Mustafa Yaprak

A mucormycosis case presented with orbital apex syndrome and hemiplegia in a renal transplant patient.

Solid organ transplantation is a risk factor for mucormycosis. Mucormycosis is a necrotizing opportunistic fungal infection with high morbidity and mortality. We report a fatal mucormycosis case with rhino-orbital-cerebral involvement in a renal transplant patient, which presented with orbital apex syndrome and hemiplegia.

Correlation between serum YKL-40 (Chitinase-3-like protein 1) level and proteinuria in renal transplant recipients

BACKGROUND YKL-40 (chitinase-3-like protein 1) is a novel inflammation and endothelial dysfunction biomarker. Although YKL-40 is associated with albuminuria and predicts cardiovascular morbidity and mortality in a non-uremic population, its status is not known in renal transplant recipients. The aim of this study was to investigate plausible links between serum YKL-40 and proteinuria. MATERIAL AND METHODS A total of 110 renal transplant recipients were included in this study. The level of proteinuria was calculated from spot urine using the protein/creatinine ratio. The estimated glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formula. Serum YKL-40 was determined by ELISA (R&D Systems, USA). RESULTS The mean patient age was 40.5 ± 10 years. The mean YKL-40, GFR, and proteinuria levels were 66 ± 46 ng/ml, 49 ± 24 ml/min/1.73 m2, and 0.77 ± 1.15 g/day, respectively. Increases in the YKL-40 tertiles were correlated with increases in proteinuria and C-reactive protein and decreases in the GFR and serum albumin. An adjusted linear regression analysis demonstrated that the YKL-40 level (t=3.28, P=0.001), GFR (t=-3.00, P=0.003), and systolic blood pressure (t=2.51, P=0.01) were independently associated with proteinuria. CONCLUSIONS This is the first study to show that increased serum YKL-40 levels are independently associated with proteinuria in renal transplant recipients. YKL-40 may be responsible for the pathogenesis of cardiovascular injury in this patient population.

The Evidence of Occult Hypervolemia; Improvement of Cardiac Functions After Kidney Transplantation

The term cardiorenal syndrome (CRS) has been used to define interactions between acute or chronic dysfunction of the heart or kidney. When primary chronic kidney disease contribute to cardiac dysfunction, it is classified as type 4 CRS. Cardiac dilatation, valve regurgitations, and left ventricular dysfunction are observed in end-stage renal failure patients with uremic cardiomyopathy. Because of perioperative risks in these patients, they may not be considered a candidate for kidney transplantation. However, uremic cardiomyopathy can be corrected when volume control is achieved by appropriate dose and duration of ultrafiltration. By presenting two cases with occult hypervolemia in uremic cardiomyopathy whose cardiac functions improved early after kidney transplantation, attention is drawn to the importance of kidney transplantation on cardiac function in such patients primarily and the importance of strict volume control on cardiac function in dialysis patients waiting for kidney transplantation.

The Efficacy of Cinacalcet in the Treatment of Hyperparathyroidism in Turkish Hemodialysis Patient Population

OBJECTIVE: Cinacalcet reduces parathyroid hormone levels by increasing the sensitivity of the parathyroid gland to calcium. In this study, we firstly aimed to evaluate the efficacy of cinacalcet in Turkish hemodialysis patients. MATERIAL and METHODS: 4483 hemodialysis patients were screened and 469 patients who had used cinacalcet were included in the study. The patients were divided into 4 groups according to drug usage durations (Group 1: 3 months, Group 2: 6 months, Group 3: 9 months and Group 4: 12 months). The patients’ Parathormone, Ca, P and CaxP levels at the 3rd, 6th, 9th and 12th months were compared to the start of treatment and previous months. RESULTS: The levels of Parathormone, Ca, P and CaxP significantly decreased compared to their initial levels in all groups (from 1412 pg/ml to 1222 pg/mL for Parathormone, p<0,001) in the 3rd month. However, this reduction was not continued in the subsequent months (Parathormone: 1381 pg/ ml for the 12th month).

A Case of Severe Hypernatremia and Rhabdomyolysis Treated by Hemodialysis without Sequelae

Hypernatremia is defined as plasma sodium concentration above 145 mEq/L. While severe symptoms are generally seen in case of plasma sodium concentration of 158 mEq/L, higher levels above 180 mEq/L are associated with a high mortality rate. Herein, a case of severe hypernatremia with a sodium level of 189 mEq/L and rhabdomyolysis treated by hemodialysis was presented. A 24-year-old woman was brought to the emergency department because of impaired general condition and confusion. She had a history of tuberculosis meningitis 1.5 years ago and left hemiplegia. Urea, creatinine, sodium, LDH and CK were 95 mg/dL, 2.6 mg/dL, 189 mEq/L, 1630 U/L, and 12601 U/L, respectively. The patient was diagnosed with hypernatremia, rhabdomyolysis and acute renal failure. Hemodialysis was performed because of anuria, increased urea and creatinine levels and metabolic acidosis. On the 5th day, the sodium level was reduced to 140 mEq/L. She was discharged from hospital uneventfully after the acute renal failure improved. In conclusion, both hypernatremia itself and its quick correction carry a risk of high mortality and morbidity. Therefore, in patients with chronic hypernatremia and need of dialysis, dialysate sodium should be lower than 10 mEq/L of serum sodium level, and if this is impossible, the duration of dialysis and blood flow rate should be reduced.

Comparison of Turkish and US haemodialysis patient mortality rates: an observational cohort study.

Background There are significant differences between countries in the mortality rates of haemodialysis (HD) patients. The extent of these differences and possible contributing factors are worthy of investigation. Methods As of March 2009, all patients undergoing HD or haemodiafiltration for >3 months (n = 4041) in the Turkish clinics of the NephroCare network were enrolled. Data were prospectively collected for 2 years through the European Clinical Dialysis Database. Mean age ± standard deviation was 58.7 ± 14.7 years, 45.9% were female and 22.9% were diabetic. Comparison with US data was performed by applying an indirect standardization technique, using specific mortality rates for patients on HD by age, gender, race and primary diagnosis as provided by the 2012 US Renal Data System Annual Data Report as reference. Results The crude mortality rate in Turkey was 95.1 per 1000 patient-years. Compared with the US reference population, the annual mortality rate for Turkey was significantly lower, irrespective of gender, age and diabetes. After adjustments for age, gender and diabetes, the mortality risk in the Turkish cohort was 50% lower than US whites [95% confidence interval (CI) 0.46–0.54, P < 0.001], 44% lower than US African-Americans (95% CI 0.52–0.61, P < 0.001) and 20% lower than Asian-Americans (95% CI 0.74–0.86, P < 0.05). Conclusions The annual mortality rate of prevalent HD patients was found to be significantly lower in the studied Turkish cohort compared with that published by the US Renal Data System Annual Data Report. Differences in practice patterns may contribute to the divergence.

Metformin Associated Lactic Acidosis without Organ Dysfunction and Effective Treatment

Lactic acidosis generally occurs in those who have kidney, liver, lung or heart dysfunction. Herein, a 73-year-old woman diagnosed as type B lactic acidosis due to metformin without any organ dysfunction was presented.

Rare cause of weight loss in a kidney transplant recipient: iron overload

Abstract Various reasons such as malignancies and chronic infections may cause weight loss in kidney transplant patients. In this report, iron overload as a rare cause of weight loss in a kidney transplant patient is presented. Forty-seven-year-old male patient who transplanted from a deceased donor 5 years ago was hospitalized because of 20 kg of weight loss. In medical history, he had history of hemodialysis for 89 months and received 100–300 mg of intravenous iron therapy per week before transplantation and transfused eight units of blood. In physical examination, weight and height were 45 kg and 185 cm, respectively. Respiratory and cardiac auscultation was normal. Laboratory results revealed as follow: glucose 76 mg/dL, urea 60 mg/dL, creatinine 1.35 mg/dL, aspartate aminotransferase 74 U/L, alanine aminotransferase 77 U/L, C-reactive protein 2.59 mg/dL, albumin 3.3 g/dL, globulin 3.4 g/dL, white blood cells 3200/mm3, hemoglobin 13.1 g/dL and platelets 190,000/mm3. Chest and abdominal tomography didn’t reveal any pathology. Portal Doppler ultrasound showed signs of early cirrhosis. Viral and autoimmune hepatitis markers were negative. Ferritin was 5300 ng/mL and transferrin saturation was 82%. In liver biopsy, hemosiderosis was diagnosed and heterozygous H63D gene mutation was detected. Totally, 19 units of phlebotomy were performed. Liver function tests and serum ferritin decreased gradually. At outpatient follow-up in 6 months, he returned to former weight. In conclusion, there can be several causes of weight loss in kidney transplant patients. Iron overload can come across as a rare cause of weight loss. In these patients, ferritin levels should be checked and diagnosis should be clarified by liver biopsy and gene mutation analysis.