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Obstructive Nephropathy Saulo Klahr REVIEW ARTICLE Obstructive Nephropathy Saulo Klahr Abstract ages. The incidence of hydronephrosis reported by Bell (1) in a series of32,360 autopsies was 3.8% (3.9% in males, 3.6% in Obstructive nephropathy is a relatively commonentity females). The incidence of clinical manifestations of obstruc- that is treatable and often reversible. It occurs at all ages tive uropathy prior to death was not reported, and it is likely from infancy to elderly subjects. Obstructive uropathy is that hydronephrosis was an incidental finding in many of these classified according to the degree, duration and site of the patients. The incidence of hydronephrosis at autopsy is some- obstruction. It is the result of functional or anatomic le- what lower in children than in adults, being 2%in one series of sions located in the urinary tract. The causes of obstructive 16, 100 autopsies (2). Over 80% of children with hydronephro- uropathy are many. Obstruction of the urinary tract may sis at autopsy were less than 1 year old, with the balance of decrease renal blood flow and the glomerular filtration rate. childhood cases being distributed uniformly through the child- Several abnormalities in tubular function mayoccur in hood years. About 166 patients per 100,000 population had a obstructive nephropathy. These include decreased reab- presumptive diagnosis of obstructive uropathy on admission sorption of solutes and water, inability to concentrate the to hospitals in the United States in 1985 (3). Amongmale pa- urine and impaired excretion of hydrogen and potassium. tients with kidney and urologic disorders, obstructive uropa- Renal interstitial fibrosis is a commonfinding in patients thy ranked fourth at discharge (242 patients/100,000 dis- with long-term obstructive uropathy. Several factors: mac- charges). In females with kidney and urologic disorders, ob- rophages, growth factors, hypoxia, cytokines are involved structive uropathy ranked sixth as a diagnosis at discharge (94 in the pathogenesis of interstitial fibrosis. It has been shown patients/100,000 discharges). In the United States in 1985, about that ACEinhibitors ameliorate the interstitial fibrosis in 387 visits per 100,000 population were related to obstructive animals with obstructive uropathy. uropathy (3). Newultrasound techniques have made possible (Internal Medicine 39: 355-361, 2000) the diagnosis of obstructive uropathy in the fetus during preg- nancy (4, 5). In the adult, the incidence and causes of urinary Key words: angiotensin II, acute renal failure, interstitial tract obstruction vary with the age and sex of the patient. In fibrosis young and middle-aged males, acute obstruction from renal calculi is commonbut temporary, and such cases would not be included in autopsy surveys. In females of this age group, on the other hand, pelvic cancer is an important cause of obstruc- Introduction tive uropathy. In the older age group, urinary tract obstruction is more commonin the male, resulting from prostatic hyper- Obstructive nephropathy is of great importance to clinicians trophy or malignancy. because it is a commonentity that is treatable and often revers- In 1985, about 80%of the operations for benign prostatic ible. Patients with obstructive nephropathy maybe asymptom- hyperplasia were performed on menage 65 years or older. From atic or mayexhibit a diversity of clinical syndromes (see Table 1989 to 1993, a 5-year span, 4,869 patients with the diagnosis 1). Obstructive uropathy refers to the presence of structural or of obstructive nephropathy began treatment for end-stage re- functional changes in the urinary tract that impedethe normal nal disease (ESRD) in the United States (3). During this pe- flow of urine. Obstructive nephropathy is the renal disease riod, obstructive nephropathy accounted for 2%of the patients caused by impaired flow of urine or tubular fluid. Hydroneph- being treated under Medicare regulations for ESRD. Among rosis denotes dilation of the urinary tract. the 4,869 patients with obstructive nephropathy being treated for ESRD, 6.9% were younger than 20 years of age, 35.7% Incidence and Prevalence of Obstructive were between the ages of 20 and 64 and 57.4% were older than 64 years. Males comprised 73.8%of patients with obstructive Urop athy nephropathy being treated with ESRD. Obstructive uropathy is a commonentity that occurs at all Simon Professor of Medicine, Department of Internal Medicine, Barnes-Jewish Hospital (North Campus) at Washington University School of Medicine, 216 South Kingshighway Boulevard, St. Louis, Missouri 63 100- 1092 355 Internal Medicine Vol. 39, No. 5 (May 2000) Klahr Table 1. Clinical Presentation of Obstructive Nephropathy Pre sentation C ause Acute renal failure Complete bilateral obstruction (or complete obstruction of a solitary kidney) Chronic renal failure Severe partial bilateral obstruction Rank pain and/or enlarged, Unilateral obstruction partial or complete tender kidney Polyuria, polydipsia, sodium Chronic partial obstruction or post- wasting, and/or renal tubular obstructive diuresis acidosis H ypertension Increased ECF volume (bilateral obstruction): increased renin-angiotensin (unilateral obstruction) Polycythem ia Increased renal production of erythropoietin (presumably due to renal ischemia during obstruction) Bladder Symptoms: hesitancy, Obstruction of lower urinary tract (bladder incontinence, decreased caliber neck, bladder pathology) of urine stream Repeated or refractory urinary Any obstructive lesion but most commonly tract infections lower urinary tract Thecausesof upperurinary tract obstructioncan be intrin- Classification and Pathogenesis sic or extrinsic. Intrinsic causesare either intraluminalor in- tramural, withrenal calculi beingthe maincauseof intralumi- Anatomicor functional factors are importantin establish- nal obstruction. Theintramural causes of obstruction are ei- ing the causeof the obstruction.Thelevel at whichthe ob- ther anatomicor functional.Anatomiclesionsof the upperuri- struction occurs in the urinary tract, and whether it is intralu- nary tract, a less commoncauseof obstruction, include ure- minal, intramural (intrinsic), or extramural (extrinsic) are help- teral strictures, benignor malignanttumorsof the renal pelvis ful. Theimportant levels of obstruction in the urinary tract are and ureter, ureteral valves and polyps. The functional disor- the urethraandthe bladderneck,the bladderandthe ureterovesi- ders include vlsicoureteral reflux andadynamicureteral seg- cal junction, the ureter, and the renal pelvis andureteropelvic ments.Themostcommonsite of functionalobstructionin the junction. ureters is a functional defect at the ureteropelvic junction. This Obstructive uropathy is classified according to the degree, is usually a diseaseof infants. Thesecondmostcommoncause duration, andsite of the obstruction.Thedegreesof obstruc- is a functional defect at the ureterovesical junction. This is a tion are said to be highgrade whenit is complete,and low disease primarily of malechildren. Theextrinsic causes of ob- gradewhenpartial or incomplete.Whenthe obstructionis of structive uropathyare best classified underthe systemof ori- short duration it is said to be acute. Mostoften this is dueto gin of the obstructing lesion. Thelesions causing obstruction stones. Obstruction that develops slowly and is long lasting is mayoriginatein the reproductivesystem,the vascularsystem, said to be chronic,as in congenitalureterovesicalabnormali- the gastrointestinal tract, or the retroperitoneal space(see Table ties and retroperitoneal fibrosis. Obstructive uropathyis due to 2). functional or anatomiclesions that can be located anywherein Thecausesof lower urinary tract obstruction include lesions the urinary tract from the renal tubules (crystals) to the ure- of the urethra, prostate, and bladder. Anatomicalor functional thral meatus. Obstructive uropathyaffecting the lumenof the abnormalitiesof the bladdermayresult in obstruction. Ure- renal tubules is said to be intrarenal, and those causes of ob- thral strictures usually result fromchronicinstrumentationor struction that arise in the urinarytract are referredto as extra- gonococcalinfections. In males, benign prostatic hyperplasia renal. Extrarenal obstruction in turn is divided into upperuri- andprostatic cancer, particularly in the elderly, are majorcauses nary tract obstruction (above the ureterovesical junction), which of lowerurinary tract obstruction. is usually unilateral in nature, andlowerurinary tract obstruc- tion, which by definition is bilateral. 356 Internal Medicine Vol. 39, No. 5 (May 2000) Obstructive Nephropathy Table 2. Causes of Urinary Tract Obstruction Upper urinary tract Lower urinary tract Intrinsic causes 1. Phimosis, meatal stenosis, paraphimosis 2. Urethra: strictures, stones, diverticulum, 1. Intralum inal posterior or anterior ureteral valves, periure- 1. Intratubular deposition of crystals (uric acid) thral abscess, urethral surgery 2. Ureter: urolithiasis, blood clots, papillary tissue 3. Prostate: benign prostatic hyperplasia, 2. Intramural prostatic calculi, abscess, prostatic carcinoma 1. Dysfunction at the ureteropelvic or ureterovesical 4. Bladder junction a. Neurogenic bladder: spinal cord defect or 2. Ureteral valve, polyp, or stricture trauma, diabetes, multiple sclerosis, cerebrovascular accidents, Parkinsons's Extrinsic causes disease . Reproductive system b. Bladder neck dysfunction a. Uterus: pregnancy, prolapse, tumors, endometriosis c. Bladder calculus b. Ovary: abscess, tumors, ovarian remnants d. Bladder
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