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The Impact of Percutaneous Nephrolithotomy in Patients with Chronic Kidney Disease

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The Impact of Percutaneous Nephrolithotomy in Patients with Chronic Kidney Disease JOURNAL OF ENDOUROLOGY Volume 23, Number 9, September 2009 Ureteroscopy and Percutaneous Procedures ª Mary Ann Liebert, Inc. Pp. 1403–1407 DOI: 10.1089=end.2009.0339 The Impact of Percutaneous Nephrolithotomy in Patients with Chronic Kidney Disease Abraham Kurien, M.S., D.N.B., Ramen Baishya, M.S., Shashikant Mishra, M.S., D.N.B., Arvind Ganpule, M.S., D.N.B., Veeramani Muthu, M.S., M.Ch., Ravindra Sabnis, M.S., M.Ch., and Mahesh Desai, M.D., FRCS (Eng), FRCS (Edin) Abstract Introduction: The impact of percutaneous nephrolithotomy (PCNL) in chronic kidney disease (CKD) patients was retrospectively analyzed in this study. We analyzed the factors that can impair renal function and predict the need for renal replacement therapy (RRT) after PCNL. Patients and Methods: Ninety-one chronic kidney patients with a mean age of 52.5 Æ 13 involving 117 renal units underwent PCNL in our institution for 5 years. A mean of 1.6 Æ 1.1 tracks and 1.3 Æ 0.6 sittings per renal unit was required for PCNL. The estimated glomerular filtration rate (eGFR) pre-PCNL (postdrainage), peak eGFR on follow-up, and eGFR at last follow-up were recorded. The CKD stage pre-PCNL was compared with the CKD stage at last follow-up. Results: Complete clearance, auxiliary procedure, and complication rates were 83.7%, 2.5%, and 17.1%, respectively. The mean eGFR pre-PCNL and peak eGFR at follow-up were 32.1 Æ 12.8 and 43.3 Æ 18.8 mL= 2 minute=1.73 m , respectively ( p < 0.0001). At a mean follow-up of 329 Æ 540 days, deterioration with up- migration of CKD stage was seen in 12 patients (13.2%). Eight patients (8.8%) required RRT in the form of either maintenance hemodialysis or renal transplantation. Postoperative bleeding complication requiring blood transfusions was seen in seven (5.9%) and two (1.7%) of the renal units subsequently required super selective angioembolization. There were two mortalities in the postoperative period. Postoperative complications and peak eGFR (less than 30 mL=minute=1.73 m2) at follow-up are two factors that predict renal deterioration and RRT. Renal parenchymal thickness (<8 mm) also predicts the need for RRT. Conclusion: PCNL has a favorable impact in CKD patients with good clearance rates and good renal functional outcome. PCNL in this high-risk CKD population is to be done with care and full understanding of its com- plications. Introduction draining all hydronephrotic kidneys with percutaneous nephrostomies (PCN). The nephrostomy tubes are placed enal stones are an important risk factor for chronic strategically with careful planning, so that the matured tracts kidney disease (CKD) in the general population.1 The R can be used for future PCNL. Multiple nephrostomy tubes prevalence of urinary stone disease in patients on maintenance may be required for adequate drainage of all calyces. Urine hemodialysis is reported to be 3.2%,2 and 1.9% to 7.7% of the obtained at the time of nephrostomy is sent for culture and patients who undergo percutaneous nephrolithotomy (PCNL) sensitivity. Urinary tract infection is treated with appropri- have CKD.3,4 The treatment for renal stones in patients with ate antibiotics. Nephrologist’s help is obtained for correction CKD should be effective so that renal function improves or of fluid overload, electrolyte imbalances, acidosis, and ane- further renal deterioration does not occur with stable renal mia. Appropriate temporary RRT may also be initiated if re- function. This stable phase can avoid the need for renal re- quired. placement therapy (RRT). The impact of PCNL in patients During PCNL the number of tracks used is kept to an op- with CKD was assessed in this retrospective evaluation. timal minimum. We routinely use Amplatz sheath after track dilatation so as to keep the intrapelvic pressures low. Patients and Methods The nephroscopy time usually does not exceed 1 hour in these Stone removal with consequent relief of obstruction and high-risk patients. Nephrostomy drainage and antegrade infection can avoid RRT. Our treatment strategy involves Double-J stents are placed if indicated. In the postoperative Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India. 1403 1404 KURIEN ET AL. period, the patient is monitored for hemodynamic stability, toms, decreased urine output, hematuria, pyuria, and grav- electrolyte imbalances, acidosis, and fluid overload. eluria. Renal stones were located on the left side, right side, We analyzed our data of 1990 adult patients who under- and bilaterally in 35, 30, and 26 patients, respectively. Of the went PCNL for renal stones in the last 5 years till 2008. To 117 renal units, PCN were placed in 91 renal units (77.8%) in eliminate the element of acute renal obstruction as a cause of view of hydronephrosis. The average number of days with elevated creatinine, the patients with evidence of obstruction nephrostomy drainage was 9.4 Æ 7.5 before PCNL. Thirteen were drained with PCN for an adequate period till nadir patients (14.3%) required pre-PCNL hemodialysis. The mean serum creatinine (a minimum of two equal lowest values) was pre-PCNL eGFR assessed on the morning of procedure after reached. Any associated infection was treated with antibiot- adequate period of drainage in those patients with hydrone- ics. Ninety-one patients who were adequately drained with phrosis was 32.1 Æ 12.8 mL=minute=1.73 m2. The stones were nephrostomies or not obstructed and persisted to have a serum solitary renal stones in 42.7%, staghorn stones in 18%, and creatinine >1.5 mg=dL were included in this study. Paediatric multiple stones in 39.3%. The mean stone size was patients (age <18) were excluded from this analysis. 758.5 Æ 864.2 mm2 (range 50–5040 mm2). Twenty-two patients All patients were assessed preoperatively by a detailed (24.2%) had solitary functioning kidneys. Apart from the 26 history, physical examination, laboratory, and radiological patients who presented with bilateral renal stones, another 34 evaluation. Laboratory evaluation included urine analysis patients gave a history of contralateral stone disease in the and culture, basic hematology, and serum biochemistry. All past which required surgical intervention. Past procedures for patients were evaluated with plain X-ray and ultrasound of removal of stones were done in 25 of the 117 renal units. The the kidney, ureter, and bladder region. However, noncontrast procedures included pyelolithotomy, PCNL, and extracor- computed tomography scan with three-dimensional recon- poreal shock wave lithotripsy. Comorbid conditions included struction is now our choice of imaging in patients with renal diabetes mellitus in 6 patients, hypertension in 18 patients, insufficiency. and both diabetes and hypertension in another 10 patients. Details on patient’s age, sex, weight, comorbidity, pre- Ischemic heart disease and chronic obstructive airway disease senting clinical features, and significant medical and surgical were seen in four and one patients, respectively. history were recorded. Pre-PCNL interventions like insertion Complete clearance defined as nonvisualization of residual of PCN, Double-J stent, and hemodialysis were noted. In- fragments in X-ray and ultrasonography at 1 month after traoperative details like number of tracks, number of sessions, PCNL was achieved in 98 renal units (83.7%). Most of the hemoglobin drop, and complications including blood trans- renal units required removal of the stones in multiple stages fusion were evaluated. Auxiliary procedures for removal of with a mean of 1.3 Æ 0.6 stages per renal unit. Multiple tracks residual stones and other procedures for management of were required with a mean of 1.6 Æ 1.1 for complete removal complications were recorded. The follow-up data were scru- of stones. The mean hemoglobin drop was 1.8 Æ 1.1 gm=dL. tinized for episodes of recurrent urinary tract infection, stone Shock wave lithotripsy as an auxiliary procedure was re- recurrences, auxiliary procedures, and the requirement of quired for clearance of residual stones in 2.5%. maintenance RRT. Complications were seen after PCNL in 20 renal units Serum creatinine was recorded on the morning before sur- (17.1%). Postoperative bleeding complication requiring blood gery (pre-PCNL), at discharge and on every follow-up visit. transfusions seen in seven (5.9%) and two (1.7%) of the renal The estimated glomerular filtration rate (eGFR) was calcu- units subsequently required super selective angioemboliza- lated using the four-variable modification of diet in renal dis- tion. Urinary tract infection defined as culture proven or ease (MDRD) equation.5,6 The pre-PCNL eGFR, peak eGFR, prolonged febrile episodes were seen in nine patients (7.7%). and eGFR at last follow-up were recorded. The five-stage Fluid overload requiring urgent hemodialysis and a peri- classification of CKD as per the National Kidney Foundation nephric urinoma requiring ultrasound-guided aspiration published guidelines was used in our study. Patients with were seen in one patient each. There were two mortalities in CKD stages 1–5 are defined as atients of chronic kidney dam- the postoperative period, one elderly hypertensive man with age with normal, mild, moderately, and severely decreased known coronary disease to myocardial infarction and another GFR of 90, 60–89, 30–59, 15–29, and <15 mL=minute= elderly lady succumbed to sepsis and shock. Blood transfu- 1.73 m2, respectively.7 The CKD stage pre-PCNL was com- sions were required in 20.5% of the patients. These include pared with the CKD stage at last follow-up. Any patient who blood transfusions given both pre- and post-PCNL. Most of migrated to a higher or lower stage was classified as deteri- these blood transfusions were given to the patients preoper- orated or improved, respectively.
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