Sunitinib-related high-grade proteinuria and allograft dysfunction in a kidney recipient: a rare case report.

BACKGROUND: Sunitinib-induced high-grade proteinuria and irreversible renal allograft dysfunction are rare conditions. Here, we present a patient who had received renal allograft and later developed metastatic clear cell renal cell carcinoma(cc-mRCC), for which he was prescribed sunitinib. High-grade proteinuria, hypoalbuminemia, peripheral edema and renal allograft dysfunction (manifesting as an increase in the serum creatinine concentration) occurred 5 months after sunitinib prescription. CASE PRESENTATION: The patient was a 58-year-old male who had end-stage renal disease with regular hemodialysis through arteriovenous fistula for 17 years since 1998 and received a renal allograft from a deceased kidney donor in 2015. Unfortunately, in 2019, the patient developed cc-mRCC originating from the left native kidney. We suggested a needle biopsy on left native kidney or radical left nephrectomy, but the patient refused. Sunitinib was prescribed. Follow-up urine analysis showed proteinuria (500 mg/dL) 2 weeks after sunitinib prescription. He was hospitalized 5 months later because of body weight gain, decreased urine output, pitting edema of both lower extremities, and shortness of breath. The image studies showed progression in his cc-mRCC. His serum creatinine level and spot urine protein at admission increased to 4.26 mg/dL and 300 mg/dL, respectively. He agreed on a biopsy for the renal allograft and the pathology studies showed focal segmental glomerulosclerosis, acute interstitial nephritis, and acute tubular injury. Based on the time sequence of clinical presentations with the laboratory and pathological findings, sunitinib-induced renal allograft dysfunction secondary to high-grade proteinuria was most likely. Despite of discontinuation of sunitinib and increased dose of everolimus, renal impairment progressed. Thus, he had to receive hemodialysis starting 2 week after hospitalization. Unfortunately, the patient died of advanced metastasis despite of aggressive medical treatments 3 weeks after admission. CONCLUSION: This case report is a reminder that renal allograft dysfunction can happen secondary to proteinuria after taking sunitinib. Hence, clinicians must regularly check renal function and urine protein for renal allograft recipients. Monitoring and modifying drug prescription, especially sunitinib, is necessary if persistent proteinuria accompanied by deteriorating serum creatinine level occurs. Renal biopsy may be considered if more evidence is required to make a differential diagnosis.

Contributing factors for fever after tubeless percutaneous nephrolithotomy.

OBJECTIVE: To evaluate the contributing factors for fever after tubeless percutaneous nephrolithotomy (PCNL). METHODS: Between May 2009 and December 2013, 395 tubeless PCNLs were performed at our hospital. After stone extraction, the bleeding points were cauterized for hemostasis to enable tubeless modification. In patients with troublesome bleeding after cauterization, oxidized regenerated cellulose (Surgicel) strips were used to tamponade the access tract to facilitate bleeding control. The contributory factors for fever were evaluated by a retrospective chart review. RESULTS: Forty-four patients (11.7%) developed fever after tubeless PCNL. There was no difference in gender, age, and body mass index in the development of fever. Episodes of febrile or septic urinary tract infection before PCNL were found to have occurred in 35 patients, but the incidence of postoperative fever was not significantly higher in these patients. There is no significant difference in the mean stone size in fever and nonfever patients. Complete staghorn stones were noted in 40 patients, and their fever rate was not significantly higher than patients with nonstaghorn stone. The operation time is not significantly higher in the group with urinary tract infection. Patients with postoperative fever had a high incidence of residual stones than the remaining patients (38.9% vs 20.4%). There was no significant difference in incidence of postoperative fever in patients with struvite stones than patients with nonstruvite stones. In patients who received Surgicel packing, the incidence of fever was not significantly higher. CONCLUSION: Incomplete stone extraction is a major contributing factor for the development of fever after tubeless PCNL.

Proteomic study of renal uric acid stone.

OBJECTIVE: To analyze urinary uric acid stone matrix proteins (SMP) with mass spectrometry (MS) to evaluate the mechanisms of uric acid stone formation. SMP plays an important role in urinary stone formation. Several proteomic studies apply to calcium-containing stones have been reported; however no proteomic study for urinary uric acid stone has been reported. METHODS: Pure kidney uric acid stones from 5 individuals were demineralized, and SMPs were isolated. The obtained proteins were analyzed with reverse-phase liquid chromatography-tandem MS. The acquired data were searched against a Swiss Prot human protein database using Matrix Science, Mascot. The identified proteins were submitted to the AmiGO Web site for gene ontology analysis. They were also sumitted to Metacore software and Kyoto Encyclopedia of Genes and Genomes website (KEGG) for pathway analysis. MS-determined protein expressions were verified by immunoblot. RESULTS: MS analysis identified 242 proteins from 5 proteomic results and the number of the identified protein of each result ranged from 52 to 156. Metacore software analysis suggested that inflammation may play an important role for kidney uric acid stone formation. Endogenous metabolic pathways were also analyzed and submitted to KEGG Web site, which revealed that these proteins may participate in fat metabolism. Five identified proteins were selected for immunoblot validation, and 3 proteins were confirmed. CONCLUSION: Our results suggest that inflammatory process may play a role in kidney uric acid stone formation. Our endogenous metabolic pathway analysis data revealed that these proteins may participate in lipid metabolism. Whether this finding implies a relation between lipotoxicity and kidney uric acid stone former requires further investigation.

Bilateral ureteral complete obstruction with huge spontaneous urinoma formation in a patient with advanced bladder cancer.

Spontaneous rupture of the collecting system with extravasation of urine and urinoma formation is usually associated with urinary tract obstruction by a ureteral calculus. Tumor growth is an extremely rare cause of urinary extravasation. Here we report a case of bilateral obstructive uropathy with a huge spontaneous left retroperitoneal urinoma caused by advanced infiltrative transitional cell carcinoma of the urinary bladder. The point of leakage was located in the left renal pelvis. The urinary leakage ceased after percutaneous nephrostomy drainage, and the patient subsequently underwent radical cystoprostatectomy. Histopathology revealed a high-grade urothelial carcinoma of the urinary bladder with pelvic lymph node metastasis. The patient refused any adjuvant treatment and expired 6 months after the operation from disseminated metastasis from bladder cancer.

Safety and efficacy of tubeless percutaneous nephrolithotomy in patients on anti-platelet therapy and cirrhotic patients.

Without the temponade effect over nephrostomy tube, postoperative hemorrhage is a major concern to the safety of tubeless percutaneous nephrolithotomy (PCNL) in patients with bleeding tendency. In this study, we would like to report our experience of performing tubeless PCNLs in these patients. At the end of PCNL, we cauterized the bleeding points in access tract for hemostasis to facilitate the achievement of tubeless PCNL. We identified and reviewed 16 patients under antiplatelet agent therapy and 6 patients with liver cirrhosis from 598 tubeless PCNLs performed in a single institute. Among the 16 patients undergoing anti-platelet therapy, the average stone size was 2.8 cm. The average operation time was 84.7 min. The stone-free rate was 87.5%. The average postoperative hospital stay was 3.8 days. Two patients (12.5%) experienced urinary tract infections after operation. There was no uncontrolled hemorrhage during and after operation and only one patient needed postoperative blood transfusion. No patient experienced any thromboembolic complication. Of the six patients with liver cirrhosis, the average stone size was 3.3 cm. The average operation time was 77.5 min. The stone-free rate is 83.4%. The average postoperative hospital stay was 4.0 days. No patient received blood transfusion after operation. There was no patient experiencing urinary tract infection after operation. Our results suggest that with careful hemostasis, tubeless PCNL is a safety modality in the treatment of urinary stone disease in patients on chronic anti-platelet therapy and cirrhotic patients.

The correlation between TWIST, E-cadherin, and beta-catenin in human bladder cancer.

PURPOSE: Epithelial-to-mesenchymal transition (EMT)- related factors are known to contribute to the invasion and migration of multiple cancers. However, the expression levels of and the relationship between TWIST, E-cadherin, and beta-catenin in bladder cancer are not yet known. Therefore, this study investigated the relationship between TWIST, E-cadherin, and beta-catenin in tissue specimens and cell lines of bladder cancer. METHODS: Microarrays of bladder cancer tissue and bladder cancer cell lines were used to study the expression levels of TWIST, E-cadherin, and beta-catenin, with disease stage and grade using immunohistochemistry. Moreover, the siRNAs of TWIST, E-cadherin, and beta-catenin were transfected into the bladder cancer cell lines to study any relationship between these factors. RESULTS: The levels of TWIST and beta-catenin were upregulated with increasing grade of malignancy. In contrast, the corresponding results for E-cadherin were just the opposite. Furthermore, inhibition of the expression of TWIST elevated the expression of E-cadherin, but reduced the expression of beta-catenin. However, reduction of beta-catenin by siRNA had no influence on TWIST, but up-regulated the expression of E-cadherin. CONCLUSION: TWIST may act upstream of E-cadherin, which can indirectly regulate the expression levels of beta-catenin. The EMT factors TWIST, E-cadherin, and beta-catenin may be a cluster of biomarkers for the metastatic progression of bladder cancer.

Tubeless percutaneous nephrolithotomy for geriatric patients.

AIM: To evaluate the safety of tubeless percutaneous nephrolithotomy (PCNL) in geriatric patients. MATERIALS AND METHOD: This is a retrospective review of 401 patients who received tubeless PCNL in a single institute. Among these, 50 were performed in patients aged older than 70 years (group 1), while 351 were performed in the remaining younger patients (group 2). RESULTS: There was no significant difference in stone size between the 2 groups (3.6 +/- 1.9 vs. 3.5 +/- 2.0 cm). The average operative time was similar in both groups (92.8 +/- 34.5 vs. 86.6 +/- 32.0 min). The stone-free rate in groups 1 and 2 was 68.0% (34/50) and 83.8% (294/351), respectively, which was statistically significantly different. The average postoperative hospital stay was longer in group 1 (4.6 +/- 3.4 days) than in group 2 (3.9 +/- 2.5 days), but the difference was not statistically significant. There was no significant difference in postoperative urinary tract infection rate and blood transfusion rate in both groups (urinary tract infection: 18.0 vs. 8.8%; blood transfusion: 4 vs. 2.6%). Two patients in group 1 and 3 patients in group 2 experienced pulmonary complications. There was no other severe complication. CONCLUSION: Tubeless PCNL is a safe procedure for the treatment of geriatric patients with urolithiasis.

Hyperbaric oxygen therapy for cyclophosphamide-induced intractable refractory hemorrhagic cystitis in a systemic lupus erythematosus patient.

Hemorrhagic cystitis is a complication of systemic lupus erythematosus and is also a common side effect after cyclophosphamide therapy. Intractable hemorrhagic cystitis is not unusual and may be a life-threatening condition; it has no effective noninvasive treatment at present. We report a case of hemorrhagic cystitis with intractable refractory bleeding that occurred in a 40-year-old woman after cyclophosphamide treatment for systemic lupus erythematosus. The hemorrhage was resistant to various therapies but resolved after hyperbaric oxygen therapy. There was no recurrent hematuria after hyperbaric oxygen therapy during 6 months of follow-up.

Delayed pneumothorax after tubeless percutaneous nephrolithotomy.

Percutaneous nephrolithotomy is the treatment of choice for large urinary stone and staghorn stone. Supracostal access through the upper calyx provides a straight tract along the long axis of the kidney and is the optimal route for the treatment of staghorn stone. However, the supracostal access bears higher risk for pleural or lung injury resulting in hydrothorax or pneumothorax. Percutaneous nephrolithotomy induced pneumothorax usually occurs immediately after operation. We report a case of delayed pneumothorax after tubeless percutaneous nephrolithotomy for a complete staghorn stone.

Innovative metal dilators for percutaneous nephrostomy tract: report on 546 cases.

OBJECTIVES: A retrospective study was conducted to evaluate the efficacy and safety of creating a percutaneous nephrostomy tract for stone removal with innovative metal dilators. METHODS: A total of 546 percutaneous nephrolithotomies was performed at Chiayi Christian Hospital from January 2001 to December 2005. Innovative metal dilators were used to create 546 percutaneous nephrostomy tracts in 520 patients. Several patients had multiple percutaneous nephrostomy tracts. Patient age, stone burden, operative time, stone-free rate, postoperative hospital day, postoperative urinary tract infection rate, and blood transfusion rate were recorded using retrospective chart review. RESULTS: The dilation time was less than 15 minutes. The average patient age was 53.7 +/- 13.1 years, and the average stone size was 3.5 +/- 2.0 cm. The average operative time was 100 +/- 45 minutes. The average postoperative hospital stay was 4.4 +/- 2.6 days. The overall stone-free rate was 84.4% (461 of 546). The stone-free rate was 99% (142 of 143) for upper ureteral stones, 87% (268 of 305) for renal stones, and 52% (51 of 98) for complete staghorn stones. The blood transfusion rate was 2.5% (14 of 546). The postoperative urinary tract infection rate was 8.6% (47 of 546). Of the 520 patients, 6 had pleural effusion and 1 had pneumothorax. CONCLUSIONS: Our innovative metal dilators saved time, resulted in less bleeding, and successfully provided one-stage tract creation in 520 patients. The dilation system also allowed the use of a ureteroscope to check the entrance tract to reduce complications.

High-power holmium:yttrium-aluminum-garnet laser for percutaneous treatment of large renal stones.

OBJECTIVES: To assess the efficacy and safety of high-power holmium-yttrium-aluminum-garnet (YAG) laser lithotripsy for percutaneous nephrolithotomy in patients with large renal stones. METHODS: We retrospectively reviewed the charts of 87 patients who underwent 91 percutaneous nephrolithotomy procedures at our hospital from April 2004 to June 2005, during which a holmium-YAG laser with a self-made fiber guider was used for lithotripsy. Of the 91 procedures, 51 were performed with the maximal power output set at 3.0 J in patients with a renal stone size of 3 cm or larger (group 1). The other 40 procedures were performed with the maximal power set at 2.0 J in patients with a renal stone size of less than 3 cm or with ureteral stones (group 2). RESULTS: The average stone size was 5.4 cm in group 1, and the stone-free rate was 61.4% after a single procedure. The average operation time was 108 minutes in group 1 and 93 minutes in group 2. The average postoperative hospital stay was 5.7 days in group 1 and 5.9 days in group 2. Two patients in group 1 and one in group 2 required blood transfusions after the procedure. Seven patients (13.7%) in group 1 and two (5.0%) in group 2 experienced a urinary tract infection after the procedure. No statistically significant difference in procedure time, postoperative hospital stay, blood transfusion rate, or postoperative urinary tract infection rate was found between the two groups. CONCLUSIONS: The results of our study have shown that using a high-power holmium-YAG laser is safe and effective in the treatment of large renal stones.

Nephrostomy tube-free percutaneous nephrolithotomy for patients with large stones and staghorn stones.

OBJECTIVES: To perform a retrospective study to assess the outcome and safety of 64 nephrostomy tube-free percutaneous nephrolithotomies (PCNLs) in 62 patients with calculi 3 cm or greater. METHODS: Between March 2001 and June 2004, 365 consecutive patients underwent 389 PCNLs at our hospital. Electrocauterization of the access tract was performed at the end of the operation in every patient. No nephrostomy tube was inserted in the patient if a bloodless tract had been obtained. Of the 389 PCNLs, 154 were performed in patients with a stone size of 3 cm or greater. Of these 154 PCNLs, 64 were performed with the nephrostomy tube-free modification (group 1) and 90 were performed with insertion of the nephrostomy tube after the operation (group 2). The hospital course and complications were evaluated in both groups. RESULTS: No statistically significant differences in age, stone size, urinary tract infection rate, or blood transfusion rate were found between those with and without insertion of the nephrostomy tube. Fourteen patients in group 1 had complete staghorn stones. A shorter operative time, lower analgesic requirement, and shorter postoperative hospital stay were noted in the group with the nephrostomy tube-free modification (group 1). CONCLUSIONS: With adequate homeostasis, nephrostomy tube-free PCNL can be performed in patients with complicated urolithiasis without any increase in morbidity.

Percutaneous nephrolithotomy with holmium: Yttrium-aluminum-garnet laser and fiber guider--report of 349 cases.

OBJECTIVES: To assess the efficacy and safety of holmium:yttrium-aluminum-garnet (YAG) laser lithotripsy for percutaneous nephrolithotomy in a cohort of 349 consecutive procedures. METHODS: We retrospectively reviewed the charts of 334 patients who had undergone 349 percutaneous nephrolithotomy (PCNL) procedures conducted at our hospital from January 2001 to March 2004 in which the holmium:YAG laser with a self-made fiber guider was used for lithotripsy. RESULTS: The average patient age was 54.1 years, and the average stone size was 3.3 +/- 1.8 cm. The average operative time was 99 +/- 38 minutes, and the average postoperative hospital stay was 4.0 +/- 2.3 days. The overall stone-free rate was 83.7%. The postoperative urinary tract infection rate was 7.2%. The postoperative transfusion rate was 2.0%. The holmium:YAG laser was effective against all kinds of stones, but sometimes it was time consuming to use the holmium:YAG laser to disintegrate a very large stone. Thirteen PCNLs (3.7%) to treat large complete staghorn stones were performed in combination with a pneumatic lithotriptor. Of the 349 procedures, 152 (43.6%) had bloodless tracts afterward, and all 152 procedures had been performed with the nephrostomy tube-free modification. CONCLUSIONS: The holmium:YAG laser is an effective and safe lithotriptor for most percutaneous stone surgery. However, in patients with a very large stone burden, the combination of this technology with another, more powerful, intracorporeal lithotriptor may be necessary.

Electrocauterization of bleeding points for percutaneous nephrolithotomy.

OBJECTIVES: To perform a retrospective study to assess the efficacy and safety of electrocauterization of bleeding points after stone extraction using the data from 249 percutaneous nephrolithotomies. METHODS: A total of 341 percutaneous nephrolithotomies in 324 patients were performed at the Chiayi Christian Hospital from July 2000 to July 2003. Electrocauterization of bleeding points with an elongated electrode probe was performed in 249 patients. The age, height, weight, preoperative hemoglobin level, stone burden, operating time, stone free rate, length of postoperative hospital stay, postoperative urinary tract infection rate, and blood transfusion rate were recorded by retrospective chart review. RESULTS: No statistically significant differences in age, height, weight, stone burden, operating time, stone free rate, or length of postoperative hospital stay were found between patients with or without electrocauterization. No increase occurred in the postoperative urinary tract infection rate in patients who received electrocauterization, and these patients had a statistically significant decrease in the transfusion rate. No nephrostomy tube was inserted at the completion of surgery in 84 (33.7%) of the 249 operations in which electrocauterization was performed. CONCLUSIONS: Electrocauterization of the bleeding points at the end of percutaneous renal surgery decreases the blood transfusion rate without causing an increase in morbidity. This procedure is safe and effective and may make more patients suitable for tubeless modification.

Cauterization of access tract for nephrostomy tube-free percutaneous nephrolithotomy.

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) is now a popular method for removal of renal and ureteral stones. Placement of a nephrostomy tube after the completion of PCNL has been considered a standard procedure by most urologists, but some authors have recently challenged this practice. Bleeding is one of the most prevalent problems after nephrostomy tube-free percutaneous renal surgery. To diminish the possibility of postoperative bleeding, we cauterized the PCNL tract to make it bloodless. The efficacy and safety of this procedure were reviewed in this study. PATIENTS AND METHODS: From March 2001 to March 2003, 51 patients underwent PCNL with a one-stage procedure and a single access tract. The stone size ranged from 1.0 to 7.0 cm (mean 2.7 +/- 1.4 cm). A holmium:YAG laser and pneumatic lithotripter were used. After stone extraction, a 6F double-J catheter was inserted antegrade. The access tract was checked, and the bleeding points were cauterized. No nephrostomy tube was inserted, but a Penrose drain was left overnight. Perforation of the collecting system was not a contraindication to tubeless PCNL. RESULTS: The stone-free rate was 80.4%, including five patients with complete staghorn stones. Twenty-one patients required postoperative analgesics. Only one patient had urine leakage for longer than 24 hours. Transient low fever was noted in five patients, but no patient experienced severe urinary tract infection. Delayed hemorrhage (1 week after the operation) secondary to irritation by the double-J ureteral stent was noted in one patient. The average postoperative hospital stay was 2.2 days (range 1-3 days). No patient required a blood transfusion. No urinoma was noted on the postoperative ultrasound follow-up. CONCLUSION: Nephrostomy tube-free percutaneous renal surgery is a safe and effective procedure for selected patients with minimal hemorrhage after PCNL. Cauterization of tract bleeding points may make this modification a more secure procedure and make it suitable for more patients.