Renal autotransplantation for complex renal arterial disease: a case report

A renal artery aneurysm in a stenotic renal artery is a rare clinical entity with an incidence of 0.015% to 1% in patients with renovascular hypertension. Interventional stent placement is the first line of treatment for simple aneurysms of the proximal renal artery. However, renal autotransplantation has been used as an alternative treatment for complex lesions and for lesions originating from the distal renal artery. We present a patient with a renal artery aneurysm, renal artery stenosis of the segmental branches of the left kidney, and occlusion of the right renal artery. The surgical strategy included renal explantation, ex vivo renal preservation, ex vivo reconstruction of the 2 renal artery branches, and renal heterotopic autotransplantation. We conclude that renal autotransplantation is a safe and effective surgical procedure for patients with complex renal arterial disease.     

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.     

核素肾动态显像对宫颈癌患者肾功能及形态检测的评估

目的探讨^99m锝-喷替酸（^99mTc-DTPA）肾动态显像在宫颈癌患者肾功能及形态检测中的应用价值。方法对确诊宫颈癌患者230例分别行双肾B型超声、血肌酐、^99mTc—DTPA肾动态显像。通过对三种检查结果的比较,评价^99mTc-DTPA肾动态显像在宫颈癌患者肾功能及形态检测中的应用价值。结果所有患者的血清肌酐均正常,未检出肾功能异常。双肾B超检出肾积水24例、肾囊肿10例、肾结石5例、单侧肾小20例、双侧肾小8例。^99mTc—DTPA肾动态显像检出单侧或双侧肾小球滤过率（GFR）下降共74例,单侧或双侧肾积水共42例,单侧或双侧肾盏。肾盂排泄欠通畅115例,肾囊肿3例,单侧或双侧肾小28例,双侧肾大11例。结论^99mTc—DTPA肾动态显像能更精确的评价肾功能,同时能了解肾的形态学变化。在宫颈癌的治疗中,^99mTc—DTPA肾动态显像是一项能较全面评价肾脏情况的检查方法。     

Evaluation of renal masses including retrograde renal brushing.

1.The evaluation of renal masses has become an increasingly important topic because of the increasing incidence of kidney cancer, the improved cure rate of renal carcinoma with the proper preoperative diagnosis, and the proliferation in renal mass diagnostic methodology. 2. A variety of benign entities can produce an abnormal renal mass with attendant difficulties in being distinguished from malignant neoplasms. Among these benign lesions are: simple renal cysts, polycystic kidneys, congenital variations in renal size and shape, segmental renal hypertrophy, renal infarcts, intrarenal hematomas, renal hamartomas, renal leiomyomas, renal adenomas, renal angiomas, renal fibrolipomatosis, hydronephrosis of a duplicated collecting system, renal abscesses, and xanthogranulomatous pyelonephritis. 3. Nephrotomography, nephrosonography (ultrasound), adrenalin renal arteriography, selective magnification renal arteriography, renal venography and cavography, lymphangiography, renal scintillation scanning, abnormal levels of enzymes in blood and urine, immunologic studies (circulating antibodies and tumor-associated antigens), percutaneous needle aspirations, and retrograde renal brushing have all increased the diagnostic accuracy of determining the etiology of renal masses. None of these diagnostic procedures is infallible. A judicious combination of procedures gives the most reliable diagnostic results. 4. A search continues for (a) chemical agent(s) or a chemical profile in the blood or urine which is (are) specific for renal carcinoma, but as yet this is an investigational area and not a practical clinical reality.     

Renal sinus involvement in renal cell carcinomas

The renal sinus is the fatty compartment located within the confines of the kidney not delineated from the renal cortex by a fibrous capsule. Because it contains numerous veins and lymphatics, invasion into this compartment may permit dissemination of a tumor otherwise regarded as renal-limited. Thirty-one consecutive renal carcinomas were studied: 22 clear cell renal cell carcinomas (3 multilocular cystic renal cell carcinomas), 4 chromophobe renal carcinomas, and 5 papillary renal carcinomas. The entire interface between the neoplasm and the sinus was embedded. Seventeen carcinomas did not invade the renal sinus and 16 were pT1 or pT2 tumors. Fourteen carcinomas, 13 clear cell renal cell carcinoma and one chromophobe renal carcinoma, invaded the renal sinus fat, and 9 of 14 invaded the lumen of renal sinus veins (all clear cell renal carcinomas). Although 14 of 22 clear cell renal carcinomas appeared to be renal limited pT1 and pT2 cancers, 6 of 14 carcinomas invaded sinus fat and 4 invaded into the lumen of renal sinus veins. Compared with the nine sinus-negative clear cell renal cell carcinomas, the 13 sinus-positive cancers were larger, exhibited more frequent renal capsule and renal vein involvement, and had higher nuclear grades. Renal sinus invasion was most common in clear cell renal cell carcinomas but was uncommon (one in 12) in 3 more indolent renal cell carcinomas: multilocular cystic renal cell carcinoma, chromophobe renal carcinoma, and papillary renal carcinoma. The follow-up period was short (1-17 months), but metastases developed in four of 31 cases. In three cases with metastases, carcinoma had involved the lumen of sinus veins but not the main renal vein, although two of three had also invaded through the renal capsule. This study shows that in carcinomas which appear to be renal limited (pT1/pT2), seven of 23 (30.4%) had invaded sinus fat and four of 23 (17.4%) had invaded sinus veins. We conclude that renal sinus invasion, especially sinus vein invasion, could identify a patient at risk for metastases even in a putative renal limited tumor, and suggest that all cases be examined for this feature. Renal sinus invasion merits further investigation to establish its prognostic importance and possible incorporation into future revisions of the TNM staging system for renal cell carcinomas.     

Nephron Sparing Surgery for De Novo Renal Cell Carcinoma in an Allograft Kidney: A Case Report

De novo renal cell carcinoma in a renal allograft is rare and has special implications in renal transplant recipients. We describe a patient with a renal allograft who developed a de novo renal cell carcinoma in the functioning renal allograft 258 months after transplantation. The patient underwent enucleation of the tumor because preoperative MRI showed it was well-encapsulated. A DNA banding study showed that the tumor originated from the donor. Indications for conservative renal surgery in renal cell carcinoma have been increasing. Accordingly, 1 option in the treatment of de novo renal cell carcinoma in a functioning renal allograft is enucleation as a method of nephron sparing surgery.     

KIT and RCC are useful in distinguishing chromophobe renal cell carcinoma from the granular variant of clear cell renal cell carcinoma

The distinction between chromophobe renal cell carcinoma, the granular cell variant of clear cell renal cell carcinoma, and renal oncocytoma is a common diagnostic dilemma. The usefulness of KIT, CD10, RCC, and RON in the differential diagnosis of these renal epithelial tumors was investigated. KIT was 100% positive in chromophobe renal cell carcinoma (11 of 11) and renal oncocytoma (12 of 12). The KIT staining pattern was identical in both tumor types, with cytoplasmic membrane attenuation, and fine granular cytoplasmic staining. In contrast, KIT was absent in all granular cell variants of clear cell renal cell carcinoma (0 of 6). RCC was observed in more than 80% of the granular cell variant of clear cell renal cell carcinoma (5 of 6) but was negative in all chromophobe renal cell carcinomas (0 of 11) and renal oncocytomas (0 of 12). CD10 was expressed in 100% of the granular cell variant of clear cell renal cell carcinoma (6 of 6), 72% of chromophobe renal cell carcinomas (8 of 11), and 58% of renal oncocytomas (7 of 12). RON was 100% positive in the chromophobe renal cell carcinomas (11 of 11) and renal oncocytomas (12 of 12) but only 50% positive in the granular cell variant of clear cell renal cell carcinoma (3 of 6). Colloidal iron was diffusely and strongly positive in more than 80% of the chromophobe renal cell carcinomas (9 of 11), focally and weakly positive in 41% of the renal oncocytomas (5 of 12) but negative in all granular cell variant of clear cell renal cell carcinoma (0 of 6). The above results demonstrate that: 1) KIT is a very sensitive marker for both chromophobe renal cell carcinoma and renal oncocytoma; 2) immunohistochemistry using antibodies to KIT combined with RCC was sufficient to discriminate between chromophobe renal cell carcinoma and the granular cell variant of clear cell renal cell carcinoma; and 3) neither RON, nor KIT, nor a combination of this panel can be used to distinguish chromophobe renal cell carcinoma from renal oncocytoma. Colloidal iron staining aided in this distinction for the majority of the chromophobe renal cell carcinomas (more than 80% positive) and renal oncocytomas (close to 60% negative).     

16层螺旋CT血管造影及三维重建技术在活体供肾动脉解剖学评估中的应用

目的 探讨16层螺旋CT血管造影在活体供肾动脉解剖学评估中的应用价值。方法 36名亲属活体供肾者在肾切取前进行肾动脉16层螺旋CT血管造影及血管三维成像，血管三维成像方法包括容积再现技术（VR）、最大密度投影（MIP）、表面遮盖成像（SSD）、血管内镜技术（CTVE）、多平面重建（MPR）及曲面重建（CPR）。结果 横断面CT及MPR显示所有供者的双肾大小、形态及位置均正常，肾实质密度正常，呈均匀强化。VR、MIP、CPR显示双肾动脉粗细、形态均正常；29例双肾均为单一肾动脉，2例双肾有2支肾动脉，2例左肾为2支肾动脉，3例右肾为2支肾动脉，上述结果均在术中得到证实。11例VR及MIP同时较好地显示双侧肾小盏、肾盂及输尿管上段。SSD均能很好显示肾动脉主干的起源、大小、形态及与周围的解剖关系。CTVE能较好显示腹主动脉、双肾动脉开口及肾动脉血管内腔。结论 16层螺旋CT血管造影可作为活体肾移植术前了解供肾血管及形态的有效方法。     

供体存在副肾动脉时大鼠肾移植模型的建立

目的 解决大鼠原位肾移植过程中供体出现副肾动脉时供肾循环难以建立的问题.方法 9例供肾存在副肾动脉,其中2例结扎副肾动脉后行肾动脉端端吻合;7例利用受体正常肾动脉在接近肾门处2到3支分支,修剪出2个吻合端,端端吻合供肾的2条肾动脉.结果 结扎副肾动脉吻合肾动脉后出现肾脏血液灌注不良以及缺血坏死,应用新设计的方法可建立良好的供肾血液循环.结论 利用新方法,解决了供肾存在副肾动脉的情况下建立的大鼠原位肾移植问题,节约了试验动物.     

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.     

The renal perfusion/excretion determination renogram: a new method of individual renal function determination in obstructive renal disease

The divided renal function of 10 patients with unilateral renal obstruction was measured with the renal perfusion/excretion determination renogram, a computerized radioisotope function study, and with endogenous creatinine clearances. Functional impairment of the obstructed kidney when estimated by the effective renal plasma flow determination of the renal perfusion/excretion determination renogram correlated closely with that measured by creatinine clearance. The clinical applications of the renal perfusion/excretion determination renogram in unilateral renal obstruction include the preoperative evaluation of individual renal function and serial estimates of individual renal function in chronic obstructive processes.     

Renal cyst formation as a complication of primary distal renal tubular acidosis

Morphologic studies using renal sonography and CT scanning were performed in 6 patients with primary distal renal tubular acidosis who were followed for 6 to 18 years. Nephrocalcinosis and renal cysts were identified in all patients. Multiple bilateral renal cysts were detected in 3 patients, and unilateral single or several renal cysts were detected in 3 patients. Size and number of the renal cysts in 1 patient did not change over 5 years of alkali therapy. Although the precise mechanism for renal cyst formation has not yet been established, renal cysts may be a common complication of primary distal renal tubular acidosis.     

Effect of Chronic Cholesterol Loading in the Development of Acute Ischemic Renal Failure in Rats

The effect of chronic cholesterol loading and lovastatin administration in renal artery clamping acute renal failure in rats is not known. Acute renal failure was induced by 60-min left renal artery clamping immediately afer right nephrectomy. The changes in renal function after renal artery clamping in the hyperlipidemic rats were unexpected. The acute renal failure in the cholesterol-loaded groups was less severe than in the nonhyperlipidemic rats. The lovastatin administration had some favorable effect on renal function afi ter ischemia; however, this effect was not additive to the high dietary cholesterol administration. Our results seems to favor the concept that in this special form of experimental renal ischemic acute renal failure, serum cholesterol levels, elevated through diet, may have protective effects with respect to renal tubular lesions during or following the acute ischemic insult.     

Neural effects of natural behavior on renal blood flow in spontaneously hypertensive rats

Background In states of stress and exercise, renal blood flow is shown to be depressed, mainly through neural mechanisms. Little is known, however, about the effects of natural or spontaneous behaviors on renal blood flow and renal sympathetic nerve activity. Methods We simultaneously measured renal sympathetic nerve activity and renal blood flow as a Doppler shift during grooming and exploring behaviors in spontaneously hypertensive rats. We also tested the effects of vasodilating drugs on changes in renal blood flow. Results Grooming behavior (n=21) increased renal sympathetic nerve activity, mean arterial pressure, and decreased renal blood flow. Percentage changes in renal sympathetic nerve activity correlated negatively with percentage changes in renal blood flow. Exploring with rearing (n=14) induced similar but larger changes in these variables. Denervation of renal nerves suppressed a reduction in renal blood flow during these behaviors. After intravenous injection of manidipine (a calcium channel blocker) or CV-11974 (an angiotensin II receptor antagonist), the behavior-induced reduction in renal blood flow was significantly smaller than that found before treatment, despite similar increases in renal sympathetic nerve activity. Conclusion Natural behaviors decrease renal blood flow in relation to the enhancement of renal sympathetic nerve activity, which is similar to the responses of the animals to stressful psychologic stimuli. Vasodilating drugs can attenuate the reduction in renal blood flow.     

Clinical indications for radiographic evaluation of blunt renal trauma

The evaluation of patients with blunt renal trauma has become controversial. We tested the hypothesis that renal contusion can be diagnosed clinically and that these patients do not require radiographic evaluation. To evaluate the association of microhematuria without shock and with renal contusion, we reviewed the medical records of 831 patients with hematuria following blunt renal trauma. Microscopic hematuria without shock was noted in 160 of 241 patients without and 334 of 590 with associated injuries. Of the former 160 patients 159 had renal contusion and 1 had a renal laceration, while of the latter 334 patients 329 had renal contusion, 3 had renal laceration, 1 had renal rupture and 1 had a pedicle injury. Most patients with microscopic hematuria and no shock after blunt renal trauma had a renal contusion, especially those with no associated injury. All of the patients with renal contusions experienced no complications from nonoperative management. However, avoiding a radiographic evaluation in patients with blunt renal trauma plus microhematuria and no shock would miss a few cases of severe renal injury.     

The effects of treatment of renal trauma on renal function

Renal function studies were performed in 275 severely injured patients with hemorrhagic shock and massive transfusion. There were 230 patients without renal injury and 45 patients with renal injury treated without exploration of the kidney in 17 patients, with exploration and renorrhaphy in nine patients, and with partial or total nephrectomy in 19 patients. In addition, 45 patients without renal injury were randomly matched by computer to the 45 patients with renal injury based on the number of blood transfusions and severity of shock as indicators of physiologic insult. Renal function was adversely affected by partial or total nephrectomy in patients with renal injury. Significant decreases in renal filtration and excretion were seen when the nephrectomy group was compared to the patients without renal injury matched for injury insult. Creatinine clearance decreased from 103 ml/min to 55 ml/min, inulin clearance from 106 ml/min to 63 ml/min, and osmolar clearance from 4.8 ml/min to 3.3 ml/min. The 230 patients without renal injury had an incidence of renal failure of 7.4% and a mortality rate of 8.2% compared to 11.4% and 15.6%, respectively, in the 45 patients with renal injury. Death and renal failure occurred in 13 of the 230 patients without renal injury (5.6%) and in two of the 45 renal injury patients (4.4%). The incidence of renal failure in the 19 patients without renal injury who died was 68% versus 29% in the seven renal injury patients who died. Preservation of renal parenchyma is recommended to provide maximal renal function in severely injured patients.     

Renal tumors in end‐stage renal disease: A comprehensive review

The incidence of end‐stage renal disease has increased owing to the greater prevalence of patients with chronic kidney disease and diabetes mellitus. End‐stage renal disease is usually accompanied by acquired cystic disease and is a risk factor for renal cell carcinoma. The present review discusses the etiology of renal cell carcinoma in end‐stage renal disease patients, focusing on two unique renal cell carcinoma histological subtypes: acquired cystic disease‐associated renal cell carcinoma and clear cell papillary renal cell carcinoma. Acquired cystic disease‐associated renal cell carcinoma occurs almost exclusively in patients who underwent hemodialysis, especially long‐term (>10 years) hemodialysis. Its histology is distinctive: a cribriform or sieve‐like architecture with intra‐ or intracystic lumina; tumor cells containing abundant eosinophilic cytoplasm and large nuclei with prominent nucleoli; and most notably, calcium oxalate crystal deposition. Recognition of the crystals is critical for diagnosing acquired cystic disease‐associated renal cell carcinoma. Acquired cystic disease‐associated renal cell carcinoma typically has an indolent clinical course, except in cases with sarcomatoid components. Clear cell papillary renal cell carcinoma also has an indolent course (no cases involving metastasis have been reported to date), and its features resemble those of both clear cell renal cell carcinoma and papillary renal cell carcinoma. Unlike acquired cystic disease‐associated renal cell carcinoma, which occurs only in end‐stage renal disease patients, clear cell papillary renal cell carcinoma occurs in non‐end‐stage renal disease patients as well. Additional renal tumors in end‐stage renal disease patients include anastomosing hemangiomas. Long‐term hemodialysis worsens the prognosis of end‐stage renal disease patients with renal cell carcinoma, regardless of its original histological subtype, presumably by inducing oxidative stress and sarcomatoid transformation.     

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.     

紧密连接蛋白ZO-1在肾癌中的表达及其临床意义

目的 探讨闭锁小带蛋白(sonula occluden-1,ZO-1)这种紧密连接相关蛋白在肾癌中的表达情况及其临床意义。方法 采用免疫组织化学法检测55例肾癌患者手术切除的肾脏病理标本中正常肾组织以及肾癌组织中ZO-1蛋白的表达,并分析肾癌组织中ZO-1的表达与肿瘤的侵袭和转移之间的关系。结果 ZO-1蛋白在正常肾组织和肾癌组织中的阳性表达率分别为74.5%和32.7%。 两组间进行比较显示,ZO-1蛋白在肾癌组织中的表达水平明显低于正常肾组织,组间具有差异性（P<0.05）。在肾癌组织中,ZO-1蛋白的表达水平与癌组织的临床分期、分化程度以及淋巴结转移有关。结论 人肾癌组织中ZO-1蛋白的表达较正常肾组织减少,并且其可能参与肾癌肿瘤细胞的侵袭和转移。     

控制肾血管的肾脏重建治疗重度肾外伤(附15例报告)

目的：提高肾外伤手术治疗的肾单位保存率。方法：采用早期控制肾血管，必要时阻断肾血管重建伤肾的方法，治疗重度肾外伤l5例。结果：5例行肾修补术，4例行肾部分切除术，2例行肾静脉修补术，4例行肾切除术，肾切除率26．3％。结论：控制肾血管的肾脏重建术能有效减少肾脏切除率，是手术治疗肾外伤的理想方法。