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Special Feature |

Radiological Case of the Month FREE

Arch Pediatr Adolesc Med. 1999;153(4):423-424. doi:.
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DENOUEMENT AND DISCUSSION: TRANSIENT ACUTE RENAL FAILURE OF THE NEWBORN

Figure 1. Sonogram of one kidney shows hyperechoic renal medullary pyramids with acoustic shadowing. There is no evidence of hydroureteronephrosis.

Renal ultrasonography plays a significant role in the diagnostic evaluation of pediatric renal disease. The normal sonographic appearance of the neonatal kidney differs greatly from that of older children. The renal medullary pyramids are hypoechoic when compared with the renal cortex, where echogenicity is comparable to the liver and spleen.1 Increased echogenicity of the renal pyramids during the neonatal period has been associated with serious renal disease, including renal vein thrombosis, nephrocalcinosis, congenital nephrotic syndrome, and cystic kidney disease.2,3 There are several reports of a distinct variety of neonatal renal disease characterized by transient oliguric renal failure and associated with hyperechoic renal medullary pyramids. These cases have been associated with an excellent prognosis in which sonographic findings and renal function return to normal.4,5

The cause of transient acute renal failure of the newborn is poorly understood. Several authors have noted significant proteinuria during the recovery phase. The protein has been identified as the Tamm-Horsfall mucoprotein, formation of which is thought to be related to tubular maturation. It is postulated that some infants are unable to excrete the increased load of mucoprotein that coincides with the transition from intrauterine to extrauterine life, and the protein is deposited in the renal tubules with subsequent obstruction of urinary flow and renal dysfunction.6,7

Other investigators postulate that transient renal failure in association with hyperechoic renal pyramids is caused by transient hyperuricemia secondary to perinatal asphyxia.8,9 Newborns generally have a transient elevation of serum uric acid concentration. The association between increased uric acid production and perinatal asphyxia is well-recognized.10 It is possible that the increased uric acid production associated with perinatal asphyxia leads to deposition of uric acid in the renal tubules, producing tubular obstruction and subsequent renal dysfunction. As the renal uric acid load is excreted, normal kidney function is restored. Therefore, uric acid would account for the increased echogenicity of the renal medullary pyramids and the transient reduced kidney function. Further support for this hypothesis is provided by the fact that serial renal ultrasonographic examinations of patients with Lesch-Nyhan syndrome, a syndrome characterized by hyperuricemia, have revealed hyperechoic renal medullary pyramids.11

Accepted for publication January 28, 1998.

Reprints: LT Derek S. Wheeler, MC, USNR, Department of Pediatrics, US Naval Hospital Guam, PSC 490, Box 221, FPO AP 96538-1600 (e-mail: ewheeler@ gam10.med.navy.mil).

Han  BKBabcock  DS Sonographic measurements and appearance of normal kidneys in children. AJR Am J Roentgenol. 1985;145611- 616
Link to Article
Slovis  TLBernstein  JGrushkin  A Hyperechoic kidneys in the newborn and young infant. Pediatr Nephrol. 1993;7294- 302
Link to Article
Shultz  PKStrife  JLStrife  CFMcDaniel  JD Hyperechoic renal medullary pyramids in infants and children. Radiology. 1991;181163- 167
Avni  EFSpehl-Robberecht  MLebrun  DGomes  HGarel  L Transient acute tubular disease in the newborn: characteristic ultrasound pattern. Ann Radiol. 1983;261175- 182
Hijazi  ZKeller  MSGaudio  KMSiegel  NJ Transient renal dysfunction of the neonate. Pediatrics. 1988;82929- 930
Salisz  JAKass  EJCacciarelli  AA Transient acute renal failure in the neonate. Urology. 1998;41137- 140
Link to Article
Starinsky  RVardi  OBatasch  DGoldberg  M Increased renal medullary echogenicity in neonates. Pediatr Radiol. 1995;25S43- S45
Ahmadian  YLewy  PR Possible urate nephropathy of the newborn infant as a cause of transient renal insufficiency. J Pediatr. 1977;12696- 100
Link to Article
Talosi  G The possible role of uric acid in renal hyper-echogenicity in neonatal hypoxic acute shock. J Perinat Med. 1996;24693- 697
Link to Article
Raivio  KO Neonatal hyperuricemia. J Pediatr. 1976;88625- 630
Link to Article
Rosenfeld  DLPreston  MPSalvaggi-Fadden  K Serial renal sonographic evaluation of patients with Lesch-Nyhan syndrome. Pediatr Radiol. 1994;24509- 512
Link to Article

Tables

References

Han  BKBabcock  DS Sonographic measurements and appearance of normal kidneys in children. AJR Am J Roentgenol. 1985;145611- 616
Link to Article
Slovis  TLBernstein  JGrushkin  A Hyperechoic kidneys in the newborn and young infant. Pediatr Nephrol. 1993;7294- 302
Link to Article
Shultz  PKStrife  JLStrife  CFMcDaniel  JD Hyperechoic renal medullary pyramids in infants and children. Radiology. 1991;181163- 167
Avni  EFSpehl-Robberecht  MLebrun  DGomes  HGarel  L Transient acute tubular disease in the newborn: characteristic ultrasound pattern. Ann Radiol. 1983;261175- 182
Hijazi  ZKeller  MSGaudio  KMSiegel  NJ Transient renal dysfunction of the neonate. Pediatrics. 1988;82929- 930
Salisz  JAKass  EJCacciarelli  AA Transient acute renal failure in the neonate. Urology. 1998;41137- 140
Link to Article
Starinsky  RVardi  OBatasch  DGoldberg  M Increased renal medullary echogenicity in neonates. Pediatr Radiol. 1995;25S43- S45
Ahmadian  YLewy  PR Possible urate nephropathy of the newborn infant as a cause of transient renal insufficiency. J Pediatr. 1977;12696- 100
Link to Article
Talosi  G The possible role of uric acid in renal hyper-echogenicity in neonatal hypoxic acute shock. J Perinat Med. 1996;24693- 697
Link to Article
Raivio  KO Neonatal hyperuricemia. J Pediatr. 1976;88625- 630
Link to Article
Rosenfeld  DLPreston  MPSalvaggi-Fadden  K Serial renal sonographic evaluation of patients with Lesch-Nyhan syndrome. Pediatr Radiol. 1994;24509- 512
Link to Article

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