Clinical analysis of 61 systemic lupus erythematosus patients with intestinal pseudo-obstruction and/or ureterohydronephrosis: a retrospective observational study

The objective of this article is to investigate the clinical features of intestinal pseudo-obstruction (IPO) and/or ureterohydronephrosis in systemic lupus erythematosus (SLE). Sixty-one SLE patients with IPO and/or ureterohydronephrosis were analyzed retrospectively. A total of 183 cases were randomly selected as controls from 3840 SLE inpatients without IPO and ureterohydronephrosis during the same period. Patients were assigned to 1 of the 3 groups (SLE with IPO and ureterohydronephrosis, SLE with IPO, and SLE with ureterohydronephrosis). The clinical characteristics, treatments, and prognosis were compared between the 3 groups. There were 57 females and 4 males, with a mean age of 32.0 years. IPO was the initial manifestation of SLE in 49.1% of the cases, whereas ureterohydronephrosis in 32.5%. All patients were initially treated with a high-dose steroid. Thirty-one of these patients (50.8%) also received intravenous methylprednisolone pulse therapy. Two patients died of bowel perforation and lupus encephalopathy, and the other 59 patients (96.7%) achieved remission after treatment. The incidences of fever, glomerulonephritis, nervous system involvement, serositis, erythrocyte sedimentation rate elevation, hypoalbuminemia, hypocomplementemia, and anti-SSA antibody positivity were significantly higher in patients with IPO and/or ureterohydronephrosis than in the control group (without IPO and ureterohydronephrosis). Also, patients with IPO and/or ureterohydronephrosis had higher SLE Disease Activity Index scores than control patients. Compared with SLE patients with IPO, the patients with IPO and ureterohydronephrosis had a significantly higher incidence of gallbladder wall thickening, biliary tract dilatation, and serositis, whereas the patients with ureterohydronephrosis had less mucocutaneous involvement and serositis. Eight of the 47 IPO patients who initially responded well to immunotherapy relapsed; however, all responded well to retreatment with adequate immunotherapy. Of these 8 patients, 4 relapsed following poor compliance and self-discontinuation of steroid or immunosuppressant therapy. The rate of poor compliance with immunotherapy and the number of organ systems involved in patients in the recurrent IPO group were significantly higher than those in the nonrecurrent IPO group. IPO and ureterohydronephrosis are severe complications of SLE. As patients usually respond readily to early optimal steroid treatment, early diagnosis and timely initiation of glucocorticoid are important to relieve symptoms, prevent complications, and improve prognosis.

[Primary diffuse large B-cell lymphoma of the uterus complicated with hydronephrosis]

Malignant lymphoma sometimes originates from extranodal sites; however, the uterus has rarely been reported as the site of the primary lesion. We present a patient with malignant lymphoma of the uterus complicating bilateral hydronephrosis. A 67-year-old previously healthy woman was seen at a clinic because of massive genital bleeding. She was referred to our hospital for further examination of a uterine tumor. Computed tomography scans revealed a pelvic tumor invading to the retroperitoneal region, which caused bilateral obstruction of the ureters and hydronephrosis. No lymph node swelling was detected. Magnetic resonance imaging showed a bulky uterine tumor that was homogenously low on T1-weighted imaging and isointense on T2-weighted imaging, while the endometrium was intact. A pathological examination of the biopsy specimen from the uterine cervix revealed diffuse infiltration of CD20-positive atypical large lymphoid cells, which was compatible with diffuse large B-cell lymphoma (DLBCL). Since the tumor expanded from the uterus and no other abnormal lesion was observed in imaging studies including gallium scintigraphy, a diagnosis of DLBCL of the uterus, clinical stage IE was made. The patient received six cycles of rituximab plus CHOP chemotherapy followed by involved field irradiation. She achieved complete remission and has been alive for more than two years without relapse.

[Case of retroperitoneal fibrosis after surgical treatment of autoimmune pancreatitis]

We present a case of retroperitoneal fibrosis (RPF) in a 72-year-old man who previously received pancreatectomy for autoimmune pancreatitis. He had received colectomy for early colon cancer on 11th November, 2005. During the routine follow-up for colon cancer, a swollen pancreas tail was detected on enhanced CT. He received distal pancreatectomy under the diagnosis of pancreas cancer on 4th October, 2007. Pathological diagnosis revealed the autoimmune pancreatitis. Eight months later, right hydronephrosis was observed in an abdominal ultrasonographic study, and at the same time, right hydroureterosis due to retroperitoneal soft tissue mass around the bifurcation was detected on enhanced CT. He was treated with predonisolone aiming at the diagnosis and/or therapy. Twelve weeks later, right hydronephrosis had disappeared and retroperitoneal mass had shrunken. Now, it is thought that autoimmune pancreatitis is a systemic sclerosing disease accompanied with extra-pancreatic pathologic changes such as RPF.

[Case of lupus nephritis and enteritis associated with bilateral hydronephrosis]

A case of nephrotic syndrome associated with bilateral hydronephrosis in a 26-year-old female is reported. She was referred to our hospital because of persistent diarrhea, abdominal pain, and urinary disorders. On admission, ascites, intestinal edema, and bilateral hydronephrosis, were demonstrated by radiographic analysis. The findings of both physical and laboratory examinations showed evidence of systemic lupus erythematosus (SLE). In addition, diffuse proliferative lupus nephritis was consistently confirmed by a renal biopsy. Immediately after the initiation of steroid treatment, her abdominal symptoms disappeared followed by an improvement in the symptoms of intestinal edema, hydronephrosis, and the renal function. The relationship between ureterohydronephrosis and lupus cystitis, and the fact that lupus enteritis is often associated with lupus cystitis have been demonstrated by previous studies. Finally, the clinical manifestations observed in our case led us to consider the association of lupus enteritis and cystitis. We should bear in mind the possible association of several disorders, including nephrotic syndrome, enteritis, and hydronephrosis due to cystitis, in cases presenting with SLE.

The long-term outcome of antenatal hydronephrosis up to 15 millimetres justifies a noninvasive postnatal follow-up

AIM

To assess the incidence of urinary tract infections (UTIs) and surgery in infants with different grades of antenatal hydronephrosis (ANH) and to evaluate incidence, severity and course of underlying vesicoureteral reflux (VUR).

METHODS

Retrospective data of 125 infants with ANH were collected. The patients were divided into two groups according to the anterior-posterior pelvis diameter: group I, 5-14 mm and group II, > or =15 mm.

RESULTS

UTIs developed in 4 of 106 infants from group I and 5 of 19 infants from group II. Surgical interventions were performed on 1 of 106 patients of group I and 7 of 19 patients of group II. These differences were statistically significant (p-values 0.004 and <0.001, respectively). In group I, 6 of 106 patients had VUR; none of them required surgical intervention and only two developed a UTI (one of whom also had contralateral ureteropelvic junction obstruction). Five of 19 infants in group II had underlying VUR, four of them with associated anomalies, 1 infant required surgical correction and 4 developed UTIs.

CONCLUSION

Infants with ANH up to 15 mm have a low incidence of UTIs and surgery and a low incidence and benign course of underlying VUR. Therefore, noninvasive postnatal follow-up is justified and standard voiding cystourethrography should not be performed, but only in cases of ureteric dilatation.

Resolution of hydronephrosis due to massive mesenteric fibromatosis using cyclo-oxygenase 2 inhibitors

Mesenteric fibromatosis is currently a diagnostic and therapeutic challenge. We report a case of mesenteric fibromatosis in a 29-year-old man with a 2-month history of periumbilical fullness who was discovered to have an abdominal mass with hydronephrosis. To the best of our knowledge, we report the first case of hydronephrosis in a mesenteric fibromatosis with Gardner's syndrome, which was successfully treated with a cyclo-oxygenase 2 inhibitor without surgical removal of the mesenteric fibromatosis. The hydronephrosis and mesenteric fibromatosis improved modestly with long-term celecoxib (200 mg twice daily). Our case also highlights the importance of performing a detailed examination in patients with hydronephrosis.

Cyclooxygenase-2 inhibitor ameliorates ureteric damage in rats with obstructed uropathy

To investigate the effect of cyclooxygenase-2 (COX-2) inhibitor on the tissue damage and fibrosis in obstructed ureters, 80 rats were studied. Celecoxib, a COX-2 inhibitor, was administered to 40 rats at the dose of 10 mg/kg per day 1 day before unilateral ligation of ureters and every day thereafter. The others, receiving unilateral ligation of ureters only, served as controls. Eight rats from each group were sacrificed for examination on days 7, 14, 21, 28 and 42 after ligation, respectively. The expressions of COX-2, prostaglandin E(2) (PGE(2)), transforming growth factor-beta(1) (TGFbeta(1)), alpha-smooth muscle actin (alpha-SMA), proliferation cell nuclear antigen (PCNA) and the apoptotic cells in the ureteric smooth muscle were examined. Hydroureter and fibrosis of the muscle layer became progressively aggravated during the period of obstruction in the ligated ureters of both groups. The severity of the hydroureter and fibrosis of muscle layer in the ligated ureters of the treated group was significantly milder than those of the control group. Expressions of COX-2 and PGE(2) were found in the smooth muscle layer of ligated ureters in the control group from day 14 after ureteric ligation, reached a peak on day 21, and then declined. Treatment with Celecoxib completely abolished the expression of COX-2 and PGE(2). The Celecoxib administration also decreased the expression of TGFbeta(1), alpha-SMA and the labeling index of apoptotic cells in the smooth muscle layer of ligated ureters in the treated group. In the contrast, treatment with Celecoxib significantly increased the expression of PCNA in the smooth muscle layer of ligated ureters in the treated group. We concluded that COX-2 inhibitor might ameliorate the damage of obstructed ureters, at least partly, via the inhibition of COX-2 and TGFbeta(1) expression.

[Retroperitoneal fibrosis]

Retroperitoneal fibrosis is a rare clinical entity characterised by the presence of patologic collagen tissue in a retroperitoneal space. The fibrous mass covers abdominal organs causing their disfunctions. RPF was described at the begining of XX century but its etiology is not clear yet. Usually it causes an ureter obstuction and hydronephrosis, that is why most commonly is diagnosed by urologists and nephrologists. However, retroperitoneal fibrosis can be multifacial disease. In some patients localisation of fibrosis is atypical and manifestationns can be varied. Gastrological symptoms like jaundice, bowel obstuction, ascites can occure. Besides, some early signs of RPF are nonspecific and can imitate alarming symptoms of neoplasma, e.g.: weight loss, anemia, malaise, anorexia, fever. This force us to initiate gastrological investigation. The awareness of this disease is important. The early diagnosis and treatment improves prognosis and alows to avoid heavy complications. In typical cases radiology is often enough for diagnosis. However, histological examination is needed in many cases, especialy when patological mass is located atypical. A treatment is made up of farmacology and surgery. The first one is based on steroids, immunossuppressant and tamoxifen. Surgery is needed to eliminate organs obstruction.

Idiopathic Neurohypophysial Diabetes Insipidus: Reversibility of Structural and Functional Renal Abnormalities after Treatment

OBJECTIVE

To present a case of untreated long-term idiopathic neurohypophysial diabetes insipidus (DI) with structural and functional renal abnormalities that regressed after treatment.

METHODS

We describe the clinical course, biochemical data, and imaging findings in a man with idiopathic neurohypophysial DI in whom structural and functional abnormalities involving the urinary tract diminished after treatment. The patient underwent intravenous pyelography, retrograde pyelography, computed tomographic (CT) scanning of the kidneys and abdomen, iodohippurate renal scanning, and voiding cystourethrography. Ultrasonography of the kidneys at presentation and at 8-year followup and serial determinations of serum creatinine for a period of 9 years were also done.

RESULTS

A 43-year-old man had polyuria for 30 years attributable to untreated idiopathic neurohypophysial DI. He presented with bilateral flank pain and a high serum creatinine level (156 mmol/L). Ultrasonography, intravenous pyelography, retrograde pyelography, and CT scan of the kidneys demonstrated severe bilateral hydronephrosis, notably dilated and tortuous ureters, a distended bladder, and atrophy of the left renal cortex. Retrograde pyelography and voiding cystourethrography confirmed the absence of mechanical obstruction or urinary reflux. A renal scan study showed bilaterally impaired function. Treatment with intranasally administered desmopressin and clean intermittent straight bladder catheterization resulted in resolution of flank pain, improvement of renal function, normalization of serum creatinine levels, and decreased hydronephrosis during 9 years of follow-up.

CONCLUSION

This case provides information about renal abnormalities in the natural history of a long-term polyuric state, idiopathic neurohypophysial DI, before and after treatment. Reversibility of renal structural and functional abnormalities after treatment is documented. Recognition of renal abnormalities associated with untreated neurohypophysial DI is important for prevention and treatment of such complications.

[A case of recurrent gastric cancer with peritoneal dissemination successfully treated with DJ stents against bilateral hydronephrosis and chemotherapy]

A 69-year-old female patient underwent total gastrectomy with a D2 lymph node dissection. Her final findings were of pT2, pN0, sP0, sH0, sM0 and Stage IB. After thirty-five months from the operation, peritoneal recurrence with ascites, bilateral hydronephrosis and stenosis of colon was found. TS-1 (80 mg/day/body) was administered for four weeks followed by a 2-week rest after DJ stents were inserted into bilateral ureters. At the end of two courses of TS-1, ascites disappeared and the decrease of tumor marker was observed. During the seventh course, symptoms such as abdominal fullness and ascites became worse. She underwent a weekly administration of paclitaxel (90 mg/body) as a second-line chemotherapy. This regimen was continued for three weeks followed by a 1-week rest. After four courses of paclitaxel, ascites disappeared and the tumor marker was gradually reduced. However, multiple bone metastases were found during the eighth course, and she died about two years after the recurrence. The toxic events were mucositis (grade 1) in TS-1, and alopecia (grade 2) and leukopenia (grade 1) in paclitaxel. No major adverse effects were observed. Although the prognosis of recurrent gastric cancer with peritoneal dissemination was extremely poor, this case might suggest a possibility that intensive therapies are useful in maintaining the quality of life and improving survival.

Delayed complications of discontinuation of intrathecal baclofen therapy: resurgence of dyssynergic voiding, which triggered off autonomic dysreflexia and hydronephrosis

STUDY DESIGN

Case report.

OBJECTIVES

To report insidious development of autonomic dysreflexia and hydronephrosis due to dyssynergic voiding following discontinuation of intrathecal baclofen therapy.

SETTING

Regional Spinal Injuries Centre, Southport, UK.

METHODS

A male patient with paraplegia at T-5 (ASIA-A) had implantation of Medtronic Synchromed 8615 s programmable pump to control intractable spasms. After 4 years, the baclofen pump needed replacement because of battery exhaustion. At this time, he was taking oxybutynin 2.5 mg twice a day. He wore a penile sheath and performed intermittent catheterisation three times a day. Intravenous urography showed no dilatation of pelvicalyceal systems or ureters. During the course of the next 4 months, the dose of baclofen had to be increased gradually to 820 microg/day in order to control the spasms. Investigations revealed disconnection of the tube from the pump. The patient decided to undergo explantation of the pump and discontinue intrathecal baclofen therapy altogether. Following removal of the pump, he was prescribed baclofen 20 mg four times a day and diazepam 5 mg twice a day. He continued penile sheath drainage with oxybutynin 2.5 mg twice a day. Although spasms were controlled with oral baclofen and diazepam, he started getting transient, mild headache during reflex voiding. After nearly 2 years, he developed unbearable and pounding headache while passing urine.

RESULTS

The dose of oxybutynin was increased to modified release formulation, 20 mg, once daily. He was prescribed modified release alfuzosin 10 mg once a day. Indwelling urethral catheter drainage was instituted. Intravenous urography showed dilation of left renal pelvis and calyces, and left ureter. After a fortnight, the dose of modified release oxybutynin was increased further to 25 mg once a day. After a month, he started performing self-catheterisation every 3 h and symptoms of autonomic dysreflexia subsided completely. A follow-up intravenous urography performed 6 months later, showed normal appearances of the left kidney.

CONCLUSION

Spinal cord injury patients, in whom intrathecal baclofen therapy is terminated, need close monitoring of their urological status. Medications, which are prescribed for neuropathic bladder, and the method of bladder drainage, may need suitable changes, as discontinuation of intrathecal baclofen therapy can result in reappearance of detrusor-sphincter dyssynergia in previously susceptible patients.

Cellular Mechanism for Mibefradil-Induced Vasodilation of Renal Microcirculation

Although nifedipine and other conventional calcium antagonists elicit preferential vasodilation of renal afferent arterioles, we demonstrate that mibefradil and nickel, T-type calcium channel blockers, reverse the angiotensin II-induced constriction of both afferent and efferent arterioles. Since the angiotensin II-induced vasoconstriction involves inositol trisphosphate (IP3)-induced calcium release from the sarcoplasmic reticulum in the afferent arteriole, and both IP3- and protein kinase C (PKC)-mediated pathways in the efferent arteriole, we investigated the cellular mechanism for the mibefradil-induced dilation of angiotensin II-constricted renal arterioles, using the isolated perfused hydronephrotic rat kidney. Mibefradil caused a dose-dependent dilation of angiotensin II-constricted afferent and efferent arterioles, with 88 +/- 9% and 74 +/- 10% reversal observed at 1 micromol/L, respectively. The blockade of PKC by staurosporine did not alter the mibefradil-induced vasodilator responses of either arterioles (P > 0.5). In contrast, the pretreatment with thapsigargin, which predominantly blocked the IP3-mediated intracellular calcium release, prevented the afferent arteriolar constrictor response to angiotensin II, but caused a significant constriction of efferent arterioles. The subsequent addition of mibefradil had no effect on the efferent arteriolar diameter. Furthermore, the efferent arteriolar constriction induced by direct PKC activation by phorbol myristate acetate was refractory to mibefradil, but completely reversed by LOE908, a nonselective cation channel blocker. In summary, mibefradil markedly dilates the angiotensin II-induced renal arteriolar constriction; the action of mibefradil is most likely mediated by the inhibition of the IP3-mediated pathway, but the inhibitory action on the PKC pathway appears modest.

Retinoid agonist isotretinoin ameliorates obstructive renal injury

PURPOSE

Interstitial fibrosis is a major cause of end stage renal failure. Retinoids, which are involved in tissue repair and fibrosis, inhibit inflammatory and proliferative pathways. Therefore, we studied the dose dependent effects of the retinoid receptor agonist isotretinoin 13-cis retinoic acid in the unilateral ureteral obstruction model (UUO).

MATERIALS AND METHODS

Sham operated control rats were compared with UUO rats treated with vehicle (UUO-Veh), or low (5 mg/kg body weight (UUO-LD) or high (25 mg/kg) (UUO-HD) dose isotretinoin. Kidneys were evaluated using reverse transcriptase-polymerase chain reaction and immunohistology 7 days after UUO. Renal injury and fibrosis were quantified by immunostaining and expression measurements of the genes involved in renal fibrosis.

RESULTS

In UUO-Veh kidneys the interstitial area was expanded 5-fold but only 3-fold in UUO-HD and 3.5-fold in UUO-LD rats. Interstitial cell counts were 3-fold higher in UUO-Veh rats but significantly less in UUO-HD or UUO-LD animals. Tubular and interstitial cell proliferation was significantly higher in UUO-Veh rats compared with sham operated control plus vehicle animals but less so in UUO-LD and UUO-HD rats. In UUO-Veh rats interstitial infiltration by monocytes/macrophages was higher compared with unobstructed controls. It was significantly less after isotretinoin treatment. In UUO-Veh rats mRNA for procollagen I, and transforming growth factor-beta1 and II receptor was significantly increased. It was significantly less after treatment with isotretinoin. Fibronectin and collagen I immunostaining was also decreased by isotretinoin.

CONCLUSIONS

Since isotretinoin limits proliferation, inflammation and fibrosis after UUO, retinoids should be further investigated as potentially promising therapeutic agents for renal disease.

Steroid therapy for idiopathic retroperitoneal fibrosis: dose and duration

PURPOSE

Idiopathic retroperitoneal fibrosis is an uncommon disease of unknown etiology that may involve the ureters and other retroperitoneal structures. Surgical ureterolysis as well as medical treatment with steroids have been used to treat these patients. However, there is no agreement as to the dose and duration of steroid. We adopted a regimen of long-term steroid use in this prospective study.

MATERIALS AND METHODS

We treated 12 patients with idiopathic retroperitoneal fibrosis with a regimen of steroids during a 10-year period. Tissue diagnosis was established by biopsy of all lesions and ureteral obstruction was managed with insertion of a nephrostomy tube or a ureteral stent. The initial dose of prednisolone was 60 mg. on alternate days for 2 months and was tapered during the following 2 months to a daily dose of 5 mg. The total duration of prednisolone use was 2 years.

RESULTS

Of the 12 patients 11 who completed this treatment regimen have been followed for a duration of 26 to 132 months (median 63.1) after discontinuation of treatment. Good response in the form of relief of symptoms and regression of the mass occurred in 9 cases and there were 2 failures. In 1 case the retroperitoneal mass did not regress and surgical ureterolysis was required. In the 2nd case symptoms recurred after discontinuation of steroid and a further small dose of steroids was required. Function deteriorated in 1 of 19 functioning renal units. No steroid related serious side effects developed.

CONCLUSIONS

This regimen of steroid may be used as the primary mode of treatment for the majority of patients with idiopathic retroperitoneal fibrosis with minimal complications. Patients with idiopathic retroperitoneal fibrosis should be followed periodically for the rest of their lives.

Pulmonary hyalinizing granuloma with hydronephrosis

A 49-year-old man was admitted for the evaluation of a bilateral mass shadow in his chest X-ray film. No definitive diagnosis was established either by brushing cytology or biopsy through bronchoscopy. No malignancies were suggested by general work-up. Both masses were surgically removed, and were diagnosed as pulmonary hyalinizing granuloma (PHG). Fifteen months later, low grade fever continued and the renal function decreased. Laboratory examinations revealed bilateral hydronephrosis with polyclonal hypergammaglobulinemia. The findings of abdominal CT and urography were compatible with retroperitoneal fibrosis. Steroid treatment completely reversed the initial abnormality in laboratory data and the symptoms disappeared.

Treatment of idiopathic retroperitoneal fibrosis using cyclosporin

The main goal of traditional treatment of idiopathic retroperitoneal fibrosis is limitation of morbidity, and surgery of already formed fibrous masses has been the main therapeutic approach. More recently, the knowledge that the disorder may be the result of an allergic reaction to atherosclerotic lipids has prompted the use of corticosteroids and cytotoxic drugs, which proved efficacious, but also toxic. On the basis of data indicating a T cell pathogenesis of idiopathic retroperitoneal fibrosis, cyclosporin, a non-cytotoxic pretranscriptional inhibitor of proinflammatory cytokines, was used to treat the case reported here. A 65 year old man with aggressive retroperitoneal fibrosis and obstructive renal failure initially received steroids, which eventually lost their efficacy and led to vertebral collapse. He responded to 5 mg/kg/day cyclosporin, with radiological reduction of tissue deposition, relief of urether compression, and reduction in acute phase reactants in the blood. Chronic disease remission required stable drug concentrations. In conclusion, progress in research into the T cell pathogenesis of idiopathic retroperitoneal fibrosis may justify attempts with drugs such as cyclosporin to block the disease at its origin rather than treating the morbidity.

[Immune disorders in congenital hydronephrosis complicated by obstructive pyelonephritis]

Congenital hydronephrotic transformation complicated by obstructive pyelonephritis with intact renal function in children exhibited association with some antigens of the major histocompatibility system and their combinations, changes in immunity and nonspecific resistance. Marked and stable shifts in immune reactivity give grounds for inclusion of immunomodulating drugs in combined treatment of the above patients.

Treatment of pseudotumors with nonsteroidal antiinflammatory drugs

Large inflammatory pseudotumors (IPT) traditionally are managed with extensive surgical resection. This approach, which often is associated with significant morbidity, has been deemed necessary because of the uncertainty of diagnosis, symptomatology, and involvement of vital structures. Also, there is a lack of other reliable therapy for this clinically aggressive yet histologically benign disease characterized by an overreactive inflammatory response. The authors treated 2 cases of abdominal IPT with nonsteroidal antiinflammatory drug (NSAID) with successful results. After a diagnosis of IPT on tumor biopsy, an NSAID trial can confirm the diagnosis and treat the disease by causing tumor shrinkage and eventual resolution. Excision remains indicated in easily resectable tumors and in nonresponders to NSAID therapy.

Effects of BQ-123 on systemic and renal hemodynamic responses to endothelin-1 in the rat split hydronephrotic kidney

OBJECTIVE

To assess the site of action of endothelin-1 in vessels of different sizes in the kidney in vivo and investigate the function of endothelin A (ET(A)) receptors in mediating renal and systemic vasoconstriction.

DESIGN

The luminal diameters of different vessels were measured and glomerular blood flow in cortical glomeruli was determined by intravital videomicroscopy in the split hydronephrotic kidney of anesthetized female Wistar rats.

METHODS

The rats were infused with endothelin-1 (40 pmol/kg per min) with or without pretreatment with the selective ET(A)-receptor antagonist BQ-123 (0.5 mg/kg). Aortic clamping was used to control renal blood pressure during the endothelin-1 infusion.

RESULTS

Exogenous endothelin-1 induced a significant rise (30+/-3%) in mean arterial pressure and a marked, long-lasting fall in glomerular blood flow (53+/-3%) related to reduction of the inner diameter of arcuate (-30%), interlobular arteries (-33%) and afferent arterioles (-17%). Aortic clamping to normalize renal blood pressure did not attenuate the vasoconstriction and reduction in glomerular blood flow. Pretreatment with BQ-123 significantly reduced both the endothelin-1-induced rise in mean arterial pressure (12+/-1%) and the fall in glomerular blood flow (-23+/-11%). BQ-123 blunted the response to endothelin-1 in arcuate (-12%), interlobular (-11%) and afferent vessels (-5%). Acetylcholine and nitroprusside completely reversed the vasoconstriction in BQ-123-pretreated animals.

CONCLUSIONS

BQ-123 largely prevented the hemodynamic effects of exogenously administered endothelin-1. Our direct in-vivo techniques showed that ET(A) receptors are, at least in part, involved in endothelin-1 -mediated vasoconstriction in the rat kidney, and support the hypothesis that ET(A) receptors may help to control arterial pressure in anesthetized rats.

Sarcoidosis presenting as bilateral hydronephrosis

We report an unusual case of sarcoidosis associated with bilateral hydronephrosis. The patient was a 53-year-old Japanese woman who presented with dysuria and urinary incontinence. Computed tomography of the abdomen showed bilateral hydronephrosis caused by a retroperitoneal mass, surrounded by enlarged retroperitoneal lymph nodes. Histological examination of the mass demonstrated noncaseating epithelioid cell granulomas involving the retroperitoneal lymph nodes. Corticosteroid therapy led to complete resolution of the retroperitoneal mass and hydronephrosis. This case emphasizes that sarcoidosis should be included in the differential diagnosis of a retroperitoneal mass.

Antihypertensive agents and renal protection: calcium channel blockers

This study defines the nature of the renal protective effects of calcium channel blockers (Ca blockers) and the effects of the Ca blocker, amlodipine, compared to those of the angiotensin-converting enzyme inhibitor (ACEI), enalapril, on the progression of renal injury in 5/6 nephrectomized spontaneously hypertensive rats (SHR) fed a high-salt diet. Furthermore, we studied the effects of various Ca blockers on the glomerular afferent and efferent arterioles using the isolated perfused hydronephrotic kidneys of six-week-old male Sprague-Dawley rats. In the first study, forty 6-week-old male SHRs which underwent 5/6 nephrectomy were equally divided into five groups. One group received no therapy. In two groups, therapy was started at four weeks post-nephrectomy, one with amlodipine and the other with enalapril. In the remaining two groups, amlodipine or enalapril therapy was started at eight weeks postnephrectomy. Amlodipine was more effective than enalapril in reducing proteinuria and glomerulosclerosis in the group that was started on drug therapy eight weeks after surgery. In the second study, at concentrations of 10(-6) to 10(-9) M, nifedipine, nicardipine and amlodipine dilated the afferent, but not the efferent, arteriole preconstricted with angiotensin II. On the other hand, efonidipine and manidipine clearly dilated angiotensin II-induced constriction of both the afferent and efferent arterioles. These results indicated that Ca blockers are effective at reducing renal injury in 5/6 nephrectomized SHR, and that they are more effective than ACEI in advanced stages of renal injury. The observation that only certain Ca blockers can dilate the efferent arteriole suggests that the renal protective effect of Ca blockers is not necessarily dependent on the dilation of the efferent arterioles.

[Left-sided hydronephrosis as the first sign of Crohn disease]

HISTORY AND CLINICAL FINDINGS

A previously well 29-year-old man was referred to the emergency department because of acute left lower abdominal pain without intestinal symptoms. Physical examination was unremarkable except for moderate suprapubic pain on pressure.

INVESTIGATIONS

There was evidence of a urinary infection. Erythrocyte sedimentation rate was increased (48 mm/h) and C-reactive protein elevated to 42 mg/l. There was mild leucocytosis (10000/microliter). Abdominal sonography revealed an enlarged left renal pelvis with hydroureter and possible prevesical stone, findings confirmed at excretion urography.

TREATMENT AND COURSE

He was discharged with the suspected diagnosis of ureteric stone and given co-trimoxazole, diclofenac and hyoscine butylbromide. After discontinuing medication the same symptoms developed two weeks later. Cystoscopy and retrograde pyelography were unremarkable and it was assumed the stone had been passed. The patient was again discharged on the above medication. When it was discontinued the same symptoms recurred and he was again admitted. Computed tomography, selective small-intestine radiology, coloscopy and biopsy indicated Crohn's disease with hydronephrosis as complication. Treatment trial with prednisone and mesalazine brought about only transient improvement so that an ileocaecal resection and ureterolysis were performed. The patient has since been free of symptoms.

CONCLUSION

If there are urological complications, chronic inflammatory intestinal disease should be included in the differential diagnosis even in the absence of any intestinal symptoms.

[Nonobstructive urinary tract dilatation due to diabetes insipidus in a patient with craniopharyngioma]

A 46-year-old man who had a history of hypogonadism, bilateral hydronephrosis and huge residual urine volume during the past ten years was admitted complaining of fever and flank pain. Polyuria which was more than 4 liters per day and inability of urine concentration suggested diabetes insipidus. Magnetic resonance imaging (MRI) demonstrated a tumor which was compatible with craniopharyngioma. Tumor resection and administration of desmopressin improved polyuria and urinary tract dilatation with marked reduction of residual urine volume from 400 ml to 20 ml.

Non-traumatic rupture of kidney in pregnancy--case report and review

During pregnancy, dilatation of the urinary collecting system is very common. Acute hydronephrosis is one of the most common causes of severe flank pain in pregnancy. Severe complications of hydronephrosis of pregnancy, such as pain, renal failure or a ruptured collecting system, occur very occasionally. A rare case of spontaneous rupture treated conservatively is presented.

Body growth in urinary tract malformations

Body height and height velocity were analysed in 54 children with obstructive urinary tract malformations over a mean period of 8.7 years, using new auxological methods. At the time of diagnosis, 9% of patients had a height of more than 2 standard deviations below the normal mean. Mean relative height changed significantly from the first to the last observation, the standard deviation score (SDS) increasing from -0.16 to +0.36 in patients with hydronephrosis compared with normal children (P < 0.05) and from -0.63 to +0.02 SDS in those without hydronephrosis (P < 0.005). The pathogenesis of the described growth disturbance is not clear. Stepwise multiple regression analysis pointed to a possible link between the duration of antibiotic treatment and the recovery of growth capacity, but improved growth could not clearly be attributed to any medical or surgical treatment. The synchronized average growth velocity curve was similar to that of healthy children and showed a normal pubertal spurt. Final height and target height calculated from parents' height differed only slightly from that of the normal population.

[Dopaminergic effect of anisodamine on the microcirculation of the hydronephrotic kidney of rats]

Anisodamine is an alkaloid extracted from the Tibetan plant "Anisodus tanguticus". Since 1965 it has been used in China for the treatment of shock but the mechanisms of its action are not fully known. The present study was performed to determine the effect of anisodamine on the renal microcirculation and to examine the underlying mechanism of its actions. The addition of anisodamine (10(-8) M to 10(-3) M) to the kidney bath resulted in a significant and dose dependent dilation of all preglomerular vessels. The maximal dilation (about 30% dilation) was found in the proximal interlobular artery. In contrast to preglomerular vessels anisodamine caused constriction of postglomerular vessels. The glomerular blood flow increased by about 50% at anisodamine concentration of 10(-3) M. Haloperidol, a dopamine receptor antagonist could abolish the renal vascular effect of anisodamine. It is suggested that anisodamine could improve renal function by the dilation of preglomerular vessels in combination with the constriction of postglomerular vessels, and the effect of anisodamine may be mediated by activation of the dopaminergic system.

A thromboxane A2 synthase inhibitor, DP-1904, prevents rat renal injury

The effects of DP-1904, a thromboxane (TX) A2 synthase inhibitor, on renal function were investigated by analysis of prostanoid metabolism in hydronephrotic and ischemic rat kidney models, and in isolated perfused normal and hydronephrotic rat kidneys. The increase in production of TXB2 in hydronephrotic or ischemic kidneys was significantly suppressed by intraperitoneal DP-1904 (10 mg/kg), with the 6-keto-prostaglandin F1 alpha to TXB2 ratio being significant increased. Urine volume, glomerular filtration rate and renal plasma flow were all improved. DP-1904 (0.3 micrograms/min) blocked the effects of infused arachidonic acid on isolated perfused normal rat kidneys thus reducing TXB2 levels and perfusion pressure but the pressor response to norepinephrine or angiotensin II remained unchanged. In isolated perfused hydronephrotic rat kidneys, DP-1904 suppressed the increase in perfusion pressure and TXB2 production caused by platelet-activating factor. These findings suggested that DP-1904 improved renal failure by specifically inhibiting TXA2 production.

Pharmacological enhancement of recovery in experimental hydronephrosis

The effects of mannitol, methylprednisolone, furosemide, inosine, indomethacin and captopril on the recovery from hydronephrosis were examined in rat kidneys. After 1 week of ureteral obstruction, left ureterocystostomy was performed in order to release the obstruction. Following ureteral release, mannitol, methylprednisolone, inosine, furosemide, captopril and indomethacin were given intravenously or orally. A saline group and non-treated control rats were also examined for comparison. 4 weeks after ureterocystostomy, 0.5 microCi of 203Hg-labelled chlormerodrin was given intravenously and the animals were sacrificed 48 h later. The left kidneys were significantly heavier in the mannitol-, methylprednisolone-, and inosine-treated groups than those of the control groups. The chlormerodrin uptake ratios of the left kidneys were significantly higher in the mannitol-, methylprednisolone-, captopril- and indomethacin-treated groups than in the control groups. These results suggest that the release of obstruction solely is not complete treatment for hydronephrosis, but that appropriate medical treatment may enhance the recovery from hydronephrosis.

[Regression of a massive hydronephrosis in familial central diabetes insipidus treated with Adiuretin]

A ten year old boy with hereditary pituitary diabetes insipidus presented with massive bilateral hydronephrosis, hydroureters and an extremely large bladder. Radiological investigations excluded a mechanical obstruction or vesicoureteral reflux. Treatment with the adiuretin analog DDAVP resulted in regression of the urinary tract changes after 5 months and an almost complete disappearance after 3 1/2 years. The urinary tract dilatation probably results from the large urine flows which exceed the capacity of the urinary tract causing a functional obstruction and residual urine.

The use of progesterone for ureteral stones: a preliminary report

Two ureteral stone patients were given injections of a progesterone derivative, resulting in prompt passage of the stones. The case reports are presented as well as a discussion of hydronephrosis of pregnancy and hormonal influences on the ureter.

Observations on the effect of metoclopramide (Primperan) on the human ureter. A preliminary communication

Metoclopramide, a procainamide derivative with a documented effect on the gastro-intestinal motility, was given to four patients with hydroureter. It induced strong peristalsis in the ureter, manifested clinically as relief of pain and fluoroscopically as emptying of the ureter and the renal pelvis.

Regression of prostatic cancer metastasis by high doses of diethylstilbestrol diphosphate

Diethylstilbestrol diphosphate (DES-P) has shown effective symptomatic relief in patients with metastatic carcinoma of the prostate. Although there is little known about its role in soft tissue metastasis, our experience in 3 patients with advanced carcinoma of the prostate infiltrating the trigone and ureterovesical junction revealed significant improvement of hydronephrosis. All patients failed to respond to conventional doses of stilbestrol. Diethylstilbestrol diphosphate is recommended in the treatment of advanced carcinoma of the prostate with soft tissue metastasis. It is safe and effective, and the tumor responses outweigh the side effects of the drug. The mechanism of action of this compound is discussed.

[Experience with amoxicillin therapy in urological field (author's transl)]

Amoxicillin (AMPC), an oral preparation of broad spectrum synthetic penicillin, was used for treatment of 10 cases with urological infection, and the following results were obtained. 1. AMPC at a daily dose of 750 approximately 1,500 mg was administered for 7 approximately 49 days to 5 cases of acute cystitis, 2 cases of acute epididymitis and one case each of calculous hydronephrosis, chronic prostatitis and postoperative cystitis. As the result, AMPC was found remarkably effective in 2 cases, effective in 7 cases and ineffective in one case; that is, the effective rate was 9/10 (90.0%). 2. Total 8 strains of bacteria, comprising 5 strains of Escherichia coli and one strain each of Klebsiella, Staphylococcus epidermidis and Pseudomonas, were isolated from the urine. These bacteria were relatively responsive to AMPC as well as to ABPC. 3. The side effect possibly due to AMPC was slight gastro-intestinal disorder only in 2 of 10 cases. No other side effect was observed.