Yilmaz Selcuk

Anti‐proteinuric effects of combination therapy with enalapril and losartan in patients with nephropathy due to type 2 diabetes

The benefits of angiotensin‐converting enzyme inhibitors and angiotensin II (ATII) receptor antagonist therapy of diabetic nephropathy (DNP) are thought to be largely the result of attenuation of ATII effects on proteinuria. The aim of the study was to ascertain whether there is the additive anti‐proteinuric effect of enalapril plus losartan in DNP. Twenty‐two patients with DNP were studied. Patients were randomly assigned to enalapril 10 mg/day (11 patients) or losartan 50 mg/day (11 patients) administered in a single oral dose in the morning for 12 weeks. and then, in 10 patients (five patients from enalapril group and five patients from losartan group), combination therapy (10 mg/day enalapril and 50 mg/day losartan) was started and continued for 12 weeks. In 12 patients, initial drugs dosages were doubled (six patients 20 mg/day enalapril and six patients 100 mg/day losartan), and monotherapy was continued for 12 weeks. Blood pressure and proteinuria were measured before and after therapy. Adverse effects were recorded at every visit. Proteinuria decreased by 33% with enalapril and losartan administered alone (p < 0.05). Co‐administration of enalapril and losartan decreased proteinuria by a greater extent compared with enalapril and losartan administered alone (51%, p < 0.05). This proteinuria level was significantly lover than the proteinuria level of 12 weeks therapy with enalapril and losartan alone. The decrease of proteinuria was 37% in double‐dose monotherapy group (p < 0.05). Reduction of mean arterial blood pressure (MAP) in co‐administration of enalapril and losartan was higher than enalapril and losartan administered alone (p < 0.05). Combination of enalapril and losartan decreased proteinuria and MAP by a greater extent compared with enalapril and losartan administered alone. We have found that proteinuria reduction induced by combined therapy is maintained throughout short‐term follow‐up; a greater anti‐proteinuric response was observed in the patients with DNP.

Urinary tuberculosis: ten years' experience.

In this study of 26 patients, clinical features diagnosed as urinary tuberculosis in our nephrology and urology clinics between 1993 and 2002 were investigated retrospectively. Fifteen patients (52%) were male, and mean age was 43.5 (18–71). Twenty percent of the patients were asymptomatic. Frequency-dysuria (46%), flank pain (33%), and macroscopic hematuria (12%) were presenting symptoms. Physical examination was not diagnostically helpful in most patients. Hematuria and/or pyuria were detected in 80% of the patients. Eleven patients had positive urine cultures of Mycobacterium tuberculosis (42%), and 7 patients had positive smears (25%). Definitive diagnosis of urinary tuberculosis was established microbiologically in 15 patients (58%) and histopathologically in 11 patients (42%). Tuberculin skin test was positive in 60% of the patients. Eight patients had an abnormal chest roentgenogram. Hydronephrosis (majority bilateral) in 11 patients (42%), contracted bladder in 9 patients (34.6%), and renal calcification in 6 patients (23%) were detected. Two patients also had genital tuberculosis (epididymoorchitis). Although only medical treatment was applied in 13 patients for 9 months, in the rest of the patients medical therapy plus surgical intervention was carried out. End-stage renal failure developed in one patient who died on hemodialysis. Renal functions had decreased moderately in two other patients. In conclusion, the diagnosis of urinary tuberculosis was able to be established after the obstructive complications and functional losses were developed in a fair number of cases. Surgical treatment was carried out in half the patients. Urinary tuberculosis should be taken into consideration because early diagnosis and treatment is very important for the presenting of irreversible sequelae.

Effect of Losartan Treatment on the Proteinuria in Normotensive Patients Having Proteinuria due to Secondary Amyloidosis

Secondary amyloidosis (AA amyloidosis) is a well known cause of nephrotic syndrome and renal failure. Several studies in patients with nephrotic syndrome have suggested a beneficial effect of angiotensin-converting enzyme inhibitors (ACEI). Angiotensin II (ATII) receptor antagonists effect on the long term is not known. In this study, we intended to study the effect of losartan, as an ATII receptor antagonist, on proteinuria and renal functions in patients with normotensive secondary amyloidosis. In total 44 patients with biopsy proven AA amyloidosis associated with nephrotic proteinuria were included. The first group of patients (n=22) was treated with losartan 50 mg/day. The second group of patients (n=22) did not receive any specific antiproteinuric treatment. Urinary protein loss was effectively lowered by losartan from 4.38±1.0 to 2.8±0.61 g/day (p<0.0001), whereas the control group showed a slight fall in proteinuria as 4.21±1.06 to 4.12±1.07 g/day (p = 0.176). Hypoalbuminemia improved significantly from 2.52±0.69 to 2.78±0.46 g/dl (p = 0.004), in the losartan group, whereas serum albumin had fallen in the control group from 2.44±0.57 to 2.27±0.41 (p = 0.041). Serum creatinine increased in the control group from 1.52±0.42 to 2.39±0.51 mg/dl (p<0.0001), and in the losartan group from 1.59±0.50 to 1.84±0.6 mg/dl (p<0.001), after 24 months of treatment. The ATII receptor blocker losartan is effective in protecting against the progression of nephropathy due to AA amyloidosis. Symptomatic treatment of proteinuria with losartan is therefore to be considered, especially with severe proteinuria even in normotensive patients.

Alkaptonuria: A Case Report

Alkaptonuria is a rare, autosomally recessive, metabolic disorder caused by a deficiency in homogentisic acid oxidase. It results in accumulation and deposition of homogentisic acid in cartilage, eyelids, forehead, cheeks, axillae, genital regions, nail beds, buccal mucosa, larynx, tympanic eardrum, and the tendons. We report a 33‐year‐old woman who presented with alkaptonuria and ochronotic pigment deposited in articular cartilage and cartilage of the ear and sclera.

Severe and prolonged febrile myalgia in familial Mediterranean fever

Familial Mediterranean fever (FMF) is characterized by recurrent attacks of fever and serositis. Typical attacks of FMF last 3 to 5 days. Fever and myalgia are not always improved by colchicine therapy and sometimes require steroid therapy. We present two cases of severe prolonged febrile myalgia where steroid therapy was needed.Familial Mediterranean fever (FMF) is characterized by recurrent attacks of fever and serositis. Typical attacks of FMF last 3 to 5 days. Fever and myalgia are not always improved by colchicine therapy and sometimes require steroid therapy. We present two cases of severe prolonged febrile myalgia where steroid therapy was needed.

Amyloidosis due to familial Mediterranean fever: clinical and laboratory findings in 51 patients

Abstract Background: Familial Mediterranean fever (FMF) is a genetic multisystem disease, characterised by recurrent episodes of fever, peritonitis, pleuritis and arthritis. The most dangereous complication of the FMF is amyloidosis leading to end stage renal disease. The purpose of this study was to evaluate clinical and laboratory characteristics of patients with amyloidos due to FMF. Methods: This study was done in Ataturk University Hospital, situated in the east of Anatolia. A total of 51 patients with systemic AA amyloidosis due to FMF were evaluated retrospectively for clinical and laboratory parameters. Results: All patients were Turks. Of these, 25 (49.3%) had family history, 41 (80.3%) abdominal pain, 4 (7.8%) chest pain, 14 (27.4%) arthritis, 2 (3.9%) febrile myalgia, 1 (1.9%) erysipelas-like skin lesions and 34 (66.6) episodic fever. Hepatomegaly, splenomegaly and oedema were recorded in 22 (43.1%), 28 (54.9%), and 32 (62.7%) of patients respectively. Scrotal swelling was observed in 3 (5.8%) ...

Serum C-reactive protein levels during attack-free periods of familial Mediterranean fever

AbstractThe purpose of this study was to o evaluate whether or not sub-clinical inflammation in attackfree periods of colchicine-taking familial Mediterranean fever (FMF) patients compared with normal healthy controls, and to determine the effect of colchicine treatment on inflammation inhibition. Serum levels of C-reactive protein (CRP) in attack-free, asymptomatic, colchicineusing FMF patients (n = 21) and in normal controls having no family history of FMF (n = 20) were studied. CRP levels were significantly higher in FMF patients than in controls (p < 0.001) in the attack-free period. High CRP levels were observed in FMF patients, which could reflect the presence of sustained inflammation in the attack-free period of these patients.

Serum Transferrin Receptor Level in the Diagnosis of Iron Deficiency due to Erythropoietin Treatment

Accessible online at: http://BioMedNet.com/karger Dear Sir, In hemodialysis patients iron deficiency frequently occurs due to recombinant human erythropoietin (r-HuEPO) treatment [1]. However, the diagnosis of iron deficiency is not always easy in such patients [2]. It has been suggested [3] that the serum transferrin receptor (s-TfR) is a sensitive quantitative measure of tissue iron deficiency. We examined the changes in s-TfR levels of 24 patients (12 males, 12 females) who received r-HuEPO (50–70 U/kg/dose i.v.) at the end of each dialysis session (three times a week) diagnosed as having iron deficiency anemia by routine laboratory methods (ferritin !50 Ìg/l, transferrin saturation !16%). These s-TfR levels were compared with those of 32 hemodialysis patients (18 females, 14 males) not receiving r-HuEPO and having no iron deficiency anemia (ferritin 1 100 Ìg/l, transferrin saturation 120%). Also, 40 healthy volunteers (24 females, 16 males) were included in the study as a control group. Patients with a history of blood transfusions within the last 3 months or with any hemolysis finding were excluded from the study. Serum ferritin and s-TfR levels were measured with enzyme-linked immunosorbent assays using monoclonal reagents. As shown in table 1, there were no differences between the groups with and without iron deficiency anemia with respect to mean age, body weight, time on hemodialysis, and hemoglobin and serum creatinine levels (p 1 0.05). For s-TfR levels, while no difference Table 1. Demographic data and biochemical characteristics of patients and controls

Bone marrow amyloidosis with erythropoietin-resistant anemia in a patient undergoing chronic hemodialysis treatment.

The resistance to erythropoietin, which is used to treat normochromic, normocytic anemia in chronic renal failure, can develop in patients with conditions such as iron deficiency, aluminum toxicity, hyperparathyroidism, chronic inflammatory diseases, and primary hematological disorders. We found amyloidosis in the bone marrow of a woman without any other etiology for erythropoietin resistance who was undergoing chronic hemodialysis. Her anemia did not improve, despite 6 months of erythropoietin therapy. Bone marrow amyloidosis was found to be the reason for erythropoietin-resistant anemia in our patient with chronic renal failure and renal anemia. We present the case of bone marrow amyloidosis because it is a very rare cause of erythropoietin resistance.

Massive pulmonary embolism and acute renal failure in a patient with systemic lupus erythematosus and secondary antiphospholipid syndrome: A case report

AbstractA 50 year old, previously healthy woman came to our attention with high fever, arthralgia and oliguria. Serological tests were positive for antinuclear antibodies, anti-double-stranded-DNA antibodies and cardiolipin antibodies. Renal histology indicated diffuse proliferative lupus nephritis. Three days after the hospitalisation, the patient developed massive pulmonary embolism and dialysis-dependent acute renal failure, for which she was dialysed. Heparin 1000 U/hour (7 days), methylprednisolone (1000 mg/day for 3 days) and cyclophosphamide (500 mg for one day) were administered. This therapy led to a dramatic improvement of renal and pulmonary functions and, consequently, treatment with hemodialysis could be stopped after 3 weeks. This case illustrates an uncommon manifestation of systemic lupus erythematosus associated with antiphospholipid syndrome.