Chapter 32

Congenital anomalies occur more frequently in the kidney than in any other organ. Some cause no difficulty, but many (eg, hypoplasia, polycystic kidneys) cause impairment of renal function. It has been noted that children with a gross deformity of an external ear associated with ipsilateral maldevelopment of the facial bones are apt to have a congenital abnormality of the kidney (eg, ectopy, hypoplasia) on the same side as the visible deformity. Lateral displacement of the nipples has been observed in association with bilateral renal hypoplasia.

A significant incidence of renal agenesis, ectopy, malrotation, and duplication has been observed in association with congenital scoliosis and kyphosis. Unilateral agenesis, hypoplasia, and dysplasia are often seen in association with supralevator imperforate anus. For a better understanding of these congenital abnormalities, see the discussion of the embryology and development of the kidney in Chapter 2.

Bilateral renal agenesis is extremely rare; no more than 400 cases have been reported. The children do not survive. The condition does not appear to have any predisposing factors. Prenatal suspicion of the anomaly exists when oligohydramnios is present on fetal ultrasound examination. Pulmonary hypoplasia and facial deformities (Potter facies) are usually present. Abdominal ultrasound examination usually establishes the diagnosis.

One kidney may be absent (estimated incidence: 1 in 450–1000 births). In some cases, this may be because the ureteral bud (from the Wolffian duct) failed to develop or, if it did develop, did not reach the metanephros (adult kidney). Without a drainage system, the metanephric mass undergoes atrophy. The ureter is absent on the side of the unformed kidney in 50% of cases, although a blind ureteral duct may be found (see Chapter 2).

Renal agenesis causes no symptoms; it is usually found by accident on abdominal or renal imaging. It is not an easy diagnosis to establish even though on inspection of the bladder, the ureteral ridge is absent and no orifice is visualized, for the kidney could be present but be drained by a ureter whose opening is ectopic (into the urethra, seminal vesicle, or vagina). If definitive diagnosis seems essential, isotope studies, ultrasonography, and computed tomography (CT) should establish the diagnosis.

There appears to be an increased incidence of infection, hydronephrosis, and stones in the contralateral organ. Other congenital anomalies associated with this defect include cardiac, vertebral column, and anal anomalies, as well as anomalies of the long bones, hands, and genitalia.

Hypoplasia implies a small kidney. The total renal mass may be divided in an unequal manner, in which case one kidney is small and the other correspondingly larger than normal. Some of these congenitally small kidneys prove, on pathologic examination, to be dysplastic. Unilateral or bilateral hypoplasia has been observed in infants with fetal alcohol syndrome, and renal anomalies have been reported in infants with in utero cocaine exposure.

Differentiation from acquired atrophy is difficult. Atrophic pyelonephritis ...

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