Renal pedicle injury in patients with multiple injuries

In a study of 41 patients seen over 24 years, renal pedicle injuries were associated with life-threatening multiple system injuries and the immediate surgical management of these associated injuries by general surgeons took precedence over that of the renal pedicle injury. The result was the delayed diagnosis of the renal pedicle injury with loss of function of the kidney. In an effort to improve the renal salvage rate aggressive management of renal pedicle injuries with immediate radiologic evaluation and early surgical treatment was instituted in 1969. The records of 41 renal pedicle injuries from 1959 to 1983 were evaluated. Blunt external trauma was the cause in 76%. All 41 patients had multiple system injuries, averaging 3.7 associated injuries per patient, with 35 (85%) having a laparotomy for intra-abdominal injuries and an overall mortality rate of 44%. Conservative management was followed in 13 patients, with injury to the renal artery in nine and a branch of the renal artery in four, with a renal loss/delayed nephrectomy rate of nine of nine (100%) renal artery injuries. Immediate surgical management was performed in 23 patients, with injury to the renal artery in nine, the renal artery and renal vein in four, a branch of the renal artery in two, and the renal vein in eight, with a renal salvage rate of seven of 21 (33%) renal artery and/or vein injuries. Five patients died on admission or on the operating room table. A significant renal salvage rate resulted from immediate radiologic evaluation and early surgical treatment of renal artery/vein injuries compared to zero salvage rate with conservative management.     

Experience of renal autotransplantation

We present 2 cases with renovascular hypertension treated by renal autotransplantation and 3 cases with extensive renal calculi treated by renal bench surgery and autotransplantation. The cases with renovascular hypertension were due to fibromuscular dysplasia in the trunk of renal artery, and return to normotension and improvement of renal function were obtained within a few days after the operation. In 2 of the cases with extensive renal calculi, the contralateral kidney was contracted. In all cases, the stones were removed completely and urinary tract infection persisting before operation was eradicated. The postoperative renal function was well preserved and no recurrence of renal calculi was observed throughout the follow up period. The indication of renal bench surgery and autotransplantation was discussed both for renal calculi and renovascular hypertension.     

Familial renal carcinoma: clinical evaluation, clinical subtypes and risk of renal carcinoma development

PURPOSE: Familial renal carcinoma is defined as families with 2 or more individuals with renal cell carcinoma without evidence of known hereditary renal carcinoma syndromes. To better characterize this familial cancer we reviewed renal carcinoma families evaluated at the National Cancer Institute between 1990 and 2004 to identify distinctive features of these families. We also determined the risk of renal carcinoma in first-degree relatives of affected family members. MATERIALS AND METHODS: We evaluated 141 at risk asymptomatic relatives of affected individuals from 50 families with 2 or more members with renal carcinoma. Histology slides of renal tumors from affected family members were reviewed. At risk members from renal carcinoma families were screened for occult renal neoplasms by renal ultrasound and computerized tomography. DNA from select families was tested for germline mutations of known renal carcinoma genes when clinically indicated and constitutional cytogenetic analysis was performed to search for germline chromosome alterations. RESULTS: Familial renal carcinoma families could be subdivided into subtypes based on tumor multiplicity and renal tumor histology. Of 141 at risk members of renal carcinoma families screened for occult renal tumors 2 were found to have occult renal tumors, which were identified as renal oncocytoma and a solid tumor that was not resected, respectively. No histologically confirmed occult renal carcinomas were detected in at risk family members. Several families previously classified as having familial renal carcinoma were found on further evaluation to have hereditary renal cancer syndromes. CONCLUSIONS: Familial renal carcinoma is a heterogeneous clinical and pathological entity. Familial renal carcinoma was subdivided into groups based on tumor multiplicity and tumor pathology. The empirical risk of histologically documented renal carcinoma in first-degree relatives who were members of familial renal carcinoma families was less than 1:141. One renal oncocytoma and 1 small solid renal tumor were detected.     

Renal transplantation in a patient with lipoatrophic diabetes. A case report.

A patient with congenital generalized lipodystrophy developed nephrotic syndrome with progressive renal glomerulosclerosis attributed to diabetic nephropathy. Renal transplantation was performed and the patient was discharged with normal renal function. Marked hyperlipidemia (17,500 mg/dl) persisted. One month later renal malfunction developed, and an open renal biopsy was performed when there was no response to antirejection therapy. Massive lipid deposition in renal tubular cells with tubular necrosis and hemorrhage was present but only minimal evidence of graft rejection. Rejection therapy was tapered and renal function stabilized. Death occurred 2 months later because of pulmonary sepsis. Patients with generalized lipodystrophy and severe hyperlipidemia may be at an unusually high risk for renal homograft destruction.     

The effects of nifedipine on blood pressure and renal function

The effects of nifedipine (NIF) on blood pressure and renal function were examined in control spontaneously hypertensive rats (SHR) (group A), SHR with moderate renal dysfunction (group B), and those with severe renal dysfunction (group C). The hypotensive effect of NIF administration was greater in SHR with severe renal dysfunction, and this might relate with pharmacokinetics of NIF, decreased sensitivity of baroreflex and low plasma renin activity in SHR with reduced renal function. When mean arterial blood pressure (MAP) was reduced by about 30% in these three groups, the baseline renal function was maintained and natriuresis was observed in group A and B, whereas the renal function and urine volume decreased transiently, and urinary sodium excretion tended to decrease in group C. In hypertensive patients with normal renal function (group I), moderate renal dysfunction (group II), and severe renal dysfunction (group III), 5 or 10 mg NIF was orally administered. In these three groups, MAP was reduced by about 20%. In group I, glomerular filtration rate tended to increase, renal plasma flow increased and natriuresis was observed. In group II and III, renal function didn't decrease with few exception, but when MAP was reduced by about 30%, renal function decreased in three of five cases. Also on long-term administration of NIF in hypertensive patients, renal function improved. The results suggests that NIF by single administration or long-term administration is effective on hypertensive patients with renal dysfunction, but we should be cautious to decide the dose of NIF and the rate of blood pressure reduction.     

鹿角形肾结石合并肾盂癌的诊治

目的:提高鹿角形肾结石合并肾盂癌的诊治水平。方法:回顾性分析16例鹿角形肾结石合并肾盂癌患者的临床资料。结果:16例患者中,13例行CT检查,确诊4例;2例行MRI检查,确诊1例。术前确诊的5例患者行根治性肾输尿管切除加膀胱袖状切除。5例分别于开放手术或PCNL术中发现新生物,活检证实后行根治性肾切除加输尿管部分切除。1例行经皮肾镜取石术(PCNL)者后2个月再次手术时发现转移而被迫放弃手术。5例无功能肾者于肾切除术后常规病检发现合并肾盂癌。病理检查证实为鳞状细胞癌12例,移行细胞癌3例,腺癌1例。获随访10例,随访时间1~35个月,死亡7例,术后生存时间1~27个月。结论:鹿角形肾结石合并肾盂癌诊断困难,预后差。对结石病史长、合并感染或肉眼血尿者,术前应考虑合并肾盂癌的可能。CT与MRI检查对诊断鹿角形肾结石合并肾盂癌有重要价值;对术前未确诊而又怀疑结石合并肾盂癌患者,建议行开放手术,勿选PCNL。     

Prevalence of microscopic tumors in normal appearing renal parenchyma of patients with hereditary papillary renal cancer

PURPOSE: We describe the earliest renal lesions associated with hereditary papillary renal cancer and estimate the prevalence of microscopic papillary renal tumors. MATERIALS AND METHODS: Grossly normal tissue was obtained from 12 kidneys during renal surgery in 9 patients with hereditary papillary renal cancer. Tissue was examined microscopically and findings were compared to those previously reported to be associated with von Hippel-Lindau disease and sporadic renal cell carcinoma. RESULTS: A total of 92 microscopic papillary renal cell carcinoma lesions were identified on 46 of 88 slides (53%). No other lesions were identified. All tumors were solid and displayed the basophilic papillary histology characteristic of hereditary papillary renal cancer. Extrapolation of the data predicted the prevalence of 1,100 to 3,400 microscopic papillary tumors in a single kidney in a patient with hereditary papillary renal cancer. CONCLUSIONS: The basophilic papillary histology characteristic of clinically apparent renal tumors in patients with hereditary papillary renal cancer also characterizes the multiple microscopic lesions seen in the kidneys. These findings suggest that the earliest renal tumor in patients with an activating hereditary mutation of the met gene is papillary basophilic renal cancer. The large number of microscopic tumors in patients with hereditary papillary renal cancer was comparable to or greater than that seen in those with von Hippel-Lindau disease.     

Parenchymal sparing surgery in patients with hereditary renal cell carcinoma: 10-year experience

PURPOSE: von Hippel-Lindau disease, hereditary papillary renal cell carcinoma, the Birt-Hogg-Dubé syndrome and familial renal oncocytoma are familial renal tumor syndromes. These hereditary disorders are noteworthy for the development of multiple bilateral renal tumors and the risk of new tumors throughout life. One management strategy is observation of solid renal tumors until reaching 3 cm, then performing parenchymal sparing surgery. We present a 5-year update on our experience. MATERIALS AND METHODS: From May 1988 to October 1998, 49 patients with hereditary renal cell carcinoma, including von Hippel-Lindau disease in 44, hereditary papillary renal cell carcinoma in 4 and the Birt-Hogg-Dubé syndrome in 1, and 1 with familial renal oncocytoma underwent exploration to attempt renal parenchymal sparing surgery. Patients were followed prospectively with periodic screening for recurrence, metastasis and loss of renal function. Median followup was 79.5 months (range 0.7 to 205). RESULTS: A total of 50 patients underwent 71 operations resulting in unilateral nephrectomy in 6, bilateral nephrectomy in 1 and partial nephrectomy in 65, with 1 to 51 tumors removed from each kidney (mean 14.7). Mean patient age was 39.5 years (range 18 to 70). Of the 65 (40%) partial nephrectomies 26 were performed with cold renal ischemia. Mean blood loss was 2.9 +/- 0.5 l (range 0.15 to 23). Postoperative complications included renal atrophy in 3 patients. Mean preoperative serum creatinine was 1.05 +/- 0.03 mg/dl (range 0.6 to 1.8), and postoperative creatinine was 1.06 +/- 0.04 mg/dl (range 0.6 to 2.0). No patient who underwent renal parenchymal sparing surgery required renal replacement therapy. Metastatic disease developed in 1 patient with a 4.5 cm renal tumor. CONCLUSIONS: Parenchymal sparing surgery with a 3 cm threshold in patients with hereditary renal cancer appears to be an effective therapeutic option to maximize renal function while minimizing the risk of metastatic disease.     

Primary hyperparathyroidism: Renal calcium excretion in patients with and without renal stone disease before and after parathyroidectomy

The effect of parathyroidectomy on renal calcium excretion per 24 hours in patients with primary hyperparathyroidism with and without a history of renal stone disease was evaluated. Altogether, 91 patients operated on for primary hyperparathyroidism formed the study group for preoperative analysis. Of these patients, 42 were evaluated 1 to 3 years postoperatively. The median preoperative serum calcium level was 2.92 mmol/L, and it was the same for patients with or without renal stones. Preoperatively we found no differences in renal calcium excretion between patients with and without renal stone disease. The median renal calcium excretion was 6.80 mmol/24 hr. At 1 to 3 years after successful parathyroidectomy the group with renal stone disease had higher renal calcium excretion than the group without renal stones (p = 0.03). The reduced effect of parathyroidectomy on renal calcium excretion in the patients with renal stone disease indicates that factors not related to the hyperparathyroid state could contribute to disturbances in renal calcium excretion and hence stone formation. In conclusion, the pathologic basis for renal stone formation in patients with primary hyperparathyroidism might not be the hyperparathyroid state alone; stone formation could be related to other predisposing factors as well. Therefore, although parathyroidectomy can cure hyperparathyroidism, the curative effect on renal stone disease should be reconsidered.     

腹腔镜下根治性肾切除并肾静脉及腔静脉取栓术

目的 探讨腹腔镜下根治性肾切除并肾静脉及腔静脉取栓术的可行性. 方法 右肾占位病变患者2例.增强CT显示1例肿物部分延伸至肾静脉及腔静脉内,1例右肾静脉内可见充盈缺损并突入腔静脉内.均在全麻下行经后腹腔镜下根治性右肾切除及肾静脉、腔静脉取栓术.术中放置4个穿刺套管针,切断肾动脉后游离腔静脉及肾静脉,腔镜血管阻断钳部分阻断腔静脉,切开腔静脉取出瘤栓,缝合腔静脉,完整切除肾脏及瘤栓. 结果 2例患者的腔静脉瘤栓长度分别为0.3和1.0 cm,均安全取出,术后恢复良好,5 d出院.病理诊断分别为上皮样肾血管平滑肌脂肪瘤和肾透明细胞癌1～2级.术后随访5个月未见肿瘤复发和转移. 结论 对选择性肾肿瘤并肾静脉及腔静脉瘤栓患者行腹腔镜下根治性肾切除并肾静脉及腔静脉取栓术安全可行.     

Impact of microvascular injury on IgA nephropathy associated with malignant hypertension: a preliminary study

ObjectiveTo observe the vascular lesions of renal small arteries and arterioles as well as clinco - pathological characteristics among patients with IgA nephropathy associated with malignant hypertension (IgAN-MHT). To explore the clinical significance of peritubular capillary (PTC) loss and renal tubulointerstitial macrophage infiltration in the same population. MethodsThirty - four (1.9%) IgAN-MHT patients were diagnosed among the 1765 cases of primary IgA nephropathy in Peking Union Medical College Hospital from January 2003 to March 2012. Their clinical records were reviewed and the lesions of glomeruli, tubules, interstitium and renal vessels were semi-quantitatively re-evaluated. PTC and renal tubulointerstitial macrophages were demonstrated by immunohistochemical staining. ResultsThe IgAN-MHT patients were mainly young males with very high blood pressure. They had variant renal function impairment and urinary protein excretion. Acute and chronic vascular changes coexisted in the renal small arteries and arterioles, but all the vascular lesions failed to correlate with renal function. The renal tubulointerstitial macrophage infiltration was prominent and correlated well with renal function. PTC loss was also prominent and the PTC proportion was correlated with renal function. ConclusionsIn IgAN - MHT patients, the renal vascular changes do not correlate with renal function, but PTC loss and renal tubulointerstitial macrophage infiltration are both prominent and may reflect renal function impairment.     

移植肾动脉瘤五例报告

目的 探讨移植肾动脉瘤(RAA)的病因、诊断及治疗. 方法 1998年8月至2004年12月共行同种异体肾移植手术1251例,发生RAA 5例(0.4%).5例均为男性,平均年龄43岁,移植肾血管吻合方式均为移植肾动脉一髂内动脉端端吻合.患者主要临床表现为进行性肾功能减退,突发少尿或无尿,顽固性高血压及肾区疼痛,均经彩色多普勒超声、数字减影血管造影检查确诊为动脉瘤,动脉瘤大小1.8 cm×2.0 cm×2.0 cm～4.0 cm×4.0 cm×5.0 cm. 结果 移植肾动脉吻合口动脉瘤2例,1例发现动脉瘤后1个月内移植肾功能丧失,行移植肾切除术,术后规律透析治疗,随访1年后行二次肾移植;1例移植肾失功后1周内行对侧髂窝二次肾移植手术,保留原移植肾,术后随访2年肾功能正常.RAA合并近端移植肾动脉狭窄2例,1例行吻合口球囊扩张并放置支架后,以弹簧螺圈栓塞动脉瘤,术后随访1年肾功能稳定;1例行移植肾切除、二次.肾移植术,术后随访3年肾功能正常.吻合口髂内动脉侧粥样硬化斑块导致髂内动脉狭窄、移植肾动脉侧动脉瘤1例,行移植肾切除术,术后2 d因脑干栓塞死亡. 结论 移植肾动脉-髂内动脉端端吻合易诱发血管并发症,RAA治疗应谨慎采用开放手术切除,可选择近期行二次肾移植和血管内介入治疗.     

Dimercaptosuccinic acid (DMSA) renal scan in the evaluation of hypertension in children

Renal scarring is known to be associated with hypertension. The primary objective of this study was to investigate the prevalence of renal scarring in children referred to our clinic with hypertension. The secondary objective was to compare renal ultrasound (US) examination with dimercaptosuccinic acid (DMSA) renal scan in diagnosing renal scars in these patients. The study included 159 patients who underwent DMSA renal scan as well as renal US for the evaluation of hypertension of unknown etiology. Thirty-three (21%) patients were found to have renal scars; their demographic details, including mean age and gender distribution, were not significantly different from those without renal scars. In comparison with the DMSA renal scan, sensitivity and specificity of renal US in diagnosing renal scars were 36% and 94%, respectively. In our study, in which the prevalence of scarring was 21%, this gave positive predictive and negative predictive values of 63% and 85%, respectively. In conclusion, our study indicates that renal scarring is present in 21% of otherwise healthy children who are evaluated for newly diagnosed hypertension, and renal US is not a sensitive imaging modality to rule out renal scarring.     

Indication, surgical technique and outcome of orthotopic renal transplantation

PURPOSE: We review the indication, surgical technique and outcome of orthotopic renal transplantation. MATERIALS AND METHODS: The medical records of 1,000 patients who underwent renal transplantation at our institution between August 24, 1993 and August 1, 2000, as well as orthotopic renal transplantation were reviewed. RESULTS: Orthotopic renal transplantation was performed in 4 males and 1 female with severe iliac atherosclerosis or retained bilateral iliac fossa kidney transplant. Mean patient age was 56 years. There were 2 patients who received kidneys from living related donors, and 3 underwent cadaveric renal transplantation. Left orthotopic renal transplantation was successful in 4 cases, and 1 was converted to iliac fossa renal transplant because of a pulseless splenic artery and renal artery thrombosis after native renal endarterectomy. Orthotopic renal revascularization was done with splenic artery in 2, native renal artery in 2 and left renal vein in all 4 patients. Urinary tract reconstruction was performed with stented (2) or nonstented (2) ureteroureterostomy. Antibody induction, purine antagonists, calcineurin inhibitors and glucocorticoids were used for immunosuppression. Mean preoperative and 1-month postoperative serum creatinine was 7.9 and 1.3 mg./dl., respectively. Patient and graft survival was 100% during followup, which ranged from 6 months to 5 years. CONCLUSIONS: Despite the technical challenges, orthotopic renal transplantation in patients with unsuitable pelvic vessels can result in excellent patient and graft survival.     

离体肾动脉瘤切除和自体肾移植术治疗复杂肾动脉瘤

目的 探讨手助腹腔镜法活体取肾、离体肾动脉瘤切除、肾动脉重建和自体肾移植技术治疗复杂性肾动脉瘤的安全性和可行性.方法 2006年10月收治1例42岁复杂性肾动脉瘤男性患者.术前彩超、CT及DSA检查显示左肾动脉瘤3.4 cm×4.3 cm×4.5cm大小,瘤内有部分血栓形成,位于左肾动脉主干分叉部,累及5支分支动脉,邻近肾门.患者有高血压病史,药物控制不佳.术中采用手助腹腔镜法活体取肾成功后,立即对离体肾脏采用4℃肾脏保存液灌注,低温保护肾脏.体外进行肾动脉瘤切除:切取自体右髂内动脉体外行肾动脉重建,最后将肾脏异位移植至右侧髂窝.结果 患者手术成功,围手术期未出现并发症.术后.肾功能正常:彩超复查显示右侧髂窝移植肾动脉及其分支血流通畅无狭窄,肾静脉血流通畅,输尿管无狭窄.术后13个月随访,血压恢复正常,肾功能正常.结论 离体肾动脉瘤切除和自体.肾移植术治疗复杂性肾动脉瘤微创、安全、可行.     

先天性肾动静脉瘘的DSA诊断与治疗

目的提高先天性肾动静脉瘘的诊治效果。方法应用肾动脉数字减影血管造影（ＤＳＡ）超选择性肾动脉介入栓塞方法诊治先天性肾动静脉瘘３例。结果３例经ＤＳＡ明确诊断,在栓塞术后当日肉眼血尿消失,２４～７２小时后尿常规正常。术后７２小时内有腰酸痛、低热、腹胀,无肾性高血压发生。结论ＤＳＡ是明确肾动静脉瘘的最佳诊断方法,可同时进行超选择性肾动脉介入栓塞,既保存了肾功能又达到止血目的     

Renal parenchymal malacoplakia: a rare cause of ARF with a review of recent literature

Renal parenchymal malacoplakia is a rare cause of acute renal failure. Traditionally, it was associated with a high mortality rate and commonly resulted in renal failure requiring renal replacement therapy. The authors report on a 70-year-old woman who presented with acute renal failure caused by renal parenchymal malacoplakia. Her renal function recovered after levofloxacin treatment. All cases reported in the English-language literature since 1990, when fluoroquinolone was first used to treat malacoplakia, were reviewed. Although some patients still had renal failure, with renal biopsy and fluoroquinolone treatment, the patient mortality rate from renal parenchymal malacoplakia is remarkably low.     

A case of multiple renal leiomyoma located at renal sinus and hilus

A case of multiple renal leiomyoma of the right kidney in a 60-year-old woman, complaining of lower abdominal pain of two months duration, is presented. Ultrasonography, intravenous pyelography and CT scan showed the masses at the right renal sinus and hilus. Selective right renal angiography demonstrated very hypovascular tumors. Right radical nephrectomy was performed. There were two lobulated tumors with no connections, which were elastic hard in consistency and smooth in surface; one was 4 x 2 x 2 cm in size and located at the renal sinus between the upper and middle calyces, the other was 6.5 x 5 x 4 cm in size and located at the renal hilus, apart from the renal parenchyma, pelvis, artery and vein. Histological examination revealed these tumors to be benign leiomyoma. Both were covered with the Gerota's fascia, but not the renal capsule. The renal parenchyma was completely covered with the renal capsule histologically, although these tumors were closely attached to the parenchyma on gross examination. The tumor at renal sinus was considered to arise from the outer layer of the renal pelvis or from the blood vessel in the connective tissues at renal sinus. The tumor at renal hilus was considered to arise from the blood vessel in the connective tissues at renal hilus. This appears to be the first reported case as multiple renal leiomyoma in both Japanese and English literatures.     

供肾动脉带主动脉袖口预防移植肾动脉狭窄

目的:探讨供肾动脉带主动脉袖口预防移植肾动脉狭窄的效果。方法:对955例(1030例次)行肾移植患者的肾移植供肾动脉,全部采用主动脉袖口与受者髂内动脉吻合。应用彩色多普勒血流B超及移植肾动脉血管造影排除移植肾动脉狭窄。结果:955例(1030例次)肾移植无一例出现移植肾动脉狭窄。结论:供肾动脉带腹主动脉袖口可以防止移植后肾动脉狭窄发生。     

不同分级肾静脉瘤栓后腹腔镜左肾癌根治术的可行性

目的：探讨左肾癌伴有不同分级肾静脉瘤栓患者经后腹腔途径腹腔镜左肾癌根治术的可行性。方法：7例左肾占位伴左肾静脉瘤栓患者,增强CT显示7例肿物不均匀强化,并伴有。肾静脉内充盈缺损,均在全麻下行后腹腔镜左肾癌根治术。术中放置4个穿刺套管针,游离腹主动脉和肾动脉后,Hem-o-lok结扎切断。肾动脉,游离肾静脉后判断7例瘤栓均为非附壁瘤栓,上托肾脏,于肾静脉近下腔静脉处Hem—O—lok结扎切断。肾静脉,完整切除肾脏及瘤栓。我们根据左。肾静脉瘤栓长度进行分级,讨论不同分级患者手术难点及可行性。结果：7例手术均获成功,术后恢复良好。病理诊断为肾透明细胞癌6例,嫌色细胞癌1例。术后随访8个月（1～18个月）,未见肿瘤复发和转移。结论：对于选择性病例伴有不同分级的肾静脉瘤栓的左肾癌行经后腹腔途径腹腔镜左肾癌根治术可行,但随瘤栓分级增加手术难度增大。