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Extracorporeal Shock-Wave
Lithotripsy: Long-Term Complications
Clyde M. William& Of 148 patients who had extracorporeal shock-wave lfthotripsy (ESWL) for renal
Jun V. Kaude1 lithiasis in 1984, 21 (14%) returned after 17-21 months for renal function tests (21
Robert C. Newman2 patients) and blood pressure determination (20 patients). Quantitative radionuclide
renography showed a statistically significant (p = .048) decrease in the percentage of
John C. Peterson3
American Journal of Roentgenology 1988.150:311-315.
effective renal plasma flow (ERPF) to the treated kidney. Two of these patients had
William C. Thomas3
developed hypertension requiring treatment but became normotensive when given
medication. In the other patients there was a statistically significant Increase in both
systolic (p = .0002) and diastolic (p = .015) blood pressures. Information about blood
pressure was also obtained from an additional 71 (48%) of the 148 patIents; of the total
91 patients (61%) in whom blood pressures were obtained, seven (8%) had developed
sufficiently severe hypertension to require treatment beginning within 21 months after
ESWL
Side effects of ESWL for renal lithiasis include hemorrhage, edema, and acute tubular
necrosis of the kidney. This form of renal trauma is associated with an immediate
decrease in renal function of the treated kidney, and this decrease may be permanent.
ESWL is also associated with the onset of hypertension, which may occur immediately
or be delayed by several weeks or months. Although the pathogenesis remains unknown,
hypertension is an important complication of ESWL in about 8% of patients.
treatment to determine the efficacy of the procedure and to (1 1 .1 -1 8.5 MBq) of 1311-orthoiodohippurate (Hippuran) are adminis-
discover possible complications. Unfortunately, there was tered intravenously 30 mm after oral ingestion of 500 ml water.
poor compliance with this requirement and in the first report Images were obtained with an Ohio Nuclear Series 100 scintillation
of the United States cooperative study [4}, 3-month follow-up camera (Solon, OH) interfaced with an MDS computer (Ann Arbor,
data were available in only 37% (926/2501) of the patients. Ml). Total ERPF was calculated from the formula of Tauxe et al. [7],
and the percentage of ERPF for each kidney was obtained from the
For these reasons, we initiated a concerted effort in 1 986 to
1 -2 mm interval after injection of the radionuclide.
have the first 1 48 patients treated here under the FDA exper-
imental protocol return to the hospital for evaluation. We
report the long-term effects of ESWL on renal function as Blood Pressure
determined by renography and the prevalence of hypertension Pre-ESWL values were obtained from the medical records in which
occurring after ESWL in this group of patients. systolic and diastolic blood pressures were measured in the hospital
at 6-hr intervals before ESWL. The average number of measurements
was 5.6 (range, 2-1 5). The mean value of the pre-ESWL blood
Materials and Methods pressures was compared with post-ESWL follow-up values obtained
A letter was sent to all 148 patients asking them to retum to the during the return visit at which time the blood pressure was measured
hospital for an abdominal radiograph, quantitative radionuclide renog- at least three times and the lowest value recorded. An increased
raphy, and blood pressure measurement. Of these 1 48 patients, only systolic blood pressure was considered to be 1 50 mm Hg; an
21 (1 4%) returned for the tests 1 7-21 months after ESWL. The mean increased diastolic blood pressure, 95 mm Hg.
age of these 21 patients was 51 years (range, 28-68 years); nine
were women and 1 2 men. The mean number of shocks per treatment
was 1 400
(range, 800-2000), and the kilovoltage used ranged from Statistical Analysis
18 to 24 kV. After these 21 patients had been tested, we were able The Student paired t-test and the Pearson correlation were used
American Journal of Roentgenology 1988.150:311-315.
Dubovsky et al. [5] and Kontzen et al. [6] in which 300-500 tCi parison with their pretreatment test (Table 1). The total ERPF
TABLE 1: Correlation of Renal Function and Hypertension Before and After ESWL
NORMAL
the ERPF to the treated kidney decreased by more than 5% 180/94
120/78 C #{149}
120/80 RANGE
in 24% (5/21) of patients. L&_ 112/74
0 130/80 C 130/84 \\\\\\.
u_ #{149}142/e0 #{149}
#{149}150/90
o_ 180/78
Comparison of Blood Pressures Before and After ESWL
son, the measurement of total renal clearance will not detect [1 1] who found that 24 (8%) of 295 patients required phar-
the presence of an adverse effect of ESWL on a treated macologic intervention for hypertension that had developed
kidney unless the untreated kidney is unable to respond. A during the 1-year period after ESWL. Beyond the age of about
compensatory increase in ERPF to the untreated healthy 45 years (in both men and women), systolic blood pressure
kidney may result in an increase in total ERPF to an amount rises at an average rate of 0.5-1 .0 mm Hg/year until the
greater than the pre-ESWL value, as was noted in the coop- seventh decade [1 2]. All of the patients with sustained hyper-
erative study [4] and also in the present report. For this tension listed in this report and in the report of Lingeman and
reason the absolute value of the ERPF to the treated kidney, KuIb [1 1] developed hypertension either immediately after
which is obtained by multiplying the percentage of ERPF to ESWL or within 1 year after ESWL, thus exceeding any age-
the treated kidney by the total ERPF, may not change signif- related increase in blood pressure. The combined results of
icantly. The assessment of a change in renal function after the two series, composed of nearly 400 patients, indicate that
ESWL is therefore incomplete without determination of the clinically significant hypertension arising from renal trauma
differential renal function of the treated kidney. Future studies caused by ESWL is likely to occur in about 8% of patients.
of the acute and long-term effects of ESWL on renal function ESWL has been described as a well-engineered, highly
should always include an analysis of the relative function of selective application of brute force [1 3]. After a few hundred
the treated kidney. shocks, macroscopic hematuria caused by intrarenal hemor-
The normal range of percentage of ERPF to a single kidney rhage occurs in virtually all patients [1 , 2], and this hemor-
in a two-kidney healthy patient is 45-55% [9]. Our range of rhage may be serious in patients who have a tendency to
35-63% in treated kidneys before ESWL was considerably bleed [1 4, 15]. Although the originators of the procedure
larger than this, presumably because of the presence of recorded a very low frequency (0.6%) of subcapsular hema-
stones and frequently some obstruction. The reproducibility toma [1 ], a prospective study with MR imaging revealed a
American Journal of Roentgenology 1988.150:311-315.
of the percentage of ERPF to a single kidney in a two-kidney much higher frequency (29%) of subcapsular, perirenal, and/
patient is ±3% (Dubovsky EV, personal communication). That or intraparenchymal hemorrhage [2]. The difference in the
is, if the percentage of ERPF to a single kidney is 45%, a rate of occurrence of renal hemorrhage may be attributed to
repeat measurement will be between 42% and 48%. Thus a the much less sensitive sonographic technique used by
decrease in the percentage of ERPF to a single kidney from Chaussy et al. [1]. The high frequency of hemorrhage that
45% pre-ESWL to 35% post-ESWL would be more than three we documented with MR has been confirmed by three recent
times the change expected from the error of measurement. studies in which CT [1 6, 1 7} and MR [1 8] were used for
In our earlier study of renal function immediately after ESWL evaluation of kidneys treated with ESWL. Experiments with
[2], we found a significant (p = .025) decrease in the per- dogs have confirmed that the clinically observed MR and CT
centage of function of the treated kidney when ERPF was abnormalities are caused by renal and subcapsular hemor-
measured. We also found that 30% of patients (1 0/33) had rhages, frequently associated with small vein thromboses,
an abnormal decrease in the percentage of ERPF to the interstitial edema, and acute tubular necrosis [19-221.
treated kidney of more than 5%. These findings have been External mechanical trauma is known to result in interstitial
confirmed by Bomanji et al. [1 0] who measured GFR in 42 edema and extravasation of urine and blood into the interstitial
patients immediately after ESWL. They found a significant (p space [23]. These same effects caused by ESWL explain the
= .01 ) decrease in the percentage function of the treated enlargement of the kidney seen on excretory urography, MR,
kidney, and 21 % of patients (9/42) had an abnormal decrease and CT [2, 16-1 8, 24], as well as the total and partial
in renal function of the treated kidney of 8% or more. When parenchymal obstructive patterns seen in renography and the
we used either our criterion of abnormality (a decrease of 6% renal edema and hemorrhages seen on MR [2].
or more) or the criterion of Bomanji et al. (a decrease of 8% We have not yet found the cause of the long-term decrease
or more) [1 0], we found that 24% of patients had an abnormal in the percentage of ERPF to the treated kidney. The partial
decrease in renal function of the treated kidney at 17-21 and total parenchymal obstructive patterns observed by re-
months. The fact that ESWL may result in a significant nography immediately after ESWL, and attributed to acute
decrease in the percentage of ERPF to the treated kidney, tubular necrosis and edema caused by hemorrhage, were not
both acutely and at 1 7-21 months, suggests that the de- seen in our patients 17-21 months after ESWL, thus indicat-
crease in renal function caused by ESWL may be permanent. ing the resolution of these two processes. All but one of 21
In none of our 21 patients was there evidence of unrecognized patients had a normal excretory phase of the renogram curve
ureteral obstruction as a possible cause of the decreased of the treated kidney, indicating the absence of mechanical
renal function of the treated kidney. obstruction due to persistent or recurrent stones. The one
Peterson and Finlayson [3] reported a 4% (three of 79 patient in whom the percentage of ERPF was reduced to a
patients) frequency of sustained hypertension occurring im- very low value had no stone but a small atrophic kidney.
mediately after ESWL. The data in the present report indicate Possibly renal fibrosis, which has been observed in canine
that sustained hypertension, either occurring immediately kidneys 30 days after ESWL [22], may be responsible for the
after ESWL or developing several months later, may be long-term decrease in the percentage of ERPF to treated
permanent. The overall frequency of hypertension requiring kidneys.
treatment in our patients was 8% (7/91 ). This frequency is in Peterson and Finlayson [3] suggested that renal trauma
close agreement with the recent report of Lingeman and KuIb caused by ESWL may cause hypertension as the result of a
AJR:150, February 1988 ESWL: LONG-TERM COMPLICATIONS 315
perirenal hematoma via the well-known Page kidney effect stone disease. Boston: Butterworth, 1986:145-150
4. Drach GW, Dretler 5, Fair W, et al. Report of the United States cooperative
(trauma perirenal
-* hemorrhage -p fibrosis compression
-p
study of extracorporeal shock wave lithotnpsy. J Urol 1986:135:1127-
of renal parenchyma - increased interstitial pressure -p 1133
decreased renal perfusion renin release
-+ generation
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angiotensin II - hypertension). In a review of 29 cases of sive evaluation of renal function in the transplanted kidney. J Nucl Med
Page kidney [25], a history of trauma could be elicited in 78%, 1975;16:1 115-1120
6. Kontzen FN, Tobin M, Dubovsky EV, Tauxe WN. Comprehensive renal
and the interval between the trauma and the discovery of function studies: technical aspects. J NucI Med Tech 1977;5:81-84
hypertension varied widely from 24 hr to 1 2 years but gen- 7. Tauxe WN, Dubovsky EV, Kidd T, Diaz F, Smith AL. New formulas for the
erally was less than 1 year. Of the seven patients in the calculation of effective renal plasma flow. Eur J NucI Med 1982;7 :51-54
present report who developed sustained hypertension after 8. Tauxe WN. Prediction of residual renal function after unilateral nephrec-
tomy. In: Tauxe WN, Dubovsky EV, ads. Nuclear medicine in clinical
ESWL, three had MR immediately after ESWL and all three
urology and nephrology. Norwalk, CT: Appleton-Century-Crofts, 1985:
of these patients had perirenal or subcapsular hemorrhage. 279-285
In the immediate post-ESWL period, decreased renal plasma 9. Tauxe WN, Totn M, Dubovsky EV, Bueschen AJ, Kontzen FN. A macro-
flow may be reasonably attributed to increased interstitial function for computer processing of comprehensive renal function studies.
EurJ NucI Med 1980:5:103-108
pressure caused by perirenal or intrarenal hemorrhage and
10. Bomanji J, Boddy SAM, Bntton KE, Nimmon CC, Whitheld HN. Radio-
the resultant edema. Up to 1 8 months after ESWL, decreased nuclide evaluation pre- and postextracorporeal shock wave lithotnpsy for
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American Journal of Roentgenology 1988.150:311-315.
function and blood pressure is weakened by the small number 13. Mulley AG. Shock wave lithotripsy. N EngI J Med 1986:314:845-847
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P The reader’s attention is directed to the Commentary on this article, which appears on the following pages.