Handan Ozdemir

Ultrastructural Examination of Glomerular and Tubular Changes in Renal Allografts with Cyclosporine Toxicity

The introduction of cyclosporine (CsA) has improved the clinical results of renal transplantation significantly; however, these improvements were closely associated with an increased incidence of renal dysfunction. The present study sought to examine the ultrastructural changes in renal allografts with CsA nephrotoxicity. Nine patients who underwent renal transplantation at the Baskent University Faculty of Medicine between 2001 and 2002 were examined; 26 biopsies of these nine patients who had received their first renal allograft were included in this study. All patients with CsA toxicity showed some form of glomerular endothelial cell injury. The swelling of mitochondria was present in three of nine renal allografts with CsA toxicity, and podocyte changes were found significantly more frequently among patients with CsA toxicity. In addition, focal segmental thickening and the duplication of glomerular basement membrane were observed statistically more frequently. In conclusion, these findings could help differentiate CsA toxicity from other conditions and develop better treatment strategies.

BRONCHIECTASIS-RELATED AMYLOIDOSIS AS A CAUSE OF CHRONIC RENAL FAILURE

Bronchiectasis is defined as acquired and permanent abnormal dilation and destruction of the bronchial walls. Secondary amyloidosis is a disorder characterized by the deposition of amyloid A (AA) in multiple organs and tissues in the body. End-stage renal disease (ESRD) secondary to bronchiectasis-related amyloidosis has only been mentioned in case reports. Little is known about the complications of bronchiectasis-related amyloidosis and the outcomes in patients who develop ESRD due to amyloid deposition in the kidneys. The aim of this study was to identify the clinical characteristics of this patient group, and to report the outcomes of these cases relative to bronchiechtasis type. We assessed the records of 40 patients with AA-type amyloid nephropathy and ESRD who were on hemodialysis (HD) at Baskent University Hospital between 1997 and 2000. The diagnosis of amyloidosis was based on histopathological findings in kidney, rectum, bone marrow, lymph node, thyroid, bladder, liver, and stomach biopsies. Bronchiectasis was diagnosed on the basis of history and findings on physical examination, chest X-ray, and thoracic high-resolution computerized tomography (HRCT). The patients’ records were retrospectively evaluated for cause of secondary amyloidosis, and cases with causes other than bronchiectasis were excluded. Secondary amyloidosis due to bronchiectasis and recurrent pulmonary infection was identified in 40% (16 patients) of the 40 patients. For each of these 16 cases, we recorded patient age, duration of bronchiectasis, duration of HD, amount of lung involvement, and biopsy site(s). The means for age, duration of bronchiectasis, and duration of HD in the 16 patients were 50.6 ± 13.5 years, 22.18 ± 12.02 years (range, 6–42 years), and 30.81 ± 36.94 months (range, 4–144 months), respectively. The most common biopsy site was the rectum (n = 8). Thoracic HRCT revealed cystic bronchiectasis in 8 cases (50%). Four of these 8 patients (25% of the group of 16) died from sepsis within 3-year follow-up period. Two of the four patients who died had bilateral cystic bronchiectasis, and the other two had unilateral cystic bronchiectasis. In the other eight patients in the group, thoracic HRCT showed chronic fibrotic changes in the pulmonary parenchyma and minimal traction bronchiectasis. Four of these patients exhibited apical fibrosis and bronchiectasis (25% of the group of 16), and these radiological findings were considered sequelae of previous tuberculosis infections. In conclusion, chronic respiratory infections and associated bronchiectasis remain a serious problem in Turkey due to insufficient prevention, diagnosis, and treatment. It is important that patients with progressive cystic and diffuse bronchiectasis be followed carefully, as they may develop amyloidosis and ESRD in time. Also, the clinical course in patients with cystic bronchiectasis may be worse than that in other types of bronchiectasis due to complicating pulmonary infections.

Nutcracker syndrome manifesting with severe proteinuria: a challenging scenario in a single-kidney patient

Nutcracker syndrome (NS) refers to compression of the left renal vein between the aorta and the superior mesenteric artery which results in left renal venous hypertension. The typical clinical presenting feature is hematuria. In this report we describe the case of patient with a single kidney who developed severe proteinuria due to NS. She was successfully treated with left renal vein transposition. This case clearly shows the relation between NS and severe proteinuria based on normal biopsy findings and the complete disappearance of proteinuria following surgery.

Comparison of Basiliximab and Daclizumab With Triple Immunosuppression in Renal Transplantation

PURPOSE Graft rejection is a serious problem despite immunosuppressive agents. Immunosuppression has been achieved with monoclonal antibodies (mAb) that bind specifically to the α subunit of the interleukin (IL)-2 receptor present on activated T lymphocytes. We explored the effects of two of the mAbs-daclizumab and basiliximab-on graft function. MATERIALS AND METHODS Our 1543 renal transplant recipients received baseline therapy with cyclosporine or tacrolimus plus corticosteroids and mycophenolate mofetil. In addition standard dosages intravenously of daclizumab (n=156) or basiliximab (n=45) in were administered intravenously to 201 renal transplant patients who included 122 men and 79 women of overall mean age of 30±13.7 years. RESULTS Patient and donor characteristics including age, sex, causes of renal failure, presence of comorbidities, panel-reactive antibodies, and numbers of human leukocyte antigen-mismatched were similar between the groups. During a mean follow-up of 27±20 months, biopsy-proven acute rejection was observed in three patients in the basiliximab group and 23 in the daclizumab group. Cytomegalovirus infection occurred in 13 patients. There was no case of posttransplant lymphoproliferative disorder. Three polyoma BK nephropathies were detected in the daclizumab group. No hypersensitivity reaction occurred in either group. One-year patient survival was 100% in the basiliximab group and 99% in the daclizumab group, with graft survivals of 95% versus 94%, respectively. The mean creatinine levels at discharge were 2 mg/dL versus 2.3 mg/dL and at 12 months, 1.3 mg/dL versus 1.2 mg/dL, respectively. CONCLUSIONS Acute rejection episodes remain a significant risk factor for the development of graft dysfunction and poor long-term graft survival. IL-2R antagonists were effective antibody therapies. There was no apparent difference between basiliximab and daclizumab treatment.

Neurofibroma of the bladder wall in von Recklinghausen's disease

Abstract Neurofibromatosis, or von Recklinghausens disease, is an autosomal dominant disease with multiple neurofibroma and café‐au‐lait spots. However, neurofibroma in the bladder wall is a rare condition in von Recklinghausens disease. A 31‐year‐old man with neurogenic voiding dysfunction due to sacral meningocele and acute urinary retention with neurofibroma of the bladder wall is presented with detailed radiologic evaluation. Patients with von Recklinghausens disease should be carefully evaluated if urological symptoms exist.

Mixed connective tissue disease: a case with scleroderma renal crisis following abortion

The term mixed connective tissue disease (MCTD) has been applied to a particular subset of patients with overlapping clinical features of systemic sclerosis, systemic lupus erythematosus, and polymyositis. Immune response to U1-ribonucleoprotein is the defining serological feature of MCTD. There are different organ and system involvements in MCTD including the heart, lung, kidney, muscle, joints, gastrointestinal, and hematologic involvements. Reports describing pregnancies in patients with MCTD are rare, and the results have been contradictory: a high risk of fetal loss and of disease exacerbation or no influence on fetus or mother. In MCTD, simultaneous pulmonary and renal involvement is very rare. In this paper, we report a case of MCTD with pulmonary involvement that developed scleroderma renal crisis after an abortion.

Medullary thyroid carcinoma in a patient with Hashimoto's thyroiditis diagnosed by calcitonin washout from a thyroid nodule

Serum calcitonin is a tumor marker used in the diagnosis and follow‐up of medullary thyroid carcinoma. Calcitonin washout evaluation is a new method used for suspicious thyroid nodules and lymph nodes. Limited clinical data are present about the efficacy of this method. A 61‐year‐old female patient with known Hashimotos thyroditis and an 8‐mm hypoechoic nodule was presented with one previously benign fine‐needle aspiration cytology (FNAC). On referral to our department, she had a moderately high‐serum calcitonin level, and we repeated the FNAC that was reported as nondiagnostic. We performed FNAC for the third time together with calcitonin washout evaluation from the thyroid nodule. The FNAC was again nondiagnostic, but the calcitonin washout level from the thyroid nodule was 152.569 pg/mL. Total thyroidectomy was performed, and the diagnosis was confirmed as medullary thyroid carcinoma. Calcitonin washout evaluation may be a useful method in the differential diagnosis of patients with thyroid nodules having moderately high‐serum calcitonin levels. Diagn. Cytopathol. 2013.

The Impact of Transient Elevation of Intra-Abdominal Pressure on Liver Regeneration in the Rat

Transient increased intra-abdominal pressure (IIAP) due to carbon dioxide insufflation is suspected to cause a form of ischemia–reperfusion injury. Considering this, a study was designed to assess the effect of transient IIAP on liver regeneration in a rat model. Six groups of animals (each n = 6) were studied. While experiments in Group 1 (IIAP + PHR) were subjected to IIAP, following partial hepatic resection (PHR), those in Group 2 (IIAP) experiments were subjected to IIAP. Animals in Group 3 (IR + PHR) were subjected to liver ischemia–reperfusion (IR) following PHR, and those in Group 4 (IR) underwent only IR. Group 5 (PHR) and Group 6 (healthy) served as controls. Blood was taken for assessment of tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 with enzyme-linked immunosorbent assay (ELISA) at day 5 postoperatively. Each rat was then given a lethal injection of pentobarbital. Gravimetric analysis and immunohistochemistry staining for proliferating cell nuclear antigen (PCNA) were used for assessments of liver regeneration. Apoptosis was assessed by immunohistochemical TUNEL index, expressed as the number of positive cells/per total number of cells at the same time. Although mean liver regeneration rates of Group 1 and Group 3 were the same, that of Group 5 was the highest (p =. 04). Serum TNF-alpha levels of Group 1 versus Group 3 were 340 pg/ml versus 352 pg/ml. Serum IL-6 levels of Group 1 versus Group 3 were 124 pg/ml versus 135 pg/ml. Serum TNF-alpha and IL-6 levels of Group 1 and Group 3 were the same at the first day of surgical procedure (p >.05). Mean serum TNF-alpha levels of Group 5 (387 pg/ml) were significantly higher than those of both Group 1 and Group 3 at 24 h of operation. Serum IL-6 levels of Group 5 (174 pg/ml) at the same time was higher than those of Group 1 and Group 3 at the same time (p =. 01). Proliferating cell nuclear antigen indices of Group 1, Group 2, Group 3, Group 4, and Group 6 were the same; however, the mean PCNA-labeling index of Group 5 was higher than those of the others. There were no significant differences between the groups (p >.05). Liver regeneration is suppressed by transient IIAP. However, the effect of IIAP on liver apoptosis needs to be clarified.

An unusual presentation of an intraosseous epidermoid cyst of the anterior maxilla: a case report

IntroductionIntraosseous epidermoid inclusion cysts are rare benign epithelial inclusion cysts in the bone. They are usually found in the cranium and hand phalanges. They are slow growing lesions, and it is difficult to differentiate them from other inflammatory and cystic lesions. Only a few cases of epidermoid inclusion cyst in the jaw have been reported in the literature. This is the fourth case reported as intraosseous epidermoid cyst of the maxilla in the English literature.Case presentationAn asymptomatic 59-year-old Caucasian man was referred to our Oral and Maxillofacial Surgery clinic for a unilocular radiolucent area at his anterior maxilla shown on an orthopantomograph. He was scheduled for surgery and underwent cyst extraction surgery. A pathological examination revealed epidermoid cyst. The diagnostic dilemma in this case report in opposition to the presented intraosseous epidermoid cysts in the literature is that there was no trauma history to his upper jaw. Treatment for this cyst is conservative surgical excision and recurrence is uncommon.ConclusionsThis report presents an unusual case of an intraosseous epidermoid cyst that occurred with no trauma history to the upper jaw. Although only three cases of epidermoid inclusion cyst have been reported in the maxilla, epidermoid inclusion cyst should be considered in the differential diagnosis of radiolucent lesions of the jaws.

Ultrastructural Examination of Glomerular and Tubular Changes in Renal Allografts with Acute Rejection

Acute rejection is the most important threat to transplanted kidneys in the early phase after transplantation. With the advances in renal transplant surgery and immunosuppressive therapies, one-year graft survival rates reached 90%, but long-term graft survival did not improve to a similar degree. To prevent acute rejection more effectively and decrease the risk of chronic nephropathy development, the pathogenesis and effects of acute rejection on renal grafts should be further explored. This study aimed to examine the glomerular and tubular changes ultrastructurally. Tissues were obtained from 11 renal allografts with acute rejection, fixed in 1% Osmium tetra oxide embedded in Epon. The changes in glomerular basement membrane, podocyte, mesangium, and proximal tubules were examined by electron microscope. Tubular changes such as tubular basement membrane multi-lamellation, MN and PMN cells in peritubular capillaries, tubular vacuolization, mitochondrial changes (increase in number, alterations in cristae organization, or cristae effacement), and infiltration of tubular epithelium by MN cells (mainly lymphocytes) were found statistically significant (p < 0.01) when compared to those of control group. Some forms of endothelial injury (swelling of endothelial cells or fenestrae loss) were also statistically significant (p < 0.01). Acute rejection is an important predictor of long-term graft survival, and there may be no clinical clue to make diagnosis easier. Therefore ultrastructural changes may help solve this problem together with molecular studies.