Diagnostic significance and antigen specificity of antineutrophil cytoplasmic antibodies in renal diseases. A prospective multicentre study

In a prospective multicentre study on the clinical significanceof ANCA in renal diseases, sera from 920 patients with rapidlyprogressive renal failure and/or renal disease in associationwith extrarenal signs suggestive of a systemic vasculitis weretested for the presence of ANCA by indirect immunofluorescence(IIF) and ELISA. 193 of 920 cases (20.9%) were positive by IIFand 180 (19.5%) by ELISA, using a ‘crude’ cytoplasmicextract as substrate. The sensitivity and specificity of IIFfor ‘pauci-immune’ crescentic necrotizing GN (CNGN),in association or not with systemic vasculitis, was 87.5 and95.6% respectively. The IIF pattern and antigen specificity (alpha granules andMPO) correlated well with the clinical features: a cANCA pattern(alpha granules) was associated with ENT involvement (probableWegener's granulomatosis); a pANCA pattern (MPO) with ‘idiopathic’CNGN and small-vessel vasculitis without respiratory tract disease(microscopic polyarteritis); patients with a pulmonary-renalsyndrome had either c or pANCA in a similar proportion. Our study confirms a high sensitivity and specificity of ANCAfor patients with CNGN. ANCA should be considered an important diagnostic test in patientswith renal diseases, especially in the presence of rapidly progressiverenal failure.     

Crescentic glomerulonephritis associated with infective endocarditis: renal recovery after immediate surgical intervention

A 57-year-old man was referred to our hospital because of acute cardiac failure and acute renal insufficiency. Laboratory data showed elevation of serum immune complex levels and antineutrophil cytoplasmic antibody (ANCA) titers, with cytoplasmic pattern (C-ANCA) on indirect immunofluorescence (IIF), and proteinase 3 specificity (PR3-ANCA) on solid-phase enzyme-linked immunosorbent assay (ELISA). Hemodialysis therapy was initiated, and this relieved the symptoms of cardiac failure. Echocardiography revealed three-grade aortic insufficiency and two large floating vegetations on the aortic valve. Considering the risk of embolism, we immediately performed aortic valve replacement and surgically removed the vegetations, subsequently giving antibiotic therapy. Six weeks after the operation, the patient's renal function showed marked improvement and the serological abnormalities, except for ANCA titers, had normalized, resulting in no need for dialysis. A renal biopsy specimen revealed diffuse proliferative glomerulonephritis (GN) with crescents including more than 50% of glomeruli, and granular deposits of IgM, C3, and C1q on immunofluorescence. ANCA titers remained high, but the patient's renal function has been stable, indicating a discrepancy between ANCA titers and his clinical course. In this patient, treatment by immediate surgical intervention, performed during the acute phase with active GN and highly reduced renal function, led to dramatic renal recovery. This case suggests that surgical removal of vegetations in the early stage of crescentic GN may result in a good renal outcome in patients with rapidly progressive GN associated with endocarditis. Although it has been suggested that ANCA may have some relationship to GN in endocarditis, in this patient, its pathogenetic significance is questionable. Received: March 10, 2000 / Accepted: May 23, 2000     

Rapid screening assay for anti-GBM antibody and ANCAs; an important tool for the differential diagnosis of pulmonary renal syndromes

Background. Pulmonary renal syndrome is encountered in several diseases such as Goodpasture's syndrome, antineutrophil cytoplasmic antibody (ANCA) associated systemic vasculitis, systemic lupus erythematosus (SLE) and infection-associated or drug-induced glomerulonephritis. To preserve organ function it is of vital importance to make the correct diagnosis and institute adequate therapy early, in the acute phase. Methods. An enzyme-linked immunosorbent assay (ELISA), specially designed as a rapid screening assay for antiglomerular basement membrane (anti-GBM) antibody proteinase-3 (PR3-) ANCA and myeloperoxidase-(PMPO-) ANCA were evaluated from 1060 serum samples drawn from patients with clinically suspected pulmonary renal syndrome or rapidly progressive glomerulonephritis (RPGN). Results. Of the 1060 serum samples, 142 were positive for anti-GBM antibody (n=19), PR3-ANCA (n=60), or MPO-ANCA (n=73). Of the 142 samples, 10 were double positive. Reanalysis of positive sera with a quantitative ELISA yielded results manifesting good correlation with those of the rapid screening assay. Of 918 sera found to be negative in the rapid screening assay, 105 were also tested with IIF, 11 being found to be positive. However, these 11 sera manifested no specificity for PR3 or MPO, but some were specific for bactericidal/permeability-increasing proteins, lactoferrin or elastase ANCAs. Two of the patients whose sera yielded negative results in the rapid assay had systemic vasculitis. Conclusions. The ELISA thus detects the true antibodies to PR3, MPO, and GBM, whereas IIF detects additional specificities. The findings suggest the rapid assay results to be of high positive predictive value, and the assay to be of high diagnostic specificity and sensitivity and thus useful in the diagnostic workup in suspected cases of RPGN or pulmonary renal syndrome.     

Transformation from Tubulointerstitial Nephritis to Crescentic Glomerulonephritis: An Unusual Presentation of ANCA-Associated Renal Vasculitis

A 44-year-old man with acute renal failure and antineutrophil cytoplasmic antibodies (ANCA) positivity was described. The first renal biopsy specimen showed tubulointerstitial nephritis (TIN) with normal glomeruli. However, delayed recovery of renal function with low-dose steroid treatment for TIN prompted a second renal biopsy 1 month later; and the specimen demonstrated a dramatically different morphology, with necrotizing and crescentic glomerulonephritis. Improvement in renal function occurred, together with reduction of ANCA titers, following intensive immunosuppressive therapy. This case illustrates an unusual presentation of TIN in ANCA-associated renal vasculitis. The possible pathogenetic mechanism are discussed.     

The Use of Colorflow Duplex Scanning to Detect Significant Renal Artery Stenosis

The purpose of this study was to review our institutional experience with colorflow duplex scanning in detecting significant renal artery stenosis and to validate the criteria used: renal artery peak systolic velocity (PSV) >/=200 cm/sec and renal-to-aortic peak systolic ratio (RAR) >/=3.5. The results of renal artery duplex and arteriography in 58 patients (107 kidneys) who underwent both exams were reviewed. Arteriography revealed 32 main renal arteries with >/=60% stenosis. The PSV criterion detected 29, for a sensitivity of 91%, specificity of 75%, positive predictive value (PPV) of 60%, negative predictive value (NPV) of 95%, and accuracy of 79%. Using RAR >/=3.5 provided a sensitivity of 72%, specificity of 92%, PPV of 79%, NPV of 88%, and accuracy of 86%. In a subset of 36 kidneys that had hilar scans, the criteria of acceleration time (AT) >/=100 cm/sec and index (AI) 相似文献   

Ultrasonic diagnosis in suspected acute appendicitis: probable or certain indications for surgery?]

The diagnostic accuracy and the clinical impact of routine ultrasonography performed by 4 surgeons, were prospectively studied in 366 unselected patients admitted for suspected acute appendicitis. Clinical and sonographic findings on admission were correlated with laparotomy findings, pathological outcome and clinical as well as follow-up data. The overall sensitivity, specificity and accuracy of the clinical diagnosis of acute appendicitis were 55.3%, 94.6% and 84.2% respectively (positive predictive value (PPV) 75.8%, negative predictive value (NPV) 87.3%). Ultrasound enabled visualization of the disease in 67 of 85 (prevalence 23.3%) patients with a histologically confirmed acute appendicitis; false positive results were recorded in 7 cases (sensitivity 78.8%, specificity 97.5%, accuracy 93.1%, PPV 90.5%, NPV 93.8%). Ultrasound was particularly useful in patients presenting with equivocal or highly unsuspective signs of acute appendicitis: of 38 patients with an acute appendicitis in this group ultrasonography enabled to make the diagnosis in 26. The combined approach of clinical evaluation and routine ultrasonography markedly improved the diagnostic accuracy (sensitivity 85.9%, specificity 96.4%, accuracy 94%) and substantially reduced the negative laparotomy rate (7.9%) in patients with suspected acute appendicitis. It is concluded, that ultrasonographic evaluation of the patient with suspected acute appendicitis performed by surgeons is of great assistance in surgical practice.     

Incidence and outcome of pauci-immune rapidly progressive glomerulonephritis in Wessex, UK: a 10-year retrospective study.

BACKGROUND: The Wessex Renal Unit serves a large stable population (2.5 million). Pauci-immune rapidly progressive glomerulonephritis (RPGN) is a frequent cause of acute renal failure requiring admission to our unit ( approximately 8%). At a population level, little is known of the epidemiology and outcome of RPGN. METHODS: Between 1 April 1986 and 31 March 1996, 141 cases of biopsy proven pauci-immune RPGN were seen in the Wessex region. The records of 128 patients were reviewed. Median (range) follow-up was 1.8 (0.9-9.64) years from diagnosis. RESULTS: The incidence of 4 per million was stable throughout the period. No clustering was seen. The diagnosis was made (median, 25th, 75th centile) 78.5 (45, 166) days after symptom onset. Co-morbidity (mostly hypertension) was seen in 47% of patients. Other organs affected were lungs 63%, nose/sinuses 50%, joints 42%, muscle 33%, skin 22% and nervous system 14%. Anti-neutrophil cytoplasmic antibody (ANCA) was positive in 73%; cytoplasmic ANCA 34%, peri-nuclear ANCA 26% and undifferentiated 14%. Twenty-seven per cent tested ANCA negative. The differences between the groups were small; time to diagnosis was shorter in the ANCA negative (-ve) group (P=0.02) and there were more airway symptoms in the ANCA positive (+ve) group (P:<0.05). All biopsies demonstrated a necrotizing process; crescents were seen in 96% involving (mean+/-SD) 54+/-26% of the glomeruli. Creatinine concentration (mean+/-SD) at diagnosis was 806+/-540 micromol/l. Treatment followed established immunosuppressive regimens. Initial dialysis was required by 59%, 36% needing long-term dialysis. At 1 year 68% were alive. The need for dialysis (P=0.0004) and age (P=0. 004) were poor prognostic markers. Ten per cent were transplanted, graft survival was 90% at 1 year, no recurrence was seen. CONCLUSIONS: This study, looking at a large cohort, has established the incidence and outcome of ANCA +ve and ANCA -ve RPGN in a defined stable population. It stresses the similarities between ANCA +ve and ANCA -ve cases and supports the notion that pauci-immune RPGN is part of a continuum of vasculitic illness. In this series transplantation is a safe option.     

ANCA相关性血管炎肾损害临床特征及早期诊治探讨

目的 分析抗中性粒细胞胞浆抗体(ANCA)相关性血管炎的临床表现和肾脏病理特征,探讨早期诊断和治疗对预后的影响.方法选取本院2000年1月至2009年8月明确诊断的ANCA相关性血管炎共21例,18例行肾活检.总结患者的临床病理资科.分析不同治疗时机对肾功能转归的影响.结果本组21例ANCA相关性血管炎平均年龄(52.5±11.5)岁,显微镜下多血管炎(MPA)16例,韦格纳肉芽肿(WG)3例,变应性肉芽肿性血管炎(CSS)2例.肾外表现主要为发烧17例(80.1%)、下呼吸道症状18例(85.7%)、肺影像学改变21例(100%)、贫血16例(76.2%)、眼耳鼻受累8例(38.1%);肾脏表现血尿21例(100%),蛋白尿19例(90.1%),血肌酐正常6例(28.5%),升高15例(71.4%),8例需透析替代.ANCA检测pANCA和MPO-ANCA阳性16例,cANCA和PR3-ANCA阳性3例.pANCA/MPO-ANCA和cANCA/PR3-ANCA均阳性1例,全阴性1例.肾活检可见节段性小血管壁纤维素样坏死,新月体多见.免疫荧光无或微量免疫复合物沉积.治疗采用糖皮质激素联合环磷酰胺,重症加用血浆置换.7例血肌酐异常但不需透析者5例治疗后血肌酐恢复正常;8例需透析者2例治疗后血肌酐恢复正常,2例脱离透析但血肌酐异常,4例未能脱离透析.结论ANCA相关性小血管炎临床表现多样,肺、肾是最常见的受累器官.ANCA检测和肾活检有助于早期诊断,尽早积极治疗有助于肾功能的恢复.     

A comparison of spiral computed tomography and latex agglutination D-dimer assay in acute pulmonary embolism using pulmonary arteriography as gold standard

OBJECTIVE: To compare the diagnostic accuracy of contrast medium enhanced spiral computed tomography of the pulmonary arteries (s-CTPA) and a latex agglutination D-dimer assay in patients with suspected acute pulmonary embolism (PE) by using pulmonary arteriography (PA) and clinical follow-up as reference method. DESIGN: Ninety hemodynamically stable patients with symptoms of acute pulmonary embolism were prospectively evaluated with s-CTPA and pulmonary arteriography (PA) within 24 h from admission. Plasma D-dimer levels on admittance were analyzed using a rapid latex agglutination D-dimer assay. The outcome of D-dimer concentrations in plasma below 0.25 and 0.5 mg/l was studied. RESULTS: All PA and s-CTPA investigations were regarded as of acceptable diagnostic quality in a consensus reading. Thirty-three patients had a positive PA (37%). Three patients had false negative and two patients had false positive s-CTPA findings. s-CTPA had 91% sensitivity, 96% specificity, 94% positive predictive value (PPV) and 95% negative predictive value (NPV). The sensitivity and specificity for D-dimer below 0.5 mg/l were 79 and 88%, respectively. The PPV and NPV were 81 and 87%. If a cut-off level of 0.25 mg/l was used the corresponding figures were 91, 65, 63 and 92%. CONCLUSION: s-CTPA has a higher sensitivity and specificity than latex agglutination D-dimer. A cut-off level of 0.25 mg/l can be used as screening method, but s-CTPA must be performed to exclude false positive cases.     

Cost-effective screening for urinary tract infections in urogynaecological patients

This study aims to test the cost-effectiveness of reagent-strip urine nitrite compared with microbiological laboratory testing for screening of urinary tract infections (UTI). The study is a retrospective review of 708 female patients who underwent cystometry during a 1-year period. Urine dipstick nitrite was used as a screening test for UTI while urine cultures were taken as an outcome. Symptoms of UTI were noted. Of 708 patients screened, 70 (9.9%) had a significant UTI. Only 32 (4.5%)of 708 patients were nitrite positive. Urine dipstick nitrite has sensitivity of 40%, specificity of 99%, positive predictive value (PPV) of 88 % and negative predictive value (NPV) of 94%. If the screening test included symptoms for UTI together with urine nitrite, the results are: sensitivity 89%, specificity 31%, PPV 12% and NPV 96%. A combination of screening with urine nitrite and UTI symptoms can increase sensitivity to 89%. A total of 29% of specimens (screen negative=nitrite negative/asymptomatic) can then be excluded from UFEME/culture testing, thus resulting in cost savings.     

ANCA in haemodialysis patients

The prevalence of positive ANCA as well as the prevalence ofPR-3 and MPO antibodies were examined in a cross-sectional sampleof 1277 haemodialysis patients from 16 German haemodialysiscentres. We found 32 patients positive for c-ANCA (median titre1:40; range 1:20–1:320) and 65 for p-ANCA (1:80; 1:20–1:1280).Twenty-two percent of the c-ANCA-positive and 31% of the p-ANCA-positivepatients had PR-3 and MPO antibodies by ELISA respectively.Clinical evidence of vasculitis was found in 11 of 32 c-ANCA-positiveand 19 of 65 p-ANCA-positive patients. Of the 11 c-ANCA-positive,four had a known diagnosis of Wegener's granulo-matosis (WG);WG was recognized after the test in a further five patientsand two had renal limited RPGN. Of the 19 p-ANCA-positive patients,three had a clinical diagnosis of microscopic polyarteritis(MP), MP was newly diagnosed in a further 12, WG in one andrenal limited RPGN in three. The patients had not received cyclophosphamide(the diagnosis had been non-specified ‘systemic disease’).Thus false-positive ANCA, as defined by absence of vasculitis,was found in 5% of dialysis patients versus 0% in patients withpreterminal renal failure {n=152) or blood donors (n=150). Patientswith vasculitis tended to have higher c-ANCA and p-ANCA titresrespectively, but there was a considerable overlap. Titres werenot higher in patients symptomatic at the time of examination(6 of 11 c-ANCA and 10 of 19 p-ANCA), but PR-3 and MPO ELISAwere positive in all but two. Thus c-ANCA were false positive(i.e. not associated with clinical vasculitis) in 66% and p-ANCAin 71%. In some patients ANCA was positive, but ELISA negative. We conclude that (i) in dialysis patients c-ANCA and p-ANCAare frequently present in the absence of vasculitis; (ii) specificitycan be improved, but sensitivity is lost, by using PR-3 andMPO ELISA respectively; (iii) serology permits the recognitionof WG or MP in cases where the diagnosis has been missed. Itis recommended that all patients with unknown primary renaldisease admitted to renal replacement therapy be examined usingboth ANCA-IF and PR-3/MPO ELISA.     

The value of clinical characteristics and breast-imaging studies in predicting a histopathologic diagnosis of cancer or high-risk lesion in patients with spontaneous nipple discharge

BACKGROUND: The purpose of this study was to determine the utility of breast-imaging studies in identifying cancer and high-risk lesions among patients with spontaneous, single-duct, nipple discharge (SSND). METHODS: The medical records of 168 cases with SSND treated with duct excision between June 1998 and May 2004 were reviewed. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of mammogram, ultrasound, and ductogram in predicting high-risk lesions and cancer were calculated. RESULTS: The sensitivity of mammography was 10%, the specificity 94%, the NPV 88%, and the PPV 18%. Ultrasonography had a sensitivity of 36%, specificity of 68%, PPV of 14%, and NPV of 89%. Ductography had a sensitivity of 75%, specificity of 49%, and NPV and PPV of 93% and 18%, respectively. CONCLUSIONS: Conventional imaging studies do not accurately identify cancer or high-risk lesions in patients with SSND.All patients with SSND should be offered duct excision.     

The clinical and pathological characteristics of Chinese patients with pauci‐immune crescentic glomerulonephritis

SUMMARY In the present study, we investigated pauci‐immune crescentic glomerulonephritis (PICGN) in Chinese patients. During 13 years (1985–98), 6400 patients underwent non‐transplanting renal biopsy in the Nanjing Jinling Hospital. Twenty‐four patients were diagnosed as having PICGN. They were 16 women and eight men with a median age of 33 (range 10–76 years). Microscopic polyarteritis (33.3%) and polyarteritis nodosa (8.3%) were the secondary diseases. The incidence of PICGN was 0.37% in renal biopsies and 22.9% in crescentic glomerulonephritis. Clinically, most patients (75.0%) showed rapidly progressive nephritis with enlarged kidneys. Onset gross haematuria was noted in 58.3% of the patients, hypertension 45.8%, nephrotic syndrome 41.7%, and oliguria 25.0%. However, systemic symptoms were rare except anaemia. Pathologically, we observed necrosis of glomerular capillaries (62.5%), infiltration of monocytes and neutrophil cells in glomeruli (66.7%), and vasculitis in interstitium (53.3%), in addition to glomerulosclerosis more than 50% (45.8%), severe tubular atrophy (83.3%) and interstitial fibrosis (75.0%). Antineutrophil cytoplasmic antibodies were positive in 52.2%. All patients except two received intensively immunosuppressive therapy. Sixteen patients were subjected to long‐term follow up (median 29.8, range 8–92 months), 12 of them had life‐sustaining renal function, four had normal range of serum creatinine (< 124 μmol/L), only four patients were dialysis dependent.     

Ultrasonography in the evaluation of renal scarring using DMSA scan as the gold standard

Dimercaptosuccinic acid (DMSA) renal scan is presently the technique of choice for assessing renal scars. Recent advances suggest that ultrasonography could replace DMSA scan for this purpose. This paper describes the experience of a tertiary pediatric referral hospital performing ultrasonography and DMSA scans in the assessment of renal scarring. Investigations were conducted 3–6 months after patients presented with urinary tract infection (UTI). Results were extracted from the radiology information system and recorded for analysis. All children with a UTI who had undergone DMSA and ultrasound examination on the same day between January 1995 and December 1999 were included; 930 kidneys were compared. DMSA scan was utilized as the reference method. When used to detect focal renal scarring, ultrasonography had a sensitivity of 5.2%, specificity of 98.3%, a positive predictive value (PPV) of 50% and a negative predictive value (NPV) of 75.8%. When used to detect diffuse renal scarring, ultrasonography had a sensitivity of 47.2%, specificity of 91.8%, PPV of 60.8% and NPV of 86.6%. Our results demonstrate that although ultrasonography has a good specificity for the detection of renal scarring compared with DMSA, it has low sensitivity, PPV and NPV. Ultrasonography cannot be substituted for DMSA scan in the evaluation of focal renal scarring.     

Supplemental ultrasound screening in patients with a history of lobular neoplasia

To investigate the role of ultrasound (US) screening as an adjunct to annual mammography (M) in breast cancer detection in women with a history of lobular neoplasia (LN) diagnosed following core needle or excisional biopsy. A retrospective review of our database was performed between 11/2006 and 11/2011 to identify patients diagnosed with LN, and underwent annual screening. Patients with a lifetime risk >20% per risk modeling were excluded. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and cancer detection rate (CDR) of each screening test were identified. Cancer type and detection modality were recorded. A total of 100 patients who had M and/or US screening were included. Mean patient age was 54.7 years (range 33‐83). All 100 patients underwent a mean of 3.9 rounds of screening M and 93 (93%) received US screening (mean 3.3 rounds). Of 93 patients who received both M and US screening, 12 (13%) were diagnosed with breast cancer. Mammographic CDR was 4%. Incremental US CDR was 6.5%. The sensitivity, specificity, and NPV for M screening alone was 33% (10%, 65%), 77% (67%, 85%), and 89% (80%, 95%), respectively. US and mammography screening had a combined sensitivity: 83% (52%, 98%), Specificity: 72% (62%, 81%), NPV: 97% (89%, 100%). Supplemental US screening resulted in a significant increase in sensitivity, yielding 6.5% incremental CDR in this high‐risk patient subgroup that does not fulfill ACS high‐risk MRI screening criteria.     

Hydralazine-Induced ANCA-Positive Pauci-immune Glomerulonephritis: A Case Report and Literature Review

We report a case of hydralazine-induced alveolar hemorrhage and anti-neutrophil cytoplasmic antibody (ANCA)-positive pauci-immune glomerulonephritis, with serum anti-histone antibodies present, features not previously described in the literature with this drug. A 50-year-old Caucasian female had hypertension treated with hydralazine 75mg TID for three years, and a lung nodule followed up periodically with chest-computed tomographies. She was admitted to the hospital for hemoptysis and newly discovered diffuse pulmonary ground-glass opacities. Transbronchial lung biopsy showed alveolar hemorrhage. Serum creatinine was 3.5 mg/dL and urinalysis showed 2+blood, 30-50RBC/hpf and red blood cell casts. ANCA against myeloperoxidase were present. Anti-double-stranded DNA, ANA, and anti-histone antibodies were positive. Serum complements were normal. Renal biopsy revealed focal crescentic necrotizing glomerulonephritis with negative immunofluorescence, consistent with pauci-immune ANCA-positive vasculitis. Serum creatinine returned to baseline three days after hydralazine was discontinued, and the hemoptysis resolved after treatment with cyclophosphamide and prednisone was started. We concluded that this case represents a hydralazine-induced small vessel vasculitis rather than an idiopathic one. The possibility of hydralazine-induced vasculitis should be considered when patients treated with hydralazine develop a pulmonary-renal syndrome. Anti-histone antibodies may be present in the absence of full classification criteria of drug-induced lupus.     

The usefulness of ureterorenoscopic examination in evaluation of upper tract disease

AIM: The objective of the present study was to clarify the indications, usefulness and limitations of ureterorenoscopy. MATERIAL AND METHODS: From January 1998 to June 2004, 72 consecutive patients (48 men and 24 women) with a mean age of 66 years (range, 27-83 years) underwent ureterorenoscopy to diagnose upper urinary tract tumors (UUT). Median follow-up was 24 months (range, 1-73 months). Patients were divided into four subgroups by voided urine cytology and preoperative radiographic findings. Group A (n=11, 15.3%), positive voided urine cytology and positive preoperative radiographic findings; group B (n=5, 6.9%), positive cytology and negative radiographic findings; group C (n=48, 66.7%), negative cytology and positive radiographic findings and group D (n=8, 11.1%), frank hematuria originating from the UUT but negative cytology and negative radiographic findings. We compared the findings of ureterorenoscopic examination and biopsy with the results of retrograde pyelography and cytology of upper tract urine. For each examination, the following diagnostic indices were assessed: sensitivity, specificity, positive-predictive-value (PPV) and negative-predictive-value (NPV) and accuracy. Statistical analysis was performed using McNemar's test. RESULTS: For ureterorenoscopy, sensitivity was 94%, specificity 59%, PPV 72%, NPV 92% and accuracy 76%. For biopsy, sensitivity was 77%, specificity 100%, PPV 100%, NPV 80% and accuracy 88%. Accuracy of ureterorenoscopy tended to be superior to that of retrograde pyelography. Ureterorenoscopy was most useful in the group which consisted of 48 patients (66.7%) with negative voided urine cytology and positive preoperative radiographic findings. This group was the only group in which accuracy of ureterorenoscopic biopsy was superior to that of urine cytology, significantly (P=0.03). CONCLUSION: Results indicated that ureterorenoscopy is most suitable and gives superior accuracy in patients with positive radiographic findings and negative voiding cytology. Ureterorenoscopic biopsy of the upper urinary tract would provide useful information when considering therapeutic strategies, such as nephron-sparing management.     

Does the presence of ANCA in patients with ulcerative colitis necessarily imply renal involvement?

BACKGROUND.: ANCA are thought to play a pathogenic role in renal vasculitis.ANCA may also be detected in patients with diseases not usuallyassociated with renal pathology, such as ulcerative colitis.Our study was conducted to determine if the presence of ANCAin patients with ulcerative colitis is associated with renalpathology. METHODS.: Eight ANCA-positive and five ANCA-negative patients with a histologicaland endoscopic diagnosis of active ulcerative colitis were investigated.Repeated complete urinalyses and determination of microalbuminuriaand creatinine clearance were performed. Serum IgG and IgA ANCAwere evaluated in all patients by indirect immunofluorescenceand ELISA, and when detected the antibodies were further characterizedby alpha granules preparation, myeloperoxidase, lactoferrin,and cathepsin G. RESULTS.: In both ANCA-positive and ANCA-negative patients renal functionwas normal or near normal and urinalyses (including microalbuminuria)failed to disclose any abnormalities. ANCA exhibited a perinuclearpattern in all ANCA-positive patients. Interestingly, none ofthe ANCA-positive patients had antibodies to myeloperoxidaseor to alpha granules which are usually found in the sera ofpatients with ANCA-associated vasculitis, and only one had antibodiesto lactoferrin. The ANCA specificity remained undetermined inthe remaining seven patients. At the end of the 1-year observationperiod, all ANCA-positive patients remained ANCA-positive withoutdeveloping symptoms, signs or laboratory abnormalities consistentwith renal involvement. CONCLUSIONS.: Renal damage was not observed in ANCA-positive patients withulcerative colitis even after 1 year of follow-up, suggestingthat the ANCA found in these patients do not share the antigenictargets with the ANCA commonly found in renal vasculitis. Thereforethe potential of ANCA of inducing renal lesions (if any) isdependent on their own antigenic specificity.     

Azurocidin-specific-ANCA-related idiopathic necrotizing crescentic glomerulonephritis

An 80-year-old woman who had rapidly progressive glomerulonephritis unaccompanied by systemic vasculitis is described. On renal biopsy, she showed necrotizing crescentic glomerulonephritis by light microscopy and pauci-immune glomerular lesions by immunofluorescent study. No dense deposits were present on electronmicroscopic study. On serum examination, indirect immunofluorescent study showed perinuclear pattern antineutrophil cytoplasmic antibody (ANCA), but myeloperoxidase-ANCA and proteinase 3-ANCA were both negative. Her serum reacted only to azurocidin excluding other ANCA antigens: bactericidal permeability-increasing protein, cathepsin G, elastase, lactoferrin, or lysozyme. Serum creatinine level decreased, and C-reactive protein turned negative after steroid therapy. Azurocidin-ANCA also turned negative. It is suggested that azurocidin-ANCA might have been related to the inflammatory process of pauci-immune necrotizing crescentic glomerulonephritis in this patient.     

Myocardial perfusion imaging is an effective screening test for coronary artery disease in liver transplant candidates

A reliable screening test for coronary artery disease (CAD) in liver transplant (LT) candidates with end‐stage liver disease is essential because a high percentage of perioperative mortality and morbidity is CAD‐related. In this study, the effectiveness of myocardial perfusion imaging (MPI) for identification of significant CAD in LT candidates was evaluated. Records of 244 patients meeting criteria for MPI were evaluated: 74 met inclusion criteria; 40 had a positive MPI and cardiology follow‐up; 27 had a negative MPI and underwent LT; and seven had a negative MPI and then had coronary angiography or a significant cardiac event. A selective MPI interpretation strategy was established where MPI‐positive patients were divided into high, intermediate, and low CAD risk groups. The overall incidence of CAD in this study population was 5.1% and our strategy resulted in PPV 20%, NPV 94%, sensitivity 80%, and specificity 50% for categorizing CAD risk. When applied only to the subset of patients categorized as high CAD risk, the strategy was more effective, with PPV 67%, NPV 97%, sensitivity 80%, and specificity 94%. We determined that renal dysfunction was an independent predictive factor for CAD (p < 0.0001, odds ratio = 8.1), and grades of coronary occlusion correlated significantly with chronic renal dysfunction (p = 0.0079).