Encrusted cystitis with ammonium acid urate calculi: a case report

We present a case of encrusted cystitis with ammonium acid urate calculi. An 88-year-old man was referred to our hospital to determine the cause of hematopyuria. He was a patient at another hospital for treatment of interstitial pneumonia with predonisolone. After admission to our hospital, kidney, ureter, bladder X-ray, computed togography and cystoscopy revealed calcification of about two-thirds of the mucosa of the bladder, and biopsy of the bladder revealed bacterial colonies with inflammation and calcification. Calculographic analysis revealed ammonium acid urate calculi. After treatment with antibiotics and irrigation with solita T1, an acidic solution of pH 3.5-6.5, inflammation and calcification were significantly reduced.     

Ureolytic Citrobacter freundii infection of the urine as a cause of dissolution of cystine renal calculi

We report a case of cystinuria with staghorn renal lithiasis in a solitary right kidney and chronic renal failure. Right nephropyelolithotomy was performed and although 29 renal calculi were extracted many stones remained in situ. A permanent nephrostomy was left in the kidney. Several months later the urine was infected chronically with a ureolytic Citrobacter freundii bacteria and urinary pH oscillated between 8.0 and 9.2. Spontaneous dissolution of the cystine calculi was observed and many tiny fragments of cystine were expulsed through the nephrostomy, following which renal function improved. Despite the conditions favoring struvite calculi, formation did not occur.     

Two cases of ammonium acid urate urinary stones related to anorexia nervosa and laxative abuse

We report two cases of urolithiasis related to anorexia nervosa and laxative abuse. Case 1: A 21-year-old woman was referred to our hospital because of left flank pain. A left ureteral stone, 10 x 6 mm in size, was successfully fragmented by extracorporeal shock-wave lithotripsy (ESWL), but she experienced repetitive formation of bilateral urinary stones and double J stent encrustation which required 13 sessions of ESWL, one session of transurethral ureterolithotripsy and one session of cystolithotripsy over a period of 5 years. All stones were comprised of pure ammonium acid urate. It was later revealed that she was diagnosed with anorexia nervosa at 15 years old and had suffered from laxative abuse (bisacodyl, 300-500 mg/day) ever since. Case 2: A 18-year-old woman was referred to our hospital because of left lower abdominal pain. A left renal stone, 15 x 10 mm in size, was successfully fragmented by ESWL, but she had double J stent encrustation which was managed by cystolithotripsy. All stones were comprised of pure ammonium acid urate. She was later diagnosed with anorexia nervosa and it turned out that she had suffered from an eating disorder and laxative abuse (bisacodyl, 200 mg/day) since the age of 15 years. Both patients had marked decrease in urine volume, hyponatremia and hypokalemia. Anorexia nervosa and laxative abuse should be suspected whenever a woman has an ammonium acid urate stone in sterile urine because the treatment of these disorders is crucial to the prevention of repetitive formation of urinary stones.     

Ammonium acid urate calculi: a reevaluation of risk factors

PURPOSE: We reevaluate the demographic and metabolic risk factors for ammonium acid urate stones. MATERIALS AND METHODS: Since 1986, 23 women and 21 men ranging in age from 20 to 81 years (mean 48.7) were treated for stones partly composed of ammonium acid urate. Stone composition ranged from 2 to 60% ammonium acid urate (mean 24.1) of the total stone mass. No patient had a pure ammonium acid urate stone, although 11 (25%) had stones with ammonium acid urate as the predominant crystal. RESULTS: In the 44 patients 1 or more potential risk factors for ammonium acid urate were identified. Of the patients 11 (25%) had a history of inflammatory bowel disease with 10 (22.7%) having undergone ileostomy diversion, 6 (13.6%) admitted to a history of significant laxative use or abuse, 18 (40.9%) were morbidly obese, 16 (36.4%) had a history of recurrent urinary tract infections and 9 (20.5%) had a history of recurrent uric acid stones. CONCLUSIONS: Patients clearly at risk for stones with an ammonium acid urate component include those with a history of inflammatory bowel disease and ileostomy diversion or laxative abuse. Other factors that may potentially enhance ammonium acid urate stone formation include morbid obesity, recurrent uric acid calculi and recurrent urinary tract infection. A careful history followed by further metabolic evaluation is warranted in these patients.     

Cavitation microjets as a contributory mechanism for renal calculi disintegration in ESWL

The rarefaction shock wave produced by an extracorporeal shockwave lithotripter can result in liquid failure at numerous discrete sites near the second focus. When the liquid fails, vapor-filled cavities can grow to relatively large sizes and subsequently collapse with enormous violence. This phenomenon, called acoustic cavitation, has been shown to cause severe erosion in materials exposed to cavitation fields. It is proposed in this paper that ESWL devices generate acoustic cavitation in vivo and that the high speed liquid microjets produced during cavitation bubble collapse play an important role in renal calculi disintegration.     

Ammonium and sodium urates precipitating from synthetic urine and fine structure of urate renal calculi

A study of ammonium and sodium urate precipitation in vitro and the fine structure of several urate renal calculi was carried out to contribute to an understanding of the participation of ammonium and sodium urates in urolithiasis. Ammonium urate precipitated in vitro in two different morphologies: a typical spherulite morphology formed at high supersaturation and disorganized needle-like crystals formed at low supersaturation. In all cases sodium urate precipitated in vitro as bundles of curved fibrils, its crystallization being inhibited by calcium in concentrations between 20 and 60 mg/l depending on the sodium urate supersaturation. From a collection of 1300 renal calculi, only three had ammonium urate as their main component (0.2%), three were mixed calculi (0.2%) consisting of ammonium urate and calcium oxalate (two) or uric acid (one), and in one calculus ammonium urate was present as a minor component. Only in a mixed calculus of uric acid and calcium oxalate was sodium urate detected in a very low quantity. The study of the fine structure of the renal calculi constituted mainly by ammonium urate demonstrated similar patterns in which spherulites, needle-like individual crystals and an amorphous mass of ammonium urate with abundant organic matter in non-organized structures coexist. As minor components, struvite or calcium oxalate crystals were found. A general mechanism of the formation of such calculi is proposed. Received: 4 December 1997 / Accepted: 9 July 1998     

The residual calculi in conservative operation for renal calculi

One hundred and three kidneys with calculi in 100 patients, were treated by conservative renal surgery from Jan., 1980 to Dec., 1982. The operative technique consisted of pyelolithotomy, extended pyelolithotomy, dismembered pyelolithotomy, nephrolithotomy (bivalve or anatrophic nephrolithotomy) partial nephrectomy and pyelo-nephrolithotomy. Intraoperative X-ray and coagulum lithotomy were employed when pyelolithotomy was performed. Thirty-five residual calculi in 20 kidneys were observed on postoperative X-ray film. The rate of residual calculi was 19.4%. Factors causing residual calculi, were analysed on these 103 kidneys. The factors were as follows; the shape of calculi: staghorn calculus with multiple small calculi, the shape of the renal collecting system: narrow pelvis with narrow caliceal neck and dilatated calices, and the operative technique: nephrolithotomy. These results suggested that it would be necessary to minimize residual calculi when performing nephrolithotomy.     

Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain

Background: Pain following cholecystectomy can pose a diagnostic and therapeutic dilemma. We reviewed our experience with calculi retained in gallbladder and cystic duct remnants that present with recurrent biliary symptoms. Methods: Over the last 6 years, seven patients were referred to us for the evaluation of recurrent biliary colic or jaundice. There were four men and three women ranging in age from 35 to 70 years. All seven had biliary pain similar to the symptoms that precede cholecystectomy; two of them also had also associated jaundice and one had pancreatitis. The time from cholecystectomy to onset of symptoms ranged from 14 months to 20 years (median, 8.5 Years). Four had undergone laparoscopic cholecystectomy and three had had an open cholecystectomy; none had an operative cholangiogram. Results: Five of seven underwent diagnostic endoscopic retrograde cholangiography (ERC), which revealed obvious filling defects in the cystic duct or gallbladder remnant. The final patient was diagnosed by laparoscopic ultrasound after eight negative radiographic studies. Four patients underwent laparotomy and resection of a retained gallbladder and/or cystic duct. Two patients were treated with extracorporeal shock-wave lithotripsy (ESWL); one of them also required endoscopic biliary holmium laser lithotripsy. One patient underwent successful repeat laparoscopic cholecystectomy. There were no treatment-related complications. At a median follow-up of 11.5 months, all have achieved complete stone clearance and are asymptomatic. Conclusion: Retained gallbladder and cystic duct calculi can be a source of recurrent biliary pain, and a heightened suspicion may be required to make the diagnosis. This entity can be prevented by accurate identification of the gallbladder–cystic duct junction at cholecystectomy and by routine use of cholangiography. A variety of therapeutic options can be employed to obtain a successful outcome.     

Saccular renal artery aneurysm as a cause of hypertension

The case of a patient with renovascular hypertension related to an arterial kink is reported. The arterial kink was caused by a renal artery aneurysm and was not apparent with angiography. This is the first reported case in which renin-mediated hypertension was clearly related to a correctable mechanical problem from a saccular renal artery aneurysm. Indications for surgical repair of renal artery aneurysms and angiographic findings indicative of a functionally significant renal artery stenosis are reviewed.     

Reflux nephropathy as a cause of end-stage renal failure

Reflux nephropathy can present as end-stage renal failure in adults without previous history of urinary infection. We describe four cases to illustrate this and suggest that in cases of end-stage renal failure with bilateral small kidneys a micturating cystogram should be performed prior to transplantation.     

Bronchiectasis-related amyloidosis as a cause of chronic renal failure

Bronchiectasis is defined as acquired and permanent abnormal dilation and destruction of the bronchial walls. Secondary amyloidosis is a disorder characterized by the deposition of amyloid A (AA) in multiple organs and tissues in the body. End-stage renal disease (ESRD) secondary to bronchiectasis-related amyloidosis has only been mentioned in case reports. Little is known about the complications of bronchiectasis-related amyloidosis and the outcomes in patients who develop ESRD due to amyloid deposition in the kidneys. The aim of this study was to identify the clinical characteristics of this patient group, and to report the outcomes of these cases relative to bronchiechtasis type. We assessed the records of 40 patients with AA-type amyloid nephropathy and ESRD who were on hemodialysis (HD) at Baskent University Hospital between 1997 and 2000. The diagnosis of amyloidosis was based on histopathological findings in kidney, rectum, bone marrow, lymph node, thyroid, bladder, liver, and stomach biopsies. Bronchiectasis was diagnosed on the basis of history and findings on physical examination, chest X-ray, and thoracic high-resolution computerized tomography (HRCT). The patients' records were retrospectively evaluated for cause of secondary amyloidosis, and cases with causes other than bronchiectasis were excluded. Secondary amyloidosis due to bronchiectasis and recurrent pulmonary infection was identified in 40% (16 patients) of the 40 patients. For each of these 16 cases, we recorded patient age, duration of bronchiectasis, duration of HD, amount of lung involvement, and biopsy site(s). The means for age, duration of bronchiectasis, and duration of HD in the 16 patients were 50.6 +/- 13.5 years, 22.18 +/- 12.02 years (range, 6-42 years), and 30.81 +/- 36.94 months (range, 4-144 months), respectively. The most common biopsy site was the rectum (n = 8). Thoracic HRCT revealed cystic bronchiectasis in 8 cases (50%). Four of these 8 patients (25% of the group of 16) died from sepsis within 3-year follow-up period. Two of the four patients who died had bilateral cystic bronchiectasis, and the other two had unilateral cystic bronchiectasis. In the other eight patients in the group, thoracic HRCT showed chronic fibrotic changes in the pulmonary parenchyma and minimal traction bronchiectasis. Four of these patients exhibited apical fibrosis and bronchiectasis (25% of the group of 16), and these radiological findings were considered sequelae of previous tuberculosis infections. In conclusion, chronic respiratory infections and associated bronchiectasis remain a serious problem in Turkey due to insufficient prevention, diagnosis, and treatment. It is important that patients with progressive cystic and diffuse bronchiectasis be followed carefully, as they may develop amyloidosis and ESRD in time. Also, the clinical course in patients with cystic bronchiectasis may be worse than that in other types of bronchiectasis due to complicating pulmonary infections.