Seronegative systemic lupus erythematosus: etiology of nephrotic syndrome and acute renal failure in early postpartum period

Systemic lupus erythematosus (SLE) is an autoimmune syndrome that occurs most commonly in women during their reproductive years. Nephritis is known to be one of the most serious complications of SLE. Lupus nephropathy is frequently associated with ANA and anti-dsDNA antibodies. Rarely, serological markers may be initially absent, and in many cases, they become positive after sometime.

We present a 28-year old, otherwise healthy female who admitted to our clinic with edema, hypertension, proteinuria and acute renal failure following her fourth delivery. Serum immunological markers were negative and renal biopsy showed histopathological changes consistent with systemic lupus erythematosus as the etiology of nephrotic syndrome. A dramatic therapeutic response was achieved by pulse steroid and cyclophosphamide treatment following oral steroid therapy.

In women with new onset nephrotic syndrome or renal function deterioration in postpartum period, even if the patient is asymptomatic or seronegative, it is crucial to exclude SLE for a rapid diagnosis and prompt treatment in the case of lupus nephritis. Renal biopsy is of diagnostic importance in such cases in which there is no other clinical, biochemical and serological evidence of the disease.

Metabolic syndrome is related to long-term graft function in renal transplant recipients

The metabolic syndrome (MS) is a known cardiovascular risk factor in the general population and a common problem among renal transplant recipients. This study investigated whether MS after renal transplantation affected long-term graft function. We included 112 transplants at our center between 2000 and 2002. We excluded patients with the presence of pretransplant diabetes or nonstable renal function at 1 year after transplantation. We evaluated parameters such as demographic features, medications, smoking history, body mass index, daily proteinuria, blood pressure, number of HLA mismatches, number of acute rejection episodes, delayed graft function, and laboratory parameters. Patients were followed for a mean of 69.86 +/- 21.94 months. The prevalence of MS was determined using the National Cholesterol Education Program-Adult Treatment Panel III criteria. At 1 year after transplant, 28.6% of subjects had MS, whereas only 10.7% had MS before transplantation. Among 27.7% of patients graft failure had occurred during the follow-up; MS was more frequent among these individuals compared with those displaying stable renal function (51.6% vs 19.8%; P = .002). Older donor age, delayed graft function, acute rejection episodes, smoking history, MS, proteinuria, serum creatinine level, and C-reactive protein were associated with graft failure. Upon multivariate Cox regression analysis, patients with MS at 1 year after transplantation showed an increased risk for graft failure (relative risk, 0.22; 95% confidence interval, 0.06-0.75; P = .016). Older donor age and proteinuria level were other independent risk factors for graft failure. The MS was a prominent risk factor for graft failure. Because MS is a cluster of modifiable risk factors, early identification of patients at risk and intervention in due time may improve graft survival.

Vitamin D status, bone mineral density, and inflammation in kidney transplantation patients

Vitamin D has immunomodulatory and anti-inflammatory activities in the healthy population and in various disease states. There are few data on the quantification of vitamin D status and inflammation with respect to changes in bone mineral density among renal transplantation patients. We analyzed the influence of vitamin D levels on allograft function and inflammatory status at the time of enrollment and at 1-year follow-up. Sixty-four renal transplant patients, including 38 males, showed an overall age of 38.61 +/- 1.05 years, had a mean graft age of 6.15 +/- 3.17 years. We excluded patients who had diabetes mellitus, chronic inflammatory disease, or chronic allograft nephropathy. We obtained pre- and posttransplantation serum samples and daily proteinuria on each patient. Measurements of bone mineral density were performed by dual-energy X-ray absortiometry. After enrollment, we followed the patients for 1 year. Thereafter we assessed serum creatinine, C-reactive protein, albumin, and spot urinary protein levels. The patients were divided into two groups based upon vitamin D levels: group I (n = 29), <20 microg/L versus group II (n = 35), >or=20 microg/L. There was no significant difference in intact parathyroid hormone levels between the two groups. Vitamin D level positively correlated with serum creatinine (r = .32, P = .01) and serum albumin levels (r = .28, P = .023) at the time of enrollment. At 1 year, patients in group I showed significantly higher creatinine (P < .001) and proteinuria levels (P < .05) than those in group II. Low vitamin D levels are not uncommon among renal transplant recipients. There was a significant association of vitamin D levels with renal allograft function. Low vitamin D levels may be a predictor of worsening of graft function and increasing proteinuria.

Bone Mineral Density in Patients on Maintenance Hemodialysis and Effect of Chronic Hepatitis C Virus Infection

OBJECTIVE

To determine the prevalence of osteopenia and osteoporosis in HD patients at our center; to investigate whether HCV infection affects BMD in hemodialysis patients; to test for correlations between bone mineral density (BMD) and clinical and laboratory parameters in this population.

SUBJECTS AND METHODS

The study involved 76 end-stage renal disease patients. Forty-three (56.6%) patients were tested negative for anti-HCV antibodies and HCV-RNA. Thirty-three (43.4%) of them had positivity of anti-HCV antibodies and permanent or intermittent HCV-RNA positivity at least for two years. Mean HD duration was 86.4 months. Patients completed a standard questionnaire that listed age, sex, occupation, education level; cause of renal failure, smoking history, dialysis duration, and sports activities engaged in during life, and pathologic bone fractures. The women answered additional items about age at menarche, number of pregnancies and menopausal status. Each subject underwent a baseline physical examination, including measurement of body weight and height for calculation of body mass index. The results of laboratory tests that had been done at monthly visits in the previous year were retrospectively evaluated, and mean levels for the year were used for correlation testing. Bone mineral density was measured in the spine, femoral neck and forearm. Relationships between BMD values and chronic HCV infection, laboratory results and clinical parameters were analyzed.

RESULTS

In the 43 patients who were negative for anti-HCV antibodies and HCV-RNA, spine BMD testing showed osteopenia in 16 (37.2%) cases and osteoporosis in 7 (16.3%) cases. The corresponding values for the neck of the femur were 14 (32.6%) and 6 (14.0%), and for the forearm were 19 (44.2%) and 15 (34.9%). In the 33 anti-HCV antibodies and HCV-RNA positive patients; spine BMD testing showed osteopenia in 10 (30.3%) cases and osteoporosis in 7 (21.2%) cases. The corresponding values for the neck of the femur were 17 (51.5%) and 4 (12.1%), and for the forearm were 4 (12.1%) and 25 (75.8%). Bone mineral density decreased as dialysis duration increased (p<0.05). There was no statistical difference between BMD measurements of chronic HCV infection positive and negative group.

CONCLUSION

However the mean BMD values for all three sites in the 76 HD patients were low HCV infection may not be a risk factor for low BMD in this population.

Factors associated with peak oxygen uptake in hemodialysis patients awaiting renal transplantation

The preoperative evaluation of pulmonary function is important in renal transplantation candidates. Exercise capacity determined by peak oxygen uptake (peak Vo(2)) is a predictor of perioperative mortality and survival. The aim of this study was to determine the factors associated with the peak Vo(2) among renal transplantation candidates undergoing hemodialysis. Thirty patients with chronic renal failure including 14 women and 16 men of mean age 40.2 +/- 10.3 years had a mean duration of dialysis of 133.1 +/- 63.3 months and were awaiting renal transplantation. None of the patients had signs or symptoms of active infection or inflammation. Each patient underwent pulmonary function and symptom-limited cardiopulmonary exercise tests. Despite the absence of clinically evident inflammation, a malnutrition inflammation score was calculated for each patient to assess comorbid conditions and the risk of atherosclerosis. Demographic and laboratory parameters were obtained from hospital records. The peak Vo(2) was positively correlated with the serum triglyceride level and negatively correlated with serum ferritin level and malnutrition inflammation score. On multiple linear regression analyses, which were performed to assess the potential predictors of the peak Vo(2), the malnutrition inflammation score was the only variable that independently correlated with the peak Vo(2) in hemodialysis patients awaiting renal transplantation. In conclusion, peak Vo(2) is associated with markers of nutrition and the malnutrition inflammation score. We suggest that chronic malnutrition and silent inflammation may be responsible for the preoperative decreased exercise capacity in renal transplantation candidates undergoing hemodialysis.

Is uric acid a predictive factor for graft dysfunction in renal transplant recipients?

Hyperuricemia is a common complication in renal transplant recipients, and uric acid (UA) may play a role in renal dysfunction. The aim of this study was to evaluate the effects of UA on chronic allograft nephropathy (CAN) in renal transplant recipients. The 133 study subjects included 34 women and 99 men of overall mean age of 34.7 +/- 9.9 years. They underwent renal transplantation between 1998 and 2000. Serum UA levels were measured in the first month after transplantation and then at yearly intervals throughout a 3-year follow-up. In the first month after transplantation, 55.3% of recipients had hyperuricemia (UA >7 mg/dL in men; UA >6 mg/dL in women), but, 3 years after transplantation, 84.6% of the subjects had that disorder (P<.001). CAN was diagnosed in 31.5% of the patients at a mean onset of 31.8 +/- 14.3 months after transplantation. Fifty-two percent of these individuals experienced graft failure within 43.3 +/- 20.8 months after transplantation. UA levels were recorded before the development of CAN. There was no association between UA levels and CAN according to a Cox regression analysis (P>.05; relative risk, 1.082; 95% confidence interval [CI] 0.9-1.3). We concluded that the prevalence of hyperuricemia was higher among recipients than in healthy individuals, but that the UA level did not affect the development of CAN during first 3 years after transplantation.

Early onset proteinuria after renal transplantation: a marker for allograft dysfunction

The objective of this study was to determine whether early proteinuria after renal transplantation affected long-term allograft survival. The 130 patients included 105 men and 25 women of overall mean age, 29.6 +/- 9.6 years. There were 105 living related and, 25 cadaveric donor transplants. Proteinuria was defined as a level in of more than 300 mg/d. Donor and recipient age at transplantation, duration of pretransplant dialysis, donor type (living related or cadaveric), the presence of delayed graft function or acute rejection, panel-reactive antibodies, the number of human leukocyte antigen mismatches, and the systolic blood pressure level were retrospectively recorded for the study subjects. Cox regression analysis was used to determine the effects of proteinuria on allograft survival. Patients with proteinuria demonstrated significantly lower graft survival rates than did those without proteinuria (54.17% vs 82.62%, respectively; P<.002). Proteinuria at the third month after transplantation (P<.004, odds ratio [OR]=3.26, confidence interval [CI]=1.46 to 7.29), donor age (P<.001, OR=1.06, CI=1.02 to 109), and panel-reactive antibodies (P<.041, OR=1.06, CI=1.00 to 1.12) were significantly associated with decreased allograft survival. Early proteinuria after renal transplantation was indicative of a high risk for allograft dysfunction. A reduction of proteinuria may be associated with improved graft survival.

Malnutrition inflammation score is associated with coronary artery disease in hepatitis C virus-infected hemodialysis patients

OBJECTIVE

Hepatitis C virus (HCV) infection exerts diverse effects on atherogenesis. We investigated whether malnutrition inflammation score (MIS) is associated with the presence of coronary artery disease (CAD) in anti-HCV-positive hemodialysis (HD) patients.

SUBJECTS/METHODS

Twenty-two anti-HCV-positive HD patients with CAD and 61 anti-HCV-positive HD patients without CAD (as controls) were included. Data were obtained from hospital records, patients were evaluated for risk factors for CAD. The same physician performed MIS evaluation.

RESULTS

MIS of anti-HCV-positive HD patients with CAD were significantly higher than patients without CAD (8.8+/-4.0 vs 6.5+/-2.6, P=0.02). In patients with CAD, basal (P=0.002) and peak C-reactive protein (P=0.03) and serum ferritin (P=0.01) concentrations were higher, serum albumin concentrations (P=0.003) were lower than those patients without CAD. MIS was positively correlated with age (r=+0.359, P=0.001) and viral load (r=+0.629, P<0.0001). In univariate logistic regression analysis, advanced age (odds ratios (OR)=1.093, confidence interval (CI): 1.039-1.150, P=0.001), hypertension (OR=3.143, CI: 1.084-9.116, P=0.035), diabetes mellitus (OR=5.344, CI: 1.343-21.269, P=0.017), low triglyceride (OR=0.992, CI: 0.984-0.999, P=0.026) and high MIS (OR=1.259, CI: 1.066-1.488, P=0.007) were associated with the presence of CAD. Multivariate logistic regression analysis identified age (OR=1.090, CI: 1.007-1.179, P=0.033) and MIS as the factors associated with the presence of CAD (OR=1.232, CI: 1.004-1.511, P=0.04).

CONCLUSIONS

MIS may be associated with CAD in anti-HCV-positive HD patients.

Pretransplantation Systolic Blood Pressure and the Risk of Delayed Graft Function in Young Living-Related Renal Allograft Recipients

Delayed graft function (DGF) is associated with decreased long-term renal allograft survival, however, the entire mechanism of action of DGF has not yet been established. The goal of this study was to determine possible risk factors for DGF in young living-related renal allograft recipients. We retrospectively analyzed the outcome of 142 renal transplant recipients (115 men and 27 women; mean age, 29.7 +/- 9.43 years; 114 living-related donors and 28 cadaveric donors). Data recorded for each patient and donor included gender, age at transplantation, duration of pretransplantation dialysis (recipients only), body mass index, number of human leucocyte antigen mismatches, panel-reactive antibodies, donor creatinine clearance, body weight, systolic and diastolic blood pressure levels, lipid profile, and biochemical parameters. Having obtained the transplant from a cadaveric donor (P<.000, odds ratio [OR]=17.556, confidence interval [CI]=5.961-51.743) and a pretransplantation systolic blood pressure level in the recipient of <120 mm Hg (P<.021, OR=3.600, CI=1.214-10.672) were possible risk factors for DGF. When only living-related recipients were considered, the systolic blood pressure level was significantly associated with DGF. We concluded that a pretransplantation systolic blood pressure level <120 mm Hg is a risk factor for DGF and that preoperative blood pressure control and intervention may help to decrease the risk of DGF.

The Association Between Cytomegalovirus Infection and Atherosclerotic Events in Renal Transplant Recipients

Cytomegalovirus (CMV) infection is a risk factor for arteriosclerosis in renal transplant recipients. We sought to investigate the effects of CMV infection on atherosclerotic events (AE) in renal transplant recipients. This retrospective analysis included 200 patients: 52 women and 148 men of overall mean age of 36.18 +/- 10.23 years who were transplanted at our center between 1998 and 2001. We analyzed demographic features, dialysis duration, diabetes, blood pressure level, body mass index (BMI), medications, and lipid parameters. CMV infection was diagnosed in 23.5% of patients in the first 2 years after transplantation; these patients were followed for 4 years. All patients had been assessed for AE, including previous myocardial infarction, angina, revascularization procedures, intermittent claudication, stroke, or transient ischemic attack. AE occurred in 13% during the follow-up period. CMV infection was more frequent among these patients compared to those without AE, namely 42.3% versus 20.6%, respectively. Although the gender, dialysis duration, serum cholesterol level, presence of acute rejection, and BMI were not associated with AE, age, hypertension, and CMV infection did show a relation. A multivariate analysis by logistic regression revealed mean age and CMV infection to be independent risk factors for AE: odds ratio (OR)=5.6, 95% confidence interval (CI)=1.3 to 24.6 (P=0.02) and OR=4, 95% CI = 1.3 to 12.3 (P=.01). This study suggested that the presence of CMV infection may be a triggering factor for AE in renal transplant recipients.

Possible Influence of Vitamin D Receptor Gene Polymorphisms on Recombinant Human Erythropoietin Requirements in Dialysis Patients

BACKGROUND

Vitamin D receptor (VDR) gene polymorphisms have been widely studied, especially to analyze their effects on calcium-phosphorus metabolism and secondary hyperparathyroidism in patients on dialysis. In this study, we sought to investigate the possible effects of these polymorphisms on the anemia of renal failure and recombinant human erythropoietin (rHuEPO) responses among patients receiving hemodialysis.

METHODS

One hundred twenty-eight patients (52 females/76 males) underwent genotyping for the insertion/deletion Bsml (B-->b, restriction site, exon VIII-->IX) and Tagl (T-->t, 352 exon IX) VDR gene polymorphisms. The mean value of the last 6 months' monthly evaluated laboratory values (C-reactive protein, hemoglobin, iron indices, PTH, and albumin) and clinical findings (rHuEPO requirement, cumulative iron supplementation doses, and body weight) were analyzed retrospectively excluding patients with chronic inflammation, hemolytic anemia, or active blood loss such as gastrointestinal bleeding.

RESULTS

Mean age and dialysis durations were 41.5 +/- 11.8 years and 91.8 +/- 45.3 months, respectively. Polymorphism percentages were as follows: Bsml; BB/Bb/bb: 32.2/63.6/4.2 and Tagl; TT/Tt/tt: 40.5/55.4/4.1%, respectively. BB variant of Bsml gene was related to lower rHuEPO needs (P < .05) and also higher hemoglobin levels (P < .005) when compared with the Bb/bb variant. Considering Tagl variants, transferrin saturation levels were lower (P < .03) among patients with the Tt/tt variant, but there was no other significant difference in the mean values of other data between TT and Tt/tt variants.

CONCLUSION

The BB variant of Bsml was related to decreased rHuEPO requirements to achieve higher hemoglobin levels among maintenance hemodialysis patients without chronic inflammation.

Lipid Profile During Azathioprine or Mycophenolate Mofetil Combinations With Cyclosporine and Steroids

BACKGROUND

Immunosuppressive therapy is the major cause of hyperlipidemia after renal transplantation. We sought to compare the effects of an azathioprine (AZA) combination (n = 26) with corticosteroid and cyclosporine (CyA; group 1) with a mycophenolate mofetil (MMF) combination (n = 71; group 2) in the first year following renal transplantation.

METHODS

Ninety-seven renal transplant patients (71 men, 26 women; aged 34.7 +/- 13.1 years; renal transplantation duration, 44.9 +/- 12.9 months) underwent serum lipid profiles--total cholesterol, triglyceride, high-density lipoprotein (HDL); low-density lipoprotein (LDL), and very low-density lipoprotein (VLDL) at the initiation of as well as 3-month intervals after grafting for 1 year retrospectively. Serum creatinine for each patient was recorded at 12 months. We evaluated possible risk factors for hyperlipidemia.

RESULTS

For all patients, the prevalence of hypercholesterolemia (>200 mg/dL) was 36.1% during the pretransplant period, 60.8% at month 3, 50.5% at month 6, and 38.1% at month 12 after renal transplantation. Total cholesterol and triglyceride levels significantly increased in both groups in the first year (P = .001 and P = .02, respectively). Three-month values for total cholesterol were higher in group 2 than group 1 (P = .001). No significant difference was observed between the groups with respect to total cholesterol and triglyceride levels (P > .05). In both groups, HDL, LDL, and VLDL levels did not change during the 12-month study (P > .05 for all).

CONCLUSIONS

Independent of hyperlipidemia risk factors, serum total cholesterol and triglyceride levels tended to increase during CyA and steroid therapy among patients undergoing renal transplantation. Combination with MMF or AZA showed no advantage over one another regarding their effects on the lipid profile.

1,25-dihydroxyvitamin D(3) therapy is protective for renal function and prevents hyperparathyroidism in renal allograft recipients

1,25-Dihydroxyvitamin D(3) (calcitriol) therapy has been extensively used for posttransplant osteoporosis. Beside its effect on bone metabolism, calcitriol has an important immunomodulatory effect. We evaluated the effects of oral calcitriol therapy on allograft function and parathyroid hormone levels after renal transplantation. The patients were retrospectively selected from a renal transplant patient population who received calcitriol (group 1, n = 59, 36 male/23 female, follow-up: 52.8 +/- 12.2 months) compared with group (group 2, n = 52, 42 male/9 female, follow-up: 62.0 +/- 24.4 months) without calcitriol therapy after renal transplantation. Calcitriol therapy was started 24.0 +/- 19.1 months posttransplantation. All patients were under three-drug immunosuppression. The pretransplant and posttransplant data were studied retrospectively. Additionally, creatinine levels before and after the initiation of calcitriol therapy were recorded at 6 months intervals for 3 successive years. Our results were analyzed according to the first and third year on therapy data. According to the first year data, there were no differences in patient groups in terms of creatinine and iPTH levels. In the third year, the patients in group 1 showed significantly lower creatinine (P = .01) and iPTH (P < .04) levels and needed lower pulse steroid doses (P < .04). According to a Friedman repeated measures variance test, the creatinine level was significantly lower among group I (P < .04) at 3-year follow-up. In conclusion, even a delayed start of calcitriol therapy after renal transplantation exerts a protective effect on renal allograft function and prevents the development of hyperparathyroidism.

Additional Effect of Hyperparathyroidism on Inflammatory Status and rHuEPO Requirements in Hemodialysis Patients

BACKGROUND

The aim of this study was to analyze the effects of elevated parathyroid hormone (iPTH) and C-reactive protein (CRP) on rHuEPO requirements and associated clinical and biochemical parameters of hemodialysis patients.

METHODS

A total of 127 hemodialysis patients were included. Laboratory values from the previous 3 months (monthly measured CRP, iPTH, albumin, prealbumin, calcium, phosphorus, and hemoglobin) and clinical findings (rHuEPO requirements, iron supplements, Kt/V) were recorded retrospectively. Patients were subgrouped according to presence of hyperparathyroidism (mean iPTH > 350 pg/mL) and chronic inflammation (mean CRP > 8.5 mg/L) as group I (low iPTH, low CRP, n = 32), group II (high iPTH, low CRP, n = 32), group III (low iPTH, high CRP, n = 32), and group IV (high iPTH, high CRP, n = 31).

RESULTS

We found that group IV had lowest hemoglobin (P < .0001, .0001, .01, respectively), albumin (P < .0001), prealbumin (P < .0001, .0001, .02, respectively), and highest rHuEPO requirements (P < .0001, .0001, .01, respectively) compared to other groups despite of similar iron indices. Group III also had lower albumin (P < .002, .0001, respectively), prealbumin (P < .001, .01, respectively), hemoglobin (P < .001, .005, respectively), but higher rHuEPO requirements (P < .01) compared to group I and group II.

CONCLUSIONS

We propose that hyperparathyroidism increases rHuEPO requirements and aggravates the negative effects of chronic inflammation in hemodialysis patients.

Diagnosing amyloid goitre with thyroid aspiration biopsy

OBJECTIVE

The aim of the study was to evaluate the value of fine needle aspiration biopsy of the thyroid as a tool for diagnosing amyloid goitre and assess how amyloidosis affects thyroid tissue and thyroid function.

METHODS

Clinical and laboratory evaluation of 50 patients with secondary systemic amyloidosis was done, and goitre was found in 38 of them. All 38 patients underwent thyroid aspiration biopsy. Tissue samples were stained with haematoxylin and eosin, May-Grünwald-Giemsa, crystal violet and Congo red.

RESULTS

Of the 38 cases of amyloid goitre, 10 showed euthyroid sick syndrome, two showed primary hyperthyroidism, two showed hypothyroidism and one showed subacute thyroiditis. The serum levels of thyroid hormones and thyroid-stimulating hormone were normal in the remaining patients. Thirty-five of the 38 patients (92%) showed amyloidosis after thyroid aspiration. One of these patients had papillary carcinoma in addition to amyloid goitre. Ten patients underwent subtotal thyroidectomy, and one patient underwent total thyroidectomy after aspiration. Microscopic evaluation revealed that the thyroid parenchyma in all patients was largely replaced with amyloid and adipose tissue.

CONCLUSION

Fine needle aspiration of the thyroid is a valuable and sensitive method for diagnosing amyloid goitre, especially because it is a safe and easily performed procedure. Further, amyloid goitre has no significant influence on thyroid function even when it causes extensive parenchyma replacement.

Hepatitis C infection in hemodialysis patients: Protective against oxidative stress?

Hepatitis C virus (HCV) infection is a common problem that increases morbidity and mortality in hemodialysis patients. These patients are also at risk of increased oxidative stress. The aim of this study was to evaluate possible interactions between HCV infection and oxidative stress indicators in a group of hemodialysis patients awaiting transplantation. We evaluated 73 patients (29 women, 44 men; ages, 49.3 +/- 13.3 years; dialysis duration, 81.7 +/- 48.8 months; Kt/V > or = 1.3). Indicators of plasma oxidative status were monitored at the beginning of a clinically stable hemodialysis session. Measurements were performed for plasma superoxide dismutase (SOD), glutathione peroxidase (GPX), and malonyldialdehyde (MDA) by spectrophotometric methods. We retrospectively recorded the prior year's monthly laboratory values for alanine aminotransferase (ALT), C-reactive protein (CRP), albumin, lipids, homocysteine, Lp(a), calcium, phosphorus, intact parathyroid hormone, and predialysis blood urea nitrogen (BUN) creatinine, as well as clinical findings of body mass index and pre- and postdialysis blood pressures. We excluded patients with chronic inflammation (mean CRP levels > or = 10 mg/L) or HCV infection of duration <12 months or clinically advanced liver failure. Twenty-six patients had HCV. The sex distribution, mean age, and dialysis duration were similar between groups. HCV-infected patients showed significantly lower levels of MDA, albumin, total cholesterol, triglyceride, predialysis creatinine, and phosphorus. Antioxidative indicator levels were also higher in the HCV group, but they were not statistically significant. In conclusion, HCV infection in dialysis patients is associated with decreased levels of plasma oxidative load.

Among therapy modalities of end-stage renal disease, renal transplantation improves survival in patients with amyloidosis

The aim of this study was to investigate the results of renal transplantation in amyloidosis patients compared with those on hemodialysis. We compared a group of 25 patients with systemic amyloidosis and end-stage renal disease (ESRD) treated with renal transplantation with a control group of 30 patients with systemic amyloidosis and ESRD treated with hemodialysis. Overall 1-, 2-, and 5-year survival rates were 86.9%, 82.6%, and 78.2%, respectively, for patients, who had renal transplantations versus 60.7%, 50%, and 46.4%, respectively, for patients on hemodialysis treatments (P < .001). Among the control group 15 patients died at 9.4 +/- 7.5 months after starting hemodialysis. Among transplantation group five patients died during follow-up (mean 12.3 +/- 13.6 months); the major cause of death was infection. Only 18 patients experienced recurrences after renal transplantation; their 5-year survival rate was 84.2% versus 50% for patients who had no recurrence (P < .001). Patients with amyloid recurrence also had better long-term survival rates than patients in hemodialysis group (P < .001). In conclusion amyloidotic patients maintained on chronic dialysis have a high mortality rate. Better survival was noted for patients who had renal transplantations despite recurrences. These results encourage transplantation in amyloid renal end-stage disease.

De novo glomerulonephritis in renal allografts with hepatitis C virus infection

The purpose of this study was to examine the influence of hepatitis C virus (HCV) infection on the occurrence of posttransplant de novo glomerulonephritis (GN). Of 165 patients selected for the study, 44 were HCV positive and 121 HCV negative. Light and immunofluorescence microscopy were performed on all biopsies and clinical and laboratory findings reviewed. Fifteen (34%) of the 44 HCV positive patients showed de novo GN (4 membranous, 11 membranoproliferative) at a mean of 47 +/- 22 months. But only 8 (6.6%) of 121 HCV negative patients showed de novo GN (5 anti-glomerular basement membrane nephritis in recipients with Alport's disease, 2 membranous GN, 1 membranoproliferative GN) at a mean of 60 +/- 39 months. The risk of development of de novo GN was higher among patients with HCV infection (P < .001). The presence of de novo GN in HCV positive patients impaired graft survival compared with HCV positive patients without de novo GN (P < .01). The incidence of recurrence of primary disease, mainly focal segmental glomerulosclerosis, membranous glomerulonephritis, membranoproliferative glomerulonephritis, and IgA nephropathy, was higher in HCV negative patients (29%) compared with HCV positive patients (6.8%; P = .001), namely, 50%, 57.6%, 25%, and 69%, respectively. In conclusion, HCV infection showed a strong influence on the development of de novo GN. For this reason, it is important to follow HCV positive recipients with a renal biopsy even when there are no significant clinical or laboratory findings.

Persistent hypercalcemia is a significant risk factor for graft dysfunction in renal transplantation recipients

Hypercalcemia is a common problem in renal transplant recipients, although in most cases, spontaneous resolution occurs within 1 year after renal transplantation. This condition may persist in some patients producing effects on renal function which are not well understood. In this study, we sought to analyze the effect of persistent hypercalcemia in the posttransplantation period on the function of renal transplants. A total of 121 recipients (31 women, 90 men; mean age, 34.1 +/- 9.9 years) underwent renal transplantation between 1999 and 2002. All patients underwent prospective evaluation of their serum calcium levels at 6-month intervals. A sustained corrected mean serum calcium level higher than 10.2 mg/dL was defined as "persistent hypercalcemia." Patients who had a gradual increase in their serum creatinine levels to >2 mg/dL or a 50% rise above the baseline were considered to display chronic allograft dysfunction (CAD). Among 121 recipients, 52 patients (43%) developed CAD and 37 patients (30.6%) had persistent hypercalcemia. Among the CAD patients, 22 suffered persistent hypercalcemia, while the other 15 patients were without CAD, a difference that was statistically significant (42.3% vs 21.7%, P = .01). The mean calcium levels were lower among patients without than with CAD, a difference that did not reach statistical significance (9.9 +/- 0.4 mg/dL vs 10.1 +/- 0.6 mg/dL, P = .1). In conclusion, persistent hypercalcemia in the posttransplantation period may significantly contribute to the development of chronic allograft nephropathy.

Effects of Immunosuppressive Drugs on Serum Lipid Levels in Renal Transplant Recipients

BACKGROUND

Hyperlipidemia is an important metabolic disorder that is common among renal transplant recipients. This study investigated the possible effects of transplantation and immunosuppressive drugs on lipid profiles in this patient group.

METHODS

We retrospectively evaluated the records of 179 patients who underwent renal transplantation between 1996 and 2000, recording lipid profile findings-total cholesterol (TC), low-density lipoprotein cholesterol (LDLc), high-density lipoprotein cholesterol (HDLc), and triglyceride (TG)-before and at least 6 months after transplantation. We also recorded patient demographics, underlying renal disorder, and immunosuppressive drug regimens.

RESULTS

Sixty-nine (38.5%) patients were women and 110 men (61.5%). The mean age (+/- SD) of the 179 recipients was 35.7 +/- 11.8 years (range, 11 to 62 years). The respective pre- versus posttransplantation lipid profile findings were: TC, 171.6 +/- 42.4 mg/dL versus 204.7 +/- 45.3 mg/dL, P < .001; LDLc, 114.5 +/- 34.5 mg/dL versus 142.2 +/- 39.7 mg/dL, P < .001; HDLc, 46.7 +/- 13.6 mg/dL versus 42.5 +/- 12.3 mg/dL, P = .001; TG, 142.9 +/- 55.7 mg/dL versus 178.8 +/- 71.8 mg/dL, P < .001. Increased lipid levels were found to be independent of patient age, sex, donor type, and immunosuppressive drug regimen.

CONCLUSION

The results suggested that antihyperlipidemic drugs should be administered routinely to renal transplant recipients irrespective of the immunosuppressive drug regimen or graft source.

Does Colchicine Have an Antifibrotic Effect on Development of Interstitial Fibrosis in Renal Allografts of Recipients With Familial Mediterranean Fever?

Colchicine, which has been reported to inhibit fibrosis, has been successfully used to treat fibrotic disorders, such as liver cirrhosis, scleroderma, and idiopathic pulmonary fibrosis. We hypothesized that besides its ability to prevent amyloid deposition, colchicine may prevent the development of interstitial fibrosis (IF) in amyloidosis patients who had undergone renal transplantation. We evaluated the influence of colchicine therapy on the development of IF in 25 patients with systemic amyloidosis secondary to familial Mediterranean fever (group 1). Twenty-five nonamyloidotic patients who did not receive colchicine therapy served as controls (group 2). The incidences of recurrence and development of IF in the first, second, and third years after transplantation were evaluated from follow-up allograft biopsies. Only four patients showed amyloid recurrence in their renal allografts. IF developed in 44% (11/25) of group 1 patients and 80% (20/25) of group 2 patients during the 36 months posttransplantation (P < .01). Development of IF in the first, second, and third years posttransplantation was significantly greater among group 2 recipients than group 1 recipients (P < .01). The overall 1-, 2-, and 3-year graft survival rates for group 1 recipients were 96%, 92%, and 80%, and those for group 2 recipients were 96%, 88%, and 60%, respectively. Our results support the thesis that colchicine therapy may help prevent the development of interstitial fibrosis in renal allografts.

Risk Factors for Development of Posttransplant Diabetes Mellitus in Renal Transplant Recipients

Diabetes mellitus appearing after kidney transplantation--posttransplant diabetes mellitus (PTDM)--is a common complication associated with poor graft and patient survival. The purpose of the current study was to determine the risk factors for developing PTDM in 204 renal transplant recipients who had been followed for at least 30 months. Posttransplant diabetes mellitus was diagnosed according to the American Diabetic Association/WHO criteria, or a requirement for insulin, an oral hypoglycemic agent, or both. Analyses of possible risk factors for PTDM included demographic features, dialysis and posttransplantation duration, smoking, body mass index, medications, co-morbid diseases, HLA mismatches, as well as laboratory metrics of serum creatinine, albumin, calcium, phosphorus, C-reactive protein, parathyroid hormone, and lipid profiles. Twenty-six patients displayed PTDM. Univariate analysis showed that older age, greater body mass index, presence of hepatitis C virus (HCV) infection, and smoking at the time of renal transplantation were associated with PTDM development. In a multivariate analysis, HCV infection, smoking, and patient age at the time of transplantation were independent risk factors for PTDM. In conclusion, the presence of HCV infection or a smoking habit in addition to older age at the time of transplantation were the main predictors for developing PTDM. Patients should be closely followed regarding their smoking habit and weight gain as modifiable risk factors for PTDM.

Subjective Global Assessment Is a Useful Method to Detect Malnutrition in Renal Transplant Patients

Adequate nutrition is essential for the well-being of renal transplant patients. While body weight gain is a common widely investigated finding, a considerable fraction of patients exhibit poor nutritional status after successful kidney transplantation. In the present study, the prevalence association with nutritional parameters and clinical data of malnutrition among kidney transplant patients were determined based upon a subjective global assessment. This cross-sectional study in the transplant outpatient clinic included 47 patients (10 women, 37 men) of mean age 37.6 +/- 10.2 years. The same dietitian performed the assessment on all patients, including anthropometric measurements of body mass index (BMI), mid-arm circumference, and triceps skinfold thickness. The patient data including medications, number of hospitalizations in the preceding year, and presence of chronic allograft failure were collected from medical records. The mean laboratory values during the last 6 months included hemoglobin, creatinine, albumin, phosphorus, C-reactive protein levels, and lipid profile. The patients were classified into 3 groups defined as A (n = 31, 66%), B (n = 11, 23.4%), and C (n = 5, 10.6%), namely, A, no malnutrition versus B/C, moderate or severe malnutrition. Comparison of the 2 groups revealed the serum albumin (P < .0001), body mass index (P = .02), and mid-arm circumference (P = .02) to be higher in group A than groups B/C. Group B/C patients showed higher levels of C-reactive protein (P < .0001). When compared to the pretransplantation period, the 31 patients in group A included 26 who had increased body mass index after transplantation versus only 3 of 16 patients in groups B/C had (P < .0001). The hospitalization rates were significantly lower in group A (P = .02). Additionally, the patients in group A tended to have a lower frequency of chronic allograft rejection when compared to group B/C subjects (P = .13). In conclusion, assessment of nutritional status of renal transplant patients combined with intervention in the nutritional intake may decrease the morbidity rates in this patient group.

Posttransplant Diabetes Mellitus: Impact of Good Blood Glucose Regulation on Renal Transplant Recipient Outcome

Posttransplant diabetes mellitus (PTDM) is a frequent complication among renal transplant recipients. This study sought to compare clinical outcomes of patients with PTDM who had strict glucose control with nondiabetic patients and to identify risk factors for atherosclerotic disease in both groups. We retrospectively examined 204 renal allograft recipients transplanted at our center between 1996 and 2002. Demographic features, dialysis and posttransplantation duration, smoking, body mass index, medications, comorbid diseases, number of HLA mismatches, and laboratory parameters including serum levels of creatinine, albumin, calcium, phosphorus, C-reactive protein, lipid parameters, and parathyroid hormone were analyzed as possible risk factors for atherosclerotic disease. Patients were followed for a mean of 59.7 +/- 23.6 months. PTDM was diagnosed according to the American Diabetic Association criteria or the need for an insulin/oral hypoglycemic agent. Twenty-six patients developed PTDM, and these patients had very good diabetes control. One patient with poorly regulated PTDM was excluded. Adverse events which were documented in 24 patients were more frequent among patients with PTDM. Mean age was found to be an independent risk factor for atherosclerotic disease, whereas PTDM was not. There were no differences regarding other atherosclerosis-related or other risk factors (including serum C-reactive protein levels and lipid profiles) between the groups. Nondiabetic subjects tended to have longer graft survival than patients with PTDM, but this finding was not statistically significant. PTDM is an important risk factor for developing atherosclerotic disease. Good control of blood glucose levels can decrease the high morbidity rates and negative influence of PTDM on patient and graft survival rates in this population.

Predictors of Vascular Access Thrombosis Among Patients on the Cadaveric Renal Transplantation Waiting List

Acute thrombotic complications remain a constant, proportionally increasing complication before and after renal transplantation. We sought to investigate predictors for a prothrombotic state that increased the risk of vascular access thrombosis, among chronic renal failure patients during the waiting period prior to cadaveric renal transplantation. Chronic renal failure patients awaiting cadaveric renal transplantation and followed between January 2002 and January 2005 were included in this study. The 109 subjects including, 61 females and 48 males of mean age: 47.4 +/- 12.9 years; There were 36 continuous ambulatory peritoneal dialysis and 73 hemodialysis patients. Serum albumin, prealbumin, CRP, d-dimer, fibrinogen, antithrombin III, anticardiolipin antibodies (immunoglobulins G and M), homocystein, vitamin B12, folic acid, total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and total platelet count were measured in each patient. Factor V Leiden, prothrombin 20210, ACE and MTHFR gene mutations were studied in all patients. Vascular Access thrombosis was detected in 62 patients. During follow-up 31 of 109 patients died. Vascular access thrombosis occurred in 78 patients who survived and 31 who died. The patients who died showed a significantly higher rate of thrombosis than those who survived (P = .003, OR: 4.61, CI: 1.70 to 12.50). Among the above biochemical risk factors, multiple regression analysis and backward logistic analysis revealed that d-dimer was the strongest biochemical predictor of thrombosis (P = .013, RR: 17.8). Upon evaluation of genetic risk factors, only factor V Leiden mutation was related to vascular access thrombosis (P = .001). In conclusion, the presence of vascular access thrombosis is a risk factor for mortality during the waiting period for cadaveric renal transplantation. As patients with factor V Leiden mutation or high serum d-dimer levels are at high risk for vascular access thrombosis, we recommend close monitorizing of these patients and use of anticoagulant therapy during the waiting period prior to renal transplantation.

Prevalence and Etiology of Anemia in Renal Transplant Recipients

We aimed to define the prevalence of anemia and possible causes for it in a group of renal transplant recipients. A total of 229 recipients (65 women; age 36.1 +/- 11.8 years; minimum posttransplant duration, 3 years) were included. Patients with iron, vitamin B(12), and folic acid deficiencies were excluded. Patients were grouped according to number of posttransplant years completed with functioning grafts (3, 5, or 10 years). Demographic data, donor information, HLA mismatches, acute rejection episodes, biochemical parameters, and medications received during the 3 months before transplant and at 3, 5, and 10 years posttransplant were collected retrospectively. The anemia threshold was 13 g/dL for men and 12 g/dL for women. Anemia prevalence was 41.5%, 35.3%, and 93.2% at 3, 5, and 10 years, respectively. Anemic patients had higher creatinine levels for all years. In the anemic patients, hemoglobin values were lower in the pretransplant period than at 3 and 5 years. Anemic patients had higher HLA mismatches for the same years. Three-year hemoglobin levels were positively correlated with pretransplant hemoglobin and negatively correlated with creatinine levels and HLA mismatches. Five-year hemoglobin levels were positively correlated with pretransplant hemoglobin and albumin levels. Ten-year hemoglobin levels were positively correlated with pretransplant hemoglobin and albumin values but negatively correlated with creatinine levels and HLA mismatches. The prevalence of anemia in renal transplant recipients increases in parallel with posttransplant duration. Hemoglobin levels in these patients are closely related with pretransplant hemoglobin, follow-up creatinine levels, and HLA mismatches.

Potential effects of 1,25-dihydroxyvitamin D3 in renal transplant recipients

Besides its effects on bone metabolism, calcitriol has an important immunomodulatory effect, which may be protective for a renal allograft. Therefore, we evaluated the effects of oral calcitriol administration in renal transplant recipients. One hundred ten renal transplant recipients (78 men, 32 women) of mean age 35.2 +/- 11.4 years and mean posttransplantation follow-up of 50.7 +/- 22.9 months were entered into the study. Patients in group 1 (n = 57) received calcitriol therapy and patients in group 2 (n = 53) did not. The mean start of calcitriol therapy was 22.4 +/- 19.1 months posttransplantation. We restrospectively collected pretransplantation and posttransplantation laboratory and clinical data as well as creatinine levels before and after the initiation of calcitriol therapy at 6-month intervals for 2 successive years. There were no significant differences in terms of age, gender, immunosuppression, bone mineral densitometry, and follow-up. Our results showed that patients in group 1 had lower pretransplantation and postransplantation body mass index (P < .03; P < .03, respectively), lower posttransplantation third year parathyroid hormone levels (P < .02), and lower requirements for pulse steroid doses (P < .04). Using Friedman repeated measures variance test to analyze the effect of calcitriol, the increase in creatinine levels was significantly lower in group 1 (P < .04). There was no significant difference between follow-up time and calcitriol dose (P > .05). In conclusion, calcitriol therapy may reduce the rate of loss of renal function among patients receiving renal transplants.

Influence of cyclosporine and tacrolimus on serum uric acid levels in stable kidney transplant recipients

Although hyperuricemia is a well-known adverse effect of cyclosporine (CsA) treatment, there are contradictory data regarding the effect of tacrolimus on uric acid levels. The aim of this study was to examine the influences of CsA and tacrolimus-based treatment regimens on serum uric acid levels in 155 renal transplant recipients with normal allograft function who underwent renal transplantation between 1999 and 2002. Serum uric acid levels were recorded at 1, 6, 12, 18, and 24 months follow-up. The patients were treated with CsA-based (n = 73), tacrolimus-based (n = 47), or conversion from CsA-based to tacrolimus-based (n = 35) immunosuppressive regimens. Serum uric acid levels for patients in the CsA and tacrolimus groups were 6.3 +/- 1.6 versus 7.9 +/- 1.9 mg/dL and 6.5 +/- 1.8 versus 8.0 +/- 1.8 mg/dL at the study outset and 24 months, respectively. Both of the treatment regimens showed progressively increasing serum uric acid levels (P < .001). Serum uric acid levels of patients with treatment conversion from CsA to tacrolimus were 8.6 +/- 2.8 mg/dL before conversion and 8.1 +/- 1.9 mg/dL after conversion. There was no alteration in serum uric acid levels after the change of treatment (P > .05). These findings indicate that, compared with CsA, tacrolimus offers no advantage for serum uric acid levels in renal transplant recipients.

Risk factors for osteoporosis in young renal transplant recipients

Osteoporosis is a frequent complication after renal transplantation. Although several risk factors have been defined in its pathogenesis, the parameters influencing this complication in young patients with functioning grafts have not been well defined. We sought to determine the possible risk factors for osteoporosis among 55 male and 27 female renal transplant patients of mean age 35.5 +/- 11.7 years with 68.8% recipients of living-related grafts. Bone mineral densitometry was performed in all patients at 1 year after transplantation. The study utilized the World Health Organization recommendations that define normal (group 1, n = 19), osteopenic (group 2, n = 24), or osteoporotic (group 3, n = 39) patients according to T-score values. Pre- and posttransplant data included gender, age at dialysis onset; age at transplantation; pretransplant dialysis duration; body mass index (BMI); serum calcium, albumin, phosphorus, parathyroid hormone (PTH), and C-reactive protein levels; lipid profile, cumulative doses of immunosuppressive drugs, and pulse steroid dose. Differences between groups 1 and 3 showed that patients with osteoporosis were younger (P < .003) and had started dialysis and underwent transplantation at a younger age than those without osteoporosis (P < .01, P < .003). In addition, pretransplant body weight (P < .02), posttransplant BMI (P < .01), and pretransplant PTH (P < .04), posttransplant total cholesterol, and high-density lipoprotein cholesterol levels were lower among group 3 (P < .004, P < .003). Young adults who started dialysis and underwent transplantation at a younger age were prone to osteoporosis. Additionally, high BMI and cholesterol levels seemed to be preventative for bone loss after transplantation.

Effects of smoking and blood eosinophil count on the development of arteriovenous fistulae thrombosis in hemodialysis patients

Arteriovenous fistulae (AVF) failure is the most common cause of morbidity and hospitalization in hemodialysis (HD) patients. The purpose of this study was to determine the effects of smoking and blood eosinophil count on the development of AVF thrombosis in HD patients. This cross-sectional study included 141 patients (M/F 80/61; age 43.4 +/- 11.6 years, HD duration 7.7 +/- 4.4 years). The following were analyzed as possible risk factors for AVF failure for all patients: demographic features, dialysis time, smoking, medications, body mass index, comorbid diseases, and various laboratory parameters (whole blood count and serum levels of albumin, calcium, phosphorus, uric acid, C-reactive protein, ferritin, and parathyroid hormone). AVF thrombosis was detected in 60 patients; in contrast, 81 patients had no thrombosis. Distributions of age, gender, and HD duration were similar between both groups. Univariate analysis showed that snuffbox AVF location (P < .0001), higher blood eosinophil count (P < .0001), smoking (P < .01), and higher hematocrit level (P < .05) were all associated with AVF thrombosis. According to multivariate analysis by logistic regression models, eosinophil count (RR = 1.005, P < .05) and snuffbox location (RR = 5.970, P < .05) were predictors of AVF thrombosis. When AVF location was excluded from the analysis, smoking (RR = 4.140, P < .01) and high blood eosinophil count (RR = 1.006, P < .005) were independent risk factors for thrombosis. Our study indicates that smoking and high blood eosinophil count may contribute to the development of AVF thrombosis.

Relationship of Posttransplantation Erythrocytosis to Hypercalcemia in Renal Transplant Recipients

Experimental studies have demonstrated that calcium is an essential molecule in modulation of erythropoiesis. The aim of this study was to investigate the role of serum calcium levels on the development of posttransplantation erythrocytosis (PTE) among renal transplant recipients. We enrolled 155 patients (36 females/119 males; mean age, 34.9 +/- 9.7 years) with normal graft function who underwent renal transplantation between 1999 and 2002. All of the demographic features and various laboratory parameters were retrospectively analyzed as possible factors associated with erythrocytosis. PTE appeared in 43 (27.7%) patients during the follow-up period. Sixty-three (40.6%) patients developed hypercalcemia (corrected serum calcium level > or =10.2 mg/dL). Serum calcium levels tended to increase in patients with PTE, but significantly decreased in patients without PTE (10.6 +/- 0.6 vs 9.8 +/- 0.5 mg/dL; P < .0001). Similarly, hypercalcemia was more common among patients with PTE compared with patients without PTE (74.4% vs 27.7%; P < .0001). Hypercalcemic patients had a significantly higher frequency of PTE than normocalcemic patients (50.7% vs 11.9%; P < .0001). There were no differences in other laboratory and demographic data between the patients with and without PTE (P > .05). These findings suggest that hypercalcemia may lead to increased PTE in renal transplant recipients.

Angiotensin-Converting Enzyme and Endothelial Constitutive Nitric Oxide Synthase Polymorphisms in Turkish Renal Transplant Population and Possible Influence on Renal Artery Atherosclerosis and Graft Survival

BACKGROUND

Renal transplant recipients are prone to accelerated atherosclerosis secondary to immunosuppressants, which may decrease graft survival. We sought to analyze the effects on renal graft survival of atherosclerotic degeneration in the renal artery and the influence of angiotensin-converting enzyme (ACE) endothelial constitutive nitric oxide synthase (ecNOS) gene polymorphisms.

METHODS AND PATIENTS

Thirty three renal transplant recipients (25 men) of mean age 28.4 +/- 9.6 years, received organs from 11 living related donors and were followed for at least 36 months. Genotyping was performed for the insertion/deletion ACE (I/D), angiotensin (AGT) (M-->T, 235), angiotensine 1 receptor (A-->C, 1166), angiotensin 2-receptor (A-->G, 1223), and ecNOS (b-->a, intron4) gene polymorphisms. Renal artery biopsies were performed during transplantation surgery to analyze the presence of atherosclerosis.

RESULTS

Pathological examination indicated that 18 donor specimens and nine recipient specimens had atherosclerotic degeneration. Survival analysis (36 months) indicated that graft survival rates of recipients who had atherosclerosis in the renal artery and who received an organ from donors with an atherosclerotic renal artery were shorter than in their counterparts (P = .02, P = .04, respectively). Comparison of genetic variations of recipients revealed that CC/TC variation of AGT was higher in patients with atherosclerosis (81% vs 53%, P = .03). There was no significant difference between groups in means of other gene polymorphisms.

CONCLUSION

Renin-angiotensin system gene polymorphism analysis of patients in renal transplantation waiting list may provide information about allograft survival and posttransplant atherosclerotic degeneration at graft vasculature of young transplant recipients.

Pretransplantation and Posttransplantation Body Mass Indices and Prognosis in Renal Transplant Recipients: Low Versus Normal

Body mass index (BMI) is strongly associated with outcomes in renal transplantation, independent of other risk factors. The aim of this study was to evaluate the impact of low BMI on graft survival in renal transplant recipients. The demographic and laboratory data as well as presence of acute or chronic rejection were retrospectively obtained for 115 recipients (80 men, 35 women) of mean age 34.56 +/- 11.14 years with posttransplantation follow-up duration of 5 years. Pretransplantation and one year posttransplantation BMIs were calculated. Patients were stratified to 2 groups according to their posttransplantation BMIs: group 1 had BMIs <19 kg/m2 (17.8 +/- 1.0; n = 23), and group 2 had BMIs > or =19 kg/m2 (23.7 +/- 1.8; n = 92). Twenty (87.0%) of 23 patients had low pretransplantation BMIs (P <.0001). Although mean serum creatinine levels at discharge after transplantation were lower among the low-BMI group (P <.03), the fifth-year levels were significantly higher in this group than in the normal-BMI group (P = .01). Follow-up serum albumin, triglyceride, and cholesterol levels were lower in group 1. According to the 5-year data, the percentages of recipients who suffered from chronic rejection (73.9% vs 20.7%; P < .001) and graft loss (73.9% vs 31.5%; P <.001) were significantly higher among group 1 than group 2. Multivariate backward analysis disclosed that BMI was closely associated with chronic rejection (P < 0.0001; odds ratio = 14.5; 95% confidence interval 4.3-49.6). In conclusion, a low BMI is an adverse prognostic factor after transplantation. To improve graft outcome, we recommend pretransplantation evaluation of recipient metabolic status, as well as early intensive dietary advice and follow-up for normalization of BMI.

Vitamin D Receptor BsmI and TagI Gene Polymorphisms in a Turkish ESRD Population: Influences on Parathyroid Hormone Response

BACKGROUND

Clinical presentation and complications of end-stage renal disease patients are influenced by many environmental and genetic factors. In this study we sought to define the frequencies of BsmI and TagI vitamin D receptor gene polymorphisms and their influences on clinical presentations in the Turkish end-stage renal disease population.

METHODOLOGY AND PATIENTS

Hemodialyzed patients (n = 186; 111 male, 75 female) were genotyped for the insertion/deletion BsmI (B --> b, restriction site, exon VIII --> IX), TagI (T --> t, 352 exon IX) vitamin D receptor gene polymorphisms. The previous 12 months of laboratory values (C-reactive protein, intact parathyroid hormone, albumin, calcium, phosphorus, CaxP product) and clinical findings (vitamin D requirement, body weight) were analyzed retrospectively.

RESULTS

Mean age and follow-up periods were 42.1 +/- 12.6 years and 76.3 +/- 43.9 months, respectively. Polymorphism percentages were BsmI; BB/Bb/bb: 28.9/65.3/5.8% and TagI; TT/Tt/tt: 36.7/60.5/2.8%, respectively. Further analysis revealed that the TT variant of TagI was related to hyperparathyroidism (P < .05). Analysis of the data after regrouping patients according to iPTH levels (0 to 249; 250 to 499; > or =500 pg/mL) and hemodialysis duration (<60 versus > or =60 months) revealed an influence of TT variation on hyperparathyroidism as a function of increased hemodialysis duration and higher iPTH levels (P < .005).

CONCLUSION

TT variants of the TagI vitamin D receptor gene influence the development of hyperparathyroidism in hemodialysis patients, an influence that becomes more evident in patients with longer hemodialysis duration.

Effect of Amyloidosis on Long-Term Survival in Kidney Transplantation

Amyloidosis is characterized by the accumulation of an amorphous material in various organs and tissues secondary to a variety of inflammatory, immune, infectious, and hereditary diseases. Since 1975, our transplantation team has performed 1470 renal transplantations. Between 1985 and July 2004, among 1159 kidney transplantations, 953 (82.3%) were from living donors and 206 (17.7%) from cadaveric donors. There were 32 recipients (28 men, 4 women; mean age, 31.4 +/- 1.7 years; range, 21 to 48 years) with amyloidosis, including, 28 (87.5%) who received grafts from living donors and 4 (12.5%) from cadaveric donors. Amyloidosis was secondary to familial Mediterranean fever in 22 (68.7%) patients and rheumatoid arthritis in 1 (3.1%). The remaining 9 (28.1%) patients had primary amyloidosis. The mean follow-up time was 51.2 +/- 5.7 months (range, 2-124 months). Mean HLA mismatch rate was 2.2 +/- 1. Twenty-six (81.2%) patients are alive at this time with functioning grafts, and a mean serum creatinine value of 2.1 +/- 1.5 ng/dL. The 1- and 5-year patient and graft survival rates were 90.6% and 84.3%, and 81.2% and 68.7%, respectively. We conclude that patients with amyloidosis may undergo kidney transplantation safely expecting outcomes similar to those patients who receive transplantations for other reasons.

Cholesterol crystal embolization mimicking vasculitis: success with corticosteroid and cyclophosphamide therapy in two cases

Cholesterol crystal embolization is a potential complication of atherosclerosis. Approximately one-third of the patients who develop this problem have a history of vascular surgery, angiography or angioplasty hours to weeks before onset. The skin and the kidneys are most frequently involved, but any organ can be affected. Livedo reticularis of the lower extremities and acrocyanosis (known as "blue toe syndrome") are the most common cutaneous manifestations. Histological examination is the only way to definitively diagnose cholesterol crystal embolization. Recently, it has been proposed that cholesterol embolization is associated with vasculitis, and some authors have labeled this condition a "vasculitis look-alike." There is still no specific treatment for this problem, even in cases that progress to renal failure. However, a few case reports in the literature have noted successful treatment with corticosteroids and cyclophosphamide in patients with deteriorating renal function. In this article, we describe two cases of severe cholesterol crystal embolization accompanied by renal dysfunction) and blue toe syndrome. Both patients benefited from corticosteroid and cyclophosphamide therapy.

Weight Gain After Living-Related Renal Transplantation Affects Long-Term Graft Function

Weight gain is a common problem in renal transplant recipients. This study investigated whether weight gain after living-related renal transplantation affects long-term graft function. The cohort included 93 patients (28 females, 65 males of mean age, 33.78 +/- 9.78 years who were recipients of kidneys from living-related donors. The data set related risk factors to occurrence of chronic allograft nephropathy (CAN): namely, number of HLA mismatches, PRA levels, delayed graft function, acute rejection, suboptimal immunosuppression, hypertension, hyperlipidemia, and size mismatch. Patients with a 10% increase in body mass index sustained throughout at least 2 years posttransplantation were categorized as group 1 (abnormal weight gain; n = 65) and the others were categorized as group 2 (no or normal weight gain; n = 28). Chronic allograft nephropathy was more frequent among group 1 (P < .03). The mean times to CAN diagnosis in groups 1 and 2 were 1053.41 +/- 461.86 days and 1128.57 +/- 416.09 days, respectively (P > .05). Of all the risk factors for CAN, occurrence of acute rejection was the most important (OR = 5.39, 95% CI: 2.07 to 14.03, P < .001). When this factor was excluded, weight gain emerged as the most important risk factor (OR = 3.04, 95% CI: 1.01 to 9.69, P < .04). There were no significant differences between the groups with respect to the frequencies of immunologic and nonimmunologic risk factors (P > .05 for all). The results suggest that excessive weight gain after living-related renal transplantation may be an additional risk factor for development of CAN. Patients should pay attention to diet and control weight gain after transplantation.

Endothelial Nitric Oxide Synthase and Angiotensin II Type 1 Receptor Gene Polymorphisms Can Influence Chronic Inflammatory State in Renal Transplant Patients

Serum C-reactive protein (CRP) is a sensitive indicator of inflammation. Because increasing evidence shows the effect of endothelial nitric oxide synthase (eNOS) and the renin-angiotensin system on inflammation, we studied the association among chronic inflammation, chronic rejection, and gene polymorphisms of angiotensin II type 1 receptor (ATR1) and eNOS in renal transplant patients.

METHODS

Data from 80 male and 35 female renal transplant patients (mean follow-up, 60.6 +/- 22.2 months) were analyzed. Patients were grouped according to posttransplant CRP levels: group 1 patients (n = 46) had normal CRP levels (CRP <10 mg/L); group 2 had intermittent (n = 26), and group 3 had persistently elevated (n = 43) CRP levels. eNOS and ATR1 gene polymorphisms of the groups and the impact of posttransplant CRP response on development of chronic rejection and graft failure were analyzed. The bb allele of the eNOS gene was found in 74% of the patients, whereas 62% had AA allele of ATR1.

RESULTS

Patients in group 1 had a significantly lower incidence of chronic rejection and graft failure when compared with patients in groups 2 and 3 (P = .05 and P = .02 respectively). The bb allele of the eNOS gene predominated in group 1 (P = .02); presence of non-AA allele of ATR1 1166 gene was found less frequently in group 3 (P = .01).

CONCLUSIONS

The presence of the bb allele of the eNOS and non-AA allele of ATR1 1166 gene is associated with an anti-inflammatory state and may predict renal outcome in transplant patients.

The importance of A3 allele in response to hepatitis B vaccine in end-stage renal disease patients

BACKGROUND

Hemodialysis (HD) patients are at high risk for hepatitis B virus (HBV) infection due to intravenous interventions and therapies: Our aim was to examine how genetic factors affect the response to HBV vaccination in HD patients.

METHODS

The frequencies of HLA class I and II alleles were investigated in responders and nonresponders. Response to vaccination was defined as anti-HBsAg > 10 SI U/L (group I). Nonresponders (anti-HBsAg < 10 SI U/L) were defined as group II. The study included HD patients who were negative for antibodies to hepatitis B surface antigen during pretransplantation evaluation.

RESULTS

Group I consisting of 166 patients and group II, of 90 patients showed a significantly higher frequency of the HLA A3 allele in group I (n = 20) than group II (n = 3) (P = .02). There were no statistical differences between the two groups regarding age and gender distribution (P > .05). Graft outcome was not different between responders and nonresponders (P > .05).

CONCLUSIONS

This preliminary study shows that HLA alleles may have immunomodulatory effects in end-stage renal failure patients. The response to hepatitis B vaccination is affected in multifactorially fashion; HLA A3 may be a genetic predictor for responders, but further studies in larger series are required.

Pregnancy during hemodialysis: perinatal outcome in our cases

The perinatal outcome of patients undergoing chronic hemodialysis has been improved in recent years. In this report we review the treatment and outcome of seven pregnancies in women undergoing chronic hemodialysis before and during pregnancy between 2000 and 2002. The hemodialysis schedule was increased from 4 hours twice weekly to 4 hours four to six times weekly. Hemodialysis was performed using a high-flux dialyzer with volume-controlled ultrafiltration. The patients were followed in close collaboration between the obstetrician and the nephrologist. Monitoring of fetal well-being was started after 24 weeks' gestation, using cardiotocography by a nonstress test twice weekly and by weekly Doppler flow measurements. All patients underwent uterine contraction monitoring immediately after the dialysis. The mean gestational age at delivery was 32 weeks (range, 26 to 36 weeks). The causes of preterm delivery were premature contractions, premature rupture of membranes, preeclampsia, and intrauterine growth restriction. The outcomes were two pregnancies complicated by polyhydramnios and six pregnancies, that resulted in live births, all of whom survived. There was one neonatal death. The mean newborn birthweight was 1400 g (range, 420 to 2640 g) and the 1- and 5-minute Apgar scores ranged from 2/8 and 4/10, respectively one infant at 29-weeks gestation experienced respiratory distress syndrome but did well after 12 days. Cesarean section was performed in four pregnancies. The mothers were discharged on postoperative days 3 to 5. It is well known that the management of pregnant patients undergoing chronic hemodialysis is difficult. However, advances in dialysis, obstetrics, and neonatal care have improved the outcomes.

Association of helicobacter pylori infection with nutritional status in hemodialysis patients

The presence of Helicobacter pylori (HP) infection may adversely influence outcome in renal transplant candidates because of its strong association with gastrointestinal disorders. We examined the association between HP infection and nutritional parameters in symptom-free hemodialysis patients and assessed prospectively the nutritional changes in patients who received therapy for the disease. The 163 study patients, including 114 men and 69 women of mean age 41.5 +/- 12.9 years on dialysis for 67.2 +/- 47.6 months, were selected from among the group who underwent routine endoscopic evaluation according to our renal transplant protocol. Patients with active peptic ulcer, acute gastritis, chronic inflammatory disease, malignancy, or diabetes mellitus were excluded. Endoscopy results revealed normal findings in 60 (group 1), gastritis in 86 (group 2), or gastritis with HP in 17 patients (group 3). Group 3 patients received a 2-week course of triple therapy (omeprazole, amoxicillin, clarithromycin). The patient groups were compared for nutritional metrics (albumin, phosphorus, interdialytic weight gain [IDWG], body mass index [BMI]), inflammatory indices (CRP, fibrinogen), and iPTH levels. Group 3 patients were observed to be malnourished when compared with groups 1 and 2, namely abnormal values of albumin (P <.0001), phosphorus (P <.009), IDWG (P <.03), and BMI (P <.02). Repeat endoscopy revealed a 94% rate of eradication of HP with increased levels of albumin and phosphorus in group 3. Although symptom-free hemodialysis patients with HP-associated gastritis displayed a state of malnutrition; its eradication improved the nutritional status. Therefore, the presence of HP infection should be sought and its eradication mandatory for this patient population.

Efficacy and safety of sildenafil citrate in hemodialysis patients

Erectile dysfunction (ED) is more frequent among end-stage renal failure patients than the normal population. Sildenafil citrate has been successfully used for the symptomatic treatment of erectile dysfunction. The aim of this study was to determine the efficacy and safety of sildenafil citrate in the treatment of ED in patients on hemodialysis. Fifty-five hemodialysis patients above 18 years suffering from ED with steady sexual partners were included in the study. The first five and fifteenth questions of the International Index of Erectile Function were employed to evaluate ED in the patient group. A Single 50-mg sildenafil citrate tablet was prescribed for each patient. The patients were encouraged to take it on the day after hemodialysis and 1 hour before sexual intercourse. The erectile function of the patients after the treatment was re-evaluated in the same manner by International Index of Erectile Function. The ages of the patients ranged between 30 and 73 years (mean 50.6 +/- 10.9). The overall response rate was 74.5% (38/51). Side effects were nausea (n = 2), palpitation (n = 2), flushing (n = 1), and angina (n = 1). Sildenafil citrate (50 mg) was observed to be safe and effective for treatment of hemodialysis patients with careful evaluation and proper patient selection.

Osteoarthritis in hemodialysis patients: relationships with bone mineral density and other clinical and laboratory parameters

OBJECTIVE

The aim of this study was to determine the role that hemodialysis (HD) plays in radiologically assessed osteoarthritis (OA) of the hand, knee, and hip.

MATERIALS AND METHODS

Eighty patients who had been on regular HD for at least 2 years were included. Anterior-posterior radiographs of the pelvis, weight-bearing knees, and hands and wrists of each patient were examined. Bone mineral density (BMD) of spine, femur, and forearm was measured.

RESULTS

Radiologic assessment of the 80 patients' hands showed that 41 individuals had osteopenia, 12 had midphalangeal subperiosteal resorption, 11 had cystic bone lesions, eight had bone erosion, four had osteophytic lesions, and three had subchondral sclerosis. Bone erosion in the hands was significantly associated with HD duration, forearm T score, and serum parathyroid hormone level. Radiologically, OA was demonstrated in eight knee and ten hip joints. Minimum joint space in the tibiofemoral compartment correlated with body mass index, and minimum joint space in the hip correlated with age. The mean BMD measurements at all three sites studied in the HD patients were low. Only the duration of HD significantly correlated with forearm BMD.

CONCLUSION

Osteoarticular complications are common in HD patients.