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Management of urolithiasis with chronic renal failure

Ganesh Gopalakrishnan and Gaurabathini Siva Prasad

Purpose of review Introduction


Epidemiological trends of urolithiasis and the prevalence of Renal insufficiency in patients with urolithiasis could be
renal failure in patients with stones have changed. This is either due to calculus nephropathy or nephropathy of
the era of minimally invasive therapy for stone disease. We medical renal disease. The exact prevalence of calculus
review the impact of minimally invasive therapy on the nephropathy alone is not known. The reported preva-
management of urolithiasis in patients with renal failure and lence of renal failure with urolithiasis is 1.7–18% [1,2].
its outcome. The definition of renal failure and its severity is different
Recent findings in various studies. Management of stones in chronic renal
The prevalence of urolithiasis has reached its peak and failure (CRF) is challenging. An appropriate approach to
plateaued in Europe and North America while it is still rising their management has been shown to stabilize renal
in the underdeveloped countries. The prevalence of renal function and delay the requirement of renal replacement
failure in patients with chronic renal failure has reduced by therapy. We focus on the topic of management of calculus
half over the last decade. Minimally invasive therapy like nephropathy.
percutaneous nephrolithotripsy has fared better than open
stone surgery in all respects. Patients with kidney stones do Problems specifically related to stones and
not have normal renal function. Recently, cystine stones, chronic renal failure
and stones in patients with renal tubular acidosis and bowel Patients with CRF are anemic, and have leucopenia
disease were shown to affect renal function significantly. (lymphopenia), a low platelet count and impaired platelet
Summary function. There is an increased tendency for bleeding
Management of stones in chronic renal failure is during intervention for removal of stones. Compared to
challenging. Efforts should be made to minimize renal injury. patients with normal renal function, they are also more
Once a ‘stone-free’ kidney is achieved, steps should be susceptible to infection and sepsis. Their body homeo-
taken to conserve renal function and address the issue of stasis is impaired, with resulting dyselecterolytemia, fluid
recurrence. overload and pulmonary edema. They might require
temporary dialysis. Depending on the duration and sever-
Keywords ity of renal failure, secondary hyperparathyroidism, renal
calculus nephropathy, renal failure, urolithiasis osteodystrophy, altered lipid profile and cardiomyopathy
are added problems. Thus, patients with CRF are high-
Curr Opin Urol 17:132–135. ß 2007 Lippincott Williams & Wilkins. risk candidates for any form of anesthesia and surgery.
Department of Urology, Christian Medical College, Vellore, Tamil Nadu, India
Management of urolithiasis in chronic
Correspondence to Dr Ganesh Gopalakrishnan, Professor and Head of Urology,
Christian Medical College, Vellore, Tamil Nadu 632004, India renal failure
Tel: +416 2282111; fax: +416 2232035; Minimally invasive therapy has replaced open stone
e-mail: ganeshgopalakrishnan@yahoo.com
surgery in the last two decades. The ultimate goal of a
Current Opinion in Urology 2007, 17:132–135 ‘stone-free kidney’ remains. Advancements have occur-
Abbreviations red in intensive care monitoring and antibiotic therapy,
CRF chronic renal failure
with resultant overall reduction in morbidity and
PCN percutaneous nephrostomy mortality.
PNL percutaneous nephrolithotripsy
SWL shockwave lithotripsy
Presentation of patients with CRF and urolithiasis can
ß 2007 Lippincott Williams & Wilkins
vary from silent uremia to loin pain, fever, urosepsis,
0963-0643 anuria and pulmonary edema. Patients with a low socio-
economic status and those with a poor understanding of
the disease can present with neglected stones and ure-
mia. Alternative medicine for stone disease is popular in
some parts of the world and such patients can ultimately
present with renal failure.

The immediate goal is to stabilize the patient with


inotropic support, empirical antibiotics and dialysis
132

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Chronic renal failure Gopalakrishnan and Siva Prasad 133

whenever required. Decompression of the pelvicalyceal in the PNL group. Intraoperative complications like
system is best done by placement of a percutaneous bleeding requiring transfusion, and ureteral and pleural
nephrostomy (PCN) when obstruction and infection is injury were significantly higher in open surgery (38%)
suspected. PCN is better than double-J stenting in compared to PNL (16%; P < 0.05). Major postoperative
relieving obstruction and control of sepsis. Sometimes complications like massive hematuria, sepsis and urine
more than one PCN may be required in different leakage were higher in the open surgery group (31%)
calyces to adequately decompress the pelvicalyceal when compared to the PNL group (18.6%); the results
system. The site of placement of the PCN should were not statistically significant. Furthermore, patients
be appropriate so that it also helps in percutaneous undergoing PNL had a shorter operation time and
retrieval of the stone in the future. Once sepsis is con- hospital stay.
trolled and the nadir level of serum creatinine is reached,
the function of individual renal units is assessed by Shockwave lithotripsy
measuring either creatinine clearance from the PCN The main concern in using shockwave lithotripsy
tube or by extraction fraction using 99Tc-labelled (SWL) in patients with renal failure is that there is
diethylenetriamine pentaacetate or L-ethyl cystine decreased fragmentation due to a deficient wet layer
dynamic renal scan. over the stone. Even if stones fragment, complete clear-
ance of fragments is doubtful due to decreased urine
Definitive management depends on the function of the output from the affected kidney. There could also be
affected renal unit and presence of any associated further loss of renal function. SWL is usually given after
anatomical anomaly. relief of obstruction by double-J stenting or PCN and
control of sepsis. There are few reports of primary
Nephrectomy SWL in the management of renal stones with renal
A nephrectomy may be indicated when the kidney failure [8,9]. Clearance rates up to 40–85% at 6 months
is either nonfunctioning or poorly functioning. It may are reported and the necessity for ancillary procedures is
be appropriate to remove a poorly functioning kidney as high as 60% to clear stone fragments. Accurate data in
when its estimated glomerular filtration rate is below this regard are lacking. In one study [8], the long-term
15 ml/min, daily PCN output is below 400 ml and renal effect on renal function was retrospectively evaluated
parenchymal thickness is below 5 mm. It is worthwhile in CRF patients who underwent SWL for renal and
to remove such a kidney and place the patient on ureteral calculi, and it was found that there was no
renal replacement therapy rather than leave behind an evidence of loss in renal function following SWL.
infective focus which could lead to life-threatening SWL is mostly used as an adjuvant to clear post open
sepsis. Nephrectomy could be performed either by a surgery or PNL residual stones. Clearance rates are only
transabdominal laparoscopic or by a retroperitoneo- up to 60% [5].
scopic approach. Ablative procedures in stone disease
are challenging and conversion rates to open surgery are Percutaneous nephrolithotripsy
high. The main modality of management in patients with
stones and CRF is PNL. There is significant evidence
Open stone surgery to support this from the Indian subcontinent [10,11]. In
Open stone surgery in whichever form, pyelolithotomy, a retrospective analysis of PNL for the treatment of
extended pyelolithotomy, anatrophic nephrolithotomy calculus nephropathy [10], a total of 1002 patients
or ureterolithotomy, improves renal function and delays underwent PNL and 78 (7%) had calculus nephropathy.
or prevents progression to end-stage renal disease PCN was placed in 64 prior to PNL, and 14 had primary
[3–5]. Open stone surgery in today’s world is, however, PNL as they had no sepsis and obvious obstruction;
recommended only for patients with complex stone 85% had improvement in renal function, 14% had no
burden and those with associated anatomic anomalies improvement and 1% required permanent maintenance
such as pelvi-ureteric junction obstruction or infundib- hemodialysis. Overall morbidity and mortality were 17.3
ular stenosis [6]. Recently, a prospective randomized and 3.8%, compared to less than 1% and none in the
study was published comparing open stone surgery group with normal renal function. All deaths were due to
and percutaneous nephrolithotripsy (PNL) in the sepsis.
management of staghorn calculi [7]. Seventy-eight
patients with 88 complete staghorn calculi were pros- In another study [11], 4400 patients with urolithiasis
pectively randomized to undergo open stone surgery underwent treatment and 84 (1.9%) had renal insuffi-
(n ¼ 45) or PNL (n ¼ 43). Both the treatment groups ciency defined as serum creatinine above 1.5 mg/dl;
were comparable with regard to stone-free rates. During 87 renal units underwent PNL and required almost
follow-up, the renal function either improved or two stages per renal unit. At 2.2 years follow-up, 39%
remained stable in 86.7% in the open surgery and 91% showed improvement, 28.6% showed stabilization and

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134 Urolithiasis

32% had deterioration in renal function; 19% required Ureteric stones


dialysis. The authors suggested that large stone bulk Improvement in renal function is probably better after
(above 1500 mm3), age below 15 years, proteinuria (above treatment of ureteric stones with renal failure. They tend
300 mg/day), thinned out renal cortex (below 5 mm) and to present early with obvious obstruction. Once renal
recurrent urinary tract infection are significant factors in function has stabilized by either PCN or double-J stent-
predicting deterioration of renal function independent of ing, management depends on the site and size of the
stone-free status. PNL fared better over open stone stone apart from renal function.
surgery in all respects [7].
Ureteric stones up to 1–1.5 cm in the upper and
PNL has its own sets of problems. There could be mid ureter are usually treated by SWL, while in the
hypothermia if the temperature of the irrigation fluid is lower ureter, ureteroscopy is preferred. Upper ureteric
not maintained. PNL operates in an almost closed system stones larger than 1.5 cm can be approached via a percu-
at a pressure of about 60 cm water, when irrigation fluid taneous route. It is advantageous if PCN placement is
absorption is likely to occur. The threshold for fluid in an appropriate calyx if stabilization of the patient
overload is low in patients with renal failure and they is being planned. Ureteroscopy with laser lithotripsy is
can develop pulmonary edema easily. Irrespective of the treatment of choice for ureteric stones as retro-
urine culture status, the presence of stones and indwel- pulsion and stone migration are greatly minimized.
ling tubes makes the pelvicalyceal system a site of Ureterolithotomy can be performed for ureteric stones
bacterial growth. Bacteremia could occur during PNL larger than 2 cm by a laparoscopic approach or by open
even if adequately covered with antibiotics. Being immu- surgery.
nocompromised, patients with CRF can go into septice-
mia easily. Although the overall operation time was Once stones and stents are removed, the patient should
shown to be shorter in PNL than open stone surgery, be kept on regular follow-up for not only stone recur-
these factors should be noted and one should attempt rence, but also for strictures after surgery on the ureter. A
to reduce complications even if this involves reducing drainage study is advisable at 6 months to rule out
the operative time or even performing it as a staged ureteric obstruction.
procedure.
How aggressive should the approach be?
There are some concerns that intracorporeal energy The history of stone disease as a possible risk factor for
sources could affect renal function. Laser lithotripsy CRF was studied in a case-control study [16]. The odds
has not been shown to affect the glomerular filtration ratios (adjusted for confounding variables) for chronic
rate of the kidney. Flexible ureteroscopy and retrograde kidney disease (overall), diabetic nephropathy and inter-
intrarenal surgery can be performed either in isolation or stitial nephritis for patients with kidney stones were 1.9
as an adjuvant to PNL to achieve a complete stone-free (95% confidence interval 1.1, 3.3), 2.5 (0.87, 7.0) and 3.4
kidney. Flexible nephroscopy either at the initial setting (1.5, 7.4), respectively. The authors [16] concluded that
of PNL or as a second-look procedure has been shown to kidney stones play a significant role in the development
enhance stone-free rates following PNL for staghorn of chronic kidney disease and suggested that the pre-
calculi [6]. vention of kidney stones may be a means of delaying
the onset of chronic kidney disease. Once the stones are
Pediatric urolithiasis removed, by whatever means, there is improvement in
Stones in the pediatric population are rarer than adults, renal function as evidenced by a mean drop of serum
comprising 1–3% of all urolithiasis. Prevalence of CRF in creatinine (1.2–2.0 mg%) [5,10] and, furthermore, there is
pediatric patients with urolithiasis in developing either prevention or delayed dialysis dependency in a
countries is 14% [12]. The pattern of pediatric urolithiasis significant percentage of patients.
is different in the developed and developing world.
Perhaps the burden is minimal in the developed world. The approach should be aggressive enough to achieve
Miniaturization of equipment has enabled us to use stone-free kidneys, but each procedure results in some
similar minimally invasive approach as in adults and loss of renal function. Stone disease that recurs requires
achieve identical clearance rates. The main concern in multiple procedures over the years and this is also a
children is that 80% of them have associated metabolic contributing factor towards chronic renal insufficiency.
abnormalities and infection is coexistent in 49% [13–15]. Measures should be taken to minimize renal injury and to
An active search should be made to identify metabolic this end minimally invasive techniques should be used as
disorders and treat them aggressively. Risk of recurrence far as possible. The approach should be planned in such a
is high and patients should be kept on active surveillance. way that it removes maximum stone burden with minimal
Specific issues like nutritional support and treatment of possible injury to the kidney. At times it may not be
infection must be addressed. advisable to chase a small residue in an inaccessible

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Chronic renal failure Gopalakrishnan and Siva Prasad 135

position which could cause more harm than benefit to the References and recommended reading
patient and at the same time one should remember its Papers of particular interest, published within the annual period of review, have
been highlighted as:
chances of stone migration and obstruction. Small-  of special interest
volume residues could be removed by flexible nephro-  of outstanding interest
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