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The results of dynamic scintigraphy of the kidneys using 99mTc-DTPA that is glomerular radiopharmaceutic in patients before and after ESWL (extracorporeal shock wave lithotripsy) are presented. Investigation was performed in 22 patients--in 8 patients immediately before ESWL, 7 days and 3 months later, and in 14 patients before and 7 days after ESWL. The time alteration of the achievement of the maximal values of radiorenographic curve obtained by dynamic scintigraphy (Tmax), as the alteration of separate clearance (SCI) counted as an integral below the other phase of renographic curve. No significant differences were observed in the values of separate clearance before and after ESWL, while Tmax was significantly reduced 3 months after ESWL (p < 0.05). Our results indicated the improvement of glomerular filtration of the kidneys 3 months after ESWL (faster passing of DTPA through the treated kidney).

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The urinary tract infection is very frequent, especially if calculosis of the urinary tract is present. Urinary infection is widespread, and it appears during the year. The people of all ages and both sexes are affected by urinary infection. In the last few years a reliable progress in the understanding and management of urinary tract infection is achieved. Numerous articles published in professional journals are a good proof of it. The urinary tract infection is frequent and is responsible for the use of large quantities of antibiotics which provoke great costs and make other problems. The role of laboratory tests in the diagnosis of infection is predominant. The clinician is completely dependent on his collegue, a bacteriologist, with regard to the results of urine culture. It is known that microorganisms grow better if they have good nourishment. Infections of the urinary tract were always a significant problem. However, over the last few decades, they became, according to some authors, the most frequent bacterial infection in humans, requiring the frequent administration of immunosuppressive agents, corticosteroids and cytostatics; and at the same time a great number of elder people and chronic patients with reduced immunity are involved. Taking into account that significant and insignificant infections of the urinary tract are frequent in nephropathology, particularly in renal and canalicular calculosis, the aim of the study was to point to extracorporeal shock wave lithotripsy without risk of impairment of already existing infections with and without administration of antibiotic and uroantiseptic agents for prophylactic purposes. A group of 5,078 patients with calculosis of the urinary tract was studied. Extracorporeal shock wave lithotripsy was performed in all patients by Siemens lithotriptor Lithostar (Germany). In patients with calculosis of the urinary tract subjected to extracorporeal lithotripsy bacteriuria was regularly followed. A group of 1,836 (36 percent) patients with urinary tract obstruction and 3,242 (64 percent) patients without urinary tract obstruction were treated (Table 1). In 895 (18 percent) patients with urinary tract obstruction infection was serious. In 321 (6 percent) patients without urinary tract infection, serious urinary tract infection was detected (Table 2). The most frequent causes of urinary tract infection are presented in Table 3. Table 4 shows a review of patients to whom antibiotic therapy, prior to extracorporeal lithotripsy, was prescribed. Infection of the urinary tract is responsible for great morbidity. The treatment of any type of urinary tract infection must include the examination of the effect of antibiotic agents. During the treatment of urinary tract infection with calculosis resistant microorganisms are also developed because of repeated administration of antibiotics to patients in health institutions, and especially to patients with ureteral catheters. The treatment of any type of urinary tract infection must include the examination of the effect of antibiotic agents used. The fundamental aims of the treatment of urinary tract infection are: the eradication of causes of infection and concurrent prevention or optimal control of recurrent infection. As long as the patients with urinary tract calculosis are susceptible of permanent infections. It is indispensable to perform sterilization, and thereafter to remove the stone from the urinary tract, because infection of the urinary tract may cause a series of sequelae in the function of the kidney. Frequently the successful urinary sterilization with antibiotic agents cannot be achieved, and consequently, the carrying out of extracorporeal lithotripsy together with administration of antibiotics, is impossible. Good results can be obtained by a combined therapy of antibiotics and extracorporeal lithotripsy in patients with urinary tract calculosis. (ABSTRACT TRUNCATED)

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Acute renal insufficiency is a severe, but most frequent reversible illness followed by sudden onset, oliguria or anuria of indefinite duration, by rapid increase in decomposition products of protein catabolism in serum, by acidosis and fluid balance and electrolytes disorder. The aetiologic factors of acute renal insufficiency are various. A very significant aetiological factor in the appearance of acute renal insufficiency is a trauma caused by any kind or type of weapons, arms or instruments [1-5, 6, 9-13, 15]. Of a total number of injured persons who were treated in our institution (4,086 injured persons), 251 (6.14 percent) were with acute renal insufficiency, and of that number with all signs and symptoms of acute renal insufficiency 37 (0.9 percent) were treated with haemodialysis. Of the number of dialysed patients 30 (80 percent) patients had oliguric form of acute renal insufficiency and 7 (19 percent) were with non oliguric form of acute renal insufficiency. The most frequent injuries were to abdomen and then to extremities, liver, chest and kidneys. The smallest percentage concerned isolated injuries in extremities. According to a pathogenic mortality mechanism, the highest mortality was in patients with haemorrhagic syndrome and in septic condition, and the minimal in patients with other syndromes, such as crush syndrome, etc. In 25 (68 percent) patients acute renal insufficiency was associated with haemorrhagic syndrome, in 7 (18.9 percent) with crush syndrome and in 5 (13.5 percent) with septic condition. In 36 (97 percent) patients haemodialysis was performed and in 1 (3 percent) subject peritoneal dialysis. The reason for such a small number of peritoneal dialysis are severe injuries to abdomen and chest, since this type of dialysis could not be performed for technical reasons. In 27 (73 percent) patients haemodialysis was performed as a type of intermittent heparinization. In 5 (14 percent) patients heparinization was a type of continual heparinization. Thanks to prompt haemodialysis together with medical therapy and surgical treatment, the mortality rate in our patients was lower in comparison to mortality rate in other centres (Table 3). The main causes of acute renal insufficiency in our patients were: Acute tubular nercosis, peripheral blood flow insufficiency (hypovolaemia, cardiovascular failure), and postrenal insufficiency (excretory obstruction, intrarenal obstruction, urinary organ ruptures, haemorrhagic shock) and the underlaying kidney disease. Acute renal insufficiency can be divided into acute renal insufficiency, primary parenchymal renal insufficiency and postrenal azotaemia [1-6, 9, 12, 13]. During the therapy of these patients it is important to evaluate the dehydration degree of patients by clinical and laboratory parameters. In case of hypovolaemia the complete compensation of fluid should consist of infusion together with administration of diuretics. The central venous pressure should be maintained at the values in a range from 6 to 8 cm H2O. In case of oliguric acute renal insufficiency the fluid intake should be equal to diuresis plus every other loss of fluids. Diet should be high-caloric with carbohydrates in the amount of 100 mg, and that amount should be given three to four times daily (both parenterally and orally) together with restriction of potassium intake due to a well known effect of potassium on myocardium function. Dosage of drugs which are eliminated via kidney should be managed promptly by parenteral administration of antibiotic agents [7, 8, 13-16]. Haemodialysis should be started at the very beginning of the patients admission to the hospital and should be associated with anticoagulant therapy for avoiding haemorrhages. Thanks to haemodialysis performed in time, the mortality rate in our patients was reduced in comparison to health centres where haemodialysis was delayed. Thanks to such treatment of patients with many severe injuries in whom the mortality rate is usuall

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ESWL has proved to be a safe and effective method in the treatment of urinary tract calculosis. The method is hardly invasive when compared to all other methods known so far, except for the treatment of calculosis with a selective pharmacotherapy. Moreover, the method is contactless, extracorporeal, mostly necessitating no anaesthesia and spasmoanalgesic therapy, except in the very small number of patients. The importance of the problem of urinary tract calculosis is enormous. Calculosis affects children, and particularly adults, predominantly psychically and physically active individuals in the most productive phase of their lives as well as elderly population. All this makes considerable its adverse effects on health, producing great interest of specialists for this disease. However, the incidence of the disease requires much better surveillance of the patients, since the preventive measures must be undertaken in time as they are of utmost importance. The treatment of urinary tract calculosis has brought great improvements enabling resolution of all types of concrements, irrespectively of their size and chemical composition, in absence of surgical incisions and anaesthesia, except for the small number of patients. Therefore, ESWL therapy has been most advantageous in different types of lithotriptors, particularly lithotriptors of the second generation, such as lithostar lithotripter. Renal calculi are the most convenient for this therapeutical procedure. Ever since its introduction into the clinical practice, the method has become the first therapeutical choice in the treatment of urinary tract calculosis. The indications for this type of therapy are enlarger and now they include all types of urinary tract calculi. Hospitalization and convalescence periods following ESWL are reduced when compared to nephrolithotomy, pyelotomy or ureterolithotomy. The study included a series of 2034 patients treated by this method. Our results revealed a low morbidity rate. Transitory haematuria occurred in almost all patients. Significant fall in haemoglobin levels was extremely rare, occurring only in four of patients with prolonged haematuria resolved following blood transfusion. In 321 patients enormous "Steinstrasse" was evidenced. In 54 patients percutaneous nephrostoma was created. Ureteroscopical removal of the stone was attempted in 14 patients; however, the success was moderate. Urosepsis developed in 29 patients. In 107 patients of the series, heart-related problems were recorded during and immediately after ESWL treatment. Paroxysmal supraventricular tachycardia was recorded in 20 patients. Arterial hypertension was evidenced in 63 patients, although they had previous history of hypotension. Skin lesions were found in 1004 patients, and none of them necessitated the therapy. It may be concluded that ESWL is the optimal method in the treatment of urinary tract calculosis; it is free of risk of development of predicted and unpredicted complications, which are now readily resolved failing to induce higher mortality rates among the patients treated by this method. The patients with cardiac problems should be previously well compensated, and after achievement of satisfactory compensation (sinus rhythm of the heart, etc.), the patients may be subjected to the treatment. This therapeutical postulate also applies to patients with coagulation disorders, when they are first subjected to an intensive treatment; after the satisfactory condition is accomplished they can undergo the treatment without any risk of haemorrhage or similar complications. Silica ureteral probes protect the kidney from complications following ESWL. Morbidity induced by ureteral obstruction is minimized, particularly if calculi of greater size than 2.5 cm are treated. Careful assessment is mandatory in patients at high risk, as well as appropriate preoperative conselling with relevant specialists. (ABSTRACT TRUNCATED)

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ESWL has been accepted as a method for treatment of urinary tract calculosis. In most cases with urinary tract calculi, the method has replaced the classic surgical procedure. Staghorn calculi are still too large to be simply managed with classic procedure; however, they may be successfully disintegrated (crushed) with the available lithotriptors, particularly with second generation lithotriptors such as LITHOSTAR. Technological innovations which appeared during the last two decades have induced sudden changes in the treatment of urinary tract calculosis. They were enabled by extracorporeal shock wave lithotripsy, which is a method associated with the lower morbidity rate. The method is readily accepted by most of the patients. It is effective in removal of calculi of different size and chemical composition. During the last decade, ESWL has been widely applied in a large proportion of patients with stag-horn calculi. Since the "STEINSTRASSE" phenomenon may develop following disintegration of the more massive stones, double J catheter (DJC) is always placed preventively before the staghorn calculi treatment. The clinicians well know how surgical treatment of staghorn calculosis is technically hard to perform, since there is a risk of renal blood vessels injuries and renal function impairment. Moreover, complete stage-horn urinary tract concrements are the most problematic stones with respect to kidney injuries, surgical treatment and rate of later complications. After the introduction into the clinical practice ESWL has become a treatment of choice for stag-horn calculi in approximately 85% of patients. It is performed in several steps. Over the last two years, 41 patients with partial or complete stag-horn calculi were treated in our institution. In 63% of cases, three treatments were performed per each patient, while 37% of our patients underwent more than three sessions. In a very small percentage, even seven treatments were performed. At the very beginning of the treatment, DJC was placed in 52% of patients, due to the expected "STEINSTRASSE" phenomenon, DJC enabled internal urine drainage and decreased the necessity of perdutaneous nephrostomy. Introduction of DJC reduced the number of cases with ureteral obstruction as well as the number of candidates for nephrostomy to below 29%. Percutaneous nephrostomy was performed in only a small number of patients, enabling satisfactory ureteral peristaltic with very good elimination of disintegrated stone detritus. Twenty-three of our patients developed urinary infections. In our series, the number of residual concrements was directly proportional to the degree of hydronephrosis before ESWL treatment (Table 1, 2, 3, 4). It may be concluded that in sity ESWL treatment of staghorn calculi with prophylactic placement of ureteral catheters is associated with lower complications rate when compared to patients who underwent the combined treatment using ESWL and percutaneous nephrolithotripsy. Single ESWL treatment should be carried out in all cases of uninfected stag-horn stones, clearly visualized upon X-ray examination, with mild hydronephrosis. In prominent hydronephrosis, with high probability of retaining of stone fragments in the lower renal calices, the therapeutical approach should include a combination of ESWL and nephrostolithotripsy. In draining stag-horn renal calculosis, disintegration should be initiated with the parts of the stone localized in the renal pelvis and upper renalc calices. Using such disintegration procedure, large stones in the urinary tract may be eliminated in several steps, which is always associated with the presence of sufficient fragments to be eliminated; however the intervals between the treatment are free of problems. In this way, stag-horn stones may be treated in out-patient wards with previous DJC catheter placement, which is a wise precaution.

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Acute renal failure (ARF) in burn disease results in a range of phenomena important not only from theoretical, but also from practical point of views, whose causes are manifold. ARF is generally defined as a rapid renal failure resulting in accumulation of protein metabolism degradation products (catabolism). It has been known, for some time, that thermal agents do not produce only local skin damages, but also disturb the integrity of the whole organism producing major functional damages of all organs and systems. Most frequently organs affected by burn disease are the following: the lungs, the heart, the kidney, the liver and blood coagulation systems. There are many factors influencing the renal function during the burns. The most important are: decreased cardiac output, respiratory failure with hypoxia and acidosis, toxaemia and sepsis [1, 4, 6 7, 8-10, 12, 19]. ARF in burn disease may be early due to hypovolaemia and hypoperfusion of the kidneys or late, occurring after a week as a consequence of infection and endotoxaemia. Development of ARF in burn disease is a very unfavorable prognostic sign necessitating a complex evaluation. Anuria in an early phase of burn disease may indicate the development of ARF, particularly if urine findings are positive to haemoglobin, proteins, myoglobin, which is of the utmost importance in deep burns inflicted by high voltage current. The immediate cause of anuria in burn disease may be a reflex transfer and penetration of the large quantities of toxic materials into the circulation form the region affected by burns leading to the spasm of afferent glomerular arteriolae producing sudden discontinuation of glomerular filtration. After burns, sudden increase in the osmotic activity ensues in the affected tissue. Some low molecular links may result, and such particles tend to change the osmotic balance and stimulate the development of oedema, and if not excreted, they increase osmolarity. In 20-30% of the patients with burn disease anuria is absent [2, 5, 11, 14, 18, 20]. The genesis of burn disease-associated anaemias is therefore multifactorial. These factors are the following: haemorrhage, haemolysis and etrythropoiesis level decrease. In massive burns, large amounts of non-specific inflammatory components are produced as well: prostaglandins, histamine, quinines leukocyte phenomena, bacterial toxins, etc. [1, 6, 13-16]. The study based on a years-long treatment of our patients with burn disease included on 100 patients. The youngest of the patients was 14 years old, and the oldest 65 years. The percent of burns-affected body surface ranged from 25% to 75%. In 3/4 of the patients the picture of an early renal failure developed, with oliguria immediately after infliction of the burns with rapid increase of serum urea and creatinine levels, while in 1/4 of the patients ARF occurred on the eighth day following the infliction of the burns. "late form of acute renal failure". Among our series with burn disease, anuria was present in 34.0% of patients and oliguria in 25.0%. ARF (early phase) occurred in 59 patients, 38 patients had no sing of ARF, while late ARF developed only in 3 patients. ARF-associated mortality rate was high among these patients (23%), being 6% among anuric patients with ARF and 17% in patients with ARF with anuria. Seventy-seven percent of the patients survived, and their serum and urine analyses performed upon subsequent out-patient follow-up examinations ranged within normal values. Such high percentage of survival among our patients included in the study is based on an early diagnosis of ARF, understanding of pathophysiology of shock associated with burn disease, adequate therapeutic approaches, including both medicamentous treatment and extracorporeal haemodialysis along with early surgical management (Shema 1, 2). For the time being, haemodialysis is the most effective therapeutical procedure in the treatment of ARF, although the mortality rate of dialyzable patients

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Arterial hypertension is frequent among chronically dialyzed patients. The kidney obviously plays a major role in arterial blood pressure control. There is a large number of experimental data emphasizing different factors (in addition to renin important in renal hypertension prognosis) such as: sodium balance, angiotensin, etc [1-8]. Sympathetic activity disorders or lack of vasodilatory prostaglandins and quinine may also play a certain role. In uremic patients peripheral arteriolar resistance is increased, unlike normotensive uremic patients or those who prove to be normotensive upon clinical examinations [8, 11-15]. Hypertension occurs in approximately 80% of patients with chronic renal failure, producing a number of complications primarily affecting the CNS and systemic circulation [5-8, 10, 11, 13]. The study concerned patients on chronic dialysis, with a male to female ratio of 69.9%:32.1%. In most of them the underlying disease, which caused chronic renal failure, was glomerulonephritis (60.0%), then pyelonephritis (17.0%) and nephrosclerosis, nephrolithiasis, polycystic kidney and, finally, renal tumours. The effect of permanent haemodialysis during the first year of treatment, was efficacious on hypertension in 1704 (65.1%) patients; in 672 (25.7%) patients therapeutical effects were achieved by dialysis and antihypertensive drugs, while in 240 (9.2%) subjects there was no improvement. General observations suggest that two types of arterial hypertension persisted in patients with chronic renal failure: volume-dependent arterial hypertension which is more frequent (90-95%) among haemodialyzed patients and renin-dependent hypertension. Such findings are of utmost importance indicating that hypervolaemia is one of the major factors in the development of arterial hypertension in patients with chronic renal failure, with renin playing the secondary role. Salt-free diet should be used in the treatment of arterial hypertension for years, a well conducted haemodialysis is highly effective in the control of arterial hypertension among these patients. In our series of patients dialysed three times a week; normalization of blood pressure was faster with lower incidence of hypertensive crises during haemodialysis and with few complications. Water and sodium excess was reduced by frequent haemodialyses and sudden changes in electrolyte, hydrostatic and other metabolic effects were minimized. Increased values of plasma renin activity were observed in a small number of patients. Ultrafiltration is insufficient for normalization of blood pressure. Hypertensive crises were frequent in these patients. Their response to medicaments such as methyldopa, beta-adrenergic blockers or other antihypertensive drugs, was good. Severe changes in blood vessels, especially in fundus oculi blood vessels were frequent in these patients. The life of hypertensive glomerulonephritis patients was especially endangered (graphs 1-6). In addition to the mentioned factors arterial hypertension during haemodialysis may also be of cardiac origin, including increase in cardiac output due to arteriovenous anastomosis, disequilibrium syndrome, changes in osmotic gradient of both extra- and intracellular spaces with resultant arteriolar wall oedema, erythrocyte amount, hypoxia, composition of dialysis fluid (sodium concentration), plasma osmotic pressure, metabolic acidosis and other factors. More recently, natriuretic hormone has also been indentified as a cause of vascular refraction. Peripherial arteriolar resistance as a cause of arterial hypertension among uremic patients must not be forgotten, because the genesis of arterial hypertension in patients with chronic renal failure is multifactorial. The highest percentage refers to volume-dependent arterial hypertension, whereas the percentage of other aetiologic factors is lower. Haemodialysis enables the normalization of blood pressure in most of hypertensive patients.

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