A prospective study assessing feasibility of performing percutaneous nephrolithotomy in chronic kidney disease patients - What factors affect the outcome?

ABSTRACT Objectives To primarily evaluate the functional outcomes of PCNL for bilateral renal calculi/calculi in solitary functioning kidney with Chronic Kidney Disease(CKD). To identify factors affecting the renal replacement therapy following PCNL. Materials and Methods Patients with bilateral renal calculi/calculi in solitary kidney and CKD (eGFR<60/s.creatinine>2) and Good Performance Status [Eastern Cooperative Oncology Group (ECOG): 0-2] were included in the study. Results A total of 60 patients with CKD who had bilateral renal calculi/calculi in solitary functioning kidney underwent PCNL. At 6 months, eGFR improved or stabilized in 45 (75%) patients, while in 15 (25%) patients eGFR deteriorated. A total of 5 (14.28%) and 2 (25%) patients of CKD stage 4 and 5 respectively had improvement in eGFR as well as CKD stage. Fourteen (82.35%), 21 (60%), 3 (37.5%) patients of CKD stage 3, 4, 5 had improvement in eGFR but not significant enough to cause stage migration. Again 3 (17.65%) , 9 ( 40%) and 3 (37.5%) patients of CKD stage 3, 4, 5 had reduction in eGFR but not significant enough to cause stage migration. None of the patients had worsening of CKD stage. Preoperative CKD stage and eGFR were compared with measurements made at the final follow up visit (6 months). Conclusion Our results indicate that most patients of renal calculi with CKD show improvement or stabilization of renal function with aggressive stone removal. Improvement is more in patients who have mild to moderate CKD. Aggressive management of comorbidities, peri-operative UTI and complications may delay or avoid progression of CKD status in such patients.

Review of post bariatric surgery effects on common genitourinary physiology

ABSTRACT Background: Obesity is a worldwide challenging health problem. Weight loss through medical management of obesity has not always been successful, thus, giving rise to the need for surgical intervention. Bariatric surgery has been shown to be helpful for morbidly obese patients. However, studies have also shown the effect of surgery on stone formation, fertility and erectile function. This review summarizes the main findings of several studies that analyze stone formation and fertility in men as well as erectile function post bariatric surgery. The underlying pathophysiologic alterations post bariatric surgery include increased absorption of oxalate leading to hyperoxaluria, hypocitraturia and increased urinary calcium oxalate supersaturation. Contradicting data exist on the effect of bariatric surgery on fertility and erectile function. Further studies are needed to analyze the mechanisms.

Long non-coding RNA CHCHD4P4 promotes epithelial-mesenchymal transition and inhibits cell proliferation in calcium oxalate-induced kidney damage

Kidney stone disease is a major cause of chronic renal insufficiency. The role of long non-coding RNAs (lncRNAs) in calcium oxalate-induced kidney damage is unclear. Therefore, we aimed to explore the roles of lncRNAs in glyoxylate-exposed and healthy mouse kidneys using microarray technology and bioinformatics analyses. A total 376 mouse lncRNAs were differentially expressed between the two groups. Using BLAST, 15 lncRNA homologs, including AU015836 and CHCHD4P4, were identified in mice and humans. The AU015836 expression in mice exposed to glyoxylate and the CHCHD4P4 expression in human proximal tubular epithelial (HK-2) cells exposed to calcium oxalate monohydrate were analyzed, and both lncRNAs were found to be upregulated in response to calcium oxalate. To further evaluate the effects of CHCHD4P4 on the cell behavior, we constructed stable CHCHD4P4-overexpressing and CHCHD4P4-knockdown HK-2 cells. The results showed that CHCHD4P4 inhibited cell proliferation and promoted the epithelial-mesenchymal transition in kidney damage and fibrosis caused by calcium oxalate crystallization and deposition. The silencing of CHCHD4P4 reduced the kidney damage and fibrosis and may thus be a potential molecular target for the treatment of kidney stones.

Impact of retrograde flexible ureteroscopy and intracorporeal lithotripsy on kidney functional outcomes

ABSTRACT Objective: The aim of the study was to evaluate renal function and to identify factors associated with renal function deterioration after retrograde intrarenal surgery (RIRS) for kidney stones. Materials and Methods: We retrospectively analyzed patients with renal stones treated by RIRS between January 2010 and June 2013 at a single institute. We used the National Kidney Foundation classification of chronic kidney disease (CKD) to classify Glomerular Filtration Rate (GFR) in 5 groups. The baseline creatinine level was systematically pre-operatively and post-operatively evaluated. All patients had a creatinine blood measurement in June 2013. A change toward a less or a more favorable GFR group following RIRS was considered significant. Results: We included 163 patients. There were 86 males (52.8%) and 77 females (47.3%) with a mean age of 52.8±17 years. After a mean follow-up of 15.5±11.5 months, median GFR was not significantly changed from 84.3±26.2 to 84.9±24.5 mL/min (p=0.675). Significant renal function deterioration occurred in 8 cases (4.9%) and significant renal function amelioration occurred in 23 cases (14.1%). In univariate analysis, multiple procedures (p=0.023; HR: 5.4) and preoperative CKD (p=0.011; HR: 6.8) were associated with decreased renal function. In multivariate analysis these factors did not remain as predictive factors. Conclusion: Stone management with RIRS seems to have favorable outcomes on kidney function; however, special attention should be given to patients with multiple procedures and preoperative chronic kidney disease.

Percutaneous Nephrolithotomy for Staghorn Stones in Patients with Solitary Kidney in Prone Position or in completely Supine Position: a Single-center Experience

To evaluate the effectivity and safety of percutaneous nephrolithotomy (PCNL) in the treatment of solitary kidney with staghorn stones in prone position or in completely supine position.

We retrospectively reviewed the records of 18 patients with staghorn stones in a solitary kidney treated with PCNL. 12 patients underwent PCNL in prone position (group A). 6 patients underwent PCNL in completely supine position (group B). Demographic data, number of accesses, operating time, stone free rate, hemoglobin values, hospital stay and complications were studied. Serum creatinine, systolic and diastolic blood pressure, and new onset hypertension were determined preoperatively and postoperatively at 3 months.

No blood transfusions were required and no abdominal or thoracic organ injuries were reported in both groups. The mean operative time was 104 minutes (range:72-145 minutes) and 128 minutes (range:80-170 minutes), respectively. The I stage stone free rate was 91.7% and 83.3%, respectively. There was no new onset hypertension by the end of follow-up in both groups. Both groups showed a similar fall in serum creatinine at 3 month follow-up period (p = 0.004 and 0.029, respectively). Systolic blood pressure showed a statistically significant improvement in group B (p = 0.034).

PCNL is safe and has an acceptably high stone free rate in patients with solitary kidneys in both prone and completely supine position. At short-term follow-up, systolic blood pressure had improved in PCNL in supine position. .

Nefrolitiasis: fisiopatología, evaluación metabólica y manejo terapéutico / Nephrolithiasis: pathofisiology, metabolic evaluation, and therapy

La nefrolitiasis es un trastorno frecuente en países desarrollados y en desarrollo. Su prevalencia varía entre el 4 y 20% según diferentes series y depende de la edad de la población analizada, las condiciones geográficas y socioeconómicas del grupo en estudio. La prevalencia de litiasis renal aumenta con la edad tanto en varones como en mujeres; es más común en varones jóvenes. Una de las características de la litiasis renal es la alta recurrencia y muchas veces la solución de los cólicos requiere de intervenciones endoscópicas u otro tratamiento urológico y esto hace a la morbilidad de la enfermedad. El promedio de diferentes trabajos que estudiaron la evolución natural de la enfermedad muestra que la posibilidad de recurrencia al año del primer episodio es del 15%, a los 5 años 40% y a los 10 años del 60%. Tanto los factores genéticos como los medioambientales contribuyen a la formación de cálculos. Los factores genéticos explican la tendencia a la agregación familiar de la enfermedad. El rol de la herencia es claro en algunas enfermedades como cistinuria o hiperoxalurias primarias, pero la litiasis idiopática también tiene una tendencia familiar, si bien los genes involucrados aún no se conocen. Dentro de los factores medioambientales se destaca la dieta, o sea determinados hábitos de ingesta que expresan la propensión a la litogénesis que tienen algunos sujetos. En aproximadamente 90% de los afectados es posible identificar alteraciones metabólicas que ayudan no sólo al diagnóstico etiológico sino que permiten también un manejo adecuado, con modificaciones dietéticas e intervenciones farmacológicas específicas. El tratamiento es eficaz en disminuir significativamente la tasa de recurrencias. En esta revisión analizamos la fisiopatología de la hipercalciuria, la hiperoxaluria, la hipocitraturia, y las litiasis úrica y cistínica. Se detallan el manejo del cólico renal y el tratamiento dietético y farmacológico apropiado para cada tipo de litiasis.

Comparative study of renal function between standard and modified anatrophic nephrolithotomy by radionuclide renal scans.

OBJECTIVE: To compare the changes in renal function after surgery between standard and modified anatrophic nephrolithotomy using the technetium 99m-DTPA renal scan in patients with complex staghorn calculi. MATERIAL AND METHOD: From July 2001 to March 2002, standard anatrophic nephrolithotomy (sANL) was performed in 7 patients with complex staghorn calculi and modified anatrophic nephrolithotomy (mANL) was performed in another group of 8 patients with the same condition. Preoperative and postoperative renal function were assessed by technetium 99m-DTPA renal scan. RESULTS: Mean patient age was 41 years in the sANL group and 45 years in the mANL group. Male to female ratio was 4:3 in the sANL group and 5:3 in the mANL group. Median operative time was 205 minutes in the sANL group compare with 180 minutes in the mANL group (P = 0.03). Median estimated blood loss was 300 ml. in the sANL group and 275 ml. in the mANL group (P = 0.17). Median percent reduction of GFR on the operated kidney was 9.13 (-30.03 to -3.15) in the sANL group and 27.25 (-41.81 to -1.55) in the mANL group (P = 0.13). Residual small stone was seen in one patient of the sANL group and ESWL was performed for stone fragmentation. There were no serious short-term complications. CONCLUSION: The average operative time of sANL was longer than mANL however, sANL preserved more renal function than mANL. This study suggested that sANL should be the procedure of choice in patients who have compromised renal function.

Prediction of renal function recovery in opstructive renal failure due to stones

Two hundred and thirty-nine patients with renal and ureteric calculi associated with renal failure were evaluated for recovery potential before definitive surgery. Ultrasonography was carried out pre-operatively in all, followed by percutaneous nephrostomy [PCN] as an initial management before definitive surgery. Diethylene triamine penta acetic acid [DTPA] scan was done in 125 patients after percutaneous nephrostomy, findings of pre- operative DTPA scan were correlated with post-operative drop in serum creatinine. Urine pH, urine Na+, initial diuresis, creatinine clearance and serum creatinine were measured serially after 24 hours and then every week for 6 weeks. Patients were re-evaluated with serum creatinine after 3 months of surgery. Ultrasonography was found to be reliable in predicting future recovery of renal functions in 76.5% cases and true obstruction of shorter duration [F4-group] on DTPA scan in 81.9% cases. Urine pH of 6 or less, post-PCN diuresis and natriuresis were good prognostic indicators. PCN was found to be most reliable method of predicting future recovery of renal function after relief of obstruction with 97.8% accuracy

Prospective and retrospective evaluation of blood pressure changes in patients treated by ESWL for renal stones

Forty-four patients were followed prospectively to detect the stepwise alteration in their blood pressure after ESWL. Further 181 patients, previously treated by ESWL for renal stones, were reevaluated after an average period of 20.3 months [range 6-40 months]to evaluate long term effect of ESWL on their blood pressure. Significant elevation of both systolic and diastolic pressures was found in the majority of patients, most marked, 24 hours after treatment sessions to decrease gradually over the following three months. The annual rise of systolic and diastolic pressures in treated patients was estimated to be 1.1 and 1.4 mmHg, respectively, and new onset of hypertension was calculated to be 4.07% with annual incidence of 3.9%. Changes of diastolic pressure appeared earlier and were statistically more significant than changes of the systolic pressure

Litíase renal: fisiopatologia e orientaçäo de enfermagem frente a esta enfermidade / Nepholithiasis: phisyopathology and nursing orientations

Os autores fazem uma breve revisäo sobre os mecanismos fisiopatológicos que levam a formaçäo de cálculo renal e as orientaçöes de enfermagem necessárias para o controle desta enfermidade.

Contribuiçäo do laboratório de análises clínicas no diagnóstico metabólico da litíase renal / The importance of laboratory tests in the metabolic evaluation of nephrolithiasis

Cerca de 5 porcento da populaçäo brasileira é portadora de litíase renal, o que corresponde a cerca de 7 milhöes de litiásicos brasileiros. É uma patologia que acomete indivíduos jovens, geralmente na terceira década de vida, nos seus anos mais produtivos, além de sua recorrência ser muito elevada. Apesar do avanço no tratamento da litíase renal nos últimos anos, através de técnicas näo invasivas, estes métodos só servem para retirar o cálculo, ou seja, eliminam a consequência da doença e näo a sua causa. Desta forma, todo paciente com urolitíase ou que já apresentou cálculo e, principalmente, aquele com história de múltiplos cálculos devem submeter-se a realizaçäo de um estudo metabólico. Com este objetivo, 73 indivíduos com litíase renal recorrente foram estudados. Destes, apenas 1 (1,4 porcento) näo apresentou alteraçäo em nenhum dos parâmetros analisados. Os principais distúrbios metabólicos encontrados foram hipercalciúria, hipernatriúria, hipocitratúria, hipomagnesúria e hiperuricosúria. Este tipo de estudo é importante e o laboratório de análises clínicas contribui na elucidaçäo dos mecanismos fisiopatogênicos responsáveis pela formaçäo de cálculos e na indicaçäo de uma terapêutica mais racional, adequada e eficaz

Litiasis urinaria en pacientes de la clinica El Bosque / Urinary lithiasis in patients of clinica El Bosque

Se llevo a cabo un estudio descriptivo retrospectivo en 77 pacientes con litiasis urinaria que consultaron al departamento de urologia de la clinica el Bosque de Bogota entre junio de 1979 a diciembre de 1987. Se encontro que la urolitiasis es mas frecuente en el sexo masculino en la poblacion que se encuentra entre los 21 a 40 anos y que realiza poca actividad fisica, ademas se vio mayor incidencia de la entidad en habitantes de clima frio siendo este el unico dato desacorde con los estudios revisados. En cuanto a la presencia de antecedentes se establecio que el 20.7% de pacientes habian presentado un episodio previo y el 212.6% tenian antecedentes personales cercanos. En el cuadro clinico se vio que los sintomas mas frecuentes acusados por los pacientes fueron el dolor abdominal 77% nauseas y vomito 24%, dolor lumbar 22%, hematuria 17%, disuria 13%. La irradiacion del dolor en la mayoria de los casos fue a los genitales 24.6%, region lumbar 14.2% y muslo 12%. Como ayudas diagnosticas fueron solicitadas el cuadro hematico, el parcial de orina y medios radiologicos. En las historias clinicas revisadas no se encontraron datos acerca del tipo de alimentacion del paciente, farmacos que venian rcibiendo y el analisis de los calculos excretados, por lo que no se pudo trabajar sobre estos puntos. Tomando como base el trabajo realizado propusimos un esquema de enfoque y manejo de la entidad, para la Clinica el Bosque (Bogota).

Calciúria, sobrecarga de cálcio e AMP cíclico urinário na avaliaçäo de pacientes com litíase cálcica / Calciuria, calcium overload and urinary cyclic AMP in the evaluation of patients with calcic lithiasis

Para avaliar a participaçäo das paratiróides nos mecanismos fisiopatológicos de pacientes litiásicos hipercalciúricos, analisamos a excreçäo urinária de AMP cíclico (AMPc). Através de dosagens das calciúrias de 24 horas e da prova de sobrecarga oral de cálcio caracterizamos os pacientes em 3 grupos, ou seja: pacientes com hipercalciúria renal (HCaR); com hiperabsorçäo intestinal de cálcio (HAInt) e pacientes litiásicos sem alteraçäo do metabolismo do cálcio. A dosagem do AMPc total urinário nos pacientes com HCaR näo se mostrou aumentada (2,9 + ou - 0,2nmol/dl de filtrado glomerular, p >0,05), näo caracterizando, portanto, hiperparatiroidismo secundário. Esta observaçäo sugere que o paratormônio (PTH) näo participa no mecanismo fisiopatológico da HCaR, ou que a sensibilidade do método näo é suficiente para detectar discretas variaçös intra-ensaio. Portanto, o AMPc total urinário näo foi útil na discriminaçäo das hipercalciúrias. Entretanto, a calciúria de 24 horas e a prova de sobrecarga de cálcio se mostraram adequadas na diferenciaçäo dos estados hipercalciúricos, permitindo com isto abordagem terapêutica mais racional nos pacientes litiásicos com distúrbios metabólicos associados