Nephroptosis - Causes, Symptoms, Diagnosis, and Management

Introduction

Nephroptosis is a rare condition in which one or both kidneys drop five centimeters below their original position in the abdominal cavity on standing up. It is also known as floating kidney and renal ptosis. Usually, nephroptosis is an asymptomatic condition that does not require any treatment. However, some people might experience symptoms like side pain or blood in the urine, thus requiring treatment. It was first described in the thirteenth century by Franciscus de Pedemonatanus. Around seventy percent of the cases affect the right kidney, ten percent affect the left kidney, and twenty percent affect both kidneys.

What Causes Nephroptosis?

Nephroptosis is a rare condition present since birth. The kidneys can move a few centimeters without causing any problems. But in nephroptosis, the kidneys move down more than five centimeters when one stands up from lying down. It is a common condition in females with a more diminutive stature. It has been found in around twenty percent of women. Most people with nephroptosis are asymptomatic; it is difficult to find the exact number of individuals with the condition.

The exact cause is not known. However, it could be due to less support from the surrounding structures or the conditions that weaken the connective tissue around the kidneys. Such conditions include:

• Abrupt weight loss.

• Pregnancy and childbirth.

• Damage to the abdomen or spinal cord.

• High-intensity exercise.

What Are the Symptoms of Nephroptosis?

Usually, nephroptosis is asymptomatic. However, some people can have varied symptoms from mild to severe when they stand up and are often relieved on lying down. The different symptoms include:

• Sharp pain in the flank (side) radiating down to the groin area.

• Nausea.

• Vomiting.

• High blood pressure.

• The feeling of a mass in the abdomen while standing up.

• Hematuria- The presence of blood in the urine.

• Proteinuria- The presence of excessive protein in the urine.

• Recurrent urinary tract infections.

How Is Nephroptosis Diagnosed?

The diagnosis is carried out based on the symptom of the patients.

• Blood test.

• Urine test.

• Urogram- A CT (computed tomography) urogram is an imaging technique used to examine the urinary tract (the kidneys, ureters, and bladder). It can also be done after injecting a contrasting media or dye into the person's blood for better visualization of the kidneys. The test is carried out in both lying down and standing positions. The images clearly show the kidney dropping down by more than five centimeters.

How Is Nephroptosis Treated?

Nephroptosis is not a life-threatening condition. Asymptomatic people do not require treatment, whereas symptomatic patients require treatment. Earlier treatment modalities such as weight gain, lying down frequently, wearing abdominal corsets or bandages, and exercises were advised to treat the symptoms. However, these methods were not found very effective and are no longer recommended. Nephroptosis is surgically treated with a procedure known as laparoscopic nephropexy. A study conducted in the year 2007 examined the short and long-term effectiveness of the procedure. Specific individuals revealed a significant reduction in pain, a decrease in urinary tract infections, and an overall improvement after the procedure. No significant complications were reported during the surgery. Nephropexy was controversial in the past. It was not very effective and carried a fair amount of mortality risk. The modern procedure of surgery is safe as it is done laparoscopically.

Before the Surgery-

• The doctor takes a thorough medical history of the patient.

• The symptoms are verified with the help of imaging techniques in both supine and upright positions.

• Antibiotics are administered before the surgery.

• Mechanical bowel preparation is done with a low-sediment diet.

• A glycerin enema is given for the stool to pass before the surgical procedure.

Laparoscopic Nephropexy- This is a minimally invasive procedure done under general anesthesia. The procedure takes forty-five minutes, requiring a hospital stay of two to four days. This procedure fixes the kidneys to the surrounding tissues. The outer part of the kidney, known as the renal capsule, is attached to the surrounding muscles with sutures with the help of a laparoscope. A laparoscope is a thin tube with a camera attached at the end, which is inserted into the abdomen via the small incisions made on the skin. This procedure was first done by Bassini and is the most common procedure.

After the Surgery- After completing the surgical procedure, the patients usually start taking fluids and food on the night of the surgery. They are advised to stroll on the first or second days after surgery. The individual is usually discharged on the second or third day. Oral painkillers are administered to control pain. Follow-up is generally two to six months after the procedure.

What Are the Complications of Nephroptosis?

Rarely some individuals with nephroptosis might develop a syndrome known as the Dietl crisis. Dietl's Crisis- It is a condition where the floating kidneys block the ureters (the thin tube that joins the kidneys with the urinary bladder), leading to:

• Severe pain in the sides or flank.

• Nausea.

• Chills.

• Tachycardia- A condition in which the heart beats faster than usual.

• Low urine output.

• Hematuria- This is the presence of blood in the urine.

• Proteinuria- A condition in which there is excessive protein in the urine.

• Enlarged and painful kidney/s.

• Urinary Tract Infections (UTI) - An UTI is an infection of the kidneys, ureters, bladder, and urethra caused by bacteria. It leads to pain and burning while passing urine, increased frequency of urination, pain in the upper back and sides, chills and fever, bloody or cloudy urine, nausea and vomiting.

Dietl's crisis is reduced by lying down and bringing the knees up to the chest area.

What Is the Prognosis of Nephropexy?

Laparoscopic nephropexy gives good results with adequate pain control in appropriately selected patients. Several outcome studies have shown that individuals undergoing laparoscopic nephropexy have decreased morbidity, postoperative pain, and faster recovery than patients undergoing open nephropexy. In addition, laparoscopic nephropexy carried out in individuals with vascular or obstructive kidney impairment, has been successful in easing the symptoms associated with kidney compromise.

Conclusion

Nephroptosis is rare, in which the kidneys drop down a little from their original position on starting up. Most cases of nephroptosis are asymptomatic and do not require treatment. Symptomatic individual surgery is the only effective treatment to relieve the symptoms. Earlier in the past, nephropexy had a high mortality rate. Modern surgical procedures are pretty safe and effective, with better outcomes.