CASE REPORTA case of reflex anuria and uremia related to a unilateral ureteral stone

Kayo HAYASHI, Satoshi HORIKOSHI, Kiyoshi HIRANO, Isao SHIRATO, and Yasuhiko TOMINO

Division of Nephrology, Department of Medicine, Juntendo University School of Medicine, Tokyo, Japan

A 63-year-old man had anuria associated with a unilateral ureteral stone for 24 hours. Laboratory data indicated marked azotemia with the serum creatinine concentration of 7.2 mg/dL and urea nitrogen of 48 mg/dL. The radiological findings revealed contralateral hydronephrosis. Spontaneous discharge of the ureteral stone reversed the anuria and uremia. Both ureteral and vascular spasms were attributed to the anuria in this patient.

Jpn J Nephrol 38:460-462, 1996

Key words: reflex anuria, unilateral ureteral stone, acute renal failure

Case report tended with tenderness, but there was no rebound tenderness or palpable organomegaly. A 63-year-old man presented to his physician with Urethral catheterization produced no urine. The serum right flank pain and macroscopic hematuria over the creatinine concentration was 7.2 mg/dl, urea nitrogen

preceding 2 days. He voided hematuria shortly after 48 mg/dl, serum sodium concentration 127 mEq/l, visiting the physician. Although 20 mg of scopolamine potassium 4.7 mEq/l, chloride 94 mEq/l, calcium and 250 mg of mefenamic acid were administered, he 4.3 mEq/l, phosphorus 5.0 mg/dl, and uric acid 12.8 mg/ noted increased right flank pain. An abdominal plain dl. The white blood cell count was 8.3 •~ 1031mm3 and film revealed a small calcified shadow in the right abdo hematocrit was 35.7%. men at the L4 vertebra level (Fig. 1). Intravenous pyel An abdominal ultrasonogram revealed dilatation of

ography (IVP) showed delayed enhancement and the left renal pelvis without any evidence of stones (Fig. enlargement of both kidneys. The right collecting system 3). The right renal calices and pelvis were normal. One was obstructed in the right mid-ureter, and the left hour after these examinations, he spontaneously voided collecting system and bladder were not enhanced (Fig. 150 ml of urine with fine white precipitate: specific gravity 2). He passed no urine for the following 24 hours although 1.005, pH 5.0, and no protein, sugar or acetone. The

1000 ml of fluid therapy was performed after IVP. There- flank pain was resolved immediately. Microscopic exam after he was referred to ination of the urine sediment showed many red blood He had a history of tuberculosis of the lung when he cells and 6-10 white blood cells per high-power field was 20 years of age and had a subtotal thyroidectomy (HPF). On the second day of hospitalization, an ab because of thyroid cancer at 43 years of age. He had dominal CT scan showed the absence of dilatation of never suffered from hematuria, dysuria or urinary stones. the left renal pelvis, but the left kidney was enhanced There was no history of hypertension, gout, hyper by residual radiocontrast which had been administered

parathyroidism or peptic ulcer. The patient was well- for IVP two days previously (Fig. 4). A small calcified developed and well-nourished. Physical examination shadow of the right abdomen disappeared in an ab revealed blood pressure of 130162 mmHg and a tempera dominal plain film, but an enhanced left nephrogram ture of 37.1•Ž. The abdomen was soft and slightly dis was still observed. Urinary volume gradually increased, and his serum creatinine was normalized (0.9 mg/dl) Accepted June 4, 1996 on the eighth day of hospitalization. All of the other Anuria related to unilateral ureteral stone 461

Fig. 1. Plain abdominal X-ray on admission (supine position). White Fig. 2. JVP after one hour of injection of radiocontrast medium arrow shows the ureteral stone at the L4 vertebra level. (standing position). Delayed visualization was observed in both kidneys. The right dilated pelvo-caliceal system and the ureter obstructed in the mid-portion were demonstrated and on the left side, only the ncphrogram was visualized. White arrow shows the calculus at the 1.5 vertebra level.

Fig. 3. Uhrasonogram of the kidneys. Dilatation of the left pelvis Fig. 4. Plain CT scan after recovery front anuria on the second day of was observed (white arrow). hospitalization. There was no dilatation of either pelvis, but the left kidney was still visualized by residual radiocontrast, which was administered for IVP. Excreted radiocontrast medium was also observed in the colon (white arrows). 462 K. Hayashi et al

Table 1. Reports of transient bilateral anuria associated with unilateral ureteral stone

blood chemistry and urinalysis values also recovered to have different compositions and to be relieved at the the normal levels. same time. The patient also had no history of hyper uricemia, gout, peptic ulcer or any other abnormalities Discussion as seen from the records of his annual medical checkups including abdominal echogram, serum chemistry and Reflex anuria is defined as the total cessation of urine urinalysis. Only four cases of reflex anuria associated output from both kidneys following irritation, trauma to with a unilateral ureteral stone have been reported in one renal unit or severely painful stimuli to other organs the literature (Table 1) [2, 3, 4, 5], although increase in [1]. Mechanical obstruction of both ureters, intrinsic serum creatinine and decrease in the urinary volume renal disease, primary decrease of renal blood flow caused after ureteral colic pain have been observed occasionally. by hypotension, hypovolemia or sepsis are excluded by Only one case, reported by Maletz in 1993 [3], showed this definition. Although the pathogenesis is still uncer prolonged anuria and remarkable azotemia as in our tain, two possible mechanisms have been suggested: case. Therefore, we reported here a very rare case of intrarenal arteriolar spasm and bilateral ureteral spasm reflex anuria with acute renal failure caused by a unilat [2, 3]. We reported here a case of reflex anuria and eral ureteral stone based on the findings of examination azotemia with a right ureteral stone. The fact that urethral of the CT, IVP and ultrasonogram, and the serum catheterization produced no urine, and spontaneous chemistry and urinalysis follow-up. relief of ureteral obstruction immediately resulted in urination and recovery from acute renal failure suggested Addressto: Dr. YasuhikoTomino, Division of Nephrology,Depart that the contralateral ureteral spasm was related to reflex ment of Medicine,Juntendo UniversitySchool of Medicine.2-1-1 anuria in this patient. However, IVP taken before ad Hongo, Bunkyo-ku,Tokyo, Japan. mission to our hospital showed significantly delayed and diminished nephrograms of both kidneys. These findings References suggested that bilateral vasoconstriction was also in volved. The very low specific gravity of initial urine 1. Sirota JH, Narins L: Acute urinary suppression after ureteral catheterization. The pathogenesis of reflex anuria. New Eng J excluded acute tubular necrosis. Although there was no Med 1957; 257: 1111-1113 evidence of a coincident calculus in the left ureter, IVP 2. Songco A, Rattner W: Reflex anuria. Urology 1987;19: 432-433 disclosed a defect of the left collecting system. There 3. Maletz R, Berman D, Peelle K, Bernard D: Reflex anuria and was a slight possibility that the left collecting system uremia from unilateral ureteral obstruction. Am J Kidney Dis was obstructed by radiolucent stones, since less than 1993; 22: 870-873 4. Hull J, Kumar S, Pletka P: Reflex anuria from unilateral uretral 10% of ureteral stones are thought to be radiolucent, obstruction. J Urol 1980; 123: 265-266 and we could not obtain the voided stone in this case. 5. Braam P, Schreinmachers L: Reflex anuria. Ned Tijdschr Geneeskd However, it is unusual for bilateral ureter stones to (Amsterdam) 1982; 126: 411-143