Acute Kidney Failure

Kidneys balance the composition of the blood by filtering waste from blood like salts, extra fluids and other substances. They maintain a perfect balance of electrolytes like sodium, potassium  and phosphate.  A kidney also contributes in the making of hormones that facilitate regulation of blood pressure, making of red blood cells and keeping the bones strong.

Acute kidney failure leads to sudden loss of kidney function. In contrast to chronic renal failure this is temporary.

Types and Causes

Pre-Renal

This is the most common type of condition found in 60-70 per cent of cases. If the blood flow is not in proper quantities to the kidney due to maybe very low blood pressure as a result of hemorrhage, septic shock, serious illness, injury then kidneys cannot filter blood effectively. This may also be due to heart failure, liver failure or blockage to the blood vessel carrying blood to the kidney. Another important factor is dehydration due to vomiting, diarrhoea or blood loss.

Post Renal

This failure may occur once the urine is produced and there is obstruction in its flow from the kidney. Most common reason may be cancer in the urinary tract , prostate in men, abdomen or pelvis that push on the ureter.  

Renal Failure

This is caused when there is damage to the kidney. It may be in the units (glomeruli) or the tubules leading from the glomeruli. The damage may be caused by an auto immune disease, infection, cancer and some medications or nephrotoxins. Kidney diseases (glomerulonephritis and nephrotic diseases, such as membranous nephropathy) can also cause this as well as well as chronic renal failure.

The causes: The Signs and Symptoms

You may experience swelling in lower half of your body - legs, ankles and feet

Shortness of breath

Drowsiness

Fatigue

Confusion

Decreased urine output although occasionally urine output remains normal

Chest Pain or Pressure

Nausea

Seizures or coma in severe cases

Treatment at Aastha Kidney Hospital

Timely treatment of the above symptoms is very important to restore normal working of the kidney. Some causes of kidney failure are treatable and the kidney function may return to normal. Unfortunately, kidney failure may be progressive in other situations and may be irreversible. Aastha Kidney Hospital, Ludhiana is renowned for having the latest equipment, lasers and treatment technology in the world in its department of Urology and Nephrology.

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Kidney Stone Diagnosis

Kidney stones can be ready diagnosed from the symptoms one is experiencing and the medical history.

Some of the initial tests that a general physician might suggest would include

URINE TEST

This will check if you are having any infection or presence of pieces of stones in the urine.

STONE ANALYSIS

Any stones that you may pass in your urine  can be collected (by urinating through a gauze) and  is then sent for a medical examination to verify its type and constitution. This is very helpful in determining the right course of treatment most beneficial to your condition.

BLOOD TEST

This is to check if your kidneys are working properly and also to determine the levels of certain substances that may lead to stone formation (e.g. calcium)
However,  in  case you  are having fever and your pain is very severe which  does not subside with pain killers you will be referred to a urologist (Specialist in treating urinary problems).

Visiting a Urologist

A urologist may suggest an imaging test. These can be of various types and are used to confirm whether a kidney stone is present or to pin point its exact location.

 

Computerized Tomography (CT Scan or CAT Scan)

This scan uses a series of x-rays taken at different angles to produce horizontal, or axial, images (often called slices) of the body which are then  put together by a computer. This scan being 2D is more detailed than a normal X-ray. 

Kidney, Ureter, Bladder X-ray (KUB X- Ray)
X-ray used a beam of high-energy radiation which is aimed at the body is used to create an image highlight the abnormalities in body tissue. KUB results may show the presence of kidney stones or gallstones. Although it may also highlight others reason for abdominal pain like injuries to the stomach or intestines, fluid in your abdominal cavity, or a blockage of your intestines, the test is sometimes a preliminary step towards further diagnosis. It is important that you mention if you might be pregnant or have an intrauterine device (IUD) or have had a contrast X-ray done.

Ultrasound Scan
Ultrasound Scan uses high-frequency sound waves to create images of the insides of the body. Because sound waves are used instead of radiation, ultrasound scans are safe. 

Intravenous Urogram (IVU) or Intravenous Pyelogram (IVP)
The test is used to look at the whole of the urinary system - the kidney, ureter and bladder. A intravenous die is injected and an X- ray image is generated which pin points any blockages if present as the kidney filters the dye out of the blood into the urine.  The test reveals the internal structure of kidney and may be used to roughly assess how well the kidney are working.

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How are Kidney Stones Formed?

Kidney filters waste products from our blood and releases them in the form of urine. However, accumulation or excess of certain salts, minerals and crystal forming substances in the body lead to accumulation of these substances over a period of time in the kidney eventually forming stones. It maybe that the urine lack substances that prevent these crystal forming substances from coagulating
Depending on the type of chemical which is accumulated either due to dietary reasons, medication or not drinking enough fluids to flush your system the stone types may vary.

Usually the following chemicals are the main culprits:

Are you having kidney stone repeatedly?

Certain people have a repeated tendency to develop kidney stones and among other people who may be more likely like the ones who:
    have had kidney stone before, especially if it was before the age of 25
    have a family history of kidney stones
    eat  a high protein diet and very little fibre.
    have had a number of kidney and urine infections
    have only one properly working kidney
    sedentary lifestyle or bed ridden
    have had intestinal bypass or Crohn's disease.
    Are on medications like asprin, antacids, certain antiretroviral medication (used to treat HIV), certain anti-epileptic medication, diuretics (used to reduce fluid build-up), certain antibiotics.

Types of kidney stones

Reason behind formation of each type or kidney stone

Calcium stones

Majority of people develop calcium stones which are the most common type of kidney stone, usually formed because of the presence of large amount of calcium in the urine. This may happen because of say an inherited condition like hypercalcuria which increases the levels of calcium in the urine, abnormal function in parathyroid gland (the parathyroid glands essentially maintains the quantity of calcium in the  body), kidney disease, some cancers or maybe a rare condition called sarcoidosis.

Appearance

Large and smooth or rough and spiky.

Struvite stones

These type of stones are commonly cause by infections. One of the major cause for their occurrence can be a urinary tract infection which has lasted a long time. Women are more likely to have them in comparison to men.

Uric acid stones

The presence of large amounts of acid in the urine can trigger the formation of uric acid stones. Eating a high protein diet especially meat, health condition like gout (an inflammatory arthritis which prevents break down of certain chemicals in the body), hereditary illness that heightens acid levels in the body and chemotherapy.    

Cystine stones

These stones affect a very small number of people and are rather rare in occurrence. An inherited condition like cystinuria which affects acid levels in the urine may cause them.

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Kidney Stones Treatment

Kidneys filter waste from blood and produce urine that is passes out of the body. However, sometime stone forming substances like (salt and minerals) may join together to form small stones which over time build and grow in size to form hard stone-like lump. The situation is more probable in case a person is dehydrated or is consuming less fluids. Certain medications also increase the levels of stone forming substances in the urine therefore it is important to keep the urine diluted and clear. Once a stone is present the body tries to pass it out when you urinate. Very smalls stones painlessly pass through the urine however if a stone is 5mm in size the changes of it passing on its own in the urine come down to 50 per cent. The small stones can be also be very painful sometimes but the pain disappears once the stone passes through the urine. 

What can help in such cases:

Medication

In case the pain is unbearable you might be given an injection for alleviate your pain. You might be administered a second dose again after half an hour depending upon the severity of your pain.

Lifestyle

If you are having a kidney stones then it is important that you drink a lot of water. In case it has passed in the urine you can collect it and send it for analysis. The doctor will check what type of changes you need to make in your diet and medication depending upon the constitution of the stone.

Clinical Procedures to treat Kidney Stone

"The latest treatment in the world to remove Kidney Stones is RIRS where NOT A SINGLE CUT IS MADE IN THE BODY to remove the kidney stones." - Department of Urology, Aastha Kidney Hospital. 

The very large stones (6-7 mm) pose problem as they try to pass through the ureter naturally from the kidney into the bladder causing very severe flank pain that extends to the groin. This is because the tube (ureter) connecting the kidney to the bladder is narrow and a large stone is not able to pass through easily. 

Extracorporeal Shock Wave Lithotripsy (ESWL)

For a Stone 4 mm to 2 cm in size and in the kidney or part of the ureter close to the kidney causing pain or blocking urine flow.  

This procedure takes about an hour. You will be made to lie down comfortably on a water filled cushion. A sedative or a local anesthesia may be administered. Following this an  X-ray or ultrasound test is carried out to locate the exact position of the stone in the body. Extracorporeal shock wave lithotripsy (ESWL) uses high energy sound waves to crack open and disintegrate the stones into smaller fragments. These high energy sound waves pass through the body without injuring it. The smaller fragments pass through the urine.

In case of a large stone a stent may be placed to keep the ureter open so that smaller stone fragments may pass easily without blocking the ureter.  

After the procedure

There is no need to stay in the hospital overnight. In fact you may go home the same day. Small pieces of stone which have disintegrated will pass out through the urine causing mild pain. This may happen for a few days. However, in case of a very large stone  the procedure may have to be repeated again or other treatments carried out.

RISKS

    Pain caused by passage of stone fragments.
    Stone fragments might get stuck in the urinary tract. These will have to be removed with a ureteroscope.
     UTI (Urinary tract infection)
    Bleeding around the outer side of the kidney

Ureteroscopy

If a stone is stuck in the ureter close to the bladder (in the lower third or ureter)

A Thin Tube (Ureteroscope ) is passed from the outside of the body into the urethera, making its way up to the bladder and from there into the ureter (i.e the pipe which carries urine from kidney to the bladder) to the point where the stone is located.  The kidney stone is removed with the forceps. Smaller stones can be removed in one piece but larger stones are broken down into smaller pieces before they are removed, most common technique being laser.  While carrying out ureterocopy no cuts or incisions are made in the body.

After the treatment

Although in most cases a person can go home the same day of the procedure. However, in case there is  a requirement for you to stay in the hospital it will only be for a day or two. After the treatment a person may experience a burning sensation while urinating which goes away in a day.  The burning can be reduced by drinking plenty of water. A doctor may also recommend a painkiller. Some blood may also come in the urine maybe for 2-3 days. 

RISKS

These usually are likely if the stone is close to the upper third of the ureter.
    Bleeding
    UTI (Urinary tract Infection)
    Injury to Ureter
    Abdominal pain

Percutaneous Nephrolithotomy (PCNL) /Nephrolithotripsy

If the Kidney stone is irregular, larger than 2 cm diameter within the kidney 

The operation takes about 20 -45 minutes. During the procedure a general anesthesia is administered the person is made to lie on the stomach.  A keyhole surgery is performed by a 1 cm incision at the back in the skin above the kidney. An X ray image is used as a guide to decide the entry point of 1cm tube into the kidney. Once the surgeon is inside the kidney a nephroscope (minature fibre optic camera) and other instruments are threaded in through the hole that are able to see, fragment and remove stones.  A drainage catheter which leaves through the skin is left in the kidney at the end of the procedure. The whole idea is to remove all the stones leaving no fragments behind that may pass through the ureter. 

After the procedure

A short hospitalization (2-3 days) may be needed. You may be off work for a week taking it easy. There should only be minimal discomfort from the wound. Oral antibiotics are given to prevent further infection. Occasionally a stent is left to ensure that urine drains correctly in the bladder which will be removed later. In case a person is feeling unwell with fever, chills or is having heavy bleeding in the urine is it important to contact your doctor.

Advantages

Most effective procedure that ensure a patient is stone free.

Risks

    Infection
    Bleeding
    Operations on the abdomen carry a small risk of injury to other nearby organs, such as the bowel, the ureter, the liver or the bladder.

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Kidney Stones Types and Symptoms

How are Kidney Stones formed?

Kidney Stones medically referred to as Nephrolithiasis are formed when there is reduction in the urine flow volume as well as because of the presence of stone forming substances (salt and minerals) in the urine which are retained inside the kidney because of not being eliminated by the kidney completely due to their excessive or concentrated presence as a result of medication, dehydration or drinking less fluids. So, these substances eventually stick together to form small kidney stones. Kidney stones can cause severe pain if it blocks the ureter (tube that carries urine from the kidney to the bladder) or the urethra (tube that leads urine out of the body) Dehydration is one the major causes leading to the formation of kidney stones, the pain caused by kidney stones can be very severe. A stone once formed tries to leave the kidney making its way to ureter, then into the bladder finally passing out of the body on its own.  

Other causes leading to the formation of kidney stones can be being overweight or obese, consuming a high-protein or glucose diet, gastric bypass surgery, disease in the bowel like inflammation that increases calcium absorption, taking medications such as diuretics, anti-seizure drugs, and calcium-based antacids.

Kidney Stone Types:

Not every person has the same type of kidney stones. The may be different in their constituency and type varying from person to person.

Major Kidney Stone Symptoms

• Flank Pain or persistent pain in the lower back which may extend up to the groin and last for a few minutes or hours.

• Hematuria (Blood in the urine)

• Pain while urinating (Dysuria)

• Nausea or feeling sick

• Feeling restless and unable to lie still

• Feeling like urinating more frequently than the normal 

In case there is an infection along with kidney stone

KIDNEY STONES - If they cause kidney infection then a person will experience additional other symptoms like:

• High fever (103.1 F or 39.5 Degree Celsius)

• Loss of appetite

• Chills and shivering

• Diarrhoea

• Fatigue

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Surgical Procedures to treat Enlarged Prostate or Prostate Cancer

Non cancerous enlargement of prostate gland (BPH- Benign Prostate Hyperplasia) may lead to urinary symptoms which can ease with certain lifestyle adaptations or in other cases with medicines. However, depending upon the severity of the symptoms and in-cases where lifestyle modification and medicine do not give sufficient relief, surgery may be recommended.

Other less common procedures which might be available in private healthcare or in clinical trials.

These are

• Photoselective Vaporisation of the Prostate 
• Minimally Invasive Surgery, such as Transurethral Needle Ablation or Transurethral Microwave  Therapy 
• Transurethral Vaporisation Resection of the Prostate. 

This is a fairly common procedure which removes the overgrown parts of prostate that press on the tube (urethra) through which urine passes out. Depending upon the aesthetic administered you may be awake (spinal anaesthetic) or asleep (general anaesthetic) during the surgery. The surgeon passes a thin tube into the urethra through your penis. The tube ending has a miniature camera so that the surgeon can see the prostate clearly. The second step involves removing tiny pieces of prostate tissue by passing an electrically-heated wire loop through the tube. Fluid is passed into the bladder to withdraw small pieces of prostate tissue that have been removed. After the surgery these removed pieces may be analysed to check for any abnormal cells. A catheter is used to remove urine from the bladder till two days after the surgery following which the nurse removes the catheter and checks if you are passing urine successfully.

Advantages:

Following the surgery one can urinate with greater ease
Effective in long run
Bladder stones if present can also be removed

Disadvantages:

The improvement in symptoms is not immediate rather it takes several weeks
In certain cases, a person maybe unable to pass urine once the catheter has been removed. If this happen a new catheter is put in place for a few more days.

This procedure is similar to TURP except instead of using electrically heated wire loop HoLEP uses high-powered laser to remove the parts of prostate tissue that press upon the urethra blocking urine flow. Prostate tissue which is removed during the procedure passes into the bladder and is removed using a different instrument. HoLEP requires specialist equipment and only a trained surgeon can carry out this procedure. Therefore, it may not be available everywhere. During surgery a person may be awake up unable to feel anything (spinal anaesthetic) or maybe asleep (general anaesthetic).  After surgery, a catheter is used to drain urine from the bladder for the next 12-24 hours. Before you are discharged, the nurse removes the catheter and checks if you are able to pass urine easily. Research studies have shown that HoLEP and TURP are equally effective in improving symptoms.

Advantages

Effective in case of men with very large prostate
More suitable than TURP in men who are on anti-coagulants (medicines that prevent blood clot)
Suitable also in treating bladder stones

Disadvantages

The treatment is relatively new and not easily available everywhere.
In case of a small percentage of men find they cannot pass urine at all after the catheter has been removed. In such cases a new catheter is put in place for a few more days

Similar to TURP but here parts of prostate tissue are burnt away by heating the prostate tissue rather than removing it. After the surgery a person is on the catheter to drain the urine for the next 9-24 hours. Depending on the anaesthetic administer you might be asleep (general anaesthetic) or awake (spinal anaesthetic )but unable feel anything during the surgery.

Disadvantage

The only disadvantage is that the tissue gets destroyed and cannot be sent for further lab examination. 
9-10 per cent men might feel that they are not able to pass urine after the surgery and may need to be on the catheter for a few more days. However, chances of this are seemingly higher in case of TURP.

Bladder neck incision is also called Transurethral Incision of the Prostate (TUIP). A doctor or a nurse may recommend this procedure in situations where a person has a small prostate and is still experiencing urinary symptoms. Although this is similar to TURP it has a shorter recovery time. Either a general or spinal anaesthetic is used. A thin tube is passed into the urethra through the penis  following which an instrument is passed which is used to make one or two small cuts in the neck of the bladder or prostate gland so that the bladder neck widens and urine can flow easily.

Advantages

Catheter is removed sooner than in case of TURP.

Disadvantages

In a small percentage of men are not able to pass urine once their catheter is removed. In such cases a new catheter is put in place for a few more days.

There is not much information about the long term effectiveness of this procedure.

The prostate tissue is not removed. Therefore cannot be analysed.

This procedure removes the inner part of the prostate gland through a cut in the stomach area. A general anaesthesia is administered during the procedure. The time a person spends in the hospital depends on the case, recovery and doctors advice. However, usually it takes up to four to six days although several months may be taken to fully recover.

Advantage

The tissue can be sent for further examination.
The treatment is as effective as HoLEP in men with very large prostate.

Other treatments

Photosensitive Vaporisation The prostate tissue with vaporised by a high energy laser. The recovery with this procedure is faster with a shorter hospital stay in comparison to TURP.
Minimally Invasive Surgery The procedures are carried out with tiny incision instead of one large incision leading to faster recovery time. 

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Enlarged Prostate - Medicines for Treatment

The Treatment Options

There are primarily three treatment options for Enlarged Prostate.

1.    Lifestyle Changes

2.    Medicines

3.    Surgery

If lifestyle changes don't work and the symptoms are not severe enough then being on mediation can be source of great relief. However, a person has to be careful that you tell your doctor if you are already on any medication to avoid any harmful consequences of drug interference and mixing.  

 

The Medicines for Treatment 

Alpha Blockers

Medicine Type: Tablet

How it works :

Alpha-blockers loosen the prostate muscles also relaxing the muscles around the opening of the bladder. Although the medicine isn't a complete cure to the problem but it is quiet effect in relieving the problematic symptoms and discomforts. However, this isn't given in case a person has a very large prostate. 

Relief and effects:

Upon taking Alpha Blockers you may experience an improvement in your symptoms usually within a few hours to days but the medicine takes its full effect after a few weeks of consumption. This can be a successful option for every 3 in 5 men and can be effective for several years. In case the treatment doesn't show any sign of improvement then a higher dose may be recommended or another treatment option suggested.  

Side Effects:

Every medicine comes with certain side effects which may vary individual to individual. The side effects go away once the medicine is stopped and off course one may not experience all the side effects at the same time. To name a few

Nausea or headache upon standing up

Fatigue

Blocked nose

Erectile dysfunction (3 per cent chances)

Dry orgasm (2 per cent chances)  

5-alpha-reductase inhibitors (5ARIs)

Type : Tablet or Capsule

How It works:

This medicine works by shrinking the prostate preventing it as a result from pressing on the urethra so that a person can urinate with ease.
Relief and effects:
Usually the prostate can shrink up to a quarter after being on this medication for about 6-12 months. It might be possibility that the prostate might shrink further if the medicine is continued for a longer duration.  Although it may take up to six months for urinary symptoms to improve but the effects of the medicine improve the symptoms in the longer run. Studies evidence a continuous symptomatic improvement for up to four years after taking 5-alpha-reductase inhibitors. The drug is also shown to help prevent acute urine retention and requirements for surgery. This is usually the first course of treatment offered in cases where the prostate is very large and is found to work particularly well. 

Side Effects:

Erectile dysfunction (4 or 5 per cent chances)

A drop in libido (2 to 3 per cent chances)

Tenderness in chest (2 per cent chances)

Dry orgasms or retrograde ejaculation (1 per cent chances)

IMPORTANT: This drug drops the PSA levels in the blood therefore one has to make sure that your doctor is aware if you are on is medication and have been asked to undergo a PSA test.

Other Medicines:

Anticholinergics help with urinary symptoms like wanting to urinate with sudden urgency, feeling like the need to urinate again and again and even leaking urine on the way to toilet. This drug works in similar ways to an alpha-blockers and can lead to side effects like constipation, dry eyes and dry mouth.

  
Phosphodiesterase type 5 (PDE5) inhibitor makes it easy to urinate by relaxing muscles in the prostate and the opening of the bladder. it may cause side effects like rhinitis (swelling in nose), back pain, itchiness, indigestion and head ache. 

Mirabegron (Betmiga®)
These are given incase Anticholinergics are not effective in relieving urinary symptoms. This new type of drug can help in case of people having very sudden and frequent urgency to urinate. The drug may give side effects like headache, increase blood pressure and urine infections. 

Desmopressin
This drug taken at bed time is effective in case a person gets up a lot at night to urinate and has a disturbed sleep. This drug works by signalling the kidney to produce less urine for 6-8 hours. However, it is not recommended for use in people with chances for heart failure or who are above the age of 65. Regular blood tests are also accompanied to monitor kidney function. 

Loop diuretic
This capsule is generally taken during late afternoon and causes a person to urinate a lot by the time one goes to bed, therefore reducing the chances to get up frequently during the night. One can have a better sleep. 

Combination Treatment

 

In case of men it has sometimes been found that taking a combination of two medicines work better than taking one single drug. Therefore, one may be given the following combination treatments.

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