Saime Paydas

Comparison of Blood Gas and Acid-Base Measurements in Arterial and Venous Blood Samples in Patients with Uremic Acidosis and Diabetic Ketoacidosis in the Emergency Room

Background/aims: The aim of this study was to examine a plausible correlation between venous and arterial blood gas values in acidotic patients with chronic uremia or diabetic ketoacidosis (DKA). Methods: A total of 152 arterial and 152 venous blood samples from uremic patients (n = 100), DKA patients (n = 21) and healthy controls (n = 31) were analyzed for measurements of blood gas and acid-base status. Results: The means of arterial and venous pH, and arterial and venous HCO^–₃ values for the uremic patients were 7.17 ± 0.14, 7.13 ± 0.14, 10.13 ± 4.26 and 11.86 ± 4.23 mmol/l, respectively. The respective mean differences between arterial and venous pH values and arterial and venous HCO^–₃ values were 0.04 ± 0.02 and –1.72 ± 0.42 mmol/l, respectively, for these patients. The means of the laboratory findings of DKA patients were arterial pH, 7.15 ± 0.15; venous pH, 7.10 ± 0.15; arterial HCO^–₃, 8.57 ± 5.71 mmol/l and venous HCO^–₃, 10.46 ± 5.73 mmol/l. The respective mean differences between arterial and venous pH and arterial and venous HCO^–₃ for this group were calculated to be 0.05 ± 0.01 and –1.88 ± 0.41 mmol/l. In the healthy controls, the means of arterial and venous pH, and arterial and venous HCO^–₃ values were 7.39 ± 0.02, 7.34 ± 0.02, 24.91 ± 0.82 and 26.57 ± 0.83 mmol/l, respectively. For the healthy controls the mean differences between the respective values in arterial and venous pH, and arterial and venous HCO^–₃ were 0.05 ± 0.01 and –1.66 ± 0.58 mmol/l. Although in healthy controls the correlation between arterial and venous pH values (r²: 0.595) and arterial and venous HCO^–₃ values (r²: 0.552) were moderate, these correlations were significantly increased in both the acidotic patient group (r²: 0.979 and 0.990) and the DKA group (r²: 0.989 and 0.995) Conclusion: A venous blood sample can be used to evaluate the acid-base status in uremic and DKA patients.

Delay in the diagnosis of SLE: the importance of arthritis/arthralgia as the initial symptom.

Despite the current diagnostic and serologic testing for SLE, the interval between the onset of symptoms and the diagnosis is still long. In this study, we aimed to show the interval between the initial symptoms and the diagnosis of SLE and to investigate the presence of any relationship between the interval and the initial symptoms. One hundred and thirty-six patients were diagnosed with SLE using the 1982 ARA criteria. The mean age of the patients at diagnosis was 29.9 +/- 10.5 years. The mean interval between the onset of symptoms and the diagnosis of SLE was 21.82 +/- 30.32 months. The subjects were evaluated twice, at intervals of < or = 3 and < or = 12 months after the onset of symptoms. Although arthritis and/or arthralgia were the most common initial symptoms (60.3%), only 26.8% of the patients with these symptoms were diagnosed earlier than 3 months after the onset. If the first initial symptoms were butterfly rash or pericarditis, pleuritis, spontaneous abortion or cognitive dysfunction, they led to early diagnosis. In conclusion, since arthritis and/or arthralgia are the most common initial symptoms of the disease, every young woman with these symptoms should be carefully evaluated for SLE.

Uncommon side effect of MMF in renal transplant recipients

Mycophenolate mofetil (MMF) is a potent immunosuppressive agent used in renal transplantation. Gastrointestinal and hematological side effects are commonly observed, but hepatotoxicity has not been reported. In this study, we assessed MMF-related hepatotoxicity in renal transplant recipients. A total of 124 renal transplantation recipients (RTRs) were evaluated for elevated liver enzymes associated with MMF, and 79 patients were enrolled to the study. Patients used MMF 2 g/day. The patients who had progressive increase in liver enzymes after renal transplantation and their AST, ALT, GGT, ALP, bilirubin levels, hepatitis, cytomegalovirus (CMV), abdominal ultrasonography, duration of hepatotoxicity, and decreased dosage or withdrawal of MMF were recorded. Also, we evaluated their liver enzymes while the patients were on the waiting list. Of the 79 patients, 11 patients (13.9%) had a progressive increase in liver enzymes. The median (min–max) age of the patients with MMF-hepatotoxicity was 29 (19–54) and 72.7% of them were male. None of the patients had hepatitis B or C, CMV infection, or other possible causes for elevated liver enzymes and their abdominal ultrasonography were normal. High liver enzyme levels regressed after the withdrawal (n = 6) or reduce dosage (n = 5) of MMF. The median time of the increase in liver enzymes was 28 (4–70) days and after 50% reduction or withdrawal of MMF, returned to normal values in 16 (4–210) days. The median levels of ALT in waiting list (I), before (II), and after (III) reduction dosage or withdrawal of MMF were 22.0 (3–22), 222.0 (51–508), and 33.0 (21–64) U/L, respectively (p I–II = 0.004, p I–II = 0.013, and p II–III = 0.005). There were no differences for ALP, GGT, total bilirubin, and direct bilirubin levels. Also, the correlation between recovery time of ALT and persistence time of ALT elevation before adjustment of MMF was significant (r = 0.739, p = 0.009). Consequently, after renal transplantation, hepatotoxicity can occur due to a lot of reason including MMF usage. If hepatotoxicity related to MMF is not considered, especially in the early period of renal transplantation, resolution of hepatotoxicity can be required long term.

Rhabdomyolysis and Acute Renal Failure Due to Honeybee Stings As an Uncommon Cause

Saime Paydaş, MD, University of Çukurova, Faculty of Medicine, Department of Nephrology, TR-01330 Adana (Turkey) Dear Sir, Rhabdomyolysis has been implicated as the cause of acute renal failure in approximately 57% of cases [1]. Many cases of rhabdomyolysis associated with acute renal failure have been published, but those due to bee stings are quite rare [2,3]. We present a case of rhabdomyolysis and acute renal failure due to honeybee stings. A 68-year-old man admitted to hospital within 2 h after being stung by thousands of honeybees. He was healthy until this event. His physical examination disclosed an-gioedema, multiple areas marked by erythema and enduring skin lesions due to bee stings on his face, scalp and extremities. Blood pressure and pulse rates were 140/100 mm Hg and 120/min, respectively. ECG was normal except sinus tachycardia. Serum AST and ALT levels were 195 and 9 U/l, respectively. Other laboratory tests were normal. He was treated with intravenous prednisolone, antihistamines and mannitol. On the 3rd day hospital, in urine volume decreased from 1,000 to 300 cc/day. Blood urea nitrogen (BUN) and serum creatinine levels increased to 87 and 6.5 mg/dl, respectively. The color of his urine changed from yellow to dark brown. Serum CPK level was 46,320 U/l (normal: 25-196); AST 899 U/l (normal 5-40); ALT 285 U/l (normal: 5^40), and LDH 3,935 U/l (normal: 150-380). Urinary sodium was 115 mEq/1. Fractional sodium excretion was 3%. Renal failure index was 4%. Myoglobin in the urine was found to be negative by the dipstick test. On the 4th day, the patient was lethargic and BUN was 107 U/l, ALT 310 U/l, LDH 4,110 U/l, Ca 9.6 mg/dl, P 10.4 mg/dl and uric acid 8.5 mg/ dl. Serum fibrinogen was 450 mg/dl; FDP < IO, and prothrombin time 14 s. Kidneys were normal with no obstruction in abdominal ultrasonography. On the 5th day, laboratory data showed BUN 210 mg/dl; creatinine 10.7 mg/dl; K 7.8 mEq/1, Ca 8.3 mg/dl, P 10.8 mg/dl, LDH 4,025 U/l, CPK 50,260 U/l, AST 120 U/l, and ALT 354 U/l. Arterial blood gas analysis disclosed metabolic aci-dosis. The patient died because of sudden cardiac arrest due to hyperkalemia (the last laboratory findings were obtained after the patient died). Rhabdomyolysis and acute renal failure due to bee stings are rare among causes of rhabdomyolysis found in the literature. Although it is not know exactly, both acute intravascular hemolysis and acute myolysis can account for kidney involvement. Nevertheless; direct toxic effects of bee venom on nephrons inducing a tubuler necrosis can not be eliminated [4].

The expression of cytoskeletal proteins (α-SMA, vimentin, desmin) in kidney tissue: A comparison of fetal, normal kidneys, and glomerulonephritis

Background: The aim of the study is a comparison of the expression of cytoskeletal proteins, alpha smooth muscle actin (α-SMA), vimentin, and desmin in fetal, normal kidney and proliferative (diffuse proliferative and membranoproliferative glomerulonephritis) and nonproliferative (membranous glomerulonephritis) glomerulonephritis.Methods: We have studied the expression of cytoskeletal proteins (α-SMA, vimentin, desmin) in the paraffin embedded tissue sections from the kidneys of 10 normal kidney (adults and infants), 13 fetal kidney, 12 membranous glomerulonephritis (MGN), 8 membranoproliferative glomerulonephritis (MPGN), 8 diffuse proliferative glomerulonephritis (DPGN). Interstitial and glomerular positive stainings were evaluated.Results: Vimentin expression was similar in normal infant and adult kidneys with positive staining in glomeruli and negative staining in interstitium. In fetal kidneys, glomerular mesangial and epithelial cells and blastematous areas showed positive reactivity with vimentin. α-SMA staining was different among the groups. In fetal kidney, α-SMA expression was found in glomerular mesangial cells and blastematous areas. α-SMAstaining was positive in peritubular area and glomerular mesangial cells in infant kidney. In adult kidneys, glomerular staining with α-SMA disappeared but peritubular positivity continued. Interstitial staining with α-SMA was positive in fibrotic areas of proliferative (MPGN, DPGN) and non-proliferative (MGN) glomerulonephritis, but positive glomerular staining with α-SMA was found only proliferative glomerulonephritis. Desmin expression was negative in all groups.Conclusions: Desmin is not expressed in early stages of kidney growth, infant and adult kidneys, and proliferative and nonproliferative glomerulonephritis. Interstitial staining of vimentin in the diseased kidney tissues revealed increased fibrosis. α-SMA revealed important differences in different stages of nephrogenesis. Glomerular mesangial staining with α-SMA in developing (fetal and infant kidneys) and proliferative glomerulonephritis suggest that it may be a marker of proliferation. In addition, it shows myofibroblastic differentiation in interstitium in diseased kidneys.

Is there any relationship between serum levels of interleukin-10 and atherosclerosis in hemodialysis patients?

Objective. Cardiovascular complications due to atherosclerosis (AS) are the major cause of mortality in hemodialysis (HD) patients. Inflammation may play an important role in the development of AS. Several studies have demonstrated an association between AS and acute-phase proteins and cytokines in the general population and in HD patients. Interleukin-10 (IL-10) is an anti-inflammatory cytokine. The aim of this study was to compare serum levels of inflammatory and anti-inflammatory indicators in HD patients according to the presence or absence of AS. Material and methods. A total of 33 HD patients were studied. AS was defined as the presence of plaques as detected by Doppler ultrasonography. The patients were subgrouped according to the presence or absence of plaques. Serum levels of IL-1, -2, -6 and -10, C-reactive protein (CRP) and tumor necrosis factor-α (TNF-α) were measured. Risk factors for AS, such as age, gender, hypertension, hyperlipidemia and duration of HD, were also evaluated. Results. Patients with AS had significantly higher high sensitivity (hs)-CRP and lower IL-10 levels. Blood pressure was also elevated in patients with AS. There was an inverse correlation between CRP and IL-10 levels in patients with AS. Conclusion. Patients with AS undergoing HD had low serum levels of the anti-inflammatory cytokine IL-10 and high serum levels of hs-CRP. These results may suggest that limitation of the anti-inflammatory response in atherosclerotic uremic patients is a triggering or contributory factor for AS.

Pauci-immune necrotizing crescentic glomerulonephritis with crescentic and full moon extracapillary proliferation: clinico-pathologic correlation and follow-up study.

The prognostic value of the type and extent of extracapillary proliferation (ECP) in pauci-immune necrotizing crescentic glomerulonephitis (PIGN) was evaluated in this study. In 141 PIGN cases, all glomeruli with ECP were grouped according to type (cellular, fibrocellular and fibrous) and extent of the lesions in Bowmans space; (segmental, semicircumferential and circumferential, which might be termed full moon-FM). Cases with cellular and fibrous lesions involving ≥ 50% of glomeruli with ECP were classified as cellular and fibrous groups, respectively, while the remaining cases were classified as fibrocellular. Cases with segmental and circumferential (FM glomerulus) lesions involving ≥ 50% of glomeruli with ECP were classified as ECPI and ECPIII (FM) groups, respectively, while the rest were classified as ECPII. All the cases were classified according to Berden et al. Significant results were only nearly obtained for the FM group, including the need for dialysis. The Cox regression model revealed a 2.6-fold risk for FM cases regarding dialysis requirement. We propose that the percentage of FM glomeruli should be noted in the pathology report, and cases with more than 50% of FM glomeruli (FM group) should be identified in the group with increased risk of dialysis requirement. Our series also suggests that classification according to Berden et al. is of clinical relevance.

Which Parameter Is More Influential on the Development of Arteriosclerosis in Hemodialysis Patients

Arteriosclerosis is characterized by stiffening of arteries. The incremental elastic modulus (Einc) measurement is a good marker of arterial wall stiffness. Metabolic, inflammatory and hemodynamic alterations cause structural changes and vascular complications in end stage renal disease. The aim of the present study was to evaluate the factors that may affect the development of arteriosclerosis by measurement of Einc in hemodialysis (HD) patients. Thirty-two patients (16 men; 16 female) on chronic HD with a mean age of 42.2 ± 19.3 (range: 15–80) were included in the study. The carotid Einc was measured to determine arteriosclerosis by high-resolution echo-tracking system (Acuson Aspen, Acuson Corp., Mountain View, California, USA). Einc measurement was calculated from transcutaneous measurements of common carotid arterial (CCA) internal diameter and wall thickness and carotid pulse pressure. Common carotid compliance and distensibility were determined from changes in carotid artery diameter during systole and simultaneously measured carotid pulse pressure. Common carotid artery stuffiness (Einc) was influenced by age, systolic blood pressure (SBP), pulse pressure (PP), calcium (Ca) and alkaline phosphatase (ALP). The distensibility of CCA was correlated with age, SBP, diastolic blood pressure (DBP), PP, Ca, ALP, and parathormone (PTH). The inflammatory parameter, hs-CRP, was increased with Einc. The mean Einc measurement was found significantly increased in patient receiving vitamin D. In conclusion, the stiffening of carotid artery in HD patients is related not only to hemodynamic changes (increased SBP, PP) but also to metabolic (increased Ca) and to inflammation (increased hs-CRP). Carotid Einc is accepted independent risk factor for cardiovascular mortality. Because of the positive correlation between Einc and serum Ca, vitamin D and Ca containing phosphorus (P) binders should be used carefully.

Heart Rate Variability, Left Ventricular Functions, and Cardiac Autonomic Neuropathy in Patients Undergoing Chronic Hemodialysis

Objective. Autonomic neuropathy and impairment of left ventricular functions (LVF) have been frequently encountered in chronic renal failure (CRF). The aim of the present study was to evaluate the relationship of cardiac autonomic modulation impairments, as assessed by means of heart rate variability (HRV), with clinical characteristics, and left ventricular function in the patients with CRF undergoing hemodialysis (HD). Methods. Twenty control subjects (Group I) and 22 comparable by age and gender patients with CRF undergoing hemodialysis (Group II) were enrolled in the study. After routine clinical and biochemical evaluations, electrocardiography, and 2 Dimensional, M Mode echocardiography were performed in all participants. Frequency domain HRV analysis was studied by using Kardiosis System. The powers (P1 and P2) and the central frequencies (F1 and F2) of low and of high frequency spectral bands were recorded. Results. End systolic (ESV) and end diastolic volumes (EDV) were significantly higher in Group II (59.3 ± 21.1 mL vs. 34.0 ± 14.3 mL and 131.5 ± 37.3 mL vs. 96.9 ± 18.9 mL, p<0.01, p<0.05, respectively) when compared to those of Group I. Ejection fraction (EF) and fractional shortening (FS) were significantly lower in Group II than in control subjects (52.3 ± 2.4% vs. 63.7 ± 10.1% and 0.29 ± 0.01 vs. 0.34 ± 0.07, p<0.001, p<0.05, respectively). P1 and P2 were decreased in Group II than in Group I (136.2 ± 173.9 m s2 vs. 911.0 ± 685.5 and 96.5 ± 149.6 vs. 499.7 ± 679.5, p<0.001, p<0.01, respectively). Significant correlations were found between high frequency spectral power and dialysis duration (DD), ESV, EDV, EF, FS (r = 0.52 p<0.01, r = 0.68 p<0.001, r = 0.65 p<0.002, r = 0.66 p<0.02, and r = 0.69 p<0.01). Conclusion. As a result, the dependence of cardiac autonomic neuropathy on the disease duration and degree of left ventricular function impairment was shown in the patients undergoing chronic hemodialysis.

Tissue Doppler is a More Reliable Method in Early Detection of Cardiac Dysfunction in Patients with AA Amyloidosis

Objective. Cardiac deposition of AA amyloidosis may result in increasing left ventricular mass and systolic and diastolic dysfunction (DD). The aim of this study was to investigate the left ventricular systolic and diastolic functions by both tissue Doppler imaging (TDI) and pulsed wave Doppler echocardiography (PWD) in patients with AA amyloidosis without congestive heart failure symptoms or arrthymia. Methods and Results. Twenty-four patients with AA amyloidosis without congestive heart failure symptoms or arrthymia (15 men and nine women; mean age 44.3 ± 16.7 years) and 25 healthy subjects (19 men and six women; mean age 43.1 ± 9.2 years) as controls were included in the study. M-mode, two-dimensional, PWD, and TDI were performed. Peak transmitral filling velocity (E wave), peak transmitral atrial filling velocity (A wave), deceleration time, and isovolumic relaxation time were measured by PWD recordings. Peak myocardial systolic velocity (Sm), peak myocardial early (Em), and late diastolic velocities (Am) were also recorded by TDI. E/A ratio less than one was accepted as DD for both methods. Ejection fraction (EF) was calculated by Teicholtz method. The subjects were divided into three groups as follows: healthy controls (group 1), patients without DD (group 2), and patients with DD (group 3) according to the PWD findings. PWD echocardiography showed that DD was present in 50% of the patients, whereas TDI showed DD in 66% of such cases. In subgroup analysis, Sm wave as a systolic function index was lower in group 3 than in groups 1 and 2, whereas mean EF values were similar in all groups. Conclusion. Although AA amyloidosis uncommonly causes cardiac symptoms and findings, according to our results, patients with AA amyloidosis may have systolic and diastolic dysfunction eventhough they are asymptomatic. Also, tissue Doppler imaging is a more reliable method in the early detection of cardiac dysfunction in such patients.