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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 19  |  Issue : 1  |  Page : 71-78

Sonographic evaluation of renal volume and its correlation with estimated glomerular filtration rate among hypertensive kidney disease patients in Kano, Nigeria


1 Department of Radiology, Rasheed Shekoni Specialist Hospital, Dutse, Nigeria
2 Department of Radiology, BUK/AKTH, Kano, Nigeria

Date of Submission25-Sep-2021
Date of Decision20-Dec-2021
Date of Acceptance28-Feb-2022
Date of Web Publication12-Jul-2022

Correspondence Address:
Dr. Abdu Hamisu Dambatta
Department of Radiology BUK/AKTH, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_53_21

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  Abstract 

Context: Glomerular filtration rate (GFR) is one of the various indicators used to assess the degree of chronic kidney disease and it is considered the best marker for the estimation of renal function. Ultrasonography has become the standard imaging modality in the investigation of renal diseases due to its noninvasive nature and availability. Aims: This study was aimed at sonographically evaluating renal volume and correlating it with estimated GFR among hypertensive kidney disease patients in Kano, Nigeria. Settings and Design: This was a cross-sectional study conducted among adults with hypertensive kidney disease at Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria from September 2019 to March 2020. A convenient sampling method was employed and included 242 adults with hypertensive kidney disease in a hypertensive group and 242 normotensive participants in a control group. Materials and Methods: Renal dimensions were measured sonographically. The eGFR of each participant was estimated and recorded. Statistical Analysis Used: The data were analyzed using SPSS Inc, USA version 22. The preset P value was 0.05. Results: The renal volumes in the hypertensive group were 91.5 ± 29.3 cm3 and 103.2 ± 39.6 cm3 for right and left kidneys, respectively, while those of normotensive group were 131.43 ± 34.89 cm3 and 168.49 ± 45.83 cm3 for right and left kidneys, respectively. In the hypertensive group, moderate positive correlations were observed between left kidney volumes and eGFR (r = 0.4; P = 0.001). However, a weak positive correlation was observed between the right kidney volumes and eGFR (r = 0.3; P = 0.001). Conclusion: Renal volume was higher in the control group than in the hypertensive group. There was a moderate positive correlation between the left kidney and eGFR; however, a weak positive correlation was obtained between the right kidney and eGFR.

Keywords: Glomerular filtration rate, hypertension, kidney disease, renal volume


How to cite this article:
Alhassan S, Isyaku K, Dambatta AH. Sonographic evaluation of renal volume and its correlation with estimated glomerular filtration rate among hypertensive kidney disease patients in Kano, Nigeria. Niger J Basic Clin Sci 2022;19:71-8

How to cite this URL:
Alhassan S, Isyaku K, Dambatta AH. Sonographic evaluation of renal volume and its correlation with estimated glomerular filtration rate among hypertensive kidney disease patients in Kano, Nigeria. Niger J Basic Clin Sci [serial online] 2022 [cited 2022 Aug 9];19:71-8. Available from: https://www.njbcs.net/text.asp?2022/19/1/71/350724


  Introduction Top


Hypertension is defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg.[1] It is a major risk factor for cardiovascular disease, cerebrovascular, and renal disease.[1] Blood pressure (BP) is characterized by high variability over period of time.[2] It is one of the most common noncommunicable diseases worldwide with an estimated prevalence of 10% in Nigeria.[3] It is estimated that hypertension affects about 1 billion people all over the world.[4] A systematic review of hypertension prevalence studies in Nigeria showed the prevalence of hypertension had increased from 8.6% in the seventies (1970–1979) to 22.5% in 2000–2011.[4] Furthermore, the prevalence of hypertension is 7.2% observed by Hadiza et al.[5] in Kano, Northern Nigeria.

The kidney plays a major role in the regulation of BP and is one of the main organs affected by high BP.[3] The kidney also plays an important role in our body such as excretion of metabolic wastes, maintaining the equilibrium between fluid and electrolyte, control of BP, and erythropoiesis. The loss of kidney mass and kidney function alters the length and size of the kidney. Many diseases adversely affect the kidney leading to its enlargement and or reduction in size. Renal dimensions are also greatly affected by age, gender, and body mass index.[6]

Worldwide, the reported prevalence of hypertensive kidney disease varies, reportedly accounting for 27% of new end-stage renal disease (ESRD) patients in France, 21% in Italy, 7% in China, 6% in Japan, and about 12% in the European Dialysis and Transplantation Association (EDTA) registry.[7] In Nigeria, it is about 29.8%.[8] A hypertensive nephropathy is a form of chronic kidney disease (CKD) associated with hypertension. The link between the kidney and hypertension has been considered an interwoven relationship. Hypertensive kidney disease is a term that clinicians use when renal damage is thought to be secondary to hypertension.[9] An increase in BP was associated with an annual decline in estimated GFR.[10] Renal insufficiency is considered if the eGFR is <60 ml/min/1.73 m.[2],[11]

Renal ultrasound scan is a simple noninvasive method for estimating the kidney size/volume and has many advantages over other imaging methods. Renal length estimation by ultrasound is an important parameter in clinical evaluation of adult patient with kidney disease and healthy adult donors and has replaced radiography as the first line investigative tool.[12] Measurement of renal size by ultrasound is essential when evaluating patients with possible renal disease. However, it requires prior knowledge of actual normal renal size in the population being studied.[13]

Various indicators are used to assess the degree of CKD, among which glomerular filtration rate (GFR) is the best marker for renal function.[14] Renal volume (RV) has been emphasized by several authors to be the actual determinant of surviving nephrons in CKD.[14] It is conceivable that the kidney volume should reflect the functional capacity of the kidneys as determined by GFR.[15] This study was aimed at sonographically evaluating renal volume and correlating it with estimated GFR among hypertensive kidney disease patients in Kano, Nigeria.


  Materials and Methods Top


This was a cross-sectional study conducted among adults with hypertensive kidney disease at Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria from September 2019 to March 2020. Ethical approval to conduct the study was obtained from the Human Research and Ethics Committee of the AKTH (AKTH/MAC/SUB/12A/P-3/VI/2461). A convenient sampling method was employed and included 242 adults with hypertensive kidney disease and 242 normotensive participants in hypertensive and control groups, respectively. In hypertensive group, there were 125 males and 117 females, while in the control group, there were 120 males and 122 females. The sample size was determined using Fishers statistical formula[16] as follows:

n = Z2pq/d2

n = Sample size

P = Prevalence of hypertensive nephropathy in population (estimated 19.6% = 0.196) by Nalado et al.[8] in Kano, North western Nigeria.

Z = 95% confidence level = 1.96

d = tolerable sampling error (level of precision) = 0.05 q = 1-P

n = (1.962) × 0.196 × (1- 0.196)/(0.052)

n = 3.8416 × 0.196 × 0.804/0.0025 = 242

n = 242

In this study, 484 subjects were enrolled based on conveniences, comprising 242 normotensive controls and 242 subjects with hypertension that developed kidney disease. Hypertensive patients (BP >140/90 mmHg) with clinical and laboratory diagnosis of kidney disease with aged ≥18 years were included in the study. Normal BP in patients on medication, diabetes mellitus, polycystic kidney disease, any known congenital renal disease, pyelonephritis, glomerulonephritis, obstructive uropathy, renal papillary necrosis, and previous renal and/or ureteral surgeries were excluded from the study. In the control group, healthy normotensive (BP ≤130/90 mmHg) individual at age ≥18 years without clinical and/or sonographic features of renal disease sourced from GOPD were included in the study. Hypertensive without renal disease and or those with clinical or sonographic features of renal disease due to other diseases were excluded from the study.

Ultrasound imaging machine (Mindray Digital Ultrasound Imaging System (Model DC-6; 2007 Shenzhen Mindray Biomed electronics, China), Sphygmomanometer (Model ST –UVL; 2015 Changzhou Kanger Medical Equipment Co Ltd Jiangau, China) and stethoscope were used as instrument for data collection. Informed consent was obtained from each participant. Both kidneys were scanned by a senior registrar supervised by a consultant radiologist with more than 10 year experience following liberal application of coupling gel to displace air from the skin surfaces. The right kidney was scanned through the left posterior oblique or the left lateral decubitus position by scanning through the anterior axillary line in sagittal or axial planes, while the left kidney was scanned through the right posterior oblique or the right lateral decubitus position by scanning through the anterior axillary line in sagittal or axial planes. The liver and spleen served as acoustic windows on the right and left sides, respectively. For detailed assessment, a longitudinal scan of each kidney was also performed with the patient in prone position and the superior and inferior poles were clearly identified and marked. The renal length (L) (in cm) was taken as the longest distance between the poles (bipolar length) as shown in [Figure 1]. The anteroposterior diameter (AP) (thickness; T) (in cm) was also measured on the longitudinal scan, with the maximum distance between the anterior and the posterior walls of the kidney at the middle. The renal width (W) (in cm) was measured on the transverse scan. The renal hilum was identified and the transverse diameter was measured at this point. Renal volume was calculated using the ellipsoid formula [17]; Length X Width X Thickness X п/6 where п/6 = 0.523
Figure 1: Sonogram of the right kidney showing renal length (orange), thickness (green) and width (red)

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Subjects with gross pathology during the ultrasound scan were excluded from the study.

Samples collected were sent to the laboratory for the determination of serum creatinine for those who have no recent creatinine result (<2 weeks). Glomerular filtration rate (GFR) is generally accepted as the best indicator of kidney function. As direct measurement of GFR is complex, GFR is commonly estimated based on serum creatinine (SCr) concentration. Height-dependent (Schwartz) and height-independent (CKD-EPI) equations have been suggested for children and adolescents. The Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault equations are widely recognized equations to estimate GFR in adults.[18] However, in this study MDRD equation was used.

MDRD equation: GFR = 186.3 × (Scr)-1.154 × (age in years)-0.203 × (0.742 if female) × (1.210 if African). The obtained data were categorized into two major groups: hypertensive and control groups, further categorized into males and females. It was subjected to normality and passed the test; therefore, parametric method of data analysis was employed. The mean ± SD and range were obtained using descriptive statistics. The difference between the right and left kidney in both males and females was obtained using paired t-test. The correlation between renal volume and eGFR was obtained using Pearson's correlation method. Furthermore, the correlation between BMI and eGFR was obtained using Pearson's method. The data were analyzed using SPSS Inc, USA version 22. The preset P value was 0.05.


  Results Top


Four hundred and eighty-four (484) participants comprising of 242 hypertensive kidney patients and 242 normotensive controls participated in the study. The age, height, weight, BMI, systolic and diastolic blood pressure in hypertensive kidney patients were 44.6 ± 12.6 years, 165.1 ± 10.2 cm, 64.8 ± 13.9 Kg, 23.6 ± 5.3 Kg/m2, 175.4 ± 26.3 mmHg, and 107.3 ± 15.5 mmHg while those of normotensive group were found to be 43.3 ± 12.4 years, 167.0 ±0.7 cm, 67.6 ± 17.0 Kg, 24.4 ± 5.7 Kg, 125.0 ± 6.6 mmHg, and 80.1 ± 5.1 mmHg, respectively [Table 1].
Table 1: Demographic variables of the hypertensive kidney patients and normotensive control group

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The estimated glomerular filtration rate, fasting blood sugar, and creatinine in hypertensive kidney patients were 20.8 ± 14.7 mL/min/1.73 m2, 5.0 ± 0.8 mmol/L, and 62.06 ± 16.64 μmol/L, respectively, while those of the normotensive control group were 98.9 ± 27.5 mL/min/1.73 m2, 4.6 ± 0.6 mmol/L, and 59.42 ± 12.52 μmol/L, respectively [Table 2].
Table 2: Biochemical variables in hypertensive kidney patients and normotensive control group

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[Table 3] shows the right and left renal parameters of the hypertensive kidney patients and control group. The mean right and left renal volumes in hypertensive kidney patients were 91.5 ± 29.3 cm3 and 103.2 ± 39.6 cm3, respectively, while the mean right and left renal volumes in normotensive group were 131.5 ± 34.2 cm3 and 164.0 ± 45.7 cm3, respectively. The mean right and left renal length in hypertensive and control groups were 8.35 ± 1.0 cm; 8.5 ± 1.2 cm and 9.4 ± 0.8 cm; 9.8 ± 1.1 cm, respectively. The mean right and left renal thickness in hypertensive and control group were 3.7 ± 0.6 cm; 4.0 ± 0.8 cm and 4.1 ± 0.6 cm; 4.8 ± 0.8 cm, respectively. The mean right and left renal width in hypertensive and control group were 5.7 ± 0.8 cm; 5.7 ± 0.8 cm and 6.3 ± 0.7 cm; 6.8 ± 0.7 cm, respectively.
Table 3: Values of the right and left renal parameters of the hypertensive kidney patients and control group

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A significant difference was found between right and left renal parameters in hypertensive kidney patients except renal length in females, which showed no statistically significant difference (ρ < 0.001) (ρ = 0.45) [Table 4]. Normotensive control group also showed a significant difference between right and left renal parameters (ρ < 0.001)
Table 4: Comparison of the renal parameters between the right and left kidney in male and female hypertensive kidney patients and normotensive control group

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[Table 5]: The right and left renal volumes in the hypertensive group showed weak positive correlation on the right (r = 0.3) and moderate positive correlation (r = 0.4) on the left with eGFR and p-values of <0.001 each of which was statistically significant. However, there is a weak negative correlation among the normotensive group between right and left renal volume with Egfr (r=-0.2 and r=-0.1) respectively with p-value of 0.009 in the right kidney which is statistically significant and p=0.09 in the left kidney which is not statistically signinificant.
Table 5: Correlation of the right and left renal parameters with eGFR in hypertensive kidney patients and normotensive control group

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There were weak positive correlations between right and left renal volumes with BMI in the hypertensive kidney disease patients (r = 0.05, ρ = 0.48); (r = 0.14, ρ = 0.003), respectively [Table 6]. In the normotensive group, there was a moderate positive correlation and weak positive correlation on the right and left renal volume, respectively (r = 0.41, ρ = 0.001); (r = 0.32, ρ = 0.001).
Table 6: Correlation between renal volumes and BMI

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  Discussion Top


The findings of this study as shown in [Table 1] indicated that the age range of the hypertensive and normotensive participants were similar to the findings of the previous studies conducted by Maaji et al.[19] in Northwestern Nigeria, Egberongbe et al.[3] in Ile-Ife, Southwestern Nigeria, and Jabbari et al.[20] in Iran that reported the age range of 18–70 years among the participants. The possible reason for the agreement between the studies might be both studies were conducted in developing countries. In this study also, as indicated in [Table 1], the mean BMI for female patients was slightly higher than that of male patients in the hypertensive group, while in the normotensive group, the mean BMI of males was slightly higher than in females. This is almost similar to the findings of Makusidi et al.[21] in Ilorin. These findings were contrary to the findings of Egberongbe et al.[3] in Ile-Ife Southwestern Nigeria, where the mean BMI in male patients (27.7 ± 5.5 Kg/m2) was significantly higher than in females (24.7 ± 4.8 Kg/m2) among the hypertensive patients, while in the normotensive group, the mean BMI in females (28.8 ± 6.4Kg/m2) was significantly higher than in males (23.1 ± 3.6 Kg/m2). The difference in this study may be due to variations in diet and environmental factors.

In this study, the mean right renal volume was higher in the normotensive group (131.4 ± 34.9 cm3) compared to the hypertensive group (91.5 ± 29.3 cm3). The mean left renal volume was also found to be lower in the hypertensive group (103.2 ± 39.6 cm3) than in the normotensive group (168.5 ± 45.8 cm3). The left renal volumes in both hypertensive and normotensive groups were higher than the right renal volumes. The mean renal volumes in the normotensive group of the current study agreed with the previous study conducted by Maaji et al.[19] in Northwestern Nigeria, where the mean renal volumes of the right kidney were lower (109.6 ± 29.3 cm3) than in the left kidney (119.7 ± 32.8 cm3). Oluwatosin et al.[22] in LUTH, Lagos, Nigeria using a multi-detector computed tomography among patients with no known renal disease also reported a larger left kidney volume of 165.66 cm3 compared to a lower right kidney volume of 149.40 cm3. The values were higher than in the current study probably due to variation in imaging modalities used. Also, in Abuja, Nigeria lower means renal volumes were reported on the right kidney (139 ± 4.2 cm3) in normal volunteers than in the left kidney (173.7 ± 13.5 cm3). Similar findings by Ugboma et al.[23] in Port Harcourt, Nigeria, Werner[16] in Bloemfontein, South Africa, Arooj et al.[24] in Malaysia, and Mujahid et al.[25] in Islamabad, Pakistan reported lower mean renal volumes on the right kidney compared to the left kidney. This could be due to the relatively smaller size of the spleen compared to the liver, which allows the left kidney more space for growth; as well as the fact that left renal artery is shorter and straighter than the right one. This allows increased blood flow in the left renal artery with resultant relative increase in the left renal volume.[26] On the contrary, other studies reported that right kidney volumes are higher than the left kidney volumes, which contrasts with the findings in this study.[27] Emamian et al.[26] in Denmark reported mean right and left kidney volumes of 146 cm3 and 134 cm3, respectively, among adult healthy volunteers. This is likely due to racial differences.

The findings of the current study showed that the mean renal length was found to be higher on the left kidneys (8.5 ± 1.2 cm and 9.9 ± 0.9 cm) than on the right kidneys (8.3 ± 0.9 cm and 9.6 ± 0.9 cm) in the hypertensive and normotensive groups, respectively. The normotensive population agreed with a similar study by Yahuza et al.[28] in Kano Nigeria among healthy subjects with the mean kidney length on the right (100.6 ± 9.5 mm), which was lower than on the left kidney (102.4 ± 9.4 mm). Maaji et al.[19] also reported a higher mean left kidney length (11.6 ± 9.8 cm) than the right kidney length (11.3 ± 8.8 cm). The findings in this study were higher than those were reported by Werner[16] in Bloemfontein, South Africa, Srivastava et al.[29] in Northern India, and El-Reshaid et al.[13] in Kuwait with the left renal length higher than the right. Eze et al.[30] in Enugu among healthy subjects reported that the mean renal length of the right kidney was 79.6 ± 8.1 mm and of the left kidney was 81.6 ± 8.3 mm due to ethnic variation and body size habitus.

The mean renal thickness in this study was found to be higher on the left kidneys (3.9 ± 0.8 cm and 4.7 ± 0.7 cm) than on the right kidneys (3.6 ± 0.6 cm and 4.1 ± 0.5 cm) in the hypertensive and normotensive groups, respectively. The findings in normotensive group were in congruence with Yahuza et al.[28] in Kano, Maaji et al.[19] in Northwestern Nigeria, and Oluseyi et al.[31] in Abuja, Nigeria who reported similar mean renal thicknesses, which were lower in the right kidneys and higher in the left kidneys. A similar study by Hammad[12] in Saudi Arabia also reported higher kidney thickness on the left compared to the right in healthy individuals.

The current study revealed that the mean right renal width was lower (5.7 ± 0.8 cm and 6.3 ± 0.6 cm) than in the mean left renal width (5.7 ± 0.9 cm and 6.7 ± 0.7 cm) in the hypertensive and normotensive groups, respectively. The normotensive group renal width showed similar findings with Maaji et al.[19] in Northwestern Nigeria with 4.4 ± 0.7 cm and 5.2 ± 0.3 cm for the right and left kidneys, respectively. Our findings were also similar to the study of Oluseyi et al.[31] in Abuja, Nigeria that found right renal width of 4.1 ± 0.6 cm and 4.7 ± 0.8 cm on the left kidney. Similarly, Hammad et al.[12] in Saudi Arabia reported a lower kidney width (5.07 cm) on the right than in the left (5.16 cm).

The findings of this study as shown in [Table 4] revealed that there was a significant difference between right and left renal volume in hypertensive kidney patients and normotensive control group. Similar findings were reported in Ile-Ife[3] in Southwestern Nigeria. The findings in the normotensive group also agreed with the study of Oluseyi et al.[31] in Abuja Nigeria, although higher than our findings, who reported that the mean renal volume in males was lower on the right kidneys (140.2 ± 33.7 cm3) and higher on the left kidneys (183.0 ± 48.9 cm3), while in the females, the mean renal volume was also higher on the left kidneys (164.3 ± 47.7 cm3) and lower on the right kidneys (138.6 ± 34.8 cm3). This may likely be due to user variability and genetic makeup. Another study in Saudi Arabia by Hammad et al.[12] agrees with our normotensive group findings that renal volumes of both right and left kidneys in the male group were higher than the renal dimensions in the females.

Furthermore, the findings of the present study as shown in [Table 4] revealed that there was a significant difference between right and left renal length, width, and thickness in hypertensive kidney patients except renal length in females, which showed no statistically significant difference. Similarly, there was a significant difference between right and left renal length, width, and thickness in normotensive control group. This is in line with the previous studies conducted by Yahuza et al.[28] in Kano, Oluseyi et al.[31] in Abuja Nigeria, Saeed et al.[32] in Karachi, Pakistan, and Srivastava et al.[29] in Northern India who all reported a statistically significant difference between right and left renal parameters in both genders.

The findings of this study as shown in [Table 6] revealed weak and moderate positive correlations in right and left renal volumes with eGFR in the hypertensive group. Furthermore, there is a weak negative correlation among the normotensive group in the right and left renal volumes with eGFR. The result of our hypertensive group agrees with the findings of Sanusi et al.[33] in Ile Ife Southwest Nigeria among CKD patients, that there is a positive correlation between the renal volumes determined sonographically using Dinkel et al.'s[34] formula and MDRD formula with a moderate correlation of 0.462 and a P value of <0.004, which is statistically significant. Zubović et al.[35] in Bosnia among CKD patients reported a statistically significant correlation with P value of <0.01 between kidney volumes and creatinine clearance but no correlation was found in the control group similar to the findings in this study. Jovanović et al.[36] in Serbia reported a moderate correlation of measured kidney dimensions, parenchymal volume, and thickness with serum creatinine concentration (r = 0.442, P = 0.05) in their study group but none with their control group. Saeed et al.[32] in Karachi, Pakistan, reported a moderate positive correlation existed between renal length and estimated GFR with coefficient of correlation r = 0.415 and P value of <0.001. These findings were contrary to our normotensive group, most likely due to racial differences.

The finding of the current study as shown in [Table 6] revealed that there is a weak positive correlation between right and left renal volumes with BMI in the hypertensive group. The difference was statistically significant in the left renal volume. Furthermore, in the normotensive group, there were moderate and weak positive correlations in right and left renal volumes. This is statistically significant. This is in agreement with the previous study conducted by Maaji et al.[19] in Northwestern Nigeria who reported that renal volume in healthy adult Nigerian population showed a moderate positive correlation with height and BMI. Similarly, Egberongbe et al.[3] in Ile- Ife South-Western Nigeria, reported volumes of both kidneys showing weak positive correlations with BMI in the hypertensive group (r = 0.25 and 0.20; P < 0.01) for right and left kidneys, respectively as well as in the normotensive group (r = 0.34 and 0.25; P = 0.01), respectively. Eze et al.[30] in Enugu, southeast Nigeria, reported a moderate Pearson correlation coefficient of kidney length with BMI of r = 0.688, and showed a moderate positive correlation (r = 0.889) between kidney length and weight. Mujahid et al.[25] in Islamabad, Pakistan revealed a direct relationship between BMI and renal size in Pakistani population. A weak positive correlation was seen between BMI and relative renal length, followed by absolute renal length and renal volume respectively. In northern India, Srivastava et al.[29] estimated the relationships between renal length and anthropometric measurements among 100 adult healthy voluntary kidney donors without any renal disease. It was shown that there was no correlation between renal length and bodyweight of the individual and also no relationship with BMI. However, moderate and weak positive correlations were found between renal length and height (r = 0.402; r = 0.299) for left kidneys and right kidneys, respectively. This could be due to racial differences with our study population. Another study by Jabbari et al.[20] in Iran showed that renal lengths have a weak positive correlation with BMI on the right (r = 0.19) and on the left (r = 0.21). The slight variation on the right kidney with our study could be due to the lower sample size and racial difference.


  Conclusion Top


In conclusion, renal volume was higher in the control group than in the hypertensive group. There was a moderate positive correlation between the left kidney volume and eGFR; however, a weak positive correlation was obtained between the right kidney volume and eGFR.

It is recommended that sonographic renal volume should be routinely included in the evaluation of renal disease patients secondary to hypertension.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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