OBSTRUCTIVE NEPHROPATHY

I. Description

Obstructive nephropathy, also known as uropathy, refers to the syndrome caused by urinary tract
obstruction, either functional or anatomic. It includes urinary tract dilatation, impedance and the resulting
slowing of urine flow, a change in the pressure inside the kidney tubular system, and impaired kidney
function. Blockage of the flow of urine leads to hydronephrosis and hydroureter. Obstructive nephropathy is
a common condition, and its incidence rises with advancing age. In children, the leading cause is
ureteropelvic junction obstruction, with an incidence of one in 1500. Urolithiasis in children occurs in 1-5%.
(Thomas, Dr. L., 2019)

Obstructive nephropathy is a relatively common entity that is treatable and often reversible. It
occurs at all ages, from infancy to the elderly. (Internal Medicine 39: 355-361, 2000)

II. Causes/Risk Factors, Signs & Symptoms, Prevalence

The causes of obstructive uropathy are many. Obstructive uropathy occurs when urine cannot drain
through the urinary tract. Urine backs up into the kidney and causes it to become swollen. This condition is
known as hydronephrosis. Obstruction of the urinary tract may decrease renal blood flow and the glomerular
filtration rate. Several abnormalities in tubular function may occur in obstructive nephropathy. These include
decreased reabsorption of solutes and water, an inability to concentrate the urine and impaired excretion of
hydrogen and potassium. Renal interstitial fibrosis is a common finding in patients with long-term obstructive
uropathy. Several factors: macrophages, growth factors, hypoxia, and cytokines—are involved in the
pathogenesis of interstitial fibrosis. It has been shown that ACE inhibitors ameliorate the interstitial fibrosis in
animals with obstructive uropathy. (Internal Medicine 39: 355-361, 2000).

The risk factors include benign prostatic hyperplasia (BPH), constipation, and medication
(anticholinergic agents, narcotic analgesia, alpha receptor agonists), and urolithiasis (ureteric calculi).

Globally, the overall incidence and prevalence of obstructive nephropathy are difficult to assess
accurately. A review based on 59,064 autopsies, ranging from neonates to the elderly, identified
hydronephrosis in 3.1% (3.3% in males and 2.9% in females). Provided that hydronephrosis can be used as
a surrogate marker of obstruction, the study showed that until the age of 20 yr there was no substantial sex
difference in the frequency of abnormalities. Between the ages of 20 and 60 yr urinary tract obstruction was
more frequent among women than among men, and above the age of 60 yr prostatic disease raised the
 frequency of urinary tract obstruction among men above that observed among women. (Nørregaard, R.,
Mutsaers, H.A.M., Frøkiær J., and Kwon, T.H., 2023)

Nationally, the prevalence of obstructive uropathy is still hypothetical. Regardless, there are
estimated frequency of 3 (2.9%) cases that occur in Pediatric Nephrology Society of the Philippines, which
indicates the presence of obstructive uropathy in the Philippines, despite its uncharted prevalence.

III. Laboratory/Diagnostic Examinations

The treatment of obstructive uropathy is based on promptly addressing the obstructive process.
Bladder volume measurements can help guide further therapies from this point. A Foley catheter is likely to
be attempted, particularly if the obstruction is due to the most frequent etiology, benign prostatic
hypertrophy, or hyperplasia. The initial attempt usually occurs with a 16- or 18-Fr Foley. The presence of
obstruction may prevent the initial success of urethral catheterization and may require higher-level
interventions. The most typical next step would be a trial of urethral catheterization using a Coudé tip Foley,
but more significant interventions may be required and are addressed in other articles.

Diagnosis is based upon clinical examination followed by imaging tests such as intravenous
urography, retrograde ureterography, ultrasound, CT scans, and contrast imaging. Ultrasound has become
the imaging technique of choice because it is available almost everywhere and is safe but sensitive. CT
scans are especially useful in identifying retroperitoneal or pelvic growths that are obstructing the ureter.
Dye excretion urography will show the characteristic dense nephrogram in cases of ureteric obstruction.
Renal scintigraphy using I123-hippuran or technetium scans is helpful in assessing kidney function in a less
invasive way, including the accumulation of the isotope, its transit time, and excretion. There are several
other methods, such as perfusion pressure studies and renal scintigraphy, to help differentiate obstructed
urinary tracts from those that are only dilated. Early diagnosis of urinary obstruction is vital to prevent further
damage or reverse renal impairment.

IV. Treatments

The treatment of obstructive uropathy is based on promptly addressing the obstructive process.
Bladder volume measurements can help guide further therapies from this point. Treatment is focused on
removing the cause of obstruction, preventing any deterioration of kidney function and if possible, reversing
any impairment that has already occurred. Acute obstruction is relieved by using stents, nephrostomy tubes
or catheters. Chronic obstruction often requires surgical repair, drainage of infection, or removal of one
kidney. Chronic obstruction may result in chronic kidney disease and renal failure. Overdistension of the
 bladder, such as following a bladder stone, may result in bladder damage and failure of proper voiding or
leakage of urine.

V. Nursing Interventions

The patient with obstructive uropathy should be educated on catheter care, including how to
properly secure the catheter, and on monitoring urine output. Advise the patient regarding potential reasons
to seek immediate care (e.g., fever, blocked Foley, gross hematuria, severe pain). They should be
counseled on the importance of adhering to recommended follow up plans, both for management of
underlying conditions and to prevent recurrent obstructions. If medications are being prescribed, it is
important to inform the patient of potential side effects.
References:

BMJ Best Practice. (2021, Febuary 09). Obstructive uropathy. BMJ Best Practice.
https://bestpractice.bmj.com/topics/en-gb/643.

Ong, S.R.K. MD, Rivera A.S. MD, and Pauig, J.P. MD. (2022). Diagnosis of Hydronephrosis or Ureteral
Obstruction using Renal Sonography among Patients with Cervical Cancer. Acta Medica Pilippina. 339-Article
Text-24955-2-10-20220330.pdf

Nørregaard, R., Mutsaers, H.A.M., Frøkiær J., and Kwon, T.H. (2023). Obstructive nephropathy and
molecular pathophysiology of renal interstitial fibrosis.
https://journals.physiology.org/doi/full/10.1152/physrev.00027.2022

Rishor-Olney, C.R. Hinson, M.R. (2023). Obstructive Uropathy. NCBI Bookshelf.

PEDIATRIC NEPHROLOGY SOCIETY OF THE PHILIPPINES. (2022). Pediatric Renal Census (Admissions
& Admission Referrals). https://pps.org.ph/wp-content/uploads/2023/05/PNSP-2022-Renal-Registry-2.pdf

Stratton, K.L. MD. (2022). Obstructive uropathy. https://medlineplus.gov/ency/article/000507.htm