Clinical features and prognostic factors of emphysematous urinary tract infection

BACKGROUND AND PURPOSE

Emphysematous urinary tract infection (EUTI) is a rare and potentially life-threatening condition that requires prompt evaluation and management. This study was conducted to ascertain the clinical features and prognostic factors of EUTI.

METHODS

Patients diagnosed with EUTI radiologically and treated at the Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, from March 2001 to February 2007 were evaluated. The patients' demographic and clinical characteristics, laboratory data, treatment, and outcomes were analyzed retrospectively.

RESULTS

Of 31 patients enrolled, 16 had emphysematous pyelonephritis (EP) and 15 had emphysematous cystitis (EC) classified according to the imaging findings. The symptoms and signs of fever, chills, flank pain, and percussion tenderness at the costovertebral angle were significantly greater among patients in the EP group than in the EC group (p = 0.029, p = 0.009, p < 0.001, and p < 0.001, respectively). There were no statistically significant differences in the initial laboratory data except for C-reactive protein between the 2 groups (220.4 microg/mL vs 91.4 microg/mL; p = 0.001). Escherichia coli was the most commonly isolated organism. The overall mortality rate was similar in both groups. Significant differences in renal function and hematuria were seen between the patients who died and the survivors in the EP group (p = 0.004 and p = 0.027, respectively), but these were not noted in the EC group.

CONCLUSIONS

There was no significant clinical feature suggesting the presence of EC. The clinical features of EP were similar to uncomplicated pyelonephritis. Impaired renal function and hematuria were poor prognostic factors for patients with EP, but not for patients with EC.

HEMATURIA FROM LEFT INTERNAL PUDENDAL AND OBTURATOR ARTERIAL BLEEDING FOLLOWING SEXUAL INTERCOURSE

Bladder tamponade is an uncommon clinical symptom among men who experience suffering related to sexual intercourse. The authors report on a 46-year-old man with this symptom 4-5 years before hospitalization. Angiography confirmed the presence of left pudendal and obturator arterial bleeding, and embolotherapy of the internal pudendal and obturator arteries was performed. There was no mortality, or limb loss or loss of sexual potency at follow-up.

Micropapillary carcinoma of the urinary bladder: a case report

BACKGROUND

Micropapillary carcinoma is a rare but unique histologic variant of urothelial carcinoma with an aggressive clinical course. In spite of well-defined clinicopathologic characteristics, the cytomorphologic features in urine specimens have been only rarely described.

CASE

A 78-year-old man presented with gross hematuria, showing a large mass on cystoscopy. Urine cytology contained tight clusters of atypical cells, originally interpreted as high-grade urothelial carcinoma or adenocarcinoma. Final diagnosis was made by histology and immunohistochemical study. On retrospective cytologic review, most presented as small cohesive cellular clusters in the clean background, showing micropapillae without fibrovascular core, morules and occasional rosette-like microacinar structures. A small number of singly scattered cells were also noted. Tumor cells had high-grade nuclear features and occasional cytoplasmic vacuoles. The inside-out pattern was confirmed on cell block by immunohistochemistry for epithelial membrane antigen. Immunoreactivity of E-cadherin disappeared, especially in the cytoplasmic membrane toward the fibrocollagenous stroma.

CONCLUSION

Micropapillary carcinoma had a somewhat characteristic cytologic appearance reflecting part of the histologic features. Cytopathologists should keep in mind the possibility of this rare entity when evaluating small papillary tumor clusters. Careful cytologic examination in combination with cell block morphology and immunohistochemistry may allow early accurate diagnosis and appropriate management.

Cytologic features of primary signet ring cell carcinoma of the bladder: a case report

BACKGROUND

Signet ring cell carcinoma is a very rare subtype of adenocarcinoma of the urinary bladder. Urine cytology is a useful method for screening and followup of urinary bladder carcinoma.

CASE

A 43-year-old woman was referred for evaluation of painless hematuria. Laboratory evaluation showed anemia, hematuria and elevated tumor marker levels. Pelvic computed tomography (CT) demonstrated diffuse wall thickening, and the chest CT suggested metastatic lesions in the lung and hepatic dome. Abdominal CT, esophagogastroduodenoscopy and colonoscopy revealed no evidence of malignancy in the gastrointestinal tract. Cystoscopy revealed very large masses in the anterior and posterior wall of the bladder. Bladder washings, urine cytology and biopsy demonstrated characteristic signet ring cells without foci of urothelial carcinoma or other lesions. Three months later, ascitic fluid was obtained; the results showed signet ring cells identical to those seen in the urine specimen.

CONCLUSION

Signet ring cell carcinoma of the urinary bladder can be diagnosed by urinary cytology and confirmed by cystoscopic biopsy.

[Neurological symptoms in patient with focal segmental glomerulosclerosis treated with cyclosporin A--case report]

Cyclosporin A using in treatment glomerulonephritis can cause neurological side effects.

CASE REPORT

Nephrotic syndrome (NS) with microscopic hematuria was recognized in a boy in the age of 9.7 years. In kidney biopsy focal and segmental glomerulosclerosis was found. Remission was obtained on oral prednisone (60 mg/24 hrs). Second relapse of NS was treated with methylprednisolone pulse (VI pulses--600 mg/pulse) with a good effect. Third relapse of NS (secondary steroidoresistency) was treated with oral cyclophosphamide in a total dose 140 mg/kg/therapy--the treatment was complicated by a massive oral cavity mycosis and sinusitis. 3 weeks after starting cyclosporine A (CsA) proteinuria subsided. During CsA treatment severe headaches and pains in orbits with nausea appeared. In neurological examinations no abnormalities were found, in ophthalmological examination--slight opacification of the lens was found. EEG revealed lesions localised in a posterior cerebral parts, and CT of the head showed slight dilatation of ventricles. In MRI foci of signal intensification were found in subcortical white substance. CsA was stopped after 4 months of the treatment and prednisone was stopped a month later. Control MRI after 6 months revealed maintenance of the foci in white substance. The patient is under nephrological care, has no proteinuria and no neurological symptoms.

CONCLUSION

In patients treated with CsA appearance of headaches may suggest medication neurotoxicity.

Clinical and morphological aspects of thin glomerular basement membrane disease

The report presents the results of investigations carried out in 63 patients (49 children and 14 adults) with thin glomerular basement membrane disease. Of 49 children, 13 came from nine families with family members suffering from kidney diseases (mostly manifested by haematuria). In the group of children, the most frequent initial clinical symptom (noted in 29 cases) was isolated haematuria, more rarely (in eight cases) haematuria and proteinuria, and (in seven cases) nephrotic syndrome. Isolated proteinuria was observed in another three children. In the adults, only in five patients was isolated haematuria the initial symptom of the disease; more frequently (in seven cases), they presented with isolated proteinuria. In two patients, proteinuria and haematuria were noted. In the two groups of patients, in addition to markers of thin glomerular basement membrane disease, the authors also observed markers indicative of other glomerulopathies: in seven children and four adults focal segmental glomerulosclerosis (FSGS) without any other glomerular pathologies (with the exception of thin glomerular basement membrane disease). Also in cases in which in addition to thin glomerular basement membrane disease other glomerular pathologies were present (mesangial hypercellularity, mesangial glomerulonephritis), matrix expansion was detected; this phenomenon might be considered a harbinger of glomerular sclerosis. In general, although not in each and every case, these pathologies were associated with duration of the disease.

Ureteral intussusception due to a polyp

Intussusception of the ureter is a rare complication of some ureteral diseases. A 49-year-old man was found to have a ureteral intussusception in the middle part of the right ureter accompanied by a polyp below the invaginated segment of the ureter. Surgery confirmed the diagnostic imaging findings. Here, we present a case of ureteral intussusception associated with a fibroepithelial polyp and discuss the radiological characteristics.

[Thin glomerular basement membrane disease]

Thin glomerular basement membrane disease (TBMD) is a hereditary nephropathy characterized by thinning of the glomerular basement membrane evinced by electron microscopy and, clinically, by isolated hematuria without extrarenal manifestations. Familial aggregation is found in 50-60% of cases, with autosomal dominant transmission. TBMD is considered to belong to the type IV collagen spectrum of diseases, since heterozygous mutations of the COL4A3 or COL4A4 gene have been detected in more than 30% of patients. The disease is found in 1-2% of biopsies, but the prevalence in the general population may be higher. The differential diagnosis with Alport's syndrome may be difficult and requires accurate family investigations, immunohistochemical evaluation of type IV collagen alpha chains in renal tissue and, if appropriate, genetic studies. Progression towards chronic renal failure, although rare, has been reported in some patients, and may be related to the phenotypical variability of COL4A3/COL4A4 mutations, to a missed Alport syndrome, or to superimposed glomerular disease. Patients suffering from TBMD and affected relatives should be periodically examined for signs of disease progression and informed about the possibility of transmitting the autosomal recessive form of Alport's syndrome.

Rabson-Mendenhall syndrome: medullary sponge kidney, a new component

Rabson-Mendenhall syndrome is a rare genetic disorder characterized by severe insulin resistance, extreme hyperinsulinemia, postprandial hyperglycemia, growth retardation, and dysmorphisms. Enlargement of the kidneys and nephrocalcinosis have been described previously. We report a 10-year-old boy who presented with gross hematuria, unilateral hydronephrosis, and the initial diagnosis of bilateral extensive medullary nephrocalcinosis. Medullary sponge kidney (MSK) was included in the differential diagnosis given the ultrasound findings. Further evaluation by intravenous pyelogram confirmed the suspected bilateral MSK. Given the patient's history of hydronephrosis due to an obstructing renal stone and MSK, urine calcium excretion was assessed and found to be markedly increased at 9.5 mg/kg per day. To our knowledge, this is the first report of Rabson-Mendenhall syndrome and an association with MSK. We recommend evaluation for nephrocalcinosis, MSK, and hypercalciuria in all children diagnosed with Rabson-Mendenhall syndrome.

Splenic peliosis in the course of IgA nephropathy

The immunoglobulin A (IgA) immunoregulation disorders lie at the basis of Henoch-Schönlein purpura nephritis and IgA nephropathy. Peliosis is the condition characterized by cystic formations within the parenchyma of solid organs filled with blood. The authors report a case of a girl presenting with hematuria occurring during the course of respiratory infections since her fifth year. Pathohistological examination was not performed at that time. At the age of 13, the girl was hospitalized for abdominal pain. Computed tomography examination showed the presence of multiple, relatively well-defined nodular formations located in the spleen parenchyma. Splenectomy was performed. Morphological finding completely corresponded to peliosis of the spleen, with the deposits of IgA in the lesions within it. A year and a half following the splenectomy, a typical clinical picture of Henoch-Schönlein purpura nephritis developed. Biopsy findings of the skin and kidneys detected deposits of IgA. This is the first case of a patient suffering from associated IgA and Henoch-Schönlein purpura nephritis complicated by splenic peliosis to be described in the world's literature.

[Clinical and pathological characteristics of patients with glomerular hematuria as the major manifestation]

OBJECTIVE

To compare the clinical and pathological characteristics between patients with and without glomerular hematuria.

METHODS

Totally 310 patients with isolated microscopic hematuria and 24-hour urinary protein <0.5 g were enrolled in this study, who were free of renal calculi, infections, or tumors. These patients were divided into glomerular hematuria group and non-glomerular hematuria group according examination by phase-contrast microscope, and their clinicopathological data were retrospectively analyzed.

RESULTS

Of the 209 patients identified to have glomerular hematuria, 46.41% had IgA nephropathy, 22.49% had small glomerular lesions, and 14.35% had non-IgA mesangioproliferative glomerulonephritis. In the patients with non-glomerular hematuria, 65.34% had IgA nephropathy, 21.78% had non-IgA mesangioproliferative glomerulonephritis, and 8.91% had small glomerular lesions. No significant differences were found in the patients' gender, age, course of disease or hypertension between the two groups (P>0.05), but renal insufficiency was more common in patients with glomerular hematuria.

CONCLUSION

IgA nephropathy is still the most frequent pathological finding in patients with hematuria, and even in non-glomerular hematuria patients severe renal pathological changes can be common.

Natural History and Prognostic Factors of IgA Nephropathy Presented with Isolated Microscopic Hematuria in Chinese Patients

BACKGROUND/AIMS

IgA nephropathy (IgAN) with isolated microscopic hematuria (IMH) is prevalent in Asian countries including China. However, the natural history of IgAN with IMH has not yet been clarified. The aim of this study was to review the natural course and prognostic factors of IgAN with IMH in Chinese patients.

METHODS

We retrospectively studied 135 patients (43 males and 92 females) followed up for a mean period of 92 +/- 28 months. In order to identify factors associated with renal progression, clinical and pathological data at onset were reviewed.

RESULTS

During the follow-up period, hematuria of 16 patients (12%) disappeared while persistent microscopic hematuria was seen in 119 patients (88%), and proteinuria was present in 39 patients (29%). The prevalence of hypertension was 32% (43 patients), and 20% (27 patients) developed renal insufficiency. The prevalence of proteinuria and hypertension in the microalbuminuria group was significantly higher than those in the normoalbuminuria group. Poor renal outcome is usually associated with hematuria, microalbuminuria, and tubulointerstitial lesions.

CONCLUSION

IgAN with IMH may not imply favorable outcome, so early diagnosis and careful follow-up are clinically significant. Hematuria, microalbuminuria, and tubulointerstitial lesions are useful markers to identify those patients at high risk for renal progression.

Immunocytology in the Assessment of Patients with Asymptomatic Microhaematuria

INTRODUCTION

Discrimination between malignant and nonmalignant conditions remains the key problem in assessing microhaematuria. This prospective study investigated the role of immunocytology in the evaluation of patients with microhaematuria.

METHODS

uCyt+ is a commercially available immunocytologic assay based on microscopic detection of tumour-associated antigens on the membrane of urothelial cells by immunofluorescence. Between October 2000 and August 2005, 189 consecutive patients with newly diagnosed painless microhaematuria without prior transitional cell carcinoma were included. All urine samples were examined cytologically and immunocytologically. Of the 189 samples, 178 (94%) were assessable.

RESULTS

Clinical assessment by physical examination, laboratory tests, endoscopy, and imaging modalities found bladder cancer in 8 patients (4%). Further diagnoses were benign prostatic hyperplasia (54 cases, 29%), cystitis (including interstitial cystitis; 20 cases, 11%), urolithiasis (18 cases, 9%), tumours of other origin (6 cases, 2%), and "further conditions" (26 cases, 13%). In 57 patients (30%) the reasons for haematuria were not disclosed. Immunocytology was positive in 7 of 8 bladder tumours (87%) and negative in 154 of 170 patients with haematuria for other reasons (91%).

CONCLUSIONS

The high sensitivity and good specificity of immunocytology in the diagnosis of bladder cancer was confirmed in this population with a low disease prevalence. Only one tumour of low malignant potential was missed by immunocytology. If assessment of these patients would have been based only on immunocytology, 154 costly and invasive diagnostic procedures could have been avoided, with only 16 of 170 individuals (9%) undergoing these examinations unnecessarily. The findings justify a prospective investigation of this issue.

Useful indicators for performing renal biopsy in adult patients with isolated microscopic haematuria

Among adult patients with isolated microscopic haematuria (IMH) which is defined as persistent microscopic haematuria but without proteinura, hypertension, renal insufficiency, urinary tract infection or structural abnormality of the urinary tract, some patients have chronic glomerulonephritis (CGN), in whom early diagnosis by renal biopsy is beneficial to timely intervention. Nevertheless, a considerable number of patients with optimistic prognosis [e.g. thin basement membrane nephropathy (TBMN)] undergo invasive and needless renal biopsy. Indicators for weighing the necessity of renal biopsy would be clinically significant. To investigate the value of urinary albumin/creatinine ratio (UACR), serum IgA level, serum C3 level and serum IgA to C3 ratio in predicting the necessity of renal biopsy for adult patients with IMH, 216 patients were studied retrospectively. Patients were divided into: (CGN group, n=137), (TBMN group, n=56) and normal biopsy (normal group, n=23). Of all patients, 131 (61%) evidenced microalbuminuria (UACR=30-299 mg/g) and 85 (39%) had normoalbuminuria (UACR<30 mg/g). The mean value of UACR in CGN group was higher (96+/-17 mg/g) compared with that in TBMN (20+/-4 mg/g, p<0.01) or normal (18+/-3 mg/g, p<0.01) group. The mean values of serum IgA and serum IgA/C3 ratio in patients with IgA nephropathy (IgAN) were significantly higher than those with non-IgAN (380+/-103:217+/-99 mg/dl, p<0.01; 4.5+/-1.2 : 2.4+/-0.9, p<0.01). The odds ratio for distinguishing IgAN from non-IgAN was significantly correlated with serum IgA level and serum IgA to C3 ratio. For adult patients with IMH, UACR, serum IgA level and serum IgA to C3 ratio are non-invasive markers for predicting the necessity of renal biopsy.

Correlation between mRNA expression level of the mutant COL4A5 gene and phenotypes of XLAS females

Alport syndrome (AS) is a progressive hereditary glomerulonephritis presented with hematuria, progressive renal failure, sensorineural deafness, and ocular lesions. Females with X-linked Alport syndrome (XLAS) have variable phenotypes, from asymptomatic hematuria to renal failure. In order to understand the possible mechanism of different phenotypes in female XLAS, we analyzed mRNA expression level of the mutant COL4A5 gene in fibroblasts, the X-inactivation pattern in peripheral blood DNA, and the phenotype variability of XLAS females. Total RNA was isolated from cultured skin fibroblasts in five females with XLAS and confirmed deletion mutations of COL4A5 mRNA. Reverse transcription-polymerase chain reaction (PCR) was performed to amplify the fragment, including the mutation sequences of the COL4A5 gene. The PCR products were electrophoresed with 8% polyacrylamide gel. Messenger RNA expression level of the mutant COL4A5 gene was analyzed with the optical density of PCR product revealed under polyacrylamide gel. The X-inactivation analysis was performed using HpaII predigestion of peripheral blood DNA followed by PCR of the highly polymorphic CAG repeat of the androgen receptor (AR) gene. All patients in the study had persistent microscopic hematuria. Two of them had gross hematuria. Three cases had persistent and severe proteinuria of 2+~3+, and the others had discontinuous and milder proteinuria of - ~+. The patients whose mRNA expression level of the mutant COL4A5 gene was higher had persistent and more severe proteinuria (r = 0.975, P = 0.005). None of them had skewed X inactivation. Our preliminary results demonstrate that the quantity of mRNA expression level of the mutant COL4A5 gene was correlated with the phenotypic severity of females with XLAS, and this could not be explained by X-inactivation pattern in peripheral blood leukocytes.

Robotic-Assisted Laparoscopic Ureteropyelostomy for Treatment of Prostatitis Secondary to Ectopic Ureteral Insertion of a Completely Duplicated Collecting System

Symptomatic presentation of a completely duplicated collecting system with upper-pole ectopic ureteral insertion is rare in the adult. We present a case of a 52-year-old man with recurrent prostatitis and hematuria secondary to an ectopic ureteral insertion from a left upper-pole moiety in a completely duplicated collecting system. He underwent a robot-assisted laparoscopic ureteropyelostomy with good results. We describe our technique in this unusual case.

Diagnosis of pediatric genitourinary embryonal rhabdomyosarcoma by urine cytology: a case report

BACKGROUND

Urinary cytology is an uncommon investigative tool for pediatric tumors.

CASE

A 16-month-old infant presented for investigation ofhematuria and blood clots into diapers. Urinary cytology showed a population of small, round, blue cells with little cytoplasm and high nuclear/cytoplasmic ratios. The cells were positive for desmin and negative for cytokeratin. A cytologic diagnosis of embryonal rhabdomyosarcoma was offered and subsequently confirmed by histopathology.

CONCLUSION

Embryonal rhabdomyosarcomas are not uncommon in the pediatric population. Urinary cytology may be useful for rapid diagnosis and early management of such cases.

Multidetector-row computed tomography (MDCT) in patients with a history of previous urothelial cancer or painless macroscopic haematuria

The sensitivity and specificity of MDCT for depiction and localization of urothelial carcinoma (UC) was determined retrospectively. Axial and coronal four-row MDCT of the urinary tract (unenhanced, contrast-enhanced nephrographic, CT urography) was independently reviewed for UC by a radiologist (R1) and a urologist (R2), without other patient information, in 27 patients (22 male, five female; age, 72 +/- 11 years) with previous UC and/or painless macroscopic haematuria. Urinary tract segments included bladder, right and left upper, middle, and lower caliceal groups, renal pelvis, uretero-pelvic junction, upper, middle, and lower ureter. MDCT findings were corroborated by surgery, other invasive procedures, and 1-year follow-up, including MDCT, intravenous urography, and cystoscopy. Receiver-operating characteristic analysis was undertaken and the the area under the curve (AUC) calculated. Eighteen of 27 patients had evidence of UC (pTa, n = 3; pT1-pT3, n = 15; TNM 2002). Tumor was correctly located by both R1 and R2 in 17 patients (sensitivity, 94%; 95% confidence interval, 84-100%) and ruled out in seven (specificity, 78%; 95% confidence interval, 51-100%), with complete agreement. Each detected ten of 11 upper urinary tracts affected by UC. For 35 urinary tract segments with UC and 308 without, the AUC was 0.910 +/- 0.035 (R1) and 0.74 +/- 0.055 (R2), z = 2.4772, Bonferroni-corrected P = 0.022. MDCT depicts urinary tracts affected by UC with high sensitivity and substantial agreement between readers with different training.

[Clinical and pathological manifestations of Chinese childhood patients with primary IgA nephropathy: a national collaborative study of 33 hospitals]

OBJECTIVE

Primary IgA nephropathy (IgAN) is characterized by a highly variable course ranging from a totally benign condition to rapidly progressive renal failure. About 30% of children with IgAN will eventually have end-stage renal failure after 20 years from onset. A nation-wide survey was conducted and data of hospitalized children (younger than 14 years old) with IgAN during the period of 1995 to 2004 were analyzed. The aim was to investigate the clinical and pathological characteristics, treatment and outcome of the hospitalized children with IgAN.

METHODS

Questionnaires concerning children with IgAN were designed by the Subspecialty Group of Nephrology, Chinese Society of Pediatrics and distributed to the doctors of 33 hospitals in China. The criterion of IgAN was prominent and diffuse IgA deposition and to a lesser extent, other immunoglobulins in the glomerular mesangium and/or capillary loops, and purpura nephritis, lupus nephritis and hepatic disease were excluded. The data were collected and analyzed.

RESULTS

From January 1, 1995 to December 31, 2004, 1349 hospitalized children were diagnosed as IgAN. The cases of childhood IgAN accounted for 1.37% of the hospitalized cases with urologic-kidney diseases and 11.18% of those who underwent renal biopsies. Complete records were available for 1203 patients. The male to female ratio was 2.07:1. Both the median ages at the disease onset and diagnosis were 9.0 years. The median duration from onset to diagnosis of IgAN was 4 months; 55.94% of patients had predisposing causes, especially infection. Recurrent macroscopic hematuria was the most common clinical manifestation (41.15%), followed by nephritic syndrome (23.77%) and hematuria and proteinuria (20.78%). Subclass III (41.40%) and II (28.51%) were the most common histologic types. The main type of immunofluorescence examination was IgA deposition (34.50%). The intensity of IgA deposition in patients with hematuria and proteinuria and in acute rapidly progressive nephritis was the strongest (+++). There was no unified treatment scheme. Some patients were treated with corticosteroids and immunosuppressants, and 69.24% of the patients with IgAN showed clinical improvement, 10.39% remained unchanged, and 2 cases presented deterioration. The rate of follow-up was 23.35%, the mean duration of follow-up was 24.4 months.

CONCLUSION

The mean age of onset of the primary childhood IgAN was after 6 years. Hematuria was the most common clinical manifestation. Subclass III and II were the most common histologic type. There was no unified treatment scheme. The rate of follow-up was lower and the rate of lost follow-up was high. It is necessary to establish a normalized management, treatment and follow-up system for childhood IgAN in China.

Importance of red patches diagnosed in cystoscopy for haematuria and lower urinary tract symptoms

BACKGROUND

Biopsy of the red patches in the bladder, when found at cystoscopy, is routinely performed in urological practice. This is done to establish the sinister diagnosis of carcinoma-in-situ among other causes.

OBJECTIVE

To analyse the pathology of the red patches and to determine if routine biopsy of these patches is warranted.

PATIENTS AND METHODS

This was a retrospective study conducted over a period of 36 months, in which 50 patients were identified, who underwent biopsies of their red patches. All patients with a history of bladder carcinoma and obvious bladder tumours were excluded from this study.

RESULTS

The mean age of the patients was 60.8 years. 25 patients had cystoscopy for lower urinary tract symptoms, 21 for haematuria and 4 for recurrent urinary tract infection. Carcinoma in situ was found in 4 (8%) patients, of whom only 2 had positive urine cytology.

CONCLUSION

It is prudent to perform a biopsy of all incidentally diagnosed red patches because of a major yield rate of carcinoma in situ. This procedure also picks up other important pathologies, which help in further management.

[The significance of urinary podocytes in patients with active lupus nephritis]

OBJECTIVE

To assess the significance of urinary podocyte and its possible implication as a marker of activity of lupus nephritis.

METHODS

The presence of podocytes in urinary sediment was detected with immunochemical staining using anti-podocalyxin antibody. The correlation of the number of urinary podocytes with activity index of renal pathological lesions, hematuria, and proteinuria was analyzed respectively. The proliferating podocytes in renal biopsy tissue and urine from patients with class IV lupus nephritis were examined with double immunohistochemical staining.

RESULTS

Thirty-one patients with lupus nephritis undergoing renal biopsy were enrolled into the study. Renal pathological findings of the patients could be classified into WHO class III (25.8%), class IV (64.5%) and class V (9.7%). 90% of the patients had positive urinary podocytes. The number of urinary podocytes was strongly and positively correlated with the severity of hematuria (r=0.639, P=0.000) and glomerular pathological activity index (r=0.487, P=0.014) in patients of class III and class IV. The amount of proteinuria was not correlated with pathological activity index, even though all the patients had proteinuria. Furthermore, the number of urinary podocytes, the severity of hematuria and the amount of proteinuria were all decreased after treatment with methyl prednisone, cyclophosphamide or mycophenolate mofetil. Interestingly, the urinary podocytes could disappear even before the remission of hematuria and proteinuria after treatment. Proliferative podocytes were observed both in biopsied kidney tissue and urinary sediments in patients of class IV.

CONCLUSION

The presence and the number of urinary podocytes can be used as a valuable marker to grade the activity of lupus nephritis and to evaluate the efficacy of steroid therapy.

Renal biopsy in lupus patients with low levels of proteinuria

OBJECTIVE

Early and accurate detection of kidney involvement in systemic lupus erythematosus (SLE) improves outcomes. Renal biopsy is required for definitive diagnosis of lupus nephritis (LN). In the absence of acute renal failure (ARF), moderate levels of proteinuria (> 1000 mg/24 h) have been recommended by some to justify biopsy. We investigated whether patients with lower levels of proteinuria without ARF have significant renal disease and should be routinely biopsied.

METHODS

We retrospectively evaluated 21 SLE patients with 24-h urine protein < 1000 mg who underwent kidney biopsies. Indications for biopsy included new-onset proteinuria, increasing proteinuria, or hematuria (> 5 red blood cells per high power field). No patient had ARF.

RESULTS

Sixteen of 21 (77%) biopsies were diagnostic of LN: 3 class II, 10 class III (5 superimposed class V), 2 class IV (one superimposed class V), and one with class V. One patient had thrombotic microangiopathy. The remaining 4 (23%) patients had non-lupus renal disease. Thirteen patients with class III or greater LN required alterations in therapeutic regimen because of biopsy findings. Of 7 patients without hematuria at the time of biopsy, 4 (57%) had class III, IV, or V LN. One patient without hematuria and < 500 mg/24 h proteinuria had class III LN.

CONCLUSION

We found significant renal involvement (Class III, IV, or V LN) in SLE patients with < 1000 mg proteinuria with or without hematuria. Our findings suggest that biopsy be strongly considered in this patient population.

Predominance of CD8+ T lymphocytes among periglomerular infiltrating cells and link to the prognosis of class III and class IV lupus nephritis

OBJECTIVE

Recent studies have revealed a potential implication of CD8+ T lymphocytes in the pathogenesis of systemic lupus erythematosus (SLE) through their ability to induce tissue damage. The aim of the present study was to analyze the localization of CD8+ cells in the kidneys of patients with class III and class IV lupus nephritis and to establish correlations with histologic, biologic, and clinical features of SLE.

METHODS

Twenty-five consecutive SLE patients with class III or class IV lupus nephritis were enrolled. Phenotype analyses of blood lymphocytes and renal immunohistochemistry studies were performed.

RESULTS

CD8+ T cells were the predominant kidney-infiltrating subset of cells. The mean +/- SD numbers of CD8+ T cells and CD4+ T cells were 66.2 +/- 65.2/mm(2) and 19.3 +/- 29.4/mm(2), respectively. There was a significant correlation between the percentage of blood CD3+,CD8+,DR+ cells and the total number of renal CD8+ T cells (r = 0.42, P = 0.039). Renal CD8+ T cell infiltration correlated well with the renal activity index (r = 0.63, P = 0.0007) and with high serum creatinine levels (r = 0.75, P = 0.0001). This CD8+ T cell infiltrate, which was predominantly in the periglomerular area, was correlated with cellular crescents and Bowman's capsule rupture and was associated with a poor response after conventional induction therapy.

CONCLUSION

CD8+ T lymphocytes infiltrate the periglomerular area in patients with severe (class III and class IV) lupus nephritis and are linked to a poor outcome after induction therapy. These results reveal a new potential effector pathway operant in lupus nephritis.