**5. Conclusions**

256 Chronic Kidney Disease

Fig. 5. Optical Image of Pyrazine **13** at 1 Hour Post Administration.

Fig. 6. Apparatus for non-invasive in vivo detection of fluorescence.

On the basis of the fluorescence properties, plasma protein binding data, the injected dose recovered in urine, the plasma clearance data, and the renal tubular secretion studies, the pyrazine deriviatives **12-15** are promising candidates as exogenous fluorescent tracer agents for the determination of GFR under both chronic and acute settings. In the rat model, these compounds display superior properties compared to iothalamate, which is currently an accepted standard for the measurement of GFR.

A prototype instrument for clinical trials has been developed based on the apparatus in Figure 4. A clinical trial with one of the pyrazine compounds is currently being planned.

Exogenous Fluorescent Agents for the Determination of Glomerular Filtration Rate 259

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The clinical trial will test the safety and efficacy of the tracer agent, as well as refine the instrumentation. Optimization parameters for the instrument include incident light power and power density, light delivery and collection fiber optics, light source and detector, placement of detector on body, and the data acquisition and analysis algorithm.

The addition of a fluorescent GFR tracer agent would be a major addition to the armament of fluorescent compounds in clinical use today. Indocyanine green (ICG) is FDA-approved for use in angiography, cardiac output, and liver function.42 Currently, there are on-going clinical trials for lymph node mapping and melanoma imaging using ICG.43 Fluorescein is the only other FDA appoved fluorescent agent, used for angiography.42 A near-infrared dye for attachment to targeting vectors for optical imaging has been studied for safety and pharmacology, and may soon be ready for human clinical trials too.44

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**1. Introduction** 

surgery.

operation. (Fig. 1-4)

Improve renal function.

Improve quality of life.

Complications of obstruction as sepsis and pain.

Independent existence at home possible.

Table 1. Indication for palliative diversion.

Localized disease that additional therapy may prolong survival.

**16**

*Thailand* 

**Modern Surgical Treatments of**

Obstructive nephropathy is a term describing the damage to the renal parenchyma that results from the obstruction to the flow of urine anywhere along the urinary system. Long term obstruction causes chronic renal disease. Obstruction coexisting with infection and impaired renal function, when complicated by elevated temperature and leukocytosis that can lead to septic shock, are an absolute indication for urinary diversion such as percutaneous nephrostomy. This particular patient needs emergency diversion. One of the most common indications of nephrostomy placement is ureteric obstruction causing uremia. It is therefore necessary to make the patients fit enough for the designated

Percutaneous nephrostomy involving supravesicle drainage is one of the most common procedures in urologic practice. Goodwin described a trocar nephrostomy technique in a markedly dilated kidney in 1955. (Goodwin et al., 1955). Percutaneous nephrostomy is performed for temporary or permanent supravesicle urinary diversion. The treatment goals in patients with malignant ureteric obstruction are symptom relief and avoidance of any complications from renal insufficiency. Permanent nephrostomy has been used in patients

The indication of nephrostomy tube placement depends on whether the procedure is elective or urgent. The purpose of nephrostomy tube placement in obstructive renal disease is to preserve kidney function and drain infected urine. Establishing a safe and reliable nephrostomy tract is key that range from simple urinary drainage to intrarenal surgical

with obstruction from uncorrectable causes such as inoperable tumors. (Table 1)

**Urinary Tract Obstruction** 

*Faculty of Medicine, Chiang Mai University* 

Bannakij Lojanapiwat

