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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2017  |  Volume : 28  |  Issue : 1  |  Page : 170-173
Perspectives on hypertension outcomes after single-stage clearance of a complete staghorn renal calculus


1 Department of Surgery, People's College of Medical Sciences, Bhopal, Madhya Pradesh, India
2 Department of Obstetrics and Gynecology, People's College of Medical Sciences, Bhopal, Madhya Pradesh, India

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Date of Web Publication12-Jan-2017
 

   Abstract 

A 55-year-old male presented, in June 2013, with left flank pain. Investigations revealed a complete staghorn stone. He had undergone two sittings of extracorporeal shock wave lithotripsy (ESWL) in 2008 for left renal stone. One year subsequent to this, he was diagnosed with hypertension and diabetes. The management of complete staghorn stones in a single sitting is a difficult proposition. Percutaneous nephrolithotomy (PCNL) is the gold standard to manage such stones. The patient was subjected to PCNL, and complete clearance was achieved in one sitting. On one-year follow-up, there was a significant reduction in blood pressure (BP) and better glycemic control. Although there are several reports where hypertension has been reported after multiple sittings of ESWL, whether ESWL contributed to the genesis of hypertension and diabetes in this patient or it was simply incidental, cannot be stated with certainty. There was a significant reduction in the BP after complete stone removal, but there is uncertainty over the effect of total clearance of renal stones on hypertension, and we need to await the results of more controlled trials studying this phenomenon. A better glycemic control was perhaps achieved secondary to the eradication of recurrent urinary tract infections due to complete stone clearance.

How to cite this article:
Chaudhary R, Singh K, Dausage CS, Jain N. Perspectives on hypertension outcomes after single-stage clearance of a complete staghorn renal calculus. Saudi J Kidney Dis Transpl 2017;28:170-3

How to cite this URL:
Chaudhary R, Singh K, Dausage CS, Jain N. Perspectives on hypertension outcomes after single-stage clearance of a complete staghorn renal calculus. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2017 Nov 23];28:170-3. Available from: http://www.sjkdt.org/text.asp?2017/28/1/170/198244

   Introduction Top


Presently, the percutaneous nephrolithotomy (PCNL) is unquestionably the "gold standard" for the management of staghorn calculi. This technique entails maximal stone clearance in a single sitting and in expert hands, has a statistitically insignificant rate of complications.

There are studies supporting a better glycemic control after complete stone clearance, perhaps due to reduced urinary tract infections. However, the relationship between staghorn calculi and hypertension is not well established, and there is a paucity of literature evaluating the changes in blood pressure (BP) after complete clearance of staghorn calculi.

We present a 55-year-old male, who presented with a complete staghorn stone in the left kidney. Previously, he had undergone multiple sessions of extracorporeal shock wave lithotripsy (ESWL), subsequent to which he developed hypertension and diabetes.

Remarkably, after a single stage clearance of the staghorn stone by PCNL, a much better glycemic control and a significant reduction in BP were achieved.


   Case Report Top


A 55-year-old male presented, in June 2013, with complaints of left flank pain secondary to a renal stone. Previously, in 2008, he had undergone two sittings of ESWL for left renal stone, subsequent to which he passed a few 4-5 mm stones. The patient did not attend follow-up after the procedure, and no further tests could be performed to evaluate the clearance of stone after ESWL. In 2009, he was diagnosed with diabetes and hypertension for which medical treatment was initiated.

At presentation, an ultrasound evaluation of the kidneys revealed a large staghorn calculus in the left kidney. His BP was 150/100, he was taking 5 mg of enalapril in the morning and 25 mg of atenolol at night.

Intravenous urogram showed bilaterally normal functioning kidneys with a staghorn stone occupying the entire pelvicalyceal system on the left side ([Figure 1], [Figure 2] and [Figure 3]).PCNL. Two punctures were made (supracostal upper calyx and subcostal lower calyx). In a single sitting lasting 150 min, complete stone clearance was achieved ([Figure 4]). No blood transfusions were needed. A double J stent was placed at the completion of the procedure, which was removed after two weeks. The nephrostomies were removed after 6 h and the patient was discharged on the 2nd postoperative day.
Figure 1. Plain X-ray of the kidney, ureter, and bladder region showing a left renal staghorn stone.

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Figure 2. Intravenous urogram, 15 min film, showing prompt bilateral excretion.

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Figure 3. Intravenous urogram, 40 min film.

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Figure 4. Postoperative X-ray of the kidney, ureter and bladder region showing total clearance. Two nephrostomy tubes denoting puncture tracts are also seen.

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   Discussion Top


The management of complete staghorn stones in a single sitting is a difficult proposition. PCNL is the gold standard to manage such stones.[1] While operating on a staghorn calculus, the punctures must be designed to facilitate maximum stone clearance with the minimum number of punctures.

After stone clearance, there was a significant reduction in the required dosage of antihypertensive and anti-glycemic medicines. We subjected the patient to a 4-hourly BP monitoring which revealed that his average BP was 130/80 mm Hg (as opposed to 150/100 preoperatively) with a 50% reduction in the dose of anti-hypertensive medications; 2.5 mg enalapril in the morning and 12.5 mg of atenolol at night. A better healing of wounds and an overall improvement in the general well-being was also reported.

The patient's history underlined that he developed diabetes and hypertension after he had undergone a session of ESWL. This encouraged us to further review the literature on the effect of "modality of stone removal" on diabetes and hypertension, and there was a report of a 19- year follow-up after ESWL that the development of hypertension and diabetes appeared to be significantly associated with ESWL.[2] However, this study had problems with its control group with a possibility of a sampling bias.[3] We attempted to evaluate if the BP would reduce after renal stone removal. We found a report that had followed up 252 patients and mentioned reduction in the systolic BP in the immediate phase, particularly in those patients who passed their renal stones, spontaneously, but this effect vanished at 24-month when the BP actually started rising in most stone passers regardless of how their stones were removed.[4] In light of this, it is imperative that the cited case be followed up to ensure that the reduction in BP is maintained over a long period of time. There are several reports where hypertension was reported after multiple sittings of ESWL. This patient developed hypertension and diabetes one year subsequent to multiple sessions of ESWL. However, whether ESWL contributed to it or it was simply incidental, cannot be stated with certainty. Although there was a significant reduction in the BP after complete stone removal, there is uncertainty over the effect of total clearance of renal stones on hypertension, and we need to await the results of more controlled trials studying this phenomenon. A better glycemic control was perhaps achieved secondary to the eradication of recurrent urinary tract infections due to complete stone clearance.

In hindsight, it would have been prudent to carry out a duplex ultrasound along with plasma renin activity (PRA) both pre- and post- operatively. Any changes seen in the cited parameters could have then helped in explaining the perceived benefits of a staghorn stone clearance with regard to BP.

Conflict of interest: None declared.

 
   References Top

1.
Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle MS, Wolf JS Jr.; AUA Nephrolithiasis Guideline Panel. Chapter 1: AUA guideline on management of staghorn calculi: Diagnosis and treatment recommendations. J Urol 2005;173:1991-2000.  Back to cited text no. 1
    
2.
Krambeck AE, Gettman MT, Rohlinger AL, Lohse CM, Patterson DE, Segura JW. Diabetes mellitus and hypertension associated with shock wave lithotripsy of renal and proximal ureteral stones at 19 years of followup. J Urol 2006; 175:1742-7.  Back to cited text no. 2
    
3.
Huang SW, Wang CJ, Chang CH. Does shockwave lithotripsy induce hypertension? JTUA 2009;20:109-16.  Back to cited text no. 3
    
4.
Strohmaier WL, Schmidt J, Lahme S, Bichler KH. Arterial blood pressure following different types of urinary stone therapy. Presented at the 8th European Symposium on Urolithiasis, Parma, Italy, 1999. Eur Urol 2000;38:753-7.  Back to cited text no. 4
    

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Correspondence Address:
Ranjit Chaudhary
Department of Surgery, People's College of Medical Sciences, Bhopal, Madhya Pradesh
India
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DOI: 10.4103/1319-2442.198244

PMID: 28098121

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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