Diagnosis Of Hydronephrosis Research Articles

Detecting Hydronephrosis Through Ultrasound Images Using State-of-the-Art Deep Learning Models.

The goal of this study was to assess the feasibility of three models for detecting hydronephrosis through ultrasound images using state-of-the-art deep learning algorithms. The diagnosis of hydronephrosis is challenging because of varying and non-specific presentations. With the characteristics of ready accessibility, no radiation exposure and repeated assessments, point-of-care ultrasound becomes a complementary diagnostic tool for hydronephrosis; however, inter-observer variability still exists after time-consuming training. Artificial intelligence has the potential to overcome the human limitations. A total of 3462 ultrasound frames for 97 patients with hydronephrosis confirmed by the expert nephrologists were included. One thousand six hundred twenty-eight ultrasound frames were also extracted from the 265 controls who had normal renal ultrasonography. We built three deep learning models based on U-Net, Res-UNet and UNet++ and compared their performance. We applied pre-processing techniques including wiping the background to lessen interference by YOLOv4 and standardizing image sizes. Also, post-processing techniques such as adding filter for filtering the small effusion areas were used. The Res-UNet algorithm had the best performance with an accuracy of 94.6% for moderate/severe hydronephrosis with substantial recall rate, specificity, precision, F1 measure and intersection over union. The Res-UNet algorithm has the best performance in detection of moderate/severe hydronephrosis. It would decrease variability among sonographers and improve efficiency under clinical conditions.

External validation of a simplified prognostic model for survival in patients with extrinsic malignant ureteral obstruction treated with tandem ureteral stents – a retrospective cohort study

Introduction Prognostic models of survival can identify patients with extrinsic malignant ureteral obstruction who will benefit from long-term drainage as offered by tandem ureteral stents. The study aims to validate a simplified prognostic model published by Cordeiro et al. and to identify additional prognostic predictors in a cohort of patients drained solely with tandem ureteral stents. Methods Medical records of consecutive patients who underwent drainage of malignant ureteral obstruction with tandem ureteral stents between 2007 and 2020 were reviewed retrospectively; patients with benign ureteral obstruction were excluded. Risk factors for survival included were: [1] the number of malignancy-related events (categorized as ≥4 and <4) and [2] the Eastern Cooperative Oncology Group Index (categorized as ≥2 and <2)]. Patients with ≥1 risk factor were grouped as intermediate-unfavorable risk and those without risk factors as favorable risk. The Kaplan–Meier and log-rank tests were used for survival analysis. Univariable and multivariable Cox regression analyses were used to identify predictors of outcome. Results The study cohort consisted of 65 patients; the median age was 60 years (IQR 51–72). The median follow-up time from diagnosis of hydronephrosis was 51 months (IQR 38–64). Estimated probabilities of survival at 1 month, 6 months 1 year, and 2 years were 100%, 87%, 75% and 57%, respectively in the favorable risk group (n = 40), and in the intermediate-unfavorable risk group (n = 25), 96%, 72%, 52%, and 20%, respectively, (p = .003). On multivariable analysis, the presence of ≥4 malignancy-related events (HR = 2.04, 95% CI [1.07–3.86], p = .03) and lung metastasis (HR = 2.37, 95% CI [1.0–5.6], p = .05) were associated with shorter survival. Conclusions Our findings validate the prognostic model published by Cordeiro et al. The model can be applied when counseling patients being considered for drainage with tandem ureteral stents.

Role of CT-KUB for Detection of Obstructive and Non-Obstructive Hydronephrosis on The Basis of Frequency of Calculi

The kidneys and ureters are the most prevalent sites for stones. The swelling of the kidneys due to renal stones, most often ureteric stones, is known as hydronephrosis. For detecting the position of stones, CT-KUB has a high sensitivity. Objective: To determine the frequency of obstructive and non-obstructive hydronephrosis due to calculi in CT-KUB. Methods: A cross-sectional study was conducted from January, 2022 to May, 2022 at Tertiary Hospital in Lahore, Pakistan. A sample size of 166 patients was obtained using a non-probability convenient sampling technique based on the previously published articles. All patients with renal calculi were included. 64 Slices Aquilian CT Machine was used. SPSS ver. 22 was used for data entry and analysis. Results: 166 Patients were in the age ranges of (15-25), (26-35), (36-45), (46-55), (56-65), and (66-75) were 27(16.3%), 39(16.3%), 32(19.3%), 37(22.3%), 22(13.3%), 9(5.4%) respectively. There were 126(75.9%) males and 40 (24.1%) females. Flank pain was present in 154(94%) and hematuria in 68(41%) patients. Stones were noted in kidneys 102(46.6%), proximal ureter 35(16%), mid ureter 21(9.6%), distal ureter 51(23.3%), urinary bladder 10(4.6%). 96 patients were diagnosed with obstructing hydronephrosis (57.8%). Conclusion: Urinary tract stones are most commonly seen in the kidneys and ureters. Obstructive and non-obstructive hydronephrosis is mostly caused by kidney stones. Obstructive hydronephrosis accounted for 57.8% of the total, whereas non-obstructive hydronephrosis accounted for 42.2%. CT-KUB plays a vital role in the diagnosis of hydronephrosis.

Diagnostic Value of DCE-MRI and Tofts Model in Children with Unilateral Hydronephrosis.

Hydronephrosis is a common condition, and the correct diagnosis of hydronephrosis is necessary to improve the early diagnosis rates of pediatric hydronephrosis. The objective of this study is to explore and analyze the diagnostic value of dynamic contrast- enhanced magnetic resonance imaging (DCE-MRI) analyzed using the Tofts model in children with unilateral hydronephrosis. We retrospectively selected data from 88 children with unilateral hydronephrosis treated in our hospital from September 2018 to October 2020. Routine and DCE-MR renal image indexes were collected and their pharmacokinetic variables were calculated based on the Tofts model to compare kinetic parameters of affected and normal kidney. We compared the renal parenchymal thickness and other renal function indexes in children with different degrees of hydronephrosis, and drew receiver operating characteristic (ROC) curves to evaluate the diagnostic value of this approach in children with hydronephrosis. The Ktrans, Kep, and Ve values in the diseased kidneys were lower than those in the normal ones (P<0.05). The thickness of the healthy renal parenchyma in children with severe hydronephrosis was higher than in children with moderate and mild hydronephrosis, but the renal parenchyma thickness and the thickness ratio of renal parenchyma on the affected side were lower than those in children with moderate and mild hydronephrosis (P<0.05). Sensitivity, specificity and accuracy of DCE-MRI and Tofts model in the diagnosis of hydronephrosis in children were higher than those of a single DCE-MRI (P<0.05). The area under the ROC curve for the DCE-MRI and Tofts model approach for the diagnosis of hydronephrosis in children was 0.789 (95% CI, 0.72-0.859), and the sensitivity and specificity were 86.36% and 71.59%, respectively. DCE-MRI and Tofts model can provide a clear picture of renal morphology, and renal function evaluation parameters. They have high sensitivity and specificity in the diagnosis of hydronephrosis in children.

Analysis of the Application Value of X-Ray Digital Tomographic Fusion Technique in Urinary System Diseases.

Objective To explore the application value of the X-ray digital tomographic fusion technique in the diagnosis of urinary system diseases. Methods 500 patients with suspected urinary diseases in our hospital were examined by three methods: X-ray digital tomographic fusion imaging (DTS), intravenous pyelography (IVP), and abdominal plain film (KUB), and the image quality before and after tomographic fusion was objectively evaluated. The image quality could be divided into three grades: excellent, good, and poor. Results The image excellent rate of DTS (88%) was higher than that of IVP (27.5%). The sensitivity of DTS in the diagnosis of renal cyst and space occupying of the bladder was higher than that of IVP (P < 0.05). The accuracy rate of DTS in the diagnosis of urinary calculi was 93.33%, higher than 63.3% of KUB (P < 0.001). The accuracy rate of DTS in the diagnosis of ureteral stricture was 90%, higher than 65% of IVP (P=0.03). The accuracy of DTS in the diagnosis of hydronephrosis was higher than that of IVP and KUB (P < 0.05). Conclusion In the examination of urinary system-related diseases, high-definition images can be obtained by timely using sectional fusion technology. Compared with conventional IVP, space occupying lesions such as the bladder and kidney can be displayed more clearly with the help of the tomographic fusion technique, which is helpful to improve the possibility of finding lesions and is of great significance in clinical application.

MP53-13 PROGNOSTIC FACTORS FOR OVERALL SURVIVAL IN MALIGNANT URETERAL OBSTRUCTION

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II (MP53)1 Sep 2021MP53-13 PROGNOSTIC FACTORS FOR OVERALL SURVIVAL IN MALIGNANT URETERAL OBSTRUCTION Michael Creswell, Jillian Egan, J Bradley Mason, Christopher Dall, Tamir Sholklapper, Lan Anh Galloway, Joanna Orzel, Harry Lee, Sameer Desale, and Lambros Stamatakis Michael CreswellMichael Creswell More articles by this author , Jillian EganJillian Egan More articles by this author , J Bradley MasonJ Bradley Mason More articles by this author , Christopher DallChristopher Dall More articles by this author , Tamir SholklapperTamir Sholklapper More articles by this author , Lan Anh GallowayLan Anh Galloway More articles by this author , Joanna OrzelJoanna Orzel More articles by this author , Harry LeeHarry Lee More articles by this author , Sameer DesaleSameer Desale More articles by this author , and Lambros StamatakisLambros Stamatakis More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002083.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral obstruction is common in the setting of advanced gynecologic malignancies (GM). Prior studies have investigated prognostic factors associated with overall survival (OS) for patients with malignant ureteral obstruction (MUO), but data is overall sparse. This information is important for appropriate patient counseling regarding the risks and benefits of urinary diversion in this setting. We attempted to identify prognostic factors for OS and stent failure (SF) in patients with MUO from GM. METHODS: A retrospective review of 126 patients with MUO from GM at two academic centers was performed. Clinical and laboratory data for patients > 18 years and a diagnosis of hydronephrosis and GM from 2011-2019 were collected. Factors related to OS were determined using a Cox regression proportional hazard model. In patients with incomplete survival data (n=30), hospice was used as a surrogate for death. RESULTS: OS of <6 months, 6-12 months, and >12 months was 52%, 8%, and 40%, respectively. On univariate analysis, age at diagnosis, Charlson Comorbidity Index (CCI) > 8, advanced clinical stage, ascites, pleural effusion, albumin at intervention and hemoglobin at intervention were associated with poor OS. OS was higher for those who received ureteral stent as compared to those with no intervention or percutaneous nephrostomy (PCN) placement. There was no survival difference based on severity of hydronephrosis, occurrence of SF, or creatinine at the time of intervention. CONCLUSIONS: OS in patients with MUO is poor. 52% will die or be in hospice within 6 months of hydronephrosis. Several prognostic factors for poor survival were identified. Ureteral stenting was associated improved OS, but selection bias likely contributed to this result. Additional studies are needed to clarify this finding. These data can be utilized to counsel patients regarding outcomes after urinary diversion in the setting of MUO. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e943-e944 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Creswell More articles by this author Jillian Egan More articles by this author J Bradley Mason More articles by this author Christopher Dall More articles by this author Tamir Sholklapper More articles by this author Lan Anh Galloway More articles by this author Joanna Orzel More articles by this author Harry Lee More articles by this author Sameer Desale More articles by this author Lambros Stamatakis More articles by this author Expand All Advertisement Loading ...

Diagnosis of Hydronephrosis or Ureteral Obstruction using Renal Sonography among Patients with Cervical Cancer

Background. Cervical cancer is the second most common malignancy among Filipino women. The recent 2018 FIGO guidelines recommend imaging in cases of grossly invasive disease to determine the presence of hydronephrosis, which would immediately classify the disease as at least stage IIIB. CT and MRI are state-of-the-art modalities that can provide such information; however, these are costly and may not be accessible in areas with limited resources. Sonography is a safe and inexpensive alternative in this regard. Objective. This study aimed to evaluate the diagnostic performance of renal sonography in identifying the presence of ureteral obstruction or hydronephrosis among patients with grossly invasive cervical cancer, with non-enhanced CT as the reference standard. Methods. A blinded, prospective study was conducted among patients diagnosed with grossly invasive cervical cancer from the Philippine General Hospital. Participants underwent same-day evaluation with both renal sonography and non-enhanced CT. The presence of either ureteral obstruction or hydronephrosis secondary to cervical cancer was independently determined. The sensitivity, specificity, positive predictive value, and negative predictive value of renal sonography were calculated, with non-enhanced CT as the reference standard. Results. A total of 127 participants were enrolled. The mean age was 46 years, with a range of 24 to 65 years. The majority had stage IIB (41.7%) and stage IIIB (52.0%) disease. On non-enhanced CT, 46 (36.2%) showed evidence of ureteral obstruction or hydronephrosis, while 81 (63.8%) had negative results. On renal sonography, 46 (36.2%) had positive results, and 81 (63.8%) had negative findings. The sensitivity, specificity, and positive and negative predictive values of sonography were 91.3%, 95.1%, 91.3%, and 95.1%, respectively. Among patients with stage IIIB disease, sonography was shown to have higher sensitivity and specificity of 92.1% and 96.4%, respectively. Meanwhile, among patients with stage IB to IIB disease, its sensitivity and specificity were 87.5% and 94.3%, respectively. Conclusion. Renal sonography has high sensitivity and specificity in the diagnosis of ureteral obstruction or hydronephrosis in patients with grossly invasive cervical cancer. Its sensitivity is higher when used in patients with stage IIIB disease, compared with those having lower-stage tumors.

The Change in the Renal Pelvis Anterior-Posterior Diameter Between Prevoiding and Postvoiding Status, and Its Correlation With Vesicoureteral Reflux.

In this study, our aim was to evaluate the significance of the change in renal pelvis anterior-posterior diameter (RPAPD) before and after micturition between vesicoureteral reflux (VUR)-positive and -negative patients to whom had voiding cystourethrography (VCUG) was performed.In this study, 69 children, age ranging from 0 to 12 years, were included. Before the VCUG imaging, the RPAPD was measured first with a full bladder and then after urination via ultrasound (US). The differences between in RPAPD measurements were noted and values compared made among VUR-positive and -negative children. Data distribution was inhomogeneous, and the Wilcoxon Sign Rank test was utilized instead of Student t test. There was no statistically significant difference in prevoiding and postvoiding RPAPD in VUR (+) and VUR (-) patients (P = 0.672). There was no statistically significant relation between VUR and the presence of hydronephrosis (P = 0.126). Vesicoureteral reflux is more common in patients with urinary tract infections (UTI) (P = 0.001). There was no statistically significant relationship between prevoiding and postvoiding RPAPD change and VUR diagnosis (P = 0,164).Ultrasound is the modality of choice for urinary system evaluation. Diagnosis of hydronephrosis via US is not sufficient in predicting VUR; however, indirect findings may reveal the diagnosis. A decrease in RPAPD in postvoiding US evaluation may not rule out the VUR diagnosis for this reason further imaging modalities, such as VCUG, should be taken into consideration for the patients with clinical suspicion.

Hidronefrosis congénita en paciente pediátrico: valoración por imágenes de un caso clínico

Entre las anomalías renales que afectan al feto y al recién nacido, la hidronefrosis es la más frecuente, muy por delante de otras como las agenesias, displasias o lesiones tumorales renales. Esta anomalía se caracteriza por la presencia de una dilatación del sistema colector renal que en función del diámetro anteroposterior de la pelvis renal, medido por ecografía, se considera que es normal cuando se encuentra por debajo de 7 mm. En la actualidad la mayoría de los diagnósticos de hidronefrosis se realizan durante el período antenatal y gracias a esto se han producido numerosos avances en el conocimiento de las malformaciones congénitas del feto, debido principalmente al diagnóstico y al diseño de mejores estrategias de manejo de la madre gestante y al tratamiento precoz en la vida postnatal de esos fetos. Se presenta el caso clínico de un paciente de 7 años de edad que acude a centro ecográfico con orden para ultrasonografía renoureteral vesical, por motivo de control de patología renal, con antecedentes de hidronefrosis detectada en etapa prenatal y complicaciones detectadas en la actualidad. La ecografía es el estudio de elección principal para el diagnóstico y seguimiento de una hidronefrosis congénita, sin embargo, la ecografía simple no aporta datos de la función renal. El desarrollo y generalización del uso de los ultrasonidos coincidió en el tiempo con el desarrollo de otras técnicas de diagnóstico por imagen, que permiten al urólogo realizar un seguimiento más exacto de las decisiones terapéuticas que debe tomar. Palabras clave: Hidronefrosis congénita, diagnóstico prenatal, ultrasonido.

Application of diffusion-weighted magnetic resonance imaging in the differential diagnosis of hydronephrosis and pyonephrosis

Objective To study the effect of diffusion-weighted magnetic resonance imaging (DW-MRI) in the differential diagnosis of hydronephrosis and pyonephrosis. Methods From March 2015 to October 2017, 50 patients with renal stone and highly suspected infectious hydronephrosis underwent renal DW-MRI, and clinical materials were collected and analyzed retrospectively. Seventeen male and 33 female patients were enrolled with a mean age of (49.40±10.51) years. The median maximum diameter of renal stone was 30.30 (17.38, 56.01) mm and hydronephrosis was 46.39 (34.33, 56.55) mm. No pyonephrosis was diagnosed by preoperative ultrasound or CT, while 29 cases of hydronephrosis and 21 cases of pyonephrosis were reported by preoperative DW-MRI. Final diagnoses of hydronephrosis and pyonephrosis were made according to whether the pelvic urine drainage was purulent or not during the surgery. DW-MRI reports and characteristics of DW images were analyzed retrospectively. Apparent diffusion coefficient (ADC) was calculated and ADC map constructed, which was compared between the two groups. Receiver operating characteristic curve (ROC) was drawn to analyze the area under curve (AUC) and the optimal cutoff of ADC value, with sensitivity and specificity. Results Thirty-three patients of hydronephrosis and 17 pyonephrosis were confirmed intraoperatively. The overall accuracy of diagnosis using DW-MRI was 84.00% (42/50), with sensitivity of 88.24% (15/17) and specificity of 81.82% (27/33). Among 30 patients who underwent CT scan in our hospital, mean CT value of 18 hydronephrosis was (7.03±3.26) HU and that of 12 pyonephrosis was (8.67±3.52) HU, with no statistical significance (P>0.05). On DW image, when b≥500 s/mm2, hydronephrosis signal intensity was lowered apparently, whereas pyonephrosis signal intensity was intensified. On ADC map, hydronephrosis appeared as hyperintensity, whereas pyonephrosis appeared as hypointensity. The mean ADC value of pyonephrosis group was lower than hydronephrosis group [(1.53±0. 58)×10-3 mm2/s vs. (2.86±0.56)×10-3 mm2/s, P<0.01]. ROC analysis revealed that AUC=0.92(95%CI 0.80-0.98), and the cut-off value of ADC for pyonephrosis diagnosis was 1.39×10-3 mm2/s, of which the sensitivity and specificity was 94.12% and 84.85% respectively. Conclusions Signal of pyonephrosis was enhanced on DW image, while decreased on ADC image. The ADC value of pyonephrosis was much lower than that of hydronephrosis, with which the differential diagnosis between pyonephrosis and hydronephrosis could be made efficiently. Key words: Hydronephrosis; Pyonephrosis; Urosepsis; Diffusion-weighted imaging; Apparent diffusion coefficient

Anomalies of the genitourinary tract in children with 22q11.2 deletion syndrome.

The 22q11.2 deletion syndrome (22q11.2DS) involves multiple organ systems with variable phenotypic expression. Genitourinary tract abnormalities have been noted to be present in up to 30-40% of patients. At our institution, an internationally recognized, comprehensive, and multidisciplinary 22q11.2DS care center has been providing care to these children. We sought to report on the incidence of genitourinary tract anomalies in this large cohort and, therefore, retrospectively reviewed all patients who underwent a complete evaluation from 1992 to March 2017. We identified all children with any genital or urinary tract anomaly. For all children with a diagnosis of hydronephrosis, the underlying etiology was determined, when possible. Overall, 1,073 of 1,267 children with 22q11.2DS underwent renal evaluations at our institution. Hundered Sixty-Two (15.1%) children had structural abnormalities of their kidneys/urinary tracts. The majority of children with hydronephrosis (63%) had isolated upper tract dilation without any additional diagnoses. Boys were significantly more likely to be diagnosed with a genital abnormality than girls (7.7 vs. 0.5%, p < 0.001). Of the 649 boys in the entire cohort, 24 (3.7%) had cryptorchidism and 24 (3.7%) had hypospadias, which was noted to be mild in all except one boy. Overall, findings of hydronephrosis, unilateral renal agenesis, and multicystic dysplastic kidney occur at higher rates than expected in the general population. Given these findings, in addition to routine physical examination, we believe that all patients with 22q11.2DS warrant screening RBUS at time of diagnosis.

THE ROLE OF RADIOACTIVE METHODS IN THE DIAGNOSTIC TYPE OF HYDRONEPHROSIS IN CLEAN-UP WORKERS OF CHORNOBYL ACCIDENT.

Since the introduction of radionuclide research methods into clinical practice, they occupy an importantplace in the diagnosis of hydronephrosis and, at the same time, sufficiently objective, sensitive and atraumaticmethods of investigation. On the basis of retrospective data, to investigate the diagnostic role of radionuclide renography (RRG)and the method of indirect radionuclide renangiography (IRAG) in clean-up workers of Chornobyl accident withhydronephrosis. A total of 257 patients with hydronephrosis (140 women and 117 men) aged 15 to 77 yearswere examined by the RRG and the IRAG. The RRG technique consists of intravenous administration of a solution of131I-hypurane (2.5 kBq/kg) and continuous registration for 20 minutes of the level of radioactivity above the kid-neys with the help of sensors of the renograph UR 1-1. The IRAG was conducted for 30-45 seconds with exposure1 frame per second after intravenous administration of a solution of 99mTc-pentatech (2 MBq/kg). The results of the radionuclide study of the hemodynamics of patients with different stages ofhydronephrosis made it possible to draw a conclusion regarding the expediency of taking into account the condi-tion of the cup-pelvic system in the preoperative period, as well as the parameters of the arterial and venous circu-lation. Combined use of X-ray and radionuclide methods allows establishing the cause and consequences ofhydronephrosis, to develop a rational treatment plan. RRG and IRAG are reliable methods of dynamic control in post-operative observation of clean-up workers of Chornobyl accident with hydronephrosis.

Analysis of postnatal outcomes of prenatally detected fetal hydronephrosis

Background: Prenatal hydronephrosis comprises 20% of the anomalies detected on ultrasound. Adequate information is required to counsel the parents regarding the diagnosis and possible need for further evaluation and postnatal therapy including surgery. The aim of the study is to analyse the postnatal outcomes of neonates with prenatal diagnosis of hydronephrosis. Material and Methods: Fetuses diagnosed with hydronephrosis from January 1, 2014 to May 31, 2015 were identified from the obstetric ultrasound database. 27 fetuses had a diagnosis of hydronephrosis and had complete postnatal follow-up. These were classified on the basis of the severity and bilaterality of hydronephrosis. Postnatal data and follow up was obtained from the hospital records and from the parents over phone when delivery had occurred at another institution. Results: Of 27 fetuses, 15 were diagnosed in second trimester and 13 in the third trimester due to late booking. No fetuses with a normal scan at second trimester subsequently developed hydronephrosis. Of 18 fetuses with mild hydronephrosis, 17 were seen to be normal at prenatal follow up or postnatally. Only one progressed and became severe requiring postnatal surgery. Of the nine fetuses classified as moderate or severe, seven neonates required surgery in the neonatal period. On comparing the two groups, this was found to be statistically significant. (p:0.005). The effect of bilateral hydronephrosis on outcomes could not be assessed due to the small numbers of fetuses in this category. Conclusion: Antenatal diagnosis of fetal hydronephrosis may progress and so parents need to be counselled regarding the need for a follow up scan which will then determine the need for post-natal follow up or treatment. Severity of the hydronephrosis seen antenatally influences the need for surgery in the neonate.

Clinical Scenarios in Chronic Kidney Disease: Chronic Tubulointerstitial Diseases.

Chronic tubulointerstitial diseases are a common final pathway toward chronic renal failure regardless the primary damage (glomerular, vascular or directly the tubulointerstitium). Chronic tubulointerstitial nephritis (CTN) is characterized by interstitial scarring, fibrosis and tubule atrophy, resulting in progressive chronic kidney disease. Most frequent causes of CTN are drugs, heavy metals, obstructive uropathy, nephrolithiasis, reflux disease, immunologic diseases, neoplasia, ischemia, metabolic diseases, genetics and miscellaneous. At ultrasound (US), kidneys' morphological aspect is similar in all forms of chronic interstitial nephropathy and only chronic pyelonephritis with or without reflux shows distinguishing characteristics. In interstitial nephropathy, kidneys' profiles are finely irregular and corticomedullary differentiation is altered because of a diffused hyperechogenicity. The only indirect sign of chronic interstitial damage can be derived from the value of intrarenal resistive indexes that hardly overcome 0.75. US is mandatory in clinical chronic pyelonephritis work-up because it provides information on kidney's diameter and on growth nomogram in children. Renal profiles can be more or less altered depending on the number of cortical scars and the presence of pseudonodular areas of segmental compensatory hypertrophy. In the early stages, US diagnosis of renal tuberculosis is difficult because parenchymal lesions are non-specific. US sensitivity in the diagnosis of hydronephrosis is very high, close to 100% and, finally, US is the first choice imaging technique in the diagnosis of urinary lithiasis.

Retrospective audit of delayed diagnosis of hydronephrosis in acute kidney injury

Retrospective audit of delayed diagnosis of hydronephrosis in acute kidney injury

Primary and minor indications to bedside renal ultrasonography

We appreciated the letter ‘‘Bedside renal ultrasonography: other utilities than hydronephrosis’’ by Chia-Ter Chao [1]. The author described the ultrasonographic (US) findings of acute pyelonephritis (APN), analysed the diagnostic accuracy of various imaging modalities in this disease, and emphasized the role of bedside US in APN. On the basis of these considerations, Chao commented on the fact that in our paper titled ‘‘Clinical applications of bedside ultrasonography in Internal and Emergency Medicine’’ [2] we considered obstructive uropathy and acute urine retention as the primary indications for bedside US in urinary tract diseases and mention, as other indications, hematuria, acute renal failure, suspected abscesses of the kidneys, and gross prostate abnormalities without including APN. We comprehend the enthusiasm of Chao for the application of US in APN that confirms the knowledge and the experience of the author in this field but completely disagree with him when he attributes the same role and similar importance of bedside US to APN versus hydronephrosis, renal stone or other obstructive uropathy. We think that between APN and the latter pathologies, there are very important differences not only for the diagnostic accuracy and the role of US, especially if performed bedside, but also for the epidemiologic occurrence in both Internal Medicine and Emergency Departments. First of all, we have to keep in mind what bedside US is. This is a rapid and simple US method for the diagnostic evaluation of emergency medical conditions in the acutely ill, critically ill or injured patient, performed bedside with small portable instruments often capable of only fundamental imaging [3]. This technique can also be executed by clinicians with a limited experience in US, equipped with only a second level of experience, according to EFSUMB learning guidelines [1]. With respect to the sonographic findings of acute pyelonephritis mentioned by Chao, we have no comment because they are well known and reported in the literature, but they do not have a high specificity, since the disease produces hypoechoic as well as hyperechoic areas. Colour and power Doppler US produces a small increase in the sensitivity of US, but mainly in the case of abscesses. Similarly angiosonography (CEUS) can be usefully employed only in the presence of renal abscesses but not in APN without complications. In fact, EFSUMB guidelines report indications for CEUS only in case of focal renal tumours, trauma, or abscesses, and not in APN [4]. Finally we have to consider that Colour and Power Doppler US, and especially CEUS, are certainly not methods used as bedside US. Moreover, a recent review on the state of the art of imaging of renal infections confirms that US is especially effective in the diagnosis of hydronephrosis or pyonephrosis, is less sensitive than computed tomography (CT) in evaluating for complications, has major limits in operator dependency and in obese patients, and remains a main stay in differentiating cystic versus solid structures [5]. The same conclusions have been reported in another important review on radiologic and pathologic aspects of pyelonephritis: diagnosis is typically based on clinical features and laboratory tests; imaging is reserved for nonresponders or patients with a typical clinical presentation. Computed tomography, over conventional radiography and US, is the preferred method for evaluating APN and emphysematous pyelonephritis. US is useful but CT A. Vincenzo C. Valeria (&) Department of Internal Medicine, Maggiore Hospital, Largo B. Nigrisoli 2, 40133 Bologna, Italy e-mail: v.camaggi@ausl.bologna.it

Type 2B-like acquired von Willebrand syndrome

More than 300 cases of acquired von Willebrand syndrome (AVWS) have been reported, but it is thought that this number reflects only the tip of the iceberg [1]. Data from an international registry has shown that AVWS may be associated with lymphoproliferative (48%) or myeloproliferative (15%) disorders, neoplasia (5%), immunological (2%), cardiovascular (21%) and miscellaneous conditions (9%) [2]. AVWS usually mimics von Willebrand disease (VWD) type 1 or 2A [3, 4]. To our knowledge, only two cases of type 2B-like AVWS have been reported previously [4, 5]. They were both associated with plasma cell dyscrasia. Here we show a new case of type 2B-like AVWS. On 2 November 2000, a 74-year-old man was referred to our hospital for the follow-up of monoclonal gammopathy of undetermined significance (MGUS). Serum immunoelectrophoresis showed two kinds of M protein, IgG (j) and IgG (k). The serum immunoglobulin levels were IgG 2289 mg/dl, IgA 175 mg/dl, and IgM 63 mg/dl. He remained relatively well until 24 July 2008, when he developed a high fever. A diagnosis of hydronephrosis and urinary tract infection due to prostatic hypertrophy was made and after transurethral resection of the prostate, which was performed on 22 August 2008, macrohematuria persisted for 4 weeks despite administration of tranexamic acid. There was no other mucocutaneous bleeding. His serum IgG level had hardly changed up to that point. Routine coagulation tests demonstrated: prothrombin time, 11.4 s (normal 10.0–13.5 s); activated partial thromboplastin time, 48.5 s (normal 25.0–40.0 s); plasma fibrinogen level, 298 mg/dl. Factor VIII activity (FVIII:C) was 17% (normal 50–150%), von Willebrand factor antigen (VWF:Ag) was 11% (normal 50–150%) and von Willebrand factor ristocetin cofactor activity (VWF:RCo) was below 10% (normal 50–150%). Activities of factor IX, factor XI and factor XII were all normal. Bleeding time was 2.0 min (normal 1.0–5.0 min). The platelet count was consistently normal. Platelet aggregation induced by ADP, collagen or epinephrine was increased when compared to that in the control. Ristocetin-induced platelet aggregation (RIPA) was also enhanced, showing 70% aggregation with 0.3 mg/ml ristocetin compared with absent aggregation in a normal control (Fig. 1). His platelet-rich plasma (PRP) aggregated spontaneously without the addition of any agonists. All aggregation studies were performed with an aggregometer (MC Medical, Tokyo, Japan) in siliconized glass cuvettes at 37.0 ± 0.5 C with constant stirring at 1000 ± 100 rpm. Plasma VWF multimeric analysis showed that large multimers were absent and medium multimers were markedly decreased. Since these results T. Shigekiyo (&) E. Sekimoto A. Shirakami H. Yamaguchi H. Shibata S. Ozaki Department of Internal Medicine, Tokushima Prefectural Central Hospital, 1-10-3 Kuramoto-cho, Tokushima 770-0042, Japan e-mail: shigekiyo@tph.gr.jp

Outcome of pregnancies complicated by oligohydramnios or anhydramnios of renal origin

To evaluate the outcome of fetuses with oligohydramnios due to kidney anomalies. A retrospective study was performed of all pregnancies diagnosed with oligohydramnios and associated kidney anomalies during the period 2000-2008. Outcome included pregnancy outcome, mortality, and morbidity. Morbidity included renal function based on the glomerular filtration rate (GFR) during follow-up. A total of 71 pregnancies were evaluated; 36 fetuses presented on ultrasound with cystic dysplasia, 15 with polycystic kidney disease (PKD) and 20 with hydronephrosis. Twenty-three (32%) had associated anomalies. In 49 fetuses (69%), the diagnosis had been made before 24 weeks of gestational age (GA); 41 of those pregnancies were terminated. Twenty-five neonates were live born: 10 survived, 15 died. Prognostic factors for survival included GA at diagnosis (32.2 weeks for survivors vs 28.1 weeks for non-survivors; P = 0.02), diagnosis of hydronephrosis (7 in the survivors vs 4 in the non-survivors: P = 0.05), isolated anomaly (9 in the survivors vs 7 in the non-survivors: P = 0.04). Severity of oligohydramnios (1 case of anhydramnios in the survivors vs 7 in the non-survivors: P = 0.08) was not significant. The 1-year GFR was below 50 mL/min.1.73 m(2) in four of the ten survivors. The prognosis of early onset renal oligohydramnios is poor. Predictive determinants of survival are: GA at diagnosis, nature of renal anomaly (hydronephrosis vs other), and presence of associated anomalies.

Harntransportstörungen (Hydronephrosen)

The prevalence of malformations of the kidneys is quite high compared to other congenital malformations. In a study of the Association for Neonatology of Mecklenburg-West Pomerania examining 37,634 births, a hydronephrotic kidney was diagnosed in 16.7 of 10,000 children. Depending on the type and severity of the congenital malformation it might be difficult to find out when there is a risk for loss of renal function. Unfortunately, in 2010 health politicians (the Gemeinsame Bundesausschuss) voted against routine ultrasound screening for renal abnormalities in newborns despite an increasing number of pre- or postnatally diagnosed dilated kidneys in recent years. Will this lead to a decrease in the diagnosis of hydronephrosis with possible loss of renal function later on? According to Roth et al. the incidence of in utero dilatations of the urinary tract is about 1:100, but only 1:500 children have a clinically relevant problem. This raises the question of which of these young patients need an intervention and which might be monitored expectantly.

Magnetic resonance urography in children - when and why?

BackgroundThe aim of the study was to determine the potential of magnetic resonance urography (MRU) in evaluation of paediatric urinary tract pathologies.Patients and methods.Twenty-one paediatric urological patients were evaluated with T1, T2 prior and after and 3D gradient echo sequences after the contrast administration. Results were compared with findings obtained with ultrasound which was performed to all of patients, intravenous urography performed to 14 patients with the diagnosis of hydronephrosis and voiding cystouretrography performed to 6 patients where hydronephrosis was suspected to be caused by vesicoureteral reflux (VUR).ResultsMRU not only established the cause of hydronephrosis in all 14 cases (5 ureteropelvic junction (UPJ) stenosis, 1 functional stenosis, 3 residual hydronephrosis, 1 combination of UPJ and vesico-ureteric junction (VUJ) stenosis with hydromegaureter, 2 fetal ureters and 3 insufficient broad ureteral orifices), but gave additional information about existing pathological conditions in all of patients compared to other previously performed examination (1 caliceal lithiasis, 4 UPJ stenosis, 1 VUJ stenosis, 1 neurogenic bladder, 1 hypotonic ureter, 1 urinary infection, 1 duplication of pelvis and ureter, 1 urinary retention and 1 fetal ureter). Other MRU findings were: 3 polycystic kidney disease, 1 caliceal cyst, 2 simple renal cysts, 1 long hypotonic twisted ureters and 1 hypertrophied column of Bertini.ConclusionsBecause of the ability to acquire high contrast and spatial resolution images of the whole urinary tract in any orthogonal plane, MRU enables a precise detection and differentiation of pathological urological conditions. We believe that in the future, because of its advantages, MRU will replace traditional methods in the evaluation of urinary tract pathologies.