[Therapeutic value of transcatheter embolization in malignant tumors of the renal parenchyma].
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Embolization, Therapeutic↗
Biomedical subjects
Lj Mladenović
Publications and source records attributed to Lj Mladenović.
[Treatment of urinary tract calculi using extracorporeal shockwave lithotripsy].
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Adult↗
[Acute renal insufficiency caused by burn injury].
Acute renal failure (ARF) in burn disease results in a range of phenomena important not only from theoretical, but also from practical point of views, whose causes are manifold. ARF is generally defined as a rapid renal failure resulting in accumulation of protein metabolism degradation products (catabolism). It has been known, for some time, that thermal agents do not produce only local skin damages, but also disturb the integrity of the whole organism producing major functional damages of all organs and systems. Most frequently organs affected by burn disease are the following: the lungs, the heart, the kidney, the liver and blood coagulation systems. There are many factors influencing the renal function during the burns. The most important are: decreased cardiac output, respiratory failure with hypoxia and acidosis, toxaemia and sepsis [1, 4, 6 7, 8-10, 12, 19]. ARF in burn disease may be early due to hypovolaemia and hypoperfusion of the kidneys or late, occurring after a week as a consequence of infection and endotoxaemia. Development of ARF in burn disease is a very unfavorable prognostic sign necessitating a complex evaluation. Anuria in an early phase of burn disease may indicate the development of ARF, particularly if urine findings are positive to haemoglobin, proteins, myoglobin, which is of the utmost importance in deep burns inflicted by high voltage current. The immediate cause of anuria in burn disease may be a reflex transfer and penetration of the large quantities of toxic materials into the circulation form the region affected by burns leading to the spasm of afferent glomerular arteriolae producing sudden discontinuation of glomerular filtration. After burns, sudden increase in the osmotic activity ensues in the affected tissue. Some low molecular links may result, and such particles tend to change the osmotic balance and stimulate the development of oedema, and if not excreted, they increase osmolarity. In 20-30% of the patients with burn disease anuria is absent [2, 5, 11, 14, 18, 20]. The genesis of burn disease-associated anaemias is therefore multifactorial. These factors are the following: haemorrhage, haemolysis and etrythropoiesis level decrease. In massive burns, large amounts of non-specific inflammatory components are produced as well: prostaglandins, histamine, quinines leukocyte phenomena, bacterial toxins, etc. [1, 6, 13-16]. The study based on a years-long treatment of our patients with burn disease included on 100 patients. The youngest of the patients was 14 years old, and the oldest 65 years. The percent of burns-affected body surface ranged from 25% to 75%. In 3/4 of the patients the picture of an early renal failure developed, with oliguria immediately after infliction of the burns with rapid increase of serum urea and creatinine levels, while in 1/4 of the patients ARF occurred on the eighth day following the infliction of the burns. "late form of acute renal failure". Among our series with burn disease, anuria was present in 34.0% of patients and oliguria in 25.0%. ARF (early phase) occurred in 59 patients, 38 patients had no sing of ARF, while late ARF developed only in 3 patients. ARF-associated mortality rate was high among these patients (23%), being 6% among anuric patients with ARF and 17% in patients with ARF with anuria. Seventy-seven percent of the patients survived, and their serum and urine analyses performed upon subsequent out-patient follow-up examinations ranged within normal values. Such high percentage of survival among our patients included in the study is based on an early diagnosis of ARF, understanding of pathophysiology of shock associated with burn disease, adequate therapeutic approaches, including both medicamentous treatment and extracorporeal haemodialysis along with early surgical management (Shema 1, 2). For the time being, haemodialysis is the most effective therapeutical procedure in the treatment of ARF, although the mortality rate of dialyzable patients
Acute Kidney Injury↗
[Arterial hypertension in patients on chronic hemodialysis].
Arterial hypertension is frequent among chronically dialyzed patients. The kidney obviously plays a major role in arterial blood pressure control. There is a large number of experimental data emphasizing different factors (in addition to renin important in renal hypertension prognosis) such as: sodium balance, angiotensin, etc [1-8]. Sympathetic activity disorders or lack of vasodilatory prostaglandins and quinine may also play a certain role. In uremic patients peripheral arteriolar resistance is increased, unlike normotensive uremic patients or those who prove to be normotensive upon clinical examinations [8, 11-15]. Hypertension occurs in approximately 80% of patients with chronic renal failure, producing a number of complications primarily affecting the CNS and systemic circulation [5-8, 10, 11, 13]. The study concerned patients on chronic dialysis, with a male to female ratio of 69.9%:32.1%. In most of them the underlying disease, which caused chronic renal failure, was glomerulonephritis (60.0%), then pyelonephritis (17.0%) and nephrosclerosis, nephrolithiasis, polycystic kidney and, finally, renal tumours. The effect of permanent haemodialysis during the first year of treatment, was efficacious on hypertension in 1704 (65.1%) patients; in 672 (25.7%) patients therapeutical effects were achieved by dialysis and antihypertensive drugs, while in 240 (9.2%) subjects there was no improvement. General observations suggest that two types of arterial hypertension persisted in patients with chronic renal failure: volume-dependent arterial hypertension which is more frequent (90-95%) among haemodialyzed patients and renin-dependent hypertension. Such findings are of utmost importance indicating that hypervolaemia is one of the major factors in the development of arterial hypertension in patients with chronic renal failure, with renin playing the secondary role. Salt-free diet should be used in the treatment of arterial hypertension for years, a well conducted haemodialysis is highly effective in the control of arterial hypertension among these patients. In our series of patients dialysed three times a week; normalization of blood pressure was faster with lower incidence of hypertensive crises during haemodialysis and with few complications. Water and sodium excess was reduced by frequent haemodialyses and sudden changes in electrolyte, hydrostatic and other metabolic effects were minimized. Increased values of plasma renin activity were observed in a small number of patients. Ultrafiltration is insufficient for normalization of blood pressure. Hypertensive crises were frequent in these patients. Their response to medicaments such as methyldopa, beta-adrenergic blockers or other antihypertensive drugs, was good. Severe changes in blood vessels, especially in fundus oculi blood vessels were frequent in these patients. The life of hypertensive glomerulonephritis patients was especially endangered (graphs 1-6). In addition to the mentioned factors arterial hypertension during haemodialysis may also be of cardiac origin, including increase in cardiac output due to arteriovenous anastomosis, disequilibrium syndrome, changes in osmotic gradient of both extra- and intracellular spaces with resultant arteriolar wall oedema, erythrocyte amount, hypoxia, composition of dialysis fluid (sodium concentration), plasma osmotic pressure, metabolic acidosis and other factors. More recently, natriuretic hormone has also been indentified as a cause of vascular refraction. Peripherial arteriolar resistance as a cause of arterial hypertension among uremic patients must not be forgotten, because the genesis of arterial hypertension in patients with chronic renal failure is multifactorial. The highest percentage refers to volume-dependent arterial hypertension, whereas the percentage of other aetiologic factors is lower. Haemodialysis enables the normalization of blood pressure in most of hypertensive patients.
Adolescent↗
[Removal of staghorn calculi from the urinary tract with extracorporeal shock wave lithotripsy and endourologic treatment methods].
ESWL has been accepted as a method for treatment of urinary tract calculosis. In most cases with urinary tract calculi, the method has replaced the classic surgical procedure. Staghorn calculi are still too large to be simply managed with classic procedure; however, they may be successfully disintegrated (crushed) with the available lithotriptors, particularly with second generation lithotriptors such as LITHOSTAR. Technological innovations which appeared during the last two decades have induced sudden changes in the treatment of urinary tract calculosis. They were enabled by extracorporeal shock wave lithotripsy, which is a method associated with the lower morbidity rate. The method is readily accepted by most of the patients. It is effective in removal of calculi of different size and chemical composition. During the last decade, ESWL has been widely applied in a large proportion of patients with stag-horn calculi. Since the "STEINSTRASSE" phenomenon may develop following disintegration of the more massive stones, double J catheter (DJC) is always placed preventively before the staghorn calculi treatment. The clinicians well know how surgical treatment of staghorn calculosis is technically hard to perform, since there is a risk of renal blood vessels injuries and renal function impairment. Moreover, complete stage-horn urinary tract concrements are the most problematic stones with respect to kidney injuries, surgical treatment and rate of later complications. After the introduction into the clinical practice ESWL has become a treatment of choice for stag-horn calculi in approximately 85% of patients. It is performed in several steps. Over the last two years, 41 patients with partial or complete stag-horn calculi were treated in our institution. In 63% of cases, three treatments were performed per each patient, while 37% of our patients underwent more than three sessions. In a very small percentage, even seven treatments were performed. At the very beginning of the treatment, DJC was placed in 52% of patients, due to the expected "STEINSTRASSE" phenomenon, DJC enabled internal urine drainage and decreased the necessity of perdutaneous nephrostomy. Introduction of DJC reduced the number of cases with ureteral obstruction as well as the number of candidates for nephrostomy to below 29%. Percutaneous nephrostomy was performed in only a small number of patients, enabling satisfactory ureteral peristaltic with very good elimination of disintegrated stone detritus. Twenty-three of our patients developed urinary infections. In our series, the number of residual concrements was directly proportional to the degree of hydronephrosis before ESWL treatment (Table 1, 2, 3, 4). It may be concluded that in sity ESWL treatment of staghorn calculi with prophylactic placement of ureteral catheters is associated with lower complications rate when compared to patients who underwent the combined treatment using ESWL and percutaneous nephrolithotripsy. Single ESWL treatment should be carried out in all cases of uninfected stag-horn stones, clearly visualized upon X-ray examination, with mild hydronephrosis. In prominent hydronephrosis, with high probability of retaining of stone fragments in the lower renal calices, the therapeutical approach should include a combination of ESWL and nephrostolithotripsy. In draining stag-horn renal calculosis, disintegration should be initiated with the parts of the stone localized in the renal pelvis and upper renalc calices. Using such disintegration procedure, large stones in the urinary tract may be eliminated in several steps, which is always associated with the presence of sufficient fragments to be eliminated; however the intervals between the treatment are free of problems. In this way, stag-horn stones may be treated in out-patient wards with previous DJC catheter placement, which is a wise precaution.
Female↗
[Chondrosarcoma and hemipelvectomy].
Unlike osteosarcoma and Ewing's sarcoma chondrosarcomas are primarily surgically managed as they are resistant to chemo- and radio-therapy. A female patient, aged 36 years, was operated in 1992 for pelvic chondroma; a year later she was reoperated due to local recurrence, and diagnosis of chondrosarcoma was established. Because of tumour regrowth she was referred to our institution for hemipelvectomy. The operative team consisted of and orthopaedic surgeon, an urologist, and a general surgeon. A (large) tumour was completely removed. The patient's recovery was rapid, and she is now able of controlling urination and defecation. This kind of operation is extensive and traumatic, but it is useful in appropriately selected cases.
Adult↗