Chinese herbs nephropathy presentation, natural history and fate after transplantation

Background. Chinese herbs nephropathy is a new type of subacute interstitial nephropathy reported in women who had followed a slimming regimen including Chinese herbs. Methods. We report the clinical presentation and follow-up of 15 cases and compare them with a control group of 15 women with interstitial nephropathies of other origins, matched for age, sex, and initial serum creatinine (mean 3 mg/dl). Results. At presentation the Chinese herbs nephropathy group differed from the control group by a lower proteinuria (P=0.009), a more severe anaemia (P=0.002), and a higher prevalence of aortic insufficiency (42% vs 0%, P <0.005). It was further characterized by mild hypertension in 80%, glycosuria and leukocyturia in 40% and asymmetric kidneys in 43% of the cases. During follow-up, deterioration of renal function was faster in the Chinese herbs nephropathy than in the control group (P <0.05). It was influenced by the duration of Chinese herbs treatment (P=0.037) and the delay between the end of Chinese herbs ingestion and diagnosis of the disease (P-0.013). In three cases, renal failure developed 3 years after Chinese herbs ingestion. Complications included severe aortic regurgitation requiring surgery (n=1), urothelial carcinoma (n=2), bilateral ureterohydronephrosis due to periureteral fibrosis (n=1). Five patients with Chinese herbs nephropathy were successfully transplanted, without evidence of recurrence of the disease. Conclusion. Chinese herbs nephropathy is characterized by a lower proteinuria, more severe anaemia, and a faster progression of renal failure than other interstitial nephropathies. The duration of Chinese herbs treatment and interval between withdrawal of Chinese herbs and diagnosis are correlated with the rate of progression. Severe, unusual extrarenal complications may affect Chinese herbs nephropathy patients.     

A stratified intraoperative surgical strategy is mandatory during laparoscopic common bile duct exploration for common bile duct stones

Background: Open exploration and endoscopic sphincterotomy (ES) remain the preferred treatment of common bile duct stones (CBDS). The recent spread of laparoscopy has worsened the dilemna of choosing between surgical and endoscopic treatment of CBDS. The aim of this study was to critically evaluate the results of our preliminary experience with laparoscopic common bile duct exploration (CBDE) for CBDS. Methods: Ninety-two consecutive patients were prospectively submitted to laparoscopic CBDE. Surgical strategy included an initial transcystic approach or laparoscopic choledochotomy. Failure of stone clearance was managed by conversion to open CBDE or by postoperative ES. Electrohydraulic lithotripsy and papillary balloon dilatation were selectively used. Stone clearance was assessed by choledochoscopy and control cholangiography. Results: The overall laparoscopic stone clearance in this series was 84% (transcystic route 63% and choledochotomy 93%). Conversion to laparotomy was mandatory in 12% of the patients because of incomplete stone clearance and in 5% because of intraoperative complications. Postoperative ES was required in 4% of the patients, giving an overall surgical success rate of 96%. When indicated (small and limited number of stones located below the cysticocholedochal junction, with a dilated and patent cystic duct) the transcystic route had the lower success rate, the higher complication rate, and the shorter operative time and postoperative hospital stay. When indicated (accessible and dilated common bile duct over 7 mm), laparoscopic choledochotomy had the higher success rate, the lower complication rate, the longer operative time, and the longer postoperative hospital stay, which is related to associated external biliary drainage. The hospital mortality included two high-risk patients (2%) and the complications rate was 15%. Conclusions: Laparoscopic CBDE is safe in selected patients. A stratified intraoperative surgical strategy is mandatory in deciding between a transcystic route and choledochotomy with specific indications for each approach. When feasible, laparoscopic choledochotomy is more efficient and safe than the transcystic route, but it is associated with a longer postoperative hospital stay, which is due to external biliary drainage. Received: 7 May 1996/Accepted: 19 November 1996     

Histological characteristics of sternoclavicular beta 2-microglobulin amyloidosis and clues for its histogenesis

BACKGROUND: The pathogenesis of beta 2-microglobulin amyloidosis (A beta 2m) has yet to be fully elucidated. METHODS: We describe the distribution and extent of A beta 2m deposition and macrophagic infiltration in cartilage, capsule, and synovium of sternoclavicular joints obtained postmortem from 54 patients after 3 to 244 (median 46) months of dialysis. Twenty-four nonuremic patients served as a control group. The diagnosis of amyloidosis (A) rested on a positive Congo Red staining (typical birefringence) and that of A beta 2m on positive immunostaining of the A deposits with a monoclonal anti-beta 2m antibody. The size of A deposits was measured. RESULTS: A beta 2m was detected in 32 (59%), and non-beta 2m amyloid (Anon beta 2m) was detected in an additional 8 (15%) of the 54 dialyzed patients. A beta 2m deposits were present in the cartilage of all A beta 2m (+) patients (100%). They were localized solely in the cartilage in 27% of the cases, either as a thin patchy layer or as a continuous thicker layer (identified as stage I). A beta 2m was additionally present in the capsule and/or synovium without macrophages in 27% of the cases (identified as stage II). The correlation between the size of cartilaginous deposits and dialysis duration (P = 0.02) as well as with the prevalence (P = 0.03) and size of capsular deposits (P = 0.02) suggests that stage II is a later stage of A deposition. Clusters of macrophages were detected around capsular and synovial amyloid deposits in 46% of the cases (identified as stage III). The longer duration of dialysis in those with stage III as well as the relationship between the size of the A beta 2m deposits and the prevalence of macrophagic infiltration suggests that stage III is the last stage of A beta 2m deposition. Marginal bone erosions were observed in 9 out of 12 patients with stage III deposits. Their size was correlated with that of cartilaginous deposits (P = 0.01). Among the 24 control patients, Anon beta 2m was detected in 12 patients (cartilage 100%, capsule 8%, synovium 30%). CONCLUSIONS: The earliest stage of A beta 2m deposition occurs in the cartilage. A beta 2m subsequently extends to capsule and synovium. These two first stages do not require macrophage infiltration. Macrophages are eventually recruited around larger synovial or capsular deposits in the final stage. Marginal bone erosions develop in this late stage.     

Allograft of ovarian cortex between two genetically non-identical sisters: case report

Aggressive chemotherapy and radiotherapy generally result inthe loss of both endocrine and reproductive functions. In 1990,a woman aged 20 years, presenting with -thalassemia major, underwentchemotherapy (busulfan and cyclophosphamide) and total bodyirradiation (TBI) before bone marrow transplantation (BMT),the donor being her 17-year-old HLA-compatible sister. The treatmentresulted in premature ovarian failure. In 2006, after excisionof ovarian cortical fragments from the HLA-compatible sister,these fragments were immediately sutured to the ovarian medullaof the patient. Both procedures were performed by laparoscopy.Six months after reimplantation, vaginal ultrasonography andhormone concentrations indicated recovery of ovarian secretionand function. From 6 to 11 months, the patient experienced menstrualbleeding and the development of a follicle concomitant withhigh estradiol levels. Eleven months after reimplantation, twofollicles were detected and punctured under vaginal ultrasonographiccontrol. Two mature oocytes were retrieved and inseminated byICSI. Two embryos (2- and 3-cell) were obtained. Allotransplantationof fresh ovarian tissue was laparoscopically performed betweentwo genetically non-identical sisters. Restoration of ovarianfunction was achieved after six months. Oocyte retrieval andembryo development were demonstrated.     

Measuring the glomerular filtration rate in different age groups using iohexol,the protocol from the Belgian iohexol study

ObjectivesMeasuring the exact glomerular filtration rate (GFR) is difficult. Iohexol can be used instead of inulin or labeled EDTA or DTPA. In recent years, different studies have validated GFR-estimating equations in adults. Validation of these estimations in adolescents and elderly is lacking. With this study, we aim to develop a simplified (only 1–3 blood collections) iohexol protocol to measure the true GFR for patients of all ages and try to develop GFR-estimating equations for adolescents and the elderly.Design and settingParticipants of different ages will be recruited: 50 adolescent (14–18 years) and 30 adults (20–65 years), 60 elderly (65–80 years) and 60 very elderly (80 + years old) stratified based on their GFR. Biometric data, serum creatinine and cystatin C will be measured. After injecting 5 mL iohexol, 9 blood samples will be taken between 20 and 360 min. First, the GFR will be calculated by using the double exponential decay method and different GFRs based on 1–3 blood samples, which will be compared with the GFR of the abovementioned 9 samples. Second, the GFR will be calculated by using new and existing equations and compared to the true GFR.DiscussionThe availability of a reliable GFR measurement is important in situations such as screening patients for kidney donation or when taking potentially nephrotoxic treatments. This study will allow us to develop a simplified protocol for measuring the true GFR in all ages and will allow us to validate existing equations and develop new eGFR equations for adolescents and the elderly.