Renal stone with poorly functioning kidney

50/m h/o right flank pain x 15 days

No urinary complaints.
WBC: 13,500/cmm, Cr: 1.4 mg% urine culture sterile
Usg, IVP and dtpa repot attached.
How to proceed??

Renal stone with poorly functioning kidney


  • Ravindra Sabnis
    Ravindra Sabnis
    24 Feb 2020 09:36:03 PM

    Post the IVP images. Unless we see anatomical deliniation, can't offer comment. Please post photographs. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    24 Feb 2020 10:20:33 PM

    Attached are IVU pictures on behalf of Dr.  Ashish Parikh 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    24 Feb 2020 10:21:33 PM

    Attaching renal scan and USG report 

  • Dr Parimal Gharia
    Dr Parimal Gharia
    25 Feb 2020 10:18:47 AM

    Patient is already CKD 4 ( Cumultative GFR of 51 ml/min) if present DTPA is representative of actual renal function which is actually not. Obstructed Infected kidney tends to give false impression of poor renal function.

    Faint contrast excretion is already seen in IVP.
    Due to CKD status, will try to preserve maximum renal function , I would like to first divert the patient in form of Left Per Cutaneous Drainage and then re evaluate.

  • Utsav Shah
    Utsav Shah
    25 Feb 2020 05:30:47 PM

    Agree with Dr Parimal. 

    Attempt to save as many nephrons as possible to avoid/delay upstaging of CKD. 
    Maybe stent the patient first to drain the infected urine, do a PCNL a week later and then reevaluate in a couple of weeks. 
    Will need minimum two sittings of PCNL to get that burden out. 
    Request seniors to correct me if wrong. Thanks. 

  • Dr. Isteaq Shameem
    Dr. Isteaq Shameem
    25 Feb 2020 07:18:34 PM

    Isteaq Shameem

    Would do a percutaneous nephrostomy first, reasses renal function after 3-4 weeks 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    25 Feb 2020 08:22:55 PM

    In my view IVU would have been avoided with available USG findings. 

    Plain CT would have been aporropriat next investigation. 
    Followed by PCN insertion. 
    And DTPA scan after few days of drainage and decompensation of left unit.
    At present level I concur with views of all three respondents, in favour of PCN. 

  • Ashish parikh
    Ashish parikh
    27 Feb 2020 01:48:59 PM

    Thank you everyone for your valuable suggestions.

    I did left PCN. Infected turbid urine present. Sent for culture. Antibiotics started. Pt is stable at present.

  • Dr.Sneh shah
    Dr.Sneh shah
    27 Feb 2020 06:21:38 PM

    Looking at parenchyma and stone on xray..doubt that PCN will help..because mutiple calculi in calyx..single pcnl will not be able to drain perfectly..

    Willing to know PCN does not look like acute obstruction that diversion may improve functional outcome..long term hydro,chronic pyelonephritis  so future of kidney doesn't seems good .even if you try to preserve kidney by stone removal I doubt 100 percent clearance is possible or not !!!and possibility of complication is more in pcnl in poor function kidney..sooner or later pt will need left nephrectomy..

  • Ashish parikh
    Ashish parikh
    28 Feb 2020 04:12:04 PM

    Agree with dr sneh sir,  

    Pt was discharged yesterday.
    PCN output 50-60 cc. 
    Will give update on follow up
    Thank you everybody.

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