1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Anonymous Resident Affiliation: National Capital Consortium

2. MedPix No: 2805 - History Pt Demographics: Age = 46 y.o. Gender = man ADPKD patient who recently underwent his second renal transplantation. The patient first underwent renal transplant 20 years ago for chronic renal failure secondary to ADPKD. After ten years, the patient rejected his transplant when he stopped taking his immunosuppresant therapy. For the past ten years, the patient has been hemodialysis-dependent. Downloaded by (-1)

3. MedPix No: 2805 - EXAM & LABS

4. KUB Enlarged, irregular kidney shadows are noted bilaterally. Surgical clips in right pelvis consistent - with sight of previous transplant. Surgical staples in left flank consistent with recent renal - transplantation. Incidental finding of calcified seminal vesicles and vas deferens is noted. - Downloaded by (-1)

5. CT of ADPKD Lower poles of bilateral enlarged kidneys distorted by multiple macrocysts. - - Downloaded by (-1)

6. CT of Transplant Transplanted kidney visible in left pelvis and surgical staples noted on right abdominal wall. - Downloaded by (-1)

7. MRI of ADPKD w/hemorrhagic cyst Bilateral enlarged kidneys with multiple low signal intensity cystic structures of various size which distort the shape of kidneys. Large area of bright signal intensity in upper pole of right kidney consistent with hemorrhagic cyst (arrowhead). - - - Downloaded by (-1)

8. MRI of ADPKD Multiple high intensity cystic structures overwhelming both kidneys, consistent with polycystic kidney disease. - - Of note is the absence of hepatic cysts, which frequently are present in patients with ADPKD. - - - - - - - - Downloaded by (-1)

9. FINDINGS 1.KUB Enlarged, irregular kidney shadows are noted bilaterally. Surgical clips in right pelvis consistentwith sight of previous transplant. Surgical staples in left flank consistent with recent renaltransplantation. Incidental finding of calcified seminal vesicles and vas deferens is noted.2.CT of abdomen (sagital view)(a) Lower poles of bilateral enlarged kidneys distorted by multiple macrocysts.(b) Transplanted kidney visible in left pelvis and surgical staples noted on right abdominal wall.3.MRI of abdomen(coronal view)(a) TI weighted-Multiple high intensity cystic structures overwhelming both kidneys, consistent with polycystic kidney disease.(b)T2 weighted-Bilateral enlarged kidneys with multiple low signal intensity cystic structures of various size which distort the shape of kidneys. Large area of bright signal intensity in upper pole of right kidney consistent with hemorrhagic cyst.*****Of note is the normal-appearing kidney present in the left pelvis, consistent with recent transplantation.*****Also of note is the absence of hepatic cysts, which frequently are present in patients with ADPKD.

10. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Given the above radiographs, the differential diagnosis for this patient is ADPKD vs. acquired cystic disease of the kidney secondary to chronic dialysis. However, acquired disease is typically less severe and the kidneys are usually small. In this case, the diagnosis of ADPKD has been long- standing. - -

11. Diagnosis: Autosomal Dominant Polycystic Kidney Disease Dx Confirmed by:

12. DISCUSSION