Obstructive Nephropathy Liza A. Lucero RN, FNP-C, MSN Renal Medicine Associates

Conflicts No conflict of interests

Obstructive Nephropathy

Objectives Definition of Obstructive Nephropathy Causes Clinical manifestations Review management and monitoring

Obstructive Nephropathy Structural or functional restriction of normal urine flow leading to renal dysfunction (renal nephropathy). Can occur anywhere between the collecting duct , urinary calculi, tumors, and luminal strictures.

Obstructive Nephropathy Intrinsic Obstructions Nephron Renal pelvis Ureteral Bladder Urethra Extrinsic Obstructions Renal Pelvis Ureter (Gilbert & Weiner, 2018)

Causes of Obstruction Intrinsic Extrinsic Intraluminal Intramural Intratubular – crystals (uric acid drugs Stones Papillary tissue Blood clots Fungal Ball Intramural Pelviureteral or vesicoureteral Tumors, malignancy Infections, granulomas, strictures Reproductive Cervix: CA Uterus: pregnancy, prolapse, endometriosis, PID Ovary: tumor, cysts Prostrate: CA Vascular Aneurysms Aberrant arteries Venous (Johnson & Jürgen, 2015)

Causes of Obstruction GI Retroperitoneal space Chrohn Dz, Pancreatitis Appendicitis Diverticulitis Tumors Retroperitoneal space Lymph nodes Fibrosis Hematoma Radiation therapy Surgical disruption or ureteral ligation (Johnson & Jürgen, 2015)

Clinical Manifestations Wide variety depending on site, degree, duration of the obstruction. Upper vs. lower differ Most common: Pain Decrease force of stream Nocturia S/S of UTI Hematuria Changes in UOP Abnormal physical findings Abnormal lab values

Assessment and Management

Case Sudy Mr. Mayle, is a 65-year-old male who is followed by Nephrology for hypertension, BPH, left hydronephrosis in 2012, chronic renal failure with a baseline creatinine 1.6-1.9. Upon review of labs prior to appointment, Cr was 6.3. He was sent to the Emergency Department by the Nephrology office. Initial evaluation revealed a creatinine of 6.09, potassium 3.0, abnormal urine wbc's 10-15 with clumps. Bladder scan showed 220 mL of urine. He was admitted to the medical service and a Foley catheter was placed with good clear urine.

HPI/PMH PRIMARY DIAGNOSES 1. Acute on chronic renal failure, creatinine 6.09, improved to 5.73. 2. Nonobstructing bilateral nephrolithiasis. 3. Large bladder calculus 1.4 cm size. 4. Hypertension 174/109 -- improved. SECONDARY DIAGNOSES: 1. Cerebrovascular accident in 2013 with residual mild right leg weakness. 2. Diabetes mellitus type 2, on no medication. 3. Hypertension. 4. Benign prostatic hypertrophy. 5. Left ureteropelvic junction stent for hydronephrosis in 2012, creatinine 3.6 at that time. 6. Possible silent inferior infarct in 2012, but had normal echocardiogram showing no ventricular wall abnormality. 7. Hyperlipidemia.

Diagnostics CT of abdomen and pelvis. Impression: Bilateral nonobstructing renal calculi, minimal fullness of the collecting system and _____ on the left and difficult to exclude, additionally, there is a large stone in the bladder measuring 1.4 cm. Ultrasound of kidney and bladder. Impression: Atrophic right kidney with a nonobstructing right renal calculus, mild hydronephrosis with lower pole left renal calculus, bladder calculi.

What Happened? We did not see any improvement over a few months, which may have been from an obstructive process, which he likely had during the prior weeks to his admission to the hospital. Continued to f/u in CKD office- did not recover function. Currently, stage V, AVF placed, waiting to start on HD . He did produce 4 more stones 1.5-2 cm in size, brought to his appointment, which he did not have any sensation of passing. Continued to f/u with urology, did have lithotripsy of bladder stone.

CKD NKF, 2016

Muchas Gracias!!

References Gilbert, S.J, Weiner, D.E, Gibson, D.S, Perazella, M.A, & Tonelli, M. (2014). National Kidney Foundation’s Primer on Kidney Diseases. Philadelphia , PA. Elsevier. Johnson, R.J, Feehally, J., & Jürgen, F. Comprehensive Clinical Nephrology. (2015). Philadephia, PA. Elseview. National Kidney Foundation. (2016, November 30). KDOQI Guidelines. Retrieved November 30, 2016 , from https://www.kidney.org/professionals/guidelines/guidelines_commentaries Uptodate. Evaluation of Acute Kidney Injury among hospitalized patients. Retrieved February 5th, 2018, from http://www.uptodate.com/home