Unraveling the Cause of Anuria Post Kidney Transplantation by Renal Scintigraphy.

A dynamic renal scintigraphy is widely used after renal transplantation to evaluate transplant function and possible complications. We report the case of a 27-year-old man with persisting anuria after kidney transplantation. A renal scintigraphy using Tc-ethylenedicysteine followed by SPECT/CT of the abdomen was performed showing tracer accumulation in the colon without any activity in the bladder, as a result of ureter reimplantation onto the sigmoid instead of onto the previously reconstructed bladder. Renal scintigraphy identified the cause and localization of the urinary leak, which led to immediate surgical reimplantation of the ureter onto the augmented bladder with onset of diuresis.

Subcapsular Hematoma Causing Anuria After Renal Graft Trauma.

A 67-year-old man presented to the emergency department 22 hours after a trauma to his kidney graft. He was asymptomatic during the first 10 hours, then he became anuric. His serum creatinine level was 2.73 mg/dL (baseline, 0.7 mg/dL), and his hemoglobin concentration was 13.1 g/dL. Computer tomography showed a 4-cm subcapsular hematoma without active bleeding. He underwent urgent decompression of the hematoma, and we did not find any active bleeding or parenchymal laceration. Urinary output had already recovered by the end of surgery without early or late complications. In conclusion, subcapsular hematoma, complicating a traumatic event on a kidney graft, can lead to a progressive parenchymal compression resulting in anuria. So, although in the absence of anemia, such events require urgent surgical decompression. Symptoms cannot be immediate, so all the graft trauma should be investigated with early ultrasound. Little is known in the case of major renal trauma but mildly symptomatic. Probably surgical exploration is better than observation to prevent possible early and late complications such as organ rejection or a Page kidney.

Intraperitoneal urine leak after prostatectomy confirmed by 99mTc-MAG3 renogram.

A 67-year-old patient presented with abdominal pain and distension 2 days after robotic radical prostatectomy for prostate carcinoma. He became anuric, and his serum creatinine level doubled, making IV contrast contraindicated. Abdominal CT without contrast demonstrated hypodense fluid in the peritoneum. Tc-MAG3 renogram detected extravasation of radiotracer from the bladder. Follow-up retrograde cystogram revealed a posterior anastomotic leak. The patient underwent uneventful surgical repair and made a full recovery. This case demonstrated that Tc-MAG3 can prove leak from the urinary tract, particularly helpful in the setting of poor renal function and contraindication to IV contrast.

Anuria in a solitary kidney with Candida bezoars managed conservatively.

UNLABELLED: Renal involvement is regularly encountered in neonates with invasive candidiasis, especially when risk factors like congenital malformations of the renal tract or poor bladder emptying and preterm birth are present. However, complete obstruction of the renal collecting system by fungal balls is rare. Although conservative management has been advocated for partial obstruction, complete obstruction is considered an indication for surgical drainage. We report a patient with anuria and Candida albicans bezoars in a solitary kidney, suggesting post-renal acute kidney injury. The patient was treated with systemic fluconazole and peritoneal dialysis for 4 days. The fungus balls disappeared and renal function recovered. CONCLUSION: Systemic antifungal therapy leads to clearance of obstructing fungus balls, and nephrostomy should be reserved for anuria due to bilateral complete obstruction with severe hydronephrosis. In these cases, temporary dialysis is a potential alternative.

Calculus anuria and its remedy.

BACKGROUND: Urinary lithiases have been a major urological problem. The objective was to determine the out come of treatment for patients with calculus anuria. METHODS: A descriptive study was conducted at Department of Urology Chandka Medical College Hospital, Larkana from March 2007 to April 2009. All patients with a diagnosis of calculus anuria of all ages and either sex were included in the study. Detailed history, physical examination and examination of genitourinary tract was performed. Investigations included complete blood examination, blood urea, serum creatinine, ultrasonography of KUB area, and X-Ray KUB. RESULTS: Among the 66 patients the cause of anuria was bilateral obstruction by the calculi in 46 cases, unilateral obstruction with small/absent/nephrectomised contralateral kidney in 20 cases. In most of the cases, ureteric catheterisation was done to relieve the obstruction. Five deaths were observed, despite emergency urinary diversion and appropriate treatment. CONCLUSION: Calculus anuria is a urological emergency. Prompt and early intervention can save the life of patient and prevent to develop chronic renal failure.

Urinary ascites and anuria caused by bilateral fungal balls in a premature infant.

A case is reported of anuria and urinary ascites secondary to bilateral ureteropelvic obstruction by fungal balls. Management consisted of bilateral nephrostomy drainage with local irrigation with amphotericin B, and systemic antifungal treatment without surgery. Aspiration by paracentesis was performed for the urinary ascites and continuous drainage through an 8 Fr pig tail catheter for the urinoma. The literature on renal fungus balls in neonates and infants is reviewed.

Calculus anuria in a spina bifida patient, who had solitary functioning kidney and recurrent renal calculi.

STUDY DESIGN: Clinical case report with comments by colleagues from Austria, Belgium, Germany, Japan, and Poland. OBJECTIVES: To discuss challenges in the management of spinal bifida patients, who have marked kyphoscoliosis and no vascular access. SETTING: Regional Spinal Injuries Centre, Southport, UK. METHODS: A female patient, who was born with spina bifida, paraplegia and solitary right kidney, had undergone ileal loop urinary diversion. Renal calculi were noted in 1986. Percutaneous nephrostolithotomy was performed in 1989 and there was no residual stone fragment. However, she developed recurrence of calculi in the lower pole of the right kidney in 1991. Intravenous urography, performed in 1995, revealed right staghorn calculus and hydronephrosis. Chest X-ray showed markedly restricted lung volume due to severe kyphoscoliosis. In 2000, she was declared unsuitable for anaesthesia due to a lack of venous access and a high likelihood of difficulty in weaning off the ventilator in the postoperative period. In June 2002, she developed anuria (urine output=18 ml/24 h) due to ball-valve-type obstruction by a renal stone at the ureteropelvic junction. Urea: 14.4 mmol/l; creatinine: 236 microl/l. Ultrasound showed right hydronephrosis. Percutaneous nephrostomy was performed. RESULTS: Following relief of urinary tract obstruction, there was postobstructive diuresis (3765 ml/24 h). However, the patient expired 19 days later due to progressive respiratory failure. CONCLUSION: In this spina bifida patient, who had reached the age of 35 years, severe kyphoscoliosis and lack of vascular access presented insurmountable challenges to implement the desired surgical procedure for removal of stones from a solitary kidney.

Routine ultrasound in acute retention of urine.

OBJECTIVE: To evaluate the frequency of urological abnormalities in routine urinary tract ultrasonography (renal and pelvic) in patients with urinary retention secondary to benign prostatic hyperplasia. METHODS: All patients presented to Salmaniya Medical Complex, Bahrain with acute retention of urine secondary to benign prostatic hyperplasia (BPH) in the period between January 2001 and December 2001 were included. The frequency of urological abnormalities, other than BPH, was obtained. RESULTS: One hundred patients were enrolled with a mean age of 67 years. Forty-one patients (41%) had other urological abnormalities. Among these, 3 cases of malignancy were discovered incidentally. A case of renal cell carcinoma, which was completely excised, and 4 cases of bladder tumor, 2 were new cases and 2 were previously known cases of cancer bladder. Other urological abnormalities were renal stones (9 cases), renal cysts (9 cases), hydronephrosis (14 cases) and bladder stones (5 cases). Asymptomatic non-urological abnormalities were gallstones (3 cases), liver cirrhosis (one case) and hepatic hemangioma (one case). Renal impairment was found in 18% of all patients and 80% with hydronephrosis. Four patients had hypoechoic nodules, and all had cancer prostate. CONCLUSION: Significant fraction of patients with acute urinary retention due to BPH have another pathology; although the majority are trivial and it did not influence the immediate management, some are life threatening such as renal cell carcinoma and bladder tumor. Hydronephrosis can be missed if one depends solely on renal biochemistry. Thus, routine evaluation of such patients with pelvic and renal ultrasonography is justified.

Noncontrast computed tomography in obstructive anuria: a prospective study.

OBJECTIVES: To evaluate the role of noncontrast computed tomography (NCCT) in the determination of the cause of obstructive anuria and to compare its accuracy with that of the traditional methods of combined plain abdominal x-ray (KUB) and gray-scale abdominal ultrasonography (US). METHODS: The study included 40 consecutive patients with obstructive anuria. In addition to the routine evaluation, which included history, clinical examination, biochemical profile, KUB, and US, all patients underwent NCCT. The study patients were tested against an age and sex-matched control group that included the normal contralateral kidneys of 57 consecutive patients who underwent KUB, US, and NCCT for acute flank pain during the same study period. The reference standard for the determination of the cause of obstruction was retrograde or antegrade ureterography with or without ureteroscopy or open surgery. The absence of obstruction in the control group was confirmed by nonequivocal normal intravenous urography of the side free of flank pain. Both NCCT and combined KUB and US were compared regarding the sensitivity, specificity, and overall accuracy. RESULTS: The study group had 48 renal units, because obstruction was bilateral in 8 patients and of a solitary kidney in 32. Of the 42 renal units with calculus obstruction, the site of stone impaction was identified in all renal units by NCCT (sensitivity 100%) and in only 25 by combined KUB and US (sensitivity 59.5%)-a significant difference (P = 0.0001). Of the 6 renal units with noncalcular obstruction, both NCCT and US diagnosed the cause of obstruction in 3. The overall sensitivity of NCCT in the determination of the cause of obstructive anuria was 94% and that of combined KUB and US was 58%-a significant difference (P = 0.0001). The specificity of NCCT was not significantly different from that of combined KUB and US (96.5% versus 93%, respectively). The overall accuracy of NCCT was 95% and that of combined KUB and US was 77%-a significant difference (P = 0.0003). CONCLUSIONS: In patients with obstructive anuria, conventional KUB and US could not identify the cause of ureteral obstruction in about 40% of the patients. Under such conditions, NCCT can accurately provide the diagnosis, obviating the need of invasive and expensive diagnostic procedures.

Utility of the inferior vena cava diameter as a marker of dry weight in nonoliguric hemodialyzed patients.

We have previously reported that the maximal inferior vena cava (IVC) diameter during quiet expiration (IVCe) measured by ultrasonography correlates well with the amount of body fluid, especially the circulating blood volume(2) and proposed using the criteria of IVC diameter to determine dry weight (DW) in anuric hemodialyzed (HD) patients: standard IVCe of pre- and post-HD are 14.9 +/- 0.4 and 8.2 +/- 0.3 mm, respectively (1). However, the same post-HD IVC criterion should not be applied to nonoliguric HD patients because it could result in rapid deterioration of residual renal function due to forced dehydration. Although the biochemical DW marker plasma atrial natriuretic peptide (ANP) is useful to evaluate hypervolemia but not hypovolemia, both hyper- and hypovolemia can be detected by IVC measurement. In the present study, we investigated whether the IVC diameter serves as an optimal evaluation of DW in nonoliguric HD (NO-HD) patients, avoiding not only overhydration but also dehydration. The IVCe and plasma ANP levels were measured in 14 euvolemic patients with chronic renal failure at conservative period (CP-CRF) and 11 NO-HD patients, in whom the average daily urine volume was more than 500 ml/day. In NO-HD patients, DW was adjusted to attain the euvolemic state with normotensive blood pressure, lack of edema, and lack of temporal oliguria after HD. The ANP in CP-CRF patients was 109.3 +/- 15.3 pg/ml, and pre- and post-HD ANP levels in NO-HD patients were 145.3 +/- 23.5 and 97.5 +/- 13.5 pg/ml, respectively. IVCe in CP-CRF was 13.4 +/- 0.9 mm, and pre- and post-HD IVCe in NO-HD patients were 14.2 +/- 1.0 mm and 11.9 +/- 0.9 mm, respectively. Although the post-HD IVCe was greater (i.e., less hypovolemic) than that in anuric HD patients, and close to the IVCe in CP-CRF, pre-HD IVCe was comparable with that in anuric HD patients. In addition, the pre-HD ANP level was no higher than that in CP-CRF. Thus, in NO-HD patients, the post-IVCe of 11.9 +/- 0.9 mm would be a marker for an appropriate DW setting avoiding severe post-HD dehydration as well as excessive hypervolemia during the interdialytic period.

Postrenal anuria after appendectomy in childhood.

An 11-year-old boy suffered from macroscopic haematuria and bilateral flank pain a few days after uneventful appendectomy for retrocaecal appendicitis phlegmonosa. Ultrasonography revealed a complete bilateral distal obstruction of the ureters. Renal failure due to postrenal anuria resolved completely after intravenous antibiotics.

The inferior vena cava diameter as a marker of dry weight in chronic hemodialyzed patients.

We have previously reported that the diameter of the inferior vena cava (IVC) reflects the amount of body fluid in hemodialyzed (HD) patients. The present study was undertaken to depict the criteria of IVC diameters for determining dry weight (DW) in anuric HD patients. In healthy subjects, the maximal diameters during quiet expiration (IVCe) and the minimal diameters during quiet inspiration (IVCi) were 16.7 +/- 3.2 and 5.7 +/- 5.4 mm, respectively (mean +/- SD). The collapsibility index (CI, 1 - IVCi/IVCe), which inversely correlates with the central venous pressure, was 0.68 +/- 0.29. In anuric HD patients, the IVCe/CI values before and after HD were 14.9 +/- 3.2/0.68 +/- 0.24 and 8.2 +/- 2.3/0.94 +/- 0.09, respectively. IVCe decreased proportionally to the amount of ultrafiltration. In HD patients with hypervolemic pulmonary edema, the IVCe and CI values were 22.4 +/- 2.9 and 0.22 +/- 0.11, respectively. We proposed that IVCe/CI after HD is 8 +/- 3 mm/0.9 +/- 0.1 as the markers of DW in anuric HD patients and that an IVCe value > or = 22 mm together with a CI < or = 0.22 implies the warning level of body fluid retention.

[Abdominal involvement in neurofibromatosis type 1]. / Abdomineller Befall bei Neurofibromatose Type 1.

Neurofibromas are benign tumours that arise from neuroectodermal tissues. They may occur as solitary lesions, or multiple, then referred to as neurofibromatosis, or von Recklinghausen's disease. We report on a 27-year old patient with large involvement of many nerve trunks and plexus (elephantiasis nervosa), responsible for bowel obstruction and anuria.