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Normal
Sonographic Patients
Length
Study
of Fetal
Kidneys:
in 397 Obstetric
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
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).
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
Kings County
Hospital,
Brooklyn,
NY, between
November
1988, and at
Health
Science
Center
at
Brooklyn,
Department
of Re-
search,
Hospital-Cornell
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
between
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
546
COHEN
ET AL.
1991
The longest
renal lengths
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
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
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
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
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
the lengths
correlated
of left and
(r = .91)
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
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.
SONOGRAPHIC
MEASUREMENT
OF FETAL
RENAL
LENGTH
547
if the echogenicity
is apparently
normal,
which
in
6J
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
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
in our larger
measurements it easier
as compared to determine
with
the
(1981-1
identification
983) studies
makes
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
#{149}-#{149}Jeanty
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
deviations
appear to be at
(Fig. 2). The
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
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.
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
Martin
Lesser
guidance;
W. Cohen,
. E2
32 33
34 35
his photographic
expertise;
E. Cohen
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
are compared
with fetal
premature
neonatal
measurements
and Rosenbaum
of Fitzsimons
[5]. Measurements
after
by
birth are
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
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
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
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