The influence of contrast agents on hemorrhage produced by lithotripter fields

Ultrasonic contrast agents greatly increase the side effects of low-amplitude lithotripter fields in mice. Using a piezoelectric lithotripter, adult mice were exposed to 200 lithotripter pulses with a peak positive pressure amplitude of 2 MPa. During the exposure period, mice were injected with approximately 0.1 mL of the ultrasonic contrast agent Albunex. For comparison, another group of mice experienced the same lithotripter exposures, but were not injected with contrast agent. Following exposures, animals were sacrificed and observed for hemorrhage in various organs and tissues. Mice exposed to the lithotripter field alone had minimal hemorrhage only in the intestine and lung. In comparison, mice injected with Albunex during exposure exhibited extensive hemorrhage in the intestine, kidney, muscle, mesentery, stomach, bladder, seminal vesicle and fat.

Is the red cell morphology really useful to detect the source of hematuria?

Morphological analysis of urinary red blood cells by phase-contrast microscopy to identify the source of bleeding was, and still is, widely used also as a starting point for workup. To evaluate the reliability of this approach, we studied 129 outpatients presenting with persistent isolated microhematuria; 31 subjects also had mild proteinuria (1 g/day), while 21 had pathological albumin levels. All patients were followed for a period of 6 years. During this time, 6 patients underwent renal biopsy for the onset of macrohematuria episodes and proteinuria of 2-3 g/day. Glomerular bleeding was identified in only 14.7% of the patients, despite the persistent microhematuria and the presence of proteinuria or microalbuminuria. The renal origin of the urinary erythrocytes correlated with histological findings in only 2 of 6 patients with dysmorphic erythrocytes who developed proteinuria (exceeding 1 g/day), and none with isomorphic erythrocytes showed urological abnormalities. These results challenge the validity and reliability of morphological analysis to identify the source of bleeding along the urinary tract.

Glomerular ICAM-1 expression related to circulating TNF-alpha in human glomerulonephritis

To clarify the in vivo involvement of cellular adhesion molecules and cytokines in human glomerulonephritis, we have investigated the glomerular and interstitial expression of intercellular adhesion molecule 1 (ICAM-1) in 69 kidney biopsy specimens by immunohistochemical methods and its correlation with serum bioactive tumor necrosis factor alpha (TNF-alpha) and soluble ICAM-1 (sICAM-1) levels in 43 cases. In normal controls, glomerular ICAM-1 expression and serum TNF-alpha and sICAM-1 levels showed a mean score of 1.0 (n = 7) and were 12.1 +/- 1.5 and 187 +/- 5 ng/ml (mean +/- SEM, n = 25), respectively. ICAM-1 was positive in 68 kidneys except in 1 patient with membranous nephropathy at various degrees in glomeruli and in 72% of peritubular capillaries or venules in the interstitium. Serum-bioactive TNF-alpha levels increased in the patients with IgA nephropathy, purpura nephritis, and lupus nephritis (LN) (18.9 +/- 4.1, 32.6 +/- 13.3, and 20.9 +/- 3.5 pg/ml) and were positively correlated with the grade of glomerular ICAM-1 expression (n = 43, r = 0.57, p < 0.001), endocapillary proliferation with exudative lesions (r = 0.72, p < 0.001) and hematuria (r = 0.62, p < 0.001). Serum sICAM-1 levels were elevated in patients with LN and purpura nephritis and decreased from 312 +/- 40 to 226 +/- 21 ng/ml after methylprednisolone pulse therapy in LN (n = 9, p = 0.0285). sICAM-1 levels were positively correlated with the grade of interstitial ICAM-1 expression (r = 0.46, p < 0.05), and sICAM-1 levels (>210 ng/ml) showed high odds ratios in the interstitial ICAM-1-positive cases and systemic vasculitides such as purpura nephritis and LN (6.00, p = 0.0355; 6.50, p = 0.0216, respectively). These results suggest that bioactive TNF-alpha might relate to glomerular ICAM-1 expression associated with endocapillary lesions in human glomerulonephritis and that sICAM-1 levels may be used as a clinical marker to assess interstitial lesions in human nephritis and systemic vasculitides.

Symptomless microhaematuria in schoolchildren: causes for variable management strategies

We reviewed published data on the frequency of underlying disorders in schoolchildren with microscopic or gross isolated haematuria (IH), and evaluated management strategies. We found five reports of microscopic IH in screened asymptomatic schoolchildren, three reports of microscopic IH detected by case-finding, and five surveys of kidney biopsies in referred children with microscopic and gross IH. We listed the reported underlying disorders, and estimated the benefit from their early detection and treatment. Most children with microscopic IH, whether detected by screening or case-finding, had no significant underlying disease. Some had disorders that may benefit from early treatment (membranoproliferative glomerulonephritis, obstructive uropathy, urolithiasis), or counselling (hereditary nephropathy, renal cystic disease). The combined prevalence of these five diseases was 0-7.2% in children with microscopic IH detected by screening, and 3.3%-13.6% in those with microscopic IH detected by case-finding. The combined prevalence of membranoproliferative glomerulonephritis and hereditary nephropathy among kidney biopsies was 11.6%-31.6% in children with microscopic IH, and 3.6%-42.1% in children with gross IH. Variable management strategies for schoolchildren with IH result from uncertainty about the frequency of underlying disorders and the efficacy of their early treatment. With no evidence that detecting IH leads to prevention of renal function impairment, screening for IH in symptomless schoolchildren is not warranted. Once detected, however, IH justifies further investigation.

Evaluation of asymptomatic microscopic haematuria--influence and clinical relevance of osmolality and pH on urinary erythrocyte morphology

OBJECTIVE

To determine whether the morphological distinction between 'dysmorphic' and 'eumorphic' erythrocytes in urinary sediment differentiates microscopic haematuria (MH) from reno-parenchymal and post-renal bleeding.

MATERIALS AND METHODS

The erythrocyte morphology of 2145 urinary sediments from 1391 patients with MH was evaluated by interference-contrast microscopy and compared with the osmolality, pH and specific gravity of the urine samples.

RESULTS

Compared with more concentrated urine specimens, samples of < 700 mOsmol/kg showed significantly lower percentages of dysmorphic erythrocytes; there was a similar reduction in this percentage at a pH > or = 7. In addition, erythrocytes lysed in diluted or alkaline urine and therefore, under these conditions, no diagnosis could be made.

CONCLUSION

The assessment of erythrocytes in urinary sediment should be performed only under 'standard conditions', i.e. in concentrated and acidic urine, > or = 700 mOsmol/kg and a pH < 7. The presence of > or = 90% dysmorphic erythrocytes in patients with asymptomatic MH, the absence of proteinuria, a normal blood pressure and normal radiological examination indicates 'reno-parenchymal MH', requiring a long-term follow-up with a routine evaluation twice a year, but no immediate treatment in most cases. In contrast, the presence of > or = 90% eumorphic erythrocytes or even 'mixed' results (10-90% eumorphic erythrocytes) indicates 'post-renal MH', requiring a complete urological evaluation.

Glomerular basement membrane thickness - a comparison of two methods of measurement in patients with unexplained haematuria

BACKGROUND

Thin glomerular basement membranes may be an important cause of microscopic haematuria. Unfortunately measurements are often not made because of the complicated methods currently employed.

METHODS

A simplified method of measurement of glomerular basement membrane thickness, involving only 16 selected measurements on a single glomerulus, was compared with the accepted, but time-consuming, orthogonal intercept technique. Thirty-one needle biopsies from patients with renal haematuria unexplained by conventional histology and immunofluorescence were studied. Measurements were made on the same ultrathin sections.

RESULTS

The new method was found to give much lower values (mean (SD) 202+/-51 versus 282+/-52 nm) with limits of agreement of -131 to -30 nm compared with the orthogonal intercept method. The coefficient of repeatability was 39 nm for the orthogonal intercept method and 56 nm for the new method. However, using two glomeruli the new method had limits of agreement of -120 to -41 nm with a coefficient of repeatability of 38 nm.

CONCLUSIONS

Provided two glomeruli are measured the new technique is sufficiently accurate for the diagnosis of thin membrane nephrology, in appropriate cases, and is much simpler and cheaper than the orthogonal intercept method.

Renal biopsy: why and when

The purpose of this paper is to emphasize the importance of information obtained by renal biopsy in the diagnosis, prognosis, and therapy of patients with renal disease. Because controversy persists regarding the value of renal biopsy as an aid in determining prognosis and in choosing appropriate therapy, there has been some reluctance to use it early after the onset of obvious signs, symptoms, and laboratory findings indicative of renal disease with or without involvement of other organs. Although all such patients may not benefit from the information provided by a proper biopsy, we will illustrate some of the characteristic histologic details found in specific circumstances in our experience where the biopsy has been particularly helpful in reaching a diagnosis, in assessing prognosis, and in choosing therapy.

Alkaline encrusted cystitis associated with malakoplakia

Alkaline encrusted cystitis is a rare inflammatory condition of the bladder which has been reported sporadically over the past 80 years. It is caused by infection with urea splitting organisms leading to the deposition of inorganic salts on to the surface of the bladder. We present three cases of alkaline encrusted cystitis. In two cases the encrusted area was associated with foci of malakoplakia. The third case occurred in a patient who had received chemotherapy for acute lymphoblastic leukaemia. To our knowledge, these are the first cases of malakoplakia associated with alkaline encrusted cystitis. These two conditions have a number of clinical and aetiological similarities, and may have more in common than has been previously thought.

Recurrent hematuria: a novel clinical presentation of hereditary complete complement C4 deficiency

A 10-year-old boy suffered from recurrent attacks of fever, vomiting, and hematuria. During disease flares, circulating immune complexes were detected in the serum. Elevated levels of Bb, Ba, and C3a indicated complement activation through the alternative pathway. Complement C4 was undetectable. C4 phenotyping by agarose gel electrophoresis showed complete C4 deficiency. Restriction fragment length polymorphism (RFLP) studies showed a homozygous deletion of the C4B and 21-hydroxylase A genes. A mild mesangioproliferative glomerulonephritis with mesangial deposits of immunoglobulin (1g) G, IgM, IgA, Clq, C3, properdin, and terminal complement complex was probably caused by immune complex deposition and alternative complement pathway activation. Treatment with low-dose prednisolone substantially reduced the frequency of further episodes.

A prospective study of the natural history of idiopathic non-proteinuric hematuria

In a prospective study of idiopathic glomerulonephritis we determined the natural history of 49 adult patients (12 primary IgA nephropathy, 13 thin GBM nephropathy, 20 normal renal tissue and 4 miscellaneous nephropathies) who presented with idiopathic non-proteinuric non-azotemic hematuria of at least six months duration, in the absence of hypertension and with a negative urological work-up. The median follow-up was 11 years with a range of 8 to 14 years. At the end of the follow-up, renal function had remained stable in all subsets except for those with miscellaneous disease. Hematuria was still present in all patients with thin GBM nephropathy, in all but two patients with IgA nephropathy who went into immunopathological remission, in three out of four miscellaneous nephropathies, and in seven out of 20 patients with normal renal tissue. Of the latter patients five had a history suggestive of urolithiasis at follow-up, which was in the absence of hypercalciuria and hyperuricosuria. Seven thin GBM patients, five IgA nephropathy patients and three miscellaneous nephropathies developed hypertension; the incidence of hypertension in each subset was significantly higher than in patients with normal renal tissue. This study shows that in young adults with idiopathic chronic non-proteinuric hematuria of four years duration, renal biopsy will give a definite diagnosis in 86% of the patients, and that those patients with so-called minor glomerular diseases are at high risk for hypertension. Those patients with normal renal tissue have a high incidence of urolithiasis and should have a urological follow-up.

Loin pain-hematuria syndrome associated with thin glomerular basement membrane disease and hemorrhage into renal tubules

Loin pain-hematuria (LPH) syndrome is a poorly understood disorder in which the patients, mainly young women, experience unexplained severe chronic unilateral or bilateral flank pain associated with gross and/or microscopic hematuria. By contrast, thin glomerular basement membrane (GBM) disease is generally thought to be a benign disorder, affecting males and females equally, in which the major manifestation is asymptomatic microscopic hematuria. Herein we describe seven patients (6 females, 1 male) in whom thin GBM appeared to be the cause of the LPH syndrome. The gross hematuria in these patients could be attributed to thin GBM disease because the renal biopsy demonstrated red cells in renal tubules (indicating glomerular hematuria) and the only glomerular abnormality present with thin GBM. In addition, the other causes of gross hematuria were excluded by appropriate testing. The flank pain in these patients might also have been the result of their thin GBM disease. This is suggested by renal biopsy findings of multiple renal tubules filled with red cells, apparently occluding the tubules. We suggest that occlusion of a relatively small fraction of renal tubules could cause renal pain if back-leak of glomerular filtrate occurred that was of sufficient magnitude to expand renal parenchymal volume and stretch the renal capsule. Preliminary observations suggest that treatment with the angiotensin converting enzyme (ACE) inhibitor enalapril importantly reduces the frequency and severity of the episodes of gross hematuria and flank pain in most patients. ACE inhibition might decrease glomerular hemorrhage in patients with think GBM by decreasing glomerular hydrostatic pressure. We conclude that (1) Thin GBM disease can be the cause of gross hematuria, apparently as a result of rupture of thin GBM. (2) Rupture of thin GBM resulting in hemorrhage into renal tubules may be the cause of the flank pain and gross hematuria in some patients with the LPH syndrome.

Isolated hematuria in adults: IgA nephropathy is a predominant cause of hematuria compared with thin glomerular basement membrane nephropathy

We examined kidney biopsy specimens obtained from 40 adult patients with isolated hematuria to determine the renal pathology and the incidence of thin glomerular basement membrane nephropathy (TGBMN). Light microscopy showed minor glomerular abnormalities in 26 patients (65%), focal and segmental lesions in 3 patients (8%), and mild diffuse proliferative glomerulonephritis in 11 patients (28%). Immunofluorescence microscopy showed IgA nephropathy (IgA-N) in 16 patients (40%), in whom no progressive lesions were identified. We measured the glomerular basement membrane (GBM) thickness using electron microscopy, and TGBMN was identified in 4 patients (10%). Our results suggest that IgA is a major pathological finding in adult patients with isolated hematuria. GBM thinning does not appear to be a major cause of glomerular hematuria.

An ultrastructural study of glomerular basement membrane in rheumatoid arthritis patients with urinary abnormalities

We measured the thickness of the glomerular basement membrane (GBM) in 48 rheumatoid arthritis (RA) patients with proteinuria and/or hematuria and studied its relationship to clinical features of RA. Ten cases with minor glomerular abnormalities, renal cancer, donor of renal transplantation, were studied as controls. Secondary glomerular diseases and hereditary thin basement membrane disease (TBMD) were excluded. Mean GBM thickness was 289 +/- 74 nm (mean +/- SD) in RA patients, which was significantly thinner than that of control group (342 +/- 38 nm) (p < 0.01). Mean GBM thickness were 276 +/- 72 nm and 336 +/- 68 nm in RA patients with and without gold sodium thiomalate (GST) treatment, respectively (p < 0.05). Mean GBM thickness of RA patients without GST and controls were not different statistically, but RA patients with GST had significantly thinner GBM, compared with controls (p < 0.01). The mean thickness of GBM were also 274 +/- 69 nm and 344 +/- 72 nm in RA patients with and without hematuria, respectively (p < 0.01). According to these results, we suspect that the thinning of GBM in RA patients may be related to GST treatment.

Estrogen receptors in the human male bladder, prostatic urethra, and prostate. An immunohistochemical and biochemical study

The distribution and quantity of estrogen receptors (ERs) in the human male bladder, prostatic urethra and the prostate were studied in eight males with recurrent papillomas of the bladder or monosymptomatic hematuria (median age 61 years), 14 men undergoing transurethral resection due to benign prostatic hyperplasia (median age 70 years), and nine men undergoing cystectomy due to malignant tumour of the bladder (median age 70 years). In the first group of patients, biopsies for immunohistochemical examination were obtained from the bladder vault, bottom, both side-walls, the trigone area, and the mid-portion of the prostatic urethra, and in the second group from three locations of the prostatic urethra (bladder neck, mid-portion and veramontanum). In the third group, tissue specimens were taken from the vault of the bladder, prostatic urethra, and the prostate, for immunohistochemical as well as biochemical analysis. In the first group, ERs were found in three out of eight specimens of the prostatic urethra, and in one of these, ERs were confined to periurethral glands. ERs could not be demonstrated in any of the bladder-biopsies. In the second group, ERs were not found in the bladder neck, but were seen in four preparations from the veramontanum and in two from the midportion of the urethra. ERs were located in the urothelium and periurethral glands. In the third group, ERs were seen immunohistochemically in the prostatic urethra (two cases) and the prostatic stromal tissue (two cases). ERs could be demonstrated in the bladder neither by immunohistochemistry nor biochemically.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bladder pheochromocytoma]

OBJECTIVES

The present study reports on a case of paraganglioma of the urinary bladder and briefly reviews the literature.

METHODS/RESULTS

The patient presented with gross hematuria and no history of hypertension. The pathological findings were diagnostic of paraganglioma of the urinary bladder.

CONCLUSIONS

Extra-adrenal pheochromocytoma is uncommon. Although it usually presents with typical symptoms, these are also determined by tumor location. Currently, there are no anatomopathological criteria to distinguish the benign from the malignant form.

Flow cytometry of urinary erythrocytes for evaluating the source of haematuria

Morphological examinations of urinary erythrocytes can be of diagnostic help in the initial evaluation of haematuria. Dysmorphic red blood cells are known to indicate a glomerular origin of bleeding. Automated flow cytometry produces objective measurements, but is hampered by disturbing signals from urinary debris. The present study is based on both volumetry and densiometry of red blood cells by the Technicon H-1TM system. Urines from 63 patients with both low grade and macroscopic haematuria were examined. The test sensitivity for detecting a non-glomerular source of bleeding was 0.75 (specificity: 0.86). After excluding 20 samples with either a low red cell count or a density below 1005, the sensitivity rose to 0.93 with a corresponding specificity of 1.00. The present findings suggest that partial reinterpretation of the autoanalyser data will enhance the diagnostic power of flow cytometry. This method could be made suitable for routine clinical use.

[Detection of glomerular and non-glomerular red blood cells by automated urinary sediment analyzer]

There is increasing interest in the examination of urine sediment to differentiate between glomerular and non-glomerular hematuria. A newly developed automated urinary sediment analyzer was used for this purpose. It clearly recognized red blood cells, white blood cells, epithelial cells, bacteria and crystals by their cell size and fluorescent intensity. Ninety-eight urine samples from 31 glomerular and 67 non-glomerular lesions were analyzed by the analyzer and 69 samples, by light microscopy. According to the analysis of their histograms, a forward scatter (FSC) intensity of less than 126, where 80% of the smaller red blood cells were observed, was diagnosed as glomerular hematuria. A FSC intensity of more than 84, where 80% of the large red blood cells were counted, was non-glomerular hematuria. An FSC intensity between 84 and 126 was considered to be the overlap zone of glomerular and non-glomerular hematuria. The sensitivity for glomerular red blood cells was found to be 100% and specificity, 92.54% by means of flow cytometric analysis. On the other hand, light microscopic analysis yielded 95.83% sensitivity and 93.33% specificity for glomerular lesions. Flow cytometric analysis of the urinary red blood cells was concluded to be a fast, simple and reliable method to differentiate glomerular and non-glomerular hematuria.

Repeat testing for haematuria and underlying urological pathology

OBJECTIVE

To assess the incidence of urological pathology in a group of patients referred for the investigation of haematuria and whose symptoms had resolved at the time of investigation.

PATIENTS AND METHODS

The results from examination of 395 patients attending for investigation of haematuria were analysed. The group comprised 198 men and 197 women with a mean age of 51 years (range 19-73).

RESULTS

In 220 patients (56%) no evidence of haematuria was detected despite its diagnosis in all patients at the time of referral. One-hundred and thirteen patients (51%) without detectable haematuria had urological pathology and 16 of these (14%) had an underlying malignancy in the urinary tract.

CONCLUSION

Repeat urine analysis to determine whether haematuria persists has been considered as a way to define a high risk group which requires urgent investigation. Our results clearly indicate that the finding of haematuria, even in one urine specimen, warrants full urological assessment.

Loin pain-hematuria syndrome with a distinctive vascular lesion and alternative pathway complement activation

We describe a 48-year-old woman with loin pain-hematuria syndrome. Her renal abnormalities included conspicuous microaneurysmal and glomeruloid (plexiform) angiomatous changes. The deposition of both properdin and the C5b-9 complex, as well as the usual C3, in arterioles argues for complement activation. To our knowledge, neither of these features has been previously described. We speculate about the cause of loin pain-hematuria syndrome and note the uncommonness of this entity in the United States as opposed to Great Britain.