Nephro-Urology Monthly
Volume:2 Issue: 4, Oct 2010

Extracorporeal shock wave lithotripsy (ESWL) represents first line therapy for the majority of urinary tract calculi and requires anesthesia. The purpose of this study is to prospectively evaluate the analgesic effects and safety of lidocaine 1% by local infiltration as a monotherapy during renal ESWL and ensure stone clearance after the procedure. One hundred patients with renal stones, aged 18 to 65 years, were randomly allocated into two groups; 49 patients in group 1 received intramuscular injection of 20 mg Ketorolac tromethamine, 20 minutes before start of the procedure and 51 patients in group 2 received Lidocaine 1% by local infiltration (5mg/kg) into the 30 cm2 area after localizing the stones site, 10 minutes before the session. A visual analog scale, (0 to 100 mm) was used to evaluate pain every 10 minutes. The visual analog scores for group 2 were significantly lower than (group 1) at 10, 20, 30 and 40 minutes till end of the procedure, (p <0.001). The mean requirements of supplemental fentanyl analgesia (μg) were significantly decreased in group 2 than group 1, (3.34 ± 7.32 versus 15.72 ± 6.41, p<0.001). All patients in group 2 were discharged earlier, 1 hour after the end of the procedure while 13 patients (26.5%) in group 1 had delayed discharge. No significant difference was detected between the two groups with regards to complete stone clearance after 1 month, no. of shocks, voltage power or duration of procedure. No patient in group 2 reported neurological side effects of local anesthesia. Lidocaine 1% by local infiltration cannot be used alone for pain relief but effectively reduced the analgesic needs and minimized hospital stay after renal ESWL, without affecting stone clearance.

The incidence of inferior vena cava tumor thrombus is 4 - 10% in patients withrenal cell carcinoma (RCC). Tumor thrombus may extend into the right atrium. Survival of patients with level IV tumor thrombus is believed to be poorer. Aim of the present study was to assess short term and long term survival in patients with level IV thrombus. From July 1996 to March 2009, 7 patients underwent surgical treatment for localized RCC and inferior vena caval thrombus extending into the right atrium. All these patients underwent radical nephrectomy with inferior vena caval thrombectomy using cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest. Pathological investigations revealed no renal capsular penetration of RCC in 4 patients and perinephric fat involvement in 3. The mean operating time was 365 min (295-390), anaesthesia time was 395 min (335-440), cardiopulmonary bypass time was 128 min (38-200) and hypothermic circulatory arrest time was 28 min (14-38). The mean follow-up time was 38 months. Presence of capsular infiltration or positive lymph nodes significantly affected survival of patients in our study with no patient having a two year survival as opposed to 100% in patients with no capsular infiltration. Long term survival following the surgical treatment is probable in individuals with localized RCC extending into the right atrium. Performance of complete radical nephrectomy along with vena caval thrombectomy under circulatory arrest is a safe procedure without significant morbidity. The management is evolving for this complex group of patients. A multidisciplinary approach is associated with good short and long term results.

AGEs (advanced glycation end products) are involved in the pathogenesis of vascular damage and progression of chronic kidney diseases. They are detoxified by the glyoxalase (GLO) system. The aim of the study was to test whether A419C polymorphism of GLO I gene is associated with the outcome of kidney transplantation. A419C polymorphism of the GLO I gene was assessed in 145 renal transplant recipients and its relationship to histological changes in 12 months protocol kidney graft biopsy and renal function was examined. Genotype frequencies of the studied polymorphism corresponded to the expected frequencies according to Hardy-Weinberg equilibrium. No significant differences among allelic and genotype frequencies among patients with normal histological findings, interstitial fibrosis/tubular atrophy and subclinical rejection and renal parameters were found. However, a trend towards lower levels of serum creatinine and proteinuria was observed in patients with CC genotype. This is the first study of glyoxalase I gene polymorphism in patients with the transplanted kidney. Although no significant relationship of the GLO I genotype to the histology of the transplanted kidney and renal parameters could be found, a trend towards better outcome in patients with the CC genotype was observed.

Nowadays with the extension and development of renal transplantation centers, the best treatment of the patients with ESRD is renal Transplantation. Renal allografts from deceased donors are being used in our center following legislation of the laws by Islamic parliament. Renal transplantation is evaluated by graft and patient survival. Therefore in this study graft and patient survival of recipients who received kidney from related, unrelated and deceased donors were reviewed. Following preoperative examinations and live donor angiography, transplantation will be ready to perform. Renal transplantation was performed in 270 patients who received kidney from unrelated and 44 from related and 125 from deceased donors. Graft and patient survival were measured. Statistical analysis was performed using SPSS soft ware, Caplan - Meyer table, Cox regression and Long rank. In this study 439 patients were evaluated. Patient's age ranged between 8 and 71 years. There were no statistical differences among 3 groups (P > 0.1). One year graft survivals of recipients who received kidney from deceased, unrelated and related donors were 90%, 89% and 93%, respectively. Three year graft survival in the mentioned groups were 82%, 84% and 91%, respectively and 5 year graft survival were 81%, 90% and 81%, respectively. Statistical analysis showed no significant differences among 3 groups (P=0.241). One, three and five year recipient's survival were evaluated in patients who received kidney from deceased, unrelated and related donors. One year recipient survivals in the 3 groups were 95%, 93% and 98%, respectively; three year patient survivals were 94%, 98% and 93%, respectively and finally the 5 year patient survivals were 89%, 93% and 88%, respectively which showed no significant differences (P = 0.489). Although graft and patient survivals are slightly better in recipients who received kidney from related donor, regarding static analysis there were no significant differences in 1, 3 and 5 years graft and patient survivals between recipients who received kidney from live (related or unrelated) and deceased donors. Therefore, deceased donors can be used as a valuable source in our country.

Nocturia is a highly prevalent and troublesome lower urinary tract symptom, with 28-36% of adults usually voiding at least twice nightly. For many patients, nocturia arises from the presence of nocturnal polyuria (NP), usually defined as being present when more than 33% of the total 24-hour urine output occurs at night while the total 24-hour urine output remains normal. We report results of an innovative evaluation in a clinical sample of 29 nocturia patients found to have NP during evaluation of their nocturia symptoms. Patients with nocturia collected 24-hour urine specimens split into two containers, one of which was collected during the daytime, the second collected during the nighttime. We analyzed patterns of solute and water excretion, comparing daytime to nighttime collections. Overall the group demonstrated remarkably abnormal patterns of solute and water excretion, with the rate of urine production dramatically greater at night (mean 118 mL/hr) than during the day (mean 56 mL/hr; p<0.001); solute excretion markedly increased at night (mean 41 mmol/hr) compared to during the day (mean 27 mmol/hr; p=0.001), and free water absorption marginally decreased at night (mean 18 mL/hr) compared to during the day (mean 33mL/hr; p=0.053). Within this broad pattern of abnormality, we found that patients fell into one of three categories: those with (1) Increased nocturnal solute diuresis, (2) Decreased nocturnal free water reabsorption, and (3) Nocturnal mixed diuresis. Nocturnal water diuresis and solute diuresis have both been noted in other studies of nocturics. Our study enhances evidence that nocturic patients may benefit from a more sophisticated evaluation than is afforded by analysis of a simple frequency-volume chart. A clinical categorization scheme based on these excretion patterns may help direct the clinician in choosing an appropriate therapy.

The precursor of the Brain Natriuretic Peptide (pro-BNP) represents a biological marker whose behavior in stress condition can reveal the beginning of a condition of chronic heart failure in patients at risk. The objective of our work was to evaluate the behavior of pro-BNP after hydrosaline overload on a sample of hypertensive patients. The authors have evaluated the incretory stimulation of brain natriuretic peptide in a group of 13 patients with arterial hypertension. All of the individuals underwent a hydrosaline overload 20% of plasmatic value. Blood samples for pro-BNP determination were obtained from the antebrachial vein at time 0, 2nd hour, 4th hour, 7th hour and 10th hour. The same procedure was applied upon a control group of healthy individuals. The study was repeated after 7 months in 18 hypertensive patients. All of the individuals underwent a hydrosaline overload 25% of plasmatic value. Statistics were calculated with intra-group and intergroup analysis. The results obtained showed an increase in the secretion of pro-BNP which became important after 4 hours from the first examination in the group of hypertnsive patients. No modifications were observed in healthy group. In the second phase of the study, the results become more statistically significant than in the first part of the study. The most interesting result is the difference in secretion of pro-BNP between the hypertension group and control group which occurs earlier in respect to the first part of the study. Moreover, there is an increased production of pro-BNP between the patients with hypertension non-dippers in respect to the dippers. The authors hypothesized that the increase of secretion of pro-BNP during arterial hypertension could be considered as a compensatory phenomenom linked to intolerance toward hydrosaline overload and if so, it can be due to a molecular pathology of the renal tubule and/or to a molecular pathology of the competent cells of cardiac muscle. This phenomenom seems particularly to be evidenced in non-dipping hypertension category of patients in which the cardiovascular risk is very high. Our study contributes to confirm that dynamic tests are more useful tools than static tests in exploring the organ reserve function.

Plasma N-amino terminal fragment of the prohormone B-type natriuretic peptide(NT-proBNP) is produced and released from cardiac ventricles; it is elevated in patient with heart failure,hypertension and chronic kidney disease (CKD). This study aims to examine the plasma levels of NTproBNPand their relationship in hypertensive patients with or without CKD. Our study population consisted of 129 patients with hypertensive CKD (stage 1-4) (Group 1)and 41 controls with hypertensive normal kidney function (Groups 2). Patients with CKD were divided intotwo groups. Group 1A (n=89) with diabetes mellitus, Group 1B (n=40) without diabetes mellitus. Serumcreatinine, NT-proBNP concentrations and proteinuria were analyzed and glomerular filtration rate, bloodpressure, weight, height were measured. The patients with hypertensive CKD were older compared to the controls (p=0.047), BMI was notstatistically significant (p>0.05). NT-pro BNP concentrations were significantly elevated in the group 1, compared to the group 2 (p=0.007). Notably, there was no significant difference between Group 1A and Group 1B (p>0.05). NT-proBNP concentrations correlated positively with longer diabetes duration (r=0.34, p=0.001),proteinuria (r=0.30, P=0.001) and negatively with BMI (r=-0.20, p=0.02) and GFR (r=-0.29, p=0.001) In patients with hypertensive CKD, levels of NT-proBNP concentrations are increased. There was no significant difference between diabetic and non diabetic patients with CKD. Because of the relationship between proteinuria and Pro-BNP, increased plasma NT-proBNP concentrations may be a risk factor for the progression of renal disease. The relationship between elevated NT-proBNP and proteinuria should be further investigated.

The combination of diabetes and chronic kidney disease (CKD) has become a major health problem. Observational studies indicate that low hemoglobin levels in diabetics may increase risk for progression of kidney disease and cardiovascular morbidity and mortality. The aim of this work was to determine kidney dysfunction and hemoglobin level among type 2 diabetic patients. This study included 307 patients, 169 (55%) of them were males, on the day of referral their age was 47±11 range 22 -74 years and their duration of diabetes mellitus ranged from 6-206 (mean 55±52) months. Estimated glomerular filtration rate (eGFR) by MDRD and CKD-EPI is expressed in ml/min per 1.73 m2. Anemia was defined as hemoglobin < 12 g/dl in females and < 13 g/dl in males. Prevalence of anemia was 39% of the patients, eGFR was 58 ± 25 ml/min/1.73m2, body mass index (BMI) was 28±7 kg/m2 mean hemoglobin for all patients was 12±2. There was a significant decrease in hemoglobin level in stage 3 CKD in comparison to stage1 and stage 2. Also there was a significant decrease in hemoglobin level in stage 4 in comparison to stage 1, 2, and 3. We found significant lower eGFR in anemic group 43±20 as compared to nonanemic group 68±22ml/min/1.73m2. Additionally, there was significant lower hemoglobin, hematocrite and eGFR in uncontrolled diabetic patients compared with the controlled ones. Anemia is prevalent among diabetics but remains under-recognized and under-treated. Therefore, we recommend screening of anemia in diabetics even at normal eGFR, and aggressive management of diabetic anemia so as to improve quality of life and outcome for the affected patients. Further studies are recommended to determine a different hemoglobin target in diabetic patients.

Patients with diabetes mellitus commonly suffer from a wide variety of cutaneous disorders. Clinical manifestations and complications of skin diseases are more common and severe in these patients. Some skin disorders are more prevalent in patients with microvascular complications. The aim of this study was to evaluate the correlation between skin lesions in type 2 diabetic patients and microvascular complications. In this study, 1135 type-2 diabetic patients were included and examined by a dermatologist for diabetes mellitus related skin lesions, skin infections and cutaneous manifestations due to treatment. Smear, culture and biopsy of the lesions were done for definite diagnosis. Retinopathy, neuropathy and nephropathy were evaluated in all the patients. The mean age of study population was 54±11 years; 619 (55%) female and 516 (45%) male. Mean duration of disease was 9±7 years and HbA1c was 7.8±1.6. Prevalence of skin lesions was 64% (95% CI: 61.2-66.8). Of all micro vascular complications, only neuropathy had a strong association with diabetes mellitus-related skin lesions with an odds ratio of 1.9 (95% CI: 1.5-2.5). Only eight percent of the skin manifestations had developed in less than one year after diagnosis of diabetes mellitus. The prevalence of neuropathy and albuminuria was significantly higher in patients with tinea pedis. The prevalence of neuropathy was significantly higher in patients with facial erythema, pyoderma, tinea pedis, nail dermatophytosis, candidial paronychia and itching. In patients with diabetic dermopathy and foot ulcer, the prevalence of retinopathy, neuropathy, albuminuria, mean age, duration of diabetes and percentage of insulin users were significantly higher than those without such lesions. This study shows that skin lesions are common in patients with type-2 diabetes mellitus. Some of cutaneous manifestations are indicative of microvascular complications and patients with these skin manifestations should be evaluated for microvascular complications.

Homocysteine is a sulphur amino acid derived from methionine. Epidemiological studies show an association between hyperhomocysteinemia and an increased cardiovascular risk, a fact that has also been confirmed in patients with chronic renal failure. This study, conducted in stage 5 chronic kidney disease patients, seeks to define the prevalence of hyperhomocysteinemia, evaluate the clearance of homocysteine with dialysis, and describe the frequency of the mutation in the mutilen-tetrahydrofolate reductase enzyme and its relationship with plasma levels of homocysteine. The reduced percentage of homocysteine and clearance of urea were analysed every six months for seven years in patients on dialysis. Urea and total homocysteine in plasma were measured in each of these studies and the type of dialyser - low or high permeability - used and the dialysis duration was determined. A molecular study of the gene coding for mutilen-tetrahydrofolate reductase enzyme was carried out in a group of patients and any C-T point mutation at position 677 of this gene was investigated. Mutation was described as not present, heterozygous for this mutation or homozygous for lactation. Neither the average levels of homocysteine before and after dialysis or the reduction percentage of homocysteine varied with gender, although purification of urea was higher in women. Comparisons of homocysteine levels and percentage reduction in this ratio according to the ultra filtration of the dialyser used showed significant results. The molecular study of the gene in mutilen-tetrahydrofolate reductase enzyme showed that mutation was present in 54.8%: 45.2% with heterozygous polymorphism and 9.7% with homozygous. Patients undergoing hemodialysis were found to have higher levels of urea and its clearance was greater with the higher the ratio of ultra filtration dialyser. Mutation of the gene in mutilen-tetrahydrofolate reductase enzyme was similar in our patients compared to the general population and had no impact on plasma levels of homocysteine.

Previous studies indicate that angiotensin converting enzyme inhibitors (ACEI) cause acute renal failure (ARF) in patients with diabetes, hypertension, and congestive heart failure. Volume depletion is a determining factor for ACEI-induced ARF. This study presents a syndrome of reversible ARF accompanied by hyperkalemia, metabolic acidosis, and anemia associated with ACEI and angiotensin receptor blocker (ARB) Data were collected from a total of 12 patients; 11 were admitted to the hospitals and 1 as an outpatient. Six patients had uncontrolled diabetes. Four of these patients also had hypertension. Eight patients (67 percent) received lisinopril; 4 (33 percent) received ARB. Diuretics were the commonest accompaniment. They showed moderate to severe azotemia. Estimated glomerular filtration rate (eGFR) ranged from 9.3 to 32.2 ml/min with an average eGFR of 14.1 ml/min. Six patients (50 percent) had moderate to severe hyperkalemia. All but 2 patients had metabolic acidosis, and 6 patients (50 percent) were anemic. ACEI or ARB and diuretics were discontinued in all patients, and all hospitalized patients were treated with normal saline or bicarbonate infusion, erythropoietin, and 9-alpha fluodrohydrocortisone, as required. Azotemia reversed and renal function improved to normal or near normal in 8 patients (67 percent). One of these patients required one-time hemodialysis. Renal function returned to baseline or better in 3 patients with preexisting renal insufficiency. Renal function improved in 1. All hyperkalemic patients became normokalemic, and all but 1 recovered from metabolic acidosis. Anemia also improved. This novel observation substantiates our previous observation and further reiterates that ACEI/ARB causes a syndrome of reversible azotemia, hyperkalemia, metabolic acidosis, and anemia. Discontinuance of ACEI/ARB and diuretics-and treatment with a combination of bicarbonate infusion, 9-alpha fluodrohydrocortisone (Florinef®), and exogenous erythropoietin-hasten recovery from this syndrome. Continuation of a diuretic but without ACEI/ARB doesnt hinder renal function recovery.

Purple urine bag syndrome (PUBS) is typically a benign condition in which the urine in a Foley bag becomes purple. This situation is thought to arise from a series of steps involving the conversion of tryptophan to pigmented indigo and indirubin. While there are multiple factors associated with PUBS, no definitive causative agent has been identified. Presented here is the case of a patient with an ileal conduit who developed purple urine during his hospitalization.