Perinephric Fluid Collections Research Articles

Radiologic evaluation of the kidney transplant donor and recipient.

The kidney is the most common solid organ transplant globally and rates continue to climb, driven by the increasing prevalence of end stage renal disease (ESRD). Compounded by advancements in surgical techniques and immunosuppression leading to longer graft survival, radiologists evermore commonly evaluate kidney transplant patients and candidates, underscoring their role along the transplant process. Multiphase computed tomography (CT) with multiplanar and 3D reformatting is the primary method for evaluating renal donor candidates, detailing renal size, vascular/collecting system anatomy, and identifying significant pathologies such as renal vascular diseases and nephrolithiasis. Ultrasound is the preferred initial postoperative imaging modality for graft evaluation due to its low cost, accessibility, noninvasiveness, and lack of radiation. CT and magnetic resonance imaging (MRI) may be useful adjunctive imaging techniques in diagnosing transplant pathology when ultrasound alone is not diagnostic. Kidney transplant complications are categorized by an approximate timeline framework, aiding in differential diagnosis based on onset, duration, and severity and include perinephric fluid collections, graft compression, iatrogenic injuries, vascular compromise, graft rejection, and neoplastic processes. This review discusses imaging strategies and important findings along the transplant timeline, from donor assessment to long-term recipient complications.

IRF4-BLOC1S5, the First Genomic Fusion Gene Identified in the TEMPI Syndrome

The TEMPI syndrome is a rare multi-systemic disease, characterize by telangiectasias, elevated erythropoietin and erythrocytosis, monoclonal gammopathy, perinephric fluid collections, and intrapulmonary shunting (Sykes et al, N Engl J Med 2011). Plasma cell is supposed to play a pathogenic role in the syndrome (Sykes et al, Blood 2020), but the underlying molecular mechanism remains poorly understood. Here, we introduced a novel IRF4-BLOC1S5 fusion gene in the TEMPI syndrome, highly expressed in the monoclonal plasma cell population. We presented one case of the TEMPI syndrome with typical clinical symptoms. The patient received bortezomib and dexamethasone treatment. After 4 cycles of treatment, the patient achieved a satisfied response with a negative MRD. The symptoms were relieved, with the disappearance of the cyanosis, telangiectasias, perinephric-fluid collection, and serum M protein, amelioration of intrapulmonary shunting, normalization of erythrocyte count and erythropoietin level. To explore the possible mechanism of the TEMPI syndrome, we performed whole genome sequencing and transcriptome analysis to identify genomic and transcriptomic abnormalities of our patient. WGS of paired tumor (CD138 + plasma cells) and normal samples revealed a somatic inversion on chromosome 6. Bulk RNA-Seq showed that this inversion caused an out-of-frame fusion transcript IRF4-BLOC1S5, which generated a short N-terminal-truncated IRF4 protein. Western blotting confirmed that the corresponding truncated-IRF4 protein was expressed in the CD138 + plasma cells, but not CD138 - cells of this patient and normal donors, as well as MM samples. We performed single cell RNA-sequencing to identify distinct clusters of this patient and found a strong expansion (11.2-fold) of plasma population companied with high expression of truncated-IRF4 in our patient in the case and this unique expanded plasma cluster expressed one specific immunoglobulin clonotype sharing the same CDR3 sequence. Functional analysis illustrated that differentially expressed genes in plasma cells between this patient and healthy controls were enriched in the KEGG pathways such as ribosome and protein processing in endoplasmic reticulum. Besides, the expression of IRF4-BLOC1S5 was only detected at diagnosis and significantly decreased after the BD treatment and in the clinical follow-up (up to 18 months). IRF4-BLOC1S5 may serve as a molecular marker to surveille the disease progression of this patient. In conclusion, IRF4-BLOC1S5 is the first fusion gene reported in the TEMPI syndrome. IRF4-BLOC1S5 was highly proposed to play an important role in the pathophysiology of the TEMPI syndrome based on the high correlation between IRF4-BLOC1S5 expression level and symptoms of the syndrome. More molecular events responsible for the TEMPI syndrome still await to be identified, albeit a ultrarare occurrence of this disease. An intensive international collaboration is strongly proposed to completely elucidate its molecular mechanisms.

Prevalence of MGCS Among Patients With Monoclonal Gammopathies.

Prevalence of MGCS Among Patients With Monoclonal Gammopathies.

PD12-04 UPDATED EVALUATION OF THE IMPACT OF ANGIOEMBOLIZATION ON THE NEED FOR DIALYSIS FOLLOWING HIGH-GRADE RENAL TRAUMA

You have accessJournal of UrologyCME1 Apr 2023PD12-04 UPDATED EVALUATION OF THE IMPACT OF ANGIOEMBOLIZATION ON THE NEED FOR DIALYSIS FOLLOWING HIGH-GRADE RENAL TRAUMA George Koch, Leah Chisholm, Rohan Bhalla, Abimbola Ayangbesan, Craig Hill, Jennifer Huang, William Walton, and Niels Johnsen George KochGeorge Koch More articles by this author , Leah ChisholmLeah Chisholm More articles by this author , Rohan BhallaRohan Bhalla More articles by this author , Abimbola AyangbesanAbimbola Ayangbesan More articles by this author , Craig HillCraig Hill More articles by this author , Jennifer HuangJennifer Huang More articles by this author , William WaltonWilliam Walton More articles by this author , and Niels JohnsenNiels Johnsen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003259.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: AUA guidelines recommend immediate intervention for hemodynamically unstable renal trauma patients. Selective angioembolization is favored due to potential nephron sparing when compared to surgery, yet the impact on renal function is not well established. We previously reported that angioembolization was associated with renal failure requiring hemodialysis (HD). We now present updated data with additional patients and associated transfusion data. We hypothesized that angioembolization for high-grade renal injuries does not increase the need for HD when corrected for the degree of hemorrhage. METHODS: 742 patients with high-grade renal trauma, defined as American Association for the Surgery of Trauma Grade (AAST) III-V injuries, from 2005 through 2022 were identified from our institutional trauma registry. Univariate and multivariate analyses were performed to identify associations with hypotension on arrival, ASST, age, injury severity score (ISS), presence of bilateral renal injuries, urinary extravasation, perinephric fluid collection, transfusion status and renal embolization with the need for HD. RESULTS: 574 (77.4%) patients had AAST III injuries, 91 (12.3%) had AAST IV and 77 (10.4%) had AAST V. Twenty-one (2.8%) of 742 patients had renal failure requiring HD during their trauma admission. Of those 21 patients, 4 (19.0%) underwent an angioembolization. Variables associated with need for HD were hypotension on admission (p=0.003), concomitant adrenal injury (p<0.001), concomitant pancreatic injury (p=0.047), renal vascular injury (p<0.0001), AAST injury grade (p<0.0001), age (p=0.003), ISS (p<0.0001), units of blood transfused in the first 24 hours (p=0.008) and angioembolization (p<0.001). ISS (OR 1.06, 95% CI 1.03-1.10) and angioembolization (OR 7.77, 95% CI 2.00-25.3) were found to be independently associated with renal failure requiring HD in a multivariate model, while blood transfused during the first 24 hours post-injury was not (OR 1.03, 95% CI 0.98-1.10). CONCLUSIONS: Current practice in high-grade renal trauma favors selective embolization as first-line therapy for renal hemorrhage in unstable patients. Our data suggest that overall injury severity and selective embolization are independently associated with need for HD following high-grade renal trauma. While angioembolization is the current best strategy to preserve renal function, further research is required to understand its impact on renal functional outcomes long-term. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e401 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information George Koch More articles by this author Leah Chisholm More articles by this author Rohan Bhalla More articles by this author Abimbola Ayangbesan More articles by this author Craig Hill More articles by this author Jennifer Huang More articles by this author William Walton More articles by this author Niels Johnsen More articles by this author Expand All Advertisement PDF downloadLoading ...

Early readmissions post kidney transplantation: lessons learned

IntroductionKidney transplantation (KT) is the gold standard treatment for end-stage renal disease (ESRD) patients. Hospital readmissions post-transplant is a common complication and can be considered an indication of avoidable morbidity and hospital quality, and there is a significant correlation between EHR and adverse patient outcomes. This study aimed to assess the readmission rate following kidney transplants, the underlying causes, and possible ways to prevent it. Material and methodsWe retrospectively reviewed the medical records of recipients from January 2016 to December 2021 in a single center. The primary objective of this study is to find the readmission rate for kidney transplants and the variables that contribute to readmission. Post-transplant complications that were resulted in the readmission categorized into surgical complications, graft-related complications, infections, DVT, and other medical complications. ResultsFour hundred seventy-four renal allograft recipients met our inclusion criteria and were included in the study. 248 (52.3%) of the allograft recipients had at least one readmission during the first 90 days after the transplantation. 89 (18.8%) allograft recipients had more than one readmission episode in the first 90 days post-transplant. The perinephric fluid collection was the most common surgical complication (52.4%), and UTI was the most common infection (50%), causing readmission in the first 90 days post-transplant. The readmission odd ratio was significantly higher in patients above 60 years old and in kidneys with KDPI ≥ 85, and in recipients with DGF. ConclusionEarly hospital readmission (EHR) following a kidney transplant is a common complication. Identifying the causes not only helps the transplant centers to take further steps to prevent some incidents and help to improve the patients’ morbidities and mortalities, but also it can reduce the unnecessary costs of readmissions.

Reingreso precoz después del trasplante renal: lecciones aprendidas

IntroductionKidney transplantation (KT) is the gold standard treatment for end-stage renal disease (ESRD) patients. Hospital readmissions post-transplant is a common complication and can be considered an indication of avoidable morbidity and hospital quality, and there is a significant correlation between early hospital readmission (EHR) and adverse patient outcomes. This study aimed to assess the readmission rate following kidney transplants, the underlying causes, and possible ways to prevent it. Material and methodsWe retrospectively reviewed the medical records of recipients from January 2016 to December 2021 in a single center. The primary objective of this study is to find the readmission rate for kidney transplants and the variables that contribute to readmission. Post-transplant complications that were resulted in the readmission categorized into surgical complications, graft-related complications, infections, DVT, and other medical complications. ResultsFour hundred seventy-four renal allograft recipients met our inclusion criteria and were included in the study. 248 (52.3%) of the allograft recipients had at least one readmission during the first 90days after the transplantation. 89 (18.8%) allograft recipients had more than one readmission episode in the first 90days post-transplant. The perinephric fluid collection was the most common surgical complication (52.4%), and UTI was the most common infection (50%), causing readmission in the first 90days post-transplant. The readmission odd ratio was significantly higher in patients above 60years old and in kidneys with KDPI ≥85, and in recipients with DGF. ConclusionEHR following a kidney transplant is a common complication. Identifying the causes not only helps the transplant centers to take further steps to prevent some incidents and help to improve the patients’ morbidities and mortalities, but also it can reduce the unnecessary costs of readmissions.

Renal Transplant Complications—A Pictorial Review

AbstractRenal transplantation is the most effective treatment for end-stage renal disease, with advanced immunosuppressive therapy and better surgical techniques resulting in better survival of the graft. Despite the advances, complications do occur in the postoperative period and timely diagnosis of the complications is vital for prompt management and salvage of the transplant. This pictorial essay aims to classify the complications of renal transplantation, describe the various imaging modalities used to detect complications, and provide a brief overview of the role of interventional radiology in their management. The complications can be broadly divided into perinephric fluid collections, vascular, collecting system, and parenchymal complications. Imaging including ultrasonography, computed tomography, magnetic resonance imaging, and newer methods like elastography, magnetic resonance imaging arterial spin labeling, diffusion-weighted imaging, diffusion kurtosis imaging, blood oxygenation-level dependent, and magnetic resonance elastography can be used in the diagnosis of these complications. Interventional radiology has advanced a lot in managing them; hence, interventional techniques can be the first choice of treatment in institutions where robust interventional radiology setup is available.

Sonography of Renal Transplant-Associated Complications: A Primer

The advent of renal transplantation has significantly improved the quality of life and mortality of patients with end-stage renal disease. Unfortunately, transplant-associated complications (TACs) are common and pose a significant risk to both the allograft and the patient. A major advancement in the care of transplant recipients is the implementation of renal ultrasound, which allows for a more detailed assessment of the renal allograft and facilitates the distinction of different TAC manifestations such as perinephric fluid collections, vascular disease, and parenchymal disease. A better understanding of the clinical and sonographic features of TACs will help guide TAC management and promote better outcomes for renal transplant recipients.

P284 A rare case of post covid bilateral renal mucormycosis

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM ObjectiveThe most commonly reported sites of COVID-associated invasive mucormycosis till now have been rhino-cerebral-orbital followed by pulmonary. This is a rare instance where an apparently healthy male, who had recovered completely from COVID-19, presented with fulminant isolated bilateral renal mucormycosis.MethodA 60-year-old male was presented with low-grade fever and increased CRP. He had a known history of diabetes, hypertension, and ischemic heart disease since 2007. On examination, he was tachypneic and afebrile; blood pressure and oxygen saturation were within normal limits.He was also double vaccinated. Also had a history of moderate COVID (Omicron) in January, 2022. His CT score was 18/25. He got admitted for 10 days because of COVID and was treated with oxygen, antibiotics, remdesivir, and steroids.Later on, patient developed fatigue, anorexia, abdominal discomfort, and pain in lower back. Also vomiting and nausea for 3 months. So patient was treated with tablets Zifi CV for 5 days bd followed by; IV meropenem 1 g tds for 5 days followed/by; tablets faropenem 200 md bd for 3 weeks followed by; tablets nitrilofurantoin 100 mg bd.Ultrasonography remains the first line of investigation and can show the enlarged echogenic kidneys with hypoechoic areas of abscesses, perinephric fluid collections, hydronephrosis, and cystitis. Cortical thickness appeared normal with raised cortical echo. An unenhanced computed tomography (CT) of his abdomen and pelvis was performed and suggested of mild changes of acute bilateral pyelonephritis. CT features include diffuse patchy nephrogram, inhomogeneous enhancement with areas of low attenuation, perinephric fluid collections, and no contrast excretion.Fungal culture sensitivity report was done and Candida albicans organism was isolated and it was found to be all drug-sensitive. Later on, a biopsy of the urethra was performed and a biopsy specimen revealed a fungal ball composed of thin septate and branching thick abroad aseptate hyphae. And also, which resembled morphologically mucor. spp and Aspergillus. A bacterial culture and sensitivity report were suggestive of E.coli.The patient underwent surgical interventions, ie, cystoscopy with B/L RGP with B/L DJ stenting done under SA with a calculated risk of diabetes, hypertension, age, nature of illness, and high creatinine.Patient started treatment with sulbacin 1.5gm injection with 100 ml sodium chloride 0.9% 6 hourly. As patient's creatinine is not stable so Liposomal Amphotericin B was not given. Later on, as creatinine stabilized patient he began receiving liposomal amphotericin B at a beginning dosage of 300 mg with 25% dextrose 250 ml over 5 h. Also, posaconazole started with a loading dose of 600 mg, and then, 300 mg OD was given to patient.ResultPatient gradually recovered and a dose of liposomal amphotericin was completed for 4 weeks.ConclusionIn conclusion, this paper describes that COVID-associated mucormycosis is a known entity, however, Renal Mucormycosis is a rare disease. Especially, bilateral involvement with limited drug penetration into a urogenital system of the agents which are active in mucormycosis. Its management involves, team approach of diabetologists, infectious disease physicians, urologists, radiologists, and microbiologists. Treatment of mucormycosis is challenging as anti-fungal penetration in renal tissue is difficult. High index of suspicion should be there to make the diagnosis. Early detection and aggressive management may have a favorable outcome.

TEMPI Syndrome: Update on Clinical Features, Management, and Pathogenesis.

TEMPI (telangiectasias, elevated erythropoietin level and erythrocytosis, monoclonal gammopathy, perinephric fluid collections, and intrapulmonary shunting) syndrome is a rare and newly defined multisystemic disease, which belongs to “monoclonal gammopathy of clinical significances”. Due to its rarity, the etiology, pathogenesis, and clinical features of this disease remain largely unknown. Owing to its hidden and diverse clinical manifestations, missed diagnosis and misdiagnosis are common. In recent years, as more patients (including three fatal cases) were identified, some special clinical manifestations other than the typical pentad of TEMPI syndrome have been reported. Meanwhile, several studies attempting to identify the pathogenesis of TEMPI syndrome were conducted. In this review, we summarize the reported clinical characteristics of TEMPI syndrome and discuss the current and potential treatment options for patients with TEMPI syndrome, including those with relapsed/refractory disease. Furthermore, we provide an overview of current knowledge on the pathophysiology of TEMPI syndrome.

Safety of Supracostal Percutaneous Nephrolithotomy in Paediatric Population: A Single Centre Experience

Objective&#x0D; The objective of this study is assessment of safety and efficacy of supracostal mini percutaneous nephrolithotomy in pediatric patients.&#x0D; Methodology&#x0D; This is prospective study of patients whose kidney stones were treated with mini percutaneous nephrolithotomy through supracostal approach between February 2019 and Dec 2020.These patients were selected for supracostal puncture based on preoperative ultrasound and CT KUB findings and peroperative assessment of stone burden, stone location and anatomy of pelvicalyceal system.&#x0D; Results&#x0D; Of 80 patients 72(90%) were treated with only one supracostal puncture while additional 2nd puncture was used for 8(10%) patients. Overall stone clearance is 85% only with percutaneous nephrolithotomy and the stone clearance has reached to 95% with ancillary procedures.13% of patient had hydrothorax , 3.75% had urosepsis, 2.75% had bleeding and 1.25 % had perinephric fluid collection.&#x0D; Conclusion&#x0D; This study concludes that the safety and efficacy of supracostal percutaneous nephrolithotomy is same as subcostal pcnl if surgical boundaries are not violated.

Atraumatic Bilateral Renal Subcapsular Urinomas in a Young, Healthy Female

BackgroundUrinomas are rare and generally result from trauma to any part of the urinary collecting system. Appropriate imaging is crucial in the timely diagnosis and management of urinomas and for ruling out other etiologies such as subcapsular renal hematomas and perinephric abscesses. Case ReportA 31-year-old woman with no past medical history or known trauma presented to the Emergency Department (ED) with a week of right flank pain, abdominal pain, and intermittent fevers. On point-of-care ultrasound (POCUS), she was found to have a complex right perinephric collection, later confirmed with computed tomography (CT) imaging. She was treated with intravenous (IV) antibiotics and discharged after a 3-day hospital admission with instructions to follow up with Urology. A day later, she was readmitted with worsening bilateral flank pain and persistent fevers. Image-guided percutaneous aspirations of her bilateral perinephric fluid collections revealed both urine and blood. A right ureteral stent was then placed with ultimate resolution of her symptoms.Why Should an Emergency Physician Be Aware of This? Urinomas without history of trauma are rare and should be on the differential for patients presenting with flank pain and infectious symptoms. Urinomas or other expanding perinephric fluid collections can result in superimposed infection, rupture, secondary hypertension, and renal failure. Here, we present an atypical case of atraumatic bilateral renal subcapsular urinomas with hemorrhagic components in a young and healthy woman. Our case further outlines the utility of POCUS in the ED for the timely diagnosis and management of this disease process.

1305 Ureteral Stenting in Conservative Management of Grade IV Blunt Renal Injury

Abstract Post-traumatic urinomas are well-described complications associated with the nonoperative management of major blunt renal injuries. A 16-year-old male sustained a motor vehicle accident. Brought after 30 minutes to emergency department, upon arrival he was fully conscious, complaining of severe right hypochondrial and loin pain, abdomen was tender and guarded over the right side, urinary catheter inserted revealed gross haematuria, the patient was resuscitated accordingly, fast ultrasound scan showed minimal fluid collection in the Morison's pouch, the right kidney was swollen with perinephric fluid collection and poor cortico-medullary differentiation. Urgent CT scan findings were deep avulsion of the right kidney. The Patient was planned for conservative management, admitted to high dependency ward, CT scan repeated, and the size of urinoma increased compared to the initial CT, so he was planned for retrograde pyelography and ureteric stenting. Intra-operatively the right ureter was canulated, contrast injected. The pelvi-ureteric junction was intact, extravasation of contrast in the upper pole of the kidney. The right ureter was stented using a size 6 multiloop stent, with the tip directed into the upper pole calyx. The Patient showed dramatic improvement, haematuria cleared and the patient was discharged well after 12 days and the stent was removed after 6 weeks. Despite the improvements with nonoperative management, complications are described and include delayed hemorrhage, delayed massive hematuria and renal scaring with loss of function. Ureteric stenting is playing a major part in the conservative management of high-grade renal injury particularly grade IV type.

The Impact of Delayed-Phase Imaging at Admission on the Management of Urinary Extravasation in High-Grade Renal Trauma.

American Urological Association Urotrauma guidelines recommend delayed-phase imaging on presentation for all renal injuries, although data to support it are anecdotal. Forgoing delays risks unrecognized collecting system injuries. We hypothesized that renal trauma patients without admission delays have more complications from urinary extravasation. From 2005 through 2020, 1,751 renal trauma patients were identified from our institutional trauma registry. Included patients had an estimated American Association for the Surgery of Trauma renal injury grade of III-V and a perinephric fluid collection. Propensity scores for receipt of delayed-phase imaging were calculated based on Injury Severity Score, arrival condition, admission systolic blood pressure, sex and renal injury grade. Propensity score-adjusted logistic regression was used to compare clinical outcomes between those with and without admission delays. Ninety (28.6%) of 315 included patients had delays on presentation. Patients without delays had higher Injury Severity Scores (29 vs 23, p=0.002), fewer isolated renal injuries (27.6% vs 38.9%, p=0.05) and lower grade renal injuries (56.9% vs 41.1% grade 3, p=0.03). After propensity score adjustment, patients with delays were more likely to undergo immediate interventions (OR 11.75, 95% CI 2.99-78.10) and interval stent placement for urinary extravasation (OR 6.86, 95% CI 1.56-47.64) without a difference in urological complications (OR 5.07, 95% CI 0.25-766.16). Delayed-phase imaging was associated with an increased odds of undergoing immediate and asymptomatic interval urological interventions without a difference in the odds of a complication after high-grade renal trauma. Post-trauma urinary extravasation requires further research to determine which patients require imaging and intervention.

Whole-genome sequencing suggests a role of MIF in the pathophysiology of TEMPI syndrome

TEMPI syndrome (telangiectasias, elevated erythropoietin level and erythrocytosis, monoclonal gammopathy, perinephric fluid collections, and intrapulmonary shunting) is a newly defined multisystemic disease with its pathophysiology largely unknown. Here, we report the whole-genome sequencing (WGS) analysis on the tumor-normal paired cells from a patient with TEMPI syndrome. WGS revealed somatic nonsynonymous single-nucleotide variants, including SLC7A8, NRP2, and AQP7. Complex structural variants of chromosome 2 were found, particularly within regions where some putative oncogenes reside. Of potential clinical relevance, duplication of 22q11.23 was identified, and the expression of the located gene macrophage migration inhibitory factor (MIF) was significantly upregulated in 3 patients with TEMPI syndrome. Importantly, the level of serum MIF in one patient with TEMPI syndrome was significantly decreased in accordance with the downtrend of plasma cells, M-protein, hemoglobin, and erythropoietin and the improvement of telangiectasias, perinephric fluid collections, and intrapulmonary shunting after treatment with plasma cell-directed therapy. In conclusion, our study provides insights into the genomic landscape and suggests a role of MIF in the pathophysiology of TEMPI syndrome.

Diagnostic Efficacy of Magnetic Resonance Imaging versus Computed Tomography in Characterisation of Renal Infections

Introduction: Urinary Tract Infections (UTI) are one of the most frequently diagnosed infections worldwide, accounting for patient morbidity at any age group. It can affect both the upper and lower urinary tract. Over the past decade, a variety of Magnetic Resonance Imaging (MRI) methods have been developed and applied to many renal diseases. Current advances in MRI techniques have enabled the non-invasive investigation of renal disease. Aim: To evaluate the efficacy of MRI in diagnosing renal infections and compare the diagnostic performance and accuracy of MRI with Contrast Enhanced Computed Tomography (CECT) in characterising renal infections. Materials and Methods: It was a hospital based cross-sectional study, conducted on total 30 patients (age group 20-70 years, 6 males and 24 females) who came to the Department of Radiology of the institute from January 2019 to October 2019, with clinical suspicion of renal infections and showed positive radiological findings in CECT that were suggestive of renal infections. Magnetic Resonance- Kidney Urinary Bladder (MR-KUB) region was performed for all the patients by 128 slice CT scanner and 1.5 Tesla MRI scanners. Special sequences like Diffusion Weighted Imaging (DWI) MRI were employed and images acquired were analysed radiographically and were reviewed to compare their ability to find various UTIs. The collected data were analysed using Statistical Package for Social Sciences (SPSS) version 23.0. Descriptive statistics frequency and percentage and mean±SD was used for analysis of the collected data. Sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated to compare the tools. Results: The current study comprised of 30 patients with male to female ratio 1:4 and 46.66% patients from 41-50 years age group. MRI along with DWI showed sensitivity of 88.46% in detecting intrinsic parenchymal signal changes, and sensitivity of 100% in detecting abscess formation, intra/extra parenchymal, perinephric fluid collections, micro-abscesses, large foci of air and obstructive calculi, whereas it was less sensitive in detecting non-obstructive calculi and tiny air foci. Non-Contrast CT (NCCT) was able to diagnose renal infection in 12 out of 30 patients with sensitivity of 40%. Conventional MRI diagnosed renal infection in 21 of these 30 patients with sensitivity of 70%, DWI was able to show the changes in 27 patients with sensitivity of 90% in comparison to the cases prediagnosed with CECT. Conclusion: MRI has higher sensitivity than non-contrast enhanced CT for detection of renal infections. DW MRI is equally sensitive in detecting renal infections, compared to contrast enhanced CT, and is more sensitive compared to conventional MR imaging. DWI can also be used to differentiate pyonephrosis from hydronephrosis and in early detection of micro-abscesses.

TEMPI syndrome in a 57-year-old man: a case report

Background: The “TEMPI” syndrome consists of five distinct clinical features: telangiectasias (T), erythrocytosis with elevated erythropoietin (EPO) levels (E), monoclonal gammopathy (M), peri-nephric fluid collections (P), and intrapulmonary shunting (I). The etiology, pathogenesis, and prevalence of this ultrarare syndrome is still being elucidated. Case Presentation: A 57-year old man was being investigated for secondary erythrocytosis. On examination he had telangiectasias over his trunk. His workup revealed high serum EPO levels, a monoclonal paraprotein band on serum protein electrophoresis and Immunofixation, peri nephric fluid on CT abdomen, and evidence of intrapulmonary shunting on arterial blood gas and an echocardiogram with bubble study. He fulfilled the diagnostic criteria for TEMPI syndrome. For reasons of worsening dyspnea, he initiated treatment and received two cycles of bortezomib, cyclophosphamide, and dexamethasone chemotherapy. Treatment was discontinued as he developed steroid induced myopathy. Planning is underway for the patient to receive daratumumab monotherapy. Conclusion: Uptil now, 23 cases have been reported in the literature from different countries across the globe. Plasma cell directed therapies including bortezomib-based regimens, daratumumab monotherapy, lenalidomide, and autologous hematopoietic stem cell transplantation in few patients have resulted in dramatic clinical responses. Thoroughly investigating patients who present with secondary erythrocytosis along with other relevant findings can help us identify more patients with TEMPI syndrome. Case reports of this ultrarare disorder from across the globe can help us in better understanding and treatment of this disease.

The First Case of TEMPI Syndrome in Japan

TEMPI syndrome, a disease entity comprising telangiectasia, erythrocytosis with high erythropoietin, monoclonal gammopathy, perinephric fluid collection, and intrapulmonary shunting, was first described by Sykes et al. in 2011. To our knowledge, only 15 cases have been reported worldwide, none of which were in Japan. We herein report a 47-year-old man who had intractable ascites for 2 and a half years and was referred to our department for a peritoneovenous shunt. In addition to ascites, he had telangiectasia, high erythropoietin, monoclonal gammopathy, and perinephric fluid collection. Thus, this is the first case of TEMPI syndrome in Japan.

Long-Term Follow-Up of Laparoendoscopic Single-Site Partial Nephrectomy for Nonfunctioning Moieties of Renal Duplication and Fusion Anomalies in Infants and Children.

Objectives: To report on long-term follow-up and outcomes of infants and small children who have undergone laparoendoscopic single-site (LESS) partial nephrectomy to manage upper urinary tract duplication and fusion anomalies. Materials and Methods: A retrospective review was performed evaluating outcomes of pediatric patients who underwent LESS partial nephrectomy for upper urinary tract duplication and fusion anomalies from January 2012 to July 2015, by a single surgeon at a tertiary pediatric referral center. Demographic and perioperative data were reviewed as well as follow-up imaging. Descriptive statistics were used for analysis. Results: A total of 18 patients were identified. Additional access was used for two patients to complete the procedure. Median follow-up was 39 months. No short-term complications were encountered. Three patients were noted to have abnormal postoperative ultrasounds: two perinephric fluid collections and one atrophy of the remaining ipsilateral moiety. One fluid collection resolved completely, and the other decreased in size. Complete atrophy of the ipsilateral moiety occurred. No secondary procedures were required. Conclusions: LESS partial nephrectomy is safe for renal duplication and fusion anomalies with good long-term outcomes. Although it can be safely performed, it is a technically demanding procedure and has been discontinued in favor of robotic partial nephrectomy.

Ureaplasma urealyticum disseminated multifocal abscesses in an immunocompromised adult patient: a case report

BackgroundUreaplasma urealyticum is a fastidious bacteria which lacks a cell wall. Extragenital infections are rare in immunocompetent adults. There are few literature reports of perinephric abscess. We present a case of non-resolving multifocal “culture-negative” abscesses in a hypogammaglobulinemic adult female due to U. urealyticum.Case presentation66-year-old female with a one-week history of fever, malaise and new right hip and leg pain. Past medical history was notable for chronic pancytopenia secondary to in remission B cell follicular lymphoma, ESRD on intermittent hemodialysis with bilateral nephrostomy tubes and Crohn’s. CT abdomen/pelvis revealed a small left perinephric hematoma and proximal right femur fluid collection. Persistent right thigh pain led to additional ultrasound with anterior thigh collection and CT revealed an irregular rim-enhancing fluid collection in the left posterior pararenal space. Antimicrobial therapy included ertapenem and vancomycin followed by meropenem, trimethoprim-sulfamethoxazole, daptomycin and metronidazole in setting of persistent culture-negative results and clinical deterioration. Following detection of U. urealyticum by 16S rDNA PCR in both left pararenal and right trochanteric bursa abscesses doxycycline was started. Despite this, the patient died four days later.ConclusionsDisseminated infection by U. urealyticum has been documented in immunocompromised adult patients with few reports of perinephric abscess. We propose that ascending genitourinary route led to perinephric abscess. The multiple disseminated fluid collections make it highly suspicious for hematogenous spread given the lack of radiographic enhancement to suggest contiguous spread. Diagnosis and treatment of U. urealyticum-disseminated infection is extremely challenging as culture is laborious and not routinely performed. Furthermore, the lack of cell wall renders beta-lactams and vancomycin ineffective and therefore requirement for “atypical” coverage. Early diagnosis and treatment are key to prevent further complications and death.