| Abstract | POZADINA I HIPOTEZE: Poznato je da bubrezi sudjeluju u dugoročnoj regulaciji
arterijskog tlaka, kao i da posebne bubrežne stanice luče hormon-eritropoetin, koji pospješuje
stvaranje eritrocita. Hipoteze istraživanja su: 1. kronična urinarna opstrukcija uslijed kamenca
urotrakta ometa te bubrežne funkcije, dovodeći do povišenja arterijskog tlaka i smanjenja
stvaranja eritrocita; 2. ti učinci mogu biti reverzibilni ako se bubrežni ili ureteralni kamenac
ukloni kirurški, metodom koja ne oštećuje bubrežni parenhim, ali ne i nakon izvantjelesne
litotripsije udarnim valovima (ESWL), za koju je poznato da može uzrokovati kronične
ozljede bubrežnog parenhima.
CILJ: 1. Usporediti razine eritropoetina u perifernoj krvi, te parametre crvene krvne slike
između bolesnika sa simptomatskom urolitijazom i usklađenom kontrolnom skupinom. 2.
Istražiti promjene arterijskog tlaka, bubrežnog krvožilnog otpora (BKO), razine renina i
eritropoetina u perifernoj krvi, te parametara crvene krvne slike (CKS) tri mjeseca nakon
uklanjanja urinarnih kamenaca, u dvije skupine bolesnika, jednoj podvrgnutoj parenhimpoštednoj operaciji, a drugoj ESWL metodi.
ISPITANICI: Sto trideset dva bolesnika sa simptomatskom jednostranom litijazom gornjeg
dijela urotrakta, te 333 kontrolna ispitanika usklađenih po dobi i spolu (143 bolnička i 190
izvanbolnička ispitanika, bez znakova ili povijesti bolesti za koje se zna da pogađaju
eritropoezu). Šezdeset šestoro bolesnika (37 žena i 29 muškaraca, medijan dobi 53 godine, u
rasponu 23-82 godina, prosječne veličine kamenca 2.5 cm) liječeno parenhim-poštednim
zahvatom. U drugih šezdeset šest bolesnika (33 žene i 33 muškarca, medijan dobi 51 godina,
u rasponu 21-78 godina, prosječne veličine kamenca 1.5 cm) provedena je izvantjelesna
litotripsija. U 55 (83%) bolesnika kamenac je uspješno uklonjen parenhim poštednom
operacijom, a u pedeset trojice (80%) ESWL-om. Dvadeset i četvoro bolesnika (13 otvorena
operacija, 11 ESWL) isključeno je iz istraživanja zbog rezidualnog ili recidivnog kamenca 3
mjeseca nakon zahvata.
METODE: U 29 bolesnika kamenci su uklonjeni intrasinusnom Gil-Vernetovom
pijelolitotomijom, u 14 bolesnika otvorenom ureterolitotomijom, u 12 bolesnika
ureterorenoskopijom, i u 53 bolesnika ESWL-om koji su primili od 1800-9000 udarnih valova
elektromagnetskog litotriptora. Arterijski tlakovi su mjereni u svih pacijenta
sfigmomanometrom, a u 63 bolesnika oscilometrijskom metodom i u 11 bolesnika 24-satnim
mjeračem arterijskog tlaka. Reninska aktivnost plazme i serumska koncentracija eritropoetina određeni su radioimunoesejem. Bubrežni krvožilni otpor (BKO) izračunat je iz arterijskog
tlaka i bubrežnog protoka krvi, procijenjenog pomoću radionuklidne scintigrafije bubrega i
razrjeđenja radioindikatora.
REZULTATI: Početna vrijednost BKO opstruiranog bubrega u obje skupine bolesnika bila je
dvostruko viša nego neopstruiranog bubrega. Reninska aktivnost plazme bila je gotovo
dvostruko niža u operiranih pacijenta nego u ESWL skupini. Gotovo sve početne vrijednosti
parametra CKS-e značajno bile su niže u obje skupine bolesnika nego u kontrolnoj skupini. U
operiranih bolesnika koncentracija eritropoetina bila je niža za 64% nego u kontroli. Tri
mjeseca nakon parenhim poštedne operacije sistolički arterijski tlak se smanjio za 7 mm Hg
(95% interval pouzdanosti (CI) 5-10 mm Hg), a dijastolički tlaka za 4 mm Hg (95% CI 2-7
mm Hg). U ESWL-skupini vrijednosti arterijskih tlakova ostale su nepromijenjene. BKO
opstruiranog bubrega vratio se na normalnu vrijednost u operiranih bolesnika, a nakon
ESWL-a ostao je na višoj razini. Reninska aktivnost plazme u parenhim poštednoj skupini
porasla je za 32%, a u ESWL skupini smanjila se za 26%. Koncentracija hemoglobina porasla
je za 9 g/l (95% CI 8-13 g/l), eritropoetina periferne krvi za 7 IJ/ml (95% CI 4-11 IJ/ml)
nakon parenhim poštednog zahvata, a nakon ESWL ostala nepromijenjena.
ZAKLJUČCI: Jednostrana bubrežna opstrukcija izazvana kamencem ima klinički relevantne
posljedice na arterijski tlak i crvenu krvnu sliku. Uklanjanjem opstrukcije izazvane kamencem
metodama koje ne izazivaju oštećenja bubrežnog parenhima dolazi do smanjenje arterijskog
tlaka i normaliziranja bubrežnog krvožilnog otpora, te oporavka parametra crvene krvne slike,
što se ne događa nakon izvantjelesne litotripsije udarnim valovima. |
| Abstract (english) | BACKGROUNDS AND AIMS: It is known that kidneys contribute to long-term regulation
of arterial blood pressure and that specialized renal cells secrete a hormone-erythropoietin that
up-regulates the production of red blood cells. The research hypotheses are: 1. chronic urinary
obstruction impairs both of these renal functions, leading to increased arterial blood pressure
and decreased red blood cell mass; 2. these detrimental effects can be reversed if renal or
ureteral stone is removed surgically, without collateral damage to renal parenchyma, but not
after extracorporeal shock wave lithotripsy (ESWL), which is known to likely cause the
chronic lesions of renal parenchyma.
AIMS: 1. To compare the parameters of the red blood cell count and peripheral levels of
erythropoietin between patients with symptomatic urolithiasis and matched controls. 2. To
investigate changes of the arterial blood pressure, renal vascular resistance (RVR) and
peripheral levels of rennin and erythropoietin 3 month after in two patient groups, one
subjected to parenchimal-saving open surgery, the other to ESWL.
PARTICIPANTS: 132 patients with symptomatic unilateral lithiasis of upper urinary tract and
333 sex-age adjusted control subjects (143 in-hospital and 190 outhospital patients without
signs or history of a disease known to affect the erythropoiesis). Sixty-six patients (37 women
and 29 men, aged 23-82, median 53 years, mean stone size 2.5 cm) were treated with
parenchimal saving open surgery. The other 66 patients (33 women and 33 men, aged 21-78,
median 51 years) were treated with ESWL. In 55 (83%) patients in the open surgery group
and in 53 (80%) in the ESWL group the treatments were successful. Twenty-four (13 in open
surgery and 11 ESWL group) patients were removed from the study due to residual or
recurrent stones at 3 months after treatment.
METHODS: In 29 patients the stones were removed by Gil-Vernet pyelolithotomy, in 14 by
open ureterolithotomy, in 12 by ureteronoscopy and in 53 by ESWL, receiving from 1800 to
9000 shock waves. The arterial blood pressures were measured by sphygmomanometer and in
63 patients with oscillometric device and, in 11 patients with blood pressure 24-hour device.
Plasma rennin activity and serum erythropoietin levels were assessed by radioimmunoassay.
The renal vascular resistance was assessed from measurements of arterial pressure and
radionuclide renal scintigraphy, in conjunction with measurement of radioindicator dilution.
RESULTS: The baseline values of RVR of the obstructed kidney were two times greater
when compared with non-obstructed, contralateral kidney, in both groups of patients. In operated patients the plasma rennin activity was near a half of the values obtained in ESWL
group. In both group of patients almost all of the parameters of the red blood cell count were
significantly lower than in control subjects. In operated patients the serum erythropoietin
levels were 64% lower than in controls. At 3 months after relief of obstruction in operated
patients the systolic blood pressure decreased for 7 mm Hg (95% confidence interval (CI) 5-
10 mm Hg) and the diastolic one for 4 mm Hg (95% CI 2-7 mm Hg), while in ESWL group
the arterial blood pressures were unchanged. At that time RVR of the obstructed kidney
renormalized, while in ESWL group it increased. The plasma rennin activity in operated
patients increased for 32%, while in ESWL group it decreased for 26%. In operated patients
the hemoglobin concentration increased for 9 g/l (95% CI 8-13 g/l) and erythropoietin levels
for 7 IU/ml (95% CI 4-11 IU/ml), while in ESWL group those variables were unchanged at 3
month follow-up.
CONCLUSIONS: Even unilateral renal stone obstruction has clinically relevant effects on
blood pressure and erythropoiesis. Relief of obstruction by methods without collateral lesions
to renal parenchyma leads to a chronic decrease in arterial blood pressure, renormalization of
renal vascular resistance and partial recovery of the parameters of the red blood cell count,
which does not happen if the stones are removed by extracorporeal lithotripsy. |
