Transplantation of a unilateral fused kidney with inferior ectopia: revascularization utilizing donor aorta and vena cava

We present a case of kidney transplantation utilizing a fused kidney with inferior ectopia. The kidney had three arteries, five veins and two ureters and was procured en bloc with the donor vena cava and aorta. The caudal end of the donor vena cava was anastomosed to the recipient's external iliac vein. The right common iliac artery of the donor, in continuity with the donor aorta, was anastomosed to the recipient's external iliac artery. The two ureters were implanted separately. The patientwas discharged home with a serum creatinine of 0.9 mg/dl. Through innovative techniques, kidneys that may not have been transplantable in the past can now be used with excellent results. This is the first known report of transplantation using a unilateral fused kidney with inferior ectopia.

Creatinine clearance and blood pressure: a 34-year circadian study

BACKGROUND AND OBJECTIVE

The first circadian study of the 361st Medical Laboratory, USAR, was conducted in May 1969 during the Annual Military Training at Brook Army Hospital, Fort Sam Houston, Texas. The study was approved by the Surgeon General, 5th US Army, and was designed to establish a circadian database for 63 medically relevant variables of 13 young members of the Unit. The subsequent studies, all in the month of May, in 1979, 1988, 1993,1998, and 2003, followed the same protocol and were conducted at Edward Hines Jr., Veterans Administration Hospital, after approval by Human Studies Subcommittees. Since a reduction in Creatinine Clearance (CrCl) to the level of 60 ml/min/1.73m2 signals the onset of kidney malfunction and since a concurrent increase in blood pressure (BP) >140/90 mm Hg, contributes greatly to an unfavorable cardiovascular prognosis, it seemed prudent to examine possible changes in these and in other relevant variables in a group of young Army men, which may have developed over a 34 year period of time.

MATERIAL AND METHODS

Thirteen US Army male volunteers (23-27y of age) served as subjects in the 1969 study. A majority of these men, two additional Army men and two non-military subjects, participated in subsequent studies: 1979 (7,2,1), 1988 (8,2,1), 1993 (5,4,1), 1998 (7,2,2), 2003 (7,2,1). In each study, subjects were admitted to a hospital ward, were given medical examination including a 12-lead electrocardiogram and followed the same Protocol. Lights "OUT" at 22:30h and "ON" at 06:30h. The meals, hospital 2400-calorie diets, were served at 17:30, 07:30 and at 13:30h. Vital signs were measured immediately after each 3h urine collections, around the clock, and bloods were collected every 3h. Blood, plasma, serum, saliva and urines were analyzed for numerous analytes including creatinine, using automated laboratory systems. Kidney functions were assessed using the measured and estimated glomerular filtration rates.

RESULTS

Over the 34y study span, 16 men provided sixty-one 24h profiles for CrCl-related variables (urine volume, creatinine, and serum creatinine) and fifty-eight profiles for BP. Using all normalized data, a significant circadian rhythm was found for each of these variables. Significant circadian variations in SBP, DBP, serum and urine creatinine, and urine volume, were evident with peak levels, on average, occurring in the evening hours.

CONCLUSIONS

In healthy subjects, age was associated with an increase in SBP and urine volume and with a decrease in urine creatinine. In diabetic subjects, aging was associated with increases in both blood pressure and Creatinine Clearance. It is interesting to note that for the 3 subjects who at a later date developed diabetes, the CrCl levels were higher than the 5 age-matched controls during each study year, over the entire 34y observation span, including the period prior to diagnosis. Clin Ter 2008; 159(6):409-417.

Cystinuria: a rare diagnosis that should not be missed

Cystinuria is a rare autosomal recessive defect causing recurrent urinary tract stone formation. Morbidity from stone formation and repeated urological interventions can be reduced by early diagnosis and adequate medical treatment. In this review, we illustrate these points by discussing three patients with cystinuria and give a brief review of its management.

Urine cortisol and cortisone and water intake in athletes

AIM

The aim of this study was to investigate the urine cortisol (F) and cortisone (E) relation, having a well-defined water intake.

METHODS

Urine specimens were collected from 10 male trained cyclists (19+/-1 year, 70+/-4 kg, 179+/-4 cm), at rest just before the test (pre-exe) and until 45 min after the cycle ergometer exercise test (45 min at 50-60% VO2max) (post-exe) in the morning. This investigation measured the diuresis in the pre-exe and post-exe after each athlete had drunk 1 L of water from waking-up, after bladder emptying, to the start of the test (pre-exe) and 1 L during the 45 min after the exercise (post-exe).

RESULTS

Urinary F and E concentrations demonstrated a significant decrease comparing pre-exe with post-exe (177+/-134 vs 64+/-21 and 706+/-475 vs 372+/-178 nmol.L(-1) respectively, p < 0.05). This significant decrease was verified when diuresis and urinary creatinine were taken into account and the ratio measured.

CONCLUSION

One litre of water intake after exercise seemed to have no effect on urine F and E excretion. Moreover the urine F/E ratio was not statistically different comparing pre-exe with post-exe.

[Usefulness of human atrial natriuretic peptide in neurosurgical perioperative management]

PURPOSE

Intensive hypotension is an important technique in neurosurgical perioperative management. However, it could decrease urine volume, and induce fluid retention resulting in cardiac failure. We evaluated the efficacy of human atrial natriuretic peptide (hANP) on diuresis in a hypotensive condition.

METHODS

In 245 patients undergoing neurosurgical operations under general anesthesia in our hospital, 26 patients demonstrated a urine volume less than 50 ml/h at 1 hour after the skin incision, despite receiving a large volume of intravenous fluid. In these 26 patients, we administered hANP (0.05 microg/kg/min) continuously, and evaluated the effect of hANP on diuresis in a hypotensive condition.

RESULTS

After the administration of hANP, the urine volume increased significantly (p<0.01) from 28.7 to 229.4 (ml/h, mean). The heart rate increased from 66.6 to 71.7 (bpm, mean), whereas the systolic blood pressure decreased from 110.3 to 102.2 (mmHg, mean). The electrocardiogram did not change during the administration of hANP.

CONCLUSIONS

Despite the hypotensive condition, hANP showed a strong diuretic effect in our study. In neurosurgical perioperative management, administration of hANP can be a useful tool for a fluid balance in the patient.

Vasopressin-like peptide and its receptor function in an indirect diuretic signaling pathway in the red flour beetle

The insect arginine vasopressin-like (AVPL) peptide is of special interest because of its potential function in the regulation of diuresis. Genome sequences of the red flour beetle Tribolium castaneum yielded the genes encoding AVPL and AVPL receptor, whereas the homologous sequences are absent in the genomes of the fruitfly, malaria mosquito, silkworm, and honeybee, although a recent genome sequence of the jewel wasp revealed an AVPL sequence. The Tribolium receptor for the AVPL, the first such receptor identified in any insect, was expressed in a reporter system, and showed a strong response (EC(50)=1.5 nM) to AVPL F1, the monomeric form having an intramolecular disulfide bond. In addition to identifying the AVPL receptor, we have demonstrated that it has in vivo diuretic activity, but that it has no direct effect on Malpighian tubules. However, when the central nervous system plus corpora cardiaca and corpora allata are incubated along with the peptide and Malpighian tubules, the latter are stimulated by the AVPL peptide, suggesting it acts indirectly. Summing up all the results from this study, we conclude that AVPL functions as a monomer in Tribolium, indirectly stimulating the Malpighian tubules through the central nervous system including the endocrine organs corpora cardiaca and corpora allata. RNA interference in the late larval stages successfully suppressed mRNA levels of avpl and avpl receptor, but with no mortality or abnormal phenotype, implying that the AVPL signaling pathway may have been near-dispensable in the early lineage of holometabolous insects.

[Burning mouth syndrome]

Burning mouth syndrome is characterized by a painful burning or stinging sensation affecting the tongue or other areas of the mouth without obvious signs of an organic cause on physical examination. A burning mouth sensation can occur in several cutaneous or systemic diseases that must be ruled out prior to making a diagnosis of burning mouth syndrome, since this term is used exclusively to refer to idiopathic forms and is included within the cutaneous sensory disorders. In most cases, patients with burning mouth syndrome have accompanying psychologic or psychiatric conditions. Consequently, the syndrome has traditionally been included among the psychogenic dermatoses. However, it is currently unclear whether psychologic factors are a cause or a consequence of the syndrome, or whether each exacerbates the other. Recent studies propose the etiology to be neurologic, either neuropathic or related to taste.

Minimally invasive versus traditional chest surgical approach in patients with reduced renal function

AIM

All surgical access approaches to the chest wall cause a different degree of muscle damage and freeing of substances as myogloblin into the bloodstream thus compromising kidney function. The aim of this study was to evaluate the potential kidney damage in relation to entity of muscle lesions caused by the different surgical approaches.

METHODS

The hematic levels of creatine phosphokinase (CPK), myoglobin, lactate dehydrogenase (LDH), creatinine as well as the amount of the diuresis at different intervals of time were taken of 66 patients who underwent a thoracic surgical operation with diverse surgical access approaches.

RESULTS

Surgery determines muscle substances to be freed into the bloodstream. Myoglo-blin levels resulted to be correlated to those of CPK (r=0.83; P<0.00005). Although serum levels of myogloblin are not determined as a routine procedure, high levels of CPK must induce to dose myogloblin. The amount of muscle substances freed depend on the width of the surgical access (r=0.7; P<0.00005) and not upon extension (r=0.36; P=0.18) or duration of surgery. (r=0.4; P=0.093).

CONCLUSION

In patients with a reduced renal function or affected by kidney failure a minimally invasive or thoracoscopic approach is indicated whenever possible in order to reduce the amount of myogloblin in the bloodstream.

Kidney function in the Spinifex hopping mouse, Notomys alexis

Notomys alexis (Spinifex hopping mouse) is found in the arid zone of Australia. The structure and function of the kidneys allow this species to conserve water. This study investigated the rate at which N. alexis can reduce urine volume and increase the concentration of electrolytes and solutes when water deprived. It also looked at the response to rehydration, following a period of water deprivation. The laboratory mouse, Mus musculus domesticus, was used for comparison. N. alexis is able to reduce urine volume and increase urine concentration more rapidly than M. m. domesticus when water deprived. This appears to occur prior to any measurable changes in plasma electrolyte concentrations and is not due to reductions in glomerular filtration rate. Gradual water deprivation over a period of 10 days allowed N. alexis to adjust so that urine composition was similar in many ways to animals that had ad libitum access to water, whereas M. m. domesticus required significant water supplementation to maintain body weight at 85% of initial body weight. Ability to concentrate urine rapidly is characteristic of a well-insulated renal medulla [Bankir, L., DeRouffignac, C., 1985. Urinary concentrating ability: insights from comparative anatomy. Am. J. Physiol. 249, R643-666]. However, a well-insulated medulla is normally associated with slow dilution of urine when animals are rehydrated. N. alexis was able to produce dilute urine very rapidly following rehydration of water deprived animals. Physiological control of renal function appears to be complex. Although M. m. domesticus is able to produce concentrated urine, it is unable to survive without free water and responds more slowly to water deprivation.

Lithium concentration and clinical responses

The clinical use of measurements of drug concentrations in blood is empirical and largely confined to compliance and toxicity monitoring. As currently used in once or thrice a day dosage, lithium treatment is pulsatile, the blood concentration varying threefold over 24 hours; routine measurements reveal nothing of this and therefore do not aid therapeutic use. In a pilot study it is shown that the plasma lithium concentration can be raised from 0 to 2 mmol/l in a few hours, inducing changes in both kidney function and neuropsychological tests after only short delay. This suggests that mania might be quickly controlled with rapid dosage and opens up a new way of analysing the mechanisms of lithium action, or of using it to reveal changes in cerebral functioning.

[Prognostic value of the ultrasound and diuretic renogram in the evolution of ureteropelvic junction obstruction]

INTRODUCTION

The congenital obstruction of the pieloureteral junction (UPJ) is the most frequent cause of hydronephrosis in children. Sometimes, establishing the convenience of a surgical procedure is difficult, mainly if we consider the literature published on the spontaneous resolution of the slight, moderate and even severe hydronephrosis in newborns.

OBJECTIVE

To determine the prognostic value of ultrasound in the evolution of the unilateral hydronephrosis, by assesing the size of the contralateral kidney. To verify if the "supranormal" renal function (SRF) is real or an artefact.

PATIENTS AND METHODS

We have performed a descriptive observational study over a 10 years period (1995-2005). The study included all patients with the only diagnosis of obstructive unilateral hydronephrosis that underwent pieloplasty, and were controlled for 1 year period after the surgical treatment.

RESULTS

Of the 66 patients in the study, 42 were boys (63.6%) and 24 girls (36.4%). After the first diuretic renogram (DR), in 57 of the patients (86.4%) the clearance half-time (T1/2) was over 20 minutes, in 6 cases (9.1%) it was 10-20 minutes and only in 3 cases it was shorter than 10 minutes. A similar differential renal function (FRD) was observed in the moderate and severe hydronephrosis. Supranormal function (FRD > 52%) was detected on DR in 11 patients, predominating in left hidronefrosis, and in more than 50% of the cases this value it did not agree with the renal function measured by dimercapto-succinic acid (DMSA), Pearson's correlation coefficient: 0.19. These kidneys experienced a greater reduction of the postoperative renal function.

CONCLUSIONS

In the unilateral obstructive hydronephrosis, the healthy contralateral kidney experiences hypertrophy detectable by ultrasound, but these ecographic diameters are within the band of individual confidence of the healthy children of reference. The supranormal function exists, but in most cases it is an artefact.

Nursing management of patients who are nil by mouth

This article examines how to manage patients who are nil by mouth (NBM) and maintain optimal nutritional status. Pre-operative fasting and other reasons why patients might be NBM, methods of administering nutritional support and nursing considerations, such as mouth care, urine output, intravenous therapy and skin assessment are also discussed. The article provides an insight into the psychological effects on patients who are NBM and emphasises the importance of patient education.

P-glycoprotein-deficient mice have proximal tubule dysfunction but are protected against ischemic renal injury

The multidrug resistance gene 1 product, P-glycoprotein (P-gp), is expressed in several excretory organs, including the apical membrane of proximal tubules. After inducing acute renal failure, P-gp expression is upregulated and this might be a protective function by pumping out toxicants and harmful products of oxidative stress. We characterized renal function of P-gp knockout mice and studied its consequences in renal ischemic damage. Compared with wild-type mice, knockout mice have a lower glomerular filtration rate and renal plasma flow. An augmented urinary excretion of sodium, numerous amino acids, calcium, glucose, and low molecular weight proteins was observed along with an increased diuresis. A higher lithium plasma clearance in the knockout mice suggested proximal tubular dysfunction. Electron microscopy showed mitochondrial abnormalities in proximal tubular cells that could account for decreased adenosine triphosphate levels in the cortex. After inducing ischemia, wild-type mice showed a decrease in creatinine clearance and severe proximal tubular necrosis. In contrast, knockout mice had no signs of tubular damage. Our data indicate that P-gp knockout mice have impaired renal function but are protected against ischemic renal injury.

The finding of vascular and urinary anomalies in the harvested kidney for transplantation

INTRODUCTION

In kidney transplantation, anatomical vascular and excretory anomalies may represent causes of failure. Today's surgical techniques have made the most of the organs with anatomic anomalies and iatrogenic injury successfully used for transplantation.

MATERIALS AND METHODS

From January 2000 to June 2006, we harvested 230 kidneys, of including 88 kidneys (20%) with vascular, urinary, or vascular-urinary anomalies; 64 kidneys were implanted and 15 were sent to other transplantation centers. Only 9 kidneys were not appropriate for transplantation.

RESULTS

All patients who received kidneys with the above-mentioned anomalies were carefully examined after the transplantation and short-term and long-term complications were evaluated with respect to controls without anomalies.

DISCUSSION

Renal anatomic anomalies are frequently observed during kidney transplantation and may produce postsurgical complications. However, the presence of these anomalies does not necessarily imply the impossibility of using the kidney for a transplant, especially because of improved surgical techniques. Our experience in transplantation procedures showed that even if kidneys present the above-mentioned anomalies they can still be considered appropriate for transplantation when we perform a correct harvesting/back-table transplant surgery. So vascular and urinary anomalies have to be considered always an incentive to research new surgical solutions and to perform a careful surgical technique.

[Cerebral salt wasting syndrome: experimental study in rats]

INTRODUCTION

The cerebral salt wasting syndrome (CSWS) is characterized by hyponatraemia secondary to excessive natriuesis with osmotic duiresis. This syndrome, frequently, occurs after subarachnoid haemorrhage (SAH), but may occur after any acute cerebral aggression.

OBJECTIVES

The aim of the study was to assess the frequency of the CSWS in animal models with, SAH, cerebral ischemia (CI), and cranial trauma (CT), and its correlation with the secretion of brain natriuretic peptide (BNP).

METHOD

Four groups of rats were selected: group SAH (n=7) consisted of SAH induced by perforation of the carotid artery in its intracerebral part; group CI (n=7) consisted of CI induced by ligature of the carotid artery; group CT (n=7) consisted of induced CT; and a control group Sham (n=7). Weight, serum sodium, BNP, and urinary sodium, were measured at baseline and 24 hours after.

RESULTS

Rats with SAH had significant natriuresis and diuresis with negative sodium balance (-95.9+/-447.4 mumol) with a significant difference (P<0.05) compared to the rats of the CI and the Sham groups. There was no difference in the 24 hours level of BNP between the four different groups.

CONCLUSION

We conclude that SAH, in animal models, induced high diuresis with negative sodium balance in the first 24 hours. These findings were absents in the others groups. This was independent of the BNP secretion and may correspond to the early occurrence of a CSWS.

LIGHT--a new member of the TNF superfamily in the plasma, dialysate and urine of uremic patients; the impact of residual diuresis and presence of viral hepatitis

OBJECTIVES

LIGHT is a cytokine involved in atherosclerosis and cardiovascular disease in general population.

DESIGN AND METHODS

We determined the levels of LIGHT in the plasma, dialysate and urine of uremic patients undergoing hemodialysis (HD) and healthy controls.

RESULTS

There were no significant differences in the pre and post-HD plasma levels of LIGHT between HD patients with residual diuresis (HD-RD) and HD anuric group (HD-A) compared to controls. HD-RD patients had the lower LIGHT values in dialysate compared to HD-A patients (p<0.001), and higher urinary LIGHT excretion compared to controls (p<0.05). Moreover, the presence of RD and chronic viral hepatitis were independent factors influencing the levels of this cytokine in dialysate.

CONCLUSIONS

The plasma levels of LIGHT seem to be similar in HD patients and healthy subjects and were not affected by gender, age, the mean period of HD history, disease etiology, type of medication and type of using dialysis membrane.

Pediatric acute kidney injury: the use of the RIFLE criteria

Outcome in pediatric acute kidney injury (AKI) is in part related to diagnosis and intervention. Standard markers of severity of illness do not identify AKI. Modified RIFLE criteria are shown to identify patients who develop AKI, potentially allowing for early intervention.

Renal expression of parvalbumin is critical for NaCl handling and response to diuretics

The distal convoluted tubule (DCT) plays an essential role in the reabsorption of NaCl by the kidney, a process that can be inhibited by thiazide diuretics. Parvalbumin (PV), a Ca(2+)-binding protein that plays a role in muscle fibers and neurons, is selectively expressed in the DCT, where its role remains unknown. We therefore investigated the renal phenotype of PV knockout mice (Pvalb(-/-)) vs. wild-type (Pvalb(+/+)) littermates. PV colocalized with the thiazide-sensitive Na(+)-Cl(-) cotransporter (NCC) in the early DCT. The Pvalb(-/-) mice showed increased diuresis and kaliuresis at baseline with higher aldosterone levels and lower lithium clearance. Acute furosemide administration increased diuresis and natriuresis/kaliuresis, but, surprisingly, did not increase calciuria in Pvalb(-/-) mice. NaCl supplementation of Pvalb(-/-) mice increased calciuria at baseline and after furosemide. The Pvalb(-/-) mice showed no significant diuretic response to hydrochlorothiazide, but an accentuated hypocalciuria. A decreased expression of NCC was detected in the early DCT of Pvalb(-/-) kidneys in the absence of ultrastructural and apoptotic changes. The PV-deficient mice had a positive Ca(2+) balance and increased bone mineral density. Studies in mouse DCT cells showed that endogenous NCC expression is Ca(2+)-dependent and can be modulated by the levels of PV expression. These results suggest that PV regulates the expression of NCC by modulating intracellular Ca(2+) signaling in response to ATP in DCT cells. They also provide insights into the Ca(2+)-sparing action of thiazides and the pathophysiology of distal tubulopathies.

[Massive intestinal resection. Nutritional adaptation process]

INTRODUCTION

Massive small bowel resection (MSBR) with a remnant jejunum shorter than 60 cm produces severe water, electrolytes, vitamins and protein-caloric depletion. While waiting for a viable intestinal transplantation, most of MSBR patients depend on total parenteral nutrition (TPN).

CLINICAL CASE

32 years old male, with MSBR due to sectioning trauma of the superior mesenteric artery root. First surgical intervention: jejunostomy with small bowel, right colon, and spleen resection. Six months later: jejunocolic anastomosis with 12-cm long jejunum remnant and prophylactic cholecystectomy.

NUTRITIONAL INTERVENTION

1st phase. Hemodynamic stabilization and enteral stimulation (6 months): TPN + enteral nutrition with elemental formula + oral glucohydroelectrolitic solution (OGHS) + 15 g/d of oral glutamine + omeprazol. Clinical course indicators: biochemistry, I/L balance. 2a phase. Digestive adaptation with colonic integration (8 months): replacement of TPN by part-time peripheral PN. Progressive cooked diet complemented with pancreatic poly-enzyme preparation, omeprazol, OGHS, glutamine, elemental formula. Clinical course indicators: biochemistry, diuresis, weight and feces. 3a phase. Auto-sufficiency without parenteral dependence: fragmented free oral diet supplemented with pancreatic poly-enzyme preparation, mineralized beverages, enteral formula supplement, Ca and Mg oral supplements, oral multivitamin and mineral preparation, monthly IM vitamin B12. Current situation actual (52 months): slight ponderal gain, diuresis > liter/day, 2-3 normal feces, no clinical signs of any deficiency and normal blood levels of micronutrients.

CONCLUSION

It may be possible to withdraw from PN in MSBR considering, as in this case, favorable age and etiology and early implementation of an appropriate protocol of remnant adaptation.

Mushroom poisoning

OBJECTIVE

We aimed to review characteristics of mushrooms and mushroom poisoning and compare clinical picture, laboratory data, treatment modalities and prognostic factors in children with amanita intoxication and non-amanita mushroom poisoning.

METHODS

We analyzed 39 pediatric patients through 1994-2004, retrospectively from the patient files and evaluated the patients in two groups as patients with amanita intoxication and patients with non-amanita mushroom poisoning. All of the cases were admitted to the hospital in autumn. Twenty three (59%) of the patients were female and 16 (41%) were male. Mean age of the patients was 8.05 +/- 2.10 years.

RESULTS

Amanita phalloides toxin was detected in the serum in 8 patients. Eleven (28%) of the cases were strongly suggestive of amanita poisoning but alpha amanitin level could not be studied. The average time of appearance of symptoms after mushroom consumption, duration of symptoms, hospital stay, serum AST, ALT, PT and creatinine levels were significantly higher in patients with amanita poisoning (p<0.01). Conventional therapy, antidote therapy together with hemoperfusion were carried out in 16 (41%) of the patients. Four of the patients in whose blood amatoxin was detected (50%) and 3 of the patients highly suggestive of amanita poisoning (30%), totally 7 patients died of hepatic coma. The average time of admission to hospital, mean AST, ALT, creatinine and PT values at 3rd day were significantly higher in patients who died of hepatic coma. Prognosis was better in case of early admittance to hospital in patients with amanita poisoning.

CONCLUSION

Early diagnosis and treatment in mushroom poisoning can be life saving. Public awareness is very important in prevention of intoxication as well as encouraging early admission to hospitals.

Successful Treatment of a Case of Severe Electrical Burns With Heart and Lung Injuries

A patient sustained high-voltage electrical burns with third-degree burns over 35.5% of his body surface, which included a large direct wound on the left chest wall, exposing the heart. The heart and lungs were severely injured. Subsequently, hydrothorax, hydropericardium, and respiratory failure developed. He was successfully treated with fluid resuscitation, antibiotics, drainage of the pericardium and pleural cavities, early removal of necrotic tissue, skin grafting, and reconstruction of the chest wall with a 13 x 27-cm delay-flap, as well as a number of supportive measures. The patient gradually recovered and was discharged in 6 months.

[Therapy with vasopressin receptor antagonists: the aquaretics]

Aquaretic drugs, by definition, can induce an increase in urinary volume and urinary free water associated with a decreased urinary osmolarity with a consequent increase in plasma sodium. This enhanced diuresis is not accompanied by an increased loss of electrolytes, whereas traditional diuretics have the opposite, so-called saluretic effect. Aquaretics belong to a family of vasopressin receptor antagonists, V2 in particular, that regulate tubular water reabsorption. Several studies have confirmed their utility in the treatment of hyponatremic states associated with water retention such as heart failure, cirrhosis related ascites and SIADH. Furthermore, new applications may include the treatment of arterial hypertension, polycystic kidney disease, glaucoma and Meniere's syndrome.

Serum levels of beta-trace protein and its association to diuresis in haemodialysis patients

BACKGROUND

Beta-trace protein (BTP) has been proposed as an alternative endogenous marker of the glomerular filtration rate. However, possible determinants of BTP in ESRD patients undergoing regular renal replacement therapy have not been evaluated.

METHODS

Serum levels of BTP, beta-2-microglobulin, creatinine and urea were analysed before and after dialysis treatment in 73 patients [haemodialysis (HD) n=52; haemodiafiltration (HDF) n=21]. Patients were categorized into four groups with residual diuresis (RD)<0.5 l/day (group 1; n=24), 0.5-1 l/day (group 2; n=18), 1.1-1.5 l/day (group 3; n=12) and >1.5 l/day (group 4; n=19). Subsequently RD was compared to pre-treatment levels of BTP.

RESULTS

HD treatment did not affect BTP serum levels [pre-treatment 8.1+/-4.1 mg/l (mean+SD) vs post-treatment 7.7+/-4.1 mg/l; -0.6 +/- 16.1%; ns]. However, in 6 out of 21 patients undergoing HDF BTP levels were reduced by more than 20%. Overall, the resulting decrease in serum concentration was minuscule (9.6+/-6.2 vs 8.3+/-4.9 mg/l; -14+/-21.9%; P=0.03). BTP serum levels were tightly associated to RD of the four groups. Comparison of BTP levels showed significant differences between patients of groups 1 vs 3 and 4 as well as 2 vs 4.

CONCLUSIONS

BTP serum levels may serve as a surrogate marker for residual renal function since HD and HDF do not exert clinical relevant alterations on them. Furthermore, BTP serum concentrations appear strongly associated to RD.

Haemodynamic monitoring in acute heart failure

Acute Heart Failure is a major cause of hospitalisation, with a rate of death and complications. New guidelines have been developed in order to diagnose and treat this disease. Despite these efforts pathophysiology and treatments options are still limited. There is agreement among the experts that increasing the cardiac output and the stroke volume without fluid overloading the patient should be the goal of every treatment. Despite this, there is no agreement on how to monitor the cardiac function and how to follow it after a therapeutic intervention. In other fields of critical care cardiovascular monitoring and application of early goal directed protocols showed benefits. This review explores the available possibilities of how to monitor the cardiac function in Acute Heart Failure. Standard and more advanced techniques are presented. Cardiac output monitors from the pulmonary artery catheter to the pulse pressure analysis and Doppler techniques are discussed, with focus on this specific clinical setting. Undoubtedly monitoring is valuable tool, but without a protocol of how to manipulate the haemodynamics, no monitor will prove alone to be beneficial. Haemodynamic driven early goal directed therapy are largely awaited in this field of medicine.

Mineralocorticoid escape by the kidney but not the heart in experimental asymptomatic left ventricular dysfunction

Unlike healthy subjects, overt congestive heart failure cannot "escape" the sodium- and water-retaining actions of mineralocorticoid excess. It is undefined whether escape occurs in asymptomatic left ventricular dysfunction (ALVD), which is characterized by preserved sodium homeostasis, natriuretic peptide activation, and normal circulating aldosterone. We hypothesized that, in ALVD, mineralocorticoid excess with exogenous deoxycorticosterone acetate (DOCA) would overwhelm renal compensatory mechanisms, resulting in sodium and water retention, and promote renal and cardiac collagen deposition. ALVD was induced in 2 groups (N=5 each) of dogs by tachypacing at 180 bpm. Urine was collected daily and blood drawn at baseline and days 2, 5, 8, and 11. One group served as control (ALVD), and the other received DOCA (ALVD+DOCA) starting at day 2 of pacing. Urine flow and sodium excretion were unchanged in the ALVD group. In ALVD+DOCA, urine flow and sodium excretion decreased on the first 2 days DOCA was given but normalized starting day 4. Urine flow and urinary cGMP excretion increased in ALVD+DOCA after DOCA escape. Plasma atrial natriuretic peptide, B-type natriuretic peptide, and cGMP increased equally in both groups. There were no differences in cardiorenal and hemodynamic parameters in an acute study on day 11. Although renal collagen area fraction was similar, left ventricular collagen area fraction in ALVD+DOCA was significantly higher than in ALVD (3.3+/-0.4% versus 2.0+/-0.2%; P=0.012). We conclude that ALVD can escape the sodium- and water-retaining effects of mineralocorticoid excess. Despite renal escape, increased left ventricular collagen deposition suggests that the heart but not the kidney failed to escape the tissue effects of DOCA.

Differential expression of cytoprotective and apoptotic genes in an ischaemia-reperfusion isolated organ perfusion model of the transplanted kidney

The optimal kidney preservation system and methods to ameliorate reperfusion injury are major factors in accomplishing successful graft function following transplantation. Ischaemia and reperfusion lead to cellular stress and the adaptive response may include the activation of genes involved in cellular protection and/or cell death by apoptosis. We investigated the expression of cytoprotective heme oxygenase-1 (HO-1), anti-apoptotic Bcl-2 and pro-apoptotic Bax after 6 h isolated organ perfusion in porcine kidneys that had been given 10 and 40 min warm ischaemic time. The level of HO-1 was shown to be significantly higher in the 10-min warm ischaemic group compared with 40-min group (0.90 +/- 0.03 vs. 0.83 +/- 0.03; P = 0.002). The levels of HO-1 showed a significant positive correlated with parameters of renal function, creatinine clearance, and renal blood flow and urine output (AUC; r = 0.8042, P = 0.03; r = 0.6028, P = 0.04; r = 0.6055, P = 0.04), demonstrating a possible protective role of this gene in this model of renal transplantation.

Identification of central nervous system sites involved in the water diuresis response elicited by central microinjection of nociceptin/ Orphanin FQ in conscious rats via c-Fos and inducible cAMP early repressor immunocytochemistry

Intracerebroventricular (i.c.v.) administration of the opioid-like peptide, nociceptin/Orphanin (nociceptin), in conscious rats produces diuretic and antinatriuretic effects. The present study utilised changes in Fos and inducible cAMP early repressor (ICER) immunocytochemistry expression to examine the central nervous (CNS) sites activated or inhibited, respectively, by central administration of nociceptin. Urine samples were collected during control (15 min) and after i.c.v. vehicle (5 microl, n = 12) or nociceptin (10 microg/5 microl; n = 12). Four additional urine samples (15-min) were collected after the i.c.v. injection. The brain was processed for Fos using a commercially available antibody (Oncogene AB-5) and for ICER using a polyclonal anti-ICER antibody raised in rabbits. In vehicle-injected conscious rats, renal excretion of water or sodium was not altered. However, nociceptin produced a rapid and marked increase in urine flow (V) and a decrease in urinary sodium excretion rate. In addition, i.c.v. nociceptin produced a significant increase in Fos staining in the dorsomedial nucleus of the hypothalamus, the perinuclear zone of the supraoptic nucleus, the organum vasculosum of the lamina terminalis (OVLT), the lateral preoptic area and the lateral hypothalamic area compared to control. By contrast, Fos expression decreased in the area postrema and locus coeruleus compared to controls. Furthermore, ICER staining was significantly increased in the perinuclear zone of the supraoptic nucleus, supraoptic nucleus, median preoptic nucleus, OVLT, medial preoptic area, central nucleus of the amygdala, and medial nucleus of the solitary tract. Together, central opioid receptor-like type 1 activation in these CNS regions may participate in the neural pathways involved in the diuretic and antinatriuretic effects of nociceptin.

Health-behavior induced disease: return of the milk-alkali syndrome

The milk-alkali syndrome is a well-documented consequence of excessive calcium and alkali intake first recognized in association with early 20th century antacid regimens. The syndrome became rare after widespread implementation of modern peptic ulcer disease therapies. With recent trends in osteoporosis therapy coupled with widely available calcium-containing supplements, the milk-alkali syndrome has reemerged as an important clinical entity. Our case illustrates a patient who self-medicated his peptic ulcer disease with a regimen resembling a common early 20th century dyspepsia regimen. When superimposed upon chronic high calcium supplementation, the patient became acutely ill from the milk-alkali syndrome. When taken to excess, or used inappropriately, medications and supplements ordinarily considered beneficial, can have harmful effects. Our case underscores the importance of obtaining a thorough medication history including use of over-the-counter supplementation.

Circadian rhythm of hydration in healthy subjects and uremic patients studied by bioelectrical impedance analysis

BACKGROUND

Healthy subjects and patients after successful kidney transplantation show a circadian rhythm for glomerular filtration rate and for the glomerular transport of macromolecules. We aimed to evaluate by bioelectrical impedance analysis (BIA) whether body hydration status also follows a circadian rhythm in patients with impaired renal function.

METHODS

The study was conducted on 28 subjects divided into 3 groups: 8 healthy volunteers, 8 patients affected by chronic kidney disease and 12 end-stage renal disease (ESRD) patients on hemodialysis. During 24 h, 9 BIA measurements were taken in every subject every 180 min.

RESULTS

BIA findings demonstrate that normal subjects have a circadian rhythm in hydration status that reaches maximum body water content at night, between 21.00 and 23.00 h. In patients with chronic kidney disease, this rhythm, with maximum at night, is maintained. The rhythm is also present in ESRD patients, if the residual diuresis is at least 500 ml/day, while there is no rhythm when residual diuresis is <300 ml/day.

CONCLUSIONS

In normal subjects, body hydration status shows a circadian rhythm, which is weakened or lost in oligoanuric patients on dialysis, but partially maintained in subjects with preterminal uremia and in hemodialyzed patients with residual diuresis >500 ml/day.

[Renal tubular dysgenesis and mutation in the renin gene]

Renal tubular dysgenesis is a severe and rare disorder of the renal development characterized by fetal anuria, oligohydramnios and early death from pulmonary hypoplasia and refractory arterial hypotension. We report on a female patient who presented with anuria in the neonatal period, requiring peritoneal dialysis until 5 months of age with unexpected diuresis recovery at 2 months of age. Clinical, histological and pathophysiological issues are discussed for this disease related to a mutation in the renin gene.

Allatotropin-like peptide released by Malpighian tubules induces hindgut activity associated with diuresis in the Chagas disease vector Triatoma infestans (Klug)

Haematophagous insects incorporate a large amount of blood with each meal,producing a big quantity of urine in a few hours to eliminate the excess water and Na+. Malpighian tubules (MTs) have traditionally been seen as a system that responds to neuroendocrine stimulus. In a related paper, we demonstrated that MTs of Triatoma infestans produce an autonomous endocrine secretion of an allatotropin-like (AT-like) peptide. In the present study, we report a myostimulatory activity of AT at the level of the hindgut(HG), associated with endocrine mechanisms regulating post-prandial diuresis. Allatotropin induced an increase in frequency and intensity of peristaltic contractions at the level of the HG. The release of the HG content in MTs–HG in vitro preparations undergoing an osmotic shock occurred at different times, depending on the number of MTs present, and there was no release in treatments without MTs. The application of an AT-antiserum to MTs–HG preparations undergoing osmotic shock produced a delay or a long-term blockade of diuresis, depending on the antiserum dilution applied. Similar results were obtained when AT-antiserum was applied in vivoprior to blood intake, decreasing the volume of urine eliminated during the first 2 h. Our results allow us to assign a specific endocrine function to the AT-like peptide released by MTs that is linked to the elimination of urine after blood meals.

Temporary abdominal vacuum-packing closure in the neonatal intensive care unit

BACKGROUND

Temporary abdominal vacuum-packing (vac-pac) closure is well known in adult literature, yet has not been reported in infants.

METHODS

A review of children in the neonatal intensive care unit who underwent vac-pac closure from 2000 to 2006 was performed.

RESULTS

During this time, 7 infants underwent vac-pac closure after abdominal surgery. Median age was 39 days, with a median weight of 3.2 kg. Reasons for vac-pac included abdominal compartment syndrome (3), ongoing intraabdominal sepsis (1), anticipated second-look procedures (2), and abdominal observation after repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation (1). PaCO2 revealed a drop from a median preoperative level of 50.3 to 44.0 mm Hg postoperatively. Median preoperative urine output was 3.9 and 3.1 mL/(kg h) postoperatively. One patient died with an open abdomen from overwhelming Escherichia coli sepsis, and all surviving patients (85.7%) proceeded to definitive abdominal closure with the median time of vac-pac use being 4 days.

CONCLUSION

Vac-pac closure in infants is a safe and effective method of temporary abdominal closure. The detrimental effects of intraabdominal hypertension as well as risk of hemorrhage after repair of congenital diaphragmatic hernia while on extracorporeal membrane oxygenation also make this an important technique for abdominal observation.

Urinary acidification assessed by simultaneous furosemide and fludrocortisone treatment: an alternative to ammonium chloride

Distal renal tubular acidosis (RTA) can lead to rickets in children or osteomalacia in adults if undetected. This disorder is normally diagnosed by means of an oral ammonium chloride-loading test; however, the procedure often leads to vomiting and abandonment of the test. In this study, we assess an alternative, more palatable approach to test urinary acidification. This was achieved by the simultaneous oral administration of the diuretic furosemide and the mineralocorticoid fludrocortisone to increase distal tubular sodium delivery, principal cell sodium reabsorption, and alpha-intercalated cell proton secretion. We evaluated 11 control subjects and 10 patients with known distal RTA by giving oral ammonium chloride or furosemide/fludrocortisone in random order on separate days. One control and two patients were unable to complete the study owing to vomiting after NH4Cl; however, there were no adverse effects with the furosemide/fludrocortisone treatment. The urine pH decreased to less than 5.3 in the controls with both tests, whereas none of the patients was able to lower the urine pH below 5.3 with either test. We conclude that the simultaneous administration of furosemide and fludrocortisone provides an easy, effective, and well-tolerated alternative to the standard ammonium chloride urinary acidification test for the diagnosis of distal RTA.

Urine specific gravity and other urinary indices: inaccurate tests for dehydration

OBJECTIVE

Urine output, specific gravity, and ketones (urinary indices) are commonly used as an objective means to assess for dehydration and gastroenteritis severity; however, their utility has not been established. The study was designed to evaluate the accuracy of urinary indices as diagnostic tests to identify acute dehydration.

METHODS

We completed a prospective cohort study in the Emergency Department of an urban pediatric hospital. Seventy-nine subjects ages 3 months to 36 months with gastroenteritis, clinically suspected moderate dehydration, and the need for intravenous rehydration were enrolled in the trial. Urine specific gravity and urine ketone levels were determined with bedside calorimetric (dipstick) testing, and urine output during rehydration and observation was measured by commonly used techniques. An internally validated, weight-based criterion standard for the percent dehydration on enrollment was used to identify the cohort of dehydrated subjects. Correlation statistics were calculated for urine output, specific gravity, and ketones. In addition, multilevel tables were created to determine the sensitivity, specificity, and likelihood ratio at varying test cutoff values to detect 3% and 5% dehydration.

RESULTS

Urine specific gravity (r = -0.06, P = 0.64), urine ketones (r = 0.08, P = 0.52), and urine output during rehydration (r = 0.01, P = 0.96) did not correlate with the initial degree of dehydration present. Clinically useful cutoff values for urine specific gravity and ketones to increase or decrease the likelihood of dehydration at the time of enrollment could not be identified.

CONCLUSIONS

Urinary indices are not useful diagnostic tests to identify the presence of dehydration during the initial assessment of children with gastroenteritis.

The effect of combining intermittent hemodiafiltration with forced alkaline diuresis on plasma myoglobin in rhabdomyolysis

BACKGROUND

Our aim was to examine the effect of combining intermittent hemodiafiltration (HDF) with forced alkaline diuresis on plasma myoglobin in rhabdomyolysis.

METHODS

This was a prospective, randomized, controlled, cross-over study. Sixteen rhabdomyolysis patients with plasma myoglobin concentrations above 10,000 microg/l were randomized. Forced alkaline diuresis was started immediately after allocation and continued throughout the study. HDF, which lasted for 4 h, was started in group A immediately after allocation and in group B 4 h later. The primary analysis was intention-to-treat by repeated measures analysis of variance and Mann-Whitney U-test.

RESULTS

The percentage elimination of myoglobin from the circulation during HDF differed significantly from that during alkaline diuresis (28.1% vs. 14.2%, respectively; P < 0.01). The mean decrease in plasma myoglobin concentration during HDF [9731 microg/l; 95% confidence interval (CI), 3672-5345 microg/l] and forced alkaline diuresis (3646 microg/l; 95% CI, 1260-6032 microg/l) did not show a statistically significant difference (P= NS). The mean total amount of myoglobin found in the ultrafiltrate was 58.4 mg.

CONCLUSION

The percentage myoglobin decrease during combined HDF and forced alkaline diuresis was higher than that during forced alkaline diuresis alone. Renal replacement therapy with filtration techniques may be considered for the clearance of myoglobin from plasma when urine alkalinization is not successful.

Cytokine-mediated regulation of urea transporters during experimental endotoxemia

Acute renal failure (ARF) is a frequent complication of sepsis and has a high mortality. Sepsis-induced ARF is known to be associated with significant impairment of tubular capacity. However, the pathogenesis of endotoxemic tubular dysfunction with failure of urine concentration is poorly understood. Urea plays an important role in the urinary concentrating mechanism and expression of the urea transporters UT-A1, UT-A2, UT-A3, UT-A4, and UT-B is essential for tubular urea reabsorption. The present study attempts to assess the regulation of renal urea transporters during severe inflammation in vivo. Lipopolysaccharide-(LPS)-injected mice presented with reduced glomerular filtration rate, fractional urea excretion, and inner medulla osmolality associated with a marked decrease in expression of all renal urea transporters. Similar alterations were observed after application of tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, interferon (IFN)-gamma, or IL-6. LPS-induced downregulation of urea transporters was not affected in knockout mice with deficient TNF-alpha, IL-receptor-1, IFN-gamma, or IL-6. Glucocorticoid treatment inhibited LPS-induced increases of tissue TNF-alpha, IL-1beta, IFN-gamma, or IL-6 concentration, diminished LPS-induced renal dysfunction, and attenuated the downregulation of renal urea transporters. Renal ischemia induced by renal artery clipping did not influence the expression of urea transporters. Our data demonstrate that renal urea transporters are downregulated by severe inflammation, which likely accounts for tubular dysfunction. Furthermore, they suggest that the downregulation of renal urea transporters during LPS-induced ARF is mediated by proinflammatory cytokines and is independent from renal ischemia because of sepsis-induced hypotension.

Receptor for advanced glycation end products--soluble form and gene polymorphisms in chronic haemodialysis patients

BACKGROUND

The receptor for advanced glycation end products (RAGE) is involved in the pathogenesis of vascular and inflammatory diseases. The pathological effects mediated via RAGE are physiologically inhibited by soluble RAGE (sRAGE). Our aim was to study sRAGE and RAGE gene polymorphisms in haemodialysis (HD) patients.

METHODS

A total of 261 stable HD patients were enrolled in the study and prospectively followed up for 30 months. At the begining of the study, sRAGE inflammatory and nutritional parameters were determined. RAGE polymorphisms were determined in a subgroup of 214 HD patients. A group of 100 healthy controls was used for comparison.

RESULTS

In HD patients, sRAGE is elevated in comparison with healthy controls (3427+/-1508 vs 1758+/-637 pg/ml, P<0.001). It correlates negatively with residual diuresis (r=-0.193, P<0.05), with the acute phase reactants fibrinogen (r=-0.174, P<0.05) and orosomucoid (r=-0.135, P<0.05) and with the leucocyte count (r=-0.158, P<0.05). On the other hand, it is not related to the presence of diabetes mellitus, cardiovascular disease, nutritional status and mortality. The highest sRAGE levels are found in -429 CC and 2184 GG polymorphisms of the RAGE gene. The same results as for sRAGE were obtained for endogenous secretory RAGE (esRAGE), which correlated significantly with sRAGE (r=0.88, P<0.001).

CONCLUSION

We conclude that in HD patients, sRAGE is increased due to decreased renal function, which is a very strong determinant of sRAGE levels, and is inversely related to inflammation. The highest sRAGE levels are influenced genetically. In our study, sRAGE levels were not related to mortality of HD patients.

PTHrP, calcitonin and calcitriol in a case of severe, protracted and refractory hypercalcemia due to a pancreatic neuroendocrine tumor

A patient with a primary neuroendocrine tumor of the pancreas, presented with severe hypercalcemia. This hypercalcemia of malignancy (HCM) failed to respond to intensive bisphosphonate treatment and needed continuous enhanced diuresis. Only after successful antitumor therapy did the hypercalcemia subside. Hypercalcemia was associated with increased concentrations of plasma PTHrP, calcitonin and 1,25-(OH)(2)D(3). Bone mineral density was markedly increased. We demonstrated the presence of both PTHrP and calcitonin in the tumor at the mRNA and protein level, using RT-PCR, immunohistochemistry and Western blotting. The high levels of plasma PTHrP and the demonstrated predominant renal mechanism in this case of HCM are suspected to be the cause for its refractoriness to bone resorption inhibitors. Our findings furthermore suggest that the tumoral production of calcitonin and PTHrP might have contributed to the increased bone mineral storage of calcium and thus probably attenuated the development of frank hypercalcemia.

Modified RIFLE criteria in critically ill children with acute kidney injury

A classification system has been proposed to standardize the definition of acute kidney injury in adults. These criteria of risk, injury, failure, loss, and end-stage renal disease were given the acronym of RIFLE. We have modified the criteria based on 150 critically ill pediatric RIFLE (pRIFLE) patients to assess acute kidney injury incidence and course along with renal and/or non-renal comorbidities. Of these children, 11 required dialysis and 24 died. Patients without acute kidney injury in the first week of intensive care admission were less likely to subsequently develop renal Injury or Failure; however, 82% of acute kidney injury occurred in this initial week. Within this group of 123 children, 60 reached pRIFLEmax for Risk, 32 reached Injury, and 31 reached Failure. Acute kidney injury during admission was an independent predictor of intensive care; hospital length of stay and an increased risk of death independent of the Pediatric Risk of Mortality (PRISM II) score (odds ratio 3.0). Our results show that a majority of critically ill children develop acute kidney injury by pRIFLE criteria and do so early in the course of intensive care. Acute kidney injury is associated with mortality and may lead to increased hospital costs. We suggest that the pRIFLE criteria serves to characterize the pattern of acute kidney injury in critically ill children.

North East Italian Prospective Hospital Renal Outcome Survey on Acute Kidney Injury (NEiPHROS-AKI): Targeting the Problem with the RIFLE Criteria

Acute kidney injury (AKI) in the intensive care unit (ICU) is associated with an enhanced mortality. The Acute Dialysis Quality Initiative group has proposed the RIFLE (Risk-Injury-Failure-Loss-ESRD) classification to standardize the approach to AKI. This study was performed to estimate the AKI incidence in ICU patients in northeastern Italy and describe clinical characteristics and outcomes of patients with AKI on the basis of their RIFLE class. A prospective multicenter observational study was performed of patients who fulfilled AKI criteria in 19 ICU in northeastern Italy. Data were analyzed using multivariate logistic regression and survival curve analysis. Of 2164 ICU patients who were admitted during the study period, 234 (10.8%; 95% confidence interval 9.5 to 12.1%) developed AKI; 19% were classified as risk (R), 35% as injury (I), and 46% as failure (F). Preexisting kidney disease was present in 36.8%. The most common causes of AKI were prerenal causes (38.9%) and sepsis (25.6%). At diagnosis of AKI, median serum creatinine and urine output were 2.0 mg/dl and 1100 ml/d, respectively. ICU mortality was 49.5% in class F, 29.3% in I, and 20% in R. Independent risk factors for mortality included RIFLE class, sepsis, and need for renal replacement therapy, whereas a postsurgical cause of AKI, exposure to nephrotoxins, higher serum creatinine, and urine output were associated with lower mortality risk. In this study, AKI incidence in the ICU was between 9 and 12%, with 3.3% of ICU patients requiring renal replacement therapy. Sepsis was a significant contributing factor. Overall mortality was between 30 and 42%, and was highest among those in RIFLE class F.

Finasteride to evaluate the efficacy of dutasteride in the management of patients with lower urinary tract symptoms and enlarged prostate

Patients with lower urinary tract symptoms and enlarged prostate were randomized to receive, in a double blind fashion, either Finasteride 5 mg/day or Dutasteride 0.5 mg/day for a period of 12 weeks. IPSS score, Qmax, and Quality of Life were assessed at the end of 0 and 12 week periods. Dutasteride significantly improved Qmax, reduced IPSS score, and improved Quality of Life as compared to Finasteride at the end of the 12-week period. Dutasteride with its inhibitory effects on type 1 and 2 5alpha-reductase, produces significantly better results than Finasteride.

Immediate Recovery of Renal Function After Orthotopic Liver Transplantation in a Patient With Hepatorenal Syndrome Requiring Hemodialysis for More Than 8 Months

Severe liver dysfunction may lead to impairment of renal function without an underlying renal pathology. This phenomenon is called hepatorenal syndrome (HRS), which is associated with a poor prognosis showing a median survival of less than 2 months if renal replacement therapy is necessary. Liver transplantation is the best therapeutic option to regain renal function, but because of poor survival, these patients often die before transplantation. Herein we report a 37-year-old patient with ethyl-toxic liver cirrhosis who underwent hemodialysis due to HRS type I for more than 8 months. After living donor liver transplantation, diuresis immediately resumed, renal function soon recovered, and intermittent hemodialysis was stopped at 18 days after transplantation. Renal function was stable with a serum creatinine <2 mg/dL during the last 5 years posttransplantation. As far as we know, only a few cases of an anuric patient suffering from HRS have been reported with a survival beyond 8 months and full recovery of renal function after liver transplantation. This underlined that renal replacement therapy in HRS should be considered as a possible bridging method to liver transplantation even for longer periods.

Evaluation of preservation solutions by ESR-spectroscopy: superior effects of University of Wisconsin over Histidine-Tryptophan-Ketoglutarate in reducing renal reactive oxygen species

Despite the causative role of oxidative stress in renal ischemia-reperfusion (I-R) injury effects of preservation solutions on reactive oxygen species (ROS) release have not been sufficiently evaluated. We compared the effects of most common solutions in kidney transplantation, University of Wisconsin (UW) and Histidine-Tryptophan-Ketoglutarate (HTK). ROS formation in isolated perfused rat kidney was detected by electron spin resonance spectroscopy using spin label 1-hydroxy-3-methoxycarbonyl-2,2,5,5-tetramethyl-pyrrolidine. Donor kidneys from Lewis rats were pretreated with saline (controls), in therapeutic groups, kidneys underwent 18 h of cold storage (CS) preserved by HTK or UW solution. Experimental protocol included a stabilization period followed by additional I-R. Kidneys preserved by HTK produced highest ROS values in the control period after CS, whereas levels in UW and control group did not vary significantly. A peak release induced by additional I-R was also significantly highest in HTK kidneys, and UW did not differ from controls. During reperfusion, levels in HTK exceeded control and UW values. Renal vascular resistance, caspase-3-activity, and tissue hydration were enhanced in HTK compared with UW group, whereas ATP concentration was less reduced in UW-preserved tissue. These data show the greater antioxidative potential of UW solution, which also attenuated organ impairment after CS in the early reperfusion period.