1984, The British Journal of Radiology, 57, 673-675

AUGUST

1984

The value of ultrasound in previously undiagnosed renal

failure
By T. Denton, M.B., B.S., D.M.R.D.; D. L Cochlin, F.R.C.R. and C. Evans, F.R.C.R.
Department of Radiology, Cardiff Royal Infirmary, Newport Road, Cardiff, CF2 1SZ
(Received February 1984)

ABSTRACT

Rapid advances in equipment and diagnostic criteria have

made ultrasound sufficiently sensitive to replace high-dose
urography (with its attendant risks and often lengthy
examination time) as the initial imaging modality in renal
failure.
A prospective study was carried out in 56 patients (109
kidneys). All hydronephroses were accurately detected on
ultrasound. 80% were due to obstruction, but showed no
features that distinguished them from other causes of
hydronephrosis.
A diagnostic pathway is suggested.

High-dose urography (IVU) has for many years been

the mainstay of diagnosis in acute renal failure (Coles,
1983; McClennan, 1979). Though there has been
improvement of the contrast media with a wider safety
margin, significant dose-related rise in serum creatinine
levels has been demonstrated (McClennan, 1979). The
prolonged examination time, along with other welldocumented risk factors, such as diabetes and dehydration, make for more cautious use of the investigation in
uraemic patients. Ultrasound does not involve any of
these risks and has the added advantage of being quick,
non-invasive and not involving ionising radiation. It
has been suggested that well-documented criteria for the
ultrasonic diagnosis of hydronephrosis (Sanders &
Bearman, 1973) and recent improvements in equipment,
with better resolution and much less operator dependence, have made ultrasound sufficiently sensitive to
replace high-dose urography as the initial investigation
in uraemia (Sherwood, 1983; Kutcher & Becker, 1979;
Talner et al, 1981). As well as the exclusion of
hydronephrosis, an estimation of renal size is also
obtained by ultrasound which is prognostically useful.
This prospective study was designed to determine the
sensitivity and specificity of ultrasound.

FIG.

1.

Ultrasound demonstrating a non-hydronephrotic kidney.

was not documented as we felt that this was dependent

on the duration of the pathological process rather than
the degree of obstruction. The presence or absence of
obstruction was confirmed by high-dose urography,
antegrade or retrograde urography or surgery. MCU
and renal biopsy were carried out in selected cases.
RESULTS

There were 31 males and 25 females with an age

range from 14 to 85 years. In two patients the
ultrasound scans were inconclusive. One of these had a
TABLE I

PATIENTS AND METHODS

Fifty-six consecutive patients (109 kidneys) presenting

between January and November 1983 with undiagnosed
renal failure were investigated by ultrasound as the first
imaging procedure. The equipment used was a
Technicare real-time sector and B-mode scanner with a
3.5 MHz transducer. No special preparation was used
prior to the examination. The presence or absence of
hydronephrosis and renal length were recorded from
the scans. The degree or severity of the hydronephrosis

Final diagnosis

Ultrasound diagnosis
Hydronephrosis

34

Non-hydronephrotic

73

Inconclusive

673

27
Obstructed
Non-obstructed
7
Obstructed
1
Non-obstructed
72
Non-obstructed polycystic 1
Renal agenesis
1

VOL.

57, No. 680

T. Denton, D. L. Cochlin and C. Evans

FIG. 2.
Antegrade pyelogram showing
obstruction without significant
dilatation.

non-obstructed polycystic kidney and the second had

unilateral renal agenesis.
Thirty-four kidneys were shown to be hydronephrotic
by ultrasound and 27 of these were subsequently proven
to be obstructed (Table I). Note should be taken that
hydronephrosis is not synonymous with obstruction.
The differences are so far not differentiable by
sonography. False positives in this study were all
related to reflux dilatation. A 0.9% (one kidney) false
negative incidence was found after analysis of the
results. This occurred in the youngest patient with a
single kidney on which a ureterolithotomy had been
performed in the previous 48 hours. Initial ultrasound
and IVU showed a non-dilated system (Figs. 1 and 2)
and antegrade urography was then performed. An
obstruction at the level of the operation site was
demonstrated and later proven to be due to surgical
oedema. Non-dilated systems in acute obstruction have
been well documented (Rascoff et al, 1983).
Renal size on IVU was consistently greater than on
674

ultrasound, though preliminary cadaver studies show

good correlation between ultrasound and the actual
renal size. This implies that the discrepancy is due to
radiographic magnification.
DISCUSSION

If high-dose urography is to be replaced as the initial

investigation in renal failure, the chosen investigation
must be at least as sensitive and specific. Previous
reports and analysis of the results of this study suggest
that ultrasound fulfils these requirements, and has the
added advantages of non-invasiveness and minimal
duration of examination without the use of ionising
radiations. A very high sensitivity is important in
patients presenting with renal failure of unknown
aetiology as immediate surgery may be necessary for
any hope of a reversal to normal renal function. Before
carrying out the ultrasound examination a plain
abdominal film must be made available for the
detection of calculi, which are a known cause of false

AUGUST 1984

Ultrasound in renal failure

Renal Failure
Ultrasound

Obstruction
CT/antegrade/retrograde

IVU

Non-obstructed

Renogram/biopsy/angiography

Surgery

exclude obstruction in the presence of polycystic disease

or multiple renal cysts. However, the sonographic
appearances are such that further investigation is
mandatory. The limitations of ultrasound in detecting
renal agenesis or ectopic kidneys were demonstrated in
one patient, in whom further investigation was also
indicated. We feel that the reluctance of clinicians to
accept ultrasound as a screening examination in
undiagnosed renal failure is because they are not as
familiar with ultrasound as with urography. This study,
however, demonstrates that ultrasound should replace
urography in this situation, and a diagnostic pathway is
presented (Fig. 3).

FIG. 3.

CONCLUSIONS

Diagnostic pathway.

1. Ultrasound and plain abdominal film should now

be used as the primary investigation in the demonstration of obstruction.
2. Kidneys appearing non-obstructed on ultrasound
can then be spared high-dose urography.
3. Kidneys appearing doubtful or hydronephrotic on
ultrasound require further urgent investigation; the
choice depending on circumstances.

negatives as they obscure hydronephrosis (Talner et al,

1981), though there were none encountered in this
study. Ultrasound detected 27 out of the 28 obstructed
kidneys, showing a high sensitivity (96.4%). In doubtful
cases, or where there is strong presumptive evidence, it
is important that obstruction be confirmed or ruled out
by more definitive investigations such as antegrade or
retrograde urography. The demonstration of hydronephrosis on ultrasound necessitates further uroradiological investigation to determine the level and
cause, but by excluding post-renal obstruction, any
patients with renal parenchymal disorders will be
spared high-dose urography. Ultrasound will show the
cause of renal failure in some cases, such as polycystic
disease or the small kidneys of end-stage chronic renal
failure, though, like other workers, we found the
cortico-medullary echodensity pattern non-specific
(Rosenfield & Siegel, 1981). Reflux nephropathy is a
well-recognised cause of a hydronephrotic calyceal
system indistinguishable from obstruction on the
sonogram. "Baggy" collecting systems and other similar
anatomical variations may also provide similar
appearances. This produces a false positive rate, varying
in different studies from 7% to 26%, indicating that
sonographic features are not entirely specific for
obstruction. Ultrasound is, however, sufficiently accurate to ensure that about three-quarters of the patients
will be spared urography. It may also be difficult to

675

REFERENCES
COLES, G. A., 1983. Acute renal failure. Hospital Update, 9,
129-130.
KUTCHER, R. & BECKER, J. A., 1979. Renal failure imaging.
Journal of the American Medical Association, 242,
2227-2229.
MCCLENNAN, B. L., 1979. Current approaches to the
azotaemic patient. Radiologic Clinics of North America, 17,
197-211.
RASCOFF,

J.

H.,

GOLDEN,

R.

A.,

SPINOWITZ,

B.

S.

&

CHARYTAN, C , 1983. Non-dilated obstructive uropathy.

Archives of Internal Medicine, 143, 696-698.
ROSENFIELD, A. T. & SIEGEL, N. J., 1981. Renal parenchymal

disease:
histologic-sonographic correlation.
Journal of Roentgenology, 137, 793-798.

American

SANDERS, R. C. & BEARMAN, S. B., 1973. B-scan ultrasound in

the diagnosis of hydronephrosis. Radiology, 108, 375-382.

SHERWOOD, T., 1983. Programmed investigation in nephrourology. In Recent Advances in Radiology (Churchill
Livingstone, Edinburgh), Vol. 7.
TALNER, L. B., SCHEIBLE, W., ELLENBOGEN, P. H., BECK, C. H.,

Jr. & COSINK, B. B., 1981. How accurate is ultrasonography

in detecting hydronephrosis in azotaemic patients? Urologic
Radiology, 3, 1-9.