Profile of renal artery embolization (RAE) for renal trauma: A comparison of data from two major trauma center

ABSTRACT Objective To evaluate usage of renal artery embolization (RAE) for renal injuries and discuss the indications for this treatment. Materials and Methods A retrospective study was performed evaluating the electronic medical records of all patients with renal trauma admitted to two major comprehensive hospitals in Shantou city from January 2006 to December 2015. Results There were 264 and 304 renal traumatic patients admitted to hospital A and B, respectively. LGRT was the reason for presentation in the majority of patients (522, 91.9%). A total of 534 (94.0%) patients were treated conservatively. RAE was performed in 9 patients from 2012 to 2015 at hospital A, including in 6 patients (6/9, 66.7%) with LGRT, and 3 patients (3/9, 33.3%) with HGRT. No patient underwent interventional therapy (RAE) at hospital B during the same period. No significant differences in the operative rate of hospital A were observed between the two time periods (2006-2011 and 2012-2015). The operative rate for LGRT between the two hospitals from 2006 to 2011 and 2012 to 2015 was not significantly different. Hospital A showed a significant decrease in the rate of conservative treatment for patients with LGRT. In the univariate and multivariate analyses, the AAST renal grade both were significantly associated with undergoing RAE. Conclusions LGRT was present in the majority of patients, and most cases of renal trauma could be treated with conservative treatment. RAE was well utilized for the treatment of renal trauma. However, some patients with LGRT were treated with unnecessary interventional therapy.

Protocolo ultrasonográfico enfocado en cirugía cardiaca posquirúrgica CCROSS (Cardiac, Cerebral, Renal, Optic nerve, lung ultraSound Study) / Ultrasonographic protocol focused on post cardiac surgery CCROSS (Cardiac, Cerebral, Renal, Optic nerve, lung ultraSound Study)

Resumen El uso de ecocardiografía enfocada es de gran utilidad en la valoración, tratamiento y seguimiento del paciente en estado crítico. Es, junto con la clínica y el estetoscopio, una herramienta que complementa el actuar del médico ante las diversas etiologías que determinan un estado de choque o aumentan la morbimortalidad, especialmente en pacientes posquirúrgicos de cirugía cardíaca, en quienes no se tiene algoritmos de manejo emergente en el posquirúrgico. Ante tal situación, en el Instituto Nacional de Cardiología Ignacio Chávez se ha realizado y propuesto un algoritmo de manejo en los pacientes posquirúrgicos cardíacos: mediante ultrasonografía enfocada, abarcando ecoscopia transtorácica, ultrasonido pulmonar, ultrasonido del nervio óptico y renal mediante la valoración de índices resistivos renales. Diversas sociedades han creado sus protocolos de abordaje en pacientes en estado crítico, por lo que en el Instituto, específicamente en la terapia intensiva cardiovascular, ha creado el protocolo CCROSS (Cardiac, Cerebral, Renal, Optic nerve, lung ultraSound Study) para el abordaje inicial de estos pacientes y se encuentra en marcha actualmente un estudio para su validación, reproducibilidad y eficacia.

Abstract The use of echocardiography is very useful in the evaluation, treatment and follow-up of the patient in critical condition. Along with clinic and the stethoscope, it is a tool that complements the act of the physician faced with the diversity of etiologies that determine the state of shock and increase morbidity and mortality, especially in post cardiac surgery patients, in whom there are no management emergency postsurgical algorithms. In view of this situation, at the National Institute of Cardiology Ignacio Chávez, a management algorithm has been made and improved in cardiac postsurgical patients: through focused ultrasonography, including transthoracic echography, pulmonary ultrasound, optic nerve ultrasound, and renal ultrasound by evaluating renal resistive indices. Several societies have created their protocols for addressing patients in critical condition, so in the Institute, specifically in cardiovascular intensive therapy, has created the CCROSS protocol (Cardiac, Cerebral, Renal, Optic nerve, lung UltraSound Study) for the initial approach of these patients, and it is being carried out a study for its validation, reproducibility and efficacy.

Laparoscopic renal biopsy

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

The role of fetal-maternal microchimerism as a natural-born healer in integrity improvement of maternal damaged kidney

ABSTRACT Purpose: To identify the fetal stem cell (FSC) response to maternal renal injury with emphasis on renal integrity improvement and Y chromosome detection in damaged maternal kidney. Materials and Methods: Eight non-green fluorescent protein (GFP) transgenic Sprague-Dawley rats were mated with GFP-positive transgenic male rats. Renal damage was induced on the right kidney at gestational day 11. The same procedure was performed in eight non-pregnant rats as control group. Three months after delivery, right ne- phrectomy was performed in order to evaluate the injured kidney. The fresh perfused kidneys were stained with anti-GFP antibody. Polymerase chain reaction (PCR) assay was also performed for the Y chromosome detection. Cell culture was performed to detect the GFP-positive cells. Technetium-99m-DMSA renal scan and single-photon emission computed tomography (SPECT) were performed after renal damage induction and 3 months later to evaluate the improvement of renal integrity. Results: The presence of FSCs was confirmed by immune histochemical staining as well as immunofluorescent imaging of the damaged part. Gradient PCR of female rat purified DNA demonstrated the presence of Y-chromosome in the damaged maternal kidney. Moreover, the culture of kidney cells showed GPF- positive cells by immuno- fluorescence microscopy. The acute renal scar was repaired and the integrity of dam- aged kidney reached to near normal levels in experimental group as shown in DMSA scan. However, no significant improvement was observed in control group. Conclusion: FSC seems to be the main mechanism in repairing of the maternal renal injury during pregnancy as indicated by Y chromosome and GFP-positive cells in the sub-cultured medium.

Extensive renal sinus lipomatosis in xanthogranulomatous pyelonephritis simulating liposarcoma

ABSTRACT Renal replacement lipomatosis is a condition characterized by varying degrees of renal parenchymal atrophy and perirenal fibrofatty proliferation secondary to chronic inflammation such as xanthogranulomatous pyelonephritis. In severe cases, imaging findings can be misdiagnosed as retroperitoneal liposarcoma.

Tumor fibroso solitario y síndrome Doege-Potter / Solitary fibrous tumor and Doege-Potter syndrome

El tumor fibroso solitario es raro. Si bien su localización más frecuente es la pleura, han sido informados algunos casos de ubicación retroperitoneal. Es difícil diferenciarlo imagenológicamente de otras neoplasias, por lo que casi siempre el diagnóstico es histológico. Dado que los tumores fibrosos solitarios tienen presentaciones clínicas muy diversas, una mejor compresión de la ubicación y sus características imagenológicas ayudaría a abreviar la lista de diagnósticos diferenciales. Comunicamos un tumor fibroso solitario de localización retroperitoneal cuyo diagnóstico fue confirmado por examen histológico.

The solitary fibrous tumor is uncommon. Even though it frequently locates in the pleura, a few cases have been reported in the retroperitoneum. Differentiation from other neoplasms is difficult, and therefore the diagnosis is always attained through histological examination. Although solitary fibrous tumors have variable clinical behaviors, a better comprehension of the location and its imaging characteristics would help to decrease the list of differential diagnoses. We report a solitary fibrous tumor located in the retroperitoneum whose diagnosis was confirmed by histological examination.

Intraparenchymal hematoma as a late complication of retrograde intrarenal surgery

ABSTRACT A 34 year-old woman was admitted to our hospital with left flank pain. A non-contrast enhanced computerized tomography (NCCT) revealed a 1.5x2cm left proximal ureter stone. Patient was scheduled for ureterorenoscopy (URS) and stone removal. She was submitted to retrograde intrarenal surgery (RIRS). At the postoperative 1st day, the patient began to suffer from left flank pain. A NCCT was taken, which revealed a subcapsular hematoma and perirenal fluid. The patient was managed conservatively with intravenous fluid, antibiotic and non-steroidal anti-inflammatory drug therapy and was discharged at the postoperative 6th day. Two weeks after the discharge the patient was admitted to emergency department with severe left flank pain, palpitation and malaise. KUB (kidney-ureter-bladder) radiography showed double-J stent (DJS) to be repositioned to the proximal ureter. Patient was evaluated with contrast enhanced CT which revealed an 8cm intraparenchymal hematoma/abscess in the middle part of the kidney. A percutaneous drainage catheter was inserted into the collection. The percutaneous drainage catheter and the DJS were removed at the 10th day of second hospitalization. RIRS surgery is an effective and feasible choice for renal stones with high success and acceptable complication rates. However, clinician should be alert to possible complications.

Ruptura pieloureteral espontánea bilateral durante un urotac: caso clínico / Bilateral spontaneous renal pelvis rupture during a computed tomography: report of one case

Spontaneous rupture of the urinary excretory system is a rare condition. It is mainly associated with obstruction of the excretory system and is usually unilateral. We report a 58 years old male who, during the performance of a computed tomography of the urinary system, felt an intense lumbar pain. A bilateral rupture at the level of the fornix was found. The patient had an uneventful evolution thereafter. Fifteen days later a new computed tomography showed indemnity of the urinary excretory system.

Retrocaval ureter and contra lateral renal agenesis – a case report and review of literature

ABSTRACT Associated congenital anomalies are seen in 21% of retrocaval ureter patients; among them, associated contralateral renal agenesis is a very rare entity. We report one such case of right circumcaval ureter with left renal agenesis, diagnosed after febrile UTI. Surgical correction with uretero-ureterostomy was successful. In literature very few such cases are reported and only one case with renal failure was reported. Unilateral renal agenesis cases complicated by associated such anomalies need definitive management and lifelong clinical monitoring to diagnose and prevent chronic kidney disease.

Comparison of Renal Function between Robot-Assisted and Open Partial Nephrectomy as Determined by Tc 99m-DTPA Renal Scintigraphy

We compared postoperative renal function impairment between patients undergoing robot-assisted partial nephrectomy (RAPN) and those undergoing open partial nephrectomy (OPN) by using Tc-99m diethylenetriaminepentaacetic acid (DTPA) renal scintigraphy. Patients who underwent partial nephrectomy by a single surgeon between 2007 and 2013 were eligible and were matched by propensity score, based on age, tumor size, exophytic properties of tumor, and location relative to the polar lines. Of the 403 patients who underwent partial nephrectomy, 114 (28%) underwent RAPN and 289 (72%) underwent OPN. Mean follow-up duration was 35.2 months. Following propensity matching, there were no significant differences between the two groups in tumor exophytic properties (P = 0.818) or nephrometry score (P = 0.527). Renal ischemic time (24.4 minutes vs. 17.8 minutes, P < 0.001) was significantly longer in the RAPN group than in the OPN group, while the other characteristics were similar. Multivariate analysis showed that greater preoperative renal unit function (P = 0.011) and nephrometry score (P = 0.041) were independently correlated with a reduction in glomerular filtration rate. The operative method did not correlate with renal function impairment (P = 0.704). Postoperative renal function impairment was similar between patients who underwent OPN and those who underwent RAPN, despite RAPN having a longer ischemic time.

Fístula nefrobronquial en paciente pediátrico: caso clínico / Nephrobronchial fistula in pediatric patient. Case report

La fístula nefrobronquial es una complicación infrecuente de las infecciones renales, que ocurre habitualmente en pacientes adultos con pielonefritis xantogranulomatosa. Comunicamos el caso de una paciente de 12 años con antecedentes de mielomeningocele operado e infección urinaria recurrente, quien consultó con historia de cuatro semanas de fiebre, tos y disnea. Ingresó en shock séptico y presentó inundación de la vía aérea por pus, que le ocasionó episodio de asistolia. Mediante tomografía computarizada de abdomen, se diagnosticó extensa colección perirrenal izquierda. Se efectuó un drenaje percutáneo, que dio salida a pus y aire. TAC de tórax y abdomen mostró fístula transdiafragmática entre la base pulmonar izquierda y colección intraabdominal. Se realizó nefrectomía total. La paciente mostró mejoría progresiva poscirugía y regresión total de la sintomatología. Este infrecuente caso clínico en niños ilustra la importancia del diagnóstico precoz de infección urinaria en pacientes con patologías asociadas y de presentar un elevado índice de sospecha ante una complicación potencialmente letal

Nephrobronchial fistula is a rare complication of kidney infections, usually occurring in adult patients with xanthogranulomatous pyelonephritis and very occasionally in children. We reported a 12-year-old girl, with a history of myelomeningocele and recurrent urinary tract infection, who presented with a four-week fever, cough and dyspnea, developing septic shock and presenting flood of airway by pus which caused cardiac arrest. A diagnosis of left perirenal extensive collection was established by abdominal computed tomography (CT). The patient first had antibiotic therapy and percutaneous drainage was performed draining pus and air. Thoracic and abdominal CT scan was performed corroborating transdiaphragmatic fistula. Total nephrectomy was performed. The patient showed gradual improvement after surgery and total regression of symptoms. Pathologic examination concluded chronic pyelonephritis. This case report illustrates a rare complication in children, the importance of early diagnosis of urinary tract infection in patients with comorbidities and of exhibiting a high index of suspicion to a potentially lethal complication.

Laparoscopic excision of a renal subcapsular abscess presenting as a subcapsular haematoma / Extirpación laparoscópica de un absceso renal subcapsular que se presenta como un hematoma subcapsular

Renal subcapsular abscess is a very rare entity that is defined by a suppurative process localized to a space between the renal capsule and the renal parenchyma. The pathogenesis and aetiology of this entity remain speculative. To our knowledge, only five cases have been reported in the English literature. We describe a 74-year old woman with renal subcapsular abscess treated with laparoscopic removal and do a review of the literature.

El absceso renal subcapsular es una entidad muy rara que se define por un proceso supurativo localizado en un espacio entre la cápsula renal y el parénquima renal. La patogénesis y la etiología de esta entidad siguen siendo asunto de especulación. Hasta donde sabemos, solamente cinco casos han sido reportados en la literatura inglesa. Describimos aquí a una mujer de 74 años de edad con un absceso renal subcapsular tratado con extirpación laparoscópica y hacemos a la par una revisión de la litera-tura

Relationship Between Uncommon Computed Tomography Findings and Clinical Aspects in Patients With Acute Pyelonephritis

PURPOSE: Computed tomography (CT) has become popular in the diagnosis of acute pyelonephritis (APN) and its related complications in adults. The aim of this study was to investigate the relationship between uncommon CT findings and clinical and laboratory data in patients with APN. MATERIALS AND METHODS: From July 2009 to July 2012, CT findings and clinical data were collected from 125 female patients with APN. The six uncommon CT findings (excluding a wedge-shaped area of hypoperfusion in the renal parenchyma) studied were perirenal fat infiltration, ureteral wall edema, renal abscess formation, pelvic ascites, periportal edema, and renal scarring. The clinical parameters analyzed were the age and body mass index of the patients as well as the degree and duration of fever. Laboratory parameters related to inflammation and infection included white blood cell count, C-reactive protein (CRP) level, erythrocyte sedimentation rate, pyuria, and bacteriuria. RESULTS: The most common CT finding was perirenal fat infiltration (69 cases, 55%). A longer duration of fever, higher CRP level, and grade of pyuria were related with perirenal fat infiltration (p=0.010, p=0.003, and p=0.049, respectively). The CRP level was significantly higher in patients with renal abscess and ureteral wall edema (p=0.005 and p=0.015, respectively). CONCLUSIONS: The uncommon CT findings that were related to aggravated clinical and laboratory parameters of APN patients were perirenal fat infiltration, ureteral wall edema, and renal abscess formation. The inflammatory reaction and tissue destruction may be more aggressive in patients with these CT findings.

Von Hippel-Lindau Syndrome: Demonstration of Entire Disease Spectrum with 68Ga-DOTANOC PET-CT

Von Hippel-Lindau (VHL) syndrome is a rare neoplastic disorder characterized by central nervous system (CNS) and visceral tumors. We here present 68Ga-labelled [1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraacetic acid]-1-Nal3-Octreotide positron emission tomography computed tomography findings in a 52 year old female with VHL syndrome, demonstrating both CNS and visceral tumors.

Evolución de Pacientes sometidos a Cirugía Vascular Periférica y rol del Cateterismo Cardiaco en la Nefropatía inducida por contraste / Outcomes of patients submitted to peripheral vascular surgery and influence of coronary angiography in renal complications

La evaluación del riesgo cardiovascular en cirugía no cardíaca presenta implicancias diversas. La nefropatía inducida por contraste (NIC) es una complicación derivada de procedimientos de intervencionismo coronario percutáneo. Esta investigación presenta como objetivos establecer el rol de la coronariografía como causante de la nefropatía por contraste, y evaluar la evolución peroperatoria y a los 6 meses de una cirugía vascular. Entre junio y diciembre de 2011 se incluyeron para el presente estudio, 30 pacientes candidatos a cirugía vascular periférica internados en el Hospital Central del Instituto de Previsión Social de Asunción, Paraguay. De ellos, 18 fueron derivados para la realización de eco-stress con dobutamina (EED) y otros estudiados por cinecoronariografía (CCG), 3 realizaron el cross over a CCG por presentar bajo umbral isquémico a la EED. Del grupo EED (n=18), 61% fueron sometidos a cirugía vascular; 50% by pass, 11% angioplastia. La evolución fue favorable en 82%. Todos los pacientes sometidos a CCG presentaban algún tipo de coronariopatía. 47% (n=15) han sido revascularizados previamente antes de ser conducidos a la cirugía vascular. El 60% (n=15) presentaban función renal normal. A los 6 meses 73% (n=15) mantuvieron los valores. Ninguno fue a diálisis y 33% (n=15) fue a cirugía vascular. La mortalidad quirúrgica fue del 20%. Del planteo inicial de cirugía vascular 41% (n=30) llegó a ser concretado. La EED debería considerarse una opción válida, sin embargo, conviene aclarar que en publicaciones actuales se sostiene el ingreso de pacientes a cirugías vasculares periféricas sin necesidad de la misma. Se concluye que la cinecoronariografía no fue determinante del empeoramiento de las cifras del perfil renal y la EED es útil para estratificar a los pacientes de alto riesgo. Palabras clave: cirugía, eco stress dobutamina, cinecoronariografía, nefropatía.

Evaluation of the cardiovascular risk in non-cardiac surgery has multiple consequences. Nephrotoxicity by IV contrast is a complication from de percutaneous coronary catheterism procedure. This study has as objectives establishing the role of the coronary catheterism as a cause of contrast nephrotoxicity and determines de peri-operative evolution of these patients and at 6 months after the vascular surgery. Between June and December of 2011, 30 patients admitted to the Hospital Central del Instituto de Previsión Social of Asunción, Paraguay and who were candidates for peripheral vascular surgery were included. From this cohort, 18 patients were send for echo-stress with dobutamine, and others were studied by cinecoronariography (CCG), 3 were crossed over to cinecoronariography because of low isquemic threshold on echo-stress with dobutamine (EED). From the EED group (n=18), 61% went to vascular surgery, 50% bypass surgery, 11% angioplasty, the outcome were favorable in 82%. All the patients that went through cinecoronariography (CCG) showed some kind of coronary problem. 47% (n=15) has been re-vascularized previously, before vascular surgery. 60% (n=15) have a normal renal function. At the 6 months mark, 73% (n=15) still have normal values for renal function, none of these patients went to dyalisis and 33% (n=15) went for vascular surgery. Surgical mortality was of 20%, from the initial planning of vascular surgery, 41% (n=30) actually went for this procedure. The echo-stress with dobutamine (EED) should be consider as a valid option, but we need to clarify that in current publications it is not sustained the need for this procedure in patients undergoing peripheral vascular surgery. We concluded that the cinecoronariography (CCG) was not cause contrast nephrotoxicity and the echo-stress with dobutamine (EED) is helpful to classify high risks patients. Key words: surgery, cinecoronariography eco stress, echo-stress with dobutamine, nephrotoxicity.

Acute Severe Thrombocytopenia Following Non-Ionic Low-Osmolarity Intravenous Contrast Medium Injection

Intravenous contrast medium (ICM) rarely induces anaphylactic reactions, including urticaria, hypotension and respiratory failure. Even the most modern ICM may cause such adverse events. Thrombocytopenia has been reported as an extreme rare consequence of ICM. Here we report on a case of a 72-year-old male patient with a self-limiting severe acute thrombocytopenia following administration of intravenous non-ionic low-osmolarity contrast medium. No such low platelet count has ever been reported. We also present a review of the literature.

Características clínicas y diagnósticas en infarto renal agudo en una serie clínica / Clinical features and diagnosis in acute renal infarction in a clinical series

El infarto renal agudo constituye un diagnóstico infrecuente. Ello puede deberse a que sus síntomas son similares a los de los cálculos renales o la pielonefritis aguda. Por esa razón, el síntoma cardinal de dolor de flanco debe ser investigado en forma muy acabada. Esta serie clínica revisa seis casos de infarto renal agudo vistos en esta institución durante el año 2007.

Acute renal infarction represents an uncommon diagnosis. Its symptoms may overlap with other disorders such as renal stones or pyelonephritis. Therefore a thoroughly study of the patient with flank pain is mandatory. This clinical series assess the main diagnostic and etiologic features of patients diagnosed as acute kidney infarction.

value of renal ultrasound in children with a first episode of urinary tract infection

Urinary tract infection [UTI] is a common pediatric problem. Guidelines recommend obtainiing a renal ultrasonogram [RUS] for young children after a first UTI. Our aim was to assess the value of routine RUS in the management of children hospitalized with a first episode of UTI. We conducted a retrospective review of the medical records of 130 children 12 years of age or younger admitted with a first UTI. Children were excluded if they had a urinary tract abnormality before admisssion and/or had been treated with an antibacterial agent within 7 days before admission. The yield of RUS was measured by ability to detect renal abnormalities, by the sensitivity and specificity for detecting vesicoureteral reflux [VUR] using voiding cystourethrogram [VCUG] as a gold standard, and by its influence on UTI managemment. RUS was conducted in 130 children, but only 118 returned for a VCUG and were included in the study. The findings were positive for VUR in 20 of 40 patients [50%] with a confirmed VUR on VCUG and posittive in 18 of 78 patients [23.1%] without VUR on VCUG. Of the 20 patients with a normal RUS who showed VUR, 2 had grade I reflux, 8 had grade II reflux, 7 had grade III reflux and 3 had grade IV reflux. The sensitivity, specificity, positive and negative predictive value of ultrasound in suggesting VUR was 50% and 76.9%, 52.6% and 75%, respectively. Except for one, the result of an abnormal RUS did not alter the management of our pattients. The results of our study show that the RUS has a little value in the management of children with a first UTI