imaging approach of renal diseases in immuno-compromised patients jacques le roux 11/05/2012
TRANSCRIPT
![Page 1: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/1.jpg)
Imaging approach Imaging approach of renal diseases in of renal diseases in
immuno-immuno-compromised compromised
patientspatients
Jacques le RouxJacques le Roux11/05/201211/05/2012
![Page 2: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/2.jpg)
•The patients
•The diseases
•Approach - clinical- imaging options- imaging approach
![Page 3: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/3.jpg)
THE PATIENTS
1. The prototype – HIV/AIDS
2. Any chronic disease e.g.•Cancer
- multiple myeloma- leukaemia (most common malignant cause of bilateral ↑ kidneys)- lymphoma (usually NHL) – kidney very common extranodal site
•Collagen vasc diseases e.g. SLE (lupus nephritis)•DM
3. Chemoradiotherapy
4. Transplant patients e.g. kidney, bone marrow
![Page 4: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/4.jpg)
THE DISEASES
A. NEPHROPATHY•This is the diff Δ of renal failure – Pre, renal, post renal
Renal: (parenchyme disease)•Imaging can suggest a diagnosis
- the delayed (persistent) nephrogram/↑echos•Diagnosis remains histological e.g.
1. Acute Tubular Necrosis - oedema•Most common cause of acute renal failure•Due to:
- drugs: Haart, antibiotics (AMPH B), contrast (Iodine), chemotherapy- ischemia (renal art stenosis)- renal transplant rejection
2. Glomerulosclerosis – cell proliferation•DM, Lupus Nephritis
3. Nephrocalsinosis - Calcifications•Hypercalcemia
![Page 5: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/5.jpg)
B. RENAL INFECTIONS1. Acute pyelonephritis - DM (E.coli)2. Emphysematous pyelonephritis – gas forming organisms - life threatening,DM3. Chronic pyelonephritis - reflux , obstruction (stones)4. Opportunistic infections – AIDS related
•Pneumocystis jiroveci •TB, MAI (mycobact avium intracellulare)•Fungi (candida, aspergillus)
C. RENAL TUMORSI. Non AIDS-related in imm. compr. patients
•Non Hodgin Lymphoma•Leukemia•M. Myeloma
II. AIDS-related•NHL•Kaposi•RCC ( 8 times more)
![Page 6: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/6.jpg)
D. DRUGS (AIDS RELATED) – HAART
1. Direct (nephrotoxic)- Nephropathy (ATN)- Stones (dark) - Indinavir- FANCONI syndrome (tubular dysfunction)
•Kidney cannot reabsorb – glucose, amino acids, phosphate•Compl. Osteopenia - rickets
- osteomalacia
2. Indirect – insulin resistance•↑Colesterol→ renal art. stenosis→ HT•DM
![Page 7: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/7.jpg)
APPROACH
•Clinical: - history, renal function (↑ creat.)
•Imaging options:
1. ULTRASOUND - choice for screening (size, hydronephrosis)•Size 9-13 cm•Central echo complex (renal sinus) – dominates sonar picture
- Contains: - fat (↑echos), vessels - renal pelvis (colleting system) - surrounded by parenchyma
•Parenchyma1 Cortex – similar or ↓echos compare to liver2 Medullary pyramids - ↓ egos (sonolucent) compare to cortex
- rounded or cone shape as they bulge into complex
•Difference between cortex and medulla echos creates cortex-medulla differentiation•Color doppler – venous involvement of renal tumors
![Page 8: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/8.jpg)
RENAL PARENCHYMA (NORMAL KIDNEY)
ADULT•Parenchyma equal or ↓ echo as liver•Central Echo Complex ↑ echo
NEONATECortex - ↑ echo compared with liver - Pyramids look like hydroneph
![Page 9: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/9.jpg)
2 CT = choice for renal tumours (replaced KUB and IVP)• Precontrast – think gasses, masses, stones, bones• The 3 phases with contrast (CT -IVP)
i Corticomenullary (early arterial 20 – 90 sec)- cortex enhances before medulla- diff between them
ii Nephrogram ( 2 – 3 minutes)- renal parenchyma uniformly enhance- size, symmetry, contour, density, parench loss
iii Pyelogram – excretory (5 - 15 minutes)- opacity collecting system- calyces cupped or clubbed
• 3D for art and venous structures
3 NM (frans en gerrit se speelveld)• DTPA (glom. function)• MAG 3 (tubular function)• DMSA anatomy (stays in cortex) e.g.
- scar tissue – pyelonephr.- Massas
4 MRI – if contraindication
![Page 10: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/10.jpg)
IMAGING APPROACH
KIDNEYS
BILAT RENAL DISEASE UNILATERAL (Systemic-medical) (Focal-surgery)
Acute: Bilat. Large >13cm Chronic (end stage): bilat small <9cm e.g. immuno compromised e.g. HT, DM
A. Nephropathy – is parenchyme disease (Edema, renal failure)
US CT - Large kidneys and smooth - ↑kidneys- ↑echo – parenchyma - Precontrast - ↑Att medulla (prot in tubuli) (cortex more than liver) - Delayed nephrogram or striated- Loss of diff. (stripes in cortex is dilated tubuli with contrast - no-↓echo-renal sinus fat uniform enhancem)
![Page 11: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/11.jpg)
NEPHROPATHY•Large kidney (13cm)•↑Echo – parenchyma•↓Echo renal sinus fat•Loss of diff.
RENAL FAILURE
•Both kidneys small (< 9cm)•↑ echo in parync. compared liver
![Page 12: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/12.jpg)
AIDS NEPHROPATHY – MEDULLARY NEPHROCALCINOSIS
•Medulla pyramids ↑ echo•Cortex and columns of Bertin (cortex between pyramids) normal
![Page 13: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/13.jpg)
ACUTE PYELONEPHRITIS - US•Focal area ↑ echo
RENAL ABSCESS - US •Cystic mass with internal heterogeneous ↑echo fluid (debri)
B. RENAL INFECTIONS
ACUTE PYELONEPHRITIS – CT with contrast•Wedges of ↓Att (edema)•Striated nephrogram
PERIRENAL ABSCESS - CT•↓ Att (fluid)•Gas bubbles
![Page 14: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/14.jpg)
EMPHYSEMATOUS PYELONEPHRITIS (GAS)
X-RAYStriations in parenchyma – is gas in collective system
![Page 15: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/15.jpg)
CHRONIC PYELONEPARITIS (REFLUX NEPHROPATHY)
IVPBlunted calyx with overlying scar
![Page 16: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/16.jpg)
END STAGE RENAL TB
R Small and calcifiedL Compensatory hypertrophy
![Page 17: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/17.jpg)
OPPORTUNISTIC INFECTIONS – IMAGING NON SPECIFIC
•Pneumocystis jiroveci (fungus) MAI, CMV- small cortical calcifications- nephrocalcinosis-striated nephrogram
•Fungi (candida, aspergillus)- micro abscesses-hydronephrosis (fungal ball)
•TB (renal second most common) ,from lungs- Acute - abscesses- Chronic - small scared KIDNEY,Ca++ ,strictures (ureters)
![Page 18: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/18.jpg)
CANDIDA ALBICANS
PyonephrosisNephrostomy in left kidney - previous hydronephrosis
![Page 19: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/19.jpg)
RENAL ABSCESS – LEFT KIDNEY
Pyelogram (excretory)Low att. mass with decreased excretion of contrast
![Page 20: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/20.jpg)
TB ABSCESS - CT WITH CONTRAST
Low att. with Ca⁺⁺
![Page 21: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/21.jpg)
RENAL TB - IVP
• R Hydronephrosis• Stricture mid uret
![Page 22: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/22.jpg)
C. RENAL TUMORS IN IMMUNE COMPROMISED PATIENTS-Look for other sites of involvement
I. NON AIDS-RELATED
1. Non Hodgkin lymphoma•Kidney very common site for extra nodal lymphoma•Renal parenchyma contains no lymph. tissue - comes from retroperitoneal nodes, renal capsule (rich lymph vessels) or with blood/hematogeneous
Lesion (75% bilat.)Classic: - large kidneys
•Tumor surrounds kidney without compression of parenchyma•Encase blood vessels but lumen remains open•No thrombosis of IVC or renal vein•Enhance less than parenchyma
2. Leukaemia•Most common cause of bilat. ↑ kidneys•Chloroma – focal mass in cortex
3. M. Myeloma •Nephrocalsinosis - Hypercalcemia•Punched lytic bone lesions
![Page 23: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/23.jpg)
NON AIDS-RELATED LYMPHOMA (NHL)
Coronal – CT with contrast•Bilat ↑•No enhancement - homogenous
![Page 24: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/24.jpg)
II. AIDS RELATED
1 NHL•Usually multiple nodules•Solitary lesions
2 KAPOSI•Rare in kidney – skin lesions•↓Att
3 RCC (8 times more)•Hypervascular•Trombosis – IVC, renal vein
![Page 25: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/25.jpg)
RCC
Solid ↑ echo mass (upper pole)
![Page 26: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/26.jpg)
AIDS – RELATED LYMPHOMA
Solitary mass – poor enhancement
![Page 27: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/27.jpg)
DRUGS ---- HAART (INDINAVIR) - CALCULI ARE DARK - NO IMAGING SUPERIOR
•SONAR - CALCIFIC FOCI - If you see calculi – calcium, uric-acid, in this case was not related to indinavir
•Indirect signs- Hydronephrosis in the absence of calculi
![Page 28: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/28.jpg)
FANCONI SYNDROME WITH RENAL FAILURE
•Bone scan – T99-MDP•Diffuse bone uptake•Kidney no uptake – kidney failure (no function)
![Page 29: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/29.jpg)
L RAS - MRA
![Page 30: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/30.jpg)
RAS - DOPPLER
Intrarenal art – Tardus parvus waveform•Parvus ↓ systolic peak •Tardus delayed before systolic peak
Main renal art - systolic peak ↑
![Page 31: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/31.jpg)
RENAL TRANSPLANTANATOMY
Kidney•R Iliac fossa – extraperit•Vessels – iliac (ext or common)•Ureter – trigone
ImagingChoice - US - grayscale, doppler - NM - MAG 3Additional - CT – anatomy,VASC, 3 phases - MRI – contra indications
![Page 32: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/32.jpg)
COMPLICATIONS
A. ↓ Kidney function (parenchyme disease)
1. ATN – ischaemia, first week 2. Rejection
• Hyperacute – minutes• Acute – after 1 week• Chronic – after months
3. Drugs (nephrotoxic) – Pat. Becomes ↓ immune• Cyclosporine – after 1 month• Post transplant lymphoproliferate diseases
(a) Lymphoma(b) RCC(c) Kaposi
IMAGING ↓ Kidney Function• US – grayscale (as before), egos,diff• NM - ATN – normal perfusion, ↓ excretion
- Rejection and cyclosporin - ↓ perfusion and excretion• To diff between ATN, rejection, cyclosporin
- Do biopsy (US or CT guidance)
![Page 33: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/33.jpg)
B. Fluid collections - HAUL 1. Hematoma – first day 2. Abscess (fever) – first week 3. Urinoma – first month 4. Lymphocele – after one month
** NM - Urinoma – takes up tracer – is in urine - Lymphocele - no uptake (cold)
- usually – ureter-bladder junction
C. Vascular 1. Prerenal – RAS, RA thrombosis 2. Post renal – RVS, RV thrombosis 3. Complications due to biopsy:
- AVF- Pseudo aneurysm
If you suspect above named – do convent. angiography for stents (RAS)- Thrombectomy (RV thrombosis)- Embolization (AVF)
![Page 34: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/34.jpg)
URINOMAUptake of tracer
LYMPHOCELENo tracer uptake
ATN•Normal perfusion•↓ excretion
![Page 35: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/35.jpg)
PULSE DOPPLER (SPECTRAL WAVE FORM)
•Normal graft - low resistance waveform - flow in sist and diast.
•Acute rejection – end-diastolic flow absent - high RI >.8
•Art. flow reversed in diast.
?Severe rejection / ?ATN / ?renal vein thromb
- ΔΔ from renal vein thrombosis•Color Doppler – vein patent
•Biopsy showed rejection
![Page 36: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/36.jpg)
RENAL VEIN THROMBOSIS•Art. flow reversed in diast. (plateau)•No venous signal in vein
PSEUDOANEURYSMMid ren art– forward and reverse flowDo conv. angio
AVF•Turbulent flow•CT showed early filling of veinDo conv. angio
![Page 37: Imaging approach of renal diseases in immuno-compromised patients Jacques le Roux 11/05/2012](https://reader031.vdocuments.us/reader031/viewer/2022032215/56649ddb5503460f94ad20d1/html5/thumbnails/37.jpg)
References
1. Symeonidou C, Imaging And Histopathology Features Of HIV Related Renal Disease, Radiographics 2008; 28: 1339 – 1354.
2. Daneman A, Renal Pyramids Focused Sonography Of Normal And Pathologic Processes, Radiographics 2010; 30: 1287 – 1307.
3. Brandt WE, Fundamentals Of Diagnostic Radiology 3rd ed. 874 – 908.
4. Brown E, Complications Of Renal Transplantation: Evaluation With US And NM, Radiographics 2000; 20: 607 – 622.