An unusual cause of acute renal failure

doi:10.1136/bmj.b4574

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Philip Dilks, specialty registrar, clinical radiology1,
Andrew Shawyer, specialty registrar, clinical radiology1,
Thomas C Booth, specialist registrar, clinical radiology2

¹Barts and the London NHS Trust, London EC1A 7BE
²Royal Free Hospital NHS Trust, London NW3 2XA

Correspondence to: P Dilks philip.dilks{at}bartsandthelondon.nhs.uk

A 46 year old woman with an uneventful medical history presented to her general practitioner with pain in her right loin and tiredness. Examination was unremarkable. Routine blood tests were within normal limits except for a urea of 20 mmol/l and creatinine of 604 μmol/l. A renal ultrasound showed bilateral pelvi-calyceal dilation. She underwent abdominal radiography and computed tomography (figs 1⇓ and 2⇓).

Fig 1 Plain abdominal radiograph

Fig 2 Computed tomography at the level of the right renal hilum

Questions

1 What interventions have been carried out and what can be deduced about the position of the ureters on the abdominal radiograph?
2 What does the computed tomogram show?
3 What is the aetiology of this condition and what other diagnostic options are available?
4 How should it be managed?

Answers

Short answers

1 The plain radiograph shows a right sided percutaneous nephrostomy catheter, bilateral ureteric (thermoexpandable) stents, and medial displacement of the ureters (fig 3⇓).

Fig 3 (a) Abdominal radiograph showing a right percutaneous nephrostomy catheter (white arrow), bilateral ureteric thermoexpandable alloy stents, and medial deviation of the ureters (blue arrows). (b) A different patient with bilateral ureteric double J stents also showing medial deviation secondary to retroperitoneal fibrosis (blue arrow)

2 The axial contrast enhanced computed tomogram shows a rim of soft tissue encasing the aorta that has medially displaced the ureters. This is in keeping with a diagnosis of retroperitoneal fibrosis.
3 Causes can be categorised as idiopathic or secondary to a wide range of conditions including neoplastic disease, infection, inflammation, trauma, and drug reactions. Ultrasound, intravenous urography, magnetic resonance imaging, and nuclear medicine can also help diagnose the condition and monitor response to treatment.
4 Treatment includes modification of risk factors and withdrawal of the causative agent, surgical and interventional relief of the mechanical …