Destruction Of Renal Parenchyma Research Articles

Renal Tuberculosis

Renal Tuberculosis

Angiotensin-converting enzyme gene insertion/deletion polymorphism and renal damage in childhood uropathies.

The activation of the renin-angiotensin system in various renal disorders is well established. Congenital urological abnormalities, such as obstruction and reflux, are common causes of renal failure in children contributing to approximately 25% of chronic renal failure in this age group. While the outlook relates to the severity of initial renal damage, there is considerable heterogeneity in renal parenchymal destruction among individuals and the reasons for this heterogeneity are not fully understood. A polymorphism within intron 16 of the angiostensin-converting enzyme (ACE) gene has been shown to influence the activity of the renin-angiotensin system, thus, it may also have an impact on the expression of renal disorders. We have determined the incidence of this ID polymorphism of the ACE gene in 47 Kuwaiti children with different urological abnormalities leading to variable degrees of renal impairment and in 48 healthy control subjects with a similar ethnic background. Blood samples were collected from the patients (n = 47) and controls (n = 48), total genomic DNA extracted and the ACE genotypes were determined using a polymerase chain reaction-based method. The DD genotype was detected in 27/47 (57%) cases compared with 25/48 (52%) controls (P = 0.439). The heterozygous genotype ID was found in 14/47 (29%) cases compared with 22/48 (46%) controls (P = 0.0138). The homozygous II genotype was detected in 6/47 (13%) cases compared with 1/48 (2%) controls (P = 0.0247). The D allele of ACE gene was detected in 41/47 (87%) uropathy cases when individuals with homozygous DD and heterozygous ID genotypes were considered collectively. The incidence of parenchymal damage was considerably higher in uropathy cases with DD genotype (62%) compared with those having ID (26%) and II (12%) genotypes. Our data suggest an association of D allele of the ACE gene insertion/deletion polymorphism and congenital urological abnormalities, which result in parenchymal damage in Kuwaiti Arab children.

Progressive Renal Failure Due to Renal Invasion and Parenchymal Destruction by Adult T-Cell Lymphoma

A 43-year-old patient of occult adult T-cell lymphoma (ATL) presenting with systemic illness and progressive renal failure due to lymphomatous infiltration of kidneys is described. The striking feature observed was destructive infiltration of the kidneys, by malignant CD4 cells, virtually replacing the normal renal architecture. The diagnosis of lymphoma was made by renal biopsy. Clinical features typical of ATL were hypercalcemia, lytic bone lesions, and profound wasting and inanition. The patient died rapidly despite attempted therapy. The case illustrates the potential of ATL for direct renal parenchymal destruction.

Emphysematous Pyelonephritis

Six patients (all women, mean age 59.8 years) with emphysematous pyelonephritis, a rare, severe inflammation causing renal parenchymal destruction and affecting diabetics more commonly than non-diabetics, are described. Four of the patients were diabetics. All underwent ultrasound examination (US), and five computed tomography (CT) of the kidneys. CT was the most reliable diagnostic method. Differentiation between gas and calcification was difficult at US in three patients. Conventional tomography was performed in two patients and showed intra-renal gas. All six patients recovered; three patients had nephrectomy, one as an emergency procedure and two as an elective procedure after two weeks of antibiotic treatment. Infection was eradicated in the other three patients by percutaneous drainage, electrolyte correction and antibiotics. It was concluded that while conventional abdominal radiography may permit the diagnosis of emphysematous pyelonephritis by demonstrating intra-renal gas, CT is the most reliable diagnostic examination. Emergency nephrectomy may not be necessary in all cases.

Chemical ablation of the canine kidney using sodium tetradecyl sulfate (Sotradecol). A histopathologic study.

We studied the histopathologic effect of intraarterial Sotradecol (Elkins-Sinn, Inc., Cherry Hill, NJ) on the kidney and examined the mechanism for destruction of renal parenchyma by Sotradecol. Sotradecol was injected into one renal artery distal to an occlusion balloon catheter in six dogs, and the kidneys were removed for histologic examination; four dogs within 20 minutes, and one each at 12 and 24 hours after embolization. The contralateral kidney of each dog underwent the same procedure but was injected with normal saline, and served as control. Histologic examination of the control kidneys was unremarkable. The embolized kidneys revealed extensive endothelial denudation and mural necrosis of the arteries and coagulation necrosis of the renal parenchyma. The changes were evident as early as 20 minutes after embolization, and necrosis became complete by 24 hours. The arteries were filled with red blood cell sludge. Sotradecol produces extensive tissue necrosis and complete renal parenchymal destruction through its direct cytotoxic action on the arterial wall, blood cell elements, and renal parenchyma.

Avascular Nephrotomy by Means of Thermography

Experience with thermography to demarcate the different arterial areas of the kidney is reported. Thermography allows the performance of nephrotomies in an avascular plane with minimal bleeding and subsequent minimal renal parenchymal destruction. It is a safe and simple method which is preferred to the intraarterial injection of dyes which is done for the same purpose.

Reflux in duplicated ureters: Treatment in children

Reflux is more common in duplicated than in nonduplicated ureters. Since reflux may cause recurrence or persistence of urinary infection and destruction of renal parenchyma, the surgical treatment of ureteral duplication with reflux may be the most important aspect of management of children with such a pathologic picture. Available surgical procedures include ureteral reimplantation, heminephroureterectomy, pyelopylostomy with removal of dilated distal ureter, primary nephro-ureterectomy of both segments, nephro-ureterectomy secondary to primary heminephrectomy, and removal of refluxing ureteral stump remaining from previous heminephrectomy. In 28 children treated surgically for refluxing duplicated ureters, the most frequently used technique was ureteral reimplantation (17 cases). Excellent results were obtained in the majority of the 28 patients.

The Treatment of Renal Tuberculosis.

Despite the introduction of potent anti-tubercutosis drugs, no decline in the incidence of genito-urinary tuberculosis had been noted in New Zealand over the last 15 years. Of all M. tuberculosis isolated at the Auckland Hospital Laboratory, 10% were resistant to one or more of the three commonly used drugs. Chemotherapeutic regimens, which may employ only oral medications, form the mainstay of successful treatment, and the possible benefits from surgical intervention are now limited to patients with advanced disease. Conservative surgery may prevent further renal parenchymal destruction and permit more effective sterilization of tuberculous foci. Nephrectomy may be undertaken with little risk and is still permissible in the presence of complete renal destruction, though there is a school of responsible thought that advocates the conservative treatment of all patients with renal tuberculosis.

Granulomatous sarcoid nephritis

A patient with impaired renal function due to granulomatous sarcoid replacement of the renal parenchyma is described through two separate courses of therapy with corticosteroids. Serial measurements of renal function, periodic renal scintiscans and intravenous pyelograms, and serial histologic studies of the kidney by percutaneous renal biopsy are presented. The variety of modes by which sarcoidosis may affect the kidneys is reviewed. Hypercalcemia or hypercalciuria is responsible for most instances of renal disease from sarcoidosis. In the present case, kidney damage resulted from extensive replacement of renal parenchyma by sarcoid lesions in the absence of hypercalcemia or hypercalciuria. The value of renal biopsy is seriously limited by reason of the focal nature of the disease and the chance of sampling error. Renal scintiscan provided not only presumptive evidence for diagnosis but also a method to assess the extent of the disease and the effect of therapy. Serial determination of renal function demonstrated improvement following each course of therapy. However, a gradual decrease in creatinine clearance was observed during the prolonged second course of steroid therapy without increase in sarcoid “lesions” by scintiscan. It is considered likely that fibrosis associated with regression or healing of active granulomas may have been responsible. It is concluded that alternate periods of exacerbation followed by regression with steroid therapy should be avoided because of the potential of progressive fibrosis and destruction of renal parenchyma.

INVASION AND DESTRUCTION OF HOMOLOGOUS KIDNEY BY LOCALLY INOCULATED LYMPHOID CELLS.

When lymphoid cell suspensions from the spleen, lymph nodes, blood, and thoracic duct of parental strain adult rats were injected beneath the renal capsule of F(1) hybrid hosts, the transferred cells and/or their progeny invaded the underlying renal cortex and destroyed most of the tubules which they surrounded. The immunogenetic conditions under which this reaction was observed defined it as a graft vs. host reaction (GVHR). On the 7th day the GVHRs were histologically similar to primary renal homografts undergoing rejection. Lymphoid cells from donors tolerant to the other parental strain were inactive after transfer to the hybrid, whereas cells from either normal or sensitized donors consistently produced reactions of about equal severity. Lewis lymphoma cells displayed malignant, invasive activity but did not destroy either isologous or homologous tissue, showing that the presence of an infiltrate was not per se sufficient to damage the parenchyma. These observations indicate that the GVHRs were manifestations of the ability of the transferred lymphocytes to enter into a homograft reaction with consequent destruction of renal parenchyma, and support the hypothesis that at least some of the lymphocytes which are seen infiltrating primary homografts are the agents which effect their destruction.

Ureterosigmoidal transplantation for exstrophy of the bladder and complete epispadias with absent urinary sphincters

I am convinced that in children with exstrophy of the bladder or complete epispadias and urinary incontinence, the ureters are best transplanted into the rectosigmoid at different stages and that accurate submucosal transplantation, with the open end of the ureter carried into the lumen of the sigmoid, can be performed with a low mortality rate and with good results. In a study of 26 such cases in which I operated at The Mayo Clinic in the last six years, one patient died from calcareous pyonephrosis of the kidney opposite to the one of which the ureter was transplanted. The others made good operative recoveries. Cabot has operated in 20 consecutive cases, without a death. The absence of clinical evidence of serious infection in or about the ureterosigmoidal anastomosis in this group of cases would seem to be convincing evidence that the open end of the ureter can be placed accurately in the lumen of the bowel without particular fear of infection developing at the site of the anastomosis. This being the case, the advantage of the transfixion suture-necrosis technique which has been described as an aseptic method of anastomosis would appear to have no particular advantage. Furthermore, the possibility is real that the suture might not cause the necessary necrosis and that the anastomosis consequently would not establish itself, thus leading to hydronephrosis and destruction of the kidney; such results have been reported. In experimental animals the transfixion suture-necrosis technique was followed by immediate or remote hydronephrosis with considerable destruction of renal parenchyma in practically every case. The time of appearance of the urine in the rectum may vary from a few hours to several days subsequent to ureterosigmoidal transplantation, without effect on renal function. Cystectomy and plastic operations on the penis should be parts of every operation for exstrophy of the bladder. These procedures remove the chronically irritated bladder that is prone to undergo malignant degeneration and restore the penis to a reasonably normal contour. When the mortality statistics of bilateral, simultaneous ureteral transplantation with the use of catheters, are compared with the results obtained by the method used in the treatment of exstrophy of the bladder in 99 cases during the past twenty-one years at The Mayo Clinic, in which the ureters have been transplanted in separate stages and tubes or catheters have not been used; it is evident that the published risk of bilateral simultaneous transplantation is far in excess of that when the ureters are transplanted in stages without the use of catheters. Furthermore, particularly in children, the advantages of simultaneous bilateral transplantation are not apparent since the hospital morbidity in these cases and in cases in which the operation in two stages is used, is practically identical. Adding further weight to the argument in favor of ureteral transplantation in stages, is the fact that more severe and more prolonged reactions follow the operation of bilateral simultaneous ureteral transplantation.