Expression of receptor activator of nuclear factor-kappa B ligand in leukocytes during acute kidney rejection after transplantation in rats.

BACKGROUND: Acute cellular rejection of the transplanted kidney is an important cause of impaired graft function. One of the basic characteristics of acute cellular rejection according to the latest Banff classification of renal allograft pathology is the presence of a large number of T lymphocytes in the allografted tissue. Osteoprotegerin, receptor activator of nuclear factor-kappa B (RANK) and RANK ligand (RANKL), three relatively novel members of the tumor necrosis factor superfamily, have crucial roles not only in physiologic and pathologic bone metabolism but also in immunologic processes. The aim of our study was to determine the expression of RANKL and RANK by T lymphocytes and macrophages in acute cellular kidney allograft rejection in rats. METHODS: The study included 15 male Wistar rats of 3 months old and 250-300 g as recipients and 15 male DA rats donors of 3 months old; and weight 250-300 g. When animals were sacrificed at 3 weeks to extract the transplanted kidney for pathohistologic analysis and immunoflorescence. all samples showed acute cellular rejection. Kidney sections were examined by dual-labeled immunofluorescence to detect CD4, CD8, or CD68 (red) and RANK or RANKL (green) with coexpressing cells as orange. RESULTS: RANKL-positive expression colocalized with CD4(+) and CD8(+) T lymphocytes in acutely rejected kidney tissue. There was no association between CD4(+) and CD8(+) T cells with RANK expression, which was evident by infiltrating CD68-positive macrophages in the kidney tissue interstitium. CONCLUSION: RANK and RANKL were expressed by T lymphocytes and macrophages in acute cellular kidney rejection after transplantation in rats.

Bone morphogenetic protein-7 reduces cold ischemic injury in rat kidney.

BACKGROUND: Deceased donor kidneys have a high incidence of delayed graft function attributable to ischemia-reperfusion injury. Although preservation solution and cold storage reduce cold ischemic injury, the depletion of cellular energy and oxidative signalling leads to cellular damage. Because bone morphogenetic protein-7 has renoprotective effect, we have hypothesized that recombinant human bone morphogenetic protein-7 (rh BMP-7) will better preserve kidney tissue exposed to prolonged cold ischemia in comparison with University of Wisconsin (UW) solution. We evaluated how the duration of cold ischemia influences the cold ischemic injury. METHODS: Levels of lipid peroxidation, protein carbonyl content, as well as superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) activities were determined in the kidneys by spectrophotometry after 6, 12, and 24 hours of cold ischemia. RESULTS: Time-dependent increases in the levels of lipid peroxidation and protein carbonyl content at all time points were significantly lower in rhBMP-7-perfused kidneys versus the UW-treated group. SOD activity after 6 hours, as well as GSH-Px activity after 24 hours of cold ischemia was significantly higher in the kidney tissue perfused by rhBMP-7 than in UW group. CONCLUSION: rhBMP-7 significantly decreases cellular damage in rat kidney versus UW preservation solution and this is attributed to lowering of cold ischemia injury and maintaining prolonged tissue antioxidant activity.

Extracorporeal shockwave lithotripsy of ureteral stone in a patient with en bloc kidney transplantation: a case report.

We report a case of ureterolithiasis in a patient with an en bloc kidney transplantation, using extracorporeal shockwave lithotripsy (ESWL). The patient presented with asymptomatic macrohematuria. Computed tomography revealed a ureteral calculus just below the pyeloureteral junction with hydronephrosis of the medially positioned kidney. Took two sessions of ESWL were required for complete disintegration of the stone. At 3 years after successful treatment, the patient has an excellent functioning and stone-free graft.

Influence on gallbladder volume of early postoperative gastric supply of nutrients.

BACKGROUND & AIM: The gallbladder volume is a predictor of biliary stasis and the formation of biliary sludge. Biliary stasis and sludge have been recently recognized as the precursors of acute acalculous cholecystitis, as well as 'idiopathic' postoperative pancreatitis, rare but very serious complications after surgery. The aim of the study was to establish how early postoperative gastric supply of nutrients affects the gallbladder volume in patients after noncardiac and cardiac surgery. METHODS: In the two prospective, randomized studies 40 patients (study I-noncardiac surgery) treated at surgical ICU after major elective extrahepatobiliary and extragastrointestinal surgeries (7 thoracic, 19 vascular, 14 urological) and 40 patients (study II-cardiac surgery) treated at cardiosurgical ICU after CABG surgery were analyzed. In both studies the patients were divided into two groups: control group C (study I: 20 patients, age 45+/-18 yrs, male 65%; study II: 20 patients age 58+/-7 yrs, male 60%) and group E (group of early postoperative gastric supply of nutrients) (study I: 20 patients, age 52+/-17 yrs, male 50%; study II: 20 patients; age 59+/-8 yrs, male 65%). For the first 24 hours the patients in group C received only crystalloid solutions and the gallbladder volume was verified 24 hours after the surgery. In group E, postoperative gastric supply of nutrients began 18 hours after surgery (Osmolite, Ross; first 3 hours 30 ml/h and second 3 hours 50 ml/h; total 240 ml after 6 hours). In all patients sonographic measurement of gallbladder volume was performed immediately before surgery and 6 hours after the start of feeding (24 hours after surgery). The measurement was done with ultrasonographic scanner Hitachi 405 EUB (convex probe 3.5-5MHz) by the same specialist, and the volume was calculated using the ellipsoid method. RESULTS: The gallbladder volume measured by ultrasonography 24 hours after surgery in study I (noncardiac surgery) in group E amounted to 43+/-25 ml while in control group C it was significantly higher, i.e. 67+/-30 ml (P<0.05). In study II (cardiac surgery) in group E gallbladder volume amounted to 59+/-15 ml while in control group C it was also significantly higher, i.e. 71+/-11 ml (P<0.05). CONCLUSION: An early postoperative gastric supply of nutrients after both noncardiac and cardiac adult surgery diminishes the volume and probably stimulates the motility of the gallbladder, thus preventing biliary stasis and the formation of biliary sludge.

Ultrasonography in the evaluation of hemoperitoneum in war casualties.

The aim of this study was to evaluate the sensitivity, specificity, accuracy, and positive and negative predictive values of emergent ultrasound examination in the detection of hemoperitoneum among war casualties, and to compare the results of this method in a specific war situation and civil conditions. Ninety-four wounded individuals with suspected blunt or penetrating abdominal trauma were treated at a level I war hospital (group W), and 242 civilians with multiple injuries with suspected blunt abdominal trauma were evaluated at the emergency center of a university hospital (group C). All examinations were performed in less than 5 minutes with a portable ultrasonographic scanner, and typical points were scanned (Morison's pouch, Douglas and perisplenic spaces, paracolic gutter). In group W, hemoperitoneum was identified correctly in 19 patients, with three false-negative and no false-positive findings, whereas group C presented 98 true-positive results, 13 false-negative results, and again no false-positive results. We observed that ultrasonography in specific war conditions showed sensitivity of 86%, specificity of 100%, accuracy as high as 97%, positive predictive value of 100%, and negative predictive value of 96%, whereas in civil conditions the corresponding values were 88%, 100%, 95%, 100%, and 91%, respectively. The sensitivity, specificity, accuracy, and positive and negative predictive values of emergent ultrasound examination in the diagnosis of hemoperitoneum are approximately equal in war and civil conditions.

Kidney length in postoperative acute renal failure.

PURPOSE: The aim of this study was to evaluate kidney length in patients with postoperative acute renal failure (PARF). METHODS: The effect of PARF on renal size was prospectively studied in 76 patients with PARF and 40 healthy volunteers. Sonographic measurements of kidney length and the level of serum creatinine were obtained each day patients stayed in our surgical intensive care unit. These measurements were done once in volunteers. All study subjects were divided into groups on the basis of age, those younger than 65 years and those 65 years or older. Statistical analyses on the relation of renal size, age, and degree of PARF used the kidney length:body height ratio (KBR) and the peak serum creatinine level. Follow-up kidney length and creatinine measurements were done in 24 patients 1-5 years after they recovered from PARF. RESULTS: Regardless of age, mean KBRs were significantly greater in patients than in healthy volunteers (< 65 years, p < 0.001; > or = 65 years, p = 0.008), with a negative correlation between KBR and patient age (r = -0.664; p < 0.001). A positive correlation was found between the KBR and the peak serum creatinine level in patients younger than 65 years (r = 0.543; p < 0.001); an insignificant negative correlation was found between these factors in patients 65 years or older (r = -0.264; p = 0.1). Follow-up on recovered patients showed that their KBRs were significantly lower than the values when patients had PARF (< 65 years, p < 0.001; > or = 65 years, p = 0.027). CONCLUSIONS: PARF produces a sonographically measurable increase in renal size.

Sonographic measurement of absolute and relative renal length in adults.

PURPOSE: The aim of this study was to evaluate sonographically measured absolute and relative lengths of normal kidneys according to subject height, sex, and age. METHODS: Real-time sonography was performed on 202 subjects. Measurements of longitudinal renal diameter represented absolute renal length. Relative renal length was calculated using the kidney length: body height ratio (KBR). RESULTS: Statistical analyses were done on findings in 175 subjects without renal impairment (104 men and 71 women) whose ages ranged from 17 to 85 years (mean +/- SD, 46.3 +/- 17.1). The mean heights of the subjects were 176 +/- 7 cm for men and 167 +/- 6 cm for women. The left kidney was absolutely (mean +/-SD, 112 +/- 9 mm) and relatively (mean KBR +/- SD, 0.655 +/- 0.042) longer than the right kidney (absolute length, 110 +/- 8 mm; KBR, 0.641 +/- 0.038), regardless of sex (p < 0.01). The absolute renal length was significantly greater in men than in women for both kidneys (p < 0.01), but there was no significant difference between KBRs (p > 0.05). Renal length decreased with age, and the rate of decrease seemed to accelerate at 60 years and older. When height and age were included in the multivariate regression analysis, sex was not a significant predictor of kidney length. CONCLUSIONS: Relative renal length better represents kidney size than absolute renal length because it eliminates sex and height differences.

Resistance and pulsatility indices in acute renal obstruction.

PURPOSE: The aim of this study was to evaluate the reliability of Doppler waveform alterations in diagnosing acute unilateral renal obstruction. METHODS: From December 1993 to January 1996, 54 patients with unilateral renal obstruction were prospectively examined by conventional and duplex Doppler sonography. Seventy-eight patients with nonrenal abdominal problems comprised the control group. Doppler signals were obtained from interlobar arteries and arcuate arteries at the corticomedullary junction. From the waveform analysis, we calculated resistance (RI) and pulsatility (PI) indices. We also used the differences in RI and PI between the 2 kidneys in the same examinee (delta RI and delta PI) for further statistical analysis. RESULTS: The mean RI and PI (+/- standard deviation) in the patients without renal impairment were 0.64 +/- 0.04 and 1.14 +/- 0.14, respectively. The mean delta RI and delta PI were 0.02 +/- 0.01 and 0.07 +/- 0.05, respectively. Both the RI and PI were significantly correlated with age (r = 0.74 and 0.69, respectively; p < 0.01). Acute renal obstruction significantly (p < 0.01) elevated the mean RI (0.72 +/- 0.04), delta RI (0.09 +/- 0.04), PI (1.42 +/- 0.17), and delta PI (0.33 +/- 0.18). Significant decreases in RI and delta RI were noted after relief of the obstruction. The best accuracy in diagnosing acute unilateral renal obstruction was achieved with the combination of delta RI > or = 0.06 and/or delta PI > or = 0.20, which had a sensitivity of 94% and specificity of 99%. CONCLUSIONS: Renal Doppler indices are reliable parameters in the sonographic diagnosis of acute unilateral obstructive uropathy.

Management and complications of urolithiasis during pregnancy.

OBJECTIVE: To identify all pregnant women with urolithiasis, and to determine the mode of diagnosis and treatment with reference to obstetric outcome. METHOD: From January 1, 1986 to December 31, 1991, relevant medical records were retrospectively analyzed. RESULTS: Among 21,597 deliveries 10 pregnant women were diagnosed as having urolithiasis. They constituted 0.04% of all women who delivered at the Department of Obstetrics and Gynecology in Rijeka during this period. Conservative treatment was successful in 5 patients. Ureteral stents were inserted in 3 patients, nephrostomy was performed in 1 patient and a nephrectomy was necessary in 1 patient because of a nonfunctional kidney and chronic pyelonephritis. CONCLUSION: In our series all applied procedures in diagnosis and treatment of urolithiasis resulted in favorable maternal and perinatal outcome.

[Emergency surgical conditions after kidney transplantation]. / Hitna kirurska stanja nakon transplantacije bubrega.

During the period from 30. 01. 1971 to 30. 03. 1988 403 kidney transplantations were performed on the Surgical clinic KBC and Medical faculty at Rijeka. Satisfactory results were achieved concerning surviving of patients and grafts. Emergency vascular complications leads to lost of graft in most cases. Urologic complications less affecting the graft but because of possible infection could jeopardize the life of patient. In the surgical treatment of urological complications recipient ureter was used in most cases and in two patients isolated ileal loop. Among gastrointestinal complications bleeding from gastroduodenal ulcer was the major problem. After onset of routine use of antagonists of histamine H2 receptors those complications has been reduced from 6.6% to 1.5%. In five patients a spontaneous rupture of graft has happened. In two patients direct suture of rupture saved the graft. All our activities with the patients after kidney transplantation should be in careful treatment and early recognition of complications and aggressive surgical approach when it is necessary.