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Suspected infected obstructed solitary kidney due to ureteric stone — MSRA MCQ

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HardUrologySuspected infected obstructed solitary kidney due to ureteric stoneMSRA

A 56-year-old woman presents to an urgent same-day GP service with 8 hours of severe right loin pain radiating to the groin, rigors and vomiting. She donated her left kidney 12 years ago. Her temperature is 38.7°C, heart rate 116 beats/min, blood pressure 102/64 mmHg and respiratory rate 22 breaths/min. She looks unwell and has right costovertebral-angle tenderness. Urine dipstick is positive for blood, nitrites and leucocytes. Her creatinine is 146 micromol/L; her documented baseline is 82 micromol/L. What is the most appropriate immediate management plan?

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

This presentation is highly concerning for an infected obstructed upper urinary tract in a patient with a solitary functioning kidney. Colicky loin-to-groin pain and haematuria suggest ureteric obstruction from a stone; fever, rigors, nitrites, leucocytes, tachycardia and hypotension indicate systemic urinary infection with possible sepsis. The acute creatinine rise further supports clinically significant obstruction or sepsis-associated acute kidney injury. An obstructed solitary kidney is an indication for immediate urological referral, and suspected pyonephrosis requires urgent imaging and source control, usually by ureteric stenting or nephrostomy alongside intravenous antibiotics. A and E inappropriately attempt community treatment despite sepsis physiology, vomiting and a solitary kidney. B applies routine analgesia and medical expulsive therapy, which may be considered in uncomplicated distal ureteric stones but not when infection and threatened renal function are present. C recognises the need for imaging but wrongly delays emergency transfer pending CT; imaging must not postpone resuscitation, parenteral antimicrobial treatment and urgent urological involvement in suspected infected obstruction.

Reference: NICE NG148: Acute kidney injury: prevention, detection and management (2019) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG111: Pyelonephritis (acute): antimicrobial prescribing (2018) — https://www.nice.org.uk/guidance/ng111/chapter/recommendations NICE NG118: Renal and ureteric stones: assessment and management (2019) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations