HYDRONEPHROSIS

INTRODUCTION-

Hydronephrosis is a condition in which one or both kidneys become swollen due to

incomplete emptying of the urinary tract. It can be sudden or chronic, partial or complete,
one-sided or bilateral. It can occur anywhere along the urinary tract from the opening of the
kidneys to the ureters (draining the kidneys to the bladder), the bladder, and the urethra
(draining the bladder). Problems with any of these structures may cause impaired emptying of
the urinary system and back up of fluid and pressure.

If only one of the kidneys is affected, the condition is called unilateral hydronephrosis. If
both kidneys are affected, it is called bilateral hydronephrosis.

Hydronephrosis may result in decreased kidney function. If not treated right away, permanent
damage to the kidney or kidneys may occur, resulting in kidney failure.

Hydronephrosis is swelling of one or both kidneys. Kidney swelling happens when urine
can't drain from a kidney and builds up in the kidney as a result. This can occur from a
blockage in the tubes that drain urine from the kidneys (ureters) or from an anatomical defect
that doesn't allow urine to drain properly.

Hydronephrosis can happen at any age. Hydronephrosis in children may be diagnosed during
infancy or sometimes during a prenatal ultrasound before the baby is born.

In many of the children who are diagnosed prenatally, the condition disappears spontaneously
by the time of birth or soon after. In children who have mild or sometimes moderate
hydronephrosis, kidney function is commonly unaffected and the condition may resolve over
a period of time after delivery.

Hydronephrosis affects the drainage of urine from the urinary system — the kidneys, ureters,
bladder, and urethra. When the urinary system is impaired, this can cause the urine to back up
and the kidney to swell. Typically, hydronephrosis is caused by either something blocking
urine flow or by urine leaking backward through the urinary system (reflux.

Your doctor will describe your child’s hydronephrosis as mild, moderate, or severe — based
on how much the kidney is stretched and how much the urinary flow is impaired — and will
tell you whether your child’s hydronephrosis affects one kidney (unilateral) or both kidneys
(bilateral). More than half of the cases resolve by the time the baby is born or soon after.

Today, hydronephrosis is usually first diagnosed on prenatal ultrasounds. Finding

hydronephrosis while the baby is the womb has become more common because of advances
in prenatal ultrasounds. Before the advancement in this technology, children born with
hydronephrosis may not have been diagnosed until they began to show symptoms, or were
not identified at all. Many children who are diagnosed with hydronephrosis before they are
born will have the condition resolve on its own while the child is young, without medical
intervention

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DEFINITION-

Hydronephrosis is defined as aseptic dilatation of the whole or a part of the pelvi-calyceal

system of the kidney due to partial or intermittent interruption to the outflow of urine.

(Hi-dro-nef-roe-sis) is a condition where urine overfills, or backs up, into the kidney, which
causes the kidney to stretch (dilate), much like a balloon when it is filled with water. Infants
with hydronephrosis may be diagnosed prenatally (before birth) or after birth during
evaluation for other issues or after a urinary tract infection.

INCIDENCE-

 Hydronephrosis is increasingly being found in unborn babies during routine

ultrasound scans.
 This is known as antenatal hydronephrosis. It's estimated to occur in at least 1 in
every 100 pregnancies.
 As a parent, it can be worrying to learn your baby has a problem with their kidneys.
 But most cases of hydronephrosis in babies are not serious and should not affect the
outcome of your pregnancy.
 About 4 out of every 5 cases will resolve on their own before or within a few months
of birth and will cause no long-term problems for you or your baby.
 The remaining cases may require treatment with antibiotics to prevent kidney
infections, and in some cases surgery may be needed.
 Read more about diagnosing antenatal hydronephrosis and treating antenatal
hydronephrosis.

Anatomy & physiology of the urinary system-

The body takes nutrients from food and converts them to energy. After the body has taken the
food that it needs, waste products are left behind in the bowel and in the blood.

The urinary system keeps the chemicals and water in balance by removing a type of waste,
called urea, from the blood. Urea is produced when foods containing protein, such as meat,
poultry, and certain vegetables, are broken down in the body. Urea is carried in the
bloodstream to the kidneys.

Urinary system parts and their functions:

 Two kidneys - a pair of purplish-brown organs located below the ribs toward the
middle of the back. Their function is to:

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 o Remove liquid waste from the blood in the form of urine.

o Keep a stable balance of salts and other substances in the blood.

o Produce erythropoietin, a hormone that aids the formation of red blood cells.

The kidneys remove urea from the blood through tiny filtering units called nephrons. Each
nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small
tube called a renal tubule. Urea, together with water and other waste substances, forms the
urine as it passes through the nephrons and down the renal tubules of the kidney.

 Two ureters - narrow tubes that carry urine from the kidneys to the bladder. Muscles
in the ureter walls continually tighten and relax forcing urine downward, away from
the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can
develop. About every 10 to 15 seconds, small amounts of urine are emptied into the
bladder from the ureters.

 Bladder - a triangle-shaped, hollow organ located in the lower abdomen. It is held in

place by ligaments that are attached to other organs and the pelvic bones. The
bladder's walls relax and expand to store urine, and contract and flatten to empty urine
through the urethra.

 Two sphincter muscles - circular muscles that help keep urine from leaking by closing
tightly like a rubber band around the opening of the bladder.

 Nerves in the bladder - alert a person when it is time to urinate, or empty the bladder.

 Urethra - the tube that allows urine to pass outside the body. The brain signals the
bladder muscles to tighten, which squeezes urine out of the bladder. At the same time,
the brain signals the sphincter muscles to relax to let urine exit the bladder through the
urethra. When all the signals occur in the correct order, normal urination occurs.

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CAUSES OF HYDRONEPHROSIS-

Congenital

1. Atresia of urethra,
2. Aberrant renal artery compressing the ureter.
3. Renal ptosis with kinking of ureter.

While there can be many conditions that lead to hydronephrosis, the most common causes are
obstructions (blockages) that reduce the ability of urine to flow out of the kidney and into the
bladder. These obstructions can include:

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  UPJ obstruction is a blockage at the point where the kidney meets the ureter (the
tube that carries urine to the bladder).
 UVJ obstruction is a blockage at the point where the ureter (the tube that carries
urine to the bladder) meets the bladder.
 Posterior urethral valves (PUV) are an obstruction that occurs prior to birth in males
that is caused by pieces of tissue in the area of the prostatic urethra.
 Ureterocele occurs when the ureter does not develop properly and causes a small
pouch into the bladder.

Other causes can be:

 Vesicoureteral reflux occurs when urine in the bladder flows back into the ureters
and often back into the kidneys.
 Ectopic Ureter drains urine somewhere outside the bladder.
 Neurogenic Bladder is a condition in which the nerves that carry messages from the
bladder to the brain and from the brain to the muscles of the bladder do not work
properly.

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 SIGNS AND SYMPTOMS OF HYDRONEPHROSIS

If a child has more severe hydronephrosis, they may experience one or more of the following
symptoms:

 Abdominal pain with nausea and/or vomiting, especially after large fluid intakes.

 Flank pain (just above the hipbone slightly to the back).

 Hematuria (blood in their urine).

 Urinary tract infections

When hydronephrosis occurs in babies, they mostly have no symptoms. When they do,
symptoms may include:

 multiple UTIs, when the only sign may be an unexplained fever

 pain in the abdomen or side
 blood in the urine

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  fever
 not feeding well
 lack of energy
 irritability

CLINICAL COURSE-

 Unilateral hydronephrosis may be silent for long period unless other kidney is
affected.
 Bilateral hydronephrosis usually lead to uremia.
 Early removal of obstruction can return the kidney function.
 However with the time the changes become irreversible.
 Bilateral complete obstruction produce anuria which need soon medial attention
 Incomplete bilateral obstruction produce polyuria rather than oliguria as a result of
defect in tubular concentrating mechanism.

DIAGNOSTIC EVALUATION-

1. LABORATORY STUDIES-
 Urinalysis is used to assess for signs of infection. Pyuria suggests the presence of
infection. Microscopic hematuria may indicate the presence of a stone or tumor.
 Complete blood cell count may reveal leukocytosis, which may indicate acute
infection.
 Serum chemistry studies can reveal an elevation of BUN and creatinine levels, which
may be the result of bilateral hydronephrosis and hydroureter. In
addition, hyperkalemia can be a life-threatening condition.
2. IMAGING STUDIES-
 Detection of antenatal hydronephrosis by ultrasound usually occurs in the second
trimester.  In this setting, hydronephrosis is defined as renal pelvic dilation (RPD) of 4
mm or more. Mild hydronephrosis (RPD of 4-10 mm or Society for Fetal Urology
[SFU] grade 1 or 2) can be associated with Down syndrome or other chromosome
anomalies. More severe dilatation increases the risk of renal and/or urinary tract
disorders.
 During the ultrasonography, the appearance of the fetal renal system can vary in both
healthy fetuses without hydronephrosis and those with hydronephrosis. Therefore, this

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 diagnosis should not be based on a single measurement. [17] An increase of maternal
hydration can also increase the RPD in both healthy fetuses and those with
hydronephrosis. [18]
 If fetal hydronephrosis is detected, the following parameters need to be evaluated
using ultrasonography, as they guide further need for evaluation and are helpful in
determining the cause of hydronephrosis

Treatment of Hydronephrosis-

Medical Care

The role of medical treatment of hydronephrosis and hydroureter in adults is limited to pain
control and treatment or prevention of infection. Most conditions require either minimally
invasive or open surgical treatment. Two notable exceptions are (1) oral alkalinization
therapy for uric acid stones and (2) steroid therapy for retroperitoneal fibrosis.

The management approach to infants with antenatal hydronephrosis is based on the

confirmation of persistent postnatal hydronephrosis and the following two predictive factors:

 Bilateral involvement

 Severe hydronephrosis: Fetuses with a renal pelvic diameter greater than 15 mm

during the third trimester are at the greatest risk for significant renal disease

Bilateral hydronephrosis

Infants with severe bilateral antenatal hydronephrosis and/or bladder distension are at
increased likelihood of having significant disease. These infants and those with a severe
hydronephrotic solitary kidney should be evaluated initially by ultrasonography on the first
postnatal day. Bilateral hydronephrosis suggests an obstructive process at the level of or
distal to the bladder, such as ureterocele or posterior urethral valves (PUV) in a male infant,
which can be associated with impaired renal function and ongoing renal injury.

If postnatal ultrasonography demonstrates persistent hydronephrosis, voiding

cystourethrography (VCUG) should be performed. In male infants, the posterior urethra
should be fully evaluated to detect possible PUVs.

Infants with mild or moderate hydronephrosis can be evaluated after 7 days of life.

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Antibiotic prophylaxis

 Higher rates of urinary tract infections have been reported in children with prenatally
diagnosed hydronephrosis compared with the general pediatric population. The risk of
infection rises if there is an underlying urologic abnormality, such as VUR or
obstructive uropathy, and is greater in girls compared with boys.
 As a result, in infants with severe hydronephrosis who are at greater risk for an
underlying urologic abnormality, antibiotic prophylaxis is started after delivery until
the diagnosis of VUR or obstructive uropathy is excluded.
 Antibiotic prophylaxis in children with mild or moderate hydronephrosis confirmed
postnatally has not been studied prospectively.
 In one retrospective study of 1514 with mild persistent hydronephrosis, the use of
prophylactic antibiotics reduced the risk of febrile urinary tract infection in patients
who had VUR.  Until further prospective studies are conducted, antibiotic prophylaxis
should be considered until VCUG has been performed and either the diagnosis of
VUR has been made or eliminated.
 Antibiotic prophylaxis is not needed in infants with normal postnatal ultrasonography
findings. 
 Four retrospective studies have considered the role of antibiotic prophylaxis in infants
with hydronephrosis. Zareba et al analyzed the risk factors for urinary tract infection
(UTI) in 376 infants with prenatal hydronephrosis and reported that infants with high-
grade hydronephrosis, girls, and uncircumcised boys were at highest risk for UTI.
Antibiotic prophylaxis did not decrease the risk in any of the groups studied. 
 In a systematic review that included 3876 newborns with antenatal hydronephrosis,
Braga et al found that infants with high-grade hydronephrosis receiving continuous
antibiotic prophylaxis (CAP) had significantly lower UTI rates than those who did not
receive an antibiotic regimen (14.6% vs 28.9%). However, the rates for infants with
low-grade hydronephrosis were similar (2.2% vs. 2.8%). The researchers cautioned
that the level of evidence of available data was moderate to low. 
 Herz et al reviewed the records of 278 children maintained on CAP and 127 who were
not and compared individual characteristics to determine risk factors for UTI. The
presence of ureteral dilation, high-grade VUR, and ureterovesical junction obstruction
were independent risk factors for development of UTI. CAP had a significant role in
reducing UTI in children with the risk factors but was unnecessary otherwise. 

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  Varda et al studied the use of CAP during the interval between birth and initial
neonatal imaging in 494 infants with a history of prenatal urinary tract dilation, and
these authors concluded that routine CAP may be of limited benefit in most patients in
this setting. The incidence of UTI prior to initial neonatal imaging was low, and was
not significantly different in study patients who received CAP and those who did not.
 A systematic review from the European Association of Urology/European Society for
Paediatric Urology Guidelines Panel found that most studies of CAP had low-to-
moderate quality of evidence and high risk of bias. Consequently, the panel concluded
that whether CAP is superior to observation in decreasing UTIs remains unproven.
However, CAP may be warranted in uncircumcised boys, children with ureteral
dilatation, and those with high-grade hydronephrosis, who may be more likely to
develop UTI. 

SURGICAL MANAGEMENT-

The specific treatment of a patient with hydronephrosis and hydroureter depends, of course,
on the etiology of the process. Several factors help determine the urgency with which
treatment should be initiated. In general, any signs of infection within the obstructed system
warrant urgent intervention because infection with hydronephrosis may progress rapidly to
sepsis.

1. Urethral catheterization is important to help rule out a lower tract cause for
hydronephrosis and hydroureter. Difficulty in placing a Foley catheter may
suggest urethral stricture or bladder neck contracture.
2. Urologists or interventional radiologists can place a percutaneous
nephrostomy tube if ureteral stenting is not possible. Usually,
ultrasonography is used first to locate the dilated collecting system. Using the
Seldinger technique, a tube ranging from 8-12F can be placed. Nephrostomies
are typically placed when a retrograde stent cannot be passed because of
anatomic changes in the bladder or high-grade obstruction in the ureter. 
3. In a study of fluoroscopically guided percutaneous nephrostomy (PCN)
placement in infants and young children (mean age 8.6 months; range, 1 day-
75.5 mo), Hwang et al reported achieving complete decompression of
hydronephrosis in 35 of 53 kidneys (66%) and incomplete decompression in
17 of 55 kidneys (32.1%). The authors concluded that PCN is a feasible and

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 effective option for relieving urinary obstruction in these patients, and can
serve as a bridging procedure to definitive corrective surgery.

NURSING MANAGEMENT-

1. Impaired balance of fluid volume associated with fluid restriction.

2.  Risk of infection associated with access haemodialise.
3. Impaired sense of comfort: pain related to acute obstruction.
4. Activity intolerance related to anemia
5. Nutrition less than the needs associated with nausea, vomiting

BIBLIOGRAPHY-

1. K, Mergener; Jl, Weinerth; J, Baillie (December 1997). "Dietl's Crisis: A Syndrome

of Episodic Abdominal Pain of Urologic Origin That May Present to a
Gastroenterologist". The American Journal of Gastroenterology. 92 (12)

2. ^ Jump up to:a b "Hydronephrosis: Merck Manuals Home Health Handbook". New Jersey:

Merck and Co., Inc. 2009. Retrieved November 5, 2010.

3. ^ Hr, Toka; O, Toka; A, Hariri; Ht, Nguyen (July 2010). "Congenital Anomalies of
Kidney and Urinary Tract". Seminars in Nephrology. 30 (4): 374–86

4. ^ Jump up to:a b c d Capriotti, Theresa (2016). Pathophysiology: Introductory Concepts and

Clinical Perspectives. Frizzell, Joan Parker. Philadelphia. 

5. ^ Js, Koh; My, Wong; Mk, Li; Kt, Foo (September 1998). "Idiopathic Retroperitoneal
Fibrosis With Bilateral Lower Ureteric Obstruction--A Case Report With Literature
Review". Singapore Medical Journal. 39 (9)

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6. ^ Estrada CR (July 2008). "Prenatal hydronephrosis: early evaluation". Current
Opinion in Urology. 18 (4): 401–3.

7. ^ Woodward, M; Frank, D (January 2002). "Postnatal management of antenatal

hydronephrosis". BJU International. 89 (2): 149–156.

8. ^ Carmody, JB; Carmody, RB (December 2011). "Question from the clinician:

management of prenatal hydronephrosis". Pediatrics in Review. 32 (12):

9. ^ Jump up to:a b c Kay, Robert, M.D. "Evaluation of Hydronephrosis in Children"

in Urology Secrets, 2nd Ed. by Resnick & Novick; 1999, Hanley & Belfus

10. ^ Aksu, N; et al. (September 2005). "Postnatal management of infants with

antenatally detected hydronephrosis". Pediatric Nephrology. 20 (9): 1253–9. 

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