UROPATHY

OBSTRUCTIVE
 Definitions:
• Hydronephrosis is the dilation of the renal pelvis or calyces. It may be
associated with obstruction but may be present in the absence of obstruction
eg UTI.
• Obstructive uropathy refers to the functional or anatomic obstruction of
urinary flow at any level of the urinary tract.
• Obstructive nephropathy is present when the obstruction causes functional
or anatomic renal damage.
 Urinary Tract obstruction
• major clinical problem that affects both children and adults and can result in permanent renal
damage
• The degree of injury to the kidney and the effect on overall renal function depend on:
• severity of the obstruction (partial or complete, unilateral or bilateral),
• the chronicity of the obstruction (acute vs. chronic)
• the baseline condition of the kidneys
• the presence of other mitigating factors such as urinary tract infection (UTI)
• The cause of urinary tract obstruction can be congenital or acquired and benign or malignant
 Prevalence
• Obstructive uropathy accounts for approximately 10% of all cases of renal
failure
• In an autopsy series of 59,064 individuals ranging, from neonates to geriatric
subjects,the prevalence of hydronephrosis was originally estimated to be
3.1%
 Clincal presentation
• Patients with new-onset hypertension
• renal failure without a history of renal disease, diabetes, or hypertension
• urinary tract obstruction always should be investigated as a possible
contributing factor in patients with recurrent UTIs
• clinical signs and symptoms of obstructive uropathy are so variable, the
diagnosis depends on prompt and appropriate imaging
 Laboratory Studies
• Urinalysis
• estimation of osmolality
• evidence of UTI
• insight into stone formation based on crystals that may be present in the urine
• presence of protein and or cellular casts
• Fractional Excretion of Sodium
• Assessment of Renal Function
• GFR
 Diagnostic Imaging
• Ultrasonography
• Nuclear Renography
• Computed Tomography
• Magnetic Resonance Urography
• Whitaker Test
• Excretory Urography
• Retrograde Pyelography
• Antegrade Pyelography
 USG
• Renal ultrasonography is a mainstay in the evaluation of suspected urinary
tract obstruction.
• Renal parenchymal thickness can be measured readily, and cortical thinning
may be indicative of chronic obstruction.
• The renal pelvis and calyces can be imaged, and dilatation is readily
identifiable.
 Nuclear Renography
• It provides a functional assessment without exposure to iodinated contrast
material.
• The glomerular agent technetium (Tc) 99m DTPA and the tubular agent
99mTc-MAG3 are most commonly used in the evaluation of obstruction
 CT Scan
• Unenhanced CT is the most sensitive method of detecting urinary tract
stones and is currently the preferred imaging modality for evaluating most
patients with suspected renal colic as a cause of urinary obstruction
 Excretory Urogram
• Acute urinary obstruction may be inferred from the functional abnormality
of a delayed nephrogram and pyelogram on the affected side or sides.
• Delayed images may then ultimately reveal the anatomic level of obstruction
and perhaps causation.
 HEMODYNAMIC CHANGES WITH
OBSTRUCTION
• Glomerular Filtration and Renal Blood Flow
• Renal Vascular Resistance
• Unilateral Ureteral Obstruction
• Bilateral Ureteral Obstruction or Obstruction of a Solitary Kidney
• Partial Ureteral Obstruction
 EFFECTS OF OBSTRUCTION ON
TUBULAR FUNCTION
• Urinary Concentrating Ability
• Sodium Transport
• Hydrogen Ion Transport and Urinary Acidification
• Other Cation Transport
 CLINICAL IMPACT OF RENAL
OBSTRUCTION
• Hypertension
• Compensatory Renal Growth
 TREATMENT OF RENAL
OBSTRUCTION
• Pain Management
• Renal Drainage
• percutaneous nephrostomy
• internal stents
• Choice of Surgical Intervention
• Definitive management of urinary tract obstruction is based on the cause of obstruction
• status of the contralateral kidney
• function ofthe affected kidney
• patient’s age and overall medical status
 Post-Obstructive Diuresis
• Following the relief of urinary tract obstruction, a period of significant
polyuria may ensue.
• Urine outputs of 200 mL/hr or greater may be encountered.
• Mainly after relief of BUO or obstruction of a solitary kidney
• Mainly physiologic
 Post-Obstructive Diuresis
• Patients susceptible to this phenomenon typically have signs of fluid
overload including edema, congestive heart failure, or hypertension
• Subjects in whom BUO or UUO in a solitary kidney is relieved should be
monitored for a postobstructive
• diuresis.
• Serum electrolytes, magnesium, blood urea nitrogen (BUN), and creatinine
should be checked daily