Crescentic IgA nephropathy following SARS-CoV-2 vaccination. Report of a case / Nefropatía por IgA extracapilar luego de la vacunación contra el SARS-CoV-2. Reporte de un caso

ABSTRACT Introduction: Studies have shown that the frequency of acute kidney injury (AKI) increases in patients with COVID-19. Acute tubular necrosis has been reported to be the most common damage in these patients, probably due to impaired renal perfusion. On the other hand, different complex pathophysiological processes may be involved due to viral infection's direct effects on the renin-angiotensin-aldosterone system, the activation of coagulopathy, the cytokine storm, and the activation of the immune system. Many glomerular diseases may be seen in these patients, like anca-associated vasculitis, membranous glomerulonephritis, and IgA nephropathy. Clinical case: We present a newly diagnosed crescentic IgA nephropathy (IgAN) case after a SARS-CoV-2 infection and vaccination. A 31-year-old man with no medical history presented with gross hematuria 24 hours after SARS-CoV-2 infection. Hematuria regressed spontaneously within three days. He was vaccinated with two doses of CoronaVac (Sinovac) three months after he had been infected by SARS-CoV-2. Then he was vaccinated with the Pfizer-BioNTech COVID-19 vaccine one month after the second dose of CoronaVac (Sinovac) vaccine. He presented with gross hematuria and subnephrotic proteinuria 24 hours after the first dose of the Pfizer-BioNTech COVID-19 vaccine. A kidney biopsy was performed and showed crescentic IgA nephropathy (IgAN). He was started on methylprednisolone and angiotensin receptor blocker. Patients who receive mRNA-based vaccines demonstrate robust antibody production against the receptor-binding domain (RBD) of the S1 protein. Similar to natural infection, due to the intense stimulation of immune response from mRNA-based vaccines compared to other vaccines, the patients may produce de novo antibodies, leading to IgA-containing immune-complex deposits. Conclusions: This case highlights the immunological effects of the novel mRNA-based SARS-CoV-2 vaccines. Nephrologists should be aware of new-onset hematuria or proteinuria after SARS-CoV-2 infection or mRNA-based SARS-CoV-2 vaccine.

RESUMEN Introducción: Los estudios han demostrado que la frecuencia de insuficiencia renal aguda (IRA) aumenta en pacientes con COVID-19. Se ha informado que la necrosis tubular aguda es el daño más común en estos pacientes, probablemente debido a la alteración de la perfusión renal. Por otro lado, pueden estar involucrados diferentes procesos fisiopatológicos complejos, debido a los efectos directos de la infección viral sobre el sistema renina-angiotensina-aldosterona, la activación de la coagulopatía, la tormenta de citoquinas y la activación del sistema inmunológico. En estos pacientes se pueden observar muchas enfermedades glomerulares, como vasculitis asociada a anca, glomerulonefritis membranosa y nefropatía por IgA. Caso clínico: Presentamos un caso de nefropatía IgA extracapilar (NIgA) de nuevo diagnóstico tras una infección por SARS-CoV-2 y vacunación. Un hombre de 31 años sin antecedentes médicos presentó hematuria macroscópica 24 horas después de la infección por SARS-CoV-2. La hematuria remitió espontáneamente en 3 días. Fue vacunado con dos dosis de CoronaVac (Sinovac) tres meses después de haber sido infectado por el SARS-CoV-2. Luego fue vacunado con la vacuna Pfizer-BioNTech COVID-19, un mes después de la segunda dosis de la vacuna CoronaVac (Sinovac). Presentó hematuria macroscópica y proteinuria no nefrótica 24 horas después de la primera dosis de la vacuna Pfizer-BioNTech COVID-19. Se realizó una biopsia renal que mostró NIgA extracapilar. Comenzó con metilprednisolona y bloqueador del receptor de angiotensina. Los pacientes que reciben vacunas basadas en ARNm demuestran anticuerpos contra el dominio de unión al receptor (RBD) de la proteína S1. De manera similar a la infección natural, debido a la fuerte estimulación de la respuesta inmunitaria de las vacunas basadas en ARNm en comparación con otras vacunas, los pacientes pueden producir anticuerpos de novo, lo que lleva a depósitos de complejos inmunitarios que contienen IgA. Conclusiones: Este caso destaca los efectos inmunológicos de las nuevas vacunas contra el SARS-CoV-2 basadas en ARNm. Los nefrólogos deben estar al tanto de la aparición de hematuria o proteinuria luego de la infección por SARS-CoV-2 o la vacuna contra el SARS CoV-2 basada en ARNm.

Optimal Timing for Removal of the Double-J Stent After Kidney Transplantation.

BACKGROUND: Urologic complications (UC) have gradually decreased in recent years after advanced surgical experience. The incidence of urologic complications varies between 0.22% and 30% in different medical studies. There is no routine usage of double-J stenting (DJS) during renal transplantation (RT) in the literature. It is a necessity, and optimal timing for stent removal is an important question for many transplantation centers. METHODS: This study includes 818 renal transplant patients whose ureteroneocystostomy anastomoses were completed by use of the Lich-Gregorie procedure during a 2-year period at a transplantation center. We performed 926 renal transplantations at Antalya Medical Park Hospital Renal Transplantation Center between January 2014 and January 2016. The patients were divided into four groups according to the timing of DJS removal. RESULTS: For group 1, removal time for DJS was between 5 and 7 days; group 2, Removal time for DJS was between 8 and 14 days; group 3, removal time for DJS was between 15 and 21 days; and group 4, removal time for DJS was later than 22 days. The patients were divided into two groups according to removal time of stent as 5 to 14 days and >15 days. DJS was performed again in the patients whose urine output was reduced during the first 5 days after removal of the DJS, whose creatine level increased, and whose graft ureter and collecting tubules were extended as an ultrasonographic finding. CONCLUSIONS: There is no declared optimal time for the removal of DJS. The removal time was reported between postoperative first week and 3 months in some of the reports of RT centers, according to their protocols. We emphasize that the optimal time for the removal of DJS is 14 to 21 days after RT, based on the findings of our large case report study.

Thiol/disulphide homeostasis levels in erectile dysfunction patients.

This study explored the use of thiol/disulphide homeostasis as a novel oxidative stress marker in patients with erectile dysfunction (ED). Fifty-five patients aged 40-57 were divided into two groups: Group I (International Index of Erectile Function [IIEF-5] score between 22 and 25, n = 20) and Group II (IIEF-5 score < 22, n = 35). Blood samples were used to evaluate hormone levels, lipid profile and thiol/disulphide levels. A novel, fully automated method measured plasma native thiol, total thiol and disulphide levels. Mean age, body mass index, total testosterone, HbA1c, triglyceride, atherogenic index (AIP) and total cholesterol levels did not significantly differ between Groups I and II (p > .05). IIEF-5 correlated weakly with native thiol level. Although non-statistically significant, native thiol (431 [SD: 105] µmol/L vs. 404 [110] µmol/L) and total thiol (426 [64] µmol/L vs. 41 [78] µmol/L) levels were lower in the ED group compared to the controls, and disulphide (14 [11] µmol/L vs. 18 [9] µmol/L) levels were higher. Mean disulphide/native thiol and mean disulphide/total thiol ratios did not statistically differ between groups. There was a weak positive correlation between AIP and total cholesterol/HDL and disulphide and disulphide/total thiol ratios. Thiol/disulphide haemostasis levels are not a single factor in ED pathophysiology but may contribute.

The relation of protein C and protein S levels with cardiovascular risk in patients with diabetic neuropathy.

BACKGROUND: This study was conducted to determine the clinically significance of protein C and protein S levels as a cardiovascular risk marker in patients with diabetic neuropathy. METHODS: We included 71 subjects. 50 of them were diabetics, 27 of them also had diabetic neuropathy(DN), 21 subjects were non diabetic. We evaluated these 3 group subjects' protein C, protein S, fibrinogen, prothrombine time (PT), activated partial thromboplastine time (aPTT), total cholesterol, levels and Framingham Coronary Risk Score (FCRS). RESULTS: Non diabetic group's protein C levels were higher than patients with DN (p<0.05) and diabetic patients without DN (p<0.05). But there were no difference in terms of protein C levels between patients with DN and diabetic patients without DN. FCRS of control group was lower than diabetic subjects(p<0.01). CONCLUSIONS: We found that protein C and S levels were much lower in diabetic patients than non diabetics.There was no difference between diabetic patients with DN and diabetic patients without DN in terms of protein C and protein S levels. Further, we couldn't detect any finding that we can say protein C and Protein S levels can be used as a cardiovascular risk assessment marker in diabetic neuropathic patients.

Preclinical impairment of myocardial function in rheumatoid arthritis patients. Detection of myocardial strain by speckle tracking echocardiography.

OBJECTIVES: The incidence of heart failure is higher in patients with rheumatoid arthritis (RA) than in the general population and contributes to elevated cardiovascular mortality and morbidity rates. Impaired myocardial function can be detected by a novel echocardiographic method, speckle tracking echocardiography (STE), when conventional methods have yielded normal findings. The aim of our study was to investigate the effect of disease duration on myocardial strain and strain rate parameters in patients with RA. METHODS: This cross-sectional study included 37 RA patients [n=16, female gender n=16, mean age, 45.7 ± 9 years in the early-stage disease (ESD); n= 21, female gender n=19, 45.7 ± 16.8 years in the advanced-stage disease (ASD) group] who were compared according to early disease duration and advanced-stage disease (2.8 ± 1.2 vs. 14.6 ± 6.8 years, respectively). Hypertension, diabetes mellitus, and other cardiovascular risk factors were excluded. Offline analysis of STE was performed and data between the two groups were compared. RESULTS: RS, RSR-E, and RSR-E/A values were statistically significantly lower in patients with ASD. Circumferential strain and strain rate were similar between the two groups. Except for LSR-E/A values, LS, LSR-S, LSR-E, and LSR-A values were decreased in patients with ASD. CONCLUSION: RA patients without clinical evidence of cardiovascular disease and in the absence of traditional cardiovascular risk factors can be followed up with STE. In this way, early impairment of myocardial deformation can be detected before the appearance of any clinical evidence of cardiac involvement.

Prediction of early postoperative atrial fibrillation after cardiac surgery: is it possible?

BACKGROUND: Postoperative atrial fibrillation is common after cardiac surgery. In this study, we aimed to investigate the value of interatrial conduction time for the prediction of early postoperative atrial fibrillation, using intra-operative transoesophageal echocardiography. METHODS: A total of 65 patients undergoing cardiac surgery in our hospital between January and March 2007 were prospectively evaluated, and 59 patients with sinus rhythm were included in the study. We performed transoesophageal echocardiography on all patients, and intra-operatively measured the interatrial conduction time, as recently described. The patients with episodes of atrial fibrillation during the postsurgery hospitalisation period were defined as group 1 and those without episodes were defined as group 2. RESULTS: Mean interatrial conduction time was 74 ± 15.9 ms in group 1 and 54 ± 7.9 ms in group 2. The difference in interatrial conduction time between the two groups was statistically significant (p < 0.05). In this study we found a statistically significant interatrial conduction delay between the groups. Postoperative atrial fibrillation was more frequent in patients with a longer interatrial conduction time. CONCLUSION: Increased interatrial conduction time may cause postoperative atrial fibrillation and it can be measured intraoperatively by transoesophageal echocardiography.

Can left internal mammary artery side branches affect blood flow rate?

The left internal mammary artery (LIMA) is the most commonly used arterial graft for coronary artery bypass graft (CABG) surgery, and occluding the LIMA side branches during surgery is important to avoid myocardial ischaemia afterwards. In this study we investigated the incidence of patent LIMA graft side branches in our coronary angiography series, and compared LIMA flow rate changes by means of the thrombolysis in myocardial infarction (TIMI) frame count in patients with and without LIMA graft side branches. Patients with a history of CABG surgery and who were scheduled for coronary angiography in our centre between 1 January and 15 December 2006 were enrolled in the study. We compared LIMA graft TIMI frame counts between patients with and without side branches. The incidence of LIMA graft side branches in our study was 18% (seven patients). Mean TIMI frame count was 27.28 +/- 3.4 in patients with LIMA graft side branches and 15.67 +/- 2.3 in patients without. There was a significant difference between the two groups (p < 0.0001). Patients with LIMA graft side branches were more likely to have anterior ischaemia, determined by myocardial perfusion scintigraphy. We suggest that TIMI frame count may be helpful in evaluating the effect of side branches on LIMA graft flow rate. The increased TIMI frame count of a LIMA graft with side branch is associated with insufficient LIMA flow.

A randomized trial of intravenous iloprost (a stable prostacyclin analogue) versus lumbar sympathectomy in the management of Buerger's disease.

AIM: The aim of this study was to compare the effects of iloprost and lumbar sympathectomy (LS) in the treatment of Buerger's disease. METHODS: Two hundred patients with rest pain and/or ischemic ulcers were randomized to undergo LS or 28-day intravenous treatment of iloprost. The primary endpoint was complete healing without pain or major amputation at 4 and 24 weeks. The secondary endpoints were analgesic requirement, reduction in the ulcer size, 50% reduction of the ulcer, and shift in the modified SVS/ISCVS clinical status grading scale. RESULTS: The comparison was carried out in 162 patients (iloprost: n=84; LS: n=78). Complete healing rate was 61.9% in the iloprost group, but 41% in the LS group at the 4th week (P=0.012); respective values for the 24th week were 85.3%, 52.3%, P<0.001. Analgesic requirement was lower in the iloprost group at the 4th and 24th weeks (P=0.01, and P=0.098, respectively). The size of the ulcers decreased more in the iloprost group than the LS group (P=0.044 and P=0.035 at 4th and 24th weeks); 50% reduction in the ulcer size in the iloprost group was greater than in the LS group (P=0.001 and P=0.009 at 4th and 24th weeks). SVS/ISCVS grading scale demonstrated a better clinical benefit in patients treated with iloprost (P<0.001 at 4th week, and P<0.001 and at 24th week). CONCLUSIONS: The results of this independent study indicate that using iloprost relieves ischemic symptoms better than LS. In the era of stable prostacyclin analogues, there is no reliable evidence to support the use of LS in Buerger's disease.

The effect of verapamil on the prevention of ischemia/reperfusion injury in the experimental retroperitoneoscopic donor nephrectomy model.

BACKGROUND: This study investigated the effect of intravenous administration of verapamil in prevention of the injury caused by free oxygen radicals generated in a rabbit retroperitoneoscopic donor nephrectomy model. METHODS: Twenty-four adult New Zealand rabbits were divided into four groups. In group I, balloon dissection of the left retroperitoneal space was performed. In group II, CO2 at 10 mmHg was applied for 3 hours after the balloon dissection. In group III, laparotomy was performed, the left renal pedicle was clamped for 3 min, and the clamp was removed 5 min before nephrectomy. In group IV, 2 min before the attempt 0.2 mg/kg verapamil was given intravenously, and the same procedure was employed as in group III. Nephrectomy was performed after each experiment. The concentrations of malonyl dialdehyde (MDA), reduced glutathione (GSH), and protein carbonyl content were measured in renal tissue samples as markers of oxidative stress. RESULTS: Pneumoretroperitoneum (Prp) promoted oxidative stress in renal tissues, with an increase of MDA and protein carbonyl content. The verapamil- pretreated group (group IV) showed statistical significantly lower values of MDA and protein carbonyl content when compared with group II and III (p < 0.05), whereas tissue GSH concentrations were unchanged in all groups. CONCLUSIONS: Our study showed that Prp causes increased oxidative stress in renal tissue. Warm ischemia lasting 3 min did not exert an additive effect on Prp-associated oxidative stress. Verapamil reduces the oxidative stress markers caused by Prp.

Induction of spermatogenesis in idiopathic hypogonadotropic hypogonadism with gonadotropins in older men.

We investigated the treatment results in 6 azoospermic idiopathic hypogonadotropic hypogonadism (IHH) cases that remained untreated 41-47 years of age. Medical history, physical examination, hormone profile measurements, peripheral blood karyotype, skull X-ray and/or magnetic resonance imaging were performed. Patients received 1,000 to 5,000 IU hCG, 2-3 times per week, and 75 to 150 IU hMG, 2-3 times per week for 24 months. Serum testosterone levels were assessed every month for maximum 6 months to evaluate optimal dose of treatment and then every 3 months thereafter. Sperm counts were assessed every 3 months. Testosterone level increased from 2.7 +/- 0.9 mIU/L to 22 +/- 7.04 mIU/L with treatment; testicular volume increased by 4.6 ml during the treatment. Sperm were detected in the ejaculate in 3 out of 6 patients on the 22nd, 18th, and 15th month of treatment. 3 patients underwent testicular biopsy; histopathology revealed tubular hyalinization. Spermatogenesis in older men with IHH was restored by exogenous gonadotropins.

Early tissue reactions in the rat bladder wall after contact with three different synthetic mesh materials.

OBJECTIVES: To investigate bladder tissue reactions to three types of implanted mesh material, i.e. polypropylene, polyglactin and polypropylene-polyglactin combined. MATERIALS AND METHODS: Forty-eight adult female Wistar albino rats were randomized to four equal groups, i.e. group 1 (sham-operated controls), group 2 (polypropylene mesh), group 3 (polyglactin mesh) and group 4 (polypropylene-polyglactin mesh). A laparotomy incision was made to access the bladder and fix a 0.5 x 1 cm piece of mesh directly on the bladder wall. Each group was randomly divided into two subgroups of six animals, killed at 7 and 14 days after mesh implantation, respectively, to study mesh and tissue features with time. Bladders were harvested for histological and immunohistochemical investigation. Microvessels that developed around the mesh were detected with the avidin-biotin peroxidase system, using antibody to Factor VIII-related antigen as an endothelial marker. Vessels were counted in the most intensely stained area of one section from each animal's bladder. RESULTS: Compared with the other groups, group 4 had more inflammatory reaction at 7 days but the tissue reactions to all mesh materials were similar at 14 days; the mesh penetrated the bladder muscularis propria at 14 days in all six rats in group 2, in one in group 3, and two in group 4. Group 4 tended to have a greater microvessel density at 14 than at 7 days. In contrast, groups 2 and 3 had lower microvessel densities at 14 than at 7 days. CONCLUSION: The rat bladder wall had a similar early response to all three types of mesh materials. Penetration was more marked with polypropylene mesh than with the other materials. This nonabsorbable material persists in tissue and is currently widely used for clinical applications. These results for penetration suggest that the use of polypropylene mesh risks serious postoperative complications, e.g. urethral tissue erosion.

The 'modified prone position': a new approach for treating pre-vesical stones with extracorporeal shock wave lithotripsy.

OBJECTIVE: To investigate the utility of a new 'modified-prone' position for treating pre-vesical stones with extracorporeal shock wave lithotripsy (ESWL), usually considered an acceptable and effective treatment for such stones, but for which many different body positions have been used in an attempt to increase its efficacy. PATIENTS AND METHODS: The study included 268 consecutive patients with a solitary pre-vesical stone who underwent ESWL either prone (69) or in the modified-prone position (199) between May 1999 and August 2001. Only those with one stone between the ureteric orifice and 1 cm proximal to the vesico-ureteric junction were included. In each case the stone diameter, days to stone clearance, number of shock waves applied per treatment, and number of sessions required to become stone-free were recorded. If the treatment failed this was also noted. Success rates in the prone and modified-prone groups were compared and analysed to assess which of the variables influenced success with ESWL. RESULTS: After ESWL, 95.5% of the 268 patients were stone-free; the rates in the prone and modified-prone groups were 89.9% and 97.5%, respectively (P = 0.015). The probability of success with ESWL therapy for pre-vesical calculi in modified-prone position was about five times (odds ratio 4.56, 95% confidence interval 1.2-17.7) greater than that expected with when prone. The modified-prone position was an independent factor most significantly influencing success with ESWL in these patients. CONCLUSION: The modified-prone position for ESWL is a new and very effective way to treat patients with pre-vesical stones.

Intratesticular varicocele treated with percutaneous embolization.

Intratesticular varicocele is an extremely rare and a relatively new clinical entity. A 22-year-old man was admitted to our hospital with left testicular pain. On physical examination, a grade III varicocele was noted on the left side, and the testis was soft as well. Gray-scale ultrasound and color Doppler ultrasound examinations revealed intratesticular and extratesticular varicocele. Testicular venography failed to demonstrate the testicular vein. Percutaneous embolization was performed through direct puncture to the dilated veins. Percutaneous embolization under local anesthesia is an alternative treatment to other techniques.

Stone fragility in shock wave lithotripsy can be predicted in vitro.

OBJECTIVE: To investigate the effect of stone size, chemical structure, radiologic appearance, stone weight and stone mineral density on in vitro stone fragility. METHODS: A total of 216 stones obtained by open surgery were stratified according to their size, chemical structure (X-ray crystallography), radiologic appearance, mineral content and density (dual photon absorptiometry) and weight. Stone fragility was measured by the number of shock waves needed to completely fragment the stones in a phantom model by Dornier. RESULTS: Stone weight increased according to stone size and mineral density varied in relation to chemical composition. The radiologic appearance was not predictive of the chemical content. The most significant variable to predict the number of shock waves needed for full fragmentation was the stone weight. The stone weight could be formulated as a function of mineral content and the equation had statistical significance (p = 0.000). The necessary number of shock waves for complete disintegration also could be estimated by using stone weight, stone size and mineral density. This equation was also statistically significant (p = 0.000). CONCLUSIONS: Stone weight which is a function of stone mineral content seems to be the single most important parameter to predict stone fragility in vitro. Stone weight can be estimated by using the stone mineral content. Prediction of the necessary number of shock waves for full fragmentation seems possible and is formulated into an equation that proved to be statistically significant in vitro. In vivo application of this estimation awaits further research.

Primary carcinoid of the kidney.

A rare case of primary renal carcinoid tumour is presented. The diagnosis was based on immunohistochemically diffuse cytoplasmic positivity for chromogranin A and neuron-specific enolase, in addition to histologic findings. Only 14 previous cases of this tumour have been documented in the literature.