LIVER DAMAGE CAUSED BY ATORVASTATIN AND CYCLOSPORINE IN PATIENTS WITH RENAL TRANSPLANT

Transplantacija bubrega jedna je od metoda izbora u liječenju završnog stadija kronične bubrežne bolesti koja uvelike poboljšava kvalitetu života bolesnika, a u usporedbi s dijalizom produžava i preživljenje. Da bi se spriječilo akutno ili kronično odbacivanje presatka potrebno je liječenje imunosupresivnom terapijom koje zahtijeva održavanje koncentracije lijeka u optimalnim vrijednostima čime će se spriječiti odbacivanje transplantata, a ujedno potencijalne nuspojave svesti na najmanju moguću mjeru. Nefrotoksičnost, hepatotoksičnost, srčano-žilne bolesti, post-transplantacijski dijabetes, kronična disfunkcija presatka, dislipidemija samo su neke od komplikacija koje mogu nastati zbog djelovanja imunosupresivne terapije. Dislipidemija je veliki problem zbog činjenice da povećava rizik od srčanožilne smrtnosti kod bolesnika u kojih je taj rizik već u startu veći nego u općoj populaciji. Osim toga vrlo često dolazi do interakcije između imunosupresivne terapije, pogotovo ciklosporina te lijekova koji se koriste u liječenju dislipidemije. Prikazujemo slučaj teške hepatotoksičnosti uzrokovane primjenom atorvastatina u bolesnika liječenog ciklosporinom. Ukidanjem atorvastatina i zamjenom ciklosporina everolimusom postignuta je normalizacija jetrene funkcije uz stabilnu funkciju presađenog bubrega.Kidney transplantation is the preferred method of treatment of end-stage renal disease, which significantly improves the quality of life, but also increases survival when compared to dialysis. Prevention of acute or chronic rejection demands the use of immunosuppression. However, nephrotoxicity, hepatotoxicity, cardiovascular disease, post-transplantation diabetes mellitus, chronic graft dysfunction and dyslipidemia may all occur as complications of immunosuppressive therapy. Dyslipidemia is a significant problem in renal transplant recipients due to the fact that it increases the risk of cardiovascular mortality in patients in whom the risk is already higher than in the general population. Very often, there is an interaction between immunosuppressive drugs, especially cyclosporine, and drugs that are used in the treatment of dyslipidemia. We present a case of a patient who developed severe hepatotoxicity after the introduction of atorvastatin in a cyclosporine-based immunosuppressive regimen. After discontinuation of atorvastatin and replacement of cyclosporine with everolimus, liver chemistries returned to normal values

Ishod starijih bolesnika s ANCA glomerulonefritisom liječenih imunosupresivnom terapijom

The most common cause of rapidly progressive glomerulonephritis in elderly, antineutrophil cytoplasmic antibody-associated glomerulonephritis (ANCA-GN), demands immunosuppressive therapy (IS) regimen in a multi-morbid disease burdened population. Our aim was to assess outcome differences in two age groups. The study included a total of 38 ANCA-GN renal limited patients (18 men) treated from 1990 to 2018, of which 11 were 65 years of age and older (median 70, min. - max. 66 - 79 years), and 27 younger than 65 (median 55, min. - max. 23 - 64 years). All patients were treated with mono/combination of IS. Most commonly applied IS in elderly was combination of IV cyclophosphamide and corticosteroids (CS) (in 9 [81.8%]), while in younger it was a combination of CS and cyclophosphamide or rituximab (59.2%). Older patients had comparable mortality (3, [14.8%] vs. 4, [27.3%]; P = 0.369), malignancies (1, [3.7%] vs. 1, [9.1%]; P = 0.5) and infectious complications (10, [46.7%] vs. 7, [63.6%]; P = 0.388). Ten patients at the end of the follow up were at renal replacement therapy (RRT ), with no difference between age groups (6, [22.2%] vs. 4, [36.4%]; P = 0.369). Interestingly, from initial need for RRT , half of the younger and older patients recovered with IS. Our findings give more credit to the current paradigm to treat elderly ANCA-GN patients with IS therapy due to the similar outcome of elderly as younger ones.Najčešći uzrok brzoprogresivnog glomerulonefritisa u starijih je glomerulonefritis s antineutrofilnim citoplazmatskim protutijelima (ANCA-GN, od eng. antineutrophil cytoplasmic antibody related glomerulonephritis), a s obzirom na komorbiditete predstavlja izazov u odluci oko primjene imunosupresivne terapije (IS). Cilj ovog istraživanja je usporediti razlike u ishodu dvije dobne skupine bolesnika. Istraživanje je obuhvatilo slučajeve ANCA-GN ograničenih na bubrege, liječene od 1990. do 2018. godine, njih 38 (18 muških), od kojih 11 ima 65 ili više godina (medijan 70, min.-max. 66 - 79 godina) a 27 mlađih (medijan 55, min. - max. 23 - 64 godina). Svi bolesnici su liječeni monoterapijom ili kombinacijom IS-a. Najčešće primjenjena IS u starijoj populaciji bila je kombinacija intravenskog ciklofosfamida i kortikosteroida (KS) (u 9 (81,8%)), u mlađoj kombinacija KS s ciklofosfamidom ili rituksimabom (59,2%). Stariji pacijenti imali su sličnu učestalost smrtnosti (3, 14,8% vs 4, 27,3%; P = 0.369), zloćudnih bolesti (1, 3,7% vs 1, 9,1%; P = 0.5) i infektivnih komplikacija (10, 46,7% vs 7, 63,6%); P = 0.388). Deset bolesnika je na kraju praćenja bila ovisno o nadomještanju bubrežne funkcije (NBF) bez razlike u dobnoj skupini (6, 22,2% vs 4, 36,4%; P = 0.369). Međutim, od inicijalne potrebe NBF-om se uz IS oporavila polovica starijih i mlađih bolesnika. Naši rezultati su u skladu trenutačnim stajalištima koja podupiru primjenu IS terapije kod starijih bolesnika sa ANCA-GN zbog usporedivih ishoda i rizika komplikacija kao u mlađih bolesnika

Typical course of cystinuria leading to untypical complications in pregnancy: A case report and review of literature

Cystinuria is a rare genetic disorder inherited by an autosomal recessive pattern which affects the transmembrane transporter for the base amino acid cystine. It has a general prevalence of 1 in 7000 with demographic variations. Patients with cystinuria have excessive urinary excretion of cystine, which can lead to the formation of stones. Up to 70% of patients will develop chronic kidney disease that can progress even to end-stage renal disease. Symptoms usually start in the first two decades of life with a typical presentation consisting of flank pain and renal colic, usually accompanied by urinary tract infection and deterioration of kidney function. Men are typically affected twice as often as women and have a more severe clinical course. Diagnosis is made by spectrophotometric analysis of the stones that are collected after spontaneous expulsion or medical intervention. Genetic testing is not mandatory but is recommended in uncertain cases or as a part of genetic counseling. Treatment consists of diet modification, alkalization of urine, and thiol-based therapies if other measures fail to prevent stone formation. In pregnancy, cystinuria with the formation of cystine stones represents a therapeutic challenge and requires a multidisciplinary approach consisting of an uro-nephrology team and a gynecologist. We present the case of a 34-year-old woman with cystinuria on whom the diagnosis was made by analysis of the expulsed stone. While her previous pregnancies were without complications, her third pregnancy was accompanied by frequent urinary tract infections, acute worsening of kidney function, and urological interventions during pregnancy due to the formation of new stones. Despite the complicated course, the pregnancy was successfully carried to term with the delivery of a healthy female child

Case report: Sevelamer-associated colitis-a cause of pseudotumor formation with colon perforation and life-threatening bleeding

Chronic kidney disease (CKD) is a very common chronic non-communicable disease. Phosphate and calcium metabolism disorders are one of the most common features of CKD. Sevelamer carbonate is the most widely used non-calcium phosphate binder. Gastrointestinal (GI) injury associated with sevelamer use is a documented adverse effect but is underrecognized as a cause of gastrointestinal symptoms in patients with CKD. We report a case of a 74-year-old woman taking low-dose sevelamer with serious gastrointestinal adverse effects causing colon rupture and severe gastrointestinal bleeding