Volume 8, Issue 3 - Advances in Nephrology

Diabetic nephropathy (DN) is a leading cause of morbidity and mortality in diabetic patients representing a huge health and economic burden. Alarming recent data described diabetes as an unprecedented worldwide epidemic, with a prevalence of ∼6.4% of the world population in 2010, while the prevalence of CKD among diabetics was approximately 40%. With a clinical field hungry for novel markers predicting DN, several clinical and laboratory markers were identified lately with the promise of reliable DN prediction. Among those are age, gender, hypertension, smoking, sex hormones and anemia. In addition, eccentric left ventricular geometric patterns, detected by echocardiography, and renal hypertrophy, revealed by ultrasonography, are promising new markers predicting DN development. Serum and urinary markers are still invaluable elements, including serum uric acid, microalbuminuria, macroalbuminuria, urinary liver-type fatty acid-binding protein (u-LFABP), and urinary nephrin. Moreover, studies have illustrated a tight relationship between obstructive sleep apnea and the development of DN. The purpose of this review is to present the latest advances in identifying promising predictors to DN, which will help guide the future research questions in this field. Aiming at limiting this paramount threat, further efforts are necessary to identify and control independent modifiable risk factors, while developing an integrative algorithm for utilization in DN future screening programs.

Anti-vimentin auto-antibodies contribute to chronic allograft nephropathy. They exist in sera of end-stage renal disease patients on hemodialysis (ESRD) already before renal transplantation. We found recently that a 49 kDa vimentin fragment is increased in lymphocytes of ESRD patients which is presented on the cell surface. In vitro studies showed that such a fragment is formed during apoptosis by active caspase-3. We hypothesized that vimentin degradation in leukocytes of ESRD patients correlates to caspase-3 activation in vivo. Lymphocytes and monocytes were isolated from ESRD patients and from healthy volunteers and analyzed for vimentin expression and caspase-3 activation. In addition, apoptosis was induced in vitro and quantified by flow cytometry. ESRD monocytes have shown only the full length 60 kDa vimentin isoform. ESRD lymphocytes, however, showed in addition a strongly increased expression of the 49 kDa vimentin in all samples. Caspase-3 activation was found in 60% of ESRD lymphocytes and 66% of ESRD monocytes but not in healthy volunteers. UV-mediated induction of apoptosis was not associated with vimentin degradation. These experiments could confirm increased vimentin degradation in ESRD lymphocytes. However, we could not validate any correlation to apoptosis.

Post-transplant malignancies present an aggressive course and are a significant cause of morbidity and mortality. Tumours of viral ethiology have the greatest risk in renal transplant recipients. Oncogenic effect of immunosuppressive therapy is another major risk factor of post-transplant malignancy. We report cases of three different types of malignancies developed after kidney transplantation: non-Hodgkin’s lymphoma, Kaposi’s sarcoma and germ cell testicular cancer (nonseminoma).

Renal lipoma is a very rare tumor that has only been described in about twenty cases in adults and in a single case in a child aged 2 years. This paper presents a renal lipoma in 63 year old female patient. The tumor size of 7.5×4.5 cm was located in her right kidney, clearly delineated from the surrounding kidney tissue, and histology was completely built of mature adipose tissue. This paper describes the case of a rare benign lipoma which histogenesis is yet not clearly understood.

In this paper we report the case of a nearly fatal hemorrhage in the artery of the renal upper pole that occurred in a 84-year-old woman on anticoagulation treatment in connection with aortic valve replacement 4 days prior to the incident. The artery was injured during the evacuation of a hematoma of the right pleural cavity. While the patient was in the intensive care unit recovering from cardiac valve surgery, the consulting urologist was summoned in order to cope with massive hematuria and acute urine retention. Unfortunately, conservative urological management based on catherization via a three-way catheter and constant transurethral lavage with saline was unsuccessful. Angio-computed tomography revealed a ruptured branch of the renal upper pole artery. A highly selective embolization using histoacryl injection during percutaneous angioplasty was performed. There were no complications in the following days. The patient was subject to postoperative follow-up at 3, 6 and 9 months and renal scintigraphy was performed at 6 months revealing symmetrical function of both kidneys without any changes in the upper pole of the right kidney.

Congenital obstruction of the male urethra is usually caused by posterior urethral valves. Anterior urethral valves (AUV) represent a rare anomaly with a wide spectrum of presentation varying from mild voiding difficulties to end-stage renal disease. Prompt diagnosis and appropriate treatment is essential to prevent renal impairment. We report the case of a 13 month-old boy who presented with deterioration of kidney function caused by unrecognized AUV disorder. Temporary cutaneous vesicostomy was necessary to protect the upper urinary tract from further damage and to stabilize renal function. Even though a voiding cystourethrogram (VCUG) demonstrated obstruction of distal urethra, AUV were initially overlooked but finally diagnosed on additional VCUG followed by urethroscopy.

There is a higher mortality between patients with end-stage renal disease than patients in the general population. These circumstances have led to a search for risk factors as predictors of mortality in dialysis patients. Amongst those, inhibitors of the nitric-oxide (NO) synthesis deserve special attention, since patients with end-stage renal disease are also characterized by accelerated atherosclerosis. Asymmetric-dimethylarginine (ADMA) and symmetric-dimethylarginine (SDMA), as well as C-reactive protein (CRP), have also been recognized as predictors of mortality in patients on dialysis. The aim of our study was to compare the prediction power of ADMA, SDMA and CRP for all-cause mortality in patients with end stage renal disease during the fourteen month follow-up. In total 162 patients on hemodialysis were included. ADMA and SDMA were measured by the high-performance liquid chromatography (HPLC); CRP was measured using immunonephelometric assays. During the 14-month period 28 patients (34.1%) died from all-cause mortality. Using univariate analysis, hazard ratios (HR) of the potential independent predictors of mortality in hemodialysis patients were ADMA (HR 1.39 (1.01–1.91) p=0.043) and CRP (HR 1.024 (1.009–1.1.040) p=0.001). Further, multivariate analysis (MVA), however, showed that ADMA is the only predictor of all-cause mortality (HR 1.76 (1.002–3.11) P=0.049), while SDMA failed to predict death in this population. Therefore, our data shows that ADMA is an independent and better marker of all-cause mortality compared with CRP.

During ceftriaxone treatment of subdural empyema caused by Streptococcus intermedius urinary and biliary stones were noticed. Increased levels of urinary calcium excretion were detected during ongoing treatment in comparison with 2 months check-up. There were no significant changes in the promoter/inhibitor urolithiasis parameters, oxalate, citrate, urate, cistine, glycosaminoglycans or their ratios. Urine saturation was calculated using EQUIL 2 computer programme (calcium oxalate, brushite) and it was normal. Probable trigger for the ceftriaxone/calcium hydroxy carbonate phosphate mixture of stones was a critical boost of solubility products caused by ceftriaxone treatment and phospnate urine content with a subsequent large-scale spontaneous precipitation of crystals.

Congenital diaphragmatic hernia (CDH) is a rare and severe disorder with a high mortality rate among infants. Unilateral renal agenesis (URA) is a relatively common congenital urinary malformation. Here, we present the case of a newborn infant with left CDH associated with ipsilateral renal agenesis. The male patient was born weighing 3.850 g through normal spontaneous vaginal delivery at 38 weeks and 6 days of gestational age at a maternity hospital. He was transferred to our neonatal intensive care unit due to respiratory distress with tachypnea, grunting and cyanosis after birth. A chest radiography indicated parts of the bowel in the thoracic cavity, consistent with CDH. Renal ultrasonography indicated no kidney structure on the left side and a 5.6 cm right kidney with normal echogenicity. Repair of the diaphragmatic hernia was performed three days after birth. Most of the colon, small bowel, stomach and spleen were located in the left pleural cavity, but the left kidney was not seen. Subsequent dimercaptosuccinic acid scintigraphy indicated non-visualized functional cortical uptake in the left kidney on day 13 after birth. Thus, we report the successful treatment of a patient with CDH accompanied by URA.

The authors presented a case report of the acute abdomen with pelvic abscess because bladder perforation in a 21-year-old patient with multiple sclerosis and intermittent catheterization of the urinary bladder.

The role of vegetable and fruit consumption in the aetiology of kidney cancer was analyzed using data from a case-control study conducted in two centres in the Czech Republic between 1999 and 2003. The study comprised 300 patients with newly diagnosed, histologically confirmed kidney cancer and 335 controls. Information on dietary habits was obtained using a standardized food frequency questionnaire including 23 food items. Odds ratios (ORs) and 95% confidence intervals were calculated using logistic regression models. A strong protective effect of vegetables consumption on renal cell carcinoma risk was observed among people with high consumption of fresh vegetables (OR 0.42 95% CI (0.29–0.60)) and cooked vegetables (OR 0.71, 95% CI (0.51–1.00)). The protective role of fresh fruit was significant as crude OR 0.71, 95% CI (0.50–1.00), but after adjusting for the main risk factors no association was found (OR 1.08, 95% CI (0.71–1.64)). The protective role of pickled vegetables disappeared after adjustment for the main risk factors.