Yasuo Shiraiwa

Prototype of a reflux-preventing ureteral stent and its clinical use.

We have experimentally produced a ureteral stent which prevents vesicorenal reflux. This stent has a thin silicon sleeve at its distal end (intravesical portion). In a model experiment the sleeve demonstrated an excellent capability to prevent reflux. The sleeve allowed flow of fluid with minimal pressure rise. A patient with bilateral ureteral obstruction was managed with endoscopic insertion of a sleeved stent in the right ureter and a usual pigtail stent in left ureter. During cystography vesicorenal reflux was not observed on the right side while reflux occurred on the left side. Excretory urography forty days after stent placement demonstrated recovery of renal function and maintenance of drainage in both renal units. Thus, the drainage characteristic of this stent appears to be approximately the same as that of usual stent.

A Case of Fibrillary Glomerulonephritis Associated with Thrombotic Microangiopathy and Anti-Glomerular Basement Membrane Antibody

We present the first report of a case of fibrillary glomerulonephritis (FGN) associated with thrombotic microangiopathy (TMA) and anti-glomerular basement membrane antibody (anti-GBM antibody). A 54-year-old man was admitted to our hospital for high fever and anuria. On the first hospital day, we initiated hemodialysis for renal dysfunction. Laboratory data revealed normocytic-normochromic anemia with schistocytes in the peripheral smear, thrombocytopenia, increased serum lactate dehydrogenase, decreased serum haptoglobin, and negative results for both direct and indirect Coombs tests. Based on these results, we diagnosed TMA. Assays conducted several days later indicated a disintegrin-like and metalloprotease with a thrombospondin motif 13 (ADAMTS13) activity of 31.6%, and ADAMTS13 inhibitors were negative. We started plasma exchange using fresh frozen plasma and steroid pulse therapy. Anti-GBM antibody was found to be positive. Renal biopsy showed FGN. Blood pressure rose on the 46th hospital day, and mild convulsions developed. Based on magnetic resonance imaging of the head, the patient was diagnosed with reversible posterior leukoencephalopathy syndrome. Hypertension persisted despite administration of multiple antihypertensive agents, and the patient experienced a sudden generalized seizure. Computed tomography of the head showed multiple cerebral hemorrhages. However, his blood pressure subsequently decreased and the platelet count increased. TMA remitted following 36 plasma exchange sessions, but renal function was not restored, and maintenance hemodialysis was continued. The patient was discharged on the 119th day of hospitalization. In conclusion, it was shown that TMA, FGN and anti-GBM antibody were closely related.

Klinefelter’s Syndrome Associated with Unilateral Cryptorchidism in Childhood

We report a case of Klinefelters syndrome in a 3-year-old boy with unilateral cryptorchidism. The literature is reviewed, and hormonal condition and treatment of Klinefelters syndrome are discussed.

Exfoliative cytology of prostatic carcinoma using a prostatic fluid collecting catheter.

In 152 patients who were suspected to have prostatic disease prostatic fluid obtained by a specially designed catheter was examined cytologically. Cytology was positive in 16 of 20 patients who initially were diagnosed clinically as having prostatic carcinoma, in 10 of 41 patients with suspected carcinoma and in 3 of 91 patients with clinical prostatic hypertrophy or other benign diseases. All but one of these cytologically positive cases finally were confirmed histologically to have prostatic carcinoma. In 4 patients initially diagnosed as having prostatic carcinoma cytology was not positive but in one the initial clinical diagnosis was incorrect and only 3 were false negative. This method of diagnosis is simple and highly effective in detecting prostatic carcinoma.

AQP-3 in the Epidermis of Haemodialysis Patients with CKD-Associated Pruritus is Overexpressed

Background: Xerosis is considered to be one of the causes of chronic kidney disease-associated pruritus (CKD-aP). In the present study, the relationship between CKD-aP and aquaporin-3 (AQP-3), the water channel in the skin was examined in light of xerosis. Methods: AQP-3 expression in the epidermis and patients characteristics included stratum corneum hydration (SCHy) were compared in haemodialysis patients (HD-pts) without pruritus (n = 23), HD-pts with slight to mild pruritus (n = 12), and HD-pts with moderate to severe pruritus (n = 7). Results: In HD-pts, there was association between CKD-aP and both range and intensity of epidermal AQP-3 expression. The range and intensity of AQP-3 expression in the skin was significantly greater in HD-pts with severe CKD-aP than in HD-pts without CKD-aP, as shown by anti- AQP-3 staining that was both more intense and extended to more superficial layers of the skin. Conclusions: CKD-aP was shown to be associated with epidermal AQP-3 expression but not with xerosis, which was quantified in this study using SC-Hy. In addition, there was no association between xerosis and epidermal AQP-3 expression. These results indicate that xerosis, which has been considered to be a cause of CKD-aP, is not a necessary and sufficient condition for CKD-aP, and that the mechanism of the onset of xerosis may not involve epidermal AQP-3 in HD-pts.

Combination Therapy of Pseudomonas Aeruginosa Pyelonephritis in Neutropenic Mice With Human Antilipopolysaccharide Monoclonal Antibody and Cefsulodin

PURPOSE These studies were designed to determine the combined inhibitory effect of a human monoclonal antibody (MAb) and cefsulodin on Pseudomonas aeruginosa renal infection in a neutropenic condition. MATERIALS AND METHODS Protection against the infection of mice was estimated by survival rate and bacterial numbers in the kidney and blood. Opsonophagocytic assay by human polymorphonuclear neutrophils (PMNs) and fluorescence activated cell sorter (FACS) analysis were also examined. RESULTS Treatment of infected mice with MAb combined with a suboptimal dose of cefsulodin prevented the mice from developing pyelonephritis and bacteremia and resulted in a significantly higher survival rate than treatment with either MAb or cefsulodin alone (p < 0.01). When bacteria were preexposed to cefsulodin, a significant enhancement in opsonophagocytic killing with MAb was observed. Fluorescence activated cell sorter analysis suggested that the bacteria incubated with 1/4 minimal inhibitory concentration (MIC) of cefsulodin showed greater binding of MAb to bacteria than the control. CONCLUSION The combination therapy with human antilipopolysaccharide MAb and cefsulodin is useful for P. aeruginosa pyelonephritis in neutropenic hosts.

Total Calcium and Albumin Are Decreased in the Deeper Epidermis of Patients with Chronic Kidney Disease-Associated Pruritus

Background/Aims: In our earlier studies, we reported high concentrations of intra- and extracellular calcium ions (Ca2+) in the deeper epidermis of patients with chronic kidney disease (CKD) and associated pruritus. To determine the cause of this phenomenon, we measured total calcium (TCa) concentrations in the deeper epidermis and performed immunostaining of epidermal albumin, which binds to Ca2+. Methods: This study included 45 patients with CKD-stage 5, which was defined as severely reduced kidney function (i.e., estimated glomerular filtration rate less than 15 mL/min or on dialysis). Subjects were divided into the pruritus group, consisting of patients with mild, moderate, or severe uremic pruritus, and the non-pruritus group, consisting of patients with no or slight pruritus. The particle-induced X-ray emission method was used to measure elements including TCa. Furthermore, we have immunostained epidermal albumin using anti-albumin antibodies and compared the results in the pruritus and non-pruritus groups. Results: The TCa concentration in the spinous layer of patients with CKD with CKD-associated pruritus was lower than in patients with CKD without pruritus (median [range], 395 [235-1,063] vs. 476 [342-1,243] μg/g). The intensity of epidermal albumin expression in the spinous layer was weaker in patients with CKD with CKD-associated pruritus than in those without. Conclusion: Patients with CKD with CKD-associated pruritus demonstrated higher Ca2+ concentrations but lower TCa concentrations than patients without CKD-associated pruritus. This could be in part due to low concentrations of epidermal albumin, which binds to Ca2+, in those with CKD-associated pruritus. These results clarify the pathophysiology of CKD-associated pruritus, providing a valuable foundation for the future development of treatments for this condition.

前立腺葉状腫瘍(phyllodes tumor)の1例

Prostatic phyllodes tumor is an unusual lesion for which there are only occasional reports in the literature. We encountered a phyllodes tumor of the prostate in a 36-year-old man who had complained of urinary frequency and dysuria for one month. In October 1998, he visited our hospital and had a transurethral resection of the prostate (TUR-P) for obstructive symptoms. He experienced recurrent same symptoms in September 1999 and underwent another TUR-P. The pathologic examination at this time revealed phyllodes tumor. In the tumor, despite its regular alternating growth of ducts and stroma, the stromal element appeared histologically malignant, showing marked atypia and rhabdomyosarcoma-like components. Consequently, in December 1999, the patient underwent radical prostatectomy with lymph node dissection. The resection margins and pelvic lymph nodes were free of tumor. The patient remains alive and well after 14 months.

Clinical study of fungal peritonitis in continuous ambulatory peritoneal dialysis patients.

1982年10月から1991年9月までの約9年間に当科および関連3施設でCAPD患者47例中6例に真菌性腹膜炎を認めた. これら症例の臨床的検討を行い次のような結果を得た.1. 真菌性腹膜炎の発生頻度は, 1回/281.7患者・月であった. 2. 原因菌はCandida albicans 5例, Candida globrata 1例であった. 3. 細菌性腹膜炎と比べ特徴的な臨床症状は認めないが, 発症前に全例で抗生剤または免疫抑制剤の投与が行われていた. 4. 末梢血中好酸球数が増加したのは, 5例中1例のみであった. 5. 治療方針はまず抗真菌剤を投与し, 反応の悪い場合にカテーテル抜去を行うこととした. これは腹膜の癒着の頻度が低く, CAPDの継続を考えた場合, 支持されるべき方法と思われた. また, 反応の悪い場合のカテーテル抜去は, 発症後1週間位で行うべきと思われた. 6. 薬剤の選択では, Candida albicansに対しfluconazoleが有効に作用した1例を認めた. 7. カテーテルは抜去後約2か月で再留置したが, その際真菌の検出された例や, 再発をみた例はなかった. しかし, 腹膜の癒着防止を考えた場合, 適切な再留置の時期は未だ定まっていないように思われた.

Sex Chromosome Abnormality in Chronic Renal Failure

Isoji Sasagawa, MD, Department of Urology, School of Medicine, Yamagata University, 2-2-2 Iidanishi, Yamagata-shi, Yamagata 990-23 (Japan) Dear Sir, Sex chromosome abnormality is one of the representative causes of male infertility. Previously, various types of the abnormality have been reported [1, 2]. Patients with the abnormality usually show gonadal dysfunction [3]. Similar dysfunction was often found in male patients with chronic renal failure [4, 5]. However, little attention has been paid to sex chromosome abnormality in men with end-stage renal disease. Herein, we report a case of Klinefelter’s syndrome with chronic renal failure undergoing hemodialysis. A 47-year-old Japanese man, on maintenance hemodialysis for 5 years, was referred to our hospital because of his infertility. He was a well-developed male weighing 68 kg and 184 cm in height. A female-type distribution of the public hair was noted. Neither malformations nor gynecomastia were seen. The penis, epididymides and spermatic cords were normal, but the prostate was barely palpable. His testes were only about 3 ml in volume with an orchidometer. Repeated sper-matograms revealed the absence of spermatozoa. A hemogram disclosed leukocytes of 8,400/mm3 (normal, 4,000-9,000), erythro-cytes 231 × lOVmm3 (normal, 430-570 × 104), hemoglobin 6.8 g/dl (normal, 14.0-18.0), hem-atocrit 21% (normal, 40-54) and platelet count 375,000/mm3 (normal, 130,000-340,000). Serum sodium was 138 mEq/1 (normal, 135-145), potassium 5.1 mEq/1 (normal, 3.2-4.5), chloride 94 mEq/1 (normal, 96-110), calcium 5.7 mg/dl (normal, 8.8-10.2) and phosphorus 5.3 mg/dl (normal, 2.94.7). Blood urea nitrogen was 81 mg/dl (normal, 9-25), serum creatinine 14.3 mg/dl (normal, 0.5-1.5) and uric acid 7.6 mg/dl (normal, 2.0-7.6). Liver function test and immunologi-cal examinations were all within the normal range. Plasma-luteinizing hormone (LH), follicle-stimulating hormone (FSH) and testosterone were 18.8 mlU/ml (normal, 1.8-5.2), 51.0 mlU/ml (normal, 2.9-8.2) and 0.3 ng/ml (normal, 2.8-8.2), respectively. Chromosome analysis of peripheral lymphocytes with 26 cells showed 47, XXY (96.2%) and 46, XY (3.8%) mosaicism (fig. 1, 2). The patient was treated with intramuscular injection of 250 mg testosterone enanthate every 3 weeks. Twelve weeks after the initiation of testosterone replacement therapy, LH, FSH and testosterone were 22.5 mlU/ml, 45.3 mlU/ml and 1.1 ng/ml, respectively.