Nephro-Urology Monthly
Volume:4 Issue: 2, Apr 2012

As the world’s population continues to age, practitioners encounter increasing numbers of older patients with end-stage renal disease (ESRD) who require renal replacement therapy (RRT). Conservative management may be considered in older patients and has been shown to offer comparable survival rates and hospital-free days to RRT patients. At present, for those who choose RRT, hemodialysis is the most commonly used modality. Many practitioners believe that peritoneal dialysis (PD), including assisted peritoneal dialysis, can be used safely in this population. Age is not a contra-indication to peritoneal dialysis, and a choice of modality should be offered to older patients. Assisted peritoneal dialysis has been used successfully in multiple regions without an increase in complication rates. Quality of life is an important issue for older patients with ESRD, and studies such as Broadening options for long-term Dialysis in the Elderly support the use of PD in older patients as it is associated with fewer fluctu ions in symptoms of ESRD and less intrusion into people’s lives. This review discusses the appropriateness of initiating RRT in older patients, choices of modality, underutilization of PD in older patients, use of assisted PD, complication rates, and quality of life in these patients. overall, PD seems to be a safe and effective modality of RRT in older patients, and assisted PD can be used in patients with limited functional impairment..

Cytomegalovirus is the most common viral infection after kidney transplantation. Clinical presentations of cytomegalovirus infection range from asymptomatic infection to organ-specific involvement. Most symptomatic infections manifest as fever and cytopenia. The gastrointestinal tract is the most common site of tissue-invasive infection,often presenting as diarrhea or gastrointestinal bleeding. Gastrointestinal obstruction,perforation, thrombosis of large gastrointestinal veins, splenic artery thrombosis,and pancreatitis are rare gastrointestinal presentations of cytomegalovirus infection.Renal-allograft ureteral stricture and skin involvement are other rare presentations of cytomegalovirus infection. Hemophagocytic syndrome, thrombotic microangiopathy,adrenal insufficiency, and renal allograft artery stenosis are other rare symptoms of cytomegalovirus infection..

Botulinum toxin (BT) is a potent presynaptic neuromuscular blocking agent which induces selective, reversible muscle weakness for months when injected intramuscularly. During recent years BT has revolutionized the treatment of previously intractable symptoms of detrusor overactivity. Based on a systematic search of the PubMed database, a review of the current literature on the use of onabotulinum toxin A (Botox®) in the treatment of neurogenic detrusor overactivity is presented.Onabotulinumtoxin A Urinary Bladder, overactive Urinary Bladder, Neurogenic Botulinum toxin (BT) is a potent presynaptic neuromuscular blocking agent which induces selective, reversible muscle weakness for months when injected intramuscularly. During recent years BT has revolutionized the treatment of previously intractable symptoms of detrusor overactivity. Based on a systematic search of the PubMed database, a review of the current literature on the use of onabotulinum toxin A (Botox®) in the treatment of neurogenic detrusor overactivity is presented. onabotulinum toxin A proved to be highly effective in the majority of studies, even though a wide range of injection techniques and dosages were described. The onset of the effect usually appeared before 2 weeks, and reached a peak within 2-6 weeks, with the clinical effect being maintained for approximately 6-8 months, or even longer. Depending on the dose, a number of patients developed high residual volume and clean intermittent self/helper catheterization (CIC) may become necessary. only a few side effects were described, and intravesical onabotulinum toxin A injection seems to be well tolerated. however, details on injection technique, dose interval between injections, etc. are still under debate and only a few randomized, placebo controlled studies have been published..

In surgical pathology, atypical small acinar proliferation is commonly detected in prostate biopsies. Most studies on atypical small acinar proliferation have examined morphological characteristics and the utility of immunohistochemical studies. however, these resources are not available to many pathology departments. We have found that examining additional sections is a simple and inexpensive method that allows better evaluation of focal prostatic glandular atypia. The present report compares the diagnostic utility of immunohistochemical techniques versus examining additional sections in prostate biopsies with focal glandular atypia.Patients and Thirty recently studied prostate biopsies with focal glandular atypia were selected. In each case, 3 additional levels were examined. An immunohistochemical study was performed on one level using an antibody against high-molecular-weight keratin (34BetaE12). Two additional sections were stained with hematoxylin and eosin. The diagnosis of focal carcinoma was established with only additional sections in 4 cases (13.3%). In 2 of these biopsies, additional areas of carcinoma were found that were not identified in the original sections. In 4 other cases, immunohistochemical analysis was the only useful method for diagnosing cancer. In 9 cases (30%), both methods were useful for classifying focal glandular atypia as carcinoma. In the remaining 13 cases, neither immunohistochemical analysis nor additional sections were useful in changing the diagnosis of focal glandular atypia. Focal glandular atypia in prostatic needle biopsies should be routinely examined with additional sections, particularly when immunohistochemical analysis is not possible. Some biopsies with atypical glandular proliferation may show focal carcinoma in additional sections, even if the immunohistochemical analysis did not provide a diagnosis of malignancy. Additional sections can also reveal areas of carcinoma that were not apparent in the original sections..

The prevalence of vesicoureteral reflux (VUR) is higher in enuretic children than in non-enuretic children. Recent studies have reported VUR in 6–23% of children withenuresis.To clarify the association of nocturnal enuresis with vesicoureteral reflux (VUR) and to identify children who are at risk for VUR.Patients and During 2007–2009, neurologically normal children who were referred with a chief complaint of nocturnal enuresis and had abnormal renal ultrasonography (US) results, daytime incontinence, abnormal results in urodynamic studies, urinary tract infection,or a history of VUR in their siblings were prospectively evaluated for VUR by voiding cystourethrography (VCUG). A total of 60 children (26 boys and 34 girls) aged 5–17 (mean ± SD: 8.46 ± 2.45) years met the inclusion criteria and were enrolled in the study. Twenty-eight (46.7%) patients had mono-symptomatic nocturnal enuresis (MNE), and 32 (53.3%) had non-mono symptomatic nocturnal enuresis (NMNE). VUR was reported in 10 (16.7%) patients and posterior urethral valve (PUV) was found in 1 (1.7%) patient. The prevalence of VUR was significantly higher in patients with daytime incontinence and in girls (P = 0.016 and 0.003 respectively). We didnot find any significant correlations between VUR and the form of enuresis (primary versussecondary), urinary tract infection, or any diurnal urinary symptoms other than daytime incontinence (P > 0.05 for all). Of 10 renal scintigrams, 5 (50%) showed renal cortical defects.VUR is uncommon in children with MNE and in those with NMNE who do not wet themselves during the day; however, it is a relatively common finding in enuretic children who have daytime incontinence. We recommend VCUG in all enuretic children who have daytime incontinence..

Retrograde intra-renal surgery (RIRS) has been used to remove stones of less than 2 cm in the kidney. however, its role is not well defined. The objective of this study was to evaluate the outcomes and safety of RIRS, used either as a primary or secondary procedure, and to analyze factors predicting the stone-free rate (SFR).Patients and A retrospective analysis was performed on data from patients who underwent RIRS over a 10-year period (2002–2012). Stone size was measured as the surface area and was calculated according to the EAU guidelines. In cases of multiple stones, the total stone burden was calculated as the sum of each stone size. Stone burden was then classified as ≤ 80 mm2 or > 80 mm2. RIRS was classified as primary procedure or secondary procedure (after failed extracorporeal shockwave lithotripsy or percutaneous nephrolithotripsy). Stone clearance was defined as a complete absence of stones or stones < 4 mm, which were deemed insignificant on ultrasonography and plain radiography. The overall SFR for renal stones treated with RIRS in our center was 55.4%, and the complication rate was 1.5%, which consisted of one case of sepsis. The only factor affecting SFR in this study was the indication for RIRS. When performed as a primary operation, RIRS showed a significantly better SFR (64.3%). The SFR for lower pole stones was only 44.4%. There were no statistically significant effects of stone burden, radio-opacity, or combination with ureteral stones on SFR. RIRS should be used as the primary treatment for renal stones whenever possible.

The incidence of prostatic abscess (PA) has markedly declined with the widespread use of antibiotics and the decreasing incidence of urethral gonococcal infections. To evaluate different treatment methods for prostatic abscess and to describe technical points that will improve the outcome of transurethral (TUR) drainage of prostatic abscess.Patients and We performed a retrospective study of a series of 11 patients diagnosed with prostatic abscess, who were admitted and treated in Farwaniya Hospital,Kuwait, between February 2008 and November 2010. Drainage was indicated when antibiotic therapy did not cause clinical improvement and after prostatic abscess was confirmed by TRUS (Transrectal ultrasonography) and/or CT computed Tomographyscan. TUR drainage was indicated in 7 cases, ultrasound-guided transrectal drainage was performed in 2 cases, and ultrasound-guided perineal drainage was performed in 2 cases. All patients that underwent TUR-drainage had successful outcomes, without the need of secondary treatment or further surgery. TUR drainage of a prostatic abscess increases the likelihood of a successful outcome and lowers the incidence of treatment failure or repeated surgery. Less invasive treatment, with perineal or transrectal aspiration, may be preferred as a primary treatment in relatively young patients with localized abscess cavities.

Playing video games in childhood may help achieve advanced laparoscopic skills later in life. The virtual operating room will soon become a reality, as “doctor games 2.0” will doubtlessly begin to incorporate virtual laparoscopic techniques. To teach surgical skills to schoolchildren in order to attract them to urology as a professional choice later in life. As part of EAU Urology Week 2010, 108 school children aged 15–19 attended a seminar with lectures and simulators (laparoscopy, TUR, cystoscopy, and suture sets) at the 62nd Congress of the German Society of Urology in Düsseldorf. A Pub-Med and Google Scholar search was also performed in order to review the beneficial effects of early virtual surgical training. MeSH terms used were “video games,” “children,”and “surgical skills.” Searches were performed without restriction for a certain period of time. In terms of publicity for urology, EAU Urology Week, and the German Society of Urology, the event was immensely successful. Regarding the literature search, four relevant publications were found involving children. An additional three articles evaluated the usefulness of video gaming in medical students and residents. Making use of virtual reality to attract and educate a new generation of urologists is an important step in designing the future of urology.

Bone morphogenetic protein 7 (BMP7) has been suggested to play a protective role against kidney injury in chronic kidney disease. To identify the critical molecular regulators in the early stage of diabetic nephropathy, we studied the expression of BMP7 and 2 important kidney-specific markers, podocin and Tamm–horsfall protein (THP). A diabetic nephropathy model was established by intraperitoneally injecting streptozotocin (STZ) in male Kunming mice. Kidney weight index was used as an indicator of early renal injury. Kidney tissue from the diabetic model mice was obtained at 4, 8, and 12 weeks, and total protein was extracted to assess the expression of BMP7, podocin, and THP by western blot analysis. Diabetic model mice were successfully established, and the kidney weight index of the model animals increased significantly. The expression of BMP7 was significantly downregulated, while the expression of THP was increased in the early stage of diabetic nephropathy. however, the expression of podocin did not change. our observations suggested that down-regulation of BMP7 expression and up-regulation of THP expression were early events that occur prior to podocyte injury with the structure protein, podocin spoiled, which further confirmed that BMP7 is a key molecular regulator in the early stage of diabetic nephropathy.

Although the immunosuppressant cyclosporine (CsA) is widely used after kidney transplantation over the long term, there is still no firm consensus on the best way to monitor of CsA blood levels. Cyclosporine (CsA) assay is critical for the management of renal transplant recipients due to inter– and intra–patient variation in CsA absorption and metabolism.Patients and In a retrospective cross sectional study, blood levels of CsA (through and 2 hours post dose) measured at least 5 times during 3 years post transplantation, in 7702 kidney transplant recipients from different transplant center of Tehran, IR Iran between 2008 and 2012. Cyclosporine absorption (CA) calculated C2/C0 ratio. CA had a significant correlation with allograft function (P = 0.000, r =.0.285), this correlation was stronger than its relationship with C0 and C2 blood levels (P = 0.000 and P = 0.000 as well as r = 0.033 and r = 0.090, respectively). In univariate analysis during different times after transplantation, C0 and C2 blood levels significantly decreased over three years follow up (P = 0.000), (P = 0.000); While, CA reversely increases over the time (P = 0.000). In linear regression model overall CA levels had correlation with lower age of recipient (P = 0.02), hypokalemia (P = 0.001), higher level of creatinine (P = 0.02) and triglyceride (P = 0.001). The present study shows that CsA absorption changes trough the post-transplant time and appears to increases over time in long–term period after kidney transplantation.

Acute rejection remains a major problem in renal transplantation and represents one of the most important causes of chronic allograft dysfunction and late graft loss. Daclizumab is a genetically engineered human IgG1 monoclonal antibody that binds specifically to the α chain of the interleukin-2 receptor, and may thus reduce the risk of rejection after renal transplantation. The aim of this study was to examine the effect of daclizumab induction therapy combined with a triple immunosuppressive protocol including prednisolone, cyclosporine microemulsion (CsA), and mycophenolate mofetil (MMF), in reducing the incidence of acute rejection in recipients of living unrelated donor kidneys.Patients and In this historical cohort study, 43 adult recipients of their first kidney allograft received daclizumab (three 1 mg/kg doses administered every 2 weeks) with triple immunosuppressive therapy (steroids, CsA, and MMF). This group was compared to 43 first-time graft recipients who received maintenance triple immunosuppressive therapy comprising steroids, CsA, and MMF. The end point was the incidence of biopsy-confirmed acute rejection within 6 months after transplantation. At 6 months, 5 (11.6%) of the patients in the daclizumab group had biopsy-proven rejections, as compared to 14 (32.5%) in the control group (P = 0.017). The sex and the age of recipients had no impact on the incidence of acute rejection episodes in the two groups. Adding interleukin-2 receptor antibody (daclizumab) to maintenance triple immunosuppressive therapy (prednisolone, CsA, and MMF) reduces the incidence of acute rejection episodes at 6 months in first-time transplant recipients of living unrelated donor.

The direct and indirect negative impacts of hypertension on mortality and morbidity and the deficiencies in physicians’ knowledge on its management prompted us to search for new methods of training this item. In this study, 2 methods of teaching—planned lecture and cooperation—were compared in instructing hypertension to medical students. This study was designed to be a prospective analysis of the efficacy of 2 models of cooperation and planned lecture teaching of hypertension. The medical students, in the second term of the 2010 academic year who were introduced to the nephrology ward for their internal medicine course, were randomly assigned to 2 groups to be taught hypertension by 2 models of cooperation and planned lecture to compare their advantages and disadvantages. In their final exam 2 questions concerning the management of hypertension were asked with regard to evaluating the long-term impact of the models on learning. Data were analyzed by paired t-test to compare pre- and post-test in each group, and independent t-test was used to compare the average and standard deviation scores between groups. Fifty-one students participated in the study. The total number of students in the lecture (group 1) and cooperation (group 2) methods was 28 and 23, respectively. By independent t-test, differences in test scores indicated a similar achievement of the 2 methods for the endpoint of basic knowledge (P = 0.253). But, the cooperation method was more successful in transferring abilities, primarily in the areas of workup and treatment (P < 0.05). The study findings show that both methods can set in the optimal training for hypertension to students but that the cooperative method is more effective for deduction analysis.

We report a case of prostatic adenocarcinoma, initially presenting with generalized lymphadenopathy, and mimicking lymphoma on flurodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT). our case suggests that in elderly men presenting with generalized lymphadenopathy, the diagnosis of metastatic prostatic carcinoma should not be overlooked even in the absence of typical urinary symptoms. The establishment of a diagnosis of metastatic prostate carcinoma is important, because even widespread prostate cancer may be responsive to hormonal treatment, as demonstrated by this case.We also describe the use of FDG PET/CT to diagnose, stage, and evaluate response to hormonal treatment in a given patient.