Can calcium, phosphate, calcium phosphate product and intact parathyroid hormone levels be appropriately controlled in dialysis patients?

OBJECTIVE: To review the target levels of calcium (Ca), phosphate (P), calcium phosphate products (Ca × P) and intact parathyroid hormone (iPTH) levels in patients undergoing hemodialysis (HD) and peritoneal dialysis (PD) and compare them with the Kidney Disease Outcome Quality Initiative (K/DOQI) recommendations. SUBJECTS AND METHODS: Three hundred and fifty-seven patients who had been undergoing dialysis for more than 3 months were included. Patients who had undergone a parathyroidectomy were excluded. The levels of Ca, P, iPTH and Ca × P were monitored for the last 3 months. The Ca and P levels were measured by standard techniques, and iPTH was assessed by the intact molecule assay. RESULTS: Between HD and PD patients, there was no statistically significant difference for age, duration of dialysis or primary disease causing end-stage renal disease. The percentage of patients whose serum Ca, P, Ca × P product and iPTH were within K/DOQI recommended target ranges were 61.2, 66.4, 82.2 and 28.3% in HD patients, and 56.3, 60.6, 85.9 and 22.5% in PD patients, respectively. When all results for each group - HD and PD - were analyzed, 12.8% of patients had all 4 markers within the target range. CONCLUSION: Achieving target ranges of mineral markers is important in dialysis patients, but reaching K/DOQI target levels is difficult. Hence, physicians should be careful in using P binders and vitamin D analogs to achieve the normal ranges.

Membranoproliferative glomerulonephritis and light-chain nephropathy in association with chronic lymphocytic leukemia.

The incidence of nephrotic syndrome co-existing with chronic lymphocytic leukemia (CLL) is a rare condition. Almost any glomerular pathology may accompany CLL. The most frequent of all is membranoproliferative glomerulonephritis (MPGN). Moreover, in 5 - 10% of patients with CLL, monoclonal gammopathy may be detected in serum and/or urine samples. There are no well-established treatment protocols for those CLL patients with accompanying nephrotic syndrome. In this case report, we present a 55-year-old female patient diagnosed with CLL, developing nephrotic syndrome, renal dysfunction and IgG k-type monoclonal gammopathy in the follow-up. The renal biopsy revealed glomerular and tubular deposits of k-chain and histopathology of membranoproliferative glomerulonephritis. Rituximab along with CVP (cyclophosphamide - vincristine - prednisolone) chemotherapy regimen was initiated. At the end of 6 courses of treatment, the patient was on "nephrologic" partial remission as the serum creatinine and albumin levels had returned to normal and proteinuria decreased by more than 50%. The patient was also in partial remission for CLL. In conclusion, in patients with CLL and nephrotic syndrome, presence of MPGN along with light-chain nephropathy is rarely reported. Several different treatment protocols are discussed for these patients. Among these regimes, R-CVP is an acceptable alternative for CLL patients with MPGN.

Successful solid organ transplantation from septicemic cadaveric donors: case report.

Systemic donor infections especially with gram-negative organisms are regarded as an absolute contraindication to cadaveric organ donation for transplantation. This is largely due to fear of transmitting the pathogenic organisms to the immunosuppressed recipient. However, due to the current shortage of organs available for transplantation, clinicians are faced with the option to use organs from infected donors. Between 1996 to January 2006, we collected 44 solid organs. Two out of nine donors had microorganisms from blood cultured. Case 1 was of 23-year old woman whose cause of brain death was intracerebral bleeding due to a traffic accident. The donor had stayed 9 days in the intensive care unit prior to brain death. Two kidneys, two livers (split), and or heart were used. Klebsiella was the organism on blood culture. Case 2 was of 35-year-old man; cause of brain death was cerebral hematoma due to traffic accident. The donor had stayed 6 days prior to brain death onset. The liver and two kidneys were used. Acinetobacter baumannii was yielded upon blood culture. All donors were treated with appropriate antibiotics for at least 48 hours prior to organ procurement with consequent negative blood cultures, while the recipients received the same culture-specific antibiotics for 10 days following transplantation. One donor (case 1) heart and both donor corneas were not used due to infection. All patients are alive with excellent graft function at a median of 90 days following transplantation. In conclusion, our results suggested that bacteremic donors with severe sepsis under proper treatment can be considered for transplantation.

Quality of life in hemodialysis, peritoneal dialysis, and transplantation patients.

UNLABELLED: Quality of life (QOL) has recently been explored as one of the main outcomes of renal replacement therapy. In this study, we sought to compare three groups of patients-hemodialysis, peritoneal dialysis, and transplantation-with regard to QOL. METHODS: Seventy-five hemodialysis, 41 peritoneal dialysis and 20 transplant patients were given Patient Information Form, Short Form Health Survey 36, Beck Depression Inventory, and State-Trait Anxiety Inventory. RESULTS: The QOL scores of the three groups were similar and lower than the normal Turkish population. Depression and anxiety levels had significant and negative effects on QOL of hemodialysis and peritoneal dialysis, but not transplant patients. In a multiple regression analysis, being male, being older than 46 years, living with family, having middle-higher income, having renal disease for a longer time, having a longer period of dialysis treatment, having comorbid illness, having not enough illness knowledge, and having higher levels of depression and of anxiety significantly correlated with a worse quality of life. CONCLUSIONS: The three forms of renal replacement therapy did not differ with regard to QOL. Among the factors that seem to affect QOL, psychological status and treatment/illness knowledge had the most significant correlation. The underlying mechanisms need to be clarified.

Dialysate leakage in CAPD patients.

Dialysate leakage may occur through the anterior abdominal wall, the genital organs or the pleural cavity during the early or late stages of dialysis in patients who are on continuous ambulatory peritoneal dialysis (CAPD). This dialysate leakage can reach such an extent that CAPD treatment may need to be halted. Dialysate leakage through the subcutaneous anterior abdominal wall can be caused by a deficiency in the abdominal muscles. In this study, 3 patients on CAPD who had a dialysate leak through the subcutaneous anterior abdominal wall were followed. An exercise programme was offered to strengthen abdominal muscles. CAPD continued but volumes were reduced by 6-25%. Exercise programmes for abdominal muscles may be useful for the prevention of leakage through the subcutaneous anterior abdominal wall, without having to interrupt CAPD treatment.

The effects of rofecoxib on 24-h ambulatory blood pressure and heart rate monitoring in patients with hypertension and osteoarthritis.

The aim of the study was to investigate the effects of the cylooxygenase (COX)-2 specific inhibitor rofecoxib, on blood pressure (BP) and heart rate (HR) in patients with well-controlled hypertension and osteoarthritis via 24-h ambulatory monitoring. Thirty patients with well controlled hypertension were included. Fifteen patients had osteoarthritis and were recommended by their rheumatologists to take rofecoxib 12.5 mg/day (rofecoxib group). The control group consisted of 15 patients who had hypertension but no clinical osteoarthritis and did not receive any anti-inflammatory drugs. Twenty-four-hour ambulatory monitoring of BP and HR were performed on the day before initiation of rofecoxib therapy and on days 3 and 14 of COX-2 therapy. The control group underwent 24-h monitoring three times at similar intervals. Antihypertensive medications were continued. On day 3 of rofecoxib therapy, mean HR for both daytime and nighttime were lower than those at baseline. On day 14, the changes in mean HR did not differ from baseline values. Similarly, diastolic BP (daytime and nighttime) on day 3 appeared to be lower than at baseline. However this difference was not observed on day 14, and mean daytime and nighttime diastolic BP returned to baseline values. There was no statistically significant difference in the mean arterial pressure or systolic BP recordings on days 3 or 14 than at baseline. Rofecoxib 12.5 mg/day did not significantly increase BP during 24-h ambulatory BP monitoring in patients with well-controlled hypertension and osteoarthritis.

Gastric emptying time in renal transplant recipients treated with cyclosporine.

Gastric emptying time (GET) appears to be a rate-limiting factor in the absorption of cyclosporine-A (CsA) and may be responsible for intra- and interpatient variability of CsA bioavailability. Few studies have assessed gastric motility after renal transplantation. The purpose of this study was to evaluate gastric emptying of semi-solid material in stable renal transplant patients with reference to blood CsA levels. The GET of semi-solids (GET t(1/2), half emptying time) was measured in 16 transplant recipients who were taking CsA (Neoral), prednisolone and azathioprine (or mycophenolate mofetil). The GET (t(1/2)) measured by radionuclide methods, was analyzed with reference to the daily CsA doses, levels of CsA (C(0)), and serum creatinine concentrations. The mean GET (t(1/2)) was 89.1 +/- 26.4 minutes. Twelve patients exhibited delayed gastric emptying with a mean CsA level of 171.8 +/- 56 ng/mL and a mean dose of 4.1 +/- 1.1 mg/kg/d. The GET (t(1/2)) was not significantly correlated with the serum creatinine levels, the time since transplantation, or the CsA concentration. In addition, the correlation between the mean daily CsA dose and the GET (t(1/2)) was only weakly positive, (r =.33, P =.2) and therefore, statistically insignificant. In conclusion, it could not be ascertained whether a higher dose of CsA delays gastric emptying or whether patients with delayed emptying require higher doses of CsA. However, it is believed that determining the GET after transplantation helps in the adjustment of immunosuppressant doses.

Localized Castleman's disease and nephrotic syndrome not responsive to resection plus colchicine therapy.

We describe one patient with localized Castleman's disease (CD) of the mixed hyaline vascular and plasma cell type located at the mesentery of the small bowel, associated with systemic amyloidosis and nephrotic syndrome. A true nephrotic syndrome has rarely been reported in patients with CD. In the literature, it has been suggested that clinical and laboratory manifestations generally improved after surgical resection of the tumor. However, in our case, clinical and laboratory findings did not regress after operation followed by colchicine therapy.

Cyclosporine-A induced neurotoxicity after renal transplantation.

Cyclosporine-A is a highly potent immunosuppressive agent for solid organ transplantation, but has many side effects including nephrotoxicity, hypertension, gum hyperplasia, hepatotoxicity, and neurotoxicity. Neurotoxicity is a less known toxic effect. The pathogenesis of this effect is unclear. However, it has been postulated that hypomagnesemia, hypocholesterolemia, corticosteroids, and/or neurotoxic substances can induce this syndrome. Also, it has been suggested that the endothelial damage caused by Cyclosporine-A may contribute to neuropeptide-mediated ischemia in the brain and lead to the development of neurological symptoms. In this report, we present a case with reversible neurologic deficits whose symptoms returned to normal after the cessation of cyclosporine-A.

Nonrelated living-donor kidney transplantation: medical and ethical aspects.

Several patients with end-stage renal disease went to Bombay for renal transplantation from nonrelated living donors and then returned to Turkey for posttransplantation follow-up. The aims of this study are to evaluate the long-term results of renal transplantation from nonrelated living donors in Turkish patients with end-stage renal disease and to discuss the ethical and social aspects of nonrelated kidney donation. One hundred and twenty-seven patients (89 males, 38 females; mean age 38.1, range 17-63 years) were investigated retrospectively. None of the patients went to Bombay on our advice. All transplantations were performed between 1991 and 1995. The mean follow-up period after transplantation was 34.2 (range 1-68) months. Graft survival rates were 85, 83, and 57% after 3 months and 1 and 5 years, respectively. Patient survival rates were 94, 93, and 92% after 3 months and 1 and 5 years, respectively. Seven patients died within the first 3 months after the transplantation. Surgical problems, infections, acute rejection, ciclosporin nephrotoxicity, and hepatic problems were common complications. We conclude that medical and surgical complications occur frequently in paid kidney transplantation, but most of these complications can be prevented by adequate preoperative management, and precautionary measures should be taken to prevent commercialization of renal transplantation before the spread of emotionally related living kidney donation.

Renal artery reconstruction in transplant kidney. Case report.

A 30 years old female patient, to whom a cadaveric kidney transplantation was performed 7 years earlier, presented severe hypertension attacks for 2 years. Renal artery stenosis diagnosed by angiography, PTA could not be performed. She underwent an operation for surgical correction of stenosis and successful internal iliac renal artery anastomosis performed by saphenous vein interposition. The patient was discharged at the fourteenth postoperative day with excellent kidney function and stable blood pressure.