[In macrohematuria, medication history also needs to be considered : Penicillin-induced immune hemolysis: a case report and review of literature]

BACKGROUND

Drug-mediated immune hemolysis is a rare but potentially life-threatening condition. Based on a case of penicillin-induced immune hemolysis, a structured literature review of case reports and studies on penicillin-mediated Drug-Induced Immune Hemolytic Anemia (DIIHA) was carried out.

CASE REPORT

A 28-year-old male patient presented to the emergency department with gross hematuria and non-specific abdominal complaints. The patient had a 10-day history of respiratory infection with bacterial tonsillitis, treated orally with penicillin V on an outpatient basis. Laboratory diagnostics detected pathologically altered direct and indirect hemolysis parameters. After stopping the medication, the patient's condition could be stabilized.

CONCLUSION

Diagnosis of penicillin-mediated immune hemolysis requires structured cooperation between clinic and laboratory, as clinical and serological findings may be highly variable with the risk of misdiagnosis. Due to the rarity of the disease, this case report is intended to raise awareness with respect to the triad of abrupt drop in hemoglobin levels in connection with drug therapy and in combination with a strongly positive direct Coombs test.

The Role of Superb Microvascular Imaging and Shear Wave Elastography in the Prediction of Hemorrhage Complications After Renal Parenchyma Biopsy

OBJECTIVES

The aim of study was to evaluate the diagnostic utility of the renal parenchyma elasticity with the shear wave elastography (SWE) and microvascularization with the superb microvascular imaging (SMI) technique before kidney biopsy and to predict the complication of hemorrhage before kidney biopsy.

METHODS

A total of 75 patients were included in the prospective study. Before the biopsy, vascularity features of the kidney parenchyma in the area to be biopsied were assessed by SMI and parenchymal stiffness by SWE and were examined by 2 independent radiologists.

RESULTS

A statistically significant difference was found in the SMI and SWE values between the groups with and without hematoma and hematuria when compared with the Student t test and Mann-Whitney U test ( P < 0.05). The SWE hardness cutoff value, which maximizes the prediction of the development of hematuria, was found to be 18.40 kPa, and the sensitivity and specificity values were 84.4% and 62.8%, respectively. In SMI vascularity index values, the cutoff value was found to be 0.247410800 kPa, and sensitivity and specificity values were 81.3% and 83.7%, respectively. The cutoff value of the SMI vascularity index values that maximized the prediction of hematoma development was 0.297009650, and the sensitivity and specificity values were 87% and 87%, respectively.

CONCLUSIONS

We believe that evaluating and standardizing the microvascularization and elasticity of the kidney parenchyma before a percutaneous kidney biopsy will be potentially useful as a guiding method in the prediction of postbiopsy hemorrhage development.

Sex-Dependent Differences in Blood-Urine Barrier Are Subtle but Significant in Healthy and Chronically Inflamed Mouse Bladders

The urothelium is a vital permeability barrier that prevents the uncontrolled flow of urinary components into and out of the bladder interstitium. Our study addressed the question of possible sex-specific variations in the urothelium of healthy mice and their impact on chronic bladder inflammation. We found that healthy female bladders have a less robust barrier function than male bladders, as indicated by significant differences in transepithelial electrical resistance (TEER) values. These differences could be attributed to detected higher claudin 2 mRNA expression and a less pronounced glycocalyx in females than in males. In addition, TEER measurements showed delayed barrier recovery in chronically inflamed female bladders. We found subtle differences in the expressions of genes involved in the regulation of the actin cytoskeleton between the sexes, as well as pronounced urothelial hyperplasia in females compensating for attenuated barrier function. The identified genetic variations in glycosylation pathways may also contribute to this divergence. Our findings add to the growing body of literature on the intricate sex-specific nuances of urothelial permeability function and their implications for chronic bladder inflammation. Understanding these differences could lead to tailored diagnostic and therapeutic approaches in the treatment of bladder disorders in the future.

The steroid-sparing effects of a mycophenolate mofetil-based regimen in the management of immunoglobulin A nephropathy in patients with histologically active lesions: A comparison with a control cohort receiving conventional therapy

INTRODUCTION

While the use of different immunosuppressants has been investigated in immunoglobulin A nephropathy, further investigation is needed to assess the effect of a regimen of mycophenolate mofetil combined with a short course of glucocorticosteroids in the subset of patients with histologically active features. We compared the efficacy and safety of a combined regimen of mycophenolate mofetil and glucocorticosteroids to a conventional regimen of glucocorticosteroids alone in patients with immunoglobulin A nephropathy who have active lesions and major urinary abnormalities.

METHODS

This retrospective study involved 30 immunoglobulin A nephropathy patients with active histological lesions, 15 of whom were treated with both mycophenolate mofetil 2 g/day for 6 months and 3 pulses of 15 mg/kg methylprednisolone, followed by a short tapering schedule of oral prednisone. The control group was made up of the remaining 15 clinically- and histologically-matched patients treated with glucocorticosteroids alone according to a validated schedule, i.e., 1 g of methylprednisolone given intravenously for 3 consecutive days, followed by oral prednisone 0.5 mg/kg every other day for 6 months. At diagnosis, all patients had urinary protein excretion > 1 g/24 h and microscopic hematuria.

RESULTS

At the end of the first year of follow-up (30 patients) and after 5 years (17 patients), there were no differences between the two groups in terms of urinary abnormalities and functional parameters. Both regimens achieved a statistically significant decrease in 24-h urinary protein excretion (p < 0.001) and a reduction of microscopic hematuria. However, the mycophenolate mofetil-based regimen allowed a cumulative sparing dose of 6 g of glucocorticosteroids.

CONCLUSION

In this single center study on immunoglobulin A nephropathy patients with active lesions and major urinary abnormalities and at increased risk of glucocorticosteroid-related complications, a mycophenolate mofetil-based regimen demonstrated similar outcomes in terms of complete response and relapse (at 1 and 5 years) compared to a conventional glucocorticosteroid-based protocol, while achieving a consistent reduction of glucocorticosteroid cumulative dose.

Urinary isomorphic red blood cells for the prediction of disease severity and renal outcomes in MPO-ANCA-associated vasculitis: a retrospective cohort study

BACKGROUND

Hematuria is common in myeloperoxidase anti-neutrophil cytoplasmic antibody associated vasculitis (ANCA-MPO). Previous studies have mainly focused on urinary dysmorphic red blood cells and few have reported the clinical significance of isomorphic urinary red blood cells. Therefore, the main aim of this study was to assess the predictive yield  of urinary isomorphic red blood cells for disease severity and renal outcomes in patients with ANCA-MPO associated vasculitis.

METHODS

A total of 191 patients with ANCA-MPO associated vasculitis with hematuria were retrospectively selected and were divided into two groups (with isomorphic red blood cells versus dysmorphic red blood cells) according to the percentage of isomorphic red blood cells on urinary sediment analysis. Clinical, biological and pathological data at diagnosis were compared. Patients were followed up for a median of 25 months and progression to end-stage kidney disease and death were regarded as main outcome events. Additionally, univariate and multivariate Cox regression models were used to estimate the risk factors for end-stage kidney disease.

RESULTS

Out of 191 patients, 115 (60%) had ≥ 70% and 76 (40%) had < 30% urine isomorphic red blood cells. Compared with patients in the dysmorphic red blood cell group, patients in the isomorphic red blood cell group had a significantly lower estimated glomerular filtration rate (eGFR) [10.41 mL/min (IQR 5.84-17.06) versus 12.53 (6.81-29.26); P = 0.026], higher Birmingham Vasculitis Activity Score [16 (IQR 12-18) versus 14 (10-18); P = 0.005] and more often received plasma exchange [40.0% versus 23.7% (P = 0.019)] at diagnosis. Kidney biopsies revealed a higher proportion of patients with glomerular basement membrane fracture in the isomorphic red blood cell group [46.3% versus 22.9% (P = 0.033)]. Furthermore, patients with predominant urinary isomorphic red blood cells were more likely to progress to end-stage kidney disease [63.5% versus 47.4% (P = 0.028)] and had a higher risk of death [31.3% versus 19.7% (P = 0.077)]. The end-stage kidney disease-free survival was lower in patients in the isomorphic red blood cell group (P = 0.024). However, urine isomorphic red blood cells ≥ 70% could not predict the presence of end-stage kidney disease in multivariate Cox analysis.

CONCLUSION

Myeloperoxidase-anti-neutrophil cytoplasmic antibody associated vasculitis patients with predominant urinary isomorphic red blood cells at diagnosis had more severe clinical manifestations and a higher risk of poor renal outcomes. In this respect, urinary isomorphic red blood cells could be viewed as a promising biomarker of ANCA_MPO vasculitis severity and progression.

A pediatric case of IgA nephropathy benefitting from targeted release formulation-budesonide

BACKGROUND

The best treatment for IgAN is still debated. The trials NEFIGAN and NEFIGARD have demonstrated that TRF-budesonide (Nefecon) efficiently and safely reduced proteinuria in adults, leading to FDA approval of Nefecon for adult IgAN. In pediatric IgAN, an etiological treatment does not yet exist, and the main therapies remain RAAS inhibitors and oral steroids. To our knowledge, this is one of the few pediatric reports of TRF-budesonide therapy.

CASE REPORT-DIAGNOSIS/TREATMENT

A 13-year-old boy underwent a kidney biopsy for recurrent macrohematuria and proteinuria, resulting in an IgAN diagnosis (MEST-C score M1-E1-S0-T0-C1). At admission, serum creatinine and UPCR were slightly increased. Three methylprednisolone pulses were performed, followed by prednisone and RAAS inhibitors therapy. However, after 10 months, macrohematuria became constant, and UPCR increased. A new kidney biopsy was performed, showing an increase in sclerotic lesions. Prednisone was discontinued, and a trial with IBD TRF-budesonide 9 mg/day started. One month later, macrohematuria episodes disappeared and UPCR decreased, with a stable kidney function. After 5 months, due to a reduction in morning cortisol levels and difficulty in drug provisioning, we started to wean TRF-budesonide by 3 mg every 3 months, with complete withdrawal after 1 year. During this period, episodes of macrohematuria dramatically decreased, and UPCR and kidney function were maintained stable.

CONCLUSION

Our case demonstrates that TRF-budesonide could be considered an effective second-line treatment in pediatric IgAN, particularly when a long course of steroids is necessary to control active inflammation. However, pediatric clinical trials to identify the correct dosage and tolerability of TRF-budesonide are urgently needed.

Emphysematous Cystitis: A Rare Urologic Emergency

BACKGROUND Emphysematous cystitis is a rare urologic condition typically characterized by abdominal pain, hematuria, and dysuria. In some cases, complications such as bladder rupture, necrosis, and septic shock have been reported. Emphysematous cystitis has been associated with several predisposing medical conditions, such as diabetes mellitus, recurrent urinary tract infections, and immunosuppression, but can also infrequently present in an undifferentiated fashion without these aforementioned risk factors, such as in our patient's case. CASE REPORT We describe a rare case of emphysematous cystitis in a 67-year-old woman presenting to the Emergency Department with hematuria. The patient's presenting symptoms also included severe lower abdominal pain and dysuria. Examination revealed suprapubic tenderness and gross hematuria. Imaging revealed gas within the bladder lumen and throughout the bladder wall. Radiography showed concerns for emphysematous cystitis, without evidence of bladder fistula formation with adjacent bowel loops or cysto-vaginal fistula. After consultation with the Urology Department, the patient was admitted for serial examinations, intravenous antibiotics, and continued monitoring. The patient was discharged in good condition after a 3-day hospitalization. CONCLUSIONS Clinicians evaluating patients for acute urologic symptoms should be alert to the possible diagnosis of emphysematous cystitis, given the potential for deterioration and concomitant complications. Although our patient's presentation included no traditional risk factors for emphysematous cholecystitis, she required hospitalization to ensure progressive improvement. Therefore, prompt management along with appropriate consultation with specialists are crucial to mitigate the risk of adverse outcomes in this rare urologic emergency.

Refractory drug-induced systemic small-vessel vasculitis with two varied extracutaneous manifestations: a case report and review of the literature

BACKGROUND

Clopidogrel and ticagrelor are rarely reported to cause vasculitis via drug hypersensitivity reaction, largely mediated by T cells and immunoglobulin E (IgE). Despite therapeutic advances, the etiology of refractory vasculitides remains incompletely understood. Recently, (non)immunological mechanisms bypassing T cells and IgE have been proposed to explain resistance to standard immunosuppressants. Herein, we report a case of refractory drug-induced systemic small-vessel vasculitis with varied extracutaneous manifestations and incorporate multiple sources of data to provide detailed accounts of complex (non)immunological phenomena involved in this case. Study objectives are to provide an insight about rare presentations of commonly used drugs, upgrade the pathophysiological concepts of drug-induced vasculitis, raise need for further investigation to define causes and risk factors for refractory vasculitis, and discuss most of the current knowledge suggesting novel therapeutic approaches to treat this vasculitis. To our knowledge, this is the first case of the two flares of systemic small-vessel vasculitis in a single patient in response to clopidogrel and ticagrelor exposure, respectively. However, this report is limited by attribution/observer bias.

CASE PRESENTATION

We herein report a 24-year-old Caucasian male student with a medical history of mild seasonal allergic rhinoconjunctivitis, tension-type headaches, posttraumatic arterial stenosis, and previous exposure to ibuprofen, acetylsalicylic acid, and mRNA coronavirus disease 2019 (COVID-19) vaccine who suffered largely from acute urticaria and dyspnea after 20 days of acetylsalicylic acid and clopidogrel introduction. A skin punch biopsy confirmed leukocytoclastic vasculitis. Serologic antibody testing, complement analysis, microbiologic testing, and cancer biomarkers revealed no abnormalities. Regarding the patient's medical history, both acetylsalicylic acid and clopidogrel were exchanged for ticagrelor. Furthermore, the addition of naproxen, cyclosporine, bilastine, prednisolone, and montelukast resulted in complete recovery. After 7 days, diarrhea and hematuria occurred. Urinalysis and computed tomography showed reversible proteinuria with gross hematuria and hypodense changes in kidney medulla, respectively, associated with discontinuation of ticagrelor and naproxen. In addition, the patient recovered completely without any immunosuppression up-titration.

CONCLUSIONS

This case highlights the role of clopidogrel and ticagrelor as possible triggering agents for systemic small-vessel vasculitis and offers an insight into novel therapeutic strategies for refractory vasculitides. Further research is needed to build on the findings of a current report.

Renal cortical necrosis - a rare manifestation of dengue fever: A case report

RATIONALE

Dengue fever is a widespread mosquito-borne viral disease, most prevalent in the tropical and subtropical areas of the world. There has been a significant rise in the incidence and number of outbreaks of dengue in recent years, which has made it a matter of global concern. It may be associated with a number of renal complications, ranging from hematuria, proteinuria, glomerulonephritis, and acute tubular necrosis. However, renal cortical necrosis (RCN) is a rare renal complication of this disease.

PATIENTS CONCERNS

We report the case of a young gentleman who presented with fever, vomiting, and anuria. On workup, he was found to be having complicated Dengue fever with RCN resulting in acute renal failure.

DIAGNOSIS

To the best of our knowledge, RCN is not a reported renal complication of dengue fever.

INTERVENTIONS AND OUTCOMES

Our report highlights the importance of early consideration of renal cortical necrosis in patients with dengue fever and persistent anuria.

LESSON

This would allow for better disease prognostication while enabling physicians to develop more effective treatment strategies.

Development of a novel combined nomogram model integrating deep learning radiomics to diagnose IgA nephropathy clinically

This study aimed to develop and validate a combined nomogram model based on superb microvascular imaging (SMI)-based deep learning (DL), radiomics characteristics, and clinical factors for noninvasive differentiation between immunoglobulin A nephropathy (IgAN) and non-IgAN.We prospectively enrolled patients with chronic kidney disease who underwent renal biopsy from May 2022 to December 2022 and performed an ultrasound and SMI the day before renal biopsy. The selected patients were randomly divided into training and testing cohorts in a 7:3 ratio. We extracted DL and radiometric features from the two-dimensional ultrasound and SMI images. A combined nomograph model was developed by combining the predictive probability of DL with clinical factors using multivariate logistic regression analysis. The proposed model's utility was evaluated using receiver operating characteristics, calibration, and decision curve analysis. In this study, 120 patients with primary glomerular disease were included, including 84 in the training and 36 in the test cohorts. In the testing cohort, the ROC of the radiomics model was 0.816 (95% CI:0.663-0.968), and the ROC of the DL model was 0.844 (95% CI:0.717-0.971). The nomogram model combined with independent clinical risk factors (IgA and hematuria) showed strong discrimination, with an ROC of 0.884 (95% CI:0.773-0.996) in the testing cohort. Decision curve analysis verified the clinical practicability of the combined nomogram. The combined nomogram model based on SMI can accurately and noninvasively distinguish IgAN from non-IgAN and help physicians make clearer patient treatment plans.

Clinical profile of children with acute post-streptococcal glomerulonephritis

BACKGROUND

Acute post-streptococcal glomerulonephritis (APSGN) is common in developing countries with a high hospitalization rate. Most patients have acute nephritic syndrome features, although some occasionally present with unusual clinical features. This study aims to describe and analyze clinical features, complications, and laboratory parameters in children diagnosed with APSGN at presentation, 4 and 12 weeks later, in a resource-limited setting.

METHODS

This cross-sectional study was conducted among children < 16 years with APSGN between January 2015 and July 2022. Hospital medical records and outpatient cards were reviewed for clinical findings, laboratory parameters, and kidney biopsy results. Descriptive analysis of multiple categorical variables was performed using SPSS version 16.0 and presented as frequencies and percentages.

RESULTS

The study included 77 patients. Most (94.8%) were older than five years, and age group 5-12 years had highest prevalence (72.7%). Boys were affected more frequently than girls (66.2% vs. 33.8%). Edema (93.5%), hypertension (87%), and gross hematuria (67.5%) were the most frequent presenting symptoms, and pulmonary edema (23.4%) was the most common severe complication. Anti-DNase B and anti-streptolysin O titers were positive in 86.9% and 72.7%, respectively, and 96.1% had C3 hypocomplementemia. Most clinical features resolved in three months. However, at 3 months, 6.5% of patients had persistent hypertension, impaired kidney function, and proteinuria alone or in combination. Most patients (84.4%) had an uncomplicated course; 12 underwent kidney biopsy, 9 required corticosteroids, and 1 required kidney replacement therapy. There was no mortality during the study period.

CONCLUSION

Generalized swelling, hypertension, and hematuria were most common presenting features. Persistent hypertension, impaired kidney function, and proteinuria persisted in a small proportion who had a significant clinical course and required kidney biopsy. A higher resolution version of the Graphical abstract is available as Supplementary information.

The effect of piezoelectric shockwave lithotripsy with 2- and 8-mm focus sizes on stone disintegration and renal injury

OBJECTIVES

To compare the efficacy and safety of shockwave lithotripsy (SWL) using a narrow focus or wide focus for renal stones.

PATIENTS AND METHODS

A double-blind randomised trial included adult patients with a solitary radio-opaque renal pelvic stone of 1-2 cm. Patients were randomised into two groups: narrow-focus (2 mm) SWL and wide-focus (8 mm) SWL. The stone-free rate (SFR) and presence of complications such as haematuria, fever, pain, and peri-renal haematoma were evaluated. Pre- and postoperative urinary markers (neutrophil gelatinase-associated lipocalin [NGAL] and kidney injury molecule 1 [KIM-1]) concentrations were compared to assess renal injury.

RESULTS

A total of 135 patients were recruited for this study. The SFR after the first SWL session was 79.2% and 69.1% in narrow- and wide-focus groups, respectively. There was a comparable rise in the median 2-h NGAL concentration in both groups (P = 0.62). However, the rise in the median (interquartile range [IQR]) 2-h KIM-1 concentration was significantly higher in the narrow-focus group at 4.9 (4.6, 5.8) ng/mL compared with the wide-focus group at 4.4 (3.2, 5.7) ng/mL (P = 0.02). Nevertheless, the 3-day NGAL and KIM-1 urinary marker concentrations were significantly improved (P = 0.263 and P = 0.963, respectively). The overall SFR after three sessions was 86.6% and 86.8% in the narrow- and wide-focus groups, respectively (P = 0.77). Both groups were comparable for complications, apart from the median pain score and the percentage of high-grade haematuria, which were significantly higher in the narrow-focus group (P < 0.001 and P = 0.03, respectively).

CONCLUSION

Narrow- and wide-focus SWL were associated with comparable outcomes and re-treatment rates. However, narrow-focus SWL was associated with significantly higher morbidity in terms of pain and haematuria.

A urinary assay for mutation and methylation biomarkers in the diagnosis and recurrence prediction of non-muscle invasive bladder cancer patients

BACKGROUND

Currently, the clinical strategy for diagnosis of non-muscle invasive bladder cancer (NMIBC) such as cystoscopy and cytology are invasive and/or with limited accuracy. OncoUrine, a urinary assay for mutation and methylation biomarkers, have showed a high accuracy in the detection of upper tract urinary carcinoma (UTUC) patients with hematuria. The aim of this study is to evaluate the performance of OncoUrine in diagnosis of NMIBC patients.

METHODS

In this multicenter prospective study, a total of 203 patients were enrolled, including 60 patients present with hematuria and 143 NMIBC patients under recurrence surveillance. Urine samples were collected before cystoscopy to undergo OncoUrine test. OncoUrine performance was calculated compared to clinical standard methods in hematuria cohort and recurrence surveillance cohort, respectively. Furthermore, NMIBC patients were followed up with a median time of 20.5 months (range 0.03 to 24.03 months) to assess the predictive value of OncoUrine during recurrence monitoring.

RESULTS

For bladder cancer diagnosis, OncoUrine tested 47 samples and achieved a sensitivity/specificity/positive predictive value (PPV)/negative predictive value (NPV) of 80% (95% CI 44.2-96.5)/91.9% (95% CI 77.0-97.9)/72.7% (95% CI 39.3-92.7)/94.4% (95% CI 80.0-99.0) (kappa value 69.4%, 95% CI 44.4-94.3), indicating 72.3% of unnecessary cystoscopy. For recurrence diagnosis, OncoUrine tested 93 samples, and the sensitivity/specificity/PPV/NPV was 100% (95% CI 59.8-100.0)/68.2% (95% CI 57.1-77.7)/22.9% (95% CI 11.0-40.6)/100% (95% CI 92.3-100.0) (kappa value 27.0%, 95% CI 11.1-42.8), indicating 62.4% of spared cystoscopy. What is more, OncoUrine correctly predicted 80% (20/25) of final recurrence with 12/25 (48%) patients who were OncoUrine positive, but cystoscopy negative was followed with recurrence during follow-up. The test result of OncoUrine was also found significantly correlated with recurrence free survival (RFS) of NMIBC patients (median 34.4-month vs unreached; HR 6.0, 95% CI 2.7-13.5, P < 0.0001).

CONCLUSIONS

OncoUrine showed potential value to reduce the frequency of unnecessary cystoscopy and the healthcare cost of bladder cancer patients. Patients with positive test results represented a population who were at high risk of recurrence and thus should be subject to frequent surveillance to ensure timely detection of any potential recurrence. This study has been registered in ClinicalTrials.gov with the number NCT04994197 posted on August 2021.

Comparison of outcomes of an 18-gauge vs 16-gauge ultrasound-guided percutaneous renal biopsy: a systematic review and meta-analysis

Background: The needle size used in ultrasound-guided percutaneous renal biopsy significantly influences the efficacy and safety of the procedure. The aim of this study is to perform a comparative analysis of 16-gauge and 18-gauge needles for ultrasound-guided percutaneous renal biopsy.Methods: This systematic review and meta-analysis included randomized controlled trials and observational studies that compared the outcomes of using 18-gauge and 16-gauge needles for ultrasound-guided percutaneous renal biopsy. The efficacy parameters included a mean number of glomeruli obtained and the number of passes, while the safety parameters focused on the rate of complications. We searched multiple databases, assessed the risk of bias, and conducted statistical analyses using appropriate models.Results: Fifteen studies were included. Compared to the 18-gauge needle, the use of 16-gauge needle for the biopsy was associated with the significantly higher mean number of glomeruli obtained (pooled SMD 0.61, 95%CI: 0.32 to 0.89; p < 0.001) and fewer required passes (pooled SMD -0.57, 95%CI: -0.97 to -0.18; p = 0.004). No significant difference was observed in the individual safety parameters, including pain, hematuria, need for blood transfusion, major, and minor complications. However, the use of 16-gauge needle was associated with higher odds of total complications (pooled OR 1.57, 95%CI: 1.16 to 2.13; p = 0.004).Conclusion: While the 16-gauge needle for ultrasound-guided percutaneous renal biopsy offers improved efficacy in terms of a higher mean number of glomeruli and fewer required passes, it is associated with higher total complications. A judicious needle size selection that would consider patient-specific factors and risk-benefit ratio, is crucial for optimizing patient outcomes.

[Genetic analysis of a patient with Alport syndrome due to compound heterozygous variants of COL4A4 gene]

OBJECTIVE

To analyze the clinical phenotype and genetic characteristics of a patient with Alport syndrome.

METHODS

A patient with Alport syndrome who had visited the First Affiliated Hospital of Zhengzhou University in November 2020 was selected as the study subject. Clinical data of the patient were collected. High-throughput sequencing was carried out to detect potential variant of the COL4A3, COL4A4 and COL4A5 genes, and Sanger sequencing was carried out for verification of candidate variants in the family.

RESULTS

The main clinical manifestations of the patient included hematuria, proteinuria, and impaired hearing. Audiometric testing suggested symmetrical cochlear sensory neural hearing loss on both sides. Renal biopsy revealed mild mesangial proliferative glomerulonephritis. Genetic testing revealed that the patient has harbored compound heterozygous variants of the COL4A4 gene, namely c.940G>A (p.Gly314Ser) and c.3773G>A (p.Gly1258Asp), which were respectively inherited from her father and mother. Neither variant has been reported before, and were predicted to be pathogenic based on the guidelines from the American College of Medical Genetics and Genomics.

CONCLUSION

The c.940G>A (p.Gly314Ser) and c.3773G>A (p.Gly1258Asp) compound heterozygous variants of the COL4A4 gene probably underlay the Alport syndrome in this patient. Above finding has enriched the mutational spectrum of the COL4A4 gene.

The role of acupuncture in women with advanced reproductive age undergoing in vitro fertilization-embryo transfer: A randomized controlled trial and follicular fluid metabolomics study

BACKGROUND

The objective of this study was to determine the efficacy of acupuncture on the outcome of in vitro fertilization (IVF) in elderly infertile patients with kidney qi deficiency, and to explore its possible mechanism from the perspective of pseudo-targeted metabolomics of follicular fluid.

METHODS

Sixty cases of elderly women undergoing IVF were sampled and randomly divided into 2 equal groups: the treatment and the elderly control (HA) group. In the treatment group, routine ovulation induction combined with acupuncture treatment was used. Routine ovulation induction combined with sham acupuncture was used in the HA group. Reproductive outcomes of the 2 groups were compared. The follicular fluid of patients obtained on the day of oocyte retrieval was analyzed by the ultra-high-performance liquid chromatography-mass spectrometry analysis system.

RESULTS

Compared with the HA group, the score of kidney qi deficiency syndrome in the treatment group was significantly decreased, and the 2 PN fertilization rate, high-quality embryo rate and cumulative pregnancy rate were significantly increased (P < .05). Through the identification of target metabolites, 3 metabolic pathways were found to be closely related to the developmental potential of oocytes, namely: Retinol metabolism pathway; Glycine, serine, and threonine metabolism pathway; Glycerophospholipid metabolism pathway.

CONCLUSION

From our findings, acupuncture can improve the quality of oocytes thus bettering the outcome of IVF-assisted pregnancy in elderly patients with kidney qi deficiency.

TRIAL REGISTRATION

ChiCTR1800018329.

Protocol for the YORKSURe prospective multistage study testing the feasibility for early detection of bladder cancer in populations with high disease-specific mortality risk

INTRODUCTION

Around 25% of patients with bladder cancer (BCa) present with invasive disease. Non-randomised studies of population-based screening have suggested reductions in BCa-specific mortality are possible through earlier detection. The low prevalence of lethal disease in the general population means screening is not cost-effective and there is no consensus on the best strategy. Yorkshire has some of the highest mortality rates from BCa in England. We aim to test whether population screening in a region of high mortality risk will lead to a downward stage-migration of aggressive BCa, improved survival and is cost-effective.

METHODS AND ANALYSIS

YORKSURe is a tiered, randomised, multicohort study to test the feasibility of a large BCa screening randomised controlled trial. In three parallel cohorts, participants will self-test urine (at home) up to six times. Results are submitted via a mobile app or freephone. Those with a positive result will be invited for further investigation at community-based early detection clinics or within usual National Health Service (NHS) pathways. In Cohort 1, we will post self-testing kits to research engaged participants (n=2000) embedded within the Yorkshire Lung Screening Trial. In Cohort 2, we will post self-testing kits to 3000 invitees. Cohort 2 participants will be randomised between haematuria and glycosuria testing using a reveal/conceal design. In Cohort 3, we will post self-testing kits to 500 patients within the NHS pathway for investigation of haematuria. Our primary outcomes are rates of recruitment and randomisation, rates of positive test and acceptability of the design. The study is currently recruiting and scheduled to finish in June 2023.

ETHICS AND DISSEMINATION

The study has received the following approvals: London Riverside Research Ethics Committee (22/LO/0018) and Health Research Authority Confidentiality Advisory Group (20/CAG/0009). Results will be made available to providers and researchers via publicly accessible scientific journals.

TRIAL REGISTRATION NUMBER

ISRCTN34273159.

Clinical characteristics of infants hospitalized with early congenital syphilitic nephropathy: a single-center retrospective cross-sectional study in China

BACKGROUND

Early studies claimed that early congenital syphilitic (CS) nephropathy was rare, and systematic studies about this disease are absent, which may lead to poor awareness of early CS nephropathy in clinicians and result in misdiagnosis and poor patient prognosis. The present study systematically and comprehensively analyzes the clinical characteristics of infants with early CS nephropathy hospitalized in Beijing Ditan Hospital, an infectious disease hospital in China in order to improve the understanding and management of this disorder.

METHODS

Data of the children with early CS from July 1, 2008, to December 31, 2021, were collected from the electronic medical record system of the hospital. Each patient's demographic characteristics, clinical history, mother's history of syphilitic infection, and laboratory values were extracted. The patients were enrolled to either the nephropathy group or the non-nephropathy group depending on diagnosis. Descriptive statistics was used to report basic demographics, clinical and laboratory test values, and variables were compared between the two groups by nonparametric tests, t test or χ2 tests.

RESULTS

Of the 122 children with early CS enrolled, 24(19.7%) were diagnosed with early CS nephropathy. All of the children with CS nephropathy were young infants < 6 months old. A majority of them showed typical congenital syphilitic skin lesions, but a quarter of them did not have skin lesions. Compared with non-nephropathic children with early CS, those with nephropathy had higher frequency of hepatosplenomegaly, fever, edema, gastrointestinal (GI) symptoms, and anemia, as well as decreased C3 levels. Urinalysis results showed hematuria in all patients with early CS nephropathy, with proteinuria and renal function impairment in 91.7% and 12.5% of the patients, respectively. Nephritic-type nephrotic syndrome and glomerulonephritis were diagnosed in 45.8% and 54.2% of these patients, respectively. All infants with CS nephropathy were cured or improved after appropriate treatments.

CONCLUSION

Infants with early CS nephropathy often presented with nephritic-type nephrotic syndrome or glomerulonephritis, and the typical skin lesions, fever, hepatosplenomegaly, and edema, etc., were its common clinical presentations, and these characteristics could help with the diagnosis. But for infants with nephropathy who did not have typical clinical presentations, CS should also be screened as an important etiology to avoid misdiagnosis.

Transperineal vs. transrectal prostate biopsies under local anesthesia: A prospective cohort study on patient tolerability and complication rates

OBJECTIVES

An increasing number of urologists is switching from transrectal (TR) to transperineal (TP) biopsy procedures for the diagnosis of prostate cancer. Local anesthesia (LA) might be advantageous in terms of patient management, risks and costs. We aimed to evaluate the tolerability and complication rates of TP prostate biopsy performed under LA.

METHODS

This is a monocentric, prospective, comparative, observational cohort study. Between July 2020 and July 2021 we included 128 consecutive patients (TR, n = 61; TP, n = 67), with a suspicion of prostate cancer. Transrectal vs. transperineal prostate biopsies were both performed under LA. To evaluate the tolerability we administered a validated visual analog pain score (VAS) during the different steps of the biopsy procedure as well as at 12-, 24- and 48-hours post procedure. The International Prostate Symptom Score (IPSS) questionnaire was administered before the procedure and at the same time intervals. The presence of hematuria, hematospermia, rectal blood loss, acute retention and febrile urinary tract infection (UTI) were also monitored.

RESULTS

There were no significant differences in pain or IPSS between groups, except for a significantly higher pain score during the LA of the prostate in the TP group. In general, complication rates were similar, only the prevalence of hematuria at 24 hours was significantly higher in the TP group, as was rectal blood loss at 12 hours postprocedure in the TR group.

CONCLUSIONS

In conclusion, our study showed that transperineal prostate biopsy under local anesthesia could be performed with similar pain scores and complication rates, compared to the transrectal procedure.

Systemic lupus erythematosus with high disease activity identification based on machine learning

OBJECTIVE

Clinical evaluation of systemic lupus erythematosus (SLE) disease activity is limited and inconsistent, and high disease activity significantly, seriously impacts on SLE patients. This study aims to generate a machine learning model to identify SLE patients with high disease activity.

METHOD

A total of 1014 SLE patients with low disease activity and 453 SLE patients with high disease activity were included. A total of 94 clinical, laboratory data and 17 meteorological indicators were collected. After data preprocessing, we use mutual information and multisurf to evaluate and select the importance of features. The selected features are used for machine learning modeling. Performance of the model is evaluated and verified by a series of binary classification indicators.

RESULTS

We screened out hematuria, proteinuria, pyuria, low complement, precipitation, sunlight and other features for model construction by integrated feature selection. After hyperparameter optimization, the LGB has the best performance (ROC: AUC = 0.930; PRC: AUC = 0.911, APS = 0.913; balance accuracy: 0.856), and the worst is the naive bayes (ROC: AUC = 0.849; PRC: AUC = 0.719, APS = 0.714; balance accuracy: 0.705). Finally, the selection of features has good consistency in the composite feature importance bar plot.

CONCLUSION

We identify SLE patients with high disease activity by a simple machine learning pipeline, especially the LGB model based on the characteristics of proteinuria, hematuria, pyuria and other feathers screened out by collective feature selection.

Glomerulonephritis

Glomerulonephritis (GN) encompasses several disorders that cause glomerular inflammation and injury through an interplay of immune-mediated mechanisms, host characteristics, and environmental triggers, such as infections. GN can manifest solely in the kidney or in the setting of a systemic illness, and presentation can range from chronic and relatively asymptomatic hematuria to fulminant renal failure. Classic acute GN is characterized by hematuria, edema, and hypertension, the latter 2 of which are the consequence of sodium and water retention in the setting of renal impairment. Although presenting signs and symptoms and a compatible clinical history can suggest GN, serologic and urinary testing can further refine the differential diagnosis, and renal biopsy can be used for definitive diagnosis. Treatment of GN can include supportive care, renin-angiotensin-aldosterone system blockade, immunomodulatory therapy, and renal transplant. Prognosis is largely dependent on the underlying cause of GN and can vary from a self-limited course to chronic kidney disease. This review focuses on lupus nephritis, IgA nephropathy, IgA vasculitis, and postinfectious GN.

Effect of hematuria on the kidney disease progression in IgA nephropathy patients with mild proteinuria and well-preserved renal function

OBJECTIVE

To investigate whether hematuria is a risk factor in IgA nephropathy (IgAN) patients with mild proteinuria and well-preserved renal function.

METHODS

This retrospective study included a total of 63 IgAN patients, with complete clinical data available for 50 patients. Hematuria assessment was conducted using two methods: 1) an automated method using a urine particle analyzer, and 2) a manual method performed by a skilled examiner to examine microscopic urine sediment.

RESULTS

The results of hematuria measurement using both automated and manual methods showed a strong linear correlation (r = 0.78, P < 0.001). In IgAN patients, those with high urinary red blood cell count (U-RBCs) exhibited higher serum IgA levels compared to patients with low U-RBCs. Additionally, patients with crescent formation had higher levels of proteinuria compared to those without crescents. Patients who received immunosuppressive treatment displayed higher levels of systolic blood pressure (SBP) and mean arterial pressure (MAP), as well as lower levels of serum hemoglobin and albumin. They also had a higher prevalence of T1 lesions compared to patients who did not undergo immunosuppression. Furthermore, among patients with crescent formation, those who received immunosuppressive agents exhibited higher levels of SBP, diastolic blood pressure (DBP), MAP, and U-RBCs, as well as lower levels of albumin and proteinuria at the time of renal biopsy. No composite kidney endpoint events were observed in these groups of patients. The U-RBCs level was not identified as a risk factor influencing the decline of estimated glomerular filtration rate (eGFR) in IgAN.

CONCLUSIONS

The presence of hematuria at the time of biopsy was not found to be associated with kidney disease progression in IgAN patients who had mild proteinuria and well-preserved renal function. This suggests that it is possible that these patients may not derive significant benefits from immunosuppressive therapy.

Kidney outcome after mild to moderate COVID-19

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has a remarkable kidney tropism. While kidney effects are common in severe coronavirus disease 2019 (COVID-19), data on non-severe courses are limited. Here we provide a multilevel analysis of kidney outcomes after non-severe COVID-19 to test for eventual kidney sequela.

METHODS

This cross-sectional study investigates individuals after COVID-19 and matched controls recruited from the Hamburg City Health Study (HCHS) and its COVID-19 program. The HCHS is a prospective population-based cohort study within the city of Hamburg, Germany. During the COVID-19 pandemic the study additionally recruited subjects after polymerase chain reaction-confirmed SARS-CoV-2 infections. Matching was performed by age, sex and education. Main outcomes were estimated glomerular filtration rate (eGFR), albuminuria, Dickkopf3, haematuria and pyuria.

RESULTS

A total of 443 subjects in a median of 9 months after non-severe COVID-19 were compared with 1328 non-COVID-19 subjects. The mean eGFR was mildly lower in post-COVID-19 than non-COVID-19 subjects, even after adjusting for known risk factors {β = -1.84 [95% confidence interval (CI) -3.16 to -0.52]}. However, chronic kidney disease [odds ratio (OR) 0.90 (95% CI 0.48-1.66)] or severely increased albuminuria [OR 0.76 (95% CI 0.49-1.09)] equally occurred in post-COVID-19 and non-COVID-19 subjects. Haematuria, pyuria and proteinuria were also similar between the two cohorts, suggesting no ongoing kidney injury after non-severe COVID-19. Further, Dickkopf3 was not increased in the post-COVID-19 cohort, indicating no systematic risk for ongoing GFR decline [β = -72.19 (95% CI -130.0 to -14.4)].

CONCLUSION

While mean eGFR was slightly lower in subjects after non-severe COVID-19, there was no evidence for ongoing or progressive kidney sequela.

A novel likely pathogenic CLCN5 variant in Dent's disease

BACKGROUND

The majority of cases of Dent's disease are caused by pathogenic variants in the CLCN5 gene, which encodes a voltage-gated chloride ion channel (ClC-5), resulting in proximal tubular dysfunction. We present three members of the same family and one unrelated paediatric patient with the same insertion-deletion CLCN5 variant. The identification of these patients and positive familial segregation led to the re-classification of this variant from one of unknown significance to one of likely pathogenicity.

CASE PRESENTATION

A 41 year old male presented with end stage kidney failure, proteinuria and haematuria. Whole genome sequencing identified an insertion-deletion variant in CLCN5, resulting in a missense change (c.1744_1745delinsAA p.(Ala582Lys)). His brother and nephew, who both exhibited renal impairment, haematuria, proteinuria, glycosuria and nephrocalcinosis, were found to have the same variant. In addition, genetic testing of an unrelated paediatric patient who presented with proteinuria and hypercalciuria, demonstrated the same variant.

CONCLUSIONS

The identification of this novel variant in four individuals with features of Dent's disease, has led to the re-classification of the variant to one of likely pathogenicity. As a result, our patients and any future patients with the same variant can be offered a likely diagnosis, without the need for kidney biopsy, and their family members can be offered genetic screening.

[Clinical characteristics, pathology, and prognosis of children with diffuse endocapillary proliferative Henoch-Schönlein purpura nephritis]

OBJECTIVES

To investigate the clinical characteristics, pathology, and prognosis of children with diffuse endocapillary proliferative Henoch-Schönlein purpura nephritis (DEP-HSPN).

METHODS

A retrospective analysis was performed on the clinical, pathological, and prognosis data of 44 children with DEP-HSPN and 765 children without DEP-HSPN. The children with DEP-HSPN were diagnosed by renal biopsy in Jiangxi Provincial Children's Hospital from January 2006 to December 2021.

RESULTS

Among the 809 children with purpura nephritis, 44 (5.4%) had DEP-HSPN, with a mean age of (8±3) years, and there were 29 boys (65.9%) and 15 girls (34.1%). Compared with the non-DEP-HSPN group, the DEP-HSPN group had a significantly shorter time from onset to renal biopsy and a significantly higher proportion of children with respiratory infection or gross hematuria, and most children had nephrotic syndrome. The DEP-HSPN group had significantly higher levels of 24-hour urinary protein, urinary protein grading, microscopic hematuria grading, serum creatinine, and blood urea nitrogen and significantly lower levels of serum albumin and complement C3 (P<0.05). The DEP-HSPN group had a higher pathological grading, with predominant deposition of IgA in the mesangial area and capillary loops, and higher activity scores in the modified semi-quantitative scoring system (P<0.05). The Kaplan-Meier survival analysis showed that there was no significant difference in the renal complete remission rate between the two groups (P>0.05).

CONCLUSIONS

Children with DEP-HSPN have a rapid onset, severe clinical manifestations and pathological grading, and high activity scores in the modified semi-quantitative scoring system. However, most of the children with DEP-HSPN have a good prognosis, with a comparable renal complete remission rate to the children without DEP-HSPN.