Nephrology for the Family Physician - O.I. Bakaliuk 2003

Certain Urological Disorders in Therapeutic Practice
Nephroptosis

Nephroptosis is defined as a clinical and laboratory syndrome caused by the pathological mobility of the Kidney resulting from congenital factors (generalized splanchnoptosis, Developmental anomalies of the renal fixation structures) or acquired causes (weight loss, Pregnancy, trauma, or Displacement of the kidney by another organ, such as an enlarged Spleen in Fieschi's syndrome).

Nephroptosis (more frequently right-sided) predominantly occurs in asthenic women aged 16–40 years. Under physiological conditions (prolonged standing, deep breathing), the kidney may shift downward by 2–4 cm; however, such transient renal displacement does not adversely affect its Blood supply or urine drainage.

There are three degrees of renal displacement (H. Mazhdrakov et al., 1980):

- I — the lower pole of the kidney is constantly palpable;

- II — the entire kidney is palpable;

- III — the kidney descends into the iliac fossa (Fig. 91).

A significant degree of renal descent is accompanied by stretching and narrowing of the renal artery lumen, kinking and twisting of the Ureter, which leads to impaired renal Blood supply and urine outflow with an increase in intrapelvic pressure, and consequently, The Development of Hydronephrosis. It should be emphasized that even minor renal descent can be combined with its rotation around the vertical or horizontal axes, leading to Torsion of the renal pedicle and substantial disorders of renal hemodynamics. These disorders consist of a decrease in arterial inflow and, to a greater extent, the development of venous Hypertension resulting from impeded venous outflow. In fact, such renal rotations without noticeable descent are the cause of diagnostic errors, as the symptoms arising from this condition (proteinuria, arterial hypertension, pain) closely resemble those characteristic of immune-inflammatory renal lesions.

Nephroptosis has no specific clinical symptoms. Certain Features of the pain syndrome may be noted: a sensation of heaviness in the lumbar region, prolonged pain that occurs or worsens with physical exertion or when transitioning from a horizontal to a vertical position, as well as a feeling of abdominal discomfort and organ displacement. Rarely (in cases of sharp and significant renal displacement and ureteral kinking), pain resembling Renal Colic occurs.

Nephroptosis is also characterized by dyspeptic manifestations—a sensation of fullness in the epigastrium, shortness of breath, and vomiting, which occur 2–3 hours after consuming fatty foods, milk, or raw vegetables (symptomatology resembling pancreatitis). These manifestations intensify in the upright position. Notably, dyspeptic disorders are also frequently observed in the so-called Horseshoe kidney (Gutierrez syndrome).

Asthenic syndrome (irritability, decreased performance, insomnia), episodes of gross Hematuria, and transient followed by persistent arterial hypertension are also distinguished.

In some cases, the clinical symptomatology of nephroptosis manifests as intoxication, inflammatory, and dysuric syndromes resulting from secondary Pyelonephritis.

The severity of individual symptoms and impaired renal hemodynamics justifies distinguishing three clinical stages of nephroptosis (I.E. Tareeva et al., 1995):

- I — nephroptosis without Complaints, objective changes in renal hemodynamics, or urine drainage;

- II — nephroptosis manifested by general complaints, without changes in renal hemodynamics or urine drainage;

- III — nephroptosis with localized syndromes, and laboratory and instrumental signs of impaired renal hemodynamics and urine drainage.

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Fig. 91. Degrees of nephroptosis (according to H. Mazhdrakov et al., 1980).

The Diagnosis of nephroptosis is based on a detailed evaluation of complaints and clinical-instrumental research data. Attention is paid to sex (women are more frequently affected), body constitution (asthenic), and the tone of the anterior abdominal wall (its decrease, especially in women postpartum).

In nephroptosis, so-called paradoxical orthostatic arterial hypertension is often observed—higher blood pressure levels in the horizontal position. This is explained by the fact that under conditions of constant impediment to venous outflow in the horizontal position, the inflow of arterial blood to the kidney increases, which in turn further impedes venous blood flow and, consequently, increases renal ischemia.

Palpation of the abdominal Organs in both supine and standing positions makes it possible to determine the degree of renal mobility.

Changes in the urinary sediment are nonspecific: moderate proteinuria (partially due to erythrocytes) depending on body position (similar to orthostatic proteinuria), hematuria; casts are absent. Indicators of the functional state of The Kidneys in the Cytology/cytology/16.html">Early stages of the disease are not impaired.

Instrumental Methods assist in diagnosing nephroptosis, notably renal ultrasound in horizontal and vertical positions (Location and degree of renal mobility, Fig. 92).

An urogram performed in horizontal, vertical, and Trendelenburg positions provides sufficient information regarding the degree of renal mobility, urine drainage, and—most importantly—the orientation of the longitudinal axis of the kidney (Figs. 93, 94).

Fig. 92. Nephroptosis combined with Chronic Pyelonephritis (ultrasound, visualization of the kidneys at the umbilical level, compaction of the pelvicalyceal system).

Fig. 93. Moderately pronounced right-sided nephroptosis (excretory urogram).

Fig. 94. Pronounced right-sided nephroptosis with pyelectasis (excretory urogram).

Transfemoral aortography performed in the upright position (revealing renal vessel stretching and lumen narrowing), selective venography with measurement of renal vein pressure, and renal Doppler Ultrasonography (demonstrating blood flow Asymmetry and signs of venous hypertension) are less frequently used for the diagnosis of nephroptosis.

Differential diagnosis is performed with chronic appendicitis, cholelithiasis, pancreatitis, urolithiasis, Ovarian Cysts, intestinal and Renal Tumors, hydronephrosis, Polycystic Kidney Disease, and hepatic echinococcosis.

Treatment for nephroptosis is strictly surgical when pronounced morphological and functional Disorders of the mobile kidney lead to disability. The most widespread methods of nephropexy include the Rivoir Procedure modified by Pytel-Lopatkin and nephropexy to the crura of the Diaphragm using lavsan threads (A.Z. Parkhomchuk, 1998). The best outcomes of such surgeries are achieved in patients with a short METABOLISM/13.html">History of the disease (up to 3 years) and minor alterations in the mobile kidney (S.A. Sukhomlyn, 1998).