What is the best course of treatment for a 66-year-old patient with impaired renal function (eGFR 96 mL/min/1.73m2), hypercalcemia (9.2 mg/dL), elevated alkaline phosphatase (168 IU/L), gallstones, adenomyomatosis, and renal lesions, including a 2.4 cm solid nodule on the left kidney and a 10 mm echogenic cortical lesion on the right kidney?

Management of Renal Lesions and Associated Findings

The 2.4 cm solid left renal nodule requires urgent further characterization with contrast-enhanced CT or MRI to determine if this represents renal cell carcinoma, and if confirmed as a cT1a tumor, partial nephrectomy should be prioritized as the definitive treatment. 1

Immediate Priority: Left Renal Nodule Evaluation

The most critical finding requiring immediate action is the 2.4 cm solid-appearing left renal nodule. For any solid renal mass in a 66-year-old patient, renal cell carcinoma must be presumed until proven otherwise, and tissue diagnosis or definitive surgical management should proceed without delay. 1

Diagnostic Workup for Renal Masses

• Obtain contrast-enhanced CT or MRI of the abdomen and pelvis to characterize the left renal nodule and determine if it represents a solid enhancing mass consistent with RCC versus a benign entity like angiomyolipoma or oncocytoma 1
• Renal mass biopsy should be considered if the mass is suspected to be hematologic, metastatic, inflammatory or infectious, but is not required if you are proceeding directly to surgical management in a healthy patient willing to accept surgical intervention 1
• The 10 mm echogenic right renal cortical lesion likely represents an angiomyolipoma or small cyst, but should also be characterized on the same contrast study 1

Surgical Management Algorithm

Partial nephrectomy is the strongly recommended treatment for cT1a renal masses (≤4 cm) when intervention is indicated, as it minimizes risk of CKD progression while providing excellent oncologic outcomes. 1 Your patient's eGFR of 96 mL/min/1.73 m² is excellent, making them an ideal candidate for nephron-sparing surgery. 1

• Laparoscopic partial nephrectomy should be offered as the preferred approach for this 2.4 cm mass, as it provides equivalent oncologic outcomes to open surgery with reduced morbidity 1
• Radical nephrectomy should be avoided unless partial nephrectomy is technically not feasible, given the patient's preserved renal function and the small size of the tumor 1
• Active surveillance is NOT appropriate for this patient, as it is reserved only for patients ≥75 years with substantial comorbidities and tumors <4 cm 1

Genetic Counseling Consideration

Genetic counseling should be considered for patients with multifocal or bilateral renal masses, which this patient has (bilateral renal lesions). 1 While the patient is 66 years old (above the age 46 threshold for mandatory genetic evaluation), the presence of bilateral lesions raises concern for hereditary RCC syndromes. 1

Left Suprarenal Nodule Management

The 2.4 cm solid-appearing left suprarenal nodule requires dedicated adrenal protocol CT or MRI to distinguish between:

• Adrenal adenoma (most common, typically <10 Hounsfield units on unenhanced CT)
• Pheochromocytoma (requires biochemical screening with plasma metanephrines)
• Adrenal metastasis (less likely without known primary malignancy)
• Adrenocortical carcinoma (rare, but must be excluded)

Before any surgical intervention for the renal mass, biochemical screening for pheochromocytoma must be performed to prevent intraoperative hypertensive crisis. 1 This includes plasma-free metanephrines or 24-hour urine metanephrines and catecholamines.

Gallstones and Adenomyomatosis

Your patient has asymptomatic cholelithiasis with gallbladder adenomyomatosis. Cholecystectomy is NOT indicated for asymptomatic gallstones, even when adenomyomatosis is present, unless the patient develops biliary colic, acute cholecystitis, or other complications. 1

• The adenomyomatosis finding is benign and does not increase malignancy risk
• If the patient develops symptoms attributable to gallstones (right upper quadrant pain, biliary colic), laparoscopic cholecystectomy should be performed 1

Hepatic Steatosis Management

The mildly increased hepatic echogenicity suggests hepatic steatosis (fatty liver). With normal liver enzymes (ALT 12, AST 14), this represents non-alcoholic fatty liver disease (NAFLD) without significant inflammation.

Management focuses on lifestyle modification:

• Weight loss of 7-10% if overweight or obese
• Regular aerobic exercise (150 minutes per week minimum)
• Mediterranean diet pattern
• Avoid alcohol consumption
• Screen for and manage metabolic syndrome components (diabetes, hypertension, dyslipidemia)

The elastography results would help determine if fibrosis is present, which would upgrade the diagnosis to NASH and require more aggressive monitoring.

Alkaline Phosphatase Elevation

The alkaline phosphatase of 168 IU/L (mildly elevated) with normal GGT (24 IU/L) and normal transaminases suggests a bone source rather than hepatobiliary source. 1

Obtain alkaline phosphatase isoenzymes or bone-specific alkaline phosphatase to confirm the source. If bone-derived, evaluate for:

• Paget's disease of bone (obtain plain radiographs of symptomatic areas)
• Vitamin D deficiency (check 25-hydroxyvitamin D level)
• Occult bone metastases (less likely given normal calcium and lack of known malignancy)

Renal Function Monitoring

Your patient's eGFR of 96 mL/min/1.73 m² is excellent and requires no specific intervention. 1, 2 However, given the planned surgical intervention:

• Nephrology referral should be considered if eGFR is expected to fall below 30 mL/min/1.73 m² after partial nephrectomy, though this is unlikely given the small tumor size and excellent baseline function 1
• Recheck eGFR 1-2 weeks post-operatively, then at 3 months, 6 months, and annually thereafter 1

Critical Pitfalls to Avoid

• Do not delay surgical evaluation of the solid renal mass while pursuing workup of other incidental findings—the renal mass takes absolute priority 1
• Do not perform prophylactic cholecystectomy at the time of renal surgery for asymptomatic gallstones 1
• Do not proceed with renal surgery without first excluding pheochromocytoma if the suprarenal nodule remains uncharacterized 1
• Do not assume the elevated alkaline phosphatase is from liver disease when GGT is normal—this pattern strongly suggests bone pathology 1