Chyluria - SGPGI experience

Chyluria Associated With Nephrotic-Range Proteinuria

Chyluria is the presence of chyle in the urine and is associated with some degree of proteinuria. We report two patients with chyluria who presented with milky urine, weight loss, and edema and were found to have nephrotic-range proteinuria. Although filarial antigen was detected in only one of the patients, flexible cystoscopy could demonstrate chyle efflux from the left ureter in first patient and from both the ureters in the second patient. Both patients received endoscopic sclerotherapy with 0.2% povidone-iodine, which resulted in the clearance of milky urine in three to five days and complete resolution of nephrotic-range proteinuria on follow-up. They remained symptom-free until the six-month follow-up. We deferred renal biopsy in both patients, as proteinuria was confirmed to be non-glomerular in origin.

Effect of Clinical, Biochemical, and Genetic Variations on Medical Management in Filarial Chyluria: A Prospective Study at a Tertiary Care Centre in North India

Objective To analyze the effect of clinical, biochemical factors, and Mannose Binding Lectin 2 (MBL2) gene variations on medical management in filarial chyluria (FC) patients. Material and methods We conducted a study between March 2013 and April 2016. MBL2polymorphisms were genotyped in confirmed 101 medically-treated cases of FC. Demographic, clinical, and biochemical variables were compared between remission and failure groups. Genotyping of MBL2 codon 54 and promoter -221 were undertaken by polymerase chain reaction. Genotype frequencies were compared with clinical and biochemical variables and medical treatment outcomes (remission/failure). The association between genotypes and treatment response was estimated by OR and 95% CI and generated by the chi-square test. Results The mean age was 36.9±10.28-years and the male-female ratio was 3:1.2. Sixty-six patients had remission (Group-A) while 35 had recurrence (Group-B) at a mean follow-up of 21 months. The success rate for medical therapy was 65.35%. There was no statistical difference observed in the demographic profile of the two groups. On multivariate analysis, patients in Group-B had a higher grade of chyluria (p=0.005), had experienced greater number of disease attacks in the past (p=0.022), and had higher urinary triglyceride levels (TG) (p<0.001) as compared to Group-A patients. A significant association of MBL2 codon 54 genotypes was observed with the recurrent presentation of chyluria (p=0.044), grade of chyluria (p=0.028), and urinary TGs (p=0.001). However, genotype distribution at -221 did not show association with clinical and biochemical parameters of FC patients. The distribution of genotypes at codon 54 differed significantly between remission and failure/recurrence group; the variant genotype BB was significantly higher in the recurrence or failure group (OR:6.00; 95%CI, 1.00-35.91; p=0.050). However, frequencies of variant genotype YX and recessive group YX+XX of MBL2 -221 promoter was higher in remission group (OR:2.97;95%CI, 1.23-7.13; p=0.018 and OR:2.76; 95%CI, 1.80-6.50; p=0.020), respectively, showing that genetic variant may be associated with response to medical therapy. Conclusion Higher grade of chyluria, a higher number of disease attacks in the past, and higher urinary TGs levels were clinical predictors of poor response to medical treatment. Our results showed that the variants of MBL2 genes have an impact on treatment outcomes in FC patients. These observations may be limited by sample size.

New developments in chyluria after global programs to eliminate lymphatic filariasis

Chyluria, commonly seen in south Asian countries, is mainly a manifestation of lymphatic filariasis as a result of infestation with Wuchereria bancrofti, although many other causes can contribute. Many patients can be effectively treated with dietary modifications and drug therapy. The most widely used drug is diethyl carbamazine. The recurrences are common after such treatment. Such patients would benefit from sclerotherapy to obliterate the lympatico-renal fistulae located mainly in the renal pelvicalyceal system. The commonly used sclerosing agent is a combination of 5% povidone-iodine and 50% dextrose instilled through a ureteric catheter. A small percentage of patients who recur after sclerotherapy and those with systemic complications, such as hypoproteinemia and edema, might require surgery in the form of renal hilar lymphatic disconnection. Although it is a major operation, the success rates are >90%. Laparoscopic and robotic techniques have minimized the morbidity related to such surgery. With the advent of the global program for eradication of filariasis initiated by the World Health Organization, the incidence of the disease is decreasing. Mass chemotherapy with diethyl carbamazine is the mainstay of this global program. Many years after eliminating filariasis, chyluria continue to occur in such populations, though in dwindling numbers. Future research should aim at finding more efficacious sclerosing agents with minimal recurrences.

Single versus multiple instillation of povidone iodine and urographin in the treatment of chyluria: A prospective randomised study

Objective

To compare the safety, efficacy and complications of single vs multiple instillations of povidone iodine (PI) and urographin as a sclerosing agent in the treatment of chyluria.

Patients and methods

The study included 58 patients diagnosed with chyluria between March 2006 and January 2013. The inclusion criteria were either severe attacks of chyluria or patients with mild-to-moderate chyluria who had failed conservative treatment. The patients were randomly allocated to one of two groups: those in Group A had a single instillation of a combination of PI 0.2% plus the contrast-agent urographin 76%, while those in Group B had multiple instillations of the same combination twice daily for 3 successive days.

Results

The mean (SD) age of the patients in Groups A and B was 38.22 (10.67) and 37.9 (10.86) years, respectively. Chyluria was severe in eight patients (14.8%), moderate in 25 (46.3%) and mild in 21 (38.9%). The success rate in Group A (single instillation) was 85.2% and in Group B (multiple instillation) was 88.9%. The recurrence rate in Group A was 14.8% with a disease-free duration (DFD) of 4–15 weeks, while in group B it was 11.1% with a DFD of 6–18 weeks.

Conclusion

There was no significant difference between a single instillation of a combination of PI 0.2% and urographin 76% as a sclerosing agent in the treatment of chyluria and multiple instillations. However, the single instillation protocol is more cost effective with a shorter hospital stay.

Is single dose povidone iodine sclerotherapy effective in chyluria?

PURPOSE

To evaluate the effectiveness and safety of single dose 0.2 % povidone iodine renal pelvic instillation sclerotherapy for the treatment for chyluria.

METHODS

In a prospective study from August 2010 till July 2013, 41 patients presenting with milky urine were included. Apart from ether test, the presence of lymphocytes in urine and urine triglycerides levels were also done to confirm chyluria. On a day care basis under local anesthesia, 5F open-ended ureteric catheter was introduced in the ureteric orifice of affected side. Freshly prepared 7-10 ml of 0.2 % povidone iodine solution was instilled with the patient in Trendelenburg position.

RESULTS

Total of 41 patients were enrolled (27 males and 14 females; mean age 40 years, SD 8.9, range 19-61) with a mean follow-up of 20 months. Immediate clearance was seen in all patients and recurrence in 7 (17 %). Mean disease-free duration was 18 months. Two patients had moderate to severe flank pain.

CONCLUSION

Single dose 0.2 % povidone iodine sclerotherapy is safe and effective treatment for chyluria. As it offers treatment on a day care basis, continuous ureteral and urethral catheterizations can be avoided.

Non-tropical chyluria: CT diagnosis

Chyluria is commonly associated with filariasis, which is prevalent among the population of tropical and subtropical regions. Chyluria is seldom encountered in the United States and other western countries, but may occur if the flow of chyle into the thoracic duct is blocked due to inflammatory, neoplastic, or various other etiologies. We report 10 adult patients, in whom the detection of fat-urine level in their bladder on abdominal CT provided the initial diagnostic clue to the presence of chyluria. This series included 7 men and 3 women, who ranged in age from 25 to 91 years (mean: 62 years). The associated lesions included renal angiomyolipomas (2), lymphangiomas of the kidney and bladder (1), metastatic testicular cancer (1), postoperative status following partial nephrectomy for renal cell carcinoma (4), left radical nephrectomy (1), and segmental cystectomy for carcinomas (1). The clinical and radiological features of this entity are presented along with a brief review of the pertinent literature.