Updated: 9/18/2018

Hydronephrosis

Topic
Review Topic
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Questions
4
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Evidence
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Snapshot
  • A 48-year-old woman presents to the emergency department due to severe back pain. Her symptoms began approximately 3 hours ago and says the pain is in her left mid-back. She describes the pain as sharp and 9/10. The pain radiates to her left groin. On physical exam, there is left-sided costovertebral angle tenderness. A non-contrast computerized tomography (CT) scan of the abdomen demonstrates left-sided urolithiasis and hydronephrosis. She is started on a nonsteroidal antiinflammatory drug (NSAID) and intravenous normal saline. (Nephrolithiasis resulting in hydronephrosis)
Introduction
  • Clinical definition
    • renal calyx and pelvis distension secondary to an obstruction in urine flow distal to the renal pelvis
      • dilation of the ureter describes hydroureter
  • Epidemiology
    • demographics
      • age
        • calculi is the most common cause of hydronephrosis and hydroureter in young adults
      • sex
        • pregnancy and gynecologic causes are more common causes in women
        • prostatic hyperplasia and cancer are a major cause of hydronephrosis in men
  • Etiology
    • pregnancy
      • normal finding
      • there may be a more prominent dilation on the right ureter and renal pelvis than the left
    • benign prostatic hyperplasia
    • calculi
    • ureteral narrowing secondary to surgery
    • malignancy
      • e.g., ureteral, cervical, and prostate
    • congenital defects between the kidney, ureter, and bladder junction
    • ureteropelvic junction obstruction
    • retroperitoneal fibrosis
  • Pathogenesis
    • pathologic or anatomic processes interupt urine flow which leads to
      • a decline in glomerular filtration rate
      • impaired ability to concentrate, dilute, and transport sodium, potassium, and hydrogen ions
    • chronic hydronephrosis results in gross changes to the kidney such as
      • renal papillae compression
      • renal septa and calyx coalescence
      • peri-calyx renal parenchymal thinning
  • Prognosis
    • variable as it is dependent on the underlying cause
Presentation
  • Symptoms
    • depends on whether the obstruction is acute or chronic
      • asymptomatic
      • pain secondary to bladder, collecting system, or renal capsule distention
      • anuria
  • Physical exam
    • palpable kidney in severe cases
    • costovertebral angle tenderness
    • distended bladder in lower urinary tract obstruction (e.g., benign prostatic hyperplasia)
Imaging
  • Renal ultrasonography
    • indication
      • imaging test of choice for evaluating urinary tract obstruction
  • Computerized tomography (CT) scan of the abdomen
    • indication
      • used when results are equivocal on renal ultrasound
Studies
  • Labs
    • urinalysis
      • to evaluate for infection, stone, or tumor
    • serum chemistry
      • ↑ BUN and creatinine
Differential
  • Pyelonephritis
  • Peripelvic cyst
  • Calyceal diverticula
Treatment
  • Conservative 
    • bladder catheterization
      • indication
        • performed initially if the clinical presentation is suggestive of a bladder neck obstruction such as
          • suprapubic pain
          • palpable bladder
  • Treatment ultimately depends on the underlying cause of hydronephrosis
    • e.g., oral alkalinization therapy for patients with uric acid stones
Complications
  • Postobstructive diuresis
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.RL.18) A 45-year-old man presents with a 3-day history of right-sided flank pain due to a lodged ureteral stone. What changes would be expected to be seen at the level of glomerular filtration?


Review Topic

QID: 100972
1

Increase in glomerular capillary oncotic pressure

18%

(2/11)

2

Increase in Bowman's space capillary oncotic pressure

9%

(1/11)

3

Increase in Bowman's space hydrostatic pressure

73%

(8/11)

4

Increase in filtration fraction

0%

(0/11)

5

No change in filtration fraction

0%

(0/11)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(M1.RL.78) A 72-year-old male presents to his primary care physician with urinary hesitancy and urinary dribbling that began 6 weeks ago and has gradually worsened. Rectal exam reveals a markedly enlarged prostate. CT scan, shown in Figure A, demonstrates dilated ureters and renal pelvises. Which of the following likely accounts for the CT scan results: Review Topic

QID: 101032
FIGURES:
1

Urethral obstruction

92%

(11/12)

2

Autosomal dominant polycystic kidney disease

0%

(0/12)

3

Prerenal azotemia

0%

(0/12)

4

Elevated serum PSA

8%

(1/12)

5

Multiple endocrine neoplasia type 1

0%

(0/12)

M1

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PREFERRED RESPONSE 1
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