Pyelectasis Complications

What is Pyelectasis?

Pyelectasis also known as pelviectasis is a condition that affects the kidneys, it is characterised by the collection of urine in the renal pelvis (central part of the kidneys).¹ This prevents the urine from getting discarded through the ureter (tubes that connect the kidneys to the urinary bladder).  It could be unilateral (affecting one kidney) or bilateral (both kidneys). It occurs in 1-5% of pregnancies.² It mostly resolves on its own without causing any clinical symptoms or problems. But sometimes depending on the severity of the dilatation (enlargement) of the renal pelvis it could lead to complications that require medical attention.

Understanding pyelectasis and its complications

The renal pelvis acts as a reservoir for the urine produced in the kidneys. When this reservoir becomes dilated leading to the enlargement of the renal pelvis, pyelectasis is diagnosed. This dilatation may result from various factors. Despite being an asymptomatic condition, it predisposes individuals to complications so it is necessary to understand the potential complications associated with pyelectasis.

How is pyelectasis detected?

Pyelectasis is detected at the routine prenatal anomaly ultrasound (USG) in pregnant mothers around 20 weeks in the second trimester. Radiologically, if the anterior poster diameter (AP) of the renal pelvis is more than 4 to 10mm it is diagnosed as pyelectasis.³ USG determines the degree of dilation, grading it from mild to severe.

What causes pyelectasis?

Pyelectasis usually manifests as a benign condition due to the premature development of the fetal urinary system. It could also develop due to structural anomalies affecting the shape, size or position of the kidneys, ureter or urinary bladder at birth. In some cases, pyelectasis occurs secondary to other renal conditions like urinary tract infection (UTI), nephritis (inflammation of the kidneys), renal stones or any medications that could lead to dilatation of the renal pelvis. At times, pyelectasis could also be idiopathic (without any underlying cause). Although the underlying mechanism is not clearly understood, down syndrome is associated with a high prevalence of pyelectasis.  But majorly, pyelectasis occurs due to:

• Ureteropelvic junction obstruction (UPJO): Any blockage or narrowing of the upper part of the ureter that connects to the renal pelvis causes UPJO. It could also be due to the impaired functioning of the smooth muscles of the ureter.⁴ This causes urine retention in the renal pelvis leading to dilation causing pyelectasis. UPJO is caused by physical obstruction like kidney stones, any congenital anomalies, tumours, strictures or compression of surrounding structures.
• Vesicourethral reflex (VUR): It is the abnormal backflow of urine from the urinary bladder to the ureters and renal pelvis. This increases the pressure in the renal pelvis leading to dilatation resulting in pyelectasis. VUR increases the risk of complications in pyelectasis.

What are the potential complications of pyelectasis?

Urinary tract infection (UTI)

The stasis of urine buildup in the dilated renal pelvis causes an ideal environment for bacterial growth leading to bacteriuria (buildup of bacteria in urine) predisposing individuals to UTI. It presents with symptoms of fever, abdominal pain, increased frequency and burning sensation during urination. Patients with pyelectasis may experience recurrent UTIs that may impact their quality of life. In some cases, if untreated, the bacteria could ascend to the kidneys and progress to pyelonephritis (bacterial infection of the kidneys). UTIs can exaggerate pyelonephritis causing severe inflammation and irritation to the dilated renal pelvis which could compromise renal function. In severe cases, if UTIs and pyelonephritis remain untreated it can increase the risk of sepsis (systemic infection).  Sepsis is triggered by infection causing widespread inflammation that could lead to organ dysfunction and life-treating complications.

Hydronephrosis

It is also characterised by the dilatation of the renal pelvis but it also involves the dilation of renal calyces (pyramid-shaped conduits that urine passes through) and it is due to the thinning of the renal parenchyma.⁵ It has an increased risk of developing renal cortex damage. In severe and prolonged cases, hydronephrosis and pyelectasis can impair kidney function leading to tissue damage and irreversible kidney damage.

Obstructive uropathy

Underlying urinary tract obstruction and pyelectasis could lead to obstructive uropathy. This could result in severe renal impairment, electrolyte imbalances and life-treating complications if not treated.

Kidney stones

The stagnant urine in the dilated renal pelvis can predispose to the collection of hard deposits of minerals and salts leading to the formation of kidney stones (renal calculi). They vary in size and composition causing severe pain, and discomfort and may require medical intervention. Untreated renal stones and pyelectasis with other complications could result in impaired kidney function or renal failure.

How can pyelectasis and its complications be managed?

Monitoring in pyelectasis

About approximately 96% of pyelectasis cases are asymptomatic and resolve on their own.⁶ Monitoring in pyelectasis is still crucial as it assesses the disease progression, identifies complications and serves as a guide for treatment. Monitoring strategies in pyelectasis patients are:

• Ultrasound (USG): It is the primary imaging tool for monitoring pyelectasis. It allows for a non-invasive visualisation of the renal system. It is done at regular intervals to assess the degree of the dilatation of the renal pelvis and observe any changes to the initial diagnosis.
• Renal function test (RFT): Monitoring of parameters such as serum creatinine, blood urea creatinine (BUN) and electrolytes can provide valuable data about any decline in the renal function about pyelectasis-related complications.
• Urine analysis: It is essential for identifying signs of urinary tract infections (UTIs). It detects bacteria or white blood cells in the urine that could indicate the presence of UTIs.
• DMSA renal scan: Dimercapto succinic acid is a short-lived radioisotope that is injected directly into the veins and gives a clear detailed picture of the kidneys. This imaging technique assesses renal function, renal scarring, recurrent UTIs or any renal parenchymal injury.
• Voiding cystourethrogram (VCUG): In the case of suspected vesiculourethral reflex (VUR), this imaging study evaluates the anatomy and function of the bladder and urethra, identifying the presence and severity of VUR.
• Serial clinical evaluation: Regular clinical checkups with healthcare providers are vital in monitoring symptoms, assessing overall health and identifying any signs of pyelectasis-related complications. Any symptoms of flank pain, fever or changes in urinary habits should be promptly reported, recorded and evaluated. Patients with pyelectasis may also require long-term follow-up to assess for any complications over time.

Overall, monitoring requires a strategic approach depending on the patient's severity of pyelectasis, individual risk factors and associated conditions. Close collaboration with patients, caregivers and healthcare providers is essential to ensure timely intervention and appropriate management of pyelectasis-related concerns

Treatment in pyelectasis

Effective management and treatment of pyelectasis play a pivotal role in preventing complications. Patients need to get their personalised treatment plan from healthcare providers. The treatment goals should be to alleviate pain, prevent complications and preserve kidney function.

• Management of underlying conditions: If pyelectasis is caused by vesicoureteral reflex, ureteropelvic obstruction or kidney stones, treatment focus should address these underlying conditions. This may involve surgical intervention to remove obstructions, repair anatomical anomalies or correct vesicourethral reflex. The obstructions could be relieved by stents or nephrostomy tubes to restore urine flow.
• Antibiotic therapy: If pyelectasis is associated with UTIs, antibiotic therapy is provided to treat the infection and prevent recurrent UTIs and sepsis. The type and duration of the antibiotics are selected by the healthcare provider depending on the specific bacteria causing the infection and the patient's clinical presentation.
• Pain management: Patients may experience pain or discomfort especially if complications are present. The healthcare provider may prescribe medications or over-the-counter pain relievers to alleviate symptoms and improve quality of life.
• Lifestyle modifications: Certain lifestyle changes could be beneficial for patients with pyelectasis. This may include a healthy diet low in salts and avoiding foods high in oxalates that predispose to the formation of kidney stones. Avoiding smoking and alcohol intake is recommended. Adequate hydration is important. Regular monitoring and follow-up are advised.

Summary

Pyelectasis is a condition affecting kidneys characterised by the dilatation of the renal pelvis. Although asymptomatic, in some cases, pyelectasis could be associated with underlying conditions or potential complications. Pyelectasis has a significant impact on kidney health if untreated. Understanding the risks and implementing appropriate treatment strategies are crucial to minimise complications and optimise long-term outcomes. Collaboration between patients and healthcare providers is important to have an effective treatment plan and ensure optimal outcomes. With close monitoring and timely interventions, patients with pyelectasis can effectively prevent and manage complications and maintain overall well-being.