Nephro-Urology Monthly
Volume:4 Issue: 3, Jul 2012

Diabetic nephropathy is a major cause of end-stage kidney disease (ESKD) in patients with type 1 and type 2 diabetes throughout the world. In human glomeruli, expansion of diffuse mesangial matrices, exudative lesions and/or segmental nodular sclerosis are pathological features of diabetic nephropathy. There have been many reports on the pathogenesis and treatment of type 2 diabetes using various animal models.It appears that KK-Ay mice, especially in terms of their immunohistological findings, are a suitable animal model for human type 2 diabetic nephropathy. Many compounds have been reported to be advanced glycation end product (AGE) inhibitors such as aminoguanidine, angiotensin II receptor inhibitors and pyridoxamine, and these are useful in therapeutic interventions for reducing AGEs. Pyridoxamine ameliorates lipid peroxidation and insulin resistance in KK-Ay mice. Combination therapy with angiotensin converting inhibitors (ACE-I) and angiotensin II type 1 receptor blockers (ARB), including an ARB and 1,25-dihydroxyvitamin D3, i.e. anti-hypertensive and anti-reactive oxygen species effects, or with eicosapentaenoic acid (EPA), i.e. anti-microinflammation effect, have shown efficacy in the treatment of diabetic nephropathy in KK-Ay mice. It appears that KK-Ay mice are a useful spontaneous animal model for the evaluation of pathogenesis and treatment in patients with type 2 diabetic nephropathy.

Approaches to the management of vesicoureteral reflux (VUR) in children have changed rapidly in recent years. Multiple studies published over the last decade have contributed to these changes by challenging the dogma that all children with reflux require and benefit from continuous antibiotic prophylaxis. The advent and wide acceptance of endoscopic treatment for VUR has also contributed to these changes. Although new guidelines for VUR management have recently been proposed, they are broad and relatively non-specific. Many physicians and parents remain unsure which children are at risk from their VUR, and which would benefit from antibiotic prophylaxis or surgical intervention. A literature search, followed by an additional search based on bibliographies, was performed for articles reporting on VUR and the utility of antibiotic prophylaxis for its treatment, as well as the chance of spontaneous resolution. Articles selected for review included those that provided information to assist physicians in determining if a child with VUR is at increased risk of pyelonephritis or persistent VUR, and would benefit from intervention. Particular emphasis was placed on recent prospective, randomized trials in children with VUR. Because of the multiple factors affecting risk in a child with VUR, specific guidelines for intervention cannot be provided. However, an accurate understanding of these risk factors will help the physician and parents to develop a more individualized management plan for a child with VUR.

Sub-inguinal varicocelectomy is widely used among surgeons. The aim of this study was to evaluate the outcome of varicocelectomy using a modified microsurgical method, specifically a loupe-assisted method, and its effects on sperm parameters in infertile men.Patients and This study was performed in 40 patients who presented with varicocele. All patients had at least a 1-year history of infertility with abnormal semen parameters and varicocele proven by physical examination and confirmed with color Doppler ultrasound. Routine preoperative investigations were performed. Semen analysis and hormonal profiling were also performed and repeated postoperatively for follow-up. Half of the patients (20 patients) were treated by a sub-inguinal approach assisted by loupe magnification (Group A) and the other half was treated by the same approach but without magnification (Group B). To facilitate the procedure, an ×3.0 loupe was used during the spermatic cord dissection at the level of the external inguinal ring. During dissection, the dilated veins, including the vassal veins and external spermatic veins, were ligated and divided. In total, 40 patients were followed for more than 6 months. The age of the patients varied from 25 to 38 years (mean 32.5). No intra-operative complications occurred in both groups. Regarding post-operative complications, Group A contained only one patient (5%) who developed scrotal hematoma and two (10%) who developed wound infection, whereas in Group B, the complication rate was higher: two patients (10%) developed scrotal hematoma, two patients (10 %) developed wound infection, three patients (15%) developed hydrocele, two patients (10%) developed recurrence, and two patients (10%) developed scrotal edema. Regarding the seminal parameters, much improvement was observed in the sperm count and sperm motility, and a decrease in abnormal forms was observed after surgery with significant differences in Group A. In Group B, similar effects were observed, but without significant differences. Loupe-assisted sub- inguinal varicocelectomy is a safe, simple, and effective method for the treatment of sub-fertile men, especially in medical facilities without microscopic equipment, and permits significant improvement in sperm parameters.

Imaging of the urinary system is considered to be responsible for significant radiation in children. This study was conducted to measure and compare the radiation dose in spot films with photofluorography voiding cystourethrography (VCUG) in children.Patients and 111 [222 Kidney Urinary Unit (KUU)] pediatric patients, aged 1 month to 5 years, with symptomatic urinary tract infection were enrolled in the study.Peak tube voltage (kVp), exposure setting (mAs), focus film distance (FFD), film size and DAP (after the exam) were recorded for all patients. To evaluate the validity of the photographs, we calculated sensitivity, specificity, predictive values and agreement between the two methods using the kappa statistic. If the kappa was greater than 0.75, between 0.4–0.75 or less than 0.4, then the agreement was excellent, good or poor, respectively. P values less than 0.05 were statistically significant. Vesicoureteral reflux (VUR) was detected in 74 KUU (33.3%) in standard films and in 71 (32%) in photographic images. The photographs had no false positives and 3 false negatives. Therefore, the new method had a sensitivity of 96%, a specificity of 100%, a negative predictive value of 98% and a positive predictive value of 100%. The two-method agreement in the VUR diagnosis for grades 1, 4, 5 and the overall grading were excellent (kappa > 0.83); however, for grades 2 and 3, agreement was 80%, which was good (kappa = 0.64). Our study suggests that the high validity and excellent agreement of the photofluorography method in the diagnosis and grading of VUR, which is comparable to spot films and represents a 50%–90% reduction in radiation, makes it the preferred method.

Recently, stem cells have been used to facilitate healing in animal models of renal failure induced by acute ischemic and nephrotoxic damage. Granulocyte colony-stimulating factor (G-CSF) has been reported to stimulate stem cell mobilization from bone marrow and these cells may contribute to renal repair. In the present study, the effects of G-CSF and stem cell administration as monotherapy or in combination, and the relation of these effects with the duration of therapy, have been investigated in an experimental rat model of carbon tetrachloride (CCl4)-induced nephrotoxicity. The fifty rats included in the study were distributed into 4 main groups, Group 1, 2, 3, and 4, and two subgroups for each group, except for Group 1. All rats received an intraperitoneal injection of CCl4. Then at 6 h, Groups 1, 2a, 3a, and 4a were administered saline, stem cells, G-CSF, and stem cell plus G-CSF, respectively. At 24 h, Groups 2b, 3b, and 4b were administered stem cells, G-CSF, and stem cell plus G-CSF, respectively. All animals were sacrificed 48 h after the CCl4 injections. Serum urea, creatinine, sodium, and potassium levels were measured from blood samples. Tissue α-glutathione S-transferase (GST) levels were also measured from renal tissues. Serum urea was reduced in all groups when compared to Group 1, but the decrease was statistically significant only in Group 3b (P = 0.04). Serum creatinine and sodium levels were similar in all groups (P > 0.05). Tissue GST levels were lower in all groups, but the reduction was significant only in Group 4a, which was administered stem cells + G-CSF at 6 h (P = 0.01). Tubular degeneration and/or tubular dilatation were the most common pathologic changes, and their incidence was similar in all groups (P > 0.05). Although both stem cell and G-CSF monotherapy led to damage reduction, the effect was not significant. However, the reduced damage by the combined use of stem cells and G-CSF, particularly during the early period, was statistically significant.

Urinary screening tests for early detection of renal diseases in asymptomatic school children and adolescents are important in the detection of silent renal diseases. The purpose of the study was to determine the prevalence of occult renal diseases by dipstick test (reagent strips) in asymptomatic Nepalese children.Patients and A total of 2,243 school children, aged 5–15 years, were screened for urinary abnormalities using dipstick test screening. The children who tested positive in the first screening were re-tested after 2–4 weeks. In the first screening, 123 children (5.5%) tested positive for isolated hematuria and proteinuria and for combined hematuria and proteinuria. Of these children, 16 (0.71%) cases tested positive in a second screening. Subsequently, 1 child from the secondary screening group was lost to follow up, 5 tested normal and 10 revealed abnormalities. Glomerulonephritis was the most commonly detected disorder (50%). Urinary screening was found to be useful in identifying occult renal diseases in asymptomatic children. Urinary screening would therefore not only help in early detection but also in the prevention of the deterioration of renal function later in life.

A review of the related medical journals indicates that there is no definite evidence-based option for managing large proximal ureteral stones, although many procedures such as transureteral lithotripsy (TUL), shock wave lithotripsy (SWL), percutaneous nephrolithotripsy, laparoscopic ureterolithotomy, and open ureterolithotomy are currently used to treat this urological problem. In this study, we tried to determine the most appropriate treatment plan for proximal ureteral stones larger than 12 mm by comparing the two most commonly used procedures.Patients and Between February 2005 and April 2011, 62 patients including 40 males and 22 females (mean age 39.5 years, range 19 to 64) with proximal ureteral stones larger than 12 mm (12–26 mm) with a mean size of 17.64 mm were prospectively divided into two groups consisting of 32 patients who underwent TUL (group A) and 30 who underwent SWL (group B). In unsuccessful cases, repeat SWL or TUL was planned. Patients who could not tolerate the lithotomy position, younger than 18 years, had undergone coagulopathy, had concurrent renal and ureteral stones, were pregnant, or had sepsis were excluded from this study. Stone access was successful in 28 patients and the treatment was efficient in 18 patients (56.25%) in group A. For the patients with successful stone access but unsuccessful TUL, a DJ was inserted and a second ureteroscopic intervention was performed. The second intervention was successful in 7 patients (21.87). SWL was successful in 14 patients (46.66%) in the first attempt and in 7 additional patients in the second intervention (23.33%). In this study, we showed different success rates for SWL and TUL because of the larger size of the stones. We achieved a success rate of 56.25% in the first attempt in the TUL group, and the overall success rate (after the second TUL) was 78.12%. In comparison, the SWL group had a success rate of 46.66% in the first attempt, and the overall success rate (after the second SWL) was 69.96%.

The aim of the present study was to compare two analgesic techniques for transrectal ultrasound (TRUS)-guided biopsy: diclofenac patch versus periprostatic nerve block with 1% lidocaine. To study the efficacy of and compare diclofenac patch and periprostatic nerve block as analgesia in TRUS-guided prostate needle biopsy.Patients and In total, 60 patients were prospectively randomized into three groups: those in whom a diclofenac patch was used (n = 20), those in whom periprostatic nerve block was used (n = 20), and a control group (n = 20). Prostate biopsy was performed after administration of analgesia according to group. The three groups were similar in terms of age, prostate volume, and PSA (prostate-specific antigen) levels. Pain scores were significantly lower in the nerve block group (P = 0.000) at the time of biopsy until 2 h postprocedure, but not at 4 h postprocedure (P = 0.068). No significant difference in pain score was observed in the diclofenac patch group at the time of biopsy (P = 0.106) as compared to the control group, but the diclofenac patch provided adequate pain relief 1 h (P = 0.000), 2 h (0.000), and 4 h (0.002) postprocedure. No significant difference was observed in pain score between the nerve block (P = 0.520) and control groups (0.057) at probe insertion. The pain score at 4 h was significantly lower in the patch group compared to the nerve block and control groups. Periprostatic nerve block provides superior analgesia for TRUS-guided biopsy. Diclofenac patch is useful as an adjunct.

Although cyclosporine (CsA) and calcium channel blockers (CCBs) parallel to each other may provoke gingival enlargement (GE), there are few considerations about combined effects of CsA and CCBs on gingival tissues. This study aimed to determine prevalence of GE among renal transplant recipients and to compare its occurrence in patients who received only CsA and those who were on CsA and amlodipine.Patients and We conducted a prospective randomized case-control trial including 213 renal transplant recipients between February 2010 and August 2010. They were randomly divided into two groups including control group (on continuous treatment with CsA alone; n = 112) and trial group (treated with combined CsA and amlodipine; n = 101). Buccal, lingual, and inter-proximal membranes at last 12 anterior teeth were assessed for GE and packet depth (PD) using Gingival Index of McGaw and others, and Packet Index of Turesky–Gilmore–Glickman, respectively. Marked GE was observed in 26 patients (25.7%) in trial group and only in 4 individuals (3.6%) in control group (P = 0.000). In logistic regression analysis, obese (OR = 3, P = 0.04), older (OR = 2.8, P = 0.03), and female (OR = 1.3, P = 0.03) recipients as well as who received high dose amlodipine (OR = 4.4, P = 0.000) were at risk for marked GE. There is a strong correlation between GE, in particular marked GE, and combination therapy with CsA and amlodipine in transplant patients compared to those treated by CsA alone. We suggest CsA dose reduction may restrain this adverse effect.

Helicobacter pylori eradication with clarithromycin is more expensive than with azithromycin. This study aimed to compare the effectiveness of these two antibiotics in eradicating H. pylori in hemodialysis (HD) patients.Patients and This is a prospective, randomized, double-blinded clinical trial analysis of HD patients. Patients who had dyspepsia and showed positive results for two of three tests, anti-H. pylori serology, H. pylori stool antigen (HpSAg), or Urease Breath Test (UBT), were included in the study. The subjects consisted of 39 dialysis patients who were randomly divided into two groups that received medication twice daily. Group OAC received 20 mg omeprazol, 500 mg amoxycilin, and 250 mg clarithromycin, and Group OAAz received 20 mg omeprazol, 500 mg amoxicillin, and 250 mg azithromycin. Both regimens were administered for 14 days. Eradication was investigated by performing the UBT and the HpSAg test eight weeks later. This study began with 39 patients, 37 of which completed the treatment schedule (20 males and 17 females, mean age 59 years). Two patients died due to MI before beginning treatment. In the OAC group, negative results on the UBT and HpSAg tests were found in 82.4% and 88.2% of the participants, respectively. In the OAAz group, these values were 80% and 85%, respectively. The data showed that the difference between the two regimens was not significant (P = 1.0). According to the data, no differences in eradication rates were apparent between the azitromycin and the claritromycin regimens. However, lower cost and fewer complaints could be considered as an advantage of the triple therapy with azithromycin..794.

Few studies in India as well as in most developing countries have compared the mortality and morbidity rates between chronic kidney disease patients who were referred early to nephrologists and those who were referred late. To study the mortality and morbidity patterns and to compare the various clinical parameters between the abovementioned early and late referrals.Patients and Fifty consecutive chronic kidney disease patients were followed up for one year. They were then classified as early referral (patients who underwent dialysis more than three months after the referral) and late referral (patients who underwent dialysis within three months of the referral). Clinical, laboratory parameters, and mortality patterns were compared between the two groups. The blood pressure, hemoglobin, glomerular filtration rate, and calcium and phosphate values were better in the early referral group. Among the 24 complications that occurred, 17 (70.8%) were seen among the patients who were referred late. Among the 13 deaths that occurred, only one belonged to the early referral group. We observed that the mortality rate and clinical parameters were better in patients who were referred early to nephrologists.

A 71-year-old male with a long history of diabetes and hypertension was admitted with mild azotemia and recurrent hyponatremia. He was diagnosed with a pituitary gland cystic tumor. On careful evaluation, his hyponatremia was found to be due to cerebral salt wasting. The patient made a full recovery following treatment for cerebral salt wasting.