Effects of Antithymocyte Globulin, Basiliximab, and Induction-Free Treatment in Living Donor Kidney Transplant Recipients on Tacrolimus-Based Immunosuppression.

OBJECTIVES: Induction treatment in renal transplant is associated with better graft survival. However, intensified immunosuppression is known to cause unwanted side effects such as infection and malignancy. Furthermore, the effects of the routine use of immunosuppressants in low-risk kidney transplant recipients are still not clear. In this study, we assessed the first-year safety and efficacy of induction treatment. MATERIALS AND METHODS: We examined first living donor kidney transplant patients who were on tacrolimus based immunosuppression therapy. We formed 3 groups according to the induction status: antithymocyte globulin induction, basiliximab induction, and no induction. We collected outcome data on delayed graft function, graft loss, creatinine levels, estimated glomerular filtration rates, acute rejection episodes, hospitalization episodes, and infection episodes, including cytomegalovirus infection and bacterial infections. RESULTS: We examined a total of 126 patients (age 35 ± 12 years; 65% male). Of them, 25 received antithymocyte globulin, 52 received basiliximab, and 49 did notreceive any induction treatment. We did not observe any statistically significant difference among the 3 groups in terms of acute rejection episodes, delayed graft function, and first-year graft loss. The estimated glomerular filtration rates were similar among the groups. Overall bacterial infectious complications and cytomegalovirus infection showed similar prevalence among all groups. Hospitalization was less common in the induction-free group. CONCLUSIONS: In low-risk patients, induction-free regimens could be associated with a better safety profile without compromising graft survival. Therefore, induction treatment may be disregarded in first living donor transplant patients who receive tacrolimusbased triple immunosuppression treatment.

NT-proCNP levels predict higher atherosclerotic cardiovascular risk profile in patients with proliferative diabetic retinopathy.

AIMS: In this study, we aimed to demonstrate the effectiveness of serum amino-terminal proCNP (NT-proCNP) levels in predicting coronary heart disease (CHD) and cardiovascular risk in type 2 diabetes mellitus (T2DM) patients. METHODS: We recruited 73 patients with T2DM in the study. Additionally, we grouped the patients according to their status of diabetic retinopathy (DR) as no DR, non-proliferative DR, or proliferative DR. Serum NT-proCNP levels of the patients were measured and their atherosclerotic cardiovascular disease (ASCVD) risk scores were calculated. RESULTS: There was no significant difference in terms of NT-proCNP levels between the groups (p = 0.3) and in terms of CHD and ASCVD risk scores (p = 0.4 and p = 0.4, respectively). In the correlation analysis, a significant correlation was observed between the NT-proCNP levels and the ASCVD risk score (r = 0.373; p = 0.008 among the entire cohort and r = 0.555; p = 0.01 in the non-proliferative-DR group), smoking status (r = 0.280; p = 0.03 among the entire cohort and r = 0.362; p = 0.035 in the non-proliferative-DR group), sBP (r = 0.278; p = 0.038 among the entire cohort), and dBP (r = 0.284; p = 0.034 among the entire cohort and r = 0.482; p = 0.004 in the proliferative-DR group). In the ROC analysis, we found that the NT-proCNP level predicted a high ASCVD risk score with 83.3% sensitivity and 70.8% specificity and a very high ASCVD risk score with 100% sensitivity and 69.2% specificity among the proliferative-DR patients. No cut-off value was calculated for the prediction of high and very-high ASCVD risk scores in patients with non-proliferative DR. Similarly, no cut-off value was revealed for the prediction of established coronary artery disease in all groups. CONCLUSIONS: Our study revealed a significant association between NT-proCNP levels and high ASCVD risk scores in patients with proliferative DR.

Renin-angiotensin system activation: may it increase frequency of obstructive sleep apnea in patients with autosomal dominant polycystic kidney disease?

PURPOSE: Renin-angiotensin system (RAS) hyperactivity is a common entity in both autosomal dominant polycystic kidney disease (ADPKD) and obstructive sleep apnea (OSA). We aimed to investigate the frequency of OSA in adults with ADPKD either with stages 3-4 or stages 1-2 chronic kidney disease (CKD) and evaluate the effect of RAS blockade on OSA in these patients. METHODS: This is a comparative, prospective, two-center clinical study. Eligible patients with ADPKD were enrolled in a polysomnography (PSG) study. Presence of OSA in patients with ADPKD was compared with individuals who underwent polisomnography study due to OSA symptoms. A subgroup analysis was performed in terms of the presence of OSA in ADPKD with eGFR values lower or higher than 60 ml/min/1.73 m2 (stages 3-4 and stages 1-2 CKD, respectively). RESULTS: Frequency of OSA (65%) was higher than in the general population and similar between the two groups (p = 0.367). Patients with ADPKD and eGFR ≥ 60 ml/min/1.73 m2 presented a similar frequency of OSA to the control group (p = 0.759). However, OSA was significantly more frequent in ADPKD with eGFR < 60 ml/min/1.73 m2 (p = 0.018). Subgroup analysis revealed that presence of OSA also was significantly higher in ADPKD with lower eGFR levels (eGFR < 60 ml/min/1.73 m2 and eGFR > 60 ml/min/1.73 m2) 14/17 (82%) and 12/23 (52%), respectively (p: 0.048). CONCLUSION: As kidney disease progresses, uremia and related factors of renal failure rather than RAS activation seem to play a more important role for the development of OSA in patients with ADPKD.

A Fabry Disease Patient Who Developed Hypersensitivity Reaction against Agalsidase Beta following COVID-19 Infection.

Fabry disease (FD) is a rare, X-linked inherited lysosomal storage disorder, characterized by the accumulation of globotriaosylceramide (Gb3) due to the deficiency or absence of alpha-galactosidase A. Due to the accumulation of Gb3, cardiac, renal, neurological, and skin manifestations can be observed. Enzyme replacement therapy (ERT) with agalsidase alfa or agalsidase beta is the cornerstone in the management of FD. Both enzymes are clinically effective and widely used. In this study, we present a 19-year-old male patient with FD who had received ERT for almost two and half years without any complications. In January 2021, he was diagnosed with COVID-19 infection. Later, he developed an infusion reaction during his first ERT infusion following the resolution of COVID-19 infection. The patient experienced shortness of breath, shivering, and rash. Despite decreased infusion rate and premedication in repetitive infusion, his symptoms were not resolved. Subsequently, he developed an IgE antibody against agalsidase beta, and his skin prick test was positive. Since IgG positivity against agalsidase beta was also detected, agalsidase beta was replaced with agalsidase alfa. The patient did not experience any allergic reaction with agalsidase alfa. Moderate to severe allergic reactions during ERT infusion should be alarming for IgE development. Furthermore, COVID-19 should be considered a trigger for allergic reaction against ERT in patients with FD.

Post-COVID-19 outcomes of non-dialysis dependent chronic kidney disease patients: a national, multicenter, controlled study.

PURPOSE: Coronavirus disease 2019 (COVID-19) has a higher mortality in the presence of chronic kidney disease (CKD). However, there has not been much research in the literature concerning the outcomes of CKD patients in the post-COVID-19 period. We aimed to investigate the outcomes of CKD patients not receiving renal replacement therapy. METHODS: In this multicenter observational study, we included CKD patients with a GFR < 60 ml/min/1.73 m2 who survived after confirmed COVID-19. Patients with CKD whose kidney disease was due to diabetic nephropathy, polycystic kidney disease and glomerulonephritis were not included in this study. CKD patients with similar characteristics, who did not have COVID-19 were included as the control group. RESULTS: There were 173 patients in the COVID-19 group and 207 patients in the control group. Most patients (72.8%) were treated as inpatient in the COVID-19 group (intensive care unit hospitalization: 16.7%, acute kidney injury: 54.8%, needing dialysis: 7.9%). While there was no significant difference between the baseline creatinine values of the COVID-19 group and the control group (1.86 and 1.9, p = 0.978, respectively), on the 1st month, creatinine values were significantly higher in the COVID-19 group (2.09 and 1.8, respectively, p = 0.028). Respiratory system symptoms were more common in COVID-19 patients compared to the control group in the 1st month and 3rd month follow-ups (p < 0.001). Mortality at 3 months after the diagnosis of COVID-19 was significantly higher in the COVID-19 group than in the control group (respectively; 5.2% and 1.4%, p:0.037). Similarly, the rate of patients requiring dialysis for COVID-19 was significantly higher than the control group (respectively; 8.1% and 3.4%, p: 0.045). CONCLUSIONS: In CKD patients, COVID-19 was associated with increased mortality, as well as more deterioration in kidney function and higher need for dialysis in the post-COVID-19 period. These patients also had higher rate of ongoing respiratory symptoms after COVID-19.

The impact of the COVID-19 pandemic on Fabry Disease Patients: an examination of Mood Status, Therapy Adherence, and COVID-19 infection.

BACKGROUND: Fabry disease (FD) is a rare metabolic disorder, in which a lifelong enzyme replacement therapy (ERT) constitutes the cornerstone of disease-specific therapy. In this study, we examined the effects of the COVID-19 pandemic and lockdown measures on the management of FD patients. METHODS: We collected data in three main domains; mood status, adherence to ERT, and COVID-19 infection. We used the Hospital Anxiety and Depression Scale (HADS) to evaluate the mood statuses of FD patients and the Morisky Medication Adherence Scale (MMAS) and the Medication Adherence Report Scale (MARS) to assess patients' adherence to non-disease specific therapy. We also examined a control group to compare the mood status data. RESULTS: A total of 67 FD patients (males: 47.8%, mean age: 37.0 years) were recruited to the study, of which 58 were receiving ERT. Both the HADS depression and anxiety scores were higher in the control group compared to FD patients. During the first wave of the pandemic, 25 patients reported to have missed an infusion for a mean of 2.3 ± 1.7 doses and half of the patients had adopted a home-based infusion treatment regimen. COVID-19 infection developed in 25 patients, of which one died. The majority of our patients (71.6%) have had at least one shot of the vaccine. CONCLUSION: We found that FD patients were more resilient to the negative psychological effects of lockdown. Traumatic growth may be an important factor in explaining this finding. Government-supported home therapy programs might be beneficial for FD patients to increase the therapy adherence.

Renal Manifestations in Inflammatory Bowel Disease: A Cohort Study During the Biologic Era.

BACKGROUND Renal involvement can complicate the course of inflammatory bowel disease (IBD). In this study, we aimed to analyze the extent of renal manifestations in patients with IBD (Crohn disease or ulcerative colitis) during the biologic era. MATERIAL AND METHODS Patients diagnosed with and followed up for IBD for a period covering 16 years were retrospectively analyzed. Patients who received IBD diagnosis with clinical, endoscopic, and histopathological findings and were older than 18 years were enrolled in the study. Demographic, clinical, laboratory, and treatment data were retrieved from the patients' medical records. RESULTS Of the 1874 patients analyzed, the diagnosis was ulcerative colitis in 1055 patients and Crohn disease in the remaining 819. Renal manifestations were found in 105 patients (5.6%), 55 (6.7%) of whom were diagnosed with Crohn disease and 50 (4.7%) with ulcerative colitis. Renal calculi was the most common renal manifestation for both Crohn disease and ulcerative colitis. Renal manifestations were related to disease activity and surgical resection history in patients with Crohn disease, whereas no such relationship was found in patients with ulcerative colitis. CONCLUSIONS Renal manifestations may be seen in up to 6% of patients with IBD, and patients with Crohn disease seems to have more risk than do patients with ulcerative colitis. Nephrolithiasis is the most common form of renal involvement in IBD and is closely associated with disease activity. This relationship between IBD and renal manifestations should be considered, especially when there are subtle renal symptoms.

Middle-term outcomes in renal transplant recipients with COVID-19: a national, multicenter, controlled study.

Background: In this study, we evaluated 3-month clinical outcomes of kidney transplant recipients (KTR) recovering from COVID-19 and compared them with a control group. Method: The primary endpoint was death in the third month. Secondary endpoints were ongoing respiratory symptoms, need for home oxygen therapy, rehospitalization for any reason, lower respiratory tract infection, urinary tract infection, biopsy-proven acute rejection, venous/arterial thromboembolic event, cytomegalovirus (CMV) infection/disease and BK viruria/viremia at 3 months. Results: A total of 944 KTR from 29 different centers were included in this study (523 patients in the COVID-19 group; 421 patients in the control group). The mean age was 46 ± 12 years (interquartile range 37-55) and 532 (56.4%) of them were male. Total number of deaths was 8 [7 (1.3%) in COVID-19 group, 1 (0.2%) in control group; P = 0.082]. The proportion of patients with ongoing respiratory symptoms [43 (8.2%) versus 4 (1.0%); P < 0.001] was statistically significantly higher in the COVID-19 group compared with the control group. There was no significant difference between the two groups in terms of other secondary endpoints. Conclusion: The prevalence of ongoing respiratory symptoms increased in the first 3 months post-COVID in KTRs who have recovered from COVID-19, but mortality was not significantly different.

Effects of SGLT2 inhibitors on patients with diabetic kidney disease: A preliminary study on the basis of podocyturia.

BACKGROUND: The aim of this study was to investigate the effects of sodium glucose cotransporter 2 inhibitors (SGLT2i) on the glomerulus through the evaluation of podocyturia in patients with diabetic kidney disease (DKD). METHODS: The study population was composed of 40 male patients with type 2 diabetes mellitus; 22 of them received SGLT2i (SGLT2i group), and the others who did not were the control. The DKD-related parameters of patients were monitored before SGLT2i initiation, and then in the third and sixth month of the follow-up period. Patients' demographic, clinical, laboratory, and follow-up data were obtained from medical charts. Microalbuminuria was measured in 24-h urine. The number of podocytes in the urine was determined by immunocytochemical staining of two different markers, namely podocalyxin (podx) and synaptopodin (synpo). Concentrations of urine stromal cell-derived factor 1a and vascular endothelial growth factor cytokines were quantified with an enzyme-linked immunosorbent assay kit. RESULTS: At the end of the follow-up period, decreases in glycosylated hemoglobin, glucose, systolic and diastolic blood pressure, uric acid level, and microalbuminuria, and improvement in body mass index level and weight loss were significant for the SGLT2i group. On the other hand, there was no significant difference in terms of these parameters in the control group. The excretion of synaptopodin-positive (synpo+ ) and podocalyxin-positive (podx+ ) cells was significantly reduced at the end of the follow-up period for the SGLT2i group, while there was no significant change for the control. CONCLUSIONS: At the end of the follow-up period, male patients receiving SGLT2i had better DKD-related parameters and podocyturia levels compared to baseline and the control group. Our data support the notion that SGLT2i might have structural benefits for glomerular health.

Blood Pressure Variability in Fabry Disease Patients.

INTRODUCTION: Fabry disease is a rare metabolic, multisystemic, and X-linked lysosomal storage disorder. The involvement of the autonomic nervous system is well defined; however, data on the variability of the blood pressure (BP) and heart rate in Fabry disease are largely missing. In this study, we aimed to examine the circadian variations of BP and heart rate variability in Fabry disease patients. METHODS: We recruited 31 consecutive adult (age >18 years) Fabry disease patients (16 males and 15 females) who were regularly followed up in our outpatient clinic between July 2019 and March 2020. We performed ambulatory blood pressure monitoring and echocardiography in all patients. We used standard deviation (SD), coefficient of variation (CV), and average real variability as the measures of variability. We constructed 2 control groups for propensity score matching using age, sex, and eGFR parameters in the first group and adding antihypertensive drug use to the above parameters in the second group. RESULTS: All BP measurements were significantly lower in the FD group compared to that of the control groups, except the nighttime systolic BP. Regarding nondipping and reverse dipping statuses, FD patients and controls were similar. We found that none of the BP variability measures were higher in FD patients. Regarding heart rate variability data, both the nighttime SD and CV were significantly lower in FD patients compared to those of the controls. CONCLUSION: A decrease in heart rate variability, rather than an increase in BP variability, might be an early marker of autonomic involvement in FD.

Reflex Decay Test Can Reveal Ear Involvement in Fabry Disease.

OBJECTIVES: Fabry disease (FD) is an X-linked lysosomal storage disorder that causes multisystem involvement, including ear disease. In this study, we aimed to investigate the nature of auditory issues in FD using a wide spectrum of audiological tests. DESIGN: This cross-sectional study was conducted between June 2017 and December 2018. We collected the clinical and laboratory data of 40 eligible FD patients, 45 healthy subjects, and 26 diabetic controls. All patients and controls completed audiologic evaluations that included tympanometry, acoustic reflex threshold test, reflex decay test, pure-tone audiometry, speech audiometry, transient otoacoustic emissions (TEOAEs), high-frequency audiometry, and distortion product otoacoustic emission (DPOAE). RESULTS: In our study population, hearing was reduced at higher frequencies starting at 4 kHz in both the FD and diabetic groups. Regarding the acoustic reflex threshold test, FD and diabetic patients had similar results. In all frequencies, positive decay was significantly more frequent in FD patients when compared with the diabetic patients and healthy controls (p < 0.001 for each ear). The FD patients and healthy controls had similar results for DPOAE testing. CONCLUSIONS: We showed that FD patients had a higher rate of reflex decay, indicating retrocochlear involvement. Thus, further investigation of factors associated with retrocochlear involvement could be investigated, such as ABR and speech in noise tests.

Evaluation of the reasons for the microvascular changes in patients with Fabry disease using optic coherence tomography angiography.

PURPOSE: To investigate the blood flow changes in the choriocapillaris and the superficial and deep capillary plexus of the retina using optic coherence tomography angiography (OCTA) in patients with Fabry disease (FD) and reveal any possible association of these changes with the systemic findings. METHODS: This cross-sectional study included 38 patients with FD and age- and gender-matched 40 healthy controls. OCTA images were obtained from all patients. Superficial (sCVD) and deep capillary vascular density (dCVD) in the foveal, parafoveal, and perifoveal zones and the whole image were recorded for each patient. Flow area in the choriocapillaris and central macular thickness (CMT) were also recorded. RESULTS: Patients with FD showed a lower whole image (54.45 ± 5.99% vs 57.32 ± 6.71%, p = 0.004), foveal (34.94 ± 7.60% vs 39.65 ± 7.03%, p = 0.003), parafoveal (57.41 ± 4.85% vs 59.19 ± 4.67%, p = 0.043), and perifoveal (55.87 ± 6.43% vs 58.87 ± 7.02%, p = 0.003) dCVD compared to the healthy controls without a significant difference in the sCVD and choriocapillaris blood flow (p > 0.05). A significantly lower whole image and foveal dCVD in the FD patients with renal involvement was observed compared to the healthy controls (p = 0.027 and p = 0.024, respectively) without any significant difference between the FD patients without renal involvement and healthy controls (p = 0.17 and p = 0.13, respectively). CMT was significantly higher in FD patients with renal involvement compared to the ones without renal involvement (252.1 ± 18.5 µm vs 235.5 ± 17.6 µm, p = 0.016). CONCLUSION: Patients with FD showed a lower dCVD without any change in sCVD and choriocapillaris compared to the healthy controls. This decrease was associated mostly with the renal involvement and duration of treatment.

Myeloid-related protein complex 8/14 increases in hypertensive patients with excessive renal damage
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AIM: Hypertension is a complex condition, and it is difficult to know whether inflammation is a cause or an effect. Information on the association between MRP-8/14 (myeloid-related protein) and hypertension is limited. In this study, we aimed to examine the relationship of MRP-8/14 with carotid intima-media thickness (CIMT) and albuminuria in hypertensive patients and to investigate whether early assay of MRP-8/14 levels could be helpful in assessment of renal damage and carotid atherosclerosis among hypertensive patients. MATERIALS AND METHODS: 61 hypertensive patients and 40 age-, gender-, and body mass index-matched controls were included into the study. Blood samples including fasting blood glucose, total cholesterol, triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, total protein, albumin, urea creatinine, uric acid, sedimentation, C-reactive protein (CRP), and MRP-8/14 were collected. 24-hour urine albumin excretion and CIMT measurements were also obtained. RESULTS: All inflammatory variables including uric acid, CRP, sedimentation, MRP-8/14, and CIMT were statistically higher in patients with hypertension than in controls. MRP-8/14 was significantly higher in hypertensive patients with macroalbuminuria than in controls (339.3 (IQR (215.2 - 661.7)) ng/mL vs. 204.9 (IQR (140.1 - 339.3)) -ng/mL, p = 0.005, respectively). The levels of CIMT were the highest in macroalbuminuric hypertensive patients (controls vs. normoalbuminuria, microalbuminuria, macroalbuminuria groups, 0.57 (0.53 - 0.67) mm vs. 0.84 (0.76 - 0.89) mm, p = 0.000; 0.57 (0.53 - 0.67) mm vs. 0.87 (0.67 - 0.93) mm, p = 0.000; 0.57 (0.53 - 0.67) mm vs. 0.92 (0.85 - 0.97) mm, p = 0.000, respectively). CONCLUSION: Plasma MRP-8/14 levels were elevated in hypertensive patients with macroalbuminuria, however, it could not serve as an early marker to determine renal damage and carotid atherosclerosis in patients with hypertension.
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Association of Nutritional Assessment by Phase Angle With Mortality in Kidney Transplant Patients in an 8-Year Follow-Up.

BACKGROUND: Phase angle is a bioimpedance analysis parameter that indirectly shows body cell mass. Its association with mortality has been shown in patients receiving dialysis treatment. However, assessment with mortality in kidney transplant recipients has not been studied previously. METHODS: We examined 158 kidney transplant recipients who underwent bioimpedance analysis 8 years ago in a cross-sectional study. We contacted them again and investigated the presence of cardiovascular events, cancer, angina pectoris, and claudication. Data regarding mortality, graft failure, and creatinine values were collected from recipients' files. FINDINGS: During the follow-up period, 15 recipients died, 26 lost graft function, 36 experienced cardiovascular events, and 4 developed cancer. Phase angle was significantly associated with mortality during the 8-year follow-up period of kidney transplant recipients (P < .001). The cutoff value for phase angle as a predictor of mortality was ≤5.85. Moreover, a phase angle value lower than 5.85 indicated 5.33 times higher risk of mortality. DISCUSSION: Phase angle was a predictor of mortality in kidney transplant recipients. Since phase angle is an inexpensive, easy-to-perform, and noninvasive method, it might be considered as an additional tool to assess survival in kidney transplant recipients.

Canakinumab treatment in kidney transplant recipients with AA amyloidosis due to familial Mediterranean fever.

BACKGROUND: Familial Mediterranean fever (FMF) is an autoinflammatory disease characterized by recurrent serosal inflammation with fever, which can result in amyloid deposition. Anti-interleukin-1 drugs emerge as a therapeutic option for colchicine-resistant patients. In this study, we aimed to document our experience with canakinumab use in kidney transplant recipients who developed AA amyloidosis due to FMF. METHODS: A total of nine patients with FMF amyloidosis treated with canakinumab were enrolled. Laboratory and clinical data were collected from the patient files, electronic database of the hospital and with interviews. RESULTS: Five of the patients were male and four were female (median age: 33, range: 27-62 years). All of the patients had rapid or gradual disappearance of FMF attacks. The following changes in the laboratory parameters were observed before and after the treatment: C-reactive protein: 18.31 ± 13.58 mg/L vs 9.98 ± 11.66 mg/L, creatinine clearance: 45.27 ± 21.5 mL/min vs 50.71 ± 22.48 mL/min, and 24-hour proteinuria: 2381.8 ± 3910.4 mg vs 710.0 ± 1117.5 mg; there were no statistically significant differences on those parameters. One patient developed a reaction to injection while another showed symptoms of Cytomegalovirus pneumonia. CONCLUSION: Canakinumab can be considered as a safe and efficient drug in preventing the FMF attacks in kidney transplant recipients.

The Use of Low-Calcium Hemodialysis in the Treatment of Hypercalcemic Crisis.

BACKGROUND: We reviewed the results of low-calcium hemodialysis (LCHD; 1.25 mmol/L) in the treatment of 42 cases admitting with hypercalcemic crisis. METHODS: All patients (≥18 years) who started LCHD due to hypercalcemia between 2002 and 2017 were retrospectively analyzed. Biochemical data were obtained at the beginning of the first hemodialysis and at the end of the last hemodialysis. -"Refractory" cases were defined as patients having albumin corrected serum total calcium (SCatotal) levels above 10.2 mg/dL despite of all medical, surgical, and hemodialysis treatments. RESULTS: By acceptance of 3 cases admitted again over 6 months as new cases, a total of 42 cases (male, 57.1%) with a mean age of 55.9 ± 14.8 years underwent urgent hemodialysis. Most of the patients (82.1%) had malignancies. The mean SCatotal level at the beginning of hemodialysis sessions was 15.89 ± 2.53 mg/dL. The mean decline of SCatotal level was 4.63 ± 2.72 mg/dL. Refractory cases received hemodialysis after admission significantly later than improved cases (48 [interquartile ranges (IQR) 24-168] vs. 24 [IQR 12-48] h, p = 0.010). Serum creatinine and SCatotal levels at the last visit were significantly more in refractory cases than improved cases (1.92 [IQR 0.81-3.41] vs. 1.30 [IQR 0.8-1.7] mg/dL, p = 0.031 and 12.43 ± 2.53 vs. 8.86 ± 0.67 mg/dL, p = 0.000 respectively). Mortality was significantly higher in refractory cases than improved cases (58.8 vs. 10.5%, p = 0.002). Overall mortality rate was 33.3%. CONCLUSION: Hypercalcemic crisis is a life-threatening condition and should be managed immediately.

A Rare Presentation of Immunoglobulin A Nephropathy: Acute Kidney Injury.

BACKGROUND: Acute kidney injury (AKI) is known as an uncommon presentation in immunoglobulin A nephropathy (IgAN). The aim of our study was to analyze the clinical data and biopsy findings in IgAN patients presenting with AKI. METHODS: We performed a retrospective analysis of all subjects who had biopsy-proven IgAN and presented with AKI during June 2002 September 2015. The following data were obtained from medical records. RESULTS: A total of 15 patients of 123 patients (12.2%) with primary IgAN admitted with AKI. Patients were generally male (73.3%), with a median age of 38 (interquartile range; IQR, 2,944) years. The serum creatinine at admission was above the normal range (median 2.3 [IQR, 2.14.7] mg/dL]). On histology, cellular/fibrocellular crescents were present in 6 patients. In most cases (53.3%), pathologic abnormalities associated with acute tubular injury/necrosis were defined. Red blood cell casts in tubules were present in 6 cases (40%). In all cases, interstitial mixed inflammatory cell infiltration was observed. In 4 cases, admixed eosinophils were also found. In 3 patients, biopsy specimens showed acute thrombotic microangiopathy lesions (20%). Median follow-up time was 13 (IQR, 346) months. Six patients (40%) progressed to end-stage renal disease (ESRD). Among patients diagnosed with primary IgAN and presenting without AKI, only 4 patients progressed to ESRD. The proportion of patients who progressed to ESRD presenting with AKI was significantly higher than the patients presenting without AKI (p = 0.000). CONCLUSIONS: In conclusion, AKI complicates IgAN more often.

Urinary tuberculosis: a cohort of 79 adult cases.

We aimed to investigate the demographic, clinical, diagnostic, treatment and outcome features of patients with urinary tuberculosis (UTB). Patients with UTB admitted to seven separate centers across Turkey between 1995 and 2013 were retrospectively evaluated. The diagnosis of UTB was made by the presence of any clinical finding plus positivity of one of the following: (1) acid-fast bacilli (AFB) in urine, (2) isolation of Mycobacterium tuberculosis, (3) polymerase chain reaction (PCR) for M. tuberculosis, (4) histopathological evidence for TB. Seventy-nine patients (49.36% male, mean age 50.1 ± 17.4 years) were included. Mean time between onset of symptoms and clinical diagnosis was 9.7 ± 8.9 months. The most common signs and symptoms were hematuria (79.7%), sterile pyuria (67.1%), dysuria (51.9%), weakness (51.9%), fever (43%) and costovertebral tenderness (38%). Cystoscopy was performed in 59 (74.6%), bladder biopsy in 18 (22.8%), kidney biopsy in 1 (1.26%) and nephrectomy in 12 (15.2%) patients. Histopathological verification of UTB was achieved in 12 (63.1%) patients who undergone biopsy and in 100% of those undergone nephrectomy. Mycobacterium tuberculosis was isolated in the urine of 50 (63.3%) cases. Four-drug standard anti-TB treatment was the preferred regimen for 87.3% of the patients. Mean treatment duration was 10.5 ± 2.7 months. Deterioration of renal function occurred in 15 (18.9%) patients two of whom progressed to end-stage renal disease and received hemodialysis. Only one patient died after 74-day medical treatment period. Cases with UTB may present with non-specific clinical features. All diagnostic studies including radiology, cyctoscopy and histopathology are of great importance to exclude UTB and prevent renal failure.

Vocal cord paralysis during the treatment of mantle cell lymphoma with vincristine.

CASE DESCRIPTION: We present a case of a seventy-eight year-old man who developed vocal cord paralysis without any sign of peripheral neuropathy during the treatment of Mantle Cell Lymphoma. He first presented in 2008 with a few bilateral small inguinal lymph nodes. Inguinal lymph node biopsy demonstrated Mantle Cell Lymphoma. Flow cytometry studies of peripheral blood and bone marrow cells were compatible with Mantle Cell Lymphoma. R-CHOP chemotherapy triweekly (Rituximab; Cyclophosphamide; Adriamycin; Vincristine; and Methylprednisolone) was planned. At the end of the second cycle, the patient complained of hoarseness without any symptoms of dysphagia or odynophagia. Direct flexible laryngoscopy showed bilateral vocal cord paralysis. Vincristine was discontinued and the patient's voice gradually resolved in about 4 months. CONCLUSION: Vincristine may cause peripheral, autonomic and cranial neuropathies. However cranial nerve involvement is quite uncommon.

Calciphylaxis: a report of six cases and review of literature.

Calciphylaxis is usually a fatal condition that develops in a few chronic renal failure patients, and it is characterized by calcifications in subcutaneous arteries, infarcts in skin, and the neighboring subcutis. Calciphylaxis, once considered as a rare condition, has been reported to have an annual incidence of 1% and a prevalence of 4% in dialysis patients. We describe our clinical experience in six end-stage renal disease patients on dialysis that presented with calciphylaxis and died due to sepsis, and review the pathogenesis, epidemiology, clinical and histopathologic features, and treatment of calciphylaxis. Physicians should initially consider the possibility of calciphylaxis in case of development of skin lesions in chronic renal failure patients with impaired calcium, phosphorus, and parathyroid hormone levels. The most important cause of mortality in this condition is infection. Therefore, differential diagnosis of these lesions from systemic vasculitis in their early stages and withdrawal of immunosuppressive therapy that increases the tendency to infections are essential.