Efficacy and safety of Sinovac vaccine administered in patients undergoing hemodialysis.

INTRODUCTION: COVID-19 disease is more serious and fatal in patients on dialysis treatment due to their immunosuppressive status. In this study, we aimed to evaluate the protection and safety of Sinovac vaccine, which is an inactivated vaccine, in patients undergoing hemodialysis. METHODOLOGY: A control group consisting of 220 hemodialysis patients (HD group) and 648 healthcare professionals who were healthy in our institution were included in the study. Quant II IgG anti-Spike antibody was measured 3 weeks after two doses of Sinovac vaccine were administered to both groups. RESULTS: The antibody response after two doses of Sinovac vaccine was 85.2% in the HD group and 99.8% in the control group. The mean antibody level before vaccination in the HD group was 3.5 ± 7.2 AU/mL and increased significantly 3 weeks after two doses of vaccine (mean 751 ± 1196 AU/mL). The control group's mean antibody level after vaccination was 1723 ± 1878 AU/mL. The mean antibody level after vaccination in the control group was significantly higher than the HD group (p < 0.0001). Despite higher levels of anti-Spike antibodies in the control group, post-vaccination antibody response was acceptable in both HD and control groups. The HD group was significantly older (mean 64 ± 12 years) than the control group (36 ± 10 years) (p < 0.0001). CONCLUSIONS: Although dialysis patients are immunocompromised, and some may not develop antibodies to the virus as strongly as healthy people, this study revealed that dialysis patients developed significant amounts of antibodies. Being old or on dialysis is an independent predictor of low antibody response to the Sinovac vaccine.

An unresolved issue: The relationship between spot urine protein-to-creatinine ratio and 24-hour proteinuria.

OBJECTIVE: To investigate the relationship between spot urine protein-to-creatinine (sP/Cr) ratio and 24-h protein excretion in patients with different diagnoses. METHODS: This retrospective study analysed data from the medical records of patients admitted for24-h proteinuria determination who also had sP/Cr ratio data for the same day. RESULTS: A total of 1222 urine samples obtained from 694 adult outpatients were analysed. The mean ± SD age of the patients was 53.6 ± 15.9 years. The mean ± SD 24-h proteinuria and sP/Cr were 1.7 ± 2.4 g/day and 1.8 ± 2.4, respectively. The correlation between the sP/Cr and 24-h protein excretion was high (R2 = 0.89). The sP/Cr ratio accounted for 72% of the variability in 24-h proteinuria in the entire study population. Areas under the curve for 24-h proteinuria at 0.3 g/day, 1.0 g/day and 3.0 g/day were 0.940, 0.966, and 0.949, respectively. The mean + 2SD limits of agreement were between +2.99 and -2.73 g/day according to the Bland Altman analysis. CONCLUSION: This current study found a clinically unacceptable deviation between 24-h proteinuria and sP/Cr ratio. Therefore, the sP/Cr ratio cannot replace 24-h proteinuria. A new method using spot urine protein and creatinine values that is able to minimize under or over estimation is still warranted.

Hyaluronic Acid as a New Biomarker to Differentiate Acute Kidney Injury From Chronic Kidney Disease.

INTRODUCTION: It may be difficult to differentiate acute kidney injury from chronic kidney disease in patients with no past medical reports of kidney function. This study aimed to investigate the role of serum hyaluronic acid (HA), which is known as a marker of fibrosis, in differential diagnosis of kidney failure. MATERIALS AND METHODS: A total of 90 patients (52 women and 38 mne) admitted to our renal unit with uremia for the first time were included. Serum HA level was measured. The diagnostic role of the test was investigated using the receiver operator curve curves. RESULTS: The mean age of the patients was 54.6 ±17.9 years. The diagnosis was chronic kidney disease (CKD) in 41.1%, acute kidney injury (AKI) in 48.9%, AKI on CKD in 6.7% (3 died without a diagnosis). The mean serum HA was significantly higher in the CKD group (146.1 ± 119.3 ng/mL) than the AKI group (68.9 ± 69.1 ng/mL; P < .001). Serum HA significantly correlated with proteinuria (r = 0.717, P < .001) and serum albumin level (r = - 0.599, P < .001) in the CKD group only. Serum HA cutoff level of 61 ng/dL had a sensitivity of 82% and specificity of 67% for differential diagnosis of AKI and CKD. CONCLUSIONS: Serum HA level may be used as tool to differentiate AKI from CKD. Further larger studies are warranted to clarify the definite the role of this marker.

A novel factor for primary arteriovenous fistula failure: hyperinsulinism.

INTRODUCTION: Dysfunction of vascular access is an important reason of morbidity for dialysis patients and it is a major factor affecting the economical burden of hemodialysis. The preferred type of vascular access is creation of an arteriovenous fistula (AVF). However, the problem of fistula maturation rate is still a challenge. Herein, we tried to search the role of hyperinsulinism and insulin resistance as a new predictor of primary AVF failure (pAVFF) that may be a cause of intimal damage. METHODS: We included 119 patients (73 male and 46 female) with a diagnosis of end-stage renal disease (ESRD) who had undergone an AVF operation by a vascular surgeon. The AVF was examined for presence of thrill on the first postoperative day. A successful cannulation with two fistula needles with a blood flow of 250 mL/min for at least one complete dialysis session, after 4 weeks of AVF surgery was defined as functioning access. Insulin resistance in our patients was determined by the standard homeostasis model assessment (homa-IR). A logistic-regression analysis was performed to investigate the independent factors related with pAVFF. FINDINGS: Detection of pAVFF occurred in 27 (22.7%) patients. The presence of thrill, amount of daily proteinuria, insulin levels, homa-IR, and serum albumin levels were found to be significantly different between patients with fistula failure and those without pAVFF. The logistic-regression analysis of preoperative factors revealed the following OR (odds ratio) and 95% CI values: homa-IR 1.205 (1.063-1.366) (p = 0.004), serum albumin 0.398 (0.178-0.892) (p = 0.025), and the amount of daily proteinuria 1.307 (1.012-1.688) (p = 0.041). Even after addition of the presence of postoperative thrill on AVF, which was a postoperative strong clinical factor to the analysis, mean homa-IR and mean serum albumin continued to be independent predictors of pAVFF. DISCUSSION: Insulin resistance or hyperinsulinism may be a significant cause of pAVFF, which emphasizes the role of endothelium in fistula dysfunction.

Type 4 renal tubular acidosis in a patient with lupus nephritis.

Although renal tubular acidosis (RTA) is a rare complication of systemic lupus erythematosus (SLE), type 4 RTA associated with lupus nephritis is extremely rare. A 20-year-old woman presented with malaise and edema in the lower extremities and face. She had multiple lymphadenopathies. There were 20% eosinophil in blood smear and 32% in bone marrow aspiration. Serology revealed positive antinuclear antibody at 1:1000 titer, positive double-stranded DNA antibodies, and low complements C3 and C4 levels. Urinary sediment was active and urinary protein excretion was 4.8 g/d. The SLE Disease Activity Index score was 23. A high SLE Disease Activity Index scores was proposed as a potential risk factor for type 4 RTA. Type 4 RTA may complicate SLE, and specifically, patients with high SLEDAI scores and lymphadenopathy may pose a high risk. Our patient responded successfully to immunomodulatory therapy.

Predictive value of serum NT-proBNP levels in type 2 diabetic people with diabetic nephropathy.

OBJECTIVE: The serum N-terminal fragment of pro brain natriuretic peptide (NT-proBNP) level in type 2 diabetic subjects with or without diabetic nephropathy (DN) is still unclear. We aimed to evaluate the relationship between serum NT-proBNP levels and different stages of diabetic nephropathy, and identify probable factors predicting serum NT-proBNP level. SUBJECTS AND METHODS: This cross-sectional study included 20 normoalbuminuric (Group-I), 28 microalbuminuric (Group-II), 20 macroalbuminuric type 2 diabetic patients (Group-III), and 20 healthy volunteers (Group-IV). Serum NT-proBNP levels were measured with highly sensitive and specific immunoassay. RESULTS: Mean NT-proBNP levels were 32 ± 55, 91 ± 95, 331 ± 297, 42 ± 34 pg/ml for Groups I-IV, respectively. When patients with LVH were excluded, mean logNT-proBNP was still significantly higher in Group-III than all other groups. The three diabetic groups were similar in age, BMI, HbA1c, fasting serum glucose, and GFR. In a multivariate linear regression model, adjusting for factors significantly correlated with NT-proBNP levels, the patient group, presence of LVH, and hemoglobin remained as an independent predictor of serum NT-proBNP. These variables explained 68% of the variability of NT-proBNP (adjusted R(2)=0.683). CONCLUSIONS: Mean serum NT-proBNP level of macroalbuminuric diabetic patients was higher than normoalbuminuric and microalbuminuric diabetic patients, and healthy control subjects even after exclusion of LVH. NT-proBNP may be a useful and predictive marker of diabetic nephropathy.

Rhabdomyolysis-induced acute renal failure following fenofibrate therapy: a case report and literature review.

Fenofibrate, a fibric acid derivative, is used to treat diabetic dyslipidemia, hypertriglyceridemia, and combined hyperlipidemia, administered alone or in combination with statins. Rhabdomyolysis is defined as a pathological condition involving skeletal muscle cell damage leading to the release of toxic intracellular material into circulation. Its major causes include muscle compression or overexertion; trauma; ischemia; toxins; cocaine, alcohol, and drug use; metabolic disorders; infections. However, rhabdomyolysis associated with fenofibrate is extremely rare. Herein we report a 45-year-old female patient who was referred to our department because of generalized muscle pain, fatigue, weakness, and oliguria over the preceding 3 weeks. On the basis of the pathogenesis and clinical and laboratory examinations, a diagnosis of acute renal failure secondary to fenofibrate-induced rhabdomyolysis was made. Weekly followups for patients who are administered fenofibrate are the most important way to prevent possible complications.

Unusual presentation of eosinophilic fasciitis: two case reports and a review of the literature.

INTRODUCTION: Eosinophilic fasciitis is an uncommon disorder with unknown etiology and a poorly understood pathogenesis. We present the cases of two patients with eosinophilic fasciitis with unusual presentation, and describe the clinical characteristics and laboratory findings related to them. CASE PRESENTATION: The first case involves a 29-year-old Turkish man admitted with pain, edema and induration of his right-upper and left-lower limbs. Unilateral edema and stiffness with prominent pretibial edema was noted upon physical examination. A high eosinophil count was found on the peripheral smear. The second case involves a 63-year-old Turkish man who had pain, edema, erythema, and itching on his upper and lower extremities, which developed after strenuous physical activity. He had cervical lymphadenopathy and polyarthritis upon physical examination, and rheumatoid factor and antinuclear antibody upon laboratory examination. CONCLUSION: Eosinophilic fasciitis can present with various symptoms. When patients exhibit eosinophilia, arthralgia and myalgia, eosinophilic fasciitis should be considered as a possible diagnosis.

Role of lean body mass for estimation of glomerular filtration rate in patients with chronic kidney disease with various body mass indices.

OBJECTIVE: Glomerular filtration rate (GFR) is the main tool used to diagnose, treat and follow up renal diseases. Age, gender, ethnicity and obesity all affect the relationship between serum creatinine, muscle mass/body weight and GFR. This study aimed to investigate the role of lean body mass for GFR estimation in patients with chronic kidney disease (CKD) with various body mass indices. MATERIAL AND METHODS: In total, 110 Caucasian adult subjects with CKD referred for GFR measurement by (99m)Tc-DTPA renography were enrolled in the study. The patients were categorized according to body mass index values: <18.5 kg/m(2) (underweight), 18.5-24.9 kg/m(2) (normal), 25-29.9 kg/m(2) (overweight) and >30 kg/m(2) (obese). Lean body mass (LBM) and fat mass were measured by leg-to-leg bioimpedance. Predictive factors were identified by linear regression analysis in each group. RESULTS: GFR measured by DTPA, creatinine clearance, Cockcroft and Gault, and Modification of Diet in Renal Disease (four-variable) equations was 37+/-27, 42+/-30, 42+/-27, and 49+/-35 ml/min/1.73 m(2), respectively. The predictive role of 1/SCr, age, serum albumin, amount of proteinuria, LBM and fat mass was investigated all groups. None of the factors was significant in underweight and healthy weight groups except for 1/serum creatinine (SCr). LBM/SCr was an independent predictive factor for both overweight and obese groups. 1/SCr accounted for 96.2% of the variability in measured GFR for underweight subjects but only 58.1% of the variability in GFR of obese subjects. CONCLUSIONS: The formulae derived from SCr should be used cautiously in overweight and obese subjects. LBM measured by bioimpedance was an independent predictive factor of GFR in obese/overweight subjects and added clinically important diagnostic value to 1/SCr. It needs to be investigated as a parameter in further studies attempting to develop formulae for estimating GFR in larger obese and overweight populations.

Thrombophilias and arteriovenous fistula dysfunction in maintenance hemodialysis.

Most episodes of fistula thrombosis are consequences of underlying physioanatomic abnormalities. However, some dialysis access thrombosis develops independent from any obvious anatomic cause. We aimed to clarify the role of thrombophilias in primary and secondary AVF failure. One hundred eighty nine arteriovenous fistulas in 116 adults on maintenance hemodialysis were analyzed. All subjects were evaluated for many thrombotic factors. Fistula information was obtained both from the patients' self reports, and from their medical records. Twenty-seven AVFs in 18 cases (14.3%) had pAVFF. The percentage of subjects with a BMI < 20 kg/m(2) was significantly lower than no-pAVFF group (P = 0.03). ATIII levels and albumin values were significantly lower in patients with sAVFF compared to those with no sAVFF. Other parameters were similar. There was no statistically significant difference between pAFFF versus No-pAFFF and sAFFF versus No-sAFFF groups with respect to all mutant alleles count. Routine extended analyses of all thrombophillic factors are not recommended in AVFF.

Thrombosis of temporal artery and renal vein in Kimura-disease-related nephrotic syndrome.

Kimura disease (KD) is an angiolymphoid proliferative disorder of unknown etiology, occurs mainly in Asian patients, presenting with subcutaneous slowly growing masses, with a predilection for preauricular and submandibular regions. The clinical course of the disease is thought to be benign. Concomitant peripheral blood eosinophilia and elevated serum immunoglobulin E levels are often observed. Main systemic manifestation of the KD is renal involvement. Renal abnormalities, notably proteinuria and nephrotic syndrome have been found to be associated with KD. We report a 42-year-old man with KD and a steroid-sensitive membraneous nephrotic syndrome with bilaterally temporal artery and renal vein thrombosis. This is the first reported case of KD associated nephrotic syndrome complicated with wide arterial and venous thrombosis from Anatolia.

Socio-cultural features and sex profile of the individuals with serious suicide attempts in southeastern Turkey: a one-year survey.

Our objective was to elucidate potential causes of higher rates of suicide attempts in females compared to males in southeastern Turkey through a 1-year survey. Gender-related differences observed in 96 subjects who attempted suicide by poisoning for the first time were as follows: in comparison to male, females were predominantly within the age interval of 15-24 years, experienced more stressful events in the previous week before suicide attempt, had lower education level, and had a lower rate of employment. One year after the suicide attempt, unfavorable attitude of family, lack of support, persisting unfavorable lifestyle comparable with that prior to the first attempt, and higher rates of domestic violence were more pronounced in females compared to males. These findings might be contributing factors to the higher suicide attempt rates observed in females compared to the males.

Snakebite-induced acute kidney injury: data from Southeast Anatolia.

Renal failure is an important complication of snakebite and a major cause of mortality. We aimed to study the clinical profile of snake envenomation in Southeast Anatolia, Turkey, in an adult population. We retrospectively analyzed the records of 200 snakebite victims from 1998 to 2006 at the Dicle University School of Medicine, Diyarbakir, Turkey. Sixteen patients (8%) developed AKI (acute kidney injury). Of those, 25% required dialysis and 18% died. There was no difference between groups in age, arrival time to hospital, and hospital stay time. Both groups received similar hydration and therapy at admission. Disseminated intravascular coagulation (DIC) was observed in 25% of the AKI group and was significantly higher than the non-AKI group (7.1%; p = 0.014). There was no significant difference regarding hemoglobin, platelet levels, and prothrombin time at admission. The prevalence of thrombocytopenia (<150,000 K/UL ) was 60% in the AKI group and 40% in the non-AKI group (p > 0.05). WBC count was significantly higher in the AKI group than in those without AKI (p = 0.001); serum albumin was significantly lower in the AKI group than in those without AKI (p = 0.013). AKI is an important complication of snakebite that may lead to mortality. Despite some troublesome aspects due to its retrospective design, this is a large series from Southeast Anatolia of Turkey in an adult population. Subjects with high WBC, low albumin, and DIC should be closely followed up for the development of AKI.

Ureterosigmoidostomy[corrected]-associated quadriparesis, non-traumatic rhabdomyolysis, and tetany in an adult.

We report an adult case of ureterosigmoidostomy-associated quadriparesis, rhabdomyolysis, and tetany which may be the first such case in the literature. A 32-year-old female patient was brought to the emergency room of our hospital, having been unable to walk or use her arms for 24 h. Neurological examination revealed quadriparesis. She had severe hypokalemia (1.27 mmol/l) and metabolic acidosis (pH=7.05). Creatine kinase value was 2,590 U/l on the third day. She received intensive therapy to correct the hypokalemia and acidosis. On the third day of hospitalization tetany was detected in her upper extremities. The patient regained full muscle power after intravenous potassium chloride, bicarbonate, and calcium replacement therapy.

Spontaneous coronary artery dissection during hemodialysis in the post-abortion period.

Spontaneous coronary dissection (SCAD) is an unusual cause of acute myocardial infarction with complex pathophysiology. We present a case of acute inferior myocardial infarction resulting from spontaneous coronary artery dissection of the right coronary artery in a 33-year-old woman during the hemodialysis due to a recent abortion and consequent curettage at first trimester of her pregnancy. This report describes a previously healthy woman without traditional cardiovascular risk factors who presented with an acute inferior myocardial infarction. Spontaneous coronary artery dissection (SCAD) should be considered as a cause of the acute myocardial infarction in young patients without traditional risk factors for coronary artery disease, in females in the both peri-partum and post-abortion period.

Spontaneous bacterial peritonitis: pathogenesis, diagnosis, and management.

Spontaneous bacterial peritonitis (SBP) is a bacterial infection of ascitic fluid which arises in the absence of any other intraabdominal infection source. SBP may develop in all cirrhotic patients with ascites. Gram-negative aerobic bacteria and non-enterococcal Streptococcus spp. are the most common organisms isolated from ascites. Diagnosis necessarily relies on paracentesis and requires a high index of suspicion. The incidence of mortality of the first episode varies between 10% and 46%. Early antibiotic treatment is warranted. Renal impairment develops in approximately one-third of patients with spontaneous bacterial peritonitis and is postulated to arise as a result of a further reduction in effective arterial blood volume. Cefotaxime has been the most extensively studied antibiotic for this infection. It is considered to be one of the first choice antibiotics because of low toxicity and excellent efficacy. Although parenteral antibiotics are generally used, studies evaluated the efficacy of several oral antibiotics in patients with relatively good clinical conditions. The reported probability of spontaneous bacterial peritonitis recurrence one year after the first attack averaged 40 to 69%. Selective intestinal decontamination with 400 mg norfloxacin per day decreased the overall probability of recurrence from 68% to 20% in 1 year of follow-up.