Urinary leakage of tubular enzymes after shock wave lithotripsy

Role of Vitamin C and E supplementation in reduction of serum level of renal injury marker following shock wave lithotripsy: Prospective single centre experience

INTRODUCTION

Shock wave lithotripsy has become first line treatment modality for renal calculi due to its noninvasiveness. However, the destructive forces like dispersion of cavitation bubbles can cause trauma to thin-walled vessels and renal parenchyma during fragmentation of the stones. Antioxidants are our first line of defense against oxidative stress. The aim of this study was to investigate whether oral administration of Vitamin C and E help in a reduction of the serum level of inflammatory mediator by serial measurement of high sensitivity C-reactive protein (hs-CRP) and by this reduction in the risk of renal damage.

PATIENTS AND METHODS

A total of 107 subjects were recruited in three groups. Group A served as a control group, and Group B and Group C received oral medication of Vitamin E 800 mg/day and Vitamin C 1000 mg/day respectively, start from 2 days prior the lithotripsy and continued for total 7 days. The level of hs-CRP was used as a mediator of the inflammatory response following lithotripsy and thus for long term renal injury. Serum level of hs-CRP was measured on 2 days prior the lithotripsy and day 2, 7 and 28 after the lithotripsy.

RESULTS

Patients who were given either Vitamin C or Vitamin E showed a significant reduction of serum level of hs-CRP when compared to control the group.

CONCLUSION

Oral administration of Vitamin C and E helps in reduction of serum levels of the inflammatory marker for acute renal injury and thus they can be useful in minimizing the kidney injury following lithotripsy for renal stone disease.

Goodpasture's disease following extracorporeal shock wave lithotripsy: a case report & literature review

Shock wave lithotripsy may unmask epitopes within the glomerular basement membrane, leading to the formation of anti-glomerular basement membrane (GBM) antibodies and clinical disease in susceptible individuals. Although rare, our case highlights the need for vigilant monitoring of renal function following extracorporeal shock wave lithotripsy. This may allow for early recognition, treatment and improved outcome of anti-GBM disease.

Antioxidant therapy is associated with a reduction in the serum levels of mediators of renal injury following lithotripsy for renal calculi

OBJECTIVE

To investigate the effects of antioxidant therapy on the levels of mediators of shock wave induced renal injury in patients with renal calculi treated with extracorporeal shock wave lithotripsy (ESWL).

PATIENTS AND METHODS

One hundred and twenty patients with renal calculi were divided into three treatment groups: Group A patients (n = 39) served as a control group; Group B patients (n = 41) were given 2 capsules of Nature Made((R)) antioxidants 2 hours before, and 2 and 8 hours after ESWL and Group C patients (n = 40) were given 2 capsules of the antioxidants at 2 and 8 hours after ESWL. Blood and urine samples were obtained from all patients just before the start of treatment with ESWL, and at 2 and 24 hours and on day 7 and 28 after ESWL. Levels of mediators of renal injury such as serum alkaline phosphatase (ALP), C-reactive protein (CRP) and lactate dehydrogenase (LDH) were measured. Urinary levels of albumin and ALP were also determined as measures of renal tubular injury.

RESULTS

Patients given antioxidants had significantly reduced mean serum concentration of ALP (p < 0.001) at 24 hours, lower serum ALP and LDH on day 7 and 28, and lowest CRP on day 28 after ESWL. They also had higher urine albumin (p < 0.001) and ALP (p < 0.001) levels (from 24 hours to day 28) compared with patients who were not given antioxidants.

CONCLUSION

These findings suggest that oral antioxidant therapy prior to lithotripsy may reduce the severity of long term renal injury caused by the shock waves.

Effect of shock wave reapplication on urinary n-acetyl-beta-glucosaminidase in canine kidney

OBJECTIVE

Renal tubular damage can be assessed with the aid of urinary dosing of N-acetyl-beta-glucosaminidase (NAG) and it is possible to demonstrate a significant correlation between shock wave and damage to renal parenchyma. The objective of this study was to assess the effect of shock wave reapplication over urinary NAG in canine kidney.

MATERIALS AND METHODS

The authors submitted 10 crossbred dogs to 2 applications of 2000 shock waves in a 24-hour interval in order to assess urinary NAG values after 12, 24, 36 and 48 hours.

RESULTS

Twelve hours following the first shockwave application there was an increase in NAG of 6.47 +/- 5.44 u/g creatinine (p < 0.05). Twelve hours and 24 h following the second application there was no increase in the urinary enzyme, -2.56 +/- -7.36 u/g creatinine and 2.89 +/- -7.27 u/g creatinine, respectively (p > 0.05).

CONCLUSION

Shock wave reapplication with a 24-hour interval did not cause any increase in urinary NAG.

Evaluation of heat shock protein 70 expression in renal parenchyma subjected to shockwave lithotripsy

PURPOSE

In this experimental study in a rabbit model, renal parenchymal heat shock protein 70 (hsp70) levels were assessed in an attempt to evaluate the traumatic effects of high-energy shockwaves (HESW), which have been found to induce transient ischemia during the procedure.

MATERIALS AND METHODS

Eighteen white New Zealand rabbits, each weighing 3 to 5 kg, were included in the study. The animals were divided into three groups, and various numbers of shockwaves (1000, 1500, or 2000) were applied to the same kidney of all animals under fluoroscopic localization with a Stonelith V5 lithotripter. Untreated contralateral kidneys were evaluated as controls. Following HESW application, the treated and untreated kidneys were removed surgically after 24 hours or 7 days. Tissue hsp70 levels were assessed by an immunohistochemistry method.

RESULTS

During early follow-up (24 hours), both treated and untreated kidneys demonstrated moderate to severe hsp70 positivity. The number of positive tubules increased as the number of shockwaves increased, and positivity became more evident, possibly because of a higher degree of tissue damage. Contralateral kidneys demonstrated a limited degree of hsp70 positivity, although it was not as evident as in the treated kidneys. Assessment of tissue hsp70 levels during late follow-up (7 days) demonstrated moderate or limited degrees of positivity in the treated kidneys. Limited or no positivity could be demonstrated in the untreated kidneys during this period.

CONCLUSIONS

Taking the known traumatic effects of HESW and the results of this study into account, the increasing positivity of hsp70 in parallel with the increasing number of shockwaves led us to think about a possible limited degree of ischemia induced by this procedure, as the traumatic effects of HESW were pronounced, as judged by tissue hsp70 positivity.

A prospective randomized trial comparing 2 lithotriptors for stone disintegration and induced renal trauma

PURPOSE

We compare the efficacy and resulting kidney trauma of the HM3 (Dornier Medical Systems, Inc., Marietta, Georgia) and Lithostar Plus (Siemens, Issaquah, Washington) lithotriptors in a prospective randomized trial treating calix and renal pelvis stones.

MATERIALS AND METHODS

Patients with a solitary renal pelvic stone 2 cm. or less in diameter or a solitary calix stone 1 cm. or less in diameter were randomized for treatment with the HM3 or Lithostar Plus. Stone disintegration and dilatation of the pyelocaliceal system were evaluated by abdominal plain x-ray and renal ultrasound 1 day and 3 months after treatment. Kidney trauma was determined by measurement of N-acetyl-beta-glucosaminidase and beta-galactosidase (NAG) in pretreatment urine and 4, 12-hour urine samples collected within the first 2 days after extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc.).

RESULTS

Of 167 patients with 176 stones 91 were randomized to the HM3 and 85 to the Lithostar Plus lithotriptor group. The preoperative stone burden was comparable in both groups. On postoperative day 1 patients treated with the HM3 or Lithostar Plus were stone-free or had fragments 2 mm. or less (91% and 65%, p <0.001), 3 to 5 mm. (8% and 25%, p = 0.003) and 6 mm. or greater (1% and 10%, p = 0.008), respectively. Patients treated with the HM3 had less posttreatment dilatation of the collecting system (p = 0.01). Obstructive pyelonephritis occurred in 1% of the HM3 and 8% of the Lithostar Plus group (p = 0.02). Re-treatment rate was 4% in the HM3 and 13% in the Lithostar Plus group (p = 0.05). Mean excretion of urinary NAG per treatment (including re-treatments) was comparable in both groups but NAG excretion in relation to stone volume and shock wave number 12 to 24 hours after ESWL was significantly higher in the HM3 group (p <0.05). At 3-months postoperatively 89% of the patients treated with the HM3 and 87% treated with the Lithostar plus were stone-free with no dilatation of the collecting system.

CONCLUSIONS

This prospectively randomized study indicated that the HM3 is still the gold standard in regard to disintegration of pelvicaliceal stones. Stone disintegration with the HM3 is better with fewer shock waves, re-treatment rate is lower, and posttreatment dilatation of the collecting system and complications such as obstructive pyelonephritis are less than those with the Lithostar Plus. ESWL induced kidney trauma is minor and resolves within 2 days. The HM3 delivers more energy per shock wave into the kidney as assessed by urinary NAG.

Assessment of the intrinsic urethral sphincter component function in postprostatectomy urinary incontinence

Postprostatectomy incontinence remains a disabling condition. Sphincter injury, detrusor instability, and decreased bladder compliance have been previously reported as major factors. The aim of this study was to evaluate the urethral sphincter intrinsic component, which may provide passive continence. A urodynamic evaluation was performed in 20 patients undergoing a radical retropubic prostatectomy in the preoperative period and 3 months after surgery. Patients with disabled urinary incontinence underwent a new urodynamic evaluation 6 months later. The urethral pressure profile was measured just before, then 10, 20, and 30 minutes after the injection of 0.5 mg/kg moxisylyte chlorhydrate, an alpha adrenergic blocker. Three different pressure components were defined in urethral sphincter capacity: baseline, adrenergic, and voluntary. A postoperative intrinsic urethral sphincter pressure component was found in 17 patients and its value was under 6 cm H(2)O in five cases of severe incontinence. No significant difference was observed for these patients on urethral profile components 6 months later. In contrast, in cases of significant intrinsic component value, no incontinence was observed in most patients. Passive continence after radical prostatectomy should be a matter of concern and may also explain paradoxical incontinence, despite high voluntary urethral pressure obtained after reeducation. A follow-up evaluation of the intrinsic sphincter component is suggested, by using an alpha receptor blockage test during urodynamic studies in the management of patients with postprostatectomy incontinence.

Short-term changes in renal function after extracorporeal shock wave lithotripsy in children

PURPOSE

To our knowledge despite numerous studies the biological effect of extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc., Marietta, Georgia) on the function of the immature kidney has not yet been evaluated. We determined the short-term effect of ESWL on renal function in children.

MATERIALS AND METHODS

In a 5-year period 65 children were treated for 77 kidney stones by ESWL and followed regularly at our department. In 16 children the short-term effect of shock wave energy was studied by measuring blood parameters (sodium, potassium, urea, creatinine and C-reactive protein), urinary electrolytes (sodium, potassium and creatinine), urinary enzyme activity (aspartate transaminase, alanine transferase, alkaline phosphatase and lactate dehydrogenase) and the excretion of beta 2-microglobulin. Samples were obtained immediately before and 2 hours after ESWL, and on days 1, 2, 8, 15, 30 and 90 after treatment.

RESULTS

Morphological changes in the kidneys were not detected by ultrasound during followup. No significant changes were noted in overall renal function, serum parameters or urine electrolytes. A significant elevation in the excretion of aspartate transaminase, alkaline phosphatase, lactate dehydrogenase and beta 2-microglobulin was observed, indicating proximal tubular dysfunction and cell destruction. Enzyme levels returned to baseline within 15 days.

CONCLUSIONS

Our results demonstrate that shock wave energy induces transient functional damage of tubular function in children. Minimizing the kV. and number of shocks may decrease the deleterious effect. When considering functional regeneration time, the minimal interval between 2 shock wave treatments should be at least 15 days. The long-term effect needs further investigation.

Current advances in shock wave lithotripsy

The introduction of shock wave lithotripsy into clinical practice revolutionized the management of urinary tract stone disease. As experience has been gained with its use, however, the limitations and adverse effects associated with it have been recognized.