Case summary

Author: Professor Guy Maddern

An 89-year-old woman from a nursing home with a history of chronic renal impairment (chronic kidney disease IIIB), non-insulin dependent diabetes, Barrett's oesophagitis, rheumatoid arthritis (on methotrexate) and cerebrovascular disease presented with an infected obstructed left kidney secondary to a small stone in the proximal ureter. The diagnosis was made in the emergency department in combination with the Urology service.

The patient underwent a technically uncomplicated ureteric (JJ) stent insertion to relieve the obstruction. However, she deteriorated into multiple organ failure despite the procedure. Three days after admission, the patient opted for palliative care. She died two days later.

Discussion
An infected obstructed kidney is a potentially life-threatening event, where bacteria from the infected urine access the circulation by pyelolymphatic reflux and can cause septic shock. In this situation, urgent decompression of the kidney with either a ureteral stent (as in this instance) or a percutaneous nephrostomy is essential.

Percutaneous nephrostomy has some advantages in certain cases, as no anaesthetic is required and has a low failure rate. In contrast, insertion of a ureteral JJ stent requires an anaesthetic and manipulation of the infected system, which in some cases may result in bacteraemia. It may also fail, particularly if the stone is impacted.

If there is ready access to percutaneous nephrostomy and the patient is cooperative, able to lie flat, and does not take anticoagulants, then this technique may be preferable. In practice—due to the limited availability of percutaneous nephrostomy outside of tertiary hospitals and the high prevalence of anticoagulant/antiplatelet medications—JJ stenting (as used in this instance) is an accepted and often more timely method for renal decompression.

Despite timely decompression and care in an intensive care unit, this patient's infection progressed to multiple organ failure. At that point, a discussion was held with the patient, who elected for palliative care. Given her poor performance status and advanced age, her comorbidities, and the protracted and possible futility of escalated care, this discussion and decision were entirely appropriate.

Clinical lesson
This patient was well managed in a regional centre and died despite timely and appropriate care. If the patient was in a major metropolitan hospital, she may have received a nephrostomy tube rather than a JJ stent to decompress the kidney. However, this is not always possible or available in a regional centre.