Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Reversible acute renal failure secondary to high creatinine level following bilateral obstructing renal stones. Abstract: This is a case of 41 year old gentleman referred to urology clinic with epigastric pain for one month duration, together with mild flank pain and dysuria, due to bilateral renal stones that lead to acute renal failure because of obstructive nephropathy, associated with marked elevation of the creatinine level. Bilateral nephrostomies, and double J stinting followed by Percutaneous Nephrostolithotomies and successful removal of both stones. Introduction: Acute renal failure (ARF) is characterized by a deterioration of renal function over a period of hours to days, resulting in the failure of the kidney to excrete nitrogenous waste products and to maintain fluid and electrolyte homeostasis. Obstructive uropathy has been identified in multiple series to account for approximately 10% of all cases of renal failure (1). In this case report we will present a case of reversible acute renal failure secondary to bilateral obstructing renal stones with very high creatinine level. Keywords: renal failure, obstructive uropathy. Case report: A 41 year old gentleman referred to urology clinic from the gastroenterology (GI) clinic, where he complained of epigastric pain for one month duration. An outpatient’s upper GI endoscopy performed and was normal. The patient started to complain from mild flank pain and dysuria, so he was referred to our clinic. The detailed history showed epigastric pain of two months duration with mild flank pain and dysuria. Family history was negative for stone formation. The physical examination showed bilateral flank tenderness. A renal ultrasound showed severe bilateral hydronephrosis with bilateral kidney stones of more than 2 x 2 cm in the renal pelvises obstructing the pelvi-uretric junction bilaterally with two small stones size 0.5 x0.6 cm in the middle calyx of the left kidney. The initial laboratory results showed a very high creatinine level (52.6 mg/dL), high blood urea nitrogen level (507 mg/dL), increased potassium level (6.41 mEq/L), mild anemia (Hemoglobin 9g/dL) and high phosphorus level (14.71 mg/dL). The white blood cells count was normal (5.74 million cells/mcL). For the urine analysis, it showed acidic reaction, turbidity, +1 dipstick protein, 6-8 red blood cells per high-power field, numerous white blood cells per highpower field, and bacteria was seen. Urine culture was positive for gram negative Acinetober bacteria sensitive to ceftriaxone. A computed tomography (CT) scan of the abdomen without contrast protocol (kidney-ureter-bladder) was done, that revealed bilateral renal stones. The patient was admitted to the hospital and the following was done for him: - On the day of admission the pt was started on intravenous ceftriaxone (Antibiotic). - CT scan guided, bilateral nephrostomies were inserted. -The creatinine level decreased gradually and reached 10.5mg/dl over one week - After one week from admission, a bilateral double J stents were inserted in the operating room and the bilateral nephrostomies were removed, the patient was discharged home and followed in our outpatient clinic . -The creatinin level started to decrease till it reached 2.7 mg/dl over one month. The pt re-admitted for right sided Percutaneous Nephrostolithotomy (PCNL) as there was a single 2×2 cm in the renal pelvis, we achieved successful PCNL with complete stone clearance, and then the patient discharged home. (Fig 1). Fig 1: A computed tomography (CT) scan of the abdomen and it revealed Left side renal stones (white arrow) and a clear right side kidney - One month later the patient was re-admitted and a left sided PCNL was successfully done and the stones were removed completely as shown in the KUB (Kidney Ureter Bladder) X ray. (Fig 2). Fig 2: KUB X ray, Post Left PCNL, showed clear left kidney from stone. The results were impressive as the creatinine dropped down to 1.2 mg/dL after three months from the first admission. The patients was kept on regular follow up in the outpatient clinic and after three years his creatinine level remained normal and the last was 1.25 mg/dl, with KUB X-ray showing the kidneys are free of stones (Fig.3) Fig 3: KUB X ray, after three years follow up, shows clear both kidneys from stone. Discussion: Obstructive uropathy refers to the condition of obstruction to urine flow from the kidney to the bladder. Such obstruction may be acute or chronic, complete or incomplete, and unilateral or bilateral. It has many diverse causes each with their own specific features and yet each producing similar disturbances to renal function and urine flow (2). The causes of ARF include pre-renal, post-renal (obstructive), and intrinsic (renal) (3). Renal obstruction is a common urological ailment (1-3). Loss of renal function can be avoided if such obstruction is timely relieved. In young and middle age patients, renal calculi are the main etiological factors of obstructive uropathy, the prevalence of stones in men was found to be 13.7%, with the highest incidence of onset of the disease during fifth decade(4). The incidence of bilateral stone when first seen is 13 % (5). Acute bilateral obstructive uropathy is a sudden blockage of the flow of urine from both kidneys and it is a urology emergency situation. Untreated obstructive uropathy can lead to obstructive nephropathy. Unless obstruction is relieved, back pressure on the kidney can result in tubular-interstitial fibrosis, tubular atrophy, and interstitial inflammation resulting in renal failure. An obstructed and infected urinary system can result in severe sepsis and cardiovascular collapse if left untreated. Sepsis may also develop after the obstruction is relieved, especially in patients who have fever and other signs of infection prior to decompression. Early diagnosis and prompt surgical intervention can lead to complete recovery and preserve renal functions (6). Because the bilateral obstructive uropathy is serious and emergency condition we started the management of our patient immediately with intravenous antibiotic. Serum creatinine level is a good index of assessment of obstruction (7). At all stages of renal insufficiency, the creatinine is a much more reliable indicator of renal function than the blood urea because the blood urea is far more likely to be affected by dietary and physiologic conditions not related to renal function. The stages of renal failure have been defined according to the creatinine as follows: creatinine level: 2.5- 4.9 mg/dl Moderate renal failure, 5 - 9.9 mg/dl sever renal failure and 10 mg/dl or greater is considered to be end stage renal disease (8). Our patient presented with very high level of creatinine (52.6 mg/dL). Shafik in his study (9) demonstrated the possible existence of a reflex relationship between the distension of the renal pelvis and ureter and the pressure of the pyloric sphincter. They call this reflex relationship the “Reno gastric reflex”, which explains the cause of gastric manifestations that might occur with reno-ureteral disorders, which explained our patient's situation. Sood et al (7), concluded in their study that percutaneous nephrostomy can be effectively performed under ultrasound guidance and should be the initial procedure in acutely obstructed kidneys with pyonephrosis and poor renal function. For our patient a bilateral percutaneous nephrostomies CT scan was done by a radiologist on the same day of admission. Since Goodwin et al published a report of the first series involving this procedure in 1955 (10), percutaneous nephrostomy catheter placement has been the prime procedure for the temporary drainage of an obstructed collecting system (11, 12). In our patient, the creatinine level started to decrease gradually and after one weak from doing bilateral nephrostomy, it reached 10.5mg/dl. In order to discharge the patient home we decided to replace the bilateral nephrostomy tubes with bilateral Double J stent. The patient discharged home and followed in the outpatient clinic and after one month the creatinine level decreased to 1.53mg/dl and we decided to do bilateral PCNL. The follow up of our patient showed near normal creatinine level over three years. Conclusion: this case showed that early intervention and removal of obstructive uropathy can revert kidney function to normal even the creatinine level was very high. Disclosure. The authors have no conflict of interests, and the work was not supported or funded by any drug company. Consent: Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-inChief of this journal on request. Author's contributors Dr. Ghazi Al-Edwan: Study design, data collections, writing. Dr. Ibrahim Qudaisat: study design, review. Dr. Kamil Fram: data collections, data analysis, writing. Dr. Sally Salman: study design, data collections. References: 1- Siddiqui M, McDougal W. Urologic Assessment of Decreasing Renal Function. Med Clin North Am. 2011 Jan;95(1):161-8. 2- O'Reilly PH.Obstructive uropathy. Q J Nucl Med. 2002 Dec; 46(4):295-303. 3- Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med 1996; 334(22):1448-60. 4- Ljunghall S, Hedstrand H. Epidemiology of renal stones in a middle-aged male population. Acta Med Scand. 1975 Jun; 197(6):439-45. 5- Luo H, Liu X, Wu T, Zhang X. Clinical application of percutaneous nephrostomy in some urologic diseases. J Huazhong Univ Sci Technolog Med Sci. Aug 2008; 28(4):439-42. 6- Anwar K, Kernohon RM, Kelly SB, Johnston SR. Percutaneous nephrostomy: a useful technique in patients with obstructive uropathy. J R Coll Surg Edinb 1988; 33; 249-50. 7- Sood G, Sood A, Jindal A, Verma DK, Dhiman DS. Ultrasound guided percutaneous nephrostomy for obstructive uropathy in benign and malignant diseases. Int Braz J. Urol 2006; 32:281-6. 8- Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Walker HK, Hall WD, Hurst JW, editors. Boston: Butterworths; 1990. 9- Shafik A. Demonstration of a "renogastric reflex" after rapid distension of renal pelvis and ureter in nonanesthetized patients. Urology. 1999 Jan; 53(1):38-43. 10- Goodwin WE, Casey WC, Woolf W. Percutaneous trocar (needle) nephrostomy in hydronephrosis. JAMA. 1955; 157:891. 11- Dyer RB, Assimos DG, Regan JD. Update on interventional uroradiology. Urol Clin North Am. Aug 1997; 24(3):623-52. 12- Kandarpa K, Aruny JE. Percutaneous Nephrostomy and Antegrade Ureteral Stenting. In: Handbook of Interventional Radiologic Procedures. 2nd ed. 1996:201.