Dietary protein and muscle wasting in chronic kidney disease: new insights.

PURPOSE OF REVIEW: Muscle wasting is an important health problem in chronic kidney disease (CKD) patients. Protein restriction in the diet can be one of the main causes of muscle wasting in this population. In this review, we aimed to investigate the relationship between dietary protein intake and muscle wasting in CKD patients according to recent literature. RECENT FINDINGS: The one of the main mechanisms responsible for the muscle wasting is the disturbances in skeletal muscle protein turnover. Muscle wasting primarily occurs when the rates of muscle protein breakdown exceed the muscle protein synthesis. Dietary protein intake represents an important role by causing a potent anabolic stimulus resulting a positive muscle protein balance. Compared to studies made in healthy populations, there are very limited studies in the literature about the relationship between dietary protein intake and muscle wasting in the CKD population. Majority of the studies showed that a more liberal protein intake is beneficial for muscle wasting in especially advanced CKD and hemodialysis population. SUMMARY: Although evaluating muscle wasting in CKD patients, the amount of protein in the diet of patients should also be reviewed. Although excessive protein intake has some negative consequences on this patient group, a more liberated dietary protein intake should be taken into account in this patient group with muscle wasting and especially in dialysis patients.

Seizures in patients with kidney diseases: a neglected problem?

Nephrologists may encounter many systemic problems in their patients, including involvement of the neurological system and the development of seizures. Seizures are defined as abnormal neurological functions that cause overstimulation of neurons in the cerebral cortex or limbic system. Seizures may be focal or generalized depending on their origin and may have tonic, clonic, tonic-clonic or myoclonic character depending on the level of involvement of the motor movements. Patients with kidney disease may develop seizures due to etiologies seen in the general population (such as intracranial bleeding, cerebrovascular events, tumors, infections and intoxications) or due to kidney-related etiologies (such as uremic encephalopathy, dialysis disequilibrium syndrome and hyponatremia). Management of seizures in kidney patients is challenging for proper determination of the type and dosage of antiepileptic drugs due to varying renal clearances. This review covers the major causes of new-onset seizures in patients with acute kidney injury, electrolyte imbalances, chronic kidney disease, dialysis, renal transplantation or hypertension, and the available management approaches.

The frequency of sarcopenia has increased in patients with glomerulonephritis.

AIM: Sarcopenia is defined as the loss of muscle mass and muscle strength, and its frequency increases in kidney patients. However, sarcopenia frequency in patients with glomerulonephritis is unknown. The present study aimed to investigate the frequency of sarcopenia in patients with glomerulonephritis and compare the results with the healthy population for the first time in the literature. PATIENTS AND METHODS: A total of 110 participants, including 70 patients previously diagnosed with glomerulonephritis and 40 healthy individuals, were included in the study. The diagnosis of sarcopenia was made based on the EWSGOP 2 Criteria. RESULTS: The mean age of the glomerulonephritis patients group was 39.3 ± 1.5. In the anthropometric measurements of the patients, walking speed was low in 50 patients (71.4%), muscle strength was decreased in 44 patients (62.9%), and sarcopenia was detected in 10 patients (14.3%) according to the EWGSOP 2 Criteria. Considering the anthropometric measurements of the control group, sarcopenia was not detected in any of the subjects according to the EWGSOP 2 Criteria. CONCLUSION: The result of the present study revealed that the rate of sarcopenia was significantly higher in glomerulonephritis patients compared to the healthy population and that sarcopenia can also be observed even in middle age in this population. We think it would be beneficial for clinicians treating glomerulonephritis to be more careful regarding sarcopenia and keep these parameters in mind during treatment.

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.

The relationship between hepatic fibrosis and arterial stiffness in hemodialysis patients.

INTRODUCTION: The main cause of death in hemodialysis patients is cardiovascular diseases. Increased arterial stiffness is a predictor of cardiovascular events for hemodialysis patients. Among the nondialysis patient population, arterial stiffness increases in those with hepatic fibrosis and nonalcoholic fatty liver disease. This study aims to examine the relationship between hepatic fibrosis and arterial stiffness in hemodialysis patients for the first time in the literature. MATERIAL AND METHOD: The study includes chronic hemodialysis patients over 18 years of age who had been treated for hemodialysis for at least 6 months. Patients with chronic liver disease, chronic viral hepatitis (HBV and HCV), alcohol use, or liver disease accompanied by polycystic kidney disease and active infection were excluded. Hepatic fibrosis scores were measured using the FibroScan device. Single-cuff Mobil-o-Graph was used for measurement of arterial stiffness. RESULTS: Fifty-nine patients were enrolled; 54.2% of the patients were male, and the mean age was 53.9 ± 12.9 years. Thirty-nine percent of the patients had diabetes. Average pulse wave velocity (PWV) value of the patients was 8.3 ± 1.6 m/s, and it had positive correlation with age, CAP score, fibrosis score, and body mass index and showed negative correlation to albumin. It was seen that the patients with a PWV value ≥ 10 m/s have significantly higher CAP score compared with the patients with a PWV < 10 m/s. When the factors predicting PWV were examined in the regression analysis, age and systolic blood pressure were found to be determinants. CONCLUSION: Increased hepatic fibrosis in hemodialysis patients is associated with increased arterial stiffness, but this relationship is not independent.

Characteristics and Survival Results of Peritoneal Dialysis Patients Suffering from COVID-19 in Turkey: A Multicenter National Study.

INTRODUCTION: We aimed to study the characteristics of peritoneal dialysis (PD) patients with coronavirus disease-19 (COVID-19), determine the short-term mortality and other medical complications, and delineate the factors associated with COVID-19 outcome. METHODS: In this multicenter national study, we included PD patients with confirmed COVID-19 from 27 centers. The baseline demographic, clinical, laboratory, and radiological data and outcomes at the end of the first month were recorded. RESULTS: We enrolled 142 COVID-19 patients (median age: 52 years). 58.2% of patients had mild disease at diagnosis. Lung involvement was detected in 60.8% of patients. Eighty-three (58.4%) patients were hospitalized, 31 (21.8%) patients were admitted to intensive care unit and 24 needed mechanical ventilation. Fifteen (10.5%) patients were switched to hemodialysis and hemodiafiltration was performed for four (2.8%) patients. Persisting pulmonary symptoms (n = 27), lower respiratory system infection (n = 12), rehospitalization for any reason (n = 24), malnutrition (n = 6), hypervolemia (n = 13), peritonitis (n = 7), ultrafiltration failure (n = 7), and in PD modality change (n = 8) were reported in survivors. Twenty-six patients (18.31%) died in the first month of diagnosis. The non-survivor group was older, comorbidities were more prevalent. Fever, dyspnea, cough, serious-vital disease at presentation, bilateral pulmonary involvement, and pleural effusion were more frequent among non-survivors. Age (OR: 1.102; 95% CI: 1.032-1.117; p: 0.004), moderate-severe clinical disease at presentation (OR: 26.825; 95% CI: 4.578-157.172; p < 0.001), and baseline CRP (OR: 1.008; 95% CI; 1,000-1.016; p: 0.040) were associated with first-month mortality in multivariate analysis. DISCUSSION/CONCLUSIONS: Early mortality rate and medical complications are quite high in PD patients with COVID-19. Age, clinical severity of COVID-19, and baseline CRP level are the independent parameters associated with mortality.

Serum NT-proBNP levels are associated with cognitive functions in hemodialysis patients.

It has been demonstrated that NT-proBNP and macrophage inhibitor cytokine-1 (MIC-1/GDF-15) are associated with cognitive functions in patients without renal disease. In the present study, we examined the association of these two molecules with cognitive functions in hemodialysis patients for the first time in the literature. A total of 94 patients were enrolled. The Mini-Mental Test and the Montreal Cognitive Assessment Test (MoCA) were applied for the purpose of measuring the cognitive functions. The NT-proBNP and MIC-1/GDF-15 levels were examined with the ELISA. The mean age of the patients was 48 ± 12; 58 (61.7%) of them were male and 21.3% were diabetic. We found that in 77% of patients have impaired cognitive functions (MoCA total score <24). The NT-proBNP level had a significant and negative correlation with the MoCA Test Delayed Recall and Total Score. When the patients were divided into two groups according to NT-proBNP levels (above 10.500 and below), it was observed that the Mini-Mental Test Record Memory, MoCA Test Delayed Recall, and MoCA test total scores were significantly different from each other. In the present study, we show, for the first time in the literature, that NT-proBNP levels are associated with cognitive functions in dialysis patients.

Determinants of mortality in a large group of hemodialysis patients hospitalized for COVID-19.

BACKGROUND: Maintenance hemodialysis (MHD) patients are at increased risk for coronavirus disease 2019 (COVID-19). The aim of this study was to describe clinical, laboratory, and radiologic characteristics and determinants of mortality in a large group of MHD patients hospitalized for COVID-19. METHODS: This multicenter, retrospective, observational study collected data from 47 nephrology clinics in Turkey. Baseline clinical, laboratory and radiological characteristics, and COVID-19 treatments during hospitalization, need for intensive care and mechanical ventilation were recorded. The main study outcome was in-hospital mortality and the determinants were analyzed by Cox regression survival analysis. RESULTS: Of 567 MHD patients, 93 (16.3%) patients died, 134 (23.6%) patients admitted to intensive care unit (ICU) and 91 of the ones in ICU (67.9%) needed mechanical ventilation. Patients who died were older (median age, 66 [57-74] vs. 63 [52-71] years, p = 0.019), had more congestive heart failure (34.9% versus 20.7%, p = 0.004) and chronic obstructive pulmonary disease (23.6% versus 12.7%, p = 0.008) compared to the discharged patients. Most patients (89.6%) had radiological manifestations compatible with COVID-19 pulmonary involvement. Median platelet (166 × 103 per mm3 versus 192 × 103 per mm3, p = 0.011) and lymphocyte (800 per mm3 versus 1000 per mm3, p < 0.001) counts and albumin levels (median, 3.2 g/dl versus 3.5 g/dl, p = 0.001) on admission were lower in patients who died. Age (HR: 1.022 [95% CI, 1.003-1.041], p = 0.025), severe-critical disease clinical presentation at the time of diagnosis (HR: 6.223 [95% CI, 2.168-17.863], p < 0.001), presence of congestive heart failure (HR: 2.247 [95% CI, 1.228-4.111], p = 0.009), ferritin levels on admission (HR; 1.057 [95% CI, 1.006-1.111], p = 0.028), elevation of aspartate aminotransferase (AST) (HR; 3.909 [95% CI, 2.143-7.132], p < 0.001) and low platelet count (< 150 × 103 per mm3) during hospitalization (HR; 1.864 [95% CI, 1.025-3.390], p = 0.041) were risk factors for mortality. CONCLUSION: Hospitalized MHD patients with COVID-19 had a high mortality rate. Older age, presence of heart failure, clinical severity of the disease at presentation, ferritin level on admission, decrease in platelet count and increase in AST level during hospitalization may be used to predict the mortality risk of these 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.

Impact of hospital-acquired acute kidney injury on Covid-19 outcomes in patients with and without chronic kidney disease: a multicenter retrospective cohort study

Background/aim: Hospital-acquired acute kidney injury (HA-AKI) may commonly develop in Covid-19 patients and is expected to have higher mortality. There is little comparative data investigating the effect of HA-AKI on mortality of chronic kidney disease (CKD) patients and a control group of general population suffering from Covid-19. Materials and methods: HA-AKI development was assessed in a group of stage 3­5 CKD patients and control group without CKD among adult patients hospitalized for Covid-19. The role of AKI development on the outcome (in-hospital mortality and admission to the intensive care unit [ICU]) of patients with and without CKD was compared. Results: Among 621 hospitalized patients (age 60 [IQR: 47­73]), women: 44.1%), AKI developed in 32.5% of the patients, as stage 1 in 84.2%, stage 2 in 8.4%, and stage 3 in 7.4%. AKI developed in 48.0 % of CKD patients, whereas it developed in 17.6% of patients without CKD. CKD patients with HA-AKI had the highest mortality rate of 41.1% compared to 14.3% of patients with HA-AKI but no CKD (p < 0.001). However, patients with AKI+non-CKD had similar rates of ICU admission, mechanical ventilation, and death rate to patients with CKD without AKI. Adjusted mortality risks of the AKI+non-CKD group (HR: 9.0, 95% CI: 1.9­44.2) and AKI+CKD group (HR: 7.9, 95% CI: 1.9­33.3) were significantly higher than that of the non-AKI+non-CKD group. Conclusion: AKI frequently develops in hospitalized patients due to Covid-19 and is associated with high mortality. HA-AKI has worse outcomes whether it develops in patients with or without CKD, but the worst outcome was seen in AKI+CKD patients.

Pregnancy and its outcomes in hemodialysis patients in Turkey.

BACKGROUND/AIM: This study aimed to investigate pregnancy frequency and evaluate the factors affecting live births in hemodialysis (HD) patients. MATERIALS AND METHODS: Female HD patients whose pregnancy was retrospectively reported between January 1, 2014, and December 31, 2019. The duration of HD, primary disease, whether the pregnancy resulted in abortion, stillbirth, or live birth, whether the HD duration was prolonged after diagnosing the pregnancy and whether it accompanied preeclampsia were recorded. RESULTS: In this study, we reached 9038 HD female patients? data in the study. A total of 235 pregnancies were detected in 145 patients. The mean age was 35.42 (35 ± 7.4) years. The mean age at first gestation was 30.8 ± 6.5 years. The average birth week was 32 (28 - 36) weeks. 53.8% (no = 78) of the patients had live birth, 51.7% (no = 70) had at least one abortion in the first 20 weeks, and 13.1% (no = 19) had at least one stillbirth after 20 weeks. The rate of patients' increased numbers of dialysis sessions during pregnancy was 71.7%. The abortion rate was 22.4% in those with increased HD sessions, whereas 79.3% in those not increased HD sessions (p < 0.001). Live birth frequency was 67.2% in the increased HD sessions group and 3.4% in those who did not differ in HD sessions (p < 0.001). CONCLUSION: For the first time, we reported pregnancy outcomes in HD female patients, covering all regions of Turkey. It has been observed that; increasing the number of HD sessions in dialysis patients will decrease fetal and maternal complications and increase live birth rates.

Mortality analysis of COVID-19 infection in chronic kidney disease, haemodialysis and renal transplant patients compared with patients without kidney disease: a nationwide analysis from Turkey.

BACKGROUND: Chronic kidney disease (CKD) and immunosuppression, such as in renal transplantation (RT), stand as one of the established potential risk factors for severe coronavirus disease 2019 (COVID-19). Case morbidity and mortality rates for any type of infection have always been much higher in CKD, haemodialysis (HD) and RT patients than in the general population. A large study comparing COVID-19 outcome in moderate to advanced CKD (Stages 3-5), HD and RT patients with a control group of patients is still lacking. METHODS: We conducted a multicentre, retrospective, observational study, involving hospitalized adult patients with COVID-19 from 47 centres in Turkey. Patients with CKD Stages 3-5, chronic HD and RT were compared with patients who had COVID-19 but no kidney disease. Demographics, comorbidities, medications, laboratory tests, COVID-19 treatments and outcome [in-hospital mortality and combined in-hospital outcome mortality or admission to the intensive care unit (ICU)] were compared. RESULTS: A total of 1210 patients were included [median age, 61 (quartile 1-quartile 3 48-71) years, female 551 (45.5%)] composed of four groups: control (n = 450), HD (n = 390), RT (n = 81) and CKD (n = 289). The ICU admission rate was 266/1210 (22.0%). A total of 172/1210 (14.2%) patients died. The ICU admission and in-hospital mortality rates in the CKD group [114/289 (39.4%); 95% confidence interval (CI) 33.9-45.2; and 82/289 (28.4%); 95% CI 23.9-34.5)] were significantly higher than the other groups: HD = 99/390 (25.4%; 95% CI 21.3-29.9; P < 0.001) and 63/390 (16.2%; 95% CI 13.0-20.4; P < 0.001); RT = 17/81 (21.0%; 95% CI 13.2-30.8; P = 0.002) and 9/81 (11.1%; 95% CI 5.7-19.5; P = 0.001); and control = 36/450 (8.0%; 95% CI 5.8-10.8; P < 0.001) and 18/450 (4%; 95% CI 2.5-6.2; P < 0.001). Adjusted mortality and adjusted combined outcomes in CKD group and HD groups were significantly higher than the control group [hazard ratio (HR) (95% CI) CKD: 2.88 (1.52-5.44); P = 0.001; 2.44 (1.35-4.40); P = 0.003; HD: 2.32 (1.21-4.46); P = 0.011; 2.25 (1.23-4.12); P = 0.008), respectively], but these were not significantly different in the RT from in the control group [HR (95% CI) 1.89 (0.76-4.72); P = 0.169; 1.87 (0.81-4.28); P = 0.138, respectively]. CONCLUSIONS: Hospitalized COVID-19 patients with CKDs, including Stages 3-5 CKD, HD and RT, have significantly higher mortality than patients without kidney disease. Stages 3-5 CKD patients have an in-hospital mortality rate as much as HD patients, which may be in part because of similar age and comorbidity burden. We were unable to assess if RT patients were or were not at increased risk for in-hospital mortality because of the relatively small sample size of the RT patients in this study.

The relation between epicardial fat tissue thickness and atrial fibrillation in hemodialysis patients.

The prevalence of arrhythmia has increased in hemodialysis (HD) patients and the most frequent is atrial fibrillation (AF). It was reported that the amount of epicardial fat tissue (EFT) in the population without renal disease is closely related to AF. In the present study of ours, the relation between EFT thickness and AF was examined in HD patients. A total of 79 patients who underwent HD for periods longer than 3 months were included in the study. The mean age of the patients was 53.6 ± 15.2 years and 50.6% were male. The mean EFT thicknesses were measured as 7.2 ± 2.3 mm (3-12). A positive correlation was found between the EFT thickness and age, C-reactive protein, and left ventricle rear wall thickness. AF was found in 18 (22.8%) patients in the Holter ECG examination. When the group with AF was compared with the non-AF group; although the mean HD duration of the group with AF was longer, there were no significant differences in terms of epicardial adipose tissue thickness and other parameters. In the present study, no relations were found between EFT thickness and AF frequency in HD patients. Further studies with a larger number of the patient population are needed in this regard.

Can vasohibin-1, an endothelium-derived angiogenesis inhibitor, be a marker of endothelial dysfunction in hemodialysis patients?

BACKGROUND: Endothelial dysfunction (ED) is associated with high cardiovascular disease burden in hemodialysis (HD) patients. Vasohibin-1, an endothelium-derived angiogenesis inhibitor, is essential for endothelial cell survival, therefore it may be a promising marker of ED. We aimed to investigate whether vasohibin-1 levels are associated with ED markers in HD patients. METHODS: Fifty HD patients and 30 healthy controls were included in the study. As markers of ED, endothelium-dependent flow-mediated dilatation (FMD), carotid intima-media thickness (CIMT), and pulse wave velocity (PWV) were examined. Serum vasohibin-1 levels were measured with ELISA. RESULTS: Serum vasohibin-1 levels were low (387.7 ± 115.7 vs 450.1 ± 140.1 P = .02), FMDs' were impaired (6.65 ± 2.50 vs 10.95 ± 2.86 P < .001), PWV (7.92 ± 1.964 vs 6.79 ± 0.96 P = .01) and CIMT (0.95 ± 0.20 vs 0.60 ± 0.11 P < .001) were increased in HD patients compared to healthy controls. In regression analysis, vasohibin-1 levels were not related with FMD, PWV, or CIMT. CONCLUSIONS: Hemodialysis patients have low serum vasohibin-1 levels but serum levels of vasohibin-1 did not show any significant relationship with FMD, PWV, and CIMT in HD patients. Since vasohibin-1 acts via paracrine pathways, serum levels may be insufficient to explain the relationship between vasohibin and ED. Local vasohibin-1 activity on tissue level may be more important instead of circulating levels.

Renal Tubular Acidosis in Patients with Systemic Lupus Erythematosus.

OBJECTIVE: Renal tubular acidosis (RTA) is a clinical manifestation that occurs with insufficiency in restoring bicarbonate or disruption in hydrogen ion elimination as a result of a disruption in tubulus functions, causing normal anion gap-opening metabolic acidosis. In the present study, we aimed to investigate the prevalence of RTA in the largest systemic lupus erythematosus (SLE) patient population to date. MATERIALS AND METHODS: SLE patients, who were followed up in 2 different healthcare centers, were included. Patients with metabolic acidosis (pH <7.35 and HCO3 <22 mEq/L) in venous blood gas analysis were determined. The serum and urine anion GAP of these patients were estimated, and the urine pH was assessed. RTA presence was evaluated as metabolic acidosis with a normal serum anion gap and a positive urine anion GAP. RESULTS: A total of 108 patients were included in the present study. The mean age of the patients was 41.5 ± 1.2 and 87% were female. The SLE diagnosis duration was 75 ± 5 months. The mean creatinine value ​​was 0.6 ± 0.1 mg/dL and the mean eGFR was 111 ± 2 mL/min. According to the blood gas analysis, 18 patients (16.7% of the total) had RTA. Sixteen of these patients had type 1 RTA and 2 had type 2 RTA; type 4 RTA was not determined in any of the patients. CONCLUSION: RTA should be considered in SLE patients even if they have normal eGFR values. This is the largest study to examine the prevalence of RTA in SLE patients in the literature.

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.

COVID-19: a novel menace for the practice of nephrology and how to manage it with minor devastation?

Coronavirus disease 19 (COVID-19) became a nightmare for the world since December 2019. Although the disease affects people at any age; elderly patients and those with comorbidities were more affected. Everyday nephrologists see patients with hypertension, chronic kidney disease, maintenance dialysis treatment or kidney transplant who are also high-risk groups for the COVID-19. Beyond that, COVID-19 or severe acute respiratory syndrome (SARS) due to infection may directly affect kidney functions. This broad spectrum of COVID-19 influence on kidney patients and kidney functions obviously necessitate an up to date management policy for nephrological care. This review overviews and purifies recently published literature in a question to answer format for the practicing nephrologists that will often encounter COVID-19 and kidney related cases during the pandemic times.

The relationship between serum osteopontin and FGF 23 levels with valvular calcification in hemodialysis patients
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BACKGROUNDS AND AIMS: Cardiovascular calcification is an important cause of morbidity and mortality in hemodialysis (HD) patients. Vascular and valvular calcification are indicators of increased tissue calcification. The relationship of osteopontin (OPN) - which is known as a vascular calcification inhibitor - and fibroblast growth factor-23 (FGF-23) - which its related to vascular calcification, as recently shown - to valvular calcification is unknown. In this cross-sectional study, we examined the relationship between heart valve calcification, serum OPN, and FGF-23 levels. MATERIALS AND METHODS: 85 adults who were on HD treatment for at least 6 months were included in the study. Echocardiographic evaluation was made with the General Electric echocardiography device and the same cardiologist. FGF-23 and osteopontin levels were measured by ELISA. RESULTS: 54% of our patients were male, mean age was 49.8 ± 15.1 years, and mean HD duration was 52.5 ± 39.6 months. 34% of the patients were diabetic, and 17.6% had a history of coronary artery disease. 1.25 mmol/L calcium were used as dialysate calcium in 84.7% of the patients. 60% of the patients were on vitamin D replacement therapy, and 7.1% were receiving cinacalcet treatment. Valvular calcification ratio of the patients was 44%. Mean FGF-23 level was 682 ± 771.7 pg/mL, and mean OPN level was 22.2 ± 8.2 ng/mL. When the patients with and without heart valve calcification were compared, the group with heart valve calcification was older and had lower serum OPN levels. There were differences between the groups on left atrial diameters, left ventricular end-diastolic diameters, and posterior-wall thicknesses. In the logistic regression analysis, it was seen that age and serum OPN levels were predictors of valvular calcification. CONCLUSION: Serum osteopontin level is associated with heart valve calcification in HD patients, but there was no relationship found with FGF-23. Further research is needed on the subject.
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Impaired cognition in hemodialysis patients: The Montreal Cognitive Assessment (MoCA) and important clues for testing
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BACKGROUND: Cognitive impairment is common among hemodialysis (HD) patients and is associated with poor treatment compliance and mortality. The aim of this study is to evaluate relatively young HD patients with less comorbidities using the Montreal Cognitive Assessment (MoCA) and identify clues for earlier detection of cognitive impairment with the help of cognitive subscale scores. MATERIALS AND METHODS: A total of 103 chronic HD patients (mean age 48.3 years) and 37 stage-3 to 5 chronic kidney disease (CKD) patients with similar demographics were included. Patients with cerebrovascular disease, dementia, depression, malignancy, and infections were excluded. All participants were tested with MoCA. Patients with an MoCA global score < 24/30 were considered cognitively impaired. Groups were compared for MoCA subscales and clinical features. RESULTS: 75 patients (72.8%) in the HD group and 19 in the CKD group (51.3%) had impaired cognition. The number of patients with cognitive impairment was significantly higher in the HD group compared with the CKD group (p = 0.024). The mean total MoCA score was lower in the HD group (p = 0.043). MoCA subscale analysis revealed that the mean score for visuospatial/executive domain was significantly lower in the HD group (p = 0.001). CONCLUSION: In this study, we showed that cognitive impairment was more common in HD patients compared with predialytic CKD patients. This difference was predominantly related to the difference in executive scores. We may think that young HD patients with less comorbidities are also at risk for cognitive impairment. Noticing progressive declines in MoCA cognitive domains, before the development of global cognitive impairment, could be beneficial for HD patients.
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Clinical problems in hemodialysis patients with autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is a common monogenic disease characterized by massive enlargement of fluid-filled cysts in the kidney. Due to its genetic pattern, the disease differs from other CKD. ADPKD is a multi-system, progressive disorder which is frequently complicated with hypertension, cardiovascular events and cerebrovascular disease. Thus, there are many clinical problems specific to ADPKD. In this article, we reviewed these clinical problems and their management in ADPKD with hemodialysis patients.