Anuria after Bilateral DJ stenting

• 13 Apr 2020 06:43:16 PM
• |Endo Urology

52 Y lady with metastatic ovarian malignancy 

Comments(12)

• 

  Pankaj N Maheshwari

  13 Apr 2020 07:04:35 PM

  Both CTscan images

  

• 

  Dr. Anil Takvani

  14 Apr 2020 08:01:37 AM

  Sir,  thank you very much for sharing very interesting case. 

  1. Let me try to attempt quarries raised by you 

  2. On first post stenting day output was almost 10 liter,  2nd post stenting it is 2400cc  and 3rd day it reduced to very less. 

  3. We don't have input charts 

  4. Could be increasing fluid deficits because of  huge out put of 1st post stenting day. 

  5. In addition there can issues related to gram negative infections 

  6. I would like to request you to provide input charts and total wbc,  neutrophil counts and CRP if done... 

  Thanks 

• 

  Pankaj N Maheshwari

  14 Apr 2020 08:20:03 AM

  Thanks Anil for your questions.

  We don't have input charts 

  Patient was given IV fluids as per the Post-obstructive diuresis protocol. 

  We give equal replacement every hour on first day

  
  

  Could be increasing fluid deficits because of  huge out put of 1st post stenting day. 

  She was not in negative fluid balance

  She was even given a fluid challenge which failed. 

  
  

  In addition there can issues related to gram negative infections. I would like to request you to provide input charts and total wbc,  neutrophil counts and CRP if done... 

  Patient is not in sepsis. 

  TLC (between 7-8 thousand: checked daily)

  CRP (<20), 

  No fever or tenderness. 

  Covered by Magnex. 

  Culture of urine from both kidney at the time of stent placement: no growth. 

• 

  Dr Prashant Mulawkar

  14 Apr 2020 02:36:00 PM

  Anuria after bilateral DJ stenting

  What can go wrong in this case: Let us think urological issues and nephrological isues

  Urological issues

  1.      Sepsis (Unlikely)

  2.      Blockage inside the PCS leading to blockage of the stents: Imaging and urine microscopy will tell

  3.      Blockage of stents because of debris shed off from dilated PCS: look for renal angle tenderness

  Nephrological issues

  She has pre-existing CKD. Her creatinine to start with was 1.8. eGFR 31.8.

  In such patients they can land up in problems during the post obstructive diuresis phase.

  Post obstructive diuresis is classified as**: In general there are 3 distinct types of post-obstructive diuresis

  1.      urea diuresis, fall in GFR >> retention of Urea >> deobstruction >> excess urea and water are excreted. This is usually self limiting.

  2.      salt diuresis (subdivided into 2 clinical varieties- the self-limited salt diuresis and a pathologic salt diuresis)

  3.      water diuresis: least common, self limiting nephrogenic diabetes insipidus. (* see below)

  Physiologic diuresis (self limiting, lasts for around 24 hours) This usually continues till the patient excretes salt and water.

  Pathologic diuresis (generally lasts for more than 48 hours, It can be exacerbated by excessive IV fluids)

  What can go wrong in Post obstructive diuresis?

  Pathologic POD: Patient losing salts in urine. The patients are at risk of severe dehydration, We need to look at her electrolytes, urea and urine specific gravity.

  Urine sp gravity of1010 suggests physiologic POD and likely to recover. Urine sp gravity of 1020 sugests the POD has recovered and Urine sop gravity of 1000 is pathologic suggesting urine is hypo-osmnotic and patient is losing salts. In those patients with urine SG of 1000, negative fluid balance should be targeted. The ideal fluids in these patients would be oral water or 0.45 NS. This should be followed till we get UOP of 3 liter per day. Vasopressin and aldosterone do not alter the diuretic state.

  Things to look at in this patient would be Volume depletion, Hyponatremia or hypernatremia, Hypokalemia, Hypomagenesemia, Metabolic acidosis

   

  What to do?

  If I have ruled out urological causes by imaging and clinical examination, hand over to nephrologist. These events are usually self limiting and correct over period of time. May require dialysis support.

   

   

  References:

  1.      Baum N, Anhalt M, Carlton Jr CE, Scott Jr R. Post-obstructive diuresis. The Journal of urology. 1975 Jul 1;114(1):53-6.

  2.      Halbgewachs C, Domes T. Postobstructive diuresis: pay close attention to urinary retention. Canadian Family Physician. 2015 Feb 1;61(2):137-42.

  *(Just adding something interesting although it is not important to this case per se: Diabetes: word comes from Mid 16th century: via Latin from Greek, literally ‘siphon’, from diabainein ‘go through’; Mellitus: mellitus is from Latin mellitus ‘sweet’. Diabetes mellitus: sweet siphoned out through urine. Insipidus: Tasteless; Diabetes insipidus: disease in which urine is tasteless)

   

  **Some theoretical points: How to differentiate urea diuresis from salt diuresis (Again this is theoretical: Get Urine Na and Urine K in mEq/L and serum urea in mg/dL (I am not very much sure about this, please conform from nephrologist) and do this calculation:

  (Na=K)x2+Urea=osmolality

  (Na+k)x2<1/2 osmolality = Urea diuresis

  (Na+K)x2>1/2 osmolality = salt diuresis

  (Please read the article no 2 mentioned above) 

• 

  Gyanendra Sharma

  14 Apr 2020 10:33:13 PM

  First of all I would like to congratulate Prashant for a very detailed analysis of post obstructive diuresis

  I will also agree to his statement that the stents get blocked

  If I am not wrong Pankaj had done a study where they found that DJ stents get blocked in 48 hours--ofcourse I believe this was in patients with stone disease

  As regards this patient I would like to state

  1. She presented with anuria
  2. She is a known case of ovarian malignancy
  3. The cause of anuria is likely to be extrinsic compression as Pankaj mentioned that the stent went very easily
  4. The patient had a drop in output and anuria  very soon after stenting
  5. She is otherwise stable and from the description given--pre renal cause is ruled out
  6. I feel that it is extrainsic compression which is the cause of anuria
  7. I would put another stent by the side of the existing stent
  8. If despite this the urine output does not improve then Nephrologist would come in picture
     

• 

  Dr. Anil Takvani

  14 Apr 2020 11:40:23 PM

  He has posted post stenting CT Image.

  No hydronephrosis.

  To me both pre stent and post stent CT images are almost same, only difference is we can see stents on both the sides well in position in post stenting image.

  I am not convince looking to images on argument of bilateral stent blockade.

  Thanks

• 

  Prabir Basu

  15 Apr 2020 12:46:43 AM

  I believe that her post obstructive diuresis part was well managed and so are the stents in position. The rapidity of development of the AKI in this ICU setting confers a provisional diagnosis of ATN. Cause maybe subtle hypotensive episodes due to diuresis, maybe significant since she had those recent TIAs. However, we maybe overlooking a very rare instance of tumor lysis syndrome. I would prefer to send blood for Ca,K,uric acid if not sent before. She needs an urgent dialysis after discussion with our nephrologist colleague.

• 

  Pankaj N Maheshwari

  15 Apr 2020 07:47:04 AM

  Follow-up of the case:

  I am impressed with the discussion and compliment Prashant, GRS & Dr Basu.

  We looked at Ca & Uric acid: both came normal

  Nephrologist was involved

  My options were:

  1. PCN (bilateral): not possible as patient is on dual anti platelets and patient was not keen
  2. Change stents: Would have got blocked again (I am impressed GRS remembers the study we had done more than 20Y back)
  3. Metallic stents: Issues were cost and non-availability due to covid lockdown.
  4. Bilateral dual stents

  after deliberation, Option 4 was chosen

  Bilateral dual stents were placed. Post-op patient has done good. In last three days creatinine has come down to 1.8

  Although i am sure all must be aware, the trick of placement of dual stents is that both need to be placed simultaneously. Place two wire and then slide both of them together under fluoroscopy guidance. You cannot place one at a time because the second one would push the first stent up the ureter. 

  will upload the dual stent images soon

• 

  Dr. Anil Takvani

  15 Apr 2020 08:04:06 AM

  Dr. Pankaj Sir,

  Reposting post stenting CT image.

  Have you considered CT findings to suspect blocked stents? Which findings?

  Or Clinical course and your experience?

  
  

  Thanks

  
  

  

• 

  Utsav Shah

  15 Apr 2020 08:04:22 PM

  Wow Pankaj sir. Haven’t ever seen a case where we did bilateral bilateral stenting in the 2.5 yrs of my ongoing residency. 

  
  

  I would also like to know the answers to Anil Sir’s question: Is there any predictor for stent block?

• 

  Pankaj N Maheshwari

  18 Apr 2020 09:13:20 AM

  To my assessment when i compare pre-stenting to post-stenting images, i thought the fullness had increased.

  Also we were not suspecting any pre-renal or nephrologic cause so giving a trial of stent change was justified. If successful, this would have avoided need for dialysis. At stent change, there was again significant hydronephrotic drip and she settled well in next 72 hours (creatinine on discharge 1.85). This was a chance worth taking.

  

• 

  Dr. Anil Takvani

  18 Apr 2020 09:20:26 AM

  Agree Sir.

  Good lessen learned from your case and discussions....

  Thanks.