病例報告：逆行性腎盂攝影手術導致無尿性急性腎衰竭

董修廷、盧則宏

國立成功大學醫學院附設醫院 泌尿部

Anuric acute kidney injury requiring hemodialysis following bilateral retrograde pyelography: a case report

Hsiu-Ting Tung, Ze‐Hong Lu

Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704302, Taiwan

Background:

Ureter catheterization and retrograde pyelography (RP) are common urologic procedures indicated for diagnostic and prophylactic purposes. It is considered a low-risk procedure for evaluating the collecting system, especially where intravenous contrast media are contraindicated due to renal insufficiency. Anuric acute kidney injury (AKI) following bilateral RP is an extremely rare complication.

Case Report:

A 75-year-old man had a medical history of severe mitral valve regurgitation with atrial fibrillation post mitral valve repair and modified maze procedure in 2013, cardiac pacemaker implantation in 2022, coronary artery disease, stage 3a chronic kidney disease (CKD), hypertension and enlarged prostate. He had been taking Edoxaban for a long time. He developed gross hematuria requiring cessation of anticoagulation one month before this admission. Considering the underlying stage 3 CKD, a contrast-enhanced computerized tomography (CT) urography was determined to be high-risk. He was therefore admitted for cystourethroscopy and bilateral RP under spinal anesthesia.

During the procedure, cystourethroscopy revealed enlarged prostatic lobes with severe intravesical protrusion and engorged vessels. Bilateral ureters were catheterized using guidewire and 5-French catheters, which posed challenges due to a huge prostatic median lobe and hematuria. Inadvertent injury to the right lower ureter occurred during catheter placement and contrast extravasation was found. Despite this, bilateral RP could still be performed, revealing otherwise unremarkable results except for pyelovenous backflow on the right side. Patient was hemodynamically stable throughout the procedure, and an 18-French 3-way Foley catheter was placed at the end for continuous bladder irrigation.

In the postoperative period, continuous bladder irrigation was maintained for 24 hours, and Foley catheter was removed 2 days after the procedure. However, he had no urine output despite drinking a lot of water. Bedside ultrasound showed minimal right hydronephrosis and nearly empty bladder. Diuretics were prescribed but he remained anuric in the next 24 hours. Blood tests revealed markedly elevated creatinine level (1.44 to 8.97 mg/dL), hyperkalemia and metabolic acidosis. He developed signs of fluid overload and became progressively lethargic. He required emergent hemodialysis, and shortly after the session, he started making urine, producing a total of 60 mL within the subsequent 8 hours. On the next day, along with increased urine output of 2480 mL per day, his symptoms had generally improved. Blood tests in the following days showed improved renal parameters. His glomerulonephritis and vasculitis workups returned negative results. After excluding prerenal, intrinsic and postrenal etiology, the patient was diagnosed with reflex anuria. He was discharged 9 days after the procedure, with creatinine level returning to baseline.

Conclusions:

Reflex anuria is an extremely rare cause of post-surgical anuric AKI and is often a diagnosis of exclusion. Management is largely supportive and should be individualized. Outcomes appear to be favorable in most cases.