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Outcome of Renal Transplants in Patients with IgA Nephropathy. Transplantation Proceedings. 33(7-8): 3429-3430. November 2001.

Immunoglobulin A nephropathy (IgAN) is the most common type of glomerulonephritis (inflammation of the filtering units of the kidney) worldwide, with 20 percent of patients progressing to end stage renal (kidney) failure. IgAN also has a strong tendency to recur in the graft after a patient receives a kidney transplant. Short term graft survival in patients with recurrent IgAN suggested excellent results, but the long term followup has noted more severe clinical courses, with nephrotic syndrome and higher rates of graft loss. This article reports on a study that evaluated the long term outcome, in terms of recurrence and graft survival, in patients with IgAN. Between December 1979 and December 2000, 38 patients (32 males), mean age at transplantation 37.6 years (range 20 to 57 years), whose original renal disease was biopsy proven IgAN, received 40 renal allografts (28 cadaveric, 12 living-related) and have been followed for an average of 68.4 months (range 3 to 280 months). Recurrence of IgAN was diagnosed by certain laboratory criteria or when graft biopsy disclosed histologic recurrence. IgAN recurred in 16 allografts (incidence of 40 percent) in 15 patients, 38.6 months (range 3 to 144) after kidney transplantation, in 6 living and 10 cadaveric grafts, and in one patient with two consecutive grafts. Followup after recurrence (mean time 48.8 months, range 2 to 138) revealed 10 patients with stable graft function and 5 patients with a significant loss of graft function. Graft failure was the consequence not only of recurrent IgAN but also poorly controlled hypertension (high blood pressure), rejection episodes, and noncompliance. The authors conclude that histologic recurrence of IgAN depends largely on the timing of renal biopsy, being approximately 50 percent at 2 to 5 years but approaching 100 percent at 10 to 20 years after renal transplantation. The risk of recurrence is similar for recipients of living related donor and cadaveric renal allografts. Hematuria (blood in the urine) and low grade proteinuria (protein in the urine) are characteristic of recurrence. 12 references.

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Suspected Kidney Disease: Putting Urinalysis Clues into Context, Part 2. Consultant. 41(12): 1829-1830, 1833-1834, 1836. December 2001.

This article, the second in a series on diagnosing suspected kidney disease, explains how urinalysis clues may be used to help the diagnosis. In evaluating a patient with acute oliguria (lack of urination), the physician must first determine whether the cause is postrenal, prerenal, or renal (kidney). Ultrasonography can rule out obstruction; minimal or no proteinuria (protein present in the urine) excludes glomerular (the filtering units of the kidney) involvement. Acute interstitial nephritis (AIN) may be present in a patient who has the classic triad of acute renal failure, fever, and rash. Drugs that can cause AIN include penicillins, cephalosporins, NSAIDs (nonsteroidal antiinflammatory drugs), diuretics, H2 blocking agents, phenytoin, phenobarbital, and allopurinol; NSAIDs are the most common culprits. In patients with AIN, urinalysis may show microscopic hematuria (blood in the urine), white blood cell casts (sterile pyuria), non nephrotic range proteinuria, or eosinophils. However, eosinophiluria can occur in other inflammatory processes, including prostatitis, cystitis, pyelonephritis, cholesterol emboli, and, on occasion, rapidly progressive glomerulonephritis. In patients with nephrolithiasis (kidney stones), crystals in the urine suggest the predominant stone composition, which can be confirmed by stone opacity (assessed by x ray), urine pH, family history, and stone anatomy. The authors use three case studies to illustrate these concepts. 7 figures. 1 table. 6 references.

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Tonsillectomy and Steroid Pulse Therapy Significantly Impact on Clinical Remission in Patients with IgA Nephropathy. American Journal of Kidney Diseases. 38(4): 736-743. October 2001.

This article reports on a retrospective investigation of kidney (renal) outcome in 329 patients with immunoglobulin A (IgA) nephropathy (kidney disease) with an observation period longer than 36 months in the authors' renal unit between 1977 and 1995. Clinical remission, renal progression, and the impact of covariates were estimated. In 157 of 329 patients (48 percent), disappearance of urinary abnormalities (clinical remission) was obtained. None of these 157 patients showed progressive deterioration, defined as a 50 percent increase in serum creatinine (Scr) level from baseline, during the observation period. Conversely, in patients without clinical remission, the estimate of probability of progressive deterioration was 21 percent (plus or minus 5 percent) at 10 years. In the multivariate Cox regression model with 13 independent covariates, initial Scr level, histological score, tonsillectomy, and high dose methylprednisolone therapy had a significant impact on clinical remission, whereas proteinuria, age, sex, levels of hematuria, blood pressure, conventional steroid therapy, ACE inhibitor therapy, and cyclophosphamide therapy had no significant effect. These findings indicate that interventions aimed at achieving clinical remission have provided encouraging results applicable to managing patients with IgA nephropathy. 7 figures. 3 tables. 27 references.

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UPJ Obstruction: Many Paths to the Same Goal. Contemporary Urology. 13(4): 67-82. April 2001.

This review focuses on the pathophysiology, diagnosis, and surgical treatment of ureteropelvic junction (UPJ, where the ureter joins the kidney) obstruction in adults. UPJ obstruction presents with a wide range of symptoms, including calculi (stones), flank pain, nausea and vomiting, and hematuria (blood in the urine). Symptoms may be intermittent, presenting themselves during periods of high urine flow. The diuretic renogram is the standard for diagnosis, as it shows renal function as well as obstruction. Doppler ultrasound can also be used to evaluate UPJ obstruction. The authors note that the wide variety of treatments available for adults with UPJ allows surgeons to individualize therapy. However, regardless of which path is taken, the goals are the same: preservation of renal (kidney) function and alleviation of symptoms. Open surgery remains the gold standard; however, endoscopy based surgical approaches have become common. The authors detail each of the surgical techniques in present use, including open pyeloplasty, antegrade endopyelotomy, retrograde endopyelotomy, Acucise endopyelotomy, and laparoscopic pyeloplasty. The type of procedure, the approach, and the cutting device used are not important prognostic indicators for the outcome of endopyelotomy. However, the length of the stricture, the baseline renal function, and the degree of hydronephrosis (fluid accumulation) are important factors, as is the presence or absence of a crossing vessel. Patients with a normal contralateral (the other side) kidney are probable candidates for nephrectomy (kidney removal) if the obstructed kidney has less than 15 to 20 percent differential function. 4 figures. 1 table. 11 references.

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Extracorporeal Shock Wave Lithotripsy. In: Tanagho, E.A. and McAninch, J.W., eds. Smith's General Urology. Fifteenth Edition. Columbus, OH: McGraw-Hill, Inc. 2000. p. 321-329.

This chapter on extracorporeal shock wave lithotripsy (ESWL, the use of shock waves outside the body to break up urinary stones and allow their passage through the normal urinary tract) is from a textbook that offers a practical and concise guide to the understanding, diagnosis, and treatment of urologic diseases. The author introduces the development of the equipment used (lithotripters) and shock wave physics, then discusses preoperative patient evaluation, intraoperative considerations (stone localization, fluoroscopic imaging, ultrasonic imaging, coupling, shock wave triggering, pain, and fragmentation), and postoperative care. The author concludes that the ultimate goal of ESWL is stone fragmentation and eventual elimination, resulting in a stone-free patient. Preoperative education of the patient and possibly the referring physician with respect to realistic expectations helps facilitate a smooth postoperative course. Gross hematuria (blood in the urine) is the norm and should resolve during the first post-operative week. Patients should be encouraged to maintain an active ambulatory (up and about) status to facilitate stone passage. 7 figures. 40 references.

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Urge Incontinence and Detrusor Instability. International Urogynecology Journal. 12(1): 58-68. February 2001.

This article reviews detrusor instability, a syndrome of urinary frequency, urgency, and urge incontinence. During bladder filling, the detrusor muscle (surrounding the bladder) gradually relaxes to accommodate the increasing volume of urine entering from the ureters. Urgency is a strong desire to urinate, accompanied by fear of leakage or fear of pain. Detrusor instability (DI) is diagnosed by using urodynamic studies to document uninhibited bladder contractions. Idiopathic (unknown cause) cases account for 90 percent; the remaining 10 percent are related to neurologic disorders, including spinal cord injury, intracranial lesions, and multiple sclerosis. Patient evaluation includes history and physical examination, a neurologic screening exam, a 24 hour bladder diary, and cystourethrography (to investigate pain or hematuria, and to rule out interstitial cystitis, cancer, and urinary stones). Urodynamics (measurements taken during urination) should be used to confirm the diagnosis, if available. Several different treatment modalities are available, including bladder training or drill, electrical stimulation, and medical and surgical therapies. Medical therapy can include anticholinergic antimuscarinics, tricyclic antidepressants, neurotoxins, and estrogens. Surgical options include partial detrusor myomectomy, augmentation cystoplasty, or urinary diversion. Not all patients may be rendered completely dry, but many may be improved with appropriate diagnosis and therapy, leading to a better quality of life. 2 tables. 115 references.

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Diagnosis and Management of Renal Trauma: Past, Present, and Future. Journal of the American College of Surgeons. 191(4): 443-451. October 2000.

In this article, the authors review the diagnosis and management of renal trauma. Adopting a historical perspective, the authors describe milestones in the management of renal injuries that have led to the current approach to assessing kidney injury. The authors then report their own strategies for assessing kidney injury, including patient selection, presentation, staging and imaging, and general principles of operative management and renal exploration. Hematuria (blood in the urine) is the herald sign of genitourinary injury, although the degree (amount) of hematuria does not predict the degree of injury. The authors use CT scanning aggressively in all patients stable enough to allow it. Their recommended surgical policy results in a large number of renal explorations for penetrating trauma (as these patients commonly require open abdominal surgery for associated injury) and less frequent renal explorations for blunt trauma (only in those undergoing open surgery for associated injuries). Renal salvage operations entail isolation of the blood vessels, complete exposure of the injured kidney, watertight closure of the collecting system injury (if any), and closure of parenchymal (body of the kidney) defects with renal capsule, omentum, or woven Vicryl mesh. The article concludes with a discussion of future trends in the assessment and treatment of kidney trauma. Two patient care algorithms are included. 11 figures. 32 references.

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Hematuria. Family Urology. 6(1): 4-7. 2000.

The presence of blood in the urine (hematuria) can be an important sign of serious disease of the urinary tract. This article, written for family care providers, reviews the problem of hematuria, noting that even one episode of hematuria warrants a visit to the doctor's office for investigation. A thorough medical history and assessment of the nature of an individual's complaint are the first steps in determining the cause of blood in the urine. Hematuria can be classified as gross hematuria (blood is visible to the naked eye) or microscopic hematuria. The authors review upper urinary (kidney or ureter) causes of hematuria, which can include medical kidney (glomerular) disease, exercise, abnormal blood coagulation, sickle cell disease, infection, stone, obstruction, kidney cyst, cancer of kidney or ureter, benign kidney tumor, and renal vascular disease. The authors then review lower urinary tract (bladder, prostate, urethra) causes of hematuria, which can include inflammation, infection, bladder stone, bladder cancer, prostate cancer, abnormal blood coagulation, trauma (instrumentation), postejaculatory bleeding, benign urethral or prostate bleeding, and benign prostatic hyperplasia (BPH). In children as in adults, hematuria is abnormal and may be serious, so it is important to determine the cause. The evaluation of hematuria includes medical history, physical examination, microscopic urinalysis, and additional tests including cystoscopy, CT scan, intravenous pyelogram (dye study of the kidneys), and ultrasound. Treatment of hematuria depends entirely upon the cause of the condition. 3 tables.

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Rationales for Treating IgA Nephropathies. Renal Failure. 21(1): 1-16. 2000.

This article offers an outline of the pathophysiology of IgA nephropathy in order to emphasize the role of eicosanoids, angiotensin II, and reactive oxygen species. The most typical cases of IgA nephropathies have hematuria (blood in the urine) following upper respiratory infection or tonsillitis. ACE inhibitors and early corticosteroid usage are prime therapies for these patients. Tonsillectomy is to be considered, certainly for individual cases. The other drugs that may be used include thromboxane antagonists, leukotriene antagonists, or PAF antagonist. In theory, there should also be benefits from antioxidants. The author notes that fish oils have not come up to expectation. PDGF aptamers look promising for the prevention of mesangial cell proliferation. The author briefly reports on the use of various other agents that could help reduce decline. 3 figures. 1 table. 116 references.

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Treatment of IgA Nephropathy. Seminars in Nephrology. 20(3): 277-285. May 2000.

IgA nephropathy (Berger's disease) is the most common primary glomerulonephritis (infection of the kidney glomeruli) worldwide and was once equated with benign recurrent hematuria (blood in the urine). This article reviews the patient care management of IgA nephropathy. Of the patient population with IgA nephropathy, 15 to 30 percent progress to end stage renal failure after 20 years of clinical manifestations. Because the pathogenesis remains enigmatic, therapy to slow disease progression cannot be disease specific. Control of blood pressure remains the cornerstone of treatment, as for patients with other types of kidney disease. Several approaches to treatment have generated increasing interest in the last few years, including angiotensin inhibition, glucocorticoids, fish oil, cyclophosphamide, tonsillectomy, and mycophenolate mofetil. For patients reaching end stage renal failure, recurrent disease after transplantation can be a clinically important problem (even in light of continued immunosuppression after the transplantation). 2 figures. 65 references.

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