Nadir creatinine in posterior urethral valves: How high is low enough?

INTRODUCTION: Large retrospective studies of people with posterior urethral valves (PUV) have reported chronic renal insufficiency (CRI) in up to one third of the participants and end-stage renal failure in up to one quarter of them. Nadir creatinine (lowest creatinine during the first year following diagnosis) is the recognised prognostic indicator for renal outcome in PUV, the most commonly used cut-off being 1 mg/dl (88.4 umol/l). OBJECTIVE: To conduct a statistical analysis of nadir creatinine in PUV patients in order to identify the optimal cut-off level as a prognostic indicator for CRI. STUDY DESIGN: Patients treated by endoscopic valve ablation at the present institution between 1993 and 2004 were reviewed. Chronic renal insufficiency was defined as CKD2 or higher. Statistical methods included receiver operating characteristic (ROC) curve analysis, Fisher exact test and diagnostic utility tests. Statistical significance was defined as P < 0.05. RESULTS AND DISCUSSION: Nadir creatinine was identified in 96 patients. The median follow-up was 9.4 (IQR 7.0, 13.4) years. A total of 29 (30.2%) patients developed CRI, with nine (9.4%) reaching end-stage renal failure. On ROC analysis, Nadir creatinine was highly prognostic for future CRI, with an Area Under the Curve of 0.887 (P < 0.001). Renal insufficiency occurred in all 10 (100%) patients with nadir creatinine >88.4 umol/l compared with 19 of 86 (22.2%) patients with lower nadir creatinine (P < 0.001). As a test for future CRI, a nadir creatinine cut-off of 88.4 umol/l gave a specificity of 100%, but poor sensitivity of 34.5%. Lowering the cut-off to 75 umol/l resulted in improvement in all diagnostic utility tests (Table). All 14 (100%) patients with nadir creatinine >75 umol/l developed CRI, compared with 15 of 82 (18.3%) patients with lower nadir creatinine (P < 0.001). Sensitivity only approached 95% at 35 umol/l, at which level specificity was low (Table). Two out of 36 (5.6%) patients with nadir creatinine <35 umol/l developed CRI. Multivariate analysis found recurrent UTI (OR 4.733; CI 1.297-17.280) and nadir creatinine >75 umol/l (OR 48.988; CI 4.9-490.11) to be independent risk factors for progression to CRI. Using cut-off values of 35 umol/l and 75 umol/l, patients can be stratified into low-, intermediate- and high-risk groups, with development of CRI in 5.3%, 28.3% and 100%, respectively (P <0.001). The stage of CKD was higher in higher risk groups. CONCLUSION: Patients with nadir creatinine >75 umol/l (0.85 mg/dl) should be considered at high risk for CRI, while patients with nadir creatinine ≤35 umol/l (0.4 mg/dl) should be considered low risk. Patients with nadir creatinine between these two values have an intermediate risk of CRI.

Spectrum of penoscrotal positional anomalies in children.

BACKGROUND: The normal relationship between the scrotum and penis during fetal development is controlled by several genetic and hormonal factors, and impairment of this positional relation results in a wide spectrum of positional congenital anomalies. OBJECTIVE: This a cohort study analysing 63 cases of penoscrotal anomalies (PSAs) according to severity and other associated malformations to provide a simple classification for recognising, describing and categorizing cases that may require surgical correction. DESIGN AND SETTING: Between 2005 and 2013, 63 diverse cases of penoscrotal positional anomaly were detected and analysed based on their hormonal profile and other associated anomaly. RESULTS: A wide variety of PSAs were included in the study, 11 cases were of major PST with complete penoscrotal transposition in three, incomplete in eight, and minor degree in 45 cases, which are symmetrical (bilateral) in 29, sixteen are asymmetrical, 4 had midline scrotlisation, and 3 had wide penoscrotal distance. Associated genitourinary anomalies were detected in 29 babies. Sex hormonal assays showed no significant differences between the PSA patients and controls (P < .05), and no gross chromosomal anomalies were detected in any cases. CONCLUSION: Penoscrotal positional anomalies include the previously described penoscrotal transposition, and the variants of a central penile scrotalisation, and wide penoscrotal distance. A simple classification for these anomalies adopted herein.

Human papillomavirus (HPV) infection in heterosexual South African men attending sexual health services: associations between HPV and HIV serostatus.

OBJECTIVES: To investigate the distribution of human papillomavirus (HPV) genotypes and determine the associations between HPV infection and HIV coinfection in sexually active heterosexual men with anogenital warts (GW), male urethral discharge or asymptomatic men. METHODS: Valid specimens for HPV genotyping were obtained from three patient groups consisting of 108 men with GW, 56 men with urethral discharge syndrome and 50 asymptomatic men attending for HIV voluntary counselling and testing. The Linear Array HPV Genotyping Test was used to determine the HPV genotype distribution among study participants. Sera were tested for HIV antibodies using two commercial rapid tests. RESULTS: The prevalence of anogenital HPV among study participants was 78% (166). HPV DNA was detected in 100% (108) of GW, 48% (27) of men with urethral discharge syndrome and 62% (31) of voluntary counselling and testing participants. HPV types 6, 11, 16 and 18 were prevalent as either single or combined infections in 81% (134) of all HPV-positive study participants. HPV types 6 and/or 11 were significantly higher among GW patients (p<0.001). After adjusting for patient groups, HIV seropositivity was significantly associated with multiple HPV infections (OR=3.98, 95% CI 1.58 to 10.03) but not with the presence of a foreskin (OR=0.67, 95% CI 0.32 to 1.40). CONCLUSIONS: Infections with HPV were prevalent among sexually active heterosexual men attending the men's sexual health clinic. Associations were observed between HIV coinfection and multiple HPV infections. Further population-based studies on the prevalence of HPV genotypes are required to determine if men should be included in any future national HPV vaccination programme in South Africa.

Validation of initial serum creatinine as a predictive factor for development of end stage renal disease in posterior urethral valves.

OBJECTIVE: The aim of this study was to determine the value of initial serum creatinine in prediction of End-stage renal disease (ESRD) in children with posterior urethral valves PUV. METHODS: In this retrospective study, patients diagnosed with PUV admitted in Aliasghar Children's Hospital in Tehran, Iran from 1991 through 2001 were studied. Based on the development of ESRD (need for dialysis) they were classified in two groups and their demographics, initial presentations, laboratory data, imaging findings and outcomes were reviewed and compared. RESULTS: Thirty six male patients with PUV, treated with valve ablation (13), vesicostomy (13), or high ureterostomy (10) were followed for developing ESRD. Sixteen of the 36 patients developed ESRD at their last follow-up. There was no significant difference in age at initial presentation, presence of urinary tract infections, incidence of vesicoureteral reflux, renal dysplasia or type of primary surgical intervention between the patients with or without ESRD. Patients who progressed to ESRD had serum creatinine concentration > 1.0 mg/dl at diagnosis as compared to those without ESRD (P = 0.001). CONCLUSION: Initial serum creatinine is a valuable factor for prediction of renal outcome in patients with PUV.

Urethral cytokine and immune responses in Chlamydia trachomatis-infected males.

Penile urethral swabs collected from PCR-confirmed Chlamydia trachomatis-infected, C. trachomatis-uninfected, and non-C. trachomatis-infected, nongonococcal urethritis-infected males were analyzed for cytokine, total immunoglobulin (Ig), and specific antibody levels by enzyme-linked immunosorbent assay. Differential cellular components of the swab transport medium were also enumerated for the same groups. Although low, the levels of C. trachomatis-specific IgA and IgG antibodies and interleukin 8 cytokine were significantly higher in C. trachomatis-infected individuals. There were no significant differences in the levels of seven additional cytokines evaluated.

Transient pseudohypoaldosteronism secondary to posterior urethral valves--a case report and review of the literature.

In transient pseudohypoaldosteronism (TPHA), renal tubular resistance to aldosterone is thought to be secondary to renal disease. We report a case of TPHA caused by posterior urethral valves associated with urinary tract infection and review 62 cases previously reported. The infant presented with unspecific signs of vomiting and dehydration, so that pyloric stenosis was first suspected. Laboratory data and retroperitoneal sonography led to the diagnosis TPHA. This case illustrates that urine culture and renal ultrasonography should be performed in any infant with electrolyte disturbances to exclude infection or obstructive uropathy.

[Follow-up of residual renal function in patients with serious forms of posterior urethral valves]. / Valutazione a distanza della funzione renale residua (FRR) in portatori di forme gravi di valvole dell'uretra posteriore (VUP).

We report the results of the trend of the residual renal function (RRF) of 15 patients with serious forms of hind urethral valves (HUV) which agreed to be long term regularly controlled after surgical correction at the Children's Surgical Hospital of Bologna University. The nephrological follow-up started in 1985 is based on a periodical control at least once a year, of some indicatives parameters of the glomerulars activity (creatinine clearance according Schwartz and creatinine reciprocal), of the tubular activity (urinary flux ml/kg/h, per cent fraction of Na excretion) and the dynamical test of the RRF started in 1991. The results although the low cases studies, are not statistically significant, the Authors underline the validity of the adopted method. Although of the simplified and/or indirect type, this is able to give clinically reliable informations of the renal functionality evolution avoiding particularly complex or invasive analysis.

Vaginal rings for continuous low-dose release of oestradiol in the treatment of urogenital atrophy.

Silicone vaginal rings for the continuous release of 17 beta-oestradiol (E2) with 2 constant in vitro release rates were used for the treatment of symptoms of urogenital atrophy in 2 groups of postmenopausal women. The very low dose of 7 micrograms/24 h was found to alleviate atrophic symptoms effectively and to induce significant maturation of vaginal and urethral epithelium. After a brief initial peak, the serum levels of E2 over 3 mth of treatment remained close to the detection limit. The 'undetectable' E2 release pattern was reflected only in increased levels of oestrone sulphate. There was no evidence of a systemic metabolic response and patient acceptance of the method was excellent. Continuous low-dose release of E2 via vaginal rings consequently offers an alternative means of administering local oestrogen therapy which may be particularly suitable for geriatric patients.

[Malakoplakia at 3 sites: the bladder, urethra and kidney. Isolation and ultrastructural study of blood monocytes]. / Malacoplasie à triple localisation: vésicale, urétérale et rénale. Isolement et étude ultrastructurale des monocytes sanguins.

We studied the blood mononuclear cells in a seventy-four-year old man who had urinary tract malacoplakia located to bladder, ureter and kidney. The blood mononuclear cells were isolated as described by Boyum [2] and studied by electron microscopy. They did not show bacilliform bodies or bacteria in the phagolysosomes. The microfilaments and the microtubules were not easily identifiable in the mononuclear cells of the patient. In the control, the internal skeleton of the mononuclear cells was normal. This ultrastructural finding may suggest that there is a relation between microfilaments and microtubules lesion and the low level of cyclic G.M.P. described by Abdou et al.