Should a double-J (DJ) stent be removed in a patient with impaired renal function, oligoanuria, and hematuria?

Urgent Stent Removal is Indicated in This Case

The DJ stent should be removed urgently and replaced with percutaneous nephrostomy drainage given the clinical deterioration with oligoanuria, persistent hematuria on dual antiplatelets, and progression to dialysis-dependent acute kidney injury. 1

Critical Analysis of This Clinical Scenario

This patient has experienced a cascade of complications directly attributable to the DJ stent placement in the setting of multiple risk factors:

Why the Stent is Likely Causing Harm

• Hematuria on dual antiplatelets: The stent is causing mechanical irritation of the bladder trigone and ureteral orifices, leading to ongoing bleeding that was "overseen" (overlooked) at discharge 2. This bleeding risk is significantly amplified by dual antiplatelet therapy.

• Progression to oligoanuria despite stent patency: The imaging confirms the stent is in place, yet renal function catastrophically declined from baseline to dialysis-dependent AKI. This suggests the stent itself may be contributing to obstruction through blood clot formation, encrustation, or inflammatory edema 1, 3.

• Acute pulmonary edema: This indicates volume overload from acute renal failure, not relief of obstruction. A functioning stent should have prevented this outcome 4.

The Appropriate Management Algorithm

Step 1: Immediate stent removal with conversion to percutaneous nephrostomy 1

• Percutaneous nephrostomy should be placed to relieve obstruction when stent-related complications occur, as recommended by the American College of Radiology 1
• This avoids further mechanical trauma to an already bleeding urinary tract while maintaining drainage 1

Step 2: Address the anticoagulation issue

• The dual antiplatelet therapy must be carefully managed in consultation with cardiology
• Percutaneous nephrostomy eliminates the intravesical foreign body that is causing ongoing hematuria 1

Step 3: Reassess after stabilization

• Once bleeding is controlled and infection (if present) is treated, consider antegrade stent placement or definitive treatment of the underlying pyelonephritis/obstruction 1
• The original indication (acute pyelonephritis with presumed obstruction) may have resolved, making long-term stenting unnecessary 5

Evidence-Based Rationale

Stent Complications in High-Risk Patients

• DJ stents increase the risk for recurrent urinary tract infection, stent encrustation, stone formation, hematuria, and severe storage lower urinary tract symptoms 6
• In this immunocompromised patient (recent COPD exacerbation, likely on steroids), these risks are magnified 6
• A forgotten or problematic DJ stent can lead to total incrustation, bladder stone formation, and loss of renal function 3

When Stents Fail to Achieve Their Purpose

• If enlarging complications, fever, increasing pain, or infection are present, urinary drainage should be augmented by percutaneous nephrostomy 1
• In cases where stent replacement fails or complications arise, percutaneous nephrostomy should be placed to relieve obstruction 1

The Pyelonephritis Context

• Emphysematous pyelonephritis and severe pyelonephritis can be managed with DJ stenting OR percutaneous nephrostomy with proper antibiotics 5
• However, when the stent is associated with clinical deterioration rather than improvement, alternative drainage is mandatory 1

Common Pitfalls to Avoid

Pitfall #1: Assuming a radiographically "well-positioned" stent is functioning properly

• Stents can be in correct position yet completely occluded by blood clots, mucus, or encrustation 1, 3
• The clinical picture (oligoanuria, dialysis requirement) trumps imaging appearance 1

Pitfall #2: Leaving the stent in place "because it was just placed"

• The timing of stent placement is irrelevant when complications develop 1
• Early stent removal with conversion to external drainage is safer than persistent internal drainage in a bleeding, failing kidney 1

Pitfall #3: Failing to recognize iatrogenic contribution to AKI

• The temporal relationship (pain relief after stenting, then progressive renal failure) suggests the stent itself may be obstructing through clot formation or inflammatory response 3
• Dual antiplatelets were "overseen"—this oversight has created a dangerous bleeding diathesis in the presence of an intravesical foreign body 2

Bottom Line

Remove the DJ stent immediately and place bilateral percutaneous nephrostomies (the right kidney likely also needs assessment given the dialysis requirement). 1 This approach provides definitive drainage, eliminates the bleeding source, allows reassessment of true renal function once obstruction and bleeding are controlled, and permits safer management of antiplatelet therapy. The stent has failed its intended purpose and is now contributing to morbidity rather than preventing it.