Tocilizumab and Renal Artery Stent—Therapeutic Strategy for Takayasu Arteritis

Takayasu vasculitis (TAK) is a form of large vessel vasculitis clinically manifesting as pulseless disease or hypertension. It is more common in South East Asia and Japan, India, and Mexico [1]. It is increasingly being recognized due to increased awareness among medical fraternity and better imaging modalities. Undetected hypertension, pulselessness, and syncope are more common symptoms and presentation during pregnancy is unusual and can lead to bad obstetric outcomes. Recent evidences support the use of tocilizumab for inducing remission in Takayasu arteritis. We report this rare case of vasculitis presenting in pregnancy as malignant hypertension. A 20-year-old pregnant woman (45 days) presented with headache and nausea but no fever. She had a history of intermittent claudication of legs for the past 3 years but not evaluated. During examination, pulses were felt normally and blood pressure (BP) 180/110, no murmurs in cardiac auscultation, but she had abdominal bruit (renal vessels). Other systems were normal. Echocardiogram (ECHO) showed dilated ascending aorta. Doppler of renal vessels showed narrowing of renal arteries. Unfortunately, she had to undergo termination of pregnancy (high BP in spite of antihypertensives). Her computed tomography (CT) angiogram showed features of TAK with type 5 pattern–she had methylprednisolone infusion 500 mg daily for 3 days, followed by injection tocilizumab 400 mg monthly 3 doses. Once remission was achieved, she had recanalization by percutaneous transluminal angioplasty of right renal artery. She is currently maintained on aspirin and telmisartan. Awareness of causes of high BP, inputs by radiologist, cardiologist, and rheumatologist and understanding by the patient and family helped to achieve good outcome albeit the miscarriage.

One-stop preoperative assessment of renal vessels for living donors with 3.0 T non-contrast-enhanced magnetic resonance angiography: compared with computerized tomography angiography and surgical results

Objective: The study was to investigate the feasibility and accuracy of assessment for living renal donors before transplantation by using 3.0 T non-contrast-enhanced magnetic resonance angiography (NCE-MRA). Methods: Thirty renal donors were investigated and underwent computed tomography angiography (CTA) and 3.0 T NCE-MRA before nephrectomy. Two radiologists independently assessed arterial and venous anatomy and potential kidney lesions. The image quality score, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), diameters and lengths of renal arteries and veins were compared between CTA and NCE-MRA. Imaging findings were compared with the surgical results served as reference standard. Agreement was assessed using κ test. The Wilcoxon test and paired sample t test were used for statistically significant differences. Results: The results of image quality score for renal arteries and veins were highly consistent between the two radiologists in NCE-MRA (p < 0.001). There was no significant difference in the scores of renal arterial and venous branches between NCE-MRA and CTA (p > 0.05). The SNR and CNR of renal vessels were higher than CTA (p < 0.001). There were no statistically significant differences in the length of renal vessels measured by the two methods (p > 0.05), and the diameter was smaller than that of CTA (p < 0.05). The detection of normal renal arteries and early branches by both examination techniques was consistent with intraoperative findings. Both methods showed good consistency between the anatomical variation of renal vein and the intraoperative diagnosis (p < 0.001). Conclusions: 3.0 T NCE-MRA can be used for evaluation of main renal arteries and veins with high accuracy for anatomy and variation classification, and can be used for preoperative vascular evaluation of living donor kidney transplantation. Advances in knowledge: 3.0 T NCE-MRA can be used for evaluation of main renal arteries and veins with high accuracy for anatomy and variation classification, and can be used for preoperative vascular evaluation of living donor kidney transplantation.

Diagnostic Role of Dopplerography of Renal Vessels in Patients with Late Dysfunction of the Transplanted Kidney

Aims: Search for non-invasive methods for diagnosing late transplant kidney dysfunction, which can improve control and monitor the condition of the kidney transplant, characterization diagnostic role of dopplerography of renal vessels in patients with late dysfunction of the transplanted kidney. Study design: When conducting dopplerometry, blood flow indices were analyzed from 3 to 6 cycles of heart contractions, followed by an averaged indicator. In addition, the linear blood flow velocity was assessed separately from the renal vein. Place and Duration of Study: For the period 2016-2017 Ultrasound of an allopod was performed in 60 recipients of RT (RENAL TRANSPLANT) in the late postoperative period. Methodology: The average age of the patients was 38.89 ± 1.52 years. There were 34 men (56.6 7%), 26 women (43.33%). All patients were divided into two groups: patients with preserved function and patients with RT (RENAL TRANSPLANT) dysfunction. Related kidney transplantation (RRT) was performed in 55.0% of patients, in 45.0% - cadaveric kidney transplantation (CKP). The groups were comparable in the main clinical and demographic parameters. Results: The reverse dynamics was observed when examining the level of the renal filtration function indicator, the estimated glomerular filtration rate (SKF) - at a TAMX level of more than 15 cm/sec, glomerular filtration was 51.18 ± 1.93 (47.32-55.04) ml/min (p <0.01), and with a decrease in TAMX of less than 15 cm/sec, the level of SKF decreased significantly, more than twice, to the level of 25.40 ± 2.19 (21.02-29.78) ml/min <0.001). Conclusion: The determination of dopplerographic parameters for TP with preserved and especially with impaired depuration function with a direct assessment of TAMX opens up wide opportunities in non-invasive assessment of RT (RENAL TRANSPLANT) changes, identification of developing complications, as well as improved transplant survival.

To the pathogenesis of acute glomerulonephritis.

According to research F a h r ъa (Dent. Med. Woch., 1926, No. 18) in this disease, the inflammatory process primarily occurs in the glomeruli and only then spreads to the arterioles. Therefore, the opinion of Volhad a, that the cause of glomerulonephritis lies in the primary spasm of small renal vessels, cannot be considered correct.

Laparoscopic transposition for crossing vessels (vascular hitch) in pure extrinsic pelvic-ureteric junction obstruction: a successful case report of a 2-year-old infant with horseshoe kidney

Background Pediatric hydronephrosis induced by pelvic-ureteric junction obstruction (PUJO) is treated by dismembered pyeloplasty (DP) via open and laparoscopic surgery. The etiology of PUJO involves both intrinsic stenosis and extrinsic compression of crossing vessels (CVs). PUJO owing to CVs is also treated by DP, as there is no consensus concerning this vascular condition. We encountered a 2-year-old infant with pure extrinsic PUJO combined with horseshoe kidney who successfully underwent laparoscopic transposition for CVs (vascular hitch). Case presentation A 2-year-old boy was prenatally diagnosed with left multicystic dysplastic kidney (MDCK) and right hydronephrosis and received a definitive diagnosis after birth. At 6 months old, renal scintigraphy revealed a non-functioning pattern in the left kidney and an obstructive pattern in the right, showing no response to furosemide loading. The patient also had recurrent urinary tract infection, and his right hydronephrosis gradually worsened. We decided to perform surgery for the right PUJO. Preoperative enhanced computed tomography detected three right renal vessels independently branching from the abdominal aorta. The middle renal vessels were located at the ventral side of the pelvis and coincident with the site of PUJO. These vessels were suspected of being CVs. The patient underwent laparoscopic surgery electively. A 5-mm trocar was inserted at the umbilicus for a 5-mm, 30° rigid scope. Two additional ports were then inserted under laparoscope inspection. The dilated right pelvis and CVs were detected after ascending colon mobilization. To confirm the pathogenesis of PUJO, the CVs were dissected and taped. After taping the CVs, an intraoperative diuretic test was performed using furosemide loading. Peristalsis of the right ureter was recognized, and the extrinsic PUJO owing to the CVs was definitively confirmed. We therefore performed transposition for the CVs (vascular hitch procedure). The CVs were mobilized in the cranial direction and those were wrapped by dilated pelvis. The post-operative course was uneventful. The renal scintigraphy findings improved and showed a favorable response of furosemide loading. Conclusions The laparoscopic vascular hitch procedure is minimally invasive and effective for extrinsic PUJO due to CVs. Anastomotic stricture after Anderson and Hynes DP can be prevented by appropriate patient selection.

Congenital renal arteriovenous malformation: a rare cause of visible haematuria

We report a case of renal arteriovenous malformation (AVM) and describe its angioarchitecture and endovascular management. A 28-year-old male patient presented with visible painless haematuria. CT of the abdomen showed a right renal AVM. Digital subtraction angiography of the right renal vessels showed an AVM of middle and lower pole segmental arteries with communication to a large saccular aneurysm, which was arising from the right main renal vein. Complete occlusion of the AVM was done by using glue (a mixture of n-butyl-cyanoacrylate and lipiodol), resulting in nonvisualisation of the aneurysm on angiography. His vital signs were stable during the procedure. Follow-up CT after 12 months showed no residual flow in the aneurysm, normal upper pole renal parenchyma and nonvisualisation of AVM. Early diagnosis of this clinical entity is of paramount importance for proper management as it can cause massive blood loss and rapid clinical deterioration.

EP3 (E-Prostanoid 3) Receptor Mediates Impaired Vasodilation in a Mouse Model of Salt-Sensitive Hypertension

We previously showed that impaired vasodilation in systemic and renal vessels contributes to salt-sensitive hypertension in a mouse model of impaired PPARγ (peroxisome proliferator-activated receptor gamma) function. We determined the mechanisms mediating impaired salt-induced vasodilation and whether improved vasodilation attenuates augmented hypertension in response to salt. Mice selectively expressing a PPARγ dominant negative mutation in vascular smooth muscle (S-P467L) exhibited salt-sensitive hypertension and severely impaired vasodilation in systemic and renal vessels. High-salt diet–fed S-P467L and control mice displayed comparable levels of renal oxidative stress markers. Preincubation with Tempol, a superoxide dismutase mimetic, or calphostin C, a PKC (protein kinase C) inhibitor, failed to improve salt-induced impairment of vasodilation in S-P467L mice, arguing against a role of oxidative stress or PKC activity. Inhibition of Rho kinase partially rescued impaired vasodilation in high-salt diet–fed S-P467L mice suggesting a contribution of the Ras homolog family member A (RhoA)/Rho kinase pathway. High-salt diet selectively increased synthesis of PGE2 (prostaglandin E2) in S-P467L aorta. Expression of EP3 (E-prostanoid 3) receptor mRNA was increased in aorta from chow-fed and high salt–fed S-P467L mice. Pharmacological inhibition of COX (cyclooxygenase) 2 or blockade of EP3 completely normalized the impaired vasodilation, and EP3 antagonism induced larger decreases in systolic blood pressure in high-salt diet–fed S-P467L mice. In conclusion, interference with PPARγ in vascular smooth muscle causes activation of the PGE2/EP3 signaling pathway in systemic and renal vasculature resulting in salt-induced impairment of vasodilation and salt-sensitive hypertension. PGE2/EP3 axis maybe a druggable target to prevent salt-sensitive hypertension in chronic conditions associated with decreased PPARγ activity.