radiological assessment of the kidney in patients with hematuria
TRANSCRIPT
Jeremy McKay, HMS III
Gillian Lieberman, MD
Radiological Assessment of Radiological Assessment of the Kidney in Patients with the Kidney in Patients with
HematuriaHematuria
Jeremy L. McKay, Harvard Medical Jeremy L. McKay, Harvard Medical School Year IIISchool Year III
Gillian Lieberman, MDGillian Lieberman, MD
March 2005
Jeremy McKay, HMS III
Gillian Lieberman, MD
HematuriaHematuria
Signs and SymptomsSigns and Symptoms–– Microscopic or gross Microscopic or gross hematuriahematuria–– Abdominal painAbdominal pain–– FeverFever–– PolyuriaPolyuria, , dysuriadysuria–– Flank painFlank pain
HematuriaHematuria is commonis common–– 2.5% of men ages 282.5% of men ages 28--57 tested positive for 57 tested positive for
hemeheme–– 5.4% men ages 185.4% men ages 18--5454
Jeremy McKay, HMS III
Gillian Lieberman, MD
HematuriaHematuria cont.cont.
Retrospective Study of 100 patients with Retrospective Study of 100 patients with hematuriahematuria–– Most Common Causes:Most Common Causes:
41.8% 41.8% NeoplasiaNeoplasia–– 19% BPH19% BPH–– 9% Bladder9% Bladder–– 6% Kidney6% Kidney–– 6% Prostate6% Prostate
26.6% Infection26.6% Infection13.6% 13.6% NephrolithiasisNephrolithiasis3.6% Congenital Abnormalities3.6% Congenital Abnormalities2% Trauma2% Trauma12% No identifiable cause12% No identifiable cause
Jeremy McKay, HMS III
Gillian Lieberman, MD
Renal Causes of Renal Causes of hematuriahematuriaVasculitisVasculitis–– HenochHenoch--SchonleinSchonlein purpurapurpura, , periarteritisperiarteritis nodosanodosa, Wegener , Wegener
granulomatosisgranulomatosis
GlomerularGlomerular diseasedisease–– PostinfectiousPostinfectious nephritis, nephritis, IgAIgA nephropathy, Lupus, nephropathy, Lupus, AlportAlport, thin , thin
basement membrane disease, Nailbasement membrane disease, Nail--patella syndrome, patella syndrome, FabryFabry diseasedisease
TubulointerstitialTubulointerstitial diseasedisease–– Polycystic kidney disease, Polycystic kidney disease, nephrolithiasisnephrolithiasis, analgesic nephropathy, , analgesic nephropathy,
reflux nephropathy, tumors, infectionreflux nephropathy, tumors, infection
Renal MassesRenal Masses–– Vascular, Vascular, neoplasticneoplastic, congenital, congenital
VascularVascular–– AV malformations, renal artery disease, renal vein thrombosisAV malformations, renal artery disease, renal vein thrombosis
Jeremy McKay, HMS III
Gillian Lieberman, MD
Diagnostic Imaging MethodsDiagnostic Imaging MethodsUSUS–– Best to exclude urinary obstructionBest to exclude urinary obstruction–– Can diagnose Can diagnose hydronephrosishydronephrosis and it’s causeand it’s cause–– Should be performed in all patients presenting Should be performed in all patients presenting
with renal failure of unknown etiologywith renal failure of unknown etiology–– Chronic Chronic pyelonephritispyelonephritis with no response to with no response to
therapytherapy–– Doppler US to evaluate renal vascular flow Doppler US to evaluate renal vascular flow
Jeremy McKay, HMS III
Gillian Lieberman, MD
Diagnostic Imaging MethodsDiagnostic Imaging Methods
CT ScanCT Scan–– Often compliments findings with Often compliments findings with
ultrasonographyultrasonography–– NonNon--contrast: Gold standard for radiologic contrast: Gold standard for radiologic
diagnosis of renal stonesdiagnosis of renal stones–– Used to evaluate and stage renal cell Used to evaluate and stage renal cell
carcinomacarcinoma–– Used to diagnose renal vein thrombosisUsed to diagnose renal vein thrombosis
Jeremy McKay, HMS III
Gillian Lieberman, MD
Diagnostic Imaging MethodsDiagnostic Imaging Methods
MRIMRI–– Gold standard for Gold standard for DxDx of renal vein thrombosis of renal vein thrombosis
along with renal along with renal venographyvenography and CTand CT–– MRA playing an increasing role in evaluating MRA playing an increasing role in evaluating
patients with patients with renovascularrenovascular hypertension hypertension decreasing need for renal angiographydecreasing need for renal angiography
–– For patients with dye allergiesFor patients with dye allergies
Jeremy McKay, HMS III
Gillian Lieberman, MD
Diagnostic Imaging MethodsDiagnostic Imaging Methods
Plain Film of the AbdomenPlain Film of the Abdomen
–– Good for patients complaining of symptoms Good for patients complaining of symptoms consistent with consistent with nephrolithiasisnephrolithiasis..
–– Will miss small and radiolucent stonesWill miss small and radiolucent stones–– Not commonly performed on patients with Not commonly performed on patients with
renal disease renal disease
Jeremy McKay, HMS III
Gillian Lieberman, MD
Diagnostic Imaging MethodsDiagnostic Imaging Methods
Intravenous Intravenous pyelogrampyelogram–– Previously the principal radiologic technique Previously the principal radiologic technique
used for patients with possible renal diseaseused for patients with possible renal disease–– High sensitivity and specificity for detection of High sensitivity and specificity for detection of
stones and degree of obstructionstones and degree of obstruction–– Structural disorders: Chronic Structural disorders: Chronic pyelopyelo, , medullarymedullary
sponge kidney, papillary necrosissponge kidney, papillary necrosis
Jeremy McKay, HMS III
Gillian Lieberman, MD
Diagnostic Imaging MethodsDiagnostic Imaging Methods
Renal Renal ArteriographyArteriography–– Used less frequently due to less invasive CT Used less frequently due to less invasive CT
and MRIand MRI–– Useful in Useful in DxDx of of polyarteritispolyarteritis nodosanodosa–– Used in preoperative mapping of vasculatureUsed in preoperative mapping of vasculature
Renal Renal VenographyVenography–– Useful for Useful for DxDx of renal vein thrombosisof renal vein thrombosis
Jeremy McKay, HMS III
Gillian Lieberman, MD
Diagnostic Imaging MethodsDiagnostic Imaging Methods
Radionuclide studiesRadionuclide studies–– Early detection of Early detection of vesicoureteralvesicoureteral reflux and reflux and
scarring; More sensitive than IVP in detecting scarring; More sensitive than IVP in detecting renal scarsrenal scars
Voiding Voiding cystourethrogramcystourethrogram–– VesicoureteralVesicoureteral refluxreflux
Retrograde/Retrograde/AnterogradeAnterograde PyelographyPyelography–– Relieve urinary tract obstructionRelieve urinary tract obstruction–– Supplanted by US and CTSupplanted by US and CT
Jeremy McKay, HMS III
Gillian Lieberman, MD
Diagnostic Imaging MethodsDiagnostic Imaging MethodsCT CT UrographyUrography–– Combines unenhanced, Combines unenhanced, nephrogenicnephrogenic--phase, phase,
and excretory phase imagingand excretory phase imagingUnenhancedUnenhanced-- detects renal calculidetects renal calculiNephrogenicNephrogenic phase phase –– renal renal parenchymalparenchymalabnormalities (esp. masses)abnormalities (esp. masses)Excretory phase Excretory phase –– urothelialurothelial diseasedisease
–– Becoming standard diagnostic methodBecoming standard diagnostic method
Jeremy McKay, HMS III
Gillian Lieberman, MD
Renal MassesRenal Masses
Renal masses frequently cause Renal masses frequently cause hematuriahematuriaCharacterization of the mass is essentialCharacterization of the mass is essential–– Simple cyst, complex cyst, or solid massSimple cyst, complex cyst, or solid mass
BosniakBosniak Classification SystemClassification System–– I and II I and II –– benignbenign–– IIIIII--IV IV –– possibly malignant, warranting possibly malignant, warranting
surgerysurgery
CTU, CT, US, MRCTU, CT, US, MR
Jeremy McKay, HMS III
Gillian Lieberman, MD
Spiral CT Evaluation of the Kidney (in: Spiral CT: Principles, Techniques and Clinical Applications. Fishman, Jeffrey, eds. 1998)
Patient 1: Simple Cysts on CT
Contrast Enhanced
Without Contrast
Jeremy McKay, HMS III
Gillian Lieberman, MD
Spiral CT Evaluation of the Kidney (in: Spiral CT: Principles, Techniques and Clinical Applications. Fishman, Jeffrey, eds. 1998)
Patient 2: Wilms Tumor
Enlarged non- functioning left renal mass
Jeremy McKay, HMS III
Gillian Lieberman, MD
Spiral CT Evaluation of the Kidney (in: Spiral CT: Principles, Techniques and Clinical Applications. Fishman, Jeffrey, eds. 1998)
Patient 3: Renal Cell Carcinoma on contrast enhanced CT
Jeremy McKay, HMS III
Gillian Lieberman, MD
Spiral CT Evaluation of the Kidney (in: Spiral CT: Principles, Techniques and Clinical Applications. Fishman, Jeffrey, eds. 1998)
Patient 4: Stage III Renal Cell Carcinoma involving left renal vein
Jeremy McKay, HMS III
Gillian Lieberman, MD
Renal InfectionsRenal Infections
PyelonephritisPyelonephritis–– Acute, chronic, reflux nephropathyAcute, chronic, reflux nephropathy–– Flank pain, fever, urgencyFlank pain, fever, urgency–– Radiologic imaging:Radiologic imaging:
IVPIVPCTUCTUUSUS
Jeremy McKay, HMS III
Gillian Lieberman, MD
BIDMC Radiology Dept.
Patient 5: Pyelonephritis on CT
Jeremy McKay, HMS III
Gillian Lieberman, MD
Patient 6: Pyelonephritis on CT
BIDMC Radiology Dept.
Jeremy McKay, HMS III
Gillian Lieberman, MD
.med.wayne.edu/ diagRadiology/TF/GU/GU09.html
Patient 7: Pyelonephritis on CT
Jeremy McKay, HMS III
Gillian Lieberman, MD
Renal CalculiRenal Calculi
NephrolithiasisNephrolithiasis–– Common cause of Common cause of hematuriahematuria–– 12% will develop kidney stones12% will develop kidney stones–– Plain film not as sensitive as unenhanced CTPlain film not as sensitive as unenhanced CT–– CT (unenhanced) for renal calculiCT (unenhanced) for renal calculi–– US also useful for detecting renal calculi as US also useful for detecting renal calculi as
well as well as hydronephrosishydronephrosis–– “Colicky pain”“Colicky pain”
Jeremy McKay, HMS III
Gillian Lieberman, MD
urologyassociates.com/ stonepuz.html
Patient 8: Right Hydronephrosis on IVP
Jeremy McKay, HMS III
Gillian Lieberman, MD
Spiral CT Evaluation of the Kidney (in: Spiral CT: Principles, Techniques and Clinical Applications. Fishman, Jeffrey, eds. 1998
Patient 9: Left Renal Pelvis Obstruction on CT
Jeremy McKay, HMS III
Gillian Lieberman, MD
Congenital AnomaliesCongenital Anomalies
Some congenital anomalies in the urinary Some congenital anomalies in the urinary tract can cause tract can cause hematuriahematuria
Well visualized with CT, US, IVP, and MR Well visualized with CT, US, IVP, and MR imagingimaging
Jeremy McKay, HMS III
Gillian Lieberman, MD
Spiral CT Evaluation of the Kidney (in: Spiral CT: Principles, Techniques and Clinical Applications. Fishman, Jeffrey, eds. 1998)
Patient 10: Adult Polycystic Renal Disease
Jeremy McKay, HMS III
Gillian Lieberman, MD
Patient 11Patient 11
63 year63 year--old maleold male–– Presented to the ED with gross Presented to the ED with gross hematuriahematuria, ,
flank pain, and fever lasting for two daysflank pain, and fever lasting for two days–– PMH: hypercholesterolemia, HTN, PE, IVC PMH: hypercholesterolemia, HTN, PE, IVC
filter, depression, filter, depression, s/ps/p cholechole–– Meds: ASA 81, Coumadin 2.5, Lipitor 80, Meds: ASA 81, Coumadin 2.5, Lipitor 80,
MetoprololMetoprolol 50, Viagra 50, 50, Viagra 50, WellbutrinWellbutrin 5050–– Exam: 97.5 207lbs 110/70 97% 64Exam: 97.5 207lbs 110/70 97% 64
Exam relatively normalExam relatively normalLabs: UA: gross Labs: UA: gross hematuriahematuria. INR = 8. INR = 8
Jeremy McKay, HMS III
Gillian Lieberman, MD
10/04 CT Abd. BIDMC Radiology Dept. PACS
Patient 11: Baseline CTU w/o contrast 10/04
Jeremy McKay, HMS III
Gillian Lieberman, MD
Patient 11: Current CT abd w/o contrast
3/05 CTU Abd. BIDMC Radiology Dept. PACS
•Bilateral fat stranding
•Both kidneys appear larger
Jeremy McKay, HMS III
Gillian Lieberman, MD Patient 11: CT abd w/o contrast
3/05 CTU Abd. BIDMC Radiology Dept. PACS
•Dilated renal pelvis
Jeremy McKay, HMS III
Gillian Lieberman, MD
Patient 11: CTU contrast phase
3/05 CTU Abd. BIDMC Radiology Dept. PACS
•Dilated renal pelvis
Jeremy McKay, HMS III
Gillian Lieberman, MD
Patient 11: CTU contrast phase
3/05 CTU Abd. BIDMC Radiology Dept. PACS
•Dilated renal pelvis
Jeremy McKay, HMS III
Gillian Lieberman, MD
Patient 11: CTU reformatted
3/05 CTU Abd. BIDMC Radiology Dept. PACS
Jeremy McKay, HMS III
Gillian Lieberman, MD
Patient 11Patient 11Findings:Findings:–– New New perinephricperinephric and and periureteralperiureteral fat strandingfat stranding–– Bilateral proximal and mid Bilateral proximal and mid ureteralureteral wall thickeningwall thickening–– Mild bilateral Mild bilateral hydronephrosishydronephrosis–– Both enhance symmetrically, no calculiBoth enhance symmetrically, no calculi
Impression:Impression:–– Concerning for transitional cell carcinomaConcerning for transitional cell carcinoma–– Further evaluation with retrograde Further evaluation with retrograde ureterogramureterogram was was
recommended after antibiotic treatmentrecommended after antibiotic treatment–– Likely Diagnosis: Acute Likely Diagnosis: Acute PyelonephritisPyelonephritis with possible with possible
underlying transitional cell carcinomaunderlying transitional cell carcinoma
Jeremy McKay, HMS III
Gillian Lieberman, MD
SummarySummary
HematuriaHematuria is commonis common–– Most Common Causes: Most Common Causes: NeoplasiaNeoplasia, infection, , infection,
stones. stones. –– Renal causes of Renal causes of hematuriahematuria
VasculitisVasculitis, , GlomerularGlomerular disease, disease, TubulointerstitialTubulointerstitialdisease, Renal masses, Vasculardisease, Renal masses, Vascular
–– US, CT (U), MR(U), IVP are great techniques US, CT (U), MR(U), IVP are great techniques for imagingfor imaging
–– CT CT UrographyUrography: Combines unenhanced, : Combines unenhanced, nephrogenicnephrogenic--phase, and excretory phase phase, and excretory phase
Becoming modality of choiceBecoming modality of choice
Jeremy McKay, HMS III
Gillian Lieberman, MD
Works CitedWorks Cited
RameshRamesh and Kimmel. and Kimmel. HematuriaHematuria: An Algorithmic : An Algorithmic ApporachApporach to Finding the to Finding the Cause. Cleveland Clinic Journal of Medicine 2002; 69: 870Cause. Cleveland Clinic Journal of Medicine 2002; 69: 870--884884FroomFroom, Gross, , Gross, FroomFroom, , CaineCaine, , MargaliotMargaliot, , BenbassatBenbassat. Factors Associated with . Factors Associated with MicrohematuriaMicrohematuria in asymptomatic young men. in asymptomatic young men. ClinClin ChemChem 1986; 32:20131986; 32:2013--20152015RithieRithie CD, Bevan EA, Collier SJ. Importance of occult CD, Bevan EA, Collier SJ. Importance of occult haematuriahaematuria found at found at screening. BMJ 1986; 292:681screening. BMJ 1986; 292:681--683683GillatGillat DA, O’Reilly PH. DA, O’Reilly PH. HematuriaHematuria Analyzed; A Prospective Study. J R Soc Analyzed; A Prospective Study. J R Soc Med 1987; 80559Med 1987; 80559--562562Carter WC, Rous SN. Gross Carter WC, Rous SN. Gross HematuriaHematuria in 110 Adult Urological Hospital in 110 Adult Urological Hospital Patients. Urology 1981; 18:342Patients. Urology 1981; 18:342--344344http://http://www.ctisus.com/ctprotocolswww.ctisus.com/ctprotocols//American College of Radiology (ACR), Expert Panel on Urologic ImAmerican College of Radiology (ACR), Expert Panel on Urologic Imaging. aging. Radiologic investigation of patients with Radiologic investigation of patients with hematuriahematuria. Reston (VA): American . Reston (VA): American College of Radiology (ACR); 2001College of Radiology (ACR); 2001JoffeJoffe, , ServaesServaes, , OkonOkon, Horowitz: Multi, Horowitz: Multi--Detector Row CT Detector Row CT UrographyUrography in the in the Evaluation of Evaluation of HematuriaHematuria. Radio Graphics 2003; 23:1441. Radio Graphics 2003; 23:1441--14561456
Jeremy McKay, HMS III
Gillian Lieberman, MD
AcknowledgementsAcknowledgementsPeter Peter RosalRosal, MD, MDDaniel Daniel CornfeldCornfeld, MD, MDGillian Lieberman, MDGillian Lieberman, MDPamela Pamela LepkowskiLepkowskiLarry Barbaras, WebmasterLarry Barbaras, Webmaster