Comparison of transvaginal sonography with endometrial biopsy in asymptomatic postmenopausal women.

The purpose of this study was to compare TVS with endometrial biopsy as a screening technique in asymptomatic postmenopausal women. Asymptomatic postmenopausal women were recruited by newspaper advertisement. Each study patient was subjected to pelvic examination and TVS followed by endometrial biopsy. Patients with suspected endometrial abnormalities by TVS (normal by endometrial biopsy) were evaluated further with hysteroscopy with biopsy or D&C or both. Eight patients were identified as having abnormalities by TVS, only one of whom had abnormalities by initial endometrial biopsy. Two patients were identified as having abnormalities by endometrial biopsy and normal by TVS. Further evaluation of the seven patients identified as having abnormalities by TVS (normal by endometrial biopsy) documented all seven patients as having abnormalities. The total yield of abnormalities with TVS was 16% (eight of 50 patients). The total yield of abnormalities with endometrial biopsy was 6% (three of 50 patients). The sensitivity of TVS in identifying endometrial abnormalities was 80% (eight of 10), while endometrial biopsy was only 30% (three of 10). TVS was more sensitive in detecting endometrial abnormalities, including endometrial hyperplasia, than was endometrial biopsy. The use of endometrial biopsy as a screening technique in asymptomatic postmenopausal patients is questioned.     

IgA肾病86例临床和病理分析

目的 :了解IgA肾病患者的临床表现及其病理情况。方法 :对 1984年 6月～ 2 0 0 0年 12月间经肾活检证实为IgA肾病患者 86例随访资料进行分析。结果 :以感染为首次发病诱因者 4 2例 ,其中呼吸道感染 36例。存在血尿 79例 ,蛋白尿 83例 ;伴高血压 4 0例 ;发生急性肾衰竭 4例。治疗前内生肌酐清除率 (Ccr>70ml/min 6 2例 ,5 0～ 70ml/min 15例 ,2 5～ 5 0ml/min 8例 ,<2 5ml/min 1例 ;治疗后Ccr>70ml/min 73例 ,5 0～ 70ml/min 5例 ,2 5～ 5 0ml/min 4例 ,<2 5ml/min 4例。除肾小球系膜增生外 ,病理改变以间质炎症和肾小球硬化出现的比例最高 ,其次为肾小管萎缩、间质纤维化等。结论 :IgA肾病的临床表现以蛋白尿和血尿多见 ,且两者合并存在的机会多见 ;部分患者可出现血压升高及肾功能恶化。IgA肾病患者应早期进行肾活检检查     

Asymptomatic isolated microscopic haematuria: long-term follow-up

BACKGROUND: Evidence to support current diagnostic and management approaches to asymptomatic haematuria is lacking and based on short-term clinical observation. AIM: To ascertain the natural history and long-term outcome of asymptomatic and isolated haematuria, and to determine the clinical correlates of adverse renal events. DESIGN: Prospective observational referral-based study. METHODS: We evaluated 90 consecutive patients with isolated microscopic haematuria, first seen between 1985 and 1996 at an out-patient nephrology clinic. We defined adverse renal events as the development of proteinuria (> 0.5 g/24 h) on two consecutive occasions, development of hypertension, or impaired renal function characterized by glomerular filtration rate (GFR) of <60 ml/min/1.73 m(2) for 3 months or more. RESULTS: There were 24 males and 66 females, median follow-up 5.2 years (total 442 patient-years). Mean age at presentation was 39 +/- 13 years. Fifteen (17%) had complete resolution of microscopic haematuria. One (1%) had transitional cell carcinoma of urinary bladder 20 months after initial presentation. Twelve (13%) developed hypertension, and 10 (11%) proteinuria. Only one developed chronic renal failure, 2.3 years after initial presentation. Altogether, 16 (19%) developed at least one adverse event, after a mean 42 months. Neither history of renal biopsy nor histological diagnosis of glomerular disease was predictive of renal events. Three independent variables were predictive of adverse renal events: baseline proteinuria (RR per 0.1 g/day 2.04; 95%CI 1.13-3.68; p = 0.018); MDRD-estimated GFR at presentation (RR per 10 ml/min/1.73 m(2) decrement 2.01; 95%CI 1.09-3.71; p = 0.025); and baseline serum urate (RR per 100 micromol/l 1.02; 95%CI 1.01-1.03; p = 0.009). DISCUSSION: Asymptomatic microscopic haematuria can lead to adverse renal events, and warrants nephrologist evaluation and regular follow-up. Its isolated microscopic haematuria is closely related to early hints of chronic kidney disease, such as low-grade proteinuria and renal insufficiency, as well as hyperuricaemia.     

零点肾穿活检:对供者临床资料与组织学异常情况的相关性分析

背景:目前,活体肾脏捐赠的数量在全国乃至全世界范围内增长,因此,保障供者安全在亲体肾移植中占有重要地位.如何准确诊断移植供者可能存在的肾脏疾病,以指导供者手术后潜在肾脏病治疗和肾功能保护成为亲体肾移植后保障供者安全的重要课题.目的:建立一种对供者捐肾前的临床资料与组织学异常情况间相关性的评价方法.方法:对解放军南京军区福州总医院2008-02/2009-11所有亲属肾移植的相关数据做回顾件分析,于供肾血管离断并灌注完成后进行穿刺.用零点肾穿的方法评估下列病变:间质纤维化,小管萎缩,微小动脉透明变性,肾小球系膜增生和肾小球硬化.移植前的统计数据包括:体质量,体质量指数,收缩压,舒张压,血清肌酸酐,肾小球滤过率和蛋白尿.结果与结论:62例供者术前检查均未发现明显肾脏疾病征象,零点肾穿活检发现肾脏病理改变28例,其中间质纤维化与收缩压和肌酐清除率,肾小管萎缩与舒张压和尿蛋白,小动脉透明样变与肌酐和肾小球滤过率,肾小球系膜增生和体质量指数具有弱相关性,肾小球硬化与其他变量均无相关性.     

The Natural History of Diabetic Renal Disease: A FOLLOW-UP STUDY OF A SERIES OF RENAL BIOPSIES

Thirty-one diabetics, on whom renal biopsies had been performedapproximately 11 years previously, were reviewed in order todetermine the natural history of diabetic renal disease overa long period. At the time of biopsy it was shown that neitherrenal function nor proteinuria was closely related to the histologicalchanges. Although all those with heavy proteinuria had advancedrenal changes, some patients with serious biopsy lesions hadno proteinuria. The worst prognosis was demonstrated among those patients withmarked (Grade II and Grade III) renal changes when this wasassociated with heavy proteinuria (more than 3 g per 24 hours):all such patients died during the follow-up period, usuallyfrom renal failure. When proteinuria was smaller in amount theprognosis was variable, regardless of the histological changes,and renal function sometimes remained unaltered for many years. The factors responsible for the onset of rapid deteriorationof renal function are not known. Hypertension was a late featureand was not usually demonstrated until the renal failure wasquite advanced. Both the age of the patients and the durationof the diabetes seemed unrelated to the prognosis. Impairment of vision due to advanced diabetic retinopathy wasa fairly constant accompaniment of chronic renal failure, andtogether with coronary artery disease, makes the value of chronicdialysis and transplantation in such patients rather uncertain.     

Follow-up of patients with microhematuria

Out of 100 patients with asymptomatic microhaematuria 21 patients showed an underlying pathological condition. In 23 patients glomerular (= dysmorphic) erythrocytes were seen on phase-contrast microscopy. Follow-up of the remaining 56 patients (over 2 to 10 years) showed the subsequent appearance of pathological urological findings in 14.3% of cases including three tumours (hypernephroma, cancer of the renal pelvis and bladder papilloma) 24 to 30 months after the diagnosis of microhaematuria. The necessity of prolonged urological observation in patients with non-glomerular (eumorphic) microhaematuria is discussed.     

Generalized secondary amyloidosis in patients with chronic rheumatoid arthritis (author's transl)]

During a period of 6 years (1968 to 1973) 177 patients with rheumatoid arthritis were submitted on one or more occasions to biopsy of the rectal mucosa for the diagnosis of amyloidosis. The indications for biopsy were as follows: 1. proteinuria, even in an intermittent form, 2. progressive type of rheumatoid arthritis with high inflammatory activity, 3. rheumatoid arthritis of longer than 2 years duration with a marked tendency to joint destruction. The histological specimens were stained with Congo red and investigated in polarized light. The biopsy for amyloidosis was positive in 80 patients (45.2%) of whom 14 showed no proteinuria, even of an intermittent nature. Patients with rheumatoid arthritis survived maximally 5 years after amyloidosis had been diagnosed. No successful therapy of amyloidosis has been devised.     

Treatment of hepatitis B virus-associated nephropathy

Epidemiological studies have shown a relationship between hepatitis B virus (HBV) infection and development of proteinuria in some patients (most commonly children), with a predominance for male gender and histological findings of membranous nephropathy on renal biopsy. The presence of immune complexes in the kidney suggests an immune complex basis for the disease, but a direct relation between HBV and membranous nephropathy (or other types of glomerular diseases) remains to be proven. Clearance of HBV antigens, either spontaneous or following antiviral treatments results in improvement in proteinuria. Thus, prompt recognition and specific antiviral treatment are critical in managing patients with HBV and renal involvement. The present review focuses on treatment of HBV with special emphasis given to antiviral therapies, its complications, and dosing in patients with HBV-associated kidney disease.     

Glomerular disease as a cause of isolated microscopic haematuria

Microscopic haematuria is a common clinical finding, with reportedprevaJences of up to 22%. The role of renal biopsy in the investigationof this condition is still debated. Currently urological investigationincluding cystourethroscopy is often regarded as adequate. We investigated 165 patients (94 male, 71 female; mean age 37.5years, range 10–71) referred with isolated microscopichaematuria, using renal biopsy and cystourethroscopy. All patientswere normotensive with normal serum creatinine, no proteinuria,sterile urine and a normal IVU. Renal biopsy abnormalities werefound in 77/165 (46.6%): IgA nephropathy (49), global or segmentalmesangial proliferative glomerulonephritis without IgA deposits(16), thin membrane nephropathy (7), vascular changes suggestiveof hypertension (3), interstitial nephritis (1), and membranousnephropathy (1). Only five abnormalities were found on cystourethroscopy(cystitis 3, urethral stricture 1, bladder stone 1). Two patientswith cystitis also had IgA nephropathy. Biopsy abnormalitieswere commonest under the age of 20 (69.2%), but 40% of biopsieswere abnormal even in the seventh decade of life. Because renal biopsy abnormalities are very frequent in patientswith isolated haematuria, renal biopsy is indicated in patientsover 45 years of age if renal imaging and cystoscopy are normal.In those under 45 years, renal biopsy should replace cystoscopyas the investigation to follow normal renal imaging.     

Chronic venous abnormalities in symptomatic and asymptomatic protein C deficiency

BACKGROUND: Thrombophilia is a frequent medical condition associated with symptomatic deep vein thrombosis (DVT). Unlike other clinical risk factors associated with DVT, such as surgery, thrombophilia has not been demonstrated to be associated with asymptomatic venous thrombotic events. Our aim was to search for asymptomatic sequelae of DVT in a protein C (PC)-deficient family. METHODS: We studied 228 individuals from a large kindred with PC deficiency and performed a systematic ultrasound examination. RESULTS: Among the 203 patients without a known history of venous thrombosis we found seven patients with abnormalities indicative of prior asymptomatic thrombosis: six (7.4%) in the PC-deficient group (n = 81) and only one (0.8%) in the non-deficient group (n = 122). The relative risk for these sequelae associated with PC deficiency was 9.0 (95% CI: 1.1-73.7). CONCLUSIONS: These data suggest that chronic venous abnormalities are frequently present and that thrombotic events in asymptomatic individuals with familial PC deficiency may be underestimated.     

Clinical indicators which necessitate renal biopsy in type 2 diabetes mellitus patients with renal disease

Background: The diagnosis of diabetic nephropathy (DN) is always based on clinical grounds. However, the necessity for renal biopsy of type 2 diabetes mellitus (DM) patients with renal disease to establish the diagnosis remains unclear. Methods: We retrospectively studied 50 type 2 diabetic patients performed with renal biopsy between December 2002 and December 2006. Based on renal pathology, patients were divided into group I: DN alone, group II: non‐diabetic renal disease (NDRD) superimposed on DN and group III: isolated NDRD. Factors like DM > 10 years, retinopathy, previous minimal proteinuria without sudden heavy proteinuria, no glomerular haematuria and non‐small‐sized kidney were collected to evaluate their sensitivity, specificity, positive predictive value and negative predictive value for prediction of DN or NDRD in type 2 diabetic patients. Results: Group I consisted of 24 patients, group II 15 patients and group III 11 patients. Acute interstitial nephritis was the most prevalent second renal disease in our study. Sensitivity and specificity for group I was poor in five features except high sensitivity in no sudden heavy proteinuria (83.3%) and non‐small‐sized kidney (95.8%). Comparable retinopathy, sudden heavy proteinuria and haematuria (p > 0.05) was noted between the three groups. Significant biopsy indicators included higher serum albumin, lower urinary daily protein excretion and lower 24‐h creatinine clearance (C_Cr) rate (p < 0.05). Conclusion: Our study demonstrated that DM > 10 years and retinopathy did not exclude NDRD in type 2 DM patients, and need for renal biopsy. Higher serum albumin, lower urinary daily protein and 24‐h C_Cr were indicative for biopsy to exclude NDRD.     

Asymptomatic nonspecific serum hyperamylasemia and hyperlipasemia: spectrum of MRCP findings and clinical implications

We assessed the magnetic resonance cholangiopancreatographic (MRCP) findings in patients with asymptomatic, mild elevations of serum amylase and lipase levels to determine whether there might be a pathoanatomic cause for these laboratory abnormalities. MRCP was performed in 633 consecutive patients. Of these, 54 (8.5%) images were obtained in patients with asymptomatic serum hyperamylasemia and hyperlipasemia. MRCP was performed on a 1.0-T MR system; breath-hold gradient-recall, half-Fourier acquisition, and rapid acquisition with relaxation enhancement sequences were obtained. Findings were verified by follow-up, biopsy, or surgery. One-sided, large-sample z tests were used to compare the incidence of abnormalities between the study and control groups (579 patients). The pancreas appeared abnormal on MRCP in 31 patients (57%), including the pancreas divisum in 10 patients (18.5%). Other findings included morphologic changes compatible with chronic pancreatitis in nine patients (16.6%) and a healed pancreatic laceration, juxtapapillary duodenal diverticulum, papillary sclerosis, intraductal pancreatic lithiasis, and hemochromatosis in one patient each (1.9%). Small cystic lesions (< 1 cm) within the pancreas were seen in 15 patients (27.8%). In eight patients, these were associated with other abnormalities (pancreas divisum in three patients, chronic pancreatitis in four, and pancreatic laceration in one). No malignancy was diagnosed. The incidences of normal examination (p = 0.01), pancreas divisum (p < 0.005), and a small cystic lesion (p = 0.01) as solitary findings in this subgroup of patients were significantly higher when compared with the remainder of the studied population. Investigation of asymptomatic patients with nonspecific hyperamylasemia and hyperlipasemia by means of MRCP yielded pancreatic findings in more than 50% of these patients. Pancreas divisum was found more often than expected in the general population.     

Acute glomerulonephritis superimposed on focal segmental glomerulosclerosis: a case report

A 9-year-old boy was referred to our hospital because of significant hematuria and proteinuria associated with hypocomplementemia. Although he had had a 3-year history of asymptomatic persistent proteinuria detected by urine screening of school children, he did not visit a physician. Finally, he visited a regional hospital, and hypocomplementemia was noted there. A percutaneous renal biopsy performed hospital day 4 revealed diffuse endocapillary proliferative glomerulonephritis with severe tubulointerstitial changes. Although his hematuria and hypocomplementemia spontaneously subsided within a month, proteinuria remained. A renal biopsy performed 4 months after the first renal biopsy revealed the lesion suggesting advanced focal segmental glomerulosclerosis (FSGS). Despite corticosteroid treatment, his proteinuria persisted, and he developed end stage renal failure. These clinical observation indicated that he had acute glomerulonephritis (AGN) superimposed on non-nephrotic FSGS, and that the episode of AGN might cause exacerbation of the FSGS.     

A microassay for mammalian renal 25-hydroxyvitamin D3-1-hydroxylase applicable to man

A micro determination of the renal 25-hydroxyvitamin D3-1-hydroxylase activity was developed that uses as little as 1 mg of rat kidney tissue. The method was applied to the remaining portions of needle kidney biopsy specimens taken for diagnostic purposes from children who had asymptomatic proteinuria and/or hematuria (more than 1-year duration) but were otherwise normal in calcium metabolism and renal function. The 25-hydroxyvitamin D3-1-hydroxylase levels of these children were found to be 66 1,25-dihydroxyvitamin D3 per milligram of tissue per 20 min for an 11-year-old male, 117 pg for a 9-year-old male, and 89 pg for a 10-year-old female.     

Unsuspected syphilitic hepatitis in a patient with low-grade proteinuria and abnormal liver function

A 25-year-old patient was found to have cholestatic liver enzyme abnormalities during assessment for asymptomatic low-grade proteinuria at the US Naval Hospital in Portsmouth, Virginia. These abnormalities persisted for a 6-month period, and an extensive workup, including viral serologic studies, rapid plasma reagin test, iron studies, ceruloplasmin, antimitochondrial, antinuclear, and anti-human immunodeficiency virus antibodies, endoscopic retrograde cholangiopancreatography, and liver biopsy, was unrevealing until serologic tests for syphilis were repeated to evaluate a new onset of urethral discharge. The patient had none of the more characteristic signs of secondary syphilis. The liver enzyme abnormalities rapidly resolved after treatment with penicillin. Syphilis remains the great impostor and still must be considered in the differential diagnosis of unexplained liver enzyme abnormalities, even in a patient with no symptoms or signs of early syphilis.     

Duodenal ulcer and chronic gastritis

The histological aspect of fundic and antral mucosa of patients with endoscopically proven duodenal ulcer was investigated and compared with that observed in asymptomatic controls of similar age. Fundic gastritis was less frequent in ulcer patients than in controls. In contrast the chronic inflammatory lesions of the antral mucosa were more frequent, more severe and appeared at an earlier age in ulcer patients than in controls.     

Renal biopsy: standard procedure of modern nephrology

For more than 50 years, renal biopsy has been an important diagnostic procedure in modern nephrology. Increasing perfection of the biopsy technique has made the procedure very safe, with rare complications and few contraindications. Improved histological diagnostics and broader therapeutic possibilities have significantly expanded the indications. The most important indications are acute renal failure, proteinuria > 1 g/d (or 3 g/d) and nephritic urinary sediment. Complications with renal grafts provide additional indications for a renal biopsy. In addition, diabetes and monosymptomatic urinfindings (isolated haematuria) as well as pregnancy induced nephropathy are indications for a renal biopsy. The procedure is performed ambulatory or during a short hospital stay and the patient can usually be discharged after a monitoring period of eight hours.     

肾自动活检术在老年肾脏病中的应用价值与风险评估

目的评估超声引导肾自动活检术在老年肾脏病患者中的临床应用价值。方法回顾性分析我院肾内科6年间对老年肾脏病患者进行肾自动活检术的成功率和并发症并探讨其临床价值。结果106例患者活检手术总成功率100%,其中取材不良2例(1.9%),取材合格12例(11.3%),取材良好92例(86.8%);共5例出现轻度并发症(4.7%),其中肉眼血尿2例(1.9%),肾周血肿3例(2.8%),无严重出血并发症;肾活检结果对诊断与治疗的影响:临床诊断修正率为35.8%,治疗方案修正率为41.5%。结论肾自动活检术在老年性肾脏疾病患者中应用的成功率高而并发症少且大多较轻,其病理结果对明确诊断和决定治疗方案具有重要意义,值得进一步推广应用。     

The course and prognosis of mesangioproliferative glomerulonephritis

AIM: A retrospective analysis of a clinical course of mesangioproliferative glomerulonephritis (MPGN) in patients with glomerular deposition of IgA (IgA nephropathy--IgA-N), with glomerular deposition of other Ig to determine prognostic factors of MpGN progression including IgA-N and to examine the patients' sensitivity to immunodepressive therapy. MATERIAL AND METHODS: 2000 patients with primary MPGN followed up from 1980 to 1999 from the disease onset to development of chronic renal failure (creatinine > 2.5 mg%). Factors affecting kidney survival were studied using the Cox regression model, factors predicting sensitivity to immunodepressive therapy--using multiple logistic regression. RESULTS: IgA-N differed by the course and prognosis from other forms of MPGN. In IgA-N urinary syndrome and macrohematuria were encountered more frequently, in other forms of MPGN more frequent was nephrotic syndrome. Prognosis of patients with IgA-N was worse than in MPGN patients without IgA deposition: 10-year "renal survival" (creatinine < 2.5 mg%) was 64 and 97% (p < 0.05), respectively. Prognosis-deteriorating factors for MPGN patients were the following: male sex, nephritis onset in 40-year-olds and older subjects, acute nephritic syndrome (creatinine > 1.5 mg%), high proteinuria, hematuria (> 50 in sight), the presence of synechia and TIC in renal biopsy, location of immune deposits both in the mesangium and basal glomerular membranes. The responders to the immunodepressive therapy had 10-year renal survival 100%. Positive results of immunodepressive therapy were observed significantly more frequently in patients with normal level of creatinine, moderate hematuria, absence of synechias and TIC in renal biopsy, given large total course dose of corticosteroids and cytostatics. Efficiency of oral cyclophosphamide and its intravenous pulse-therapy did not differ significantly. In pulse therapy an average cumulative dose was lower 6 times, side effects occurred 3 times less frequently. CONCLUSION: The importance of morphological information for prognosis and predicting sensitivity of MPGN patients to immunosuppressive therapy necessitates renal biopsy before therapy. Intravenous pulse therapy with cyclophosphamide is preferable as an active treatment in patients with sclerosis in renal biopsy.     

Useful indicators for performing renal biopsy in adult patients with isolated microscopic haematuria

Among adult patients with isolated microscopic haematuria (IMH) which is defined as persistent microscopic haematuria but without proteinura, hypertension, renal insufficiency, urinary tract infection or structural abnormality of the urinary tract, some patients have chronic glomerulonephritis (CGN), in whom early diagnosis by renal biopsy is beneficial to timely intervention. Nevertheless, a considerable number of patients with optimistic prognosis [e.g. thin basement membrane nephropathy (TBMN)] undergo invasive and needless renal biopsy. Indicators for weighing the necessity of renal biopsy would be clinically significant. To investigate the value of urinary albumin/creatinine ratio (UACR), serum IgA level, serum C3 level and serum IgA to C3 ratio in predicting the necessity of renal biopsy for adult patients with IMH, 216 patients were studied retrospectively. Patients were divided into: (CGN group, n=137), (TBMN group, n=56) and normal biopsy (normal group, n=23). Of all patients, 131 (61%) evidenced microalbuminuria (UACR=30-299 mg/g) and 85 (39%) had normoalbuminuria (UACR<30 mg/g). The mean value of UACR in CGN group was higher (96+/-17 mg/g) compared with that in TBMN (20+/-4 mg/g, p<0.01) or normal (18+/-3 mg/g, p<0.01) group. The mean values of serum IgA and serum IgA/C3 ratio in patients with IgA nephropathy (IgAN) were significantly higher than those with non-IgAN (380+/-103:217+/-99 mg/dl, p<0.01; 4.5+/-1.2 : 2.4+/-0.9, p<0.01). The odds ratio for distinguishing IgAN from non-IgAN was significantly correlated with serum IgA level and serum IgA to C3 ratio. For adult patients with IMH, UACR, serum IgA level and serum IgA to C3 ratio are non-invasive markers for predicting the necessity of renal biopsy.