Complications of polycystic kidney disease

Computed Tomographic Findings in Unsuspected Aortic Dissection and Adult Polycystic Kidney Disease

The coexistence of adult polycystic kidney disease and aortic dissection should be recognized by forensic pathologists and radiologists. Two cases with postmortem computed tomography prior to autopsy illustrate the appearance of polycystic kidneys and the hemorrhage patterns that provide clues to the presence and approximate location of the aortic dissections. Optimal imaging technique is discussed.

Intraoperative pathology consultation for kidney and urinary bladder specimens

CONTEXT

Intraoperative pathology consultation for kidney and urinary bladder specimens is relatively infrequent. Scant literature is devoted to this topic.

OBJECTIVE

The clinical indications and diagnostic usefulness and pitfalls of intraoperative pathology consultation of kidney and urinary bladder specimens will be reviewed, based on literature and personally encountered cases.

DATA SOURCES

The indications for intraoperative pathology consultation for renal lesions included (1) surgical margins in partial nephrectomy specimens, (2) solid renal mass in unusual clinical or radiologic settings, (3) synchronous renal and extrarenal masses, (4) cystic renal lesions, (5) ureteral surgical margin for transitional cell carcinoma, (6) multiple renal masses, (7) solid mass in a diffusely cystic kidney, and (8) evaluation of renal injury. The indications for urinary bladder included (1) status of the surgical margins, (2) diagnosis of bladder tumor biopsy, (3) diagnosis of extravesical tumors with vesical extension, (4) diagnosis of extravesical mass, including pelvic lymph nodes encountered during cystectomy, and (5) status of bladder neck margin during radical prostatectomy for cancer. The frequent problematic areas for the kidney included misdiagnosis or incorrect classification of cystic tumors or spindle cell tumors, and confusion of clear cell renal cell carcinoma with inflammatory lesions. The problematic areas for urinary bladder included the differential diagnoses of high-grade dysplasia/carcinoma in situ with reactive changes at the ureteral or urethral surgical margins.

CONCLUSIONS

Distinctive indications and diagnostic pitfalls are recognized for intraoperative consultation of renal or urinary bladder lesions. Awareness of the pertinent problems should improve diagnostic accuracy and facilitate the proper management of these lesions.

Recurrence of intracranial aneurysms in autosomal-dominant polycystic kidney disease

BACKGROUND

The natural history of intracranial aneurysms (ICAs) in individuals with autosomal-dominant polycystic kidney disease (ADPKD) is poorly defined.

METHODS

We followed twenty ADPKD subjects, eleven with ruptured and nine with intact ICA, for 15.2 +/- 8.1 years (range, 6.0 to 33.2 years). Initial diagnosis was by four-vessel cerebral angiography in eighteen subjects. Follow-up examinations were four-vessel cerebral angiography in fourteen and magnetic resonance angiography (MRA) in six subjects. We examined the occurrence of new ICAs, an increase in size of existing ICAs, recurrent rupture or surgical intervention, and death.

RESULTS

Age at initial diagnosis of ICA was 37.7 +/- 10.4 years (range, 20.2 to 53.1 years). Seventeen subjects (85%) had an anterior and three (15%) had a posterior ICA at initial diagnosis. On restudy, five subjects (25%) had a significant change, consisting of new ICAs in a different location in all five and an increase in size of an existing ICA in two of the five. All subjects with ruptured ICA and one subject with intact ICA had undergone surgery at the time of initial diagnosis. Ten subjects (50%) underwent further surgery 8.1 +/- 6.1 years later (1.3 to 17 years). No subject died during follow-up and one subject experienced a recurrent RICA (RICA). We were unable to identify risk factors associated with development of a new ICA or increase in size of an existing ICA.

CONCLUSION

Individuals with ADPKD and ICA appear to be at moderate risk for new ICAs and increase in size of existing ICAs; mortality and risk of recurrent rupture, however, appear to be low.

Familial clustering of ruptured intracranial aneurysms in autosomal dominant polycystic kidney disease

Ruptured intracranial aneurysm (RICA) is a life-threatening complication of autosomal dominant polycystic kidney disease (ADPKD). A family history of RICA may be a risk factor for RICA. Six hundred eight adult members of 199 ADPKD families were interviewed, and family pedigrees were constructed. Individuals were classified as having definite, probable, or possible RICAs from evidence and history obtained in interviews. Central nervous system (CNS) events not consistent with RICA were classified as other CNS events. Seventy-seven CNS events occurred in 906 subjects with ADPKD (8.5%) versus 13 events in 823 subjects without ADPKD (1.6%; P < 0.0001). No event in subjects without ADPKD was consistent with an RICA. Twenty-seven other (non-RICA) CNS events occurred in subjects with ADPKD (3%) versus 13 events in subjects without ADPKD (1.6%; P = 0.05). The frequency of RICA was increased in subjects with ADPKD: 21 definite RICAs in subjects with ADPKD (2%) versus none in subjects without ADPKD (P < 0.001); 28 definite and probable RICAs in subjects with ADPKD (3%) versus none in subjects without ADPKD (P < 0.001); and 50 definite, probable, and possible RICAs in subjects with ADPKD (5.5%) versus none in subjects without ADPKD (P < 0.001). The null hypothesis that RICAs are randomly distributed among subjects with ADPKD was tested for definite RICAs (n = 21), definite and probable RICAs (n = 28), and definite, probable, and possible RICAs (n = 50). In the three categories, the null hypothesis was rejected at P less than 0.05, P less than 0.05, and P less than 0.005, respectively. Vascular CNS events occurred more frequently in ADPKD than non-ADPKD family members, and clustering of RICAs occurred in families with ADPKD.

Traumatic Hematuria in Patients with Polycystic Kidney Disease

Autosomal dominant polycystic kidney disease (PKD) is the most prevalent hereditary disorder in this country and a common cause of chronic renal failure. Patients frequently present with hematuria as the initial manifestation of PKD. We describe a patient with gross hematuria after blunt trauma who was found to have previously undiagnosed PKD. We review present diagnostic and treatment modalities and suggest potential management strategies for surgeons caring for patients presenting with traumatic hematuria and PKD.