Features and complications of nephroptosis causing the loin pain and hematuria syndrome. A preliminary report.
OBJECTIVE
Loin pain with and without hematuria is a serious clinical problem that is most difficult to diagnose and treat. The underlying symptomatic nephroptosis was disparaged long ago, the loin pain hematuria syndrome is doubted and the link between the 2 conditions remains unknown. The lack of demonstrable pathology on all supine imaging has caused disbelieve. This article aims to demonstrate underlying symptomatic nephroptosis features and complications including loin pain hematuria syndrome and discuss the patho-etiology mechanism.


METHODS
Observational study and thorough investigations of patients presenting with loin pain and hematuria showed that all supine standard and ancillary imaging was normal. Upright intravenous urography and isotope renography, however, showed features of symptomatic nephroptosis causing the initial intermittent renal pain. Retrograde pyelography demonstrated late organic complications of symptomatic nephroptosis causing pain and hematuria of loin pain hematuria syndrome. Observations detected the illusive overlooked anomalies demonstrable on photographs.


RESULTS
All supine standard and ancillary imaging appeared deceptively normal in patients presenting with recurrent episodes of loin pain with or without hematuria. Upright imaging demonstrated gross nephroptosis with pelvi-ureteric junction kink, causing the initial intermittent and later organic obstruction pain. Renal pedicle stretch or twist was also demonstrable on upright intravenous urography and isotope renography as causes of ischemic renal pain. Retrograde pyelography demonstrated the organic renal damage of symptomatic nephroptosis when complicated into loin pain hematuria syndrome. Pyelocalyctaisis with eroded papillae, peritubular backflow and intrarenal extravasation of contrast medium with venous leakage, showed the renal site and cause of hematuria fulfilling the definition of loin pain hematuria syndrome. "Auto-nephropexy" and "sympathetic nephroplegia" were illusive neuro-ischemic findings that took years of follow up observation to affirm in cases of symptomtic nephroptosis complicated into loin pain hematuria syndrome. Other complications included segmental infarction and renal atrophy "auto-nephrectomy".


CONCLUSIONS
The presented photographs demonstrate that loin pain and hematuria have real heterogeneous patho-etiology of ureteral kink obstruction and pedicle stretch or twist ischemia of symptomatic nephroptosis with intermittent and irreversible stages. The overlooked anomalies on all supine imaging are demonstrable on upright imaging and retrograde pyelography with pyelocalyctaisis that may affect both kidneys via sympathetic neuropathy. The reproducible evidence affirms that pain is genuine and symptomatic nephroptosis may be complicated into loin pain hematuria syndrome.
Ghanem
Ahmed N
AN
Department of Urology, King Khalid Hospital, Najran, Kingdom of Saudi Arabia. an_ghanem@hotmail.com
D000328:Adult; D001342:Autonomic Nervous System Diseases / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology; D005260:Female; D006417:Hematuria / Q000209:etiology*; D006801:Humans; D007511:Ischemia; D007668:Kidney / Q000098:blood supply / Q000294:innervation; D007674:Kidney Diseases / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology; D008297:Male; D017699:Pelvic Pain / Q000209:etiology*; D014567:Urography