Complications of Nephrostomy Tube Placement

Causes and Risk Factors

• The risk of pleural complications with percutaneous nephrostomy (PCN) is approximately 1% according to the Society of Interventional Radiology quality improvement guidelines 1
• Pleural complications are more common with supracostal (upper pole) access during nephrostomy tube placement, with a risk of up to 15% of patients 1
• Patients with end-stage renal failure (ESRF) who develop pleural effusions have significantly higher mortality (46% at 1 year vs 15.6% in general ESRF population) 2
• Common mechanisms in ESRF patients include fluid overload (most common - 61.5% of cases), hydrostatic and oncotic imbalances, and uraemic pleuritis (exudative, often hemorrhagic) 2
• Hyponatremia contributes to fluid overload, which is the leading cause (61.5%) of pleural effusions in hospitalized ESRF patients, and can exacerbate hydrostatic and oncotic imbalances in ESRF patients 2
• Patients with cirrhosis and serum sodium ≤130 mEq/L have a higher risk of hepatic encephalopathy (3.4 times), hepatorenal syndrome (3.5 times), and spontaneous bacterial peritonitis (2.4 times) 3

Diagnosis

• Chest radiography and CT scan can be used to confirm and quantify pleural effusion, and identify fistulous tracts or anatomical abnormalities 2
• Renal scintigraphy with 99mTc ethylene dicysteine can be used to detect tracer in pleural space (for urinothorax) 2
• Pleural fluid analysis can help diagnose urinothorax if the pleural fluid/serum creatinine ratio is >1 2
• Evaluate pleural fluid characteristics, including:

• Use thoracic ultrasound to assess for simple vs. complex effusion, presence of interstitial syndrome, and diaphragmatic defects (in hepatic hydrothorax) 2
• Echocardiography can evaluate cardiac function and pulmonary pressures 2

Management

• Ensuring proper urinary drainage, such as repositioning or replacing displaced nephrostomy tube, and considering ureteral stenting to bypass obstruction, can help manage nephropleural fistula or urinothorax 2
• Intensifying medical therapies to treat fluid overload (diuresis, dialysis) and considering indwelling pleural catheter (IPC) for recurrent effusions can help manage ESRF-related effusions 2
• Careful planning of nephrostomy tube placement, use of ultrasound and fluoroscopic guidance during procedure, and regular monitoring of nephrostomy tube position and function can help prevent pleural complications 1
• Management of hyponatremia is based on severity:
• For hepatic hydrothorax:
• Increase intensity of renal replacement therapy and consider thoracentesis for symptomatic relief 2
• Address underlying fluid overload and consider diuretic therapy for transudative pleural effusions, according to the European Respiratory Society guidelines 2
• Serial monitoring of serum sodium levels during treatment of hyponatremia and follow-up chest imaging to assess resolution of pleural effusions are necessary 4, 5
• Monitoring for complications of interventions (pneumothorax, bleeding, infection) and determining the etiology of pleural effusions are crucial to guide treatment, as recommended by the American Thoracic Society and European Respiratory Society 5, 2