Unilateral cysts as an incidental finding (14)

A 79 year old gentleman had an abdominal ultrasound scan due to the incidental finding of abnormal LFTS.  This was reported to show slightly increased echogenicity of the liver in keeping with fatty infiltration.  He was also noted to have small, simple cortical cysts, with the largest measuring 36mm by 31mm, in his left kidney.  The visualised pancreas, aorta, right kidney, gall bladder and biliary tree all appeared normal and the spleen measured 9.8 cm, which was also normal.

The reason I write is to establish whether any further action is required regarding his cysts in his left kidney or whether in fact they can be ignored as they are not causing him any symptoms at present and should be viewed as an incidental finding only?

 What further information would you seek before giving your opinion?

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Results of investigations are as follows;

 Blood – Urea 7 / Creatinine 102 / eGFR >60 / Electrolytes within normal ranges

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This should be viewed as an incidental finding and you can essentially just ignore the result.  It is not an uncommon finding and not expected to give rise to any symptoms or indicate an adverse renal prognosis.  Of note, complex cysts can indicate malignancy but this is not what is being described here.


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Incidental finding of abnormal renal ultrasound (13)

A 47 year old man recently had an ultrasound scan, and the report stated: right kidney could not be identified in the renal bed or right pelvic region. Left kidney =16.6cm, presumably due to compensatory hypertrophy. The left kidney appears normal in echopattern with no hydronephrosis or renal calculi. 

He is not aware of having had his kidney removed. The scan was requested as he had a dull ache in both renal angles and abdominal bloating.  He still gets a dull ache over his right loin a couple of times per week, lasting a few hours.  He does not need to take analgesia for this discomfort.  No aggravating factors.  He wonders himself if he could have pulled a muscle as he works delivering food.  He sometimes feels pulling in right groin when he bends forward.

Does he need any kind of follow up with regards to having 1 kidney, such as regular blood tests to check his kidney function?

 What further information would you seek before giving your opinion?

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Results of investigations are as follows;

Bloods: FBC and U+Es normal

 BP: 148/87

We discussed lifestyle advice regarding his blood pressure, as he is not keen to start medication.  I have arranged to repeat the blood pressure reading in 2 months and if still elevated commence him on amlodipine.

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This man just needs sensible attention to general healthcare and cardiovascular risk.

Single kidneys are common and, as in this case, the opposite one compensates for the loss of the other.  He will almost undoubtedly do well but probably should know that anything else that comes along in the next few decades that injures kidneys e.g. worsening hypertension, diabetes, NSAIDS,etc should probably be looked at with care and attention.

I would treat his hypertension as you are doing and repeat his bloods perhaps yearly as you might do for anyone with hypertension.


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Drop in GFR in Alcohol Dependence (8)

This 78 year old man has a medical history complicated by previous alcoholic dependence, alcoholic cardiomyopathy, recurrent bouts of atrial fibrillation and flutter.  He also suffers from hypertension, Vit.B12 deficiency and hypothyroidism.

Up to now his kidney function has remained quite stable with his last normal blood result in 8 months ago. On routine kidney screening last month there was a marked deterioration in his kidney function with eGFR dropping to 39 and ACR 7.5.  There was no obvious cause for this but the patient did admit to drinking most of a bottle of wine per day and described slight dehydration and mild metallic taste in his mouth.

On discussion he agreed to cut alcohol out, drink more fluids, and we stopped his Bendroflumethiazide and reduced his Enalapril to 10mgs. Repeat U&E shows little change in his function and I would appreciate your advice as to his further assessment.

I am unsure whether he needs referral to yourselves in view of his sudden deterioration without obvious cause, or whether it would be worthwhile monitoring this further and arranging an USS in the community?

What further information would you seek before giving your opinion?

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Current medication; Bendroflumethiazide, Folic acid, Atorvastatin, Amiodarone, Levothyroxine, Enalapril, Hydroxocobalamin, Paracetamol.

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It’s a little bit difficult to know with this one; he’s complicated with quite a few things going on. In the first instance, I’d give him time. If he was dehydrated on a full dose of enalapril plus a diuretic he may have some tubular necrosis that may take time to heal; he may also have done some irreversible damage.

I don’t think there’s anything else to do at the moment. I’d be tempted to maximise his enalapril back up again if reducing it hasn’t had any effect – he needs it for his cardiomyopathy. Repeat his bloods in another month or so – if better, great, and if stable, then he’s got enough renal function to survive on. If he’s worse then perhaps we should see him, given everything that’s going on with him.

I wouldn’t rush to scan unless you’ve get any other reason to – haematuria, suprapubic mass, urinary symptoms etc; we do many scans and get back little in the way of positive results. If he’s worse again then that becomes more important.


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Anaemia in CKD (11)

This fairly fit 83 year old lady with a history of hypertension usually has an eGFR around 40.  She is on lisinopril 10mg and furosemide 40mg (best tolerated combination, bendroflumethiazide did not have any effect on blood pressure) and her BP is well controlled on this combination at around 130/68 at her latest visit.

For several months she has had a haemoglobin of around 106 g/l.  Her haematinics and blood indices are otherwise normal apart from a slightly low haematocrit of 0.32.

Is an eGFR of around 40 low enough to cause renal anaemia?  She is only a little tired, are we best just to monitor things?  Should I be looking for another cause for her anaemia?

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That haemoglobin is a little low for that eGFR, but it may be that you find no other cause. There is a big range of Hb values at any eGFR, including at end stage.

It is unusual to drop below 100g/l until eGFR is substantially less than 30, but she isn’t below 100. This level of renal impairment could be compounding another cause and look for deficiencies of haematinics and check a CRP as an indicator of inflammation.

Interestingly ACEi do worsen renal anaemia slightly. However the effect isn’t huge, if this is the best combination for her, she might prefer to tolerate the slightly lower Hb.  Her current level of Hb is above the level at which guidelines would recommend commencing EPO therapy.


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