Nephroptosis is a pathological mobility of the kidney, manifested by the displacement of the organ beyond its anatomical bed. Minor and moderate nephroptosis is asymptomatic; with disorders of urodynamics and hemodynamics, lower back pain, hematuria, arterial hypertension, pyelonephritis, hydronephrosis, nephrolithiasis occur. Pathology recognition is carried out using ultrasound of the kidneys, excretory urography, angiography, MSCT, nephroscintigraphy. Surgical treatment is required for secondary changes and consists in fixing the kidney in its anatomically correct position – nephropexy.
ICD 10
N28.8 Other specified diseases of the kidneys and ureter. Nephroptosis
Meaning
Normally, the kidneys have a certain physiological mobility: for example, with physical effort or the act of breathing, the kidneys shift within the permissible limit, not exceeding the height of the body of one lumbar vertebra. In the event that the displacement of the kidney downwards with a vertical body position exceeds 2 cm, and with forced breathing – 3-5 cm, we can talk about pathological mobility of the kidney or nephroptosis.
The right kidney is usually 2 cm below the left; in children, the kidneys are located below the normal border and occupy a physiological position by the age of 8-10. In their anatomical bed, the kidneys are fixed by ligaments, surrounding fascia and paranephral fatty tissue. Nephroptosis is more common in women (1.5%) than in men (0.1%) and, as a rule, is right-sided.
Causes
Unlike congenital ectopic kidney, this pathology is an acquired condition. The development of nephroptosis is caused by pathological changes in the apparatus that holds the kidney – the peritoneal ligaments, the renal bed (fascia, diaphragm, muscles of the lower back and abdominal wall), own fat and fascial structures. Hypermobility of the kidney may also be due to a decrease in its fat capsule or an incorrect position of the vessels of the renal pedicle.
To the development of nephroptosis predispose:
- low muscle tone of the abdominal wall
- sudden loss of body weight
- hard physical work
- power sports, lumbar injuries.
The disease is often found in people with systemic weakness of connective tissue and ligamentous apparatus – hypermobility of joints, visceroptosis, myopia, etc. Nephroptosis is most susceptible to people of certain professions: drivers (due to constantly experiencing vibration during shaking driving), movers (due to physical stress), surgeons and hairdressers (due to prolonged stay in vertical position).
Kidney prolapse can be combined with various congenital anomalies of the skeleton – underdevelopment or absence of ribs, violation of the position of the lumbar vertebrae. During puberty, nephroptosis can occur in adolescents of asthenic constitutional type, as well as as a result of rapid changes in body proportions with rapid growth. In women, pathology can be caused by numerous pregnancies and childbirth, especially a large fetus.
Classification
According to the degree of displacement of the kidney below the limits of the physiological norm, 3 degrees of nephroptosis are distinguished in modern urology. At grade I, the lower pole of the kidney descends by more than 1.5 lumbar vertebrae. At grade II, the lower pole of the kidney shifts below the 2 lumbar vertebrae. Nephroptosis of the III degree is characterized by the lowering of the lower pole of the kidney by 3 or more vertebrae. The degree of kidney prolapse affects the clinical manifestations of the disease.
Symptoms
In the initial stage, during inhalation, the kidney is palpated through the anterior abdominal wall, and when exhaling, it hides in the hypochondrium. In an upright position, patients may be disturbed by pulling unilateral lower back pain, discomfort and heaviness in the abdomen, which disappear in the supine position. With moderate lowering in an upright position, the entire kidney shifts below the hypochondrium line, however, it can be painlessly adjusted by hand. Lower back pain is more pronounced, sometimes it spreads to the entire abdomen, increases with exertion and disappears when the kidney takes its place.
With nephroptosis of the III degree in any position of the body, the kidney is located below the costal arch. Abdominal and lumbar pains become permanent, do not disappear in the supine position. Renal colic may develop, gastrointestinal disorders, neurasthenic conditions, renovascular hypertension may appear.
The development of a painful renal syndrome is associated with a possible inflection of the ureter and a violation of the passage of urine, stretching of nerves, as well as an inflection of the renal vessels leading to kidney ischemia. Neurasthenic symptoms (headache, fatigue, irritability, dizziness, tachycardia, insomnia) are probably caused by chronic pelvic pain. On the part of the gastrointestinal tract, loss of appetite, nausea, heaviness in the epigastric region, constipation or, conversely, diarrhea are determined. Hematuria and proteinuria are detected in the urine; in the case of pyelonephritis, pyuria is detected.
Complications
Periodic or permanent urostasis caused by an inflection of the ureter creates conditions for the development of infection in the kidney and the addition of pyelonephritis, cystitis. In these cases, urination becomes painful and frequent, there is chills, fever, the release of cloudy urine with an unusual smell. In the future, against the background of urostasis, the probability of developing hydronephrosis, kidney stones increases.
Due to the tension and inflection of the vessels feeding the kidney, a persistent increase in blood pressure with hypertensive crises develops. Renal hypertension is characterized by extremely high blood pressure, which sometimes reaches 280/160 mm Hg. The twist of the vascular pedicle of the kidney leads to local veno- and lymphostasis. With bilateral nephroptosis, signs of kidney failure increase early – swelling of the extremities, fatigue, nausea, ascites, headache. Patients may need hemodialysis or kidney transplantation.
Diagnostics
Recognition of nephroptosis is based on patient complaints, examination data, palpation of the kidney, results of laboratory and instrumental diagnostics. The examination is performed in the patient’s position not only lying down, but also standing. Carrying out a polypositional palpation of the abdomen allows you to identify the mobility and displacement of the kidney. Measurement and monitoring of blood pressure shows an increase in blood pressure values by 15-30 mm Hg. when changing the horizontal position of the body to vertical. In urine tests, erythrocyturia, proteinuria, leukocyturia, bacteriuria are determined.
- Ultrasound of the kidneys. It is carried out in a standing and lying position, reflects the localization of the kidney, changes in its location depending on the position of the body. With the help of sonography, it is possible to detect inflammation in the renal tissue, concretions, hydronephrotic dilation of the cup-pelvic complex. Ultrasound of the renal vessels is necessary to visualize the vascular bed of the kidney, to determine blood flow indicators and the degree of renal hemodynamic disorders.
- X-ray diagnostics. Excretory urography allows you to assess the degree of pathological kidney prolapse in relation to the lumbar vertebrae, kidney rotation. Overview urography in nephroptosis is usually uninformative. Renal angiography and venography are required to assess the condition of the renal artery and venous outflow. CT, MSCT, and MRI of the kidneys serve as a highly accurate and informative alternative to radiopaque methods.
- Scintigraphy. Dynamic radioisotope nephroscintigraphy is indicated to detect violations of the passage of urine and the functioning of the kidney as a whole.
Various studies of the gastrointestinal tract (gastric X–ray, irrigoscopy, colonoscopy, EGDS) are necessary to detect displacement of internal organs – splanchnoptosis, especially with bilateral nephroptosis.
Treatment
In case of pathology of the first degree, conservative therapy is carried out. The patient is assigned to wear individual orthopedic devices (bandages, corsets, belts), therapeutic gymnastics to strengthen the muscles of the back and abdominal press, abdominal muscle massage, sanatorium treatment, restriction of physical exertion, if underweight – enhanced nutrition.
With nephroptosis of the II-III degree, complicated by a violation of hemodynamics, urodynamics, chronic pain syndrome, pyelonephritis, nephrolithiasis, hypertension, hydronephrosis, surgical tactics are required – nephropexy. The essence of the intervention is to return the kidney to its anatomical bed with fixation to neighboring structures. In the postoperative period, a long bed rest is required, being in a bed with a raised leg end for reliable strengthening of the kidney in its bed. Nephropexy is not indicated for splanchnoptosis, severe intercurrent background, elderly patient.
Prognosis and prevention
After timely nephropexy, as a rule, blood pressure indicators are normalized, pain disappears. With delayed treatment, chronic conditions may develop – pyelonephritis, hydronephrosis. In persons with nephroptosis, professional activity should not be associated with a long stay in an upright position or heavy physical exertion.
Prevention of nephroptosis includes the formation of correct posture in children, strengthening of abdominal muscles, prevention of injuries, exclusion of constant exposure to adverse factors (heavy physical activity, vibration, forced vertical position of the body, sudden weight loss). Pregnant women are recommended to wear an antenatal bandage. If there are pulling pains in the lower back in a standing position, an immediate appeal to a nephrologist is necessary.