Association Between Membranoproliferative Glomerulonephritis and Colorectal Cancer - A Case Report.

Membranoproliferative glomerulonephritis (MPGN) is a rare glomerular disease characterized by mesangial hypercellularity and thickening of the glomerular basement membrane (GBM). MPGN can be idiopathic or associated with malignancy, systemic immune complex disorders and chronic infections. It has rarely been associated with solid organ tumors, such as lung, gastric, breast or prostate cancer. We report a patient with MPGN and coexisting colorectal carcinoma. A 48-year-old man presented with anemia, loss of weight, hypertension, and nephrotic syndrome. The renal biopsy findings were compatible with type 1 MPGN. The antineutrophilic cytoplasmic antibodies, antinuclear antibodies, anti-GBM, serologic markers of hepatitis B and hepatitis C and tumor markers were negative. After ruling out the secondary causes of MPGN, the patient was treated with pulse doses of methylprednisolone and a single dose of cyclophosphamide. However, due to the worsening anemia and rectal bleeding, a colonoscopy was performed, which established a diagnosis of adenocarcinoma of the descending colon. The patient was treated with left hemicolectomy and oral corticosteroids. Within a year after the cancer treatment, the patient experienced a complete resolution of the proteinuria and improvement of the kidney function. Although rare, MPGN can be associated with hematologic malignancies and solid organ tumors. The most common causes of secondary MPGN should be ruled out before starting specific treatment. In our patient, cancer treatment has led to a subsequent remission of the nephrotic syndrome, which indicated that this association was not coincidental but rather causal. In patients with a tumor and concomitant glomerulopathy which is suspected to be paraneoplastic in etiology, the treatment of the underlying malignancy should be prioritized.

Glomerulopathies with Fibrillary Deposits.

The glomerulopathies associated with the deposition of extracellular fibrils in the glomeruli are subdivided into Congo red positive (amyloidosis) and Congo red negative (non-amyloidotic glomerulopathies) based on Congo red staining. The non-amyloidotic glomerulopathies are divided into immunoglobulin-derived and non-immunoglobulin-derived glomerulopathies. The immunoglobulin-derived glomerulopathies: fibrillary glomerulopathy (FGn) and immunotactoid glomerulopathy (ITG) are rare glomerulopathies. The diagnosis of fibrillary-immunotactoid glomerulopathy depends on electron microscopy, which shows the presence of microfibrils in the glomeruli. The microfibrils in FGn are randomly arranged with diameters less than 30 nm. The microfibrils in ITG are larger than 30 nm with a visible lumen (microtubules), focally arranged in parallel bundles. Patients with fibrillary-immunotactoid glomerulopathy present with proteinuria (usually in the nephrotic range), microscopic hematuria, arterial hypertension, and chronic kidney disease that progresses to kidney failure over months to years. Currently, there are no guidelines for the treatment of fibrillary-immunotactoid glomerulopathy, although immunotactoid glomerulopathy could be associated with underlying hematologic disorders with the need for clone-directed therapy.

Immunotactoid Glomerulopathy: A Rare Glomerular Disease Case Study.

Immunotactoid glomerulopathy (ITG) is a rare glomerular disease with variable responsiveness to the immunosuppressive therapy and with uncertain prognosis. ITG was diagnosed in two patients with type 2 diabetes mellitus with nephrotic syndrome and chronic kidney disease. The absence of diabetic retinopathy in the first case and the recent onset of diabetes in the second case accompanied with sudden increase in the 24-hour proteinuria and rapid decline in kidney function, prompted us to perform kidney biopsy. The electron microscopy set the diagnosis of ITG in both cases. There is no consensus for the treatment of ITG. The first patient was treated with combination of steroids and mycophenolate mofetil with reduction of the 24-hour proteinuria, but with persistence of the chronic kidney disease. The second patient received high doses of steroids with continuous deterioration of kidney function with the need of hemodialysis treatment.

Comparison of Oxidative Stress Levels in Healthy Children and Children with Allergic Rhinitis.

Background/aim: Allergic rhinitis (AR) is characterized by chronic inflammation of the nasal mucosa. Under the influence of exogenous factors - allergens, reactive oxygen species (ROS) are released during cellular metabolism. They induce a series of pathological changes in the mucosa. Oxidative stress is а result of an imbalance between the production of ROS and the ability to neutralize them. The aim of this study is to compare the levels of oxidative stress between healthy children and children with allergic rhinitis. Material and methods: A total number of 60 children were included (30 healthy children and 30 children with AR). The oxidative stress index was determined by using the FRAS 5 (Free Radical Analytical System) Bravo system. Demographic characteristics, medical history, children's living conditions and eating habits were obtained from the questionnaire. Anthropometric measurements and the absolute number of eosinophils in the peripheral smear were performed on each child. Results: This study showed high oxidative stress index and a significantly higher value of the absolute number of eosinophils in the peripheral smear in children with AR in comparison to healthy children (p<0.05). The group of children with AR had more atopic characteristics and was more exposed to passive smoking than healthy children. Conclusion: Compared to healthy children, children with AR have a high index of oxidative stress, despite of the very high mean value of the concentration of water-soluble antioxidants in serum (PAT test) in the group of children with AR.

The blood flow rate on the first day after arteriovenous fistula creation is a predictor of successful fistula maturation.

BACKGROUND: The determination of blood flow rate (BFR) is a useful tool for assessing the function of arteriovenous fistula (AVF). METHODS: Eighty patients with a newly created radio cephalic AVF were analyzed. Hemodynamics and morphological characteristics of the blood vessels were assessed by Doppler ultrasound. RESULTS: The mean age of patients was 59.9 ± 13.5 years. A successful rate of AVF maturation was 62.5% at 8 weeks. Six adjusted models of multivariate analysis showed that BFR at Day 1 was a predictor for AVF maturation both at 4 weeks (p < 0.001) and 8 weeks (p < 0.001). Receiver operating characteristic analysis showed an optimal cut-off point for BFR at Day 1 of 395 ml/min for successful maturation at 4 weeks (sensitivity 0.714, specificity 0.889) and 344 ml/min for successful maturation at 8 weeks (sensitivity 0.860, specificity 0.867). CONCLUSION: BFR at Day 1 is a powerful predictor for successful AVF maturation at 4 and 8 weeks.

Rhabdomyolysis Associated with Recent SARS-COV-2 Infection in a Patient with Carnitine Palmitoyltransferase II Deficiency.

Carnitine palmitoyltransferase II deficiency (CPT II) is an autosomal recessive inherited disorder of long-chain fatty acid oxidation in the mitochondrial matrix, resulting in an inability to utilize fat for energy in cells. The most frequent myopathic form occurs in young adults and is associated with recurrent episodes of exercise-induced rhabdomyolysis. The myopathic form is caused by the Ser113Leu mutation of the CPT II gene. Rarely, massive rhabdomyolysis could be complicated by acute kidney injury (AKI), cardiomyopathy, and respiratory insufficiency. We present a case of an 18-year old male with myalgia, muscular weakness, and dark-colored urine after prolonged exercise and a recent mildSARS-CoV-2infection. Massive rhabdomyolysis was diagnosed with markedly increased serum concentrations of myoglobin and creatine kinase, with normal kidney function. The patient experienced two similar episodes in the years 2017 and 2018, with rhabdomyolysis and AKI treated with hemodialysis. After excluding autoimmune and infectious diseases as causes of recurrent rhabdomyolysis, the patient was genetically tested and Ser113Leu mutation of the CPT II gene was confirmed. When a patient presents with myalgia and dark-colored urine triggered by minor physical activities, genetic testing for possible CPT II deficiency should be initiated. TheSARS-CoV-2infection could be a factor that triggers the occurrence of rhabdomyolysis and aggravates the severity of the attack in patients with CPT II deficiency.

Percutaneous Nephrostomy in the Treatment of Hydronephrosis in Renal Transplant Patients - Case Report.

Percutaneous nephrostomy is a first-line minimal invasive treatment option for ureteral obstruction following kidney transplantation, with high effectiveness and a low complication rate. Percutaneous nephrostomy might be used as a temporary salvage therapy, providing acute decompression of the kidney collecting system and preventing graft loss. It can also function as a permanent and sometimes only possible option in transplant patients with frequent recurrences of ureteral stenosis who either fail an open surgical reconstruction or who are not good candidates for these procedures. We present two patients with acute decline in urine output after renal transplantation with radiologically verified hydroureteronephrosis of the transplanted kidney (graft) caused by stenosis of distal ureter. In both cases, nephrostomy was placed within 48 hours as a temporary salvage treatment that ameliorates renal function and prevents graft loss. The permanent nephrostomy was the only possible solution for the preservation of the graft's function in the first case because of the recurrences of ureteral stenosis after several percutaneous interventions and open-surgery ureteral reconstruction. A few episodes of nephrostomy tube-related infections were resolved with antibiotics in the first case. The second case was treated with open ureteroneocystostomy with resection of stenotic segment and reinsertion of the ureter into the bladder (ureterocystoneostomy) because of the length of the involved ureteral segment. Both patients had stable graft function in the follow-up period.

Uric acid and left ventricular hypertrophy: another relationship in hemodialysis patients.

BACKGROUND: The impact of serum uric acid (UA) on morbidity and mortality in hemodialysis (HD) patients is quite controversial in relation to the general population. The aim of this study was to evaluate the association of serum UA with both mortality and left ventricular hypertrophy (LVH) in HD patients. METHODS: This longitudinal study enrolled 225 prevalent HD patients who were classified into three groups according to their follow-up-averaged UA (FA-UA) levels: low FA-UA (FA-UA <400 µmol/L), intermediate/reference FA-UA (FA-UA between 400 and 450 µmol/L) and high FA-UA (FA-UA >450 µmol/L). Echocardiography was performed on a nondialysis day and the presence of LVH was defined based on a left ventricular mass index (LVMI) >131 and >100 g/m2 for men and women, respectively. The patients were followed during a 60-month period. RESULTS: The mean FA-UA level was 425 ± 59 µmol/L (range 294-620). There was a consistent association of higher FA-UA with better nutritional status (higher body mass index, normalized protein catabolic rate, creatinine, albumin and phosphorus), higher hemoglobin, but lower C-reactive protein and LVMI. During the 5-year follow-up, 81 patients died (36%) and the main causes of death were cardiovascular (CV) related (70%). When compared with the reference group, the hazard ratio for all-cause mortality was 1.75 [95% confidence interval (CI) 1.02-2.98; P = 0.041] in the low FA-UA group, but there was no significant association with the high FA-UA group. In contrast, FA-UA did not show an association with CV mortality neither with the lower nor with the high FA-UA group. The unadjusted odds ratio (OR) of LVH risk in the low FA-UA compared with the reference FA-UA group was 3.11 (95% CI 1.38-7.05; P = 0.006), and after adjustment for age, gender, diabetes and CV disease, ORs for LVH persisted significantly only in the low FA-UA group [OR 2.82 (95% CI 1.16-6.88,); P = 0.002]. CONCLUSIONS: Low serum UA is a mortality risk factor and is associated with LVH in HD patients. These results are in contrast with the association of UA in the general population and should be the subject of further research.

COVID 19 Pneumonia and a Rare Form of Fungal Peritonitis in a Patient Survivor on Peritoneal Dialysis.

Peritoneal dialysis (PD) related peritonitis is usually caused by bacteria, but viruses and fungi could also affect the peritoneal membrane and cause cloudy effluent with negative bacterial cultures. We present a case of a PD patient who survived fungal peritonitis caused by Geotrichum klebahnii (March 2015) and COVID-19 pneumonia (April 2021) with peritonitis probably caused by the SARS-CoV-2 virus. The fungal peritonitis followed one episode of exit-site infection and two episodes of bacterial peritonitis treated with a wide-spectrum antibiotic. The patient's PD catheter was removed immediately upon the diagnosis of fungal peritonitis, and an antifungal treatment was continued for 3 weeks after catheter removal. The new peritoneal catheter was reinserted 8 weeks after complete resolution of peritonitis, and the patient continued treatment with PD. The patient developed severe Covid-19 pneumonia with a sudden appearance of cloudy peritoneal effluent. There was no bacterial or fungal growth on the effluent culture. A PCR test for SARS-CoV-2 in peritoneal effluent was not performed. The peritoneal effluent became transparent with the resolution of the severe symptoms of Covid-19 pneumonia.

Peritoneal Dialysis-Related Peritonitis: Rate, Clinical Outcomes and Patient Survival.

Peritoneal dialysis-related peritonitis remains the major complication and primary challenge to the long-term success of peritoneal dialysis (PD). The study aimed to analyze the peritonitis rate, the cause, the outcomes, and the association of peritonitis with the survival of patients on peritoneal dialysis. Patient data were collected retrospectively from medical charts. A total of 96 patients received peritoneal dialysis in the PD center from 1 January 1999 to 31 December 2018. Episodes of peritonitis (n=159) were registered in 54 (56.3%) patients. The study population was divided into two groups, a group of patients (n=54) who experienced peritonitis and a group of patients free of peritonitis (n=42). The peritonitis rate was 0.47 episodes per patient year. The majority of causative microorganisms were gram-positive bacteria (53.5%). Outcomes of the episodes of peritonitis were resolved infection in 84.9% of episodes, catheter removal in 11.3% of episodes, and death in 3.8% of the episodes of peritonitis. A Kaplan-Meier analysis and log-rank test revealed that the group with peritonitis tended to survive significantly longer than the peritonitis-free group. A 67% reduction rate in the risk of patient mortality was observed for the peritonitis group compared with the peritonitis-free group (hazard ratio: 0.33, 95% CI 0.19-0.57, P=0.000). The prevention and management of PD-related infections, resulted in their worldwide reduction, supporting the use of PD as a first-line dialysis modality.

Impact of preoperative arterial and venous diameter on achievement of the adequate blood flow in arteriovenous fistula for hemodialysis.

An arteriovenous fistula (AVF) remains the best choice of vascular access (VA) for hemodialysis (HD). The aim of the study was to determine the factors associated with the achievement of adequate blood flow (BF) of AVFs at the 4th week after creation. Created AVFs in 63 patients with chronic kidney disease (CKD) stage 4/5 and CKD stage 5 on hemodialysis (CKD5D) were analyzed in a prospective study. Doppler ultrasound (DUS) was used for measuring the diameter of the radial artery, the brachial artery and the cephalic vein before AVF creation. The BF of AVF was calculated by DUS at the 4th week after creation and adequate BF was defined as ≥ 600 mL/min. The average age of patients was 61.31 ± 12.9 years. An adequate BF of AVF at the 4th week after creation was achieved in 43.54% of patients. The BF of AVF measured in male patients was significantly higher compared to the BF of AVF obtained in females (576.03 mL/min vs 375.12 mL/min, P = 0.004). The diameter of the blood vessels with achieved adequate BF was significantly larger compared to the diameter of the blood vessels without adequate BF (radial artery: 2.45 mm vs 2.03 mm, P = 0.000; brachial artery: 4.78 mm vs 4.06 mm, P = 0.001 and cephalic vein: 3.12 mm vs 2.83 mm P = 0.018). The gender and the diameter of the blood vessels before AVF creation were significantly associated with achievement of adequate BF of AVF at the 4th week of creation.

Primary antiphospholipid syndrome in a hemodialysis patient with recurrent thrombosis of arteriovenous fistulas / Síndrome antifosfolípide primária em paciente em hemodiálise com trombose recorrente de fístulas arteriovenosas

ABSTRACT Introduction: The antiphospholipid syndrome is a systemic autoimmune disease defined by recurrent vascular and/or obstetrical morbidity that occurs in patients with persistent antiphospholipid antibodies. Case presentation: A patient on hemodialysis with a primary antiphospholipid syndrome presented with recurrent vascular access thrombosis, obstetrical complications, and positive lupus anticoagulant. The patient had multiple arteriovenous fistulas that failed due to thrombosis. The obstetrical morbidity was defined by one miscarriage at the 7th week of gestation and a pregnancy complicated by pre-eclampsia with preterm delivery at the 28th week of gestation. A thorough thrombophilia screening confirmed the presence of antiphospholipid antibody. Lupus anticoagulant was present in plasma, measured on two occasions 12 weeks apart. Conclusion: Thrombophilias are inherited or acquired predispositions to vascular thrombosis and have been associated with thrombosis of the arteriovenous fistula. Patients on hemodialysis with recurrent vascular access thrombosis and presence of thrombophilia should be evaluated about the need for anticoagulant therapy with a vitamin K antagonist.

RESUMO Introdução: A síndrome antifosfolipídica é uma doença autoimune sistêmica definida por morbidade vascular e/ou obstétrica, recorrente, que acomete pacientes com anticorpos antifosfolípides persistentes. Apresentação do caso: Uma paciente em hemodiálise com síndrome antifosfolípide primária apresentou trombose recorrente do acesso vascular, complicações obstétricas e anticoagulante lúpico positivo. A paciente apresentava múltiplas fístulas arteriovenosas que falharam devido à trombose. A morbidade obstétrica foi definida por um aborto espontâneo na 7ª semana de gestação e uma gravidez complicada por pré-eclâmpsia com parto prematuro na 28ª semana de gestação. Um rastreamento completo de trombofilia confirmou a presença de anticorpo antifosfolípide. O anticoagulante lúpico estava presente no plasma, medido em duas ocasiões, com 12 semanas de intervalo. Conclusão: As trombofilias são predisposições hereditárias ou adquiridas para trombose vascular e têm sido associadas à trombose da fístula arteriovenosa. Pacientes em hemodiálise com trombose recorrente de acesso vascular e presença de trombofilia devem ser avaliados quanto à necessidade de terapia anticoagulante com um antagonista da vitamina K.

Primary antiphospholipid syndrome in a hemodialysis patient with recurrent thrombosis of arteriovenous fistulas.

INTRODUCTION: The antiphospholipid syndrome is a systemic autoimmune disease defined by recurrent vascular and/or obstetrical morbidity that occurs in patients with persistent antiphospholipid antibodies. CASE PRESENTATION: A patient on hemodialysis with a primary antiphospholipid syndrome presented with recurrent vascular access thrombosis, obstetrical complications, and positive lupus anticoagulant. The patient had multiple arteriovenous fistulas that failed due to thrombosis. The obstetrical morbidity was defined by one miscarriage at the 7th week of gestation and a pregnancy complicated by pre-eclampsia with preterm delivery at the 28th week of gestation. A thorough thrombophilia screening confirmed the presence of antiphospholipid antibody. Lupus anticoagulant was present in plasma, measured on two occasions 12 weeks apart. CONCLUSION: Thrombophilias are inherited or acquired predispositions to vascular thrombosis and have been associated with thrombosis of the arteriovenous fistula. Patients on hemodialysis with recurrent vascular access thrombosis and presence of thrombophilia should be evaluated about the need for anticoagulant therapy with a vitamin K antagonist.

Primary Failure of the Arteriovenous Fistula in Patients with Chronic Kidney Disease Stage 4/5.

BACKGROUND: An Arteriovenous fistula (AVF) is a creation of the natural blood vessels. It is a "gate of life" for the patients on hemodialysis. AIM: The study aimed to analyze the predictors for primary failure of AVF such as gender, age, number and location of AVF, and primary renal disease in patients with chronic kidney disease (CKD) stage 4/5. MATERIAL AND METHODS: The medical records of 178 created arteriovenous fistulae in patients with CKD stage 4/5, were retrospectively studied. Primary failure of AVF was defined as thrombosis or inability for cannulation of AVF within 3 months. Adequate maturation of AVF was defined as successful cannulation of AVF treatment and blood flow of > 600 ml/min. RESULTS: The mean age of the patients was 59.75 ± 14.65 years, and 65.16% (116/178) were men. Adequate maturation of AVF was achieved in 83.71% (149/178). Primary failure of AVF occurred in 16.29% (29/178) of the created fistulae, while 10.11% (18/178) had early thrombosis. The distal arteriovenous fistulae were significantly more frequently created in male patients (51 vs 18; p = 0.015). The female patients were significantly older than the male patients (63.27 vs 57.86 years; p = 0.018). CONCLUSION: Male gender was associated with better maturation of AVF. The age, number and location of AVF, and primary renal disease in patients with CKD stage 4/5 were not associated with primary failure of AVF.

Complications and Risks of Percutaneous Renal Biopsy.

BACKGROUND: Renal biopsy performed in native and transplant kidneys is generally considered a safe procedure. AIM: In this study, we evaluated renal biopsy complications and risk factors in one nephrology facility. MATERIAL AND METHODS: We conducted a three-year retrospective study on patients who underwent renal biopsy between January 2014 and December 2016. Strict written biopsy protocol was followed. Clinical and laboratory data were obtained from medical charts. Complications were categorised as minor and major, according to the need for intervention. Minor complications included macrohematuria and/or hematoma that did not require intervention. Major complications included hematuria or hematoma with fall of hematocrit that required a blood transfusion, surgery or caused death. A binary logistic regression model was used to analyse the possible factors associated with complications after the biopsy. RESULTS: We analysed 345 biopsies; samples were taken from patients aged from 15-81 years, of whom 61% were men. A total of 21 (6%) patients developed a complication, 4.4% minor and 1.7% major complications. There were no nephrectomy or death due to biopsy intervention. Overweight patients, as well as those with higher creatinine, lower hemoglobin, higher blood pressure and biopsy due to AKI had higher chances to develop complications (p = 0.037, p = 0.023, p = 0.032, p = 0.002, p = 0.002, respectively). The patients' age, gender, kidney dimension, number of passes and uninterrupted aspirin therapy were not found as significant predictors of complications. In the multivariate logistic model, body weight (OR = 1.031, 95%CI = 1.002-1.062), lower hemoglobin (OR = 0.973, 95%CI = 0.951-0.996) and hypertension (OR = 1.025, 95%CI = 1.007-1.044) increased the risk of complications in biopsied patients. CONCLUSION: Renal biopsy is a safe procedure with a low risk of complications when strict biopsy protocol is observed. Correction of anaemia and blood pressure is to be considered before the biopsy.

Quality of Life-Repeated Measurements Are Needed In Dialysis Patients.

BACKGROUND: There is a general agreement that, besides survival, the quality of life is a highly relevant outcome in the evaluation of treatment in patients with the end-stage renal disease. Moreover, it is very important to determine whether the quality of life impacts survival. AIM: This study aims to assess whether changes or absolute scores of the quality of life (QOL) measurements better predict mortality in dialysis patients. MATERIAL AND METHODS: In a longitudinal study comprising 162 prevalent hemodialysis patients QOL was assessed with the 36-item - Short Form Health Survey Questionnaire (SF-36) at baseline and after 12 months. Patients were followed for 60 months. Mortality risk was assessed using Cox proportional hazards analysis for patients with below and above median levels of both physical and mental QOL component scores (PCS and MCS, respectively). RESULTS: At the beginning of the study the mean Physical Component score was 47.43 ± 26.94 and mean Mental Component Score was slightly higher 50.57 ± 24.39. Comparative analysis of the changes during the first year showed a marked deterioration of all quality of life scores in surviving patients. The 5-point decline for PCS was noted in 39 (24%) patients and 42 (26%) for MCS. In the follow-up period of 60 months, 69 (43%) patients died. In the Cox analysis, mortality was significantly associated with lower PCS: HR = 2.554 [95% confidence interval (CI): 1.533-4.258], (P < 0.000) and lower MCS: 2.452 (95% CI: 1.478-4.065), P < 0.001. The patients who had lower levels of PCS and MCS in the second QOL survey 1 year later, had similarly high mortality risk: 3.570 (95% CI: 1.896-6.727, P < 0.000); 2.972 (95% CI: 1.622-5.490, P < 0.000), respectively. The hazard ratios for mortality across categories for the change of PCS and MCS were not significant. In the multivariate model categorising the first and second scores as predictors and adjusted for age, only the second PCS and MCS score were associated with mortality. CONCLUSION: Low QOL scores are associated with mortality in repeated measurements, but only the more recent overwhelmed the power of the decline.

Carnitine Palmitoyltransferase II Deficiency (CPT II) Followed By Rhabdomyolysis and Acute Kidney Injury.

BACKGROUND: Carnitine palmitoyltransferase II deficiency (CPT II) is an autosomal recessive disorder and the most common inherited disorder of mitochondrial long-chain fatty acid oxidation, characterised by attacks of myalgia and myoglobinuria. The most common "classic" myopathic form occurs in young adults and is characterised by recurrent episodes of rhabdomyolysis triggered by prolonged exercise, fasting or febrile illness. CASE PRESENTATION: We present a case of a 22-year-old Caucasian male admitted to our hospital with fever, dyspnea, fatigue, myalgia and dark urine (brown-coloured). The symptoms appeared after viral infection followed by fever. Acute kidney injury (AKI) developed as a complication, and there was a need for treatment with hemodialysis. At the clinical presentation, the patient had plasma creatine kinase (pCK) level of 130.383 U/L and plasma myoglobin level over 5000 µg/L. Genetic testing (molecular analysis) confirmed the diagnosis of inherited rhabdomyolysis, a metabolic disorder of carnitine palmitoyltransferase II deficiency. A previous episode with the same symptoms, the patient had four years ago but did not ask for medical treatment. The patient was discontinued from hemodialysis because of the resolution of acute kidney injury. The patient was discharged from the hospital in good condition, with a recommendation about his future lifestyle in order to prevent similar episodes. CONCLUSION: Every patient presenting with myalgia, dark urine (brown-coloured), high level of pCK and development of AKI requiring hemodialysis, should be explored for inherited rhabdomyolysis induced by CPT II deficiency.

Hepatitis C Virus Infection in Kidney Transplant Patients: Current Treatment Options.

Hepatitis C virus infection is highly prevalent among kidney transplant recipients, occurring consequently to their previous treatment with hemodialysis. Hepatitis C virus infection has been associated with lower graft and patient survival compared with that shown in patients without infection. The lower survival has been associated with the posttransplant progression of liver disease and increased risk for development of extrahepatic complications. The choice of immunosuppressive drugs could significantly affect the course of the infection with an accelerated viral replication after kidney transplant. Eradicating hepatitis C virus infection with antiviral treatment is imperative to increasing graft and patient survival after transplant. Antiviral treatment options include standard interferon-based therapy and new directacting antiviral agents. Interferon-based treatment is rarely used in kidney transplant recipients because it has been associated with high risk of interferoninduced acute graft rejection. Several novel studies have shown that the new direct-acting antiviral agents are highly efficacious for treatment of hepatitis C infection in kidney transplant patients.