Pretreatment with low‐energy shock waves induces renal vasoconstriction during standard shock wave lithotripsy (SWL): a treatment protocol known to reduce SWL‐induced renal injury

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Abstract
OBJECTIVE To test the hypothesis that the pretreatment of the kidney with low‐energy shock waves (SWs) will induce renal vasoconstriction sooner than a standard clinical dose of high‐energy SWs, thus providing a potential mechanism by which the pretreatment SW lithotripsy (SWL) protocol reduces tissue injury. MATERIALS AND METHODS Female farm pigs (6‐weeks‐old) were anaesthetized with isoflurane and the lower pole of the right kidney treated with SWs using a conventional electrohydraulic lithotripter (HM3, Dornier GmbH, Germany). Pulsed Doppler ultrasonography was used to measure renal resistive index (RI) in blood vessels as a measure of resistance/impedance to blood flow. RI was recorded from one intralobar artery located in the targeted pole of the kidney, and measurements taken from pigs given sham SW treatment (Group 1; no SWs, four pigs), a standard clinical dose of high‐energy SWs (Group 2; 2000 SWs, 24 kV, 120 SWs/min, seven pigs), low‐energy SW pretreatment followed by high‐energy SWL (Group 3; 500 SWs, 12 kV, 120 SWs/min + 2000 SWs, 24 kV, 120 SWs/min, eight pigs) and low‐energy SW pretreatment alone (Group 4; 500 SWs, 12 kV, 120 SWs/min, six pigs). RESULTS Baseline RI (≈0.61) was similar for all groups. Pigs receiving sham SW treatment (Group 1) had no significant change in RI. A standard clinical dose of high‐energy SWs (Group 2) did not significantly alter RI during treatment, but did increase RI at 45 min after SWL. Low‐energy SWs did not alter RI in Group 3 pigs, but subsequent treatment with a standard clinical dose of high‐energy SWs resulted in a significantly earlier (at 1000 SWs) and greater (two‐fold) rise in RI than that in Group 2 pigs. This rise in RI during the low/high‐energy SWL protocol was not due to a delayed vasoconstrictor response of pretreatment, as low‐energy SW treatment alone (Group 4) did not increase RI until 65 min after SWL. CONCLUSIONS The pretreatment protocol induces renal vasoconstriction during the period of SW application whereas the standard protocol shows vasoconstriction occurring after SWL. Thus, the earlier and greater rise in RI during the pretreatment protocol may be causally associated with a reduction in tissue injury.