Station 1.4: Renal enlargement

Question 1

Clinical Signs

What are the peripheral clinical signs of Renal enlargement?

Renal enlargement

This woman has been referred by her GP for investigation of hypertension. Please examine her
abdomen.

Answer 1

*  Blood pressure: hypertension
*  Arteriovenous fistulae (thrill and bruit), tunnelled dialysis line
*  Immunosuppressant ‘stigmata’, e.g. Cushingoid habitus due to steroids, gum
hypertrophy with ciclosporin

Question 2

Clinical Signs

What are the abdomen clinical signs of Renal enlargement?

Renal enlargement

This woman has been referred by her GP for investigation of hypertension. Please examine her
abdomen.

Answer 2

*  Palpable kidney: ballotable, can get above it and moves with respiration
*  Polycystic kidneys: both may/should be palpable, and can be grossly enlarged (will feel
‘cystic’, or nodular)
*  Iliac fossae: scar with (or without!) transplanted kidney
*  Ask to dip the urine: proteinuria and haematuria
*  Ask to examine the external genitalia (varicocele in males)

Question 3

Clinical Signs

What are the associated signs of Renal enlargement?

Renal enlargement

This woman has been referred by her GP for investigation of hypertension. Please examine her
abdomen.

Answer 3

*  Hepatomegaly: polycystic kidney disease
*  Indwelling catheter: obstructive nephropathy with hydronephrosis
*  Peritoneal dialysis catheter/scars

Question 4

Discussion

What are the causes of unilateral enlargement?

Renal enlargement

This woman has been referred by her GP for investigation of hypertension. Please examine her
abdomen.

Answer 4

*  Polycystic kidney disease (other kidney not palpable or contralateral nephrectomy –
flank scar)
*  Renal cell carcinoma
*  Simple cysts
*  Hydronephrosis (due to ureteric obstruction)

Question 5

Discussion

What are the causes of bilateral enlargement?

Renal enlargement

This woman has been referred by her GP for investigation of hypertension. Please examine her
abdomen.

Answer 5

*  Polycystic kidney disease
*  Bilateral renal cell carcinoma (5%)
*  Bilateral hydronephrosis
*  Tuberous sclerosis (renal angiomyolipomata and cysts)
*  Amyloidosis

Question 6

Discussion

What investigations do recommend?

Renal enlargement

This woman has been referred by her GP for investigation of hypertension. Please examine her
abdomen.

Answer 6

*  U&E
*  Urine cytology
*  Ultrasound abdomen ± biopsy
*  IVU
*  CT if carcinoma is suspected
*  Genetic studies (ADPKD)

Question 7

Discussion

Autosomal dominant polycystic kidney disease?

Renal enlargement

This woman has been referred by her GP for investigation of hypertension. Please examine her
abdomen.

Answer 7

*  Progressive replacement of normal kidney tissue by cysts leading to renal enlargement
and renal failure (5% of end‐stage renal failure in UK)
*  Prevalence 1:1000
*  Genetics: 85% ADPKD1 chromosome 16; 15% ADPKD2 chromosome 4

*  Present with:
⚬ Hypertension
⚬ Recurrent UTIs
⚬ Abdominal pain (bleeding into cyst and cyst infection)
⚬ Haematuria
*  End‐stage renal failure by age 40–60 years (earlier in ADPKD1 than 2)
*  Other organ involvement:
⚬ Hepatic cysts and hepatomegaly (rarely liver failure)
⚬ Intracranial Berry aneurysms (neurological sequelae/craniotomy scar?)
⚬ Mitral valve prolapse
*  Genetic counselling of family and family screening; 10% represent new mutations
*  Treatment: nephrectomy for recurrent bleeds/infection/size, dialysis and renal
transplantation