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Acute Renal Failure Secondary to Ureteral Obstruction by a Gravid Uterus
0022-534 7 /82/~_284-0803$02.00/0 Vol. 128, OctoOer
T:iE ,JOURNAL OF :.JROLOG-1:
Copyright© 1982 by The 'Nilliarns & Wifains Co.
Printed in U.S.A.
ACUTE RENAL FAILURE SECONDARY TO URETERAL OBSTRUCTION BY A GRAVID UTERUS FRANKL. D'ELIA, RICHARD E. BRENNAN
AND
P. KENNETH BROWNSTEIN
From the Division of Urology and Department of Radiology, Jefferson University Hospital, Philadelphia, Pennsylvania
ABSTRACT
We :report a case of acute renal failure secondary to left ureteral obstruction by a gravid uterus. Marked atrophy of the right kidney and lower pole of the left kidney had been documented before pregnancy. Radiographic, laboratory and operative evidence of the diagnosis is offered. Ureteral obstruction in pregnancy associated with rapidly deteriorating renal function is a reportedly rare entity. 1-• Herein we describe such a case. CASE REPORT
A 25-year-old gravida I, para 0, white woman with a solitary functioning left kidney presented with acute onset of left flank pain at 39 weeks of gestation. During the next few hours the pain increased in severity and radiated down to the left thigh. The patient was nauseated and vomited. The right kidney was markedly atrophic due to reflux that had been surgically corrected during childhood. In addition, a duplicated left pyelocaliceal system and ureter were documented associated with marked atrophy of the left lower pole renal parenchyma (fig. 1).
Admission blood urea nitrogen was 20 mg./dl. Creatinine was 1.8 mg./dl. and urine was sterile. Ultrasound examination revealed marked hydronephrosis of the left kidney and dilatation of the left ureter down to the pelvic brim (fig. 2, A). A limited excretory urogram (IVP) confirmed the ultrasound findings and demonstrated no evidence ofureteral calculus (fig. 2, Band C). Urine output was 20 cc during the first 8 hours of hospitalization. With change in position from supine to decubitus the urine output improved. Serum creatinine increased to 2.8 mg./ dL and, subsequently, to 3.1 mg./dl. the next day. The renal failure worsened and cesarean section was done. After delivery of a normal newborn, examination of the ureter revealed no cause for the ureterru obstruction other than the gravid uterus. Postoperatively, the patient underwent marked diuresis (150 to 250 cc per hour) and the serum creatinine decreased to 1.6 mg./ dl. 1 day postoperatively. At the time of discharge from the hospital 6 days later the serum creatinine was 1.3 mg./dl. COMMENT
The diagnosis of ureteral obstruction due to compression the gravid uterus should be considered in pregnant patients with symptoms of renal colic or renal failure. Based on previous reports patients with polyhydramnios or a solitary kidney appear to be at risk for renal failure in pregnancy secondary to ureteral obstruction. 4 • 5 We believe that patients with renal failure during pregnancy should be studied with ultrasound as the initial imaging moAccepted for publication January 8, 1982.
803
Fm. 1. Prone radiograph from IVP performed about 2 years before hospitalization demonstrates poor contrast material excretion by small atrophic right kidney and duplication of left pyelocaliceal system. Marked atrophy of left lower pole parenchyma and complete ureteral duplication were seen on additional views (not shown).
dality. Ultrasound can determine kidney size and number, and can exclude pyelocaliceal dilatation. 6 In azotemic patients with pyelocaliceal dilatation we suggest a limited IVP to delineate further the level and cause of the dilatation.
804
D'ELIA, BRENNAN AND BROWNSTEIN
FIG. 2. A, ultrasound examination of left lower renal pole reveals "ballooning" of lower caliceal moiety (arrows) and dilatation of ureter (open arrows) medially. Additional ultrasound images (not shown) demonstrated dilatation of upper caliceal group. B, oblique abdominal radiograph from IVP shows full-term fetus and dilatation of left upper renal pyelocaliceal system (arrow) and ureter (open arrows). C, Coned-down pelvic radiograph reveals smooth tapering of distal left ureter that is displaced laterally by fetal head. REFERENCES 1. Rubin, S.-0.: Anuria during pregnancy. Report of one case. Acta
Chir. Scand., 132: 330, 1966. 2. LaPata, R. E., McElin, T. W. and Adelson, B. H.: Ureteral obstruction due to compression by the gravid uterus. Amer. J. Obst. Gynec., 106: 941, 1970. 3. Kolbusz, W. E. and Carter, M. F.: Renal insufficiency in a solitary kidney secondary to hydronephrosis of pregnancy. J. Urol., 122: 823, 1979.
4. Fox, J. J., Katz, M., Klein, S. A. and Young, B. K.: Sudden anuria in a pregnant woman with a solitary kidney. Amer. J. Obst. Gynec., 132: 583, 1978. 5. O'Shaughnessy, R., Weprin, S. A. and Zuspain, F. P.: Obstructive renal failure by an overdistended pregnant uterus. Obst. Gynec., 55: 247, 1980. 6. Ellenbogen, P. H., Scheible, F. W., Talner, L. B. and Leopold, G. R.: Sensitivity of gray scale ultrasound in detecting urinary tract obstruction. Amer. J. Roentgen., 130: 731, 1978.
T:iE ,JOURNAL OF :.JROLOG-1:
Copyright© 1982 by The 'Nilliarns & Wifains Co.
Printed in U.S.A.
ACUTE RENAL FAILURE SECONDARY TO URETERAL OBSTRUCTION BY A GRAVID UTERUS FRANKL. D'ELIA, RICHARD E. BRENNAN
AND
P. KENNETH BROWNSTEIN
From the Division of Urology and Department of Radiology, Jefferson University Hospital, Philadelphia, Pennsylvania
ABSTRACT
We :report a case of acute renal failure secondary to left ureteral obstruction by a gravid uterus. Marked atrophy of the right kidney and lower pole of the left kidney had been documented before pregnancy. Radiographic, laboratory and operative evidence of the diagnosis is offered. Ureteral obstruction in pregnancy associated with rapidly deteriorating renal function is a reportedly rare entity. 1-• Herein we describe such a case. CASE REPORT
A 25-year-old gravida I, para 0, white woman with a solitary functioning left kidney presented with acute onset of left flank pain at 39 weeks of gestation. During the next few hours the pain increased in severity and radiated down to the left thigh. The patient was nauseated and vomited. The right kidney was markedly atrophic due to reflux that had been surgically corrected during childhood. In addition, a duplicated left pyelocaliceal system and ureter were documented associated with marked atrophy of the left lower pole renal parenchyma (fig. 1).
Admission blood urea nitrogen was 20 mg./dl. Creatinine was 1.8 mg./dl. and urine was sterile. Ultrasound examination revealed marked hydronephrosis of the left kidney and dilatation of the left ureter down to the pelvic brim (fig. 2, A). A limited excretory urogram (IVP) confirmed the ultrasound findings and demonstrated no evidence ofureteral calculus (fig. 2, Band C). Urine output was 20 cc during the first 8 hours of hospitalization. With change in position from supine to decubitus the urine output improved. Serum creatinine increased to 2.8 mg./ dL and, subsequently, to 3.1 mg./dl. the next day. The renal failure worsened and cesarean section was done. After delivery of a normal newborn, examination of the ureter revealed no cause for the ureterru obstruction other than the gravid uterus. Postoperatively, the patient underwent marked diuresis (150 to 250 cc per hour) and the serum creatinine decreased to 1.6 mg./ dl. 1 day postoperatively. At the time of discharge from the hospital 6 days later the serum creatinine was 1.3 mg./dl. COMMENT
The diagnosis of ureteral obstruction due to compression the gravid uterus should be considered in pregnant patients with symptoms of renal colic or renal failure. Based on previous reports patients with polyhydramnios or a solitary kidney appear to be at risk for renal failure in pregnancy secondary to ureteral obstruction. 4 • 5 We believe that patients with renal failure during pregnancy should be studied with ultrasound as the initial imaging moAccepted for publication January 8, 1982.
803
Fm. 1. Prone radiograph from IVP performed about 2 years before hospitalization demonstrates poor contrast material excretion by small atrophic right kidney and duplication of left pyelocaliceal system. Marked atrophy of left lower pole parenchyma and complete ureteral duplication were seen on additional views (not shown).
dality. Ultrasound can determine kidney size and number, and can exclude pyelocaliceal dilatation. 6 In azotemic patients with pyelocaliceal dilatation we suggest a limited IVP to delineate further the level and cause of the dilatation.
804
D'ELIA, BRENNAN AND BROWNSTEIN
FIG. 2. A, ultrasound examination of left lower renal pole reveals "ballooning" of lower caliceal moiety (arrows) and dilatation of ureter (open arrows) medially. Additional ultrasound images (not shown) demonstrated dilatation of upper caliceal group. B, oblique abdominal radiograph from IVP shows full-term fetus and dilatation of left upper renal pyelocaliceal system (arrow) and ureter (open arrows). C, Coned-down pelvic radiograph reveals smooth tapering of distal left ureter that is displaced laterally by fetal head. REFERENCES 1. Rubin, S.-0.: Anuria during pregnancy. Report of one case. Acta
Chir. Scand., 132: 330, 1966. 2. LaPata, R. E., McElin, T. W. and Adelson, B. H.: Ureteral obstruction due to compression by the gravid uterus. Amer. J. Obst. Gynec., 106: 941, 1970. 3. Kolbusz, W. E. and Carter, M. F.: Renal insufficiency in a solitary kidney secondary to hydronephrosis of pregnancy. J. Urol., 122: 823, 1979.
4. Fox, J. J., Katz, M., Klein, S. A. and Young, B. K.: Sudden anuria in a pregnant woman with a solitary kidney. Amer. J. Obst. Gynec., 132: 583, 1978. 5. O'Shaughnessy, R., Weprin, S. A. and Zuspain, F. P.: Obstructive renal failure by an overdistended pregnant uterus. Obst. Gynec., 55: 247, 1980. 6. Ellenbogen, P. H., Scheible, F. W., Talner, L. B. and Leopold, G. R.: Sensitivity of gray scale ultrasound in detecting urinary tract obstruction. Amer. J. Roentgen., 130: 731, 1978.