Hydronephrosis

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Gross specimen showing renal hydronephrosis[1]
Closer view of pyelonephritis and hydronephrosis in a 10-year-old Boxer associated with chronic cystitis[2]

Hydronephrosis, which refers to refers to distension and dilation of the renal pelvis and calyces, is a frequently reported renal disease in dogs associated with renal or post-renal urinary obstruction.

Hydronephrosis can be caused by any process which interferes with urine flow from the renal pelvis to the urethra. Hydroureter (distension of ureter with urine) is a common concurrent disease[3]. Distension of the renal pelvis is often the result of urine accumulation and retropulsion into the pelvis from post-renal obstruction, but other causes can be involved. As the renal pelvis distends, intra-renal hydrostatic pressure rises (often >50 mmHg), leading to renal tubular cell death due to cell apoptosis, rather than necrosis[4]. Cellular apoptosis is triggered by inflammatory responses within the kidney.

Increased hydrostatic pressure leads invariably to pronounced changes firstly in the renal collecting ducts, distal tubules and tubular interstitium and finally the cortical glomerulus. Histologically, an increase in apoptotic rate in medullary tubular cells is seen within the first 24 hours of urinary obstruction. Dilation is accompanied by flattening of the tubular epithelial cells. As obstruction persists, dilation extends to the proximal tubules and tubular atrophy is seen.[5]. Contributing to these changes is a combination of pressure atrophy, pyelotubular reflux and ischemia. These effects have been shown, at least in vitro, to be inhibited by use of sodium nitroprusside or L-arginine[6].

Compensatory mechanisms within the kidney attempt to accommodate the elevated intrapelvic pressure, including dilation of the renal pelvis, afferent vasoconstriction and dilation of pelvic lymphatics with increased shunting of urine into the perirenal lymphatics[7]. Intervention of ureteral obstruction allows a gradual resolution to normal over a 4- 6 weeks period. Sustained hydrostatic pressure due to congenital ureteral defects or neoplasia commonly lead to irreversible renal damage due to sustained hydrostatic hypertension.

Developmental renal defects are relatively common and may lead to unilateral or bilateral hydronephrosis, such as ectopic ureter (unilateral), ureteral duplication, ureteral atresia or absent ureter (unicornis; unilateral).

There are a number of underlying etiologies, including:

  • Genetic
- Amyloidosis
- Circumcaval ureter associated with portosystemic shunt[8]
- Ureteral atresia
- Ureteral duplication[9]
- Ureteral ectopia[10]
- Ureteral stenosis[11]
- Hereditary nephropathy - Cocker Spaniel
- Polycystic kidney disease
- Renal agenesis - Pekingese[12]
- Renal dysplasia
- X-linked hereditary nephropathy
  • Obstructive causes
- Uroliths[13], ureteroliths, nephroliths
- Iatrogenic ureteral ligation
- Ureteral trauma during ovariohysterectomy[14]
- Renal biopsy[15]
- Chronic prostatitis
- Chronic cystitis
- Leptospira spp
- Pyelonephritis and secondary pyonephrosis[16]
- Balamuthia mandrillaris
- Dioctophyme renale
- Pearsonema plica
- Ureteral fibroepithelial polyps[17]
- Lymphoma - urinary bladder, retropelvic or prostatic[18]
- Transitional cell carcinoma - urinary bladder
- Rhabdomyosarcoma - urinary bladder[19]
- Ureteral giant cell tumor[20]
- Ureteral sarcoma[21]

In cases of ureteral or urethral blockage, hydronephrosis should be considered a medical emergency as renal failure can ensue rapidly due to increased intrapelvic hydrostatic pressure.

Clinically affected dogs shown varying degrees of acute or chronic renal disease, depending on cause, but consistent biochemical changes include hyponatremia, hypokalemia, elevated BUN and creatinine and metabolic acidosis.

A tentative diagnosis can be ascertained from ultrasonography, which shows hypoechoic renal medulla and pelvis. Renomegaly may be evident in dogs with acute ureteral obstruction, and renal shrinkage with chronic ureteral blockage.

Depending on cause, blood tests may indicated acute renal disease or chronic renal disease with hyponatremia and hyperkalemia.

A definitive diagnosis requires renal biopsy or exploratory laparotomy wedge biopsy.

Treatment is aimed at remedying the initiating cause and treatment of secondary renal disease. Ureteral defects such as ureteral atresia may be corrected surgically with autologous grafts or stents[22]. Urinary bladder obstructions which cannot be relieved by urinary catheterization may require temporary marsupialization.

Response to therapy is dependent upon initiating cause.

References

  1. Uni of Penn
  2. Vetpath
  3. Benigni L et al (2006) Lymphoma affecting the urinary bladder in three dogs and a cat. Vet Radiol Ultrasound 47(6):592-596
  4. Gobe, GC & Axelsen, RA (1987) Genesis of renal tubular atrophy in experimental hydronephrosis in the rat. Role of apoptosis. Lab Invest 56:273–281
  5. Truong, L et al (1996) Cell apoptosis and proliferation in experimental chronic obstructive uropathy. Kidney Int 50:200–207
  6. Hegarty NJ et al (2002) Cytoprotective effects of nitrates in a cellular model of hydronephrosis. Kidney Int 62(1):70-77
  7. Naber, KG & Madsen, PO (1974) Renal function in chronic hydronephrosis with and without infection and the role of lymphatics: an experimental study on dogs. Urol Res 2:1–9
  8. Doust RT et al (2006) Circumcaval ureter associated with an intrahepatic portosystemic shunt in a dog. J Am Vet Med Assoc 228(3):389-391
  9. Esterline ML et al (2005) Ureteral duplication in a dog. Vet Radiol Ultrasound 46(6):485-489
  10. North C et al (2010) Congenital ureteral ectopia in continent and incontinent-related Entlebucher mountain dogs: 13 cases (2006-2009). J Vet Intern Med 24(5):1055-1062
  11. Pullium JK et al (2000) Congenital bilateral ureteral stenosis and hydronephrosis in a neonatal puppy. Contemp Top Lab Anim Sci 39(5):34-36
  12. Agut A et al (2002) Unilateral renal agenesis associated with additional congenital abnormalities of the urinary tract in a Pekingese bitch. J Small Anim Pract 43(1):32-35
  13. Houston DM et al (2012) 2,8-dihydroxyadenine uroliths in a dog. J Am Vet Med Assoc 241(10):1348-1352
  14. Ruiz de Gopegui R et al (1999) Bilateral hydroureter and hydronephrosis in a nine-year-old female German shepherd dog. J Small Anim Pract 40(5):224-226
  15. Vaden SL et al (2005) Renal biopsy: a retrospective study of methods and complications in 283 dogs and 65 cats. J Vet Intern Med 19(6):794-801
  16. Choi J et al (2010) Ultrasonographic features of pyonephrosis in dogs. Vet Radiol Ultrasound 51(5):548-553
  17. Reichle JK et al (2003) Ureteral fibroepithelial polyps in four dogs. Vet Radiol Ultrasound 44(4):433-437
  18. Winter MD et al (2006) Imaging diagnosis - urinary obstruction secondary to prostaticlymphoma in a young dog. Vet Radiol Ultrasound 47(6):597-601
  19. Gerber K & Rees P (2009) Urinary bladder botryoid rhabdomyosarcoma with widespread metastases in an 8-month-old Labrador cross dog. J S Afr Vet Assoc 80(3):199-203
  20. Rigas JD et al (2012) Primary ureteral giant cell sarcoma in a Pomeranian. Vet Clin Pathol 41(1):141-146
  21. Deschamps JY et al (2007) Ureteral sarcoma in a dog. J Small Anim Pract 48(12):699-701
  22. Zhang J et al (2012) Ureteral reconstruction using autologous tubular grafts for the management of ureteral strictures and defects: an experimental study. Urol Int 88(1):60-65
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