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, pulmonary edema, dialysis requirement) trumps imaging appearance 4

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

• The timing of stent placement is irrelevant when complications occur 1
• Early stent failure or intolerance requires prompt intervention, not observation 7

Pitfall #3: Failing to recognize iatrogenic harm

• The patient was "getting better" before stent placement, then deteriorated afterward 6
• The hematuria began after stenting in a patient on dual antiplatelets—this is a direct stent complication 2

Definitive Recommendation

Remove the DJ stent immediately and place bilateral percutaneous nephrostomy tubes (or unilateral if only one kidney is affected). 1 This approach:

• Eliminates the source of hematuria 2
• Provides reliable drainage without intravesical foreign body 1
• Allows reassessment of renal function without confounding variables 4
• Permits safe management of antiplatelet therapy 1

The original indication for stenting (acute pyelonephritis) does not require indefinite stenting and may be better managed with temporary percutaneous drainage followed by reassessment once the acute inflammatory process resolves. 5