Kidney disease

Multicystic Dysplastic
Kidney Disease
Presenter:
Ifeanyi N. Malu, BSc., MA., RDMS
(expected)
Instructor:
Mrs. Shelia Chong,MBA,RDMS
May 2015

Archiving Images and HIPPA
• Privacy and confidentiality
• Images sent to your doctor via the Picture
Archiving and communication Systems(PACS)
-Method of storing sonographic images in digital
format to ensure complete privacy. Once stored,
only your doctor will access your medical
information.
Your doctor will review your images and contact
you if there's any need.
-Craig, M(2006)
Format by Sheila Chong ©

New or Difficult Terms
• Kidney dysplasia
• Potter type 2
-http://www.fetalsono.com/teachfiles/mcdk.lass
--
http://library.med.utah.edu/WebPath/TUTORIAL
/RENCYST/RENCYST.html

Normal Anatomy
Anatomic Drawing Sonographic Image
Source: http://healthcare.utah.edu/healthlibrary/health-lib-
image.php?imageid=125836

Fetal Kidney
May 2015
• The baby's kidneys start to produce
urine beginning between the 11th and
12th week.
• The kidneys are visible at 15th
– 17th
weeks
-Chong, S. (2015)
-Hagen-Ansert, S.L.(2012).

Multicystic Left Kidney
Left Kidney Measured
May 2015

Rt Kidney
http://sonoworld.com/fetus/page.aspx
?id=553

Multicystic dysplastic kidney
(MCDK)
• Multicystic dysplastic kidney
(MCDK) is a congenital
maldevelopment in which the
renal cortex is replaced by
numerous cysts of multiple
sizes
-Medscape,2015.
• Enlarged, echogenic kidneys
with multiple cysts, unilateral
or bilateral, probably due to an
early obstructive defect.
-Sleurs & Valero, 2001
• Anatomic Drawing
May 2015

May 2015
Multicystic Dysplastic Kidney
(MCDK)
•Affected kidney has zero function.
•Bilateral MCDK is fatal.
•With bilateral involvement, there is
associated absence of the bladder and
oligohydramnios -Hagen-Ansert,2012; Chong, 2015.
-http://sonoworld.com/Client/Fetus/html/

May 2015
• The kidneys are positioned
bilaterally in the upper,
posterior portion of the
abdomen.
• Affected kidney looks like a
bunch of grapes

-Fetal Multicystic Dysplastic Kidney. Available at
https://www.luriechildrens.org/en-us/care-
services/conditions-treatments/fetal-multicystic-
dysplastic-kidney/Pages/index.aspx
• Most common in Caucasians
• Most common renal cystic in
childhood
• Occurs at the same rate in both
females and males
Epidemiology and Demographics

Epidemiology and Demographics
• In the United States, the incidence of
MCDK is estimated to be 1 in every 2400
live births
• Occurs at the same rate in both females
and males
– Luriechildren.org(n.d).
Source: http://www.childrenshospital.org/conditions-and-
treatments/conditions/multicystic-dysplastic-kidney

Sonogram of Anomaly
• Sonographic Image • The kidney appear enlarged with
multiple cysts which are
– mostly randomly positioned,
but sometimes peripheral;
– variable in size and number
– non-communicating
– Nonfunctioning
– Smooth-walled
-Sleurs, E., & Valero, G. (n.d.).
Image Source: Pediatrics Urinary tract cases (n.d.). Available at
http://www.ultrasoundcases.info/Slide-View.aspx?cat=483&case=4457

Potential Associated
Sonographic Findings
• The two most common birth defects seen
with MCDK are esophageal atresia (a condition
in which the food pipe, does not connect to the stomach)
• vesicoureteral reflux (is an abnormal backward
movement of urine from the bladder into ureters or kidneys)
• uretero-pelvic junction obstruction(obstruction is
defined as an obstruction of the flow of urine from the renal pelvis to the
proximal ureter)
-Children Hospital of Wisconsin(n.d.).
-http://www.mayoclinic.org/diseases
May 2015

Etiology
• Unknown
• Some studies suggest certain viral
infections and some drugs might also play
a role if exposure occurs at a critical stage
of development.
• There are rare cases when multicystic
dysplastic kidney runs in families because
of a genetic trait.
-nationwidechildrens.org, (n.d.).
May 2015

Pathophysiology
• The pathogenesis is unknown but a hypothesis
is that an early obstructive defect of the
developing kidney causes the disorder
• Exposure to viral infections in utero has been
associated with multicystic dysplastic kidney
• Teratogens may also play a role in abnormal
renal development
Swiatecka-Urba, A., & Langman, C. (2013)
Sleur & Valero, (2001).
May 2015

Signs & Symptoms
• Severe deformities or polysystemic malformation
syndromes
• In bilateral cases, the newborn has
oligohydramnios
• Baby born with unilateral multicystic dysplastic
kidney disease and a normal, working kidney on
the other side should have very little effect
• Rare problem is hypertension
-Kishikawa, T; Toda, T et al. ,1981,Wikipedia,2015
May 2015

Prenatal Screening
• Ultrasound
• X-rays
May 2015

Prenatal Diagnosis
• A fetal MCDK is generally diagnosed by
ultrasound (sonogram) examination before birth
• The condition is usually found during a prenatal
ultrasound or when a doctor discovers an
abdominal mass during a routine physical
examination.
• Sometimes a nuclear scan is required to
differentiate a multicystic dysplastic kidney from
a blocked kidney
nationwidechildrens.org/multicystic-dysplastic-kidney(n.d.).

Prenatal Treatment
• The multicystic dysplastic kidney requires
no specific treatment. Over time, the
abnormal kidney regresses and just goes
away
luriechildrens.org/en-us(n.d.).
May 2015

Postnatal Treatment
• After the baby is born, the progress of the
MCDK is tracked through a series of
ultrasound examinations every six months
to a year. It is monitored to make sure that
it does not grow or develop a tumor.
• Voiding cystourethrogram: special X-ray
that watches the kidney as it makes urine
and watches the filling and emptying of the
bladder
-www.luriechildrens.org
May 2015

Complications
• Hypertension, hematuria, infection, flank
pain
• MCDK should not be confused with
polycystic kidney disease (PCKD) or other
renal cystic diseases
-nationwidechildrens.org(n.d.)
May 2015

Monitoring
• The condition is being monitored by a national
registry (i.e.,National Multicystic Kidney
Registry)
• By age 5, the kidney may no longer be visible in
x-ray or ultrasound examinations
• Surgical removal is an option.
May 2015

Sonographic monitoring
• Ultrasound is an excellent diagnostic test
with a “high degree of confidence.”
-http://emedicine.medscape.com/article/411365-overview#a22
May 2015

Lab monitoring
Alpha fetoprotein assay
•Can detect fetal defects
•Monitor fetal distress
•Monitor fetal abnormalities
•Usually performed at 16 weeks
-Craig, M (2006)
May 2015

CASE PRESENTATION
Multicystic Dysplastic Kidney
May 2015

Case information
May 2015
• 2nd trimester scan
• There were no risk factors.
• The mother is 26 years old with a
previous normal pregnancy

Chong Imaging Institute CII Exam Request
Patient Information Physician Information
First Name: Jane
LastName:_Doe_________________
HP_____________ CP___________
Sex M/XF DOB
_02_/_26____/__1986__
Name_Shelia Chong
Address________________________
Phone696-698-9992__________
Fax___________
Date __/_____/____
Appointment
Date___05__/__15___/__2015___
Appointment Time
08:00AM_______________
Clinical History
XRoutine ASAP 
Stat
Obstetrics LMP____/_____/_____
Under 16 weeks
18 – 20 weeks
> 30 weeks
High Risk
Amniocentesis
May 2015

Room Set-Up
• Ultrasound machine
• Curved linear transducer
• Examination table(powered adjustable)
• Acoustic gel(pre-warmed)
• Latex gloves
• Towel
• pillow
May 2015

Prevent nosocomial infections
• Hand washing
• Wear gloves
• Gown( lab coat,uniform,scrups)
May 2015

Wash your hands, Apply Gloves
-IMAGES SOURCE:
MooreMedical(n.d.).

Assisting patients with special
needs
• Adopting friendly and nonjudgmental
approach
• Be sensitive about privacy concerns
• Assure confidentiality
• Respect ethnic and culture
-Craig,M. (2006).

Patient Rights
• Health Insurance Portability and
Accountability Act (HIPPA)
• Right to refuse procedure
• Have informed consent
-Craig, M(2006).
May 2015

Get the Patient
Hi, my name is Ifeanyi Malu. I am the
sonographer for your exam. I will perform your
second trimester ultrasound exam. The exam will
take about 30 minutes. You will be provided with
appropriate dress for the exam. The exam will
involve exposing your lower abdomen by raising
your dress. Liquid gel will be applied on your body;
if you feel uncomfortable, please let me know.
May 2015

Ensure you have the right Patient
• Confirmation of name and date of birth
• Check the wristband to reconfirm identity
• Check clinical information
May 2015

Sonographer’s Interview
1 Q What is your name? What is your date of birth?
A Jane Doe
2 Q What is your address?
A 711 Steward Ave, Garden City NY
3 Q What are you here for?
A Second trimester sonogram
4 Q What is the date of your last normal menstrual period?
A: 02/15/2015
5 Q: Do you have regular or irregular period?
A: Regular
May 2015

Interview
• 6Q:Is there any complication with previous
pregnancy?
• A: No
• 7Q:Is there previous surgery?
• A:No
• 8Q: Are you taking any medication?
• A:No
• 9Q:Do you smoke?
• A: No May 2015

Explain Dress for exam
• This exam will take about 30 minutes to
complete. It involves exposing your
abdomen. I will apply gel on your body.
You will change into an exam gown. For
your privacy, there’s a room to change
your clothes. Ultrasound is highly safe and
will not harm you or your fetus. Let me
know if you need additional information
and privacy.
May 2015

MCKD Video
Source: YouTube Video Available at https://www.youtube.com/watch?
v=0IbITe_rULU&list=PLY73TA67Kf_kL4UWRN6DAAXwpb90dJAI7&in
dex=2

Fetus Lt kidney
http://www.ultrasoundpaedia.com/nor
mal-2ndtrimester/

Image(s)
Rt Kidney
• Sag right kidney
demonstrates multicystic
with the absence of renal
parenchyma, renal sinus
Multicystic RK
emedicine.medscape.com/article/411
365-overview

RT KID
• A coronal prenatal
sonogram of the
retroperitoneum shows
both kidneys. The cystic
hypoechoic area is the
right multicystic kidney.
The normal kidney looks
slightly hypoechoic and
lobulated
Source: http://emedicine.medscape.com/article/411365-
overview

Sag Rt Kidney
• A prenatal sonogram
shows the right
multicystic dysplastic
kidney in a longitudinal
view. The spine underlies
the affected kidney.
Sag RK
overview

MCDKD
Sag Rt Kid prone
• A longitudinal sonogram
of the right kidney shows
multiple diffuse
hypoechoic renal cysts,
without any significant
normal renal
parenchyma.
overview

RK Prone Position
SAG RK
• A Longitudinal sonogram
of the right kidney shows
multiple diffuse,
hypoechoic renal cysts,
without any significant
normal renal parenchyma
overview

• A nongenetic defect due to
malformation of the kidney which
appears as a bunch of grapes
with multiple renal cysts but
lacking the normal renal bean
shape, and the collection
drainage system

Wash your hands, Apply Gloves
Begin the Exam
IMAGES SOURCE:
MooreMedical(n.d.).

OB Exam Basic Protocol Images with
sonographic images & measurements
• Head, face, and neck:
• Lateral cerebral ventricles;
• Choroid plexus;
• Midline falx;
• Cavum septi pellucidi;
• Cerebellum;
• Cistern magna; and
• Upper lip. AIUM(2013). Obstetric Ultrasound Examinations. Available at
http://www.aium.org/resources/guidelines/obstetric.pdf

OB Exam Basic Protocol
• Chest:
• Heart:
• Four-chamber view;
• Left ventricular outflow tract; and
• Right ventricular outflow tract.
AIUM(2013). Obstetric Ultrasound Examinations. Available at http://www.aium.org/resources/guidelines/obstetric.pdf
May 2015

Fetal Head Measurement
May 2015

• Abdomen:
• Stomach (presence, size, and situs);
• Kidneys;
• Urinary bladder;
• Umbilical cord insertion site into the fetal
abdomen; and
• Umbilical cord vessel number.
AIUM(2013). Obstetric Ultrasound
Examinations. Available at
http://www.aium.org/resources/guid
elines/obstetric.pdf

Abdominal Circumference
May 2015

Kidneys: Coronal
http://sonoworld.com/Client/Fetus/html/11-
14week/chapter-04/chapter-04-final.htm

• Spine:
• Cervical, thoracic, lumbar, and sacral
spine.
• Extremities:
• Legs and arms.
AIUM(2013). Obstetric Ultrasound
Examinations. Available at
http://www.aium.org/resources/gui
delines/obstetric.pdf

Pathology Sonographic Image(s)
with Sonographer Report of this (these) Image(s)
Image
Sonographers Report as
done at your site
• The left kidney looks
enlarged with multiple
randomly positioned non-
communicating cysts of
various sizes.
-www.med-ed.virginia.edu

Case presentation:
Fetal Bladder
Fetal Bladder
Sonographic image of
fetal bladder
Shepherd, W. (n.d.). Multicystic Dysplastic Kidney . Reterived from
http://sonoworld.com/CaseDetails/multicystic_Dysplastic_Kidney.aspx?
ModuleCategoryId=1478
• Fetal Bladder
• The Bladder filled and
emptied during the 30
minute exam

Length of left fetal kidney 4cm
Left kidney
Shepherd, W. (n.d.). Multicystic Dysplastic Kidney . Retrieved from
• Length of left fetal kidney
4cm

Right kidney
Right kidney measures
2.76cm
Sonographic image of
fetal right kidney
Shepherd, W. (n.d.). Multicystic Dysplastic Kidney . Reterived from
• Length of fetal right
kidney 2.76cm

A transaxial image of
both fetal kidneys
-Shepherd, W. (n.d.).
• There is a discordance
between the size and
appearances of the right
and left kidneys

Enlargement of the
transaxial view of the
kidneys.
-Shepherd, W. (n.d.).
• There are many cysts
within the left kidney.
There is mild dilation of
the right renal pelvis. The
extent of this dilation
varied between 2-5mm
during the scan

Preliminary Completion of the
Exam
• Wash hands after the exam
• I will show the images to the Radiologist
who will provides a report to your
Obstetrician. The Radiologist might also
carry out further scanning . A full report of
your examination will be sent to your
doctor. If you need further information
about your exams today, please contact
your doctor.
May 2015

Other Useful Imaging Test
• X-rays
-Kidney, ureter, and bladder (KUB) images of an infant with a right multicystic dysplastic kidney
demonstrate displacement of bowel loops away from the right abdomen
overview

Review Images with the
Interpreting Physician
• The enlarged left kidney could contain a
mass, be obstructed, or be a multicystic
dysplastic kidney. The normal renal cortex
is progressively replaced by many cysts of
different sizes. Multicyctic Dysplastic
Kidney Disease is diagnosed

Differential considerations
• Hydronephrosis (condition that typically
occurs when one kidney becomes swollen
due to the failure of normal drainage of
urine from the kidney to the bladder)
http://www.healthline.com/health/unilateral-hydronephrosis#Overview1
-Hagen-Ansert, S.L. (2012).

Release the Patient
Q: The exam is now completed. I will not provide
the results or diagnostic information to you. Only
your doctor can provide diagnostic information.
I will show the images to the Radiologist who will
provides a report to your Obstetrician . A full report
of your examination will be sent to your doctor.
Your doctor may contact you if need be.
Q: Do you have any questions?
A: NO
Q: You may proceed to the reception area.
May 2015

Consent Form
Patient Name:Patient Name:
I approve Dr.I approve Dr. ChongChong to perform anto perform an Ultrasound examsUltrasound exams
second trimestersecond trimester
I understand the general risks forI understand the general risks for SonogramSonogram are:are:
•NoneNone
May 2015

Consent Form
I understand the benefits ofI understand the benefits of second trisecond tri are:are:
•To detect birth defect (multicystic kidney in your baby)To detect birth defect (multicystic kidney in your baby)
•Multicystic dysplasia of the kidney is the most
common cause of an abdominal mass in a newborn
SignaturesSignatures
Patient _____________________ Date ____/____/____Patient _____________________ Date ____/____/____
Doctor _____________________ Date ____/____/____Doctor _____________________ Date ____/____/____
Witness _____________________ Date ____/____/____Witness _____________________ Date ____/____/____
May 2015

Explanation of Time-Out
Procedure
• Ensure that the correct patient is present
• Correct examination is being performed
• Clinical history corresponds to the
requested examination
• Correct side/site is being examined
• All patient identification documentation is
completed.
May 2015

References
•AIUM.(2013). Obstetric Ultrasound Examinations. Available at
ahttp://www.aium.org/resources/guidelines/obstetric.pdf
•Aslam, M., Watson, A.R on behalf of the Trent & Anglia MCDK Study Group.
(2006). Unilateral multicystic dysplastic kidney (MCDK): long-term outcomes.
Arch Dis Child 2006;91: 820-823
•Children Hospital of Wisconsin(n.d.). Multicystic dysplastic kidney. Available at
http://www.chw.org/medical-care/fetal-concerns-center/conditions/infant-
complications/multicystic-dysplastic-kidney/
•Chong,S. (March, 2015) Lecture Note. Sanford-Brown Institute, Garden City
NY
•Craig, M. (2006). Essentials of Sonography and Patient Care. Second Edition.
Saunders, St. Louis, MO.
•eMedicine(n.d.). Multicystic Dysplastic Kidney Imaging .Retrieved electronically
from http://emedicine.medscape.com/article/411365-overview
May 2015

References
• Hagen-Ansert, S.L. (2012). Textbook of Diagnostic Sonography, Seventh
Edition, Elsevier Mosby St, Louis, MO.
• Kiyak, A., Yilma,z A., Turha,n P., Sander, S., Aydin, G.,& Aydogan, G.
(1997). Unilateral multicystic dysplastic kidney: single-center experience.
Pediatr Nephrol. Jan 2009;24(1):99-104
• Shepherd, W.(n.d.). Multicystic Dysplastic Kidney. Retrieved from
• Singh, J.K., Kanojia, R.P.&, Narasimhan KL.(2014). Multicystic dysplastic
kidney in children--a need for conservative and long term approach. Indian J
Pediatric. Aug 2009;76(8):809-12
• Sleurs, E., & Valero, G. (2001). Multicystic Dysplastic Kidney Disease.
Available at http://sonoworld.com/fetus/page.aspx?id=553
• Sukthankar, S.,& Watson ,A.R.(2000), Unilateral multicystic dysplastic
kidney disease: defining the natural history. Acta Paediatrica 2000;89:811-
813.
• .
May 2015

References
• Swiatecka-Urba, A., & Langman, C. (2013). Multicystic Renal Dysplasia:
Pathophysiology. Retrieved from
http://emedicine.medscape.com/article/982560-overview#a0104
• Moore Medical(n.d.). Electronically retrieved from
https://www.mooremedical.com/index.cfm?/Flexam -Sterile-Powder-Free-�
Nitrile-Exam-
Gloves/&PG=CTL&CS=HOM&FN=ProductDetail&PID=18014&spx=1
• Miller-Keane Encyclopedia & Dictionary
• US Department of Health and Human Services. Available at
http://www.niddk.nih.gov/health-information/health-topics/kidney-
disease/kidney-dysplasia/Pages/facts.aspx
May 2015

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