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  Tuesday, 02 April 2013
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I am a 59yo female - no previous history of any renal problems. Initial complaint was persistent frank / gross hematuria starting Jan 2013. Investigations include CT scan with contrast (no abnormalities), cystoscopy (bleeding from right ureteral orifice seen), right retrograde pyelogram on March 6th (blood clot seen in proximal ureter/kidney pelvis, but no diagnosis for hematuria). Suffered both paralytic ileus and renal colic following the procedure. A UTI (coag-neg staph) was found about 10 days following the retrograde pyelogram, resistant to many antibiotics. I was feeling quite ill. It was treated with one week of IV Vancomycin - eGFR, Cr, and trough levels were monitored during treatment, with dosage adjustments. Prior to the retrograde pyelogram, on Mar 5th, Cr was 78 umol/L, eGFR 66 ml/min, urea 5 mmol/L (Hgb 118) The day of the 1st dose of Vancomycin, on Mar 22nd, Cr was 112, eGFR 43. On March 24th Cr 115, eGFR 42 (vanco trough level 16.5; dose was reduced). On March 27th, Cr 119, eGFR 40, urea 3 (vanco trough level 11.9; vancomycin was discontinued after one further dose, on March 28th). On April 1st (4 days post-vancomycin), Cr is 179, eGFR 25, urea 5, Hgb 104. Modest pitting edema in ankles/shins began March 30th, and is getting worse. Other than to suggest doing an ultrasound to rule out obstruction of the right ureter, the urologist seems quite casual about the decline in kidney function. My questions: 1) even if there is an obstruction on the right, would an unobstructed left kidney not take up the slack - are these lab results consistent with a one-sided obstruction, or are they indicative of a bilateral problem? 2) Does this scenario warrant an urgent referral to a nephrologist? How long do I sit at home with a Cr of 179 and eGFR of 25, before i start squawking?? Thanks very much in advance for your response.
11 years ago

Thank-you for your post.

You are right to be concerned. This is a significant drop in renal function, that is out of keeping with a unilateral obstruction. You are correct that usually, the other side will compensate, albeit incompletely - assuming of course that the other side is normal at the time the opposite kidney is obstructed.

Do you know if you have any protein in your urine? The exact amounts would be helpful here. Have you had any serology or urine microscopic exam done? It sounds like the falling renal function preceded the starting of vancomycin, so I'm reluctant to blame it entirely. In this case a nephrologist's input would be very important.

Dr. Jordan Weinstein
11 years ago
Hi - thanks for the reply!

The original hematuria was asymptomatic, by the way (no discomfort, no UTI). UA / R&M results from January 22nd through to March 20th consistently showed too many RBC to count and Protein 1.0 g/L.

The latest R&M, however, done April 1st along with the bloodwork, is negative for protein Is this possibly a result of the decrease in kidney function (not filtering stuff), or ... ?

I will ask for a nephrology referral. However, even with an urgent referral it may take days (or ore likely weeks) before i end up in a nephrologist's office. Are you able to advise me on my timeline here - is this a significant enough problem that i do not have the time to wait for a referral to go through?

Thank you so much.
11 years ago
It seems you are not excreting large amounts of protein, which is good.

I would try and get seen sooner rather than later; it is a significant problem. You need a more complete workup to assess this further. In the meantime, avoid unnecessary medications, and especially those harmful to the kidneys (for example NSAIDs).

Dr. Jordan Weinstein
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