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Kidney Problems


Table of Contents
Kidney Problems and Diving
Renal Failure
Kidney Transplant
Polycystic Kidney Disease
Renal Stones, Infections
Bladder
Prostate
Urinary tract Surgery
Kidney Problems and Diving

Diving and the physical changes that take place with the underwater environment have little to relate to the urological system. There is very little in the way of articles and reports concerning the urological system and sport diving. However, there are some factors that must be taken into consideration by the diver and his doctor when deciding if a person with conditions of the urinary tract should dive. The entire urologic complex of the kidneys, ureters, bladder, prostate and urethra have to be considered  -- not just the kidneys alone. 

The examination of prospective divers, sports scuba divers, underwater photographers and diving instructors with kidney disease should include the pertinent aspects of present and past history, review of systems and physical examination directed and designed to specifically detect those conditions that place a person in jeopardy for the following:

1). decompression illness

2). pulmonary over pressure accidents

3). loss of consciousness

4). inability to mentally or physically handle the in-water environment.

The obvious reasons why a person should not dive are as follows:
Basic Urological Anatomy and Physiology 

The kidneys themselves, concerning their function as a 'waste disposal unit', and the adrenals 'belong' to internal medicine or nephrology. The general surgeon performs operations concerning the adrenals. Kidney transplants are often performed by specialized surgical teams. 
Kidney

Diving with Renal Failure

When the kidneys are damaged by some systemic disease process (such as diabetes, arteriosclerosis, heavy metal poisoning or drugs) it's ability to function as a filter is diminished and products of metabolism such as urea nitrogen and creatinine are not removed from the blood. This leads to blunting of the sensorium, loss of cognition and decrease in underwater skills. The extent to which this occurs varies greatly with the individual and a critical level of 'BUN' and creatinine (azotemia) causing mental and cerebral changes dangerous to a diver cannot be stated with accuracy. Individuals can continue to function with remarkably high levels of creatinine, having some degree of accommodation. These people also have significant fluid and electrolyte shifts, blood pressure problems and renal insufficiency to the point of requiring dialysis (peritoneal or AV shunt). Significant anemia occurs for several reasons and the O2 carrying capacity of the anemic diver in renal failure would be dangerous.

Case Question:

Dear colleague: did you ever hear from any active divers suffering from complete renal insufficiency - dialysis dependent? We have decided to let him not dive furthermore because of his massive imbalance in his sodium and potassium- results. Very careful immersion in a swimming pool leads to a rise in blood pressure (170/95 at surface, 200/105 immersed). Do you know any literature dealing with this very special 
question?

Answer:

"Unless there is some abrogation of Boyle's Law, there should be no contraindication to diving with peritoneal dialysis. If there are any air containing spaces in the abdomen or tubal appliances, your patient might have some problem with the volume changes that take place upon ascent while diving on compressed air"

Your patient probably should not dive anyway, with a pressure such as you describe. This is very interesting and I'd be interested in whether or not the immersion had any effects on his hyperkalemia.


Kidney Transplant

Transplant patients would be at little risk of sport diving given good recovery from the surgery and no evidence of organ rejection. However, there are risks for diving in the marine environment while taking immunosuppressants (see Marine Infections and Diving in Polluted Water). In addition to increased risk of infection by organisms not ordinarily pathogens, there is alo the effect the drug protocols have on the bone marrow (anemia) and on blood clotting (hemorrhage from barotrauma of the ears, sinuses and lungs). It is thought by some that spinal decompression illness is worsened by hemorrhage from a clotting deficit. 

There is also the possibility of pulmonary fibrosis from the immunosuppressing drugs. The dangers from pulmonary fibrosis would be the increased risk of hypoxia with low oxygen transfer and the increased risk of pulmonary barotrauma from blockage of the terminal airways. (air trapping).

Fitness to Dive?
It is thought that if there has been a sufficient period of time after the transplant to assess the function of the kidney as concerns the renal and cardiovascular system (blood pressure, pulmonary function) - usually about one year - and if a person has no adverse drug reactions - that a person can return to diving, considering the discussion above.

Kidney Donor Diving?

Given complete recovery from any surgery required for the donation, there would be no reason for the donor not to dive.


Polycystic Kidney Disease

In this condition there are innumerable fluid-filled cysts in the kidneys. Early on this offers little or no risk due to diving since there is no abrogation of Boyle's law. However, the condition would be dangerous from other aspects due to the possibility of anemia, azotemia and infection. The cysts of this disease are fluid -filled and therefore would not be subject to the effects of pressure/volume changes. In later stages of the condition problems of alertness and changes in sensorium due to azotemia would be important to take into consideration. There is also the problem of possible anemia with low oxygen carrying potential.


Renal stones, kidney infections

A diver with renal stones or infection poses a problem as to the differential diagnosis of renal colic and pain from infection and the symptoms of decompression sickness. 

Stones and stents for drainage of urine are not affected by depth/pressure and should not in themselves be a reason not to dive. However, medications taken to relieve pain and spasms and to prevent reflux (such as Detrol) can have side effects that in theory could pose problems for the diver. Drowsiness, from any cause can be additive to the ever present effects of nitrogen narcosis. Detrol also can interact with other medications such as some antibiotics. 

The diver should  carefully document symptoms prior to your dives and observe and note any changes during and after the dive. Advise your divemaster and your buddy of your symptoms so that you will have a disinterested observer. The problems that would be encountered by the commercial diver in a saturation situation with renal colic would be considerable. The sport diver at remote dive sites is also placed in jeopardy.



Bladder Problems

Bladder drainage systems (catheters) have bulbs or balloons that require inflating in order to secure them in place. A diver with one of these should ensure that the bulb does not contain air but it should be inflated with water or saline.

Frequency of urination, as is often seen in men with prostate enlargement and women with bladder problems related to childbirth, should not be a significant problem with the diver. 'Peeing' in the wet suit is not a forbidden or unforgiveable act and is not harmful. 


Prostate Problems

Other than the symptoms of dysuria, frequency of urination and urgency that make this condition so unpleasant there are few caveats concerning diving. However, the medications used to traet this condition can cause considerable difficulty. 

One of the prominent non-surgical therapies for an enlarged prostate is a group of drugs called alpha blockers, an old blood pressure medication. Two tradenames are 'Hytrin' and 'Flomax'. They are quite effective in relieving symptoms but have a major side effect - they cause significant nasal mucosal congestion and can be a cause of extreme difficulty in equalizing while scuba diving. 

Another side effect is hypotension; what effect the changes that take place in immersion would have on the diver on this medication would need careful titration and observation for the first few dives.

Diving after urinary tract surgery



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Kidney Options

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 Ernest Campbell, MD, FACS All Rights Reserved.


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