Open Renal Biopsy Research Articles

Chronic kidney disease associated with extremely premature birth and extremely low birth weight may progress through the burden of growth.

Chronic kidney disease associated with low birth weight and/or premature birth (L/P-CKD) in infants may result from a decreased number of nephrons at birth. These infants may develop acute kidney injury due to exposure to nephrotoxic substances or other events during nephrogenesis in early infancy. Nonetheless, L/P-CKD progression remains unclear. We present three cases of L/P-CKD diagnosed after neonatal intensive care unit (NICU) discharge. Three patients were born extremely prematurely (gestational age, 24-26weeks) with extremely low birth weight (606-906g). They were admitted to the NICU (117-311days) anad received several nephrotoxic medications during the early postnatal period. They showed elevated serum creatinine levels at 4weeks after birth, which decreased to normal levels at NICU discharge. Proteinuria was first detected during adolescence (10-15years) on annual school urine screening, with a remarkable increase in their height (18 - 50.8cm), without known episodes of urinary tract infection, dehydration, lifestyle-related issues, such as excessive salt/protein intake, and extreme lack of exercise that might have caused kidney damage. Their kidneys were smaller than normal on renal ultrasonography. Open renal biopsy findings indicated glomerulomegaly and perihilar glomerulosclerosis in two of the three patients, suggesting glomerular hypertension. The remarkable differences between the body height before CKD and the timing of diagnosis of CKD could contribute to the progress of CKD. Long-term follow-up of low birth weight and extremely premature infants, from NICU discharge until adulthood, should be established.

Airway Obstruction Caused by Sputa in Heat and Moisture Exchange Filter During Ventilation Using Supra-Laryngeal Mask Airway: A Case Report

Introduction: Supra-laryngeal mask airway (LMA) is widely accepted as an alternative to the tracheal tube. However, compared to the use of a tracheal tube, it may take longer to identify the many different causes of sudden respiratory distress. In particular, heat and moisture exchange filters are one of the most overlooked causes. Case presentation: The case was that of a 76-year-old male Japanese patient (161.9 cm, 66.5 kg) who underwent an open renal biopsy. He presented with chronic obstructive pulmonary disease, with a Hugh–Jones dyspnea score of 2. The patient did not discontinue smoking prior to the operation. Anesthesia was induced using propofol (100 mg), fentanyl (100 ?g), and remifentanil (0.3 ?g/kg/min). I-gel™ #4 was inserted following neuromuscular blockade with rocuronium (40 mg). Anesthesia was maintained with 3–6% desflurane under positive pressure ventilation. After induction in the left lateral and jackknife positions, the following ventilator settings were used: volume-controlled ventilation with tidal volumes of 450 mL, respiratory rate of 12 breaths per minute, an inspiratory: expiratory ratio of 1:2, and a positive end expiratory pressure of 5 cmH2O. With these settings, the peak inspiratory pressure was 16 cmH2O. Five minutes after initiating the operation, the peak inspiratory pressure steadily increased to 30 cmH2O. Although we administered rocuronium, the peak inspiratory pressure and end-tidal carbon dioxide concentration increased over time. When we disconnected the heat and moisture exchange filter and LMA, we noticed a large quantity of sputa. A suction catheter was passed down the LMA and the sputa was removed, but the LMA was not obstructed. The peak inspiratory pressure continued to increase with tidal volumes of only 20–30 mL. Despite a normal external appearance of the heat and moisture exchange filter, we replaced it with a new one. The ability to ventilate improved immediately and the SpO2 recovered from 92% to 100%. Conclusions

Proteinuria and Renal Dysfunction Due to Extremely Low Birth Weight in a Patient with Silver-Russell Syndrome.

A 36-year-old woman diagnosed with Silver-Russell syndrome during childhood presented to our department after a primary care physician suspected renal dysfunction. At birth, she had an extremely low weight (1210 g), and in childhood, she was diagnosed with Silver-Russell syndrome. At the age of 14 she was found to have proteinuria; however, the condition was never further examined. One month prior to her presentation to our department, the following were noted: 3+ urinary protein, 3.9 urinary protein/creatinine ratio, and 48 mL/min/1.73 m2 estimated glomerular filtration rate. Abdominal computed tomography revealed small kidneys difficult to visualize using ultrasound. Therefore, an open renal biopsy was performed. The renal biopsy revealed no significant findings in the glomerulus except glomerular hypertrophy, and the glomerular density in the cortical area was low (0.6/mm2). The patient was diagnosed with oligomeganephronia. Proteinuria and renal dysfunction were likely due to glomerular hyperfiltration resulting from a low nephron count caused by low birth weight. Silver-Russell syndrome is characterized by intrauterine growth retardation and additional developmental disorders after birth. Here, we detected oligomeganephronia following kidney biopsy in a patient with Silver-Russell syndrome. We suspect that a reduced number of nephrons due to low birth weight caused proteinuria and renal dysfunction.

Open Versus Percutaneous Approach of Renal Tumor Biopsy at Cipto Mangunkusumo Hospital: A Single-center Experience

BACKGROUND: Renal tumor biopsy is beneficial as it is capable of distinguishing between histological types of renal tumor; hence, it plays an important role in deciding the best therapy regimen. AIM: This study aims to evaluate the clinical experiences of renal biopsy in Cipto Mangunkusumo National Referral Hospital (RSCM), with both a percutaneous and open approach. It also aims to analyze the indications, results, intraoperative information, and complications of the two approaches. METHODS: This study was conducted using the retrospective cohort design; meanwhile, data were collected from RSCM from 1990 to 2019. The biopsy sample was taken using percutaneous and open renal biopsy, while comparative analysis was done between the two biopsy approaches. RESULTS: Data were collected from 33 patients that underwent renal biopsy from 1990 to 2019. Majority of the cases were diagnosed as unresectable renal tumor, while histological examination found clear cell carcinoma in most of the cases (73%). Furthermore, the open approach showed longer duration and higher blood loss compared to percutaneous technique with median 60 (30–120) versus 30 (5–60) min (p < 0.001) and 100 (5–650) versus 2 (1–5) ml (p < 0.001), respectively. In general, complications were reported to be low for both techniques. CONCLUSION: Based on the results, percutaneous renal biopsy has similar efficacy and complications rates in tumor sampling for histopathology together with open approach. However, there were significant differences in the duration and blood loss; hence, percutaneous biopsy is more favorable.

Study of Glomerulopathy in Donors after Kidney Transplantation

Introduction: Living kidney donation improves the lives of individuals with kidney failure; however, recent studies have suggested that living kidney donors may be at a relatively higher risk of reduced renal function than healthy non-donors. We therefore aimed to evaluate the clinical and pathological findings in living kidney donors who developed kidney disease. Methods: From January 1991 to May 2019, 1,625 live kidney donations were performed at our hospital. Among the donors, 7 developed kidney disease after donation and underwent open renal biopsy. We studied the clinical and pathological findings of these patients from their clinical records. Results: There were 3 patients with immunoglobulin A (IgA) nephropathy, 2 with membranous nephropathy, 1 with anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis, and 1 with secondary focal segmental glomerulosclerosis (FSGS). All patients with IgA nephropathy had latent IgA deposition on their baseline biopsy. One patient with membranous nephropathy demonstrated findings of membranous nephropathy on the baseline biopsy, despite being asymptomatic. All patients, except for those with ANCA-associated nephropathy and secondary FSGS, recovered from the nephritis or maintained an adequate renal function after treatment. Discussion/Conclusion: Baseline biopsy is necessary for assessing the renal condition of kidney donors, and these donors require long-term follow-up based on their baseline biopsy findings. If donors develop kidney disease, appropriate diagnosis and treatment are essential.

Can a Modified Bosniak Classification System Risk Stratify Pediatric Cystic Renal Masses?

We characterize and apply the modified Bosniak classification system to a cohort of children with cystic renal lesions and known surgical pathology. We identified all patients at our institution with cystic renal masses who also underwent surgery for these lesions. Patients without available preoperative imaging or pathology were excluded. All radiological imaging was independently reviewed by a pediatric radiologist blinded to pathological findings. Imaging characteristics (size, border, septations, calcifications, solid components, vascularity) were recorded from the most recent preoperative ultrasounds and computerized tomograms. The modified Bosniak classification system was applied to these scans and then correlated with final pathology. A total of 22 patients met study criteria. Median age at surgery was 6.1years (range 11 months to 16.8 years). Of the patients 12 (54.5%) underwent open nephrectomy, 6 (27.3%) open partial nephrectomy, 2 (9.1%) laparoscopic cyst decortication, 1 (4.5%) open renal biopsy and 1 (4.5%) laparoscopic partial nephrectomy. Final pathology was benign in 9 cases (41%), intermediate in 6 (27%) and malignant in 7 (32%). All malignant lesions were modified Bosniak class 4, all intermediate lesions were modified class 3 or 4 and 8 of 9 benign lesions (89%) were modified class 1 or 2. Cystic renal lesions in children with a modified Bosniak class of 1or 2 were most often benign, while class 3 or 4 lesions warranted surgical excision since more than 90% of masses harbored intermediate or malignant pathology. The modified Bosniak classification system appears to allow for a reasonable clinical risk stratification of pediatric cystic renal masses.

Biopsy in native kidney diseases

Abstract Renal biopsy is usually obtained to establish a diagnosis, help guide therapy, and ascertain the degree of active and chronic changes. The routine evaluation of a percutaneous renal biopsy involves examination of the tissue under light, immunofluorescence, and electron microscopy. The indications for performing a renal biopsy vary among concerned physicians, being determined in part by the clinical features, signs, and symptoms. Among patients with the nephrotic syndrome and no evidence of systemic disease, renal biopsy is performed both to determine treatment and to make an unidentified diagnosis. The acute nephritic syndrome is often caused by a systemic disease that requires a renal biopsy to establish the diagnosis and guide treatment. Even in the absence of a systemic disease, the acute nephritic syndrome commonly needs a biopsy to ascertain a diagnosis and guide treatment. Among patients with unexplained acute kidney injury, a biopsy is obtained in those settings, in which the diagnosis is uncertain. Among patients with isolated glomerular hematuria, a renal biopsy is not routinely performed, unless there is evidence of progressive disease such as increasing proteinuria or a rising serum creatinine concentration. A renal biopsy is also generally not obtained in patients, who presents with low-grade proteinuria (less than 500–1000 mg/day), the absence of glomerular hematuria, usually normal renal function, and an absence of clinical or serologic evidence of a systemic disease that can cause glomerulonephritis. Prior to a percutaneous renal biopsy, a history, physical examination, and selected laboratory tests should be performed. Recommended laboratory tests include complete blood count, platelet count, prothrombin time, partial thromboplastin time, and bleeding time. Percutaneous renal biopsy is usually performed under real time ultrasonic guidance in local anesthesia with spring-loaded needle. Bleeding is the primary complication of renal biopsy. Nonpercutaneous renal biopsies (open, laparoscopic, and transjugular renal biopsy) are indicated in settings, in which a percutaneous renal biopsy cannot be performed (uncorrectable bleeding diathesis, failed attempts at percutaneous biopsy).

Oxidative Stress Candidate Biomarkers of Renal Warm Ischaemia: A Proteomic Study

Introduction: Warm Ischaemia (WI) during Donation after Circulatory Death (DCD) organ retrieval leads to higher rates of delayed graft and primary non-function. The development of a biomarker of warm ischaemia would aid viability assessment prior to use and potentially open avenues for therapeutic intervention. Data from cell lines, isolated kidney perfusion studies and small animal DCD models demonstrate limited clinical applicability. We describe the use of a Porcine DCD model of renal WI to stratify potential candidate biomarkers across clinically relevant time points. Methods: Open renal biopsies were obtained following on-table termination of 3 Large White wild pigs. These were taken at 0 (control), 30, 120 and 180 minutes and immediately frozen in liquid nitrogen. Protein extracts were then subjected to two-dimensional gel electrophoresis (2-DE). Resulting protein maps were analysed with Progenesis SameSpots and differentially expressed proteins (p < 0.05) were excised for identification via tandem mass spectrometry. Results: From a total of 1211 protein spots separated by 2-DE, 28 were found to be significantly altered between the control and ischaemia groups. Of these, 13 were uniquely identified. These included metabolic enzymes which were both up- (aldehyde dehydrogenase) and down regulated (phosphate cytidylyltransferase 2, 3-hydroxyanthranilate 3,4-dioxygenase and fructokinase) during ischaemia. Markers of protection from the oxidative stress response increased in expression (Heat Shock Protein 60 and peroxiredoxin 2 and 3). Fetuin A, a potential urinary biomarker of Acute Kidney Injury, was also significantly upregulated throughout the ischaemic time period. The anti-apoptotic cell signalling target valosin containing protein (VCP), showed persistent downregulation up to 120 minutes, however, it demonstrated a return towards baseline after 120 minutes WI (Figure 1).Figure: [Log Normalised Volumes of VCP (ANOVA p<0.05)]Conclusions: Using global proteomic analysis, 13 proteins demonstrated unique differential expression during 30 to 180 minutes of WI. The identification of the 3 oxidative stress protective proteins, is comparable to previous cell line reports (1–3). The trend of VCP expression across WI time points may suggest that apoptotic changes commence after 120 minutes WI. This is the first large animal study to demonstrate specific candidate biomarkers of WI as the only independent factor. Further validation into upstream gene expression and Western blotting of identified protein targets of interest in underway.

2136 IS UROLOGIC SURGICAL TRAINING BENFICIAL IN THE POSTOPERATIVE CARE OF THE RENAL TRANSPLANT PATIENT?

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Vascular Surgery I1 Apr 20122136 IS UROLOGIC SURGICAL TRAINING BENFICIAL IN THE POSTOPERATIVE CARE OF THE RENAL TRANSPLANT PATIENT? Hannah Kerr, Antonia Harford, and Michael Davis Hannah KerrHannah Kerr Albuquerque, NM More articles by this author , Antonia HarfordAntonia Harford Albuquerque, NM More articles by this author , and Michael DavisMichael Davis Albuquerque, NM More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2306AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Historically, urologists have had a dominant role in renal transplantation. However, with the advent of other abdominal organ transplants, this procedure has become the purview of general surgeons. At UNM, renal transplantation is performed by the Division of Urology. We analyzed our experience to ascertain whether renal transplant recipients benefited postoperatively from the surgical expertise of a urologic renal transplant surgeon. METHODS We retrospectively reviewed 172 renal transplants from 2006–2010, looking at operative procedures up to 36 months after transplant that related to the transplant outcome. We compared the procedures that required a urologist to the procedures that any trained renal transplant surgeon could perform. RESULTS 132 of 172 patients (77%) required at least 1 subsequent surgical procedure. 178 procedures were performed. Of these, 144 (81%) were urologic procedures, and 34 (19%) were procedures that any trained renal transplant surgeon could perform. See table. Urologic Procedures Number General Transplant Surgery Procedures Number Cystoscopy/stent removal 119 Removal of PD catheter 15 Native nephrectomy 5 Revision of ureteroneocystotomy 2 TURP/TUIP 4 Seroma/lymphocele drainage 5 Radical orchiectomy 1 Removal of JP drain 2 Ileal conduit stoma revision 1 Transplant nephrectomy 5 Bladder biopsy 1 Wound dehiscence closure 1 Retrograde pyelograms 5 Adrenalectomy 1 Re-stenting 5 Open renal biopsy 3 Deflux injection 2 Dorsal slit 1 Total 144(81%) 34(19%) CONCLUSIONS Our data demonstrates that renal transplant patients benefit from the expertise of a urologist. A number of secondary operations/procedures are performed post-transplant which influence graft outcome. The advantage of having a urologist as the renal transplant surgeon is that care does not have to be coordinated with another specialist. The ultimate benefit is long term continuity of surgical care for these complex patients. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e862-e863 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hannah Kerr Albuquerque, NM More articles by this author Antonia Harford Albuquerque, NM More articles by this author Michael Davis Albuquerque, NM More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Hyperechogenic renal parenchyma in potential live related kidney donors: Does it justify exclusion?

ObjectivesTo assess the predictive importance of ultrasonic grade 1 hyperechogenicity in potential live related kidney donors in the absence of urinary abnormalities and with perfect renal function. Subjects and methodsThe study included 34 potential living related kidney donors with this abnormality; their mean (SD, range) age was 32.7 (8.45, 23–48) years. Ten matched healthy donors with normal ultrasonographic appearance of the kidneys were studied as controls. All cases were thoroughly investigated, including measuring glomerular filtration rate by isotopic scintigraphy. The renal reserve was estimated by dopamine and amino-acid infusion in all subjects (study and control groups). A percutaneous renal biopsy was taken from 17 subjects in the abnormal echogenicity group and open renal biopsy was taken from eight of the control subjects. ResultsThe renal reserve was comparable in both groups. Abnormal histopathological changes were found in seven subjects (41%) of the abnormal echogenicity group, i.e. partial glomerulosclerosis in one, mesangial thickening in two, interstitial fibrosis in one, focal tubular atrophy in one, immunoglobulin (Ig M) immune deposits in three and IgA in one. Only one subject in the control group showed mild mesangial thickening. ConclusionGrade 1 echogenicity might be a sign of unrecognized kidney disease. Renal biopsy is mandatory when such related donors are the only available ones. Abnormal histopathology contraindicates donation.

Open renal biopsy: comorbidities and complications in a contemporary series

Therapy (case series) Level of Evidence 4. To report the indications and outcomes of a contemporary series of patients with contraindications to percutaneous renal biopsies (PRBs) who had an operative RB (ORB), as although ORB is a relatively infrequent procedure, it remains an important and underreported operation. In a retrospective review of patients who had an ORB we examined comorbidities, indications, and 30-day morbidity and mortality. Preoperative comorbidities were stratified according to the Charlson comorbidity index. In all, 115 patients had ORB between 1991 and 2006 (mean age 48 years, range 18-83); 60% of the patients were American Society of Anesthesiologists class >or=3. The median Charlson comorbidity index score was 3, with a score of 0 in 20.9%, 1-2 in 27.8%, 3-4 in 30.4% and >or=5 in 20.9% of patients. Indications for an ORB included morbid obesity, failed PRB, coagulopathy, and solitary kidney. In all, 47.8% of patients had a serum creatinine level of <3.0 mg/dL, 34.8% of >3.0 mg/dL and 17.4% were dialysis-dependent. There were 43 complications in 36 patients. The mortality rate after surgery was 0.8%. There were eight major complications in seven patients (6.1%) including cardiac arrest, stroke, sepsis, reoperation and re-intubation. There were minor complications 34 times in 31 patients (27%), the most common being wound infection, pneumonia, intraoperative transfusion of >2 units, arrhythmia, postoperative retroperitoneal bleed, and seep vein thrombosis. This study shows that there are significant comorbidities in patients referred to urologists for an ORB. With a mortality rate of 0.8% and major and minor complication rates of 6.1% and 27%, respectively, the ORB, while infrequent, carries a significant risk in this population that should be included in preoperative decision making and used for patient counselling.

Autosomal dominant polycystic kidney disease with diffuse proliferative glomerulonephritis - an unusual association: a case report and review of the literature

IntroductionAutosomal dominant polycystic kidney disease is an inherited disorder that is characterized by the development and growth of cysts in the kidneys and other organs. Urinary protein excretion is usually less than 1 g/24 hours in autosomal dominant polycystic kidney disease, and an association of nephrotic syndrome with this condition is considered rare. There are only anecdotal case reports of autosomal dominant polycystic kidney disease associated with nephrotic syndrome, with focal segmental glomerulosclerosis being the most commonly reported histopathological diagnosis. Nephrotic-range proteinuria in the presence of autosomal dominant polycystic kidney disease, with or without an accompanying decline in renal function, should be investigated by open renal biopsy to exclude coexisting glomerular disease. To the best of our knowledge, this is the first case of autosomal dominant polycystic kidney disease with histologically proven diffuse proliferative glomerulonephritis presenting with nephrotic-range proteinuria. No other reports of this could be found in a global electronic search of the literature.Case presentationWe report the case of a 35-year-old Indo-Aryan man with autosomal dominant polycystic kidney disease associated with nephrotic syndrome and a concomitant decline in his glomerular filtration rate. Open renal biopsy revealed diffuse proliferative glomerulonephritis. An accurate diagnosis enabled us to manage him conservatively with a successful outcome, without the use of corticosteroid which is the standard treatment and the drug most commonly used to treat nephrotic syndrome empirically.ConclusionDespite the reluctance of physicians to carry out a renal biopsy on patients with autosomal dominant polycystic kidney disease, our case supports the idea that renal biopsy is needed in patients with polycystic kidney disease with nephrotic-range proteinuria to make an accurate diagnosis. It also illustrates the importance of open renal biopsy in planning appropriate treatment for patients with autosomal dominant polycystic kidney disease with nephrotic-range proteinuria. The treatment for various histological subtypes leading to nephrotic syndrome is different, and in this modern era we should practice evidence-based medicine and should avoid empirical therapy with its associated adverse effects.

Efficiency of laparoscopic-assisted renal biopsy

This study was made to present our experience and results with transperitoneal laparoscopic-assisted renal biopsy (LARB) in Nagoya University Hospital as a good alternative for open renal biopsy. 21 patients (14 male, 7 female, mean age 58 years, range 21-83 years) were unsuitable for percutaneous renal biopsy. Therefore, they underwent laparoscopic-assisted renal biopsy. The kidney was approached transperitoneally via three ports, cortical tissue was obtained using a 16-gauge gun-mounted semiautomatic biopsy needle. Hemostasis was obtained by applying pressure on the renal puncture using gauze until bleeding had been stopped (range 5-20 min). Adequate cortical tissue and accurate diagnoses were obtained in all patients. Mean operative time was 83 min (range 65-120 min) and mean estimated blood loss was 5.5 ml (range 1-10 ml). There were no intraoperative complications: no open conversion, blood transfusions or gross hematuria. All patients walked about freely and could tolerate regular food on the first postoperative day. The only postoperative complication was a hernia formation at the place of trocar insertion 3 months after the operation in one patient who previously underwent multiple surgery for 3 arterial grafts and appendicitis. LARB is a safe and accurate procedure for obtaining cortical biopsies with minimal blood loss. Although LARB remains a surgical procedure which requires general anesthesia, LARB to date may be considered as a good alternative to open renal biopsy for patients in whom a closed percutaneous approach is either a relative or absolute contraindication.

Imaging accuracy and incidence of Wilms' and non-Wilms' renal tumors in children

Purpose The purpose of this study is to determine the actual incidence, age distribution, and preoperative imaging accuracy of non-Wilms' tumors (nWT) in children with renal masses. Methods Pathologic reports from all tumor nephrectomies or open renal biopsies performed at a single institution from September 1999 to June 2005 were analyzed. Patient demographics, pathologic findings, specific imaging study descriptors, and differential diagnoses were tabulated. Accuracy of imaging studies in identifying specific tumors was calculated. Results Ninety-two patients were identified. Sixty-eight had Wilms' tumor (WT) and 24 had an nWT. The nWT group included congenital mesoblastic nephroma (5), clear cell sarcoma (4), neuroblastoma (4), renal cell carcinoma (4), lymphoma (2), angiomyolipoma (2), teratoma (1), hemangioma (1), and renal epithelial tumor (1). When grouped by ages, the incidence of nWT was between 0% and 83%. Sensitivity, specificity, positive predictive value, and negative predictive value for computed tomography (CT) determining a diagnosis of WT were 0.92, 0.55, 0.84, and 0.73, respectively. The CT reports explicitly stated a potential diagnosis in 89% of cases, with a diagnostic accuracy of 82%. Conclusions Non-Wilms' tumors may represent a significant proportion of renal tumors in children, especially in children aged less than 6 months or greater than 12 years. Preoperative imaging is of limited value in differentiating these tumors. These data have significant implications for parental counseling, surgical plan, and the choice of neoadjuvant chemotherapy and argue in favor of obtaining a tissue diagnosis before instituting therapy.

Intravascular Hemolysis and Acute Renal Failure After Mitral and Aortic Valve Repair

Intravascular Hemolysis and Acute Renal Failure After Mitral and Aortic Valve Repair

Acute Tubular Necrosis Associated with Chromium Picolinate–Containing Dietary Supplement

To report a case of acute tubular necrosis associated with the use of a chromium picolinate-containing dietary supplement. A 24-year-old white male who had been ingesting a dietary supplement (Arsenal X) for 2 weeks during his workout sessions developed acute renal failure. Radiologic investigation showed the presence of a solitary right kidney, and an open renal biopsy confirmed features of acute tubular necrosis. He developed significant renal impairment that required hemodialysis. He was also treated with plasmapheresis and steroids, as a diagnosis of pulmonary-renal syndrome was entertained early in the disease course, which was subsequently ruled out. The patient ultimately recovered and, on outpatient visits, was noted to have normal renal function. The use of dietary supplements has become increasingly popular in the US, and these supplements are not subject to stringent premarketing testing or postmarketing surveillance. The main ingredients in the supplement discussed here were chromium picolinate, Sida cordifolia, synephrine, and guarana. An objective causality assessment using the Naranjo probability scale indicated a probable association between the use of this supplement and the development of acute renal failure in this patient. Current information regarding the beneficial effects of trivalent chromium is not very robust; therefore, use of this agent cannot be recommended at this time. This report serves as an important reminder to the public, as well as healthcare providers, of potential nephrotoxic reactions to dietary supplements.

Nephronophthisis in two siblings

We describe here two sisters with nephronophthisis, which was not detected until the development of endstage renal failure. Twenty- and 15-year-old female siblings were admitted to our hospital for further examination of renal dysfunction. No urinalysis abnormalities had been found in yearly health checks in either patient. The serum creatinine level was 7.2 mg/dl in case 1 (the 20-year-old) and 6.4 mg/dl in case 2. Medical history, physical findings, and laboratory tests showed no evidence of urinary tract infection, use of any drugs, arthritis, or skin eruptions. To identify the cause of the renal failure, open left renal biopsies were performed in both patients. Histopathological findings were very similar in the two patients and included marked tubular and interstitial changes (tubular dilatation, focal tubular atrophy, interstitial fibrosis, and infiltration of mononuclear cells). The glomeruli were devoid of mesangial proliferation, mesangial expansion, and adhesion of Bowman's capsule. Based on the clinical and pathological findings, the final diagnosis was nephronophthisis in both patients. It is important to remember that some progressive renal diseases, including nephronophthisis, cannot be detected even by annual urinary screening tests, which are widely performed in Japan.

Place de la ponction biopsie rénale dans l'insuffisance rénale aiguë en réanimation

Acute renal failure (ARF) in intensive care unit patients is mostly due to ischemic acute tubular necrosis. ARF may have numerous other etiologies and the timely institution of the appropriate treatment for some causes may preserve renal function and improve outcome. The role of renal biopsy (RB) in the diagnosis and prognosis of ARF is debated and only few data have been published on this topic in ICU patients. RB is unnecessary when ARF is due to urinary tract obstruction, to vascular obstruction, and to acute tubular necrosis. The use of RB in the early phase of ARF is usually considered in patients with extrarenal manifestations suggesting the possibility of a systemic disease, in patients with a clinical evaluation and biological findings suggesting a glomerulonephritis, an acute interstitial nephritis or a microangiopathy, and in the absence of an obvious cause of ARF. The contraindications to RB included uncontrolled hypertension, cysts and tumors in the kidney, renal artery aneurysm, uncontrolled hemorrhagic diathesis, single or malformative kidney, perinephric abcess, and pyonephrosis. The precautions in performing RB included correcting arterial hypertension, normalizing coagulation and keeping hematocrit over 30%. The technique of RB in ICU patients is quite similar to the standard procedure and use of 18-gauge automated needle with real time ultrasonography guidance is recommended, making the procedure safer. Following the biopsy, blood pressure and pulse rates should be monitored and urines samples should be checked for possible macroscopic hematuria. The patient hematocrit should be checked 6 hours and then 24 hours after biopsy. In patients with contraindications open renal biopsy is a safer procedure. Recently, the transjugular renal biopsy technique was reported to be a relatively safe, reliable and minimally invasive procedure with an excellent diagnostic yield in high risk patients.

Vascular endothelial growth factor gene expression is correlated with glomerular neovascularization in human diabetic nephropathy

In diabetic nephropathy (DN) small vessels are frequently observed around the glomerular vascular pole in addition to normal afferent and efferent arterioles; this is regarded as neovascularization . Because vascular endothelial growth factor (VEGF) promotes vascular generation, the authors investigated the relationship between glomerular VEGF gene expression and structural glomerular changes in the early stage of human DN. Kidney specimens were obtained from 18 type 2 DN patients by open renal biopsy. Additional vessels were distinguished by light microscopy as either afferent or efferent arterioles. Glomerular VEGF messenger RNA expression was determined by using in situ hybridization. The mesangial matrix area was quantified, and the ratio of the mesangial matrix area to the whole glomerular area was calculated to determine the mesangial matrix index (MMI). There were significantly more glomeruli with extra vessels in DN than in normal kidneys. The degree of neovascularization was significantly increased in DN and correlated with the magnitude of VEGF messenger RNA expression (r 2 = 0.46, P = 0.010) and MMI (r 2 = 0.45, P = 0.0093). These findings suggest that glomerular VEGF may be involved in structural changes in human DN at an early stage.

Glomerular expression of platelet-derived growth factor (PDGF)-A, -B chain and PDGF receptor-alpha, -beta in human diabetic nephropathy.

Mesangial expansion is thought to be a major cause of diabetic nephropathy (DN). Platelet-derived growth factor (PDGF) plays an important role in the production of extracellular matrix proteins in renal diseases. The present study was designed to determine the expression of PDGF and PDF receptor (PDGFR) mRNA in the renal tissues of type 2 diabetic patients with DN. We examined open renal biopsies of 20 type 2 diabetic patients with DN, and 10 normal human kidneys (NHK). Histopathologically, the severity of DN was classified as grade I (DN I, n = 10; mild mesangial expansion) or grade II (DN II, n = 10; moderate mesangial expansion). We evaluated the expression and localization of PDGF-A, -B, and PDGFR-Alpha, -Beta using in situ hybridization, and quantified PDGF and PDGFR mRNA expression by counting all nuclei, and nuclei surrounded by PDGF-positive cytoplasm and PDGFR-positive cytoplasm, in at least ten randomly selected cross-sections of nonsclerotic glomeruli. In all glomeruli, PDGF and PDGFR mRNAs were expressed mainly in glomerular resident cells, predominantly glomerular mesangial and epithelial cells. The percentages of cells positive for PDGF-A and PDGFR-Alpha mRNA in DN were similar to those in NHK. In contrast, the percentages of PDGF-B and PDGFR-Beta mRNA-positive cells in DN were significantly higher than those in NHK, and were significantly higher in DN I than in DN II: The percentages of cells positive for PDGF-B correlated with the PDGFR-Beta mRNA level. Our results suggest that the expression of PDGF-B and PDGFR-Beta is an important factor in histologically early glomerular lesions of DN. Mesangial expansion is thought to be a major cause of diabetic nephropathy (DN). Platelet-derived growth factor (PDGF) plays an important role in the production of extracellular matrix proteins in renal diseases. The present study was designed to determine the expression of PDGF and PDGF receptor (PDGFR) mRNA in the renal tissues of type 2 diabetic patients with DN.