Download Reversible acute renal failure with very high creatinine level

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.
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