Role of 5-aminolevulinic acid in the diagnosis and treatment of superficial bladder cancer: improvement in diagnostic sensitivity

OBJECTIVES

To use 5-aminolevulinic acid (5-ALA) in diagnostic cystoscopy and during transurethral resection of the bladder (TURB) to treat transitional cell carcinoma. The efficacy of this new technique was compared with standard cystoscopy.

METHODS

The 5-ALA, instilled in the bladder 2 hours before cystoscopy, makes the pathologic tissue fluorescent when illuminated with blue light (375 to 400 nm). This allows a better recognition of the neoplastic forms for both diagnostic and therapeutic purposes during TURB. This method has been used since May 1997 on 49 patients in whom bladder tumor was diagnosed either immediately or during postchemotherapy follow-up.

RESULTS

One hundred seventy-nine biopsies were taken of fluorescent and nonfluorescent areas (3.5 per patient) to check the effectiveness of the new method compared with standard cystoscopy. A good correlation was found between 5-ALA cystoscopy and the histopathologic diagnosis, with a good sensitivity (87%). The 5-ALA cystoscopy allowed the diagnosis of a tumor in 24 patients with negative standard cystoscopic findings. Furthermore, 5-ALA cystoscopy detected 7 cases of carcinoma in situ. Neither local nor systemic (because of endovesical instillation) side effects were noted.

CONCLUSIONS

We believe that 5-ALA could be routinely used in the diagnosis of superficial bladder tumors, as it was shown to improve the diagnostic sensitivity for carcinoma in situ and to reduce the risk of recurrence related to missed cancerous lesions or incomplete TURB.

Percutaneous sclerotization of simple renal cysts with 95% ethanol followed by 24-48 h drainage with nephrostomy tube

AIM OF THE STUDY

We propose some technique devices for treating simple renal cysts with percutaneous puncture (PCN) to reduce recurrences.

MATERIALS AND METHODS

Between January 1995 and December 1998, a series of 42 patients, 13 females and 29 males, ranging in age between 49 and 73 were treated for symptomatic kidney cystic disease. The cysts varied between 7.4 and 13.6 cm in diameter and from 100 to 570 cm(3) in volume. This technique consists of echo-guided emptying of the cyst, and slowly inserting a quantity of pure 95% ethanol, equivalent to about 1/3 of the cyst volume, into the cavity. This acts as a sclerosant agent on the cyst walls. The protocol of this technique also includes positioning a curled drainage catheter, for 24-48 h, in suction, to ensure a correct collapse of the cyst walls and to avoid cyst recurrence.

RESULTS

Of the 42 patients treated, only 4 did not complete the protocol. In 3 cases, the patients were not able to stand the procedure because of intense pain during cyst filling with alcohol. The other patient had intracystic hemorrhage. The results were evaluated by ultrasonography at 7 days post-operatively and then at 1, 3, 6, 9 and 12 months later. There was a further follow-up lasting from 12 to 36 months. Of 38 patients treated, 29 (76%) did not have any recurrence. 8 patients (21%) developed a small liquid layer of 3-4 cm, which did not enlarge in subsequent check-ups. We observed a recurrence, which spontaneously reduced in volume, only in 1 patient.

CONCLUSIONS

This procedure was simple to apply in an out-patient setting and used low-cost materials which are easily obtained. Moreover, the results appear to confirm the validity of this technique.

The deletion polymorphism of the angiotensin-converting enzyme is associated with nephroangiosclerosis

The D allele of the angiotensin-converting enzyme (ACE) gene has been linked with diabetic nephropathy and IgA glomerulonephritis and with faster renal disease progression. The association of this allele with nephroangiosclerosis has been scarcely investigated. We have tested this association in 45 hypertensive patients (all whites) with well defined nephroangiosclerosis (diagnosis established on the basis of renal biopsy in all cases) and moderate to severe renal failure. As studies of genetic association of small size often produce conflicting results, besides a control group of 343 Italian patients with essential hypertension and normal renal function, we elected to use also a very large control group of race-matched subjects taken from a meta-analysis of 27,565 whites. The proportion of patients with the D allele (64%) was higher in patients with nephroangiosclerosis than that in Italian hypertensives (54%) and in whites (54%). DD and DI genotypes were more prevalent in patients than in control groups. The dominant model (DD and DI v II: nephroangiosclerosis v Italian controls: chi2 = 6.19, P = .012; nephroangiosclerosis v whites chi2 = 6.86, P = .009) fitted the data better than the codominant and the recessive model (P < or = .022). The D allele is associated with nephroangiosclerosis with a dominant effect in the sample of patients studied. Although intervention studies are needed to see whether these findings imply a causal association, our data suggest that this allele may at least act as disease marker in nephroangiosclerosis.

3 R study: renal outcome in renal ischemia: revascularisation or medical treatment

Ischemic nephropathy refers to the kidney damage following stenosis or an obstructive lesion in the main kidney arteries. This disorder has been overlooked in the past and a more rational and specific use of clinical criteria, and the development of not very invasive techniques with a good diagnostic accuracy such as spiral CT angiography, NMR angiography and echo-colour-Doppler have improved our ability to identify these patients. It is therefore likely that, in the next few years, we will find ourselves treating an increasing number of patients with renovascular ischemic disorders. Transluminal angioplasty and, more recently, the use of endovascular stents, have led to a marked improvement in the treatment of stenoses and, together with vascular surgery, allow to treat almost all patients with this disorder. There is, however, a lack of prospective and controlled studies, which demonstrate the long term benefit of revascularization treatment, as compared with optimum conservative treatment in reducing cardiovascular mortality, cardiovascular events and preserving renal function. The Ischemic Nephropathy Study Group of the Italian Society of Nephrology has organized a prospective, controlled study over a period of three years, aimed at comparing the effect of revascularization versus medical therapy in 300 patients with renal artery stenosis, ranging between 50 and 90 per cent, who will be randomly assigned to the two treatments. End point will be cardiovascular mortality and morbidity and need for renal replacement therapy.

Ischemic nephropathy

Ischemic nephropathy, involving stenotic lesions in the renal arteries, associated with renal insufficiency, is now recognized as a frequent disease. It may be responsible for a significant proportion of end stage renal disease, at least in the Caucasian population. Some non-invasive but reliable techniques such as echo-color-Doppler, gadolinium-enhanced magnetic resonance and spiral CT angiography are now available for diagnosis. Revascularization with either angioplasty, stent or surgery improves renal function in many patients. In the near future systemic and/or local medical therapy will provide better answers for renovascular disease.

Renovascular disease in diabetes mellitus: treatment by percutaneous transluminal renal angioplasty

BACKGROUND

Diabetes mellitus is an important cause of end-stage renal failure (ESRF). Although classic diabetic nephropathy accounts for the majority of patients reaching ESRF, renovascular disease, which is frequent in such patients, plays an increasingly important role. Percutaneous transluminal renal angioplasty (PTRA) has been proven to be an efficacious measure for renal revascularization.

METHODS

Ninety-nine patients with diabetes mellitus and renal artery stenosis, corresponding to 16.6% of the entire population of diabetic patients, were treated by PTRA or with the Palmaz-Schatz stent in our clinic. Technical success was achieved by PTRA in 92/99 patients, in 10 patients a Palmaz-Schatz stent was implanted.

RESULTS

Hypertension was cured in eight and improved in 44 patients. In 47 patients, there was no impact on blood pressure. An improvement in renal function was evident 1 month after PTRA in 8/27 patients. A further improvement occurred in another four patients after 6 months. The re-stenosis rate was 22% after 5 years. Serious complications occurred in seven patients (one patient required surgery and two patients had regular dialysis treatment).

CONCLUSIONS

Renovascular disease is an important cause of ESRF in diabetic patients. PTRA is a valid tool to revascularize renal artery stenosis and improve blood pressure control and renal function both in diabetic and non-diabetic patients.

Ischemic nephropathy: diagnosis and treatment

Recent epidemiologic studies have shown that ischemic nephropathy secondary to stenosis or obstruction of the main renal arteries in the cause of renal insufficiency in a growing number of subjects. The clinicians dealing with renovascular disease need non-invasive diagnostic tools and effective therapeutic measures to successfully face the problem. Duplex ultrasound scanning is a non-invasive, non expensive diagnostic tool and when an experienced, dedicated technologist is available, it should be suggested as the first-step test. Magnetic resonance angiography and spiral CT angiography play an ancillary role in detecting patients with renovascular disease. Captopril-enhanced (CE) scintigraphy when positive indicates the activation of intrarenal renin-angiotensin system and may be useful in detecting patients with renal artery stenosis. Moreover, CE scintigraphy can play an important role in the choice between the revascularization and a wait-and-see approach. As a matter of fact, the presence of an activated intrarenal renin-angiotensin system furnishes theoretical as well practical reasons in favour of the revascularization. In the recent years percutaneous transluminal renal angioplasty has become the cornerstone of therapeutic strategy. The introduction of the metallic stent has dramatically improved its efficacy in ostial stenoses and has reduced the indication for surgical revascularization.

The kidney as a victim of essential hypertension

Over the past decade the prevalence of end stage renal disease has risen progressively in industrialized societies. According to the data of renal disease Registries hypertensive nephrosclerosis appears to be a very important cause of progressive renal disease. However epidemiological data on the risk of hypertensive patients to develop renal failure offer contrasting results. In observational longitudinal studies a higher rate of decline in renal function is generally found in hypertensive compared to normotensive subjects. On the other hand, the inability of antihypertensive therapy to influence kidney destiny emerges from the large majority of interventional studies on mild-moderate hypertension in caucasian patients. At variance, the role of hypertension as etiologic factor seems to be sufficiently clear in African Americ: hypertension is more common, more severe and less easily to handle in a black patients. It is probable that the diagnosis of hypertensive nephrosclerosis is a confounding label laidon a heterogeneous group of diseases comprising a true hypertensive nephropathy (typical of black patients) along with occlusive or atheroembolic diseases common in aged caucasian patients. Our future efforts will have to be directed towards better identifying and properly classifying the various subgroup in order to optimize the treatment and prevent renal failure.

Recent data on hypertension and progressive renal disease

Arterial hypertension may favour the progression of non-diabetic primary renal disease and participate in the appearance of atheromatous renovascular disease. In AIPRI trial (ACE-inhibition in the progression of renal insufficiency) the ACE-inhibitor benazepril was able to protect patients with mild-to-moderate renal disease against the progression of renal insufficiency. Some clinical observations suggest that in many aged patients with long-standing hypertension the appearance of renal failure may be related to atheromatous reno-vascular disease. This disease may be responsible for progressive renal failure through renal artery stenosis and/or cholesterol microembolization.

Hypertension and renal dysfunction

The various end-stage renal disease registries have documented a progressive and substantial increase of hypertension as a cause of renal failure. However, the relationship between essential hypertension and progressive renal disease is unclear. Black hypertensive patients, who are more prone to renal failure during their middle age, have a peculiar hypertensive nephropathy possibly requiring an aggressive antihypertensive therapy. Hypertension-associated progressive renal disease in the Caucasian population usually appears in the elderly and may be related to atheromatous renovascular disease. Only a few hypertensive patients have a true progressive hypertensive nephrosclerosis.

Renal artery angioplasty for renovascular hypertension and preservation of renal function: long-term angiographic and clinical follow-up

OBJECTIVE

Percutaneous transluminal angioplasty of stenoses of the renal artery can be used to treat hypertension and renal insufficiency. Although many studies have been published on the short-term results of this procedure, few long-term studies are available.

SUBJECTS AND METHODS

One hundred ninety-five patients (123 men and 72 women 19-79 years old; mean age, 56 years) with stenosis of the renal artery and hypertension underwent renal percutaneous transluminal angioplasty at our institution. The stenosis was unilateral in 66% of patients, bilateral in 26%, and in a solitary functioning kidney in 8%. Renal insufficiency was present in 31% of patients. After renal percutaneous transluminal angioplasty, long-term clinical and angiographic follow-up was evaluated by life-table analysis.

RESULTS

In patients with fibromuscular disease, blood pressure returned to normal in 57%, improved in 21%, and was unchanged in 21%. In patients with atherosclerotic stenosis, blood pressure returned to normal in 12%, improved in 51%, and was unchanged in 37%. After percutaneous transluminal angioplasty, renal function improved in 48% of patients with renal insufficiency due to bilateral stenosis or stenosis in the single functioning kidney, whereas none of the patients with unilateral stenosis of renal artery and renal insufficiency had any notable improvement. Long-term follow-up showed a high rate (82%) of patency of revascularized arteries and a low rate (21%) of hypertension recurrence at 5 years.

CONCLUSION

Renal percutaneous transluminal angioplasty is useful for treating hypertension and for reestablishing renal function. Its effects on blood pressure and renal function are long-lasting in the large majority of patients.

The diagnostic dilemma of hypertensive nephrosclerosis: the nephrologist's view

The appearance of progressive renal disease in elderly patients with essential hypertension, sometimes irrespective of blood pressure control, is frequently related to the association of hypertension and atheromatous renal disease. This disease may lead to renal failure through a renal artery stenosis and/or chronic microembolization into the kidney. Nonsevere uncomplicated essential hypertension is constantly associated with renal vascular changes that are qualitatively indistinguishable from those related to aging. Notwithstanding the fairly constant presence of so-called benign hypertensive nephrosclerosis in patients with established hypertension, only a subset of these patients show progressive renal damage. Three mechanisms of progression may be at play: (1) a combination of ischemic and hypertensive glomerular mechanisms in some susceptible humans; (2) nonhemodynamic factors such as local immune mechanisms; or (3) the involvement of metabolic abnormalities which favor glomerulosclerosis.

Fibromuscular dysplasia of the renal arteries associated with antiphospholipid autoantibodies: two case reports

A relationship appears to exist between antiphospholipid autoantibodies (APLA) and vascular occlusion, although the exact mechanism is still a matter of debate. We present and comment on two cases of renal artery occlusion in patients with concomitant presence of arterial fibromuscular dysplasia and high APLA titers.

Long-term comparison between captopril and nifedipine in the progression of renal insufficiency

To verify the hypothesis that angiotensin-converting enzyme (ACE) inhibitors possess a unique renoprotective effect in progressive chronic renal disease, we decided to compare the effects of an ACE inhibitor and a calcium antagonist on both hypertension and the progression of non-diabetic renal insufficiency in a long-term study. A four-year, multicenter, prospective, randomized trial was conducted on 142 hypertensive patients (pts) with established chronic renal failure from six Italian nephrology departments. They were on standard antihypertensive therapy with a low-protein diet and underwent twice-monthly surveillance for a one year pre-randomization period. After that year, 121 pts were randomly allocated to captopril or slow-release nifedipine therapies for a three-year study period. The progression of renal insufficiency was monitored every two months. Blood pressure control was significantly better after randomization than during the year of standard antihypertensive therapy. The progression rate before randomization (BR) was definitely higher before than after randomization (AR): Creatinine clearance (CCr) change BR = -0.46 +/- 0.45 ml/min/month, creatinine clearance change AR = -0.23 +/- 0.43 ml/min/month (P less than 0.01). After randomization, the mean blood pressure values were virtually the same throughout the three year period of the study in the two groups treated by captopril (group I), or nifedipine (group II).(ABSTRACT TRUNCATED AT 250 WORDS)

[Duplex and Doppler color echocardiography for the study of renovascular hypertension. Comparison with arteriography]

Doppler US was employed to examine 46 patients with suspected renovascular hypertension (RVI) to detect stenosis/occlusion of the renal artery. In 25 cases duplex-Doppler technique was used, in 19 color-Doppler US, and 2 patients were examined with both methods. Doppler US was always performed before angiography which was considered as the reference gold standard. Using duplex-Doppler US, the diagnosis of renal artery stenosis was based on qualitative (spectral analysis of the waveform and absence of flow signal in cases of renal artery occlusion), and semiquantitative parameters (resistive index). Diagnostic accuracy of duplex US--which was compared with that of angiography--was 83%, its sensitivity was 91.6%, and specificity was 85%. With color-Doppler, two additional quantitative parameters were used (peak systolic frequency shift at the stenosis and stenosis index). In this group of patients sensitivity was 70%, specificity was 100%, and accuracy 85%. The good diagnostic yield of the method is counter-balanced by some limitations--e.g., operator dependence and long examination time (30-40 minutes, especially with duplex US). In the authors' opinion, Doppler technique can be used in the diagnosis of RVI, even though further study is necessary to exactly define diagnostic parameters, and to verify reproducibility and both inter- and intra-observer repeatibility. Technological progress may in the future reduce both difficulty and time of the examination.

Renal functional reserve in patients with a reduced number of functioning glomeruli

Renal functional reserve (RFR) has been reported to be either reduced or absent in patients with renal insufficiency. Our study consisted in measuring RFR by acute protein load (PL) in 3 groups of patients: the first one was composed of 20 patients (pts) with biopsy-proven glomerular disease (GN) and a varying percentage of sclerotic glomeruli (15-70%); the second one consisted of 10 patients with acquired single kidney (SK) and the third group contained 5 patients with surgical ablation of more than 50% renal tissue (LRRM). Twenty-four healthy volunteers were studied as control subjects. The GFR percentage increase (delta GFR%) after PL in CS did not differ from that of the three groups of patients, despite a significant difference in resting GFR (CS = 113 +/- 11 ml/min/1.73 m2: GN 72 +/- 28 ml/min/1.7, p less than 0.01 vs CS; SK 81 +/- 20 ml/min/1.73 m2, p less than 0.01 vs CS; LRRM 45 +/- 10 ml/min/1.7, p less than 0.01 vs CS; Moreover, an inverse correlation was not found either between GFR and the percentage of sclerotic glomeruli in GN (r = 0.01, p = NS) or between GFR and the extent of excised renal tissue in the other two groups (r = 0.38, p = NS). In conclusion, our data do not confirm that RFR is necessarily reduced or absent in patients with a reduced number of functioning glomeruli, nor do they uphold the hypothesis of constant hyperfiltration in the remaining glomeruli.