Chyluria with massive proteinuria: Do not reach for the biopsy gun!

We report on a patient presenting with persistent chyluria due to filariasis, whose clinical course was complicated by massive proteinuria and severe hypoalbuminemia. Treatment with dietary manipulation, antifilarials, and sclerotherapy resulted in successful reversal of the above abnormalities. It has been reported that chyluria is not associated with massive proteinuria, or that even in cases of massive proteinuria, hypoalbuminemia is not seen and implies a glomerular pathology. We argue that chyluria is always associated with proteinuria, which may be massive, and does not warrant a kidney biopsy unless proteinuria persists despite resolution of chyluria.

Can kidneys be saved in patients with urinary tuberculosis? A study in the era of modern chemotherapy and surgical armamentarium.

OBJECTIVE: To assess renal unit survival and factors affecting renal salvageability in a cohort of patients receiving modern medical and surgical therapy for urinary tuberculosis. METHODS: This was a retrospective single-center study including all patients diagnosed and treated as urinary tuberculosis between 2005 and 2015 at Christian Medical College, Vellore, Tamil Nadu, India. The primary outcome was time to renal unit non-salvageability (estimated glomerular filtration rate of <15 mL/min). RESULTS: A total of 128 patients were included in the study. The mean age was 37.7 ± 11.3 years, 33% had microbiological and 73% had histopathological confirmation in addition to radiological diagnosis. The estimated median survival of the involved renal units (n = 187) on Kaplan-Meier estimate was 75 months (95% CI 39-99). On multivariate analysis, renal units with initial split function >15 mL/min had fivefold the survival estimate as compared with those ≤15 mL/min (P < 0.001); the presence of one, two and three infundibular strictures had a 2.2-, 2.9- and fivefold higher hazard of renal unit loss respectively, and lower ureteric strictures had fivefold longer estimated survival (P = 0.015) after treatment. Renal units in the reconstruction group had 5.44-fold (95% CI 2.71-10.88, P < 0.001) longer survival than the permanent diversion group, with a mean change in split function of +0.76 (±16.11) mL/min, versus -5.61 (±10.87) mL/min respectively. CONCLUSIONS: Loss of renal units is a function of time despite modern treatment. Baseline renal unit function, site of ureteric involvement and extent of infundibular involvement on imaging are helpful in predicting the duration of renal salvageability. When feasible, reconstruction is better at renal function preservation.

A rare cause of anuria: Bilateral synchronous isolated mid-ureteric tubercular lesions.

A young female presenting with right flank pain, fever, raised creatinine and bilateral hydronephrosis was treated with antibiotics elsewhere, with presumptive diagnosis of bilateral pyelonephritis. She had partial relief in symptoms and her creatinine level showed an improvement. Three months later during evaluation at our center she had anuria, hypertensive crisis and pulmonary edema which were managed with emergency bilateral percutaneous nephrostomies. Cross-sectional imaging and ureteroscopy suggested bilateral synchronous intramural mid-ureteric lesions as underlying pathology. Histopathology of the ureteric segments during laparotomy revealed caseating granulomas suggestive of tuberculosis. This clinical presentation has not been previously described in urinary tuberculosis.