1C, serum albumin and proteinuria did not differ in the differential diagnosis of DN and PGN, whereas complications of DM (retinopathy, neuropathy, hypertension, coronary artery disease) were more characteristic in differentiation. Detection of PGN in a diabetic patient is crucial for the success of the treatment, according to DN.

Renal expression of PLA2R, THSD7A, and IgG4 in patients with membranous nephropathy and correlation with clinical findings.

BACKGROUND: Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in nondiabetic adults. M-type phospholipase A2 receptor (PLA2R), thrombospondin type-1 domain-containing 7A (THSD7A) are known as target podocyte antigens in membranous nephropathy (MN). Antibodies against these podocyte antigens are used in the initiation of treatment and response monitoring. However, the relationship between renal podocyte antigens and treatment response is not clear yet. We evaluated the relationship between immunohistochemical PLA2R, THSD7A and IgG4 staining, clinical findings and treatment response in kidney biopsies. METHODS: Fifty-eight patients with MN were included in this retrospective study. In the renal biopsy samples of the patients, PLA2R, THSD7A and IgG4 were stained immunohistochemically and evaluated by light microscopy. The clinical, laboratory and treatment results of the patients were obtained from the hospital records. RESULTS: The study included a total of 58 patients with MN and a mean follow-up period of 32.3 ± 19.7 months. In patients with primary MN; PLA2R, THSD7A and IgG4 were positive in 57.1% (n = 28), 12.2% (n = 6) and 69.4% (n = 34), respectively. Only PLA2R staining was distinctly higher in patients with primary MN than secondary MN (P = .025). Dual positivity (PLA2R + THSD7A) was detected in five (10.2%) of patients with primary MN. We did not determine any relationship between the PLA2R, THSD7A and IgG4 staining patterns and treatment response of the patients. CONCLUSION: It was found no correlation between PLA2R, THSD7A and IgG4 staining in kidney tissue and treatment response. Interestingly, dual positivity (PLA2R + THSD7A) was detected only in primary MN.

Serum fibroblast growth factor 23 levels do not correlate with carotid intima-media thickness in patients with chronic kidney disease.

High levels of fibroblast growth factor 23 (FGF 23) are associated with mortality and cardiovascular events in patients with chronic kidney disease (CKD). Carotid intima-media thickness (CIMT) is a useful marker of subclinical atherosclerosis. This study aimed to investigate the relationship between serum FGF23 levels and CIMT of CKD patients. In this cross-sectional study, CIMT was measured in 162 patients with CKD Stage of 2-5 (age range 18-79 years, 61.7% males). Serum FGF23 levels were determined by enzyme-linked immunosorbent assay. CIMT was measured by ultrasonography. Serum FGF-23 levels were significantly higher (P = 0.046) in advanced CKD patients. CIMT was thicker in patients with advanced CKD patients (P = 0.01). CIMT was correlated with age (r = 0.486, P <0.001), smoking (r = 0.411, P <0.001), and 25-OH Vitamin D (r = -0.195, P= 0.045). There was no correlation between serum FGF23 and CIMT. Multivariate analysis showed that age (ß = 0.373, P <0.001), smoking (ß = 0.228, P = 0.004), and serum 25-hydroxyvitamin D levels (ß = -0.164, P = 0.042) were associated with CIMT. There was no relationship between FGF23 and CIMT. The CIMT was found to be related to increased age, smoking, and 25-hydroxyvitamin D in CKD patients.

Evaluation of the Relationship Between Homocysteine, Parathormone, Vitamin D3, and Bone Mineral Densitometry in Recipients of Kidney Transplant.

PURPOSE: In this study, we evaluated the relationship between serum homocysteine level and proteinuria, parathyroid hormone, vitamin D, and bone mineral density in kidney transplant recipients (KTR). MATERIALS AND METHODS: A total of 117 stable KTR older than 18 years was followed in our outpatient clinic. Demographic data were recorded. Simultaneously biochemical parameters, including glucose, blood urea nitrogenous, creatinine, calcium, phosphorus, sodium, potassium, albumin, parathormone, vitamin D3, homocysteine, vitamin B12, folate, and 24-hour urine protein, and bone mineral density of the femoral neck and spine by dual-energy x-ray absorptiometry (DEXA) were measured. RESULTS: DEXA measurements were normal, osteoporotic, and osteopenic (12.3%, 36.3%, and 51.3%, respectively). There was a relationship between the serum homocysteine and usage of rapamycin (P = .05), statins (P = .057), and beta blockers (P = .01), DEXA measurements were not related with serum homocysteine levels and immunosuppressive drugs used. Serum homocysteine levels correlated negatively with blood urea nitrogen (P = .002), creatinine (P = .001), vitamin B12 (P < .001), and a positively daily proteinuria (rho = 0.203, P = .031). There was a negative relationship between proteinuria and serum level of vitamin D. CONCLUSIONS: The bone mineral density decreased in more than 87% of our KTR. We did not find any relationship between DEXA measurements and levels of homocysteine, vitamin D, parathormone, and immunosuppressive drugs. It should be noted that some drugs used may affect serum homocysteine levels. Interestingly, there was a relationship between proteinuria and serum levels of homocysteine and vitamin D. Therefore, serum levels of homocysteine and vitamin D should be evaluated for preventing renal damage in KTR.

Evaluation of Living Kidney Donor and Recipient Candidates: The Experience of Our Center.

PURPOSE: We evaluated potential kidney living donors and recipients for donation in our transplant center. MATERIALS AND METHODS: Candidates to be kidney living donors and kidney transplant recipients (KTxR) were retrospectively evaluated. All candidates were informed and assessed by transplant coordinator and nephrologists. All data were obtained from archive records. RESULTS: The mean ages of 194 kidney living donors and 182 KTxR were 45.7 ± 13.1 and 37.7 ± 14.6 years, respectively. Percentages of female candidates were 55.2% and 34.1% among kidney living donors and KTxR respectively. The kidney living donor candidates were the patients' mothers (27.3%), spouses (24.2%), siblings (21.6%), fathers (12.4%), and sons or daughters (6.2%) of KTxRs and others (8.2%). The numbers of donors with body mass index (BMI) > 30 kg/m2 and > 35kg/m2 were 56 (28.9%) and 17 (8.8%) respectively. Due to withdrawal from donation (21.2%) and renal problems (15.3%), 85/194 (43.8%) kidney living donors were excluded. Of the remaining 51/182 (28%) KTxR candidates, 26/182 (14.2%) were unsuitable because their panel-reactive antibody (PRA) > 20%. Sixty-six KTxR were performed in our center. Nine donor candidates were rejected due to obesity (BMI > 35 kg/m2). CONCLUSION: Most of our kidney living donors were mothers, housewives, and uneducated persons. Due to high percentages of suitability among candidates of KTxRs and kidney living donors as 72% and 56% may be an advantage for living kidney donation. However, PRA positivity in the recipients drew attention as a major barrier. The high incidence of obesity among the donor candidates suggests that societies must be more sensitive about this issue.

Relationship Between Peripheral-Central Blood Pressure and Cardiac-Renal Damage in Kidney Transplant Recipients.

OBJECTIVES: Hypertension is a common and important problem in kidney transplant recipients, directly affecting graft and patient survival. Here, we evaluated the relationship between renal-cardiac damage and peripheral and central aortic blood pressure levels in renal transplant recipients. MATERIALS AND METHODS: We measured peripheral blood pressure (office, daytime ambulatory, and central aortic) in 46 kidney transplant recipients. Biochemical parameters were simultaneously measured. Electrocardiography and echocardiography were performed. Patients with office blood pressure > 140/90 mm Hg or who were treated with antihypertensive drugs were accepted as hypertensive. RESULTS: Ambulatory blood pressure measurements were higher than office blood pressure measurements (at 135.6/85.6 mm Hg vs 121.8/77.5 mm Hg in hypertensive and at 118.8/77.6 mm Hg vs 101.6/62.5 mm Hg in normotensive patients) (P < .05). There were 40 hypertensive and 6 normotensive kidney transplant recipients according to ambulatory blood pressure measurement and 33 hypertensive and 13 normotensive according to office blood pressure measurements. Central aortic pressure measurements were significantly higher in hypertensive patients versus office or ambulatory blood pressure (P = .045 and .048, respectively). Left ventricle mass index and proteinuria were significantly correlated with central aortic pres sure (P = .015, r = 0.358 and P = .022, r = 0.499, respectively) and nonsignificantly correlated with peripheral blood pressure measurements (P > .05). Left ventricle hypertrophy was found to be less common in patients using angiotensin-converting enzyme, although not significantly (P > .05). CONCLUSIONS: In kidney transplant recipients, blood pressure should be monitored with ambulatory blood pressure measurements, even when normal office pressure levels are shown. The aim of antihypertensive therapy is not only to decrease brachial artery pressure but also to keep central aortic systolic blood pressure in the proper interval, adjusted according to age. This may more effectively prevent the development of renal cardiac damage versus peripheral blood pressure measurement monitoring.

Prevalence of cardiac arrhythmia and risk factors in chronic kidney disease patients.

Chronic kidney disease (CKD) patients have a high risk for cardiac arrhythmia. This study aimed to investigate the prevalence of cardiac arrhythmia in CKD patients and to evaluate the relationship between arrhythmia and biochemical and echocardiographic parameters. CKD patients between 18 and 80 years of age were enrolled from the nephrology outpatient clinic. Physical examination, complete blood count, urinalysis biochemical analysis, electrocardiogram, echocardiogram, and 24-h Holter electrocardiogram were performed. Patients with and without cardiac arrhythmia were compared regarding their characteristics, laboratory findings, and echocardiographic parameters. Risk factors for cardiac arrhythmia were also evaluated. The carotid intima-media thickness was measured using Doppler ultrasonography. In our study involving 59 patients, 44 (74%) had atrial arrhythmia (AA) and 40 (68%) had ventricular arrhythmia (VA). Atrial and/or VA were diagnosed in 46 patients (78%), of whom six (10.2%) had AA, two (3.4%) had VA and 38 (64.4%) had AA plus VA. Atrial fibrillation (AF) was present in two patients (3.4%) in the form of paroxysmal AF. Risk factors for AA were low calcium level and posterior wall thickness, while factors associated with VA were age, triglyceride level, leukocyte count, and nonusage of angiotensin 2 receptor blockers. Risk factors for AA and/or VA included increased platelet count, age, and leukocyte count. AA and/or VA were found in as high as 78% of CKD patients. Further studies evaluating course of the disease from early stages are needed to identify risk factors.

Acute renal failure secondary to drug-related crystalluria and/or drug reaction with eosinophilia and systemic symptom syndrome in a patient with metastatic lung cancer.

Drug reaction with eosinophilia and systemic symptoms (DRESS) or drug-induced hypersensitivity is a severe adverse drug-induced reaction. Aromatic anticonvulsants, such as phenytoin, phenobarbital, and carbamazepine, and some drugs, can induce DRESS. Atypical crystalluria can be seen in patients treated with amoxycillin or some drugs and can cause acute renal failure. We describe a 66-year-old man who presented fever and rash and acute renal failure three days after starting amoxycillin. He was also using phenytoin because of cerebral metastatic lung cancer. Investigation revealed eosinophilia and atypical crystalluria. The diagnosis of DRESS syndrome was made, amoxicillin was stopped, and dose of phenytoin was reduced. No systemic corticosteroid therapy was prescribed. Symptoms began to resolve within three to four days. The aim of this paper is to highlight the importance of microscopic examination of urine in a case with acute renal failure and skin lesions to suspect DRESS syndrome.

Prolonged hypophosphatemia following parathyroidectomy in chronic hemodialysis patients.

Secondary hyperparathyroidism (SHPT) is a common problem in patients with end-stage renal disease. In cases with severe and resistant SHPT, surgical parathyroidectomy (PTX) is recommended. Hungry bone syndrome (HBS) following surgical PTX is most often associated with hypocalcemia and hypophosphatemia. The mechanisms for the HBS are not clear, and a method for its prevention has not been established. We present three hemodialysis patients with persistant hypophosphatemia after PTX. In our parathyroidectomized patients, hypocalcemia could be corrected with calcium and vitamin D treatment, but hypophosphatemia continued for eight months in one patient and in two other patients until the last visit (10 and 2 months, respectively). Predisposing factors such as old age, diabetes mellitus and parathyroid adenoma were not found in our patients. All three patients were younger (<35 years old) and anuric. Hemodialysis durations were seven, three and two years. In summary, HBS presented with hypocalcemia, and especially hypophosphatemia cannot be developed uncommonly and may persist for a long time following PTX in HD patients.

Expression of p53, Ki67, epidermal growth factor receptor, transforming growth-factorα, and p21 in primary and secondary hyperparathyroidism.

BACKGROUND: Secondary hyperparathyroidism (SH) is major problem in chronic renal failure. There are studies to examine proliferation and apoptosis associated biomarkers expressions in parathyroid lesions to reveal specific features. In this study, we evaluated the expression of some growth factors and their receptors in parathyroid gland of patients with SH or primary hyperparathyroidism (PH). MATERIALS AND METHODS: A total of 49 patients had been operated for PH and 26 for SH. Parathyroid tissue samples were evaluated histopathologically and immunohistochemically using antibodies to human p53, KI-67, anti-human p21, antitransforming growth factor (TGF) α, CPP32 (caspase 3), and epidermal growth factor receptor (EGFR). RESULTS: Adenoma was higher in PH compared with SH as 48/49 and 3/26, respectively (P = 0.000). Parathyroid hyperplasia was found in 23/26 patients with SH and 1/49 patient with PH. In parathyroid tissue there were no difference between PH and SH for p53, Ki-67, caspase, EGFR expressions; while there were significantly difference for TGFα (P = 0.047) and borderline significant difference for p21 (P = 0.06) expressions. CONCLUSION: Adenoma was priority present in PH patients, hyperplasia was present in SH. There were no differences between primary and SH or adenoma and hyperplasia for expressions of cycline-dependent kinase inhibitor p21, p53, EGFR, Ki67, caspase; while TGFα expression was found to be different.

Outcomes of Total Parathyroidectomy with Autotransplantation versus Subtotal Parathyroidectomy with Routine Addition of Thymectomy to both Groups: Single Center Experience of Secondary Hyperparathyroidism.

BACKGROUND: Secondary hyperparathyroidism is a common acquired disorder seen in chronic renal failure. It may result in potentially serious complications including metabolic bone diseases, severe atherosclerosis and undesirable cardiovascular events. Parathyroidectomy is required in about 20% of patients after 3-10 years of dialysis and in up to 40% after 20 years. AIMS: The aim of the current study was to evaluate the short-term and long-term outcomes of patients with secondary hyperparathyroidism who had undergone total parathyroidectomy with autotransplantation and thymectomy or subtotal parathyroidectomy with thymectomy by the same surgical team during the study period. STUDY DESIGN: Retrospective comparative study. METHODS: Clinical data of 50 patients who underwent parathyroid surgery for secondary hyperparathyroidism between 2003 and 2011 were reviewed retrospectively. Patients were divided into two subgroups of total parathyroidectomy with autotransplantation or subtotal parathyroidectomy. Thymectomy was routinely performed for both groups. Short term outcome parameters included intact parathyroid hormone, ionized calcium and alkaline phosphatase levels. Bone pain, bone fractures, persistent or recurrent disease were included in long term outcome parameters. RESULTS: The mean duration of dialysis was eight years. The mean ionized calcium levels dropped significantly in the total parathyroidectomy with autotransplantation group (p=0.016). No serious postoperative complications were observed. Postoperative intravenous calcium supplementation was required in four patients in the total parathyroidectomy with autotransplantation group (total PTX+AT) and in three patients in the subtotal parathyroidectomy group (subtotal PTX). Postoperatively, all patients received oral calcium carbonate and calcitriol. The length of average hospital stay was 5 (3-10) days. Including nine patients who underwent successful renal transplantation pre-operative bone symptoms, hypercalcemia, hyperphosphatemia, and an increased alkaline phosphatase levels were improved or resolved in all patients. After a mean follow-up of 65 months, three patients (6%) had persistent and one (2%) had recurrent disease. CONCLUSION: Total parathroidectomy with autotransplantation is a beneficial and safe surgical procedure for patients on chronic dialysis with otherwise uncontrollable secondary hyperparathroidism and even in patients who have undergone renal transplantation after parathyroidectomy. Careful cervical exploration and routine thymectomy should be considered as a routine part of the surgical approach regardless of the preferred technique.

Biological variations of some analytes in renal posttransplant patients: a different way to assess routine parameters.

BACKGROUND: Biological variation (BV) data of analytes have been used to evaluate the significant changes in serial results (reference change value, RCV) of healthy individuals in clinical laboratories. However, BV data of healthy subjects may not be identical to the analytes of patients with ongoing clinical condition. The aim of this study was to calculate intra-(CVw) (coefficient of variation for intra-individual BV) and inter-individual (CVg) BV, index of individuality, and RCV of nine serum analytes of renal posttransplant patients. METHODS: Six serum specimens were obtained in an interval of two months in a one-year period from 70 transplant patients who had been stable for three years. Each time creatinine, uric acid, urea, sodium, potassium, calcium, inorganic phosphate, total protein, and albumin of these patients were analyzed with an integrated clinical chemistry/immunoassay auto-analyzer. ANOVA tests were used to calculate the variations. Results were compared with the data of healthy subjects obtained from BV database. RESULTS: CVw of all nine analytes of the renal transplant patients were higher than the healthy subjects. RCVs of these analytes were calculated as 14.5% for creatinine, 16.5% for urea, 13.7% for urate, 12.57% for albumin, 8.26% for total protein, 3.25% for sodium, 12.81% for potassium, 5.88% for calcium, and 21.57% for inorganic phosphate. CONCLUSION: RCV concept for predicting the clinical status in posttransplant population represents an optimization of laboratory reporting and could be a valuable tool for clinical decision.

Milk alkali syndrome induced by calcitriol and calcium bicarbonate in a patient with hypoparathyroidism.

The milk-alkali syndrome (MAS) was a common cause of hypercalcemia, metabolic alkalosis, and renal failure in the early 20(th) century. This syndrome was first recognized secondary to treatment of peptic ulcer disease with milk and absorbable alkali. Its incidence fell after the introduction of H2-blocker and proton pump inhibitor. Persistent ingestion of calcium carbonate and vitamin D caused MAS. We report a patient presenting with a triad of hypercalcemia, metabolic alkalosis and renal failure secondary to treatment of idiopathic hypoparathyroidism.