RENAL DOPPLER

INTRODUCTION
Renal doppler is
Noninvasive test for many important renal diseases Important initial test for suspected renal artery stenosis Difficult to perform routinely Technical failure rate of upto 90% for the study of main renal arteries

 Problems in performing renal doppler:

Obese patients Patients with gaseous abdomen Patients who can not suspend respiration

Indications of renal doppler

Renal artery stenosis (RAS) Renal arterial occlusion and infarction Renal vein thrombosis Renal artery aneurysm Renal arteriovenous fistula and malformations Renal Transplants.

ANATOMY
The renal arteries usually arise as lateral aortic branches slightly below the disk between L1 and L2, immediately distal to the origin of the superior mesenteric artery Rarely, they may arise below the inferior aspect of D12 or below the lower border of L2 The right renal artery passes underneath the inferior vena cava (IVC) and posterior to the right renal vein

Sagittal ultrasound image in grayscale (A) and color (B) showing the IVC in long axis and right renal artery in short axis as it courses underneath the IVC. B. Color Doppler shows flow within the IVC, hepatic veins and renal artery.

 The left renal artery is located posterior to the renal vein. Left renal vein passes between the aorta and SMA

(A) Ultrasound image is a sagittal view of the abdominal aorta. The left renal vein can be seen in its short axis between the SMA and aorta. (B) Ultrasound image is a transverse color Doppler view showing the anatomical relationship between the SMA, celiac trunk, aorta, IVC and left renal vein.

`The main renal artery divides into ventral and dorsal divisions which further divide into segmental arteries (usually 5 segmental arteries). `Segmental arteries give interlobar branches. `The interlobar branches repeatedly branch to give rise to arcuate arteries. `The interlobular arteries arise from the arcuate arteries, where they extend into the renal cortex in a parallel fashion.

Color Doppler image demonstrating normal intrarenal vasculature The arteries are encoded red, as the flow is coursing toward the probe to the periphery of the kidney

Variant anatomy:
Common in the renal vascular system. Approximately 30% of individuals have more than a single renal artery on each side Supernumery arteries may occur unilaterally or bilaterally. Most accessory renal arteries arise from the abdominal aorta, but they may also originate from the common iliac, superior or inferior mesenteric, adrenal, and right hepatic arteries. Early division of the main renal artery occurs in about 15% of the population.

 For identification of multiple right renal arteries, it is helpful to obtain a long axis view of the IVC Another useful view to demonstrate supernumery renal arteries is a coronal image of the aorta. This view provides an excellent angle for imaging the origins of both the right and left renal arteries using color/Power Doppler.

Sagittal grayscale and coronal color images in patient with two renal arteries on either side.

Sagittal grayscale and coronal power doppler images in the patient with three right renal arteries.

Color Doppler depiction of supernumery renal arteries. The patient has a single right renal artery and duplicate left renal arteries.

Renal veins
` The renal veins empty into the IVC. ` They are located anterior to each renal artery. ` The left renal vein courses between the SMA and the abdominal aorta in its path to the IVC. ` The right renal vein courses directly to the IVC from the renal hilum.

Anomalous anatomy of the venous drainage

The left renal vein may follow a retroaortic course The left renal vein may be circumaortic, dividing before reaching the aorta with one branch coursing anteriorly and another posteriorly

A retroaortic left renal vein. A transverse color Doppler image shows the renal vein passing posterior to the aorta before emptying into the IVC (A). A sagittal power Doppler image shows the left renal vein in cross section just underneath the abdominal aorta (B).

A circumaortic left renal vein. The transverse grayscale image shows the left renal vein dividing before reaching the aorta with one branch passing posterior and the other anterior between the SMA and aorta (A). A sagittal color Doppler image captured in diastole shows the renal vein in cross section on each side of the abdominal aorta (B).

Scanning Technique
Two approaches:
Anterior approach Flank approach

Anterior approach:
The proximal course of the right renal artery is often perpendicular to the beam. This is an excellent angle for B mode imaging but is not suitable for Doppler. Moving the probe slightly to the left of midline and angling it toward the patient s right side can sometimes improve the Doppler angle

 Color Doppler helps to localize the artery and define the Doppler angle. The mid to distal right renal artery is not often imaged adequately from an anterior This decreases Doppler sensitivity

Transverse Bmode view of the abdominal aorta and right renal artery from an anterior approach. The ultrasound probe is oriented at midline and the Doppler cursor placed in the proximal right renal artery (A). The angle of incidence of the Doppler beam to the flow is unacceptable at approximately 89 degrees. By moving the probe to the left of midline and angling toward the patient s right, an acceptable Doppler angle of 60 degrees is achieved (B).

Transverse color Doppler images of the right renal artery passing underneath the IVC. It is difficult to recognize the right renal artery or distinguish the boundary between the IVC and right renal artery when using a low PRF. This is because color Doppler aliasing tends to hide the boundary between the two vessels (A). By increasing the PRF, flow direction becomes more apparent and the right renal artery is readily identified separate from the IVC (B).

 The origin of the left renal artery is posterior compared to the right renal artery. On grayscale alone, the left renal artery is usually difficult to see from an anterior approach, but once color is activated the proximal portion is often well visualized. The left renal vein is an excellent landmark for locating the renal artery

 By positioning the transducer slightly to the right of midline and angling toward the left, an adequate Doppler angle can usually be achieved for the proximal portion of the artery. The mid to distal left renal artery is often not seen in this view except in ideal patients.

Transverse color Doppler images of the abdominal aorta, left renal vein and artery. The left renal vein is a good landmark for locating the artery. The renal vein is usually recognized first as a red vessel just lateral to the aorta (A). Careful inspection will reveal the renal artery as a blue vessel (color Doppler is NOT inverted), located just posterior to the renal vein

Flank Approach
The flank approach is usually the most successful view for imaging the entire length of both renal arteries. An excellent Doppler angle (60 degrees or less) can nearly always be achieved with this view. There are several variations to the flank approach. It s often necessary to slightly vary the window until an optimal view is found for each individual patient.

Evaluation of Rt. Renal Artery

Patient is rolled into a left decubitus position. The patient is asked to relax the abdominal muscles as much as possible. The probe is placed in a sagittal view in the soft part of the abdomen below the rib cage. The probe is manipulated slightly until the aorta and IVC are seen in long axis. By slightly varying the probe angle, both renal arteries can be seen arising from the aorta. This has been described as the banana peel view. The right renal artery will course toward the probe and the left will course away. This is an excellent view for obtaining a Doppler signal from each renal artery origin as well as the abdominal aorta

Flank approach showing the abdominal aorta and origin of both renal arteries

The Doppler sample volume is placed within the proximal right renal artery. In this view, an acceptable Doppler angle of 60 degrees or less is easily obtained (A). The Doppler reading of the abdominal aorta is taken near the level of the renal arteries. This value is applied to the RAR (B).

`Next, the probe is oriented into a transverse plane and positioned at the renal hilum to image the mid and distal portion of the right renal artery `The entire length of the renal artery from the aorta to the renal hilum can be visualized. `A transverse view of the kidney will be seen at the top left of the image and the aorta will be seen in transverse at the bottom right. `The renal artery will be seen just posterior to the vein.

Transverse color Doppler image using the flank approach

Evaluation of left renal artery

The patient is rolled into a right decubitus position. The probe is positioned in a sagittal plane over the left kidney. Again, color Doppler is activated and the color box sized so that it is long and narrow. The probe is angled until both the abdominal aorta and left kidney are visible in the image. Imaging of the renal artery can be performed through either a sagittal or transverse orientation of the kidney

Color Doppler highlights the origins of both renal arteries and a Doppler reading obtained from the left renal artery

Image (A) shows aliasing of the spectral waveform. The frequency shift is too high for the PRF setting & velocity measured is incorrect. By raising the PRF and lowering the baseline, the peak velocity is displayed correctly and an accurate velocity is obtained (B).

Evaluation of intrarenal vasculature:

In lateral decubitus position, the probe is placed along the axillary line. ` The kidney is close to the surface in this view and the segmental renal arteries will course directly toward the probe at small angles ` There should be no spleen or liver visible between the probe and the kidney to minimize the distance to the intrarenal vessels ` Color Doppler is essential to map the vascular anatomy.

 The intrarenal Doppler waveforms must be obtained at angles less than 30 degrees or the early systolic peak may not be visualized The probe is rotated more posteriorly to improve the Doppler angle for the upper pole intrarenal arteries. For the mid kidney, the probe is centered in a coronal plane. The best Doppler angle for the lower pole intrarenal arteries is usually obtained by rotating the probe slightly anterior to the mid coronal line

 Doppler frequency of 3.5 MHz or higher is preferred. High Doppler frequencies provide larger waveforms compared to lower frequencies The patient is asked to suspend respiration and a Doppler reading is taken from within one of the arteries best aligned to the cursor

Color and spectral Doppler image of the intrarenal vasculature Color Doppler identifies the vessels and helps to locate a segmental or interlobar artery at an optimal angle of 30 degrees or less

` A range of normal waveforms. ` The early systolic peak (ESP) is detected on each waveform. ` In some cases, the ESP is the highest peak, but in others, the highest peak occurs later in systole. ` The Acceleration Time (AT) is always measured to the first systolic peak, which is the ESP in normal waveforms.

Correct and incorrect measurement of AT: The systolic acceleration time (AT) is measured from start of the systolic upstroke to the first peak or ESP

` Systolic acceleration times greater than 0.07 second are consistent with a main renal artery stenosis exceeding 60%. ` The RI is measured and compared between kidneys. ` A difference in RI between the ipsilateral and contra lateral kidney increases suspicion for renal artery stenosis on the side with the lowest RI. ` This difference is significant when it exceeds 5%. ` Other parameters that have been recommended include acceleration (ACC) and acceleration index (AI).

Image shows the most advantageous scanning position on obese patients: ` The patient is positioned in a lateral decubitus position and asked to relax the abdomen. ` This lets most of the adipose tissue fall forward onto the scanning bed. ` The probe is then placed in the soft part of the abdomen in a sagittal plane.

Renal Doppler Waveform Analysis

The normal Doppler waveform obtained from the renal artery demonstrates a low resistance profile with continuous forward flow throughout the cardiac cycle. The resistive index is less than 0.70. Increased vascular resistance with decreased diastolic flow may be seen in hydronephrosis, renal vein thrombosis and chronic renal disease.

 Waveforms obtained from the main renal arteries demonstrate a rapid upstroke in systole when normal. The intrarenal waveform obtained from a segmental or interlobar artery has an acceleration time (AT) of less than .07 seconds. A small notch is visible near peak systole and is known as the early systolic peak (ESP).

Acceleration index (AI)= Slope of the systolic upstroke: >3m/s2 The normal peak systolic velocity of the main renal artery is less than 150 cm/sec. The velocity decreases in the distal intrarenal arteries.

Normal Doppler waveforms obtained from the main renal artery and segmental renal artery, The early systolic peak (arrow). The systolic upstroke is rapid. ..

Renal Artery Stenosis (RAS)

RAS accounts for ~1% of patients with hypertension Significant RAS : >60% reduction in the internal diameter of the renal artery Potentially curable condition Ultrasound may play a role in helping to determine which patients will benefit from intervention.

 Radermacher published a study suggesting that patients with a renal artery resistive index (RI) greater than 0.80 are unlikely to benefit from interventional therapy, whereas patients with an RI less than 0.80 are more likely to show improvement.

Causes:
Atherosclerotic disease:
Older patients Typically males Mostly proximal segment of the artery

Fibromuscular dysplasia:
Younger patients. Typically females. Commonly in the mid to distal aspect of the renal arteries. Produces a beaded appearance on angiography that has been described as a string of pearls

Others: Arteritis, arterial dissection, AAA etc.

Ultrasound Diagnosis of Renal Artery Stenosis

Combination of
Direct: evaluation of the main renal artery & Indirect: evaluation of the segmental/interlobar arteries used.

The examination begins with imaging of the kidneys

Small, smooth affected kidney in RAS.

Direct method:
` The direct method involves Doppler interrogation of the entire length of the main renal artery, including any accessory renal arteries ` The highest velocity found in the renal artery is compared to that of the abdominal aorta (at the level of the renal arteries). ` This is termed the renal/aortic ratio or RAR ` Doppler angle correction is more accurate with the use of color Doppler since visualization of the path of the vessel is improved

Direct criteria for detection of >60% RAS Peak systolic velocity >180- 200 cm/sec Renal :Aortic peak systolic velocity Ratio (RAR) > 3.5 Post-stenotic turbulence/ spectral broadening

A color Doppler image of a stenotic right renal artery origin. A color bruit is seen in the tissue surrounding the area of the post stenotic turbulence. The presence of the bruit can help to identify the location of the stenosis and increase diagnostic confidence

A Doppler reading obtained near the renal artery origin shows velocities over 600 cm/s in systole and over 300 cm/s in diastole consistent with a high grade stenosis. The arrows are pointing to a bruit that is evident on the spectral display

Color Doppler & spectral images of the stenotic left renal artery origin. The highest velocity obtained was approximately 350 cm/s

Indirect evaluation
Indirect evaluation involves Doppler interrogation of the segmental or interlobar arteries within the kidney. A complete exam includes evaluation of the upper, mid and lower pole segmental arteries. If a stenotic accessory artery is feeding one of the renal poles, an abnormal waveform will be detected in that segment. This helps to compensate for any missed accessory renal arteries with the direct method.

Indirect criteria for detection of >60% RAS 1. 2. 3. 4. 5. Tardus Parvus waveform Absence of Early Systolic Peak (ESP) Acceleration time (AT) >0.07 sec Acceleration index (AI) <3m/s2 RI difference between kidneys >5%.

The Doppler waveform obtained from the segmental renal arteries within the right kidney shows a tardus parvus shape with absence of the ESP. The AT measures 0.11 sec.

The waveform obtained from the left intrarenal artery shows an absence of the ESP and a tardus and parvus shape consistent with stenosis of the main renal artery

` A range of abnormal waveforms with increasing levels of renal artery stenosis from top to bottom. ` Since the ESP is absent on abnormal waveforms, the AT is measured from the beginning of systole to the systolic peak

Pitfall: Exaggerated ESP associated with high resistance waveforms (RI = 0.78). With increased resistance, the early systolic peak becomes exaggerated and will persist even though stenosis is present in the main renal artery.

Renal Arterial Occlusion & Infarction

`Acute complete obstruction:
Gray scale image: Normal/ swollen echo poor kidney Absent flow to the kidney in duplex and color doppler sonography.

`Segmental of focal infarction:

Wedge-shaped mass indistinguishable from acute pyelonephritis Absent flow in the affected branch artery

`Chronic occlusion:
Small, scarred kidney.

A-V fistula & malformations:

Causes:
~75% acquired: mostly iatrogenic; secondary to tumor erosion, traumatic ~25% congenital

Imaging:
Gray-scale may reveal no abnormality

 Duplex imaging
Increased flow velocity, decreased resistivity (0.3-0.4) & turbulent flow in arterial side Arterial pulsations in draining vein Spectral broadening

Color doppler:
Tangle of tortuous vessels with multiple colors indicative of the haphazard orientation & turbulent flow within the malformation.

Renal artery aneurysm:

Cause:
Congenital Inflammatory Traumatic Atherosclerotic Related to fibromuiscular disease

If large (>2.5cm), non calcified or associated with pregnancy, possibility of rupture increases.

 Imaging:
Gray-scale sonography: A cystic mass Duplex & color doppler: Arterial flow within the cystic mass

Renal vein thrombosis:

Causes:
Idiopathic Abnormal coagulation (e.g.DIC) Connective tissue diease Sepsis Trauma Secondary to dehydration Intrinsic abnormality of kidney: Nephrotic syndrome Tumor: e.g. RCC, Extrinsic compression

Imaging in RVT:
Gray-scale:
Enlarged, edematous, hypoechoic kidney, Loss of corticomedullay differentiation, Thrombus in the vein may be seen.

Color doppler & duplex scan:

Absent flow in the affected renal vein. Absent or reversed diastolic signals in the renal artery

Chronic RVT: small, echogenic kidney.

Parenchymal Complications
Acute Tubular Necrosis (ATN) ATN occurs in 20-60% of cadaveric renal grafts and is the most frequent complication in the first 48 hours after transplantation. ATN is due to reversible ischemic damage to the renal tubular cells prior to engraftment. Risk factors include: Cadaveric graft Hypotension in the donor prior to implantation (aggravated by the use of diuretics or vasoconstrictors to maintain urine output or blood pressure) Long warm (over 30 minutes) and cold (over 24 hours) ischaemic times. Although ATN-induced graft dysfunction may be severe, it is usually fully reversible and requires only supportive therapy. Short-term dialysis may be required in severe cases. The spectrum of sonographic features of ATN is quite variable (Fig 8). The kidney may appear normal, but in severe cases it is typically enlarged, grossly oedematous and echo poor with loss of the normal sonographic cortical/medullary differentiation. The renal sinus echo may be compressed or obliterated due to swelling. Kidneys with severe ATN generally have elevated RIs (over 0.8) but clinically significant ATN may be seen in conjunction with a normal RI, especially within the first 24 hours after surgery [16].

Rejection
Allograft rejection can be classified as either antibody (humoral) or cellular rejection. Antibody-mediated rejection always involves blood vessels and is therefore correctly referred to as vascular rejection [6]. Rejection occurring within the first postoperative month may be classified as either acute rejection (AR) or accelerated acute rejection (AAR). Chronic rejection (CR) is an insidious process developing months to years after transplantation.

Acute Rejection (AR): AR is a common complication occurring in 20-30% of cadaveric grafts. The occurrence of an AR episode is the single most important event determining the short (1 year) and long-term (5 year) graft survival. Among those grafts afflicted, roughly equal proportions have single and multiple episodes [6]. Fortunately, AR is successfully treated in over 80% of cases through the selective use of pulsed intravenous corticosteroids, Cs-A, and the monoclonal antibody OKT3 [6]. The first episode of AR typically occurs within six months of transplantation and often within the first 5 weeks [6]. Before the introduction of Cs-A, AR frequently presented in an advanced form with the classic clinical triad of a tender swollen graft, fever and rising creatinine. With the widespread use of Cs-A, AR is now a more indolent process commonly diagnosed by biopsy done for a rising creatinine in an asymptomatic patient. AR is characterized pathologically by lymphocytic and polymorphonuclear cell infiltrates into the interstitial space (tubular interstitial rejection) and/or the subendothelial portion of the vessel walls (vascular rejection). Infiltrates may vary in severity and be diffuse or focal within the graft. Hemorrhage may accompany interstitial edema in severe cases. Vascular rejection may range from mild (subendothelial cellular infiltrates) to severe necrotizing arteritis with in situ vascular thrombosis, ischemia and parenchymal necrosis [6]. The more severe forms of vascular AR are associated with a higher incidence of graft loss.

 The sonographic hallmarks of severe AR reflect the underlying pathology and include: Graft enlargement due to edema Decreased cortical echogenicity and swelling of the medullary pyramids resulting in loss of cortical/medullary differentiation (Fig 9a) Oedema within the renal sinus fat which may efface or obliterate the sinus echo complex (Fig 9b).

 Accelerated Acute Rejection (AAR): AAR typically occurs within the first postoperative week, but is uncommon due to extensive antibody screening currently in use. The incidence of AAR is greater among patients who have rejected a previous graft. AAR is combined cellular and humoral immune response; low levels of circulating antibodies or presensitized T lymphocytes are thought to be responsible [20]. AAR can be an unusually severe form of rejection, presenting with oliguria and rapidly rising serum creatinine. The prognosis is poor with graft loss rates as high as 60% [6]. The sonographic features are identical to those seen in AR and ATN. Chronic Rejection (CR): Chronic rejection develops months to years after engraftment and is due to antibodies directed to the graft endothelium as a consequence of repeated episodes of AR. This results in progressive vascular compromise of the graft associated with insidious decline in renal function. Sonographic findings are those of a small graft with thinned echogenic cortex and relative sparing of the medullary pyramids (Fig 11). The RI is typically normal or slightly elevated. Biopsy is often required to exclude superimposed and potentially treatable AR.

Vascular Complications
Renal Vein Thrombosis or Occlusion (RVT) Renal Artery Thrombosis (RAT) Renal Artery Stenosis (RAS)