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Obstructing distal ureteric calculus in a solitary kidney with acute kidney injury — MSRA MCQ

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HardNephrolithiasisObstructing distal ureteric calculus in a solitary kidney with acute kidney injuryMSRA

A 54-year-old woman is reviewed urgently by her GP after emergency department assessment for renal colic. She donated her right kidney 8 years ago and had a 3 mm ureteric stone that passed spontaneously 2 years ago. Low-dose non-contrast CT performed yesterday shows a 5 mm distal left ureteric calculus with moderate hydroureteronephrosis. Her pain is now controlled with paracetamol, she is drinking normally and has no vomiting. She is afebrile, observations are normal, and urine dipstick is positive for blood but negative for nitrites and leucocytes. Her creatinine has increased from a baseline of 67 micromol/L to 118 micromol/L. What is the most appropriate immediate management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Discuss immediately with the urology on-call team and arrange emergency admission today

Explanation lettering: E = shown as A · D = shown as B · A = shown as C · B = shown as D · C = shown as E

This patient requires immediate emergency urological assessment. Although the stone is small and distal, her reassuring features (controlled pain, ability to drink, absence of fever and a urine dip negative for infection markers) do not make outpatient management appropriate. She has a solitary functioning kidney, CT-confirmed obstruction and an acute rise in creatinine, indicating clinically important threatened renal function. Current NHS urology referral guidance advises immediate emergency admission for a known stone former at increased risk of acute kidney injury, including people with a solitary kidney. The priority is urgent specialist assessment and relief of obstruction if required; definitive stone treatment is secondary to protecting renal function. A and C are attractive because alpha-blockers can be considered for distal ureteric stones smaller than 10 mm, but medical expulsive therapy must not delay emergency assessment when renal function is deteriorating in a solitary kidney. D may be appropriate definitive treatment for selected stable ureteric stones, but it does not address the immediate risk from obstruction and acute kidney injury. E would be reasonable only for an uncomplicated stone in a person without high-risk renal circumstances and with stable renal function.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — Recommendations (Published 08 January 2019; last reviewed 26 February 2021) — https://www.nice.org.uk/guidance/ng118/chapter/recommendations NHS Lanarkshire Right Decisions: Renal Colic Referral Pathway (Last reviewed 30 December 2024; document approved May 2025) — https://www.rightdecisions.scot.nhs.uk/nhsl-referral-pathways/urology-referral-pathways/renal-colic-referral-pathway/