What is the diagnosis for a 76-year-old male with Chronic Kidney Disease (CKD), abdominal pain, and ultrasonography findings of gallstones, renal cysts, and echogenic renal cortex?

From the Guidelines

I strongly recommend scheduling an MRI without contrast to further evaluate the variant renal cyst in the left kidney, given the patient's chronic kidney disease and potential risks associated with contrast agents 1. The patient's abdominal pain and bloating could be contributed by the gallstones and sludge, but clinical correlation with the patient's symptoms is necessary to determine the cause of the symptoms. While waiting for imaging, symptomatic management can include:

• Dietary modifications (low-fat diet)
• Adequate hydration
• Over-the-counter pain relievers like acetaminophen (500-1000mg every 6 hours as needed, not exceeding 3000mg daily in CKD) The patient should continue nephrology follow-up for the chronic kidney disease, which is also evidenced by the echogenic renal cortex on ultrasound 1. The multiple renal cysts are likely simple cysts common in older adults, but the variant cyst requires further characterization to rule out any malignant features 1. If gallstones are determined to be symptomatic after other causes are ruled out, surgical consultation for possible cholecystectomy may be warranted, though the risks must be carefully weighed given the patient's age and kidney disease 1.

From the Research

Imaging Findings

• The patient has multiple renal cysts with a slightly variant appearing cyst in the left central kidney, as shown on the ultrasound abdomen [(2,3)].
• The ultrasound also shows small gallstones mixed with isoechoic gallbladder sludge, but no wall thickening or biliary dilatation 2.
• The renal cortex is mildly echogenic bilaterally, suggesting an underlying medical renal disease 4.

Diagnostic Approach

• A CT of the abdomen before and after contrast is recommended to further characterize the renal cysts, if feasible [(2,3)].
• Alternatively, an MRI without contrast could be performed [(2,3)].
• Contrast-enhanced ultrasound (CEUS) has been shown to be useful in characterizing complex renal cysts, particularly in cases where CT or MRI is inconclusive [(5,6)].

Bosniak Classification

• The Bosniak classification system is a useful tool for classifying cystic renal masses, and can help guide management decisions [(2,3,6)].
• The classification system is based on the results of a computed tomography protocol, but can also be applied to ultrasound and MRI findings [(2,3)].

Management

• Patients with complex renal cysts may require surgical management, particularly if the cysts are classified as Bosniak category 3 or higher 6.
• In cases where the diagnosis is uncertain, further imaging studies or follow-up examinations may be necessary to determine the best course of management 6.