INTRODUCTION:
Kidney stones are a common entity, affecting approximately 5% of
women and 12% of men in general population.
Prevalence of kidney stone disease is increasing and likewise the
complications associated with stone disease .The most life threatening
being sepsis and renal failure. Both could be treated with return of good
renal function if managed early and meticulously.
The pathophysiology of renal insufficiency in obstructive uropathy
is well studied. Similar mechanism is seen in stone disease also. but specific
feautures of calculous disease like duration of obstruction, type of
stone, Infected system, location of stone plays an additional role along
with obstruction. Renal calculous disease may be associated with various degrees of
renal insufficiency secondary to a combination of obstruction, urinary
infection, frequent surgical intervention, and coexisting medical disease.
Many patients with calculous disease on conservative management
by themself or by a nonspecialists land up in renal insufficiency due to
lack of timely referral to urologist and intervention. This type of
presentation was seen in many patients .there are many queries about the
recoverability of renal function in them if renal parenchyma was thinned
out. In 25 patients with stone disease and elevated renal parameters we
have studied the various factors influencing the outcome -preoperative,
intraoperative, postoperative. We have analysed all the entities and the results after intervention in these patients.
AIM OF STUDY:
1. To analyze the preoperative factors causing renal insufficiency in stone disease.
2. To assess the interventions done to improve renal function.
3. To discuss the factors that decide the outcome.
4. To analyse the improvement in renal function after intervention.
5. Follow up in treated patients.
MATERIALS AND METHODS:
Study group: Patients who were admitted in the Kilpauk Medical College Hospital and Govt. Royapettah Hospital, Chennai , with clinical diagnosis of urolithiasis from January 2009 – March 2011. Study design: cross sectional study.
Inclusion criteria:
1) Patients with stone disease,
2) Increased renal parameters.
Exclusion criteria:
1) Known case of medical renal disease,
2) Patients with associated congenital anomalies of urinary tract causing obstruction.
Total number of patients included in the study are 25. Among them 20 were male and 5 were female patients.
RESULTS:
Complete clearance defined as no visible fragment on KUB films
and renal ultrasonography at 1 month follow-up was achieved in 22
patients (88%), while 3 patients (12%) had residual fragments.
Over a mean follow-up of 1 to 2 years , 1 patients showed evidence
of recurrent calculi, and 5 patients had recurrent urinary tract infection.
Overall, 20 patients (80%) showed improvement, 5 patients (20 %)
showed stabilization.
The baseline serum creatinine concentration correlated well with
the postoperative renal function which stabilized or improved in nearly
all patients.
DEMOGRAPHIC DATA:
No. of patients 25, Mean age (years) -40 yrs, Sex (% male) 72%, Side (% right) 53%, Complete staghorn -3, Partial staghorn -2, Pelvic -5, Mean calculus size -3cm, Prior stone treatment -2, Associated hypertension -3, Associated diabetes -8, Associated urinary infection -8, Nephrostomy drainage required -4, Dialysis required preoperatively -1, Mean postoperative serum creatinine (mg/dL)-1mg%.
Large stag horn calculus if nonobstructing had good preserved renal function. Of the various factors Preop serum creatinine ,cortical
thickness, diabetes mellitus, proteinuria, and recurrent urinary infection were found to correlate with post operative renal deterioration.
CONCLUSION:
Most patients presenting with renal insufficiency due to calculous
disease experience improvement or stabilization of renal function with
early aggressive intervention aimed at complete stone clearance.
Serum creatinine - was the most important predictor of renal
recovery high baseline creatinine indicated severity of renal damage, post
operative creatinine showed only moderate decrease in these patients.
Cortical atrophy - if associated with bilateral obstruction
recoverability is moderate.even in unilateral cortical thinning opposite
kidney goes for hyperfiltration injury and focal nephrosclerosis.
Renal preservative measures followed during this period helps in
preventing hyperfiltration renal damage.
Diabetes mellitus - patients with DM had more chances of
progressing to renal insufficiency following calculous obstruction due to
diabetic nephropathy with superimposed resistant urinary tract
infections.even in this group early intervention by diabetic
control,infection control and stone removal showed good results
Large stone burden - implied more fibrotic reaction .stag horn
calculus were having preserved parenchyma due to lack of
obstruction.Recurrent or persistent urinary infection in these patients
were associated with high incidence of post operative renal deterioration.
Residual stones - Meticulous attention should be given towards
stone clearance since residual stones can regrow, cause obstruction, and
urinary tract infection
Morbidity and mortality is reduced in these group of patients by
judiciously handling the condition with timely interventions and further
prevention of renal deterioration and follow up of these patients
