Arzu Kahveci

Unusual causes of peritonitis in a peritoneal dialysis patient: Alcaligenes faecalis and Pantoea agglomerans

An 87 -year-old female who was undergoing peritoneal dialysis presented with peritonitis caused by Alcaligenes faecalis and Pantoea agglomerans in consecutive years. With the following report we discuss the importance of these unusual microorganisms in peritoneal dialysis patients.

Fibroblast Growth Factor–23 Levels Are Associated With Uric Acid But Not Carotid Intima Media Thickness in Renal Transplant Recipients

INTRODUCTION Cardiovascular disease (CVD) is the leading cause of mortality in chronic kidney disease (CKD) patients. Fibroblast growth factor-23 (FGF-23) is associated with atherosclerosis and cardiovascular mortality in CKD patients and healthy subjects. However, data in renal transplant recipients (RTR) are scarce. We aimed to determine factors associated with FGF-23 and to explore its relationship to atherosclerosis. METHODS Forty-six patients and 44 controls were included. FGF-23 was measured from plasma. Carotid intima media thickness (CIMT) was evaluated ultrasonographically. RESULTS Patients had higher waist circumference (WC; 92.2 ± 14.9 vs 85.3 ± 11.0 cm; P < .05), glucose (99.8 ± 17.2 vs 90.3 ± 6.5 mg/dL; P < .01), creatinine (1.43 ± 0.6 vs 0.86 ± 0.1 mg/dL; P < .01), triglyceride (160.4 ± 58.9 vs 135.6 ± 59.8 mg/dL; P < .05), white blood cells (WBC; 7938.6 ± 2105.2 vs 6715.7 ± 1807.5 WBC/mm(3); P < .01), ferritin (217.0 ± 255.8 vs 108.3 ± 142.4 ng/mL; P < .05), uric acid (6.5 ± 1.6 vs 4.7 ± 1.3 mg/dL; P < .01), C-reactive protein (CRP; 8.2 ± 18.2 vs 5.3 ± 7.9 mg/L; P < .01), parathyroid hormone (PTH; 89.7 ± 59.2 vs 44.1 ± 16.7 pg/mL; P < .01), and alkaline phosphatase (ALP; 162.5 ± 86.6 vs 74.2 ± 21.9 U/L; P < .01). FGF-23 was higher in patients (11.7 ± 7.2 vs 9.6 ± 6.8 pg/mL; P < .05). CIMT was similar (0.58 ± 0.09 vs 0.57 ± 0.1 mm; P > .05). WC, creatinine, and uric acid were positively correlated with FGF-23, whereas albumin showed negative correlation. On multivariate analysis only creatinine and uric acid were determinants of FGF-23. CONCLUSION FGF-23 levels are associated with uric acid in RTR. Larger studies are needed to confirm this finding.

Protective effect of the vasopressin agonist terlipressin in a rat model of contrast-induced nephropathy.

Background/Aims: Contrast-induced nephropathy (CIN) remains a leading cause of iatrogenic acute renal failure. Terlipressin, a long-acting analog of vasopressin, may improve renal function. This study aimed to investigate the possible protective effect of terlipressin against the development of experimental CIN in rats. Methods: Wistar albino rats (n = 32) were allocated randomly into four equal groups of 8 each, i.e. control, terlipressin, contrast media (CM), and terlipressin plus contrast media (TCM). CIN was induced by intravenous administration of indomethacin (10 mg/kg), N-nitro L-arginine methyl ester (L-NAME, 10 mg/kg, twice at 15 and 30 min), and high-osmolar contrast media meglumine amidotrizoate 60%. Renal function parameters, kidney histology, and tubular expression of vascular endothelial growth factor (VEGF) were determined. Results: Mean serum creatinine levels were decreased (p < 0.05) and creatinine clearance (p < 0.05) increased in the TCM group compared with the CM group. Notably, rats in the TCM group displayed less tubular necrosis (p < 0.05), medullary congestion (p < 0.05), and a reduced tubular expression of VEGF (p < 0.05) compared with the CM group. Conclusion: These results demonstrate that terlipressin can inhibit the development of CIN.

Streptococcus bovis bacteremia related to colon adenoma in a chronic hemodialysis patient.

We report the case of a 54‐year‐old hemodialysis patient who presented with recurrent fever due to Streptococcus bovis bacteremia related to colonic tubulovillous adenoma. Following polypectomy and broad‐spectrum antibiotic therapy, the patient totally recovered. In this paper, we discussed the relation between S. bovis bacteremia, colonic adenomas, and hemodialysis. Awareness of this association is critical for early diagnosis and management.

Fibroblast growth factor-23 levels are associated with vascular calcifications in peritoneal dialysis patients.

Background: The aim of the study was to assess the relationship between fibroblast growth factor-23 (FGF-23) and vascular calcifications (VC) in peritoneal dialysis (PD) patients. Methods: A cross-sectional study was performed in 55 PD patients who underwent pelvic X-ray to assess for VC. Patients with and without linear calcifications were recorded. Results: Fifteen patients (27.3%) had linear calcifications on pelvic X-ray. FGF-23 levels were higher in patients with VC (299.5 (30.4-2,410.0) vs. 74.4 (14.8-1,030) pg/ml, p < 0.01). Diabetic patients had lower FGF-23 values (43.2 (14.9-134.0) vs. 103.5 (14.8-2,410) pg/ml, p < 0.01). Patients with residual renal function (RRF) had lower FGF-23 levels (70.6 (14.8-513) vs. 179.5 (30.4-2,410) pg/ml, p = 0.06); however, this did not reach statistical significance. FGF-23 levels, age, creatinine, Ca, dialysis duration and HbA1c were positively correlated with VC, whereas RRF, Ca intake and ALP were negatively associated. Multivariate logistic analysis confirmed FGF-23 levels, age, dialysis duration and RRF to be associated with VC. Conclusions: FGF-23 levels are associated with VC in PD patients. Further studies are needed to clarify whether it is simply a marker or a potential factor. It may prove to be an important therapeutic target for VC management.

Peritoneal Dialysis Catheter Removal by Nephrologists: Technical Aspect from a Single Center

Despite improvements in peritoneal dialysis (PD) techniques during past years, PD-related problems may still warrant removal of the catheter. Mechanical catheter problems, persistent or relapsing peritonitis, and exitsite infections are the most common causes of removal. PD catheters may also be removed after successful renal transplantation. Recent data reported by Asif emphasized that the most common PD access procedures performed by nephrologists include PD catheter insertion, removal, and repositioning (1). Traditionally, PD catheter removal and repositioning are performed by surgeons. Due to surgeons’ long waiting lists, there is usually a delay in the procedure, with adverse effects on outcome. Therefore, we set out to introduce a technique for removal of Tenckhoff PD catheters described by Ash (2). We retrospectively evaluated the PD catheter removal procedures that were performed by nephrologists in our clinic.

Once-monthly continuous erythropoietin receptor activator (CERA) for haemoglobin maintenance in haemodialysis patients with chronic renal anaemia

Background This study was conducted to evaluate the efficacy and safety of once-monthly continuous erythropoietin receptor activator (CERA) for maintenance of stable haemoglobin (Hb) levels in adult chronic renal anaemia patients on dialysis according to local clinical judgment in Turkey. Methods This was a prospective, open-label, single-arm, multi-centre study conducted in 20 centres in Turkey. After a 4-week screening period, eligible patients receiving conventional erythropoiesis-stimulating agents were converted to monthly intravenous CERA and entered a 16-week CERA dose-titration period (DTP) followed by an 8-week efficacy evaluation period (EEP) and a 4-week safety follow-up. The primary endpoint was the proportion of patients whose Hb concentration remained stable within ±1.0 g/dL of their reference Hb and within the range of 10.0–12.0 g/dL during the EEP. Results A total of 173 patients were screened, 132 entered the DTP and 84 completed the study. Thirty-nine patients [46.4% (95% confidence interval: 35.5–57.7%)] maintained stable target Hb concentrations. The mean change in time-adjusted average Hb concentration was 0.29 ± 1.08 g/dL between baseline and the EEP. The mean CERA monthly dose was 112.4 ± 76.78 µg during the EEP, and the CERA dose was adjusted in 39 patients (36.4%). Eleven patients (8.4%) reported 13 treatment-related adverse events, the most frequent adverse events being infections and infestations, gastrointestinal and vascular disorders. Conclusions Once-monthly CERA maintains stable Hb concentrations in chronic renal anaemia patients on dialysis in Turkey. The study results confirm the known efficacy and safety profile of CERA.

Thymic Neuroendocrine Carcinoma Presenting as Cushing’s Syndrome: Treatment with Octreotide Combined with Surgery and Radiotherapy

A 28-year-old woman, 7 weeks pregnant, presented to a community hospital complaining of intermittant vaginal bleeding, weight gain, hirsutism, and pustular lesions on the face. Past medical history revealed that she was HBsAg (+) (carrier state) and had two abortions previously. The weight gain had started about 2 months prior to pregnancy, affecting mainly the face and neck, accompanied by facial plethora. Hirsutism and pustular lesions developed during pregnancy, mainly on the face. Vaginal bleeding started shortly after, and an obstetrician noted elevated blood pressure of 160/90 mmHg. Upon admission she was anxious and diaphoretic. Blood pressure was 130/100 mmHg. She had a moon face appearance and facial plethora with hirsutism and pustular lesions predominantly on the face. Ecchymotic lesions were noted on the forearms for which she did not recall any trauma. She had pitting pretibial edema. Her vaginal bleeding increased necessitating medical abortion. Blood count was unremarkable. Blood chemistry revealed hypernatremia and hypokalemia. Fasting blood glucose level was 112 mg/dl. Morning blood cortisol and the 24-h urinary free cortisol levels were both elevated and still remained so after the 2-mg and 8-mg dexamethasone suppression tests; the adrenocorticotropic hormone (ACTH) level was also elevated (table 1). Magnetic resonance imaging (MRI) of the pituitary gland was normal. Abdominal MRI showed bilateral adrenal gland hyperplasia. She was diagnosed with Cushing’s syndrome due to ectopic ACTH secretion. The search for the ectopic origin of ACTH revealed a 28 × 24 × 28 mm mass in the upper mediastinum on chest computed tomography (CT) without any invasion into adjacent structures (fig. 1). Octreotide scanning showed a selective uptake in the same area. Mediastinoscopic biopsy confirmed neuroendocrine carcinoma of the thymus. A left thoracotomy was performed, however invasion into the surrounding structures, including the left common carotid artery, the brachiocephalic vein, the vena cava superior and the right atrium, made the lesion irresectable during the operation. She refused further treatment and was transferred to our hospital at her request. Upon admission, octreotide treatment at a dose of 100 mg three times daily was started. After consulting with pulmonary surgeons, reoperation

Malign epithelioid tumor at the site of an arteriovenous fistula in a dialysis patient

the AV fistula site in a dialysis patient has not been previously reported. Previously published reports show that tumors arising from AV fistula sites are consistent with angiosarcomas and this entity has only been described in renal transplant patients (1, 2). It has been associated with antecedent trauma, including scar tissue and immunosuppressive therapy. In our patient, the diagnosis of angiosarcoma was excluded due to the lack of CD31 expression. Although the biopsy material was not sufficient for distinguishing between epithelioid sarcoma or carcinoma, epithelioid sarcoma was presumed as the final diagnosis since there was no evidence of primary focus of carcinoma in the PeT/ CT images. In conclusion, clinicians should be aware that a mass around the AV fistula can be malignant and an urgent biopsy should be scheduled. Furthermore, a PeT/CT scan can be helpful in distinguishing among the complications arising from the AV fistula site.

Unusual presentation of peritonitis with persistent clear aspirate: a case report

IntroductionPeritonitis is the most frequent complication of peritoneal dialysis. Diagnosis of peritonitis includes symptoms and signs of peritonitis with a cloudy aspirate of more than 100 WBC/ml, as well as positive cultures. Although sterile peritonitis has been reported in the literature, to the best of our knowledge this is the first report of an unusual presentation of peritonitis without any white blood cells in the peritoneal aspirate despite multiple positive peritoneal cultures.Case presentationAn 82-year-old Caucasian man who had been on continuous cycling peritoneal dialysis for 12 years was admitted to our hospital with general malaise, loss of appetite, weight loss and somnolence. He did not describe abdominal pain or fever. Even though his peritoneal fluid was consistently negative for leukocytes and clear, he had peritonitis with different organisms consecutively.ConclusionsOur case report shows that any patient on peritoneal dialysis presenting with evidence of infection (fever, peripheral leukocytosis) without an obvious cause should have aspirate cultures done even if the aspirate is clear and abdominal pain is absent. Our case report may change the initial work-up and management of these patients. We believe this report is of interest to general medicine and emergency room physicians as well as nephrologists.