Nephro-Urology Monthly
Volume:6 Issue: 3, May 2014

Due to its immunosuppressive properties, local graft irradiation (LGI) has been proposed as a second line therapy for treatment of acute kidney rejection. In this case-series we report 6 patients with biopsy proven acute kidney allograft rejection refractory to conventional antirejection therapy who underwent LGI for treatment of acute rejection at our center. Three of these patients had living donor transplants, 2 had deceased donor transplants, and one had received a simultaneous kidney/pancreas transplant. All patients were treated with anti thymocyte-globulin or muromonab-CD3, and intravenous steroids for initial treatment of rejection. Three patients also received intravenous immunoglobulin. LGI was tried as a last resort and was well tolerated and resulted in either improvement or stabilization of renal function in 5 patients. One patient could not be given the complete course of chemical immunosuppression for treatment of rejection due to concomitant cryptococcal meningitis and was switched to LGI with good short-term response. Our results suggest that LGI could be considered a second line therapy to the conventional anti-rejection therapy for patients with refractory acute kidney allograft rejection, or for patients who cannot receive systemic immunosuppression due to severe infection.

Complete androgen insensitivity syndrome (previously called testicular feminization) is specified by a 46 XY karyotype and negative sex chromatin, bilateral undescended testes, female genitalia appearance, and lack of mullerian derivatives. A 28-year-old woman with complete (severe) androgen resistance underwent prophylactic laparoscopic bilateral gonadectomy because of the eventually increased risk of gonadal malignancy. Although the gonads appeared grossly normal, microscopic examination revealed bilateral well differentiated sertoli–leydig cell tumor (SLCT). Our Medline search revealed that this is the first reported case of bilateral sertoli–leydig cell tumor (SLCT) in androgen insensitivity syndrome.

Malnutrition is a common problem in patients with end stage renal disease (ESRD) undergoing hemodialysis that increases morbidity and mortality rate in them. Subjective global assessment (SGA) is a tool used by health care providers to assess nutritional status in these patients. In addition, biochemical parameters are used to assess the nutritional status in all people. In this study, we evaluated the nutritional status of patients with ESRD undergoing hemodialysis using SGA and assessed probable association between biochemical parameters and malnutrition in this population.Patients and Using SGA, the nutritional status of 105 patients (60 males and 45 females) of two dialysis centers in Sari, Iran, was evaluated during years 2007-2008. It is a semiquantitative scoring system that has seven variables derived from medical history and physical examination. The biochemical parameters including hemoglobin, albumin, cholesterol, BUN, and creatinine were also measured. Among 105 patients, 98 (93.33%) patients consisted of 56 males and 42 females had mild to moderate malnutrition and 3 (2.86%) women had severe malnutrition. In addition, all of the patients without malnutrition were men. We found significant association between patient’s sex and the SGA score (P = 0.03) but no significant association was seen between age and duration of hemodialysis with SGA score. In addition, we did not find significant association between the measured biochemical parameters and malnutrition. According to high prevalence of malnutrition in our patients with ESRD undergoing hemodialysis, periodic assessment of nutritional status is necessary in them. Meanwhile we found SGA as the best tool to assess nutritional status in patients with ESRD undergoing hemodialysis, because it can recognize various degrees of malnutrition that may remain undetected by a single laboratory assessment.

The Page kidney is a rare phenomenon that refers to hypertension resulting from any external compression of a kidney by a hematoma, tumor, lymphocele, or urinoma. The activation of the renin-angiotensin-aldosterone system is believed to be the main mechanism responsible for development of resistant hypertension in Page kidney. We reported a patient with chronic pancreatitis who presented with hypotension due to splenic artery aneurysmal bleed; following the resuscitation, accelerated hypertension secondary to Page kidney caused by perinephric hematoma presented. Early diagnosis by contrast-enhanced computed tomography of the abdomen and renal angiogram was followed by therapeutic angioembolization. However, ultrasound guided aspiration was not done because of denial by the patient for further treatment. Follow-up showed normalization of blood pressure and resolution of hematoma on subsequent abdomen ultrasound evaluation. Splenic artery aneurysm is a very uncommon cause of Page kidney and to our knowledge, it was the first case of its kind ever reported in the literature.

Urethritis is characterized by urethral inflammation, and it can result from both infectious and noninfectious conditions. Physicians and other health care providers play a critical role in preventing and treating urethritis. The aim of this study was to describe and identify predictors of health care seeking behavior among men with urethritis.Patients and In total, 98 male patients aged between 16 to 52 years-of-age (mean 30.9 ± 8.0 years), who attended our clinic with symptoms of urethritis, were included in the study. We conducted face-to-face interviews with the patients using a 9-item survey questionnaire. Patients were divided into three groups according to their level of education as follows: group I (n = 44), elementary school; group II (n = 38), high school; and group III (n = 16), university. Among the 98 patients evaluated, the source of treatment was physicians in 44 patients (44.9%), drugstores in 38 cases (38.77%), and friends in 16 patients (16.32%). There was a statistically significant difference found between the groups according to the source of treatment (P < 0.001). The most common factors associated with seeking care from other sources, rather than physicians, were economic reasons in 19 patients (35.18%), confidentiality concerns in 24 (44.4%), and ease of access in 11 patients (20.37%). A substantial proportion of patients with urethritis sought help from other sources, rather than physicians. The results of our study show that the patients with higher levels of education were more likely to seek help from health care services. It is important to promote the public’s knowledge through informative studies and educational materials in order to encourage patients to seek rapid and effective treatment from proper sources.

Considering all the couples willing and trying to get pregnant, the incidence of infertility is 15% of which approximately half of the cases are due to the male factors. The aim of this study was the investigation of the effects of ubiquinol, reduced form of coenzyme Q10 (Co-Q10), an empiric treatment modality, on sperm parameters in idiopathic subfertility.Patients and In this retrospective study, 62 patients who had received 100 mg ubiquinol twice a day for six months due to idiopathic infertility since January 2012 to January 2013 were included. Only infertile patients with astheno-teratozoospermia without any identified etiology and with a spermatozoa concentration of greater than 13 × 106/mL were included. The increase in mean values of concentration after the ubiquinol treatment was not statistically significant (P value = 0.065). However, the changes in morphology and motility (fast progressive [a] and a + slow progressive [b]) were statistically significant (P < 0.00). The weakness of the literature with regard to coenzyme Q10 is about its effects in patients with severely diminished sperm densities and the physiologic steps of morphologic improvements.

Clitromegaly can be congenital or acquired with the former type being more prevalent. The main etiology behind the acquired type is hormonal imbalance affecting mainly adult women. This type is seen mostly in association with polycystic ovarian syndrome, hyperthecosis, ovarian tumors, and clitoral cysts or it can be drug-induced. Clitoral leiomyoma is a rare benign tumor of female genitalia and is an uncommon cause of clitromegaly.Case Report: We reported a 42-year-old premenopausal woman with a progressively increasing mass since five years ago, who had attended our clinic with urinary retention. It was a fungating mass with ulceration arising from the crus of the clitoris with the size was 11 × 9 cm. After detailed laboratory investigations, she had normal karyotyping. Hormonal assay for testosterone, dehydroepiandrosterone sulphate, and follicle stimulating hormone, luteinizing hormone, parathormone, and prolactin levels revealed values within the normal range. Twenty-four hours urinary excretion levels of free cortisol and ketosteroids were within normal limits. Beta-hCG level was also in normal range. Thyroid function tests and X-ray chest results were normal. Contrast enhanced computed tomography (CECT) of the abdomen showed no abnormality in adrenals and there was no pituitary enlargement on brain MRI. Pelvis MRI showed a large 11 × 9 × 8 cm clitoral mass. Diagnostic biopsy done from ulcer margin was suggestive of leiomyoma. The mass was completely excised preserving the tip of clitoris. The histopathology showed spindle-shaped cells arranged in palisading form. On immunohistochemistry, tumor cells were positive for smooth muscle actin (SMA) as well as for estrogen and progesterone receptor (ER/PR), confirming the diagnosis of leiomyoma. The patient was regularly followed, and was doing well with no voiding difficulty. We reported the world largest clitoral leiomyoma presenting with symptoms of acute urinary retention. MRI has important role in diagnosis and biopsy is confirmative with spindle-shaped cells arranged in palisading pattern and simple excision would be curative.

Plasma selenium (Se) concentration and glutathione peroxidase (GSH-Pxs) enzyme activity of the patients with chronic kidney disease (CKD) are usually lower than healthy individuals; however, the effect of Se supplementation on the GSH-Pxs activity in those patients remains unclear. This study aimed to assess the effect of Se supplementation on plasma Se concentration and red blood cell (RBC) GSH-Pxs activity in patients with different stages of CKD.Patients and In this randomized clinical trial, forty-five patients with CKD who attended in a nephrology clinic were recruited. The patients were randomly allocated into three groups according to their creatinine clearance rate and were supplemented with daily Se 200 mcg for three months. Plasma Se concentration and RBC GSH-Pxs activity were measured in each patient at the beginning and at the end of the study. This clinical trial was registered in the Iranian Registry of Clinical Trials (www.irct.ir) with registration number ID of IRCT201305318501N2. Plasma Se concentration and RBC GSH-Pxs activity increased significantly in all three groups of patients with CKD (P < 0.05). There were no significant differences between three groups regarding baseline plasma Se (P = 0.268) and RBC GSH-Pxs activity (P = 0.741). Se supplementation can increase plasma Se concentration and RBC GSH-Pxs activity in patients with different stages of CKD.

Recently, the development of new biomarkers as prognostic and predictive markers in prostate cancer has been crucial.

This study was aimed to determine whether serum vascular endothelial growth factor (VEGF) levels would be a prognostic marker or risk assessment factor in patients with prostate cancer and to investigate whether it could differentiate cancerous tissue from benign prostate hyperplasia (BPH).Patients and

We enrolled 44 patients with prostate cancer, 57 patients with BPH, and 57 healthy individuals. Serum VEGF levels was measured by ELISA and was compared among all groups; then, its correlation with PSA and Gleason score in cancerous group was assessed. In addition, by using receiver operating characteristic (ROC) curve and area under curve (AUC), we determined the sensitivity and specificity of VEGF as well as combined variable of VEGF and PSA as a diagnostic marker of prostate cancer.

Serum VEGF level was significantly higher in patients with prostate cancer in comparison to the other groups (P value < 0.001); however, it was not different between BPH and control groups. Only in cancerous group a significant correlation between VEGF and PSA was found (r = 0.425, P = 0.004). Assessing the risk of prostate cancer, we found a powerful correlation between the VEGF alone as well as the combination of VEGF and PSA with prostate cancer.

VEGF may be a diagnostic biomarker of prostate cancer. In addition, it may differentiate the cancerous tissue from BPH. We suggest that VEGF combined with PSA may be used as a screening test of prostate cancer.

Premature ejaculation is one of the most problems in clinical practice. The association between varicocele and premature ejaculation was poorly understood. The effects of varicocelectomy on premature ejaculation in varicocele patient was studied.The aim of this study was to determine the impacts of varicocelectomy on patients with both premature ejaculation and varicoceles.Patients and This was a clinical trial study, conducted on 124 patients (20-35 years old), with varicoceles and premature ejaculation (PE), since March 2011 to April 2013. Inguinal and sub inguinal varicocelectomy were performed for them. All patients had both impairment of spermiogram and PE. These patients were followed up for about 2 years and evaluated for PE, in addition to parameters of spermiogram, before and after the surgery. A total number of 124 patients with varicoceles and PE were enrolled into the study. Following the surgery 46 patients (37%) were fully treated (P < 0.001), 78 patients (63%) had improvements in PE symptoms changed to early ejaculation (P < 0.05) and 89 patients (72%) had improved parameters of spermiogram (P < 0.002). In a significant number of patients who had clinical varicocele and not well responded to medical treatments for PE, varicocelectomy could effectively improve PE and spermiogram parameters.

Voiding Cystourethrography (VCUG) is the gold standard of detecting and grading the vesicoureteral reflux. Moreover, VCUG is a part of the standard review for infants and children with a urinary tract infection and urinary dysfunction. The purpose of our study was to compare using oral midazolam in contrast to prescribing no sedative medication for voiding dysfunction in children undergoing VCUG.Patients and In a clinical trial, we studied 84 children referred for VCUG. Children were allocated randomly into two equal groups. The intervention group received 0.5 mg/kg midazolam orally half an hour before the VCUG procedure. Then both groups were compared using statistical methods. Then both groups were compared using statistical methods. In more than half of the patients, the main cause of performing VCUG was urinary tract infection. Dysuria was evaluated immediately after VCUG and was more frequent in girls than in boys (P = 0.006). After one week, the urinary irritation and restlessness in the intervention group was significantly lower than the control group. The use of midazolam 0.5 mg/kg reduced children's stress and increased their cooperation during the procedure.