Glomerular alterations in idiopathic haematuria--ultrastructural and morphometric analysis

Re-evaluation of kidney biopsies has been done along with morphometric analysis of glomerular basement membrane thickness (G.B.M.) in 41 cases of idiopathic haematuria, in whom the initial routine light, immunofluorescent and electron microscopic examination had not shown any significant alterations. Extreme attenuation of G.B.M. (mean thickness of 2581 +/- 488 A) had been found in thirty one patients in contrast to mean GBM thickness of 4295 +/- 470 A found in control group. Absence of any history of familial haematuria in these patients distinguished them from hereditary nephropathies and hence categorized under the term thin basement membrane nephropathy. Follow up of these patients for upto 8 years had shown persistence of symptoms without further deterioration of renal function as well as morphology.

[The clinico-laboratory characteristics of glomerulonephritis]

Results are reported of 83 patients with glomerulonephritis with the hematuria syndrome and 75 patients without hematuria syndrome. 19 clinico-laboratory signs were analyzed. Data indicate that hematuric nephritis may be signaled out in a separate nosological entity necessitating differentiated treatment.

Bracken poisoning and enzootic haematuria in cattle in China

Acute bracken poisoning and enzootic haematuria are believed to have occurred in cattle in China for a long time. It is only in the past 10 years, however, that these diseases associated with the consumption of bracken ferns have been studied in detail and this paper reviews these recent studies. Based on a large scale survey, both conditions were found to be serious problems with a wide geographical distribution, especially in the mountainous regions of southwest China. Epidemiological and experimental work revealed that two species of bracken ferns, Pteridium aquilinum and Pteridium revolutum, were associated with these diseases, but the latter seems more important in China.

The mechanism of glomerular dysmorphic red cell formation in the kidney

The mechanism of glomerular dysmorphic cell formation was studied in a in vitro system simulating the process of concentrated acidic urine formation along the nephron. Red cells suspended in phosphate buffer were exposed to three sequential pH gradients, (1) pH 7.4-6.6, (2) pH 6.6-6.5, and (3) pH 6.5-5.2, accompanying osmolality gradients, (1) 280-1200 mOsm/kg H2O, (2) 1,200-140 mOsm/kg H2O, and (3) 140-1,100 mOsm/kg H2O, respectively, for 15 to 60 min, and red cell shapes were observed by differential interference microscopy. The appearance rate of glomerular dysmorphic cells was 37.7 to 47.1% after finishing all the gradients. The last gradient, simulating the work of the collecting duct, was essential for the dysmorphic cell formation; maximal formation was at the final pH of 5.0 and osmolality of 1,000 mOsm/kg H2O. No dysmorphic cells were observed in gradients simulating alkaline or diluted urine formation. In 10 glomerulonephritic patients, glomerular dysmorphic cells appeared over five times as frequently in concentrated acidic urine as in alkaline or diluted urine. Results of in vitro and patient studies coincided well with each other, suggesting that in glomerulonephritic patients, dysmorphic cells might be produced while red cells are passing through the tubules, where concentrated acidic urine is formed.

[Clinical assessment of patients with microscopic hematuria pointed out by mass screening examination]

We clinically examined 445 patients with positive urine occult blood test found by mass screening examination. Among them, 41 cases had the history of macroscopic hematuria. Urological abnormalities were observed in 169 (41.8%) of the patients with microscopic hematuria, and in 22 (53.7%) of those with a history of macroscopic hematuria. Genitourinary neoplasms were found less frequently in the patients with microscopic hematuria (1.2%) than in those with macroscopic hematuria (22%). We couldn't find a correlation between the degree of hematuria and the severity of the underlying diseases. Hematuria is often thought to appear intermittently, and urinalyses of the patients with so-called significant disease may not be found at the first visit.

Glomerular basement membrane thinning in adults: clinicopathological correlations of a new diagnostic approach

We have studied glomerular basal laminar thickness in biopsy material, using a simple technique involving 16 selected measurements per case. Twenty-nine biopsied cases of adult glomerular haematuria were examined together with 'diseased' controls represented by a variety of glomerulopathies including minimal-change disease and IgA nephropathy. 'Normal' control populations were provided by 13 patients with acute-onset renal failure of non-glomerular origin and nine patients undergoing nephrectomy. Analysis of groups determined by the presence or absence of haematuria, the degree of proteinuria and presence or absence of a diagnostically characteristic immunofluorescence pattern showed that the nine patients with haematuria and proteinuria of less than 200 mg/24 h represented a distinct subpopulation with a mean membrane thickness of 225 nm compared to the control mean of 343 nm (P less than 0.0001). All members of this subpopulation had mean values below an arbitrary cut-off value of 270 nm. Within other specific disease categories, sporadic cases had mean membrane thicknesses below this critical value, indicative of an overlap of pathologies. On short-term follow-up there is no evidence that the 'pure' thin-membrane population are subject to any deterioration in renal function. It is of further interest that eight of nine thin-membrane 'syndrome' cases were O Rh positive. This finding may provide a starting point for investigation of a specific genetic defect.

IgA nephropathy: acute renal failure, acute tubular necrosis, and features of postinfectious acute glomerulonephritis

From 1976 to 1987 on our Nephrological Unit, 57 patients with IgA nephropathy (IgAN) proven by renal biopsies were found. Three of those presented with acute tubular necrosis (ATN) and glomerulitis, without extrarenal predisposing cause in two; and showed, as prominent manifestation, a severe acute renal failure syndrome (ARFS), needing dialytic treatment. All three had hematuria, which was macroscopic in two and microscopic in one. Thus the prevalence of the association of glomerulitis and ATN was about 5.2%. There was complete recovery of renal functions in all three patients, but the usual symptomatology of IgAN. Two patients presented polymorphonuclear neutrophils infiltration of glomerular capillaries and in one of them, electron-dense deposits on the epithelial side of glomerular basement membrane ("humps") were observed, as well as those identified in the mesangial area. The glomerular polymorphonuclear neutrophils infiltration and endothelial cells proliferation (cases 1 and 3), the presence of "humps" (case 1), high antistreptolysin O (ASO) titers (cases 1 and 2), and low serum complement levels (case 1), suggest the possibility that antigens able to cause postinfectious glomerulonephritis (streptococcal or not) could induce in some individuals, by another immunopathogenetic route, mixed histopathological and clinical features of IgAN and postinfectious glomerulonephritis.

Phaeochromocytoma--an unusual cause of haematuria

A patient was admitted to hospital because of haematuria. A papillomatous bladder tumor was removed. Histological examination revealed a phaeochromocytoma. Fourteen days postoperatively the urinary excretion rates of catecholamines were elevated but normalized afterwards. Abdominal computed tomography and metaiodobenzylguanidine scintigraphy were normal. No hypertension or characteristic micturitional attacks preceded removal of the tumor.

Bladder cancer in spinal cord injury patients

A total of 8 cases of bladder cancer in spinal cord injury men (4 quadriplegics and 4 paraplegics) was seen at 3 medical centers since 1985. All 8 men had a hyperreflexic bladder and 3 of them had associated detrusor-sphincter dyssynergia. Upper tract changes were noted in 4 patients: 2 with distal ureterectasis and 2 with mild hydronephrosis. Only 1 of these men did not have historical films with which to compare results. Histology was transitional cell carcinoma in 6 men and squamous cell carcinoma in 2. Four patients presented with muscle invasion and 1 presented with diffuse carcinoma in situ involving the penile urethra. Three patients presented with superficial transitional cell carcinoma and 2 of them had progression to muscle invasion within 6 and 11 months. All but 2 of the patients with invasive disease underwent a radical operation and urinary diversion. Although followup is short (range 6 to 17 months), 5 patients are well with no evidence of disease and of the 3 who died 2 had no evidence of disease. We found a lower incidence of bladder cancer and a decreased percentage of squamous cell carcinoma than in previous reports, which may reflect an improvement in the lower tract management of these patients. Survival with appropriate bladder cancer treatment appears to correlate well with that of the ambulatory population.

Urinary tract injuries in multiply-injured patients: a rational guideline for the initial assessment

In a retrospective study involving 866 multiply-injured patients we demonstrated urinary tract injuries in 72 patients (8.3 per cent), 17 (2 per cent) of which were serious. Haematuria was a frequent finding in multiply-injured patients. In patients with serious lesions of the urinary tract, more than 35 RBCs/HPF in the sediment or macroscopic haematuria were found. All major injuries were demonstrated by the emergency intravenous urogram. Ultrasonography demonstrated contusions of the kidney or bladder and ruptures of the kidneys, but was not reliable in diagnosing ruptures of the bladder. Of 155 patients with a pelvic fracture 13 (8 per cent) had lower urinary tract injuries. In all these patients the fracture was located in the pubic arch. If a retrograde urethrogram was performed in these patients all urethral lesions were detected. We propose a rational guideline, which guarantees diagnostic accuracy of serious injuries of the urinary tract after blunt trauma, while interfering as little as possible with the resuscitative and diagnostic procedures in severely injured patients.

C3 deposition in IgA nephropathy in children and adolescents

The aim of this study was to assess the significance of C3 deposition in IgA nephropathy in children and adolescents. One hundred and two patients aged 5-21 years (57 male and 45 female) were studied. The findings of C3 deposition were classified into 8 groups by immunofluorescent (IF) pattern and intensity as follows: group MC3+ (N = 12): mesangiocapillary pattern and 3+ in intensity; group MC2+ (N = 13): mesangiocapillary and 2+; group MC1+ (N = 4): mesangiocapillary and 1+; group M3+ (N = 11): mesangial and 3+; group M2+ (N = 24): mesangial and 2+; group M1+ (N = 18): mesangial 1+; group S (N = 12): only segmentally positive; and group N (N = 8): negative. Histological changes were scored semiquantitatively as an activity index (cellular proliferation, necrosis, interstitial cell infiltration, and cellular crescents) and a chronicity index (mesangial sclerosis, segmental and global glomerular sclerosis, fibrous crescents, adhesion and tubulo-interstitial change). IF findings were scored semiquantitatively and laboratory findings were also studied. The following results were obtained: 1) The scores of total activity index in MC groups were higher than in the M, S or N groups, and the greater the degree of C3 deposition, the higher the score; 2) Such result was not evident in the chronicity index; 3) High IF scores of IgG and IgM were found in the MC3+ and MC2+ groups; 4) Hematuria was more severe in MC3+ and MC2+ than in other groups, and proteinuria was more prominent in the MC than other groups. Thus the degree of C3 deposition was parallel with histological activity and urinary findings.

[Diagnosis of glomerular microhematuria. Study of general practice-relevant form stability and stainability of dysmorphic glomerular erythrocytes]

The high diagnostic sensitivity and specificity of microscopically visible, typically glomerular dysmorphic erythrocytes for identification of the cause of glomerular bleeding is now recognized all over the world. Although glomerular dysmorphic erythrocytes are simple to detect in phase-contrast microscopy, immediate microscopic diagnosis is still indispensable, since a change in the morphology of the erythrocytes with reduced accuracy of the diagnosis must be anticipated because of the high autolytic potency of urine. It may be postulated that this need for immediate diagnosis has led to neglect of the method, owing to the high workload in hospitals and doctor's surgeries. Moreover, a physician who does not carry out microscopic investigations him/herself or who lacks experience with the method has not been able to use this diagnostic technique, since it appeared impossible to send urine samples by post. In the context of a pilot study comprising 30 patients, 10 of whom had developed histologically confirmed glomerulonephritis, we have shown that glomerular dysmorphic erythrocytes have manifest form stability for at least 3 days. The preservative used was thiomersal. Also, the urine can be investigated regardless of the time lapse since sampling, even after Papanicolaou alcohol staining, with no alteration of erythrocyte morphology by alcoholic dehydration, which would limit the value of the diagnosis. The practicability of the form stability of glomerular erythrocytes can be exploited in everyday medical routine. This would increase the rate of early diagnosis of glomerulonephritis and make it more likely that patients will receive adequate nephrological therapy in good time.

[Clinicopathological study of patients presenting hematuria and proteinuria by renal biopsy]

We performed 308 series renal biopsies during 4 years (1985-1989) and 289 cases were examined by light microscopic, electron microscopic, or immunofluorescent study. Clinically, chronic nephritic syndrome was most frequent (55.4%), followed by nephrotic syndrome (15.1%), and recurrent or persistent hematuria (12.8%). Pathologically, IgA nephropathy was most popular (39.3%), followed by normal glomerulus (9.1%), and thin basement membrane disease (8.7%). Glomerulonephritis clinically recognized with recurrent or persistent hematuria, hardly showing proteinuria, in 81.6% of the cases, consisted of normal glomerulus, or thin basement membrane disease by electron microscopic and immunofluorescent examinations. The remainder (18.4%) was with IgA nephropathy, which was histologically mild. On the other hand, cases of chronic nephritic syndrome (latent type) with persistent proteinuria and hematuria were with glomerulonephritis of various types including IgA nephropathy in 78.8% of the total cases. Therefore, proteinuria is an important sign of glomerulonephritis. In investigation in different age groups, IgA nephropathy was seen in about 40% of both pediatric and adult cases, whereas minor glomerular abnormalities and thin basement membrane disease were more frequent in pediatric cases. Tubulo-interstitial lesions and glomerular lesions in vascular or metabolic diseases were recognized more in adults than in children. Membranous glomerulonephritis (17 cases including 4 pediatric cases), complicated with malignant tumors such as bladder or rectal cancers and hepatoma was found in 3 aged patients. Examination for malignant tumor would be necessary for aged patients with membranous glomerulonephritis. As for the prognosis of IgA nephropathy, because histological changes of IgA nephropathy varied widely from very mild state to severe state, the prognosis is not always good.(ABSTRACT TRUNCATED AT 250 WORDS)

Haemostatic changes in the loin pain and haematuria syndrome: secondary to renal vasospasm?

Twenty-five patients (seven male, 18 female) were diagnosed as having the loin pain and haematuria syndrome. Presenting symptoms were either loin pain alone or pain associated with macroscopic or microscopic haematuria, and were longstanding, having been present for mean of 9.3 years in males, and 10 years in females. Ten patients described symptoms of passing gravel or renal stones but these were only demonstrated radiologically in two patients. Investigation of all patients showed anatomically normal renal tracts, normal renal function, and no significant proteinuria. Phase-contrast microscopy during episodes of haematuria revealed dysmorphic red cells in all 10 patients studied. Renal biopsies were performed in 20 patients and showed no glomerular pathology, but arteriolar and arterial hyalinosis was seen in 13 of 20 (65 per cent), fibro-elastosis in larger vessels in eight of 20 (40 per cent) and red blood cells in tubules in 13 of 20 (65 per cent) patients. The histological appearance in vessels was similar to that seen in cyclosporin A nephrotoxicity and would be consistent with the hypothesis that regional vasospasm occurs in the cortical circulation. Haematological studies in 22 patients, when compared with age and sex matched controls, showed the presence of circulating platelet aggregates, elevation of plasma beta-thromboglobulin (p less than 0.001), and increased platelet aggregation in response to serotonin and ADP (p less than 0.05 and p less than 0.03, respectively). Plasma concentrations of D dimer (p less than 0.02) and C-reactive protein (p less than 0.03) were also significantly elevated in the patient group. There was no deterioration of renal function during a mean observation period of 3.7 years and no patients developed proteinuria. Treatment was largely supportive; seven patients with intractable loin pain underwent surgical denervation with the relief of pain in four.

[Morphological study of renal changes with age: the possibility of kidney donations by the elderly]

Samples from seventy autopsy cases ranging from 27 to 79 years of age who had shown no evidence of renal or malignant diseases were examined histologically to clarify renal changes with age. We evaluated scores for renal histological change and referred the scores to clinical laboratory data; blood pressure, complete blood counts (RBC count, hematocrit, hemoglobin), serum chemistry values (creatinine, urea nitrogen, total cholesterol, total protein, sodium, potassium, chloride) and urinalysis (protein, sediment). We found the score to be related to serum creatinine level, blood urea nitrogen level and the degree of hematuria but not related to the other factors. The progression of arteriosclerosis, tubulo-interstitial change and global sclerosis were found to be severe with ageing. Also renal weight decreased with increasing age. However there were great differences among individuals in the extent of changes. We could not assume histological changes were generally severe in those of more than 55-65 years of age. It was impossible to clarify renal states only with clinical findings. Some kidneys had severe histological changes though less than 2.0 mg/dl of serum creatinine level. It suggests that living relatives and cadavers over 60 years old can be donors for renal transplantation when there are no significant findings of abnormality in preoperative evaluations of their physical state. If insufficient examinations are done, we cannot determine which of them will be good donors. Therefore preoperative biopsy is the best way to evaluate donor suitability. To evaluate only clinical data, it is necessary that serum creatinine level be less than 1.2 mg/dl, blood urea nitrogen level be less than 23 mg/dl and there be no hematuria.