First Case of Right Malrotated Kidney Transplantation.

Vascular anatomy may widely vary in malrotated kidneys, depending on the degree of rotation. Polar arteries and venules are often accompanied by structural and positional anomalies of the kidney that can make donor nephrectomy more complicated. Detailed evaluation of the donor before surgery is very important for both surgeon and patient. In particular, vascular anatomy should be evaluated in detail by modern imaging methods in donor nephrectomy. Herein we share our experience with right malrotated kidney open donor nephrectomy.

Posttransplant Urinary Tract Infection Rates and Graft Outcome in Kidney Transplantation for End-Stage Renal Disease Due to Reflux Nephropathy Versus Chronic Glomerulonephritis.

BACKGROUND: The goal of this study was to evaluate posttransplant urinary tract infection (UTI) rates and graft outcome in kidney transplantation for end-stage renal disease (ESRD) due to vesicoureteral reflux (VUR)-related reflux nephropathy (RN) versus chronic glomerulonephritis (CGN). METHODS: A total of 62 patients with ESRD who underwent kidney transplantation for VUR-related RN (VUR-RN group, n = 31; mean ± standard deviation age, 34.1 ± 6.0 years; 58.1% female) or CGN (CGN group, n = 31; mean age, 34.2 ± 6.8 years; 71.0% male) at our unit between January 1996 and January 2011 were included in this retrospective study. Baseline recipient and donor characteristics, renal replacement therapy, posttransplant data on serum creatinine levels, graft outcome, and UTIs were recorded. Posttransplant UTIs and graft outcome were compared between the VUR-RN and CGN groups, as well as between patients with and without pretransplant nephrectomy in the VUR-RN group. RESULTS: The frequency of overall (72 vs 18 of 90; P = .05) UTI episodes was significantly higher in the VUR-RN group than in the CGN group; Escherichia coli (64.2%) was the most common pathogen. The VUR-RN and CGN groups were similar in terms of 1-year (100.0% for each), 5-year (95.8% vs 96.8%), and 10-year (82.0% vs 96.8%) graft survival. VUR-RN patients with and without nephrectomy were similar in terms of 1-year (100.0% for each), 5-year (91.7% vs 85.7%), and 10-year (81.5% vs 85.7%) graft survival. CONCLUSIONS: Our findings indicate kidney transplantation is a safe and effective option in ESRD patients with RN secondary to VUR. It resulted in high 1-year, 5-year, and 10-year graft survival rates.

Renal Damage Frequency in Patients with Solitary Kidney and Factors That Affect Progression.

Background. The aim of this study is to assess renal damage incidence in patients with solitary kidney and to detect factors associated with progression. Methods. Medical records of 75 patients with solitary kidney were investigated retrospectively and divided into two groups: unilateral nephrectomy (group 1) and unilateral renal agenesis/dysplasia (group 2). According to the presence of kidney damage, each group was divided into two subgroups: group 1a/b and group 2a/b. Results. Patients in group 1 were older than those in group 2 (p = 0.001). 34 patients who comprise group 1a had smaller kidney size (p = 0.002) and higher uric acid levels (p = 0.028) than those in group 1b at presentation. Uric acid levels at first and last visit were associated with renal damage progression (p = 0.004, 0.019). 18 patients who comprise group 2a were compared with those in group 2b in terms of presence of DM (p = 0.038), HT (p = 0.003), baseline proteinuria (p = 0.014), and uric acid (p = 0.032) levels and group 2a showed higher rates for each. Progression was more common in patients with DM (p = 0.039), HT (p = 0.003), higher initial and final visit proteinuria (p = 0.014, for both), and higher baseline uric acid levels (p = 0.047). Conclusions. The majority of patients with solitary kidney showed renal damage at presentation. Increased uric acid level is a risk factor for renal damage and progression. For early diagnosis of renal damage and reducing the risk of progression, patients should be referred to a nephrologist as early as possible.

Effects of infectious complications on patients' survival in peritoneal dialysis.

AIM: To investigate the impacts of infectious complications on mortality and morbidity; and to identify the other potential factors effective in mortality in peritoneal dialysis (PD) patients. PATIENTS AND METHODS: We included patients who initiated therapy between 2001-2011. Patients were divided into two groups regarding to presence or absence of infectious complications. Socio-demographic data and clinical courses were compared and the reasons for PD withdrawal were obtained. Survival analysis of all patients was performed and the effects of infectious complications on mortality were investigated. RESULTS: 301 patients were included in this retrospective study. 214 patients (mean follow-up time 28.7±16.5 months) had infection history, 87 patients (mean follow-up time 48.9±29.6 months) had no infection history. There were no statistically significant difference in comparison of the groups in terms age, gender, education levels, hemodialysis history. In patients with infection history, 465 peritonitis and 213 catheter exit site infection attacks were diagnosed. The most frequently agent was methicillin-sensitive Staphylococcus aureus and Methicillin-resistant Staphylococcus aureus in both conditions, while 25% of catheter exit site infection and 25% of peritonitis attacks were culture negative. During follow-up period, 60 patients transferred to hemodialysis, 58 patients died, 18 patients had renal transplantation in patients with infection history. In other group, 27 patients died, 23 patients had renal transplantation and 11 patients transferred to hemodialysis. Mean survival times were 56.3±2.8 months in patients with infection history and 86.8±6.1 months in other group. Mortality rate was found higher in patients with infection history (long-rank: 0.030). PD preference (OR: 5.213, p < 0.001), pretreatment low serum albumin (OR: 0.378, p = 0.001), low hemoglobin levels (OR: 0.810, p = 0.029) were found as predictors of survival in patients with infection history. CONCLUSIONS: Infectious complications have negative effects on patient survival. Nature of PD preference, initial hypoalbuminemia and anemia were found to increase the mortality rate. The major causes of deaths were peritonitis and/or sepsis in patients with infectious complications, while the major cause of death was cardiac reasons in patients without infectious complications.

Effects of rosiglitazone treatment on insulin resistance and TNF-alpha levels in patients with chronic kidney disease: a prospective study.

AIM: The aim of the study was to investigate the effects of rosiglitazone treatment on insulin resistance (IR) and tumor necrosis factor-alpha (TNF-alpha) levels in non-diabetic chronic kidney disease (CKD) patients with IR. PATIENTS AND METHODS: Thirty non-diabetic CKD patients with IR were enrolled in the study. Patients were grouped into two: group 1 (n = 15) received rosiglitazone 4 mg tablet for 3 months and patients who did not receive rosiglitazone treatment constituted the group 2 (n = 15). Baseline and after rosiglitazone treatment, homeostatis model assessment-insulin resistance (HOMA-IR) and TNF-alpha levels were measured. RESULTS: There were no statistical differences in gender, age, HOMA-IR and TNF-alpha levels among group 1 and group 2 (p > 0.05 for all). Compared to baseline in group 1, significant differences were found in HOMA-IR and TNF-alpha levels after 3 months (p = 0.023; p = 0.001, respectively). CONCLUSIONS: Our study indicates that, rosiglitazone treatment improves the IR and decreases TNF-alpha levels in non-diabetic patients CKD with IR.

Fungal peritonitis in peritoneal dialysis: a 10 year retrospective analysis in a single center.

INTRODUCTION: Fungal peritonitis (FP) is a rare but serious complication in patients undergoing peritoneal dialysis (PD), and is associated with higher morbidity, mortality. We aimed to analyze the predisposing factors, etiological agents, outcome and treatment of FP in patients with PD. METHODOLOGY: We evaluated retrospectively all PD patients PD center between 2001 and 2011. Sixteen patients with FP were included into the study. RESULTS: The clinical records of 16 patients with FP among 355 patients were reviewed for the clinical and laboratory data. Among 506 episodes of PD-related peritonitis in 10 years, we identified 16 episodes of FP. Median PD duration was 36.7±22.2 months. In 87.5% of patients had one or more previous episode of bacterial peritonitis that were treated with multiple broad-spectrum antibiotics. FP was primary infection in five patients, whereas eleven patients experienced FP during the course of treatment of bacterial peritonitis. Six patients died due to the fungal infection whereas others were transferred to haemodialysis. CONCLUSIONS: Treatment of bacterial peritonitis with broad spectrum antibiotics was an important risk factor predisposing to the development of FP. The catheter removal and initiation of antifungal therapy as soon as possible are obligatory in episode of FP because it is responsible from high mortality rate.

Risk factors for progression of renal disease in patient with diabetic nephropathy.

AIM: The aim of this study was to investigate the annual rate of glomerular filtration rate (GFR) decline and associated risk factors with this decline in diabetic nephropathy patients. PATIENTS AND METHODS: A total of 122 type 2 diabetes mellitus (DM) patients (66F, mean follow up time 39 +/- 19 months, mean age 56 +/- 10 years, mean duration of diabetes diagnosis 12.1 +/- 9.5 years) between 2003 and 2010 were evaluated retrospectively. Socio-demographic characteristics and blood pressure data, laboratory parameters, HbAlc, daily urine protein excretion both of the first and last visits of all patients were recorded. Patients were separated into three groups according to rate of GFR decline. Group 1 (n:35), group 2 (n:42) and group 3 (n:45) consisted of patients < 1 ml/dk/1.73 m2, 1-5 ml/dk/1.73 m2 and > 5 ml/dk/1.73 m2 annual rate of GFR decline respectively. Demographics, laboratory data and their treatments were compared in all three groups and were investigated factors that may influence the rate of GFR decline. RESULTS: The annual rate of GFR decline was 1.4 +/- 2.3 ml/sec, -2.9 +/- 1.0 ml/sec and -11.9 +/- 9.1 ml/sec in group 1, 2 and 3 respectively. Daily urine protein excretion was 0.9 +/- 1.3, 1.2 +/- 1.5 and 5.2 +/- 5.5 g in groups respectively, was found significantly higher in group 3 (p < 0.001). Serum albumin level was significantly lower in group 3 (p < 0.001). We found positive correlation between annual rate of GFR decline and last visit systolic blood pressure (SBP), daily proteinuria and parathormone levels (r: 0.339, 0.447 and 0.289 p < 0.001, < 0.001 and 0.02 respectively) and negative correlation between GFR decline and deltaSBP (delta systolic blood pressure), pretreatment albumin, calcium and hemoglobin levels (r: -0.409, -0.526, -0.233 and -0.467, p < 0.001, < 0.001, < 0.001 and 0.016 respectively). CONCLUSIONS: Proteinuria, hypoalbuminemia, anemia, and a change in SBP were found most effective in annual rate of GFR decline in patients with diabetic nephropathy. The early detection of these factors may slow the progression of nephropathy.

Correlation between the resistive index values of renal and orbital arteries.

BACKGROUND: Resistive index (RI) is an indirect measurement of blood flow resistance that can be used to evaluate vascular damage. AIMS: The purpose of this study is to evaluate the association between RI values of orbital and intrarenal arteries by means of Doppler ultrasonography (US). METHODS: We evaluated 103 diabetic patients. As a control group, 30 subjects were examined. The patients were divided into two groups. Group 1 consisted of patients with urinary albumin excretion (UAE) <300 mg/day and estimated glomerular filtration rate (eGFR) levels >90 ml/min (n = 50); Group 2 had a UAE >300 mg/day and/or eGFR levels between 89 and 60 ml/min (n = 53). The association between RI values obtained with Doppler US of the ophthalmic artery, central retinal artery, posterior ciliary artery and intrarenal arteries were calculated. RESULTS: Both orbital and intrarenal arterial RI values in Group 1 and Group 2 were higher than the control group (p = 0.001); furthermore, values were higher in Group 2 than in Group 1 (p = 0.0004/0.029/0.036, p = 0.016, respectively). A positive correlation was found between orbital and intrarenal arterial RI values in Group 2 (r = 0.475, 0.285, 0.363, p < 0.01, respectively). CONCLUSION: Both orbital and renal arterial RI values were shown to be higher than the control group. Further, a trend towards higher RI values was observed with renal disease. RI may be useful as one of the markers for early diagnosis and follow-up of diabetic nephropathy and retinopathy.

Effect of cholecalciferol on parathyroid hormone and vitamin D levels in chronic kidney disease.

AIM: We aimed to determine the effect of a monthly oral vitamin D on the serum 25-hydroxyvitamin D levels and iPTH levels in patients with CKD. METHODS: This was a prospective controlled trial of 48 patients with CKD stage 3-4. Patients were divided into two groups Group1 the cholecalciferol treatment group, Group 2, the control group. One patient in Group 1, and 3 patients in Group2 were excluded after the baseline 25(OH)D levels were determined to be greater than 30ng/ml. Two patients in Group1, and one patient in Group 2 were excluded after the baseline iPTH was determined to be less than 70 pg/ml and greater than 300 pg/ml. Five patients in both groups were lost to follow-up. Thus, a total of 16 patients in Group 1 and 15 patients in Group2 completed the three month study. Group1 patients received 300,000 IU month oral cholecalciferol. RESULTS: The mean serum 25(OH)D concentration of the group1 was significantly higher at baseline (P=0.039). At the end of the three months; serum 25 (OH) D level increased significantly in Group1 (P=0.001). iPTH level of Group1 was significantly lower at baseline (P=0.034). The values of the group1 before and end of third month was compared, serum Ca (P=0.011), P (P=0.013) level showed significant increase, but no significant increase in the Group 2 (P>0.05). The groups had not a clinically significant change in serum Ca and P level (P>0.05). CONCLUSION: Oral cholecalciferol supplementation can be used safely and effective in reducing iPTH levels and correcting vitamin D insufficiency/deficiency in patients with CKD.

Membranoproliferative glomerulonephritis and a rare bleeding disorder: Factor X deficiency.

Factor X (FX) deficiency is a rare hereditary coagulation disorder. This is the first case report on the association of FX deficiency and membranoproliferative glomerulonephritis (MPGN) type I. The patient, a 17-year-old male, presented with edema, hypertension, and microscopic hematuria, followed by a mild upper respiratory tract infection. Laboratory tests revealed: serum creatinine 1.6 mg/dl, serum albumin 2.80 g/dl, C3 16 mg/dl and proteinuria (1,800 mg/day). The renal biopsy showed MPGN type I. The coagulation profile prior to percutaneous renal biopsy revealed prolonged prothrombin time and activated partial thromboplastin time values. The patient was given fresh frozen plasma and vitamin K before the biopsy. Further evaluation showed the functional activity of FX was 7% of the norm. This case emphasizes the need for routine coagulation screening before percutaneous renal biopsy.

Effect of Olmesartan on serum cystatin C levels in the patients with essential hypertension.

AIM: We aimed to investigate whether Olmesartan had an effect on cystatin C levels in hypertensive patients, and evaluate its correlation with blood pressure (BP). MATERIALS AND METHODS: Seventy-two patients essential hypertension patients with a known for, at most, the last 3 years were enrolled to the study. Patients were divided in three groups (group 1; receives 20 mg/day olmesartan; group 2, receives 40 mg/day olmesartan; group 3, receives Olmesartan plus hydrochlorothiazide), according to their BP measurements. Blood samples (serum urea, creatinine, sodium, potassium and cystatin C) were collected initially and at the end of the study from all patients and the correlation of these parameters with BP and drug use was investigated. RESULTS: There were no significantly difference between the groups in terms of age, gender, serum urea, creatinine, cystatin C and diastolic BP levels (p > 0.05); while, systolic BP was significantly higher in group 3 at baseline (p = 0.001). After 3 months of olmesartan treatment, the mean serum cystatin C (p: 0.001, 0.023 and 0.018 respectively), systolic (p: 0.001, 0.001 and 0.001 respectively) and diastolic BP levels (p: 0.001, 0.001 and 0.001 respectively) decreased in all groups. However, there was no significant difference in serum creatinine levels (p > 0.05). There were not found correlation between the changes of systolic and diastolic BP and cystatin C levels. CONCLUSIONS: Cystatin C is a more sensitive marker to detect of early kidney dysfunction compared to serum creatinine level. Olmesartan treatment led to a decrease of cystatin C level. Therefore, olmesartan can be used to prevent the renal damage in patients with hypertensive and it is independent of drop in blood pressure.

Urinary N-acetyl B glucosaminidase as an earlier marker of diabetic nephropathy and influence of low-dose perindopril/indapamide combination.

INTRODUCTION: Tubulointerstitial injury is both a key feature of diabetic nephropathy and an important predictor of renal dysfunction. N-Acetyl B glucosaminidase (NAG) is derived from proximal tubular cells and is widely used to evaluate tubular renal function. OBJECTIVE: The objective of this study is whether NAG can be used as an early marker of diabetic nephropathy by comparing the urinary NAG levels between healthy controls and diabetic patients and determining changes in urinary NAG excretion after treatment with low-dose combination perindopril (2 mg)/ indapamide (0.625 mg)/o.d. MATERIALS AND METHODS: A total of 50 patients (29 female) with type II diabetes mellitus applying to our diabetes outpatient clinics for the first time were included in our study (Group 1). Diabetic patients were classified into three subgroups on the basis of their duration of diabetes: Group 1A (n = 15) < or = 3 years, Group 1B (n = 19) 3 to 5 years, and Group 1c (n = 16) > 5 years. The inclusion criteria were no prior use of antihypertensive agents; blood pressure < 130/85 mmHg; urinary albumin excretion < 30 mg/day; and absence of renal failure, diabetietes, and hypertensive retinopathy. A total of 30 healthy individuals (16 female) (Group 2) were assessed as the control group. Systolic and diastolic blood pressures, HbA1c, body mass index, 24-h microalbuminuria (MAU), and NAG measurements in urine samples were performed by using colorimetric assay method in an analyzer (Roche Cobas Mira). The assay defined as fragmentation of 3-cresolsulfonphthaleinyl-N-acetyl-beta-D-glucosaminide molecule by NAG to 3-cresolsulphonphthalein and N-acetylglucosamine molecules and serum creatinine were measured in all groups. Type II diabetic patients were administered perindopril (2 mg)/indapamide (0.625 mg) combination once daily for 4 months, and urinary NAG levels were measured at the end of treatment. RESULTS: Statistically significant differences were observed between the groups 1 and 2 with respect to the levels of NAG and HbA1c (p < 0.05). In the treatment group, NAG levels decreased significantly (p < 0.05), whereas blood pressure and HbA1c levels did not change significantly (p > 0.05). In diabetic patients, pretreatment NAG were lowest in Group 1A and highest in Group 1c, although the difference between the treatment subgroups was not statistically significant (p > 0.05). CONCLUSION: Urinary NAG excretion is elevated in type II diabetic patients as compared with the healthy individuals. Perindopril/indapamide administration is effective in reducing urinary NAG excretion in these patients, and this effect seems to be independent from blood pressure and glycemia control. Presence of tubular proteinuria may be an early indicator of diabetic renal disease in patients without microalbuminuria. Perindopril (2 mg)/ indapamide (0.625 mg)/o.d. treatment may have beneficial effect on the tubulointerstitial damage in diabetic kidney disease.

Effect of acetylsalicylic acid and dipyridamole in primary membranoproliferative glomerulonephritis type I.

Primary membranoproliferative glomerulonephritis (MPGN) has a poor long-term prognosis, with 40 per cent of patients reaching end-stage renal failure after 10 years of observation. Approximately 35 per cent of patients die due to complications of the nephrotic syndrome. This study investigates the effect of acetylsalicylic acid (ASA) combined with dipyridamole on proteinuria and renal function in nephrotic MPGN patients with normal/moderately reduced glomerular filtration rate (GFR). Fourteen patients with biopsy-proven type I MPGN received ASA (1000 mg/day) and dipyridamole (300 mg/day) for 24 months. Proteinuria was reduced from 6.8 +/- 2.4 g/day to 1.1 +/- 0.6 g/day (p < 0.001). Serum albumin levels increased from 2.2 +/- 0.5 g/dL to 3.7 +/- 0.4 g/dL (p < 0.001) during the study period after 24 months compared to baseline. Serum creatinine and GFR did not significantly change in patients treated with acetylsaliclylic acid and dipyridamole during the observation period (p < 0.05). Our study suggests that ASA combined with dipyridamole significantly reduces proteinuria without impairing renal function in patients with MPGN.