The clinical presentation of patients with bilateral stones is discussed. The majority of patients presenting to the Nephrology Unit were in renalfailure. Aggressive medical treatment allowed diagnostic procedures and definitive surgery to be performed in uraemic patients. Most patients presenting in uraemia benefittedfrom treatment

Hussein Awang

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Med. J. Malaysia Vol. 36 No. 1 March 1981.
BILATERAL STONES AND RENAL FAILURE
ABU BAKAR SULEIMAN
HUSSEIN AWANG
F.PROEHOEMAN
SUMMARY
The clinical presentation of patients with
bilateral stones is discussed. The majority of
patients presenting to the Nephrology Unit were in
renalfailure. Aggressive medical treatment allowed
diagnostic procedures and definitive surgery to be
performed in uraemic patients. Most patients
presenting in uraemia benefittedfrom treatment.
INTRODUCTION
Forty patients with bilateral stones were treated
by the Nephrology unit over 2 years (1977, 1978).
This retrospective study was undertaken to review
the clinical presentation, and results of acute
medical treatment followed by definitive surgery in
patients with bilateral stones, particularly among
those presentingwith impaired renal function.
CLINICAL MATERIAL
All patients with calculi In both outflow tracts
treated by the Nephrology Unit over the 2 year
period were included in this review. Patients
admitted to the Urology Unit and not initially
treated by the Nephrology Unit were excluded.
Resuscitative measures including intravenous
therapy, control of infection and hypertension,
correction of anaemia, and peritoneal dialysis were
Abu Bakar Suleiman MBBS (Mon.), M.Med., FRACP
Hussein Awang MBBS (Melb.) FRACS
F.Proehoeman M.D.
Departments of Urology and Nephrology
General Hospital
Kuala Lumpur.
14
performed where necessary. Radiological
examinations including intravenous urograms were
done on 38 patients and retrograde pyelograms in
4. Biochemical tests including the serum
creatinine, blood urea and electrolytes, uric acid,
calcium and phosphates were performed
periodically. The presence of calculi was diagnosed
from radiological studies, operative findings and
from a clear history of passing outofstones.
CLINICAL PRES:F.NTATION
There were 29 males and 11 females with ages
ranging from 22 to 69. There were 20 Malays, 15
Chinese and 5 Indians.
The main clinical features were uraemia in 15
(37.5 percent) loin pain in 16 (40 percent) and
complete anuria (for at least 24 hours) in 7 (17.5
percent). Hypertension was present in 8 patients
and 5 were known to have gout. 3 patients were
known to have had renal stones before admission.
20 patients were admitted with serum creatinine
greater than 8 mg% per 100 ml. 10 of these 20
patients underwent definitive surgery, 6 were
operated upon both sides and 4 on one side.
Surgery was refused by 2 patients and not
performed on 1 with extensive calculous disease in
both kidneys. 4 patients presented in complete
anuria, 2 of whom improved rapidly after passing
out calculi and the other 2 diuresed after
rehydration and peritoneal dialysis. 3 patients died
after admission
6 patients were admitted with serum creatinine
between 4 mg and 8 mg. Surgery was performed on
4 patients but not on 2 with bilateral extensive
calculus disease. Of 14 patients with serum
creatinine below 4 mg, surgery was performed on 8
(3 both sides, 5 one side) but not on the other 6 (4refused surgery, 2 had bilateral calculous disease).
Peritoneal dialysis was performed on 7 patients. All
patients were followed up for at least 4 months.
RESULTS
Of 22 patients operated upon, 9 out of 10
patients improved with serum creatinine greater
than 8 mg. In 8 the serum creatinine stabilised
below 4 mg and remained at 5.5 mg in the other.
No improvement was detectedin 1 patient. 2 out of
4 patients with serum creatinine between 4 mg and
8 mg improved, with the creatinine remaining
below 2 mg, renal function did not improve in the
other 2. Of8 patients withserum creatinine below 4
mg, renal function remained stable in 7, but
deteriorated in 1.
2 patients developed septicaemia In the
immediate post-operative period. 1 patient
developed hepatitis and another a stroke. All
recovered completely.
18 patients were treated medically and 5 out of 7
patients with serum creatinine greater than 8 mg%
improved, with serum creatinine below 2 mg% on
discharge. The other 2 patients remained severely
uraemic. Renal function in the 2 patients with
serum creatinine between 4 mg% and 8 mg%
remained stable. Six patients with serum creatinine
below 2 mg% maintained stable renal function.
There were 3 deaths. All were uraemic and 2 died
within 24 hours of admission. The other died of
myocardial infarction after 7 days.
Of26 patients with serum creatininegreater than
4 mg%, 6 had calculi in both ureters, 8 in both
kidneys and 12 in one kidney and the opposite
ureter. All 6 patients with bilateral ureteric calculi
had serum creatinine greater than 8 mg%, 2
improved without surgery with serum creatinine
remaining less than 2 mg% on discharge. Following
surgery serum creatinine improved to below 2 mg%
in 2 patients and 2.7 mg% and 4.5 mg% in another
2. Two patients were found to have bilateral
radiolucent calculi and 2 others had primary
hyperparathyroidism.
15
DISCUSSION
Bilateral calculi causing renal failure IS
uncommon (Muerchke, 1969). In a series of 200
patients with obstructive renal failure over a 10 year
period reported by Chisolm (1970) 17 percent were
caused by calculi. In a large series of over 1000
cases of urolithiasis, over a four and a half year
period reported by Sreenevasan (1974), 10.7
percent ofthese patientshad bilateral calculi.
Uraemia 15 (37 percent), loin pain 16 (40
percent) and hypertension 8 (20 percent) were
common clinical features. Complete anuria, a
characteristic (Pillay & Dunea, 1971) of complete
obstruction was present in 7 patients (17.5 percent).
Although the majority of patients seen had severe
impairment ofrenal function, all except 3 patients
up to the time of admission were not aware oftheir
calculous disease. Presumably the silent nature of
their disease resulted in late clinical presentation,
by which time significant renal damage had
occurred.
Aggressive resuscitative measures in uraemic
patients allowed radiological examinations to be
safely performed, followed by definitive surgery, as
advocated by Chisolm (1970) and Sreenevasan
(1974). The majority of patients who presented in
uraemia showed improved renal function after
treatment. Patients who presented in complete
anuria all responded well to treatment. Patients
with less. severe renal impairment and presenting
less acutely, responded less dramatically to medical
and surgical treatment.
Despite the presence of uramia, the intravenous
urograms were helpful in providing information
regarding the level and degree of obstruction.
However it is less helpful in evaluating functional
changes (Wilkiemayer et all 1972; Hoffman and
Grayhack, 1960) and in assessing recoverability of
renal function following surgery. A radionuclide
procedure recently reported by Buescher et al, 1978
is helpful in evaluating functional changes and in
the following of patients with stones. The dynamic
renal scan has also recently been reported to be
a sensitive method in predicting recoverability ofTABLE I
BILATERAL STONES AND RENAL FAILURE
CLINICAL FEATURES
Uraemia
Loin pain
Bilateral (6) }
Unilateral (10)
Complete Anuria
Hypertension
Haematuria & Passage
of calculi
Dysuria
Recurrent UTI
Gout
renal function after surgery (Lome et at) 1979).
These procedures may be helpful in assessing the
possible benefits of surgery in cases of stones with
severelyimpaired renal function.
Early detection, investigation for causes of
uninary calculi, appropriate treatment, and
privention of recurrence, are all 0 bviously
important in preventing renal damage. Patients
with bilateral stones and severe renal failure pose
difficult problems in management. Despite reliefof
obstruction, improvement in renal function is less
likely in long standing obstruction, emphasising the
important for early diagnosis and treatment to
prevent irrecessible renal damage.
REFERENCES
Buescher, H.J., Llyod, L.K., Dubovsky, E.V., et. al. (1978)
Radionuclide Kidney Function Evaluation in the
Management of Urolithiasis.]. ofu-»; 120: 16-20.
15(37.5%)
16(40 %)
7(17.5%)
8(20 %)
3
2
1
5
Chisolm, G.D. (1970) Obstructive Nephropathy Proceedings
Roy. Soc. Med. 63 : 1242-1245.
Hoffman, W.W. and Grayhack, J.T. (1960) The limitations of
the intravenous pyelogram in assessment of renal function.
Surg., Gynae. e Obstet. 110: 503-507.
Lome, L.G., Puisky, S and Levy L. (1979) Dynamic Renal Scan
in the Non-visualingkidney.]. ofUrol. 121: 148-152.
Muerchke, R.C. (1969) Acute Renal Failure. St. Louis, W.
Mosby. P.P. 26-28.
Pillay, V.K.G., Dunea, G. (1971) Clinical Aspects of Obstructive
Uropathy. Med. Clin. N. America 55: 1417-1427.
Sreenevasan, G. (1974) Bilateral Renal Calculi. Annals Royal
College ofSurgeons (Lond) 55: 3-12.
Wilkiemayer, R.M., Boyce, W.A., and Malek, R.S. (1972) Vali-
dity of the intravenous urogram in, the assessment of renal
function. Surg., Gynae., & Obstet. 135: 897-899.
16

BILATERAL STONES AND RENAL FAILURE ABU BAKAR SULEIMAN

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