Case Study - May 2011

A 72 year old man presents with acute renal failure and uraemic symptoms. His creatinine on admission is 790 micromol/litre and his potassium is 7.6. He has a past history of prostatic carcinoma for which he had external beam radiotherapy and is currently on a LHRH analogue with a stable PSA of 1.89ng/ml. He is haemodynamically stable and his examination reveals no abnormality. He goes on to have a CT KUB (and subsequent nephrostogram).

  1. What do these images show?
  2. What should his immediate management be?
  3. What should we do next?
  4. What are the possible causes of the appearances in the CT?

Reveal Answer

Open answer There is no fixed answer to this question, however your response should be similar to the one below:

  1. There is an obstructed left kidney due to a 3cm mass outside the renal pelvis/PUJ and an atrophic/shrunken right kidney. The nephrostogram looks like PUJ obstruction with multiple filling defects in the renal pelvis (which turn out to be blood clots).
  2. He needs urgent resuscitation according to ALS protocols. His immediate management (after ABC) should include an ECG looking for tented T waves. He should be put in a high care environment such as A+E Resus, HDU or ITU with cardiac monitoring. 10% Calcium gluconate 10mls should be administered via a large bore cannula and an actrapid infusion given. Having decompressed his system with a nephrostomy, the electrolytes should then be checked in 2 hours and discussed with the renal team as appropriate with view to dialysis if potassium remains high.
  3. Ideally discussed in a MDT setting. The mass could be biopsied percutaneously (as was done in this scenario) or an open biopsy could be performed. Para-aortic lymph nodes could be testicular in origin so one should send testicular tumour markers and undertake an USS scrotum if any doubt (normal in this case). The ultimate treatment may include surgical excision, radiotherapy or chemotherapy depending on the primary cause.
  4. Cancer – Lymphoma, testicular, intra-abdominal malignancy. Infection – TB, HIV. Inflammatory – para-aortitis (eg Abdominal Aortic Aneurysm). Sarcoid.
    This gentleman’s histology was actually small cell neuroendrocrine carcinoma of uncertain origin.

The cookie setting on this website is set to ‘allow cookies’ to give you the very best experience.

If you continue without changing this setting, you consent to this - but if you want, you can change your setting at any time using the ‘change cookie setting’ link at the bottom of this page.

Cookie Setting

Our Cookies

Cookie NamePurpose
eu_ask This is used to store the cookie setting you set in the form above.
If you choose 'Do Not Allow Cookies' we will need to store this information as a cookie with the value N.
If you choose 'Allow Cookies' or do not make a choice, we will store this information as a cookie with the value Y.

The value is kept for one year.

3rd Party Cookies

Cookie NamePurpose
Google Analytics This website uses Google Analytics, a web analytics service provided by Google, Inc.
Google Analytics sets a cookie in order to evaluate your use of the website and compile reports for us on activity on the website.
Google stores the information collected by the cookie on servers in the United States.
Google may also transfer this information to third parties where required to do so by law,
or where such third parties process the information on Google's behalf.
Google will not associate your IP address with any other data held by Google
By using this website, you consent to the processing of data about you by Google in the manner and for the purposes set out above.

How to reject or delete this cookie