Metastatic renal clear cell carcinoma mimicking stage IV lung cancer

We present a 63-year-old man who wasinvestigated for a lesion in the apex of theleft lung and a coexisting osteolytic lesion inthe right major trochanter. FNA of the thoracicmass was suggestive for malignancy yet notdiagnostic regarding the tumor type and thesite of the primary tumor. A diagnosis of astage IV lung cancer was favored and heunderwent a left exploratory thoracotomy inview to resect the primary tumor. Anextrapulmonary mass localized to the pleura notinvolving the ipsilateral lung was disclosed.Multiple biopsies revealed metastatic clearcell RCC. A 5×7 cm left renal tumor wasrevealed in a postoperative abdominal CT scan.He was treated with combination of interferon Aand vinblastin followed by radical nephrectomy.Twenty-four months after the diagnosis he is alivewithout evidence of local or distant recurrence.Pleural metastases from RCC are mainlypresented as malignant pleural effusions.Thoracic metastatic lesions localized to thepleura, forming solitary or multiple mass(es)have been rarely reported. We review theliterature regarding this rare clinicalmanifestation of the disease and we discussdiagnostic and therapeutic options.     

Posterior nutcracker syndrome with left renal vein duplication: An uncommon cause of hematuria

INTRODUCTIONPosterior Nutcracker syndrome (NCS) is a rare anomaly in which the left renal vein passes behind the aorta which compresses it against the vertebral column, restricting the venous drainage of the left kidney.PRESENTATION OF CASEA 46 year-old lady presented with intermittent painless hematuria for 6 years. Urinalysis showed microscopic hematuria. An abdominal CT scan showed left renal vein duplication with the retroaortic branch trapped between the vertebral column and the aorta at the level of the aortic bifurcation, suggestive of posterior NCS. There were multiple small cortical cysts, sand-like stones in the left kidney and duplication of both right and left renal arteries.DISCUSSIONPosterior NCS in a patient with a duplicated left renal vein may not show all the clinical features of a typical NCS as the elevated pressure due to compression is dissipated through the pre-aortic branch of the duplicated renal vein. CT Angiography can be helpful in such a patient with multiple abnormalities. Management can range from simple surveillance to nephrectomy depending on the symptoms and renocaval pressure gradient.CONCLUSIONAlthough posterior NCS is a rare anomaly of the left renal vein, it should be considered in the differential diagnosis of haematuria.     

Influence of renal nerves on renal function during development

The present review summarizes recent studies describing the role of renal sympathetic innervation in the regulation of renal function during development. The afferent renal innervation appears early during fetal life and probably precedes the development of efferent renal nerves. There is suggestive evidence that renal nerves are required for the proper development of the kidney and that neurotrophic growth factors play an important role in renal embryogenesis and in renal tubular differentiation. Renal sympathetic innervation modulates renal hemodynamics early during development. Renal nerve stimulation during -adrenoceptor blockade produces renal vasodilation in fetal and newborn animals but not in adults. Unlike the effect of renal nerves on fetal renal hemodynamics which is observed in the young fetus, the role of renal sympathetic nerves in modulating fluid and electrolyte homeostasis seems to develop during late gestation. Recent studies have also shown that renal nerves play an important role in regulating renin secretion during the transition from fetal to newborn life. For example, renal denervation during fetal life suppressed the physiological rise in plasma renin activity associated with delivery and decreased renal renin mRNA levels after birth. Taken together, these studies suggest that renal nerves influence fetal renal development and that the influence of renal sympathetic innervation on renal hemodynamics and function changes with maturation.     

肢体缺血后处理和肾脏缺血后处理对大鼠肾脏缺血-再灌注损伤的影响

目的 探讨肢体缺血后处理和肾脏缺血后处理对大鼠肾脏缺血-再灌注(I-R)损伤的影响.方法 24只大鼠随机均分为假手术组(S组)、缺血-再灌注组(I-R组)、左下肢缺血后处理组(LIP组)及肾脏缺血后处理组(RIP组).S组仅对左肾动脉进行游离;I-R组:夹闭左肾动脉45 min后松开,左肾再灌注6 h;LIP组在左肾复灌前6 min时左股动脉夹闭5 min;RIP组在左肾缺血45min后灌注10 s,停灌10 s,反复6次;检测复灌6 h时血清肌酐(Cr)、血尿素氮(BUN);光镜下观察肾组织病理改变,TUNEL法检测肾组织中凋亡细胞并计算凋亡指数(AI);免疫组化法检测肾组织Fas、Caspase-3表达;电镜下观察肾单位超微结构改变.结果 与S组比较,其他三组大鼠BUN、Cr浓度升高(P<0.01)、肾组织病理改变明显、肾组织Fas、Caspase-3阳性指数和AI增加(P<0.01).与I-R组比较,LIP、RIP组大鼠BUN、Cr浓度降低(P<0.01),肾组织Fas、Caspase-3阳性指数和AI降低(P<0.01).RIP组AI明显低于LIP组(P<0.05).结论 在肾脏I-R损伤的病理过程中,肾小管上皮细胞凋亡可以由胞膜上的Fas被激活而最终导致靶细胞凋亡;两种后处理都可以抑制肾小管上皮细胞凋亡,减轻I-R损伤.     

Unilateral renal angiodysplasia in a girl with hypertension

We report a case of very unusual renal vascular anomaly: angiodysplasia. The patient suffered from acute pyelonephritis immediately after birth. Renal ultrasonography, performed at age 1 day, revealed an enlarged left kidney with heterogeneously increased echogenicity, which involuted rapidly in 3 months. At age 10 years, she presented with severe hypertension during a course of acute pyelonephritis. Peripheral plasma renin activity was high. Computed tomographic angiogram revealed a very small but functioning left kidney. A single, narrow, left renal artery did not have focal stenosis. Pathology examination revealed dysplastic arterioles at the subcapsular area. After left nephrectomy, the blood pressure and the plasma renin activity were normalized. In conclusion, this is an unusual case of renal angiodysplasia, which induced renin-dependent hypertension.     

Renal cell carcinoma originating in a renal cyst in a 12-year-old girl

We report a 12-year-old girl with renal cell carcinoma originating in a cyst of the left kidney. Ultrasonography revealed 2 small hyperechoic masses in the luminal side of a cyst. Although hypervascularity was not detected in the cyst by computed tomography, the possibility of malignancy could not be ruled out because of the presence of 2 solid masses. Therefore, partial left nephrectomy was performed. On histopathologic examination, the 2 solid masses within the cyst were found to be renal cell carcinoma. This patient remains disease-free at 4 years after partial nephrectomy.     

Bilateral multifocal renal oncocytoma

Renal oncocytoma is a rare benign tumor. Bilateral and multifocal renal oncocytoma has rarely been described in childhood. We report a 12-year-old girl who presented with massive left renomegaly and who was found to have bilateral cystic kidneys. A left nephrectomy was undertaken because of the renal enlargement, the radiological evidence of extensive disease, and to make a diagnosis. A diagnosis of multifocal oncocytoma was made after detailed histological examination.     

离体肾动脉瘤修补、肾动脉重建和自体肾移植治疗复杂性孤肾肾动脉瘤一例并文献复习

目的探讨离体肾动脉瘤修补、肾动脉重建和自体肾移植技术治疗复杂性孤肾肾动脉瘤的安全性和可行性。方法CT血管造影（CTA）确诊复杂性孤肾肾动脉瘤1例,病变位于肾动脉主干分叉部,累及节段分支动脉,深入肾门内。肾脏暂时性离体后,在低温和肾脏灌注液灌注保护肾脏的前提下,体外进行肾动脉瘤修补和自体大隐静脉肾动脉重建,然后将肾脏异位移植到右侧髂窝。结果手术成功,围手术期无严重并发症发生。术后血肌酐暂时性升高至约200μmol／L,半个月后逐渐恢复正常;术后2周复查CTA示右髂窝移植肾动脉及其分支血流通畅无狭窄,肾静脉回流通畅,输尿管无狭窄。结论该方法治疗复杂性孤肾肾动脉瘤安全可行,并为以后类似的复杂性肾脏疾病的处理提供了可行方法。     

Xanthogranulomatous pyelonephritis-mimicking renal mass in 5-month-old child

Xanthogranulomatous pyelonephritis is a rare, chronic inflammatory lesion of the kidney associated with chronic infection and obstruction. It is uncommon in children and extremely rare in infants. Because of its rarity, the condition is often not considered in the differential diagnosis of a renal mass in children. We report a case of a 5-month-old boy presenting with fever and a left renal mass. The findings from radiologic investigations were suggestive of a renal mass and urine culture suggestive of urinary tract infection. Left radical nephrectomy was performed with difficulty because of the dense adhesions to the adjacent structures. Histopathologic examination confirmed the diagnosis of xanthogranulomatous pyelonephritis.     

Waardenburg syndrome associated with bilateral renal anomaly

A 1-year-old girl with Waardenburg syndrome type I presented with double collecting system of left kidney accompanied by nonobstructive hydronephrosis of lower pole and by ureteropelvic junction obstruction of right kidney. Renal involvement in Waardenburg syndrome was reported once in a 4-month-old boy with unilateral duplication of the renal collecting system and in a 16-day-old girl who had right multicystic dysplastic kidney and hydronephrosis in the left kidney. The third case of renal involvement in Waardenburg syndrome is presented here, with special emphasis on early diagnosis and management of renal anomaly. The authors conclude that urinary system anomalies should also be considered in the wide spectrum of Waardenburg syndrome clinical features to avoid life-threatening complications.     

Reliability of renal ultrasound measurements in children

The aim of the investigation reported here was to assess the intraobserver and interobserver variability of renal measurements in children. The study comprised 56 paired measurements in 28 children (median age 7.5 years, range 3.0–15.0 years) without renal or ureterovesical anomalies. Intraobserver and interobserver reproducibility was assessed by repeated measurements of the left and right renal length, width, and thickness. Intraclass correlation coefficients (ICCs) with the corresponding 95% confidence interval (CI) were calculated. Bland and Altman plots were computed to assess the agreement of the measurements. Limits of agreement ± 2 standard deviations (SD) for the mean differences in renal measurements were derived. Intraobserver ICCs ranged from 0.93 (left and right renal width and right renal thickness) to 0.99 (left renal length), and interobserver ICCs ranged from 0.64 (right renal thickness) to 0.90 (right renal length). Limits of agreement in the Bland and Altman plots ranged from −8.0 to 9.2% (intraobserver left renal width) to the widest limit from −18.0 to 19.2% (interobserver left renal length). Overall, this study demonstrated the good reproducibility and agreement of most renal dimensions in children measured by ultrasound (US). Based on these results, we conclude that US is an appropriate measure to assess renal dimensions in both clinical and epidemiological studies.     

Case report: Leiomyosarcoma of the renal pelvis

We present a new case of leiomyosarcoma, a very rare clinical entity, arising from the renal pelvis. The primary diagnosis, based on asymptomatic gross hematuria and imaging findings, was tumor of the left kidney. After a left radical nephro-ureterectomy, histology confirmed a leiomyosarcoma of the renal pelvis. No adjuvant treatment was provided and the patient remains healthy 3 years after surgery.     

A left circum-aortic renal vein aneurysm

A well-defined, slow-flowing vascular lesion was found incidentally by Doppler abdominal sonography in the left renal hilar region of a 36-year-old Taiwanese woman. Clinically, the physical examination and laboratory screening were unremarkable. A magnetic resonance angiography of the area near the renal hilum showed a saccular mass (3.5 × 3.1 × 2.5 cm) embracing the aorta by the anterior and posterior branch of the aneurysm originating from the left renal vein to the inferior vena cava. However, the patient refused further invasive intervention and has since been examined periodically by ultrasonography for 18 months without increasing size or symptoms.     

多靶点药物治疗晚期肾癌肾功能改善的临床观察

目的 总结多靶点药物治疗1例晚期双肾癌患者肾功能改善的效果. 方法 晚期双肾癌患者1例,男,60岁.腰痛1个月.B超及CT检查提示双肾癌.左肾肿瘤11.0 cm×9.4 cm×8.5 cm,右肾肿瘤3.5 cm×4.3 cm×4.1 cm,肾穿刺活检诊断为肾透明细胞癌.X线检查示肝及右下肺转移灶.实验室检查:左肾肾小球滤过率(GFR)20.39 ml/min,右肾25.40 ml/min.予多靶点药物索拉非尼400 mg,1～2次/d口服,共治疗12周. 结果 经索拉非尼治疗12周后.CT检查示左肾肿瘤缩小至9.0 cm×8.5 cm×7.4 cm,右肾肿瘤缩小至3.0 cm×3.6 cm×4.0 cm,病灶内部见液化坏死,未见新的转移灶.总肾GFR由治疗前45.79 ml/min升至71.38 ml/min,左肾GFR 31.57ml/min,较治疗前提高11.18 ml/min,右肾GFR 39.81 ml/min,较治疗前提高14.41 ml/min. 结论 多靶点药物治疗晚期肾癌可使肿瘤缩小,并改善肾功能.     

多层螺旋CT血管成像在肾静脉血栓诊断和治疗中的应用

目的探讨多层螺旋CT血管成像（multi-slice spiral CT angiography,MSCTA）在肾静脉血栓（renal vein thrombosis,RVT）诊断和治疗中的临床应用价值。方法收集首诊RVT患者8例,慢性期RVT并左肾静脉重度狭窄或闭塞患者5例,均行CT平扫、动脉期及静脉期增强扫描,采用容积再现（volume rendering,VR）血管生长技术（addvessel,AV）进行血管重建,分析RVT、肾静脉侧支循环表现。结果13例RVT患者中,首诊8例（双侧3例,左侧5例）,CT平扫呈均匀稍高密度影,增强扫描示肾静脉主干及分支内见充盈缺损影,4例血栓延伸至下腔静脉内,1例合并左腰静脉干、左睾丸静脉内血栓,1例左睾丸静脉侧支循环形成。慢性期5例,CT平扫左。肾静脉结构显示不清,左肾静脉主干4例不显影,1例细如线样,均显示左卵巢静脉曲张,右卵巢静脉、双侧髂内静脉侧支循环形成。结论MSCTA能准确诊断RVT及肾静脉侧支循环,指导临床制定治疗方案。     

腹腔镜活体供肾切取术中皮质肾单位及间质损伤的实验研究

目的研究腹腔镜猪活体供肾切取术中气腹高压、超声刀声热效应、机械挤压对皮质肾单位及肾间质的影响。方法将26只猪分成3组:腹腔镜下行左侧活体供肾切取术20只(腹腔镜组),采用14 mmHg CO2气腹压,根据手术时间长短又分为两组,其中手术时间300～360 min的10只设为A组,手术时间60～120 min的10只设为B组;余6只为C组(对照组),行开放手术切取左肾,手术时间60～120 min。手术结束时切除每只猪右肾保留左肾。三组均于开始手术时、手术结束时、术后30 d穿刺取左肾肾皮质组织于光镜及电镜下观察组织及其超微结构的改变,并比较三组间术后1 d、15 d、30 d血清肌酐水平。结果手术结束时A组、B组、C组每高倍视野有病理改变的肾小球中位数分别为3.5个、0、0.5个(H=13.475,P0.01);术后30 d分别为0.5个、0、0(H=0.325,P0.05)。手术结束时A组、B组、C组肾小管与肾间质有病变的猪只数分别为8只、2只、1只和8只、1只、0。电镜观察A组有阳性病变的肾组织:肾小球毛细血管袢血管腔扩张、其内有大量的红细胞,上皮细胞足突肿胀;肾近曲小管上皮细胞线粒体明显肿胀、嵴模糊断裂、空泡化;间质少量淋巴细胞浸润、毛细血管明显扩张、充血;肾小球及肾小管基底膜均完好。术后30 d均恢复正常。A组、B组、C组血清肌酐值在不同时间分别为术后1 d:(159±21)μmol/L、(110±10)μmol/L、(98±5)μmol/L(P0.05);术后15 d:(121±15)μmol/L、(101±8)μmol/L、(96±11)μmol/L(P0.05);术后30 d:(98±20)μmol/L、(112±12)μmol/L、(94±10)μmol/L(P0.05)。结论长时间(300～360 min)CO2高压气腹、超声刀声热效应、机械挤压可引起皮质肾单位轻微损伤,间质水肿、炎性浸润,上述损伤在无热、冷缺血及免疫因素影响时可自行修复逆转。     

活体肾移植供肾动脉解剖学特点及其处理的临床体会

目的 总结活体肾移植供者肾动脉解剖学特点及多支动脉供肾的手术处理方式.方法 分析我中心142例活体肾移植供者术前数字减影血管造影和CT血管成像的供肾动脉解剖结果.用6种不同方式对多支动脉供肾进行显微技术处理,比较供肾多支动脉受者(n=31)与供肾单支动脉受者(n=111)术后早期的临床疗效.结果 30.99%的供者存在肾脏多支动脉,两侧肾脏相似(左肾22.54%,右肾22.13%),在一侧存在时,对侧也存在的概率分别为56.25%和60.00%.左肾动脉主干稍粗(P=0.001)且主干上第1个分支距腹主动脉距离稍近(P=0.004).多支动脉组受者手术时间和供肾冷、热缺血时间延长,但在术中出血量、移植肾功能延迟恢复、急性排斥反应及移植肾彩超弓形动脉流速等方面与单支动脉组差异并无统计学意义.在术后7 d、1个月、3个月3个观察点2组受者血清肌酐和肌酐清除率相似,重复测量的方差分析还表明供肾是否为多支动脉对术后早期肾功能的变化趋势并无影响.结论 充分了解活体供肾的动脉解剖并采用正确的处理方式是保证移植效果的重要因素.     

A case of non-functioning adrenocortical adenoma associated with renal cell carcinoma

Left renal and left adrenal masses were incidentally found by computerized tomography (CT) in a 56-year-old man who was admitted to our hospital for treatment of upper digestive tract hemorrhage. Apparently no clinical signs suggestive of Cushing's syndrome existed. The renal tumor was diagnosed as renal cell carcinoma based on the findings on enhanced CT. 131I-adosterol uptake in the examination of adrenal scintigraphy under dexamethasone suppression was definitely increased in the left adrenal gland, although hormonal examinations of serum and urine for adrenal functions were within the normal range. Plasma adrenocorticotropic hormone (ACTH) and serum cortisol were suppressed by administration of 2 mg dexamethasone for 2 days. The left kidney was radically removed by surgery together with the left adrenal gland. Histological diagnoses were left renal cell carcinoma and adrenocortical adenoma.     

原发性肾窦肿瘤三例报告

目的 总结原发性肾窦肿瘤的临床特点及治疗方法.方法 原发性肾窦肿瘤患者3例.女2例,男1例.平均年龄40(33～55)岁.临床表现为腰痛伴血尿1例,单纯腰部疼痛2例.肿瘤位于右侧2例,左侧1例.直径平均5.5(3.5～8.5)cm.3例均经行手术治疗. 结果行右肾窦肿瘤探查术1例,术中病理提示良性肿瘤,单纯切除肿瘤,病理报告为血管平滑肌瘤,随访3年未见复发.1例术中因肿瘤出血及肾盂破坏严重,行右肾切除,病理报告为血管平滑肌脂肪瘤,随访10个月未见复发.1例因肿瘤包绕肾动静脉,局部严重黏连,行左肾切除术,病理报告为脂肪瘤,随访4年未见肿瘤复发.结论 原发性肾窦肿瘤临床罕见,多为良性,易误诊为肾盂肿瘤,CT、MRI、IVU检查有助于鉴别;良性肿瘤直径<4 cm且无症状者可密切随访,有症状或直径>4 cm者可行肿瘤切除;肿瘤累及肾蒂并严重破坏肾盂者可行单纯肾切除;恶性肿瘤应行根治性肾切除.