Nephro-Urology Monthly
Volume:2 Issue: 2, Apr 2010

The aim of this review is to discuss the practical use of duplex ultrasonography in the setting of dialysis vascular access, based on the current evidence and own experience. After explaining the necessary tools and practical considerations, the role of ultrasonography in the placement of dialysis catheters will be described. Then we discuss the importance of vascular access selection with vascular mapping, followed by an overview of the most frequent vascular access related complications (thrombosis, stenosis, dysmaturation, access induced ischemia and (pseudo) aneurisms) and their ultrasonographical approach..

Cardiovascular complications are major causes of morbidity and mortality in patients with autosomal dominant polycystic kidney disease (ADPKD). In particular, hypertension is insidious and remains a continuous problem that evolves during the course of the disease. Hypertension in ADPKD has been associated with abnormality in the renin-angiotensin-aldosterone system (RAAS). Early vascular changes have also been reported in young ADPKD patients. In addition, the cellular functions of mechanosensory cilia within vascular system have emerged recently. The basic and clinical perspectives of RAAS, vascular remodeling and sensory cilia are reviewed with regard to hypertension in ADPKD..

Idiopathic hypercalciuria (IH) is defined as hypercalciuria with no detectable cause. Patients with IH might have low bone mineral density (BMD) with increased fracture risk and tendency to short stature. Our aim was to perform calcaneal quantitative ultrasonometry (QUS) in children with IH and relate to calciuria, body height and number of prevalent fractures (Fx)..
0.1 mmol/kg/24h) were enrolled. The patients were not receiving any drugs known to influence bone metabolism. Fx was 1.4±1.2 per patient. Body height was recorded and QUS was measured on both heels with Cuba Clinical. The 24-h U-Ca excretion (U-Ca/24 h) was assessed and calculated in mmol/kg/24 h. Results were expressed as Z-scores ± SD and matched to values of healthy European pediatric population..
Body height was normal for chronological age (p=0.96). Broadband ultrasound attenuation (BUA), either age-related of height-adjusted, was normal (p=0.18 and 0.26, respectively). Velocity of sound (VOS), either age-related of height-adjusted, was low (p=0.002 and p=0.003, respectively). We found no correlations between Fx and BUA or Fx and VOS (either age-related or height-adjusted) (r =0.01 and 0.02; r =0.32 and 0.26 ). Neither were there any correlations between U-Ca and Fx (r =0.28), or U-Ca and BUA (r =0.21 and 0.32) or VOS (r =0.40 and 0.42), respectively..
Contrary to previous observations where dual-energy X-ray absorptiometry (DXA) was used for BMD evaluation, we found only mild decrease in one QUS parameter with no relationship to fracture rate or calciuria. Children with IH have normal values of BUA and low VOS, not related to calciuria and Fx. QUS is not a surrogate to DXA and its role needs to be further clarified. .

Factor V Leiden mutation (G1691A) has been recognized to be the most prevalent genetic risk factor for venous thrombosis. Other common risk factor for venous thrombosis is Prothrombin 20210 G-A alteration, which causes a gain of function in the coagulation system with an increase of prothrombin levels, associated with an increased potential to form thrombin. Plasminogen activator inhibitor type 1 (PAI-1) 4G/5G polymorphism is the most frequently studied in thrombotic events. Aim of this study was to investigate the relationship between these polymorphisms and arteriovenous fistula (AVF) thrombosis in hemodialysis (HD) patients..
The study included 31 HD patients with AVF thrombosis and 51 HD patients without AVF thrombosis. DNA was extracted from peripheral blood samples from the patient and control groups. Polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) methods were used to identify the polymorphisms. .
There were no significant differences between HD patients with and without AVF thrombosis in terms of Factor V Leiden and Prothrombin G20210A mutations. PAI-1 4G allele in heterozygous state have an effect on the thrombosis risk in HD patients (O.R= 4.271). .
Only carrying PAI-1 4G/5G genotype had an additional risk for thrombosis in HD patients. .

Dyslipidemia is one of the well known risk factor for cardiovascular disease in patients on dialysis. The aim of the present study was to assess the influence of vitamin E therapy on lipid profile in patients on hemodialysis (HD) and peritoneal dialysis (PD). .
This was a case-control study. The study was performed on 34 HD patients, 13 PD patients and 22 healthy volunteers with a mean age of 45.57 ± 8.54 years. HD patients were divided into two groups, i.e. treatment (n=19) and control (n=15). Vitamin E was administered, 300 mg/day, to the HD treatment group and PD patients for 20 weeks. Plasma total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, very-low density lipoprotein cholesterol, apolipoprotein A-I, apolipoprotein B, and lipoprotein(a) were examined before and after vitamin E treatment..
Before vitamin E treatment, the levels of high-density lipoprotein cholesterol were significantly lower in the HD patient group (35.91±10.54 mg/dl) and PD group (37.92±7.19 mg/dl) than the healthy group (44.27±8.33 mg/dl), (p=0.008). Before the treatment the levels of lipoprotein(a) were significantly higher in the HD group (28.12±10.85 mg/dl) and PD group (31.64±15.12 mg/dl) than the healthy group (22.09±9.05 mg/dl), (p=0.008). Lipid and lipoprotein levels in HD and PD groups were not changed significantly after vitamin E treatment. .
Vitamin E supplementation is not effective on lipid and lipoprotein levels in patients on HD and PD. .

It is renowned that the principal causes of oxidative stress will disappear after transplantation. However, it does not seem to improve totally, which may be due to an immunologic response to the graft or possibly immunosuppressive agents. This study was conducted to investigate the possible relation between oxidative stress and different immunosuppressive regimens (cyclosporine versus sirolimus based) in renal transplant patients..
Twenty-five renal transplanted patients with uneventful operation and stable function were randomly assigned to one regimen of immunosuppressive protocols cyclosporine (CsA) (Group A) or sirolimus (Group B) plus mycophenolate mofetil (MMF) and Steroids. Erythrocyte Glutathione (GSH), Superoxide dismutase activity, plasma malondialdehyde (MDA) and α-tocopherol were measured and compared. .
There were no significant changes of SOD activity in CsA group in different days. However, there was a significant reduction of SOD activity in sirolimus group 14 days after transplantation. Erythrocyte GSH did not show any significant changes between the groups. Plasma MDA and vitamin E level were not significantly different between the groups before and 48 hour after transplantation.‍‍ Considerably higher MDA (1.82 ± 0.43 vs. 1.03 ± 0.12, µmol/l, p<0.05) and vitamin E levels (0.18 ± 0.008 vs. 0.12 ± 0.006 µmol/l, p<0.05) were seen 2 weeks after transplantation in sirolimus group compared to CsA group. .
The results of the present study showed that although sirolimus-treated recipients had decreased activity of SOD in 14th day of transplantation but no alteration of GSH during this period in comparison with cyclosporine-treated recipients was found. Increased level of plasma vitamin E on 14th day was possibly a secondary response to the change of MDA level. .
It seems that sirolimus may not offer better protection against increased reactive oxygen species (ROS) production in early period of renal transplantation..

The aim of the present study was to find the relationships between mental health component (depression, anxiety and stress) with marital satisfaction in hemodialysis patients. .
43 patients were recruited from the hemodialysis unit aged from 22 to 83. All the participants were requested to fill in the Depression, Anxiety, and Stress scale (DASS) and Enrich Inventory as well as a demographic Form..
Results revealed that the majority of patients suffered from depression, anxiety and stress. Patients with severe to clinically symptoms of depression showed more marital conflicts including personality issues, communication, leisure activities, sexual relations, children and parenting, and total scores of Enrich. However, for anxiety and stress marital conflicts were found for children and parenting and sexual relation subscales..
Conclusions: This study showed that depression had the most significant influence on marital conflicts than anxiety and stress which should be considered in psychological support program for hemodialysis patients. .

The transmembrane pressure (TMP) is an important factor in removing the molecules during hemodialysis. In this study we explained the effect of ultrafiltration increase on the clearance of middle molecules in the hemodialysis patients of Kashan..
This clinical trial is a before-after study that was performed on 40 hemodialyzed individuals in 2008. At the first stage, the participants were dialyzed with ultrafiltration equal to the difference of their present weight and their dry weight and in the 2nd stage the ultrafiltration was increased 2 liters and clearance of each solute was mesured in both stages..
In the first stage, the amount of reduction in predialysis serum beta 2 microglobulin (beta2M) level was 3.5% (p = 0.05) and in the second stage it was 14.4% (p = 0.001). Excretion of the small molecules (BUN, Cr and P) in the second stage of hemodialysis in comparision with the first stage of dialysis (conventional method) revealed no meaningful change..
In the all previous studies, low flux dialysis membrane had been used in a standard way, and these studies didn''t pay attention to ultrafiltration increase but in this research we improved the role of convection in excretion of the middle molecules by ultrafiltration increase through adding TMP. All pores of the low flux membranes are not uniform and unisize. This manufacturing was problem associated with rising hydrostatic pressure through increase TMP help us for removing beta2M with convection..
The results showed that we can increase the amount of excretion of the middle molecules and dialysis capability with increasing the TMP during bicarbonate base hemodialysis through low flux membranes..

Urogenital tuberculosis (UGT) is a worldwide disease with non-typical and misleading clinical features, resulted in late diagnosis. Late diagnosed complicated forms of renal tuberculosis (TB) are poor for standard chemotherapy, the additional pathogenetic therapy is necessary. The aims of the current study were to estimate the epidemiological situation on UGT in the region with high incidence rate and to value the efficiency of the complex etiopathogenetic therapy for bladder TB..
Estimates of extrapulmonary tuberculosis incidence and its structure in Siberia have been made on the basis of the data available in official reporting forms No 8 (approved by Resolution No 175 of the Russian Statistics Agency 11 November, 2005)..
In addition, 102 patients with bladder TB were enrolled in study: 76 were treated with standard tetrad (isoniazid streptomycin pyrazinamid rifampicin), and 26 received modified tetrad in combination with trospium chloride. .
Results: During the last 5 years the incidence of TB maintains stable high in Siberia, and in 2008 it raised up to 139.6 per 100000 habitants. UGT was the prevalent form (46.0 - 33.5%); TB of bone and joints was in the second place (20.1 - 32.7%), this was followed by lymphonodal TB (14.7 - 14.9%). .
Standard chemotherapy had poor efficiency for bladder TB: only 42.1% could be cured, 57.9% developed complications such as posttuberculous cystalgia (36.8%) and microcystis (21.1%). In patients received the combined treatment outcome was favourable: urinary frequency reduced about 75%, bladder capacity increased an average of 4.7 fold. None of these patients developed true microcystis..
In Siberia, there is an epidemic of TB. UGT is the most common form among extrapulmonary TB. Standard chemotherapy for bladder TB demonstrated poor results, but combination chemodrug plus trospium chloride was more effective and should be recommended to all patients with bladder TB grade 2-3..

To assess helical CT sensitivity in detecting preoperatively Multifocal Renal Cell carcinoma (MFRCC) and clinical occult multifocality in a contemporary and consecutive set of patients according to a multidisciplinary approach. .
The renal masses were assessed preoperatively by volumetric multislice helical CT with the objective to detect multifocality. Renal cells carcinoma (RCCs) were classified as unifocal (UF) or multifocal (MF). MFRCCs were selected in 2 groups including CT detected (CT) and CT undetected (CT-). RCCs were classified in UF and MF. MFRCCs were selected in 2 groups including CT and CT-. CT and pathologic findings of MFRCCs were correlated and CT sensitivity was assessed. Statistical methods were performed in order to compare the CT sensitivity with the overall mean sensitivity calculated from the reported literature, to assess statistical inference between UF and MF - RCCs; and to detect statistical significance between CT() and CT(-) MFRCCs ..
Over a period of 24 months, 116 kidney units (KU) of 111 patients were surgically treated for RCC. Multifocality was assessed in 13/116 KU of 12 patients (10.8%). Helical CT detected preoperative multifocality in 8/111 patients (7.2%) and preoperative occult multifocality was assessed in 4 (3.6%), as well. Helical CT sensitivity difference between our (66.7%) and the reported literature experience (22.9%) was significant (p <0.0001). Significant predictors for multifocality were tumor size (p = 0.007), laterality (p = 0.002), pT (p = 0.008) and surgery (p = 0.0002). Primary tumor size (p = 0.05) and satellite tumor size (p = 0.01) were significantly correlated to CT-undetected (CT-) multifocal tumors. .
In our experience, helical CT was effective in improving preoperative detection of sporadic primary MRCC as well as in lowering clinical occult multifocality. Clinical predictors of multifocality including bilaterality and primary tumor size as well as technical and methodological improvements in performing Helical CT will improve its sensibility in detecting renal masses less than 0.5 cm. CT preoperative detection of clinical multifocality may help in planning effective preoperative surgical treatment as well as lowering local recurrence after nephron sparing surgery. .

The Doppler resistive index was advanced as a useful parameter for quantifying the alterations in renal blood flow that may occur with renal diseases. The presence of splenomegaly is very significant in the diagnosis of several groups of diseases: immunological, inflammatory, reticuloendothelial proliferations, storage diseases and portal hypertension. This prospective study is designed to investigate whether there is an effect of splenomegaly on renal resistive index value of extrinsically compressed left kidney by using renal Doppler US. .
130 mm) were evaluated by renal Doppler US examination. The etiologies and durations of splenomegaly were found to be different. Renal sphericity indices were calculated for demonstration of extrinsic compression (long axis/short axis). The resistive index values obtained via both compressed left kidney by splenomegaly and contralateral right kidney were measured. Mean values were calculated and difference of mean resistive index between both kidneys were compared..
The sphericity indices were higher in compressed left kidney (mean SD) (2.4 0.4) than contralateral normal side (2.3 0.3). The mean RI of the compressed and contralateral kidney were 0.67 0.5 and 0.65 0.4, respectively. The mean RI value of the left side is statistically higher than right side (p< 0.01). .
During renal Doppler examinations it should be kept in mind that the extrinsic pressure caused by enlarged spleen may significantly alter renal RI measurements. .

Fetal urinary tract anomalies can be reliably detected antenatally by ultrasonography. The present study was done with objective to find out the incidence and pattern of fetal urinary tract abnormalities. .
A prospective hospital based study included 5450 pregnant women. The ultrasonography was done after 20 weeks of gestation and the cases found to have urinary tract anomalies were followed till 4 weeks of postnatal life..
The abnormalities were found in 20 fetuses (0.36%) involving 33 kidney units. The dilated renal system was found in 24 (72.7%), multicystic dysplastic kidneys in 6 (18.2%), polycystic kidney disease in 2 (6.1%) and renal agenesis in 1 (3.0%) kidney units. Five (25%) affected babies died and they had significantly lower mean birth weight, hemoglobin and higher blood urea and serum creatinine levels as compared to survivors. Renal anomalies resolved spontaneously in 6 (18.2 %) kidney units. The ureteropelvic junction / ureterovesical junction obstruction was the commonest abnormality followed by ureterovesical reflux at 4 weeks life. Antero-posterior renal pelvis diameter and renal size were significantly higher in cases in which anomalies persisted. .
Thus, the babies with foetal urinary tract abnormalities require close follow up in post natal life regarding their persistence and renal function. .

Intrauterine Contraceptive Devices (IUD) have been commonly used method for birth spacing in Asian countries. In the rural areas of India infrequently these IUDs are placed by trained multipurpose health workers. We report a 30 years-old women with erroneously placed IUD, transurethrally into urinary bladder which later on presented as vesicle calculus and it was removed endoscopically. To our knowledge for presenting this misplacement, no such cases have been reported earlier in scientific literature..

C1q nephropathy (C1q-N) is an uncommon condition characterized by predominant mesangial complement-C1q deposition. It commonly presents as a nephrotic syndrome in young adults. Despite of many histologic similarities with lupus nephritis there were no clinical or laboratory findings of SLE in this patient who had C1q-N associated with joint involvements..