Assessment of Toll-like receptor-4 gene polymorphism on pyelonephritis and renal scar.

The aim of this study was to evaluate the effect of the TLR-4 gene TLR4 c.896A < G polymorphism on the development and clinical severity of urinary tract infections (UTI) and renal scar formations in children. The patients with first diagnosis of UTI (n = 112) and healthy controls (n = 93) were enrolled in the study. The TLR4 c.896A < G polymorphism was analysed in groups. The mean age of the patients in the study group was 8.1 ± 3.5 years and 9.2 ± 2.7 years for those in the control group. The TLR4 c.896A < G polymorphism was detected in 12.5% in the UTI group and in 15.1% of the control group. Forty patients showed pyelonephritis (PN) with scar tissue, 37 patients had PN without scars, and 35 patients had lower UTI. The TLR4 c.896A < G polymorphism was found in 22.5% of patients with scar-positive PN, and it was also present in 10.8% of patients with scar-negative PN and 2.9% of patients with lower UTI. We found higher TLR4 c.896A < G polymorphism and allelic frequency in patients with upper UTI compared to patients with lower UTI (P = 0.041 and P = 0.039, respectively). No significant difference was observed between patients and the control group for TLR-4 c.896A3. The TLR4 c.896A < G polymorphism and alleles were higher in patients with upper UTI than in patients with lower UTI. The TLR4 c.896A < G polymorphism frequency was nearly twice that in the scar-positive PN patients when compared to the scar-negative patients. Larger-scale studies involving larger numbers of patients should be performed.

Combined liver-kidney transplantation and follow-up in primary hyperoxaluria treatment: report of three cases.

INTRODUCTION: Primary hyperoxaluria type-1 (PH1) is an autosomal recessive disorder caused by impaired activity of the hepatic peroxisomal alanine-glyoxilate aminotransferase, which leads to end-stage renal disease (ESRD) and requires combined liver-kidney transplantation (CLKT). Herein, we have reported 3 children diagnosed with PH1 who received CLKT. CASE 1: A 4.5-year-old boy with an elder brother diagnosed with PH1 was diagnosed during family screening when the sonography showed multiple calculi. Within 5 years he experienced flank pain, hematuria attacks, and anuric phases due to obstruction and received hemodialysis (HD) when ESRD appeared. CLKT was performed from his full-match sister at the age of 9.5. He is doing well at 5.5 years. CASE 2: A 7-year-old boy was admitted with polyuria, polydypsia, and stomach pain with renal stones on sonography. PD was instituted when serum creatinine and BUN levels were measured as high values. At the age of 10, CKLT was performed from his mother. His liver and renal function tests are well at 14 months after CKLT. CASE 3: A 2.5-year-old girl had attacks of dark urine without any pain; renal stones were imaged on sonography. She was diagnosed with PH1 and operated on several times due to obstruction. She received peritoneal dialysis and a cadaveric CLKT was performed when she was 9 years old. At the age of 16, she experienced chronic allograft nephropathy requiring HD and subsequent cadaveric donor renal transplantation at 1.5 years after initiation of HD. CONCLUSION: Herein, we have presented the favorable clinical outcomes of patients with CKLT to indicate the validity of this treatment choice for PH1.

Biodistribution of 99m technetium- labeled creatinine in healthy rats.

The distribution of creatinine, one of the toxic guanidine compounds, in various tissues has not been studied in detail by using radiolabeled creatinine. Our objective was to investigate the biodistribution of creatinine labeled with 99m technetium (99mTc) by the stannous (II) chloride method in healthy male Wistar rats. Quality controls were carried out by radio thin layer chromatography, high-performance liquid chromatography, and paper electrophoresis. The labeling yield was 85 +/- 2% under optimum conditions (pH 7 and 100 microg stannous chloride). Rats (N = 12) were injected intravenously with 99mTc-creatinine and their blood and visceral organs were evaluated for 99mTc-creatinine uptake as percent of the injected dose per gram wet weight of each tissue (%ID/g). The lowest amount of uptake was detected in the brain and testis. When the rate of uptake was evaluated, only the kidney showed increasing rates of uptake of 99mTc-creatinine throughout the study. Kidneys showed the highest amount of uptake throughout the study (P < 0.001 compared to all other organs), followed by liver, spleen and lung tissue.

Renal medullary changes in renal allograft recipients with raised serum creatinine.

OBJECTIVE: To test the hypothesis that the renal medulla may reflect rejection related changes and thus have a predictive value in the assessment of acute renal allograft rejection or chronic graft damage. METHODS: 75 post-transplant biopsies from 57 patients were scored according to the Banff 1997 scheme. The biopsies with adequate cortical and medullary tissue (n = 23) were selected and medullary tissues were reviewed for rejection related lesions except intimal arteritis. Chronic damage was determined by image analysis depending on periodic acid-methenamine silver (PAMS)-Masson trichrome (MT) staining. Medullary and cortical changes were compared. RESULTS: Interstitial inflammation and tubulitis were more frequent and severe in the cortex (p<0.001). Medullary tubulitis was associated with intimal arteritis (p = 0.003, r = 0.598). Medullary interstitial inflammation (n = 8) and tubulitis (n = 4) were associated with cortical borderline changes (n = 5) or allograft rejection (n = 3). The sensitivity, specificity, and positive and negative predictive values of medullary inflammatory changes in predicting cortical allograft rejection were 43%, 69%, 37%, and 73%, respectively. A significant association was observed between medullary MT-SAP and cortical PAMS-SAP values (p = 0.02, R(2) = 0.23). CONCLUSIONS: Acute rejection related lesions are more common and severe in the cortex, and the renal medulla does not sufficiently reflect cortical rejection. The positive and negative predictive values of medullary changes for allograft rejection are low, and medullary inflammation is not a reliable indicator of allograft rejection. Increased medullary fibrosis is correlated with chronic cortical damage.

Effect of obesity and overweight on cyclosporine blood levels and renal functions in renal adolescent recipients.

INTRODUCTION: The impact of obesity, a frequent problem after renal transplantation, which has been associated with poor graft and patient survival, was evaluated on renal function and cyclosporine (CsA) blood levels. PATIENTS: We retrospectively evaluated the data of adolescent renal recipients between 1994 and 2004. Patients with serum creatinine > or = 2.5 mg/dL were excluded. We grouped the data with regard to the body mass index (BMI) percentiles as group I (BMI > 95th), group II (BMI < 95th), group III (BMI > 85th), group IV (BMI < 85th). We compared the clinical and laboratory findings between groups I and II and between groups III and IV. RESULTS: We evaluated 778 visits of 27 patients (M/F: 19/8). There were 30 visits in the obesity period (group I) and 72 visits after the overweight periods were added (group III). Serum creatinine levels were significantly higher and glomerular filtration rate levels significantly lower among obese and/or overweight than lean periods (P < .05). Proteinuria levels were similar in groups I and II, but significantly higher in group III than group IV (P = .356 and .000, respectively). CsA(mg/bw), CsA(mg/bmi), and CsA(mg/bsa) levels were significantly lower in group I than group II and in group III than group IV (P < .05), while C0 and C2 levels were similar (P > .05). CONCLUSION: Weight gain is associated with worse renal functions but not greater proteinuria in our patients. Smaller CsA doses were sufficient to maintain C0 and C2 levels similar to the lean patients, results that were parallel to those of adult renal recipients.

Quantitative digital histochemistry with methenamine silver staining in renal allograft biopsies excluding pure chronic allograft nephropathy cases.

Deterioration of renal function is correlated with irreversible damage in chronic diseases. Recently we described a digital quantitative histochemistry method, relying on periodic acid methenamine silver (PAMS) staining to determine the chronic renal lesions. This index was strongly correlated with progressive deterioration of renal function in grafts with chronic allograft nephropathy (CAN). Herein the method has been applied to a cohort of renal allografts which were biopsied for various reasons, we sought to highlight its value to quantify chronic graft damage. Forty-four renal allograft biopsies from 37 patients with elevated serum creatinine values (SCr) underwent light microscopic image analysis (Mediscope, Dokuz Eylül University, Clinical Engineering Department, Izmir, Turkey) of the PAMS-stained area percentage (SAP). SCr was recorded at four intervals to overcome acute effects: the under SCr value before (SCr1) and after a biopsy within 3 months (SCr3), SCr at the time of the biopsy (SCr2), and the latest value (SCr4). The PAMS-SAP scores were strongly associated with increased interstitial fibrosis and tubular atrophy Banff scores (Kruskal-Wallis test, P = .006 and P = .003, respectively). There was a moderate positive correlation between PAMS and SCr3 (Pearson correlation test, P = .04, r = .312), and a strong positive correlation between time from transplantation to biopsy (Pearson correlation test, P << .000, r = .532). The present results show that PAMS-SAP seems to be of value to quantify renal scarring in allograft biopsies, reflecting four compartments. The strong correlation with time is noteworthy especially as a probable reflection of aging of the renal allograft.

Correlation of C0 and C2 levels with lipid profiles in adolescent renal transplant recipients in the early and late posttransplant periods.

Hyperlipidemia is a frequent complication after renal transplantation. Cyclosporine therapy is an important cause of hyperlipidemia. It is still controversial whether C0 or C2 is the most effective way to monitor blood cyclosporine concentrations to guide dosages. We sought to evaluate the relationship of C0 or C2 to serum lipid levels in the early and late posttransplant periods among adolescent renal transplant recipients. The posttransplantation charts of 26 adolescent renal transplant recipients were evaluated retrospectively. Serum C0 and C2 levels and serum lipid (triglyceride and total cholesterol) levels were analyzed both in the early (first 6 months) and the late (thereafter) posttransplant periods. Hypertriglyceridemia and hypercholesterolemia were defined as levels above the 95th percentile adjusted for age and gender. To evaluate the influence of C0 and C2 levels on serum lipids, we excluded one patient with familial hyperlipidemia. In addition, serum lipid levels of the remaining 25 patients were excluded in acute rejection periods and when the serum creatinine levels were above 2.5 mg/dL, representing chronic allograft nephropathy. Concurrently recorded serum C0 and C2 levels were present for only 21 patients. Overall, we evaluated the records of 245 visits for these 21 patients. The incidence of hyperlipidemia decreased in the late posttransplant period, being significant for hypercholesterolemia. C2 had strong negative correlation with serum lipids; it was significant for total cholesterol in the early posttransplant period (r=-0.542, P=.005), but weaker in the late posttransplant and whole posttransplant periods. Thus correlation of C2 with serum lipids showed differences during posttransplant follow-up. C0, on the other hand, was positively correlated with total cholesterol levels in all periods, being significant for the whole posttransplant period (r=0.293, P=.000) and for the late posttransplant period (r=0.196, P=.025). Although not statistically significant, C0 levels were higher among hypertriglyceridemic or hypercholesterolemic episodes both in the early and the late posttransplant periods. When only the C0 levels of all 25 patients were analyzed (789 visits), C0 and serum cholesterol levels were positively correlated both in the early and the late posttransplant periods (P=.013, r=0.198 and P=.000, r=0.177, respectively). We concluded that C0 has a more predictable correlation with serum cholesterol levels after renal transplantation in adolescent patients.

What is the risk of pyelonephritis due to desmopressin in rats with cystitis?

The risk of pyelonephritis in children with asymptomatic cystitis or bacteriuria, using desmopressin for primary nonpoliuric nocturnal enuresis, is not known. The aim of this study was to study whether there is a risk of pyelonephritis in rats with cystitis using desmopressin. Wistar rats (n = 28) were divided into four groups of cystitis (groups I-IV). DDAVP (2 microg daily) and saline (0.5 ml daily) were injected intramuscularly for 7 days in groups II and IV and groups I and III, respectively. The urinalysis, urine culture, and 24-h urinary volume (UV(24)) were assessed for all rats on days 1, 3, 5, and 7. In groups III and IV these studies were also performed on days 14, 21, and 28. Serum creatinine was determined on day 7 in all rats and on day 28 in groups III and IV. Groups I and II and groups III and IV were killed at the end of days 7 and 28, respectively. Kidneys and urinary bladders were graded subjectively for inflammation and fibrosis. Inflammation and fibrosis scores in kidney and bladder tissues were not different between DDAVP or saline-injected rats in cystitis groups at weeks 1 and 4. No fibrosis was found in any of the urinary bladders on histological examination. Ascendant pyelonephritis was detected in each of the four rats in DDAVP-administered and saline-administered cystitis groups. The histopathologic scores of the renal tissue with pyelonephritis showed no correlation with the daily urine volume, the positive test results for urine leukocyte esterase with dipstick test, the urine culture results for E. coli based on colony-forming unit per milliliter, or serum creatinine levels in cystitis groups. It was found that the administration of DDAVP to cystitis groups did not increase the risk of ascendant pyelonephritis.

Evaluation of ureteral jet dynamics in pediatric kidney stone formers: A cross-sectional study.

INTRODUCTION: The risk of kidney stone formation increases with urinary stasis, which is associated with decreased peristaltism. The relationship between nonobstructive kidney stone formation and ureteral jet dynamics, which can be measured with Doppler ultrasonography (US) and provide information about ureteral peristaltism, has been demonstrated in adults. OBJECTIVE: To investigate the relationship between ureteral jet dynamics, which provide information about ureteral peristaltism, and stone formation in children. STUDY DESIGN: Children admitted to Dokuz Eylul University Hospital with flank pain, and asymptomatic age-matched children for the control group, were prospectively enrolled and underwent Doppler US for diagnostic reasons and bilateral ureteral jet flow measurements. Children diagnosed with unilateral nonobstructive lower pole kidney stones formed Group 1, and the control group, without any evidence of stone disease, formed Group 2. Ureteral jet dynamics were compared between the affected renal units in Group 1, and healthy renal units in Group 1 and Group 2. RESULTS: A total of 32 children were included for each group. The mean average jet flow-rate (JETave (cm/second)) in affected renal units in Group 1 was found to be significantly lower than in the healthy renal units in Group 1 and left and right healthy renal units in Group 2 (P < 0.05). The continuous JETpattern rate in affected renal units in Group 1 was found to be significantly higher compared with healthy renal units in Groups 1 and 2 (P = 0.012) (Table). The odds ratio for kidney stone formation was 5.6 for renal units with JETave <9.5 cm/s when compared with renal units with JETave ≥9.5 cm/s. DISCUSSION: In a recent study, it was demonstrated in adults that low ureteral jet flow-rate and continuous JETpattern were significantly higher in affected renal units. The findings in children were also similar to adults: the mean JETave was significantly lower and determination rate of continuous flow pattern was significantly higher in affected renal units. CONCLUSIONS: Children with low JETave and continuous JETpattern as a sign of decreased ureteral peristaltism are at an increased risk of kidney stone formation. However, it is vital that further studies are conducted to elaborate on this topic.

Significance of ligature technique on the formation of pulmonary artery stump thrombosis in a canine model.

BACKGROUND: Thrombo-embolism following pulmonary resection is a serious complication with a fatal outcome. We have tried to clarify the role of ligature techniques used in pulmonary resection on the formation of pulmonary artery stump thrombosis, which may lead to a subsequent pulmonary thrombo-embolism. MATERIAL AND METHODS: Two groups of 10 mongrel dogs underwent a standard left pneumonectomy under anesthesia. The transfixation, or the continuous ligature technique, was applied to close the pulmonary artery stump in each group. Morphological evaluation of the ligated pulmonary artery was carried out, including the macroscopic thrombus formation and microscopic findings. RESULTS: The transfixation ligature technique showed a significantly greater incidence of macroscopic thrombosis in the pulmonary artery stump when compared with the continuous ligature technique (p = 0.033). This was confirmed by microscopic changes (p = 0.020). CONCLUSION: Thrombus formation in the pulmonary artery stump is more likely to occur following the closure of the stump with the transfixation ligature technique compared with the continuous ligature technique.

An unusual central retinal dystrophy associated with ichthyosis vulgaris.

A number of ichthyosis syndromes may have retinal abnormalities such as the retinitis pigmentosa-like diffuse rod-cone dystrophy in Refsum's syndrome and the maculopathy in Sjögren-Larsson syndrome. We present two sisters who have an unusual, almost identical, bilaterally symmetric central retinal dystrophy associated with ichthyosis vulgaris in the absence of other systemic disorders. We believe that this dystrophy has not been previously described in patients with any of the known varieties of ichthyosis.

Bilateral megalocornea with unilateral lens subluxation.

Megalocornea refers to an enlarged cornea that measures 13 mm or more in horizontal diameter in the absence of raised intraocular pressure. We describe a five-month-old boy with bilateral megalocornea with unilateral lens subluxation. No other ophthalmological abnormality was present. In all previously reported cases with megalocornea and ectopia lentis, the lens was cataractous and the dislocation was in the inferior and posterior direction. In contrast, our case had a clear lens which was displaced superonasally.

Neurofibromatosis type I and unilateral ophthalmic artery occlusion.

Etiological investigation of a 15-year-old boy with left ophthalmic artery occlusion led us to a diagnosis of neurofibromatosis type I as there were numerous large cafe-au-lait spots, axillary freckling, and brain MRI changes consistent with a hamartoma. In light of the present case, ophthalmic artery occlusion may be a rare feature of neurofibromatosis type I besides more commonly described cerebrovascular changes.

Intercostal arteriovenous hemangioma.

We report a case of a 46-year-old man who presented with a chest wall tumor in the right hemithorax. He underwent thoracotomy to remove the mass, which was found to be an arteriovenous hemangioma arising from the intercostal muscle. Arteriovenous hemangioma is a rare tumor and chest wall is an extremely rare site for this tumor. This tumor should be considered in the differential diagnosis of the chest wall tumors. Complete surgical excision offers the best treatment.

Implantation metastasis caused by fine needle aspiration biopsy following curative resection of stage IB non-small cell lung cancer.

Fine needle aspiration is a useful procedure in the diagnosis of lung cancer, however controversy still remains as to whether it should be employed particularly in patients with operable lung cancer. We report herein a case of metastatic tumor at the site of transthoracic needle biopsy following a curative resection in a patient with stage IB bronchogenic carcinoma. The patient was managed with aggressive chest wall resection and subsequent musculocutaneus flap transposition, however he died 11 months after the initial operation. The tumor implantation risk and the related complications should be considered in patients with operable bronchogenic carcinoma undergoing a tranthoracic needle aspiration biopsy.

Successful removal of a giant recurrent mediastinal liposarcoma involving both hemithoraces.

Primary liposarcomas of the mediastinum are unusual tumors. We report herein a case of a 52-year-old woman, who was found to have a mediastinal tumor involving both hemithoraces and radiologically showing non-resectable-invasive features to the adjacent vital structures. She had a history of left thoracotomy for mediastinal schwannoma 14 years previously. The patient underwent an exploratory thoracotomy following a preoperative misdiagnosis of an ancient schwannoma. Complete removal of the tumor was accomplished through a right posterolateral thoracotomy with a subsequent histological diagnosis of a recurrent low-grade liposarcoma. A resectable liposarcoma should be considered in the differential diagnosis of a mediastinal tumor, although radiologically, the tumor presents with invasive features.

Proximal bronchial extension with special reference to tumor localization in non-small cell lung cancer.

OBJECTIVE: Surgery is the optimal treatment in patients with non-small cell lung cancer (NSCLC) and tumor-negative bronchial resection margins should be maintained for a curative resection. The epidemiology of NSCLC, including the aspects of tumor localization, has been changing during the recent decades. The aim of this study was to evaluate microscopic proximal bronchial extension with special reference to the site of the tumor. METHODS: Surgical specimens of 70 NSCLC cases were examined histologically for proximal bronchial extension of the tumor. The entire bronchial tree with the tumor was extracted from the specimen and serially cut at a thickness of 5 mm in the transverse plane of the bronchus. Microscopic proximal extension of the tumor was classified as either endobronchial or peribronchial. RESULTS: Thirty-three (47.1%) tumors had central and 37 (52.9%) had peripheral localization. Among the central and peripheral tumors, 10 (30.3%) and seven (18.9%) had microscopic proximal extension, respectively. In total, the mean length of proximal extension was 10.94 +/- 7.07 mm. The mean length of extension for peripheral tumors was 15.71 +/- 8.38 mm, significantly greater than that of central tumors, which was 7.60 +/- 3.47 mm (P = 0.026). Peripheral tumors showed a significant peribronchial extension (P = 0.024). CONCLUSIONS: A greater percentage of central tumors show microscopic proximal bronchial extension, whereas the length of microscopic proximal bronchial extension is significantly greater in peripheral tumors. Peripheral tumors preferentially have a peribronchial extension pattern.

Transthoracic approach in surgical management of Morgagni hernia.

OBJECTIVE: Morgagni hernia is an uncommon type of diaphragmatic hernias. Numerous approaches have been described and, particularly the significance of laparatomy has been emphasized as an operative technique. We present our experience on patients with Morgagni hernia operated on via transthoracic approach in our department. MATERIALS AND METHODS: Between January 1986 and March 2000, 16 patients with Morgagni hernia were operated in our department. Their ages ranged from 16 to 68 years (mean 51.5). Five (31.25%) patients were male, and 11 (68.75%) patients were female. Chest roentgenograms, thorax CT, barium enema roentgenographic studies were used as diagnostic utilities. Right posterolateral thoracotomy was performed in all patients. RESULTS: Hernia sac was present in all cases. Exploration revealed omentum in hernia sac in eight patients (50%), colon and omentum in seven patients (44%), only colon in one patient (%6). Postoperative course was uneventful. The mean follow-up was 5.7 years. There was no recurrence or symptoms related to the operation. CONCLUSIONS: We advocate transthoracic approach for surgical exposure as it provides wide exposure and easy repair of the hernia sac in Morgagni hernia.

The factors affecting blood pressure in pediatric renal transplant recipients.

To investigate the parameters affecting systemic blood pressure in pediatric renal transplant recipients, we retrospectively examined the data from 19 adolescent renal transplant recipients including 6 girls overall, mean age of 15,47 +/- 3.56 years. Serum creatinine (Scr), fractional extraction of sodium (FENa), whole blood trough cyclosporine(C0), plasma total cholesterol (TC) and triglyceride levels, and systolic and diastolic blood pressure (SBP and DBP) were monitored during a total of 677 visits. SBP and DBP, classified as <95p (groups 1s and 1d) and >95p (groups 2s and 2d), were correlated with differences between groups 1 and 2. Group 2s Scr and FENa levels were higher than group 1s (P =.002 and P =.048, respectively), whereas C0 and FENa levels were higher in Group 2d than Group 1d (P = 0.028 and P = 0.036, respectively). Among the entire group, SBP and DBP positively correlated with C0; Scr and SBP, with FENa. While there was a positive correlation between SBP and C0 in groups 1s and 2s (r = 0.188, P <.000; and r = 0.145, P =.040), DBP was only associated with C0 in group 1d (P =.03, r = 0.156). In contrast, DBP showed a positive correlation with Scr in group 2d (P =.023, r = 0.132), and SBP with Scr in Group 1s. C0 and Scr levels were correlated in Groups 1s, 1d and 2d. At high BP levels (>95p), SBP is mostly affected by C0; DBP, with Scr. However, in both groups these two parameters positively correlate with each other. Thus, in adolescent renal transplant recipients the cause of high blood pressure does not appear to be solely related to cyclosporine related to induced allograft dysfunction.

Surgical treatment of pulmonary hydatid cysts in children.

PURPOSE: Ten years' experience is analyzed in pediatric patients with pulmonary hydatid cysts. METHODS: Between 1990 and 2000, 33 pediatric patients (2 to 15 years of age) with pulmonary hydatid cysts were operated on in Department of Thoracic Surgery in Ankara University School of Medicine. There were 17 girls and 16 boys. RESULTS: Twenty-three cases presented as a solitary lung cyst, whereas the remaining 10 were found to have multiple cysts in one or both lungs. Cystotomy and capitonnage were performed in 25 patients, cystotomy was done in 6 patients, and only 2 patients underwent the wedge resection. The authors used no scoliocidal agent in our approach. There was no operative mortality. Recurrence after operation was seen in one patient. CONCLUSION: Pulmonary hydatid cysts in children can be treated successfully by cystotomy and capitonnage or only cystotomy. J Pediatr Surg 36:917-920.