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Horseshoe Kidney with Hydronephrosis – Tales of the Unexpected

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Horseshoe Kidney with Hydronephrosis – Tales of the Unexpected 10.2478/AMB-2018-0008 HORSESHOE KIDNEY WITH HYDRONEPHROSIS – TALES OF THE UNEXPECTED M. Nikolova, R. Krasteva, B. Bogov, T. Tsocheva, Vl. Milenova, K. Petkov, N. Chernev University Hospital Alexandrovska, Medical University – Sofi a, Bulgaria Abstract. Horseshoe kidney is an inborn renal fusion anomaly. It is frequently associated with renal stones and infections. The diagnosis is made using imaging methods – ultrasound, X-ray of the abdomen and intravenous pyelography, computed tomography (CT), magnetic resonance imaging (MRI) and radionuclide investigations. The diagnosis sometimes is hard, especially when other abnormalities are present, i.e. hydronephrosis, nephrolithiasis, ste- nosis of the ureteropelvic junction, etc. The authors present a male patient with horseshoe kidney and unilateral hydronephrosis due to obstruction of the ureteropelvic junction and discuss the diagnosis of horseshoe kidney and the diagnostic approach in such patients. Key words: horseshoe kidney, hydronephrosis, diagnosis, abdominal ultrasound, renal imaging Correspoding author: Milena Nikolova, MD, PhD, Clinic of Nephrology, University Hospital Alexan- drovska, Medical University, 1 G. Sofi yski St., 1431 Sofi a, Bulgaria, e-mail: [email protected] INTRODUCTION tion of right-sided hydronephrosis discovered during ultrasound examination of the abdomen performed Horseshoe kidney (HSK) is one of the most common for right-sided orchiepidydimitis. The patient reported inborn renal abnormalities, observed in 1:400-1:600 mild discomfort in the right fl ank area. He had history newborns [1, 2, 3]. It tends to have marked variability of arterial hypertension with good control on bisopro- in the structure, position, blood supply and drainage lol 2.5 mg a day. He also had past history of appen- of the fused kidneys. Usually, the lower poles of both dectomy and family history of arterial hypertension. kidneys are connected by a fi brous or parenchyma- The physical examination at the admission revealed tous isthmus (i.e., bridge) and rarely the upper poles a palpable painless round formation in the right ab- are connected. The kidneys can be rotated and ure- dominal fl ank approximately 15-16 cm in diameter. ters – malpositioned (frequently with obstruction of Arterial blood pressure was 130/80 mm Hg. The rest the ureteropelvic junction) as can be the renal ves- of the physical examination was unremarkable. sels. HSK can be accompanied by other renal and extrarenal abnormalities and can be complicated with The clinical laboratory investigations at the admission re- renal stones, infections and renal tumors [1, 4, 5, 6]. If vealed normal ESR, blood count, liver enzymes, blood not complicated by urinary tract infections or stones, glucose, calcium and phosphate levels, serum creatinine this anomaly usually remains undiagnosed [2]. 111 mcmol/l, estimated creatinine clearance of 99.6 ml/ min, urea 5.4 mmol/l, urinalysis was unremarkable, urine sediment revealed several white blood cells per power CLINICAL CASE fi eld. The urine cultures showed no bacterial growth. A 40-years-old male patient was admitted to the Clin- The abdominal ultrasound examination (fi gure 1) ic of Nephrology in June 2016 for diagnostic evalua- revealed hyperechogenic liver, normal image of 42 Acta Medica Bulgarica, Vol. XLV, 2018, № 1 // Case report the spleen, pancreas, urinary bladder and prostatic part located below at the level of L4-L5. Both pelvic gland. The right kidney was enlarged – 170 mm, with structures to the left were drained by a single left ure- the image of giant hydronephrosis of long duration – ter. The intravenous pyelogram was suggestive of a anechogenic dilated pelvis and renal calyces and re- single S-shaped kidney to the left with absent or “si- nal parenchyma of 7-8 mm between the anechogenic lent” right kidney. zones. The left kidney was also enlarged – 150 mm, The abdominal CT revealed HSK with old hydro- with normal parenchyma and parenchymal “bridge” nephrosis to the right due to stenotic obstruction connecting it to the right kidney. The lower pole of the of the right ureteropelvic junction and double left left kidney was elongated and tapered appearing to pelvis. Unfortunately, we lack the images of this in- be curved away from the transducer (boomerang-like vestigation. shape), suggesting the presence of HSK. After the abdominal CT the patient was eventually After the abdominal ultrasound examination an intra- diagnosed with combined urological anomaly: horse- venous pyelography was performed (fi gure 2). The shoe kidney with impaired function of the right kidney plain abdominal X-ray revealed normal position of due to stenosis of the ureteropelvic junction and a both kidneys. After the intravenous administration of longstanding hydronephrosis with consumption of re- contrast medium the right kidney remained “silent” – nal parenchyma, along with double left renal pelvis no excretion of contrast medium. The left kidney ex- with single draining ureter. Subsequently the patient creted the contrast medium on minute 10 with double was referred to urologist for further treatment and pelvis – the upper part appearing normal, and lower evaluation for nephrectomy to the right. A B C Fig. 1. Abdominal ultrasound examination. (A) Right kidney – hydronephrosis. (B) Left kidney – note the elongation and tapering of the lower pole making the kidney curved away from the transducer (arrow), suggesting the presence of HSK. (C) Parenchymal “bridge” con- necting both kidneys (isthmus) A B C D Fig. 2. Intravenous pyelogram. (A) Plain X-ray of the abdomen revealing normal position of both kidneys with well visible renal contours (arrows). (B) After the intravenous administration of contrast medium the right kidney remained “silent” – no excretion of contrast me- dium. The left kidney excretes the contrast medium on minute 10 with double pelvis – the upper part appearing normal, and lower part is located below, at the level of L4-L5. (C) Both pelvic structures to the left were drained by a single left ureter (arrow). (D) The same image of a double left renal pelvis on targeted X-rays in standing position Horseshoe kidney with hydronephrosis... 43 DISCUSSION may not be clearly seen on ultrasound investigation [3]. The intravenous pyelogram and the contrast CT/ HSK is the most common congenital fusion abnor- MRI may reveal the typical U-shaped kidney with two mality of the urinary tract. It is observed in 1:400-600 ureters, and the CT/MRI reveal changes in renal ves- live births, more frequently in men (male to female sels [1]. In cases of hydronephrosis CT/MRI and ra- ratio approximately 2:1) [1, 2, 3]. HSK usually com- dionuclide assays are very valuable, as they reveal bines three distinct anomalies: renal ectopia, malro- both renal structure and excretion. tation of the kidneys and renal vascular abnormalities In our patient we observed unilateral hydronephrosis [1]. In the majority of cases the kidneys are connect- with palpable formation in the right fl ank, boomerang- ed by an isthmus located at their lower poles (a U- shaped left kidney suggesting HSK, and X-ray data shaped kidney), and less frequently the isthmus con- for a silent right kidney, suggesting complete obstruc- nects to the upper poles, forming an “inverted” HSK tion of the urinary fl ow to the right. The presence of [1, 2]. Horseshoe kidney represents a defect of renal a single left ureter to the left does not confi rm the ascending combined with fusion defect. It starts be- suspected S-shaped left kidney (homolateral fusion tween the week 4 and 6 of gestation when the lower abnormality) but does suggest double pyelo-calical (inferior) part of the metanephric blastema fuses be- system to the left with a sigle draining ureter. The CT fore the kidneys ascend and rotate. The fused tis- confi rmed the presence of HSK with unilateral hydro- sue is the isthmus and it prevents the kidneys from nephrosis (right-sided) due to obstruction of uretero- ascending and rotating due to the resistance it exerts pelvic junction and double left renal pelvis. There- as it reaches the inferior mesenteric artery. HSK may fore, the patient had three urinary tract abnormalities: be associated with other urinary tract and extrarenal HSK, stenosis of the right ureteropelvic junction and abnormalities, including stenosis of the ureteropelvic double left pelvis. The combined efforts of several junction, double pelvis, abnormalities of the urinary imaging methods led to the correct diagnosis. The bladder, supernumerary kidneys with horseshoe el- ultrasound could not detect the cause of the right- ements, undescended testis and hypospadias, sep- sided hydronephrosis but suggested the presence of tate vagina; skeletal, cardiovascular, gastrointestinal HSK, the intravenous pyelogram did not reveal the and central nervous system malformations, chro- right kidney and suggested S-shaped left kidney, and mosomal abnormalities (including Patau and Gard- the contrast CT revealed all three abnormalities and ner syndromes, Down and Turner syndromes) [1-6]. explained the palpable formation in the right fl ank. Moreover, HSK has been found even more frequently Therefore, we would like to underline the importance in autopsy examinations of children and infants, sug- of the thorough physical examination and of the com- gesting the high risk of mortality in young age, prob- bined use of multiple imaging methods for the detec- ably due to severe associated organ and/or chromo- tion of urinary tract abnormalities. somal abnormalities [1]. HSK can be complicated by the formation of kidney REFERENCES stones, hydronephrosis (due to stenosis of the ure- teropelvic junction, malrotation and/or malposition 1. Natsis K, Piagkou M, Skotsimara A, et al. Horseshoe kidney: a review of anatomy and pathology. Surg Radiol Anat. 2014 of the kidneys and ureters, obstruction by stones), Aug;36(6):517-26. urinary tract infections and tumors (Wilms’ tumor – 2. Rao K EV, Battula SR. Horseshoe kidney: a review article. Int usually in the isthmus, transitional cell carcinoma, J Res Med Sci. 2015;3(11):3004-3007. oncocytoma, carcinoid tumors) [1-6].
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