Protective Effects of Omega-3 Fatty Acids Supplementation Against Renal Parenchymal Scarring in Children with Acute Pyelonephritis: Results of a Pilot Clinical Trial.

AIM: This trial aimed to determine if supplementation with omega-3 fatty acids as an adjunct therapy to antibiotic treatment can have protective effects against renal scar formation after acute pyelonephritis (APN) in pediatric patients. BACKGROUND: Current evidence points out that besides antibiotic treatment, early administration of antioxidant and anti-inflammatory compounds may be effective in reducing the occurrence of renal damage following APN in children. OBJECTIVE: The main endpoint of the trial was the comparison of the development of renal scarring formation after APN in an omega-3 fatty acids-treated group and in a control-treated group. METHODS: This prospective randomized, controlled trial study was conducted from March 2016 to May 2018 on 60 children with a diagnosis APN in a tertiary hospital in Iran. After the diagnosis of APN based on the clinical signs and symptoms, urine analysis, urine culture, and dimercaptosuccinic acid renal scan (DMSA scan), the patients were randomly allocated into either the control group (n=30 patients: received standard antibiotic treatment only) or the intervention group (n=30 patients: received standard antibiotic-treatment in combination with oral omega-3 fatty acids based on the children's weight for three consecutive days). A second DMSA scan was performed for the patients at a minimum of six months after treatment. The development of renal scars was evaluated by comparing the baseline DMSA scan lesions with the follow-up DMSA scan lesions. RESULTS: Fifty patients, including 26 and 24 individuals in the control and intervention groups, respectively, completed the entire course of the study. Renal parenchymal involvement based on the baseline DMSA scan was similar in the two groups (p-value =0.85, 0.90, and 0.53 regarding the right, left, and both kidney units together, respectively). Although comparison of the follow-up DMSA scan lesions to the baseline DMSA scan lesions considering the right and left kidneys as separate units between two groups did not reach the significant level, when considering both left and right kidney units together, results showed a statistically significant difference between groups in favor of the intervention group (p-value =0.04). CONCLUSION: Although preliminary, the results of this study showed that administration of omega-3 fatty acids, a natural supplement with well-known anti-inflammatory and antioxidant properties, as an adjunct therapy to standard antibiotic treatment might significantly reduce the incidence of the occurrence renal scarring following APN in children. Confirmation of these results requires further studies.

Vitamin A supplementation is effective for improving the clinical symptoms of urinary tract infections and reducing renal scarring in girls with acute pyelonephritis: a randomized, double-blind placebo-controlled, clinical trial study.

INTRODUCTION: It is believed that tubulointerstitial inflammation plays a role in the formation of renal scarring secondary to acute pyelonephritis (APN). Vitamin A is an anti-inflammatory agent that is involved in the re-epithelialization of damaged mucosal surfaces. OBJECTIVE: The aim of this study was to evaluate the efficacy of vitamin A supplementation in combination with antibiotics for improving urinary tract infections (UTIs) symptoms and preventing renal scarring in girls with APN. STUDY DESIGN: This randomized, double-blind, placebo-controlled clinical trial was conducted on 90 girls aged 2 to 12 years old between 2015 and 2017. Patients with UTIs and first episode of APN diagnosed based on 99 mTc-DMSA scintigraphy (uptake defect) were assessed for eligibility. Patients were randomly divided into two groups that either received 10 days of oral vitamin A (intervention group) or 10 days of placebo (control group) in addition to antibiotics during the acute phase of infection. The clinical response was considered as the primary outcome [duration (positive days) of UTI symptoms during trial treatment period] and secondary outcomes (no change, improving and or worsening of 99 mTc-DMSA scan results 6 months after treatment from baseline). P < 0.05 was considered to be statistically significant. RESULTS: Seventy-four patients (vitamin A group: 36 patients, placebo: 38 patients) were included in the analysis. The mean age was 5.25 ± 1 year old. Three patients (7.89%) in the placebo group and 2 patients (5.55%) in the vitamin A group had vesicoureteral reflux (VUR) (p = 0.114). Duration of fever (vitamin A group: 1.8 days, placebo: 3.1 days, p = 0.0026), urinary frequency (1.3 days vs. 2.8 days, p = 0.003) and poor feeding (2.3 days vs. 4.2 days, p = 0.005) were significantly lower in the vitamin A group. Following the second 99 mTc-DMSA scan, worsening of lesions was observed among 8 (22.2%) and 17 (44.7%) patients in the vitamin A and placebo groups, respectively (p = 0.003). 63.8% (23 patients) of the vitamin A group and 21% (8 patients) of placebo group showed lesion improving in the photopenic region. (P < 0.0001) There was no evidence of vitamin A intolerance. DISCUSSION: Our results show the efficacy of vitamin A supplementation on reducing renal scarring secondary to APN and on fever, urinary frequency and poor feeding duration in girls with APN. CONCLUSION: Vitamin A supplementation is effective for improving the clinical symptoms of UTI and reducing renal injury and scarring following APN in girls with first APN. However, larger randomized clinical trials (RCTs) with longer follow up are needed to confirm these effects.

Cicatrices renales en menores de 36 meses ingresados por pielonefritis aguda / Renal scarring in children under 36 months hospitalised for acute pyelonephritis

INTRODUCCIÓN: Una de las causas más frecuentes de infección bacteriana grave en lactantes es la pielonefritis aguda (PNFA), cuya secuela más prevalente a largo plazo es la instauración de cicatrices renales. OBJETIVOS: Revisar la incidencia de cicatrices renales a los 6 meses de un episodio de PNFA en niños menores de 36 meses y su relación con la clínica, las pruebas de imagen y la bacteriología. MÉTODO: Estudio retrospectivo de pacientes de uno a 36 meses previamente sanos ingresados por un primer episodio de PNFA, con un seguimiento mínimo de 6 meses. Se recogieron las variables demográficas junto con bacteriología, ecografía, cistourografía miccional seriada, recidivas y gammagrafía-DMSA. RESULTADOS: Se incluyeron 125 pacientes, 60% varones, la mayoría febriles al ingreso (92%), debido a E. coli (74,6%). Existía antecedente de alteración ecográfica prenatal solo en el 15,4%. La ecografía detectó dilatación de la vía urinaria en el 22,1%. En 70 pacientes se indicó cistourografía miccional seriada: 54,3% sin anomalías, 12,8% con reflujo vesicoureteral (RVU) grado i-iii y 32,9% con RVU iv-v. Seis pacientes presentaban RVU iv-v con ecografías normales. La adherencia a la gammagrafía DMSA a los 6 meses fue solo del 61% de los indicados. De los efectuados (60 casos), en un 44,3% se hallaron cicatrices renales, relacionadas significativamente con la recurrencia y el RVU iv-v, pero no con la bacteriología ni con la elevación de reactantes. CONCLUSIONES: El 44% de las gammagrafías-DMSA de pacientes de uno a 36 meses hospitalizados por PNFA desarrolla cicatrices renales a los 6 meses. Estas se relacionaron con las recurrencias y el RVU grave, pero no con la bacteriología y los reactantes inflamatorios

INTRODUCTION: Acute pyelonephritis (APN) is one of the most common causes of serious bacterial infection in infants. Renal scarring is the most prevalent long-term complication. OBJECTIVES: To review the incidence of renal scarring within 6 months after an episode of APN in children under 36 months and its relationship with imaging studies, clinical settings, and bacteriology. Method. A retrospective study of previously healthy patients aged one to 36 months, admitted for a first episode of APN, with a minimum follow-up of 6 months. Demographic and clinical variables were collected along with bacteriology, renal and bladder ultrasound scan, voiding cystourethrography, DMSA-scintigraphy, and re-infection events. RESULTS: A total of 125 patients were included in the study, of which 60% were male, the large majority (92%) febrile, and due to E. coli (74.6%). There was a history of prenatal ultrasound scan changes in 15.4%. Ultrasound scan found dilation of the urinary tract in 22.1%. Voiding cystourethrography was performed on 70 patients: 54.3% no abnormalities, 12.8% vesicoureteral reflux (VUR) grade i-iii, and 32.9% iv-v grade VUR. Six patients had iv-v grade VUR with a normal ultrasound scan. Adherence to DMSA-scintigraphy at 6 months was only 61% of that indicated. Renal scarring was found in 44.3% of those in which it was performed (60 cases). CONCLUSIONS: Almost half (44%) DMSA-scintigraphy in children aged one to 36 months hospitalised for APN show renal scarring at 6 months, which was found to be associated with the re-infection events and the iv-v grade VUR. There was no relationship between scarring and the bacteriology or the elevations of inflammatory biochemical markers

[POSITIVE EFFECTS OF MODERN IMMUNOCORRECTION ACCORDING TO THE ANALYSIS OF CYTOKINES AND SLPI IN PATIENTS WITH PYELONEPHRITIS].

The peculiarities of cytokines as compounds of immunogenesis are shown in the patients having acute (A) and chronic (Ch) pyelonephritis (PN). The combination of antibacterial therapy with Nukleinat and Galavit promotes the positive changes of cytokin-producing ability of immunocompetent cells and decrease in the level of proinflammation cytokines in blood and urine, secretory leucocyte protease inhibitor (SLPI) in urine. In children with PN and adult patients with diagnostically elevated titres of antibodies (IgG) to Herpes simplex virus, Cytomegalovirus are shown the positive effects of Kanephron® H and Proteflazidum, accordingly. Clinico-immunological effects of immunomodulators testify to the expediency of this usage in complex therapy with the aim to modulate the cytokine link of immunity for improvement of the effective treatment in APN and the protection against aggravation of kidney functioning in ChPN.

[Clinical-biochemical and immunological parameters in the diagnosis and treatment of chronic pyelonephritis on the background of intercurrent diseases].

Studies have shown that complicated chronic pyelonephritis in the active phase is characterized by structural and functional instability cytomembranes and decreased immunological resistance of the patient man. Supplement standard antibiotic treatment with ozone therapy antioxidant immunomodulation drug thus received immunobiochemical study.

The effect of vitamin E or vitamin A on the prevention of renal scarring in children with acute pyelonephritis.

BACKGROUND: Numerous factors may contribute to renal tissue injury after urinary tract infection. We have evaluated the effects of vitamins A or E supplementation in combination with antibiotics for the prevention of renal scarring in acute pyelonephritis. METHODS: A simple non-blind randomized clinical trial was conducted on 61 children aged 1 month to 10 years between 2004 and 2006. The inclusion criteria were positive urine culture, clinical findings, and 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy-based evidence in favor of acute pyelonephritis. The children were randomized into three treatment groups: 10-day treatment with only antibiotics (control group; n = 25) and 10-day treatment with supplements of vitamin A (n = 17) or vitamin E (n = 18) in addition to antibiotics during the acute phase of infection. The final analysis was performed after excluding male patients. Each patient was evaluated twice by 99mTc-DMSA scintigraphy performed at least 6 months apart. P < 0.05 was considered to be statistically significant. RESULTS: The analysis included 108 kidney units. The frequency of inflammation at the beginning of therapy was not significantly different in the three groups (63.3 % in vitamin A, 61 % in vitamin E, and 76.2 % in the control group). A worsening of lesions, based on the second 99mTc-DMSA scan, was observed in 42.5, 0, and 23.3 % of the control, vitamin E, and vitamin A patients, respectively (LR = 26.3, P < 0.001). CONCLUSION: Vitamins A or E supplements were effective in reducing renal scarring secondary to acute pyelonephritis.

Infecciones del tracto urinario: sensibilidad antimicrobiana y seguimiento clínico / Urinary tract infections: antibiotic resistance and clinical follow up

El tratamiento inicial de las infecciones del tracto urinario (ITU) es empírico por lo que es prioritario conocer la resistencia antibiótica de los microorganismos más frecuentes en una población. Además, tras la sospecha de pielonefritis aguda se debe descartar la presencia de cicatriz renal que puede dar lugar a complicaciones posteriores. Presentamos un estudio longitudinal y retrospectivo de todos los menores de 14 años diagnosticados de ITU desde el 1 de enero del 2009 hasta el 31 de diciembre del 2009. Se analizaron los datos de sensibilidad a antimicrobianos de los patógenos urinarios más importantes, el seguimiento posterior y la presencia de cicatrices. Las bacterias aisladas con mayor frecuencia fueron: Escherichia coli (80%) Proteus mirabillis (9,7%) y Klebsiella pneumoniae (4,2%). En el antibiograma, E. coli presentó una alta sensibilidad frente a fosfomicina (99,1%), cefotaxima (98,2%) cefuroxima (97,3%) y gentamicina (95,6%). La sensibilidad obtenida frente a amoxicilina-clavulánico fue del 83,2%, mientras que la obtenida frente a cotrimoxazol fue del 78,9%.Se encontraron cicatrices pospielonefríticas en el 19% de los pacientes con ITU febril, 17% de los no ingresados y 20% de los ingresados(AU)

The initial treatment of the urinary tract infections (UTI) is empirical and it is a priority to determine the antibiotic resistance of most common germs in a population. Furthermore, due to the suspicion of acute pyelonephritis the presence of renal scarring should be ruled out as this may lead to further complications. A retrospective longitudinal study was performed on all children under 14 years diagnosed with UTI from January 1 2009 to December 31 2009. The in vitro susceptibility to the most important urinary pathogens was analysed, along with the presence of scars, and a subsequent follow-up. The most frequently isolated bacteria were E. coli (80%), P. mirabilis (9.7%) and K. pneumoniae (4.2%). In the antibiogram, E coli showed a high sensitivity to fosfomycin (99.1%), cefotaxime (98.2%) cefuroxime (97.3%) and gentamicin (95.6%). The sensitivity obtained against amoxicillin-clavulanate was 83.2%, while that obtained against cotrimoxazole was 78.9%.Post-pyelonephritis scars were found in 19% of patients with febrile UTI, 17% out-patients and 20% of those admitted(AU)

[Phytotherapy in combined treatment of chronic infection of the upper urinary tract in patients exposed to extracorporeal shock-wave lithotripsy].

Multicomponent biologically active additive Uroprofit made by Russian company Ecomir is used for phytotherapy of urolithiasis and urogenital infectious and inflammatory processes. Of 60 patients with urolithiasis and chronic pyelonephritis exposed to extracorporeal shock-wave lithotripsy (ECSWL), 30 patients received additional anti-inflammatory therapy with Uroprofit. As shown by reduction of leukocyturia and crystalluria, increased 24-h diuresis in patients with urolithiasis after exposure to ECSWL, a positive effect was achieved on urethral inflammation. Thus, Uroprofit phytotherapy has antiinflammatory, diuretic, lithokinetic effects which makes it appropriate for treatment and prophylaxis of infectious-inflammatory process in the urethra.

The role of functional urodynamic disorders in the pathogenesis of urolithiasis.

OBJECTIVE: The aim of this study was to analyze the functional urodynamic parameters, which affect renal function and can promote stone formation. MATERIALS AND METHODS: We examined sixty consecutive patients with renal and ureteral stones and indication to urinary diversion by nephrostomy tube or indwelling catheter In upper urinary tract, urodynamics was assessed with the help of electromanometry and multichannel impedance ureterography. To measure ureteral peristalsis, a probe equipped with 9 successively incorporated electrodes was indwelled retrogradely into distal ureter through a urethroscope. The documented data included renal pelvic pressure (RPP) and the number of ureteric contractility parameters such as peristalsis amplitude, peristalsis rate, the ureteral wall tone, the characteristics of contractile waveform and its direction (antegrade or retrograde). Urinary biochemistry and enzymuria were studied in order to characterize the lithogenic activity and renalfunction. The patients were divided into three groups: group 1 included patients with acute pyelonephritis caused by unilateral stone obstruction (n = 24), group 2 patients with stones and non-acute latent chronic pyelonephritis (n = 31) and group 3 unobstructed patients without signs of inflammation (n = 5). RESULTS: In the three groups of patients, the mean baseline RPP values were, respectively 28.7 +/- 2.6 (range 20.0-32.4); 15.6 +/- 1.9 (range 3.5-29.0); and 3.6 +/- 1.4 (range 0-8) cm H2O. The ratio of GGT to urinary creatinine changed similarly: it was elevated during acute inflammation, moderately enhanced during the chronic process, but significantly decreased after stone removal and resolution of inflammation (11.5 +/- 3.2; 8.1 +/- 2.0, and 1.6 +/- 0.5 unit/L). Biochemical evaluation revealed 54% patients with enhanced lithogenic activity assessed by elevated calcium and oxalates in the urine (4.95 +/- 0.25 mM and 504 +/- 35 microM, correspondingly) and low level of citrates (2.5 +/- 0.1 mM). In a subgroup of 11 patients with urolithiasis the baseline RPP values were assessed in relation to ureteral contractile activity in the distal region of ureter. Low RPP was found in a patient (9%) with strong ureteral contractions and a low tone while RPP was moderately higher in another patient (9%) with moderate mean peristaltic amplitude value but with elevated tone of ureteral wall. In the majority of examined patients with significantly elevated mean RPP value (45%), peristalsis of distal ureter was characterized by weak long-term and frequent contractions as well as increased tone with respect to the patients with normal RPP. The patients (36%) with moderately increased RPP demonstrated strong frequent contractions in the distal ureter and low ureteral wall tone. Changes in urodynamic parameters in patients examined before and immediately after ureteroscopy and lithotripsy procedures were observed. Factors affecting the ureteral wall tone were duration of stone disease, location and disposition of stones. CONCLUSIONS: Our clinical observations obtained with the help of physiological methods revealed various factors modulating the urodynamic disorders in renal pelvis: temporary or persistent elevation of pelvic pressure; peculiarities of contractile function in distal ureter manifested by the tonic changes and variations in contractile amplitude, and certain abnormalities in propagation of contractile wave in the upper urinary tract. The reported urodynamic changes in patients with stone disease can be supplementary pathogenic factors causing deterioration of renal function probably followed by stone formation.

[Intravesical electrostimulation and magnetotherapy in chronic pyelonephritis and cystitis in children with urodynamic disorders].

The results of the treatment of 38 children (6 boys and 32 girls, age 6-14 years) with chronic pyelonephritis and/or cystitis complicated with neurogenic dysfunction of the urinary bladder (NDUB) and/or vesicoureteral reflux (VUR) of the first-third degree demonstrate efficacy of intravesical electrostimulation (IVES) and adrenal magnetotherapy. IVES was conducted with high-frequency current impulses (2.2 kHz) by means of INTRASTIM attachment to the device AMUS-01-INTRAMAG in the region of the urethrovesical anastomosis via solution of the drugs for instillation. As the result of exposure to both physical factors in the presence of standard medication, NDUB symptoms alleviated (by E.L. Vishnevsky's criteria) by 59.5% against 38.1% in the control group. Dopplerographic examination of renal vessels stated a 24.3% increase in blood flow in the major renal artery in the study group against 10.5% in the control. The proposed complex pharmacological plus physiotherapeutic treatment of chronic pyelonephritis and cystitis in abnormal urodynamics resulted in a 2.2-fold decrease in the number of recurrences compared to the standard treatment.

Acute pyelonephritis in children: antibiotic therapy depending on the clinical context.

Children over 2 years of age with complicated acute pyelonephritis or at risk of complications should first be treated with a parenteral antibiotic, for example ceftriaxone, for 2 to 4 days, then switched to oral antibiotic therapy for a total treatment period of 10 to 14 days, taking into account the results of antimicrobial susceptibility testing. First-choice antibiotic therapy, in the absence of known risk, is oral cefixime for 7 days to 10 days. Second-line treatments include amoxicillin plus clavulanic acid or co-trimoxazole, taking account of the results of antimicrobial susceptibility testing.

[Prophylaxis and prognosis of preeclampsia in patients with chronic pyelonephritis and chronic glomerulonephritis].

The investigations performed showed that pregnant women with chronic pyelonephritis (CP) and chronic glomerulonephritis (CG) have certain response to therapy done in accordance with level of kidney function activity. In the pregnant women with CP and CG and kidney functional reserve KFR > 10% and from 5 to 10% the treatment efficacy was higher and practically absent in pregnant women with KFR < 5%.

Acute pyelonephritis: clinical characteristics and the role of the surgical treatment.

The epidemiology of acute pyelonephritis (APN) has changed with time. Therefore we investigated the current clinical characteristics of APN and the significance of proper surgical management for treatment of 1,026 APN patients in South Korea for the past 5 yr. The male-to-female ratio was about 1:8. The peak ages of female patients were 20s (21.3%) and over 60s (23.7%), while that of male was over 60s (38.1%). The occurrence of sepsis was 10.1%. Complicated APN patients were 35.4%. Ninety-four patients (9.2%) needed urological procedures. The duration of the flank pain and of the costovertebral angle tenderness in complicated APN patients was statistically significantly longer than that with simple APN patients (4.3 vs. 3.4 days, 4.4 vs. 4.0 days). If flank pain and costovertebral angle tenderness sustain over 4 days, proper radiologic studies should be performed immediately with the consideration of surgical procedure. Also the resistance to antibiotics was increasing. As the sensitivities to ampicillin (27.2%) and trimethoprim/sulfamethoxazole (44.7%) of Escherichia coli and Klebsiella pneumoniae were very low, it is necessary to take the careful choice of antibiotics into consideration.

Acute Pyelonephritis: Clinical Characteristics and the Role of the Surgical Treatment

The epidemiology of acute pyelonephritis (APN) has changed with time. Therefore we investigated the current clinical characteristics of APN and the significance of proper surgical management for treatment of 1,026 APN patients in South Korea for the past 5 yr. The male-to-female ratio was about 1:8. The peak ages of female patients were 20s (21.3%) and over 60s (23.7%), while that of male was over 60s (38.1%). The occurrence of sepsis was 10.1%. Complicated APN patients were 35.4%. Ninety-four patients (9.2%) needed urological procedures. The duration of the flank pain and of the costovertebral angle tenderness in complicated APN patients was statistically significantly longer than that with simple APN patients (4.3 vs. 3.4 days, 4.4 vs. 4.0 days). If flank pain and costovertebral angle tenderness sustain over 4 days, proper radiologic studies should be performed immediately with the consideration of surgical procedure. Also the resistance to antibiotics was increasing. As the sensitivities to ampicillin (27.2%) and trimethoprim/sulfamethoxazole (44.7%) of Escherichia coli and Klebsiella pneumoniae were very low, it is necessary to take the careful choice of antibiotics into consideration.

Pseudohypoaldosteronisms, report on a 10-patient series.

BACKGROUND: Type 1 pseudohypoaldosteronism (PHA1) is a salt-wasting syndrome caused by mineralocorticoid resistance. Autosomal recessive and dominant hereditary forms are caused by Epithelial Na Channel and Mineralocorticoid Receptor mutation respectively, while secondary PHA1 is usually associated with urological problems. METHODS: Ten patients were studied in four French pediatric units in order to characterize PHA1 spectrum in infants. Patients were selected by chart review. Genetic, clinical and biochemistry data were collected and analyzed. RESULTS: Autosomal recessive PHA1 (n = 3) was diagnosed at 6 and 7 days of life in three patients presenting with severe hyperkalaemia and weight loss. After 8 months, 3 and 5 years on follow-up, neurological development and longitudinal growth was normal with high sodium supplementation. Autosomal dominant PHA1 (n = 4) was revealed at 15, 19, 22 and 30 days of life because of failure to thrive. At 8 months, 3 and 21 years of age, longitudinal growth was normal in three patients who were given salt supplementation; no significant catch-up growth was obtained in the last patient at 20 months of age. Secondary PHA1 (n = 3) was diagnosed at 11, 26 days and 5 months of life concomitantly with acute pyelonephritis in three children with either renal hypoplasia, urinary duplication or bilateral megaureter. The outcome was favourable and salt supplementation was discontinued after 3, 11 and 13 months. CONCLUSIONS: PHA1 should be suspected in case of severe hyperkalemia and weight loss in infants and need careful management. Pathogenesis of secondary PHA1 is still challenging and further studies are mandatory to highlight the link between infection, developing urinary tract and pseudohypoaldosteronism.

Criterios clínicos y radiológicos en la decisión terapéutica del reflujo vesicoureteral. Un análisis retrospectivo de nuestra experiencia / Clinical and radiological criteria for the therapeutic decision for vesicoureteral reflux. Retrospective analysis of our experience

Objetivo: Establecer, en base a nuestra experiencia, unos esquemas terapéuticos del reflujo vesicoureteral en el niño, apoyándonos en resultados clínicos y radiológicos, observando cómo han ido evolucionando las indicaciones y tiempos de tratamiento con el advenimiento de las técnicas endoscópicas. Métodos: Se han analizado los pacientes con reflujo vesicoureteral tratados en dos periodos de similar duración: el primero (106 pacientes), entre 1995 y marzo 2001 (fecha en que se introdujeron las técnicas endoscópicas); el segundo, (138 pacientes), desde esa fecha hasta marzo de 2007. En todos los pacientes se estudiaron variables clínicas, diagnósticas y terapéuticas, así como el resultado obtenido. Resultados: El número de pacientes tratados aumentó en el segundo período, en él disminuyó ostensiblemente (de 24 a 7) el número de pacientes que requirieron reimplantación vesicoureteral. La proporción de éxitos del tratamiento endoscópico ascendió al 94,9%, no apreciándose diferencias significativas en función de la edad o el grado de reflujo, aunque se observa un mayor porcentaje de fracasos en niños menores de 3 años y en reflujos de alto grado. La presencia de malformaciones asociadas no se relacionó con una peor evolución tras el tratamiento. Conclusiones: En aquellos reflujos donde el tratamiento médico no ha sido eficaz, persistiendo o empeorando el mismo, y como alternativa a la cirugía abierta (con buenos resultados pero con una morbilidad no desdeñable), el tratamiento endoscópico se convierte en una alternativa de eficacia similar y mínimamente agresiva. Proponemos un esquema orientativo para establecer las indicaciones de cada estrategia terapéutica en función del grado de reflujo y su evolución clínica (AU)

Objectives: According to our experience, we present a proposal for the treatment of vesicoureteral reflux, based on both clinical and radiological evidences. We also describe how the introduction of endoscopic procedures has influenced the evolution of treatment indications as well as the time intervals for treatment. Methods: We have analysed all cases of vesicoureteral reflux treated in our Department in two periods of similar length: The first one (106 patients) comprised from 1995 to March 2001 (when endoscopic procedures were introduced). The second one (138 patients), comprised from March, 2001 to March 2007. Clinical, diagnostic, therapeutic and outcome-related variables were studied for all cases. Results: The number of patients was higher in the se-cond period. In this period the number of cases requiring ureteral reimplantation decreased with respect to the first one (from 24 to 7). The success rate with endoscopic treatment reached 94,9%, with no significant differences regarding age or grade of reflux, although higher rates of failures were observed in children aged less than 3 years old and in high-grade reflux. The association of reflux with other malformations was not related with a worse evolution after treatment. Conclusions: Endoscopic treatment, due to its similar efficacy and low aggressiveness, should be considered a valid alternative to open surgery (which offers good results but non-negligible comorbidity) for persistent reflux in which medical treatment has not been useful. We propose a tentative therapeutic scheme to establish the indications for each type of treatment depending on the grade of reflux and its clinical evolution (AU)

Nuestra experiencia en el empleo de diferentes materiales inyectables en el tratamiento endoscópico del reflujo vesicoureteral / Our experience using various injectable materials for the endoscopic treatment of vesicoureteral reflux

Objetivo: El Reflujo Vésico Ureteral (RVU) es la anomalía urológica más común en la infancia, afectando al 1% de la población pediátrica. El tratamiento endoscópico del RVU está aceptado como la primera opción terapéutica del mismo y desde su implantación se han utilizado diferentes materiales inyectables. Exponemos nuestra experiencia en el tratamiento endoscópico del RVU con las distintas sustancias que hemos ido empleando desde que comenzamos a realizar el procedimiento. Métodos: Hemos realizado un estudio retrospectivo descriptivo de los 445 pacientes que han sido tratados endoscópicamente de reflujo vesicoureteral (RVU) en nuestro centro entre los años 1988 y 2004. Hemos tratado un total de 568 uréteres y hemos analizado los resultados en función del material empleado, el grado de reflujo y la patología asociada. Resultados: De los 569 uréteres con RVU tratados, 457 eran RVU (79%) simples, 76 (15%) estaban incluidos en un sistema renal doble, 24 (4%) se asociaban a vejiga neurógena y 12 (2 %) eran RVU secundarios a cirugía antirreflujo abierta. Utilizamos tres tipos de materiales, predominado el politetrafluoroetileno con 257 uréteres, siguiéndole el dextranómero de ácido hialurónico con159 y por último el polidimetilsilixano con 153. En los “RVU simples” la tasa de curación global fue del 88% (381 uréteres), con mejora importante del grado de reflujo en el 7% (51 uréteres), precisando una reimplantación tipo Cohen en el 5,5% de los casos (25 pacientes). Observamos un menor índice de éxitos y mayor necesidad de más inyecciones en los reflujos grado IV y V. En los “RVU asociados a duplicidad” los resultados empeoran, con menos éxitos y mayor necesidad de procedimientos para su resolución. Curamos 59 uréteres (77%) sobre 76 uréteres tratados, 13 uréteres (19%) mejoraron y 4% precisaron de reimplantación tipo Cohen. En los “RVU asociados a vejiga neurógena” se consiguió curación en 20 uréteres (83%). Hubo mejoría significativa del reflujo en 2 uréteres (8%). Fracasamos en dos (8%), necesitando de reimplantación tipo Cohen para evitar el deterioro progresivo del riñón. En los “RVU de uréteres reimplantados mediante cirugía abierta” curamos 12 uréteres (100%) sobre 12 tratados. Hubo 8 uréteres simples, solucionando el reflujo en 6 con un único procedimiento, mientras que uno precisó de dos procedimientos. En total el número de uréteres curados ha sido de 496 (87%) y 51 (9%) han mejorado. Se han intervenido 22 uréteres (4%). Con 1 inyección hemos curado un 68%, con 2 inyecciones un 16,5% y con 3 el 1%. Las complicaciones acaecidas en estos 569 procedimientos, fueron 5 (0,8%): 1 caso de cistitis hemorrágica que cedió espontáneamente en dos días y 4 pielonefritis que se trataron con antibiótico adecuado según antibiograma. No hemos tenido casos de infecciones urinarias bajas de repetición. El tiempo de seguimiento ha variado de 1´5 años a 15 años. Conclusiones: Parece que tanto el polidemitilsiloxano como el dextranómero de ácido hialurónico son materiales buenos y seguros y no tienen el peligro de migración a distancia que tiene el politetrafluoroetileno (AU)

OBJETIVES: Vesicoureteral reflux (VUR) is the most commoObjetives: Vesicoureteral reflux (VUR) is the most common urologic anomaly in childhood, affecting 1% of the pediatric population. Endoscopic treatment of VUR is accepted as the first therapeutic option and various injectable materials have been used since its implantation. We present our experience in the endoscopic treatment of VUR with various substances which we have been employing since we started performing the procedure. Methods: We have performed a retrospective descriptive study including 445 patients that underwent endoscopic treatment for vesicoureteral reflux in our centre between 1988 and 2004. We treated a total of 568 ureters, and we analyze results depending on the material employed, grade of reflux and associated pathology. Results: Among 569 ureters with vesicoureteral reflux undergoing treatment 457 were single VUR (79%), 76 (15%) were part of a double renal system, 24 (4%) were associated with neurogenic bladder, and 12 (2%) were secondary VUR after antireflux open surgery. We use three types of materials, with predominance of polytetrafluorethylene in 257 ureters, followed by hyaluronic acid dextranomer in 159, and finally polydimethylsiloxane in 153. In the cases of single VUR global cure rate was 88% (381 ureters), with significant improvement of the grade of reflux in 7% (51 ureters), and 5.5% of the cases (25 patients) requiring a Cohen type reimplantation. We observed a lower success rate and greater need of repeated injections in grade IV and V refluxes. In VUR associated with duplication results are worse, with less successes and greater need of procedures for its resolution. We cured 59 ureters (77%) out of 76 treated, 13 (19%) improved, and 4% required Cohen type reimplantation. In cases of VUR associated with neurogenic bladder 20 ureters were cured (83%). There was significant improvement in two ureters (8%); there were two failures (8%), requiring Cohen type reimplantation to avoid progressive deterioration of the kidney. In the cases of VUR after open surgical reimplantation all 12 ureters treated were cured (100%). Among 8 single ureters, reflux was solved with 1 procedure in 6 and 1 required 2 procedures. The total number of cured ureters has been 496(87%), and 51(9%) have improved. 22 ureters underwent surgery (4%). 68% of the cases were cured after 1 injection, 16.5% after 2 , and 1& after 3. There have been 5 complications (0,8%): 1 case of hemorrhagic cystitis which resolved spontaneously in two days, and 4 pyelonephritis which received the appropriate antibiotic therapy following antibiogram. We did not have any case of recurrent lower urinary tract infections. Follow-up has range it from 1.5 to 15 years. Conclusions: It seems that both polydimethylsiloxane and hyaluronic acid dextranomer are good and safe materials, and do not have the risk of distant migration of polytetrafluorethylene (AU)

[Application of sinusoidal modulated currents and radon therapy in patients with uroliths in upper urinary tracts]. / Primenenie sinusoidal'nykh modulirovannykh tokov i radonoterapii bol'nym s kamniami verkhnikh mochevyvodiashchikh putei.

The paper describes the method of elimination of the upper urinary tract uroliths using a combination of the following modalities: sinusoidal modulated currents, drinking of artificial radon water, radon water baths and no-spa medication. Evacuation of the concrements or their fragments from the upper urinary tracts reached 80%.

Antimicrobial-induced endotoxaemia in patients with sepsis in the field of acute pyelonephritis.

BACKGROUND: In vitro results have shown that antimicrobial agents may induce the Gram-negative bacteria to release endotoxins (LPS), which in turn, could trigger the secretion of cytokines from monocytes. AIMS: To compare the effect of cefuroxime, netilmicin or ciprofloxacin on serum levels of LPS and tumour necrosis factor-alpha (TNFalpha). METHODS: Seventy-four patients with acute pyelonephritis caused by Gram-negative bacteria and signs of sepsis were randomly assigned to receive one of three intravenous regimens of cefuroxime, netilmicin or ciprofloxacin. Blood samples were collected before therapy and at specified time intervals for 96 hours after the initiation of treatment for the determination of serum levels of LPS and of TNFalpha. RESULTS: Patients treated with cefuroxime presented an early peak of LPS and of TNFalpha in serum two hours after the initiation of treatment compared to the other study groups. After that time interval, concentrations of LPS and TNFalpha were similar in all the study groups. Fever accompanied by endotoxaemia was still detected for 48 hours after the start of therapy in 36, 37.5 and 36% of patients treated with cefuroxime, netilmicin and ciprofloxacin respectively. The corresponding figures for these agents at 72 hours were 28, 12.5 and 24%, respective and 12, 4.2 and 4% at 96 hours (P value not significant). CONCLUSIONS: With the exception of an early peak in the serum levels of LPS and TNFalpha in patients treated with cefuroxime, no significant difference could be detected amongst the study groups as far as their effect on serum levels of LPS and TNFalpha were concerned. This suggests that these three antimicrobial agents may be administered safely at the early stages of sepsis.