Chronic pyelonephritis as a cause of end stage renal disease.
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Biomedical subjects
Publications and source records attributed to R Busch.
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33 patients with 46 sterile vesicoureteral refluxes were followed by repeated clinical-urological and radiological studies over a period from 1 to more than 6 years. The results of the evaluation, obtained by only looking at the urograms, were compared with the following measurements: the length of each kidney, the length ratio right to left, and the parenchymal area. At the end of the follow-up period, 2 out of 32 initially normal kidneys (about 6%) had pathologically low values, whereas 3 out of 14 already initially damaged kidneys (21,5%) showed a further decrease of these values. Preceding urinary tract infections with consecutive pyelonephritis, leading to a progressive shrinkage of the organ over many years, are thought and discussed to be more responsible for these results than the sterile reflux itself.
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The causes of the high incidence of vesicoureteral reflux in 161 patients with end stage renal disease was studied. In about half of these patients with pyelonephritis, reflux in combination with urinary tract infections is the cause of renal failure. Reflux is therefore found more often in this specific group. The incidence of reflux correlates with the duration of uremia. Reflux also is more common in patients with little or no diuresis. Theories of reflux into the "unused ureter" are discussed.
Coagulum pyelolithotomy is a time-saving and tissue-conserving method which minimizes the danger of small crystallizations being left behind for new stone formation. A coagulum of excellent elasticity and tenacity can be obtained from the following mixture: first syringe, 20 ml thrombocyte-enriched plasma plus 5 ml human fibrinogen, and second syringe, 1 ml thrombin plus 4 ml calcium chloride. During the last 7 years this procedure has been employed in 120 selected patients; of these 84 involved multiple stones and 36 a single stone in a dilated intrarenal system. In only six cases were there residual caliceal fragments. The risk of hepatitis seems to be negligible since (1) only HBsAG-negative plasma and blood extracts are used, and (2) a comparison of two groups of 120 pyelolithotomies, with and without the coagulum, showed only two cases of hepatitis in each group while preoperative hepatitis occurred in five and seven cases, respectively. The enzymatic action or urokinase ensures that missing fibrin particles are dissolved before encrustation can occur. All free stones are caught and extracted with the coagulum. In 23% of cases additional fragments, not indicated by preoperative X-rays, were extracted as well.
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In 20 rats open or transcutaneous ligation of the spermatic cords was followed by total necrosis of the testes and decrease of serum testosterone to levels seen after castration. The value of this uncomplicated approach for bilateral castration in clinical practice is discussed.
Malformations were recorded from 17.4 per cent (n = 293) of all perinatal deaths which had occurred in the region of Rostock, between 1968 and 1974. No case of metabolic disease was identified. Two and more malformations were recorded from 44.7 per cent of the newborns. Pre-term infants accounted for 47.8 per cent of all perinatal deaths. Twenty-five per cent of the mothers were 30 years of age and more. Pathological phenomena had grown manifest during pregnancy in 56.4 per cent of the women involved. Complete registration of all cases of malformation and abnormality of metabolism is proposed and should be achieved by close examination of all perinatal deaths.
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With the help of three arguments which come from the data analysis of a special consulting hour is demonstrated the ascents of germs into the prevesical urinary tracts in female patients with relapsing, non-obstructive urinary infections not in the least in every case lead to a recognizable lesion of the kidney. The thesis is erected that the generally tabooed pyelitis by all means corresponds to a clinical reality. This thesis is discussed in the light of findings from animal experiments and clinical findings from literature.
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This study evaluates (a) the ability of house staff physicians to diagnose acute myocardial infarction (AMI) in patients with chest pain and (b) the usefulness of immediate ("stat") creatine kinase determinations in aiding the decision to hospitalize patients with chest pain. Of 80 emergency room patients with chest pain, 34 were admitted to an intensive care unit and 46 were either discharged or admitted to a general medical unit. Of the 34 patients admitted to intensive care, 11 fulfilled criteria for AMI. Of the 46 who were not admitted, two met criteria for AMI: one had abnormal initial enzyme values; the other had normal initial values but diagnostic 48-hour values. Both had abnormal electrocardiograms. On the other hand, 11 patients who were not admitted had elevated initial enzyme values but did not have myocardial infarctions and might have been admitted inappropriately on the basis of their initial enzyme values. Five patients who were admitted had normal initial values but did develop infarctions and might have been sent home inappropriately on the basis of initial enzymes values. We conclude that: (a) physicians discharged 2 of 13 patients with AMI drawn from a population of 80 with chest pain and (b) the availability of stat cardiac enzymes could have prevented the discharge of only 1 patient and may have caused the inappropriate admission of 11 and discharge of 5 patients.
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In 40 girls and 9 women with recurrent, non-obstructive urinary tract infections, and in 5 patients with nephrolithiasis the site of infection was determined by 108 bladder washout tests. The corresponding sediments were examined for antibody-coaded bacteria using an immunofluorescence test (IFT). The IFT was positive in 18 (72%) of 25 supravesical bacteriurias. Out of 75 vesical bacteriurias 39 infantile and 7 adult (together 61%) specimens contained antibody-coaded bacteria. We think the IFT is of no diagnostic value in localizing recurrent urinary tract infections in girls. For adults such an evaluation is not yet possible due to our small number of cases.
Level diagnosis repeatedly performed in patients without roentgenologically demonstrable reflux demonstrated bladder bacteriuria in 80% of the cases. The remaining 20% had supravesical bacteriuria. We called this occult reflux, if reinfection was demonstrated. Contamination of the upper tract by occult reflux can, but must not induce pyelonephritis. Bilateral antireflux surgery frequently eliminates occult reflux of bacteria, so this seems a debatable method of treatment.