sup 99m TECHNETIUM-DIMERCAPTO-SUCCINIC ACID RENAL SCAN IN THE EVALUATION OF POTENTIAL LONG-TERM RENAL PARENCHYMAL DAMAGE ASSOCIATED WITH EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY IN CHILDREN

Purpose

Extracorporeal shock wave lithotripsy (ESWL ^†) has been reported as efficient and safe in children. Because of reports of renal parenchymal damage in adults, this study was designed to assess the effects of ESWL in pediatric kidneys evaluated before and after treatment with^99m technetium dimercapto-succinic acid (DMSA) renal scan.

Materials and Methods

A total of 15 children, 9 months to 15 years old (mean age 6.5 years), underwent ESWL treatment for urolithiasis. Evaluation imaging included plain abdominal radiography, excretory urogram and/or renal sonography. DMSA renal scan was performed 24 hours before ESWL and at least 6 months after treatment.

Results

ESWL was performed in 1 session for 8 patients, 2 sessions for 6 and 3 sessions for 1, delivering a range of 600 to 3,000 shock waves per session. Treatment was successful in achieving stone-free status in 87% of the cases. Long-term followup (1 to 5 years) showed no blood pressure changes. On DMSA renal scan no acquired parenchymal scar was identified at least 6 months after ESWL treatment.

Conclusions

The efficacy of ESWL in treating pediatric urolithiasis is confirmed. Renal parenchymal trauma associated with ESWL does not appear to cause long-term lesions identifiable by DMSA renal scan.     

New Onset Hypertension After Extracorporeal Shock Wave Lithotripsy: Age Related Incidence and Prediction by Intrarenal Resistive Index

Purpose

In a recent study we found an increased resistive index immediately after extracorporeal shock wave lithotripsy (ESWL^*) in patients older than 60 years, which suggests renovascular disturbance. The present 26-month followup study was undertaken to investigate the relevance of elevated resistive index levels and the incidence of new onset hypertension.

Materials and Methods

Of the initial 76 patients 57, including 20 of the 23 at risk patients 60 or greater years, group 3), were followed for more than 26 +/− 6 months after ESWL. Followup included 2 resistive index measurements by Doppler ultrasound of the treated and the contralateral kidney, at least 2 blood pressure measurements 1 week apart and excretory urography as well as determination of plasma renin activity in 9 patients.

Results

With 1 exception, elevated resistive index levels and hypertension were observed exclusively in patients older than 60 years. In these patients the resistive index ranged between 0.65 and 0.86 (mean plus or minus standard deviation 0.74 +/− 0.05, normal less than 0.7). This increase in resistive index was statistically significant (p <0.0001). Compared to the levels obtained immediately after ESWL, the resistive index continued to increase in all 9 patients older than 60 years who had hypertension (45%), whereas in the normotensive patients the resistive index was either stable or decreased. There was a strong positive correlation (0.903) between pathological resistive index levels and blood pressure.

Conclusions

Patients older than 60 years are at risk for disturbances of renal perfusion as assessed by the resistive index, and 45% of these patients have new onset hypertension within 26 months of treatment.     

A RANDOMIZED CONTROLLED TRIAL TO ASSESS THE INCIDENCE OF NEW ONSET HYPERTENSION IN PATIENTS AFTER SHOCK WAVE LITHOTRIPSY FOR ASYMPTOMATIC RENAL CALCULI

Purpose

To answer the question of whether extracorporeal shock wave lithotripsy (ESWL*) induces hypertension, a prospective, randomized controlled trial of normotensive patients with asymptomatic renal calculi was designed.

Materials and Methods

Patients were randomized to receive immediate ESWL versus observation, reserving ESWL for the onset of symptoms. The rates of new onset hypertension were evaluated for both groups.

Results

There was no observed difference in the incidence of hypertension between the treatment and observation groups.

Conclusions

The risk of hypertension in patients undergoing ESWL therapy is similar to that of a control cohort of initially observed asymptomatic patients.     

Effects of Extracorporeal Shock Wave Lithotripsy to One Kidney on Bilateral Glomerular Filtration Rate and PAH Clearance in Minipigs

Purpose

This study examined the acute time course of effects of extracorporeal shock wave lithotripsy (ESWL)¹ on renal hemodynamics in anesthetized minipigs with and without pretreatment with verapamil.

Materials and Methods

We applied ESWL (2000 shocks, 24 kV, unmodified Dornier HM3), to the right kidneys of isoflurane-anesthetized female pigs. Urine flow and renal hemodynamics were monitored from each kidney via ureteral balloon catheters. Arterial blood pressure and bilateral urine flow, glomerular filtration rate (GFR, inulin clearance) and renal plasma flow (RPF, para-aminohippurate clearance) were monitored for 45 minutes before ESWL, and at 1, 4 and 24 hours after ESWL.

Results

Treatment with ESWL consistently caused unilateral hematuria and subcapsular renal hematomas in the shocked kidneys and significantly reduced GFR and RPF in those kidneys at 1 and 4 hours after ESWL. Urine flow was reduced through 24 hours in the shocked kidneys. Renal plasma flow, but not GFR, was significantly reduced in the contralateral (unshocked) kidneys at 1 and 4 hours after ESWL to the other kidneys. Verapamil blunted the ESWL-induced reductions of urine flow, GFR and RPF in the shocked kidneys and eliminated the reduction of RPF in the unshocked kidneys.

Conclusions

These experiments demonstrate that ESWL to 1 kidney acutely impaired hemodynamics in both kidneys and that verapamil attenuated the response in the shocked kidneys and eliminated it in the contralateral unshocked kidneys.     

New Stone Formation: A Comparison of Extracorporeal Shock Wave Lithotripsy and Percutaneous Nephrolithotomy

Purpose

There is theoretical concern that stone recurrence rates may be higher following extracorporeal shock wave lithotripsy (ESWL*) compared to other techniques because of residual stone debris.*Dornier Medical Systems, Inc., Marietta, Georgia.

Materials and Methods

We documented all new stone formations in 298 consecutive patients who initially achieved a stone-free status following ESWL for renal calculi less than 2 cm. in largest dimension, and compared the findings to those of 62 patients treated with percutaneous nephrolithotomy without ultrasonic fragmentation. Stone-free status was assessed by a centrally reviewed plain abdominal film and renal tomograms at 3 months. A plain abdominal film was repeated at 12 and 24 months to detect recurrence.

Results

New stones formed in 22.2 percent of patients after ESWL and 4.2 percent after percutaneous nephrolithotomy at 1 year (p = 0.004), and in 34.8 percent versus 22.6 percent, respectively, at 2 years (p = 0.190). Furthermore, more new stones recurred in the lower and mid calices compared to baseline location in the ESWL group (chi-square less than 0.0001), which was not observed in the percutaneous nephrolithotomy group.

Conclusions

Our data support a trend toward higher stone recurrence rates in ESWL treated patients, which may be due to microscopic sand particles migrating to dependent calices and acting as a nidus for new stone formation.     

Extracorporeal shock wave lithotripsy (ESWL) of a renal calculus in a liver transplant recipient: report of a severe complication--a case report

Introduction

Extracorporeal shock wave lithotripsy (ESWL) has evolved as a standard treatment modality for calculi of the upper urinary tract. Noninvasive ESWL shows rare life-threatening complications. Herein we have reported the case of a liver transplant recipient who developed severe renal hemorrhage after ESWL of a renal calculus. Transfusion of erythrocytes and platelets led to anaphylactic shock with acute renal failure requiring intensive care. The patient fully recovered shortly thereafter and was discharged home with a residual left kidney stone measuring 8 mm.

Case Presentation

A 55-year-old man with a single left kidney underwent ESWL due to symptomatic left nephrolithiasis. He had undergone successful liver transplantation 11 years earlier. At the time of ESWL his liver functions were normal and his serum creatinine level was 1.3 mg/dL. Two weeks before the treatment a double pigtail ureteral stent was inserted because of a symptomatic left hydronephrosis. Serveral hours after ESWL treatment the patient complained of left-sided flank pain. An ultrasound revealed a large subcapsular hematoma of the left kidney, which was confirmed using abdominal computed tomography (CT). With the patient being hemodynamically stable, we opted for conservative management. Despite postinterventional complications, the patient made a fast recovery.

Conclusion

ESWL is a noninvasive, safe, and efficient method to treat renal calculi. Patients who are at risk for hemorrhage should undergo close postinterventional monitoring, including red blood cell count and renal ultrasound.     

Do hydronephrosis and extracorporeal shock wave lithotripsy affect carbohydrate antigens?

Objectives

To investigate carbohydrate antigen (CA 19-9, CA 15-3, and CA 125) levels in the patients who had hydronephrosis with renal stones and in whom Extracorporeal shock wave lithotripsy (ESWL) was performed.

Materials and Methods

This prospective study included 20 people with no known disease for control group and 30 patients who had hydronephrosis with renal stones and in whom ESWL was performed between January 2005 and January 2006. None of patients had urinary infection and malignancy. The blood for carbohydrate antigens was taken pre-ESWL and 30 min after ESWL in both groups. CA 19-9, CA 15-3, and CA 125 in the serum were tested with the electro-immunoassay method on the Roche^® E-170 apparatus with the original Roche^® kit.

Results

The CA 19-9 and CA 125 values in the patients group were found to be statistically significant when compared with the control group but the CA 15-3 was not found to be significant. However, CA 19-9, CA 15-3, and CA 125 values of post-ESWL were not statistically significant when compared with pre-ESWL group (P > 0.05).

Conclusions

The average serum values of CA 125 and CA 19-9 in patients were found to be significantly high. However, serum values of CA 19-9, CA 15-3, and CA 125 were not affected by ESWL.

     

Long-Term Stone Recurrence Rate After Extracorporeal Shock Wave Lithotripsy

Purpose

We followed patients who were stone-free after extracorporeal shock wave lithotripsy (ESWL^*) to investigate the factors that contributed to recurrent calculi.

Materials and Methods

For longer than 5 years 903 patients without residual fragments 3 months after ESWL were enrolled in this study. Plain abdominal films and/or excretory urograms were evaluated every 6 months for recurrent stones on the side of ESWL. Patients who presented with colic pain or other complaints and who were suspected of having recurrent stones were also examined. Stone recurrence rates were calculated with the Kaplan-Meier method. We assessed the influence of patient age; size, location, composition and configuration of the original stones, and pyuria after ESWL on stone recurrence.

Results

Mean followup was 25 months and stones recurred in 183 of 903 renal units (20.3 percent). Kaplan-Meier recurrence rates were 6.7, 28.0 and 41.8 percent after 1, 3 and 5 years, respectively. There was a significant correlation between stone recurrence and multiple stones on one hand, and pyuria after ESWL on the other hand. Stones recurred most frequently in the lower calix. Recurrent stones were passed without intervention in 33 cases, while ESWL was repeated in 53.

Conclusions

These data demonstrate the importance of long-term followup and the search for an effective prophylactic therapy to prevent recurrence.     

Idiopathic pre-capillary pulmonary hypertension in patients with end-stage kidney disease: effect of endothelin receptor antagonists

Background

We examined the prevalence, prognosis, and effect of endothelin receptor antagonists on survival in end-stage kidney disease patients with idiopathic pre-capillary pulmonary hypertension.

Methods

We investigated 1988 end-stage kidney disease patients in Toujinkai Hospital from January 1, 2001 to December 31, 2014. Pulmonary hypertension was screened by symptoms (dyspnea, hypotension, or near syncope) and echocardiography, and diagnosed by computed tomography with enhancement, pulmonary flow scintigraphy, and right heart catheterization.

Results

Fifteen patients (67 ± 11 years; 12 women and 3 men) were diagnosed as idiopathic pre-capillary pulmonary hypertension; mean pulmonary arterial pressure, pulmonary vascular resistance, or pulmonary artery wedge pressure were 55 ± 11 mmHg, 7.5 ± 2.9 Woods units, or 12 ± 2 mmHg, respectively. Of the 15 patients, 14 received hemodialysis, and 1 was in a pre-dialysis stage. Patients were followed through December 31, 2015, and 11 died of heart failure; their mean survival time was 26.4 ± 21.0 months. Endothelin receptor antagonists were used for 11 patients, and mean survival times were 57.3 ± 12.1 months in patients with endothelin receptor antagonists and 7.5 ± 2.1 months in those without. In the Kaplan–Meier analysis, heart failure death-free survival rates were higher in patients with endothelin receptor antagonists than in those without (P < 0.001); 100 versus 25 % at one year and 71 versus 0 % at 3 years.

Conclusion

The prognosis of idiopathic pre-capillary pulmonary hypertension seems to be poor in end-stage kidney disease patients. Administration of endothelin receptor antagonists might improve the survival by inhibiting heart failure death. Registration of clinical trials This study was registered to the ClinicalTrials.gov (https://clinicaltrials.gov/): protocol identifier, NCT02743091.

     

Is quantitative diffusion-weighted MRI a valuable technique for the detection of changes in kidneys after extracorporeal shock wave lithotripsy?

Objective

The aim of this study was to evaluate the capability and the reliability of diffusion-weighted imaging (DWI) in the changes of kidneys occurring after extracorporeal shock wave lithotripsy (ESWL) treatment for renal stones.

Materials and Methods

A total of 32 patients who underwent ESWL treatment for renal stone disease between June and December 2011 were enrolled in this prospective study. Color Doppler ultrasonography (CDUS) and DWI were performed before and within 24 hours after ESWL. DWI was obtained with b factors of 0, 500 and 1000 s/mm² at 1.5 T MRI. Each of Resistive index (RI) and ADC values were calculated from the three regions of renal upper, middle and lower zones for both of the affected and contralateral kidneys. Paired sample t test was used for statistical analyses.

Results

After ESWL, the treated kidneys had statistically significant lower ADC values in all different regions compared with previous renal images. The best discriminative parameter was signal intensity with a b value of 1000 s/mm². The changes of DWI after ESWL were noteworthy in the middle of the treated kidney (p<0.01). There were no significant difference between RI values in all regions of treated and contralateral kidneys before and after treatment with ESWL (p>0.05).

Conclusion

DWI is a valuable technique enables the detection of changes in DWI after ESWL treatment that may provide useful information in prediction of renal damage by shock waves, even CDUS is normal.     

Effect of Extracorporeal Shock Wave Lithotripsy on Prostate Specific Antigen

Purpose

We evaluated the effects of extracorporeal shock wave lithotripsy (ESWL^*) of distal ureteral calculi on serum prostate specific antigen (PSA).

Materials and Methods

A total of 29 consecutive men with distal ureteral calculi at a maximum of 25 mm. from the ureteral orifice, and without any history of urinary tract infection, benign prostatic hyperplasia or prostate cancer underwent ESWL with the Dornier MPL 9000 × lithotriptor. The therapeutic focus size was 48 × 7 mm. PSA was measured exactly 5 minutes before ESWL, as well as 120 minutes, 24 hours and 7 days after termination of treatment.

Results

Fragmentation rate was 100 percent and all patients were stone-free within 1 week of therapy. There was no statistically significant difference between PSA values before and after treatment. Only 15 patients had a slight increase in PSA at 120 minutes after treatment (range 0.01 to 0.41 ng./ml., mean 0.07).

Conclusions

ESWL can be performed in men at risk for prostate cancer without impairing the predictive value of PSA.     

Comparison of unilateral renal artery embolization versus bilateral for treatment of severe refractory hypertension in hemodialysis patients

Objective

Hypertension in ESRD patients is common, and often refractory to common medical interventions. Bilateral renal embolization (BRE) is an alternative to nephrectomy in treating severe refractory hypertension in hemodialysis patients, but has drawbacks in residual renal function preservation and post-infarction syndrome. We evaluated the efficacy and safety of unilateral renal embolization (URE) for the treatment of severe refractory hypertension in hemodialysis patients.

Patients and methods

From January 2000 to May 2007, 16 hemodialysis patients with severe refractory hypertension were randomized to URE or BRE group, and received percutaneous transcatheter unilateral or bilateral renal embolization, respectively. The efficacy and complications of these two procedures were compared. The plasma renin activity (PRA), plasma angiotensin II, aldosterone and endothelin-1 (ET-1) were measured pre- and post-renal embolization in both groups.

Results

The procedures were completed successfully without severe immediate complications. The blood pressure decreased from 211/122 to 127/81 mmHg in URE group (P < 0.0001), and in BRE group from 208/117 to 124/76 mmHg (P < 0.0001) with significantly reduced need for antihypertensive medications. The residual renal function was reasonably kept and post-infarction syndrome was milder in URE group compared with BRE group. No activation of RAS was observed in this series and no RAS activity dynamic change occurred post-procedure. Decreased circulating ET-1 was accompanied with the lowering of blood pressure after the procedure (P < 0.0001).

Conclusions

Unilateral renal embolization is as effective as BRE in treating severe refractory hypertension in hemodialysis patients, with advantages over BRE in residual renal function preservation and milder post-infarction syndrome.     

Immediate and long-term high levels of plasma homocysteine after extracorporeal shock wave lithotripsy in patients with renal stone disease

Background

Plasma homocysteine levels increase in patients with chronic renal failure. Numerous studies have demonstrated that kidney function is one of the most important determinants of plasma total homocysteine (tHcy) concentration. In this study we aimed to evaluate the relationship between tHcy levels and extracorporeal shock wave lithotripsy (ESWL) for patients with renal stones and to see if the change in homocysteine levels continued if renal dysfunction improved.

Materials and methods

The study consisted of 20 patients who underwent first-time ESWL for renal stones. Every patient gave 3 blood samples at 24 h before surgery and at 2 days and at 3 months after ESWL for measurement of plasma levels of tHcy, creatinine, vitamin B₆, and vitamin B₁₂.

Results

The 20 patients (12 male, 8 female) had a mean age of 42.8 ± 11.7 years. tHcy levels showed a statistically significant increase from 9.4 ± 1.4 to 18 ± 4.8 and 11.2 ± 2.1 at 2 days and at 3 months, respectively. Serum creatinine also showed a statistically significant increase compared to baseline at 2 days and at 3 months after ESWL.

Conclusion

After first-time ESWL, the increase in serum levels of creatinine and tHcy due to renal injury, such as ischemia/reperfusion injury, may be severe and continue for a long period, such as 3 months. According to baseline levels, the increase in homocysteine levels as an indicator of oxidant stress was more severe than the creatinine levels after ESWL for renal stones. Our patients were first-time ESWL patients; however, in patients who undergo EWSL more than once long-term high tHcy levels should also be considered as renal.     

Extracorporeal Shock Wave Lithotripsy for Obstructing Pancreatic Duct Calculi

Purpose

A review was done to determine the effectiveness of extracorporeal shock wave lithotripsy (ESWL^†) in the treatment of impacted pancreatic duct calculi.

Materials and Methods

A total of 19 patients, who were potential candidates for radical pancreatic surgery after unsuccessful endoscopic retrograde cholangiopancreatography, sphincterotomy and attempted stone extraction from the pancreatic ducts, underwent ESWL of the calculi. Followup ranged from 6 months to 6 years.

Results

Of the 19 patients 14 avoided a major operation and 6 have remained pain-free for the long term. Two patients died of causes not related to ESWL or endoscopic retrograde cholangiopancreatography. Five patients eventually underwent a Whipple or Puestow procedure for relief of symptoms or persistent obstruction. Complications were minimal.

Conclusions

ESWL is a valuable adjunct in patients with impacted pancreatic duct calculi unretrievable by primary endoscopic retrograde cholangiopancreatography.     

Extracorporeal shock-wave lithotripsy monotherapy in renal pelvic ectopia

Objectives

To determine the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in the treatment of urinary stones in pelvic kidneys.

Methods

Fourteen male patients with renal pelvic ectopia and stones were treated with ESWL monotherapy using the unmodified Dornier HM3 lithotriptor with its original generator and ellipsoid. Twelve patients were treated in the prone position using cystoscopically placed ureteral catheters to aid in fluoroscopic localization, whereas 2 patients were treated in the supine position. A review of their stone disease, ESWL treatment, ancillary procedures, outcome, and complications is presented.

Results

All pelvic kidneys were free of infection and obstruction in this group. The mean stone burden was 30.2 ± 37.8. Most patients required a single session (9 of the 14 [64%]), 2 patients required two sessions, and 2 patients required multiple sessions. The average number of shock waves per session was 1689 (range 450 to 3500), with average kilovoltage of 21.5 (range 18 to 24). Eighty-two percent of the patients followed (9 of 11 ) were stone-free at 3 months. No ancillary endourologic procedures were required to deal with the presenting stones. Obstructive steinstrasse complicated treatment in only 2 patients (14%) and was successfully treated by further ESWL in both patients; in 1 of them, ureteroscopy was needed.

Conclusions

ESWL monotherapy of renal pelvic ectopia stones is very effective and should be considered as the first therapeutic option for these patients, provided that accurate localization of the stone treated and proper positioning of patients that ensures adequate delivery of shock-wave energy can be maintained.     

Renin inhibition ameliorates renal damage through prominent suppression of both angiotensin I and II in human renin angiotensinogen transgenic mice with high salt loading

Background

The renin–angiotensin–aldosterone system (RAAS) plays pivotal roles in the pathogenesis of chronic kidney disease (CKD) progression. Aliskiren, a direct renin inhibitor, inhibits the rate-limiting step of the RAAS without any alternative pathway. It is proven to reduce albuminuria in CKD patients treated with angiotensin blockade. However, there are few reports which evaluate the advantage of aliskiren as the first-line drug against CKD progression in RAAS-activated hypertensive patients.

Methods

Tsukuba hypertensive mice (THM), double transgenic mice carrying both the human renin and human angiotensinogen genes, were fed a high-salt diet and treated with hydraladine, ramipril and aliskiren for 10 weeks. Blood pressure and urinary albumin excretion were measured every 2 weeks during the experimental period. We evaluated renal histological changes and gene expression. Plasma angiotensin concentration was measured to evaluate the RAAS inhibitory effect.

Results

High-salt-loaded THM showed severe hypertension and renal injury. All antihypertensive drugs suppressed blood pressure and prevented renal disease progression. RAAS blockade showed a higher renoprotective effect than hydraladine despite an equivalent blood pressure lowering effect. Aliskiren exhibited even stronger renoprotection than ramipril. Plasma angiotensin concentration was increased in THM fed both normal salt and high salt. Hydraladine did not alter the plasma angiotensin concentration. Ramipril significantly decreased angiotensin II concentration. Aliskiren treatment almost completely suppressed angiotensin I and resulted in lower angiotensin II concentration than ramipril treatment.

Conclusion

Aliskiren prevents renal disease progression by suppressing both angiotensin I and II in RAAS-activated pathology. Our data suggest the application of a renin inhibitor for preventing kidney disease progression in CKD patients.     

Clinical Implications of Clinically Insignificant Stone Fragments After Extracorporeal Shock Wave Lithotripsy

Purpose

We determined the natural history and clinical significance of small, asymptomatic, noninfection related stone fragments after extracorporeal shock wave lithotripsy (ESWL*).

Materials and Methods

We prospectively followed 160 patients with 4 mm. or less asymptomatic calcium oxalate/phosphate stone fragments after ESWL for 1.6 to 88.8 months (mean 23) to stone-free status, censorship or intervention. Kaplan-Meier estimates of probability to anatomical stone-free, decreased or stable status were determined as well as the probability of symptomatic episodes or required urological intervention.

Results

Stone-free status or a decreased, stable or increased amount of residual stone occurred in 38 (23.8 percent), 26 (16.3 percent), 67 (41.9 percent) and 29 (18.1 percent) of the 160 patients, respectively. At 5 years after ESWL the probability of a stone-free, stone-free or decreased status, or stone-free, decreased or stable status was 0.36, 0.53, and 0.80, respectively. A total of 91 patients (56.9 percent) remained asymptomatic while 69 (43.1 percent) had a symptomatic episode or required intervention 1.6 to 85.4 months (mean 26) after ESWL (probability estimated at 0.71 at 5 years).

Conclusions

While patients with small noninfection related stone fragments after ESWL may be followed expectantly, a significant number will require intervention or have symptomatic episodes within 2 years. The term clinically insignificant applied to any residual stone after ESWL is likely a misnomer.     

Effects of tezosentan, a dual endothelin receptor antagonist, on the cardiovascular and renal systems of neonatal piglets during endotoxic shock

Background/Purpose: Endothelin is a potent mediator of the cardiovascular and renal systems. Studies have found that endothelin has an important role in regulating cardiac function and renal perfusion in neonates who are suffering from endotoxic shock. The authors believe that blockade of the endothelin response during endotoxemia will have a beneficial effect on neonatal cardiac and renal functions. In this study the authors have examined the effects of tezosentan, a dual endothelin-receptor antagonist, on the cardiovascular and renal systems of neonatal piglets during endotoxemia. Methods: Thirteen piglets were subjected to endotoxic shock and divided into a fluid-therapy group that received 0.9% normal saline and a group that received tezosentan (1 mg/kg/h). Mean arterial pressure (MAP), heart rate (HR), and glomerular filtration rate (GFR) were plotted at baseline, 1, 2, and 3 hours. Cardiac index (CI), renal blood flow (RBF), systemic vascular resistance (SVR), and renal vascular resistance (RVR) were obtained at baseline, 1, and 3 hours after baseline. Results: (P [lt ] .05 for 3 hours versus baseline and tezosentan versus fluid). Although fluid therapy in endotoxemia had no significant effect on MAP and RVR, it significantly increased HR (139 [plusmn] 17 to 246 [plusmn] 17 beats/min) and SVR (0.08 [plusmn] 0.05 to 0.33 [plusmn] 0.09 mm Hg/mL/min) and decreased CI (407 [plusmn] 208 to 98 [plusmn] 13 mL/min/kg), RBF (1.84 [plusmn] 0.38 to 0.97 [plusmn] 0.34 mL/min/kg kidney), and GFR (0.20 [plusmn] 0.05 to 0.11 [plusmn] 0.04 mL/min/kg) at 3 hours. The use of tezosentan also significantly increased HR (130 [plusmn] 14 to 220 [plusmn] 31 beats/min), but unlike in the fluid therapy group, there was a significant fall in MAP (77 [plusmn] 10 to 54 [plusmn] 9 mm Hg) and RVR (1.92 [plusmn] 0.44 to 1.77 [plusmn] 0.64 mm Hg/mL/min) and a less severe decrease in CI (482 [plusmn] 188 to 176 [plusmn] 67 mL/min/kg) at 3 hours. SVR, RBF, and GFR were maintained. Conclusions: Endotoxic shock affected cardiac and renal functions in both treatment groups. Fluid therapy alone could not prevent a statistically significant fall in CI, RBF, and GFR or prevent the increase in HR and SVR. Endothelin antagonism with tezosentan resulted in a statistically significant fall in MAP and RVR from baseline, not seen in the fluid-therapy group. CI and RBF were significantly higher, and MAP, SVR, and RVR were significantly lower when compared with the fluid-therapy group at 3 hours. GFR also was maintained at baseline with tezosentan. During endotoxemia, endothelin antagonism maintained renal and cardiac functions better than with fluid therapy alone.     

Use of Intravenous Contrast Material During in Situ Extracorporeal Shock Wave Lithotripsy of Ureteral Calculi

Purpose

We prospectively studied the usefulness of contrast material to facilitate extracorporeal shock wave lithotripsy (ESWL†) of ureteral calculi in situ.

Materials and Methods

Followup was available for 67 consecutive patients with ureteral calculi treated in situ (without ureteral catheterization) on an unmodified Dornier HM-3 lithotriptor. In 30 patients radiographic contrast material was administered to facilitate targeting of calculi. Intraoperative obstruction was determined by the lack of passage of contrast material beyond the calculus during treatment. Immediate postoperative obstruction was defined as prolonged retention of contrast material on a postoperative radiograph.

Results

Passage of contrast material beyond the calculus was note noted in 9 of 26 evaluable patients, 5 of whom appeared to have obstruction on postoperative radiography. Of these 5 patients 3 required immediate hospitalization for pain control, compared to none of those without intraoperative obstruction. The stone-free rates after ESWL, including success following adjunctive measures or repeat ESWL, were 83, 100 and 87% for calculi in the proximal, middle and distal ureter, respectively. Neither use of contrast material, nor intraoperative or postoperative obstruction altered the eventual success of ESWL.

Conclusions

The administration of intravenous contrast material during ESWL allows for effective treatment of ureteral calculi that otherwise could not be imaged adequately without ureteral catheterization, and provides information valuable for short-term prognosis.