Efficacy of mTOR Inhibitors and Intravenous Immunoglobulin for Treatment of Polyoma BK Nephropathy in Kidney Transplant Recipients: A Biopsy-Proven Study.

OBJECTIVES: We investigated the efficacy of a predetermined protocol that consisted of immunosuppressive drug reduction/withdrawal and intravenous immunoglobulin administration for the treatment of polyoma BK virus nephropathy. MATERIALS AND METHODS: Patients with biopsy-proven polyoma BK virus nephropathy received a treatment regimen based on discontinuation of both calcineurin inhibitors and antiproliferative agents and switching to mTOR inhibitors accompanied by intravenous immunoglobulin administration. RESULTS: Our study included 508 patients, with polyoma BK viremia detected in 80 patients. The mean age was 45.3 ± 9.5 years (range, 18-71 y), 64% were male, and mean follow-up was 37 ± 21 months (6-94 mo). All 16 patients who developed polyoma BK virus nephropathy and 9 patients who had highgrade polyoma BK viremia without nephropathy received intravenous immunoglobulin treatment. Compared with patients with viremia, patients with polyoma BK virus nephropathy had significantly higher rates of graft loss due to rejection (18.8% vs 1.6%; P = .024) and all-cause graft loss (31.2% vs 6.3%; P = .014). Histopathologically, viral inclusion bodies disappeared and SV40 became negative after treatment in all 13 patients who underwent protocol biopsies. Unfortunately, histopathologically complete recovery without chronic tubular and interstitial tissue damage was achieved in only 4 patients after treatment. In addition, 3 patients lost their grafts due to acute antibody-mediated or mixed-type rejection (18.8%). CONCLUSIONS: In patients with polyoma BK virus nephropathy, clearance of viremia and SV40 should not be the sole outcomes to obtain. Aggressive reductions in maintenance immunosuppression and switching to double-drug therapy combined with high-dose intravenous immunoglobulin leads to high rates of graft loss/rejection and sequalae of chronic histological changes.

The Oncologic Safety of Sentinel Lymph Node Biopsy in Patients with Node-Positive Breast Cancer with Complete Response to Neoadjuvant Chemotherapy: A Single-Center Experience.

Objective: To evaluate the efficiency and safety of sentinel lymph node biopsy (SLNB) in patients with breast cancer with complete response to neoadjuvant chemotherapy (NAC). Methods: Ninety-two consecutive (T1-4 and N1-2) patients with breast cancer who had pathologic and/or clinical and radiologic axillary lymph node involvement were included. All patients received NAC. Patients with a clinical and radiologic complete response in the axilla after NAC underwent SLNB. Pathologic complete response (ypCR) was defined as the absence of residual invasive and in situ cancer, and near-complete response (ypNCR) represented in situ and/or ≤ 1 mm residual tumor in the breast and/or presence of malignant cell clusters (≤0.2 mm) and/or micrometastases (≤2.0 mm) in the axillary lymph nodes (ALN) (ypTis/T1mi, ypN0i+/pN1mi). Results: The mean age of the 92 patients was 49.6 ± 10.3 years and the mean follow-up was 34.0 ± 17.8 months. With respect to breast tumors, 23 (25.0%) patients had complete and 14 (15.2%) had a near-complete response to NAC. Complete response in ALN was obtained in 39 (42.4%) patients and near-complete in six (6.5%) patients. The overall survival of the 33 patients who achieved ypCR and ypNCR was 100% and the remaining 59 patients with partial or no response to NAC was 83.1% at a mean follow-up of 34 months (p=0.063). Conclusions: In this study, no event developed in cases with ypCR and ypNCR in the breast and axilla. The persistence of the same results in long-termfollow-ups may enable the use of ypNCR as a positive prognostic marker in addition to ypCR.

Gastrointestinal Tract Metastases of Invasive Lobular Carcinoma of the Breast: An Immunohistochemical Survey Algorithm.

Invasive lobular carcinoma (ILC) accounts for almost 15% of all breast carcinomas. The potential of ILC to metastasize to the gastointestinal system is significantly greater than that of invasive ductal carcinoma. Gastric metastasis occurred in the ninth year of the follow-up in a patient who was operated on the right breast due to ILC. The patient was investigated for simultaneous masses in the stomach and colon, and a random mass was found in her right breast.

Hearing Impairments as an Overlooked Condition in Kidney Transplant Recipients.

It is not known whether hearing disorders improves with kidney transplantation. One of the neurotoxic effects of immunosuppressive drugs may be unrecognized hearing loss. In this study, our aim was to evaluate the hearing disorders in kidney transplant patients. Hearing problems in 46 kidney transplant patients [eGFR ≥ 60 ml/min/1.73 m2 (30 Tacrolimus, 16 mTOR inhibitor users)], 23 hemodialysis patients, and 20 healthy controls were evaluated with a questionnaire and high-frequency audiometry. More than half (58.7%) of the transplant patients had at least one hearing problem. Hearing loss was observed in 50%, 60.9% and 76.1% of the transplant patients at 8,000, 16,000 and 20,000 Hz. Hearing thresholds of transplant and hemodialysis patients increased from 4,000 to 20,000 Hz and was higher than that of controls. Hearing thresholds were higher at 1,000-2,000 Hz in patients using tacrolimus and at 16,000-20,000 Hz in patients using mTOR inhibitor. No correlation was found between hearing threshold and blood tacrolimus or mTOR inhibitor levels. Most kidney transplant and hemodialysis patients have hearing loss at higher frequencies than medium frequencies. Hearing loss in chronic kidney patients is likely to be permanent and kidney transplantation may not improve hearing problems. Hearing problems may be more pronounced at medium frequencies in patients receiving tacrolimus but at higher frequencies in patients receiving mTOR inhibitors.

Acute Allograft Pyelonephritis: Vague Symptoms, Indeterminate Laboratory Results, and the Necessity of Indication Biopsy.

OBJECTIVES: In this study, we examined the clinical and biochemical features of biopsy-proven acute pyelonephritis among 769 kidney transplant recipients. MATERIALS AND METHODS: This cohort study was performed between January 2003 and December 2019 at the University of Health Sciences (Izmir, Turkey). Acute pyelonephritis refers to urinary tract infection with acute graft dysfunction. All patients with suspected acute pyelonephritis underwent diagnostic biopsy and received antibiotic treatment for an average of 14 to 21 days. Patients with acute pyelonephritis (18/769, 2.3%) were categorized into groups of 9 patients each: group 1 developed acute pyelonephritis in the first 6 months, and group 2 developed acute pyelonephritis >6 months posttransplant. RESULTS: All patients in group 1 had acute graft dysfunction; only 2 (22%) were symptomatic. All patients recovered baseline graft function after treatment. Patients in group 2 had at least 2 laboratory findings that included leukocytosis, neutrophilia, and high C-reactive protein values. Six patients had urine culture positivity. Recurrent pyelonephritis occurred in 3 patients. Four patients had graft loss. Over the mean follow-up of 48.0 ± 28.4 months, 14 patients (78%) were alive with a functioning graft. CONCLUSIONS: Diagnostic biopsy is of great importance in patients with urinary tract infection accompanied by acute graft dysfunction in the first 6 months after transplant.

Genitourinary Cancers Following Kidney Transplant: Our 20 Years of Experience With Mechanistic Target of Rapamycin Inhibitors.

OBJECTIVES: We investigated patients with genitourinary cancer after kidney transplant and the effects of immunosuppression reduction and switching to mechanistic target of rapamycin inhibitors. MATERIALS AND METHODS: We retrospectively evaluated kidney transplant recipients seen at our center between January 2000 and January 2020. Patients with <1 year of follow-up were excluded. RESULTS: Of 827 patients, genitourinary cancer was detected in 11 (1.3%): prostate cancer in 5 patients (45%), renal cell carcinoma in native kidney in 3 (27%), renal cell carcinoma in allograft kidney in 2 (18%), and transitional cell carcinoma of the bladder in 1 (9%). All patients had surgery. Two patients had bone metastasis due to prostate cancer at diagnosis. Two patients had allograft nephrectomy due to de novo renal cell carcinoma. Mean follow-up and age were 97 ± 45 months (range, 26-189) and 50 ± 10.2 years (19% female). After cancer diagnosis, excluding the 2 patients with allograft nephrectomy, immunosuppression was changed in 8 patients (88.8%) (1 patient received the same treatment before and after cancer diagnosis). Six patients received double-drug and 3 received triple-drug protocols. Of 9 patients, 2 were already using mechanistic target of rapamycin inhibitors before cancer diagnosis and 7 were switched: 4 to double-based and 3 to triple-based regimens. Six were switched from tacrolimus. With new treatments, patients showed no progressive kidney failure or rejection (38 ± 40 mo average follow-up). At last follow-up, mean glomerular filtration rate was 62.8 ± 34 mL/min/1.72 m2, which was similar to rate at cancer diagnosis (58.9 ± 24 mL/ min/1.72 m2; P = .78). During follow-up, no patients developed local recurrence of primary tumor or new metastasis, and none showed adverse effects after switch to mechanistic target of rapamycin inhibitors. Three patients died of malignancy-unrelated reasons (ileus, urinary sepsis, heart failure). CONCLUSIONS: Mechanistic target of rapamycin inhibitor-based drugs can be an important maintenance immunosuppressive treatment option for kidney transplant recipients with genitourinary cancers.

Outcomes of 6 Human Leukocyte Antigen-Mismatched Living Donor Kidney Transplant: A Study With Biopsy Amendment.

OBJECTIVES: In this study, we examined the graft and patient survival outcomes in patients with end-stage kidney disease who received 6 HLA-mismatched incompatible living donor kidney transplant. MATERIALS AND METHODS: Patients who underwent living donor kidney transplant between January 2010 and March 2020 were evaluated retrospectively. Group A included kidney transplant recipients with 6 HLA mismatches, and group B included kidney transplant recipients with 0 to 5 HLA mismatches. Patients with <1 year of follow-up were excluded. All rejection episodes were diagnosed via Tru-Cut biopsy and histopathological evaluation. RESULTS: There were 15 patients in group A and 176 patients in group B. The mean follow-up was 54.1 ± 30 months. The number of patients who underwent pretransplant immune desensitization and received tacrolimus-based triple maintenance immunosuppression therapy was significantly higher in group A. In group A, there were 13 acute rejections seen in 9 patients (81<); in group B, there were 67 acute rejections seen in 51 patients (28.9<; P = .019). No differences were observed between the groups in terms of baseline glomerular filtration rate (60 ± 16 vs 61.6 ± 20 mL/min/1.72 m2; P = .76), final control glomerular filtration rate (60.7 ± 15 vs 58 ± 19 mL/ min/1.72 m2; P = .59), graft loss (0< vs 4<; P = .94), and mortality (6.6< vs 3<; P = .39). CONCLUSIONS: The presence of 6 HLA mismatches was associated with higher rates of biopsy-proven acute rejection. However, 6 HLA-mismatched incompatible living donor kidney transplant can be safely performed in centers where posttransplant followup is supported by indication and protocol biopsies and where there is a pathological infrastructure with extensive knowledge and experience.

Coexistencia infrecuente de la enfermedad de Tay-Sachs, coartación aórtica y reflujo vesicoureteral de grado V / Rare coexistence of Tay-Sachs disease, coarctation of the aorta and grade V vesicoureteral reflux

La enfermedad de Tay-Sachs es una enfermedad metabólica hereditaria neurodegenerativa. Existen cuatro tipos según el inicio de los síntomas clínicos: infantil, infantil de inicio tardío, juvenil y adulto. El tipo infantil tiene el peor pronóstico. Recientemente, se describieron diferentes anomalías que acompañan a los trastornos metabólicos e influyen en el pronóstico. Presentamos el caso de un lactante con enfermedad de Tay-Sachs junto con coartación aórtica y reflujo vesicoureteral bilateral (RVU) de grado V. Se realizó el seguimiento del paciente en el consultorio externo de Cardiología Pediátrica. En la ecografía abdominal, se observó ectasia pielocalicial, y se detectó reflujo vesicoureteral bilateral de grado V en la cistouretrografía miccional. No se ha informado previamente la coexistencia de estas anomalías. Este caso pone de manifiesto que no se deben subestimar las anomalías del examen neurológico en los pacientes con una cirugía cardíaca reciente, porque podría perderse la oportunidad de diagnosticar enzimopatías congénitas.

Tay-Sachs disease is a neurodegenerative inherited metabolic disease. There are four forms classified by the time of first clinical symptoms: infantile, late infantile, juvenile and adult. Infantile form has the poorest prognosis. Lately, different abnormalities which accompany metabolic disorders and affect the prognosis have been described. We present an infant with Tay-Sachs disease accompanied by coarctation of the aorta and bilateral grade V vesicoureteral reflux (VUR). The patient was followed up in the outpatient clinic of Pediatric Cardiology. The abdominal ultrasonography showed pelvicalyceal ectasia; bilateral grade V VUR in voiding cystourethrography was found. This coexistence has not been previously reported. This case emphasizes that abnormalities in the neurological examination of cardiac postsurgical patients should not be underestimated because the opportunity to diagnose inborn errors of metabolism could be missed.

Rare coexistence of Tay-Sachs disease, coarctation of the aorta and grade V vesicoureteral reflux. / Coexistencia infrecuente de la enfermedad de Tay-Sachs, coartación aórtica y reflujo vesicoureteral de grado V.

Tay-Sachs disease is a neurodegenerative inherited metabolic disease. There are four forms classified by the time of first clinical symptoms: infantile, late infantile, juvenile and adult. Infantile , Ebru Candab, Ertürk Leventc , The infantile form has the poorest clinical prognosis. First symptoms of this form, such as muscle weakness and hypotonia, occur around form has the poorest prognosis. Lately, different abnormalities which accompany metabolic disorders and affect the prognosis have been described. We present an infant with Tay-Sachs disease accompanied by coarctation of the aorta and bilateral grade V vesicoureteral reflux (VUR). The patient was followed up in the outpatient clinic of Pediatric Cardiology. The abdominal ultrasonography showed pelvicalyceal ectasia; bilateral grade V VUR in voiding cystourethrography was found. This coexistence has not been previously reported. This case emphasizes that abnormalities in the neurological examination of cardiac postsurgical patients should not be underestimated because the opportunity to diagnose inborn errors of metabolism could be missed.

La enfermedad de Tay-Sachs es una enfermedad metabólica hereditaria neurodegenerativa. Existen cuatro tipos según el inicio de los síntomas clínicos: infantil, infantil de inicio tardío, juvenil y adulto. El tipo infantil tiene el peor pronóstico. Recientemente, se describieron diferentes anomalías que acompañan a los trastornos metabólicos e influyen en el pronóstico. Presentamos el caso de un lactante con enfermedad de Tay-Sachs junto con coartación aórtica y reflujo vesicoureteral bilateral (RVU) de grado V. Se realizó el seguimiento del paciente en el consultorio externo de Cardiología Pediátrica. En la ecografía abdominal, se observó ectasia pielocalicial, y se detectó reflujo vesicoureteral bilateral de grado V en la cistouretrografía miccional. No se ha informado previamente la coexistencia de estas anomalías. Este caso pone de manifiesto que no se deben subestimar las anomalías del examen neurológico en los pacientes con una cirugía cardíaca reciente, porque podría perderse la oportunidad de diagnosticar enzimopatías congénitas.

Acute lower gastrointestinal bleeding due to low-grade mucinous neoplasm of appendix.

INTRODUCTION: Lower gastrointestinal tract (GIT) bleeding originating from the appendix is rare and may be difficult to diagnose. PATIENTS AND METHODS: In this case report, we present an 88-year-old male patient who was admitted with hematochezia due to appendiceal bleeding. A colonoscopy revealed bleeding in the appendix orifice so an appendectomy was performed, and bleeding did not recur in the postoperative period. RESULTS: The results of the microscopic examination showed low-grade mucinous neoplasm (LGMN) of the appendix. CONCLUSION: It should be kept in mind that bleeding may originate from the appendix in patients presenting with GIT bleeding. Our patient is the first to present with an acute lower GIT bleed who was diagnosed as having LGMN in the appendectomy specimen.

Breast cancer patients with isolated bone metastases and oligometastatic bone disease show different survival outcomes.

In this study, we planned to investigate the clinical course of patients with breast cancer with oligometastatic bone disease (OMBD). The patients were grouped according to the characteristics and the sites of metastases. Group I included 928 patients without metastasis. Group II, the OMBD group, included 68 patients. Group III, the widespread metastasis group, comprised 185 patients with multiple bone metastases and/or solid organ metastases. The mean overall survival of the groups was 16.7 ± 0.3 years in group 1, and 7.8 ± 0.8 and 5.9 ± 0.4 years in groups 2 and 3, respectively (p < 0.001 for the comparison of all three groups together; p < 0.001 for group 1 vs. 2 and 3) and (p = 0.037 for group 2 vs. group 3). In the subgroup survival analysis of patients in group 2 (OMBD), the mean and median survival was 5.5 ± 0.8 and 4.0 ± 0.8 years vs. 9.2 ± 0.98 and 9.0 ± 1.05 years in patients with more than one bone metastasis and single bone metastasis, respectively (p = 0.019). OMBD seems to be a different disease than breast cancer with isolated bone metastases. The high risk of developing OMBD, especially following locoregional recurrence, increases the importance of locoregional therapy in large T and N stage tumors.

The efficacy of interleukin-1 antagonist drugs in combination with colchicine in patients with FMF-AA with colchicine resistance after kidney transplantation: A study with histopathologic evidence.

BACKGROUND: The efficacy of anti-interleukin-1 (IL-1) drugs in kidney transplant patients with FMF-AA who developed colchicine resistance has not been clearly demonstrated. METHOD: Thirty nine kidney transplant recipients with FMF-AA were evaluated. Group 1 consisted of patients who were in remission after transplantation with colchine and Group 2 included those who developed colchicine resistance. RESULTS: The mean follow-up of the patients was 88.5 ± 61.9 months. Following the treatment with IL-1 antagonists; serum Amyloid A (SAA) averages (79.4 ± 35.3 mg/L) as well as the average number of hospitalizations per month due to FMF episodes (1.4 ± 0.5 times/month) decreased significantly (26.6 ± 25.9 mg/L and 0.1 ± 0.3 times/month) (p < .001). Rates of death with a functional graft were 30% and 0% in group 1 and 2 (p = .086). Biopsy-proven AA amyloidosis recurrence in the allograft was observed in 11 of 19 (58%) and seven of nine (78%) patients in group 1 and 2, respectively. Interestingly, glomerular amyloid deposition was not present in the vast majority of biopsies. De novo vasculer amyloid deposition was observed during treatment. CONCLUSION: IL-1 antagonist drug and colchicine combination almost completely prevented acute FMF attacks in kidney transplant patients with colchicine resistance. However, amyloid accumulation did not cease during IL-1 antagonist drug treatment.

Clinicopathologic features of single bone metastasis in breast cancer.

ABSTRACT: The most common site for metastasis in patients with breast cancer is the bone. In this case series, we investigated patients whose surgical and medical treatment for primary breast cancer was conducted at our center and first disease recurrence was limited to only 1 bone.We analyzed 910 breast cancer patients, 863 had no metastasis and 47 cases had a single bone metastasis ≥ 6 months after their first diagnosis. Demographic, epidemiological, histopathological and intrinsic tumor subtype differences between the non-metastatic group and the group with solitary bone metastases and their statistical significance were examined. Among established breast cancer risk factors, we studied twenty-nine variables.Three variables (Type of tumor surgery, TNM Stage III tumors and mixed type (invasive ductalcarsinoma + invasive lobular carcinoma) histology) were significant in multivariate logistic regression analysis. Accordingly, the risk of developing single bone metastasis was approximately 15 times higher in patients who underwent mastectomy and 4.8 and 2.8 times higher in those with TNM Stage III tumors and with mixed type (invasive ductal carcinoma + invasive lobular carcinoma) histology, respectively.In conclusion, the risk of developing single bone metastasis is likely in non-metastatic patients with Stage III tumors and possibly in mixed type tumors. Knowing this risk, especially in patients with mixed type tumors, may be instrumental in taking measures with different adjuvant therapies in future studies. Among these, treatment modalities such as prolonged hormone therapy and addition of bisphosphonates to the adjuvant treatments of stage III and mixed breast cancer patients may be considered.

Response to treatment in kidney transplant recipients with acute antibody-mediated rejection: A follow-up biopsy study
.

BACKGROUND: The aim of this study is to evaluate the efficacy of a treatment protocol for the management of acute antibody-mediated rejection (AAMR) and mixed-type rejection (MTR), both histopathologically and clinically. MATERIALS AND METHODS: Of the 362 cases undergoing kidney transplantation from January 2010 to January 2018, patients with AAMR or MTR in the first 3 months after transplantation were included. All patients had follow-up biopsy (Bx) after treatment. RESULTS: 33 (9.1%) patients had diagnosis of AMR. Mean follow-up was 35 ± 20 months. 28.5% of patients had poor clinical progression at the last follow-up. Of the 25 patients with functional grafts, the mean serum creatinine was 1.6 ± 0.6 mg/dL for live and 2.1 ± 1.0 mg/dL for deceased transplant recipients. In diagnostic biopsies, there were 61% MTR. In follow-up Bx, after treatment, both C4d positivity and the severity of rejection had decreased while the mean chronic allograft damage index (CADI) score and transplant glomerulopathy showed an increase. CONCLUSION: With effective antibody mediated rejection (AMR) therapy, renal function parameters were significantly improved. Histologically, improvement in tubulointerstitial inflammation may be responsible for this process. However, progressive chronic changes, particularly in the glomeruli, are noteworthy.

Anatomical distribution and number of parathyroid glands, and parathyroid function, after total parathyroidectomy and bilateral cervical thymectomy.

The normal distribution of parathyroid glands is well documented. However, this study aims to evaluate the efficacy of total parathyroidectomy (TPTx) and bilateral cervical thymectomy (BCTx) for the treatment of secondary hyperparathyroidism (SHPT) through identifying the location of parathyroid glands with attention to the pattern and frequency of orthotopic and ectopic glands.Between 2013 and 2018, sixty chronic hemodialysis patients with medically refractory SHPT underwent TPTx & BCTx. The adequacy of the operation was defined by the pathological confirmation of at least 4 parathyroid glands, accompanied by an intact parathormone (iPTH) value of <60 pg/mL on postoperative day 1(POD1). Based on their anatomical localizations, four distinct sites were identified for both the upper (Zone I-IV) and lower parathyroid glands (Zone V-VIII).The mean follow-up was 15.2 ±â€Š14.6 months. The mean iPTH values on POD1 were normal in 50 patients, with an average of 11.7 ±â€Š14.4 pg/mL. Ten patients (16.6%) had persistent HPT after the operation, three of whom underwent complementary parathyroidectomy. The surgical success rates after first and second operations were both 83.3%. A total of 235 parathyroid glands were detected. Ninety-two percent of the upper parathyroids were located in Zones I and II. However, almost 28% of the lower parathyroids were ectopic and located in Zones VII and VIII.At least one fourth of the lower parathyroids are ectopic; for this reason, Zones VII and VIII require careful investigation during surgery. For upper parathyroids not found in Zone I-III, total thyroidectomy on the same side is recommended.

Tubular vesicopyelostomy for the management of types 2 and 3 (long-segment) ureteric stenosis after kidney transplantation.

Late ureteral stenosis following kidney transplantation needs immediate correction in order to protect allograft function and requires a complicated surgical procedure. In this study, we present the long-term results of tubular bladder reconfiguration and cystopyelostomy (tubular vesicopyelostomy), an innovative and practical procedure for the management of long-segment ureteric stenosis (types 2 and 3) after transplantation. Between 2002 and 2017, 722 kidney transplant patients were monitored at the University of Medical Sciences, Bozyaka Organ Transplantation and Research Center. Twenty-eight of these patients underwent tubular vesicopyelostomy operation; 17 male and 11 female patients with a mean age of 45.6 ± 10.5 years. Time to surgical intervention for urinary tract obstruction was 122.5 ± 114.7 months. The mean serum creatinine values previous to and 3 days following the tubular vesicopyelostomy operation were 3.46 ± 1.5 mg/dL and 1.75 ± 0.7 mg/dL, respectively (p < 0.0001). Within a mean follow-up period of 55.1 ± 40.9 months, functional grafts were recorded in 22 patients with a mean serum creatinine value of 1.92 ± 0.8 mg/dL. Only one patient developed anastomotic stenosis after the tubular vesicopyelostomy procedure, giving an overall success rate for tubular vesicopyelostomy of 96.4%. Six patients returned to hemodialysis. In five, the underlying etiology was not related to recurrent obstruction or surgical complications. Sixteen patients underwent allograft biopsy after the operation, but features of tubulointerstitial nephritis were seen in only one. Tubular vesicopyelostomy operation is a safe and successful method for the surgical treatment of late and complicated ureteral obstructions with excellent long-term results. It may be a good, practical alternative to other more sophisticated surgical options.

Relationship between diurnal blood pressure and renal histopathological changes in white coat hypertension.

BACKGROUND: Multiple epidemiological studies have clearly demonstrated the macrovascular risks associated with white coat hypertension (WCH) or sustained hypertension (SH). In patients with WCH, there is no literature available on renal histopathological changes and that on blood pressure pattern and native kidney outcome is scant. We aimed to clarify the relationship between blood pressure variables and pathological features of kidney biopsies in living kidney donors with WCH. METHODS: This cross-sectional study included living kidney donors with WCH (n = 10) and SH (n = 10), and 20 healthy kidney donors with similar demographic features (control group). Kidney allograft biopsy samples were obtained during transplantation and chronic glomerular, vascular and tubulointertitial changes were semiquantitatively scored according to the Banff classification. RESULTS: The mean age of the 20 hypertensive subjects (Group 1) and controls (Group 2) was 59.3 ± 8.5 versus 59.6 ± 7.6 years and almost half were female. There was no difference in renal function parameters between the groups; however, kidney histopathology in Group 1 was worse than Group 2 with a chronicity index of 2.80 ± 1.67 versus 1.75 ± 1.16 (p = 0.02). There was no difference between histopathological scores of patients with WCH or SH (chronicity index: 2.60 ± 1.43 vs. 2.70 ± 1.70, p = 0.88). Night-to-day mean arterial pressure (MAP) ratio was significantly associated with chronicity index in patients with WCH. Moreover, WCH patients with non-dipper hypertensive pattern had a worse chronicity index. CONCLUSIONS: Significant histopathological alterations in the kidney were observed in patients with WCH and SH, and were accentuated in WCH patients with non-dipper blood pressure pattern.

Infections After Renal Transplant in Recipients With Familial Mediterranean Fever: A Life-Threatening Issue.

OBJECTIVES: We evaluated long-term results and infections requiring hospitalization in kidney transplant patients with Familial Mediterranean Fever (associated amyloidosis-type). MATERIALS AND METHODS: We retrospectively reviewed medical records of patients with familial Mediterranean fever with at least 1-year posttransplant follow-up. Kidney transplant recipients with primary glomerulonephritis and equivalent demography, immunity status, and follow-up comprised the control group. RESULTS: In 32 patients with familial Mediterranean fever versus 25 control patients (mean follow-up 82 ± 57 vs 79 ± 54 mo; P = .82), average serum creatinine values were 1.7 ± 0.9 versus 1.5 ± 1.0 mg/dL (P = .41) at discharge, 1.4 ± 0.4 versus 1.3 ± 0.5 mg/dL (P = .44) at 1 year, 1.4 ± 0.6 versus 1.3 ± 0.5 mg/dL (P = .63) at 3 years, and 2.0 ± 1.5 versus 2.1 ± 1.5 mg/dL (P = .92) at last follow-up. Groups were not statistically different regarding average inpatient and number of hospitalizations due to infections at 1 year; however, at last follow-up, 26 patients with familial Mediterranean fever (81%) had 8.6 average admissions and 13 control patients (52%) had 2.8 average admissions (P = .02, P < .01). Early posttransplant, both groups were taking a triple drug immunosuppression regimen. However, at 1 and 3 years posttransplant, withdrawal and/or minimization occurred in 40.6% and 83.3% of patients with familial Mediterranean fever and 28% and 55.5% of control patients (P < .05, P < .05). During follow-up, 6 familial Mediterranean fever patients (18.7%) and 2 control patients (8%) died (P = .23). CONCLUSIONS: Although renal transplant patients with associated amyloidosis-type familial Mediterranean fever and those with glomerulonephritis have similar rejection and/or graft loss rates, hospital admissions due to infection and increased mortality are more common in the familial Mediterranean fever group, with immunosuppression drug withdrawal.

Evaluation of Indication Biopsies ≥5 Years After Kidney Transplant: A Single-Center Experience.

OBJECTIVES: Rejection is a common cause of late graft dysfunction seen on biopsy studies. The aim of this study was to evaluate indication biopsy findings ? 5 years after kidney transplant and to assess the effectiveness of applied treatments. MATERIALS AND METHODS: Between January 2013 and December 2015, 30 patients who underwent renal transplant indication biopsies and were followed up for ≥ 6 months were evaluated retrospectively. A >30% increase in serum creatinine and/or development of > 1 g/day proteinuria was considered an acceptable indication for biopsy. RESULTS: Of the 156 indication biopsies obtained within a 3-year period, 30 of them were indication biopsies performed ≥ 5 years after transplant. Twenty patients (67%) demonstrated late graft rejection, 6 patients (20%) had recurrent or de novo glomerulonephritis, and 4 patients (13%) were diagnosed with idiopathic chronic allograft nephropathy. The mean total histologic score was 6.2 ± 2.6, and the chronicity rate was 70%. For patients with late rejection, treatment consisted of pulse steroids in 11, intravenous immunoglobulin in 5, plasmapheresis in 4, antithymocyte globulin in 3, and rituximab in 2 cases. Five patients with glomerulonephritis received pulse steroids, 1 received rituximab therapy, and 3 were treated with cyclophosphamide. The mean follow-up after indication biopsy was 16 ± 11 months. Eleven patients (37%) had a progressive disease course and 7 patients (23%) resumed hemodialysis. Of the 30 patients, the 15 whose glomerular filtration rate was < 30 mL/min/1.72 m² at biopsy were more likely to have a progressive disease course (53% vs. 20%; P = .05) and more commonly resumed dialysis (40% vs. 7%; P = .03). CONCLUSIONS: Rejection was the most common cause of graft dysfunction long term. Chronic histologic changes predominated in indication biopsies ≥ 5 years posttransplant. Regardless of diagnosis, a low glomerular filtration rate at biopsy was closely associated with poor renal outcomes.