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.

Could mesangial C3 deposition be an independent prognostic marker in immunoglobulin A nephropathy?

BACKGROUND: Immunoglobulin A nephropathy (IgAN) is a common primary glomerulonephropathy. There is evidence that mesangial C3 deposition plays a role in the development of the disease. The aim of this study was to examine the effect of C3 deposition on the prognosis of IgAN patients. METHOD: The study included 1135 patients with biopsy-confirmed IgAN from the database of the Turkish Nephrology Association Glomerular Diseases Working Group (TSN-GOLD). Patients were excluded from the study if they were aged < 18 or > 75 years or if C3 staining had not been performed in the immunofluorescent analysis. C3 deposition was defined as an immunofluorescence intensity of C3 ≥ 2 + within the mesangium. The primary endpoints were the development of end-stage renal disease, a 30% decrease in glomerular filtration rate compared to the basal value or an elevation in proteinuria to a nephrotic level (3.5 gr/day). RESULTS: Mesangial C3 deposition was observed in 603 (53.1%) patients. No statistically significant difference was found at baseline between the groups with and without mesangial C3 deposition, as for age, sex, BMI, proteinuria level, or the presence of hypertension. In the follow-up period with a mean duration of 78 months, no significant difference was found between the two groups regarding the primary endpoints (p = 0.43). A significant correlation between C3 deposition and segmental glomerulosclerosis (S1) according to the Oxford MEST-C classification was found (p = 0.001). CONCLUSION: Although a correlation was observed between mesangial C3 deposition and the S1 MEST-C classification, mesangial C3 deposition was not a prognostic factor in IgAN.

Demographic, clinical and laboratory characteristics of adult-onset minimal change disease in Turkey: Turkish Society of Nephrology-Glomerular Diseases (TSN-GOLD) Working Group.

PURPOSE: In our study, diagnostic and demographic characteristics of patients diagnosed with minimal change disease (MCD) 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. The data presented are cross-sectional and includes application data for the biopsy period. RESULTS: Of 3875 patients, 233 patients with MCD (median age 35.0 years) were included in the study, which constitutes 6.0% of the total glomerulonephritis database. Renal biopsy was performed in 196 (84.1%) patients due to nephrotic syndrome. Median serum creatinine was 0.7 (0.6-1.0) mg/dl, mean eGFR was 104 ± 33 ml/min/1.73 m2 and median proteinuria 6000 mg/day. The number of patients under the age of 40 years was 139 (59.7%) (Group A), and the number of patients aged 40 years and over was 94 (40.3%) (Group B). Compared to Group A, global sclerotic glomeruli (24 vs. 43, p < 0.001) interstitial inflammation (15 vs. 34, p < 0.001), interstitial fibrosis (20 vs. 31, p = 0.001, vascular changes (10 vs. 25, p < 0.001) and tubular atrophy (18 vs. 30, p < 0.001) were found to be significantly higher in Group B. There was no difference in immunofluorescent staining properties between the two groups. CONCLUSION: Our data are generally compatible with the literature. Chronic histopathological changes were more common in patients aged 40 years and older than younger patients. Studies investigating the effects of these different features on renal survival are needed.

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.

Retrospective analysis of patients diagnosed with severe hyponatraemia in the emergency department.

Background . We investigated the demographic, aetiological and clinical characteristics of patients who presented to the emergency department and had severe hyponatraemia. Methods . We retrospectively evaluated 1171 patients who presented to the emergency department and were diagnosed with severe hyponatraemia. Results . Over half the patients studied were women (53.5%). The mean age of women was higher (p<0.0001). The most common complaint was dyspnoea (16.8%) and 42.5% of the patients had an oral intake disorder. In addition, 22.3% of the patients were on loop diuretics. About 76.3% of patients were conscious, and the mean sodium level of these patients was higher than the mean sodium level of those who responded to verbal and painful stimuli (p<0.001). Severe isolated hyponatraemia was observed in 61.8% of the patients. The mortality rate was 12.8%. There was no difference between the mean sodium levels of the deceased and discharged patients (p=1.0). The mortality rate was higher in patients who had a history of cirrhosis and cancer, but was lower in patients with a history of coronary artery disease (p=0.0002, p<0.0001 and p=0.04, respectively). Conclusion . Severe hyponatraemia was more prevalent in women, serum sodium levels were higher in conscious patients, and the mortality rate was higher in patients who had a history of cirrhosis and cancer. We found that the mean serum sodium levels did not help in distinguishing between the deceased and discharged patients.

The relationship between glomerular IgG staining and poor prognostic findings in patients with IgA nephropathy: the data from TSN-GOLD working group.

BACKGROUND: Galactose-deficient IgA1 (Gd-IgA1) has an increased tendency to form immunocomplexes with IgG in the serum, contributing to IgAN pathogenesis by accumulating in the glomerular mesangium. Several studies showed that glomerular IgG deposition in IgAN is an important cause of mesangial proliferation and glomerular damage. This study aims to determine the association of the positivity of IgG and the intensity of IgG staining with a poor renal prognosis. METHODS: A total of 943 IgAN patients were included in the study. Glomerular IgG staining negative and positive patients were compared using Oxford classification scores, histopathological evaluations, proteinuria, eGFR, albumin, blood pressures. IgG positive patients were classified as (+), (++), (+++) based on their staining intensity, and the association with the prognostic criteria was also evaluated. RESULTS: 81% (n = 764) of the patients were detected as IgG negative, while 19% (n = 179) were positive. Age, gender, body mass index, blood pressure, proteinuria, eGFR, uric acid values were similar in IgG positive and negative patients who underwent biopsy (p > 0.05). Intensity of glomerular IgG positivity was not found to be associated with diastolic and systolic blood pressure, urea, uric acid, age, eGFR, albumin, proteinuria (p > 0.05 for all, r = - 0.084, r = - 0.102, r = - 0.006, r = 0.062, r = 0.014, r = - 0.044, r = - 0.061, r = - 0.066, r = 0.150, respectively). There was no difference for histopathological findings between IgG (+), IgG (++), IgG (+++) groups (for all, p > 0.05). CONCLUSION: Glomerular IgG negativity and positivity detected by routine IFM in IgAN patients is not associated with poor renal prognostic risk factors.

Clinical characteristics and cost of hospital stay of octogenarians and nonagenarians in intensive care nephrology unit.

PURPOSE: As the population gets older, the elderly and very elderly patients are increasingly been treated in nephrology intensive care units (ICU). In this study we evaluated the characteristics and outcomes of the octogenarians (80-89 years old), nonagenarians (≥ 90 years old) and compared them with elderly (65-79 years old) patients treated in nephrology ICU. METHODS: Eighteen nonagenarians, 70 octogenarians and 88 elderly patients were included in the study. Indication for hospitalization, presence of comorbid diseases, and requirement for acute dialysis treatment were investigated. Need for mechanical ventilation, vasopressors, central venous catheterization, urinary catheterization, anticoagulation, and transfusion of blood products were evaluated. Mortality rate and hospital cost were calculated. Data about survival at 1 month after discharge was collected. RESULTS: Causes of hospitalization, need for dialysis treatment, mechanical ventilation, vasopressors, central venous catheterization, urinary catheterization, anticoagulation, and transfusion of blood products were not different between age groups. Diabetes mellitus and malignancy were more frequent in elderly, whereas dementia/Alzheimer's disease was more common in nonagenarians. Although, mortality in ICU was increased as the age increased, it was statistically insignificant. However, 1 month mortality rate after discharge from hospital was increased especially in nonagenarians. In nonagenarians infection, whereas in octogenarians need for dialysis treatment, were related with mortality. Length of intensive care stay and hospital cost did not differ between age groups. CONCLUSION: Length of nephrology intensive care stay, mortality rate and hospital cost did not differ for very elderly age groups, but mortality risk was higher for nonagenarians after discharge from hospital.

Epidemiological features of primary glomerular disease in Turkey: a multicenter study by the Turkish Society of Nephrology Glomerular Diseases Working Group.

BACKGROUND: The largest data on the epidemiology of primary glomerular diseases (PGDs) are obtained from the databases of countries or centers. Here, we present the extended results of the Primary Glomerular Diseases Study of the Turkish Society of Nephrology Glomerular Diseases (TSN-GOLD) Working Group. METHODS: Data of patients who underwent renal biopsy and received the diagnosis of PGD were recorded in the database prepared for the study. A total of 4399 patients from 47 centers were evaluated between May 2009 and May 2019. The data obtained at the time of kidney biopsy were analyzed. After the exclusion of patients without light microscopy and immunofluorescence microscopy findings, a total of 3875 patients were included in the study. RESULTS: The mean age was 41.5 ± 14.9 years. 1690 patients were female (43.6%) and 2185 (56.3%) were male. Nephrotic syndrome was the most common biopsy indication (51.7%). This was followed by asymptomatic urinary abnormalities (18.3%) and nephritic syndrome (17.8%). The most common PGD was IgA nephropathy (25.7%) followed by membranous nephropathy (25.6%) and focal segmental glomerulosclerosis (21.9%). The mean total number of glomeruli per biopsy was 17 ± 10. The mean baseline systolic blood pressure was 130 ± 20 mmHg and diastolic blood pressure was 81 ± 12 mmHg. The median proteinuria, serum creatinine, estimated GFR, and mean albumin values were 3300 (IQR: 1467-6307) mg/day, 1.0 (IQR: 0.7-1.6) mg/dL, 82.9 (IQR: 47.0-113.0) mL/min and 3.2 ± 0.9 g/dL, respectively. CONCLUSIONS: The distribution of PGDs in Turkey has become similar to that in other European countries. IgA nephropathy diagnosed via renal biopsy has become more prevalent compared to membranous nephropathy.

Amyloidosis Associated Kidney Failure with Gross Hypermetabolic Intra-abdominal Mass

A 23-year-old male patient who presented with impaired kidney function tests attended to hospital for hemodialysis and underwent 18F-FDG positron emission tomography/computed tomography (PET/CT) examination for the metabolic characterization of the intra-abdominal mass which was found in the ultrasonography. 18F-FDG PET/CT revealed a mass lesion adjacent to the liver which was hypermetabolic and the pathology of the lesion was determined as amyloidosis. To the best of our knowledge, the case with 18F-FDG PET/CT images of a huge amyloid mass is the first in the literature.

Acute renal infarction in Turkey: a review of 121 cases.

PURPOSE: Renal infarction is a clinical condition which is caused by renal artery occlusion and leads to permanent renal parenchymal damage. In the literature, there are generally case reports on this subject, and few studies that include a large group of patients. Therefore, we aimed to present the data of a large group of patients who were diagnosed with acute renal infarction in our country in this retrospective study. METHODS: The data of patients who were diagnosed with acute renal infarction according to clinical and radiological findings in Turkey in the last 3 years were examined. For this purpose, we contacted with more than 40 centers in 7 regions and obtained support from clinically responsible persons. Demographic data of patients, laboratory data at the time of diagnosis, tests performed for etiologic evaluation, given medications, and patients' clinical status during follow-up were obtained from databases and statistical analysis was performed. RESULTS: One-hundred and twenty-one patients were included in the study. The mean age was 53 ± 1.4 (19-91) years. Seventy-one (58.7%) patients were male, 18 (14.9%) had diabetes, 53 (43.8%) had hypertension, 36 (30%) had atrial fibrillation (AF), and 6 had a history of lupus + antiphospholipid syndrome (APS). Forty-five patients had right renal infarction, 50 patients had left renal infarction, and 26 (21.5%) patients had bilateral renal infarction. The examinations for the ethiologies revealed that, 36 patients had thromboemboli due to atrial fibrillation, 10 patients had genetic anomalies leading to thrombosis, 9 patients had trauma, 6 patients had lupus + APS, 2 patients had hematologic diseases, and 1 patient had a substance abuse problem. Fifty-seven (57%) patients had unknown. The mean follow-up period was 14 ± 2 months. The mean creatinine and glomerular filtration rate (GFR) values at 3 months were found to be 1.65 ± 0.16 mg/dl and 62 ± 3 ml/min, respectively. The final mean creatinine and GFR values were found to be 1.69 ± 0.16 mg/dl and 62 ± 3 ml/min, respectively. CONCLUSIONS: Our study is the second largest series published on renal infarction in the literature. More detailed studies are needed to determine the etiological causes of acute renal infarction occurring in patients.

An unusual cause of duodenal obstruction: mesenteric fibromatosis in a patient with type I Mayer-Rokitansky-Kuster-Hauser syndrome.

Patients with mesenteric fibromatosis (MF) are clinically asymptomatic, with little or no focal symptoms until later in their course, at which time they complain of pain, abdominal discomfort, constipation, vomiting, abdominal mass, weight loss, and symptoms due to organ compression. Generally, it occurs as an abdominal mass but may also present in many different ways. In some cases, trauma, previous abdominal surgery, and hormonal stimulation (such as estrogen) may play a role in onset of this neoplasm. Patients with Mayer-Rokitansky-Kuster-Hauser syndrome present primary amenorrhea and may have some other anomalies, including hearing defects, heart defects, skeletal deformities, and genital neoplastic diseases. We diagnosed duodenal obstruction due to MF in a patient with type I Mayer-Rokitansky-Kuster-Hauser syndrome.

Lack of nephrotoxicity of gadopentetate dimeglumine-enhanced non-vascular MRI and MRI without contrast agent in patients at high-risk for acute kidney injury.

BACKGROUND: Gadolinium chelates (GCs) have been traditionally considered as non-nephrotoxic magnetic resonance imaging (MRI) contrast materials. However, it has been suggested in some recent articles that GCs may have a nephrotoxic potential, but most of these reports are retrospective. However, the evaluated contrast agents, their doses, and the tests used to determine the kidney function were not consistent across studies. We aimed to investigate the effect of magnetic field and an MRI contrast agent, gadopentetate dimeglumine (GD), on renal functions in patients at high risk for acute kidney injury (AKI). MATERIAL AND METHODS: We designed a prospective case-control study with 2 age- and sex-matched groups of patients at high-risk for AKI (n=72 for each group). Patients in Group 1 received a fixed dose of (0.2 mmol/kg) GD-enhanced non-vascular MRI and patients in Group 2 received MRI without GD. Before the MRI and at 6, 24, 72, and 168 hours after the MRI, biochemical tests, estimated glomerular filtration rate (eGFR), albumin/creatinine ratio in spot urine, and early AKI biomarkers (cystatin C, N-Acetyl-Glucosaminidase [NAG], Neutrophil gelatinase-associated lipocalin [NGAL]) were measured. RESULTS: Serum creatinine, albumin/creatinine ratio, and eGFR were not different between Group 1 and 2 (p>0.05). There were no significant changes in renal function tests and AKI biomarkers (∆serum creatinine, ∆albumin/creatinine ratio, ∆GFR, ∆cystatin C, ∆NAG, and ∆NGAL) for either groups 6, 24, 72, and 168 hours after the procedures (p>0.05). CONCLUSIONS: MRI without contrast agent and non-vascular contrast-enhanced (GD, 0.2 mmol/kg) MRI are not nephrotoxic procedures for patients at high risk for AKI.

Serum levels of cancer biomarkers in diabetic and non-diabetic proteinuric patients: a preliminary study.

BACKGROUND: Cancer biomarkers (CBs) can be used in early detection of several cancers as well as in detection of recurrence and following response to treatment. We aimed to investigate the levels of CBs in proteinuric patients with primary glomerular disease (PGD) and diabetes mellitus, and compare them with healthy controls. METHODS: One hundred and two patients with untreated PGD, 62 proteinuric patients with diabetic nephropathy, and 84 healthy controls were enrolled. Levels of cancer antigen 125 (CA 125), cancer antigen 15-3 (CA 15-3), carcinoembriogenic antigen (CEA), α-fetoprotein (AFP), total prostate specific antigen (TPSA), free prostate specific antigen (FPSA) and carbohydrate antigen 19-9 (CA 19-9) were measured. RESULTS: Compared to healthy controls, levels of CA 125, CA 15-3 and CA 19-9 were higher in patients with PGD and diabetic patients (all p<0.05), while levels of TPSA, FPSA, AFP and CEA were lower (all p<0.05). There was no correlation between levels of cancer biomarkers and serum fibrinogen and serum amyloid A protein levels (all p>0.05). Both urinary protein excretion rate and serum albumin levels were correlated with all CBs (all p<0.05). CONCLUSIONS: CBs levels seem to be changed in different proteinuric patients. This condition should be kept in mind when evaluating CBs levels in proteinuric patients.

Reversible minimal change nephrotic syndrome and glomerular IgA deposition associated with nonparenteral heroin abuse: a case report.

OBJECTIVE: To report for the first time a case of reversible minimal change nephrotic syndrome with immunoglobulin A (IgA) deposition associated with heroin. CLINICAL PRESENTATION AND INTERVENTION: A 29-year-old male heroin abuser who developed nephrotic syndrome was admitted to our clinic. Renal biopsy revealed minimal change disease with IgA deposition. Because spontaneous complete remission was observed after cessation of heroin, a diagnosis of minimal change nephrotic syndrome with IgA deposition associated with heroin abuse was considered. CONCLUSION: This case showed minimal change nephrotic syndrome with IgA deposition that had a benign clinical course.

Development of high-output heart failure after correction of central venous occlusion: a case report.

Temporary or permanent central venous catheter (CVC) insertion has been performed frequently for hemodialysis treatment. One of the most important long-term complications of CVC is the central venous occlusion (CVO). Treatment of CVO consists of percutaneous angioplasty (PTA), PTA and stent implantation, or surgical procedure for resistant occlusions. Clinical outcome and long-term results of the revascularization procedures are well documented. However, there is no clear information about acute medical complications of the procedures. High-output heart failure (HOHF) is associated with several diseases including chronic anemia, psoriasis, systemic arteriovenous fistula, sepsis, hypercapnia, multiple myeloma, and hyperthyroidism. Herein, we report a case of chronic kidney disease with CVO that developed acute HOHF immediately after the revascularization procedure (PTA and stenting).