Management of Acute Kidney Injury with Hematuria in Chronic UPJ Obstruction
This patient requires urgent urinary drainage via percutaneous nephrostomy (PCN) or retrograde ureteral stent replacement, with immediate broad-spectrum antibiotics if infection is suspected, followed by definitive surgical reconstruction once renal function stabilizes. 1
Immediate Management Priorities
Assess for Infection and Sepsis
- Check for fever, leukocytosis, and signs of sepsis immediately - if purulent urine or pyonephrosis is present, this is a medical emergency requiring urgent drainage and antibiotics 1
- Obtain urine culture before starting antibiotics 1
- If septic or hemodynamically unstable, abort any stone procedures and establish drainage immediately with either PCN or ureteral stent 1
- Third-generation cephalosporins (ceftazidime) are superior to fluoroquinolones for infected obstructed systems 1
Determine Stent Patency and Obstruction Severity
- Obtain CT urography or renal ultrasound to assess degree of hydronephrosis and stent position 1
- The severe renal dysfunction (Cr 3.55, BUN 79) suggests either stent failure, complete obstruction, or bilateral disease 1
- Hematuria may indicate stent encrustation, migration, or stone formation around the stent 1
Drainage Options Based on Clinical Scenario
If Stents Are Occluded or Malpositioned
Retrograde ureteral stent exchange should be attempted first in hemodynamically stable patients 1, 2
- Technical success approaches 90-95% for retrograde approaches 3
- If retrograde access fails due to chronic UPJ changes or tight stricture, proceed immediately to PCN 1
If Patient Has Signs of Infection
PCN is preferred over retrograde stenting in infected, obstructed systems 1
- PCN has >95% technical success for dilated systems and provides immediate decompression 1
- PCN allows bacteriological sampling and improves antibiotic sensitivity testing 1
- Preprocedural antibiotics within 60 minutes are mandatory 1
- Postprocedural bacteremia is common when draining infected systems 1
If Hemodynamically Unstable
Emergent PCN placement is indicated for unstable patients with obstructive uropathy 1
- In pyonephrosis, PCN achieves 92% survival vs 60% with medical therapy alone 1
- Resuscitative endovascular balloon occlusion of aorta (REBOA) may bridge to definitive procedures if hemorrhagic shock develops 1
Definitive Management After Stabilization
Surgical Reconstruction Timing
Once renal function stabilizes and infection clears, definitive pyeloplasty with concomitant reconstruction should be planned 1
- Open, laparoscopic, or robotic pyeloplasty is indicated for chronic UPJ obstruction requiring reconstruction 1
- This is one of the rare exceptions where open/laparoscopic/robotic surgery is appropriate first-line therapy - specifically for anatomic abnormalities with concomitant UPJ obstruction requiring reconstruction 1
Stent Management During Recovery
- Double-J stents should remain in place for 4-8 weeks post-pyeloplasty 4
- Stented pyeloplasty shows more rapid improvement of hydronephrosis than unstented approaches 4
- For chronic obstruction, stent diameter and single vs tandem configuration have minimal impact on failure rates once >90% occlusion occurs 5
Critical Pitfalls to Avoid
Do Not Delay Drainage
- Renal function at this level (Cr 3.55) indicates critical obstruction requiring urgent intervention within hours, not days 1
- Delayed drainage in infected obstruction leads to irreversible renal damage and septic shock 1
Do Not Attempt Stone Procedures in This Setting
- If purulent urine is encountered, abort any stone removal, establish drainage, and continue antibiotics 1
- Stone analysis should be sent if fragments are present to guide future prevention 1
Avoid Diuretics Without Drainage
- Furosemide is contraindicated in obstructive uropathy as it worsens hydronephrosis without relieving obstruction 6
- Never attempt medical management alone without decompression in this clinical scenario 1