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Indian Journal of Surgery, Vol. 67, No. 2, March-April, 2005, pp. 111-112 Letter To Editor The obstructed kidney Singh Iqbal Department of Surgery, University College of Medical Sciences, (University of Delhi) and G.T.B. Hospital, Delhi - 95 Code Number: is05032 Dear Editor, As a urologist I read with great interest the above review article[1] published in the Indian Journal of Surgery. I would like to complement them for tabulating all the data in such a precise and organized manner. While their manuscript discusses the evaluation and management of the obstructed kidney in detail; many common practical issues and situations faced by many of us especially in developing countries like ours have not been given their due attention in the manuscript. 1. Is a renal unit in a patient with renal failure really obstructed or not especially in the absence of marked hydronephrosis? What should one do when stenting has failed and PCN is not feasible as in the above situation? [Open surgery carries a high risk especially in the presence of CRF, and PCNL carries the risk of irrigant fluid overload and retention even with adequate dialysis] 2. Patients of bilateral stone disease or bilateral hydronephrosis presenting with varying degrees of chronic renal failure, is it really an irreversible renal failure? Patients of ureteric stones in solitary poorly functioning kidneys, are these renal units salvageable? 3. Patients of bilateral "obstructive uropathy" presenting with azotemia/CRF, in the absence of significant hydronephrosis, are they really obstructed renal units or are they cases of advanced medical renal disease"? 4. Renal scans in patients of nephrolithiasis with impaired renal function (CRF) how reliable are they? 1. These are tricky and challenging situations for both surgeons and urologists. The problem of chronic renal failure in calculus kidneys is common in developing countries. [2],[3],[4] The authors talk of the use of renal dynamic scans in these situations ; but renal dynamic scans(RDS) are often misleading: (i) they are fallacious especially in the presence of elevated serum creatinine, (ii) only RDS carried out with glomerular and tubular agents such as l-ethyl-cysteine(LLEC) scans may be of some benefit, that too only if the serum creatinine levels are at or below 5 mgs%, (iii) even if a RDS is done the initial scans in such patients nearly always reveal non functioning or very poorly functioning kidneys (<10%), which may be misleading. Thus greater attention should be given to the clinical history details. Could the authors comment on these aspects? 2. The CRF label invariably gets attached to prematurely to such patients, with the clinicians often condemning them to an end stage renal disease; while the so called "CRF" is often potentially reversible in many of them. Though patients with nephrolithiasis and renal failure may appear to have a dismal outcome, with proper pre-op stabilization, correction of metabolic aberrations/dialysis, timely decompression it is possible to salvage many of these renal units to an extent where the need for dialysis may be forestalled and renal replacement therapy be deferred.[2] Could the authors comment on this? 3. Decompressing obstructed renal units is in perfect order, but what should a clinician do when the so-called "obstructed kidney" shows minimal hydronephrosis, (a situation where PCN is likely to fail or DJS is not feasible) are we actually missing out a medical renal disease? These have serious implications for the surgeons and patients alike, could the authors comment on these problems. References
Copyright 2005 - Indian Journal of Surgery |
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