Nephroptosis: Floating (mobile) kidney as a cause of unexplained abdominal and flank pain

Overview

Renal ptosis, nephroptosis or “floating kidney,” describes a phenomenon where the kidney descends within the retroperitoneal and causes a range of symptoms including episodic renal colic-like severe pain, flank pain, abdominal pain, testicular pain that can be accompanied by nausea and vomiting.

  • The distance of descent downward of the kidney is defined as >5cm or two vertebral bodies while moving from the supine to erect position.
  • Diagnostic studies to confirm this elusive diagnosis include a range of different imaging modalities combined with supporting history.

Below is a list of articles I read to help me understand how I will approach this enigmatic and controversial diagnosis for a patient I care for who has suggestive symptoms.

I have shared this list for colleagues that may need to consider this diagnosis in a patient.

If you want to get a sense of what patients report and how nephropexy can resolve symptoms, read a few of the case reports. This diagnosis will not be easy to make, but if you make the correct diagnosis and treat the patient, you may save him or her a lot of pain and suffering.

 

Selected Literature

Hoenig DM, Hemal AK, Shalhav AL, Clayman RV. Nephroptosis: a “disparaged” condition revisited. Urology. 1999 Oct;54(4):590–6.

Nanayakkara PWB, van Bunderen CC, Santerse B. A bumpy ride to a discarded diagnosis. Lancet. 2007 Feb 3;369(9559):436.

Yoshida S, Matsumura M, Maekawa K, Minaga K, Kamata K, Nozawa M, et al. Recurrent abdominal pain caused by nephroptosis. Clin J Gastroenterol [Internet]. 2020 Feb 28; Available from: http://dx.doi.org/10.1007/s12328-020-01110-x

Taylor J, Prasad K, Rohrer R. Dynamic Renal Ptosis Demonstrated on 18F-FDG PET/CT. Clin Nucl Med. 2019 Apr;44(4):303–4.

Mogorovich A, Selli C, De Maria M, Manassero F, Durante J, Urbani L. Clinical reappraisal and state of the art of nephropexy. Urologia. 2018 Nov;85(4):135–44.

Arnerlöv C, Söderström M, Öhberg L. Mobile kidney pain provocation ultrasonography before surgery for symptomatic mobile kidney: A prospective study of 43 consecutive patients. Scand J Urol. 2016;50(1):61–4.

Golab A, Slojewski M, Gliniewicz B, Sikorski A. Retroperitoneoscopic nephropexy in the treatment of symptomatic nephroptosis with 2-point renal fixation. Surg Laparosc Endosc Percutan Tech. 2009 Aug;19(4):356–9.

Barber NJ, Thompson PM. Nephroptosis and nephropexy--hung up on the past? Eur Urol. 2004 Oct;46(4):428–33.

Plas E, Daha K, Riedl CR, Hübner WA, Pflüger H. Long-term followup after laparoscopic nephropexy for symptomatic nephroptosis. J Urol. 2001 Aug;166(2):449–52.

Cholelithiasis during Octreotide Therapy

PICO Question

In patients undergoing long term therapy with octreotide what is the incidence of cholelithiasis compared to untreated patients and what is the outcome of patients with cholelithiasis?

Gallstones occur very commonly in patients on long term octreotide therapy  (Sandostatin) and infrequently require cholecystectomy.

Selected Studies

Hussaini, S. H., Pereira, S. P., Veysey, M. J., Kennedy, C., Jenkins, P., Murphy, G. M., et al. (1996). Roles of gall bladder emptying and intestinal transit in the pathogenesis of octreotide induced gall bladder stones. Gut, 38(5), 775–783.

  • Study population: acromegalic patients vs controls examining effect of octreotide
  • A single dose of Octreotide 50 mug essentially abolished meal stimulated (Ensure 250 ml) gall bladder emptying in both acromegalic and control subjects
  • Octreotide prolongs small bowel transit time
  • Nice graphs

 

Trendle, M. C., Moertel, C. G., & Kvols, L. K. (1997). Incidence and morbidity of cholelithiasis in patients receiving chronic octreotide for metastatic carcinoid and malignant islet cell tumors. Cancer, 79(4), 830–834.

  • Study population: patients with metastatic carcinoid or malignant pancreatic islet cell tumors who were receiving chronic therapy with octreotide.
  • Among 44 patients followed over about 50 months, approximately 50% developed cholelithiasis.  The incidence of acute cholecystitis was about 11%.

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