Long-Term Outcomes of Kidney Paired Donation Transplantation: A Single Center Retrospective Cohort Study.

BACKGROUND: This study aimed to compare the kidney paired donation (KPD) program recipients with the traditional living donor kidney transplantation (LDKT) recipients regarding patient and graft survival. METHODS: We retrospectively analyzed 141 recipients of the KPD program and 141 classic LDKT recipients that we matched for age and sex as controls between July 2005 and June 2019. We compared the 2 transplant groups for patient and kidney survival using the Kaplan-Maier test. We also performed Cox Regression analysis to examine factors affecting patient survival, including transplant type. RESULTS: The average follow-up period was 96.17 ± 44.22 months. Of the 282 patients, 88 died in the follow-up period. There was no statistically significant difference in graft and patient survival between the KPD and LDKT groups. In the Cox regression model, including the transplant type, only the serum creatinine level measured in the first month after discharge was a significant factor in predicting patient survival. CONCLUSIONS: The findings of this study indicate that the KPD program is an effective and reliable method to increase LDKT. Country-wide multicentric studies should confirm the results of this study. In countries where cadaver transplantation is insufficient, efforts should be made to expand the KPD program.

Acute kidney injury in Turkey: epidemiological characteristics, etiology, clinical course, and prognosis.

BACKGROUND: This study aimed to evaluate the etiologies, comorbidities, and outcomes of acute kidney injury (AKI) in Turkey and determine any potential differences among different geographical parts of the country. METHODS: This prospective observational study was conducted by the Acute Kidney Injury Working Group of the Turkish Society of Nephrology. Demographical and clinical data of patients with AKI at the time of diagnosis and at the 1st week and 1st, 3rd, and 6th months of diagnosis were evaluated to determine patient and renal survival and factors associated with patient prognosis. RESULTS: A total of 776 patients were included (54.7% male, median age: 67 years). Prerenal etiologies, including dehydration, heart failure, and sepsis, were more frequent than other etiologies. 58.9% of the patients had at least one renal etiology, with nephrotoxic agent exposure as the most common etiology. The etiologic factors were mostly similar throughout the country. 33.6% of the patients needed kidney replacement therapy. At the 6th month of diagnosis, 29.5% of the patients had complete recovery; 34.1% had partial recovery; 9.5% developed end-stage kidney disease; and 24.1% died. The mortality rate was higher in the patients from the Eastern Anatolian region; those admitted to the intensive care unit; those with prerenal, renal, and postrenal etiologies together, stage 3 AKI, sepsis, cirrhosis, heart failure, and malignancy; those who need kidney replacement therapy; and those without chronic kidney disease than in the other patients. CONCLUSION: Physicians managing patients with AKI should be alert against dehydration, heart failure, sepsis, and nephrotoxic agent exposure. Understanding the characteristics and outcomes of patients with AKI in their countries would help prevent AKI and improve treatment strategies.

The Longitudinal Evolution of Post-COVID-19 Outcomes Among Hemodialysis Patients in Turkey.

Introduction: Hemodialysis (HD) patients have increased risk for short-term adverse outcomes of COVID-19. However, complications and survival at the post-COVID-19 period have not been published extensively. Methods: We conducted a national, multicenter observational study that included adult maintenance HD patients recovered from confirmed COVID-19. A control HD group without COVID-19 was selected from patients in the same center. We investigated the characteristics and outcomes in the follow-up of HD patients and compare them with the non-COVID-19 group. Results: A total of 1223 patients (635 patients in COVID-19 group, 588 patients in non-COVID-19 group) from 47 centers were included in the study. The patients' baseline and HD characteristics were almost similar. The 28th-day mortality and mortality between 28th day and 90th day were higher in the COVID-19 group than non-COVID-19 group (19 [3.0%] patients vs. none [0%]; 15 [2.4%] patients vs. 4 [0.7%] patients, respectively). The presence of respiratory symptoms, rehospitalization, need for home oxygen therapy, lower respiratory tract infection, and arteriovenous (AV) fistula thrombosis was significantly higher in the COVID-19 group in both the first 28 days and between 28 and 90 days. In the multivariable analysis, age (odds ratio [OR] [95% CI]: 1.029 [1.004-1.056]), group (COVID-19 group vs. non-COVID-19 group) (OR [95% CI]: 7.258 [2.538-20.751]), and vascular access type (tunneled catheter/AV fistula) (OR [95% CI]: 2.512 [1.249-5.051]) were found as independent parameters related to 90-day mortality. Conclusion: In the post-COVID-19 period, maintenance HD patients who have had COVID-19 have increased rehospitalization, respiratory problems, vascular access problems, and high mortality compared with the non-COVID-19 HD patients.

Blood pressure, inflammation, and quality of life in patients treated with different renal replacement therapies.

Our aim was to determine the relationship between the modality of renal replacement therapy and inflammation markers, BP control, and quality of life (QoL). Sixteen hemodialysis, 17 peritoneal dialysis patients, and 27 kidney transplant receivers (KTr) have been included in this study. Short Form-36 (SF-36) for the evaluation of QoL and ambulatory BP monitoring were performed on the same day. Erythrocyte sedimentation rate, CRP, IL-6, and IL-10 were measured. While the mean IL-10, IL-6, and CRP levels were the highest in the dialysis groups, there were no significantly differences any parameters for all groups. QoL was better in the KTr almost as in healthy controls but worse in the dialysis patients. It should be taken into account that hypertension may occur at night even if the daytime BP is normal in KTr.

The impact of COVID-19 pandemic on glycemic control in patients with diabetes mellitus in Turkey: a multi-center study from Kocaeli.

AIMS: The aim of this study is to determine the impact of the COVID-19 pandemic on the management and disease control of the patients with diabetes mellitus in Kocaeli. METHODS: This study was carried out in six leading central hospitals in five major districts of Kocaeli. The study was conducted between June 2020 and November 2020. The patients who had previous admissions to these clinics within 6 months prior to the pandemic were enrolled in the study. RESULTS: A total of 283 patients were enrolled in the study, among them 151 (53%) patients were female, 268 (95%) had type 2 DM and remaining 5% had type 1 DM. The median weight of the patients was similar between the previous and last visits (84 kg vs 83 kg, p = 0,88). Laboratory parameters of previous and current visits revealed that mean fasting plasma glucose (FPG) and HbA1c levels were not significantly changed. The number of the patients who had controlled blood pressure was significantly decreased. The number of those who had neuropathic complains and the severity of dyslipidemia significantly increased during pandemic period. CONCLUSION: Our study demonstrated that despite decreased compliance with diet and exercise, and difficulty in accessing medication, there was no significant change in weight, FPG and HbA1c levels in diabetic patients. Since cultural differences, education level and socioeconomic opportunities differ between societies, national and international studies will be more accurate to evaluate the effects of epidemics on the course of chronic diseases.

Characteristics and outcomes of acute kidney injury in hospitalized COVID-19 patients: A multicenter study by the Turkish society of nephrology.

BACKGROUND: Acute kidney injury (AKI) is common in coronavirus disease-2019 (COVID-19) and the severity of AKI is linked to adverse outcomes. In this study, we investigated the factors associated with in-hospital outcomes among hospitalized patients with COVID-19 and AKI. METHODS: In this multicenter retrospective observational study, we evaluated the characteristics and in-hospital renal and patient outcomes of 578 patients with confirmed COVID-19 and AKI. Data were collected from 34 hospitals in Turkey from March 11 to June 30, 2020. AKI definition and staging were based on the Kidney Disease Improving Global Outcomes criteria. Patients with end-stage kidney disease or with a kidney transplant were excluded. Renal outcomes were identified only in discharged patients. RESULTS: The median age of the patients was 69 years, and 60.9% were males. The most frequent comorbid conditions were hypertension (70.5%), diabetes mellitus (43.8%), and chronic kidney disease (CKD) (37.6%). The proportions of AKI stages 1, 2, and 3 were 54.0%, 24.7%, and 21.3%, respectively. 291 patients (50.3%) were admitted to the intensive care unit. Renal improvement was complete in 81.7% and partial in 17.2% of the patients who were discharged. Renal outcomes were worse in patients with AKI stage 3 or baseline CKD. The overall in-hospital mortality in patients with AKI was 38.9%. In-hospital mortality rate was not different in patients with preexisting non-dialysis CKD compared to patients without CKD (34.4 versus 34.0%, p = 0.924). By multivariate Cox regression analysis, age (hazard ratio [HR] [95% confidence interval (95%CI)]: 1.01 [1.0-1.03], p = 0.035], male gender (HR [95%CI]: 1.47 [1.04-2.09], p = 0.029), diabetes mellitus (HR [95%CI]: 1.51 [1.06-2.17], p = 0.022) and cerebrovascular disease (HR [95%CI]: 1.82 [1.08-3.07], p = 0.023), serum lactate dehydrogenase (greater than two-fold increase) (HR [95%CI]: 1.55 [1.05-2.30], p = 0.027) and AKI stage 2 (HR [95%CI]: 1.98 [1.25-3.14], p = 0.003) and stage 3 (HR [95%CI]: 2.25 [1.44-3.51], p = 0.0001) were independent predictors of in-hospital mortality. CONCLUSIONS: Advanced-stage AKI is associated with extremely high mortality among hospitalized COVID-19 patients. Age, male gender, comorbidities, which are risk factors for mortality in patients with COVID-19 in the general population, are also related to in-hospital mortality in patients with AKI. However, preexisting non-dialysis CKD did not increase in-hospital mortality rate among AKI patients. Renal problems continue in a significant portion of the patients who were discharged.

Comparison of erectile function in patients with end-stage renal disease receiving haemodialysis and kidney transplantation.

To investigate the frequency and risk factors of ED in haemodialysis patients (HDps) and kidney transplantation (KTx) recipients (KTxRs). HDps and KTxRs between the ages of 18-65 were compared in terms of ED. IEFF-15 (International Index of Erectile Function) score was used to evaluation of ED. Fifty-seven male HDps and 52 male KTxRs with a mean age of 45.6 ± 10.4 years were included in our study. DM, CAD, hyperlipidaemia, smoking and beta blocker use were higher HDps (p = 0.037, p < 0.001, p = 0.001, p = 0.001 and p = 0.031 respectively). There was no ED in five (8.8%) HDps and 27(51.9%) KTxRx. Severity of ED was significantly higher in HDps (p < 0.001). In multiple logistic regression analysis, KTx was found the most relevant associated factor with ED. KTxRs had decreased risk for ED (OR = 0.09, 95% CI 0.02-0.30, p < 0.001). ED is significantly more common in HDps than KTxRs. Known risk factors for ED, HT, DM, CAD, HL, smoking, obesity and beta-blocker use were not related to ED in the HDps and KTxRs, and the KTx was positively effective for ED in patients undergoing renal replacement therapy.

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.

Does altitude affect blood gases in hemodialysis patients?

INTRODUCTION: This study aimed to determine whether predialysis blood gases is affected by altitude differences in hemodialysis patients with arteriovenous fistulas living in Turkey at three different altitudes. METHODS: Patients' predialysis blood gases were compared by standardizing both arterial blood gases collections and working methods for patients undergoing hemodialysis using a dialysate with the same properties at altitudes of 30 m (sea level), 1020 m (moderate altitude), and 1951 m (high altitude). FINDINGS: Blood gases disorders were detected in 32 (82.1%) high altitude group patients, whereas 49 (74.2%) sea level group patients had no blood gases disorders (P < 0.001). pH values in the high altitude group were significantly lower than those in the other groups, and the pH increased as altitude decreased (P < 0.001). The partial pressure of carbon dioxide (PaCO2 ) values was higher in the sea level group than in the other groups and increased at lower sea levels (P < 0.001). Bicarbonate values were significantly higher in the sea level group than in the other groups and increased at lower sea levels, similar to PaCO2 values (P < 0.001). The partial pressure of oxygen (PaO2 ) values in the high altitude and sea level groups were significantly higher and increased at lower sea levels (P < 0.001). The oxygen saturation (SaO2 ) values were significantly lower in the high altitude group than in the other groups and increased gradually at lower sea levels (P < 0.001). DISCUSSION: Predialysis metabolic acidosis was more pronounced in patients undergoing hemodialysis at high altitudes, whereas PaCO2 , PaO2 , and SaO2 values were lower.

Prevalence of cardiac arrhythmia and risk factors in chronic kidney disease patients.

Chronic kidney disease (CKD) patients have a high risk for cardiac arrhythmia. This study aimed to investigate the prevalence of cardiac arrhythmia in CKD patients and to evaluate the relationship between arrhythmia and biochemical and echocardiographic parameters. CKD patients between 18 and 80 years of age were enrolled from the nephrology outpatient clinic. Physical examination, complete blood count, urinalysis biochemical analysis, electrocardiogram, echocardiogram, and 24-h Holter electrocardiogram were performed. Patients with and without cardiac arrhythmia were compared regarding their characteristics, laboratory findings, and echocardiographic parameters. Risk factors for cardiac arrhythmia were also evaluated. The carotid intima-media thickness was measured using Doppler ultrasonography. In our study involving 59 patients, 44 (74%) had atrial arrhythmia (AA) and 40 (68%) had ventricular arrhythmia (VA). Atrial and/or VA were diagnosed in 46 patients (78%), of whom six (10.2%) had AA, two (3.4%) had VA and 38 (64.4%) had AA plus VA. Atrial fibrillation (AF) was present in two patients (3.4%) in the form of paroxysmal AF. Risk factors for AA were low calcium level and posterior wall thickness, while factors associated with VA were age, triglyceride level, leukocyte count, and nonusage of angiotensin 2 receptor blockers. Risk factors for AA and/or VA included increased platelet count, age, and leukocyte count. AA and/or VA were found in as high as 78% of CKD patients. Further studies evaluating course of the disease from early stages are needed to identify risk factors.

Is the preoperative MPV value related to early thrombus formation in microvascular anastomosis?

OBJECTIVE: One of the most common encountered problems in free flap surgeries is anastomotic thrombosis. The mean platelet volume (MPV) may indicate the concentration of intra-platelet proactive substances and the thrombogenic potential of the platelets. MPV is used as a clinical monitoring index in routine blood counts, it has not yet been effectively used in free flap surgery. METHODS: This study evaluates the relationship between the preoperative MPV value and anastomotic thrombus formation during the postoperative 48 hours in 32 free flap operations from September 2013 to September 2014. The mean patient age was 36.75 years. The preoperative MPV value, which was obtained from the complete blood count, was recorded and correlation of MPV and postoperative thrombus formation was investigated. RESULTS: Four anastomotic thrombus were encountered in 34 free flaps during the postoperative 48 hours. Two of them were salvaged by performing thrombectomy and/or administration of i.v. heparin. There was no statistical relationship between MPV value and postoperative thrombus formation during 48 hours follow-up (p = 0.925). CONCLUSION: Even though this study didn't find a correlation between preoperative MPV value and postoperative early anastomotic thrombus, it would be helpful to validate the results using multi-centre and comprehensive studies with larger patient cohorts.

Prolonged hypophosphatemia following parathyroidectomy in chronic hemodialysis patients.

Secondary hyperparathyroidism (SHPT) is a common problem in patients with end-stage renal disease. In cases with severe and resistant SHPT, surgical parathyroidectomy (PTX) is recommended. Hungry bone syndrome (HBS) following surgical PTX is most often associated with hypocalcemia and hypophosphatemia. The mechanisms for the HBS are not clear, and a method for its prevention has not been established. We present three hemodialysis patients with persistant hypophosphatemia after PTX. In our parathyroidectomized patients, hypocalcemia could be corrected with calcium and vitamin D treatment, but hypophosphatemia continued for eight months in one patient and in two other patients until the last visit (10 and 2 months, respectively). Predisposing factors such as old age, diabetes mellitus and parathyroid adenoma were not found in our patients. All three patients were younger (<35 years old) and anuric. Hemodialysis durations were seven, three and two years. In summary, HBS presented with hypocalcemia, and especially hypophosphatemia cannot be developed uncommonly and may persist for a long time following PTX in HD patients.

Expression of p53, Ki67, epidermal growth factor receptor, transforming growth-factorα, and p21 in primary and secondary hyperparathyroidism.

BACKGROUND: Secondary hyperparathyroidism (SH) is major problem in chronic renal failure. There are studies to examine proliferation and apoptosis associated biomarkers expressions in parathyroid lesions to reveal specific features. In this study, we evaluated the expression of some growth factors and their receptors in parathyroid gland of patients with SH or primary hyperparathyroidism (PH). MATERIALS AND METHODS: A total of 49 patients had been operated for PH and 26 for SH. Parathyroid tissue samples were evaluated histopathologically and immunohistochemically using antibodies to human p53, KI-67, anti-human p21, antitransforming growth factor (TGF) α, CPP32 (caspase 3), and epidermal growth factor receptor (EGFR). RESULTS: Adenoma was higher in PH compared with SH as 48/49 and 3/26, respectively (P = 0.000). Parathyroid hyperplasia was found in 23/26 patients with SH and 1/49 patient with PH. In parathyroid tissue there were no difference between PH and SH for p53, Ki-67, caspase, EGFR expressions; while there were significantly difference for TGFα (P = 0.047) and borderline significant difference for p21 (P = 0.06) expressions. CONCLUSION: Adenoma was priority present in PH patients, hyperplasia was present in SH. There were no differences between primary and SH or adenoma and hyperplasia for expressions of cycline-dependent kinase inhibitor p21, p53, EGFR, Ki67, caspase; while TGFα expression was found to be different.

Lactic acidosis induced by metformin in a chronic hemodialysis patient with diabetes mellitus type 2.

Metformin is a biguanide group oral antidiabetic drug used for the treatment of type 2 diabetes mellitus. Nausea, vomiting, diarrhea, abdominal pain, and anorexia are the most common adverse effects encountered during treatment. Lactic acidosis is a serious side effect seen with metformin use, and while the incidence of lactic acidosis is similar to other oral antidiabetics, metformin is not recommended to patients with certain risk factors, such as cardiovascular, pulmonary, and renal and liver failure. We describe a chronic hemodialysis patient treated with metformin, presenting to the nephrology department with altered mental status.

Milk alkali syndrome induced by calcitriol and calcium bicarbonate in a patient with hypoparathyroidism.

The milk-alkali syndrome (MAS) was a common cause of hypercalcemia, metabolic alkalosis, and renal failure in the early 20(th) century. This syndrome was first recognized secondary to treatment of peptic ulcer disease with milk and absorbable alkali. Its incidence fell after the introduction of H2-blocker and proton pump inhibitor. Persistent ingestion of calcium carbonate and vitamin D caused MAS. We report a patient presenting with a triad of hypercalcemia, metabolic alkalosis and renal failure secondary to treatment of idiopathic hypoparathyroidism.

An unusual case of recurrent endometrial cancer presented with isolated cervical lymph node metastasis.

Endometrial cancer (EC) is the most common malignancy of the female genital tract. Lymph node involvement is one of the major prognostic factors. Therefore, pelvic and paraaortic lymph nodes dissection is a part of the surgical management of these patients. Isolated peripheral lymph node metastasis has not been previously reported as a finding of recurrence in EC. We report a 67-year-old woman with recurrent EC presented with an isolated cervical lymph node metastasis (ICLM). Following the combination chemotherapy of doxorubicin, cisplatin and cyclophosphamide, her cervical lymph node was completely regressed. To our knowledge, this is the first case of recurrent EC presented with ICLM. We suggest that for women with EC who had isolated peripheral lymphadenopathies, peripheral lymph node metastasis should be considered as the finding of recurrence in patient with EC.