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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
6.9 Renal Insufficiency and Acute Renal Failure
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Heart Failure with Low-Output Syndrome (Figs. 169–171)
..............................................................................................................
n
See also Shock Kidney, p. 136; Ascites, Right Heart Failure, p. 160; Edema, Left
Heart Failure, p. 119; Hepatosplenomegaly, Cardiac Inflow Stasis, p. 149.
n
Note: The effects of cardiac failure are twofold: a decreased arterial supply to the
organs (with a potential for anuria) and reflux leading to the venous engorgement
of organs (resulting in pleural effusion and eventual ascites). The organic changes
can be detected sonographically.
ab
Fig. 169a, b Sonographic renal changes in low-output syndrome.
a Hypoechoic right kidney with a thickened parenchymal rim. The patient
presented clinically with acute anuria, an empty bladder, and mildly elevated
creatinine. b The renal vein (RV) is congested. Renal vein thrombosis was excluded
by duplex sonography
ab
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
Fig. 170a, b Sonographic liver changes in low-output syndrome.
a Diffusely hypoechoic liver with obstructed hepatic veins. The patient
presented clinically with extremely high transaminase levels. L = right lobe of liver,
RHV = right hepatic vein. b Posterior to the liver (L) is the strongly congested
vena cava (cursors), which is dilated to 2.6 cm
127
6.9 Renal Insufficiency and Acute Renal Failure
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
ab
Fig. 171a, b Pericardial effusion (PE) impairs ventricular filling, causing a global
reduction of cardiac output. a Echogenic bolus-like mass in the pericardial sac
(cursors) is consistent with hemopericardium. The heart shows very little ventricular filling with prominent atria and tricuspid valve regurgitation. LA = left atrium,
Principal Signs and Symptoms
Principal Signs and Symptoms
RA = right atrium, LV = left ventricle, RV = right ventricle. b Echogenic pericardial
effusion (cursors: 2.76 cm). The patient presented clinically with impending ventricular tamponade in a setting of myocardial infarction with pericarditis
Kimmelstiel–Wilson Glomerulosclerosis
..............................................................................................................
n
See also Kidney, Diabetic Nephropathy, p. 269, 270.
n
Clinical manifestations: long-standing diabetes mellitus, hypertension. The
disease eventually progresses to terminal renal failure requiring dialysis.
n
Diagnosis:
x
Laboratory tests: 24 hour urine, measurement of total protein excretion;
increased solute retention (creatinine, urea)
x
Sonography
x
Percutaneous biopsy: rarely necessary (histology: diffuse, exudative and nodular changes; in end-stage glomerulosclerosis, the underlying disease can no
longer be determined histologically)
n
Sonographic findings : bilateral changes:
x
Initially, hyperfiltration with enlarged kidneys
x
With progression, signs of chronic glomerulonephritis:
– Echogenic parenchyma
– Prominent hypoechoic medullary pyramids
– Loss of parenchyma
x
Possible signs of chronic pyelonephritis:
– Scars (echogenic parenchymal retraction)
– Abscesses
– Papillary necrosis
– Papillary calcifications
n
Accuracy of sonographic diagnosis: Under favorable scanning conditions,
the sonographic signs are conclusive. When the underlying diabetes is known,
the diagnosis can be established by ultrasound and no further tests are needed.
Generally there is no need for renal biopsy.
Chronic Glomerulonephritis
..............................................................................................................
n
See also Kidney, p. 270.
n
Clinical manifestations: insidious onset with peripheral edema, followed later by
hypertension and impaired renal function
128
6.9 Renal Insufficiency and Acute Renal Failure
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
n
Diagnosis:
x
Urinalysis. 24 hour urine collection: nonselective proteinuria, microhematuria,
possible erythrocyturia, possible red-cell and white-cell casts (which confirm
glomerular disease), also hyaline and granular cysts
x
Laboratory findings : dysproteinuria, hyperlipidemia
x
Sonography with follow-up
x
Renal biopsy: histologic detection and differentiation (histology shows leukocytic infiltration, hyaline deposition, sclerosis, fibrosis, and tubular atrophy).
Renal biopsy is unnecessary when overall findings suggest a minimal lesion
(good general health, normal filtration rate, acellular urinary sediment, normal
blood pressure).
n
Sonographic findings: The sonographic findings are uniform, regardless of the
cause of the glomerulonephritis. The end stage cannot be differentiated even by
histologic examination. Sonographic findings may remain essentially normal for
some time (at least with regard to renal size), and sonographic abnormalities
are found only with the onset of renal failure and significantly elevated creatinine
levels (look for subtle changes).
x
Diffuse increase in echogenicity
x
Loss of corticomedullary differentiation
x
Prominent hypoechoic medullary pyramids
x
Bilateral small kidneys with a homogeneous echo pattern
n
Accuracy of sonographic diagnosis: The sonographic findings in later stages are
unequivocal, but the cause cannot be determined.
Antiglomerular Basement Membrane Disease
..............................................................................................................
n
Clinical manifestations: hemoptysis in cases with pulmonary involvement and
consolidation; microcytic anemia; progressive renal failure
n
Diagnosis:
x
History and physical examination, including inspection of the pharynx
x
Urinalysis: erythrocyturia and proteinuria
x
Chest radiograph: specific changes
x
Antibody detection: detection of antiglomerular basement membrane antibodies in the blood (even in emergency cases); renal biopsy for detection of antiglomerular basement membrane antibodies by fluorescent microscopy. (In
Wegener granulomatosis, by contrast, antineutrophilic cytoplasmic antibodies
[C-ANCA] are positive in only 88 % of patients with active disease, and in up
to 44 % of patients during the remission phase.)
n
Sonographic findings :
x
Enlarged, rounded kidney
x
Ill-defined medullary pyramids
x
Nonhomogeneous, echogenic parenchymal pattern
n
Accuracy of sonographic diagnosis: The signs of acute renal failure are easily
recognized with ultrasound, but their cause cannot be determined. An etiologic
diagnosis requires additional tests (so that the patient can be referred as soon
as possible for antibody elimination therapy such as plasmapheresis).
Renal Artery Embolism (Figs. 172–174)
..............................................................................................................
n
See also Upper Abdominal Pain, Renal Infarction, p. 73; Kidney, Renal atrophy due
to vascular occlusive disease, p. 270; Vascular Scars, p. 280.
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
129
6.9 Renal Insufficiency and Acute Renal Failure
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
ab
Fig. 172a, b Exclusion of renal artery
embolism. a Transverse scan of the kid-
Principal Signs and Symptoms
Principal Signs and Symptoms
ney. Doppler demonstrates normal flow
in the renal artery as it enters the renal
hilum. b Longitudinal scan of the kidney.
Doppler signals from the segmental
arteries also show no evidence of renal
artery embolism
Fig. 173 Normal flow pattern in the
proximal right renal artery
n
Occurrence: Renal artery embolism is probably not an extremely rare condition.
Etiologically, renal artery embolism due to cholesterol crystals should be considered in addition to cardiac arrhythmias (e.g., absolute arrhythmia in atrial fibrillation).
n
Sonographic diagnosis: CDS can advance the diagnosis. Ultrasound contrast
agents are helpful in defining the renal arteries and delineating the perfusion
defect in the renal tissue.
Chronic Pyelonephritis
..............................................................................................................
n
See also Kidney, p. 271.
n
Clinical manifestations: nycturia and other nonspecific micturition problems;
progressive renal insufficiency with lethargy, decreased exercise tolerance,
fatigue, anemia, and visual deterioration; hypertension. An acute exacerbation
of pyelonephritis is marked by local tenderness to pressure.
n
Diagnosis:
x
History: recurrent episodes of pyelonephritis, history of early childhood diseases, known voiding problems (e.g., previous bedwetting, ureterocele)
Fig. 174 Proximal stenosis of the left
renal artery (RA)
130
6.9 Renal Insufficiency and Acute Renal Failure
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
x
Urinalysis: bacteriuria; the causative organism should be identified and tested
for antibiotic sensitivity; leukocyturia with white-cell casts, proteinuria; creatinine clearance in 24 hour urine
x
Laboratory tests: CRP, simple blood count, electrolytes, creatinine, uric acid,
urea, glucose
x
Sonography
x
High-quality scans obviate the need for further tests such as CT, plain radiographs, or intravenous pyelography (IVP).
n
Sonographic findings :
x
Small kidney
x
Changes usually limited to one side
x
Circumscribed thinning and increased echogenicity of the parenchymal rim
x
Irregular renal surface with areas of scar retraction (differential diagnosis:
previous renal infarction, resection and nephrostomy, tuberculosis)
x
Calyceal cysts or ectasia
x
Frequent calcifications
x
End stage: Shrunken, atrophic kidney
n
Accuracy of sonographic diagnosis: Typical sonographic signs with circum-
scribed parenchymal changes provide a reasonably high degree of confidence.
Calyceal cysts confirm the diagnosis.
Hydronephrosis
..............................................................................................................
n
See also Urogenital Organs, Obstructive pyelocalyceal ectasia, p. 380, 382.
n
Clinical manifestations: possible flank tenderness, slowly progressive decline in
renal function.
n
Diagnosis:
x
History: Ask about underlying diseases that may be associated with outflow
obstruction, bladder dysfunction, or bladder atony.
x
Sonography
n
Sonographic findings :
x
Full urinary bladder in patients with bladder dysfunction
x
Obstructed ureter
x
Outflow obstruction may be detectable in the ureter, due to an intraluminal
stone or extrinsic compression by a tumor/metastasis or lymph node.
x
Dilated pyelocalyceal system
x
Displaced renal sinus
x
Loss of renal parenchyma
n
Accuracy of sonographic diagnosis: An obstruction can be detected sonographi-
cally with up to 98 % confidence, but the precise cause cannot always be determined.
Ureteral Obstruction (Fig. 175)
..............................................................................................................
n
See also Upper Abdominal Pain, Renal Colic, p. 65.
n
Clinical manifestations : colicky flank pain, oligo- or anuria. With an intermittent
obstruction, intermittent polyuria may occur. With a long-standing obstruction
and reflux, the loss of renal parenchyma leads to renal insufficiency with increased
solute retention.
n
Diagnosis:
x
Laboratory tests: complete blood count, creatinine, electrolytes, urea and uric
acid
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
131
6.9 Renal Insufficiency and Acute Renal Failure
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
x
Urinalysis: bacteriuria, leukocyturia (with infection), hematuria (with stone or
tumor), crystals
x
Sonography
x
The diagnostic workup may include IVP and CT
!
Caution: IVP should be used with caution in renal insufficiency.
n
Sonographic findings :
x
Ureteral dilatation or obstruction
x
Possible dilatation of the pyelocalyceal system
x
Degree of obstruction can be graded based on the extent of the changes
(see p. 382)
x
Intraluminal obstruction by a stone, pus, clot, or tumor
x
Extrinsic compression by a tumor, metastasis, retroperitoneal fibrosis (Ormond
disease), or malignant lymphoma
x
An empty bladder is seen only with bilateral obstruction (rare).
Principal Signs and Symptoms
Principal Signs and Symptoms
n
Accuracy of sonographic diagnosis: The sonographic diagnosis is very accurate
(almost 100 %) in cases where the renal collecting system has also become dilated
(necessary for renal insufficiency to occur). Frequently the cause of the obstruction
cannot be identified. Because the ureter is retroperitoneal, it is often difficult to
visualize and its course can be traced only when it is dilated. If a high ureteral
obstruction is suspected but the cause is not seen on ultrasound, the condition
may be confused with fibrolipomatosis or small peripelvic cysts.
ab
Fig. 175a, b Prostatic carcinoma in two planes. The prostate (P) has an irregular
shape and a nonhomogeneous internal echo pattern. It has indented the bladder
(B), leading to outflow obstruction and the collection of sludge (arrows). The ureter
(U) is compressed and obstructed
Pyonephrosis (Fig. 176)
..............................................................................................................
n
See also Kidney, Chronic pyelonephritis, p. 271; Infected obstruction, p. 286.
n
Clinical manifestations: long history of lethargy, urinary tract infection, and fever.
The systemic manifestations are usually severe, ranging to sepsis.
n
Diagnosis:
x
Laboratory tests: blood chemistry, ESR; bacteriologic testing of urinary sediment; identify the causal organism and determine its antibiotic sensitivity
x
Sonography
x
Ultrasound-guided aspiration and drainage of the pus; necessary when outflow
obstruction is present
132
6.9 Renal Insufficiency and Acute Renal Failure
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
Fig. 176a, b Pyonephrosis: relatively hypoechoic renal parenchyma (K). The renal
pelvis is splayed open, and the renal collecting system (arrows in right image) is
dilated into the proximal ureter (arrows in left image) and filled with high-level
echoes (pus). a Transverse scan, b longitudinal scan. Clinical presentation: young
male with diabetes mellitus
n
Sonographic findings :
x
Dilated renal collecting system
x
Occasional high-level internal echoes representing pus or debris
n
Accuracy of sonographic diagnosis: Ultrasound suggests the correct diagnosis,
which can be established by percutaneous aspiration biopsy. The therapeutic
response and sonographic follow-ups also confirm the diagnosis.
Analgesic Nephropathy
..............................................................................................................
n
See also Kidney, p. 271.
n
Clinical manifestations: diffuse pattern of complaints with pain, mental abnorm-
alities, possible colicky abdominal pain (due to the passage of necrotic papillary
tips), and dysuria. Slowly progressive renal insufficiency usually establishes the
diagnosis. Pathogenic mechanism: analgesics compromise the blood supply to
the kidneys.
n
Diagnosis:
x
History: Most patients do not give a history of heavy analgesic use, partly
because they do not appreciate its significance. Careful questioning is essential
x
Urinalysis: mild proteinuria, microhematuria, sterile leukocyturia. Salt loss
i 30 mmol/day on a salt-free diet, renal tubular acidosis. Metabolites of phenacetin (paracetamol, N-acetyl-p-aminophenol) are detectable in the urine.
x
Blood chemistry: elevated creatinine level, anemia (due also to gastrointestinal
blood loss)
x
Sonography: May also be used to direct percutaneous biopsy
x
Exclude diabetic nephropathy, sickle cell anemia, renal tuberculosis, and acute
pyelonephritis.
n
Sonographic findings :
x
Poor delineation
x
Irregular increase in parenchymal echogenicity
x
Ringlike calcifications at the tips of the papillae
x
Secondary cysts
n
Note: The changes begin at the papillary tips and spread toward the cortex.
Papillary tip necrosis may also occur in chronic pyelonephritis, diabetes mellitus, sickle cell anemia, and obstructive uropathy.
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
133
6.9 Renal Insufficiency and Acute Renal Failure
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
n
Accuracy of sonographic diagnosis: The sonographic detection of papillary tip
necrosis makes a diagnosis of analgesic nephropathy very likely. A known history
of analgesic abuse is considered to establish the diagnosis.
Atrophic Kidney
..............................................................................................................
n
See also Renal Artery Embolism, p. 129; Kidney, Renal atrophy due to vascular
occlusive disease, p. 270.
n
Classification:
x
Unilateral: chronic pyelonephritis, renal artery stenosis, long-standing renal
vein thrombosis. The differential diagnosis includes hypoplastic kidney.
x
Bilateral: chronic glomerulonephritis, diabetic nephropathy, nephrosclerosis,
other systemic diseases; less commonly, bilateral chronic pyelonephritis
n
Clinical manifestations: end stage of chronic nephritis with renal insufficiency;
Principal Signs and Symptoms
Principal Signs and Symptoms
often rapid fatigability, poor exercise tolerance, dyspnea with pleural effusion
and edema, anemia. Dialysis is necessary in bilateral cases.
n
Diagnosis:
x
History
x
Laboratory tests: simple blood count; urine culture and urinary sediment,
24 hour urine, creatinine: and creatinine clearance
x
Sonography
n
Sonographic findings :
x
Disproportionately small kidneys. (When only one kidney is affected, there is
generally compensatory enlargement of the contralateral kidney.)
x
Parenchymal thinning
x
Increased parenchymal echogenicity
x
Poor organ delineation. Occasionally the kidney can be identified only by the
presence of cortical cysts (cystic degeneration of medullary pyramids or secondary retention cysts).
n
Accuracy of sonographic diagnosis: The diagnosis is considered to be established
if the kidney can be visualized and is disproportionately small. There is no need for
percutaneous biopsy because histologic confirmation is unnecessary in end-stage
disease.
Bladder Tamponade (Fig. 177)
..............................................................................................................
n
Clinical manifestations: anuria, possible lower abdominal pain and tenderness.
Colicky flank pain occurs in long-standing cases with stasis.
n
Diagnosis:
x
History and examination: palpable lower abdominal mass (distended bladder).
Ask about a precipitating event (renal biopsy, bladder aspiration, etc.).
Fig. 177 Bladder tamponade.
A layered, hypoechoic mass
(clotted blood) is visible within the
bladder lumen following the insertion
134
of a suprapubic catheter
6.9 Renal Insufficiency and Acute Renal Failure
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
x
Sonography: May also be used to direct percutaneous aspiration
x
Cystoscopy
n
Sonographic findings :
x
Full urinary bladder
x
Frequent high-level internal echoes from clotted blood (e.g., after bladder
aspiration, catheterism), debris, stone, or tumor
n
Accuracy of sonographic diagnosis: Bladder tamponade can be confidently diag-
nosed with ultrasound. Other tests are necessary only to investigate the cause.
Acute Glomerulonephritis
..............................................................................................................
n
See Edema, p. 119; and Kidney, p. 269.
Hepatorenal Syndrome (Fig. 178)
..............................................................................................................
n
Clinical manifestations: known hepatic cirrhosis, usually decompensated with
ascites and gastrointestinal bleeding; hypertension; progressive renal insufficiency ranging to anuria. May be precipitated by forced diuresis, percutaneous
aspiration of ascites, bleeding, sepsis, or potentially nephrotoxic drugs.
n
Diagnosis:
x
History and clinical findings : basic neurological staging examination (flapping
tremor, writing test, connect-the-numbers test)
x
Laboratory tests
x
Sonography
x
Esophagogastroduodenoscopy: esophageal varices, fundal varices
x
Reasons for impaired renal function are not found: urinalysis normal, IVP
normal (and therefore rarely necessary), negative renal biopsy (rarely done)
n
Sonographic findings :
x
Free fluid in the abdominal cavity (ascites)
x
Signs of hepatic cirrhosis (see Ascites, p. 155) or other causes of liver cell
destruction
x
Both kidneys show normal sonographic features.
n
Note: It is important to look for other renal diseases that are independent of the
liver disease.
n
Accuracy of sonographic diagnosis: The sonographic signs are clear-cut, and the
diagnosis is supported by the overall clinical presentation and course. The cause of
the syndrome is not precisely known but presumably relates to diminished blood
flow.
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
Fig. 178 Acute renal failure in
hepatorenal syndrome: hepatic cirrhosis
with echogenic areas of liver necrosis
and ascites. CDS shows predominantly
large-caliber arteries; hepatic veins are
not visualized
135
6.9 Renal Insufficiency and Acute Renal Failure
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
6
6
Shock Kidney (Fig. 179a)
..............................................................................................................
n
See also Kidney, Acute Renal Failure, p. 267.
n
Classification: Shock kidney is characterized by the development of renal failure
due to prerenal causes – traumatic, postoperative, or septic.
n
Clinical manifestations : oliguria, anemia, peripheral edema, hypertension, pul-
monary edema
n
Diagnosis:
x
History: may suggest the precipitating cause – volume deficit, cardiogenic
shock, sepsis, medications
x
Blood tests and urinalysis
x
Sonography
n
Sonographic findings :
x
Enlarged kidneys
Principal Signs and Symptoms
Principal Signs and Symptoms
x
Markedly hypoechoic parenchyma; distal acoustic shadowing enhancement
may occur (depending on the extent of edema)
x
Swollen medullary pyramids
x
Typically, the boundary between the renal pelvis and renal sinus is indistinct.
x
Renal sinus is compressed and narrowed as a result of parenchymal swelling.
n
Accuracy of sonographic diagnosis: The findings resemble the features of right
heart failure and renal congestion. Sonography can establish the diagnosis in conjunction with clinical findings.
ab
Fig. 179a,b a Acute prerenal renal failure in a patient with severe vomiting and
alcohol disease. The kidney (K) is markedly enlarged to a longitudinal diameter of
15 cm. The parenchyma is thickened and hypoechoic, with swollen medullary
pyramids. b Gouty nephropathy; small kidney with elevated echogenicity, swollen
pyramids and a secondary lyst (arrow)
Gouty Nephropathy (Fig. 179b)
..............................................................................................................
n
Occurrence, course:
x
Chronic hyperuricemia
x
Deposition of sodium urate in the pyelocalyceal system
x
Crystalization in the renal tubule and collecting duct
x
Inflammatory processes
x
Development of medullary fibrosis, with fibrosis of the papillary tips
n
Clinical manifestations: progressive signs of renal insufficiency, frequent hyper-
tension, frequent pyelonephritis
136