Nephro-Urology Monthly
Volume:3 Issue: 3, Jul 2011

Overweight (body mass index [BMI] = 25 - 30 kg/m2) and obesity (BMI ≥ 30 kg/m2) have become mass phenomena with a pronounced upward trend in prevalence in most countries throughout the world and are associated with increased cardiovascular risk and poor survival. In patients with end stage renal disease (ESRD) undergoing maintenance hemodialysis an 'obesity paradox' has been consistently reported, i.e., a high BMI is incrementally associated with better survival. Whereas this 'reverse epidemiology' of obesity is relatively consistent in maintenance hemodialysis patients, studies in peritoneal dialysis patients have yielded mixed results. Moreover, the effect of pre- and post-transplant obesity in kidney transplanted patients on long-term graft and patient survival has not been well established. However, BMI is unable to differentiate between adiposity and muscle mass and may not be an acceptable metric to assess the body composition of ESRD patients. Assessing lean body mass, in particular skeletal muscle, and fat mass separately are needed in ESRD patients using gold standard techniques such as imaging techniques. Alternatively, inexpensive and routinely measured surrogate markers such as serum creatinine, waist and hip circumference or mid-arm muscle circumference can be used. We have reviewed and summarized salient recent data pertaining to body composition and clinical outcomes about the association of survival and body composition in maintenance dialysis patients and kidney transplanted recipients.

Chronic kidney disease (CKD) is a major health problem throughout the worldand understanding the pathological condition of CKD has become increasingly important. The recent development of advanced metabolomic assay techniques now allows the human metabolic condition to be evaluated sensitively and comprehensively. The aim of this study was to use metabolomic analysis to perform a preliminary survey of metabolic changes occurring in patients with stage 1-2 CKD.Patients and Serum and urine metabolomic profiles of 15 patients with stage 1-2 CKD were analyzed using our previously reported capillary electrophoresis time-of-flight mass spectrometry (CE-TOFMS) systems, and compared to 7 healthy volunteers. The CE-TOFMS systems in three different modes for cation, anion, and nucleotide analyses detected multiple metabolites in serum and urine samples. In cation analysis mode, several increases in nonessential amino acids were identified in patients with stage 1-2 CKD, similar to those reported for end-stage renal disease (ESRD). Free-radical scavengers carnosine and hypotaurine were decreased in the urine, whereas serum hypotaurine and taurine were increased, consistent with changes in renal and/or systemic oxidative stress. Moreover, the cardiotoxin hypoxanthine was markedly increased in the serum, whereas serum and urine adenosine and urine guanine were decreased, suggesting changes in purine nucleotide metabolism which could affect cardiovascular prognosis. Changes in other unidentified metabolites were also detected. These results suggest that multiple changes in the metabolism are already detectable in stage 1-2 CKD using metabolome analysis. Further studies on these metabolic changes may result in new strategies to prevent cardiovascular events and progression to ESRD in patients with CKD.

Anemia is a frequent complication among pediatric transplant recipients. However, limited published studies are currently available about anemia in these patients. We conducted a retrospective study to determine the prevalence and risk factors of late post-transplant anemia (PTA) among pediatric kidney transplant patients.Patients and A total of 78 kidney transplant patients ≤ 18 years old were enrolled. Prevalence of late PTA, beyond 1 year after transplantation, in children was evaluated between 2008 and 2011. We considered anemia as hemoglobin concentration of ≤ 11 mg/dl and less than 10 mg/dl as a severe anemia. Both univariate and multivariate analyses were performed to determine the correlation of PTA with other risk factors such as renal allograft function and other laboratory parameters. The mean age of recipients was 10 ± 3 years (range: 3 to 18 years); 58% male and 42% female. The prevalence PTA in this survey was 15.4% (n = 12). The prevalence of late PTA was not different in both boys and girls (p = 0.38). At univariate analysis, a significant relationship was seen between serum creatinine concentrations and Hb levels (P = 0.005, r = 0.32) and there was also a significant relationship between serum Hb and cyclosporine trough blood level (p = 0.009, r = 0.29) and 2 hour post dose level of cyclosporine (p = 0.03, r = 0.29). At multivariate logistic regression after adjustment for other factors, however, renal allograft impairment was the only a risk factor for late PTA (P = 0.05, EXP (B) = 2.5; 95 % CI = 1.0- 6.3). The prevalence of late PTA in our children was lower than previously reported in literature from both adult and pediatric transplant patients.

The distension of the pelvis and calyces of the kidney due to the obstruction and stasis of urinary flow or Hydronephrosis, caused by a lesion in the upper or lower urinary tract. The giant hydronephrosis (GH) is a rare entity and its etiologies are varied. Most reported cases of GH occur in infants and children, and are congenital in origin. To formulate and validate a strategic approach for the treatment of giant hydronephrosis (GH) based upon anatomical and functional status of renal units in adults.Patients and We present a retrospective review about 24 cases of GH managed between February 2001 and February 2010. Epidemiologic data, radiological investigations, therapeutic indications, preoperative findings and follow-up were reviewed. Therapeutic indications were based upon functional status of GH. The age of the patients ranged from 19 to 61 years. Ten patients were males and 14 were females. IVU revealed non-visualized unit of the affected side in 4 patients. The quantity of urine drained was between 1.1 litres and 3.5 litres. Seven patients were subjected to nephrectomy. Eight patients underwent reduction pyeloplasty. Nine patients were treated for urolithiasis. Follow-up was in the range of 9 to 73 months (mean = 32 months). Four patients had chronic renal failure requiring hemodialysis and one patient presented with recurrent pyelonephritis. In very poorly functioning unit, nephrectomy is the procedure of choice. In salvageable unit, anatomical configuration should dictate the type of reconstructive procedur

Bladder cancer health care costs are high, primarily due to the need for long-term follow-up. Several markers have been developed to detect the presence of urothelial cell carcinoma (UCC) in the urinary tract. These markers have differing sensitivity and specificity. The nuclear matrix protein-22 (NMP22) test increases the ability to detect recurrent bladder cancer. The aim of this study was to evaluate possible changes in the results of this test depending on the length of the retention time in the bladder of the collected urine.Patients and Between January and June 2006 we prospectively evaluated voided urine specimens in 69 patients undergoing control cystoscopy or transurethral resection of primary or recurrent bladder cancer. We tested for NMP22 in the first morning urine sample and samples collected after 5 min, 30 min and 2 h of urine retention in the bladder. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were determined, and results were grouped according to tumor stage and grade. Global sensitivity was similar in all groups (first morning sample and 5-min, 30-min and 2-h urine retention); the best sensitivity was observed at the 30-min sample point (80%). Specificity varied from 75% to 100% and the best results were obtained in first morning urine and at 30 min and 2 h. PPV was 95.5–100% at the different urine retention periods, while NPV was in the range of 27.3–33.3%. Although this was not a large series, it appears that there is a tendency towards better results with the 30-min urine retention time. It is not necessary to wait 2 h for test operability.

Transrectal ultrasound (TRUS)-guided needle biopsies of prostate are considered the gold standard for the diagnosis of the prostatic cancer. Currently, there is no information on the spectrum of pathological lesions in TRUS biopsies of prostate in men from Pakistan. To determine the spectrum of pathological lesions in TRUS-guided needle biopsies of prostate in men with increased serum prostatic specific antigen (PSA) levels with or without symptoms of prostatism.Patients and A prospective study carried out at the Department of Histopathology, Sindh Institute of Urology and Transplantation (SIUT), Karachi from September 2001 to June 2002. Fifty four men underwent TRUS-guided prostate biopsies for suspected prostate cancer. Raised serum PSA levels were arbitrarily divided into mild (≥ 4 to 20 ng/ml), moderate (≥ 20.1 to 50 ng/ml) and marked elevations (≥ 50.1 to highest). In most cases, eight cores were taken per case. Each core was individually labeled and submitted for histopathological study. The mean age of patients was 66.9 ± 9.4 years (range: 5 2-100 years). The mean serum PSA was 97.1±119.4 ng/ml (range: 4-449 ng/ml). Mean number of cores obtained per case was 7.8±0.9 (range: 4-9). Overall, 30 (55.6%) cases showed benign lesions and 24 (44.4%), malignant. Benign lesions consisted of adenomyomatous hyperplasia. Fourteen of benign cases (46.6%) showed significant inflammatory changes. Among malignant lesions, all cancers were of moderate to high Gleason grades and scores. Mild serum PSA rise was seen in 26 (48.1%) patients; among these, 19 (73%) cases showed benign lesions and 7 (26.9%), malignant. Moderate serum PSA rise was seen in 14 (25.9%) cases; among these 9 (64.3%) were benign and 5 (35.7%) malignant. Fourteen (25.9%) patients had serum PSA ≥ 50.1 ng/ml. Among these, 12 (85.7%) had adenocarcinoma, 2 (14.3%) hyperplasia, one of the later with active prostatitis. In conclusion, this is first study from Pakistan on the spectrum of pathological lesions in prostate TRUS-guided biopsies in men with suspected prostate cancer. The detection rate of prostate cancer is similar to that reported previously from around the world and rises with an increase in serum PSA level

Experience with vesicoureteral reflux (VUR) resolution differs in different centers. The aim of this study was to evaluate the epidemiologic characteristics and outcome of VUR among Iranian children.Patients and In this cohort study, 1278 children with urinary tract infection (UTI) who were visited at the pediatric nephrology clinic; Tehran, IR Iran during 1999 to 2007 were studied. Following the diagnosis, patients received prophylactic low-dose oral antibiotic and one to two yearly follow-ups with Radionuclide Cystography (RNC). Patients underwent surgery in case of breakthrough infection or new renal scar formation. Vesicoureteral reflux was found in 533 patients (42%) with a mean age of 6.3± 3.6 years (Range 2 days to 18 years), out of which 436 (82%) were females. During 3.3 ± 2.2 years follow-up, spontaneous resolution was observed in 109 (39%) of 279 patients with follow-up RNCs. Mean time to spontaneous resolution was 1.5 ± 1 years. Frequencies of VUR grades at initial investigation were 18%, 37%, 26%, 11% and 8% for grades I to V respectively, and 46% had bilateral VUR. Grades I to V resolved in 63%, 57%, 27%, 22% and 10%, respectively. Anti reflux surgery was performed in 27(10%) of patients. Two handred fourty nine patients proceeded to follow-up with Dimercaptosuccinic acid (DMSA) scan. There were 4 (4%) renal scars in patients with spontaneous resolution and 8 (5%) renal scars in patients without spontaneous resolution of VUR (P > 0.05). According to the excellent results with medical therapy, it is recommended that VUR grades 1 to 4 be managed medically with low-dose antibiotic prophylaxis and close follow-ups.

Cryptorchidism as the most prevalent congenital anomalies after birth is evident in more than 3% of live male newborns. The relative risk of neoplastic changes in undescended testes has been shown to be 40 times more in comparison to normal population. It is now believed that pre-malignant changes cannot be expected in undescended testes before puberty; therefore performing testicular biopsy while orchiopexy during pre-puberty has been gradually abandoned and its predictive value has become less valuable. Studying intraoperative pathology samples of undescended testis (UDT) to determine the rate of their malignancies.Patients and From 2002 to 2006, we investigated pathology specimens of our patients including adults above 14 years old undergoing orchiopexy due to UDT at Kermanshah University Medical hospitals. Studied population were 100 patients 14 to 45 years old with average age of 20.5 years, among them 52 persons had right UDT, 40 persons with left UDT and 8 persons with bilateral UDT.A total of 108 testes were studied. In 89 cases testicular atrophy proved to exist while not in the rest 11 ones. In 71 cases, testes were intracanalicular while in the other 37 cases were intra-abdominal. After studying the pathology results, no report of pre-malignant changes carcinoma in-situ status (CIS) was found in all 100 patients. The indication of doing testicular biopsy in adults suffering from UDT can be revised. Owing to no report of any malignancy in these cases, substitution of intraoperative testicular biopsy with long-time follow up can be utilized to reduce expenses and surgical trauma.

Karyomegalic tubulointerstitial nephritis is a rare disease of uncertain etiology with typical clinical features of slowly progressive renal failure in the third decade of life. Histological findings characterize striking enlarged and hyperchromic nuclei in numerous tubular epithelial cells throughout the nephron accompanied by interstitial fibrosis around atrophic tubules. Herein, we report a case of 30 year-old patient who presented with asymptomatic progressive renal dysfunction in 2009. Renal biopsy revealed chronic tubulointerstitial nephritis and an unusually marked karyomegaly particularly of the tubular epithelium.

A 33 year old man with unknown cause of end stage renal disease received a renal graft from a deceased donor. Triple immunosuppression with cyclosporine A (CyA), mycophenolate mofetil and prednisone was prescribed. Four months after transplantation the patient developed general weakness, fever, diarrhea and bleeding to the intestinal tract leading to severe anemia. Due to the fact that no bleeding site was found during gastroduodenoscopy and colonoscopy, open surgery was performed and revealed bleeding ulcerations in small intestine. Partial resection of small intestine and hemicolectomy was performed and histopathological examination revealed Kaposi’s sarcoma (KS) infiltration in the ulceration. CyA was withdrawn and rapamycine started. After 4 years post surgery the patient has been doing well, without symptoms of KS.