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111-490: Causes of chronic kidney disease include diabetes , high blood pressure , glomerulonephritis , and polycystic kidney disease . Risk factors include a family history of chronic kidney disease. Diagnosis is by blood tests to measure the estimated glomerular filtration rate (eGFR), and a urine test to measure albumin . Ultrasound or kidney biopsy may be performed to determine the underlying cause. Several severity-based staging systems are in use. Screening at-risk people

222-625: A CKDu referred to as the Mesoamerican nephropathy (MeN). It was estimated in 2013 that at least 20,000 men had died prematurely, some in their 20s and 30s; a figure of 40,000 per year was estimated in 2020. In some affected areas CKD mortality was five times the national rate. MeN primarily affects men working as sugarcane labourers. The cause is unknown, but in 2020 the science found a clearer connection between heavy labour in high temperatures and incidence of CKDu; improvements such as regular access to water, rest and shade, can significantly decrease

333-451: A Doppler signal, which are not obvious simple cysts on US and CT, should be further investigated with CEUS, as CEUS is more sensitive than both Doppler US and CT for the detection of hypovascular tumors. Other malignant tumors in the kidney are transitional cell carcinoma and squamous cell carcinoma, which arise from the urothelium and are found the renal sinus, as well as adenocarcinoma, lymphoma and metastases, which can be found anywhere in

444-405: A decrease in the delivery of sodium chloride to the macula densa in the distal tubules, promoting the release of renin and over-activating RAAS. Hyperfiltration is one of the earliest features of DN. Several mechanisms have been proposed to cause hyperfiltration. One of these mechanisms is that as glomeruli becomes hypertrophied, filtration surface area initially increases. Another possible mechanism

555-441: A distortion of the normal renal architecture. Most renal masses are simple cortical renal cysts with a round appearance and a smooth thin capsule encompassing anechoic fluid. The incidence increases with age, as at least 50% of people above the age of 50 have a simple cyst in one of the kidneys. Cysts cause posterior enhancement as a consequence of reduced attenuation of the ultrasound within the cyst fluid (Figure 5). The simple cyst

666-497: A gradual transition can help preserve remaining kidney function. More research is ongoing to improve CKD management and patient outcomes. Angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor antagonists (ARBs) are recommended as first-line agents since they have been found to slow the decline of kidney function, relative to a more rapid decline in those not on one of these agents. They have also been found to reduce

777-608: A high-flux membrane, hemodiafiltration and hemofiltration. However, conventional dialysis treatment is limited in its ability to remove protein-bound uremic toxins. CKD increases the risk of cardiovascular disease, and people with CKD often have other risk factors for heart disease, such as high blood lipids . The most common cause of death in people with CKD is cardiovascular disease rather than kidney failure. Chronic kidney disease results in worse all-cause mortality (the overall death rate) which increases as kidney function decreases. The leading cause of death in chronic kidney disease

888-437: A history of kidney disease in the past, and subjects who have relatives who had kidney disease requiring dialysis. Screening should include calculation of the estimated GFR (eGFR) from the serum creatinine level, and measurement of urine albumin-to-creatinine ratio (ACR) in a first-morning urine specimen (this reflects the amount of a protein called albumin in the urine), as well as a urine dipstick screen for hematuria. The GFR

999-418: A low-salt diet and the right amount of protein. Treatments for anemia and bone disease may also be required. Severe disease requires hemodialysis , peritoneal dialysis , or a kidney transplant for survival. Chronic kidney disease affected 753 million people globally in 2016 (417 million females and 336 million males.) In 2015, it caused 1.2 million deaths, up from 409,000 in 1990. The causes that contribute to

1110-490: A lower sensitivity and specificity than CT for the detection of kidney stones (urolithiasis), US, if available, is recommended as the initial imaging modality in patients with renal colic and suspected urolithiasis. US has no risk of radiation, is reproducible and inexpensive, and the outcome is not significantly different for patients with suspected urolithiasis undergoing initial US exam compared to patients undergoing initial CT exam. With US, larger stones (>5–7 mm) within

1221-762: A negative impact in CKD, increasing the risk of disease progression to ESKD or kidney failure compared to controls with healthy weight, and when in advanced stages also may hinder people's eligibility to kidney transplantation . For example, the consumption of high calorie and high fructose beverages can make an individual "60% more likely to develop CKD". Weight management interventions in overweight and obese adults with CKD include lifestyle inverventions (dietary changes, physical activity / exercise , or behavioural strategies), pharmacological (used to reduce absorption or suppress appetite ) and surgical interventions. Any of these can help people with CKD loose weight, however, it

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1332-486: A normal of over 90 ml/min/1.73m to less than 15, at which point the patient is said to have end-stage renal disease . It usually is slowly progressive over years. Pathophysiologic abnormalities in diabetic nephropathy usually begin with long-standing poorly controlled blood glucose levels. This is followed by multiple changes in the filtration units of the kidneys, the nephrons . (There are normally about 750,000–1.5 million nephrons in each adult kidney). Initially, there

1443-407: A positive effect on the progression of diabetic nephropathy are GLP-1 agonists and DPP-4 inhibitors. The success of diabetic nephropathy management depends greatly upon the ability of individuals to self-manage this condition, encompassing glycaemic control, and the adoption of healthy lifestyles. Appropriate self-management often requires patient education and behavioural counselling. However, there

1554-415: A reducing sugar (glucose in this case) reacts non-enzymatically with an amine group, predominantly lysine and arginine, which are attached on proteins, lipids and nucleic acids. These glycation products accumulate on the proteins of vessel wall collagen, forming an irreversible complex of cross-linked AGEs. An important way AGEs exert their effect is through a receptor-mediated mechanism, most importantly by

1665-553: A reference range may reinforce stereotypes and perpetuate health disparities. This approach fails to account for the complex interplay of genetic, environmental, and social factors influencing kidney function. Depending solely on race-based metrics may lead to misdiagnosis or underdiagnosis in minority populations. Alternative approaches that consider socioeconomic status, environmental exposures, and genetic vulnerability, are needed to accurately assess kidney function and address CKD care disparities. The International Society of Nephrology

1776-411: A sharp hollow needle, called a trocar. A round-tipped guidewire is then advanced through the lumen of the trocar, and after withdrawal of the trocar, a catheter or nephrostomy can be inserted over the guidewire to ensure correct placement. The one-step technique is when insertion of the drain or nephrostomy is done without the aid of a guidewire. The interventions are performed under local anesthesia and in

1887-439: A sterile setup. The procedures can be carried out with or without needle guidance according to preference, experience and setup (Figure 29). Contrast-enhanced ultrasound (CEUS) can evaluate microvasculature, which color Doppler US is unable to detect. In renal US examination, CEUS can be used to differentiate tumor and pseudotumor, such as prominent columns of Bertin. Pseudotumors enhance as adjacent renal tissue. The use of CEUS

1998-526: A substantial economic burden. The estimated cost of management of patients with ESRD due to diabetic nephropathy in the US is US$ 39.35 billion in 2010. Within developed countries, certain ethnic groups such as African Americans and Native Americans are at higher risk of developing diabetic nephropathy and ESRD. Renal ultrasonography Renal ultrasonography ( Renal US ) is the examination of one or both kidneys using medical ultrasound . Ultrasonography of

2109-525: A sudden increase in the serum creatinine (several days to weeks). In many people with CKD, previous kidney disease or other underlying diseases are already known. A significant number present with CKD of unknown cause. Screening those who have neither symptoms nor risk factors for CKD is not recommended. Those who should be screened include: those with hypertension or history of cardiovascular disease, those with diabetes or marked obesity, those aged > 60 years, subjects with African American ancestry, those with

2220-714: Is 5 to 10 years after the disease begins. A usual first symptom is frequent urination at night: nocturia . Other symptoms include tiredness , headaches , a general feeling of illness , nausea , vomiting , frequent daytime urination, lack of appetite , itchy skin , and leg swelling . The clinical presentation of diabetic nephropathy (DN) is characterized by proteinuria (protein in the urine), hypertension and progressive loss of kidney function. The process may be initially indolent, making regular screening for diabetic nephropathy in patients with diabetes mellitus of great importance. Not all patients with diabetes go on to develop diabetic nephropathy. The main risk factors that increase

2331-430: Is a benign lesion, which does not require further evaluation. Complex cysts can have membranes dividing the fluid-filled center with internal echoes, calcifications or irregular thickened walls. The complex cyst can be further evaluated with Doppler US, and for Bosniak classification and follow-up of complex cysts, either contrast-enhanced ultrasound (CEUS) or contrast CT is used (Figure 6). The Bosniak classification

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2442-403: Is a common complication from CKD. Children with CKD will be shorter than 97% of children the same age and sex. This can be treated with additional nutritional support, or medication such as growth hormone . Survival rates of CKD are generally longer with dialysis than without (having only conservative kidney management). However, from the age of 80 and in elderly patients with comorbidities there

2553-515: Is a protein that is freely filtered in the glomeruli before it is reabsorbed and catabolized in the renal tubular cells. Its serum level is independent of muscle mass, making more accurate at estimating GFR than creatinine serum levels. The goals of treatment are to slow the progression of kidney damage and control related complications. Management of diabetic nephropathy currently centers over four main areas: Cardiovascular risk reduction, glycemic control, blood pressure control as well as inhibition of

2664-486: Is a serious complication that affects approximately one quarter of adults with diabetes in the United States. Affected individuals with end-stage kidney disease often require hemodialysis and eventually kidney transplantation to replace the failed kidney function. Diabetic nephropathy is associated with an increased risk of death in general, particularly from cardiovascular disease . The onset of symptoms

2775-496: Is a serious condition often linked to diabetes and high blood pressure. There is no cure, but a combination of lifestyle changes and medications can help slow its progression. This might include a plant-dominant diet with less protein and salt, medications to control blood pressure and sugar, and potentially newer anti-inflammatory drugs. Doctors may also focus on managing heart disease risk, preventing infections, and avoiding further kidney damage. While dialysis may eventually be needed,

2886-633: Is an international body representing specialists in kidney diseases. It was said to be costing the National Health Service about £1.5 billion a year in 2020. Kidney Care UK and The UK National Kidney Federation represent people with chronic kidney disease. The Renal Association represents Kidney physicians and works closely with the National Service Framework for kidney disease. Kidney Health Australia serves that country. The incidence rate of CKD in dogs

2997-644: Is associated with von Hippel–Lindau disease, and with tuberous sclerosis, and US has been recommended as a tool for assessment and follow-up of renal masses in these patients. However, US is not the primary modality for the evaluation of solid tumors in the kidney, and CT is the first choice modality. Nevertheless, hemorrhagic cysts can resemble RCC on CT, but they are easily distinguished with Doppler ultrasonography. In RCCs, Doppler US often shows vessels with high velocities caused by neovascularization and arteriovenous shunting. Some RCCs are hypovascular and not distinguishable with Doppler US. Therefore, renal tumors without

3108-429: Is based on the measurement of abnormal levels of urinary albumin in an individual with diabetes coupled with exclusion of other causes of albuminuria. Albumin measurements are defined as follows: It is recommended that individuals with diabetes have their albumin levels checked annually, beginning immediately after a diagnosis of type 2 diabetes and five years after a diagnosis of type 1 diabetes. Medical imaging of

3219-419: Is cardiovascular disease, regardless of whether there is progression to stage 5. While kidney replacement therapies can maintain people indefinitely and prolong life, the quality of life is negatively affected. Kidney transplantation increases the survival of people with stage 5 CKD when compared to other options; however, it is associated with an increased short-term mortality due to complications of

3330-445: Is common and intensity of end-of-life care is highly variable among people opting out of dialysis. About one in ten people have chronic kidney disease. In Canada 1.9 to 2.3 million people were estimated to have CKD in 2008. CKD affected an estimated 16.8% of U.S. adults aged 20 years and older in the period from 1999 to 2004. In 2007 8.8% of the population of Great Britain and Northern Ireland had symptomatic CKD. Chronic kidney disease

3441-487: Is considered normal without chronic kidney disease if there is no kidney damage present. Kidney damage is defined signs of damage seen in blood, urine, or imaging studies which includes lab albumin/creatinine ratio (ACR) ≥ 30. All people with a GFR <60 mL/min/1.73 m for 3 months are defined as having chronic kidney disease. Protein in the urine is regarded as an independent marker for worsening of kidney function and cardiovascular disease. Hence, British guidelines append

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3552-504: Is constriction of the efferent arterioles and dilation of afferent arterioles , with resulting glomerular capillary hypertension and hyperfiltration particularly as nephrons become obsolescent and the adaption of hyperfiltration paradoxically causes further shear stress related damage to the delicate glomerular capillaries, further proteinuria, rising blood pressure and a vicious circle of additional nephron damage and decline in overall renal function. Concurrently, there are changes within

3663-450: Is derived from the serum creatinine and is proportional to 1/creatinine, i.e. it is a reciprocal relationship; the higher the creatinine, the lower the GFR. It reflects one aspect of kidney function, how efficiently the glomeruli – the filtering units – work. The normal GFR is 90–120 ml/min. The units of creatinine vary from country to country, but since the glomeruli make up <5% of the mass of

3774-459: Is divided into four groups going from I, corresponding to a simple cyst, to IV, corresponding to a cyst with solid parts and an 85–100% risk of malignancy. In polycystic kidney disease, multiple cysts of varying size in close contact with each other are seen filling virtually the entire renal region. In advanced stages of this disease, the kidneys are enlarged with a lack of corticomedullary differentiation (Figure 7). A solid renal mass appears in

3885-417: Is divided into the outermost cortex and the innermost and slightly less echogenic medullary pyramids. Between the pyramids are the cortical infoldings, called columns of Bertin (Figure 1). In the pediatric patient, it is easier to differentiate the hypoechoic medullar pyramids from the more echogenic peripheral zone of the cortex in the parenchyma rim, as well as the columns of Bertin (Figure 2). The length of

3996-474: Is easily performed, and US is often used as image guidance for renal interventions. Furthermore, novel applications in renal US have been introduced with contrast-enhanced ultrasound (CEUS), elastography and fusion imaging. However, renal US has certain limitations, and other modalities, such as CT and MRI, should always be considered as supplementary imaging modalities in the assessment of renal disease. The ultrasonic renal exam does not require any preparation of

4107-467: Is glomerular sclerosis, tubular atrophy, interstitial fibrosis, or inflammation, the result is often increased echogenicity of the cortex. The echogenicity of the kidney should be related to the echogenicity of either the liver or the spleen. Moreover, decreased kidney size and cortical thinning are also often seen and especially when disease progresses. However, kidney size correlates to height, and short persons tend to have small kidneys; thus, kidney size as

4218-407: Is made. One of the primary indications for referral to US evaluation of the kidneys is evaluation of the urinary collecting system. Enlargement of the urinary collecting system is usually related to urinary obstruction and can include the pelvis, the calyces and the ureter. Hydronephrosis is seen as an anechoic fluid-filled interconnected space with enhancement within the renal sinus, and normally,

4329-404: Is metabolized and cleared by the kidneys. This means that as kidney function worsens in the setting of DN, some patients with insulin-dependent DM may find that their regular insulin doses are lasting longer than normal, or that they are experiencing an increasing frequency of hypoglycemic episodes. It is also crucial to closely monitor kidney function to properly dose medications that are cleared by

4440-556: Is more than 30 mg/mmol, when blood pressure is difficult to control, or when hematuria or other findings suggest either a primarily glomerular disorder or secondary disease amenable to specific treatment. Other benefits of early nephrology referral include proper education regarding options for kidney replacement therapy as well as pre-emptive transplantation, and timely workup and placement of an arteriovenous fistula in those people with chronic kidney disease opting for future hemodialysis. At stage 5 CKD, kidney replacement therapy

4551-454: Is no difference in survival between the two groups. Quality of life might be better for people without dialysis. People who had decide against dialysis treatment when reaching end-stage chronic kidney disease could survive several years and experience improvements in their mental well-being in addition to sustained physical well-being and overall quality of life until late in their illness course. However, use of acute care services in these cases

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4662-674: Is not certain that protein supplements affect quality of life, life expectancy, inflammation or body composition . Intravenous (IV) iron therapy may help more than oral iron supplements in reaching target hemoglobin levels. However, allergic reactions may also be more likely following IV-iron therapy. People with CKD experience sleep disorders, thus unable to get quality sleep. There are several strategies that could help, such as relaxation techniques, exercise, and medication. Exercise may be helpful with sleep regulation and possibly decreases fatigue and depression in people with CKD. However, none of these options have been proven to be effective in

4773-865: Is not known if they can also prevent death or cardiovascular events like heart complications or stroke. It is recommended that weight management interventions should be individualised, according to a thorough patients' assessment regarding clinical condition, motivations and preferences. High dietary sodium intake may increase the risk of hypertension and cardiovascular disease. The effect of dietary restriction of salt in foods has been investigated in people with chronic kidney disease. For people with CKD, including those on dialysis, reduced salt intake may help to lower both systolic and diastolic blood pressure, as well as albuminuria . Some people may experience low blood pressure and associated symptoms, such as dizziness, with lower salt intake. The effect of salt restriction on extracellular fluid, oedema, and total body weight reduction

4884-414: Is not known. EHealth interventions may improve dietary sodium intake and fluid management for people with CKD. In people with CKD who require hemodialysis, there is a risk that vascular blockage due to clotting , may prevent dialysis therapy from being possible. Even though Omega-3 fatty acids contribute to the production of eicosanoid molecules that reduce clotting, it does not have any impact on

4995-492: Is often required. While lower socioeconomic status contributes to the number of people affected with CKD, differences in the number of people affected by CKD are still evident between Africans and Whites when controlling for environmental factors. Although CKDu was first documented among sugar cane workers in Costa Rica in the 1970s, it may well have affected plantation labourers since the introduction of sugar cane farming to

5106-446: Is preferred in renal traumas, but US is used for follow-up, especially in the patients suspected for the formation of urinomas (Figure 28). Sonography is the modality of choice for guidance when performing intervention in the kidney, whether it is kidney biopsy, percutaneous nephrostomy or abscess drainage. Historically, thermal ablation of renal tumors is performed under CT guidance, as the risk of injuring neighboring intestines during

5217-400: Is recommended in special cases to distinguish between cystic and hypovascularized solid lesions, to characterize complex cysts, abscesses, traumatic lesions and ischemic lesions. Solid malignant tumors in the kidney do not exhibit specific enhancement patterns like some liver lesions, and no valid enhancement criteria between benign and malignant renal lesions have been proposed. However, CEUS

5328-562: Is recommended. Initial treatments may include medications to lower blood pressure, blood sugar, and cholesterol. Angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor antagonists (ARBs) are generally first-line agents for blood pressure control, as they slow progression of the kidney disease and the risk of heart disease. Loop diuretics may be used to control edema and, if needed, to further lower blood pressure. NSAIDs should be avoided. Other recommended measures include staying active, and certain dietary changes such as

5439-426: Is seen as a thin linear structure. The kidney is divided into parenchyma and renal sinus. The renal sinus is hyperechoic and is composed of calyces, the renal pelvis, fat and the major intrarenal vessels. In the normal kidney, the urinary collecting system in the renal sinus is not visible, but it creates a heteroechoic appearance with the interposed fat and vessels. The parenchyma is more hypoechoic and homogenous and

5550-495: Is sodium glucose cotransporter 2 (SGLT2) inhibitors. The mechanism of action of this drug is to the sodium-glucose uptake cotransporter in the proximal tubule, thereby generating natriuresis and glucosuria. In multiple clinical trials, SGLT2 inhibitors showed improved cardiovascular outcomes in patients with DM as well a positive effect on kidney outcomes, mainly a reduction in albuminuria and progression of renal damage. Other classes of diabetic medications that have been shown to have

5661-497: Is still insufficient evidence to draw conclusions regarding the effects, regarding both benefits and harms, of educational programmes for people with diabetic nephropathy. Further high-quality studies are warranted. Diabetic nephropathy in type 2 diabetes can be more difficult to predict because the onset of diabetes is not usually well established. Without intervention, 20–40 percent of patients with type 2 diabetes/microalbuminuria, will evolve to macroalbuminuria. Diabetic nephropathy

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5772-400: Is that abnormal vascular control in diabetic nephropathy leads to a reduction in afferent glomerular arteriolar resistance and an increase in efferent glomerular arteriolar resistance, leading to a net increase in renal blood flow (RBF) and glomerular filtration rate (GFR). Glomerular hyperfiltration and an aberrant regulation of RAAS lead to increased intraglomerular pressure, causing stress on

5883-454: Is the most common cause of end-stage kidney disease , which may require hemodialysis or even kidney transplantation . It is associated with an increased risk of death in general, particularly from cardiovascular disease . Diabetic nephropathy affects approximately a third of patients with type 1 and type 2 diabetes mellitus. Diabetic nephropathy is responsible for about a third of cases of ESRD worldwide, and an even larger fraction in

5994-584: Is thus not recommended in most patients as it could increase the risk of hypoglycemic episodes. Blood pressure control: Multiple randomized clinical trials have demonstrated a benefit of decreasing systolic blood pressure to <140 mmHg in patients with diabetic nephropathy. High blood pressure is associated with accelerated development of microalbuminuria, over proteinuria and declining kidney function. Angiotensin-converting-enzyme inhibitors, as well as angiotensin II receptor blockers, are particularly helpful in patients with diabetes to lower blood pressure and slow

6105-496: Is used in some patients after ablation of renal cell carcinoma to evaluate contrast uptake in the treated area (Figure 30). Image fusion of ultrasound with a previously recorded dataset of CT or other modalities is rarely used in renal US. Reports on image fusion using CEUS or US combined with CT or MRI in the examination of renal lesions and in difficult US-guided renal interventions have been published (Figure 31). However, no recommendations have been published so far. Elastography

6216-418: Is usually required, in the form of either dialysis or a kidney transplant . In CKD numerous uremic toxins accumulate in the blood. Even when ESKD (largely synonymous with CKD5) is treated with dialysis, the toxin levels do not go back to normal as dialysis is not that efficient. Similarly, after a kidney transplant, the levels may not go back to normal as the transplanted kidney may not work 100%. If it does,

6327-444: Is with tobacco cessation, lipid-lowering therapies (e.g., statins) as well as regular exercise and healthy eating. In patients with kidney disease, atorvastatin is preferred over other statins as it does not require dose-adjustment based on GFR. Glycemic control: Multiple studies have found a positive effect of improved glycemic control on clinical outcomes of patients with diabetic nephropathy. Intensive glycemic control also reduces

6438-409: The arteriole exiting the glomerulus, thus reducing the blood pressure within the glomerular capillaries, may slow (but not stop) progression of the disease. Three classes of diabetes medications – GLP-1 agonists , DPP-4 inhibitors , and SGLT2 inhibitors – are also thought to slow the progression of diabetic nephropathy. Diabetic nephropathy is the most common cause of end-stage renal disease and

6549-1089: The Caribbean in the 1600s. In colonial times the death records of slaves on sugar plantations was much higher than for slaves forced into other labour. Denial of care in chronic kidney disease treatment and management is a significant issue for minority populations. This can be due to healthcare provider bias, structural barriers, and health insurance coverage disparities. Healthcare provider biases can lead to under-treatment, misdiagnosis, or delayed diagnosis. Structural barriers, such as lack of insurance and limited healthcare facilities, hinder access to timely care. Furthermore, health insurance coverage disparities, with minority populations lacking adequate coverage, contribute to these disparities. Denial of care worsens health outcomes and perpetuates existing health inequities. Race-based kidney function metrics, particularly normalizing creatinine, pose ethical challenges in diagnosing and managing chronic kidney disease (CKD). While certain racial and ethnic groups are at higher risk, using race as

6660-476: The RAAS system. Cardiovascular risk reduction: Patients with diabetes mellitus are at significantly increased risk of cardiovascular disease, which is also an independent risk factor for kidney failure. Therefore, it is important to aggressively manage cardiovascular risk factors in patients with diabetes mellitus and in particular those with diabetic nephropathy. The main components of managing cardiovascular disease

6771-607: The US exam with internal echoes, without the well-defined, smooth walls seen in cysts, often with Doppler signal, and is frequently malignant or has a high malignant potential. The most common malignant renal parenchymal tumor is renal cell carcinoma (RCC), which accounts for 86% of the malignancies in the kidney. RCCs are typically isoechoic and peripherally located in the parenchyma, but can be both hypo- and hyper-echoic and are found centrally in medulla or sinus. The lesions can be multifocal and have cystic elements due to necrosis, calcifications and be multifocal (Figure 8 and Figure 9). RCC

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6882-522: The US-guided procedure was considered too high due to poor identification of the moving bowels. However, recent guidelines for renal interventional US include radiofrequency, microwave and cryoablation with US as the ideal imaging guide. For percutaneous nephrostomy and abscess drainage, either the one-step or the Seldinger technique is used. Using the Seldinger technique, the cavity is punctured with

6993-430: The activation of growth factors TGF-B and vascular endothelial growth factor (VEGF). These factors, along with the hemodynamic changes that occur, lead to podocyte injury, oxidative stress, inflammation and fibrosis. As injury worsens, kidney function decreases and glomerular basement membrane (GBM) become more permeable and less efficient at filtration. This is accompanied by a steady decline in kidney function. Diagnosis

7104-500: The adult kidney is normally 10–12 cm, and the right kidney is often slightly longer than the left kidney. The adult kidney size is variable due to the correlation with body height and age; however, normograms for pediatric kidney size are available. Cortical thickness should be estimated from the base of the pyramid and is generally 7–10 mm. If the pyramids are difficult to differentiate, the parenchymal thickness can be measured instead and should be 15–20 mm (Figure 3). The echogenicity of

7215-502: The amount of protein in the urine - proteinuria ; and a blood test called the serum creatinine . The amount of the proteinuria reflects the degree of damage to any still-functioning glomeruli. The value of the serum creatinine can be used to calculate the estimated glomerular filtration rate (eGFR), which reflects the percentage of glomeruli which are no longer filtering the blood. Treatment with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker , which dilates

7326-626: The breeds with the lowest rates. Cats with chronic kidney disease may have a buildup of waste products usually removed by the kidneys. They may appear lethargic, unkempt, and lose weight, and may have hypertension. The disease can prevent appropriate concentration of urine, causing cats to urinate greater volumes and drink more water to compensate. Loss of important proteins and vitamins through urine may cause abnormal metabolism and loss of appetite. The buildup of acids within blood can result in acidosis , which can lead to anemia (which can sometimes be indicated by pink or whitish gums, but by no means does

7437-435: The cause is unknown, it is called idiopathic . Diagnosis of CKD is largely based on history , examination , and urine dipstick combined with the measurement of the serum creatinine level. Differentiating CKD from acute kidney injury (AKI) is important because AKI can be reversible. One diagnostic clue that helps differentiate CKD from AKI is a gradual rise in serum creatinine (over several months or years) as opposed to

7548-470: The cortex decreases with age and is less echogenic than or equal to the liver and spleen at the same depth in individuals older than six months. In neonates and children up to six months of age, the cortex is more echogenic than the liver and spleen when compared at the same depth. Doppler ultrasonography of the kidney is widely used, and the vessels are easily depicted by the color Doppler technique in order to evaluate perfusion. Applying spectral Doppler to

7659-613: The creatinine level is often normal. The toxins show various cytotoxic activities in the serum and have different molecular weights, and some of them are bound to other proteins, primarily to albumin. Uremic toxins are classified into three groups as small water-soluble solutes, middle molecular-weight solutes, and protein-bound solutes. Hemodialysis with high-flux dialysis membrane, long or frequent treatment, and increased blood/dialysate flow has improved removal of water-soluble small molecular weight uremic toxins. Middle molecular weight molecules are removed more effectively with hemodialysis using

7770-679: The degree of damage in this (and any) kidney disease, the serum creatinine is determined and used to calculate the estimated glomerular filtration rate ( eGFR ). Normal eGFR is equal to or greater than 90ml/min/1.73 m . On biopsy, the following classification has been suggested by Tervaert et al. : Although albuminuria is the most frequently used marker of DN, it has a limited sensitivity as many patients with diabetic nephropathy experience GFR loss and glomerulosclerosis without immediate elevation in albuminuria. Many novel markers are currently being studied that potentially detect diabetic nephropathy at earlier stages and identify progression risk. Cystatin C

7881-452: The developed countries. Worldwide, the prevalence of diabetes is projected to increase from 382 million in 2013, to over 592 million by 2035. This increase is projected to be sharpest in developed countries. The prevalence of type 2 DM is particularly increasing due to the rising prevalence of obesity worldwide. Diabetic kidney disease progression could lead to ESRD as well as an increased risk of cardiovascular complications, all of which cause

7992-497: The dilated pelvis can be differentiated from the dilated calyces. Several conditions can result in urinary obstruction. In both adults and children, masses, such as abscesses and tumors, can compress the ureter. In children, hydronephrosis can be caused by ureteropelvic junction obstruction, ectopic inserted ureter, primary megaureter and posterior urethral valve (Figure 13). In the latter, both kidneys will be affected. In adults, hydronephrosis can be caused by urolithiasis, obstructing

8103-511: The dilated renal pelvis in the transverse scan plane and the cortical thickness, as explained previously (Figure 16 and Figure 17). If the fluid in the dilated collecting system has echoes, pyonephrosis should be excluded by clinical exam, blood analysis and, in special cases, puncture or drainage. Hydronephrosis can also be caused by non-obstructive conditions, such as brisk diuresis in patients treated with diuretics, in pregnant women and in children with vesicoureteral reflux. Even though US has

8214-413: The endothelial cells, the mesangial cells and the podocytes. This exacerbates the dysfunction caused by the metabolic effects of hyperglycemia. Metabolic factors include the formation of advanced glycation end-products (AGEs), which have a central role in the pathophysiology of many of the complications of diabetes mellitus, including cardiovascular complications. AGEs are chemical groups that form when

8325-515: The glomerulus itself: these include a thickening of the basement membrane , a widening of the slit membranes of the podocytes , an increase in the number of mesangial cells , and an increase in mesangial matrix. This matrix invades the glomerular capillaries and produces deposits called Kimmelstiel-Wilson nodules. The mesangial cells and matrix can progressively expand and consume the entire glomerulus, shutting off filtration. The status of diabetic nephropathy may be monitored by measuring two values:

8436-562: The greatest number of deaths are high blood pressure at 550,000, followed by diabetes at 418,000, and glomerulonephritis at 238,000. CKD is initially without symptoms, and is usually detected on routine screening blood work by either an increase in serum creatinine , or protein in the urine . As the kidney function decreases, more unpleasant symptoms may emerge: The most common causes of CKD are diabetes mellitus , hypertension , and glomerulonephritis . About one of five adults with hypertension and one of three adults with diabetes have CKD. If

8547-542: The interstitium. Renal fibrosis is the final common pathway of DN. This fibrosis is a product of multiple mechanisms including renal hemodynamic changes, glucose metabolism abnormalities associated with oxidative stress as well as inflammatory processes and an overactive renin-angiotensin-aldosterone system (RAAS). The pathophysiology of diabetic nephropathy is thought to involve an interaction between hemodynamic and metabolic factors. Hemodynamic factors include an increase in systemic and intraglomerular pressure, as well as

8658-414: The kidney (Figure 10). Benign solid tumors of the kidney are oncocytoma and angiomyofibroma. Oncocytoma has a varying ultrasonic appearance, but may have a central scar or calcification as a hallmark. Angiomyofibroma are often found in patients with tuberous sclerosis. They are composed of fat, smooth muscle tissue and vascular elements. The echogenicity is governed by the composition of these elements, but

8769-416: The kidney will follow the diaphragm and change position accordingly. In the longitudinal scan plane, the kidney has the characteristic oval bean-shape. The right kidney is often found more caudally and is slimmer than the left kidney, which may have a so-called dromedary hump due to its proximity to the spleen. The kidney is surrounded by a capsule separating the kidney from the echogenic perirenal fat, which

8880-484: The kidney, i.e., in the calyces, the pelvis and the pyeloureteric junction, can be differentiated, especially in the cases with accompanying hydronephrosis (Figure 18 and Figure 19). Hyperechoic stones are seen with accompanying posterior shadowing. Additional twinkling artifacts below the stone can often be seen using Doppler US. Large stones filling the entire collecting system are called coral stones or staghorn calculi and are easily visualized with US (Figure 20). Stones in

8991-423: The kidney, the GFR does not indicate all aspects of kidney health and function. This can be done by combining the GFR level with the clinical assessment of the person, including fluid status, and measuring the levels of hemoglobin, potassium, phosphate, and parathyroid hormone. Kidney ultrasonography is useful for diagnostic and prognostic purposes in chronic kidney disease. Whether the underlying pathologic change

9102-487: The kidneys is essential in the diagnosis and management of kidney-related diseases. The kidneys are easily examined, and most pathological changes in the kidneys are distinguishable with ultrasound. US is an accessible, versatile inexpensive and fast aid for decision-making in patients with renal symptoms and for guidance in renal intervention. Renal ultrasound (US) is a common examination, which has been performed for decades. Using B-mode imaging , assessment of renal anatomy

9213-580: The kidneys, generally by ultrasonography , is recommended as part of a differential diagnosis if there is suspicion of urinary tract obstruction , urinary tract infection , kidney stones or polycystic kidney disease . Conformation kidney biopsy should only be performed if non-diabetic kidney disease is suspected. Urine analysis in patients with diabetic kidney disease is often bland. In cases of severely increased microalbuminuria, hematuria might be present. fat bodies might be present in patients who develop nephrotic-range proteinuria. To clinically stage

9324-641: The kidneys. Some of the most commonly used nephrotoxic medications are non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. With worsening kidney function, it might also be necessary to follow a renal-diet to avoid complications such as hyperkalemia and metabolic acidosis. Some evidence suggests that limiting dietary protein could slow the progression of DN, but further evidence is needed to confirm this benefit. Patients with diabetic nephropathy might go on to develop end stage renal disease and require kidney transplantation or hemodialysis. A relatively new medication that has been approved for treatment for DM

9435-407: The lesion is often hyperechoic (Figure 11 and Figure 12). Benign tumors are difficult to separate from malignant tumors using US. Thus, solid renal masses found on US are difficult to classify and should be further evaluated with CT. In special cases of cystic or solid renal masses, additional US guided biopsy or drainage is performed to identify the histologic tumor type before a decision on surgery

9546-485: The letter "P" to the stage of chronic kidney disease if protein loss is significant. The term "non-dialysis-dependent chronic kidney disease" (NDD-CKD) is a designation used to encompass the status of those persons with an established CKD who do not yet require the life-supporting treatments for kidney failure known as kidney replacement therapy (RRT, including maintenance dialysis or kidney transplantation ). The condition of individuals with CKD, who require either of

9657-448: The likelihood of developing diabetic nephropathy are: The disease progression of diabetic nephropathy involves various clinical stages: hyperfiltration, microalbuminuria, macroalbuminuria, nephrotic proteinuria to progressive chronic kidney disease leading to end-stage renal disease (ESRD). The damage is exerted on all compartments of the kidney: the glomerulus, the renal tubules, the vasculature (afferent and efferent renal arterioles) and

9768-446: The long diameter of the kidney, as the kidney is easier to distinguish. In the adult patient, a curved array transducer with center frequencies of 3–6 MHz is used, while the pediatric patient should be examined with a linear array transducer with higher center frequencies. Artifacts of the lowest ribs always shadow the upper poles of the kidneys. However, the whole kidney can be examined during either normal respiration or breath hold, as

9879-458: The most effective therapy to slow the progression of diabetic nephropathy in all stages. Although RAAS blockade using more than one agent may further reduce proteinuria, the risk of adverse events (such as hyperkalemia, acute kidney injury) outweigh the potential benefits. Therefore, it is recommended that only one agent is used in patients with DM who have hypertension or any signs of microalbuminuria or diabetic nephropathy. About half of insulin

9990-484: The only parameter is not reliable. The acute changes in the kidney are often examined with US as the first-line modality, where CT and magnetic resonance imaging (MRI) are used for the follow-up examinations and when US fails to demonstrate abnormalities. In evaluation of the acute changes in the kidney, the echogenicity of the renal structures, the delineation of the kidney, the renal vascularity, kidney size and focal abnormalities are observed (Figure 26 and Figure 27). CT

10101-404: The only parameter is not reliable. Additional tests may include nuclear medicine MAG3 scan to confirm blood flow and establish the differential function between the two kidneys. Dimercaptosuccinic acid (DMSA) scans are also used in kidney imaging; with both MAG3 and DMSA being used chelated with the radioactive element technetium-99 . A glomerular filtration rate (GFR) ≥ 60 mL/min/1.73 m

10212-430: The outlet of the renal pelvis or the ureter, and compression of the ureter from, e.g., pregnancy and retroperitoneal fibrosis. Urolithiasis is the most common cause of hydronephrosis in the adult patient and has a prevalence of 10%–15%. Under normal conditions, the ureter is not seen with US. However, in, e.g., urinary obstruction and vesicoureteric reflux with dilation of the ureter, the proximal part in continuation with

10323-421: The over-activation of the RAAS. Studies have shown that in the setting of diabetes, various factors stimulate the RAAS, which is one of the most important pathways in diabetic nephropathy pathophysiology. Due to the higher load of filtered glucose, there is an up-regulation in the sodium-glucose cotransporter 2 (SGLT2) in the proximal tubules, which cotransports sodium and glucose back into circulation. This leads to

10434-435: The patient and is usually performed with the patient in the supine position. The kidneys are examined in longitudinal and transverse scan planes with the transducer placed in the flanks. When insonation of the kidney is obscured by intestinal air, the supine scan position is combined with the lateral decubitus position with the transducer moved dorsally. Preferably, the exam is initiated in the longitudinal scan plane, parallel to

10545-904: The potential CKDu incidence. CKDu also affects people in Sri Lanka where it is the eighth largest cause of in-hospital mortality. African, Hispanics , and South Asians, particularly those from Pakistan, Sri Lanka, Bangladesh, and India, are at high risk of developing CKD. Africans are at greater risk due to the number of people affected with hypertension among them. As an example, 37% of ESKD cases in African Americans can be attributed to high blood pressure, compared with 19% among Caucasians. Treatment efficacy also differs between racial groups. Administration of antihypertensive drugs generally halts disease progression in white populations but has little effect in slowing kidney disease among black people, and additional treatment such as bicarbonate therapy

10656-443: The presence of normal colored gums guarantee that anemia is not present or developing), and lethargy. Diabetic nephropathy Diabetic nephropathy , also known as diabetic kidney disease , is the chronic loss of kidney function occurring in those with diabetes mellitus . Diabetic nephropathy is the leading causes of chronic kidney disease (CKD) and end-stage renal disease (ESRD) globally. The triad of protein leaking into

10767-433: The prevention of vascular blockage in people with CKD. Regular consumption of oral protein-based nutritional supplements may increase serum albumin levels slightly in people with CKD, especially among those requiring hemodialysis or who are malnourished. Prealbumin level and mid-arm muscle circumference may also be increased following supplementation. Despite possible improvement in these indicators of nutritional status, it

10878-617: The progression of nephropathy. More intensive blood pressure lower (125-130/<80) in patients with diabetic mellitus has been shown to decrease the risk of progression of diabetic nephropathy as well as other diabetic complications. Some patients might require dual therapy to adequately control pressure, in which case calcium channel blockers or diuretics are a good second-line option. RAAS inhibition: Inhibition can be achieved with multiple therapies, mainly ACE inhibitors, angiotensin receptor blockers, direct renin inhibitors, and mineralocorticoid antagonists. RAAS inhibition has been proven to be

10989-474: The rate of other DM complications, such as retinopathy and neuropathy. Glycemic control is maintained mainly with insulin in patients with Type 1 DM and with hypoglycemic agents and/or insulin in patients with type 2 DM. Studies showed a decrease in microvascular complications of diabetic nephropathy with a target goal HbA1c concentration of 7%. Further reduction in the HbA1c did not correlate with better outcomes and

11100-464: The receptor for advanced glycation end products (RAGE). RAGE is a signal transduction receptor found on a number of cell types including macrophages, endothelial cells, renal mesangial cells and podocytes in the glomerulus. Bindings of AGEs to RAGE receptors enhances production of cytosolic Reactive Oxygen Species (ROS) as well as stimulates intracellular molecules such as Protein Kinase C (PKC), NF-κB and

11211-446: The renal artery and selected interlobular arteries, peak systolic velocities, resistive index, and acceleration curves can be estimated (Figure 4) (e.g., peak systolic velocity of the renal artery above 180 cm/s is a predictor of renal artery stenosis of more than 60%, and a resistive index, which is a calculated from peak systolic and end systolic velocity, above 0.70 is indicative of abnormal renovascular resistance). Masses are seen as

11322-425: The renal pelvis, as well as the distal part near the ostium can be evaluated (Figure 14). The hydronephrosis is typically graded visually and can be divided into five categories going from a slight expansion of the renal pelvis to end-stage hydronephrosis with cortical thinning (Figure 15). The evaluation of hydronephrosis can also include measures of calyces at the level of the neck in the longitudinal scan plane, of

11433-404: The risk of major cardiovascular events such as myocardial infarction , stroke , heart failure , and death from cardiovascular disease when compared to placebo in individuals with CKD. ACEIs may be superior to ARBs for protection against progression to kidney failure and death from any cause in those with CKD. Aggressive blood pressure lowering decreases people's risk of death. Obesity may have

11544-659: The surgery. Transplantation aside, high-intensity home hemodialysis appears to be associated with improved survival and a greater quality of life, when compared to the conventional three-times-a-week hemodialysis and peritoneal dialysis . People with ESKD are at increased overall risk for cancer. This risk is particularly high in younger people and gradually diminishes with age. Medical specialty professional organizations recommend that physicians do not perform routine cancer screening in people with limited life expectancies due to ESKD because evidence does not show that such tests lead to improved outcomes. In children, growth failure

11655-455: The treatment of sleep disorders. This means that it is unknown what is the best guidance to improve sleep quality in this population. Guidelines for referral to a nephrologist vary between countries. Most agree that nephrology referral is required by Stage 4 CKD (when eGFR/1.73m is less than 30 mL/min; or decreasing by more than 3 mL/min/year). It may also be useful at an earlier stage (e.g. CKD3) when urine albumin-to-creatinine ratio

11766-593: The two types of kidney replacement therapy ( dialysis or transplant ), is referred to as the end-stage kidney disease (ESKD). Hence, the start of the ESKD is practically the irreversible conclusion of the NDD-CKD. Even though the NDD-CKD status refers to the status of persons with earlier stages of CKD (stages 1 to 4), people with advanced stage of CKD (stage 5), who have not yet started kidney replacement therapy, are also referred to as NDD-CKD. Chronic kidney disease (CKD)

11877-550: The underlying pathologic change is glomerular sclerosis, tubular atrophy, interstitial fibrosis or inflammation, the result is often increased echogenicity of the cortex. The echogenicity of the kidney should be related to the echogenicity of either the liver or the spleen (Figure 22 and Figure 23). Moreover, decreased renal size and cortical thinning are also often seen and especially when disease progresses (Figure 24 and Figure 25). However, kidney size correlates to height, and short persons tend to have small kidneys; thus, kidney size as

11988-463: The ureters are usually not visualized with US due to the air-filled intestines obscuring the insonation window. However, ureteral stones near the ostium can be visualized with a scan position over the bladder. An exam of the ureteric orifices and the excretion of urine to the bladder can be performed by inspecting the ureteric jets in the bladder with color Doppler US. US is useful for diagnostic and prognostic purposes in chronic kidney disease . Whether

12099-427: The urine (proteinuria or albuminuria), rising blood pressure with hypertension and then falling renal function is common to many forms of CKD. Protein loss in the urine due to damage of the glomeruli may become massive, and cause a low serum albumin with resulting generalized body swelling (edema) so called nephrotic syndrome . Likewise, the estimated glomerular filtration rate (eGFR) may progressively fall from

12210-460: Was 15.8 cases per 10,000 dog years at risk. The mortality rate of CKD was 9.7 deaths per 10,000 dog years at risk. (Rates developed from a population of 600,000 insured Swedish dogs; one dog year at risk is one dog at risk for one year). The breeds with the highest rates were the Bernese mountain dog , miniature schnauzer and boxer . The Swedish elkhound , Siberian husky and Finnish spitz were

12321-494: Was the cause of 956,000 deaths globally in 2013, up from 409,000 deaths in 1990. The cause of chronic kidney disease is in some cases not known; it is referred to as chronic kidney disease of unknown aetiology (CKDu). As of 2020 a rapidly progressive chronic kidney disease, unexplained by diabetes and hypertension, had increased dramatically in prevalence over a few decades in several regions in Central America and Mexico,

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