Evaluating the importance of mean stone density and skin-to-stone distance in predicting successful shock wave lithotripsy of renal and ureteric calculi

Shock wave lithotripsy (SWL) is considered the first line treatment for the majority of patients with renal and ureteric calculi, with success rates from contemporary series varying from 60 to 90%. Success is dependent on many patient and stone-related factors. We conducted a retrospective analysis of mean stone CT density (MSD) and skin-to-stone distance (SSD) to determine their influence on the success of SWL of renal and ureteric calculi. Data from all patients treated at the St. Michael’s Hospital Lithotripsy Unit from May 2004 to June 2009 were reviewed. Analysis was restricted to those patients with a pre-treatment non-contrast CT scan conducted at our center demonstrating a solitary renal or ureteric calculus ≤20 mm in maximal diameter. Successful treatment of renal stones was defined as those patients who were stone free or had asymptomatic, clinically insignificant residual fragments ≤4 mm in diameter, as measured by KUB X-ray, 3 months after a single SWL treatment. Successful treatment of ureteric stones was defined as being stone free on KUB X-ray, 2-weeks post-SWL. Demographic, stone, patient, treatment and follow-up data were collected from a prospective database and review of CT and KUB imaging by two independent urologists and one radiologist. Data were analyzed with logistic regression, Chi square analysis and ANOVA where appropriate. 422 patients (69.7% male) with a mean age of 51.4 years (SD 12.9) and mean BMI 27.0 kg/m² (SD 4.9) were analyzed. Mean stone size was 78.9 mm² (SD 77.3) for ureteral stones and 66.1 mm² (SD 63.2) for renal stones, with 95 (43.6%) of the renal stones located in the lower pole. The single-treatment success rates for ureteral and renal stones were 62.3% and 68.8%, respectively. On univariate analysis, predictors of SWL success, regardless of stone location, were age (p = 0.01), BMI (p = 0.01), stone size (p < 0.01), MSD (p < 0.01) and SSD (p < 0.01). On multivariate analysis, MSD >900 HU (OR = 0.49, CI: 0.32–0.75) and SSD >110 mm (OR = 0.49, CI: 0.31–0.78) were both significant predictors of outcome. We have identified in a large series of renal and ureteric calculi that both MSD and SSD can reliably predict SWL outcomes. This data can be used in combination with other patient and stone-related factors to facilitate optimal treatment-based decisions and provide patients with more accurate single-treatment success rates for SWL.     

Efficacy of extracorporeal shock wave lithotripsy for ureteric stones in children

Objectives: Management of ureteral stones in children represents a challenging problem. In this study, we retrospectively analyzed our experience with extracorporeal shock wave lithotripsy (ESWL) in 192 children with ureteric stones. Methods: Between 1990 and 2003, 192 children (≤ 14 years old) with ureteric calculi were treated with the Siemens Lithostar Plus (Siemens Medical Systems, Iselin, NJ). There were 39 stones in the proximal ureter, 19 in the mid-ureter and 134 in the distal ureter. Results: Mean patient age was 7.3±4.1 years (6 months–14 years). There were 122 boys (64.2%) and 70 girls (35.8%). All procedures were performed on an outpatient basis with intravenous sedation in 73 cases (38.1%), general anesthesia in 68 cases (35.7%) and no anesthesia in 51 cases (26.2%). A maximum of 3500 shocks and 18 kV per session were used. A 94% success rate was achieved in proximal (n: 39) and mid-ureteral stones (n: 19). Stone free rates for distal ureteral calculi were 90.6% for stones less than 1 cm in diameter (n: 94) and 91.7% for stones between 1 and 2 cm (n: 26). Overall re-treatment and efficacy quotient rates for proximal ureteral stones were 45.1% and 68.9%, 62.5% and 61.5% for mid-ureteral calculi, and 49.6% and 60.0% for distal ureteral stones. Conclusion: Our results indicate that ESWL with highly satisfactory stone free rates ranging between 90 and 100% and negligible complications can be considered as a first line treatment for ureteric stones in the pediatric age group.     

Laparoscopic pyelolithotomy versus percutaneous nephrolithotomy for treatment of large renal pelvic calculi (diameter >2 cm): a meta-analysis

Objective: To systematically assess the efficacy and safety of laparoscopic pyelolithotomy (LP) versus percutaneous nephrolithotomy (PCNL) for the treatment of renal pelvic calculi >2?cm.

Methods: We searched PubMed, Embase, Cochrane Library, and Google Scholar about LP and PCNL for the treatment of renal stones. The retrieval time ended in September 2015. Two reviewers independently assessed the quality of all included studies. The available data in the studies were analyzed using the RevMan 5.2 software.

Results: Four randomized controlled trials (RCTs) and nine Non-Randomized Concurrent Controlled Trials (NRCCTs) were included, involving a total of 766 patients. This meta-analysis showed that LP has a statistically higher stone-free rate than PCNL [I^2?=?0, OR?=?0.26 (95% CI 0.10–0.64), p?=?0.003], lower drop in hemoglobin level [I^2?=^?0, difference in mean drop?=??0.83 (95% CI ?1.05 to ?0.61), p?I^2?=^?0, OR?=?0.36 (95% CI 0.14–0.89), p?=?0.03], and PCNL is associated with a lower length of hospital stay [I^2?=^?74%, difference in mean of hospital stay?=?0.72 (95% CI 0.04–1.40), p?=?0.04].

Conclusion: LP is an alternative for the treatment of large solitary renal stone. LP may have a higher stone-free rate, lesser blood loss, lower postoperation fever rate, while PCNL may have a lower length of hospital stay. However, further well designed and large volume randomized controlled trials are needed to confirm these findings.     

Immediate or delayed SWL in ureteric stones: a prospective and randomized study

The objective is to compare immediate and delayed SWL as a treatment for ureter stones between 5 and 20?mm. Patients who applied to the emergency department with single, radio opaque ureteric stone of 5–20?mm size were included in the study. Patients were randomized into immediate and delayed SWL groups. SWL were carried out after pain relief in the delayed group. Maximum of three SWL sessions were applied to the patients with stones of 5?mm or bigger in diameter, leaving at least 3?days interval in-between. Stone-free rate after first session was similar in two groups. When CIRF was also considered as success, the success rate of SWL in the immediate SWL group was higher after first session (p?=?0.02). Immediate SWL had a greater success rate in upper ureteric stones (p?=?0.019). Overall average time required for elimination of stones was shorter in immediate SWL group than delayed SWL group (p?=?0.033). The success rate after first SWL session (including CIRF) was 59?% for patients with chronic pain in the delayed group and 100?% for patients with acute pain in the immediate group. According to the hydronephrosis grade, success rates were 71 and 44.4?% for patients with grade 1 or no hydronephrosis in the immediate SWL group, and for patients with grade 2 or larger hydronephrosis in the delayed SWL group, respectively, after first SWL session. Immediate SWL insures stone-free status in a shorter time in cases with renal colicky pain and ureteral stones, particularly upper ureteral stones.     

Prolonged elevated postprandial sugar augments severity in kidney disease: a North Indian hospital-based study

Aim: Diabetes plays a major role in progression of renal failure. The risk-factor profile changes during the progression of chronic kidney disease (CKD) from mild/moderate to end-stage renal disease. The relationship between glycemic indices, blood pressure, body mass index (BMI) and age at diagnosis in Indians has been less investigated. We assessed association of these risk factors with CKD stages in Indian population. Methods: This study was carried out on patients (n?=?162) who were diagnosed with CKD and normal control group (n?=?155). For BMI, National Institutes for Health criteria were used to categorize the patients. Result: The mean age of CKD patients were significantly increased with the advancement of stage. BMI, systolic blood pressure (SBP), postprandial sugar level (PP), urea and creatinine were also significantly higher with elevated stages, whereas no differences were observed in diastolic blood pressure (DBP) and fasting blood sugar (FBS). The logistic regression study gave a significant result (p?=?0.000) when we compared the group of CKD patients with established/prolonged postprandial blood sugar. It was independently associated with mild CKD [odds ratio (OR)?=?5.213, 95% confidence interval (CI)?=?2.06–13.21, p?=?0.000], moderate CKD (OR?=?7.724, 95% CI?=?4.05–14.74, p?=?0.000) and severe CKD (OR?=?7.610, 95% CI?=?4.03–14.36, p?=?0.000). Conclusion: SBP and PP were the best predictors of prevalent nephropathy in this population, while DBP and FBS were found to be less effective. This may have implication for kidney disease risk stratification and protection.     

Do the variations in renal pelvic angles play a role in the formation of renal stone? A computed tomography study

Abstract

Objective: In this study, we aimed to investigate the effect of variations in renal pelvic angle on urinary calculi development. Materials and methods: A total of 2456 unenhanced abdominal CT scans were retrospectively evaluated and 262 kidneys of 131 patients were compared. Patients included in this study were identified and qualified as follows: Having unilateral calculi, having no calculi or a history of calculi in contra-lateral side and having totally normal renal morphology. Results: The mean angle of kidneys with calculi was 55?±?9°, while the average angle measurement was 61?±?11° in kidneys without calculi. The mean angle measured from the kidneys with calculi was statistically smaller (p?<?0.001). Conclusion: Our study suggests that the possibility of calculi development in kidneys, which have more anteriorly localized pelvic angulation tends to be significantly higher in individuals, who did not have any congenital or acquired renal pathology before.     

A retrospective analysis of kidney function and risk factors by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation in elderly Chinese patients

Abstract

Chronic kidney disease accounts for much of the increased mortality, especially in the elder population. The prevalence of this disease is expected to increase significantly as the society ages. Our aim was to evaluate the kidney function and risk factors of reduced renal function among elderly Chinese patients. This study retrospectively collected clinical data from a total of 1062 inpatients aged 65 years or over. Estimated glomerular filtration rate (eGFR) was calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Renal function and risk factors were also analyzed. For all 1062 subjects, the mean eGFR was 71.0?±?24.8?mL/min/1.73?m², and the incidence rates of reduced renal function, proteinuria, hematuria and leukocyturia were 31.1%, 11.8%, 6.6% and 8.7%, respectively. The eGFR values were 83.4?±?28.4, 72.2?±?22.9, 67.8?±?24.3 and 58.8?±?29.1?mL/min/1.73?m² in the groups of 60–69, 70–79, 80–89 and ≥90 years age group (F?=?15.101, p?=?0.000), respectively; while the incidences of reduced renal function were 12.8%, 27.0%, 37.8% and 51.7% (χ²?=?36.143, p?=?0.000). Binary logistic regression analysis showed that hyperuricemia (OR?=?4.62, p?=?0.000), proteinuria (OR?=?3.96, p?=?0.000), urinary tumor (OR?=?2.92, p?=?0.015), anemia (OR?=?2.45, p?=?0.000), stroke (OR?=?1.96, p?=?0.000), hypertension (OR?=?1.83, p?=?0.006), renal cyst (OR?=?1.64, p?=?0.018), female (OR?=?1.54, p?=?0.015), coronary artery disease (OR?=?1.53, p?=?0.008) and age (OR?=?1.05, p?=?0.000) were the risk factors of reduced renal function. In conclusion, eGFR values decreased by age, while the incidence of reduced renal function, proteinuria, hematuria and leukocyturia increased with age. Treatment and control of comorbidities may slow the decline of renal function in elderly patients.     

Retrograde intrarenal surgery by flexible ureteroscope in patients with spinal deformities

Objective: To present our experience with retrograde intrarenal surgery (RIRS) for managing renal stones in patients with spinal deformities.

Design: We retrospectively reviewed the records of patients.

Methods: We retrospectively reviewed the records of seven patients with congenital scoliosis (n?=?5), spina bifida (n?=?2) who had undergone RIRS for renal stones. Stone-free status was determined by CT 30 days after the procedure and was defined as the absence of stones in the kidney or residual fragments ≤1?mm.

Results: Mean patient age was 27 years (18–45 years), and mean stone size was 176?mm (143–340?mm). The average operative time was 38 minutes (25–53 minutes), and postoperative hospital stay was 1 day (1–2 days). A stone-free status was obtained in six (85.7 %) patients, and one patient was considered to have treatment failure. This patient was managed by a repeat RIRS. A Double-J stent was placed at the end of the procedure in all (100 %) patients. No severe complications, either from anesthesia or the surgical procedure, were observed, and no blood transfusion was reported.

Conclusions: The good clearance rate with a low incidence of complications shown by the present study has demonstrated that RIRS is a safe and effective procedure for renal stones in patients with spinal deformities.     

Spontaneous spondylodiscitis and endocarditis: interdisciplinary experience from a tertiary institutional case series and proposal of a treatment algorithm

Previously, the simultaneous presence of endocarditis (IE) has been reported in 3–30% of spondylodiscitis cases. The specific implications on therapy and outcome of a simultaneous presence of both diseases are not yet fully evaluated. Therefore, the aim of this study was to investigate the influence of a simultaneously present endocarditis on the course of therapy and outcome of spondylodiscitis. A prospective database analysis of 328 patients diagnosed with spontaneous spondylodiscitis (S) using statistical analysis with propensity score matching was conducted. Thirty-six patients (11.0%) were diagnosed with concurrent endocarditis (SIE) by means of transoesophageal echocardiography. In our cohort, the average age was 65.82?±?4.12 years and 64.9% of patients were male. The incidence of prior cardiac or renal disease was significantly higher in the SIE group (coronary heart disease SIE n?=?13/36 vs. S n?=?57/292, p?<?0.05 and chronic heart failure n?=?11/36 vs. S n?=?41/292, p?<?0.05, chronic renal failure SIE n?=?14/36 vs. S n?=?55/292, p?<?0.05). Complex interdisciplinary coordination and diagnostics lead to a significant delay in surgical intervention (S?=?4.5?±?4.5 days vs. SIE?=?8.9?±?9.5 days, p?<?0.05). Mortality did not show statistically significant differences: S (13.4%) and SIE (19.1%). Time to diagnosis and treatment is a key to efficient treatment and patient safety. In order to counteract delayed therapy, we developed a novel therapy algorithm based on the analysis of treatment processes of the SIE group. We propose a clear therapy pathway to avoid frequently observed pitfalls and delays in diagnosis to improve patient care and outcome.

     

Renal colic and urolithiasis practice patterns in Canada: a survey of Canadian Urological Association members

Background:

We describe the practice variability of CUA (Canadian Urological Association) members and factors which predict these patterns for common stone scenarios.

Methods:

We asked 308 English- and 52 French-speaking CUA members to complete online surveys in their respective languages. We collected demographic information on fellowship training, shock wave lithotripsy (SWL) access, academic setting and whether they are at a hospital with regionalized surgical services. Respondents indicated their actual as well as ideal treatment for scenarios of renal, proximal and distal ureteric calculi.

Results:

In total, 131 urologists responded (36% response rate), all of whom treated urolithiasis. Of this number, 17% had endourology fellowship training, 76% had access to SWL, 42% were at an academic institution and 66% were at institutions with regionalized surgical services. Actual and ideal treatment modalities selected for symptomatic, distal and proximal ureteric stones (4, 8, 14 mm) were consistent with published guidelines. There were discrepancies between the use of ureteroscopy and SWL in actual versus ideal scenarios. Actual and ideal practices were congruent for proximal ureteric stones and asymptomatic renal calculi. In multivariate analysis, respondents were less likely to perform ureteroscopy on proximal 4- and 8-mm stones if they were at a hospital with regionalized surgical services (OR: 0.097; 95% CI: 0.01–0.76, p = 0.03 and OR: 0.330; 95% CI: 0.13–0.83, p = 0.02).

Interpretation:

There is clinical variability in the management of urolithiasis in Canada; however, management approaches fall within published guidelines. Type of hospital and access to operating room resources may affect treatment modality selection.     

Dream anxiety in renal transplant recipients

Abstract

Objective: Although low quality of sleep has been reported in kidney transplant patients with functioning allografts, there are no previous studies investigating the dreams of these patients. We aimed to investigate the differences in dream anxiety level between renal transplant patients and healthy control subjects. We also planned to compare depression and anxiety symptoms, sleep quality and sleepiness level between these two groups. Methods: Twenty-two living-donor renal transplant recipients followed at an outpatient nephrology clinic and 22 healthy controls were enrolled in this observational cross-sectional study. Sociodemographic Data Collection Form, and the Van Dream Anxiety Scale (VDAS), the Pittsburg Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI), Beck Depression and Anxiety Inventories were used for the assessment of the necessary features. Hemoglobin (Hb), blood urea nitrogen (BUN), creatinine (Cr) and glucose levels were measured. Results: There were no significant differences between the groups in terms of dream anxiety (p?=?0.45), depression (p?=?0.76), sleep quality (p?=?0.8), insomnia severity (p?=?0.08) and Hb (p?=?0.11) and glucose levels (p?=?0.14). Although, BUN (p?=?0.00) and creatinine (p?=?0.00) levels differed significantly between the two groups, both parameters were found to be within their normal range. Conclusions: In our study, chronic renal failure patients with a successful kidney transplant were found to be able to completely return to normal in terms of metabolic parameters, sleep quality and mood. Similar levels of dream anxiety are also consistent with these findings.     

Stepwise shock wave lithotripsy: Results of initial study for the treatment of urinary stones in childhood

Objective: To assess the effectiveness of stepwise extracorporeal shock wave lithotripsy in the treatment of upper urinary stones in childhood. Patients and methods: Between August 1998 and August 2003, 31 patients were treated for renal or ureteric stones. All treatments were performed with Dornier Compact Delta lithotripter. The number of shock wave was limited to maximum 3000 shock waves/session. The voltage was started at 10 kV and increased stepwise to 12.75 kV. Stone clearance was assessed at 3 months. The stone free state was defined as the absence of stone fragments. Results: Total 31 stones (24 renal and 7 ureteral stones) were treated. The age of the patients was median 8 (min–max: 0.8–12) years. The length of the stones was median 1 (min–max: 0.5–1.5) cm for renal stones and median 0.5 (min–max: 0.5–1) cm for ureteral stones. As an auxiliary procedure, open pyelolithotomy was required for 1 patient. The overall stone free rates for renal and ureter stones were 79% and 100%, respectively. Post-treatment insignificant hematuria was observed in all cases. Conclusion: Stepwise shock wave lithotripsy was an effective procedure for the treatment of urinary calculi in childhood.     

The relationship between atherogenic index of plasma and epicardial adipose tissue in hemodialysis and peritoneal dialysis patients

Abstract

Introduction: Epicardial adipose tissue (EAT) is the true visceral fat depot of the heart. The relationship between coronary artery disease and EAT was shown in end-stage renal disease (ESRD) patients. One of the established risk factor in this population is dyslipidemia. We aimed to determine the relationship between atherogenic index of plasma (AIP) and EAT in ESRD patients. Methods: This was a cross-sectional study involving 76 ESRD patients receiving PD or HD for ≥6 months and 42 healthy subjects. EAT was measured by using an electrocardiogram-gated 64-multidetector computed tomography (MDCT). Atherogenic index of plasma was calculated as the logarithmically transformed ratio of the serum trigliseride to HDL-cholesterol. Results: The etiology of ESRD patients was diabetic nephropathy (n?=?16), chronic glomerulonephritis (n?=?10), hypertensive nephropathy (n?=?23), polycystic kidney disease (n?=?7), nephrolithiasis (n?=?5) and unknown (n?=?15). There were no differences with respect to the following variables between ESRD patients and healthy subjects: age; sex; BMI; predialysis levels of DBP; serum levels of albumin, HDL-cholesterol and hemoglobin. However, ESRD patients had higher serum levels of trigliseride, hs-CRP and AIP when compared to healthy subjects. There was a statistically significant relationship between EAT, BMI and AIP in ESRD patients (r?=?0.42, p?<?0.001 and r?=?0.25, p?=?0.028, respectively). The stepwise linear regression analysis revealed that age, as well as BMI were independent predictors of EAT. Conclusion: We found a relationship between EAT as defined by MDCT and AIP in ESRD patients. Further clinical and experimental studies are needed.     

Retrograde Intrarenal Surgery is equally efficient and safe in patients with different American Society of Anesthesia physical status

Objective To assess the efficacy and safety of Retrograde Intrarenal Surgery to treat renal stones in patients with different American Society of Anesthesia (ASA) physical status. Material and methods We performed a retrospective analysis of 150 patients who underwent Retrograde Intrarenal Surgery for renal stone between October 2013 and December 2014. Patients were categorized into three groups according to their ASA physical status: ASA Class 1 (Group 1, n?=?23), ASA Class 2 (Group 2, n?=?113) and ASA Class 3 (Group 3, n?=?14). We documented and stratified the per-operative and postoperative complications according to modified Satava Classification System and Clavien–Dindo Classification. Results The mean age of the patients was 44 years. The total stone-free rate was 81.2%. According to the groups, the stone-free rate was 75% in Group 1, 82.5% in Group 2, and 83.3% in Group 3 (p = 0.340). Per-operative and postoperative complications were recorded in 12% (n?=?18) and 5.3% (n?=?8) of the patients. We did not find significant difference in terms of per-operative and postoperative complication rates among patients with different ASA physical status (p_{per-operative}?=?0.392 and p_{postoperative}?=?0.136). Conclusions Retrograde Intrarenal Surgery is an effective and safe surgery with high stone-free rates and low morbidity in patients with different ASA physical status.     

Cystatin C,vascular biomarkers and measured glomerular filtration rate in patients with unresponsive hypertensive phenotype: a pilot study

Background: Biomarkers are commonly used to estimate the presence of subclinical cardiovascular disease (CVD) in patients with essential arterial hypertension (HT). In addition to known association between cystatin C and glomerular filtration rate (GFR), elucidating the association between cystatin C and vascular biomarkers (intima-media thickness of common carotid arteries (CCIMT), carotid plaque and renal artery resistance index (RRI)) in patients with unresponsive hypertensive phenotype could be of significant clinical interest.

Methods: Participants (n?=?200, median age 58 (52–64) years, 49% female) under treatment with antihypertensive drugs were stratified into two subgroups based on their blood pressure level as having responsive hypertension (RHT – compliant and responsive to treatment, n?=?100), or nonresponsive (URHT – compliant but nonresponsive to treatment, n?=?100). GFR was measured by isotopic (slope-intercept) method (99m Tc diethylene triamine penta-acetic acid – mGFR).

Results: The URHT group had significantly higher median cystatin C serum concentration (p?=?0.02) and CCIMT (p?=?0.00) compared to the RHT group, with no significant difference in RRI (p?=?0.51) and mGFR among subgroups [69.9?±?28.2 vs 76.74?±?23.61?ml/min/1.73m², p?=?0.27]. In the URHT group, cystatin C was found to be associated with CCIMT (p?=?0.02), hsCRP (p?=?0.01) and duration of HT (p?=?0.02), independently of mGFR and age. Independent predictors of URHT phenotype were CCIMT (p=?0.02) and hsCRP (p=?0.04).

Conclusion: In addition to GFR, cystatin C serum concentration is positively and independently associated with CCIMT in patient with URHT phenotype and subclinical CVD. Prospective larger studies should further investigate the clinical importance of this relationship.     

Tamsulosin versus nifedipin in medical expulsive therapy for distal ureteral stones and the predictive value of Hounsfield unit in stone expulsion

We evaluated the efficacy of tamsulosin and nifedipine in medical expulsive therapy (MET) in patients with distal ureteral stone. In addition, we tried to determine the predictive value of Hounsfield Unit (HU) of the stone in the success of MET. A total of 75 patients with a distal ureteral stone of 5–10?mm diameter were randomly divided into three groups. Group 1 (n?=?25) received tamsulosin 0.4?mg/d; group 2 (n?=?25) received nifedipine 10?mg/day p.o and group 3 (n?=?25) received diclofenac sodium 50?mg p.o. when required. At the beginning of each treatment, the HU of the stone was also measured using a non-contrast computerized tomography in all the patients. The results were evaluated at week four. The mean age of the patients was 36.8 (range, 16–68) years. Stone expulsion was observed in 19 (76%) patients in group 1, 16 (64%) patients in group 2 and 9 (36%) patients in group 3 (p_group1-3?=?0.004, p_group2-3?=?0.048 and p_group1-2?=?0.355). The mean expulsion time was 9, 9.1 and 10.3 d, respectively (p_group1-3?group2-3?group1-2?=?0.619). The mean diclofenac sodium dose per patient was 544, 602 and 1408?mg in groups 1, 2 and 3, respectively (p_group1-3?group2-3?group1-2?=?0.977). The mean HU of the stone in patients with and without a successful MET was 363 and 389, respectively (p?=?0.462). Our results showed that MET with both nifedipine and tamsulosin provided a similar increase in the expulsion rate for distal ureteral stones. HU does not seem to be a predictive parameter for stone expulsion.     

Association between Human Leukocyte Antigens (HLA-A, -B,and -DR) and end-stage renal disease in Kuwaiti patients awaiting transplantation

The number of patients with end stage renal disease (ESRD) is increasing considerably worldwide. Human Leukocyte Antigens (HLAs) are relevant for the expression of many immunological diseases and contribute to the development of different nephropathies. Therefore, we aimed from the present work to investigate the possible association between the frequency of HLA-A, -B, and –DR antigens and ESRD in Kuwaiti patients awaiting renal transplant. HLA-A, -B, and –DR typing was performed by complement-dependent cytotoxicity (CDC) method for 334 patients with ESRD awaiting renal transplantation and 191 healthy controls. The frequency of HLA-B8 antigen was significantly higher in ESRD patients (OR?=?2.62, p?=?0.001, p_c?=?0.038), and the frequency of HLA-A28, HLA-DR11 antigens was significantly higher in healthy controls (OR 0.42, p?=?0.0001; p_c?=?0.0021, and OR?=?0.44, p?=?0.0007, p_c?=?0.01 respectively). While the HLA-B8 antigen may be a susceptibility risk factor for development of ESRD, the HLA-A28, and HLA-DR11 antigens may be protective against development of ESRD in Kuwaiti population.     

N-acetylcysteine for the prevention of contrast-induced nephropathy in patients with pre-existing renal insufficiency or diabetes: a systematic review and meta-analysis

Abstract

Purpose: To identify benefit of N-acetylcysteine (NAC) on patients with pre-existing renal insufficiency or diabetes. Background: NAC administration is a common method for prevention of contrast-induced nephropathy (CIN). Nevertheless, its benefit on patients with pre-existing renal insufficiency or diabetes remains uncertain and controversial. Methods: Randomized controlled trials (RCTs) to evaluate the efficacy of NAC for the prevention of CIN in patients with pre-existing renal insufficiency or diabetes were searched from the databases of MEDLINE, EMBASE, and Cochrane library. Pooled odds ratio (OR) with 95% confidence interval (95% CI) were calculated using fixed-effects model by the Mantel–Haenszel test. Results: Twenty RCTs involving 3466 subjects (1756 assigned to NAC and 1710 assigned to the control) were included in the pre-existing renal dysfunction group. Pooled analysis suggested a significant reduction in CIN among this group (OR, 0.76; 95% CI, 0.61–0.93; p?=?0.008). However, the nine trials comparing NAC versus control among patients with diabetes (NAC, 367 subjects; control, 358 subjects) showed no benefit of NAC for prevention of CIN (OR?=?0.87; 95% CI, 0.58–1.30; p?=?0.50). No significant heterogeneity was detected (p?=?0.07; I²?=?34% for the group of pre-existing renal dysfunction; p?=?0.40; I²?=?5% for the group of diabetes). Conclusion: Our results suggest that NAC decreases the incidence of contrast-induced nephropathy among patients with pre-existing renal insufficiency. The benefit was not existed in patients with diabetes.     

Midkine release during hemodialysis is predictive of hypervolemia and associates with excess (cardiovascular) mortality in patients with end-stage renal disease: a prospective study

Background

In end-stage renal disease, a high cardiovascular risk profile and endothelial damage prevails. The heparin-binding growth factor midkine stimulates neo-angiogenesis in ischemic diseases, coordinates neutrophil influx, and raises blood pressure through stimulated angiotensin synthesis.

Methods

We determined changes of midkine serum levels during hemodialysis sessions under the assumption that endothelial cell-derived midkine is released. Periprocedural differences (?midkine) were calculated and correlated with cardiovacular biomarkers and fluid status (clinical assessment, V. cava collapse, comet tail phenomenon), cardiovascular morbidities, mortality rates. Blood was collected before and after dialysis from hemodialysis patients (n?=?171; diabetes: n?=?70; hypervolemia: n?=?83; both: n?=?32).

Results

Baseline midkine levels were?~?fourfold elevated compared to healthy controls (n?=?100). Further, on average a tenfold rise was detected during dialysis, the extent of which was partially related to non-fractionated heparin application (r²?=?0.17). Inter-individual differences were highly reproducible. Hypervolemic patients responded with a less than average rise in midkine levels during dialysis (p?<?0.02), this difference became more obvious with co-existing diabetes (p?<?0.001 for long dialysis-free interval) and was confirmed in an independently enrolled dialysis cohort (n?=?88). In Kaplan Meier survival curves, low delta midkine levels correlated with cardiovascular/overall mortality rates, similar to elevated uPAR levels, whereas other markers (NTproANP, galectin, tenascin-C) were less predictive. Following intervention with successful fluid removal in hypervolemic dialysis patients to optimize fluid homeostasis, midkine values increased (p?<?0.002), which was not observed in patients that failed to decrease weight.

Conclusion

Thus, for dialysis patients inadequate periprocedural midkine upregulation is linked with hypervolemia and associates with cardiovascular events.

     

Causes of renal forniceal rupture

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Renal forniceal rupture is a common finding in patients with ureteral obstruction. It is thought to be due to increased renal pelvis pressure from backup of urine, causing one or more renal fornices to leak urine. This phenomenon has not been systematically studied. Herein we retrospectively review the causes and associated clinical findings in over 100 cases of renal forniceal rupture.

OBJECTIVE

? To perform a retrospective review aiming to identify causes of renal forniceal rupture.

PATIENTS AND METHODS

? A retrospective review was performed of the longitudinal medical record and CT records for patients identified as having renal ‘forniceal rupture’ or ‘calyceal rupture’ using a radiological database.

RESULTS

? In total, 108 patients were identified with the CT diagnosis of renal ‘forniceal’ or ‘calyceal’ rupture. ? Forniceal rupture was caused by ureteric stones in 80 cases (74.1%), malignant extrinsic ureteric compression in nine cases (8.3%), benign extrinsic ureteric compression in two cases (1.9%), pelvic‐ureteric junction obstruction in two cases (1.9%), vesico‐ureteric junction (VUJ) obstruction in one case (0.9%), bladder outlet obstruction in one case (0.9%) and iatrogenic causes in four cases (3.7%). ? No definitive cause was found in nine cases (8.3%). For patients in whom a ureteric stone was the cause of forniceal rupture, the level of obstruction was proximal ureter in 24.3% of cases, distal ureter in 17.6% of cases and VUJ in 58.1% of cases. ? Mean (sd ) stone size was 4.09 (2.0) mm. Mean (sd ) stone size was 5.34 (1.87) mm for proximal stones, 4.08 (1.69) mm for distal stones and 3.53 (1.96) mm for VUJ stones (P= 0.005). ? Urinary tract infection was present in five out of 97 patients (5.2%) in whom data were available for analysis.

CONCLUSION

? The most common aetiology of renal forniceal rupture is obstruction caused by distal ureteric stones followed by malignant extrinsic ureteric compression.