Treatment of subclinical injuries detected by protocol biopsy improves the long-term kidney allograft function: a single center prospective randomized clinical trial

BACKGROUND

The long-term benefit of early treatment of subclinical disorders detected in kidney allografts by protocol biopsy is controversial. We collected 145 protocol biopsies from 113 recipients for comparison with 51 control patients in a single-center, prospective, randomized trial.

METHODS

Ultrasound-guided biopsies were performed in recipients with stable renal function. Samples were taken at 3 (n=66) and/or 12 months (n=79) after transplantation. The biopsies were evaluated according to the Banff scheme, and patients were treated based on the diagnosis. Changes in glomerular filtration rate (GFR) were compared with 51 patients who were randomized as a control group.

RESULTS

The findings on 38 samples (29%) were considered to be normal. Based on the pathology findings, such as subclinical acute rejection (n=23), calcineurin inhibitor toxicity (n=28), chronic rejection (n=6), and other specific pathologies (n=23), including polyoma virus nephropathy (n=2), induced treatment among 82 recipients (57%). Significantly better graft function was observed at 3-year follow-up among the biopsy group, compared with controls: GFR = 46.0 ± 13.8 vs 35 ± 15 mL/min (P=.002). The 5-year graft survival was significantly higher in the biopsy (81%) than in the control (55.6%) group (P=.0012).

CONCLUSION

Early detection and treatment of subclinical pathologies improved graft function and long-term survival. Protocol biopsies were a valuable tool for posttransplantation management.

Peritubular capillary damage in acute humoral rejection: an ultrastructural study on human renal allografts

The ultrastructural features of peritubular capillary (PC) damage was studied in 12 kidney allografts with acute humoral rejection (AHR). AHR manifested in diffuse linear PC staining for C4d, and histology consistent with Banff grade III in 7 recipients and Banff grade II in 5. Allografts with acute tubular necrosis served as controls. First biopsies (post-transplantation day 16.2 +/- 2.2): The intra-capillary exudate comprised monocytes (59%), polymorphonuclears (14%), lymphocytes (12%) and not otherwise specified mononuclears (15%). Three patterns of focal PC endothelial injury were observed: lysis, an increased rate of apoptosis and fragmentation. No correlation was found between the respective damage types and the inflammatory cell types or the Banff grades. Controls revealed endothelial swelling, detachment from basement membrane and fragmentation. Follow-up biopsies: Monocytes transformed into macrophages intra-luminally. The reparative changes comprised endothelial cytoplasmic protrusions, binucleated endothelial cells and capillary sprouts. Early transplant capillaropathy and transplant glomerulopathy were noted in 2 recipients. Literature data indicate that lysis is mediated by anti-HLA alloantibodies; apoptosis, demonstrated first in the present study, may be induced by non-HLA-type anti-endothelial antibodies. Fragmentation is caused by ischemia. Ongoing endothelial injury leads to transplant capillaropathy and transplant glomerulopathy, the characteristic lesions of chronic rejection.

Surgical intervention for pulmonary tuberculosis: analysis of indications and perioperative data relating to diagnostic and therapeutic resections

OBJECTIVE

To analyze the data on patients operated on for pulmonary tuberculosis (TB) with (Group I) or without (Group II) a correct TB diagnosis and preoperative anti-TB treatment.

METHODS

Between 1980 and 1997, 144 resections for TB (Groups I+II) were performed. The 80 patients in Group I underwent therapeutic resections: 32 cases involved recurrent cavities or tuberculomas, three involved post-TB bronchiectasis, 13 involved progression of cavities or tuberculomas, and 32 involved persistent tuberculomas after 6 months of anti-TB therapy. The 64 patients in Group II were operated on for a suspicion of malignancy in 49 cases, for cavitary lesions with haemophthysis in six cases, for multiple lesions in seven cases, and for recurrent hydrothorax in two cases.

RESULTS

Groups I and II included 0 and five pneumonectomies, 32 and 29 lobectomies, 48 and 20 wedge resections, 0 and nine videothoracoscopic biopsies, and 0 and one hilar lymphadenectomy, respectively. In Groups I and II, the mean duration of postoperative hospitalization was 13.2 and 10.4 days, and the frequency of postoperative pneumothorax was 11.25 and 4.6%, respectively. The incidence of bronchopleural fistula was 1.25 and 0%, the mortality was 0 and 3.1%, and the morbidity was 53.7 and 35.9% in Groups I and II, respectively. Two patients with active disease died in Group II. Pathology demonstrated that the frequency of acid-fast bacilli in Groups I and II was 40 and 25%, respectively.

CONCLUSIONS

Patients without a correct preoperative TB diagnosis underwent more extensive parenchyma resection. Postoperative complications increased when acid-fast bacilli were present. The lack of preoperative anti-TB treatment did not involve a higher risk of minor complications, but death occurred only in this group.

Thoracic core needle biopsy using ultrasound guidance

This article demonstrates the usefulness of ultrasound (US)-guided core needle biopsy in the diagnosis of thoracic lesions. Between January 1997 and June 2000, 45 US-guided core needle biopsies were performed in the department of radiology. This method was chosen in every case when the lesion abutted the chest wall. Conventional histologic examinations supplemented by immunohistochemical methods were performed. The location and size of the mass, the number of samplings, the needle size, the histologic results, and any complications were recorded. Twenty-two lesions reached the anterior, six reached the lateral, and 14 reached the posterior chest wall. Biopsies were performed on three masses from the supraclavicular region. The mean diameter was 4.5 cm and the number of passes was 1.8; 18-G, 16-G, and 14-G needles were used in 41, two, and two cases, respectively. In 43 of the 45 cases (95.68%), an exact histologic diagnosis could be provided. In two cases, only necrotic tissue was seen in the biopsy sample. No major complications occurred. Minor complications, including pain and collaptiform weakness, were documented in four patients. Ultrasound-guided core needle biopsy of thoracic lesions is a safe, quick, and accurate method. For diagnosing thoracic lesions, a single sample with an 18-G biopsy needle is sufficient to achieve a final diagnosis when using appropriate histologic methods.

[Uterine artery embolization for the conservative management of leiomyoma]

Uterine leiomyoma, a benign, monoclonal tumor derived from a single myometrial cell, is one of the most frequent diseases in the female reproductive system. However, the factors involved in its initiation and growth remain poorly understood. Most commonly, it results in dysmenorrhea, menorrhagia, urinary tract and neurological symptoms, and abdominal distension. Additionally, it may cause infertility, late miscarriage or other severe complications in pregnancy. The conventional treatment for fibroids has been hysterectomy. However, many women do not like to lose their uterus and potential fertility. Myomectomy and medical treatment with GnRH analogue are accepted as alternative organ-conserving methods with limited efficacy. Selective embolization of uterine arteries might therefore have a significant role in the management of the disease. The purpose of this study was to determine the effectiveness of uterine embolization as primary therapy in the management of myomas. Uterine arterial embolization was performed in 3 patients with symptomatic leiomyomas. The uterus and fibroids were objectively evaluated with ultrasound and MRI. The efficacy and safety convinced the authors that this promising technique is at present the only reasonable alternative method in organ-conserving therapy. It is less invasive than surgery, it can restore fertility, it is well tolerated and the recovery time is shorter than that following surgical procedures. This preliminary experience is sufficient to encourage gynecologists to introduce the method in Hungary.

[Treatment of renal artery stenoses with stent implantation]

The authors report on their experience with the treatment of renovascular hypertension by stent implantation. In the past 4 years different types of stents (Palmaz [9], Palmaz-Corinthian [4], Memotherm [1] and AVE [1]) were implanted into 15 renal arteries of 11 patients. The indication was primary in 8 cases, and secondary in 3 patients, because of restenosis of a previously dilated renal artery. 14 stents were implanted into narrowed renal arteries, and in the remaining one case a stent was placed in an occluded renal artery immediately after recanalization. The technical success was 100%. In all but the recanalized case in which the renal artery was occluded, stents are still open. On the basis of this experience and the literature, the authors suggest the more extensive usage of this less invasive method.

Ureter diverticulum of transplanted kidney. Case report

OBJECTIVES

Authors present a case of successful surgical treatment of a ureter diverticulum observed 3 months after kidney transplantation.

METHODS

The fluid collection was detected by ultrasound. Percutaneous drainage was performed, after that the excretion of 4 litres of fluid was observed during 12 hours. This finding clearly indicated the connection with the urinary system. This fact was proved and precisely localised by contrast filling of the lesion under fluoroscopic control.

RESULTS

Resection of the ureter diverticulum was performed, and the patient recovered fully, there was no change observed in the graft function during the whole procedure.

CONCLUSION

The ureter diverticulum is a rare complication after kidney transplantation: the present case is the only one observed among more then 600 kidney transplantations performed during 20 years in our centre.

Shear rate estimation using a clinical ultrasound scanner

Wall shear stress is a factor in the development of atherogenesis, thrombus formation, and embolization, but its existence is very difficult to determine with ultrasonography. Instead, we estimated shear rates using a clinical ultrasound scanner and compared results from vessels with and without stenoses. Velocity profiles were obtained from color M-mode images on a P700 scanner. Maximum shear rates were calculated off-line as the maximum velocity gradients. In vitro, studies were performed on a flow phantom with a vessel containing a 50% stenosis. Shear rates within the stenosis were significantly higher than those obtained outside the stenosis (P < 0.00001) and varied more than the peak velocities. In vivo, the internal carotid artery of 10 volunteers and 13 patients (with stenoses) was studied. The mean shear rate was 414 s(-1) +/- 154.5 s(-1) in normal vessels and 687 s(-1) +/- 263.5 s(-1) in stenotic vessels (P = 0.00017). In conclusion, shear rate estimates can be obtained with a clinical ultrasound scanner from color M-mode images. Shear rates estimated in vessels with stenoses are significantly higher than those obtained in normal vessels in vitro as well as in vivo.

[Transbronchial catheterization: a method for outpatient angiographic examination]

The authors report on their own experiences with a not unknown, but not widely used catheter technique. On the basis of 607 transbrachial angiographies, they have established the possibilities and occasional dangers of this method. They conclude that the transbrachial technique is suitable not only for aortography, but also for selective angiography and vascular interventions. In cases involving cooperative patients, this method can furnish a basis for the angiography of outpatients.

[Value of CT-guided biopsy compared to fluoroscopy-guided transthoracic biopsy and bronchoscopic sampling in the diagnosis of pulmonary nodules]

CT-guided histological sampling is nowadays used routinely in the differential diagnosis of focal lung diseases with no characteristic morphology. The aim of this study was to determine the value of the method. CT-guided core biopsy was performed in 25 patients with pulmonary nodules. 16 patients underwent bronchoscopy where cytological sampling was also carried out, while 5 patients underwent fluoroscopically guided biopsy. The histological diagnosis resulting from CT-guided biopsy specimens was compared with the findings from the other diagnostic procedures (bronchoscopy or fluoroscopically guided biopsy), with the results of surgery and/or chemotherapy and with the follow-up data. The result of CT-guided biopsy was true in 20/25 and falls in 5/25 cases. Of the 16/25 patients undergoing bronchoscopy, 13/16 gave negative results. In 11/16 cases, the result of the CT-guided biopsy was positive. The fluoroscopically guided biopsy was negative in 4/5 cases, and in 3/5 of these cases the diagnostic CT-guided biopsies proved positive. Our results demonstrate the better diagnostic value of CT-guided core biopsy relative to fluoroscopically guided biopsy or bronchoscopic sampling in those cases where the size and localization of the nodule make it inaccessible with the latter two methods.

[The role of ultrasonography and biopsy following kidney transplantation]

Several complications can occur during both the early and late postoperative periods after kidney transplantation. The methods used to follow up 575 kidney transplanted patients, (transplantations performed between October 1979 and November 1997) in the early (within 6 weeks) and late postoperative periods have been assessed. The diagnostic value of core biopsies and ultrasound examinations, the prevalence of complications, and the applicability of the diagnostic tools in the evaluation of the graft status and viability were analyzed. In the early postoperative period, graft rupture occurred more frequently after biopsy than in the late period (7.4% vs 0.82%), this leading graft loss in 18 of 20 cases. The sonographically diagnosed morphologic and functional changes were also analyzed. Sonography proved a very accurate method for the detection of perirenal fluid collections and masses and severe vascular complications. The data demonstrated that biopsy is indicated in the early postoperative period when the result of sonography is doubtful. In the late postoperative period, biopsy should be performed in every case.

[Management of hydatid disease of the lung]

Cystic echinococcosis is a worldwide zoonose which is not infectious from man to man occurring seldom in our country. The diagnosis and the treatment of a case of a 4-year-old girl with large left-sided lung cyst were presented. Diagnosis was based on history, clinical findings, imaging techniques (conventional X-ray examination, ultrasonography, computer tomography), eosinophilia (7-50%) in blood smear, leucocytosis (28,000), increased sedimentation of blood (85 mm/hour), significantly elevated antibody against of Echinococcus in immunodiagnostic test (passive haemagglutination) with high sensitivity and specificity, light microscopic radiological and scanning electronmicroscopic analysis of cyst content. Continuous thoracic drainage, twice percutan drainage under CT guidance and a new technique for treatment as Puncture-Aspiration-Injection-Respiration and lavage with hypertonic sodium chlorate, long-term chemotherapy with benzimidazole-carbamates (Vermox: 20 mg/kg/day, Zentel: 30-50 mg/kg/day) were reported. The cyst was grown down into a solid mass as large as 4 cm. The body-weight of this child has grown 6 kilograms and laboratory parameters were normalized.

The diagnosis and treatment of intratesticular varicocele

A case of varicocele is reported. The dilated veins were situated in the left testis. The diagnosis required color Doppler sonography. Successful treatment was performed by transcatheter embolization of the left spermatic vein. The control sonogram revealed complete regression. A literature search yielded only three previous cases of intratesticular varicocele. No data were found on the treatment of this entity.

Drugs acting on calcium channels modulate the diuretic and micturition effects of dexmedetomidine in rats

The purpose of this study was to assess the effects of calcium channel antagonist, verapamil, and agonist, Bay K 8644, on the alpha 2-adrenoceptor agonist, dexmedetomidine-induced (300 micrograms kg-1 subcutaneously) diuresis and overflow incontinence, in rats. Ultrasonography study revealed that verapamil (2.5 mg kg-1 subcutaneously) or Bay K 8644 (0.5 mg kg-1 intraperitoneally) coadministrations delayed dexmedetomidine-induced bladder filling and significantly prolonged the latency of urination (P < 0.05). Bay K 8644 decreased relative bladder volume and stopped continuous urination from dexmedetomidine, whereas verapamil had neither effect. However, none of the drugs eliminated the overflow incontinence. Dexmedetomidine alone increased the hourly and total (for 4 hours) urine volume. Bay K 8644 (0.5 or 1 mg kg-1) dose-dependently decreased the diuretic effect of dexmedetomidine (P < 0.01). Verapamil (0.5, 1 or 2.5 mg kg-1) dose-dependently decreased urine volume in the first hour (P < 0.01), and thereafter potentiated the diuretic effect of dexmedetomidine. Simultaneous determinations of mean arterial blood pressure (MAP) and urine output after dexmedetomidine and the highest dose of verapamil coadministration demonstrated a significant correlation between these variables (r = 0.537; P < 0.001). MAP of 100 mmHg or less was associated with a urine output significantly lower (P < 0.001) than that at higher pressures. Thus, hypotension during the first hour after dexmedetomidine-verapamil may explain the transient reduction in urination during this period. We conclude that modulation of calcium channel affects dexmedetomidine actions on both urine formation and micturition. Since both alpha 2-adrenoceptor agonists and calcium channel blockers have frequently been used for antihypertensive therapy and as adjuvant drugs during anesthesia, these interactions may have some practical importance.

An ultrasonographic method for the evaluation of dexmedetomidine on micturition in intact rats

We describe a simple, noninvasive, nontraumatic, and reproducible ultrasonographic method to determine the effect of the alpha 2-adrenoceptor agonist dexmedetomidine in anesthetic dose (300 micrograms/kg subcutaneously) on the micturition reflex in intact rats. The bladder volumes were estimated by an ellipsoid equation. To validate the reliability of the method, an in vitro model assessment also was performed. The mean difference between estimated and instilled volumes were 27.3 microL (-21.61, 76.23). The highly significant correlation (r = 0.98, p < .001) indicates that the ultrasonography with the equation is a reliable tool. After the dexmedetomidine administration to intact rats, urine dribbling occurred at 30 +/- 4.8 min. The volume threshold for urination was 2100 +/- 100 microL. Although dribbling of the urine was observed almost continuously, significant differences were not observed between bladder volumes obtained at any time (from 10 to 100 min). This study indicates that the alpha 2-adrenoceptor agonist dexmedetomidine inhibits the micturition reflex in intact rats. The method described, which is both noninvasive and nonpainful, may therefore be widely used to quantify in small animals pharmacological effects on the urinary bladder.

[Comparative analysis of ultrasonic studies, histopathological data and clinical parameters in dysfunctioning renal transplantation]

The correlation of B mode and Doppler sonographic parameters and diagnoses established by histological examination of graft biopsies, nephrectomies and clinical data are discussed. 48 histological samples from 36 patients were reevaluated. The maximum interval between sonography and histology was 36 hours. The Banff classification criteria were used during histological examinations. Doppler examination evaluation was based on the resistance index (RI). Reproducibility was controlled by means of intra- and interobserver variability in 10 patients. RI values higher than 75% were regarded as abnormal. On the basis of these observations and the literature data specific sonographic features can be detected in renal artery occlusion and renal vein thrombosis. In pyelonephritis, dilatation of the collecting system was frequent. No morphological changes were detected in cyclosporin-A nephrotoxicity and the Doppler signs were not characteristic for this disease. No differentiation was found between acute rejection and acute tubular necrosis. The noninvasive duplex sonographic examinations can provide very important information regarding the flow situation of a transplanted kidney. In some cases a definitive diagnosis can be achieved, but in other cases biopsy is the method of choice.

[The value of acetazolamide provocation combined with blood flow tests in the diagnosis of ischemic cerebrovascular diseases]

In 28 (3 normal, 11 TIA, 14 completed stroke) patients 99mTc-HMPAO rCBF SPECT studies were performed at rest and after acetazolamide administration. For the investigations, a one-day protocol (the stress study directly followed the rest investigation) was used. The reconstructed and normalized slices were evaluated visually and semiquantitatively with a side difference analysis method. In the group of TIA patients, the abnormal results of the rCBF investigations increased from 55% to 82% after acetazolamide provocation. The corresponding results in the completed stroke group were 80% and 87%. After acetazolamide stimulation, hypoperfusion appeared or become more pronounced in the majority of the TIA group patients in contrast with the completed stroke patients with an unchanged or decreased perfusion abnormality. The semiquantitative evaluation method was mostly effective in the TIA group, where predominantly a one-sided cerebrovascular disorder was suspected. It was concluded that the 99mTc-HMPAO studies allow demonstration of the acetazolamide-induced cerebral perfusion alterations, and this method can be useful in the diagnosis and management of cerebrovascular disorders.

[SPECT follow-up of cerebral blood circulation after stroke]

rCBF SPECT investigations with 99mTc-HMPAO were performed in 22 completed ischemic stroke patients on average 2.5, 16.8 and 38.0 days after stroke onset. As control group, 12 neurologically healthy volunteers were examined with the same method. The overall sensitivity of the rCBF SPECT method in the detection of cerebral blood flow abnormalities was 91%, with a specificity of 83% and an accuracy of 88%. The rCBF study was highly effective, particularly in the acute phase of the disease. Regional increased tracer uptake or a false normal 99mTc-HMPAO distribution due to the developing hyperemia mostly complicated the rCBF image interpretations in the subacute period. In the chronic phase, the spatial resolution of the SPECT system limited the detection of the continuously retracted stroke lesions.

[Anatomical bases of ultrasonic examination of the shoulder joint]

Authors present the parts of the shoulder that can be represented by ultrasound. Beside the rotator cuff of accentuated significance (within this, first of all the tendon of the supraspinatus muscle) the subacromial bursa, the tendon of the long head of the biceps, the muscle-tendon junction of the infraspinatus muscle are analysed. It is stated that the ultrasonography is suitable for a reliable representation of the soft tissues, surrounding the shoulder joint, further in possession of literary data they see possibility for a very exact judgement of the pathological alterations, too.

[Ultrasonic diagnosis of pathological changes of the knee]

54 knee joints clinically suspicious of presenting a lesion were examined. The ultrasound examination proved to be of great value in disclosing both anatomical details and lesions. Our results closely correlate with the abnormalities found at operation. We agree with literature that ultrasound method is adequate for diagnosing abnormalities in the knee. This method has been recommended as first choice for in many cases it fields a final diagnosis.

[Ultrasonic examination of ankle and knee ligament injuries]

Ultrasound examinations and stress radiographs of 61 patients with suspected ligamentar lesion of the ankle and knee joints were compared in order to clear, whether radiography could be replaced by sonography. In our experience, the opening of the joint gap can also be adequately demonstrated even without ionizing radiation and the results achieved by ultrasound were nearly as accurate as by X-rays. Being a rather simple, inexpensive and real time method, producing acceptable visual information and practicable on almost all preexisting equipments, sonography is advised for detecting of ligamentar lesions.

[Ultrasonic diagnosis of kidney injuries]

The authors analyse on the basis of a one-year patient material the significance and primary role of ultrasonography of renal injuries in the diagnostic tactics. The importance of follow-up examination is emphasized and the ultrasonographic signs of different types of renal injuries are characterized. The attention is drawn to the ultrasonographic technique which is indispensable in the emergency attendance, quick, inexpensive, non-invasive means little stress for the patient and replaces other methods too.