Acute kidney injury due to bilateral malignant ureteral obstruction: Is there an optimal mode of drainage?

Abstract

There is a well-known relationship between malignancy and impairment of kidney functions, either in the form of acute kidney injury or chronic kidney disease. In the former, however, bilateral malignant ureteral obstruction is a surgically correctable factor of this complex pathology. It warrants urgent drainage of the kidneys in emergency settings. However, there are multiple controversies and debates about the optimal mode of drainage of the bilaterally obstructed kidneys in these patients. This review addressed most of the concerns and provided a comprehensive presentation of this topic from the recent literature. Also, we provided different perspectives on the management of the bilateral obstructed kidneys due to malignancy. Despite the frequent trials for improving the success rates and functions of ureteral stents, placement of a percutaneous nephrostomy tube remains the most recommended tool of drainage due to bilateral ureteral obstruction, especially in patients with advanced malignancy. However, the disturbance of the quality of life of those patients remains a major unresolved concern. Beside the unfavorable prognostic potential of the underlying malignancy and the various risk stratification models that have been proposed, the response of the kidney to initial drainage can be anticipated and evaluated by multiple renal prognostic factors, including increased urine output, serum creatinine trajectory, and time-to-nadir serum creatinine after drainage.

Keywords: Acute kidney injury, Kidney, Malignancy, Percutaneous nephrostomy, Ureteral obstruction, Ureter

Core Tip: Acute kidney injury due to malignant ureteral obstruction is a complex nephrological and urological emergency. Its management includes an initial resuscitation of the metabolic abnormalities, minimally invasive drainage of the obstructed kidneys, and correction of the underlying etiology. Several prognostic models have been proposed to clarify the best approach. However, there are controversies about the optimal mode of drainage of the kidneys, regarding the tool and laterality of drainage. Despite the practical preference of using the percutaneous nephrostomy rather than the double-J stent, the optimal mode of drainage has not been defined yet. The parameters of kidney response to drainage and the status of the underlying malignancy are important prognostic factors.