545

Normal
Sonographic Patients

Length
Study

of Fetal

Kidneys:

in 397 Obstetric

Harris L. James Cooper1 Peter Eisenberg1 Francine S. Mandel3 Beth R. Gross1

Mitchell A. Goldman1

This study was done to measure normal lengths of fetal kidneys sonographically during pregnancy. Knowledge of these measurements may allow earlier diagnosis of a variety of abnormalities. The greatest length of each of 498 kidneys in 397 consecutive fetuses between 18 and 41 weeks gestation was measured on sonograms. Gestational

Keith

Eyal Barzel2 F. Rawlinson4

ages were determined by last menstrual period and biometry; significant discrepancies led to case exclusion. Abnormal fetuses, twins, offspring of diabetic mothers, and fetuses with renal pelvic dilatation of 4 mm or greater were excluded to avoid any
questionable measurements. The results show that mean lengths are greater and

confidence intervals are wider than previously reported. Renal lengths are similar to those reported in premature and full-term neonates. Strong correlation exists between renal length and gestational age, determined by biparietal diameter, femoral length, and abdominal circumference, and an average of the three. No significant difference was
found between right and left renal lengths in fetuses in whom both kidneys were imaged.

Average

renal lengths

are significantly
No correlation

different
is seen

gestational

ages (p

< .001).

when compared across the range of (r = .00) between parental height or

than previously reported.

weight and fetal renal length. Our results show that fetal renal
AJR 157:545-548,

lengths

are longer

September

1991

Received February 5, 1991; accepted after revision April 23, 1991. 1 Division of Ultrasound, Department of Radiol-

An accurate baseline of the lengths of normal fetal kidneys is necessary to diagnose fetal abnormalities associated with abnormal kidney size. Accurate measunements also may be helpful in determinations of gestational age, particularly when the mothers last menstrual period is unknown and routine methods used to determine gestational age give conflicting results. Current radiology textbooks [1-3] refer to the measurements provided by Bertagnoli et al. [4]. Because our measurements have been consistently larger than theirs, we did this study to determine the normal length of the fetal kidney at various gestational ages.

ogy,

North

Shore

University

Hospital-Comell

Uni-

Material

and Methods
of 397 consecutive women examined at various stages of pregnancy at

versity Medical College, Manhasset, NY 11030. Address reprint requests to H. L. Cohen, 78 Grove Ave., Cedarhurst, NY 11516. 2 Department of Radiology, State University of New York
Brooklyn,
3

The fetal kidneys

Kings County

Hospital,

Brooklyn,

NY, between

November

1987 and October

1988, and at

Health

Science

Center

at

Brooklyn,

NY 11203. Division of Biostatistics,

North Shore University

Department

of Re-

search,

Hospital-Cornell

University Medical College, Manhasset,

4

NY 11030.

Division of Matemal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital-Comell University Medical College, Manhasset, NY 11030. 0361-803X/91/1
American

North Shore University Hospital-Cornell University Medical College between November 1988 and November 1990 were evaluated for greatest length. We measured from outer to outer margin as did Bertagnoli et al. [4]. These lengths were analyzed in relationship to gestational ages determined on the basis of bipanietal diameter (BPD), femoral length (FL), abdominal circumference (AC), and an average of those three gestational ages in weeks, which we termed average weeks or AVW. These measurements were correlated with gestational ages determined on the basis of last menstrual period (LMP) and, in a few cases, crown-rump length (CRL). Renal lengths were

excluded

from the study if discrepancies

between

the ages determined

less

573-0545
Ray Society

Roentgen

those by LMP were greater than 2 weeks for gestational ages greater than 3 weeks for gestational ages of 30 weeks or more.

than

by biometry and 30 weeks or

546

COHEN

ET AL.

AJR:1 57, September

1991

The longest

renal lengths

also were assessed

in relationship
sonographic in a group

to

maternal and paternal heights and weights and reported measurements of renal length in neonates [5-8]. Our goal was to measure normal fetal renal lengths

of

fetuses with no known anatomic or chromosomal abnormality and no known reason to have an abnormal renal length. Patients were excluded from the study if they had sonographic (>90th percentile for estimated fetal weights according to LMP dates) or birth evidence
of being
for

large for gestational

fetal weights

age, or sonographic
according to LMP,

(<10th

percentile
or

were imaged adequately and measured. The Pearson comelation coefficient for the length of the right kidney compared with that of the left kidney was 0.91. We found a strong correlation between kidney length and gestational age as predicted by BPD (r = .81), FL (r = .82), AC (r = .80), and AVW (n = .82). Extremely strong correlation was found between each of the three component measurements (BPD weeks, FL weeks, or AC weeks) and AVW (r =

estimated

oligohydramnios,

.99). These

measurements

are not statistically

different,

and

FL/AC ratio 23.5) or birth evidence of having intrauterine growth retardation. Infants of diabetic mothers were excluded. Only singleton
pregnancies were used. Only those kidneys for which a complete outline could be imaged were included. Unclear adrenal or renal borders, abnormal renal morphology, and renal pelvic dilatation

greater than 4 mm in anteroposterior diameter were grounds excluding the measurement. We used the last criteria, despite

for the

fact that dilatations as great as 1 cm may be found in fetuses who at birth have no evidence of renal obstruction or vesicoureteral reflux [9], because we wished to avoid any suggestion offalsely long kidney measurements due to dilatation. Measurements were obtained with a DRF 400 (Diasonics, Milpitas, CA), the ATL Ultramark 4 and 9 (Advanced Technology Laboratories,

each can be used to correlate renal length. Mean renal lengths, their standard deviations, and 95% confidence intervals are presented for each week of gestation from 1 8 weeks to 41 weeks determined by AVW (Table 1). A significant difference in the average fetal renal length is found when lengths are compared across the 1 8 to 41 week range of gestational ages (p < .001). No correlation was found between fetal renal length and fathers height (n = .00), fathers weight (n = .00), mothers height (r = .00), and mothers prepregnancy weight (r = .00)
when a partial correlation was performed and gestational age

Bothell, WA), and the Acuson

Information was obtained

128 (Acuson,
about maternal

Mountainview,
height

CA).
before

and weight

pregnancy and about paternal height and weight. Gestational ages were determined by using Hadlocks chart of predicted fetal measurements at specific menstrual weeks for BPD and FL and his

was partialled out. Although not all fetuses in this study were born in the institutions where their sonognaphic examinations were done, to the best of our knowledge, none of them had abnormal kidneys as neonates.

gestational
cephalic or >86),

age/abdominal

circumference

chart for AC [1 0]. If the

index was beyond two standard deviations of normal (<70 the BPD was excluded [1 1]. This was done to decrease the

Discussion
It

known significant variation in determinations of gestational age on the basis of BPD, especially in the third trimester. Hadlock et al. [12]
noted an improvement in the high variability of third-trimester biometnic measurements to 2.3-2.4 weeks when a mean measurement of BPD, FL, AC, and head circumference was used. We averaged

is helpful

to know
fetal renal

normal

lengths

of fetal kidneys
This in particularly

in order
true

to diagnose

abnormalities.

TABLE

1: Mean Gestational

Renal

Lengths Mean

for Various

Gestational

Ages

gestational ages obtained by BPD, FL, and AC. Although we did not measure head circumference in many of our cases, removal of BPD measurements when there was an abnormal cephalic index would
logically suggest a similar limitation to the variability of our mean lengths. Statistical analyses were conducted by using the SAS software

Age
(weeks) 18 19
20 21

Length
(cm) 2.2 2.3
2.6 2.7

SD
0.3 0.4
0.4 0.3

95% Cl
1.6-2.8 1 .5-3.1
1 .8-3.4 2.1-3.2

14 23
22 20

package

(SAS Institute,
were

Cary, NC). Because

found to be significantly

the lengths
correlated

of left and
(r = .91)

right fetal kidneys

22
23 24

2.7
3.0 3.1

0.3
0.4 0.6

2.0-3.4
2.2-3.7 1.9-4.4

18
13 13

with each other in the subset of patients in whom both right and left fetal kidneys could be measured adequately (n = 101), it was necessary to determine if this might affect results. As we found no
significant difference between mean lengths of left and right kidneys in this subset and as the lengths were highly correlated, results were similar whether we examined (1 ) paired kidneys with measurements of left and right kidneys separated, (2) paired kidneys with lengths of left and right kidneys combined, or (3) all kidneys (paired or not) with measurements combined. We chose the third approach to maximize our use of the data with no apparent bias. An analysis of variance was used to compare mean renal lengths for each week of gestational age (weeks 1 8-41). Pearson product moment correlation coefficients were used to measure the degree of relationship among the various biometric gestational age measurements. Partial correlation was used to determine the relationship between parental height and weight and renal length when age was controlled for.

25 26 27

3.3 3.4 3.5

0.4 0.4 0.4

2.5-4.2 2.4-4.4 2.7-4.4

28
29 30 31

3.4
3.6 3.8 3.7

0.4
0.7 0.4 0.5

2.6-4.2
2.3-4.8 2.9-4.6 2.8-4.6

9 9 15 19 12 24 23

32
33 34 35

4.1
4.0 4.2 4.2

0.5
0.3 0.4 0.5

3.1-5.1
3.3-4.7 3.3-5.0 3.2-5.2

23
28 36 17

36
37

4.2
4.2

0.4
0.4

3.3-5.0
3.3-5.1

36
40

38 39
40 41

4.4 4.2
4.3 4.5

0.6 0.3
0.5 0.3

3.2-5.6 3.5-4.8
3.2-5.3 3.9-5.1

32 17
10 4

Results
Lengths of 498 fetal kidneys were measured in 397 pregnant women. In 1 01 fetuses, both the right and left kidney

Note.-Gestational age is an average of the gestational ages in weeks determined on the basis of biparietal diameter, femoral length, and abdominal circumference. SD standard deviation, 95% Cl 95% confidence interval, n number of fetuses. A t distribution was used when n < 30.

AJR:1 57, September1991

SONOGRAPHIC

MEASUREMENT

OF FETAL

RENAL

LENGTH

547

if the echogenicity

is apparently

normal,

which

may occur detenmi-

in

6J

some early cases of polycystic

disease

of the kidney.

Knowl-

edge of normal renal length can be helpful in early nations of nephromegaly or hypoplasia [13].

The kidney is imaged in 90% of fetuses between 17 and 22 weeks [14]. Maternal obesity can hinder imaging [1 5]. As the pregnancy progresses, increased echogenicity from increasing allowing peninephnic fat is said to make easier separation of the kidney them from more visible by its surrounding

soft tissues be hindered

the upper

[1]. However, by uncertainty

pole, if hidden

exact measurements of renal end points

by fetal ribs

continue especially

to at

or obscured

by the

adrenal gland [14, 15]. Improved resolution with current machinery and transducers seems to make this less of an issue. Identification of
the kidneys borders and the adrenal gland and distinction of

the adrenal gland from the kidney is easier (Fig. 1). Improvements in sonognaphic technology may be the key factor
resulting
earlier

Fig. 2.-Plot

of kidney

length

vs gestational

age. Our measurements

in our larger

measurements it easier

as compared to determine

with

the

(1981-1
identification

983) studies
makes

[4, 13, 14]. The current

ease of

(solidlines) are compared with those of Bertagnoll et al. (4] (broken lines). central lines represent mean. Superior and inferior lines represent two standard deviations of mean. Plot has been smoothed by using cubicspline interpolation.

renal

a foneshort4.600 4.200
-C
C

ened renal measurement (e.g., by noting asymmetry of the visualized pyramids in relationship to the imaged kidney) and therefore allows the examiner to image a truer (longer) length by subtly adjusting the angle of the transducer. Unless the fetus is prone with its back facing the transducer, usually only the bonders of the near kidney can be imaged adequately. We attempted to be strict with our border visualization before accepting a measurement so as to decrease the possibility of incorrect, especially falsely elevated, measurements. Kurtz and Goldberg stetnic measurements,

3.800
3.400 3.000 /

ci) -J
>,

+
/

ci)
C

o-o
&-L

2.600

Bertagnoli Lawson Cohen

-H

#{149}-#{149}Jeanty

[1], in their review

noted only two

of studies
studies

of obof fetal

2.200

earlier

,
1.800

ov,
22

,
25

,
28 31

t----t

kidney

length

that

used

neal-time

equipment.

Both

those

studies [4, 1 31 showed measurements smaller than ours. The work by Bertagnoli et al. [4] and their chart were necom-

34

37

40

Week
Fig. 3.-Plot of kidney length

of Gestation
vs gestational age. Measurements of

mended.
the lowest

Their mean and standard

point

deviations

appear to be at
(Fig. 2). The

of our 95% confidence

intervals

kidney length at several points within pregnancy obtained by Bertagnoli et al. [4], Jeanty et al [13], and Lawson et al. [14] are compared with our (cohen et al.) larger measurements.

referenced articles showed, as did we, that mean length increases with gestational age. The study of Lawson et al. [1 4], using articulated arm scanning, showed measurements of 3.2 cm at 30 weeks and measurements of 4.2-4.3 cm at term, which are closer to our measurements. Figure 3 is a graphic representation of our measurements at various weeks of gestation compared with those of the aforementioned authors. Although renal dilatation as great as 1 0 mm may be consid-

ened physiologic

and normal [9, 15-1 7], we arbitrarily

decided

Fig. 1.-Longitudinal sonogram of fetal kidney and adrenal gland at paravertebral position shows minimal central pyelectasis (arrow). upsidedown V-shaped structure superior to kidney is adrenal gland (arrowhead). Cursors mark off kidney borders for measurement. 5 = spine.

to exclude kidneys with anteropostenion pelvic measurements greater than 4 mm. We did so in order to avoid the possibility of considering pelvic dilatation, even if physiologic, a reason for the longer lengths that we measured. To confirm our measurements, we correlated our figures with published neonatal studies. Rosenbaum et al. [6] noted the mean renal length in neonates (0-1 week) as 4.48 cm with a 0.31 -cm standard deviation. Han and Babcock [7]

548

COHEN

ET AL.

AJR:1 57, September

1991

confirming

other

questionable

biometric

measurements

of

gestational
4
C

age.

A-A

ACKNOWLEDGMENTS

-J > ci)
C

ci)

o-__ _-o---_______
+
O

o----o
.-. A---L A-A Cohen
Fitzsimons Holloway

We thank
Clifford, Dennis

Dara

Muller,
Parcell,

Cheryl
Donna

Jacoby,
Denicola,

Lauri
and

Federbush,
Sakni

Maria
for their

Maureen Skahil for

Kathrin and Sandra

sonographic Karl Drehobl,

expertise; and Lauren

Martin

Lesser

for his biostatistical

guidance;
W. Cohen,

. E2
32 33
34 35

his photographic

expertise;

E. Cohen

for their computer

consultations.

-36

of

-37 38

+-+--

439 40 0 7

REFERENCES
Week Gestation Days in late preget al. [4] and 1 . Kurtz A, Goldberg B. Obstetrical measurements in ultrasound: a reference manual. Chicago: Year Book Medical, 1988:88-92 2. Kurtz A, Goldberg B. Fetal body measurements. In: Goldberg B, Kurtz A, eds. Atlas of body measurements. Chicago: Year Book Medical, 1990:

Fig. 4.-Plot
nancy

of kidney

length vs age. Our measurements

measurements of Bertagnoli

are compared

with fetal

premature

neonatal

measurements
and Rosenbaum

of Fitzsimons

[5]. Measurements
after

by

Holloway et al. [18] used for reference.

et al. [6] in first week

birth are

332-333 3. Mahony B. The genitourinary

4.

noted measurements of 3.9-5.9 cm in neonates. Fitzsimons measurements of neonatal kidneys among premature infants

5. 6. 7.

whose gestational age was determined by menstrual history, fetal sonographic measurements, or maturity assessment were similar to those of our fetuses of equivalent gestational age (Fig. 4). Both our measurements and those of Fitzsimons showed little difference in the renal length measurements
between weeks 35 and 40. We have no explanation for this finding. Although we do not have birth weights of all fetuses for comparison, Erwin et al. [1 9] found mean neonatal renal lengths to be 4.8 cm for those greater than 3500 g and 4.5 cm for those between 3.0 and 3.5 kg, numbers similar to

system. In: Callen PW, ed. Ultrasonography in obstetrics and gynecology, 2nd ed. Philadelphia: Saunders, 1988:256 Bertagnoli L, Lalatta F, Gallicchio R, et al. Quantitative characterization of the growth of the fetal kidney. JCU 1983;1 1:349-356 Fitzsimons R. Kidney length in the newborn measured by ultrasound. Acta Paediatr Scand 1983:72:885-887 Rosenbaum D, Komgold E, Teele R. Sonographic assessment of renal lengths in normal children. AJR 1984;142:467-469 Han B, Babcock D. Sonographic measurements and appearance of normal kidneys in children. AJR 1985:145:611-616 G, Barbanni
length

8. Chiara A, Chirico
evaluation 9. Grignon of kidney A, Filion

M, DeVecchi
and

E, Rondini
infants. tract

G. Lfltrasonic
Eur J Pediatr in utero:

in term

preterm

1989:149:94-95
R, Filiatrault D, et al. Unnary dilatation classification and clinical applications. Radiology 1986:160:645-647 1 0. Athey PA, Hadlock FP. Ultrasound in obstetrics and gynecology, 2nd ed. St Louis: Mobsy, 1985:323-325 1 1 . Hadlock F, Deter R, Carpenter R, Park S. Estimating fetal age: effect of head shape on BPD. AJR 1981;137:83-85 12. Hadlock F, Deter R, Hamst R, Park S. Estimating fetal age: computerassisted analysis of fetal growth parameters. Radiology 1984:152: 497-501 13. Jeanty P. Dramaix-Wilmet M, Elkhazen N, Hubinot C, van Regemorter N. Measurement of fetal kidney growth on ultrasound. Radiology

those of our older fetuses

and larger than those of Bertagnoli

et al. Holloway et al. [1 8] noted neonatal (0-7 days) mean renal lengths to be 4.3 cm (SD, 0.48 on left side, 0.44 on night side) in males and between 4.1 and 4.2 cm for females. These measurements are similar to our length of 4.3 cm (SD, 0.5) at 40 weeks gestation. The study by Chiara et al. [8] of term and preterm neonates showed that the average kidney length

1982:144:159-162
14. Lawson T, Foley W, Berland L, Clark K. LJtrasonic evaluation of fetal kidneys: analysis of normal size and frequency of visualization as related to stage of pregnancy. Radiology 1981;138: 153-156 1 5. Sagi I, Vagman I, David M, et al. Fetal kidney size related to gestational age. Gynecol Obstet Invest 1987:23: 1-4 16. Hoddick W, Filly R, Mahony B, Callen P. Minimal fetal renal pyelectasis. J Ultrasound Med 1985;4: 85-89 17. Arger P, Coleman B, Mintz M, et al. Routine fetal genitourinary tract screening. Radiology 1985;156:485-489

was 4.0 cm (SD, 0.7). Gestational

ages were determined

by

maternal dates and Dubowitz assessment; mean measurements and (upper limit measurements) obtained from their graph were 4.4 cm (5.0 cm) at 38 weeks and 4.8 cm (5.4 cm) at 41 weeks [8]. In conclusion, gestational age is related to renal length. Our mean lengths are longer than those of earlier reports, yet are consistent with neonatal measurements in other published studies. Parental height and weight cannot be used to predict fetal or neonatal renal length. Fetal renal lengths may aid in

18. Holloway

H, Jones T, Robinson A, Harpen M, Wiseman H. Sonographic

determination of renal volumes in normal neonates. Pediatr Radiol 1983;13:21 2-214 1 9. Erwin B, Carrol B, Muller H. Sonographic assessment of neonatal renal parameters. J Ultrasound Med 1985;4:21 7-220