Ilhan Kurultak

Urinary Angiotensinogen Level Is Correlated with Proteinuria in Renal Transplant Recipients

OBJECTIVE Along with immunologic mechanisms, intrarenal renin-angiotensin system (RAS) activation has been suggested to play a role in the development and progression of chronic allograft injury. In various glomerular diseases, urinary angiotensinogen (AGT) level is a good indicator for the activation of intrarenal RAS. In this study, we aimed to investigate the parameters associated with urinary AGT level in patients with kidney transplantation. METHODS Seventy renal transplant patients with stable graft function (≥ 6 months after transplantation, serum creatinine level <2 mg/dL) and 21 healthy volunteers were included in the study. Patients were taking standard triple immunosuppressive treatment. Demographic characteristics of patients and healthy volunteers, drug use, and 24-hour ambulatory blood pressure measurements were recorded. Morning second urine and fasting blood samples were taken from all participants. Serum biochemical markers and urine Na, K, uric acid, creatinine, and protein levels were measured. Urinary AGT levels were determined by enzyme-linked immunosorbent assay. RESULTS Mean systolic and diastolic blood pressures in patients with renal transplantation were higher than in healthy volunteers. Both urinary AGT-urinary creatinine ratio (UAGT/UCr) and urinary protein-urinary creatinine ratio (UPro/UCr) were higher in kidney transplant patients than in healthy volunteers (P < .01; P < .0001; respectively). In patients with renal transplantation, UAGT/UCr was positively correlated with UPro/UCr and negatively correlated with estimated glomerular filtration rate (eGFR) (r = 0.738; P = .01; and r = -0.397; P = .01; respectively). There was no correlation between UAGT/UCr and other study parameters, including bood pressure levels. CONCLUSIONS Our findings indicate that high urinary excretion of AGT is associated with proteinuria and lower eGFR in kidney transplant recipients without overt chronic allograft injury. These preliminary results encourage us to design a long-term longitudinal analysis using urinary AGT along with multiple markers to obtain early diagnosis and to predict the prognosis of chronic allograft dysfunction.

Peritonitis due to Pseudomonas stutzeri, an organism that may be difficult to culture.

prevented by keeping the bristles inside the sheath while the brush moves near the tip of the PD catheter. Moreover, the brush has an injection port that can be used to flush the catheter with heparinized saline during brushing and while advancing the brush toward the catheter tip without the need to remove the brush from the PD catheter between each trial of flushing. To confirm the patency of the catheter, a contrast can be injected through the same injection port while the brush is still inside the catheter.

Urinary angiotensinogen, related factors and clinical implications in normotensive autosomal dominant polycystic kidney disease patients

Abstract Background: Although several lines of evidence suggest that renin angiotensin system (RAS) proteins are synthesized by cyst epithelium and dilated tubules, role of intrarenal RAS in the progression of otozomal dominant polycystic kidney disease (ADPKD) is not well known. We aimed to study the levels and clinical correlations of urinary angiotensinogen (UAGT) in normotensive ADPKD patients compared with age- and sex-matched healthy subjects. Methods: The study included 20 normotensive ADPKD patients (F/M: 11/9) and 20 age and sex matched healthy controls (F/M: 9/11). Diagnosis of ADPKD was made based on Ravine criteria. Twenty-four hours ambulatory blood pressure monitoring (ABPM) was performed. Serum concentrations of creatinine, Na, K, uric acid, and urinary concentrations of Na, K, uric acid, creatinine, protein and albumin were measured. UAGT were measured via commercially available ELISA kit. Results: ADPKD patients had higher urinary albumin:creatinine ratio (UAIb/UCrea) than healthy controls (p < 0.01). UAGT/UCrea levels significantly positively correlated with urinary protein: creatinine ratio (UPro/UCrea) (r = 0.785, p = 0.01), and UAIb/UCrea (r = 0.681, p = 0.01) in normotensive ADPKD patients. Conclusion: This pilot study demonstrates that UAGT levels tend to be elevated and are correlated with proteinuria and albuminuria in normotensive ADPKD patients during relatively early stages of the disease.

An unusual cause of focal segmental glomerulosclerosis: psoriasis vulgaris

Psoriasis, being limited to the skin, is generally a chronic inflammatory disorder. Several glomerular diseases have been distinguished due to renal histological findings of psoriatic patients to date. The underlying pathogenetic mechanisms of these associations remain unclear because of the limited number of cases. We report a second case of focal segmental glomerulosclerosis in a psoriatic patient.

An Unusual Presentation of Vaginal Leakage in a Peritoneal Dialysis Patient

A 39-year-old woman with IgA nephropathy was commenced on nocturnal intermittent PD in 2007 after a failed renal transplant and recurrent vascular access problems. To improve dialysis adequacy, daytime exchanges were needed 1 year later following an episode of uremic pericarditis. The patient presented in 2010 with her first episode of peritonitis. Analysis of the peritoneal effluent demonstrated a white cell count of 730/mm3, with 59% neutrophils. The patient was treated initially with intraperitoneal cefazolin and ceftazidime. Gram stain revealed the presence of gram-negative bacilli: cefazolin was discontinued. Resolution of peritoneal fluid cloudiness was noted within 3 days of initiation of antibiotics but the identity of the gramnegative organism remained obscure over the ensuing 3 weeks. The organism was subsequently identified as a Capnocytophaga species. Further questioning revealed the patient had two cats as household pets. There was no history of animal bites but the patient admitted to having been regularly licked on the face by her two favorite domestic cats. The patient was fond of kissing her cats and seldom wore a mask during the PD exchange procedure. She also reported fair adherence to proper hand washing after contact with her cats. The cats were allowed in her room except while she was performing PD exchanges. She could not exclude contamination by cat fur and dander because she switched on an electric fan heater at the time of the exchange procedure on the evening prior to developing peritonitis. In light of the patient’s lifestyle, her exposure to cats is considered the primary source of her Capnocytophaga infection. The prolonged period required to identifying Capnocytophaga species is related to the slow growth of these thin gram-negative rods that are facultative anaerobes. The name of the organism derives from its property as the “eater of carbon dioxide” because Capnocytophaga species grow best in a carbon dioxide-enriched atmosphere. Both C. canimorsus and C. cynodegmi are part of the normal flora of dogs and cats. Peritonitis infection with Capnocytophaga species has been reported in only 3 PD patients (1–3). Of the three cases reported in the literature, two were highly suspicious of cat-associated peritonitis. One patient on nocturnal automated PD reported sleeping with his domestic cat, which had punctured the PD tubing (1), whereas the other had frequent visits by the neighbor’s cat, which he occasionally fed (2). In addition to the relatively well-known transmission of Pasteurella multocida from cats (4), we believe that Capnocytophaga infection should also be considered in PD patients in close contact with cats. DISCLOSURES

Focal segmental glomerulosclerosis in association with Gitelman syndrome

Gitelman syndrome (GS) is an autosomal recessive disorder characterized by hypokalemia, metabolic alkalosis, hypomagnesemia and hypocalciuria. Glomerulonephritis associated with GS is rarely documented in the literature. We present an adult patient with GS whose renal biopsy revealed focal segmental glomerulosclerosis.

Serum creatinine elevation caused by bupropion

Bupropion is a widely used drug in the world for smoking cessation, and it has a lot of side effects, which had been determined in literature before [1–3]. However, there were no data about serum creatinine elevation associated with bupropion. Herein, we report a case with serum creatinine elevation caused by bupropion as first of its kind. A 34-year-old male patient had been admitted to a clinic for smoking cessation, and bupropion therapy had been begun (150 mg/day for first 3 days and 150 mg twice daily after 3 days), with information about drug action and side effects given to the patient after the first medical evaluation. Serum creatinine level was 1.09 mg/dl, serum urea level was 32.6 mg/dl and other routine laboratory results were in normal range on initial evaluation. There was no problem till the end of the first week, but serum creatinine was elevated on the second week (1.31 mg/dl). The patient was referred to our nephrology clinic after these results. Other laboratory findings, including serum lipids, albumin, total protein, creatine phosphokinase, C-reactive protein, anti-nuclear antibody, anti-neutrophil cytoplasmic antibody, C3, C4, immunoglobulin (Ig) G, IgA, IgM and urine analysis, were normal, and he had no complaint. The patient was evaluated about the existence of possible reasons that could cause this condition such as gastroenteritis, use of new drugs/herbals, severe exercise, polyuria and other urinary problems. Nothing was detected. His blood pressure was normal, and there was no positive finding on physical examination. Urinary/renal ultrasonography was performed in pre–post void phase and was normal. Serum creatinine level was estimated at 2.12 mg/dl at the end of the third week of initiation on follow-up. Repeated urine analysis with sediment revealed no sign of renal injury, and spot urine protein/creatinine ratio was 0.1. Finally, bupropion was stopped despite absence of data that it may lead this condition. The serum creatinine levels were decreased gradually to baseline level in 9 days after withdrawal of bupropion. Bupropion can cause several genitourinary symptoms, including polyuria (2–5 %), urinary urgency (≤ 2 %), urinary incontinence (< 1 %) and urinary retention (< 1 %), which had been described in literature before [2, 3]. However, only serum creatinine elevation without the aforementioned symptoms and signs of kidney injury was detected in our patient. We did not clearly understand what the mechanism is, although it seemed that the balance between serum creatinine excretion and reabsorbtion might be diminished by bupropion or its metabolites. Its metabolism is extensively hepatic via CYP2B6 to hydroxybupropion, and non-CYP-mediated metabolism to erythrohydrobupropion and threohydrobupropion. Approximately 87 % of these metabolites are excreted owing to urination [3–5]. It can be speculated that these substances may lead to augmentation of the reabsorbtion and/or to decrease in the excretion of creatinine via the affected tubular cells. Further investigations are needed to understand the real mechanism. Bupropion may lead to elevation of serum creatinine without other signs of renal injury. Clinicians should consider these data while they are managing the patients Dr. M. Ceri () Nefroloji Klinigi, S. B. Şanlıurfa Egitim ve Arastirma Hastanesi, Sanliurfa, Turkey e-mail: mevlutceri@gmail.com

Atypical Presentation of Rectus Sheath Hematoma in a Hemodialysis Patient: Recurrent Abdominal Pain After Dialysis Sessions

Rectus sheath hematoma is a rare but well-known cause of acute abdominal pain. Rectus sheath hematoma is largely misdiagnosed as seen rarely. As a fatal disorder it must be suspected especially in patients receiving anticoagulant therapy for any reason. Heparin exposure during hemodialysis sessions and uremic bleeding diathesis causes chronic hemodialysis patients to be vulnerable to rectus sheath hematoma. Rectus sheath hematoma may be mild and self-limiting but also be so severe that it threatens life because of hypotensive shock and anemia-related risks. The patient may present without symptoms, with abdominal pain or with hemodynamic shock. We present a case report describing a patient with recurrent abdominal pain due to rectus sheath hematoma exacerbating after hemodialysis sessions.

Atypical Peritonitis Agents and Clinical Follow-Up in Peritoneal Dialysis Patients: Case Report

ritoneal fluid culture is obtained by proper culture technique, it is very likely to diagnose the culprit microbial agent. Gram positive organisms are the most common organisms whereas anaerobic, enteric organisms or multiple enteric organisms suggest secondary peritonitis. Sometimes uncommon organisms can be seen as peritonitis agents. We had 3 uncommon organisms that growth in the peritoneal cultures of peritonitis patients recently. Samples of dialysis fluid were aspirated by our specialist continuous ambulatory peritoneal dialysis (CAPD) nurse by an aseptic technique and sent to our microbiological laboratory in 30 minutes. Leu-

Missed Diagnosis of Aspergillus Niger Peritonitis in a Peritoneal Dialysis Patient with Standard Culture: Might Enriched Blood Culture Materials have an Advantage?

1 Trakya University Faculty of Medicine, Department of Nephrology, Edirne, Turkey 2 Pamukkale University Faculty of Medicine, Department of Nephrology, Denizli, Turkey 3 Haydarpaşa GATA Training Hospital, Department of Infectious Diseases, İstanbul, Turkey 4 Haydarpaşa GATA Training Hospital, Department of Nephrology, İstanbul, Turkey 5 Ankara Training and Research Hospital, Department of Infectious Diseases, Ankara, Turkey doi: 10.5262/tndt.2016.35