The Discovery of an S-shaped Kidney in a Patient With Prostate Cancer: A Rare Finding

Crossed fused renal ectopia (CFRE) constitutes a rare congenital anomaly of the urinary tract, typically characterized by its predominantly asymptomatic nature and frequent incidental discovery. This case report delineates the clinical profile of a 56-year-old male admitted to our Prostate Cancer Outpatient Clinic due to elevated prostate-specific antigen (PSA) levels, ultimately leading to the diagnosis of prostate cancer. The patient was asymptomatic, with no family or surgical background. Notably, a fused ectopic kidney was incidentally identified during the staging process involving abdominal computed tomography (ACT) scanning. Remarkably, no additional abnormalities of the urinary tract or renal dysfunction manifested in this specific case. The significance of this report lies in the underscored emphasis on the importance of employing precise imaging techniques and tailored management strategies for patients harboring such anatomical variations.

The effect of standard percutaneous nephrolithotomy, miniaturized percutaneous nephrolithotomy and retrograde intrarenal surgery on biomarkers of renal injury: a randomized clinical trial

Background

Observational studies on the association of endourological procedures with renal parenchymal damage are lacking. This randomized trial examined the effect of standard percutaneous nephrolithotomy (sPCNL) in comparison with miniaturized-PCNL (mini-PCNL) and retrograde intrarenal surgery (RIRS) for nephrolithiasis treatment on novel biomarkers of renal injury.

Methods

Seventy-five patients were randomized in a 1:1:1 ratio to receive sPCNL, mini-PCNL and RIRS for nephrolithiasis. The ratios of neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1) and interleukin-18 (IL-18) normalized for urinary creatinine (Cr) were calculated from urine samples collected at baseline (2-h preoperatively) and at 2-, 6-, 24- and 48-h postoperatively. Two-way mixed analysis of variance (ANOVA) for repeated measurements was used to evaluate the effects of type of procedure and time on studied biomarkers.

Results

Between baseline and 2-h postoperatively, no significant differences were observed in NGAL/Cr changes between sPCNL [median (interquartile range) 9.46 (4.82-14.9)], mini-PCNL [12.78 (1.69-25.24)] and RIRS [6.42 (2.61-23.90)] (P = .902). Similarly, no between-group differences were observed for KIM-1/Cr (P = .853) and IL-18 (P = .980) at 2 h, and all biomarkers at any time-point postoperatively. Within-groups, significant increases from baseline were noted for NGAL/Cr (sPCNL, P < .001; mini-PCNL, P < .001; RIRS, P = .001), KIM-1/Cr and IL-18/Cr at 2 h; progressively lower increases from baseline were noted in all groups for KIM-1/Cr and IL-18/Cr at 6-, 24- and 48-h postoperatively. As such, a significant effect of time but not of type of procedure was evidenced with two-way mixed ANOVA. No significant between-group differences were observed in acute kidney injury incidence and complications.

Conclusions

The endourological procedures under study are associated with similar patterns of early tubular injury, detected by novel biomarkers, which is largely reduced within 48 h and no changes in glomerular function.

Overview of current pharmacotherapeutic options in benign prostatic hyperplasia

INTRODUCTION

Benign prostatic hyperplasia (BPH) represents the histological entity of prostate cell proliferation, which inflicts a gradually increasing obstruction of the bladder outlet and is accompanied by a progressing manifestation of lower urinary tract symptoms (LUTS). BPH management algorithm includes conservative measures, pharmaceutical agents, and surgical procedures.

AREAS COVERED

A comprehensive literature review was performed using PubMed, Scopus, and Google Scholar databases to identify publications written in English, analyzing BPH pharmaceutical treatment. The search was conducted from January 2000 to January 2023. Six main drug classes can be administered, either as monotherapy or in combination. Furthermore, the authors provide current direction of research on future medications, which focuses on a more etiological interference to the BPH pathophysiological mechanism.

EXPERT OPINION

The available medications represent an effective first-line step of BPH/LUTS therapy. Currently, the administration of BPH medications is tailored to patient/disease characteristics and entails long-time adherence to therapy. The emergence of new surgical modalities, which combine significantly lower morbidity compared to standard procedures and more durable effects than the available medications, seems to challenge the current treatment algorithm. More direct comparisons and the increasing experience with these surgical modalities will delineate the switch points between various therapy levels along the BPH management sequence.

Transforming urinary stone disease management by artificial intelligence-based methods: A comprehensive review

Objective

To provide a comprehensive review on the existing research and evidence regarding artificial intelligence (AI) applications in the assessment and management of urinary stone disease.

Methods

A comprehensive literature review was performed using PubMed, Scopus, and Google Scholar databases to identify publications about innovative concepts or supporting applications of AI in the improvement of every medical procedure relating to stone disease. The terms ''endourology'', ''artificial intelligence'', ''machine learning'', and ''urolithiasis'' were used for searching eligible reports, while review articles, articles referring to automated procedures without AI application, and editorial comments were excluded from the final set of publications. The search was conducted from January 2000 to September 2023 and included manuscripts in the English language.

Results

A total of 69 studies were identified. The main subjects were related to the detection of urinary stones, the prediction of the outcome of conservative or operative management, the optimization of operative procedures, and the elucidation of the relation of urinary stone chemistry with various factors.

Conclusion

AI represents a useful tool that provides urologists with numerous amenities, which explains the fact that it has gained ground in the pursuit of stone disease management perfection. The effectiveness of diagnosis and therapy can be increased by using it as an alternative or adjunct to the already existing data. However, little is known concerning the potential of this vast field. Electronic patient records, containing big data, offer AI the opportunity to develop and analyze more precise and efficient diagnostic and treatment algorithms. Nevertheless, the existing applications are not generalizable in real-life practice, and high-quality studies are needed to establish the integration of AI in the management of urinary stone disease.

En bloc resection, is this the future of non-muscle invasive bladder cancer management? Presentation of our technique and brief review of the literature

INTRODUCTION

The quality of the initial transurethral resection of bladder tumors (TURBT) plays a key role in accurate local staging thus affecting treatment decision-making and disease prognosis. TURBT is still the gold standard for non-muscle invasive bladder cancer (NMIBC). However, en bloc resection of bladder tumors (ERBT) gradually expanded as a promising alternative to TURBT, aiming to overcome certain inherent limitations of conventional resection. We hereby describe a step-by-step bipolar ERBT technique and briefly review the current trends surrounding the role of various en bloc techniques in the field.

CASE PRESENTATION

We present the case of a 65-year old patient undergoing bipolar ERBT for a single, approximately 2 cm, papillary bladder mass. An experienced urologist completed the procedure within 17 min and without any intra- or postoperative complications. No conversion to TURBT was needed, and an adequate specimen for histological assessment was obtained. The patient made an uneventful recovery, and no recurrence was noted at 12-months.

CONCLUSION

Our initial experience demonstrates that ERBT via bipolar current is relatively quick, safe, and reliable. Prospective comparative clinical trials will examine its efficacy, and long-term oncological superiority in managing NMIBC.

Jackstone: A Calculus “Toy” in the Bladder. A Case Report of Rare Entity and Comprehensive Review of the Literature

 Background: An uncommon type of urinary calculus, Jackstone was named after its distinct resemblance to the children’s game “Jacks.” It typically involves the bladder and, to a lesser extent, the upper urinary tract.Case Presentation: Herein, we report a case of Jackstone vesical calculus in a 75-year-old male undergoing elective open prostate surgery for benign prostate hyperplasia refractory to medical treatment. Preoperative clinical examination revealed intermittent gross hematuria and symptoms suggestive of bladder outlet obstruction, while radiological investigation confirmed the presence of a solitary star-shaped spike-like bladder stone along with an overly enlarged prostate. Following open simple prostatectomy and concomitant intact stone removal, our patient made an uneventful postoperative recovery.Conclusion: This case highlights an infrequent subtype of bladder lithiasis and further expands upon the importance of promptly treating the underlying cause once this rare entity is detected. A comprehensive review of the literature on Jackstone calculi is further presented.

Hypoxia-Inducible Factor 2a Expression Is Positively Correlated With Gleason Score in Prostate Cancer

Background:

One of the main factors in response to hypoxia in the tumor microenvironment is the hypoxia-inducible factor (HIF) pathway. Although its role in other solid tumors, particularly renal cell carcinoma, has been sufficiently elucidated, it remains elusive in prostate cancer. The aim of the present study was to investigate the expression of main proteins involved in this pathway and determine the correlation of the results with clinicopathological outcomes of patients with prostate cancer.

Methods:

The immunohistochemical expression of HIF-1a, HIF-2a and their regulators, prolyl hydroxylase domain (PHD)1, PHD2 and PHD3 and factor inhibiting HIF (FIH), was assessed on a tissue microarray. This was constructed from radical prostatectomy specimens, involving both tumor and corresponding adjacent non-tumoral prostate tissues from 50 patients with localized or locally advanced prostate cancer.

Results:

In comparison with non-tumoral adjacent tissue, HIF-1a exhibited an equal or lower expression in 86% of the specimens (P = 0.017), while HIF-2a was overexpressed in 52% (P = 0.032) of the cases. HIF-1a protein expression was correlated with HIF-2a (P < 0.001), FIH (P = 0.004), PHD1 (P < 0.001), PHD2 (P < 0.001) and PHD3 (P = 0.035). HIF-2a expression was positively correlated with Gleason score (P = 0.017) and International Society of Urological Pathologists (ISUP) grade group (P = 0.022).

Conclusions:

The findings of the present study suggest a key role for HIF-2a in prostate cancer, as HIF-2a expression was found to be correlated with Gleason score and ISUP grade of the patients. However, further studies are required to validate these results and investigate the potential value of HIF-2a as a therapeutic target in prostate cancer.

Incidental discovery of endourethral clip migration 10 years after radical prostatectomy: A case report and review of the literature

INTRODUCTION

Surgical clips (SCs) have been widely used for a variety of surgical procedures over the years. Despite their advantages and proven effectiveness, several clip-related complications have been reported, creating dilemmas as to their optimal use.

CASE DESCRIPTION

Herein, we present a rare delayed and incidental discovery of two endourethral metallic SCs in a 77-year-old male seeking treatment for acute renal colic. The patient had undergone open radical retropubic prostatectomy 10 years ago, and had an uneventful postoperative recovery. Computed tomography scan revealed left-sided hydronephrosis secondary to proximal ureteral calculus, as well as SCs at the level of vesico-urethral (VUR) anastomosis. Flexible cystoscopy confirmed the imaging findings, showing two endourethral clips, partly obstructing the VUR. Firstly, a serial wire-guided dilation took place, followed by left ureteral double-J stent placement. Unfortunately, the clips could not be concurrently removed due to their firm attachment to the bladder neck. Hence, our patient was scheduled for transurethral resection of the bladder neck and simultaneous endoscopic clip removal.

CONCLUSIONS

To the best of our knowledge, this is the first report to highlight such a delayed incidental finding, 10 years after open retropubic radical prostatectomy (RRP), during a JJ stent insertion for obstructive uropathy without previous clip-induced lower urinary tract symptoms. Although rare, physicians should be aware of the potential clip-related complications arising either in the short- or long-term postprostatectomy setting.

Evaluating the usefulness of antibiotic prophylaxis prior to ESWL in patients with sterile urine: a systematic review and meta-analysis

INTRODUCTION

The aim of this review is to evaluate the effect of antibiotic prophylaxis (AP) on asymptomatic bacteriuria (AB) and urinary tract infection (UTI) in patients with sterile urine undergoing ESWL.

EVIDENCE ACQUISITION

PubMed, Scopus, Web of Science and Cochrane Registry were searched systematically for randomized clinical trials assessing the effect of AP in patients with sterile urine undergoing SWL up to May 2020. Risk ratios were used to compare dichotomous outcomes. A stratified analysis was performed depending on the risk of bias assessment of the included studies. Subgroup analysis was performed in patients that underwent instrumentation of the urinary tract.

EVIDENCE SYNTHESIS

Sixteen studies were evaluated including 2442 patients. When evaluating all the included studies (regardless of the risk of bias assessment), the risk of AB was RR: 0.88, 95% CI: 0.64-1.21, P=0.42 and the risk of UTI was RR: 0.55, 95% CI: 0.22-1.36, P=0.19. When excluding the high risk of bias studies, the risk for AB was RR: 0.9, 95% CI: 0.63-1.28, P=0.55 and for UTI RR: 1.18, 95% CI: 0.38-3.72, P=0.77. When evaluating patients that underwent instrumentation of the urinary tract the risk for AB was RR: 0.92, 95% CI: 0.66-1.27, P=0.6 and for UTI was RR: 0.69, 95% CI: 0.22-2.22, P=0.54.

CONCLUSIONS

AP is not necessary for patients with sterile urine prior to ESWL for the prevention of UTI. Also, patients that undergo instrumentation of the urinary tract prior to or during ESWL do not benefit from antibiotic prophylaxis but further research is required.

Evaluating the usefulness of antibiotic prophylaxis prior to ESWL in patients with sterile urine: a systematic review and meta-analysis

INTRODUCTION

The aim of this review is to evaluate the effect of antibiotic prophylaxis (AP) on asymptomatic bacteriuria (AB) and urinary tract infection (UTI) in patients with sterile urine undergoing ESWL.

EVIDENCE ACQUISITION

PubMed, Scopus, Web of Science and Cochrane Registry were searched systematically for randomized clinical trials assessing the effect of AP in patients with sterile urine undergoing SWL up to May 2020. Risk ratios were used to compare dichotomous outcomes. A stratified analysis was performed depending on the risk of bias assessment of the included studies. Subgroup analysis was performed in patients that underwent instrumentation of the urinary tract.

EVIDENCE SYNTHESIS

Sixteen studies were evaluated including 2442 patients. When evaluating all the included studies (regardless of the risk of bias assessment), the risk of AB was RR: 0.88, 95% CI: 0.64-1.21, P=0.42 and the risk of UTI was RR: 0.55, 95% CI: 0.22-1.36, P=0.19. When excluding the high risk of bias studies, the risk for AB was RR: 0.9, 95% CI: 0.63-1.28, P=0.55 and for UTI RR: 1.18, 95% CI: 0.38-3.72, P=0.77. When evaluating patients that underwent instrumentation of the urinary tract the risk for AB was RR: 0.92, 95% CI: 0.66-1.27, P=0.6 and for UTI was RR: 0.69, 95% CI: 0.22-2.22, P=0.54.

CONCLUSIONS

AP is not necessary for patients with sterile urine prior to ESWL for the prevention of UTI. Also, patients that undergo instrumentation of the urinary tract prior to or during ESWL do not benefit from antibiotic prophylaxis but further research is required.

Are endourological procedures for nephrolithiasis treatment associated with renal injury? A review of potential mechanisms and novel diagnostic indexes

Nephrolithiasis is one of the most common urological conditions with a huge socio-economic impact. About 50% of recurrent stone-formers have just one lifetime recurrence and >10% of patients present with a high recurrent disease requiring subsequent and sometimes multiple surgical interventions. The advent of new technology has made endourological procedures the pinnacle of stone treatment, including procedures like percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery and miniaturized PCNL procedures. Researchers have primarily focused on comparisons with respect to stone-free rates, procedure parameters and post-operative complications. However, the effect of these three procedures on renal function or indexes of renal injury has not been sufficiently examined. This was only reported in a few studies as a secondary objective with the use of common and not the appropriate and detailed renal parameters. This review presents current literature regarding the use of novel and highly predictive biomarkers for diagnosing acute kidney injury, discusses potential mechanisms through which endourological procedures for renal stone treatment may affect renal function and proposes areas with open questions where future research efforts in the field should focus.

Ureteral Guidewire Looping and Entrapment above an Impacted Ureter Stone

We present a rare case of a hydrophilic guidewire looping and entrapment in the ureter of a patient with an impacted stone in the proximal ureter during a simple double-J stent insertion. Looping of guidewire is a rare complication in urology and only few cases have been described. In that case, release and removal of the entrapped guidewire was possible only after one step fragmentation of the stone with laser lithotripsy.

Low-intensity shockwave therapy (LiST) for erectile dysfunction: a randomized clinical trial assessing the impact of energy flux density (EFD) and frequency of sessions

The impact of energy flux density (EFD) used on low-intensity shockwave therapy (LiST) for erectile dysfunction (ED) has not been explored. Our aim was to compare EFD 0.05 versus 0.10 mJ/mm² regarding efficacy and safety of 12-treatment sessions when applied two or three times per week. Ninety-seven patients with vasculogenic ED, PDE5 inhibitors users were randomized into four groups, to receive 12 LiST sessions. Group A (n = 24) : two sessions per week, EFD 0.05 mJ/mm²; Group B (n = 24): three sessions per week, EFD 0.05 mJ/mm²; Group C (n = 24): two sessions per week, EFD 0.10 mJ/mm²; Group D (n = 25): three sessions per week, EFD 0.10 mJ/mm². International Index for Erectile Function-Erectile Function domain (IIEF-EF), Minimally clinical important differences (MCID), sexual encounter profile, and triplex ultrasonography parameters were used to asses erectile function. Eighty-nine patients completed the 6-month follow-up (FU). All four groups improved in mean IIEF-EF score, average SEP3 "Yes" response rates at 6-month FU visit compared with baseline (p < 0.001). MCID at 6-month FU visit was achieved in 82.6%, 77.3%, 87%, and 81% in Groups A, B, C, and D, respectively. Mean PSV (cm/s) at baseline versus 3-month FU visit were 30.32 versus 34.67 for Group A, 30.02 versus 35.02 for Group B, 30.2 versus 36.02, for Group C, 29.43 versus 34.3 for Group D (p < 0.01). There were no statistical significant differences in the change of all outcome measures assessing erectile function between different sessions frequency. A tendency for better efficacy using EFD 0.10 mJ/mm² was noticed, although it did not reach statistical significance. No treatment-related side-effects were reported. This study lacks a sham-controlled arm. However, all patients were randomized to the four groups, and baseline characteristics were similar between the groups. Moreover, arterial insufficiency was confirmed among all patients by penile triplex ultrasonography. Conclusively, patients may benefit equally when sessions are applied either two or three per week. An EFD of 0.10 mJ/mm² could result in better outcomes, but further studies are needed to validate this observation.

Stem cell therapy in erectile dysfunction: science fiction or realistic treatment option?

Stem cell therapy has become a subject of great interest to researchers worldwide. One of the medical conditions being studied for possible treatment with the use of stem cells is erectile dysfunction, and particularly organic and post-radical prostatectomy erectile dysfunction. However, is stem cell therapy a viable treatment option for erectile dysfunction? The current body of literature provides a wide array of clinical trials performed on animal models simulating different types of human erectile dysfunction. Unfortunately, only a handful of studies have been performed on human patients and almost all of them were phase 1 studies limited by the small sample size. This review aims to summarize the available evidence on the use of stem cell therapy for the treatment of erectile dysfunction and also to provide an overview of upcoming and ongoing clinical trials in this field.

Risk of hospitalization associated with body mass index and weight changes among prevalent haemodialysis patients

The impact of body mass index (BMI) and body weight on hospitalization rates in haemodialysis patients is unknown. This study hypothesizes that being either underweight or obese is associated with a higher hospitalization rate. Observational study of 6296 European haemodialysis patients with prospective data collection and follow-up every six months for three years (COSMOS study). The risk of being hospitalized was estimated by a time-dependent Cox regression model and the annual risk (incidence rate ratios, IRR) by Poisson regression. We considered weight loss, weight gain and stable weight. Weight change analyses were also performed after patient stratification according to their baseline BMI. A total of 3096 patients were hospitalized at least once with 9731 hospitalizations in total. The hospitalization incidence (fully adjusted IRR 1.28, 95% CI [1.18-1.39]) was higher among underweight patients (BMI <20kg/m²) than patients of normal weight (BMI 20-25kg/m²), while the incidence of overweight (0.88 [0.83-0.93]) and obese patients (≥30kg/m², 0.85 [0.79-0.92]) was lower. Weight gain was associated with a reduced risk of hospitalization. Conversely, weight loss was associated with a higher hospitalization rate, particularly in underweight patients (IRR 2.85 [2.33-3.47]). Underweight haemodialysis patients were at increased risk of hospitalization, while overweight and obese patients were less likely to be hospitalized. Short-term weight loss in underweight individuals was associated with a strikingly high hospitalization rate.

Treatment of adynamic bone disease in a haemodialysis patient with teriparatide

Prevalence of adynamic bone disease (ABD), characterized by low bone turnover and absence or a reduced number of osteoblasts and osteoclasts, is increasing steadily over the last years. We present a dialysis patient, with recurrent bone fractures and biopsy-proven ABD, who was treated with teriparatide. Nine months after initiation of treatment, iPTH plasma levels increased to 520 pg/mL and a second bone biopsy revealed high bone turnover, normal mineralization and normal bone volume. Two years later, iPTH was 250-350 pg/dL and bone metabolism parameters within normal range. The probable utility of teriparatide in the treatment of ABD in dialysis patients is discussed.

Unit dosing of darbepoetin alfa for thetreatment of anemia in patients with end-stage renal disease being switched from recombinant human erythropoietin: Results of a phase IIIb, 27-week, multicenter, open-label study in Greek patients

BACKGROUND

Darbepoetin alfa is an erythropoietis-stimulating glycoprotein with a ∼3-fold longer t1/2 and greater biological activity compared with recombinant human erythropoietin (rHuEPO).

OBJECTIVE

The objective of this study was to evaluate the efficacy andtolerability of long-term (24-week) darbepoetin alfa treatment in maintaining hemoglobin (Hb) concentrations in the target range of 10 to 13 g/dL in patients undergoing dialysis; the patients were switched from rHuEPO to a less-frequent dosing regimen of darbepoetin alfa without an increase in dose.

METHODS

In this Phase IIlb, open-label, multicenter study, patients withend-stage renal disease (ESRD) undergoing dialysis who were receiving rHuEPO BIW or TIW at baseline were switched to darbepoetin alfa QW; patients receiving rHuEPO QW were switched to darbepoetin alfa Q2W Administration of darbepoetin alfa was by the same route as previous rHuEPO administration (IV or SC). Patients received darbepoetin alfa for 24 weeks, including a 20-week drug titration period followed by a 4-week, stable-dose evaluation period. The mode, dose, and frequency of administration of darbepoetin alfa were compared with those of baseline rHuEPO. Tolerability assessment was based on spontaneous reporting and laboratory tests (hematology, vital sign measurement, iron status, and biochemistry).

RESULTS

The study comprised 173 patients who were divided into 2 groups by route of administration (IV group, n = 146; SC group, n = 27). Mean (SE) adjusted increases in Hb concentration from baseline to the evaluation period for patients receiving darbepoetin alfa QW were 0.94 (0.32) g/dL and 0.38 (0.30) g/dL for the IV or SC routes, respectively (P = 0.004 and NS, respectively). For patients receiving darbepoetin alfa Q2W the mean (SE) adjusted increases in Hb concentration were 0.08 (0.53) g/dL and 0.48 (0.35) g/dL for the IV and SC routes, respectively (both, P = NS). No significant differences in IV/SC dose ratio were observed between the 2 routes of administration. In addition, no increases in darbepoetin alfa dose were observed. The most commonly reported adverse events were hypertension (8 patients [5%]) and vascular access thrombosis (4 [2%]). The incidence of treatment-related adverse events was 6 (3%).

CONCLUSIONS

Darbepoetin alfa effectively maintained Hb concentrations within the target range without an increase in dose, even at a reduced dosing frequency. Overall, darbepoetin alfa was well tolerated.

Impact of inflammation on anti-oxidative effects of vitamin E-coated membrane dialyzer in patients on chronic hemodialysis

Hemodialysis (HD) with the use of vitamin E-coated membrane (VEM) dialyzers is shown to exert anti-inflammatory and antioxidative effects in patients with end-stage renal disease on HD. However, the association of baseline inflammatory status with the antioxidative effects of VEM has not been investigated thus far. Thirty-five stable end-stage renal disease patients treated with VEM for 6 months were enrolled in the present prospective, observational cohort study. For the previous 3 months minimum, 17 (48%) patients were dialyzed with a cellulose, eight (23%) patients with a hemophane, and 10 (29%) patients with a polysulfone 1.2 to 1.5 m(2) hollow fiber dialyzer. The effects of treatment on oxidized low-density lipoprotein (oxLDL) were stratified according to half percentiles of baseline serum logC-reactive protein and interleukin-6, and the association between treatment goal, arbitrarily defined as a minimum 30% decrease in baseline oxLDL, was assessed with the use of logistic regression analysis. The higher C-reactive protein and interleukin-6 half percentiles were independently and additively associated with a higher odds ratio for achieving treatment goal. Adjustment for baseline oxLDL, age, sex, HD duration, smoking, and body mass index did not attenuate the odds ratios, whereas the history of diabetes, as primary renal disease, significantly decreased the odds ratio for achieving treatment goal. Increased baseline C-reactive protein and interleukin-6 are independent, additive factors associated with the effect of VEM on oxLDL in HD patients.

Influence of body mass index on the association of weight changes with mortality in hemodialysis patients

BACKGROUND AND OBJECTIVES

A high body mass index (BMI) is associated with lower mortality in patients undergoing hemodialysis. Short-term weight gains and losses are also related to lower and higher mortality risk, respectively. The implications of weight gain or loss may, however, differ between obese individuals and their nonobese counterparts.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Current Management of Secondary Hyperparathyroidism: A Multicenter Observational Study (COSMOS) is an observational study including 6797 European hemodialysis patients recruited between February 2005 and July 2007, with prospective data collection every 6 months for 3 years. Time-dependent Cox proportional hazard regressions assessed the effect of BMI and weight changes on mortality. Analyses were performed after patient stratification according to their starting BMI.

RESULTS

Among 6296 patients with complete data, 1643 died. At study entry, 42% of patients had a normal weight (BMI, 20-25 kg/m(2)), 11% were underweight, 31% were overweight, and 16% were obese (BMI ≥ 30 kg/m(2)). Weight loss or gain (<1% or >1% of body weight) was strongly associated with higher rates of mortality or survival, respectively. After stratification by BMI categories, this was true in nonobese categories and especially in underweight patients. In obese patients, however, the association between weight loss and mortality was attenuated (hazard ratio, 1.28 [95% confidence interval (CI), 0.74 to 2.14]), and no survival benefit of gaining weight was seen (hazard ratio, 0.98 [95% CI, 0.59 to 1.62]).

CONCLUSIONS

Assuming that these weight changes were unintentional, our study brings attention to rapid weight variations as a clinical sign of health monitoring in hemodialysis patients. In addition, a patient's BMI modifies the strength of the association between weight changes with mortality.

Use of phosphate-binding agents is associated with a lower risk of mortality

Hyperphosphatemia has been associated with higher mortality risk in CKD 5 patients receiving dialysis. Here, we determined the association between the use of single and combined phosphate-binding agents and survival in 6797 patients of the COSMOS study: a 3-year follow-up, multicenter, open-cohort, observational prospective study carried out in 227 dialysis centers from 20 European countries. Patient phosphate-binding agent prescriptions (time-varying) and the case-mix-adjusted facility percentage of phosphate-binding agent prescriptions (instrumental variable) were used as predictors of the relative all-cause and cardiovascular mortality using Cox proportional hazard regression models. Three different multivariate models that included up to 24 variables were used for adjustments. After multivariate analysis, patients prescribed phosphate-binding agents showed a 29 and 22% lower all-cause and cardiovascular mortality risk, respectively. The survival advantage of phosphate-binding agent prescription remained statistically significant after propensity score matching analysis. A decrease of 8% in the relative risk of mortality was found for every 10% increase in the case-mix-adjusted facility prescription of phosphate-binding agents. All single and combined therapies with phosphate-binding agents, except aluminum salts, showed a beneficial association with survival. The findings made in the present association study need to be confirmed by randomized controlled trials to prove the observed beneficial effect of phosphate-binding agents on mortality.

Associations of fetuin-A and osteoprotegerin with arterial stiffness and early atherosclerosis in chronic hemodialysis patients

BACKGROUND

Cardiovascular morbidity and mortality remains excessive in patients with chronic kidney disease. The association of vascular changes with regulators of extraosseous calcification in this patient population is still under investigation. The aim of the present study was to investigate the associations of the calcification inhibitor fetuin-A, and the anti-osteoclastic factor osteoprotegerin (OPG) with vascular pathology in chronic hemodialysis patients.

METHODS

In this cross-sectional study including 81 stable chronic hemodialysis patients, we measured carotid-to-femoral pulse wave velocity (cfPWV) with applanation tonometry, reflecting arterial stiffness, and common carotid intima-media thickness (ccIMT), a surrogate of early atherosclerosis, as well as serum levels of fetuin-A and OPG. Co-morbidities, traditional cardiovascular risk factors, inflammatory markers and mineral-bone disease serology parameters were also recorded.

RESULTS

cfPWV correlated inversely with fetuin-A (r=-0.355, p=0.001) and positively with OPG (r=0.584, p<0.001). In multilinear regression analysis including age, gender, diabetes, cardiovascular disease, hypertension, pulse pressure, LDL, logCRP, both fetuin-A and OPG were independently associated with cfPWV (p=0.024 and p=0.041 respectively). ccIMT was negatively associated with fetuin-A (r=-0.312, p=0.005) and positively with OPG (r=0.521, p<0.0001); however these associations lost statistical significance after adjustment for age.

CONCLUSION

In chronic hemodialysis patients both fetuin-A and OPG levels are independently associated with arterial stiffness but not with early atherosclerotic vascular changes.

COSMOS: the dialysis scenario of CKD-MBD in Europe

BACKGROUND

Chronic kidney disease-mineral and bone disorders (CKD-MBD) are important complications of CKD5D patients that are associated with mortality.

METHODS

COSMOS is a multicentre, open cohort, prospective, observational 3-year study carried out in haemodialysis patients from 20 European countries during 2005-07. The present article describes the main characteristics of the European dialysis population, the current practice for the prevention, diagnosis and treatment of secondary hyperparathyroidism and the differences across different European regions.

RESULTS

The haemodialysis population in Europe is an aged population (mean age 64.8±14.2 years) with a high prevalence of diabetes (29.5%) and cardiovascular disease (76.0%), and 28.7% of patients have been on haemodialysis more than 5 years. Patients from the former Eastern countries are younger (59.3±14.3 versus 66.0±13.9), having a lower proportion of diabetics (24.1 versus 30.7%). There were relevant differences in the frequency of measurement of the main CKD-MBD biochemical parameters [Ca, P and parathyroid hormone (PTH)] and the Eastern countries showed a poorer control of these biochemical parameters (K/DOQI and K/DIGO targets). Overall, 48.0% of the haemodialysis patients received active vitamin D treatment. Calcitriol use doubled that of alfacalcidiol in the Mediterranean countries, whereas the opposite was found in the non-Mediterranean countries. The criteria followed to perform parathyroidectomy were different across Europe. In the Mediterranean countries, the level of serum PTH considered to perform parathyroidectomy was higher than in non-Mediterranean countries; as a result, in the latter, more parathyroidectomies were performed in the year previous to inclusion to COSMOS.

CONCLUSIONS

The COSMOS baseline results show important differences across Europe in the management of CKD-MBD.

The effects of vitamin E-coated membrane dialyzer compared to simvastatin in patients on chronic hemodialysis

BACKGROUND

We investigated the effects of the use of vitamin E-coated membrane (VEM) dialyzer in comparison to simvastatin on markers of chronic inflammation, oxidative stress, and endothelial cell apoptosis in ten patients on chronic hemodialysis (HD), aiming at distinguishing the different treatment effects and their time sequence on these pathogenetic routes.

METHODS

Ten HD patients were sequentially submitted to a 6-month treatment with the use of VEM and 10 mg of simvastatin daily, interrupted by a 3-month washout period. At baseline, at 3, and 6 months of each trial, serum C-reactive protein (CRP), apolipoprotein (Apo) A1 and B, lipoprotein-a [Lp(a)], high-sensitivity interleukin-6 (hsIL-6), monocyte chemoattractant protein-1 (MCP-1), soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), soluble E-selectin (sE-selectin), soluble Fas (sFas), soluble Fas ligand (sFasL), and plasma oxidized low-density lipoproteins (oxLDL) levels were determined.

RESULTS

VEM treatment resulted in a significant decrease in CRP, IL-6, sICAM-1 at 3 months, and oxLDL at 6 months, compared to baseline. Simvastatin resulted in a significant decrease in CRP, which correlated with decreases in both total (r = 0.87, p < 0.05) and low-density lipoprotein cholesterol, IL-6, sICAM-1, sVCAM-1, oxLDL, and sFas at 6 months, compared to baseline. Simvastatin effects on sVCAM-1 (mean difference = 652 ng/mL; 95% CI = 294 to 2686; p < 0.05) and sFas (mean difference = 1284 pg/mL; 95% CI = 510 to 1910; p < 0.05) differed significantly from the corresponding VEM effects.

CONCLUSIONS

The 6-month use of VEM resulted in more direct and immediate anti-inflammatory effects compared with those caused by the 6-month treatment with simvastatin. Simvastatin caused a more intense decrease in the markers of inflammation, which was in part correlated with its lipid-lowering effects.

Impact of long-term cinacalcet, ibandronate or teriparatide therapy on bone mineral density of hemodialysis patients: a pilot study

BACKGROUND

Insufficient evidenced-based information is available for the treatment of osteoporosis in hemodialysis (HD) patients.

METHODS

In 102 HD patients, bone mineral density (BMD) was measured twice 16 ± 3 months apart. In the second BMD measurement 66 of them had a femoral neck (FN) T-score <-2.5. Of these 66 patients, 38 consented to a bone biopsy. Depending on both the bone biopsy findings and parathyroid hormone levels, patients were assigned to treatment groups. Eleven patients with osteitis fibrosa and iPTH >300 pg/ml received cinacalcet, 11 with osteitis fibrosa and iPTH <300 pg/ml received ibandronate, 9 with adynamic bone disease received teriparatide, and 7 with mild abnormalities received no treatment. A third BMD measurement was done after an average treatment period of 13-16 months. We compared the annual percent change of FN and lumbar spine (LS) BMD before and during treatment.

RESULTS

FN and LS BMD decreased significantly in the cinacalcet group, with an annual change of 3.6 and 3.4% before treatment to -4.2% (p = 0.04) and -7.7% (p = 0.02) during treatment, respectively. In the teriparatide group, FN and LS BMD increased, although not significantly, with an annual change of -5.4 and -2.6% before treatment to 2.7 and 4.9% during treatment, respectively. In both the ibandronate and the no treatment groups, BMD change rate remained negative during the whole study.

CONCLUSIONS

Teriparatide administration improved BMD in HD patients with adynamic bone disease, although these results did not reach statistical significance. In HD patients with osteitis fibrosa, ibandronate did not improve BMD while cinacalcet reduced BMD.

Detection of multiple cytokines in the urine of patients with focal necrotising glomerulonephritis may predict short and long term outcome of renal function

BACKGROUND

Detection of urinary cytokines in pauci-immune focal segmental necrotizing glomerulonephritis (FSNGN) may provide valuable information about disease pathogenesis and prognosis.

METHODS

Epidermal growth factor (EGF), transforming growth factor (TGF-β1) and vascular endothelial growth factor (VEGF) were measured by ELISA, and Interleukins, monocyte chemotactic protein-1 (MCP-1), macrophage inflammatory protein (MIP1β) by a multiplex cytokine assay, in 38 patients with FSNGN. Their levels were correlated with severity of histological findings and renal function outcome in short and long term.

RESULTS

The percentage of crescents in renal biopsy had positive correlation with TGF-β1 (p=0.004) and IL-15 urinary excretion (p=0.01), and negative correlation with EGF (p=0.01). Increased urinary excretion of IL-6, IL-15, VEGF and MIP-1β was associated with poor renal function outcome, but increased levels of EGF, IL-2 and IL-9 predicted a favourable prognosis. In multiple regression analysis IL-6 and VEGF urinary levels were independent predictors of no-response at the acute phase (p=0.001 and p<0.0001, respectively), while, IL-6 was the only factor (p=0.03) predicted worse outcome at the end of follow-up (39.4±45 months).

CONCLUSION

Increased urinary excretion of IL-6, IL-15, VEGF, TGF-β1, MCP-1 and MIP-1β and reduced EGF, IL-2, IL-9 may be associated with histological damage and influence response to treatment in pauci-immune FSNGN.

Steroids and azathioprine in the treatment of IgA nephropathy

AIM

IgA nephropathy (IgAN) is a very common glomerulonephritis among young adults, but the best therapeutic approach has not been fully elucidated. This study evaluated the effect of two different treatment regimes in IgAN, steroids alone or in combination with azathioprine.

METHODS

Among 122 patients with primary IgA nephropathy diagnosed in the 2000-2007 period, 22 fulfilled the inclusion criteria for the study: estimated glomerular filtration rate (eGRF) ≥30 ml/min/1.73 m(2), urine protein (Upr) ≥1 g/24 h, blood pressure (BP) <130/80 mmHg, and previous treatment with renin-angiotensin system inhibitors (RAASi) and polyunsaturated fatty acids (PFA) for at least 6 months. Patients were randomized to receive either methylprednisolone alone (MP group) or MP in combination with azathioprine (MP + Aza group) for 12 months, while treatment with RAASi + PFA continued unchanged in both groups.

RESULTS

At the completion of the trial, renal function in the MP group remained stable, eGFR from 52 ± 26.7 to 53.6 ± 27.3 ml/min/1.73 m(2), p = NS, and Upr decreased from 2.4 ± 0.9 to 0.8 ± 0.5 g/24 h, p < 0.001. In the MP + Aza group, eGFR slightly increased from 57.4 ± 28.7 to 66 ± 31 ml/min/1.73 m(2), p = NS, and Upr decreased from 2.4 ± 1 to 0.7 ± 0.7 g/24 h, p < 0.001. Four patients from the MP group with partial remission at the end of the trial had a complete response when converted to Aza. Eleven patients (5 from the MP and 6 from the MP + Aza group) relapsed after stopping treatment and were restarted on lower doses.

CONCLUSIONS

Both, steroid treatment alone and steroids in combination with azathioprine seem to be effective in reducing the severity of proteinuria and stabilizing renal function in IgAN. Patients who do not respond to steroids may have a better response with the combination of steroids and azathioprine.

New insights of osmoregulatory system changes in ovarian hyperstimulation syndrome

This study evaluated the osmoregulatory system changes in 39 patients with severe ovarian hyperstimulation syndrome. Plasma osmolality (Posm) less or more than 280 mOsm/kg body weight were associated with inappropriate antidiuretic hormone secretion syndrome and hypovolemia, respectively.

Osmotic nephrosis due to the use of anti-adhesive membrane intraperitoneally

BACKGROUND

A common strategy for the prevention of intra-abdominal adhesions post-operatively has been the application of adhesion barriers into the peritoneal cavity. Side effects of these barriers are infection, abscesses and inadequate wound healing. There is no information about such a side effect of these materials on renal function. The aim of this study was to evaluate the effect of two different, commercially available polysaccharide-based anti-adhesive materials on renal function.

METHODS

In 24 adult Wistar rats, an abdominal midline incision was performed, and an anti-adhesion membrane was placed in the peritoneal cavity so as to cover its whole surface. Four rats were used as the control group. In 12 rats, a membrane of macromolecular polysaccharides, weighing 40 mg/cm2, was placed intra-abdominally and in 8 rats, a hyaluronic acid-hydroacidmethylcellulose membrane weighing 0.4 mg/cm2 was placed. At 24 or 70 h, the rats were sacrificed, and we evaluated changes in serum creatinine, urea, uric acid, K and Na, and histologic examination of the kidney was performed.

RESULTS

The use of the thicker macromolecular membrane was associated with a rise in serum creatinine and urea levels, vacuolization of all the tubular epithelial cells and mild interstitial infiltration. Rats in which the hyaluronic acid-hydroacidmethylcellulose membrane was used did not show any creatinine elevation, and they presented milder histologic lesions.

CONCLUSION

Polysaccharide and cellulose anti-adhesive membrane cause renal damage with tubular cell vacuolization. The severity of kidney damage is relative to the quantity of the membrane material used.

Strumpell's Disease in a Family with Hereditary Focal Segmental Glomerulosclerosis

Strumpell's familial spastic paraplegia is a rare hereditary disease, clinically characterized by progressive disturbance of gait. Focal Segmental Glomerulosclerosis (FSGS) is a frequent glomerulopathy, with an extremely rare familial subtype. The cases of two brothers with Strumpell' s disease are reported, who also developed glomerular renal disease, most probably familial FSGS. The genetics of the two disorders, Strumpell's paraplegia and familial FSGS, are discussed, together with the possibility of a parallel transmission.