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Infected obstructed ureteric stone in pregnancy with acute kidney injury and a functionally solitary kidney —

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HardNephrolithiasisInfected obstructed ureteric stone in pregnancy with acute kidney injury and a functionally solitary kidneyMSRA

A 32-year-old woman who is 24 weeks pregnant presents to her GP with 18 hours of worsening left flank pain, vomiting and fever. She has a congenital atrophic right kidney and her usual creatinine is 72 micromol/L. An urgent renal ultrasound arranged earlier today shows moderate left hydronephrosis and an 8 mm proximal left ureteric calculus. Her temperature is 38.6°C, heart rate 116 beats/minute and BP 104/66 mmHg. Urine dipstick is positive for nitrites, leucocytes and blood. Her creatinine is now 128 micromol/L. She has taken paracetamol with little benefit. What is the most appropriate immediate management?

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Correct answer: D — Transfer immediately to hospital for sepsis management, intravenous antibiotics and urgent urological decompression

This is an infected obstructed urinary system: fever, tachycardia and nitrite-positive urine indicate upper urinary tract infection in the context of an obstructing ureteric stone and hydronephrosis. Her creatinine has risen substantially from baseline, and she has a functionally solitary kidney, making ongoing obstruction particularly hazardous. This requires immediate hospital transfer for resuscitation and intravenous antimicrobials, with urgent urological drainage (ureteric stent or percutaneous nephrostomy as locally appropriate); definitive stone treatment is deferred until sepsis and obstruction are controlled. A is wrong because low-dose non-contrast CT is first-line imaging for most non-pregnant adults with suspected renal colic, but ultrasound is preferred in pregnancy and imaging must not delay management of suspected infected obstruction. B is initially attractive for a stable urinary infection, but oral community treatment is inadequate where obstruction, systemic infection and acute kidney injury coexist. C reflects NICE advice that alpha blockers may be considered for distal ureteric stones under 10 mm, but this stone is proximal and medical expulsive therapy is inappropriate in infected obstruction. E may form part of later definitive management, but urgent drainage—not elective stone removal—is the immediate priority.

Reference: NICE NG118: Renal and ureteric stones: assessment and management (2019) — https://www.nice.org.uk/guidance/ng118 NICE NG118 recommendations: diagnostic imaging and medical expulsive therapy (2019) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations NHS Greater Glasgow and Clyde: Nephrolithiasis and/or nephrocalcinosis (management and evaluation) (2021) — https://www.rightdecisions.scot.nhs.uk/nhsggc-guidelines/nhsggc-guidelines/kidney-diseases/nephrolithiasis-andor-nephrocalcinosis-management-and-evaluation/