SPECIFIC FEATURES OF ENDOSCOPIC CORRECTION TECHNIQUE OF VESICOURETERAL REFLUX IN CHILDREN

Vesicoureteral reflux (VUR) is one of the most frequent diseases in pediatric urology studied since the 19th century. It has an increased risk of infection of the urinary tract, sclerosis of the renal parenchyma and development of reflux-nephropathy with an outcome in renal failure. Several treatment options have been developed for patients with VUR. For 50 years, open ureteral reimplantation has been considered the «gold standard» of treatment, but over the past 20 years there has been a shift towards less invasive methods, primarily endoscopic administration of bulking agents. In order to increase the effectiveness of endoscopic treatment, several basic recommendations for the operation have been identified and many volume-forming drugs have been developed. The most important is the correct choice of one of the three main methods of drug administration and the hydrodilation of the ureteral orifice during injection. Performing of endoscopic correction in compliance with all the rules and the use of the latest generation of bulking agents ensure the frequency of elimination of VUR up to 90% after the first injection.

B-mode gray-scale ultrasound abnormalities in adult patients: A useful tool in diagnosis of kidney diseases

Ultrasound scanning of the urogenital tract has a pivotal role in revealing most etiologies of renal disease. Moreover, it is also of value in assessment of disease prognosis and its progression. In this review article, details of the examination technique, ultrasonic kidney norms and the clinicoradiological correlation regarding acute and chronic kidney disease are presented. Specific characteristics of diseases viz. acute and chronic glomerulopathy, diabetes, amyloidosis, chronic reflux nephropathy, Nephroangiosclerosis, vasculitis, nephrocalcinosis, cystic diseases of the kidney, renal infarction and obstructive uropathy are presented. Keywords: acute, chronic, diagnosis, diseases, ultrasound, kidney.

MO1026MICROALBUMIN LEVEL IN URINE DEPENDING ON ACE GENE POLYMORPHISM IN PATIENTS WITH VUR

Background and Aims reflux nephropathy (RN) is the most serious complication of vesicoureteral reflux (VUR). The aim of the study was to assess the urinary level of MA (microalbumin) as an expression of tubulointerstitial damage depending of ACE genotype polymorphisms in children with VUR. Method 94 patients, with VUR at the age from 3 year to 16 years (average age of 6.72 ± 0.68 years), including 65 girls (69,1%) were enrolled. As a control population to compare the distribution of genotypes and alleles of ACE gene used a sample of 100 healthy children (82girls), indigenous ethnic groups, mean age of 11.3 ± 5.4 years. To determine the gene polymorphism of ACE we used the method of polymerase chain reaction. Renal scar in DMSA scan was performed at least six months after urine tract infection (UTI). According to DMSA scan results, children were divided into 2 groups: gr. 1 - 12p. (VUR without RN), gr. 2 – 82 p. (VUR with RN). Urinary excretion of MA was measured by ELISA method. Results In gr. 1 is the frequency of genotype I/I amounted to 58%, I/D is 42% and D/D – is not detected. In the scar group (gr.2) frequency of genotype I/I is 12% (p1,2<0,05), I/D is 63% and (p>0.05), and D/D is 25% (p<0.05), respectively. In the distribution of I and D allele in children with VUR (71,3% of children with RN has got D allele). In RN groups with genotype D/D, the level of MA/Cr in the urine was 1,5 times higher than in children with genotype I/D (p<0.05) and 3-3,5 times higher than in patients with genotype I/I (р=0.0001). Significant difference in urinary levels of MA/Cr in the non scar group with genotype I/I and I/D is not revealed. Conclusion D/D-genotype of ACE may be a genetic susceptibility factor contributing to adverse renal prognosis – reflux nephropathy and presenting as risk factor for scar formation. A high urinary level of MA/Cr and positive correlation with genotype D/D is a significant and sensible marker of tubulointerstitial damage

MO955RENAL TRANSPLANTATION IN PATIENTS WITH LOW URINARY TRACT ABNORMALITIES

Background and Aims Kidney transplantation is the only curative treatment for chronic kidney failure that allows to restaure a normal quality of life for patients. In case of abnormalities of the lower urinary tract, there is a risk of recurrence of renal failure due to urodynamic disturbances. The objective of our study is to analyze the profile of transplanted patients with urodynamic abnormalities and to study their impact on the graft. Method Our study was conducted within our Nephrology Department, including renal transplant patients during the period from 2007 to 2020 and who underwent a pre-transplant urodynamic evaluation. Patients with vesical or sphincteral abnormalities were selected, their demographic characteristics, graft survival and infectious complications compared to patients without vesico-sphincteral abnormalities were studied. Results Of 209 kidney transplant patients during the period 2007-2020, 54 had undergone a pre-transplant urodynamic assay, which resulted in 32 patients having an abnormality: 12 cases of vesical hypertonia or hypotonia, 12 cases of sphincteral hypertonia and 9 patients had vesico-sphincteral dyssynergy. In this group with vesical abnormalities, the average age was 24 years, with extremes of 7 and 49 years, 19 were male versus 13 females. Initial nephropathy was tubulointerstitial in 75% of cases with reflux nephropathy in 17 patients. Comparing this group (G1) to the group of patients with no vesico-sphincteral abnormalities (G2), there was more graft reflux 34.4% in G1 compared to 18.2% in G2 (p= 0.16), more urological complications (p=0.2), more urinary tract infections, 0.55 episodes per patient per year in G1 versus 0.98 in G2 (p=0.21). For the graft function, there was no statistically significant difference between the 5-year creatinine post-transplant averages. Conclusion Vesico-sphincteral abnormalities are frequently found in young patients with pre-transplant NIC, they are not responsible for more post-transplant complications or significant graft failure

Vesicoureteral reflux as a manifestation of CAKUT-syndrome in children: the problem of late diagnosis

CAKUT-syndrome includes combined congenital abnormalities of the kidneys and urinary tract and is a complex problem in pediatrics, requiring an interdisciplinary approach of doctors of various specialties. One of the most severe manifestations of CAKUT-syndrome is vesicoureteral reflux, which is often the main manifestation of a congenital abnormality of the kidneys and urinary tract. Structural and urodynamic disorders in the organs of the urinary system in vesicoureteral reflux can lead to the formation of reflux nephropathy and chronic kidney disease. Low-symptom clinical manifestations of reflux nephropathy make it difficult to diagnose it early. Vesicoureteral reflux leads to intrarenal reflux, repeated attacks of pyelonephritis and sclerosis of the renal tissue, which in 25-60 % of cases causes end-stage chronic renal failure due to vesicoureteral reflux. Given the absence of specific pathognomonic clinical manifestations of reflux nephropathy, laboratory indicators are of fundamental importance in the diagnosis-levels of albuminuria, leukocyturia, urinary sediment fermenturia, urine osmolarity, daily urinary excretion of β2 – microglobulin and a wide arsenal of methods for diagnosing reflux nephropathy and scarring of the renal parenchyma: ultrasound with dopplerography of the renal blood flow, magnetic resonance imaging and computed tomography, radioisotope scanning. The imperfection of instrumental methods for visualizing the initial stages of kidney fibrosis dictates the need to develop alternative, more sensitive methods for early diagnosis of reflux nephropathy. One of the directions of this search is molecular diagnostics, which allows you to detect possible damage to the renal tissue at the subcellular level long before the clinical manifestations of pathology, personify nephroprotective therapy and prevention of reflux nephropathy. The article presents clinical observations from our own practice of late diagnosis of reflux nephropathy, in which renal pathology was first detected at stages 5 and 3 of chronic kidney disease in two boys aged 10 and 16 years, respectively, who were on inpatient treatment in the Nephrology Department of the Children's Republican clinical hospital.

Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.

Compensatory renal hypertrophy in reflux nephropathy presenting as hypertensive emergency

ABSTRACT Hypertensive emergency in the paediatric population is not uncommon. However, due to its numerous etiologies, care should be taken in determining the approach of management. We report a case of a child who presented with double vision, giddiness and elevated blood pressure. Blood investigations were normal. Renal ultrasound and magnetic resonance imaging of the abdomen were performed which both showed findings suspicious of a large heterogeneous mass at the lower pole of the left kidney with dysplastic right kidney. A final diagnosis of bilateral vesicoureteric reflux with left compensatory hypertrophy was made based upon micturating cystourethrography findings and was later confirmed by 99mTc-dimercaptosuccinic acid (DMSA) study. The objective of this case is to share the importance of the appropriate choice of radiological examinations, not only in achieving an accurate diagnosis but to ensure that unnecessary investigations are avoided.

Clinicopathological Analysis of Medullary Ray Injury in 1-Year Protocol Paediatric Renal Allograft Biopsies

<b><i>Aim:</i></b> Medullary ray injury was recently reported in renal transplant biopsies. This study was performed to clarify the clinicopathological features of medullary ray injury in paediatric living renal transplant recipients. <b><i>Methods:</i></b> Paediatric recipients who completed a 5-year follow-up after living renal transplantation were enroled. We evaluated the clinical and pathological parameters of the presence or absence of medullary ray injury in their 1-year protocol biopsies. <b><i>Results:</i></b> Of 48 1-year protocol biopsies, 18 (37.5%) showed histological evidence of medullary ray injury. The 48 paediatric recipients were classified as those with medullary ray injury (<i>n</i> = 18; MRI-1Y [+] group) and those without medullary ray injury (<i>n</i> = 30; MRI-1Y [−] group) in the 1-year protocol biopsies. The prevalence of histological evidence of calcineurin inhibitor (CNI) nephrotoxicity, chronic obstruction or reflux nephropathy, and imaging findings of vesicoureteral reflux was 66.7, 22.2, and 7.7% in the MRI-1Y (+) group and 33.3, 13.3, and 15.4% in the MRI-1Y (−) group, respectively. Only the prevalence of CNI nephrotoxicity was significantly different between the 2 groups. There was no significant difference in the mean estimated glomerular filtration rate at 1, 3, or 5 years after transplantation between the 2 groups. <b><i>Conclusion:</i></b> In total, 37.5% of 1-year protocol biopsies showed histological evidence of medullary ray injury. This finding suggests that CNI nephrotoxicity might be the main contributor to medullary ray injury in 1-year protocol biopsies. The presence of medullary ray injury had little influence on renal function, at least during the first 5 years after transplantation.