|Year : 2022 | Volume
| Issue : 3 | Page : 165-170
Changes in renal function following per cutaneous nephro lithotomy in chronic kidney disease patients with symptomatic renal calculus disease
Anil N Kumar1, AY Tyagi1, Tushar Sharma1, MM Suchitra2, Sivaparvathi Karanam3, KV Siva3
1 Department of Urology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Biochemistry, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
|Date of Submission||15-Sep-2020|
|Date of Acceptance||23-Mar-2021|
|Date of Web Publication||26-Dec-2022|
Dr. Sivaparvathi Karanam
Flat No. 203, Padmavathi Plaza, K. R Nagar, Tirupathi - 517 503, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Preserving renal function is the Achilles heel in the management of chronic kidney disease (CKD) patient due to the influence of multiple factors in its progression both reversible and irreversible. Renal calcular disease has both cause-and-effect relationship with CKD. Symptomatic renal calcular disease in a CKD patient gives an opportunity to preserve renal function to a variable extent depending on the stage of CKD as well as other comorbities of the patient. Percutaneous nephro lithotripsy is one of the best modalities to relieve obstructed renal tracts and its beneficial effects are established in patients with normal renal function however its efficacy in preserving renal function in CKD patients is less well studied, hence we have undertaken this study.
Materials and Methods: A prospective observational study was done to study the changes in renal function as assessed by eGFR and Sr creatinine following Per Cutaneous Nephro Lithotripsy at 0-, 1-, and 3-months interval in CKD patients with symptomatic renal calculus disease. Repeated measure ANNOVA test followed by multiple comparison test was applied to study the outcome. P < 0.05 was considered statistically significant.
Results: A total of 60 patients were studied, 80% were male and 20% female. Mean age of the patients in our study was 50.66 ± 13.82 years. out of 60 patients, 36.7% patients had diabetes mellitus, 55% patients had hypertension, and 11.6% had coronary heart disease. The most common presenting symptom was pain 70%, followed by recurrent fever. Most of the patients belong to CKD stage IV (30%). 65% showed improvement in renal function, 25% has stabilization in renal function, and only 10% showed deterioration of renal function. The complication rate was 23%.
Discussion and Conclusion: In our study male to female patients' ratio was 4:1 and the most common presenting symptom is flank pain (70%). The renal function improved or stabilized in 90% of patients which was high compared to other studies and deteriorated in 10% patients. PCNL has favourable outcomes in CKD patients with improvement in eGFR, good clearance rate, and low secondary procedure rates. CKD Patients with age above 60 years and having both Diabetes Mellitus and Hypertension may not show significant improvement in Serum creatinine and eGFR. In conclusion, CKD patients can be benefitted by PCNL with good improvement of eGFR and acceptable morbidity when aggressive preoperative stabilization is being done.
Keywords: Effect of PCNL, renal calculus disease in CKD, renal function
|How to cite this article:|
Kumar AN, Tyagi A Y, Sharma T, Suchitra M M, Karanam S, Siva K V. Changes in renal function following per cutaneous nephro lithotomy in chronic kidney disease patients with symptomatic renal calculus disease. J NTR Univ Health Sci 2022;11:165-70
|How to cite this URL:|
Kumar AN, Tyagi A Y, Sharma T, Suchitra M M, Karanam S, Siva K V. Changes in renal function following per cutaneous nephro lithotomy in chronic kidney disease patients with symptomatic renal calculus disease. J NTR Univ Health Sci [serial online] 2022 [cited 2023 Jan 27];11:165-70. Available from: https://www.jdrntruhs.org/text.asp?2022/11/3/165/365012
| Introduction|| |
Renal calculus disease has a prevalence of 1.7% to 18% in patients with chronic kidney disease (CKD), and renal calculus related CKD contributed to 3.2% of the total patients who started maintenance dialysis therapy. The classic presentation of renal calculus is abdominal or flank pain. Patient may have dysuria, urgency, and frequency depending upon whether patient have associated urinary tract infection. Approximately 30% of patients will report hematuria. Patients will experience nausea and vomiting due to the shared splanchnic innervations of the renal capsule and intestine. Fever is not typically present, unless associated with infection. Patients may be asymptomatic also. Long standing obstructive renal calculi may present with decreased urine output or even complete anuria.
Calculi in the urinary tract cause renal damage because of resultant obstruction, infection, frequent surgical interventions, and coexisting medical disease.,,, The mechanism of post-obstructive AKI has been well understood. Unilateral ureteral obstruction leads to increased intratubular pressure leading to intense renal vasoconstriction which in the end leads to rapid fall in renal blood flow and GFR. If the obstruction is prolonged, it leads to interstitial fibrosis and nephron loss, ending to CKD. Another potential mediator of nephrolithiasis associated kidney damage is direct toxicity caused by crystals to nephrons. Multiple biological effects of calciu moxalatecry stals and solubleoxalateionhavebeen found on renal epithelial cells, which includes apoptosis and cell death because of mitochondrial dysfunction and release of reactive oxygen species. Deposition of calcium oxalate crystals in the interstitium can also cause fibrosis. Several recent reports suggested that nephrolithiasis is independent risk factor for both CKD and ESRD. The mechanism for same remain unclear. It was seen that calculi formers more so non calcium (struvite and uric acid) calculi formers were two time more likely have higher risk of developing ESRD over 25 years follow-up, which was independent of cardiovascular risk factors and baseline CKD. Finally patients with certain hereditary calculi such as primary hyperoxaluria, cystinuria, Dent disease, and adenine phosphoribosyl transferase deficiency are at increased CKD and ESRD risk.
Options for preserving kidney function include watchful waiting, shockwave lithotripsy (SWL), an endourologic approach, and laparoscopic or conventional open surgery. Watchful waiting usually leads to the progressive loss of functioning renal tissue. SWL has limitations in poorly functioning kidneys. The only goal of treatment for patients with upper urinary tract obstruction with renal failure should be urgent decompression of the blocked upper tract. Urgent temporary decompression when warranted is performed either with retrograde placement of ureteral stents or percutaneous nephrostomy tube placement. Both procedures have an established track record with high success rates and low complication rates.
Percutaneous nephrostomy or nephropyelostomy is an interventional procedure used mainly in the decompression of the renal collecting system. Goodwin et al. were the first to publish a report involving this procedure in 1955, since then percutaneous nephrostomy catheter placement has become the important procedure for the temporary drainage of an obstructed collecting system.
Any surgical intervention is complicated in the presence of azotemia and may result in injury to renal parenchyma. Percutaneous endourologic procedures are the most suitable option and cause minimum morbidity and mortality. However patients with CKD are anemic with impaired platelet function and are at increased risk of bleeding and infection during surgical interventions. Their body homeostasis is impaired with resulting electrolyte imbalances and fluid overload. Depending on the duration and severity of CKD, altered lipid profile, secondary hyperparathyroidism, renal osteodystrophy, and cardiomyopathy are added problems. Patients with CKD are thus at a high risk for any form of anesthesia and surgery. Major complications with percutaneous nephrostomy tube placement include bleeding, sepsis, injury to an adjacent organ. Other major complications, though somewhat rare, have been reported occur in as many as 5% of patients. Keeping this in view, we have studied the efficacy of percutaneous nephrolithotomy (PCNL) in patients with CKD who have symptomatic renal calculi.
| Aims and Objectives|| |
To study the changes in renal function as assessed by serum creatinine and eGFR following Per Cutaneous Nephro Lithotomy in Chronic kidney Disease patients with symptomatic renal calculus disease.
| Materials and Methods|| |
Study design: Prospective observational study, conducted after obtaining research and ethics committee approvals and patients consent.
Study subjects: The present study include 60 Chronic Kidney Disease patients with symptomatic Renal calculi attending urology department at our center in whom Per Cutaneous Nephrolithotomy indicated. All Patients with Chronic Kidney Disease stages 2 and above with symptomatic renal calculus disease were included and pediatric patient (age <18 years) were excluded. All patients were classified according to the K/DOQI CKD classification system as stage I if patient has kidney damage with normal or increased GFR (eGFR > or equal to 90 ml/min/1.73 m2) and stage II with kidney damage with mild decrease in GFR (eGFR 60-89 ml/min/1.73 m2)), stage III with moderate decrease in GFR (eGFR 30-59 ml/min/1.73 m2), stage IV with severe decrease in GFR (eGFR 15-29 ml/min/1.73 m2), and stage V kidney failure with (eGFR <15 ml/min/1.73 m2 or requirement of dialysis). Our treatment strategy was draining all hydronephrotic kidneys with percutaneous nephrostomies (PCN) or by Double “J” stenting before the definitive procedure. The nephrostomy tubes were placed strategically, so that the matured tracts were for PCNL. Urine obtained at the time of nephrostomy or Senting was sent for culture and sensitivity. Urinary tract infection was treated with appropriate antibiotics Nephrologist's help was taken for correction of fluid overload, electrolyte imbalances, acidosis, and anemia. In the postoperative period, the patients were monitored for hemodynamic stability, electrolyte imbalances, acidosis, and fluid overload. To eliminate the element of acute renal obstruction as a cause of elevated creatinine, the patients with evidence of obstruction were drained with PCN or Double J stents for an adequate period till nadir serum creatinine (a minimum of two equal lowest values) was reached. Renal function was assessed by measuring serum creatinine and estimated glomerular filtration rate eGFR preoperatively, at 1 month and at 3-month intervals. Serum creatinine was assessed by Modified Jaffe's Rate reaction method on Beckman UnicelDxC 600 Autoanalyzer using commercial kits, in Biochemistry department. eGFR was calculated using MDRD formula.
Statistical analysis was performed using SPSS package (version window 22 package). The data was entered into an ExcelTM (Microsoft, Redmond, WA) database and analysis was performed with SPSS software. After compiling the data, statistical analysis was performed. The sample size required was calculated using the formula
n = required sample size
z = value of standard normal variate at 95% level (standard value is 1.96) p = estimated prevalence
m = margin of error at 5% (standard value of 0.05)
Categorical variables were presented as numbers (percentages) and Continuous variables presented as median/mean. Repeated measure ANNOVA test followed by multiple comparison test was applied to compare the outcome. P < 0.05 was considered statistically significant. By applying this formula approximately sample size is 63. Our study included 60 patients.
| Results|| |
Total number of patients included in the study were 60. of them 48 (80%) were men and 12 (20%) were women. Mean age of the patients in our study was 50.66 ± 13.82 years. out of 60 patients, 36.7% patients had diabetes mellitus, 55% patients had hypertension and 11.6% had coronary heart disease. The etiology of CKD was probably of interstitial secondary to renal calculi and of diabetic origin as there was no obvious history of glomerular diseases and could not be definitely ascertained. The most common presenting symptom was pain 70%, followed by recurrent fever. Out of 60 patients, 28 (46.6%) patients required pre-operative drainage, of which 8 patients required per cutaneous nephrostomy and 20 patients required double J stenting [Table 1]. The mean preoperative Sr creatinine was 2.35 ± 1.24 mg/dl and at end of 1 month and 3 month it was 2.05 ± 1.02 mg/dl and 1.99 ± 1.16 mg/dl respectively. Mean preoperative eGFR was 37.3 ± 15.8 mL/minute/1.73 m2. At the end of 1 month and 3 month it was 44.3 ± 20.3 mL/minute/1.73 m2 and 49.6 ± 26.3 mL/minute/1.73 m2 respectively, [Figure 1] and [Figure 2].
Majority of the calculi were of calcium oxalate type (35.5%), followed by calcium phosphate (33.3%), calcium carbonate (18.3%) and uric acid (13.3%) respectively. Fifty patients were completely free of calculi after the PCNL while three patients required blood transfusion post-surgery and eleven patients went into sepsis following PCNL, all of them responded to higher antibiotic and conservative management. Five patients required secondary procedure.
Most of the patients belong to CKD stage IV (30%), followed by IIIa and III b, CKD V, CKD II respectively. The stage migration of patients following PCNL was shown in [Table 2]. We had divided all 60 patients into two groups depending upon age (< or >60 years) and comorbidity, to see if they have any effect on renal function. There was no significant improvement of renal function in CKD patient's age beyond 60 years and patients having both DM and HTN [Table 3].
|Table 2: Classification of patients according to their stage and stage migration following PCNL|
Click here to view
| Discussion|| |
Patients with CKD and renal calculus are at higher risk of complications. Every attempt should be made to optimize these patients before taking patients for definitive procedure. Nephrologists help was taken to optimize the patients before any surgical procedure. Patients with severe hyperkalemia and pulmonary oedema need dialysis if indicated. Most importantly these patients should be counselled for associated need for RRT (renal replacement therapy) preoperatively and need for dialysis post-surgery. In our study male to female patients ratio was 4:1, which is high compared to other studies., The most common presenting symptom was flank pain (70%) in our study as seen by other studies. In our study renal function improved or stabilized in 90% of patients which was better compared to other studies and deteriorated in 10% patients similar to other studies as shown in [Table 4].
| Conclusion|| |
PCNL has favorable outcomes in CKD patients with improvement in eGFR, good clearance rate, and low secondary procedure rates. The renal function improved or stabilized in 90% of patients after PCNL. CKD Patients with age above 60 years and having both Diabetes Mellitus and Hypertension may not show significant improvement in Serum creatinine and eGFR. But to validate the above result, a larger study is required.
In conclusion, CKD patients can be benefitted by PCNL with good improvement of eGFR and acceptable morbidity when aggressive preoperative stabilization is being done using preoperative drainage of the renal unit if required, with adequate treatment of sepsis and good perioperative care are provided.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Marangella M, Tricerri A, Bruno M, Vitale C, Bianco O, Martini C, et al
. [Nephrolithiasis due to infections. Analysis of the mode and factors of progression toward renal failure.] (Ita) Minerva Urol Nefrol 1986;38:103-6.
Gupta M, Bolton DM, Gupta PN, Stoller ML. Improved renal function following aggressive treatment of urolithiasis and concurrent mild to moderate renal insufficiency. J Urol 1994;152:1086-90.
Jungers P, Joly D, Barbey F, Choukroun G, Daudon M. ESRD caused by nephrolithiasis: Prevalence, mechanisms, and prevention. Am J Kidney Dis 2004;44:799-805.
Moe OW. Renalcalculis: Pathophysiology and medical management. Review. Lancet 2006;367:333-44.
Gambaro G, Favaro S, D'Angelo A. Risk for renal failure in nephrolithiasis. Am J Kidney Dis 2001;37:233-43.
Michel MS, Trojan L, Rassweiler JJ. Complications in percutaneous nephrolithotomy. Eur Urol 2007;51:899-906.
Canes D, Hegarty NJ, Kamoi K, Haber GP, Berger A, Aron M, et al
. Functional outcomes following percutaneous surgery in the solitary kidney. J Urol 2009;181:154-60.
Kukreja R, Desai M, Patel S, Bapat S, Desai M. Factors affecting blood loss during percutaneous nephrolithotomy: Prospective study. J Endourol 2004;18:715-22.
Mullins JK, Semins MJ, Hyams ES, Bohlman ME, Matlaga BR. Half Fourier single- shot turbo spin-echo magnetic resonance urography for the evaluation of suspected renal colic in pregnancy. Urology 2012;79:1252-5.
Regan F, Kuszyk B, Bohlman ME, Jackman S. Acute ureteric calculus obstruction: Unenhanced spiral CT versus HASTE MR urography and abdominal radiograph. Br J Radiol 2005;78:506-11.
Hamm M, Knopfle E, Wartenberg S, Wawroschek F, Weckermann D, Harzmann R. Low dose unenhanced helical computerized tomography for the evaluation of acute flank pain. J Urol 2002;167:1687-91.
McCollough CH, Schueler BA, Atwell TD, Braun NN, Regner DM, Brown DL, et al
. Radiation exposure and pregnancy: When should we be concerned? Radiographics 2007;27:909-17.
Shafi H, Moazzami B, Pourghasem M, Kasaeian A. An overview of treatment options for urinary stones. Caspian J Intern Med 2016;7:1-6.
Ahmed AF, Al-Sayed AY. Tamsulosin versus alfuzosin in the treatment of patients with distal ureteral stones: Prospective, randomized, comparative study. Korean J Urol 2010;51:193-7.
Lingeman JE, Woods J, Toth PD, Evan AP, McAteer JA. The role of lithotripsy and its side effects. J Urol 1989;141:793.
Spies JB, Rosen RJ, Lebowitz AS. Antibbioticprophyaxis in vascular and interventional radiology: A rational approach. Radiology 1988;166:381-7.
Pollard AJ, Nicholson DA. Percutaneous nephrostomy: How to do it. J Intervent Radiol 1994;9:129-41.
Gopalakrishnan G, Prasad GS. Management of urolithiasis with chronic renal failure. Curr Opin Urol 2007;17:132-5.
Goel MC, Ahlawat R, Kumar M, Kapoor R. Chronic renal failure and nephrolithiasis in a solitary kidney: Role of intervention. J Urol 1997;157:1574-7.
Kurien A, Baishya R, Mishra S, Ganpule A, Muthu V, Sabnis R, et al
. The impact of percutaneous nephrolithotomy inpatients with chronic kidney disease. J Endourol 2009;23:1403-7.
Kumar S, Sandeep, Ganesamoni R, Mandal AK. Efficacy and outcome of percutaneous nephrolithotomy in patients with calculus nephropathy. Urol Res 2011;39:111-5.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]