2022 Recommendations of the AFU Lithiasis Committee: Specific cases - chronic kidney disease, bilateral stones, and solitary kidney.

Chronic kidney disease, diabetes and hypertension are risk factors of kidney function impairment. The relative risk of kidney failure is 1.52 in patients with urinary stone disease. The various techniques used to remove upper urinary tract stones generally do not alter kidney function in patients with normal kidney function and may sometimes improve kidney function or slow its deterioration in patients with kidney disease. Compared to the asynchronous treatment of bilateral renal and ureteral stones, concomitant treatment is associated with higher risk of anuria and the need of additional interventions, in the absence of postoperative stenting. For the treatment of solitary kidney stones, the absence of postoperative stenting increases the risk of postoperative anuria. Moreover, the multiplication of percutaneous nephrolithotomy access tracts increases the risk of bleeding and that of kidney function impairment. METHODOLOGY: These recommendations were developed according to two methods: the Clinical Practice Recommendations (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and their adaptability to the French context.

Anuria since birth: does it impact outcome of kidney transplant in infants?

Kidney transplantation (txp) in infants has recently made much progress but provides a unique challenge in infants anuric since birth. Little data exists on outcome of renal txp recipients with anuria since birth. Retrospective chart review was done for outcome of 27 children with wt ≤15 kg and they were divided into two groups: Group A (N=21) with urine output and Group B (N=6) anuric since birth had their urological complications and long-term outcome compared. Median age at the time of txp 18 vs 23 months, mean wt 10.8 vs 11.8 kg, and mean ht 77 cm in both, mean follow-up post-txp: 9.4 vs 5.6 years, and neurological problems were noted in 48% and 33% in Group A and Group B. There was no graft thrombosis or post-transplant lymphoproliferative disease and only two rejections. Anuric Group B were older, had more post-txp urological surgeries (66% vs 19%) and UTIs (66% vs 38%) compared to Group A. The overall graft survival at 1, 5, and 10 years was 96%, 86%, and 70%; patient survival at 1, 5, and 10 years was 96%, 85%, and 85%. Long-term graft outcomes in small children, anuric prior to txp, were excellent despite higher rates for UTIs and urological complications.

Ureteric stents vs percutaneous nephrostomy for initial urinary drainage in children with obstructive anuria and acute renal failure due to ureteric calculi: a prospective, randomised study.

OBJECTIVES: To compare percutaneous nephrostomy (PCN) tube vs JJ ureteric stenting as the initial urinary drainage method in children with obstructive calcular anuria (OCA) and post-renal acute renal failure (ARF) due to bilateral ureteric calculi, to identify the selection criteria for the initial urinary drainage method that will improve urinary drainage, decrease complications and facilitate the subsequent definitive clearance of stones, as this comparison is lacking in the literature. PATIENTS AND METHODS: A series of 90 children aged ≤12 years presenting with OCA and ARF due to bilateral ureteric calculi were included from March 2011 to September 2013 at Cairo University Pediatric Hospital in this randomised comparative study. Patients with grade 0-1 hydronephrosis, fever or pyonephrosis were excluded. No patient had any contraindication for either method of drainage. Stable patients (or patients stabilised by dialysis) were randomised (non-blinded, block randomisation, sealed envelope method) into PCN-tube or bilateral JJ-stent groups (45 patients for each group). Initial urinary drainage was performed under general anaesthesia and fluoroscopic guidance. We used 4.8-6 F JJ stents or 6-8 F PCN tubes. The primary outcomes were the safety and efficacy of both groups for the recovery of renal functions. Both groups were compared for operative and imaging times, complications, and the period required for a return to normal serum creatinine levels. The secondary outcomes included the number of subsequent interventions needed for clearance of stones. Additional analysis was done for factors affecting outcome within each group. RESULTS: All presented patients completed the study with intention-to-treat analysis. There was no significant difference between the PCN-tube and JJ-stent groups for the operative and imaging times, period for return to a normal creatinine level and failure of insertion. There were significantly more complications in the PCN-tube group. The stone size (>2 cm) was the only factor affecting the rates of mucosal complications, operative time and failure of insertion in the JJ-stent group. The degree of hydronephrosis significantly affected the operative time for PCN-tube insertion. Grade 2 hydronephrosis was associated with all cases of insertion failure in the PCN-tube group. The total number of subsequent interventions needed to clear stones was significantly higher in the PCN-tube group, especially in patients with bilateral stones destined for chemolytic dissolution (alkalinisation) or extracorporeal shockwave lithotripsy (ESWL). CONCLUSION: We recommend the use of JJ stents for initial urinary drainage for stones that will be subsequently treated with chemolytic dissolution or ESWL, as this will lower the total number of subsequent interventions needed to clear the stones. This is also true for stones destined for ureteroscopy (URS), as JJ-stent insertion will facilitate subsequent URS due to previous ureteric stenting. Mild hydronephrosis will prolong the operative time for PCN-tube insertion and may increase the incidence of insertion failure. We recommend the use of PCN tube if the stone size is >2 cm, as there was a greater risk of possible iatrogenic ureteric injury during stenting with these larger ureteric stones in addition to prolongation of operative time with an increased incidence of failure.

Calculus anuria: a urological emergency with an excellent outcome.

Calculus anuria is a catastrophic condition with dire consequences if not treated promptly. The purpose of this study was to identify factors which influence the short-term outcome of patients with calculus anuria. A retrospective analysis was conducted from January 2016 to December 2021, in children up to the age of 18 years, who presented with calculus anuria and required emergency decompression at Sindh Institute of Urology and Transplantation, Pakistan. One hundred and twenty-five children were included. Majority were born to consanguineous parents and a few of them had positive family history of stone disease. Severe illness was found in 25 (20%) patients and among them 8 (32%) required hemodialysis. Decompression by double J stenting is the preferred intervention in our institute and was done in 106 (85%) children, followed by percutaneous nephrostomy tube in 10 (8%) successfully. A small number of patients, 9 (7%) required both procedures to relieve their obstruction. A significant number of patients, about 115 (92%), attained normal renal functions after intervention. No pertinent factors were identified, relating to incomplete renal recovery in nine (7%) of the patients who unfortunately progressed to chronic kidney disease.

Surgical rescue and restoration of renal function in an anuric renal failure patient: a case report.

We present a case of anuric renal failure in a forty-nine year old woman secondary to bilateral renal artery occlusion that responded favorably to surgical revascularization. The patient presented with a three day history of diminished to absent urine output. The patient's BUN and creatinine were 52 mg/dL and 9.3 mg/dL, respectively. The patient remained anuric and required hemodialysis. Chronic atherosclerotic occlusion of both renal arteries with reconstitution of the renal arteries via collateral support was seen on angiography. Twenty-six days after presentation, the patient had aortorenal artery bypass using a saphenous vein graft. Postoperatively the patient had excellent diuresis with the creatinine improving to a nadir of 1.5 mg/dL. This case is a demonstration that the kidneys can remain viable with subacute renal artery occlusion in the presence of adequate collateral blood flow. Surgical or transcatheter renal revascularization should be considered in appropriate patients.

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.

A transplanted kidney surviving total vessel occlusion and anuria.

We report a case of a 46-year-old white male with renal graft artery stenosis who developed acute renal shutdown with total anuria while on the ACE inhibitor lisinopril, one week following the discontinuation of aspirin. The serum creatinine was 8.5 mg/dl. Doppler ultrasound and MAG3 scintigraphy of the grafted kidney were highly suggestive of a viable but nonfunctioning kidney. A femoro-femoral bypass for total thrombosis of the right common iliac artery was performed distal to the occlusion. Immediate diuresis was obtained after establishing the bypass. Serum creatinine dropped to 1.35 mg/dl three days later. In this case we believe that the collateral circulation played a significant role in immediate recovery of kidney function by maintaining renal perfusion pressure and preventing acute tubular necrosis (ATN). We also believe that the ACE inhibitor might have contributed to salvaging the kidney by improving medullary oxygen balance and maintaining adequate medullary blood flow.

Reversal of postoperative anuria by decompressive celiotomy.

Postoperative oliguria or anuria can rarely be attributed to an increase in intra-abdominal pressure. In this documented case, postoperative anuria responded to reduction in abdominal pressure by celiotomy. Actual abdominal pressure measurements are not available but probably would not be useful. However, hemodynamic measurements that were not consistent with diminished renal blood flow in a middle-aged patient were nevertheless associated with anuria, which responded to release of the abdominal pressure. Because of the association of regional pressure and acute renal decompensation, release of abdominal tension should be considered as a therapeutic option when hemodynamic measurements cannot explain a rapid decline in urine production.

An alternative surgical technique for the management of afferent limb structure in Kock pouch continent urinary diversion.

Stenosis of the afferent limb has recently been recognized as a rare cause of upper urinary tract obstruction in patients with a Kock pouch continent urinary diversion. Usually, it can be managed by endoscopic balloon dilation but occasionally open surgical reconstruction is required. We describe an alternative simpler surgical technique that was used in a patient who presented with anuria due to afferent limb stenosis 13 years after the construction of a Kock pouch continent urinary diversion.

Percutaneous nephrostomy drainage in the management of neonatal anuria secondary to renal candidiasis.

We report a case of anuria in a premature neonate secondary to bilateral ureteropelvic junction obstructions related to Candida bezoars. Percutaneous decompression and drainage of both kidneys contributed significantly to the successful management of renal candidiasis in this patient. A review of the literature is presented.

Acute thrombosis of renal artery: restoration of renal function after late revascularization.

The authors report a successful surgical revascularization of a solitary kidney after 34 days of anuria in a patient affected by acute thrombosis of the renal artery. Since the renal function can be restored even after prolonged anuria, acute renal artery occlusions should be promptly diagnosed and treated.

Percutaneous nephrostomy under ultrasonographic control--experience from a 2-year material.

The advantages of, and the two-year experience from, ultrasonographically controlled percutaneous nephrostomy are analyzed. Nephrostomy was performed under control by a Brüel-Kjaer type 1846 ultrasonographic apparatus which established compression anuria of tumorous origin, septic state owing to ureteral occlusion and solitary nephrolithic occlusion among the pathogenic causes. The advantages include speed of performance, minimum strain imposed on the patient as well as the possibility in tumorous anuria to create a definite urinary bypass.

[Postrenal amuria in polycystic degeneration of a residual kidney (author's transl)]. / Postrenale Anurie bei polycystischer Degeneration einer Restniere

A case of a residual kidney and polycystic renal degeneration is reported in which postrenal anuria developed from a cluster of cysts filling the entire renal pelvis. The anuria was repired by removing the intrapelvic cysts and creating a temporary renal fistula. A sudden onset of anuria and the corresponding symptoms (e.g., acute abdominal pain) and also the familiar progressive polycystic degeneration of the kidney should arouse suspicion of an obstruction caused by cysts.

[Obstructive anuria due to renal candidiasis in a newborn male (author's transl)]. / Mechanische Anurie eines Säuglings bei Candidapyelonephritis.

Mechanical anuria developed in a neonate during a period of intensive care following birth trauma. The obstruction of the urinary tract was due to yeast clumps from a candida pyelonephritis. Urine flow was reestablished after a unilateral nephrostomy and antimycotic therapy. There were no anatomical abnormalities of the urinary tract.

[Restoration of urinary tract continuity in a non-functioning bladder after renal transplantation]. / Rétablissement de la continuité urinaire après transplantation rénale dans les vessies exclues.

The restoration of the continuity of the urinary tract after renal transplantation in anuric patients, an increasingly frequent situation, raises a number of theoretical problems: is it possible to use a bladder which has been non-functioning, sometimes for many years (20 years)? What should be performed during pre-operative assessment? Which surgical technique should be used? The authors try to answer these questions on the basis of their experience of 116 transplanted anuric patients. Anuria, even of long duration, does not prevent the use of the bladder, provided that the bladder was originally normal and is not infected. The pre-operative assessment is the same as for other patients and urodynamic investigations are not required. The optimal reimplantation technique is the Leadbetter-Politano open bladder technique and every effort should be made to obtain abundant diuresis immediately. Under these conditions, reimplantation into these non-functioning bladders is not associated with more complications than in the case of normal bladders.

[Obstructive anuria. Thirty cases]. / Anuries obstructives. A propos de 30 cas.

The authors report 30 cases of obstructive anuria during the last fifteen years. The anuria was secondary to lithiasis in 60 per cent, in 26.6 per cent to pelvic cancer and in 13.4 per cent to retroperitoneal fibrosis. The diagnosis was facilitated by ultrasonography. Emergency treatment of obstructive anuria is based on urinary diversion by ureteral stent or by percutaneous nephrostomy under ultrasound control. Later the treatment depend of etiology.

[Obstructive anuria in children. Apropos of 22 cases]. / Anurie obstructive chez l'enfant. A propos de vingt-deux cas.

The authors report twenty two cases of obstructive anuria observed in children. Causes are diverse: 6 cases were observed during the course of tumors, 4 cases were secondary to bilateral renal stones (or unilateral in a single kidney), 3 cases were observed before surgical correction of latent or well tolerated congenital uropathy, and 9 cases in the immediate postoperative period (including 8 after antireflux surgery). In the emergency situation, treatment of obstructive anuria is based on urinary diversion ideally by percutaneous nephrostomy under ultrasonic control. But prevention is the best treatment of anuria: treatment of urinary tract infections resulting in renal stones, in case of tumor, ultrasonographic survey of chronic upper tract dilatation: rigorous atraumatic operative technique avoiding any oedema.

[Obstructive anuria: unilateral cutaneous ureterostomy with remission of contralateral ureter obstruction].

We experienced 1 case of obstructive anuria. This patient had received radiotherapy for uterine cancer. We performed unilateral cutaneous ureterostomy. Excretion of urine from the contralateral kidney occurred from the 17th postoperative day indicating improvement in renal functions. The possible mechanism for improvement of functions of the contralateral kidney is considered to be release of unilateral obstruction resulting in improvement in edema of tissues around kidney and ureter and remission of intravesical ureter obstruction caused by inflammation as a sequela of radiotherapy through improvement in inflammation.