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INTRODUCTION Numerous studies showed that higher body mass index (BMI) is associated with better survival in hemodialysis (HD) patients. Most of them evaluated short-term mortality. It has been suggested that presence of inflammation may be a key modifier of relationship between BMI and mortality in incident HD patients. We examined whether presence of inflammation modifies the association between BMI and mortality in both short-term and long-term follow-up in a large group of prevalent HD patients. METHODS A total of 3.252 HD patients from 41 HD centers were enrolled; the patients were divided into quartiles based on time-averaged BMI (Q1

Background: Kidney involvement is a common manifestation that contributes to morbidity and mortality in systemic amyloidosis. Amyloid load can be predicted by histopathological grading of amyloid deposits in kidney biopsy specimens. Our aim was to determine the relationship of renal amyloid deposition grade with clinical manifestations and outcomes in patients with biopsy proven renal non-AA amyloidosis. Methods: This retrospective cohort study included 74 subjects with renal non-AA amyloidosis (52 AL amyloidosis and 22 unclassified amyloidosis). Baseline characteristics and follow-up data were recorded. Pattern and quantity of amyloid deposition in glomeruli, interstitium, vessels and tubulointerstitial changes were scored. Renal Amyloid Prognostic Score (RAPS) was obtained by addition of all scores and divided into three grades (RAPS grade I, II, III). Results: In AL amyloidosis group, median follow-up was 11 (4-45 months). Among 52 patients, 17 received autologous stem cell transplantation and 29 received bortezomib based chemotherapy. Baseline eGFR was significantly lower among patients with RAPS grade III. Renal survival was significantly lower among patients with RAPS grade III. Patient survival was not significantly different according to RAPS grade. Type of amyloid could not be determined in 22 patients. In this group, baseline eGFR was significantly lower in patients with RAPS grade III. Conclusions: In patients with AL amyloidosis, baseline kidney functions are associated with RAPS grade. Renal survival is significantly lower in patients with highest RAPS grade. However, patient survival is not significantly different according to RAPS grade.

Background Induction therapy is mostly recommended for deceased-donor transplantation, whereas it has some controversies in live-donor transplantation. In this study, we described the outcomes of live-donor renal transplant recipients who received ATG-Fresenius (ATG-F) induction. Methods Live-donor transplantations in patients over 18 years old with ATG-F induction between 2009 and 2015 were included. All patients received quadruple immunosuppression, one of which was ATG-F induction. Biopsies after the artery anastomosis (zero hour) and protocol biopsies at the 6th month and at the 1st first year were obtained. Acute graft dysfunction was defined as a 20% to 25% increase in creatinine level from baseline. All acute rejection episodes were biopsy-confirmed. All episodes were initially treated with intravenous methyl prednisolone (MP) or ATG-F if resistant to MP. Four hundred twenty-two patients with live-donor transplantation were evaluated. The mean age was 40 ± 13 (18–73) years. The mean panel-reactive antibody levels were 42% ± 30% and 45% ± 30% for class I and II, respectively. Results The mean mismatch number for living unrelated donors (n = 112) was 4.6 ± 1.0. Acute rejection rate was 29.1% (123 patients) within the first year. The mean cumulative ATG-F doses for per patient and per kilogram were 344 ± 217 mg and 5.1 ± 2.7 mg, respectively. Patient survival rates were 98.3% and 96.7% for 12 months and 60 months, respectively. Death-censored graft survival rates were 97.6% and 92.1% for 12 months and 60 months, respectively. Conclusions ATG-F induction provided excellent graft and patient survival rates without any significantly increased side effects. Increasing sensitized patient numbers, more unrelated donors, increasing re-transplantation numbers, and more desensitization protocols make ATG-F more favorable in an induction regimen.

In solid organ transplant recipients, it is recommended that the necessary vaccinations be completed at least 4 weeks before transplant. Chickenpox infection in adulthood can lead to serious clinical conditions such as pneumonia, hepatitis, and central nervous system infections. Herein, the case of chickenpox in a 36-year-old female patient with renal transplantation for end-stage renal disease due to vesicoureteral reflux 11 years previously and without a history of chickenpox or its vaccination before and after transplantation is reported. In this case, because of the development of thrombocytopenia associated with intravenous acyclovir, treatment was successfully concluded with oral valacyclovir.

Purpose Renal involvement is associated with significant morbidity and mortality in AA amyloidosis. Extend of amyloid deposition in kidney biopsies may be predictive for clinical manifestations and outcomes. the aim of our study is to assess clinical features of patients with biopsy-proven renal AA amyloidosis and to evaluate the relationship between histopathological scoring and grading of renal amyloid deposition with clinical findings and outcomes. Methods the study included 86 patients who were diagnosed with renal AA amyloidosis. the demographic and clinical features at the time of biopsy and follow-up data were retrospectively collected. Amyloid deposition in glomeruli, interstitium, vessels and tubulointerstitial findings were scored and renal amyloid prognostic score (RAPS) was assigned by adding all scores. RAPS was further divided into three grades (RAPS grade I, II, III). Results Median age was 50 (36-59) years. Familial Mediterranean fever was the leading cause. RAPS grade and interstitial inflammatory infiltration were associated with baseline eGFR and glomerular amyloid deposition was associated with proteinuria. During the follow-up period (median 50 months), 39 patients developed ESRD. Extensive (involving > 50%) glomerular amyloid deposition, baseline eGFR and proteinuria were independent risk factors for progression to end stage renal disease. Death censored renal survival was significantly lower among patients with RAPS grade III compared to those with RAPS grade I and II. Patient survival rate was not different according to RAPS grade. Conclusions Degree of renal amyloid accumulation is associated with renal function and outcome. the scoring and grading system may be predictive in clinical outcome and contribute to understanding of disease mechanism.

Aim Lupus nephritis (LN) is an important complication of systemic lupus erythematosus (SLE). The aim is to use indication and protocol biopsies to determine clinicopathological findings and outcomes of patients with LN undergoing kidney transplantation (KTx). Methods Patients who underwent KTx due to LN were retrospectively analyzed. Recurrent LN (RLN) was diagnosed by transplant kidney biopsy. Results Among 955 KTx patients, 12 patients with LN as the cause of end-stage renal disease were enrolled. Five patients were male. Mean follow-up time was 63 ± 34 months. At the last follow-up visit, mean levels of serum creatinine and proteinuria were 137.0 ± 69.0 µmol/L and 0.26 ± 0.26 g/day, respectively. Eighteen indication and 22 protocol biopsies were performed; 27 biopsies were additionally evaluated by immunofluorescence. In two recipients, subclinical RLN was confirmed by protocol biopsies. Clinical recurrence occurred in four patients. Among patients with RLN, time from diagnosis of LN to KTx was significantly shorter and use of ATG as induction treatment was significantly lower. Graft loss occurred in two recipients who had clinical RLN. Five-year overall graft survival was 85.7%. Conclusion Kidney transplantation is a reasonable option for patients with ESRD secondary to SLE. However, recurrence of LN is common if protocol biopsies are included in post-transplantation surveillance.

WOS: 000435081200008, PubMed ID: 29722904, ObjectivesLipodystrophy syndromes are a group of heterogeneous disorders characterized by adipose tissue loss. Proteinuria is a remarkable finding in previous reports. Study designIn this multicentre study, prospective follow-up data were collected from 103 subjects with non-HIV-associated lipodystrophy registered in the Turkish Lipodystrophy Study Group database to study renal complications in treatment naive patients with lipodystrophy. MethodsMain outcome measures included ascertainment of chronic kidney disease (CKD) by studying the level of proteinuria and the estimated glomerular filtration rate (eGFR). Kidney volume was measured. Percutaneous renal biopsies were performed in 9 patients. ResultsSeventeen of 37 patients with generalized and 29 of 66 patients with partial lipodystrophy had CKD characterized by proteinuria, of those 12 progressed to renal failure subsequently. The onset of renal complications was significantly earlier in patients with generalized lipodystrophy. Patients with CKD were older and more insulin resistant and had worse metabolic control. Increased kidney volume was associated with poor metabolic control and suppressed leptin levels. Renal biopsies revealed thickening of glomerular basal membranes, mesangial matrix abnormalities, podocyte injury, focal segmental sclerosis, ischaemic changes and tubular abnormalities at various levels. Lipid vacuoles were visualized in electron microscopy images. ConclusionsCKD is conspicuously frequent in patients with lipodystrophy which has an early onset. Renal involvement appears multifactorial. While poorly controlled diabetes caused by severe insulin resistance may drive the disease in some cases, inherent underlying genetic defects may also lead to cell autonomous mechanisms contributory to the pathogenesis of kidney disease., NIHUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USA [RO-1DK88114], NIH, Grant/Award Number: RO-1DK88114

WOS: 000371398300006, PubMed ID: 26935363, Objective Primary Sjogren's syndrome (pSS) is a common chronic autoimmune disease that primarily affects the salivary and lacrimal glands. Arterial stiffness is one of the earliest detectable manifestations of adverse structural and functional changes within the vessel wall. The aim of this study was to evaluate the relationship between arterial stiffness and pSS. Methods In this study, 75 female patients with pSS who fulfilled the American European Consensus Criteria for Sjogren's syndrome, were included. A total of 68 age-, sex-and body mass index-matched subjects were recruited as the control population. Arterial stiffness was assessed by measurement of the carotid-femoral pulse wave velocity (PWV). Results The mean age of the patients was 54.0 +/- 9.3 years and the median duration of the disease was 10 years. Compared with the control subjects, patients with pSS had a higher mean PWV (8.2 +/- 1.5 m/s vs. 7.5 +/- 1.4 m/s; p=0.01). Correlation analysis showed that the PWV was positively correlated with age, body mass index, serum cholesterol, low-density lipoprotein (LDL) and C-reactive protein levels, blood pressure, mean arterial pressure (MAP), pulse pressure and left ventricular mass index. A multiple linear regression analysis revealed that arterial stiffness was associated with age, MAP and LDL levels in pSS patients. Conclusion Although patients with pSS appear to have increased arterial stiffness, risk factors associated with arterial stiffness in these patients are similar to the general population. However, we cannot exclude the possibility that a higher PWV in pSS patients is caused, not by pSS itself, but by the use of steroids, hypertension and dyslipidemia.

Background and Aim The incidence of obesity is increasing all around the world and Turkey is no exception. In Turkey, 80.1% of all kidney transplants performed in 2013 were living donor kidney transplants. In this study we compare the early postoperative complications of living kidney donors with a body mass index (BMI) over 30 to those with BMIs under 30. Patients and Method All donor nephrectomies performed at the Ege University School of Medicine Hospital between May 2013 and May 2014 were included in the study. Donors' demographics, preoperative BMI, operation time, length of hospital stay, postoperative complications, and perioperative blood creatinine levels were analyzed. Results There were a total of 72 donors, 50 of whom had a BMI below 30 (group 1), whereas 22 had a BMI of 30 or higher (Group 2). The median age was 47 (±12.6) and 52.2 (±8.4) for Groups 1 and 2, respectively. The median BMI was 26.1 (±2.3) for Group 1 and 31.8 (±1.5) for Group 2. There was no significant difference in operation time ( P = .980) between the 2 groups. There was no difference in the length of hospitalization with an average hospital stay of 3 days for both groups. No major complications were observed in either group. There was no difference in minor complication rates for both groups. Conclusion High BMI donors can safely donate their kidney with no significant increase in complication rates at high-volume transplantation centers.

Chronic dialysis hypotension is described as low systolic blood pressure (

Women with previous gestational diabetes mellitus (pGDM) are at high risk for type 2 diabetes and cardiovascular disorders. In this study, we aimed to compare plasma apelin levels between women with and without pGDM, and to investigate the possible association of apelin with cardiometabolic risk factors.Among 252 consecutive Caucasian women with GDM being included in a prospective postpartum follow-up protocol, 141 women eligible for the study protocol were enrolled. Control group consisted of 49 age- and body mass index-matched healthy women without pGDM. Circulating apelin, IL-6 and plasminogen activator inhibitor levels, and carotid intima media thickness (IMT) were measured. To evaluate carbohydrate intolerance, 75-g oral glucose tolerance test was performed. Fasting insulin and lipids were measured, and homeostasis model assessment index was calculated.Plasma apelin levels were reduced in women with pGDM (p 0.001). In multiple regression analysis, apelin was negatively associated with fasting (r (2) 0.090, β -0.273, p = 0.001) and post-load glucose (r (2) 0.061, β -0.187, p = 0.022), serum IL-6 (r (2) 0.082, β -0.234, p = 0.002), and carotid IMT (r (2) 0.057, β -0.168, p = 0.033).Our results suggested that suppressed apelin levels were associated with increased cardiovascular risk in women with pGDM.

WOS: 000428115400002, PubMed ID: 29631525, Introduction: Colistimethate sodium (CMS) is frequently used in the treatment of nosocomial multidrug-resistant gram-negative infections. Nephrotoxicity is the most important side effect. The aim of this study is to evaluate the effect of colistin on nephrotoxicity and to assess prognosis in patients treated with CMS due to hospital-acquired pneumonia (HAP). Materials and Methods: Patients treated with CMS for HAP due to multidrug-resistant Pseudomonas aeruginosa or Acinetobacter baumannii were included in this cohort study. Results: We evaluated 281 patients treated with two different brands of CMS whose administration dose is different: imported (n=58, low dose/kg) and domestic (n=223, high dose/kg). Nephrotoxicity developed in 175 patients (62.3%). The median age (73 vs. 66 years, p=0.004) and mortality rates were higher (66.9% vs. 52.8%, p=0.022) in patients having nephrotoxicity. The patients receiving high dose/kg had higher nephrotoxicity rate (67.7% vs. 41.4%, p < 0.001). The clinical, bacteriological response and mortality rates of the whole group were 52.0%, 61.0%, 61.6%, respectively. The clinical and bacteriological response rates were similar in the different dose groups. Multivariate analysis showed that nephrotoxicity was associated with domestic brand depending on use of high dose (OR=3.97), advanced age (beta=0.29, p=0.008), male gender (OR=2.60), hypertension (OR=2.50), red blood cells transfusion (OR=2.54), absence of acute kidney injury (OR=10.19), risk stage of RIFLE (OR=11.9). Conclusion: Nephrotoxicity is associated with the use of high dose colistin, age, gender, hypertension, red blood cells replacement and RIFLE stage. The mortality rate is higher in patients developing nephrotoxicity.

Purpose: Mean platelet volume (MPV) is an indicator of platelet activation which plays an important role in the pathogenesis of atherosclerosis. The purpose of this study was to compare MPV values in patients with previous gestational diabetes (pGDM), who have different degrees of carbohydrate intolerance with that in women without pGDM; and to retrospectively analyze MPV in these women during pregnancy. Material and Method: One hundred and five consecutive women with gestational diabetes mellitus (GDM) and 40 women with negative screening for GDM were studied. Results: There was no statistically significant difference in MPV between women with pGDM and health controls. Although not significant, women with pGDM developing type 2 diabetes had elevated levels of MPV compared to their normoglycemic counterparts (p=0.092). MPV was positively correlated with fasting glucose levels (r=0.215, p=0.009). During pregnancy, the mean platelet volume was significantly higher in women with GDM than in healthy pregnant controls (p

Persistent hypercalcemia after kidney transplantation (KTx) may cause nephrocalcinosis and graft dysfunction. The aim of this study was to evaluate patients with hypercalcemia and assess its effect on tubulointerstitial calcification. A total of 247 recipients were enrolled. Transient and persistent hypercalcemia was defined as hypercalcemia (corrected serum calcium >10.2 mg/dL) persisting for 6 and 12 months after KTx, respectively. The severity of calcification in the 0-h, 6- and 12-month protocol biopsies of patients with transient (n = 8) and persistent hypercalcemia (n = 20) was compared with a matched control group (n = 28). Twenty-eight patients were hypercalcemic at 6 months posttransplantation. Serum calcium levels were normalized in eight of them at the end of the first year. Dialysis duration was a positive predictor of persistent hypercalcemia. Tubulointerstitial calcification was detected in 70.6 and 90 % of patients with persistent hypercalcemia at 6 and 12 months posttransplantation, respectively. In 20 % of patients with transient hypercalcemia, severity of calcification regressed at 12 months posttransplantation along with normalization of serum calcium levels. Graft functions and histopathological findings (ci, ct, ci + ct, cv, ah, percentage of sclerotic glomeruli) were not different at 6 and 12 months posttransplantation. Hypercalcemia and persistent hyperparathyroidism are not rare after KTx. Tubulointerstitial calcification is more common and progressive among patients with persistent hypercalcemia. Normalization of calcium levels may contribute to regression of calcification in some patients.

We aimed to evaluate the predictors of subsequent development of postpartum carbohydrate intolerance, metabolic syndrome and cardiovascular risk factors in women with previous GDM. Two hundred fifty-two consecutive women with GDM were enrolled. After exclusion of women who did not attend to the hospital for follow-up visits for minimum 1 year, data of 195 patients were evaluated. Seventy-one lean women with negative screening for GDM were included as a control group. The prevalence of diabetes, impaired glucose tolerance and impaired fasting glucose and metabolic syndrome was significantly higher in women with previous GDM than healthy controls. Women with previous GDM were more insulin resistant, had an atherogenic lipid profile and increased carotid IMT. The most important predictors of postpartum diabetes were the need for insulin treatment during index pregnancy and glucose values on antepartum OGTT. Among women with previous GDM, the development of postpartum diabetes and metabolic syndrome was associated with increased carotid IMT. Our data show that women with previous GDM are at high risk for developing carbohydrate intolerance, metabolic syndrome and atherosclerosis. Antepartum prediction of high risk subjects for the subsequent development of postpartum carbohydrate intolerance and metabolic syndrome seems to be vital to prevent cardiovascular outcomes.

Gestational diabetes mellitus is a common disorder which is defined as any degree of glucose intolerance with onset at, or first recognized during pregnancy. Women with gestational diabetes are at greater risk for many adverse pregnancy outcomes and maternal or fetal mortality. We tried to conduct the cumulative experience regarding the management of the disease, especially emphasizing the novel therapeutic approaches like new types of insulin preparations, oral hypoglycemic agents and herbal drugs or supplements. In this review important recent patents are also discussed. © 2008 Bentham Science Publishers Ltd.

WOS: 000386130100021, PubMed ID: 27274836, Background: There are significant differences between countries in the mortality rates of haemodialysis (HD) patients. The extent of these differences and possible contributing factors are worthy of investigation. Methods: As of March 2009, all patients undergoing HD or haemodiafiltration for >3 months (n = 4041) in the Turkish clinics of the NephroCare network were enrolled. Data were prospectively collected for 2 years through the European Clinical Dialysis Database. Mean age +/- standard deviation was 58.7 +/- 14.7 years, 45.9% were female and 22.9% were diabetic. Comparison with US data was performed by applying an indirect standardization technique, using specific mortality rates for patients on HD by age, gender, race and primary diagnosis as provided by the 2012 US Renal Data System Annual Data Report as reference. Results: The crude mortality rate in Turkey was 95.1 per 1000 patient-years. Compared with the US reference population, the annual mortality rate for Turkey was significantly lower, irrespective of gender, age and diabetes. After adjustments for age, gender and diabetes, the mortality risk in the Turkish cohort was 50% lower than US whites [95% confidence interval (CI) 0.46-0.54, P < 0.001], 44% lower than US African-Americans (95% CI 0.52-0.61, P < 0.001) and 20% lower than Asian-Americans (95% CI 0.74-0.86, P < 0.05). Conclusions: The annual mortality rate of prevalent HD patients was found to be significantly lower in the studied Turkish cohort compared with that published by the US Renal Data System Annual Data Report. Differences in practice patterns may contribute to the divergence.

İnsanlarda nadiren enfeksiyona sebep olan Pseudallescheria boydii, toprakta bulunan saprofitik mikroorganizmalardır. Bu yazıda P. boydii nedenli sol tibia ön yüzde deri yumuşak doku enfeksiyonu olan böbrek nakilli bir hasta sunulmaktadır. Doku biyopsisi alınan hastada patolojik incelemede hifler ve fungal sporlar ile birlikte mikolojik kültürde P. boydii üremesi saptandı. Aynı zamanda üreyen mantar moleküler yöntemler kullanılarak da tanımlandı. Flukonazol ile topical izokonazol nitrat tedavileri antifungal duyarlılık sonuçları elde edilene dek uygulandı. Duyarlılık sonuçları ile birlikte flukonazol, itrakonazol olarak değiştirildi. Bir ay sonra kontrolde klinik olarak yanıt alındığı görüldü. P. boydii için uygun antifungal tedavi seçimi ve tedavi süresi hakkında yeterli veri bulunmamasından dolayı patojenin tanımlanması ve antifungal duyarlılık sonuçlarının alınması çok önemlidir, Pseudallescheria boydii, a rare cause of infection in humans, are saprofitic microorganisms which are found in soil. In this report, we describe a renal transplant patient who had a skin-soft tissue infection at the anterior side of her left tibia due to P. boydii. Tissue biopsy was taken from her tibial lesion. Pathologic examination revealed hyphae plus fungal spores and mycological cultures were positive for P. boydii. The fungus was also identified by molecular methods. Fluconazole and topical isoconazole nitrate were given to the patient until the antifungal susceptibility results were seen. Fluconazole was changed to itraconazole via susceptibility results. Clinical response was seen at the 1 month control.Because of limited data regarding the optimal antifungal drug choice and duration of treatment for P. boydii infections, the proper identification of pathogen and antifungal susceptibility tests have vital importance. J Microbiol Infect Dis 2015;5(4): 176-179

Background and Aim The effect of preemptive transplantation of kidneys from living donors on patient and allograft survival is controversial. In this study, we aimed to evaluate whether preemptive kidney transplantation performed without the development of patient dialysis-related complications has a favorable effect on patient and graft survival. Patients and Method The study included 334 adult renal transplant recipients. Patients who underwent renal transplantation between January 2008 and December 2012 at a tertiary referral teaching hospital were followed, and outcomes were obtained by retrospective chart review. A total of 244 patients underwent dialysis before renal transplantation, whereas 90 patients underwent preemptive transplantation. Results There were no significant differences between the 2 groups with regard to patients and graft survival rates ( P > .05). Patient survival rates in preemptive and nonpreemptive groups were 98.9% and 96.3% in the first year, respectively ( P = .199). Graft survival rates in preemptive and nonpreemptive groups were 96.7% and 93.0% in the first year, respectively ( P = .163). Patient survival rates in preemptive and nonpreemptive groups were 98.9% and 95.7% in the third year, respectively ( P = .155). Graft survival rates in preemptive and nonpreemptive groups were 93.5% and 88.5% in the third year, respectively ( P = .138). There was a significant difference among years with regard to ratio of patients with preemptive transplantation ( P = .009). The ratio was 17.5% in 2008, whereas it rose to 43.1% in 2012. Conclusion Although preemptive kidney transplantation does not provide a significant patient and allograft survival advantage compared to nonpreemptive kidney transplantation, both therapeutic modalities provide good outcomes. Preemptive kidney transplantation has been an increasingly frequent renal replacement therapy option in recent years.

Background/Aims: Double-balloon endoscopy (DBE) is a technique that enables the evaluation and treatment of small intestinal diseases. The aim of the study was to evaluate the indications, therapeutic interventions, complications, and safety and to describe the experience with DBE in Turkish patients. Materials and Methods: Four hundred twenty consecutive patients undergoing DBE were included in our study. Demographic features, indications, diagnostic findings, therapeutic interventions, complications, and technical aspects of the procedure were recorded. A total of 513 DBEs were carried out. Results: In all, 420 patients underwent a total of 513 DBE procedures (369 (72%) oral and 144 (28%) anal). The most common clinical indications were obscure bleeding (26%), abdominal pain (25.2%), anemia (20%), chronic diarrhea (10.5%), and inflammatory bowel diseases (5.2%). A proper diagnosis was obtained or confirmed in 222 of 420 patients (52.3%). Ulcers/erosions (23.6%), vascular lesions (8.1%), and polyps/tumors (7.4%) represented the most common endoscopic findings. Perforation occurred in one patient as a complication after polypectomy. No major complications due to sedation occurred. Conclusion: Double-balloon endoscopy is effective for the diagnosis and treatment of small intestinal diseases. Therapeutic interventions carried out by DBE seem to be useful and safe.

WOS: 000327875200025, PubMed ID: 24059653, Various reasons such as malignancies and chronic infections may cause weight loss in kidney transplant patients. In this report, iron overload as a rare cause of weight loss in a kidney transplant patient is presented. Forty-seven-year-old male patient who transplanted from a deceased donor 5 years ago was hospitalized because of 20 kg of weight loss. In medical history, he had history of hemodialysis for 89 months and received 100-300 mg of intravenous iron therapy per week before transplantation and transfused eight units of blood. In physical examination, weight and height were 45 kg and 185 cm, respectively. Respiratory and cardiac auscultation was normal. Laboratory results revealed as follow: glucose 76 mg/dL, urea 60 mg/dL, creatinine 1.35 mg/dL, aspartate aminotransferase 74 U/L, alanine aminotransferase 77 U/L, C-reactive protein 2.59 mg/dL, albumin 3.3 g/dL, globulin 3.4 g/dL, white blood cells 3200/mm(3), hemoglobin 13.1 g/dL and platelets 190,000/mm(3). Chest and abdominal tomography didn't reveal any pathology. Portal Doppler ultrasound showed signs of early cirrhosis. Viral and autoimmune hepatitis markers were negative. Ferritin was 5300 ng/mL and transferrin saturation was 82%. In liver biopsy, hemosiderosis was diagnosed and heterozygous H63D gene mutation was detected. Totally, 19 units of phlebotomy were performed. Liver function tests and serum ferritin decreased gradually. At outpatient follow-up in 6 months, he returned to former weight. In conclusion, there can be several causes of weight loss in kidney transplant patients. Iron overload can come across as a rare cause of weight loss. In these patients, ferritin levels should be checked and diagnosis should be clarified by liver biopsy and gene mutation analysis.

Background Renal transplantation is the best renal replacement therapy because it significantly improves patient survival. The developments in transplantation and increasing number of patients with end-stage renal disease (ESRD) have unmasked long-term complications secondary to immunosuppressive drugs and chronic renal failure. Methods and Results Eighty-six renal transplant recipients with grafts that have functioned more than 15 years were included in the study. This cross-sectional retrospective analysis of demographic, clinical, and laboratory findings was conducted in 3 Turkish transplantation centers. The mean age was 30.4 ± 10.2 years at the time of the transplantation. The mean time between the transplantation and the study was 19.1 ± 3.6 years. At the time of the study, mean creatinine level was 1.52 ± 0.60 mg/dL, 70.09% of the patients displayed glomerular filtration rates 2 . Urinary protein excretion was 0.57 ± 0.65 g/d. Hypertension and hyperlipidemia were the most common comorbid diseases. Twelve patients had diabetes and 9 cardiovascular disease. Seventeen patients had been diagnosed with skin and 5 with non-skin cancer. Conclusions As the number of recipients with long-term functioning grafts increases, long-term complications become evident, particularly chronic renal failure. Survivors should be evaluated regularly and treated early for risk factors and complications to improve long-term graft and patient survival.

BACKGROUND YKL-40 (chitinase-3-like protein 1) is a novel inflammation and endothelial dysfunction biomarker. Although YKL-40 is associated with albuminuria and predicts cardiovascular morbidity and mortality in a non-uremic population, it's status is not known in renal transplant recipients. The aim of this study was to investigate plausible links between serum YKL-40 and proteinuria. MATERIAL AND METHODS A total of 110 renal transplant recipients were included in this study. The level of proteinuria was calculated from spot urine using the protein/creatinine ratio. The estimated glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formula. Serum YKL-40 was determined by ELISA (R&D Systems, USA). RESULTS The mean patient age was 40.5 ± 10 years. The mean YKL-40, GFR, and proteinuria levels were 66 ± 46 ng/ml, 49 ± 24 ml/min/1.73 m2, and 0.77 ± 1.15 g/day, respectively. Increases in the YKL-40 tertiles were correlated with increases in proteinuria and C-reactive protein and decreases in the GFR and serum albumin. An adjusted linear regression analysis demonstrated that the YKL-40 level (t=3.28, P=0.001), GFR (t=-3.00, P=0.003), and systolic blood pressure (t=2.51, P=0.01) were independently associated with proteinuria. CONCLUSIONS This is the first study to show that increased serum YKL-40 levels are independently associated with proteinuria in renal transplant recipients. YKL-40 may be responsible for the pathogenesis of cardiovascular injury in this patient population.

AMAÇ: Karotis arter intima media kalınlığı (KA-İMK) ölçümü aterosklerotik kardiyovasküler sonlanımlar ile ilişkilidir. Retrospektif olan bu çalışmada, periton diyalizi yapan hastalarda KA-İMK progresyonunun yeni gelişen kardiyovasküler (KV) olaylar üzerine etkisini araştırdık. GEREÇ ve YÖNTEMLER: Periton diyalizi ünitemizde takip edilen hastaların (n=163) dosyaları tarandı. KA-İMK ölçümü olmayan hastalar dışlandı. Bazal KA-İMK ölçümü olan 96 hasta çalışmaya dahil edildi. İkinci KA-İMK ölçümü olan 52 hasta mevcuttu. Ölümcül ve ölümcül olmayan KV olaylar hasta dosyalarından tarandı. BULGULAR: Bazalde ortalama KA-İMK 0.62±0.16 mm (medyan 0.60 mm) idi. İki yıldan fazla süreyle PD yapan hastalarda, bazal KA-İMK 0.60 mm’nin üzerinde olanlarda olmayanlara göre KV olay oranı daha yüksekti (%22.2’ye karşılık %4.2, p=0.041). İkinci kez KA-İMK ölçülen hastalarda ortalama KA-İMK 0.62±0.17 mm’den 0.66±0.17 mm’ye yükseldi (p=0.002). ROC eğrisinde KV olay için saptanan en iyi cut-off değeri 0.0062 mm/ay idi. (AUC 0.752±0.066, p=0.046). Hastalar bu değerine göre iki gruba ayrıldığında aylık progresyonu 0.0062 mm’nin üzerinde olanlarda olmayanlara göre KV olay daha yüksek saptandı (%33.3’e karşılık, OBJECTIVE: Measurement of carotid artery intima-media thickness (CA-IMT) is directly associated with cardiovascular (CV) outcomes. We retrospectively investigated the impact of CA-IMT progression on new CV events in patients on peritoneal dialysis (PD). MATERIAL and METHODS: All PD patients who have been followed in our unit (n=163) were screened. The patients who had no CA-IMT were excluded. Ninety-six patients who had baseline CA- IMT measurement were included. Fifty-two patients had second CA-IMT measurement. Fatal and nonfatal CV events were screened from patients’ charts. RESULTS: At baseline, mean CA-IMT was 0.62±0.16 mm (median 0.60 mm). In patients treated with PD more than 2 years, CV event rate was higher in patients with high CA-IMT (>0.60 mm) compared to the patients with low CA-IMT at baseline (22.2% versus 4.2%, p=0.041). In patients who had second CA-IMT measurement, mean CA-IMT increased from 0.62±0.17 mm to 0.66±0.17 mm (p=0.002). In ROC analysis, best cut-off value of CA-IMT progression was 0.0062 mm/month for prediction of CV events (AUC 0.752±0.066, p=0.046). When patients were grouped according to this cut-off value, CV event rate was higher in patients showed CA-IMT progression above 0.0062 mm/month (33.3% versus 2.7%, p=0.001). In Cox-regression analysis, progression of CA-IMT more than 0.0062 mm/month was only predictor for new CV events (ExpB=14.57, p=0.015). CONCLUSION: Consecutive assessment of atherosclerosis progression by CA-IMT measurement has importance for prediction of new CV events in PD patients. %2.7, p=0.001). Cox regresyon analizinde geleneksel risk faktörleri de değerlendirmeye alındığında, KV olay belirleyicisi sadece aylık KA-İMK progresyonunun 0.0062 mm olması idi (ExpB=14.57, p=0.015). SONUÇ: Periton diyalizi hastalarında KA-İMK ölçümü ile aterosklerozun progresyonunun takibi, yeni gelişebilecek KV olayların belirlenmesinde önemlidir.

Metformin is a biguanide used in the treatment of type 2 diabetic patients with normal renal function. Lactic acidosis is the most serious side effect of metformin. Renal failure is the most common cause of reduced lactate excretion. It is aimed to present a case of metformin-induced lactic acidosis exacerbated by acute renal failure. A 68-year-old female patient used metformin was admitted to the infectious disease department due to diarrhea, nausea and vomiting. Type B lactic acidosis due to metformin was diagnosed after the detection of high anion gap metabolic acidosis and high lactate level on blood gas analysis. Hemodialysis was performed because of acute renal failure. The patient was discharged on the 11th day of the hospitalization with normal serum parameters. Metformin may cause lactic acidosis among patients with acute renal failure; early hemodialysis provides rapid clinical improvement. KEy woRDS: Acute renal failure, Hemodialysis, Lactic asidosis, Metformin doi: 10.5262/tndt.2013.1001.24 Yazisma Adresi: Mustafa YAPRAK Ege Universitesi Tip Fakultesi, Ic Hastaliklari Anabilim Dali, Nefroloji Bilim Dali, Izmir, Turkiye Gsm : 0 505 572 56 67 E-posta : mustafayaprakdr@yahoo.com Gelis Tarihi : 20.05.2012 Kabul Tarihi : 11.06.2012 duyarliligini artirir. Ayrica glikozun gastrointestinal sistemden absorbsiyonunu azaltir (4). Metforminin en sik yan etkisi diyare, bulanti ve kusma semptomlarini iceren gastrointestinal sistem yan etkileridir (5). Laktik asidoz, metformin kullaniminin seyrek gorulen ama ciddi bir yan etkisidir. Karaciger ve bobrek fonksiyon bozuklugu gibi komorbid durumlarin varliginda daha sik gorulmektedir (6). Insidansi her 100.000 hasta yilinda 9’dur (7). Laktat, hepatik glukoneogenez icin bir substrat oldugundan, metGIRIS Metformin biguanid sinifindan oral antidiyabetik bir ilactir. Tip 2 diyabetes mellitusta (DM), bobrek fonksiyonlari normal olanlarda ilk basamak ilac secenegidir (1). Metformin primer olarak hepatik glikoz uretimini baskilayarak hiperglisemiyi iyilestirir (2). Tip 2 DM’li kisiler normale gore 3 kat fazla glukoneogenez oranina sahiptir; metformin tedavisi bunu ucte bir oranina kadar azaltir (3). Buna ek olarak metformin periferik glikoz alimini artirarak insulin Yaprak M ve ark : Akut Bobrek Yetmezliginde Metformine Bagli Laktik Asidoz Turk Neph Dial Transpl 2013; 22 (1): 133-135 134 Turk Nefroloji Diyaliz ve Transplantasyon Dergisi Turkish Nephrology, Dialysis and Transplantation Journal Δ bikarbonata orani 1,42 saptandi. Bakilan laktat duzeyi 9,88 mmol/L saptanmasi uzerine metformin kullanimina bagli Tip B laktik asidoz olarak degerlendirildi. Metformin ve laktat klirensini saglamak ve metabolik asidozu duzeltmek amaciyla hasta bikarbonatli hemodiyalize (HD) alindi. Takibinde hastanin idrar cikisi basladi. Ikinci gun asidozu devam eden hasta tekrar HD’ye alindi. Ucuncu gun kan gazinda asidozu duzelen, laktati normale gelen hasta bikarbonat duzeyi dusuk oldugu icin tekrar HD’ye alindi. Kan gazi takipleri ve diyaliz tedavisi Tablo I’de verildi. Dorduncu gun kan gazi normal sinirlarda saptandi. Daha sonraki gunlerde HD ihtiyaci olmadi. Hastaya sonrasinda metformin kullanmamasi, DM tedavisi icin insulin kullanmasi onerildi. Yatisinin 11. gununde tum kan parametreleri duzelmis olarak sifa ile taburcu edildi.

OBJECTIVE Women with gestational diabetes mellitus (GDM) treated with insulin are more likely to develop type 2 diabetes after pregnancy compared to mild GDM cases treated with medical nutrition treatment (MNT) alone. We aimed to compare levels of subclinical atherosclerosis markers in women with previous GDM treated with insulin and MNT alone. METHODS Eighty-one women with previous GDM (45 treated with insulin, 36 treated with MNT) and 35 age-matched lean controls were included. Fasting glucose, insulin and lipids, circulating fibrinogen, CRP, PAI-1 and IL-6 levels were assayed. Carotid intima media thickness (IMT) was measured. RESULTS Women with previous GDM treated with insulin in pregnancy had significantly higher fasting glucose, plasma PAI-1 levels and carotid IMT compared to women treated with MNT alone. In multiple regression analysis, insulin need in pregnancy was associated with increased carotid IMT and plasma PAI-1 levels (corrected for age, BMI, postpartum duration, fasting glucose and lipids; model r(2)=0.132; beta=0.297, p=0.014 for carotid IMT; model r(2)=0.198; beta=0.345, p=0.003 for PAI-1). CONCLUSION Women with previous GDM treated with insulin in pregnancy had a worse cardiovascular risk profile compared to mild GDM patients. An intensive preventive approach for cardiovascular disorders is particularly essential for this subgroup of women.

We aimed to determine plasma thrombin-activatable fibrinolysis inhibitor (TAFI) antigen levels in women with previous gestational diabetes mellitus (GDM) and to evaluate the possible association of plasma TAFI with glucose intolerance and markers of subclinical atherosclerosis. This cross-sectional study was performed in 111 women with previous GDM and 60 controls. Glucose intolerance was evaluated. Homeostasis model assessment score was calculated. Circulating lipids, interleukin-6, matrix metalloproteinase-1, fibrinogen, plasminogen activator inhibitor-1, and TAFI antigen levels were assayed. Carotid intima media thickness (IMT) was measured. Women with previous GDM had increased levels of atherosclerosis markers and carotid IMT. On the other hand, plasma TAFI antigen levels were similar ( P = .395). Thrombin-activatable fibrinolysis inhibitor was not associated with the indices of insulin resistance, glucose intolerance, markers of atherosclerosis, and carotid IMT. Our data demonstrated that plasma TAFI was not altered in women with previous GDM. TAFI was not associated with glucose intolerance and subclinical atherosclerosis.

Osteoprotegerin (OPG), a novel soluble member of tumour necrosis factor receptor superfamily, has been shown to link cardiovascular disorders. The aim of this study is to investigate the potential relationship between serum OPG levels, cardiovascular risk factors and metabolic syndrome in a relatively large group of women with previous GDM. In this cross-sectional case-control study, 128 women with previous GDM and 67 age-matched controls were enrolled. Subjects were evaluated for the diagnosis of metabolic syndrome according to the criteria of the American Heart Association (AHA). Fasting glucose, insulin, serum lipids, CRP and OPG were assayed. HOMA score was calculated. Carotid intima media thickness (IMT) was measured. There was no significant increase in OPG levels in women with previous GDM when compared to controls. On the other hand, women with previous GDM developing metabolic syndrome had higher OPG levels than those without metabolic syndrome and healthy controls. Serum OPG levels were associated with obesity, insulin resistance, serum CRP and carotid IMT. Serum OPG is related to cardiovascular risk factors and metabolic syndrome, and might be involved in the development of cardiovascular disorders in women with previous GDM.

Objective To determine the predictors of subsequent development of metabolic syndrome (MS) in women with previous gestational diabetes mellitus (GDM). Design Controlled clinical study. Setting University hospital. Patient(s) One hundred sixty-four consecutive women with previous GDM were evaluated after a mean follow-up of 40.54 months from index pregnancy. Sixty-five lean women with negative screening for GDM were included as a control group. Intervention(s) None. Main Outcome Measure(s) Subjects were evaluated for diagnosis of MS according to criteria of the National Cholesterol Education Program and the International Diabetes Federation. Tests were performed including a 75-g oral glucose tolerance test (OGTT), fasting insulin, lipids, plasma fibrinogen, blood pressure, and body measurements. The homeostasis model assessment score was calculated. Result(s) The MS prevalence was higher in women with previous GDM, according to both definitions. Univariate analysis showed that prepregnancy obesity, weight gain during follow-up, and fasting glucose level at the OGTT of the index pregnancy were predictors of developing MS. Multivariate analysis showed that fasting glucose level >100 mg/dL at the OGTT of the index pregnancy was an independent predictor of the MS development. Conclusion(s) We suggest that early prediction of women with previous GDM who are at high risk for developing MS is possible, and it is vital to prevent MS-related complications.

Circulating levels of osteoprotegerin (OPG) have been shown to be increased in patients with cardiovascular disorders and diabetes. The aim of this study was to determine serum OPG levels in women with previous gestational diabetes (GDM), and to investigate the relationship between OPG and carotid intima media thickness (IMT) and circulating cardiovascular risk factors. Serum OPG was measured in 46 women with previous GDM and 30 age-matched healthy controls. Carotid IMT was evaluated. Serum lipid, insulin and hsCRP levels, plasma fibrinogen, vWF and PAI-1 levels were measured. Serum OPG levels tended to be increased in women with previous GDM (p=0.058). Carotid IMT was increased in the study group. Women with previous GDM had elevated levels of hsCRP and PAI-1. OPG levels were positively correlated with age, fasting and post-load glucose levels, hsCRP, and carotid IMT. Multiple regression analysis showed that serum OPG was a statistically significant predictor for elevated carotid IMT. Our results revealed that OPG levels tended to be elevated in women with previous GDM. Significant association of OPG with carotid IMT suggested that OPG might play a role in the pathogenesis of endothelial dysfunction in women with previous GDM.

Cytomegalovirus (CMV) disease is an important complication and an independent risk factor for acute rejection and recipient morbidity-mortality. The aim of this study was to review the results of CMV disease in renal transplant recipients. Method. We have retrospectively analyzed CMV disease in 120 renal transplant recipients and recorded the demographic features, clinical manifestations, and immunosuppressive regimens. Results. Twenty-nine recipients (24.1%) developed CMV disease after a median interval of 2.8 +/- 2,6 months from transplantation. CMV disease developed in 36.3% of recipients who received basiliximab as induction therapy and 21.4% of recipients who were treated with anti-thymocyte globulin (ATG). The most commonly used immunosuppressive regimen was cyclosporine-A (CsA)based (79.3%). The mean cumulative steroid dose until the diagnosis was 3,600 mg methyl prednisolone per patient. Malaise, fever, and diarrhea were the most common symptoms. Gastritis, pneumonia, and transaminitis were the most commonly seen end-organ involvements. Frequent laboratory findings were leukopenia (34.5%), increased serum creatinine level (34.5%), and leukocytosis (20.7%). We performed renal biopsy to seven patients and detected acute rejection in four patients. In 25 patients, immunosuppressive treatment was modified. Relapsing CMV disease was seen in seven patients. Conclusion. In our study, CMV disease was seen in recipients who were treated with basiliximab, a finding similar to recipients who were treated with ATG.