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Two young patients with increased renal cortical echogenicity

We previously discussed that not all increased cortical echogenicity is chronic kidney disease (CKD). Here are two more illustrative cases.

A young woman with a history of systemic lupus nephritis was seen for facial swelling, worsening serum creatinine and proteinuria. Renal sonogram (Images below) demonstrated thick, enlarged kidneys with hyperechoic parenchyma. Patient was only 5’ 4” tall but the kidneys were ~13 cm long. Also, there was good color Doppler flow in the kidneys. This is consistent with acute insult rather than CKD. Renal biopsy demonstrated class IV lupus nephritis with crescents; treated with cyclophosphamide.

Another young patient was seen for a serum creatinine of 16 mg/dL. No prior labs available, no known family history of inherited kidney disease. Renal sonogram demonstrated markedly echogenic kidneys with loss of corticomedullary differentiation (that means, it is difficult to distinctly identify cortex and medullary pyramids). Kidney length was ~10.5 cm but the patient was 6 feet tall (small for his age and height) – findings consistent with CKD. Also note that the color flow pick up is not great (compare to that of above lupus patient) – another feature of CKD kidney, though not specific. Other pertinent laboratory work up was also suggestive of CKD (anemia, secondary hyperparathyroidism etc.) and dialysis planning/transplant evaluation was initiated without pursuing a biopsy.

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