Lee B. Talner

Pretreatment with corticosteroids to alleviate reactions to intravenous contrast material

The x-ray contrast mediums used over the past three decades have been salts of iodinated acids administered in highly hypertonic concentrations. We conducted a multiinstitutional randomized study of the protective effects of pretreatment with corticosteroids against reactions to intravenous contrast material. We gave 6763 patients two doses of oral corticosteroids (methylprednisolone, 32 mg) approximately 12 hours and 2 hours before challenge with contrast material, one dose of oral prednisolone approximately 2 hours before challenge, or placebo in the same dosages. The two-dose corticosteroid regimen, but not the one-dose regimen, significantly reduced the incidence of reactions of all types (P less than 0.05) except a category of reactions dominated by hives, for which the reduction approached significance (P = 0.055). In recent years, several relatively expensive monomeric nonionic iodinated compounds having approximately half the osmolality of the corresponding ionic compounds and a lower reaction rate have become available. With our two-dose corticosteroid regimen, the incidence of reactions necessitating therapy in patients receiving the ionic medium approximated that reported in an unblinded nonrandomized study of patients receiving a newer intravenous nonionic medium without corticosteroid pretreatment. We conclude that the much less expensive ionic medium, if administered with corticosteroid pretreatment, may serve as a reasonable alternative to intravenous nonionic medium, without loss of safety.

Renal vasculature in essential hypertension: racial differences.

In an attempt to explain the greater morbidity from essential hypertension in the black as compared with the white race, we evaluated the intrarenal vasculature of 27 patients with hypertension (19 white and 8 black). All patients had mild-to-moderate hypertension (mean arterial pressure, 110 to 125 mm Hg), normal renal function, and minimal target-organ damage. All patients had selective renal angiograms, which were evaluated for arterial nephrosclerosis. Additionally, renal blood flow was estimated by the clearance of para-aminohippurate. Patient age, blood pressure, and plasma renin activity did not differ between the two races. Black hypertensives had significantly (P less 0.01) more severe nephrosclerosis than the white patients. Renal blood flow was lower (P less than 0.05) in black patients (390 +/- 35 ml/min - m2 body surface area) than white patients (473 +/- 19 ml/min - m2 body surface area). These findings may help to explain racial differences in morbidity and mortality from essential hypertension.

Lupus cystitis: primary bladder manifestations of systemic lupus erythematosus.

Clinical and radiographic findings of cystitis are reported in six patients with systemic lupus erythematosus. All patients had clinical manifestations of cystitis; radiography showed the bladder capacities were reduced and the bladder walls were thickened and irregular. Ureterohydronephrosis was found in some patients. Abnormal clinical and roentgenographic findings were reversed with high-dose corticosteroid therapy. These patients had concomitant widespread multisystem manifestations, especially of the central nervous system and gastrointestinal tract. No explanation for the bladder findings could be found other than lupus erythematosus. Urinary bladder involvement may be a primary manifestation of systemic lupus erythematosus, sometimes overshadowed by other major organ system disease. Corticosteroids appear to reverse most of the acute manifestations but the long-term prognosis is not known and may not be favorable.

Renal Ultrasonography: An Updated Approach to the Diagnosis of Renal Cyst

Ultrasonic B-scanning has proved to be accurate in determining whether a renal mass is solid or cystic. It is, therefore, an ideal technique by which to select those renal masses (cysts) which are suitable for percutaneous puncture for the purpose of diagnosis. When a definite cyst pattern is indicated by the ultrasonogram, percutaneous puncture is performed. A clear aspirate with negative cytology and normal LDH is considered diagnostic of benign renal cyst. If a solid mass is suggested by ultrasonography, renal angiography is performed. The results of such studies in 84 patients are discussed.

Urographic and Angiographic Abnormalities in Adult-Onset Acute Bacterial Nephritis

Five cases of a severe form of acute bacterial renal infection are presented. Urographic findings included enlargement of the renal outline and marked decrease of nephrographic density on the involved side. In 3 patients no calyceal opacification occurred due to the severe impairment of contrast agent excretion (retrograde pyelography excluded obstruction). Fine linear stripes thought to represent occlusive or vasoreactive changes at the level of the interlobular artery or afferent arteriole were seen at angiography. There was acute interstitial inflammatory infiltrate in 2 resected kidneys. Three patients treated with antibiotics returned toward normal within 25 days of the initial urographic examination.

How accurate is ultrasonography in detecting hydronephrosis in azotemic patients

Screening for hydronephrosis continues to be an essential part of the evaluation of patients with azotemia of unknown cause. To determine whether sonography is as reliable as nephrotomography for screening purposes, we carried out a prospective, comparative study. Sixty-two patients were evaluated. Mean serum creatinine was 4.3 mg/dl. Of 116 kidneys, 45 were obstructed according to urographic criteria and 42 of these were correctly called hydronephrotic by sonography. The 3 false negative sonographic studies occurred in 2 patients. All 3 kidneys contained radiopaque calculi visible on the plain abdominal film. Of the 71 nonobstructed kidneys, 5 were mistakenly called hydronephrotic by ultrasound, giving a false positive rate of 7%. We believe it is appropriate to use gray-scale ultrasound as a screening test for urinary obstruction in azotemic patients providing the plain abdominal radiograph shows no calcifications.

Preoperative localization of a testosterone-secreting ovarian tumor by retrograde venous catheterization and selective sampling

Abstract A 20-year-old woman was evaluated to determine the cause of rapidly progressive virilism. Serum testosterone levels were markedly elevated ranging between 6,528 and 13,554 pg. per milliliter and showed no consistent response to either dexamethasone suppression or human chorionic gonadotropin stimulation. Serum androstenedione (1,013 pg. per milliliter) and dehydroepiandrosterone (4.10 ng. per milliliter) levels were normal. Retrograde venous catheterization and selective sampling of the adrenal and ovarian veins showed an enormous step-up of testosterone (293,333 pg. per milliliter) in the right ovarian vein. A hilus cell tumor of the right ovary was found at operation. Following oophorectomy there was a rapid and sustained fall of serum testosterone and a resolution of the patients hirsutism and amenorrhea. This report demonstrates that retrograde catheterization and selective venous sampling can be effectively used preoperatively to localize androgen-secreting tumors.

Why does kidney size change during I.V. urography

Meglumine iothalamate (280 ml I/ml) and sodium iothalamate (400 mg I/ml) in doses of 700 mg I/kg bw, were injected i.v. as a bolus in dogs. Renal size, urine flow rate, arterial pressure, renal blood flow and mean transit time and renal blood volume were measured before and after injection. All changes were qualitatively and quantitatively identical for both drugs. They produced a small transient renal shrinkage followed by a greater and prolonged renal enlargement. During the period of renal enlargement, urine flow increased. The time course of the enlargement paralleled the increase of urine flow rate. Renal blood flow also increased but both the mean transit time and renal vascular volume decreased. Therefore, the kidney size increase after i.v. injection of large doses of urographic contrast media cannot be attributed to an increased volume of the vessels. Most likely it is caused by diuresis-induced increase in the volume of the tubules.

Intrarenal backflow during retrograde pyelography with graded intrapelvic pressure. A radiologic study.

Thomson HS, Talner LB, Higgins CB. Intrarenal backflow during retrograde pyelography with graded intrapelvic pressure: a radiologic study. Invest Radiol 1982;17:593–603. Intrarenal backflow (IRB)—a form of pyelorenal backflow where contrast material appears in the renal parenchyma during retrograde pyelography—seems to be the same phenomenon as intrarenal reflux (IRR), sometimes observed during micturating cystography in children or animals with vesicour- eteral reflux. Retrograde pyelography experiments were performed on baby pigs to study the relationship between renal pelvic pressure and IRB. Intrapelvic pressure was raised to 30–35 mm Hg (moderate) or 70–75 mm Hg (high) for 5 minutes. IRB developed in only four of 12 kidneys at moderate pressure but in all six kidneys at high pressure. Similar experiments were conducted on kidneys which had been rendered temporarily ischemic prior to retrograde pyelography. Twenty-seven kidneys were so studied 30 minutes after a 30− or 60-minute period of ischemia. With moderate and high pressure retrograde pyelography, all kidneys developed IRB. The most intense and widespread IRB occurred after 60 minutes of ischemia and at high pressure. IRB localized to the upper pole most frequently but was also observed in other portions of the kidney. The effect of IRB upon renal blood flow (RBF) was determined with electromagnetic flow probes during the same experiments. IRB caused a 16% mean decrease in RBF at moderate pressures and a 57% mean decrease in RBF at high pressures and was independent of preceding ischemia. It is concluded that both raised intrapelvic pressure and preceding renal ischemia are important factors determining the degree of IRB during retrograde pyelography and that backflow itself causes decreased RBF.

Percutaneous nephrostomy: experience in 107 kidneys

We were successful using percutaneous nephrostomy to relieve upper urinary obstruction in 98 of 107 kidneys. In two thirds of our patients obstruction was due to neoplasm, with prostatic cancer the leading cause. Percutaneous nephrostomy proved to be ideally suited for drainage of pyonephrosis and in azotemic patients. Its use can obviate surgical nephrostomy and prolonged ureteral catheter drainage. We also are encouraged by our early experience with extensions of percutaneous nephrostomy, including percutaneous ureteral stenting, renal stone dissolution, and percutaneous pyelolithotomy.