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A Two-Step Method for Percutaneous Transhepatic Choledochoscopic Lithotomy
Published on: September 13, 2022
Is percutaneous nephrolithotomy safe in chronic kidney disease patients!!!
Pramod Adiga1, Sanjay Ramachandra Pudakalkatti1, V Shivakumar1
1Department of Urology, Institute of Nephrourology, Bengaluru, Karnataka, India.
Insights
Percutaneous nephrolithotomy (PCNL) is effective for managing kidney stones in chronic kidney disease (CKD) patients, showing good stone clearance. However, careful monitoring is needed as some patients may experience CKD stage deterioration or require renal replacement therapy.
Area of Science:
- Nephrology
- Urology
- Surgical Innovation
Background:
- Management of renal calculus in patients with chronic kidney disease (CKD) presents unique challenges.
- Percutaneous nephrolithotomy (PCNL) is the gold standard for large renal calculi (≥1.5 cm) in healthy kidneys.
Purpose of the Study:
- To analyze the safety and efficacy of PCNL for renal calculus (≥1.5 cm) in patients with CKD.
- To evaluate the impact of PCNL on renal function in CKD patients.
Main Methods:
- A study included sixty CKD patients with renal calculus, divided into two groups based on glomerular filtration rate (GFR): Group A (GFR ≤30 ml/min/m²) and Group B (GFR >30 <60 ml/min/m²).
- Key metrics recorded included pre- and post-PCNL estimated GFR (eGFR), stone-free rates, complications, and changes in CKD stage.
Main Results:
- PCNL achieved a 94% complete stone clearance rate.
- Mean eGFR improved post-PCNL in both groups, but 21.6% of patients showed CKD stage deterioration, particularly in Group A.
- Complications included bleeding requiring transfusion (20%) and ICU admission (5%); 10% required maintenance hemodialysis, with no mortality observed.
Conclusions:
- PCNL is an effective strategy for renal calculus in CKD patients, offering acceptable stone clearance and manageable complications.
- Pre-procedure peak eGFR <30 ml/min/m² and post-procedure complications are predictors of renal function deterioration and the potential need for renal replacement therapy (RRT).
Introduction:
Management of renal calculus in a patient of chronic kidney disease (CKD) is always challenging. Treatment options include extracorporeal shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy (PCNL). With PCNL being gold standard for renal calculus ≥1.5 cm in normal kidneys, we aimed to analyze the safety and efficacy of PCNL in CKD patients with calculus ≥1.5 cm.
Materials And Methods:
Sixty patients of CKD with renal calculus were included in the study: Group A with glomerular filtration rate (GFR) ≤30 ml/min/m2 and Group B with GFR >30 <60 ml/min/m2. The estimated GFR (eGFR) pre-PCNL, peak eGFR on follow-up, and eGFR at last follow-up, stone free rates, and complications were recorded. The CKD stage before and after PCNL were also compared at the last follow-up.
Results:
The mean age of patients was 52 years. A mean of 1.14sittings per renal unit was required for PCNL. Complete clearance was 94% after all auxiliary procedures. The mean prePCNL eGFR was 26.5 ± 4.01 and 43.6 ± 9l. 14 ml/min/1.73 m2 in Groups A and B, respectively. The mean post-PCNL eGFR was 32 ± 9.94 and 51 ± 8.85 ml/minute/1.73 m2, respectively, in Groups A and B. At a mean follow-up of 180 days, deterioration with the migration of CKD stage was seen in 13 patients (21.6%) out of which 10 patients were of Groups A and 3 in Group B. Six patients (10%) required maintenance hemodialysis. Postoperative bleeding complication requiring blood transfusions was seen in 12 (20%) and 3 (5%) required intensive care unit care postoperatively. No mortality was observed in our study.
Conclusion:
PCNL is an effective management strategy for renal calculus in patients with CKD with an acceptable stone clearance rates and manageable complications. Peak eGFR <30 ml/min/m2 and postprocedure complications predict deterioration and need for RRT.
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