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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Idiopathic retroperitoneal fibrosis &#40;IRF&#41; is an uncommon condition that usually presents obstructive uropathy&#46; The fibrous tissue of IRF consists of an inflammatory infiltrate characterised by perivascular myofibroblasts that contain lymphocytes&#44; macrophages&#44; plasma cells and eosinophils&#46;<span class="elsevierStyleSup">1&#44;2</span> The ureter is often trapped in this fibrous tissue and this causes obstructive uropathy and consequently&#44; chronic ascending pyelonephritis&#46;<span class="elsevierStyleSup">3</span> The prognosis of this disease seems to have improved in the last decade as different treatments have been tested and urinary bypasses have been carried out&#46;</p><p class="elsevierStylePara">We have retrospectively reviewed the cases of nine patients diagnosed with IRF in one centre&#44; after excluding patients with retroperitoneal fibrosis associated with neoplasia&#44; radiotherapy or previous administration of gandolinium derivatives when advanced kidney disease was present&#46; We reviewed the symptoms that led to diagnosis&#44; the treatment administered and the progress of the condition&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHOD</span></p><p class="elsevierStylePara">We retrospectively reviewed cases of patients diagnosed with IRF during the last 16 years in Parc Taul&#237; Health Corporation in Sabadell&#44; which covers a health care area with 400&#44;000 people&#46; These patients were monitored until 31 December 2008&#46; The objectives of this study were&#58; 1&#41; to review the clinical manifestations of IRF that lead to its diagnosis&#44; as well as the age and sex of patients&#59; 2&#41; the effect on the kidneys if any&#59; 3&#41; extrarenal complications if any&#59; 4&#41; drug treatments administered and urological procedures carried out if applicable&#59; 5&#41; clinical progress&#58; follow up time and complications&#46;</p><p class="elsevierStylePara">All patients with a history of neoplasia or radiotherapy were excluded&#46; Drug treatment prior to diagnosis has been taken into consideration&#44; especially the use of ergotics&#44; betablockers and gandolinium&#46; A history of aortic aneurisms and retroperitoneal surgery was also taken into account&#46;</p><p class="elsevierStylePara">The diagnostic criteria were based on the histology&#58; the biopsied tissue had to present fibrosis with inflammatory infiltrate containing lymphoplasmacytic cells and macrophages&#59; it should be predominantly perivascular and contain irregular bands of collagen &#40;figure 1&#41;&#46; In the case of a radiological diagnosis&#44; a fibrotic band around the aorta or iliac vessels would confirm IRF&#46; In both cases&#44; patients with infectious diseases &#40;especially tuberculosis in this context&#41;&#44; neoplasia&#40;especially lymphoproliferative syndromes&#41;&#44; sarcoidosis and autoimmune diseases were ruled out in accordance with the clinical and analytical criteria&#46;</p><p class="elsevierStylePara">Kidney function was measured at the time of diagnosis and during the final check-up with the study deadline being 31 December 2008&#46; Therefore&#44; plasma creatinine was measured in mg&#47;dl at both times&#46; The existence of obstructive uropathy was determined using ultrasound or an abdominal scanner&#46;</p><p class="elsevierStylePara">At the time of diagnosis&#44; any non-nephrourological damage to theabdomen was established&#44; paying particular attention to the possibility of vascular &#40;aorta or iliac&#41; and digestive &#40;bile duct and alimentary canal&#41; problems&#44; using ultrasound or abdominal scanner&#44; as well as the relevant tests associated with the symptoms present&#46;</p><p class="elsevierStylePara">The progress of the condition was evaluated during weekly check-ups which included GSV testing&#44; a haemogram&#44; kidney function testing &#40;creatinine and glomerular filtration&#41; and liver function testing &#40;GOT&#44; GPT&#44; gamma GT&#44; alkaline phosphatase&#41;&#44; cholesterol&#44; triglycerides&#44; total proteins and PCR&#44; and the following was tested in urine&#58; proteinuria and sediment&#46; Even though there was no deterioration in kidney function&#44; abdominal check-ups using a scanner were carried out annually&#46;</p><p class="elsevierStylePara">There was a particular focus on the possibility of complications occurring&#44; especially vascular complications &#40;arterial ischemia or vein thrombosis in the lower limbs&#41;&#44; urological complications &#40;the emergence or worsening of hydronephrosis if already present&#44; urinary infections&#44; hydrocele&#44; varicocele&#41; and digestive complications &#40;hepatobiliar or pancreatic damage&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">From 1 October 1991 to 31 December 2008 nine patients were diagnosed with IRF in our centre&#46; In six cases the diagnosis was made on the basis of the histology and in three cases it was diagnosed radiologically using a scanner and MR&#46; In all cases&#44; especially in the three cases diagnosed radiologically&#44; 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and 22&#37; presented deep vein thrombosis in the legs&#46;</p><p class="elsevierStylePara">One mg&#47;kg&#47;day of Prednisone was administered for three months&#44; with this amount being reduced later on in eight of the nine cases&#46; Double-J catheters were inserted in the ureters of the seven patients that presented hydronephrosis&#59; a nephrostomy was initially carried out on one of them&#46;</p><p class="elsevierStylePara">The average follow-up time for patients was 89&#46;<span class="elsevierStyleSup">4</span> months &#40;26-156&#41;&#46; Two patients did not experience recurring symptoms&#44; although the fibrotic band was still present &#40;smaller&#41; in the radiological exams using an abdominal scanner throughout the follow up period&#44; which lasted 40 and 156 months respectively for these patients&#46; The three patients diagnosed radiologically were monitored for 69&#44; 110 and 156 months respectively&#46; The patient with a history of vascular surgery was monitored for 110 months&#46;</p><p class="elsevierStylePara">A third patient&#44; who was the only one not treated with prednisone and who had a history of vascular surgery&#44; did not experience recurring symptoms although the periaortic band was still present in the radiological exam&#46;</p><p class="elsevierStylePara">Five patients treated with prednisone have become dependent on corticoids since they regularly relapsed&#46; One patient began haemodialysis 48 months after he was diagnosed with IRF and presented frequent outbreaks and relapses&#46; He died 10 years later on dialysis because of cardiovascular complications&#46; A kidney transplant was never performed since the possibility of a bypass graft was rejected&#46; There were no other complications associated with the IRF while the patient was in dialysis&#46; In total&#44; 62&#46;5&#37; of patients were dependent on corticoids&#46;</p><p class="elsevierStylePara">With the exception of the patient with the poor prognosis who started haemodialysis&#44; the other eight patients presented complications shown in table 2&#46; One patient who presented peribiliary fibrosis also presented choledocholithiasis as a complication during the follow up period&#46; Another patient also presented sclerosing cholangitis lesions and bridging hepatic fibrosis in the liver biopsy carried out because of dissociated cholestasis&#44; however cirrhosis was not confirmed&#46; Six years before being diagnosed with IRF&#44; this patient also presented an episode of acute pancreatitis and cutaneous panniculitis&#44; and for that reason a differential diagnosis including vasculitis and sarcoidosis was insisted upon&#46;</p><p class="elsevierStylePara">The two patients with right renal atrophy already presented atrophy at the time of diagnosis&#46; One of them presented contralateral hydronephrosis and for that reason the left ureter was catheterized&#46; The other patient was unaffected&#46; Two patients presented iliac artery obstruction&#44; and one of them significant arteriosclerosis&#46; One patient presented femoropopliteal vein thrombosis during the follow up period&#46; In addition to this&#44; one patient presented obesity&#44; Cushing&#8217;s syndrome and obstructive sleep apnoea in response to prednisone rather than as a result of IRF&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">The term &#8220;retroperitoneal fibrosis&#8221; is used to describe different physiopathological conditions that all generate fibrosis in the retroperitoneal space&#46; They cause obstructive kidney failure by affecting the ureter unilaterally or bilaterally&#46; This can potentially be reversed as long as all other obstructive uropathies are taken into consideration in the differential diagnosis&#46;</p><p class="elsevierStylePara">The anatomopathological substratum of the illness is the chronic&#44; non-specific inflammatory process&#44; with an abundance of macrophages<span class="elsevierStyleSup">2</span> and perivascular distribution&#44; which in general is periaortic&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">In most cases&#44; retroperitoneal fibrosis is idiopathic&#44; however 30&#37; of cases are associated with other factors such as drugs &#40;ergotics and betablockers are most commonly cited&#41;&#44; neoplasia&#44; aortic aneurisms&#44; collagenopathies and vasculitis&#46;<span class="elsevierStyleSup">4-8</span> Eight out of nine patients in our study presented idiopathic etroperitoneal fibrosis&#46; One patient underwent aortoiliac surgery three years before&#44; however this was considered an unlikely cause of retroperitoneal fibrosis and the case was recorded as idiopathic&#46;</p><p class="elsevierStylePara">Fifteen percent of patients also presented extra-retroperitoneal fibrosis<span class="elsevierStyleSup">9</span> &#40;figure 2&#41;&#46; Thus&#44; all the organs in the abdominal cavity can be enveloped by fibrosis &#40;sclerosing cholangitis&#44; pancreas and pelvic organs are most commonly described&#41;&#46; Cases of mediastinal fibrosis&#44; Riedel thyroiditis&#44; orbital pseudotumours nd fibrosis of the maxillary sinus have also been described outside the abdomen&#59; all are examples of multifocal fibrosclerosis syndromes&#46;<span class="elsevierStyleSup">10-12</span></p><p class="elsevierStylePara">The case of the patient who was administered gandolinium&#44; which caused systemic fibrosis and symptoms that have been described in recent years as those of nephrogenic systemic fibrosis&#44; was excluded&#46;<span class="elsevierStyleSup">13-15</span></p><p class="elsevierStylePara">Six of our cases were diagnosed on the basis of the histology and three radiologically&#44; and all patients presenting neoplasia &#40;lymphoma&#44; sarcoma&#41; and infections &#40;tuberculosis&#41; were excluded&#46; We excluded patients with concomitant neoplasia &#40;transitional cell carcinoma of the urinary tract was the most common&#41; and those undergoing radiotherapy&#46; The abdominal scan&#44; in particular the MR scan&#44; are the techniques of choice used to confirm a diagnosis of IRF&#46;<span class="elsevierStyleSup">3&#44;16</span></p><p class="elsevierStylePara">The age of onset and sex of IRF patients &#40;mostly male&#41; coincidewith other studies<span class="elsevierStyleSup">3&#44;16</span>&#58; The average age was 47&#46;7 years in our study compared with 56 years in others&#44; and the percentage of males affected was 89&#37; in our study compared with 86&#37; and 63&#37; respectively in others&#46;<span class="elsevierStyleSup">3&#44;16</span></p><p class="elsevierStylePara">Abdominal or lumbar pain was the most common symptom &#40;67&#37;&#41;&#46; This also coincides with the findings of other authors&#46; In general&#44; pain was accompanied by other non-specific symptoms like weakness&#44; loss of appetite&#44; weight loss and fever&#46; With these symptoms and the imaging findings&#44; a differential diagnosis is made that includes other processes like lymphoproliferative syndromes&#44; sarcomas&#44; sarcoidosis and vasculitis&#46; Therefore&#44; the histological diagnosis is often indispensable&#46; In this study&#44; the last four patients described were effectively diagnosed using an MR-guided biopsy&#46; This could be the method of choice in the future&#46; Corradi et al&#46;<span class="elsevierStyleSup">3</span> obtained histological samples from laparotomies or laparoscopies&#44; taking advantage of ureterolysis in 24 patients&#46; Van Bommel et al&#46;&#44; who also included 24 patients in their study&#44; only carried out biopsies on two of them&#44; since the diagnosis in most cases was made radiologically&#46;<span class="elsevierStyleSup">16</span> Moroni et al&#46; confirmed the diagnosis histologically in 8 of their 17 patients by using biopsies obtained from laparotomies and&#44; in one case&#44; from a laparoscopy&#46;<span class="elsevierStyleSup">17</span></p><p class="elsevierStylePara">The percentage of patients who presented obstructive uropathy was 77&#46;8&#37;&#46; Initially&#44; 33&#37; of males also presented hydrocele&#46;</p><p class="elsevierStylePara">After kidney complications&#44; vascular complications were the most common finding at the time of diagnosis &#40;22&#37;&#41; and throughout the follow up period &#40;33&#37;&#41;&#46; Artery complications caused by extravascular fibrosis was slightly more common than vein complications&#46;</p><p class="elsevierStylePara">One patient presented sclerosing cholangitis at the time of diagnosis and another presented it during the follow up &#40;22&#37; in total&#41;&#46; The latter patient required a special differential diagnosis which included vasculitis&#44; sarcoidosis and the aftereffects of pancreatitis because he had suffered from acute pancreatitis and panicullitis six years earlier&#46;</p><p class="elsevierStylePara">Other studies describe vascular&#44; artery or vein complications as being more common&#44;<span class="elsevierStyleSup">17</span> although they refer to radiological &#40;65&#37; of cases&#41; not clinical effects like the ones described in our study &#40;44&#37;&#41;&#44; which takes into account the findings both at the time of diagnosis and during the follow-up&#46; In most of the cases in this study&#44; the fibrotic band surrounded the large abdominal vessels&#44; the aorta or the inferior vena cava&#46; Corradi et al&#46;<span class="elsevierStyleSup">3</span> described how 17&#37; of cases presented vascular complications&#46; In the study by Van Bommel et al&#46;<span class="elsevierStyleSup">16</span> 25&#37; initially presented vascular complications&#44; however only 8&#46;3&#37; of cases presented any clinical damage&#46; In these studies&#44; the effects on the bile ducts&#44; gallbladder&#44; liver and pancreas have not been described&#46;</p><p class="elsevierStylePara">The treatment administered in this centre was prednisone and ureterolysis in cases of ureteral compression&#46;<span class="elsevierStyleSup">17</span> These studies are retrospective like ours and include a population that is too small to draw significant conclusions&#44; however&#44; it seems that immunosuppression and urological procedures are the treatment of choice&#46; Immunosuppression involves corticotherapy&#44; although in some cases it is administered along with azathioprine&#44; cyclophosphamide or tamoxifen&#44;<span class="elsevierStyleSup">17&#44;18</span> despite the fact that there is no evidence to suggest that these immunosuppressants improve patient prognosis during follow up&#46; Marcolongo et al&#46;&#44;<span class="elsevierStyleSup">18</span> in a series of 26 patients&#44; obtained good results administering prednisone and azathioprine&#46; In the future&#44; treatments that inhibit the proliferation of fibroblasts or their apoptosis&#44; like interferon&#44; may be preferable&#46;</p><p class="elsevierStylePara">The average follow up time for our patients of 89&#46;4 months was significant even though the duration of the study was short&#46; This made it possible to recommend conservative treatment for patients by administering prednisone and carrying out urological procedures using double-J catheters&#44; which were generally inserted at the site of previous nephrostomies or via an ascending route&#46; This long follow up period also rules out the possibility of retroperitoneal fibrosis which is often secondary to lymphoproliferative processes and low grade lymphomas&#46; Oshiro et al&#46;<span class="elsevierStyleSup">19</span> in particular insist on this possibility&#46;</p><p class="elsevierStylePara">We can conclude that IRF is an uncommon clinical condition that mainly affects males of around 50 years of age&#46; This condition can be diagnosed histologically through biopsies and monitored using abdominal imaging techniques&#46; Because of its pathogenic nature&#44; the treatment of this condition currently involves administering corticotherapy&#46; Urological procedures should be undertaken with care and should be as non-invasive as possible&#44; like double-J catheters&#46; Relapses are common and should be treated once again with prednisone and possibly endoureteral catheterization&#46; The current prognosis using these measures is satisfactory&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10818078&#95;f1&#95;299&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818078_f1_299.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;10818078&#95;t1&#95;300&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818078_t1_300.jpg" alt="Characteristics of patients at the time of diagnosis of idiopathic retroperitoneal fibrosis"></img></a></p><p class="elsevierStylePara">Table 1&#46; Characteristics of patients at the time of diagnosis of idiopathic retroperitoneal fibrosis</p><p class="elsevierStylePara"><a href="grande&#47;10818078&#95;t2&#95;301&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818078_t2_301.jpg" alt="Progress of patients diagnosed with idiopathic retroperitoneal fibrosis"></img></a></p><p class="elsevierStylePara">Table 2&#46; Progress of patients diagnosed with idiopathic retroperitoneal fibrosis</p><p class="elsevierStylePara"><a href="grande&#47;10818078&#95;f2&#95;301&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818078_f2_301.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; </p>"
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        "resumen" => "<p class="elsevierStylePara">Introducci&#243;n&#58; La fibrosis retroperitoneal idiop&#225;tica es una entidad cl&#237;nica de presentaci&#243;n poco frecuente&#44; que suele cursar con uropat&#237;a obstructiva por atrapamiento ureteral por el tejido fibroso e inflamatorio cr&#243;nico&#44; constituido por miofibroblastos de disposici&#243;n perivascular&#46; En los &#250;ltimos a&#241;os&#44; el pron&#243;stico parece haber mejorado con el tratamiento m&#233;dico inmunosupresor y con las intervenciones urol&#243;gicas de liberaci&#243;n de los ur&#233;teres&#46; Hemos revisado los pacientes diagnosticados de fibrosis retroperitoneal idiop&#225;tica en nuestro centro con el objetivo de revisar el motivo de presentaci&#243;n cl&#237;nica&#44; de afectaci&#243;n renal y extrarrenal&#44; el tratamiento realizado y la evoluci&#243;n cl&#237;nica seguida&#46; Han sido nueve enfermos no neopl&#225;sicos&#44; no tratados previamente con radioterapia y sin administraci&#243;n previa de gadolinio en presencia de insuficiencia renal avanzada&#46; Seis de ellos tienen diagn&#243;stico histol&#243;gico y tres radiol&#243;gico&#46; Han sido tratados con prednisona&#44; 1 mg&#47;kg&#47;d&#237;a durante tres meses&#44; y la posibilidad de colocaci&#243;n de cat&#233;teres endoluminales doble J&#46; El 89&#37; de estos pacientes ha seguido una buena evoluci&#243;n sin insuficiencia renal cr&#243;nica progresiva&#46; Las recidivas han sido frecuentes a lo largo de su seguimiento&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">Idiopathic retroperitoneal fibrosis is a rare disease often causing obstructive uropathy because the fibrosis entraps the ureters&#46; The retroperitoneal tissue is constituted by a fibrous component and a chronic inflammatory infiltrate with the former characterized by miofibroblasts&#46; The infiltrate displayed perivascular&#46; Last years&#44; the immunosuppressive therapy and the decompression of obstructive renal failure have improved the prognostic&#46; We reported 9 patients with Idiopathic retroperitoneal fibrosis in a Centre&#46; We evaluate clinical symptoms at the presentation with the signs of renal and non-renal involvement&#46; We evaluate the achieved therapy and the follow-up&#46; All 9 patients had a radiological and&#47;or histological diagnosis in the absence of malignancy&#44; previous radiotherapy or gadolinium&#8217;s administration with severe renal failure&#46; The patients were treated with 1 mg&#47;kg&#47;day of prednisone three months and possibly the insertion of ureteral catheters&#46; 89&#37; patients have a high rate of initial success without renal failure&#44; despite frequent disease relapse&#46; A patient developed progression of the fibrosis&#46;</p>"
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Idiopathic retroperitoneal fibrosis: clinico-pathological characteristics
FIBROSIS RETROPERITONEAL IDIOPÁTICA: CARACTERÍSTICAS CLINICOPATOLÓGICAS.
ANGEL RODRIGUEZ JORNETa, FRANCISCO JAVIER ANDREU NAVARROb, RUTH ORELLANA FERNÁNDEZb, JOSÉ IBEAS LÓPEZa, MANUEL GARCIA GARCIAa
a SERVICIOS DE NEFROLOGÍA, CORPORACIÓN SANITARIA PARC TAULÍ, SABADELL, BARCELONA, ESPAÑA,
b SERVICIOS DE PATOLOGÍA, CORPORACIÓN SANITARIA PARC TAULÍ, SABADELL, BARCELONA, ESPAÑA,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Idiopathic retroperitoneal fibrosis &#40;IRF&#41; is an uncommon condition that usually presents obstructive uropathy&#46; The fibrous tissue of IRF consists of an inflammatory infiltrate characterised by perivascular myofibroblasts that contain lymphocytes&#44; macrophages&#44; plasma cells and eosinophils&#46;<span class="elsevierStyleSup">1&#44;2</span> The ureter is often trapped in this fibrous tissue and this causes obstructive uropathy and consequently&#44; chronic ascending pyelonephritis&#46;<span class="elsevierStyleSup">3</span> The prognosis of this disease seems to have improved in the last decade as different treatments have been tested and urinary bypasses have been carried out&#46;</p><p class="elsevierStylePara">We have retrospectively reviewed the cases of nine patients diagnosed with IRF in one centre&#44; after excluding patients with retroperitoneal fibrosis associated with neoplasia&#44; radiotherapy or previous administration of gandolinium derivatives when advanced kidney disease was present&#46; We reviewed the symptoms that led to diagnosis&#44; the treatment administered and the progress of the condition&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHOD</span></p><p class="elsevierStylePara">We retrospectively reviewed cases of patients diagnosed with IRF during the last 16 years in Parc Taul&#237; Health Corporation in Sabadell&#44; which covers a health care area with 400&#44;000 people&#46; These patients were monitored until 31 December 2008&#46; The objectives of this study were&#58; 1&#41; to review the clinical manifestations of IRF that lead to its diagnosis&#44; as well as the age and sex of patients&#59; 2&#41; the effect on the kidneys if any&#59; 3&#41; extrarenal complications if any&#59; 4&#41; drug treatments administered and urological procedures carried out if applicable&#59; 5&#41; clinical progress&#58; follow up time and complications&#46;</p><p class="elsevierStylePara">All patients with a history of neoplasia or radiotherapy were excluded&#46; Drug treatment prior to diagnosis has been taken into consideration&#44; especially the use of ergotics&#44; betablockers and gandolinium&#46; A history of aortic aneurisms and retroperitoneal surgery was also taken into account&#46;</p><p class="elsevierStylePara">The diagnostic criteria were based on the histology&#58; the biopsied tissue had to present fibrosis with inflammatory infiltrate containing lymphoplasmacytic cells and macrophages&#59; it should be predominantly perivascular and contain irregular bands of collagen &#40;figure 1&#41;&#46; In the case of a radiological diagnosis&#44; a fibrotic band around the aorta or iliac vessels would confirm IRF&#46; In both cases&#44; patients with infectious diseases &#40;especially tuberculosis in this context&#41;&#44; neoplasia&#40;especially lymphoproliferative syndromes&#41;&#44; sarcoidosis and autoimmune diseases were ruled out in accordance with the clinical and analytical criteria&#46;</p><p class="elsevierStylePara">Kidney function was measured at the time of diagnosis and during the final check-up with the study deadline being 31 December 2008&#46; Therefore&#44; plasma creatinine was measured in mg&#47;dl at both times&#46; The existence of obstructive uropathy was determined using ultrasound or an abdominal scanner&#46;</p><p class="elsevierStylePara">At the time of diagnosis&#44; any non-nephrourological damage to theabdomen was established&#44; paying particular attention to the possibility of vascular &#40;aorta or iliac&#41; and digestive &#40;bile duct and alimentary canal&#41; problems&#44; using ultrasound or abdominal scanner&#44; as well as the relevant tests associated with the symptoms present&#46;</p><p class="elsevierStylePara">The progress of the condition was evaluated during weekly check-ups which included GSV testing&#44; a haemogram&#44; kidney function testing &#40;creatinine and glomerular filtration&#41; and liver function testing &#40;GOT&#44; GPT&#44; gamma GT&#44; alkaline phosphatase&#41;&#44; cholesterol&#44; triglycerides&#44; total proteins and PCR&#44; and the following was tested in urine&#58; proteinuria and sediment&#46; Even though there was no deterioration in kidney function&#44; abdominal check-ups using a scanner were carried out annually&#46;</p><p class="elsevierStylePara">There was a particular focus on the possibility of complications occurring&#44; especially vascular complications &#40;arterial ischemia or vein thrombosis in the lower limbs&#41;&#44; urological complications &#40;the emergence or worsening of hydronephrosis if already present&#44; urinary infections&#44; hydrocele&#44; varicocele&#41; and digestive complications &#40;hepatobiliar or pancreatic damage&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">From 1 October 1991 to 31 December 2008 nine patients were diagnosed with IRF in our centre&#46; In six cases the diagnosis was made on the basis of the histology and in three cases it was diagnosed radiologically using a scanner and MR&#46; In all cases&#44; especially in the three cases diagnosed radiologically&#44; other possible diagnoses of secondary IRF were ruled out&#46; Table 1 shows that the cases reviewed involved eight men and one woman with an average age of 47&#46;7 &#40;28-60&#41; at the time of diagnosis&#46; One patient diagnosed in 1982 who suffered a subsequent relapse in 1995 and one case with a history of an aortobifemoral graft were included&#46;</p><p class="elsevierStylePara">All patients with a history of neoplasia or concomitant conditions were excluded&#46;</p><p class="elsevierStylePara">The most common symptom was abdominal or lumbar pain&#44; which was the reason for seeking medical advice in 67&#37; of cases&#46; At the time of diagnosis&#44; 33&#37; of patients presented kidney failure&#44; 33&#37; were experiencing unilateral obstructive kidney damage and 44&#37; were experiencing bilateral obstructive kidney damage&#59; there was no initial kidney affectation in 22&#37; of cases&#46; A third of male patients &#40;33&#37;&#41; initially presented unilateral or bilateral hydrocele&#44; and 22&#37; presented deep vein thrombosis in the legs&#46;</p><p class="elsevierStylePara">One mg&#47;kg&#47;day of Prednisone was administered for three months&#44; with this amount being reduced later on in eight of the nine cases&#46; Double-J catheters were inserted in the ureters of the seven patients that presented hydronephrosis&#59; a nephrostomy was initially carried out on one of them&#46;</p><p class="elsevierStylePara">The average follow-up time for patients was 89&#46;<span class="elsevierStyleSup">4</span> months &#40;26-156&#41;&#46; Two patients did not experience recurring symptoms&#44; although the fibrotic band was still present &#40;smaller&#41; in the radiological exams using an abdominal scanner throughout the follow up period&#44; which lasted 40 and 156 months respectively for these patients&#46; The three patients diagnosed radiologically were monitored for 69&#44; 110 and 156 months respectively&#46; The patient with a history of vascular surgery was monitored for 110 months&#46;</p><p class="elsevierStylePara">A third patient&#44; who was the only one not treated with prednisone and who had a history of vascular surgery&#44; did not experience recurring symptoms although the periaortic band was still present in the radiological exam&#46;</p><p class="elsevierStylePara">Five patients treated with prednisone have become dependent on corticoids since they regularly relapsed&#46; One patient began haemodialysis 48 months after he was diagnosed with IRF and presented frequent outbreaks and relapses&#46; He died 10 years later on dialysis because of cardiovascular complications&#46; A kidney transplant was never performed since the possibility of a bypass graft was rejected&#46; There were no other complications associated with the IRF while the patient was in dialysis&#46; In total&#44; 62&#46;5&#37; of patients were dependent on corticoids&#46;</p><p class="elsevierStylePara">With the exception of the patient with the poor prognosis who started haemodialysis&#44; the other eight patients presented complications shown in table 2&#46; One patient who presented peribiliary fibrosis also presented choledocholithiasis as a complication during the follow up period&#46; Another patient also presented sclerosing cholangitis lesions and bridging hepatic fibrosis in the liver biopsy carried out because of dissociated cholestasis&#44; however cirrhosis was not confirmed&#46; Six years before being diagnosed with IRF&#44; this patient also presented an episode of acute pancreatitis and cutaneous panniculitis&#44; and for that reason a differential diagnosis including vasculitis and sarcoidosis was insisted upon&#46;</p><p class="elsevierStylePara">The two patients with right renal atrophy already presented atrophy at the time of diagnosis&#46; One of them presented contralateral hydronephrosis and for that reason the left ureter was catheterized&#46; The other patient was unaffected&#46; Two patients presented iliac artery obstruction&#44; and one of them significant arteriosclerosis&#46; One patient presented femoropopliteal vein thrombosis during the follow up period&#46; In addition to this&#44; one patient presented obesity&#44; Cushing&#8217;s syndrome and obstructive sleep apnoea in response to prednisone rather than as a result of IRF&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">The term &#8220;retroperitoneal fibrosis&#8221; is used to describe different physiopathological conditions that all generate fibrosis in the retroperitoneal space&#46; They cause obstructive kidney failure by affecting the ureter unilaterally or bilaterally&#46; This can potentially be reversed as long as all other obstructive uropathies are taken into consideration in the differential diagnosis&#46;</p><p class="elsevierStylePara">The anatomopathological substratum of the illness is the chronic&#44; non-specific inflammatory process&#44; with an abundance of macrophages<span class="elsevierStyleSup">2</span> and perivascular distribution&#44; which in general is periaortic&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">In most cases&#44; retroperitoneal fibrosis is idiopathic&#44; however 30&#37; of cases are associated with other factors such as drugs &#40;ergotics and betablockers are most commonly cited&#41;&#44; neoplasia&#44; aortic aneurisms&#44; collagenopathies and vasculitis&#46;<span class="elsevierStyleSup">4-8</span> Eight out of nine patients in our study presented idiopathic etroperitoneal fibrosis&#46; One patient underwent aortoiliac surgery three years before&#44; however this was considered an unlikely cause of retroperitoneal fibrosis and the case was recorded as idiopathic&#46;</p><p class="elsevierStylePara">Fifteen percent of patients also presented extra-retroperitoneal fibrosis<span class="elsevierStyleSup">9</span> &#40;figure 2&#41;&#46; Thus&#44; all the organs in the abdominal cavity can be enveloped by fibrosis &#40;sclerosing cholangitis&#44; pancreas and pelvic organs are most commonly described&#41;&#46; Cases of mediastinal fibrosis&#44; Riedel thyroiditis&#44; orbital pseudotumours nd fibrosis of the maxillary sinus have also been described outside the abdomen&#59; all are examples of multifocal fibrosclerosis syndromes&#46;<span class="elsevierStyleSup">10-12</span></p><p class="elsevierStylePara">The case of the patient who was administered gandolinium&#44; which caused systemic fibrosis and symptoms that have been described in recent years as those of nephrogenic systemic fibrosis&#44; was excluded&#46;<span class="elsevierStyleSup">13-15</span></p><p class="elsevierStylePara">Six of our cases were diagnosed on the basis of the histology and three radiologically&#44; and all patients presenting neoplasia &#40;lymphoma&#44; sarcoma&#41; and infections &#40;tuberculosis&#41; were excluded&#46; We excluded patients with concomitant neoplasia &#40;transitional cell carcinoma of the urinary tract was the most common&#41; and those undergoing radiotherapy&#46; The abdominal scan&#44; in particular the MR scan&#44; are the techniques of choice used to confirm a diagnosis of IRF&#46;<span class="elsevierStyleSup">3&#44;16</span></p><p class="elsevierStylePara">The age of onset and sex of IRF patients &#40;mostly male&#41; coincidewith other studies<span class="elsevierStyleSup">3&#44;16</span>&#58; The average age was 47&#46;7 years in our study compared with 56 years in others&#44; and the percentage of males affected was 89&#37; in our study compared with 86&#37; and 63&#37; respectively in others&#46;<span class="elsevierStyleSup">3&#44;16</span></p><p class="elsevierStylePara">Abdominal or lumbar pain was the most common symptom &#40;67&#37;&#41;&#46; This also coincides with the findings of other authors&#46; In general&#44; pain was accompanied by other non-specific symptoms like weakness&#44; loss of appetite&#44; weight loss and fever&#46; With these symptoms and the imaging findings&#44; a differential diagnosis is made that includes other processes like lymphoproliferative syndromes&#44; sarcomas&#44; sarcoidosis and vasculitis&#46; Therefore&#44; the histological diagnosis is often indispensable&#46; In this study&#44; the last four patients described were effectively diagnosed using an MR-guided biopsy&#46; This could be the method of choice in the future&#46; Corradi et al&#46;<span class="elsevierStyleSup">3</span> obtained histological samples from laparotomies or laparoscopies&#44; taking advantage of ureterolysis in 24 patients&#46; Van Bommel et al&#46;&#44; who also included 24 patients in their study&#44; only carried out biopsies on two of them&#44; since the diagnosis in most cases was made radiologically&#46;<span class="elsevierStyleSup">16</span> Moroni et al&#46; confirmed the diagnosis histologically in 8 of their 17 patients by using biopsies obtained from laparotomies and&#44; in one case&#44; from a laparoscopy&#46;<span class="elsevierStyleSup">17</span></p><p class="elsevierStylePara">The percentage of patients who presented obstructive uropathy was 77&#46;8&#37;&#46; Initially&#44; 33&#37; of males also presented hydrocele&#46;</p><p class="elsevierStylePara">After kidney complications&#44; vascular complications were the most common finding at the time of diagnosis &#40;22&#37;&#41; and throughout the follow up period &#40;33&#37;&#41;&#46; Artery complications caused by extravascular fibrosis was slightly more common than vein complications&#46;</p><p class="elsevierStylePara">One patient presented sclerosing cholangitis at the time of diagnosis and another presented it during the follow up &#40;22&#37; in total&#41;&#46; The latter patient required a special differential diagnosis which included vasculitis&#44; sarcoidosis and the aftereffects of pancreatitis because he had suffered from acute pancreatitis and panicullitis six years earlier&#46;</p><p class="elsevierStylePara">Other studies describe vascular&#44; artery or vein complications as being more common&#44;<span class="elsevierStyleSup">17</span> although they refer to radiological &#40;65&#37; of cases&#41; not clinical effects like the ones described in our study &#40;44&#37;&#41;&#44; which takes into account the findings both at the time of diagnosis and during the follow-up&#46; In most of the cases in this study&#44; the fibrotic band surrounded the large abdominal vessels&#44; the aorta or the inferior vena cava&#46; Corradi et al&#46;<span class="elsevierStyleSup">3</span> described how 17&#37; of cases presented vascular complications&#46; In the study by Van Bommel et al&#46;<span class="elsevierStyleSup">16</span> 25&#37; initially presented vascular complications&#44; however only 8&#46;3&#37; of cases presented any clinical damage&#46; In these studies&#44; the effects on the bile ducts&#44; gallbladder&#44; liver and pancreas have not been described&#46;</p><p class="elsevierStylePara">The treatment administered in this centre was prednisone and ureterolysis in cases of ureteral compression&#46;<span class="elsevierStyleSup">17</span> These studies are retrospective like ours and include a population that is too small to draw significant conclusions&#44; however&#44; it seems that immunosuppression and urological procedures are the treatment of choice&#46; Immunosuppression involves corticotherapy&#44; although in some cases it is administered along with azathioprine&#44; cyclophosphamide or tamoxifen&#44;<span class="elsevierStyleSup">17&#44;18</span> despite the fact that there is no evidence to suggest that these immunosuppressants improve patient prognosis during follow up&#46; Marcolongo et al&#46;&#44;<span class="elsevierStyleSup">18</span> in a series of 26 patients&#44; obtained good results administering prednisone and azathioprine&#46; In the future&#44; treatments that inhibit the proliferation of fibroblasts or their apoptosis&#44; like interferon&#44; may be preferable&#46;</p><p class="elsevierStylePara">The average follow up time for our patients of 89&#46;4 months was significant even though the duration of the study was short&#46; This made it possible to recommend conservative treatment for patients by administering prednisone and carrying out urological procedures using double-J catheters&#44; which were generally inserted at the site of previous nephrostomies or via an ascending route&#46; This long follow up period also rules out the possibility of retroperitoneal fibrosis which is often secondary to lymphoproliferative processes and low grade lymphomas&#46; Oshiro et al&#46;<span class="elsevierStyleSup">19</span> in particular insist on this possibility&#46;</p><p class="elsevierStylePara">We can conclude that IRF is an uncommon clinical condition that mainly affects males of around 50 years of age&#46; This condition can be diagnosed histologically through biopsies and monitored using abdominal imaging techniques&#46; Because of its pathogenic nature&#44; the treatment of this condition currently involves administering corticotherapy&#46; Urological procedures should be undertaken with care and should be as non-invasive as possible&#44; like double-J catheters&#46; Relapses are common and should be treated once again with prednisone and possibly endoureteral catheterization&#46; The current prognosis using these measures is satisfactory&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10818078&#95;f1&#95;299&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818078_f1_299.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;10818078&#95;t1&#95;300&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818078_t1_300.jpg" alt="Characteristics of patients at the time of diagnosis of idiopathic retroperitoneal fibrosis"></img></a></p><p class="elsevierStylePara">Table 1&#46; Characteristics of patients at the time of diagnosis of idiopathic retroperitoneal fibrosis</p><p class="elsevierStylePara"><a href="grande&#47;10818078&#95;t2&#95;301&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818078_t2_301.jpg" alt="Progress of patients diagnosed with idiopathic retroperitoneal fibrosis"></img></a></p><p class="elsevierStylePara">Table 2&#46; Progress of patients diagnosed with idiopathic retroperitoneal fibrosis</p><p class="elsevierStylePara"><a href="grande&#47;10818078&#95;f2&#95;301&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818078_f2_301.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; </p>"
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        "resumen" => "<p class="elsevierStylePara">Introducci&#243;n&#58; La fibrosis retroperitoneal idiop&#225;tica es una entidad cl&#237;nica de presentaci&#243;n poco frecuente&#44; que suele cursar con uropat&#237;a obstructiva por atrapamiento ureteral por el tejido fibroso e inflamatorio cr&#243;nico&#44; constituido por miofibroblastos de disposici&#243;n perivascular&#46; En los &#250;ltimos a&#241;os&#44; el pron&#243;stico parece haber mejorado con el tratamiento m&#233;dico inmunosupresor y con las intervenciones urol&#243;gicas de liberaci&#243;n de los ur&#233;teres&#46; Hemos revisado los pacientes diagnosticados de fibrosis retroperitoneal idiop&#225;tica en nuestro centro con el objetivo de revisar el motivo de presentaci&#243;n cl&#237;nica&#44; de afectaci&#243;n renal y extrarrenal&#44; el tratamiento realizado y la evoluci&#243;n cl&#237;nica seguida&#46; Han sido nueve enfermos no neopl&#225;sicos&#44; no tratados previamente con radioterapia y sin administraci&#243;n previa de gadolinio en presencia de insuficiencia renal avanzada&#46; Seis de ellos tienen diagn&#243;stico histol&#243;gico y tres radiol&#243;gico&#46; Han sido tratados con prednisona&#44; 1 mg&#47;kg&#47;d&#237;a durante tres meses&#44; y la posibilidad de colocaci&#243;n de cat&#233;teres endoluminales doble J&#46; El 89&#37; de estos pacientes ha seguido una buena evoluci&#243;n sin insuficiencia renal cr&#243;nica progresiva&#46; Las recidivas han sido frecuentes a lo largo de su seguimiento&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">Idiopathic retroperitoneal fibrosis is a rare disease often causing obstructive uropathy because the fibrosis entraps the ureters&#46; The retroperitoneal tissue is constituted by a fibrous component and a chronic inflammatory infiltrate with the former characterized by miofibroblasts&#46; The infiltrate displayed perivascular&#46; Last years&#44; the immunosuppressive therapy and the decompression of obstructive renal failure have improved the prognostic&#46; We reported 9 patients with Idiopathic retroperitoneal fibrosis in a Centre&#46; We evaluate clinical symptoms at the presentation with the signs of renal and non-renal involvement&#46; We evaluate the achieved therapy and the follow-up&#46; All 9 patients had a radiological and&#47;or histological diagnosis in the absence of malignancy&#44; previous radiotherapy or gadolinium&#8217;s administration with severe renal failure&#46; The patients were treated with 1 mg&#47;kg&#47;day of prednisone three months and possibly the insertion of ureteral catheters&#46; 89&#37; patients have a high rate of initial success without renal failure&#44; despite frequent disease relapse&#46; A patient developed progression of the fibrosis&#46;</p>"
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