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Oganes E. Dilanyan
Urologist, MD, PhD
+7(499)344-03-03

Nephroptosis

In this article

Nephroptosis or floating kidney is a very common condition which manifests as abnormal movement and low positioning of the kidney. In rare cases this can cause lower back pain, increased blood pressure, blood in urine, formation of kidney stones and development of pyelonephritis.

Nephroptosis or floating kidney

What is nephroptosis? Why in some cases floating kidney does not cause any problems and in some cases the patients experience pain, kidney stones and high blood pressure or even the risk of the kidney dying all together. Sometimes a patient with a floating kidney is forever treated for recurrent pyelonephritis and kidney colic with passing of kidney stones. After a long walk the patient can experience pain in the lower back, which are often blamed on the spine. In advanced cases young people with nephroptosis have to take blood pressure lowering medication

Treatment of Nephroptosis

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Laparoscopic surgery of the floating kidney also known as laparoscopic nephropexy is the modern standard of treatment for the floating kidney. The point of both open and laparoscopic surgery is to fix the kidney in it’s normal place. However, unlike open surgery, laparoscopic surgery does not leave scars, is well tolerated and does not carry the risk of inflammation and the need to stay in hospital for a month. 
Full recovery time after laparoscopic surgery is 2 days in hospital. After that the patient can return to their normal life.  

23-year-old patient is complaining about pain in the lumbar region towards the right, frequent rising of their blood pressure to   150/110, frequent episodes of acute pyelonephritis on the right side for which they undergo treatment with antibiotics and constant present of blood in urine when tested.  

Dry short phrases in the medical history file. And before me is a slim young woman afraid to fall pregnant, terrified of even slight drops of temperature and fearful of getting too cold, afraid of walking too much and carrying blood pressure medication with her at all times. Active lifestyle is out of the question. 

Can’t see the wood for the trees

Floating kidney symptoms

Unfortunately, floating kidney does not have many symptoms. Lumbar pain is usually blamed on back problems and degenerative disk disease, especially because this pain goes away when lying down. The increase in blood pressure is often blamed on stress and being hereditery, and even frequent inflammation of the kidney and pyelonephritis are often thought to be the consequence of colds and flu. And then during an ultrasound scan the patient lies down, the kidney returns to its normal place and the report reads “the kidneys are positioned normally”.

A usual story of a floating kidney

... — Were you standing up or lying down during your ultrasound scan? 
—  I was lying down…on my side. They just told me I had some signs of chronic pyelonephritis, that’s all. No kidney tumours, no stones. But they never told me where this recurring pyelonephritis comes from. Blood is always present in the urine and red blood cells count is never less than 20-30, constant pain in the lumbar region. My gynaecologist does not recommend pregnancy just yet, and there are no antibiotics left that I have not tried in my attempts to treat my pyelonephritis.

“Understanding the cause of illness is half of the cure”
Hippocrates

Complications and stages of nephroptosis

Nephroptosis
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Nephroptosis complications include two factors: disruption of urinary flow and disruption of blood flow. 
The dangers are as follows: when the kidney is “floating” it sort of hangs supported only by its own artery. The artery stretches. As any other tube’s diameter shrinks when stretched so does the artery’s and as a result less blood is able to get to the kidney in the presence of nephroptosis. The kidney tries to get its share of blood and starts producing a special substance called rennin that leads to blood pressure rising. Another problem is urinary outflow. When the kidney floats it goes down and the ureter creates bends which are hard for the urine to pass through. Urine stagnation is the ideal breeding ground for bacteria.  The latter, not being flushed away with the urine start multiplying causing acute pyelonephritis. And this in turn leads to kidney stone formation.

A common floating kidney story

— Please stand with your back facing me. I place the ultrasound probe on the back but there is no kidney to be seen in the usual place. I move the probe lower. – Right, good, breath in and you’re your breath. You have a floating kidney on the right-hand side, also known as nephroptosis. And it is very likely the cause of your problems.
— Yes, I have been told many times that I have a floating right kidney. But how is it connected to constant inflammation and my blood pressure going up?
—  Look. When the kidney is floating the urinary flow is disrupted and the ureter bends and bacteria get the perfect breeding place. This is the reason for pyelonephritis. When urinary flow is disrupted kidney stones may form. On the other hand, in the presence of nephroptosis the kidney sort of hangs supported only by the artery it is attached to. The artery stretches and narrows and the blood supply to the kidney is reduced. The kidney starts producing rennin, a special substance that causes the rise in blood pressure. The kidney calls for more blood. There are two stages of nephroptosis. During the first stage the kidney is lowered by more than 1.5 vertebra length, during the second stage this is increased to 2 vertebrae and in the third stage the distance is greater than 3 vertebrae. But the stages do not always correlate with the degree to which kidney function is disrupted.

“The patient always ends up paying for the doctor’s mistake. And they pay very dearly”
Professor Alyaev

Floating kidney: Diagnosis

Diagnosis of the floating kidney almost always runs into certain difficulties, it is important to remember that the patient might have nephroptosis and the ultrasound scan should therefore be performed with the patient standing up. When the patient assumes a horizontal position, the kidney returns to it’s normal pace. Final diagnosis of the floating kidney is only possible using a special x-ray investigation such as general and excretion urography.  
The aim of this test is to administer radiographic contrast material to the patient that will be excreted by the kidneys without affecting the body. We then see the image of the kidneys in various positions: lying down, standing up, breathing in and breathing out. This test also allows us to test kidney function.  

A common floating kidney story

— You need to undergo general and excretion urography. And this has to be done standing up and lying down.
— But you have already performed a kidney ultrasound. And everything can be seen on there. 
— Ultrasound scan does not provide definite diagnosis of nephroptosis. We need to understand how the kidney is functioning and see if the flow of the contrast fluid is slowed or see any other reasons for your complaints, as well as confirm the stage of nephroptosis. This is only possible during urography. Are you allergic to iodine? 
— I don’t think so…Are you planning to smear me with iodine?
— Well, not quite. Contrast fluid that is administered during urography contains iodine. This fluid is visible on x-ray. It is excreted from the body via the kidneys and opens amazing diagnostic possibilities: we can assess kidney function by looking at the speed with which it leaves the body, we can see renal calices, renal pelvis and the ureters and detect the disruption in urinary outflow and clearly see the reason of this disruption. Performing this test in the standing and lying down position we will see the displacement of the kidney depending of the body position and so will be able to accurately determine the presence and stage of the floating kidney condition.

“Every time when suggesting surgery to your patient think about this: Would you suggest the same to your relative?”
A Stepanyan, Oncologist/Gynaecologist

Floating Kidney treatment

Treating floating kidney is a difficult task. It is often the case that the patient has a floating kidney but no other problems can be seen. No kidney pain, no blood in the urine, the blood pressure is normal and no history of pyelonephritis. This means that the kidney is not affected and there is no real need for treatment. The patient just needs regular annual follow ups and some diet recommendations.
But in some cases nephroptosis can ruin a patient’s life and that is a completely different story: Pain in the kidney, blood in the urine and frequent kidney inflammation all affect the patient’s quality of life by not allowing them to have an active lifestyle. Then there is a question of the treatment method. Can one try and cure them by recommending a special diet aimed at increasing body mass or promoting physical exercise? Will wearing a support belt help in this case? Or is nephroptosis surgery necessary?

A common floating kidney story

— Well… — I am looking at the x-ray results realising that no exercise or support belt are going to help here. The kidney is down by 3 vertebrae and one third of the kidney is positioned in the pelvis. – You know, I think you should have surgery.
— I knew it, I knew this would not end well, - the patient says while looking defeated. This is just what happened to my aunt.
— Your aunt?
— Yes… My mum’s sister had a floating kidney and had surgery for it. It ruined her life. After the operation she stayed in bed for 30 days. She had terrible pain. She and her husband got divorced because of her scar. 15 years after the surgery she has a hernia on the incision site and this hernia had been operated on 7 times. I don’t want surgery.  
— Or maybe you don’t want the same surgery your aunt had?
— Yes, I would rather be taking medication all my life than suffer the same way my aunt did.
— You see, nowadays open surgery is practically never used to treat floating kidney. There is laparoscopic surgery. And instead of a large incision there are 3 small punctures, each no bigger than 5 mm in diameter. 
— I thought laparoscopy was only used for ovarian examinations.
— It’s not just for that. Laparoscopic surgery has now replaced many different operations. And some operations are only performed laparoscopically. For example, the lifting and fixation of the kidney in the presence of nephroptosis.
—  What do you mean by “kidney fixation”?
— A special mesh is placed under the kidney. It is secured in the way that the kidney sort of sits in a hammock. The mesh supports the kidney not allowing it to go down more than it should. The urinary outflow is then normalised, the bacteria does not have time to multiply, and pyelonephritis is gone. The artery returns to its normal position and its diameter returns to its normal size therefore high blood pressure problems also disappear.
— And what about scarring? After surgery, there surely are scars. And how long will I have to stay in hospital for?
— After 6 month you won’t be able to find them even if you look for them. Hospital stay is 2-3 days. Maximum. 
— Does the mesh need to be removed at a later date?
— No, it stays in the body for good. 
— Will I be able to feel it?
— Of course not, like you don’t feel the fillings in your teeth.
— Doctor, tell me, will I be able to give birth?
— Of course. Pyelonephritis will be gone and your blood pressure will be normal, and there are no other contraindications. 
— And... — My patient is slightly embarrassed and is looking awayПациентка смущенно отводит глаза, — Will I be allowed a parachute jump? It’s my dream. I know it sounds stupid but what if the mesh tears off? 
— Nothing stupid about this question. A month later a very strong connective capsule forms around the kidney and creates a natural supporting structure for the kidney. So, jump to your heart’s content. 

Nephroptosis surgery

Surgical fixation of a floating kidney is called nephropexy. The aim of this surgery is to place a special mesh underneath the kidney fixing it in place. As a result, the kidney finds itself in a special hammock which limits its movements not allowing it to move downwards. The artery is no longer stretched and the ureter is no longer bent. Blood pressure problems disappear and so does the pain and pyelonephritis. And the best this is, that if in the past this surgery required a large 20 cm incision accompanied by pain, scarring and other problems, now this operation is performed laparoscopically and only leaves 3 small punctures no bigger than 5mm each. The patient can usually be discharged on the following day without suffering from any pain or discomfort. They can return to their normal activities including sport after 2-3 weeks.

A common floating kidney story

… I should never have allowed her that parachute jump. Should have talked her out of it. Three months after her surgery I got an email that read: “Dear doctor Oganes, my parachute jump did not affect my kidney, and I don’t even feel it. I no longer suffer from pyelonephritis and my blood pressure is normal. It is a shame you did not place a mesh in my leg as well. I am in hospital with a badly sprained ankle. Do you know any good trauma surgeons?”

Certificates
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Information for foreign patients:

If you require treatment for a floating kidney in Moscow please contact us. We will arrange your admission to hospital on the day of your arrival and will carry out all necessary investigations and will operate one or two days after your arrival. Another two or three days later you will be able to return home.  

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