Ureteroscopy and Percutaneous Procedures The Impact of Percutaneous Nephrolithotomy in Patients with Chronic Kidney Disease Abraham Kurien, M.S., D.N.B., Ramen Baishya, M.S., Shashikant Mishra, M.S., D.N.B., Arvind Ganpule, M.S., D.N.B., Veeramani Muthu, M.S., M.Ch., Ravindra Sabnis, M.S., M.Ch., and Mahesh Desai, M.D., FRCS (Eng), FRCS (Edin) Abstract Introduction: The impact of percutaneous nephrolithotomy (PCNL) in chronic kidney disease (CKD) patients was retrospectively analyzed in this study. We analyzed the factors that can impair renal function and predict the need for renal replacement therapy (RRT) after PCNL. Patients and Methods: Ninety-one chronic kidney patients with a mean age of 52.5  13 involving 117 renal units underwent PCNL in our institution for 5 years. A mean of 1.6  1.1 tracks and 1.3  0.6 sittings per renal unit was required for PCNL. The estimated glomerular filtration rate (eGFR) pre-PCNL (postdrainage), peak eGFR on follow-up, and eGFR at last follow-up were recorded. The CKD stage pre-PCNL was compared with the CKD stage at last follow-up. Results: Complete clearance, auxiliary procedure, and complication rates were 83.7%, 2.5%, and 17.1%, respectively. The mean eGFR pre-PCNL and peak eGFR at follow-up were 32.1  12.8 and 43.3  18.8 mL= minute=1.73 m 2 , respectively ( p < 0.0001). At a mean follow-up of 329  540 days, deterioration with up- migration of CKD stage was seen in 12 patients (13.2%). Eight patients (8.8%) required RRT in the form of either maintenance hemodialysis or renal transplantation. Postoperative bleeding complication requiring blood transfusions was seen in seven (5.9%) and two (1.7%) of the renal units subsequently required super selective angioembolization. There were two mortalities in the postoperative period. Postoperative complications and peak eGFR (less than 30 mL=minute=1.73 m 2 ) at follow-up are two factors that predict renal deterioration and RRT. Renal parenchymal thickness (<8 mm) also predicts the need for RRT. Conclusion: PCNL has a favorable impact in CKD patients with good clearance rates and good renal functional outcome. PCNL in this high-risk CKD population is to be done with care and full understanding of its com- plications. Introduction R enal stones are an important risk factor for chronic kidney disease (CKD) in the general population. 1 The prevalence of urinary stone disease in patients on maintenance hemodialysis is reported to be 3.2%, 2 and 1.9% to 7.7% of the patients who undergo percutaneous nephrolithotomy (PCNL) have CKD. 3,4 The treatment for renal stones in patients with CKD should be effective so that renal function improves or further renal deterioration does not occur with stable renal function. This stable phase can avoid the need for renal re- placement therapy (RRT). The impact of PCNL in patients with CKD was assessed in this retrospective evaluation. Patients and Methods Stone removal with consequent relief of obstruction and infection can avoid RRT. Our treatment strategy involves draining all hydronephrotic kidneys with percutaneous nephrostomies (PCN). The nephrostomy tubes are placed strategically with careful planning, so that the matured tracts can be used for future PCNL. Multiple nephrostomy tubes may be required for adequate drainage of all calyces. Urine obtained at the time of nephrostomy is sent for culture and sensitivity. Urinary tract infection is treated with appropri- ate antibiotics. Nephrologist’s help is obtained for correction of fluid overload, electrolyte imbalances, acidosis, and ane- mia. Appropriate temporary RRT may also be initiated if re- quired. During PCNL the number of tracks used is kept to an op- timal minimum. We routinely use Amplatz sheath after track dilatation so as to keep the intrapelvic pressures low. The nephroscopy time usually does not exceed 1 hour in these high-risk patients. Nephrostomy drainage and antegrade Double-J stents are placed if indicated. In the postoperative Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India. JOURNAL OF ENDOUROLOGY Volume 23, Number 9, September 2009 ª Mary Ann Liebert, Inc. Pp. 1403–1407 DOI: 10.1089=end.2009.0339 1403