ULTRASOUND DIAGNOSIS ULTRASOUND DIAGNOSIS OF KIDNEY DISEASESOF KIDNEY DISEASES

Christian Gh Klein, MDChristian Gh Klein, MDUniversity Hospital Clinic of University Hospital Clinic of

Nephrology Carol DavilaNephrology Carol Davila

22

33

Renal ultrasonography. Renal ultrasonography. Indications Indications

Urinary tract infectionsUrinary tract infections Renal colicRenal colic Macroscopic haematuriaMacroscopic haematuria Congenital abnomaliesCongenital abnomalies Obstructive uropathyObstructive uropathy UrolithiasisUrolithiasis NephrocalcinosisNephrocalcinosis Differential diagnosis of abdominal solid masses from cystic massesDifferential diagnosis of abdominal solid masses from cystic masses Benign renal neoplasmBenign renal neoplasm Malignant renal neoplasmMalignant renal neoplasm Renal parenchyma diseasesRenal parenchyma diseases Cystic diseases of the kidneyCystic diseases of the kidney Renal traumaRenal trauma Vascular diseasesVascular diseases Renal transplantsRenal transplants Acute renal failureAcute renal failure Chronic renal failureChronic renal failure Sonographically guided renal biopsySonographically guided renal biopsy Sonographically guided percutaneous nephrostomySonographically guided percutaneous nephrostomy

44

Size of normal adult kidneySize of normal adult kidney

MaleMale FemaleFemale

Longitudinal axisLongitudinal axis Right KidneyRight Kidney 11.3±0.8 11.3±0.8 (10.5-12.1)(10.5-12.1)

10.8±0.810.8±0.8(10-11.6)(10-11.6)

Left KidneyLeft Kidney 11.5±0.9 11.5±0.9 (10.6-12.4)(10.6-12.4)

10.9±110.9±1(9.9-11.9)(9.9-11.9)

Cross sectional areaCross sectional area 16-30 cm16-30 cm22 16-30 cm16-30 cm22

Volume (ml)Volume (ml) Right KidneyRight Kidney147±38147±38

(109-185)(109-185) 118±27118±27

(91-145)(91-145)

Left KidneyLeft Kidney154±37154±37

(117-191)(117-191) 125±26125±26

(99-151)(99-151)

55

Characteristics of normal adult Characteristics of normal adult kidneykidney

CharacteristicCharacteristic SizeSize EchogenicityEchogenicity ParenchymaParenchyma Renal sinusRenal sinus SurfaceSurface

AppearanceAppearance Average: 11cm (range, 9-13cm)Average: 11cm (range, 9-13cm) Right, ≤ liver, left < spleenRight, ≤ liver, left < spleen Homogeneous (except for Homogeneous (except for

hypoechoic pyramids)hypoechoic pyramids) HyperechoicHyperechoic SmoothSmooth

66

Features who are evaluate in Features who are evaluate in renal ultrasonographyrenal ultrasonography

Kidney positionKidney position Kidney sizeKidney size Kidney surfaceKidney surface Kidney anatomyKidney anatomy

Cortical renal parenchyma: Echogenicity, sizeCortical renal parenchyma: Echogenicity, size Medullar renal parenchyma: Echogenicity, size Medullar renal parenchyma: Echogenicity, size

Renal sinus: pelvis, calyces, arteries, veins Renal sinus: pelvis, calyces, arteries, veins Visualization of other abdominal organs: liver, spleen, Visualization of other abdominal organs: liver, spleen,

abdominal aorta, vena cava inferior, ureteres, prostate, abdominal aorta, vena cava inferior, ureteres, prostate, bladder, urethra, pelvis and uterus. bladder, urethra, pelvis and uterus.

77

Renal Contour AbnormalitiesRenal Contour AbnormalitiesNormal variants:Normal variants: Fetal lobulationFetal lobulation ““Dromedary’ kidneyDromedary’ kidney Hypertrophy of the renal column of BertinHypertrophy of the renal column of Bertin

Prominence of the renal contour:Prominence of the renal contour: CystsCysts AbscessesAbscesses Perinephretic hematomaPerinephretic hematoma NeoplasmNeoplasmRetraction of renal contour:Retraction of renal contour: Renal infarctionRenal infarction Chronic pyelonephritis (obstruction, vesicoureteral reflux)Chronic pyelonephritis (obstruction, vesicoureteral reflux) Kidney duplicationKidney duplication Segmental renal hypoplasia: Ask-Upmark kidneySegmental renal hypoplasia: Ask-Upmark kidney

88

Renal Size AbnormalitiesRenal Size Abnormalities Bilateral Renal Enlargement (Nephromegaly)Bilateral Renal Enlargement (Nephromegaly) Acute pyelonephritisAcute pyelonephritis Acute glomerulonephritisAcute glomerulonephritis Nephrotic syndromeNephrotic syndrome Bilateral hydronephrosis Bilateral hydronephrosis Autosomal dominant kidney polycystic diseaseAutosomal dominant kidney polycystic disease Acute renal failureAcute renal failure Amyloidosis, myeloma, lymphoma, leukemiaAmyloidosis, myeloma, lymphoma, leukemia Bilateral NeoplasmBilateral Neoplasm Renal bilateral venous thrombosisRenal bilateral venous thrombosis

99

Renal Size AbnormalitiesRenal Size AbnormalitiesUnilateral Renal Enlargement (Nephromegaly)Unilateral Renal Enlargement (Nephromegaly) Unilateral acute pyelonephritisUnilateral acute pyelonephritis Unilateral hydronephrosisUnilateral hydronephrosis Renal abscessRenal abscess NeoplasmNeoplasm Benign unilateral cysts (simple cysts, multiloculated Benign unilateral cysts (simple cysts, multiloculated

cysts, cystic dysplastic kidney)cysts, cystic dysplastic kidney) Renal venous thrombosisRenal venous thrombosis Renal congenital abnomalies: renal duplication, Renal congenital abnomalies: renal duplication,

renal ectopy with fusion of lower or upper polerenal ectopy with fusion of lower or upper pole Compensatory hypertrophy (unilateral renal Compensatory hypertrophy (unilateral renal

agenesis, unilateral hypoplasia, nephrectomia) agenesis, unilateral hypoplasia, nephrectomia)

1010

Renal Size AbnormalitiesRenal Size AbnormalitiesBilateral Small KidneysBilateral Small Kidneys Chronic glomerulonephritis (both kidney equal size, Chronic glomerulonephritis (both kidney equal size,

renal symmetry)renal symmetry) Chronic pyelonephritis (kidney with unequal size, Chronic pyelonephritis (kidney with unequal size,

one of them are atrophic, renal asymmetry)one of them are atrophic, renal asymmetry) Bilateral renal artery stenosisBilateral renal artery stenosis NephrosclerosisNephrosclerosis Bilateral renal hypoplasiaBilateral renal hypoplasia End-stage inflammatory renal disease (end-stage End-stage inflammatory renal disease (end-stage

chronic renal failure)chronic renal failure)

1111

Renal Size AbnormalitiesRenal Size Abnormalities

Unilateral Small KidneyUnilateral Small Kidney Chronic pyelonephritisChronic pyelonephritis Hydronephrosis (end stage)Hydronephrosis (end stage) Reflux nephropathyReflux nephropathy Renal artery stenosisRenal artery stenosis

1212

Renal Anatomy (Structure) Renal Anatomy (Structure) AbnormalitiesAbnormalities

Abnormalities of Renal SinusAbnormalities of Renal Sinus DuplicationDuplication

IncompleteIncompleteRenal pyramid hypertrophyRenal pyramid hypertrophyBertin column hypertrophyBertin column hypertrophyPelvic duplicationPelvic duplication

CompleteCompleteComplete or incomplete ureteral duplicationComplete or incomplete ureteral duplication

1313

Renal Anatomy (Structure) Renal Anatomy (Structure) AbnormalitiesAbnormalities

Anechoic images in renal sinusAnechoic images in renal sinus HydronephrosisHydronephrosis Caliceal diverticula (caliceal cysts)Caliceal diverticula (caliceal cysts) Peripelvic cystsPeripelvic cysts

Hypoechoic images in renal sinusHypoechoic images in renal sinus Sinusal lipomatosisSinusal lipomatosis NeoplasmNeoplasm

1414

Renal Anatomy (Structure) Renal Anatomy (Structure) AbnormalitiesAbnormalities

Hypoechoic images in renal sinusHypoechoic images in renal sinus Sinusal lipomatosisSinusal lipomatosis NeoplasmNeoplasm

Hyperechoic images with acoustic shadow in Hyperechoic images with acoustic shadow in the renal sinusthe renal sinus Renal calculi: caliceal stones, pelvic stonesRenal calculi: caliceal stones, pelvic stones Arcuate calcifications (curved, ring shaped): Arcuate calcifications (curved, ring shaped):

hydatic cysts, abscesses, aneurysmshydatic cysts, abscesses, aneurysms Dystrophic calcifications: xantogranulomatous Dystrophic calcifications: xantogranulomatous

pyelonephritis pyelonephritis

1515

Renal Anatomy (Structure) Renal Anatomy (Structure) AbnormalitiesAbnormalities

Abnormalities of renal parenchymaAbnormalities of renal parenchyma CalcificationsCalcifications

DiffuseDiffuseCorticalCortical

Chronic glomerulonephritisChronic glomerulonephritisAcute cortical necrosisAcute cortical necrosisRenal transplant rejectionRenal transplant rejectionCortical nephrocalcinosis, rare: acute cortical Cortical nephrocalcinosis, rare: acute cortical

necrosis, hyperoxalurianecrosis, hyperoxaluriaMedullarMedullar

Medullary nephrocalcinosis: distal tubular Medullary nephrocalcinosis: distal tubular acidosis, hyperparathyroidism, medullary sponge acidosis, hyperparathyroidism, medullary sponge kidneykidney

1616

Renal Anatomy (Structure) Renal Anatomy (Structure) AbnormalitiesAbnormalities

Abnormalities of renal parenchymaAbnormalities of renal parenchyma CalcificationsCalcifications

LocalizedLocalizedCorticalCortical

− TuberculosisTuberculosis− Renal infarctionRenal infarction

MedullaryMedullary− Hyperechoic images ± calcifications: Hyperechoic images ± calcifications:

angiomyolipomaangiomyolipoma− Ring calcifications: tuberculosis cavern, Ring calcifications: tuberculosis cavern,

echinococcal cyst, abscessechinococcal cyst, abscess− Anarchic: renal cell carcinomaAnarchic: renal cell carcinoma

1717

Renal Anatomy (Structure) Renal Anatomy (Structure) AbnormalitiesAbnormalities

Abnormalities of renal parenchymaAbnormalities of renal parenchyma Anechoic images in renal parenchymaAnechoic images in renal parenchyma

− Hereditary cysts: autosomal dominant polycystic disease, Hereditary cysts: autosomal dominant polycystic disease, von Hippel- Lindau disease, tuberous sclerosis Bournevillevon Hippel- Lindau disease, tuberous sclerosis Bourneville

− Congenital non-hereditary cysts: cystic dysplastic kidney, Congenital non-hereditary cysts: cystic dysplastic kidney, medullary sponge kidneymedullary sponge kidney

− Acquired cystsAcquired cysts Solid localized images (hypoechoic, hyperechoic):Solid localized images (hypoechoic, hyperechoic):

− AbscessAbscess− Xantogranulomatous pyelonephritis Xantogranulomatous pyelonephritis − Benign renal neoplasmsBenign renal neoplasms− Malignant renal neoplasmsMalignant renal neoplasms

1818

Renal Anatomy (Structure) Renal Anatomy (Structure) AbnormalitiesAbnormalities

Diffuse hyperechoic abnormalities of renal parenchymaDiffuse hyperechoic abnormalities of renal parenchyma With normal renal sizeWith normal renal size

− Glomerulonephritis: acute, chronicGlomerulonephritis: acute, chronic− Acute pyelonephritis: areas of both increased and Acute pyelonephritis: areas of both increased and

decreased echogenicitydecreased echogenicity− Chronic pyelonephritisChronic pyelonephritis− Acute renal failure: acute tubulointerstitial nephropathyAcute renal failure: acute tubulointerstitial nephropathy− Chronic rejection of renal graftChronic rejection of renal graft− Amyloidosis and glomerular diseases with monoclonal Amyloidosis and glomerular diseases with monoclonal

immunoglobulin deposition immunoglobulin deposition With small kidneyWith small kidney

1919

Perirenal abnormalitiesPerirenal abnormalitiesHematomaHematomaAbscessAbscessNeoplasmsNeoplasmsUrinoma Urinoma

2020

Causes of hydronephrosisCauses of hydronephrosis

COMMONCOMMONObstructionObstructionPrevious obstructionPrevious obstructionExtrarenal pelvisExtrarenal pelvisDistended bladderDistended bladderPregnancyPregnancy

UNCOMMONUNCOMMONActive diuresisActive diuresisDiabetes insipidusDiabetes insipidusReflux nephropathyReflux nephropathy

2121

Renal cystic diseasesRenal cystic diseasesKidney

sizeKidneytumors

Extrarenalcysts

Extrarenallesions

APKD Large None Liver Cerebral aneurysms

VHL Normal/large RCC Pancreas

Pancreas cystic neoplasms

Pancreas islet cell tumors

Pheochromocytomas

SNC hemangioblastomas

Retinal angiomas

ACD Small RCC None None

TS Normal/large AML None

Cerebral hamartomas

Periventricularnodules

Subungual fibromas

Cardiac rhabdomyomas

Lung lymphangiomyomatosisAPKD, adult polycystic kidney disease; VHL, von Hippel-Lindau disease; RCC, renal cell carcinoma; CNS, central nervous system; ACD, acquired cystic disease; TS, tuberous sclerosis; AML, angiomyolipoma