Arzu Velioglu

Full blown nephrotic syndrome due to unilateral obstruction of the uretero-pelvic junction

A 45-year-old womanwas referred to the nephrology outpatient clinic with bilateral ankle swelling. She was normotensive and physical examination was unremarkable except for bilateral pitting pedal oedema. Blood results showed: Serum creatinine 72.49mmol/L; albumin 29g/L, total cholesterol (TC) 7.36mmol/L, LDL-C 5mmol/L, tyrigliseride 0.95mmol/L, and 24h urine protein excretion 5.5 g/day. Urine sediment revealed 10–12 erythrocytes/hpf, complement levels were normal, hepatic serology and anti-HIV were negative. Abdominal CT demonstrated gross right-sided hydronephrosis due to obstruction of the uretero-pelvic junction.MAG3and 99m-Tc scans confirmed the obstruction in the right kidney due to UPJ narrowing with split renal functions of the right and left kidney being 45% and 55% respectively. Biopsy of the left kidney showed 25 glomeruli with four of thembeing globally sclerotic. Thereweremild thickening of the glomerular basement membranes. Direct immunofluorescence examination and congo-red staining were negative. As minimal change disease could not be ruled out, the patient was started on oral methyl prednisolone therapy. After six weeks of treatment, proteinuria increased to 7.6 g/day and steroid therapy was slowly tapered and stopped. She was scheduled for cystoscopy and selective ureteric urine sampling to determine if the urine protein excretion was selective for one kidney. The protein leakwas significantly higher in the right kidney compared to the left kidney (+++ versus +, respectively). 2months after the placement of a double J stent, proteinuria significantly decreased. A month later proteinuria increased to 4.3 g/day because of the displaced double J stent. A new stent was inserted, followed by a progressive decline in proteinuria to 354mg/day. The patient has undergone a successful laparoscopic pyeloplasty and is still free of proteinuria (Fig. 1).

Peritoneal Dialysis-Related Peritonitis With Acinetobacter Ursingii.

Dear Editor On-line hemodiafiltration (HDF) has been suggested to improve the global care of end-stage renal disease and has been regarded as “suitable for patients with a variety of pathologies who regularly undergo maintenance dialysis” (1). As such, HDF is expected to become an even more common clinical practice in the near future. However, an ethical issue arises. It is well known that in diabetes patients a dialysis fluid containing glucose should be used to avoid both intradialytic changes in plasma glucose level and hemodialysis-induced hyperglycemia (2). As a result, the glucose concentration in dialysis fluid usually amounts to 100 mg/dL (5.55 mmol/L) (2). In HDF the substitution fluid—the infusate—has the same composition of the dialysis fluid. It is worth noting that in post-dilution HDF the glucose burden would be delivered directly to the patients’ bloodstream as, in fact, is currently done worldwide also in diabetes patients. Furthermore, randomized clinical trials (RCT) aimed at studying themortality reduction byHDFhave provided inconsistent results (3). The researchers are therefore investigating the existence of a convection volume threshold associated with survival advantage, which has been recently reported (4). The mortality reduction is associated with a convective volume close to 20 L per dialysis session.Accordingly, efforts are currently made to reach this threshold in the clinical practice. Obviously, a larger convection volume leads to a larger amount of glucose delivery to patients. In the absence of diabetes this could improve caloric balance and also the survival rates, whereas in diabetes patients it could adversely affect the outcomes. In published RCTs, findings have been always adjusted for diabetes status, but significant differences in outcomes were never found (3); however, they were not focused on intradialytic changes in plasma glucose level or glycemic control. It would be reasonable to deeply investigate the suitability of HDF in diabetes patients because they represent a large percentage of the dialysis population with increasing prevalence. In our opinion, future trials will need unavoidably to take into account both the diabetes status and the infusate composition, in order to avoid the ethical issue of delivery of glucose to diabetes patients. In the meantime, some caution in recommending HDF seems to be needed.

Salvage of accidentally sectioned peritoneal dialysis catheters

Between 1994 and September 2015, a total of 564 peritoneal dialysis patients were followed in our PD unit. Nineteen of them were admitted to the hospital due to a cut of the catheter with leakage of dialysis fluid (mean age: 47.8 ± 16; range [21–82 years]; F/M: 13/6; range PD time [1–125 months]). Eighteen of the patients had accidentally cut the catheter with scissors while they were applying the dressing to the exit site. One patient had accidentally punctured the catheter by needle (Fig. 1). Seven of the catheters were totally cut while the others were partially intact. The same salvage method was used in all of these patients. All patients resumed PD in 24 h. Two patients presented with culture-negative peritonitis after the procedure. Both were treated successfully with intraperitoneal antibiotics. Infectious and mechanical complications are the major limitations for long-term use of PD catheters. Technical problems, including omental wrapping, kinking or external cuff extrusions, are frequently seen in daily practice. However, catheter damage due to mechanical breaks is a rare but significant complication of PD. Even though patients are vigorously instructed not to use scissors or other sharp objects such as needles during a dressing change, accidental catheter damage remains a risk for PD patients. Furthermore, repeated use of disinfectants, barium sulfate and mupirocin, for exit-site care might also be responsible for the catheter to become brittle and break [1]. Repair of the damaged peritoneal catheter is recommended instead of removal in order to salvage PD therapy [2]. Previously published reports on damaged peritoneal catheters, which are limited in number, have mainly focused on splicing the old catheter and extension tube using a special kit [3, 4]. It contains a threaded connector side, a beta-cap adapter side, a plastic mold with a locking ring and a silicone adhesive. After using this material, PD can be resumed after 24–48 h. Although all reported papers Editor,

Pseudoporphyria in a Peritoneal Dialysis Patient

1. Georgi A, Milly M, Lena S, Aparajitha S, Uma S, Soundarajan P. Tuberculous peritonitis in a cohort of continuous ambulatory peritoneal dialysis patients. Perit Dial Int 2001; 21(3):S202–4. 2. Gautam G, Milly M, Georgi A. Tuberculous peritonitis, poor ultrafiltration, and hypotension in a patient on continuous ambulatory peritoneal dialysis. Indian J Perit Dial 2010; 18:32–6. doi: 10.3747/pdi.2014.00086 Pseudoporphyria in a Peritoneal Dialysis Patient

Role of Tyrosine Kinase Inhibition with Imatinib in an Encapsulating Peritoneal Sclerosis Rat Model

Background: Encapsulating peritoneal sclerosis (EPS) is characterized by neovascularization, increased inflammation, and interstitial fibrosis of the peritoneum. We investigated the effects of imatinib on the peritoneal membrane in an experimental EPS model. Methods: We separated 24 non-uremic Wistar rats into four groups: the control group which was injected with 2 mL isotonic saline intraperitoneally (IP) daily for 3 weeks, the CG group which was injected with chlorhexidine gluconate (CG) IP daily for 3 weeks, the resting group which was injected with CG IP between weeks 0–3 followed by a peritoneal rest period between weeks 3–6, and the CG + Imatinib mesylate group (CG + IMA) which received CG through weeks 0–3 followed by 50 mg/kg imatinib mesylate through weeks 3–6. At the end of the study, we performed a 1-h-peritoneal equilibration test and examined the peritoneal function and transforming growth factor-β1 (TGF-β1) in dialysate. Morphologic changes were evaluated by microscopy and immunohistochemistry. Results: An increased ultrafiltration, dialysate/plasma-creatinine-ratio, end-to-initial-dialysate-glucose-ratio, decreased active mesothelial cell ratio and inflammation, and a slightly decreased TGF-β1 of dialysate were found in the CG + IMA group compared to CG alone. Furthermore, the CG + IMA group had a lower concentration of active mesothelial cells than did the resting group. Ultrafiltration was improved in CG + IMA group compared to resting group, however, significant decrease in peritoneal thickness and inflammation were not found compared to those in resting group. Furthermore, there was no significant difference in fibrosis or TGF-β1-positivity on immunohistochemistry between the groups. Conclusions: Tyrosine kinase inhibition with imatinib may lead to a decrease in mesothelial cell activity and an increase in ultrafiltration. However, peritoneal fibrosis was unchanged by imatinib in EPS model.