Myoglobin cast nephropathy in a kidney transplant patient with normal creatine kinase.

Delayed graft function in kidney transplant recipients is a known complication associated with increased risk of acute rejection and reduced transplant survival after 1 year. There are multiple risk factors, including prolonged cold ischemia time, donor age, and cause of donor's death. Major causes of delayed graft function are acute kidney injury in the donor, often from prolonged terminal ischemia, reflected by acute tubular injury in the recipient. However, the differential diagnosis of delayed graft function includes acute rejection, recurrence of the primary glomerular diseases, and other less commonly encountered conditions. A transplant kidney biopsy usually is required to elucidate the correct cause and initiate the right treatment, which is crucial for transplant survival. We report a case of a transplant recipient who developed delayed graft function due to an uncommon cause. After correct diagnosis, the patient's transplant function improved.

Reduced flow after tubularized incised plate urethroplasty--increased fibrogenesis, elastin fiber loss or neither?

PURPOSE: Low urinary flow rates are common after tubularized incised plate urethroplasty but the etiology remains unclear and may be related to low urethral compliance due to abnormal collagen concentrations and/or fewer elastic fibers in the healed urethral plate. We hypothesized that inserting a preputial mucosal graft over the dorsal raw area after the midline incision may avoid scarring and improve urethral compliance. MATERIALS AND METHODS: Adult rabbits were submitted to tubularized incised plate urethroplasty with or without inlay preputial graft according to a previously described protocol. Tissular concentrations of collagens I, III, IV, VI, VIII and XIII were measured. Histomorphometric analysis was used to quantify elastic fibers in the urethra. Tubularized incised plate urethroplasty with and without inlay preputial graft was compared to normal rabbit urethras (controls). RESULTS: mRNA concentrations for collagens I, II and XIII were similar between controls and operated rabbits. The proportions between collagens I and III were 1.05, 0.87 and 1.21, respectively, in controls and animals undergoing tubularized incised plate urethroplasty with and without inlay preputial graft. mRNA concentrations for collagen IV and collagens VI/VIII tended to be higher and lower, respectively, in the operated urethras, despite showing statistical significance only for collagen VIII in animals undergoing tubularized incised plate urethroplasty with inlay preputial graft vs controls (p=0.02). The operated animals did not demonstrate a reduced number of elastic fibers in the urethral tissues compared to controls. CONCLUSIONS: Elastic fiber number and distribution were similar between tubularized incised plate urethroplasty cases and controls, suggesting that decreased concentrations of elastic fibers do not explain the reduced urethral compliance after tubularized incised plate urethroplasty. The raw area determined by the dorsal urethral incision regenerated after standard tubularized incised plate urethroplasty, while cicatrization with fibrosis occurred in correspondence to the grafted areas after tubularized incised plate urethroplasty with inlay preputial graft.

Epidemiological, clinical and laboratorial profile of renal amyloidosis: a 12-year retrospective study of 37 cases.

BACKGROUND: Renal amyloidosis is one of the main differential diagnoses in the investigation of nephrotic proteinuria in adults, especially elderly patients. OBJECTIVES: The aim of this article is to contribute to international research with epidemiologic data of renal amyloidosis, given the lack of uniformity described in the literature. PATIENTS AND METHODS: A retrospective study of 37 cases of renal amyloidosis diagnosed by kidney biopsy, between 2000 and 2011, considering epidemiological, clinical and laboratory data. RESULTS: Subjects aged between 32 and 80 years. Of the 37 cases, 21 (56.8%) were diagnosed as non-light chain (non-AL) renal amyloidosis and 16 (43.2%) as light chain amyloidosis (AL). There was seen an increase in number of both AL and non-AL cases, with a slight predominance in non-AL. The mean 24-hour proteinuria was 5839.0 mg/day. Hematuria was present in 75% of patients. Hypertension was reported in 34% of patients. Acute renal failure, occurred in about 10% of patients, and chronic loss of renal function was present in about 5% at diagnosis. CONCLUSIONS: Renal amyloidosis is a disease of increasing incidence. The forms of clinical presentation proved to be variable, but the presence of proteinuria or nephrotic syndrome in elderly patients should always prompt the suspicion of renal amyloidosis and is a formal indication of renal biopsy.

Nonfunctioning giant pituitary adenomas: Invasiveness and recurrence.

BACKGROUND: We report our surgical series of 35 patients with giant nonfunctioning pituitary adenomas (GNFPA). We analyzed the rule of Ki-67 antigen expression in predicting recurrence. METHODS: Thirty-five patients were operated between 2000 and 2010. Suprassellar extension of the tumors were classified according to Hardy and Mohr based on magnetic resonance (MR) studies. Pituitary endocrine function and MR scans were assessed preoperatively and at 1, 6, and 12 months postoperatively. Immunohistochemical studies were based in regard to the expression of the proliferative Ki-67 index and the hormonal receptor for luteinizing hormone, follicle stimulating hormone, growth hormone, thyroid stimulating hormone, adrenocorticotropic hormone, and prolactin. Tumors specimens were obtained from 35 patients with GNFPA. Endoscopic transsphenoidal surgery was the approach of choice. RESULTS: Thirty-five patients were submitted to 49 surgeries, 44 (89.8%) were transsphenoidal and 5 (10.2%) were transcranial. The most frequent preoperative complaints were visual acuity impairment and visual field defect in 25 (71.2%) and 23 (65.7%) cases, respectively. Improvement of visual acuitiy and visual field deficit after surgery was seen in 20 (80%) and 17 (73.9%) patients, respectively. Endocrinological deficits were encountered in 20 patients (57.1%). After surgery, 18 patients (51.4%) required hormonal replacement. Three patients had visual symptoms related to pituitary apoplexy and recovered after surgery. The Ki-67 labeling index (LI) ranged from <1% to 4.8%. The rate of recurrence in tumors with Ki-67 <3% was 7.7% (2 patients), Ki-67 >3% was present in 5 patients and the recurrence committed 3 patients. CONCLUSION: In our series, regardless the improvement of visual function and compressing symptoms, 5 patients with expression of Ki-67 LI more than 3% experienced a recurrence.

Granulomatous orchitis in a pre-pubertal school-aged child: differential diagnosis dilemmas.

A 6-year-old male presented with testicular growth and persistent chronic orchiepididymitis with high inflammatory markers (C reactive protein and erythrocyte sedimentation rate). Biopsies of the testes and epididymides showed bilateral epididymal and testicular granulomata, testicular fibrosis and chronic inflammatory infiltration, and the histological diagnosis was granulomatous orchitis. The symptoms receded with oral corticosteroids. Although rare, granulomatous orchitis is a possible diagnosis in children presenting testicular enlargement. It is important to differentiate it from testicular tumors (if necessary with testicular biopsy) and to investigate its association with systemic vasculitis and infectious diseases.