Biopsy-proven BK virus nephropathy in renal transplant recipients: A -multi-central study from Turkey (BK-TURK STUDY).

AIM: BK polyomavirus infection is a challenging complication of renal transplantation. The management is not standardized and is based on reports from transplantation centers' experiences, usually with small sample sizes. Therefore, we aimed to present our countrywide experience with BK virus nephropathy (BKVN) in renal transplant recipients. MATERIALS AND METHODS: Our study was carried out with the participation of 30 transplantation centers from all regions of Turkey. Only cases with allograft biopsy-proven BKVN were included in the study. RESULTS: 13,857 patients from 30 transplantation centers were screened, and 207 BK nephropathy cases were included. The mean age was 46.4 ±  13.1 years, and 146 (70.5%) patients were male. The mean time to diagnosis of BK nephropathy was 15.8 ± 22.2 months after transplantation. At diagnosis, the mean creatinine level was 1.8 ±  0.7 mg/dL, and the mean estimated glomerular filtration rate was 45.8 ± 19.6 mL/min/1.73m2 . In addition to dose reduction or discontinuation of immunosuppressive drugs, 18 patients were treated with cidofovir, 11 patients with leflunomide, 17 patients with quinolones, 15 patients with intravenous immunoglobulin (IVIG), 5 patients with cidofovir plus IVIG, and 12 patients with leflunomide plus IVIG. None of the patients receiving leflunomide or leflunomide plus IVIG had allograft loss. During follow-up, allograft loss occurred in 32 (15%) out of 207 patients with BK nephropathy. CONCLUSION: BKVN is still a frequent cause of allograft loss in kidney transplantation and is not fully elucidated. The results of our study suggest that leflunomide treatment is associated with more favorable allograft outcomes.

Trends of primary glomerular disease in Turkey: TSN-GOLD registry report.

BACKGROUND: Although several renal biopsy registry reports have been published worldwide, there are no data on primary glomerular disease trends in Turkey. METHODS: Three thousand eight-hundred fifty-eight native kidney biopsy records were assessed in the Turkish Society of Nephrology Primary Glomerulopathy Working Group (TSN-GOLD) Registry. Secondary disease and transplant biopsies were not recorded in the registry. These records were divided into four periods, before 2009, 2009 to 2013, 2013-2017, and 2017-current. RESULTS: A total of 3858 patients (43.6% female, 6.8% elderly) were examined. Nephrotic syndrome was the most common biopsy indication in all periods (58.6%, 53%, 44.1%, 51.6%, respectively). In the whole cohort, IgA nephropathy (IgAN) (25.7%) was the most common PGN with male predominance (62.7%), and IgAN frequency steadily increased through the periods (× 2 = 198, p < 0.001). MGN was the most common nephropathy in the elderly (> 65 years), and there was no trend in this age group. An increasing trend was seen in the frequency of overweight patients (× 2 = 37, p < 0.0001). Although the biopsy rate performed with interventional radiology gradually increased, the mean glomeruli count in the samples did not change over the periods. CONCLUSIONS: In Turkey, IgAN is the most common primary glomerulonephritis, and the frequency of this is increasing.

Bacillus Calmette-Guérin-induced perinuclear antineutrophil cytoplasmic antibodies associated vasculitis in bladder cancer.

Intravesical instillation of Bacillus Calmette-Guérin (BCG) immunotherapy remains the most effective adjuvant treatment for noninvasive bladder cancer. Systemic BCG-related complications are rare and usually related to infective agent or an immune-mediated reaction. We discussed a case with perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) vasculitis, developing after instillation of BCG for non-invasive bladder cancer. A 68-year-old man presented with nephritic syndrome a few months after BCG instillations which was performed for his non-muscle-invasive bladder cancer adjuvant therapy. The renal function had declined slowly after the first instillation and urinary sediment reveals the new onset of nephritic proteinuria and hematuria. High titer of p-ANCA was present. His renal biopsy was consistent with acute renal vasculitis. The patient's creatinine level regressed with immunosuppressive therapy and he was clinically followed up without hemodialysis. Here, we presented a patient that diagnosed as p-ANCA related vasculitis occurred after BCG instillation.

Can robot-assisted kidney transplantation provide higher quality of life than open kidney transplantation during the early postoperative period?

PURPOSE: Purpose of this study is to investigate the quality of life (QoL) in patients with end-stage renal disease who underwent open or robot-assisted kidney transplantation (OKT and RAKT). MATERIALS AND METHODS: Patients who underwent OKT and RAKT at Bakirkoy Sadi Konuk Training and Research Hospital between June 2016 and December 2018 constituted the target population of this study. The patient group was divided into two groups as per the surgical technique (ie, open vs. robot-assisted). Demographic data, preoperative and postoperative data of all patients were collected prospectively. The QoL of the patients was assessed preoperatively and on the postoperative 30th day. RESULTS: Sixty-seven patients who underwent OKT and 60 patients who underwent RAKT were included. The mean patient age and BMI were calculated as 40.9 ± 11.6 years and 24.4 ± 2.9 kg/m2 , respectively. Patients in the RAKT group were significantly younger than the patients in the OKT group (P = .002). There were no significant differences between the two groups in terms of gender, BMI, ASA and the ratio of premptive patients. The mean preoperative hemoglobin level was significantly higher in the OKT group than the RAKT group (P = .003). While mean total ischemia time was shorter in the "open" group, intraoperative blood loss and incision length were shorter in the RAKT group. Duration of surgical drainage and hospital stay was shorter in the "robot-assisted" group. There was no significant difference between the groups in terms of SF-36 subparameters preoperatively. The physical component scores of the QoL questionnaire revealed that postoperative impairment of quality of life in the early postoperative period was more significant in the OKT than the RAKT. CONCLUSION: Patients who underwent RAKT have a higher QoL than the patients who were treated with OKT as per their self-reported QoL scores in the early postoperative period.

Demographic, clinical and laboratory characteristics of rapidly progressive glomerulonephritis in Turkey: Turkish Society of Nephrology-Glomerular Diseases (TSN-GOLD) Working Group.

BACKGROUND: In our study, diagnostic and demographic characteristics of patients diagnosed with RPGN by biopsy, clinical and laboratory findings in our country were investigated. METHODS: Data were obtained from the Turkish Society of Nephrology Glomerular Diseases (TSN-GOLD) Working Group database. Demographic characteristics, indications for biopsy, diagnosis of the glomerular diseases, comorbidities, laboratory and biopsy findings of all patients were recorded. According to their types, RPGN patients were classified as type 1 (anti-GBM related), type 2 (immuncomplex related) and type 3 (pauci-immune). RESULTS: Of 3875 patients, 200 patients with RPGN (mean age 47.9 ± 16.7 years) were included in the study which constitutes 5.2% of the total glomerulonephritis database. Renal biopsy was performed in 147 (73.5%) patients due to nephritic syndrome. ANCA positivity was found in 121 (60.5%) patients. Type 1 RPGN was detected in 11 (5.5%), type 2 RPGN in 42 (21%) and type 3 RPGN in 147 (73.5%) patients. Median serum creatinine was 3.4 (1.9-5.7) mg/dl, glomerular filtration rate was 18 (10-37) ml/min/1.73m2 and proteinuria 2100 (1229-3526) mg/day. The number of crescentic glomeruli ratio was ratio 52.7%. It was observed that urea and creatinine increased and calcium and hemoglobin decreased with increasing crescentic glomerular ratio. CONCLUSIONS: Our data are generally compatible with the literature. Advanced chronic histopathological findings were prominent in the biopsy of 21 patients. Early biopsy should be performed to confirm the diagnosis of RPGN and to avoid unnecessary intensive immunosuppressive therapy. In addition to the treatments applied, detailed data, including patient and renal survival, are needed.

Leptospirosis With Acute Renal Failure and Vasculitis: A Case Report.

Leptospirosis is a zoonotic disease that occurs worldwide. Various clinical manifestations of leptospirosis can be seen. In this article, we present a case with acute renal failure, severe vasculitis and hyperbilirubinemia occurring simultaneously with leptospirosis. A 45-year-old male patient presented with fever, myalgia, jaundice and reddish skin lesions and anuria. Physical examination findings were icteric sclera, large tender hepatomegaly, and lower extremities' cutaneous necrosis due to vasculitis. Hemodialysis was started. Kidney biopsy revealed degenerative changes of proximal tubules, some of them containing bile casts. Microscopic agglutination test was positive and consistent with leptospirosis. Intravenous ampicillin and oral tetracycline were started. Methylprednisolone 60 mg per day was given for skin vasculitis. Hemodialysis therapy was discontinued. All clinical findings gradually regressed.

Evaluation of kidney biopsies in elderly patients.

OBJECTIVE: The renal parenchymal disease spectrum in geriatric patients is similar to that in younger patients and can be controlled by appropriate treatment. We evaluated the clinicopathological features of kidney biopsies from geriatric patients. MATERIALS AND METHODS: One hundred nine native kidney biopsies from older patients (> 65 years old) obtained from 2005 to 2014 were evaluated retrospectively. The specimens were inspected by the same pathologist in the same laboratory by light microscopy and immunofluorescence. RESULTS: The mean age of the patients was 72.4 ± 7.8 years (range 65-90 years), and 51.3% were female. The most frequent indication for kidney biopsy was proteinuria at the nephrotic level (56.8%). The most frequent histopathological diagnoses were focal segmental glomerulosclerosis in primary glomerulonephritis and secondary amyloidosis in secondary glomerulonephritis. The rate of major complications due to kidney biopsy was < 1%. RESULT: Kidney biopsy is an effective and safe method of evaluating renal parenchymal diseases in older patients.

The Factors Affecting Survival in Geriatric Hemodialysis Patients.

INTRODUCTION: The number of geriatric patients is increasing in hemodialysis population over the years and mortality is higher in this group of patients. This study evaluated the factors affecting geriatric hemodialysis patient survival. MATERIALS AND METHODS: This retrospective cohort study enrolled patients discharged from our nephrology clinic from 2009 to 2014. Data collected included demographics, Eastern Cooperative Oncology Group-Performance Status, vascular access type, and metabolic parameters. Comorbidity was quantified using the modified Liu comorbidity index. The outcome measure was mortality. RESULTS: The study enrolled 99 elderly dialysis patients (42.4% women (n = 42); mean age 75 ± 7 years). The mean follow-up duration was 19.7 ± 11 months. The mortality rate over the four years was 47.5% (n = 46). The modified Liu comorbidity index score, patient age, and Eastern Cooperative Oncology Group-Performance Status were significantly related to mortality in univariate and multivariate analyses. CONCLUSION: The present study revealed that comorbidities and low performance status at the onset of dialysis had shortened the survival time in the geriatric hemodialysis patient group.

Robot-assisted kidney transplantation: comparison of the first 40 cases of open vs robot-assisted transplantations by a single surgeon.

OBJECTIVE: To compare the outcomes of the first 40 patients to undergo robot-assisted kidney transplantation (RAKT) with those of the first 40 patients who underwent open KT (OKT) by a single surgeon at the Dr Sadi Konuk Training Hospital. PATIENTS AND METHODS: We prospectively collected the data of the first 40 patients to undergo RAKT between January 2016 and February 2017 (RAKT group), and compared them with the first 40 patients to undergo OKT between November 2010 and April 2015 (OKT group). Comparisons were made using one-way analysis of variance or the Kruskal-Wallis test for continuous variables, and the chi-squared or Fisher's exact test for categorical variables. RESULTS: There were 40 patients in both the RAKT and OKT groups. In the RAKT group, the mean (SD) operative time was 265.375 (46.63) min, total ischaemia time was 96.7 (30.02) min, re-warming time was 54.70 (17.80) min, and estimated blood loss (EBL) was 182.25 (55.26) mL. Whilst in the OKT group the mean (SD) operative time was 250.25 (41) min (P = 0.129), total ischaemia time was 71.79 (8.55) min (P < 0.01), re-warming time was 37.30 (4.07) min (P < 0.001), and EBL was 210.75 (28.96) mL (P = 0.005). At 12-24 h postoperatively, linear visual analogue scale pain scores were significantly lower in the RAKT group (P < 0.001), and the RAKT group had a significantly shorter drain withdrawal time, at a mean (SD) of 3.45 (0.93) vs 7.67 (2.11) days in the OKT group (P < 0.001). CONCLUSION: Satisfactory functional outcomes can be achieved by either OKT or RAKT. However, the latter technique seems to have some advantages over the former in that it is less invasive, results in less pain postoperatively, has a shorter drain withdrawal time, and has the potential for fewer complications.

Robotic kidney transplantation: The Bakirköy experience.

OBJECTIVE: Robotic kidney transplantation, first described by Hoznek and colleagues, and has been improved by investigators like Oberholzer and Menon. We realized the first robotic kidney transplant (RKT) in our clinic in December 2015. In this study, we aimed to present the first 15 cases we performed within 3 months. MATERIAL AND METHODS: Starting from January 2016, we performed 15 RKTs in our hospital. Before surgery, the whole robotic procedure was thoroughly explained to the patients and their informed consents were taken. RESULTS: We performed RKT in 7 male and 8 female patients. Mean patient age was 37.4±10.8 years. Mean body mass index of the patients was 22.6±3.35 kg/m2. Mean preoperative creatinine and hemoglobin levels were 6.14±2.12 mg/dL and 10.04±1.64 g/dL, respectively. Mean operative time was 300.3±104.2 minutes. Mean warm ischemia and re-warming times were 1.9±0.54 minutes and 73.3±30.7 minutes, respectively. We did not need any necessity to switch to open surgery, and any intraoperative complication did not develop in any patient. Lymphocele which is one of the most frequently encountered complications was not observed in our series. CONCLUSION: We think that using a minimally invasive approach greater number of patients will be able to benefit from this treatment modality, and this important health issue may decrease significantly.

Brown Tumors: A Case Report and Review of the Literature.

Brown tumors are focal bone lesions, encountered in patients with uncontrolled hyperparathyroidism. They can be located in any part of the skeleton. Clinically significant lesions in the craniofacial bones are rare. Craniofacial involvement may cause facial disfiguration and compromise social ease of the patient and normal functions, such as chewing, talking, and breathing. In this case report, we present a patient with a brown tumor of the craniofacial bones provoked by secondary hyperparathyroidism and review the last 10 years of craniofacial brown tumors associated with secondary hyperparathyroidism in the English literature.

Prophylactic Eculizumab Use in Kidney Transplantation: A Review of the Literature and Report of a Case with Atypical Hemolytic Uremic Syndrome.

BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is a very rare disease, which presents with microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Progression to end-stage renal disease (ESRD) from acute kidney injury is observed in 60% of aHUS cases. The prognosis of aHUS patients who undergo kidney transplantation (Ktx) is generally poor, but these patients should be treated prophylactically with eculizumab to prevent recurrence after transplantation. CASE REPORT: An 18-year-old man was referred to our center with a history of rapid progression to ESRD with unknown etiology. He had anemia, thrombocytopenia, high levels of LDH, and indirect bilirubin and creatinine on initial laboratory results. Our diagnosis was aHUS due to initial results, normal level of ADAMTS activity, and lack of predisposing factors seen in typical HUS. We planned to perform genetic analysis for the patient and the donor candidate (mother). The variations found on exon 7 of the CFH gene had not been reported previously. According to PolyPhen analysis, this mutation was reported as a potential cause for aHUS. We decided to perform Ktx under eculizumab prophylaxis. Weekly administration of prophylaxis was extended to 1 month. The graft functioned immediately after Ktx. The patient has completed his first year uneventfully in our follow-up, with a creatinine 0.79 mg/dl at his last control visit. CONCLUSIONS: We found favorable results of an aHUS case successfully treated with kidney transplantation combined with short-term prophylactic eculizumab therapy.

Coronary artery calcification and chronically decreased GFR in living kidney donors.

BACKGROUND: In the presence of decreased glomerular filtration rate (GFR), the risk of morbidity and mortality caused by cardiovascular disease (CVD) is increased markedly. Increased coronary artery calcification (CAC) is proposed as a pathogenetic link between CVD and chronic kidney disease. We examined the frequency and severity of CAC in living kidney donors to test the hypothesis that decreased GFR is associated with increased CAC. METHODS: We used multidetector spiral computed tomography to examine CAC in 101 living kidney donors and 99 age- and sex-matched healthy control subjects without diabetes and a history of coronary artery disease. The extent of calcification was measured by means of the Agatston score. GFR was calculated by using the abbreviated Modification of Diet in Renal Disease formula. The frequency of risk factors for coronary artery disease was compared in kidney donors and controls, and the relation between kidney donors' clinical characteristics and the presence or absence of CAC was examined. RESULTS: CAC frequency and mean calcification scores were similar between kidney donors (13.9%; 4.5 +/- 22.6) and controls (17.2%; 13.2 +/- 89.2). CAC was not associated with decreased GFR, and the correlation between CAC and GFR was not statistically significant. Kidney donors with calcification were more likely to be older (P = 0.003) and male (P = 0.001). Age- and sex-adjusted analysis showed an association between greater parathormone levels (odds ratio, 1.023; 95% confidence interval, 1.001 to 1.045; P = 0.037) and CAC in kidney donors. CONCLUSION: A mild decrease in GFR without the presence of diabetes does not seem to be associated with increased CAC. These findings need to be confirmed in different and larger study populations.

Intracranial calcification and tumoural calcinosis during vitamin D therapy.

Extraskeletal calcifications are frequently observed in patients with chronic renal failure. However, clinically, they usually remain silent. In this report, we describe two patients with massive extraskeletal calcifications that caused significant morbidity. The first patient had tumoural calcification located on the shoulder and the second patient had severe neurological symptoms caused by intracranial calcifications. High calcium phosphorus product and severe secondary hyperparathyroidism were present in both patients. Furthermore, they both received inappropriately high doses of active vitamin D, even though they failed to respond to this therapy. We suggest to monitor closely the calcium, phosphorus and parathyroid hormone levels during calcitriol therapy and to perform parathyroidectomy, without delay, in patients who were resistant to calcitriol.