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BACKGROUND: A severe degree of ureteral obstruction is viewed as a predictor of poor outcome in shockwave lithotripsy (SWL). Impacted stones are often considered a contraindication to in-situ SWL. PATIENTS AND METHODS: Impaction in our study was defined as failure to visualize the ureter distal to the calculus with proximal hold-up of contrast for as long as 3 hours on an intravenous urogram (IVU). We evaluated 30 patients with impacted ureteral calculi, who were compared with a second unimpacted group matched for stone size and stone location. The calculi were reorganized into < or =10-mm and >10-mm groups. The results were compared in terms of clearance rates, number of shockwaves, number of sessions, and number of days between the start of SWL and clearance. RESULTS: Between January 1998 and December 2001, 30 impacted stones were treated with lithotripsy. Complete clearance rates in the impacted as well as the non-impacted group were 76.7%. There was no statistical difference in the number of shockwaves, sessions, or time to clearance. The results were poorer in lower-ureteral than upper-ureteral calculi, but this difference did not reach statistical significance. However, the differences between the < or =10-mm and >10-mm stones were statistically significant. CONCLUSION: Impaction on an IVU does not affect the results of lithotripsy.

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OBJECTIVE: To review the outcome of paediatric renal transplantation over a period of 15 years in a developing country. METHODS: This is a retrospective study of 63 children, less than 15 years of age, who underwent living-related renal transplantation in Christian Medical College and Hospital Vellore between 1984 and 1996. RESULTS: The records of 12 patients were not adequate for detailed analysis. Parents were the donors for these children in 84.3% of cases. The most common known cause of end-stage renal disease in these children was reflux nephropathy. Combinations of cyclosporine, azathioprine and prednisolone were used as immunosuppressive drugs. Complications occurred in 16 patients. During the follow-up period, eight patients died and two returned to receiving haemodialysis. Patient survival was 92% at the end of 1 year and 90% at the end of 3 years. Graft survival was 88% and 86% at 1 and 3 years, respectively. CONCLUSION: Our study validates the concept of renal transplantation as optimal therapy with adequate medical, social and functional rehabilitation for children with end-stage renal disease. Our study also indicates that vesicoureteric reflux appears to be underdiagnosed and should be actively pursued to prevent complications.

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BACKGROUND: The results of regular intermittent self catheterization were compared with regular outpatient dilatation after endoscopic internal urethrotomy for urethral strictures. METHODS: The records of patients who were treated for urethral stricture disease over a 4-year period from 1991 to 1994 were reviewed. They were either on regular urethral dilatation or were advised to carry out self calibration. A follow-up questionnaire was sent to them and they were asked to attend a review. Student's t-test and Proportion Test were used to find out if there was any significant difference between the two groups. RESULTS: There were 78 patients who were on self calibration and 49 patients on regular urethral dilatation. There was no significant difference between the two groups regarding the duration of follow-up (21.5 and 23.7 months, respectively); the length of stricture (1.5 and 1.7 cm, respectively); and complications (two and four, respectively). However, patients on self calibration had narrower strictures (4.8 and 5.7 F) and a significantly lower restricture rate (5 and 16%). The current urinary stream was compared to the immediate postoperative stream. This showed that a higher number of patients in the dilatation group were voiding at less than 25% of their immediate postoperative flow. People from high and low socio-economic groups were able to carry out self calibration satisfactorily. CONCLUSION: Patients from high and low socio-economic groups found that self calibration resulted in a lower restricture rate and better stream when compared to regular urethral dilatation.

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The clinical presentation, radiological manifestations and response to therapy of seven cases of biopsy-proven eosinophilic cystitis seen over an 8-year period were evaluated retrospectively. All of the five men and two women had symptoms of dysuria and frequency, with haematuria in two cases. One developed acute painful retention. The urine was sterile in all. Radiological findings included bladder mass lesions and upper tract dilatation. Cystoscopy showed papillary, erythematous and ulcerative mucosal lesions, and in one instance a large mass lesion. The various procedures carried out were cold cup biopsies, transurethral resections, or fulgration of lesions and partial cystectomy. Medical therapy included non-steroidal anti-inflammatory drugs and prophylactic antibiotics to cover the procedures carried out. There was excellent symptomatic improvement in all patients. This is the largest single-centre experience reported, and is unusual as the majority of the patients in this series were men.

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A retrospective study of 1000 live renal transplants was performed in order to assess the factors associated with hypertension in renal transplant recipients. The prevalence of hypertension prior to transplantation was 48%. The need for antihypertensive drugs decreased in 43%, increased in 31% and remained the same in 26%. The presence of hypertension before transplantation, rejection episodes, transplant renal artery stenosis and native kidney disease were the main factors associated with post-transplant hypertension. An algorithm for the management of post-transplant hypertension is suggested.

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One hundred live related voluntary kidney donors were studied prospectively. During donor nephrectomy the actual kidney bipolar length was measured and compared to the renal bipolar length estimated from abdominal sonogram, abdominal plain X-ray, intravenous pyelogram, and renal angiogram. Ultrasound was found to measure the kidney more accurately (mean difference between estimated size and actual = -3.4 mm +/- SD 6.96), than plain X-ray (mean difference from actual 13mm +/- SD 5.24), IVP (mean difference from actual 16.9 mm +/- SD 5.74), and renal angiogram (mean difference from actual 15.2 mm +/- SD 5.77).

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A review has been made of the indications, technical problems, complications and results of 31 allograft nephrectomies in 29 patients; 12 patients died between 15 days and 1 month after graft nephrectomy, which was undertaken within 6 months of transplantation. Gross local and general complications occurred in 7 patients who survived graft nephrectomy. The procedure is recommended when graft failure occurs within 6 months of transplantation provided it is associated with systemic signs of severe rejection or sepsis, or if it occurs in cases where continuation of immunosuppressants is life-threatening.

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In a series of 650 renal transplantations performed over a 4- year period, the results were evaluated of 125 Leadbetter-Politano and 125 extravesical ureteroneocystostomies. The Leadbetter-Politano technique had a complication rate of 4%, with 3.2% of these patients having a vesical leak. Extravesical ureteroneocystostomy also had a 4% complication rate but only 1.6% of these patients had a vesical leak. Although there was no statistical difference between the two groups with regard to complications, we feel that extravesical ureteroneocystostomy is a quick and simple procedure and well suited to the special challenge presented by renal transplant recipients.

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In a study of 656 urine specimens from 53 consecutive recipients of live related donor renal allografts we found an excellent correlation between the protein content of 24-h urines and protein/creatinine ratio (Up/Ucr) in overnight urine samples. Using this ratio, we evaluated proteinuria up to 180 days after renal transplantation (overnight urine samples analysed, n = 2745). Heavy proteinuria in the immediate post-operative period had no prognostic significance. Eighty-nine percent of all clinically observed acute rejection episodes were accompanied by an increase over baseline of Up/Ucr; in 56.5% of these episodes elevation of Up/Ucr preceded that of serum creatinine. However, as a marker of rejection the usefulness of this parameter was limited owing to large number of false positive elevations. In 50 recipients whose grafts survived for more than 3 mth, proteinuria was graded into minimal, moderate and heavy. Renal function at the end of six months was good in all patients who exhibited proteinuria with Up/Ucr less than 100 mg/mmol creatinine. Persistent proteinuria with Up/Ucr above 100 mg/mmol preceded significant deterioration of graft function. Therefore, a protein-creatinine ratio of 100 mg/mmol can be considered as an apparent cut-off to differentiate stable from deteriorating graft function in long term evaluation of transplant recipients.

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An evaluation of the usefulness of urinary N-acetyl-beta-D-glucosaminidase (NAG) and aminopeptidase N (AAP) measurements in the diagnosis and prediction of acute and chronic renal allograft rejection was made. Enzyme activities were measured in 2,745 morning spot urine samples from 53 consecutive live donor renal allograft recipients up to 180 days after transplantation. Reference ranges of urinary enzyme activities in 14 recipients with normal graft function were higher than those established in a carefully selected group of healthy controls. 89 and 91% of 76 clinically diagnosed acute rejection episodes (ARE) in the remaining 39 graft recipients were accompanied by sharp increase over baseline of NAG and AAP respectively. All rejection episodes occurring in the early period after transplantation were characterised by high enzymuria. AAP was more sensitive than NAG as the magnitude of its increase over baseline was more, while NAG was more specific with less number of false positive elevations. Both enzymes were found to be equally good prognostic indices of graft loss and chronic graft deterioration. Regular monitoring of urinary NAG and AAP activities throughout the post transplant period would thus be valuable in (a) diagnosis and prediction of ARE in the early as well as late post operative period and (b) prediction of eventual graft outcome.

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