Febrile urinary tract infection after pediatric kidney transplantation: a multicenter,prospective observational study

Background

Febrile urinary tract infections (fUTIs) are common after kidney transplantation (KTx); however, prospective data in a multicenter pediatric cohort are lacking. We designed a prospective registry to record data on fUTI before and after pediatric KTx.

Methods

Ninety-eight children (58 boys and 40 girls)?≤?18 years from 14 mid-European centers received a kidney transplant and completed a 2-year follow-up.

Results

Posttransplant, 38.7 % of patients had at least one fUTI compared with 21.4 % before KTx (p?=?0.002). Before KTx, fUTI was more frequent in patients with congenital anomalies of kidneys and urinary tract (CAKUT) vs. patients without (38 % vs. 12 %; p?=?0.005). After KTx, fUTI were equally frequent in both groups (48.7 % vs. 32.2 %; p?=?0.14). First fUTI posttransplant occurred earlier in boys compared with girls: median range 4 vs. 13.5 years (p?=?0.002). Graft function worsened (p?<?0.001) during fUTI, but no difference was recorded after 2 years. At least one recurrence of fUTI was encountered in 58 %.

Conclusion

This prospective study confirms a high incidence of fUTI after pediatric KTx, which is not restricted to patients with CAKUT; fUTIs have a negative impact on graft function during the infectious episode but not on 2-year graft outcome.

     

Technique of Laparoscopic-Endoscopic Single-Site Surgery Radical Nephrectomy

Background

Laparoscopic-endoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery.

Objective

To assess the feasibility of LESS radical nephrectomy (LESS-RN).

Design, setting, and participants

Ten patients with body mass index (BMI) ≤30 underwent LESS-RN for renal tumour by two experienced laparoscopists.

Surgical procedure

TriPort (Olympus Winter &; Ibe, Hamburg, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and flexible grasper and scissors was used. A 5-mm 30° camera was also used. The standard laparoscopic transperitoneal nephrectomy technique was performed.

Measurements

Patient demographics, operative details, and final pathology were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded.

Results and limitations

Ten cases were successfully accomplished (two right-sided tumours and eight left-sided tumours; tumour diameter ranges: 4–8 cm). The mean patient age was 63.5 yr (22–77 yr), and median BMI was 23.56 (18.2–26.6). The mean operative time was 146.4 min (120–180 min), and the mean blood loss was 202 ml (50–900 ml). Pathological examination observed organ-confined T1 renal cell carcinoma in nine cases and pT3b tumour in one case. One bleeding complication occurred. Limitations regarding the intraoperative instrument ergonomics and the requirement for ambidexterity of the surgeon were noted.

Conclusions

LESS-RN proved to be safe and feasible. Further clinical investigation in comparison to the established techniques should take place to evaluate the outcome of LESS-RN.     

Impact of several histopathological prognosticators and local tumour extension on oncological outcome in pT3b/c N0M0 renal cell carcinoma

OBJECTIVE

To investigate the prognostic relevance of different histopathological features and local tumour extension in patients with pT3b/c N0M0 renal cell carcinoma (RCC), as recently new proposals of reclassifying tumour fat invasion in pT3b/c RCC have been made but the effect of other histopathological tumour characteristics and combinations thereof with tumour invasion has yet to be determined in these patients.

PATIENTS AND METHODS

Between 1990 and 2006, 1943 patients underwent surgical treatment for renal tumours in our institution, of which 175 patients (8.7%) had pT3b/c RCC. After exclusion of 57 patients (32.6%) with lymph node and/or distant metastases at the time of diagnosis, 118 (67.4%) remained for retrospective analysis. Different histopathological features and local tumour extension were studied for their association with cancer‐specific‐survival (CSS) and progression‐free‐survival (PFS) by univariate and multivariate analyses. Histopathology was reviewed and revised according to the 2002 Tumour‐Nodes‐Metastasis (TNM) classification system by one pathologist (S.B.). CSS and PFS were estimated by the Kaplan–Meier method.

RESULTS

Follow‐up data were obtained from 110 patients at a median (range) of 3.2 (0.3–16.1) years. In univariate analysis, microvascular invasion (MVI) and capsular invasion increased the risk of tumour progression by 2.05‐ and 2.72‐times (P = 0.037 and P < 0.001). Overall, tumour fat invasion (TFI) and the presence of areas composed by cells with eosinophilic cytoplasm were associated with a higher risk of progression (P = 0.001 and P = 0.011) and reduced CSS (P = 0.037 and P = 0.017). In multivariate analysis, MVI and capsular invasion were associated with a two‐fold increased risk of dying from cancer (hazard risk ratio, HR 2.22, P = 0.045 and HR 2.31, P = 0.011). TFI in general (P = 0.004) and specifically coexistent perirenal fat invasion (PFI) and renal sinus fat invasion (RSFI) were associated with a three‐fold increased risk of developing tumour progression (HR 3.36, P = 0.001). The 10‐year CSS and PFS rates were 39% and 36% for all patients, 47% and 45% for pT3b/c RCC with no PFI or RSFI, and 25% and 10% for PFI + RSFI.

CONCLUSION

Patients with pT3b/c RCC with MVI, capsular invasion, TFI and especially PFI + RSFI, have a markedly reduced prognosis compared with patients with pT3b/c RCC without these features. When these results are corroborated by additional studies and external validation, modification of the TNM classification system would be a sensible consequence.     

Decontamination of deep dentin by means of erbium, chromium:yttrium-scandium-gallium-garnet laser irradiation

The aim of this in vitro study was to evaluate the depth of effectiveness of erbium, chromium:yttrium-scandium-gallium-garnet (Er,Cr:YSGG) laser irradiation on microorganism reduction. From human roots, dentin slices of 100 μm to 1,000 μm thickness were prepared. These specimens were sterilized and then inoculated with 1 μl of Enterococcus faecalis suspension. The backs of the specimens were then irradiated with Er,Cr:YSGG radiation at a pulse energy of 3.13 mJ, delivered at an incidence angle of 5° to the dentin slice surface. A control group was left without irradiation. The remaining bacteria were collected in 1 ml sterilized NaCl solution, serially diluted and seeded in Columbia-Agar plates. Despite the low pulse energy of 3.13 mJ, the Er,Cr:YSGG laser irradiation resulted in significant bacterial reduction up to a dentin thickness of 500 μm (P < 0.05). Scanning electron microscopy (SEM) micrographs of the contaminated and irradiated surfaces showed the absence of a smear layer and opened dentinal tubules.     

Transcortical or transcallosal approach to ventricle-associated lesions: a clinical study on the prognostic role of surgical approach

Most entities in and around the anterior two-thirds of the supratentorial ventricles can be reached via transcortical or transcallosal approach. This study examined the effect of surgical approach on the postoperative neurological outcome. Thirty-eight patients with intra- and periventricular supratentorial lesions were operated on by either frontal transcortical or anterior transcallosal approach. Postoperative diencephalic damage occurred in 22% of patients in the transcortical group and in 36% in the transcallosal group; transient mutism was virtually equivalent in the two groups. Postoperative epilepsy (26%) and subdural fluid collections (30%) occurred only in the transcortical group. The incidence of postoperative hemiparesis was higher in the transcallosal group. There was a high correlation between postoperative Glasgow Outcome Score of 5 and preoperative severity of neurological disease but no correlation between postoperative Glasgow Outcome Score of 5 and location of the lesion or between postoperative clinical course and surgical approach. Surgical outcome of ventricle-associated lesions depends mainly on the severity of preoperative symptoms and not on surgical approach. Additionally, the incidence of postoperative seizures and subdural fluid collections after transcortical surgery is high.     

Comparison of reconstruction accuracy and efficiency among autocalibrating data‐driven parallel imaging methods

The class of autocalibrating “data‐driven” parallel imaging (PI) methods has gained attention in recent years due to its ability to achieve high quality reconstructions even under challenging imaging conditions. The aim of this work was to perform a formal comparative study of various data‐driven reconstruction techniques to evaluate their relative merits for certain imaging applications. A total of five different reconstruction methods are presented within a consistent theoretical framework and experimentally compared in terms of the specific measures of reconstruction accuracy and efficiency using one‐dimensional (1D)‐accelerated Cartesian datasets. It is shown that by treating the reconstruction process as two discrete phases, a calibration phase and a synthesis phase, the reconstruction pathway can be tailored to exploit the computational advantages available in certain data domains. A new “split‐domain” reconstruction method is presented that performs the calibration phase in k‐space (k_x, k_y) and the synthesis phase in a hybrid (x, k_y) space, enabling highly accurate 2D neighborhood reconstructions to be performed more efficiently than previously possible with conventional techniques. This analysis may help guide the selection of PI methods for a given imaging task to achieve high reconstruction accuracy at minimal computational expense. Magn Reson Med 59:382–395, 2008. © 2008 Wiley‐Liss, Inc.     

The role of ultrasonography in the assessment of renal function in the elderly

BACKGROUND: Ageing is associated with a progressive loss of renal mass and kidney length and a decline in glomerular filtration rate (GFR). This study evaluated a possible correlation between renal function and kidney size measured by ultrasonography (US), and whether the latter helps estimate GFR in the elderly. METHODS: Twenty-five medically stable elderly patients (mean age 85 +/- 5 yrs) were examined in a geriatric ward at a university hospital. Blood samples were taken to determine serum creatinine (Cr) levels. On the same day, 51chromium ethylenediamine tetraacetic acid (51Cr-EDTA) clearance was performed as the gold standard of GFR. US measured kidney length, transverse and anteroposterior dimensions. RESULTS: Serum Cr (r=-0.67; p=0.0002), Cockcroft-Gault formula (r=0.82; p<0.0001), absolute length (r=0.51; p=0.008) and volume kidney (r=0.46; p=0.02) correlated significantly with GFR. After receiver operating curve (ROC) analysis, length was less specific than sensitive in detecting renal impairment. Adding length to the Cockcroft-Gault formula did not improve GFR estimation (p=0.44). In contrast, adding length to serum Cr levels improved GFR estimation (p=0.015). CONCLUSION: In the elderly, kidney length and volume significantly correlated with GFR. However, length has a low specificity in predicting renal impairment. Therefore, in clinical practice, serum Cr levels and calculated Cr clearance are more useful in predicting renal impairment. However, normal kidney length can help to exclude renal impairment in the elderly at risk of GFR underestimation by a calculated Cr clearance.     

Reliability of serial bone scintigraphy classification according to Conway in Legg-Calvé-Perthes disease

Serial bone scintigraphy in Legg-Calvé-Perthes disease (LCP) has a good early prognostic value. So far, no intra- and inter-observer reliability study on this classification has been published. Serial technetium scintigraphy of the hips was performed in 40 children with LCP disease, and the hips were classified based on their scintigraphic patterns according to Conway. Forty hips were classified twice by six observers. The two assessments were made in a different order, with a minimum time interval of one month. Unweighted kappa coefficients were calculated. Only moderate reliability was measured: intra-observer reliability: kappa = 0.573 and inter-observer reliability: kappa = 0.525. Serial bone scintigraphy in LCP has an inter- and intra-observer reliability that is only moderate. The reliability is better than that observed for the radiological Catterall classification and head-at-risk factors, but worse than the reliability of the radiological Herring classification.