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Renal ultrasound

woneill7

Among all kidney diseases, autosomal dominant polycystic kidney disease (ADPKD) is probably the one where point-of-care ultrasound can have the greatest impact. This includes diagnosis, prognosis, and complications, all of which are demonstrated in the following examples.

Figure 1
Figure 1

A 40 year-old male is referred for evaluation of hypertension and an elevated serum creatinine

of 1.6. There is no family history of kidney disease. A sonogram performed in the clinic reveals markedly enlarged kidneys full of cysts (Fig. 1). This is consistent with ADPKD but not diagnostic. While the marked enlargement and mild renal insufficiency essentially rules out acquired cystic disease, there are other less

Figure 2
Figure 2

common causes of multicystic kidneys. In this case, further scanning reveals hepatic cysts (Fig. 2), which are common in ADPKD but rarely if ever seen in the other cystic renal diseases. 

 

After discussion of the pros and cons with the patient, he decides to have his 2 children evaluated and brings them for scanning at his next visit. You find normal kidneys in one, but a 16 year-old daughter has two cysts in each kidney (Fig. 3) with some probable tiny

Figure 3
Figure 3

cysts as well (dotted arrows).  This meets the criteria for the diagnosis of ADPKD in someone with a family history. The other child is not completely ruled out but can be reassured that ADPKD is unlikely.

Kidney cysts are easily identified on ultrasound and ADPKD can be readily diagnosed, particularly when the sonographer has the knowledge to scan for hepatic cysts as well. Thus point-of-care ultrasound can greatly expedite the diagnosis and exclusion of ADPKD.



A 25 year-old male is self-referred to the nephrology clinic because of a diagnosis of ADPKD. The ultrasound report that he brings with him indicates multiple cysts in both kidneys with a right kidney length of at least 14.5 cm and a left kidney length of at least 15.0 cm. But this is not very helpful since the kidneys could be just 16 cm long or over 20 cm long and size is an important determinant of prognosis. You could order an MRI, but this is expensive and requires another appointment. Better yet, you could scan the kidneys yourself.  Since the kidneys extend beyond the sector of the probe, size can only be measured by interpolation. So separate images are obtained with each pole in view and the distance from each pole to the same landmark (arrows) is measured on each image (Fig 4 and 5). Summing the 2 lengths yields a

Figure 5
Figure 5
Figure 4
Figure 4










total length of 12.2 cm. Of course, designating a landmark in PKD kidneys can be like picking out a tree in a forest, but usually a unique cyst can be identified. Although there is some error in this measurement, we have shown that is sufficiently accurate to assess prognosis (Bhutani et al. Kidney International 88:146-151, 2015).

Assessing prognosis is critical in ADPKD and requires appropriate measurements that can easily be accomplished by ultrasound.  This is a common scenario that illustrates the importance of nephrologists performing renal ultrasounds in these patients.


Figure 6
Figure 6

A 36 year-old female patient followed for ADPKD develops L flank pain. This started relatively suddenly a few days ago without fever or other abdominal complaints. On exam, there is point tenderness over the left flank. A sonogram in the clinic reveals a left kidney cyst with layering of echogenic material within (Fig. 6). Furthermore, depression of the abdomen with the probe over that cyst exacerbates the pain and

Figure 7
Figure 7

identifies that cyst as the culprit. This is typical for hemorrhage into a cyst, which is a common occurrence in ADPKD. An infected cyst may have a similar presentation and appearance but, with the absence of fever, is less likely. Complex cysts (often called dirty cysts) are very common in ADPKD, usually the result of prior hemorrhage. Also, reverberation artifact is common in large cysts and can mimic echogenicity (Fig. 7). This can usually be recognized as a series of lines that are always in the direction of the sound.


Figure 8
Figure 8

Another cause of pain and/or hematuria related to ADPKD is kidney stones (Fig. 8), the incidence of which is increased in ADPKD. These can be difficult to identify on ultrasounds, so careful scanning for stones is indicated in ADPKD patients with pain, which usually can identify the stone. Acoustic shadowing may be apparent because it can be obscured by the the enhancement from the   to the fact in small stones such as this one.


During a routine follow-up visit, a patient with ADPKD is noted to have an unexpected increase in the serum creatinine level. A sonogram is performed in the clinic and reveals some caliectasis in the R kidney (Fig. 9, left). The color Doppler (Fig. 9, right) demonstrates vessels on


Figure 9
Figure 9

each side of the fluid but no flow within, indicating that it is urinary space. As in any patient, stones can obstruct the ureter and, because the other kidney often cannot compensate in ADPKD, lead to worsening renal function. This should always be suspected in patients with an unexpected increase in their serum creatinine. Obstruction can be more difficult to detect in ADPKD kidneys, not only because of the cysts but also because the caliectasis is usually not as pronounced. However, with the clinical suspicion and careful scanning, it can usually be detected.  


These scenarios demonstrate the key role ultrasound plays in the evaluation and management of ADPKD, and who better to do this than nephrologists because they are aware of the clinical presentation and knowledgeable about cystic kidney disease. Point-of-care ultrasound also facilitates the management and is far more convenient for the patients. ADPKD is yet another example of why nephrologists should be performing renal sonograms.

 
 
 
woneill7

Figure 1
Figure 1

A 75 year-old female was referred to the nephrology clinic for evaluation of kidney stones and cysts. A ultrasound performed in the clinic showed hyperechoic foci with acoustic shadowing in each kidney consistent with stones (Fig. 1 and 2).

Figure 2
Figure 2





In addition, several cystic areas were seen (Fig. 3).

Figure 3
Figure 3




A key finding was that the medullary pyramids, which are normally less echogenic than the cortex, were echogenic (Fig. 4), indicating some process within the medulla.

Figure 4
Figure 4


The differential diagnosis includes interstitial nephritis, nephrocalcinosis, gouty kidney, and medullary sponge kidney. There is no shadowing from the medullae, which is inconsistent with nephrocalcinosis. A closer look at the “stones” revealed that they were located at the apices of the pyramids, in other words, in the papillae, indicating that they are likely to be calcified papillae. This can be the initial finding in papillary necrosis.

Figure 5
Figure 5

Closer inspection of the “cysts” reveals that they are located within the echogenic medullae (Figure 5).









This is also apparent when you zoom in on Fig. 1 (right). Thus, these cysts are actually papillary cavities. These findings are typical for analgesic nephropathy. When asked during the sonogram, the patient admitted to chronic back pain with a long history of NSAID use.




This case illustrates several points. First, not all echogenic foci with shadows are stones. Second, not all cystic lesions are simple cysts. Lastly, and most importantly, this case illustrates the importance of nephrologists performing and interpreting renal ultrasounds. A differential diagnosis often needs to be established during the exam, along with immediate clinical correlation, in order to guide and focus the examination.

 
 
 
woneill7

Updated: Jan 22

A 41 y.o. female with a history of bilateral stone disease resulting in a right nephrectomy in the past. An ultrasound was performed in the renal clinic.




A stone is present in the lower pole (black arrow) on a longitudinal image. Note that there is large shadow (white arrows) not emanating from the stone, without an obvious source.








The renal parenchyma is thin, indicative of chronic damage, and there is some dilatation of the renal pelvis and proximal ureter.






On further longitudinal imaging, there is an echogenic focus within the renal pelvis (while arrow) that is distinct from the lower pole stone (black arrow).







This was confirmed on transverse imaging through the mid kidney.














In the bladder, transverse imaging revealed two separate echogenic structures that appeared connected on longitudinal imaging. While stones can be present in the bladder, they should either be affixed to the wall or lie against the dependent surface.







On further questioning, the patient recalls that there may have been a stent inserted in the left ureter in the past. This would explain the shadow of unapparent source, the additional echogenic focus in the renal pelvis and the findings in the bladder. Stents are often not visible on sonograms due to their variable relationship to the sound beam. The mild dilatation of the renal pelvis and proximal ureter is common with stents unless the bladder is empty. So instead of multiple stones, this patient probably has just one stone. This was confirmed on a subsequent CT scan.


This case illustrates several important points:

  • sonography often requires interpretation and clinical correlation during the study, which is one reason why nephrologists should be performing renal ultrasounds.

  • Not every echogenic structure with shadowing is a stone.

  • The bladder should always be examined.

 
 
 
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