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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 1  |  Page : 120-123
Reflex anuria affecting both kidneys following hysterectomy

1 Department of Nephrology, Ekbatan Hospital, Hamedan University of Medical Sciences and Health Services, Hamedan, Iran
2 Sina Hospital, Hamedan University of Medical Sciences and Health Services, Hamedan, Iran
3 Department of Urology, Ekbatan Hospital, Hamedan University of Medical Sciences and Health Services, Hamedan, Iran
4 Faculty of Nursing and Midwifery, Zanjan University of Medical Sciences and Health Services, Zanjan, Iran
5 Faculty of Nursing Department, Islamic Azad University, Birjand Branch, Birjand, Iran

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In situations when there is unilateral ureteral obstruction, the contralateral kidney retains its normal function. In rare instances however, it has been reported that unilateral ureteral obstruction can lead to reflex anuria (RA) and acute renal failure (ARF). Even more unusually, RA with ARF can occur without organic obstruction due to ureteric manipulation during pelvic surgery. We report a 78- year-old woman, who underwent hysterectomy because of endometrial carcinoma. She developed ARF evidenced by anuria of 120-hours duration, and gradual rise of serum creatinine levels to 11.8 mg/dL on the fifth day after hysterectomy. Ultrasound study of the urinary tract revealed bilateral moderate hydronephrosis. Detailed evaluation did not reveal any organic obstruc­tion. She was managed with hemodialysis, control of hypertension and correction of fluid and elec­trolyte imbalances. By the sixth day, diuresis was established, and the blood urea and serum crea­tinine levels decreased to normal by the sixteenth day. The patient was finally discharged on the eighteenth day. Our case suggests that urologists and nephrologists should consider RA as one of the causes of anuria and ARF.

How to cite this article:
Gholyaf M, Afzali S, Babolhavaegi H, Rahimi A, Wagharseyedayn SA. Reflex anuria affecting both kidneys following hysterectomy. Saudi J Kidney Dis Transpl 2009;20:120-3

How to cite this URL:
Gholyaf M, Afzali S, Babolhavaegi H, Rahimi A, Wagharseyedayn SA. Reflex anuria affecting both kidneys following hysterectomy. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2023 Feb 5];20:120-3. Available from: https://www.sjkdt.org/text.asp?2009/20/1/120/44718

   Introduction Top

During unilateral ureteral obstruction, the con­tralateral kidney retains its normal function. In rare instances, however, it has been reported that unilateral ureteral obstruction can lead to reflex anuria (RA) and acute renal failure (ARF). [1],[2],[3],[4]

RA is defined as "cessation of urine output from both kidneys in response to irritation or trauma to one kidney or its ureter or severely painful stimuli to other organs". [1],[4],[5] The diag­nosis of RA is based on three criteria:

  1. a normal contralateral kidney, which retains normal function soon after the disease causing non-function of the other kidney has been treated,
  2. subsequent investigation of the contralateral kidney shows that a pathological process is un­likely to have caused its loss of function, and
  3. surgical intervention to the contralateral shut­down kidney does not result in return of func­tion in either kidney.

Anuria and ARF due to RA are rare, and occur almost always after surgical procedures and manipulation of the ureter (without obstruction due to stone or ligation). Rarely, RA has been reported in unilateral ureteral obstruction due to ureteral stone. We herewith describe a case of RA affecting both kidneys due to ureteric mani­pulation during hysterectomy for endometrial carcinoma; this entity is very rare in general practice and very few reports exist in the lite­rature. [4],[5],[6]

   Case report Top

We report the case of a 78-year-old Iranian woman, admitted to the Ekbatan Hospital in the city of Hamedan, who underwent hysterectomy for endometrial carcinoma. Despite effective hydration after recovery, she developed anuria (urine volume < 20 mL daily) of 120-hours duration and ARF. Routine pre-operative tests showed normal serum creatinine, which rose gradually to 11.8 mg/dL by the fifth day after hysterectomy. Ultrasound study revealed bilate­ral moderate hydronephrosis, but cortical thick­ness and corticomedullary differentiation were reported to be normal.

A Tc-99m DTPA scan was performed which revealed severely decreased flow to the kidneys in perfusion phase and mildly decreased paren­chymal uptake. In late images, good parenchy­mal transit of activity was seen with delayed drainage and increased background uptake. The findings were consistent with delayed drainage of the kidneys with relatively good glomerular filtration and early parenchymal uptake, sug­gesting post-renal etiology. Because of poor drainage, the ureters could not be evaluated [Figure 1],[Figure 2], and [Figure 3].

Voiding cystourethrogram (VCUG) and retro­grade pyelography did not show any mecha­nical obstruction to the ureters. Also, cystos­copy and ureteroscopy did not show any evi­dence of inflammation. Urinary sediment and urine cytologic studies revealed no evidence in favor of malignancy, acute tubular necrosis (ATN), glomerulonephritis or interstitial nephritis.

Management included hemodialysis, control of hypertension and correction of fluid and electrolyte imbalance. On the sixth day, diuresis was established. Thereafter, from the seventh to the ninth day, the patient went into polyuric phase. Gradually, the blood urea and serum creatinine levels declined and on the sixteenth day, the serum creatinine was found to be 1.6 mg/dL. The patient was discharged two days later with normal kidney function (serum crea­tinine, 1.4 mg/dL) and relatively good general condition.

   Discussion Top

Renal function is usually normal or only mar­ginally affected in patients with unilateral ure­teral obstruction due to the compensatory hyper­function of the contralateral kidney. [4] RA is a very rare event, which can occur following neu­ral irritation of the bladder or ureter.

Catalano et al (2002) reported a female patient who developed anuria of 72-hours duration and ARF due to a 2-cm stone located in the pelvis of the right kidney. The patient had not taken any nephrotoxic agents, nor did she have any infection or dehydration. [4] Ultrasound showed that the affected kidney had normal dimensions with a hydronephrotic pelvis. [4] Excretory uro­graphy performed later showed prompt and simultaneous excretion of contrast medium by both kidneys and normally shaped urinary tract and bladder. [4]

Stamey in 1974 and Sirota in 1954 described occurrence of anuria following urethral cathete­rization and mentioned that vesicoureteral obs­truction due to edema, was the cause of this event. [7] Shearlock and Howards in 1976 des­cribed RA in a 32-year-old nurse, who under­went right nephrectomy, because of xanthogra­nulomatous pyelonephritis. Retrograde pyelo­graphy and arteriography were normal. Diuresis resumed after six days; further studies in this patient, showed retroperitoneal fibrogranular infiltration with pulmonary, pericardial and bone marrow involvement, which was treated with vincristine, prednisolone and cyclophospha­mide. [8] In 1980, Hull and co-workers described a case of RA due to unilateral distal ureteral stone. After removal of the stone, diuresis was established. [1]

We report a patient with post-hysterectomy bilateral RA, which is a very rare event. In this case, ureteral spasm due to hyper-excitability of the autonomic nervous system may be the cause of RA. [4] There is experimental support for the neurovascular hypothesis. Di Salvo and Fell were able to shut off the renal blood supply by using pulsatile renal nerve stimulation. [9]

In the case reported by Maletz et al, renal scintigraphy was performed before and after the acute episodes, and the findings appear to sup­port the role of angiospasm in causing anuria.During the acute episode, there was low uptake of radioactivity bilaterally with a higher uptake by the obstructed kidney. They suggested that the autonomic nervous system in patients who presented with RA was extremely sensitive to visceral stimuli. [2]

Hull et al [1] suggested two reflex mechanisms to explain RA; an arteriolar intrarenal spasm, or a ureteral spasm, both associated with pain. [3] Suzuki et al [10] reported a case supporting the role of ureteral spasm in which a boy expe­rienced anuria after partial hepatectomy, in whom bilateral ureteral catheterization was followed by heavy diuresis. Maletz et al [2] des­cribed a case in which the positioning of a ureteral stent was followed by the disappea­rance of pain and the start of diuresis. These cases do not exclude the possibility that renal vasoconstriction might be associated with ure­teral spasm but, suggest that by stopping the latter, anuria could be resolved.

However, RA (which can cause ARF) is so rare that many physicians believe it to be a myth. Consequently, RA might not be consi­dered in the differential diagnosis of ARF. [4] Also, most reference textbooks do not discuss RA as a cause for ARF. [11],[12] An important exception is Rose's UpToDate; [13] Maletz et al [2] reviewed RA in 1993.

We conclude that urologists and nephrologists should consider RA as one of the causes of anuria and ARF however uncommon it may be.

   Competing interests Top

The author(s) declare that they have no compe­ting interests.

   Authors' contributions Top

AR and MG drafted the manuscript, prepared illustrations and performed the literature search. SA, HB and SAW helped to draft the manus­cript, paying particular attention to the patho­logical aspect and kindly acquired histological images for illustration. MG conceived this study and supervised the drafting and overall struc­ture of the manuscript. All authors have read and approved the final manuscript.

   Consent Top

The authors confirm patient consent has been sought and received.

   References Top

1.Hull JD, Kumar S, Pletka PG. Reflex anuria from unilateral ureteral obstruction. J Urol 1980;123(2):265-6.  Back to cited text no. 1    
2.Maletz R, Berman D, Peelle K, Bernard D. Reflex anuria and uremia from unilateral ureteral obstruction. Am J Kidney Dis 1993;22(6):870-3.  Back to cited text no. 2    
3.Songco A, Rattner W. Reflex anuria. Urology 1987;29(4):432-3.  Back to cited text no. 3    
4.Catalano C, Comuzzi E, Davi L, Fabbian F. Reflex anuria from unilateral ureteral obstruction. Nephron 2002;90(3):352-4.  Back to cited text no. 4    
5.Kervancioglu S, Sirikci A, Erbagci A. Reflex anuria after renal tumor embolization. Cardio­vasc Intervent Radiol 2007;30(2):304-6.  Back to cited text no. 5    
6.Hayashi K, Horikoshi S, Hirano K, et al. A case of reflex anuria and uremia related to a unila­teral ureteral stone. Nippon Jinzo Gakkai Shi 1996;38:460-2.  Back to cited text no. 6    
7.Sirota JH, Narins L. Acute urinary suppression after ureteral catheterization: The pathogenesis of reflex anuria. N Engl J Med 1957;257(23): 1111-3.  Back to cited text no. 7    
8.Shearlock KT, Howards SS: Post-obstructive anuria: a documented entity. J Urol 1976;115 (2):212-3.  Back to cited text no. 8    
9.Di Salvo J, Fell C. Changes in renal blood flow during renal nerve stimulation. Proc Soc Exp Biol Med 1970;136:150-3.  Back to cited text no. 9    
10.Suzuki T, Komuta H, Tsuchiya R. Postrenal reflex anuria. Nippon Geka Hokan 1966;5:421-6.  Back to cited text no. 10    
11.Brady HR, Brenner BM, Clarkson MR, Lieber­thai W. Acute renal failure: Postrenal azotemia. In: Brenner BM, Levine SA (eds): Brenner and Rector's the Kidney, edi 6. Philadelphia, Saun­ders; 2000.  Back to cited text no. 11    
12.Brenner BM, Milford EL, Seifter JL. Urinary tract obstruction. In Harrison's Principles of Internal Medicine, ed II. Philadelphia, McGraw­Hill; 1987.  Back to cited text no. 12    
13.Rose BD. Diagnosis of urinary tract obstruction and hydronephrosis. In: Rose BD (ed): Up­ToDate. Wellesley, MA, UpToDate; 2000.  Back to cited text no. 13    

Correspondence Address:
Mahmoud Gholyaf
Department of Nephrology, Hamedan University of Medical Sciences and Health Services, Hamedan
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Source of Support: None, Conflict of Interest: None

PMID: 19112230

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  [Figure 1], [Figure 2], [Figure 3]

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