Proliferative glomerulopathy following extracorporeal shock wave lithotripsy in the pig

Shock Waves Enhance Expression of Glycosphingolipid Tumor Antigen on Renal Cell Carcinoma: Dynamics of Physically Unmasking Hidden Intracellular Markers Independent of Gene-Signaling Pathways

Antigens associated with tumors have proven valuable in cancer immunotherapy. Their insufficient expression in the majority of tumors, however, limits their potential value as therapeutic markers. Aiming for a noninvasive approach applicable in clinical practice, we investigated the possibility of using focused shock waves to induce membrane expression of hidden intracellular tumor markers. Here, we studied the in vitro effect of a thousand focused shock waves at 16 MPa overpressure on the membrane expression of a cytosolic glycosphingolipid, monosialosyl-galactosyl-globoside (MSGG). Double-staining flow cytometry with propidium-iodide and monoclonal antibody RM1 revealed an immediate increase in MSGG expression on renal carcinoma cells (18% ± 0.5%) that reached its peak value (20.73% ± 0.4%) within one hour after the shock waves. The results of immunoelectron microscopy confirmed the incorporation of MSGG into newly formed cytosolic vesicles and their integration with the cell membrane. Based on the enzymatic nature of MSGG production that is not controlled directly by genes, the immediate upregulation of MSGG membrane expression implies that a chain of mechanochemical events affecting subcellular structures are responsible for the shock-wave-induced antigenic modification. Physically unmasking hidden tumor antigens and enhancing their expression by focused shock waves presents a potential noninvasive method of boosting tumor immunogenicity as a theranostic strategy in cancer immunotherapy.

The clinical and immunological features of the post-extracorporeal shock wave lithotripsy anti-glomerular basement membrane disease

Introduction

Extracorporeal shock wave lithotripsy (ESWL) is a noninvasive modality to treat urolithiasis, with complications including tissue damage and hematoma of kidney parenchyma. Anti-glomerular basement membrane (GBM) disease is suggested to be a rare complication of ESWL since it was reported in several cases to occur after ESWL. However, the clinical and immunological features of the ESWL-associated anti-GBM disease have not been fully investigated so far.

Case Presentation

Here, we present the clinical, pathological, and immunological characteristics of three patients with the post-ESWL anti-GBM disease in our hospital. Anti-GBM disease occurred within a median of 22 months after ESWL treatment. It presented with similar clinical features to the classic anti-GBM disease, including fever, gross hematuria, and rapidly progressive glomerulonephritis (RPGN) with poor renal prognosis. Sera from all patients recognized the α3(IV)NC1 in GBM, but with IgG2 and IgG4 as the dominant IgG subclasses.

Conclusion

Although further exploration is required to prove the causal relationship in this rare condition, our study reminds physicians that patients developing acute renal insufficiency after ESWL should lead to the suspicion of anti-GBM disease and in-time diagnosis and treatment.

Localization of renal oxidative stress and inflammatory response after lithotripsy

OBJECTIVE To determine if the acute renal oxidative stress and inflammation after extracorporeal shock wave lithotripsy (ESWL), thought to be mediated by ischaemia, is most severe in the portion of the kidney within the focal zone of the lithotripter, and if these effects result primarily from ischaemic injury. MATERIALS AND METHODS Pigs (7-8-weeks old) received either 2000 shock waves at 24 kV to the lower-pole calyx of one kidney or unilateral renal ischaemia for 1 h. A third group (sham) received no treatment. Timed urine and blood samples were taken for analysis of lipid peroxidation and the inflammatory cytokines, tumour necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6). At 4 h after treatment, kidneys were removed and samples of cortex and medulla were frozen for analysis of cytokines and heme oxygenase-1 (HO-1). RESULTS ESWL did not affect urinary excretion of malondialdehyde, but did elicit an eight-fold induction of HO-1 in the portion of the renal medulla within the focal zone of the lithotripter (F2), while remaining unchanged elsewhere in the treated kidney. There was no induction of HO-1 in renal tissue after ischaemia-reperfusion. Urinary excretion of TNF-alpha increased from the lithotripsy-treated kidney by 1 h after treatment, but was unaffected by ischaemia-reperfusion. As with the HO-1 response after lithotripsy, IL-6 increased only in the renal medulla at F2. By contrast, ischaemia-reperfusion increased IL-6 in all samples from the treated kidney. CONCLUSION These findings show that the acute oxidative stress and inflammatory responses to ESWL are localized to the renal medulla at F2. Furthermore, the differing patterns of markers of injury for ESWL and ischaemia-reperfusion suggest that ischaemia is not the principal cause of the injury response after ESWL.

The acute and long-term adverse effects of shock wave lithotripsy

Shock wave lithotripsy (SWL) has proven to be a highly effective treatment for the removal of kidney stones. Shock waves (SWs) can be used to break most stone types, and because lithotripsy is the only noninvasive treatment for urinary stones, SWL is particularly attractive. On the downside SWL can cause vascular trauma to the kidney and surrounding organs. This acute SW damage can be severe, can lead to scarring with a permanent loss of functional renal volume, and has been linked to potentially serious long-term adverse effects. A recent retrospective study linking lithotripsy to the development of diabetes mellitus has further focused attention on the possibility that SWL may lead to life-altering chronic effects. Thus, it appears that what was once considered to be an entirely safe means to eliminate renal stones can elicit potentially severe unintended consequences. The purpose of this review is to put these findings in perspective. The goal is to explain the factors that influence the severity of SWL injury, update current understanding of the long-term consequences of SW damage, describe the physical mechanisms thought to cause SWL injury, and introduce treatment protocols to improve stone breakage and reduce tissue damage.

Effects of high-energy shock wave on organs adjacent to the kidney in the growing rat

OBJECTIVE

To assess the effects of high-energy shock waves (HESW) on organs adjacent to the kidney, in the growing rat.

MATERIALS AND METHODS

We studied 60 Wistar male rats. Upon completing 30 days of age, a radiopaque marker was placed in the animals' left renal cavity. With 40 days of age, after radiologically confirming the markers' position, the rats were divided into 2 groups: control-group--30 rats that did not receive shock waves; experimental group--30 rats exposed to 1000 shock waves of 17.2 KV in intensity. The rats were sacrificed 7, 90 and 180 days after exposure to HESW. The bodily growth was assessed and the analysis of macro- and microscopic morphology of liver, spleen, pancreas, lungs and adrenals.

RESULTS

There was no statistical difference in the animals' bodily growth. The microscopic morphologic analysis demonstrated significant alterations in spleen (proliferative changes in the red pulp) and liver (cloudy swelling) of the animals submitted to HESW and sacrificed on the seventh day. These changes completely disappeared in subsequent analyses.

CONCLUSION

HESW applied to rat did not inhibit the animals' growth and caused transitory histological lesion in spleen (proliferative changes in the red pulp) and in liver (cloudy swelling of hepatocytes). Such changes were observed only in the group that was exposed to HESW and was sacrificed 7 days following the experiment, presenting spontaneous recovery.

Morphological changes induced in the pig kidney by extracorporeal shock wave lithotripsy: nephron injury

While shock wave lithotripsy (SWL) is known to cause significant damage to the kidney, little is known about the initial injury to cells along the nephron. In this study, one kidney in each of six juvenile pigs (6-7 weeks old) was treated with 1,000 shock waves (at 24 kV) directed at a lower pole calyx with an unmodified HM-3 lithotripter. Three pigs were utilized as sham-controls. Kidneys were fixed by vascular perfusion immediately after SWL or sham-SWL. Three of the treated kidneys were used to quantitate lesion size. Cortical and medullary samples for light (LM) and transmission electron microscopy (TEM) were taken from the focal zone for the shock waves (F2), the contralateral kidney, and the kidneys of sham-SWL pigs. Because preservation of the tissue occurred within minutes of SWL, the initial injury caused by the shock waves could be separated from secondary changes. No tissue damage was observed in contralateral sham-SWL kidneys, but treated kidneys showed signs of injury, with a lesion of 0.2% +/- 0.1% of renal volume. Intraparenchymal hemorrhage and injury to tubules was found at F2 in both the cortex and medulla of SWL-treated kidneys. Tubular injury was always associated with intraparenchymal bleeding, and the range of tissue injury included total destruction of tubules, focal cellular fragmentation, necrosis, cell vacuolization, and membrane blebbing. The initial injury caused by SWL was cellular fragmentation and necrosis. Cellular vacuolization, membrane blebbing, and disorganization of apical brush borders appear to be secondary changes related to hypoxia.

Evaluation of basal membrane antibody (immunoglobulin G) formation after high-energy shockwave application in rats

To evaluate the immune pathologic effects of high-energy shockwave (HESW) application on glomerular and tubular basal membrane antibody (IgG) formation, an experimental study on rats has been performed. Following application of different numbers of shockwaves (100-200-500), the presence of antibody was examined with the direct immunofluorescent technique 2 weeks and 3 months postprocedure. Whereas specimens examined after 2 weeks showed antibody formation in only one animal (500 HESWs), being located in the tubular tissues, all treated kidneys demonstrated various degrees of antibody formation in both tubular and glomerular tissues after 3 months. Antibody formation had a close relation to the number of HESWs applied and the time of examination after shockwave application. Apart from the well-defined functional and morphologic side effects of shockwave therapy, the possibility of immunologic alterations after this form of therapy has to be evaluated thoroughly in both clinical and experimental studies.

Prevalence of autoantibodies associated with glomerulonephritis, unaffected after extracorporeal shock wave lithotripsy for renal calculi, in a three-year follow-up

Extracorporeal shock wave lithotripsy (ESWL) has become a useful tool in the treatment of renal calculi, but side effects may occur. Hitherto, two case reports have been published of an anti-glomerular basement membrane disease resulting in end-stage renal failure following ESWL treatment. In this prospective study of 59 consecutive patients undergoing ESWL for renal calculi, the prevalence of autoantibodies associated with glomerulonephritis was investigated before ESWL and at 3-year follow-up. The prevalences of antinuclear, anti-glomerular basement membrane, anti-neutrophil cytoplasmic and thyroid antibodies were found to be within the respective normal ranges prior to the first ESWL treatment and to be unaffected at follow-up.

Preservation of shock-wave-induced renal histologic changes by dermatan sulfate

OBJECTIVES

To evaluate the protective effects of glycosaminoglycan (GAG) administration on shock-wave-induced renal histologic alterations, an experimental study using dermatan sulfate administration (DS) in rabbits was performed.

METHODS

The study included 45 white New Zealand rabbits; 36 were divided into two groups before shock-wave application. Animals in the first group (n = 18) received no specific medication before or after shock-wave treatment; animals in the second group (n = 18) received subcutaneous DS administration for a period of 2 months, beginning 2 weeks before shock-wave application. Following different numbers of shock-wave application (500, 1000, or 1500 shock waves), histopathologic evaluation of treated kidneys was made under light microscopy after 24 hours and 3 months. Nine animals were used for the control group.

RESULTS

During 24-hour examination, most of the kidneys in both groups demonstrated varying degrees of histopathologic alterations, depending on the number of shock waves applied. Among the most prominent pathologic features were protein deposition with free erythrocytes in the tubular lumen, glomerular hemorrhage, tubular dilation and degeneration, protein in Bowman's capsule, hyperemia, and mononuclear cell infiltration at the interstitial level. As opposed to the 24-hour evaluation findings, long-term (3-month) follow-up examination revealed histopathologic alterations that decreased but did not totally disappear in animals receiving no DS. Glomerular basement membrane thickening, mononuclear cell infiltration and limited protein deposition in some tubules, together with cortical interstitial fibrosis, were observed to some extent in these animals. On the other hand, no severe histopathologic alteration with normal glomerular basement membrane appearance was noted in animals receiving DS medication.

CONCLUSIONS

Our results indicated a long-term favorable protective effect of DS administration on morphologic abnormalities in rabbits undergoing shock-wave treatment. Although tubular alterations persisted to some extent, mononuclear cell infiltration has been limited and the natural appearance of the basement membrane has been well preserved in most of the treated animals.

Pediatric urolithiasis: review of research and current management

The treatment of urolithiasis in children has changed dramatically in recent years. With the proven safety and efficacy of extracorporeal shock wave lithotripsy (ESWL), percutaneous lithotripsy and ureteroscopy in adults, these modalities are now in the forefront of the treatment of pediatric urinary stones. Our research in the juvenile non-human primate with ESWL indicates that renal damage in most cases is neither significant or persistent. In addition, technological advances in instrumentation have cleared the way for the use of percutaneous lithotripsy and ureteroscopy in most pediatric patients. Today, open surgical procedures for stone disease in children should be a last resort.

Excretion of urinary enzymes after extracorporeal shock wave lithotripsy: a critical reevaluation

The excretion of the urinary enzymes alanine aminopeptidase, alkaline phosphatase, gamma-glutamyl-transferase and N-acetyl-beta-D-glucosaminidase, and the 99mtechnetium-diethylenetriaminepentaacetic acid isotope clearance were studied in 35 patients treated with extracorporeal shock wave lithotripsy (ESWL*). Enzyme measurements were made before and consecutively on days 1, 2 and 5, and at 3 months after treatment. A control group investigated at the same intervals was included. Posttreatment enzyme values were not significantly different from those before treatment except for alkaline phosphatase on day 1 after ESWL. Some individuals had short-term increases of enzymuria that were greater than biological variations in the control group. The transient changes of enzymuria after ESWL had no predictive value for kidney function, since no decreased renal function was observed in individual patients with high enzyme excretions after ESWL.