Nephro-Urology Monthly
Year:2010 | Volume:2 | Issue:1|Papers Count:14

Background and Aims: In this part of the review, particular attention is drawn towards the mechanisms by which one can pre-condition the kidneys pre-operatively by using several strategies that are nutritional, biochemical, pharmacological and environmental in nature. In addition, ideas and hypotheses are put forward that are relevant to modulating the anoxic and autophagic response to ischemic damage during laparoscopic partial nephrectomy, particularly with respect to reducing the endoplasmic reticulum stress. Finally, the current trends in research involving the role of stem cells, renal hibernation and the role of the innate immune response are highlighted with the aim of exploiting these mechanisms to achieve reduced kidney damage during ischemia. Finally, the common thread behind all these approaches, namely empowering the renal mitochondria during ischemia is emphasized.

Background and Aims: Autosomal dominant polycystic kidney disease (ADPKD) is a common cause of end stage renal disease and accounts for a substantial number of dialysis and transplant patients worldwide.Studies over the years have revealed precious information about the disorder’s genetic profile, pathogenesis, systemic manifestations and its progression. An increased understanding of these aspects has enabled the development of clinical trials and potentially effective treatments.Relevant data on this topic was procured and synthesized with the aid of a comprehensive Medline search in addition to nephrologic and urologic literature review on ADPKD. The article provides an in-depth review into the natural history and pathogenesis of ADPKD; various clinical manifestations; progression of the disease; accuracy, reliability and need of screening and diagnostic procedures in different age groups; and novel therapeutic approaches that are being evaluated in ADPKD.

Background and Aims: Chronic hemodialysis (HD) patients are associated with an increased thrombotic tendency, a frequent and costly cause of morbidity in this patient population. HD patients often have multiple defects in their hematologic/coagulation factors; however, few convincing associations have been made between these abnormalities and clinical thrombotic events. Alternatively spliced human tissue factor (asHTF), a recently discovered soluble form of tissue factor (TF), circulates in blood and exhibits procoagulant activity. Therefore, the present investigation was designed to initially determine if asHTF levels are correlated to thrombotic tendencies in HD patients.Methods: Pre-dialysis blood samples were drawn from a cohort of 84 hemodialysis patients immediately prior to dialysis. Plasma asHTF levels were quantified and then compared to a variety of patient parameters collected for each patient.Results: Mean plasma asHTF levels for HD patients varied significantly compared to 30 healthy normal subjects. We found a positive correlation between asHTF concentration and access thrombosis in hemodialysis patients (r=0.31, p=0.0046). When patients without any episodes of thrombosis were excluded, correlation increased (r=0.59, p=0.0001). The patient with the highest number of incidences of thrombosis (n=25) also had the highest plasma asHTF concentration (1066.61 pg/ml), over seven standard deviations above the mean.Conclusions: These initial results suggest that plasma asHTF antigen levels may be associated with access thrombosis in HD patients. Further studies are needed to confirm our findings and to determine whether elevated asHTF levels indicate a causal or responsive role in HD associated access thrombosis.

Background and Aims: Minimal change disease (MCD) is uncommon in Nigeria; in the sixties and eighties quartan malaria nephropathy accounted for more than 80.0% of all cases of childhood nephrotic syndrome (CNS). There is paucity of current clinical and morphologic data on CNS. This study therefore determined the incidence and prevalence of CNS, pre-treatment glomerular pathology of idiopathic CNS (ICNS), renal and patient outcome in steroid sensitive ICNS.Methods: A non-randomized prospective study of consecutive cases of Nigerian children with idiopathic nephrotic syndrome was conducted over a 9-year period.Results: CNS accounted for 1.26% of pediatric admissions. Fifty-four of 78 (69.2%) nephrotic children had ICNS (incidence, 0.44/100000/year). Median NS onset age was 7.1 (2.5-14.0) years. Male: female ratio was 1.7. The histopathologic lesions were membranoproliferative glomerulonephritis (MPGN, 44.4%), focal segmental glomerulosclerosis (FSGS, 25.9%), MCD (18.5%), mesangial proliferative glomerulonephritis (7.4%) and membranous nephropathy (3.7%). Overall cumulative complete remission (CR) rate 4 to 8 weeks post prednisolone treatment was 49.6%. Twenty-two of 25 with CR were early steroid responders while 3 were late responders. Median time to CR was 12.0 (3.0-46.0) days. Thirty relapses occurred; median time to first relapse was 11.0 months. Cumulative five-year relapse-free rate was 26.6%. Five-year renal survival was 16.1%. All patients with CR were followed-up for 6-93 (median, 22.0) months.Conclusions: Prevalence of non-MCD was very high with significant resistance to prednisolone; poor renal survival was due to high frequency of MPGN and FSGS. Pre-treatment renal biopsy is advocated in our kind of patients so that steroid-sparing agents can be started early.

Background and Aims: To discuss sources of error and pitfalls of color duplex sonography (CDUS) in screening for renovascular hypertension (RVH).Methods: We retrospectively reviewed 47 patients with positive CDUS in patients with suspected RVH from May 1, 2007 to February 28, 2009. Manifestations of RVH on CDUS were analyzed. The results of main renal artery stenosis on CDUS were confirmed with that of magnetic resonance angiography (MRA), computed tomographic angiography (CTA), or digital subtraction angiography (DSA). Pitfalls and sources of error of CDUS in screening for RVH were identified. RVH was classified into three groups: 1) main renal artery stenosis (RAS), 2) intrarenal artery stenosis, and 3) intrarenal arteriovenous fistula (AVF).Results: Two cases of false positive and two cases of false negative main RAS on CDUS were corrected by MRA or DSA. Three cases with intrarenal artery stenosis and four cases with intrarenal AVF were not visualized at the initial CDUS but detected on repeat studies. Peak systolic velocity>2 m/s at the stenotic artery was the most sensitive parameter for detecting RAS in either main renal artery or intrarenal artery.Acceleration time>0.07 m/s in the intrarenal artery was seen in only 10 cases (10 /20, 50%) with hemodynamically significant main RAS (>60% arterial lumen reduction).Conclusions: Some pitfalls and sources of error of CDUS can be corrected and minimized with proper scanning and interpretation. Intrarenal RAS and AVF should be investigated with optimized Doppler settings. CDUS, with its advantages outweighing its limitations, should be considered a first line study in screening for RVH by experienced ultrasound professionals.

Background and Aims: Hypertension is both a cause and effect of renal impairment and its treatment influences kidney function outcome, interests in the study of albuminuria in hypertensive patients has grown as it may represent a useful and relatively inexpensive clinical tool for the identification of hypertensive patients at higher risk for developing early renal impairment. In Egypt, hypertension is one of the most important causes of end stage renal disease (ESRD). The aim of the work is to identify albuminuria in Egyptian essential hypertensive patients, and its relation with kidney function outcome.Methods: Two hundred and forty one essential hypertensive patients, were included in a cross-section study for the presence of albuminuria and its relation to estimated glomerular filtration rate (eGFR); their history of hypertension ranges from 12-240 months with a mean of 75±54 (aged 48±11 years, range 20 – 76 years) any patient with doubtful history of essential hypertension were excluded from the study, patients included in the study were 148 (61%) males and 93 females, their mean body mass index was 27±5 kg/m2.Results: Prevalence of normoalbuminuria was 59%, microalbuminuria 31%, and macroalbuminuria 10%. eGFR was significantly decreased in microalbuminuria and macroalbuminuria groups, on further analysis this reduction in eGFR was not related to severity of hypertension but to its duration. There was a significant increase in the duration of history hypertension in eGFR<60 ml/min/1.73 m2 in comparison to eGFR>60 ml/min/1.73 m2 in all groups (Normo, Micro and Macroalbumiuria). There was no significant difference eGFR between controlled and uncontrolled groups (either by MDRD or Mayo clinic formula).Conclusions: Albuminuria is a risk marker for prediction of the progression of nephropathy in Egyptian essential hypertensive patients and may reflect hypertensive injury to the kidney.

Background and Aims: Nowadays, percutaneous nephrolithotomy (PNL) is a common method for removal of renal and ureteral stones. Although renal parenchymal damage occurs during this procedure, but the burden of this damage to the kidney function is not clearly understood. dimercapto-succinic acid (DSMA) renal radioisotopes scan is one of the best methods for analyzing parenchymal kidney function. In this study we are going to show the extent of kidney function before and after PNL procedure.Methods: In this study, we collected 37 symptomatic patients with renal calculi who were candidates for the removal of these renal calculi by PNL procedure. They underwent DMSA renal scan before and after the PNL by with 99m technetium dimercapto-succinic acid (Tc-99m DMSA SPECT). The kidney function and the extent of parenchymal damage compared and analyzed by SPSS 13.Results: Our results showed that mean renal split function was 62.95% in the healthy (not operated) kidney and 37.05% in the affected (operated) kidney before PNL. After PNL the mean of renal split function were 63.30% in the healthy kidney and 36.71% in the affected kidney. The renal functional changes were not significant before and after PNL (P. Value>0.05).Conclusions: The renal parenchymal function preserved after PNL. These results advocate treating patients with symptomatic renal stone disease by PNL without any concern about parenchymal damage.

Background and Aims: Trans-rectal ultrasound guided prostate biopsy (TRUS) remains the gold standard to diagnose patients with prostate cancer. The purpose of this study is to prospectively evaluate the efficacy of diclofenac suppository versus diclofenac patch as compared to placebo, on pain reduction during prostate biopsy.Methods: A prospective, randomized, single-blind, placebo controlled study was performed in 73 patients requiring transrectal ultrasound guided prostate biopsy (TRUS). Patients were randomly allocated to receive 100 mg diclofenac suppository or 100 mg diclofenac patch or matching placebo 1 hour prior to the procedure.They were asked to indicate on a 10 cm visual analogue scale the degree of discomfort during probe insertion, needle penetration and four hours post biopsy. Statistical analysis was done using one way ANOVA. The data was analyzed using SPSS version 10.0.Results: Patients given diclofenac suppository and diclofenac patch had statistically significant lower four hour pain scores than those who were given placebo. There was no statistically significant difference in the pain scores between the three groups during probe insertion and needle penetration. The three groups were similar in regards to age, prostate volume, biopsy number, prostate specific antigen levels, histological diagnosis and complication rate.Conclusions: Diclofenac in the form of a patch or suppository does not confer a superior intraprocedural analgesic effect compared to the placebo, but it reduces post procedural pain to a significant extent. We do not recommend its use as a single agent analgesic for prostate biopsy and it should be used as an adjunctive analgesic for reducing post procedural pain.

Background and Aims: In this study, we aimed to examine possible relationship between the serum inflammation markers such as C-reactive protein (CRP), lactate dehydrogenase (LDH), erythrocyte sedimantation rate (ESR), ceruloplasmin; and the stage of prostate cancer (Pca), serum prostate specific antigen (PSA) level and the Gleason score in patients with Pca.Methods: Fourtyone patients diagnosed with prostate cancer, and 46 patients forming the control group, and diagnosed as having benign prostatic hyperplasia (BPH) were included in this study.The prostate cancer group was divided into subgroups according to the following parameters; PSA£20 ng/ ml and>20 ng/ ml, Gleason scores of £6 and>6, and further the cases with and without bone metastasis.Results: It was detected that serum levels of CRP, ceruloplasmin and ESR were significantly higher in prostate cancer group, compared with the control group (p<0, 05). Serum levels of CRP, ceruloplasmin, LDH and ESR were significantly higher in the Pca group with Gleason score of>6 compared with the Pca patients Gleason score£6 (p<0.05). Also, CRP, ceruloplasmin, alkaline phosphatase (ALP), LDH and ESR were significantly higher in the patients with PSA>20 ng/ ml, compared with the ones with serum PSA levels£20 ng/ ml in the Pca group, as well (p<0.05).Conclusions: We conclude that the serum inflammation markers are elevated significantly higher in patients with prostate cancer, especially for the ones with higher PSA and Gleason score.

Background and Aims: There is controversy on change of Prostate specific antigen (PSA) levels after some urological procedures such as cystoscopy. In this study, we evaluated the effect of cystoscopy on PSA levels in patients with urologic diseases.Methods: In a before-after study, 190 patients with urologic diseases such as relapsing urinary tract infection (UTI), urinary incontinency, hematuria, transitional cell carcinoma (TCC) follow up, DJ catheter removal and urinary retention were investigated. PSA levels were measured before and after cystoscopy.Results: Mean age of patients was 63±13 years. Mean duration of procedure was 2.5±1.2 minutes. Total PSA level increased in all groups after cystoscopy. More changes were found in patients with urinary retention (P<0.01). There was a relation between patients’ ages and primary and secondary PSA levels (P=0.0001).Moreover there was a statistically significant direct relation between the PSA levels and the duration of procedures in different groups of patients (P=0.001).Conclusions: Total PSA increases after cystoscopy and the level of PSA is higher in patients with urinary retention and change in level of PSA was higher in these patients. The results can have implications for the screening for prostate cancer patients.

Background and Aims: Human prostate cancer is a heterogeneous combination of androgen-dependent and androgen-independent cells, and then potential strategies for eradication of cell mixture have been focused on androgen ablation and radiation or cytotoxic drugs. This study explored the efficacy of two treatment protocols.Methods: A retrospective review was performed on a total 302 patients with distant metastases between 1986 and 1995 in Kyrgyzstan. This study includes 146 patients with systemically recurrent prostate cancer (group 1) and 156 patients with primary metastasized carcinoma (group 2). In each group the patients were treated by chemo-hormonal therapy or only by hormonal therapy. In Group 1 patients were treated with hormone deprivation alone by fosfestrol (n=68) and a combination of polychemotherapy and fosfestrol (n=78). In Group 2 only hormonal treatment had 62 (39.7 %) and a combined chemo-hormonal therapy had 94 (60.3%) patients.The patients were also grouped by the load of metastases, in low (<5 metastases), intermediate (>5 metastases confined to one organ or skeleton) and high (multiorgan metastasis).Results: A statistically significant prolonged survival in patients treated with chemo-hormonal therapy compared to the patients treated with hormonal therapy alone in both groups. In group 1 and 2 the median survival in the chemo-hormonal group was 24.5 and 25 months (p<0.0001) versus 8 and 10.5 months in hormone group (p<0.0001), respectively. Metastases distention did not change the significant disease specific survival advantage of the combined chemo-hormonal treatment in both groups.Conclusions: Chemo-hormonal therapy in recurrent metastasized and primary metastasized prostatic cancers significantly have prolonged overall and disease specific survival in comparison to hormonal therapy alone.Combined chemo-hormonal treatment should be started early in metastasized cancer, before the outgrow of hormone refractory tumor cell clones.

Background and Aims: Surgery and radiotherapy continue to be the treatments of choice for localised and locally advanced prostate cancer. In recent years, we have witnessed significant development in radiotherapy techniques in order to increase the dose on the target volume and diminish side effects. In the following work, we describe the technique of insertion of gold fiducial markers (gold seeds) as well as their application and usefulness in the treatment of localized and locally advanced prostate adenocarcinoma with image guided radiotherapy (IGRT) by means of the Exac Trac® system.Methods: We did a prospective descriptive study including consecutive patients undergoing IGRT in our hospital. Patients were reviewed one week after the insertion of the markers and in each radiotherapic session.Between October 2005 and June 2007, we carried out a total of 126 procedures using this technique.Each patient was interviewed in each radiotherapic session. Three or four gold intraprostatic fiducial markers were implanted in each patient by transrectally and ultrasound guided. We reported patients tolerance of this technique by a satisfaction questionnaire, as well as the early and late complications derived from the insertion of the markers in the clinical interview. We collected the movements of the gold seeds.Results: Complications observed were: urinary infection in 4 cases (3.2%), prostatitis in 2 cases (1.6%), slight pelvic pain in 6 patients (4.8%) and self-limited rectal bleeding in 8 patients (6.4%). None of the patients presented hematuria. Loss of 1 marker was registered in 7 patients (5.5%) and loss of 2 markers in 2 patients (1.6%).Conclusions: Insertion of fiducial markers for prostate cancer treatment is a technique of very simple execution, easy to reproduce almost free of adverse effects, which is able to reduce toxicity derived from radiotherapy and allows dose escalation in radiotherapy.

Background and Aims: The combination of ulcerative colitis (UC) and end stage renal disease (ESRD) is uncommon. Immunosuppressive drugs that are used after kidney transplantation are considered as effective therapeutic alternatives for UC. We report two renal transplant recipients with long term refractory UC prior to kidney transplantation and confirmed by histological examination, cured following transplantation.Clinical remission occurred immediately after kidney transplantation, and they had no symptoms of UC during 3 and 8 years of follow up periods. Their immunosuppression regimens were cyclosporine, mycophenolate mofetil / azathioprine and prednisone. In conclusion, kidney transplantation with immunosuppression leads to clinical remission in patients with the inflammatory bowel diseases and ESRD.

Background and Aims: Transverse testicular ectopia (TTE) or testicular pesudoduplication is a rare anomaly in which both testis lies in one hemiscrotum. We present a case of 11- month old boy with transverse testicular ectopia that presented to our clinic with left inguinal hernia and a right non-palpable testis. Patient was operated on left herniotomy and transseptal orchiopexy after mobilization of spermatic cord. We also describe its embryology and management in brief, and review the previously reported cases.