Bilateral Scarring Research Articles

Differential excretion of urinary proteins in children with vesicoureteric reflux and reflux nephropathy.

We studied 40 children with a history of vesicoureteric reflux (VUR) without evidence of renal scarring, 93 children with a history of VUR and renal scarring and 10 children with previous urinary tract infections in whom the urinary tract was radiologically normal. Urine retinol-binding protein (RBP), albumin and N-acetyl-beta-D-glucosaminidase (NAG) were measured in each child. All were free from infection at the time of the analysis. Urinary RBP and NAG levels were significantly elevated (P < 0.001) in the group of children with renal scarring. Elevated RBP levels were detected in 51% of children with bilateral renal scarring compared with 7% of children with unilateral scarring. Urine RBP excretion increased progressively according to the type of scarring, best determined by the type of scarring of the less affected kidney. In children with renal scarring, elevated NAG levels were seen mostly in the 65 children with bilateral scarring and severe reflux. Urine albumin excretion was elevated in 10 children, 9 with bilateral scarring, all of whom had elevated RBP excretion. Urine protein excretion was unaffected by the presence or absence of persisting VUR. There was a strong negative correlation between glomerular filtration rate and RBP excretion (r = -0.69). We conclude that evidence of tubular dysfunction is common in children with bilateral renal scarring and usually precedes any glomerular protein leak. Tubular dysfunction may be the consequence of relative nephron hyperperfusion in the presence of bilateral scarring.

Results of Penetrating Keratoplasty in Aniridia

Eight aniridic patients with bilateral corneal scarring, vascularization, or edema underwent corneal transplantation in one or both eyes (11 eyes). Follow-up ranged from eight months to 5 1/2 years (average, three years). Six of 11 eyes (55%) had at least a two-line improvement in visual acuity and eight of 11 (73%) had at least one line of improvement. Best-corrected visual acuity was 20/200 or worse in nine of 11 eyes (82%), however. Postoperative complications included whorl keratopathy, persistent epithelial defects, central subepithelial scarring, peripheral vascularization with pannus, and graft rejection. Glaucoma was well controlled medically but five of nine patients (56%) with preexisting glaucoma needed an increase in medication for intraocular pressure control. Graft rejection occurred in seven of 11 eyes (64%) and three of these eyes required repeat transplantation.

Lower urinary tract function after exstrophy closure.

Twenty-eight children with bladder exstrophy, prior to surgery for continence, underwent a urodynamic evaluation, cystogram, ultrasound and dimercaptosuccinic acid scan, to define parameters of lower urinary tract function that are a risk for upper tract damage and/or impair development of bladder capacity. The bladders in 7 of 28 demonstrated no storage function [leak pressure)LP) = 0]; but storage parameters could be measured in the other 21. Their LP was 10-35 cm H2O; 17 of 21 revealed involuntary contractions and 7 of 21 had an end-fill pressure greater than 10 cm H2O. Bladder capacity was better in those with a higher LP and those with no involuntary contractions. The 4 patients with bilateral hydronephrosis (3 of whom also had bilateral multiple scars) were among the 6 with LP greater than 30 cm H2O. Of the 7 with an end-fill pressure greater than 10 cm H2O, 5 had upper tract damage. Involuntary contractions may impair development of capacity. A LP of greater than 30 cm H2O is a risk factor for upper tract damage and an end-fill pressure greater than 10 cm H2O may also be a factor.

Radiographic pulmonary changes of gastro-oesophageal reflux disease in elderly patients.

The aim of this study was to investigate the association of gastro-oesophageal reflux disease (GORD) with radiographic pulmonary changes. One hundred and thirty-seven patients aged over 60 years referred for endoscopy for abdominal symptoms were included in the study. In patients with any suspicion of GORD (n = 95), 24-hour oesophageal pH monitoring was carried out. All the patients were interviewed before the examinations. Chest radiography was performed in all patients. Odds ratio of respiratory symptoms was 8.7 (95% confidence interval 3.4-22.4) in patients with total reflux time of more than 10% compared with those who had total reflux time of less than 10%. In chest radiography, bilateral pleural adhesions and thickenings and bilateral parenchymal scars were significantly more common in patients with, than in those without, regurgitation or large hiatal openings. The occurrence of bilateral scars and pleural thickenings increased with the extent of gastro-oesophageal reflux in pH monitoring. Odds ratios of bilateral pleural thickening and pulmonary scars were 3.1 (95% confidence interval 0.8-11.5) and 5.8 (1.1-29.6) in patients with total reflux time over 10%, compared with patients who had normal total reflux time. The findings indicate that respiratory involvement is a characteristic feature of GORD in elderly patients.

Long-term prognosis of post-infectious renal scarring in relation to radiological findings in childhood--a 27-year follow-up.

In a previous report the long-term prognosis of 30 patients with renal scarring after pyelonephritis in childhood was described. In this study, we have related the extent of renal scarring present in childhood to the conditions in early adulthood. A radiological progression of scarring from childhood to adulthood was seen in one-third of the kidneys. The 7 patients with bilateral scarring in childhood had a smaller renal area, lower glomerular filtration rate and higher plasma vasopressin at follow-up than 13 healthy controls. The 20 patients who had unilateral scarring in childhood had a smaller renal area, lower glomerular filtration rate, higher diastolic blood pressure and higher plasma renin at follow-up than controls; 4 had hypertension. The most important finding was that children with unilateral disease are at risk of serious long-term complications. Filtration fraction at follow-up was higher in patients with extensive renal scarring in childhood compared with those with a normal renal area or small scars in childhood (r = -0.43, P less than 0.05). This may indicate glomerular hyperfiltration by remnant glomeruli. This paper emphasizes t the potential seriousness of childhood urinary tract infections especially when early infantile infections are overlooked. A follow-up of more than 4 decades may be necessary before the ultimate prognosis can be established, especially in patients with unilateral renal disease. It is advised that most patients with post-infectious renal scars are followed as high-risk patients, and that treatment continuity is established between paediatricians, nephrologists and, when required, obstetricians.

The progression of renal damage in reflux nephropathy--clinical analysis of proteinuria in children with vesicoureteral reflux

To clarify the mechanism for reflux nephropathy to progress to irreversible or marginal renal damages, this study was conducted. We studied 57 cases of VUR in children followed-up more than 3 years after anti-reflux operation and investigated the correlation between changes of urinary protein excretion and clinical data. In general, proteinuria is the most important feature heralding a poor outcome in patients with reflux nephropathy. 9 cases (15.8%) in our series were positive of proteinuria postoperatively. In this positive group, scarring grade had been higher and renal size had been smaller significantly before operation than in other group. From these facts, it would appear that prognosis of refluxing kidney was determined by volume of remnant kidney, and glomerular hyperfiltration of remnant nephron would affect the progression of reflux nephropathy. According to the relationship between changes of urinary protein excretion and scarring grade or renal size, poor prognosis (proteinuria will worsen) would be more than 5 of scarring grade score (cumulation of bilateral scarring grades, Smellie's a = 1, b = 2, c = 3, d = 4) and less than -4S.D. in cumulative renal ratio preoperatively. Then border to progression in reflux nephropathy was between 2 and 4 of scarring grade score, and between -2S.D, and -4S.D. in cumulative renal ratio. In this marginal progression urinary protein excretion and GFR were found to be 100-300 mg/day and 60-75 ml/min, respectively.

Symmetry of disciform scars in bilateral age-related macular degeneration.

The size of the final macular scar in subretinal neovascularisation (SRNV) is one of the most important determinants of final visual function in patients with subfoveal disease. We studied patients with bilateral macular scars from age-related subretinal neovascular membranes retrospectively in order to determine whether or not fellow eyes behave similarly. We found a significant correlation between eyes in terms of final scar size (r = 0.50, p less than 0.01). We found that 50% of fellow eyes with large macular scars (greater than 3 x 10(6) microns2) had similar sized lesions, while only 16% of fellow eyes with small macular scars (less than 0.5 x 10(6) microns2) had large scars (p less than 0.01). We discuss the significance of these findings in relation to the pathogenesis of subretinal neovascular membranes, and their implications for treatment.

A Five-Year Prospective Follow-Up of Women with Non-Obstructive Pyelonephritic Renal Scarring

Fifty women with pyelonephritic renal scarring were prospectively followed for five years and the changes in renal function were related to blood pressure control, plasma renin activity, urinary albumin excretion and the incidence of urinary tract infections (UTI). Five patients (10%) developed end stage renal disease. All these patients had bilateral disease, proteinuria and anti-hypertensive treatment at presentation. The mean +/- SD glomerular filtration rate (GFR) of all patients with renal scarring was 74 +/- 27 ml/min x 1.73 m2 at presentation which was significantly lower than the GFR in 55 patients with a recent episode of acute pyelonephritis (p less than 0.001) and 10 healthy controls (p less than 0.001). GFR and age corrected GFR decreased significantly during follow-up (p less than 0.001) and p less than 0.02 respectively). The decrease in GFR was significantly higher in patients with bilateral scarring, in patients on blood pressure treatment and in patients with an episode of symptomatic UTI during follow-up. Eight patients (16%) had antihypertensive treatment at presentation and another 11 patients (26%), of whom 10 had bilateral scarring, developed hypertension (greater than 140/90 mmHg) during follow-up. Seventy-five per cent of all patients had symptomatic UTI and 40% had an episode of acute pyelonephritis during follow-up. In conclusion, patients with pyelonephritic scarring have a high incidence of UTI and are at high risk of developing renal failure and hypertension. It is essential that recurrent episodes of symptomatic UTI are treated promptly and that blood pressure is monitored carefully in these patients.

A five-year prospective follow-up of women with non-obstructive pyelonephritic renal scarring

Fifity women with pyelonephritic renal scarring were prospectively followed for five years and the changes in renal function were related to blood pressure control, plasma renin activity, urinary albumin excretion and the incidence of urinary tract infections (UTI). Five patients (10%) developed end stage renal disease. All these patients had bilateral disease, proteinuria and anti-hypertensive treatment at presentation. The mean ± SD glomerular filtration rate (GFR) of all patients with renal scarring was 74 ± 27 ml/min × 1.73 m2 at presentation which was significantly lower than the GFR in 55 patients with a recent episode of acute pyelonephritis (p < 0.001) and 10 healthy controls (p < 0.001). GFR and age corrected GFR decreased significantly during follow-up (p < 0.001 and p < 0.02 respectively). The decrease in GFR was significantly higher in patients with bilateral scarring, in patients on blood pressure treatment and in patients with an episode of symptomatic UTI during follow-up. Eight patients (1...

Reflux Nephropathy and Primary Vesicoureteric Reflux in Adults

We have studied the clinical features and course of adults with reflex nephropathy and/or primary vesicoureteric reflux, paying particular attention to the differences between males and females, and the presenting features that influence prognosis. In our series of 293 patients, females outnumbered males in the ratio 5:1 and most presented with urinary infection, whereas males most commonly presented with features of renal damage such as proteinuria, hypertension or renal failure. Males more commonly had bilateral scarring and persistent reflux. One hundred and forty-seven patients were followed for two years or more (range 2-19 years); deterioration in renal function occurred in 55 (37 per cent). Risk factors for a rise in plasma creatinine were, in descending order, the presence of proteinuria, an elevated plasma creatinine concentration, bilateral scarring, male sex and the presence of hypertension. Stepwise multiple regression analysis showed that the independent risk factors were proteinuria, elevated plasma creatinine concentration and hypertension; gender and the presence of persistent reflux had no independent influence on the course of renal failure.

Increase in Ocular Axial Length in Patients with Corneal Opacification

Seventy-nine patients were studied for corneal opacification and axial myopia. They were divided into three groups. One group had bilateral clear corneas; the second had unilateral corneal scars; and the third had bilateral corneal scars. A statistically significant difference was found in the mean axial length of eyes with bilateral corneal scars when compared with age- and sex-matched controls with normal corneas (P < 0.0001). In addition, there was a significant increase in the mean axial length of eyes with corneal scars when compared with their fellow eyes (P = 0.025).

Clinical and radiological follow-up of chronic non-obstructive pyelonephritis. A retrospective study covering thirty years.

The outcome of uni- or bilateral chronic pyelonephritis was retrospectively studied in 26 patients. The material consists of all positive intravenous urographies performed at the hospital during three years in the 1950s and the follow-up time was approximately 30 years. Development of uraemia or death owing to renal disease occurred in 15% of the patients. The majority of patients with unilateral pyelonephritic changes showed unchanged scarring during the years, while progressive scarring mainly occurred in younger patients. The development of renal failure was found in patients with extensive bilateral scarring, proteinuria and hypertension.

Keratopathy in a Family with the Ectrodactyly-Ectodermal Dysplasia-clefting Syndrome

Four members of a family with the ectrodactyly-ectodermal dysplasiaclefting (EEC) syndrome and associated keratopathy are presented. The main features of this syndrome include lobster-claw deformities of the hands and feet, abnormalities of the hair and teeth, cleft lip and palate, nasolacrimal abnormalities, and a progressive keratopathy ranging in severity from an asymptomatic pannus to bilateral dense corneal scarring and neovascularization. Despite congenital limb abnormalities, the major functional disability of three of these patients stems from severe photophobia and decreased visual acuity secondary to the corneal disease. Treatment with cycloplegics, topical steroids, and bandage soft contact lenses was unsuccessful. The EEC syndrome is transmitted in an autosomal dominant manner. The spectrum of keratopathy demonstrated in this family can be explained by the different ages of the patients, by variation in gene penetrance and expressivity and by differing durations and severity of dacryocystitis and related keratoconjunctivitis. The etiology of the keratopathy appears to be primarily a manifestation of the underlying ectodermal dysplasia with probable contributions from associated tearfilm abnormalities and external ocular infection.

Spontaneous visual improvement in the first affected eye of patients with bilateral disciform scars.

Patients with macular disciform degeneration may undergo spontaneous improvement in visual acuity of the first affected eye when the second eye later undergoes a decrease in vision. Three hundred twenty-nine cases of age-related macular degeneration (AMD) and presumed ocular histoplasmosis syndrome (POH) were examined. There were 20 patients who strictly met the criteria of a disciform scar causing visual acuity of 20/200 or worse in one eye, and 20/50 or better vision in the second eye, who subsequently developed involvement of the second eye with a decrease in visual acuity to 20/200 or less. Six of these 20 patients (30%), after mean follow-up of 32.8 months, achieved spontaneous visual acuity improvement, defined as at least a five-line improvement on a decimal (logarithmic) scale, with an average increase of 7.6 lines in the first affected eye. At extended mean follow-up of 50.1 months, two of the six lost vision, so that four of the 20 (20%) had five lines or more of improvement.

Vesicoureteral Reflux in the Adult. II. Nephropathy, Hypertension and Stones

The level of renal function, presence of hypertension or characteristics of nephrolithiasis were analyzed in relation to the severity of renal scarring and other clinical parameters in 67 patients with primary bilateral vesicoureteral reflux. A significant positive correlation was observed between impairment of renal function and severity of renal scarring. Renal insufficiency occurred only in patients with bilateral scarring. Significant proteinuria was found more often in patients with depressed renal function. Hypertension was observed in 34 per cent of the patients, mostly in those with bilateral scarring or depressed renal function. Radiopaque calculi were noted in 18 per cent of the patients. In all but 1 case these calculi occurred in scarred kidneys.

The Keratopathy of Crohn's Disease

A distinctive subepithelial keratopathy developed in four adult patients with Crohn's disease (granulomatous ileocolitis). Small, bilateral, symmetrical subepithelial, and anterior proliferative infiltrates and scarring were present 2 to 3 mm inside the entire corneoscleral limbus. Vision was not affected because the lesions spared the central cornea. The mechanism is not known and the lesion should be regarded as a distinct clinical sign of Crohn's disease.

Renal clubbing and scarring in adults: a retrospective study of 110 cases.

A urographic pattern of renal clubbing and scarring was found in 182 scarred kidneys of 110 adult patients. Homolateral vesicoureteric reflux was demonstrated by reliable techniques in 90/135 scarred kidneys. Urinary tract infections occurred in 75 patients. Hypertension developed in 20 patients with normal renal function and was not related to the extent of scarring. Chronic renal failure occurred in 30 patients with diffuse bilateral scarring. Four patients showed histologic changes of chronic pyelonephritis. Two hypertensive patients had a typical histologic pattern of Ask-Upmark kidney (segmental hypoplasia). Development of renal scars in adulthood was demonstrated in 2 cases.

Broncholith as a Cause of Fatal Hemoptysis

EPISODES of minor hemoptysis in a patient with old, calcific tuberculous scars may herald massive pulmonary hemorrhage. We report such a case that was due to erosion of a pulmonary artery by a broncholith. Report of a Case A 70-year-old woman was admitted to the hospital because of hemoptysis of two days' duration. Her pulmonary tuberculosis had been treated with thoracoplasty, streptomycin sulfate, and isoniazid 26 years ago. During the past two years, she was hospitalized three times for minor and self-limiting episodes of hemoptysis, which were attributed to old pulmonary tuberculosis with bilateral fibrocalcific scarring and bronchiectasis. No bronchoscopic study had been done during that period. She received isoniazid prophylactically, although repeated smears and cultures of sputum for acid-fast bacilli were negative. Two days before admission, she started coughing up copious amounts of bright red blood. She felt mild shortness of breath until the bleeding ceased, after which she

乳中切歯結節, 過剰歯およびその他数種の異常を伴った 1 例

We recently encountered a female patient of 3 years of age whose chief complaint was her esthetic deformity owing to the bilateral congenital scars in the upper lip which were treated surgically in our clinic. Beside the above deformity, she had several comblicatious such as incisive tuber of deciduous central incisor, a supernum erary milk tooth, submucosal cleft of jaw-palate and adhesion of the frenulum of upper lip. Search of literatures revealed that so far only about 4 cases of abnormal tuber in deciduous incisor and as few as only 10 cases of supernumerary deciduous tooth were reported. According to Kurosu et al. (1968), the occurrence of incisive tuber of deciduous teeth was one to one thousand, and the occurrence was more frequently in upper jaw than in lower jaw. They also reported that the tuber occurred more frequently in central incisor than in lateral incisor and canine of the deciduous dentition. According to Ogiwara et al. (1967), the incisive tuber was an outcome of abnormal development of the lingual cervical ridge. As to the frequency of supernumerary appearance deciduous tooth, Okamoto (1941) reported that it occurred once in tens of thousands, Ikuta (1925) repoted 2 cases in 23, 600 and Fukada (1957) failed to see any in 10, 149 subjects examined. It should be noted that all these supernumerary tooth, as they appeared in so few instances, occurred in the upper frontal teeth, except that which was reported by Tochihara (1936) to have occurred in the lower frontal teeth. The incisive tuber in the present case appeared as an irregularly formed pyramidal elevation that grew upward from the cervical region of a__-|. The tuber extended to about two third of length of the crown. Radiographic examination revealed that the pulp cavity was extended into the inside of tuber, and the tooth root showed no sign of fusion with other tooth and was single-rooted. The patient also showed jaw cleft between the teeth |<bc>___- and the presence of submucosal cleft of palate was confirmed by means of radio-graphy. The deciduous tooth which was apparently supernumerary, was dislocated lingually, and the tooth |b__- was twisted by 90 degree with its labial side turned toward distal direction. Two theories have been advanced as to possible origin of the supernumeray tooth in the deciduous dentition, of which the one is based on the ontogenetic dysplasia and the other based on the phylogenetic atavism. In view of our findings on the position of the tooth erupted and the shape and size of the tooth itself, we would like to favor the theory advanced by Fujita (1958) for the origin of the supernumerary tooth as being the result of a morphological disturbance that occurred in the dental lamina.

Retinal artery tortuosity in ex-premature infants. 18-year follow-up on eyes of premature infants.

Ophthalmic examinations have been performed on 52 expremature infants who had reached their late teens. These patients all weighed 1500 g or less at birth, and were born during a period of transition from liberal to restricted oxygen therapy for premature infants. Fourteen patients had some degree of retrolental fibrosis. In 4 cases there was complete, bilateral, destructive retrolental fibroplasia (RLF) with microphthalmos; and in 3 cases in which RLF was complete unilaterally, the other eye showed retinal scarring with traction of the disc in 2 patients and extreme tortuosity of the retinal arteries in the third. There were 7 patients who showed bilateral retinal scarring with distortion of the retinal architecture, 35 patients showed tortuosity of the retinal arteries, and 3 patients had normal retinas. It seems that tortuosity of the retinal arteries represents a persistence of the proliferative stage of RLF. In the present study the condition carried no ophthalmic morbidity. Myopia was associated with retrolental scarring, but not with tortuosity of the retinal arteries. Corneal curvature was normal in these patients, excluding this as the cause of the myopia of RLF.