Metin Sarikaya

Complete Heart Block in a Patient with Wegener's Granulomatosis in Remission: A Case Report

Wegeners granulomatosis is a systemic inflammatory disorder of unknown cause that usually affects the upper and lower respiratory tracts as well as the kidney. Cardiac involvement is rare, although electrocardiographic abnormalities, coronary artery vasculitis, cardiac arrhyth mias, and myocardial infarction have been reported in the literature. A 27-year-old female patient with Wegeners granulomatosis in remission is described in whom complete heart block developed in the 13th month of treatment with cyclophosphamide. A temporary pacing was applied and pulse methylprednisolone and cyclophosphamide were commenced. On the ninth day of treatment, normal sinus rhythm was achieved. In conclusion, cardiac rhythm abnormalities should always be kept in mind both in the diagnosis and follow-up of Wegeners granulomatosis.

Bismuth Subcitrate Nephrotoxicity

Bismuth subcitrate is a known nephrotoxic agent that may lead to acute oliguric renal failure when ingested in toxic doses. We report a 17-year-old girl who was admitted to the emergency room with complaints of nausea, vomiting, and anuria. She had taken 25 tablets containing 300 mg bismuth subcitrate (total 7.5 g). The patient was managed with hemodialysis started a week after ingestion. Bismuth subcitrate nephrotoxicity should be considered in the differential diagnosis of acute renal failure.

Soluble Klotho and fibroblast growth factor 23 levels in diabetic nephropathy with different stages of albuminuria

The relationship between soluble Klotho (s-Klotho) levels, fibroblast growth factor 23 (FGF23) levels, and albuminuria in patients with diabetic chronic kidney disease (CKD) remains unclear. A total of 109 patients with type 2 diabetes (mean age 61.63±9.77 years), at the outpatient clinic of the Antalya Research and Training Hospital Nephrology Unit between January and June 2014, as well as 32 healthy controls (mean age 49.53±7.32 years) were enrolled for this cross-sectional study. Patients were classified into three groups according to their urinary albumin creatinine ratio (UACR), normoalbuminuria (UACR<30 mg/g), microalbuminuria (UACR 30–300 mg/g), and macroalbuminuria (UACR>300 mg/g). The blood was analyzed for FGF23, s-Klotho, parathyroid hormone (PTH), P, Ca, creatinine, and 25-hydroxyvitamin D3 (25hD) levels. Creatinine, s-Klotho, FGF23, and PTH levels were significantly higher and 25hD levels were significantly lower in the patient group than in the healthy controls (p<0.001). Between the groups according to UACR, 1-way analysis of variance revealed statistically significant differences for creatinine (p<0.001), 25hD (p<0.001), PTH (p=0.002), Ca (p=0.002), and albumin levels (p<0.001). A statistically significant positive correlation was found between s-Klotho and FGF23 (r=0.768; p=0.001), and between FGF23 levels and UACR (r=0.768; p=0.001). In conclusion, the results of the present study suggest that s-Klotho levels are significantly elevated in patients with diabetes and s-Klotho levels decreased with increasing albumin excretion in our patients despite a reduction in estimated glomerular filtration rate.

Serum prolactin and macroprolactin levels in diabetic nephropathy

OBJECTIVE Three molecular forms of prolactin with molecular weights of 23 (monomeric), 50 - 60 and > 100 kDA (macroprolactin) have been defined. Prolactin levels have been shown to be reduced in especially poorly controlled diabetes mellitus and the prevalence of macroprolactinemia in diabetic patients has been higher than the non-diabetic population. PATIENTS AND METHODS A total 234 Type 2 diabetic patients with different nephropathy stage was included in the study. Serum prolactin levels were analyzed by the Electrochemiluminescense method. Following polyethylene glycol (PEG) precipitation, recovery less than or equal to 40% was taken as evidence that a significant level of macroprolactin was present in the serum. RESULTS Hyperprolactinemia and macroprolactinemia were detected in 40 (17%) and 13 (5.5%) patients, respectively. Macroprolactinemia was detected 13 of 40 patients with hyperprolactinemia (32.5%). Increased prolactin and macroprolactin levels in patients with moderate and severe renal failure (Stage 3, 4, and 5) according to the U.S. NKF-DOQI classification (p < 0.001). Prolactin and macroprolactin levels were not increased in patients with normoalbuminuria, microalbuminuria and macroalbuminuria (p > 0.05). Serum creatinine levels correleted positively with both prolactin (r = 0.51, p < 0.001) and macroprolactin levels (r = 0.43, p < 0.001). On the other hand, glomerular filtration rate correlated negatively with both prolactin (r = -0.54, p < 0.001) and macroprolactin levels (r = -0.44, p < 0.001). Albuminuria significantly related with neither prolactin nor macroprolactin levels (p > 0.05). CONCLUSION In the present study, we found that not only serum prolactin but also serum macroprolactin levels increased especially in moderate to severe renal failure which was due to decreased glomerular filtration and renal parenchymal function resulting in an increased amount of monomeric prolactin and macroprolactin in the circulation in patients with Type 2 diabetes mellitus.

High serum soluble CD200 levels in patients with autosomal dominant polycystic kidney disease

This study aims to determine fibroblast growth factor-23 and soluble α-Klotho levels in patients with autosomal dominant polycystic kidney disease. A total of 76 patients with autosomal dominant polycystic kidney disease and 32 healthy volunteers were included in the study. Serum fibroblast growth factor-23 and soluble α-Klotho levels were measured with ELISA kits. Parathyroid hormone, phosphate, calcium, creatinine, 25-hydroxyvitamin D3 levels, urinary protein to creatinine ratio and estimated glomerular filtration rate were also measured or calculated. Patients with autosomal dominant polycystic kidney disease had significantly higher serum parathyroid hormone (p<0.001), fibroblast growth factor-23 (p<0.001), soluble α-Klotho levels (p=0.001) and lower serum 25-hydroxyvitamin D3 levels (p<0.001) as compared with healthy volunteers. Serum fibroblast growth factor-23, soluble α-Klotho and 25-hydroxyvitamin D3 levels were similar in all five chronic kidney disease stages of autosomal dominant polycystic kidney disease (p>0.05). Fibroblast growth factor-23 (r=−0.251, p=0.034) and soluble α-Klotho levels (r=−0.251, p=0.034) were found to be negatively correlated with estimated glomerular filtration rate. This study shows increased fibroblast growth factor-23 levels in patients with autosomal dominant polycystic kidney disease which is in harmony with the general trend in patients with chronic kidney disease of other aetiologies, but, unlike them, also a significant increase in serum soluble α-Klotho levels in patients with autosomal dominant polycystic kidney disease suggesting an aberrant production or a decreased clearance of α-Klotho molecule. Considering the unique increases in erythropoietin levels due to erythropoietin production in renal cysts, we assume, patients with autosomal dominant polycystic kidney disease may potentially have different soluble α-Klotho production/clearance characteristics than the patients with other parenchymal renal diseases.

Effects of ivabradine on 6-minute walk test and quality of life in patients with previously implanted CRT-D.

Background We aimed to evaluate clinical effects of additional heart rate control by ivabradine on life quality score and 6-minute walking test in patients with previously implanted biventricular cardiac resynchronization therapy defibrillator (CRT-D) with ischemic heart failure under regular treatment. Methods Fifteen men and 14 women with a median age of 63 years (range, 48–79 years) were studied. Twenty-one patients were in New York Heart Association class II (8 patients were in class III), CRT-D implanted previously, and with resting heart rates greater than 70 beats per minute with sinus rhythm despite conventional medication. Patients were given 2.5- to 7.5-mg ivabradine orally twice a day, and drug dosage was titrated to decrease the patients’ average heart rate to 70 beats per minute. Before and 3 months after ivabradine treatment, all patients underwent extensive clinical, echocardiographic, and laboratory evaluation. Results Ivabradine treatment produced dose-dependent reductions in heart rate at rest and at peak exercise (91.9 ± 6.3 to 71.7 ± 4.8 and 114.4 ± 7.6 to 96.8 ± 4.8; P = 0.001 and P = 0.001, respectively). There were also significant improvements in life quality score (52.4 ± 9.5 to 37.9±7.8; P = 0.001) and 6-minute walking distance (278.7 ± 85.8 to 373.3 ± 94.0; P = 0.001) of patients. All patients with New York Heart Association class III became class II after 3 months of ivabradine treatment. Conclusion Heart rate reduction in a short-term period by ivabradine produced significant improvements in exercise capacity and life quality in patients with CRT-D and conventional therapy.

Eculizumab experience in an adult patient with atypical hemolytic uremic syndrome

Atypical hemolytic-uremic syndrome is a disease characterized by nonimmune hemolytic anemia, thrombocytopenia, and renal failure. In this study, we present a case of a patient with atypical hemolytic-uremic syndrome treated successfully with eculizumab. A 20-year-old female was admitted with clinical signs of atypical hemolytic syndrome. The laboratory findings were as follows: hemoglobin 9.2 g/dL, platelet count 18 × 103/μL, creatinine 4.69 mg/dL, schistocytes were in peripheral blood smear, lactate dehydrogenase 2080 U/L, and emergency plasmapheresis procedure with fresh frozen plasma were initiated. The patient was anuric within 12 h of her admittance. ADAMTS13 activity was normal. Her mothers cousin developed acute rejection immediately after receiving a renal transplant and died two months later. As she did not respond to the treatment and considering her family history, eculizumab was initiated which resulted in platelet counts starting to rise on day 5, and the patient no longer needed dialysis after 22 days.

Comparison of Intraperitoneal Amino Acid and Oral Amino Acid Supplements in Peritoneal Dialysis Patients

Purpose: Among patients end-stage renal disease who receive peritoneal dialysis, malnutrition is an strong predictor of increased morbidity and mortality rates. In cases with malnutrition, hypoalbuminemia occurs mainly due to the leakage of albumin through peritoneal membrane. Therefore, the current study aimed to investigate and compare the effects of intraperitoneal or oral amino acid supplements in preventing hypoalbuminemia. 1.2 1.2 Method: Our study included 36 patients on continuous ambulatory peritoneal dialysis (CAPD) in our center. In one group, one of the exchanges was replaced with a daily dose of 2000ml of peritoneal dialysis solution with 1.1% amino acids (AAs). The other group was given oral supplementation of keto/amino acids. The group receiving intraperitoneal (IP) AAs was composed of 16 patients, while oral keto/amino acid group included 20 patients. The baseline levels of serum albumin, prealbumin, transferrin, CRP, CO2, cholesterol panels and weights (recorded during PET) were compared with the values measured after 6 months of treatment. Results: The baseline albumin levels in the IP AA group were lower than the Oral AA group (p=0.008). When we categorized the patients based on their peritoneal membrane permeability, we found no difference between the peritoneal membrane permeability values of the groups and their laboratory variables (p>0.05). At the end of month 6, the BUN levels significantly elevated in the group receiving IP AA solution, whereas their levels of phosphorus and HDL declined (p <0.05). The group receiving oral AAs supplement had lower levels of albumin and HbA1C at the end of month 6 (p <0.05). Conclusion: Although treatment with AAs supplements administered either intraperitoneally or orally, can be considered a good nutritional support, it should be borne in mind that the important point is to increase the amount of dietary protein intake in individual patients.