Percutaneous nephrostomy performed by a nephrologist in a resource-limited public hospital: a case report

Percutaneous nephrostomy performed by a nephrologist in a resource-limited public hospital: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Percutaneous nephrostomy performed by a nephrologist in a resource-limited public hospital: a case report José Lascano Contreras¹, José Lascano Contreras This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7893839/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Percutaneous nephrostomy (PN) is a well-established minimally invasive procedure for the decompression of the obstructed urinary tract, traditionally performed by urologists or interventional radiologists. In medium-sized public hospitals where these specialists are often unavailable, delays in urinary drainage may worsen clinical outcomes, prolong dialysis dependence, and postpone the initiation of oncologic therapies. This report describes a successful case of percutaneous nephrostomy performed by a nephrologist in a public hospital without urological or interventional radiology coverage, highlighting the feasibility and safety of the procedure in emergency conditions. Case presentation A 65-year-old man presented with a two-month history of weight loss and poor appetite. Laboratory tests revealed markedly elevated nitrogenous waste products. Point-of-care ultrasonography (POCUS) demonstrated severe bilateral hydronephrosis, confirmed by abdominal computed tomography (CT), which also showed irregular thickening of the posterior bladder wall suggestive of neoplasia. Due to acute worsening of renal function, urgent haemodialysis was initiated. In the absence of available specialists and with delays in state-regulated referral, the nephrologist performed an emergency percutaneous nephrostomy. Using image guidance, an ultrasound-guided puncture was performed, followed by hydrophilic guidewire insertion under fluoroscopy, progressive dilation, and placement of a 10Fr pigtail catheter. Pre- and post-procedure images documented effective decompression of the collecting system. The patient showed marked clinical and biochemical improvement, recovery of diuresis (2,200 mL/24 h), and discontinuation of dialysis. He remains under outpatient oncologic follow-up. Conclusions This case demonstrates that trained nephrologists can safely perform percutaneous nephrostomy in resource-limited settings, reducing delays in urinary decompression and improving outcomes in obstructive acute kidney injury. Expanding procedural competence within nephrology represents a promising strategy to enhance patient care in public hospitals. percutaneous nephrostomy interventional nephrology obstructive acute kidney injury public hospital resource-limited setting Figures Figure 1 Background Percutaneous nephrostomy (PN), first described by Goodwin et al. in 1955 ( 1 ), is indicated for decompression of the obstructed urinary tract to preserve renal function and relieve obstructive symptoms. It is traditionally performed by urologists or interventional radiologists, with reported success rates exceeding 95% and complication rates below 5% ( 2 ). However, in resource-limited environments such as medium-sized public hospitals, the unavailability of these specialists can delay urinary diversion and compromise outcomes in patients with obstructive acute kidney injury (AKI-O). Interventional nephrology has expanded over recent decades as a subspecialty incorporating minimally invasive, image-guided techniques. Efstratiadis et al. (2007) ( 3 ) described the emergence of this field as one encompassing renal biopsies and the implantation of vascular accesses under ultrasound guidance, skills also essential for performing PN ( 4 ). This procedure has previously been successfully carried out by nephrologists, as demonstrated by Gonçalves et al. (1992) ( 5 ), supporting its potential role in clinical nephrology, especially where urologists or interventional radiologists are not available. Furthermore, recent surveys have shown growing interest among nephrologists in acquiring interventional procedural training, although structural and educational gaps persist in many countries ( 6 ). The present report describes an urgent percutaneous nephrostomy performed by a nephrologist in a public hospital without urological or radiological support, emphasising its technical aspects, clinical outcomes, and educational relevance. Case presentation Initial clinical data: A 65-year-old male presented with approximately two months of weight loss and anorexia. He was referred to the emergency department after outpatient laboratory review revealed serum creatinine of 4.0 mg/dL and urea of 101 mg/dL. Diagnostic evaluation: Point-of-care ultrasonography (POCUS) demonstrated severe bilateral hydronephrosis (Fig. 1 A). Abdominal CT confirmed these findings and revealed irregular thickening of the posterior bladder wall suggestive of neoplasia (Fig. 1 B). Initial course: During hospitalisation, creatinine rose to 6.38 mg/dL and serum potassium to 6.6 mEq/L, requiring urgent haemodialysis. The patient remained anuric while awaiting referral to a urology service through the state health system, which did not occur in time. Intervention: Given the patient’s clinical deterioration and the unavailability of specialists for immediate intervention, the nephrology team, with institutional authorisation from the hospital administration, proceeded with emergency percutaneous nephrostomy. The procedure was performed in the operating room with the patient in the prone position, under strict aseptic conditions and local anaesthesia. Access to the right renal collecting system was obtained by ultrasound-guided puncture using a 20G needle, directed toward the lower posterior calyx through the safety zone (Fig. 1 C). After sonographic confirmation of the correct needle position, a 0.035-inch hydrophilic guidewire was advanced under fluoroscopic guidance (C-arm), followed by progressive dilation of the nephrostomy tract. A 10Fr pigtail catheter was then inserted (Fig. 1 D). Immediate and abundant urinary drainage was observed, consistent with effective relief of urinary tract obstruction (Fig. 1 E). Follow-up ultrasound confirmed complete decompression of the pelvicalyceal system (Fig. 1 F), verifying the technical success of the procedure. Outcome: Following the procedure, the patient showed marked clinical improvement with urine output of 2,200 mL/24 h and a fall in creatinine to 2.1 mg/dL (Table 1 ). No complications occurred. The patient is currently undergoing outpatient follow-up for investigation of bladder neoplasia. Table 1 Laboratory parameters and urine output before and after percutaneous nephrostomy Date 03/09/2025 04/09/2025 04/09/2025 16/09/2025 23/09/2025 (post-PN) Serum creatinine (mg/dL) 4,0 6,38 5 pós HD PN 2,1 Urea (mg/dL) 101 149 100 pós HD 61 Potassium (mEq/L) 6,6 5,8 5,2 pós HD 5,2 Urine output (mL/24 h) 50 Anuria Anuria 2.200 (post-PN) Abbreviations: HD – haemodialysis; PN – percutaneous nephrostomy. Discussion This case reinforces the feasibility and safety of percutaneous nephrostomy performed by a nephrologist in a public hospital without urological or radiological coverage. When adequately trained, nephrologists can perform minimally invasive procedures with high success and safety rates comparable to those reported in the literature ( 5 ). The adoption of image-guided techniques has significantly expanded the scope of modern nephrology practice. The classic study by Gonçalves et al. (1992) reported 27 nephrostomies performed by nephrologists with excellent outcomes and minimal complications, providing an early foundation for incorporating this procedure into nephrology practice ( 5 ). Efstratiadis et al. (2007) identified interventional nephrology as an emerging subspecialty integrating renal biopsies, vascular access procedures, and other ultrasound-guided interventions — technical competencies that share principles with PN ( 3 ). In Latin American and other resource-limited settings, the scarcity of specialists and advanced equipment highlights the need to broaden procedural capabilities among nephrologists. Studies by Beathard (2015) and Jha et al. (2016) emphasise that multidisciplinary integration and structured procedural training programmes can optimise renal care, reduce hospital costs, and minimise dependency on other specialties ( 4 , 6 ). In the present case, technical proficiency with ultrasound, appropriate use of fluoroscopy, and adherence to strict aseptic principles enabled effective urinary decompression without complications and with rapid renal recovery. These findings demonstrate how nephrologist-led emergency interventions can have a direct impact on morbidity, mortality, and healthcare efficiency, particularly within public health systems with limited resources. Conclusions Percutaneous nephrostomy can be safely performed by properly trained nephrologists, provided that technical standards and safety conditions are met. The incorporation of interventional skills into nephrology training and practice represents a cost-effective, sustainable, and clinically relevant strategy to reduce therapeutic delays and improve outcomes for patients with obstructive acute kidney injury in public hospitals. Abbreviations PN – Percutaneous nephrostomy AKI-O – Obstructive acute kidney injury POCUS – Point-of-care ultrasonography CT – Computed tomography HD – Haemodialysis Declarations Ethics approval and consent to participate This case report was conducted in accordance with institutional and national ethical standards and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The case was approved by the Medical Directorate of Hospital São Vicente de Paulo, Osório, RS, Brazil. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and materials All data generated or analysed during this study are included in this article. Competing interests The author declares no competing interests. Funding No external funding was received. Authors’ contributions CONTRERAS, J. J. L performed the procedure, collected the clinical data, analysed the results, and drafted the final manuscript. Acknowledgements The author thanks the staff of Hospital São Vicente de Paulo and Associação Hospitalar Vila Nova for their institutional support during patient care and the procedure. Authors’ information CONTRERAS, J. J. L is a nephrologist specialising in clinical and interventional nephrology, a member of the POCUS – Ultrasonography in Nephrology Committee of the Brazilian Society of Nephrology, with interest in ultrasound-guided procedures in resource-limited settings. References Dagli M, Ramchandani P. Percutaneous nephrostomy: technical aspects and indications. Semin Intervent Radiol. 2011;28(4):424–37. 10.1055/s-0031-1296085 . Romero FR, et al. Indications for percutaneous nephrostomy in patients with obstructive uropathy due to malignant urogenital neoplasias. Int Braz J Urol. 2005;31(2):117–24. 10.1590/s1677-55382005000200005 . Efstratiadis G et al. Interventional Nephrology: a new subspecialty of Nephrology. Hippokratia. 2007;11(1):22–24. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC2464263/ Beathard GA. Role of interventional nephrology in the multidisciplinary approach to hemodialysis vascular access care. Kidney Res Clin Pract. 2015;34(3):125–31. Gonçalves MS, Adragão T, Negrão AP, Simões J. Interesse da Nefrostomia Percutânea em Nefrologia: revisão de 27 casos. Acta Med Port. 1992;5:533–7. Jha V, et al. Achieving procedural competence during nephrology fellowship training: current requirements and educational research. J Am Soc Nephrol. 2016;27(1):1–8. 10.2215/CJN.08940815 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 04 Dec, 2025 Reviews received at journal 03 Dec, 2025 Reviewers agreed at journal 25 Nov, 2025 Reviewers invited by journal 25 Nov, 2025 Editor invited by journal 24 Oct, 2025 Editor assigned by journal 23 Oct, 2025 Submission checks completed at journal 23 Oct, 2025 First submitted to journal 18 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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1","display":"","copyAsset":false,"role":"figure","size":792507,"visible":true,"origin":"","legend":"\u003cp\u003eSequence of images of the percutaneous nephrostomy procedure: \u003cstrong\u003e(A)\u003c/strong\u003e bilateral hydronephrosis on POCUS; \u003cstrong\u003e(B) \u003c/strong\u003eCT showing posterior bladder wall thickening; \u003cstrong\u003e(C)\u003c/strong\u003e ultrasound-guided puncture of the right kidney; \u003cstrong\u003e(D)\u003c/strong\u003e insertion of hydrophilic guidewire and tract dilation under fluoroscopy; \u003cstrong\u003e(E) \u003c/strong\u003eimmediate urine drainage through the pigtail catheter; \u003cstrong\u003e(F)\u003c/strong\u003e post-procedure ultrasound confirming complete collecting system decompression.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7893839/v1/625ee9011a57d5256c797018.jpeg"},{"id":97145268,"identity":"835522da-7941-45a0-9c7e-5700666c3c9b","added_by":"auto","created_at":"2025-12-01 10:13:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1290523,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7893839/v1/a22c7dfd-1827-48a0-bf5c-d3f9f5b00e47.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Percutaneous nephrostomy performed by a nephrologist in a resource-limited public hospital: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003ePercutaneous nephrostomy (PN), first described by Goodwin et al. in 1955 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), is indicated for decompression of the obstructed urinary tract to preserve renal function and relieve obstructive symptoms. It is traditionally performed by urologists or interventional radiologists, with reported success rates exceeding 95% and complication rates below 5% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, in resource-limited environments such as medium-sized public hospitals, the unavailability of these specialists can delay urinary diversion and compromise outcomes in patients with obstructive acute kidney injury (AKI-O).\u003c/p\u003e\u003cp\u003eInterventional nephrology has expanded over recent decades as a subspecialty incorporating minimally invasive, image-guided techniques. Efstratiadis et al. (2007) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) described the emergence of this field as one encompassing renal biopsies and the implantation of vascular accesses under ultrasound guidance, skills also essential for performing PN (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis procedure has previously been successfully carried out by nephrologists, as demonstrated by Gon\u0026ccedil;alves et al. (1992) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), supporting its potential role in clinical nephrology, especially where urologists or interventional radiologists are not available. Furthermore, recent surveys have shown growing interest among nephrologists in acquiring interventional procedural training, although structural and educational gaps persist in many countries (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe present report describes an urgent percutaneous nephrostomy performed by a nephrologist in a public hospital without urological or radiological support, emphasising its technical aspects, clinical outcomes, and educational relevance.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eInitial clinical data:\u003c/h2\u003e\u003cp\u003eA 65-year-old male presented with approximately two months of weight loss and anorexia. He was referred to the emergency department after outpatient laboratory review revealed serum creatinine of 4.0 mg/dL and urea of 101 mg/dL.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDiagnostic evaluation:\u003c/h3\u003e\n\u003cp\u003ePoint-of-care ultrasonography (POCUS) demonstrated severe bilateral hydronephrosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Abdominal CT confirmed these findings and revealed irregular thickening of the posterior bladder wall suggestive of neoplasia (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB).\u003c/p\u003e\n\u003ch3\u003eInitial course:\u003c/h3\u003e\n\u003cp\u003eDuring hospitalisation, creatinine rose to 6.38 mg/dL and serum potassium to 6.6 mEq/L, requiring urgent haemodialysis. The patient remained anuric while awaiting referral to a urology service through the state health system, which did not occur in time.\u003c/p\u003e\n\u003ch3\u003eIntervention:\u003c/h3\u003e\n\u003cp\u003eGiven the patient\u0026rsquo;s clinical deterioration and the unavailability of specialists for immediate intervention, the nephrology team, with institutional authorisation from the hospital administration, proceeded with emergency percutaneous nephrostomy.\u003c/p\u003e\u003cp\u003eThe procedure was performed in the operating room with the patient in the prone position, under strict aseptic conditions and local anaesthesia. Access to the right renal collecting system was obtained by ultrasound-guided puncture using a 20G needle, directed toward the lower posterior calyx through the safety zone (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC).\u003c/p\u003e\u003cp\u003eAfter sonographic confirmation of the correct needle position, a 0.035-inch hydrophilic guidewire was advanced under fluoroscopic guidance (C-arm), followed by progressive dilation of the nephrostomy tract. A 10Fr pigtail catheter was then inserted (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD).\u003c/p\u003e\u003cp\u003eImmediate and abundant urinary drainage was observed, consistent with effective relief of urinary tract obstruction (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE). Follow-up ultrasound confirmed complete decompression of the pelvicalyceal system (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eF), verifying the technical success of the procedure.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eOutcome:\u003c/h3\u003e\n\u003cp\u003eFollowing the procedure, the patient showed marked clinical improvement with urine output of 2,200 mL/24 h and a fall in creatinine to 2.1 mg/dL (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No complications occurred. The patient is currently undergoing outpatient follow-up for investigation of bladder neoplasia.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eLaboratory parameters and urine output before and after percutaneous nephrostomy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e03/09/2025\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e04/09/2025\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e04/09/2025\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16/09/2025\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23/09/2025 (post-PN)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSerum creatinine (mg/dL)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4,0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6,38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 p\u0026oacute;s HD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003ePN\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2,1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUrea (mg/dL)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100 p\u0026oacute;s HD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePotassium (mEq/L)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6,6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5,8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5,2 p\u0026oacute;s HD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5,2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUrine output (mL/24 h)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnuria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAnuria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e2.200\u003c/b\u003e (post-PN)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAbbreviations: HD\u003c/b\u003e \u0026ndash; haemodialysis; \u003cb\u003ePN\u003c/b\u003e \u0026ndash; percutaneous nephrostomy.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case reinforces the feasibility and safety of percutaneous nephrostomy performed by a nephrologist in a public hospital without urological or radiological coverage. When adequately trained, nephrologists can perform minimally invasive procedures with high success and safety rates comparable to those reported in the literature (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe adoption of image-guided techniques has significantly expanded the scope of modern nephrology practice. The classic study by Gon\u0026ccedil;alves et al. (1992) reported 27 nephrostomies performed by nephrologists with excellent outcomes and minimal complications, providing an early foundation for incorporating this procedure into nephrology practice (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEfstratiadis et al. (2007) identified interventional nephrology as an emerging subspecialty integrating renal biopsies, vascular access procedures, and other ultrasound-guided interventions \u0026mdash; technical competencies that share principles with PN (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Latin American and other resource-limited settings, the scarcity of specialists and advanced equipment highlights the need to broaden procedural capabilities among nephrologists. Studies by Beathard (2015) and Jha et al. (2016) emphasise that multidisciplinary integration and structured procedural training programmes can optimise renal care, reduce hospital costs, and minimise dependency on other specialties (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the present case, technical proficiency with ultrasound, appropriate use of fluoroscopy, and adherence to strict aseptic principles enabled effective urinary decompression without complications and with rapid renal recovery. These findings demonstrate how nephrologist-led emergency interventions can have a direct impact on morbidity, mortality, and healthcare efficiency, particularly within public health systems with limited resources.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePercutaneous nephrostomy can be safely performed by properly trained nephrologists, provided that technical standards and safety conditions are met. The incorporation of interventional skills into nephrology training and practice represents a cost-effective, sustainable, and clinically relevant strategy to reduce therapeutic delays and improve outcomes for patients with obstructive acute kidney injury in public hospitals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePN \u0026ndash; Percutaneous nephrostomy\u003c/p\u003e\n\u003cp\u003eAKI-O \u0026ndash; Obstructive acute kidney injury\u003c/p\u003e\n\u003cp\u003ePOCUS \u0026ndash; Point-of-care ultrasonography\u003c/p\u003e\n\u003cp\u003eCT \u0026ndash; Computed tomography\u003c/p\u003e\n\u003cp\u003eHD \u0026ndash; Haemodialysis\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report was conducted in accordance with institutional and national ethical standards and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The case was approved by the Medical Directorate of Hospital São Vicente de Paulo, Osório, RS, Brazil.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCONTRERAS, J. J. L performed the procedure, collected the clinical data, analysed the results, and drafted the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author thanks the staff of Hospital São Vicente de Paulo and Associação Hospitalar Vila Nova for their institutional support during patient care and the procedure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCONTRERAS, J. J. L is a nephrologist specialising in clinical and interventional nephrology, a member of the POCUS – Ultrasonography in Nephrology Committee of the Brazilian Society of Nephrology, with interest in ultrasound-guided procedures in resource-limited settings.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDagli M, Ramchandani P. Percutaneous nephrostomy: technical aspects and indications. Semin Intervent Radiol. 2011;28(4):424\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0031-1296085\u003c/span\u003e\u003cspan address=\"10.1055/s-0031-1296085\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRomero FR, et al. Indications for percutaneous nephrostomy in patients with obstructive uropathy due to malignant urogenital neoplasias. Int Braz J Urol. 2005;31(2):117\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/s1677-55382005000200005\u003c/span\u003e\u003cspan address=\"10.1590/s1677-55382005000200005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEfstratiadis G et al. \u003cem\u003eInterventional Nephrology: a new subspecialty of Nephrology.\u003c/em\u003e Hippokratia. 2007;11(1):22\u0026ndash;24. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pmc.ncbi.nlm.nih.gov/articles/PMC2464263/\u003c/span\u003e\u003cspan address=\"https://pmc.ncbi.nlm.nih.gov/articles/PMC2464263/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBeathard GA. Role of interventional nephrology in the multidisciplinary approach to hemodialysis vascular access care. Kidney Res Clin Pract. 2015;34(3):125\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGon\u0026ccedil;alves MS, Adrag\u0026atilde;o T, Negr\u0026atilde;o AP, Sim\u0026otilde;es J. Interesse da Nefrostomia Percut\u0026acirc;nea em Nefrologia: revis\u0026atilde;o de 27 casos. Acta Med Port. 1992;5:533\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJha V, et al. Achieving procedural competence during nephrology fellowship training: current requirements and educational research. J Am Soc Nephrol. 2016;27(1):1\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2215/CJN.08940815\u003c/span\u003e\u003cspan address=\"10.2215/CJN.08940815\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"percutaneous nephrostomy, interventional nephrology, obstructive acute kidney injury, public hospital, resource-limited setting","lastPublishedDoi":"10.21203/rs.3.rs-7893839/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7893839/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePercutaneous nephrostomy (PN) is a well-established minimally invasive procedure for the decompression of the obstructed urinary tract, traditionally performed by urologists or interventional radiologists. In medium-sized public hospitals where these specialists are often unavailable, delays in urinary drainage may worsen clinical outcomes, prolong dialysis dependence, and postpone the initiation of oncologic therapies. This report describes a successful case of percutaneous nephrostomy performed by a nephrologist in a public hospital without urological or interventional radiology coverage, highlighting the feasibility and safety of the procedure in emergency conditions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 65-year-old man presented with a two-month history of weight loss and poor appetite. Laboratory tests revealed markedly elevated nitrogenous waste products. Point-of-care ultrasonography (POCUS) demonstrated severe bilateral hydronephrosis, confirmed by abdominal computed tomography (CT), which also showed irregular thickening of the posterior bladder wall suggestive of neoplasia. Due to acute worsening of renal function, urgent haemodialysis was initiated.\u003c/p\u003e\n\u003cp\u003eIn the absence of available specialists and with delays in state-regulated referral, the nephrologist performed an emergency percutaneous nephrostomy. Using image guidance, an ultrasound-guided puncture was performed, followed by hydrophilic guidewire insertion under fluoroscopy, progressive dilation, and placement of a 10Fr pigtail catheter. Pre- and post-procedure images documented effective decompression of the collecting system. The patient showed marked clinical and biochemical improvement, recovery of diuresis (2,200 mL/24 h), and discontinuation of dialysis. He remains under outpatient oncologic follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case demonstrates that trained nephrologists can safely perform percutaneous nephrostomy in resource-limited settings, reducing delays in urinary decompression and improving outcomes in obstructive acute kidney injury. Expanding procedural competence within nephrology represents a promising strategy to enhance patient care in public hospitals.\u003c/p\u003e","manuscriptTitle":"Percutaneous nephrostomy performed by a nephrologist in a resource-limited public hospital: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-01 08:37:20","doi":"10.21203/rs.3.rs-7893839/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"156440519444181268344661474359957362093","date":"2025-12-04T13:28:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-03T18:19:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"245329545644684903844471319318694613497","date":"2025-11-25T13:12:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-25T11:34:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-24T08:25:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-23T10:58:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-23T10:57:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2025-10-18T13:40:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7e9a7a8b-3aab-4a9f-95eb-da73b9e75644","owner":[],"postedDate":"December 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T08:37:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-01 08:37:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7893839","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7893839","identity":"rs-7893839","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}