PARATHYROID ADENOMA MIMICKING TUBERCULOSIS IN A PERITONEAL DIALYSIS PATIENT.

The most common cause of hypercalcemia is parathyroid hyperplasia and carcinoma. Tuberculosis(TB) and sarcoidosis are the most common granulomatous diseases of the parathyroid. We report a case of parathyroid adenoma that can mimic many lesions. A 46-year-old woman on continuous ambulatory peritoneal dialysis (CAPD) with symptoms and signs of hypercalcemia. Laboratory findings were consistent with tertiary hyperparathyroidism. She underwent elective parathyroidectomy due to high PTH values despite effective treatment including calcimimetics and vitamin D receptor activators. Subtotal thyroidectomy and three and a half of parathyroid adenomas were removed. Histopathological examination revealed features of parathyroid adenoma with granulomatosis infection that supports tuberculosis. In order to confirm the pathological findings, the PCR study was performed on the pathology specimens. After obtaining a negative result, the treatment was stopped. We have reported a case of parathyroid adenoma that mimicking tuberculosis.

Comparison of laboratory findings in patients with glomerulonephritis classified according to histopathologic diagnosis.

AIM: The aim of the present study was to assess whether laboratory investigations have predictional values for histopathological diagnosis of glomerulonephritis before performing renal biopsy. METHODS: The study enrolled 452 patients, who underwent kidney biopsy and were examined retrospectively; 128 patients with the histopathological diagnosis of glomerulonephritis were included in the study. Serum CRP, albumin, uric acid levels, 24 hour urine protein presence, leucocyte count, C3, C4, IgG, IgA and IgM levels were assessed. RESULTS: The most common diagnosis of glomerulonephritis was IgAN with the percentage of 29.7% within the groups. Male gender was predominant except lupus group. Only the ones with crescentic glomerulonephritis had higher CRP levels. In 20% of patients with IgAN, in 8.3% of the ones with MN, in 35% of crescentic group, in 42% of FSGS group, in 30% of patients with MPGN and in 33% of the ones with lupus nephritis uric acid levels were found as elevated. In IgAN, FSGS and lupus nephritis normoalbuminemia and nephritic proteinuria, in MN and crescentic glomerulonephritis hypoalbuminemia, nephrotic proteinuria, in MPGN hypoalbuminemia, nephritic proteinuria were established. Serum Ig G levels were lower in MN and MPGN. Serum IgA levels were found as elevated in IgAN. Serum C4 levels were found as lower in lupus nephritis and MPGN. CONCLUSION: In patients admitted in clinical picture of glomerulopathy, since measurements of serum CRP, albumin, uric acid, C3, C4,IgG, IgA, IgM levels, leucocyte count and 24 hour urine protein amount can lead to predict the histopathological diagnosis, their significance in routine investigations has been suggested also in our study.

Effect of novel vitamin D receptor activator paricalcitol on renal ischaemia/reperfusion injury in rats.

INTRODUCTION: Despite the developments in modern medicine, acute renal injury is still a challenging and common health problem. It is well known that ischaemia and reperfusion takes place in pathological mechanisms. Efforts to clarify the pathophysiology and interventions to improve outcomes are essential. Our study aimed to investigate whether the prophylactic use of paricalcitol is beneficial in renal ischaemia/reperfusion (I/R) injury. METHODS: Twenty-four Wistar albino rats were assigned randomly to four groups. Right nephrectomies were performed at the time of renal arterial clamping. Sham surgery was performed on the rats in group 1. For the rats in group 2, the left renal artery was clamped for 45 minutes. The rats in group 3 received paricalcitol for seven days (0.2µg/kg/day); following this, a right nephrectomy and left renal arterial clamping were not performed. The rats in group 4 received paricalcitol for seven days (0.2µg/kg/day); following this, a right nephrectomy and left renal arterial clamping for 45 minutes were performed. Tissue thiobarbituric acid reactive substances (TBARS), superoxide dismutase, sulfhydryl groups as well as nitric oxide metabolites, serum urea and creatinine levels were measured for all four groups. RESULTS: In group 4, there were some improvements in terms of TBARS, nitrite, nitrate, superoxide dismutase and creatinine levels. In the histopathological evaluation, paricalcitol therapy improved tubular necrosis and medullar congestion but there was no significant difference in terms of tubular cell swelling, cellular vacuolisation or general damage. Immunohistopathological examination revealed lower scores for vascular endothelial growth factor in the group 4 rats than in group 2. CONCLUSIONS: Paricalcitol therapy improved renal I/R injury in terms of serum and histopathological parameters. These potential beneficial effects need to be further investigated.

Takayasu arteritis and ulcerative colitis; coexistence or misdiagnosis?

Takayasu arteritis is a chronic inflammatory disease that primarily affects large arteries such as the aorta and its proximal branches. The association between Takayasu arteritis and ulcerative colitis is an extremely rare condition. Ulcerative colitis is an inflammatory bowel disease, clinical presentation is not specific and may mimic Crohn's disease, radiation colitis, ischemic colitis, a variety of infectious processes, and colitis related to medications. Herein we report a case of Takayasu arteritis who had been misdiagnosed and treated as ulcera-

Association between nitric oxide and oxidative stress in continuous ambulatory peritoneal dialysis patients with peritonitis.

BACKGROUND: Peritonitis is a major complication in continuous ambulatory peritoneal dialysis (CAPD) patients, and the mechanisms involved in the pathology are important if the success rate of treatment strategies is to increase. MATERIAL AND METHODS: A total of 50 CAPD patients (25 with 25 episodes of peritonitis and 25 with no clinical or laboratory signs of infection) were included in the study. Malondialdehyde (MDA) and nitric oxide (NO) metabolites in serum and dialysate effluents were determined. RESULTS: The dialysate/serum (D/S) ratio of the NO metabolites and serum NO metabolite concentrations were significantly higher in the peritonitis group. Serum and dialysate MDA concentrations were also significantly higher in the peritonitis group. The D/S ratio of MDA was significantly higher in the control group. CONCLUSIONS: Local peritoneal NO production and oxidative stress seem to increase in CAPD patients during the peritonitis attack.

Effect of peritoneal dialysis solution type on serum lipid levels in end-stage renal disease.

Among the different cardiovascular risk factors, lipid abnormalities dominate the high mortality in chronic ambulatory peritoneal dialysis patients. So far, no data comparing the effect of standard glucose-containing, amino acid-containing, and icodextrin-containing peritoneal dialysis solutions on serum lipid concentrations in a chronic ambulatory peritoneal dialysis population are available. To determine the effect of peritoneal dialysis solutions on parameters of lipid metabolism, 67 subjects who had continued their usual dialysis for the last six months were enrolled in the study. Group A consisted of 18 patients who were receiving only glucose-based peritoneal dialysis solutions, group B consisted of 18 patients who were receiving glucose and amino acid-based peritoneal dialysis solutions, and group C consisted of 31 patients who were receiving glucose and icodextrin-based peritoneal dialysis solutions. Serum lipid parameters including total cholesterol, low-density lipoprotein, high-density lipoprotein, triglyceride, and lipoprotein (a) were determined in all groups. No significant difference in serum lipid parameters was found between groups A, B, and C. These results demonstrate the lack of the effect of amino acid or icodextrin-based peritoneal solutions on dyslipidemia of CAPD patients.

Cardiovascular risk factors in hemodialysis and peritoneal dialysis patients.

BACKGROUND: Cardiovascular disease (CVD) is the major cause of mortality and morbidity of hemodialysis (HD) and peritoneal dialysis (CAPD) patients. We aimed to investigate the cardiovascular risk factors and their correlation with CVD in groups of HD and CAPD patients. METHODS: Thirty HD patients, 30 CAPD patients and 30 healthy controls were included in the study. Apolipoprotein A-l (apo A-l), apolipoprotein B (apo B), apolipoprotein(a) [Lp(a)] and high-sensitivity CRP (hs-CRP) were measured with a Beckman Coulter nephelometer, and homocysteine (Hcy) was determined with an Agilent HPLC analyzer. Lipid profile was determined with a Synchron LX 20 Pro analyzer. RESULTS: Hcy levels were 41.9+/-19.4, 41.8+/-38.5 and 9.3+/-3.5 micromol/L; Lp(a) levels were 325+/-315, 431+/-367 and 130+/-97 mg/L; hs-CRP levels were 3.78+/-3.21, 4.34+/-3.39 and 2.07+/-1.67 mg/L; apo A1/apo B ratios were 1.46+/-0.6, 1.36+/-0.5 and 1.80+/-0.59; total cholesterol levels were 3.56+/-0.7, 4.84+/-1.1 and 4.39+/-0.5 mmol/L; triglycerides were 1.44+/-0.5, 1.60+/-0.8 and 0.85+/-0.5 mmol/L in the HD, CAPD and control groups, respectively. CONCLUSION: HD and CAPD patients had higher Hcy, hs-CRP and Lp(a) levels and lower apo A/B ratios than controls. There was no significant difference between the HD and CAPD groups. Hypertension, age and hs-CRP showed a positive correlation with CVD.

Serum potassium in the crush syndrome victims of the Marmara disaster.

BACKGROUND: Hyperkalemia is a major cause of mortality in the patients who suffer from crush syndrome in the aftermath of major earthquakes. The aim of this study is to investigate the frequency and effects of hyperkalemia in the 639 victims of catastrophic Marmara earthquake that struck northwestern Turkey, in August 1999. PATIENTS AND METHODS: Within the first week of disaster, questionnaires were sent to 35 reference hospitals that treated the victims. Information on serum potassium which was provided in 595 out of 639 questionnaires was submitted to analysis. RESULTS: In the patients who were admitted within the first 3 days of the disaster (n = 401) serum potassium was 5.4 +/- 1.3 mEq/l, which was higher than in those admitted thereafter (n = 171) (4.5 +/- 1.1 mEq/l) (p = 0.02). Considering the whole series, males (p = 0.01), patients needing dialysis support (p < 0.001) and non-survivors (p = 0.001) were characterized by higher serum potassium at admission. Seventy patients' serum potassium was above 7 mEq/l, while 22 patients were hypokalemic (< 3.5 mEq/l). Admission potassium correlated with many clinical and laboratory variables indicating the severity of the trauma, and a logistic regression model with clinical and laboratory parameters upon admission, revealed potassium as the most significant predictor of dialysis needs in the victims admitted within the first 3 days (p = 0.008, OR = 3.33). Among the victims who were admitted to hospitals 1 week after the disaster, 8 had serum potassium levels above 6.5 mEq/l; among 4 of them were complicated by hyperkalemia even higher than 7.5 mEq/l. These findings undeline the importance of hyperkalemia during clinical course. CONCLUSION: The most important and fatal medical complication in crush syndrome patients is hyperkalemia. Risk of fatal hyperkalemia continues even after hospitalization. Empirical therapy at the scene is indicated especially in male victims with severe soft tissue traumas. Early detection and treatment of hyperkalemia may improve the final outcome of renal disaster victims.

Phagocytic activity in familial Mediterranean fever.

Familial Mediterranean fever (FMF) is an autosomal recessive disease. Although the possibility of multiple immunologic mechanisms have been studied, the actual mechanism is still unresolved. Forty-one patients with FMF (24 males and 17 females with a mean age and disease duration of 17.8 +/- 4.1 and 4.7 +/- 2.3 years, respectively) and 14 healthy controls (10 males and 4 females with a mean age 23.2 +/- 5.1) were involved in the study. A phagotest was studied in both the patients and control groups with a FACScalibur Flow. All patients were in the acute stages of the disease and had not undergone colchicine treatment for 2 months. The percentage blood phagocytic activity of both granulocytes and monocytes were 84.23 +/- 8.76 and 67.28 +/- 10.15 in the patient group and 94.68 +/- 3.24 and 76.23 +/- 5.7 in the control group, respectively. There was no statistically significant difference in the percentage of phagocytic activity of the granulocytes and monocytes between the FMF patients and healthy controls (p > 0.05 and p > 0.05, respectively).

Tc-99m DTPA acetylsalicylic acid (aspirin) renography in the detection of renovascular hypertension.

PURPOSE: Prostaglandins play important roles in renal physiology and in the development of renovascular hypertension. In a recent study, inhibition of renal prostaglandin synthesis was found to be useful for detecting renovascular hypertension using renal scintigraphy. In the current study, the authors evaluated the role of aspirin (an inhibitor of prostaglandin synthesis) and compared it with Tc-99m DTPA captopril renal scintigraphy (CS). MATERIALS AND METHODS: Twenty-five patients were examined with Tc-99m DTPA in a three-step manner: a baseline study, CS, and aspirin scintigraphy (AS). Each scintigraphic study was interpreted visually and according to the renogram curve patterns. Semiquantitative parameters (Tmax, renal indices [%], 20-minute/max count ratio, glomerular filtration rate) were also calculated. Plasma renin activity was determined for each study. The blood pressures of all patients were measured during AS. All patients had a contrast-enhanced angiogram that was used as the reference test. RESULTS: Three groups of patients were observed based on the scintigraphic and angiographic results. In each group, no difference was observed in blood pressure after aspirin administration. In group 1, seven patients had normal angiographic and scintigraphic results. In group 2, eight patients had angiographically confirmed renal artery stenosis (RAS). In 6 patients (mean, 47% RAS), both AS and CS were negative for RVH. In the remaining two patients with RAS (mean, 83% stenosis), the kidneys were atrophic on the stenotic side, and thus the kidneys did not respond to the interventions. No difference was observed in plasma renin activity in groups 1 and 2. Group 3 included 10 patients who had angiographically confirmed RAS (mean, 86%). In 9 patients, both CS and AS were positive for RVH. In the remaining one patient, scintigraphic results were falsely negative. Statistical analyses performed for semiquantitative parameters did not reveal any significant difference in this group, although there was a tendency toward prolonged Tmax values after captopril and aspirin administration. In four cases, unexpected elevation of plasma renin activity was observed in group 3. CONCLUSIONS: These data indicate that AS with Tc-99m DTPA is an alternative for CS. It has the advantage of having no effect on blood pressure and does not require that angiotensin-converting enzyme inhibitors be discontinued. Although in this study 9 of 10 patients had correct diagnoses of RAS, further studies, especially using tubular agents with the calculation of parenchymal transit time, might provide valuable information in this patient group. An ongoing study is being performed in the authors' institute.

Comparison of Tc-99m EC and Tc-99m DTPA captopril scintigraphy to diagnose renal artery stenosis.

PURPOSE: Although, captopril scintigraphy is a well established method to detect renovascular hypertension, the optimal radiopharmaceutical for this test remains to be determined. Recently, Tc-99m ethylenedicysteine (Tc-99m EC) appeared as an alternative agent for captopril scintigraphy. The aim of this study was to compare the diagnostic accuracy of Tc-99m EC with Tc-99m DTPA, which is a well-established renal radiopharmaceutical for the captopril test. METHODS: Nineteen hypertensive patients who had various degrees of renal artery stenosis on angiography were included in the study. All patients had baseline and captopril Tc-99m EC and Tc-99m DTPA scintigraphy within a 1-week period. The results were compared with angiography and in eight patients with changes in blood pressure after revascularization. The images were interpreted without knowledge of the angiography and revascularization data as low, intermediate, or high probability for hemodynamically significant renal artery stenosis, which was defined as an area of stenosis exceeding 50%. RESULTS: Tc-99m EC and Tc-99m DTPA study results were in agreement in 16 of the 19 patients. In two patients with branch artery stenosis, Tc-99m EC was definitely superior to Tc-99m DTPA and correctly identified the probability of stenosis on scintigraphy. On kidney analysis, Tc-99m EC had a slightly greater diagnostic sensitivity compared with Tc-99m DTPA (79% vs. 68%; P > 0.05 by the chi-squared test) but equal specificity (93% for both agents). Both Tc-99m EC and Tc-99m DTPA showed the same accuracy in predicting the outcome after revascularization in all but one patient with branch artery stenosis, in whom Tc-99m EC accurately predicted a successful outcome of the intervention but Tc-99m DTPA did not. Tc-99m EC had better renal uptake in patients with decreased renal function and provided more dramatic evidence of renogram changes after captopril intervention, which resulted in more confident interpretation. CONCLUSIONS: There is no significant difference between Tc-99m EC and Tc-99m DTPA captopril scintigraphy for detecting renal artery stenosis. However, because of the better imaging characteristics and more confident interpretation provided by the dramatic changes in the degree of renogram abnormality after captopril intervention, Tc-99m EC captopril scintigraphy should be used, particularly in patients with decreased renal function or branch artery stenosis.