Idiopathic portal hypertension during a catastrophic attack in a patient with primary antiphospholipid syndrome.

A 43-year old male patient with hyponatremic hypertensive syndrome was diagnosed as catastrophic primary antiphospholipid syndrome (PAPS). He subsequently developed hepatosplenomegaly. The patient also carried thrombophilia- and haemochromatosis-associated gene mutations. Further investigations upon persistence of splenomegaly indicated development of idiopathic portal hypertension.

Doxazosin, but not amlodipine decreases insulin resistance in patients with chronic renal failure: a prospective, randomized-controlled study.

Insulin resistance (IR) in chronic renal failure (CRF) is well-known. In this randomized-controlled study, we aimed to compare the effect of doxazosin and amlodipine on IR in patients with CRF. Fifteen patients with CRF (male/female: 5/10, mean age: 46 +/- 13 years) and 9 controls (male/female: 3/6, mean age: 35 +/- 8 years) were included. Patients and controls had no family history of diabetes mellitus. Homeostasis model assessment (HOMA) was calculated as a marker of IR. Patients were grouped randomly to doxazosin (n = 8; 2-4 mg/day) and amlodipine (n = 7; 5-10 mg/day) arms. Baseline biochemical analysis (fasting serum glucose, BUN, creatinine, uric acid, cholesterol and cholesterol subgroups) and parameters related with insulin metabolism (insulin, C peptide, HOMA) were similar between amlodipine and doxazosin groups. There was no difference in age, gender and body mass index among study groups. The follow-up time was 12 weeks. Patients with CRF had higher HOMA (1.83 +/- 0.55 vs 1.00 +/- 0.36, p = 0.001), fasting insulin (8.06 +/- 1.98 vs 4.46 +/- 1.31 IU/l, p < 0.001) and serum triglyceride levels (197 +/- 136 vs 112 +/- 67 mg/dl, p = 0.04) as compared to controls. Serum HDL cholesterol levels were significantly lower in patients with CRF than controls (40 +/- 10 vs 57 +/- 14 mg/dl, p = 0.02). HOMA significantly decreased after doxazosin (1.91 +/- 0.45 vs 1.41 +/- 0.21, p = 0.02), however, no difference was found after amlodipine. Also, fasting insulin levels were decreased after a 12-week doxazosin therapy from 8.17 +/- 1.22 vs 6.58 +/- 0.84 IU/l, p = 0.02), but no change was seen after amlodipine. Lipid parameters did not significantly change during the study period in 2 groups. No adverse effect requiring drug discontinuation was observed during the 12-week period in the study groups. In conclusion, doxazosin decreases IR in patients with CRF, whereas amlodipine has no effect. This may be of advantage in the treatment of hypertension in this group of patients for preventing some long-term complication of IR.

Outcome of living unrelated (commercial) renal transplantation.

BACKGROUND: Due to inadequate cadaveric and living related organ supply, many end-stage renal disease patients go to Third World countries for commercial transplantation, although the high risk of complications is well established and ethical arguments debate this practice. METHODS: The midterm outcome of 115 patients who had been commercially transplanted in various countries and admitted to our center for post-transplant care and follow-up between 1992 and 1999 was retrospectively analyzed. Data considering the transplantation practice and post-transplant course were collected from the patient files. Outcome of these patients was compared with those with a living related transplant performed at our center. RESULTS: The patients (91 male and 24 female; mean age of 42 +/- 12 years) were transplanted in India (N = 106), Iraq (N = 7), and Iran (N = 2). The mean follow-up period was 64.5 +/- 23.9 months. Post-transplant course was complicated by numerous surgical and/or medical complications, and many of the latter were unconventional infections caused by malaria, invasive fungal infections, and pneumonia due to various opportunistic pathogens. Overall, 52 patients still have functioning allografts, while 22 lost their grafts, 20 died, and 21 were lost to follow-up. Graft survival rates at two, five, and seven years were 84, 66, and 53%, respectively, for the study group, while it was 86, 78, and 73% for living related transplantations performed at our center (P = 0.036). Patient survival rates for the same periods were 90, 80, and 74% for the study group and 90, 85, and 80% for the living related transplantations (P = 0.53). CONCLUSIONS: Besides the ongoing ethical debate, commercial transplantation carries a high risk of unconventional complications, and despite that the patient survival rate is comparable, graft survival is worse than conventional living related transplantations at the midterm.

Successful therapy combined with surgery for severe post-transplant nocardiosis.

We report a case of a 35-year-old man with nocardiosis infection involving soft tissue and the central nervous system who had received a cadaveric donor kidney. The patient was admitted with fever, malaise and right shoulder pain. Soft tissue abscess was seen on ultrasound examination. It was presumed due to gram (+) microorganisms, so 4 g day (IV) ampicillin/sulbactam was started empirically once the abscess was drained. Nocardia asteroides was found in the pus specimen. On the second day in hospital, severe headache, ataxia and signs of meningeal irritation appeared. The cranial CT showed two intracranial abscesses in the frontal lobe and cerebellum. We assumed Nocardia asteroides was the infective agent for the cerebral abscesses, so antibiotic therapy was switched to trimethoprim-sulphamethox-asole (3x160/800 mg/d). Nausea and vomiting occurred on the fifth day of therapy, improving after drainage from the frontal abscess. However, these complaints recurred five days later. CT showed cerebellar abscess had become bigger. The patient's complaints improved after the second surgical drainage. N. asteroides was again grown in the aspiration fluids of both cerebral abscesses. Complete regression of the abscesses was seen in the CT after two months. Co-trimoxazole was continued for six months then withdrawn. Graft dysfunction was not observed. Early medical and surgical interventions may be life-saving in this potentially lethal disease.

The outcome of patients presenting with crush syndrome after the Marmara earthquake.

In this study, we evaluated the clinical and laboratory data of the patients presenting after the Marmara earthquake. Crush syndrome was diagnosed in 60 patients (30 M, 30 F, mean age: 31.3+/-13.8 years). They were buried under the rubble for a mean period of 12.3+/-15.1 hours. On admission, 27 patients were oligoanuric and the mean serum creatinine, creatinine phosphokinase and potassium levels were 4.4+/-3.2 mg/dl, 18453.1+/-24527.2 IU/L, and 4.9+/-1.7 mEq/L, respectively. The most frequent site of trauma was the lower extremity. Dialysis treatment was initiated in 40 patients (19 M, 21 F; mean age: 32.7+/-13.0 years). Mean number of hemodialysis sessions/patient was 8.9+/-6.8. Nine (23%) patients among the dialyzed and 4 (20%) among the non-dialyzed died leading to an overall mortality of 21.6%. This low mortality rate suggests that the death rate from acute renal failure due to crush syndrome could be decreased by extensive follow-up.

Immunization of renal transplant recipients with pneumococcal polysaccharide vaccine.

BACKGROUND: Streptococcus pneumoniae, a common pathogen leading to pneumonia, is a cause of morbidity and mortality in immunosuppressed patients. Vaccination against this agent can be recommended for immunosuppressed patients, including those with chronic renal failure, nephrotic syndrome and renal transplant recipients; however, a diminished immune response and loss of protective antibodies have been observed. PATIENTS AND METHODS: In our prospective study, the efficacy and side effects of polyvalent pneumococcal vaccination were investigated in renal transplant recipients. A total of 21 patients (6 female, 15 male) with well-functioning renal allografts, who had transplant surgery at least 2 months before, were included in the study. The patients were stratified according to the immunosuppressive protocol and 8 received double, while 13 received triple, immunosuppressive agents. After obtaining basal serum samples, all cases were vaccinated with the 0.5 mL intramuscular administration of polyvalent polysaccharide pneumococcal vaccine (Pneumo 23 Pasteur Merieux, lot No: K 1131). RESULTS: Following a mean of 6 wk in all patients and also a mean of 12 wk in 12 patients, serum samples were again obtained to measure pneumococcal antibodies. Antibody titers following 6 and 12 wk of vaccination were significantly higher, as compared with basal values in all patients, except one. These titers did not show any statistically significant difference between double and triple therapies. There was no significant difference between the 12th and 6th wk postvaccination antibody titers. No systemic or local adverse effects were observed. CONCLUSION: Pneumococcal vaccination is safe and effective in patients with well-functioning renal allografts, at least in the short term. This vaccination policy may be useful for preventing invasive pneumococcal disease in immunosuppressed patients.

Clinical outcomes of renal cholesterol crystal embolization.

Cholesterol crystal embolization is an increasingly recognized disease, presenting with a wide clinical spectrum, usually occurring in elderly men who undergo an angiographic procedure or vascular surgery. We report three patients who developed systemic cholesterol embolic disease and varying degrees of renal failure after angiographic interventions of the coronaries.

Kaposi's sarcoma after renal transplantation in Turkey.

In this report, incidence and clinical characteristics of Kaposi's sarcoma (KS) were retrospectively analyzed among renal transplant recipients who were being followed-up in the outpatient clinic of the Istanbul School of Medicine. Between October 1983 and December 1997, 17 cases of KS were diagnosed among 557 patients (3%). Of the total 25 post-transplant malignancies, KS was the most common tumor, representing a rate of 68%. Diagnosis was suspected with typical skin lesions and was confirmed by biopsy. Gastroduodenal endoscopy was applied to 7 patients in order to assess gastrointestinal tract involvement. Of the total number of patients diagnosed with KS 14 were male and 3 female, with the mean age of 40 +/- 15 (range 13-68) yr. The mean duration between the date of transplantation and diagnosis of KS was 15.9 +/- 20.3 (range 1-65) months. The lesions were limited to the skin in 13 patients, while skin and gastrointestinal tract were involved in 2 patients and generalized disease was noted in 2 patients. The initial therapeutic approach was to withdraw cyclosporine and to reduce azathioprine. In the case of progression of the lesions azathioprine was also stopped. Besides, surgical excision of the lesions, radiotherapy and/or chemotherapy were performed according to the clinical picture. Remission was observed in 14 patients after this therapy protocol. The 2 patients with gastrointestinal involvement and 1 patient with generalized KS died in spite of the above-mentioned therapeutic interventions. One of the patients on remission died of pneumonia. It was concluded that KS carried a high risk of morbidity and mortality in renal transplant recipients, and tapering of immunosuppression, especially withdrawal of cyclosporine, affected the prognosis favorably.