Dynamics of Capillaria-hepatica-induced hepatic septal fibrosis in rats

INTRODUCTION: The pathogenesis of septal hepatic fibrosis, induced in rats by Capillaria hepatica infection, was studied with the aid of a large collection of stored paraffin blocks, representative of the different evolutive phases of fibrosis which appeared in 100% of infected rats. METHODS: Studies were conducted involving histology, immunohistochemistry, immunofluorescence and morphometric methods, in order to observe the dynamic behavior of the cellular and matrix components of fibrosis, over a one year period of evolution. RESULTS: Observation verified that septal fibrosis originates from several portal spaces simultaneously. Its origin and progression involve blood vessel proliferation (angiogenesis), multiplication of actin-positive cells (pericytes and myofibroblasts) and progressive collagen deposition. By the end of 4-5 months, a progressive decrease in all these components was observed, when signs of regression of septal fibrosis became more evident over time. CONCLUSIONS: Besides indicating the fundamental role played by angiogenesis in the pathogenesis of fibrosis, these morphological data concerning the dynamics of this C. hepatica experimental model proved to be adequate for future investigations regarding the functional aspects of fibrosis induction, progression and regression.

Endomyocardial fibrosis associated with mansoni schistosomiasis

Endomyocardial fibrosis (EMF) is a neglected tropical disease that affects millions of people worldwide. EMF is the most common cause of restrictive cardiomyopathy, caused by deposition of fibrous tissue on endocardial surfaces. EMF is a major cause of death in areas where it is endemic, but the pathogenesis of the disease is poorly understood. Schistosomiasis mansoni is a parasitic disease endemic in Brazil, where EMF has also been described. The association between EMF and schistosomiasis has been suggested in various publications, seeking a possible correlation between endocardial and periportal fibroses. This report describes a case of EMF associated with schistosomiasis.

Liver fibrosis progression in HIV/hepatitis C virus coinfected patients with normal aminotransferases levels

INTRODUCTION: Approximately 30% of hepatitis C virus (HCV) monoinfected patients present persistently normal alanine aminotransferase (ALT) levels. Most of these patients have a slow progression of liver fibrosis. Studies have demonstrated the rate of liver fibrosis progression in hepatitis C virus-human immunodeficiency virus (HCV-HIV) coinfected patients is faster than in patients infected only by HCV. Few studies have evaluated the histological features of chronic hepatitis C in HIV-infected patients with normal ALT levels. METHODS: HCV-HIV coinfected patients (HCV-RNA and anti-HIV positive) with known time of HCV infection (intravenous drugs users) were selected. Patients with hepatitis B surface antigen (HBsAg) positive or hepatitis C treatment before liver biopsy were excluded. Patients were considered to have a normal ALT levels if they had at least 3 normal determinations in the previous 6 months prior to liver biopsy. All patients were submitted to liver biopsy and METAVIR scale was used. RESULTS: Of 50 studied patients 40 (80%) were males. All patients were treated with antiretroviral therapy. The ALT levels were normal in 13 (26%) patients. HCV-HIV co-infected patients with normal ALT levels had presented means of the liver fibrosis stages (0.77±0.44 versus 1.86±1.38; p<0.001) periportal inflammatory activity (0.62±0.77 versus 2.24±1.35; p<0.001) and liver fibrosis progression rate (0.058±0.043 fibrosis unit/year versus 0.118±0.102 fibrosis unit/year) significantly lower as compared to those with elevated ALT. CONCLUSIONS: HCV-HIV coinfected patients with persistently normal ALTs showed slower progression of liver fibrosis. In these patients the development of liver cirrhosis is improbable.

Bloodstream infection in patients with end-stage renal disease in a teaching hospital in central-western Brazil

Introduction Vascular access in patients undergoing hemodialysis is considered a critical determinant of bloodstream infection (BSI) and is associated with high morbidity and mortality. The purpose of this study was to investigate the occurrence of BSI in patients with end-stage renal disease using central venous catheters for hemodialysis. Methods A cohort study was conducted in a public teaching hospital in central-western Brazil from April 2010 to December 2011. For every patient, we noted the presence of hyperemia/exudation upon catheter insertion, as well as fever, shivering, and chills during hemodialysis. Results Fifty-nine patients were evaluated. Thirty-five (59.3%) patients started dialysis due to urgency, 37 (62.7%) had BSI, and 12 (20%) died. Hyperemia at the catheter insertion site (64.9%) was a significant clinical manifestation in patients with BSI. Statistical analysis revealed 1.7 times more cases of BSI in patients with hypoalbuminemia compared with patients with normal albumin levels. The principal infective agents identified in blood cultures and catheter-tip cultures were Staphylococcus species (24 cases), non-fermentative Gram-negative bacilli (7 cases of Stenotrophomonas maltophilia and 5 cases of Chryseobacterium indologenes), and Candida species (6). Among the Staphylococci identified, 77.7% were methicillin-resistant, coagulase-negative Staphylococci. Of the bacteria isolated, the most resistant were Chryseobacterium indologenes and Acinetobacter baumannii. Conclusions Blood culture was demonstrated to be an important diagnostic test and identified over 50% of positive BSI cases. The high frequency of BSI and the isolation of multiresistant bacteria were disturbing findings. Staphylococcus aureus was the most frequently isolated microorganism, although Gram-negative bacteria predominated overall. These results highlight the importance of infection prevention and control measures in dialysis units.

Treatment and education reduce the severity of schistosomiasis periportal fibrosis

Introduction This study evaluates the factors associated with the development of severe periportal fibrosis in patients with Schistosoma mansoni. Methods A cross-sectional study was conducted from April to December 2012 involving 178 patients infected with S. mansoni who were treated in the Hospital das Clínicas of Pernambuco, Brazil. Information regarding risk factors was obtained using a questionnaire. Based on the patients' epidemiological history, clinical examination, and upper abdomen ultrasound evaluation, patients were divided into 2 groups: 137 with evidence of severe periportal fibrosis and 41 patients without fibrosis or with mild or moderate periportal fibrosis. Univariate and multivariate analyses were conducted using EpiInfo software version 3.5.5. Results Illiterate individuals (30.1%) and patients who had more frequent contact with contaminated water in towns in the Zona da Mata of Pernambuco (33.2%) were at greater risk for severe periportal fibrosis. Based on multivariate analysis, it was determined that an education level of up to 11 years of study and specific prior treatment for schistosomiasis were preventive factors for severe periportal fibrosis. Conclusions The prevailing sites of the severe forms of periportal fibrosis are still within the Zona da Mata of Pernambuco, although there has been an expansion to urban areas and the state coast. Specific treatment and an increased level of education were identified as protective factors, indicating the need for implementing social, sanitary, and health education interventions aimed at schistosomiasis to combat the risk factors for this major public health problem.

Avaliação económica em transplantação renal : abordagem estratégica do processo de doação e análise de custo-utilidade do programa de transplantação renal versus hemodiálise

SUMÁRIO - O desafio atual da Saúde Pública é assegurar a sustentabilidade financeira do sistema de saúde. Em ambiente de recursos escassos, as análises económicas aplicadas à prestação dos cuidados de saúde são um contributo para a tomada de decisão que visa a maximização do bem-estar social sujeita a restrição orçamental. Portugal é um país com 10,6 milhões de habitantes (2011) com uma incidência e prevalência elevadas de doença renal crónica estadio 5 (DRC5), respetivamente, 234 doentes por milhão de habitantes (pmh) e 1.600 doentes/pmh. O crescimento de doenças associadas às causas de DRC, nomeadamente, diabetes Mellitus e hipertensão arterial, antecipam uma tendência para o aumento do número de doentes. Em 2011, dos 17.553 doentes em tratamento substitutivo renal, 59% encontrava-se em programa de hemodiálise (Hd) em centros de diálise extra-hospitalares, 37% viviam com um enxerto renal funcionante e 4% estavam em diálise peritoneal (SPN, 2011). A lista ativa para transplante (Tx) renal registava 2.500 doentes (SPN 2009). O Tx renal é a melhor modalidade terapêutica pela melhoria da sobrevida, qualidade de vida e relação custo-efetividade, mas a elegibilidade para Tx e a oferta de órgãos condicionam esta opção. Esta investigação desenvolveu-se em duas vertentes: i) determinar o rácio custo-utilidade incremental do Tx renal comparado com a Hd; ii) avaliar a capacidade máxima de dadores de cadáver em Portugal, as características e as causas de morte dos dadores potenciais a nível nacional, por hospital e por Gabinete Coordenador de Colheita e Transplantação (GCCT), e analisar o desempenho da rede de colheita de órgãos para Tx. Realizou-se um estudo observacional/não interventivo, prospetivo e analítico que incidiu sobre uma coorte de doentes em Hd que foi submetida a Tx renal. O tempo de seguimento mínimo foi de um ano e máximo de três anos. No início do estudo, colheram-se dados sociodemográficos e clínicos em 386 doentes em Hd, elegíveis para Tx renal. A qualidade de vida relacionada com a saúde (QVRS) foi avaliada nos doentes em Hd (tempo 0) e nos transplantados, aos três, seis, 12 meses, e depois, anualmente. Incluíram-se os doentes que por falência do enxerto renal transitaram para Hd. Na sua medição, utilizou-se um instrumento baseado em preferências da população, o EuroQol-5D, que permite o posterior cálculo dos QALY. Num grupo de 82 doentes, a QVRS em Hd foi avaliada em dois tempos de resposta o que permitiu a análise da sua evolução. Realizou-se uma análise custo-utilidade do Tx renal comparado com a Hd na perspetiva da sociedade. Identificaram-se os custos diretos, médicos e não médicos, e as alterações de produtividade em Hd e Tx renal. Incluíram-se os custos da colheita de órgãos, seleção dos candidatos a Tx renal e follow-up dos dadores vivos. Cada doente transplantado foi utilizado como controle de si próprio em diálise. Avaliou-se o custo médio anual em programa de Hd crónica relativo ao ano anterior à Tx renal. Os custos do Tx foram avaliados prospetivamente. Considerou-se como horizonte temporal o ciclo de vida nas duas modalidades. Usaram-se taxas de atualização de 0%, 3% e 5% na atualização dos custos e QALY e efetuaram-se análises de sensibilidade one way. Entre 2008 e 2010, 65 doentes foram submetidos a Tx renal. Registaram-se, prospetivamente, os resultados em saúde incluíndo os internamentos e os efeitos adversos da imunossupressão, e o consumo dos recursos em saúde. Utilizaram-se modelos de medidas repetidas na avaliação da evolução da QVRS e modelos de regressão múltipla na análise da associação da QVRS e dos custos do transplante com as características basais dos doentes e os eventos clínicos. Comparativamente à Hd, observou-se melhoria da utilidade ao 3º mês de Tx e a qualidade de vida aferida pela escala EQ-VAS melhorou em todos os tempos de observação após o Tx renal. O custo médio da Hd foi de 32.567,57€, considerado uniforme ao longo do tempo. O custo médio do Tx renal foi de 60.210,09€ no 1º ano e 12.956,77€ nos anos seguintes. O rácio custo-utilidade do Tx renal vs Hd crónica foi de 2.004,75€/QALY. A partir de uma sobrevivência do enxerto de dois anos e cinco meses, o Tx associou-se a poupança dos custos. Utilizaram-se os dados nacionais dos Grupos de Diagnóstico Homogéneos e realizou-se um estudo retrospectivo que abrangeu as mortes ocorridas em 34 hospitais com colheita de órgãos, em 2006. Considerou-se como dador potencial o indivíduo com idade entre 1-70 anos cuja morte ocorrera a nível hospitalar, e que apresentasse critérios de adequação à doação de rim. Analisou-se a associação dos dadores potenciais com características populacionais e hospitalares. O desempenho das organizações de colheita de órgãos foi avaliado pela taxa de conversão (rácio entre os dadores potenciais e efetivos) e pelo número de dadores potenciais por milhão de habitantes a nível nacional, regional e por Gabinete Coordenador de Colheita e Transplantação (GCCT). Identificaram-se 3.838 dadores potenciais dos quais 608 apresentaram códigos da Classificação Internacional de Doenças, 9.ª Revisão, Modificações Clínicas (CID- 9-MC) que, com maior frequência, evoluem para a morte cerebral. O modelo logit para dados agrupados identificou a idade, o rácio da lotação em Unidades de Cuidados Intensivos e lotação de agudos, existência de GCCT e de Unidade de Transplantação, e mortalidade por acidente de trabalho como fatores preditivos da conversão dum dador potencial em efetivo e através das estimativas do modelo logit quantificou-se a probabilidade dessa conversão. A doação de órgãos deve ser assumida como uma prioridade e as autoridades em saúde devem assegurar o financiamento dos hospitais com programas de doação, evitando o desperdício de órgãos para transplantação, enquanto um bem público e escasso. A colheita de órgãos deve ser considerada uma opção estratégica da atividade hospitalar orientada para a organização e planeamento de serviços que maximizem a conversão de dadores potenciais em efetivos incluindo esse critério como medida de qualidade e efetividade do desempenho hospitalar. Os resultados deste estudo demonstram que: 1) o Tx renal proporciona ganhos em saúde, aumento da sobrevida e qualidade de vida, e poupança de custos; 2) em Portugal, a taxa máxima de eficácia da conversão dos dadores cadavéricos em dadores potenciais está longe de ser atingida. O investimento na rede de colheita de órgãos para Tx é essencial para assegurar a sustentabilidade financeira e promover a qualidade, eficiência e equidade dos cuidados em saúde prestados na DRC5.

Study of the risk factors related to acquisition of urinary tract infections in patients submitted to renal transplant

INTRODUCTION: Urinary tract infections (UTI) among transplant recipients are usually caused by gram-negative microorganisms and can provoke a high incidence of morbidity and mortality. The aim of this study was to evaluate the risk factors associated with the acquisition of UTIs during the first year after renal transplantation. METHODS: Here, we report a single-center retrospective cohort study of 99 renal transplant patients followed for the first year after surgery. The definition of a UTI episode was a urine culture showing bacterial growth and leucocyturia when patients presented with urinary symptoms. The absence of infection (asymptomatic bacteriuria) was defined as an absence of symptoms with negative urine culture or bacterial growth with any number of colonies. RESULTS: Ninety-nine patients were included in the study. During the study, 1,847 urine cultures were collected, and 320 (17.3%) tested positive for bacterial growth. Twenty-six (26.2%) patients developed a UTI. The most frequent microorganisms isolated from patients with UTIs were Klebsiella pneumoniae (36%), with 33% of the strains resistant to carbapenems, followed by Escherichia coli (20%). There were no deaths or graft losses associated with UTI episodes. CONCLUSIONS: Among the UTI risk factors studied, the only one that was associated with a higher incidence of infection was female sex. Moreover, the identification of drug-resistant strains is worrisome, as these infections have become widespread globally and represent a challenge in the control and management of infections, especially in solid organ transplantation.

Evaluation of the cytokine mannose-binding lectin as a mediator of periportal fibrosis progression in patients with schistosomiasis

INTRODUCTION : We hypothesized higher mannose-binding lectin level and classic factors (i.e., age, sex, alcohol consumption, exposure, and specific treatment) are associated with the severity of periportal fibrosis in schistosomiasis. METHODS : This cross-sectional study involved 79 patients infected with Schistosoma mansoni with severe or mild/moderate periportal fibrosis. Serum concentrations of mannose-binding lectin were obtained by enzyme-linked immunosorbent assay (ELISA). RESULTS: Higher serum level of mannose-binding lectin was significantly associated with advanced periportal fibrosis. CONCLUSIONS: Mannose-binding lectin may contribute to liver pathology in schistosomiasis and may represent a risk factor for advanced periportal fibrosis in the Brazilian population studied.

The absence of the human platelet antigen polymorphism effect on fibrosis progression in human immunodeficiency virus-1/hepatitis C virus coinfected patients

AbstractINTRODUCTION:Hepatic fibrosis progression in patients with chronic hepatitis C virus infections has been associated with viral and host factors, including genetic polymorphisms. Human platelet antigen polymorphisms are associated with the rapid development of fibrosis in HCV-monoinfected patients. This study aimed to determine whether such an association exists in human immunodeficiency virus-1/hepatitis C virus-coinfected patients.METHODS:Genomic deoxyribonucleic acid from 36 human immunodeficiency virus-1/hepatitis C virus-coinfected patients was genotyped to determine the presence of human platelet antigens-1, -3, or -5 polymorphisms. Fibrosis progression was evaluated using the Metavir scoring system, and the patients were assigned to two groups, namely, G1 that comprised patients with F1, portal fibrosis without septa, or F2, few septa (n = 23) and G2 that comprised patients with F3, numerous septa, or F4, cirrhosis (n = 13). Fisher's exact test was utilized to determine possible associations between the human platelet antigen polymorphisms and fibrosis progression.RESULTS:There were no deviations from the Hardy-Weinberg equilibrium in the human platelet antigen systems evaluated. Statistically significant differences were not observed between G1 and G2 with respect to the distributions of the allelic and genotypic frequencies of the human platelet antigen systems.CONCLUSION:The greater stimulation of hepatic stellate cells by the human immunodeficiency virus and, consequently, the increased expression of transforming growth factor beta can offset the effect of human platelet antigen polymorphism on the progression of fibrosis in patients coinfected with the human immunodeficiency virus-1 and the hepatitis C virus.

Determinantes socioculturais e políticas de saúde que influenciam a incidência da insuficiência renal crónica terminal, sob terapêutica de substituição da função renal : revisão sistemática

RESUMO - Asumo Insuficiência Renal Crónica Terminal é um problema de Saúde Pública, com elevada incidência e prevalência a nível mundial. Contudo, persistem variações geográficas destes indicadores que não são explicados pelos fatores clínicos ou fisiológicos. O objetivo do estudo é identificar os determinantes socioculturais e políticas de saúde que poderão influenciar a variação geográfica da incidência da insuficiência renal crónica sob terapêutica de substituição da função renal. Realizou-se uma revisão sistemática da literatura segundo a metodologia Prisma Statement nas bases de dados PubMed, Web of Science, Reportório Científico de Acesso Aberto de Portugal, Biblioteca Online e Google Académico, no período de 2010 a 2015, em inglês e português. De acordo com a metodologia eleita, foram definidos critérios de elegibilidade e, após a aplicação dos mesmos e avaliação da qualidade dos estudos (através do sistema de GRADE), foram identificados 5 artigos. Tendo por base os resultados obtidos, não foi possível identificar fatores socioculturais com influência na variação da incidência da insuficiência renal crónica sob terapêutica de substituição da função renal nos diferentes países. Por outro lado, constatou-se que as políticas de saúde, questões de acessibilidade e investimento na prevenção e diagnóstico precoce da patologia são fatores que exercem forte influência na incidência das terapêuticas de substituição da função renal. A identificação destes fatores é de extrema importância para intervir na promoção da saúde e diminuição das co-morbilidades relacionadas com a insuficiência renal crónica.

Hyperhomocyst(e)inemia in chronic stable renal transplant patients

PURPOSE: Hyperhomocyst(e)inaemia is an important risk factor for atherosclerosis, which is currently a major cause of death in renal transplant patients. The aim of this study was to assess the influence of immunosuppressive therapy on homocyst(e)inemia in renal transplant recipients. METHODS: Total serum homocysteine (by high performance liquid chromatography), creatinine, lipid profile, folic acid (by radioimmunoassay-RIA) and vitamin B12 (by RIA) concentrations were measured in 3 groups. Group I patients (n=20) were under treatment with cyclosporine, azathioprine, and prednisone; group II (n=9) were under treatment with azathioprine and prednisone; and group III (n=7) were composed of renal graft donors for groups I and II. Creatinine, estimated creatinine clearance, cyclosporine trough level, lipid profile, folic acid, and vitamin B12 concentrations and clinical characteristics of patients were assessed with the aim of ascertaining determinants of hyperhomocyst(e)inemia. RESULTS: Patient ages were 48.8 ± 15.1 yr (group I), 43.3 ± 11.3 yr (group II); and 46.5 ± 14.8 yr (group III). Mean serum homocyst(e)ine (tHcy) concentrations were 18.07 ± 8.29 mmol/l in renal transplant recipients; 16.55 ± 5.6 mmol/l and 21.44 ± 12.1 mmol/l respectively for group I (with cyclosporine) and group II (without cyclosporine) (NS). In renal donors, tHcy was significantly lower (9.07 ± 3.06 mmol/l; group I + group II vs. group III, p<0.008). There was an unadjusted correlation (p<0.10) between age (r=0.427; p<0.005) body weight (r=0.412; p<0.05), serum creatinine (r=0.427; p<0.05), estimated creatinine clearance (r=0.316; p<0.10), and tHcy in renal recipients (group I +II). Independent regressors (r²=0.46) identified in the multiple regression model were age (coefficient= 0.253; p=0.009) and serum creatinine (coefficient=8.07; p=0.045). We found no cases of hyperhomocyst(e)inemia in the control group. In contrast, 38% of renal recipients had hyperhomocyst(e)inemia: 7 cases (35%) on cyclosporine and 4 (45%) without cyclosporine, based on serum normal levels. CONCLUSIONS: Renal transplant recipients frequently have hyperhomocyst(e)inemia. Hyperhomocyst(e)inemia in renal transplant patients is independent of the scheme of immunosuppression they are taking. The older the patients are and the higher are their serum creatinine levels, the more susceptible they are to hyperhomocyst(e)inemia following renal transplantation.

Kidney function after left renal vein ligation in the dog

The ligature of the left renal vein is an alternative whenever this vessel is injured. The purpose of this study was to evaluate the capacity of the affluents of the left renal vein, proximal to the ligature, to maintain tissue vitality and function of the left kidney. Fifteen mongrel male dogs were divided in 3 groups of 5 dogs: Group I (control) - a laparotomy was performed, and the abdominal structures were only identified; Group II - the left renal vein was tied, close to vena cava; Group III - the same procedure as for Group II and a right nephrectomy. Blood urea nitrogen and serum creatinine levels were measured before the procedure, and every 3 days during 4 weeks in the postoperative period. Renal arteriography and an excretory urogram were performed on the animals that survived 60 days. Thereafter, or immediately after precocious death, the kidneys were removed for histological examination. All the animals of Group III died before two months (mean = 10.5 +-3.2 days), while the animals of Group II survived during that period. There was a complete exclusion of the left kidney in all dogs that underwent renal vein ligature. In the animals of Group II, the renal cortico-medullary limits could not be identified. At microscopy, the aspect was suggestive of nephrosclerosis. In the animals of Group III, the left kidney was enlarged, and a great amount of intravascular and intrapelvic blood clots were observed. At microscopy, extensive areas of necrosis, inflammatory infiltration, and hemorrhage were identified. In conclusion, the tributaries of the renal vein were not sufficient to maintain the tissue vitality and function of the left kidney after ligature of its main vein.

Acute renal failure due to abdominal compartment syndrome: report on four cases and literature review

We report on 4 cases of abdominal compartment syndrome complicated by acute renal failure that were promptly reversed by different abdominal decompression methods. Case 1: A 57-year-old obese woman in the post-operative period after giant incisional hernia correction with an intra-abdominal pressure of 24 mm Hg. She was sedated and curarized, and the intra-abdominal pressure fell to 15 mm Hg. Case 2: A 73-year-old woman with acute inflammatory abdomen was undergoing exploratory laparotomy when a hypertensive pneumoperitoneum was noticed. During the surgery, enhancement of urinary output was observed. Case 3: An 18-year-old man who underwent hepatectomy and developed coagulopathy and hepatic bleeding that required abdominal packing, developed oliguria with a transvesical intra-abdominal pressure of 22 mm Hg. During reoperation, the compresses were removed with a prompt improvement in urinary flow. Case 4: A 46-year-old man with hepatic cirrhosis was admitted after incisional hernia repair with intra-abdominal pressure of 16 mm Hg. After paracentesis, the intra-abdominal pressure fell to 11 mm Hg.

Bilateral giant renal angiomyolipoma associated with hepatic lipoma in a patient with tuberous sclerosis

OBJECTIVE: To report a case of bilateral giant renal angiomyolipoma associated with tuberous sclerosis, with successful treatment, and to review the literature concerning angiomyolipoma treatment. CASE REPORT: Patient with tuberous sclerosis and angiomyolipoma diagnosed by ultrasonography during her pregnancy. At that time, the angiomyolipoma on the right side was 9 cm in diameter. Conservative management was selected during her pregnancy. The patient returned 7 years later, with a 24.7 x 19.2 x 10.7 cm tumor on the right side and another of 13 x 11.5 x 6.5 cm on the left side, in addition to multiple small angiomyolipomas. A nephron-sparing surgery with tumoral enucleation was performed on the right side, and after 3 months, the tumor on the left side was removed. Renal function in the post-operative period was preserved, and contrast medium progression was uniform and adequate in both kidneys. CONCLUSION: We conclude that an angiomyolipoma larger than 4 cm should be removed surgically, since they have a greater growth rate and pose a risk of hemorrhage. Resection of smaller tumors is safe and has decreased morbidity. Tumoral enucleation is an effective treatment method that preserves kidney function.