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Pisani I, Giacosa R, Giuliotti S, Moretto D, Regolisti G, Cantarelli C, Vaglio A, Fiaccadori E, Manenti L. Ultrasound to address medullary sponge kidney: a retrospective study. BMC Nephrol 2020; 21:430. [PMID: 33046028 PMCID: PMC7552549 DOI: 10.1186/s12882-020-02084-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/30/2020] [Indexed: 01/01/2023] Open
Abstract
Background Medullary sponge kidney (MSK) is a rare disease characterized by cystic dilatation of papillary collecting ducts. Intravenous urography is still considered the gold standard for diagnosis. We identified a cohort of patients from our outpatient clinic with established diagnosis of MSK to outline some ultrasonographic characteristics that may help establish a diagnosis. Methods We conducted a retrospective study of patients seen between January 1st 2009 and January 1st 2019 in our clinic. Out of 4321 patients, 18 had a diagnosis of MSK. We reviewed their clinical and family history, laboratory data and imaging studies. Specifically, we focused on ultrasound imaging. Results Patients were referred to our outpatient clinic because of renal impairment (44%), family history of nephropathy (17%), nephrolithiasis or an established diagnosis of MSK (39%). Seventy-two percent of patients presented with chronic kidney disease, 22% required hemodialysis. Urinary tract infections (44%), nephrolithiasis (33%), microscopic hematuria (50%) and proteinuria (44%) were reported. Seven patients underwent computed tomography; all of them received ultrasound. Ultrasound examination showed bilateral renal cysts, usually small and located in the renal medulla, and microcalcifications located in the medulla or within the cysts. Conclusion We identified a peculiar tetrad associated with MSK: 1) hypoechoic medullary areas, 2) hyperechoic spots, 3) microcystic dilatation of papillary zone, 4) multiple calcifications (linear, small stones or calcified intracystic sediment) in each papilla. The presence of this diagnostic tetrad, added to laboratory data and clinical history, could be helpful in the differential diagnosis to identify patients with MSK.
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Affiliation(s)
- Isabella Pisani
- U.O. Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Via Gramsci 14, 43126, Parma, Italy.
| | - Roberto Giacosa
- Casa di Cura Città di Parma, Unit of Diagnostic, Contrast enhanced and Interventional Ultrasound, Parma, Italy
| | - Sara Giuliotti
- Struttura complessa di Radiologia, Azienda Ospedaliero-universitaria di Parma, Parma, Italy
| | - Dario Moretto
- U.O. Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Giuseppe Regolisti
- U.O. Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Chiara Cantarelli
- U.O. Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Firenze, Florence, Italy.,Nephrology and Dialysis Unit, Meyer Children's University Hospital, Florence, Italy
| | - Enrico Fiaccadori
- U.O. Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Lucio Manenti
- U.O. Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Via Gramsci 14, 43126, Parma, Italy
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Gaunay GS, Berkenblit RG, Tabib CH, Blitstein JR, Patel M, Hoenig DM. Efficacy of Multi-Detector Computed Tomography for the Diagnosis of Medullary Sponge Kidney. Curr Urol 2018; 11:139-143. [PMID: 29692693 DOI: 10.1159/000447208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/27/2017] [Indexed: 11/19/2022] Open
Abstract
Objective To expand the diagnostic armamentarium for medullary sponge kidney (MSK), we evaluate the use of high-resolution multidetector computed tomography (MDCT) for MSK diagnosis and compare to the standard intravenous urography (IVU). Despite a significant prevalence amongst stone formers, diagnosis of this well described condition has declined. IVU, the gold standard in MSK diagnosis, has largely been replaced by CT, which has previously been shown unable to demonstrate signs of MSK. Methods and Materials Patients with known history of MSK based on IVU underwent limited MDCT urogram. Control group patients, without MSK, also had MDCT urograms performed for other clinically indicated conditions. Studies were scored by board-certified radiologists on a 0-2 scale based on the likelihood of MSK. IVU studies, when available, were similarly graded. Results MDCT was diagnostic of MSK in 9 out of the 10 patients with known history of MSK. No false positives were present in our series. The one case of MSK not detected on MDCT was graded as a "1" on its respective IVU. Sensitivity and specificity were 90 and 100%, respectively, when compared with IVU. Conclusion Concordance with IVU findings, despite a small reduction in sensitivity, indicates MDCT to be a suitable, and more readily available replacement for IVU in the diagnosis of MSK.
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Affiliation(s)
- Geoffrey S Gaunay
- Smith Institute for Urology, Hofstra Northwell School of Medicine, New Hyde Park, New York, NY, USA
| | | | - Christian H Tabib
- Smith Institute for Urology, Hofstra Northwell School of Medicine, New Hyde Park, New York, NY, USA
| | | | | | - David M Hoenig
- Smith Institute for Urology, Hofstra Northwell School of Medicine, New Hyde Park, New York, NY, USA
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Hickling DR, Sun TT, Wu XR. Anatomy and Physiology of the Urinary Tract: Relation to Host Defense and Microbial Infection. Microbiol Spectr 2015; 3:10.1128/microbiolspec.UTI-0016-2012. [PMID: 26350322 PMCID: PMC4566164 DOI: 10.1128/microbiolspec.uti-0016-2012] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Indexed: 02/07/2023] Open
Abstract
The urinary tract exits to a body surface area that is densely populated by a wide range of microbes. Yet, under most normal circumstances, it is typically considered sterile, i.e., devoid of microbes, a stark contrast to the gastrointestinal and upper respiratory tracts where many commensal and pathogenic microbes call home. Not surprisingly, infection of the urinary tract over a healthy person's lifetime is relatively infrequent, occurring once or twice or not at all for most people. For those who do experience an initial infection, the great majority (70% to 80%) thankfully do not go on to suffer from multiple episodes. This is a far cry from the upper respiratory tract infections, which can afflict an otherwise healthy individual countless times. The fact that urinary tract infections are hard to elicit in experimental animals except with inoculum 3-5 orders of magnitude greater than the colony counts that define an acute urinary infection in humans (105 cfu/ml), also speaks to the robustness of the urinary tract defense. How can the urinary tract be so effective in fending off harmful microbes despite its orifice in a close vicinity to that of the microbe-laden gastrointestinal tract? While a complete picture is still evolving, the general consensus is that the anatomical and physiological integrity of the urinary tract is of paramount importance in maintaining a healthy urinary tract. When this integrity is breached, however, the urinary tract can be at a heightened risk or even recurrent episodes of microbial infections. In fact, recurrent urinary tract infections are a significant cause of morbidity and time lost from work and a major challenge to manage clinically. Additionally, infections of the upper urinary tract often require hospitalization and prolonged antibiotic therapy. In this chapter, we provide an overview of the basic anatomy and physiology of the urinary tract with an emphasis on their specific roles in host defense. We also highlight the important structural and functional abnormalities that predispose the urinary tract to microbial infections.
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Affiliation(s)
- Duane R Hickling
- Division of Urology, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1Y 4E9, Canada
| | - Tung-Tien Sun
- Departments of Cell Biology, Biochemistry and Molecular Pharmacology, Departments of Dermatology and Urology, New York University School of Medicine, New York, NY, 10016
| | - Xue-Ru Wu
- Departments of Urology and Pathology, New York University School of Medicine, New York, NY, 10016
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Koraishy FM, Ngo TTT, Israel GM, Dahl NK. CT urography for the diagnosis of medullary sponge kidney. Am J Nephrol 2014; 39:165-70. [PMID: 24531190 DOI: 10.1159/000358496] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 01/02/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Medullary sponge kidney (MSK) is characterized by malformation of the terminal collecting ducts and is associated with an increased risk of nephrolithiasis, nephrocalcinosis, urinary tract infections, renal acidification defects, and reduced bone density. It has been historically diagnosed with intravenous pyelography (IVP), which is falling out of favor as an imaging modality. CT urography (CTU) performed with multidetector CT (MDCT) has been shown to create images of the renal collecting system with similar detail as IVP; however, its utility in diagnosing MSK has not been defined. CASE REPORT We present the first 15 patients with recurrent symptomatic nephrolithiasis who were evaluated in our renal stone clinic with CTU. Four patients were diagnosed with MSK after visualization of the characteristic radiologic findings. DISCUSSION CTU effectively demonstrates the characteristic radiologic findings of MSK including collecting tubule dilatation, medullary nephrocalcinosis, nephrolithiasis, and medullary cysts. Dose reduction protocols can reduce radiation exposure below that associated with conventional IVP. We propose CTU be considered for the diagnosis of MSK.
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Affiliation(s)
- Farrukh M Koraishy
- Section of Nephrology, Yale University School of Medicine, New Haven, Conn., USA
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Fabris A, Anglani F, Lupo A, Gambaro G. Medullary sponge kidney: state of the art. Nephrol Dial Transplant 2012; 28:1111-9. [PMID: 23229933 DOI: 10.1093/ndt/gfs505] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Medullary sponge kidney (MSK) is a kidney malformation that generally manifests with nephrocalcinosis and recurrent renal stones; other signs may be renal acidification and concentration defects, and pre-calyceal duct ectasias. MSK is generally considered a sporadic disorder, but an apparently autosomal dominant inheritance has also been observed. As MSK reveals abnormalities in both the lower and the upper nephron and is often associated with urinary tract developmental anomalies, its pathogenesis should probably be sought in one of the numerous steps characterizing renal morphogenesis. Given the key role of the GDNF-RET interaction in kidney and urinary tract development and nephrogenesis, anomalies in these molecules are reasonable candidates for explaining a disorder such as MSK. As a matter of fact, we detected two, hitherto unknown, rare variants of the GDNF gene in MSK patients. We surmise that a defective distal acidification has a central role in MSK and is followed by a chain of events including defective bone mineralization, hypercalciuria, hypocitraturia and stone formation.
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Affiliation(s)
- Antonia Fabris
- Division of Nephrology, Department of Medicine, University Hospital of Verona, Verona, Italy
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Hida T, Nishie A, Asayama Y, Ishigami K, Fujita N, Inokuchi J, Naito S, Ando S, Honda H. MR imaging of focal medullary sponge kidney: case report. Magn Reson Med Sci 2012; 11:65-9. [PMID: 22450389 DOI: 10.2463/mrms.11.65] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
We present a case of focal medullary sponge kidney (MSK) that mimicked a renal tumor. Evaluation of a patient with history of macrohematuria revealed a left renal mass of 3-cm diameter. T(1)-weighted magnetic resonance (MR) images revealed a mass of mixed intensity protruding toward the renal sinus. On fat-saturated T(2)-weighted MR images, the lesion's remarkable hyperintensity suggested the presence of an aggregation of tiny cysts. On diffusion-weighted MR images, the mass also demonstrated high intensity, and its apparent diffusion coefficient was partly decreased (1.12 × 10(-3) mm(2)/s). On computed tomography, precontrast images revealed no calcification in the mass. Although slight enhancement was seen in the corticomedullary phase, thick and dense streaks of contrast radiating peripherally were identified in the mass in the excretory phase. Focal MSK was diagnosed. We discuss the potential of MR imaging for diagnosing focal MSK.
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Affiliation(s)
- Tomoyuki Hida
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Composition and morphology of phosphate stones and their relation with etiology. ACTA ACUST UNITED AC 2010; 38:459-67. [DOI: 10.1007/s00240-010-0320-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 09/29/2010] [Indexed: 11/25/2022]
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Maw AM, Megibow AJ, Grasso M, Goldfarb DS. Diagnosis of Medullary Sponge Kidney by Computed Tomographic Urography. Am J Kidney Dis 2007; 50:146-50. [PMID: 17591535 DOI: 10.1053/j.ajkd.2007.03.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2006] [Accepted: 03/27/2007] [Indexed: 11/11/2022]
Abstract
The diagnosis of medullary sponge kidney traditionally was established by means of intravenous pyelography. Beginning in the mid-1990s, intravenous pyelography rapidly was supplanted by computed axial tomography as the preferred imaging study for evaluating patients with renal stone disease. Conventional computed tomographic imaging has not been satisfactory for diagnosing medullary sponge kidney. The introduction of multidetector-row computed tomography in 1999 allowed radiologists to acquire images composed of elements allowing the creation of high-resolution 3-dimensional displays. Computed tomographic urography is an imaging technique that provides both cross-sectional displays and images of the contrast-filled renal collecting systems, ureters, and urinary bladder that are the equivalent of intravenous pyelography. We report a case of medullary sponge kidney diagnosed by means of 3-dimensional multidetector-row computed tomographic urography.
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Affiliation(s)
- Anna M Maw
- New York University School of Medicine, New York, NY, USA
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Cheidde L, Ajzen SA, Tamer Langen CH, Christophalo D, Heilberg IP. A critical appraisal of the radiological evaluation of nephrocalcinosis. Nephron Clin Pract 2007; 106:c119-24. [PMID: 17522474 DOI: 10.1159/000102999] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2006] [Accepted: 02/14/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM The level of agreement concerning the diagnosis of nephrocalcinosis (NC) based on ultrasonography (US), computed tomography (CT) or kidney/ureter/bladder (KUB) X-ray was assessed. METHODS Sequences of KUB+US+CT from 62 patients, 48 with at least one exam suggesting NC and 14 with pelvicalyceal calcifications (nephrolithiasis) were reviewed twice by 3 radiologists (firstly randomized and secondly presenting KUB+US+CT of each patient together). RESULTS The intraobserver concordance varied from 76 to 90% for KUB, 77 to 85% for US and 82 to 89% for CT. There was a significant change in diagnosis between the 1st and 2nd reviews for observer 1 in KUB and CT, for observer 2 in US, but not for observer 3. Evaluating patients' exams together did not provide a better agreement. The highest sensitivity and specificity (92 and 89%, respectively) were only attained when 2 exams suggested NC diagnosis, being CT one of them. These enabled us to suggest that 33 out of 48 (62.5%) patients had NC (evidenced in US+CT+KUB (81.8%), US+CT (12.1%) or KUB+CT (6.1%). CONCLUSION The low level of concordance renders the radiological diagnosis of NC difficult. Nephrocalcinosis should be confirmed by CT combined with either US or KUB.
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Affiliation(s)
- Lara Cheidde
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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Gambaro G, Feltrin GP, Lupo A, Bonfante L, D'Angelo A, Antonello A. Medullary sponge kidney (Lenarduzzi–Cacchi–Ricci disease): A Padua Medical School discovery in the 1930s. Kidney Int 2006; 69:663-70. [PMID: 16395272 DOI: 10.1038/sj.ki.5000035] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The introduction of radiological contrast media and intravenous (i.v.) urography in clinical diagnostics in the 1930s enabled the discovery of several diseases, including the medullary sponge kidney (MSK). MSK is a renal malformation characterized by cystic anomalies of precalyceal ducts, which is frequently associated with nephrocalcinosis and renal stones. Although it was first recognized by G Lenarduzzi in 1939, its thorough description was the result of the ante litteram multidisciplinary cooperation between a radiologist (Lenarduzzi), a urologist (Cacchi), and a pathologist (Ricci), all at the Padua University Hospital. These authors 'established' the paradigm for its diagnosis that is still used today. I.v. urography is the gold standard for the diagnosis of MSK, but as the technique is used less and less, there is a concrete possibility of this renal condition being forgotten in the future. Although the pathogenesis of MSK has yet to be elucidated, its association with different malformative conditions supports the idea that it is a developmental disorder. Recent findings suggest that MSK may be the consequence of a disruption of the ureteral-bud/metanephric-blastema interface.
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Affiliation(s)
- G Gambaro
- Division of Nephrology, Department of Biomedical and Surgical Sciences, University Hospital of Verona, Verona, Italy.
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Torres VE, Wilson DM, Hattery RR, Segura JW. Renal stone disease in autosomal dominant polycystic kidney disease. Am J Kidney Dis 1993; 22:513-9. [PMID: 8213789 DOI: 10.1016/s0272-6386(12)80922-x] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Nephrolithiasis is an important manifestation of autosomal dominant polycystic kidney disease (ADPKD), which occurs in approximately 20% of patients. It should always enter the differential diagnosis of flank pain in patients with ADPKD. The diagnosis is hindered by the distorted anatomy of the polycystic kidneys and the frequent occurrence of parenchymal and cyst wall calcifications, and requires demonstration of the relationship to the collecting system by intravenous urography and/or computed tomography. Computed tomography is the most sensitive imaging technique for detection of stones or calcifications, whereas intravenous urography is the most sensitive for visualization of the intrarenal collecting system. Precaliceal tubular ectasia can be detected in 15% of patients with ADPKD and nephrolithiasis, but this association may not be specific to ADPKD. The composition of the stones is most frequently uric acid and/or calcium oxalate. Metabolic factors are important in their pathogenesis. Distal acidification defects may be important in a few patients, while an abnormal transport of ammonium, low urine pH, and hypocitruria are the most common abnormalities. The treatment of nephrolithiasis in patients with ADPKD is not different from that in patients without ADPKD. Extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy in patients with early disease and normal renal function are not contraindicated.
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Affiliation(s)
- V E Torres
- Division of Nephrology and Internal Medicine, Mayo Clinic, Rochester, MN 55905
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