Introdução: A alteração dos níveis normais de marcadores séricos e urinários ocorre na presença de dano renal associado à uropatia obstrutiva. Valores séricos e e urinários de TGF beta1 e CA 19-9 ainda não foram avaliados em modelo experimental de uropatia obstrutiva. Material e Métodos: Ratos foram divididos em sete grupos: referência, sham operation, nefrectomia unilateral, ligadura completa de ureter unilateral, obstrução parcial de ureter unilateral, obstrução parcial de ambos ureteres, nefrectomia unilateral associada à obstrução parcial do ureter contralateral. Morfometria renal e ureteral, concentrações séricas e urinárias de TGF beta1 e CA 19-9 e expressão tecidual renal de CA 19-9 foram analisadas. A correlação destes marcadores com os grupos submetidos a obstrução completa, obstrução parcial ou sem obstrução foi realizada. Resultados: Achados anatomopatológicos correlacionaram-se positivamente à intensidade da obstrução ureteral e negativamente aos níveis urinários de CA 19-9. Subexpressão acentuada do CA 19-9 foi observada em unidades renais com obstrução completa. Não foram encontradas diferenças estatisticamente significativas para os marcadores TGF beta1 urinário, TGF beta1 sérico e para o CA 19-9 sérico Conclusões: O CA 19-9 urinário correlacionou-se negativamente com o grau de obstrução ureteral. A análise imuno-histoquímica demonstrou a expressão do CA 19-9 no citoplasma das células epiteliais tubulares, sugerindo produção renal do marcador. O TGF beta1 sérico e urinário não apresentaram modificações de acordo com o grau de severidade e tempo de obstrução, o que pode estar relacionado a remodelamento renal menos intenso em resposta à uropatia obstrutiva nestes ratos / Introduction: Abnormal levels of serum and urinary markers occur in the presence of renal damage associated to obstructive uropathy. Urinary and serum TGFbeta1 and CA 19- 9 have not yet been evaluated in an experimental model of obstructive uropathy. Material and Methods: Rats were divided into seven groups: reference, sham operation, unilateral nephrectomy, complete unilateral ureteral obstruction, partial unilateral ureteral obstruction, partial bilateral ureteral obstruction, and unilateral nephrectomy with contralateral partial ureteral obstruction. Kidney and ureter morphometry, TGFbeta1 and CA 19-9 serum and urinary concentrations and CA 19-9 renal tissue expression were analysed. Correlation of these markers to complete, partial obstruction or unobstructed groups was performed. Results: Pathological findings correlated positively with the degree of ureteral obstruction, but negatively with urinary CA 19-9 levels. Marked underexpression of CA 19-9 was observed in kidneys with complete ureteral obstruction. No statistically significant differences were found for urinary and serum TGFbeta1 and also for serum CA 19-9. Conclusions: Urinary CA 19-9 correlated negatively with ureteral obstruction grade. Immunohistochemistry depicted CA 19-9 expression on epithelial tubular cells cytoplasm, suggesting renal origin. Serum and urinary TGFbeta1 did not show alterations in response to severity and length of urinary obstruction, which might be associated with less intense renal remodeling

Hydronephrosis, due to ureteropelvic junction obstruction, is a common condition in infants with an incidence of approximately 0.5-1%. During the last decade, the surgical management of non-symptomatic hydronephrosis has become more conservative, and the long-term physiological consequences of this new policy are unclear. The overall aim of this thesis was to determine whether there is a link between hydronephrosis and the development of hypertension. Hydronephrosis was induced by partial ureteral obstruction in 3-week old rats or mice. In the adult animals, blood pressure was measured telemetrically during different sodium conditions and the renal function was evaluated. Both species developed salt-sensitive hypertension and histopathological changes (i.e. fibrosis, inflammation, glomerular and tubular changes) that correlated with the degree of hydronephrosis. An abnormal renal excretion pattern with increased diuresis and impaired urine concentrating ability was observed in hydronephrosis. The mechanisms were primarily located to the diseased kidney, as relief of the obstruction attenuated blood pressure and salt-sensitivity. Increased renin angiotensin system activity, due to ureteral obstruction, might be involved in the development but not necessary the maintenance of hypertension. Hydronephrotic animals displayed reduced nitric oxide availability, which might be due to increased oxidative stress in the diseased kidney. Renal nitric oxide deficiency and subsequent resetting of the tubuloglomerular feedback mechanism, appeared to have an important role in the development of hypertension. In conclusion, experimental hydronephrosis, induced by partial ureteral obstruction, provides a new model for studies of salt-sensitive hypertension. Furthermore, the new findings imply that the current conservative treatment strategy in hydronephrosis should be reconsidered in favour of treatment that is more active, in order to prevent the development of renal injury and hypertension in later life.

Σκοπος της μελέτης είναι να συγκρίνει τις απλές μεταλλικές ενδοπροθέσεις (stents) με τις εσωτερικά και εξωτερικά επικαλυπτόμενες μεταλλικές ενδοπροθέσεις σε πειραματόζωο χοίρο. Τοποθετήθηκαν μεταλλικά stents σε 9 θηλυκούς χοίρους που ζύγιζαν 25-30 κιλά. Τοποθετήθηκαν stent σε 18 ουρητήρες είτε στον δεξιό είτε στον αριστερό ουρητήρα. Σε έξι ουρητήρες τοποθεητήθηκε ενδοπρόθεση Wallstent (Schneider,Zurich,Switzerland)σε έξι τοποθετήθηκε Passager stent (Βoston Scientific, Natick,MA,USA)και σε έξι Corvita endoluminal graft- CEG(Boston Scientific, Natick, MA, USA). Εγινε έλεγχος της βατότητας με νεφροστομογραφία 24ώρες και 21ημέρες μετά την τοποθέτηση. Σε τεσσερεις περιπτώσεις το Passager stent μετανάστευσε στην ουροδόχο κύστη με αποτέλεσμα την ουρητηρική απόφραξη. Σε όλες τις άλλες περιπτώσεις η ροή των ούρων ήταν φυσιολογική. Το Wallstent stent προκάλεσε ήπια φλεγμονώδη αντίδραση και μεταπλασία του ουροθηλίου; Το CEG stent πιο έντονη αντίδραση και τέλος την πίο έντονη φλεγμονώδη αντίδραση προκάλεσε το Passager stent με συνοδό νέκρωση του ουροθηλίου. Τα επικαλλυμένα stents δεν εμφάνισαν ουροθηλιακή υπερπλασία στην έσω επιφάνεια του stent. Τα πειραματικά αποτελέσματα δείχνουν ότι το απλό Wallstent stent προκαλεί λιγότερη φλεγμονώδη αντίδραση των παρακείμενων ιστών σε σύγκριση με τα επικαλλυμένα stents. Απο την αλλη πλευρά τα επικαλυπτόμενα stents περιορίζουν σημaντικά την ουροθηλιακή υπερπλασία αλλα έχουν την τάση να μεταναστεύουν προς την ουροδόχο κύστη. / We report out experience with the use of metallic self expandable and balloon expandable stents for the treatment of malignant ureteral obstruction. We treated 12 consecutive patients with malignant ureteral obstruction, for a total of 14 ureters with stents placed. We placed metallic balloon exspandable stents in 6 patients and self-expandable metallic stents in the remaining 6. mean patient age was 65 years and mean followup was 9 months.(range 8 to 16). Of the ureters 11 were patent without any additional manipulations during the followup of 8 to 16 months. Secondary interventions were needed in 3 cases because of obstructive urothelial hyperplastic reaction,tumor ingrowth and local recurrence of the primary cancer invading the upper end of the stent. Two patients died 2 and 10 months after placement of the stent. Both types of metal stents have advantages and disadvantages that must be balanced against each other when choosing the ideal device for the treatment of obstruction. Implantation of a metal self-expanding or balloon expanding stent is safe and effective for the palliative treatment of malignant ureteral obstruction in late stage cancer patient.

As células intersticiais de Cajal (CIC) têm sido estudadas como participante do peristaltismo em vários sistemas. Sua presença no trato geniturinário pode sustentar a importância dessas células na fisiopatologia da estenose da junção ureteropielica (JUP). O Objetivo desse estudo foi avaliar a densidade das CIC em pacientes adultos e no final da adolescência, portadores de estenose da JUP, submetidos à pieloplastia e verificar se há associação entre a densidade das CIC com os achados clínicos e de imagem pré e pós-operatórios, notadamente ultrassonografia e cintilografia renal. Foram estudados 23 pacientes com estenose da JUP, submetidos à pieloplastia desmembrada pela técnica videolaparoscópica na Divisão de Clínica Urológica do Departamento de Cirurgia do HCFMUSP, de forma consecutiva, pelo mesmo grupo de cirurgiões, no período entre fevereiro de 2011 a janeiro de 2012. Foi realizada análise imunohistoquímica para expressão do receptor de tirosina quinase (c-KIT) em todas as amostras das JUP e quantificada a densidade das CIC. Os pacientes foram acompanhados periodicamente para avaliação da resposta clínica e dos exames de imagem. Foi encontrado que a média de idade da amostra foi de 34,83 anos. Houve predomínio do gênero masculino (56,5%). O rim direito foi o mais acometido (56,5%). A hidronefrose grave foi identificada na maioria dos pacientes (52,2%). A média da função renal do rim acometido estimada pela cintilografia, pré e pós-operatória foi de respectivamente, 33,7 e 33,4%. Dos 23 pacientes, 20 apresentaram melhora do padrão cintilográfico de drenagem ureteral. Houve predomínio de pacientes que apresentavam alta densidade das CIC (52,2%). Houve significância estatística quando associado a densidade das CIC e a melhora do padrão ultrassonográfico (p= 0,032). Contudo, não houve associação entre a densidade das CIC e as outras variáveis clínicas ou de imagem. Pode-se concluir que a densidade das CIC pode ser um bom preditor da resposta ultrassonográfica pósoperatória em pacientes adultos com estenose da JUP submetidos à pieloplastia / The interstitial cells of Cajal (ICC) have been studied as peristalsis participating in various systems. Its presence in the genitourinary tract can sustain the importance of these cells in the pathophysiology of ureteropelvic junction obstruction (UPJO). The aim of this study was to evaluate the density of ICC in adults and in the late adolescence patients with UPJO, undergoing pyeloplasty and to check if there is association of changes in the ICC density with clinical findings, as well as pre and postoperative images, especially ultrasound and diuretic radioisotope renography. We selected 23 patients with UPJO, undergoing laparocopic dismembered pyeloplasty in the Urology Division of the HC-FMUSP Department of Surgery, consecutively, by the same group of surgeons in the period between February 2011 and January 2012. It was performed immunohistochemical analysis for tyrosine kinase receptor expression (c-KIT) in all samples of UPJO quantified the ICC density. The patients were followed up periodically to evaluate the clinical response and imaging. The average age of the sample was 34.83 years. There was a predominance of males (56.5%). The right kidney was the most affected (56.5%). Severe hydronephrosis was identified in most patients (52.2%). The average renal function affected estimated by diuretic radioisotope renography, pre and post-operative was respectively 33.7 and 33.4%. Of the 23 patients, 20 had an improvement on diuretic radioisotope renography pattern of ureteral drainage. There was a predominance of patients with high ICC density (52.2%). There was statistical significance when associated with ICC density and the improvement of ultrasonographic pattern (p = 0.032). However, there was no association between the ICC density and other clinical or imaging variables. It can be concluded that the density of the ICC maybe a good predictor of post-operative ultrasound response in adult patients with UPJO undergoing pyeloplasty

Introdução e Objetivo: Hidronefrose e Obstrução são condições associadas, entretanto dilatações da via excretora podem ocorrer na ausência de obstruções clinicamente importantes. Ultra-sonografia convencional e Renograma com Diuréticos são os métodos diagnósticos complementares mais utilizados na avaliação das hidronefroses na infância. Recentes trabalhos têm demonstrado a possibilidade de observarmos os jatos ureterais com o Estudo Ultra-sonográfico com Doppler Colorido e sugerido a sua aplicação no diagnóstico diferencial das hidronefroses. O objetivo do presente trabalho foi avaliar a aplicabilidade do estudo dos jatos ureterais como método diagnóstico na identificação das hidronefroses obstrutivas e não obstrutivas na população pediátrica. Métodos: Foram estudadas 48 crianças (35 meninos e 13 meninas) com idade que variou de um mês a 14 anos (mediana de 4 anos), que se apresentaram com Hidronefroses Unilaterais, Graus III e IV, e com suspeita de obstrução da junção pieloureteral. Todos os sujeitos foram submetidos ao Estudo dos jatos ureterais e ao Renograma com Diuréticos num período de duas semanas. As unidades hidronefróticas foram consideradas obstruídas quando a Função Renal Diferencial era menor do que 40%, ou em indivíduos mais velhos que apresentavam dor lombar intermitente. Os jatos ureterais de cada meato foram contados por um período de 5 minutos e considerados separadamente. Freqüência Relativa dos Jatos (FRJ) foi definida como o numero de jatos ureterais no lado afetado dividido pela soma dos jatos ureterais observados bilateralmente. Resultados: Vinte e duas (45,8%) unidades hidronefróticas foram consideradas obstruídas.A média da FRJ diferiu significativamente entre as hidronefroses obstrutivas (0,09 ± 0,15) e não obstrutivas (0,41 ± 0,11). (p<0.001). Análise da Curva ROC revelou que FRJ < 0,25 é o melhor valor que distingue as hidronefroses obstrutivas e não obstrutivas e o faz corretamente em 91,2 % dos casos, com uma Sensibilidade de 86,4% (IC95%=78,6-98,2%) e Especificidade de of 96.15% (IC95%=87.8-99%). O Índice de Probabilidade Positivo foi de 22,45 e a Razão de Chances Diagnóstica de 158,3. A área sob a curva ROC foi de 0,91 (IC95%=0,86-0,98) indicando a excelente acurácia do método. Conclusões: FRJ < 25 % mostrou ser um bom indicador de obstrução nas hidronefroses unilaterais da infância. O estudo dos jatos ureterais a Ultrasonografia com Doppler Colorido é método simples, não invasivo e pode ser utilizado na abordagem inicial e no seguimento, na diferenciação das hidronefroses obstrutivas e não obstrutivas na população pediátrica / Introduction and Objective: Hydronephrosis (HN) and obstruction are closely associated, but upper urinary tract dilatation can occur without significant obstruction. Despite some pitfalls, conventional ultrasonography and diuretic renography (DR) are the main modalities in the evaluation of HN in children. Recent reports have demonstrated the usefulness of Color Doppler Ultrasonography (CDUS) as a reliable method to identify the ureteric jets (UJ) in the bladder. The aim of this study was to evaluate CDUS evaluation of the UJ in the bladder as a diagnostic tool to distinguish obstructive from non-obstructive dilatations of the upper tract in pediatric population. Methods: We evaluated 48 patients (35 boys and 13 girls), aged 1 month to 14 years (median = 4 ys.), who presented with unilateral grade III and IV hydronephrosis suspicious of pyeloureteral junction obstruction. All patients underwent DR and evaluation of UJ by transverse CDSG of the bladder within a maximum of 2 weeks. Obstruction was considered in the DR when the hydronephrotic unit showed Differential Renal Function of less than 40%, or when symptomatic intermittent renal colic was present in older children. The number of UJ was counted over a 5 min period and its frequency was calculated for each ureteral orifice. Relative Jet Frequency (RJF) was defined as the UJ frequency of hydronephrotic side divided by total UJ frequency. Receiver-Operating Characteristic (ROC) plots were constructed to determine the best cuttoff for RJF, in order to identify renal units with obstructive hydronephrosis. Results:Twenty-two(45.8%) hydronephrotic units were considered obstructed. The mean RJF differed significantly between obstructive (0.09 ± 0,15) and non-obstructive hydronephrosis (0.41± 0.11)(p<0.001). ROC analysis revealed that RJF< 0.25 was the best threshold and it correctly discriminates obstruction in 91.2% of the childrens with a sensitivity of 86.4% (95%CI=78.6-98.2%) and specificity of 96.15% (95%CI=87,8-99%). The Positive Likelihood Ratio was 22.45 and Diagnostic Odds Ratio was 158.3.The area under the ROC curve was 0.91 (95%CI=0.86-0.98), indicating excellent discrimination power. Conclusions: In this study RJF < 25% was found to be a good indicator of obstruction in children with unilateral hydronephrosis. CDUS evaluation of UJ is an easy and non-invasive method that can be used as an initial diagnostic tool and in follow-up cases, to differentiate obstructed from non-obstructed hydronephrosis in the pediatric population

Introdução: A alteração dos níveis normais de marcadores séricos e urinários ocorre na presença de dano renal associado à uropatia obstrutiva. Valores séricos e e urinários de TGF beta1 e CA 19-9 ainda não foram avaliados em modelo experimental de uropatia obstrutiva. Material e Métodos: Ratos foram divididos em sete grupos: referência, sham operation, nefrectomia unilateral, ligadura completa de ureter unilateral, obstrução parcial de ureter unilateral, obstrução parcial de ambos ureteres, nefrectomia unilateral associada à obstrução parcial do ureter contralateral. Morfometria renal e ureteral, concentrações séricas e urinárias de TGF beta1 e CA 19-9 e expressão tecidual renal de CA 19-9 foram analisadas. A correlação destes marcadores com os grupos submetidos a obstrução completa, obstrução parcial ou sem obstrução foi realizada. Resultados: Achados anatomopatológicos correlacionaram-se positivamente à intensidade da obstrução ureteral e negativamente aos níveis urinários de CA 19-9. Subexpressão acentuada do CA 19-9 foi observada em unidades renais com obstrução completa. Não foram encontradas diferenças estatisticamente significativas para os marcadores TGF beta1 urinário, TGF beta1 sérico e para o CA 19-9 sérico Conclusões: O CA 19-9 urinário correlacionou-se negativamente com o grau de obstrução ureteral. A análise imuno-histoquímica demonstrou a expressão do CA 19-9 no citoplasma das células epiteliais tubulares, sugerindo produção renal do marcador. O TGF beta1 sérico e urinário não apresentaram modificações de acordo com o grau de severidade e tempo de obstrução, o que pode estar relacionado a remodelamento renal menos intenso em resposta à uropatia obstrutiva nestes ratos / Introduction: Abnormal levels of serum and urinary markers occur in the presence of renal damage associated to obstructive uropathy. Urinary and serum TGFbeta1 and CA 19- 9 have not yet been evaluated in an experimental model of obstructive uropathy. Material and Methods: Rats were divided into seven groups: reference, sham operation, unilateral nephrectomy, complete unilateral ureteral obstruction, partial unilateral ureteral obstruction, partial bilateral ureteral obstruction, and unilateral nephrectomy with contralateral partial ureteral obstruction. Kidney and ureter morphometry, TGFbeta1 and CA 19-9 serum and urinary concentrations and CA 19-9 renal tissue expression were analysed. Correlation of these markers to complete, partial obstruction or unobstructed groups was performed. Results: Pathological findings correlated positively with the degree of ureteral obstruction, but negatively with urinary CA 19-9 levels. Marked underexpression of CA 19-9 was observed in kidneys with complete ureteral obstruction. No statistically significant differences were found for urinary and serum TGFbeta1 and also for serum CA 19-9. Conclusions: Urinary CA 19-9 correlated negatively with ureteral obstruction grade. Immunohistochemistry depicted CA 19-9 expression on epithelial tubular cells cytoplasm, suggesting renal origin. Serum and urinary TGFbeta1 did not show alterations in response to severity and length of urinary obstruction, which might be associated with less intense renal remodeling

INTRODUÇÃO E OBJETIVO: A estenose de junção ureteropélvica (EJUP) é importante causa de obstrução do trato urinário e pode levar a deterioração progressiva da função renal. Há espaço para o aprimoramento de novos métodos diagnósticos capazes de discriminar hidronefrose e uropatia obstrutiva. Acredita-se que os biomarcadores urinários podem fornecer indícios de lesão renal precoce na obstrução urinária. Neste contexto, KIM-1 pode elevar-se na urina por lesão tubular proximal, NGAL por lesão no túbulo proximal, distal ou alça de Henle, CA19-9 por produção excessiva no túbulo obstruído e ?2-microglobulina (beta2M) por injúria ao glomérulo ou ao túbulo proximal. O objetivo do presente estudo foi avaliar as propriedades diagnósticas dos biomarcadores urinários citados em adultos com EJUP, sendo o primeiro estudo na literatura a avaliar tais moléculas nesta população. MÉTODOS: Foram estudados de modo prospectivo pacientes consecutivos acima de 18 anos com diagnóstico de EJUP submetidos a pieloplastia videolaparoscópica de dezembro de 2013 a fevereiro de 2015. Foram excluídos do estudo pacientes com EJUP bilateral, rim contralateral patológico, EJUP em rim único, antecedentes de tratamento cirúrgico para estenose de JUP ou taxa de filtração glomerular inferior a 60 ml/min/1,73m2. Cada paciente forneceu quatro amostras de urina para medição de biomarcadores, uma no pré-operatório e outras com 1, 3 e 6 meses de seguimento pós-operatório. O grupo controle foi constituído por voluntários saudáveis sem hidronefrose à ultrassonografia. RESULTADOS: Foram incluídos 47 pacientes com idade média de 38,6 ± 12,7 anos (intervalo 19 a 64 anos), sendo 17 (36,2%) do sexo masculino e 30 (62,8%) do sexo feminino. O grupo controle foi composto por 40 indivíduos semelhantes ao grupo com EJUP no que concerne idade (p = 0,95) e sexo (p = 0,82). KIM-1 foi o marcador com melhores propriedades diagnósticas, apresentando área sob a curva (AUC) de 0,79 (95% CI 0,70 a 0,89). O NGAL, por sua vez, teve AUC de 0,71 (95% CI 0,61 a 0,83), CA19- 9 teve AUC de 0,70 (95% CI 0,60 a 0,81) e (beta2M) apresentou AUC de 0,61 (95% CI 0,50 a 0,73), sendo o único biomarcador com propriedades inadequadas neste cenário. O KIM-1 foi o marcador mais sensível com o ponto de corte 170,4 pg/mg de creatinina (sensibilidade 91,4%, especificidade 59,1%) e o CA 19-9 o mais específico para o ponto de corte de 51,3 U/mg de creatinina (sensibilidade 48,9%, especificidade 88,0%), enquanto o NGAL foi o que apresentou maior queda após desobstrução, com 90,0% dos pacientes apresentando clareamento superior a 50%. CONCLUSÕES: A avaliação dos biomarcadores urinários é útil no diagnóstico de obstrução em adultos com EJUP submetidos a pieloplastia videolaparoscópica. O KIM-1 foi o marcador mais sensível e o CA 19-9 o mais específico, enquanto o NGAL foi o que apresentou maior que com a desobstrução. Houve queda das concentrações dos marcadores após pieloplastia no período estudado. O papel exato dos biomarcadores urinários no cenário de obstrução em adultos deve ser mais amplamente investigado / INTRODUCTION AND OBJECTIVE: Ureteropelvic junction obstruction (UPJO) is an important cause of urinary tract obstruction and can lead to progressive deterioration of renal function. Thus the development of novel non-invasive methods capable of discriminating obstruction and hydronephrosis may be useful. Elevation of urinary biomarkers may provide early evidence of kidney damage in urinary obstruction. In this scenario, urinary concentrations of KIM-1 may be elevated following proximal tubular injury, while NGAL may increase as result of injury to proximal or distal tubule as well as to loop of Henle, CA19-9 after overproduction in the obstructed tubule and ?2 microglobulin (beta2M) after injury to the glomerulus or the proximal tubule. The aim of this study was to evaluate the diagnostic properties of these urinary biomarkers in adults with UPJO. METHODS: We prospectively studied consecutive patients older than 18 years diagnosed with UPJO undergoing laparoscopic pyeloplasty from December 2013 to February 2015 in our institution. Exclusion criteria included patients with bilateral UPJO, unilateral UPJO with contralateral pathologic kidney, solitary kidney, history of previous surgical treatment for UPJO or glomerular filtration rate below 60 ml/min/1,73m2. Each patient provided four voided urine samples for biomarker measurement, one at preoperative consultation and the others at 1, 3 and 6 months of postoperative follow-up. Healthy individuals with no hydronephrosis on ultrasound evaluation constituted our control group. RESULTS: We included 47 patients with a mean age of 38.6 ± 12.7 years (range 19-64 years), from which 17 (36.2%) were males and 30 (62.8%) were females. The control group consisted of 40 subjects with no statistical difference to the study group regarding age (p = 0.95) and gender (p = 0.82). KIM-1 had an area under the curve (AUC) of 0.79 (95% CI 0.70 to 0.89) and was the biomarker with the best diagnostic properties. CA19-9 had an AUC of 0.70 (95% CI 0.60 to 0.81), NGAL had an AUC of 0.71 (95% CI 0.61 to 0.83) and beta2M had an AUC of 0.61 (95% CI 0.50 to 0.73). KIM-1 was the most sensitive marker with a cutoff of 170.4 pg/mg creatinine (sensitivity 91.4%, specificity 59.1%) whereas CA 19-9 as the most specific one, displaying a cutoff of 51.3 U/mg creatinine (sensitivity 48.9%, specificity 88.0%). NGAL showed the greatest decrease in urinary concentrations after pyeloplasty, in which 90.0% of patients had a clearance greater than 50% in comparison to preoperative values. CONCLUSIONS: The evaluation of urinary biomarkers is useful in the assessment of UPJO in adults undergoing laparoscopic pyeloplasty. Urinary concentrations of CA 19-9, NGAL and KIM-1 were elevated in patients with UPJO and significantly decreased after pyeloplasty. The exact role of those biomarkers in the setting of obstruction in adults should be further evaluated

INTRODUÇÃO E OBJETIVO: A estenose de junção ureteropélvica (EJUP) é importante causa de obstrução do trato urinário e pode levar a deterioração progressiva da função renal. Há espaço para o aprimoramento de novos métodos diagnósticos capazes de discriminar hidronefrose e uropatia obstrutiva. Acredita-se que os biomarcadores urinários podem fornecer indícios de lesão renal precoce na obstrução urinária. Neste contexto, KIM-1 pode elevar-se na urina por lesão tubular proximal, NGAL por lesão no túbulo proximal, distal ou alça de Henle, CA19-9 por produção excessiva no túbulo obstruído e ?2-microglobulina (beta2M) por injúria ao glomérulo ou ao túbulo proximal. O objetivo do presente estudo foi avaliar as propriedades diagnósticas dos biomarcadores urinários citados em adultos com EJUP, sendo o primeiro estudo na literatura a avaliar tais moléculas nesta população. MÉTODOS: Foram estudados de modo prospectivo pacientes consecutivos acima de 18 anos com diagnóstico de EJUP submetidos a pieloplastia videolaparoscópica de dezembro de 2013 a fevereiro de 2015. Foram excluídos do estudo pacientes com EJUP bilateral, rim contralateral patológico, EJUP em rim único, antecedentes de tratamento cirúrgico para estenose de JUP ou taxa de filtração glomerular inferior a 60 ml/min/1,73m2. Cada paciente forneceu quatro amostras de urina para medição de biomarcadores, uma no pré-operatório e outras com 1, 3 e 6 meses de seguimento pós-operatório. O grupo controle foi constituído por voluntários saudáveis sem hidronefrose à ultrassonografia. RESULTADOS: Foram incluídos 47 pacientes com idade média de 38,6 ± 12,7 anos (intervalo 19 a 64 anos), sendo 17 (36,2%) do sexo masculino e 30 (62,8%) do sexo feminino. O grupo controle foi composto por 40 indivíduos semelhantes ao grupo com EJUP no que concerne idade (p = 0,95) e sexo (p = 0,82). KIM-1 foi o marcador com melhores propriedades diagnósticas, apresentando área sob a curva (AUC) de 0,79 (95% CI 0,70 a 0,89). O NGAL, por sua vez, teve AUC de 0,71 (95% CI 0,61 a 0,83), CA19- 9 teve AUC de 0,70 (95% CI 0,60 a 0,81) e (beta2M) apresentou AUC de 0,61 (95% CI 0,50 a 0,73), sendo o único biomarcador com propriedades inadequadas neste cenário. O KIM-1 foi o marcador mais sensível com o ponto de corte 170,4 pg/mg de creatinina (sensibilidade 91,4%, especificidade 59,1%) e o CA 19-9 o mais específico para o ponto de corte de 51,3 U/mg de creatinina (sensibilidade 48,9%, especificidade 88,0%), enquanto o NGAL foi o que apresentou maior queda após desobstrução, com 90,0% dos pacientes apresentando clareamento superior a 50%. CONCLUSÕES: A avaliação dos biomarcadores urinários é útil no diagnóstico de obstrução em adultos com EJUP submetidos a pieloplastia videolaparoscópica. O KIM-1 foi o marcador mais sensível e o CA 19-9 o mais específico, enquanto o NGAL foi o que apresentou maior que com a desobstrução. Houve queda das concentrações dos marcadores após pieloplastia no período estudado. O papel exato dos biomarcadores urinários no cenário de obstrução em adultos deve ser mais amplamente investigado / INTRODUCTION AND OBJECTIVE: Ureteropelvic junction obstruction (UPJO) is an important cause of urinary tract obstruction and can lead to progressive deterioration of renal function. Thus the development of novel non-invasive methods capable of discriminating obstruction and hydronephrosis may be useful. Elevation of urinary biomarkers may provide early evidence of kidney damage in urinary obstruction. In this scenario, urinary concentrations of KIM-1 may be elevated following proximal tubular injury, while NGAL may increase as result of injury to proximal or distal tubule as well as to loop of Henle, CA19-9 after overproduction in the obstructed tubule and ?2 microglobulin (beta2M) after injury to the glomerulus or the proximal tubule. The aim of this study was to evaluate the diagnostic properties of these urinary biomarkers in adults with UPJO. METHODS: We prospectively studied consecutive patients older than 18 years diagnosed with UPJO undergoing laparoscopic pyeloplasty from December 2013 to February 2015 in our institution. Exclusion criteria included patients with bilateral UPJO, unilateral UPJO with contralateral pathologic kidney, solitary kidney, history of previous surgical treatment for UPJO or glomerular filtration rate below 60 ml/min/1,73m2. Each patient provided four voided urine samples for biomarker measurement, one at preoperative consultation and the others at 1, 3 and 6 months of postoperative follow-up. Healthy individuals with no hydronephrosis on ultrasound evaluation constituted our control group. RESULTS: We included 47 patients with a mean age of 38.6 ± 12.7 years (range 19-64 years), from which 17 (36.2%) were males and 30 (62.8%) were females. The control group consisted of 40 subjects with no statistical difference to the study group regarding age (p = 0.95) and gender (p = 0.82). KIM-1 had an area under the curve (AUC) of 0.79 (95% CI 0.70 to 0.89) and was the biomarker with the best diagnostic properties. CA19-9 had an AUC of 0.70 (95% CI 0.60 to 0.81), NGAL had an AUC of 0.71 (95% CI 0.61 to 0.83) and beta2M had an AUC of 0.61 (95% CI 0.50 to 0.73). KIM-1 was the most sensitive marker with a cutoff of 170.4 pg/mg creatinine (sensitivity 91.4%, specificity 59.1%) whereas CA 19-9 as the most specific one, displaying a cutoff of 51.3 U/mg creatinine (sensitivity 48.9%, specificity 88.0%). NGAL showed the greatest decrease in urinary concentrations after pyeloplasty, in which 90.0% of patients had a clearance greater than 50% in comparison to preoperative values. CONCLUSIONS: The evaluation of urinary biomarkers is useful in the assessment of UPJO in adults undergoing laparoscopic pyeloplasty. Urinary concentrations of CA 19-9, NGAL and KIM-1 were elevated in patients with UPJO and significantly decreased after pyeloplasty. The exact role of those biomarkers in the setting of obstruction in adults should be further evaluated

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-07-18T17:29:53Z No. of bitstreams: 1 fabianaaparecidamayrinkdeoliveira.pdf: 602450 bytes, checksum: 44abccc7edd994e7c93876d1aac063dd (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-07-22T15:11:02Z (GMT) No. of bitstreams: 1 fabianaaparecidamayrinkdeoliveira.pdf: 602450 bytes, checksum: 44abccc7edd994e7c93876d1aac063dd (MD5) / Made available in DSpace on 2016-07-22T15:11:02Z (GMT). No. of bitstreams: 1 fabianaaparecidamayrinkdeoliveira.pdf: 602450 bytes, checksum: 44abccc7edd994e7c93876d1aac063dd (MD5) Previous issue date: 2011-02-24 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / FAPEMIG - Fundação de Amparo à Pesquisa do Estado de Minas Gerais / Justificativa e Objetivo: Independente da etiologia, a doença renal crônica (DRC) envolve fibrose generalizada e progressiva do tecido, atrofia tubular e a perda da função renal. Atualmente, as terapias eficazes para esta condição são escassas. Neste estudo, foram investigados os efeitos da terapia laser de baixa intensidade (LLLT) sobre a fibrose intersticial, que ocorre após obstrução ureteral unilateral (OUU) em ratos, um modelo experimental de doença renal crônica. Materiais e Métodos: Foram utilizados 32 ratos Wistar, 8 em cada grupo, machos, com 250 a 300g de peso aproximadamente e 8 semanas de idade. O rim obstruído de metade dos ratos, submetidos à OUU receberam dose única intra-operatória do LLLT (AlGaAs laser, 780 nm, 22,5 J / cm ², 30 mW, 30 segundos em cada um dos nove pontos). Após 14 dias, a fibrose renal foi avaliada pela coloração por picrosírius e medição da área transversal sob luz polarizada. Análise imunohistoquímica quantificou células do tecido renal que expressam marcadores de fibroblastos (FSP-1) e miofibroblastos (α-SMA). RT-PCR foi realizado para determinar a expressão de mRNA de genes chaves relacionados com a fibrose: TGF-β1, Smad3 e colágeno I (Col I). Resultados: No grupo OUU e tratado pelo LLLT os animais apresentaram menos fibrose renal do que os animais obstruídos (OUU). α-SMA, TGF-β1 e Smad3 foram aumentados no interstício renal de ratos OUU. LLLT reduziu a expressão de todas essas moléculas. LLLT não parece ter um efeito significativo no Col I ou FSP-1, que também foram induzidos por OUU. Conclusão: Pela primeira vez, nós mostramos que LLLT tem um efeito protetor em relação à fibrose intersticial renal. Entende-se que, atenuando a inflamação, a laserterapia pode impedir a ativação tubular e transdiferenciação, que são os dois processos principais que formam a fibrose renal no modelo OUU. / Background and Objective: Regardless of the etiology, chronic kidney disease (CKD) involves progressive widespread tissue fibrosis, tubular atrophy and loss of kidney function. At present, effective therapies to this condition are lacking. We investigated the effects of low level laser therapy (LLLT) on the interstitial fibrosis that occurs after unilateral ureteral obstruction (UUO) in rats, an experimental model of CKD. Study Design/Materials and Methods: We used 32 Wistar rats, 8 in each group, males, 250 to 300g weight and 8 weeks old. The occluded kidney of half of the Wistar rats that underwent UUO received a single intraoperative dose of LLLT (AlGaAs laser, 780 nm, 22.5 J/cm², 30 mW, 30 seconds on each of nine points). After 14 days, renal fibrosis was assessed by Sirius red staining and measurement of the cross-sectional area under polarized light. Immunohistochemical analyses quantitated the renal tissue cells that expressed fibroblast (FSP-1) and myofibroblast (α-SMA) markers. RT-PCR was performed to determine the mRNA expression of key fibrosis-related genes, namely TGF-β1, Smad3 and collagen I (Col I). Results: The UUO-LLLT animals had less severe renal fibrosis than OUU animals. α- SMA, TGF-β1 and Smad3 were increased in the renal interstitium of UUO rats. LLLT reduced the expression of all of these molecules. LLLT did not appear to have a significant effect on Col I or FSP-1, which were also induced by UUO. Conclusion: For the first time, we showed LLLT had a protective effect regarding renal interstitial fibrosis. It is conceivable that by attenuating inflammation, LLLT can prevent tubular activation and transdifferentiation, which are the two processes that mainly drive the renal fibrosis of the UUO model.

Les proteins matricellulaires (MPs) sont des macromolécules non structurales de la matrice extracellulaire (ECM) qui sont induites de façon transitoire lors du développement, de la réparation et du remodelage tissulaire et lors de l’inflammation. L’expression des MPs peut être déclenchée par des dommages tissulaires aigus, et leur expression à long terme peut contribuer à certaines maladies chroniques. Les MPs agissent principalement pour médier les événements du remodelage tissulaire en facilitant les interactions et les signaux à partir de l’ECM vers l’environnement cellulaire avoisinant. En utilisant des données de RNA-seq provenant de deux modèles distincts de dommages rénaux, soit l’Acide Folique (FA) ou l’Obstruction Urétérale Unilatérale (UUO), nous avons analysé les profils d’expressions de plusieurs familles bien connues de MPs lors des blessures aigues et chroniques. Nous révélons de nouvelles MPs impliquées dans les dommages rénaux et présentons de nouveaux réseaux entre les membres de chaque famille de MPs, en utilisant des outils bioinformatiques. L’expression de l’ARNm de certaines MPs a été confirmée par immuno-buvardage de type Western (WB). Afin d’approfondir notre connaissance des mécanismes de réparation tissulaire et de remodelage de la matrice, nous avons choisi SMOC-2 comme MP modèle dans l’étude des carcinomes cellulaires rénaux (RCC), cancers qui présentent de fortes tendances métastatiques. Nous avons démontré que la surexpression de SMOC-2 ainsi que le traitement avec la protéine recombinante de lignées cellulaires RCC (786-O, et ACHN) induisent un profil métastatique de transition épithélio-mésenchymateuse (EMT) par WB et des tests fonctionnels. Nous avons également démontré que l’inhibition de SMOC-2 par siRNA donne les résultats opposés. L’ensemble de nos travaux utilise la compréhension des patrons d’expressions temporels des MPs pour améliorer notre compréhension des mécanismes et conditions qui supportent une activation persistante dans des états pathologiques chroniques. Globalement, notre étude sur SMOC-2 offre une perspective ainsi qu’un modèle intéressant pour l’étude et la caractérisation de nouvelles MPs dans des maladies impliquant le remodelage et la réparation de la matrice. / Matricellular proteins (MPs) are non-structural ECM macromolecules induced transiently during development, tissue repair and remodeling, and inflammation. Expression of MPs can be triggered by acute tissue injury and their sustained expression can contribute to chronic disease. MPs primarily act to mediate tissue remodeling events by facilitating interactions and signals from the ECM to the surrounding cellular niche. Using published RNA-seq data from two distinct models of kidney injury, Folic Acid (FA) and Unilateral Ureteral Obstruction (UUO), we analyzed the expression profile of various members of well-known MP families during the acute and fibrotic injury phases. We reveal novel MPs implicated in renal injury and present informative networks between members of each MP family using bioinformatic tools. mRNA expression of select candidate MPs were confirmed by Western blot. To extend our understanding of translatable mechanisms in repair and matrix remodeling, we chose SMOC-2 as our MP model to study in Renal Cell Carcinoma (RCC) which has strong metastatic tendencies. SMOC-2 overexpression and recombinant protein treatment of RCC cell lines (786-O, ACHN) were shown to induce a metastatic EMT profile by Western blot analysis, supported by functional assays (proliferation, migration). Silencing SMOC-2 by siRNA showed the contrary results. Taken together, our work utilizes the understanding of temporal expression patterns of MPs to gain insight into mechanisms and conditions that support persistent activation in chronic injury states. Overall, our work with SMOC-2 provides a valuable perspective and template to approach studying and characterizing novel MPs in diseases involving pathological matrix remodeling and repair.