A case of crescentic IgA nephropathy treated with prednisolone and cyclophosphamide.

IgA nephropathy (IgAN) is the most common glomerulonephritis in the world, and currently is known to be an important cause of end stage renal disease (ESRD). Hypertension, proteinuria more than 1 g/d, and the presence of severe lesions on initial renal biopsy such as crescents and interstitial fibrosis are the most significant predictive factors for progression to ESRD. Despite its prevalence and clinical importance, there is no consensus for the treatment of patients with risk factors for a worse prognosis. Our aim is to describe here a case of crescentic IgAN, and to emphasize the effect of immunosuppressive treatment.

Leukodepletion improves renal function in patients with renal dysfunction undergoing on-pump coronary bypass surgery: a prospective randomized study.

BACKGROUND: We aimed to show the impact of leukodepletion on renal function in patients undergoing on-pump coronary revascularization. PATIENTS AND METHODS: Fifty patients awaiting elective on-pump coronary revascularization with normal preoperative cardiac functions and with plasma creatinine levels ranging between 1.5 and 2.0 mg/dL were prospectively randomized into two groups: on-pump CABG with (group A: n = 25) and without leukodepletion (group B, n = 25). Renal glomerular and tubular injury were assessed by urinary alpha glutathione s-transferase (GST), plasma creatinine, and blood urea nitrogen (BUN) levels. RESULTS: The patients consisted of 14 females and 36 males with a mean age of 57.6 +/- 5.3 years. In the leukodepletion group, the mean levels of creatinine, BUN and urinary GST were found to be decreased on the first, third and fifth postoperative days compared with the control group. There was no mortality. Three patients in the control group needed postoperative dialysis. CONCLUSION: Patients with renal dysfunction undergoing on-pump CABG surgery seem to benefit from leukodepletion as a measure to prevent tubular damage and renal impairment compared with a control group.

ADMA, proteinuria, and insulin resistance in non-diabetic stage I chronic kidney disease.

The rationale of this study is based on the fact that, both proteinuria and elevated asymmetric dimethyl arginine (ADMA) levels have been linked to the progression of vascular disease. Currently, there is not enough knowledge about any association between the levels of proteinuria and ADMA levels. Seventy-eight non-diabetic patients (42 men, 36 women, mean age of 26.1+/-5.2 years) with proteinuria having normal glomerular filtration rate were enrolled along with 38 healthy subjects (20 men, 18 women, mean age of 26.9+/-5.9 years). Proteinuria was below 3.5 g/day in 40 patients and above 3.5 g/day in 38 patients. Both groups had similar age, gender, and body mass index distributions. Serum ADMA, symmetric dimethyl arginine (SDMA), immunoreactive insulin, and high sensitivity C reactive protein (hsCRP) levels were measured. Insulin resistance was determined by homeostasis model assessment (HOMA). Serum ADMA, SDMA, insulin, hsCRP levels, and HOMA indexes were significantly higher in patients than in healthy control subjects. The above parameters were higher in the nephrotic range proteinuria group when compared to patients having protein levels below 3.5 g/day. There were significant correlations between the levels of proteinuria and the above parameters. According to the regression analysis, levels of proteinuria and hsCRP were significant determinants of serum ADMA levels. Our results indicate that, independent of other risk factors, ADMA is directly associated with proteinuria. Further studies are recommended to find out whether elevated ADMA levels are implicated in the high cardiovascular risk of proteinuric nephropathies.

Persistent mediastinal and axillary lymph node tuberculosis in a renal transplant patient with successful outcome.

Tuberculosis is an opportunistic infection that carries substantial morbidity and mortality in renal transplant recipients. We report here about a 21 year-old man with a living related renal transplant from his mother who developed persistent extra-pulmonary tuberculosis. The disease showed aggressive invasion to the axillary and mediastinal regions with abscess formations, despite standard antituberculosis treatment. During the course of the disease, immunosuppressive therapy was stopped, and the patient received extraordinary doses of multiple antituberculosis drugs. The patient then showed an uneventful course with good clinical and radiological responses.

Adiponectin level is reduced and inversely correlated with the degree of proteinuria in type 2 diabetic patients.

AIMS: Adiponectin seems to be an important modulator for metabolic and vascular diseases. We aimed to measure plasma adiponectin levels in type 2 diabetic patients and investigate any association with the severity of proteinuria. METHODS: 80 patients (mean age, 46.9 +/- 5.1 years; body mass index (BMI), 25.8 +/- 1.98 kg/m2) and 47 healthy volunteers (mean age, 46.1 +/- 5.5 years; BMI 26.74 +/- 2.23 kg/m2) were included. Plasma adiponectin concentration, insulin levels, homeostasis model assessment (HOMA) indices, calculated glomerular filtration rate (GFR), high sensitive C reactive protein (hsCRP) and biochemistry panel were determined in all subjects. The association between adiponectin concentration and proteinuria was evaluated. Additionally, the relationship between adiponectin and hsCRP and calculated GFR were also investigated. RESULTS: Adiponectin levels in patients were significantly lower than those of controls (n = 80; 8.76 +/- 4.50 microg/ml for patients, n = 47; 24.27 +/- 5.59 microg/ml for controls, p < 0.001). Plasma adiponectin levels in patients with proteinuria were significantly lower than those without proteinuria (n = 43; 6.81 +/- 2.82 microg/ml for proteinuria, n = 37; 11.98 +/- 3.32 microg/ml for no proteinuria, p < 0.001). There was a significant negative correlation between plasma adiponectin concentrations and the degree of proteinuria (r = -0.433, p < 0.001). There were also significant negative correlations between adiponectin concentrations and insulin levels as well as HOMA index in the patient group (r = -0.322, p = 0.004; r = -0.301, p = 0.032). Additionally there was a significant negative correlation between adiponectin and hsCRP levels in the patient group (r = -0.872, p < 0.001). CONCLUSION: The results show that adiponectin is lower in patients with type 2 diabetes and the levels are negatively correlated with the severity of proteinuria.

A long-forgotten indwelling ureteral stent in a renal transplant patient.

Ureteral stents have proved to be an invaluable tool in the armamentarium of the urological surgeon. Stents have also been advocated as an adjunct for ureteral reconstruction in renal transplantation. However, stents can cause significant problems, including migration, fragmentation, and incrustation. More interestingly, it may possibly be forgotten. We herein report a case of a long-forgotten indwelling ureteral stent for 7 years in a renal transplant patient.

Lessons learned from the catastrophic Marmara earthquake: factors influencing the final outcome of renal victims.

BACKGROUND: During catastrophic earthquakes, crush syndrome is the second most frequent cause of death after the direct impact of trauma. The Marmara earthquake, which struck Northwestern Turkey in August 1999, was characterized by 639 crush syndrome victims with acute renal problems. The factors influencing their final outcome have been the subject of this study. PATIENTS/METHODS: Within the first week of the disaster questionnaires asking about 63 clinical and laboratory variables were sent to 35 reference hospitals that treated the victims. Information obtained by means of these questionnaires, including the factors with a potential influence on outcome, was submitted to analysis. RESULTS: Overall mortality rate was 15.2%. In univariate analysis, nonsurvivors were older (p = 0.048); the highest mortality rates were observed among the victims coming from the closest cities to the reference hospitals. Admission within the first 3 days of the disaster (p = 0.016), with oliguria (p = 0.042), lower figures for blood pressure (p < 0.001), platelets (p = 0.004) and serum albumin (p = 0.005) were associated with mortality. Also, higher body temperature (p = 0.013) and serum potassium (p < 0.001) as well as suffering from thoracic or abdominal traumas, extremity amputations and medical complications other than renal failure (for all 4: p < 0.0001) in addition to need of dialysis support (p = 0.015) and mechanical ventilation (p < 0.0001) indicated higher risk of death. In the multivariate analysis, age (p = 0.030, OR = 1.02), presence of disseminated intravascular coagulation (p = 0.001, OR = 4.49), abdominal trauma (p = 0.012, OR = 4.05) and amputations (p = 0.010, OR = 2.81) were predictors of mortality. Dialyzed patients were characterized by higher mortality rates than nondialyzed victims (17.2% versus 9.3%, p = 0.015). CONCLUSION: Outcome of the renal victims of catastrophic earthquakes is influenced by the type of trauma, comorbid events and complications observed during the clinical course as well as epidemiological features such as age, distance to reference hospitals and time lapse between disaster and admission to reference hospitals.

The midnight-to-morning urinary cortisol increment method is not reliable for the assessment of hypothalamic-pituitary-adrenal insufficiency in patients with end-stage kidney disease.

A previous study reported that the midnight-to-morning urinary cortisol increment method could be used to reliably assess the insufficiency of the hypothalamic-pituitary-adrenal (HPA) axis. The principal aim of the present study is to verify whether the midnight-to-morning urinary cortisol increment is a reliable method for the assessment of the HPA axis in patients with various degrees of impaired kidney function. Fifty-six clinically stable patients with chronic kidney disease (CKD) and 14 healthy subjects were enrolled in the present study. Patients with CKD were divided on the basis of glomerular filtration rate (GFR) into the following arbitrary groups: mild (GFR: 60-89 ml/min/1.73 m2, no.=15), moderate (GFR: 30-59 ml/min/1.73 m2, no.=12) and severe kidney insufficiency (GFR: 15-29 ml/min/1.73 m2, no.=13), and hemodialysis patients. Plasma cortisol and ACTH levels were measured. The HPA axis was assessed by short Synacthen test and overnight dexamethasone suppression test. Double voided urine samples were collected at midnight and waking in the patients and the controls. Urinary free cortisol (UFC) and creatinine levels were measured and the UFC/creatinine ratio (Cort/Cr) was calculated. Then, the Cort/Cr increment was calculated as the morning Cort/Cr minus the midnight Cort/Cr. Baseline plasma cortisol levels were not significantly different between two groups. However, we found that CKD patients had significantly greater plasma ACTH levels than controls. The patients with CKD had also significantly lower morning UFC levels than controls and there was a progressive fall in morning UFC levels with decreasing GFR. The assessment of the HPA axis in patients with GFR lower than 29 ml/min was hampered by falsely abnormal responses to the midnight-to-morning urinary cortisol increment method. Plasma cortisol responded normally to exogenously administered ACTH, while plasma cortisol was suppressed by overnight dexamethasone administration in all patients with CKD. In conclusion, this method is not a reliable test for assessment of the HPA insufficiency in patients with GFR lower than 29 ml/min.

A practical approach to glomerular filtration rate measurements: creatinine clearance estimation using cimetidine.

Determination of creatinine clearance (Ccr) is not a reliable indicator of glomerular filtration rate (GFR), owing to tubular secretion of creatinine. It has been reported that Ccr measurements can approximate true GFR after cimetidine (Ci) administration. In this study, GFR was estimated by Cockcroft and Gault's equation (C(C-G)) based on measurement of plasma creatinine, and Ccr was determined by the standard clearance equation using 4- and 24-hr urine samples (Ccr4 and Ccr24, respectively) in 17 patients and 10 healthy controls. After cimetidine administration (800 mg, 3 times daily), GFR values were recalculated at the same time periods (C(CiC-G), CcrCi4 and CcrCi24, respectively). The results were all compared to those obtained by the 99mTc-DTPA protein-free double-sample method (C(DTPA)), which is a reference method for GFR determination. The coefficient of variation (CV%) for Ccr24/C(DTPA) was high before cimetidine administration; Ccr24 and CcrCi24 values were significantly different from C(DTPA) (CV 23.1%, Ccr24/C(DTPA) = 1.17, p 0.005; and CV 14.1%, CcrCi24/C(DTPA) = 0.92, p 0.006, respectively). Ccr4 values obtained before cimetidine ingestion showed large variation and were significantly different from C(DTPA) (CV 15.5%, Ccr4/C(DTPA) = 1.11, p 0.001). CcrCi4 values after cimetidine were similar to CDTPA (CV 6.9%, CcrCi4/C(DTPA) = 1.01, p 0.28). C(C-G) estimates were higher before cimetidine intake (CV 12.4%, C(C-G)/C(DTPA) = 1.21, p <0.001), whereas C(CiC-G) values were not significantly different from C(DTPA) values (CV 7.0%, C(CiC-G)/C(DTPA) = 1.01, p 0.67). This study shows that GFR estimations by C(C-G), Ccr4, Ccr24, or CcrCi24 are insufficiently reliable. On the other hand, C(CiC-G) and CcrCi4 results are acceptable for true GFR estimations.

Polycystic horseshoe kidney.

Horseshoe kidney is a renal fusion anomaly during embryogenesis. The reported incidence of horseshoe kidney varies from 1 in 400 to 1 in 1,800 live births (commonly quoted 1 per 400) [Wilson and Azmy 1986]. Adult polycystic kidney disease is a hereditary disorder with autosomal-dominant transmission. Its incidence is approximately one in every 1,000-5,000 cases [Levine et al. 1997]. Polycystic horseshoe kidney is a very rare occurrence with incidence ranges of 1 in 134,000 to 1 in 8,000,000 cases [Brum et al. 1997]. We add another case to the literature.

Nonrelated living-donor kidney transplantation: medical and ethical aspects.

Several patients with end-stage renal disease went to Bombay for renal transplantation from nonrelated living donors and then returned to Turkey for posttransplantation follow-up. The aims of this study are to evaluate the long-term results of renal transplantation from nonrelated living donors in Turkish patients with end-stage renal disease and to discuss the ethical and social aspects of nonrelated kidney donation. One hundred and twenty-seven patients (89 males, 38 females; mean age 38.1, range 17-63 years) were investigated retrospectively. None of the patients went to Bombay on our advice. All transplantations were performed between 1991 and 1995. The mean follow-up period after transplantation was 34.2 (range 1-68) months. Graft survival rates were 85, 83, and 57% after 3 months and 1 and 5 years, respectively. Patient survival rates were 94, 93, and 92% after 3 months and 1 and 5 years, respectively. Seven patients died within the first 3 months after the transplantation. Surgical problems, infections, acute rejection, ciclosporin nephrotoxicity, and hepatic problems were common complications. We conclude that medical and surgical complications occur frequently in paid kidney transplantation, but most of these complications can be prevented by adequate preoperative management, and precautionary measures should be taken to prevent commercialization of renal transplantation before the spread of emotionally related living kidney donation.

Detection of source of haematuria after extracorporeal shock wave lithotripsy (ESWL) by automated measurement of urinary red cell volume.

Midstream urine samples taken from 35 patients with secondary haematuria due to nephrolithiasis and 31 patients with haematuria after ESWL were compared using a red cell analyser (RCA) to differentiate the source of haematuria. Urine samples obtained from both groups were examined by RCA for urinary red cell mean corpuscular volume (UMCV) and urinary red cell volume distribution curves (RCVDC). To rule out the influence of blood MCV (BMCV), BMCVs were determined separately and the ratio of UMCV/BMCV (R) was calculated. Although our findings showed no difference between haematurias after ESWL and nephrolithiasis, we cannot exclude a direct effect of shock waves on renal tissue.

Predictive measures of vascular access thrombosis: a prospective study.

Malfunction of permanent vascular accesses remains a cause of frequent and costly morbidity in patients receiving chronic hemodialysis (CHD). Several recommendations for routine monitoring of these permanent vascular accesses for incipient failure have been proposed. In this study, multiple indicators of incipient vascular access dysfunction, including "venous" and "arterial" pressures at serial blood flows (200 ml/min, 300 ml/min, and 400 ml/min), percent urea recirculation, Doppler ultrasound, and access blood flow by ultrasound dilution technique were simultaneously evaluated in a total of 220 vascular accesses in 170 chronic hemodialysis patients in two separate study periods (6 months apart). The rate of thrombosis was determined within the subsequent 12 weeks of each study period to assess the short-term predictive power of access thrombosis. During the period of follow-up, there were 34 thrombotic events in 172 polytetrafluoroethylene (PTFE) grafts and only one thrombotic event in 48 arterio-venous fistulas (AVF). Therefore, the statistical analysis was limited to the PTFE grafts. When grafts with thromboses were compared to those without thrombosis by univariate analysis, access blood flow measured either by ultrasound dilution technique (875 +/- 426 ml/min with thrombosis vs. 1193 +/- 677 ml/min without thrombosis, P = 0.001) or by Doppler ultrasound (762 +/- 420 ml/min with thrombosis vs. 1171 +/- 657 ml/min without thrombosis, P = 0.001) were significantly different in the two groups. There was good correlation (r = 0.79, P = 0.0001) between the blood flows determined by both techniques. The grade of stenosis determined by ultrasound was also a statistically significant predictor (P = 0.02). "Venous" and "arterial" pressures were numerically similar and were not statistically different between the accesses that did and those that did not thrombose. When multivariate analysis was used, there was a significantly increased risk of thrombosis only with decreasing access blood flow determined by ultrasound dilution techniques after adjusting for other confounding variables. When the average blood flow of all grafts (1134 ml/min) is considered as the reference access blood flow (relative risk of 1.0), the relative risk of a PTFE thrombotic event within the subsequent 12 weeks was 1.23 at a blood flow 950 ml/min, 1.67 at a blood flow of 650 ml/min and to 2.39 at a blood flow of 300 ml/min. In summary, access blood flow measured by either Dilution or Doppler is a reliable indicator of subsequent short-term thrombosis risk. Other proposed methods of evaluating access dysfunction were not useful in our patients. If simple to use, cost-effective devices to measure dialysis access blood flow become readily available, the measurement of access blood flow will likely become the method of choice for screening of PTFE vascular access dysfunction in hemodialysis patients.

Nitrogen balance in hospitalized chronic hemodialysis patients.

Malnutrition is an important factor in the increased morbidity and mortality of chronic hemodialysis (CHD) patients. Dietary protein intake necessary to maintain neutral nitrogen balance appears to be higher in CHD patients due to various catabolic effects of the hemodialysis procedure, including nutrient losses and increased energy expenditure. Dietary intake may be further decreased in hospitalized CHD patients. We examined this issue in 18 CHD patients (9 male, 9 female) who were admitted to a regular ward. Daily protein intake (DPI) and daily caloric intake were measured for each patient. In addition, protein catabolic rate (PCR) calculated from interdialytic changes in BUN were calculated. Our results showed that mean (+/- SD) DPI was 0.79 +/- 0.41 g/kg/day, while PCR was 0.93 +/- 0.38 g/kg/day. Dietary protein and energy intake were 66% and 50% of suggested values, respectively, and DPI accounted for only 85% of PCR. Mean nitrogen balance was negative by -2.11 +/- 2.77 g of nitrogen/day (range -9.91 g of nitrogen/day to +3.89 g of nitrogen/day). Biochemical nutritional parameters such as serum albumin, cholesterol, prealbumin and transferrin obtained one week following admission were also indicative of undernutrition (3.16 +/- 0.39 g/dl, 132 +/- 30 mg/dl, 20 +/- 7.4 mg/dl, 154 +/- 49 mg/dl, respectively). We conclude that hospitalized CHD patients have inadequate protein and energy intake and this is evidenced by a significant deterioration in nutritional parameters during hospitalization. More aggressive nutritional interventions may be needed for this group of patients to prevent the adverse effects of hospitalization on nutritional status.

Secondary oxalosis of bone in a dialysis patient.

Secondary oxalosis of bone is a complication of chronic renal failure. Its frequency and the mechanism of the deposition is unknown. We report the case of chronic renal failure patient on hemodialysis with deposition of oxalate in bone. Possible mechanisms and the significance of the depositions is also discussed.