Nephrostomy issues

Nephrostomies are percutaneously inserted conduits facilitating drainage of the renal pelvis. Refer to patient records for the indication of the nephrostomy, such as a stone/cancer / after a ureteric injury / ureteric stricture.

All nephrostomy tubes should be exchanged every 3 months. Although some may require shorter intervals between changes due to frequent blockages.

As is the case with any external drain or tube, nephrostomies occasionally present challenges and issues, most of which can be managed the following day if sensible.

As a general rule, nephrostomy problems in a single functioning kidney should be assessed and managed urgently to preserve renal function and avoid developing an AKI or infection.

When dealing with nephrostomies, as with catheters, using incontinence sheets to keep the patient and linen dry is recommended and your nursing and HCA colleagues will be grateful.

Common problems with nephrostomies:

1. Blocked tube

2. Blood-stained urine

3. Displaced nephrostomy

   
   

Blocked nephrostomy

Patients note that there is little to no urine output. Sometimes their carer would have noticed this at the time of emptying the bag or changing the bag.

If the patient can pass reasonable amounts of urine per urethra, this is a reassuring first step as it implies urine is draining down the ureters at the very least.

1. Remove the nephrostomy bag gently by peeling away the sticky bits. Avoid tugging on the nephrostomy tube as it will cause pain and risk displacing the tube.

2. Once the bag has been removed, examine the port and tube as well as the skin surrounding the nephrostomy. The presence of heavy encrustation (chunky salt deposits) indicates that the lumen may very well be occluded by the same and may require a change if the following measures fail.

3. Look for any obvious kinks in the tube. If you attempt to straighten the kink, please secure the proximal end to avoid tugging on the tube.

4. Draw 10-20mL of normal saline in a syringe. You may need a normal tipped syringe or a luer-lock syringe (the screw on type), depending on the nephrostomy port, so keep a spare handy.

5. Gently push the saline through the nephrostomy. Use as much pressure as you would when you flush a cannula. If this works, well done!

6. If pushing the saline through is futile, gently pull on the plunger and try pushing again; this may displace some of the debris within the tube. Do this a few times before moving on.

7. If the patient is tolerating the procedure, apply firmer pressure. Stop when there is discomfort.

8. Gently push the nephrostomy tube into the stoma slightly and try flushing again. This manipulation may help bypass a renal stone or detach it from the walls of the pelvis and into the pelvis proper, allowing drainage.

9. Whether you succeeded or failed, place a fresh nephrostomy bag and revisit the patient in an hour to check if the tube has started to drain.

If there is no urine coming out, book the patient for a nephrostomy exchange.
Escalate early if the patient has a solitary kidney / single functioning kidney / an infected and obstructed system / AKI.

Blood-stained urine:

-Blood-stained urine immediately after a nephrostomy exchange or first-time insertion can be expected and should resolve within the day.

-Should a patient with a nephrostomy present with bloody urine and feeling unwell with elevated white cell counts and inflammatory markers, think about pyelonephritis and manage on the lines of sepsis.

-If there is more blood than urine in the nephrostomy output - chart the output, obtain all routine bloods, including a VBG, ensure a cross-match is available and escalate to your senior urgently as there is a risk of injury to the renal vasculature at the time of insertion. Clamping the nephrostomy or IR-guided embolisation may be required.

Displaced nephrostomy

-Delirium can be a confusing time for all involved, and it is not unusual to receive a call regarding a patient who has pulled their nephrostomies out.

-Assess the patient, start appropriate antibiotics if infection is suspected and arrange for urgent nephrostomy exchange in this instance.

-Remember, infected and obstructed kidneys are a recipe for septic shock.