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

2. Conflicts
No conflict of interests

3. Obstructive Nephropathy

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

5. 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.

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

7. 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)

8. 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)

9. 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

10. Assessment and Management

11. 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 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 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.

12. 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/ 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.

13. 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.

14. 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 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.

15. CKD
NKF, 2016

16. Muchas Gracias!!

17. 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
Uptodate. Evaluation of Acute Kidney Injury among hospitalized patients. Retrieved February 5th, 2018, from